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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: \ntramadol / lisinopril\n \nAttending: ___.\n \nChief Complaint:\nFever, abdominal pain, loose stools\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ w/ locally advanced pancreatic CA, biliary obstruction s/p \nPTBD ___, admitted to the FICU with septic shock in the \nsetting of E coli and enterococcus bacteremia of presumed \nbiliary source. \n\nThe patient presented on ___ with fever to 100.9, worsening \nabdominal pain, and loose stools. She was noted to have soft BP \nand lactate of 3.0. Tbili was lower than prior and URQ US showed \nno acute ductal dilitation with drain appropriately placed; ___ \nwas consulted and the drain was uncapped for external drainage. \nBlood culture x1 was collected, she was given vanc/zosyn, IVF, \nand was admitted to the FICU. \n\nIn the FICU, she was continued on Vanc/Zosyn and IVF but \nintermittently required phenylephrine during the first hospital \nday. Blood cultures grew enterococcus and E coli. When stable \noff pressors for over 24 hours, she was transferred to the \nfloor.\n\nROS as above, otherwise negative in remaining systems.\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: \nVITALS: T 98.8, HR 114, BP 111/52, RR 19, O2 98% 2L NC \nGENERAL: Mild jaundice, NAD\nHEENT: PERRL, MMM \nNECK: JVP not elevated\nCARDIAC: RRR, S1/S2, systolic murmur at base \nLUNG: Bibasilar crackles \nABDOMEN: R PTBD in place covered with clean bandage, ecchymosis \naround edge of bandage. Non-tender to palpation. Abdomen soft, \nnt, nd. \nEXTREMITIES: WWP, no ___ edema\nPULSES: 2+ DP pulses bilaterally \nNEURO: No gross deficits appreciated\n\nDischarge exam\nVitals stable.\nNo jaundice or scleral icterus\nPTBD in place, capped, abdomen non tender.\nExt without edema.\n \nPertinent Results:\n=====================\nADMISSION LABS\n=====================\n___ 09:30PM BLOOD WBC-9.6 RBC-3.11* Hgb-9.7* Hct-29.8* \nMCV-96 MCH-31.2 MCHC-32.6 RDW-14.8 RDWSD-51.9* Plt ___\n___ 09:30PM BLOOD Neuts-83.5* Lymphs-8.2* Monos-7.2 \nEos-0.5* Baso-0.2 Im ___ AbsNeut-8.03* AbsLymp-0.79* \nAbsMono-0.69 AbsEos-0.05 AbsBaso-0.02\n___ 09:30PM BLOOD ___ PTT-34.6 ___\n___ 09:30PM BLOOD Glucose-129* UreaN-20 Creat-0.5 Na-131* \nK-3.8 Cl-92* HCO3-26 AnGap-17\n___ 09:30PM BLOOD ALT-93* AST-90* AlkPhos-472* TotBili-3.4*\n___ 09:30PM BLOOD Lipase-41\n___ 09:30PM BLOOD Albumin-3.7\n___ 04:17AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7\n___ 09:40PM BLOOD Lactate-1.8\n\nBlood culture ___: \n ESCHERICHIA COLI\n | ENTEROCOCCUS FAECALIS\n | | \nAMPICILLIN------------ =>32 R <=2 S\nAMPICILLIN/SULBACTAM-- =>32 R\nCEFAZOLIN------------- 8 R\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nDAPTOMYCIN------------ S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPENICILLIN G---------- 2 S\nPIPERACILLIN/TAZO----- 8 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\nVANCOMYCIN------------ 2 S\n\nRUQ US ___. Heterogeneous hepatic parenchyma likely due to areas of prior \nGel-Foam \nembolization/biloma seen on recent CT. \n2. Percutaneous transhepatic biliary drain in the right \nposterior biliary \nsystem, extending to the region of the common bile duct. No \nintrahepatic \nbiliary dilation. \n3. Sludge filled gallbladder. \n\nECHO ___\nThe left atrium is elongated. The right atrium is moderately \ndilated. No atrial septal defect is seen by 2D or color Doppler. \nLeft ventricular wall thickness, cavity size and regional/global \nsystolic function are normal (LVEF >55%). There is no \nventricular septal defect. Right ventricular chamber size and \nfree wall motion are normal. The diameters of aorta at the \nsinus, ascending and arch levels are normal. The aortic valve \nleaflets (3) are mildly thickened. There is mild to moderate \naortic valve stenosis (valve area 1.2 cm2). Trace aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. Mild (1+) mitral regurgitation is seen. The tricuspid \nvalve leaflets are mildly thickened. There is mild pulmonary \nartery systolic hypertension. There is no pericardial effusion. \n\n\n___ Renal ultrasound\nFINDINGS: \n The right kidney measures 10.7 cm. The left kidney measures \n10.3 cm. There is no hydronephrosis, stones, or masses \nbilaterally. Normal cortical echogenicity and corticomedullary \ndifferentiation are seen bilaterally. \n The bladder is moderately well distended and normal in \nappearance. \n \nIMPRESSION: \n \nNo hydronephrosis. Normal cortical echogenicity and \ncorticomedullary \ndifferentiation. \n\ndischarge labs:\n___ 06:07AM BLOOD WBC-6.7 RBC-2.58* Hgb-8.0* Hct-25.1* \nMCV-97 MCH-31.0 MCHC-31.9* RDW-15.2 RDWSD-54.6* Plt ___\n___ 06:07AM BLOOD Glucose-105* UreaN-30* Creat-2.0* Na-138 \nK-3.9 Cl-100 HCO3-25 AnGap-17\n___ 06:07AM BLOOD ALT-45* AST-36 AlkPhos-284* TotBili-2.0*\n \nBrief Hospital Course:\n___ w/ locally advanced pancreatic CA, biliary obstruction s/p \nPTBD ___, admitted to the FICU with septic shock in the \nsetting of E coli and enterococcus bacteremia of presumed \nbiliary source. \n\n#ENTEROCOCCUS AND E COLI BACTEREMIA OF PRESUMED BILIARY SOURCE\n#SEPTIC SHOCK\nOn arrival patient was hypotensive and a lactate of 3.0 despite \nfluids. The patient intermittently required a small dose of \nphenylephrine. Blood cultures grew E coli (resistant to early \ngeneration beta lactams) and enterococcus (not VRE). She was on \nempiric vanc/Zosyn since ___, which has now been narrowed to \nvanc/CTX based on sensitivities. Her urine culture was negative \nand her CT showed no obvious biliary pathology. The perc biliary \ndrain has been uncapped for external drainage in the setting of \npossible cholangitis and the patient improved. On transfer to \nthe medical floor,the patient's antibiotics were narrowed to \nCipro/Ampicllin. She subsequently developed renal failure \nthought to be due to betalactams so Vancomycin was restarted. \nUnfortunately, she developed recurrent lft and bilirubin \nelevation, and underwent repeat PTBD placed on ___, with \nsubsequent improvement. She was discharged to complete a 2 week \ncourse of ciprofloxacin and ampicillin (ampicillin was restarted \nas likelihood of AIN was quite low per nephrology, with ATN more \nlikely).\n\n#PANCREATIC ADENOCARCINOMA \n#Malignant biliary obstruction. \nDiagnosed ___ by EUS/FNA. It is locally advanced and \nunresectable (encases vasculature). Pt will f/u with Dr. ___ \nto discuss palliative chemo if functional status allows and she \nwants to pursue treatment. She was followed by interventional \nradiology and had placement of metal stent on ___ with \nremoval of external PTBD, and then replacement after she \ndeveloped recurrent obstruction as described above. She will \nhave ___ follow up next week for repeat stent evaluation to try \nto clarify reason for rapid failure of stent.\n\n#ACUTE RENAL FAILURE\nThe patient developed acute renal failure. She was seen by \nnephrology who felt her renal failure was likely due to either \nAIN in the setting of antibiotics or ATN from sepsis. Her renal \nfunction slowly improved, but plateaued at approximately 2. She \nwill have nephrology follow up for further evaluation.\n\n#HTN: \n- Resumed metoprolol given recent hypotension\n\n#VASCULAR DISEASE\nRemote history of carotid endarterectomy.\n- Continue ASA 81 mg\n\n#AS\nWould not arrange cardiology follow up given that the valve will \nnot progress to critical stenosis within her duration of \nexpected survival.\n\n#HCP: ___, daughter. ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 40 mg PO DAILY \n2. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral \nDAILY \n3. Aspirin 81 mg PO DAILY \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Fish Oil (Omega 3) 1000 mg PO DAILY \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Vitamin D 1000 UNIT PO DAILY \n8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH \nPAIN \n\n \nDischarge Medications:\n1. Ampicillin 2 g IV Q6H \nRX *ampicillin sodium 2 gram 2 g IV q 6 hours Disp #*20 Vial \nRefills:*0 \n2. Ciprofloxacin HCl 500 mg PO Q24H \nRX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth daily \nDisp #*5 Tablet Refills:*0 \n3. Aspirin 81 mg PO DAILY \n4. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral \nDAILY \n5. Cyanocobalamin 1000 mcg PO DAILY \n6. Fish Oil (Omega 3) 1000 mg PO DAILY \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Omeprazole 40 mg PO DAILY \n9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH \nPAIN \n10. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSepsis\nBacteremia\nMalignant biliary obstruction\nAcute renal failure\nPancreatic cancer\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 with a bloodstream infection from your bile \nduct blockage. You were treated with antibiotics with \nimprovement in your infection. You were seen by the radiologists \nand had the external drain removed and a metal stent placed into \nyour bile ducts, but this did not work, and you needed another \ndrain put in. While you were hospitalized, you developed kidney \nfailure which is likely because you were dehydrated.\n\nYou need to take another 5 days of antibiotics - the \nciprofloxacin pills once a day as well as the ampicillin IV 4 \ntimes per day.\n\nAfter you go home you need to see a number of doctors:\n\nThe kidney doctor - they will call you with an appointment.\nDr. ___ cancer doctor - they will call you with an \nappointment.\nDr. ___ - a new primary care doctor - whom you are \nscheduled to see on ___\nDr. ___ - an interventional radiologist - who will \nreschedule you to have another interventional procedure to \nevaluate your drain and your stent.\n\nIf you develop fever or right sided abdominal pain - you should \nreattach the drain to a bag.\n\n \nFollowup Instructions:\n___\n" ]

[ "A4151", "R6521", "N179", "C250", "K831", "N009", "A4181", "I10", "E785", "I350", "T85898A", "Y838", "Y92230", "I4891" ]

[ "A4151: Sepsis due to Escherichia coli [E. coli]", "R6521: Severe sepsis with septic shock", "N179: Acute kidney failure, unspecified", "C250: Malignant neoplasm of head of pancreas", "K831: Obstruction of bile duct", "N009: Acute nephritic syndrome with unspecified morphologic changes", "A4181: Sepsis due to Enterococcus", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "I4891: Unspecified atrial fibrillation" ]

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

[]

[ " \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:\nOSH transfer s/p ERCP here for obstructive jaundice, pancreatic \nhead mass\n \nMajor Surgical or Invasive Procedure:\nEUS with fine needle biopies of pancreatic mass ___\nPercutaneous transhepatic biliary drain placement ___\n\n \nHistory of Present Illness:\n___ hx AS, HTN, HLD, remote carotid endarterectomy, s/p \ngastrojejunostomy ___ for gastric outlet obstruction (EGD \nwith duodenal apex stricture, benign pathology; MRCP ___ \nwith dilated pancreatic duct, normal CBD and no mass), repeat \nEGD ___ with persistent duodenal stricture, transfer from \nOSH with painless jaundice, hyperbilirubinemia, and found to \nhave pancreatic head mass, s/p EGD/EUS now admitted to ___ for \nfurther w/u. \n\nHistory taken from patient, her two daughters, and available \n___ records. The surgery above did relieve her feelings of \nnausea and vomiting, but she continued to have LUQ pain \nintermittently that was attributed to post-operative pain. \nDespite being able to eat and drink and having a near-normal \nappetite, her weight dropped about 10lbs. She noticed that her \nstools were getting lighter, and more recently, that her urine \nwas darker. On ___, her daughter visiting her noticed that \nshe was jaundiced (she lives with another daughter, but that \ndaughter had been away for hip surgery); on ___, the \npatient was itching but did not have a rash. She was taken to \n___ were labs were notable for Bilirubin 7.7, AST \n155/ALT 176, AP 742. CA ___ was elevated at 282. An MRI/MRCP \nshowed (Impression): 2.9x2.0cm mass in the pancreatic head \ncausing obstruction of the CBD with moderate biliary ductal \ndilatation. \n\nHMED and ERCP were contacted for transfer, with patient going to \nthe ERCP suite prior to admission. EGD/EUS was with the \nfollowing findings:\nEUS was performed using a linear echoendoscope at ___ MHz \nfrequency: The head and uncinate pancreas were imaged from the \nduodenal bulb and the second / third duodenum. The body and tail \n[partially] were imaged from the gastric body and fundus. Mass: \nA 3.4 cm X 2.9 cm ill-defined mass was noted in the head of the \npancreas. The mass was hypoechoic and heterogenous in \nechotexture. The borders of the mass were irregular and poorly \ndefined. FNB was performed. Color doppler was used to determine \nan avascular path for needle biopsy. A 22-gauge needle with a \nslow pull technique was used to perform biopsy. Five needle \npasses were made into the mass. biopsy was sent for pathology. \n(Impression as below.) \n\nWhen seen on the floor, patient contributes to the history as \nabove and below. She is currently feeling okay. She denies \ncurrent abdominal pain, HA, n/v, fevers, chills. She denies \nvision change, dizziness, lightheadedness, cough, congestion, \nchest pain, sob, urinary frequency or pain with urination, \ndiarrhea or constipation, focal weakness. Her daughters note \nshe's been stooling x3 per day, not loose, but pt again confirms \nthe light color. \n \nPast Medical History:\nHTN, HLD, AS, remote carotid endarterectomy, s/p \ngastrojejunostomy ___ for gastric outlet obstruction\n \nSocial History:\n___\nFamily History:\nMother died at ___ unclear reasons, did have a stroke before \ndeath\nFather died in old age of stroke\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVitals: 96.1 100 / 62 83 16 96 RA \nGen: Pleasant elder female, sitting in chair, NAD\nHEENT: NCAT, EOMI, PERRLA, icteric sclera, clear OP, MMM \nCV: II/VI SEM best heard RUSB, RRR\nChest: CTAB, no w/r/r\nGI: soft, NT, ND, BS+\nMSK: Mild kyphosis. No synovitis.\nSkin: +Jaundice. Varicose veins b/l ___. \nNeuro: AAOx3. No facial droop. Full strength all extremities. \nPsych: Full range of affect\n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 10:24PM BLOOD WBC-4.4 RBC-2.95* Hgb-9.3* Hct-27.5* \nMCV-93 MCH-31.5 MCHC-33.8 RDW-18.4* RDWSD-62.6* Plt ___\n___ 10:24PM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-138 \nK-3.3 Cl-100 HCO3-25 AnGap-16\n___ 10:24PM BLOOD ALT-154* AST-168* AlkPhos-648* \nTotBili-7.9* DirBili-6.3* IndBili-1.6\n___ 10:24PM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7\n\nDISCHARGE LABS:\n==============\n\nIMAGING:\n========\n\nOSH MRI/MRCP showed (Impression): 2.9x2.0cm mass in the \npancreatic head causing obstruction of the CBD with moderate \nbiliary ductal dilatation\n\nCT chest with Contrast ___:\nIMPRESSION: \n1. No specific CT evidence of active intrathoracic infection or \nmetastasis. \n2. Sub-2 mm right upper lobe subpleural pulmonary nodule. \n\nCT abdomen/pelvis ___:\n1. There are several hypoattenuating lesions within the right \nhepatic lobe \nsome of which demonstrate internal foci of air and the largest \ndemonstrates \nrim enhancement. After discussion with the interventional \nradiology team, in \nlight of the somewhat difficult recent PTBD placement with \ngelfoam \nembolization these are likely sequela of this procedure \n(hmeatoma/bilioma) . \n2. Ill defined hypoenhancing 3.0 x 2.5 cm pancreatic head mass \nis concerning \nfor pancreatic adenocarcinoma. Arterial and venous invasion as \nwell as \ninvasion of adjacent structures is described in detail above. \nSpecifically, \nthe main portal vein, SMV, gastroduodenal artery, proper \nhepatic artery, and \nduodenum are affected by this lesion. \n3. There is no calcified gallstone or pericholecystic fluid, \nhowever, the \ngallbladder wall is thickened. This could be further evaluated \nwith \nultrasound if indicated. \n\nPROCEDURES:\n===========\n___ ___ EGD/EUS:\nImpression: \n•Normal mucosa in the esophagus \n•Previous Gastro-Jejunal bypass of the stomach body \n•A malignant intrinsic stricture was found in the first part of \nthe duodenum. \n•The scope did not traverse the lesion. \n•EUS was performed using a linear echoendoscope at ___ MHz \nfrequency \n•The head and uncinate pancreas were imaged from the duodenal \nbulb and the second / third duodenum. The body and tail \n[partially] were imaged from the gastric body and fundus. \n•Mass: A 3.4 cm X 2.9 cm ill-defined mass was noted in the head \nof the pancreas. \n•The mass was hypoechoic and heterogenous in echotexture. \n•The borders of the mass were irregular and poorly defined. FNB \nwas performed. Color doppler was used to determine an avascular \npath for needle biopsy. \n•A 22-gauge needle with a slow pull technique was used to \nperform biopsy. \n•Five needle passes were made into the mass. biopsy was sent for \npathology. \n•Otherwise normal upper eus to third part of the duodenum\n\n___: Percutaneous Transhepatic Biliary Drain placement:\nFINDINGS: \n1. Dilated biliary system. While many left-sided biliary ducts \nwere dilated, \nthe left-sided system was inaccessible due to what appeared to \nbe an overlying \nbowel on ultrasound.. \n2. High-grade severe CBD obstruction with intrahepatic ductal \ndilatation. \n3. 10 ___ internal external drain through the right \nposterior ducts. \n4. Initial placement complicated by peribiliary sheath \nplacement and wire \ntraversion into hepatic parenchyma. This track was gelfoam \nembolized and a \nsecond access was obtained in uncomplicated fashion. \n \nIMPRESSION: \n Successful placement of the right ___ internal-external biliary \ndrain. \nHigh-grade distal CBD obstruction. \n\n___ 07:10AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.7* Hct-29.8* \nMCV-97 MCH-31.6 MCHC-32.6 RDW-16.7* RDWSD-59.4* Plt ___\n___ 07:30AM BLOOD WBC-6.7 RBC-3.02* Hgb-9.5* Hct-28.5* \nMCV-94 MCH-31.5 MCHC-33.3 RDW-17.6* RDWSD-61.5* Plt ___\n___ 07:10AM BLOOD Glucose-92 UreaN-14 Creat-0.6 Na-133 \nK-3.8 Cl-93* HCO3-28 AnGap-16\n___ 07:10AM BLOOD ALT-121* AST-89* AlkPhos-488* \nTotBili-3.8*\n___ 07:30AM BLOOD ALT-156* AST-151* AlkPhos-552* \nTotBili-4.5*\n___ 06:30AM BLOOD ALT-156* AST-176* AlkPhos-654* \nTotBili-10.3*\n___ 06:35AM BLOOD ALT-156* AST-172* LD(LDH)-168 \nTotBili-10.1* DirBili-7.9* IndBili-2.2\n___ 06:30AM BLOOD CEA-6.2*\n Result Reference Range/Units\nCA ___ 83 H <34 U/mL\n\nCT chest\nIMPRESSION: \n \n1. No specific CT evidence of active intrathoracic infection or \nmetastasis.\n2. Sub-2 mm right upper lobe subpleural pulmonary nodule.\n\nCT abd/pelvis:\nIMPRESSION:\n \n \n1. There are several hypoattenuating lesions within the right \nhepatic lobe\nsome of which demonstrate internal foci of air and the largest \ndemonstrates\nrim enhancement. After discussion with the interventional \nradiology team, in\nlight of the somewhat difficult recent PTBD placement with \ngelfoam\nembolization these are likely sequela of this procedure \n(hmeatoma/bilioma) .\n2. Ill defined hypoenhancing 3.0 x 2.5 cm pancreatic head mass \nis concerning\nfor pancreatic adenocarcinoma. Arterial and venous invasion as \nwell as\ninvasion of adjacent structures is described in detail above. \nSpecifically,\nthe main portal vein, SMV, gastroduodenal artery, proper \nhepatic artery, and\nduodenum are affected by this lesion.\n3. There is no calcified gallstone or pericholecystic fluid, \nhowever, the\ngallbladder wall is thickened. This could be further evaluated \nwith\nultrasound if indicated.\n\nImpression:\nNormal mucosa in the esophagus\nPrevious Gastro-Jejunal bypass of the stomach body\nA malignant intrinsic stricture was found in the first part of \nthe duodenum.\nThe scope did not traverse the lesion. \nEUS was performed using a linear echoendoscope at ___ MHz \nfrequency\nThe head and uncinate pancreas were imaged from the duodenal \nbulb and the second / third duodenum. The body and tail \n[partially] were imaged from the gastric body and fundus.\nMass: A 3.4 cm X 2.9 cm ill-defined mass was noted in the head \nof the pancreas.\nThe mass was hypoechoic and heterogenous in echotexture.\nThe borders of the mass were irregular and poorly defined. FNB \nwas performed. Color doppler was used to determine an avascular \npath for needle biopsy.\nA 22-gauge needle with a slow pull technique was used to perform \nbiopsy.\nFive needle passes were made into the mass. biopsy was sent for \npathology.\nOtherwise normal upper eus to third part of the duodenum\nRecommendations:\nClear liquid diet when awake, then advance diet as tolerated.\nFollow-up with Dr. ___ as previously scheduled.\nIf any fever, worsening abdominal pain, or post procedure \nsymptoms, please call the advanced endoscopy fellow on call \n___/ pager ___.\nFollow-up will depend on pathology results. Patient will be \ncontacted to discuss when results become available.\nFollow up with pathology reports. Please call Dr. ___ \noffice ___ in 7 days for the pathology results.\nPlease obtain chest CT and CTA abdomen and pelvis\nPlease contact ___ service/Dr. ___ contact ___ for PTBD evaluation\n\nPATHOLOGIC DIAGNOSIS:\nPancreas, mass, core needle biopsy: - Adenocarcinoma.\n \nBrief Hospital Course:\n___ hx HTN, HLD, remote carotid endarterectomy, s/p \ngastrojejunostomy ___ for gastric outlet obstruction \nrecent presentation to OSH with painless jaundice and \nhyperbilirubinemia, found to have pancreatic head mass, \ntransferred for ERCP/EUS and ___ evaluation.\n\n# Jaundice, Hyperbilirubinemia, Pancreatic Head Mass: Pt \ntransferred from ___ for painless jaundice, newly \ndiagnosed pancreatic head mass c/f adenocarcinoma, rapidly \nprogressive as per report as not seen on imaging ___ \nduring evaluation for gastric outlet obstruction (which did not \nhave another obvious cause). She underwent EUS with fine-needle \nbiopsy on ___ which she tolerated well. Pathology returned \nc/w adenocarcinoma. However, as endoscopy was unable to traverse \nduodenal stricture ___ mass, pt underwent PTBD placement on \n___ which she tolerated well. Post-procedure bilis \ndowntrended. Drain was capped on ___ without issue and pt \nwill be discharged with drain pending ___ surgery's \ndecision regarding potential surgical options. CTA pancreatic \nprotocol obtained prior to pt's discharge.\n Per ___, if surgery is not an option, will plan to replace \ndrain with stent. Pt will be seen in ___ clinic \non ___.\n\n# HTN: Continued home metoprolol\n\n# HLD: Held home statin given elevated LFT's, held on discharge. \n\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lovastatin 40 mg oral DAILY \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. Fish Oil (Omega 3) 1000 mg PO DAILY \n4. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral \nDAILY \n5. Vitamin D 1000 UNIT PO DAILY \n6. Cyanocobalamin 1000 mcg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Omeprazole 40 mg PO DAILY \n\n \nDischarge Medications:\n1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN BREAKTHROUGH \nPAIN \nRX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours as \nneeded Disp #*20 Tablet Refills:*0 \n2. Aspirin 81 mg PO DAILY \n3. calcium carbonate-vitamin D3 600 mg(1,500mg) -800 unit oral \nDAILY \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Fish Oil (Omega 3) 1000 mg PO DAILY \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Omeprazole 40 mg PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPancreatic head mass\nDuodenal stricture\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 transferred from ___ due to a newly \ndiagnosed pancreatic mass which was causing an obstruction in \ndrainage of your bile ducts. You underwent placement of an \nexternal biliary drain which is currently working well and has a \ncap on it. You will meet with the surgeons and oncologists in \nclinic to decided how to proceed with further work-up and \ntreatment of your pancreatic mass. \n\nYou were prescribed a medication for pain called oxycodone. This \nmedication can be addictive and can cause difficulty breathing \nand even death. Please only use this medication as prescribed \nand do not drive when taking this medication. Do not take with \nother sedating medications. You may have a partial fill. \n\nIt was a pleasure taking care of you at ___ \n___.\n \nFollowup Instructions:\n___\n" ]

[ "A4151", "R6521", "N179", "C250", "K831", "N009", "A4181", "K315", "K838", "I10", "E785", "I350", "T85898A", "Y838", "Y838", "Y92230", "Z934" ]

[ "A4151: Sepsis due to Escherichia coli [E. coli]", "R6521: Severe sepsis with septic shock", "N179: Acute kidney failure, unspecified", "C250: Malignant neoplasm of head of pancreas", "K831: Obstruction of bile duct", "N009: Acute nephritic syndrome with unspecified morphologic changes", "A4181: Sepsis due to Enterococcus", "K315: Obstruction of duodenum", "K838: Other specified diseases of biliary tract", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "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", "Z934: Other artificial openings of gastrointestinal tract status" ]

[ "N179", "I10", "E785", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nR arm paralysis\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ RHD M w/ PMH HepC, IVDU presents with R arm weakness.\n\nPatient was in his usual state of health until ___, when he\nwoke up he noticed R arm felt numb, thought he slept on it \nfunny,\nwent to sleep and woke up and it was still the same. He also\nnoticed he couldn't move it. When he woke up around lunch time\nthat day, he stated he couldn't use it to do anything. States it\nseems like it affects the whole arm up to the shoulder. \nsensation\nintact in shoulder. He states he has sensation and has been able\nto feel people examine him. He is not sure exactly how the\nsensation is different than normal. Was normal on ___ night,\nno preceding symptoms. No headache. No tingling. Denies fever or\nchills. Gets night sweats periodically, states it drenches the\nsheets. He is not sure how frequently. No palpitations, chest\npain. He states he was arrested ___, and has been in jail since\nthen. No head trauma.\n\nAfter initial evaluation, he later states he developed mild\nheadache of gradual onset thatstarted while he was in the\nemergency room. that he states was due to the beeping noise from\nteh infusion pump.\n \nOn neuro ROS, the pt denies headache, loss of vision, blurred\nvision, diplopia, dysarthria, dysphagia, lightheadedness,\nvertigo, tinnitus or hearing difficulty. Denies difficulties\nproducing or comprehending speech. Denies parasthesiae. No \nbowel\nor bladder incontinence or retention. Denies difficulty with\ngait. \n \nOn general review of systems, the pt denies recent fever or\nchills. No night sweats or recent weight loss or gain. Denies\ncough, shortness of breath. Denies chest pain or tightness,\npalpitations. Denies nausea, vomiting, diarrhea, constipation \nor\nabdominal pain. No recent change in bowel or bladder habits. \nNo\ndysuria. Denies arthralgias or myalgias. Denies rash. \n \nPast Medical History:\nHepC (has not taken any medications for it, diagnosed ___ year \nago)\nlyme disease (had general fatigue, dx by blood test, took 1 \nmonth\nof antibiotics for that, about ___ year ago)\nback and knee problems\n \nSocial History:\n___\nFamily History:\nFather overdose\nBrother suicide\n \n \nPhysical Exam:\nAdmission Physical Exam: \nVitals: T98.5 HR 76 BP 108/76 RR18 Spo2 99% RA \n\nGeneral: Awake, cooperative, NAD, thin \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. many tattoos\n \nNeurologic:\n-Mental Status: Alert, oriented to ___ ___. Able to\nrelate history without difficulty. name ___ backward gets to\n___. DOWB gets to ___. Does DOWF easily. Language is\nfluent with intact repetition and comprehension. Normal prosody.\nThere were no paraphasic errors. Pt was able to name both high\nand low frequency objects. Able to read without difficulty.\nSpeech was not dysarthric. Able to follow both midline and\nappendicular commands. Pt was able to register 3 objects and\nrecall ___ at 5 minutes. There was no evidence of apraxia or\nneglect.\n\n-Cranial Nerves: \nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. Visual acuity\n___ bilaterally. Fundoscopic exam revealed no papilledema,\nexudates, ___ spots\nV: Facial sensation intact to light touch. \nVII: No facial droop, facial musculature symmetric. \nVIII: Hearing intact to finger-rub bilaterally. \nIX, X: Palate elevates symmetrically. \nXI: ___ strength in trapezius on R, no movement noted on L \nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n \n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally. \nNo adventitious movements, such as tremor, noted. No asterixis\nnoted. \n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 5 ___ ___ 5 5 5 5 \nR 2 ___ 0 5 5 5 5 5 5 \n \n-Sensory: No deficits to light touch, cold sensation, vibratory\nsense, proprioception throughout. No extinction to DSS. \ndecreased sensation to pinprick in R arm to shoulder level\n \n-DTRs: \n Bi Tri ___ Pat Ach \nL 2 2 2 2 1 \nR 1 0 0 2 1 \nPlantar response was flexor bilaterally.\n \n-Coordination: No intention tremor. Normal finger-tap . No\ndysmetria on FNF or HKS on L. \n \n-Gait: deferred, patient handcuffed to bed \nDischarge Physical Exam:\nTmax: 36.8 °C (98.2 °F)\nTcurrent: 36.6 °C (97.8 °F)\nHR: 81 (52 - 91) bpm\nBP: 109/80(90) {94/60(71) - 120/87(97)} mmHg\nRR: 19 (18 - 26) insp/min\nSpO2: 97% \nHeart rhythm: SR (Sinus Rhythm)\n\nGeneral: young man lying in bed, NAD\nHEENT: NC/AT\nPulmonary: breathing comfortably on room air\nCardiac: warm, well-perfused\nAbdomen: soft, NT/ND\nExtremities: wwp, no C/C/E bilaterally\nSkin: no rashes or lesions noted. \nNeurologic: \n-MS: Awake, alert. Oriented to self, hospital, date. Able to\nrelay history clearly. Language is fluent. No paraphasic errors.\nNo dysarthria. Follows midline and appendicular commands. \n-CN: PERRL 7-5mm b/l. VFF to confrontation. EOMI, no nystagmus. \nSensation intact and equal b/l. No facial asymmetry. Tongue \nprotrudes to midline. Symmetric palate elevation. \n-Motor: Intermittent tremor in R thumb/some fingers. \nRUE unable to move at all except R deltoid is 2. LUE with full \nROM and ___.\nBoth ___. Bilateral IP, TA ___.\n-Sensory: Equal and symmetric sensation to pinprick.\n-Reflexes: Deferred.\n-Coordination: deferred\n-Gait: deferred.\n \nPertinent Results:\n___ 06:05AM BLOOD WBC-7.9 RBC-4.34* Hgb-13.9 Hct-40.2 \nMCV-93 MCH-32.0 MCHC-34.6 RDW-14.4 RDWSD-48.4* Plt ___\n___ 06:05AM BLOOD Neuts-33.7* Lymphs-53.5* Monos-10.1 \nEos-1.2 Baso-0.9 Im ___ AbsNeut-2.76 AbsLymp-4.39* \nAbsMono-0.83* AbsEos-0.10 AbsBaso-0.07\n___ 02:30PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL \nPoiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL\n___ 06:05AM BLOOD ___ PTT-83.7* ___\n___ 06:05AM BLOOD Glucose-98 UreaN-6 Creat-0.6 Na-143 K-4.3 \nCl-108 HCO3-24 AnGap-11\n___ 09:22AM BLOOD ALT-27 AST-27 LD(LDH)-386* AlkPhos-75 \nTotBili-0.3\n___ 06:05AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.0\n___ 06:10AM BLOOD %HbA1c-5.3 eAG-105\n___ 06:10AM BLOOD Cryoglb-NO CRYOGLO\n___ 06:10AM BLOOD Triglyc-149 HDL-21* CHOL/HD-8.2 \nLDLcalc-122\n___ 06:10AM BLOOD TSH-2.6\n___ 06:10AM BLOOD CRP-50.8*\n___ 06:15AM BLOOD PEP-ABNORMAL B IgG-1099 IgA-268 IgM-263* \nIFE-MONOCLONAL\n___ 02:06AM BLOOD PEP-ABNORMAL B IgG-1268 IgA-295 IgM-315* \nIFE-MONOCLONAL\n___ 02:36PM BLOOD Lactate-0.9\n\nMRI ___: IMPRESSION: \n \n1. Study is mildly degraded by motion. \n2. Dural venous sinus thrombosis involving the superior sagittal\nsinus, left transverse sinus, left sigmoid sinus, proximal left\ninternal jugular vein, and multiple bilateral cerebral veins at\nthe vertex. \n3. Left frontoparietal acute to subacute infarct with adjacent\nsubarachnoid hemorrhage as described. \n4. Right frontal thrombosed vessel versus small subarachnoid\nhemorrhage as described. \n5. Additional chronic left frontal infarcts. \n6. Partial opacification of the left mastoid air cells is\nnonspecific and appears increased compared with outside CT head\nperformed earlier on same day, suggesting it is possibly due to\npatient's left-sided dural venous sinus thrombosis, however\nmastoiditis as a source of the dural sinus venous thrombosis\ncannot be excluded. \n\nTEE ___\nIMPRESSION: Small PFO by color flow corroborated by crossing of\nsaline contrast into the left atrium. Unable\nto quantify with confidence the volume of bubbles crossing due \nto\necho reverberations right above the\ninteratrial septum. There is no interartial septal aneurym\nhowever the interatrial septum appears dynamic.\nThe anatomy lends itself to interatrial septal occluder device\nplacement. No ___ thrombus or spontaneous\necho contrast\n\nScrotal US ___: \nIMPRESSION: \n \nNormal scrotal ultrasound. No testicular mass is identified. \n\nCTA Chest ___: IMPRESSION:\n \n1. Bilateral lobar and subsegmental pulmonary embolisms without\nsigns of right heart strain or pulmonary infarcts, most likely\nacute. Bilateral subsegmental atelectasis in both bases, \nwithout\nclear pulmonary infarcts.\n\nCT A/P with cont ___: IMPRESSION:\n\n1. Distended gallbladder with surrounding fat stranding and \nstone\nin the gallbladder neck consistent with acute cholecystitis.\n2. Nonocclusive thrombus in the distal right common iliac vein.\n3. Age indeterminate compression deformity of T12, although\nchronic appearing.\n4. No evidence of intra-abdominal intrapelvic malignancy.\n\nRUQ US ___: IMPRESSION:\n \n1. Cholelithiasis with findings concerning for acute\ncholecystitis, as seen on same day CT abdomen and pelvis.\n2. No biliary dilatation.\n\n \nBrief Hospital Course:\nBrief Hospital Course: \n___ is a ___ yo M with a past medical history of \nHepC, IVDU , currently incarcerated who presented with R arm \nweakness since ___. He was brought to the ER where acute \nimaging was obtained. A Non contrast head ct was obtained and \nshowed a hypodensity in L corona radiata some of the L \nprecentral gyrus, CTA showed concern for transverse sinus \nthrombosis. CTA also shows 8 mm L ICA aneurysm. His exam on \nadmission was notable for R arm weakness, decreased sensation to \npinprick. He was admitted to the stroke team for further \nmanagement and work up: \n\n#Acute R arm weakness secondary to venous sinus thrombosis: \n-The patient was admitted to the stroke service where MRI was \ncompleted. MRI showed: \na subacute L frontoparietal infarction likely due to\ncompression from cortical vein thrombosis. CTA and MRI showed L\ntransverse venous thrombosis and sagittal venous sinus\nthrombosis. No clear explanation for a venous sinus thrombosis.\n-The patient had an extensive hypercoaguable work up and was \ninitiated on a heparin drip (gtt, no bolus, stroke protocol goal \nPTT 50-70). \n-Hematology/oncology was also consulted\n-The patient was treated with heparin gtt. Bridging to Coumadin. \nHis INR on discharge was 1.9\n\n#Fever: \n- Patient febrile to ___ F on ___. \n- Blood cultures and urine culture negative. TEE was complete \nand negative for any source of vegetation. \n-CT abdomen showed possible evidence of acute cholecystitis \n- Treated empirically with ceftriaxone, flagyl, vancomycin for 7 \nday course to complete after last doses on ___. \n- no further fevers or symptoms\n\n#Pulmonary embolism - bilateral PEs seen on CTA. No R heart \nstrain on TTE. \n- treated with heparin gtt bridged to Coumadin, will need \nCoumadin indefinitely and to be discussed with hematology \noncology\n\n#Hypercoagulable state - still uncertain etiology\n- CT Torso did not show obvious mass concerning for malignancy\n- Beta-2 glycoprotein negative. Anti-cardiolipin pending. \n\n#Acute cholecystitis seen on CT abdomen : \n-CT obtained when patient was febrile. Acute cholecystitis on CT \nabd and abd US - patient afebrile and\nnot symptomatic. General surgery was consulted, however given \nthat the patient was asymptomatic, they did not think the \ncholecsytitis was acute nor did it need intervention. Patient \ntolerating PO diet well without symptoms \n\nChronic issues: \n#Multi-substance abuse\n- patient with history of active IVDU with heroin. Also uses \ncocaine, fentanyl, marijuana, Xanax illegally\n- No withdrawal symptoms seen except for frequent night sweats. \n-was written for Ativan prn 0.5mg Q8hours for anxiety. \nTransitional Issues: \n[] check INR daily to adjust Coumadin dose, please overlap \nheparin and Coumadin for 48 hours once Coumadin is therapeutic. \nWill need Coumadin indefinitely. INR goal 2.0-3.0. \n[] complete IV antibiotics; last day ___\n[] Follow up with hematology, appointment to be scheduled by \ncalling ___.\n[] Follow up anti-cardiolipin ab (still pending)\n[] Follow up with neurology (scheduled ___ at 8 AM) \n[] ___ need resources for substance abuse vs possible rehab \nreferral\n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack \n1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed () No. If no, reason why: \n2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not \n(I.e. bleeding risk, hemorrhage, etc.) \n3. Antithrombotic therapy administered by end of hospital day 2? \n() Yes - (x) No. If not, why not? Therapeutic \nanticoagulated.(I.e. bleeding risk, hemorrhage, etc.)\n4. LDL documented? (x) Yes (LDL = 122) - () No \n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL \n>70, reason not given: Stroke caused by compression from venous \nthrombosis\n [ ] Statin medication allergy \n [ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n [ ] LDL-c less than 70 mg/dL \n6. Smoking cessation counseling given? (x) Yes - () No [reason \n() non-smoker - () unable to participate] \n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given (verbally or \nwritten)? (x) Yes - () No \n8. Assessment for rehabilitation or rehab services considered? \n() Yes - () No. If no, why not? (I.e. patient at baseline \nfunctional status)\n9. Discharged on statin therapy? () Yes - (x) No [if LDL >70, \nreason not given: Stroke caused by compression from venous \nthrombosis \n [ ] Statin medication allergy \n [ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n [ ] LDL-c less than 70 mg/dL \n10. Discharged on antithrombotic therapy? (x) Yes [Type: () \nAntiplatelet - (x) Anticoagulation] - () No \n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - If no, why not (I.e. \nbleeding risk, etc.) (x) N/A \n \nMedications on Admission:\nNone\nHe states that he was taking Xanax 1mg TID which he obtained \nfrom\nillicit sources for anxiety. He states he last took this prior \nto\nbeing arrested, around ___\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN pain or temp > ___ \n2. CefTRIAXone 2 gm IV Q24H \n3. Docusate Sodium 100 mg PO BID \n4. Heparin IV per Weight-Based Dosing Protocol\nIndication: Anticoagulation in Patient with Acute Stroke\nContinue existing infusion at 850 units/hr\nTherapeutic/Target PTT Range: 50 - 70.9 seconds\nStart: Today - ___, First Dose: 1300 hrs \nStop Instructions: When Coumadin is consistently therapuetic \nbetween ___ for 3 days \n5. LORazepam 0.5 mg PO Q8H:PRN Anxiety \n6. MetroNIDAZOLE 500 mg PO TID \nContinue until ___ \n7. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate \n8. Vancomycin 1500 mg IV Q 8H \nContinue until ___ \n9. Warfarin 5 mg PO DAILY16 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nVenous sinus thrombosis \nDVT\nPulmonary Embolism \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to the hospital because you had paralysis of \nyour right arm along with right arm numbness. You were found to \nhave multiple blood clots in the vein around your brain. These \nalso caused compression and caused a small stroke with a small \namount of bleeding around it. \n\nMore scans showed you also have blood clots in both your lungs \nand a vein in your abdomen. You were started on blood thinners \nto prevent further clots from forming. We are not sure why you \nseem predisposed to developing clots right now. \n\nPlease follow up with neurology. An appointment has been made \nfor you on ___ at 8:00 AM. \nPlease follow up with hematology within ___ weeks of discharge, \nplease call ___ to schedule if you do not hear from \nthem this week. \nPlease follow up with your primary care physician ___ ___ \nweeks of discharge. \n\n \nFollowup Instructions:\n___\n" ]

[ "I636", "I608", "I2699", "I82421", "Q211", "K8000", "D6859", "G8101", "R29704", "F1410", "F1210", "F1910", "F1110", "R61", "B1920", "F17210", "F1010", "Z818", "Z814", "Z7901", "R509" ]

[ "I636: Cerebral infarction due to cerebral venous thrombosis, nonpyogenic", "I608: Other nontraumatic subarachnoid hemorrhage", "I2699: Other pulmonary embolism without acute cor pulmonale", "I82421: Acute embolism and thrombosis of right iliac vein", "Q211: Atrial septal defect", "K8000: Calculus of gallbladder with acute cholecystitis without obstruction", "D6859: Other primary thrombophilia", "G8101: Flaccid hemiplegia affecting right dominant side", "R29704: NIHSS score 4", "F1410: Cocaine abuse, uncomplicated", "F1210: Cannabis abuse, uncomplicated", "F1910: Other psychoactive substance abuse, uncomplicated", "F1110: Opioid abuse, uncomplicated", "R61: Generalized hyperhidrosis", "B1920: Unspecified viral hepatitis C without hepatic coma", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1010: Alcohol abuse, uncomplicated", "Z818: Family history of other mental and behavioral disorders", "Z814: Family history of other substance abuse and dependence", "Z7901: Long term (current) use of anticoagulants", "R509: Fever, unspecified" ]

[ "F17210", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nWeakness, malaise, cough, congestion, diarrhea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ gentleman with a PMH significant for \nmultiple myeloma s/p autologous transplant in ___ who presents \nwith weakness, malaise, cough, congestion, and diarrhea.\n\nThe patient was feeling well up until last ___. On \n___, he started feeling unwell with weakness, myalgias, and \nthroughout his body, especially in his shoulders. He then \nprogressed to have cough, congestion, and rhinorrhea. On ___ \n(___), he started having diarrhea, which improved the day of \npresentation. He has had no sick contacts. The day prior to \npresentation, he felt so weak that he fell while in the bathroom \nwith unsteadiness on his feet. He had no loss of consciousness \nor head strike.\n\nIn the ED, initial VS were: T 98.1 HR 94 BP 107/50 RR 22 SAT \n100% on RA.\nLabs were notable for: K 2.6 that trended to 3.1 then 2.9. \nLactate 1.4. WBC 6.7, H/H 12.6/35.4, PLT 99. BUN/Cr ___. \nTBILI 1.8, DBILI 0.8.\nImaging included: chest x-ray.\n\nTreatments received: cefepime 2 gm IV x1, 500 mL NS, 1L NS with \n40 mEq KCl, KCl 40 mEq PO x1, Mg 2 gm IV x1, oxycodone 5 mg PO \nx1, and home medications of venlafaxine, acyclovir, allopurinol, \naspirin, clonazepam, gabapentin, omeprazole, and sertraline 100 \nmg.\n\nOn arrival to the floor, the patient reports feeling unwell but \nslightly improved. He has had no more diarrhea since reaching \nthe ED. He still has whole body weakness. He reports no \nshortness of breath or chest pain. He has some mild abdominal \npain. He makes mention of a red, slightly painful lesion at his \nright lateral malleolus that has been there for 2 weeks. Of \nnote, he has been feeling more depressed recently with the \ndivorce, having to live with his mother, financial stresses, and \ncoping with his cancer. He denies any suicidal ideation or prior \nsuicide attempts. He does have access to a gun due to his work \nas a ___, and he keeps it locked.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n- ___: Diagnosed with stage III multiple myeloma, treated \nwith Velcade, Revlimid, and dexamethasone\n- ___: Autologous stem cell transplant\n- ___: Restarted on Revlimid and dexamethasone\n- ___: Completed protocol ___, including pomalidomide, \ndexamethasone, and Velcade\n- ___: Represented after being lost to follow up, restarted \non pomalidomide at 4 mg daily, but decreased dose due to \ncytopenia. Eventually had to complete 4 cycles of Velcade, \npomalidomide, and dexamethasone with good disease control. On \npomalidomide maintenance therapy (21 days on, 7 days off).\n\nPAST MEDICAL HISTORY: \n- Multiple myeloma\n- Anxiety/Depression\n- Gout\n- History of opioid abuse\n- History of benzodiazepine abuse\n \nSocial History:\n___\nFamily History:\nSon has a history of opioid dependence. Multiple family members \nwith depression and substance abuse.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: T 98.0 HR 86 BP 126/80 RR 20 SAT 96% O2 on RA\nGENERAL: Middle aged gentleman lying in bed, no acute distress \nbut appears lethargic and ill\nHEENT: PERRL, MMM, sclerae anicteric, no JVD\nCARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops\nLUNG: Appears in no respiratory distress, diffuse wheezing \nthroughout\nABD: Normal bowel sounds, soft, nontender, nondistended, no \nhepatomegaly, no splenomegaly\nEXT: Warm, well perfused, no lower extremity edema\nPULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses\nNEURO: Alert, oriented, CN II-XII intact, motor and sensory \nfunction grossly intact\nSKIN: Has a ~3x3 cm area of erythema on the right lateral \nmalleolus that is mildly painful\n\nDISCHARGE PHYSICAL EXAM\nVS: 98.2, 132/82 78 18 95% on RA 1200cc UOP\nGENERAL: Middle aged gentleman lying in bed, no acute distress\nHEENT: PERRLA, MMM, sclerae anicteric, no JVD\nCARDIAC: RRR, no murmurs, rubs, or gallops\nLUNG: faint bibasilar rhonchi, otherwise CTAB, normal work of \nbreathing on RA\nABD: Normal bowel sounds, soft, nontender, nondistended, no \nhepatomegaly, no splenomegaly\nEXT: Warm, well perfused, no lower extremity edema\nPULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses\nNEURO: Alert, oriented, CN II-XII intact, motor and sensory \nfunction grossly intact\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 08:22PM ___ PTT-26.9 ___\n___ 08:22PM PLT SMR-LOW PLT COUNT-99*\n___ 08:22PM NEUTS-66 BANDS-0 ___ MONOS-11 EOS-2 \nBASOS-1 ___ MYELOS-0 AbsNeut-4.42 AbsLymp-1.34 \nAbsMono-0.74 AbsEos-0.13 AbsBaso-0.07\n___ 08:22PM WBC-6.7# RBC-3.97* HGB-12.6* HCT-35.4* MCV-89 \nMCH-31.7 MCHC-35.6 RDW-13.2 RDWSD-43.2\n___ 08:22PM ALBUMIN-3.8 CALCIUM-8.5 PHOSPHATE-2.5* \nMAGNESIUM-1.7\n___ 08:22PM LIPASE-13\n___ 08:22PM ALT(SGPT)-18 AST(SGOT)-20 LD(LDH)-161 ALK \nPHOS-72 TOT BILI-1.8* DIR BILI-0.8* INDIR BIL-1.0\n___ 08:22PM estGFR-Using this\n___ 08:22PM GLUCOSE-112* UREA N-12 CREAT-1.0 SODIUM-136 \nPOTASSIUM-2.6* CHLORIDE-100 TOTAL CO2-22 ANION GAP-17\n___ 08:43PM LACTATE-1.4\n___ 09:40PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 11:47PM URINE RBC-3* WBC-0 BACTERIA-FEW YEAST-NONE \nEPI-<1\n___ 11:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 11:47PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 11:47PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 11:47PM URINE UHOLD-HOLD\n___ 11:47PM URINE HOURS-RANDOM\n___ 06:48AM CALCIUM-8.1* PHOSPHATE-2.5* MAGNESIUM-2.3\n___ 06:48AM GLUCOSE-93 UREA N-9 CREAT-0.9 SODIUM-141 \nPOTASSIUM-3.1* CHLORIDE-108 TOTAL CO2-24 ANION GAP-12\n___ 10:25AM CALCIUM-8.6 PHOSPHATE-1.5* MAGNESIUM-2.1\n___ 10:25AM GLUCOSE-152* UREA N-10 CREAT-0.9 SODIUM-140 \nPOTASSIUM-2.9* CHLORIDE-106 TOTAL CO2-25 ANION GAP-12\n___ 11:03AM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 06:45PM PHOSPHATE-2.7 MAGNESIUM-1.9\n___ 06:45PM SODIUM-136 POTASSIUM-3.4 CHLORIDE-104\n\nIMAGING STUDIES\n===============\n___ 10:09 ___ CHEST (PA AND LAT)\nFINDINGS:\nPA and lateral views of the chest provided. A retrocardiac \nopacity contains a small air bubble likely a small hiatal \nhernia. Lungs are clear. There is no focal consolidation, \neffusion, or pneumothorax. The cardiomediastinal silhouette is \nnormal. Imaged osseous structures are intact. No free air below \nthe right hemidiaphragm is seen.\nIMPRESSION: \nNo acute intrathoracic process. Small hiatal hernia. \n\n___ CT Chest\nFINDINGS: The thyroid is normal. Supraclavicular, axillary, \nmediastinal and hilar lymph nodes are not enlarged, though are \nmore prominent than on prior examination, measuring up to 1 cm \nin short axis, likely reactive, particularly in the peritracheal \nregion. Aorta and pulmonary arteries are normal size. Cardiac \nconfiguration is normal. Again seen are aortic valvular and \nannular calcifications as well as mitral annular calcifications. \n Coronary calcifications and/or stenting is noted. \n \nIn comparison to the prior examination, scattered ___ \nopacities are seen involving primarily the right middle and \nlower lobes. There is diffuse bronchial wall thickening with \nscattered secretions, particularly involving the bilateral lower \nlobes. No large focal consolidation is identified. \n \nLimited evaluation of the upper abdomen shows no significant \nabnormalities. The esophagus is patulous. \n \nBony changes are similar to the prior examination. \n \nIMPRESSION: \n1. Diffuse airways thickening with scattered secretions and \n___ \nopacities, primarily involving the right middle and lower lobes, \nare \nsuspicious for bronchopneumia or possibly aspiration in the \nappropriate \nclinical context. \n2. Otherwise stable examination since priors. \n\nDISCHARGE LABS\n==============\n___ 07:18AM BLOOD WBC-3.7*# RBC-3.71* Hgb-11.8* Hct-33.9* \nMCV-91 MCH-31.8 MCHC-34.8 RDW-12.5 RDWSD-41.1 Plt ___\n___ 07:18AM BLOOD Glucose-85 UreaN-6 Creat-1.0 Na-137 K-4.2 \nCl-103 HCO3-25 AnGap-13\n___ 07:18AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9\n\nMICROBIOLOGY\n============\n___ 8:22 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\nTime Taken Not Noted Log-In Date/Time: ___ 11:05 pm\n BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 11:47 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\n___ 6:20 am 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___ 7:42 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n Legionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n (Reference Range-Negative). \n 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 \nBrief Hospital Course:\nMr. ___ is a ___ year-old gentleman with a past medical history \nsignificant for multiple myeloma s/p autologous transplant in \n___ who presents with weakness, malaise, cough, congestion, and \ndiarrhea.\n\n# Bronchitis: patient presented with cough, congestion, diarrhea \nand myalgia initially attributed to a viral syndrome. \nRespiratory viral screen and culture negative x2. Legionella \nurinary antigen, urine culture, blood cultures x2 negative. He \nhad no further loose stools to send C. difficile PCR. No oxygen \nrequirement or hypoxia. Placed on nebulizers treatments but \ngiven persistence of wheezing and paroxysmal coughing, underwent \nCT chest which showed diffuse airways thickening with scattered \nsecretions and ___ opacities, primarily involving the \nright middle and lower lobes, suspicious for bronchopneumonia or \npossibly aspiration. Started on levofloxacin for a planned 5 day \ncourse with daily improvement in symptoms. Remained afebrile \nthroughout admission.\n\n# Electrolyte disturbances: noted hypokalemia 2.6 and \nhypophosphatemia 3.0 are likely consequences of diarrhea. \nImproved with aggressive IV and PO potassium and phosphate \nrepletion.\n\n# Fall: (prior to arrival) mechanical in nature with no prodrome \nand likely occurred in the setting of dehydration and acute \nillness. No further episodes following hydration and electrolyte \nrepletion. Physical therapy consulted and recommended continued \nwork with outpatient ___ on discharge.\n\n# Multiple Myeloma: on pomalidomide, which was held during acute \nillness. Chronic anemia and thrombocytopenia were at baseline, \nlikely secondary to his multiple myeloma. Continued prophylaxis \nwith Acyclovir 400 mg PO Q8H. He will follow-up with Dr. ___ \nas an outpatient.\n\n# Depression/Anxiety: Patient had been feeling more depressed \nrecently due to multiple stressors, including financial issues, \nrecent divorce, losing his house and having to live with his \nmother, and coping with cancer. Denied SI or recent substance \nabuse. Urine toxicology screen negative. Continued on home \nSertraline 200 mg PO DAILY, Doxepin HCl 150 mg PO QHS, and \nClonazePAM 0.5 mg PO TID. Social Work consulted for adjustment \nfor illness.\n\n# Gout: continued on home Allopurinol ___ daily\n\nTRANSITIONAL ISSUES\n[ ] f/u with PCP and primary oncologist\n[ ] Needed 1 more day of levofloxacin for 5 days total on \ndischarge (course ___ to ___\n[ ] Patient needed home ___ on discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sertraline 200 mg PO DAILY \n2. Doxepin HCl 150 mg PO QHS \n3. ClonazePAM 0.5 mg PO TID \n4. pomalidomide 3 mg oral DAILY \n5. Allopurinol ___ mg PO DAILY \n6. Acyclovir 400 mg PO Q8H \n7. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q8H \n2. Allopurinol ___ mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. ClonazePAM 0.5 mg PO TID \n5. Doxepin HCl 150 mg PO QHS \n6. Sertraline 200 mg PO DAILY \n7. Guaifenesin ___ mL PO Q6H:PRN cough \nRX *guaifenesin 100 mg/5 mL ___ mL by mouth every six (6) hours \nRefills:*1\n8. Acetaminophen 650 mg PO Q6H:PRN pain \n9. Levofloxacin 750 mg PO DAILY \nRX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBronchitis, bacterial vs. viral\nMultiple myeloma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ for evaluation and treatment of your \nmalaise, cough and diarrhea. We carefully monitored your \nhydration and electrolytes and gave you IV fluids and extra \npotassium and phosphorus to help you maintain your blood levels. \nWe ran several tests and believe your symptoms are most likely \nrelated to a viral syndrome. However, in the event that there \ncould a bacteria contributing to your symptoms, we treated you \nwith an antibiotics, levofloxacin, for 5 days.\n\nIt was a pleasure taking care of you during your stay; we wish \nyou all the best!\n\n- Your ___ Oncology Team\n \nFollowup Instructions:\n___\n" ]

[ "J208", "Z9484", "C9000", "D6959", "E8339", "R197", "E876", "D630", "M109", "Z87891", "E860", "F329" ]

[ "J208: Acute bronchitis due to other specified organisms", "Z9484: Stem cells transplant status", "C9000: Multiple myeloma not having achieved remission", "D6959: Other secondary thrombocytopenia", "E8339: Other disorders of phosphorus metabolism", "R197: Diarrhea, unspecified", "E876: Hypokalemia", "D630: Anemia in neoplastic disease", "M109: Gout, unspecified", "Z87891: Personal history of nicotine dependence", "E860: Dehydration", "F329: Major depressive disorder, single episode, unspecified" ]

[ "M109", "Z87891", "F329" ]

[]

[ " \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:\nRib/back pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo man with a history of substance abuse\ndisorder (opioids and benzodiazepines) and multiple myeloma (Dx\n___, s/p multiple lines of treatment as described below, s/p\nauto SCT ___, currently being treated with Daratumumab and\nDexamethasone, who is now presenting with pain crisis.\n\nThe patient was found to have a T7/T8 mass in ___, which is\ncompressing the neural foramen, but with no evidence of cord\ncompression. He is receiving T6-T9 radiation therapy for this (2\nmore sessions, last ___. He presented to clinic today with\nongoing pain that starts in L ribs and radiates posteriorly and\nsuperiorly to his left scapula. He describes this as a sharp,\nstabbing pain. It started ___, but became more severe when he\nstopped his dexamethasone yesterday (___). XR T-spine on ___\nshowed no new findings.\n\nIn clinic, he received IV decadron 10 mg, IV Zofran 8 mg, \nTylenol\n___ mg and Tramadol 25 mg po with some effect. Pain rated ___\nbefore medications ___ after. He was sent to MRI to evaluate \nfor\npossible pathologic fracture. \n\nPatient notes nausea and early satiety, which began around the\nsame time as his pain. He notes 10lbs weight loss over the past\nweek. He denies recent episodes of vomiting. He also notes\ndiaphoresis today, but denies subjective fevers or chills. He\ndenies bowel/bladder incontinence, weakness, numbness,\nparasthesias. \n\n \nPast Medical History:\n*S/P AUTOLOGOUS STEM CELL TRANSPLANT \nACUTE RENAL FAILURE \nAUTO HPC, APHERESIS INFUSION \nGOUT \nMULTIPLE MYELOMA \nSTEM CELL COLLECTION \nSTUDY ___ \nTHERAPUTIC PLASMAPHERESIS \nMULTIPLE MYELOMA \nDEPRESSION \nADVANCE CARE PLANNING \nBACK PAIN \n - Denies h/o head injuries or seizure\n \nSocial History:\n___\nFamily History:\npaternal grandmother was institutionalized. \n \nPhysical Exam:\nADMISSION:\n=========\nVitals: 24 HR Data (last updated ___ @ 1837)\n Temp: 98.3 (Tm 98.3), BP: 125/84, HR: 101, RR: 18, O2 sat:\n98%, O2 delivery: Ra, Wt: 169.1 lb/76.7 kg \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP not appreciable. Normal carotid upstroke without\nbruits.\nBACK: Tenderness to palpation ~T8. Full ROM without pain. \nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi. \n\nABD: NABS. Tenderness to palpation in LUQ underlying incisions.\nSoft, ND. \nEXT: WWP. No ___ edema. \nSKIN: Well healing incisions over LUQ of abdomen. No\nrashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. Strength LUE ___. RUE 4+/5, RLE ___, LLE ___.\nSensation intact to light touch. Reflexes 2+ and symmetric\nthroughout. Plantar reflex neutral bilaterally. \nLINES: PIV\n\nDISCHARGE:\n=========\nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP not appreciable. Normal carotid upstroke without \nbruits.\nBACK: No tenderness to palpation. Full ROM without pain. \nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No increased WOB. CTAB. No wheezes, crackles, or rhonchi. \n\nABD: NABS. Tenderness to palpation in LUQ underlying \nwell-healing incisions.\nSoft, ND. \nEXT: WWP. No ___ edema. \nSKIN: Well healing incisions over LUQ of abdomen. No\nrashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3. Strength LUE ___. RUE 4+/5, RLE ___, LLE ___.\nSensation intact to light touch. Reflexes 2+ and symmetric\nthroughout. Plantar reflex neutral bilaterally. \nLINES: PIV \n \nPertinent Results:\nADMISSION:\n=========\n___ 09:19AM BLOOD WBC-7.2 RBC-4.91 Hgb-16.1 Hct-45.7 MCV-93 \nMCH-32.8* MCHC-35.2 RDW-13.1 RDWSD-44.8 Plt Ct-80*\n___ 09:19AM BLOOD Neuts-83.6* Lymphs-8.4* Monos-6.8 \nEos-0.3* Baso-0.1 Im ___ AbsNeut-6.04 AbsLymp-0.61* \nAbsMono-0.49 AbsEos-0.02* AbsBaso-0.01\n___ 09:19AM BLOOD Plt Ct-80*\n___ 05:30AM BLOOD ___ PTT-27.0 ___\n___ 09:19AM BLOOD UreaN-19 Creat-1.2 Na-141 K-4.2 Cl-100 \nHCO3-28 AnGap-13\n___ 09:19AM BLOOD ALT-18 AST-12 LD(LDH)-125 AlkPhos-90 \nTotBili-0.6\n___ 09:19AM BLOOD TotProt-6.4 Calcium-9.2\n___ 05:30AM BLOOD Albumin-4.1 Calcium-9.0 Phos-3.4 Mg-2.0\n\nDISCHARGE:\n=========\n___ 05:30AM BLOOD WBC-5.1 RBC-4.16* Hgb-13.7 Hct-39.6* \nMCV-95 MCH-32.9* MCHC-34.6 RDW-12.9 RDWSD-44.7 Plt Ct-90*\n___ 05:30AM BLOOD Neuts-78.4* Lymphs-13.5* Monos-7.1 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-3.96 AbsLymp-0.68* \nAbsMono-0.36 AbsEos-0.00* AbsBaso-0.01\n___ 05:30AM BLOOD Plt Ct-90*\n___ 05:30AM BLOOD ___ PTT-27.0 ___\n___ 05:30AM BLOOD Glucose-122* UreaN-20 Creat-0.9 Na-139 \nK-4.7 Cl-100 HCO3-29 AnGap-10\n___ 05:30AM BLOOD ALT-26 AST-18 LD(LDH)-117 AlkPhos-84 \nTotBili-0.4\n \nBrief Hospital Course:\nMr. ___ is a ___ yo man with a history of substance abuse\ndisorder (opioids and benzodiazepines) and multiple myeloma (Dx\n___, s/p multiple lines of treatment as described below, s/p\nauto SCT ___, currently being treated with Daratumumab and\nDexamethasone), who is now presenting with acute pain crisis.\n\n#Pain Crisis \nThis pain is most likely related to his underlying T7/T8 lesion.\nHe has a history of acute worsening of his pain upon cessation \nof\nsteroids, with this most recent episode of pain worsening after\nhis dexamethasone was tapered. MRI (___) showed stable lesion at\nT2, T7, T8, and L1 (similar to ___, with known T7 lesion\nocludes left neural foramina, similar to before. No indication\nfor kyphoplasty or other procedures at this point. He was given \nDexamethasone 10mg for 2 days, with plan to taper for 4mg BID x4 \ndays, then 4mg daily x4 days, then 2mg daily x4 days, then 2mg \nevery other day x4 day. He was also give tramadol 50mg PO q4h \nPRN and scheduled Tylenol ___ q8h with good pain control. Was \nseen by chronic pain service who recommended increasing home \ngabapentin to 400mg TID. Ultimately, he was discharged home with \ngood pain control.\n\n#Nausea \nPatient's nausea suspected to be ___ to pain. KUB negative for \nobstruction or ileus. improved with pain control and Zofran.\n\n#Multiple Myeloma\nRelapsed, IgG Lambda previously treated on pomalidomide\nmaintenance. Switched to Daratumumab, Pomalyst and Dexamethasone\ndue to disease progression with good response. Pomalidomide\nstopped due to possible pulmonary fibrosis. ___ his PET scan\ncontinued to show improvement in his disease burden. He received \ndaratumumab + Dexamethasone Cycle #: 6 Day 1: ___. (Dose\nevery 4 weeks). His counts remained stable while in house. \n\n#Depression \n#Substance Use Disorder\nPatient recently discharged on risperidone, however, he is no \nlonger taking this. We attempted to obtain records from his \noutpatient psychiatrist, however were not able to while in \nhouse. Patient should follow-up as outpatient for further \nmanagement of psychiatric medication management. Pain management \nas above.\n\nTRANSITIONAL ISSUES\n[] Patient should taper dexamethasone for 4mg BID for 4 days, \nthen 4mg for 4 days, then 2mg daily for 4 days, then 2mg every \nother day for 4 days.\n[] Continue with gabapentin to 400 mg TID. Per chronic pain \nservice, you may increase the dose by 100 mg each dose every 3 \nto 7 days to a max of 800mg TID. If the patient reports \ndrowsiness or unsteady gait, please titrate down the dose by 100 \nmg each time. \n[] Patient was discharged on scheduled Tylenol q8h. Would stop \nthis after acute pain issues to avoid liver toxicity\n[] Patient was previously discharged from ___ on risperidone \nQHS and 0.5mg BID PRN anxiety, though has not been taking it at \nhome. Will follow up with psychiatrist ___ to discuss \nrestarting psych med regimen. \n\n# CODE: Presumed Full\n# EMERGENCY CONTACT: ___ (sister) ___ ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n4. Gabapentin 300 mg PO TID \n5. Aspirin 81 mg PO DAILY \n6. ClonazePAM 0.5 mg PO TID:PRN anxiety \n7. Qvar RediHaler (beclomethasone dipropionate) 40 mcg/actuation \ninhalation BID \n\n \nDischarge Medications:\n1. Dexamethasone 4 mg PO BID Duration: 4 Days \nthen 4mg daily x4 days, then 2mg daily x4 days, then 2mg EOD for \n4 days \nRX *dexamethasone 2 mg 2 tablet(s) by mouth twice daily Disp \n#*30 Tablet Refills:*0 \n2. Famotidine 20 mg PO Q12H gi ppx \nRX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n3. Lidocaine 5% Patch 1 PTCH TD DAILY pain \nRX *lidocaine [Lidoderm] 5 % Place 1 patch on back QAM Disp #*30 \nPatch Refills:*0 \n4. Gabapentin 400 mg PO TID back pain \nRX *gabapentin 400 mg 1 capsule(s) by mouth three times a day \nDisp #*90 Capsule Refills:*0 \n5. Acyclovir 400 mg PO Q12H \n6. Allopurinol ___ mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. ClonazePAM 0.5 mg PO TID:PRN anxiety \n9. Qvar RediHaler (beclomethasone dipropionate) 40 \nmcg/actuation inhalation BID \n10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY\n----------\nPain Crisis\n\nSECONDARY\n----------\nMultiple Myeloma\nNarcotic use disorder, stable\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___!\n\nYou were here because you were having significant back pain.\n\nWhile you were here, you were seen by the pain service who \nrecommended to increase your gabapentin for pain. You also \nunderwent your scheduled radiation therapy. We started you on \nsteroids to help with your pain.\n\nWhen you leave, it is important to take your medications as \nprescribed. It is also important you follow-up at the \nappointments as listed below. If you have any fevers, chills, \narm or leg numbness or tingling, bowel or bladder dysfunction, \nor significant worsening of your back pain, come back to the ER \nimmediately.\n\nWe wish you the best of luck!\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "C9002", "Z9484", "R110", "F329", "M109", "J45909", "M5414" ]

[ "C9002: Multiple myeloma in relapse", "Z9484: Stem cells transplant status", "R110: Nausea", "F329: Major depressive disorder, single episode, unspecified", "M109: Gout, unspecified", "J45909: Unspecified asthma, uncomplicated", "M5414: Radiculopathy, thoracic region" ]

[ "F329", "M109", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nnausea, vomiting, diarrhea\n \nMajor Surgical or Invasive Procedure:\nIntubated ___\nExtubated ___\n___ LP ___\nLP ___\nBone marrow biopsy ___\n\n \nHistory of Present Illness:\n___ with h/o multiple myeloma c/b recent spinal lesions s/p\nradiation with recent initiation of clinical trial drug regimen\non ___ (___; ___ and history of opiate withdrawal\nwith recent decrease in outpatient pain medication regimen who\npresented to the ED on ___ with c/o nausea, vomiting and\ndiarrhea. Shortly after receiving clinical trial medications,\npatient developed profuse non-bloody, non-bilious vomiting and\nnon-bloody diarrhea. Patient called EMS given concern for\nsymptoms; when EMS arrived they had difficulty obtaining an \nSpO2,\nwith the highest recorded level in the ___ with poor waveform. \nEn\nroute to the emergency department, patient developed a sharp,\nperiumbilical abdominal pain. He otherwise noted subjective\nchills and dysuria, but denied any fever, chest pain, SOB,\nmelena, or BRBPR.\n\nIn the ED, \n\n- Initial Vitals: T 98.0 HR 108 BP 96/53 RR 18 SpO2 76% 4L NC \n \n- Exam:\nMottled skin, appears chronically ill\nRRR, no murmur, no JVD\nDecreased breath sounds in LLL, no wheezing or crackles\nAbdomen soft, no focal tenderness, no rebound or guarding\nSkin warm and dry\n\n- Labs:\nWBC 6.4\nHg 13.3\nPlt 67\nD-dimer 1718\nFibrinogen 546\nINR 1.4\n\nLDH 656\nUric Acid 10.0\nK 3.1\n\nCr 1.5 (baseline 0.9)\nHCO3 21\nAG 20\n\nVBG @ ___: 7.42 | 42 Lactate 4.0\nVBG @ 0000: 7.58 | 26 Lactate 1.4\n\nTrop < 0.01\n\nAST 50 \nALT 79 \nALP 100 \nTbili 1.5\n\n- Imaging:\n\nCTA CHEST: \n1. No evidence of pulmonary embolism.\n2. Fluid throughout all visualized bowel loops with diffuse \nbowel\nwall\nhyperemia, likely reflecting diffuse enteritis, likely \ninfectious\nor\ninflammatory. No bowel wall thickening.\n3. New ground-glass opacities within the lower lobes \nbilaterally,\ncompatible with infection.\n4. Mild bladder wall thickening anteriorly, which should be\ncorrelated with urinalysis for evidence of cystitis.\n5. Known osseous myeloma lesions are better visualized on prior\nexaminations. Soft tissue within the spinal canal at the level \nof\nL3 is re-demonstrated, but better evaluated on the MR ___\ndated ___.\n6. Large hiatal hernia.\n\n___ IMAGING PRELIM READS:****\n\nCT ___ WITHOUT CONTRAST:\nNo acute intracranial abnormality.\n\nCTA ___:\nThe vessels of the circle of ___ and their principal\nintracranial branches appear normal without stenosis, occlusion,\nor aneurysm formation. The dural venous sinuses are patent.\n\nCTA NECK:\nThere are atherosclerotic calcifications of the bilateral \ncarotid\nbifurcations, without evidence of internal carotid stenosis by\nNASCET\ncriteria. The vertebral arteries and their major branches appear\nnormal with no evidence of stenosis or occlusion.\n\nPERFUSION: No evidence of abnormal perfusion.\n\n- Consults:\nCode Stroke: low suspicion for stroke given no evidence large\nterritory infarct/bleed on CT and non-localizing exam.\nRecommended - MRI Brain w/ and ___ contrast, LP for CSF gram\nstain/culture, cell count, protein, glucose, HSV PCR,\nCryptococcus antigen, flow cytometry, cytology and CSF\nHold.Recommend empiric treatment with meningitic dosing of\nvanc/CTX and acyclovir. Neurology Consult service will follow\nalong.\n\n- Interventions:\n___ 22:05 IVF LR ( 1000 mL ordered) \n___ 23:49 IV CefePIME 2 g\n___ 00:33 IVF LR ( 1000 mL ordered) \n___ 00:33 IV Vancomycin (1500 mg ordered)\n\nCentral venous line placed in ED.\nLP deferred iso thrombocytopenia and agitation. \n\nIn the unit, patient was agitated and attempting to remove\nclothing, screaming at staff for help. He was unable to\ncommunicate when asked ROS questions and did not fully\nparticipate in examination. Received 5 mg IV Haldol, placed on\nCIWA, reinitiated on opiates to minimize risk of withdrawal,\ninitiated on IVF, administered morphine IV x2 in s/o likely\nwithdrawal and ordered for stat TLS labs.\n\n \nPast Medical History:\nMultiple myeloma s/p autologous stem cell transplant, radiation\nOrthostatic hypotension\nOpiate withdrawal w/ substance use disorder\nDepression\nGout\n\n \nSocial History:\n___\nFamily History:\npaternal grandmother was institutionalized. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: T 99.7 HR 63 BP 134/53 RR 23 SPO2 100%\nGEN: ___ yo M, sitting up in bed, repeatedly screaming out \"god\nhelp please\" and trying to get out of bed.\nEYES: Pupils equal round reactive and dilated at 5 mm\nHENNT: Poor dentition\nCV: RRR no M/R/G\nRESP: No increased work of breathing. Decreased basilar breath\nsounds. No crackles, rhonchi.\nGI: Non-distended. Voluntary guarding. Soft with patient unable\nto communicate if pain to palpation.\nMSK: No peripheral edema.\nSKIN: Petechiae over bilateral legs.\nNEURO: Unable to follow commands. AAOx0\nPSYCH: Agitated.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals:24 HR Data (last updated ___ @ 651)\n Temp: 98.0 (Tm 98.3), BP: 130/80 (102-177/67-102), HR: 104\n(79-113), RR: 18, O2 sat: 97% (96-99), O2 delivery: Ra, Wt: \n137.2\nlb/62.23 kg \nGen: sitting up in bed, alert and interactive, in no acute \ndistress\nCV: regular rhythm, tachycardic, no m/g/r\nLUNGS: CTAB, breathing comfortably on room air\nABD: soft, nontender, nondistended\nEXT: warm and well-perfused, no ___ edema. \nNEURO: alert, grossly oriented, ___ strength on ankle \ndorsiflexion and plantarflexion bilaterally\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 09:31PM BLOOD WBC-6.4 RBC-4.23* Hgb-13.3* Hct-38.6* \nMCV-91 MCH-31.4 MCHC-34.5 RDW-13.2 RDWSD-41.1 Plt Ct-67*\n___ 09:31PM BLOOD Neuts-81.9* Lymphs-10.9* Monos-4.1* \nEos-0.2* Baso-0.2 Im ___ AbsNeut-5.25 AbsLymp-0.70* \nAbsMono-0.26 AbsEos-0.01* AbsBaso-0.01\n___ 09:31PM BLOOD ___ PTT-29.0 ___\n___ 09:31PM BLOOD ___ D-Dimer-1718*\n___ 09:31PM BLOOD Glucose-114* UreaN-19 Creat-1.5* Na-142 \nK-3.1* Cl-101 HCO3-21* AnGap-20*\n___ 09:31PM BLOOD Albumin-4.2 Calcium-9.7 Phos-2.4* Mg-1.9 \nUricAcd-10.0*\n___ 09:31PM BLOOD ALT-50* AST-79* LD(LDH)-656* AlkPhos-100 \nTotBili-1.5\n___ 09:31PM BLOOD Lipase-22\n___ 09:31PM BLOOD cTropnT-<0.01\n___ 09:31PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG\n___ 09:42PM BLOOD ___ pO2-19* pCO2-42 pH-7.42 \ncalTCO2-28 Base XS-1\n___ 09:42PM BLOOD Lactate-4.0* Na-140 K-3.1*\n\nPERTINENT LABS/MICRO/IMAGING:\n=============================\n___ 11:19AM BLOOD Osmolal-272*\n___ 06:43AM URINE Osmolal-522\n___ 06:43AM URINE Hours-RANDOM Na-127\n\n___ 06:14AM BLOOD Osmolal-269*\n___ 03:16PM URINE Osmolal-415\n___ 03:16PM URINE Hours-RANDOM Na-146\n\n___ 12:00PM BLOOD TSH-3.8\n___ 06:35AM BLOOD Cortsol-17.4\n___ 07:07AM BLOOD Cortsol-25.5*\n___ 07:44AM BLOOD Cortsol-29.5*\n\n___ 06:35 \nACTH - FROZEN \n Test Result Reference \nRange/Units\nACTH, PLASMA 21 ___ pg/mL\n\n___ 12:40PM BLOOD CK-MB-3 cTropnT-<0.01\n___ 02:49AM BLOOD cTropnT-0.02*\n___ 01:57AM BLOOD cTropnT-<0.01\n\n___ 12:00AM BLOOD PEP-NO MONOCLO FreeKap-1.0* FreeLam-0.9* \nFr K/L-1.1 IgG-394* IgA-18* IgM-22* IFE-NO MONOCLO\n\n___ 00:00 VitB12 155* Folate 4\n\n___ 12:07 Osmolal 281\n\nMICRO:\n--------\n___ 10:20 am URINE Source: Catheter. \n URINE CULTURE (Final ___: NO GROWTH. \n\n___ 2:41 am BLOOD CULTURE Source: Venipuncture. \n Blood Culture, Routine (Final ___: NO \nGROWTH. \n\n___ 2:42 am BLOOD CULTURE Source: Venipuncture. \n Blood Culture, Routine (Final ___: \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. \n Isolated from only one set in the previous five days. \n SENSITIVITIES PERFORMED ON REQUEST.. \n\n Aerobic Bottle Gram Stain (Final ___: \n Reported to and read back by ___. ___ ON ___ AT \n0115. \n GRAM POSITIVE COCCI IN CLUSTERS. \n\n___ 9:29 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. CDT ADDED ON ___ AT 0035. \n FECAL CULTURE (Final ___: \n NO ENTERIC GRAM NEGATIVE RODS FOUND. \n NO SALMONELLA OR SHIGELLA FOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n\n Cryptosporidium/Giardia (DFA) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n\n C. difficile PCR (Final ___: \n NEGATIVE. \n (Reference Range-Negative). \n\n___ 12:45 pm BLOOD CULTURE\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 11:20 pm BLOOD CULTURE Source: Line-cvl. \n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 2:22 pm URINE Source: ___. \n URINE CULTURE (Final ___: NO GROWTH. \n\n___ 4:02 pm CATHETER TIP-IV Source: central line. \n WOUND CULTURE (Final ___: No significant growth. \n\n___ 12:34 am BLOOD CULTURE Source: Line-right IJ. \n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 12:34 am BLOOD CULTURE Source: Venipuncture. \n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 9:31 am URINE Source: Catheter. \n URINE CULTURE (Final ___: NO GROWTH. \n\n___ 05:14PM CEREBROSPINAL FLUID (CSF) TNC-99* ___ \nPolys-73 ___ ___ 05:14PM CEREBROSPINAL FLUID (CSF) TotProt-___* \nGlucose-78\n\n___ 5:14 pm CSF;SPINAL FLUID SOURCE: LP. \n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n___ 04:20PM CEREBROSPINAL FLUID (CSF) TNC-11* ___ \nPolys-9 ___ ___ 04:20PM CEREBROSPINAL FLUID (CSF) TotProt-255* \nGlucose-108\n\n___ 4:18 pm CSF;SPINAL FLUID Source: LP TUBE #3. \n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\nIMAGING:\n---------\nCXR ___:\nNo acute cardiopulmonary abnormality. Moderate-sized hiatal \nhernia.\n\nCTA ___ AND NECK ___:\n1. No acute intracranial abnormality by unenhanced ___ CT. No \nhemorrhage. \n2. No large vessel occlusion. Minimal narrowing, left cavernous \nICA. \nOtherwise, unremarkable circle of ___. \n3. 55 mL volume of elevated MTT, primarily left temporal lobe. \nNo evidence of \nabnormal cerebral blood flow or cerebral blood volume. No \nevidence of infarct \ncore. \n4. Calcified atherosclerotic plaque causes 18% proximal right \nICA luminal \nnarrowing by NASCET criteria. Mild narrowing, bilateral ECA \norigins. \nOtherwise, widely patent cervical vertebral and carotid \narteries. No left ICA \nnarrowing. \n5. Lytic lesions in the right clavicle and humerus, unchanged in \nsize, \npreviously FDG avid on PET-CT from ___, better \nevaluated on that \nstudy. \n6. Ground-glass opacity in the superior segment, left lower \nlobe, better \nevaluated on same-day CTA chest. \n\nCTA CHEST AND CT ABDOMEN ___:\n1. No evidence of pulmonary embolism. \n2. Fluid throughout all visualized bowel loops with diffuse \nbowel wall \nhyperemia, likely reflecting diffuse enteritis, likely \ninfectious or \ninflammatory. No bowel wall thickening. \n3. New ground-glass opacities within the lower lobes \nbilaterally, compatible \nwith infection. \n4. Mild bladder wall thickening anteriorly, which should be \ncorrelated with \nurinalysis for evidence of cystitis. \n5. Known osseous myeloma lesions are better visualized on prior \nexaminations. \nSoft tissue within the spinal canal at the level of L3 is \nre-demonstrated, but \nbetter evaluated on the MR ___ dated ___. \n___. Large hiatal hernia. \n\nEEG ___:\nThis continuous ICU monitoring study was abnormal due to 1) \nattenuation and continuous focal slowing in the left hemisphere, \nindicative of \nfocal cerebral dysfunction. 2) Generalized background slowing \nsuggestive of a \nmild encephalopathy, non-specific in etiology, however toxic \nmetabolic \ndisturbances, infection, or medication effect are possible \ncauses. There were \nno push button events. There were no electrographic seizures or \nepileptiform \ndischarges. \n\nCT ___ WITHOUT CONTRAST ___:\n1. No acute intracranial abnormality. \n2. Bilateral periventricular and subcortical hypodensities that \nare most \nlikely related to chronic small vessel ischemia. \n\nMR ___ WITHOUT CONTRAST ___:\n1. No acute intracranial abnormality. \n2. Chronic findings include global parenchymal volume loss and \nmild changes of \nchronic white matter microangiopathy. \n\nEEG ___:\nThis continuous ICU monitoring study was abnormal due to: Near \ncontinuous focal slowing in the left temporal and parasagittal \nregions \nsuggestive of focal cerebral dysfunction. There were no push \nbutton events. \nThere were no electrographic seizures or epileptiform \ndischarges. Compared to \nthe previous day there was no significant change. \n\nCHEST X RAY ___:\nProbable mild bronchitis lung bases again noted. Hazy opacity \nleft lung base appears slightly improved. \n\nCXR ___:\nNo evidence of pneumonia or pleural effusion.\n\nTTE ___:\nThe left atrial volume index is mildly increased. The inferior \nvena cava diateter is normal. There is\nnormal left ventricular wall thickness with a normal cavity \nsize. There is normal regional and global left\nventricular systolic function. Quantitative biplane left \nventricular ejection fraction is 57 %. There is\nno resting left ventricular outflow tract gradient. Tissue \nDoppler suggests an increased left ventricular\nfilling pressure (PCWP greater than 18mmHg). Normal right \nventricular cavity size with normal free\nwall motion. The aortic sinus diameter is normal for gender with \nnormal ascending aorta diameter for\ngender. The aortic arch is mildly dilated. The aortic valve \nleaflets (?#) are mildly thickened. There is\nmild aortic valve stenosis (valve area 1.5-1.9 cm2). There is no \naortic regurgitation. The mitral valve\nleaflets are mildly thickened with no mitral valve prolapse. \nThere is moderate mitral annular\ncalcification. There is trivial mitral regurgitation. The \ntricuspid valve leaflets appear structurally normal.\nThere is physiologic tricuspid regurgitation. The estimated \npulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\nIMPRESSION: Normal biventricular function. Mildly thickened \naortic valve leaflets with mild\nAS. Mildly thickened mitral valve leaflets with moderate MAC. \nTrivial MR.\n\n___ ___:\n1. No acute intracranial abnormality. Please note MRI of the \nbrain is more \nsensitive for the detection of acute infarct. \n2. Atrophy, probable small vessel ischemic changes, and \natherosclerotic \nvascular disease as described. \n\nEEG ___:\nThis is an abnormal ICU EEG study because of diffuse slowing of \nbackground with periods of diffuse voltage attenuation \nindicative of moderate- \nsevere encephalopathy, which is nonspecific as to etiology. \nFrontal rhythmic \ndelta activity is a nonspecific finding that can be seen with \ndiffuse \nencephalopathies as well as structural disorders involving deep \nmidline \nstructure or increased intracranial pressure. There are no \nepileptiform \ndischarges or electrographic changes. \n\nCTA ___ ___:\n1. No evidence of mass, hemorrhage or infarction. \n2. The major arteries the ___ and neck are patent. \n3. Partially imaged left lower lobe collapse. Difficult to \nexclude pneumonia \nin the appropriate clinical setting. Please see report for \nsubsequent chest \nradiograph dated ___. \n\nEEG ___:\nThis is an abnormal ICU EEG study because of diffuse slowing of \nthe background indicative of mild-moderate encephalopathy, which \nis \nnonspecific as to etiology. Frontal rhythmic delta activity is a \nnonspecific \nfinding that can be seen with diffuse encephalopathies as well \nas structural \ndisorders involving deep midline structure or increased \nintracranial pressure. \nThere are no epileptiform discharges or electrographic changes. \nCompared to \nthe prior day's recording, there is improvement in background. \n\nMR ___ contrast ___:\nNo acute infarction or evidence of other acute intracranial \nabnormalities.\n\nEEG ___:\nThis is an abnormal ICU EEG study because of diffuse slowing of \nbackground indicative of mild-moderate encephalopathy, which is \nnonspecific as \nto etiology. Frontal rhythmic delta activity is a nonspecific \nfinding that can \nbe seen with diffuse encephalopathies as well as structural \ndisorders \ninvolving deep midline structure or increased intracranial \npressure. There are \nno epileptiform discharges or electrographic changes. Compared \nto the prior \nday's recording, there is no significant change. \n\nMR ___/ and ___ contrast ___:\n1. Multiple T2 hyperintense, T1 hypointense enhancing lesions \nthroughout the \nthoracic and lumbar ___ are consistent with clinical history \nof multiple \nmyeloma. Dominant lesion in the L3 vertebral body has slightly \ndecreased in \nsize compared to prior exam with resolution of the soft tissue \ncomponent. \n2. Subtle enhancement of the cauda equina nerve roots on the \nleft at the level \nof L2 are new compared to prior exam concerning for \nleptomeningeal metastatic \ninfiltration. \n3. Multilevel degenerative disc disease in the cervical ___, \nmost pronounced \nat C4-C5 with moderate spinal canal narrowing. \n4. Multilevel degenerative disc disease in the lumbar ___, \nmost pronounced \nat L3-L4 with moderate spinal canal narrowing and moderate right \nspinal canal \nnarrowing. \n5. Small bilateral pleural effusions with consolidations in the \ndependent \nportions of the lungs are consistent with worsening \npleural-parenchymal \ndisease. \n\nCXR ___:\nComparison to ___. Resolution of a pre-existing \nleft pleural \neffusion. Stable normal size of the cardiac silhouette. No \npulmonary edema, \nno pneumonia, no pleural effusions. Stable correct position of \na right \ninternal jugular vein catheter. A previous left lower lobe \nconsolidation is \nstill visualized. The consolidation shows air inclusion and \ncould correspond \nto the hiatal hernia, documented on the CT examination from ___. \nNo pleural effusions. No pulmonary edema. \n\nMRI ___ w/ and ___ contrast ___:\n1. Multiple T2 hyperintense, T1 hypointense enhancing lesions \nthroughout the\nlumbar ___ are consistent with clinical history of multiple \nmyeloma, similar\ncompared to prior exam.\n2. Increasing subtle enhancement of the cauda equina nerve roots \nare\nconcerning for worsening leptomeningeal metastatic infiltration.\n3. Moderate to severe spinal canal narrowing at L3-L4 appears \nminimally\nprogressed.\n\nDISCHARGE LABS:\n===============\n___ CBC: 2.4>10.3/30.4<93 ANC 1.26\n___ Coags: ___ 11.0, PTT 31.2, INR 1.0\n___ BMP: 136/3.9 | ___ | ___ < 109 Ca 9.0, Phos 4.1, \nMg 2.0\n___ LFTs: ALT 15, AST 10, AlkP 82, tBili 0.6\n\n \nBrief Hospital Course:\nPATIENT SUMMARY:\n================\n___ with history of multiple myeloma c/b recent spinal lesions \ns/p radiation with recent initiation of Ninlaro ___ (held on \nadmission), also with history of opiate/benzo use and \nwithdrawal, who presented to the ED on ___ with c/o nausea, \nvomiting, diarrhea, AMS with aphasia in the setting of taking an \nextra dose of Ninlaro. Stroke workup and EEG negative, treated \nempirically for meningoencephalitis and mental status back to \nbaseline within 24 hours (though also in setting of holding \nsedating meds). Course c/b persistent thrombocytopenia \nrefractory to transfusion, persistent pain requiring narcotics, \northostatic hypotension on midodrine, and hyponatremia. Patient \nhad unresponsive/hypoxic/hypotensive episode on ___ required \nintubation and transfer to the ICU, with ICU course c/b \nintermittent hypotensive/unresponsive episodes, Afib with RVR, \nand agitation. Stabilized and transferred back to the floor with \nongoing severe orthostasis and pain, now under better control. \nAlso found to have possible leptomeningeal involvement on MRI \n___ discharged on dexamethasone.\n\nACUTE ISSUES:\n=============\n#AMS:\n#Aphasia:\nPer daughter, patient had been intermittently confused since \n___. Patient then developed acute change in mental status in \nED, with inability to follow commands and word finding \ndifficulties/word salad. Given concern for stroke, code stroke \ncalled. NIHSS 4. No evidence of hemorrhage or large territory \ninfarct on ___. No new abnormalities noted on MRI, and CTA \n___ without significant stenosis. Neuro with low suspicion \nfor stroke as exam did not localize to a particular vascular \nterritory. EEG showed no epileptiform activity. He was started \non empiric treatment for meningoencephalitis with \nvanc/ceftriaxone/acyclovir/ampicillin while awaiting LP. \nUnfortunately LP could not initially be done due to \nthrombocytopenia that did not improve with transfusions. \nAntibiotics were discontinued on ___ after about 5 days of \ntreatment given low suspicion for infection. Unclear what caused \nthe acute change in mental status/word finding difficulties. \nPotentially related to the Ninlaro, as patient reports taking \ntwo pills instead of one, however nothing like this has been \nreported in the literature. He was monitored off antibiotics. LP \nwas able to be done later in hospital course, which was negative \nfor infection. He did have further episodes of \nAMS/unresponsiveness during hospitalization (see below) which \nsubsequently improved.\n\n# Unresponsive episodes:\n# Hypotension:\n# Fever:\nStarting on ___, patient had numerous unresponsive episodes. \nDuring these, he did not respond to voice or sternal rub, SBP \nwas low in 60-80s and HRs were high normal. Basic labs were \nchecked and no clear etiology was found. There was no evidence \nof infection. Differential diagnosis included primary neurologic \nprocess such as autonomic dysreflexia secondary to spinal \nradiation vs. multiple myeloma meningeal involvement vs. \nmetastasis to the ___. These episodes were felt to be less \nlikely due to drug overdose as narcan did not help, though could \nhave still been benzo OD given he was found to have pill bottle \nin his room earlier in his course. During the first episode, the \npatient was intubated due to agonal breathing and transferred to \nthe ICU. He was then extubated and continued to have \nunresponsive episodes. EEG showed no seizures. MRI showed no \nacute infarcts or evidence of prior. Infectious workup was \nunremarkable. LP done by ___ on ___ was traumatic but \nunrevealing. He was then transferred back to the floors. Repeat \nLP by Dr. ___ ___ showed no evidence of myeloma, though \nrepeat MRI ___ showed increasing enhancement around the \ncauda equina concerning for leptomeningeal involvement and he \nwas started on dexamethasone. Overall etiology of these episodes \nis still unclear at this point, though the thought is that there \nis an element of autonomic dysfunction secondary to prior \nmyeloma treatment, and now possibly and element of \nleptomeningeal involvement. \n\n#Orthostatic hypotension:\nOn ___ patient noted to be hypotensive to SBP 99 (from SBP \n140s a few hours earlier) and on manual repeat SBP 80. HR ___, \nno hypoxia, asymptomatic. Positive orthostatic vitals. \nOrthostasis did not improve with IVF so unlikely due to \nhypovolemia. Sepsis workup negative. No medications on list that \nlead to hypotension. ___ stim negative for adrenal \ninsufficiency. Likely due to autonomic dysfunction in the \nsetting of Velcade/Ninlaro treatment. Started on midodrine 5mg \nTID, which was downtitrated to 2.5mg BID given supine \nhypertension. \n\n#Multiple myeloma:\n#Pancytopenia:\nPt with relapsed multiple myeloma diagnosed in ___ c/b ___ \nlesions s/p radiation. Recent ___ PET/CT c/f disease \nprogression with decision to move forward with triple therapy \nwith ninlaro, dexamethasone, and revlimid as part of a clinical \ntrial at ___ in the s/o multiple failed prior \ntreatments. Received first dose of Ninlaro at 8mg (initial \nstarting dose usually 4 mg) on ___ with plan to initiate \nrevlimid if well tolerated at a later date. He reported taking \nan extra dose of Ninlaro prior to admission. He was noted to \nhave worsening pancytopenia, especially thrombocytopenia, which \nwas though to be due to the Ninlaro. Thrombocytopenia was \nminimally responsive to transfusions, and IVIG/hydrocortisone \nalso had minimal effect. Counts uptrended and plateaued. Bone \nmarrow biopsy done ___ which showed no disease. LP was also \ndone on ___ due to c/f leptomeningeal involvement on MRI \n___, and this also showed no evidence of myeloma on cytology \n(specimen inadequate for flow). However MRI ___ did show \nenhancement of cauda equina which was thought to more likely \nrepresent leptomeningeal involvement, though could be \narachnoiditis due to radiation. He was started on dexamethasone \nand will follow up with Dr. ___ Dr. ___ \nfor further workup. He was seen by radiation oncology and they \ndid not feel that he was a candidate for further radiation \nshould this represent disease.\n\n#DOE, improved:\nPatient complaining of increased SOB on exertion since \nhospitalization. Lungs clear, no peripheral edema. TTE done \nearlier in the hospitalization without any e/o heart failure. \nConsider deconditioning vs. symptomatic anemia vs. cardiopulm \netiology. Improved after pRBC transfusion. Continued to work \nwith ___ while inpatient.\n\n#Afib with RVR, resolved:\nSymptomatic AFib with RVR in the ICU without a known history \nalthough prior EKGs have shown frequent ectopy with PVCs and \nPACs. Unclear trigger without obvious signs of infection or ACS. \nThere was concern for autonomic dysfunction and any adrenergic \nstimuli could be responsible. Reverted to sinus on diltiazem. \nRemained in NSR off nodal agents.\n\n#Hyponatremia, resolved:\nNa noted to be 130 (had downtrended daily), asymptomatic. Serum \nosm 269 with urine osm and urine Na elevated which would be \nconsistent with SIADH picture. Had been on IVF and received \nboluses, so less likely hypovolemic hyponatremia. No renal \nfailure, diuretic use, peripheral edema or ascites. ___ stim \nand TSH wnl. Placed on fluid restriction 1200cc. After he \nreturned to the floor from the ICU, fluid restriction lifted and \nNa remained within normal range.\n\n#Diarrhea, resolved:\n#Enteritis:\n#Hypokalemia:\nCT scan with diffuse bowel wall hyperemia. Likely infectious vs. \ninflammatory in the setting of recent medication introduction. \nC.Diff negative and stool cultures negative. Symptomatic \ntreatment with loperamide. Also may be element of opioid \nwithdrawal. Resolved about a week into hospitalization.\n\nCHRONIC ISSUES:\n===============\n#Chronic pain:\n#Opiate use:\n#Benzodiazepine use:\nPatient on significant opiate regimen (oxycodone, morphine) as \noutpatient with recent decrease in opiate dosing (oxycodone 10 \nmg TID to 5 mg TID) on ___ and history of withdrawal in the \npast per daughter. On initial exam, patient with pupillary \ndilation and recent complaints of diarrhea, concerning for \npossible withdrawal. Patient also on significant benzodiazepine \nregimen as outpatient with patient completing medications prior \nto end of prescription in recent past per family members. During \nthis hospitalization, found to have empty Klonapin bottle and \nbottle with 2 pills of ambien. Reports he last took pills 2 days \nprior to being found. He continued to report severe pain while \non oxycodone 10mg TID, so his regimen was changed to oxycodone \n15mg q4h prn which he was taking consistently. Klonapin was \ndecreased from 1mg TID to BID. Pain management intermittently \nfollowed and then palliative care came on board to help optimize \npain regimen. He was ultimately discharged on oxycontin 20mg \nq12h, oxycodone 5 mg PO q4h prn BTP, gabapentin \n800mg/800mg/1200mg, cymbalta 40mg. He was also discharged on \ndexamethasone for presumed cord irritation symptoms.\n\n#Insomnia:\n#Anxiety:\n#Agitation:\nPatient with hx of anxiety and insomnia, multiple prior psych \nadmissions, most recently ___, who is now complaining of \nworsening insomnia and anxiety. Normally takes Ambien and \nKlonapin 1mg TID at home. Tried on various regimens inpatient, \nincluding ramelteon, zyprexa, and trazodone. Tried ambien, \nhowever patient had episode of sleepwalking where he felt like \nhe was in a dream. Required Haldol for agitation in the ICU. Was \nplaced on Olanzapine standing and PRN with some improvement in \nmood and agitation, which was d/c-ed when the above changes were \nmade to regimen. Psychiatry was briefly involved in medication \nmanagement. \n\nTRANSITIONAL ISSUES:\n===================\n[ ] Discharged on dexamethasone 4mg PO q8h. Up- or down-titrate \nas appropriate.\n[ ] Will require follow-up with Dr. ___ further \nworkup/treatment of possible leptomeningeal involvement on MRI.\n[ ] Follow-up orthostatic hypotension/autonomic dysfunction. Can \nconsider up-titrating midodrine (currently on 2.5mg BID) however \nbe mindful of supine hypertension. Can also consider addition of \nfludrocort. Would likely benefit from ___ clinic \nfollow-up.\n[ ] Given frequent PVCs, PACs, and episode of Afib in the ICU, \nmay consider outpatient Holter monitor.\n[ ] Would benefit from follow-up with palliative care for help \nwith analgesic management given history of opioid use disorder \nand chronic pain. The ___ care team ___ MD) is \ncurrently working on scheduling this appointment. \n[ ] Patient qualifies for home ___ and OT per inpatient team \nrecs.\n\nCODE: Full\nEMERGENCY CONTACT HCP: ___, daughter\n\nThis patient was prescribed, or continued on, an opioid pain \nmedication at the time of discharge (please see the attached \nmedication list for details). As part of our safe opioid \nprescribing process, all patients are provided with an opioid \nrisks and treatment resource education sheet and encouraged to \ndiscuss this therapy with their outpatient providers to \ndetermine if opioid pain medication is still indicated.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. OxyCODONE (Immediate Release) 5 mg PO TID \n2. Doxepin HCl 100 mg PO HS \n3. ClonazePAM 1 mg PO TID \n4. Morphine SR (MS ___ 60 mg PO Q12H \n5. Zolpidem Tartrate 12.5 mg PO QHS \n6. Promethazine 25 mg PO Q6H:PRN \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*84 Tablet Refills:*0 \n2. Acyclovir 400 mg PO Q12H \nRX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12) \nhours Disp #*60 Tablet Refills:*0 \n3. Atovaquone Suspension 1500 mg PO DAILY \nRX *atovaquone 750 mg/5 mL 1500 mg by mouth daily Refills:*0 \n4. Bengay Cream 1 Appl TP BID:PRN knee pain \nRX *menthol [Bengay Cold Therapy] 5 % Apply to painful areas \ntwice a day Refills:*0 \n5. Cyanocobalamin 1000 mcg PO DAILY \nRX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n6. Dexamethasone 4 mg PO Q8H \nRX *dexamethasone 4 mg 1 tablet(s) by mouth every eight hours \nDisp #*90 Tablet Refills:*0 \n7. 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 \n8. DULoxetine 40 mg PO DAILY \nRX *duloxetine 40 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n9. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n10. Gabapentin ___ mg PO TID \nPlease take 800mg at 8am, 800mg at 3pm, and 1200mg at 11pm. \nRX *gabapentin 800 mg ___ tablet(s) by mouth three times a day \nDisp #*105 Tablet Refills:*0 \n11. Midodrine 2.5 mg PO BID \nPlease check BP in AM. If SBP > 150, please hold both daily \ndoses and recheck the next morning. \nRX *midodrine 2.5 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n12. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H \nRX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours \nDisp #*14 Tablet Refills:*0 \n13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \nRX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily \nDisp #*30 Packet Refills:*0 \n14. 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 \n15. ClonazePAM 1 mg PO BID \nRX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*14 \nTablet Refills:*0 \n16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four hours Disp \n#*20 Tablet Refills:*0 \n17. Promethazine 25 mg PO Q6H:PRN \nRX *promethazine 25 mg 1 tablet by mouth every six (6) hours \nDisp #*20 Tablet Refills:*0 \n18. HELD- Doxepin HCl 100 mg PO HS This medication was held. Do \nnot restart Doxepin HCl until you speak with your doctor.\n19. HELD- Morphine SR (MS ___ 60 mg PO Q12H This medication \nwas held. Do not restart Morphine SR (MS ___ until you speak \nwith your doctor.\n20. HELD- Zolpidem Tartrate 12.5 mg PO QHS This medication was \nheld. Do not restart Zolpidem Tartrate until you speak with your \ndoctor.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\n-Altered mental status/aphasia\n-Unresponsive episodes\n-Orthostatic hypotension\n\nSECONDARY:\n-Multiple myeloma\n-Pancytopenia\n-Chronic pain/neuropathic pain\n-Atrial fibrillation\n-Agitation\n-Hyponatremia\n-Diarrhea\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___.\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\nYou were admitted to the hospital because you were vomiting and \nhaving diarrhea, and you were feeling more confused. You were \ninitially admitted to the ICU, then transferred to the floor \nonce you were feeling better. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n-In the emergency room, you were unable to speak normally. \nImaging of your ___ was done, which did not show any stroke. \nYou also had an EEG which did not show any seizures. You were \ngiven antibiotics to treat a possible infection.\n-No infectious cause of your diarrhea was found. It was probably \ndue to the extra chemotherapy medication that you took. Your \ndiarrhea improved.\n-Your platelets became low, so you were given a few platelet \ntransfusions as well as some medications to try to increase your \nplatelets.\n-You were seen by the psychiatry team to help manage medications \nfor your insomnia. You were also seen by the pain management \nteam to help manage your pain, and you were started on \ngabapentin. You were later seen by palliative care who optimized \nyour pain regimen.\n-You had frequent episodes of low blood pressure, mostly upon \nsitting or standing, so you were started on a medication \n(midodrine) to help with this.\n-You had an episode where you became unresponsive and your \noxygenation level was low, so you were intubated and transferred \nback to the ICU. In the ICU you continued to have a few episodes \nwhere your blood pressure dropped. You also were noted to have \nan irregular and fast heart rhythm which resolved with \nmedications. \n-You had a lumbar puncture and bone marrow biopsy which did not \nshow myeloma in the spinal fluid or bone marrow. However, you \nhad an MRI of your ___ which showed findings that could be \nconsistent with myeloma of the ___. You were then started on \nsteroids and you will need to follow up with Dr. ___ Dr. \n___ for further workup.\n\nWHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?\n-Continue to take all of your medications as prescribed.\n-Have your sister check your BP every morning. If the systolic \nBP is greater than 150, hold your midodrine doses for that day.\n-Please attend all ___ clinic appointments.\n-The inpatient physical and occupational therapy teams evaluated \nyou and you qualify for home physical therapy (___) and \noccupational therapy (OT), which can be set up.\n-If you develop sudden weakness in your legs, worsening \nnumbness/tingling, or you feel you cannot control your urination \nor defecation, please immediately go to the ED.\n\nWe wish you all the best,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "R4182", "J690", "J9601", "D61818", "Z9481", "C9002", "E222", "A09", "E873", "N179", "I951", "I4891", "Z006", "F329", "M109", "I959", "E876", "F419", "G4700", "Y929", "T451X1A" ]

[ "R4182: Altered mental status, unspecified", "J690: Pneumonitis due to inhalation of food and vomit", "J9601: Acute respiratory failure with hypoxia", "D61818: Other pancytopenia", "Z9481: Bone marrow transplant status", "C9002: Multiple myeloma in relapse", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "A09: Infectious gastroenteritis and colitis, unspecified", "E873: Alkalosis", "N179: Acute kidney failure, unspecified", "I951: Orthostatic hypotension", "I4891: Unspecified atrial fibrillation", "Z006: Encounter for examination for normal comparison and control in clinical research program", "F329: Major depressive disorder, single episode, unspecified", "M109: Gout, unspecified", "I959: Hypotension, unspecified", "E876: Hypokalemia", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "Y929: Unspecified place or not applicable", "T451X1A: Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional), initial encounter" ]

[ "J9601", "N179", "I4891", "F329", "M109", "F419", "G4700", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\nPt reports that he has had episodic shortness of breath x \nseveral\nmonths which has worsened significantly over the last week. He\nnoted that it occurs both at rest and with exertion. Noted that\nit causes him to breathe deeply/quickly, and improves with rest.\nFor example, he noted that he gets SOB after the third step in a\nstaircase, but is able to make it to the top with great\ndifficulty, and will need to rest for 15 at the top of the \nstairs\nbefore trying to walk again. This week, he felt so SOB in\n___ he had to have ___ employee bring a chair for him to\nsit on. He noted that episodes wake him up at night but ___ does\nnot awake gasping for air. Pt reports that he has more episodes\nof shortness of breath than asymptomatic periods. \n\nHe noted that symptoms became persistent in the 2 days prior to\nadmission so he presented here. Noted that symptoms have \nimproved\nsince being in the ED. He denies any new allergens at home. \nNoted\nthat he is without recent travel. \n\nDenied fevers, cough, sore throat, rhinorrhea, rash, sick\ncontacts. Denied chest pain, palpitations, lightheadedness\n\nIn the ED, initial vitals: 97.9 ___ 16 96% RA. However,\nhe was noted to desaturate with ambulation. Coags wnl, WBC 2.7,\nHgb 10.5, plt 80, BNP ___, Uric Acid 7.4, LFTs wnl, CHEM w/ Cr\nof 1.1, K 3.0, HCO3 20, lactate 3.2 (decreased to 1.8 on \nrepeat),\nTrop <0.01, Flu negative. \n\nCXR:\nThere has been interval development of a right small pleural\neffusion and patchy opacity at the right base since the prior\nstudy. There is no overt pulmonary edema or pneumothoraces. \nHeart\nsize is within normal limits. \n\nInitial EKG\nAFib w/ RVR, prolonged QT interval 517, no STEMI. \n\nRepeat EKG:\nSinus, prolonged QTC 487, no STEMI\n\nPatient was given NS, CTX, Azithromycin, Metoprolol and admitted\nfor further care.\n \nPast Medical History:\n[ONCOLOGIC & TREATMENT HISTORY]:\nPer primary hemoncologist Dr. ___: Diagnosed with multiple\nmyeloma in acute renal failure in ___. He was found to be\nanemic with a hemoglobin of 7 to 9.9 with splenomegaly seen on \nCT\nof the abdomen. Bone marrow biopsy and aspirate on ___\nshowed that CD138 positive cells replaced 90% of his marrow with\nabnormal plasma cells seen. Cytogenetics showed a normal male\nkaryotype and skeletal survey done on ___ showed\ndegenerative disease in the cervical and lumbar spine and a\nquestion of a ___ versus a lytic lesion in the frontal\nskull. He had an elevated serum free lambda of 1140 mg/L, beta \n2\nof 10, IgG of 2.3 g/dL, calcium of 10.1, creatinine of 1.18 and\nalbumin of 3.6. However, over the span of ___ weeks he \ndeveloped\nrenal failure and ultimately was admitted for plasmapheresis and\nVelcade. \nTREATMENT HISTORY: \n --___: Cycle 1 Plasmapheresis + Velcade\n Cycle 2 Velcade + Dexamethasone(severe \nneuropathy)\n Cycle 3 - 5 Revlimid/Dexamethasone \n--___: High Dose Cytoxan for Mobilization\n--___: Autologous Stem cell Transplant\n--Treated on Protocol ___ vaccination with DC/Tumor fusion\nvaccine in patients with multiple myeloma\n--___: Completed ___ fusion vaccines\n--___: Found modest rise in paraprotein. Started on Revlimid\nbut tolerated poorly due to nausea and loose stools and\nultimately stopped in ___.\n--Slow rising paraprotien over the following year\n--___: Started on Protocol ___ A Phase I multicenter,\nopen label, dose-escalation to determine the maximum tolerated\ndose for the combination of Pomalidamide, Velcade and low dose\ndexamethasone in subject with relapsed or refractory multiple\nmyeloma.\n --Lost to follow up for one year, re-presented in ___ with\na rising light chain. M protein was found to be 780 with a max\nof 1110 and a free light chain of 270. His free lambda did rise\nto as high as 447 in ___ prior to initiating treatment. \n --___: Placed back on pomalidomide at 4 mg daily;\ndecreased to 2mg due to cytopenias. \n --___: Found to have a small rise in his light chain,\nand SPEP revealed a monoclonal protein of 910 and a free light\nchain of 293. Reinitiated treatment with Velcade and\ndexamethasone and increased the pomalidomide to 3 mg daily. \n --Received four cycles of Velcade, pomalidomide and\ndexamethasone with great disease control, then placed on\npomalidomide maintenance for close to ___ years. Dose was\ndecreased from 3mg to 2mg ___ due to fatigue and\nnausea. \n --___: Presented with right sacral pain unrelieved by\nTylenol. Pelvic and lumbar sacral MRI obtained. Clear\nprogression of disease including L3 and L5 lesions.\n --___: Daratumumab added to current pomalidomide\ntreatment.\n --Treatment plan: Daratumumab 16 mg/kg weekly for 8 weeks\n Pomalidomide 2 mg p.o. daily for 21 out of 28\ndays will increase to 3 mg next cycle\n Dexamethasone 20 mg p.o. day of and day\nfollowing Daratumumab\n ___: Week 2 ___\n ___: Week 3 ___\n ___: Week 4 ___\n ___: Week 5 ___\n ___: Week 6 ___\n ___: Week 7 ___\n ___: Week 8 ___ (Dexamethasone decreased to 10\nmg on day of ___ and ___ 4 mg on following 2 days)\n ___: Treatment held and admitted for respiratory work up\n ___: Started Daratumumab/Dexamethasone alone \n ___: T7-T8 lesions. RT therapy started \n ___: Retuned to Daratumumab Monthly \n ___: Pet shows progression of disease. RT to L spine and\nfemur \n ___: started Ninlaro/Dex but accidently took two Ninlaro\npills in two subsequent days. Admitted for MS changes.\n ___: PET CT shows interval resolution uptake in the \nbones,\nnow demonstrating background uptake. No new suspicious uptake. \n\n___ 2. Mild uptake along the thoracic esophagus, likely\nrepresenting mild esophagitis secondary to hiatal hernia. \n \nProblems (Last Verified ___ by ___:\n*S/P AUTOLOGOUS STEM CELL TRANSPLANT \nACUTE RENAL FAILURE \nAUTO HPC, APHERESIS INFUSION \nGOUT \nMULTIPLE MYELOMA \nSTEM CELL COLLECTION \nSTUDY ___ \nTHERAPUTIC PLASMAPHERESIS \nMULTIPLE MYELOMA \nDEPRESSION \nADVANCE CARE PLANNING \nBACK PAIN \nASTHMA \nNARCOTICS AGREEMENT \nDYSPNEA \n\n \nSocial History:\n___\nFamily History:\npaternal grandmother was institutionalized. \n \nPhysical Exam:\nADMISSION PHYSICAL\nVitals: ___ Temp: 97.5 PO BP: 166/87 R Lying HR: 71 \nRR:\n18 O2 sat: 98% O2 delivery: RA \nGENERAL: laying in bed, smiling, comfortable NAD\nEYES: PERRLA, anicteric\nHEENT: OP clear, MMM\nNECK: supple, normal ROM\nLUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR, no \nincreased\nWOB at rest but became dyspneic while ambulating in hallway,\nrecovered within 5 minutes, auscultation unchanged at that point\nCV: RRR no murmur, normal distal perfusion, no peripheral edema\nABD: soft, NT, ND, normoactive BS\nGENITOURINARY: no foley or suprapubic tenderness\nEXT: warm, no deformity, normal muscle bulk, no peripheral \nedema\nSKIN: warm, dry, no rash\nNEURO: AOx3 fluent speech\nACCESS: PIV\n\nDISCHARGE PHYSICAL\nsee flow sheet of vitals\nGEN: A&Ox3, resting in bed, in no acute distress, cooperative\nwith exam.\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary lymphadenopathy. \nCV: RR,S1/S2 appreciated; no S3/S4, no MRG\nPULM: Lungs CTAB. No adventitious LS. Respirations are even,\nnon-labored. \nABD: BS+ x4 quadrants, soft, NT/ND, no masses or\nhepatosplenomegaly\nMUSC: No edema, BLE are equal in size, no erythema or tenderness\non palpation of RLE. Negative ___ sign. \nSKIN: No rashes or lesions, skin warm and dry. \nACCESS: Dressing CDI. \n \nPertinent Results:\nADMISSION LABS: \nReviewed\n___ 11:40AM BLOOD WBC: 2.7* RBC: 3.21* Hgb: 10.5* Hct: \n31.7*\nMCV: 99* MCH: 32.7* MCHC: 33.1 RDW: 15.5 RDWSD: 54.8* Plt Ct: \n80*\n\n___ 11:40AM BLOOD Glucose: 190* UreaN: 14 Creat: 1.1 Na: \n145\nK: 3.0* Cl: 106 HCO3: 20* AnGap: 19* \n___ 11:40AM BLOOD ALT: 8 AST: 16 LD(LDH): 216 AlkPhos: 74\nTotBili: 0.8 \n___ 11:40AM BLOOD TotProt: 6.2* Albumin: 4.2 Globuln: 2.0\nCalcium: 8.6 Phos: 3.4 Mg: 1.7 UricAcd: 7.4* Iron: Pending \nMICROBIOLOGY: \nReviewed\nBlood Cx pending\n\nSTUDIES: \nReviewed\nCXR:\nThere has been interval development of a right small pleural\neffusion and patchy opacity at the right base since the prior\nstudy. There is no overt pulmonary edema or pneumothoraces. \nHeart\nsize is within normal limits. \n\nInitial EKG\nAFib w/ RVR, prolonged QT interval 517, no STEMI. \n\nRepeat EKG:\nSinus, prolonged QTC 487, no STEMI\n\necho ___\nIMPRESSION: Normal left ventricular wall thickness and \nbiventricular cavity sizes and regional/ global biventricular \nsystolic function. No right-to-left intracardiac shunt at rest. \nMild pulmonary artery systolic hypertension.\nCompared with the prior TTE (images reviewed) of ___, the \nseverity of tricuspid regurgitation is now decreased.\n\n___ CT chest\n\nIMPRESSION: \n \nStable bilateral pleural effusions right greater than left. \nBibasilar\natelectasis. Subsegmental atelectasis in the right lower lobe. \nNo new\nconsolidations concerning for pneumonia.\n\n___ CTA\n1. No evidence of pulmonary embolism or acute aortic \nabnormality.\n2. Interval increase in size of a moderate sized right pleural \neffusion and a\nnew small left pleural effusion, with adjacent compressive \natelectasis.\n3. No focal consolidation to suggest pneumonia.\n4. Similar diffuse moderate bronchial wall thickening, \nconsistent with small\nairway inflammation.\n5. Stable moderate-sized hiatal hernia and patulous esophagus.\n6. Subtle sclerotic region at the left humeral head, in keeping \nwith known\nhistory of multiple myeloma, better assessed on prior FDG PET-CT \nfrom ___.\n\n___ 06:10AM BLOOD WBC-2.5* RBC-2.78* Hgb-8.9* Hct-27.0* \nMCV-97 MCH-32.0 MCHC-33.0 RDW-14.8 RDWSD-51.8* Plt Ct-72*\n___ 06:10AM BLOOD Neuts-55.3 ___ Monos-13.7* \nEos-2.0 Baso-0.4 Im ___ AbsNeut-1.37* AbsLymp-0.69* \nAbsMono-0.34 AbsEos-0.05 AbsBaso-0.01\n___ 06:10AM BLOOD Glucose-92 UreaN-8 Creat-0.8 Na-147 K-3.6 \nCl-108 HCO3-24 AnGap-15\n___ 06:10AM BLOOD ALT-6 AST-13 LD(LDH)-215 AlkPhos-58 \nTotBili-0.6\n___ 06:10AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.___SSESSMENT & PLAN: \n___ PMh of AFib, MM (in partial response, not currently on\ntreatment), Prior substance abuse, Anxiety/Depression, presented\nto ED with shortness of breath\n\n#Shortness of breath\nSymptoms have been ongoing for months but are now worse. \nEtiology\nremains unclear despite extensive workup in past which included\nPFTs (decreased DLCO suggestive perfusion deficit but CTA normal\nat the time), STRESS ECHO (no ischemia, though was suboptimal\nstudy), Repeat TTE (mod TR, borderline pHTN). AFib was \nconsidered\nas cause but patient has been dyspneic while in sinus rhythm. \nExaggerated\nresponse to allergen considered but patient denied new \nexposures.\nRAD does not appear to be cause, as no wheezing with ambulation, \nand \nno improvement with albuterol inhaler. On this\nadmission, patient with question of pneumonia, which is a\npossible cause of worsening dyspnea but does not explain his\nbaseline dysfunction. That said, is worthwhile to treat. BNP was\nalso elevated but patient is without JVP or lower extremity/pulm\nedema. CTA without PE. No PNA on CT. Echo with \n-Initially started CTX/Doxycycline for empiric pneumonia\ntreatment (Azithro contraindicated with his prolonged QTC). No\nPNA on CT and deescalated to just doxycycline. \n-RVP pending. \n-Duonebs q6h:prn\n-Continuous O2 monitoring\n-Repeat TEE improved EF 57%, improved severity of MVR\n-encouraged to follow up with pulmonary and cardiology as \noutpatient. \n\n#Prolonged QTC\n-Avoid QTC proloning meds\n\n#MM\nIn partial response, not currently on treatment\n-F/u light chains\n-Continue pred, acyclovir\n-Care per outpatient team. \n\n#AFib\nRVR in ED, now in sinus\n-Continue metoprolol\n-Off A/C given ongoing thrombocytopenia, will order for ppx\ndosing lovenox and trend platelets daily, hold for count>50K\nPLts now 77 can resume epixaban upon discharge.\n\n#Hypokalemia\n-Replete PO as needed\n\n#Anxiety/Depression\nEuthymic, but noted that his living situation stresses him out\nand likely potentiates his SOB\n-Continue home escitalopram, gabapentin, klonopin\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Escitalopram Oxalate 20 mg PO DAILY \n3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n4. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral \nDAILY \n5. ClonazePAM 1 mg PO QID anxiety \n6. Fludrocortisone Acetate 0.2 mg PO DAILY \n7. Gabapentin 900 mg PO QHS \n8. Gabapentin 600 mg PO BID \n9. Cyanocobalamin 1000 mcg PO DAILY \n10. Metoprolol Succinate XL 25 mg PO DAILY \n11. Midodrine 2.5 mg PO BID orthostasis \n12. Midodrine 5 mg PO DAILY \n13. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild \n14. Omeprazole 40 mg PO DAILY \n15. PredniSONE 7.5 mg PO DAILY \n16. FoLIC Acid 1 mg PO DAILY \n17. Multivitamins W/minerals 1 TAB PO DAILY \n18. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose \n19. Zolpidem Tartrate 12.5 mg PO QHS \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild \n2. Acyclovir 400 mg PO Q12H \n3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n4. ClonazePAM 1 mg PO QID anxiety \n5. Cyanocobalamin 1000 mcg PO DAILY \n6. Escitalopram Oxalate 20 mg PO DAILY \n7. Fludrocortisone Acetate 0.2 mg PO DAILY \n8. FoLIC Acid 1 mg PO DAILY \n9. Gabapentin 900 mg PO QHS \n10. Gabapentin 600 mg PO BID \n11. Metoprolol Succinate XL 25 mg PO DAILY \n12. Midodrine 5 mg PO DAILY \nas needed. \n13. Multivitamins W/minerals 1 TAB PO DAILY \n14. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose \n15. Omeprazole 40 mg PO DAILY \n16. PredniSONE 7.5 mg PO DAILY \n17. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral \nDAILY \n18. Zolpidem Tartrate 12.5 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses\n=====================\nRule out pneumonia\nDyspnea without Hypoxia\nHypertension\n\nSecondary Diagnoses\n===========================\nMultiple Myeloma\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. ___,\nYou were admitted due to worsening shortness of breath. You \nunderwent a workup including imaging, blood work and an \nechocardiogram. We did not find any infection in your blood. \nYou received antibiotics for a possible pneumonia. The rest of \nyour work up was reassuring, however, we recommend you follow up \nwith your outpatient pulmonologist. \n\nPlease continue to take all of your medications as prescribed. \nYour appointment with Dr. ___ is as listed below. It was an \nabsolute pleasure taking care of you.\n\nSincerely,\nYour ___ TEAM\n \nFollowup Instructions:\n___\n" ]

[ "J189", "C9000", "Z9484", "J45909", "I4891", "F419", "E876", "F329", "Z87891", "F1511", "R0602", "I951", "C44529" ]

[ "J189: Pneumonia, unspecified organism", "C9000: Multiple myeloma not having achieved remission", "Z9484: Stem cells transplant status", "J45909: Unspecified asthma, uncomplicated", "I4891: Unspecified atrial fibrillation", "F419: Anxiety disorder, unspecified", "E876: Hypokalemia", "F329: Major depressive disorder, single episode, unspecified", "Z87891: Personal history of nicotine dependence", "F1511: Other stimulant abuse, in remission", "R0602: Shortness of breath", "I951: Orthostatic hypotension", "C44529: Squamous cell carcinoma of skin of other part of trunk" ]

[ "J45909", "I4891", "F419", "F329", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nnausea, vomiting, diarrhea and subacute SOB\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___ year old M\nadmitted for dyspnea, n/v, and abdominal pain found to have ___,\npancytopenia and klebsiella bacteremia. His PMH is significant\nfor multiple myeloma s/p auto SCT in ___, afib, asthma,\ndepression, substance abuse in remission, orthostatic\nhypotension, and other co-morbidities.\n\nHe was in his usual state of health until approximately two \nweeks\nprior to admission when he began to feel more SOB. This was on\nexertion and began to become more prominent. No CP, leg \nswelling,\nfevers or chills. Notably, he has been having exertional dyspnea\nepisodically since approximately ___. He has seen Pulmonology\nand Cardiology as well as Hem/Onc. Studies have included PFTs,\nTTE, EKG, and routine imaging with no definitive cause found. \nPer\nPulm, suspicion for deconditioning. Infectious workup on\nadmission showed pan-sensitive klebsiella bacteremia and\npseudomonas aeruginosa UTI. \n\n \nPast Medical History:\n[ONCOLOGIC & TREATMENT HISTORY]:\nPer primary hemoncologist Dr. ___: Diagnosed with multiple\nmyeloma in acute renal failure in ___. He was found to be\nanemic with a hemoglobin of 7 to 9.9 with splenomegaly seen on \nCT\nof the abdomen. Bone marrow biopsy and aspirate on ___\nshowed that CD138 positive cells replaced 90% of his marrow with\nabnormal plasma cells seen. Cytogenetics showed a normal male\nkaryotype and skeletal survey done on ___ showed\ndegenerative disease in the cervical and lumbar spine and a\nquestion of a ___ versus a lytic lesion in the frontal\nskull. He had an elevated serum free lambda of 1140 mg/L, beta \n2\nof 10, IgG of 2.3 g/dL, calcium of 10.1, creatinine of 1.18 and\nalbumin of 3.6. However, over the span of ___ weeks he \ndeveloped\nrenal failure and ultimately was admitted for plasmapheresis and\nVelcade. \nTREATMENT HISTORY: \n --___: Cycle 1 Plasmapheresis + Velcade\n Cycle 2 Velcade + Dexamethasone(severe \nneuropathy)\n Cycle 3 - 5 Revlimid/Dexamethasone \n--___: High Dose Cytoxan for Mobilization\n--___: Autologous Stem cell Transplant\n--Treated on Protocol ___ vaccination with DC/Tumor fusion\nvaccine in patients with multiple myeloma\n--___: Completed ___ fusion vaccines\n--___: Found modest rise in paraprotein. Started on Revlimid\nbut tolerated poorly due to nausea and loose stools and\nultimately stopped in ___.\n--Slow rising paraprotien over the following year\n--___: Started on Protocol ___ A Phase I multicenter,\nopen label, dose-escalation to determine the maximum tolerated\ndose for the combination of Pomalidamide, Velcade and low dose\ndexamethasone in subject with relapsed or refractory multiple\nmyeloma.\n --Lost to follow up for one year, re-presented in ___ with\na rising light chain. M protein was found to be 780 with a max\nof 1110 and a free light chain of 270. His free lambda did rise\nto as high as 447 in ___ prior to initiating treatment. \n --___: Placed back on pomalidomide at 4 mg daily;\ndecreased to 2mg due to cytopenias. \n --___: Found to have a small rise in his light chain,\nand SPEP revealed a monoclonal protein of 910 and a free light\nchain of 293. Reinitiated treatment with Velcade and\ndexamethasone and increased the pomalidomide to 3 mg daily. \n --Received four cycles of Velcade, pomalidomide and\ndexamethasone with great disease control, then placed on\npomalidomide maintenance for close to ___ years. Dose was\ndecreased from 3mg to 2mg ___ due to fatigue and\nnausea. \n --___: Presented with right sacral pain unrelieved by\nTylenol. Pelvic and lumbar sacral MRI obtained. Clear\nprogression of disease including L3 and L5 lesions.\n --___: Daratumumab added to current pomalidomide\ntreatment.\n --Treatment plan: Daratumumab 16 mg/kg weekly for 8 weeks\n Pomalidomide 2 mg p.o. daily for 21 out of 28\ndays will increase to 3 mg next cycle\n Dexamethasone 20 mg p.o. day of and day\nfollowing Daratumumab\n ___: Week 2 ___\n ___: Week 3 ___\n ___: Week 4 ___\n ___: Week 5 ___\n ___: Week 6 ___\n ___: Week 7 ___\n ___: Week 8 ___ (Dexamethasone decreased to 10\nmg on day of ___ and ___ 4 mg on following 2 days)\n ___: Treatment held and admitted for respiratory work up\n ___: Started Daratumumab/Dexamethasone alone \n ___: T7-T8 lesions. RT therapy started \n ___: Retuned to Daratumumab Monthly \n ___: Pet shows progression of disease. RT to L spine and\nfemur \n ___: started Ninlaro/Dex but accidently took two Ninlaro\npills in two subsequent days. Admitted for MS changes.\n ___: PET CT shows interval resolution uptake in the \nbones,\nnow demonstrating background uptake. No new suspicious uptake. \n\n___ 2. Mild uptake along the thoracic esophagus, likely\nrepresenting mild esophagitis secondary to hiatal hernia. \n \nProblems (Last Verified ___ by ___:\n*S/P AUTOLOGOUS STEM CELL TRANSPLANT \nACUTE RENAL FAILURE \nAUTO HPC, APHERESIS INFUSION \nGOUT \nMULTIPLE MYELOMA \nSTEM CELL COLLECTION \nSTUDY ___ \nTHERAPUTIC PLASMAPHERESIS \nMULTIPLE MYELOMA \nDEPRESSION \nADVANCE CARE PLANNING \nBACK PAIN \nASTHMA \nNARCOTICS AGREEMENT \nDYSPNEA \n\n \nSocial History:\n___\nFamily History:\npaternal grandmother was institutionalized. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION\n============================\nGeneral: Sitting upright, in no acute distress\nSkin: No obvious rashes/lesions, pale\nHENT: Normocephalic, atraumatic. Oropharynx clear with moist\nmucous membranes, no lesions\nEyes: Extraocular movements intact, non-injected, no scleral\nicterus. \nLymph: No palpable cervical, submandibular, or supraclavicular\nlymphadenopathy.\nCV: Regular rate and rhythm, S1, S2, systolic murmur noted, no\naudible rubs, ___\nResp: CTAB with diminishment in bases, no inc WOB\nAbd: Bowel sounds present, soft, nondistended. Tender in RUQ and\nLUQ to deep palpation. No palpable hepatosplenomegaly\nExtremities: Warm, without edema\nNeuro: Grossly normal, moving all limbs\nPsych: Alert & oriented to conversation, euthymic, appropriately\nconversant\nECOG performance status: 2\n\nDISCHARGE PHYSICAL EXAMINATION\n===================================\n24 HR Data (last updated ___ @ 1114)\n Temp: 97.8 (Tm 98.4), BP: 144/81 (134-175/69-91), HR: 60 \n(55-73), RR: 20 (___), O2 sat: 98% (97-98), O2 delivery: RA, \nWt: 161.4 lb/73.21 kg \nGEN: A&Ox3, NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular\nlymphadenopathy. \nCV: Irregularly irregular sometimes but currently in sinus\nbradycardia. No murmurs, rubs or gallops\nPULM: non-labored, fine crackles at bases. No rhonchi or \nwheezing\nABD: BS+, soft, NT/ND, no masses or hepatosplenomegaly. No\nrebound or guarding. \nMUSC: No edema or tremors\nSKIN: Dry. Pink papules with concave yellow center noted on \nright\nchest. No other lesions\nACCESS: PIV C/D/I\n\n \nPertinent Results:\nADMISSION LABS\n======================\n___ 08:54PM URINE HOURS-RANDOM TOT PROT-9\n___ 08:54PM URINE U-PEP-ALBUMIN IS\n___ 08:54PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 08:54PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-LG*\n___ 08:54PM URINE RBC-1 WBC-33* BACTERIA-FEW* YEAST-NONE \nEPI-<1 TRANS EPI-<1\n___ 07:11PM LIPASE-31\n___ 07:11PM TOT PROT-6.3*\n___ 07:11PM PEP-ABNORMAL B Free K-19.4 Free L-76.7* Fr \nK/L-0.25* b2micro-6.5*\n___ 10:58AM cTropnT-<0.01\n___ 07:55AM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG\n___ 07:52AM ___ PTT-34.2 ___\n___ 07:52AM D-DIMER-871*\n___ 07:29AM GLUCOSE-83 UREA N-24* CREAT-1.8* SODIUM-136 \nPOTASSIUM-3.4* CHLORIDE-101 TOTAL CO2-20* ANION GAP-15\n___ 07:29AM estGFR-Using this\n___ 07:29AM ALT(SGPT)-14 AST(SGOT)-29 ALK PHOS-70 TOT \nBILI-0.5\n___ 07:29AM LIPASE-17\n___ 07:29AM proBNP-670*\n___ 07:29AM cTropnT-<0.01\n___ 07:29AM ALBUMIN-3.8 CALCIUM-8.0* PHOSPHATE-3.4 \nMAGNESIUM-1.8\n___ 07:29AM WBC-1.4* RBC-3.12* HGB-10.0* HCT-29.8* MCV-96 \nMCH-32.1* MCHC-33.6 RDW-14.2 RDWSD-49.2*\n___ 07:29AM NEUTS-32.4* ___ MONOS-33.1* EOS-0.0* \nBASOS-0.0 IM ___ AbsNeut-0.45* AbsLymp-0.47* AbsMono-0.46 \nAbsEos-0.00* AbsBaso-0.00*\n___ 07:29AM PLT COUNT-58*\n\nIMAGING STUDIES\n============================\n\n___ CT abd/pelv\nIMPRESSION: \nNo acute intra-abdominal pathology to account for patient's\nsymptoms, within the limitations of this unenhanced scan. \n\n___ RUQ U/S\nIMPRESSION: \nNo cholelithiasis or evidence of acute cholecystitis. No \nbiliary\nductal dilatation. \n\n\"Laboratory pulmonary function tests from ___ show total \nlung\ncapacity 7.4 (107% predicted and residual volume 3.5 (138%\npredicted with an RV/TLC of 130% predicted. Slow vital capacity\nis 88% predicted and forced vital capacity is 3.96 (91%\npredicted). FEV1 to vital capacity ratio is 74% (99% predicted).\nDiffusing capacity is 16.8 (66% predicted) DL divided by \nalveolar\nvolume is 2.9 (77% predicted).\"\n\nDISCHARGE LABS\n\n___ 07:10AM BLOOD WBC: 2.9* RBC: 2.76* Hgb: 8.6* Hct: 27.1* \nMCV: 98 MCH: 31.2 MCHC: 31.7* RDW: 15.3 RDWSD: 49.2* Plt Ct: 57* \n\n___ 07:10AM BLOOD Neuts: 48.9 Lymphs: ___ Monos: 16.0* \nEos: 0.7* Baso: 0.7 Im ___: 3.1* AbsNeut: 1.44* AbsLymp: 0.90* \nAbsMono: 0.47 AbsEos: 0.02* AbsBaso: 0.02 \n___ 07:10AM BLOOD Glucose: 88 UreaN: 13 Creat: 0.8 Na: 145 \nK: 4.2 Cl: 106 HCO3: 29 AnGap: 10 \n___ 07:10AM BLOOD ALT: 8 AST: 12 LD(LDH): 204 AlkPhos: 53 \nTotBili: 0.5 \n___ 07:10AM BLOOD Calcium: 8.6 Phos: 3.7 Mg: 1.9 \n\n___ 9:00 BLOOD CULTURE: KLEBSIELLA PNEUMONIAE. \nSENSITIVITIES: MIC expressed in MCG/ML\n \n_________________________________________________________\n KLEBSIELLA PNEUMONIAE\n | \nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nCTA ___: \n1. No evidence of pulmonary embolism centrally through the \nsegmental pulmonary \narteries. Evaluation of the subsegmental pulmonary arteries is \nlimited due to \ntiming of the contrast bolus. \n2. Trace right nonhemorrhagic pleural effusion is new from \nprior. \n3. Stable to slightly improved diffuse bronchial wall \nthickening. \n4. Stable right upper lobe 4 mm pulmonary nodule. \n5. Severe coronary artery and mitral annular calcifications. \n6. Moderate hiatal hernia and patulous esophagus, which may \npredispose to \naspiration. \n \nbil LENIs ___: \n\nNo evidence of deep venous thrombosis in the right or left lower \nextremity \nveins. \n \nCT chest ___: \nNo evidence of pneumonia in the present examination. \n \nStable right upper lobe 4 mm nodule (5:34). \n \nModerate bronchial wall thickening reflecting chronic \nbronchitis. \n \nSevere coronary artery atherosclerotic disease. \n \nSevere mitral annulus calcification. \n \n___: CT abd/pelvis\n1. No acute intra-abdominal pathology to account for patient's \nsymptoms, \nwithin the limitations of this unenhanced scan. \n \n\n \nBrief Hospital Course:\nASSESSMENT AND PLAN: Mr. ___ is a ___ year old male admitted\nwith dyspnea, N/V/D, and abdominal pain found to have ___, \npancytopenia as well as klebsiella bacteremia and pseudomonas\nUTI. His PMH is significant for MM (s/p auto SC in ___, afib,\nasthma, depression, substance abuse in remission, orthostatic\nhypotension, and other comorbidities. \n\nAcute Conditions\n========================\n\n#Bacteremia (Klebsiella Pneumoniae):\n#UTI (Pseudomonas Aeruginosa, initial culture < 100K):\nPresented with SOB, N/V/D and abdominal discomfort. CT Torso and\nCXR ___ without evidence of infection. Blood culture\n(___) grew GNR. Started on cefepime while awaiting culture\ndata - which showed klebsiella. Additionally, UA showed 33 WBC\nwith culture growing pseudomonas A. Of note, patient left ___ with PIV which may have been likely source of \nbacteremia\nbut source of UTI is unclear (imaging did not show enlarged\nprostate, recent PSA ___ = 0.6). He did have urinary \nsymptoms\n(urgency and dysuria on presentation) but since these have\nresolved.\n-PIV Culture No growth \n-Repeat UA improved and Ucx without growth\n-Cefepime (___) x7 days then transitioned to\nCiprofloxacin x7 days ___ - ___ with plan for a 14 \nday\ncourse per ID\n-Surveillance cultures NGTD\n-ID signed off\n\n#Multiple Myeloma:\n#Pancytopenia (Improving):\nDiagnosed in ___ with anemia, ___ showing CD138 cells in 90% of\nmarrow with abnormal plasma cells. He is status post\nplasmapharesis, velcade, auto transplant, ___, and \nother\ntherapies with his last treatment being in ___. His counts the\nday of admission showed pancytopenia with neutropenia and a Cr \nof\n1.8. His recent numbers over the past few months when trended\n(see above) showed a worsening free kappa/lambda since ___\nwith rising IgG. His ___ SPEP was deemed monoclonal. Given\nthis change, plan was to obtain PET scan to further evaluate\nwhether he has evidence of disease progression. Unclear if his\npancytopenia is related to progression of disease or infection\n(counts improving now so presume likely infection related).\nReceived x1 dose of GSCF on ___. Has mild LDH elevation\nwhich may be due to counts recovery/recent GSCF. Free Lamdba\ntrending up modestly. Bone marrow biopsy done ___ (results \npending).\n-Continue infectious prophylaxis: acyclovir\n-Transfuse if plts < 10 and/or hgb < 7\n-B12 & folate normal; F/U zinc & copper\n-Plan for PET scan ___ outpatient. \n- follow up bone marrow bx results.\n\n#Asthma:\n#AS:\n#DOE/SOB:\nImproving overall since admission but persists. His SOB is\nsubacute, has been ongoing episodically with exertion since\napproximately ___. He has had workup with cardiology,\npulmonary, and hem/Onc with PFTs, TTE, EKG, and myeloma\nrestaging. Overall, he has known asthma and AS; however, his\nother studies do not point to a clear cause. Per Pulmonary,\nconcern raised for deconditioning. As suspicion for myeloma\nrecurrence looms, his SOB may be a constitutional symptom\nreflecting brewing underlying disease. EKG and troponins are\nappropriate. CXR x2 without evidence of infection. No evidence \nof\nclot on CTA or LENIs. Of note, patient has been recently on\napixaban (~ 2 weeks) as part of afib management but this has \nbeen\non hold in s/o TCP. \n-Consider restarting apixaban if plts remains > 50K. \n -Continue supportive care\n\n#Epigastric & Chest Pain: Largely resolved but occasionally\nreports symptoms. Chest pain is sharp in intensity but does not\nrefer elsewhere. No worsening of SOB or hypoxia. No exacerbating\nfactors. Suspect GERD related. Current cardiac workup negative\n(no new arrhythmias, cardiac enzymes flat and repeat chest\nimaging without acute pulmonary infection). Improved with H2\nblocker and continues on home PPI. \n-Remains on telemetry\n-Trend examination\n\n___ (Resolved):\n#Abdominal Pain (Resolved):\n#N/V/D (Largely resolved): \nResolved since admission but with recrudescence of diarrhea on\n___ (? due to IV ABX). On admission, BUN/Cr = ___ was\nabove his usual of 0.9 significantly. His bicarb is low\nreflecting metabolic acidosis. Previous values from ___ show\na rising trend: Cr 0.9 on ___ and Cr 1.2 on ___. Thus,\nthis has been a protracted process again, consistent with\nmultiple myeloma. Contribution may also be from vomiting and\ndiarrhea; Notably, RUQ U/S and CT A/P did not reveal abnormality\nso fundamental reason for his GI symptoms is unclear. ___\nresolved with IVF. Overall stool studies have been unrevealing. \n-Repeat stool studies if persists\n-Loperamide prn\n-IVF prn\n-Lipase normal\n\n#Atrial Fibrillation with RVR: History of a-fib (on metoprolol \nER\n25mg). Held apixaban in setting of low plts. On telemetry and \nhad\nbeen in NSR until ___ when he was in afib with rvr (rates \nin\n170s, no recurrence since then). He was asymptomatic and\nmaintaining BPs. \n-Continue metoprolol\n-Continue telemetry\n-Holding apixaban as above\n\n#Hypertension: Improved. SBPs ranging between 150-170s since\nadmission, asymptomatic. Besides BB (metoprolol) for rate \ncontrol\nin s/o known afib, patient is not on anti-HTNs. Unclear\nexacerbating factor at this point but will hold off on \ninitiating\nnew regimen. \n-Monitor and trend BPs\n\n#Hypophosphatemia: Suspect ___ decreased PO intake, repleting \nprn\n\nChronic/Stable/Resolved Conditions\n==========================================\n\n#Substance Use Disorder:\n#Depression: \nHas had issues in the past with improper use of benzodiazepines\nand opiates. Follows OSH Psychiatry and states he has been in\nremission for months.\n-Continue clonazepam as 1mg QID \n-Continue home escitalopram\n-Takes cannabinoid at home - but holding inpatient\n-B12 & folate normal as above\n\n#Lesion on Chest:\n#History of Basal Cell: \nPatient has lesion on chest which should be biopsied. However,\ngiven low counts, we will hold but will likely pursue \ndermatology\nfollow up (could be done as an outpatient). \n\n#Orthostatic Hypotension: Continues florinef. \n-Hold off on daily orthostatic VS as stable\n-Held midodrine as he only takes it PRN.\n\nTransitional Issues\n========================\n[ ] Bone marrow biopsy results pending\n\n[ ] Stable right upper lobe 4 mm nodule \n \n[ ] follow up with cardiology\n\n[ ] consider restarting anticoagulation depending on platelet \ncount. \n \n[ ] \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H \n2. Acyclovir 400 mg PO Q12H \n3. ClonazePAM 1 mg PO BID \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Escitalopram Oxalate 20 mg PO DAILY \n6. Fludrocortisone Acetate 0.2 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. Gabapentin 900 mg PO QHS \n9. Gabapentin 600 mg PO BID \n10. Multivitamins W/minerals 1 TAB PO DAILY \n11. Omeprazole 40 mg PO DAILY \n12. PredniSONE 10 mg PO DAILY \n13. Zolpidem Tartrate ___ mg PO QHS:PRN sleep \n14. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose \n15. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral \nDAILY \n16. Midodrine 2.5 mg PO TID \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H \nContinue as ordered until ___ \n2. Acetaminophen 325-650 mg PO Q4H:PRN Pain - Mild \n3. ClonazePAM 1 mg PO QID:PRN anxiety \n4. Acyclovir 400 mg PO Q12H \n5. Cyanocobalamin 1000 mcg PO DAILY \n6. Escitalopram Oxalate 20 mg PO DAILY \n7. Fludrocortisone Acetate 0.2 mg PO DAILY \n8. FoLIC Acid 1 mg PO DAILY \n9. Gabapentin 900 mg PO QHS \n10. Gabapentin 600 mg PO BID \n11. Midodrine 2.5 mg PO TID:PRN orthostasis \n12. Multivitamins W/minerals 1 TAB PO DAILY \n13. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose \n14. Omeprazole 40 mg PO DAILY \n15. PredniSONE 7.5 mg PO DAILY \n16. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral \nDAILY \n17. Zolpidem Tartrate ___ mg PO QHS:PRN sleep \n18. HELD- Apixaban 5 mg PO BID This medication was held. Do not \nrestart Apixaban until instructed to restart by your healthcare \nprovider (due to low platelet count). \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses\n=====================\nKlebsiella Bacteremia\nPseudomonas UTI\nDyspnea without Hypoxia\nHypertension\n\nSecondary Diagnoses\n===========================\nMultiple Myeloma\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. ___,\nYou were admitted due to worsening shortness of breath, nausea, \nvomiting and diarrhea. Extensive workup showed infection in your \nblood and urine which were treated with IV antibiotics. You will \ncomplete treatment for your infections with oral antibiotics, \nciprofloxacin. \n\nPlease continue to take all of your medications as prescribed. \nYour appointment with Dr. ___ is as listed below. It was an \nabsolute pleasure taking care of you.\n\nSincerely,\nYour ___ TEAM\n \nFollowup Instructions:\n___\n" ]

[ "D61818", "C9000", "T80211A", "N179", "N390", "R7881", "Z9484", "E872", "E440", "B961", "I4891", "J45909", "F329", "I951", "M109", "B965", "Z85828", "L988", "F1290", "F1111", "F1511", "E8339", "Z7901", "K219", "Y848", "Y92239", "E876", "Z87891", "I350", "G4730", "Z6823" ]

[ "D61818: Other pancytopenia", "C9000: Multiple myeloma not having achieved remission", "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "R7881: Bacteremia", "Z9484: Stem cells transplant status", "E872: Acidosis", "E440: Moderate protein-calorie malnutrition", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "I4891: Unspecified atrial fibrillation", "J45909: Unspecified asthma, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "I951: Orthostatic hypotension", "M109: Gout, unspecified", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "Z85828: Personal history of other malignant neoplasm of skin", "L988: Other specified disorders of the skin and subcutaneous tissue", "F1290: Cannabis use, unspecified, uncomplicated", "F1111: Opioid abuse, in remission", "F1511: Other stimulant abuse, in remission", "E8339: Other disorders of phosphorus metabolism", "Z7901: Long term (current) use of anticoagulants", "K219: Gastro-esophageal reflux disease without esophagitis", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "E876: Hypokalemia", "Z87891: Personal history of nicotine dependence", "I350: Nonrheumatic aortic (valve) stenosis", "G4730: Sleep apnea, unspecified", "Z6823: Body mass index [BMI] 23.0-23.9, adult" ]

[ "N179", "N390", "E872", "I4891", "J45909", "F329", "M109", "Z7901", "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ndizziness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old male with multiple myeloma and\northostatic hypotension who presents with dizziness and poor PO\nintake after a mechanical fall. \n\nOf note, the patient was admitted at ___ from ___\nwith nausea, vomiting and diarrhea. This was complicated by\nintermittent confusion and aphasia. Stroke and seizure work up\nwas negative. He was treated empirically for meningoencephalitis\nbut abx were d/c'd after 5 days due to low concern for \ninfection.\nLP negative for infection, but noted that this was delayed due \nto\nthrombocytopenia. The patient continued to have intermittent\nepisodes of unresponsiveness of unclear etiology with associated\nhypotension to the ___. This required intubation nand ICU\ntransfer with again negative stroke and seizure work up. This \nwas\nthought to possibly be due to leptomeningeal involvement of the\npatient's myeloma due to enhancement found around the cauda\nequina on MRI L spine for which the patient was started on\ndexamethasone. \n\nFurthermore, the patient's hospitalization was further\ncomplicated by orthostatic hypotension. Negative infectious and\nendocrinologic work up. Patient was started on midodrine with\nunderlying etiology thought to be due to treatment with\nvelcade/ninlaro. \n\nInitially after discharge the patient had been feeling well. He\nwas seen by Dr. ___ on ___ in follow up where further\ntreatment plans were held until more work up could be completed\nfor the patient's symptoms. In addition, the patient underwent\nEGD on ___ for progressive weight loss that demonstrated mild\ngastritis. Biopsy was negative for malignant invasion.\n\nOver the last ___ days, the patient has complained of \nprogressive\ndizziness. He describes this as feeling as if he is about to \npass\nout with tunnel vision upon changes in position. This is\noccasionally associated with dyspnea but no chest pain or\npalpitations. He has noted occasional fevers/chills but no\nrecorded temperatures. No cough. No abdominal pain. 1 episode of\nnausea and vomiting the day prior to admission. He notes no\ndiarrhea or constipation. No blood in his stool and occasional\ndysuria. \n\nInitial vitals in the ED:\nT 97.2 HR 108 BP 117/82 R 16 SpO2 98% RA\n\nLabs notable for:\nNormal Chem7\nWBC 10.1 Hgb 13.3 plt 72\nLactate 1.4\nINR 1.3\n\nImaging was notable for:\n___ 21:12 CT C-Spine W/O Contrast \n1. No acute fracture or traumatic malalignment.\n2. Moderate to severe cervical spondylosis.\n\n___ 21:11 CT Head W/O Contrast \nNo acute intracranial abnormality. No fracture.\n\n___ 21:39 Chest (Pa & Lat) \nIMPRESSION: \n1. No acute osseous abnormality. \n2. No acute cardiopulmonary process. \n\nECG:\nSinus tachycardia, rate 106 with occasional PACs. No ST T wave\nchanges. Normal intervals. \n\nPatient received:\n___ 20:56 IVF NS ( 1000 mL ordered) \n\nUpon arrival to ___, the patient endorses the above history and\nfeels improved but fatigued. He notes stable pain in his back \nand\nis requesting his breakthrough oxycodone. \n\nROS: 10 point review of systems discussed with patient and\nnegative unless noted above\n \nPast Medical History:\nMultiple myeloma s/p autologous stem cell transplant ___,\nradiation\nOrthostatic hypotension\nOpiate withdrawal w/ substance use disorder\nDepression\nGout\n \nSocial History:\n___\nFamily History:\npaternal grandmother was institutionalized. \n \nPhysical Exam:\n======================\nADMISSION PHYSICAL EXAM\n======================\nVITALS: T 98.2 BP 174/83 HR 99 R 16 SpO2 100 Ra \nGENERAL: Tired, NAD\nHEENT: Multiple, scattered white plaques. No erythema. Noted\ntemporal wasting\nEYES: PERRL, anicteric\nNECK: supple\nRESP: No increased WOB, CTAB\n___: no MRG, RRR\nGI: Soft, NTND no HSM\nEXT: warm, noted sarcopenia. No edema\nSKIN: dry\nNEURO: CN II-XII intact. Strength ___ ___ b/l\nACCESS: PIV\n\n======================\nDISCHARGE PHYSICAL EXAM\n======================\nVITALS: 24 HR Data (last updated ___ @ 604)\n Temp: 97.6 (Tm 98.4), BP: 166/100 (84-166/57-100), HR: 91\n(85-122), RR: 18 (___), O2 sat: 96% (96-99%), O2 delivery: Ra,\nWt: 132.7 lb/60.19 kg \nGENERAL: alert an interactive, in no acute distress\nHEENT: NC/AT, sclera anicteric and without injection\nRESP: breathing comfortably on room air, CTAB\nCARDIAC: normal rate, regular rhythm, normal S1 and S2, no m/r/g\nGI: soft, non-distended, non-tender\nEXT: WWP, no ___ edema\n \nPertinent Results:\n=============\nADMISSION LABS\n=============\n___ 06:48PM ___ PTT-25.7 ___\n___ 06:48PM PLT COUNT-72*\n___ 06:48PM NEUTS-88.4* LYMPHS-5.8* MONOS-5.0 EOS-0.1* \nBASOS-0.1 IM ___ AbsNeut-8.92* AbsLymp-0.59* AbsMono-0.51 \nAbsEos-0.01* AbsBaso-0.01\n___ 06:48PM WBC-10.1* RBC-4.03* HGB-13.3* HCT-39.2* \nMCV-97 MCH-33.0* MCHC-33.9 RDW-15.4 RDWSD-54.6*\n___ 06:48PM cTropnT-<0.01\n___ 06:48PM estGFR-Using this\n___ 06:48PM GLUCOSE-177* UREA N-22* CREAT-1.0 SODIUM-141 \nPOTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13\n___ 06:52PM LACTATE-1.4\n___ 06:52PM ___ COMMENTS-GREEN TOP\n\n================\nPERTINENT STUDIES\n================\nNCHCT ___\nFINDINGS: \n \nThere is no evidence of infarction, hemorrhage, edema, or mass. \nThere is\nprominence of the ventricles and sulci suggestive of \ninvolutional changes. \nMild periventricular and subcorticalwhite matter hypodensities \nare\nnonspecific, but likely reflect the sequela of chronic \nmicrovascular\ninfarction.\n \nThere is no evidence of fracture. The visualized portion of the \nparanasal\nsinuses, mastoid air cells, and middle ear cavities are clear. \nThe visualized\nportion of the orbits are unremarkable.\n \nIMPRESSION: \n \nNo acute intracranial abnormality. No fracture.\n\nCT C-spine w/o contrast ___\nFINDINGS: \n \nAlignment is unchanged with minimal retrolisthesis of C4 on \nC5.No fractures\nare identified.Moderate to severe multilevel degenerative \nchanges with\nintervertebral disc space narrowing, endplate sclerosis and \ncystic change, and\nanterior and posterior osteophyte formation, most pronounced \nfrom C4-C5\nthrough C6-C7. Multilevel mild to moderate central canal \nstenosis is most\nsevere at C3-C4 and C4-C5 due to combination of a disc bulge and \nposterior\nosteophyte. Bilateral mild-to-moderate neural foraminal \nnarrowing due to\nuncovertebral spurring and facet hypertrophy is most pronounced \nC4-5. There\nis no prevertebral soft tissue swelling. There is no evidence of \ninfection or\nneoplasm.\n \nThe esophagus is patulous. Visualized lung apices are clear. \nThe thyroid\ngland is unremarkable. Partially imaged is a periapical lucency \nwithin the\nleft mandibular molar tooth.\n \nIMPRESSION:\n \n1. No acute fracture or traumatic malalignment.\n2. Moderate to severe cervical spondylosis.\n\nCarotid U/S ___\n1. Mild partially calcified atheromatous plaque involving the \nproximal left\ncommon carotid artery and the bilateral carotid bulbs.\n2. No significant stenosis of the extracranial portions of the \ncarotid\narteries and vertebral arteries.\n\nMRI brain w/ and w/o contrast ___:\nSmall area of dural thickening, enhancement left vertex, \nnonspecific,\ndifferential considerations include posttraumatic change, recent \nlumbar\npuncture, inflammatory, neoplastic etiology. Follow-up brain \nMRI without and\nwith gadolinium recommended.\n\nTTE ___\nThe left atrium is mildly dilated. The right atrial pressure \ncould not be estimated. There is normal left\nventricular wall thickness with a normal cavity size. There is \nsuboptimal image quality to assess regional left\nventricular function. Overall left ventricular systolic function \nis hyperdynamic. The visually estimated left\nventricular ejection fraction is 75%. Left ventricular cardiac \nindex is high (>4.0 L/min/m2). There is no\nleft ventricular outflow tract gradient at rest or with \nValsalva. Tissue Doppler suggests an increased left\nventricular filling pressure (PCWP greater than 18 mmHg). Normal \nright ventricular cavity size with normal\nfree wall motion. The aortic sinus diameter is normal for \ngender. The aortic valve leaflets (?#) are mildly\nthickened. There is minimal aortic valve stenosis. There is no \naortic regurgitation. The mitral valve leaflets are\nmildly thickened with no mitral valve prolapse. There is \nmoderate mitral annular calcification. There is trivial\nmitral regurgitation. Due to acoustic shadowing, the severity of \nmitral regurgitation could be UNDERestimated.\nThe tricuspid valve leaflets appear structurally normal. There \nis physiologic tricuspid regurgitation. The\nestimated pulmonary artery systolic pressure is normal. There is \nno pericardial effusion.\n\nCompared with the prior TTE (images reviewed) of ___, \nleft ventricular function is hyperdynamic\nand the resting heart rate is significantly faster.\n\nMRI thoracic and lumbar spine ___\n1. No evidence of fracture.\n2. Scattered myelomatous lesions are unchanged. No new or \nenlarging lesions.\n3. Unchanged mild enhancement of the cauda equina nerve roots.\n4. Mild thoracic and lumbar spondylosis.\n\n============\nMICROBIOLOGY\n============\n__________________________________________________________\n___ 7:35 am SEROLOGY/BLOOD\n\n RAPID PLASMA REAGIN TEST (Pending): \n__________________________________________________________\n___ 4:45 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 4:50 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 8:38 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 6:48 pm BLOOD CULTURE #1. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n==============\nDISCHARGE LABS\n==============\n___ 07:35AM BLOOD WBC-3.3* RBC-3.22* Hgb-10.7* Hct-31.6* \nMCV-98 MCH-33.2* MCHC-33.9 RDW-15.0 RDWSD-53.1* Plt Ct-57*\n___ 07:35AM BLOOD Glucose-84 UreaN-21* Creat-0.6 Na-139 \nK-4.0 Cl-103 HCO3-27 AnGap-9*\n___ 07:35AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.___ with multiple myeloma presents with failure to thrive,\ndizziness and mechanical falls after recent prolonged\nhospitalization for altered mental status.\n\n#recurrent falls\nPatient presented s/p fall complicated by two toe fractures. \nThis is a recurrent issue. Also had two falls while in house. \nEtiology of falls likely multifactorial: orthostatic \nhypotension, polypharmacy (including opioids), non-compliance \nwith walker, and possible large fiber sensory neuropathy \n(positive Romberg test). See below for expanded discussion of \nthese separate issues.\n\n#orthostatic hypotension\nPatient with profound orthostatic hypotension. Etiology of \northostasis unclear but most likely related to autonomic \nfailure. Good PO intake and supine hypertension so hypovolemia \nunlikely. Low AM cortisol in setting of dexamethasone use but \n___ stim test during prior admission negative so adrenal \ninsufficiency unlikely. No signs/symptoms of Parkinsonism. \nHgbA1C wnl. B12 repleted. VEGF level (POEMS syndrome), \nanti-nicotinic acetylcholine receptor antibody pending. Started \nmidodrine, salt tabs, and compression stockings with improvement \nsymptoms though remains orthostatic. Will follow-up in \n___ clinic with Dr. ___. \n\n#subacute comminuted fracture of the L first proximal phalanx\n#subacute fracture of the shaft of the L fifth proximal phalanx \nwithout intra-articular extension \nSecondary to trauma. Seen by ortho who recommended a walking \nboot for LLE when ambulating. Will follow-up in ___ clinic.\n\n#multiple myeloma\nPatient was most recently treated with Ninlaro/Dex on ___.\nUnclear status of disease, in some ways appears well controlled:\nPET on ___ showed resolution of previously identified bony\nlesions, he has low paraprotein levels, and bone marrow biopsy \non\n___ showed no involvement by MM. MRI lumbar spine\non ___ showed enhancement of the cauda equina nerve roots\nconcerning for worsening leptomeningeal metastatic infiltration\nvs. post-radiation changes. Reassuringly, MRI ___, showed \nstable enhancement of cauda equina nerve roots, arguing against \nmetastatic infiltration. His dexamethasone was tapered \n(discharged on 2mg PO daily). He was continued on acyclovir and \natovaquone for prophylaxis.\n\n#pancytopenia\nUnclear etiology. BM biopsy on ___ did not show replacement\nof marrow by MM cells. B12, folate, copper, and zinc levels all\nnormal. Viral labs (HIV, EBV, CMV) have been negative in the \npast. Parvovirus Ab and PCR pending at time of discharge.\n\n#acute on chronic pain\n#opioid use disorder\nPatient with acute pain from toe fractures and trauma to \nthoracic\nspine in setting of recent fall. However, also with history of\nmisusing opioids with concern that opioids may have contributed\nto his fall and to his AMS during his prior admission. We weaned \nhis pain regimen while he was here - should be further tapered \noff as an outpatient. \n\n#malnutrition\nNoted progressive weight loss over the past year. Recent EGD \nwith mild gastritis. No signs of malignant invasion on biopsy. \nFollowed by nutrition in house who recommended ___ nutritional \nsupplements per day. Weight increased from 128 lbs to 135 lbs \nduring this admission. He was continued on his home B12 and \nfolate.\n\n#prolonged QTc\nQTc was prolonged at 496 on ___, this improved to 467 on \n___.\n\n#thrush\nWhite plaques were noted on exam. No dysphagia/odynophagia to \nsuggest\nesophagitis. The patient was started on Nystatin swish and \nswallow. \n\n#depression\nThe patient was continued on his home clonazepam and duloxetine.\n\n===================\nTRANSITIONAL ISSUES\n===================\n\n#discharge weight: 134.7 lbs\n#discharge QTc: 467\n\n#NEW MEDICATIONS: sodium chloride 2 g PO TID with meals, \nomeprazole 40 mg PO daily, nystatin swish and swallow 10 mL PO \nQID:PRN thrush, ondansetron 4 mg q8H:PRN PO nausea\n#CHANGED MEDICATIONS: dexamethasone 4 mg PO q8H changed to 2 mg \nPO daily, gabapentin ___ mg changed to ___ mg, \noxycodone SR 20 mg PO BID changed to 10 mg PO BID, oxycodone ___ \n5 mg q4H:PRN breakthrough pain changed to q8H:PRN breakthrough \npain \n#STOPPED MEDICATIONS: promethazine \n\n[] Please check orthostatics at next outpatient appointment. \n[] Please follow-up pending labs for orthostatic hypotension \nworkup: VEGF level, anti-nicotinic acetylcholine receptor \nantibody, RPR. Patient will need to follow-up in ___ \nclinic with Dr. ___ ___.\n[] Please ensure patient compliant with compression stockings \nand walker. He should be taking his midodrine first thing in the \nmorning and then staying upright throughout the day. He should \nnot take his third dose of midodrine past 6 pm - want it to be \nout of his system before going to bed to prevent supine \nhypertension. He should be taking his salt tabs with meals.\n\n[] Patient will need to follow-up in orthopedics clinic for his \ntoe fractures. Dr. ___ ___. Should be ambulating \nwith a walking boot on his LLE. \n\n[] dexamethasone was tapered to 2mg PO daily in house - please \ncontinue to taper as appropriate for management of multiple \nmyeloma\n\n[] Please follow-up pending parvovirus studies for pancytopenia \nworkup.\n\n[] Please wean opioids and gabapentin as tolerated to reduce \nfalls\n\n[] Please check weight at next outpatient appointment. At high \nrisk for malnutrition.\n\n[] Please check QTc at next outpatient appointment. Was \nprolonged during hospital course.\n\n[] Please examine oropharynx for resolution of thrush.\n\n[] Omeprazole started given dyspepsia and gastritis seen on \nrecent EGD as well as steroid use. \n\n[] Promethazine stopped because it can cause hypotension. \nPatient was treated with ondansetron for nausea in house so he \nwas discharged on this medication. Please re-evaluate need for \nanti-emetics and titrate as needed. \n\n#HCP/CONTACT: \nName of health care proxy: ___ \nRelationship: daughter \nPhone number: ___ \nAlternate HCP: ___ (son) ___ \n#CODE STATUS: Full, confirmed \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Promethazine 25 mg PO Q6H:PRN \n2. Senna 8.6 mg PO BID \n3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n4. Docusate Sodium 100 mg PO BID \n5. Bengay Cream 1 Appl TP BID:PRN knee pain \n6. Atovaquone Suspension 1500 mg PO DAILY \n7. Acyclovir 400 mg PO Q12H \n8. ClonazePAM 1 mg PO BID \n9. Acetaminophen 1000 mg PO Q8H \n10. Cyanocobalamin 1000 mcg PO DAILY \n11. Dexamethasone 4 mg PO Q8H \n12. DULoxetine 40 mg PO DAILY \n13. FoLIC Acid 1 mg PO DAILY \n14. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H \n15. Gabapentin ___ mg PO TID \n16. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n17. Midodrine 2.5 mg PO BID \n\n \nDischarge Medications:\n1. Nystatin Oral Suspension 10 mL PO QID:PRN thrush \nRX *nystatin 100,000 unit/mL 10 mL by mouth four times per day \nDisp #*480 Milliliter Milliliter Refills:*0 \n2. Omeprazole 40 mg PO DAILY \nRX *omeprazole 40 mg 1 capsule(s) by mouth every day Disp #*30 \nCapsule Refills:*0 \n3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \nRX *ondansetron 4 mg 1 tablet(s) by mouth every eight hours Disp \n#*90 Tablet Refills:*0 \n4. Sodium Chloride 2 gm PO TID W/MEALS \nRX *sodium chloride 1 gram 2 tablet(s) by mouth three times per \nday with meals Disp #*180 Tablet Refills:*0 \n5. Dexamethasone 2 mg PO DAILY \nRX *dexamethasone 2 mg 1 tablet(s) by mouth every day Disp #*10 \nTablet Refills:*0 \n6. Gabapentin 600 mg PO BID \nRX *gabapentin 300 mg 2 capsule(s) by mouth every morning and \nafternoon Disp #*120 Capsule Refills:*0 \n7. Gabapentin 900 mg PO QHS \nRX *gabapentin 300 mg 3 capsule(s) by mouth every night before \nbed Disp #*90 Capsule Refills:*0 \n8. Midodrine 5 mg PO TID \nRX *midodrine 5 mg 1 tablet(s) by mouth Three times per day at \n6AM, 12PM, and 6PM Disp #*90 Tablet Refills:*0 \n9. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 capsule(s) by mouth every eight hours Disp \n#*21 Capsule Refills:*0 \n10. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H \nRX *oxycodone 10 mg 1 tablet(s) by mouth every twelve hours Disp \n#*14 Tablet Refills:*0 \n11. Acetaminophen 1000 mg PO Q8H \n12. Acyclovir 400 mg PO Q12H \n13. Atovaquone Suspension 1500 mg PO DAILY \n14. Bengay Cream 1 Appl TP BID:PRN knee pain \n15. ClonazePAM 1 mg PO BID \n16. Cyanocobalamin 1000 mcg PO DAILY \n17. Docusate Sodium 100 mg PO BID \n18. DULoxetine 40 mg PO DAILY \n19. FoLIC Acid 1 mg PO DAILY \n20. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n21. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n=================\nPRIMARY DIAGNOSIS\n=================\nrecurrent falls\northostatic hypotension \nsubacute comminuted fracture of the L first proximal phalanx\nsubacute fracture of the shaft of the L fifth proximal phalanx \nmultiple myeloma\npancytopenia\nacute on chronic pain\nopioid use disorder\nmalnutrition\n\n===================\nSECONDARY DIAGNOSIS\n===================\nthrush\ndepression\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___.\n\nYou were here because of a fall and you were found to have \nfractures in two of the toes of your left foot. For the two \nfractures, you were given a boot to help you walk while your \nfractures heal. You will need to follow-up in orthopedics clinic \nfor this issue.\n\nWe believe there are several factors contributing to your falls. \nOne factor is the drop in blood pressure that you get when you \nstand up from a seated position (called orthostatic \nhypotension). We are not entirely sure what is causing this \nproblem but we feel it is most likely related to your multiple \nmyeloma. For this issue, we increased your midodrine dose, gave \nyou compression stockings to wear, and started you on salt tabs. \nWe also believe the pain and anxiety medications you are taking \nare contributing to your falls. We reduced the amount of pain \nmedications you are getting. You will need to follow-up in \nneurology clinic for this issue.\n\nTo prevent falls in the future, please get up slowly from a \nseated position, wear your compression stockings, and use your \nwalker. Please take you midodrine first thing in the morning. \nThis medicine raises your blood pressure, so you should stay in \nan upright position throughout the day and not take your \nafternoon and evening doses too late - we want it to be out of \nyour system before you go to sleep at night. Please continue to \ntake your salt tabs - if you take them with meals they should be \nless nauseating. Finally, you should only take pain medication \nwhen you ABSOLUTELY need it and should try your best to taper \noff of the pain medications over the next few days.\n\nAfter you leave the hospital, please take all of your \nmedications as prescribed and attend all of your scheduled \nappointments.\n\nWe wish you the best in the future!\n\nSincerely,\n\nYour ___ care team.\n\n \nFollowup Instructions:\n___\n" ]

[ "I951", "E43", "Z9484", "Z681", "B370", "D61818", "C9000", "F329", "G629", "Z9221", "G893", "Z87891", "D696", "R296", "W19XXXA", "S92412A", "S92512A", "Y92009", "D472", "F1190", "I4581", "K2970", "T402X5A", "T424X5A", "T43215A", "Z9119" ]

[ "I951: Orthostatic hypotension", "E43: Unspecified severe protein-calorie malnutrition", "Z9484: Stem cells transplant status", "Z681: Body mass index [BMI] 19.9 or less, adult", "B370: Candidal stomatitis", "D61818: Other pancytopenia", "C9000: Multiple myeloma not having achieved remission", "F329: Major depressive disorder, single episode, unspecified", "G629: Polyneuropathy, unspecified", "Z9221: Personal history of antineoplastic chemotherapy", "G893: Neoplasm related pain (acute) (chronic)", "Z87891: Personal history of nicotine dependence", "D696: Thrombocytopenia, unspecified", "R296: Repeated falls", "W19XXXA: Unspecified fall, initial encounter", "S92412A: Displaced fracture of proximal phalanx of left great toe, initial encounter for closed fracture", "S92512A: Displaced fracture of proximal phalanx of left lesser toe(s), initial encounter for closed fracture", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "D472: Monoclonal gammopathy", "F1190: Opioid use, unspecified, uncomplicated", "I4581: Long QT syndrome", "K2970: Gastritis, unspecified, without bleeding", "T402X5A: Adverse effect of other opioids, initial encounter", "T424X5A: Adverse effect of benzodiazepines, initial encounter", "T43215A: Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounter", "Z9119: Patient's noncompliance with other medical treatment and regimen" ]

[ "F329", "Z87891", "D696" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDyspnea, Abdominal Pain, Elevated Bilirubin\n \nMajor Surgical or Invasive Procedure:\nNone this hospitalization.\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of multiple \nmyeloma on Daratumumab/Pomalidomide/Dex who presents from clinic \nwith dyspnea, abdominal pain, and elevated bilirubin.\n\nPatient reports that two days ago he was prescribed doxepin for \nsleep by his Psychiatrist. Prior to this he was taking abmien \nand has continued to take klonopin. He took the doxepin for the \npast two nights. During this time he has been feeling sick. He \nhas been dizzy. Two nights ago he got out of bed to use the \nbathroom and lost his balance, falling on his right side. He \ndenies head stroke, loss of consciousness, and chest pain. He \nwas unable to get up due to weakness and slept on the floor. His \ndaughter helped him up in the morning. He also notes shortness \nof breath with exertion for the past two days. He has been more \nnervous and shaky. He also developed a sharp pain across his \nmid-abdomen and burning sensation in his throat when drinking \nGatorade and soda that feels like reflux. He notes decreased \nappetite and 20 pound weight loss in 3 weeks. He notes multiple \nfamily issues at home.\n\nHe presented to clinic for Daratumumab. Vitals were Temp 98.5, \nBP 146/97, HR 66, RR 16, O2 sat 100% RA. Ambulatory O2 sat was \n95% on RA. EKG showed sinus tachycardia without other \nabnormalities. His chemotherapy was held. He had a CTA chest \nwhich was negative for PE. His labs were notable for elevated \nbilirubin. He got 1L IVF.\n\nOn arrival to the floor, patient reports cough with deep \nbreaths. His abdominal pain has resolved. He denies \nfevers/chills, night sweats, headache, vision changes, \nweakness/numbness, hemoptysis, chest pain, palpitations, \nnausea/vomiting, diarrhea, hematemesis, hematochezia/melena, \ndysuria, hematuria, and new rashes.\n \nPast Medical History:\nMr. ___ was diagnosed with multiple myeloma in acute renal \nfailure in ___. He was found to be anemic with a hemoglobin of \n7 to 9.9 with splenomegaly seen on CT of the abdomen and he \nunderwent a bone marrow biopsy and aspirate on ___, which \nshowed that CD138 positive cells replaced 90% of his marrow. \nThere were abnormal plasma cells seen. Cytogenetics showed a \nnormal male karyotype and skeletal survey done on ___ \nshows degenerative disease in the cervical and lumbar spine and \na question of a ___ versus a lytic lesion in the frontal \nskull. He had an elevated serum free lambda of 1140 mg/L, beta 2 \nof 10, IgG of 2.3 g/dL, calcium of 10.1, creatinine of 1.18 and \nalbumin of 3.6 however over the span of only ___ weeks he \ndeveloped renal failure and ultimately was admitted for \nplasmapheresis and Velcade.\n\nTREATMENT HISTORY: \n\n___: Cycle 1 Plasmapheresis + Velcade\n\n Cycle 2 Velcade + Dexamethasone (severe neuropathy)\n\n Cycle 3 - 5 Revlimid/Dexamethasone \n\n___: High Dose Cytoxan for Mobilization\n\n___: Autologous Stem cell Transplant\n\nTreated on Protocol ___ vaccination with DC/Tumor fusion \nvaccine in patients with multiple myeloma\n\n___: Completed ___ fusion vaccines\n\n___: Found modest rise in paraprotein. Started on Revlimid \nbut tolerated poorly due to nausea and loose stools and \nultimately stopped in ___.\n\nSlow rising paraprotien over the following year\n\n___: Started on Protocol ___ A Phase I multicenter, \nopen label, dose-escalation to determine the maximum tolerated \ndose for the combination of Pomalidamide, Velcade and low dose \ndexamethasone in subject with relapsed or refractory multiple \nmyeloma.\n \nHe was lost to follow up for one year, re-presented in ___ \nwith a rising light chain. \n\n___: His M protein was found to be 780 with a max of 1110 \nand a free light chain of 270. His free lambda did rise to as \nhigh as 447 in ___ prior to initiating treatment. \n\n___: He was placed back on pomalidomide at 4 mg daily; \nhowever, was decreased to 2mg due to cytopenias. \n\n___: Found to have a small rise in his light chain, and \nSPEP revealed a monoclonal protein of 910 and a free light chain \nof 293. This did seem to be after a period of dose decrease, and \ntherefore we reinitiated treatment with Velcade and \ndexamethasone and increased the pomalidomide to 3 mg daily. \n\nHe completed four cycles of Velcade, pomalidomide and \ndexamethasone with great disease control, and he has now been on \npomalidomide maintenance for close to ___ years. This dose \nwas decreased from 3mg to 2mg ___ due to fatigue and \nnausea. \n\n___: Presented with right sacral pain unrelieved by \nTylenol. Pelvic and lumbar sacral MRI obtained. Clear \nprogression of disease including L3 and L5 lesions.\n\n___: At Daratumumab addition to current pomalidomide \ntreatment.\nTreatment plan: Daratumumab 16 mg/kg weekly Ã-8 weeks\n Pomalidomide 2 mg p.o. daily for 21 out of 28 \ndays will increase to 3 mg next cycle\n Dexamethasone 20 mg p.o. day of and day \nfollowing\nDaratumumab\n\n___: Week 2 ___\n___: Week 3 ___\n___: Week 4 ___\n___: Week 5 ___\n___: Week 6 ___\n___: Week 7 ___\n___: Week 8 ___\n\nPAST MEDICAL HISTORY:\n- Multiple myeloma\n- Anxiety/Depression\n- Gout\n- History of opioid abuse\n- History of benzodiazepine abuse\n \nSocial History:\n___\nFamily History:\nSon has a history of opioid dependence. Multiple family members \nwith depression and substance abuse.\n \nPhysical Exam:\n========================\nAdmission Physical Exam:\n========================\nVS: Temp 97.9, BP 124/75, HR 92, RR 18, O2 sat 100% RA.\nGENERAL: Pleasant man, very anxious appearing, lying in bed \ncomfortably. Ambulating independently around the hallways \nwithout difficulty.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi. Speaking in full \nsentences.\nABD: Soft, mild lower abdominal tenderness to deep palpation \nwithout rebound or guarding, non-distended, normal bowel sounds.\nEXT: Warm, well perfused, no lower extremity edema, erythema or \ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII \nintact. Strength full throughout. Sensation to light touch \nintact.\nSKIN: No significant rashes.\n\n========================\nDischarge Physical Exam:\n========================\nVS: Temp 98.5, BP 118/73, HR 91, RR 18, O2 sat 95% RA.\nExam otherwise unchanged.\n \nPertinent Results:\n===============\nAdmission Labs:\n===============\n___ 09:50AM BLOOD WBC-4.5 RBC-3.62* Hgb-11.9* Hct-33.8* \nMCV-93 MCH-32.9* MCHC-35.2 RDW-14.0 RDWSD-46.8* Plt Ct-99*\n___ 09:50AM BLOOD Neuts-71 Bands-1 Lymphs-11* Monos-17* \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-3.24 AbsLymp-0.50* \nAbsMono-0.77 AbsEos-0.00* AbsBaso-0.00*\n___ 09:50AM BLOOD UreaN-18 Creat-1.3* Na-133* K-4.2 Cl-94* \nHCO3-22 AnGap-17\n___ 09:50AM BLOOD ALT-68* AST-24 LD(___)-263* AlkPhos-92 \nTotBili-2.7* DirBili-1.1* IndBili-1.6\n___ 09:50AM BLOOD Calcium-8.4\n\n===============\nDischarge Labs:\n===============\n___ 07:02AM BLOOD WBC-2.6* RBC-2.74* Hgb-8.9*# Hct-25.6* \nMCV-93 MCH-32.5* MCHC-34.8 RDW-14.0 RDWSD-47.8* Plt Ct-67*\n___ 01:00PM BLOOD WBC-2.7* RBC-2.77* Hgb-9.0* Hct-25.7* \nMCV-93 MCH-32.5* MCHC-35.0 RDW-14.0 RDWSD-47.1* Plt Ct-73*\n___ 07:02AM BLOOD Glucose-105* UreaN-10 Creat-0.9 Na-139 \nK-3.8 Cl-102 HCO3-26 AnGap-11\n___ 07:02AM BLOOD ALT-41* AST-13 LD(___)-201 AlkPhos-70 \nTotBili-1.5\n___ 07:02AM BLOOD Calcium-7.7* Phos-2.1* Mg-1.9\n___ 07:02AM BLOOD Hapto-73\n\n========\nImaging:\n========\nCTA Chest ___\nImpression: Mild bibasilar fibrotic changes. No evidence of \npulmonary embolism.\n\nRUQ Ultrasound ___\nImpression: Splenomegaly. Otherwise, unremarkable abdominal \nultrasound.\n \nBrief Hospital Course:\nMr. ___ is a ___ male with history of multiple \nmyeloma on Daratumumab/Pomalidomide/Dex who presents from clinic \nwith dyspnea, abdominal pain, and elevated bilirubin.\n\n# Elevated Bilirubin: Unclear etiology. ___ medication \nrelated, possibly doxepin or pomalidomide. Abdominal pain has \nresolved. RUQ US negative for biliary process. LFTs improving at \ntime of discharge. Possibly intermittent hemolysis as indirect \nwas elevated. Please continue to monitor.\n\n# ___: Patient found to have evidence of ___ \nesophagitis given oral thrush on exam and odynophagia. He was \nprescribed a 14-day course of fluconazole for total duration to \nbe determined by outpatient providers. Also checked baseline QTc \nwhich was 400. Please continue to monitor.\n\n# Dyspnea: Normal O2 sats at rest and ambulation. Does not \nappear in respiratory distress. CTA chest unremarkable. Resolved \nat time of discharge.\n\n# Acute Kidney Injury: Cr 1.3 on admission, baseline 0.9-1.1. \nLikely due to poor PO intake. Improved with IVF.\n\n# Hyponatremia: Mild. Likely hypovolemic due to poor PO intake. \nImproved with IVF.\n\n# Multiple Myeloma: Relapsed, refractory IgG Lambda multiple \nmyeloma currently on Daratumumab/Pomalidomide/Dex. Continued \nBactrim and acyclovir for prophylaxis. Follow-up with outpatient \nOncologist\n\n# Depression/Anxiety: Multiple stressors in life. Follows with \nPsychiatrist Dr. ___. Severe anxiety and insomnia. \nHeld home doxepin. Continued Lexapro and clonazepam.\n\n# Anemia/Thrombocytopenia: Counts at baseline. All lines down on \n___ likely ___ IVF and stable on recheck.\n\n# Abdominal Pain: Unclear cause. Currently resolved.\n\n# Gout: Continued home allopurinol.\n\n# Chronic Pain: Continue gabapentin and Tylenol.\n\n# Severe Protein-Calorie Malnutrition: Patient with weight loss \nand poor PO intake. He was seen by Nutrition.\n\n====================\nTransitional Issues:\n====================\n- Patient found to have evidence of ___ esophagitis given \noral thrush on exam and odynophagia. He was prescribed a 14-day \ncourse of fluconazole for total duration to be determined by \noutpatient providers.\n- Patient had baseline EKG with QTc of 400 given interaction \nbetween fluconazole and escitalopram. Please continue to monitor \nQTc.\n- Patient with mildly elevated bilirubin on admission which \nnormalized without intervention. Please consider intermittent \nhemolysis and continue to monitor LFTs.\n- Please note CTA chest with mild bibasilar fibrotic changes.\n- Please note abdominal ultrasound with splenomegaly of 15.5cm.\n- Patient's doxepin held at time of discharge. Please ensure \nfollow-up with Psychiatry.\n- Patient was seen by Nutrition given evidence of malnutrition.\n- Please ensure follow-up with Oncology.\n\n# BILLING: 45 minutes spent completing discharge paperwork, \ncounseling patient, and coordinating with outpatient providers.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO TID \n2. Allopurinol ___ mg PO DAILY \n3. ClonazePAM 1 mg PO QHS \n4. ClonazePAM 1 mg PO QID \n5. Dexamethasone 4 mg PO AS DIRECTED WITH CHEMOTHERAPY \n6. Doxepin HCl 100 mg PO HS \n7. Gabapentin 300 mg PO TID \n8. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting \n9. pomalidomide 2 mg oral DAILY AS DIRECTED \n10. Prochlorperazine 5 mg PO Q6H:PRN nausea/vomiting \n11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n12. Aspirin 81 mg PO DAILY \n13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n14. Escitalopram Oxalate 20 mg PO DAILY\n \nDischarge Medications:\n1. Fluconazole 200 mg PO Q24H \nRX *fluconazole 200 mg Take 1 tablet by mouth daily. Disp #*14 \nTablet Refills:*0 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n3. Acyclovir 400 mg PO TID \n4. Allopurinol ___ mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. ClonazePAM 1 mg PO QHS \n7. ClonazePAM 1 mg PO QID \n8. Dexamethasone 4 mg PO AS DIRECTED WITH CHEMOTHERAPY \n9. Escitalopram Oxalate 20 mg PO DAILY \n10. Gabapentin 300 mg PO TID \n11. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting \n12. pomalidomide 2 mg oral DAILY AS DIRECTED \n13. Prochlorperazine 5 mg PO Q6H:PRN nausea/vomiting \n14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n- ___\n- Elevated Bilirubin\n- Acute Kidney Injury\n- Hyponatremia\n- Multiple Myeloma\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at the ___ \n___. You were admitted to the hospital for \nshortness of breath, abdominal pain, and elevated liver numbers.\n\nFor your shortness of breath, you had a chest CT scan which did \nnot show any blood clots in your lungs. It did not show any \ncause for your difficulty breathing. Most importantly, your \nbreathing improved while in the hospital and were having no \nsymptoms when being discharged. \n\nYour abdominal pain also resolved. You had an ultrasound of your \nliver that did not show any cause of your elevated liver \nnumbers. This improved the following day and your Oncologist \nwill continue to monitor.\n\nYou also reported throat discomfort with swallowing. You had \nsigns of ___ infection in your mouth. This throat pain is \nlikely due to a ___ infection in your esophagus. You were \nstarted on a medication called fluconazole which you have been \non in the past. This should help your symptoms improve. Please \ndiscuss how long you should continue this medication with your \nOncologist.\n\nWe did stop your doxepin which may have been causing some of \nyour side effects.\n\nPlease continue the remainder of your home medications. Please \nfollow-up with your Oncologist as below. Please call your \ndoctors ___ have any fevers.\n\nAll the best,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "B3781", "R17", "N179", "E871", "C9002", "R0600", "F418", "D649", "D696", "R109", "M109", "G8929", "E43", "Z87891", "Z6826" ]

[ "B3781: Candidal esophagitis", "R17: Unspecified jaundice", "N179: Acute kidney failure, unspecified", "E871: Hypo-osmolality and hyponatremia", "C9002: Multiple myeloma in relapse", "R0600: Dyspnea, unspecified", "F418: Other specified anxiety disorders", "D649: Anemia, unspecified", "D696: Thrombocytopenia, unspecified", "R109: Unspecified abdominal pain", "M109: Gout, unspecified", "G8929: Other chronic pain", "E43: Unspecified severe protein-calorie malnutrition", "Z87891: Personal history of nicotine dependence", "Z6826: Body mass index [BMI] 26.0-26.9, adult" ]

[ "N179", "E871", "D649", "D696", "M109", "G8929", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"I'm sick and tired of being sick and tired.\"\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nBriefly, Mr. ___ is a ___ year old man with prior psychiatric\nhistory of depression, opiate and benzo use disorders, as well \nas\nmedical history of multiple myeloma currently on daratumumab and\ndexamethasone. Patient presented to his outpatient oncologist's\noffice at ___, without an appointment, with complaint of\nworsening symptoms of confusion and mood. \n\nPer Dr. ___ ___ consultation note:\n\"Patient presented to his outpatient oncologist's\noffice at ___, without an appointment, with complaint of\nworsening symptoms of confusion and mood. Patient was referred \nto\nthe ED for further evaluation and psychiatry is now asked to\nassess patient for safety and treatment planning.\n\nPatient has been calm and cooperative in the ED overnight. This\nmorning he is awake, alert, listening to music. He reports that\nover the past months he has been having a lot of difficulties\nwith his thinking and hallucinating. He gives an example of \ngoing\nto look for a new apartment and believing that his sister is \nwith\nhim. He reports he parked his car to go get paperwork and \nthought\nshe stayed behind, when he returned to the car she was not there\nand he began to look for her. Eventually he called her to ask\nwhere she went and she was surprised by his phone call as she \nwas\nnot with him for any part of that day. ___ family gives\nother examples of such odd behaviors and confusion (refer to Dr.\n___ note in ___. \n\nPatient and his family noted that in the past few months he has\nstarted psychiatric treatment with a new psychiatrist in ___\nand ___ been started on a number of medications. Patient also\nreports that when stressed or anxious he 'reaches for pills' and\nis using significantly more than prescribed.\n\nPatient reports fairly steady mood but with significant\nstressors. He continues to go through process of divorced and\ncope with his grandson's special needs. He continues to live in\nhis home with his wife (separated), daughter, and grandchildren.\nDuring our interview he has a bright and reactive affect, notes\nthat his ___ year old granddaughter is the light of his life, asks\nfriendly questions of myself. \n\nPatient denies any current ownership or access to firearms. Does\nreport that he continues to have a permit but does not own any\nweapons.\n\nPatient completed MOCA exam this morning. Total score ___. He\nlost points in all domains. Copy in paper chart.\"\n \nOn admission interview, patient describes how it has been\ndifficult for him since being diagnosed with multiple myeloma in\n___. He discusses his ongoing treatment, and states that after\nbeing diagnosed he went \"doctor shopping.\" He states that\nyesterday he felt a pain in his shoulder and worried that it was\nconnected to his multiple myeloma and so he decided to go to his\noncologist's office. From his oncologist office, he was referred\nto the ED for additional help.\n\nThe patient states that he has been previously treated for\nsubstance abuse, and continue to misuse Klonopin and Ativan. He\nstates \"I can't live like this anymore.\" He goes into detail\nabout how his wife filed for divorce a couple of years ago. He\nwent to live with his mother initially but then had difficultly\nliving with her and so his wife allowed him to move back into \nthe\nhouse. He currently has a difficult relationship with his wife.\nHe reports multiple verbal altercations and states that his wife\nhas called the police on him, but denies that any of the\narguments have been physical. \n\nHe reports that his family has been concerned over he past few\ndays due to his confusion. He states that yesterday, he thought\nthat it was Christmas. He states that he \"told the doctor this,\"\npointing to Dr. ___ in the room. Of note, the patient had not\ntold this story previously to Dr. ___. He states that his\ndaughter was worried about him watching his grandson alone due \nto\nhis confusion. \n\nRegarding his Klonopin and Ativan use, the patient reports that\nhe generally will use around 4 mg per day or Klonopin or Ativan,\nbut may use up to 10 mg per day. He states that he will \nalternate\nwhich medication he takes. He states that he has learned \"what \nto\nsay\" to doctors in order to obtain prescriptions. He has also\nbeen taking Seroquel around 4x/day, although is unsure of the\ndose. \n\nHe reports recent thoughts of \"wanting to let his cancer kill\nhim\" but denies current SI. Reports that he currently feels safe\non the unit. States that he would not want to hurt himself\nbecause of his children. \n\nPAST PSYCHIATRIC HISTORY:\nPer Dr. ___ ___ consultation note, confirmed and\nupdated with patient: \n - Diagnoses: Depression\n - Hospitalizations: ___ prior hospitalizations at ___ on a\nspecial unit for police and firemen\n - Current treaters and treatment: Dr. ___ in ___ with\n___ Psychiatry, sees a therapist before his medication\nappointment \n - Medication and ECT trials:\n He is currently unsure - per review of ___ looks like he \nhas\nbeen on Zoloft, Quetiapine, Lorazepam, Clonazepam, Doxepin\n - Self-injury: Unknown \n - Harm to others: Denies \n - Access to weapons: Denies \n\n \nPast Medical History:\n*S/P AUTOLOGOUS STEM CELL TRANSPLANT \nACUTE RENAL FAILURE \nAUTO HPC, APHERESIS INFUSION \nGOUT \nMULTIPLE MYELOMA \nSTEM CELL COLLECTION \nSTUDY ___ \nTHERAPUTIC PLASMAPHERESIS \nMULTIPLE MYELOMA \nDEPRESSION \nADVANCE CARE PLANNING \nBACK PAIN \n - Denies h/o head injuries or seizure\n \nSocial History:\n___\nFamily History:\npaternal grandmother was institutionalized. \n \nPhysical Exam:\nPHYSICAL EXAMINATION:\n\nVS: T: 97.7 , BP: 158/88, HR: 82, R: 20, O2 sat: 99% on RA\n\nGeneral: elderly male in NAD. Well-nourished, well-developed.\nAppears stated age.\nHEENT: Normocephalic, atraumatic. PERRL, EOMI. Oropharynx clear.\nNeck: Supple.\nBack: No significant deformity.\nLungs: CTA ___. No crackles, wheezes, or rhonchi.\nCV: RRR, no murmurs/rubs/gallops. \nAbdomen: +BS, soft, nontender, nondistended. No palpable masses\nor organomegaly.\nExtremities: No clubbing, cyanosis, or edema.\nSkin: No rashes, abrasions, scars, or lesions. \n\nNeurological:\n\nCranial Nerves:\n-Pupils symmetry and responsiveness to light and accommodation:\nPERRLA\n-EOM: full\n-Facial sensation to light touch in all 3 divisions: equal\n-Facial symmetry on smile: symmetric\n-Hearing bilaterally: normal\n-Phonation: normal\n-Tongue: midline\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\nno tremor. Gait: Steady. Normal stance and posture. No truncal\nataxia.\n\nIn initial personal interview, pt reported:\"I am sick and tired \nof being\nsick and tired\". He admitted experiencing several major losses \nwithin last couple years: loss of health ___ Multiple Myeloma; \nloss of job ___ health issues; marriage falling apart and wife \ndivorcing him ___ ___ ago; feeling that \"kids are ashamed\" of him. \nHe admitted dealing with depression in the context of multiple \nlosses. Denied S/H/I. Reported that children are important\nprotective factors for him. \nHe admitted to have problem controlling intake of \nBenzodiazepines and opiates. Pt reported that Seroquel has been \ncontributing to his confusion. Per ___, pt's daughter expressed \nconcern about pt's decline in the context of starting Ambien. Pt \nalso reported being confused: e.g., he started to talk about \nChristmas in the middle of the ___; per daughter, pt has been \nfrequently confused about time of the day. Pt described episode \nof confusion/visual\nhallucinosis when he thought his sister was sitting with him in\nthe car. Pt exhibited some confabulation during the interview \n(he\nbelieved that he already spoke with writer and told his story).\n\nRe. medical sx's, he complained of pain in L shoulder blade\n(___), acceptable level of pain ___.\n\nVS: 158/88; 82\nPt's initial clinical exam could be summarized as delirious \nsyndrome: he\nappeared to be somewhat confused in the sequency of events.\nHowever, he was able to state date (___). NAD, no facial\nasymmetry, unremarkable gait. His face appeared to be flushed. \nHe\nwas friendly, cooperative with interview. Spontaneous fluent\nspeech in normal rate and prosody. Somewhat vague TP, vague \nabout\ntime sequence of the events. Described depression, severe \nanxiety\n(___). Described episode of confusion with VH (seeing sister \nin\nhis car). Clearly denied S/H/I. Stating that his cares about his\nchildren. Pt's insight and judgment were decreased ___\nneuro-cognitive issues. He was quite inattentive. He was unable\nto register ___ even after 3 attempts (registered ___ recalled\n___ after 3 min delay. Identified third item from the list.\nDecreased digit span: 5df and 3 db. He was unable to answer\nquestion \"If the flag waves towards the Southeast, where is the\nwind coming from?\" He responded: \"Southeast...Northeast?\"\n\nIMP: While there was concern for mood disorder in the context of\nmultiple psycho-social and medical stressors, delirium better\ndescribed pt's initial clinical presentation. As for possible\ncontributors: benzodiazepines; benzodiazepine withdrawal;\nexposure to meds with anticholinergic side effects (e.g.,\nseroquel, Doxepin) have been considered on top of diff \ndiagnosis.\n\n \nPertinent Results:\n___ 07:55PM BLOOD WBC-4.1 RBC-4.49* Hgb-14.7 Hct-40.8 \nMCV-91 MCH-32.7* MCHC-36.0 RDW-13.4 RDWSD-42.9 Plt Ct-83*\n___ 06:30PM BLOOD Glucose-108* UreaN-10 Creat-1.2 Na-141 \nK-4.7 Cl-102 HCO3-19* AnGap-20*\n___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-POS*\n___ 07:30PM URINE bnzodzp-POS* barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n \nBrief Hospital Course:\n1. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. On ___ the patient signed a 3 \nday notice, and was discharged prior to the 3 day notice \nexpiring. He was placed on 15 minute checks status on \nadmission. The patient was briefly switched to q5 minute checks \nper patients request, as patient felt unsafe with other patients \nknowing that he was a police officer. However, he was quickly \nchanged back to q15 minute checks, which remained the rest of \nhospitalization while being unit restricted. There were no \nbehavioral concerns requiring restraint or seclusion. \n\n2. PSYCHIATRIC:\nOn admission, patient reported worsening depression in the \ncontext of psychosocial stressors and medical issues. Given the \n___ confusion, the ___ Seroquel and Doxepin were \nheld on admission. The patient consistently denied SI. The \npatient had initially reported to his oncology providers that he \nhad a gun at home, however he consistently denied this during \nhospitalization. The patient was started on Risperdal 0.5 mg QHS \nwith 0.5 mg BID PRN, which he tolerated well. The patient was \ninitially irritable, and was focused on being discharged to a \nprogram at ___ that he had previously attended. Social work \ndiscussed the patient with this program, however patient was \ndeclined due to acuity. During hospitalization, the patient \nreported improvement in his depressive symptoms and became more \nengaged in sessions with the treatment team. He was motivated to \nengage in further treatment and was agreeable attending PHP at \n___ after discharge. \n\n3. SUBSTANCE USE DISORDERS:\n#) Benzodiazepine use disorder\nThe patient reported misusing benzodiazepines. On admission, he \nreported using around 4 mg per day or Klonopin or Ativan, but \nmay use up to 10 mg per day. Per ___, the patient was \nprescribed Klonopin 1 mg QID. On admission, the patient was \nplaced on standing Klonopin 1 mg TID and placed on CIWA with 0.5 \nmg q4h PRN CIWA >10. During the first couple of days of \nadmission, the patient intermittently required PRN Klonopin per \n___ protocol. During admission, CIWA was discontinued and \n___ standing Klonopin was decreased to 1 mg qAM, 0.5 mg in \nthe afternoon, and 1 mg qPM, which he tolerated well. The team \ndiscussed with the patient extensively the risks of ongoing use \nof benzodiazepines. The patient was instructed to not drive once \ndischarged. He was encouraged to follow up in outpatient to \ncontinue to decrease his use of benzodiazepines, and patient \nreported motivation to do this. \n\n4. MEDICAL\n#)Delirium\nOn presentation, patient reported confusion and MSE was notable \nfor tangential and circumstantial thought process. This \ncoincided with initiation of multiple psychotropic medications, \nmany of which have sedating and anticholinergic\nproperties (Seroquel, Doxepin), coupled with ongoing misuse and \nover use of benzodiazepines. A MOCA was completed in the ED, and \nthe patient scored a ___, losing points in all domains. \n___ daughter reported that in the past few months, the \npatient has seemed disoriented and did odd behaviors such as not \nremembering how to turn on a car and putting things in the \nmicrowave that should not be microwaved. On admission, the \n___ Seroquel and Doxepin were held. He was given ramelteon \nQHS to help with sleep. Extensively discussed with the patient \nhow his misuse of benzodiazepines is contributing to his \ncognitive issues. His Klonopin was down titrated to 1 mg qAM, \n0.5 mg at 3 ___, and 1 mg QHS. During admission, the patient \nreported improvement in his confusion. He was able to attend to \nhis ADLs and participated in interview, although continued to be \ntangential. His completed another MOCA on ___, and scored a \n___. At discharge, the patient was engaged with his treatment \nteam with a linear thought process and was able to discuss \noutpatient treatment options, as above. He reported motivation \nto continue to reduce his benzodiazepine use. \n\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. The \npatient initially refused to attend groups, however was later \nable to engage in some groups. He was social in the milieu. \nThere were no behavioral concerns requiring restraint or \nseclusion. \n\n#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT\n\nThe team communicated with Dr. ___ outpatient \npsychiatrist, with ___ permission. Dr. ___ \nthat he was not aware of the patient misusing his medication. \nConfirmed that the patient has been hospitalized at ___ \npreviously. He stated that the patient was often anxious, but no \nhistory of SI. \n\n#) INTERVENTIONS\n- Medications: started Risperdal 0.5 mg QHS, Risperdal 0.5 mg \ndaily PRN, discontinued Seroquel and Doxepin, down titrated to \nKlonopin 1 mg BID\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: Patient to follow up with his \noutpatient psychiatrist, Dr. ___ as well as ___ ___\n-Guardianships: N/A\n\nOn the discharge day, Mr. ___ was adamant that he would like to be \ndischarged. He said that he will continue with outpatient \ntreatment. He claimed that he will follow up with recommendation \nto attend partial hospital program. He clearly and repeatedly \ndenied any intend to hurt himself or anybody else.\nWhile inpt team recommended pt to continue with inpt level of \ncare, there were no legal grounds to impose inpt level of \ntreatment.\n\nINFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nstarting this medication Risperdal, and risks and benefits of \npossible alternatives, including not taking the medication, with \nthis patient. We discussed the ___ right to decide whether \nto take this medication as well as the importance of the \n___ actively participating in the treatment and discussing \nany questions about medications with the treatment team. The \npatient appeared able to understand and consented to begin the \nmedication.\n\nRISK ASSESSMENT & PROGNOSIS\nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to himself based upon inability to care \nfor self. His static factors noted at that time include age, \nCaucasian race, previous psychiatric hospitalization, chronic \nmedical illness, and divorced. His modifiable risk factors \nincluded active substance use disorder, poor coping skills, and \ndepression. During hospitalization, the patient reported \nimprovement in his depressive symptoms. He was encouraged to \nattend groups to develop coping skills. He reported motivation \nto continue to engage in outpatient treatment for his \nbenzodiazepine use. The patient is being discharged with many \nprotective risk factors, including no SI, no major mood episode, \nno psychosis, help seeking, and outpatient follow up. Based on \nthe totality of our assessment at this time, the patient is not \nat an acutely elevated risk of self-harm nor danger to others. \n\nOur Prognosis of this patient is guarded. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Acyclovir 400 mg PO Q12H \n3. ClonazePAM 1 mg PO QID \n\n \nDischarge Medications:\n1. RisperiDONE 0.5 mg PO QHS \nRX *risperidone [Risperdal] 0.5 mg 1 tablet(s) by mouth at \nbedtime Disp #*14 Tablet Refills:*0 \n2. RisperiDONE 0.5 mg PO BID:PRN anxiety/agitation \nRX *risperidone [Risperdal] 0.5 mg 1 tablet(s) by mouth daily \nPRN Disp #*14 Tablet Refills:*0 \n3. ClonazePAM 1 mg PO BID anxiety/withdrawal \nRX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*10 \nTablet Refills:*0 \n4. Acyclovir 400 mg PO Q12H \n5. Allopurinol ___ mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBenzodiazepine use disorder\nDelirium - resolved.\nDepression, not otherwise specified.\n\n \nDischarge Condition:\nVitals: T 97.7 BP 136/92 HR 81 RR 16 O2 95%\nMental Status:\nAppearance: No apparent distress, appears stated age, fair\ngrooming, appropriately dressed\nBehavior: calm, cooperative, appropriate eye contact, no\npsychomotor agitation or retardation\nMood and Affect: 'good' / euthymic, appropriate to situation\nThought Process: logical, linear\nThought Content: denies SI/HI, does not report AVH, no evidence\nof delusions or paranoia\nJudgment and Insight: fair/fair\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" ]

[ "F332", "C9000", "Z9484", "R45851", "F411", "Z818", "F1990", "F1190", "M109", "R0789", "D696", "Z9181" ]

[ "F332: Major depressive disorder, recurrent severe without psychotic features", "C9000: Multiple myeloma not having achieved remission", "Z9484: Stem cells transplant status", "R45851: Suicidal ideations", "F411: Generalized anxiety disorder", "Z818: Family history of other mental and behavioral disorders", "F1990: Other psychoactive substance use, unspecified, uncomplicated", "F1190: Opioid use, unspecified, uncomplicated", "M109: Gout, unspecified", "R0789: Other chest pain", "D696: Thrombocytopenia, unspecified", "Z9181: History of falling" ]

[ "M109", "D696" ]

[]

[ " \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:\nSOB, weight loss\n \nMajor Surgical or Invasive Procedure:\nBone marrow biopsy ___\nEGD ___\nColonoscopy ___\n\n \nHistory of Present Illness:\n___ is a ___ year old man with multiple myeloma,\northostatic hypotension, anxiety who presents with worsening\ndyspnea and weakness since he was discharged 3 days ago. The\npatient was just admitted ___ for similar symptoms of\nweakness, lightheadedness, shortness of breath, and failure to\nthrive. Overall, his symptoms were felt to be from a combination\nof polypharmacy, orthostatic hypotension, psychosocial stress,\nand severe malnutrition. Work up for his dyspnea was negative \nfor\nPE, pneumonia, and severe weakness. He did have an mild\nobstructive pattern on PFTs with a reduced negative inspiratory\nforce, normal sniff test. TTE on ___ revealed normal EF of\n60-65%. He was discharged home with services, with a plan to\nfollow up with palliative care outpatient, as well as ___\nclinic. \n\nHis symptoms now continue with marked dyspnea and weakness,\nthough he is satting well on room air in the ED. As was the case\nwhen he was discharged, he is only able to walk a few steps\nbefore needing to catch his breath. He has a poor appetite and\nstill has not been eating much. \n\nIn the ED, work up was performed to ensure no new causes of his\nsymptoms. ECG reassuring, trop negative, CXR clear, and his\nvitals are normal satting 99% on room air. \n \nUpon arrival to the floor, the patient confirms that he has not\nhad any new symptoms since discharge, just increasing concern\nthat he is not feeling better. While his appetite was good \nduring\nthe end of his last admission, it has worsened significantly\nagain. \n\nREVIEW OF SYSTEMS: \nA 10-point ROS was taken and is negative except otherwise stated\nin the HPI. \n \n \nPast Medical History:\nMultiple myeloma s/p autologous stem cell transplant ___,\nradiation\nOrthostatic hypotension\nOpiate withdrawal w/ substance use disorder\nDepression\nGout\n \nSocial History:\n___\nFamily History:\npaternal grandmother was institutionalized. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n======================\nVITALS: T 98.3 BP 158/100 HR 90 RR 16 O2 98% RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present,\nno organomegaly, no rebound or guarding \nGU: +foley \nExt: Warm, well perfused, no clubbing, cyanosis or edema --\ncompression stockings in place\nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII intact, ___ strength upper/lower extremities,\ngrossly normal sensation\nPsych: Flat affect\n\nDISCHARGE PHYSICAL EXAM:\n======================\n___ 1202 Temp: 97.5 PO BP: 152/78 L Sitting HR: 95 RR: 18 \nO2\nsat: 99% O2 delivery: RA \nGeneral: thin, no acute distress. \nLungs: clear bilaterally\nHeart: s1, s2 normal, nl rate, regular rhythm\nAbd: soft, non-tender.\nLower extremities: no edema\nSkin: no rash\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 06:25PM URINE HOURS-RANDOM\n___ 06:25PM URINE UHOLD-HOLD\n___ 06:25PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 06:25PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 06:25PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 06:25PM URINE MUCOUS-RARE*\n___ 05:30PM GLUCOSE-126* UREA N-15 CREAT-0.9 SODIUM-140 \nPOTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-23 ANION GAP-12\n___ 05:30PM ALT(SGPT)-12 AST(SGOT)-13 CK(CPK)-16* ALK \nPHOS-52 TOT BILI-1.0\n___ 05:30PM LIPASE-9\n___ 05:30PM cTropnT-<0.01\n___ 05:30PM CK-MB-<1 proBNP-400*\n___ 05:30PM ALBUMIN-4.5 CALCIUM-9.1 PHOSPHATE-3.2 \nMAGNESIUM-1.9\n___ 05:30PM WBC-4.6 RBC-3.16* HGB-10.7* HCT-31.3* MCV-99* \nMCH-33.9* MCHC-34.2 RDW-14.0 RDWSD-49.5*\n___ 05:30PM NEUTS-86.7* LYMPHS-7.4* MONOS-4.8* EOS-0.0* \nBASOS-0.4 IM ___ AbsNeut-3.98 AbsLymp-0.34* AbsMono-0.22 \nAbsEos-0.00* AbsBaso-0.02\n___ 05:30PM PLT COUNT-77*\n\nINTERVAL LABS:\n===============\nTest Result Reference \nRange/Units\nCALPROTECTIN, STOOL 178.0 H mcg/g\n___ 07:00AM BLOOD TSH-1.0\n___ 06:26AM BLOOD T4-5.8 T3-61*\n___ 06:14AM BLOOD HIV Ab-NEG\n\nDISCHARGE LABS:\n===============\n\nIMAGING:\n========\nCXR ___:\nIMPRESSION: No evidence of a cute cardiopulmonary process.\n\nColonoscopy ___:\nImpressions: high residue material was noted throughout. \nMultiple\nattempts were made to irrigate the colon but the mucosa could \nnot\nbe visualized adequately. Normal mucosa in the whole colon, with\nbiopsy. \nRecommendations: Follow up pending biopsy results. No evidence \nof\ncolitis or abnormal mucosa. Given inadequate prep, colonoscopy \nis\nin adequate for screening. \n\nEGD ___:\nImpressions: Normal mucosa in the whole esophagus, esophageal\nhiatal hernia. Erythema in the stomach compatible with \ngastritis,\nbiopsy done. Erosions in the antrum. Normal mucosa in the whole\nexamined duodenum, biopsy done. \nRecommendations: Follow up pending biopsies, continue daily PPI,\nproceed with colonoscopy. \n\nPATHOLOGIC DIAGNOSIS:\n1. Stomach, biopsy:\n-Antral and fundic mucosa within normal limits.\n2. Duodenum, biopsy:\n-Duodenal mucosa within normal limits.\n3. Right colon, biopsy:\n-Colonic mucosa within normal limits.\n4. Transverse colon, biopsy:\n-Colonic mucosa within normal limits.\n5. Left colon, biopsy:\n-Colonic mucosa within normal limits.\nAll tested for ___ RED and Negative\n\nMICROBIOLOGY:\n=============\nUrine culture negative\n\n \n\n \nBrief Hospital Course:\n___ who presents after a recent discharge just a few days prior \nto admission with continued failure to thrive at home with \ncontinued dyspnea, weakness, and malnutrition. At discharge, \netiology was unclear, however given substantial weight gain \nwhile inpatient, determined discharge with close follow-up would \nbe sufficient. \n\nTRANSITIONAL ISSUES: \n==================\n[] Noted to have low T3 with normal T4 and TSH; Recommend \nrechecking thyroid function tests in outpatient setting and \nconsideration of levothyroxine initiation\n[] Fecal calprotectin level pending at discharge; please \nfollow-up. Recommend GI referral for further evaluation if this \nremains abnormal. \n[] A script was provided for outpatient physical therapy. \nPatient states he goes to his local YMCA which has a physical \ntherapy outpatient program. \n[] At discharge, following appointments were pending scheduling: \n\n- Urology (Dr. ___ to coordinate; follow-up for urinary \nretention and bladder training)\n- ___ (Request placed for Dr. ___\n- Palliative Care (Dr. ___ \n\nACTIVE ISSUES:\n==============\n#Failure to thrive and weakness: Unclear etiology, likely \nmultifactorial. He was placed on fall precautions and instructed \nto ambulate with a walking. We discontinued salt tabs as pt was \ndrinking enough fluid and sodium was increasing. Continue home \nMV, B12, folate supplements, vit D. Nutrition and ___ evaluate \nthe patient and recommended SAR. Palliative care clinician and \nSW continued to participate care and with their help we were \nable to discontinue tramadol. He continued to eat and drink well \nwhile in house. All testing returned reassuring - specifically \nEGD/Colon with biopsies, MR ___. Repeat bone marrow \nbiopsy without any evidence of myeloma activity. \n\n#elevated calprotectin\nTo evaluate the elevated calprotectin an EGD and Colonoscopy \nw/biopsies were done on ___, mucosa generally normal, some \nknown gastritis, biopsies normal and amyloid negative. MRE was \ndone to eval the small bowel which was normal. As testing was \nnormal a repeat calprotectin was done and pending at discharge. \n\n#Chronic Pancytopenia\nUnclear etiology of chronic pancytopenia. Pt has not been on \nrecent tx of MM since ___. Also does not clearly \ncorrelate with known dates of treatment. \n\n#MULTIPLE MYELOMA: \nMost recently he was treated with a dose of ixazomib but has \nbeen off therapy now for a months due to significant \ndeconditioning and incorrectly taking the medication which \nrequired a prolonged hospital admission including ICU in \n___. Most recent PET in ___ negative for MM. Continued \nhome prednisone 10mg plan to continue taper as outpatient. \nContinued atovaquone and acyclovir ppx. Bone marrow biopsy did \nnot show any myeloma activity. \n\n#ORTHOSTATIC HYPOTENSION: DAILY orthostatic blood pressure \nmeasurements were done, which redemonstrated significant \northostatic hypotension, however pt denies symtoms. Increased \nfludrocortisone from 0.1 to 0.2mg PO daily. Continued thigh high \ncompression stockings. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose \n2. Nystatin Oral Suspension 10 mL PO QID:PRN thrush \n3. Fludrocortisone Acetate 0.1 mg PO DAILY \n4. PredniSONE 10 mg PO DAILY \n5. Acetaminophen 1000 mg PO Q8H \n6. Acyclovir 400 mg PO Q12H \n7. Atovaquone Suspension 1500 mg PO DAILY \n8. Bengay Cream 1 Appl TP BID:PRN knee pain \n9. ClonazePAM 1 mg PO BID \n10. Cyanocobalamin 1000 mcg PO DAILY \n11. Escitalopram Oxalate 20 mg PO DAILY \n12. FoLIC Acid 1 mg PO DAILY \n13. Gabapentin 900 mg PO QHS \n14. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n15. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \n16. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H \n17. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n18. Senna 8.6 mg PO BID \n19. TraMADol 50 mg PO QHS \n20. Zolpidem Tartrate 12.5 mg PO QHS \n21. Multivitamins W/minerals 1 TAB PO DAILY \n22. Mirtazapine 15 mg PO QHS \n23. Docusate Sodium 100 mg PO BID \n24. Omeprazole 40 mg PO DAILY \n25. Gabapentin 600 mg PO BID \n26. Sodium Chloride 2 gm PO TID W/MEALS \n27. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral \nDAILY \n\n \nDischarge Medications:\n1. Fludrocortisone Acetate 0.2 mg PO DAILY \n2. Zolpidem Tartrate ___ mg PO QHS:PRN sleep \n3. Acetaminophen 1000 mg PO Q8H \n4. Acyclovir 400 mg PO Q12H \n5. Atovaquone Suspension 1500 mg PO DAILY \n6. Bengay Cream 1 Appl TP BID:PRN knee pain \n7. ClonazePAM 1 mg PO BID \n8. Cyanocobalamin 1000 mcg PO DAILY \n9. Docusate Sodium 100 mg PO BID \n10. Escitalopram Oxalate 20 mg PO DAILY \n11. FoLIC Acid 1 mg PO DAILY \n12. Gabapentin 900 mg PO QHS \n13. Gabapentin 600 mg PO BID \n14. Mirtazapine 15 mg PO QHS \n15. Multivitamins W/minerals 1 TAB PO DAILY \n16. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose \n17. Nystatin Oral Suspension 10 mL PO QID:PRN thrush \n18. Omeprazole 40 mg PO DAILY \n19. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n20. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \n21. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H \n22. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n23. PredniSONE 10 mg PO DAILY \n24. Senna 8.6 mg PO BID \n25. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral \nDAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n=================\nOrthostatic hypotension\n\nSECONDARY DIAGNOSIS:\n===================\nFailure to thrive\nmalnutrition\nurinary retention\ndyspnea without hypoxia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Mr. ___, \n \nIt was a privilege caring for you at ___. \nPlease see below for more information on your hospitalization. \n \nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- For shortness of breath and unsteadiness on your feet. \n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- We looked at your entire gut system with upper endoscopy, \ncolonoscopy, and imaged your small intestine. \n- We took biopsies of your gut which were normal\n- All of this testing was normal. \n- We increased a medication to help with your orthostatic \nhypotension\n- We did a bone marrow biopsy that showed no myeloma activity in \nyour bone marrow.\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- Seek medical attention if you have new or concerning symptoms \nor you develop shortness of breath, chest pain, falls, or weight \nloss.\n\nIt was a pleasure taking part in your care here at ___! \nWe wish you all the best! \n- Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I951", "E43", "C9001", "D61818", "Z681", "F1120", "Z9484", "Z923", "M109", "F329", "R627", "R7989", "R531", "K449", "K2970", "Z7902", "Z7952", "Z9181", "G8929", "G629", "R339" ]

[ "I951: Orthostatic hypotension", "E43: Unspecified severe protein-calorie malnutrition", "C9001: Multiple myeloma in remission", "D61818: Other pancytopenia", "Z681: Body mass index [BMI] 19.9 or less, adult", "F1120: Opioid dependence, uncomplicated", "Z9484: Stem cells transplant status", "Z923: Personal history of irradiation", "M109: Gout, unspecified", "F329: Major depressive disorder, single episode, unspecified", "R627: Adult failure to thrive", "R7989: Other specified abnormal findings of blood chemistry", "R531: Weakness", "K449: Diaphragmatic hernia without obstruction or gangrene", "K2970: Gastritis, unspecified, without bleeding", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z7952: Long term (current) use of systemic steroids", "Z9181: History of falling", "G8929: Other chronic pain", "G629: Polyneuropathy, unspecified", "R339: Retention of urine, unspecified" ]

[ "M109", "F329", "Z7902", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nFall\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo M with history of multiple myeloma, anxiety, and\northostatic hypotension presenting with weakness,\nlightheadedness, shortness of breath, decreased intake by mouth,\nand weight loss. \n\nHe had 2 falls today ___ when getting up from the bed and\nwalking to the bathroom. He reports feeling dizzy with SOB,\ndenies palpitations/CP. He fell on his back denies headstrike. \nHe\nthen tried to get back up and fell again. He denies LOC. \n\nOver the past 2 wks he had has progressive SOB. He reports that \n4\nwks ago he was able to walk over a block, but now is unable to\nwalk more than a few steps before feeling SOB. Denies any cough,\nsputum production, hemoptysis, congestion. He reports that SOB\nwas not present during his last admission. Pt reports he sleeps\nwith 4 pillows but is able to lay flat w/o dyspnea, denies PND. \n\nHe also mentions that for the past 3 days he has had minimal \noral\nintake due to lack of appetite. He reports 6lbs unintentional wt\nloss since discharge. Denies n/v/diarrhea. Mentioned that his\nappetite has been low since about ___. \n\nOf note, was recently admitted at ___ ___ with similar\nsymptoms of dizziness, poor oral intake and fall. It was that\nthat his falls were due to orthostatic hypotension which was\ntreated with midodrine, compression stockings and salt tabs. It\nwas also thought that the medications could also be contributing\nand a taper was started. He was also instructed to f/u with\n___ clinic w/Dr ___ reports that his appointment\nwas scheduled for today ___ but he presented to the ED for\nthe fall. \n\nLast saw Dr. ___ on ___ after discharge, pt reported\nworsening neuropathy in setting of decreased gabapentin. At that\ntime it seemed that his MM did not require immediate therapy as\nrecent evaluation w/o clear evidence of disease. \n\nIn the ED:\n- Initial vital signs were notable for: afeb, 110, 116/73, 18 \n95%\nRA, lowest BP 81/55\n- Exam notable for: oral thrush, tachycardic. \n- Labs were notable for:\n142 | 106 | 16 / \\ 11.1 /\n----------- 124 5.5 --- 111\n3.9 | 22 | 1.2 \\ / 31.5 \\\n\nCa 9 | Mg 2 |Phos 2.4\n___ 12 |PTT 23.1 | INR 1.1\nLactate 3.2\nBlood cultures pending\n- Studies performed include:\nCXR, CT Head\n- Patient was given: \n1L IVF\n- Consults: None\nVitals on transfer: 98.4 91 118/69 18 99% RA\n\nUpon arrival to the floor, pt reports that he is hungry and \nwould\nlike a diet so that he can order food. He reports that his\nsymptoms are similar to his last admission but the SOB is new,\nagain he emphasized that he is unable to ambulate more than a \nfew\nsteps before feeling SOB. Again denies fever, chills, n/v,\ndiarrhea, dysuria, cough, palpitations, CP, orthopnea, PND, leg\nswelling. Also mentioned that his sister, who he lives with had \na\ncold last week. \n \nPast Medical History:\nMultiple myeloma s/p autologous stem cell transplant ___,\nradiation\nOrthostatic hypotension\nOpiate withdrawal w/ substance use disorder\nDepression\nGout\n \nSocial History:\n___\nFamily History:\npaternal grandmother was institutionalized. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n======================\nVitals: 24 HR Data (last updated ___ @ 1731)\n Temp: 98.1 (Tm 98.1), BP: 115/77, HR: 94, RR: 20, O2 sat:\n100%, O2 delivery: Ra, Wt: 129 lb/58.51 kg \nGen: Cachectic, Lying in bed. NAD\nHEENT: PERRLA, EOMI, pupils 4mm. No conjunctival pallor. No\nicterus. Dry MM. No visible thrush. \nNECK: JVP wnl, no hepatojugular reflux\nLYMPH: No cervical or supraclav LAD\nCV: Tachycardic, irregular rhythm. No MRG. \nLUNGS: No incr WOB. reduced air movement B/L. No wheezes, \nrales,\nor rhonchi. When standing pt becomes dyspneic\nABD: ND, nl bowel sounds, NT, no HSM.\nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: AOx3. CN ___ intact. Full strength in upper and lower\nextremities \n\nDISCHARGE PHYSICAL EXAM:\n======================\nGen: Cachectic, Lying in bed. NAD\nHEENT: PERRLA, EOMI, No conjunctival pallor. No icterus. Dry MM.\nNo visible thrush. \nNECK: JVP present about mid neck\nLYMPH: No cervical or supraclav LAD\nCV: regular rhythm . No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: thin,ND, nl bowel sounds, NT, no HSM.\nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: AOx3. CN ___ intact. Full strength in upper and lower\nextremities \nGU: normal appearing genitalia. Testes w/o edema or erythema. L\ntesticle tender, no palpable masses. Unable to appreciate\ninguinal hernia. R testicle normal\n\n \nPertinent Results:\nADMISSION LABS:\n==============\n\n___ 07:35PM ALT(SGPT)-6 AST(SGOT)-7 LD(LDH)-160 ALK \nPHOS-47 TOT BILI-1.3\n___ 07:35PM TOT PROT-5.1* ALBUMIN-3.9 GLOBULIN-1.2*\n___ 07:35PM PEP-HYPOGAMMAG Free K-1.5* Free ___ Fr \nK/L-0.25* IgG-292* IgA-16* IgM-12*\n___ 07:35PM D-DIMER-824*\n___ 03:06PM ___ COMMENTS-GREEN TOP \n___ 03:06PM LACTATE-1.4\n___ 10:39AM ___ COMMENTS-GREEN TOP \n___ 10:39AM LACTATE-3.2*\n___ 10:32AM GLUCOSE-124* UREA N-16 CREAT-1.2 SODIUM-142 \nPOTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14\n___ 10:32AM estGFR-Using this\n___ 10:32AM CALCIUM-9.0 PHOSPHATE-2.4* MAGNESIUM-2.0\n___ 10:32AM ASA-NEG ACETMNPHN-NEG tricyclic-NEG\n___ 10:32AM WBC-5.5 RBC-3.30* HGB-11.1* HCT-31.5* MCV-96 \nMCH-33.6* MCHC-35.2 RDW-14.3 RDWSD-48.4*\n___ 10:32AM NEUTS-56.5 ___ MONOS-11.7 EOS-0.2* \nBASOS-0.6 IM ___ AbsNeut-3.08 AbsLymp-1.65 AbsMono-0.64 \nAbsEos-0.01* AbsBaso-0.03\n___ 10:32AM ___ PTT-23.1* ___\n___ 10:32AM PLT COUNT-111*\n\nDISCHARGE LABS:\n===============\n\n___ 06:40AM BLOOD WBC-2.8* RBC-2.58* Hgb-8.7* Hct-26.3* \nMCV-102* MCH-33.7* MCHC-33.1 RDW-14.3 RDWSD-51.5* Plt Ct-63*\n___ 06:00AM BLOOD Neuts-49.3 ___ Monos-13.0 \nEos-0.5* Baso-0.5 Im ___ AbsNeut-1.02* AbsLymp-0.74* \nAbsMono-0.27 AbsEos-0.01* AbsBaso-0.01\n___ 06:40AM BLOOD Plt Ct-63*\n___ 06:35AM BLOOD ___ PTT-UNABLE TO ___\n___ 07:35PM BLOOD D-Dimer-824*\n___ 06:40AM BLOOD Glucose-86 UreaN-17 Creat-0.7 Na-142 \nK-4.6 Cl-104 HCO3-30 AnGap-8*\n___ 06:40AM BLOOD ALT-7 AST-9 LD(LDH)-156 AlkPhos-52 \nTotBili-0.5\n___ 06:40AM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.3 Mg-2.0\n___ 06:15AM BLOOD VitB12-450 Folate-13 Hapto-<10*\n___ 03:20PM BLOOD calTIBC-222* Ferritn-370 TRF-171*\n___ 03:40PM BLOOD %HbA1c-4.4 eAG-80\n___ 06:00AM BLOOD 25VitD-21*\n___ 06:00AM BLOOD Cortsol-1.6*\n___ 07:35PM BLOOD PEP-HYPOGAMMAG FreeKap-1.5* FreeLam-5.9 \nFr K/L-0.25* IgG-292* IgA-16* IgM-12*\n___ 10:32AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG\n___ 03:40PM BLOOD tTG-IgA-0\n___ 10:39AM BLOOD Lactate-3.2*\n___ 03:06PM BLOOD Lactate-1.4\n___ 03:40PM BLOOD HVY MTL (WHLE BLD NVY/EDTA)-Test \n\nIMAGING:\n========\nCXR ___: IMPRESSION: No acute intrathoracic process.\n\nCT Head ___: IMPRESSION:1. No acute intracranial process. No\nfracture.\n \nTTE ___: EF 60-65% suboptimal study, no change obvious \nchange\nfrom prior\n\nMRI spine ___:\nIMPRESSION:\n1. Study is moderately degraded by motion.\n2. No definite evidence of fracture.\n3. Scattered myelomatous lesions are unchanged.\n4. Within limits of study, no definite new or enlarging \nmyomatous\nlesions identified.\n5. Previously seen enhancement of the cauda equina nerve roots \nis\nless\nconspicuous.\n6. Grossly stable multilevel thoracic and lumbar spondylosis\ncompared to 3 weeks prior thoracic and lumbar spine contrast MRI\nas described, again most pronounced at L3-4 where there is\nmild-to-moderate vertebral canal, moderate left and severe right\nneural foraminal narrowing.\n7. Limited imaging of the lungs suggests bilateral scarring and\nprobable dependent atelectasis. If concern for lung opacities,\nconsider dedicated chest imaging for further evaluation.\n\nSniff test ___:\nIMPRESSION: No evidence of diaphragmatic paralysis.\n\nPFTS: ___\nFEV1/FVC: 62% \nDsbHb 83% \nMIP 44%\nMEP 33%\n\nScrotal U/S ___:\nIMPRESSION:\n1. Heterogeneous echotexture of the right testis without \nevidence of focal\nmass or abnormal vascularity. Findings may reflect sequelae of \nprior injury.\n2. Otherwise normal scrotal ultrasound.\n\nMICROBIOLOGY:\n=============\n\n___ 3:40 pm Blood (LYME)\n\n Lyme IgG (Pending): \n\n Lyme IgM (Pending): \n__________________________________________________________\n___ 5:42 am URINE Source: Catheter. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n__________________________________________________________\n___ 10:32 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n \nBrief Hospital Course:\n___ with multiple myeloma presents with progressive dyspnea, \nfailure to thrive, dizziness and mechanical falls after recent \nhospitalization for similar symptoms.\n\nTRANSITIONAL ISSUES: \n==================\n[] New Meds:\nFludrocortisone 0.1mg PO Daily for orthostatic hypotension\nNaloxone Inhaler for opioid overdose\nPrednisone 10mg PO daily WILL NEED TAPER ONLY GIVEN 7DAY Rx\nMultivitamins with minerals daily\nVitamin D3 2000U daily\n[] Stopped/Held Meds:\nDexamethasone\nMidodrine \n[] Discharge weight: 62 kg \n[] Consider ADDRESSING POLYPHARMACY to help reduce the risk of \nfalls: patient on multiple psych/sedating medications as well as \nopioid/pain medications\n[] f/u orthostatic blood pressure and symptoms consider \nuptitrating Fludrocortisone to 0.2mg daily \n[] Continue to wear thigh high compression stockings\n[] F/u weights for adequate oral intake, encourage fluid intake \n___ daily \n[] Discharge Creatinine: 0.7\n[] Continue BM regimen as on chronic opioids \n[] Only new medication Rx's were provided, no opioid, psych, \nsleep prescriptions were provided as pt should have enough at \nhome after reviewing fill history and time in hospital\n\nFOLLOW UP APPOINTMENTS:\n[] F/u with urology: Dr. ___ will coordinate f/u for urinary \nretention and bladder training\n[] f/u with ___ clinic: Request placed for Dr. ___, \n___ will f/u on HBA1c, B1, B6, ___, Ro, La, ACE, heavy metals, \ntTG IgA, lyme, HIV, urine PBG, BNP\n[] f/u with palliative care: Dr. ___ ___ 9am\n[] f/u PCP: Dr. ___ ___ 10AM\n\nACTIVE ISSUES:\n=============\n#POLYPHARMACY:\nPt is on many medications that may be contributing to his \nrecurrent falls which include Clonazepam, gabapentin, oxycodone, \noxycontin, tramadol, zolpidem, and mirtazepapine. We would \nhighly suggest that his polypharmacy burden be reduced given \nrecurrent admissions. \n\n#dyspnea: Pt with 4wk hx of dyspnea that has been progressively \nworsening now he can only take a couple steps. Modified Wells \nscore 2.5/unlikely. CXR clear. Denies hemoptysis. On exam Tachy, \nwith reduced air movement. Dyspnea upon standing. CTA negative \nfor PE. Monitored on Tele which was NSR. PFTs were done showing \nobstructive pattern with reduced MIP. Sniff test nl diaphragm \nmovement. Pulmonology was consulted. Dyspnea improved with IVF \nand nutrition, thus it was thought to be secondary to underlying \northostatic hypotension. This improved prior to discharge\n\n#Falls\n#Orthostatic hypotension\nPt has long hx of falls which are likely multifactorial: \northostatic hypotension, polypharmacy (including opioids), \nnon-compliance with walker, and possible large fiber sensory \nneuropathy. Pt with hx of orthostatic hypotension. Recently has \nalso had poor PO intake which may further exacerbate orthostatic \nhypotension. Other possibilities include adrenal insufficiency, \nPOEMS syndrome, autonomic dysfunction ___ Parkinsonism (no \nsigns/symptoms). Was instructed to f/u with Dr ___ \n___ clinic. Neurology was consulted and suggested a \npanel of labs for small fiber polyneuropathy, most of which are \npending, we have requested f/u with Dr. ___ will f/u on \nthe labs. We continued compression stockings. Stopped home \nmidodrine and started Fludrocortisone 0.1 mg po daily for \northostatic hypotension in the hopes of better home compliance. \n\n#urinary retention\n#testicular pain\nDuring admission pt had intermittent urinary retention requiring \nstraight catheterization. Urology was consulted, they \nrecommended foley placement and will f/u with him as an \noutpatient for straight cath education and urodynamic testing. \nMRI was done to evaluate his thoracic and lumbar spine which \nrevealed no change in known lesions. Pt then complained of \ntesticular pain, testicular U/S was reassuring and it was likely \ndue to tension on foley, this resolved when foley was addressed. \n\n\n#Multiple Myeloma\nMM studies were stable. He was admitted on dexamethasone 2mg po \ndaily and was transitioned to prednisone 10mg PO daily. He \ncontinued home acyclovir, atovaquone and omeprazole.\n\n#FFT\n#severe MALNUTRITION: \nLikely multifactorial given multiple chronic issues outlined \nabove. As well as psychosocial stressors at home. Psych was \nconsulted and helped to clarify medications. Palliative was \nconsulted as they followed him during the last admission. \nNutrition was consulted. We continued B12, folate, and MVI. GI \nwas consulted and suggested stool elastase and calprotectin both \nremain pending. SW was consulted to help with resources. \n\n___ (resolved): Creatine on admission was 1.2 with rehydration \ndecreased to 0.5, suggesting it was likely pre-renal in setting \nof poor PO intake. Urine culture was negative. PO intake was \nencouraged. Creatinine upon discharge was \n\n#CHRONIC MALIGNANCY ASSOCIATED PAIN\n#Opiate use \nPer OMR, Management previously complicated by history of opiate \nmisuse. Recently transitioned from morphine to oxycodone. Stable \npain in knees and back. Has narcotic contract with ___, \nhowever this was discontinued due to violation on ___. Has \nbeen Rx OxyCONTIN and Oxycodone by Dr. ___ filled ___ \nwith one month supply. Serum and urine tox screen were as \nexpected. No prescriptions for controlled substances were \nprovided on discharge. Home oxyCONTIN, oxycodone, lorazepam were \ncontinued as inpatient. Please consider reducing opioid \nmedications as may contribute to fall risk. Also on discharge \nwas given inhaled naloxone as a precaution for opioid overdose. \n\n#pancytopenia\n#thrombocytopenia \n#anemia\nOn arrival counts were low normal, however with IVF counts \ndecreased and remained low. Unclear etiology but counts were \nstable. MM may be contributing however MM labs do not suggest \nactive disease. There was was appears to be a spurious low \nplatelet count to 15, upon repeat was back up to 57, HIT abs \nwere checked and were negative. Smear was also done, no \nschistocytes were seen. \n\n#hypophos\nwas repleted per scale\n\n#Thrush\nPt reports 2 wks of stomach pain, denies odynophagia. On exam no \noral thrush. Pt may continue home nystatin as needed. \n\n#lactic acidosis (Resolved)\nLikely secondary to hypovolemia as improved with IVF\n\nCHRONIC ISSUES:\n==============\n#DEPRESSION: Continued home clonazepam BID (pt reports he takes \nit TID), home gabapentin, home Escitalopram and mirtaz\n\n#insomnia: continued home ?tramadol, home zolpidem\n\n# CODE: Presumed Full\n# EMERGENCY CONTACT: \nName of health care proxy: ___ \nRelationship: daughter \nPhone number: ___ \nAlternate HCP: ___ (son) ___ \n\nThis patient was prescribed, or continued on, an opioid pain \nmedication at the time of discharge (please see the attached \nmedication list for details). As part of our safe opioid \nprescribing process, all patients are provided with an opioid \nrisks and treatment resource education sheet and encouraged to \ndiscuss this therapy with their outpatient providers to \ndetermine if opioid pain medication is still indicated.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H \n2. Acyclovir 400 mg PO Q12H \n3. Atovaquone Suspension 1500 mg PO DAILY \n4. Bengay Cream 1 Appl TP BID:PRN knee pain \n5. ClonazePAM 1 mg PO BID \n6. Cyanocobalamin 1000 mcg PO DAILY \n7. Dexamethasone 2 mg PO DAILY \n8. Docusate Sodium 100 mg PO BID \n9. FoLIC Acid 1 mg PO DAILY \n10. Gabapentin 600 mg PO BID \n11. Gabapentin 900 mg PO QHS \n12. Midodrine 5 mg PO TID \n13. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \n14. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H \n15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n16. Senna 8.6 mg PO BID \n17. Nystatin Oral Suspension 10 mL PO QID:PRN thrush \n18. Omeprazole 40 mg PO DAILY \n19. Sodium Chloride 2 gm PO TID W/MEALS \n20. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n21. TraMADol 50 mg PO QHS \n22. Escitalopram Oxalate 20 mg PO DAILY \n23. Mirtazapine 15 mg PO QHS \n24. Zolpidem Tartrate 12.5 mg PO QHS \n\n \nDischarge Medications:\n1. Fludrocortisone Acetate 0.1 mg PO DAILY \nRX *fludrocortisone 0.1 mg 1 tablet(s) by mouth daily in the \nmorning Disp #*30 Tablet Refills:*0 \n2. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals [Vitamins and Minerals] 1 \ntablet(s) by mouth daily Disp #*30 Tablet Refills:*0 \n3. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose \nDuration: 1 Dose \nRX *naloxone [Narcan] 4 mg/actuation 1 spray nasal spray once \nDisp #*1 Spray Refills:*0 \n4. PredniSONE 10 mg PO DAILY \nRX *prednisone 5 mg 2 tablet(s) by mouth daily Disp #*20 Tablet \nRefills:*0 \n5. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral \nDAILY \nRX *cholecalciferol (vitamin D3) 2,000 unit 1 capsule(s) by \nmouth daily Disp #*30 Capsule Refills:*0 \n6. Acetaminophen 1000 mg PO Q8H \n7. Acyclovir 400 mg PO Q12H \n8. Atovaquone Suspension 1500 mg PO DAILY \n9. Bengay Cream 1 Appl TP BID:PRN knee pain \n10. ClonazePAM 1 mg PO BID \n11. Cyanocobalamin 1000 mcg PO DAILY \n12. Docusate Sodium 100 mg PO BID \n13. Escitalopram Oxalate 20 mg PO DAILY \n14. FoLIC Acid 1 mg PO DAILY \n15. Gabapentin 900 mg PO QHS \n16. Gabapentin 600 mg PO BID \n17. Mirtazapine 15 mg PO QHS \n18. Nystatin Oral Suspension 10 mL PO QID:PRN thrush \n19. Omeprazole 40 mg PO DAILY \n20. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n21. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \n22. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H \n23. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n24. Senna 8.6 mg PO BID \n25. Sodium Chloride 2 gm PO TID W/MEALS \n26. TraMADol 50 mg PO QHS \n27. Zolpidem Tartrate 12.5 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n=================\nOrthostatic hypotension\n\nSECONDARY DIAGNOSIS:\n===================\nFailure to thrive\nmalnutrition\nacute kidney injury\nurinary retention\ndyspnea without hypoxia\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 ___. \nPlease see below for more information on your hospitalization. \n \nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You fell, lost weight, had low blood pressure, and was short \nof breath\n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- We gave you fluid through your IV for hydration\n- We made sure you were eating 3 meals a day\n- We had neurology see you they recommended some lab testing and \nthe results are pending, you will follow up with Dr. ___ in \nthe ___ clinic to follow up on those results. \n- We had urology see you because you were having difficulty \nurinating, we placed a foley to drain your bladder. You will \nfollow up with urology as an outpatient they will come up with a \nplan regarding the foley\n- We had our pulmonology (lung) doctors ___ for your \nshortness of breath, we did imaging and testing which came back \nreassuring. \n- We monitored your orthostatic blood pressures and your \nsymptoms. Similar to prior hospital admissions your blood \npressure dropped when you stood up, when you first arrived you \nwould become dizzy and short of breath. This improved but you \nwere still orthostatic after you were hydrated and well fed. \n- You complained of testicular pain we did an ultrasound which \nwas normal\n- We had psychiatry see you to help us with your medications. \n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) We \nARE VERY CONCERNED ABOUT YOUR MEDICATION LIST. There are \nmultiple medications that you take that may be contributing you \nyour recurrent falls. It would be beneficial to reduce the \namount of sedating medications that you take. \n \n- Follow up with your doctors as listed below \n- Seek medical attention if you have new or concerning symptoms \nof falls, dizziness, or shortness of breath. \n\nIt was a pleasure taking part in your care here at ___! \nWe wish you all the best! \n- Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I951", "E43", "Z681", "N179", "C9001", "F339", "Z9484", "D61818", "E872", "G990", "R339", "R0609", "G909", "F419", "Z923", "M109", "F1110", "N50812", "N50811", "G893", "E8339", "G4700", "E861", "Z9181" ]

[ "I951: Orthostatic hypotension", "E43: Unspecified severe protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "N179: Acute kidney failure, unspecified", "C9001: Multiple myeloma in remission", "F339: Major depressive disorder, recurrent, unspecified", "Z9484: Stem cells transplant status", "D61818: Other pancytopenia", "E872: Acidosis", "G990: Autonomic neuropathy in diseases classified elsewhere", "R339: Retention of urine, unspecified", "R0609: Other forms of dyspnea", "G909: Disorder of the autonomic nervous system, unspecified", "F419: Anxiety disorder, unspecified", "Z923: Personal history of irradiation", "M109: Gout, unspecified", "F1110: Opioid abuse, uncomplicated", "N50812: Left testicular pain", "N50811: Right testicular pain", "G893: Neoplasm related pain (acute) (chronic)", "E8339: Other disorders of phosphorus metabolism", "G4700: Insomnia, unspecified", "E861: Hypovolemia", "Z9181: History of falling" ]

[ "N179", "E872", "F419", "M109", "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:\nsevere throat/esophageal pain\n \nMajor Surgical or Invasive Procedure:\nEGD with biopsies ___\niliac bone bx ___\n\n \nHistory of Present Illness:\nMr. ___ is a pleasant ___ w/ benzo/opiate disorder and MM s/p\nauto HSCT ___, now on Daratumumab/dex + XRT for T7-T8 who p/w\nsevere burning sensation radiating down his throat. 10 day \ncourse\nof radiation therapy ended ~10 days ago. Since, has developed a\nburning sensation that travels down his throat to his stomach\nthat worsens significantly to meals but not exertion. Feels at\ntimes that the food is stuck in his throat. Has had decreased PO\nfor several days now as a result. No f/c, SOB, CP\n\nIn ED VSS w/ SBP 99/70 HR 86. 98% RA. REceived maalox, donnatal,\nviscous lidocaine 10 ml, Pronix, and gabapentin 400. GI \nconsulted\nand recommended bid PPI and judicious pain management. \n\nOn arrival to ___, pt notes hat this back pain for which he's had\nXRT is now essentially gone. Had effective relief. But he notes\nthat he's been having \"stabbing pain\" in the epigastric area,\nradiating to both sides that is constant, and worse w/ eating. \nIt\nis always there. Then on swallowing food, he has a\nburning/painful sensation throughout the entire esophagus. \nDenied\nCP/SOB, admits to cough. States he's been able to tolerate\npancakes the best. \n\nREVIEW OF SYSTEMS:\n10 point ROS reviewed in detail and negative except for what is\nmentioned above in HPI\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\nMr ___ was diagnosed with multiple myeloma in acute renal\nfailure in ___. He was found to be anemic with a hemoglobin of \n7\nto 9.9 with splenomegaly seen on CT of the abdomen. Bone marrow\nbiopsy and aspirate on ___ showed that CD138 positive\ncells replaced 90% of his marrow with abnormal plasma cells \nseen.\nCytogenetics showed a normal male karyotype and skeletal survey\ndone on ___ showed degenerative disease in the cervical\nand lumbar spine and a question of a ___ versus a lytic\nlesion in the frontal skull. He had an elevated serum free \nlambda\nof 1140 mg/L, beta 2 of 10, IgG of 2.3 g/dL, calcium of 10.1,\ncreatinine of 1.18 and albumin of 3.6. However, over the span of\n___ weeks he developed renal failure and ultimately was admitted\nfor plasmapheresis and Velcade.\n\n--___: Cycle 1 Plasmapheresis + Velcade\n Cycle 2 Velcade + Dexamethasone(severe europathy)\n Cycle 3 - 5 Revlimid/Dexamethasone \n--___: High Dose Cytoxan for Mobilization\n--___: Autologous Stem cell Transplant\n--Treated on Protocol ___ vaccination with DC/Tumor fusion\nvaccine in patients with multiple myeloma\n--___: Completed ___ fusion vaccines\n--___: Found modest rise in paraprotein. Started on Revlimid\nbut tolerated poorly due to nausea and loose stools and\nultimately stopped in ___.\n--Slow rising paraprotien over the following year\n--___: Started on Protocol ___ A Phase I multicenter,\nopen label, dose-escalation to determine the maximum tolerated\ndose for the combination of Pomalidamide, Velcade and low dose\ndexamethasone in subject with relapsed or refractory multiple\nmyeloma.\n --Lost to follow up for one year, re-presented in ___ with\na rising light chain. M protein was found to be 780 with a max\nof 1110 and a free light chain of 270. His free lambda did rise\nto as high as 447 in ___ prior to initiating treatment. \n --___: Placed back on pomalidomide at 4 mg daily;\ndecreased to 2mg due to cytopenias. \n --___: Found to have a small rise in his light chain,\nand SPEP revealed a monoclonal protein of 910 and a free light\nchain of 293. Reinitiated treatment with Velcade and\ndexamethasone and increased the pomalidomide to 3 mg daily. \n --Received four cycles of Velcade, pomalidomide and\ndexamethasone with great disease control, then placed on\npomalidomide maintenance for close to ___ years. Dose was\ndecreased from 3mg to 2mg ___ due to fatigue and\nnausea. \n --___: Presented with right sacral pain unrelieved by\nTylenol. Pelvic and lumbar sacral MRI obtained. Clear\nprogression of disease including L3 and L5 lesions.\n --___: Daratumumab added to current pomalidomide\ntreatment.\n --Treatment plan: Daratumumab 16 mg/kg weekly for 8 weeks\n Pomalidomide 2 mg p.o. daily for 21 out of 28\ndays will increase to 3 mg next cycle\n Dexamethasone 20 mg p.o. day of and day\nfollowing Daratumumab\n ___: Week 2 ___\n ___: Week 3 ___\n ___: Week 4 ___\n ___: Week 5 ___\n ___: Week 6 ___\n ___: Week 7 ___\n ___: Week 8 ___ (Dexamethasone decreased to 10\nmg on day of ___ and ___ 4 mg on following 2 days)\n ___: Treatment held and admitted for respiratory work up\n ___: Started Daratumumab/Dexamethasone alone \n ___: T7-T8 lesions. RT therapy started\n\nPAST MEDICAL/SURGICAL HISTORY: \n- Substance use disorder\n- Depression \n- Multiple Myeloma \n- Gout \n- Back pain \n\n \nSocial History:\n___\nFamily History:\npaternal grandmother was institutionalized. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITAL SIGNS: 97.6 PO 100 / 65 67 18 96 Ra\nGeneral: NAD, Resting in bed comfortably\nHEENT: MMM, no OP lesions, no thrush, no ulcerations noted\nCV: RR, NL S1S2 no S3S4 No MRG\nPULM: CTAB, No C/W/R, No respiratory distress\nABD: BS+, soft, mostly TTP in epigastric area but also \ndiffusely\nTTP, no peritoneal signs \nLIMBS: WWP, no ___, no tremors\nSKIN: No notable rashes on trunk nor extremities\nNEURO: CN III-XII intact, strength b/l ___ intact\nPSYCH: Thought process logical, linear, future oriented\nACCESS: PIV\n\nDISCHARGE PHYSICAL EXAM:\nVSS\nGEN: NAD, Resting in bed comfortably\nHEENT: MMM. No visible OP lesions, thrush, ulcerations noted\nCV: RR, NL S1/S2 no S3/S4 No MRG\nPULM: CTA. No increased WOB. \nABD: BS+, soft, non tender\nLIMBS: mild pain and swelling RUE, no ___ or tremors\nSKIN: palpable mass to L rib. Multiple healed scars on abdomen\nwith scattered old bruising. No notable new rashes on trunk nor\nextremities\nNEURO: CN III-XII intact, strength b/l ___ intact\nPSYCH: Thought process logical, linear, future oriented\nACCESS: PIV C/D/I\n \nPertinent Results:\nADMISSION LABS\n\n___ 10:33AM PLT COUNT-55*\n___ 10:33AM NEUTS-68.8 ___ MONOS-9.4 EOS-0.5* \nBASOS-0.0 IM ___ AbsNeut-2.93 AbsLymp-0.87* AbsMono-0.40 \nAbsEos-0.02* AbsBaso-0.00*\n___ 10:33AM WBC-4.3 RBC-4.20* HGB-13.8 HCT-39.3* MCV-94 \nMCH-32.9* MCHC-35.1 RDW-12.9 RDWSD-43.9\n___ 10:33AM ALBUMIN-3.6\n___ 10:33AM LIPASE-26\n___ 10:33AM ALT(SGPT)-20 AST(SGOT)-17 ALK PHOS-78 TOT \nBILI-0.8\n___ 10:33AM GLUCOSE-107* UREA N-14 CREAT-1.0 SODIUM-135 \nPOTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-11\n\nDISCHARGE LABS:\n\n___ 07:10AM BLOOD WBC-3.1* RBC-3.62* Hgb-11.8* Hct-33.9* \nMCV-94 MCH-32.6* MCHC-34.8 RDW-13.7 RDWSD-43.8 Plt Ct-93*\n___ 07:10AM BLOOD Neuts-50.0 ___ Monos-8.3 Eos-0.3* \nBaso-1.0 Im ___ AbsNeut-1.56* AbsLymp-1.23 AbsMono-0.26 \nAbsEos-0.01* AbsBaso-0.03\n___ 07:10AM BLOOD Glucose-112* UreaN-8 Creat-0.9 Na-145 \nK-4.0 Cl-102 HCO3-27 AnGap-16\n___ 07:10AM BLOOD ALT-15 AST-19 LD(LDH)-258* AlkPhos-94 \nTotBili-0.7\n___ 07:10AM BLOOD Albumin-4.1 Calcium-9.2 Phos-3.7 Mg-1.9 \nUricAcd-4.___ w/ benzo/opiate disorder and MM s/p auto\nHSCT ___, now on Daratumumab/dex + XRT for T7-T8 who p/w 5 day\nprogressively worsening constant epigastric band like pain w/\nworsening \"whole esophagus pain\" w/ eating. \n\nACUTE ISSUES\n---------------\n#Epigastric pain:\n#Esophageal pain:\nIn discussion with radiation oncology, his symptoms are felt \nmost\nconsistent with esophageal candidiasis particularly given \nhistory\nof chronic steroids albeit there may have been some component of\nradiation esophagitis. He was started empirically outpatient on\nfluconazole (day 1: ___ completed over two week \ncourse.\nENT evaluated ___ and their exam was consistent w/ OP\ncandidiasis. GI was consulted ___ for additional workup.\nObtained CT neck ___ which showed no \nabnormal enhancement in the neck but did note severe\natherosclerotic plaque at the origin of the right ICA as well as\n2 mm lung nodule at the right lung apex. Upon discussion with GI\nteam, felt it was prudent to obtain further imaging with CT\nabdomen and chest to evaluate for other abnormalities that may \nbe\ncontributing to his esophageal pain. CT abd/pelvis benign,\nunderwent EGD with biopsies ___. radiation esophagitis most\nlikely cause as bx stains negative with slow improvement over \nthe last two weeks\n-EGD results, fungi neg, CMV/EBV/HSV stains neg, CMV/EBV vL\nneg, ENT/GI signed off\n-ADAT per GI, on regular diet, speech/swallow also cleared\npatient\n-Judicious pain control, consulted CPS and followed throughout \nadmission. originally added Oxycodone ___ Q6hr prn ___ \nand increased gabapentin from 400mg TID to ___ TID ___ \nweaned gaba back to home dosing in setting\nof no improvement in pain and increased lethargy, lower RR.\ntrying to wean off oxycodone, alternating between 5mg and \nTylenol\nwith no relief, started low dose methadone per CRS ___ with\nsignificant relief overnight\n-will go home with 5mg methadone BID prn x14days only (28 tabs \nonly), expect resolution in XRT esophagitis over the next two \nweeks\n-CPS recs, requested follow up with Dr. ___ pain service \noutpatient end of ___, request placed in OMR, pain \nreceptionist said they would book \n-Continues with supportive care including PPI, sucralfate, tums\n\n#Multiple Myeloma: Relapsed after AutoSCT, IgG Lambda previously\ntreated on pomalidomide maintenance. Switched to Daratumumab,\nPomalyst and Dexamethasone due to disease progression with good\nresponse. Pomalidomide stopped due to possible pulmonary\nfibrosis. He mostly received daratumumab + Dexamethasone Cycle \n#:\n6 Day 1: ___. (Dose every 4 weeks). His counts seem to be\nstable on admission though does have evidence of leukopenia and\nthrombocytopenia as below. Bone marrow on ___ showed no\nmorphologic evidence of his myeloma. He does report new pain to\nhis left rib. Most recent PET/CT showed multiple small areas of\nlytic lesions which seem to show progression from prior imaging\nstudies. \n-Consulted ___ about biopsy; underwent iliac bone bx ___, \nresults\nconsistent with no malignancy, likely repeat PET outpatient to \ncompare results\n-Holding ASA due to TCP instructed to hold until outpatient team \ntells him to restart\n-Continue ACV, increased to 400mg TID from BID (to cover for ?\nherpes esophagitis) back to BID dosing on discharge \n-Continue allopurinol, and gabapentin\n-holding Bactrim due to TCP\n-F/U Spep/M protein--continued response, ratio 0.17\n\n#RUE swelling/pain: mild pain and swelling associated with PIV\ninfiltration. u/s neg for DVT but noted sup R cephalic\nthrombosis, supportive care for now\n\n#Leukopenia:\n#Thrombocytopenia:\nMost likely secondary to recent radiotherapy in combination with\nrecent chemotherapy and underlying malignancy, r/o viral cause.\nNot requiring transfusion support at this time.\n-holding Bactrim for now due to TCP with improvement in counts\n-Transfuse if platelets < 10K and hgb <7]\n-Monitor and Trend CBC\n-Active T&S\n\n#High risk for Malnutrition: In the context of nutritional\ndecline in setting of limited PO intake with esophageal pain.\n-Appreciate nutrition recommendations\n-Daily MVI \n-Trend weights daily \n\nCHRONIC CONDITIONS\n--------------------\n\n#Depression: \n#Substance Use Disorder:\nPatient recently discharged on risperidone, however, he is no \nlonger taking this. \n-Judicious use of benzos/narcotics\n-Continues on clonazepam 1mg TID \n-Appreciate CPS recommendations, SW\n-going home on 14d of methadone for acute esophagitis pain, will \nf/u pain service end of ___\n\nCORE MEASURES\n-----------------\n#FEN: ADAT/mIVF\n#DVT PROPH: None due to TCP\n#ACCESS: PIV \n#CODE STATUS: Full code, presumed\n#EMERGENCY CONTACT: ___ (sister) ___ ___\n\nDISPO: home\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Allopurinol ___ mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. ClonazePAM 1 mg PO TID anxiety \n5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n6. Gabapentin 400 mg PO TID back pain \n7. Famotidine 20 mg PO Q12H gi ppx \n8. Qvar RediHaler (beclomethasone dipropionate) 40 mcg/actuation \ninhalation DAILY \n9. Zolpidem Tartrate 5 mg PO QHS \n\n \nDischarge Medications:\n1. Calcium Carbonate 500 mg PO QID \nRX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by \nmouth four times a day Disp #*56 Tablet Refills:*0 \n2. Methadone 5 mg PO BID:PRN pain \nRX *methadone 5 mg 1 tab by mouth BID prn Disp #*28 Tablet \nRefills:*0 \n3. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*3 \n4. Sucralfate 1 gm PO QID \nRX *sucralfate 1 gram/10 mL 10 suspension(s) by mouth four times \na day Disp #*1 Bottle Refills:*0 \n5. Acyclovir 400 mg PO Q12H \n6. Allopurinol ___ mg PO DAILY \n7. ClonazePAM 1 mg PO TID anxiety \n8. Gabapentin 400 mg PO TID back pain \n9. Qvar RediHaler (beclomethasone dipropionate) 40 \nmcg/actuation inhalation DAILY \n10. Zolpidem Tartrate 5 mg PO QHS \n11. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until outpatient team tells you to do so\n12. HELD- Sulfameth/Trimethoprim SS 1 TAB PO DAILY This \nmedication was held. Do not restart Sulfameth/Trimethoprim SS \nuntil outpatient team tells you to restart\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nmyeloma\nesophagitis \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 due to throat pain associated with radiation. \nThis improved with methadone and time. You will follow up with \nDr. ___ as stated below. It was a pleasure taking care of \nyou.\n \nFollowup Instructions:\n___\n" ]

[ "K208", "B3781", "C9000", "I82611", "B0089", "T801XXA", "F329", "E860", "M109", "D72819", "R509", "D696", "I6521", "R911", "E8339", "R1310", "Z923", "Z7982", "J45909", "Z87891", "R451", "Z7952", "K449" ]

[ "K208: Other esophagitis", "B3781: Candidal esophagitis", "C9000: Multiple myeloma not having achieved remission", "I82611: Acute embolism and thrombosis of superficial veins of right upper extremity", "B0089: Other herpesviral infection", "T801XXA: Vascular complications following infusion, transfusion and therapeutic injection, initial encounter", "F329: Major depressive disorder, single episode, unspecified", "E860: Dehydration", "M109: Gout, unspecified", "D72819: Decreased white blood cell count, unspecified", "R509: Fever, unspecified", "D696: Thrombocytopenia, unspecified", "I6521: Occlusion and stenosis of right carotid artery", "R911: Solitary pulmonary nodule", "E8339: Other disorders of phosphorus metabolism", "R1310: Dysphagia, unspecified", "Z923: Personal history of irradiation", "Z7982: Long term (current) use of aspirin", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "R451: Restlessness and agitation", "Z7952: Long term (current) use of systemic steroids", "K449: Diaphragmatic hernia without obstruction or gangrene" ]

[ "F329", "M109", "D696", "J45909", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCodeine / Latex\n \nAttending: ___.\n \nChief Complaint:\npresyncope\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThe patient is a ___ year old woman with PMH of ___ \nesophagus and HTN who presents with acute onset nausea, \nlightheadedness and pallor. She describes that in the afternoon \non ___ she suddently felt nauseated, and her granddaughter who \nwas present said she looked \"white as a ghost.\" She felt \nlightheaded, and her vision went black. She then had the \nimmediate urge to have a bowel movement, and proceeded to have a \nwatery bowel movement, after which her symptoms improved. \n Of note, the patient has a longstanding history of HTN. She was \nrecently seen in the ED for hypertensive urgency with BP \n>200/90s with flushing and palpitations, and was discharged \nafter BP normalized without intervention. During this visit she \ndescribed having ___ swelling, which never happens to her at \nhome. She was then evaluated by ___ cardiology on ___ for \nfollow-up. At this visit she also reported episodes of \npalpitations and facial flushing. At this visit her atenolol was \nincreased to 25mg daily. \n Labs from this visit: ESR 49, CRP 6.2, TSH 2.81. Urinary \nmetanephrines were ordered but not yet sent. CTA chest was also \nordered but not performed, since the patient had a reaction to \nIV contrast in the past. \n She describes occasional episodes of palpitations and flushing \nassociated with elevated BP around 200/90 in the past. The \nepisodes always resolve on their own. She has also had nausea \nand worsening back pain after eating the last few months, that \nshe thinks is possibly due to her ___ esophagus. She says \nduring these episode she does not have abdominal pain. \n In the ED, initial VS were: 97.7 75 117/69 18 98% RA. Right arm \nBP 154/68 and left arm BP 125/96. CBC and chem 7 were WNL. CXR \nshowed no acute process. CTA chest was ordered but not \nperformed. \n On the floor the patient endorses the above history and does \nnot currently feel any SOB, CP, palpitations, flushing, sweating \nor abdominal pain. \n\n \nPast Medical History:\nHTN \n___ esophagus \n \nSocial History:\n___\nFamily History:\nFamily history of leukemia, daughter with breast cancer, aunts \nwith stomach cancer. No family history of adrenal tumors, \nepisodic hypertension, flushing or palpitations. \n \nPhysical Exam:\nADMISSION:\n============\nVS: 98.3 102 / 60 59 20 95 RA \nGeneral: Well-appearing, speaking calmly, NAD \nHEENT: OP clear, symmetric palate elevation \nNeck: Supple, no LAD \nCV: RRR, no m/r/g \nPulm: CTAB without wheezes or rales \nAbd: Soft, NT, ND, NABS \nExt: No ___ edema, WWP \nNeuro: CNII-XII intact, UE and ___ strength ___, sensation \ngrossly intact \n\nDISCHARGE EXAM\n============\nVITALS: 97.7 | BP 110-125/60-70s | 50-60s | 18 | 95%RA \nGENERAL: NAD, skin dry, comfortable appearing\nHEENT: Face erythematous but no diaphoresis. MMM.\nNECK: supple\nHEART: normal S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: BS+, soft, nontender, nondistended, no masses palpated\nEXTREMITIES: warm, no edema\nNEURO: alert and interactive. Face grossly symmetric, moving \nboth\nlimbs with purpose against gravity. \n \nPertinent Results:\nADMISSION:\n___ 09:29PM BLOOD WBC-7.1 RBC-4.37 Hgb-12.9 Hct-37.8 MCV-87 \nMCH-29.5 MCHC-34.1 RDW-12.3 RDWSD-38.9 Plt ___\n___ 09:29PM BLOOD Neuts-66.4 ___ Monos-5.9 Eos-0.3* \nBaso-0.1 Im ___ AbsNeut-4.70 AbsLymp-1.91 AbsMono-0.42 \nAbsEos-0.02* AbsBaso-0.01\n___ 09:29PM BLOOD Glucose-89 UreaN-19 Creat-0.7 Na-142 \nK-4.3 Cl-103 HCO3-24 AnGap-15\n___ 07:32AM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.0 Mg-2.1\n___ 09:29PM BLOOD ALT-85* AST-71* LD(LDH)-240 AlkPhos-84 \nTotBili-0.7\n___ 09:29PM BLOOD cTropnT-<0.01\n___ 09:29PM BLOOD D-Dimer-521*\n\nIMAGING:\n___ CT head:\n1. No acute intracranial abnormalities \n2. Paranasal sinus disease, as above. \n\n___ CTA torso:\n1. No acute pulmonary embolism. \n2. No acute intra-abdominal findings. \n3. Mild hepatic steatosis. \n4. No evidence of dissection in the thoracic or abdominal aorta. \n\n\n___ CXR IMPRESSION: No acute intrathoracic process. \n\nDISCHARGE \n___ 05:35AM BLOOD WBC-8.3 RBC-4.15 Hgb-11.9 Hct-36.7 MCV-88 \nMCH-28.7 MCHC-32.4 RDW-12.6 RDWSD-40.6 Plt ___\n___ 05:35AM BLOOD Glucose-87 UreaN-21* Creat-0.6 Na-143 \nK-3.7 Cl-106 HCO3-25 AnGap-___ with history of ___ esophagus, hypertension, \npalpitations and recent episode of uncontrolled hypertension and \nflushing who presents with back pain and episode of presyncope \nassociated with nausea and vomiting. \n\n# Presyncopal episode: She had symptoms of vision going black \nand felt better with sitting, suggesting orthostasis versus \nvasovagal. Hyaline casts in urine support dehydration and \nuptitration of antihypertensives in outpatient setting may have \ncontributed. Stroke ruled out with negative head CT head was \nunremarkable. Already had Holter monitor, which has not been \nread yet. \n\n# Tachycardia: She had episodes of sinus tachycardia to the 150s \nwhile in the hospital that were thought to be due to \nhypovolemia. She did not have any for 24h prior to discharge. \n\n# Hypertension with labile blood pressures:\n# Episode of flushing with elevated BP:\nConcern for pheochromoyctoma given flushing, episodic \npalpitations and hypertension, although CT was negative for \nadrenal mass. Patient appears to be medication adherent and \ndenies substance abuse. No history to suggest panic disorder. \nImaging and history not consistent with vasculopath to suggest \nrenal artery or other stenosis. Of note, did not have \nhypertension recorded during inpatient portion of this present \nhospitalization. \n\n# Back pain: concern for dissection especially with labile BP \nbut CTA negative was for dissection. \n\nTRANSITIONAL ISSUES\nNEW MEDS:\n - carvedilol 6.25mg BID\n - hctz 12.5 mg daily\n\nSTOPPED MEDS:\n - Atenolol 25 mg PO DAILY \n - valsartan-hydrochlorothiazide 160-25 mg oral DAILY \n\n[ ] Follow up blood pressures and adjust as needed\n[ ] Follow up Holter Monitor\n[ ] Follow up urine metanephrines \n[ ] Consider outpatient renal artery ultrasound given report of \nhypertension\n[ ] Hepatitis B surface antibody negative; consider vaccination\n[ ] CT abdomen showed hepatic steatosis; consider lifestyle \nmodification counseling, diet counseling, trending LFTs, \nstarting statin \n[ ] Incidental finding: A mucous retention cyst is noted in the \nright maxillary sinus.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atenolol 25 mg PO DAILY \n2. Omeprazole 20 mg PO DAILY \n3. valsartan-hydrochlorothiazide 160-25 mg oral DAILY \n\n \nDischarge Medications:\n1. Carvedilol 6.25 mg PO BID \nRX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n2. Hydrochlorothiazide 25 mg PO DAILY \nRX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n3. Omeprazole 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\n#ORTHOSTATIC HYPOTENSION d/t HYPOVOLEMIA\n#LABILE BLOOD PRESSURES w/ FLUSHING\n#ATRIAL TACHYCARDIA\n\nSECONDARY DIAGNOSIS\n===================\n#HEPATIC STEATTHOSIS\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nWHY WASI IN THE HOSPITAL?\n=========================\n- You had an episode of feeling like you were going to lose \nconsciousness, associated with vomiting and diarrhea. This was \nlikely due to low blood pressure. \n\nWHAT HAPPEENED IN THE HOSPITAL?\n================================\n- You were admitted to the hospital to work up your episodes of \nvery high blood pressure and periods of fast heart rate. \n- You had a CT scan which did not show an obvious cause of your \nsymptmos. We started doing an extended workup. \n\nWHAT SHOULD I DO WHEN I GO HOME?\n================================\n- Follow up with your cardiologist regarding changes to your \nblood pressure medicines\n- Follow up with your doctors regarding the results of your \nurine tests\n- Take all medicines as prescribed\n\nIt was a pleasure participating in your care. We wish you all \nthe best!\nSincerely,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "I951", "E861", "R0989", "R232", "I471", "K7581", "I10", "K219", "K2270", "M549" ]

[ "I951: Orthostatic hypotension", "E861: Hypovolemia", "R0989: Other specified symptoms and signs involving the circulatory and respiratory systems", "R232: Flushing", "I471: Supraventricular tachycardia", "K7581: Nonalcoholic steatohepatitis (NASH)", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "K2270: Barrett's esophagus without dysplasia", "M549: Dorsalgia, unspecified" ]

[ "I10", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Bactrim DS / Fosamax / Scallops / atorvastatin\n \nAttending: ___.\n \nChief Complaint:\nParoxysmal Afib\n \nMajor Surgical or Invasive Procedure:\nPVI/AP Ablation ___\nPercardiocentesis and Pericardial Drain Placement ___\n \nHistory of Present Illness:\n___ hx. paroxysmal Afib s/p PVI x2, cardioversion and multiple \nAADs, with symptomatic Afib/AT admitted for redo PVI/AT \nablation. The patient was intubated and sedated for procedure. \nDuring EP procedure, the patient became hypotensive and was \nfound to be in cardiac tamponade. The patient was started on \ndopamine for hypotension and subsequently had pericardiocentesis \nwith 550 cc removed. TTE and ICE showed no further effusion- 1 \nhour post). Pericardial drain was sutured in. \n\nOn arrival to the CCU, the patient continued to be intubated and \nsedated. She was hemodynamically stable and did not appear to be \nin cardiac tamponade. Pericardial drain continued to have \nhemorrhagic output. The patient was continued on dopamine and \nfentanyl for pain and sedation. \n\n \nPast Medical History:\n1. Hypertension\n2. Long-standing paroxysmal atrial fibrillation with initial \nreasonable control for over ___ years on Norpace which became \nineffective in ___. Followed by a trial of quinidine, \nprocainamide, and amiodarone. She continued symptomatic atrial \nfibrillation despite theseefforts and so she underwent pulmonary \nvein isolation in ___. \n\nRecurrent AF following the pulmonary vein isolation, and\nunderwent DC cardioversion x 2 later in ___ at which\npoint Norpace was restarted.\n\nRecurrent symptomatic AF in ___ with increasing\nfrequency over time. Holter monitoring revealed atrial\nfibrillation. \n\nDue to ongoing symptomatic episodes and that she had failed\nmultiple antiarrhythmic medications in the past, a decision was\nmade to proceed with repeat PVI which was performed on ___. \nFollowing PVI she had recurrence of AT/AF, her Norpace was\ndiscontinued, and amiodarone was resumed at a dose of 400 mg\ndaily x 30 days, she is now on 200 mg daily.\n\nOngoing symptomatic palpitations almost daily for the past 3\nweeks for ___ hours which give her a feeling of anxiety.\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\nON ADMISSION:\nVS: HR 57 BP 146/59 RR 10 SpO2 100% on vent settings \nGen: Intubated and sedated but appears comfortable. \nHEENT: Sclera clear. \nNECK: No JVD or cervical lymphadenopathy \nCV: RRR, no m,r,g. \nLUNGS: Pericardial drain in place with bloody output but appears \nclean, dry, and intact. CTAB in anterior lung fields. \nABD: L groin sheath appears clean, dry, and intact. \nEXT: Warm, well perfused, no ___ edema \nSKIN: No petechiae or ecchymoses. \nNEURO: Moving all extremities with purpose. Biting on breathing \ntube. \n\nON DISCHARGE:\nVS: Tc 97.9 HR 80-120 BP 120s/50s RR ___ SpO2 97% RA\nWt 69.4 kg, I/O 24h ___, 8h NPO/\nGen: alert and appears comfortable but anxious\nHEENT: Sclera clear.\nNECK: No JVD or cervical lymphadenopathy \nCV: fast rate irregular rhythm , no m,r,g. PPM in place left \nupper chest wall, mildly ttp but no surrounding warmth or \nerythema or drainage\nLUNGS: CTAB in anteriolateral lung fields. \nABD: soft nt nd\nEXT: Warm, well perfused, no ___ edema \nSKIN: No petechiae or ecchymoses. \nNEURO: Moving all extremities with purpose. \n \nPertinent Results:\nLABS:\n======================\n\nADMISSION LABS:\n___ 07:15AM BLOOD WBC-7.0 RBC-4.51 Hgb-13.6 Hct-42.0 MCV-93 \nMCH-30.2 MCHC-32.4 RDW-13.1 RDWSD-44.4 Plt ___\n___ 07:15AM BLOOD Neuts-58.1 ___ Monos-8.7 Eos-1.3 \nBaso-0.4 Im ___ AbsNeut-4.09 AbsLymp-2.19 AbsMono-0.61 \nAbsEos-0.09 AbsBaso-0.03\n___ 07:15AM BLOOD ___\n___ 07:15AM BLOOD Plt ___\n___ 07:15AM BLOOD Glucose-72 UreaN-31* Creat-1.1 Na-141 \nK-4.1 Cl-104 HCO3-27 AnGap-14\n___ 10:55AM BLOOD ___ pO2-35* pCO2-39 pH-7.33* \ncalTCO2-21 Base XS--4 Intubat-NOT INTUBA\n___ 11:47AM BLOOD Hgb-10.6* calcHCT-32\n___ 02:21PM BLOOD Glucose-170* Lactate-1.0\n\nDISCHARGE LABS:\n___ 05:50AM BLOOD WBC-8.4 RBC-3.84* Hgb-11.9 Hct-36.5 \nMCV-95 MCH-31.0 MCHC-32.6 RDW-13.5 RDWSD-45.6 Plt ___\n___ 10:05AM BLOOD ___ PTT-31.0 ___\n___ 05:50AM BLOOD Glucose-102* UreaN-18 Creat-0.8 Na-138 \nK-4.0 Cl-103 HCO3-26 AnGap-13\n___ 05:50AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0\n\nINR TREND:\n___ 07:15AM BLOOD ___\n___ 10:40AM BLOOD ___ PTT-45.0* ___\n___ 11:45AM BLOOD ___ PTT-31.9 ___\n___ 02:00PM BLOOD ___ PTT-34.6 ___\n___ 03:51AM BLOOD ___ PTT-34.6 ___\n___ 04:23AM BLOOD ___ PTT-43.0* ___\n___ 06:55AM BLOOD ___ PTT-37.8* ___\n___ 08:00AM BLOOD ___ PTT-27.8 ___\n___ 07:25AM BLOOD ___ PTT-27.5 ___\n___ 09:55AM BLOOD ___ PTT-28.1 ___\n___ 10:05AM BLOOD ___ PTT-31.0 ___\n\nIMAGING:\n=====================================\nTRANSTHORACIC ECHOCARDIOGRAM ___:\nConclusions \nOverall left ventricular systolic function is normal (LVEF>55%). \nRight ventricular chamber size and free wall motion are normal. \nThere is a trivial/physiologic pericardial effusion. There are \nno echocardiographic signs of tamponade. \n\nTRANSTHORACIC ECHOCARDIOGRAM ___:\nConclusions \nFOCUSED STUDY/LIMITED VIEWS. Overall left ventricular systolic \nfunction is normal (LVEF>55%). Right ventricular chamber size \nand free wall motion are normal. There is a very small \npericardial effusion best seen on subcostal images anterior to \nthe right ventricle. There is an anterior space which most \nlikely represents a prominent fat pad. There are no \nechocardiographic signs of tamponade. \nCompared with the prior study (images reviewed) of ___, \nthe pericardial effusion is minimally larger. \n\nCXR ___:\nIMPRESSION: \nHeart size and mediastinum are stable. Central venous line of \nunclear origin, potentially pulmonary is present projecting over \nthe heart, please correlate with patient history. Lungs are \nclear. There is no pleural effusion or pneumothorax. \n\nMICRO:\n====================\n___ 8:53 pm MRSA SCREEN Source: Nasal swab. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: No MRSA isolated. \n \nBrief Hospital Course:\n___ y.o. woman with paroxysmal Afib/Atach s/p PVI x2, \ncardioversion and multiple AADs, with symptomatic Afib/AT \nadmitted for redo PVI/AT ablation complicated by pericardial \ntamponade during ablation s/p pericardiocentesis and drain \nplacement. \n\n#Tamponade: On ___ she underwent PVI/AT ablation. During the \nprocedure on ___, she was found to be in cardiac tamponade \nrequiring pericardiocentesis. Pericardial drain was removed \n___ and she remained hemodynamically stable; Echo showed no \nreaccumulation of pericardial fluid. \n\n#Atrial fibrilliation: She went back into afib with rates in the \n130s despite third PVI. Metoprolol was uptitrated but given \nrecurrent medication failure and now 3 failed PV ablations, \ndecision was made for AVJ ablation and pacemaker. On ___ \nunderwent dual chamber pacemaker placement. Patient was briefly \non Dronedarone but discontinued after AVJ ablation. Her home \nnorpace was discontinued as well. On ___ underwent successful \nAV nodal ablation. These procedures were uncomplicated.\n\n# Urinary Tract Infection: She was started on macrodantin for a \nurinary tract infection on ___ as an outpatient with a plan \nfor ___nd macrodantin was continued until full 5 day \ncourse was complete. She had no urinary tract symptoms while \ninaptient. \n\nTRANSITIONAL ISSUES:\n[] She will follow up in device clinic and with her primary \ncardiologist.\n[] Her norpace was stopped during this admission\n[] Patient discharged on Metoprolol Succinate 100 mg PO QDaily \n[] INR 2.2 at discharge. She was discharged on her home Coumadin \nregimen; please recheck an INR within next few days and adjust \nCoumadin dosing as needed. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Disopyramide Phosphate 300 mg PO Q12H \n3. Metoprolol Tartrate 75 mg PO BID \n4. Warfarin 5 mg PO DAILY16 \n5. Simvastatin 20 mg PO QPM \n6. lutein 10 mg oral BID \n7. Vitamin D 1000 UNIT PO DAILY \n8. Nitrofurantoin (Macrodantin) 100 mg PO BID \n\n \nDischarge Medications:\n1. Lisinopril 10 mg PO DAILY \n2. Vitamin D 1000 UNIT PO DAILY \n3. biotin 1000 mcg oral DAILY \n4. cranberry conc-ascorbic acid unknown ORAL DAILY \n5. lutein 10 mg oral BID \n6. Simvastatin 20 mg PO QPM \n7. Metoprolol Succinate XL 100 mg PO DAILY \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*1\n8. Warfarin 7.5 mg PO 2X/WEEK (___) \n9. Warfarin 5 mg PO 5X/WEEK (___) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\natrial fibrillation\ncardiac tamponade\n\nSECONDARY DIAGNOSES:\nanxiety\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for your during your hospitalization at \nthe ___. As you know, you were \nadmitted for a procedure to address your atrial fibrillation but \ndeveloped bleeding around your heart covering called pericardial \neffusion/cardiac tamponade leading to low blood pressures. You \nhad a procedure to drain the bleeding and temporarily had a \ndrain in place which was removed. You had a pacemaker placed and \nhad a procedure called atrioventricular junction (AVJ) ablation. \nPlease take your medication as instructed. Please followup with \nyour cardiologists and primary care doctors.\n\nSincerely,\n___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I480", "I313", "I314", "N390", "I9589", "I9788", "Z7901", "Y838", "Y92238", "I10", "E785", "F419", "I471", "Z87891" ]

[ "I480: Paroxysmal atrial fibrillation", "I313: Pericardial effusion (noninflammatory)", "I314: Cardiac tamponade", "N390: Urinary tract infection, site not specified", "I9589: Other hypotension", "I9788: Other intraoperative complications of the circulatory system, not elsewhere classified", "Z7901: Long term (current) use of anticoagulants", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92238: Other place in hospital as the place of occurrence of the external cause", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F419: Anxiety disorder, unspecified", "I471: Supraventricular tachycardia", "Z87891: Personal history of nicotine dependence" ]

[ "I480", "N390", "Z7901", "I10", "E785", "F419", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncodeine / ciprofloxacin / diphenhydramine\n \nAttending: ___.\n \nChief Complaint:\nRLQ abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThis is a ___ female with a past medical history of\n___'s thyroiditis diagnosed 1 month ago, diverticulosis,\nwho presents to the ED with 2 days of sharp right lower quadrant\nabdominal pain.\n\nThe patient notes that she had constipation for the past week,\nand took MiraLAX which allowed her to have a bowel movement\nyesterday. The pain was initially crampy and then became more\nacute and sharp. She continues to pass flatus.\n\nShe also noted 2 episodes of blood in the tissue status post\nbowel movements, however she did not notice any blood in her\nstool. She had fevers and some chills on ___. She denies\nany nausea or vomiting.\n\nOf note, she traveled to ___ 1 month ago, but she felt fine\nupon return. She denies any fevers or diarrhea while traveling.\n\nIn the ED, initial VS were: 96.6 90 131/98 19 100% RA\n\nLabs showed: Normal CBC, lactate 1.1, normal chemistry panel, UA\nwithout evidence of infection, LFTs normal\n\nImaging showed:\nCT Abd/Pelvis w/ contrast impression:\n1. Ascending colonic diverticulitis. No fluid collection or\nperforation. Follow-up colonoscopy or cross-sectional imaging is\nrecommended in ___ weeks after treatment, to ensure absence of \nan\nunderlying mass lesion.\n\n2. Focus of gas within the bladder lumen. Correlation with any\nhistory of recent instrumentation is recommended, and if no such\nhistory is present, correlation with urinalysis is recommended \nas\ninfectious cystitis may be present.\n\nACS was consulted after diverticulitis was seen on CT scan. \nThey\nrecommended n.p.o., IV fluids, IV antibiotics, and admission to\nmedicine.\n\nPatient received: IV Dilaudid, IV Tylenol, 2 L IV fluid, IV\nciprofloxacin, IV metronidazole, IV Zofran\n\nOn evaluation in the ED, the patient verifies the above history. \n\nShe reports nausea, but no vomiting. She reports some burning\nwith urination. She is not sure how long she has been having\nthis dysuria. She reports a fever to 102 for 1 day, the day\nprior to admission. She was hoping that her abdominal pain \nwould\nget better, but when it got worse, she presented to the ED. \nFurther, she states she developed right leg pain on the morning\nof admission. She says is in her groin and upper thigh. It so\nsevere, that is causing weakness in her leg.\n\nThe patient states that, at baseline, she has a bowel movement\nevery ___ days. Prior to this admission, she had not had a \nbowel\nmovement for approximately 1 week.\n\nOf note, she was recently diagnosed with ___'s \nthyroiditis,\nand took ibuprofen for approximately 2 days. It was giving her\nstomach cramps, so she stopped 2 days ago.\n\nREVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as\nper HPI\n\n \nPast Medical History:\nPAST MEDICAL AND SURGICAL HISTORY:\n___'s Thyroiditis\nDiverticulosis\nOsteopenia\n\nPSH:\nlap cholecystectomy (___)\nappendectomy (30+ years ago)\n\n \nSocial History:\n___\nFamily History:\nNo family history of colon cancer.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: 98.4PO 117 / 68 74 20 97\nGENERAL: Uncomfortable appearing, lying in bed\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB \nGI: Severe tenderness to palpation in the right lower quadrant. \nAlso severely tender in the right groin. Hypoactive bowel \nsounds\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert, sensation intact in bilateral lower cavities. \nPatient unable to flex right lower extremity at the hip \nsecondary\nto pain. 5 out of 5 strength in the left lower extremity.\nDERM: warm and well perfused, no excoriations or lesions, no\nrashes\n\nDISCHARGE PHYSICAL EXAM:\nVS: Reviewed in POE. \nGENERAL: Comfortable appearing, sitting in bed watching movie on\nlaptop\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB \nGI: mild TTP in RLQ, no guarding / rebound, +BS\nEXTREMITIES: no cyanosis, clubbing, or edema\nNEURO: Alert, sensation intact in bilateral lower extremities. \nPatient now able to flex right lower extremity at the hip \nwithout\npain. ___ strength b/l ___.\nDERM: warm and well perfused, no excoriations or lesions, no\nrashes\n \nPertinent Results:\nADMISSION LABS\n--------------\n\n___ 09:20PM BLOOD WBC-6.1 RBC-3.88* Hgb-11.3 Hct-34.4 \nMCV-89 MCH-29.1 MCHC-32.8 RDW-12.4 RDWSD-40.0 Plt ___\n___ 09:20PM BLOOD Neuts-59.7 ___ Monos-11.8 Eos-2.1 \nBaso-0.7 Im ___ AbsNeut-3.65 AbsLymp-1.56 AbsMono-0.72 \nAbsEos-0.13 AbsBaso-0.04\n___ 12:50PM BLOOD Glucose-109* UreaN-12 Creat-0.7 Na-141 \nK-4.7 Cl-98 HCO3-29 AnGap-14\n___ 12:50PM BLOOD ALT-19 AST-20 AlkPhos-89 TotBili-0.6\n___ 12:50PM BLOOD Lipase-36\n___ 12:50PM BLOOD Albumin-4.6\n___ 07:25AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0\n___ 12:57PM BLOOD Lactate-1.3\n___ 09:25PM BLOOD Lactate-1.1\n\nPERTINENT INTERVAL AND DISCHARGE LABS\n\n___ 07:45AM BLOOD WBC-4.3 RBC-3.92 Hgb-11.4 Hct-34.5 MCV-88 \nMCH-29.1 MCHC-33.0 RDW-12.0 RDWSD-38.6 Plt ___\n___ 07:45AM BLOOD Glucose-115* UreaN-8 Creat-0.7 Na-142 \nK-4.0 Cl-105 HCO3-23 AnGap-14\n___ 07:45AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9\n\nMICRO\n-----\n___ 4:09 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Preliminary): \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n No E. coli O157:H7 found. \n\nIMAGING\n-------\n___ CT A/P\n\n1. Ascending colonic diverticulitis. No fluid collection or \nperforation. \nFollow-up colonoscopy or cross-sectional imaging is recommended \nin ___ weeks \nafter treatment, to ensure absence of an underlying mass lesion. \n\n2. Focus of gas within the bladder lumen. Correlation with any \nhistory of \nrecent instrumentation is recommended, and if no such history is \npresent, \ncorrelation with urinalysis is recommended as infectious \ncystitis may be \npresent. \n \nRECOMMENDATION(S): Follow-up colonoscopy or cross-sectional \nimaging is \nrecommended in ___ weeks after treatment, to ensure absence of \nan underlying \nmass lesion. \n\n \nBrief Hospital Course:\nPt presented to the ED with severe sharp RLQ pain and right \nupper leg and groin pain with movement as well as urinary \nfrequency and fever, found to have diverticulitis, treated \nconservatively with 14-day course Levofloxacin and Flagyl.\n\nActive Issues\n================\n# Diverticulitis\nCT A/P showed diverticulitis of the ascending colon, \ncorresponding to the pts reported pain and TTP. This was treated \nwith IV fluids, bowel rest, and ciprofloxacin and metronidazole. \nHowever, cipro was discontinued given c/f allergic reaction as \nbelow. Her regimen of ciprofloxacin and metronidazole was \nswitched to amoxicillin-clavulanic acid for 1 dose but out of \nconcern for E.coli resistance and due to low rate of cross \nreactivity between ciprofloxacin and levofloxacin, per pharmacy \nrecommendation we switched to levofloxacin and metronidazole. \nShe tolerated levofloxacin without apparent allergic reaction. \nPt was monitored until she was pain free and could tolerate \nadequate PO intake. Nausea had almost completely resolved at the \ntime of discharge. Provided with a prescription for prn Zofran \n(QTc 399ms on discharge). \n\n# Ciprofloxacin reaction\nAfter three doses of ciprofloxacin the pt had a reaction in \nwhich she had an itchy rash extend proximally from the site of \ninfusion and experienced lightheadedness. Subsequently switched \nto Levofloxacin as above without recurrent reaction. \n\n# Dysuria\nUA showed blood and few bacteria, but otherwise was fairly \nbland. CT scan showed gas in the bladder lumen. Her symptoms \nresolved on their own without intervention. \n\n# Diarrhea\nPt had one episode of watery diarrhea up to every 20 mins for \n___ days. Diarrhea resolved on its own. Likely antibiotic \nrelated. Given spontaneous resolution, low suspicion for C diff.\n\n# Sensitivity to anti-cholinergic medications\nIn the setting of the above-noted allergic reaction to \nciprofloxacin, patient received diphenhydramine (Benadryl) and \nbecame acutely confused. This medication was added to her \nadverse drug reaction (ADR) list. On ___, she was given a \nscopolamine patch for nausea and developed abrupt onset of \nmoderate/severe blurry vision that was very concerning to the \npatient, as well as dry mouth and drowsiness. These \nanticholinergic symptoms resolved shortly after removing the \nscopolamine patch. We would advise extreme caution in utilizing \nany medications with anti-cholinergic effects going forward.\n\nTransitional issues \n===================\n[] Completing 14-day antibiotic course with levofloxacin and \nFlagyl for diverticulitis (last dose = ___. \n[] Please refer to GI for colonoscopy in ___ weeks.\n- Had allergic reaction to cipro, but tolerated levofloxacin \n- Seems to be very sensitive to anti-cholinergic medications\n\nCore issues\n===========\n# Code: Full (presumed)\n# Contact: ___ (friend) ___\n.\n.\n.\n.\nTime in care: greater than 30 minutes in discharge-related \nactivities on the day of discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg) \noral DAILY \n\n \nDischarge Medications:\n1. Levofloxacin 750 mg PO Q24H Duration: 8 Doses \nRX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily \nDisp #*8 Tablet Refills:*0 \n2. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8 \nhours Disp #*24 Tablet Refills:*0 \n3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \nDuration: 3 Days \nRX *ondansetron 4 mg 1 tablet(s) by mouth three times daily as \nneeded Disp #*9 Tablet Refills:*0 \n4. Calcium 500 (calcium carbonate) 500 mg calcium (1,250 mg) \noral DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nDiverticulitis of the ascending colon. \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure taking care of you at ___.\n\nWhy you were in the hospital:\n- You had severe pain in your right lower abdomen, pain in your \nright upper leg, and urinary frequency. \n\nWhat was done for you in the hospital:\n- We did a CT scan of your abdomen and pelvis to evaluate your \npain and found diverticulitis, which is inflammation in \ndiverticula of the colon. These are small out-pouchings that can \nbecome inflamed and cause pain. \n- We gave you antibiotics to treat diverticulitis and when you \nreacted to one of the antibiotics (ciproflaxacin) we switched \nyou to another (levofloxacin). \n- We gave you IV fluids and encouraged rest of your bowels \nfollowed by light intake of clear liquids then soft foods. \n- We gave you a medication to help with nausea with eating\n- We did an analysis of your urine and did not see clear \nevidence of an infection. We did not intervene because the \nsymptoms resolved on their own.\n\nWhat you should do after you leave the hospital:\n- Please take your medications as detailed in the discharge \npapers. If you have questions about which medications to take, \nplease contact your regular doctor to discuss.\n- Please go to see your primary care doctor as detailed in \ndischarge papers. Please also visit a gastroenterologist for a \ncolonoscopy ___ weeks after discharge.\n- Please monitor for worsening symptoms. If you do not feel like \nyou are getting better or have any other concerns, please call \nyour doctor to discuss or return to the emergency room.\n\nWe wish you the best!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K5732", "K521", "Z23", "R300", "K5900", "T368X5A", "Y92239", "L271", "T3695XA", "H538", "R400", "T450X5A" ]

[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "K521: Toxic gastroenteritis and colitis", "Z23: Encounter for immunization", "R300: Dysuria", "K5900: Constipation, unspecified", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "L271: Localized skin eruption due to drugs and medicaments taken internally", "T3695XA: Adverse effect of unspecified systemic antibiotic, initial encounter", "H538: Other visual disturbances", "R400: Somnolence", "T450X5A: Adverse effect of antiallergic and antiemetic drugs, initial encounter" ]

[ "K5900" ]

[]

[ " \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:\nLUQ pain\n \nMajor Surgical or Invasive Procedure:\n___: Gel-Foam embolization of the left gastric artery.\n___: Upper endoscopy\n\n \nHistory of Present Illness:\n___ PMHx for alcoholism, DM, vasculitis and a remote hx of a\nrupture splenic artery pseudoaneurysm that was embolized\n___ who was admitted from OSH with concerns for\nhemoperitoneum. Of significance, patient was seen by the \nsurgical\nservice in ___, for an acute onset of UGI bleed, with \nsubsequent\nfindings significant for ruptured pseudoaneurysm into the lesser\nsac of the stomach. CT scan back in ___ characterized two\nsplenic ( proximal, distal) aneurysms. The proximal\npseudoaneurysm that was ruptured was coiled. Patient did have a\nprolonged hospital course, but was eventually discharged in\nstable condition. Patient now states that she has been\ncomplaining of significant \" bilateral rib pain\" since ___\nthat have progressed. She now complains of colicky sharp left\nupper quadrant abdominal pain, as well as difficulty with PO\nintake. She states that she hasn't passed gas for ___ days.\nDenies fevers, BRBPR or UGB. She went to OSH where she was\nscanned, and was found to have a three pockets of \nhemoperitoneum,\nperihepatic, pelvic, and near the stomach. \n \nPast Medical History:\nPAST MEDICAL HISTORY: \nAutoimmune hepatitis \nVasculitis \nHTN \nIBS \nDepression \nDM \nAlcoholism \nMigraines \n.\nPAST PSYCHITATRIC HISTORY: \nPt sees a psychiatrist and a therapist\nfor likely depression, with possibility of mania, per patient\nreport. This is to be confirmed with her Psychiatrist (Dr\n___ and therapist (Dr ___.\nShe denies ever being hospitalized for such depressions. She\nstates that she has contemplated suicide but has bot been really\nserious about it. She has poor sleep, treated with sleeping\nmedicines, and feels guilty about not feeling good and letting\nher family down by not taking care of herself. Her mother's \ndeath\n___ years ago, remains a source of her depression.\n\n \nSocial History:\nSOCIAL HISTORY:\nPt is older of two children, describes happy childhood. Denies \nabuse. One year of college. Works as a ___ for \nthe fourth grade. Married with ___ old twins and is happy that \nshe has coinciding holidays with them. \n\nSUBSTANCE USE:\n-Denies tobacco.\n-History of ETOH abuse though claims sobriety from ETOH for past \n___ years. Used -to drink 1 qt whisky qday x years; denies ___. + \nblackouts,\nno seizures, no severe withdrawal. History of 2 detoxes at \nleast, including\n___ in ___.\n-History of fairly heavy marijuana use x years between ages \n___\n-History of heavy daily cocaine use x years between ages ___\n-Denies IVDU\n\n \nFamily History:\nFAMILY PSYCHIATRIC HISTORY: Sister and Grandmother diagnosed \nwith\ndepression. Her grandmother had been hospitalized for this.\n\n \nPhysical Exam:\nAdmission Physical exam:\nVitals: Stable\nGeneral: AAOx3\nCardiac: Normal S1, S2\nRespiratory: Breathing comfortably on room air\nAbdomen: Soft, distended, tenderness in LUQ, mid tenderness RUQ.\nNo rebound or guarding. No signs of peritonitis. \nSkin: No lesions\n\nDischarge Physical Exam:\nVS: 98.2, 99, 171/87, 18, 98%\nGEN: AA&O x 3, NAD, calm, cooperative.\nHEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, \nPERRL.\nCHEST: Clear to auscultation bilaterally, (-) cyanosis.\nABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation \nEXTREMITIES: Warm, well perfused, pulses palpable, (-) edema\n \nPertinent Results:\n___ 03:15PM BLOOD Hct-29.9*\n___ 03:11AM BLOOD WBC-11.2* RBC-2.88* Hgb-9.0* Hct-28.1* \nMCV-98 MCH-31.3 MCHC-32.0 RDW-12.9 RDWSD-45.1 Plt ___\n___ 07:22PM BLOOD WBC-11.5* RBC-2.76* Hgb-8.9* Hct-26.9* \nMCV-98 MCH-32.2* MCHC-33.1 RDW-12.9 RDWSD-45.0 Plt ___\n___ 05:10PM BLOOD WBC-11.7* RBC-2.72* Hgb-8.8* Hct-26.5* \nMCV-97 MCH-32.4* MCHC-33.2 RDW-12.9 RDWSD-45.2 Plt ___\n___ 12:50PM BLOOD WBC-12.7* RBC-2.80* Hgb-8.8* Hct-27.2* \nMCV-97 MCH-31.4 MCHC-32.4 RDW-12.9 RDWSD-45.2 Plt ___\n___ 11:06PM BLOOD WBC-10.3* RBC-2.55* Hgb-8.1* Hct-25.2* \nMCV-99* MCH-31.8 MCHC-32.1 RDW-13.0 RDWSD-46.2 Plt ___\n___ 07:44PM BLOOD WBC-11.0* RBC-2.36* Hgb-7.6* Hct-23.3* \nMCV-99* MCH-32.2* MCHC-32.6 RDW-12.9 RDWSD-45.1 Plt ___\n___ 02:27PM BLOOD WBC-13.3* RBC-2.66* Hgb-8.4* Hct-26.2* \nMCV-99* MCH-31.6 MCHC-32.1 RDW-12.8 RDWSD-45.3 Plt ___\n___ 05:26AM BLOOD WBC-9.9 RBC-2.97* Hgb-9.4* Hct-29.0* \nMCV-98 MCH-31.6 MCHC-32.4 RDW-12.8 RDWSD-45.2 Plt ___\n\nImaging:\n___ CT A/P: \n1. No evidence of aneurysm, pseudoaneurysm or active \nextravasation. \n2. Small volume hemoperitoneum in the upper abdomen and pelvis, \nlittle changed from the outside hospital CT performed several \nhours earlier. \n3. More localized fluid with surrounding stranding along the \ngreater curvature of the stomach, raising the possibility that \nthe source of bleeding is from the gastroepiploic territory. \nHowever, an underlying lesion cannot be excluded, and an MRI is \nrecommended for further evaluation when clinically appropriate. \n\n___ MESENTERIC ARTERIOGRAM:\nAbnormal appearance of the left gastric artery treated with \nGel-Foam \nembolization. Otherwise, normal arteriograms of the celiac, \ngastroduodenal artery, gastroepiploic artery, and superior \nmesenteric artery, without active extravasation. \n\n___ MRI Abdomen:\n1. Limited exam due to the artifact from splenic artery \nembolization coils. Diffusion, and pre and post contrast \nsequences cannot be used to assess for tumor given this \nartifact. However, no obvious signal abnormality or other \nfinding is seen in the gastric wall on other T1 or T2 weighted \nsequences. \n2. Similar appearance of hematoma along the greater curvature of \nthe stomach, intimately associated with the gastric wall, again \nraising the possibility of a gastroepiploic artery or gastric \nwall vascular abnormality as the etiology of this finding. \n3. Main pancreatic ductal dilation to 6 mm without extrahepatic \nor \nintrahepatic biliary dilation. A ___ at the ampulla or \nampullary stenosis is not excluded. \n4. Bibasilar atelectasis, right greater than left. \n5. 4 mm gallbladder polyp. No specific follow-up is needed for \nthis finding. \n\n \nBrief Hospital Course:\nMs. ___ was admitted to spontaneous hemoperitoneum with \nunknown etiology. CTA did not reveal any extravasation. ___ was \nconsulted and an angiogram was performed. They did not see any \nextravasation but noted the left gastric to be abnormal in \nappearance. The left gastric was then gel-foam embolized given \nit's abnormal appearance. An MRI was obtained to rule out any \ngastric masses. It revealed a possibly abnormal gastric wall and \na possibly stenotic ampulla. Given these findings GI was \nconsulted. During this time, she was admitted to the ICU with \nthe following course.\nNeuro: Her pain was controlled with IV and then subsequently PO \npain medication. \nCV: hemodynamics were monitored closely. She was intermittently \ntachycardic upon arrival which shortly resolved. \nResp: She remained stable on room air\nGI: Please see above imaging and intervention course. Her diet \nwas advanced once her Hcts were stable. \nGU: UOP was adequate with a foley in place\nHeme: Serial hematocrits were obtained without need for \ntransfusions. \nID: no acute issues\n\nShe was stable for transfer to the floor on ___. Hematocrit \nwas stable and subcutaneous heparin was restarted for DVT \nprophylaxis. On HD5 the patient was triggered for hypotension, \nhypoxia, and downtrending hematocrit. Repeat CT of abdomen / \npelvis showed mild interval decrease in the amount of small \nvolume hemoperitoneum. Chest xray and cardiac enzymes were \nnormal. The following day the hematocrit came up on its own. GI \nwas consulted for endoscopic evaluation to rule out a gastric \nmalignancy that may have led to her bleed. on HD7, the patient \nunderwent an EGD, which was normal and showed no findings to \nexplain the bleeding. \n\nPain was well controlled. Diet was progressively advanced as \ntolerated to a regular diet with good tolerability. The patient \nvoided without problem. During this hospitalization, the patient \nambulated early and frequently, was adherent with respiratory \ntoilet and incentive spirometry, and actively participated in \nthe plan of care. The patient received subcutaneous heparin and \nvenodyne boots were used during this stay.\n.\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home without services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. TraZODone 200 mg PO QHS:PRN insomnia \n2. Verapamil 360 mg PO Q12H \n3. Venlafaxine XR 150 mg PO DAILY \n4. PredniSONE 7 mg PO DAILY \n5. Metoclopramide 10 mg PO DAILY \n6. Pramipexole 1 mg PO QHS \n7. Omeprazole 20 mg PO BID \n8. MethylPHENIDATE (Ritalin) 20 mg PO TID \n9. NovoLIN 70/30 (insulin NPH and regular human) 8 units \nsubcutaneous DAILY \n10. Gabapentin 1200 mg PO BID \n11. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n12. Fluoxetine 20 mg PO DAILY \n13. Celebrex ___ mg oral BID \n14. Atenolol 25 mg PO DAILY \n\n \nDischarge Medications:\n1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*20 Tablet Refills:*0\n2. NovoLIN 70/30 (insulin NPH and regular human) 8 units \nsubcutaneous DAILY \n3. Celebrex ___ mg oral BID \n4. Senna 8.6 mg PO BID \n5. Atenolol 25 mg PO DAILY \n6. Fluoxetine 20 mg PO DAILY \n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n8. Gabapentin 1200 mg PO BID \n9. MethylPHENIDATE (Ritalin) 20 mg PO TID \n10. Metoclopramide 10 mg PO DAILY \n11. Omeprazole 20 mg PO BID \n12. Pramipexole 1 mg PO QHS \n13. PredniSONE 7 mg PO DAILY \n14. TraZODone 200 mg PO QHS:PRN insomnia \n15. Venlafaxine XR 150 mg PO DAILY \n16. Verapamil 360 mg PO Q12H \n17. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n18. Docusate Sodium 100 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHemoperitoneum\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 transferred to ___ with complaints of abdominal pain \nand CT imaging concerning for blood in your peritoneum but did \nnot show any active bleeding. You were admitted for close \nmonitoring for any sign of continued bleeding. Your hematocrit \nand vital signs have been stable and you did not require any \nblood transfusions or interventional procedure to stop the \nbleeding. The Gastroenterology doctors were ___, and they \nperformed an endoscopic exam of your stomach, which showed no \nfindings on EGD to explain the bleeding. You are now tolerating \na regular diet and your pain is improved. You are ready to be \ndischarged home to continue your recovery. Please note the \nfollowing discharge instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. \n \nFollowup Instructions:\n___\n" ]

[ "K661", "K831", "K754", "I10", "K589", "F329", "E119", "Z794", "I776", "I9581" ]

[ "K661: Hemoperitoneum", "K831: Obstruction of bile duct", "K754: Autoimmune hepatitis", "I10: Essential (primary) hypertension", "K589: Irritable bowel syndrome without diarrhea", "F329: Major depressive disorder, single episode, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "I776: Arteritis, unspecified", "I9581: Postprocedural hypotension" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nDiflucan\n \nAttending: ___.\n \nChief Complaint:\nLeft ankle and foot pain\n \nMajor Surgical or Invasive Procedure:\nLeft cephalo-medullary nail, air cast boot for ankle\n\n \nHistory of Present Illness:\n___ female with a history of Ehlers-Danlos syndrome, pots\ndisease, and dysautonomia presents with left hip and left ankle\npain for 1 days duration.\n\nToday, the patient was sitting on the couch watching TV for\nprolonged period of time. She stood up and her foot was asleep\nand she attempted to ambulate into her kitchen. She stumbled on\nher sleeping foot landing onto her left side. She denies head\nstrike or loss of consciousness. She denies presyncopal\nsymptoms. She complains of isolated left hip and left ankle\npain. She denies numbness and tingling in the extremity. She\ndenies headache, neck pain, back pain, chest pain, shortness of\nbreath, abdominal pain, nausea, and other medical complaints\n \nPast Medical History:\nPOTs\nALLERGIC RHINITIS \nATTENTION DEFICIT DISORDER WITHOUT HYPERACTIVITY \nGASTRITIS \nHAYFEVER \nL5 DISC \nMACROSCOPIC HEMATURIA \nOSTEOPOROSIS \nRAYNAUD'S PHENOMENON \nPLANTAR FASCIITIS \nIRRITABLE BOWEL SYNDROME \nLACTOSE INTOLERANCE \nEHLERS DANLOS SYNDROME \nSLEEP APNEA \nCENTRAL SLEEP APNEA \n \nSocial History:\n She lives locally. She is a former ___ of astro___. \nShe works mostly from home. She drinks a small amount of \nalcohol\non very rare occasions. Denies tobacco, marijuana, and illicit\ndrug use. She is a community ambulator that completes all her\nactivities of daily living.\n\nMarital status:Married \nName ___ \n___: \nChildren: No \nLives with: ___ \nWork: ___\nDomestic violence: Denies \nContraception: N/A \nTobacco use: Never smoker \nTobacco Use no tobacco products ever \nComments: \nAlcohol use: Present \nAlcohol use 4/ year \ncomments: \nRecreational drugs Denies \n(marijuana, heroin, \ncrack pills or \nother): \nDepression: Based on a PHQ-2 evaluation, the patient \n does not report symptoms of depression \nExercise: Activities: ___ walks daily. limited by \n plantar fascitis ___ \nExercise comments: Footnote: treadmill \nDiet: coffee 2/day \nSeat belt/vehicle Always \n\n \nFamily History:\nNC\n \nPhysical Exam:\nGen: NAD\nRes: No resp distress\n\nLLE\n+Knee effusion\nFires ___, ___\nPulses - WWP\nDressing - C/D/I\nSILT Sural/saphenous/tibial/ peroneal distributions\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 subtrochanteric femur fracture and was admitted \nto the orthopedic surgery service. The patient was taken to the \noperating room on ___ for a cephalo-medullary nail, which \nthe patient tolerated well. For full details of the procedure \nplease see the separately dictated operative report. The patient \nwas taken from the OR to the PACU in stable condition and after \nsatisfactory recovery from anesthesia was transferred to the \nfloor. The patient was initially given IV fluids and IV pain \nmedications, and progressed to a regular diet and oral \nmedications 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 patient also has a left ankle fracture, \nwhich will be managed non-operatively in an air cast boot. The \n___ hospital course was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nweight bearing as tolerated in the left lower extremity \nextremity, and will be discharged on lovenox for DVT \nprophylaxis. The patient will follow up with Dr. ___ \nroutine. A thorough discussion was had with the patient \nregarding the diagnosis and expected post-discharge course \nincluding reasons to call the office or return to the hospital, \nand all questions were answered. The patient was also given \nwritten instructions concerning precautionary instructions and \nthe appropriate follow-up care. The patient expressed readiness \nfor discharge.\n \nMedications on Admission:\n1. ACETAZOLAMIDE - acetazolamide 125 mg tablet. 1 tablet(s) by \nmouth\nonce As needed for sleep study\n2. ESTROGEN-TESTOSTERON-PROGESTERONE - Dosage uncertain - \n(Prescribed by Other Provider)\n3. IODORAL - Iodoral . 6.25 mg by mouth three times a week - \n(Prescribed by Other Provider)\n4. QUERCETIN DIHYDRATE (BULK) - Dosage uncertain - (Prescribed \nby\nOther Provider)\n5. ACTIVATED CHARCOAL - activated charcoal 200 mg capsule.\ncapsule(s) by mouth as needed - (OTC)\n6. CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) \n2,000\nunit capsule. 1 Capsule(s) by mouth once a day - (Prescribed by\nOther Provider)\n7. COENZYME Q10 [CO Q-10] - Dosage uncertain - (OTC)\n8. DIGESTIVE ENZYMES - digestive enzymes capsule. capsule(s) by\nmouth daily - (OTC)\n9. FERROUS SULFATE [IRON] - iron 325 mg (65 mg iron) tablet.\ntablet(s) by mouth three times a week - (Prescribed by Other\nProvider; Dose adjustment - no new Rx)\n10. LORATADINE [CLARITIN] - Claritin 10 mg tablet. tablet(s) by \nmouth\n- (Prescribed by Other Provider; Dose adjustment - no new Rx)\n11. MAGNESIUM - magnesium 200 mg tablet. 2 tablet(s) by mouth - \n\n(Prescribed by Other Provider; Dose adjustment - no new Rx)\n12. MULTIVITAMIN - multivitamin tablet. tablet(s) by mouth - \n(OTC;\nDose adjustment - no new Rx)\n13. PHYTONADIONE (VITAMIN K1) - phytonadione (vitamin K1) 100 \nmcg\ntablet. tablet(s) by mouth - (OTC)\n14. WODENZYME - wodenzyme . ___ tablets daily - (OTC)\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Cyclobenzaprine 5 mg PO TID:PRN Spasm \n3. Docusate Sodium 100 mg PO BID \n4. Enoxaparin Sodium 40 mg SC DAILY \nRX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous daily Disp \n#*28 Syringe Refills:*0 \n5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nPartial fill ok \nRX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4 \nhours Disp #*30 Tablet Refills:*0 \n6. Loratadine 10 mg PO DAILY \n7. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft subtrochanteric femur fracture, Left bimalleolar ankle \nfracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n-Weightbearing as tolerated left lower extremity\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add oxycodone as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 tablet every 3 hours as needed x 1 day,\nthen 1 tablet every 4 hours as needed x 1 day,\nthen 1 tablet every 6 hours as needed x 1 day,\nthen 1 tablet every 8 hours as needed x 2 days, \nthen 1 tablet every 12 hours as needed x 1 day,\nthen 1 tablet every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \nANTICOAGULATION:\n- Please take 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- Splint must be left on until follow up appointment unless \notherwise instructed.\n- Do NOT get splint wet.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever ___ 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB\n\nPhysical Therapy:\nActivity: Activity: Out of bed w/ assist\n Left lower extremity: Full weight bearing\nEncourage turn, cough and deep breathe q2h when awake\n\nTreatments Frequency:\nAny staples or superficial sutures you have are to remain in \nplace for at least 2 weeks postoperatively. Incision may be \nleft open to air unless actively draining. If draining, you may \napply a gauze dressing secured with paper tape. You may shower \nand allow water to run over the wound, but please refrain from \nbathing for at least 4 weeks postoperatively.\n \nFollowup Instructions:\n___\n" ]

[ "S7222XA", "D62", "W010XXA", "G4731", "S82842A", "M810", "I498" ]

[ "S7222XA: Displaced subtrochanteric fracture of left femur, initial encounter for closed fracture", "D62: Acute posthemorrhagic anemia", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "G4731: Primary central sleep apnea", "S82842A: Displaced bimalleolar fracture of left lower leg, initial encounter for closed fracture", "M810: Age-related osteoporosis without current pathological fracture", "I498: Other specified cardiac arrhythmias" ]

[ "D62" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCodeine / pseudoephedrine\n \nAttending: ___.\n \nChief Complaint:\nhyperglycemia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with a history of type 1\ndiabetes on insulin pump as well as non-Hodgkin lymphoma who\npresents with concern for hyperglycemia after starting \nprednisone\nfor chemotherapy. She reports that she just received \nchemotherapy\nincluding prednisone on day of presentation to the ED and that\nher blood sugars have been elevated above 300 since. She is due\nto receive 4 more days of 100 mg prednisone. She is finished \nwith\nthe rest of the chemotherapeutic agents. She did receive\nNeulasta. She spoke to her endocrinologist at ___ and ___\nrecommended that she come in to be evaluated. She recently was\ninpatient for hyperglycemia in the setting of steroids for a\nprior chemotherapy regimen as well. She is currently completely\nasymptomatic.\n\nPer phone call note in OMR, patient stated her NHL returned\naggressively and that she is currently on 100mg of steroids\ndaily. She was last admitted in ___ also for hyperglycemia\nin the setting of dexamethasone. \n\nIn the ED:\n- Initial vital signs were notable for: T 96.5, HR 84, BP \n150/72,\nRR 18, O2 sat 99% on RA, FSBG 378\n- Exam notable for: no concerning findings\n\n-Labs were notable for:\n--CBC: WBC 8.5, Hb 10.3, Hct 29.5, Plt 239\n--VBG: pH 7.46, pCO2 30, pO2 110, HCO3 22\n--BMP: Na 136, K 4.3, Cl 102, Bicarb 18, BUN 35, Cr 0.9, Glu \n319,\nAG 16\n\n-Studies performed include:\n--U/A: neg leuk est/blood/nitr/ketones, 1000 gluc, <1 RBC, 1 WBC\n--No imaging\n\n-Patient was given: none\n-Consults: ___\n\nVitals on transfer: T 98.2, HR 68, BP 122/70, RR 16, O2 sat 99%\non RA\n\nUpon arrival to the floor, patient is very anxious regarding her\nhospitalization, specifically being in a shared room because she\nis afraid of catching infection given chemotherapy. Patient\nstarted R-CHOP therapy on ___ and is due for prednisone 100mg\ndaily for 5 days (___). She reports her blood glucose \nwas\nincreased to >450 last night, prompting decision to come to the\nED because she lives alone and was afraid that she would not be\nokay by herself. \n\nOn interview, she denies any infectious symptoms, including\ncough, dysuria, fever, chills. She also denies chest pain,\ndyspnea, change in bowel habits, nausea, vomiting, headache,\nnumbness or dizziness. She got neulasta yesterday as part of her\nchemotherapy regimen. She had previously gotten dexamethasone \nand\nrituximab over the ___ for NHL but notes her disease is\nmore aggressive now, and so she will be getting R-CHOP chemo q3\nweeks until ___. \n\nREVIEW OF SYSTEMS: See above as per HPI. \n\n \nPast Medical History:\n- Type I DM (on insulin pump)\n- Non-Hodgkin's Lymphoma (diagnosed ___ and never treated)\n- Hyperlipidemia\n- Hypertension\n\n \nSocial History:\n___\nFamily History:\nNon-contributory to this hospitalization\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n========================\nVITALS: ___ 1756 Temp: 98.4 PO BP: 130/65 R Lying HR: 79 \nRR:\n18 O2 sat: 98% O2 delivery: Ra \nGENERAL: Alert and interactive. Anxious-appearing. Wearing latex\ngloves and surgical mask. \nHEENT: NCAT. PERRL, EOMI. Sclera anicteric and without \ninjection.\nMMM.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing on RA.\nABDOMEN: +BS, soft ND, NT to palpation. No organomegaly. Insulin\npump on RLQ, site without erythema or tenderness. \nEXTREMITIES: No clubbing, cyanosis, or edema.\nSKIN: Warm. No rash.\nNEUROLOGIC: AOx3. No focal neurologic deficits. CN2-12 grossly\nintact. \n\nDISCHARGE PHYSICAL EXAM\n========================\nVITALS: 24 HR Data (last updated ___ @ 1144)\n Temp: 98.7 (Tm 98.9), BP: 157/72 (109-157/63-72), HR: 83\n(62-89), RR: 18, O2 sat: 96% (95-98), O2 delivery: Ra \nGENERAL: Alert and interactive. Anxious-appearing. \nHEENT: NCAT. PERRL, EOMI. Sclera anicteric and without \ninjection.\nMMM.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing on RA.\nABDOMEN: +BS, soft ND, NT to palpation. No organomegaly. Insulin\npump on RLQ, site without erythema or tenderness. \nEXTREMITIES: No clubbing, cyanosis. Non-pitting edema is present\nbilaterally\nSKIN: Warm. No rash.\nNEUROLOGIC: AOx3. No focal neurologic deficits. CN2-12 grossly\nintact. \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 01:25AM BLOOD WBC-8.5 RBC-3.58* Hgb-10.3* Hct-29.5* \nMCV-82 MCH-28.8 MCHC-34.9 RDW-13.5 RDWSD-40.9 Plt ___\n___ 01:25AM BLOOD Neuts-83.5* Lymphs-8.9* Monos-6.9 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-7.12* AbsLymp-0.76* \nAbsMono-0.59 AbsEos-0.00* AbsBaso-0.02\n___ 06:38AM BLOOD Glucose-319* UreaN-35* Creat-0.9 Na-136 \nK-4.3 Cl-102 HCO3-18* AnGap-16\n___ 08:25AM BLOOD Calcium-10.0 Phos-1.7* Mg-2.0\n___ 01:28AM BLOOD ___ pO2-110* pCO2-30* pH-7.46* \ncalTCO2-22 Base XS-0 Comment-GREEN TOP\n\nIMAGING\n=======\nNone\n\nMICROBIOLOGY\n=============\n___ 1:25 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n\nDISCHARGE/INTERVAL LABS\n======================\n___ 07:35AM BLOOD WBC-19.5* RBC-3.55* Hgb-10.1* Hct-31.0* \nMCV-87 MCH-28.5 MCHC-32.6 RDW-13.6 RDWSD-43.7 Plt ___\n___ 07:35AM BLOOD Glucose-110* UreaN-28* Creat-0.8 Na-139 \nK-3.6 Cl-102 HCO3-25 AnGap-12\n___ 07:35AM BLOOD Calcium-9.9 Phos-2.4* Mg-2.0\n \nBrief Hospital Course:\nMs. ___ is a ___ female with past medical history \nnotable for Type 1 DM with insulin pump and Non-Hodgkin's \nLymphoma started on R-CHOP ___ who presented with \nhyperglycemia in the setting of taking prednisone, without \nevidence of inciting infection or DKA.\n\nACUTE ISSUES:\n=============\n#Hyperglycemia\n#Type 1 DM with insulin pump. Patient with Type I DM and \npresenting with elevated sugars in the setting of taking \nprednisone for treatment of Non-Hodgkin's Lymphoma. Patient has \nan insulin pump for management and is followed by Dr. ___ at \n___. Blood glucose elevated to 300s on admission. No evidence \nof DKA as normal anion gap (16) and no ketonuria. No evidence of \ninfection and patient not reporting any localizing symptoms. \nPatient also denies chest pain or cardiac symptoms. Of note\npatient is able to manage her insulin pump quite well, as \ndocumented in previous notes. Patient will need prednisone until \n___ and will continue to require increased insulin during this \nperiod of time, as well as with future chemotherapy cycles. \nPatient evaluated by ___ with recommendations to add 10 U NPH \nin AM and 5 U NPH at 1300. On the first day, patient agreed to 5 \nU NPH in AM and in afternoon with improvement in FSBGs. On the \nday of discharge, patient took 10 U NPH in AM but refused to \ntake additional NPH in ___. She was evaluated by ___ who felt \nthat she was safe to discharge and can manage her FSBGs on her \nown with the assistance of the on-call ___ physician. \n\n#Leukocytosis. No localizing symptoms concerning for infection. \nU/A without pyuria, nitrites, leuk esterase or bacteria. Most \nlikely due to recent Neulasta injection, which patient received \non ___ with chemotherapy.\n\n#Non-Hodgkins lymphoma. Diagnosed in ___. Previously treated \nwith rituximab, now more aggressive per patient. Her primary \noncologist is Dr. ___ at ___. She initiated R-CHOP on \n___ with plan for chemotherapy q3 weeks until ___. She \nwill continue prednisone 100mg\nx5d as part of the chemotherapy protocol, ___. \n\nCHRONIC ISSUES:\n===============\n#Hyperlipidemia. Continue atorvastatin 20mg qPM\n\nTRANSITIONAL ISSUES\n====================\n[ ] Insulin plan while on Prednisone, per ___: 10 units NPH \nat time of steroid dose administration in am. Then give another \n5 units NPH at ~1pm\n[ ] She should be continued on a similar regimen at her next \nsteroid cycle to avoid hospital readmissions\n[ ] Will need to reschedule her eye appointment with ___\n[ ] Continue to engage with ___ team about obtaining assistance \nfor anxiety/coping\n.\n.\n.\n.\n.\n.\n.\n\nAttending addendum \n\nGreater than 30 minutes were spent providing and coordinating \ncare for this patient on day of discharge. \n\n___ MD \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. \nacidophilus-L. rhamnosus;<br>L.rhamn \nA\n-\n___\n-\n___ \n40-Bifido 3-S.thermop;<br>Lactobacillus \nacidophilus;<br>lactobacillus comb no.10;<br>lactobacillus \ncombination no.4;<br>lactobacillus combo no.11) 10 billion cell \noral DAILY \n3. PredniSONE 100 mg PO DAILY \n4. Atorvastatin 20 mg PO QPM \n5. Insulin Pump SC (Self Administering Medication)Insulin \nLispro (Humalog)\nTarget glucose: 80-180\n\n \nDischarge Medications:\n1. Insulin Pump SC (Self Administering Medication)Insulin \nLispro (Humalog)\n\nBasal Rates:\n Midnight - 0430: .7 Units/Hr\n 0430 - 0900: .85 Units/Hr\n 0900 - 1200: .9 Units/Hr\n 1200 - 1500: .88 Units/Hr\n 1500 - 2200: .88 Units/Hr\n 2200 - 0000: .7 Units/Hr\nMeal Bolus Rates:\n Breakfast = 1:7\n Lunch = 1:7\n Dinner = 1:6\nMD has ordered ___ consult\nUse of ___ medical equipment: Insulin pump\nReason for use: medically necessary and justified as ___ \ncannot provide this type of equipment or suitable alternative \nnot appropriate.\nProvider acknowledges patient competent\n \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. PredniSONE 100 mg PO DAILY \n5. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L. \nacidophilus-L. rhamnosus;<br>L.rhamn \nA\n-\n___\n-\n___ \n40-Bifido 3-S.thermop;<br>Lactobacillus \nacidophilus;<br>lactobacillus comb no.10;<br>lactobacillus \ncombination no.4;<br>lactobacillus combo no.11) 10 billion cell \noral DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES \n================= \nHYPERGLYCEMIA \nTYPE I DIABETES MELLITUS \nLEUKOCYTOSIS \n \nSECONDARY DIAGNOSES \n=================== \nNON-HODGKIN'S LYMPHOMA \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 Ms. ___,\n\nYou were admitted to the ___ for hyperglycemia that was \nexacerbated by your recent Prednisione use associated with your \nchemotherapy. ___ saw you while hospitalized and recommended \nthat you take NPH twice a day while you are on Prednisone. Your \nblood sugars were better controlled while taking NPH. You will \nneed close follow-up with ___ after discharge.\n\nIt is really important that you take your medications and attend \nyour follow-up appointments listed below. \n\nIf you have difficulty with managing your blood sugars over the \nweekend, please call ___ and ask for pager ___. \n\nIt was a pleasure taking care of you!\n\nWe wish you the best!\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "E1065", "C8590", "T380X5A", "I10", "E785", "Z9641" ]

[ "E1065: Type 1 diabetes mellitus with hyperglycemia", "C8590: Non-Hodgkin lymphoma, unspecified, unspecified site", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z9641: Presence of insulin pump (external) (internal)" ]

[ "I10", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCodeine / pseudoephedrine\n \nAttending: ___\n \nChief Complaint:\nHyperglycemia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with past medical history\nnotable for Type 1 DM and NHL who presented with hyperglycemia \nin\nthe setting of taking steroids.\n\nPatient states it all began ~ 2 weeks prior to admission where\nshe noticed LLE>RLE. She was sent to ___ where significant \nworkup\nwas done to rule out PE (with CTA and LENIs). It was concluded\nshe had no clot, however she was found to have worsening of her\nNon-Hodgkin's lymphoma.\n\nHer oncologist prescribed dexamethasone for 4 days which she\nstarted taking 2 days prior to admission (with plan for\ninitiation of rituximab in 1 week - ___. Both patient and\nproviders were aware of hyperglycemia and thus she was closely\nmonitoring her sugars. Of note patient is very knowledgeable\nabout her sugars and diabetes management. She uses an insulin\npump with Humalog and noticed elevated sugars as expected.\nHowever when sugars started being uncontrolled and instructions\nby phone from ___ did not resolve them (with basal insulin\nadjustment), she presented to the emergency room.\n\nShe denies any symptoms except a cough for the past month. She\ndenies dizziness, increased urinary frequency, chest pain,\nN/v/Diarrhea\n\nIn the ED\n- Initial vitals: 96.6 74 110/66 16 100% on RA\n- Labs: \n+ WBC 13.4 Hgb 10.8 Plt 267\n+ Na 123, K 6.5 (hemolyzed) creatinine 1.2\n- Imaging: Cxray with no findings\n- Patient was given ceftriaxone for a question of UTI and \nregular\ninsulin 10units, followed by 8 units humalog\n\nTransfer vitals HR 77 BP 126/93 RR 16 98% on RA. Patient's ___ on\narrival to the floor is ~ 180\n\n \nPast Medical History:\n- Type I DM (on insulin pump)\n- Non-Hodgkin's Lymphoma (diagnosed ___ and never treated)\n- Hyperlipidemia\n- Hypertension\n\n \nSocial History:\n___\nFamily History:\nReviewed and found to be not relevant to this\nillness/reason for hospitalization.\n\n \nPhysical Exam:\nAdmission physical exam:\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate, oral\nmucosa is dry\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM. Insulin pump attached to RLQ - area is\nclean with no erythema\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs, 2+ BLE with LLE>RLE\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDischarge physical exam:\n___ 0818 Temp: 98.5 PO BP: 107/58 HR: 93 RR: 18 O2 sat: 99%\nO2 delivery: Ra \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate, oral\nmucosa is dry\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM. Insulin pump attached to RLQ - area is\nclean with no erythema\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs, 3+ BLE with LLE>RLE\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\nAdmission labs\n===============\n___ 04:17AM BLOOD WBC-13.4* RBC-4.03 Hgb-10.8* Hct-32.6* \nMCV-81* MCH-26.8 MCHC-33.1 RDW-13.8 RDWSD-40.4 Plt ___\n___ 04:17AM BLOOD Glucose-441* UreaN-45* Creat-1.2* Na-123* \nK-6.5* Cl-87* HCO3-19* AnGap-17\n___ 04:17AM BLOOD Calcium-12.2* Phos-4.6* Mg-1.6\n___ 05:55AM BLOOD 25VitD-10*\n___ 06:42AM BLOOD PTH-20\n___ 05:55AM BLOOD PEP-NO MONOCLO IgG-628* IgA-90 IgM-31* \nIFE-NO MONOCLO\n\nDischarge labs\n================\n\n___ 05:55AM BLOOD WBC-6.6 RBC-3.93 Hgb-10.6* Hct-31.8* \nMCV-81* MCH-27.0 MCHC-33.3 RDW-14.2 RDWSD-41.3 Plt ___\n___ 05:55AM BLOOD Glucose-60* UreaN-37* Creat-1.0 Na-140 \nK-4.0 Cl-103 HCO3-23 AnGap-14\n___ 05:55AM BLOOD TotProt-4.8* Albumin-2.9* Globuln-1.9* \nCalcium-12.4* Phos-4.3 Mg-1.8\n___ 04:31AM BLOOD Lactate-2.1* K-4.2\n \nBrief Hospital Course:\nMs. ___ is a ___ female with past medical history \nnotable for Type 1 DM and NHL who presented with hyperglycemia \nin the setting of taking steroids.\n\nACUTE/ACTIVE PROBLEMS:\n# Hyperglycemia: \n# Type 1 DM: Patient with Type I DM and presenting with elevated \nsugars in the setting of taking dexamethasone for treatment of \nadvancing NHL. No evidence of DKA currently. Patient uses an \ninsulin pump and very experienced with its use, and given \nability to manage her own sugars with well controlled numbers we \ncontinued to use the pump with her direction and ___ support. \nNo evidence of infection. No chest pain/cardiac symptoms.\n\n# Hyponatremia: Resolved/ likely in the setting of high sugars. \nNa was 123 on admission but corrected for sugars was ~130. \nDischarge Na was 140\n\n# Hypercalcemia: Currently asymptomatic and stable. We reviewed \n___ records where her last calcium in ___ was ~10.1. This is \nlikely new in the setting of malignancy. In order not to anchor \non that, work up done to rule out other etiologies (workup \npending at the time of discharge): PTH, Vitamin D, SPEP and UPEP \ngiven trace anemia. Patient educated to avoid factors that can \naggravate hypercalcemia, including thiazide diuretics, volume \ndepletion (to drink ___ glasses of water daily given risk of \ndehydration in the setting of diabetes, avoid high calcium diet \n(>1000 mg/day). \n\n# Leukocytosis: Resolved. No evidence of infection despite \nintermittent cough for ~ 1 month (patient states was treated for \nPneumonia ~ 1 month ago). Leukocytosis likely due to steroids.\n\n# NHL: Significantly advanced per patient report and CT image \nrecords patient presented. LLE>RLE worked up and DVT ruled out \nat ___ ~ 2 weeks earlier with suspicion for malignancy as \netiology.\n\nTRANSITIONAL ISSUES\n======================\n- F/u on workup sent for hypercalcemia\n- Continue to monitor calcium as outpatient and ensure it is \nmild or moderate\n\n>30 minutes spent on discharge planning and coordination\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Dexamethasone 4 mg PO DAILY \n2. Probiotic (B. coagulans) (Bacillus coagulans) 10 billion cell \noral DAILY \n3. Insulin Pump SC (Self Administering Medication)Insulin \nLispro (Humalog)\nTarget glucose: 80-180\n\n4. Simvastatin 20 mg PO QPM \n5. Aspirin EC 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using HUM Insulin \n2. Aspirin EC 81 mg PO DAILY \n3. Probiotic (B. coagulans) (Bacillus coagulans) 10 billion \ncell oral DAILY \n4. Simvastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHyperglycemia\nHypercalcemia\nHyponatremia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Miss ___,\n\n___ were admitted due to uncontrolled sugar in the setting of \ntaking steroids. ___ improved significantly managing your sugars \nwith your insulin pump. Please DO NOT take anymore steroids and \nfollow up with your doctor.\n\nYour calcium levels were also found to be moderately elevated. \n___ had no symptoms and ___ were also hydrated significantly in \nthe hospital. We sent labs to understand what caused this (which \nwere pending by discharge) though we also suspect the Lymphoma \ncould be the cause.\n\nPlease follow up with your doctor to ensure your calcium levels \nare rechecked.\n\nIt was a pleasure being part of your team\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "E1065", "C8590", "E871", "E8352", "T380X5A", "Y92019", "Z794", "Z9641", "E785", "Z87891", "D72829" ]

[ "E1065: Type 1 diabetes mellitus with hyperglycemia", "C8590: Non-Hodgkin lymphoma, unspecified, unspecified site", "E871: Hypo-osmolality and hyponatremia", "E8352: Hypercalcemia", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause", "Z794: Long term (current) use of insulin", "Z9641: Presence of insulin pump (external) (internal)", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "D72829: Elevated white blood cell count, unspecified" ]

[ "E871", "Z794", "E785", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nOxycodone / Naprosyn\n \nAttending: ___.\n \nChief Complaint:\nL flank pain\n \nMajor Surgical or Invasive Procedure:\ncystoscopy, L ureteral stent\n \nHistory of Present Illness:\nThis is a ___ year old female who\npresents with right lower quadrant pain. She reports sudden \nonset\nof RLQ pain starting 2 days ago that radiated to her right \nflank.\nThis was associated with nausea, emesis x1, and chills. Denies\ndysuria, hematuria, fevers. She denies history of\nnephrolithiasis.\n \nPast Medical History:\nPGynHx: No abl paps, regular menses until ___, no STIs\n\nPObHx: G5P4, 1 TAB\n\nPMH: Reported no current medical issues, though in reports found\nnotes re. ___ right breast granular cell tumor found on bx but\nno f/u from pt. Also h/o back pain.\n\nPSH:\n___ - laparoscopically assisted vaginal hysterectomy with\ncystoscopy \n___: Operative hysteroscopy with myomectomy and endometrial\nablation with rollerball\n___: R breast bx\n\n \nSocial History:\n___\nFamily History:\nFamHx: no breast, gyn, colon malignancy. + fam history of \nfibroids. \n \nPhysical Exam:\nOn discharge:\n\nNAD\nNo cardiopulmonary distress\nAbd soft nt nd\n \nPertinent Results:\n___ 06:15AM BLOOD WBC-7.4 RBC-4.35 Hgb-11.8 Hct-37.8 MCV-87 \nMCH-27.1 MCHC-31.2* RDW-15.6* RDWSD-49.5* Plt Ct-94*\n___ 06:15AM BLOOD Glucose-110* UreaN-11 Creat-1.1 Na-142 \nK-3.8 Cl-108 HCO3-21* AnGap-13\n \nBrief Hospital Course:\nThis is a ___ yF who presented with obstructive uropathy and SIRS \n(fevers, leukocytosis) due to a L ureteral calculus. She \nunderwent a cystoscopy, R ureteral stent placement by Dr. ___ \non ___.\n\nPost-operatively, the patient's hospitalization stay involved \ntreating septicemia (Proteus, pan-sensitive) that grew in her \nblood on presentation. She stayed until ___ when she \nde-effervesced. Her Foley was removed prior to discharge. When \nit was demonstrated that she was afebrile x 24 hours on oral \ntherapy and voiding without issues, she was discharged on \n___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n2. Ibuprofen 600 mg PO Q8H:PRN pain/fever \n3. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n4. Sulfameth/Trimethoprim DS 1 TAB PO BID \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by \nmouth twice a day Disp #*22 Tablet Refills:*0 \n5. Tamsulosin 0.4 mg PO DAILY \nRX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*1 \n6. TraMADol 50-100 mg PO Q4H:PRN BREAKTHROUGH PAIN \nRX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*15 Tablet Refills:*0 \n7. Lisinopril 10 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUrosepsis secondary to obstructed ureteral stone\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nTake antibiotic as prescribed for 11 days.\n\nDrink 8 or more glasses of water daily.\n\nGo to emergency room if you develop any of the following:\nfevers\nnausea/vomiting leading to inability to tolerate fluids\nworsening pain\npersistent shakes and chills\n\nThe urology office phone number is ___. Call office on \n___ to confirm your surgery date.\n\n \nFollowup Instructions:\n___\n" ]

[ "A4159", "J439", "I10", "N136", "N390", "Z6841", "B964", "F17210", "E559", "E669" ]

[ "A4159: Other Gram-negative sepsis", "J439: Emphysema, unspecified", "I10: Essential (primary) hypertension", "N136: Pyonephrosis", "N390: Urinary tract infection, site not specified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E559: Vitamin D deficiency, unspecified", "E669: Obesity, unspecified" ]

[ "I10", "N390", "F17210", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nOxycodone / Naprosyn\n \nAttending: ___.\n \nChief Complaint:\nback pain, fever\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w/ NSCLC (s/p VATS wedge resection LUL and LLL ___ w/ \npath showing positive margins), COPD, hypoxic respiratory \nfailure (on O2 w/ exertion), chronic nephrolithiasis, presenting \nwith midline low back pain, fevers, and malaise. \n\nPt presents now with reports of feeling generally unwell x1 \nweek. She now works the 11 pm-7 am shift at a homeless shelter; \nat about 8 am on ___ she returned home from work, and noted \nchills. Temp at home was 99.7, and she notes that she typically \nruns between 97 and 98. She took theraflu, and slept all day \nuntil 11 pm that evening. On ___ morning, she noted low back \npain. At that point, temp was increasing to 100.2, with \ndrenching sweats. She central low back pain as \"shooting,\" worse \nwith movement, rated as ___, without associated nausea. She \ntook tylenol extra strength without relief for pain; she takes \ntylenol every day for arthritis. Associated symptoms included \ndecreased appetite and malaise. Denies dysuria, but did notice \nincreased urinary frequency over the past week, without \nsensation of incomplete voiding. She noted dark, cloudy urine, \nbut no hematuria. She went to church on ___ morning, and \nnoted increasing back pain, with onset of lightheadedness. EMTs \nwere called. Apparently her O2 dipped down to 85% on 2L, SBP 160 \n(some members of church are RNs and did a brief assessment \nbefore EMTs arrived). She denies chest pain, but did notice a \nsensation of dyspnea transiently at church, resolved within \nminutes. She denies headaches, had ___ epistaxis overnight \nearlier in the week, which resolved with pressure after approx 5 \nminutes. She denies urinary retention, fecal incontinence, or \nsaddle anesthesia.\n\nIn the ___ ED:\nVS 98.5->101.5->99.3, 140/70, 100% 2L\nUA markedly positive with WBCs too numerous to count.\nCXR and CT abdomen were fairly unremarkable for acute \npathologies.\nFlu negative.\nReceived: CTX 1g, symptomatic treatments\n\nOn arrival to the floor, pt feels \"rested.\" She endorses ___ R \nlow back pain, \"dull, crampy feeling,\" without nausea. With \nadditional probing, pt notes that she has two separate kinds of \nback pain. One pain is R flank, ___, aching, \"like you \nexercised after not exercising for a while,\" intermittent, has \nbeen present on and off ___ years, without associated nausea. \nThe pain that prompted presentation to the ED is not R flank \npain, but rather low midline back pain, in the region of the \ncoccyx. This low, midline pain reached ___, stabbing, worse \nwith movement. It is the low midline back pain that is \nreminiscent of prior episodes of obstructing nephrolithiasis.\n\n \nPast Medical History:\n- Stress urinary incontinence\n- COPD\n- Vitamin D deficiency\n- Vaginal hysterectomy\n- Nephrolithiasis status post right ureteral stent placement, \nlithotripsy and basket extraction of stone, and stent removal \n- L VATS wedge resection x 2, mediastinal lymph node dissection\n\n \nSocial History:\n___\nFamily History:\nMother with history of breast cancer (died aged ___. Family\nhistory also notable for HTN and diabetes mellitus. Son died \nfrom GBM.\n\n \nPhysical Exam:\nADMISSION EXAM\nVS: ___ 2244 Temp: 99.0 PO BP: 113/74 HR: 91 RR: 18 O2 sat: \n96% O2 delivery: 2L \nGEN: obese female, delightful, alert and interactive, \ncomfortable, no acute distress\nHEENT: PERRL, anicteric, conjunctiva pink, oropharynx without\nlesion or exudate, moist mucus membranes, ears without lesions \nor apparent trauma\nLYMPH: no anterior/posterior cervical, supraclavicular \nadenopathy\nCARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, \nor gallops\nLUNGS: clear to auscultation bilaterally without rhonchi, \nwheezes, or crackles, diminished breath sounds at L base\nGI: soft, obese, TTP at RUQ and epigastrium, without rebounding \nor guarding, nondistended with normal active bowel sounds, no \nhepatomegaly appreciated\nEXTREMITIES: no clubbing, cyanosis, or edema\nGU: no foley\nSKIN: no rashes, petechia, lesions, or echymoses; warm to \npalpation\nNEURO: Alert and interactive, cranial nerves II-XII grossly \nintact, strength is ___ in bilateral ___: normal mood and affect\n\nDISCHARGE EXAM\nVITALS: Afebrile >24 hours. No O2 requirement at rest.\nCONSTITUTIONAL: obese woman in NAD\nEYE: sclerae anicteric, EOMI\nENT: audition grossly intact, MMM, OP clear\nLYMPHATIC: No LAD\nCARDIAC: RRR, no M/R/G, JVP not elevated, no edema\nPULM: normal effort of breathing while on NC O2, LCAB\nGI: soft, ND, NABS. Minimal residual TTP in the mid-abdomen and \nthe RLQ\nGU: no CVA tenderness, suprapubic region soft and nontender\nMSK: no visible joint effusions or acute deformities. Minimal \nresidual TTP over sacrum, point tenderness on bilateral flanks \n(but no pain when striking the flank with a dull impact). \nDERM: no visible rash. No jaundice.\nNEURO: AAOx3. No facial droop, moving all extremities.\nPSYCH: Full range of affect\n \nPertinent Results:\nADMISSION LABS\n___ 01:43PM BLOOD WBC: 4.0 RBC: 5.21* Hgb: 13.6 Hct: 44.4 \nMCV: 85 MCH: 26.1 MCHC: 30.6* RDW: 14.4 RDWSD: 44.___* \n\n___ 01:43PM BLOOD Neuts: 67.1 Lymphs: ___ Monos: 11.4 Eos: \n0.0* Baso: 0.3 Im ___: 0.5 AbsNeut: 2.66 AbsLymp: 0.82* \nAbsMono: 0.45 AbsEos: 0.00* AbsBaso: 0.01 \n___ 01:43PM BLOOD Glucose: 121* UreaN: 14 Creat: 0.9 Na: \n140 K: 4.0 Cl: 104 HCO3: 22 AnGap: 14 \n___ 01:43PM BLOOD Calcium: 8.6 Phos: 4.1 Mg: 1.8 \n___ 01:49PM BLOOD Lactate: 1.3 \n___ 03:00PM URINE Color: Yellow Appear: Hazy* Sp ___: \n1.027 \n___ 03:00PM URINE Blood: SM* Nitrite: POS* Protein: 30* \nGlucose: NEG Ketone: NEG Bilirub: NEG Urobiln: NEG pH: 6.0 \nLeuks: LG* \n___ 03:07PM OTHER BODY FLUID FluAPCR: NEGATIVE FluBPCR: \nNEGATIVE \n\nDISCHARGE LABS\n___ 07:15AM BLOOD WBC-3.8* RBC-5.12 Hgb-13.2 Hct-42.0 \nMCV-82 MCH-25.8* MCHC-31.4* RDW-13.9 RDWSD-41.4 Plt ___\n___ 07:15AM BLOOD Glucose-123* UreaN-10 Creat-0.9 Na-139 \nK-3.5 Cl-97 HCO3-26 AnGap-16\n\nCT ABD AND PELVIS WITH CONTRAST \n1. No hydronephrosis. Stable right lower pole staghorn \ncalculus. \n2. Symmetric enhancement of the kidneys with stable scarring of \nthe interpolar region of the right kidney. \n3. New small left pleural effusion. Evidence of interval left \nlower lobe \nresection given surgical chain sutures. \n\nCXR ___:\nLeft lower lobe consolidation is improving. Subtle opacity in \nthe right lower lobe may be related to low lung volumes. There \nis no definite pleural effusion or pneumothorax. Volume loss in \nthe left hemithorax is compatible with multiple left-sided \nresections. The heart size is mildly enlarged, not \nsignificantly changed from prior exam. The pulmonary \nvasculature is mildly engorged without overt edema. \n\n \nBrief Hospital Course:\n___ w/ NSCLC (s/p VATS wedge resection LUL and LLL ___ w/ \npath showing positive margins), COPD, hypoxic respiratory \nfailure (on O2 w/ exertion), chronic nephrolithiasis, admitted \nw/ UTI. \n\n# UTI (cystitis vs pyelonephritis)\n# Fever\n Pt presented with fevers, urinary frequency, and positive UA, \nconsistent with UTI. Urine culture grew pan-sensitive E coli. \nHer pains and her fevers were a bit slow to improve, but she has \nbeen afebrile for over 24 hours and has only minimal residual \npain on day of discharge. She received four doses of CTX, which \nis appropriate for this pathogen, then was transitioned to Cipro \nat discharge to complete a seven-day course for complicated UTI. \n\n Although she has no \"typical\" flank pain and CT showed no \nperinephric stranding, she is still suspected to have an upper \ntract infection. This would better explain her high fevers and \nher disparate atypical pains around her pelvis, abdomen, and \nflanks. Given some incongruity between her symptoms and what \nmight be expected with a UTI, and because she had a transient \nleukopenia instead of the expected leukocytosis, the possibility \nof some other concurrent infection causing the fevers was \nseriously considered. However, she has no other localizing \nsymptoms or signs, and no exposure history whatsoever to suggest \na tick-borne illness or systemic viral illness (if necessary, \nplease see note from ___ for details of all the various \ninfectious exposures that she has denied). \n\n# Midline low back pain, overlying coccyx: \n This correlates poorly with the expected location of pain \nfrom a UTI. She has a nonspecific soft tissue abnormality on CT \ndeep to the coccyx, but on review of serial imaging (by me), it \nis entirely stable over at least a year and was not PET-avid on \nher recent staging PET-CT; probably incidental and unrelated. \nPain has resolved, so no further imaging w/u was pursued. \n\n# LUL and LLL lung carcinomas: \n Two different NSCLCs in the left lung, now s/p wedge \nresections. LLL lesion resected with positive margins. Due to \nher tenuous respiratory function, risks of re-operation for \nlobectomy probably outweigh benefits, so plan is referral to \nrad-onc.\n- booked her an appointment with Dr. ___ rad onc in late \n___\n- patient was made aware of results \n\n# HCP: ___ ___ - (her friend, and a local \n___; same last name, no relation)\n# Code Status: presumed Full\n\nTRANSITIONAL ISSUES\n1) Ensure follow up with radiation oncology (scheduled) \nregarding management of her positive surgical margins after \nwedge resection of NSCLC. Consider also a medical oncology \nreferral (deferred).\n2) Ensure f/u with urology (scheduled) regarding management of \nher chronic nephrolithiasis.\n3) All her molars on the upper right are completely rotten and \nneed extraction. Please ensure this occurs before she suffers an \ninfectious complication of her poor dentition. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q6H \n2. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO BID Duration: 3 Days \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*6 Tablet Refills:*0 \n2. Acetaminophen 1000 mg PO Q6H \n3. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nUTI, presumed pyelonephritis\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 fevers and also pains in your \nabdomen/back/flanks. These were probably both caused by a \nurinary tract infection. You were treated with IV antibiotics \n(ceftriaxone) and have improved greatly. Please take antibiotic \npills twice daily for three more days ___ through ___ to \ncomplete your treatment.\n\nYou also had residual cancer cells after your surgery (\"positive \nmargins\"). You will probably need radiation therapy to the \nsurgical site to mop up the final cancer cells. We have booked \nyou with a radiation oncologist, Dr. ___ month. \n\nPlease also get your three rotten teeth taken care of before \nthey cause some more serious problem. \n \nFollowup Instructions:\n___\n" ]

[ "N10", "C3432", "J9611", "B9620", "N200", "Z87442", "Z902", "J449", "E559", "Z87891", "Z803", "Z808", "Z833", "R5081", "K029" ]

[ "N10: Acute pyelonephritis", "C3432: Malignant neoplasm of lower lobe, left bronchus or lung", "J9611: Chronic respiratory failure with hypoxia", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "N200: Calculus of kidney", "Z87442: Personal history of urinary calculi", "Z902: Acquired absence of lung [part of]", "J449: Chronic obstructive pulmonary disease, unspecified", "E559: Vitamin D deficiency, unspecified", "Z87891: Personal history of nicotine dependence", "Z803: Family history of malignant neoplasm of breast", "Z808: Family history of malignant neoplasm of other organs or systems", "Z833: Family history of diabetes mellitus", "R5081: Fever presenting with conditions classified elsewhere", "K029: Dental caries, unspecified" ]

[ "J449", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nOxycodone / Naprosyn\n \nAttending: ___.\n \nChief Complaint:\nDOE\n \nMajor Surgical or Invasive Procedure:\n___\nVATS, left upper lobe wedge resection, left lower\nlobe wedge resection, and mediastinal lymph node dissection.\n\n \nHistory of Present Illness:\n___ with LUL lung cancer, hilar FDG-avid lymphadenopathy and\nLLL FDG-avid lesion. Discussed findings with patient, who was\nalso seen by Dr. ___ today. Marginal lung function\nand continues to smoke, though she is trying to stop. Higher\nrisk pulmonary resection but would be helpful to be able to\nexcise LLL lesion and hilar lymphadenopathy to more fully stage\nat the same time of sublobar resection of the LUL. \n\nOverall, patient continues to smoke and feels as though her\nbreathing is labored at baseline. Occasional cough, not \nworsened\nrecently. No fevers, chills, sweats. No weight gain or loss, \nno\nlightheadedness, headaches, bony pains. \n\n \nPast Medical History:\n- Hypertension\n- Stress urinary incontinence\n- Emphysema\n- Vitamin D deficiency\n- Vaginal hysterectomy\n- Nephrolithiasis status post right ureteral stent placement,\nlithotripsy and basket extraction of stone, and stent removal\n\n \nSocial History:\n___\nFamily History:\nMother with history of breast cancer (died aged ___. Family\nhistory also notable for HTN and diabetes mellitus.\n\n \nPhysical Exam:\nBP: 160/87. Heart Rate: 83. O2 Saturation%: 98. Weight: 273.5\n(With Clothes). Height: 66.750. BMI: 43.2. Temperature:\n98.0.GENERAL \n[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:\n\nHEENT \n[x] NC/AT [] EOMI [x] PERRL/A [x] Anicteric\n[x] OP/NP mucosa normal [x] Tongue midline\n[x] Palate symmetric [x] Neck supple/NT/without mass\n[x] Trachea midline [] Thyroid nl size/contour\n[ ] Abnormal findings:\n\nRESPIRATORY \n[x] CTA bilat [] Excursion normal [ ] No fremitus\n[] No egophony [] No spine/CVAT\n[ ] Abnormal findings:\n\nCARDIOVASCULAR \n[x] RRR [] No m/r/g [] No JVD [] PMI nl [x] No edema\n[] Peripheral pulses nl [] No abd/carotid bruit\n[ ] Abnormal findings:\n\nGI \n[x] Soft [x] NT [x] ND [] No mass/HSM [] No hernia\n[ ] Abnormal findings:\n\nGU [x] Deferred \n[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE\n[ ] Abnormal findings:\n\nNEURO \n[] Strength intact/symmetric [] Sensation intact/ symmetric\n[] Reflexes nl [x] No facial asymmetry [x] Cognition intact\n[] Cranial nerves intact [ ] Abnormal findings:\n\nMS \n[ ] No clubbing [x] No cyanosis [x] No edema \n[uses a cane] Gait nl\n[] No tenderness [] Tone/align/ROM nl [] Palpation nl\n[] Nails nl [ ] Abnormal findings:\n\nLYMPH NODES \n[x] Cervical nl [x] Supraclavicular nl [] Axillary nl\n[] Inguinal nl [ ] Abnormal findings:\n\nSKIN \n[x] No rashes/lesions/ulcers on visible skin\n[] No induration/nodules/tightening [ ] Abnormal findings:\n\nPSYCHIATRIC \n[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect\n[ ] Abnormal findings:\n\n \nPertinent Results:\n WBC RBC Hgb Hct MCV MCH MCHC RDW \nRDWSD Plt Ct \n___ 05:20 8.4 4.10 11.0* 36.2 88 26.8 30.4* 15.0 \n48.5* 162 \n___ 05:06 10.2* 4.48 12.4 39.7 89 27.7 31.2* 15.1 \n48.9* 175 \n \n Glucose UreaN Creat Na K Cl HCO3 AnGap \n___ 05:20 ___ 141 4.0 ___ \n \n___ CXR :\nIn comparison with the study of ___, the left chest tube \nremains in place and there is no evidence of appreciable \npneumothorax. Postsurgical changes are again seen in the left \nlung. Continued enlargement of the cardiac silhouette with \nelevated pulmonary venous pressure and small bilateral pleural \neffusions with compressive atelectatic changes at the bases. \n \n___ CXR :\nInterval improvement of left midlung consolidation. Unchanged \nmoderate left pleural effusion with overlying volume loss. No \nevidence of focal \nconsolidation or pneumothorax. \n\n \nBrief Hospital Course:\nMs. ___ was admitted to the hospital and taken to the \nOperating Room where she underwent a VATS, left upper lobe wedge \nresection, left lower lobe wedge resection, and mediastinal \nlymph node dissection. She tolerated the procedure well and \nreturned to the PACU in stable condition. She maintained stable \nhemodynamics and her pain was controlled with IV Tylenol. Her \n___ drain put out a modest amount of serosanguious fluid and \nhad no air leak.\n\nFollowing transfer to the Surgical floor she continued to have \nadequate pain control with scheduled Tylenol. Her port sites \nwere healing well and her ___ drain was removed on post op day \n#1 as the drainage was minimal. Her post pull chest xray showed \nno pneumothorax and bibasilar atelectasis. She was encouraged \nto use her incentive spirometer frequently and she was also \nencouraged to increase her ambulation. She noticed that she had \nmore dyspnea than pre op. She was placed on Mucinex to thin out \nher secretions and also tried some nebulizer treatments. \nAttempts were made to wean her oxygen but she was unable to \nmaintain room air saturations > 90% with ambulation. She \ncontinued to use her incentive spirometer effectively and a \nrepeat chest xray showed some accumulation of a left pleural \neffusion. As her ambulatory saturations were in the 82-88% \nrange, home oxygen was arranged so that she could use it with \nall activity. The ___ was set up to help assess her O2 needs \nand attempt to wean the oxygen off. \n\nShe was discharged to home on ___ on oxygen at 2 LPM and \nwill follow up with Dr. ___ in 2 weeks with a chest xray \nprior to the appointment.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n2. ibuprofen-diphenhydramine cit 200-38 mg oral QHS \n3. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*2 \n2. GuaiFENesin ER 600 mg PO Q12H \nRX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp \n#*28 Tablet Refills:*0 \n3. Acetaminophen 1000 mg PO Q6H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*100 Tablet Refills:*0 \n4. ibuprofen-diphenhydramine cit 200-38 mg oral QHS \n5. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft upper lobe lung cancer.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent w/ O2 at 2 LPM\n\n \nDischarge Instructions:\n* You were admitted to the hospital for lung surgery and you've \nrecovered well. You are now ready for discharge but will need to \ngo home on oxygen until your lungs heal and your oxygenation \nimproves. \n\n* Use oxygen at 2 LPM via nasal cannula to maintain saturations \n> 90% at rest and with activity.\n\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Check your incisions daily and report any increased redness or \ndrainage. Cover the area with a gauze pad if it is draining.\n\n* Your chest tube dressing may be removed in 48 hours. If it \nstarts to drain, cover it with a clean dry dressing and change \nit as needed to keep site clean and dry.\n\n* You may need pain medication once you are home but you can \nwean it over the next week as the discomfort resolves. Make \nsure that you have regular bowel movements while on narcotic \npain medications as they are constipating which can cause more \nproblems. Use a stool softener or gentle laxative to stay \nregular.\n\n* No driving while taking narcotic pain medication.\n\n* Take Tylenol on a standing basis to avoid more opiod use.\n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* No heavy lifting > 10 lbs for 4 weeks.\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\n Call Dr. ___ ___ if you experience:\n -Fevers > 101 or chills\n -Increased shortness of breath, chest pain or any other \nsymptoms that concern you.\n\n** If pathology specimens were sent at the time of surgery, the \nreports will be reviewed with you in detail at your follow up \nappointment. This will give both you and your doctor time to \nunderstand the pathology, its implications and discuss options \ngoing forward.**\n\n \n\n \n \nFollowup Instructions:\n___\n" ]

[ "C3412", "J90", "C3432", "F17210", "I10", "N393", "E559", "J439" ]

[ "C3412: Malignant neoplasm of upper lobe, left bronchus or lung", "J90: Pleural effusion, not elsewhere classified", "C3432: Malignant neoplasm of lower lobe, left bronchus or lung", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "N393: Stress incontinence (female) (male)", "E559: Vitamin D deficiency, unspecified", "J439: Emphysema, unspecified" ]

[ "F17210", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nOxycodone / Naprosyn\n \nAttending: ___.\n \nChief Complaint:\nCough/RLQ pain/Urinary frequency\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS:\n___ with history of HTN, emphysema, and vitamin D deficiency, \nwho\npresented to the ED with cough, right lower quadrant/suprapubic\npain, and urinary frequency.\n\nPatient was in her usual state of health until ___. At that\ntime, she developed cough and mild sore throat. Of note, her\npartner and coworkers had been sick with a similar respiratory\nillness over the past week. Cough has progressively worsened,\nbecoming productive in nature over the weekend and she would\ncough up large quantities of clear mucous. Yesterday, she had 1\nepisode of hemoptysis where she coughed up dark red sputum with\nmucous about the size of a quarter. She reports associated\nmuscular pain when coughing, SOB and DOE when walking to the\nbathroom. She has had fatigue, myalgias, and poor oral intake,\nendorses nausea without vomiting, and denies unintentional \nweight\nloss. Patient noted subjective fever and took her temperature\nwhich was 100 but was febrile to 102.7F at one point in the ED..\nAlso reported some loose stools/non-bloody diarrhea. Receives\nyearly influenza vaccines and PPD tests as part of her\noccupation.\n\nOver the same time period, patient also reported right lower\nquadrant pain, radiating to her back, similar feeling to \nprevious\nUTIs. Pain had been present for about one week, during which \ntime\nshe also had urinary frequency and increased leakage of urine\nwith coughing. Of note, she does carry a history of stress\nurinary incontinence. Denied dysuria, urgency, hematuria, or \nfoul\nsmelling urine.\n\nPatient also has a history of shortness of breath on exertion.\nFor several years, she has noticed becoming progressively short\nof breath after walking only a few steps and needing to stop to\ncatch her breath. She breathes comfortably at rest but notices\nlabored breathing after approximately 10 steps.\n\nPatient denies additional pain, chills, nausea, or vomiting.\n\nIn the ED, initial VS were notable for; Temp 99.4 HR 103 BP\n150/86 RR 16 SaO2 93% RA. Exam notable for; Comfortable\nappearing woman, distant lung sounds but overall clear\nbilaterally, normal S1 and S2 without murmurs, soft/non-tender,\nno lower extremity edema.\n\nLabs were notable for;\nWBC 5.1 Hgb 13.7 Plt 137\n___ 13.3 PTT 26.2 INR 1.2\nNa 137 K 3.8 Cl 100 HCO3 25 BUN 11 Cr 0.9 Gluc 112\nALT 19 AST 31 ALP 138 Lipase 25 Tbili 0.2 Alb 4.1\nCa 8.8 Mg 1.8 Phos 2.8\nLactate 1.2\n\nUrine studies notable for large leuk, positive nitrites, >182 \nWBC\nwith 36 RBCs, moderate bacteria, and 8 epithelial cells.\nInfluenza A PCR positive. ECG with sinus tachycardia, normal\nintervals and axis, no significant territorial ST segment\ndeviation or T wave inversion to suggest ischemia, non-specific\nST-T changes throughout, and intra-atrial conduction delay.\n\nCXR demonstrated a 2.8 x 2.0cm oval round opacity projecting \nover\nthe left mid lung field, new from prior, may represent \nmalignancy\nor infection. CT torso with contrast with new 3cm left upper \nlobe\nmass and a smaller 1cm left lower lobe mass, concerning for\nprimary left upper lobe lung malignancy with metastasis to the\nleft lower lobe, mediastinal lymphadenopathy measuring up to 1 \ncm\nin the prevascular region, n-non-obstructing 1.5 x 1.1 cm\ncalcified stone outlining the calyx of the right lower pole, no\nevidence of abdominopelvic metastases, no suspicious osseous\nlesions, 1.7 cm hypoattenuating nodule within the isthmus of the\npartially imaged enlarged thyroid gland, and mild nonspecific\nfocal thickening of the left common iliac artery wall.\n\nPatient was given; IV acetaminophen 1000mg x2, 1L D5LR, IV\nceftriaxone 1g, PO trazodone 25mg \n\nVital signs on transfer notable for; Temp 101.0 HR 105 BP\n137/84 RR 18 SaO2 100% RA\n\nSUBJECTIVE HISTORY morning of ___:\nPatient describes feeling better this morning. Weakness and\nmylagias are improved but still with DOE when walking to\nbathroom. Describes no chills or fever overnight. Notes coughing\nless since her admission last night and experiencing less\nabdominal pain. Reports SOB characteristic of her baseline,\ncomfortable at rest but labored after walking approximately 10\nsteps. Denies other pain, fever, chills, nausea, or vomiting.\n\n \nPast Medical History:\n- Hypertension\n- Stress urinary incontinence\n- Emphysema\n- Vitamin D deficiency\n- Vaginal hysterectomy\n- Nephrolithiasis status post right ureteral stent placement,\nlithotripsy and basket extraction of stone, and stent removal\n\n \nSocial History:\n___\nFamily History:\nMother with history of breast cancer (died aged ___. Family\nhistory also notable for HTN and diabetes mellitus.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION:\nVS: 24 HR Data (last updated ___ @ 1142)\n Temp: 99.1 (Tm 99.5), BP: 126/82 (126-134/79-82), HR: 82\n(79-88), RR: 18 (___), O2 sat: 94% (92-94), O2 delivery: Ra,\nWt: 275.35 lb/124.9 kg \nGENERAL: lying comfortably in bed, no distress\nHEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM\nNECK: supple, non-tender, no JVP elevation\nCV: RRR, S1 and S2 normal, no murmurs/rubs/gallops\nRESP: Diminished lung sounds throughout but weakest in left \nupper\nlobe, mild wheezing in lower lobes bilaterally, no crackles\n___: Tender to deep palpation in RLQ and suprapubic region, no\ntenderness to superficial palpation throughout, soft, ND, BS+\nEXTREMITIES: WWP, no lower extremity edema\nNEURO: A/O x3, otherwise grossly intact\n\nDISCHARGE PHYSICAL EXAM\nVS: 98.4, 115 / 72, 77, 18, O2 93 Ra \nGENERAL: lying comfortably in bed, no distress\nHEENT: AT/NC, no conjunctival pallor, anicteric sclera,\noropharynx clear without erythema or exudates, MMM\nNECK: supple, non-tender\nCV: RRR, S1 and S2 normal, no murmurs/rubs/gallops\nRESP: Diminished lung sounds throughout, no wheezing, crackles,\nor rhonchi\n___: Soft, NTND, BS+\nEXTREMITIES: WWP, no lower extremity edema\nNEURO: A/O x3, otherwise grossly intact\n\n \nPertinent Results:\n___ 05:14PM BLOOD WBC-5.1 RBC-5.06 Hgb-13.7 Hct-43.9 MCV-87 \nMCH-27.1 MCHC-31.2* RDW-14.7 RDWSD-46.5* Plt ___\n___ 05:40AM BLOOD WBC-5.0 RBC-4.69 Hgb-12.9 Hct-40.4 MCV-86 \nMCH-27.5 MCHC-31.9* RDW-14.6 RDWSD-45.5 Plt ___\n___ 05:45AM BLOOD WBC-4.8 RBC-4.66 Hgb-12.6 Hct-40.8 MCV-88 \nMCH-27.0 MCHC-30.9* RDW-14.6 RDWSD-46.9* Plt ___\n___ 06:15AM BLOOD WBC-4.4 RBC-4.63 Hgb-12.5 Hct-40.5 MCV-88 \nMCH-27.0 MCHC-30.9* RDW-14.4 RDWSD-45.5 Plt ___\n___ 05:14PM BLOOD Neuts-62.4 ___ Monos-15.5* \nEos-0.2* Baso-0.2 Im ___ AbsNeut-3.19 AbsLymp-1.10* \nAbsMono-0.79 AbsEos-0.01* AbsBaso-0.01\n___ 07:00PM BLOOD ___ PTT-26.2 ___\n___ 05:45AM BLOOD ___ PTT-30.5 ___\n___ 05:14PM BLOOD Glucose-112* UreaN-11 Creat-0.9 Na-137 \nK-3.8 Cl-100 HCO3-25 AnGap-12\n___ 05:40AM BLOOD Glucose-137* UreaN-12 Creat-0.9 Na-141 \nK-3.8 Cl-103 HCO3-21* AnGap-17\n___ 05:45AM BLOOD Glucose-135* UreaN-12 Creat-0.7 Na-141 \nK-3.5 Cl-104 HCO3-24 AnGap-13\n___ 06:15AM BLOOD Glucose-119* UreaN-12 Creat-0.8 Na-144 \nK-3.4* Cl-105 HCO3-25 AnGap-14\n___ 05:14PM BLOOD ALT-19 AST-31 AlkPhos-138* TotBili-0.2\n___ 05:45AM BLOOD ALT-25 AST-38 AlkPhos-113* TotBili-0.2\n___ 05:14PM BLOOD Albumin-4.1 Calcium-8.8 Phos-2.8 Mg-1.8\n___ 05:45AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8\n___ 06:15AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9\n___ 09:03PM BLOOD Lactate-1.2\n\nIMAGING\nCXR (___)\nFINDINGS: \n \nThe lungs are well aerated. There is a linear opacity in the \nright lung base\nwhich may represent chronic atelectasis. There is an oval 2.8 x \n2.2 cm mass\nprojecting over the left midlung field which is new from prior, \nthe\ndifferential for which includes malignancy versus infection. No \npleural\neffusion or pneumothorax. The heart appears normal in size. No \nevidence of\npulmonary edema\n \nIMPRESSION: \n \n2.8 x 2.0 cm oval round nodular opacity projecting over the left \nmid lung\nfield is new from prior, this may represent malignancy or \ninfection. Chest CT\nis recommended for further evaluation.\n\nCT Torso (___)\n1. New 3 cm left upper lobe mass and a smaller 1 cm left lower \nlobe mass are\nconcerning for primary left upper lobe lung malignancy.\n2. Borderline enlarged mediastinal lymph nodes measuring up to 1 \ncm in the\nprevascular region.\n3. Nonobstructing 1.5 x 1.1 cm calcified stone outlining the \ncalyx of the\nright lower pole is smaller in size when compared to ___ CT abdomen\nand pelvis.\n4. No evidence of abdominopelvic metastases. No suspicious \nosseous lesions.\n5. 1.7 cm hypoattenuating nodule within the isthmus of the \npartially imaged\nenlarged thyroid gland. This can be further evaluated with \noutpatient thyroid\nultrasound if not previously worked up.\n6. Mild nonspecific focal thickening of the left common iliac \nartery wall is\nnew from ___ CT, query vasculitis.\n\nMICRO\n___ 1:57 pm SPUTUM Source: Induced. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Pending): \n\n MTB Direct Amplification (Preliminary): \n M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT \ncannot rule\n out TB or other mycobacterial infection. \n . \n NAAT results will be followed by confirmatory testing with\n conventional culture and DST methods. This TB NAAT method \nhas not\n been approved by FDA for clinical diagnostic purposes. \nHowever, this\n laboratory has established assay performance by in-house \nvalidation\n in accordance with ___ standards. \n . \n Test done at ___ Mycobacteriology \nLaboratory.. \n\n___ 11:26 pm SPUTUM Source: Induced. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Pending): \n\n___ 10:51 am SPUTUM Source: Induced. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Pending): \n\n MTB Direct Amplification (Final ___: \n CANCELLED. PATIENT CREDITED. \n Specimen received less than 7 days from previous \ntesting. \n\n___ 7:00 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ 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-------- 32 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n \nBrief Hospital Course:\n___ with h/o HTN, emphysema, and vitamin D deficiency, who \npresented to the ED with cough, RLQ pain, and urinary frequency, \ntreated for influenza A, UTI, pending outpatient workup of lung \nnodules and mediastinal LAD.\n\nACUTE/ACTIVE ISSUES:\n====================\n# Multiple lung nodules \n# Mediastinal LAD: CXR with new opacity in left mid lung. \nSubsequent CT with new 3cm left upper love mass and smaller 1cm \nleft lower lobe mass, with mediastinal lymphadenopathy in the \nprevascular region, most concerning for new lung cancer \ndiagnosis given extensive smoking history. Also considering \nhistory of homelessness and current occupation as ___ of \n___ need to r/o mycobacterial infection. IP \nconsulted, planned outpatient PETCT + bronch/biopsy. SW \nconsulted given possible cancer diagnosis. Induced sputum x 3 \nwith NAAT were sent, 3 AFB smears finalized as negative with MTB \nand AFB culture pending at time of discharge.\n\n# Influenza A: Presented with three days of productive cough, \nsore throat, muscle aches, and shortness of breath/fatigue on \nexertion, in the setting of multiple sick contacts. Febrile to \n102.7 in the ED. Influenza A positive. Started oseltamivir 75mg \nBID given possible underlying lung disease.\n\n# Possible UTI: One week of RLQ pain and urinary frequency, \nsimilar to previous episodes of UTI. Urine studies notable for \nlarge leuks, positive nitrites, >182 WBC, and moderate bacteria, \nalthough 8 epithelial cells were present indicating contaminated \nsample. History of nephrolithiasis; CT abdomen/pelvis did show \n1.5 x 1.1cm calcified stone in lower pole of right kidney, but \nno evidence of pyelonephritis. Repeat UA with WBC > 182 and \nlarge leuks; UCx growing E Coli sensitive to CTX. Completed 3d \ncourse CTX 1g daily for uncomplicated UTI.\n\n======================\nCHRONIC/STABLE ISSUES:\n======================\n# Vitamin D deficiency: continued vitamin D2 50,000 units weekly\n\nTransitional Issues:\n====================\n#CODE STATUS: Full\n#HCP: ___ (___) ___\n\n[ ] Acid fast MTB pending at time of discharge, with two smears \nfinalized as negative\n[ ] 1.7cm hypoattenuating nodule in isthmus of thyroid gland; \nrecommend thyroid US as outpatient\n[ ] Outpatient bronchoscopy tentatively scheduled for ___, \nPET-CT scheduled for ___, depending on results of pathology, \nwill need follow-up with heme-onc in clinic\n[ ] Recommend further conversation about smoking cessation. \nPatient provided with nicotine lozenges prior to discharge. \nWould continue to encourage healthy lifestyle change.\n[ ] Recommend checking vitamin D level and evaluate continued \nneed for vitamin D supplementation, especially in setting of \npossible lung CA \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Vitamin D ___ UNIT PO 1X/WEEK (___) \n2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n\n \nDischarge Medications:\n1. GuaiFENesin ___ mL PO Q6H:PRN cough \nRX *guaifenesin 100 mg/5 mL 5 mL by mouth every 6 hours Disp \n#*473 Milliliter Milliliter Refills:*0 \n2. Nicotine Lozenge 2 mg PO Q2H:PRN nicotine craving \nRX *nicotine (polacrilex) 2 mg take 1 lozenge every 2 to 4 hours \nDisp #*81 Lozenge Refills:*0 \n3. OSELTAMivir 75 mg PO BID \nRX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*5 \nCapsule Refills:*0 \n4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n5. Vitamin D ___ UNIT PO 1X/WEEK (___) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\nInfluenza A\nLung nodules\nMediastinal LAD\nUrinary Tract Infection\n\nSecondary diagnoses:\nVitamin D Deficiency\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital because:\n- You had a fever, cough, and shortness of breath \n\nDuring your stay:\n-You were found to be positive for the flu and received Tamiflu\n-A new lung nodule was noted on chest x-ray. Therefore you \nunderwent a chest CT which showed a lung mass and enlarged lymph \nnodes. You will have further workup as an outpatient.\n\nAfter you leave: \n-Please finish your course of Tamiflu, last day ___\n-You have a PET/CT scan scheduled on ___. You will \nalso undergo a bronchoscopy tentatively scheduled on ___. The interventional pulmonology team/office will be in \ntouch with you after discharge to finalize the timing of the \nbronchoscopy. \n-Please attend any other outpatient appointments you have \nupcoming. You have a PCP appointment scheduled on ___ with Dr. ___.\n-Please continue taking vitamin D for 6 more weeks, 1 per week, \nstarting on ___\n\nIt was a pleasure participating in your care! We wish you the \nvery best!\n\nYour ___ Healthcare Team\n\n \nFollowup Instructions:\n___\n" ]

[ "J101", "N390", "I10", "J439", "F17210", "R918", "R590", "B9620", "E559" ]

[ "J101: Influenza due to other identified influenza virus with other respiratory manifestations", "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "J439: Emphysema, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R918: Other nonspecific abnormal finding of lung field", "R590: Localized enlarged lymph nodes", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E559: Vitamin D deficiency, unspecified" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nLeft sided weakness and tingling\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is an ___ yo right handed man with a history \nof metastatic SCLC with solitary left cerebellar brain met s/p \ngamma knife radiosurgery in ___ (gets care at ___) who \npresents with transient left arm weakness, as well as abnormal \nsensation in his face. \n\nThe day of presentation he tried to pick up a glass of juice \nwith his left hand at around 6:30 pm but found he was unable. He \ncould reach to the glass and wrap his fingers around it, but \ncouldn't bring it to his mouth. He denies having shaking in his \narm. At the same time his left face began to \"feel funny\" like a \nswollen numb feeling. The arm was weak for ___ minutes. The left \nface was numb for ~7 minutes. Then, the sensation he had on his \nleft face moved to his right face. He walked to the kitchen and \ntold his daughter about his symptoms, who called an ambulance. \nHe was taken to ___ where ___ was read as having a SAH \nvs. laminar necrosis with edema in the right parietal cortex. He \nwas transferred to ___ for neurology evaluation. He denied \ntrouble talking or walking. He doesn't know if his face was \ndrooping. This morning, he feels back to normal apart from a \nmild headache, though this is similar to his chronic headaches \nwhich are a pressure like sensation in his forehead bilaterally. \n\n\nHe gets care at ___ for \"brain cancer and lung cancer\". He's \nhad radiation treatment for the brain cancer. He doesn't know \nwhat type of cancer it is, but denies it being a metastasis from \nhis lung cancer. He says he was treated for his cancer ___ years \nago and he's been told he is currently cancer free.\n\nReview of Systems: + for recent cough w/ SOB, chronic dizziness, \nchronic memory problems, and headache;\nThe pt denies loss of vision, blurred vision, diplopia, \ndysarthria, dysphagia, lightheadedness, tinnitus or new hearing \ndifficulty. Denies difficulties producing or comprehending \nspeech. No bowel or bladder incontinence or retention. Denies \nnew difficulty with gait. The pt denies recent fever or chills. \nDenies chest pain or palpitations. Denies nausea, vomiting, \ndiarrhea, constipation or abdominal pain. No recent change in \nbowel or bladder habits. No dysuria. Denies rash.\n\n \nPast Medical History:\n-metastatic small cell lung cancer diagnosed ___ - s/p chemo \nand radiation (___, metastatic to L1, adrenal \ngland, and brain\n-solitary brain met to left cerebellum s/p gamma knife \nradiosurgery ___\n-diabetes\n-HLD\n-hypothyroidism\n-HTN\n \nSocial History:\n___\nFamily History:\nhistory of cancer in family \n \nPhysical Exam:\nAdmission Exam:\nVitals: 97.1 69 136/77 15 96% RA \nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT\nNeck: Supple. \nPulmonary: breathing comfortably on RA\nCV: RRR\nAbdomen: soft, nondistended\nExtremities: no edema, warm\nSkin: no rashes or lesions noted.\n\nNeuro:\n-Mental Status: Awake, not oriented to ___ but knows he's in a \nhospital. Has difficulty relating details of his medical \nhistory.\nLanguage is fluent with intact repetition and comprehension. \nNormal prosody. There were no paraphasic errors. Pt. was able \nto name both high and low frequency objects. Speech was not \ndysarthric. Able to follow both midline and appendicular \ncommands. Inattentive, unable to name ___ backward (stuck at \n___. There was no evidence of neglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: in light: left pupil 3.5->2.5, right 2.5->1.5mm; pupillary \nasymmetry is more pronounced in the dark. VFF to confrontation \nwith finger counting. \nIII, IV, VI: EOMI without nystagmus. slightly smaller palpebral \nfissure on right \nV: Facial sensation intact to light touch and pin in all \ndistributions \nVII: Subtle decreased activation of left lower face with \nflattening of the NLF. \nVIII: hard of hearing.\nIX, X: Palate elevates symmetrically.\nXI: full strength in trapezii bilaterally.\nXII: Tongue protrudes in midline \n \n-Motor: Normal bulk throughout. No pronator drift bilaterally. \nNo tremor noted. \n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL ___ ___ ___ 5 5 5 5 5\nR ___ ___ ___ 5 5 5 5 5\n \n-DTRs: \n ___ Tri ___ Pat Ach\nL 1 tr tr 1+ 0\nR 1 tr tr 1+ 0\n- Toes were downgoing bilaterally.\n\n-Sensory: left arm and leg with 50% pinprick sensation compared \nto right. Decreased temperature sensation in left arm. \nTemperature gradient in the legs. Vibration absent in the feet. \n\n-Coordination: ?subtle dysmetria on FNF bilaterally. Rapid \nalternating movements are slower on the left. \n\n-Gait: Good initiation. Narrow-based, normal stride, appears \nmildly unsteady. Romberg absent but with subjective \nunsteadiness.\n\nDischarge Exam:\nVitals: 97.9 155/95 66 17 98% RA \nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT\nNeck: Supple. \nPulmonary: breathing comfortably on RA\nCV: RRR\nAbdomen: soft, nondistended\nExtremities: no edema, warm\nSkin: no rashes or lesions noted.\n\nNeuro:\n-Mental Status: Awake, initially not oriented to date, but \nrecalled that it was \n___ and ___ is fluent with \nintact repetition and comprehension. Normal prosody. Pt. was \nable to name high but not low frequency objects (\"pen\" but not \n\"tip\", \"glasses\" but not \"lens\"). Speech was not dysarthric. \nAble to follow both midline and appendicular commands. \nInattentive, unable to name ___ backward (stuck at ___. \nThere was no evidence of neglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: in light: left pupil 3->2, right 2->1mm; pupillary asymmetry \nis more pronounced in the dark. VFF to confrontation with finger \ncounting. \nIII, IV, VI: EOMI without nystagmus. slightly smaller palpebral \nfissure on right (pseudoptosis, R eye inverse ptosis)\nV: Facial sensation intact to light touch and pin in all \ndistributions \nVII: face symmetrical with mild flattening of NLF on left\nVIII: hard of hearing.\nIX, X: Palate elevates symmetrically.\nXI: full strength in trapezii bilaterally.\nXII: Tongue protrudes in midline \n \n-Motor: Normal bulk throughout. No pronator drift bilaterally. \nNo tremor noted. \n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL ___ ___ ___ 5 5 5 5 5\nR ___ ___ ___ 5 5 5 5 5\n \n-DTRs: \n ___ Tri ___ Pat Ach\nL 1 tr tr 1+ 0\nR 1 tr tr 1+ 0\n- Toes were downgoing bilaterally.\n\n-Sensory: intact to light touch throughout\n\n-Coordination: subtle dysmetria on FNF bilaterally with \npass-pointing. \n \nPertinent Results:\nOSH Labs:\nNa 143\nK 4.6\nCl 103\nGlu 90\nbicarb 28\nCr 1.2\nBUN 18\nALT 10\nAST 17\ntrop <0.01\nWBC 4.6\nHb 13.1\n___ 12.8\nINR 1.15\nPTT 31.6\n\nAdmission Labs ___ @12:15am:\nWBC-3.3* RBC-3.84* Hgb-12.9* Hct-38.5* MCV-100* MCH-33.6* \nMCHC-33.5 RDW-12.7 RDWSD-46.8* Plt Ct-72*\nNeuts-47.3 ___ Monos-10.1 Eos-1.8 Baso-0.6 Im ___ \nAbsNeut-1.55* AbsLymp-1.31 AbsMono-0.33 AbsEos-0.06 AbsBaso-0.02\n___ PTT-30.4 ___\nGlucose-92 UreaN-18 Creat-1.0 Na-139 K-4.1 Cl-103 HCO3-24 \nAnGap-16\n\nDischarge Labs ___ @07:45am\nWBC-3.9* RBC-3.96* Hgb-13.2* Hct-39.6* MCV-100* MCH-33.3* \nMCHC-33.3 RDW-12.4 RDWSD-46.4* Plt ___\nGlucose-80 UreaN-15 Creat-0.9 Na-141 K-3.7 Cl-105 HCO3-25 \nAnGap-15\nCalcium-9.1 Phos-2.7 Mg-1.6\n\nImages:\n\nNCHCT ___\n- ___ PRIMARY READ: ribbon-like high density in the right \nparietal lobe superiorly with surrounding mild intra-axial \nedema. Finding is nonspecific may be secondary to small \nsubarachnoid hemorrhage or possibly laminar necrosis secondary \nto recent infarct in this area.\n- ___ SECOND READ: \n1. Right frontal subarachnoid hemorrhage. \n2. Reported brain tumor not visualized on this non-contrast \nenhanced study and review of prior imaging is recommended. \n\nCTA HEAD & CTA NECK: WET READ ___\nNon con head: Stable to perhaps minimal increase in right \nfrontal \nsubarachnoid hemorrhage. Otherwise no significant change from \nprior. \nCTA: Final read pending 3D recons. The carotid and vertebral \narteries and \ntheir major intracranial branches are patent with no aneurysm \ngreater than 3mm, high-grade stenosis or other vascular \nabnormality. Numerous pulmonary \nnodules bilaterally. Comparison with prior imaging would be \nhelpful to \nevaluate stability. \n\nMR HEAD W & W/OUT CONTRAST: ___\n1. Sulcal FLAIR hyperintensity and leptomeningeal enhancement \ninvolving the right central, precentral and superior frontal \nsulci. Additional focus of leptomeningeal enhancement at the \nleft frontal superior gyrus. Findings may represent reactive \nchanges secondary to subarachnoid hemorrhage versus \nleptomeningeal carcinomatosis, given clinical history of lung \ncancer. \nConsider correlation with CSF cytology and/or follow up imaging \nto \ncharacterize the evolution of these findings. \n2. Extensive bilateral cortical siderosis consistent with prior \nsubarachnoid hemorrhages. \n3. No discrete parenchymal lesion. \n\nCXR PA & LAT: ___\nThe lungs are mildly hyperinflated. The cardiomediastinal \ncontour is within normal limits. The heart is not enlarged. \nThere is a slightly prominent epicardial fat pad along the right \nheart border. No consolidation, pneumothorax or pleural \neffusion seen. There are moderately severe multilevel \ndegenerative changes in the thoracic spine. \n\n \nBrief Hospital Course:\n___ is an ___ yo R-handed man with a history of \nmetastatic SCLC (with a single cerebellar met s/p knife \nradiosurgery) who presented to OSH with transient left arm \nweakness, as well as left followed by right face numbness. A \n___ at ___ demonstrated a right frontal convexal \nsubarachnoid hemorrhage, which may have prompted a seizure \nleading to his transient symptoms. The etiology of his SAH is \nunclear; the differential includes metastatic lesion from his \nknown expanding primary lung cancer (no current evidence of \nMRI), amyloidosis (no evidence on MRI), AVM (no evidence on \nCTA), traumatic (no history but patient poor historian), \naneurysm (not seen on CTA), or RCVS. \n\nUpon admission to ___, all of his labs were within normal \nlimits; he was given Keppra 1000mg PO for seizure prophylaxis. A \nCTA of the head and neck showed no aneurysms with patent carotid \nand vertebral arteries. An MRI did not show any discrete masses \nor evidence of amyloid. It did show sulcal FLAIR hyperintensity \nand leptomeningeal enhancement involving the right central, \nprecentral and superior frontal sulci. Additional focus of \nleptomeningeal enhancement at the left frontal superior gyrus. \nThis could be consistent with reactive changes secondary to SAH \nversus leptomeningeal carinomatosis. The MRI also showed \nevidence of extensive bilateral sidersosis from prior SAHs. He \nimproved over the course of his admission, and his neurological \nexam was unremarkable the day after admission. He was discharged \nhome on 1g Keppra BID with plans to follow-up with his \noncologist at ___ for further workup regarding the etiology of \nhis SAH including outpatient LP once SAH resorbs and plans to \nhave his PCP refer him to a neurologist for outpatient titration \nof Keppra.\n\nTransitional Issues:\n-Spoke with outpatient ___ on-call oncologist, Dr. ___ \nagreed to pursue further work-up for etiology of ___ as \noutpatient\n- Will need to follow-up with oncologist, Dr. ___ evidence of mass or amyloid on MRI\n- Will need outpatient referral by PCP to neurologist in home \nnetwork for titration of Keppra; currently on 1g Keppra BID due \nto concern for seizure\n- Will need outpatient monitoring of blood pressure (goal \nBP<140/90)\n-CTA final read pending (wet read only)\n-Numerous pulmonary nodules on CTA\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 750 mg PO TID \n2. Pioglitazone 15 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. Levothyroxine Sodium 25 mcg PO DAILY \n5. Lisinopril 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 20 mg PO QPM \n2. Levothyroxine Sodium 25 mcg PO DAILY \n3. Lisinopril 10 mg PO DAILY \n4. Pioglitazone 15 mg PO DAILY \n5. LeVETiracetam 1000 mg PO BID \nRX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice daily Disp \n#*30 Tablet Refills:*2\n6. MetFORMIN (Glucophage) 750 mg PO TID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSubarachnoid hemorrhage \n\n \nDischarge Condition:\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\nMental Status: Confused - sometimes.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted with a brain bleed (\"subarachnoid \nhemorrhage\"). There was no evidence of a new mass on your MRI. \nIt will be important for you to buy a blood pressure cuff and \nmeasure your blood pressure once daily at home and keep a diary \nof blood pressures. Bring this diary to your primary care \ndoctor. Your goal blood pressure should be less than 140 for the \ntop number and less than 90 for the bottom number. \n\nWe are concerned that your symptoms may have been due to a \nseizure due to irritation of your brain by the blood. We have \nstarted you on a seizure medication (Keppra); you will need to \ntake 1 gram twice a day.\n\nWe spoke with the on-call oncologist at the office at ___ that \nfollows you for your cancer. It will be very important that you \ncall them to make a follow-up appointment due to the growing \ncancer in your lungs and for further work-up to make sure you do \nnot have a new mass in your brain. \n\nIt was a pleasure meeting you!\nYour ___ Neurology Team\n \nFollowup Instructions:\n___\n" ]

[ "I609", "G8194", "R200", "R51", "E119", "E785", "I10", "E039", "Z85118", "Z87891" ]

[ "I609: Nontraumatic subarachnoid hemorrhage, unspecified", "G8194: Hemiplegia, unspecified affecting left nondominant side", "R200: Anesthesia of skin", "R51: Headache", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Z87891: Personal history of nicotine dependence" ]

[ "E119", "E785", "I10", "E039", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nhydromorphone\n \nAttending: ___\n \nChief Complaint:\nRecurrent pleural effusion\n \nMajor Surgical or Invasive Procedure:\n___ - Left anterior mini-thoracotomy, pericardial window.\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of aortic \nstenosis and coronary artery disease status post aortic valve \nreplacement and coronary artery bypass grafting x 2 in ___. His medical history is also notable alcohol abuse \ndisorder, atrial fibrillation, diabetes mellitus, goat, \nhyperlipidemia, and hypertension. He was admitted to the \ncardiology service after being redirected by outpatient \ncardiologist, for evaluation of worsening pericardial effusion. \n\nHe was recently admitted to ___ (___) for pericardial \ntamponade (?Dressler syndrome?), that required emergent \npericardiocentesis (subxiphoid approach, removed over 800cc of \nfluid) and subsequent CCU level of care. A pericardial drain was \nleft in-situ at the time and then removed on ___, prior to \nhome discharge on ___. \n\nToday, he was following up with his cardiologist, Dr. ___ \n(___) and he was describing progressive shortness of breath \nand some orthopnea over the last two days along with increase in \nhis weights from 178 lb (baseline) to 185 (today). Still frames \nfrom the echo performed in the office two days ago show an \nincreased amount of fluid around the right ventricle. After \nreviewing the images during Today's visit, inpatient \ncardiologist at ___ (Dr. ___ was contacted. He recommended \nredirecting patient to the ED for further evaluation and \npotential pericardial window (given failure of recent\npercutaneous pericardial drainage). During office visit this \nmorning, patient's vital signs remained stable. His clinical \ncondition was considered appropriate for direct admission to the \ngeneral cardiology floor. \n \nPast Medical History:\nAlcohol Abuse\nAortic Stenosis\nDiabetes Mellitus Type II\nGout\nHyperlipidemia\nHypertension\n \nSocial History:\n___\nFamily History:\nNo family history of heart disease \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: T: 97.8 F, BP 130/74 mmHg, HR 89 x min, RR 18 x min, O2 SAT\n95% RA. \n\nPulsus paradoxus: \nSBP (expiration): 110 mmHg\nSBP (inspiration): 102-104 mmHg\n\nBedside TTE (performed by ___: Cardiology Fellow). \nNo signs of tamponade. Large posterior pericardial effusion. \n\n \nGENERAL: Well developed, well nourished in NAD. Oriented x3.\nMood, affect appropriate. \nHEENT: Sclera anicteric. PERRL. EOMI. \nNECK: JVP 10 cmH2O, sitting upright. \nCARDIAC: RRR, normal intensity of S1/S2, ___ holo-systolic\nmurmur, best appreciated over the apex. no g/r. Negative pulsus\nparadoxus. \nCHEST: Healed sternotomy scar; hypoventilation on B/l bases,\nclear to auscultation otherwise, no crackles or no wheezes. \nABDOMEN: NTND, bowel sounds present \nEXTREMITIES: WWP, no pitting edema noted over lower extremities\nSKIN: No significant lesions or rashes. \nPULSES: Distal pulses palpable and symmetric\n\nDischarge Exam:\nPhysical Examination:\nGeneral: c/o chest wall pain at CT insertion site. [x] \nNeurological: A/O x3 [x] non-focal [] \nHEENT: PEERL [] \nCardiovascular: RRR [x] Irregular [] Murmur [] Rub [] \nRespiratory: Decreased at the bases- left >right [] No resp \ndistress [x]\nGI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]\nExtremities: \nRight Upper extremity Warm [x] Edema none\nLeft Upper extremity Warm [x] Edema none\nRight Lower extremity Warm [x] Edema none\nLeft Lower extremity Warm [x] Edema none\nPulses:\nDP Right: + Left:+\n___ Right: + Left:+\nRadial Right: + Left:+\nSkin/Wounds: Dry [x] intact [x]\nThoracotomy site: CDI [x] no erythema or drainage [x]\n Sternum stable - well healed [x] \n\n \nPertinent Results:\nLABS:\n___ 04:58AM BLOOD WBC-6.0 RBC-4.81 Hgb-9.5* Hct-31.9* \nMCV-66* MCH-19.8* MCHC-29.8* RDW-16.0* RDWSD-37.1 Plt Ct-91*\n___ 04:58AM BLOOD ___ PTT-30.5 ___\n___ 04:58AM BLOOD Glucose-149* UreaN-12 Creat-0.8 Na-139 \nK-4.2 Cl-101 HCO3-26 AnGap-12\n___ 04:23AM BLOOD WBC-5.1 RBC-4.49* Hgb-9.0* Hct-30.1* \nMCV-67* MCH-20.0* MCHC-29.9* RDW-16.3* RDWSD-38.2 Plt Ct-80*\n___ 04:20AM BLOOD WBC-8.4 RBC-5.10 Hgb-10.1* Hct-34.1* \nMCV-67* MCH-19.8* MCHC-29.6* RDW-16.3* RDWSD-37.7 Plt Ct-86*\n___ 04:23AM BLOOD ___\n___ 04:20AM BLOOD ___ PTT-26.7 ___\n___ 04:23AM BLOOD Glucose-229* UreaN-12 Creat-0.9 Na-136 \nK-4.1 Cl-100 HCO3-26 AnGap-10\n___ 04:20AM BLOOD Glucose-178* UreaN-11 Creat-0.9 Na-136 \nK-4.2 Cl-99 HCO3-24 AnGap-13\n___ 06:07AM BLOOD Glucose-237* UreaN-13 Creat-1.0 Na-139 \nK-4.5 Cl-98 HCO3-22 AnGap-19*\n___ 07:05AM BLOOD Glucose-204* UreaN-12 Creat-0.8 Na-138 \nK-3.9 Cl-100 HCO3-24 AnGap-14\n___ 05:00PM BLOOD WBC-7.1 RBC-5.35 Hgb-10.6* Hct-35.3* \nMCV-66* MCH-19.8* MCHC-30.0* RDW-16.0* RDWSD-36.3 Plt ___\n___ 05:00PM BLOOD ___ PTT-28.8 ___\n___ 05:00PM BLOOD Glucose-144* UreaN-15 Creat-0.8 Na-139 \nK-4.1 Cl-99 HCO3-24 AnGap-16\n___ 07:05AM BLOOD ALT-30 AST-25 LD(LDH)-168 AlkPhos-66 \nAmylase-53 TotBili-0.3\n___ 07:05AM BLOOD Lipase-34\n___ 05:00PM BLOOD cTropnT-<0.01 proBNP-399*\n___ 05:00PM BLOOD Calcium-9.9 Phos-4.7* Mg-1.7\n___ 05:00PM BLOOD CRP-1.4\n\nIMAGING: \nTransthoracic Echocardiogram ___\nThe left atrial volume index is SEVERELY increased. The \nestimated right atrial pressure is ___ mmHg. There is normal \nleft ventricular wall thickness with a normal cavity size. There \nis normal regional and global left ventricular systolic \nfunction. Quantitative biplane left ventricular ejection \nfraction is 58 % (normal 54-73%). There is no resting left \nventricular outflow tract gradient. Normal right ventricular \ncavity size with depressed free wall motion. Tricuspid annular \nplane systolic excursion (TAPSE) is depressed. The aortic sinus\ndiameter is normal for gender with normal ascending aorta \ndiameter for gender. An aortic valve bioprosthesis is present. \nThe prosthesis is well seated with normal gradient. There is no \naortic regurgitation. The mitral valve leaflets are mildly \nthickened with mild bileaflet systolic prolapse. There is \nmoderate mitral annular calcification. There is trivial mitral \nregurgitation. Due to acoustic shadowing, the severity of mitral \nregurgitation could be UNDERestimated. The pulmonic valve \nleaflets are normal. The tricuspid valve leaflets are mildly \nthickened. There is no tricuspid regurgitation. The pulmonary \nartery systolic pressure could not be estimated. There is a \nlarge circumferential pericardial effusion. There are no 2D or \nDoppler echocardiographic evidence of tamponade. Compared with \nthe prior TTE (images reviewed) of ___, pericardial \neffusion is significantly larger, but without evidence of frank \ncardiac tamponade. \n\nChest CT ___\nLarge nonhemorrhagic pericardial effusion. Correlate clinically \nfor\ntamponade.\n\nCXR ___\nIMPRESSION: \nComparison with the study of ___, the cardiac silhouette \nappears slightly less prominent than the left hemidiaphragmatic \ncontour is sharply seen. However, there is opacification along \nthe lateral chest wall with a \nconfiguration raising the possibility of a loculated collection. \nThe pulmonary vascular congestion has essentially cleared. No \nevidence of \nacute pneumonia. \n \n___ Pericardial tissue pathology \nOrganizing fibrinous pericarditis.\n- No malignancy identified, specimen entirely submitted for \nhistologic examination.\n\n \nBrief Hospital Course:\n___ year-old male patient of PCP ___ and Dr(s). \n___ with H/O CAD S/P CABG ___ (___) \n(LIMA-LAD, SVG-D for LAD and diagonal CAD) and AVR (23 mm \npericardial) for aortic stenosis, type 2 diabetes mellitus, \nhypertension, hyperlipidemia, paroxysmal atrial fibrillation \npreviously on apixiban, EtOH use disorder, gout, S/P \npericardiocentesis ___ (865 mL amber serosanguinous fluid; \nnegative for malignancy or bacterial growth) with subsequent \ncolchicine therapy presenting with worsening pericardial \neffusion, progressive shortness of breath, exertional fatigue \nand ___ transferred to ___ for pericardial window. He \nwas treated for acute on chronic diastolic heart failure with \nintermittent Lasix 40 mg. An echocardiogram demonstrated \npericardial effusion was significantly larger, but without \nevidence of frank cardiac tamponade. A chest CT revealed a large \nhemorrhagic pericardial effusion. He was taken to the operating \nroom on ___ and underwent pericardial window via anterior \nmini-thoracotomy. Per OR note, 1.5L drained of serous \npericardial effusion. He tolerated the procedure well and \npost-operatively returned to the floor. Chest tube discontinued \nwithout complication. Pain was controlled with ATC Tylenol, \nToradol (changed to Ibuprofen for discharge - oxycodone and \nDilaudid cause confusion). Follow-up chest XRay stable with \nopacification along the lateral chest wall with a configuration \nraising the possibility of a loculated collection. The pulmonary \nvascular congestion had essentially cleared. No evidence of \nacute pneumonia. The patient was discharged home on POD 3 with \n___ services. He is to follow up with Dr ___ in 2 weeks with CXR \nprior to clinic visit. He was discharged home in stable \ncondition with follow up appointments arranged. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. Losartan Potassium 25 mg PO DAILY \n4. Thiamine 100 mg PO DAILY \n5. Colchicine 0.6 mg PO BID \n6. Rosuvastatin Calcium 20 mg PO QPM \n7. Amaryl (glimepiride) 4 mg oral BID \n8. Furosemide 40 mg PO DAILY \n9. Januvia (SITagliptin) 100 mg oral DAILY \n10. MetFORMIN (Glucophage) 500 mg PO BID \n11. Ranitidine 150 mg PO DAILY \n12. Metoprolol Succinate XL 100 mg PO DAILY \n13. GuaiFENesin ER 1200 mg PO Q12H \n14. GuaiFENesin-Dextromethorphan ___ mL PO Q6H Cough \n15. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Apixaban 5 mg PO BID \n3. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \nTake with food \n4. Senna 17.2 mg PO QHS \n5. GuaiFENesin ER 1200 mg PO Q12H:PRN cough \n6. Metoprolol Tartrate 25 mg PO BID \nRX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*1 \n7. Amaryl (glimepiride) 4 mg oral BID \n8. Aspirin 81 mg PO DAILY \n9. Colchicine 0.6 mg PO BID \n10. FoLIC Acid 1 mg PO DAILY \n11. Losartan Potassium 25 mg PO DAILY \n12. MetFORMIN (Glucophage) 500 mg PO BID \n13. Pantoprazole 40 mg PO Q24H \n14. Ranitidine 150 mg PO DAILY \n15. Rosuvastatin Calcium 20 mg PO QPM \n16. Thiamine 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRecurrent Pericardial Effusion\nAcute on Chronic Congestive Heart Failure\n\nAlcohol Abuse\nAortic Stenosis\nCongestive Heart Failure, chronic\nDiabetes Mellitus Type II\nGout\nHyperlipidemia\nHypertension\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal\nAmbulating, gait steady\nThoracotomy pain managed with oral analgesics\nThoracotomy Incision - healing well, no erythema or drainage\nNo edema\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\nPlease - NO lotion, cream, powder or ointment to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving while taking narcotics\nClearance to drive will be discussed at follow up appointment \nwith surgeon\nNo lifting more than 10 pounds for 2 weeks\nEncourage full shoulder range of motion, unless otherwise \nspecified\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I313", "I5033", "D62", "I2510", "I110", "Z951", "Z952", "F1010", "E785", "E119", "M109", "I480", "Z87891", "R410", "T402X5A", "Y92239" ]

[ "I313: Pericardial effusion (noninflammatory)", "I5033: Acute on chronic diastolic (congestive) heart failure", "D62: Acute posthemorrhagic anemia", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I110: Hypertensive heart disease with heart failure", "Z951: Presence of aortocoronary bypass graft", "Z952: Presence of prosthetic heart valve", "F1010: Alcohol abuse, uncomplicated", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "M109: Gout, unspecified", "I480: Paroxysmal atrial fibrillation", "Z87891: Personal history of nicotine dependence", "R410: Disorientation, unspecified", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "D62", "I2510", "I110", "Z951", "E785", "E119", "M109", "I480", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nPericardiocentesis \n \nHistory of Present Illness:\n___ with PMHx aortic stenosis s/p AVR(#23MM Magna Ease) and\ncoronary artery disease s/p coronary artery bypass graft x 2\n(LIMA-LAD, SVG-D) ___, alcohol use disorder, T2DM, gout, HLD,\nHTN, a-fib on apixiban admitted to the CCU for management of\npericardial tamponade and cardiogenic shock. He presented with 1\nday of significant shortness of breath, inability to lay flat \nand\nextreme weakness. The patient denies any chest pain or abdominal\npain. He also has hyperglycemia and metabolic acidosis \nconcerning\nfor DKA. Bedside ultrasound showed a large pericardial effusion\nwith significant right ventricular collapse consistent with\npericardial tamponade. The patient received K-Centra. \n\nIn the ED, \n- Initial vitals were: 96.0 100 ___ 95% 2L NC \n- Labs notable for: \n -H/H 12.1/41.8, WBC 15.0, plt 239\n -Na 128, BUN 22, Cr 1.7, glucose 390\n -___ 19.9, PTT 27.1, INR 1.8\n -Trop-T < 0.01\n -VBG 7.18/42\n \n- Studies notable for:\nCXR: Low lung volumes with mild retrocardiac atelectasis and\ntrace left pleural effusion. Possible mild pulmonary vascular\ncongestion without frank pulmonary edema. \n\n- Patient was given: IV Kcentra, 1L NS\n\nBedside ECHO performed by cardiology fellow notable for large\npericardial effusion. Patient subsequently taken to the cath lab\nfor emergent pericardiocentesis. \n\nPer procedural report, \"The pericardial space was accessed from\nthe subxiphoid approach with echocardiographic and fluoroscopic\nguidance. The initial mean pericardial pressure was 35 mm Hg \nwith\nan amber fluid dripping back. After removal of 865 mL of dark\namber (slightly reddish brown fluid: 60+60+20 mL in syringes, \n725\nin vacuum bottle), the pericardial effusion was minimal on\nechocardiogram with marked symptomatic improvement and closing\npericardial pressure of 3 mm Hg. The pericardial drainage\ncatheter was secured in place.\"\n\nOn arrival to the CCU, the patient feels much improved and was\nsitting comfortably in bed. He denied any dizziness, LH, CP, \nSOB,\nabdominal pain, n/v/d, or urinary symptoms. \n\nROS: Positive per HPI. Remaining 10 point ROS reviewed and\nnegative. \n\n \nPast Medical History:\nAlcohol Abuse\nAortic Stenosis\nDiabetes Mellitus Type II\nGout\nHyperlipidemia\nHypertension\n \nSocial History:\n___\nFamily History:\nNo family history of heart disease\n \nPhysical Exam:\nADMISSION EXAM:\n===============\nVS: Reviewed in MetaVision\nGENERAL: Well developed, well nourished in NAD. Oriented x3.\nMood, affect appropriate. \nHEENT: Sclera anicteric. PERRL. EOMI. \nNECK: Supple. JVP 10 at 60 degrees. \nCARDIAC: rrr, ___ holo-systolic murmur, no g/r \nCHEST: Healing sternotomy scar; mild-moderate bibasilar \ncrackles,\nno wheeze. \nABDOMEN: NTND, bowel sounds present \nEXTREMITIES: WWP, no pitting edema \nSKIN: No significant lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: CNII-XII intact\n\nDISCHARGE LABS:\n===============\n24 HR Data (last updated ___ @ 316)\n Temp: 98.0 (Tm 98.8), BP: 147/83 (123-147/62-88), HR: 97\n(75-97), RR: 18, O2 sat: 96% (96-99), O2 delivery: Ra \nGENERAL: Well developed, well nourished in NAD. Oriented x3.\nMood, affect appropriate. \nHEENT: Sclera anicteric. PERRL. EOMI. \nNECK: Supple. JVP 8 at 60 degrees. \nCARDIAC: rrr, ___ holo-systolic murmur, no g/r \nCHEST: Healing sternotomy scar; mild-moderate bibasilar \ncrackles,\nno wheeze.\nABDOMEN: NTND, bowel sounds present \nEXTREMITIES: WWP, no pitting edema \nSKIN: No significant lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: CNII-XII intact\n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 06:55PM BLOOD WBC-15.0* RBC-5.92 Hgb-12.1* Hct-41.8 \nMCV-71* MCH-20.4* MCHC-28.9* RDW-18.6* RDWSD-42.3 Plt ___\n___ 06:55PM BLOOD Neuts-72.0* ___ Monos-4.6* \nEos-0.2* Baso-0.9 NRBC-0.2* Im ___ AbsNeut-10.78* \nAbsLymp-3.18 AbsMono-0.69 AbsEos-0.03* AbsBaso-0.13*\n___ 06:55PM BLOOD ___ PTT-27.1 ___\n___ 06:55PM BLOOD Glucose-390* UreaN-22* Creat-1.7* Na-128* \nK-7.5* Cl-95* HCO3-11* AnGap-22*\n___ 01:52AM BLOOD ALT-261* AST-186* AlkPhos-76 TotBili-0.5\n___ 06:55PM BLOOD cTropnT-<0.01\n___ 10:01PM BLOOD Calcium-8.6 Phos-5.8* Mg-1.7\n___ 07:05PM BLOOD Lactate-9.2*\n\nDISCHARGE LABS\n==============\n___ 07:27AM BLOOD WBC-7.7 RBC-5.92 Hgb-12.0* Hct-40.5 \nMCV-68* MCH-20.3* MCHC-29.6* RDW-17.3* RDWSD-38.7 Plt ___\n___ 07:27AM BLOOD Glucose-239* UreaN-19 Creat-0.9 Na-136 \nK-4.6 Cl-100 HCO3-22 AnGap-14\n___ 06:55AM BLOOD ALT-182* AST-25 AlkPhos-102 TotBili-0.5\n___ 07:27AM BLOOD Calcium-9.8 Phos-4.1 Mg-1.9\n\nPERTINENT LABS\n==============\n___ 05:06AM BLOOD CK-MB-2 cTropnT-0.05*\n___ 06:55PM BLOOD Beta-OH-0.2\n___ 05:06AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* HAV \nAb-POS*\n___ 06:27AM BLOOD CRP-18.7*\n___ 05:06AM BLOOD HCV Ab-NEG\n___ 10:19PM BLOOD Lactate-5.8*\n___ 02:14AM BLOOD Lactate-2.8*\n___ 12:19PM BLOOD Lactate-1.3\n___ 05:06AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* HAV \nAb-POS*\n___ 02:56PM BLOOD IgM HAV-NEG\n___ 06:27AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT\n___ 05:06AM BLOOD HCV Ab-NEG\n\nIMAGING\n=======\nCXR - ___ \nLow lung volumes with mild retrocardiac atelectasis and trace \nleft pleural \neffusion. Possible mild pulmonary vascular congestion without \nfrank pulmonary edema.\n\nTTE - ___\nEF > 60%. Well seated, normal functioning bioprosthetic AVR with \nnormal gradient and no aortic regurgitation. Normal left \nventricular wall thickness and biventricular cavity sizes and \nregional/global systolic function. Small circumferential \npericardial effusion without echocardiographic evidence for \ntamponade physiology. Compared with the prior TTE (images \nreviewed) of ___ , the pericardial effusion is now \nslightly larger but remains small and without echo evidence of \nhemodynamic compromise.\n \nCXR - ___ \nIn comparison with the study of ___, following \npericardiocentesis the \ncardiac silhouette is now essentially within normal limits. \nPericardial drain is in place. Blunting of the left \ncostophrenic angle is consistent with pleural fluid. No \nevidence of appreciable vascular congestion or acute focal \npneumonia. \n\nRUQUS - ___ \n1. Echogenic liver consistent with steatosis. Other forms of \nliver disease and more advanced liver disease including \nsteatohepatitis or significant hepatic fibrosis/cirrhosis cannot \nbe excluded on this study. \n2. Mild splenomegaly. \n3. Cholelithiasis. \n\nFocused TTE - ___ \nThe estimated right atrial pressure is ___ mmHg. There is \nsuboptimal image quality to assess regional left ventricular \nfunction. Overall left ventricular systolic function is normal. \nThe visually estimated left\nventricular ejection fraction is 60%. Normal right ventricular \ncavity size with depressed free wall motion. The mitral valve \nleaflets are mildly thickened. There is moderate mitral annular \ncalcification. Due to acoustic\nshadowing, the severity of mitral regurgitation could be \nUNDERestimated. There is a small posterior pericardial effusion. \nThe effusion is echo dense, c/w blood, inflammation or other \ncellular elements. There are\nno 2D or Doppler echocardiographic evidence of tamponade.\nCompared with the prior TTE (images reviewed) of ___, \nthere is no obvious change, but the suboptimal image quality of \nthe studies precludes definitive comparison.\n\nCT abdomen/pelvis without contrast - ___ \n1. Punctate, subpleural nodules in the right lower lobe are \nnonspecific, but likely infectious versus inflammatory in \netiology. \n2. Trace residual pericardial effusion with a pericardial drain \nin situ. \n3. Incidentally noted are multiple healing right-sided rib \nfractures. \n\nTTE - ___ \nSmall posterior loculated pericardial effusion without \ntampoande.\nCompared with the prior TTE ___ , small posterior \neffusion not echolucent. Appears slightly larger (see apical 4 \nand apical long axis views).\n\nMICRO\n=====\nPERICARDIAL FUID. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count, if \napplicable. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n\nURINE CULTURE (Final ___: NO GROWTH. \n\nBlood Culture, Routine (Final ___: NO GROWTH.\n\nPATH\n====\nPericardial fluid - ___: NEGATIVE FOR MALIGNANT CELLS. \nPredominantly lymphocytes, with scattered admixed reactive \nmesothelial cells.\n\n \nBrief Hospital Course:\n___ with PMHx aortic stenosis s/p AVR(#23MM Magna Ease) and \ncoronary artery disease s/p coronary artery bypass graft x 2 \n(LIMA-LAD, SVG-D) ___, alcohol use disorder, T2DM, gout, HLD, \nHTN, a-fib on apixiban admitted to the CCU for management of \npericardial tamponade and cardiogenic shock.\n\nACUTE ISSUES\n============\n# Pericardial effusion w/ effusoconstrictive physiology\nPatient presented to ED on ___ with 1-month cough and 2-day \nworsening dyspnea on exertion. Bedside TTE in the ED showed \nlarge effusion with normal global LV function and signs of RV \ncollapse. Had an emergent pericardiocentesis with mean \npericardial opening pressures of 35 mmHg and closing pressures \nof 3 mm Hg. 875 mL of dark amber fluid was removed and a \npericardial drainage catheter was secured in place. He was \ntransferred to the CCU where he continued to be monitored. The \ndrainage catheter was removed on ___ after 24-hour \ncollection was <50cc. Pericardial fluid fluid cell count, \nchemistry, cytology, culture was c/w post surgical/inflammatory \npericardial effusion. CRP was 18.7. Patient was started on \ncolchicine 0.6mg BID for 3 months (End date ___. The \npatient's apixaban was held at discharge. Would consider \nrestarting after repeating TTE in 1 week. \n\n#Post surgical cough\n#Dysphonia \nPatient has noticed a chronic cough after his CABG. Despite \nbeing euvolemic, the patient continues to have a cough. CT Chest \nwas done without evidence of cause. The patient was started on \ncough suppressants and had a SNIFF test given L diaphragm was \nslightly elevated on CXR. This showed no evidence diaphragmatic \nweakness. He was started on pantoprazole for empiric treatment \nof GERD. Planned for ENT referral as an outpatient. \n\n# Lactic acidosis \n# Hypotensive shock \nPt presented with lactic acidosis to 9.2 which down-trended to \n2.8; pH of 7.18 and PCO2 42, Bicarbonate of 16. Labs were \ninitially concerning for DKA given FBG of 390 so pt was placed \non insulin gtt which was weaned to SSI after urine ketones and \nserum beta-hydroxybutyrate resulted negative. Lactic acidosis \nlikely in the setting of poor cadiac perfusion d/t tamponade \nphysiology which responded to therapeutic pericardiocentesis. \n\n# ___\nCr baseline 0.9-1.2; peak 1.7, down-trended to 0.9. Likely \npre-renal given hypoperfusion iso tamponade. Cr on discharge 0.9\n\n# Paroxysmal AF\nMetoprolol succinate was held initially iso temponade and \nhypotension. Patient had one episode of afib with RVR and was \nstarted on metoprolol tartrate that was consolidated to \nmetoprolol succinate 100mg daily. Apixaban was held initially \ndue to concerns that the pericardial effusion was hemorrhagic. \nPatient was discharged on metop succinate 100mg daily and held \napixaban 5mg BID. \n\n# Transaminitits (improving): \non ___, ALT was 542 and AST of 187 with normal total \nBilirubin. No clear etiology; however, this coincidenced with \nstarting colchicine. RUQUS showed hepatic steatosis without \nobstruction. Hep. B serology showed immunity due to previous \ninfection. Hep B viral load was pending. Hep A antibodies were \nnegative and Hep C antibodies were negative. Atorvastatin was \nswitched to Crestor 20mg. LFTs came down. On discharge, ALT was \n182 and AST was 25. \n\n#Gout Flare\nPt had gout flare in R second PIP joint on ___, was given three \ndays of PO prednisone 20 mg. \n\nCHRONIC ISSUES\n==============\n#NIDDM \nThe patient was placed on insulin sliding scale while inpatient. \nHis home oral regimen was continued on discharged. Would \nconsider switching to SGLT2 for cardiovascular benefit. \n- home Amaryl (glimepiride); pt not taking\n- home Januvia (SITagliptin) 100 mg oral daily \n- home MetFORMIN (Glucophage) 500 mg PO BID\n\n#Aortic Stenosis s/p Aortic valve replacement\n#Coronary Artery Disease s/p coronary artery bypass graft x 2\n- Cont ASA 81.\n- Cont Atorvastatin 40mg qHS \n\nTRANSITIONAL ISSUES\n[] repeat CRP after treatment. CRP was 18.7 while inpatient \n[] Will need repeat echo in ___ weeks to ensure no \nreaccumulation. Would consider restarting apixaban if stable. \n[] Consider switching from glimepiride to SGLT2 given \ncardiovascular benefit \n[] Ensure ENT follow up for chronic cough \n[] f/u HBV and HCV VL\n\n#CODE: Full code (confirmed) \n#CONTACT/HCP: ___ (wife) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. GuaiFENesin ER 1200 mg PO Q12H \n4. Ranitidine 150 mg PO DAILY \n5. Senna 17.2 mg PO QHS \n6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n7. Apixaban 5 mg PO BID \n8. Amaryl (glimepiride) 4 mg oral BID \n9. Januvia (SITagliptin) 100 mg oral DAILY \n10. Losartan Potassium 25 mg PO DAILY \n11. MetFORMIN (Glucophage) 500 mg PO BID \n12. FoLIC Acid 1 mg PO DAILY \n13. Thiamine 100 mg PO DAILY \n14. TraZODone 25 mg PO QHS:PRN insomnia \n15. Furosemide 40 mg PO DAILY \n16. Metoprolol Succinate XL 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Colchicine 0.6 mg PO BID \nRX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*2 \n2. GuaiFENesin-Dextromethorphan ___ mL PO Q6H Cough \n3. Pantoprazole 40 mg PO Q24H \n4. Rosuvastatin Calcium 20 mg PO QPM \nRX *rosuvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*3 \n5. Amaryl (glimepiride) 4 mg oral BID \n6. Aspirin 81 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. GuaiFENesin ER 1200 mg PO Q12H \n9. Januvia (SITagliptin) 100 mg oral DAILY \n10. Losartan Potassium 25 mg PO DAILY \n11. MetFORMIN (Glucophage) 500 mg PO BID \n12. Metoprolol Succinate XL 100 mg PO DAILY \n13. Ranitidine 150 mg PO DAILY \n14. Senna 17.2 mg PO QHS \n15. Thiamine 100 mg PO DAILY \n16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n17. TraZODone 25 mg PO QHS:PRN insomnia \n18. HELD- Apixaban 5 mg PO BID This medication was held. Do not \nrestart Apixaban until you see your cardiologist\n19. HELD- Furosemide 40 mg PO DAILY Duration: 7 Days This \nmedication was held. Do not restart Furosemide until you are \ntold to by your heart doctor\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\nPericardial Effusion with tamponade physiology \n\nSECONDARY DIAGNOSES:\n====================\nAtrial fibrillation \nChronic cough \ntransaminitis \nGout \nType 2 diabetes mellitus \nAcute kidney injury \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure taking care of you at ___. \n\nWHY WAS I IN THE HOSPITAL?\n- You were admitted to the hospital because you were having \ntrouble breathing. \n\nWHAT WAS DONE IN THE HOSPITAL?\n- You had an ultrasound of your heart. This showed that there \nwas a collection of fluid surrounding your heart. \n- You had a procedure called a pericardiocentesis to remove the \nextra fluid surrounding your heart. \n\nWHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?\n- Continue to take all your medications as prescribed. \n- Make sure to follow-up with your heart doctor and primary care \ndoctor.\n\nWe wish you the best!\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I313", "R571", "E872", "N179", "I314", "Z952", "I2510", "Z951", "E785", "I10", "M109", "F1010", "E119", "Z7901", "Z87891", "Z7984", "I480", "R05", "R740" ]

[ "I313: Pericardial effusion (noninflammatory)", "R571: Hypovolemic shock", "E872: Acidosis", "N179: Acute kidney failure, unspecified", "I314: Cardiac tamponade", "Z952: Presence of prosthetic heart valve", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "M109: Gout, unspecified", "F1010: Alcohol abuse, uncomplicated", "E119: Type 2 diabetes mellitus without complications", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "Z7984: Long term (current) use of oral hypoglycemic drugs", "I480: Paroxysmal atrial fibrillation", "R05: Cough", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]" ]

[ "E872", "N179", "I2510", "Z951", "E785", "I10", "M109", "E119", "Z7901", "Z87891", "I480" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDyspnea and cough with thick sputum\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old man with a history of alcohol abuse, aortic \nstenosis,\nhyperlipidemia, and hypertension. On ___ he underwent\ncoronary artery bypass grafting x 2 \nand aortic valve replacement (tissue). His post operative\ncourse was complicated by gout and hyperglycemia. In addition he\nreturned to the ICU due to cough and possible pneumonia with\nthick secretions and leukocytosis. He remained hemodynamically\nstable and was transferred back to the floor on POD 9 and\ndischarged home on ___. \nDuring his time at home he complains of worsening dyspnea and\nproductive cough. He denies fever, chills, or chest pain. His \n___\nwas concerned and sent him to the ER for further evaluation. \n\nUpon presentation to the ER he was HD stable and O2 sat 98% on \n2L\nNC. CXR concerning for fluid overload, pleural effusion\nbilaterally. Otherwise he appears deconditioned and complains of\nin ability to sleep due to his persistent coughing. He is unable\nto lie flat.\n\n \nPast Medical History:\nAlcohol Abuse\nAortic Stenosis\nDiabetes Mellitus Type II\nGout\nHyperlipidemia\nHypertension\n \nSocial History:\n___\nFamily History:\nNo family history of heart disease\n \nPhysical Exam:\nPulse: Resp: 62 O2 sat: 99% on 2L NC (95% on RA)\nB/P Right: 132/80 Left: \nHeight: Weight:\n\nGeneral:\nSkin: Dry [X] intact [X]\nHEENT: PERRLA [X] EOMI [X]\nNeck: Supple [] Full ROM [X]\nChest: Coarse breath sounds and crackles at lung bases\nbilaterally. Healing sternotomy incision. No erythema, drainage. \n\nHeart: RRR [X] Irregular [] Murmur [] grade ______ \nAbdomen: Soft [X] non-distended [] non-tender [] bowel sounds +\n[]\nExtremities: Warm [], well-perfused [] Edema [X] 1+ pitting\nedema in B/L ___\nVaricosities: None []\nNeuro: Grossly intact []\nPulses:\nFemoral Right: Left:\nDP Right: + Left:+\n___ Right: + Left:+\nRadial Right:+ Left:+\n\nCarotid Bruit: Right: None Left: None\n\nDischarge Exam:\n \nPertinent Results:\n___ CXR\nMild to moderate pulmonary edema with grown small bilateral \npleural effusions and bibasilar opacities which may reflect \natelectasis adjacent to the pleural effusions although \nsuperinfection cannot be excluded. Cardiomegaly. \n\n___ Abdominal xray\nNo radiographic evidence of ileus or bowel obstruction.\n\n \nBrief Hospital Course:\nMr. ___ was readmitted to the ___ on ___ for \nfurther management of his cough and bilateral pleural effusions. \nHe was diuresed aggressively with good results. Shortness of \nbreath resolved. His rhythm was alternating between atrial \nfibrillation/ flutter and NSR. He is anticoagulated with Eiquis. \nEP was consulted regarding his rhythm and concern for using \nAmiodarone with his recent eval done by Hepatology. Amiodarone \nwas discontinued per their recommendation. On ___ Mr. \n___ was successfully electrically cardioverted to sinus \nrhythm. He remained so during the rest of his hospitalization. \nBy the time of hospital day six, he was ambulating \nindependently, his wound was healing, and his pain was well \ncontrolled. He was cleared for discharge to home with ___ \nservices. All follow up appointments were advised. \n \nMedications on Admission:\n1. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*1 \n2. Atorvastatin 20 mg PO QPM \nwill need to increase to 40mg daily once off amiodarone \nRX *atorvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30 \n\nTablet Refills:*1 \n3. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n4. Furosemide 40 mg PO DAILY Duration: 10 Days \nRX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth once a day \nDisp #*10 Tablet Refills:*0 \n5. GuaiFENesin ER 1200 mg PO Q12H \nRX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp \n#*20 Tablet Refills:*0 \n6. Lactulose 30 mL PO DAILY \nRX *lactulose 20 gram/30 mL 1 ml by mouth once a day Disp #*1 \nBottle Refills:*0 \n7. Lisinopril 2.5 mg PO DAILY \nRX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n8. Metoprolol Tartrate 37.5 mg PO TID \nRX *metoprolol tartrate 37.5 mg 1 tablet(s) by mouth three times \n\na day Disp #*90 Tablet Refills:*1 \n9. Ranitidine 150 mg PO DAILY Duration: 1 Month \nRX *ranitidine HCl [Zantac Maximum Strength] 150 mg 1 tablet(s) \nby mouth once a day Disp #*30 Tablet Refills:*0 \n10. Senna 17.2 mg PO QHS \nRX *sennosides [senna] 8.6 mg 2 tablet(s) by mouth at bedtime \nDisp #*30 Tablet Refills:*0 \n11. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \n\nday Disp #*30 Tablet Refills:*0 \n12. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \nRX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth four times a \nday Disp #*60 Tablet Refills:*0 \n13. Aspirin 81 mg PO DAILY \n14. glimepiride 4 mg oral BID \n15. Januvia (SITagliptin) 100 mg oral DAILY \n16. MetFORMIN (Glucophage) 500 mg PO BID \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg one tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*2 \n2. Aspirin 81 mg PO DAILY \n3. Furosemide 40 mg PO DAILY Duration: 7 Days \nRX *furosemide 40 mg one tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*0 \n4. Losartan Potassium 25 mg PO DAILY \nRX *losartan 25 mg one tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*2 \n5. Metoprolol Succinate XL 100 mg PO DAILY \nRX *metoprolol succinate 100 mg one tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*2 \n6. Amaryl (glimepiride) 4 mg oral DAILY \n7. Atorvastatin 40 mg PO QPM \n8. FoLIC Acid 1 mg PO DAILY \n9. GuaiFENesin ER 1200 mg PO Q12H \n10. Januvia (SITagliptin) 100 mg oral DAILY \n11. MetFORMIN (Glucophage) 500 mg PO BID \n12. Ranitidine 150 mg PO DAILY \n13. Senna 17.2 mg PO QHS \n14. Thiamine 100 mg PO DAILY \n15. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \n16. TraZODone 25 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAortic Stenosis s/p Aortic valve replacement\nCoronary Artery Disease s/p coronary artery bypass graft x 2\n\nSecondary Diagnosis:\nAlcohol Abuse\nDiabetes Mellitus Type II\nGout\nHyperlipidemia\nHypertension\n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\nEdema: trace R>L\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\nPlease - NO lotion, cream, powder or ointment to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics\nClearance to drive will be discussed at follow up appointment \nwith surgeon\nNo lifting more than 10 pounds for 10 weeks\nEncourage full shoulder range of motion, unless otherwise \nspecified\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "E8770", "I4892", "J90", "E785", "E871", "Z952", "Z87891", "Z7901", "I4891", "Z7984", "I129", "E1122", "N189", "I2510", "Z951" ]

[ "E8770: Fluid overload, unspecified", "I4892: Unspecified atrial flutter", "J90: Pleural effusion, not elsewhere classified", "E785: Hyperlipidemia, unspecified", "E871: Hypo-osmolality and hyponatremia", "Z952: Presence of prosthetic heart valve", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants", "I4891: Unspecified atrial fibrillation", "Z7984: Long term (current) use of oral hypoglycemic drugs", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft" ]

[ "E785", "E871", "Z87891", "Z7901", "I4891", "I129", "E1122", "N189", "I2510", "Z951" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nhydromorphone\n \nAttending: ___.\n \nChief Complaint:\nDyspnea on exertion \n \nMajor Surgical or Invasive Procedure:\nCoronary Angiography \n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with paroxysmal Atrial\nfibrillation (on apixaban), CHFpEF, CAD s/p CABG ___, AS s/p\nAVR, recurrent pericardial effusions s/p pericardiocentesis\n(___) f/b pericardial window (___), and diabetes mellitus,\nwho presents with chest discomofort, dyspnea, and dizziness. \n\nThe patient developed progressive dyspnea on exertion and chest\npressure approximately one week ago. The chest pressure occurs\nwith exertion. It is located substernally and radiates to the\nneck with a \"choking\" sensation. The chest pressure is \nassociated\nwith dyspnea, occasional palpitations, and, most recently,\ndizziness. The dyspnea has progressed to the point where he can\nonly walk a few steps before feeling symptomatic and has to stop\nand rest. These symptoms prompted the patient to present to the\nED. \n\nIn the ED, the patient was afebrile, HR ___, BPs normal \n(100s\n- 120s/60s), SpO2 100% RA. Exam showed ___ systolic murmur,\npulsus of 6, lungs clear, benign abd, no edema or elevated JVP.\nBedside echo with pericardial effusion. EKG w/ first degree AV\nblock, TWI V4-6. Labs notable for Hgb 12 (MCV 64), Plt 138, BNP\n277, normal LFTs and electrolytes, with tropT < assay. CXR with\nsmall left effusion vs pleural thickening. Cardiac surgery was\nconsulted and did not feel that his symptoms were secondary to\nthe pericardial effusion. \n\nOn arrival to the floor, the patient appears well and is\ncomfortable. He is concerned that the above symptoms are related\nto \"electricity\" abnormalities in his heart. He reports that he\nis beginning to feel short of breath just speaking with me. He\nhas no fevers, chills, or cough. No positional chest pain. \nDenies\nPND or orthopnea. No ___ swelling. \n\n \nPast Medical History:\nAlcohol Abuse\nAortic Stenosis\nDiabetes Mellitus Type II\nGout\nHyperlipidemia\nHypertension\nCAD s/p CABG ___\nrecurrent pericardial effusions s/p pericardiocentesis\n(___) f/b pericardial window (___)\nparoxysmal a fib \n? CHFpEF,\n \nSocial History:\n___\nFamily History:\nNo family history of heart disease \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 431)\n Temp: 97.6 (Tm 97.7), BP: 150/79 (148-150/79-89), HR: 82\n(82-85), RR: 20 (___), O2 sat: 97%, O2 delivery: RA \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. \nsystolic\nejection murmur best at RUSB.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nBACK: No CVA tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rashes.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. ___ strength throughout. Normal sensation.\n\nDischarge Physical Exam: \n24 HR Data (last updated ___ @ 728)\n Temp: 98.2 (Tm 98.2), BP: 152/88 (120-154/66-88), HR: 95\n(80-95), RR: 20, O2 sat: 96% (94-98), O2 delivery: Ra, Wt: \n185.85\nlb/84.3 kg \nFluid Balance (last updated ___ @ 659) \n Last 8 hours Total cumulative -1454.8ml\n IN: Total 70.2ml, IV Amt Infused 70.2ml\n OUT: Total 1525ml, Urine Amt 1525ml\n Last 24 hours Total cumulative -___\n IN: Total 970.2ml, PO Amt 900ml, IV Amt Infused 70.2ml\n OUT: Total 2995ml, Urine Amt 2995ml \nGENERAL: Alert and interactive. In no acute distress.\nNECK: No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. \nsystolic\nejection murmur best at RUSB.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm.\nNEUROLOGIC: Moving all four extremities spontaneously, alert and\ninteractive. \n\n \nPertinent Results:\nAdmission Labs: \n\n___ 07:50PM BLOOD WBC-7.1 RBC-5.94 Hgb-11.7* Hct-37.9* \nMCV-64* MCH-19.7* MCHC-30.9* RDW-17.6* RDWSD-36.9 Plt ___\n___ 07:50PM BLOOD Neuts-44.6 ___ Monos-8.4 Eos-4.8 \nBaso-1.1* Im ___ AbsNeut-3.18 AbsLymp-2.91 AbsMono-0.60 \nAbsEos-0.34 AbsBaso-0.08\n___ 05:58PM BLOOD ___ PTT-32.1 ___\n___ 07:50PM BLOOD Glucose-130* UreaN-21* Creat-0.8 Na-137 \nK-4.2 Cl-102 HCO3-23 AnGap-12\n___ 07:50PM BLOOD ALT-30 AST-23 AlkPhos-85 TotBili-0.3\n___ 07:50PM BLOOD Albumin-4.6 Calcium-9.7 Phos-4.5 Mg-1.9\n\nDischarge Labs :\n\n___ 01:40AM BLOOD WBC-6.4 RBC-5.64 Hgb-11.0* Hct-36.2* \nMCV-64* MCH-19.5* MCHC-30.4* RDW-16.7* RDWSD-37.0 Plt ___\n___ 09:15AM BLOOD ___ PTT-65.6* ___\n___ 01:40AM BLOOD Glucose-286* UreaN-20 Creat-0.9 Na-137 \nK-4.1 Cl-99 HCO3-23 AnGap-15\n___ 01:40AM BLOOD Calcium-9.3 Phos-4.9* Mg-2.0\n\nReports: \n\nTTE: \nLEFT ATRIUM (LA)/PULMONARY VEINS: SEVERELY increased LA volume \nindex.\nRIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC): \nModerately\ndilated RA. No atrial septal defect by 2D/color Doppler.\nLEFT VENTRICLE (LV): Normal cavity size. Focal (non-obstructive) \nbasal septal hypertrophy.\nNormal regional/global systolic function. The visually estimated \nleft ventricular ejection fraction is 55%.\nNo ventricular septal defect. No resting outflow tract gradient.\nRIGHT VENTRICLE (RV): Normal cavity size. Mild global free wall \nhypokinesis. Depressed\ntricuspid annular plane systolic excursion (TAPSE).\nAORTA: Normal sinus diameter for gender. Normal ascending \ndiameter for gender. Normal descending\naorta.\nAORTIC VALVE (AV): Bioprosthesis. Well seated prosthesis. Normal \nprosthesis leaflet motion and\ngradient. No stenosis. Trace regurgitation. Paravalvular \nregurgitant jet.\nMITRAL VALVE (MV): Mildly thickened leaflets. No systolic \nprolapse. Mild MAC. Mild chordal\nthickening. Trivial regurgitation.\nPULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation.\nTRICUSPID VALVE (TV): Normal leaflets. Trivial regurgitation. \nNormal pulmonary artery systolic\npressure.\nPERICARDIUM: Small-moderate effusion. Circumferential effusion. \nEcho dense\n\nThe left atrial volume index is SEVERELY increased. The right \natrium is moderately enlarged. There is\nno evidence for an atrial septal defect by 2D/color Doppler. The \nleft ventricle has a normal cavity size.\nThere is mild (non-obstructive) focal basal septal hypertrophy. \nThere is normal regional and global left\nventricular systolic function. The visually estimated left \nventricular ejection fraction is 55%. There\nis no resting left ventricular outflow tract gradient. No \nventricular septal defect is seen. Normal right\nventricular cavity size with mild global free wall hypokinesis. \nTricuspid annular plane systolic excursion\n(TAPSE) is depressed. The aortic sinus diameter is normal for \ngender with normal ascending aorta\ndiameter for gender. There is a normal descending aorta \ndiameter. An aortic valve bioprosthesis is\npresent. The prosthesis is well seated with normal leaflet \nmotion and gradient. There is no aortic valve\nstenosis. There is a paravalvular jet of trace aortic \nregurgitation. The mitral valve leaflets are mildly\nthickened with no mitral valve prolapse. There is trivial mitral \nregurgitation. The pulmonic valve leaflets\nare normal. The tricuspid valve leaflets appear structurally \nnormal. There is trivial tricuspid\nregurgitation. The estimated pulmonary artery systolic pressure \nis normal. There is a small\ncircumferential pericardial effusion, measuring up to 1.3 cm \nanterior to the right atrium, 1.2 cm\ninferolateral to the left ventricle, and 0.8 cm anterior to the \nright ventricle. The effusion is echo dense, c/\nw blood, inflammation or other cellular elements. There are no \n2D or Doppler echocardiographic\nevidence of tamponade.\nIMPRESSION: Small to moderate, circumferential pericardial \neffusion without\nechocardiographic evidence of tamponade. Biatrial enlargement. \nMild right ventricular\nhypokinesis. Preserved left ventricular systolic function.\n\nCardiac Catheterization: \nCoronary Description\nThe coronary circulation is right dominant.\nLM: The Left Main, arising from the left cusp, is a large \ncaliber vessel. This vessel bifurcates into the\nLeft Anterior Descending and Left Circumflex systems.\nLAD: The Left Anterior Descending artery, which arises from the \nLM, is a large caliber vessel. There is\nsevere calcification in the proximal segment. There is a 99% \nstenosis in the proximal segment.\nThe ___ Diagonal, arising from the proximal segment, is a very \nsmall caliber vessel. There is a 100%\nstenosis in the proximal segment.\nThe ___ Diagonal, arising from the proximal segment, is a medium \ncaliber vessel.\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel.\nThe ___ Obtuse Marginal, arising from the proximal segment, is a \nmedium caliber vessel.\nThe ___ Obtuse Marginal, arising from the mid segment, is a \nmedium caliber vessel.\nRCA: The Right Coronary Artery, arising from the right cusp, is \na large caliber vessel.\nThe Right Posterior Descending Artery, arising from the distal \nsegment, is a medium caliber vessel.\nThe Right Posterolateral Artery, arising from the distal \nsegment, is a medium caliber vessel.\nBypass Grafts:\nLIMA: A medium caliber arterial LIMA graft connects to the \nproximal segment of the LAD. This graft\nis patent.\nName: ___ MRN: ___ Study Date: ___ \n11:23:35 p. ___\nSVG: A medium caliber saphenous vein graft connects to the \nproximal segment of the ___ Diag. This\ngraft is patent.\nInterventional Details\nComplications: There were no clinically significant \ncomplications.\nFindings\n• Elevated left heart filling pressure.\n• Single vessel coronary artery disease.\n• Patent LIMA-LAD and SVG-D1.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ male with paroxysmal Atrial\nfibrillation (on apixaban), CHFpEF, CAD s/p CABG ___, AS s/p\nAVR, recurrent pericardial effusions s/p pericardiocentesis\n(___) f/b pericardial window (___), and diabetes mellitus,\nwho presents with chest discomofort, dyspnea, and dizziness.\n\nACUTE/ACTIVE ISSUES:\n====================\n#Chest Pain \n#CAD s/p CABG ___\nUnderwent cardiac catheterization as he is about 3 months out \nfrom CABG with chest pain. Catheterization showed patent grafts. \nLow suspicion for PE as he was not tachycardic and on apixaban. \nTTE was performed which revealed moderate pericardial effusion \nwithout tamponade and pt is status post window on recent \nadmission. Patient ambulated about the floor without return of \nsymptoms. Rosuvastatin was increased from 20 mg to 40 mg. He \nwill continue on aspirin and metoprolol. \n\n#CHFpEF. No e/o decompensation on exam. No need for active\ndiuresis. Not on maintenance diuretic dose at home. \n\n#Recurrent pericardial effusion s/p pericardial window. \nTTE with moderate pericardial effusion without evidence of\ntamponade. He is continuing a 3 month course of colchicine which \nwill stop in early ___.\n\nChronic Problems: \n=================\n#Aortic Stenosis s/p AVR: continue metoprolol\n#Paroxysmal Afib: continue metoprolol and apixaban \n\nTransitional Issues: \n===================\n[ ] Please ensure resolution of chest pain, consider further \nworkup for non cardiac chest pain \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. FoLIC Acid 1 mg PO DAILY \n2. Ranitidine 150 mg PO DAILY \n3. Rosuvastatin Calcium 20 mg PO QPM \n4. Pantoprazole 40 mg PO Q24H \n5. Amaryl (glimepiride) 4 mg oral BID \n6. Aspirin 81 mg PO DAILY \n7. Colchicine 0.6 mg PO BID \n8. GuaiFENesin ER 1200 mg PO Q12H:PRN cough \n9. Losartan Potassium 25 mg PO DAILY \n10. MetFORMIN (Glucophage) 500 mg PO BID \n11. Thiamine 100 mg PO DAILY \n12. Acetaminophen 1000 mg PO Q6H \n13. Apixaban 5 mg PO BID \n14. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n15. Senna 17.2 mg PO QHS \n16. Metoprolol Tartrate 25 mg PO BID \n\n \nDischarge Medications:\n1. Rosuvastatin Calcium 40 mg PO QPM \nRX *rosuvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n2. Acetaminophen 1000 mg PO Q6H \n3. Amaryl (glimepiride) 4 mg oral BID \n4. Apixaban 5 mg PO BID \n5. Aspirin 81 mg PO DAILY \n6. Colchicine 0.6 mg PO BID \n7. FoLIC Acid 1 mg PO DAILY \n8. GuaiFENesin ER 1200 mg PO Q12H:PRN cough \n9. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n10. Losartan Potassium 25 mg PO DAILY \n11. MetFORMIN (Glucophage) 500 mg PO BID \n12. Metoprolol Tartrate 25 mg PO BID \n13. Pantoprazole 40 mg PO Q24H \n14. Ranitidine 150 mg PO DAILY \n15. Senna 17.2 mg PO QHS \n16. Thiamine 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNon-Cardiac Chest Pain\n\nSecondary Diagnoses \n-Coronary Artery Disease post Coronary Artery Bypass Graft\n-Pericardial Effusion \n-Hypertension \n-Diabetes Mellitus II \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 being involved in your care while you were \nadmitted at ___. \n\nWhy were you admitted to the hospital?\n-You were having chest pain. \n\nWhat happened while you were in the hospital? \n-We performed several tests to evaluate the cause of your \nsymptoms including a catheterization. The catheterization was \nnegative for blockages in the blood vessels around your heart. \n\nWhat should you do when you go home? \n-Continue taking all of your medications as prescribed. \n-Keep all of your appointments with you clinicians. \n\nSincerely, \nYour ___ Team. \n \nFollowup Instructions:\n___\n" ]

[ "R0789", "I5030", "I313", "R0609", "I480", "I110", "I4430", "R008", "I2510", "E119", "Z951", "Z952", "E785", "M1A9XX0", "Z7901", "Z87891", "Z7289", "K219" ]

[ "R0789: Other chest pain", "I5030: Unspecified diastolic (congestive) heart failure", "I313: Pericardial effusion (noninflammatory)", "R0609: Other forms of dyspnea", "I480: Paroxysmal atrial fibrillation", "I110: Hypertensive heart disease with heart failure", "I4430: Unspecified atrioventricular block", "R008: Other abnormalities of heart beat", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E119: Type 2 diabetes mellitus without complications", "Z951: Presence of aortocoronary bypass graft", "Z952: Presence of prosthetic heart valve", "E785: Hyperlipidemia, unspecified", "M1A9XX0: Chronic gout, unspecified, without tophus (tophi)", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "Z7289: Other problems related to lifestyle", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "I480", "I110", "I2510", "E119", "Z951", "E785", "Z7901", "Z87891", "K219" ]

[]

[ " \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:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\n___ - Coronary artery bypass grafting x2 with the left \ninternal mammary artery to left anterior descending artery and \nreverse saphenous vein graft to diagonal artery. Aortic valve \nreplacement with a 23 ___ Ease pericardial tissue \nvalve.\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of alcohol \nabuse, aortic stenosis, hyperlipidemia, and hypertension. He \npresented to ___ with worsening shortness of \nbreath on exertion. He ruled in for non-ST elevation myocardial \ninfarction. An echocardiogram demonstrated moderate aortic \nstenosis with normal ejection fraction. He underwent a coronary \nangiogram which revealed two-vessel coronary artery disease. He \nwas transferred to ___ for surgical evaluation. \n \nPast Medical History:\nAlcohol Abuse\nAortic Stenosis\nDiabetes Mellitus Type II\nGout\nHyperlipidemia\nHypertension\n \nSocial History:\n___\nFamily History:\nNo family history of heart disease\n \nPhysical Exam:\nBP: 183/94 HR: 90 RR: 18 O2 Sat: 96% RA\n\nGeneral: A&O, NAD\nSkin: Dry [] intact []\nHEENT: PERRLA [] EOMI [x]\nNeck: Supple [x] Full ROM []\nChest: Lungs (B)scattered rhonchi\nHeart: RRR [x] Irregular [] Murmur [x] grade ___ \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+[x], umbilicus bruits noted\nExtremities: Warm [x], well-perfused [] Edema none\nVaricosities: None [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: Left:\nDP Right: Left:\n___ Right: Left:\nRadial Right: 2+ Left:2+\n\nCarotid Bruit: (B), Right > Left; Umbilicus bruit appreciated\n\nDischarge Exam:\n\nTemp: 98.0 (Tm 98.0), BP: 136/78 (122-165/55-86), HR: 66\n(54-67), RR: 18 (___), O2 sat: 95% (95-99), O2 delivery: Ra\nwgt:92kg\n\nGeneral: NAD [x] \nNeurological: A/O x3 [x] non-focal [x] \nHEENT: PEERL [] \nCardiovascular: RRR [x] Irregular [] Murmur [] Rub [] \nRespiratory: (B)rhonchi noted, No resp distress [x], mostly NPC\nnoted\nGI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]\nExtremities: \nRight Upper extremity Warm [] Edema \nLeft Upper extremity Warm [] Edema \nRight Lower extremity Warm [x] Edema trace\nLeft Lower extremity Warm [x] Edema trace\nPulses:\nDP Right: Left:\n___ Right: Left:\nRadial Right: Left:\nSkin/Wounds: Dry [] intact []\nSternal: CDI [x] no erythema or drainage [x]\n Sternum stable [x] Prevena []\nLower extremity: Right [] Left [] CDI []\nUpper extremity: Right [] Left [] CDI []\nOther:\n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 09:29PM BLOOD WBC-7.4 RBC-5.10 Hgb-10.7* Hct-34.2* \nMCV-67* MCH-21.0* MCHC-31.3* RDW-15.5 RDWSD-36.1 Plt ___\n___ 09:29PM BLOOD ___ PTT-40.3* ___\n___ 09:29PM BLOOD Glucose-169* UreaN-12 Creat-0.7 Na-140 \nK-4.0 Cl-103 HCO3-23 AnGap-14\n___ 09:29PM BLOOD ALT-31 AST-27 LD(LDH)-180 AlkPhos-57 \nAmylase-55 TotBili-0.6\n___ 09:29PM BLOOD Albumin-4.4 Mg-1.8\n___ 09:29PM BLOOD %HbA1c-6.9* eAG-151*\n.\nTransthoracic Echocardiogram ___\nThe left atrial volume index is SEVERELY increased. The right \natrium is mildly enlarged. There is mild symmetric left \nventricular hypertrophy with a normal cavity size. There is \nnormal regional left ventricular systolic function. Overall left \nventricular systolic function is low normal. The visually \nestimated left ventricular ejection fraction is 50-55%. There is \nno resting left ventricular outflow tract gradient. Tissue \nDoppler suggests an increased left ventricular filling pressure\n(PCWP greater than 18 mmHg). Normal right ventricular cavity \nsize with normal free wall motion. The aortic sinus diameter is \nnormal for gender with mildly dilated ascending aorta. The \naortic arch diameter is normal. The aortic valve leaflets are \nseverely thickened. There is SEVERE aortic valve stenosis (valve \narea 1.0 cm2 or less). There is mild [1+] aortic regurgitation. \nThe mitral valve leaflets are mildly thickened with no mitral \nvalve prolapse. There is moderate mitral annular calcification. \nThere is mild [1+] mitral regurgitation. Due to acoustic \nshadowing, the severity of mitral regurgitation could be \nUNDERestimated. The pulmonic valve leaflets are normal. The \ntricuspid valve leaflets appear structurally normal. There is \nmild [1+] tricuspid regurgitation. There is mild pulmonary \nartery systolic hypertension. There is a trivial pericardial \neffusion.\nIMPRESSION: Severe calcific aortic stenosis. Symmetric LVH with \nlow-normal left ventricular systolic function. Mild pulmonary \nhypertension.\n.\nCarotid Ultrasound ___\nSignificant atherosclerotic/calcified plaque bilaterally.\n< 40% stenosis of the right internal carotid artery.\n< 40% stenosis of the left internal carotid artery.\n.\nTransesophageal Echocardiogram ___\nPRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm.\nLeft Atrium (LA)/Pulmonary Veins: Normal LA size.\nRight Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): \nNormal interatrial septum.\nLeft Ventricle (LV): Normal cavity size. Normal regional & \nglobal systolic function Normal ejection fraction.\nRight Ventricle (RV): Normal cavity size. Normal free wall \nmotion.\nAorta: Normal sinus diameter. Normal ascending diameter. Normal \narch diameter. Normal descending aorta diameter. Simple \ndescending atheroma.\nAortic Valve: Severely thickened leaflets. SEVERE (less than or \nequal 1.0cm2) stenosis. Trace regurgitation.\nMitral Valve: Normal leaflets. Mild leaflet calcification. No \nstenosis. Mild annular calcification. No regurgitation.\nTricuspid Valve: Trace regurgitation.\nPericardium: No effusion. Normal pericardial thickness.\nMiscellaneous: No pleural effusions.\nPOST-OP STATE: The post-bypass TEE was performed at. Atrial \npaced rhythm.\nLeft Ventricle: Similar to preoperative findings. Similar \nregional function.\nAorta: No change from pre-op state.\nAortic Valve: Bioprosthetic valve. Normal gradient for \nprosthesis. Normal gradient for prosthesis. No regurgitation.\nMitral Valve: No change in mitral valve morphology from \npreoperative state. Similar gradient to preoperative state. No \nchange in valvular regurgitation from preoperative state.\nPericardium: No effusion.\n\n___ Abd US\n1. Echogenic liver may be due to steatosis, however apparent \nslight nodular \ncontour of the liver raises concern for more advanced liver \ndisease. \n2. Mild splenomegaly, small amount of ascites, and right pleural \neffusion. \n3. Cholelithiasis and nonspecific gallbladder wall edema, may be \ndue to \nhepatic dysfunction/third spacing, however acute cholecystitis \ncannot be \nexcluded. Nuclear medicine hepatobiliary scan is recommended \nfor further \nevaluation. \n \nRECOMMENDATION(S): \n1. Nuclear medicine hepatobiliary scan. \n2. Radiological evidence of fatty liver does not exclude \ncirrhosis or \nsignificant liver fibrosis which could be further evaluated by \n___. \nThis can be requested via the ___ (FibroScan) or the \nRadiology \nDepartment with either MR ___ or US ___, in \nconjunction with \na GI/Hepatology consultation* \n* ___ et al. The diagnosis and management of nonalcoholic \nfatty liver \ndisease: Practice guidance from the ___ Association for the \nStudy of \nLiver Diseases. Hepatology ___ 67(1):328-357 \n \n___ PA&lat\n \nSlightly increased aeration of left lower lung. Improved left \nlower lobe \natelectasis and small left pleural effusion. Slightly improved \ntrace right \npleural effusion. Resolved mild pulmonary edema. Residual mild \npulmonary \nvascular congestion. \n\n___ 05:41AM BLOOD WBC-8.9 RBC-3.90* Hgb-8.5* Hct-28.3* \nMCV-73* MCH-21.8* MCHC-30.0* RDW-20.8* RDWSD-49.8* Plt ___\n___ 05:41AM BLOOD ___\n___ 05:41AM BLOOD Glucose-73 UreaN-25* Creat-1.0 Na-136 \nK-4.6 Cl-97 HCO3-24 AnGap-15\n \nBrief Hospital Course:\nHe was admitted on ___ and underwent routine preoperative \ntesting and evaluation. A transthoracic echocardiogram \ndemonstrated severe aortic stenosis. A carotid ultrasound \nrevealed moderate bilateral plaque but stenosis of < 40% \nstenosis. He remained stable and was taken to the operating room \non ___. He underwent coronary artery bypass grafting x 2 \nand aortic valve replacement. Please see operative note for full \ndetails. He tolerated the procedure well and was transferred to \nthe CVICU in stable condition for recovery and invasive \nmonitoring. \n \nHe weaned from sedation, awoke neurologically intact and was \nextubated on POD 1. He was weaned from inotropic and vasopressor \nsupport. Beta blocker was initiated and he was diuresed toward \nhis preoperative weight. He was noted to have diffuse ST \nelevation and mild gout and was started on colchicine. Patient \ntransferred to the floor. While recovering on the floor he was \nweak and deconditioned, slow to progress. He developed rate \ncontrol afib. On POD 4 he had significant hyperglycemia with \nlactate 4.8 and peak creatinine 1.7, and returned to the CVICU \nfor insulin gtt and medical management. He transitioned to \nlantus and Humalog sliding scale. Oral diabetic agents and \ncolchicine were held due to mild ___. During his ICU stay he \nalso developed leukocytosis and culture data was negative. \nPatient had a persistent cough with thick secretions that \neventually resolved into a dry persistent cough.\nCXR was not concerning for pneumonia. Patient also has a known \nsignificant alcohol intake. As part of his fever work-up he \nunderwent RUQ US and this was significant for fatty liver \nconcerns for cirrhosis or significant liver fibrosis. He was \nseen by hepatology and medications were adjusted, amiodarone for \nafib was discontinued. LFTs were initially elevated but are \ncurrently downtrending. He will need to follow-up with \nhepatology as an outpatient Dr. ___. Lopressor was optimized \nand he was in and out of afib and apixaban was initiated for \nanticoagulation. He remained hemodynamically stable and was \ntransferred back to the floor on POD 9. All surgical tubes and \nwires were remove without incident. He was evaluated by the \nphysical therapy service for assistance with strength and \nmobility. By the time of discharge on POD 11. He was ambulating \nfreely, his wounds were healing, and pain was controlled with \noral analgesics. He continued to have a mild dry cough, with \nstable sternum. He was discharged to home in good condition \nwith appropriate follow up instructions.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. MetFORMIN (Glucophage) 500 mg PO BID \n3. glimepiride 4 mg oral BID \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Januvia (SITagliptin) 100 mg oral DAILY\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*1 \n2. Atorvastatin 20 mg PO QPM \nwill need to increase to 40mg daily once off amiodarone \nRX *atorvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*1 \n3. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n4. Furosemide 40 mg PO DAILY Duration: 10 Days \nRX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth once a day \nDisp #*10 Tablet Refills:*0 \n5. GuaiFENesin ER 1200 mg PO Q12H \nRX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp \n#*20 Tablet Refills:*0 \n6. Lactulose 30 mL PO DAILY \nRX *lactulose 20 gram/30 mL 1 ml by mouth once a day Disp #*1 \nBottle Refills:*0 \n7. Lisinopril 2.5 mg PO DAILY \nRX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n8. Metoprolol Tartrate 37.5 mg PO TID \nRX *metoprolol tartrate 37.5 mg 1 tablet(s) by mouth three times \na day Disp #*90 Tablet Refills:*1 \n9. Ranitidine 150 mg PO DAILY Duration: 1 Month \nRX *ranitidine HCl [Zantac Maximum Strength] 150 mg 1 tablet(s) \nby mouth once a day Disp #*30 Tablet Refills:*0 \n10. Senna 17.2 mg PO QHS \nRX *sennosides [senna] 8.6 mg 2 tablet(s) by mouth at bedtime \nDisp #*30 Tablet Refills:*0 \n11. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n12. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \nRX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth four times a \nday Disp #*60 Tablet Refills:*0 \n13. Aspirin 81 mg PO DAILY \n14. glimepiride 4 mg oral BID \n15. Januvia (SITagliptin) 100 mg oral DAILY \n16. MetFORMIN (Glucophage) 500 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAortic Stenosis s/p Aortic valve replacement\nCoronary Artery Disease s/p coronary artery bypass graft x 2\n\nSecondary Diagnosis:\nAlcohol Abuse\nDiabetes Mellitus Type II\nGout\nHyperlipidemia\nHypertension\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\nEdema: trace\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\nPlease - NO lotion, cream, powder or ointment to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics\nClearance to drive will be discussed at follow up appointment \nwith surgeon\nNo lifting more than 10 pounds for 10 weeks\nEncourage full shoulder range of motion, unless otherwise \nspecified\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I214", "N179", "D62", "E871", "E872", "J9811", "I309", "I2510", "M109", "D696", "F1010", "K700", "E785", "I10", "I083", "I672", "I4891", "E1165", "D72829", "Z87891" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "N179: Acute kidney failure, unspecified", "D62: Acute posthemorrhagic anemia", "E871: Hypo-osmolality and hyponatremia", "E872: Acidosis", "J9811: Atelectasis", "I309: Acute pericarditis, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M109: Gout, unspecified", "D696: Thrombocytopenia, unspecified", "F1010: Alcohol abuse, uncomplicated", "K700: Alcoholic fatty liver", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I672: Cerebral atherosclerosis", "I4891: Unspecified atrial fibrillation", "E1165: Type 2 diabetes mellitus with hyperglycemia", "D72829: Elevated white blood cell count, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "D62", "E871", "E872", "I2510", "M109", "D696", "E785", "I10", "I4891", "E1165", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest Pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old man with PMH notable for CAD s/p CABG, BMS and DES \nas well as DM and HTN. ___ has had four admissions since \n___ with complaints of chest pain. He underwent a PCI to \nOM1 with DES in ___. He\nunderwent angiography again on ___ which showed stable\nnonobstructive CAD with evidence of diffuse microvascular \ndisease. At discharge ___, added amlodipine, increased \nisosorbide from 15mg to 30mg and added protonix. He again \npresents with c/o CP. Per EMS report, was distraught and crying \nin the ambulance. He was admitted through the ED to rule out for \nMI. \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS\n- Diabetes (+)\n- Hypertension (+)\n- Dyslipidemia (+)\n\n2. CARDIAC HISTORY\n- CABG: ___\n- PERCUTANEOUS CORONARY INTERVENTIONS: ___ (BMS to proximal\nanomalous RCA), ___\n- PACING/ICD: None\n\n3. OTHER PAST MEDICAL HISTORY\n- Osteoarthritis\n- Constipation\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death.\n \nPhysical Exam:\nAdmission exam:\nPhysical Examination:\nGeneral: chronically ill appearing man looking older than stated\nage sitting up in bed in NAD\nNeuro: alert and oriented w/o focal deficit, speech clear and\ncoherent\nCardiac: RRR, no M/R/G\nLungs: diminished bilat, breathing regular and unlabored\nAbd: +BS, soft NT ND\nExtremities: Warm and dry w/o edema, +2 palpable peripheral\npulses. Bilateral knees with long scars because of BKA. No\nobvious swelling or tenderness to palpation.\nAdmission weight:109.2 kg\n\nDischarge exam:\nVS: 97.9, 112/73-118/73, HR 64-98, RR 16, 02 sat 96% RA\nWEIGHT: 108.9 kg\nI/O: 120/1000cc\nTELEMETRY: SR 70's, no alarms per telemetry review\nPhysical Examination:\nGen: Patient is comfortable, 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+.\nAbd: Rounded, soft, non-tender.\nDiagnostic studies:\nCXR ___:\nNo focal consolidations. No pneumothorax. \n\n \n\n \nPertinent Results:\n___ 07:27PM cTropnT-<0.01\n___ 11:11AM cTropnT-<0.01\n___ 05:00AM cTropnT-<0.01\n___ 04:45AM cTropnT-<0.01 proBNP-47\n___ 11:11AM GLUCOSE-165* UREA N-10 CREAT-0.8 SODIUM-141 \nPOTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13\n \nBrief Hospital Course:\nMr. ___ is an ___ gentleman with a history of coronary \nartery disease status post CABG and multiple PCI's, \nhypertension, hyperlipidemia, type 2 diabetes who has had \nmultiple admissions for chest pain in recent months. He resides \nat the ___ in ___, \n___ due to chronic disability and being \nwheelchair-bound at this time. His last cardiac catheterization \nwas in ___ showing stable CAD and chest pain \nthought to be secondary to micro vascular disease. On ___, he was residing at the rehab when he was anxious and upset \nand reports a delay in response to complaints of chest pain. He \nthen called ___ himself and was brought to the emergency \ndepartment by EMS. His troponins were negative x5 with no new \nEKG changes. We increased his metoprolol succinate to 50 mg \ndaily as his heart rate was initially in the ___, which he has \ntolerated well. On day of discharge his heart rate was 60-80. \nWe did not increase isosorbide mononitrate due to blood \npressure; he has been running SBP 112-118. That might be a \nconsideration in the future if his blood pressure is higher and \nhe tolerates the increased dose of beta-blocker. We also \nconsidered introducing Ranexa but felt he may benefit from \nmaximizing beta blockade (goal HR 60 bpm as BP tolerates) and \nhaving his anxiety managed first and see if that helps decrease \nchest pain. He had a few transient episodes of chest pain in \nthe setting of anxiety and in the absence of EKG changes while \nadmitted. He was given Ativan 0.5 mg on 2 separate occasions \nwhich was very effective and chest pain resolved without any \nfurther intervention. He admits to high anxiety and stress \nbeing a trigger for his multiple episodes of chest pain \nrequiring hospital admission. He is anxious about his \ndisability, being wheelchair-bound, and needing knee surgery \nwhich he reportedly has not been cleared to undergo. He is \nwilling to follow-up with his PCP and willing to trial \nmedication in attempt to better manage his anxiety which seems \nto be consistently a trigger for these chest pain episodes. For \nnow, we will prescribe Ativan 0.5 mg up to twice daily for \nanxiety. He was instructed not to drive while taking this \nmedication. (He is currently wheelchair-bound and in a long-term \ncare facility so this should not impact him at this time.) We \nrequested that the rehab make a hospital follow-up appointment \nwith his PCP ___ 1 week of discharge to address ongoing \nanxiety and stress. We are hopeful that managing this will \ndecrease his episodes of chest pain. He may also benefit from \nadditional support services such as social work. For cardiac \nmedications, he will continue atorvastatin, Plavix, aspirin, \nisosorbide, metoprolol succinate, amlodipine and as needed \nnitro. He may benefit from an ACE given prior NSTEMI with \nhypertension and diabetes, though we will not start it now given \nrecent reported orthostasis prior to this hospitalization and \nsoft BP. He has a follow-up appointment with Dr. ___ who is \nhis primary cardiologist in ___ and continues to be followed \nby orthopedics for his ongoing knee issue. Also to note, there \nwas some report of pyuria prior to admission and reportedly was \nordered for Cipro at the rehab but never took it. A urine \nculture done here this admission was negative for growth . He \nwas afebrile and had no urinary complaints and did not get any \nantibiotics during this admission. He is voiding without \ndifficulty. We will discharge him back to rehab today via chair \ncar.\n\n>30 minutes spent on discharge planning/coordination of care.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Gabapentin 300 mg PO TID \n3. Metoprolol Succinate XL 25 mg PO DAILY \n4. MetFORMIN (Glucophage) 1000 mg PO BID \n5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n6. Docusate Sodium 100 mg PO BID \n7. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third Line \n\n8. amLODIPine 5 mg PO DAILY \n9. Atorvastatin 80 mg PO QPM \n10. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID \n11. Glargine 18 Units Bedtime\n12. Senna 17.2 mg PO QHS:PRN Constipation - First Line \n13. Multivitamins 1 TAB PO DAILY \n14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n16. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n17. melatonin 3 mg oral HS \n18. Clopidogrel 75 mg PO DAILY \n19. Pantoprazole 40 mg PO Q24H \n20. Aspirin 81 mg PO DAILY \n21. Tamsulosin 0.4 mg PO QHS \n22. GlipiZIDE 10 mg PO BID \n\n \nDischarge Medications:\n1. LORazepam 0.5 mg PO Q12H:PRN anxiety \nRX *lorazepam 0.5 mg 1 tablet by mouth every twelve (12) hours \nDisp #*30 Tablet Refills:*0 \n2. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n4. amLODIPine 5 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n8. Clopidogrel 75 mg PO DAILY \n9. Docusate Sodium 100 mg PO BID \n10. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID \n11. Gabapentin 300 mg PO TID \n12. GlipiZIDE 10 mg PO BID \n13. Glargine 18 Units Bedtime \n14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n15. melatonin 3 mg oral HS \n16. MetFORMIN (Glucophage) 1000 mg PO BID \n17. Multivitamins 1 TAB PO DAILY \n18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n19. Pantoprazole 40 mg PO Q24H \n20. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third \nLine \n21. Senna 17.2 mg PO QHS:PRN Constipation - First Line \n22. Tamsulosin 0.4 mg PO QHS \n23. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nChest pain, coronary microvascular disease\n\n \nDischarge Condition:\nSee discharge summary\n\n \nDischarge Instructions:\nYou were admitted to ___ with chest pain. You EKG and blood \nwork showed that you did not have a heart attack. You had a \nrecent cardiac catheterization in ___ during prior \nadmission which showed stable coronary arteries. It is felt that \nyou have \"microvascular\" disease which involves the very small \nbranches off the main coronary arteries. We have optimized your \nmedical management to treat this and attempt to prevent chest \npain. There also appears to be a component of stress/anxiety \nwhich precipitates the chest pain episodes. You were given a \ndose of Ativan during one of your episodes here at the hospital \nwhich worked well to decrease the stress and the chest pain \nresolved at that time without further intervention. We request \nthat you see your PCP within one week of discharge in order to \ndiscuss medication options and perhaps start on something daily \nto help decrease your baseline anxiety. If your stress/anxiety \nwas better managed, it may decrease your episodes of chest pain. \nMeanwhile we have prescribed Ativan/Lorazepam 0.5mg by mouth to \ntake up to twice daily as needed for anxiety. PLEASE ONLY TAKE \nWHEN NEEDED TO MANAGE ACUTE ANXIETY. YOU CAN NOT DRIVE WHILE \nTAKING THIS MEDICATION. \n\nYou should continue your current medications with the following \nchanges:\n1. Increase Metoprolol Succinate to 50mg daily\n2. Start Ativan (Lorazepam) 0.5mg every 12 hours AS NEEDED for \nanxiety. \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\nYou will follow-up with PCP within one week of hospital \ndischarge. We have asked the rehab to scheduled this appointment \nand necessary transportation to and from. \n\nYou will follow-up with your cardiologist as scheduled below. \n \n It has been a pleasure to have participated in your care and we \nwish you the best with your health! \n Your ___ Cardiac Care Team \n\n \n \nFollowup Instructions:\n___\n" ]

[ "I25110", "Z955", "I10", "F419", "E785", "E119", "Z993", "M170", "K5900", "Z7902", "Z794", "Z951" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z993: Dependence on wheelchair", "M170: Bilateral primary osteoarthritis of knee", "K5900: Constipation, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z794: Long term (current) use of insulin", "Z951: Presence of aortocoronary bypass graft" ]

[ "Z955", "I10", "F419", "E785", "E119", "K5900", "Z7902", "Z794", "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:\nchest pain\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of CAD s/p CABG,\nType II diabetes, hypertension, and chronic knee pain, who\npresents from rehab with chest pain. \n\nPatient states at rehab he had to use the bathroom and called \nfor\nassistance, but nobody would come to help him. He then called\n___. EMS helped him to the restroom. During this interaction he\ndeveloped sudden-onset moderate chest pain, which he describes \nas\na left-sided heaviness, that then radiated to the right side.\nThis is in the setting of coronary artery disease and is typical\nfor his episodes of angina. He was therefore brought to the ED. \nDenies any associated shortness of breath, cough, fever,\ndiaphoresis, nausea, vomiting. Denies abdominal pain. Denies\ndizziness or lightheadedness. \n\nPatient states that his typical chest pain will start on the \nleft\nside. He will often try SL nitro at this point, which most often\nrelieves the pain. However, at times it does not and radiates to\nthe right side and will become squeezing. He states that this\nhappened a lot in ___ and ___, but has been doing\nbetter. He feels that it is triggered by stress.\n\nRegarding his UTI, he notes that had he has had two urinary \ntract\ninfections this past month. The one he is being treated for now\nhe did not have any symptoms, but it was found on testing. \n\nRegarding his knee pain, he notes that he both knees hurt,\nespecially the left, which will buckle sometimes, causing him to\nfall. This was worse after knee replacements ___ years ago. Uses \na\nwheelchair. He has discussed an operation to help repair his\nknees, but states that his cardiologist doesn't feel that a\nsurgery would be safe until can go a year without a cardiac\nevent. \n\nHe states that being in rehab has been very difficult. He notes\nthat he is there with many people who are much older than him,\nand this has taken a mental toll. He has seen many things that\nhave made him uncomfortable and feel that the care he gets is\noften very poor. He also struggles with the idea of being stuck\nin a wheelchair at a rehab at such a young age. \n\nHe also reports that he used to see Dr ___, who is now at\n___. Would like to see her again, previously limited by\ninsurance. \n\nOn review of records, patient has had around five admissions\nsince ___ with chest pain, and several additional ED\nvisits. He underwent a PCI to OM1 with DES in ___. \nHe underwent angiography again on ___ which showed stable\nnonobstructive CAD with evidence of diffuse microvascular\ndisease. He most recently underwent a nuclear stress on ___\nwhich was normal. \n\nIn the ED:\n\nInitial vital signs were notable for: T 97, HR 95, BP 133/86, RR\n20, 97% RA \n \nExam notable for: well-appearing on exam. He has tenderness to\npalpation of the anterior chest wall. He is breathing \ncomfortably\non room air and lungs are clear to auscultation. Radial pulses\nintact. Abdomen soft and nontender.\n\nLabs were notable for:\n- CBC: WBC 4.8, hgb 12.9, plt 354\n\n- Lytes:\n139 / 103 / 11 AGap=12 \n-------------- 242 \n4.4 \\ 24 \\ 0.8 \n \n- trop <0.01 x2\n\nStudies performed include: CXR with no acute intrathoracic\nprocess. \n\nPatient was given:\n___ 06:40 IV Ketorolac 15 mg\n___ 08:02 PO/NG amLODIPine 5 mg \n___ 08:02 PO/NG Clopidogrel 75 mg \n___ 08:02 PO/NG Gabapentin 300 mg \n___ 08:02 PO Isosorbide Mononitrate (Extended Release) 30\nmg \n___ 08:02 PO Metoprolol Succinate XL 25 mg \n___ 08:02 PO Pantoprazole 40 mg \n___ 08:03 SC Insulin 2 Units \n___ 08:04 PO/NG Aspirin 81 mg \n___ 08:04 PO TraMADol 75 mg \n___ 15:19 PO/NG Gabapentin 300 mg \n___ 17:08 SC Insulin 6 Units \n___ 18:10 PO TraMADol 75 mg \n\nPlan was initially for patient to return to rehab. However, he\ndeclined to go with plan to go to Motel. After multiple\ndiscussions with ___, CM, SW, plan to admit patient to medicine\nfor further physical therapy and discuss returning to rehab.\nPatient amenable with this plan.\n\nVitals on transfer: T 98.3, HR 81, BP 134/70, RR 18, 95% RA \n\nUpon arrival to the floor, patient recounts history as above. He\nhas no chest pain now.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n \nPast Medical History:\n1. CARDIAC RISK FACTORS\n- Diabetes (+)\n- Hypertension (+)\n- Dyslipidemia (+)\n\n2. CARDIAC HISTORY\n- CABG: ___\n- PERCUTANEOUS CORONARY INTERVENTIONS: ___ (BMS to proximal\nanomalous RCA), ___\n- PACING/ICD: None\n\n3. OTHER PAST MEDICAL HISTORY\n- Osteoarthritis\n- Constipation\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death.\n \nPhysical Exam:\nADMISSION EXAM:\n====================\nVITALS: T 98.2, HR 79, BP 120/70, RR 18, 99% RA \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities. Lower extremities with\nknee pain to flexion and extension \nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\n====================\nGENERAL: Alert and in no apparent distress, sitting up in CHAIR\nEYES: Anicteric, pupils equally round\nCV: RRR no m/r/g\nLUNGS: CTAB\nABD: obese, normal bowel sounds.\nNEURO: Alert, oriented, face symmetric, speech fluent\nPSYCH: Calm\n \nPertinent Results:\nADMISSION LABS:\n\n___ 12:14AM BLOOD WBC-4.8 RBC-4.50* Hgb-12.9* Hct-40.8 \nMCV-91 MCH-28.7 MCHC-31.6* RDW-12.4 RDWSD-41.1 Plt ___\n___ 12:14AM BLOOD Neuts-53.8 ___ Monos-7.6 Eos-3.1 \nBaso-1.0 Im ___ AbsNeut-2.60 AbsLymp-1.66 AbsMono-0.37 \nAbsEos-0.15 AbsBaso-0.05\n___ 12:14AM BLOOD Glucose-242* UreaN-11 Creat-0.8 Na-139 \nK-4.4 Cl-103 HCO3-24 AnGap-12\n___ 12:14AM BLOOD cTropnT-<0.01\n___ 03:24AM BLOOD cTropnT-<0.01\n___ 03:24AM BLOOD cTropnT-<0.01\n\n======================================\n\nEXAMINATION: CHEST (PA AND LAT)\n \nINDICATION: History: ___ with chest pain// eval pna\n \nCOMPARISON: Chest radiograph ___\n \nFINDINGS: \n \nAP and lateral views of the chest.\n \nMid sternotomy wires are again seen and appear similarly \npositioned. Low lung\nvolumes bilaterally, particularly on the right where there is \nunstable right\nhemidiaphragm elevation. No areas of focal consolidation, \npulmonary edema,\npneumothorax or pericardial effusion. Cardiac size is normal.\n \nIMPRESSION: \n \nNo acute intrathoracic process.\n \nBrief Hospital Course:\nMr. ___ is a ___ male with history of CAD s/p CABG, \ntype II diabetes, hypertension, and chronic knee pain, who \npresents from rehab with recurrent chest pain with negative \nworkup for acute cardiac cause, admitted as declined to return \nto nursing facility. Patient was ultimately discharged to a \nhotel as patient refused to return to prior SAR. \n\n# Coronary artery disease/Microvascular coronary disease:\n# Chest Pain:\n# Chronic stable angina:\nPatient with significant history of CAD and what is felt to be \nangina from microvascular disease. Multiple troponins negative \nand EKG without ischemic changes. No chest pain since arrival, \nand extensive recent workup, including nuclear stress last \nmonth. This was thought to be exacerbated by anxiety. patient \nalso complained of pleuritic chest pain and lightheadedness and \nunderwent a CT chest that was negative. \n\n# Osteoarthritis:\n# Knee pain:\nPatient is unable to ambulate as knees buckle, which has \ncurrently left him wheelchair-bound and previously in rehab. \nThis is reportedly due to prior failed knee surgery. Plan for \neventual surgery, though first would need to be improved from a \ncardiac standpoint. Discharged with wheelchair and bedside \ncommode. \n\n#UTI \n-previously treated with cefpodoxime for a Klebsiella UTI, \npatient unaware if he received the antibiotics as he was in \nrehab. UA suggestive of infection. Culture pending at discharge. \nGiven Cipro for 10day course. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lidocaine 5% Patch 1 PTCH TD QAM \n2. LORazepam 0.5 mg PO BID:PRN anxiety \n3. Clopidogrel 75 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. amLODIPine 5 mg PO DAILY \n8. Pantoprazole 40 mg PO Q24H \n9. melatonin 3 mg oral QHS \n10. Tamsulosin 0.4 mg PO QHS \n11. Glargine 18 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n13. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third \nLine \n14. Gabapentin 300 mg PO TID \n15. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n16. GlipiZIDE 10 mg PO BID \n17. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n18. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second \nLine \n19. Cefpodoxime Proxetil 100 mg PO Q12H \n20. MetFORMIN (Glucophage) 1000 mg PO BID \n21. Acetaminophen 975 mg PO Q6H:PRN Pain - Mild/Fever \n22. Aspirin 81 mg PO DAILY \n23. Multivitamins 1 TAB PO DAILY \n24. Senna 17.2 mg PO QHS \n25. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n26. Mylanta 30 ml oral Q4H:PRN dyspepsia \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection \nRX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*20 Tablet Refills:*0 \n2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \nRX *acetaminophen [8HR Muscle Aches-Pain] 650 mg 1 tablet(s) by \nmouth q8 Disp #*30 Tablet Refills:*0 \n3. Glargine 18 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\nRX *blood sugar diagnostic [Blood Glucose Test] use for blood \nsugar monioring 4x dialy Disp #*200 Strip Refills:*0\nRX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL \n(3 mL) ___ Units before BED; Disp #*3 Syringe Refills:*0\nRX *blood-glucose meter [Blood Glucose Monitoring] blood sugar \nmonitoring 4X day Disp #*1 Kit Refills:*0\nRX *lancets [BD Microtainer Lancet] 30 gauge use for glucose \nmonitoring Disp #*200 Each Refills:*0 \n4. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 81 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n5. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet \nRefills:*0 \n6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n7. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \nRX *exenatide [Byetta] 10 mcg/0.04 mL per dose (250 mcg/mL) 2.4 \nmL 10 mcg twice a day Disp #*1 Syringe Refills:*0 \n8. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n9. Gabapentin 300 mg PO TID \nRX *gabapentin 300 mg 1 capsule(s) by mouth three times a day \nDisp #*90 Capsule Refills:*0 \n10. GlipiZIDE 10 mg PO BID diabetes \nRX *glipizide 10 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \nRX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n12. Lidocaine 5% Patch 1 PTCH TD QAM \n13. LORazepam 0.5 mg PO BID:PRN anxiety \nRX *lorazepam [Ativan] 0.5 mg 1 tablet(s) by mouth twice a day \nDisp #*10 Tablet Refills:*0 \n14. melatonin 3 mg oral QHS \n15. MetFORMIN (Glucophage) 1000 mg PO BID \nRX *metformin [Fortamet] 1,000 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*0 \n16. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate [Kapspargo Sprinkle] 50 mg 1 capsule(s) \nby mouth once a day Disp #*30 Capsule Refills:*0 \n17. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second \nLine \n18. Multivitamins 1 TAB PO DAILY \n19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \nRX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min Disp \n#*15 Tablet Refills:*0 \n20. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth q24h Disp #*30 \nTablet Refills:*0 \n21. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin [Flomax] 0.4 mg 1 capsule(s) by mouth at bedtime \nDisp #*30 Capsule Refills:*0 \n22. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \nRX *tramadol [Ultram] 50 mg 1.5 tablet(s) by mouth every six (6) \nhours Disp #*30 Tablet Refills:*0 \n23.bedside Commode\nDrop arm, no diagnosis: ambulatory dysfunction \nphysical function: good\nlength of need: 13 months\n24.Standard Manual Wheelchair \nStandard Manual Wheelchair, Seat and back cushion, Elevating \nleg rests, Anti tip and brake extensions \nDx: Ambulatory dysfunction\nPx: good\n___ 13 months\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nDiabetes, type II\nCoronary artery disease\nAnxiety\nKnee osteoarthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nMr. ___,\n\nYou were admitted to the hospital for chest discomfort and \nanxiety while at rehab. We made adjustments in your blood \npressure regimen to help in case the chest pain was due to heart \ndisease. We also adjusted your insulin regimen since you had \nelevated blood sugars. You should continue your home regimen at \ndischarge. \n\nYour urine studies revealed elevation in WBC concerning for a \nurinary tract infection. You are prescribed 10 days of \nCiprofloxacin antibiotics. \n \nFollowup Instructions:\n___\n" ]

[ "R0789", "I25118", "Z951", "Z955", "Z7902", "M170", "G8929", "F419", "N390", "E119", "Z794", "I10", "E785", "K5900", "K219", "N400", "Z993" ]

[ "R0789: Other chest pain", "I25118: Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "M170: Bilateral primary osteoarthritis of knee", "G8929: Other chronic pain", "F419: Anxiety disorder, unspecified", "N390: Urinary tract infection, site not specified", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K5900: Constipation, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z993: Dependence on wheelchair" ]

[ "Z951", "Z955", "Z7902", "G8929", "F419", "N390", "E119", "Z794", "I10", "E785", "K5900", "K219", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old M w/ hx of CAD s/p CABG x1 SVG-dRCA,\nDES to OM, and BMS to RCA; HTN; DM; and anxiety who was recently\ndischarged from the hospital who presents from rehab with chest\npain. He was at ___ but left ___ after a dispute over \na\nTV. He was supposed to be picked up by a family member but they\ndid not come. He then started to complain of chest pain and was\nbrought to ___. He was given aspirin in the ambulance. \n\nIn the ED, initial vitals were notable for tachycardia to 104\nwith BP 148/90. A code stroke was called as the patient was\nnon-verbal in the ED with lack of movement in his RUE. He was\nevaluated by Neurology who felt his exam had many functional\nfeatures and he was noted to intermittently able to speak in \nfull\nsentences and move LUE and LLE antigravity. CTA head/neck and\nNCHCT were unremarkable. Further history was limited by minimal\npatient participation regarding his chest pain. Troponin \nnegative\nx1 and EKG showed sinus tachycardia. He was not given any\nmedications. \n\nOf note, on his last admission, he also had a code stroke which\nshowed no evidence of TIA or stroke and were more consistent \nwith\na functional disorder. He also had chest pain felt to be\nsecondary to microvascular disease vs. anxiety. He has had\nmultiple admissions with complex care involved, as he is unable\nto care for himself at home.\n \nOn arrival to the floor, the patient complains of right-sided\nheadache that he describes as similar to \"someone sticking\nneedles\" in his head. He denies nausea, vomiting,\nlightheadedness, dizziness, blurry vision. He also complains of\nchest pain which he said has been ongoing since his fight at\nrehab on day prior to admission. He describes it as a squeezing,\npulling pain. He also notes that he intermittently \"can hear but\ncan't respond or move as directed\". He notes that when this\nhappens, he cannot move his RUE.\n \nPast Medical History:\nDiabetes \nHTN \nHLD \nCABGx1 SVG-dRCA (___) \nBMS to anomalous RCA ___, DES to OM ___ \nChronic knee pain \nAnxiety \nWheelchair bound\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\n VITALS: 24 HR Data (last updated ___ @ 721)\n Temp: 98.3 (Tm 98.3), BP: 118/77, HR: 90, RR: 18, O2 sat:\n98%, O2 delivery: Ra, Wt: 253.31 lb/114.9 kg \n GENERAL: Alert and interactive. In no acute distress. \n HEENT: PERRL, EOMI. Sclera anicteric and without injection. \nMMM.\n\n NECK: No cervical lymphadenopathy. No JVD. \n CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. mild TTP on left chest wall.\n LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi \nor\nrales. No increased work of breathing. \n BACK: No CVA tenderness. \n ABDOMEN: Normal bowels sounds, non distended, non-tender to \ndeep\npalpation in all four quadrants. No organomegaly. \n EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial\n2+ bilaterally. \n SKIN: Warm. Cap refill <2s. No rashes. \n NEUROLOGIC: AOx3. did not participate in CN exam. Strength ___\nin ___ upper extremities, ___ in LLE and ___ in RLE at the time \nof\nmy exam. Normal sensation. \n\nDISCHARGE PHYSICAL EXAM\n=======================\n GENERAL: Alert and interactive. In no acute distress. \n HEENT: PERRL, EOMI. Sclera anicteric and without injection. \nMMM.\n NECK: No cervical lymphadenopathy. No JVD. \n CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. mild TTP on left chest wall.\n LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi \nor\nrales. No increased work of breathing. \n BACK: No CVA tenderness. \n ABDOMEN: Normal bowels sounds, non distended, non-tender to \ndeep\npalpation in all four quadrants. No organomegaly. \n EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial\n2+ bilaterally. \n SKIN: Warm. Cap refill <2s. No rashes. \n NEUROLOGIC: AOx3. did not participate in CN exam. Strength ___\nin ___ upper extremities, ___ in LLE and ___ in RLE at the time \nof\nmy exam. Normal sensation. \n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 03:07AM BLOOD WBC-6.7 RBC-4.71 Hgb-13.4* Hct-42.5 \nMCV-90 MCH-28.5 MCHC-31.5* RDW-14.0 RDWSD-45.4 Plt ___\n___ 03:07AM BLOOD Neuts-58.8 ___ Monos-5.6 Eos-3.2 \nBaso-0.8 Im ___ AbsNeut-3.93 AbsLymp-2.07 AbsMono-0.37 \nAbsEos-0.21 AbsBaso-0.05\n___ 03:25AM BLOOD ___ PTT-22.5* ___\n___ 03:07AM BLOOD Glucose-161* UreaN-10 Creat-0.8 Na-138 \nK-4.5 Cl-101 HCO3-22 AnGap-15\n___ 03:07AM BLOOD ALT-21 AST-23 AlkPhos-96 TotBili-0.4\n___:07AM BLOOD cTropnT-<0.01\n___ 03:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG\n___ 03:25AM BLOOD Glucose-160* Creat-0.7 Na-140 K-4.7 \nCl-105 calHCO3-34*\n\nSTUDIES\n=======\n___ ___\nNo evidence of intracranial hemorrhage, acute large territorial \ninfarction, edema, or mass. \n\nCTA HEAD AND NECK ___\nNo evidence of dissection, occlusion, high-grade stenosis, or \naneurysm greater than 3 mm within the great vessels of the head \nor neck. The vessels of the circle of ___ and their principal \nintracranial branches appear patent. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old M w/ hx of CAD s/p CABG x1 SVG-dRCA, \nDES to OM, and BMS to RCA; HTN; DM; and anxiety who was recently \ndischarged from the hospital who presents from rehab with chest \npain and a code stroke in the ED with concern for functional \nneurological disorder.\n\nTRANSITIONAL ISSUES:\n====================\n[]Will need psychiatry outpatient follow up and consideration of \ninitiation of SSRI for anxiety\n[]Patient will need ongoing management with social work and case \nmanagement as he has had numerous recent hospitalizations\n[]He would benefit from ongoing outpatient workup for etiology \nof headache \n[]Please consider referral to Dr. ___ at ___ for suspect \nfunctional neurological disorder\n\nACUTE/ACTIVE ISSUES: \n==================== \n# Chest pain \nWhile patient certainly has a history of CAD and risk factors, \ntrop negative x1 and EKG shows no signs of ischemia (although \ncould be microvascular disease). In addition, constant pain for \n>24hrs with TTP on exam is not consistent with cardiac etiology. \nMost likely Ddx at this point includes malingering given no \nplace to reside vs. anxiety. Patient was continued on home \naspirin, Plavix, atorvastatin, metoprolol and nitroglycerin prn \nchest pain. \n\n# Unresponsiveness \n# Functional neurological deficit\nPatient had a code stroke in the ED with inconsistent neurologic \nexam, more consistent with functional neurological deficit. All \nhead imaging including NCHCT and CTA were negative for \nintracranial etiology. In addition, exam changed between ED exam \nand admission exam. Neurology was consulted and agree with \ndiagnosis of likely functional neurological deficit. He was \ncontinued on home tramadol, gabapentin and lorazepam. Recommend \nfollowup with Dr. ___ at ___ for further evaluation.\n\n# Headache\nAll imaging was negative for intracranial etiology. He was seen \nby neurology in the ED who felt that this was less likely a \ncomplex migraine. More likely ___ medication overuse given \nongoing headache and numerous recent hospitalizations and rehab \nstay. Tylenol was discontinued. He should be considered for \nbridge therapy (with NSAIDS vs steroids vs DHE) if he continued \nto experience severe headaches despite holding likely culprit. \nPossibly also a component of left sided occipital neuralgia. \nRecommend warm compresses to back of head, followup with \nneurology if headache fails to improve.\n\nCHRONIC/STABLE ISSUES: \n====================== \n# Anxiety \nSocial work was consulted. He was continued on home lorazepam. \nHe should have outpatient f/u with psychiatry and should \nconsider initiation of an SSRI.\n\n# Type II DM \nHeld home exanetide, placed on ISS while inpatient.\n\n# Knee osteoarthritis \nContinued home lidocaine patch, gabapentin and tramadol. Held \nhome Tylenol.\n\n# BPH \nContinued home Tamsulosin \n\n# GERD \nContinued home pantoprazole \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n5. Clopidogrel 75 mg PO DAILY \n6. Gabapentin 300 mg PO TID \n7. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS \n8. Lidocaine 5% Patch 1 PTCH TD QAM \n9. LORazepam 0.5 mg PO BID:PRN anxiety \n10. Metoprolol Succinate XL 50 mg PO DAILY \n11. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second \nLine \n12. Multivitamins 1 TAB PO DAILY \n13. Pantoprazole 40 mg PO Q24H \n14. Tamsulosin 0.4 mg PO QHS \n15. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n16. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n17. GlipiZIDE 10 mg PO BID diabetes \n18. melatonin 3 mg oral QHS \n19. MetFORMIN (Glucophage) 1000 mg PO BID \n20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n21. Glargine 18 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Glargine 18 Units Bedtime \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n5. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n6. Clopidogrel 75 mg PO DAILY \n7. Gabapentin 300 mg PO TID \n8. GlipiZIDE 10 mg PO BID diabetes \n9. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS \n10. Lidocaine 5% Patch 1 PTCH TD QAM \n11. LORazepam 0.5 mg PO BID:PRN anxiety \n12. melatonin 3 mg oral QHS \n13. MetFORMIN (Glucophage) 1000 mg PO BID \n14. Metoprolol Succinate XL 50 mg PO DAILY \n15. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second \nLine \n16. Multivitamins 1 TAB PO DAILY \n17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n18. Pantoprazole 40 mg PO Q24H \n19. Tamsulosin 0.4 mg PO QHS \n20. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\nFunctional neurological deficit\n\nSECONDARY DIAGNOSIS\nChest pain (non-cardiac)\nHeadache\nAnxiety\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 part in your care here at ___! \n\nWhy was I admitted to the hospital? \n- You were admitted for chest pain and a headache.\n \nWhat was done for me while I was in the hospital? \n- We did tests of your heart and your chest pain was determined \nto not be coming from your heart\n- You had trouble moving your arm and leg but we took images and \ndetermined you did not have a stroke\n- You complained of a headache which we think may be because you \ntake so many medications or an irritated nerve\n\nWhat should I do when I leave the hospital? \n- Take all of your medications as prescribed\n- Go to all of your appointments\n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "R0789", "R51", "R29818", "I2510", "Z951", "Z955", "E119", "F419", "M1710", "G8929", "Z993", "N400", "Z794", "Z7902", "K219", "I252", "I10", "E785" ]

[ "R0789: Other chest pain", "R51: Headache", "R29818: Other symptoms and signs involving the nervous system", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "E119: Type 2 diabetes mellitus without complications", "F419: Anxiety disorder, unspecified", "M1710: Unilateral primary osteoarthritis, unspecified knee", "G8929: Other chronic pain", "Z993: Dependence on wheelchair", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z794: Long term (current) use of insulin", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "K219: Gastro-esophageal reflux disease without esophagitis", "I252: Old myocardial infarction", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified" ]

[ "I2510", "Z951", "Z955", "E119", "F419", "G8929", "N400", "Z794", "Z7902", "K219", "I252", "I10", "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:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ man with history of CAD s/p CABG (SVG to RCA, ___, \nas well as BMS to RCA, DES to distal OM1), HTN, HLD, and \ndiabetes presenting for recurrent chest pain. Reports symptoms \nof left-sided and sub-sternal squeezing chest\npain that began yesterday around 4 ___ while at ___ rehab. \nOccurs intermitently throughout the day, ___ minutes per \nepisode. Non-radiating, no improvement with nitro SL that he \nreceived. No dyspnea. Describes symptoms as similar to his prior \nACS events but worse in severity this time. Because of this was \nbrought to the ED from ___ rehab where he has been since \ndischarge approximately two weeks ago. He was at rest when pain \nbegan; denies any exertional component to his symptoms.\n\nOf note, he was recently admitted in ___ for recurrent \nchest pain for which he underwent coronary angiography with no \nevidence of new/progressive disease; all grafts and vessels \nsimilarly patent to prior study in ___. Attempted to \nmaximize medical therapy with anti-anginals however this has \nbeen limited by orthostatic hypotension and dizziness. Of note \nhis Imdur appears\nto have been decreased from 30 to 15 mg daily while at rehab. \nOtherwise denies any fever, chills, weight gain/loss, back pain, \ndyspnea, cough, abdominal pain, nausea, vomiting, or diarrhea.\n\nIn the ED, initial vitals were: 96 160/80 16 99 \n- Exam notable for: No increased work of breathing. CTAB. RRR.\nNormal S1/S2. 2+ radial pulse bilaterally.\n- Labs notable for: troponin <0.01 x2.\n- Imaging was notable for CXR with no acute process.\n- Notable medications received: nitroglycerin SL 0.4 mg x2, \nImdur\n30, aspirin 81 + 243, metoprolol succinate 25, started on \nheparin\ngtt.\n\nReports currently being chest pain free on arrival.\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS\n- Diabetes (+)\n- Hypertension (+)\n- Dyslipidemia (+)\n\n2. CARDIAC HISTORY\n- CABG: ___\n- PERCUTANEOUS CORONARY INTERVENTIONS: ___ (BMS to proximal\nanomalous RCA), ___\n- PACING/ICD: None\n\n3. OTHER PAST MEDICAL HISTORY\n- Osteoarthritis\n- Constipation\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death.\n \nPhysical Exam:\nADMISSION PE:\nVITALS: 98.1 149/88 80 18 100 Ra \nGENERAL: Older appearing man in no acute distress. Comfortable. \nAAOx3.\nNEURO: AAOx3. CNII-XII grossly intact. Moving all four \nextremities with purpose.\nHEENT: NCAT. EOMI. MMM.\nCARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs, \nor gallops.\nCHEST: Well healed midline sternotomy scar.\nPULMONARY: Clear to auscultation bilaterally. Breathing\ncomfortably on room air.\nABDOMEN: Soft, non-tender, non-distended.\nEXTREMITIES: Warm, well perfused, non-edematous. \nSKIN: No significant rashes.\n\nDISCHARGE PE:\nVS: 97.5, 121/70, 70, 16, 100%RA\nGENERAL: Older appearing man in no acute distress. Comfortable. \nAAOx3.\nNEURO: AAOx3. CNII-XII grossly intact. Moving all four \nextremities with purpose.\nHEENT: NCAT. EOMI. MMM.\nCARDIAC: Regular rate & rhythm. Normal S1/S2. No murmurs, rubs, \ngallops, clicks.\nCHEST: Well healed midline sternotomy scar.\nPULMONARY: Clear to auscultation bilaterally. Breathing \ncomfortably on room air. No wheezes/rubs/rhonchi or accessory \nuse.\nABDOMEN: Soft, non-tender, non-distended, normoactive BS \nthroughout, no HSM.\nEXTREMITIES: Warm, well perfused, non-edematous. \nSKIN: No significant rashes or varicosities\n\nWT:\nADMIT: 112.31 kg\nDISCHARGE: 109.5 kg\n\n \nPertinent Results:\n___ 06:26AM BLOOD WBC-3.9* RBC-4.45* Hgb-13.5* Hct-41.5 \nMCV-93 MCH-30.3 MCHC-32.5 RDW-12.9 RDWSD-43.8 Plt ___\n___ 06:14AM BLOOD WBC-5.0 RBC-4.60 Hgb-13.9 Hct-44.3 MCV-96 \nMCH-30.2 MCHC-31.4* RDW-12.9 RDWSD-45.7 Plt ___\n___ 12:44AM BLOOD WBC-5.3 RBC-4.04* Hgb-12.3* Hct-37.1* \nMCV-92 MCH-30.4 MCHC-33.2 RDW-12.7 RDWSD-42.9 Plt ___\n___ 12:44AM BLOOD Neuts-51.0 ___ Monos-8.6 Eos-4.2 \nBaso-0.8 Im ___ AbsNeut-2.69 AbsLymp-1.85 AbsMono-0.45 \nAbsEos-0.22 AbsBaso-0.04\n___ 06:26AM BLOOD Plt ___\n___ 08:41AM BLOOD PTT-54.6*\n___ 06:14AM BLOOD Plt ___\n___ 06:26AM BLOOD UreaN-10 Creat-0.7 Na-139 K-4.7\n___ 10:42AM BLOOD Glucose-199* UreaN-8 Creat-0.7 Na-141 \nK-4.3 Cl-103 HCO3-25 AnGap-13\n___ 06:14AM BLOOD Glucose-185* UreaN-9 Creat-0.9 Na-132* \nK-GREATER TH Cl-95* HCO3-14* AnGap-23*\n___ 12:44AM BLOOD Glucose-214* UreaN-9 Creat-0.7 Na-135 \nK-5.1 Cl-99 HCO3-24 AnGap-12\n___ 08:15PM BLOOD CK-MB-2 cTropnT-<0.01\n___ 05:10AM BLOOD cTropnT-<0.01\n___ 12:44AM BLOOD cTropnT-<0.01\n___ 06:26AM BLOOD Mg-2.0\n___ 10:42AM BLOOD Calcium-9.3 Mg-1.8\n___ 06:14AM BLOOD Calcium-LESS THAN Phos-4.0 Mg-LESS THAN \n___ 12:44AM BLOOD %HbA1c-8.8* eAG-206*\n \nBrief Hospital Course:\nAssessment: ___ man with history of CAD s/p CABG (SVG to \nRCA, ___\nwell as BMS to RCA, DES to distal OM1), HTN, HLD, and diabetes \npresenting for recurrent chest pain most likely due to chronic \nstable angina in the setting of microvascular disease.\n\nPlan:\n#CAD:\n#Microvascular disease:\n#Chest Pain:\nOngoing intermittent symptoms >24h similar in character to prior \nangina though without dynamic EKG changes or troponin elevation. \nGiven recent stable cor angio this is more likely reflective of \nknown microvascular disease instead of acute thrombosis. Has \nbeen CP free for greater than 24 hours.\n- Continue Aspirin 81 mg PO/NG DAILY\n- Continue Atorvastatin 80 mg PO/NG QPM\n- Continue Clopidogrel 75 mg PO/NG DAILY\n- Changed Metop Tartrate and Isosorbide dinatrate back to home \nImdur and Metop succinate as pt not orthostatic.\n- Amlodipine added yesterday; increase to 5mg once daily today \nand monitor orthostatics post, no signs of orthostasis\n- Consider increasing Imdur, if continued symptoms and if BP \ntolerates\n- Would benefit from ACE given prior NSTEMI with concurrent \nhypertension & diabetes though may be limited given recent \northostasis and need for uptitrtation of antianginals\n- ___ consulted to assess for activity tolerance and assess if \nany CP with activity\n\nCHRONIC / STABLE ISSUES\n=======================\n# Osteoarthritis: Needs bilat knee replacement, work up in \nprogress. Has been largely wheel chair bound for about 3 months.\n -Return to rehab \n -___ consult while inpatient; encourage up OOB to recliner\n\n# DIABETES: Hgb 8.8% down from 10.1% in ___. Continue close \nmanagement as likely exacerbating microvascular disease\n- Monitor blood glucose QACHS; Diabetic diet\n- Continue Glargine 18 QHS with sliding scale\n- Holding outpatient PO medications while inpatient, resume on \ndischarge\n\n# HYPERTENSION: BP 110-130/50-70's.\n- Increasing Amlodipine to 5mg daily for microvascular disease\n- Metoprolol succinate, Imdur as above\n- Monitor orthostatic vital signs, no evidence while in hospital\n\n# CHRONIC CONSTIPATION\n- Continue home regimen\n\n # PROPHYLAXIS: \n - DVT prophylaxis with: Heparin SC\n - Pain management with: Tylenol, gabapentin and Tramadol\n - Bowel regimen with Senna QD and Milk of Mag, miralax and \nDucolax as PRN\n \n # Emergency contact: ___ (sister: ___\n\n # Family/HCP updated? No. Patient updated\n\nDispo: Continued medication management today, discharge to \nrehab.\n\nDischarge time 35 min\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n5. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n6. Gabapentin 300 mg PO TID \n7. Lidocaine 5% Patch 1 PTCH TD QAM \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n11. Senna 17.2 mg PO DAILY \n12. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n13. GlipiZIDE 10 mg PO BID \n14. melatonin 3 mg oral QHS \n15. MetFORMIN (Glucophage) 1000 mg PO BID \n16. Milk of Magnesia 30 mL PO QHS:PRN Constipation - First Line \n17. Docusate Sodium 100 mg PO BID \n18. Polyethylene Glycol 17 g PO BID:PRN Constipation - First \nLine \n19. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n20. Mylanta 30 ml oral Q4H:PRN \n21. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY \n22. Glargine 18 Units Bedtime\n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \n2. Pantoprazole 40 mg PO Q24H \n3. Glargine 18 Units Bedtime \n4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n9. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n10. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n11. Docusate Sodium 100 mg PO BID \n12. Gabapentin 300 mg PO TID \n13. GlipiZIDE 10 mg PO BID \n14. Lidocaine 5% Patch 1 PTCH TD QAM \n15. melatonin 3 mg oral QHS \n16. MetFORMIN (Glucophage) 1000 mg PO BID \n17. Metoprolol Succinate XL 25 mg PO DAILY \n18. Milk of Magnesia 30 mL PO QHS:PRN Constipation - First Line \n \n19. Multivitamins 1 TAB PO DAILY \n20. Mylanta 30 ml oral Q4H:PRN \n21. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n22. Polyethylene Glycol 17 g PO BID:PRN Constipation - First \nLine \n23. Senna 17.2 mg PO DAILY \n24. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nChest pain, CAD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nYou were admitted to the hospital with chest pain and ongoing \nissues with dizziness. Your heart enzymes were negative and you \ndid not have any changes on your EKGs while admitted to the \nhospital. Given that you recently had cardiac catheterization in \n___ with stent placement and again in ___ and known \nmicrovascular disease, you did not undergo additional imaging. \nWe increased some of your medications while you were in the \nhospital to help with your ongoing issues with chest pain. We \ncontinued to monitor your blood pressure and heart rate \nthroughout your hospital course. We completed orthostatic blood \npressures daily and they were normal. \n \nPlease continue ALL of your current medications with the \nfollowing changes: \n - Isosorbide Mononitrate INCREASED from 15 mg daily back to 30 \nmg daily\n - Amlodipine 5 mg daily NEW\n - Protonix 40 mg daily NEW\n\nIt is very important to take all of your heart healthy \nmedications. In particular, aspirin and clopidogrel (Plavix) \nkeep the stents in the vessels of the heart open from stent \nplaced in ___ and help reduce your risk of having a \nfuture heart attack. If you stop these medications or miss ___ \ndose, you risk causing a blood clot forming in your heart \nstents, and you may die from a massive heart attack. Please do \nnot stop taking either medication without taking to your heart \ndoctor, even if another doctor tells you to stop the \nmedications. \n\nIf 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\nIt has been a pleasure to have participated in your care and we \nwish you the best with your health! \n\nYour ___ Cardiac Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I25119", "R42", "I10", "E119", "K5909", "M170", "F419", "E785", "Z794", "Z993", "Z951", "Z955", "I252" ]

[ "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "R42: Dizziness and giddiness", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "K5909: Other constipation", "M170: Bilateral primary osteoarthritis of knee", "F419: Anxiety disorder, unspecified", "E785: Hyperlipidemia, unspecified", "Z794: Long term (current) use of insulin", "Z993: Dependence on wheelchair", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction" ]

[ "I10", "E119", "F419", "E785", "Z794", "Z951", "Z955", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ man with past medical history notable \nfor CAD with anomalous RCA s/p S/P BMS to mid-RCA in ___, S/P \n1-vesel CABG (SVG-dRCA in ___, S/P DES to ___, type \n2 diabetes mellitus, hypertension, hyperlipidemia, severe \nanxiety, and chronic debilitating knee pain rendering him \nwheelchair bound, presenting with chief complaint of chest \ndiscomfort.\n\nPatient noted he had substernal chest pain that he described as \na pressure, starting at 2:00 pm the afternoon of presentation \nwhile he was sitting down watching TV. He received sublingual \nnitroglycerin x3 with relief. The pain returned when he got up \nto use the bathroom. It was not associated with any \nlightheadedness, nausea, diaphoresis, or abdominal pain. He has \nnot had this pain before. It was worse with deep breathing. He \ndenied any fevers, cough, trauma, or lower extremity swelling.\n \nIn the ED, initial vitals: T 98.1 HR 94 BP 121/74 RR 20 SaO2 97% \non RA. Benign physical examination. Labs/studies notable for WBC \n5.3, Hgb 13, Hct 39.7%, Pl5 307, INR 1.2, PTT 28, Na 138, K 7.5 \n-> 3.9 on repeat, BUN 11, Cr 0.8, glc 76, \nD-Dimer, 1837. CTA showed no evidence of pulmonary embolism or \naortic abnormality. Patient was given nitroglycerin SL 0.4 mg X \n2, morphine sulfate IV. Vitals on transfer: T 97.7 PO BP 155/73 \nHR 91 RR 17 SaO2 98% on RA.\n\nAfter arrival to the cardiology ward, the patient confirmed the \nhistory as above. He has a history of chest pain, but felt the \npain he had ambulating to the bathroom was much more severe than \nhe has had in the past.\n \nPast Medical History:\n1. CAD RISK FACTORS\n- Diabetes mellitus (+)\n- Hypertension (+)\n- Dyslipidemia (+)\n\n2. CARDIAC HISTORY\n- CAD, S/P CABGx1 SVG-dRCA (___)\n- BMS to anomalous RCA ___, DES to OM ___\n- PACING/ICD: None\n\n3. OTHER PAST MEDICAL HISTORY\n- chronic knee pain from OA, wheelchair-bound\n- anxiety\n \nSocial History:\n___\nFamily History:\nBoth his mother and father had cardiac issues. His mother died \nin her ___ or ___ due to some issue with her pacemaker. His \nfather died in his ___, he thinks from a massive stroke.\n \nPhysical Exam:\nOn admission\nGENERAL: Well-developed, well-nourished middle aged black man in \nNAD. Mood, affect appropriate.\nVITALS: T 97.7 PO BP 155/73 HR 91 RR 17 SaO2 98% on RA\nHEENT: Sclera anicteric. EOMI. Conjunctiva pink, no pallor or \ncyanosis of the oral mucosa.\nNECK: No appreciable JVD\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RRR, normal S1, S2. No murmurs, rubs, gallops.\nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi.\nABDOMEN: Soft, non-tender, not distended.\nEXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n \nAt discharge\nGeneral: in NAD, sitting comfortably in bed\n24 HR Data (last updated ___ @ 1512) Temp: 98.4 (Tm 98.6), \nBP: 121/75 (101-143/55-81), HR: 80 (68-80), RR: 20 (___), O2 \nsat: 98% (96-99), O2 delivery: RA, Wt: 257.5 lb/116.8 kg\nHEENT: NCAT, PERRL, mucous membranes moist.\nNeck: Supple, trachea midline\nHeart: RRR; no murmurs, rubs or gallops. No peripheral edema.\nLungs: CTAB--No wheezes, rales, or rhonchi.\nAbd: Soft, non-tender, not distended.\nMSK: No obvious limb deformities.\nDerm: Skin warm and dry\nNeuro: Awake, alert, moves all extremities.\n \nPertinent Results:\n___ 04:21PM WBC-5.3 RBC-4.49* HGB-13.0* HCT-39.7* MCV-88 \nMCH-29.0 MCHC-32.7 RDW-14.0 RDWSD-45.1\n___ 04:21PM NEUTS-55.9 ___ MONOS-6.9 EOS-2.9 \nBASOS-0.6 IM ___ AbsNeut-2.94 AbsLymp-1.75 AbsMono-0.36 \nAbsEos-0.15 AbsBaso-0.03\n___ 04:21PM PLT COUNT-307\n___ 04:21PM ___ PTT-28.0 ___\n\n___ 04:21PM GLUCOSE-76 UREA N-11 CREAT-0.8 SODIUM-138 \nPOTASSIUM-7.5* CHLORIDE-101 TOTAL CO2-23 ANION GAP-14\n___ 05:36PM K+-3.9\n\n___ 04:21PM cTropnT-<0.01\n___ 04:21PM CK-MB-3\n___ 09:45PM cTropnT-<0.01\n___ 09:45PM CK-MB-3\n___ 06:35AM CK-MB-3 cTropnT-<0.01\n\n___ 05:30PM D-DIMER-___*\n\nECG ___ 16:01:59\nSinus rhythm. Normal ECG\n\nCXR ___\nMedian sternotomy wires are intact and unchanged from prior. \nSurgical clips project over the right border of the mediastinum. \nStable elevation of the right hemidiaphragm. No areas of focal \nconsolidation, pleural effusion or pneumothorax. \nCardiomediastinal contours are normal.\nIMPRESSION: No acute cardiopulmonary findings.\n\nCTA Chest ___\nHEART AND VASCULATURE: Pulmonary vasculature is well opacified \nto the segmental level without filling defect to indicate a \npulmonary embolus. Subsegmental branches are not particularly \nwell assessed due to timing of the contrast bolus. Main \npulmonary artery is top normal in size, which may suggest \npulmonary arterial hypertension. Mild atherosclerotic \ncalcifications of the thoracic aorta. The thoracic aorta is \nnormal in caliber without evidence of dissection or intramural \nhematoma. Patient is status post CABG. Otherwise, the heart, \npericardium, and great vessels are within normal limits. No \npericardial effusion is seen.\nAXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or \nhilar lymphadenopathy is present. No mediastinal mass.\nPLEURAL SPACES: No pleural effusion or pneumothorax.\nLUNGS/AIRWAYS: Linear atelectasis within the right lower lobe is \nunchanged. No new focal consolidations. No suspicious pulmonary \nnodules. Small amount of secretions within the trachea at the \ncarina. Otherwise, the airways are patent to the level of the \nsegmental bronchi bilaterally.\nBASE OF NECK: Visualized portions of the base of the neck show \nno abnormality.\nABDOMEN: Simple cyst partially imaged within the upper pole of \nthe right kidney.\nBONES: Sternotomy wires appear intact and appropriately aligned. \nWell-circumscribed sclerotic lesion within the manubrium is \nlikely a bone island. Lucent lesions in the anterolateral right \nfourth rib and the posterolateral right seventh rib are \nunchanged dating back to ___ and of doubtful clinical \nsignificance. No suspicious osseous abnormality is seen.? There \nis no acute fracture.\nIMPRESSION: No evidence of pulmonary embolism or aortic \nabnormality.\n\nVasodilator nuclear stress test ___\nThis ___ year old IDDM man with a h/o CAD, HTN, HLD, anomalous \nRCA s/p CABG x1 (SVG-dRCA) in ___, BMS x1 to the mid-RCA in \n___ and DES x1 to the OM1 in ___ was referred to the lab \nfor evaluation of chest discomfort. The patient is wheelchair \nbound and arm ergometer was unable to be performed, therefore \nthe patient was administered 0.4 mg of regadenoson IV bolus over \n20 seconds. At 1 minute post-infusion the patient reported a \ndiffuse chest discomfort, which he was unable to characterize \nfurther but different from the discomfort he was referred for. \nThis discomfort improved during recovery and was absent by 4.25 \nminutes of recovery. There were no significant ST segment \nchanges seen during the infusion or in recovery. The rhythm was \nsinus with occasional isolated APBs and question of a two sinus \npauses, one at 6 minutes and 7 minutes of recovery. Apppropriate \nblood pressure and heart rate responses to the infusion and in \nrecovery. Post-MIBI, the regadenoson was reversed with 60 mg IV \ncaffeine.\nIMPRESSION: Atypical type symptoms in the absence of significant \nST segment changes. Appropriate hemodynamic response to \nvasodilator stress.\nIMAGING: Left ventricular cavity size is normal. Rest and stress \nperfusion images reveal uniform tracer uptake throughout the \nleft ventricular myocardium. Gated images reveal normal wall \nmotion. The calculated left ventricular ejection fraction is \n55%.\nIMPRESSION: Normal myocardial perfusion. Left ventricular \nejection fraction of 55%. \n\nDISCHARGE LABS:\n___ 06:35AM BLOOD WBC-4.7 RBC-4.44* Hgb-12.6* Hct-39.3* \nMCV-89 MCH-28.4 MCHC-32.1 RDW-14.3 RDWSD-45.9 Plt ___\n___ 05:35AM BLOOD Glucose-184* UreaN-13 Creat-0.8 Na-139 \nK-4.5 Cl-102 HCO3-25 AnGap-12\n___ 05:35AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8\n \nBrief Hospital Course:\nMr. ___ is a ___ man with past medical history notable \nfor CAD with BMS to anomalous mid-RCA in ___, s/p 1 vessel CABG \n(SVG-dRCA in ___, DES to ___, type 2 diabetes \nmellitus, hypertension, hyperlipidemia, severe anxiety, and \nchronic debilitating knee pain rendering him wheelchair bound, \npresenting with acute on chronic chest discomfort.\n\nACTIVE ISSUES\n# Chest pain. CAD with anomalous RCA arising next to the ___ \ns/p BMS to mid-RCA in ___ for NSTEMI, 1 vessel CABG (SVG-dRCA \nin ___, DES to ___: He has had multiple admissions \nfor chest pain atypical for ischemia with extensive negative \nwork-up, including 2 coronary angiograms, nuclear stress \ntesting, transthoracic echocardiograms, and multiple evaluations \nfor unstable angina with serial troponins and normal EKGs. His \nwork-up this admission again was reassuring with no evidence of \nacute cardiac pathology. ECG was normal, serial troponin-T \nnormal. CTPA for elevated D-dimer showed no evidence of \npulmonary embolus or aortic pathology. Patient was medically \nmanaged with aspirin, clopidogrel, atorvastatin, metoprolol, \nisorbide mononitrate and sublingual nitroglycerin prn (all his \nhome medications). As patient moves his wheelchair using his \narms to spin the rims on the wheels of his chair, the \npossibility of ischemia or musculoskeletal pain from exertion \nusing upper chest/arm musculature was entertained. \nUnfortunately, we were unable to obtain arm ergometry stress \ntesting. Vasodilator nuclear stress test on ___ showed uniform \nmyocardial perfusion with left ventricular ejection fraction of \n55%. He was started on scheduled acetaminophen for \nmusculoskeletal chest pain.\n\nCHRONIC/STABLE ISSUES: \n# Anxiety: Continued home lorazepam. It was hypothesized that \nthe patient's chest discomfort may be related to his underlying \nanxiety given that cardiac ischemia was exonerated. Please \nstrongly consider referral for CBT and or initiation of an SSRI \nversus buspirone.\n\n# Type 2 diabetes mellitus: Patient did have glucose of 60 while \nin ED, therefore his Lantus was dose reduced from 25 to 20 \nunits. He was also placed on insulin sliding scale. Held home \nliraglutide and glipizide while patient in hospital, but they \nwere restarted on discharge.\n\n# Knee osteoarthritis: Continued home acetaminophen, lidocaine \npatch, gabapentin and tramadol\n\n# BPH: Continued home tamsulosin \n\n# GERD: Continued home pantoprazole\n\nTRANSITIONAL ISSUES\nNew meds: none\nHeld/discontinued meds:\nChanged medication regimen: scheduled acetaminophen for presumed \nmusculoskeletal chest pain\n[] It was hypothesized that the patient's chest discomfort may \nbe related to his underlying anxiety given that cardiac ischemia \nwas exonerated. Please strongly consider referral for CBT and or \ninitiation of an SSRI versus buspirone.\n\nCODE: Full per MOLST \nCONTACT: Name of health care proxy: ___ (Sister) \n___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Gabapentin 300 mg PO TID \n3. Metoprolol Succinate XL 50 mg PO DAILY \n4. MetFORMIN (Glucophage) 1000 mg PO BID \n5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n6. Atorvastatin 80 mg PO QPM \n7. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY \n8. Glargine 25 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n9. Multivitamins 1 TAB PO DAILY \n10. Isosorbide Mononitrate 120 mg PO DAILY \n11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n12. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n13. Melatin (melatonin) 3 mg oral QHS \n14. Clopidogrel 75 mg PO DAILY \n15. Pantoprazole 40 mg PO Q24H \n16. Aspirin 81 mg PO DAILY \n17. Tamsulosin 0.4 mg PO QHS \n18. GlipiZIDE 10 mg PO BID \n19. LORazepam 0.5 mg PO BID:PRN anxiety \n20. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second \nLine\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n5. Clopidogrel 75 mg PO DAILY \n6. Gabapentin 300 mg PO TID \n7. GlipiZIDE 10 mg PO BID \n8. Glargine 25 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n9. Isosorbide Mononitrate 120 mg PO DAILY \n10. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY \n11. LORazepam 0.5 mg PO BID:PRN anxiety \n12. Melatin (melatonin) 3 mg oral QHS \n13. MetFORMIN (Glucophage) 1000 mg PO BID \n14. Metoprolol Succinate XL 50 mg PO DAILY \n15. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second \nLine \n16. Multivitamins 1 TAB PO DAILY \n17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n18. Pantoprazole 40 mg PO Q24H \n19. Tamsulosin 0.4 mg PO QHS \n20. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \nRX *tramadol 50 mg 1.5 tablet(s) by mouth every six (6) hours \nDisp #*18 Tablet Refills:*0\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n-Chest pain without objective evidence of myonecrosis or \nischemia\n-Coronary artery disease with prior bypass surgery for \ncongenitally anomalous coronary arteries and prior stenting\n-Anxiety\n-Chronic knee osteoarthritis with pain\n-Gastroesophageal reflux disease\n-Diabetes mellitus, type 2, with\n-Hypoglycemia\n-Benign prostatic hypertrophy\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n \nDischarge Instructions:\nDear Mr. ___, \nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were admitted to the hospital because you were having \nchest discomfort \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- In the hospital we tracked your blood levels of certain \nenzymes which indicate whether someone has had a heart attack. \nWe also performed a stress test to see if your heart was getting \nreduced blood flow.\n- All of the cardiac testing came back normal. The pain you were \nfeeling is not due to a heart attack.\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" ]

[ "R0789", "I2510", "I10", "E119", "F419", "K219", "N400", "M1710", "E785", "Z993", "Z794", "Z951", "Z955", "Z8249" ]

[ "R0789: Other chest pain", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M1710: Unilateral primary osteoarthritis, unspecified knee", "E785: Hyperlipidemia, unspecified", "Z993: Dependence on wheelchair", "Z794: Long term (current) use of insulin", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "I2510", "I10", "E119", "F419", "K219", "N400", "E785", "Z794", "Z951", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nFrom admitting H&P:\n___ male with history of CAD s/p CABGx1 SVG-dRCA \n(___), BMS to anomalous RCA ___, DES to OM ___, T2DM, \nHTN and chronic knee pain from OA wheelchair-bound, multiple \nrecent admissions for chest pain, who presents with chest pain. \n\nOn day of admission, he reports waking up with ___ chest pain \nfrom sleep at 7 am, no shortness of breath, nausea or vomiting. \nHe says the pain has been persistent over the day and has not \nimproved with sublingual nitro. He does not notice any change \nwith inspiration, position, or with exertion. \n\nOf note, he's had 6 admissions over the last 6 months for chest \npain, and several additional ED visits. In ___ he presented \nwith unstable angina and underwent DES to OM ___. On the \nsubsequent admissions, chest pain was thought to be related to \neither anxiety or microvascular disease, as he's had negative \ntroponins and no ischemic changes on EKG. He underwent \nangiography again on ___ which showed stable nonobstructive \nCAD with evidence of diffuse microvascular disease. He most \nrecently underwent a nuclear stress on ___ which was normal. \nHis recent admission was ___ to ___ with chest pain \nthought to be related to anxiety. \n\nAfter his last admission, he was discharged to a hotel rather \nthan to a skilled nursing facility. Per the note, \"He states \nthat being in rehab has been very difficult. He notes that he is \nthere with many people who are much older than him, and this has \ntaken a mental toll. He has seen many things that have made him \nuncomfortable and feel that the care he gets is often very poor. \nHe also struggles with the idea of being stuck in a wheelchair \nat a rehab at such a young age.\"\n\nHe reports that he's very anxious regarding his ability to care \nfor himself. He feels he made a mistake by requesting discharge \nto hotel and he has trouble getting in and out of bed and \ngetting to the bathroom. He has not been taking Ativan recently \nbut he reports that the Ativan appears to help his chest pain. \n\nIn the ED while he was getting an EKG, he suddenly became \nconfused and complained of sudden onset headache. Then had \nweakness and inattentiveness. A code stroke called. CTA head \nshowed no hemorrhage or large vessel occlusion. Neurology \nevaluated him and found no neurologic deficits, exam notable for\nanxiety, and treated his headache with IVF and migraine \ncocktail. He reports he's never had these types of symptoms \nbefore. \n\n- In the ED, initial vitals were: 97.8 90 135/71 18 96% RA\n- Exam was notable for: Confused, in pain, unable to state \nname, location, date, inattentive on the right. Weakness RUE > \nLUE, weakness RLE > LLE, inattentive on right, not able to \nfollow exam commands for CN, able to wiggle toes. \n- Labs were notable for: trop negative x2, negative serum \ntox/urine tox, normal CBC, Cr, lytes, LFTs.\n- Studies were notable for: 4 EKG's obtained showing NSR, normal \nintervals, no ischemic changes \n- The patient was given: SL nitro x 3, ASA 325, Tylenol, \nprochlorperazine, 1L LR, plavix, atorvastatin 80 mg, tramadol 50 \nmg, insulin 4 U\n- cardiology was consulted, recommended admission for medication \ntitration given his recurrent presentations to the ED for chest \npain.\n\nOn arrival to the cardiology service, he endorses history above. \nHe reports constant chest pain which is ___ and unchanged \nfrom prior. He does appear comfortable and has been mostly \nconcerned with anxiety surrounding inability to complete ADLs.\"\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS\n- Diabetes (+)\n- Hypertension (+)\n- Dyslipidemia (+)\n\n2. CARDIAC HISTORY\n- CABGx1 SVG-dRCA (___)\n- BMS to anomalous RCA ___, DES to OM ___\n- PACING/ICD: None\n\n3. OTHER PAST MEDICAL HISTORY\n- chronic knee pain from OA wheelchair-bound\n- anxiety \n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death.\n \nPhysical Exam:\nOn day of discharge:\nVitals: 24 HR Data (last updated ___ @ 800)\n Temp: 98.3 (Tm 98.4), BP: 119/73 (108-143/64-89), HR: 74 \n(70-78), RR: 18 (___), O2 sat: 96% (96-99), O2 delivery: Ra \nWeight: 113kg \nWeight on admission: 110.3 kg\nTelemetry: sinus rhythm\nGeneral: Well appearing, no apparent distress \nHEENT: Normocephalic, atraumatic. EOMI.\nNeck: Supple, trachea midline. \nLungs: Decreased breath sounds throughout, but otherwise clear \nto auscultation bilaterally in all lung fields. \nCV: RRR. Normal S1, S2. No murmurs, rubs or gallops. \nAbdomen: Bowel sounds present throughout. Nontender to palpation \nin 4 quadrants.\nExt: Warm, well perfused. No cyanosis\nNeuro: CN II-XII intact. UE strength ___ bilaterally. ___ \nstrength ___ bilaterally. Sensation intact and symmetric \nthroughout. Tone normal.\n\n \nPertinent Results:\nAt admission:\n___ 01:10PM BLOOD WBC-5.9 RBC-4.43* Hgb-12.8* Hct-39.4* \nMCV-89 MCH-28.9 MCHC-32.5 RDW-13.1 RDWSD-42.7 Plt ___\n___ 01:10PM BLOOD ___ PTT-28.0 ___\n___ 05:28AM BLOOD Glucose-153* UreaN-11 Creat-0.6 Na-141 \nK-3.9 Cl-101 HCO3-28 AnGap-12\n___ 01:10PM BLOOD ALT-22 AST-19 AlkPhos-104 TotBili-0.3\n___ 01:10PM BLOOD Lipase-18\n___ 01:10PM BLOOD cTropnT-<0.01\n___ 05:05PM BLOOD cTropnT-<0.01\n___ 01:10PM BLOOD Albumin-3.7\n\nInterim labs:\n\nAt discharge:\n\nCTA head/neck:\n1. No evidence of acute territorial infarction or intracranial \nhemorrhage.\n2. CT perfusion is nondiagnostic due to poor bolus timing.\n3. No evidence of large vessel occlusion, stenosis, aneurysm, or \ndissection.\n\nMRI brain:\n1. There is no evidence of hemorrhage, edema, mass, or \ninfarction. The ventricles and sulci are age-appropriate. There \nis no mass effect or midline shift. \n2. Scattered T2 and FLAIR hyperintense foci in the \nperiventricular and subcortical white matter are nonspecific, \nbut likely reflect chronic small \nvessel ischemic changes. \n3. There is mild mucosal thickening of the paranasal sinuses. \nThere is mild fluid signal in the left mastoid air cells. The \nintraorbital contents are unremarkable. \n\n \nBrief Hospital Course:\n#Chest Pain \nThe patient presented with chest pain similar to previous \nmultiple admissions over the last 6 months. Patient has known \nCAD and microvascular disease. Workup in the ED for ischemia was\nnegative. No pleurisy. Chest pain not responsive to sublingual \nnitroglycerin and the pain persisted through 2 sets of negative \nbiomarkers and repeated EKGs. During his most recent admission, \n___, his chest pain was thought to be related to \nanxiety. He was given small dose Ativan to see if the chest pain \nwould improve on anxiolytics, and although the pain improved, it \ndid not go away. The cause of the chest pain remains unclear, \nwith anxiety vs microvasular disease both possible. Low \nsuspicion for ACS. Given his known CAD, he was continued on \nImdur, but the timing of the dose was changed to nightly for \nimproved antianginal effect in the morning. \n\n#CAD\nPatient is s/p CABGx1 SVG-dRCA (___), BMS to anomalous RCA \n(___), and DES to OM (___). Additionally, coronary \nangiography on ___ showed stable nonobstructive CAD with \nevidence of diffuse microvascular disease. Nuclear stress on \n___ was normal. Troponin negative x 2 this admission. EKG \nwithout ischemic changes x4. Initially, it was thought that the \nchest pain could be due to microvascular disease, but the pain \ndid not improve after nitroglycerin administration, making this \nunlikely. He was continued on his aspirin and Plavix, as well as \nToprol XL. His Imdur was changed to nightly, as stated above.\n\n#Anxiety \nPatient has a hx of anxiety, however, he is not followed by a \ntherapist or a psychiatrist as an outpatient and is not on an \nSSRI. His stress is worsened by his inability to perform his \nADLs. Pt denies anxiety specifically but endorses significant \nworry and stress. He was trialed on Ativan 0.5mg prn on prior \nadmission and currently, with some relief, and discharged with \nlimited course. Recommend trial of longer acting anxiolytic, \nSSRI or a TCA for anxiety symptoms. Social work was consulted \nfor assistance with discharge planning and coping. It was felt \nthat discharging the patient back to a hotel was unsafe given \nfailure of this strategy requiring rehospitalization. He was set \nup with a complex case manager and discharged to a SNF.\n\n#Code stroke in ED\nWhile in the ED, the patient had an episode where he felt unable \nto speak. A code stroke was called. NIHSS 0. The episode was \nbrief and the symptoms resolved by time the patient was \nevaluated by neurology. CT head and CTA head/neck showed no \nevidence of hemorrhage. The patient had no residual deficits or \nrecurrence of his symptoms. He was monitored on telemetry for \nthe duration of his hospital stay and no arrhythmias were \nrecorded. MRI brain was obtained with no evidence of bleed or \nacute ischemia. The transient speech difficulty was felt highly \nunlikely to represent TIA, and was not due to stroke given lack \nof findings on imaging. His symptoms, given his underlying \npsychiatric symptoms, are more consistent with a functional \nneurologic symptom disorder. Neurology recommended 1 month of \noutpatient heart monitoring, but this was deferred given lack of \nMRI findings and no recorded arrhythmias on telemetry, \nsuggesting a low likelihood of arrhythmia leading to an embolic \nevent. This should be readdressed by the PCP.\n\n#T2DM\nHome ___ held while hospitalized, but restarted at discharge. \nPatient covered with sliding scale insulin while in hospital. \n\n#Osteoarthritis\nPatient reports history of work injury and is s/p bilateral knee \nreplacement complicated by chronic knee pain. Patient is unable \nto bear weight and is wheelchair-bound. Patient is reportedly \nplanning for surgery however, needs to be stable from cardiac \nperspective. He was continued on his home analgesic regimen \nwithout changes. \n\n#Prior UTI\nPatient was found to have Klebsiella UTI at last admission \n___. He remained on ___ with plan to finish course ___. \n\n\nThis patient was prescribed, or continued on, an opioid pain \nmedication at the time of discharge (please see the attached \nmedication list for details). As part of our safe opioid \nprescribing process, all patients are provided with an opioid \nrisks and treatment resource education sheet and encouraged to \ndiscuss this therapy with their outpatient providers to \ndetermine if opioid pain medication is still indicated.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n5. Clopidogrel 75 mg PO DAILY \n6. Gabapentin 300 mg PO TID \n7. GlipiZIDE 10 mg PO BID diabetes \n8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n9. Lidocaine 5% Patch 1 PTCH TD QAM \n10. LORazepam 0.5 mg PO BID:PRN anxiety \n11. MetFORMIN (Glucophage) 1000 mg PO BID \n12. Metoprolol Succinate XL 50 mg PO DAILY \n13. Multivitamins 1 TAB PO DAILY \n14. Pantoprazole 40 mg PO Q24H \n15. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n16. Tamsulosin 0.4 mg PO QHS \n17. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n18. melatonin 3 mg oral QHS \n19. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second \nLine \n20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n21. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection \n\n \nDischarge Medications:\n1. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS \n2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n6. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n7. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection \nDuration: 2 Doses \n8. Clopidogrel 75 mg PO DAILY \n9. Gabapentin 300 mg PO TID \n10. GlipiZIDE 10 mg PO BID diabetes \n11. Glargine 18 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n12. Lidocaine 5% Patch 1 PTCH TD QAM \n13. LORazepam 0.5 mg PO BID:PRN anxiety \n14. melatonin 3 mg oral QHS \n15. MetFORMIN (Glucophage) 1000 mg PO BID \n16. Metoprolol Succinate XL 50 mg PO DAILY \n17. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second \nLine \n18. Multivitamins 1 TAB PO DAILY \n19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n20. Pantoprazole 40 mg PO Q24H \n21. Tamsulosin 0.4 mg PO QHS \n22. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nChest pain\nCoronary artery disease\nTransient aphasia\nUrinary tract infection\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 taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL? \n- You were admitted to the hospital because of chest pain\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL? \n- In the emergency room, you had an episode where you were \nunable to speak, so you were evaluated by the neurology team\n- Your chest pain was evaluated with EKGs and lab work, all of \nwhich was reassuring and not indicative of a cardiac cause of \nyour chest pain. Your pain was felt to be most likely related \nto anxiety \n- You were evaluated by the physical therapists who felt you \nwould benefit from a rehab facility. We agreed, so you were \ndischarged to a skilled nursing facility to help you with \nself-care and medication administration\n\nWHAT SHOULD I DO WHEN I GO HOME? \n- You should continue to take your medications as prescribed. \n- You should attend the appointments listed below. \n- 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\nWe wish you the best! \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "R079", "N390", "R4701", "R531", "R51", "F419", "I2510", "I10", "E785", "E119", "G8929", "M25562", "M25561", "Z96653", "B961", "N400", "Z951", "Z955", "Z993", "Z7902" ]

[ "R079: Chest pain, unspecified", "N390: Urinary tract infection, site not specified", "R4701: Aphasia", "R531: Weakness", "R51: Headache", "F419: Anxiety disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "G8929: Other chronic pain", "M25562: Pain in left knee", "M25561: Pain in right knee", "Z96653: Presence of artificial knee joint, bilateral", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z993: Dependence on wheelchair", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "N390", "F419", "I2510", "I10", "E785", "E119", "G8929", "N400", "Z951", "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:\nChest Pain\n \nMajor Surgical or Invasive Procedure:\nPercutaneous Coronary Intervention (PCI) ___\n\n \nHistory of Present Illness:\n___ y.o. M w/ h/o CAD w/anomalous\nRCA, prior NSTEMI w/BMS to anomalous RC and CABG w/SVG to\nanomalous ___ ___, DM2, HTN, and HLD who presents \nw/worsened\nchest pain. He states that his chest pain began around 4 pm this\nafternoon while watching TV and was at its worst in the right\nside of his chest. It is associated with tingling that spreads\ndown his right arm. He took SLNTG with some relief which \nimproved\nto 'discomfort.'\n\nPatient was last seen in the ED on ___ at that time, he\nunderwent stress test which revealed mild fixed defect and\nhypokinesis of septum c/w patient's prior CABG, no perfusion\ndefects or other wall motion abnormalities, EF 61%, CTA chest \nw/o\nPE. He was subsequently discharged. \n\nSince ___ discharge, patient has noted more frequent \nepisodes\nof chest pain; he states he never used to take SLNTG but now has\nbeen taking SLNTG ___ times/day. Symptoms are relieved briefly \nby\nSLTNG but recur. Chest pain can occur at rest (minimally active,\noften in wheelchair). He describes it as a sensation of chest\nheaviness/tightness with some arm radiation, similar to prior \nMI.\nGiven more frequent SLNTG use and chest pain, he presented to ED\nagain today.\n\nHe denies vomiting, diarrhea, lightheadedness, palpitations,\nfevers, cough, sore throat, abdominal pain, bleeding, or black\nstools\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS\n- Diabetes (+)\n- Hypertension (+)\n- Dyslipidemia (+)\n\n2. CARDIAC HISTORY\n- CABG: ___\n- PERCUTANEOUS CORONARY INTERVENTIONS: ___ (BMS to proximal\nanomalous RCA), ___\n- PACING/ICD: None\n\n3. OTHER PAST MEDICAL HISTORY\n- Osteoarthritis\n- Constipation\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death.\n \nPhysical Exam:\nAdmission:\nVS: 97.9PO ___\nGENERAL: NAD, AAOx3\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\nDERM: warm and well perfused, no excoriations or lesions, no\nrashes\n\nDischarge:\nGen: in NAD, ambulating in halls\n Neuro: alert and oriented x4, no focal deficits or asymmetries. \n\nAmbulation is very slow with difficulty standing up due to knee\npain. No obvious focal weaknesses.\n Neck/JVP: neg JVD, neg carotid bruits bilaterally\n CV: RRR, S1/S2 no m/r/g or clicks\n Chest: CTA throughout, no wheezes/rubs or accessory use\n ABD: soft/nt/nd with +BS throughout, no rebound tenderness or\nguarding and no hepatosplenomegaly\n Extr: +peripheral pulses, no clubbing/cyanosis or edema\n Skin: warm/dry and well perfused\n Access sites: RRA with no hematoma or ecchymosis.\n \nPertinent Results:\nAdmission Labs:\n___ 08:00PM BLOOD WBC-5.2 RBC-4.47* Hgb-13.5* Hct-41.4 \nMCV-93 MCH-30.2 MCHC-32.6 RDW-12.4 RDWSD-42.4 Plt ___\n___ 08:00PM BLOOD Glucose-150* UreaN-10 Creat-0.6 Na-138 \nK-4.3 Cl-100 HCO3-25 AnGap-13\n___ 08:00PM BLOOD cTropnT-<0.01\n___ 01:57AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 05:56AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 05:56AM BLOOD Triglyc-69 HDL-35* CHOL/HD-2.7 LDLcalc-45\n\nCath Report ___:\nCoronary Description\nThe coronary circulation is right dominant.\nLM: The Left Main, arising from the left cusp, is a large \ncaliber vessel. This vessel bifurcates into the Left Anterior \nDescending and Left Circumflex systems.\nLAD: The Left Anterior Descending artery, which arises from the \nLM, is a large caliber vessel. There is a 30% stenosis in the \nproximal segment. There is a 30% stenosis in the proximal and \nmid segments. The Septal Perforator, arising from the proximal \nsegment, is a small caliber vessel. The Diagonal, arising from \nthe proximal segment, is a medium caliber vessel.\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel. The ___ Obtuse Marginal, arising from the \nproximal segment, is a medium caliber vessel. There is an 80% \nstenosis in the mid segments. The ___ Obtuse Marginal, arising \nfrom the mid segment, is a medium caliber vessel.\nRCA: The Right Coronary Artery, arising from the mid cusp, is a \nlarge caliber vessel. There is a 50% in-stent restenosis in the \nmid segment. There is a stent in the mid segment. The Acute \nMarginal, arising from the proximal segment, is a small caliber \nvessel. The Right Posterior Descending Artery, arising from the \ndistal segment, is a medium caliber vessel. The Right \nPosterolateral Artery, arising from the distal segment, is a \nmedium caliber vessel.\nBypass Grafts:\nSVG: A medium caliber saphenous vein graft connects to the \ndistal segment of the RCA. This graft is patent.\n\nInterventional Details\nPercutaneous Coronary Intervention: Percutaneous coronary \nintervention (PCI) was performed on an ad hoc basis based on the \ncoronary angiographic findings from the diagnostic portion of \nthis procedure. A 6 ___ AL2 guide provided adequate support. \nCrossed with the IFR wire into the distal OM1 Predilated with a \n2.0 mm balloon and then deployed a 2.5mm x 12mm Onyx DES at 14 \natms for 15 seconds. THe stent delivery system was removed. \nFinal angiography revealed excellent results. There was no \nevidence of perforation, distal embolization or dissection and \n0% residual stenosis.\n\nComplications: There were no clinically significant \ncomplications.\n\nRecommendations\n• ASA 81mg per day\n• Plavix 75mg/day\n.\nDischarge labs:\n\n___ 08:20AM BLOOD WBC-4.0 RBC-4.53* Hgb-13.8 Hct-41.7 \nMCV-92 MCH-30.5 MCHC-33.1 RDW-12.6 RDWSD-42.5 Plt ___\n___ 08:20AM BLOOD ___ PTT-25.4 ___\n___ 08:35AM BLOOD UreaN-8 Creat-0.7 Na-140 K-4.5 Cl-102 \nHCO3-22 AnGap-16\n___ 05:56AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 01:57AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 05:56AM BLOOD Triglyc-69 HDL-35* CHOL/HD-2.7 LDLcalc-___ y.o. M w/ h/o CAD w/ anomalous RCA, prior NSTEMI w/ BMS to\nanomalous RC and CABG w/ SVG to anomalous dRCA ___, DM2, \nHTN,\nand HLD who presents w/ worsened chest pain requiring more SLNTG\nthan before, concerning for unstable angina.\n\n #. CAD/USA: Presents with increased chest pain episodes\nrequiring increasing use of SLNTG. Ruled out. PCI as above with\nDES to distal OM1. Chest pain overall is better today than\nyesterday, though had a minor fleeting episode during \nambulation.\nAppears to be tolerating isosorbide well with mild headache. \nHeart rate slightly slower today with increased metoprolol.\n- continue ASA 81 mg daily, isosorbide 30\n- start clopidogrel\n- inc atorvastatin 80 mg QHS\n- inc metoprolol to 75mg\n-Restart lisinopril\n-___ with Dr. ___ in 1 month\n-PCP ___ deferred as patient is going to rehab. \n\n #. Type 2 diabetes: Fingersticks in the mid ___. On metformin,\nbyetta, and glipizide as an outpatient, glipizide restarted but\ncontinue to hold metformin and Byetta. \n\n #. Severe osteoarthritis of bilateral knee status post\nreplacement in ___, with recent fall and severe pain with\nambulation.\n-Continue lidocaine ointment\n-Change APAP to around-the-clock\n-Start gabapentin 3 times daily\n-___ recommends continued rehab\n-___ with previous orthopedist here \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n3. GlipiZIDE 10 mg PO BID \n4. Lisinopril 5 mg PO DAILY \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n11. Lidocaine 5% Patch 1 PTCH TD QAM \n12. Milk of Magnesia 30 mL PO QHS:PRN Constipation - First Line \n13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n2. Gabapentin 300 mg PO TID \n3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Metoprolol Succinate XL 75 mg PO DAILY \n6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n7. Aspirin 81 mg PO DAILY \n8. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n9. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n10. GlipiZIDE 10 mg PO BID \n11. Lidocaine 5% Patch 1 PTCH TD QAM \n12. Lisinopril 5 mg PO DAILY \n13. MetFORMIN (Glucophage) 1000 mg PO BID \n14. Milk of Magnesia 30 mL PO QHS:PRN Constipation - First Line \n \n15. Multivitamins 1 TAB PO DAILY \n16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary Artery Disease\nDiabetes\nHypertension\nHyperlipidemia\nCAD\nSevere bilateral knee osteoarthritis\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 because of your symptoms of chest pain. You \nunderwent a cardiac catheterization in which a drug coated stent \nwas placed to open a blockage in your Left Cirucmflex (OM1) \ncoronary artery. \n\n Instructions regarding care of the right wrist access site are \nincluded with your discharge information. \n\n Please continue your current medications with the following \nchanges: \n - Continue Aspirin 81mg daily, lifelong. \n - Start Plavix 75mg daily, you should take this for a minimum \nof one year and ONLY stop when told by a cardiologist \nspecifically. \n - Hold Metformin for 48 hours after the procedure. \n - start isosorbide to prevent chest pain\n- start Tylenol and gabapentin to help with your knee pain\n\n It is very important to take all of your heart healthy \nmedications. In particular, aspirin and clopidogrel (Plavix) \nkeep the stents in the vessels of the heart open and help reduce \nyour risk 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 you may die from a massive \nheart attack. Please do not stop taking either medication \nwithout taking to your heart doctor, even if another doctor \ntells you to stop the medications. \n\n It is strongly recommended that you attend a cardiac rehab \nprogram in the near future. A referral form was provided to you \nthat lists the locations of these programs. Please bring this \nwith you to your follow up visit with your cardiologist, and \nthey will inform you when it is safe to begin a program. \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 It has been a pleasure to have participated in your care and we \nwish you the best with your health! \n \n Your ___ Cardiac Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I25110", "R0789", "I252", "Z951", "E119", "I10", "E785", "Z7984", "M170", "Z96653" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "R0789: Other chest pain", "I252: Old myocardial infarction", "Z951: Presence of aortocoronary bypass graft", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z7984: Long term (current) use of oral hypoglycemic drugs", "M170: Bilateral primary osteoarthritis of knee", "Z96653: Presence of artificial knee joint, bilateral" ]

[ "I252", "Z951", "E119", "I10", "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:\nChest Pain\n \nMajor Surgical or Invasive Procedure:\n___ Cardiac Cath\n\n \nHistory of Present Illness:\n___ y.o. male w/ h/o CAD\nw/anomalous RCA, prior NSTEMI w/BMS to anomalous RC and CABG\nw/SVG to anomalous dRCA ___ and s/p PCI ___ with DES to\ndistal OM1 on ASA and plavix, DM2, HTN, and HLD presenting with\nchest pain. He says he has been having chest pain intermittently\nsince discharge that he describes as sharp stabbing pains. He \nhas\nbeen taking SL nitro which improved his pain except for today.\nThis morning the patient developed substernal CP at rest that\nlasted 10 secs. At 4 ___ he developed L sided chest pressure ___\nat rest that was non-radiating and worsened with talking and got\nbetter with resting. The pain was also associated with\nlightheadness and he said it felt like pressure/squeezing. He\ntried NTG x3 and full-dose ASA with slight improvement. Denies\nnausea, vomiting, diaphoresis, abdominal pain, SOB. Initial\nreports from EMS was that the patient had ST depressions on EKG.\n\nHe was discharged to rehab ___ after undergoing PCI. He saw\nhis cardiologist on ___ as an outpatient at which point he\nreported frequent presyncopal episodes with standing and \nreported\nthat his blood pressure has been low. His lisinopril was \nstopped\nby the rehab but his symptoms continued. Dr. ___\nhis metoprolol and Imdur dosing. \n\nIn the ED...\n- Initial vitals: 96.9F, BP 120/80, RR 16, 100% on RA\n- EKG: Slight horizontal flattening of inferior leads, otherwise\nnot significantly changed from prior\n- Labs/studies notable for: Trop neg x1 \n- Patient was given: SL nitro x2 \n- Vitals on transfer: HR 81, BP 98/59, RR 25, 95% on RA\n\nOn the floor he reports that his chest pain improved from ___ \nto\n___ since receiving 2 SL nitro in the ED. He said the pain \nnever\nwent away completely. He received a ___ SL nitro during the\ninterview with ultimate resolution of chest pain. He reports \nthat\nhe was feeling lightheaded at his rehab when getting up to be\nwashed and reports that his SBP was as low as 74 during these\nepisodes. He says that once his Imdur and metoprolol doses were\nreduced he noticed improvement in those symptoms. \n \nPast Medical History:\n1. CARDIAC RISK FACTORS\n- Diabetes (+)\n- Hypertension (+)\n- Dyslipidemia (+)\n\n2. CARDIAC HISTORY\n- CABG: ___\n- PERCUTANEOUS CORONARY INTERVENTIONS: ___ (BMS to proximal\nanomalous RCA), ___\n- PACING/ICD: None\n\n3. OTHER PAST MEDICAL HISTORY\n- Osteoarthritis\n- Constipation\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION:\n=====================\nVS: 97.4F, 122/78, HR 81, RR 18, 96% on RA\nGENERAL: Sitting on the edge of the bed, in no acute distress \nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nCHEST: pain not reproducible to palpation \nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\n\nDISCHARGE PHYSICAL EXAM:\nVS: 24 HR Data (last updated ___ @ 828)\n Temp: 98.6 (Tm 98.7), BP: 106/62 (103-128/62-80), HR: 84\n(79-94), RR: 17 (___), O2 sat: 96% (94-100) \n\nGENERAL: Sitting on the edge of the bed, in some pain.\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD\nCV: NR, RR. Nl S1, S2. No m/r/g.\nCHEST: Pain not reproducible to palpation \nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\n\n \nPertinent Results:\nADMISSION/PERTINENT LABS\n========================\n___ 06:43PM BLOOD WBC-5.0 RBC-4.38* Hgb-13.4* Hct-40.5 \nMCV-93 MCH-30.6 MCHC-33.1 RDW-12.8 RDWSD-43.8 Plt ___\n___ 06:35AM BLOOD WBC-3.9* RBC-4.28* Hgb-12.9* Hct-39.7* \nMCV-93 MCH-30.1 MCHC-32.5 RDW-13.0 RDWSD-44.2 Plt ___\n___ 06:43PM BLOOD Neuts-56.3 ___ Monos-8.5 Eos-3.0 \nBaso-0.6 Im ___ AbsNeut-2.83 AbsLymp-1.57 AbsMono-0.43 \nAbsEos-0.15 AbsBaso-0.03\n___ 06:43PM BLOOD ___ PTT-26.8 ___\n___ 06:35AM BLOOD Glucose-173* UreaN-14 Creat-0.7 Na-140 \nK-4.4 Cl-103 HCO3-25 AnGap-12\n___ 06:43PM BLOOD cTropnT-<0.01\n___ 12:58AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 08:31AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 06:35AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0\n\nSTUDIES\n=======\nCath ___\nLM: The left main coronary artery had mild plaquing.\nLAD: The left anterior descending coronary artery had an ostial \n30% stenosis. The mid LAD had a slightly hazy 30% stenosis \nunchanged from prior angiogram. The distal LAD wrapped well \naround the apex. Flow in the LAD was delayed and pulsatile, \nconsistent with microvascular dysfunction.\nCirc: The circumflex coronary artery had a near ostial 20% \nplaque. The retroflexed OM1 had an origin 40% stenosis. The mid \nOM1 was angulated with some dynamic bending during systole. The \nangulated OM2 had mild proximal plaquing. The AV groove CX was \nretroflexed after OM2 with mild plaquing\nbefore supplying 2 LPLs. Flow in OMs and LPLs was delayed, \nconsistent with microvascular dysfunction.\nRCA: The right coronary artery arose anomalously adjacent to the \nLMCA and had mild luminal irregularities. The proximal stent had \nmild in-stent restenosis. There was competitive flow in the mid \nRCA from the SVG.\nSVG-RCA: The saphenous vein graft to the distal RCA had luminal \nirregularities. There was antegrade perfusion into the RPDA and \nretrograde perfusion into the native mid RCA.\nComplications: There were no clinically significant \ncomplications.\nFindings\n1. Stable native coronary atherosclerosis with patent recent OM1 \nstent and mild restenosis of the prior\nstent in the anomalous RCA arising adjacent to the LMCA.\n2. Patent SVG-distal RCA.\n3. Diffuse slow pulsatile flow consistent with microvascular \ndysfunction.\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old man w/ h/o CAD w/anomalous RCA, prior \nNSTEMI w/BMS to anomalous RC and CABG w/SVG to anomalous dRCA \n___ and s/p PCI ___ with DES to distal OM1 on ASA and \nplavix, DM2, HTN, and HLD presenting with chest pain.\n\n# CORONARIES: Patent SVG-distal RCA, patent recent OM1 stent and \nmild restenosis of prior stent in anomalous RCA arising adjacent \nto LMCA, diffuse slow pulsatile flow consistent with \nmicrovascular dysfunction, \n# PUMP: EF 55%\n# RHYTHM: NSR\n\nACTIVE ISSUES\n=============\n# Unstable Angina\n# CAD\nH/o DES to OM1 last month, with remainder of vessels relatively \npatent. Had decreased Imdur and Metoprolol I/s/o presyncope at \nlast visit with Dr. ___. Presented with multiple intermittent \nepisodes of CP, initially atypical and mostly stabbing, then \nprogressive to more of a pressure sensation, which responded to \nNTG. Trops negative x3. EKGs unchanged. Started on NTG drip due \nto persistent pain. Underwent cath via RRA with no evidence of \nnew/progressive disease and all grafts and vessels similarly \npatent to prior study in ___. Increased imdur to 30mg. \nContinued on ASA, Plavix, Metoprolol, Atorvastatin.\n\n# Pre-syncope\nReports several episodes at rehab of orthostasis and pre-syncope \nand reports low systolic blood pressures. His lisinopril was \ndiscontinued but symptoms persisted. Imdur and metroprolol doses\nwere reduced at recent outpatient cardiology visit as above and \nsince then symptoms have resolved. Orthostatics here negative. \nIncreased imdur without recurrence in symptoms.\n\nCHRONIC ISSUES\n==============\n# Type 2 diabetes\nOn lantus, metformin, byetta, and glipizide as an outpatient. \nA1c 10.1% in ___ and since then has been started on \ninsulin. Continued on Lantus and ISS.\n\n# Severe osteoarthritis of bilateral knee status post \nreplacement\nWheelchair bound. Continued lidocaine patches, APAP, tramadol, \ngabapentin.\n\nTRANSITIONAL ISSUES\n===================\n[ ] Increased Imdur due to persistent CP though most likely \nsmall-vessel I/s/o no intervenable lesions on cath. Monitor for \npresyncope/syncopal symptoms.\n[ ] ___ likely continue with some CP; can take SL nitroglycerin \nfor pain that lasts more than a few seconds. If pain persists \ndespite SL nitro, should come to ED for evaluation.\n[ ] Patient brought up desire for surgery for OA of knees. \nDiscussed that orthopedics can communicate with Dr. ___ \n___ regarding ___ risk evaluation.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n5. GlipiZIDE 10 mg PO BID \n6. Lidocaine 5% Patch 1 PTCH TD QAM \n7. Metoprolol Succinate XL 25 mg PO DAILY \n8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n9. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n10. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY \n11. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n12. MetFORMIN (Glucophage) 1000 mg PO BID \n13. Milk of Magnesia 30 mL PO QHS:PRN Constipation - First Line \n14. Multivitamins 1 TAB PO DAILY \n15. Gabapentin 300 mg PO TID \n16. melatonin 3 mg oral QHS \n17. Glargine 18 Units Bedtime\n18. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \n19. Senna 17.2 mg PO DAILY \n\n \nDischarge Medications:\n1. Glargine 18 Units Bedtime \n2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n7. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL \nsubcutaneous BID \n8. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \n9. Gabapentin 300 mg PO TID \n10. GlipiZIDE 10 mg PO BID \n11. Lidocaine 5% Patch 1 PTCH TD QAM \n12. melatonin 3 mg oral QHS \n13. MetFORMIN (Glucophage) 1000 mg PO BID \n14. Metoprolol Succinate XL 25 mg PO DAILY \n15. Milk of Magnesia 30 mL PO QHS:PRN Constipation - First Line \n \n16. Multivitamins 1 TAB PO DAILY \n17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n18. Senna 17.2 mg PO DAILY \n19. TraMADol 75 mg PO Q6H:PRN Pain - Moderate \nRX *tramadol 50 mg 1.5 tablet(s) by mouth every six (6) hours \nDisp #*30 Tablet Refills:*0 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nUnstable Angina\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 taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital because you were having \nchest pain.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- We gave you medicine to treat your chest pain.\n- We did a cardiac catheterization to look at the stents and the \nblood vessels in your heart, which showed no new disease.\n- We changed your medications to try and reduce the frequency of \nyour chest pain.\n\nWHAT SHOULD I DO WHEN I GO HOME?\n- You should continue to take your medications as prescribed. \n- You should attend the appointments listed below. \n\nWe wish you the best!\nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I25110", "I951", "E119", "I10", "E785", "K5900", "M170", "E7800", "Z951", "Z955", "Z993" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "I951: Orthostatic hypotension", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K5900: Constipation, unspecified", "M170: Bilateral primary osteoarthritis of knee", "E7800: Pure hypercholesterolemia, unspecified", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z993: Dependence on wheelchair" ]

[ "E119", "I10", "E785", "K5900", "Z951", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nFatigue, decreased voice, globus sensation, drooling, diplopia: \nMyasthenia ___ Flare\n\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nThe patient is a ___ woman with medical history of MuSK \npositive myasthenia ___ with predominantly bulbar symptoms \nMGFA classification II-B followed in neurology clinic by Dr. \n___ presents to the ED for evaluation of worsening \nbulbar symptoms in the setting of a cold and medication \nnoncompliance. \n\nShe reports was in her usual state of health which includes \nindependence in all activities of daily living until ___. Of note she stopped taking her prednisone around ___ for the space of 2 weeks and felt well, so she discontinued \nthe use of her azathioprine (last filled in ___ as well). She \nthen developed an upper respiratory tract infection in ___ and has not been feeling like herself. Subsequently she \nhas been complaining of progressive fatigue which is especially \nworse at the end of the day or when climbing up stairs. She has \nalso noted her voice has a different quality as she is somewhat \nhypophonic and describes that her tongue is very slow. She has \nto repeat what she wants to say several times as people have \ntrouble comprehending her. Additionally she has been \ncomplaining of upper back pain like she is carrying camping bag. \n She reports a sensation like something is caught in her throat \nhowever denies choking. She does complain that her throat is \ndry but has persistent drooling. She is concerned that the \nsweating palms have returned. Her eyes are also tearing \nexcessively which is unusual for her and 2 days ago she \ndeveloped horizontal diplopia which resolves when covering \neither eye. She denies any breathing difficulties, nausea \nvomiting or diarrhea but reports poor appetite which has been a \nproblem in the past. \n\nShe initially presented in ___ with acute respiratory failure \nrequiring intubation and was found to have Musk antibody \npositive myasthenia ___ with predominantly bulbar features. \nHer initial symptoms were fluctuating diplopia, left eyelid \nptosis, dysphagia, dysarthria, lightheadedness and generalized \nweakness. She was treated with 5 days of plasma exchange and \nsubsequently prednisone. She had also been prescribed a BiPAP \nmachine upon discharge for overnight respiratory support. She \nhas been managed in neurology clinic by Dr. ___ \nhas slowly tapered her prednisone from 5060 mg p.o. daily down \nto 5 mg p.o. daily and continued her on azathioprine 50 mg every \nmorning and 100 mg every afternoon.\n\nNeurologic review of systems notable for the above-mentioned \nsymptoms otherwise unremarkable.\n\nOn general review of systems, the patient reports recent upper \nrespiratory tract infection. Otherwise denies fevers, rigors, \nnight sweats, or noticeable weight loss. Denies chest pain, \npalpitations, dyspnea, or cough. Denies nausea, vomiting, \ndiarrhea, constipation, or abdominal pain. No recent change in \nbowel or bladder habits. Denies dysuria or hematuria. Denies \nmyalgias, arthralgias, or rash.\n\n--------------- --------------- --------------- ---------------\n\nALLERGIES:\nAllergies (Last Verified ___ by ___:\nPatient recorded as having no known allergies to drugs \n\n \nPast Medical History:\nPMH/PSH:\nProblems (Last Verified ___ by ___, \nMD):\nMYASTHENIA ___ \nOSTEOPENIA \nPREDIABETES \nVITAMIN D DEFICIENCY \nHEADACHE \n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY:\nReports no family history of neurologic conditions\n\n \nPhysical Exam:\nADMISSION EXAMINATION: \nVitals: \n98.0 \n81 \n128/67 \n16 \n100% RA \nNIF > -60 \nFVC 2.5L\nGeneral: NAD\nHEENT: NCAT, LT proptosis without scleral irritation, no \noropharyngeal lesions\n___: RRR, no M/R/G\nPulmonary: CTAB, no crackles or wheezes\nAbdomen: Soft, NT, ND, +BS, no guarding\nExtremities: Warm, no edema\n\nNeurologic Examination:\nMS: Awake, alert, oriented x 3. Able to relate history without \ndifficulty. Attentive. Speech is fluent with full sentences, but \nmildly hypophonic. Normal prosody. No evidence of hemineglect. \nNo left-right confusion. Able to follow both midline and \nappendicular commands.\n\nCranial Nerves: PERRL 4->2 brisk. VF full to confrontation. \nEOMI, but notable for saccadic pursuit. Horizontal diplopia \nworse on LT gaze. Outer image disappears when covering her \nright eye. V1-V3 without deficits to light touch bilaterally. \nNo facial movement asymmetry. Hearing intact to finger rub \nbilaterally. Palate elevation symmetric. SCM/Trapezius strength \n___ bilaterally. Tongue midline. There is mild upgaze \nfatigability with frontalis activation, left greater than right \norbicularis oculi weakness on forced eye closure, full strength \nin her orbicularis oris, jaw and tongue. Does exhibit some \nweakness when trying to keep her cheeks puffed. Neck flexion \nand extension full-strength.\n\nMotor: Normal bulk and tone. No drift. No tremor or asterixis.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5 ___ ___ 4+ 5 5 5 5 5\nR 5 ___ ___ 4+ 5 5 5 5 5\n\nSensory: No deficits to light touch bilaterally. No extinction \nto DSS.\n\nDTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 2\nR 2 2 2 2 2\nPlantar response flexor bilaterally.\n\nCoordination: No dysmetria with finger to nose testing \nbilaterally. Good speed and intact cadence with rapid \nalternating movements.\n\nGait: Normal initiation. Narrow base. Normal stride length and \narm swing. Stable without sway. Negative Romberg.\nDISCHARGE EXAMINATION:\nVitals: T 98.6 BP 111 / 75 HR 71 RR 16 spO2 100 RA \nGeneral: thin ___ female, appears well, in no acute \ndistress\nHEENT: NCAT, LT proptosis without scleral irritation, no \noropharyngeal lesions, mild soft tissue swelling in anterior \nneck on left, no LAD\n___: RRR, no M/R/G\nPulmonary: CTAB, no crackles or wheezes, breathing comfortably \nwithout use of accessory respiratory muscles, counts to 30 in \none breath\nAbdomen: soft, NT, ND, +BS, no guarding\nExtremities: warm, no edema\n\nNeurologic Examination:\nMS: Awake, alert, oriented x 3. Able to relate history without\ndifficulty. Attentive. Speech is fluent with full sentences, but\nmildly hypophonic. Normal prosody. Able to follow both midline\nand appendicular commands.\n\nCranial Nerves: PERRL 6->4 brisk. VF full to confrontation. \nEOMI, but notable for saccadic pursuit. There is subtle hyper \nand exotropia on the left and exotropia on the right on \ncover-uncover tests. Lower lid retraction bilaterally. No \nreported diplopia on resting gaze and left gaze. Horizontal \ndiplopia on far right gaze with outside image disappearing with \ncovering right eye. Upgaze intact, with fatigability after 10 \nseconds. Mild bifacial weakness, left slightly greater than \nright, with decreased forehead wrinkling and orbicularis oris \nstrength, orbicularis oculi is ___ bilaterally. Hearing intact \nto finger rub bilaterally. Palate elevation symmetric. \nSCM/Trapezius strength ___ bilaterally. Tongue midline. \n\nMotor: Normal bulk and tone. No drift. No tremor or asterixis.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5 ___ ___ 5 5 5 5 5 5\nR 5 ___ ___ 5 5 5 5 5 5\nNeck flexion and extension ___.\nThere is fatigability to 4+ on the right deltoid.\n\nSensory: No deficits to light touch bilaterally. No extinction \nto DSS.\n\nDTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 2\nR 2 2 2 2 2\nPlantar response flexor bilaterally.\n\nCoordination: No dysmetria with finger to nose testing \nbilaterally. \n\nGait: Good initiation, narrow based gait with normal arm swing. \nCan ascend 2 flights of stairs with minimal dyspnea.\n\n \nPertinent Results:\nIMAGING:\nNoncontrast head CT with look at the orbits with No acute \nintracranial process. \n\nCXR without acute intrathoracic process\n\n___ 07:10AM BLOOD WBC-4.9 RBC-3.89* Hgb-11.5 Hct-35.5 \nMCV-91 MCH-29.6 MCHC-32.4 RDW-12.4 RDWSD-41.1 Plt ___\n___ 07:00PM BLOOD WBC-4.7 RBC-4.29 Hgb-12.7 Hct-39.6 MCV-92 \nMCH-29.6 MCHC-32.1 RDW-12.7 RDWSD-42.7 Plt ___\n___ 07:10AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-140 \nK-4.1 Cl-100 HCO3-23 AnGap-17\n___ 07:00PM BLOOD Glucose-89 UreaN-15 Creat-0.6 Na-140 \nK-4.9 Cl-100 HCO3-26 AnGap-14\n___ 07:00PM BLOOD ALT-11 AST-21 AlkPhos-68 TotBili-0.2\n___ 07:00PM BLOOD Lipase-19\n___ 07:00PM BLOOD TSH-2.2\n___ 07:00PM BLOOD T4-7.8\n___ 07:00PM BLOOD antiTPO-LESS THAN \n\n \nBrief Hospital Course:\nThe patient is a ___ year old woman with history of MUSK-ab \npositive myasthenia ___ who presents with a few weeks of \nfatigue, blurred vision, and hypophonia in the setting of a \nrecent respiratory viral illness, and after self-tapering her \nantimyasthenic medications several months ago. Her respiratory \nstatus was stable and inspiratory force/vital capacity in the \nnormal ranges. She had mild anterior neck swelling that was Her \nneurologic examination was notable for bilateral proptosis, \ndiplopia in horizontal endgaze and upgaze, mild bifacial \nweakness, and full motor power in skeletal muscles (including \nneck flexors/extensors) though with mild fatigability. An active \ninfection was excluded with negative CXR and UA. She was started \non prednisone 10mg daily and azathioprine 50mg BID and mestinon \n30 mg TID. Her fatigue and neurologic examination improved with \nthese interventions, and her respiratory status remained stable, \nwith consistent ability to count to 30 in one breath and daily \nrespiratory mechanics Nif -60 and VC 2.75. For neck swelling, \nTSH was negative, anti-TPO antibodies were also negative; she \nwill be ordered for outpatient thyroid ultrasound. Given her \ngood social supports with family to monitor her, she was deemed \nsafe to discharge with follow up in the ___ clinic \nwith her provider ___.\n\nTransitional issues:\n[ ] Consider uptitrating her prednisone to 20mg this week- \npatient will contact Dr. ___ to discuss this.\n[ ] Follow up with Dr. ___ on ___.\n[ ] Follow up thyroid ultrasound to be performed outpatient.\n\n \nMedications on Admission:\nMEDICATIONS: See the prescribed medication list below, however \nshe reports has not been taking any medications since ___ \n___. As per pharmacy records she last filled her as a therapy \nand prednisone in ___.\n\n--------------- --------------- --------------- ---------------\nActive Medication list as of ___:\n \nMedications - Prescription\nAZATHIOPRINE - azathioprine 50 mg tablet. 1 tablet(s) by mouth \ntwice daily\nERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000 \nunit capsule. 1 (One) capsule(s) by mouth weekly for 12 weeks\nFOLIC ACID - folic acid 1 mg tablet. 1 tablet(s) by mouth once a \nday\n \nMedications - OTC\nACETAMINOPHEN [TYLENOL] - Dosage uncertain - (OTC; as needed)\nCALCIUM CITRATE-VITAMIN D3 - calcium citrate-vitamin D3 315 \nmg-250 unit tablet. 2 (Two) tablet(s) by mouth once a day\nCHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) \n2,000 unit capsule. 2 (Two) capsule(s) by mouth once a day\nTOLNAFTATE [TINACTIN] - Tinactin 1 % topical spray. Apply to \naffected areas twice a day\n\n \nDischarge Medications:\n1. AzaTHIOprine 50 mg PO BID \nRX *azathioprine 50 mg 1 tablet(s) by mouth twice daily Disp \n#*60 Tablet Refills:*1 \n2. PredniSONE 10 mg PO DAILY \nRX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*1 \n3. Pyridostigmine Bromide 30 mg PO TID \nRX *pyridostigmine bromide [Mestinon] 60 mg/5 mL 2.5 mL by mouth \nthree times daily Refills:*1 \n4. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMUSK myasthenia ___ flare\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 because of recent fatigue, blurred vision, and \nvoice changes, which we felt was likely symptoms of a myasthenia \nflare, which probably resulted from a recent viral infection. \nBecause this is now your second presentation of myasthenia, we \nrestarted you on your medications, including Azathioprine at \n50mg twice daily, and prednisone, at a low dose of 10mg daily. \nYou will need to remain on these medications for a prolonged \nlength of time in order to prevent another myasthenia flare. For \nsymptomatic relief, we also started on you a medication called \nMestinon (pyridostigmine), at a dose of 30mg, which you may take \nthree times a day.\n\nFortunately, you responded well to the above treatments. Your \nrespiratory status was monitored and you showed no sign of any \nweakness in your breathing muscles. Your neurologic examination \nwas also improved. Therefore, we will discharge you home as long \nas you remain well monitored by your family members and come \nback to the Emergency Department for any signs of worsening or \ndevelopment of difficulty breathing. You should call Dr. \n___ and keep your follow up appointment with \nher on ___ in order to address next steps.\n\nIt was a pleasure taking care of you. We wish you the best!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "G7001", "Z9114", "M8580", "R7303", "E559" ]

[ "G7001: Myasthenia gravis with (acute) exacerbation", "Z9114: Patient's other noncompliance with medication regimen", "M8580: Other specified disorders of bone density and structure, unspecified site", "R7303: Prediabetes", "E559: Vitamin D deficiency, unspecified" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nMyasthenia ___ subacute worsening\n \nMajor Surgical or Invasive Procedure:\ntunneled plasmapheresis catheter\n \nBrief Hospital Course:\nMs. ___ is a ___ y/o female w/ myasthenia ___ (MUSK +) who \npresented to the ED for b/l leg pain. Pain improved w/ \nanalgesics.\nShe has also had subacute worsening of her myasthenic symptoms.\nExam only significant for diplopia on L-lateral gaze.\nNo respiratory signs/symptoms.\nIt was decided to have her admitted.\nCase was discussed w/ Dr. ___ neurologist), \nwho felt that pt needs pheresis catheter placed for recurrent \noutpt plasmapheresis.\nIt was arranged for ___ to place pheresis catheter.\nAfter catheter placement, pt reported chest pain at site of line \nplacement. Likely pleuritic pain; CXR negative. Pain improved by \nAM.\nDischarged in stable condition to continue outpt care.\nShe will undergo plasmapheresis as outpt starting ___ and f/up \nw/ Dr. ___ in clinic.\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nMyasthenia ___ (subacute worsening)\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nMs. ___,\n You were diagnosed with a worsening of your myasthenia ___ \nthat will require plasmapheresis. For this, you had a \nplasmapheresis catheter placed. You will receive plasma exchange \non ___, and ___. You should also follow-up with Dr. \n___ in clinic.\n \nFollowup Instructions:\n___\n" ]

[ "G7000", "E663", "Z6829", "E559" ]

[ "G7000: Myasthenia gravis without (acute) exacerbation", "E663: Overweight", "Z6829: Body mass index [BMI] 29.0-29.9, adult", "E559: Vitamin D deficiency, unspecified" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCelebrex / codeine / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nunwitnessed fall with headstrike\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nIn brief, this is a ___ year-old woman with a history of R \nthalamic stroke, recent scapula and R 2nd rib fx, h/o syncope \nand orthostatic hypotension, who initially presented s/p \nunwitnessed fall at ___.\n\nShe was brought to ___ ED on ___ early morning. Vitals: \n145/78; 68; 22; 96.4; 90%RA->96% 2L O2. Troponin T < 0.01. CT \nhead negative for bleed. CT C-spine with minimally displaced \nfracture of C7 facet and transverse process. There was no \nneurosurgeon on call so she was transferred to ___ on ___ for \nneurosurgery evaluation.\n \nAt ___, Neurosurgery evaluated and recommend conservative \nmanagement with outpatient follow-up and imaging in 1 month. She \nwas admitted to ___ service for monitoring. Overnight ___ she \ntriggered for tachypnea to 32-34 and increasing hypoxia with new \n4L O2 requirement. She was also noted to be febrile to Tmax \n101.0. CXR re-demonstrated L pleural effusion seen on OSH film. \nGiven her new O2 requirement and isolated fever, the patient was\ntransferred to medicine for further management.\n\nOn arrival to the floor, the patient states that she feels very \ntired, but does not have any specific complaints. Does not think \nshe has had fevers and chills. Does not report chest pain, \nshortness of breath, nausea, vomiting, abdominal pain, and \nchanges in bowel or bladder habits.\n\nFor complete medication, past medical, social and family \nhistories please see the admission note.\n\nROS: Full 10 point ROS otherwise negative except as described \nabove\n\n \nPast Medical History:\nPMH: Falls, thalamic stroke, dysphagia, cognitive communication \ndeficit, anxiety, osteoporosis, scapular fracture, compression \nfractures, 2nd rib fracture, constipation, hypertension, UTIs, \nbronchitis, left pleural effusion\n\nPSH: THR\n \nSocial History:\n___\nFamily History:\nUnable to obtain given poor historian\n \nPhysical Exam:\nAdmission Physical Exam:\n===========================\nVitals: T 95.5 HR 57 BP 132/55 RR 22 SatO2 98% 2L NC \nGeneral: NAD, Alert, oriented to person and place\nNeck: no signs of trauma to the head C collar in place, No \ntenderness to palpation of the spine, from cervical to sacral\nLungs: CTA bil\nChest: No tenderness to palpation of the chest\nAbdomen: soft, non-tender, non-distended\nPelvis stable\nMotor and sensory intact in 4 extremities, no deformity\nNo edema\n\nDischarge Physical Exam:\n===========================\nVitals: 99.1, HR 71, BP 136/77, RR 18, 93% 2L \nGen: sitting up in chair, c-collar in place, awake and alert \nHEENT: EOMI, MMM, oropharynx clear\nNeck: Aspen C-collar in place \nPULM: CTAB in anterior lung fields, no wheezes, rales, or \nrhonchi\nCV: RRR, nl S1/S2, no m/r/g/t \nAbd: softly distended, minimally periumbilical tenderness, no \nrebound or guarding\nExt: no clubbing or cyanosis, warm and well-perfused \nNeuro: difficult neuro exam due to mental status; pt able to \nlift right leg with strength ___, left leg ___. Good \ndorsiflexion and plantarflexion. Good hand grips bilaterally. \nFollows simple commands (\"squeeze fingers, lift arms/legs\") \nMental Status: inattentive, lethargic, generally hypoactive \n\n \nPertinent Results:\nADMISSION LABS ___:\n==========================\nGLUCOSE-88 UREA N-21* CREAT-0.8 SODIUM-140 POTASSIUM-4.2 \nCHLORIDE-101 TOTAL CO2-27 ANION GAP-12 CALCIUM-8.3* \nPHOSPHATE-3.4 MAGNESIUM-1.9\nWBC-9.3 HGB-12.3 HCT-38.3 MCV-95 PLT COUNT-155\n___ PTT-22.6* ___\nProBNP 362\n\nSIGNIFICANT LABS:\n==========================\nOSH: troponin < 0.01\n\nDISCHARGE LABS:\n==========================\n___ 05:20AM BLOOD WBC-8.7 RBC-3.73* Hgb-11.4 Hct-34.8 \nMCV-93 MCH-30.6 MCHC-32.8 RDW-13.9 RDWSD-47.4* Plt ___\n___ 05:20AM BLOOD Glucose-84 UreaN-18 Creat-0.8 Na-142 \nK-4.1 Cl-104 HCO3-30 AnGap-8*\n___ 05:20AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8\n\nIMAGING:\n==========================\n___: OSH CT Head: No intracranial injury\n\n___: OSH CR Chest:\nMinimally displaced fracture of R C7 facet and right transverse \nprocess. Fracture extends through the transverse foramen and \ncould be associated with vertebral artery injury\n\n___: CXR:\nNo definite focal consolidation. Improved pulmonary vascular \ncongestion. Probable small left pleural effusion. \n\n___: CXR:\nLungs are low volume with bibasilar atelectasis. \nCardiomediastinal silhouette is stable. \nSmall left small bilateral pleural effusions are unchanged. No \npneumothorax is seen \n\nMICROBIOLOGY:\n==========================\n___ URINE \nColor-Yellow Appear-Clear Sp ___ Blood-NEG Nitrite-NEG \nProtein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG \npH-6.0 Leuks-NEG\n\n___ URINE\nColor-Yellow Appear-Clear Sp ___ Blood-NEG Nitrite-NEG \nProtein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG \npH-6.0 Leuks-MOD*\nRBC-7* WBC-28* Bacteri-FEW* Yeast-NONE Epi-<1\n\n___ 12:06 am URINE Source: Catheter. \n**FINAL REPORT ___\nURINE CULTURE (Final ___: ENTEROCOCCUS SP: \n10,000-100,000 CFU/mL. \nAMPICILLIN------------ <=2 S\nNITROFURANTOIN-------- <=16 S\nTETRACYCLINE---------- <=1 S\nVANCOMYCIN------------ 1 S\n\n \nBrief Hospital Course:\nSUMMARY:\n=======================\n___ with history of right thalamic stroke, recent scapula and R \n2nd rib fx, h/o syncope and orthostatic hypotension presents s/p \nunwitnessed fall at ___. Course complicated by hypoxia and \nhypoactive delirium. \n\nACTIVE ISSUES:\n=======================\n# Fall, unwitnessed:\n# Minimally displaced fracture of C7 facet and transverse \nprocess:\nArrived to ___ ED on ___ s/p unwitnessed fall + head \nstrike. Vitals notable for new 2L O2 requirement. Troponin T < \n0.01. EKG with sinus bradycardia 57. CT head negative for bleed. \nCT C-spine with minimally displaced fracture of C7 facet and \ntransverse process. Transferred to ___ for neurosurgery \nevaluation. Recommended conservative management (c-collar) with \noutpatient follow-up and imaging in 1 month. Pt's daughter \nreports pt has frequent dizzy spells at ___. Given bradycardia \non admission, home metoprolol 100mg once daily was decreased to \n50mg once daily. \n\n# Hypoxia:\n# Left pleural effusion:\n# Aspiration risk:\nTriggered overnight ___ for hypoxia (4L O2 requirement), \nassociated with low grade fever and mild leukocytosis. CXR \nnotable for a left small to moderate pleural effusion of unknown \nchronicity. Fevers and leukocytosis resolved within 24 hours. \nShe was on room air-1L O2 during the day and ___ at bedtime. \nHer acute episode was attributed to an aspiration event and we \ndid not think that the small pleural effusion was contributing \nsignificantly to her hypoxia or mental status. Speech and \nswallow recommended ground, nectar thickened food, meds whole in \npuree and 1:1 supervision with feeds. Plan for surveillance CXR \nat rehab next week. \n\n# Hypoactive delirium:\nPt alert and oriented x1 throughout the admission. She was \ninattentive, emotionally labile (crying spells) and would fall \nasleep during conversations. Etiology multifactorial: underlying \ncognitive impairment, hospitalization, fracture/pain/c-collar, \nhypoxia, constipation, and a likely urinary tract infection. \nPain was addressed the Acetaminophen and lidocaine patches. She \nrequired suppositories and an enema to relieve her constipation. \nLines and tubes were limited. Deliriogenic medications held \n(e.g. home benzodiazepine). She was treated for a CAUTI (see \nbelow). Mental status slowly improving. \n\n# Catheter associated urinary tract infection, \nampicillin-sensitive enterococcus:\n# Urinary retention:\nPrior to admission the patient was treated for a UTI with \nciprofloxacin. Admission UA unremarkable w/ negative culture. \ns/p catheter placement ___. Pancultured on ___ for fever and \nrepeat UA showed moderate leuks, trace protein, 28 WBC/hpf and \nfew bacteria with no squamous cells. Culture grew enterococcus \n10,000-100,000 CFU. Given the delirium, low grade fever and mild \nleukocytosis and recent catheterization, the patient was treated \nfor a catheter associated UTI. Pending sensitivities she \nreceived vancomycin (___) and was transitioned to \namoxicillin on ___ for completion of a ___uring \nthis time, the patient was intermittently retaining urine and \nrequiring straight caths, thought to be secondary to trauma from \nthe foley in addition to constipation. This resolved by \ndischarge. Pt is incontinent at baseline.\n\n# Constipation: resolved with aggressive bowel regimen. Likely \ncontributed to delirium and urinary retention. \n\nCHRONIC ISSUES:\n=======================\n# Hypertension: HCTZ held during hospitalization\n\n# Scapula and R 2nd rib fx, recent: pain management with \nacetaminophen and lidocaine patch. Home tramadol was held due to \nconcern altered mental status\n\n# History of right thalamic stroke: continued home aspirin \n325mg; consider decreasing to 81mg if indicated\n\n# Anxiety: intermittent episodes of acute anxiety. However, \ngiven delirium, home clonazapam was held. Per ___ records, she \nhad not received it in 5 days, therefore there was no concern \nfor withdrawal. \n\nTRANSITIONAL ISSUES:\n=======================\nCode status: Full, presumed\nContact: Daughter, ___ ___\n\n- Fall, unwitnessed:\n[ ] Metoprolol succinate decreased from 100mg to 50mg; assess \nheart rates and whether this has helped with \"episodes of \ndizziness\"\n\n- Hypoxia\n[ ] 1L intermittent O2 requirement at discharge\n[ ] Please obtain surveillance chest x-ray (PA and lateral) \nafter completion of antibiotics (___) to determine interval \nchange of left pleural effusion. \n[ ] Modified diet (see below) to help prevent aspiration\n\n- Hypoactive delirium\n[ ] Continue to reorient, avoid delirogenic medications, and \nmonitor for infections. If new focal neurologic findings are \ndiscovered (none at discharge) could consider head CT\n\n- CAUTI\n[ ] Amoxicillin 500mg PO TID (final day ___\n\n- Hypertension:\n[ ] Restart HCTZ if medically indicated\n\n- History of stroke:\n[ ] Consider decreasing home ASA 325mg to ASA 81mg if indicated\n\n- Anxiety:\n[ ] Would consider discontinuing all BZDs, especially given risk \nof delirium and frequent falls\n \nMedications on Admission:\nacetaminophen 325 mg every ___ hrs\nAcidophilus BID\nAspirin 325 mg daily\nAtorvastatin 40 mg daily\nDiazepam 5 mg BID\nDocusate sodium 100 mg BID\nAllergy Relief (fluticasone) 50 mcg/actuation nasal \nHydrochlorothiazide 25 mg daily\nMelatonin 3 mg daily\nToprol XL 100 mg daily\nTramadol 50 mg every ___ hours\n \nDischarge Medications:\n1. Amoxicillin 500 mg PO TID Duration: 5 Days \n2. Bisacodyl ___AILY:PRN constipation \n3. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain \n4. Polyethylene Glycol 17 g PO DAILY Please hold for loose \nstools \n5. Senna 8.6 mg PO BID \n6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Acidophilus (Lactobacillus acidophilus) 1 quantity oral \nDAILY \n9. Aspirin 325 mg PO DAILY \n10. Atorvastatin 40 mg PO QPM \n11. Docusate Sodium 100 mg PO BID \n12. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n13. melatonin 3 mg oral QHS \n14. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication \nwas held. Do not restart Hydrochlorothiazide until your doctor \nsays it is safe to do so\n15. HELD- TraMADol 50 mg PO Q6H:PRN Pain - Moderate This \nmedication was held. Do not restart TraMADol until your doctor \nsays it is safe to do so\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n================\nFall, unwitnessed \nMinimally displaced fracture of C7 facet and transverse process\n\nSECONDARY:\n================\nHypoxia, left pleural effusion, aspiration risk\nHypoactive delirium\nCatheter associated urinary tract infection, \nampicillin-sensitive enterococcus\nUrinary retention\nConstipation\nHypertension\nScapula and R 2nd rib fx, recent\nRight thalamic stroke, history of\nAnxiety\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid \n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ after \na fall. You have a small fracture in your spine and it is \nimportant that you wear a cervical collar until you follow up \nwith the neurosurgeon in clinic. \n\nWhile you were in the hospital, you needed oxygen to help you \nbreathe but this got better. You were also treated for a urinary \ntract infection and will need to keep taking your antibiotics \nwhen you leave. \n\nIt was a pleasure taking part in your care. We wish you all the \nbest with your future health!\n\nSincerely,\nThe team at ___\n \nFollowup Instructions:\n___\n" ]

[ "S12600A", "G9340", "T83511A", "N390", "J90", "J9811", "W19XXXA", "Y92129", "R296", "Z9181", "S42109D", "S2231XD", "Z8673", "Z87440", "F419", "I951", "R1310", "R0902", "M810", "I10", "R41841", "F0390", "B952", "Y846", "Y92230", "R339", "K5900", "E8770" ]

[ "S12600A: Unspecified displaced fracture of seventh cervical vertebra, initial encounter for closed fracture", "G9340: Encephalopathy, unspecified", "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "N390: Urinary tract infection, site not specified", "J90: Pleural effusion, not elsewhere classified", "J9811: Atelectasis", "W19XXXA: Unspecified fall, initial encounter", "Y92129: Unspecified place in nursing home as the place of occurrence of the external cause", "R296: Repeated falls", "Z9181: History of falling", "S42109D: Fracture of unspecified part of scapula, unspecified shoulder, subsequent encounter for fracture with routine healing", "S2231XD: Fracture of one rib, right side, subsequent encounter for fracture with routine healing", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87440: Personal history of urinary (tract) infections", "F419: Anxiety disorder, unspecified", "I951: Orthostatic hypotension", "R1310: Dysphagia, unspecified", "R0902: Hypoxemia", "M810: Age-related osteoporosis without current pathological fracture", "I10: Essential (primary) hypertension", "R41841: Cognitive communication deficit", "F0390: Unspecified dementia without behavioral disturbance", "B952: Enterococcus as the cause of diseases classified elsewhere", "Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R339: Retention of urine, unspecified", "K5900: Constipation, unspecified", "E8770: Fluid overload, unspecified" ]

[ "N390", "Z8673", "F419", "I10", "Y92230", "K5900" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nErythromycin Base / medline brand surgical film (NOT tegederm \nbrand) / Iodinated Contrast Media - IV Dye / thimerosal / \nNeomycin / fentanyl\n \nAttending: ___.\n \nChief Complaint:\nAbd pain -- second opinion\n \nMajor Surgical or Invasive Procedure:\nIleoscopy\n\n \nHistory of Present Illness:\n___ with h/o ulcerative colitis (s/p ileoanal pouch ___ \nresection for closed loop bowel stricture, s/p loop ileostomy \n___ for anastomotic leak, s/p permanent ileostomy ___ at \n___, s/o LOA ___, chronic abdominal pain with multiple \nhospitalizations, depression, chronic opiate use, anxiety \ndisorder is transferred from ___ for second opinion of \nabdominal pain.\n\nAdmitted ___ to ___ surgical service with abdominal \npain, bloating, nausea. Fluoroscopic small bowel series ___ \nwas without obstruction.CT abd/pelvis ___ showed no \nobstruction, though showed portion of small bowel adhered to the \nwall, 6 x 4 cm presacral fluid collection with question ovarian \ncyest versus postop seroma. Was seen also by GI service and \nthought was possible ileus. Was on up to 15mg Oxycodone q4hr \nand still requesting breakthrough IV dilaudid for breakthrough. \nSurgical, GI and pain service saw her and determined no clear \nrole for IV narcotics, and concurrent opiate risks for \nhyperalgesia and decreased intestinal motility. \n\nRe-admitted ___ ___ clinic with pain aftger toast and \ninability to keep down PO. Continued symtoms of bloating, \nintermittent absence of ostomy output followed by immediate \nlarge volume release. She was on oral oxycodone with \nintermittent IV dilaudid administrations, and had heightened \nanxiety. OSH notes reflect multiple conversations with GI, \nsurgery, psychiatry, medical team, patient and husband around \nopiate use. There was questionable suicidal ideation on ___ \nwhich prompted the psychiatric evaluation.\n\nShe was difficult to arouse upon meeting her, though when awake \nshe was able to give a history. She would intermittently c/o \nabdominal pain when we approached a discussion of setting \ngeneral expectations with respect to pain management and her \nexpectation that the ___ team missed the diagnosis. She \nbelieves she has a problem \"behind the stoma\" and has read about \nstomal stenosis.\n\nROS: \n(-) fevers, vomiting, weight loss, paresthesias, bloody stool\n(+) bloating, intermittent cramping, thicker ostomy output\n\nOther 10pt ROS negative\n \nPast Medical History:\nPMH:\nUlcerative colitis s/p J pouch (reversed), now with end \nileostomy \nChronic abdominal pain \nOPiate use \nPanic attacks/anxiety \nDepression\nAlcohol use \n\nPSH: \n___ total colectomy w/ diverting ileostomy \n___ - j-pouch creation \n___ - ileostomy takedown \n___ - admitted with closed loop obstruction and had small \nbowel resection (all surgeries done by Dr. ___ at ___ \n___) \nC-Section x2 \nR Inguinal Hernia repair at ___ years old. \n\n \nSocial History:\n___\n___ History:\nMother had IBS.\n \nPhysical Exam:\nAVSS\nDifficult to arouse initially, otherwise able to engage \nthereafter, intermittently tearful.\nPupils dilated, OP clear, neck supple, no JVD\nLungs CTA bilat\nCOR RRR\nABD mild distention, stoma bag with scant liquid brown stool, \nper GI fellow digital exam at bedside there are no obvious \nstomal strictures\nEXT no edema\nSKIN no rashes\nNEURO CN2-12 intact bilat, pupils 5-6mm bilat, EOMI, fluent \nspeech, normal strength, gait not tested\nPSYCH flat, tearful, fluent speech, perseverates on need for IV \ndilaudid\n\nExam on discharge:\n97.6 BP 95 / 59 lying HR: 72 Standing: 96/67 HR 76 O2 95%RA\nWell appearing female laying in bed, intermittently tearful\nHEENT: MMM\nLungs : Clear B/L on auscultation\n___: RRR S1 S2 present no M/R/G\nAbdomen: Soft, stoma in right lower quadrant, tender on \npalpation of LLQ, no rebound or guarding\nExt:No edema\nneuro: CN II- XII grossly intact AAOx3\nPsych: intermittently tearful, flat affect mood: depressed, \ndenies SI\n \nPertinent Results:\nADMISSION LABS:\n___ 07:20PM BLOOD WBC-5.6 RBC-4.19 Hgb-12.8 Hct-38.1 MCV-91 \nMCH-30.5 MCHC-33.6 RDW-11.9 RDWSD-39.6 Plt ___\n___ 07:20PM BLOOD ___ PTT-35.6 ___\n___ 07:20PM BLOOD Glucose-89 UreaN-6 Creat-0.8 Na-138 K-4.1 \nCl-100 HCO3-24 AnGap-18\n___ 07:20PM BLOOD ALT-28 AST-34 AlkPhos-42 Amylase-42 \nTotBili-0.2\n___ 07:20PM BLOOD Lipase-13\n___ 07:20PM BLOOD Albumin-3.9 Iron-127\n___ 07:20PM BLOOD calTIBC-304 Ferritn-82 TRF-234\n\n___ 05:00AM URINE Color-Straw Appear-Clear Sp ___\n___ 05:00AM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR\n___ 05:00AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-9 \nTransE-<1\n___ 06:38AM URINE Porphob-NEGATIVE\n___ 06:38AM URINE UCG-NEGATIVE\n\nMRE - IMPRESSION: \n1. Evaluation of the upper abdomen is markedly limited due to \nrespiratory motion. No findings of small bowel inflammation \nactive disease or bowel \nobstruction. \n2. Mild interval increase of presacral fluid collection as \ndescribed. \n3. Status post hysterectomy. 4.7 cm fluid collection at the \napex of the vaginal cuff without surrounding inflammation, \npossibly postoperative although nonspecific. \n\nIleoscopy - At 25 cm from the stoma there is an area of stenosis \nof benign appearance. A diverticulum was seen as well. The \nendoscope could not be advanced passed the area of stenosis.\n\nSecond Ileoscopy\nEvidence of a previous side to side anastomosis was seen at \n25cm. There was acute angulation at this point, but no intrinsic \nstricture and the scope passed easily. The scope was then \nadvanced to 35cm. \nImpression:Previous intervention of the small bowel\nOtherwise normal ercp to ileum to 35cm\n\nRecommendations:- previously described narrowing likely \nrepresents blind limb of previous side-to-side anastomosis\n- there was acute angulation of the lumen at that point, but no \nintrinsic stricture\n\nBarium Enema - IMPRESSION: \nHigh grade narrowing within the ileum at approximately 25 cm \nfrom the ileostomy with mild proximal dilation. No evidence of \nleak. \n\nCT \n\n \n1. Ileostomy present in the right lower abdomen. The ileum is \nsuboptimally\nopacified with contrast. No extravasation of contrast. No \ncomplete\nobstruction.\n2. Presacral collection measuring 48 x 42 mm in the axial plane \n(is increased\nin size compared to prior) appears to displace the ileum to the \nleft and it\nmay correlate to the area of acute ileal angulation that was \nseen on the\nloopogram.\n3. Multiple air-fluid levels (at the same level) in nondilated \nsmall bowel\nsuggests ileus.\n\n \n \nBrief Hospital Course:\n___ y/o F with h/o ulcerative colitis (s/p ileoanal pouch ___, \n___ resection for closed loop bowel stricture, s/p loop \nileostomy ___ for anastomotic leak, s/p permanent ileostomy \n___ at ___, s/o LOA ___, chronic abdominal pain with \nmultiple hospitalizations, depression/anxiety, chronic opiate \nuse, transferred from ___ for second opinion of abdominal \npain. \n\n# Acute on Chronic Abdominal Pain: GI and CRS were consulted. \nInitially used PO narcotics for pain given lack of clear \netiology for pain (work-up at OSH was largely negative). She \nunderwent MRE here which showed no evidence of obstruction or \nother acute pathology. Around the time of the MRE, decision was \nmade to try bowel rest (initial read of MRE was concerning for \npossible early partial SBO, ultimately felt to not be the case). \nSo, she was transitioned to IV narcotics and all oral meds were \nheld. Pain largely unchanged with bowel rest and IV pain \nmedications. The patient ultimately underwent ileoscopy (and f/u \nbarium enema) which showed high grade narrowing of the bowel 25 \ncm from the ileostomy. She then underwent a second ileoscopy \nthat showed acute angulation at site of side to side anastomosis \nin ileum but scope was passed beyond this to 35 cm. The feeling \nis that the area noted in the initial illeoscopy was blind limb \nof previous side-to-side anastomosis and not an obstructing \nstricture. GI here spoke with her colorectal surgeon at ___ \n___ per patient request. Integrating all the available, \nimaging and endoscopy data the consulting gastroenterology and \ncolorectal teams did not think the findings above were \nclinically significant and that the risks of surgery would \noutweigh any benefits of which there were felt to be few, if \nany. No clear cause was found for the patient's pain. It is \nlikely functional with possible component of hyperalgesia from \nongoing opiate use. \n\nThe patient was frustrated with her plan of care while \nhospitalized. She felt that surgery was the only way that her \npain would improve. She expressed concern that this was being \nwithheld despite numerous conversations with the patient, her \nhusband regarding lack of surgical option, her ability to \ntolerate a regular diet and no objective evidence of \ndehydration. \n\nIn terms of pain management, the patient was managed actively \nwith the pain service and the patient's PCP. Given minimal \nimprovement with IV narcotics and bowel rest, and the concern \nthat part of the patient's presentation may be due to opiate \nhyperalgesia, the patient was weaned off of IV opioids.. She \nwas provided a script for oral oxycodone until her PCP follow up \nat which time PCP ___ begin wean of oxycodone. The need to \ntaper oxycodone was discussed with the patient. She was also \ncounseled on the risks of narcotic and benzodiazepines and \nbarbiturates together. She was continued on a number of \nantiemetics (Zofran, phenergan, ativan, donnatol) these were \ncontinued on discharge.\n\n#Concern for dehydration\nThe patient had concerns that she was dehydrated. She had labs \nchecked which had no abnormalities. Orthostatic vital signs were \nchecked daily after IV fluids were discontinued and the patient \nhad no evidence of orthostatic hypotension. She was tolerating a \nregular diet prior to discharge. \n \n# Depression/Anxiety: With reported SI and psych evaluation at \nOSH. While patient denies active SI, she did continue to endorse \nsome passive SI (suggestive that she doesn't know what she will \ndo in the future if her pain doesn't get better). Psych saw her \nand did not feel that there was any contraindication to d/c when \nshe is medically stable. \n\n# Severe protein calorie Malnutrition:\nThe patient during her hospitalization was unable to eat due to \nreports of nausea. TPN was recommended several times which she \ndeclined. The patient was ultimately able to advance her diet. \nShe was tolerating a regular diet prior to discharge and her \nweight remained stable throughout her hospitalization. \n\nTransitional issues:\n- Please continue to wean narcotics as an outpatient\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. LORazepam 0.5 mg PO Q8H:PRN anxiety \n3. diphenhydrAMINE HCl 25 mg oral Q6H:PRN \n4. FLUoxetine 40 mg oral DAILY \n5. gabapentin 875 mg oral TID \n6. Hyoscyamine 0.125 mg SL TID:PRN abd pain \n7. Ondansetron ODT 8 mg PO Q8H:PRN nausea \n8. OxycoDONE Liquid 15 mg PO Q4H:PRN Pain - Moderate \n9. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg oral \nTID \n10. Promethazine 12.5 mg PO Q8H:PRN nausea \n\n \nDischarge Medications:\n1. Multivitamins W/minerals Liquid 15 mL PO DAILY \n2. OxycoDONE Liquid 10 mg PO Q4H:PRN Pain - Moderate \nRX *oxycodone 5 mg/5 mL 10 ml by mouth Q4hs as needed for pain \nDisp #*240 Milliliter Refills:*0 \n3. Tizanidine 2 mg PO QHS \nRX *tizanidine 2 mg 2 capsule(s) by mouth at bedtime Disp #*7 \nCapsule Refills:*0 \n4. Acetaminophen 1000 mg PO Q8H \n5. Gabapentin 900 mg PO TID \n6. Promethazine 25 mg PO Q6H:PRN nausea \n7. diphenhydrAMINE HCl 25 mg oral Q6H:PRN \n8. FLUoxetine 40 mg oral DAILY \n9. Hyoscyamine 0.125 mg SL TID:PRN abd pain \n10. LORazepam 0.5 mg PO Q8H:PRN anxiety \n11. Ondansetron ODT 8 mg PO Q8H:PRN nausea \n12. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg oral \nTID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute on Chronic Abdominal Pain\nUlcerative Colitis\nDepression / Anxiety\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___, \n\nYou were transferred here for a second opinion of your ongoing \nabdominal pain. You had an MRI which did not show any clear \ncause for your pain. You also had an endoscopy and a barium \nenema, which did not show any clinically significant disease. \nAfter several consultations with gastroenterology and colorectal \nsurgery, they felt that surgery would not be helpful and could \ncause more harm. \n\nIt is very important that you take the minimal amount of pain \nand nausea medications to treat your symptoms. These \nmedications, when used together can cause respiratory depression \n(reduced breathing rate), constipation and even death. It is \nvery important that you follow up with your PCP for ongoing care \nand to slowly reduce your dose of narcotic pain medications.\n\nWe wish you the best,\nYour ___ Care team\n \nFollowup Instructions:\n___\n" ]

[ "R109", "E43", "K5190", "Z932", "F329", "F419", "R339", "Z87891", "Z6825", "G8929" ]

[ "R109: Unspecified abdominal pain", "E43: Unspecified severe protein-calorie malnutrition", "K5190: Ulcerative colitis, unspecified, without complications", "Z932: Ileostomy status", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "R339: Retention of urine, unspecified", "Z87891: Personal history of nicotine dependence", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "G8929: Other chronic pain" ]

[ "F329", "F419", "Z87891", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nBactrim DS / nadolol / Motrin / NSAIDS (Non-Steroidal \nAnti-Inflammatory Drug)\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 left TKR.\n \nPast Medical History:\nasthma, GERD, migraine headaches, obesity, seasonal allergies \nwith sinusitis, hypertension, hyperlipidemia and depression\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\n Well 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___ 07:15AM BLOOD Hct-30.0*\n___ 08:07AM BLOOD Hgb-10.4* Hct-32.3*\n___ 08:40PM BLOOD WBC-11.2* RBC-3.41* Hgb-10.1* Hct-31.4* \nMCV-92 MCH-29.6 MCHC-32.2 RDW-13.3 RDWSD-44.7 Plt ___\n___ 07:55AM BLOOD Hgb-10.7* Hct-33.8*\n___ 08:40PM BLOOD Neuts-77.9* Lymphs-12.4* Monos-8.3 \nEos-0.7* Baso-0.2 Im ___ AbsNeut-8.69* AbsLymp-1.38 \nAbsMono-0.93* AbsEos-0.08 AbsBaso-0.02\n___ 09:55PM BLOOD ___ PTT-29.8 ___\n___ 08:40PM BLOOD Plt ___\n___ 08:40PM BLOOD Glucose-121* UreaN-14 Creat-0.8 Na-136 \nK-3.9 Cl-97 HCO3-25 AnGap-14\n___ 07:55AM BLOOD Creat-0.9\n___ 07:15AM BLOOD Mg-2.1\n___ 08:40PM BLOOD Calcium-8.6 Phos-3.7 Mg-1.5*\n___ 08:57PM BLOOD Type-ART pO2-184* pCO2-43 pH-7.43 \ncalTCO2-29 Base XS-4 Intubat-NOT INTUBA\n \nBrief Hospital Course:\nThe patient was admitted to the orthopedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nPOD #1, drain discontinued. Patient had ongoing nausea despite \nIV Zofran and was given a scopolamine patch and Phenergan was \nordered. Patient noted to be acutely confused overnight and was \ntriggered. CXR, EKG and arterial gases were obtained - all \nwithin normal limits. Patient was given Narcan x 1 and \nGabapentin was discontinued. Oxycodone was switched to Tramadol \nPRN.\nPOD #2, Tramadol was switched back to low dose Oxycodone due to \ninadequate pain control. Patient cleared ___ without further \nissues.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Eliquis 2.5 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. ALPRAZolam 0.5 mg PO ASDIR \n2. Docusate Sodium 100 mg PO BID \n3. Tizanidine ___ mg PO BID:PRN ASDIR \n4. Pravastatin 20 mg PO QPM \n5. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN Pain - \nModerate \n6. diclofenac sodium 1 % topical ASDIR \n7. Chlorpheniramine Maleate 4 mg PO ASDIR \n8. Pantoprazole 40 mg PO Q24H \n9. Fexofenadine 60 mg PO DAILY \n10. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB \n11. FLUoxetine 10 mg PO TID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Apixaban 2.5 mg PO BID \n3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - \nModerate \n4. Senna 8.6 mg PO BID \n5. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB \n6. ALPRAZolam 0.5 mg PO ASDIR \n7. Chlorpheniramine Maleate 4 mg PO ASDIR \n8. Docusate Sodium 100 mg PO BID \n9. Fexofenadine 60 mg PO DAILY \n10. FLUoxetine 10 mg PO TID \n11. Pantoprazole 40 mg PO Q24H \n12. Pravastatin 20 mg PO QPM \n13. Tizanidine ___ mg PO BID:PRN ASDIR \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 Eliquis 2.5 mg twice \ndaily for four (4) weeks to help prevent deep vein thrombosis \n(blood clots).\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", "F05", "J45909", "K219", "I10", "E785", "F329", "E669", "Z6834", "T426X5A", "Y92239", "R0902", "E8342" ]

[ "M1712: Unilateral primary osteoarthritis, left knee", "F05: Delirium due to known physiological condition", "J45909: Unspecified asthma, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "T426X5A: Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R0902: Hypoxemia", "E8342: Hypomagnesemia" ]

[ "J45909", "K219", "I10", "E785", "F329", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nprolonged menses, fever \n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nPhysical Exam:\nDischarge physical exam\nVitals: stable and within normal limits\nGen: no acute distress; alert and oriented to person, place, and \ndate\nCV: regular rate and rhythm; no murmurs, rubs, or gallops\nResp: no acute respiratory distress, clear to auscultation \nbilaterally\nAbd: soft, appropriately tender, no rebound/guarding\nExt: no tenderness to palpation\n\n \nPertinent Results:\nLabs on Admission:\n\n___ 05:45PM BLOOD WBC-13.7* RBC-3.78* Hgb-8.9* Hct-29.8* \nMCV-79* MCH-23.5* MCHC-29.9* RDW-15.3 RDWSD-43.8 Plt ___\n___ 05:45PM BLOOD Neuts-77.7* Lymphs-15.1* Monos-6.1 \nEos-0.2* Baso-0.4 Im ___ AbsNeut-10.61* AbsLymp-2.06 \nAbsMono-0.83* AbsEos-0.03* AbsBaso-0.05\n___ 05:45PM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-140 \nK-4.1 Cl-97 HCO3-23 AnGap-20*\n___ 05:45PM BLOOD ALT-6 AST-14 AlkPhos-62 TotBili-0.5\n___ 05:45PM BLOOD Lipase-16\n___ 05:45PM BLOOD Albumin-4.3\n___ 05:45PM BLOOD HCG-<5\n___ 11:04PM BLOOD Lactate-1.6\n___ 10:41PM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 10:41PM URINE Blood-SM* Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-150* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 10:41PM URINE RBC-<1 WBC-3 Bacteri-FEW* Yeast-NONE \nEpi-3\n\nRelevant Labs:\n\n___ 06:48AM BLOOD WBC-15.5* RBC-3.26* Hgb-7.7* Hct-25.7* \nMCV-79* MCH-23.6* MCHC-30.0* RDW-15.2 RDWSD-43.7 Plt ___\n___ 12:53PM BLOOD WBC-13.4* RBC-3.25* Hgb-7.8* Hct-25.4* \nMCV-78* MCH-24.0* MCHC-30.7* RDW-15.3 RDWSD-42.9 Plt ___\n___ 08:06PM BLOOD WBC-11.9* RBC-3.44* Hgb-8.2* Hct-27.0* \nMCV-79* MCH-23.8* MCHC-30.4* RDW-15.5 RDWSD-43.8 Plt ___\n___ 04:54AM BLOOD WBC-10.4* RBC-3.36* Hgb-8.0* Hct-26.4* \nMCV-79* MCH-23.8* MCHC-30.3* RDW-15.3 RDWSD-43.7 Plt ___\n___ 04:54AM BLOOD Neuts-61.4 ___ Monos-8.5 Eos-1.3 \nBaso-0.3 Im ___ AbsNeut-6.38* AbsLymp-2.93 AbsMono-0.88* \nAbsEos-0.14 AbsBaso-0.03\n\n___ 04:49AM BLOOD WBC-8.5 RBC-2.98* Hgb-7.0* Hct-23.4* \nMCV-79* MCH-23.5* MCHC-29.9* RDW-15.2 RDWSD-43.3 Plt ___\n___ 04:49AM BLOOD Neuts-57.0 ___ Monos-6.2 Eos-2.2 \nBaso-0.4 Im ___ AbsNeut-4.85 AbsLymp-2.87 AbsMono-0.53 \nAbsEos-0.19 AbsBaso-0.03\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service with \nprolonged menses and pelvic pain. Transabdominal US showed \ndidelphys uterus, dilated tubular structure concerning for \nhydrosalpinx and possibly blood within the endometrial cavity of \nleft horn. Patient spiked a fever to a Tmax of 102.9. CXR showed \nno evidence of acute processes. WBC was 13.7. U/A was negative. \nFlu swab was negative. She was given 1 dose of IV flagyl and \nciprofloxacin. Her fever resolved and further antibiotics were \ndeferred given no clear etiology of infection. She then had an \nMRI pelvis that showed unicornuate uterus with left rudimentary \nnon-communicating horn containing blood products, pelvic \nendometriosus with a large hematosalpinx, and non-visualized \nleft kidney. On ___, patient underwent diagnostic laparoscopy \nunder ultrasound guidance. Please see operative report for full \ndetails. Her post-operative course was uncomplicated. \nImmediately post-operatively her pain was controlled with PO \nacetaminophen and ibuprofen. Her diet was advanced without \ndifficulty. \n\nBy hospital day 3, she was tolerating a regular diet, ambulating \nindependently, and pain was controlled with oral medications. \nShe was then discharged home in stable condition with outpatient \nfollow-up scheduled and prescription for continuous combined \noral contraceptives. \n\n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Apri (desogestrel-ethinyl estradiol) 0.15-0.03 mg oral daily \n\nRX *desogestrel-ethinyl estradiol 0.15 mg-0.03 mg 1 tablet(s) by \nmouth daily Disp #*90 Tablet Refills:*3 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nunicornate uterus with left rudimentary non-communicating horn \ncontaining blood products, left hematosalpinx \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service with prolonged \nmenses and fever. You were given IV antibiotics to treat a \npossible pelvic infection. You had a pelvic ultrasound that \nshowed your previously diagnosed uterine abnormality. You then \nhad an MRI that showed that the left side of your uterus was a \nseparate entity that is closed off and does not connect with the \nright side of your uterus or your vagina. Accordingly, there was \nblood visualized within the left side of uterus that was found \nto be spilling back through your fallopian tube on that side \ninto your pelvis. We recommended that you start continuous oral \ncontraceptive pills to prevent further menstrual blood from \ncollecting in the left side of your uterus. We also recommended \nthat you have surgery to remove the left side of your uterus. \nThe team believes you are now ready to be discharged home. \nPlease call our Ob/Gyn office at ___ with any \nquestions or concerns. Please follow the instructions below.\n\nCall your doctor for:\n* fever > 100.4F\n* severe abdominal pain\n* difficulty urinating\n* vaginal bleeding requiring >1 pad/hr\n* abnormal vaginal discharge\n* redness or drainage from incision\n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n\n \nFollowup Instructions:\n___\n" ]

[ "Q514", "Q51818", "N857" ]

[ "Q514: Unicornate uterus", "Q51818: Other congenital malformations of uterus", "N857: Hematometra" ]

[]

[]

[ " \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:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\nFoley catheter placed ___\n\n \nHistory of Present Illness:\nAs per HPI by admitting MD: \n\nMs. ___ is an ___ female w/ PMH hypothyroidism,\ndepression, HLD, OA, esophageal spasm, OSA, urinary \nincontinence,\nHTN, HOCM who presents with altered mental status.\n\nThe patient is not able to answer questions on my interview on\narrival to the floor.\n\nPer ED notes, she was found wandering the streets and the water\nwas left on in her house. She was found to have a subarachnoid\nhemorrhage in the right parietal lobe at an OSH and was\ntransferred here.\n\nVS significant for T101, HR 102. She had a normal neurologic\nexam, ___ cardiac murmur.\n\nNeurosurgery was consulted and said: Patient examined and \nimaging\nreviewed with attending neurosurgeon. The right parietal SAH is\nnot the cause of her altered mental status. She is not on\nanticoagulation. There is no indication for urgent or emergent\nneurosurgical intervention. Recommended toxic metabolic work up.\n\nPsych consulted and said: Impression: most likely delirium\nsuperimposed on dementia. Recommended to hold lithium and\nrisperidone for now and to use Haldol for agitation.\n\nNeurology consulted and said:\n Rads confirms that subarachnoid blood present in R parietal\nlobe, potentially d/t underlying amyloid angiopathy or\nunwitnessed trauma. Exam shows pt to be disoriented and poorly\ninteractive, although intermittently regards and follows simple\ncommands. At this time, pt's clinical condition is more likely\nrelated to a systemic issue with resulting delirium. Do not\nclearly see complication from newfound SAH. \n -Will consider MRI in future to assist with determining \netiology\nof SAH, pending improvement in pt's mentation\n\nShe was given IV Olanzapine and IV Ativan multiple doses in the\nED for agitation. She was also given IV Zosyn for possible UTI\nbased on UA results and IVF.\n \nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n \nPast Medical History:\nHypothyroidism\nDepression\nHLD\nOA\nEsophageal spasm\nOSA\nHTN\nHypertrophic obstructive cardiomyopathy\n \nSocial History:\n___\nFamily History:\n-1 grandchild with bipolar disorder\n-1 grandchild with anxiety\n \nPhysical Exam:\nADMISSION EXAM:\nGENERAL: sleeping, not opening eyes to voice\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, ___ systolic murmur heard best at axilla, no\nS3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, appears tender to palpation in\nlower abdomen/suprapubic area. Bowel sounds present. No HSM\nGU: No suprapubic fullness, tender to palpation.\nMSK: Neck supple, moves all extremities\nSKIN: No rashes or ulcerations noted\nNEURO: not opening eyes to voice, not responding, does respond \nto\ntouching all limbs by withdrawing, moves all limbs, sensation to\nlight touch grossly intact throughout\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\nT98.0, BP 170/90, HR 83, RR 18, O2 96 RA \nGeneral - awake, appears a bit uncomfortable\nHEENT - slightly dry oral mucosa\n___ - rrr, s1/2, no murmurs\nLungs - diminished but CTA from anterior aspect, no w/r/r\nGI - soft NT ND +BS\nExt - no edema or cyanosis\nSkin - warm, dry, no rash\nPsych - awake but not fully alert, able to make eye contact and \nstate 'doctor' but none further. Unable to follow commands\nGU - +foley \n\n \nPertinent Results:\nADMISSION LABS:\n___ 02:25PM WBC-12.0* RBC-4.28 HGB-13.2 HCT-41.3 MCV-97 \nMCH-30.8 MCHC-32.0 RDW-13.3 RDWSD-46.7*\n___ 02:25PM NEUTS-67.2 ___ MONOS-9.1 EOS-0.1* \nBASOS-0.3 IM ___ AbsNeut-8.04* AbsLymp-2.71 AbsMono-1.09* \nAbsEos-0.01* AbsBaso-0.03\n___ 02:25PM PLT COUNT-281\n___ 02:25PM GLUCOSE-118* UREA N-10 CREAT-0.6 SODIUM-143 \nPOTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17\n___ 02:25PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \ntricyclic-NEG\n___ 02:25PM LITHIUM-0.4*\n___ 08:09PM URINE RBC-<1 WBC->182* BACTERIA-MOD* \nYEAST-NONE EPI-1\n___ 08:09PM URINE BLOOD-MOD* NITRITE-POS* PROTEIN-30* \nGLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-LG*\n___ 08:30PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 06:30AM BLOOD VitB12-396 Folate-5\n___ 10:43AM BLOOD %HbA1c-5.4 eAG-108\n___ 10:31AM BLOOD Triglyc-169* HDL-52 CHOL/HD-3.2 \nLDLcalc-78\n___ 06:26AM BLOOD TSH-0.16*\n___ 06:30AM BLOOD Free T4-1.6\n___ 06:30AM BLOOD Trep Ab-NEG\n\nIMAGING:\n===============================\n___ CTA Head & Neck\nIMPRESSION: \n1. Study graded by dental and overlying surgical hardware streak \nartifact and motion. \n2. Right parietal ill-defined hyperdensity, concerning for \nintraparenchymal or subarachnoid hemorrhage, grossly stable \ncompared to prior. Please note that underlying mass is not \nexcluded on the basis examination. If concern for intracranial \nmass, consider contrast brain MRI for further evaluation. \nRecommend follow-up imaging to resolution. \n3. Nonocclusive probable atherosclerotic narrowing of circle of \n___ as \ndescribed. \n4. Otherwise, patent circle of ___ without definite evidence \nof \nstenosis,occlusion,or aneurysm. \n5. Grossly patent bilateral cervical carotid and vertebral \narteries without definite evidence of stenosis, occlusion, or \ndissection. \n6. Limited imaging of lungs suggest biapical patchy opacities \nversus artifact, and central airway thickening. If clinically \nindicated, consider correlation with dedicated chest imaging. \n7. Calcified bilateral thyroid nodules measuring up to 0.8 cm. \n8. Nonspecific subcentimeter cervical lymph nodes as described, \nwhich may be reactive. \n9. Left maxillary molar tooth dental disease as described. \n \nRECOMMENDATION(S): Right parietal ill-defined hyperdensity, \nconcerning for intraparenchymal or subarachnoid hemorrhage, \ngrossly stable compared to prior. Please note that underlying \nmass is not excluded on the basis examination. If concern for \nintracranial mass, consider contrast brain MRI for further \nevaluation. Recommend follow-up imaging to resolution. \n\nMRI Head w/o contrast\nIMPRESSION: \n1. The study was terminated prematurely due to patient's \ninability to \ncooperate and is moderately limited by motion. Only sagittal \nand axial T1 \nprecontrast imaging was performed. \n2. Within the above limitations, no definite large hemorrhage or \nintracranial mass identified. Please see the subsequent complete \nMRI that was obtained on the same date. \n\n___ MRI Head w/ and w/o contrast\nIMPRESSION: \n1. Trace right parietal subarachnoid hemorrhage, corresponding \nto the \nhyperdensity seen on prior CT. No new or worsening hemorrhage. \n2. Punctate right putaminal, right frontal and bilateral \noccipital subacute infarcts. \n3. Pontine, periventricular and deep white matter FLAIR \nhyperintensities are nonspecific but likely represent sequela of \nchronic microangiopathy. \n\n___ TTE\nIMPRESSION: Moderate symmetric left ventricular hypertrophy with \nnormal cavity size and regional/global biventricular systolic \nfunction. Moderate aortic valve stenosis with moderately \nthickened leaflets. Moderate mitral regurgitation. Mild \npulmonary artery systolic hypertension. No\ndefinite structural cardiac source of embolism identified.\nCLINICAL IMPLICATIONS: The patient has moderate aortic valve \nstenosis. Based on ___ ACC/AHA Valvular Heart Disease \nGuidelines, if the patient is asymptomatic, a follow-up \nechocardiogram is suggested in ___ years.\n\nEEG ___\nIMPRESSION: This is an abnormal continuous video-EEG monitoring \nstudy due to: \n1) Occasional to frequent bursts of generalized rhythmic delta \nactivity with embedded multifocal sharps (GRDA+S). The finding \nindicates diffuse cortical hyperexcitability with potential for \nseizure. \n2) Persistent mild attenuation of voltages, especially of the \nfaster rhythms, present broadly in the right hemisphere, \nindicating a focal region of cortical dysfunction that is \nnonspecific in etiology. \n3) Diffuse slowing and disorganization present in the \nbackground, indicating moderate superimposed diffuse cerebral \ndysfunction that is nonspecific in etiology. Common causes \ninclude medications/sedation, toxic metabolic disturbances, and \ninfections. \n\nEEG ___\nIMPRESSION: This is an abnormal continuous video-EEG monitoring \nstudy due to: \n1) Occasional to frequent bursts of generalized rhythmic delta \nactivity with embedded multifocal sharps (GRDA+S). The finding \nindicates diffuse cortical hyperexcitability with potential for \nseizure. \n2) Persistent mild attenuation of voltages, especially of the \nfaster rhythms, present broadly in the right hemisphere, \nindicating a focal region of cortical dysfunction that is \nnonspecific in etiology. \n3) Diffuse slowing and disorganization present in the \nbackground, indicating moderate superimposed diffuse cerebral \ndysfunction that is nonspecific in etiology. Common causes \ninclude medications/sedation, toxic metabolic disturbances, and \ninfections. \n \nThere are no pushbutton events. Compared to the prior day's \nstudy, the degree of encephalopathy has improved, and the \nrhythmic/periodic patterns are less abundant. \n\nEEG ___\nIMPRESSION: This is an abnormal continuous video-EEG monitoring \nstudy due to: \n1) Abundant generalized periodic discharges with associated \nrhythmic delta \n(GPD+R) and a shifting lateral predominance. The finding \nindicates diffuse \ncortical hyperexcitability, lies on the ictal end of the \nictal-interictal \ncontinuum, and is at times concerning for electrographic status \nepilepticus. \n2) Persistent mild attenuation of voltages, especially of the \nfaster rhythms, present broadly in the right hemisphere, \nindicating a focal region of cortical dysfunction that is \nnonspecific in etiology. \n3) Diffuse slowing and disorganization present in the \nbackground, indicating moderate superimposed diffuse cerebral \ndysfunction that is nonspecific in etiology. Common causes \ninclude medications/sedation, toxic metabolic disturbances, and \ninfections. \n\nCT head ___\n \nIMPRESSION: \n \nNo acute intracranial abnormality since prior. Evolving \nsubarachnoid \nhemorrhage in the right parietal lobe. \n\nMicro\n=========================\nUrine culture ___\nURINE CULTURE (Final ___: \n Culture workup discontinued. Further incubation showed \ncontamination\n with mixed skin/genital flora. Clinical significance of \nisolate(s)\n uncertain. Interpret with caution. \n 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-- <=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\nBlood culture ___ - negative\n\nUrine culture ___ 9:31 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n\n \nBrief Hospital Course:\n___ yo F w/ PMHx HOCM, hypothyroidism, HLD, OA, OSA, HTN, \ndepression with SI, new diagnosis of bipolar and subacute \nneurocognitive decline who presents with encephalopathy \n(knocking on neighbors doors, roaming around apartment building) \nfound to have UTI and CT head with small non-aneurysmal R \nparietal SAH. \n\nHer hospital course was prolonged and involved many different \ndiagnostic tests to better understand her encephalopathy. \nBriefly, she was treated with Depakote for seizures and aspirin \nfor subacute ischemic stroke. Concern for autoimmune process or \ninfectious process remained in the differential diagnosis and LP \nwas recommended, however ultimately this was declined (would \nhave needed intubation/sedation) and her goals of care were \nshifted to hospice. Her overall encephalopathy persists but \netiology remains unclear. Clinically she continues to be \nconfused and not significantly awake or alert, but after \ndiscussions with her family, transition to hospice was felt \nappropriate and she will be admitted to an ___ \nfacility. \n\n# Agitation \n# Acute encephalopathy\n# Seizures:\nSuspect multifactorial ___ new SAH, subacute seizures, subacute \ncerebral infarct and UTI. These insults occurred in the setting \nof underlying mood disorder with sub-acute cognitive decline and \npossibly early dementia, although never formally diagnosed. \ncvEEG initially showed bilateral multifocal discharges \nsuggestive of diffuse cortical irritability, as well as diffuse \nslowing suggestive of delirium. She was started on Depakote \nwith improvement in noted EEG findings. Valproate levels were \nmonitored while she was in the hospital and were appropriate. \nMRI showed punctate bilateral ischemic infarcts as below. \nWork-up for underlying dementia including B12, TSH, syphilis Ab \nwere all within normal limits. Neurology and Psychiatry were \nconsulted. Hospital course was complicated by behavioral \nchallenges and agitation with patient combative and requiring \nmany doses of IM Haldol. She was initiated on standing Haldol \nwith improvement in combativeness however still difficult to \nredirect and for some time required 1:1 sitter to maintain \nsafety. She was treated with five days of empiric steroids \n(1000mg IV solumedrol) daily to treat for a possible underlying \nautoimmune encephalitis. Neurology was particularly concerned \nabout ___'s encephalopathy given positive anti-TPO \nantibodies. Serum encephalopathy panel was also sent, results \npending at the time of discharge. Given lack of improvement of \nsymptoms with further decompensation GOC initiated. It was \nultimately decided to change code status to CMO and pursue \nhospice. She was continued on Depakote for comfort/to prevent \nseizures but all other non essential medications were \ndiscontinued (including aspirin, statin).\n\n# Hypernatremia\nNa up to 154 the day before discharge, had been trending up. Her \nfluids were changed to D5W (from LR) to help with sodium \nmanagement but given her transition to hospice, no further labs \nwere checked. Fluids were discontinued before discharge from the \nhospital. Her son inquired if fluids would be used at ___ \nfacility - advised him not unless needed for comfort but \ngenerally not felt necessary/within ___. Sodium was not \nrechecked before discharge (most recent ___ 154).\n\n# Unresponsive episodes: patient began to develop episodes of \nunresponsiveness with accompanying hypotension (60s-70s \nsystolic) and bradycardia. EEG was negative for seizure activity \nduring this time. Episodes were suspected to be due to autonomic \ndysfunction secondary to her underlying CNS process. Her last \nepisode was ___. \n\n#SAH: \nSuspected traumatic given bruising on exam. CTA and MRI without \nsigns of vascular abnormality. Neurosurgery was consulted but \ndid not recommend any surgical intervention.\n\n# Punctate bilateral ischemic infarcts\nMRI brain with punctate subacute R putaminal and punctate \nbilateral infarcts. DDx cardioembolic or hypercoagulable state. \n TTE did not show any thrombus. Telemetry monitoring x 48 hours \ndid not show any atrial fibrillation. Lipids and A1c were \nwithin acceptable range. She was started on a statin. \nUltimately given her transition of care to hospice, aspirin and \nstatin were discontinued. \n\n#UTI: \nUcx with pansensitive E coli early in hospitalization. She \ncompleted a course of ceftriaxone. Patient endorsed UTI symptoms \non ___ and less lucid so started on Bactrim given prior \nsensitivities which she completed. A foley catheter was placed \n___ due to the need for a urinalysis (she had had a low \ngrade temp); the UA was negative and because of her transition \nto hospice, the Foley was left in place. \n\n# HTN\nPoorly controlled at admission. She was continued on home \nmetoprolol. Given intermitent episodes of hypotension newly \nstarted on amlodipine was discontinued. Ultimately given GOC her \nanti hypertensives were discontinued. \n\nCHRONIC/STABLE PROBLEMS:\n#Hypothyroidism: discontinued levothyroxine\n#HOCM: discontinued metoprolol\n\n#Psychiatric disorders: \nLithium was held per psychiatry recs. As above, she was started \non Depakote for EEG findings.\n\n#Overall GOC \n-MOLST form filled while in the hospital\n-Bowel regimen and narcotics continued for comfort, she has only \nrequired ___ doses of IV morphine in the 24 hours before \ndischarge\n-Has not required any benzos, but has been on Haldol which will \nbe continued on med-rec\n-Discontinued all non essential meds\n-Discontinued IV fluids\n\n#Contact - son ___ ___, updated via phone \nregarding discharge plan and plans to discontinue non essential \nmeds. \n\n55 minutes spent in discharge planning. \nPCP notified of hospital discharge.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Lithium Carbonate 150 mg PO BID \n2. RisperiDONE 2 mg PO QHS \n3. TraZODone 25 mg PO QHS \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n5. Levothyroxine Sodium 75 mcg PO 6X/WEEK (___) \n6. Levothyroxine Sodium 150 mcg PO 1X/WEEK (___) \n7. Oxybutynin 5 mg PO BID \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. Pregabalin 50 mg PO DAILY \n10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n12. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n13. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever \n\n \nDischarge Medications:\n1. Depakote Sprinkles (divalproex) 375 mg oral BID \n2. Docusate Sodium 100 mg PO BID \n3. Haloperidol 4 mg PO QHS \n4. Haloperidol 1 mg PO DAILY \n5. Mirtazapine 15 mg PO QHS \n6. Morphine Sulfate 0.5 mg IV Q4H:PRN pain \n7. Ramelteon 8 mg PO QHS \nShould be given 30 minutes before bedtime \n8. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever \n\n \nDischarge Disposition:\nExtended Care\n \nDischarge Diagnosis:\nEncephalopathy, toxic metabolic\nSeizure\nIschemic stroke\nHemorrhagic stroke\nHypernatremia \nHypotension\n___\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou will be discharged to a ___ facility to focus on your \ncomfort and symptoms related to well-being. We have discontinued \nmany of your medications that are not felt to be essential to \nyour care. We wish you and your family the very best during this \ntime. \n\nSincerely, \nYour care team at ___ \n \nFollowup Instructions:\n___\n" ]

[ "S066X0A", "G92", "I6340", "I421", "F05", "N390", "Z515", "F0391", "E870", "N179", "E039", "M1990", "G4733", "K224", "R32", "I10", "I959", "E876", "E785", "F319", "R001", "R0902", "R569", "R402142", "R402242", "R402362", "B9620", "Z9183", "Z66", "Z781", "Z91130", "X58XXXA", "Y929" ]

[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "G92: Toxic encephalopathy", "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "I421: Obstructive hypertrophic cardiomyopathy", "F05: Delirium due to known physiological condition", "N390: Urinary tract infection, site not specified", "Z515: Encounter for palliative care", "F0391: Unspecified dementia with behavioral disturbance", "E870: Hyperosmolality and hypernatremia", "N179: Acute kidney failure, unspecified", "E039: Hypothyroidism, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K224: Dyskinesia of esophagus", "R32: Unspecified urinary incontinence", "I10: Essential (primary) hypertension", "I959: Hypotension, unspecified", "E876: Hypokalemia", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified", "R001: Bradycardia, unspecified", "R0902: Hypoxemia", "R569: Unspecified convulsions", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402242: Coma scale, best verbal response, confused conversation, at arrival to emergency department", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z9183: Wandering in diseases classified elsewhere", "Z66: Do not resuscitate", "Z781: Physical restraint status", "Z91130: Patient's unintentional underdosing of medication regimen due to age-related debility", "X58XXXA: Exposure to other specified factors, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "N390", "Z515", "N179", "E039", "G4733", "I10", "E785", "Z66", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\naltered mental status\n \nMajor Surgical or Invasive Procedure:\nNone. \n\n \nHistory of Present Illness:\n Ms. ___ ___ female with unknown medical history \nwho presents to the ED for unknown reasons with TWIs on EKG. As \nper EMS, the patient did not know why she called an ambulance \nand was rambling when they arrived. Patient denies any \nparticular complaints or pain. At one point she did apparently \nstate,\" I'm not right in the head.\" Patient frequently made \nreferences to events that have happened in the past and was \nunable to answer questions. She was unable to give any names or \ncontact information for family. She declined labs and imaging. \n In the ED, initial vitals were: HR76, BP114/60, RR18 \n \n - Exam notable for: Moving all extremities, no dysarthria, \nsmile symmetric, atraumatic exam \n \n - Labs notable for: \n Tbili: 1.6 \n Trop-T: <0.01 \n Leuk Sm, Nitr neg, WBC, Bact few \n INR: 1.5 \n - Imaging was notable for: \n Unable to obtain a CT Head secondary to agitation \n - Patient was given: \n ___ 17:55 injection OLANZapine *NF* 5 mg \n ___ 17:55 PO Aspirin 324 mg \n ___ 18:53 IM OLANZapine 10 mg \n ___ 19:30 IV Lorazepam .5 mg \n ___ 20:10 IV Lorazepam .5 mg \n \n - Vitals prior to transfer: \n T97.5, HR81, BP122/70, RR18, SaO2 95% RA \n Upon arrival to the floor, patient reports she has no \ncomplaints. She is interviewed by a ___ interpreter and was \nunable to articulate why she came in. \n REVIEW OF SYSTEMS: \n (+) Per HPI \n (-) 10 point ROS reviewed and negative unless stated above in \nHPI \n \nPast Medical History:\nCVA (___): cardioembolic inferior cerebellar, occipital and \nparietal stroke; has residual aphasia\nAtrial fibrillation\nHypertension\nHyperlipidemia\nReactive Airway disease\nThyroid Nodule \n \n \nSocial History:\n___\nFamily History:\nUnknown. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVital Signs: BP 125/76 HR81 O2 saturation 91% RA \nGeneral: Alert, oriented to person, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. \nNeck: Supple. JVP not elevated. no LAD \nCV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, \ngallops. \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno rebound or guarding \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, gait deferred. Patient unwilling to \nparticipate in pronator drift test. \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVital Signs: 97.9 104/64 (93-136/55-80) 79 (74-88) ___ 92-95% \nRA General: Alert, oriented to person, no acute distress. \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. \nNeck: Supple. JVP not elevated. no LAD \nCV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs, \ngallops. \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, tender to deep palpation diffusely (difficult to \nlocalize given patient's attentional deficits), non-distended, \nbowel sounds present, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNII-XII intact. ___ strength throughout. \nNormal sensation to light palpation.\nGait deferred. FNF intact. \nPatient unable to sustain attention to answer questions.\nPatient's thought process is not goal directed or linear.\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 07:33PM URINE HOURS-RANDOM\n___ 07:33PM URINE UHOLD-HOLD\n___ 07:33PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 07:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-SM \n___ 07:33PM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE \nEPI-1 TRANS EPI-<1\n___ 07:33PM URINE AMORPH-RARE\n___ 07:33PM URINE MUCOUS-RARE\n___ 06:45PM WBC-6.4 RBC-4.63 HGB-13.8 HCT-41.5 MCV-90 \nMCH-29.8 MCHC-33.3 RDW-13.0 RDWSD-42.6\n___ 06:45PM NEUTS-56.7 ___ MONOS-9.2 EOS-1.4 \nBASOS-0.3 IM ___ AbsNeut-3.62 AbsLymp-2.03 AbsMono-0.59 \nAbsEos-0.09 AbsBaso-0.02\n___ 06:45PM PLT COUNT-237\n___ 05:39PM ___ PTT-30.6 ___\n___ 04:00PM GLUCOSE-126* UREA N-13 CREAT-0.8 SODIUM-140 \nPOTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-20* ANION GAP-20\n___ 04:00PM estGFR-Using this\n___ 04:00PM ALT(SGPT)-13 AST(SGOT)-30 ALK PHOS-124* TOT \nBILI-1.6*\n___ 04:00PM cTropnT-<0.01\n___ 04:00PM ALBUMIN-3.5\n\nMICROBIOLOGY:\n============\nURINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nBlood culture x2 (___): No growth to date\nBlood culture (___): No growth to date\nBlood culture (___): No growth to date\n\nIMAGING:\n=======\nPortable CXR (___): \n\nFindings: Slightly low lung volumes noted. There are regions of \nparenchymal opacity at the left lung base. Elsewhere, lungs are \nclear. Cardiac silhouette is\nslightly enlarged but likely accentuated by portable technique. \nNo acute\nosseous abnormalities.\n \nIMPRESSION: \nPatchy left basilar opacities which could represent pneumonia.\n\nNon-contrast head CT (___):\nFINDINGS: \nThere is hypoattenuation and encephalomalacia in the left \nparietal lobe\ncompatible with chronic infarct. There is no intra-axial or \nextra-axial\nhemorrhage, edema, shift of normally midline structures, or \nevidence of acute\nmajor vascular territorial infarction. Prominent ventricles \nsulci compatible\nwith age-related involutional changes. Periventricular and \nsubcortical\nconfluent hypoattenuation is nonspecific but likely represent \nsequelae of\nsmall vessel ischemic disease in this age group. There are \nmoderate\natherosclerotic calcifications in the carotid siphons and \nintracranial\nportions of the vertebral arteries bilaterally.\nImaged paranasal sinuses are clear. Mastoid air cells and middle \near cavities\nare well aerated. The bony calvarium is intact.\nIMPRESSION:\n1. Hypoattenuation and encephalomalacia in the left parietal \nlobe likely\nrepresents a chronic infarct.\n2. No acute intracranial abnormality.\n3. Age-related involutional changes and chronic small vessel \nischemic disease.\n\nAbdominal U/S (___):\nFINDINGS: \nLIVER: The hepatic parenchyma appears within normal limits. The \ncontour of\nthe liver is smooth. There are multiple echogenic foci \nconsistent with\ngranulomas. The main portal vein is patent with hepatopetal \nflow. There is\nno ascites.\nBILE DUCTS: There is no intrahepatic biliary dilation. The CHD \nmeasures 9 mm.\nGALLBLADDER: The patient is status post cholecystectomy.\nPANCREAS: The imaged portion of the pancreas appears within \nnormal limits,\nwithout masses or pancreatic ductal dilation, with portions of \nthe pancreatic\ntail obscured by overlying bowel gas.\nSPLEEN: Normal echogenicity, measuring 8.1 cm.\nKIDNEYS: The right kidney measures 10.4 cm. The left kidney \nmeasures 10.1 cm.\nNormal cortical echogenicity and corticomedullary \ndifferentiation is seen\nbilaterally. There is no evidence of masses, stones, or \nhydronephrosis in the\nkidneys.\nRETROPERITONEUM: The visualized portions of aorta and IVC are \nwithin normal\nlimits.\nIMPRESSION: \n1. Status post cholecystectomy. Hepatobiliary system is within \nnormal\nlimits.\n2. Hepatic granulomata.\n\nCXR PA&LAT (___):\nFINDINGS: \nIncreased left lower lobe and right basal parenchymal opacities \nwhich may\nreflect atelectasis and/or consolidation. No pleural effusion \nor pneumothorax\nidentified. The size of the cardiac silhouette is unchanged.\nIMPRESSION: \nSlight interval increase in left lower lobe and right basilar \nopacities which\nmay reflect atelectasis and/or consolidation.\n\nDISCHARGE AND PERTINENT LABS:\n===========================\n___ 07:20AM BLOOD WBC-6.6 RBC-4.59 Hgb-13.9 Hct-42.0 MCV-92 \nMCH-30.3 MCHC-33.1 RDW-12.8 RDWSD-42.7 Plt ___\n___ 07:20AM BLOOD Plt ___\n___ 07:20AM BLOOD Ret Aut-2.1* Abs Ret-0.09\n___ 07:20AM BLOOD Glucose-169* UreaN-15 Creat-0.9 Na-139 \nK-3.7 Cl-103 HCO3-25 AnGap-15\n___ 05:15PM BLOOD ALT-12 AST-16 LD(___)-200 AlkPhos-126* \nTotBili-1.8*\n___ 07:30AM BLOOD ALT-12 AST-15 LD(___)-198 AlkPhos-126* \nTotBili-1.8*\n___ 08:15AM BLOOD ALT-11 AST-15 LD(___)-228 AlkPhos-129* \nTotBili-2.4* DirBili-0.3 IndBili-2.1\n___ 07:20AM BLOOD ALT-10 AST-14 LD(___)-255* AlkPhos-114* \nTotBili-2.5* DirBili-0.3 IndBili-2.2\n___ 07:20AM BLOOD GGT-PND\n___ 04:00PM BLOOD cTropnT-<0.01\n___ 02:50AM BLOOD CK-MB-3 cTropnT-<0.01\n___ 07:20AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1\n___ 07:20AM BLOOD Hapto-PND\n___ 02:50AM BLOOD TSH-1.9\n___ 08:15AM BLOOD ___\n___ 08:15AM BLOOD AMA-NEGATIVE\n___ 02:50AM BLOOD Digoxin-<0.2*\n___ 08:15AM BLOOD Digoxin-0.3*\n___ 07:20AM BLOOD Digoxin-0.4*\n___ 02:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 05:30PM BLOOD ___ pO2-25* pCO2-38 pH-7.45 \ncalTCO2-27 Base XS-1\n \nBrief Hospital Course:\nMs. ___ ___ woman w/ hx of Afib on Apixaban, \ninferior cerebellar, occipital and parietal cardioembolic \nstroke, HLD, HTN, DMII, hyperactive airway disease of unknown \netiology who presents to the ED for AMS with TWIs on EKG. \n\n# Dyspnea: Patient has known history of reactive airway disease \nof unknown etiology. She was admitted at ___ for \nbronchitis and was discharged with 5-day course of azithromycin \nand prednisone, which she feels did not help. She denies smoking \nhistory. She desatted to 86% on RA while walking, stopped and \ntook deep breaths, with O2 increasing back to 93-95% in a few \nseconds. Etiology was considered to be cardiac vs chronic \npulmonary etiology (e.g., indolent infection vs reactive airway \ndisease vs COPD vs interstitial lung disease). On admission, \nportable CXR showed patchy left basilar opacities and repeat CXR \nPA&LAT on ___ demonstrated interval increase in LLL and R \nbasilar opacities, which may be atelectasis vs consolidation. \nGiven concern for hepatic granulomas on abdominal CT imaging \n(see below), some concern also for sarcoid vs TB, although no \nhilar lymphadenopathy or cavitary lesions on CXR and Ca wnl. \nPatient was started on empiric albuterol inhaler 2 puffs q6h, \nresulting in her ability to ambulate without desatting (O2Sat in \n___ on RA) and without dyspnea or other symptoms, suggesting \nobstructive picture consistent with reactive airway disease. \nPatient may benefit from outpatient PFTs. \n \n# Altered mental status: \n# History of cardioembolic stroke: The patient has known \ninferior cerebellar, occipital, and parietal cardioembolic \nstrokes (___) and she has a residual aphasia (Wernicke-type) \nworsened by anxiety. Per daughter and ___, she does not take her \nmedications as prescribed and has likely missed doses of her \nanti-hypertensive medications and apixaban. Patient has been \nmore aphasic and confused in the week of ___ since her discharge \nfrom ___. Her neurology exam was non-focal and \nstrength, sensation, cerebellar function were intact, although \npatient demonstrated difficulty with attention, which her \ndaughter felt was worse than her baseline. There was photophobia \nor meningeal signs. Urine toxicology screen was negative. TSH \n1.9. Portable chest x-ray on admission showed patchy left \nbasilar opacities consistent with atelectasis versus less likely \npneumonia, although patient was afebrile, had no other signs of \ninfection, had no leukocytosis, and urine and blood cultures \nwere negative. Antibiotics were therefore deferred. Patient was \nagitated initially, requiring wrist restraints, and then IV \nHaldol, although became much calmer within 24hrs of admission, \nallowing for discontinuation of both restraints and haldol. Her \nchange in mental status given her history of atrial fibrillation \nand prior cardioembolic strokes, was concerning for a new CVA, \nespecially in the setting of possible medication noncompliance. \nNon-contrast head CT on ___ showed chronic parietal lobe infarct \nbut no new acute intracranial abnormality. \n\n# Abdominal tenderness\n# Indirect bilirubinemia: \nPatient endorsed mild tenderness to deep abdominal palpation \n(although were unable to localize quadrant in the setting of her \nattention deficits), but had no jaundice, and was afebrile. She \nhad an Alk phos of 126 and indirect bilirubinemia with Tbili of \n1.8 w/ normal transaminases. Tbili continued to uptrend during \nhospitalization, and was 2.5 at time of discharge. This was in \nthe setting of a stable H&H, retic % 2.1 and abs retic count \nwithin normal limits. Haptoglobin is pending at time of \ndischarge. GGT is also pending at time of discharge. Patient had \nabdominal U/S which demonstrated that she is status post \ncholecystectomy, but had multiple echogeneic foci suspicious for \nhepatic granulomas. Overall, picture is suspicious for biliary \nconjugation defect, e.g., ___ syndrome. Of note, however, \npatient did not have bilirubinemia duing prior hospitalization \nin ___ ___. Patient should have \noutpatient hepatology follow-up and should have repeat LFTs \nwithin ___ days of discharge. \n\n# Diffuse TWI on EKG\n# Coronary artery disease: Patient's admission EKG was notable \nfor diffuse TWI. CKMB and trop flat x2. Patient denied chest \npain, but did endorse dyspnea and feeling as if she was gasping \nfor air as above. Per records from ___, \npatient had a p-mibi scan in ___ showing ischemia and infarct \nin the LAD territory and her prior EKGs on ___ and ___ \nshowed diffuse TWI similar to that seen on admission EKG here. \nShe was monitored on telemetry and for anginal equivalents \nthroughout her hospitalization. \n\n# Atrial fibrillation: CHADSVASC2 = 8. Patient is rate \ncontrolled at home on atenolol 50mg BID and digoxin 0.125mg \ndaily. Digoxin was initially held until home dose was clarified, \nand was restarted on ___. Digoxin level at time of discharge on \n___ was 0.4. Patient was also continued on her home apixaban \n5mg BID. \n \n# Type 2 Diabetes mellitus: Patient takes glimepiride 2 mg daily \nat home. This was held and patient was maintained on house \ninsulin sliding scale while inpatient. Home glimepiride was \nresumed for discharge. \n\n# Hypertension: Patient was continued on her home \nhydrochlorothiazide 12.5mg daily, amlodipine 5mg daily, \natenololl 50mg daily, and valsartan 160mg daily. Her BP at time \nof discharge was 104/64. \n\n#Hyperlipidemia: Patient was continued on her home atorvastatin \n40mg QPM. \n\n# Anxiety: Patient's home clonazepam 1mg qhs was held initially \nin the setting of altered mental status as above, but was \nrestarted for discharge. \n \nTRANSITIONAL:\n============\n- Patient was started on albuterol INH 2 puffs q6hr. \n- Patient may benefit from outpatient pulmonary function \ntesting. \n- Patient should have repeat LFTs within ___ days of discharge. \n- At time of discharge, haptoglobin and GGT labs are pending. \n- The ___ clinic will contact patient to schedule \noutpatient hepatology follow-up. If the patient does not hear \nfrom them within 48hrs of discharge, she should call \n___ to schedule an appointment. \n\n- CODE: full (confirmed) \n- CONTACT: Daughter, ___ ___, Home care extended in \n___ ___, ___ ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. Atenolol 50 mg PO BID \n3. Atorvastatin 40 mg PO QPM \n4. ClonazePAM 1 mg PO DAILY \n5. Digoxin 0.125 mg PO DAILY \n6. Apixaban 5 mg PO BID \n7. glimepiride 2 mg oral Other \n8. Hydrochlorothiazide 12.5 mg PO DAILY \n9. Valsartan 160 mg PO DAILY \n10. Aspirin EC 81 mg PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n12. Bisacodyl 5 mg PO DAILY:PRN constipation \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H \n2. glimepiride 2 mg oral DAILY \n3. amLODIPine 5 mg PO DAILY \n4. Apixaban 5 mg PO BID \n5. Aspirin EC 81 mg PO DAILY \n6. Atenolol 50 mg PO BID \n7. Atorvastatin 40 mg PO QPM \n8. Bisacodyl 5 mg PO DAILY:PRN constipation \n9. ClonazePAM 1 mg PO DAILY \n10. Digoxin 0.125 mg PO DAILY \n11. Hydrochlorothiazide 12.5 mg PO DAILY \n12. Valsartan 160 mg PO DAILY \n13. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n==================\nDyspnea\nAltered mental status\nIndirect bilirubinemia\nCoronary artery disease\n\nSECONDARY DIAGNOSES:\n====================\nAtrial fibrillation\nHypertension\nHyperlipidemia\nType 2 Diabetes mellitus\nAnxiety\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\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!\n\nWhy you were admitted: \n-You were admitted with shortness of breath. \n\nWhat we did for you:\n-We started you on an albuterol inhaler which helped improve \nyour breathing. \n-We obtained laboratory studies which showed that you have a \nhigh bilirubin level, which is particular type of liver function \ntest. \n\nWhat you should do when you go home:\n- Please continue to use your albuterol inhaler as directed. \n- Please take your other medications as directed. \n- The ___ clinic will contact you to schedule \noutpatient hepatology follow-up. If you do not hear from them \nwithin 48hrs of discharge, she should call ___ to \nschedule an appointment. \n\nWe wish you all the best!\nYour ___ Medicine Team\n\n \nFollowup Instructions:\n___\n" ]

[ "R4182", "R0600", "F0390", "I4891", "Z781", "R451", "R9431", "I69320", "I10", "I2510", "E785", "J45909", "E041", "Z7902", "E119", "K753", "R10819", "E806", "F419", "Z9114" ]

[ "R4182: Altered mental status, unspecified", "R0600: Dyspnea, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "I4891: Unspecified atrial fibrillation", "Z781: Physical restraint status", "R451: Restlessness and agitation", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "I69320: Aphasia following cerebral infarction", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "E041: Nontoxic single thyroid nodule", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E119: Type 2 diabetes mellitus without complications", "K753: Granulomatous hepatitis, not elsewhere classified", "R10819: Abdominal tenderness, unspecified site", "E806: Other disorders of bilirubin metabolism", "F419: Anxiety disorder, unspecified", "Z9114: Patient's other noncompliance with medication regimen" ]

[ "I4891", "I10", "I2510", "E785", "J45909", "Z7902", "E119", "F419" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nibuprofen / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)\n \nAttending: ___.\n \nChief Complaint:\nSymptomatic choledocolithiasis\n \nMajor Surgical or Invasive Procedure:\n___: Open cholecystectomy\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of symptomatic \ncholedocolithiasis. Patient had ERCP with stent placement on \n___. Stent was removed on ___. Patient was followed by \nDr. ___ today he is present for elective interval \ncholecystectomy.\n \nPast Medical History:\nMultifocal Parieto-occipital CVA (___) - (left\nparieto-occipital area most affected, some left MCA involvement)\nHTN, HLD\nCarotid stenosis s/p bilateral CEA\nAAA without rupture (2.6 cm)\nAortic dissection - not otherwise specified \nEsophageal adenocarcinoma\nGERD, ___ Esophagus, s/p ___ fundoplication revision\nDiverticulitis\nAdrenal Adenoma\nAsthma, COPD, Former smoker (40-pack yrs, Asbestos exposure)\nPneumonia, recurrent\nChronic pain - pain agreement, potentially broken ___\nLow back pain\nUrinary frequency\nInguinal hernia, ventral hernias \nPrior alcohol abuse\n\nSurgical or Invasive Procedure:\nBilateral carotid endarterectomies\nInguinal and ventral hernia repair x4\nEndoscopic mucosal resection of mass at ___ junction ___\nRevision of ___ Fundoplication\nUpper EUS (___)\nERCP and biliary stent placement (___)\n\n \nSocial History:\n___\nFamily History:\nMother - CAD, PVD\nFather - Liver ca\nOther - Uncles - CVA, ___ cancer\n\n \nPhysical Exam:\nVitals: 98.2 PO 141 / 75 76 18 93 Ra \nGen: well appearing, AAOX3\nHEENT: EOMI, PERRLA, MMM, oropharynx clear\nCV: RRR, no m/r/g\nLungs: CTAB, breathing comfortably on RA\nAbd: soft, mild ___ tenderness and edema but no \nerythema or drainage, Incision healing well, c/d/I \nExt: WWP, no edema\nNeuro: CN ___ grossly intact, motor and sensory ___ bilaterally \nin upper and lower extremities, sensation grossly intact\n \nPertinent Results:\nRECENT LABS:\n\n___ 06:40AM BLOOD WBC-9.3 RBC-4.23* Hgb-12.5* Hct-38.1* \nMCV-90 MCH-29.6 MCHC-32.8 RDW-13.0 RDWSD-43.0 Plt ___\n___ 06:40AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-140 K-4.3 \nCl-98 HCO3-31 AnGap-11\n___ 03:42AM BLOOD ALT-29 AST-31 AlkPhos-87 TotBili-1.0\n___ 06:40AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0\n \nBrief Hospital Course:\nThe patient was admitted to the General Surgical Service for \nelective open cholecystectomy. On ___, the patient underwent \nopen cholecystectomy, which went well without complication \n(reader referred to the Operative Note for details). After a \nbrief, uneventful stay in the PACU, the patient arrived on the \nfloor NPO, on IV fluids and antibiotics, with a foley catheter, \nand Dilaudid PCA for pain control. The patient was \nhemodynamically stable.\n\nPost-operative pain was initially well controlled with Dilaudid \nPCA, which was converted to oral pain medication when tolerating \nclear liquids. The patient was started on sips of clears on POD# \n1. Diet was progressively advanced as tolerated to a regular \ndiet by POD# 2. Patient failed to void post operative and Foley \nwas placed on POD 0. The foley catheter was discontinued at \nmidnight of POD# 1. The patient subsequently voided without \nproblem. On POD 1, patient was hypotensive and received fluid \nboluses. Blood pressure improved on POD 2 and remained stable \nprior discharge. \n\nDuring this hospitalization, the patient ambulated early and \nfrequently, was adherent with respiratory toilet and incentive \nspirrometry, and actively participated in the plan of care. \nPatient anticoagulation was restarted on POD 2, his INR on \ndischarge was 1.1, he will be doing a lovenox bridge and \nfollowing up with his PCP.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nAlbuterol sulfate [ProAir HFA] 90 mcg HFA inhaler 2 puffs inh \nprn, Atorvastatin 80', Lovenox 80 mg/0.8 mL syringe SQH'', \nLevetiracetam 1,000'', Lorazepam 1''',Metoprolol XL 100', Zofran \n4 q8h, Pantoprazole 40'', Sertraline 100 ohs, Trazodone 50', \nCoumadin, Zolpidem 10' (when not taking Trazadone)\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nDo not exceed 4000mg in 24 hours. \n2. Docusate Sodium 100 mg PO BID \nPlease use while taking narcotics \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day as \nneeded Disp #*100 Capsule Refills:*0 \n3. Ondansetron ODT 4 mg PO Q8H:PRN nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*15 Tablet Refills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nDo not drive or drink alcohol on this med. \nRX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours as \nneeded for pain Disp #*30 Tablet Refills:*0 \n5. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n6. Atorvastatin 80 mg PO QPM \n7. Enoxaparin Sodium 80 mg SC BID lovenox bridge \nRX *enoxaparin 80 mg/0.8 mL 80 mg every twelve (12) hours Disp \n#*30 Syringe Refills:*1 \n8. LevETIRAcetam 1000 mg PO BID \n9. LORazepam 1 mg PO TID \nDo not take this while you take narcotic pain medications like \noxycodone. \n10. Metoprolol Succinate XL 100 mg PO DAILY \n11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nDAILY:PRN \n12. Sertraline 100 mg PO DAILY \n13. TraZODone 50 mg PO QHS:PRN sleep \n14. Warfarin 5 mg PO DAILY16 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCholedocolithiasis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\nYou were admitted to the surgery service at ___ for elective \ncholecystectomy. You have done well in the post operative period \nand are now safe to return home to complete your recovery with \nthe following instructions:\n.\nPlease call Dr. ___ office at ___ or Office RNs \nat ___ if you have any questions or concerns.\n.\nPlease resume all regular home medications , unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon, who will instruct you further regarding activity \nrestrictions.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\nPlease follow-up with your surgeon and Primary Care Provider \n(PCP) as advised.\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 steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n\n \n\n \nFollowup Instructions:\n___\n" ]

[ "K8020", "E785", "Z87891", "I10", "J45909", "Z8501", "F329", "F419" ]

[ "K8020: Calculus of gallbladder without cholecystitis without obstruction", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "Z8501: Personal history of malignant neoplasm of esophagus", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "E785", "Z87891", "I10", "J45909", "F329", "F419" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nibuprofen\n \nAttending: ___\n \nChief Complaint:\nR sided weakness\n \nMajor Surgical or Invasive Procedure:\nendoscopic mucosal resection with GI ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old gentleman who awoke this morning \nat\n7am with right sided arm and leg weakness with decreased\nsensation to light touch. He was last known well last night at\n11pm. CT at OSH showed wedge-shaped hypodensity in\nparieto-occipital lobe. CTA showed \"no flow-limiting stenosis.\"\n\n \nPast Medical History:\nPAST MEDICAL HISTORY:\nPost-op from ___ fundoplication revision. \nPneumonia, recurrent\nLow back pain\nGERD\n___ Esophagus\nHLD\nUrinary frequency\nInguinal hernia, ventral hernias\nHTN\nDiverticulitis\nAsthma\nChronic pain - pain agreement, potentially broken ___\nCarotid stenosis\nAAA without rupture (2.6 cm)\nAortic dissection - not otherwise specified\nCOPD\nAdrenal Adenoma\nEsophageal adenocarcinoma \nPrior alcohol abuse\nPrior tobacco use\n \nSocial History:\n___\nFamily History:\nMother - CAD, PVD\nFather - Liver ca\nOther - Uncles - CVA, ___ cancer\n\n \nPhysical Exam:\nADMISSION\n\nPHYSICAL EXAMINATION\nVitals: T: 98.6 HR: 78 BP: 110/81 RR: 20 SaO2: 95% on RA.\n\nGeneral: Appeared uncomfortable and slightly distressed at \nrest,\nlying in stretcher bed.\nHEENT: NCAT, no oropharyngeal lesions, neck supple\nPulmonary: Breathing comfortably on room air.\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: Awake, alert, oriented x 2 (said ___\ninstead of ___. Able to relate history without difficulty.\nAttentive. Speech is fluent with full sentences, intact\nrepetition, and intact verbal comprehension. Naming with a few\nerrors with low-frequency objects. No paraphasias. No\ndysarthria. Normal prosody. Able to follow both midline and\nappendicular commands.\n\n- Cranial Nerves: PERRL 3->2 brisk. Right homonymous \nhemianopia.\nEOMI, no nystagmus. V1-V3 without deficits to light touch\nbilaterally. No facial movement asymmetry, but slight right\nfacial droop at rest. Hearing intact to finger rub bilaterally. \nPalate elevation symmetric. Tongue midline.\n\n- Motor: Normal bulk and tone. No drift. No tremor or \nasterixis.\n [___]\nL 5 5 5 5 ___ 5 5 5 5 5\nR 4 3 3 3 ___ 3+ 3+ 3 3 3 \n \n- Reflexes: \n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 2+ UN 2+ 2+ 0\n R 2+ UN 2+ 2+ 0 \n\nPlantar response flexor bilaterally \n\n- Sensory: Unable to sense pinprick or any touch in right upper\nextremity. Pinprick felt dull in right lower extremity. No\ndeficits on left upper and lower extremities.\n- Coordination: + dysmetria with finger to nose testing on left;\nunable to complete FNF on right. \n\n- Gait: Unable to assess.\n\nDISCHARGE PHYSICAL EXAM\nVitals: T 98 BP 115-130/68-96 HR 53-68 RR ___ SpO2 95-98%\nGeneral: Appeared comfortable at rest, lying in bed\nHEENT: NCAT, no oropharyngeal lesions, neck supple\nPulmonary: Breathing comfortably on room air.\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: AAOX3 (person, place, full date). Fluent speech\nwith intact repetition and comprehension. Follows multistep \naxial\nand appendicular commands without difficulty. Naming intact. No\ndysarthria. \n\n- Cranial Nerves: PERRL 3->2. EOMI without nystagmus. V1-V3 \nintact\nbilaterally. V1-V3 intact to light touchbilaterally. Hearing \nintact to finger rub bilaterally. Face symmetric with full \nfacial strength. Symmetric palate elevation. Midline tongue with \nprotrusion. No visual field deficits to confrontational testing.\n\n- Motor: Normal bulk and tone throughout. Slight R sided \npronator drift No tremor.\n\n [___]\nL 5 5 5 5 ___ 5 5 5 5 5\nR 5 5 5 5 ___ 5 5 5 5 5 \n \n- Sensory: Grossly intact to light touch throughout.\n\n- Coordination: Deferred.\n\n- Gait: Deferred.\n\n \nPertinent Results:\nAdmission\n\n___ 02:10PM BLOOD WBC-8.9 RBC-3.87*# Hgb-11.6*# Hct-35.5*# \nMCV-92 MCH-30.0 MCHC-32.7 RDW-12.7 RDWSD-42.3 Plt ___\n___ 02:10PM BLOOD Neuts-74.1* Lymphs-13.1* Monos-11.8 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-6.57* AbsLymp-1.16* \nAbsMono-1.05* AbsEos-0.00* AbsBaso-0.02\n___ 02:10PM BLOOD ___ PTT-30.8 ___\n___ 02:10PM BLOOD Glucose-86 UreaN-19 Creat-1.4* Na-140 \nK-4.5 Cl-99 HCO3-27 AnGap-14\n___ 02:10PM BLOOD ALT-36 AST-53* CK(CPK)-1339* AlkPhos-80 \nTotBili-0.2\n___ 02:10PM BLOOD CK-MB-32* MB Indx-2.4\n\nDischarge\n___ 05:10AM BLOOD WBC-10.4* RBC-4.39* Hgb-13.4* Hct-39.6* \nMCV-90 MCH-30.5 MCHC-33.8 RDW-13.2 RDWSD-43.0 Plt ___\n___ 05:10AM BLOOD ___ PTT-30.2 ___\n___ 05:10AM BLOOD Glucose-84 UreaN-9 Creat-0.9 Na-140 K-3.8 \nCl-100 HCO3-27 AnGap-13\n___ 05:10AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.9\n___ 02:03AM BLOOD D-Dimer-1655*\n\nIMAGING: \n\nMRI/MRA ___\nMRI brain: Several foci of slow diffusion are demonstrated in \nthe\nleft parieto-occipital cortex, deep white matter, as well as the\nleft frontal lobe (see 07:13, 15, 24). There is corresponding T2\nand FLAIR hyperintensity in these regions. Additionally, in the\nparieto-occipital region there is susceptibility suggestive of\nhemorrhage (11:13). This is most consistent with multifocal\ninfarcts with hemorrhagic transformation in the \nparieto-occipital\nportion. \nAddendum (___): Partially visualized right supra-auricular \nscalp\nsoft tissue enhancement is noted (see 105:35; 4, 15:8; 105:64). \nFinding is nonspecific, however dermal lesion is not excluded on\nthe basis of this examination. Recommend correlation with \ndirect\nexamination.\n \nMRA: Vessels of the circle of ___ and their major branches \nare\npatent without evidence of stenosis, occlusion or dissection.\nThere is a right-sided dominant vertebrobasilar system. \n\nECHO ___\nNo definite cardiac source of embolism identified in the setting\nof suboptimal agitated saline injection. Mild symmetric left\nventricular hypertrophy with normal cavity size, and\nregional/global systolic function. Normal right ventricular\ncavity size and systolic function. Mild to moderate mitral\nregurgitation. Mild tricuspid regurgitation.\n\nCTA HEAD AND CTA NECK\n1. Known, subacute infarcts within left parietal and occipital\nlobes. The extent of these are better characterized on the\npatient's recent MRI examination.\n2. Hyperdensity within the dominant left occipital lobe infarct\nis compatible with hemorrhagic conversion, correlating with\nfindings on gradient echo sequences on recent MRI examination.\n3. Luminal irregularity involving the left greater than right\nproximal internal carotid arteries, demonstrating a mildly \nbeaded\nappearance on the left with up to approximately 50% stenosis by\nNASCET criteria. Findings may reflect noncalcified\natherosclerotic disease versus fibromuscular dysplasia.\n4. Multifocal calcified atherosclerotic disease within the\nbilateral V4\nsegments and cavernous internal carotid arteries. No high-grade\nstenosis, occlusion, dissection, or aneurysm greater than 3 mm.\n5. ETT terminating in the lower thoracic trachea near the level\nof the carina and directed into the proximal right mainstem\nbronchus.\n6. Moderate right pleural effusion and small left pleural\neffusion, with bilateral emphysematous changes and dependent\natelectasis. If clinically indicated, consider correlation with\ndedicated chest imaging.\n\nBTCPS SPECTRO AND PERF TUMOR CLINIC PROTOCOL ___ MR HEAD\n1. Interval evolution of a dominant left parieto-occipital\ninfarction with increasing internal hemorrhagic products, with\nsurrounding edema and enhancement.\n2. Multiple additional areas of known subacute infarction, as\nabove, several of which also demonstrate increasing internal\nhemorrhagic components.\n3. MR contrast perfusion of the dominant infarct demonstrates\nincreased mean transit time and areas of decreased cerebral \nblood\nvolume, compatible with infarction.\n4. ASL perfusion demonstrates several areas curvilinear and \nfocal\nincreased perfusion, generally involving the smaller, more\nsuperior areas of infarction and correlating with areas of\nenhancement. These findings may represent reactive changes in\nthe setting of recent ischemia.\n5. MR spectroscopy of the dominant left parieto-occipital \ninfarct\nis limited secondary to extensive hemorrhagic products within \nthe\nlesion. Allowing for this, there are increased choline and\ncreatinine levels, although the choline/NAA ratio remains at 1 \nor\nbelow. Associated areas of increased MI/creatinine ratio are\nsuggestive of a non neoplastic etiology such as infarction,\nincluding the possibility of a cortical hemorrhagic venous\ninfarct. Increased lipids and lactate likely correlate with\nareas of necrosis following infarction.\n6. These findings taken together are suggestive of areas of\nevolving ischemia/infarction, some of which contain internal \nhemorrhagic\ncomponents, a venous hemorrhagic cortical infarction is a\nconsideration, recommend attention at follow-up imaging to\nfurther exclude any underlying mass.\n\nCT abdomen \n1. No retroperitoneal hematoma or active extravasation of\ncontrast in the abdomen or pelvis. \n2. Soft tissue stranding in the omentum and gastroesophageal\njunction presumably related to recent revision of ___\nfundoplication. \n3. 2 cm right adrenal adenoma, mildly increased compared to \n___.\n\n \nBrief Hospital Course:\n#stroke - Mr. ___ is a ___ year old man with history of \nadrenal adenoma, recent esophageal adenocarcinoma, AAA without \nrupture, s/p bilateral carotid endarterectomies, HLD, HTN, who \npresented with acute onset right arm and leg weakness with left \nhomonymous hemianopia. Found to have multifocal infarcts with \nthe left parieto-occipital area. He was started on heparin \ndrip, as it felt that his strokes were likely due to \nhypercoaguability of malignancy (D-dimer was ~1600) or embolic. \nTTE showed enlarged left atrial size. MR spect of his brain was \nperformed to assess for underlying malignancy but was \nunremarkable. He underwent endoscopic mucosal resection of a \nmass at the GE junction on ___. This procedure had already \nbeen planned for prior to admission. Pathology was pending at \nthe time of discharge. He was transitioned from heparin to \naspirin 325 mg daily and warfarin. Warfarin was chosen instead \nof lovenox because of cost considerations, and it was felt that \nself-administration of lovenox would not be ideal for him. He \nwas discharged to rehab. An order for an outpatient ___ of \nhearts event monitor was placed as well. He should be on tele at \nrehab for post stroke monitoring for afib. He is on high \nintensity statin, atorvastatin 80 mg qhs as well.\n\n#seizure - He had an episode of apnea, unwitnessed shaking \nactivity, was intubated for airway protection and transferred to \nNeuroICU for further care and stabilization while on the floor. \ncvEEG with was with no epileptiform discharges and was \ndiscontinued. CTA head and neck negative for acute process. \nEvent felt to be related to seizure in the setting of acute \nstroke, or perhaps may be related to chronic benzodiazepine use \nas well. He was continued on Keppra 1000 mg BID and transferred \nto the floor, and did not have further seizure activity. He was \non IV keppra while vomiting, this can be switched to PO at rehab \nas long as he is tolerating PO.\n\n#abdominal pain/nausea vomiting - he was given PRN Zofran and \nreglan. CT A/P was unremarkable. Improved after resection of \nesophageal mass. Given PRN tramadol. Occasionally received low \ndoses of morphine. He was on IV fluids due to his vomiting. This \ncan be discontinued once his PO intake is more consistent.\n\n#esophageal mass - resected by GI on ___. He should be on an \nIV PPI for 7 days post procedure until ___ to prevent bleeding \nper GI recs. He is on esomeprazole 40 mg q12h. Afterwards he \nshould be on oral PPI, pantoprazole 40 mg BID.\n\nChronic issues\nheld home hypertensives due to hypotension, these can be resumed \nas tolerated. He is on metoprolol succinate 100 mg daily at \nhome.\n\nTransitional issues\n#Stroke\n-titrate warfarin until therapeutic, goal INR ___\n-discontinue aspirin 325 mg daily once therapeutic on warfarin \nfor 24 hours\n-___ of hearts monitor ordered as an outpatient, follow up \nresults\n-should be referred to neurology by his PCP, as he is an Atrius \npatient\n\n#seizure\n-keppra 1 gm BID until seen by neurology\n-should be referred to neurology by his PCP, as he is an Atrius \npatient\n\n#esophageal resection\n-follow up with GI as an outpatient\n-should continue on IV PPI until ___ per GI, he is on \nesomeprazole 40 mg q12h, then should be oral PPI, pantoprazole \n40 mg BID.\n- follow up pathology from biopsy\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 = 113) - () No \n 5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL \n>70, reason not given: \n [ ] Statin medication allergy \n [ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n [ ] LDL-c less than 70 mg/dL \n ] \n 6. Smoking cessation counseling given? () Yes - (x) No [reason \n(x) non-smoker - () unable to participate] \n 7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given (verbally or \nwritten)? (x) Yes - () No \n 8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No \n 9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, \nreason not given: \n [ ] Statin medication allergy \n [ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n [ ] LDL-c less than 70 mg/dL \n 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - (x) Anticoagulation] - () No \n 11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - (x) N/A \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 80 mg PO DAILY \n2. LORazepam 0.5 mg PO BID:PRN anxiety/sleep \n3. Albuterol Sulfate (Extended Release) Dose is Unknown PO \nDAILY:PRN asthma \n4. Metoprolol Succinate XL 100 mg PO DAILY \n5. Sertraline 25 mg PO DAILY \n6. TraZODone 50 mg PO QHS \n7. Zolpidem Tartrate 10 mg PO QHS \n8. Nicotine Patch 14 mg TD DAILY \n9. Pantoprazole 40 mg PO BID \n10. Sucralfate 1 gm PO QIDACHS \n11. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing \n2. Docusate Sodium 100 mg PO BID:PRN constipation \n3. Esomeprazole sodium 40 mg IV Q12H \n4. LevETIRAcetam 1000 mg PO BID \n5. Metoclopramide 10 mg IV Q6H:PRN Nausea \n6. Ondansetron 4 mg IV Q8H:PRN nausea \n7. Senna 8.6 mg PO BID:PRN Constipation \n8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n9. Warfarin 5 mg PO DAILY16 \n10. Aspirin 325 mg PO DAILY \n11. Atorvastatin 80 mg PO QPM \n12. Sertraline 50 mg PO DAILY \n13. TraZODone 50 mg PO QHS:PRN insomnia \n14. LORazepam 0.5 mg PO BID:PRN anxiety/sleep \n15. Metoprolol Succinate XL 100 mg PO DAILY \n16. Nicotine Patch 14 mg TD DAILY \n17. Zolpidem Tartrate 10 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nMutlifocal parieto-occipital strokes \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\nNeuro exam: nonfocal\n\n \nDischarge Instructions:\nDear Mr. ___,\n \nYou were hospitalized here after your were presented with acute \nonset right arm and leg weakness with visual problems resulting \nfrom an ACUTE ISCHEMIC STROKE, a condition where a blood vessel \nproviding oxygen and nutrients to the brain is blocked by a \nclot. The brain is the part of your body that controls and \ndirects all the other parts of your body, so damage to the brain \nfrom being deprived of its blood supply can result in a variety \nof symptoms. The etiology may be due to increased chance of \nclotting due to cancer but an abnormal heart rhythm causing \nclots traveling to your brain also remain as a possibility. You \nwere temporarily on a blood thinner on IV heparin, we changed \nthis to aspirin 325 mg daily and started a blood thinner called \nwarfarin for anticoagulation to decrease your risk of strokes. \nThe aspirin is temporary until the warfarin has completely taken \neffect. You should continue taking these medications as \nindicated. \n\nNew medications:\nAspirin 325 mg daily, this should be discontinued once your \nwarfarin has completely kicked in, in other words once your INR \nis ___.\nwarfarin 5 mg daily (your dose will be adjusted at rehab to \nreach the goal INR)\n\nPlease follow up with Neurology and your primary care physician \nas listed below. \n\nIf you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms: \n - Sudden partial or complete loss of vision \n - Sudden loss of the ability to speak words from your mouth \n - Sudden loss of the ability to understand others speaking to \nyou \n - Sudden weakness of one side of the body \n - Sudden drooping of one side of the face \n - Sudden loss of sensation of one side of the body \n \nSincerely, \nYour ___ Neurology Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I63412", "J9600", "I619", "N179", "D6869", "I959", "C160", "G8191", "J9811", "R569", "H53462", "I10", "Z87891", "D72829", "R109", "I714", "E785", "M545", "K219", "J449", "F329", "F419", "Z9119" ]

[ "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "I619: Nontraumatic intracerebral hemorrhage, unspecified", "N179: Acute kidney failure, unspecified", "D6869: Other thrombophilia", "I959: Hypotension, unspecified", "C160: Malignant neoplasm of cardia", "G8191: Hemiplegia, unspecified affecting right dominant side", "J9811: Atelectasis", "R569: Unspecified convulsions", "H53462: Homonymous bilateral field defects, left side", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "D72829: Elevated white blood cell count, unspecified", "R109: Unspecified abdominal pain", "I714: Abdominal aortic aneurysm, without rupture", "E785: Hyperlipidemia, unspecified", "M545: Low back pain", "K219: Gastro-esophageal reflux disease without esophagitis", "J449: Chronic obstructive pulmonary disease, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z9119: Patient's noncompliance with other medical treatment and regimen" ]

[ "N179", "I10", "Z87891", "E785", "K219", "J449", "F329", "F419" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nibuprofen / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)\n \nAttending: ___.\n \nChief Complaint:\nAbdominal wall abscess\n \nMajor Surgical or Invasive Procedure:\n___: Ultrasound-guided drainage of superficial right \nabdominal \ncollection \n\n \nHistory of Present Illness:\nWe have been consulted on this patient known to Dr. ___\nwho is status post open cholecystectomy for choledocolothiasis\nwho presents to the ED with dehydration, leukocytosis and\nclinical/radiological findings concerning for abdominal wall\nabscess\n\nHe's a ___ year old very frail male with medical history \npertinent\nfor multifocal parieto-occipital CVA, carotid stenosis s/p\nbilateral CEA, COPD, HTN, HLD, history of a Nissen \nfundoplication\nand a subsequent takedown, ___ esophagus that progressed \nto\nesophageal carcinoma. \n\nAs above, he is status post open cholecystectomy performed for\ncholedocholithiasis on ___ with uncomplicated postoperative\ncourse and discharged home on POD#3.\n\nSince discharge he endorses area of swelling, pain and \necchymosis\nat his incision. He was given Rx for Oxycodone post-op, used\nthese, but still in pain. He presented to PCP to follow on these\nsymptoms on ___. At that time he was found with area of\necchymosis and distention at incision site, as well as tender to\npalpation. A CT abdomen was performed which demonstrated\npostsurgical changes as well as a postoperative seroma along the\nright rectus musculature measuring approximately 2.2 cm. He\npresents to the ED today with progression of symptoms, more\nspecifically he feels a \"lump\" at his incision. Denies any \nfever,\nnausea, chills, chest pain, shortness of breath, change in bowel\nhabits, GI bleeding. Of note, he endorses lack of appetite (but\nthis seems usual after each of the prior operations he has had)\nas well as intermittent dysuria.\n\nUpon arrival to the ED, VS: 98.8, 66, 108/66, 16, 97% RA. He is\nno in acute distress but oral mucosa is dry. Abdominal exam\nnotable for area of swelling to subcostal incision with two \necchymotic areas at the mid portion of the incision. I could not\nexpress any purulent material of the incision. Slight tenderness\nto palpation. Otherwise abdomen is soft. Outside hospital labs\nremarkable for leukocytosis to 15 and hypokalemia. Liver \nfunction\ntest unrevealing. Outside hospital CT abdomen performed today\ndemonstrating a 7cm walled off collection with some fat \nstranding\nat the right upper quadrant abdominal wall. This collection \nseems\nnot to communicate with the abdominal wall cavity. I could not\nappreciate any intraabdominal process. \n\nROS:\n(+) per HPI\n(-) Denies pain, fevers chills, night sweats, unexplained weight\nloss, fatigue/malaise/lethargy, changes in appetite, trouble \nwith\nsleep, pruritis, jaundice, rashes, bleeding, easy bruising,\nheadache, dizziness, vertigo, syncope, weakness, paresthesias,\nnausea, vomiting, hematemesis, bloating, cramping, melena, \nBRBPR,\ndysphagia, chest pain, shortness of breath, cough, edema, \nurinary\nfrequency, urgency\n\n \nPast Medical History:\nPer HPI. Multifocal Parieto-occipital CVA (___) - (left \nparieto-occipital area most affected, some left MCA involvement)\nHTN, HLD, carotid stenosis s/p bilateral CEA \nAAA without rupture (2.6 cm), Aortic dissection - not otherwise\nspecified, Esophageal adenocarcinoma, GERD, ___ Esophagus,\ns/p Nissen fundoplication revision, Diverticulitis, Adrenal\nAdenoma Asthma, COPD, Former smoker (40-pack yrs, Asbestos\nexposure)Pneumonia, recurrent, Chronic pain - pain agreement,\npotentially broken ___, Low back pain, Urinary frequency,\nInguinal hernia, ventral hernias, Prior alcohol abuse \n\nPast Surgical History:\nPer HPI. \nBilateral carotid endarterectomies \nInguinal and ventral hernia repair x4 \nEndoscopic mucosal resection of mass at ___ junction ___ \n___ and revision of ___ Fundoplication \nUpper EUS (___) \nERCP and biliary stent placement (___) \n\n \nSocial History:\n___\nFamily History:\nMother - CAD, PVD\nFather - Liver ca\nOther - Uncles - CVA, ___ cancer\n \nPhysical Exam:\nPhysical Exam on arrival:\nVitals: 98.8, 66, 108/66, 16, 97% RA\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended, nontender, no rebound or guarding,\nnormoactive bowel sounds, no palpable masses\nDRE: normal tone, no gross or occult blood\nExt: No ___ edema, ___ warm and well perfused\n\nPhysical Exam on arrival:\nVitals: Stable\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended, nontender, no rebound or guarding, \nnormoactive bowel sounds, no palpable masses; upper quadrant \nwound packed with wick (healing appropriately)\nExt: No ___ edema, ___ warm and well perfused\n\n \nPertinent Results:\nLab Results:\n___ 05:22AM BLOOD WBC-8.1 RBC-3.63* Hgb-10.7* Hct-31.7* \nMCV-87 MCH-29.5 MCHC-33.8 RDW-12.0 RDWSD-39.1 Plt ___\n___ 06:00AM BLOOD WBC-9.2 RBC-3.68* Hgb-11.0* Hct-32.1* \nMCV-87 MCH-29.9 MCHC-34.3 RDW-12.3 RDWSD-39.5 Plt ___\n___ 05:42AM BLOOD WBC-9.7 RBC-3.70* Hgb-10.6* Hct-32.9* \nMCV-89 MCH-28.6 MCHC-32.2 RDW-12.4 RDWSD-40.2 Plt ___\n___ 06:45AM BLOOD WBC-12.0* RBC-3.83* Hgb-10.9* Hct-33.3* \nMCV-87 MCH-28.5 MCHC-32.7 RDW-12.5 RDWSD-40.0 Plt ___\n___ 08:18AM BLOOD WBC-11.6* RBC-3.65* Hgb-10.8* Hct-32.5* \nMCV-89 MCH-29.6 MCHC-33.2 RDW-12.5 RDWSD-40.6 Plt ___\n___ 04:35AM BLOOD WBC-14.5* RBC-3.84* Hgb-11.1* Hct-33.4* \nMCV-87 MCH-28.9 MCHC-33.2 RDW-12.5 RDWSD-39.7 Plt ___\n___ 05:22AM BLOOD Neuts-60.2 ___ Monos-12.5 Eos-5.2 \nBaso-0.5 Im ___ AbsNeut-4.88 AbsLymp-1.69 AbsMono-1.01* \nAbsEos-0.42 AbsBaso-0.04\n___ 08:18AM BLOOD Neuts-68.6 Lymphs-17.3* Monos-12.8 \nEos-0.2* Baso-0.3 Im ___ AbsNeut-7.98* AbsLymp-2.01 \nAbsMono-1.49* AbsEos-0.02* AbsBaso-0.04\n___ 04:35AM BLOOD Neuts-74.2* Lymphs-11.5* Monos-13.0 \nEos-0.0* Baso-0.4 Im ___ AbsNeut-10.76* AbsLymp-1.67 \nAbsMono-1.88* AbsEos-0.00* AbsBaso-0.06\n\n___ 05:22AM BLOOD Glucose-80 UreaN-6 Creat-1.2 Na-140 K-3.5 \nCl-97 HCO3-31 AnGap-12\n___ 06:00AM BLOOD Glucose-100 UreaN-5* Creat-1.1 Na-141 \nK-3.4 Cl-99 HCO3-29 AnGap-13\n___ 05:42AM BLOOD Glucose-90 UreaN-9 Creat-1.3* Na-143 \nK-3.9 Cl-99 HCO3-29 AnGap-15\n___ 06:45AM BLOOD Glucose-87 UreaN-6 Creat-0.8 Na-136 K-3.3 \nCl-93* HCO3-29 AnGap-14\n___ 08:18AM BLOOD Glucose-89 UreaN-14 Creat-0.8 Na-142 \nK-3.6 Cl-106 HCO3-26 AnGap-10\n___ 04:35AM BLOOD Glucose-106* UreaN-17 Creat-0.9 Na-140 \nK-3.9 Cl-103 HCO3-25 AnGap-12\n___ 05:22AM BLOOD Plt ___\n___ 05:22AM BLOOD ___ PTT-37.7* ___\n___ 09:50PM BLOOD PTT-36.3\n___ 01:20PM BLOOD PTT-49.3*\n\nImaging:\nPERC IMAGE GUID FLUID COLLECT DRAIN W CATH (___): \nIMPRESSION: Successful US-guided placement of ___ pigtail \ncatheter into the right abdominal wall collection. Sample was \nsent for microbiology evaluation.\n\nMicrobiology results from drain:\nGRAM STAIN (Final ___: \n4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. \n2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). \nFLUID CULTURE (Final ___: NO GROWTH. \nANAEROBIC CULTURE (Preliminary): ANAEROBIC GRAM NEGATIVE ROD(S). \n SPARSE GROWTH\n \n \n\n \nBrief Hospital Course:\nThe patient presented to Emergency Department on ___. \nPatient was found to have an abdominal wall abscess. For this \nreason he was admitted to the ___ Surgery for further \nmanagement. On admission the patient's INR was 4.3 and for this \nreason it was not possible to have the abscess drained on \npresentation. For this reason he was admitted for further \nmanagement. His Coumadin was held and he was also given fresh \nfrozen plasma and vitamin K. The following day the patient went \nto ___ and got the fluid drained and a drainage was placed. The \nfluid collected from the peritoneal fluid collected it grew \nsparse anaerobic gram negative rods (for full results please see \nresults section of discharge summary). The patient's creatinine \nwas elevated to 1.3 during the admission and for this reason he \nwas started on IV normal saline. Following the ___ procedure the \npatient was restarted on a heparin drip. The heparin drip was \nthen stopped and the patient was placed on warfarin with lovenox \nbridging. His creatinine function was downtrending. On discharge \nhis INR was therapeutic and his lovenox was discontinued. \n\nFurthermore in summary during this hospital course review of \nsystems had as follow:\n\nNeuro: The patient was alert and oriented throughout \nhospitalization pain was well controlled with acetaminophen and \noxycodone.\n\nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. He had two \nepisodes of asymptomatic high blood pressure that responded to \nIV hydrazine. \n\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \n\nGI/GU/FEN: The patient was on a regular diet, which was well \ntolerated. Patient's intake and output were closely monitored. \nHe had two episodes of emesis during the hospital course that \ndid not require further work up at the time.\n\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none. When the patient's \nadmission the ___ was 14 that was within normal limits on \ndischarge. The patient was placed on IV antibiotics (Vancomycin \nand zosyn) that was transitioned to oral augmentin on discharge. \nThe patient needs to complete a two weeks course of augmentin \nupon discharge. \n\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none. The patient was bridged \nback to Coumadin with lovenox. The INR level was appropriate at \nthe time of discharge. \n\nProphylaxis: ___ dyne boots were used during this stay and was \nencouraged to get up and ambulate as early as possible.\n\nSocial work: During this hospital course the patient expressed \nfeelings of having difficulty coping. For this reason a social \nwork consult was obtained and coping strategies and resources \nwere put in place.\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 may be inaccurate and requires \nfuther investigation.\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing \n2. Atorvastatin 80 mg PO QPM \n3. Zolpidem Tartrate 10 mg PO QHS \n___ MD to order daily dose PO DAILY16 \n5. TraZODone 50 mg PO QHS:PRN insomnia \n6. Sertraline 100 mg PO DAILY \n7. Pantoprazole 40 mg PO Q12H \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. Metoprolol Succinate XL 100 mg PO DAILY \n10. LORazepam 1 mg PO Q8H:PRN anxiety \n11. LevETIRAcetam 1000 mg PO BID \n12. Enoxaparin Sodium 70 mg SC Q12H \nStart: ___, First Dose: Next Routine Administration Time \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild \n Reason for PRN duplicate override: Patient is NPO or unable to \ntolerate PO\nRX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp \n#*30 Tablet Refills:*0 \n2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth \ntwice a day Disp #*17 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*30 Tablet Refills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Mild \nRX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*9 Tablet Refills:*0\nRX *oxycodone 5 mg ___ tablet(s) by mouth every 8 hours Disp \n#*25 Tablet Refills:*0 \n5. Senna 8.6 mg PO BID \n6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing \n7. Atorvastatin 80 mg PO QPM \n8. Enoxaparin Sodium 70 mg SC Q12H \nIf your INR is between ___ you can stop taking this medication. \n\nRX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours \nDisp #*10 Syringe Refills:*0 \n9. LevETIRAcetam 1000 mg PO BID \n10. LORazepam 1 mg PO Q8H:PRN anxiety \n11. Metoprolol Succinate XL 100 mg PO DAILY \n12. Ondansetron 4 mg PO Q8H:PRN nausea \n13. Pantoprazole 40 mg PO Q12H \n14. Sertraline 100 mg PO DAILY \n15. TraZODone 50 mg PO QHS:PRN insomnia \n16. ___ MD to order daily dose PO DAILY16 \n17. Zolpidem Tartrate 10 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal wall 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 admitted to the ___ Surgery because you were \nfound to have an abdominal wall abscess. You were placed on \nantibiotics and your anticoagulation was reversed. Then you had \nthe abdominal wall abscess drained and have recovered well. You \nare now ready for discharge. \n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nCoumadin: Please follow up with your PCP ___ ___ for an INR \ncheck and instructions on dosing your warfarin.\n\nAntibiotics: Please complete the full 9 day course(finish all \nthe pills)that you were prescribed at discharge. \n\nIncision Care:\nYour dressing was changed on the day of discharge. Please \ncontinue to change it daily with clean dry gauze until it heals \nor scabs over. Then you should keep it covered only as needed. \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\nIt has been a pleasure looking after you and we wish you a \nspeedy recovery.\n\n___ Surgery \n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "L02211", "Y838", "Y929", "E860", "R110", "Z8673", "I10", "E785", "Z8501", "K219", "J45909", "Z87891", "G8929" ]

[ "T814XXA: Infection following a procedure", "L02211: Cutaneous abscess of abdominal wall", "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", "E860: Dehydration", "R110: Nausea", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z8501: Personal history of malignant neoplasm of esophagus", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "G8929: Other chronic pain" ]

[ "Y929", "Z8673", "I10", "E785", "K219", "J45909", "Z87891", "G8929" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nibuprofen\n \nAttending: ___\n \nChief Complaint:\npost ERCP\n\n \nMajor Surgical or Invasive Procedure:\nERCP with sphincterotomy and CBD stent placement\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of HTN,\nHL, PAD, former alcohol abuse, recent multifocal CVA started on\nCoumadin, post-CVA course complicated by seizure now on AEDs,\nGERD, ___, s/p Nissen fundoplication with recent revision\nand newly diagnosed Esophageal adenocarcinoma, who p/w biliary\nobstruction and underwent ERCP for CBD stone with biliary stent\nplacement earlier today, now admitted for post-ERCP care. \n\nHe initially presented with w/ elevated LFT's, found to have a\nCBD stone on EUS ___. Today (___), he underwent ERCP with\nbiliary sphincterotomy after PD stent to assist cannulation,\nballoon sweeps performed but no clear stones removed. There was\nquestion of retroperitoneal contrast extravasation during\nprocedure, concerning for possible small perforation in the\ndistal CBD for which fully covered biliary metal stent was \nplaced\n(treatment of choice). He is expected to have some pain given\nabove. Per ERCP fellow, plan to keep NPO today, with IVF & abx,\nadvance to clears in AM, and resume lovenox on ___. \n\nPatient was started on Coumadin in ___ of this year after\npresenting with acute multifocal CVA with left parieto-occipital\narea most affected, but also with left MCA involvement. This was\nthought to be related to hypercoagulability of malignancy and\ndecision made to start patient on Coumadin for secondary stroke\nprevention. At the time, Coumadin was thought to be preferable\nover Lovenox due to concern that he would not be able to\nself-administer Lovenox. More recently, in the setting of \nplanned\nendoscopic procedures, his Coumadin has been held since ___,\nand he has been on Lovenox instead with plan to continue through\nboth his endoscopic procedures (EUS on ___, ERCP ___. Per\ninstructions, his ___ dose of Lovenox the night before each\nprocedure has been held. Per ERCP recs, will continue to hold\nLovenox until ___ at least.\n\nOn arrival to the floor, patient stated that his pain and nausea\nimproved after Zofran and dilaudid. He reports poor po intake\nsince ___ with persistent N/V and RUQ abdominal pain. He\ndenies fevers/chills, SOB, cough, chest pain, dysuria. He does\nnote mild hematochezia with his BM's this morning. He states he\nhas not taken his keppra since discharge from rehab 3 weeks ago\nbecause he didn't have refills but denies any episodes of \nseizure\nlike activity. He ambulates with cane and has been continuing\nwith outpatient ___ and speech therapy since discharge from\nrehab. \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\nMultifocal Parieto-occipital CVA (___) - (left\nparieto-occipital area most affected, some left MCA involvement)\nHTN, HLD\nCarotid stenosis s/p bilateral CEA\nAAA without rupture (2.6 cm)\nAortic dissection - not otherwise specified \nEsophageal adenocarcinoma\nGERD, ___ Esophagus, s/p Nissen fundoplication revision\nDiverticulitis\nAdrenal Adenoma\nAsthma, COPD, Former smoker (40-pack yrs, Asbestos exposure)\nPneumonia, recurrent\nChronic pain - pain agreement, potentially broken ___\nLow back pain\nUrinary frequency\nInguinal hernia, ventral hernias \nPrior alcohol abuse\n\nSurgical or Invasive Procedure:\nBilateral carotid endarterectomies\nInguinal and ventral hernia repair x4\nEndoscopic mucosal resection of mass at GE junction ___\nRevision of ___ Fundoplication\nUpper EUS (___)\nERCP and biliary stent placement (___)\n\n \nSocial History:\n___\nFamily History:\nMother - CAD, PVD\nFather - Liver ca\nOther - Uncles - CVA, ___ cancer\n\n \nPhysical Exam:\nADMISSION EXAM:\n==============\nVITALS: 97.8, P 68, BP 164/97, RR 17, 93% on RA\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate. Dry MM. \nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. Old surgical scars across abdomen. Marks from\nLovenox injection sites on left side of abdomen. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\n==============\nVITALS: 97.9PO 153 / 89 59 18 93 RA \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate. Dry MM. \nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. Old surgical scars across abdomen. Marks from\nLovenox injection sites on left side of abdomen. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\nADMISSION LABS:\n___ 12:50PM BLOOD WBC-6.0 RBC-4.12* Hgb-12.5* Hct-36.6* \nMCV-89 MCH-30.3 MCHC-34.2 RDW-13.2 RDWSD-43.3 Plt ___\n___ 12:50PM BLOOD ___ PTT-33.1 ___\n___ 12:50PM BLOOD UreaN-13 Creat-0.9 Na-141 K-3.3 Cl-97 \nHCO3-33* AnGap-11\n___ 12:50PM BLOOD ALT-22 AST-20 AlkPhos-77 Amylase-51 \nTotBili-0.5\n\nDISCHARGE LABS:\n___ 07:13AM BLOOD WBC-6.4 RBC-4.00* Hgb-11.9* Hct-35.6* \nMCV-89 MCH-29.8 MCHC-33.4 RDW-13.2 RDWSD-43.3 Plt ___\n___ 07:13AM BLOOD Glucose-87 UreaN-6 Creat-0.8 Na-142 K-3.6 \nCl-98 HCO3-35* AnGap-9*\n___ 07:13AM BLOOD ALT-15 AST-14 AlkPhos-80 TotBili-0.5\n___ 07:13AM BLOOD Albumin-3.6 Calcium-8.7 Mg-1.8\n\n___: ERCP Report\nImpression: •The scout film was normal. \n•During difficult biliary cannulation, the pancreatic duct was\npartially filled with contrast and visualized proximally. \n•The course and caliber of the duct was normal with no evidence\nof filling defects, masses, chronic pancreatitis or other\nabnormalities. \n•To aid in difficult biliary cannulation, a ___ x 5 cm single\npigtail plastic pancreatic duct stent was placed. The bile duct\nwas deeply cannulated with the sphincterotome. \n•Contrast was injected and there was brisk flow through the\nducts. \n•Contrast extended to the entire biliary tree. The CBD was 6 mm\nin diameter. \n•There was no clear evidence of a filling defect. Opacification\nof the gallbladder was incomplete. \n•The left and right hepatic ducts and all intrahepatic branches\nwere normal. \n•Given CBD stone seen on EUS, a biliary sphincterotomy was made\nwith a sphincterotome. \n•There was no post-sphincterotomy bleeding. \n•The biliary tree was swept with a 9-12mm balloon starting at \nthe\nbifurcation. \n•Scant sludge was removed successfully. \n•Given evidence of a small amount of contrast extravasation near\nthe distal CBD compatible with possible small perforation, a \n10mm\nx 60 mm ___ ___, REF ___, LOT ___ fully\ncovered metal biliary stent was placed. \n•The final occlusion cholangiogram showed no evidence of filling\ndefects in the CBD. \n•Excellent bile and contrast drainage was seen endoscopically \nand\nfluoroscopically.\n•Otherwise normal ercp to third part of the duodenum\n\nRecommendations: •Admit to hospital for monitoring\n•NPO overnight with aggressive IV hydration with LR at 200 cc/hr\n•If no abdominal pain in the morning, advance diet to clear\nliquids and then advance as tolerated\n•Recommend surgical evaluation for possible cholecystectomy in\nthe future once fully covered metal stent is removed\n•Resume lovenox on ___\n•Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.\n•Repeat ERCP in 4 weeks for PD and CBD stent pull and\nre-evaluation.\n•Follow for response and complications. If any abdominal pain,\nfever, jaundice, gastrointestinal bleeding please call Advanced\nEndoscopy Fellow on call ___\n \nBrief Hospital Course:\nMr. ___ is a ___ male with history of HTN, HL, PAD, \nformer alcohol abuse, recent multifocal CVA started on Coumadin, \npost-CVA course complicated by seizure now on AEDs, GERD, \n___, s/p ___ fundoplication with recent revision and \nnewly diagnosed Esophageal adenocarcinoma, who p/w biliary \nobstruction and underwent ERCP for CBD stone with biliary stent \nplacement, now admitted for post-ERCP\ncare.\n\n#CBD Stone, s/p ERCP - He initially presented with w/ elevated \nLFT's, found on EUS ___ to have a CBD stone. He underwent \nERCP with biliary sphincterotomy after PD stent to assist \ncannulation, balloon sweeps, no clear stones removed. There was\nquestion of retroperitoneal contrast extravasation during \nprocedure, concerning for possible small perforation in the \ndistal CBD for which fully covered biliary metal stent placed \n(which is treatment of choice). Can have some expected pain due\nto this. He was monitored post-procedure and was noted to have \nstable labs, vitals and exam. He was tolerating a regular diet \non discharge. Sent home with a few days of oxycodone for \npost-procedural pain. He will also complete 5 days of \nCiprofloxacin. Pt will be called to return for repeat ERCP in 4 \nweeks for stent pull and evaluation. He was also provided with \nnumber for Surgery clinic to discuss optimal timing of ccy.\n\n#Chronic anticoagulation - Coumadin held since ___. \n Anticoagulation Indication: Stroke/TIA \n INR goal 2.0-3.0, last outpatient INR 2.2 on ___ \n Plan: ___: Hold; ___: Hold; ___: Hold; \n ___: Hold; ___: Hold; ___: 6 mg; ___: 6 mg; ___: 6 mg. \n\n Next INR check ___. \nResumed ___ on ___ per ERCP team\n\nCHRONIC/STABLE PROBLEMS:\n#Recently diagnosed Esophageal Adenocarcinoma - mass at ___\njunction s/p endoscopic mucosal resection in ___, c/w\nlow-grade Adenocarcinoma. Per outpatient notes from ___,\nfound to have positive resection margins, but Surgery \nrecommended\nagainst esophagectomy given recent CVA. He will f/u with OP \nproviders\n___ CVA c/b seizure - A/C plan as above, restarted \nkeppra\n#HTN - continued home antihypertensives\n#HL - continued home statin\n#GERD - continued home PPI\n#Asthma/COPD - prn inhalers\n#Hx depression/anxiety/insomnia - continude home SSRI & prn \nativan\n\nBilling: greater than 30 minutes spent on discharge counseling \nand coordination of care.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Zolpidem Tartrate 10 mg PO QHS \n2. Atorvastatin 80 mg PO QPM \n3. Pantoprazole (Granules for ___ ___ 20 mg PO DAILY \n4. Sertraline 100 mg PO QHS \n5. TraZODone 100 mg PO QHS:PRN sleep if not taking ambien \n6. LORazepam 1 mg PO Q8H:PRN anxiety \n7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing \n8. Docusate Sodium 100 mg PO BID:PRN constipation \n9. LevETIRAcetam 1000 mg PO BID \n10. Senna 8.6 mg PO BID:PRN Constipation \n11. Warfarin 6 mg PO DAILY16 \n12. Metoprolol Succinate XL 100 mg PO DAILY \n13. Nicotine Patch 14 mg TD DAILY \n14. Enoxaparin Sodium 80 mg SC Q12H \n15. Ondansetron 4 mg PO Q8H:PRN nausea \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours \nDisp #*6 Tablet Refills:*0 \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp \n#*20 Tablet Refills:*0 \n3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing \n4. Atorvastatin 80 mg PO QPM \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Enoxaparin Sodium 80 mg SC Q12H \n7. LevETIRAcetam 1000 mg PO BID \n8. LORazepam 1 mg PO Q8H:PRN anxiety \n9. Metoprolol Succinate XL 100 mg PO DAILY \n10. Nicotine Patch 14 mg TD DAILY \n11. Ondansetron 4 mg PO Q8H:PRN nausea \n12. Pantoprazole (Granules for ___ ___ 20 mg PO DAILY \n13. Senna 8.6 mg PO BID:PRN Constipation \n14. Sertraline 100 mg PO QHS \n15. TraZODone 100 mg PO QHS:PRN sleep if not taking ambien \n16. Warfarin 6 mg PO DAILY16 \n17. Zolpidem Tartrate 10 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCholedocholithiasis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou came in with abdominal pain and abnormal liver tests. We \ndid a procedure called an ERCP which showed you had a gallstone \nobstructing your bile duct. They cleared the stone and placed a \nstent to assist drainage of the duct. You tolerated this \nprocedure well.\n\nYou will need a repeat ERCP in 4 weeks for reevaluation and \nstent removal. You will get called by the Endoscopy Department \nfor this appointment.\n\nPlease call ___ and make an appointment in the Surgery \nDepartment to discuss timing of gallbladder removal.\n\nIt was a pleasure taking care of you at ___ ___ \n___.\n \nFollowup Instructions:\n___\n" ]

[ "K8050", "E785", "I10", "Z8501", "Z87891", "I69398", "K219", "J45909", "F329", "F419" ]

[ "K8050: Calculus of bile duct without cholangitis or cholecystitis without obstruction", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "Z8501: Personal history of malignant neoplasm of esophagus", "Z87891: Personal history of nicotine dependence", "I69398: Other sequelae of cerebral infarction", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "E785", "I10", "Z87891", "K219", "J45909", "F329", "F419" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nibuprofen / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)\n \nAttending: ___.\n \nChief Complaint:\nGERD\n \nMajor Surgical or Invasive Procedure:\n___\nLaparoscopic lysis of adhesions.\n\n \nHistory of Present Illness:\n___ is a ___ former ___ py smoker with hx of prior\n___ repair s/p ___ EGD, lap lysis of adhesions, takedown\nof prior fundoplication, closure of diaphragm for treatment by\nEMR of recently diagnosed T1 esophageal cancer. Unfortunately\nfollowing discharge from hospital he had a parieto-occipital\nstroke and had undergone intense rehabilitation. He continues \nto\nbe followed closely by GI for his esophageal ca with EGD q 6\nmonths with last on ___ showed no malignancy. He presents \nfor\ndiscussion of consideration of redo fundo. \n\nHe reports worsening of his GERD symptoms even though he is on \nprotonix 40 mg twice a day. He notes increase acid reflux, sour \ntaste in mouth, bubble, lots of\nbelching, gurling sound in stomach, bloating ,early satiety,\nregurgitation, vomiting. Otherwise denies dysphagia or food \nstuck\nin mid epigastric area but finds himself at times needing to\nstand up mostly at restaurant to make the food go down. Denies\nabdominal pain, diarrhea, constipation, melena, hematochezia. He\nreports some difficulty concentrating or words finding but no\ndysphasia per se mostly when he feels anxious and overwhelmed. \nHe\nis careful with walking at times notes some imbalance, no falls\notherwise no new or worsening neurologic concerns. \n\n \nPast Medical History:\nPer HPI. Multifocal Parieto-occipital CVA (___) - (left \nparieto-occipital area most affected, some left MCA involvement)\nHTN, HLD, carotid stenosis s/p bilateral CEA \nAAA without rupture (2.6 cm), Aortic dissection - not otherwise\nspecified, Esophageal adenocarcinoma, GERD, ___ Esophagus,\ns/p ___ fundoplication revision, Diverticulitis, Adrenal\nAdenoma Asthma, COPD, Former smoker (40-pack yrs, Asbestos\nexposure)Pneumonia, recurrent, Chronic pain - pain agreement,\npotentially broken ___, Low back pain, Urinary frequency,\nInguinal hernia, ventral hernias, Prior alcohol abuse \n\nPast Surgical History:\nPer HPI. \nBilateral carotid endarterectomies \nInguinal and ventral hernia repair x4 \nEndoscopic mucosal resection of mass at ___ junction ___ \nNissen and revision of ___ Fundoplication \nUpper EUS (___) \nERCP and biliary stent placement (___) \n\n \nSocial History:\n___\nFamily History:\nMother - CAD, PVD\nFather - Liver ca\nOther - Uncles - CVA, ___ cancer\n \nPhysical Exam:\nBP: 158/87. Heart Rate: 64. O2 Saturation%: 99. Weight: 170 \n(With\nClothes; With Shoes). BMI: 26.6. Temperature: 97.8. Resp. Rate:\n16. Pain Score: 0. Distress Score: 0.\n\nGen:AxOx3. NAD. Conversing in full sentences. No dysarthria\nNeck: WNL\nChest: CTAB\nAbd: Soft,NT,ND. Well healed abd incisions. Multiple ecchymotic\nareas from old injections sites\nExtrem: Warm and well perfused. Gait guarded but stable. \n\n \nPertinent Results:\n___ Ba swallow :\nEvaluation demonstrates GE junction just below the diaphragm\n \nBrief Hospital Course:\nMr. ___ was admitted to the hospital and taken to the \nOperating Room where he underwent laparoscopic lysis of \nadhesions. The planned Linx procedure was aborted to dense \nadhesions. Please see formal op note for details. He recovered \nwell in the PACU and returned to the Surgical floor for further \nmonitoring.\n\nHis diet was gradually advanced to regular and his port sites \nwere healing well. His pre op Lovenox and Coumadin were resumed \non ___ with an INR of 1.0. His pain was controlled with \nOxycodone and Tylenol and he was up and ambulating \nindependently. He will follow up with Dr. ___ in a few weeks \nand discuss his further surgical options at that time. He was \ndischarged on ___.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n2. LevETIRAcetam 1000 mg PO BID \n3. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n4. LORazepam 1 mg PO TID \n5. amLODIPine 5 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Pantoprazole 40 mg PO Q12H \n8. Aspirin 81 mg PO DAILY \n9. TraZODone 50 mg PO QHS:PRN insomnia \n10. Warfarin 3 mg PO DAILY16 \n11. Enoxaparin Sodium 70 mg SC BID \nStart: ___, First Dose: Next Routine Administration Time \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n2. Lidocaine 5% Patch 1 PTCH TD ONCE prev patch fell off \nDuration: 1 Dose \nRX *lidocaine 5 % 1 patch once a day Disp #*15 Patch Refills:*0 \n3. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - First Line \n \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q ___ hrs Disp #*20 \nTablet Refills:*0 \n5. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*100 Tablet Refills:*0 \n6. amLODIPine 5 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. Enoxaparin Sodium 70 mg SC BID \nStart: ___, First Dose: Next Routine Administration Time \n10. LevETIRAcetam 1000 mg PO BID \n11. LORazepam 1 mg PO TID \n12. Pantoprazole 40 mg PO Q12H \n13. TraZODone 50 mg PO QHS:PRN insomnia \n14. Warfarin 3 mg PO DAILY16 \n15. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nGastroesophageal 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:\nCall Dr. ___ ___ if you experience:\n -Fevers > 101 or chills\n -Difficult or painful swallowing\n -Increased shortness of breath\n\n Pain control\n\n-You may need pain medication once you are home but you can wean \nit over the next few days as the discomfort resolves. Make sure \nthat you have regular bowel movements while on narcotic pain \nmedications as they are constipating which can cause more \nproblems. Use a stool softener or gentle laxative to stay \nregular.\n\n-No driving while taking narcotic pain medication.\n\n-Take Tylenol on a standing basis to avoid more opiod use.\n\n Activity\n -Shower daily. Wash incision with mild soap and water, rinse, \npat dry\n -No tub bathing, swimming or hot tubs until incision healed\n -No lotions or creams to incision\n -Walk ___ times a day for ___ minutes increase to a Goal of \n30 minutes daily\n\n Diet:\n Regular diet\n\n** Anticoagulation **\n\nContinue your Lovenox shots twice a day.\nTake your Coumadin 3 mg daily\nYou will need an INR drawn on ___ at ___ and the \n___ clinic will follow up the result and adjust your \nCoumadin as needed. They will also decide when you will stop the \nLovenox.\n\n \n\n \n\n \n \nFollowup Instructions:\n___\n" ]

[ "K219", "C159", "Z9049", "K660", "Z87891", "J449", "E785", "I10", "I739", "Z7901", "I69398", "R569", "F329", "F419" ]

[ "K219: Gastro-esophageal reflux disease without esophagitis", "C159: Malignant neoplasm of esophagus, unspecified", "Z9049: Acquired absence of other specified parts of digestive tract", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "Z87891: Personal history of nicotine dependence", "J449: Chronic obstructive pulmonary disease, unspecified", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "I739: Peripheral vascular disease, unspecified", "Z7901: Long term (current) use of anticoagulants", "I69398: Other sequelae of cerebral infarction", "R569: Unspecified convulsions", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "K219", "Z87891", "J449", "E785", "I10", "Z7901", "F329", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nlamotrigine / codeine\n \nAttending: ___\n \nChief Complaint:\nright renal pelvis tumor\n \nMajor Surgical or Invasive Procedure:\nRight robotic assisted laparoscopic nephroureterectomy\n\n \nHistory of Present Illness:\n___ is a ___ female with history of gross hematuria. \n\nShe has been having blood in the urine on and off for about the \npast ___ months. She was seen in the ___ about 9 months \nago and was found to have very small right-sided kidney stones \non CT scan. She had a ultrasound in ___ that again showed \nsome small stones. She was evaluation by Dr. ___ \nmonth. A CT Urogram was obtained and cystoscopy was performed \nrevealing\nright-sided hematuria. She underwent right ureteroscopy 4 days \nago that revealed a papillary tumor arising out of the lower \npole calyx within the right kidney suspicious for transitional \ncell carcinoma. Urinary cytologies were obtained from the renal \npelvis and returned positive for high-grade urothelial \ncarcinoma. The stent was left in place.\n\nShe complains of some mild right-sided upper back and abdominal \npain, similar to gallbladder pain she previously had. No \ndysuria urgency or frequency.\n\n \nPast Medical History:\nABNL LFT'S \nCHOLECYSTECTOMY \nCOLONIC POLYPS \nGYNECOLOGIC \nHYPOTHYROIDISM \nMENOPAUSE \nROSACEA \nSEIZURE DISORDER \nHYPERCHOLESTEROLEMIA \nPYELONEPHRITIS \nNEPHROLITHIASIS \n \nSocial History:\nCountry of Origin: US \nMarital status: Divorced \nChildren: Yes: dtr, ___, grandson, ___, . ___\nLives with: Alone \nLives in: Apartment \nWork: ___\nSexual activity: Past \nSexual orientation: Male \nSexual Abuse: Denies \nDomestic violence: Denies \nContraception: N/A; None \nTobacco use: Never smoker \nAlcohol use: Present \ndrinks per week: 4 \nAlcohol use Footnote: few glasses of WINE, QO NIGHT \ncomments: \nRecreational drugs Denies \n(marijuana, heroin, \ncrack pills or \nother): \nDepression: Patient already being treated for depression\nExercise: Activities: walks ___ x/week \nExercise comments: Footnote: WALKS, climbs stairs. WTS, less \n recently \nDiet: low sugar \nSeat belt/vehicle Always \nrestraint use: \nBike helmet use: N/A \n \nFamily History:\n[-] Nephrolithiasis\n[-] Malignant Hyperthermia\n[-] Renal Cell CA\n[-] Testisa CA\n[-] Prostate CA\n[-] Bladder CA\n \nPhysical Exam:\nWdWn, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, appropriately tender along incisions\nIncisions otherwise c/d/I\nFoley catheter in place draining clear yellow urine\nExtremities w/out edema or pitting and there is no reported calf \npain to deep palpation\n\n \nPertinent Results:\n___ 06:21AM BLOOD WBC-7.4 RBC-3.01* Hgb-8.5* Hct-27.5* \nMCV-91 MCH-28.2 MCHC-30.9* RDW-13.7 RDWSD-45.1 Plt ___\n___ 06:50AM BLOOD Hct-30.6*\n___ 06:50AM BLOOD Glucose-92 UreaN-12 Creat-0.9 Na-141 \nK-4.7 Cl-103 HCO3-28 AnGap-10\n___ 10:14AM ASCITES Creat-1.0\n \nBrief Hospital Course:\nPatient was admitted to Urology after undergoing laparoscopic \nRIGHT radical\nnephroureterectomy. No concerning intraoperative events \noccurred; please see dictated operative note for details. The \npatient received perioperative antibiotic prophylaxis. The \npatient was transferred to the floor from the PACU in stable \ncondition. On POD0, pain was well controlled on PCA, hydrated \nfor urine output >30cc/hour, provided with pneumoboots and \nincentive spirometry for prophylaxis, and ambulated once. \n\nOn POD1, the patient was restarted on home medications, basic \nmetabolic panel and complete blood count were checked, pain \ncontrol was transitioned from PCA to oral analgesics, diet was \nadvanced to a clears/toast and crackers diet. On POD2, JP was \nchecked for creatinine, found to be consistent with serum, and \nwas removed without difficulty and diet was advanced as \ntolerated. The remainder of the hospital course was relatively \nunremarkable. The patient was discharged in stable condition, \neating well, ambulating independently, catheter draining clear \nyellow urine, and with pain control on oral analgesics. On exam, \nincision was clean, dry, and intact, with no evidence of \nhematoma collection or infection. The patient was given explicit \ninstructions to follow-up in 1 week for a cystogram with an \nantibiotic to take beforehand.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Phenazopyridine 100 mg PO TID:PRN bladder pain/spasms \n2. Docusate Sodium 100 mg PO BID \n3. Simvastatin 10 mg PO QPM \n4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe \n5. Aspirin 81 mg PO DAILY \n6. Citalopram 20 mg PO DAILY \n7. Levothyroxine Sodium 88 mcg PO DAILY \n8. Liothyronine Sodium 50 mcg PO DAILY \n9. Vitamin D Dose is Unknown PO Frequency is Unknown \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Sulfameth/Trimethoprim DS 1 TAB PO ONCE Duration: 1 Dose \nTake tablet 1 hour prior to cystogram \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by \nmouth once Disp #*1 Tablet Refills:*0 \n3. Vitamin D 1000 UNIT PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Citalopram 20 mg PO DAILY \n6. Docusate Sodium 100 mg PO BID \n7. Levothyroxine Sodium 88 mcg PO DAILY \n8. Liothyronine Sodium 50 mcg PO DAILY \n9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe \n\n10. Simvastatin 10 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight renal pelvic tumor\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\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" ]

[ "C651", "E039", "E785", "F329" ]

[ "C651: Malignant neoplasm of right renal pelvis", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified" ]

[ "E039", "E785", "F329" ]

[]

[ " \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:\nLLQ Abdominal Pain \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w/ PMHx appendicitis s/p appendectomy presents with LLQ \npain. Patient reports being in his USOH other than a mild URI \nabout a week ago until this morning when he developed sudden \nonset LLQ pain. Patient was at work when he first noticed this \npain around noon. Reports that it began as \"squeezing\" and \nbecame progressively more severe as the day went continued. Said \nit was\ninitially intermittent but had periods where it got to about an \n___. He also developed nausea but no episodes of vomiting. No \ndiarrhea or constipation, but notes stools have been dark. \nDenied urinary symptoms. Reports some subjective fevers at home. \nHe said he was unable to take in much after breakfast as he was \ntoo nauseous and uncomfortable. His pain increased in intensity \n(up to a reported ___ to the point where he decided to come \nin for further evaluation.\n\nIn the ED, initial vitals: \n- Labs notable for: \n -WBC 19.4, lactate 2.2, otherwise unremarkable \n\n- Imaging notable for: \nCT A/P: Acute uncomplicated diverticulitis involving the distal\ndescending colon.\n\n- Pt given: \n___ 20:21 IV Morphine Sulfate 4 mg \n___ 20:21 IV Ondansetron 4 mg \n___ 21:15 IVF NS 1000 mL \n___ 21:47 IV Ondansetron 4 mg\n___ 22:34 IV Morphine Sulfate 4 mg \n___ 22:43 IV CefTRIAXone 1 gm \n___ 22:43 IV Acetaminophen IV 1000 mg\n___ 23:50 IVF NS 1000 mL \n\n- Vitals prior to transfer: 99.7 91 115/79 17 99% RA \n \nOn the floor, the patient reports his pain is tolerable after \nrecently having a dose of IV morphine.\n \nPast Medical History:\nSciatica\nB/l tonsillectomy in ___\n \nSocial History:\n___\nFamily History:\nNoncontributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=========================\nVITALS: 98.1 128 / 84 100 20 96 Ra \nGeneral: Pleasant M in NAD \nHEENT: NCAT, MMM\nCV: RRR, no m/r/g \nLungs: CTAB \nAbdomen: Soft, TTP in LLQ, no rebound/guarding, BS+ \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: AAOx3, grossly intact \n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVS: 24 HR Data (last updated ___ @ 1305)\n Temp: 99.5 (Tm 99.5), BP: 123/74 (123-131/74-84), HR: 93\n(85-100), RR: 18 (___), O2 sat: 97% (96-97), O2 delivery: RA \nGENERAL: Pleasant, lying in bed comfortably \nHEENT: NT/AC, MMM\nCARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops \nLUNG: Breathing comfortably, clear to auscultation bilaterally,\nno crackles, wheezes, or rhonchi \nABD: Normal bowel sounds, soft, diffusely tender worst in LLQ to\ndeep palpation, nondistended, no hepatomegaly, no splenomegaly \nEXT: Warm, well perfused, no lower extremity edema \nPULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses \nNEURO: Alert, oriented, CN II-XII intact, motor and sensory\nfunction grossly intact \nSKIN: No significant rashes \n \nPertinent Results:\nADMISSION LABS:\n================\n___ 06:45PM BLOOD WBC-19.4* RBC-4.92 Hgb-14.7 Hct-44.9 \nMCV-91 MCH-29.9 MCHC-32.7 RDW-12.5 RDWSD-41.1 Plt ___\n___ 06:45PM BLOOD Neuts-70.0 ___ Monos-6.9 Eos-0.2* \nBaso-0.4 Im ___ AbsNeut-13.62* AbsLymp-4.27* AbsMono-1.34* \nAbsEos-0.03* AbsBaso-0.08\n___ 07:56PM BLOOD Glucose-126* UreaN-13 Creat-0.9 Na-138 \nK-3.7 Cl-99 HCO3-22 AnGap-17\n___ 07:59PM BLOOD Lactate-2.2*\n\nDISCHARGE LABS:\n================\n___ 06:34AM BLOOD WBC-12.3* RBC-4.46* Hgb-13.3* Hct-40.8 \nMCV-92 MCH-29.8 MCHC-32.6 RDW-12.8 RDWSD-42.5 Plt ___\n___ 06:34AM BLOOD Glucose-83 UreaN-11 Creat-0.9 Na-140 \nK-4.0 Cl-100 HCO3-24 AnGap-16\n\nMICROBIOLOGY:\n================\n___ 6:45 pm BLOOD CULTURE\n Blood Culture, Routine (Pending): No growth to date. \n\n___ 10:40 pm BLOOD CULTURE\n Blood Culture, Routine (Pending): No growth to date. \n\nIMAGING:\n===============\nCT ABD & PELVIS WITH CONTRAST Study Date of ___ 9:50 ___ \nAcute uncomplicated diverticulitis involving the distal \ndescending colon. \n \nBrief Hospital Course:\nPATIENT SUMMARY: \n==================== \n___ w/ PMHx appendicitis s/p appendectomy presents with LLQ pain \nfound on imaging to have acute diverticulitis.\n\n==================== \nACUTE ISSUES: \n====================\n#Uncomplicated Diverticulitis\nNoted to have leukocytosis of 19.4 and Tmax 100.4. Started on \nCTX/flagyl and transitioned to cipro/flagyl. Following day, WBC \ndown to 12.3. Patient reported feeling much better. Pain was \nthen well controlled with Tylenol. Over the first 24 hours, diet \nwas slowly progressed which patient tolerated. He was discharged \nwhen he showed that he consistently tolerated PO intake. Due to \nthe holiday, patient was unable to pick up antibiotics on day of \ndischarge. He was given doses of medications to take home and \ninstructed to take them at appropriate times: 10pm for \nciprofloxacin and midnight for flagyl. Patient then was \ninstructed to fill out prescription as soon as the pharmacy \nopened the next day. \n\n==================== \nTRANSITIONAL ISSUES: \n==================== \n- New Meds: Ciprofloxacin 500mg BID; flagyl 500mg TID\n- Stopped/Held Meds: None\n- Changed Meds: None\n# CODE: Full\n# CONTACT: None provided\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*12 Tablet Refills:*0 \n3. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole 500 mg 1 tablet(s) by mouth three times a day \nDisp #*18 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n===================\nUncomplicated Diverticulitis\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 abdominal pain and found to have \ndiverticulitis\n \nWhat was done for me while I was in the hospital? \n- You were started on antibiotics, ciprofloxacin and \nmetronidazole\n- Your pain was monitored and treated as needed with standing \nTylenol ___ every 6 hours\n\nWhat should I do when I leave the hospital? \n- Please follow-up with your PCP office, call ___ to \nschedule with ___, MD\n- Complete your antibiotic course of ciprofloxacin twice a day \nand metronidazole three times a day. Your last doses will be on \n___\n- Please continue with Tylenol ___ every 4 to 6 hours as \nneeded\n- Start with liquids and clear solids (i.e. jello, then slowly \nadvance diet over the next day or two to foods that are not \nheavy, like rice and toasts.\n- Do not drink alcohol while you are taking metronidazole. \nCombining the two will cause severe nausea and/or vomiting\n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "K5732" ]

[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: lap appy\n\n \nHistory of Present Illness:\n___, PMH significant for sciatica ___ remote MVC, who was \ntransferred from ___ for concern of appendicitis. \nPatient relays that last night he was awoken at 2am due to acute \nonset of RLQ pain and vomited shortly thereafter. He then went \nto his usual day of IT work, went home at 4pm, and then \npresented to ___ at 5pm. \nHe endorses the following symptoms: nausea, constipation (last \nbowel movement ___ at 4:30AM). Workup there includes WBC of \n___ with CT scan c/w acute uncomplicated appendicitis. He was \ngiven cipro/flagyl and transferred to ___. \n\nAt ___, he continues to be HDS and was given morphine for pain \ncontrol. Resuscitation efforts continued. His pain has come down \nsome, however, character and location remains unchanged. \nSubjective fevers, chills, nausea, and po intolerance are all \nendorsed. No chest pain, shortness of breath, other GI, or GU \nsymptoms. \n\n \nPast Medical History:\nSciatica\nB/l tonsillectomy in ___\n \nSocial History:\n___\nFamily History:\nNoncontributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n========================= \nVitals: 96.6 98 130/76 16 99% RA \nGEN: A&O, NAD \nCV: RRR, No M/G/R \nPULM: Clear to auscultation b/l, No W/R/R \nABD: Soft, mildly distended, tender to deep palpation in RLQ; \npositive rebound. No guarding. normoactive bowel sounds, no \npalpable masses; negative psoas and obturator signs\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVitals: 98.8 125/78 97 18 99% RA \nGEN: A&O, NAD\nCV: RRR, No M/G/R\nPULM: CTAB\nABD: soft, nondistended, appropriately TTP, surgical incisions \nc/d/I without erythema\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 01:10AM BLOOD WBC-13.0*# RBC-4.34* Hgb-13.2* Hct-39.1* \nMCV-90 MCH-30.4 MCHC-33.8 RDW-12.8 RDWSD-42.4 Plt ___\n___ 01:10AM BLOOD Neuts-68.8 ___ Monos-6.9 Eos-1.2 \nBaso-0.3 Im ___ AbsNeut-8.94* AbsLymp-2.91 AbsMono-0.89* \nAbsEos-0.15 AbsBaso-0.04\n___ 01:10AM BLOOD Glucose-93 UreaN-8 Creat-0.7 Na-135 K-4.9 \nCl-98 HCO3-24 AnGap-18\n___ 01:10AM BLOOD ALT-27 AST-31 AlkPhos-67 TotBili-0.5\n___ 01:10AM BLOOD Albumin-3.8\n___ 01:13AM BLOOD Lactate-1.2\n\n \nBrief Hospital Course:\nThe patient was transferred from ___ and admitted to \nthe General Surgical Service on ___ for evaluation and \ntreatment of abdominal pain. OSH abdominal/pelvic CT revealed \nthickened appendix with stranding and fecalith. WBC was elevated \nat 13.0. The patient underwent laparoscopic appendectomy, which \nwent well without complication (reader referred to the Operative \nNote for details). After a brief, uneventful stay in the PACU, \nthe patient arrived on the floor tolerating PO intake, on IV \nfluids, and on PO Tylenol and oxycodone for pain control. The \npatient was hemodynamically stable.\n\nDiet was progressively advanced as tolerated to a regular diet \nwith good tolerability. The patient voided without problem. \nDuring this hospitalization, the patient ambulated early and \nfrequently, was adherent with respiratory toilet and incentive \nspirometry, and actively participated in the plan of care. The \npatient received subcutaneous heparin and venodyne boots were \nused during this stay.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home without services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen [Acetaminophen Pain Relief] 500 mg 2 tablet(s) \nby mouth every eight (8) hours Disp #*90 Tablet Refills:*0 \n2. Artificial Tear Ointment 1 Appl RIGHT EYE PRN Right Eye \nDiscomfort \nRX *dextran 70-hypromellose [Artificial Tears (PF)] ___ drops \nin the right eye PRN Disp #*1 Bottle Refills:*0 \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg ___ tablet(s) by mouth q4h PRN Disp #*20 \nTablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAppendicitis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were recently admitted to ___ \n___ abdominal pain. You were found to have appendicitis \n(an inflamed appendix) and had an operation to remove your \nappendix. The surgery went well and was uncomplicated. Please \nfollow the below instructions to ensure a smooth 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.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n \nFollowup Instructions:\n___\n" ]

[ "K3580", "K388", "H578", "Z006", "M549", "G8929" ]

[ "K3580: Unspecified acute appendicitis", "K388: Other specified diseases of appendix", "H578: Other specified disorders of eye and adnexa", "Z006: Encounter for examination for normal comparison and control in clinical research program", "M549: Dorsalgia, unspecified", "G8929: Other chronic pain" ]

[ "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nshellfish derived\n \nAttending: ___.\n \nChief Complaint:\nBreast cancer\n \nMajor Surgical or Invasive Procedure:\nBilateral Total Mastectomies and Left Axillary Lymph Node \nDissection and Right Sentinel Lymph Node Biopsy and Left \nLymphaticovenous axillary bypass\n\n \nHistory of Present Illness:\n___ is a ___ year old woman who presented with left \ninflammatory breast cancer. Her staging was negative for distant \ndisease (ipsilateral axillary node uptake on PET). She has \nunderwent neoadjuvant chemotherapy but had\npersistent nodal involvement. She elected to undergo bilateral \nmastectomy, due to her wish to have contralateral prophylactic \nmastectomy. She is not interested in breast reconstruction and \nhas met with Plastics. She will undergo left axillary lymph node \ndissection, given the persistent nodal involvement. She will \nalso undergo right axillary sentinel lymph node biopsy in the \nevent that an occult invasive disease is identified in the right \nbreast\nfollowing the mastectomy. At the same time she will undergo \nlymphatic bypass performed by Dr. ___.\n \nPast Medical History:\nGlaucoma, hypertension, and asthma.\n \nSocial History:\n___\nFamily History:\nThere is a positive family history for breast cancer. The \npatient has a maternal aunt who had breast cancer at age ___ and \na maternal cousin who had breast cancer in her ___. Three \ndaughters of that first cousin have breast cancer in their late \n___ or early ___.\n \nPhysical Exam:\nVS: 24 HR Data (last updated ___ @ 526)\n Temp: 98.2 (Tm 99.1), BP: 130/81 (130-137/81-84), HR: 79 \n(79-\n 82), RR: 18, O2 sat: 95% (95-98), O2 delivery: Ra, Wt: 198.0 \n\n lb/89.81 kg \nGEN: NAD, A&O\nHEENT: NCAT, EOMI, anicteric\nCV: RRR, No JVD\nPULM: normal excursion, no respiratory distress\nABD: soft, nontender, ND\nEXT: WWP, no CCE, 2+ B/L radial\nNEURO: A&Ox3, no focal neurologic deficits\nPSYCH: normal judgment/insight, normal memory, normal \nmood/affect\nWOUND: Wounds c/d/i. Serosanguinous output in both JP drains.\nAxillae soft.\n\n \nPertinent Results:\nPlease see OMR\n \nBrief Hospital Course:\nMs. ___ presented to pre-op holding at ___ on \n___ for Bilateral Total Mastectomies and Left Axillary \nLymph Node Dissection and Right Sentinel Lymph Node Biopsy and \nleft Lymphaticovenous axillary bypass. She tolerated the \nprocedure well without complications (Please see operative note \nfor further details). After a brief and uneventful stay in the \nPACU, the patient was transferred to the floor for further \npost-operative management.\n\nNeuro: Pain was well controlled on tylenol and oxycodone.\nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulm: The patient remained stable from a pulmonary standpoint; \noxygen saturation was routinely monitored. Had good pulmonary \ntoileting, as early ambulation and incentive spirometry were \nencouraged throughout hospitalization.\nGI: The patient was advanced to and tolerated a regular diet \nafter the procedure and at time of discharge. Patient's intake \nand output were closely monitored.\nGU: Urine output was monitored as indicated. At time of \ndischarge, the patient was voiding without difficulty. Foley \ncatheter was not placed during patient's admission.\nID: The patient was closely monitored for signs and symptoms of \ninfection and fever, of which there were none. She received \n___ antibiotics per routine.\nHeme: The patient had blood levels checked on POD1 to monitor \nfor signs of bleeding. The patient received ___ dyne boots and \nwas encouraged to get up and ambulate as early as possible.\n\nOn ___ (POD1) the patient was discharged to home with ___ \nservices. At discharge, she was tolerating a regular diet, \npassing flatus, voiding, and ambulating independently. She will \nfollow-up in the clinic in ___ weeks. This information was \ncommunicated to the patient directly prior to discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n2. Lisinopril 5 mg PO DAILY \n3. Omeprazole 20 mg PO DAILY \n4. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n5. Prochlorperazine 10 mg PO Q12H:PRN Nausea/Vomiting - Second \nLine \n6. Calcium Carbonate 500 mg PO TID \n7. Hydrocortisone Cream 0.5% 1 Appl TP BID:PRN Dermatitis \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q5H:PRN Pain - Mild/Fever \nRX *acetaminophen 650 mg 1 tablet(s) by mouth every five (5) \nhours Disp #*35 Tablet Refills:*0 \n2. Diazepam 2 mg PO Q6H:PRN chest wall spasms \nRX *diazepam 2 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*4 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*20 Capsule Refills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*12 Tablet Refills:*0 \n5. Senna 17.2 mg PO HS \nRX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth at bedtime \nDisp #*10 Tablet Refills:*0 \n6. Calcium Carbonate 500 mg PO TID \n7. Hydrocortisone Cream 0.5% 1 Appl TP BID:PRN Dermatitis \n8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n9. Lisinopril 5 mg PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First \nLine \n12. Prochlorperazine 10 mg PO Q12H:PRN Nausea/Vomiting - Second \nLine \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nBreast cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPersonal Care: \n1. You may keep your incisions open to air or covered with a \nclean, sterile gauze that you change daily.\n2. Clean around the drain site(s), where the tubing exits the \nskin, with soap and water. \n3. Strip drain tubing, empty bulb(s), and record output(s) ___ \ntimes per day. \n4. A written record of the daily output from each drain should \nbe brought to every follow-up appointment. Your drains will be \nremoved as soon as possible when the daily output tapers off to \nan acceptable amount. \n5. You may wear a surgical bra or soft, loose camisole for \ncomfort. \n6. You may shower daily with assistance as needed. Be sure to \nsecure your drains so they don't hang down loosely and pull out.\n7. The Dermabond skin glue will begin to flake off in about ___ \ndays. \n\nActivity: \n1. You may resume your regular diet. \n2. Walk several times a day. \n3. DO NOT lift anything heavier than 5 pounds or engage in \nstrenuous activity for 6 weeks following surgery. \n\nMedications: \n1. Resume your regular medications unless instructed otherwise \nand take any new meds as ordered. \n2. You may take your prescribed pain medication for moderate to \nsevere pain. You may switch to Tylenol or Extra Strength Tylenol \nfor mild pain as directed on the packaging. Please note that \nPercocet and Vicodin have Tylenol as an active ingredient so do \nnot take these meds with additional Tylenol. \n3. Take prescription pain medications for pain not relieved by \nTylenol. \n4. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescription pain medication. You may use a different \nover-the-counter stool softener if you wish. \n5. Do not drive or operate heavy machinery while taking any \nnarcotic pain medication. You may have constipation when taking \nnarcotic pain medications (oxycodone, percocet, vicodin, \nhydrocodone, dilaudid, etc.); you should continue drinking \nfluids, you may take stool softeners, and should eat foods that \nare high in fiber. \n\nCall the office IMMEDIATELY if you have any of the following: \n1. Signs of infection: fever with chills, increased redness, \nswelling, warmth or tenderness at the surgical site, or unusual \ndrainage from the incision(s). \n2. A large amount of bleeding from the incision(s) or drain(s). \n\n3. Fever greater than 101.5 oF \n4. Severe pain NOT relieved by your medication. \n \nReturn to the ER if: \n* If you are vomiting and cannot keep in fluids or your \nmedications. \n* If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) degrees, increased redness, swelling or \ndischarge from incision, chest pain, shortness of breath, or \nanything else that is troubling you. \n* Any serious change in your symptoms, or any new symptoms that \nconcern you. \nDRAIN DISCHARGE INSTRUCTIONS \nYou are being discharged with drains in place. Drain care is a \nclean procedure. Wash your hands thoroughly with soap and warm \nwater before performing drain care. Perform drainage care twice \na day. Try to empty the drain at the same time each day. Pull \nthe stopper out of the drainage bottle and empty the drainage \nfluid into the measuring cup. Record the amount of drainage \nfluid on the record sheet. Reestablish drain suction. \nPlease assist patient with drain care. A daily log of individual \ndrain outputs should be maintained and brought with patient to \nfollow up appointment with your surgeon.\n \nFollowup Instructions:\n___\n" ]

[ "C50912", "C773", "Z006", "Z803", "I10", "K219" ]

[ "C50912: Malignant neoplasm of unspecified site of left female breast", "C773: Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z803: Family history of malignant neoplasm of breast", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "I10", "K219" ]

[]

[ " \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:\n___ to R hand\n \nMajor Surgical or Invasive Procedure:\nI&D x2\nBone graft to thumb MC and ring MC from iliac crest\n\n \nHistory of Present Illness:\nCC: ___ to right hand\n\nHPI:\nMr. ___ is a ___ year old RHD man with PMH of smoking and heavy\nEtOH use who presents with ___ to right hand. At baseline the\npatient smokes 1PPD and drinks 1 liter of hard EtOH per day and\nis currently unemployed. The patient was drinking EtOH overnight\nwhen he was shot in the hand just a few feet away at\napproximately 1:30am the morning of presentation. He initially\npresented to an OSH who transferred him to ___ for evaluation\nand treatment. He notes pain of his hand and swelling and\ndecreased sensation of his third webspace. He has two wounds, \none\nat the site of his right dorsal radial thumb, and the other\nbetween his ___ and ___ distal metacarpals on the dorsal aspect\nof his hand. He does not recall his last tetanus shot. He last\nate around 6pm the prior evening and last drank EtOH at\napproximately the time of the gun shot at 1:30am. \n\nROS:\n(+) per HPI\n(-) Denies fevers, chills, headache, dizziness, nausea, \nvomiting,\nchest pain, shortness of breath\n\nPast Medical History:\n___ to left thigh\n\nPast Surgical History:\nL thigh surgery for ___\n\nMedications:\nNone \n\nAllergies: NKDA\n\nSocial History:\nDrinks 1 bottle hard liquor daily (tequila). Smokes 1PPD ___\nyears). Smokes occasional marijuana. Denies other illicit drugs\nand IVDU. Not currently employed. Lives with sister.\n\nPhysical ___: T: 98.6, HR 69, BP 103/58, RR 16, SpO2 100% RA\nGEN: A&O, NAD\nHEENT: mucus membranes moist\nCV: RRR\nPULM: Breathing comfortably on room air\nExt: ___ on right hand dorsal radial base of thumb and ___ right\nhand dorsal between ring and little finger distal metacarpals.\nDoppler signal intact all digital arteries and palmar arch.\nRadial pulse 2+ palpable. Decreased sensation ulnar aspect \nmiddle\nfinger and radial aspect of ring finger. Motor and tendon exam\nlimited due to pain. Deficiency in right middle and index finger\nextension from MCP, but exam difficult due to limitation of \npain.\nSome extension and flexion of right thumb IP joint however\nlimited due to pain. Able to extend and flex wrist but limited\ndue to pain. Right hand with volar and dorsal swelling but\nforearm and hand compartments currently soft. \n\nLaboratory: pending\n\nImaging:\nR hand x-ray: Severely comminuted and intraarticular fracture\nright base of thumb metacarpal. Comminuted extraarticular\nfractures of distal ___ and ___ metacarpals.\n\nAssessment/Plan:\nMr. ___ is a ___ year old RHD man with PMH of smoking and heavy\nEtOH use who presents with ___ to right hand. He is vascularly\nintact without current signs of compartment syndrome. He has\nextremely comminuted right proximal thumb metacarpal\nintraarticular fractures and right distal ring and little finger\ndistal metacarpal extraarticular fractures, right ulnar middle\nfinger and radial ring finger decreased sensation suggesting\nnerve injury, and inability to extend right middle and ring\nfingers suggestive of possible tendon injury, although exam\nlimited due to pain. Plan for tetanus shot, IV antibiotics, and\nlikely OR today for right hand I+D, ORIF of right thumb, ring,\nand little finger fractures, possible neurovascular repair,\npossible tendon repair, and possible ex fix. Given history of\nheavy EtOH use, will need to be monitored closely for withdrawal\nsigns and symptoms.\n \nPast Medical History:\nAsthma\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nNo acute distress\nUnlabored breathing\nAbdomen soft, non-tender, non-distended. ICBG site c/d/i. \nRUE: \nIncision clean/dry/intact with no erythema or discharge, minimal \necchymosis. \nSplint in place, clean, dry, and intact\n\n \nPertinent Results:\n___ 06:15AM GLUCOSE-127* UREA N-17 CREAT-1.0 SODIUM-140 \nPOTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-21*\n___ 06:15AM estGFR-Using this\n___ 06:15AM WBC-13.7* RBC-4.50* HGB-14.8 HCT-41.5 MCV-92 \nMCH-32.9* MCHC-35.7 RDW-12.2 RDWSD-41.1\n___ 06:15AM NEUTS-85.9* LYMPHS-7.2* MONOS-6.2 EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-11.73* AbsLymp-0.98* AbsMono-0.84* \nAbsEos-0.00* AbsBaso-0.03\n___ 06:15AM PLT COUNT-240\n___ 06:15AM ___ PTT-27.6 ___\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 gunshot wound to the right hand and was admitted to \nthe orthopedic surgery service. The patient was taken to the \noperating room on for I&D x2 and bone graft to thumb MC and ring \nMC from iliac crest, 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. He will be discharged on oral antibiotics for 7 \ndays. The patient's home medications were continued throughout \nthis hospitalization. The patient worked with ___ who determined \nthat discharge to home was appropriate. The ___ hospital \ncourse was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nNWB in the RUE, and will be discharged on Keflex for antibiotics \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:\nN/a\n \nDischarge Medications:\n1. Cephalexin 500 mg PO Q6H Duration: 7 Days \nRX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*28 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*30 Tablet Refills:*0 \n3. Gabapentin 300 mg PO TID \nRX *gabapentin 300 mg 1 capsule(s) by mouth three times a day \nDisp #*30 Capsule Refills:*0 \n4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate \nRX *hydromorphone 2 mg ___ tablet(s) by mouth Q3H PRN Disp #*72 \nTablet Refills:*0 \n5. Acetaminophen 1000 mg PO Q8H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n___ to R hand. \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions:\n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- NWB RLE\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Please remain in your dressing and do not change unless it is \nvisibly soaked or falling off.\n- Splint must be left on until follow up appointment unless \notherwise instructed\n- Do NOT get splint wet\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nFOLLOW UP:\nPlease follow up with your surgeon Dr. ___ in 2 weeks. Please \ncall ___ to make an 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" ]

[ "S62304B", "S62511B", "S62306B", "X93XXXA", "Y9229", "F17210", "F1010" ]

[ "S62304B: Unspecified fracture of fourth metacarpal bone, right hand, initial encounter for open fracture", "S62511B: Displaced fracture of proximal phalanx of right thumb, initial encounter for open fracture", "S62306B: Unspecified fracture of fifth metacarpal bone, right hand, initial encounter for open fracture", "X93XXXA: Assault by handgun discharge, initial encounter", "Y9229: Other specified public building as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1010: Alcohol abuse, uncomplicated" ]

[ "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nEpinephrine / Novocain\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nPercutaneous coronary intervention with drug-eluting stent \nplacement\n\nattach\n \nPertinent Results:\nADMISSION LABS: \n==============\n___ 10:27AM BLOOD WBC-6.6 RBC-3.89* Hgb-12.5* Hct-37.1* \nMCV-95 MCH-32.1* MCHC-33.7 RDW-12.4 RDWSD-42.9 Plt ___\n___ 10:27AM BLOOD ___ PTT-29.3 ___\n___ 10:27AM BLOOD Glucose-381* UreaN-20 Creat-1.2 Na-129* \nK-5.2 Cl-92* HCO3-23 AnGap-14\n___ 10:27AM BLOOD cTropnT-<0.01\n___ 01:55PM BLOOD cTropnT-<0.01\n___ 07:40PM BLOOD cTropnT-<0.01\n___ 10:27AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.8\n___ 10:57AM BLOOD pO2-60* pCO2-37 pH-7.43 calTCO2-25 Base \nXS-0 Comment-GREEN TOP\n___ 11:04AM BLOOD ___ pO2-76* pCO2-40 pH-7.40 \ncalTCO2-26 Base XS-0\n\nDISCHARGE LABS: \n==============\n___ 08:56AM BLOOD WBC-6.8 RBC-4.29* Hgb-13.8 Hct-40.8 \nMCV-95 MCH-32.2* MCHC-33.8 RDW-12.7 RDWSD-43.8 Plt ___\n___ 08:56AM BLOOD Glucose-255* UreaN-17 Creat-1.0 Na-135 \nK-4.9 Cl-100 HCO3-21* AnGap-14\n___ 08:56AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.0\n\nIMAGING: \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 a \nsmall to moderate area of regional left ventricular systolic \ndysfunction with hypo to akinesis of the basal inferior and \nbasal inferolateral walls, mid to apical anterior wall and \ninterventricualr septum (see schematic). The visually estimated \nleft ventricular ejection fraction is 35-40%. There is no \nresting left ventricular outflow tract gradient. Normal right \nventricular cavity size with uninterpretable free wall motion \nassessment. The aortic sinus diameter is normal for gender with \na normal ascending aorta diameter for gender. There is a normal \ndescending aorta diameter. The aortic valve leaflets (?#) appear \nstructurally normal. There is no aortic valve stenosis. There is \nno aortic regurgitation. The mitral valve leaflets appear \nstructurally normal with no mitral valve prolapse. There is \ntrivial mitral regurgitation. The pulmonic valve leaflets are \nnormal. The tricuspid valve is not well seen. There is \nphysiologic tricuspid regurgitation. The estimated pulmonary \nartery systolic pressure is normal. There is no pericardial \neffusion. IMPRESSION: Suboptimal image quality. Mild to moderate \nregional dysfunction c/w multiveselCAD/infarction. Cannot assess \nright ventricular function due to poor image quality. No overt \nvalvular abnormalities. Compared with the prior TTE (images not \navailable for review) of ___, the findings are new.\n\nCARDIAC CATHETERIZATION - ___ \nCoronary Description\nLM:\nThe left main coronary artery is with eccentric 30% distal.\nCirc:\nThe circumflex coronary artery is with widely patent stent and \n90% hazy stenosis distal prior to bifurcation. L-L and L-R \ncollaterals are present.\nRCA:\nThe right coronary artery is with multiple prior stents and mid \nocclusion. A moderate branching AM is now with origin occlusion \nand fills slowly via R-R collaterals.\nLIMA-LAD:\nA left internal mammary artery to the LAD is widely patent. \nThere is retrograde filling of a diagonal branch. L-L and L-R \ncollaterals are present.\nSVGs: \nKnown occluded and not engaged.\nRI:\nThe ramus intermedius is small caliber with diffuse 70-80% \nproximal.\n\nComplications:\nThere were no clinically significant complications.\nFindings:\n• Three vessel coronary artery disease.\n• Successful PCI with drug-eluting stent of the circumflex \ncoronary artery.\nRecommendations\n• ASA 81mg per day.\n• Plavix 75mg/day\n• Secondary prevention of CAD\n• Maximize medical therapy\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with PMH of CAD s/p 4v CABG as \nwell as numerous PCIs, HTN, HLD, T1DM on insulin pump, who \npresented with recurrent MI equivalent pain of jaw/L arm pain \nwith EKG negative for ischemia and troponins negative x2, most \nconcerning for unstable angina. The patient was admitted with \ninitial plan for nuclear stress test. Following admission the \npatient had significant chest pain not relieved with sublingual \nnitro, with no troponin elevation or EKG changes. He was started \non a nitro gtt and underwent PCI with coronary angiography, with \nplacement of one DES for 90% hazy stenosis distal prior to \nbifurcation in the circumflex artery. The patient remained free \nfrom chest pain following PCI and was discharged home in stable \ncondition with continuation of dual-antiplatelet therapy.\n\n#CORONARIES: CABG ___ with LIMA to LAD, SVG to OM, Diagonal, \nPDA\n(___). Multiple PCI's on SVG's, the last in ___ PTCA to \nramus, PCI of mid LCX ___.\n#PUMP: LVEF 45-50% (echo from ___\n#RHYTHM: NSR\n\n#CODE: Full Code (Presumed)\n#CONTACT: No healthcare proxy selected\n\nTRANSITIONAL ISSUES:\n====================\n[] Discharge weight: 182.98 lb (83 kg)\n[] Discharge creatinine: 1.0\n[] Discharge Hgb/Hct: 13.8/40.8\n[] Please check Chem-7 at discharge to monitor electrolytes on \nlisinopril\n[] Consider increasing dose of lisinopril from 5mg to 10mg daily\n[] Continue dual-antiplatelet therapy with ASA 81mg and Plavix \n75mg daily indefinitely for coronary artery disease\n[] Consider increasing atorvastatin from 40mg to 80mg daily if \npatient tolerates.\n[] Recommend repeating TTE within 5-weeks of discharge to \nevaluate LVEF and regional wall motion abnormalities. Pre-cath \nTTE revealed suboptimal image quality, mild to moderate regional \ndysfunction c/w multiveselCAD/infarction and no overt valvular \nabnormalities, with LVEF 35-40% (reduced from prior 45-50% in \n___.\n\n#ACTIVE ISSUES:\n===============\n# Unstable Angina\nThe patient presented with intermittent return of MI equivalent \npain represented as jaw/L arm pain at rest. Symptoms started \nseveral weeks prior to admission and recurred, most recently \nexperiencing these symptoms a few days prior to admission, while \nat rest. He had been using SL nitro with relief of his symptoms \nas well as restarted Imdur per the advice of his RN sister. He \nwas free from chest pain upon arrival. EKG re-demonstrated LBBB. \nTroponins were negative x2. His presentation is concerning for \nUA. After discussion with patient, decision was originally to go \nfor cardiac nuclear stress test. However due to several episodes \nof chest pain overnight ___ requiring nitro gtt, the patient \nunderwent PCI for unstable angina on ___. Pre-cath TTE \nrevealed suboptimal image quality, mild to moderate regional \ndysfunction c/w multivesel CAD/infarction and no overt valvular \nabnormalities, with LVEF 35-40%. Coronary angiography revealed \n3-vessel CAD with 90% hazy stenosis distal prior to bifurcation \nin the circumflex artery, for which 1 DES was placed without \ncomplications.\n- Continued optimal medical management for CAD with aspirin, \nclopidogrel, atorvastatin, lisinopril and metoprolol succinate\n\n#HTN\nContinued home Lisinopril 5mg daily and home metoprolol \nsuccinate 100mg daily.\n- Consider increasing lisinopril from 5mg to 10mg daily if \ntolerated.\n\n#CHRONIC ISSUES:\n================\n#T1DM on insulin pump:\n___ Diabetes was consulted for in-patient diabetes \nmanagement, who determined that the patient was fully capable of \noperating his insulin pump. The patient managed his insulin \nindependently throughout the admission without complications.\n\n#CAD s/p 4v CABG and numerous PCIs\n#Ischemic cardiomyopathy without evidence of HF, EF 45-50% \n(___)\nContinued Atorvastatin, ASA, clopidogrel and metoprolol\n- Consider increasing atorvastatin from 40mg to 80mg daily if \npatient tolerates.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Clopidogrel 75 mg PO DAILY \n3. Lisinopril 5 mg PO QHS \n4. Atorvastatin 40 mg PO QPM \n5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n6. Metoprolol Succinate XL 100 mg PO DAILY \n7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Neck/L arm pain \n8. Terazosin 5 mg PO QHS \n9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID \n10. Vitamin D 1000 UNIT PO DAILY \n11. Insulin Pump SC (Self Administering Medication)Insulin \nLispro (Humalog)\nTarget glucose: ___\nFingersticks: QAC and HS\n\n \nDischarge Medications:\n1. Insulin Pump SC (Self Administering Medication)Insulin \nLispro (Humalog)\nTarget glucose: ___\nFingersticks: QAC and HS\n \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n5. Clopidogrel 75 mg PO DAILY \n6. Lisinopril 5 mg PO QHS \n7. Metoprolol Succinate XL 100 mg PO DAILY \n8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Neck/L arm pain \n9. Terazosin 5 mg PO QHS \n10. Timolol Maleate 0.25% 1 DROP BOTH EYES BID \n11. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \nUnstable angina\nCoronary artery disease \n\nSECONDARY DIAGNOSIS: \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:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___.\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were having chest pain and there was concern for a \nblockage in one of the arteries that supplies your heart.\n\nWHAT WAS DONE IN THE HOSPITAL?\n- The function of your heart and lungs was monitored. You were \ngiven medications to treat your chest pain.\n- You had a procedure called a cardiac catheterization and a \nstent was placed to open a blockage in one of your coronary \narteries.\n\nWHAT SHOULD I DO WHEN I GET HOME FROM THE HOSPITAL?\n- Continue to take all of your medications as prescribed.\n- Follow-up with your Cardiologist and your other doctors. \n- If you experience chest pain, shortness of breath or generally \nfeel unwell, call your doctor or go to the nearest emergency \nroom. \n\nSincerely,\nYour ___ Treatment Team\n \nFollowup Instructions:\n___\n" ]

[ "I25110", "T82218A", "I10", "Z951", "Z955", "Z23", "Z794", "Z7984", "Z9641", "E785", "I255", "E109", "Y832" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "T82218A: Other mechanical complication of coronary artery bypass graft, initial encounter", "I10: Essential (primary) hypertension", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z23: Encounter for immunization", "Z794: Long term (current) use of insulin", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z9641: Presence of insulin pump (external) (internal)", "E785: Hyperlipidemia, unspecified", "I255: Ischemic cardiomyopathy", "E109: Type 1 diabetes mellitus without complications", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure" ]

[ "I10", "Z951", "Z955", "Z794", "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:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___ - Coronary angiogram with POBA\n \nHistory of Present Illness:\n___ year old male with no known PMH presents as a transfer from\n___ with NSTEMI and ongoing CP at rest\nconcerning for ACS. \n\nPatient developed severe chest pressure/pain around 9PM last\nnight. He tried to go to sleep but was unable to get \ncomfortable.\nHE denied any associated shortness of breath, N/V, diaphoresis,\nradiation, or lightheadedness. He denied any pleuritic or\npositional component to the pain. Has not had recent infection.\nHe has no cardiac history, but does get occasional chest pain\nlasting a few minutes relieved by drinking water. No exertional\nchest pain. \n\nIn the ED initial vitals were: 98.4 60 144/80 20 96% RA \n\nEKG: NSR, LVH, diffuse J-point elevation, Not particularly\nischemic.\n \nLabs/studies notable for: CKmb 94, troponin 1.38\n\nPatient was given: IV heparin. full dose ASA, 500 cc IV fluids. \n\n\nVitals on transfer: 50 127/69 12 95% RA \n\nOn the floor He was complaining of ___ typical chest pain,\nrefractory to SL nitro glycerine. \n\n \nPast Medical History:\nNo known medical history. Denied HTN, HLD, DM. \n \nSocial History:\n___\nFamily History:\nMother with cardiac disease in early ___. Divorced. Works in\n___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\n24 HR Data (last updated ___ @ 1701)\n Temp: 98.3 (Tm 98.3), BP: 109/57 (109-152/57-83), HR: 63\n(51-63), RR: 18, O2 sat: 97% (97-98), O2 delivery: RA, Wt: \n159.83\nlb/72.5 kg (159.83-161.82) \nGENERAL: Well developed, well nourished male in NAD. Oriented \nx3.\nMood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.\nConjunctiva were pink. No pallor or cyanosis of the oral mucosa.\nNo xanthelasma. \nNECK: Supple. JVP not elevated \nCARDIAC: Regular rate and rhythm. Soft heart sounds, but nl S1,\nS2. No murmurs, rubs, or gallops. no thrills or lifts. \nLUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No\nsplenomegaly. \nEXTREMITIES: clammy, but 2+ DP's and radial pulses. \nSKIN: clammy \nPULSES: Distal pulses palpable and symmetric.\n\nDISCHARGE PHYSICAL EXAM\n=======================\n24 HR Data (last updated ___ @ 1205)\n Temp: 98.8 (Tm 98.8), BP: 104/64 (91-152/50-83), HR: 57\n(47-67), RR: 16 (___), O2 sat: 95% (94-98), O2 delivery: RA,\nWt: 159.83 lb/72.5 kg (159.83-161.82) \nFluid Balance (last updated ___ @ 601) \n Last 8 hours Total cumulative -470ml\n IN: Total 130ml, IV Amt Infused 130ml\n OUT: Total 600ml, Urine Amt 600ml\n Last 24 hours Total cumulative -408ml\n IN: Total 992ml, PO Amt 50ml, IV Amt Infused 942ml\n OUT: Total 1400ml, Urine Amt 1400ml \nGENERAL: Well developed, well nourished male in NAD. Oriented \nx3.\nMood, affect appropriate. \nHEENT: PERRLA. MMM. \nNECK: Supple. JVP not elevated \nCARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,\nrubs, or gallops. no thrills or lifts. \nLUNGS: Normal work of breathing on RA. No crackles, wheezes or\nrhonchi. \n \nPertinent Results:\nADMISSION LAB RESULTS\n=====================\n___ 02:29PM BLOOD WBC-6.7 RBC-4.21* Hgb-13.3* Hct-39.0* \nMCV-93 MCH-31.6 MCHC-34.1 RDW-11.5 RDWSD-38.8 Plt ___\n___ 02:29PM BLOOD Glucose-112* UreaN-11 Creat-1.2 Na-139 \nK-4.4 Cl-100 HCO3-25 AnGap-14\n___ 02:29PM BLOOD cTropnT-1.38*\n___ 07:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.2 Cholest-157\n\nPERTINENT LAB RESULTS\n=====================\n___ 02:29PM BLOOD cTropnT-1.38*\n___ 07:36PM BLOOD CK-MB-96* cTropnT-1.68*\n___ 03:00AM BLOOD CK-MB-64* cTropnT-2.22*\n___ 07:00AM BLOOD CK-MB-45* cTropnT-1.96*\n\nDISCHARGE LAB RESULTS\n=====================\n___ 07:00AM BLOOD WBC-7.2 RBC-3.64* Hgb-11.7* Hct-34.2* \nMCV-94 MCH-32.1* MCHC-34.2 RDW-11.9 RDWSD-41.0 Plt ___\n___ 07:00AM BLOOD Glucose-107* UreaN-11 Creat-1.2 Na-140 \nK-4.2 Cl-105 HCO3-21* AnGap-14\n\nIMAGING\n=======\n___ CXR\nNo evidence of pulmonary edema. Mildly enlarged cardiac \nsilhouette when \ncompared to prior. \n \n___ Coronary angiogram\nA 6 ___ EBU3.5 guide provided adequate support. Crossed with \na Prowater wire into the distal LAD.Dilated with a 2.0 mm \nballoon. Final angiography revealed normal flow, no dissection \nand 40% residual\nstenosis.\n\nFindings\n• Two vessel and branch coronary artery disease.\n• Successful POBA of the diagonal coronary artery.\n• Possible culprits tiny OM not amenable to PCI or diseased \ndiagonal branch.\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n====================\n[] New medications on discharge: metoprolol-XL 25 mg daily, \natorvastatin 80 mg daily, clopidogrel 75 mg daily for one year, \nimdur 30 mg, and aspirin 81 mg daily. \n\nSUMMARY STATEMENT:\n==================\n___ year old male with no known past medical history transferred \nfrom ___ with ongoing chest pain and troponin \nelevations, concerning for NSTEMI. Patient was placed on a \nheparin and nitro drip and noted to have troponins \n1.38->1.68-2.22. Cardiac cath showed 90% stenosis of the first \ndiagonal branch of the LAD. PCTA was performed at the site. \nPatient was Plavix loaded and discharged on statin, aspirin, \nmetoprolol, and Plavix for one year.\n\nHOSPITAL COURSE:\n================\n# NSTEMI\nPatient presented with typical cardiac chest pain at rest \nwithout known cardiac risk factors except for family history of \nheart disease. EKG non-ischemic, with likely LVH. Patient was \naspirin loaded, placed on a heparin drip, and nitro drip. Hb A1c \n4.9% and lipids were within normal limits. Chest pain resolved \nas of ___ AM after being on nitro drip. Troponin elevations \nwere noted 1.38->1.68-2.22 along with lactate elevations to 2.3. \nHe was taken to cath, which showed 90% stenosis of the ___ \ndiagonal branch of the LAD. PCTA was performed at this site. \nPatient was Plavix loaded and discharged on Plavix for one year, \nasa 81, metoprolol-xl 25, imdur 30 mg, and atorvastatin 80. TTE \nand ___ eval were performed prior to discharge.\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*0 \n2. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*0 \n3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \nRX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*0 \n4. 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 \n5. Metoprolol Succinate XL 25 mg PO DAILY \nRX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp \n#*30 Tablet Refills:*0 \n6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain \nRX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Q5MIN:PRN Disp \n#*30 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNon-ST elevation myocardial infarction\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr ___,\n\nIt was a pleasure taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital because of chest pain\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You were found to have a heart attack. You were started on \nblood thinning medication and medication to help increase blood \nflow in the heart. Your chest pain went away on this medication.\n- A procedure was done to see the vessels around the heart. It \nshowed a significant blockage of one of the vessels. A procedure \nwas performed to open the blockage up with a balloon through the \nvessel.\n- When your chest pain improved, you were discharged home.\n\nWHAT SHOULD I DO WHEN I GO HOME?\n- You should continue to take your medications as prescribed. \n- You should attend the appointments listed below. \n- Please return to the emergency room if you have severe chest \npain, worsening shortness of breath, or loss of consciousness. \n\nWe wish you the best!\nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I214", "I2510", "Z7902" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I2510", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nChest pain, shortness of breath\n \nMajor Surgical or Invasive Procedure:\nCardiac catheterization\n\n \nHistory of Present Illness:\nMs. ___ is an ___ year old female with PMH of HTN, HLD, \nLVH,\nCOPD, and CKD III who was transferred from ___ with\nnon-exertional chest pain.\n\nPatient reports that she has been having chest pain for several\nmonths. Of note she had an outpatient stress test performed last\nweek which she reports was 'abnormal.' She was scheduled to see\ncardiology tomorrow but this morning developed worsening of her\nchest pain. She describes it as a midsternal chest pressure with\nno radiation. She reports that she took 4 chewable aspirin at\nhome and this resulted in resolution of her symptoms. Her\nsymptoms then returned several hours later and her pain has been\nconstant since this afternoon. Her EKG at ___ was reportedly\nconcerning for ischemia and she was transferred to ___ for\nurgent cardiology consult and likely cath. \nReport of the EKG at ___:\nECG Impression : Sinus rhythm\nECG Impression : Short PR interval\nECG Impression : Borderline ST depression, lateral leads\nECG Impression : Minimal ST elevation, inferior leads\n\nTroponin-T at ___ was <0.010 at 18:35\n\n*Of note was only able to access the report of the EKG and \nimages\nof the EKG were not sent with the patient.* EKG done at ___ \nwas negative for ischemic changes. Patient was given SL nitro \nwith no relief of her pain and started on a heparin gtt prior to \ntransfer to ___. \n\n \nPast Medical History:\n- Wegener's granulomatosis \n- OSTEOARTHRITIS - MULT JOINTS \n- Kidney, horseshoe \n- Esophageal reflux \n- Hyperlipidemia \n- Basal cell carcinoma \n- Diverticulosis \n- Impaired fasting glucose \n- Microalbuminuria \n- Mitral regurgitation \n- LVH (left ventricular hypertrophy) \n- Pulmonary hypertension \n- Kidney disease, chronic, stage III (___ ___ ml/min) \n- Raynaud disease \n- COPD (chronic obstructive pulmonary disease) \n- Gastritis \n- Gastroparesis \n- Non-rheumatic tricuspid valve insufficiency \n- Lung nodule, multiple \n- Lung mass-lung biopsy, giant cell vasculitis \n \nSocial History:\n___\nFamily History:\nBrother CAD/PVD \nDaughter Cancer - ___ \nFather CAD/PVD \nMother Cancer - ___ \n \nPhysical Exam:\nADMISSION EXAM\n================\nVITALS:\n24 HR Data (last updated ___ @ 213)\n Temp: 97.8 (Tm 97.8), BP: 117/56 (84-117/46-61), HR: 53, RR:\n16, O2 sat: 93%, O2 delivery: RA, Wt: 167.99 lb/76.2 kg \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. MMM.\nCARDIAC: RRR no m/r/g appreciated\nLUNGS: CTAB no r/r/w\nABDOMEN: Soft, NT, ND, +BS\nEXTREMITIES: No clubbing, cyanosis, or edema. \nSKIN: Warm. No rashes.\nNEUROLOGIC: AOx3. Grossly intact.\n\nDISCHARGE EXAM\n===============\n24 HR Data (last updated ___ @ 1154)\n Temp: 97.7 (Tm 97.8), BP: 127/66 (84-127/46-74), HR: 69\n(53-69), RR: 16, O2 sat: 95% (93-96), O2 delivery: Ra, Wt: \n167.99\nlb/76.2 kg \n\nFluid Balance (last updated ___ @ 839) \n Last 8 hours Total cumulative -374.2ml\n IN: Total 75.8ml, IV Amt Infused 75.8ml\n OUT: Total 450ml, Urine Amt 450ml, Emesis 0ml\n Last 24 hours Total cumulative 125.8ml\n IN: Total 575.8ml, IV Amt Infused 575.8ml\n OUT: Total 450ml, Urine Amt 450ml, Emesis 0ml \n \nWeight: 76.2kg\nWeight on admission: unknown\n \nTelemetry: NSR\nGeneral: Ill appearing, tremulous, pale\nHEENT: +JVD up to 8cm, no masses or thyromegaly. \nLungs: +bibasilar crackles, no wheezes\nCV: RRR no m/r/g. 2+ radial and dp pulses\nAbdomen: Soft, NTND. Normoactive BS\nExt: Trace edema b/l. \n\n \nPertinent Results:\nADMISSION LABS\n==================\n___ 09:36PM BLOOD WBC-5.4 RBC-3.15* Hgb-10.0* Hct-29.4* \nMCV-93 MCH-31.7 MCHC-34.0 RDW-12.8 RDWSD-43.6 Plt ___\n___ 09:36PM BLOOD Neuts-64.6 ___ Monos-11.7 \nEos-0.9* Baso-0.6 Im ___ AbsNeut-3.47 AbsLymp-1.18* \nAbsMono-0.63 AbsEos-0.05 AbsBaso-0.03\n___ 09:36PM BLOOD Glucose-120* UreaN-21* Creat-0.9 Na-131* \nK-5.7* Cl-92* HCO3-23 AnGap-16\n___ 09:36PM BLOOD Calcium-9.3 Phos-4.0 Mg-1.8\n\nDISCHARGE LABS\n====================\n___ 07:07AM BLOOD WBC-6.4 RBC-3.05* Hgb-9.7* Hct-29.1* \nMCV-95 MCH-31.8 MCHC-33.3 RDW-12.8 RDWSD-43.9 Plt ___\n___ 07:07AM BLOOD Glucose-128* UreaN-16 Creat-0.7 Na-131* \nK-3.9 Cl-95* HCO3-25 AnGap-11\n\nCARDIAC CATH ___\n=================\nMild coronary coronary artery, mild 30% stenosis in the LAD\n \nBrief Hospital Course:\nHOSPITAL COURSE:\n====================\nMs. ___ is an ___ year old female with PMH of HTN, HLD, \nLVH, COPD, and CKD III who was transferred from ___ \nwith non-exertional chest pain.\n\nPatient reports that she has been having chest pain for several \nmonths. Of note she had an outpatient stress test performed last \nweek which she reports was 'abnormal.' She was scheduled to see \ncardiology tomorrow but on the morning of presentation developed \nworsening of her chest pain. She describes it as a midsternal \nchest pressure with no radiation. She reports that she took 4 \nchewable aspirin at home and this resulted in resolution of her \nsymptoms. Her symptoms then returned several hours later and her \npain has been constant since this afternoon. Her EKG at ___ \nwas reportedly concerning for ischemia and she was transferred \nto ___ for urgent cardiology consult and likely cath. \n\nReport of the EKG at ___:\nECG Impression : Sinus rhythm\nECG Impression : Short PR interval\nECG Impression : Borderline ST depression, lateral leads\nECG Impression : Minimal ST elevation, inferior leads\n\nTroponin-T at ___ was <0.010 at 18:35\n\n*Of note was only able to access the report of the EKG and \nimages\nof the EKG were not sent with the patient.* EKG done at ___ \nwas negative for ischemic changes. Patient was given SL nitro \nwith no relief of her pain and started on a heparin gtt prior to \ntransfer to ___. \n\nTRANSITIONAL ISSUES \n==================== \n[ ] Ongoing management of CAD risk factors\n[ ] Further treatment of noncardiac chest pain\n[ ] Further work up of her hyponatremia\n\nACUTE/ACTIVE ISSUES:\n====================\n#Chest Pain\n#Unstable Angina \nStress test from At___ last week showed mild to moderate \nischemia at ___. Unable to review EKG from OSH but no ST \nelevations seen on EKG done in the ED. Troponin negative at OSH \nand repeat negative here as well. Cardiac cath performed today \nshowed only non obstructive disease with ___ in LAD, nothing \non RCA or LCx as previously suspected. We increased the dose of \nher atorvastatin to 80mg daily.\n\n#Hyponatremia\nGiven not volume overloaded and not in acute heart failure, \neuvolemic causes including SIADH are high on the differential, \ngiven her medications. Her Na 131 is unchanged from OSH records \nlast week, so it is possible this is her baseline. Did not \nreplete prior to discharge\n\nCHRONIC/STABLE ISSUES:\n======================\n#HTN\n- Continue home antihypertensive regimen\n\n#HLD\n- Increased atorvastatin to 80mg\n\n#GERD\n- Continued pantoprazole, Ativan for nausea\n\n#COPD\n- Albuterol nebulizer PRN\n- Pts inhalers not formulary; did not stay inpatient long enough \nfor family to bring them in\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Atorvastatin 40 mg PO QPM \n2. Atenolol 25 mg PO DAILY \n3. Losartan Potassium 25 mg PO DAILY \n4. Pantoprazole 40 mg PO Q12H \n5. LORazepam 0.5 mg PO Q8H:PRN anxiety \n6. Hydrochlorothiazide 25 mg PO DAILY \n7. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nDAILY \n8. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB \n\n \nDischarge Medications:\n1. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n2. Atenolol 25 mg PO DAILY \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nDAILY \n5. LORazepam 0.5 mg PO Q8H:PRN anxiety \n6. Losartan Potassium 25 mg PO DAILY \n7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUnstable angina \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___, \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 because you had worsening chest pain and an \nabnormal stress test result. \n\n WHAT HAPPENED IN THE HOSPITAL? \n ============================== \n - In the hospital, we obtained further tests to look for \nperformed a cardiac cath to assess for possible blockage in the \nvessels of your heart that could explain the cause of your chest \npain, which was negative. \n- We increased the dose of your statin to 80 mg.\n\n WHAT SHOULD I DO WHEN I GO HOME? \n ================================ \n- Please continue to take your medications as prescribed\n- Please follow up with your cardiologist in ___ weeks for \nfurther management. \n\n Thank you for allowing us to be involved in your care, we wish \nyou all the best! \n Your ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I200", "E871", "E785", "J449", "N183", "I129", "Z87891", "K219" ]

[ "I200: Unstable angina", "E871: Hypo-osmolality and hyponatremia", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z87891: Personal history of nicotine dependence", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "E871", "E785", "J449", "I129", "Z87891", "K219" ]

[]

[ " \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:\n___\n \nMajor Surgical or Invasive Procedure:\n___: Diagnostic angiogram\n \nHistory of Present Illness:\n___ yo female with known ___ s/p right EDAS. She had\nprevious admission her since then in ___ with ___ that required\nbilateral EVDs and TPA. She returns with 1 week of HA and\nnausea. Head CT at the OSH shows left occipital IPH with ___. \nShe c/o continued HA and Nausea. \n \nPast Medical History:\n___: Thalamic bleed, admitted to ___ Stroke, angio showed \n___ and 2 small aneurysms near the ventricles. Patient was seen\nat ___ and underwent bypass surgery with Dr ___. \nDepression- was on medication but discontinued secondary to side\neffects.\n\n \nSocial History:\n___\nFamily History:\nUnknown hx of vascular anomalies\n\n \nPhysical Exam:\nON ADMISSION\n============\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place, and date.\nLanguage: Speech fluent with good comprehension and repetition.\nNaming intact. No dysarthria or paraphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, to\nmm bilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift\n\nSensation: Intact to light touch, propioception, pinprick and\nvibration bilaterally.\n\nCoordination: normal on finger-nose-finger, rapid alternating\nmovements, heel to shin\n\nON DISCHARGE\n============\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\nOrientation: [x]Person [x]Place [x]Time\nFollows commands: [ ]Simple [x]Complex [ ]None\nPupils: 2.5-2mm b/l PERRL\nEOM: [x]Full [ ]Restricted\nFace Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No\nPronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No\nComprehension intact [x]Yes [ ]No\n\nMotor:\nTrapDeltoidBicepTricepGrip\n___\n\nIPQuadHamATEHLGast\n___\nLeft5 5 5 5 5 5\n\n[x]Sensation intact to light touch throughout\n \nPertinent Results:\nPlease see OMR for pertinent imaging & labs\n \nBrief Hospital Course:\n___\nOn ___, Ms. ___ was admitted to the Neuro ICU. Arterial \nline was placed for BP control with SBP goal <160. Diagnostic \nangio on ___ re-demonstrated bilateral ___. U/S of right \ngroin was obtained on ___ for palpable nodule and was negative \nfor pseudoaneurysm. Medications were adjusted for headache \nmanagement. On ___ she was called out of the ICU to ___ where \nshe remained neurologically stable. She was mobilized and \nencouraged POs. She was transferred to the neuro floor. NCHCT on \n___ was stable to improved.\n\n#Moyamoya\nNeurology was consulted to assist with management of her \nMoyamoya. It was recommended to avoid significant hypotension. \nPatient was cleared to start ASA 81mg on ___. She should \nfollow-up with Dr. ___ discharge. \n\n#Depression/anxiety\nPsych was consulted for the patient stating \"I want to die.\" It \nwas felt the patient did not require a 1:1 sitter. The valium \nwas discontinued and the patient was started on Seroquel per \nPsych recommendation. The Seroquel was discontinued and low dose \nAtivan was ordered BID PRN. Patient was started on mirtazepime \n7.5mg qHS to help with sleep, mood, appetite, and nausea. Social \nwork was consulted to assist with setting up outpatient psych \nfor follow-up after discharge. \n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Aspirin 81 mg PO DAILY \nRX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*2 \n3. Docusate Sodium 100 mg PO BID \n4. LORazepam 0.25 mg PO BID PRN anxiety \nRX *lorazepam 0.5 mg 0.5 (One half) tab by mouth BID PRN Disp \n#*7 Tablet Refills:*0 \n5. Mirtazapine 7.5 mg PO QHS \nRX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n6. Multivitamins W/minerals 1 TAB PO DAILY \n7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4H PRN \nDisp #*24 Tablet Refills:*0 \n8. Senna 17.2 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n___\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \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• Please do NOT take any blood thinning medication (Ibuprofen, \nPlavix, Coumadin) until cleared by the neurosurgeon. \n• Your neurosurgeon is recommending starting aspirin 81mg daily \nstarting on ___.\n• You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n• You may have difficulty paying attention, concentrating, and \nremembering new information.\n• Emotional and/or behavioral difficulties are common. \n• Feeling more tired, restlessness, irritability, and mood \nswings are also common.\n• Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nHeadaches:\n• Headache is one of the most common symptom after a brain \nbleed. \n• Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n• Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n• There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n\nWhen to Call Your Doctor at ___ for:\n• Severe pain, swelling, redness or drainage from the incision \nsite. \n• Fever greater than 101.5 degrees Fahrenheit\n• Nausea and/or vomiting\n• Extreme sleepiness and not being able to stay awake\n• Severe headaches not relieved by pain relievers\n• Seizures\n• Any new problems with your vision or ability to speak\n• Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n• Sudden numbness or weakness in the face, arm, or leg\n• Sudden confusion or trouble speaking or understanding\n• Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n• Sudden severe headaches with no known reason\n\n \nFollowup Instructions:\n___\n" ]

[ "I615", "I675", "R45851", "F329", "F419", "D649" ]

[ "I615: Nontraumatic intracerebral hemorrhage, intraventricular", "I675: Moyamoya disease", "R45851: Suicidal ideations", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "D649: Anemia, unspecified" ]

[ "F329", "F419", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nDulcolax Balance\n \nAttending: ___.\n \nChief Complaint:\nInsomnia\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with a PMHx of T1DM (since \nage ___ and paranoid schizophrenia who presents to the ED on \n___ w/insomnia x3 days. Pt states that she has not slept a \nwink for the past three nights and has \"hysteria.\" Patient \ncannot pinpoint any specific triggers but mentions she is a \nlight sleeper and \"everything\" can interrupt her sleep.\n\nShe has not followed with a psychiatrist in ___ months, as she \nstates her psychiatrist told her she needed to find a new \nprescriber because of her schedule. She states that she has not \nmissed any doses of her psychiatric medications. She also \nreports good control of her diabetes. She did not take her \ninsulin prior to coming to hospital because when she woke her \nblood sugar was 90.\n\nIn the ED, initial vitals were: 97.3 115 141/69 20 100% RA FSBG \n302 \nExam notable for delirium\nLabs notable for: 9.3>14.0/40.9<290, 130/5.1 ___ 412 \n-Gap = 10\n-Correct Na = 135\n-U/A: large leuks, trace prot, 1000 gluc, 80 ket, blood, WBCs\n-HbA1C pending\nStudies:\n-ECG (___): NSR, normal axis, 0.5mm depression in V4, 1mm \ndepression in V5, 0.5mm depression II, no STE\nPatient was given: \n-___ 18:21 SC Insulin 4 Units \n-___ 23:32 SC Insulin 6 Units \n-___ 23:45 PO Chlorpheniramine Maleate 4 mg \n-___ 05:44 IVF 1000 mL NS 1000 mL \n-___ 05:44 PO Sulfameth/Trimethoprim DS 1 TAB \nPatient was seen by Psychiatry who evaluated the patient and \nstated: \"Pt appears delirious (initially appeared oriented, \nattentive, and organized, now disoriented, inattentive, short \nterm memory deficits, though also unclear her baseline \nfunctioning, but\ndefinitely a change in later several days) in setting of \nhyperglycemia (unclear adherence at home), UTI.\" Recommended \nrestarting Trifluoperazine 10 mg PO daily, Benztropine 0.5 mg PO \ndaily.\n\nPatient was kept overnight in the ED for monitoring. Decision \nwas made to admit for management of hyperglycemia, UTI.\n \nOn the floor, patient is upset because \"someone poisoned her \nwater.\" Her step-father was present in the room and patient \nreported she wanted him to \"stay away\" and wasn't sure \"what he \nwas going to do\" to her if they left. She reports palpitations \nwhich she attributed to not sleeping. She denies f/c, \nlightheadedness/dizziness, CP, SOB, abd pain/N/V, dysuria. She \nis unsure when she had her last BM.\n\nPer review of OMR, patient was recently seen by GI for (+) \nhemoccult test. Noted to have difficulty with constipation and \nwill often go ___ w/o bowel movement. Patient attributes her \nconstipation to her psychiatric medications. She was started on \nLinzess; she reports she has not started this medication. \n\nReview of systems: \n(+) Per HPI \n(-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies cough, shortness of breath. Denies chest pain \nor tightness. Denies nausea, vomiting, diarrhea, constipation or \nabdominal pain. No recent change bladder habits. No dysuria. \nDenies arthralgias or myalgias. \n \nPast Medical History:\n-Paranoid schizophrenia on trifluoperazine, benztropine\n-IDDM (dx age ___ c/b retinopathy\n-Constipation\n-Stress test (___): \nIMPRESSION: Borderline EKG evidence of myocardial ischemia in \nthe absence of anginal symptoms at the achieved level of work. \n \nSocial History:\n___\nFamily History:\nMother is alive and well. Father is deceased, had lung cancer. \nShe has two sisters and two brothers, all of whom are relatively \nhealthy.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM (___):\nVS: T 97.9, BP 145/63, HR 118, RR 16, O2 sat 100% RA, fs 162\nGen: Well-appearing, NAD, sitting up in bed\nHEENT: Sclera anicteric, dry mucous membranes, oropharynx clear\nNeck: supple, JVP not elevated, no LAD, normal thyroid exam\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: RRR, (+)S1, S2, no m/r/g\nAbdomen: soft, ND/NT, no rebound/guarding, bowel sounds present\nBack: no CVAT b/l\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: improving non-tender non-pruritic papules on erythematous \nbase on cheeks and upper chest \nNeuro: PERRL, EOMI\nPsych: Oriented x3. Good attention (+MOYB), ___ registration, \n___ spontaneous recall, ___ recall with multiple choice. Can \nfollow 2-step commands. Speech and language comprehension \nintact. Can name both low and high frequency objects. Mildly \ntangential in thought process. Mildly paranoid thought content. \nModerate insight.\n\nDISCHARGE PHYSICAL EXAM (___):\nVS: HR 65-81, RR ___, O2 99-100% RA\nfingersticks: daytime 66-106, nighttime 246-488\nGen: Well-appearing, NAD, walking around floor\nHEENT: Sclera anicteric, dry mucous membranes, oropharynx clear\nNeck: supple, JVP not elevated, no LAD, normal thyroid exam\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: RRR, (+)S1, S2, no m/r/g\nAbdomen: soft, ND/NT, no rebound/guarding, bowel sounds present\nBack: no CVAT b/l\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSkin: improving non-tender non-pruritic papules on erythematous \nbase on cheeks and upper chest \nNeuro: PERRL, EOMI\nPsych: Oriented x3, Good attention (+MOYB), ___ registration and \nrecall at 3 minutes, moderate intermediate memory (names last 3 \npresidents), good comprehension/speech, follows 1-step commands \nbut struggles w/ 2-step commands, mildly tangential thought \nprocess.\n \nPertinent Results:\nADMISSION LABS:\n___ 11:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-1000 KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-LG\n___ 02:34PM GLUCOSE-412* UREA N-16 CREAT-0.8 SODIUM-130* \nPOTASSIUM-5.1 CHLORIDE-92* TOTAL CO2-28 ANION GAP-15\n___ 02:34PM CK-MB-3 cTropnT-<0.01\n___ 02:34PM TSH-2.0\n___ 02:34PM WBC-9.3 RBC-4.51 HGB-14.0 HCT-40.9 MCV-91 \nMCH-31.0 MCHC-34.2 RDW-12.1 RDWSD-40.2\n\nINTERIM LABS:\n___ 05:03PM BLOOD CK-MB-3 cTropnT-<0.01\n___ 05:30AM BLOOD CK-MB-3 cTropnT-<0.01\n___ 10:37AM BLOOD %HbA1c-8.6* eAG-200*\n\nDISCHARGE LABS:\n___ 09:10AM BLOOD WBC-6.4 RBC-3.88* Hgb-12.1 Hct-36.1 \nMCV-93 MCH-31.2 MCHC-33.5 RDW-12.4 RDWSD-42.5 Plt ___\n___ 09:10AM BLOOD ___ PTT-26.4 ___\n___ 09:10AM BLOOD Glucose-191* UreaN-15 Creat-0.9 Na-135 \nK-4.8 Cl-100 HCO3-25 AnGap-15\n___ 05:30AM BLOOD ALT-16 AST-21 LD(LDH)-177 AlkPhos-61 \nTotBili-0.4\n___ 02:27AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 09:10AM BLOOD Calcium-9.6 Phos-3.8 Mg-1.8\n\nSTUDIES:\n-ECG (___): Sinus rhythm. Non-specific ST-T wave changes. \nNo previous tracing available for comparison. \n-ECG (___): Sinus rhythm. ST-T wave changes concerning for \nischemia or infarction. Compared to the previous tracing of the \nsame day ST-T wave changes are more significant. Clinical \ncorrelation is suggested. \n-ECG (___): Sinus rhythm. Baseline artifact. Compared to \nthe previous tracing of ___ the ST segment depression in \nthe inferolateral leads has improved while the rate has slowed. \nConsider active inferolateral ischemic process. Followup and \nclinical correlation are suggested.\n-Transthoracic ECHO (___): The left atrium is normal in \nsize. No atrial septal defect is seen by 2D or color Doppler. \nLeft ventricular wall thicknesses and cavity size are normal. \nRegional left ventricular wall motion is normal. Overall left \nventricular systolic function is low normal (LVEF 50-55%). The \ninferior wall appears borderline hypokinetic in some views. \nThere is no ventricular septal defect. Right ventricular chamber \nsize and free wall motion are normal. The diameters of aorta at \nthe sinus, ascending and arch levels are normal. The aortic \nvalve leaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosis or aortic regurgitation. The \nmitral valve appears structurally normal with trivial mitral \nregurgitation. The estimated pulmonary artery systolic pressure \nis normal. There is no pericardial effusion. \n\nIMAGING:\n-CT HEAD W/O CONTRAST (___):\nIMPRESSION: No acute intracranial process, specifically, no \nhemorrhage.\n-CHEST (PORTABLE AP) (___):\nIMPRESSION: Lungs are fully expanded and clear. \nCardiomediastinal and hilar silhouettes and pleural surfaces are \nnormal. In ___ the patient had severe disseminated \npredominantly micronodular infiltrative pulmonary abnormality \nand abundant central adenopathy. Although that appears to have \ncleared. Investigation of that diagnosis may be pertinent to her \nmedical management. \n\n \nBrief Hospital Course:\n___ yo woman w/PMHx schizophrenia and IDDM presenting in a \ndelirious state in the setting of insomnia x3 days and admitted \nfor further evaluation and monitoring of hyperglycemia, UTI, and \na question of NSTEMI.\n\n#Myocardial Ischemia: In the ED, patient was found on ECG to \nhave diffuse ST depressions (but 2mm depressions in V4 V5). On \nfloor patient was given 325mg of ASA. Of note, patient received \nstress test in ___, which showed borderline myocardia ischemia. \nPatient denied symptoms of chest pain, substernal pressure, SOB, \ncough, or N/V. Upon further probing, however, she did report \nhaving had SOB with exercise and recent heart palpitations, \nwhich she attributes her insomnia. On the inpatient floor, \npatient was put on tele and her troponins and CK-MB were \ntrended; returned all negative, ruling out NSTEMI. ECGs were \ntrended and remained stable. Cardiology was consulted, and \nmedical management was initiated with daily 81mg aspirin, \nmetoprolol 12.5mg TID, atorvastatin, and lisinopril. (Of note, \nPlavix was contraindicated due to concern for potential cath). \nGiven stability of ECGs, negative trops catheterization was \ndeferred. Hospital stay was complicated by a hypotensive episode \novernight on ___ to 84/50, in the setting of new \nmedications and NPO, which improved with ambulation and IV \nfluids. Her lisinopril was discontinued given low BPs and normal \nBUN/Cr. She received a TTE which revealed normal EF (50-55%) and \ninferior wall appears borderline hypokinesis in some views; she \nwas discharged on metoprolol, asa, atorvastatin. She will follow \nup with Cardiology in x2 weeks as an outpatient for further \nevaluation. \n\n#Hyperglycemia: Patient who has a hx of type I DM since age ___ \nwas found to have 412 serum glucose in the ED on day of \npresentation (___) and 209 the day after. Patient says she \nhad been compliant with her insulin regimen but may have been \nless strict about her doses due to recent insomnia for 3 days. \nShe also reports missing her insulin the morning of her \npresentation to ED. Labs in the ED were reassuring w/ corrected \nsodium 135 and normal anion gap, ruling out DKA. On admission, \npatient was continued on home insulin regimen ___ Novolog w/ \nmeals, 14 Humulin N qAM, 10 Humulin N QHS) and monitored by \nfingersticks. Fingersticks which showed normal glucose during \nthe day (60s-100s) but increased glucose during the night \n(246-488), possibly due to binging on night snacks after being \nNPO during the day. No changes were made to her insulin regimen. \nBy day of discharge, serum glucose decreased to 191 (___). \nHer HbA1c was found to be 8.6% which is reassuring for relative \ncompliance. Our recommended goal for Ms. ___ is an HbA1c \nbelow 8.0%.\n\n#UTI: In the ED, patient was found concerning for UTI due to WBC \n>182 on microscopy. Both urine microscopy and culture, however, \nshowed contamination. Patient denied any fever, dysuria, \nhematuria, or changes in urinary habits. Patient received x1 \ndose of Bactrim in the ED and was admitted for continued \nmonitoring. Repeat UA on admission showed increased WBC (56) and \nminimal epithelial cells, so Bactrim DS BID was restarted on \n___. Antibiotics was stopped the following day, however, when \nrepeat urine culture returned skin flora in the absence of \nsymptoms. \n\n#Psych: Patient has history of undifferentiated psychosis with \ndifferential including paranoid schizophrenia. On day of \npresentation, patient presented with complaints of insomnia x3 \ndays and \"hysteria.\" Patient is unsure of specific triggers; \nhowever, patient reports she is a light sleeper and that \n\"everything\" can interrupt her sleep, including sounds of car \nalarms and people talking coming from the parking lot during the \nnight. Patient also does mention she has been recently \ndistressed by many people, including boyfriend, telling her what \nto do, which has contributed to her coming to the ED. Of note, \npatient has not seen her outpatient psych therapist for couple \nmonths due reasons that are unclear even to the patient and even \nher stepfather. (Tried calling outpt therapist, but staff says \nprovider does not direct calls.) In the ED, patient received \npsych consult and found to have inconsistent orientation, \nattentiveness, organization, and short term memory on mental \nstatus exam. Patient denied any SI, HI, or any hallucinations. \nPatient was suspected, however, to be delirious ___ \nhyperglycemia, UTI, and/or sleep-wake cycle disruptions, \nsuperimposed on long-standing schizophrenia. On admission, \npatient presented with some paranoia/delusions, including \nthoughts that \"someone poisoned my water\" and that her chest was \nshrinking. Patient was started on home trifluoperazine 10mg \ndaily and Benztropine 0.5mg daily. While patient did not sleep \nthe first night of admission, she reported she slept 7.5 hrs the \nfollowing night. Serial mental status exams were negative except \nfor moderately tangential thought processes and mildly paranoid \ndelusional thought content. Close PCP ___ for psych med \nmanagement is recommended until patient can reconnect or find \nnew outpt psychiatrist.\n\nTransitional Issues:\n[] pt reported no contact w/her psychiatrist since ___ \nplease try to have pt reestablish care\n[] HbA1C = 8.6% on current regimen\n[] close ___ with cardiology. started on asa 81mg, \natorvastatin 80mg, metoprolol XL 12.5mg given high concern for \nCAD/stable angina\n#Code status: Full\n#Contact: ___ ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. NPH 14 Units Breakfast\nNPH 10 Units Bedtime\nNovolog 2 Units Breakfast\nNovolog 2 Units Lunch\nNovolog 2 Units Dinner\n2. Trifluoperazine HCl 10 mg PO DAILY \n3. Benztropine Mesylate 0.5 mg PO DAILY \n4. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Medications:\n1. Benztropine Mesylate 0.25 mg PO DAILY \n2. Senna 8.6 mg PO BID:PRN constipation \n3. Trifluoperazine HCl 10 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n5. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0\n6. Metoprolol Succinate XL 12.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n7. NPH 14 Units Breakfast\nNPH 10 Units Bedtime\nNovolog 2 Units Breakfast\nNovolog 2 Units Lunch\nNovolog 2 Units Dinner\nRX *insulin NPH human recomb [Humulin N] 100 unit/mL AS DIR 14 \nUnits before BKFT; 10 Units before BED; Disp #*10 Vial \nRefills:*0\nRX *insulin aspart [Novolog] 100 unit/mL AS DIR 2 Units before \nBKFT; 2 Units before LNCH; 2 Units before DINR; Disp #*10 Vial \nRefills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n-Coronary artery disease\n-Angina\n-Hyperglycemia\n-UTI\n\nSECONDARY DIAGNOSES:\n-Schizophrenia\n-Type 1 DM\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 your blood sugars were \nhigh and you had a urinary tract infection. We restarted you on \nyour home insulin regimen and your blood sugars returned to \nnormal. You were treated for your urinary tract infection with \nan antibiotic.\n\nWhile you were in the hospital, we noticed that your heart \nshowed signs of coronary artery disease, which means you have \nnarrowing of the vessels in your heart. You were evaluated by \nthe Cardiologists and had an ultrasound of your heart performed. \nYou should continue taking aspirin 81mg daily along with \natorvastatin 80mg daily. You should also take metoprolol XL \n12.5mg daily. You will need to ___ with your new \ncardiologist, Dr. ___ on ___ at 140PM.\n\nThank you for letting us be a part of your care! \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I25119", "G92", "E10319", "I959", "F200", "Z794", "G4700", "I259", "E861" ]

[ "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "G92: Toxic encephalopathy", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "I959: Hypotension, unspecified", "F200: Paranoid schizophrenia", "Z794: Long term (current) use of insulin", "G4700: Insomnia, unspecified", "I259: Chronic ischemic heart disease, unspecified", "E861: Hypovolemia" ]

[ "Z794", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nlatex\n \nAttending: ___.\n \nChief Complaint:\nlarge pelvic pass, rectal bleeding \n \nMajor Surgical or Invasive Procedure:\nTOTAL ABDOMINAL HYSTERECTOMY, BILATERAL SALPINGO-OOPHORECTOMY\n\n \nHistory of Present Illness:\nMs. ___ is a ___ y/o G1P1 transferred from ___ with a\nlarge pelvic mass, which was found on CT scan after she \npresented\nto the ED with worsening abdominal pain, nausea, and vomiting on\n___. On arrival to the floor today, she had repeated severe\nrange BPs of 210s/100. Denied SOB, chest pain, palpitations,\nchange in baseline dizziness, and HA. Denies h/o HTN but notes\ndoes not follow with PCP. On arrival to the ED 2 weeks ago, her\nBP was 170s/90 but states she has never started HTN medications. \n\n\nIn regards to her rectal bleeding. She notes noticing\nintermittent black stools for the past month. She denies overt\nrectal bleeding but states she has noticed a small amount of\nblood covering the stools intermittently. Also endorses recent\nweakness because of change in ability to tolerate solids. Has\ncontinued to ambulate. Has never had colonoscopy. \n\n \nPast Medical History:\nGlaucoma \n \nSocial History:\n___\nFamily History:\n- Denies family history of breast cancer, Gyn cancer, or colon\ncancer\n- Family history of prostate cancer in dad and brother (both\ndeceased)\n\n \nPhysical Exam:\nPhysical Exam on Discharge:\n\nGen: elderly female lying in bed\nCV: RRR S1S2\nPulm: CTAB\nAbd: soft, nontender, vertical low abdominal incision c/d/I with\nstaples in place\nNeuro: A&O x 2(oriented to self, type of building, identified\nmonth as ___ or ___ but did not know year), grossly wnl\n \n \nPertinent Results:\nLabs on Admission:\n\n___ 07:50PM WBC-10.6* RBC-3.70* HGB-10.9* HCT-33.2* \nMCV-90 MCH-29.5 MCHC-32.8 RDW-12.4 RDWSD-40.6\n___ 07:50PM PLT COUNT-425*\n___ 07:50PM ___ PTT-28.3 ___\n___ 07:50PM ___ 07:50PM GLUCOSE-163* UREA N-10 CREAT-0.5 SODIUM-141 \nPOTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-29 ANION GAP-___bdomen: bilateral renal cysts \n\nLabs on Discharge: \n\n___ 07:31AM BLOOD WBC-12.2* RBC-3.52* Hgb-10.6* Hct-31.4* \nMCV-89 MCH-30.1 MCHC-33.8 RDW-12.9 RDWSD-41.9 Plt ___\n___ 07:31AM BLOOD Plt ___\n___ 07:31AM BLOOD Glucose-87 UreaN-10 Creat-0.4 Na-144 \nK-2.9* Cl-104 HCO3-28 AnGap-12\n___ 07:31AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service for a \nlarge pelvic mass and rectal bleeding. \n \nUpon arrival to the hospital, her BP was 216/100. Patient was \nasymptomatic at the time. EKG showed normal sinus rhythm. She \nwas given 25mg hydralazine and placed on telemetry. The medicine \nservice was consulted regarding her hypertensive urgency. They \nrecommended 5mg Amlodipine QD and 25mg Q6 PRN hydralazine for \nSBP >160. Given continued elevated BP, medicine consult team \ndecided to change regimen to Diltiazem 60mg Q6H with PRN \nhydralazine for SBP >180. They also recommended no further \ntesting needed to optimize patient prior to surgery. Patient is \nto follow up with her PCP outpatient for HTN. \n\nThe GI service was consulted regarding her rectal bleeding. They \nperformed an EGD and colonoscopy on HD#2 and found an esophageal \nhiatal hernia, duodenal bulb ulcer, mild diverticulosis. Biopsy \nof ulcer was positive for H. pylori. Patient was then started on \n14 day course of prevpac. \n\nOf note, on the night of HD#1, patient was had a code blue for \nloss of conscious while on the toilet after drinking the bowel \nprep for her GI procedure. Patient returned to conscious after \n~10 seconds. Stat labs, EKG, telemetry, and CXR were ordered and \nwere assuring. Patient was given two 500mL bolus of LR and \nsymptoms improved. After careful evaluation, event was \nattributed to a likely vagal response while using the restroom. \n\nPatient then underwent exlap, TAH, BSO, pelvic mass resection \nfor serous cyst adenofibroma. Her post-operative course is \ndetailed as follows. Immediately postoperatively, her pain was \ncontrolled with IV dilaudd. Her diet was advanced without \ndifficulty and she was transitioned to PO tramadol and \nacetaminophen. On post-operative day #1, her urine output was \nadequate so her Foley catheter was removed and she voided \nspontaneously. \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:\nTimolol eye drops \n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \nDo not exceed 4000mg in 24 hours \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*50 Tablet Refills:*1 \n2. Amoxicillin 1000 mg PO Q12H \nTake until ___ \nRX *amoxicillin 500 mg 2 tablet(s) by mouth twice a day Disp \n#*48 Tablet Refills:*0 \n3. Clarithromycin 500 mg PO Q12H \nTake until ___ \nRX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day Disp \n#*24 Tablet Refills:*0 \n4. Diltiazem 60 mg PO Q6H \nRX *diltiazem HCl 360 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*3 \n5. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n6. Lansoprazole Oral Disintegrating Tab 30 mg PO Q12H \nRX *lansoprazole 30 mg 1 tablet(s) by mouth twice a day Disp \n#*24 Tablet Refills:*0 \n7. Lisinopril 10 mg PO DAILY \nRX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*3 \n8. TraMADol 25 mg PO Q6H:PRN pain \nDo not drink or drive while taking this medication. \nRX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 4 \nhours Disp #*50 Tablet Refills:*0 \n9. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSerous cystadenofibroma\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 \nbeing seen in clinic for a large pelvic mass in the setting of \nrecent weight loss and rectal bleeding. \n\nWe consulted the gastrointestinal physicians and they scoped \nboth your upper and lower gastrointestinal tract. During the \nprocedure, they found a hiatal hernia and an ulcer. They took a \nbiopsy of the ulcer and it showed a bacterial infection. We \nstarted you on treatment for this infection while you were in \nthe hospital. You will continue to take these medications to \ncomplete a 14 day course. \n\nThe gynecology oncology service then performed the procedures \nlisted below. You have recovered well after your operation, and \nthe team feels that you are safe to be discharged home. \n\nWhile you were here, your blood pressures were elevated. We \nconsulted the internal medicine physicians to evaluate you. They \nrecommended we start you on a new blood pressure medication \ncalled Diltiazem and Lisinopril. You will continue to take this \nmedication as an outpatient. Please follow up with your primary \ncare physicians for ongoing treatment. \n\nYou had an episode of loss of consciousness while on the toilet \nduring your bowel preparation for the scoping procedure. We did \nan EKG, imaging of your chest, and blood work that was all \nreassuring. You were given more fluids and your symptoms \nresolved. \n\nPlease follow these instructions: \n\nAbdominal instructions: \n* Take your medications as prescribed. We recommend you take \nnon-narcotics (i.e. Tylenol) regularly for the first few days \npost-operatively, and use the narcotic as needed. As you start \nto feel better and need less medication, you should \ndecrease/stop the narcotic first.\n* Take a stool softener to prevent constipation. You were \nprescribed Colace. If you continue to feel constipated and have \nnot had a bowel movement within 48hrs of leaving the hospital \nyou can take a gentle laxative such as milk of magnesium. \n* Do not drive while taking narcotics. \n* Do not combine narcotic and sedative medications or alcohol. \n* Do not take more than 4000mg acetaminophen (tylenol) in 24 \nhrs. \n* No strenuous activity until your post-op appointment. \n* Nothing in the vagina (no tampons, no douching, no sex) for 12 \nweeks. \n* No heavy lifting of objects >10 lbs for 6 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n\nIncision care: \n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* If you have staples, they will be removed at your follow-up \nvisit. \n\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\n \nFollowup Instructions:\n___\n" ]

[ "D282", "Q613", "I471", "D271", "D270", "R55", "K449", "K269", "H409", "I160", "B9681", "K2960", "E8352", "E876", "K5730" ]

[ "D282: Benign neoplasm of uterine tubes and ligaments", "Q613: Polycystic kidney, unspecified", "I471: Supraventricular tachycardia", "D271: Benign neoplasm of left ovary", "D270: Benign neoplasm of right ovary", "R55: Syncope and collapse", "K449: Diaphragmatic hernia without obstruction or gangrene", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "H409: Unspecified glaucoma", "I160: Hypertensive urgency", "B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere", "K2960: Other gastritis without bleeding", "E8352: Hypercalcemia", "E876: Hypokalemia", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nTrulicity\n \nAttending: ___.\n \nChief Complaint:\nDKA\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ year-old man with a pmh of DMII, HTN, HLD, and\nacute pancreatitis, who presents with DKA. He was previously on\ninsulin (70U Tresiba, 30U short-acting w/ meals). Per the\npatient, he was having consistent BG in 300s despite compliance\nwith insulin regimen. 3 months ago his endocrinologist held his\ninsulin and started metformin and glipizide, and his BGs were\n200s. On ___, he was started on ketogenic diet (Kind Bar in\nam, ___ drink for lunch, normal dinner meal) and he was\nstarted on oral Jardiance and phentermine ___. He\nsubsequently lost 25 lbs in 18 days and was feeling well. \n\n5 days prior to presentation, he started feeling fatigued and\nlightheaded when walking around. He was concerned this was\nrelated to his new diabetic medications and self-discontinued\nthem 3 days ago. His symptoms continued to progress and worsen\nand he developed lightheadedness at rest, new DOE with stairs,\nheadache, nausea and vomiting (1x on day of presentation after\neating a donut). During this time he continued his ketogenic \ndiet\nand had a normal appetite. His BG levels remained <200 \nthroughout\n(checking twice daily) which has been his baseline since \nstarting\nJardiance. However, on the day of presentation he had some coke\nand his BG were subsequently 400s, prompting presentation to the\nED. \n\nHe recently had a mild sore throat and rhinorrhea for several\ndays but improved prior to presentation. He denies fevers,\nchills, night sweats, cough, chest pain, abdominal pain, back\npain, diarrhea, ___ swelling, dysuria, hematuria, polyuria,\nmelena, BRBPR. He has not had a BM for the past 5 days. \n\n \nPast Medical History:\nHTN\nHLD\nDMII\nPancreatitis ___\n\n \nSocial History:\n___\nFamily History:\nFather (deceased): lung cancer and diabetes. \nMother (alive): CAD\nSister (deceased): uterine cancer \n3 aunts had colon cancer.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM \nVS: HR 88 BP 150/66 RR 16 SaO2 97% on RA\nGENERAL: well-appearing, alert and interactive, in no acute\ndistress, lying in bed\nCARDIAC: RRR, nl s1/s2, no m/g/r\nLUNGS: CTAB, no wheezing, crackles, or other adventitious breath\nsounds\nBACK: No CVA tenderness\nABDOMEN: NABS, obese, soft, nondistended, nontender\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally. \nSKIN: Warm. Cap refill <2s. No rash. \nNEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal\nsensation. Gait is normal. AOx3.\n\nDISCHARGE EXAM\nVS: 98.0 149/80 67 18 99/RA \nGEN: Alert and in no apparent distress\nEYES: Anicteric, non-injected\nENT: MMM, grossly nl OP\nCV: RRR nl S1/S2 no g/r/m\nCHEST: CTAB no w/r/r EWOB\nABD: soft, NT/ND, NABS no r/g\nEXT: WWP, no edema. \nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI, speech fluent, moves all limbs, sensation to light touch \ngrossly intact throughout\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 02:17PM BLOOD WBC-12.4* RBC-5.19 Hgb-15.3 Hct-47.4 \nMCV-91 MCH-29.5 MCHC-32.3 RDW-13.1 RDWSD-43.8\n___ 02:17PM BLOOD Neuts-83.6* Lymphs-10.3* Monos-5.2 \nEos-0.2* Baso-0.2 Im ___ AbsNeut-10.38* AbsLymp-1.28 \nAbsMono-0.64 AbsEos-0.02* AbsBaso-0.03\n___ 09:39PM BLOOD ___ PTT-25.0 ___\n___ 02:17PM BLOOD Glucose-472* UreaN-30* Creat-1.6* Na-136 \nK-5.5* Cl-100 HCO3-6* AnGap-29*\n___ 07:25PM BLOOD TotBili-0.4\n___ 03:17AM BLOOD ALT-13 AST-12 LD(LDH)-156 AlkPhos-89 \nTotBili-0.5\n___ 02:17PM BLOOD Calcium-9.8 Phos-4.5 Mg-2.6\n___ 03:17AM BLOOD %HbA1c-10.2* eAG-246*\n___ 07:25PM BLOOD Beta-OH-6.0*\n___ 03:50PM BLOOD ___ pO2-48* pCO2-22* pH-7.18* \ncalTCO2-9* Base XS--18\n___ 07:32PM BLOOD Lactate-1.3\n___ 07:32PM BLOOD O2 Sat-79\n___ 09:53PM BLOOD freeCa-1.23\n\nMIBROBIOLOGY:\n===============\n___ 3:20 pm URINE\n **FINAL REPORT ___\n URINE CULTURE (Final ___: NO GROWTH.\n\nIMAGING/STUDIES:\n=================\n___ CXR \nCardiac size is normal. The lungs are clear. There is no \npneumothorax or \npleural effusion. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old man with a pmh of DMII, HTN, and HLD, \nadmitted for euglycemic DKA from SGLT-2 use (recently switched \nfrom insulin) and ketogenic diet. \n \n# Euglycemic DKA: Presented with blood glucose of 440, pH 7.18, \nbicarbonate of 8, anion gap 29. Admitted to ICU for insulin \ndrip. ___ consult, felt mixed picture from Jiardance use and \nstarvation ketosis (from pre-admission extremely low-carb diet). \nHis ICU course was slightly prolonged due to rising anion gap \n(but euglycemic) after transition from an insulin ggt to SubQ. \nHowever, once Jiardance washout time completed, AG closed and \nHCO3 subsequently rose to normal. He was transferred to the \nfloor where ___ service continued to make insulin \nadjustments. It was decided to transition back to lantus/Humalog \nas patient had been on previously. On day of discharge patient \nwas feeling well, with controlled FSBS, closed AG, near normal \nHCO3. ___ service felt that glycemic control was stable \nenough for discharge and he was discharged with intent for close \n___ outpatient follow-up.\n\nCHRONIC ISSUES \n# HTN: Continued home antihypertensives. \n# HLD: Medication list with atorvastatin but pt not taking \n\nTRANSITIONAL ISSUES\n- Jiardance discontinued, pt returned to ___. Has all \nsupplies at home in sufficient quantity.\n- Temporary phosphate and potassium repletion provided for \nlimited prescription after discharge. \n\nTime spent coordinating discharge > 30 minutes\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Losartan Potassium 100 mg PO DAILY \n2. phentermine 37.5 mg oral DAILY \n3. empagliflozin 25 mg oral DAILY \n\n \nDischarge Medications:\n1. Glargine 24 Units Bedtime\nHumalog 4 Units Breakfast\nHumalog 4 Units Lunch\nHumalog 4 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n2. Phosphorus 500 mg PO BID Duration: 2 Days \nRX *sod phos di, mono-K phos mono [Phosphorous] 250 mg 2 \ntablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0 \n3. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days \nRX *potassium chloride 10 mEq 2 capsule(s) by mouth once a day \nDisp #*10 Capsule Refills:*0 \n4. Losartan Potassium 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nEuglycemic Diabetic Ketoacidosis\nStarvation Ketosis\nType II 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 Mr ___,\n\nYou were admitted to the hospital with diabetic ketoacidosis, a \nsevere complication of diabetes due to your jiardance and \nextremely low carb diet. You were treated in the ICU with an \ninsulin drip and your condition improved. After you had \nrecovered, it was decided to change your medications back to \ninsulin. You were seen by the ___ diabetes service while \nhospitalized and will need to follow-up with your \nendocrinologist after you leave the hospital. \n\nMedication changes:\n- Jiardance and phentermine were stopped\n- Phosphprus supplements for the next two days ___ and ___, \nthen stop\n- Potassium supplements for the next 5 days\n- Insulin (lantus and Humalog) were restarted\n\nPlease take all medications as prescribed and keep all scheduled \ndoctor's appointments. Seek medical attention if you develop a \nworsening or recurrence of the same symptoms that originally \nbrought you to the hospital, experience any of the warning signs \nlisted below, or have any other symptoms that concern you.\n\nIt was a pleasure taking care of you!\nYour ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "E1110", "N179", "I10", "E8770", "E669", "D72829", "E785", "Z7984", "Z9114", "J3489", "D649", "Z794", "Z6835" ]

[ "E1110: Type 2 diabetes mellitus with ketoacidosis without coma", "N179: Acute kidney failure, unspecified", "I10: Essential (primary) hypertension", "E8770: Fluid overload, unspecified", "E669: Obesity, unspecified", "D72829: Elevated white blood cell count, unspecified", "E785: Hyperlipidemia, unspecified", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z9114: Patient's other noncompliance with medication regimen", "J3489: Other specified disorders of nose and nasal sinuses", "D649: Anemia, unspecified", "Z794: Long term (current) use of insulin", "Z6835: Body mass index [BMI] 35.0-35.9, adult" ]

[ "N179", "I10", "E669", "E785", "D649", "Z794" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___ - Coronary artery bypass grafting x 4: left internal \nmammary artery to left anterior descending artery; saphenous \nvein graft to ramus intermedius; saphenous vein graft to obtuse \nmarginal branch; saphenous vein graft to posterior descending \nartery.\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a strong family history \nof early coronary artery disease. He developed substernal chest \npain radiating to his left shoulder. He denied associated \nnausea, vomiting, diaphoresis, cough, shortness of breath, or \nsyncope. He had stuttering symptoms over the course of the day \nand presented to the ED and was placed on a nitgroglycerin drip. \nAn EKG revealed Q waves inferiorly. A cardiac catheterization \nthe following day revealed multivessel coronary artery disease. \nHe was transferred to ___ for surgical revascularization. \n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nunremarkable\n \nPhysical Exam:\nBPL 139/83 RR: 18 O2 sat: 96%\nHeight: 69\" Weight: 255 lbs\n\nGeneral:\nSkin: Dry [X] intact [X]\nHEENT: PERRLA [X] EOMI [X]\nNeck: Supple [X] Full ROM [X]\nChest: Lungs clear bilaterally [X]\nHeart: RRR [X] Irregular [] Murmur [] grade ______ \nAbdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds \n+ []\nExtremities: Warm [X], well-perfused [X] Edema [] _____\nVaricosities: None []\nNeuro: Grossly intact []\nPulses:\nFemoral Right: 2+ Left: 2+\nDP Right: 2+ Left: 2+\nRadial Right: 2+ Left: 2+\n\n \nPertinent Results:\nTransthoracic Echocardiogram ___\nThe left atrium is normal in size. There is mild symmetric left \nventricular hypertrophy with normal cavity size. There is mild \nregional left ventricular systolic dysfunction with focal \ndyskinesis of the inferior wall and severe hypokinesis to \nakinesis of the remainder of the inferior wall. There is an \ninferobasal left ventricular aneurysm. Overall ejection fraction \nis mildly depressed (EF 50-55%). Right ventricular chamber size \nand free wall motion are normal. The aortic valve leaflets (3) \nappear structurally normal with good leaflet excursion and no \naortic stenosis or aortic regurgitation. The mitral valve \nleaflets are mildly thickened. There is no mitral valve \nprolapse. Trivial mitral regurgitation is seen. The pulmonary \nartery systolic pressure could not be determined. There is no \npericardial effusion. \n\nIMPRESSION: Suboptimal image quality. Mild symmetric left \nventricular hypertrophy with regional left ventricular systolic \ndysfunction c/w CAD. Normal right ventricular cavity size and \nsystolic function. \n\nTransesophageal Echocardiogram ___\nPRE BYPASS No spontaneous echo contrast or thrombus is seen in \nthe body of the left atrium/left atrial appendage or the body of \nthe right atrium/right atrial appendage. No atrial septal defect \nis seen by 2D or color Doppler. There is mild regional left \nventricular systolic dysfunction with severe hypokinesis of the \nbasal inferior wall. The right ventricle displays normal free \nwall contractility. There are simple atheroma in the ascending \naorta. There are simple atheroma in the aortic arch. There are \nsimple atheroma in the descending thoracic aorta. The aortic \nvalve leaflets (3) are mildly thickened but aortic stenosis is \nnot present. No aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. Mild (1+) mitral regurgitation is \nseen. There is no pericardial effusion. Dr. ___ was \nnotified in person of the results in the operating room at the \ntime of the study. \n\nCXR ___\nMedian sternotomy wires are intact. Postoperative widening of \nthe \ncardiomediastinal silhouette is stable. No pulmonary edema. \nStable, moderate left pleural effusion with an air-fluid level \nseen medially and posteriorly suggesting a small pneumothorax. \nNo right pleural effusion. Stable, low lung volumes \nbilaterally. Stable, substantial left lower lobe atelectasis. \nIMPRESSION: \n1. Stable, moderate left pleural effusion with a small, \nposteromedial \npneumothorax. \n2. Stable, substantial left lower lobe atelectasis. \n\nAdmission Labs:\n___ WBC-9.8 RBC-4.48* Hgb-13.5* Hct-40.1 MCV-90 MCH-30.1 \nMCHC-33.7 RDW-12.5 RDWSD-40.9 Plt ___\n___ ___ PTT-33.6 ___\n___ Glucose-101* UreaN-8 Creat-0.9 Na-134 K-3.9 Cl-101 \nHCO3-24 \n___ ALT-52* AST-42* LD(LDH)-289* AlkPhos-116 TotBili-0.6\n___ Calcium-8.4 Phos-2.8 Mg-2.0\n___ %HbA1c-6.6* eAG-143*\n\nDischarge Labs:\n\n___ 06:10AM BLOOD WBC-9.3 RBC-3.96* Hgb-11.9* Hct-35.8* \nMCV-90 MCH-30.1 MCHC-33.2 RDW-12.7 RDWSD-42.0 Plt ___\n___ 02:05AM BLOOD ___ PTT-30.4 ___\n___ 06:10AM BLOOD Glucose-150* UreaN-26* Creat-1.0 Na-135 \nK-4.1 Cl-96 HCO3-27 AnGap-16\n \nBrief Hospital Course:\nHe was admitted on ___ and underwent routine preoperative \ntesting and evaluation. Prior to his cardiac catheterization he \nwas given a Plavix load of 600mg. This was allowed to wash out \nand he was taken to the operating room on ___. He \nunderwent coronary artery bypass grafting x 4. Please see \noperative note for full details. He tolerated the procedure well \nand was transferred to the CVICU in stable condition for \nrecovery and invasive monitoring. \n \nHe weaned from sedation, awoke neurologically intact and was \nextubated on POD 1. He was weaned from inotropic and vasopressor \nsupport. Beta blocker was initiated and he was diuresed toward \nhis preoperative weight. He remained hemodynamically stable and \nwas transferred to the telemetry floor for further recovery. \nDiltiazem and Lopressor was continued for sinus tachycardia. He \nwas hypoxic from left lower lobe atelectasis and pleural \neffusion. Aggressive pulmonary toilet, nebs and ambulation he \nimproved. He was evaluated by the physical therapy service for \nassistance with strength and mobility. By the time of discharge \non POD #6 he was ambulating freely, the wound was healing, and \npain was controlled with oral analgesics. He was discharged to \nhome in good condition with appropriate follow up instructions.\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN pain \nRX *acetaminophen 500 mg 2 tablet(s) by mouth four times a day \nDisp #*160 Tablet Refills:*0\n2. Aspirin EC 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0\n3. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0\n4. Fluticasone Propionate 110mcg 2 PUFF IH BID \nRX *fluticasone [Flovent HFA] 110 mcg/actuation 2 puffs twice a \nday Disp #*1 Inhaler Refills:*0\n5. Guaifenesin ER 1200 mg PO Q12H \nRX *guaiFENesin 1 tablets by mouth twice a day Disp #*30 Tablet \nRefills:*0\n6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain \nRX *hydromorphone 2 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*60 Tablet Refills:*0\n7. Ipratropium Bromide MDI 2 PUFF IH QID \nRX *ipratropium bromide 0.2 mg/mL (0.02 %) 2 puffs four times a \nday Disp #*1 Inhaler Refills:*0\n8. Potassium Chloride 40 mEq PO BID \nRX *potassium chloride 20 mEq 2 tablet(s) by mouth twice a day \nDisp #*56 Tablet Refills:*0\n9. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0\n10. Metoprolol Tartrate 50 mg PO Q8H \nRX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a \nday Disp #*90 Tablet Refills:*0\n11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing \nRX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs every four (4) \nhours Disp #*1 Inhaler Refills:*0\n12. Furosemide 40 mg PO BID Duration: 14 Days \nRX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*28 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary Artery Disease s/p CABG x 4 ___\n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\nPlease NO lotions, cream, powder, or ointments to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I214", "J90", "J9811", "I25119", "R0902", "F17200", "Z8249" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J90: Pleural effusion, not elsewhere classified", "J9811: Atelectasis", "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "R0902: Hypoxemia", "F17200: Nicotine dependence, unspecified, uncomplicated", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \natenolol / Paxil / iv contrast / gabapentin / o2 nose cannula\n \nAttending: ___.\n \nChief Complaint:\nright leg rest pain\n \nMajor Surgical or Invasive Procedure:\n___:\n1. Femoral-to-femoral bypass with ringed PTFE.\n2. Catheter placement into abdominal aorta.\n3. Abdominal aortogram.\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with previous pelvic radiation \nand urostomy bag with iliac stenting on the right. She \npresented to clinic with continued rest pain on the right. \nAfter reviewing her CT scan from ___ as well as her ultrasound \nin ___, Dr. ___ for a left to right fem-fem \nbypass and possible left external iliac stent and possible\ncommon iliac artery stent. \n \nPast Medical History:\n1. peripheral arterial disease s/p right external iliac artery \nstent in ___, unsuccessful.\n2. Cervical cancer status post chemo and radiation. diagnosis \nin ___.\n3. Hydronephrosis. \n4. Hepatitis C, past infection.\n5. Polysubstance abuse.\n6. Trigeminal neuralgia.\n7. Hypertension.\n8. Active smoker.\n9. Myocardial infarction ___\n10. Hypertension.\n12. DVT.\n13. anxiety and depression.\n\nPSH:\nR iliac stent, urostomy secondary to ureter obstruction from \nradiation.\n \nSocial History:\n___\nFamily History:\nheart disease, heart failure, COPD\n \nPhysical Exam:\nDischarge Physical Exam:\nGen: Alert and oriented x 3, NAD\nHEENT: Neck supple, full ROM, Carotids: 2+, no bruits or JVD\nResp: nl effort, CTABL, no wheezes/rales/rhonchi\nCV: RRR, S1/S2, no S3/S4, no mrumurs/rubs/gallops\nAbd: Soft, non-tender, non-distended\nExt: Pulses: Left Femoral palp, DP doppler, ___ palp // Right \nFemoral palp, DP palp, ___ doppler\nFeet warm, well-perfused. No open areas\nLeft and Right groin puncture site: Dressing clean dry and \nintact. Soft, no hematoma or ecchymosis\n\n \nPertinent Results:\nLabs:\n___ 06:00AM BLOOD WBC-6.4 RBC-3.83* Hgb-12.3 Hct-38.3 \nMCV-100* MCH-32.1* MCHC-32.1 RDW-13.2 RDWSD-48.5* Plt ___\n___ 06:00AM BLOOD Glucose-83 UreaN-15 Creat-0.8 Na-137 \nK-4.2 Cl-103 HCO3-23 AnGap-15\n___ 06:00AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.8\n___ 06:00AM BLOOD VitB12-279 Folate-17.6\n___ 06:00AM BLOOD TSH-0.69\n___ 06:00AM BLOOD T4-6.8\n\nOperative Report: ___\nSurgeon: ___, M.D. ___\nSERVICE: Vascular Surgery.\nASSISTANT: ___\nPREOPERATIVE DIAGNOSIS: Right leg rest pain.\nPOSTOPERATIVE DIAGNOSIS: Right leg rest pain.\nPROCEDURES PERFORMED:\n1. Femoral-to-femoral bypass with ringed PTFE.\n2. Catheter placement into abdominal aorta.\n3. Abdominal aortogram.\n\nCONTRAST USED: Used 7.5 mL Omnipaque.\nFLUORO DOSE: 39 mGy.\nFLUORO TIME: 1.4 minutes.\n\nINDICATIONS: ___ woman with history of right iliac\nocclusion presents for femoral-femoral bypass and possible\nleft iliac stenting.\n\nDESCRIPTION OF PROCEDURE: The patient was brought to the\noperating room and placed in the supine position. Both\ngroins and the abdomen were prepped and draped in standard\nfashion, and a time-out was performed. Two horizontal\nincisions were made overlying the femoral arteries in both\ngroins. The soft tissue was divided using electrocautery.\nOnce the femoral sheaths were identified, these were incised,\nand the arteries were identified. The SFA and profunda were\nisolated with vessel loops bilaterally. The common femoral\nartery was then dissected out proximally and isolated with a\nvessel loop. Once all of these major vessels and their\nbranches had been controlled, the patient was given full-dose\ntherapeutic heparin, and the left common femoral artery was\naccessed with the access needle. There was an excellent\npulse and good return of blood. A 0.035 wire was passed into\nthe abdominal aorta under direct visualization. A ___\nsheath was placed. We then placed a flush catheter into the\naortic bifurcation and performed an aortogram. This revealed\npatent left common iliac, external iliac, and hypogastric\nwith good flow into the common. There was a small area of\nstenosis of the proximal common as well as areas of the\nexternal iliac that looked irregular on the left. Therefore,\nwe advanced a pressure catheter and checked pressure\nmeasurements across all of the areas of the iliac system on\nthe left. We found that there was no pressure gradient\nacross the left common iliac stenosis, and there was no\npressure gradient across the length of the external iliac.\nTherefore, the decision was made not to treat these areas.\nThe right iliac system was occluded on angiography as was\nsuspected.\n\nTherefore, we removed the needle and clamped the inflow and\noutflow vessels. We then extended the arteriotomy using\nPotts scissors. Prior to heparinization, we had created a\ntunnel in the subcutaneous tissue of the anterior abdominal\nwall using blunt dissection. We then passed a ringed 7 mm\nPTFE bypass graft through this area. Now with the left\narteriotomy prepared, we beveled the bypass graft and\nperformed a circumferential anastomosis using a Gore-Tex\nsuture. We reinforced this with BioGlue. We then restored\nflow through the bypass graft and had good hemostasis. We\npacked the wound and re-clamped the graft after flushing it.\nWe then turned our attention to the right groin. We clamped\nthe inflow and the outflow of the right groin and made an\narteriotomy at the very distal common femoral onto the SFA\nitself. We then beveled the graft and performed a\ncircumferential anastomosis using a Gore-Tex suture. Prior\nto completing this, we backflushed from the SFA, and then we\nflushed the graft, making sure there was no debris or air in\nthe system. We then completed the anastomosis and placed\nglue on the anastomosis to reinforce it. We then restored\nflow. There was good hemostasis. We spent some time\nassuring this using electric cautery in both groins. We then\nclosed the femoral sheath with interrupted 3-O Vicryl suture\nand closed the fat over the bypass graft with ___ suture. We\nthen closed the soft tissue bilaterally with ___ Vicryl\nsuture and the skin with a ___ Monocryl. The skin was then\ncovered with Dermabond. At the completion of this, the\npatient's drapes were taken down. She was noted to have\nbilateral palpable pedal pulses. She was extubated and\ntransferred to the PACU for recovery.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ old woman with right leg rest pain who \npresented to ___ on ___ for planned left to right \nfemoral-femoral bypass, which she underwent at this time. For \nfull details of this procedure, please refer to the operative \nreport. She tolerated this procedure well, and was taken to the \nPACU, then the vascular surgery step-down unit, for further \nmonitoring and recovery from surgery. She remained \nhemodynamically stable. She was started on low dose aspirin and \natorvastatin post-operatively. Because she was on narcotics \npre-operatively including long-acting morphine, and she has a \nhistory of drug abuse, anesthesia suggested we start a dilaudid \nPCA for pain control. Her pain was controlled with a dilaudid \nPCA and her home meds except MS ___. \n\nOn POD#1, she continued to have pain, and it was difficult to \nexamine her due to pain. She maintained palpable pedal pulses on \nthe right. Chronic pain service was consulted, and suggested her \nto be put back on all home medications including MS ___, with \nincrease from BID to TID, increase dosage of oxycodone, and add \npregabalin. These changes had good effect, and her pain was \nadequately controlled for the rest of her hospitalization. Over \nthe next several days, she progressed in terms of eating as well \nas ambulation. She continued to have adequate urine output \nthrough her urostomy. On POD#4, she worked with physical \ntherapy, who recommended home with home ___. At this time, her \npain was well-controlled, she was tolerating regular diet, \nmaking adequate urine, and ambulating with assistance. \nShe was given instructions to wean her MS contin back to her \nhome dose of BID next week. In addition, she was also instructed \nto wean off the oxycodone to her home dose or less, as she \nshould no longer have rest pain. She was discharged to home with \nservices and ___ on POD#4, with follow-up in vascular surgery \nclinic in about 1 month with a duplex. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 4 mg PO Q8H:PRN nausea \n2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n3. QUEtiapine Fumarate 50 mg PO QHS \n4. ClonazePAM 1 mg PO Q8H:PRN anxiety \n5. OxyCODONE (Immediate Release) 5 mg PO BID severe pain \n6. Vitamin D 1000 UNIT PO BID \n7. Morphine SR (MS ___ 30 mg PO Q12H \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n3. Docusate Sodium 100 mg PO DAILY:PRN constipation \nHold for loose stool/diarrhea. \n4. Nicotine Patch 14 mg TD DAILY \nFollow up with your PCP to further discuss smoking cessation. \nRX *nicotine 14 mg/24 hour apply 1 patch to skin daily Disp #*14 \nPatch Refills:*0 \n5. Omeprazole 40 mg PO DAILY \n6. Pregabalin 75 mg PO BID \nRX *pregabalin [Lyrica] 75 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n7. Senna 8.6 mg PO BID:PRN constipation \nHold for loose stool/diarrhea. \n8. Morphine SR (MS ___ 30 mg PO Q8H \nDecrease to your home dose of 30mg every 12 hours for pain on \n___. \nRX *morphine 30 mg 1 tablet(s) by mouth three times a day Disp \n#*20 Tablet Refills:*0 \n9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN severe \npain \nAs your pain improves, wean off of this medication to your home \ndose of ___ twice a day, or less \nRX *oxycodone 10 mg 0.5-1.5 tablet(s) by mouth q4hrs Disp #*30 \nTablet Refills:*0 \n10. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n11. ClonazePAM 1 mg PO Q8H:PRN anxiety \n12. QUEtiapine Fumarate 50 mg PO QHS \n13. Vitamin D 1000 UNIT PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nright leg rest pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___ \n___. You were admitted to the hospital after surgery \non your leg. This surgery was done to improve blood flow to \nyour leg. You tolerated the procedure well and are now ready to \nbe discharged from the hospital. Please follow the \nrecommendations below to ensure a speedy and uneventful \nrecovery.\n\nDivision of Vascular and Endovascular Surgery\nLower Extremity Bypass Surgery Discharge Instructions\n\nWHAT TO EXPECT:\n1. It is normal to feel tired, this will last for ___ weeks \n•You should get up out of bed every day and gradually increase \nyour activity each day \n•Unless you were told not to bear any weight on operative foot: \nyou may walk and you may go up and down stairs \n•Increase your activities as you can tolerate- do not do too \nmuch right away!\n2. It is normal to have swelling of the leg you were operated \non:\n•Elevate your leg above the level of your heart (use ___ \npillows or a recliner) every ___ hours throughout the day and at \nnight\n•Avoid prolonged periods of standing or sitting without your \nlegs elevated\n3. It is normal to have a decreased appetite, your appetite will \nreturn with time \n•You will probably lose your taste for food and lose some \nweight \n•Eat small frequent meals\n•It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing\n•To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication\n\nMEDICATION:\n•Take aspirin as instructed \n•Follow your discharge medication instructions\n\nACTIVITIES:\n•No driving until post-op visit and you are no longer taking \npain medications\n•Unless you were told not to bear any weight on operative foot: \n\n•You should get up every day, get dressed and walk\n•You should gradually increase your activity\n•You may up and down stairs, go outside and/or ride in a car\n•Increase your activities as you can tolerate- do not do too \nmuch right away!\n•No heavy lifting, pushing or pulling (greater than 5 pounds) \nuntil your post op visit \n•You may shower (unless you have stitches or foot incisions) no \ndirect spray on incision, let the soapy water run over incision, \nrinse and pat dry\n•Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing \nover the area that is draining, as needed\n\nCALL THE OFFICE FOR: ___\n•Redness that extends away from your incision\n•A sudden increase in pain that is not controlled with pain \nmedication\n•A sudden change in the ability to move or use your leg or the \nability to feel your leg\n•Temperature greater than 100.5F for 24 hours\n•Bleeding, new or increased drainage from incision or white, \nyellow or green drainage from incisions\n \nFollowup Instructions:\n___\n" ]

[ "I70221", "B1920", "I252", "G500", "Z8541", "Z9221", "Z923", "I2510", "F17210" ]

[ "I70221: Atherosclerosis of native arteries of extremities with rest pain, right leg", "B1920: Unspecified viral hepatitis C without hepatic coma", "I252: Old myocardial infarction", "G500: Trigeminal neuralgia", "Z8541: Personal history of malignant neoplasm of cervix uteri", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "I252", "I2510", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \natenolol / Paxil / iv contrast / o2 nose cannula\n \nAttending: ___.\n \nChief Complaint:\nR foot pain \n \nMajor Surgical or Invasive Procedure:\nS/p fem-fem bypass revision with thrombectomy ___ ___\n\n \nHistory of Present Illness:\n___ is a ___ w/ hx of PVD w/ occluded R iliac\nstent s/p fem-fem (L->R) bypass w/ PTFE ___ (Dr.\n___ who is presenting here to the ED w/ a 1 wk hx of\nworsening R leg pain. She says she has been having R foot\nnumbness and ?pain since her fem-fem bypass, and was o/w in her\nusual state of health, when ~1 wk ago she had sudden onset L leg\npain throughout her entire leg, which has worsened over time, \nand\nprompted her to present to an OSH, and she was txfr'ed here for\nfurther management, for which we were consulted. Of note, she \nwas\nlast seen by us in clinic on ___, but has not f/u'd since -\nshe notes that her PCP has been managing all of her care.\n\n \nPast Medical History:\nPMHx: PVD w/ occluded R iliac stent s/p fem-fem (L->R) bypass w/\nPTFE ___, cervical cancer s/p chemo/XRT, HCV, HTN, smoking,\nMI, HTN, DVT, anxiety d/o, depressive d/o, polysubstance use \nd/o,\nhydronephrosis\n\nPSHx: fem-fem (L->R) bypass w/ PTFE ___, prior R iliac \nstent,\nurostomy ___ ureteral obstruction related to XRT)\n \nSocial History:\n___\nFamily History:\nheart disease, heart failure, COPD\n \nPhysical Exam:\nAdmission Physical Exam \n===================\nVS - 98.1 79 143/77 24 96% RA \nGen - appears in pain\nCV - RRR\nPulm - non-labored breathing, no resp distress, \nMSK & extremities/skin - L: p//p/p, R leg: L foot and lower leg\ncool, slight skin discoloration, ttp, -//-/?d (venous), limited\nROM of L foot, decreased sensation, decreased strength\n\nDischarge Physical Exam \n===================\nVitals: 24 HR Data (last updated ___ @ 745)\nTemp: 97.4 (Tm 98.5), BP: 136/70 (88-136/55-73), HR: 64\n(58-87), RR: 16 (___), O2 sat: 94% (92-98), O2 delivery: RA,\nWt: 160.93 lb/73.0 kg\nGENERAL: [x]NAD \nCV: [x]RRR \nPULM: [x]no respiratory distress \nABD: [x]soft [x]Nontender \nEXTREMITIES: Warm, no peripheral edema\nPULSES: L: p//p/p R: d/d\n \nPertinent Results:\nLab Results \n=========\n___ 04:32AM BLOOD WBC-7.6 RBC-3.12* Hgb-9.7* Hct-29.9* \nMCV-96 MCH-31.1 MCHC-32.4 RDW-13.5 RDWSD-47.7* Plt ___\n___ 04:13AM BLOOD WBC-7.8 RBC-3.23* Hgb-10.0* Hct-31.1* \nMCV-96 MCH-31.0 MCHC-32.2 RDW-13.4 RDWSD-47.0* Plt ___\n___ 05:30PM BLOOD WBC-9.0 RBC-3.41* Hgb-10.7* Hct-32.9* \nMCV-97 MCH-31.4 MCHC-32.5 RDW-13.2 RDWSD-46.5* Plt ___\n___ 04:15AM BLOOD WBC-8.2 RBC-4.59 Hgb-14.3 Hct-43.7 MCV-95 \nMCH-31.2 MCHC-32.7 RDW-13.2 RDWSD-46.4* Plt ___\n___ 05:27AM BLOOD WBC-6.7 RBC-4.51 Hgb-13.9 Hct-43.3 MCV-96 \nMCH-30.8 MCHC-32.1 RDW-13.2 RDWSD-47.3* Plt ___\n___ 03:09PM BLOOD WBC-7.2 RBC-4.54 Hgb-14.3 Hct-42.8 MCV-94 \nMCH-31.5 MCHC-33.4 RDW-13.5 RDWSD-46.9* Plt ___\n___ 03:09PM BLOOD Neuts-56.4 ___ Monos-6.7 Eos-1.8 \nBaso-0.4 Im ___ AbsNeut-4.07 AbsLymp-2.45 AbsMono-0.48 \nAbsEos-0.13 AbsBaso-0.03\n\n___ 04:32AM BLOOD Glucose-103* UreaN-9 Creat-0.8 Na-141 \nK-4.0 Cl-107 HCO3-24 AnGap-10\n___ 04:13AM BLOOD Glucose-87 UreaN-9 Creat-0.8 Na-141 K-4.4 \nCl-107\n___ 05:30PM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-141 \nK-3.9 Cl-108 HCO3-23 AnGap-10\n___ 04:15AM BLOOD Glucose-124* UreaN-13 Creat-0.9 Na-139 \nK-4.4 Cl-101 HCO3-25 AnGap-13\n___ 05:27AM BLOOD Glucose-98 UreaN-13 Creat-1.0 Na-139 \nK-4.4 Cl-99 HCO3-26 AnGap-14\n___ 03:09PM BLOOD Glucose-78 UreaN-15 Creat-0.9 Na-139 \nK-6.1* Cl-101 HCO3-26 AnGap-12\n\n___ 04:13AM BLOOD CK-MB-<1 cTropnT-<0.01\n___ 06:29PM BLOOD CK-MB-<1 cTropnT-<0.01\n___ 04:32AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9\n___ 05:30PM BLOOD Phos-3.3\n___ 04:15AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.8\n___ 05:27AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.9\n \nBrief Hospital Course:\n Neuro: Pain was initially controlled with a dilaudid PCA, which \nwas transitioned to po oxycodone. Chronic pain services were \nconsulted within admission, and recommended increasing patient's \ngabapentin dosage to 300mg TID which was well tolerated. \n CV: Vital signs were routinely monitored during the patient's \nlength of stay. \n Pulm: The patient was encouraged to ambulate, sit and get out \nof bed, use the incentive spirometer, and had oxygen saturation \nlevels monitored as indicated. \n GI: The patient was initially kept NPO after the procedure. The \npatient was later advanced to and tolerated a regular diet at \ntime of discharge. \n GU: Patient has a urostomy bag at baseline. \n ID: The patient's vital signs were monitored for signs of \ninfection and fever.\n Heme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding. \nPatient was initially kept on a heparin gtt, and \npre-authorization was obtained to discharge patient on Xarelto. \nThe patient had vital signs, including heart rate and blood \npressure, monitored throughout the hospital stay. \n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n2. Docusate Sodium 100 mg PO BID constipation \n3. Rivaroxaban 20 mg PO DAILY \n4. Gabapentin 300 mg PO TID \n5. amLODIPine 2.5 mg PO DAILY \n6. ClonazePAM 1 mg PO TID \n7. Morphine SR (MS ___ 30 mg PO Q12H \n8. QUEtiapine Fumarate 50 mg PO QHS \n9. Topiramate (Topamax) 100 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nOcclusion of fem-fem bypass \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ and \nunderwent revision of your fem-fem bypass graft, thrombectomy, \nand right lower extremity patch angioplasty. You have now \nrecovered from surgery and are ready to be discharged. Please \nfollow the instructions below to continue your recovery: \n\nWHAT TO EXPECT: \n1. It is normal to feel tired, this will last for ___ weeks \n• You should get up out of bed every day and gradually increase \nyour activity each day \n• Unless you were told not to bear any weight on operative foot: \nyou may walk and you may go up and down stairs \n• Increase your activities as you can tolerate- do not do too \nmuch right away! \n2. It is normal to have swelling of the leg you were operated \non: \n• Elevate your leg above the level of your heart (use ___ \npillows or a recliner) every ___ hours throughout the day and at \nnight \n• Avoid prolonged periods of standing or sitting without your \nlegs elevated \n3. It is normal to have a decreased appetite, your appetite will \nreturn with time \n• You will probably lose your taste for food and lose some \nweight \n• Eat small frequent meals \n• It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing \n• To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication \n\nMEDICATION: \n• Take your Xarelto as instructed for anticoagulation \n• Follow your discharge medication instructions \n\nACTIVITIES: \n• No driving until post-op visit and you are no longer taking \npain medications \n• Unless you were told not to bear any weight on operative foot: \n\n• You should get up every day, get dressed and walk \n• You should gradually increase your activity \n• You may up and down stairs, go outside and/or ride in a car \n• Increase your activities as you can tolerate- do not do too \nmuch right away! \n• No heavy lifting, pushing or pulling (greater than 5 pounds) \nuntil your post op visit \n• You may shower (unless you have stitches or foot incisions) no \ndirect spray on incision, let the soapy water run over incision, \nrinse and pat dry \n• Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing \nover the area that is draining, as needed \n\nCALL THE OFFICE FOR: ___ \n• Redness that extends away from your incision \n• A sudden increase in pain that is not controlled with pain \nmedication \n• A sudden change in the ability to move or use your leg or the \nability to feel your leg \n• Temperature greater than 100.5F for 24 hours \n• Bleeding, new or increased drainage from incision or white, \nyellow or green drainage from incisions \n\n \n ___ MD ___\n \nCompleted by: ___\n" ]

[ "T82868A", "F17210", "I10", "F419", "F329", "I252", "K589", "G893", "Z86718", "Z8541", "Z23" ]

[ "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I252: Old myocardial infarction", "K589: Irritable bowel syndrome without diarrhea", "G893: Neoplasm related pain (acute) (chronic)", "Z86718: Personal history of other venous thrombosis and embolism", "Z8541: Personal history of malignant neoplasm of cervix uteri", "Z23: Encounter for immunization" ]

[ "F17210", "I10", "F419", "F329", "I252", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlisinopril / niacin\n \nAttending: ___\n \nChief Complaint:\nWeakness\n \nMajor Surgical or Invasive Procedure:\n___: EGD and Colonoscopy\n\n \nHistory of Present Illness:\nMr. ___ is a ___ gentleman with PMH significant for \natrial fibrillation on warfarin, prostate cancer s/p radiation, \nHFrEF (EF 40-45%), and history of lower GI bleed in ___ due to \nrectal angioectasia in the setting of radiation proctitis who \npresents with weakness found to have BRBPR and Hgb 4.4.\n\nPer patient, he was at work earlier today when he developed \nfeelings of weakness, lightheadedness, and dizziness while \nstanding. He reports he sat down to take a break and, on \nattempting to stand back up, became extremely dizzy again. He \nreports a co-worker told him he looked really pale and ill, and \nso called EMS. On EMS arrival, patient was noted to have 1 mm \nSTE in I and aVL. He received aspirin x4 and was transferred to \n___. \n\nOf note, patient reports x3 days of BRBPR; he reports seeing \nbright red blood in the toilet bowl and mixed with his stool. He \nalso notes some maroon colored stools; he denies tarry or black \nstools, diarrhea, increased frequency of BM. He denies N/V/abd \npain, f/c, CP/palp, SOB, dysuria, MSK/joint pain. \n\nIn the ED, initial vitals: HR 71, BP 90/64, RR 18, SAT 98% on \nRA.\n- Exam notable for gross blood in the rectum.\n- Labs were notable for H/H 4.4/16.1, PLT 52, INR 3.1, Cr 2.2, \nTrop-T 0.02.\n- CXR showed \"Cardiomegaly without evidence of pulmonary edema. \nNo evidence of pneumonia.\"\n- Patient was given: 1L NS, 1 unit of uncrossmatched blood, \npantoprazole 40 mg IV x1, Kcentra 2490 units, vitamin K 10 mg \nIV, 1u crossmatched blood.\n- GI was consulted in the ED.\n\nOn arrival to the MICU, patient reports feeling \"much better\" \nthan this AM. He denies current dizziness, lightheadedness. \n\n \nPast Medical History:\nAtrial fibrillation\nSystolic heart failure (LVEF of 40-45% in ___\nHypertension\nHyperlipidemia\nGout\nProstate cancer status post radiation therapy\nSarcoidosis\nSickle cell trait\nRight total knee replacement in ___\nSolitary pulmonary nodule followed since ___\nOsteoarthritis\nPeripheral neuropathy\nAsthma\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n===========================\nVitals: afebrile, 70 126/71 15 97% RA\nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, pale conjunctiva, MMM, oropharynx clear \n \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: clear without ecchymoses/rash\nNEURO: AAOx3, moves all extremities spontaneously \nACCESS: PIVs \n\nDISCHARGE PHYSICAL EXAM:\n===========================\nVS: 97.8, 74, 110/72, 18, 100%RA\nGENERAL: NAD, pleasant \nHEENT: PERRL, EOMI, poor dentition\nNECK: no JVD\nCARDIAC: Irregularly irregular, S1/S2, no MRG\nLUNG: LCTA-bl, no w/r/r\nABDOMEN: Soft, NTND, no HSM \nEXTREMITIES: FROM, no c/e/e\nPULSES: 2+ DP pulses bilaterally \nNEURO: CN II-XII intact; strength and sensation symmetric and\nintact bl \n\n \nPertinent Results:\nADMISSION LABS:\n===================\n___ 09:30AM BLOOD WBC-4.7 RBC-2.50*# Hgb-4.4*# Hct-16.1*# \nMCV-64*# MCH-17.6*# MCHC-27.3*# RDW-23.7* RDWSD-53.5* Plt Ct-52*\n___ 09:30AM BLOOD Neuts-70.5 Lymphs-13.8* Monos-11.0 \nEos-3.9 Baso-0.2 NRBC-1.1* Im ___ AbsNeut-3.28 \nAbsLymp-0.64* AbsMono-0.51 AbsEos-0.18 AbsBaso-0.01\n___ 09:30AM BLOOD ___ PTT-59.0* ___\n___ 09:30AM BLOOD Glucose-137* UreaN-58* Creat-2.2* Na-138 \nK-4.9 Cl-104 HCO3-22 AnGap-17\n___ 09:30AM BLOOD ALT-12 AST-21 AlkPhos-82 TotBili-0.4\n___ 02:03PM BLOOD Ret Man-4.1* Abs Ret-0.12*\n___ 09:30AM BLOOD proBNP-1654*\n___ 09:30AM BLOOD cTropnT-0.02*\n___ 09:30AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.6 Mg-2.2 \nIron-46\n___ 09:30AM BLOOD calTIBC-455 ___ Ferritn-5.8* \nTRF-350\n___ 09:36AM BLOOD Glucose-131* Lactate-1.9 Na-138 K-4.9 \nCl-105 calHCO3-23\n___ 09:36AM BLOOD Hgb-4.9* calcHCT-15\n\nMICRO DATA:\n===================\n___ MRSA Screen: Negative\n\nIMAGING/STUDIES:\n===================\n- CXR (___): IMPRESSION: Cardiomegaly without evidence of \npulmonary edema. No evidence of pneumonia \n\nEKG ___: \nSinus rhythm. Left axis deviation with left anterior fascicular \nblock. Right\nbundle-branch block. Occasional premature ventricular \ncontraction. Compared\nto the previous tracing of ___ atrial flutter has now \nconverted to sinus\nrhythm.\n\nAbd US ___:\nFINDINGS: \n \nLIVER: The hepatic parenchyma appears coarsened. The contour of \nthe liver is\nnodular. There is no focal liver mass. The main portal vein is \npatent with\nhepatopetal flow. There is no ascites.\n \nBILE DUCTS: There is no intrahepatic biliary dilation. The CBD \nmeasures 7 mm.\n \nGALLBLADDER: There is no evidence of stones or gallbladder wall \nthickening.\n \nPANCREAS: Imaged portion of the pancreas appears within normal \nlimits, without\nmasses or pancreatic ductal dilation, with portions of the \npancreatic tail\nobscured by overlying bowel gas.\n \nSPLEEN: Normal echogenicity, measuring 12.1 cm.\n \nKIDNEYS: The right kidney measures 11.3 cm. The left kidney \nmeasures 10.9 cm. \n2 parapelvic cysts are noted in the upper pole of the right \nkidney. Several\ncysts are that are identified in the left kidney. The largest \nmeasures 3.6\ncm. A 2.0 cm cyst is seen in the interpolar region on the left. \n A 4 cm cyst\nis seen in the lower pole a 2.8 cm cyst is seen in the upper \npole. Normal\ncortical echogenicity and corticomedullary differentiation is \nseen\nbilaterally. There is no evidence of masses, stones, or \nhydronephrosis in the\nkidneys.\n \nRETROPERITONEUM: Visualized portions of aorta and IVC are within \nnormal\nlimits.\n \nIMPRESSION: \n \n1. Coarsened liver echotexture and nodular contour of the liver \nare\nconcerning for cirrhosis.\n2. Multiple bilateral renal cysts\n3. Normal size of spleen\n\nEGD ___:\nFindings:\nEsophagus:Normal esophagus.\nStomach:\nMucosa:Diffuse angioectasias of the antrum consistent with \nGAVE. There were also more scattered angioectasias spreading up \ninto the body. Some of those in the body displayed mild ooze and \nwere treated with APC. Small areas in the antrum were also \ntreated with APC. An Argon-Plasma Coagulator was applied for \nhemostasis and tissue destruction successfully. \nDuodenum:Normal duodenum.\nImpression:Diffuse angioectasias of the antrum, with scattered \nin the stomach (thermal therapy)\nOtherwise normal EGD to third part of the duodenum\nRecommendations:GAVE likely a source of chronic blood loss, but \nlikely does not explain acute bleeding\nBID PPI\nSucralfate QID for a week\nConsider repeat EGD in 8 weeks\nProceed to colonoscopy\n\nColonoscopy ___:\nFindings:\nContents:Dark red and clotted blood was seen only in the rectum \nand the recto-sigmoid junction. Despite extensive washing, no \nsource of underlying mucosal abnormality was identified. Careful \nexam in retroflexion also did not reveal any abnormalities. \nExcavated LesionsMultiple non-bleeding diverticula were seen. \nDiverticulosis appeared to be of mild severity. \nImpression:Diverticulosis of the colon\nBlood in the colon\nOtherwise normal colonoscopy to cecum\nRecommendations:Return to hospital ward\nSource of bleeding likely from rectum or rectosigmoid given the \ndistribution of blood, however no specific source identified. A \nrectal Dieulafoy is possible.\n\nDISCHARGE LABS:\n===================\n\n___ 06:55AM BLOOD WBC-7.4 RBC-3.29* Hgb-7.3* Hct-24.0* \nMCV-73* MCH-22.2* MCHC-30.4* RDW-28.2* RDWSD-72.5* Plt Ct-36*\n___ 06:55AM BLOOD ___ PTT-31.9 ___\n___ 06:55AM BLOOD Glucose-89 UreaN-30* Creat-2.0* Na-138 \nK-4.1 Cl-108 HCO3-24 AnGap-10\n___ 06:55AM BLOOD ALT-10 AST-18 AlkPhos-73 TotBili-0.5\n___ 06:55AM BLOOD ALT-10 AST-18 AlkPhos-73 TotBili-0.5\n___ 06:55AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8\n\nOther Relevant Labs:\n\n___ 07:43PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-3+ \nMacrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Spheroc-OCCASIONAL \nOvalocy-OCCASIONAL Schisto-OCCASIONAL Pencil-OCCASIONAL Tear \n___\n___ 02:03PM BLOOD Ret Man-4.1* Abs Ret-0.12*\n___ 09:30AM BLOOD proBNP-1654*\n___ 09:30AM BLOOD cTropnT-0.02*\n___ 07:43PM BLOOD cTropnT-0.01\n___ 07:43PM BLOOD TotProt-6.7\n___ 09:30AM BLOOD D-Dimer-167\n___ 09:30AM BLOOD calTIBC-455 ___ Ferritn-5.8* \nTRF-350\n___ 07:43PM BLOOD PEP-TRACE ABNO IgG-1031 IgA-398 IgM-147 \nIFE-TRACE MONO\n___ 09:36AM BLOOD Glucose-131* Lactate-1.9 Na-138 K-4.9 \nCl-105 calHCO3-23\n___ 09:36AM BLOOD Hgb-4.9* calcHCT-15\n___ 07:42PM URINE Hours-RANDOM TotProt-7\n___ 07:42PM URINE U-PEP-NO PROTEIN\n \nBrief Hospital Course:\nBRIEF SUMMARY STATEMENT:\n==========================\nMr. ___ is a ___ man with atrial fibrillation on \nwarfarin, prostate cancer s/p radiation, HFrEF (EF 40-45%), and \nhistory of lower GI bleed in ___ due to rectal angioectasia \nlikely secondary to radiation proctitis who presented with \nweakness, found to have new profound anemia with gross rectal \nbleeding, concerning for lower GI bleed. Pt was admitted to the \nICU but transferred to general medicine floor on ___.\n\n# LOWER GI BLEED:\nOn admission, Hgb 4.4 with GI bleed was thought to be lower \ngiven gross blood. He had a history of angioectasia in the \nrectum secondary to radiation proctitis and had APC in ___. \nHe also had a coagulopathy with thrombocytopenia, and received \nreversal with Kcentra, vitamin K, and platelets. On admission, \nhe was not tachycardic or hypotensive, but he was taking a beta \nblocker at home. He received 4 units of pRBCs on ___ with \nimprovement in H/H. He also received 1U platelts. GI was \nconsulted, and patient received EGD/colonoscopy on ___, which \nshowed GAVE and mild diverticulosis. Colonoscopy showed likely \nrectal bleeding but no clear lesion. Bleeding was thought to be \n___ diverticulosis vs. rectal dieulafoy lesion. On discovery of \npt's cirrhosis, rectal varices vs. other ectopic varices were in \nddx but given pt's creatinine, further eval was limited. During \nColonoscopy, these were not noted. Pt GIB resolved during \nhospitalization and HCT remained stable. Per GI, pt was felt to \nbe safe for discharge. \n\n# ___ on CKD: \nBaseline Cr ~1.5-1.7 c/w grade 3 CKD, based on previous labs \nhere in ___ and at ___ in ___. Here on admission 2.2, likely \npre-renal in the setting of poor renal perfusion from blood \nloss. At time of discharge, creatinine was 2, which was \nconsidered close to baseline. ___ was held at time of discharge. \n\n\n# THROMBOCYTOPENIA: \nBaseline low PLT ~100s. S/p 1u platelets in ED with \ninappropriate response. LFTs were normal, haptoglobin and \nfibrinogen were normal, SPEP showed non-specific abnormality and \nUPEP wnl. Abd US showed cirrhosis. \n\n# CHRONIC COMPENSATED SYSTOLIC HEART FAILURE: last TTE (___) \nshowed LVEF 45%. Euvolemic on exam. CV meds were held on initial \npresentation given concern for instability. As he stabilized, \nhis Nifedipine was re-started. Metoprolol was re-started at \nbelow home dose (Metoprolol 50mg/day as compared to 100mg per \nday in outpatient setting). ___ was held prior to discharge \ngiven Cr 2 and normotension. Lasix was also held in setting of \neuvolemia. \n\n# Atrial Fibrillation: CHADS2-VASc score of 3 for (C-H-A). Given \nactive bleeding, patient received kaycentra and vitamin K in ED. \nIn anticipation of GI intervention, patient's anticoagulation \nwas held. given cirrhosis/thrombocytopenia and recent GIB and \nper conversation with pt's Cardiologist, decision was made to \nhold anticoagulation pending outpatient re-assessment. Notably \npt was in sinus rhythm during admission. \n\n# Anemia: concern for acute on chronic etiology given low MCV, \npatient reported \"weeks\" of fatigue. Has known Sickle Cell \ntrait. Iron studies were notable for low ferritin. \n\n# Cirrhosis: Given thrombocytopenia, pt underwent abd US which \nshowed evidence of cirrhosis. Dx discussed with pt and he \nendorsed drinking a considerable amount of etoh use (several \nbeers/shots of liquor per day). He denied prior hx of withdrawal \nsx. Folate and thiamine were prescribed after discharge and sent \nto pt's pharmacy. DDx for cirrhosis included sarcoid. Per GI, pt \nwas felt to be safe for discharge with outpatient Hepatology \nfollow-up. \n\nTRANSITIONAL ISSUES:\n===========================\n- Please start on iron supplementation given low ferritin\n- Consider hematology CS\n- Please ensure Sucralfate is continued for 1 week\n- Per GI, f/u for repeat EGD in 8 weeks \n- Please ensure follow-up with Hepatology for evaluation of new \ndx of cirrhosis\n- Please ensure follow-up with Cardiology for decision re \nrisk/benefit of resuming anticoagulation\n- Please note, Lasix and Valsartan held; metoprolol re-started \nat below home dose; consider switching to Carvedilol given lower \nselectivity and possible advantage from Hepatology perspective \nif pt were to develop varices. \n- Please repeat CBC at follow-up \n- Please note evidence of ?MGUS on SPEP, please consider repeat \nSPEP \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 50 mg PO BID \n2. Atorvastatin 40 mg PO QPM \n3. NIFEdipine CR 60 mg PO DAILY \n4. Tamsulosin 0.4 mg PO BID \n5. Allopurinol ___ mg PO DAILY \n6. Furosemide 40-80 mg PO ASDIR \n7. Warfarin 2.5-5 mg PO DAILY16 \n8. Valsartan 160 mg PO DAILY \n9. Aspirin EC 81 mg PO 3X/WEEK (___) \n10. Vitamin D 1000 UNIT PO DAILY \n11. Osteo Bi-Flex Triple Strength \n(___) 750 mg-644 mg- 30 mg-1 mg oral \nDAILY \n12. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Aspirin EC 81 mg PO 3X/WEEK (___) \n2. NIFEdipine CR 60 mg PO DAILY \n3. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0\n4. Allopurinol ___ mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. Tamsulosin 0.4 mg PO BID \n7. Multivitamins 1 TAB PO DAILY \n8. Osteo Bi-Flex Triple Strength \n(___) 750 mg-644 mg- 30 mg-1 mg oral \nDAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0\n11. Sucralfate 1 gm PO QID \nRX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp \n#*28 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Lower GI bleeding\n# Cirrhosis\n# GAVE\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 participate in your care at ___. You were \nadmitted for gastric bleeding. You underwent blood transfusion, \nplatelet transfusion, EGD and Colonoscopy and your symptoms \nresolved. You were found to have scarring of the liver. Your \nblood-thinning medications were held because of your recent \nbleeding though there is a slight increase in stroke risk as a \nresult. Please follow up with your Cardiologist to discuss if it \nis safe to re-start Coumadin. Please follow up with a liver \nspecialist to discuss treatment plan for cirrhosis. Please note \nthat a repeat endoscopy was recommended in approximately 8 \nweeks. If you experience any recurrence in bleeding, please seek \nmedical attention.\n\nBest Regards,\n\nYou ___ Medicine Team\n \nFollowup Instructions:\n___\n" ]

[ "K922", "N179", "D684", "I4891", "I5022", "D696", "G629", "K7460", "I129", "D869", "C61", "D500", "K31819", "K5790", "N189", "Z7901", "E785", "M109", "D573", "M1990", "J45909", "Z96651", "Z923" ]

[ "K922: Gastrointestinal hemorrhage, unspecified", "N179: Acute kidney failure, unspecified", "D684: Acquired coagulation factor deficiency", "I4891: Unspecified atrial fibrillation", "I5022: Chronic systolic (congestive) heart failure", "D696: Thrombocytopenia, unspecified", "G629: Polyneuropathy, unspecified", "K7460: Unspecified cirrhosis of liver", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "D869: Sarcoidosis, unspecified", "C61: Malignant neoplasm of prostate", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "K31819: Angiodysplasia of stomach and duodenum without bleeding", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "N189: Chronic kidney disease, unspecified", "Z7901: Long term (current) use of anticoagulants", "E785: Hyperlipidemia, unspecified", "M109: Gout, unspecified", "D573: Sickle-cell trait", "M1990: Unspecified osteoarthritis, unspecified site", "J45909: Unspecified asthma, uncomplicated", "Z96651: Presence of right artificial knee joint", "Z923: Personal history of irradiation" ]

[ "N179", "I4891", "D696", "I129", "N189", "Z7901", "E785", "M109", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlisinopril / niacin\n \nAttending: ___\n \nChief Complaint:\n3 weeks of worsening\nlower extremity edema, abdominal distension, and 30-pound weight\ngain.\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with NICM (EF 45%), CKD Stage III-IV (baseline Cr 3, eGFR\n22), alcoholic cirrhosis, presenting with 3 weeks of worsening\nlower extremity edema, abdominal distension, and 30-pound weight\ngain. He has noticed decreased urine output over the same time\nperiod. He has had increasing difficulty walking due to leg\nswelling, but he denies any dyspnea on exertion. No orthopnea,\nPND, or cough. No chest pain, diaphoresis, nausea, or\npalpitations. He follows a low-salt diet and restricts himself \nto\n1 quart of water a day. He is adherent to all medications. His\nLasix was increased from 40 to 80 mg several days ago. He\ncontinues to drink up to 1 cocktail per day (had 5 last week,\nnone this week). No tobacco, cocaine, or drug use. No fevers,\nchills, or localizing infectious symptoms. No abdominal pain,\nnausea, melena, hematochezia, or jaundice. \n\nIn the ED initial vitals were: 97.4 73 160/93 18 93% RA \n \nPast Medical History:\nAtrial fibrillation\nSystolic heart failure (LVEF of 40-45% in ___\nHypertension\nHyperlipidemia\nGout\nProstate cancer status post radiation therapy\nSarcoidosis\nSickle cell trait\nRight total knee replacement in ___\nSolitary pulmonary nodule followed since ___\nOsteoarthritis\nPeripheral neuropathy\nAsthma\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\n========================\nADMISSION PHYSICAL EXAM:\n========================\nVS: 97.7 PO 166/108 L Lying 83 20 97 ra \nGENERAL: Appears well, lying comfortably flat in bed. \nHEENT: No icterus or injection. MMM. No xanthelasma. \nCV: JVP 16cm. RRR, soft heart sounds, no audible murmurs or\ngallops. LUNGS: Normal work of breathing. Decreased breath \nsounds\nat bilateral bases. No dullness to percussion or egophony.\nABDOMEN: Soft, distended, +shifting dullness.\nEXTREMITIES: Warm. 4+ pitting edema to thighs. No erythema.\nSKIN: No spider angiomata, rashes, or other lesions. \nNEURO: Alert, oriented, intact attention and memory. No \ndeficits.\n\n========================\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: T:98.2, BP: 115 / 70, HR: 76, RR: 18, 95% RA\nGENERAL: Appears well, sitting in bedside chair \nHEENT: No icterus or injection. MMM. No xanthelasma. \nCV: JVP not visible. Irregularly irregular, soft heart sounds, \nno\naudible murmurs or gallops. \nLUNGS: Normal work of breathing. Decreased breath sounds at\nbilateral bases. No dullness to percussion or egophony.\nABDOMEN: Soft, distended, non-tender to palpation in all 4\nquadrants\nEXTREMITIES: Warm. 2+ pitting edema up to knees. \nSKIN: No spider angiomata, rashes, or other lesions. \nNEURO: Alert, oriented, intact attention and memory. No \ndeficits.\n \nPertinent Results:\n===============\nADMISSION LABS:\n___\n___ 02:00PM BLOOD WBC-3.6* RBC-3.43* Hgb-10.4* Hct-31.8* \nMCV-93 MCH-30.3 MCHC-32.7 RDW-16.2* RDWSD-54.4* Plt ___\n___ 02:00PM BLOOD Neuts-70.9 Lymphs-18.0* Monos-9.4 Eos-1.4 \nBaso-0.0 NRBC-0.6* Im ___ AbsNeut-2.57 AbsLymp-0.65* \nAbsMono-0.34 AbsEos-0.05 AbsBaso-0.00*\n___ 02:00PM BLOOD ___ PTT-30.9 ___\n___ 02:00PM BLOOD Glucose-73 UreaN-82* Creat-4.4*# Na-149* \nK-3.9 Cl-111* HCO3-20* AnGap-18\n___ 02:00PM BLOOD Albumin-3.7\n___ 11:31PM BLOOD Lactate-1.0\n\n========================\nPERTINENT INTERVAL LABS:\n========================\n___ 02:00PM BLOOD CK-MB-3 proBNP->70000\n___ 02:00PM BLOOD cTropnT-0.12*\n___ 10:30PM BLOOD cTropnT-0.10*\n\n___ 06:05AM BLOOD calTIBC-199* Ferritn-161 TRF-153*\n___ 06:05AM BLOOD TSH-1.2\n\n___ 02:00PM BLOOD ALT-15 AST-28 LD(LDH)-262* CK(CPK)-44* \nAlkPhos-214* TotBili-0.7\n___ 06:05AM BLOOD ALT-10 AST-14 LD(LDH)-197 AlkPhos-177* \nTotBili-0.6\n\n===============\nDISCHARGE LABS:\n===============\n___ 06:30AM BLOOD WBC-2.8* RBC-3.18* Hgb-9.7* Hct-28.5* \nMCV-90 MCH-30.5 MCHC-34.0 RDW-15.4 RDWSD-50.6* Plt ___\n___ 06:30AM BLOOD Glucose-75 UreaN-97* Creat-4.4* Na-140 \nK-3.9 Cl-95* HCO3-32 AnGap-13\n___ 06:30AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0\n\n================\nIMAGING STUDIES:\n================\nCXR (___):\nMarked cardiomegaly, small right effusion and hilar congestion, \nno frank edema or pneumonia.\n\nTTE (___): The left atrial volume index is severely \nincreased. No atrial septal defect is seen by 2D or color \nDoppler. The estimated right atrial pressure is at least 15 \nmmHg. There is moderate symmetric left ventricular hypertrophy. \nThe left ventricular cavity is moderately dilated. There is \nmoderate regional left ventricular systolic dysfunction with \nakinesis of the basal to mid inferior and inferolateral walls as \nwell as the basal inferior septum. There is hypokinesis of the \nremaining segments (LVEF = 25 %). There is considerable \nbeat-to-beat variability of the left ventricular ejection \nfraction due to an irregular rhythm/premature beats. The \nestimated cardiac index is depressed (<2.0L/min/m2). The right \nventricular cavity is markedly dilated with moderate to severe \nglobal free wall hypokinesis. There is abnormal septal \nmotion/position in part due to volume overload and also IVCD. \nThe aortic root is mildly dilated at the sinus level. The \nascending aorta is mild to moderately dilated. There are focal \ncalcifications in the aortic arch. The aortic valve leaflets (3) \nappear structurally normal with good leaflet excursion and no \naortic stenosis. Mild (1+) aortic regurgitation is seen. The \nmitral valve leaflets are structurally normal. There is no \nmitral valve prolapse. Mild (1+) mitral regurgitation is seen. \nModerate to severe [3+] tricuspid regurgitation is seen. There \nis moderate pulmonary artery systolic hypertension. [In the \nsetting of at least moderate to severe tricuspid regurgitation, \nthe estimated pulmonary artery systolic pressure may be \nunderestimated due to a very high right atrial pressure.] There \nis a small pericardial effusion. The effusion appears \ncircumferential. There are no echocardiographic signs of \ntamponade.\n\nIMPRESSION: Moderate left ventricular hypertrophy with moderate \nchamber dilation, moderate regional and severe global systolic \ndysfunction. Severely dilated right ventricle with moderate to \nsevere global hypokinesis. Moderate to severe tricuspid \nregurgitation. At least moderate pulmonary hypertension. Small \ncircumferential pericardial effusion without chamber collapse. \n\nCompared with the prior study (images reviewed) of ___ the \npericardial effusion is slightly larger. There are frequent \nVPBs. Global left ventricular systolic function is reduced in \nthat context. There is less mitral regurgitation. The left \nventricle is more dilated.\n\nAbdominal U/S (___):\nIMPRESSION:\n1. Small amount of non-specific perihepatic ascites.\n2. Sludge is seen layering in a distended gallbladder. However, \nthere is no\npericholecystic fluid or gallbladder wall thickening to suggest \nacute\ncholecystitis.\n3. The IVC and hepatic veins are enlarged, likely due to known \ncongestive\nheart failure.\n4. Incidental note is made of a right pleural effusion. \n\n \nBrief Hospital Course:\nASSESSMENT AND PLAN: \n====================\n___ with NICM (25%, ___, CKD stage ___, cirrhosis with \nongoing alcohol use, presenting with marked volume overload, \nincluding dyspnea on exertion, lower extremity edema, 30lb \nweight gain, and oliguric ___. \n\n-Pump: LVEF 25% (___)\n-Coronaries: MIBI ___ with no ischemia, scarce CAD in \ncircumflex/OM\n-Rhythm: sinus with frequent PVCs, RBBB\n\nACUTE/ACTIVE ISSUES:\n====================\n#Acute on chronic HFrEF exacerbation\n#Non-ischemic cardiomyopathy (EF 25%, ___\nPatient admitted with evidence of significant volume overload \n(peripheral edema, ascites, dyspnea on exertion, weight gain \n30lb over last few weeks) with proBNP > 70k, and cardiomegaly on \nCXR concerning for decompensated heart failure. Repeat TTE on \nadmission showing reduced LVEF 25% from 55% (___) with \nmoderate LVH and severely dilated right ventricle with moderate \nto severe global hypokinesis. Differential also includes \nworsening renal failure (as below). In terms of triggers for \nheart failure exacerbation, most likely ___ poorly controlled \nHTN. Low suspicion for ischemia; trops 0.12->0.10 in setting of \nrenal failure and CK-MB 3, without ischemic EKG changes or chest \npain. Low suspicion for infection without fevers/chills or \nlocalizing infectious symptoms. During this admission, he was \nsuccessfully diuresed with IV Lasix gtt and metolazone, from \n89.5kg (197lbs) to 82.8kg (182lbs). His reported dry weight is \n180lbs. He was transitioned to PO torsemide 30mg daily at \ndischarge which is an increase from his home Lasix 40mg daily. \nAfterload reducing medications were also up-titrated during \nadmission for systolic BP 140s-180s, including hydralazine 20mg \nto 75 mg TID and Imdur 30mg to 120mg daily. Metoprolol succinate \n50mg also switched to Carvdedilol 50 mg BID. Continue home ASA \n81mg and atorvastatin 40mg daily. Will need EP follow up at \ndischarge for evaluation for ICD placement with newly reduced EF \n25%.\n\n#Elevated troponin: \nTrop 0.12->0.10, CK-MB 3. No ischemic symptoms or EKG changes to \nsuggest ischemia. Suspect decreased clearance from renal failure \nand CHF rather than active ischemia.\n\n#Asymptomatic ___:\nPatient noted to have intermittent second degree heart block on \ntelemetry during this admission. Asymptomatic and normotensive. \n___ be precipitated by up-titration of Coreg. Consider \ndown-titration of Coreg if symptomatic as an outpatient. \n\n___ on CKD Stage III-IV:\nCr elevated to ___ during admission from last baseline of 3.0 \non ___ (eGFR 22). Unclear whether this preceded or resulted \nfrom patient's worsening heart failure, however Cr has not \nimproved with significant diuresis as above. Likely related to \nprogression of underlying CKD, which may be exacerbated by \npoorly controlled HTN. Held patient's home ___ (valsartan 160mg \ndaily) and allopurinol during this admission. Discharge Cr 4.4, \nwith plan to re-establish follow up with renal as an outpatient.\n\n#Poorly controlled HTN:\nSBP 140-180s on admission. Also recorded as 182/100 in clinic \nrecently (___), likely ___ volume overload and worsening \nrenal function. Home hypertensive medications were uptitrated \nduring admission, Hydralazine 20mg to 75 mg TID, Imdur 30mg to \n120mg daily, and Metoprolol succinate 50mg to Carvdedilol 50 mg \nBID. Discharge BP \n\n#Cirrhosis with ascites:\nLikely due to cardiogenic congestion, with possible contribution \nfrom alcohol use. Fibroscan in ___ with stage 2 fibrosis. MELD \n22 on admission. LFTs down-trended with diuresis. EGD ___ \nwith 2 cords of possible small esophageal varices without high \nrisk features. Plan for follow up with ___ as an \noutpatient. Of note, he is due for screening EGD this year.\n\nCHRONIC/STABLE ISSUES:\n======================\n#BPH\nPost-void residual 0cc during this admission.\n- Continue home tamsulosin\n\n#GERD\n- Continue home pantoprazole\n\nTRANSITIONAL ISSUES:\n====================\nADMISSION WEIGHT: 89.5 kg\nDISCHARGE WEIGHT: 82.8 kg\nDISCHARGE CR: 4.4\n\n[ ] Continue titration of BP medications as an outpatient, Goal \nBP <130/80\n[ ] Consider restarting home valsartan as an outpatient, as he \nwould likely benefit from ___ in the setting of CKD\n[ ] Continue Torsemide 30mg daily, with daily weights at home, \nplan for follow up with ___ clinic as well as outpatient \ncardiologist Dr. ___\n[ ] Found to have intermittent second degree heart block on \ntelemetry during this admission. Asymptomatic and normotensive. \n___ be precipitated by up-titration of Coreg. Consider \ndown-titration of Coreg if he becomes symptomatic as an \noutpatient. \n[ ] Will also need EP follow up at discharge for evaluation for \nICD placement with newly reduced EF 25%\n[ ] Follow up with liver clinic, he is due for screening EGD \nthis year\n[ ] Please care connect with renal for progression of CKD, \nappears that he has seen a nephrologist in the past, but this \nwas years ago and he cannot recall the physician's name\n\n* ___ changes:\n- ___ 40mg daily to torsemide 30mg daily\n- Hydralazine 20mg to 75 mg TID \n- Imdur 30mg to 120mg daily \n- Metoprolol succinate 50mg to Carvdedilol 50 mg BID\n\n* Medications continued:\n- ASA 81mg\n- Atorvastatin 40mg daily\n- Pantoprazole\n- Tamsulosin\n- Vit D\n\n* Medications held:\n- Allopurinol\n- Valsartan\n\nHCP: Proxy name: ___ \nRelationship: son Phone: ___ \nFull code, presumed\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. HydrALAZINE 25 mg PO TID \n2. Valsartan 160 mg PO DAILY \n3. Tamsulosin 0.4 mg PO BID \n4. Pantoprazole 40 mg PO Q24H \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n7. Furosemide 80 mg PO DAILY \n8. Aspirin 81 mg PO 3X/WEEK (___) \n9. Vitamin D 1000 UNIT PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Allopurinol ___ mg PO DAILY \n12. Ferrous Sulfate 325 mg PO DAILY \n13. Osteo Bi-Flex Triple Strength \n(___) 750 mg-644 mg- 30 mg-1 mg oral \nDAILY \n14. Atorvastatin 40 mg PO QPM \n\n \nDischarge Medications:\n1. Carvedilol 50 mg PO BID \nRX *carvedilol 25 mg 2 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n2. Torsemide 30 mg PO DAILY \nRX *torsemide 10 mg 3 tablet(s) by mouth once a day Disp #*90 \nTablet Refills:*0 \n3. HydrALAZINE 75 mg PO TID \nRX *hydralazine 50 mg 1.5 tablet(s) by mouth three times a day \nDisp #*135 Tablet Refills:*0 \n4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY \nRX *isosorbide mononitrate 120 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n5. Aspirin 81 mg PO 3X/WEEK (___) \n6. Atorvastatin 40 mg PO QPM \n7. Ferrous Sulfate 325 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Osteo Bi-Flex Triple Strength \n(___) 750 mg-644 mg- 30 mg-1 mg oral \nDAILY \n10. Pantoprazole 40 mg PO Q24H \n11. Tamsulosin 0.4 mg PO BID \n12. Vitamin D 1000 UNIT PO DAILY \n13. HELD- Allopurinol ___ mg PO DAILY This medication was held. \nDo not restart Allopurinol until speaking with your kidney \ndoctors\n14. HELD- Valsartan 160 mg PO DAILY This medication was held. \nDo not restart Valsartan until speaking with your kidney doctors\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\n- Congestive Heart Failure\n- CKD Stage III-IV\n\nSecondary:\n- Hypertension\n- Cirrhosis with ascites\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWhy was I admitted to the hospital? \n-You were admitted because you had worsening leg swelling, \nabdominal swelling, and 30-pound weight gain. \n\nWhat happened while I was in the hospital? \n- While you were here we did a chest x-ray, blood tests, and an \nultrasound of your heart and abdomen. All of these tests showed \nthat you had increased fluid in your body, likely because of \nyour heart failure.\n- We gave you medicines through your veins to help you urinate \nout this extra fluid, and you lost over 15lbs of fluid while in \nthe hospital. We changed your home Lasix to a stronger \nmedication called torsemide while you were in the hospital. You \nwill need to continue to take torsemide 30mg daily at home to \nprevent this extra fluid from re-accumulating. \n- You were also found to have high blood pressures in the \nhospital, which can increase the stress on your heart. We \nincreased your blood pressure medications while you were in the \nhospital. Please continue to take these medications at higher \ndoses (Isosorbide Mononitrate 120 mg daily, Carvedilol 50 mg \ntwice daily, and hydralazine 75 mg three times daily)\n\nWhat should I do after leaving the hospital? \n- Please weigh yourself when you get home and every morning, \ncall MD if weight goes up more than 3 lbs.\n- Please take your medications as listed in discharge summary \nand follow up at the listed appointments. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nSincerely,\n\nYour ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5023", "N184", "N179", "E870", "I441", "N138", "K7031", "I428", "N401", "D649", "F1020" ]

[ "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", "N184: Chronic kidney disease, stage 4 (severe)", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "I441: Atrioventricular block, second degree", "N138: Other obstructive and reflux uropathy", "K7031: Alcoholic cirrhosis of liver with ascites", "I428: Other cardiomyopathies", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "D649: Anemia, unspecified", "F1020: Alcohol dependence, uncomplicated" ]

[ "I130", "N179", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nlisinopril / niacin\n \nAttending: ___.\n \nChief Complaint:\nLeukocytosis, fever\n \nMajor Surgical or Invasive Procedure:\nDiagnostic Paracentesis ___ \n\n \nHistory of Present Illness:\n___ with history of NICM (EF 25% ___, CKD Stage IV \n(baseline Cr 4.4 from ___ presumed due to cardiorenal \norigin, alcoholic cirrhosis who was discharge from ___ ___ \nto rehab who re-presents to the ED from rehab after being found \nto have WBC of 17 and temp of 100.9 at rehab. Per report, he \nwas also extremely agitated and tried to remove his dialysis \nline, and is now restrained. He was also found to have a \nhematocrit of 22, which is in the range of his norm, and the ED \ntransfused 1 unit of pRBC. The patients labs reflect CHF \nexacerbation as he has a BNP of >70000. No immediate source of \ninfection was found on initial ED workup. Of note, the patient \nreceived a ketamine bolus and was started on a ketamine drip \nprior to surgical consult, so no history or reliable physical \nexam can be obtained.\n \nPast Medical History:\nAtrial fibrillation\nSystolic heart failure (LVEF of 40-45% in ___\nHypertension\nHyperlipidemia\nGout\nProstate cancer status post radiation therapy\nSarcoidosis\nSickle cell trait\nRight total knee replacement in ___\nSolitary pulmonary nodule followed since ___\nOsteoarthritis\nPeripheral neuropathy\nAsthma\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\nAdmission\nVitals: 98.5, 82, 109/74, 17, 94% on 40%\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, mildly distended, nontender (on ketamine), no rebound\nor guarding, no palpable masses\nExt: No ___ edema, ___ warm and well perfused\n \nBrief Hospital Course:\nMr. ___ was admitted to the Trauma ICU where he was known \ngiven his recent hospital admission. \n\nHe was off pressors and off ketamine drip. His mental status \nimproved. His WBC was 17.3. He continued to produce copious \namounts of respiratory secretions and receive chest physical \ntherapy as before. He was on trach mask with intermittent vent \nrequirement for agitation. CT abd/pelvis showed ascites, \npost-surgical changes in the splenic fossa and no drainable \ncollections. He had no abdominal pain. He was started on CTX. \nDiagnostic paracentesis suggested spontaneous bacterial \nperitonitis. A 10 day Ceftriaxone course was planned followed by \nprophylactic Ciprofloxacin per Hepatology recommendation. He \nreceived HD as scheduled. \n\nThe patient remained stable with normal vital signs. He was \ndischarged to ___ to continue his recovery. \n\n \nMedications on Admission:\n1. Acetaminophen (Liquid) 650 mg PO Q8H:PRN Pain - Moderate \nRX *acetaminophen 325 mg/10.15 mL 20 cc by mouth Every 8 hours \nDisp #*2 Bottle Refills:*0 \n2. Albuterol Inhaler ___ PUFF IH Q6H \nRX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff Trach Every 6 \nhours Disp #*2 Inhaler Refills:*0 \n3. Carvedilol 25 mg PO BID \nRX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \nRX *chlorhexidine gluconate 0.12 % Mouth rinse with 15 cc three \ntimes a day Refills:*0 \n5. Docusate Sodium (Liquid) 100 mg PO BID \nRX *docusate sodium [Diocto] 50 mg/5 mL 100 mg by mouth twice a \nday Disp ___ Milliliter Refills:*0 \n6. Heparin 5000 UNIT SC TID \nRX *heparin (porcine) 5,000 unit/mL (1 mL) 5000 units \nSubcutaneous three times a day Disp #*90 Cartridge Refills:*0 \n7. Ipratropium Bromide MDI 2 PUFF IH Q6H \nRX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 PUFF \nTrach every six (6) hours Disp #*2 Inhaler Refills:*0 \n8. Metoprolol Tartrate 12.5 mg PO BID \nRX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a \nday Disp #*30 Tablet Refills:*0 \n9. OLANZapine 2.5-5 mg PO QHS \nRX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n10. OxycoDONE Liquid 2.5-5 mg PO Q8H:PRN Pain - Severe \nRX *oxycodone 5 mg/5 mL 5 mg NG tube three times a day \nRefills:*0 \n11. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth \nDaily Refills:*0 \n12. Ramelteon 8 mg PO QHS:PRN insomnia \nRX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth QHR Disp #*30 \nTablet Refills:*0 \n13. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.8 mg/5 mL 8.8 mg by mouth twice a day \nDisp ___ Milliliter Refills:*0 \n14. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H:PRN resp \nsecretions \nRX *sodium chloride 3 % 15 cc Trach Q6H PRN Disp #*100 Vial \nRefills:*0 \n15. Vancomycin Oral Liquid ___ mg PO/NG Q6H \nRX *vancomycin [Firvanq] 50 mg/mL 125 mg by mouth every six (6) \nhours Refills:*0 \n\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 160 mg/5 mL 650 mg by mouth Every 6 hours Disp \n#*2 Bottle Refills:*0 \n2. Carvedilol 25 mg PO BID \nRX *carvedilol 25 mg 1 tablet(s) by mouth every 12 hours Disp \n#*60 Tablet Refills:*0 \n3. CefTRIAXone 2 gm IV Q24H \nRX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV Daily \nDisp #*7 Intravenous Bag Refills:*0 \n4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \nRX *chlorhexidine gluconate 0.12 % 15 ml for mouth rinse twice a \nday Refills:*0 \n5. Heparin 5000 UNIT SC TID \nRX *heparin (porcine) 5,000 unit/mL (1 mL) 5000 units \nSubcutaneous twice a day Disp #*30 Cartridge Refills:*0 \n6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID \nRX *lansoprazole 30 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n7. OLANZapine 2.5-5 mg PO QHS \nRX *olanzapine 5 mg ___ tablet(s) by mouth Every night Disp #*30 \nTablet Refills:*0 \n8. Ramelteon 8 mg PO QHS \nRX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth Every night \nDisp #*30 Tablet Refills:*0 \n9. Vancomycin Oral Liquid ___ mg PO Q6H \nRX *vancomycin [Firvanq] 25 mg/mL 125 mg by mouth Every 6 hours \nRefills:*0 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nSpontaneous Bacterial Peritonitis\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\nYou were re-admitted to ___ for fevers and a high white blood \ncell count suggestive of infection. You were found to have \nSpontaneous Bacterial Peritonitis which was treated with \nantibiotics. You are ready for discharge. \n\nFollow these instructions\n- You should continue to take your oral Vancomycin 125 mg Q6H \nuntil ___.\n- You should continue your antibiotic (Ceftriaxone 2gr/day) \nuntil ___. \n- On ___, you should start taking Ciprofloxacin 500 mg/day \nto prevent recurrent infections. Keep taking this medication \nuntil you see your Hepatologist in clinic.\n\n \nFollowup Instructions:\n___\n" ]

[ "K652", "J9691", "I5023", "I130", "N184", "A0472", "I429", "F05", "Z992", "D869", "I4891", "K7031", "G629", "D573", "E785", "M109", "Z96651", "Z8546", "Z923", "Z930", "D649", "E162" ]

[ "K652: Spontaneous bacterial peritonitis", "J9691: Respiratory failure, unspecified with hypoxia", "I5023: Acute on chronic systolic (congestive) heart failure", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N184: Chronic kidney disease, stage 4 (severe)", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "I429: Cardiomyopathy, unspecified", "F05: Delirium due to known physiological condition", "Z992: Dependence on renal dialysis", "D869: Sarcoidosis, unspecified", "I4891: Unspecified atrial fibrillation", "K7031: Alcoholic cirrhosis of liver with ascites", "G629: Polyneuropathy, unspecified", "D573: Sickle-cell trait", "E785: Hyperlipidemia, unspecified", "M109: Gout, unspecified", "Z96651: Presence of right artificial knee joint", "Z8546: Personal history of malignant neoplasm of prostate", "Z923: Personal history of irradiation", "Z930: Tracheostomy status", "D649: Anemia, unspecified", "E162: Hypoglycemia, unspecified" ]

[ "I130", "I4891", "E785", "M109", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nlisinopril / niacin\n \nAttending: ___\n \nChief Complaint:\nFall, unwitnessed\n \nMajor Surgical or Invasive Procedure:\nExploratory laparotomy with splenectomy\n \nHistory of Present Illness:\n___ with NICM (EF 25% ___, CKD Stage IV (baseline Cr 4.4 \nfrom ___ presumed due to cardiorenal origin, alcoholic \ncirrhosis who was found down at home with a pool of blood around \nhis head. Upon arrival to ED, he was found to be hypotensive to \nSBP ___ and bradycardic. A large scalp lac was documented and \nFAST was positive. He received 2 units od RBC without \nimprovement in his SBP. \n \nPast Medical History:\nAtrial fibrillation\nSystolic heart failure (LVEF of 40-45% in ___\nHypertension\nHyperlipidemia\nGout\nProstate cancer status post radiation therapy\nSarcoidosis\nSickle cell trait\nRight total knee replacement in ___\nSolitary pulmonary nodule followed since ___\nOsteoarthritis\nPeripheral neuropathy\nAsthma\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nBrief Hospital Course:\nMr. ___ was transported to the OR in the setting of \nhypotension non-responsive to blood products, Hct 17.5 and \npositive FAST exam (splenic window). He underwent exploratory \nlaparotomy and splenectomy (for details on the procedure, refer \nto the operative report). His scalp lac was washed and stapled. \nHe received a total of 2uPRBC in ED and 5uPRBC and 1 unit of \nplatelets in OR. He was transported to the Trauma ICU intubated \nand on pressors. \n\nHe underwent CT head and C spine which showed no evidence of \ntraumatic injury. His C collar was cleared. CT chest showed no \nacute rib fractures. He presented with a CKD requiring CRRT for \nvolume overload. Echocardiogram showed LVEF = ___ % with \nbiventricular hypokinesis (focal in left, global in right).\n\nThe patient remained intubated with poor mental status and \nrequiring pressors for the following 10 days. There was no \nconcern for bleeding given stable H/H and no concern for \ncardiogenic shock given CI ___. There was no concern for \ninfection given lack of leukocytosis, fevers, stable CXR and \nnormal UA. \n\nWhile his pressors and ventilator support were being slowly \nweaned, he was started on tube feeds with adequate tolerance. \nCRRT continued attempting to remove volume as tolerated. On ___, \nhe underwent bedside bronchoscopy that showed left lung \nsecretions. He was started on CTX/azithro for 7 days and post \nprocedure CXR showed lung reinflation. BAL did not grew anything \nin cultures. \n \nOn ___, the patient was extubated to a face mask but eventually \nrequired reintubation due to poor cough and hypercapnia. On ___, \nhe had a low grade temperature 100.1 and a work-up was sent. UC \nwas growing pseudomonas and he was started on Cefepime. His OGT \nhad been pulled and coiled repeatedly at 35 cm when attempting \nto replace. EGD was performed showing hardened, caked matter in \nthe mid esophagus. An NJ tube was placed and tube feeds were \nrestarted. \n \nOn ___, the patient had low grade temperatures. UA/UC showed \n>100,000 CFU of pseudomonas resistant to Cefepime and he was \ntreated with a 10 day course of Cipro. EGD was performed showing \nhardened, caked matter in the mid esophagus (?TF) and an OG tube \nwas placed. Tube feeds were advanced to goal.\n\nOn ___, the patient underwent bedside uncomplicated \ntracheostomy. Over the next ___ days, he was slowly weaned from \nthe vent to a trach mask. He would develop tachycardia, \ntachypnea and ectopy requiring placement on the vent. \n\nThere was concern for tamponade physiology given his persistent \npericardial effusion on echocardiogram. Cardiology and Thoracic \nsurgery were consulted but deferred pericardiocentesis and \npericardial window. He was started on Seroquel for agitation. \n\nOn ___, he was started on PO Vancomycin for C. diff (Course \n___. \n\nOn ___, Hepatology was consulted. GGT was 188. Ammonia level \n12. Liver ultrasound showed cirrhosis with mild ascites, patent \nPV. Paracentesis was deferred. \n\nOn ___, single-lumen R PICC and RIJ tunneled pheresis line \nplaced. RIJ temporary catheter removed. His scalp staples were \nremoved.\n\n \nMedications on Admission:\nMEDS AT HOME: \n 1. Carvedilol 50 mg PO BID \n RX *carvedilol 25 mg 2 tablet(s) by mouth twice a day Disp #*60 \n \n Tablet Refills:*0 \n 2. Torsemide 30 mg PO DAILY \n RX *torsemide 10 mg 3 tablet(s) by mouth once a day Disp #*90 \n Tablet Refills:*0 \n 3. HydrALAZINE 75 mg PO TID \n RX *hydralazine 50 mg 1.5 tablet(s) by mouth three times a day \n\n Disp #*135 Tablet Refills:*0 \n 4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY \n RX *isosorbide mononitrate 120 mg 1 tablet(s) by mouth once a \n day Disp #*30 Tablet Refills:*0 \n 5. Aspirin 81 mg PO 3X/WEEK (___) \n 6. Atorvastatin 40 mg PO QPM \n 7. Ferrous Sulfate 325 mg PO DAILY \n 8. Multivitamins 1 TAB PO DAILY \n 9. Osteo Bi-Flex Triple Strength \n (___) 750 mg-644 mg- 30 mg-1 mg oral \n \n DAILY \n 10. Pantoprazole 40 mg PO Q24H \n 11. Tamsulosin 0.4 mg PO BID \n 12. Vitamin D 1000 UNIT PO DAILY \n 13. HELD- Allopurinol ___ mg PO DAILY This medication was held. \n \n Do not restart Allopurinol until speaking with your kidney \n doctors \n 14. HELD- Valsartan 160 mg PO DAILY This medication was held. \n Do not restart Valsartan until speaking with your kidney \ndoctors \n* Medication changes done on recent admission ___: \n - Lasix 40mg daily to torsemide 30mg daily \n - Hydralazine 20mg to 75 mg TID \n - Imdur 30mg to 120mg daily \n - Metoprolol succinate 50mg to Carvdedilol 50 mg BID \n * Medications continued: \n - ASA 81mg \n - Atorvastatin 40mg daily \n - Pantoprazole \n - Tamsulosin \n - Vit D \n * Medications held: \n - Allopurinol \n - Valsartan \n\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q8H:PRN Pain - Moderate \nRX *acetaminophen 325 mg/10.15 mL 20 cc by mouth Every 8 hours \nDisp #*2 Bottle Refills:*0 \n2. Albuterol Inhaler ___ PUFF IH Q6H \nRX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff Trach Every 6 \nhours Disp #*2 Inhaler Refills:*0 \n3. Carvedilol 25 mg PO BID \nRX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \nRX *chlorhexidine gluconate 0.12 % Mouth rinse with 15 cc three \ntimes a day Refills:*0 \n5. Docusate Sodium (Liquid) 100 mg PO BID \nRX *docusate sodium [Diocto] 50 mg/5 mL 100 mg by mouth twice a \nday Disp ___ Milliliter Refills:*0 \n6. Heparin 5000 UNIT SC TID \nRX *heparin (porcine) 5,000 unit/mL (1 mL) 5000 units \nSubcutaneous three times a day Disp #*90 Cartridge Refills:*0 \n7. Ipratropium Bromide MDI 2 PUFF IH Q6H \nRX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 PUFF \nTrach every six (6) hours Disp #*2 Inhaler Refills:*0 \n8. Metoprolol Tartrate 12.5 mg PO BID \nRX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a \nday Disp #*30 Tablet Refills:*0 \n9. OLANZapine 2.5-5 mg PO QHS \nRX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n10. OxycoDONE Liquid 2.5-5 mg PO Q8H:PRN Pain - Severe \nRX *oxycodone 5 mg/5 mL 5 mg NG tube three times a day \nRefills:*0 \n11. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth \nDaily Refills:*0 \n12. Ramelteon 8 mg PO QHS:PRN insomnia \nRX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth QHR Disp #*30 \nTablet Refills:*0 \n13. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.8 mg/5 mL 8.8 mg by mouth twice a day \nDisp ___ Milliliter Refills:*0 \n14. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H:PRN resp \nsecretions \nRX *sodium chloride 3 % 15 cc Trach Q6H PRN Disp #*100 Vial \nRefills:*0 \n15. Vancomycin Oral Liquid ___ mg PO/NG Q6H \nRX *vancomycin [Firvanq] 50 mg/mL 125 mg by mouth every six (6) \nhours Refills:*0 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n- Splenic laceration\n- Postoperative respiratory failure \n- UTI\n- C diff colitis\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to ___ after a fall. You had a scalp \nlaceration and bleeding from your spleen. You were taken to the \noperating room as an emergency, and your spleen was removed. You \nremained intubated requiring support from the ventilator. On \n___, you underwent tracheostomy. This allowed to remove the tube \nin your mouth that helped you breath, while allowing to help you \nbreath with the ventilator. You also had a urinary tract \ninfection and an infection of your colon that were treated with \nantibiotics. You are now ready to be discharged to a facility to \ncontinue your recovery. \n \nFollowup Instructions:\n___\n" ]

[ "S36039A", "N170", "T794XXA", "N186", "J95822", "I313", "I4892", "I428", "N390", "A0472", "I132", "I5022", "T17490A", "I248", "W19XXXA", "Y92009", "I493", "I4891", "Z23", "S0101XA", "N400", "M109", "K7031", "E785", "D573", "J45909", "G629", "Z96651", "Z8546", "Z923", "B952", "I351", "Z992", "I4510", "X58XXXA", "Y92230", "E162" ]

[ "S36039A: Unspecified laceration of spleen, initial encounter", "N170: Acute kidney failure with tubular necrosis", "T794XXA: Traumatic shock, initial encounter", "N186: End stage renal disease", "J95822: Acute and chronic postprocedural respiratory failure", "I313: Pericardial effusion (noninflammatory)", "I4892: Unspecified atrial flutter", "I428: Other cardiomyopathies", "N390: Urinary tract infection, site not specified", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5022: Chronic systolic (congestive) heart failure", "T17490A: Other foreign object in trachea causing asphyxiation, initial encounter", "I248: Other forms of acute ischemic heart disease", "W19XXXA: Unspecified fall, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "I493: Ventricular premature depolarization", "I4891: Unspecified atrial fibrillation", "Z23: Encounter for immunization", "S0101XA: Laceration without foreign body of scalp, initial encounter", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M109: Gout, unspecified", "K7031: Alcoholic cirrhosis of liver with ascites", "E785: Hyperlipidemia, unspecified", "D573: Sickle-cell trait", "J45909: Unspecified asthma, uncomplicated", "G629: Polyneuropathy, unspecified", "Z96651: Presence of right artificial knee joint", "Z8546: Personal history of malignant neoplasm of prostate", "Z923: Personal history of irradiation", "B952: Enterococcus as the cause of diseases classified elsewhere", "I351: Nonrheumatic aortic (valve) insufficiency", "Z992: Dependence on renal dialysis", "I4510: Unspecified right bundle-branch block", "X58XXXA: Exposure to other specified factors, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "E162: Hypoglycemia, unspecified" ]

[ "N390", "I4891", "N400", "M109", "E785", "J45909", "Y92230" ]

[]

[ " \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:\ncoronary angiography \n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of CAD with a stent\nto the RCA in ___ who presents with chest pain and shortness of\nbreath over the past two days.\n\nHe had been in his normal state of health until 10 days ago when\nhe deveoped severe chest pain associated with nausea, vomiting\nand presyncope. He presented to an ED in ___ and was\ndischarged with follow-up with his primary cardiologist. He had \na\nstress test on ___ that showed newly depressed LVEF with\ninferosetpal hypokinesis. His cardiologist wanted to treat him\nmedically and he was started on metoprolol, which he has only\ntaken for three days. However, since that time he has \nexperienced\nchest pain with shortness of breath, including paroxysmal\nnocturnal dyspnea. \n\nHe describes the CP as a tightness/pressure in the ___ his\nchest, nonradiating, assoc w/ SOB and lightheadedness. It\nsubsides w/in 1 min. He has not taken anything to relieve the\npain. Pt takes 81mg ASA every day, he took it this AM.\n\nPrior to the past 10 days he has been able to ski, boat, fish \nall\nwithout any chest pain. He has never taken his sublingual\nnitroglycerin. \n\nHe denies weight gain, orthopnea, PND, palpitations, syncope\naside from 10 days ago, lower extremity edema, fevers, chills,\nnausea, vomiting diarrhea, dysuria. Had cough several days ago\nthat resolved. \n\nEMERGENCY DEPARTMENT COURSE\nIn the ED initial vitals were: \n- T 96.8; HR 68; BP 147/85; RR 18; O2 99% RA\n \nExam notable for: \n- Heart: RRR, no murmur\n- Lungs: CTAB\n- No JVD\n- No ___ edema\n\nEKG: \n- Normal sinus rhythm, no ST changes, unchanged from EKG in ___\n \nLabs/studies notable for: \n- Trop<0.01, normal electrolytes and CBC\n \nImaging studies notable for: \n- CXR: No acute intrathoracic process \n\nPatient was given:\n- Aspirin 243\n- Heparin bolus and infusion \n \nVitals on transfer: \n- T98.1; HR 58; BP 115/75; RR 18; O2 98% RA \n\nUpon Arrival to the Floor\n- He initially reported no chest pain and then subsequently\ndevelop central chest pain rated ___ while at rest. \n \n================\nREVIEW OF SYSTEMS\n================\nA 10 point review of systems was positive per the history of\npresent illness, and otherwise negativ\n \nPast Medical History:\n==================\nPAST MEDICAL HISTORY \n==================\n1. CARDIAC RISK FACTORS \n- Known CAD \n\n2. CARDIAC HISTORY \n- CAD PCI to distal RCA ___ (3.25x18mm Xience at ___\n\n3. OTHER PAST MEDICAL HISTORY\n- Thrombophlepitis of lower extremity\n- Hypertension\n- Colonic polyp\n- Hyperlipidemia \n \nSocial History:\n___\nFamily History:\n============\nFAMILY HISTORY\n============ \n- Brother: ___ cancer, hypertension\n- Father: CAD/PVD early\n- Maternal Aunt: Cancer \n- ___ Grandfather: Severe HTN with sympathectomy \n- Maternal Grandmother: ___ \n \nPhysical ___:\n==================\nPHYSICAL EXAMINATION \n===================\nVS: T:98.0 BP:122/76, HR:50 RR:18 O2:97 on RA \nGENERAL: Comfortable appearing man sitting up and bed and\nspeaking to me in no distress \nHEENT: Pupils equal and reactive, no scleral icterus or\ninjection, moist mucous membranes\nNECK: JVP approximately 10 with positive hepatojuglar reflex \nCARDIAC: S1/S2 bradycardic, regular, no murmurs, rubs or S3/s4\nLUNGS: Clear bilaterally\nABDOMEN: Soft, non-tender, non-distended\nEXTREMITIES: Warm. No lower extremity edema. \nSKIN: No abnormal skin findings \nPULSES: Strong pedal pulses \n\nDISCHARGE EXAM:\nGENERAL: sitting up and bed and speaking in short sentences \nHEENT: Pupils equal and reactive, no scleral icterus or\ninjection, moist mucous membranes\nNECK: JVP approximately 10 \nCARDIAC: S1/S2 bradycardic, regular, no murmurs, rubs or S3/s4\nLUNGS: Clear bilaterally\nABDOMEN: Soft, non-tender, non-distended\nEXTREMITIES: Warm. No lower extremity edema. \nSKIN: No abnormal skin findings \nPULSES: Strong pedal pulses\n \nPertinent Results:\n___ 07:45AM BLOOD Hct-42.7 Plt ___\n___ 03:44PM BLOOD WBC-8.1 RBC-4.60 Hgb-14.2 Hct-41.1 MCV-89 \nMCH-30.9 MCHC-34.5 RDW-12.4 RDWSD-40.4 Plt ___\n___ 03:44PM BLOOD Neuts-69.3 Lymphs-17.7* Monos-9.8 Eos-2.1 \nBaso-0.5 Im ___ AbsNeut-5.61 AbsLymp-1.43 AbsMono-0.79 \nAbsEos-0.17 AbsBaso-0.04\n___ 07:45AM BLOOD Plt ___\n___ 03:44PM BLOOD Plt ___\n___ 07:45AM BLOOD UreaN-17 Creat-0.9 K-4.6\n___ 03:44PM BLOOD Glucose-91 UreaN-25* Creat-1.0 Na-142 \nK-5.1 Cl-105 HCO3-25 AnGap-12\n___ 07:18AM BLOOD ALT-19 AST-22 LD(LDH)-197 AlkPhos-62 \nTotBili-0.6\n___ 07:45AM BLOOD cTropnT-<0.01\n___ 03:44PM BLOOD cTropnT-<0.01\n___ 07:18AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.0 Iron-102\n___ 10:15PM BLOOD Calcium-9.2 Phos-2.7 Mg-2.1\n___ 07:18AM BLOOD calTIBC-330 Ferritn-123 TRF-254\n___ 07:18AM BLOOD TSH-2.2\n___ 03:44PM BLOOD HoldBLu-HOLD\n___ 03:44PM BLOOD GreenHd-HOLD\n\n___ TTE \nIMPRESSION: Suboptimal image quality. Normal biventricular \ncavity sizes, and low normal global\nsystolic function. Mild mitral regurgitation. Normal estimated \npulmonary artery systolic pressure.\n\n___ CATH REPORT\nImpressions:\nUlcearted 50-60% stenosis in the distal RCA (by ___) that was \nsuccesfully treated with 2 DES.\n\n \nBrief Hospital Course:\nSummary\n============\nMr. ___ is a ___ year old gentleman with hisotry of CAD with a \nstent to the RCA in ___ who presents with chest pain and \nshortness of breath over the past two days with negative \ntroponins concerning for unstable angina, developed STEMI ___ \nam, went for cath s/p ___ 2 to RCA (ulcerated RCA lesion).\n\nACTIVE ISSUES \n==============\n#STEMI \nKnown history of CAD with stent to RCA in ___. He had a stress \ntest a month after his PCI in ___ that was negative for \nischemia, and a stress test a year later showed ischemia in a \nsmall inferoapical segment. On stress test two days prior to \nadmission, he had newly depressed EF and moderately increased \nischemia, concerning for worsening ischemia. On admission, ECG \nshowed anterior and inferior sub-mm elevations, and continues to \nhave some vague ___ pain, but he has had three negative \ntroponins and no progression on his ECG, all consistent with \nunstable angina. On the mornign of ___ with new chest pain and \necg changes with ST elevations in II, III, aVF indicative of \ninferior (RCA) STEMI. Patient was loaded with ASA, ticag, \nheparin bolus taken to cath lab and received 2 DES to RCA. He \nremained CP free for the remainder of his hospital admission. He \nwas discharged on ASA81, Ticagrelor 90BID, atorva 80, lisinopril \n5, metoprolol xl 12.5. \n\n#Heart failure with reduced ejection fraction\n___ stress test shows newly depression LVEF of 40% related \nto inferior hypokinesis only after exercise. Etiology is likely \nischemic given evidence of increased ischemia on stress test \nfrom prior. He is not currently decompensated. Does endorse \ndyspnea with exertion, but CXR does not show pulmonary edema and \nhe has been able to exercise to his full capacity. He denies \northopnea, PND, weight gain or leg swelling. Post PCI TTE \ndemonstrated Normal biventricular cavity sizes, and low normal \nglobal systolic function, Mild mitral regurgitation, Normal \nestimated pulmonary artery systolic pressure and an EF of 55%. \n\nCHRONIC ISSUES\n=============\n#Attention Deficit Disorder\n- Held amphetamine in setting of ongoing ischemia \n- Resumed methylphenidate 20mg ER daily after angiography \n\n#Depression\n- Continued citalopram\n\nTRANSITIONAL ISSUES\n====================\n[] DAPT for >12 months recommended\n[] Should be set up for cardiac rehab as an outpatient\n\nMedication Changes:\nAtorvastatin 40 --> 80mg daily \nMetoprolol XL 25 daily --> Metoprolol Succinate XL 12.5 mg PO \nDAILY \n\nMedication Additions:\nTiCAGRELOR 90 mg PO/NG BID \n\nMedications Discontinued:\nnone \n\nCode Status: full\nContact: wife ___ cp ___ \n\nCr:0.9\nEF: 55% on ___ \nWeight:103.1kg \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. Methylphenidate SR 20 mg PO QAM \n3. Citalopram 20 mg PO DAILY \n4. Lisinopril 5 mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis \nRX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day \nDisp #*180 Tablet Refills:*0 \n2. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*90 \nTablet Refills:*0 \n3. Metoprolol Succinate XL 12.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth \ndaily Disp #*90 Tablet Refills:*0 \n4. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet \nRefills:*0 \n5. Citalopram 20 mg PO DAILY \n6. Lisinopril 5 mg PO DAILY \n7. Methylphenidate SR 20 mg PO QAM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis\n=================\nSTEMI\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 came to ___ because you were having chest pain. You were \nfound to have a blockage in an artery that supplies blood to \nyour heart. \n\nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL: \n- You were found to have a blockage in an artery that supplies \nblood to your heart. \n- You underwent an intervention to place a stent to re-open the \nblocked artery \n- You improved considerably and were ready to leave the hospital \n\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL: \n- Please follow up with your primary care doctor and other \nhealth care providers (see below) \n- Please take all of your medications as prescribed (see below). \n\n- It is very important that you do NOT miss ___ dose of your \naspirin or ticagrelor, as these medications are to keep the \nstent open. Missing a dose could cause a heart attack.\n- Seek medical attention if you have shortness of breath, chest \npain, abdominal pain, weight gain, leg swelling, or other \nsymptoms of concern.\n- Weight yourself daily and call your PCP if your weight is \ngreater than 3lb from discharge weight of 227 pounds. \n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I213", "I2542", "I25110", "T859XXA", "Y840", "Y92239", "I10", "E785", "F988", "F329" ]

[ "I213: ST elevation (STEMI) myocardial infarction of unspecified site", "I2542: Coronary artery dissection", "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "T859XXA: Unspecified complication of internal prosthetic device, implant and graft, initial encounter", "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", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F988: Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence", "F329: Major depressive disorder, single episode, unspecified" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nDilantin Kapseal / Depakote / Tegretol / Codeine / Phenobarbital \n/ Penicillins\n \nAttending: ___.\n \nChief Complaint:\ntransfer\n \nMajor Surgical or Invasive Procedure:\nN/A\n \nHistory of Present Illness:\n___ is a ___ year old man followed at ___ Epilepsy clinic\n(Dr. ___ diagnosis of intractable complex partial\nepilepsy status post VNS (affecting right arm & leg) and PNES \nwho\nis transferred from an OSH in ___ for seizure management. \n\nHis typical events occur ___ times per month. ___ weeks ago, \nthey\nbegan to happen daily without a clear precipitant. Describes\nevents as 15 min of room-spinning vertigo and rt arm/leg \nnumbness\n(sometimes with right face) followed by ___ hours of right\narm/leg shaking. Afterwards, he is often confused (but \nfrequently\nreceives Ativan). Does not lose consciousness, can hear\nthroughout, may or may not follow commands, eyes closed, +/-\nurinary incontinence. Denies eye deviation, eyes rolling up, \nhead\nversion, tongue biting, frothing/drooling at mouth, stool\nincontinence. Had 2 GTCs in 1990s, not since. \n\nPatient presented to the OSH on ___ after he had about 6 hrs of\ncontinuous jerking of his rt arm and leg. Per report he was able\nto walk to the car with his wife. Upon arrival to the ED, he\nreceived 4 mg of IV Ativan, 5 mg of valium, and 4 mg of Versed\nbefore his seizure was aborted. He was set to be discharged on\nthe morning of ___ then had recurrence of the\nintermittent jerking movements. In the early AM hours of ___, he\nonce again had jerking movements of the right arm/leg which took\n11 mg Ativan to abate. The ED attending called Dr. ___\nrecommended transfer. In the past, when seizure-like events have\nbeen refractory to Ativan, they have been psychogenic in nature.\n\nEn route to ___, he had an 8-minute long event characterized \nby\nshaking and unresponsiveness; limbs and side involved unclear. \nHe\nreceived 1mg of Ativan at 6:18pm and another at 6:23pm. He\nsubsequently was unable to recall the date and was \"more\nsubdued.\" \n\nToday, patient denies recent illnesses or missing AED doses. No\nrecent stressors. Is non-compliant with ketogenic diet. \n\n \nPast Medical History:\n- PNES and seizures\n- Depression - No suicidal ideation. Follows with Dr. ___ \n2x/year \n- Sleep apnea, on CPAP \n- Prior myocarditis (details unclear), since on Toprol \n- Hypercholesterolemia \n- Gastroesophageal reflux \n- Chronic headaches and prior sinusitis \n- Low back surgery, L4-5 disc herniation s/p left L4-5 \nhemilaminectomy, median facetectomy and L4-5 diskectomy ___ \n(___) \n- Tonsillectomy \n- Vasectomy \n- Benign hematuria, kidney stones (thought to be ___ topamax) \n- Pulmonary Embolus in ___, ~6 months of Coumadin\" \n\n \nSocial History:\n___\nFamily History:\nMother passed last year ___ with a history of MI and uterine \ncancer. Father died at age ___ of a stroke and MI. \n \nPhysical Exam:\nPhysical Exam: \n General: Awake, cooperative, NAD. \n HEENT: NC/AT, no scleral icterus noted, MMM \n Neck: Supple \n Pulmonary: Regular respirations \n Cardiac: RRR \n Abdomen: soft \n Skin: maculopap rash on chest \n \nNeurologic: \n-Mental Status: Alert, oriented x 3. Able to relate history \nwithout difficulty. Able to name months of year backwards. \nLanguage is fluent with intact repetition and comprehension. \nNormal prosody. There were no paraphasic errors. Pt was able to \nname both high and low frequency objects. Speech was not \ndysarthric. Able to follow both midline and appendicular \ncommands. Pt was able to register 3 objects and recall ___ at 5 \nminutes. There was no evidence of apraxia or neglect. \n\n-Cranial Nerves: \nI: Olfaction not tested. \nII: PERRL 3 to 2mm and brisk. VFF to confrontation. \nIII, IV, VI: EOMI full.\nV: Facial sensation intact to light touch. \nVII: No facial droop, facial musculature symmetric. \nVIII: Hearing intact to finger-rub bilaterally. \nIX, X: Palate elevates symmetrically. \nXI: ___ strength in trapezii and SCM bilaterally. \nXII: Tongue protrudes in midline. \n\n-Motor: Normal bulk, tone throughout. No pronator drift \nbilaterally. No adventitious movements, such as tremor, noted. \nNo asterixis noted. \n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ \n L ___ 5 5 \n R ___ 5 5 \n \n-Sensory: No deficits to light touch, pinprick, cold sensation,\nproprioception throughout. Decreased vibration at toes, present\nat ankles. Unable to test Romberg due to inability to stand with\nfeet together, eyes open.\n\n-DTRs: \nBi Tri ___ Pat Ach \nL ___ 2 1 \nR ___ 2 1 \nPlantar response was flexor bilaterally. \n\n-Coordination: No intention tremor, no dysdiadochokinesia noted. \nNo dysmetria on FNF or HKS bilaterally. \n\n-Gait: Good initiation. Narrow-based, normal stride and arm \nswing. Able to walk in tandem without difficulty. \n\n \nPertinent Results:\nLABS ON ADMISSION:\n\n___ 06:39AM BLOOD WBC-9.0 RBC-4.32* Hgb-13.3* Hct-40.5 \nMCV-94 MCH-30.8 MCHC-32.8 RDW-13.8 RDWSD-46.4* Plt ___\n___ 06:39AM BLOOD ___ PTT-36.4 ___\n___ 06:39AM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-142 \nK-4.0 Cl-102 HCO3-27 AnGap-17\n___ 06:39AM BLOOD ALT-27 AST-32 AlkPhos-116 TotBili-0.2\n___ 09:06AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.7\n\nEEGs:\n\n___\nIMPRESSION: This is an abnormal video-EEG monitoring session \nbecause of an \nasymmetry between the two hemispheres. Amplitudes over the left \nhemisphere, \nparticularly in the temporal region, are of high amplitude, more \ndisorganized, \nand with sharp features. This finding is consistent with known \nbreach \nartifact. There are no patient events captured during this \nrecording. There \nare no definite epileptiform discharges or electrographic \nseizures. \n\n___\nIMPRESSION: This is an abnormal video-EEG monitoring session \nbecause of intermittent focal slowing over the left hemisphere, \nindicative of focal \nsubcortical dysfunction in this region. Higher amplitude, \nsharper, more \nchaotic activity over the left hemisphere is consistent with \nknown breach artifact. There are 3 pushbutton activations for a \nprolonged (> half hour) episode of non-rhythmic, waxing and \nwaning right arm and leg movements associated with \nunresponsiveness and deep breathing, with no associated \nepileptiform activity on EEG. This event is consistent with a \nnon-epileptic seizure. There are no definite epileptiform \ndischarges or electrographic seizures. \n\n___\nIMPRESSION: This is an abnormal video-EEG monitoring session \nbecause of (1) rare left mid-temporal sharp waves, and (2) \nintermittent focal slowing over the left hemisphere, indicative \nof focal subcortical dysfunction in this region. Higher \namplitude and sharper activity over the left hemisphere is \nconsistent with known breach artifact. There are 4 pushbutton \nactivations for two episodes of non-rhythmic, asynchronous right \narm and leg movements associated with unresponsiveness and deep \nbreathing, which have no associated epileptiform activity on \nEEG. These two events are both consistent with non-epileptic \nseizures. There are no definitely epileptiform discharges or \nelectrographic seizures in this recording. \n\n___\nIMPRESSION: This is an abnormal video-EEG monitoring session \nbecause of (1) rare left mid-temporal sharp waves, and (2) \nintermittent focal slowing over the left hemisphere, indicative \nof focal subcortical dysfunction in this region. Higher \namplitude, sharper, more chaotic activity over the left \nhemisphere is consistent with known breach artifact. There is a \npushbutton activation at 04:22 for an 8-minute long episode of \nnon-rhythmic right arm and leg movements associated with \nunresponsiveness, with a normal posterior dominant rhythm \nthroughout. This episode is similar in semiology to previous \nevents captured during hospitalization, and is consistent with a \nnon-epileptic seizure. There are no definite epileptiform \ndischarges or electrographic seizures in this recording. \n\n___\nIMPRESSION: This is an abnormal video-EEG monitoring session \nbecause of \nintermittent focal slowing over the left hemisphere, indicative \nof focal \nsubcortical dysfunction in this region. Higher amplitude, \nsharper, more \nchaotic activity over the left hemisphere is consistent with \nknown breach \nartifact. There are no definite epileptiform discharges or \nelectrographic \nseizures in this recording. \n\n \nBrief Hospital Course:\nPatient was transferred from ___ for evaluation of prolonged \nevents concerning for seizures including right face and arm \ntwitching nonrhythmically which lasted up to a few hours and \nrequired large benzodiazepine doses before aborting.\n\nAt ___, he was started on continuous video EEG. He had \nnumerous events ranging from 8 to 45 minutes which were captured \nand had NO electrographic correlate on EEG. These were also \nclinically variable, with right upper extremity +/- lower \nextremity nonrhythmic and variable-frequency shaking, with \npreserved consciousness and ability to cooperate fully with \ncommands. Therefore, these were all felt to be non-epileptic \nevents. He was discharged with close follow up with his \nEpilepsy provider. \n\nOf note, there was some confusion with his anti-epileptic \nmedications based on an incongruent list from the outside \n___, and these were clarified that he was taking \nthe appropriate regimen as prescribed by Dr. ___. Please \nrefer to the discharge medication regimen for an accurate list.\n\nHe was seen by the Psychiatry liaison consultant for the \nEpilepsy team, who recommended increasing his Effexor from 150mg \nto 187.5mg daily and ultimately to 225mg. He also recommended an \noutpatient referral to Psychiatry or cognitive behavioral \ntherapist for assistance in reducing the frequency of his \nnon-epileptic events.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Venlafaxine XR 150 mg PO DAILY \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. Atorvastatin 40 mg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n5. LevETIRAcetam 1000 mg PO TID \n6. LACOSamide 200 mg PO TID \n7. felbamate 1800 mg oral QAM \n8. Ezetimibe 10 mg PO DAILY \n9. Ranitidine 300 mg PO DAILY \n10. LamoTRIgine 200 mg PO BID \n11. Clobazam 10 mg PO QAM \n12. Clobazam 20 mg PO QHS \n13. felbamate 1200 mg oral QPM \n14. LamoTRIgine 300 mg PO QPM \n15. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO DAILY \n2. Clobazam 10 mg PO QAM \n3. Clobazam 20 mg PO QHS \n4. Ezetimibe 10 mg PO DAILY \n5. felbamate 1800 mg oral QAM \n6. felbamate 1200 mg ORAL QPM \n7. LACOSamide 200 mg PO TID \n8. LamoTRIgine 200 mg PO BID \n9. LamoTRIgine 300 mg PO QPM \n10. LevETIRAcetam 1000 mg PO TID \n11. Metoprolol Succinate XL 50 mg PO DAILY \n12. Omeprazole 20 mg PO DAILY \n13. Ranitidine 300 mg PO DAILY \n14. Venlafaxine XR 225 mg PO DAILY \nRX *venlafaxine 225 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*1\n15. Aspirin 81 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNon-epileptic events of nonrhythmic arm shaking and altered \nawareness, with NO EEG correlate\nPrior history of epilepsy\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 from your local hospital in ___ for \nprolonged episodes of arm shaking which were concerning for \nepileptic events. We started continuous EEG monitoring which \nshowed that the events you were having were NOT epileptic \nseizures. While you were in the hospital, you were evaluated by \nour psychiatrist who recommended increasing your Effexor to \n225mg daily. You should follow up with your PCP who can refer \nyou to a psychiatrist or cognitive behavioral therapist who can \nhelp you decrease the frequency of these events.\n\nPlease ensure that you take your medications exactly as listed \non your medication list. Please call your Epilepsy provider as \nlisted below if you have any questions or concerns. You should \nfollow up with ___ and Dr. ___ as below.\n\nIt was a pleasure taking care of you. We wish you the best.\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "R569", "F329", "Z8669", "G4730", "E785", "K219", "Z86711" ]

[ "R569: Unspecified convulsions", "F329: Major depressive disorder, single episode, unspecified", "Z8669: Personal history of other diseases of the nervous system and sense organs", "G4730: Sleep apnea, unspecified", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z86711: Personal history of pulmonary embolism" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nDilantin Kapseal / Depakote / Tegretol / Codeine / Penicillins\n \nAttending: ___.\n \nChief Complaint:\nEpilepsy\n \nMajor Surgical or Invasive Procedure:\n___ REPLACEMENT OF VNS (LEAD AND BATTERY)\n \nHistory of Present Illness:\n___ is a ___ year old man who presented for elective admit \nfor VNS battery w/lead replacement. The patient experienced \nreported seizure in OR after extubation, eyes rolled back into \nhead, right arm and mouth twitching-given 1 mg of midazolam in \nOR. Epilepsy service consulted and patient transferred to Neuro \nICU for monitoring of seizures/respiratory status. Respiratory \nstatus improved back to baseline overnight. Patient continued on \nall home medications. \n\n \nPast Medical History:\n- Viral meningitis at ___\n-PNES and seizures as above\n- Depression - No suicidal ideation. Follows with Dr. ___ \n2x/year \n- Sleep apnea, on CPAP \n- Prior myocarditis (details unclear), since on Toprol \n- Hypercholesterolemia \n- Gastroesophageal reflux \n- Chronic headaches and prior sinusitis \n- Low back surgery, L4-5 disc herniation s/p left L4-5 \nhemilaminectomy, median facetectomy and L4-5 diskectomy ___ \n(___) \n- Tonsillectomy \n- Vasectomy \n- Benign hematuria, kidney stones (thought to be ___ topamax) \n- Pulmonary Embolus in ___, ~6 months of Coumadin\"\n \nSocial History:\n___\nFamily History:\nMother passed at ___ with a history of MI and uterine cancer. \nFather died at age ___ of a stroke and MI. \n \nPhysical Exam:\nOn admission: \nGeneral: drowsy with non-rebreather on face \nHEENT: NCAT, gauze/tegaderm intact on left neck and upper chest\nwith serosang on neck bandage\n___: RRR, no murmur \nPulmonary: CTAB, +upper transmitted airway sounds, +snoring\nAbdomen: Soft, NT, ND,\nExtremities: Warm, no edema \n\nNeurologic Examination: \nMS: Drowsy, but opens eyes to voice. Regards examiner. Follows\ncommand to give thumbs up and raise hands. \n \nCranial Nerves - PERRL 3->2 brisk. Face symmetric. EOM crosses\nmidline. \n\nMotor - Normal bulk and tone. Raises arms on command\nanti-gravity, wiggles toes b/l. \nSensory - No deficits to light touch bilaterally. \nDTRs: \n [Bic] [___] [Quad] \n L 1+ 2+ tr \n R 1+ 2+ tr \nPlantar response flexor bilaterally. \n\nCoordination - deferred. \n\nGait - deferred.\n \nOn discharge: \nGeneral: cooperative, attentive, conversive \nHEENT: non traumatic, incision clean and dry \nNeck: NO JVD \nCV: RRR\nLungs: clear bilaterally\nAbdomen: abdomen obese, bowel sounds present \nGU: foley in place \nExt: warm and well perfused \nSkin: neck and chest incision intact\n\nNeuro: \nMS-GCS 15- oriented to person/place/time\nCN-PERRL 3->2 brisk. Face symmetric. EOMI. \nSensory/Motor-right delt/biceps/triceps/ grip 4+/5 otherwise \nLUE, BLE full, no pronator drift.\n\n \nPertinent Results:\nLabs: \n\n___ TYPE-ART PO2-83* PCO2-47* PH-7.37 TOTAL CO2-28 BASE \nXS-0 \n\n141 104 17 AGap=18 \n------------< 113 \n4.6 24 0.9 \n\nComments: K: Hemolysis Falsely Elevates This Test\nGlucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes \n\nCa: 8.3 Mg: 1.8 P: 3.6\n\n 12.1\n12.2 >----< 249 \n 37.8 \n\n___: 11.7 PTT: 30.9 INR: 1.1 \n\n \nBrief Hospital Course:\n___ is a ___ year old man who presented for elective admit \nfor VNS battery w/lead replacement. The patient experienced \nreported seizure in OR after extubation, eyes rolled back into \nhead, right arm and mouth twitching-given 1 mg of midazolam in \nOR. Epilepsy service consulted and patient transferred to Neuro \nICU for monitoring of seizures/respiratory status. Respiratory \nstatus improved back to baseline overnight. Patient continued on \nall home medications. Video EEG recorded one nonepileptic \npsychogenic event. No electrographic seizures.\n\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Clobazam 20 mg PO BID \n3. Clobazam 10 mg PO NOON \n4. Ezetimibe 10 mg PO DAILY \n5. Felbatol (felbamate) 600 mg oral NOON \n6. Felbatol (felbamate) 400 mg oral QPM \n7. LACOSamide 200 mg PO TID \n8. LevETIRAcetam 1000 mg PO TID \n9. LamoTRIgine 200 mg PO BID \n10. LamoTRIgine 300 mg PO QPM \n11. Omeprazole 20 mg PO DAILY \n12. Ranitidine 300 mg PO QHS \n13. Venlafaxine XR 75 mg PO QPM \n14. Venlafaxine XR 150 mg PO QAM \n15. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Clobazam 20 mg PO QPM \n4. Clobazam 10 mg PO QAM \n5. Ezetimibe 10 mg PO DAILY \n6. felbamate 1800 mg oral DAILY 1200 \n7. felbamate 1200 mg oral QPM qpm \n8. LACOSamide 200 mg PO TID \n9. LamoTRIgine 200 mg PO BID \n10. LamoTRIgine 300 mg PO QPM \nAt 6pm \n11. LevETIRAcetam 1000 mg PO TID \n12. Omeprazole 20 mg PO DAILY \n13. Ranitidine 300 mg PO QHS \n14. Venlafaxine XR 150 mg PO QAM \n15. Venlafaxine XR 75 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nIntractable focal epilepsy with complex partial seizures.\nIntractable nonepileptic psychogenic events.\nObstructive sleep apnea.\nRespiratory compromise.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nSURGERY:\nYou underwent a VNS replacement including battery and lead.\n\n· Your dressing may come off on the second day after surgery. \n\n· Your incision is closed with dissolvable sutures underneath \nthe skin. You do not need suture removal.\n\n· Please keep your incision dry for 72 hours after surgery.\n\n· Please avoid swimming for two weeks.\n\n· Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \nMedications\n\n· You may use Acetaminophen (Tylenol) for minor discomfort \nif you are not otherwise restricted from taking this medication.\n\n· It is important to increase fluid intake while taking pain \nmedications. We also recommend a stool softener like Colace. \nPain medications can cause constipation. \n\n- Your Aspirin can be re-started 3 days after your surgery. \n\nWhen to Call Your Doctor at ___ for:\n\n· Severe pain, swelling, redness or drainage from the \nincision site. \n\n· Fever greater than 101.5 degrees Fahrenheit\n\n· New weakness or changes in sensation in your arms or legs.\n\n \nFollowup Instructions:\n___\n" ]

[ "T85111A", "G40219", "Z6842", "T85113A", "F458", "Z8661", "F329", "G4733", "E669", "E785", "K219", "R51", "Z86711", "Z87891", "F4320", "I10" ]

[ "T85111A: Breakdown (mechanical) of implanted electronic neurostimulator of peripheral nerve electrode (lead), initial encounter", "G40219: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "T85113A: Breakdown (mechanical) of implanted electronic neurostimulator, generator, initial encounter", "F458: Other somatoform disorders", "Z8661: Personal history of infections of the central nervous system", "F329: Major depressive disorder, single episode, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E669: Obesity, unspecified", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R51: Headache", "Z86711: Personal history of pulmonary embolism", "Z87891: Personal history of nicotine dependence", "F4320: Adjustment disorder, unspecified", "I10: Essential (primary) hypertension" ]

[ "F329", "G4733", "E669", "E785", "K219", "Z87891", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / NSAIDS (Non-Steroidal \nAnti-Inflammatory Drug) / shrimp / shellfish derived\n \nAttending: ___.\n \nChief Complaint:\nDyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\n___ Mitral valve repair with a resection of the middle \nscallop of the posterior leaflet P2 and a mitral valve \nannuloplasty with a 32 ___ annuloplasty band\n \nHistory of Present Illness:\n___ year old female who was found to have a murmur in ___ and an \nechocardiogram at that time demonstrated MVP with moderate MR. \n___ had remained fairly asymptomatic and requested to defer any \ntype of surgical intervention at that time. Over the past year \nshe has been experiencing progressive shortness of breath with \nwalking up inclines or stairs. A stress echocardiogram in ___ demonstrated severe MVP and MR. ___ was referred for a \ncardiac catheterization to further evaluate. She was found to \nhave insignificant coronary artery disease and is now being \nreferred to cardiac surgery for a mitral valve repair vs \nreplacement. A TEE performed today showed 4+ mitral \nregurgitation with bileaflet prolapse.\n \nPast Medical History:\nMitral regurgitation and prolapse\nHypertension \nHypothyroidism/___'s thyroiditis \nBladder CA ___ s/p excision \nStrep UTI ___ \nIrritable bowel syndrome \nBladder Excision d/t CA \nHysterectomy \nTonsillectomy\n \nSocial History:\n___\nFamily History:\nFather died at ___ of CVA\n \nPhysical Exam:\nBP: 128/85. Heart Rate: 68. Resp. Rate: 12. O2 Saturation%: 100.\nHeight:5'6\" Weight: 134lb\n\nGeneral: WDWN in NAD. Somewhat somnolent from anesthetic at this \nmornings TEE\nSkin: Dry [X] intact [X] Warm [X]\nHEENT: PERRLA [X] EOMI [X] Sclera anicteric, OP benign. Teeth in \ngood repair. \nNeck: Supple [X] Full ROM [X] No JVD\nChest: Lungs clear bilaterally [X]\nHeart: RRR, IV/VI systolic murmur heard best at mid sternal \nborder and apex\nAbdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds \n+[X]\nExtremities: Warm [X], well-perfused [X] No Edema\nVaricosities: None [X]\nNeuro: Grossly intact [X]\nPulses:\nFemoral Right:2 Left:2\nDP Right:2 Left:2\n___ Right:2 Left:2\nRadial Right:2 Left:2\n\nCarotid Bruit Right: None Left: None\n \nPertinent Results:\nEcho ___: The left ventricular cavity size is normal. \nOverall left ventricular systolic function is normal (LVEF>55%). \nRight ventricular chamber size and free wall motion are normal. \nThe ascending, transverse and descending thoracic aorta are \nnormal in diameter and free of atherosclerotic disease.. The \naortic valve leaflets (3) appear structurally normal with good \nleaflet excursion. There is no aortic valve stenosis. Trace \naortic regurgitation is seen. There is moderate/severe mitral \nregurgitaion.the P2 leaflet is flail.There are ___ \npredictors.The posterior mitral leaflet length is >=1.0cm . \nSevere (4+) There is mild tricuspid regurgitation.. There is no \npericardial effusion. \nPost bypass: There is mild mitral regurgitation .No mitral \nstenosis.The ___ ring is intact.The LVEF is 55% the rest of \nthe exam is unchnged. The thoracic aorta os intact.\n \nBrief Hospital Course:\nMrs. ___ was a same day admit and on ___ she was brought to \nthe operating room where she underwent a mitral valve repair. \nPlease see operative note for surgical details. Following \nsurgery she was transferred to the CVICU for invasive monitoring \nin stable condition. on POD#0 she was weaned from sedation, \nawoke neurologically intact and extubated.\nBeta blocker was initiated and the patient was gently diuresed \ntoward the preoperative weight. The patient was transferred to \nthe telemetry floor for further recovery. Chest tubes and \npacing wires were discontinued without complication. The \npatient was evaluated by the physical therapy service for \nassistance with strength and mobility. By the time of discharge \non POD#5 the patient was ambulating freely, the wound was \nhealing and pain was controlled with oral analgesics. The \npatient was discharged to home in good condition with \nappropriate follow up ___ and home ___.\n\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amitriptyline 10 mg PO QHS \n2. Amoxicillin ___ mg PO ONCE dental \n3. Calcitriol 0.25 mcg PO DAILY \n4. Levothyroxine Sodium 125 mcg PO DAILY \n5. Acetaminophen 650 mg PO Q6H:PRN pain \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q4H:PRN pain \n2. Amitriptyline 10 mg PO QHS \n3. Calcitriol 0.25 mcg PO DAILY \n4. Levothyroxine Sodium 125 mcg PO DAILY \n5. Aspirin EC 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n6. Docusate Sodium 100 mg PO BID \n7. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet \nRefills:*0\n8. Potassium Chloride 20 mEq PO DAILY \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp \n#*5 Tablet Refills:*0\n9. Metoprolol Tartrate 6.25 mg PO BID \nRX *metoprolol tartrate 25 mg ___ tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0\n10. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n11. Milk of Magnesia 30 mL PO DAILY \n12. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain \nRX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3 \nhours Disp #*65 Tablet Refills:*0\n13. Amoxicillin ___ mg PO ONCE dental \n14. Outpatient Physical Therapy\nRolling walker\n\ndiagnosis: s/p mitral valve repair\nprognosis: good\nexpected length of use: 13 months\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nMitral regurgitation and prolapse s/p Mitral valve repair \nPast medical history: \nHypertension \nHypothyroidism/___'s thyroiditis \nBladder CA ___ s/p excision \nStrep UTI ___ \nIrritable bowel syndrome \nBladder Excision d/t CA \nHysterectomy \nTonsillectomy \n \nDischarge Condition:\nAlert and oriented x3 nonfocal \nAmbulating with steady gait\nIncisional pain managed with oral analgesics\nIncisions: \nSternal - healing well, no erythema or drainage \nEdema: trace\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\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" ]

[ "I340", "I511", "D62", "I10", "Z8551", "K589", "I341", "E039", "Z87891", "Y831", "Y92239" ]

[ "I340: Nonrheumatic mitral (valve) insufficiency", "I511: Rupture of chordae tendineae, not elsewhere classified", "D62: Acute posthemorrhagic anemia", "I10: Essential (primary) hypertension", "Z8551: Personal history of malignant neoplasm of bladder", "K589: Irritable bowel syndrome without diarrhea", "I341: Nonrheumatic mitral (valve) prolapse", "E039: Hypothyroidism, unspecified", "Z87891: Personal history of nicotine dependence", "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" ]

[ "D62", "I10", "E039", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nImdur / nitroglycerin / Bactrim\n \nAttending: ___\n \nChief Complaint:\nChest Pain \n \nMajor Surgical or Invasive Procedure:\n___ Cardiac catherization \n\n \nHistory of Present Illness:\nMr. ___ is a ___ gentleman with atypical chest \npain and CAD s/p PCI and stent to LAD, cardiomyopathy, \nhypertension, hypercholesterolemia, paroxysmal atrial \nfibrillation s/p multiple ablations, and defibrillator who \npresents with chest pain. \n\nHe had a stress test during his recent admission to ___ \n___ which was indeterminate for inducible ischemia \nsecondary to maximum heart rate and since chest pain was \nproducible he is now referred for coronary angiogram. He has \nbeen treated with a\nLovenox bridge since discharge on ___. On interview today \nMr ___ reports no chest discomfort since his stress test two \ndays ago. Reports decreased appetite and mild nausea. Denies \nshortness of breath or diaphoresis. Has been belching a lot \nwith gas. \n\nDenies palpitations, lightheadedness, presyncope, syncope, and\nfalls. Denies pedal edema and claudication. Denies orthopnea\nand PND. Sleeps with one pillow\n\nIn the ED initial vitals were: 97.9 88 121/73 18 95% RA. EKG: \nAtrial paced rhythm, Rate 70, PR 193, QTc 469 Labs/studies \nnotable for: trops 2X <0.01, electrolytes w/ K+ 4.4 and Cr 0.8, \nALT 55, AST 34 Alkphos 83 with LDH 302 tbili 1.0 Alb 4.3. WBC \nslightly elevated at 10.1 with normal hgb 14.6, plt 132. Patient \nwas given ASA 325 mg, Ondansetron 4 mg, SLN 0.3, morphine 2 mg \nIV. Vitals on transfer: 98.4F, HR 70 bpm, BP 125/75, RR 16 96% \nRA.\n\nOn the floor patient complaining of pains in his shoulder blades \npresent since his dobutamine stress echo on ___. He \nstates early this AM he had chest pressure worse with deep \ninspiration but sharp stabbing pains that he experienced after \ndobutamine stress echo had resolved. He states the morphine in \nED somewhat relieved his shoulder blade pain. \n\nROS: Denies hx GI bleed, CVA, DVT. Denies recent fevers, chills \nor rigors. Denies exertional buttock or calf pain. Cardiac \nreview of systems is notable for absence dyspnea on exertion, \nparoxysmal nocturnal dyspnea, orthopnea, ankle edema, \npalpitations, syncope or presyncope.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY:\n1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia, -diabetes\n2. CARDIAC HISTORY:\n- CABG: None\n- PERCUTANEOUS CORONARY INTERVENTIONS: None\n- PACING/ICD: ICD \n3. PAST MEDICAL HISTORY:\nAtypical chest pain\nCAD stenting of LAD and multiple attempts to intervene on ___ \ndiagonal\nVentricular tachycardia / fibrillation w/ cardiac arrest during \nstress test, s/p defibrillator and demand pacemaker \nDefibrillator\nParoxysmal atrial fibrillation w/ Lovenox bridge; s/p multiple \nablations\n1st degree AV block\nHx of pericarditis at age ___\nCellulitis\nHypothyroidism\nBorderline diabetes\n\n \nSocial History:\n___\nFamily History:\nFather with CAD and MI at age ___. \n\n \nPhysical Exam:\nON ADMISSION: \n===============================\nPHYSICAL EXAM:\nVS: T= 98.1 BP= Left 142/93 Right 155/90 ___ RR=20 O2 \nsat=97% RA \nGENERAL: Oriented x3. Mood, affect appropriate.\nHEENT: Sclera anicteric. PERRL, Conjunctiva were pink, no pallor \nor cyanosis of the oral mucosa. No xanthelasma.\nNECK: Supple with JVP of 5 cm.\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.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES: Distal pulses palpable and symmetric\n\nON DISCHARGE: \n=================================\nPHYSICAL EXAM:\nVS: T=98.3 BP=108/64-121/81 HR=70 ___ O2 sat=99% RA \nI/O 120+/950++\nWeight 114.7 kg \nGENERAL: Oriented x3. Mood, affect appropriate.\nHEENT: Sclera anicteric. PERRL, Conjunctiva were pink, no pallor \nor cyanosis of the oral mucosa. No xanthelasma.\nNECK: Supple with JVP of 5 cm.\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.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES: Distal pulses palpable and symmetric\n\n \nPertinent Results:\nLABS ON ADMISSION: \n===================================\n___ 03:00PM cTropnT-<0.01\n___ 10:50AM GLUCOSE-109* UREA N-15 CREAT-0.8 SODIUM-136 \nPOTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16\n___ 10:50AM ALT(SGPT)-55* AST(SGOT)-34 LD(LDH)-302* ALK \nPHOS-83 TOT BILI-1.0\n___ 10:50AM LIPASE-37\n___ 10:50AM cTropnT-<0.01\n___ 10:50AM ALBUMIN-4.3\n___ 10:50AM WBC-10.1* RBC-5.10 HGB-14.6 HCT-44.3 MCV-87 \nMCH-28.6 MCHC-33.0 RDW-12.9 RDWSD-40.7\n___ 10:50AM NEUTS-62.9 ___ MONOS-11.6 EOS-3.3 \nBASOS-0.8 IM ___ AbsNeut-6.37* AbsLymp-2.13 AbsMono-1.17* \nAbsEos-0.33 AbsBaso-0.08\n___ 10:50AM PLT COUNT-132*\n___ 10:50AM ___ PTT-36.6* ___\n\nLABS ON DISCHARGE: \n=======================================\n___ 05:35AM BLOOD WBC-7.5 RBC-5.12 Hgb-14.6 Hct-43.9 MCV-86 \nMCH-28.5 MCHC-33.3 RDW-12.6 RDWSD-39.2 Plt ___\n___ 05:35AM BLOOD Plt ___\n___ 05:35AM BLOOD Glucose-94 UreaN-17 Creat-0.9 Na-135 \nK-4.4 Cl-95* HCO3-30 AnGap-14\n___ 07:35AM BLOOD ALT-50* AST-30 AlkPhos-84 TotBili-1.1\n___ 07:35AM BLOOD Lipase-27\n___ 03:00PM BLOOD cTropnT-<0.01\n___ 10:50AM BLOOD cTropnT-<0.01\n___ 05:35AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.0\n\nIMAGES/STUDIES/PROCEDURES: \n========================================\n\n___ Cardiac Cath\nSystolic 128 Diastolic 89 MAP 89 HR 69\nLMCA short vessel without disease \nLAD ___ stent patent without restenosis D1 ostial 75% \nstenosis (jailed vessel) thin vessel. \nCircumflex without disease. Large dominant vessel. \nRCA ostial 30% stenosis suspicious for spasm \nImpression: \nCAD with patent LAD stent and partially jailed thin D1 vessel \nwith ostial 75% stenosis. HTN. HLD. \n\n___ CXR \nA left-sided pacemaker and dual leads are seen in expected \nposition. The \ncardiomediastinal and hilar contours are within normal limits. \nThe lungs are clear without focal consolidation, pleural \neffusion, pulmonary edema or pneumothorax. \nIMPRESSION: No acute cardiopulmonary process. \n\n___\nAtrial pacing with ventricular sensing. No previous tracing \navailable for \ncomparison. \nIntervals Axes \nRate PR QRS QT QTc (___) P QRS T \n70 193 98 ___ ___ year old gentleman with atypical chest pain and CAD status \npost PCI and stent to LAD, cardiomyopathy, hypertension, \nhypercholesterolemia, paroxysmal atrial fibrillation status post \nmultiple ablations, and defibrillator presented to ED on \n___ with ongoing chest pain and back pain after \ndobutamine stress ECHO on ___. \n# CORONARIES: CAD stenting of LAD and multiple attempts to \nintervene on ___ diagonal \n# PUMP: LEVF 65% no segmental wall motion abnormalities. \n# RHYTHM: Atrial paced sinus rhythm \n\n# Coronary Artery Disease: \nIn the ED, patient was normotensive and ECG showed an atrial \npaced rhythm, Rate 70, PR 193, QTc 469 but was otherwise \nunremarkable. Trops 2X <0.01. Patient presented on enoxaparin \n120 mg BID as a bridge from warfarin for his scheduled cardiac \ncatherization on ___. On arrival to the floor, patient was \nchest pain free. He was continued on home dose 81 mg ASA, \natorovstatin 80 mg, metoprolol 100 mg, lisinopril 10 mg and \nsotalol 120 mg. He remained chest pain free during admission. He \nunderwent cardiac catherization on ___ that showed clean \ncoronaries and no intervention was done. Lisinopril was held day \nof cardiac cath and restarted on discharge. \n\n# Back Pain: \nHe experienced ___ pain in paraspinal muscle bilaterally \nradiating to his shoulder blades that was somewhat responsive to \nbaclofen and PO diludad. No pulsatile mass in abdomen, bilateral \nBP were 150's/90's and equal. ALT was mildly elevated to 55 but \nLFTs were otherwise unremarkable with normal lipase. Prior to \ncardiac catherization, patient's back pain resolved. \n\n# Paroxysmal afib: \nPatient remained in a paced sinus rhythm at a rate of 70's \nduring admission. Patient has a history of paroxysmal atrial \nfibrillation s/p pacemaker. Patient stopped warfarin on ___ \nand bridged with 120 mg BID enoxaparin in preparation for \ncardiac cath. On admission, he was continued on 120 mg BID \nenoxaparin while inpatient with last dose evening of ___ \nprior to cardiac catherization. Enoxaparin should be restarted \nmorning of ___ and warfarin restarted evening ___. \nHis INR should be checked on ___. Patient states he \nchecks his INR at home and calls into his physician. He verified \nhe would check on ___ and call his physician. \n\n# h/o ventricular tachycardia: s/p backup pacemaker. He was \ncontinued on home dose sotolol. \n \n# Hypothyroidism: Continued home dose levothyroxine \n\n======================\nTransitional Issues \n======================\n- Patient was chest and back pain free on day of discharge. \n- Warfarin was restarted on discharge with bridge with \nenoxaparin 120 mg BID. ___ should be checked on ___\n- Cardiac Cath on ___ showed clean coronaries no \nintervention was done.\n- Full code \n- Contact Wife ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Warfarin 5 mg PO DAILY16 \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Levothyroxine Sodium 88 mcg PO DAILY \n5. Lisinopril 10 mg PO DAILY \n6. Metoprolol Succinate XL 100 mg PO DAILY \n7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n8. Sotalol 120 mg PO BID \n9. Enoxaparin Sodium 120 mg SC BID \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Levothyroxine Sodium 88 mcg PO DAILY \n4. Metoprolol Succinate XL 100 mg PO DAILY \n5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n6. Sotalol 120 mg PO BID \n7. Lisinopril 10 mg PO DAILY \n8. Warfarin 5 mg PO DAILY16 \nStart taking this medicine tomorrow evening (___) \n9. Enoxaparin Sodium 120 mg SC BID \nStart taking tomorrow morning (___) \n10. Outpatient Lab Work\nICD 10: I48 Atrial Fibrillation \nPlease check ___ \nFax result: ATTN ___. MD ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY: \nCoronary Artery Disease\nAfib paroxysmal on warfarin anticoagulation\nh/o ventricular tachycardia w/ s/p backup pacemaker \n\nCHRONIC: \nHypothyroidism\nHTN \nHLD \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to ___ for chest and back pain after your \nstress test. While you here to underwent a procedure called a \ncardiac catheterization to look at the coronary arteries that \nsupple blood to the muscles in your heart. The arteries that \nsupply your heart are clear and healthy, you did not have a \nheart attack. \n\nYou should start taking your lovenox (enoxaparin) 120mg BID \nstarting morning of ___ and warfarin 5 mg on the evening \nof ___. Please check your ___ on ___ and call \nyour results in. \n\nPlease keep your appointments as scheduled below. Please call \nyour primary care doctor if your chest or back pain returns. \n\nThank you for allowing us to participate in your care. \n-___ care team \n \nFollowup Instructions:\n___\n" ]

[ "I25110", "I429", "I480", "E039", "I10", "E785", "Z7982", "Z7901", "Z95810", "Z9861" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "I429: Cardiomyopathy, unspecified", "I480: Paroxysmal atrial fibrillation", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z7982: Long term (current) use of aspirin", "Z7901: Long term (current) use of anticoagulants", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "Z9861: Coronary angioplasty status" ]

[ "I480", "E039", "I10", "E785", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril / amlodipine / iodine\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nHISTORY OF THE PRESENTING ILLNESS: \n___ man with past medical history of coronary artery\ndisease s/p 4 stents (most recent in ___, difficult to control\ndiabetes, GERD, HIV with recent CD4 of 1700, and obesity who\npresents today with 24 hours of atypical chest pain while flying\nfrom ___. He states yesterday evening while resting in bed \nin\n___, he felt pressure over his xiphoid process/epigastrum\nassociated with nausea that prevented him from sleeping and\nlasted about 8 hours. With this episode, he had no associated\nvomiting, diaphoresis, arm pain, jaw pain, or left chest pain or\ndyspnea. In the morning, on his flight back to the ___, he \nhad\n2 separate events lasting 5 minutes each of stabbing chest pain\nover the left pectoral No radiation to his arms and was not\nassociated with dyspnea, diaphoresis, nausea, vomiting, or jaw\npain. Both these episodes abated on their own. He was able to\nambulate once he returned to the ___, but was \nconcerned\nas this was similar to prior presentation of ACS when traveling\nfrom ___. He denies any recent surgery, immobilization, \nleg\nswelling, calf pain, or history of cancer.\nHe denies any infectious symptoms or traumatic events.\n\nIn the ED, initial vitals were: T 98.5 73 137/72 17 98% RA \n- Exam notable for: A&Ox3, RRR with nl S1S2 no MRG, CTAB, no \ncalf\nswelling, erythema, or bilateral lower extremity swelling\n- Labs notable for: negative trops x2, D-dimer 378, Mg 1.5, Cr\n1.5, Hgb 12.4\n- Imaging was notable for: \n___ CXR PA/LAT: No acute cardiopulmonary process. \n- Patient was given: 1 L NS IVF, heparin gtt\n\nUpon arrival to the floor, patient is doing well and has no\nsymptoms. \n\nROS: Positive per HPI. Remaining 10 point ROS reviewed and\nnegative \n \nPast Medical History:\n1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension \n2. CARDIAC HISTORY: \n- CABG: None\n- PERCUTANEOUS CORONARY INTERVENTIONS: S/P prior D1 Cypher \nstenting on ___ at ___ and an Endeavor stent to the LAD in \n___. Had a50% D1 lesion at last cath. Had ___ cath at ___ \n\nwith finding of 80% instent resten of the LAD, treated with \nangioplasty. A 3-4 mm pseudoaneurysm was seen at the distal tip \nof the patent stent in the diag. Dr. ___ a 6 mos CT scan \nof the chest for that. That was done in ___, and no FA was \nnoted. \n- PACING/ICD: None \n3. OTHER PAST MEDICAL HISTORY:\nHIV recently put on therapy \nPUD w/ h/o GIB\nCAD\nDM with DIABETIC RETINOPATHY- am sugar 100-135\nSLEEP APNEA\nHTN\nHLD\nGERD\nED\nBPH\nRHINITIS\nCLBP\nOBESITY\nDEPRESSION\nASTHMA\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nPHYSICAL EXAM:\nVS: ___ 1042 Temp: 98.3 PO BP: 144/82 L Lying HR: 52 RR: 18\nO2 sat: 97% O2 delivery: Ra FSBG: 125 \nGENERAL: AA gentleman in NAD\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, obese, nondistended, nontender in all \nquadrants\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\n\nDISCHARGE PHYSICAL EXAM:\n========================\n24 HR VS: afebrile, HR 48-67, BP 105-138/64-81, RR ___, O2 sat\n96-98% on room air \nGENERAL: NAD, alert and interactive \nHEENT: AT/NC, anicteric sclera\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, obese, nondistended, nontender in all \nquadrants\nEXTREMITIES: no edema\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 09:30PM BLOOD WBC-4.0 RBC-4.52* Hgb-12.4* Hct-38.9* \nMCV-86 MCH-27.4 MCHC-31.9* RDW-14.6 RDWSD-45.8 Plt ___\n___ 09:30PM BLOOD Neuts-50.8 ___ Monos-11.0 Eos-3.8 \nBaso-0.3 Im ___ AbsNeut-2.04 AbsLymp-1.35 AbsMono-0.44 \nAbsEos-0.15 AbsBaso-0.01\n___ 09:30PM BLOOD Glucose-181* UreaN-21* Creat-1.5* Na-139 \nK-3.5 Cl-101 HCO3-28 AnGap-10\n___ 09:30PM BLOOD cTropnT-<0.01\n___ 03:44AM BLOOD cTropnT-<0.01\n___ 02:45PM BLOOD CK-MB-5 cTropnT-<0.01\n___ 09:30PM BLOOD Calcium-8.9 Phos-2.1* Mg-1.5*\n___ 09:30PM BLOOD D-Dimer-378\n\nPERTINENT STUDIES:\n==================\n___ Cardiac perfusion imaging\nFINDINGS: Left ventricular cavity size is mildly enlarged. \nResting and stress perfusion images reveal uniform tracer uptake \nthroughout the \nleft ventricular myocardium. \n \nGated images reveal normal wall motion. \nThe calculated left ventricular ejection fraction is 54%. \n \nIMPRESSION: Mildly enlarged left ventricular cavity. Normal \nsystolic \nventricular function. No focal perfusion defects. \n\n___ Stress Test (exercise EKG)\nINTERPRETATION: This ___ year old IDDM man with a h/o CAD, HTN \nand \nHLD s/p MI in ___ and stenting x4 in ___ was referred to \nthe \nlab for evaluation of chest discomfort. The patient exercised \nfor 9.25 \nminutes of ___ protocol and stopped for fatigue. The \nestimated peak \nMET capacity is 10.4, representing a good functional capacity \nfor his \nage. There were no chest, neck, arm or back discomforts reported \nduring \nexercse; however at 1.5 minutes of recovery the patient reported \na ___ \nfocal upper left-sided chest discomfort (different from the \ndiscomfort \nhe was referred for), which was reportedly absent by 4.25 \nminutes of \nrecovery. At peak exercise there was 2.0-2.5 mm horizontal ST \nsegment \ndepression in the inferior leads, 1.5-2.0 mm horizontal ST \nsegment \ndepression in leads I, V4-6 and 1.0-1.5 mm ST segment elevation \nin lead \naVR. These changes slowly improved with rest during recovery and \n\nreturned to baseline by 10 minutes of recovery. The rhythm was \nsinus \nwith one isolated APB and one isolated VPB early post-exercise. \nAppropriate blood pressure response to exercise and recovery \nwith a \nblunted heart rate response to exercise in the setting of beta \nblockade. \n \nIMPRESSION: Ischemic EKG changes in the absence of anginal type \nsymptoms \nduring exercise. Atypical anginal type symptoms early \npost-exercise. \nGood functional capacity. Nuclear report sent separately. \n\nCHEST (PA & LAT)Study Date of ___ 12:30 AM\nNo acute cardiopulmonary process.\n\nECGStudy Date of ___ 9:41:58 ___\nSporadically abnormal T-wave inversions, mild ST depressions in \nleads I and aVL as noted in ___ EKG, less prominent bleeding \nnoted on post angioplasty EKG but ___ EKG with same T-wave \ninversions arguably even mildly more\nprominent ST depression in I and aVL, chronic Q-wave in lead III \nwith mild ST elevation 0.5-1 mm which was also in today's study, \nnot dramatically different from most previous EKGs.\n\nMICROBIOLOGY:\n=============\nNone\n\nDISCHARGE LABS:\n===============\n\n___ 06:20AM BLOOD WBC-5.3 RBC-4.75 Hgb-13.5* Hct-41.9 \nMCV-88 MCH-28.4 MCHC-32.2 RDW-14.7 RDWSD-47.3* Plt Ct-ERROR\n___ 06:20AM BLOOD ___ PTT-28.8 ___\n___ 06:20AM BLOOD Glucose-206* UreaN-15 Creat-1.2 Na-139 \nK-4.2 Cl-101 HCO3-25 AnGap-13\n___ 06:20AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8\n \nBrief Hospital Course:\nMr. ___ is a ___ AA gentleman with CAD s/p stentsx4,\ndifficult to control T2DM, obesity, GERD, HIV with recent CD4 of\n1700, and CKD stage 3, presenting with atypical chest pain. ACS\nworkup negative. First episode of xiphoid/epigastric pressure\nthat lasted for 8hr while lying in bed at night favored to be \nGERD. Second episode of sharp stabbing pain on plane the next \nday more worrisome given hx of similar\nsymptoms that resulted in previous positive ACS workup. \n\nACTIVE PROBLEMS:\n================\n# Atypical chest pain iso CAD s/p stentsx4 (most recent ___:\nPresented with atypical chest pain. ACS work-up negative and \nd-dimer within normal limits. Patient was placed on heparin gtt \nfor 24 hours and remained chest pain free. Heparin gtt was \ndiscontinued and patient had no recurrent of chest pain. He had \nexercise stress test on ___ which showed ischemic EKG \nchanges in the absence of anginal-type symptoms during exercise. \nHe had good functional capacity as well. Patient discharged with \nCardiology follow-up. \n\n#HTN\nOn amlodipine, metop, losartan, terazosin, and chlorthalidone at\nhome. Held losartan and chlorthalidone for renal protection and \npatient will continue to hold Chlorthalidone and losartan until \nhe has outpatient cardiology follow-up on ___. \n\nTRANSITIONAL ISSUES:\n====================\nDischarge weight: 105 kg\n[] Check BP at follow-up Cardiology appointment. Would recommend \nrestarting Chlorthalidone and losartan at outpatient follow-up \nappointment ___. \n[] Recheck BMP at follow-up appointment. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Terazosin 10 mg PO DAILY \n2. Losartan Potassium 50 mg PO BID \n3. Gabapentin 300 mg PO TID \n4. Metoprolol Succinate XL 50 mg PO BID \n5. MetFORMIN (Glucophage) 500 mg PO BID \n6. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n7. amLODIPine 5 mg PO DAILY \n8. Dolutegravir 50 mg PO DAILY \n9. LaMIVudine 300 mg PO DAILY \n10. Atorvastatin 80 mg PO QPM \n11. Aspirin 81 mg PO DAILY \n12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n13. Pantoprazole 40 mg PO QAM \n14. TraZODone 200 mg PO QHS \n15. Vitamin D ___ UNIT PO DAILY \n16. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY \n17. Oxybutynin 10 mg PO DAILY \n18. ammonium lactate 12 % topical BID \n19. Chlorthalidone 25 mg PO DAILY \n20. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL \nsubcutaneous TID W/MEALS \n21. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL \n(3 mL) subcutaneous QAM \n\n \nDischarge Medications:\n1. amLODIPine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*0 \n2. ammonium lactate 12 % topical BID \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Dolutegravir 50 mg PO DAILY \n6. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n7. Gabapentin 300 mg PO TID \n8. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL \nsubcutaneous TID W/MEALS \n9. LaMIVudine 300 mg PO DAILY \n10. Lantus Solostar U-100 Insulin (insulin glargine) 100 \nunit/mL (3 mL) subcutaneous QAM \n11. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY \n12. MetFORMIN (Glucophage) 500 mg PO BID \n13. Metoprolol Succinate XL 50 mg PO BID \n14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n15. Oxybutynin 10 mg PO DAILY \n16. Pantoprazole 40 mg PO QAM \n17. Terazosin 10 mg PO DAILY \n18. TraZODone 200 mg PO QHS \n19. Vitamin D ___ UNIT PO DAILY \n20. HELD- Chlorthalidone 25 mg PO DAILY This medication was \nheld. Do not restart Chlorthalidone until you follow-up with \nyour cardiologist on ___.\n21. HELD- Losartan Potassium 50 mg PO BID This medication was \nheld. Do not restart Losartan Potassium until you follow-up with \nyour cardiologist on ___.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Atypical chest pain \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear Mr. ___, \nIt was a pleasure caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were having chest pain and came to the hospital. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- Your cardiac enzymes were checked and were negative. You were \nput on heparin to thin your blood while your chest pain was \nevaluated.\n- You had a stress test which did not show any new concerning \nfindings. \n \nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- You should take all of your medications as prescribed.\n- You should attend all of your follow-up appointments.\n- You should not take Chlorthalidone or losartan until you \nfollow-up with your Cardiologist on ___. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R0789", "E1122", "I129", "N183", "K219", "Z21", "I2510", "Z955", "E785", "G4733", "D472", "E669", "Z6832", "J45909", "E11319" ]

[ "R0789: Other chest pain", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "K219: Gastro-esophageal reflux disease without esophagitis", "Z21: Asymptomatic human immunodeficiency virus [HIV] infection status", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "D472: Monoclonal gammopathy", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "J45909: Unspecified asthma, uncomplicated", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema" ]

[ "E1122", "I129", "K219", "I2510", "Z955", "E785", "G4733", "E669", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nHayfever / Keflex / filbert nuts / Penicillins\n \nAttending: ___.\n \nChief Complaint:\nweight loss, L groin pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n ___ yo M with history of recent hospitalization \n___ for PE diagnosis then started on rivaroxaban \nwho returns to clinic for continued weight loss. \n Patient has several-year history of weight loss, from 200 lbs \nin ___ to 155 lbs now. He saw his PCP ___ in \nclinic today for hospitalization follow up and complained of new \nonset groin pain on L in addition to 10 lbs weight loss since \ndischarge. PCP noticed hernia and was also concerned about \n?extension of known DVT in RLE to abdomen despite being on \nrivaroxaban. With addition of weight loss PCP concerned for \nunderlying malignancy as cause of VTE so was sent to ED for \nevaluation. \n In the ED, initial vitals were: 98.0 68 135/68 16 99% RA \n Labs notable for: \n Normal CBC \n Ca ___ \n INR 1.6 \n Imaging notable for: \n CT Abd/Pelvis W & W/O Contrast ___ \n 1. No acute process within the abdomen or pelvis. \n 2. Left inguinal hernia containing fat and nonobstructed \nportion of descending colon. \n 3. Thrombus within the right common femoral vein. No evidence \nof \n intraabdominal extension of deep vein thrombus. \n 4. Enlarged prostate. \n Patient was given: nothing \n \n Vitals prior to transfer: 74 159/112 18 98% RA \n \n On the floor, patient endorses some L groin pain but otherwise \nis comfortable. He states that he has had 3 inguinal hernias in \nhis life, and then this most recent time pain started about 3 \nweeks ago. He was pretty sure it was a hernia again. He \ncontinues to have bowel movements/flatus. Pain is ___ and \nmostly when he sits bent at the waist. \n Regarding weight loss, he says over the past years he has lost \nweight unintentionally. He denies diarrhea, polyuria, or \ndysphagia. He does note that some days he does not have an \nappetite so will eat little more than some fruit and a muffin. \nNo nausea or vomiting associated with this, simply states that \nhe's not hungry. Denies night sweats. No red or black stools. No \ndifficulty with urination. \n Of note he has had recent issues with memory loss and has been \nseen by our cognitive neurology team. Initially started on \ndonepezil, he stopped this 5 days ago in case this was \ncontributing to weight loss. \n\n \n ROS: \n Complete ROS obtained and is otherwise negative \n \n \n \nPast Medical History:\n HL \n HTN \n BPH a/w elevated PSA to 18. Sees Urology regularly, bx in ___ \nwas negative for malignancy. Last PSA 15.5 ___ \n Nasal plyps \n Elevated PSA \n Spinal stenosis \n Varicose veins \n History of remote spine surgery \n History of hernia repair \n \nSocial History:\n___\nFamily History:\nHistory of provoked DVT in daughter in her ___ w/ neg coag w/u. \n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION\n============================\n Vital Signs: 97.7 104/40 68 18 100RA \n ___: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: bulge TTP in L groin region, did not attempt to reduce; no \noverlying erythema \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Neuro: CNII-XII intact, ___ strength upper/lower extremities \n Rectal: hemoccult negative, no gross blood \n \n\nPHYSICAL EXAM ON DISCHARGE\n==========================\nAM of discharge:\nStates he is feeling well this AM. States good understanding of \nwhy PCP was concerned, describes Dr. ___ that blood \nclot could be linked to underlying cancer but reviewed recent \nscan results with no obvious cancer source at this time (and UTD \non screenings). Concerned about recent weight loss in setting \nof loss of appetite; per patient no problems at home, no \nstressors, not feeling depressed. Denies CP/SOB, states \notherwise he is feeling well. L inguinal hernia per patient is a \n\"small problem\"; he has some mild pain with palpation and with \nmovement but laying bed very little pain. Denies pain in legs.\n\nVital Signs: (1725)___ / ___\n ___: Alert, oriented, no acute distress. Pleasant and \ncooperative white male, sleeping/laying comfortably in bed in \nNAD. \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: ? mild bulge mildly TTP in L groin region, did not attempt \nto reduce; no overlying erythema \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema. Has superficial varicose veins noted bilaterally, and \nlarge superficial mass likely clot in L inner thigh. No palpable \ncord, no calf tenderness. \n Neuro: CNII-XII intact, ___ strength upper/lower extremities \n \n \nPertinent Results:\nPERTINENT LAB RESULTS\n=====================\n___ 05:27PM BLOOD WBC-9.0 RBC-4.96 Hgb-14.0 Hct-44.9 MCV-91 \nMCH-28.2 MCHC-31.2* RDW-12.3 RDWSD-40.2 Plt ___\n___ 10:40AM BLOOD WBC-8.3 RBC-5.15 Hgb-14.5 Hct-45.2 MCV-88 \nMCH-28.2 MCHC-32.1 RDW-12.3 RDWSD-39.1 Plt ___\n___ 05:27PM BLOOD ___ PTT-40.5* ___\n___ 05:27PM BLOOD Glucose-155* UreaN-26* Creat-1.0 Na-140 \nK-4.4 Cl-100 HCO3-30 AnGap-14\n___ 10:40AM BLOOD Glucose-97 UreaN-24* Creat-0.9 Na-139 \nK-3.6 Cl-97 HCO3-30 AnGap-16\n___ 05:27PM BLOOD Albumin-3.9 Calcium-10.5* Phos-3.6 Mg-2.1\n___ 10:40AM BLOOD Calcium-10.0 Phos-3.5 Mg-2.1\n\nMICROBIOLOGY\n=============\nnone\n\nIMAGING AND PERTINENT PREVIOUS RESULTS\n=======================================\nCT Abd/Pelvis W & W/O Contrast ___ \n 1. No acute process within the abdomen or pelvis. \n 2. Left inguinal hernia containing fat and nonobstructed \nportion of descending colon. \n 3. Thrombus within the right common femoral vein. No evidence \nof \n intraabdominal extension of deep vein thrombus. \n 4. Enlarged prostate. \n CTA ___ \n 1. Subsegmental pulmonary emboli involving the left lower lobe \nwith probable left lower lobe infarct. \n 2. Filling defects within subsegmental pulmonary veins in the \nright and left lower lobes. \n 3. Intermediate density small left pleural effusion. \n \n R ___ ___ \n There is thrombosis of the majority of the greater saphenous \nvein from its origin to the level of the distal calf with \nextension into the common femoral vein at the greater saphenous \nvein origin, compatible with superficial and deep venous \nthrombosis. \n\nColonoscopy ___ \n Retroflex view of right colon was undertaken. \n Diverticulosis of the sigmoid colon \n Sessile polyp in the mid rectum (path = hyperplastic polyp) \n Otherwise normal colonoscopy to cecum \n\nCTA CHEST ___\nThere is no supraclavicular, axillary, mediastinal, or hilar \nlymphadenopathy. The thyroid gland appears unremarkable. \n \nThere is no evidence of pericardial effusion. There is a small \nintermediate density left pleural effusion. \n \nThe major airways are patent. There is mild compressive \natelectasis adjacent to the left lung base pleural effusion. \nMild dependent atelectasis is noted along the posterior aspect \nof the right lung. There is no evidence of pneumonia. \n \nLimited images of the upper abdomen demonstrate hypodensities \nwithin the liver, the largest measuring 1.3 cm, unchanged from a \nprior CT from ___, likely cysts and/or biliary hamartomas. \n \nNo lytic or blastic osseous lesion suspicious for malignancy is \nidentified. \n\nIMPRESSION: \n1. Subsegmental pulmonary emboli involving the left lower lobe \nwith probable \nleft lower lobe infarct. \n2. Filling defects within subsegmental pulmonary veins in the \nright and left lower lobes. \n3. Intermediate density small left pleural effusion. \n \n\n \nBrief Hospital Course:\n___ yo M with history of PE now on rivaroxaban who presents for \nchronic ongoing weight loss and newly diagnosed L inguinal \nhernia. CT ABdomen/Pelvis on admission with no acute process in \nabdomen/pelvis, L inguinal hernia with nonobstructed descending \ncolon, no evidence of intraabdominal extension of DVT, and \nenlarged prostate. Recent weight loss thought to be \nmultifactorial, given negative colonoscopy ___ and no occult \nblood on rectal exam, normal TSH, and previous screenings of \nprostate and skin as outpatient. Perhaps recent contribution of \nstress (death of close family member, recent hospitalization for \nDVT, diagnosis of mild cognitive impairment), GI upset from \nrecent medications (Donepezil, Ibuprofen). Hernia pain \nimproving, patient counseled about need for close follow up of \nweight loss and symptoms with outpatient provider. Patient was \nup to date on recommended screening tests. During his inpatient \nstay Lisinopril was held ___ low blood pressures (100s-110s \nsystolic). \n\n#Weight loss: weight trend 155.4 lbs in clinic ___ <- 165 ___ \n<- ___ <- ___. Possible malignant sources include \nGI (had colonoscopy ___ that removed 1 hyperplastic polyp) or \nGU (has history of enlarged prostate with elevated PSA, bx \nnegative); last PSA downtrending ___ . Rectal exam on \nadmission negative for blood and hemoccult negative. A1c pending \nbut unlikely source of weight loss. TSH 1.5 on admission, \nthyroid disorder unlikely. Unclear source of weight loss, but \npotentially multifactorial (GI upset related to donepezil, \nrecent inpatient admission for DVT/PE, stress of death of close \ncousin, recent ___ use in setting ___ pain.) At this \ntime, patient would most likely benefit from close outpatient \nfollow up and workup for underlying malignancy. \n\n #L inguinal hernia: new diagnosis, does not appear incarcerated \nat this time. No leukocytosis, afebrile. Patient has significant \nhistory of hernias s/p repair; potentially worsened in the \nsetting of recent constipation. Care Connections to set up Gen \nSurg appointment as outpatient. Warning signs for return to ED \nwere discussed with the patient. Pain improved on morning of \ndischarge. \n \n #Recent PE: on rivaroxaban since ___. PCP concerned for GI \nmalignancy so overnight team started on heparin gtt (held \nRivaroxaban on admission) in case planning for procedure. \nHeparin gtt d/ced and Rivaroxaban restarted. Will continue \nhomegoing Rivaroxaban with plans to follow up with outpatient \nPCP for follow up of dosing after ___ontinued. \n \n #HTN: holding lisinopril as inpatient ___ soft BPs. Will \ndetermine plan to restart or hold on discharge, recommend \nfurther follow up as outpatient.\n\n #Memory loss: patient is recently off donepezil. per patient \nand wife, significant GI issues after taking medication. Will \nrecommend further follow up with medication regimen as \noutpatient with cognitive neurology.\n \n#BPH: not taking meds at this time, no symptoms. Recommend ___ and consider Urology follow up as outpatient.\n \n\nTRANSITIONAL ISSUES\n====================\n- patient weight loss thought to be multifactorial (GI \nirritation from Donepezil, stress surrounding hospitalization \nand stress of cousin's recent death, possible irritation from \nIbuprofen in setting of DVT pain); started on symptomatic \ntreatement with tums, Maalox. Consider initiation of PPI if \ncontinued upper GI symptoms as outpatient. \n- held patient's Lisinopril in the setting of low BPs to \n100-110s as inpatient. Please reassess BPs as outpatient and \nrestart as needed\n- appointment made with ___ Surgery team for consideration \nof elective hernia repair\n- recommend continued follow up with other specialists (Urology, \nNeurology) as needed\n- continued on Rivaroxaban for DVT\n- please follow up repeat PSA sent while inpatient\n- HbA1c pending. Please follow up\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Rivaroxaban 15 mg PO BID \n2. Lisinopril 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Rivaroxaban 15 mg PO BID \n2. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do \nnot restart Lisinopril until you discuss it with your primary \ncare doctor\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\n- Left inguinal hernia\n- Weight loss NOS\n\nSecondary:\n- Unprovoked RLE DVT/PE\n- Hypertension\n- BPH\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 came into the hospital because your Primary Care doctor was \nconcerned that you were having worsening weight loss and groin \npain. In the hospital, you got a CT scan that showed that you \nhad a hernia. The CT scan showed that your blood clot was stable \nand was not worsening. \n\nFor your burping and reflux, we will recommend you try over the \ncounter medications like Tums or Maalox. Please discuss these \nsymptoms with Dr. ___.\n\nFor your hernia, please call your primary care doctor or return \nto the hospital if the bulge becomes larger, if it won't \"pop\" \nback in on it's own, if you have severe abdominal pain, or if \nthe area over the hernia becomes very red or discolored.\n\nIf you are having trouble with constipation, you may try over \nthe counter medications like Colace, Senna, or Miralax to help \nyour bowel movements stay regular. \n \nFollowup Instructions:\n___\n" ]

[ "K4090", "R634", "Z6824", "I10", "N400", "I82411", "Z86711", "Z7902", "Z87891" ]

[ "K4090: Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent", "R634: Abnormal weight loss", "Z6824: Body mass index [BMI] 24.0-24.9, adult", "I10: Essential (primary) hypertension", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I82411: Acute embolism and thrombosis of right femoral vein", "Z86711: Personal history of pulmonary embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "N400", "Z7902", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nHayfever / Keflex / filbert nuts\n \nAttending: ___.\n \nChief Complaint:\npleuritic chest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a history of varicose \nveins who presented to his PCP earlier today with ___ weeks of \nR leg pain. The pain developed while he was on vacation in ___ \nbut he did not mention the pain to his family until 3 days ago, \nat which time he was brought to ___ in ___ and extensive \nsuperficial venous thrombosis was noted and it was recommended \nthat he undergo f/u ultrasound in ___ days, which he underwent \nthis morning and was found to have worsening SVT and also DVT. \nWhen he presented to his PCP this AM he denied dyspnea but did \nendorse some pleuritic L sided chest pain and worsening ___ \nedema. He was referred from PCP to ___ for PE scan, which L \nsubsegmental pulmonary emboli involving the LLL with possible \nearly infarct.\n\nOf note the patient reports ~50 lbs weight loss over \napproximately ___ years. He reports mostly this has been gradual, \nalthough potentially more rapid recently. He reports that to \nsome degree he feels he is less hungry but his wife also reports \nthat sometimes he \"forgets to eat.\" He also notes that he is in \nthe process of evaluation for memory loss. He is still able to \ndo complex legal work (he is a retired ___) and manage \nfinances but has been somewhat slower at these jobs and repeats \nthings more often than he used to. He is awaiting brain MRI. He \nhas been taken off Lipitor for this reason. He has also been \ntaken off some of his antihypertensives recently (atenolol and \namlodipine). He reports that he is up to date on colonoscopy \nscreening. He also reports that he has an elevated PSA that has \nbeen attributed to BPH and that he is followed closely by \nurology who does not feel he has prostate cancer. \n\nNo recent prolonged immobility. Patient's daughter believes he \nhad superficial vein thrombosis remotely. His daughter also had \na DVT in her ___ with negative work-up for hypercoagulability. \nShe was on OCP and had been on long plane flight. \n\n___ Course:\nAfebrile, HRs ___, BPs 120s-150s/50s-80s, 99-100% on RA\nReceived 500 cc NS and 70 mg lovenox\n\nReview of systems: \nConst: no fevers, chills, dizziness, +weight change as above\nHEENT: no HA, changes in vision or hearing\nCV: +pleuritic chest pain\nPulm: no dyspnea, cough, or wheezing\nGI: no abd pain, n/v, c/d, + increased eructation today\nGU: no changes in urine or dysuria\nMSK: no new myalgias/arthralgias\nNeuro: no new focal weakness or numbness\nDerm: no new rashes\nHem: no new bleeding/bruising\nEndo: no hot/cold intolerance\nPsych: no recent mood changes per patient, although his wife \nfeels he has been down at times\n \nPast Medical History:\nHL\nHTN\nBPH\nNasal plyps\nElevated PSA\nSpinal stenosis\nVaricose veins\nHistory of remote spine surgery \nHistory of hernia repair\n \nSocial History:\n___\nFamily History:\nHistory of provoked DVT in daughter in her ___ w/ neg coag w/u. \n \nPhysical Exam:\nAdmission Physical Exam:\nVital signs: 97.9 188/78 87 16 100% on RA\ngen: pt in NAD\nHEENT: nc/at, sclera anicteric, conjunctiva noninjected, PER, \nEOMI, MMMs\nCV: RRR no m/r/g\nPulm: CTAB No c/r/w (notes L sided lateral chest wall pain w/ \ndeep inspiration)\nAbd/GI: S NT ND BS+, no masses/HSM palpated\nExtr: wwp, distal pulses intact, bilateral legs w/ varicose \nveins, R medial thigh with hardened cords and tenderness, mild \nedema R>L\nGU: no CVA tenderness, no Foley\nNeuro: alert and interactive, strength intact, sensation to \nlight touch slightly reduced over distal RLE\nSkin: no rashes on limited skin exam\nPsych/MS: normal range of affect'\n\nDISCHARGE\nVS: 97.8 124/64 62 16 100%RA \nGen: sitting up in bed, comfortable\nEyes - EOMI\nENT - OP clear, MMM\nHeart - RRR no mrg\nLungs - CTA bilaterally\nAbd - soft nontender, normoactive bowel sounds\nExt - no edema\nSkin - chronic venous stasis changes bilaterally\nVasc - venous varicosities over R leg; 2+ ___ pulses \nbilaterally\nNeuro - AOx3, moving all extremities\nPsych - appropriate\n \nPertinent Results:\nADMISSION\n___ 02:40PM BLOOD WBC-7.6 RBC-4.38* Hgb-12.5* Hct-39.0* \nMCV-89 MCH-28.5 MCHC-32.1 RDW-12.9 RDWSD-42.2 Plt ___\n___ 02:40PM BLOOD ___ PTT-29.2 ___\n___ 02:40PM BLOOD Glucose-125* UreaN-27* Creat-0.9 Na-142 \nK-3.8 Cl-107 HCO3-27 AnGap-12\n\nDISCHARGE\n___ 08:00AM BLOOD WBC-6.3 RBC-4.45* Hgb-12.6* Hct-38.9* \nMCV-87 MCH-28.3 MCHC-32.4 RDW-12.5 RDWSD-40.2 Plt ___\n___ 08:00AM BLOOD ___ PTT-38.1* ___\n___ 08:00AM BLOOD Glucose-99 UreaN-19 Creat-0.7 Na-141 \nK-3.8 Cl-107 HCO3-27 AnGap-11\n\nRLE Doppler\nThere is thrombosis of the majority of the greater saphenous \nvein from its origin to the level of the distal calf with \nextension into the common femoral vein at the greater saphenous \nvein origin, compatible with superficial and deep venous \nthrombosis.\n\nCTA Chest\n1. Subsegmental pulmonary emboli involving the left lower lobe \nwith probable left lower lobe infarct.\n2. Filling defects within subsegmental pulmonary veins in the \nright and left lower lobes.\n3. Intermediate density small left pleural effusion.\n \nBrief Hospital Course:\nThis is a ___ year old male with past medical history of \nhypertension, BPH, varicose veins, who was referred for \nadmission from PCP's office after diagnosis of new DVT in the \nsetting of pleuritic chest pain, subsequently found to have \nacute pulmonary embolism, with reassuring telemetry and EKG, \nstarted on rivaroxaban and able to be discharged home\n\n# Acute pulmonary embolism / Acute right Common Femoral DVT - \nPatient with several days worsening leg swelling in setting of \nrecent diagnosis of superficial thromboembolism, found to have \nacute R common femoral DVT--given ongoing pleuritic chest pain, \nhe was referred to ___ ___, where he was found to have acute \nDVT. He was started on lovenox and admitted to medicine. Per \nPESI score he was intermediate risk (based on age and gender, no \nadditional risk factors). EKG without signs of right heart \nstrain and patient was without any vital sign abnormalities or \nsymptoms (other than mild pleuritic L chest pain). Telemetry \nwas unremarkable. After discussion with patient and his PCP ___. \n___ was prescribed rivaroxaban, delivered to bedside, \nand instructed to begin taking 12 hours after last dose of \nlovenox. At time of discharge patient was ambulating \ncomfortably. He and wife were educated on warning signs that \nshould prompt additional care, and verbalized their \nunderstanding. \n\n# Hypertension - continued lisinopril \n\n# Mild Cognitive Impairment - continued donezpezil \n\nTRANSITIONAL\n- Discharged home with 21-day supply of rivaroxaban twice \ndaily--at follow-up visit he will need prescription for \nmaintenance daily dosing of rivaroxaban\n- Defer to outpatient providers regarding utility of additional \nworkup for unprovoked venous thromboembolism\n\n> 30 minutes spent on this discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 40 mg PO DAILY \n2. Donepezil 5 mg PO QHS \n3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Rivaroxaban 15 mg PO BID \nwith food; continue for 21 days \nRX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day \nDisp #*42 Tablet Refills:*0 \n2. Donepezil 5 mg PO QHS \n3. Lisinopril 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Acute pulmonary embolism / Acute right Common Femoral DVT\n# Hypertension\n# Mild Cognitive Impairment\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___: \n\nIt was a pleasure caring for you at ___. You were admitted \nwith a new diagnosis of a deep vein thrombosis (blood clot) in \nyour leg, and a pulmonary embolism (blood clot) in your lung. \nYou were treated with a blood thinning medication. You \nunderwent cardiac testing that was reassuring. \n\nWe discussed the situation with your primary care doctor who \nrecommended the medication Xarelto (rivaroxaban). \n\nPlease take it twice a day for 21 days. After this you will be \nable to take it once a day--please see your primary doctor who \nwill provide you with this once-a-day prescription. \n \nFollowup Instructions:\n___\n" ]

[ "I2699", "I82411", "I8390", "Z7902", "I10", "G3184", "Z87891" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "I82411: Acute embolism and thrombosis of right femoral vein", "I8390: Asymptomatic varicose veins of unspecified lower extremity", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I10: Essential (primary) hypertension", "G3184: Mild cognitive impairment, so stated", "Z87891: Personal history of nicotine dependence" ]

[ "Z7902", "I10", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nback pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ with history of COPD, CHF, hypertension, TIA, osteoarthritis\nand remote colon cancer, who presented with atraumatic back pain\nthat started when she was getting out of bed and found to have a\nT-spine fracture. She developed atraumatic back pain 3 days \nprior\nto admission while walking to the bathroom. She states the pain\nwas ___ in severity and non-radiating. She states it is worse\nwith movement and pain medication helps with the pain. \n\nShe also reported some subjective left leg weakness. She\npresented to the eye ___ where she was found to have urinary\nretention and a Foley was placed. She states that she has been\nhaving urinary retention for about a year but never sought\nmedical attention. She also states that she has not had a bowel\nmovement in 3 days and has good appetite. She denied any fever,\nnight sweats, chest pain, shortness of breath, lightheadedness,\nabdominal pain, nausea, vomiting. \n\n- In the ED, initial vitals were:\nT 97.7 HR 94 BP 138/51 RR 16 O2 96% RA \n \n- Exam was notable for:\n\"Midline low T-spine and ___ tenderness. Strength and\nsensation intact in distal extremities although the right lower\nextremity flexion is limited by pain. Normal rectal tone.\"\n\n- Labs were notable for:\nCBC unremarkable\nBMP unremarkable \nLFTs unremarkable\nUA unremarkable \nINR 1.0 \n\n- Studies were notable for:\nMR ___ spine with and without contrast \nCord or cauda equina compression: No. Please note that imaging\ncan make the anatomic diagnosis of cauda equina COMPRESSION, but\nthat cauda equina SYNDROME is a clinical diagnosis based on the\npatient examination. Imaging can never make a diagnosis of cauda\nequina SYNDROME.\nCord signal abnormality: no\nEpidural collection: no\nOther: Increased fluid signal within the T12 and L1 vertebral\nbodies at the site of known compression fractures. Multilevel\ndisc bulges, most prominent at L2-L3 causing moderate spinal\ncanal stenosis and bilateral neural foraminal stenosis.\n\n- The patient was given:\nIV morphine sulfate 2 mg x3 \n\n- Spine were consulted and recommended: \n \"TLSO ___ at edge of bed, no ___ restrictions, \nfollow\nup with Dr. ___ in 1 month with lumbar spine AP/lateral\nx-ray, pain management.\" \n\nOn arrival to the floor, She states her pain is ___ and her \npain\nis adequately controlled. She also complains of constipation.\n \nPast Medical History:\nHTN\nCOPD\nTIA\nOsteoarthritis\nHypothyroidism \nCHF (EF 60% in ___\nColon cancer\nSigmoid diverticulitis\nHysterectomy\nColectomy in ___\nCOPD\nSquamous cell carcinoma\n \nSocial History:\n___\nFamily History:\nNot relevant to current presentation\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS:\n24 HR Data (last updated ___ @ 742)\n Temp: 98.4 (Tm 98.4), BP: 172/70, HR: 86, RR: 20, O2 sat:\n97%, O2 delivery: 2L \nFluid Balance (last updated ___ @ 756) \n Last 8 hours Total cumulative 360ml\n IN: Total 360ml, PO Amt 360ml\n OUT: Total 0ml\n Last 24 hours Total cumulative 360ml\n IN: Total 360ml, PO Amt 360ml\n OUT: Total 0ml \nGENERAL: Alert and interactive. In no acute distress.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2.\ncrescendo-decrescendo murmur RUSB\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nBACK: No CVA tenderness. Non-tender to palpation. Deferred\nSciatic exam given fracture. \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. multiple healed scars.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. ___ strength throughout. Normal sensation.\n\nDISCHARGE PHYSICAL EXAM\n=======================\nPHYSICAL EXAM:\nVS:\n___ 1115 Temp: 98.0 PO BP: 123/61 HR: 70 RR: 18 O2 sat: 94%\nO2 delivery: Ra \n \nFluid Balance (last updated ___ @ 1200) \n Last 8 hours Total cumulative 185mL\n IN: Total 360 ml PO\n OUT: Total 175ml, Urine Amt 175ml + inctx1\n Last 24 hours Total cumulative 700ml\n IN: Total 940ml, PO Amt 940ml\n OUT: Total 285ml +inctx3 \nGENERAL: Alert and interactive. In no acute distress. Not \nwearing\nTLSO brace while in bed.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2.\n___ crescendo-decrescendo murmur appreciated throughout\nprecordium\nLUNGS: Decrease breath sound in all lung fields anteriorly\nBACK: Deferred Sciatic exam given fracture. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants.\nEXTREMITIES: 1+ pitting edema in bilateral lower extremities.\nPulses DP/Radial 2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. multiple healed scars.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs.\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 01:10PM WBC-9.4 RBC-3.79* HGB-11.7 HCT-35.6 MCV-94 \nMCH-30.9 MCHC-32.9 RDW-14.5 RDWSD-49.6*\n___ 01:10PM NEUTS-78.7* LYMPHS-11.1* MONOS-7.2 EOS-2.1 \nBASOS-0.4 IM ___ AbsNeut-7.39* AbsLymp-1.04* AbsMono-0.68 \nAbsEos-0.20 AbsBaso-0.04\n___ 01:10PM PLT COUNT-242\n___ 01:10PM GLUCOSE-63* UREA N-25* CREAT-0.7 SODIUM-138 \nPOTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-24 ANION GAP-18\n___ 01:10PM estGFR-Using this\n\nIMAGING\n=======\nMR ___ & W/O CONTRAST ___. No evidence of cauda equina compression. \n2. Compression fractures of L1 vertebral body (severe and with \nmild \nretropulsion) and L3 vertebral body (moderate). Superior \nendplate fracture of \nT12 vertebral body. The L1 and T12 fractures appear recent. \n3. Moderate lumbar spondylosis, most marked at L2-L3, with \nmoderate spinal \ncanal narrowing, secondary to diffuse disc bulge and ligamentum \nflavum \nthickening. There is moderate bilateral neural foraminal \nnarrowing at L3-L4. \n\nChest radiograph ___. Mild pulmonary vascular congestion without frank pulmonary \nedema. \n2. Consolidation in the left lower lung field, consistent with \nmoderate left \npleural effusion alongside associated atelectasis. Remaining \nleft lung is \nclear. Right lung is free of consolidation \n3. Density projecting above the aortic arch is of unknown \netiology. Recommend \nclinical correlation. \n\nDISCHARGE LABS:\n===============\n___ 07:59AM BLOOD WBC-7.1 RBC-3.56* Hgb-11.1* Hct-34.6 \nMCV-97 MCH-31.2 MCHC-32.1 RDW-14.6 RDWSD-52.4* Plt ___\n___ 07:59AM BLOOD Glucose-88 UreaN-27* Creat-0.8 Na-138 \nK-5.1 Cl-99 HCO3-31 AnGap-8*\n___ 07:59AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.8*\n \nBrief Hospital Course:\n___ with history of COPD, DMII, hypertension, and remote colon\ncancer who presented with atraumatic back pain and found to have\nT-spine fracture, urinary retention (for about a year) and\nhypoxia which has improved. Currently has a TSLO brace for\nsupport and HD and vitally stable. Discharged to rehab.\n\nACUTE/ACTIVE ISSUES:\n====================\n# Atraumatic T-spine fracture\nConcerning for underlying osteoporosis. No cord compression by \nimaging and urinary symptoms of unclear duration potentially. No \nsurgical intervention per spine surgery. Being treated with TLSO \nbrace when ambulating and pain medications. She also has an \nappointment with Dr. ___ in 2 weeks. She should continue to \nwear TLSO for duration when out of bed until f/u appointment. \nShe should continue to take calcium and vitamin D and f/u with \npcp for osteoporosis management. Pain control with Tylenol and \nPRN oxycodone, pt at times not taking oxycodone. Encourage pt to \nconsider small dose in AM to help with mobilization/getting out \nof bed to chair. \n\n#Constipation - resolved\nPatient complained of 5 days with no BM and recent indigestion. \nShe was started on multiple bowel regiments and had 2 bowel \nmovements on ___ and multiple BM on ___. Outpatient bowel \nregimen can be PRN. \n\n# Urinary retention - resolved\nConcerning for cord compression, but no evidence on imaging and \nrectal tone is normal, which is reassuring. Patient states that \nshe has been having an issue with urinary retention for about a \nyear. Perhaps secondary to severe pain. Foley in place and \nremoved on ___. She has been voiding without complaint.\n\n# New Left pleural effusion- Resolved \n# Hypoxemia \nShe was noted to be hypoxic to the low ___ on RA after receiving \nmultiple doses of IV morphine. CXR revealed left-sided pleural \neffusion which was resolved after continuation of home lasix. \nSubsequent CXR shows resolved effusion.\n\nCHRONIC/STABLE ISSUES:\n======================\n# Hypertension\n- Continue home amlodipine and losartan\n\n# Hypothyroidism\n- Continue home levothyroxine \n\nTRANSITIONAL ISSUES:\n===================\n[] f/u appointment with Dr. ___ in 2 weeks ___ \nat 10:45 am at ___. She should \ncontinue to wear TLSO brace when out of bed until this \nappointment.\n-- She will repeat Xray on same day as appt with Dr. ___ \n___: no HCP on file\nEmergency ___: ___ (___ (DAUGHTER ___ \n___) \n\nNew medications\n- oxycodone \n- vitamin d\n\nChanged medications\nnone\n\nStopped medications\nnone\n\nCORE MEASURES:\n==============\n# CODE: DNR/DNI\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Furosemide 20 mg PO DAILY \n2. amLODIPine 10 mg PO DAILY \n3. Levothyroxine Sodium 50 mcg PO DAILY \n4. Losartan Potassium 100 mg PO DAILY \n5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN wheezing \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*14 Tablet Refills:*0 \n3. Vitamin D 1000 UNIT PO DAILY \n4. amLODIPine 10 mg PO DAILY \n5. Furosemide 20 mg PO DAILY \n6. Levothyroxine Sodium 50 mcg PO DAILY \n7. Losartan Potassium 100 mg PO DAILY \n8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN wheezing \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\n# Atraumatic T-spine fracture\n# Constipation\n# Urinary retention\n# pleural effusion- Resolved \n# Hypoxemia \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear Ms. ___, \nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were in the hospital because severe back pain. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- At the hospital we did imaging of your back that showed a \nfracture in your lower back.\n- We got a brace for you to stabilize your back.\n- We also noted that you were having a hard time with passing \nstool which we gave you some medication to help you have a bowel \nmovement.\n- You were also having a hard time voiding so we place a foley \nthat we removed on ___. You were voiding with no issues \nafterward. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n-Please continue to take all of your medications and follow-up \nwith your appointments as listed below.\n-You should wear your brace when out of bed until your follow up \nappointment with Dr. ___. \nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "M8088XA", "I5030", "I110", "K5900", "R339", "J449", "E039", "Z66", "R0902", "Z85038" ]

[ "M8088XA: Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture", "I5030: Unspecified diastolic (congestive) heart failure", "I110: Hypertensive heart disease with heart failure", "K5900: Constipation, unspecified", "R339: Retention of urine, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "E039: Hypothyroidism, unspecified", "Z66: Do not resuscitate", "R0902: Hypoxemia", "Z85038: Personal history of other malignant neoplasm of large intestine" ]

[ "I110", "K5900", "J449", "E039", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PLASTIC\n \nAllergies: \ncefaclor\n \nAttending: ___.\n \nChief Complaint:\nCRPP and EPL repair\n \nMajor Surgical or Invasive Procedure:\nCRPP and EPL repair of left thumb\n\n \nHistory of Present Illness:\n___ yo Healthy LHD Male who sustained table saw injury to L thumb \ntoday at 1pm. Was working with his grandfather when table saw \nkicked back on him and lacerated the dorsum of thumb. \n++bleeding, no amputated parts. No other injuries. Went to \n___ where he received a nerve block and ancef. tetanus \nUTD. Transferred here for further care\n \nPast Medical History:\nPMH: denies\nPSH: appendectomy, bilateral ___ fasciotomies for compartment \nsyndrome of unknown origin, septoplasty\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nBrief Hospital Course:\nThe patient was admitted to the plastic surgery service on \n___ and had a CRPP and EPL repair of the left thumb. The \npatient tolerated the procedure well.\n \n Neuro: Post-operatively, the patient received oral pain \nmedications with good effect.\n \n CV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n \n Pulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n \n GI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. His diet was advanced when appropriate, \nwhich was tolerated well. He was also started on a bowel regimen \nto encourage bowel movement. Intake and output were closely \nmonitored.\n \n ID: Post-operatively, the patient was started on IV cefazolin, \nthen switched to PO cefadroxil for discharge home. The patient's \ntemperature was closely watched for signs of infection.\n \n Prophylaxis: The patient was encouraged to get up and ambulate \nas early as possible.\n \n At the time of discharge, the patient was doing well, afebrile \nwith stable vital signs, tolerating a regular diet, ambulating, \nvoiding without assistance, and pain was well controlled. He was \ndischarged in a splint with follow-up with Dr. ___ in 2 weeks.\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN pain \n2. cefaDROXil 500 mg oral BID Duration: 5 Days \nRX *cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp \n#*10 Capsule Refills:*0\n3. Docusate Sodium 100 mg PO BID \n4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q4H: PRN Disp #*50 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ntable saw injury to Left thumb w/ EPL laceration and P1 frx\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___\n" ]

[ "S62515A", "S56322A", "W312XXA", "Y929" ]

[ "S62515A: Nondisplaced fracture of proximal phalanx of left thumb, initial encounter for closed fracture", "S56322A: Laceration of extensor or abductor muscles, fascia and tendons of left thumb at forearm level, initial encounter", "W312XXA: Contact with powered woodworking and forming machines, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nLumbar stenosis\n \nMajor Surgical or Invasive Procedure:\nAnterior Lumbar Decompression and Fusion L3-S1\nLateral Decompression and fusion L1-L3\nPosterior Decompression and Fusion L1-S1\nIntubation\nCentral line placement\nArterial line placement \n\n \nHistory of Present Illness:\nPt is a ___ who was on the spine service s/p anterior, lateral,\nand posterior spine fusion c/b post-operative ileus. The team \nhad\nalso been concerned about rising O2 requirement and tachycardia. \n\n\nUpon arrival she was on her side with copious bilious vomit\ncoming from he mouth. She was unresponsive and pulseless and CPR\nwas initiated. Pads were placed and her rhythm was consistent\nwith PEA. Epinephrine was given first at 3:55 and 3 additional\ntimes prior to ROSC. She was intubated at 4:02 AM. There were\nseveral prior attempts that were difficult due to copious\nvomitus. At 4:03 AM, ROSC was achieved. She was noted to have\nagonal breathing and had a blood pressure of 183/95. She was\ntransported to the ICU for further care. \n\n \nPast Medical History:\nHTN\nMacular Degeneration\nDepression\nGERD\n\nSpine Fusion\nTAH\nCysto\nGiant cell tumor excision\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nMICU ADMISSION PHYSICAL EXAM: \n============================= \nVS: reviewed in metavision \nGEN: Intubated and sedated, bilious output from NGT\nHEENT: Triple lumen right IJ. PERRLA, \nCV: Tachycardic, regular rhythm, no m/r/g\nRESP: Course breath sound bilateral with rhonchi throughout\nGI: Nontender abdomen\nSKIN: No bruising or petechia\n.\n.\nICU DISCHARGE EXAM:\n===================\n24 HR Data (last updated ___ @ 1418)\n Temp: 100.1 (Tm 101.9), RR: 28 (___) \nGENERAL: lying in bed, elevated RR but otherwise appears\ncomfortable, nonresponsive to verbal stimuli\nHEENT: eyes open, NC/AT\nLUNGS: RR elevated currently\nSKIN: No rash\nNEUROLOGIC: nonresponsive to verbal stimuli\n.\n.\nDISCHARGE EXAM:\n===============\nDeceased.\n \nPertinent Results:\nAdmission Labs\n==============\n___ 06:29AM BLOOD WBC-10.7* RBC-3.87* Hgb-11.5 Hct-36.6 \nMCV-95 MCH-29.7 MCHC-31.4* RDW-12.8 RDWSD-44.3 Plt ___\n___ 06:29AM BLOOD Plt ___\n___ 06:29AM BLOOD Glucose-80 UreaN-8 Creat-0.6 Na-139 K-3.9 \nCl-103 HCO3-24 AnGap-12\n___ 06:29AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.7\n___ 05:02AM BLOOD Lactate-5.3*\n\nNo Discharge Labs\n \nBrief Hospital Course:\n___ ANTERIOR LUMBAR FUSION, L3-S1 no intraop comps\n___ LATERAL LUMBAR INTERBODY FUSION (XLIF) RIGHT L1-L3 no \ninraop comps ebl 20.\n___ LUMBAR LAMINECTOMY & FUSION, L1-S1 EBL 750, \n\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 was \nwithout complication and the patient was transferred to the PACU \nin a stable condition. ___ were used for \npostoperative DVT prophylaxis. Intravenous antibiotics were \ncontinued for 24hrs postop per standard protocol. Initial postop \npain was controlled with oral and IV pain medication. Diet was \nadvanced as tolerated. She developed a post op ileus and was \nmade NPO. Foley was removed on POD#2. Physical therapy and \nOccupational therapy were consulted for mobilization OOB to \nambulate and ADL's. Hospital course was complicated by ileus and \non ___ she developed increasing tachycardia, SOB, RT attempted \nNT suctioning pt began vomiting copious amounts of bilious \nvomit, aspirated PEA arrested, cpr immediately initiated, pt was \nintubated, brought to MICU, labile BP on 3 pressors evaluated \nfor ecmo. \n\nPatient developed ARDS. Patient was proned and paralyzed with \neventual improvement in ARDS. Targeted temperature management \nwas instituted. Eventually had an MRI showing evidence of anoxic \nbrain injury. No improvement in neurological status after \nseveral days off sedation. Patient was made CMO after discussion \nwith family. \n\nDEATH NOTE:\nNote Date: ___ Time: 0430\nNote Type: Event\nNote Title: Death Note\nElectronically signed by ___, MD on ___ at \n4:36 am Affiliation: ___\nElectronically cosigned by ___, MD on ___ at \n5:47 pm\n \nCalled to bedside by RN. \n No spontaneous movements were present. There was no response to\n verbal or tactile stimuli. Pupils were mid-dilated and fixed. \nNo\n breath sounds were appreciated over either lung field. No\ncarotid\n pulses were palpable. No heart sounds were auscultated over\n entire precordium.\n\n Patient pronounced dead at 23:15 on ___ and primary care \nphysician\n___.\n ___ were notified.\n\n Family wanted autopsy, and both Medical Examiner Office and\nPathology \n were contacted.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Omeprazole 40 mg PO DAILY \n\n \nDischarge Medications:\nN/A\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nLumbar Stenosis\nPEA arrest\nARDS\nSepsis\n\n \nDischarge Condition:\nN/A - deceased\n \nDischarge Instructions:\nN/A\n \nFollowup Instructions:\n___\n" ]

[ "M47816", "J80", "J690", "A4181", "R6521", "I82492", "K567", "E872", "N179", "J90", "D62", "G931", "M5136", "M419", "I10", "K219", "R578", "H3530", "Z66", "Z515", "I469", "T2101XA", "T24012A", "T24011A", "Y658", "Y92230", "H168", "R740" ]

[ "M47816: Spondylosis without myelopathy or radiculopathy, lumbar region", "J80: Acute respiratory distress syndrome", "J690: Pneumonitis due to inhalation of food and vomit", "A4181: Sepsis due to Enterococcus", "R6521: Severe sepsis with septic shock", "I82492: Acute embolism and thrombosis of other specified deep vein of left lower extremity", "K567: Ileus, unspecified", "E872: Acidosis", "N179: Acute kidney failure, unspecified", "J90: Pleural effusion, not elsewhere classified", "D62: Acute posthemorrhagic anemia", "G931: Anoxic brain damage, not elsewhere classified", "M5136: Other intervertebral disc degeneration, lumbar region", "M419: Scoliosis, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "R578: Other shock", "H3530: Unspecified macular degeneration", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "I469: Cardiac arrest, cause unspecified", "T2101XA: Burn of unspecified degree of chest wall, initial encounter", "T24012A: Burn of unspecified degree of left thigh, initial encounter", "T24011A: Burn of unspecified degree of right thigh, initial encounter", "Y658: Other specified misadventures during surgical and medical care", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "H168: Other keratitis", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]" ]

[ "E872", "N179", "D62", "I10", "K219", "Z66", "Z515", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nciprofloxacin / Unasyn\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: ERCP\n.\n___: CT-guided drainage of a retroperitoneal and pelvic \ncollections.\n.\n___: ___\n.\n___: CT-guided drainage of right perinephric collection. \n \n\n \nHistory of Present Illness:\nMrs. ___ is a ___ w/ h/o chest/epigastric pain who presents \nwith 3 days of symptoms and U/S concerning for acute \ncholecystitis. Patient reports that she has had a few of these \n\"attacks\" over the past ___ years, occurring about every 6 months, \nand described mostly as \"twisting\" chest pain, but usually\nspontaneously resolves. For her current episode, she had \nsymptoms again mostly described as chest pain, and was worsened \nwith food intake. Her pain had not improved over the past few \ndays, thus she went to her PCP. There, she was noted to have RUQ \ntenderness, and an U/S was obtained which was concerning for \nacute cholecystitis. Patient underwent ERCP with sphincterotomy \non ___. Post ERCP patient developed abdominal pain, \ndistention, lipase was 1886 concerning for post ERCP \npancreatitis. Patient was admitted to the ___ surgery \nservice for evaluation, management of pancreatitis and possible \ncholecystectomy. \n \nPast Medical History:\nNone \n \nSocial History:\n___\nFamily History:\nDiabetes, h/o CAD\n \nPhysical Exam:\nPrior to Discharge:\nVS: 98.3, 61, 118/78, 18, 97% RA\nGEN: Somewhat anxious without acute distress \nHEENT: NC/AT, EIOM, PERRL, neck supple, no scleral icterus \nSKIN: Trunk and thighs with multiple dark circular spots \nCV: RRR, no m/r/g\nPULM: CTAB\nABD: Soft non tender, non distended. Right flank with ___ drain \nto bulb suction with minimal cloudy yellow output. Site with \ndrain sponge over and c/d/I.\nEXTR: Warm, no c/c/e\n \nPertinent Results:\nRECENT LABS: \n___ 11:40AM BLOOD WBC-11.1* RBC-2.81* Hgb-7.8* Hct-24.1* \nMCV-86 MCH-27.8 MCHC-32.4 RDW-13.8 RDWSD-43.8 Plt ___\n___ 11:40AM BLOOD Glucose-124* UreaN-10 Creat-0.6 Na-132* \nK-4.0 Cl-98 HCO3-24 AnGap-14\n___ 06:01AM BLOOD ALT-156* AST-90* AlkPhos-289* TotBili-0.9\n___ 11:40AM BLOOD Lipase-62*\n___ 11:40AM BLOOD Calcium-7.7* Phos-3.5 Mg-2.3\n\nMICROBIOLOGY:\n___ 12:30 pm PERITONEAL FLUID\n PERITONEAL FLUID ( FROM RETROPERITONEAL ABSCESS DRAIN ). \n\n **FINAL REPORT ___\nGRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \nFLUID CULTURE (Final ___: \n ___ ALBICANS, PRESUMPTIVE IDENTIFICATION. \n Isolated from broth media only, INDICATING VERY LOW \nNUMBERS OF\n ORGANISMS. \n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n\n___ 4:40 pm FLUID,OTHER PERIPHERAL COLLECTION. \n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: \n ___ ALBICANS. SPARSE GROWTH. \n Yeast Susceptibility:. \n Fluconazole MIC = 0.5 MCG/ML = SUSCEPTIBLE. \n Results were read after 24 hours of incubation. \n Sensitivity testing performed by Sensititre. \n\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. \n\nRADIOLOGY:\n\n___ LIVER US:\nIMPRESSION: \n1. Mobile gallstones and sludge within a moderately distended \ngallbladder. No gallbladder wall edema or pericholecystic fluid \nis seen at the present \ntime, although findings may represent early acute cholecystitis. \n In addition there is note of choledocholithiasis, with at least \n1 shadowing stone seen in the common bile duct. \n2. Echogenic liver consistent with steatosis. Other forms of \nliver disease and more advanced liver disease including \nsteatohepatitis or significant hepatic fibrosis/cirrhosis cannot \nbe excluded on this study. Relative areas of hypo echogenicity \nwithin the liver parenchyma are consistent with geographic \nsparing from steatosis. \n3. Trace right pleural effusion. \n\n___ ERCP:\n The scout film was normal.\n•Normal major papilla. \n•Cannulation of the biliary duct was successful and deep with a \nsphincterotome using a free-hand technique. \n•Contrast medium was injected resulting in complete \nopacification. \n•The common bile duct, common hepatic duct, right and left \nhepatic ducts, biliary radicles and cystic duct were filled with \ncontrast and well visualized. \n•The course and caliber of the structures are normal with no \nevidence of extrinsic compression, no ductal abnormalities, one \nsmall stone was noted at the distal CBD \n•A sphincterotomy was performed in the 12 o'clock position using \na sphincterotome over an existing guidewire.\n•No evidence of post sphincterotomy bleeding was noted. \n•Balloon sweeps reveled small amount of sludge and one small \nstone. \n•Occlusion cholangiogram showed no evidence of filling defects. \n•Post balloon sweeps good drainage of contrast and bile was \nnoted both endoscopically and fluoroscopically \n•Otherwise normal ercp to third part of the duodenum\n\n___ KUB:\nIMPRESSION: \nNo evidence of free intraperitoneal air. \n\n___ CT ABD:\nIMPRESSION: \n1. Extraluminal retroperitoneal air is identified posterior to \nthe second \nportion of duodenum. There is fluid extending from the duodenum \nand to right perinephric space. Duodenal wall is thickened. \nFindings are suspicious for duodenal perforation although no \noral contrast extravasation or discrete duodenal wall defect is \nidentified. \n2. Cholelithiasis with gallbladder wall thickening. \nHyperenhancement of \ngallbladder mucosa and extrahepatic bile ducts may be \ninflammatory. \n3. Peritoneal enhancement is consistent with peritonitis. \nOmental nodularity may reflect edema. \n4. Right colonic wall thickening may reflect secondary \ninflammation. \n5. Small to moderate ascites. \n6. Bilateral pleural effusions are small. \n\n___ CT ABD:\nIMPRESSION: \n1. Unchanged extraluminal retroperitoneal air and fluid \nposterior to the \nsecond portion of the duodenum and extending throughout the \nright perirenal space, remaining suggestive of duodenum \nperforation. \n2. Moderate free fluid throughout the abdomen pelvis is slightly \nincreased \nfrom prior with new rim enhancement suggestive of organizing \nfluid \ncollections/ early abscess formation. New peritoneal \nenhancement, \nparticularly in the pelvis, suggestive of peritonitis. \n3. Mildly prominent small bowel loops with air-fluid levels are \nsuggestive of reactive ileus. \n4. Probable reactive colonic mucosal thickening. \n5. No definite CT evidence of acute cholecystitis. \n\n___ ___ PROCEDURE:\n1. Repositioning of wire placed under CT guidance from the \nretroperitoneal \nabscess into the retro duodenum region \n2. Placement of 8 ___ biliary drain over wire with pigtail \nformed in the retro duodenum region \n3. Upper GI series through NG tube to evaluate for persistent \nduodenum \nperforation \n\n___ CT ABD:\nIMPRESSION: \n1. Interval placement of a pigtail catheter, with resulting \ndecrease in size of the retroperitoneal fluid collection along \nits course. \n2. However, remainder of the small multiloculated perirenal \nfluid collections on the right are unchanged in size. \n3. Within the pelvis, a new 3.7 x 1.9 cm organized collection in \nthe region of the left adnexa could represent walled-off \nascites. Fluid collection along the posterior uterine wall has \ndecreased. \n4. Fatty infiltration of the liver. \n5. Trace pericardial effusion, grossly unchanged. \n\n___ ___ PROCEDURE:\nIMPRESSION: \nSuccessful CT-guided placement of an ___ pigtail catheter \ninto the \ncollection. Samples were sent for microbiology evaluation. \n\n \nBrief Hospital Course:\nThe patient is a ___ female with acute cholecystitis \ns/p ERCP. She was admitted to the HPB Surgical Service for \npossible cholecystectomy. Overnight patient developed abdominal \npain and her lipase was 1886 with WBC 12. Surgery was postponed \nand patient was started treatment for acute pancreatitis. She \nwas started on Unasyn, aggressive fluid resuscitation and made \nNPO, pain was controlled with Dilaudid PCA. On HD 3, patient was \npatient was noticed to have SOB, she was required supplemental \nO2. Fluid rate was turned down, she was diuresed with Lasix x 2 \nand her respiratory status improved. On HD 6, patient's diet was \nadvanced to clear liquids. After taking clears, patient's \nabdominal pain increased and she developed fever, she was made \nNPO. On HD 7 (___) patient's WBC increased to 14K and CT scan \nwas obtained. Abdominal CT demonstrated extraluminal \nretroperitoneal air, thickened duodenal wall, no active contrast \nextravasation, peritoneal enhancement concerning for \nperitonitis, ascites and acute cholecystitis. Patient's \nantibiotics were changed to Cipro/Flagyl in the setting of \npossible perforation. On HD 8 (___), patient's diet was \nadvanced to clears per GI recommendations. Patient spiked fever \nto 103, vomited, and WBC increased to 16K, she was pan cultured \nand ID was consulted. Cipro/Flagy was changed to meropenem per \nID recommendations. On HD 9 (___), patient remained febrile, \nher blood, urine and stool cultures were negative. Patient \ndeveloped itchy rash, which start on her abdomen and spread. \nDermatology was consulted. Patient's WBC continued to climb and \nwas 18K. Patient was started on Allegra for itching and \nDiprolene cream per Dermatology. On HD 10 (___) patient's WBC \ncontinued to increase to 18.8, patient was afraid to have CT \nscan secondary to her resent allergic reaction. On HD 11 (___), \nWBC up to 19.6 and CT scan was obtained. CT demonstrated \nunchanged extraluminal retroperitoneal air and fluid posterior \nto the second portion of the duodenum and extending throughout \nthe right perirenal space, remaining suggestive of duodenum \nperforation; moderate free fluid throughout the abdomen pelvis \nis slightly increased from prior with new rim enhancement \nsuggestive of organizing fluid collections/ early abscess \nformation; new peritoneal enhancement, particularly in the \npelvis, suggestive of peritonitis (please see Radiology report \nfor details). ___ was consulted for possible CT-guided drainage \nof the fluid collections. On HD 12 (___) patient underwent \nplacement of two drains, one in retroperitoneal, and second into \npelvic fluid collections. Sample was sent for microbiology and \ncell count. On HD 13 (___), patient underwent PICC line \nplacement and TPN was started for nutritional support. Abdominal \nfluid cultures were positive for yeast and Mucafungin was added \nper ID recommendations. On HD 14 (___) patient's diet was \nadvanced to clears and was well tolerated. On HD 15 (___) \nmicofungin was changed to Fluconazole as cultures growing \n___. Patient's pelvic drain was discontinued. On HD 16 \n(___) patient's diet advanced to fulls. Patient's spiked a \nfever to 101.7, WBC started to downward. Patient remained \nfebrile next four days with Tmax 102.1, WBC continued to \ndowntrend. On HD 19 (___) patient underwent CT scan, which \nrevealed decreased retroperitoneal fluid collection, small \nmultiloculated perirenal fluid collections and small walled off \nascites (please see Radiology report for details). On HD 20 \n(___) patient underwent CT-guided drainage of right \nperinephric collection. After drainage diet was advanced to \nregular. HD 21 (___), pain was well controlled, both \nretroperitoneal and perinephric drain with minimal output, WBC \ndown tranding and patient remained afebrile. HD 22 (___), TPN \nwas discontinued. On HD 23 (___), perinephric drain fluid \npositive for Candina, retroperitoneal drain was discontinued as \noutput was scant. HD 23 (___) patient discharged home in \nstable condition with one drain remained in place and on \nFluconazole for 7 days total. Prior to discharge, patient \nremained afebrile, pain was well controlled, PICC line was \nremoved, patient tolerated regular diet and ambulate without \nassistance. Patient was discharged home with ___ services to \ncontinue drain care. Follow up appointment with abdominal CT was \nscheduled prior to discharge, patient instructed to call back if \nfever or increased output from ___ drain. \n \n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \ndo not exceed more then 3000 mg/day \n2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \nRX *betamethasone, augmented 0.05 % aplly twice a day on \naffected areas twice a day Refills:*0 \n3. Docusate Sodium 100 mg PO BID \n4. Fexofenadine 180 mg PO DAILY \n5. Fluconazole 400 mg PO Q24H \nRX *fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*0 \n6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Acute cholecystitis\n2. Post ERCP pancreatitis and small bowel perforation\n3. Severe allergic reaction to antibiotics \n(Unasyn/Ciprofloxacin) with skin rash\n4. ___ peritonitis with intra 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:\nYou were admitted to the surgery service at ___ for management \nacute pancreatitis and small bowel perforation after ERCP, which \nwas performed for acute cholecystitis. Your recovery was \ncomplicated by severe allergic reaction to antibiotics and \n___ peritonitis with intraabdominal abscesses, which \nrequired ___ drainage. You required bowel rest and were placed on \nTPN for nutritional support. Your diet is now advanced and TPN \nwas discontinued. You are now safe to return home to complete \nyour recovery with the following instructions:\n.\nPlease call Dr. ___ office at ___ or ___ \n___, RN at ___. During off hours: Call pager \noperator at ___ and ask to page ___ ___ \n___ team.\n.\nPlease call back right away if you have fever > 100.5 or \nincreased abdominal pain. Call the numbers above if you drain \noutput significantly increase.\nPlease resume all regular home medications , unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon, who will instruct you further regarding activity \nrestrictions.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\nPlease follow-up with your surgeon and Primary Care Provider \n(PCP) as advised.\n.\n___ drain care: \n*Keep to bulb suction. \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*Please note color, consistency, and amount of fluid in the \ndrain. Call the doctor, ___, or ___ nurse if the \namount increases significantly or changes in character. Be sure \nto empty the drain frequently. Record the output, if instructed \nto do so.\n*Wash the area gently with warm, soapy water or ___ strength \nhydrogen peroxide followed by saline rinse, pat dry, and place a \ndrain sponge. Change daily and as needed.\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\n \n \n\n \nFollowup Instructions:\n___\n" ]

[ "K8042", "K8590", "K651", "K631", "B3789", "K9189", "Y838", "L270", "T360X5A", "Y92239", "R197" ]

[ "K8042: Calculus of bile duct with acute cholecystitis without obstruction", "K8590: Acute pancreatitis without necrosis or infection, unspecified", "K651: Peritoneal abscess", "K631: Perforation of intestine (nontraumatic)", "B3789: Other sites of candidiasis", "K9189: Other postprocedural complications and disorders of digestive system", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "T360X5A: Adverse effect of penicillins, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R197: Diarrhea, unspecified" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nciprofloxacin / Unasyn\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nPatient is a ___ year old woman with history of \ncholedocholithiasis, cholecystitis in ___ s/p ERCP \ndecompression complicated by post-ERCP pancreatitis, duodenal \nmicroperforation with RP and pelvic abscesses (s/p ___ \ndrain placement) briefly requiring TPN, s/p cholecystectomy \n___ now with episodic epigastric pain who presents with \nworsening of her known abdominal pain.\n\nPatient has had episodic epigastric pain for the past ___ year. \nPrior to her cholecystitis episode in ___, she used to \nexperience the epigastric pain during ___ episodes per day, \ncharacterized by sudden onset burning/throbbing pain that \"feels \nlike spasms.\" The pain lasted 30 seconds to 1 minute and then \nwould go away. \n\nShe was admitted for abdominal pain and was diagnosed to have \ncholecystitis. She underwent ERCP with stone extraction. However \nsubsequently had a complicated course with worsening \nsxs/fever/leukocytosis, and eventually diagnosed with duodenal \nperforation with RP/pelvic abscesses. SHe was treated with a \nprolonged course of antibiotics \n(unasyn-->cipro/flagyl-->meropenem) and ___ drainage of the fluid \ncollections. Abdominal fluid cultures were positive for yeast \nand Mucafungin was also added per ID recommendations. SHe also \nbriefly required TPN. Her LFTs, WBC were trending down on day of \ndischarge. Her drains were removed at outpatient follow up and \nshe completed her course of abx. Her fluid collections improved \non post-dc CT scans.\n\nSHe was then admitted in ___ for n/v, presumed to viral \ngastroenteritis, improved with symptomatic therapy. SHe then \nunderwent CCY on ___.\n\nFor the past week she has been having ___ episodes of the \nepigastric pain per day and also has a baseline ___ aching in \nepigastrium for most of the day. Severe, cramping, non \nradiating, worse when she does not eat for a long time, worst in \nthe morning. Also associated with several episodes of bilious \nemesis over the past 2 days. Denies fevers, chills, recent \nweight loss \n\nIn ED, VSS\nOn exam, tender in epigastrium to light palpation, voluntary \nguarding in epigastrium. \nLabs unremarkable\nKUB did not show any free air under diaphragm, or any other \nabnormality\nDeclined any pain medications\n\nOn arrival to floor, ROS negative except for as noted above. \nDuring interview, noted to have one of the episodes of pain, \nlasted 30 seconds, patient curled up clutching stomch, visibly \nin significant distress, associated with retching.\n \nPast Medical History:\n- Choledocholithiasis and cholecystitis ___ s/p ERCP \ndecompression complicated by post-ERCP pancreatitis, duodenal \nmicroperforation with RP and pelvic abscesses (s/p ___ \ndrain placement) briefly requiring TPN\n- S/p cholecystectomy ___ \n- Chronic abdominal pain\n \nSocial History:\n___\nFamily History:\n- No liver/gallbladder FH\n- Dyslipidemia, HTN, diabetes, CAD\n \nPhysical Exam:\n Gen: NAD, lying in bed\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n GI: soft, epigastric tenderness, guarding, ND\n MSK: No significant kyphosis. No palpable synovitis.\n Skin: No visible rash. No jaundice.\n Neuro: AAOx3. No facial droop.\n Psych: Full range of affect\n \nPertinent Results:\n___ 01:14PM ___ PTT-31.0 ___\n___ 12:37PM ___ COMMENTS-GREEN TOP\n___ 12:37PM LACTATE-0.9\n___ 12:34PM GLUCOSE-95 UREA N-15 CREAT-0.7 SODIUM-137 \nPOTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16\n___ 12:34PM estGFR-Using this\n___ 12:34PM ALT(SGPT)-20 AST(SGOT)-21 ALK PHOS-63 TOT \nBILI-0.2\n___ 12:34PM LIPASE-57\n___ 12:34PM ALBUMIN-4.5 CALCIUM-9.2 PHOSPHATE-3.8 \nMAGNESIUM-2.0\n___ 12:34PM WBC-9.9 RBC-4.87 HGB-13.2 HCT-40.0 MCV-82 \nMCH-27.1 MCHC-33.0 RDW-14.7 RDWSD-44.4\n___ 12:34PM NEUTS-58.5 ___ MONOS-4.4* EOS-1.9 \nBASOS-0.6 IM ___ AbsNeut-5.78 AbsLymp-3.40 AbsMono-0.44 \nAbsEos-0.19 AbsBaso-0.06\n___ 12:34PM PLT COUNT-292\n___ 11:45AM URINE HOURS-RANDOM\n___ 11:45AM URINE UCG-NEGATIVE\n___ 11:45AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 11:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-SM \n___ 11:45AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE \nEPI-2\n___ 11:45AM URINE MUCOUS-RARE\n\nKUB: There is a nonobstructive bowel gas pattern. No large \nair-fluid levels are seen. There is no evidence of free air. \nRight upper quadrant surgical clips are from presumed \ncholecystectomy. The lung bases are grossly clear. \n \nMRCP: official read pending at time of discharge \n\n \nBrief Hospital Course:\n___ year old woman with history of choledocholithiasis, \ncholecystitis in ___ s/p ERCP decompression complicated by \npost-ERCP pancreatitis, duodenal microperforation with RP and \npelvic abscesses (s/p ___ drain placement) briefly \nrequiring TPN, s/p cholecystectomy ___ now with episodic \nepigastric pain who presented with worsening of her chronic \nabdominal pain. The cause of the acute increase of her chronic \nabdominal pain remained unclear. She had no signs of perforation \nor obstruction on KUB. MRCP was performed. GI team contacted \nradiology who stated the wet read had no concerning findings. \nLabs including lipase are unremarkable. She remained \nhemodynamically stable with no systemic signs of toxicity. GI \nand ERCP teams recommended discharge to home on PPI BID and \nhyoscyamine prn abdominal cramping. They plan on performing an \noutpatient EGD in the next ___ days. \n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Docusate Sodium 100 mg PO BID \n2. Polyethylene Glycol 17 g PO DAILY \n3. Ranitidine 150 mg PO BID \n4. Senna 8.6 mg PO BID \n5. Multivitamins 1 TAB PO DAILY \n6. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate \n\n\n \nDischarge Medications:\n1. Hyoscyamine 0.125 mg SL Q4H:PRN abdominal cramping \nRX *hyoscyamine sulfate 0.125 mg 1 tablet(s) sublingually every \nfour (4) hours Disp #*30 Tablet Refills:*0 \n2. Omeprazole 40 mg PO BID \nRX *omeprazole 20 mg 2 capsule(s) by mouth twice a day Disp \n#*120 Capsule Refills:*0 \n3. Docusate Sodium 100 mg PO BID \n4. Multivitamins 1 TAB PO DAILY \n5. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - \nModerate \n6. Polyethylene Glycol 17 g PO DAILY \n7. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nabdominal pain\n\n \nDischarge Condition:\ncondition: good\nmental status: intact at baseline\nambulatory status: independent\n\n \nDischarge Instructions:\nYou were admitted to the hospital for abdominal pain and \nexpedited work-up. You had an MRCP that was unrevealing. You \nwere seen by GI who recommend an outpatient EGD be done early \nthis week. They will contact you with the specific date and \ntime. They have also recommended you start 2 new medications. \nOmeprazole is to decrease gastric acid production and Levsin \n(hyoscyamine) to treat abdominal cramping/muscle spasms. \n \nFollowup Instructions:\n___\n" ]

[ "R1013", "G8929", "K830", "Z9049" ]

[ "R1013: Epigastric pain", "G8929: Other chronic pain", "K830: Cholangitis", "Z9049: Acquired absence of other specified parts of digestive tract" ]

[ "G8929" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nciprofloxacin / Unasyn\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs ___ is a ___ with no PMHx and recent ERCP (___) \ncomplicated by post-ERCP pancreatitis, microperforation with RP \nand pelvic abscesses (s/p ___ drain placement) briefly \nrequiring TPN who presents with sudden onset epigastric/RUQ \npain, nausea, and vomiting. She states that the pain began the \nevening prior to arrival; she last had a small meal of ___ \nfries and tomato soup that evening. Shortly thereafter, she \nstarted having ___ \"stabbing, burning, throbbing, aching\" \nepigastric abdominal pain that radiates up into the sternum. \nShe also had nausea and vomiting several times throughout the \nnight; she was unable to tolerate anything by mouth overnight. \nShe tried taking two oxycodone tablets overnight, which did not \nimprove the pain.\n\nPt has had pain similar to this (in the epigastrium and RUQ) \nwith her prior flare of cholecystitis. She states she has had \nthese episodes of pain every ___ weeks over the past ___ years, \nalso associated with nausea; generally, however, the pain has \nimproved with several bouts of nausea and vomiting. The current \npain persisted despite her vomiting. For this reason, she \npresented to the ED for further evaluation.\n\nOf note, Pt has two children at home with a similar vomiting \nillness. Her husband also just started having diarrhea today. \n \nIn the ED, initial vitals were: T 97.7 BP 130/96 HR 68 RR 22 O2 \n100% on RA\n- Labs notable for: Lactate 1.6, WBC 12.9 (baseline ___, \nplatelets 574, lipase 42, AST/ALT/ALP within normal limits\n- Imaging notable for:\n\n+ CT ABDOMEN AND PELVIS WITH CONTRAST (___): \n1. Retroperitoneal fat stranding and scattered small fluid \ncollections\nextending inferiorly and posteriorly from the pancreatic head \nare unchanged compared to 2 weeks prior.\n2. Cholelithiasis.\n3. A small amount of pneumobilia is not unexpected status-post \nERCP with sphincterotomy.\n\n+ LIVER OR GALLBLADDER ULTRASOUND (___):\n1. Cholelithiasis without cholecystitis.\n2. Pneumobilia is not unexpected given history of ERCP with \nsphincterotomy.\n3. Somewhat heterogeneous appearing visualized pancreas may be \nthe sequela of recent pancreatitis documented in the electronic \nmedical record.\n\n- Consults called:\n\n+ SURGERY: \nNo radiographic, laboratory or physical exam findings suggestive \nof acute cholecystitis. Pain is predominantly \nsub-xiphoid/midline. Both children at home w/ recent vomiting \nillness from possible gastroenteritis, which could be a \ncomponent of her current presentation. Recommend medicine \nadmission for hydration, pain control, further workup. Would \nconsider GI consult as the patient is well-known to their \nservice.\n \n+ GASTROENTEROLOGY: \nPending\n\n- Treatments given: A total of 14mg IV morphine, ondansetron \n4mg IV x3, and 750cc NS. \n\nOn the floor, Pt endorses the above history. She states that \nshe has been very thirsty and drinking a lot of water down in \nthe ED without issue. She is willing to try a diet of clear \nliquids and toast and advance from there. Her pain is currently \nimproved (down to a ___, as is her nausea. She notes some \nassociated lightheadedness, constipation (last bowel movement \nwas some time last week, which she attributes to taking \noxycodone intermittently), and a 15-pound weight loss since her \nlast admission. She denies CP, SOB, fevers/chills, diarrhea, \nvaginal bleeding/discharge, and dysuria/hematuria. \n \nPast Medical History:\nCholelithiasis/cholecystitis\n \nSocial History:\n___\nFamily History:\n- No liver/gallbladder FH\n- Dyslipidemia, HTN, diabetes, CAD\n \nPhysical Exam:\n=============\nADMISSION EXAM\n=============\nVital Signs: T 98.4 BP 110/68 HR 105 RR 20 O2 99% on RA\nGeneral: Alert, oriented female laying in bed, occasionally \njoking with friend. In no acute distress.\nHEENT: Sclerae anicteric, MMM. \nCV: Borderline tachycardic with regular rhythm, normal S1 + S2, \nII/VI systolic ejection murmur best heard at ___ and ___. \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Very hypoactive bowel sounds. Abdomen is distended per \nPt report, diffusely tender to light palpation (worst in the \nepigastrium and RUQ). Pt with positive ___ sign. No \nsplenomegaly appreciated.\nGU: No foley \nExt: Warm, well perfused, wearing stockings this evening. 2+ \ndorsalis pedis pulses, no pitting edema \nNeuro: Moves all four extremities spontaneously\n\n==============\nDISCHARGE EXAM\n==============\nVitals: T 98.3-98.5 BP 97-104/47-70 HR ___ RR ___ O2 97-99% \non RA\nGeneral: Oriented female laying in bed in no acute distress, \nfatigued appearing.\nHEENT: Sclera anicteric\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: Hypoactive bowel sounds. Abdomen is soft, exquisitely \ntender in epigastrium, no rebound or guarding. \nExt: Warm, well perfused, 2+ pulses in the dorsalis pedis \nbilaterally, no peripheral edema \nNeuro: A&O x3, moves all extremities purposefully.\n \nPertinent Results:\n=============\nADMISSION LABS\n=============\n___ 04:26AM ___ COMMENTS-GREEN TOP\n___ 04:26AM LACTATE-1.6\n___ 04:05AM GLUCOSE-147* UREA N-9 CREAT-0.7 SODIUM-134 \nPOTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-23 ANION GAP-20\n___ 04:05AM estGFR-Using this\n___ 04:05AM LIPASE-42\n___ 04:05AM ALBUMIN-3.9\n___ 04:05AM HCG-<5\n___ 04:05AM WBC-12.9* RBC-3.91 HGB-9.7* HCT-31.6* MCV-81* \nMCH-24.8* MCHC-30.7* RDW-13.5 RDWSD-39.4\n___ 04:05AM NEUTS-75.1* ___ MONOS-4.2* EOS-0.7* \nBASOS-0.4 IM ___ AbsNeut-9.69* AbsLymp-2.46 AbsMono-0.54 \nAbsEos-0.09 AbsBaso-0.05\n___ 04:05AM PLT COUNT-574*#\n\n===============\nPERTINENT IMAGING\n===============\nRUQ ULTRASOUND (___):\n1. Cholelithiasis without cholecystitis.\n2. Pneumobilia is not unexpected given history of ERCP with \nsphincterotomy.\n3. Somewhat heterogeneous appearing visualized pancreas may be \nthe sequela of\nrecent pancreatitis documented in the electronic medical record.\nCT ABDOMEN AND PELVIS W/CONTRAST (___): \n1. Retroperitoneal fat stranding and scattered small fluid \ncollections\nextending inferiorly and posteriorly from the pancreatic head \nare unchanged\ncompared to 2 weeks prior.\n2. Cholelithiasis.\n3. A small amount of pneumobilia is not unexpected status-post \nERCP with\nsphincterotomy.\n\n==============\nPERTINENT MICRO\n==============\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n=============\nDISCHARGE LABS\n=============\n___ 07:40AM BLOOD WBC-13.0* RBC-3.45* Hgb-8.5* Hct-27.7* \nMCV-80* MCH-24.6* MCHC-30.7* RDW-13.5 RDWSD-39.5 Plt ___\n___ 07:40AM BLOOD Glucose-108* UreaN-7 Creat-0.6 Na-137 \nK-3.8 Cl-101 HCO3-23 AnGap-17\n___ 07:40AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1 Iron-13*\n___ 07:40AM BLOOD calTIBC-177* Ferritn-448* TRF-136*\n___ 04:26AM BLOOD Lactate-1.___ with PMH cholecystitis (complicated by post-ERCP \npancreatitis, microperforation, retroperitoneal and \nintra-abdominal abscesses s/p ___ drainage from ___ planned for outpatient CCY in ___ who presented with \nsudden-onset RUQ and epigastric abdominal pain, accompanied by \nN/V and inability to tolerate PO. Pt with a husband and two \nchildren at home who seem to have come down with a similar \n\"stomach bug\" (all with vomiting, husband with some diarrhea) \nwithin the past few days. Pt presented to the ED due to her \nabdominal pain; she has had some bouts of similar abdominal pain \nover the past ___ years that generally improve with vomiting, but \nthe current episode did not. She denied concomitant fevers, \ndiarrhea, dysuria/hematuria. Pt's exam notable for significant \ndiffuse abdominal tenderness without peritoneal signs. Lab \nworkup notable for leukocytosis to 18.2, presumed due to viral \netiology; a CT scan of the abdomen did not show any acute \ncholecystitis. She was given IV fluids, pain medication, \nranitidine, and ondansetron to improvement of her Sx. The \nmorning after she arrived, she was tolerating PO and her pain \nmuch improved. She was discharged with plan to follow up as \noutpatient with the surgery team to plan her outpatient \ncholecystectomy. \n\n===================\nTRANSITIONAL ISSUES\n===================\n# CODE STATUS: Presumed full\n# CONTACT: \n- Hiren, husband (___)\n- ___ (___) as backup\n\n[ ] MEDICATION CHANGES:\n- Added ranitidine 150mg BID for possible gastritis\n- Added stool softeners, though Pt may use her OTC softeners as \nshe wishes.\n- Held oxycodone, as it can worsen constipation and contribute \nto abdominal pain as well as feelings of nausea and vomiting.\n\n[ ] FOLLOW-UP APPOINTMENTS:\n- Please follow up with Dr. ___ as scheduled.\n\n[ ] FOLLOW-UP LABS:\n- Iron studies drawn ___ for anemia.\n\n==============\nACTIVE PROBLEMS\n==============\n# RUQ/EPIGASTRIC/CHEST PAIN: Imaging negative for acute \ncholecystitis; Pt with negative lipase on admission. Most \nlikely some element of gastritis as well as her baseline \ncholelithiasis and cholecystitis, superimposed on retching with \nviral gastroenteritis (see below). Resolved on arrival to the \nfloor. \n- Acetominophen PRN\n- Ranitidine 150mg BID provided for possible gastritis\n\n# NAUSEA & VOMITING: In the setting of ill children and husband \nat home with vomiting/diarrheal illness. Most likely some \ncombination of viral gastroenteritis combined with Pt's baseline \nchronic cholelithiasis/cholelithiasis, as well as gastritis. \nAssociated with abdominal pain that did not relent with \nvomiting, as well as several days of preceding constipation \n(while taking percocet). Initially received IV fluids for \nhydration and IV ondansetron. On arrival to floor, was able to \ntolerate clear liquid diet. Advanced as tolerated to regular \ndiet. \n- Oxycodone held given propensity to cause constipation and \nexacerbate N/V\n- Ranitidine 150mg BID provided for possible gastritis\n\n#Malnutrition \nSeen by nutrition and patient is with severe malnutrition. \nEncouraged patient to supplement diet with ensure. She will need \nto discuss her nutrition with her primary care doctor. \n\n# HYPOCHLORMEIA: Likely due to ongoing vomiting. Improved with \nIVF and PO intake.\n\n# LEUKOCYTOSIS: Patient with chronic leukocytosis in teens. \nLikely due to viral infection + reactive in setting of N/V as \nabove. Improved prior to discharge. Blood cultures negative.\n\n# CONSTIPATION: Patient reported no BM in the last 2 days. \nGiven bowel regimen with senna, docusate, and polyethylene \nglycol. \n\n===================\nCHRONIC/STABLE ISSUES\n===================\n# CHOLELITHIASIS: Patient has ___ year history of abdominal \npain and N/V. Had imaging consistent with cholelithiasis during \nthis stay. \n- Patient is scheduled to have gallbladder removed electively at \n___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Multivitamins 1 TAB PO DAILY \n2. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate \n\n\n \nDischarge Medications:\n1. 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 \n2. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily \nDisp #*30 Packet Refills:*0 \n3. Ranitidine 150 mg PO BID \nRX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1 \ntablet(s) by mouth twice a day Disp #*56 Tablet Refills:*0 \n4. 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 \n5. Multivitamins 1 TAB PO DAILY \n6. HELD- OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - \nModerate This medication was held. Do not restart OxyCODONE \n(Immediate Release) until you speak with Dr. ___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\nViral gastroenteritis\nConstipation\n\nSECONDARY:\nHistory of cholelithiasis and cholecystitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Dr. ___,\n\n___ was a pleasure to care for you at the ___ \n___. You were seen at our hospital because you were \nhaving a lot of abdominal pain with nausea and vomiting that did \nnot improve for several hours. We gave you fluids through the \nIV, as well as medicine to reduce your nausea and pain. \n\nThere may be several things that contributed to your symptoms - \nyour husband and children at home with a stomach bug, your \nconstipation, and your history of gallstones with cholecystitis \ncould all have played a part. Fortunately, you were feeling \nbetter the morning after you arrived. Your pain and nausea had \nimproved, and you were able to eat and drink without vomiting. \nFor these reasons, we were able to discharge you home today.\n\nPlease follow up with Dr. ___ office as below for further \ndiscussion as to when you should have your gallbladder out.\n\nWe wish you the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "A084", "E43", "E878", "K8020", "K219", "K5900", "D649", "Z6822" ]

[ "A084: Viral intestinal infection, unspecified", "E43: Unspecified severe protein-calorie malnutrition", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "K219: Gastro-esophageal reflux disease without esophagitis", "K5900: Constipation, unspecified", "D649: Anemia, unspecified", "Z6822: Body mass index [BMI] 22.0-22.9, adult" ]

[ "K219", "K5900", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nAugmentin / Bactrim\n \nAttending: ___.\n \nChief Complaint:\ncough, confusion\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\n___ y.o male with h.o positive PPD per OMR, rheumatoid arthritis, \nDM, asthma, HL who presented with cough. Pt reports that he \ndeveloped new cough x 1 day last night and felt dehydrated. He \nreports that he felt well up until that point. He reports that \nthe hardwood floors in his home were redone an he attributes the \ncough to this process. He reports feeling drowsy and confused x \n1 day with chills and fever but denies SOB, CP, palpitations, \nheadache, ST, abdominal pain, nausea, vomiting, diarrhea, \nconstipation, dysuria, myualgias, arthralgias. \n.\nIn the ED, he was given IVF, Tylenol, ibuprofen, levofloxacin. \nHe presented with fever and tachycardia. Flu negative. \nLast vitals T 97.9 BP 119/86 HR 98 RR 24 sat 97% on RA \n.\n10Pt ROS reviewed and otherwise negative. \n \nPast Medical History:\nRheumatoid arthritis - on methotrexate\nAsthma\nDM type II\nHTN\nChronic sinusitis\nHx of positive PPD \n \nSocial History:\n___\nFamily History:\nDad-MI\nmom-colon cancer \n \nPhysical Exam:\n========================\nADMISSION EXAM:\n.\nGEN: well appearing, NAD\nvitals:T 97.4 BP 120/59 HR 95 RR 18 sat 96% on RA\nHEENT: ncat eomi anicteric MMM\nneck: supple\nchest: b/l ae rhonchi L.mid and lower lung\nheart: s1s2 rr no m/r/g\nabd: +bs, soft, NT, ND, no guarding or rebound\next: no cce 2+pulses\nneuro: face symmetric, speech fluent\npsych: calm, cooperative \n.\n========================\nDISCHARGE EXAM:\n.\nGEN: well appearing, NAD\nVS: Tc 97.2 Tm 97.4 BP 116/71 HR 98 RR 16 sat 100% on RA\nAmbulatory sats: 97% on RA with max HR 109, no \ndyspnea/palpitations/CP\nHEENT: ncat eomi anicteric MMM\nneck: supple\nchest: mild crackles in bilateral lower lung fields, more \nprominent at bases, trace rhonchi L.mid and lower lung, good air \nmovement, no increased WOB or accessory muscle use at rest or \nwith ambulation\nheart: s1s2 rr no m/r/g\nabd: +bs, soft, NT, ND, no guarding or rebound\next: WWP, no cyanosis or edema, 2+pulses\nneuro: face symmetric, speech fluent, AOx3, stable gait\npsych: calm, cooperative \n \nPertinent Results:\n___ 09:58PM URINE HOURS-RANDOM\n___ 09:58PM URINE UHOLD-HOLD\n___ 09:58PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 09:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-LG\n___ 09:58PM URINE RBC-2 WBC-41* BACTERIA-NONE YEAST-NONE \nEPI-0 TRANS EPI-1\n___ 09:58PM URINE HYALINE-1*\n___ 09:58PM URINE CA OXAL-RARE\n___ 09:58PM URINE MUCOUS-RARE\n___ 09:25PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 09:01PM LACTATE-1.6\n___ 08:55PM GLUCOSE-136* UREA N-20 CREAT-1.0 SODIUM-137 \nPOTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16\n___ 08:55PM estGFR-Using this\n___ 08:55PM WBC-9.0 RBC-4.04* HGB-11.9* HCT-36.3* MCV-90 \nMCH-29.5 MCHC-32.8 RDW-14.8 RDWSD-47.9*\n___ 08:55PM NEUTS-82.6* LYMPHS-5.7* MONOS-10.8 EOS-0.2* \nBASOS-0.3 IM ___ AbsNeut-7.39* AbsLymp-0.51* AbsMono-0.97* \nAbsEos-0.02* AbsBaso-0.03\n___ 08:55PM PLT COUNT-202\n.\nCXR:\nIMPRESSION: \nFindings compatible with right middle lobe pneumonia. \n.\n.\nDISCHARGE LABS:\n___ 05:53AM BLOOD WBC-9.2 RBC-3.33* Hgb-9.8* Hct-29.9* \nMCV-90 MCH-29.4 MCHC-32.8 RDW-14.9 RDWSD-47.5* Plt ___\n___ 05:53AM BLOOD Glucose-105* UreaN-19 Creat-0.9 Na-140 \nK-4.1 Cl-111* HCO3-22 AnGap-11\n___ 05:53AM BLOOD Phos-2.7 Mg-2.0\n.\n.\nMICROBIO:\n___ URINE URINE CULTURE-PENDING INPATIENT \n___ BLOOD CULTURE Blood Culture, \nRoutine-PENDING EMERGENCY WARD \n___ BLOOD CULTURE Blood Culture, \nRoutine-PENDING EMERGENCY WARD \n\n \nBrief Hospital Course:\n___ y.o male with PMH of positive PPD who presented with cough \nand reports of confusion found to have PNA.\n.\n# Community acquired bacterial pneumonia with sepsis (fever, \ntachycardia, tachypnea-IN ED). CXR with infiltrate. Flu \nnegative. Notably was treated with cipro for chronic sinusitis \napproximately 1 month ago, so there was concern that he might \nhave a resistant organism. However, he responded well to \nlevofloxacin (chosen initially in ED because of reported \nAugmentin allergy, however patient notes that this is NOT an \nallergy, he did not have rash, just had mild/moderate diarrhea). \n Also given IVF with improvement in his tachycardia. Continued \nlevofloxacin on discharge given his good clinical response. On \nday of discharge he had mild tachycardia (HR ___ at rest), but \nambulatory sats were wnl, ambulatory HR was only 100s, and he \nwas feeling well without any cardiopulmonary symptoms. Advised \nhim to seek immediate medical attention of recurrent fevers, \nchills, worsening cough/SOB/DOE, or other concerning symptoms \ndue to risk of antibiotic resistance. Advised follow-up with \nPCP ___ 1 week.\n.\n# Confusion - resolved quickly with treatment of CAP as above.\n.\n# Anemia- Asymptomatic. Patient denies any recent evidence of \nbleeding (no hemoptysis, epistaxis, hematemesis, melena, BRBPR, \nor hematuria). Reports he has chronic anemia due to his RA. Hgb \n9.8 on discharge. Outpatient follow-up.\n.\n# Positive UA in ED: large leuk esterase, 41 WBCs, but no \nurinary symptoms to suggest UTI. UCx pending at the time of \ndischarge, if UCx grows fluoroquinolone-resistant organisms, \nwould advocate for changing abx given his initial presentation \nwas consistent with sepsis (by old criteria).\n.\n# Day of discharge: was feeling well, VSS, afebrile, ambulatory \nsats wnl and no symptoms with ambulation. Tolerating PO meds. \nPatient comfortable with discharge (wanted to go) and verbalized \nunderstanding of need for seeking medical attention immediately \nif recurrent fevers, chills, worsening cough/SOB/DOE, or other \nconcerning symptoms. Time in care: 35 minutes in patient care \nand discharge-related activities.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n2. Tamsulosin 0.4 mg PO QHS \n3. MetFORMIN (Glucophage) 500 mg PO BID \n4. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -200 unit oral DAILY \n5. Tiotropium Bromide 1 CAP IH DAILY \n6. Vitamin D 1000 UNIT PO DAILY \n7. Cetirizine 10 mg PO DAILY \n8. Naproxen 500 mg PO Q8H:PRN pain \n9. Fish Oil (Omega 3) 1000 mg PO BID \n10. Benicar (olmesartan) 20 mg oral DAILY \n11. Methotrexate Dose is Unknown PO Frequency is Unknown \n\n \nDischarge Medications:\n1. Cetirizine 10 mg PO DAILY \n2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n3. Tamsulosin 0.4 mg PO QHS \n4. Tiotropium Bromide 1 CAP IH DAILY \n5. Acetaminophen 325-650 mg PO Q6H:PRN pain \nDo not take more than ___ mg of acetaminophen in any 24 hour \nperiod. \n6. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough \n7. Levofloxacin 500 mg PO DAILY Duration: 5 Days \nRX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*5 \nTablet Refills:*0\n8. Benicar (olmesartan) 20 mg oral DAILY \n9. Fish Oil (Omega 3) 1000 mg PO BID \n10. MetFORMIN (Glucophage) 500 mg PO BID \n11. Methotrexate 8 tabs PO QWED \nPatient does not know strength of tabs. Thinks are 1 mg each for \ntotal dose of 8 mg. \n12. Naproxen 500 mg PO Q8H:PRN pain \n13. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -200 unit oral DAILY \n14. Vitamin D 1000 UNIT PO DAILY \n15. Tessalon Perles (benzonatate) 100 mg oral TID:PRN cough \nDuration: 3 Days \nRX *benzonatate 100 mg 1 capsule(s) by mouth TID:PRN Disp #*9 \nCapsule Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRML Pneumonia\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 due to cough and CXR findings \nconcerning for pneumonia. You were started on oral antibiotics \n(levofloxacin) and given IV fluids with improvement. You were \nfeeling well on the day of discharge and your vital signs were \nstable. You are being discharged on the same antibiotic \n(levofloxacin) and will need to take this for 5 more days. \nPlease arrange to see your primary care physician ___ 1 week to \nensure that your symptoms have resolved upon completion of \nantibiotics. Please seek immediate medical attention if you \ndevelop fevers, shaking chills, worsening productive cough, \nshortness of breath, shortness of breath with exertion, or \nworsening fatigue. As we discussed, because of your underlying \nmedical conditions (rheumatoid arthritis and diabetes) as well \nas the medication you take for RA (methotrexate), you are at \nhigher risk for serious infection. As a result, if you start \nfeeling unwell despite the antibiotics, do not hesitate to seek \nmedical attention.\n\nIt was a pleasure caring for you while you were in the hospital, \nand we wish you a speedy recovery!\n\nSincerely,\nThe ___ Medicine Team\n \nFollowup Instructions:\n___\n" ]

[ "J189", "E119", "D649", "J45909", "I10", "M069" ]

[ "J189: Pneumonia, unspecified organism", "E119: Type 2 diabetes mellitus without complications", "D649: Anemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "I10: Essential (primary) hypertension", "M069: Rheumatoid arthritis, unspecified" ]

[ "E119", "D649", "J45909", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ by ___ is a ___ year old man with PMH CVA, \nHTN, HLD, DM2 (diet controlled), remote CABG w/ subsequent \noccluded grafts s/p stents to OM and LAD (___) and dementia who \npresents with one week intermittent chest pain w/ rad to left \narm. Per history taken in the ED his chest pain is worsened by \nwalking, relieved by rest and nitroglycerin. History limited by \npatient dementia. Patient denies concomitant SOB, DOE, N/V, \nchanges in bowel, bladder. \n\nOf note, patient reports tumultuous living condition due to \nconflict with his landlord. Intermittently endorsing wanting to \nharm someone, but no clear plan. Per review of Atrius records, \nthis has been chronic and is being actively worked on by PCP who \nis involving social work and legal. Per last PCP ___:\n\n\"___ services has gone into his home which has \nrevealed unusual behavior such as keeping refrigerator locked, \nclaiming someone stealing his food, claiming strangers come in \nto use his telephone and he has no phone. Multiple unpaid bills. \nHe is at risk of being evicted because of the disruption his \nparanoia thoughts are causing to the management of the complex. \nIt appears he may not be safe to be living alone.\"\n \nIn the ED, initial vitals were: 97.8 77 149/84 18 99% RA \n \nExam notable for\nsating well on RA, RRR, CTABL, no ___ edema, AO to person, \n___\" Year: ___ Month: ___ Date: ___, word \nfinding difficulties, perseverates on conflict w/ landlord, \nfixed paranoia, NOT aggressive or violent, redirectable \n\nLabs showed leukopenia to 3.9, Hgb 12.9, plts 201. Chem 7 WNL. \nTrop negative x1 with another pending on transfer. \nImaging showed CXR with Low lung volumes. Subtle left base \nopacity could be due to atelectasis, although infection or \naspiration are also in the differential. \n\nReceived 324 of aspirin\n \nTransfer VS were 97.9 75 135/85 19 99% RA \n\n___ cardiology was consulted and agreed with ED plan for \nnuclear stress test. \n\nPsych were consulted for fixed delusions and intent to harm \nlandlord. They recommended:\n - Patient does not currently meet ___ criteria \n - Please continue 1:1 sitter to monitor acute agitation and \nfall prevention\n - For acute agitation that does not respond to verbal \nredirection, can offer PRN Seroquel 25mg BID\n - Patient may benefit from outpatient formal neurocognitive \ntesting for dementia evaluation\n \nDecision was made to admit to medicine for further management \nand for nuclear stress testing. \n\nOn arrival to the floor, patient denies having chest pain. Last \nchest pain was \"3 weeks ago.\" Was also nauseous \"3 weeks ago.\" \nHe denies SOB. No palpitations. Tangential on history. Stating, \n\"I don't want to hurt no one.\" \n \nPast Medical History:\nHypertension, essential \nCerebrovasc disease \nElevated PSA \nBlood in stool \nHypercholesterolemia \nDM (diabetes mellitus), type 2 with ophthalmic complications \nScreening for colon cancer \nHistory of coronary artery bypass surgery \nObesity \nMCI (mild cognitive impairment)\n \nSocial History:\n___\nFamily History:\nMother died of a heart attack. Otherwise, does not know family \nhistory. \n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVital Signs: 97.9 155/81 70 18 95 RA\nGeneral: Alert, oriented to person, place and time. Not oriented \nto situation, no acute distress. \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 1+ \n___ edema bilaterally \nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, gait deferred. No asterixis. Patient \nmirroring suggestive of frontal release. \nPsych: Tangential speech\n\nDischarge Physical Exam:\n========================\nVital Signs: 97.5 155/88 66 18 96% RA\nGeneral: Alert, oriented to person, place and time. Not oriented \nto situation, no acute distress. \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended\nGU: No foley \nExt: Warm, well perfused, ___ b/l lower extremity edema\nNeuro: CNII-XII grossly intact\nPsych: Tangential speech\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 07:51PM BLOOD WBC-3.9* RBC-4.38* Hgb-12.9* Hct-39.4* \nMCV-90 MCH-29.5 MCHC-32.7 RDW-15.6* RDWSD-51.0* Plt ___\n___ 07:51PM BLOOD Neuts-47.5 ___ Monos-13.3* \nEos-1.0 Baso-0.5 Im ___ AbsNeut-1.85 AbsLymp-1.46 \nAbsMono-0.52 AbsEos-0.04 AbsBaso-0.02\n___ 07:51PM BLOOD Glucose-106* UreaN-9 Creat-0.9 Na-142 \nK-4.2 Cl-105 HCO3-26 AnGap-15\n___ 07:51PM BLOOD cTropnT-<0.01\n___ 02:10AM BLOOD cTropnT-<0.01\n\nPertinent Labs:\n===============\n___ 06:15AM BLOOD VitB12-___\n___ 06:15AM BLOOD TSH-2.5\n\nImaging:\n=======\n___ CXR:\nLow lung volumes. Subtle left base opacity could be due to \natelectasis, \nalthough infection or aspiration are also in the differential. \nPosterior to a lower thoracic vertebral body is a radiopaque \nstructure \nmeasuring ~ 1.6 x 0.9 cm of unclear etiology but could represent \nshrapnel.\n\n___ P-MIBI:\nThe image quality is adequate but limited due to soft tissue \nattenuation. \nResting perfusion images reveal uniform tracer uptake throughout \nthe myocardium.\n \nDischarge Labs:\n=============== \n\n___ 06:15AM BLOOD WBC-4.9 RBC-4.11* Hgb-11.9* Hct-36.8* \nMCV-90 MCH-29.0 MCHC-32.3 RDW-15.5 RDWSD-50.3* Plt ___\n___ 06:15AM BLOOD Glucose-152* UreaN-9 Creat-0.9 Na-142 \nK-3.9 Cl-106 HCO3-26 AnGap-___ year old man with ___ CVA, HTN, HLD, DM2 (diet controlled), \nremote CABG w/ subsequent occluded grafts s/p stents to OM and \nLAD (___) and cognitive impairment who presents with one week \nintermittent chest pain and chronic paranoid delusions. \n\n# CAD: \n# Chest pain: significant PMH for CAD s/p CABG and PCIs. Per \nhistory obtained by EMS and ED patient was having active chest \npain which prompted his presentation, but he denied chest pain \non arrival to the floor and could not recall any recent chest \npain. Troponin was negative x 2. P-MIBI was attempted but after \nobtaining resting images patient refused further testing and \nattempted to leave. Continued home aspirin. metoprolol, \natorvastatin, diltiazem \n\n# Paranoid delusions: ongoing issue that is referred to in \nrecent Atrius notes. He was evaluated by psychiatry who did not \nfeel that inpatient psychiatric hospitalization was indicated. \nThey recommended Risperdal with close monitoring of QTc but \npatient refused. Spoke to patient's PCP ___. \nCurrently he lives alone with meal and homemaking services per \nelder services and per Dr. ___ has been managing but has come \nclose to eviction in the past. He and others within the ___ \nsystem have been working on arranging a more supervised living \narrangement. He will follow up with Dr. ___ will \ncontinue to process of transitioning to more supervised living \nsituation\n \n# HTN: continued home lisinopril, furosemide, metoprolol, and \ndiltiazem\n\nTransitional Issues:\n====================\n- needs follow up for housing issues\n- TSH, RPR, B12 pending at discharge\n- consider Risperdal 0.5mg BID per psychiatry recommendations, \nwill need monitoring of QTc\n\n>30 minutes spent coordinating discharge home\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Potassium Chloride 20 mEq PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Metoprolol Succinate XL 200 mg PO DAILY \n4. Lisinopril 5 mg PO DAILY \n5. Diltiazem Extended-Release 180 mg PO DAILY \n6. Furosemide 40 mg PO DAILY \n7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n8. Multivitamins 1 TAB PO DAILY \n9. Aspirin EC 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin EC 325 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Diltiazem Extended-Release 180 mg PO DAILY \n4. Furosemide 40 mg PO DAILY \n5. Lisinopril 5 mg PO DAILY \n6. Metoprolol Succinate XL 200 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n9. Potassium Chloride 20 mEq PO DAILY \nHold for K > \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nChest pain\n\nSecondary:\nCognitive impairment\nPsychosis\nCoronary artery disease, chronic\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nWHY YOU CAME TO THE HOSPITAL:\nYou came to the hospital because you were having chest pain\n\nWHAT WE DID FOR YOU HERE:\nYou had blood tests that showed that you were not having a heart \nattack\n\nWHAT YOU SHOULD DO AFTER LEAVING THE HOSPITAL:\n1. Please follow up for Dr. ___ - see below for your \nappointment\n \nFollowup Instructions:\n___\n" ]

[ "R079", "G3184", "F22", "I2510", "Z951", "Z955", "Z8673", "I10", "E785", "E7800", "E119", "E669", "Z6832", "Z87891" ]

[ "R079: Chest pain, unspecified", "G3184: Mild cognitive impairment, so stated", "F22: Delusional disorders", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E7800: Pure hypercholesterolemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "Z87891: Personal history of nicotine dependence" ]

[ "I2510", "Z951", "Z955", "Z8673", "I10", "E785", "E119", "E669", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nEpinephrine\n \nAttending: ___\n \nChief Complaint:\nleft hip pain \n \nMajor Surgical or Invasive Procedure:\n___: left total hip arthroplasty \n\n \nHistory of Present Illness:\n___ year old male with history of left hip osteoarthritis present \nfor definitive treatment. \n \nPast Medical History:\nOA, s/p hernia repair (remote), hx of vasovagal with blood draws \n\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Incision healing well with staples \n* Scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm \n\n \nPertinent Results:\n___ 06:15AM BLOOD WBC-7.6 RBC-3.10* Hgb-9.3* Hct-28.8* \nMCV-93 MCH-30.0 MCHC-32.3 RDW-13.7 RDWSD-46.8* Plt ___\n___ 05:10AM BLOOD WBC-7.6 RBC-3.11* Hgb-9.3* Hct-28.9* \nMCV-93 MCH-29.9 MCHC-32.2 RDW-13.8 RDWSD-46.9* Plt ___\n___ 05:15AM BLOOD WBC-8.5# RBC-3.55* Hgb-10.7* Hct-32.7* \nMCV-92 MCH-30.1 MCHC-32.7 RDW-13.8 RDWSD-47.3* Plt ___\n___ 01:29PM BLOOD WBC-5.4 RBC-4.01* Hgb-11.8* Hct-37.0* \nMCV-92 MCH-29.4 MCHC-31.9* RDW-13.4 RDWSD-45.8 Plt ___\n___ 06:15AM BLOOD Plt ___\n___ 05:10AM BLOOD Plt ___\n___ 05:15AM BLOOD Plt ___\n___ 01:29PM BLOOD Plt ___\n___ 06:15AM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-138 \nK-3.6 Cl-101 HCO3-31 AnGap-10\n___ 05:10AM BLOOD Glucose-106* UreaN-13 Creat-0.7 Na-136 \nK-3.7 Cl-100 HCO3-33* AnGap-7*\n___ 05:15AM BLOOD Glucose-127* UreaN-16 Creat-0.7 Na-136 \nK-3.7 Cl-100 HCO3-28 AnGap-12\n___ 01:29PM BLOOD Glucose-126* UreaN-15 Creat-0.7 Na-137 \nK-3.9 Cl-104 HCO3-28 AnGap-9\n___ 06:15AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.0\n___ 05:10AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.9\n___ 05:15AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9\n___ 01:29PM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0\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\nFollowing the placement of the spinal by anesthesia, patient had \na suspected vaso-vagal episode with lightheadedness, \nbradycardia, and hypotension. During this time he complained of \nmid chest pressure (no pain). Responded to ephedrine and \nglycopyrrolate with improvement in hemodynamics and resolution \nof symptoms. Rest of case was uneventful. He was monitored on \ncontinuous O2 monitoring/telemetry. The patient's urine looked \ncloudy. His urine tests came back negative for an infection.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received lovenox for DVT \nprophylaxis starting on the morning of POD#1. The foley was \nremoved and the patient was voiding independently thereafter. \nThe overlying dressing was removed on POD#2 and the Silverlon \ndressing was found to be clean and dry. The patient was seen \ndaily by physical therapy. Labs were checked throughout the \nhospital course and repleted accordingly. At the time of \ndischarge the patient was tolerating a regular diet and feeling \nwell. The patient was afebrile with stable vital signs. The \npatient's hematocrit was acceptable and pain was adequately \ncontrolled on an oral regimen. The operative extremity was \nneurovascularly intact and the wound was benign. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity with posterior precautions. \nWalker or two crutches at all times for 6 weeks.\n \nMr. ___ is discharged to home with services in stable \ncondition.\n\n \nMedications on Admission:\n1. Acetaminophen ___ mg PO Q8H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Naproxen 220 mg PO PRN: pain \n5. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Multivitamins 1 TAB PO DAILY \n3. Senna 8.6 mg PO BID \n4. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days \nStart: ___, First Dose: First Routine Administration Time \n5. Docusate Sodium 100 mg PO BID \n6. Acetaminophen 1000 mg PO Q8H \n7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain \n8. Fish Oil (Omega 3) 1000 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft hip osteoarthritis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc).\n \n8. ANTICOAGULATION: Please continue your Lovenox for four (4) \nweeks to help prevent deep vein thrombosis (blood clots). If \nyou were taking aspirin prior to your surgery, it is OK to \ncontinue at your previous dose while taking anticoagulation \nmedication. ___ STOCKINGS x 6 WEEKS.\n \n9. WOUND CARE: It is okay to shower five days after surgery but \nno tub baths, swimming, or submerging your incision until after \nyour four (4) week checkup. You may place a dry sterile dressing \non the wound, otherwise leave it open to air. Check wound \nregularly for signs of infection such as redness or thick yellow \ndrainage. Staples will be removed by the visiting nurse or rehab \nfacility in two (2) weeks.\n \n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks, and staple removal at two weeks after \nsurgery.\n \n11. ACTIVITY: Weight bearing as tolerated with walker or 2 \ncrutches at all times for six weeks. Posterior precautions. No \nstrenuous exercise or heavy lifting until follow up appointment. \n Mobilize frequently.\nPhysical Therapy:\nWeight bearing as tolerated with walker or 2 crutches at all \ntimes for six weeks. Posterior precautions. No strenuous \nexercise or heavy lifting until follow up appointment. Mobilize \nfrequently.\nTreatments Frequency:\ndaily dressing changes as needed for drainage\nwound checks daily\nice\nTEDs\nstaple removal and replace with steri-strips on POD#14 at \n___ \n \nFollowup Instructions:\n___\n" ]

[ "M1612", "R55", "T8859XA", "T4145XA", "Y92234", "Z7982" ]

[ "M1612: Unilateral primary osteoarthritis, left hip", "R55: Syncope and collapse", "T8859XA: Other complications of anesthesia, initial encounter", "T4145XA: Adverse effect of unspecified anesthetic, initial encounter", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z7982: Long term (current) use of aspirin" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncodeine\n \nAttending: ___\n \nChief Complaint:\ndyspnea\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n ___ y/o female with a past medical history significant for \nsarcoidosis (c/b neuropathy, wide complex tachycardia and \nparoxysmal AV block s/p PPM in ___, spinal stenosis, obesity, \nand hypothyroidism, presenting with dyspnea. \n\n She notes ___ weeks of increased dyspnea on exertion. She is \nshort of breath with small amounts of walking. She is not short \nof breath at rest. She is able to lie flat, but notes that she \nis undergoing testing for sleep apnea in the near future given \nconcern of her husband that she has \"heavy breathing at night.\" \n \n At the direction of her outpatient Neurologist, she underwent \noutpatient chest CT on ___. This showed stable mediastinal \nadenopathy but \"abnormal wall thickening of the right \nbrachiocephalic artery and ascending aorta, which can be seen \nwith ___'s arteritis.\" Her Neurologist directed the patient \nto ___ ED for admission for further evaluation. She \nrecommended ECHO and possible CTA to rule out pulmonary \nembolism. \n\n Regarding the patient's sarcodiosis history, she was \nhospitalized in ___ for workup of extensive paraspinal, \ncervical, parasplenic and mediastinal lymphadenopathy found on \nCT while being worked up by her neurologist for limb \nparesthesias, numbness and gait disturbance. More specifically, \nmultiple CTs revealed cervical and mediastinal lymphadenopathy \nand a PET scan on ___ was concerning for lymphoma with \npossible cord involvment/compression. MRI ___ revealed \nsignificant brain and cord involvement with concern for cord \ncompression at C3 and T8 despite absence of clinical findings.\n \n She underwent mediastinoscopy for biopsy and tissue and the \npathology was c/w sarcoidosis. She was given IV pulse \nmethylprednisolone x3 days and discharged on 50mg PO. LP for CSF \nevaluation was unable to be performed ___ risk of herniation. \nShe also had gait problems during that hospitalization thought \nto be related to spinal stenosis. \n\n In the ED, initial vitals were: 97.1 88 143/61 18 100%RA \n Labs notable: \n 9.7>13.2/40/8<174 MCV 103 88.5% neuts \n ___ 9.8 PTT 26.7 INR 0.9 \n Bicarb 21 \n BUN/Cr ___ \n Bland U/A \n Lactate 2.6 \n ProBNP 82 \n\n Upon arrival to the floor, she is without complaints. She also \nnotes that she has had several days of a cough, that is mildly \nproductive of white sputum. She has had no fevers. Her daughter \nand several co-workers have had upper respiratory infections.\n \n\n \nPast Medical History:\n Wide-complex tachycardia pacemaker in ___ \n Hypothyroidism \n Lymphadenopathy \n GERD (gastroesophageal reflux disease) on pantoprazole \n SUI (stress urinary incontinence, female) \n Tinnitus \n Depression \n Adenomatous colon polyp due ___ \n Genital herpes \n Obesity, morbid \n THYROID DISEASE \n polycysitc ovaries \n \nSocial History:\n___\nFamily History:\nBrother: DM \nFather: Died of lung cancer \nMGF: Heart disease \nMGM: Lung cancer \nPGM: Aneurysm \nPGF: Stomach cancer \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n Vital Signs: 98.9 160/76 93 20 95% on room air \n Resting HR 80-90ss, O2 sat 95-96% on room air \n Ambulation HR 90-100s, O2 sat 94-95% on room air \n General: Alert, oriented, no acute distress. Prominent \ncushinoid appearance. \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n NECK: supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, no murmurs \n Lungs: Distant breath sounds, but few wheezes appreciated \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, no edema \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \nno focal deficits \n\nDISCHARGE PHYSICAL EXAM: \nVitals: Tm 98.7 Tc 98.7 ___ 20 97% RA\nGeneral: Alert, oriented, no acute distress. Prominent cushinoid \nappearance. \nHEENT: Sclera anicteric, conjunctivae noninjected, MMM, \noropharynx clear, alopecia \nNECK: supple, JVP difficult to appreciate secondary to body \nhabitus, no LAD \nCV: Regular rate and rhythm, no murmurs \nLungs: CTAB no wheezes, rales, rhonchi appreciated\nAbdomen: Soft, non-tender, non-distended, bowel sounds present\nGU: No foley \nExt: Warm, well perfused, ___ pitting edema to knee\nNeuro: MAE, no focal deficits\n \nPertinent Results:\nADMISSION LABS:\n___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 05:40PM ___ PTT-26.7 ___\n___ 05:40PM PLT COUNT-174\n___ 05:40PM NEUTS-88.5* LYMPHS-6.0* MONOS-4.1* EOS-0.1* \nBASOS-0.1 IM ___ AbsNeut-8.60*# AbsLymp-0.58* AbsMono-0.40 \nAbsEos-0.01* AbsBaso-0.01\n___ 05:40PM WBC-9.7 RBC-3.97 HGB-13.2 HCT-40.8 MCV-103*# \nMCH-33.2* MCHC-32.4 RDW-13.5 RDWSD-50.4*\n___ 05:40PM proBNP-82\n___ 05:40PM GLUCOSE-142* UREA N-15 CREAT-0.7 SODIUM-139 \nPOTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18\n___ 05:54PM LACTATE-2.6*\n\nSTUDIES:\n___ Chest X ray: \nModerate cardiomegaly is stable. Pacer leads are in standard \nposition. The lungs are clear. There is no pneumothorax or \npleural effusion. \n\n___ TTE: \nVery poor image quality (unable to perform bubble study due to \npoor echo windows). The left atrium is elongated. There is mild \nsymmetric left ventricular hypertrophy with normal cavity size \nand regional/global systolic function (LVEF>55%). There is no \nventricular septal defect. Right ventricular chamber size and \nfree wall motion are normal. The diameters of aorta at the \nsinus, ascending and arch levels are normal. The aortic valve \nleaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosis or aortic regurgitation. \nTrivial mitral regurgitation is seen. The left ventricular \ninflow pattern suggests impaired relaxation. The pulmonary \nartery systolic pressure could not be determined. There is no \npericardial effusion. \n\nCompared with the prior study (images reviewed) of ___, no \nclear change. \n\n___ MRA chest:\n1. Subacute compression fracture of the T8 vertebral body with \ngreater than 50% loss of height, new since ___. \n \n2. Mild thickening along the proximal right subclavian artery \nhas imaging \nfeatures most consistent with fibrosis and healing, likely from \nprior \nvasculitis, rather than active inflammation. There is no \nluminal narrowing. \n \n3. Resolution of ascending thoracic aortic wall thickening with \nnormal \nappearance of the wall and no luminal narrowing, consistent with \nresolution of previously seen extensive inflammatory changes on \nthe prior FDG PET-CT. \n\nMICROBIOLOGY:\n___ BLOOD CULTURE: negative\n\nDISCHARGE LABS:\n___ 06:14AM BLOOD WBC-8.1 RBC-4.06 Hgb-13.4 Hct-43.3 \nMCV-107* MCH-33.0* MCHC-30.9* RDW-13.9 RDWSD-54.4* Plt ___\n___ 06:14AM BLOOD Glucose-72 UreaN-12 Creat-0.8 Na-143 \nK-4.0 Cl-103 HCO3-30 AnGap-14\n___ 06:14AM BLOOD Calcium-9.9 Phos-4.0 Mg-2.___ is a ___ year old woman with a past medical \nhistory significant for sarcoidosis (c/b wide complex \ntachycardia and paroxysmal AV block s/p PPM in ___ obesity, \nand hypothyroidism, who presented with dyspnea. \n\nInvestigations/Interventions:\n1. Dyspnea - Patient presenting with 2 weeks of worsened dyspnea \non exertion. She had an outpatient CT chest which showed stable \nadenopathy but new abnormal wall thickening of the right \nbrachiocephalic artery and ascending aorta, which was concern \nfor ___'s arteritis. She had an MRA which was more \nconsistent with sarcoidosis than ___'s, however, and \nchanges were noted to be more fibrotic and chronic than acute. \nACE level was 20, down from 30 in ___. A TTE was done to \nevaluate for pulmonary hypertension but unfortunately, due to \npoor windows was unable to do so. She did have normal EF and no \nsignificant valvular disease. Her dyspnea may represent \nworsening sarcoidosis. Her outpatient rheumatologist had been \nconsidering initiating infliximab (she is currently on \nprednisone and MMF). She was seen by rheumatology as an \ninpatient but decisions about further treatment of her \nsarcoidosis were deferred to her outpatient provider, Dr. \n___. She may also benefit from PFTs and sleep study as an \noutpatient as she was noted to desaturate at night, but never \nduring the day. Pt had slight expiratory wheeze on exam, so was \ndischarged with albuterol inhaler with plan for outpatient PFTs\n2. Compression Fracture - No notable abnormalities on neuro \nexam, but pt did have mild pain in the corresponding area. \nLikely ___ chronic prednisone use and therefore downtitration \nshould be considered as well as treatment of osteoporosis with \nbisphosphonate and Ca/Vitamin D.\n\nTransitional issues:\n=====================================\n- Patient found to have a mid-thoracic compression fracture on \nMRA from ___ (seen on outside CT, but not present on MRI from \n___. Thus, needs outpatient osteoporosis workup and treatment \n(bisphosphonate/calcium/vitamin D) \n- Patient had normal oxygen saturations during the day, both at \nrest and with ambulation; however, she desaturated transiently \nto the high ___ while sleeping. She is encouraged to follow \nup as scheduled for an outpatient sleep study.\n- Pt would benefit from outpatient PFTs as had slight expiratory \nwheeze on exam\n\n- CODE: Full code\n- CONTACT: ___ (husband) ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Timolol Maleate 0.25% 2 DROP BOTH EYES BID \n2. Pantoprazole 20 mg PO Q24H \n3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n4. PredniSONE 40 mg PO DAILY \n5. Mycophenolate Mofetil 1000 mg PO BID \n6. Gabapentin 600 mg PO QAM \n7. Gabapentin 900 mg PO QHS \n8. Levothyroxine Sodium 150 mcg PO DAILY \n9. urea 40 % topical BID \n10. Docusate Sodium 100 mg PO BID \n11. Senna 8.6 mg PO BID \n12. Acyclovir 400 mg PO Q12H \n13. Metoprolol Succinate XL 100 mg PO QHS \n14. Vitamin D 1000 UNIT PO DAILY \n15. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. PredniSONE 40 mg PO DAILY \n3. Gabapentin 600 mg PO QAM \n4. Gabapentin 900 mg PO QHS \n5. Levothyroxine Sodium 150 mcg PO DAILY \n6. Metoprolol Succinate XL 100 mg PO QHS \n7. Multivitamins 1 TAB PO DAILY \n8. Mycophenolate Mofetil 1000 mg PO BID \n9. Pantoprazole 20 mg PO Q24H \n10. Senna 8.6 mg PO BID \n11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n12. Timolol Maleate 0.25% 2 DROP BOTH EYES BID \n13. Vitamin D 1000 UNIT PO DAILY \n14. Docusate Sodium 100 mg PO BID \n15. urea 40 % topical BID \n16. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB \nRX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff INH q6h:prn \nDisp #*1 Inhaler Refills:*0\n17. Lidocaine 5% Patch 1 PTCH TD QAM \n18. Lidocaine 5% Ointment 1 Appl TP DAILY \nRX *lidocaine 5 % Apply to painful area of back Daily Refills:*0\nRX *lidocaine 5 % Apply to painful area of back for 12 hours \nDaily Disp #*30 Patch Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnoses:\nDyspnea\nSarcoidosis\nVertebral Compression Fracture\n\nSecondary diagnoses:\nHypothyroidism\nGastroesophageal reflux disease\nDepression\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were hospitalized because you were having trouble breathing. \nUnfortunately, we are not sure what was causing your symptoms. \nBefore coming into the hospital, you had imaging of your lungs \nand chest (a CT scan) which showed some changes in your aorta, \nthe major blood vessel leaving your heart, which were concerning \nfor an inflammatory condition called arteritis. You had an MRI \nthat did not show any evidence of arteritis but it did show \npossible chronic changes due to your sarcoid.\n\nYour shortness of breath may be due to your sarcoidosis, asthma, \nor sleep apnea. You should follow up with your rheumatologist \nafter you leave the hospital and you may need additional testing \nof your lung function and sleep study. \n\nYou will also need to follow up with your rheumatologist \nregarding your compression fracture in your spine, as it is \nlikely caused by your chronic prednisone use. \n\nIt was a pleasure participating in your care. We wish you all \nthe best in the future.\n\nSincerely,\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "R0600", "M314", "M4854XA", "Z6842", "D869", "I272", "M4800", "Z23", "E039", "R591", "G629", "K219", "N393", "H9319", "F329", "E6601", "G4733", "Z950" ]

[ "R0600: Dyspnea, unspecified", "M314: Aortic arch syndrome [Takayasu]", "M4854XA: Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "D869: Sarcoidosis, unspecified", "I272: Other secondary pulmonary hypertension", "M4800: Spinal stenosis, site unspecified", "Z23: Encounter for immunization", "E039: Hypothyroidism, unspecified", "R591: Generalized enlarged lymph nodes", "G629: Polyneuropathy, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "N393: Stress incontinence (female) (male)", "H9319: Tinnitus, unspecified ear", "F329: Major depressive disorder, single episode, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z950: Presence of cardiac pacemaker" ]

[ "E039", "K219", "F329", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nFatigue, weight loss, and chest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with no past medical\nhistory who presents with two months of B symptoms, found to \nhave\nsignificant chest and mesenteric LAD c/w lymphoma. He was in his\nnormal state of health until about two months ago, when he began\nto develop fevers, chills, and a significant amount of weight\nloss -- almost 40 lbs. In the past several weeks, he has\ndeveloped increasing chest pain and right arm pain. He had an \nMRI\ntoday which showed lymphadenopathy, and was referred to the ED.\nIn our emergency room, labs were normal. He had a CT of his \nchest\nwhich showed: \n\n1. Extensive mediastinal, bilateral hilar and paraesophageal\nlymphadenopathy. \nDifferential considerations include lymphoma or metastatic\ndisease. Right \nparatracheal station nodal conglomerate measures up to 3.5 cm \nand\ncauses mild \nnarrowing of the mid SVC without occlusion. \n2. Bilateral pulmonary nodules measuring up to 8 mm. \n3. Mildly enlarged mesenteric lymph node in the left mid \nabdomen.\nNo other \nevidence of malignancy in the abdomen or pelvis. \n\nPatient therefore admitted to medicine.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nNo family history of malignancy.\n \nPhysical Exam:\nADMISSION EXAM:\nVITALS: 98.6 PO 107 / 71 56 18 94 RA \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nLYMPH: no cervical, supraclavicular, and pelvis lymphadenopathy\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 11:50AM WBC-5.2 RBC-5.03 HGB-15.3 HCT-46.1 MCV-92 \nMCH-30.4 MCHC-33.2 RDW-12.6 RDWSD-41.9\n___ 11:50AM NEUTS-56.4 ___ MONOS-15.0* EOS-1.0 \nBASOS-0.8 IM ___ AbsNeut-2.91 AbsLymp-1.37 AbsMono-0.77 \nAbsEos-0.05 AbsBaso-0.04\n___ 11:50AM PLT COUNT-202\n___ 11:50AM ___ PTT-28.3 ___\n___ 11:50AM RET AUT-1.6 ABS RET-0.08\n___ 11:50AM GLUCOSE-94 UREA N-14 CREAT-1.1 SODIUM-141 \nPOTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11\n___ 11:50AM CALCIUM-9.5 PHOSPHATE-3.2 MAGNESIUM-2.0 URIC \nACID-7.4*\n___ 11:50AM LD(LDH)-168\n___ 11:57AM CREAT-1.0 K+-4.0\n___ 03:10PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 03:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 03:10PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE \nEPI-0\n\nIMAGING:\n=========\nEXAMINATION: CT CHEST/ABDOMEN/PELVIS \n \nINDICATION: History: ___ with 1 month of night sweats and \nweight loss, \nincidentally found to have mediastinal adenopathy on cervical \nspine MRI.// \nFurther evaluate mediastinal adenopathy seen on earlier MRI of \nthe cervical \nspine at ___ ___. Evaluate for evidence of other \nadenopathy, \nSVC syndrome. \n \nTECHNIQUE: MDCT axial images were acquired through the chest, \nabdomen and \npelvis following intravenous contrast administration with split \nbolus \ntechnique. \nOral contrast was not administered. \nCoronal and sagittal reformations were performed and reviewed on \nPACS. \n \nDOSE: Total DLP (Body) = 1,018 mGy-cm. \n \nCOMPARISON: None. \n \nFINDINGS: \n \nCHEST: \n \nHEART AND VASCULATURE: The thoracic aorta is normal in caliber. \nThe heart, \npericardium, and great vessels are within normal limits. No \npericardial \neffusion is seen. There is mild narrowing of the midportion of \nthe SVC by \nmediastinal lymphadenopathy, without occlusion. There is also \nmild narrowing \nof the right upper lobar artery by hilar lymphadenopathy. \n \nAXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy is \npresent. \nExtensive supraclavicular, mediastinal, and bilateral hilar \nadenopathy is \ndemonstrated, with index lesions as follows: \n1.6 cm left supraclavicular lymph node (2:7). \n3.5 x 2.8 cm right paratracheal nodal mass (02:21). \n2.1 cm left hilar lymph node (02:30). \n1.9 cm right hilar lymph node (02:34). \n4.3 x 2.5 cm subcarinal nodal mass (02:30). \n \nPLEURAL SPACES: No pleural effusion or pneumothorax. \n \nLUNGS/AIRWAYS: Multiple pulmonary nodules are visualized \nbilaterally. For \nexample, a right upper lobe nodule measures 8 mm (02:32), a \nright lower lobe \nnodule measures 6 mm (02:44), a left upper lobe nodule measures \n7 mm (02:19), \nand a subpleural posterior left lower lobe nodule measures 4 mm \n(02:38). \nAdditional scattered and smaller pulmonary nodules are \nvisualized bilaterally. \nNo focal consolidations are identified. The airways are patent \nto the level \nof the segmental bronchi bilaterally. \n \nBASE OF NECK: The thyroid is unremarkable. \n \nABDOMEN: \n \nHEPATOBILIARY: The liver demonstrates homogenous attenuation \nthroughout. \nThere is no evidence of focal lesion. There is no evidence of \nintrahepatic or \nextrahepatic biliary dilatation. The gallbladder is within \nnormal limits. \n \nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence of \nfocal lesions or pancreatic ductal dilatation. There is no \nperipancreatic \nstranding. \n \nSPLEEN: The spleen shows normal size and attenuation throughout, \nwithout \nevidence of focal lesion. \n \nADRENALS: The right and left adrenal glands are normal in size \nand shape. \n \nURINARY: The kidneys are of normal and symmetric size with \nnormal nephrogram. \nThere is no evidence of focal renal lesions or hydronephrosis. \nThere is no \nperinephric abnormality. \n \nGASTROINTESTINAL: The stomach is unremarkable. Small bowel \nloops demonstrate \nnormal caliber, wall thickness, and enhancement throughout. The \ncolon and \nrectum are within normal limits. The appendix is not \nvisualized. \n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is no \nfree fluid in the pelvis. \n \nREPRODUCTIVE ORGANS: The prostate and seminal vesicles are \nunremarkable. \n \nLYMPH NODES: There is a distal paraesophageal nodal conglomerate \nmeasuring 3.3 \nx 2.1 cm and a 8 mm in short axis lymph node near the \ngastroesophageal \njunction (02:53). There is a mildly enlarged 8 mm lymph node in \nthe left mid \nabdomen (2:73). Other small mesenteric and retroperitoneal \nlymph nodes are \nnot enlarged by CT size criteria. There is no pelvic or \ninguinal \nlymphadenopathy. \n \nVASCULAR: The abdominal aorta and IVC are normal in course and \ncaliber. \n \nBONES: There is no acute fracture. No focal suspicious osseous \nabnormality. \n \nSOFT TISSUES: The abdominal and pelvic wall is within normal \nlimits. \n \nIMPRESSION: \n1. Extensive mediastinal, bilateral hilar and paraesophageal \nlymphadenopathy. \nDifferential considerations include lymphoma or metastatic \ndisease. Right \nparatracheal station nodal conglomerate measures up to 3.5 cm \nand causes mild \nnarrowing of the mid SVC without occlusion. \n2. Bilateral pulmonary nodules measuring up to 8 mm. \n3. Mildly enlarged mesenteric lymph node in the left mid \nabdomen. No other \nevidence of malignancy in the abdomen or pelvis. \n\n \nBrief Hospital Course:\nAssessment:\n============\n___ man with no significant PMHx who was referred to ED \nafter an outpatient MRI of the spine (ordered for \"pinched \nnerve\") showed extensive thoracic lymphadenopathy. Upon further \nquestioning, patient also notes few months of increased chills \n(denies fevers), weight loss of 20 lbs, and mild dyspnea with \nstrenuous activity. Clinical picture and imaging concerning for \nlymphoma.\n\nBrief Hospital Course:\n=======================\n#) Lymphadenopathy, concerning for lymphoma\nThe patient was admitted to medicine for further work-up. Chest \nCT (as above) showed extensive supraclavicular, mediastinal, and \nbilateral hilar adenopathy, an enlarged mesenteric lymph node in \nthe left mid-abdomen. It also showed right paratracheal nodal \nconglomerate measures up to 3.5 cm which was causing mild \nnarrowing of the mid SVC without occlusion. Acute Care Surgery \nand Interventional Pulmonology were consulted for lymph node \nbiopsy. Surgery felt excisional biopsy of the cervical lymph \nnodes may be difficult to perform and recommended endobronchial \nbiopsy. IP evaluated the patient and scheduled him for flexible \nbronchoscopy EBUS-TBNA with lymphoma protocol for diagnosis on \n___. The patient was adamant about leaving the hospital to \nbe home for ___ and did not want to stay for the biopsy \nwhile hospitalized. He had no symptoms of TLS or SVC syndrome. \nHe was counseled on warning signs that would indicate he needed \nto return to the hospital sooner. He will follow-up with his \nPCP ___ ___ and with IP for procedure on ___ as above. \nHematology Oncology was not formally consulted but the case was \ndiscussed with them over the phone.\n\nTRANSITIONAL ISSUES:\n[] Needs lymph node biopsy -- schedule for core biopsy with IP \non ___\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\nNone\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMediastinal lymphadenopathy\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou came to the hospital with abnormal findings on an outpatient \nMRI. You had a CT scan of the chest, abdomen and pelvis which \nshowed swelling in the lymph nodes. You were seen by our \nsurgery team and our interventional pulmonology team. You will \nneed a biopsy of one of these lymph nodes.\n\nThe Interventional Pulmonology team will call you with the time \nof the biopsy. It is tentatively scheduled for ___. \n\nPlease follow-up with your PCP as below.\n\nPlease call your doctor or return to the hospital if you develop \nshortness of breath, chest pain, cough, headache, \nlightheadedness, face or arm swelling, abnormal bleeding, vision \nchange.\n \nFollowup Instructions:\n___\n" ]

[ "R591", "R5383", "R634", "R079", "Z23" ]

[ "R591: Generalized enlarged lymph nodes", "R5383: Other fatigue", "R634: Abnormal weight loss", "R079: Chest pain, unspecified", "Z23: Encounter for immunization" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ntofu / moxifloxacin\n \nAttending: ___.\n \nChief Complaint:\nDOE\n \nMajor Surgical or Invasive Procedure:\nAborted ___ occlusion device implant ___\nCPR ___\nIntubation ___\n\n \nHistory of Present Illness:\n___ woman with atrial fib flutters s/p AVNRT ablation\n___, COPD on home 3L, and diabetes now s/p failed ___\ndevice procedure c/b episode of pulseless who is transferred to\nthe CCU as remain intubated for airway protection. \n\n Given a history of falls, she was anticoagulated with coumadin\nand plan for ___ device placement. This decision was made\nafter recent admission to ___ for dyspnea found to have\nacute on chronic COPD exacerbation and atrial fibrillation with\nrapid ventricular response. \n\n Prior to this, her metoprolol dose had been decreased to 25 mg\ntwice a day. On discharge, she was started on diltiazem 120 mg\np.o. daily. In the past, diltiazem had thought to cause\nlightheadedness, falling, and questionable syncopal episodes. \nAs\nsuch she never started diltiazem. Per report she refused\nthromboembolic prophylaxis with anticoagulation as such her\naspirin dose was increased from 81 mg to 325 daily. Since the\ntime of discharge, she was sent to rehab and was there until 10\ndays prior [___]. \n\n During attempted ___ on ___, underwent general anesthesia\nwith 14 sheath and left arterial line. Once transeptal attempted\ndevice placement x2, which failed she then became hypotensive,\nbradycardic, ST elevation in inferior leads, with suspected air\nembolism to RCA. While in atrial fibrillation with profound\nbradycardia there was concern for loss of pulse, epinephrine was\ngiven then CPR performed for 3min, after repeat epi regained\npulse. She received 1L NS. A third trial of ___ device\nplacement was attempted but failed. ___ femoral sheath in right\nwas closed. Left aline remained in place, L antecubital PIV in\nplace. She arrived on propofol 20 mcg/kg/min and phenylephrine\n0.3 mcg/kg/min. \n \nOn arrival to the CCU, she is intubated but responsive,\nmouthing words, to simple commands including taking deep breath,\nsticking out tongue, squeezing fingers. \n \nPast Medical History:\n1. HTN\n2. Hypercholesterolemia\n3. chronic back pain\n4. COPD/emphysema\n5. C spine disc disease\n6. Depression\n7. pneumonia ___. Right brachial plexus neuropathy\n9. Right eye with decreased vision, ? macular degeneration\n10. SLE (severe ophthalmopathy, diffuse arthropathy)\n11. OSA/cpap\n12. MVP\n13. Fibromyalgia\nPSH\n1. S/P B/L cataracts\n2. S/P C4-5 fusion\n3. S/P multiple skin Ca exc both squamous and basal cell\n\n \nSocial History:\n___\nFamily History:\nSignificant for an uncle with diabetes.\n \nPhysical Exam:\nADMISSION PHYSICAL\n==================\nGENERAL: Intubated, no distress, RASS -___ \nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. \n\nNECK: Supple. JVP flat. \nCARDIAC: Irregular no murmurs nor rubs appreciated\nLUNGS: equal breath sounds with no crackles nor rhonchi\nappreacited \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No\nsplenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE PHYSICAL\n==================\nVS: 97.9 (Tm 98.7), BP: 160/93 (129-160/72-97), HR: 73 (72-87),\nRR: 16 (___), O2 sat: 94% (94-100), O2 delivery: 3L \nGENERAL: sitting up in bed\nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. \n\nNECK: Supple. JVP flat. \nCARDIAC: Irregular no murmurs nor rubs appreciated\nLUNGS: equal breath sounds with no crackles nor rhonchi\nappreacited \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No\nsplenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 09:33PM GLUCOSE-173* UREA N-11 CREAT-0.8 SODIUM-142 \nPOTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15\n___ 09:33PM estGFR-Using this\n___ 09:33PM CK-MB-7 cTropnT-0.14*\n___ 09:33PM CALCIUM-8.4 PHOSPHATE-3.7 MAGNESIUM-1.9\n___ 09:33PM WBC-8.2 RBC-3.41* HGB-10.2* HCT-31.8* MCV-93 \nMCH-29.9 MCHC-32.1 RDW-14.3 RDWSD-48.9*\n___ 09:33PM PLT COUNT-266\n___ 03:09PM TYPE-ART PO2-119* PCO2-57* PH-7.32* TOTAL \nCO2-31* BASE XS-1\n___ 02:16PM TYPE-ART PO2-83* PCO2-64* PH-7.29* TOTAL \nCO2-32* BASE XS-1\n___ 02:16PM LACTATE-1.2\n___ 02:16PM freeCa-1.14\n___ 02:00PM GLUCOSE-123* UREA N-12 CREAT-0.7 SODIUM-141 \nPOTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12\n___ 02:00PM CK(CPK)-69\n___ 02:00PM CK-MB-6 cTropnT-0.13*\n___ 02:00PM CALCIUM-8.0* PHOSPHATE-4.8* MAGNESIUM-1.9\n___ 02:00PM WBC-9.7 RBC-3.40* HGB-9.9* HCT-31.9* MCV-94 \nMCH-29.1 MCHC-31.0* RDW-14.0 RDWSD-47.6*\n___ 02:00PM PLT COUNT-312\n___ 10:12AM TYPE-ART PO2-434* PCO2-55* PH-7.27* TOTAL \nCO2-26 BASE XS--2 INTUBATED-INTUBATED\n___ 10:12AM GLUCOSE-239* NA+-138 K+-2.9* CL--104\n___ 10:12AM HGB-10.1* calcHCT-30\n___ 06:45AM ___\n\nPERTINENT LABS\n==============\n___ 02:00PM BLOOD CK-MB-6 cTropnT-0.13*\n___ 09:33PM BLOOD CK-MB-7 cTropnT-0.14*\n___ 02:00PM BLOOD CK(CPK)-69\n\nMICRO\n=====\nNone\n\nSTUDIES\n=======\nTEE ___\nTEE for Procedural Guidance during ___ Procedure\n 1. Mild spontaneous echo contrast is seen in the body of the \nleft atrium. No mass/thrombus is seen in the left atrium or left \natrial appendage. Left atrial appendage flow velocity 0.27 m/s\n 2. ___ neck and length measured at 0 degrees, 45, 90 and 135 \nand discussed with ___ device representatives, Dr. ___ \n___ Dr. ___. Maximum orifice diameter ~ 1.9 cm, depth ~ 2.5 \ncm. Appenadge has at least two lobes. 3D view of demonstrates \nelliptical shaped orifice.\n 3. Overall left ventricular systolic function is low normal \n(LVEF 50-55%). \n 4. There is mild global RV free wall hypokinesis. \n 5. There are focal calcifications in the aortic arch as well as \nsimple atheroma in the arch and descending aorta. \n 6. There are three aortic valve leaflets.\n 7. There is a very small pericardial effusion.\n\nCXR ___\nET tube tip is 5.5 cm above the carina. Heart size and \nmediastinum are \nunchanged in appearance. Right mediastinal shift is stable. \nHyperinflation in the upper lungs is demonstrated as well as \nevidence of previous right upper lobectomy. No new \nconsolidations demonstrated. \n \nNo definitive evidence of new rib fractures demonstrated on this \nnon dedicated radiograph. \n\nTTE ___\nThe left atrium is mildly dilated. There is mild symmetric left \nventricular hypertrophy with a normal cavity size.\nThere is normal regional left ventricular systolic function. \nGlobal left ventricular systolic function is normal. The \nvisually estimated left ventricular ejection fraction is 55-60%. \nThere is no resting left ventricular outflow tract gradient. \nNormal right ventricular cavity size with mild global free wall \nhypokinesis. The aortic sinus diameter\nis normal for gender with normal ascending aorta diameter for \ngender. The aortic arch diameter is normal. The aortic valve \nleaflets (?#) appear structurally normal. There is no aortic \nvalve stenosis. There is no aortic\nregurgitation. The mitral leaflets appear structurally normal \nwith no mitral valve prolapse. There is trivial mitral \nregurgitation. The tricuspid valve leaflets appear structurally \nnormal. There is mild [1+] tricuspid regurgitation. There is \nmoderate pulmonary artery systolic hypertension. There is no \npericardial effusion.\n\nIMPRESSION: Adequate image quality. Mild symmetric left \nventricular hypertrophy with normal cavity size and \nregional/global systolic function. MIld global RV systolic \ndysfunction. Moderate pulmonary artery systolic\nhypertension.\n\nDISCHARGE LABS\n==============\n___ 06:30AM BLOOD WBC-7.2 RBC-3.48* Hgb-10.2* Hct-33.3* \nMCV-96 MCH-29.3 MCHC-30.6* RDW-14.3 RDWSD-50.3* Plt ___\n___ 06:30AM BLOOD ___ PTT-31.4 ___\n___ 06:30AM BLOOD Glucose-130* UreaN-9 Creat-0.7 Na-143 \nK-4.1 Cl-101 HCO3-28 AnGap-14\n___ 06:30AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.___ woman with persistent atrial fib/flutter, AVNRT s/p \nablation ___, COPD on home 3L, admitted for ___ device \nplacement. Procedure was c/b PEA arrest and was not completed. \nPatient was quickly resuscitated and briefly admitted to the \nCCU. She was discharged at baseline functional status on her \nprior rate/rhythm control agents and warfarin.\n\nACUTE ISSUES: \n============= \n# PEA Arrest\n# Shock\nPt experienced PEA arrest in dueing attempted implantion of \n___ device and underwent 3 min of chest compressions and \ntreatment with epinephrine, after which ROSC was achieved. Cause \nof arrest may have been severe vasovagal vs air embolism in \ncoronary artery. After ROSC, she was hypotensive requiring \nphenylephrine. Pressor requirement post-procedurally was in \nsetting of propofol. Successfully weaned of vasopressors after \nextubation. Her neuro exam was intact. TTE was unchanged from \nprior. \n\n# Atrial fibrillation s/p PVI\n# S/p aborted ___ device implant\nPermanent afib, CHA2DS2VASC(HTN, age, female): 3, HASBLED: ___ s/p\nAVNRT in ___ on warfarin but deemed not to be long-term a/c \ncandidate. After extubation, she was continued on home \nmetoprolol and digoxin. After discussion with EP, she was \ncontinued on warfarin and will continue on warfarin until follow \nup appointment next week. \n\n# Hypoxemic respiratory failure - Resolved\nInitially intubated in setting of procedure, successfully \nextubated and on home NC. \n\n# Fall Risk\nPt undergoing ___ procedure due to frequent falls with \nheadstrike at home. Falls appear to be from a combination of \npoor vision, occasional lightheadedness and dizziness, general \nweakness, and mechanical falls. She is also on a number of \nsedating medications as home, including gabapentin, clonazepam, \ndiazepam, and hydrocodone. ___ consult recommended home with \n___. Would recommend continued down titration of these \nmedications as an outpatient.\n\nCHRONIC ISSUES: \n=============== \n# COPD FEV/FVC 23%, severely depressed DLCO. follows with Dr. \n___,\nsupposed to be on Spiriva 2.5 two puffs daily, pro-air HFA \ninhalers 2 puffs up to ___ times a day, prednisone 5mg daily, \nhome O2 3L (6L pulse when walking) with goal So2 >90%. She was \ncontinued on home Spiriva, and had standing albuterol nebs. \n\n# Diabetes: She was maintained on HISS in house.\n\n===================\nTRANSITIONAL ISSUES\n===================\n\n[] Discharge INR: 1.6 \n[] Discharge warfarin dose: 2.5 mg daily\n[] Pt will need INR checked on ___\n[] Pt will need follow up with electrophysiology to ongoing \ndiscussion about anticoagulation\n[] Please continue to titrate down sedating medications in this \npatient with history of multiple falls.\n\nNEW MEDICATIONS: none\nCHANGED MEDICATIONS: Clonazepam decreased to 1 mg QHS PRN\nSTOPPED MEDICATIONS: HYDROcodone-acetaminophen 7.5-325 mg oral \nQ6H:PRN\n\n#CODE: Full\n#CONTACT/HCP: ___ home ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 5 mg PO DAILY \n2. azelastine 137 mcg (0.1 %) nasal QPM \n3. Gabapentin 800 mg PO QHS \n4. Nicotine Polacrilex 4 mg PO Q1H:PRN urge to smoke \n5. ClonazePAM ___ mg PO QHS:PRN insomnia \n6. Diazepam 5 mg PO Q12H:PRN muscle spasm as needed caution re \nsedation and fall risk \n7. Metoprolol Tartrate 25 mg PO BID \n8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n9. Digoxin 0.125 mg PO DAILY \n10. HYDROcodone-acetaminophen 7.5-325 mg oral Q6H:PRN \n11. flaxseed oil 1,000 mg oral DAILY \n12. Sucralfate 1 gm PO QID \n13. Cetirizine 10 mg PO DAILY allergy symptoms \n14. DULoxetine 120 mg PO DAILY \n15. Albuterol Inhaler ___ PUFF IH Q6H \n16. Warfarin 2.5 mg PO 3X/WEEK (___) \n17. Warfarin 2.5 mg PO 4X/WEEK (___) \n\n \nDischarge Medications:\n1. ClonazePAM 1 mg PO QHS:PRN insomnia \n2. Albuterol Inhaler ___ PUFF IH Q6H \n3. azelastine 137 mcg (0.1 %) nasal QPM \n4. Cetirizine 10 mg PO DAILY allergy symptoms \n5. Diazepam 5 mg PO Q12H:PRN muscle spasm as needed caution re \nsedation and fall risk \n6. Digoxin 0.125 mg PO DAILY \n7. DULoxetine 120 mg PO DAILY \n8. flaxseed oil 1,000 mg oral DAILY \n9. Gabapentin 800 mg PO QHS \n10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n11. Metoprolol Tartrate 25 mg PO BID \n12. Nicotine Polacrilex 4 mg PO Q1H:PRN urge to smoke \n13. PredniSONE 5 mg PO DAILY \n14. Sucralfate 1 gm PO QID \n15. Warfarin 2.5 mg PO 4X/WEEK (___) \n16. Warfarin 2.5 mg PO 3X/WEEK (___) \n17.Outpatient Lab Work\n I48.91 \n___\n___\nplease fax results to ___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\nPEA Arrest\nCardiogenic shock\nAcute hypoxemic respiratory failure\nAtrial fibrillation \n\nSECONDARY DIAGNOSES\nCOPD\nType II Diabetes\nHTN\nHLD\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 in the hospital!\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital because you had a procedure \nfor your heart to stop blood clots from forming. Unfortunately, \nthis procedure was unable to be completed.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- Your blood pressure became very low and your heart rate was \nvery slow. You needed CPR and a breathing tube to save your \nlife. You came to the cardiac intensive care unit. You got the \nbreathing tube out and are able to go home.\n\nWHAT SHOULD I DO WHEN I GO HOME?\n- Continue to take all of your medications. See below for an \nupdated list.\n- Go to the follow up appointments listed.\n- Talk to your primary care doctor about the medications you \ntake which are sedating. \n- Weigh yourself every morning. Call your doctor if your weight \ngoes up more than 3 lbs.\n\nWe wish you all the best,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I481", "T8111XA", "J9601", "I97710", "Z7901", "Y840", "Y92238", "Z5309", "J439", "Z9981", "E1122", "I129", "N189", "Z9181", "E785", "G8929", "M549", "F329", "Z8701", "G540", "H5461", "M3219", "G4733", "I341", "M797", "Z981", "Z87891", "R911", "Z006" ]

[ "I481: Persistent atrial fibrillation", "T8111XA: Postprocedural cardiogenic shock, initial encounter", "J9601: Acute respiratory failure with hypoxia", "I97710: Intraoperative cardiac arrest during cardiac surgery", "Z7901: Long term (current) use of anticoagulants", "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", "Y92238: Other place in hospital as the place of occurrence of the external cause", "Z5309: Procedure and treatment not carried out because of other contraindication", "J439: Emphysema, unspecified", "Z9981: Dependence on supplemental oxygen", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z9181: History of falling", "E785: Hyperlipidemia, unspecified", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z8701: Personal history of pneumonia (recurrent)", "G540: Brachial plexus disorders", "H5461: Unqualified visual loss, right eye, normal vision left eye", "M3219: Other organ or system involvement in systemic lupus erythematosus", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I341: Nonrheumatic mitral (valve) prolapse", "M797: Fibromyalgia", "Z981: Arthrodesis status", "Z87891: Personal history of nicotine dependence", "R911: Solitary pulmonary nodule", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "J9601", "Z7901", "E1122", "I129", "N189", "E785", "G8929", "F329", "G4733", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \ntofu / moxifloxacin\n \nAttending: ___\n \nChief Complaint:\npersistent atrial fibrillation\n \nMajor Surgical or Invasive Procedure:\n___\nLeft mini-thoracotomy, Left atrial appendage\nexclusion with Atriclip\n\n \nHistory of Present Illness:\nMs. ___ is a very nice ___ year old woman with a history of\natrial fibrillation, severe chronic obstructive pulmonary \ndisease\non oxygen, and frequent falls. She was deemed to be high risk \nfor\nchronic anti-coagulation therapy due to recurrent fall history.\nShe was admitted to ___ in ___ for ___ occlusion device\nwhoever the procedure was aborted due to recurrent device\ndislodgements. During the procedure she had an episode of\nsevere hypotension and bradycardia requiring two minutes of CPR\nuntil her condition stabilized. This was thought to be secondary\nto an air embolism. Dr. ___ was consulted for left atrial\nappendage ligation.\n\nShe presented for preadmission testing and evaluation. She \nstated\nthat she feels overall improved due following her\nhospitalization. She continues to have shortness of breath and\ndyspnea on exertion. She also noted episodes of\ndizziness/lightheadedness. She denied chest pain, palpitations,\northopnea, paroxysmal nocturnal dyspnea, or lower extremity\nedema.\n\n \nPast Medical History:\n1. HTN\n2. Hypercholesterolemia\n3. chronic back pain\n4. COPD/emphysema\n5. C spine disc disease\n6. Depression\n7. pneumonia ___. Right brachial plexus neuropathy\n9. Right eye with decreased vision, ? macular degeneration\n10. SLE (severe ophthalmopathy, diffuse arthropathy)\n11. OSA/cpap\n12. MVP\n13. Fibromyalgia\nPSH\n1. S/P B/L cataracts\n2. S/P C4-5 fusion\n3. S/P multiple skin Ca exc both squamous and basal cell\n\n \nSocial History:\n___\nFamily History:\nNo family history of premature coronary artery disease,\ncardiomyopathy, congestive heart failure, or sudden death.\n\n \nPhysical Exam:\nAdmission Exam:\nHeight: 71 inches Weight: 85.28 kg\n\nGeneral: Pleasant woman, WDWN, NAD\nSkin: Warm, dry, intact\nHEENT: NCAT, PERRLA, EOMI, OP benign []\nNeck: Supple, limited ROM\nChest: Lungs clear bilaterally but breath sounds faint\nHeart: Distant heart sounds, irregularly irregular rhythm, no\nmurmur \nAbdomen: Normal BS, soft, non-tender, non-distended \nExtremities: Warm, well-perfused, no edema\nNeuro: Grossly intact \nPulses:\nDP Right: 2+ Left: 2+\n___ Right: 2+ Left: 2+\nRadial Right: 2+ Left: 2+\n\nCarotid Bruit: none appreciated\n.\nDischarge Exam:\n98.6 140/86 67 18 98 Ra \nGeneral/Neuro: NAD [x] A/O x3 [] non-focal [x] \nCardiac: RRR [] Irregular [x] Nl S1 S2 []\nLungs: CTA [x] No resp distress [x]\nAbd: NBS [x]Soft [x] ND [x] NT [x]\nExtremities: no CCE[] Pulses doppler [] palpable [] \nWounds left min-thoracotomy: CDI [x] no erythema or drainage [x]\n\n \nPertinent Results:\n___ 05:56AM BLOOD WBC-6.4 RBC-3.75* Hgb-10.9* Hct-35.3 \nMCV-94 MCH-29.1 MCHC-30.9* RDW-14.3 RDWSD-49.0* Plt ___\n___ 04:47AM BLOOD WBC-11.2* RBC-3.36* Hgb-9.6* Hct-31.6* \nMCV-94 MCH-28.6 MCHC-30.4* RDW-14.4 RDWSD-49.0* Plt ___\n___ 05:56AM BLOOD ___\n___ 05:18AM BLOOD ___\n___ 05:13AM BLOOD ___\n___ 08:59AM BLOOD ___\n___ 02:00AM BLOOD ___ PTT-25.6 ___\n___ 05:56AM BLOOD Glucose-122* UreaN-16 Creat-0.8 Na-144 \nK-4.3 Cl-99 HCO3-34* AnGap-11\n___ 05:18AM BLOOD Glucose-121* UreaN-16 Creat-0.7 Na-144 \nK-4.4 Cl-101 HCO3-34* AnGap-9*\n.\n___ Echo\nConclusions \nEcho performed for intraoperative guidance of left atrial \nappendage ligation via left minithoracotomy. \n\n ___:\n The left atrium is mildly dilated. No mass/thrombus is seen in \nthe left atrium or left atrial appendage. The left atrial \nappendage emptying velocity is depressed (<0.2m/s). No thrombus \nis seen in the left atrial appendage. \n In its longest dimension, 3.09cm was measured before the \nexclusion of the left atrial appendage. After exclusion, 2.12cm \nremained.\n\n RA/IAS:\n No spontaneous echo contrast is seen in the body of the right \natrium. No atrial septal defect is seen by 2D or color Doppler.\n\n LV:\n Overall left ventricular systolic function is normal \n(LVEF>55%). Post exclusion of the left atrial appendage all \nwalls (lateral wall included) remained with normal systolic \nfunction (unchanged).\n\n RV:\n Right ventricular chamber size and free wall motion are normal. \n\n\n Aorta:\n There are simple atheroma in the ascending aorta. There are \nsimple atheroma in the aortic arch. There are complex (>4mm) \natheroma in the descending thoracic aorta. \n\n AV:\n There are three aortic valve leaflets. The aortic valve \nleaflets (3) are mildly thickened. There is no aortic valve \nstenosis. No aortic regurgitation is seen. \n\n MV:\n The mitral valve leaflets are moderately thickened. Mild (1+) \nmitral regurgitation is seen. \n\n TV:\n Normal leaflets, mild TR. There is mild pulmonary artery \nsystolic hypertension. \n\n Pericardium:\n There is no pericardial effusion. No pericardial effusion \npost-procedure. \n I certify that I was present for this procedure in compliance \nwith ___ regulations.\n\nInterpretation assigned to ___, MD, Interpreting \n___ \n \n.\n\n \nBrief Hospital Course:\nThe patient was brought to the Operating Room on ___ where \nthe patient underwent Exclusion of left atrial appendage via \nleft mini thoracotomy with Dr. ___. Overall the patient \ntolerated the procedure well and post-operatively was \ntransferred to the CVICU in stable condition for recovery and \ninvasive monitoring. \n POD 1 found the patient extubated, alert and oriented and \nbreathing comfortably. The patient was neurologically intact \nand hemodynamically stable. Beta blocker was initiated and the \npatient was gently diuresed toward the preoperative weight. The \npatient was transferred to the telemetry floor for further \nrecovery. Chest tubes and pacing wires were discontinued \nwithout complication. Coumadin resumed for AFib. The patient \nwas evaluated by the Physical Therapy service for assistance \nwith strength and mobility. By the time of discharge on POD 5 \nthe patient was ambulating freely, the wound was healing and \npain was controlled with oral analgesics. The patient was \ndischarged home in good condition with appropriate follow up \ninstructions.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob \n2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob \n3. azelastine 137 mcg (0.1 %) nasal QPM \n4. Cetirizine 10 mg PO DAILY \n5. ClonazePAM ___ mg PO QHS:PRN agitation \n6. DULoxetine 120 mg PO DAILY \n7. Diazepam 5 mg PO Q12H:PRN m spasm \n8. Digoxin 0.125 mg PO DAILY \n9. flaxseed oil ___ units oral DAILY \n10. Gabapentin 2400 mg PO QHS \n11. VICOdin ES (HYDROcodone-acetaminophen) 7.5-300 mg oral \nQ6H:PRN \n12. melatonin 10 mg oral QHS:PRN \n13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n14. Metoprolol Tartrate 25 mg PO BID \n15. nicotine (polacrilex) 4 mg buccal DAILY:PRN \n16. Omeprazole 40 mg PO DAILY \n17. PredniSONE 5 mg PO DAILY \n18. Sucralfate 1 gm PO QID \n19. Warfarin 5 mg PO DAILY16 \n\n \nDischarge Medications:\n1. Aspirin EC 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*1 \n2. Docusate Sodium 100 mg PO BID \nhold for loose stool \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Furosemide 20 mg PO DAILY Duration: 7 Days \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet \nRefills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*60 Tablet Refills:*0 \n5. Metoprolol Tartrate 25 mg PO TID \nRX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a \nday Disp #*90 Tablet Refills:*1 \n6. Warfarin ___ mg PO DAILY16 \ndose to change daily per ___ clinic \n7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob \n8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob \n9. azelastine 137 mcg (0.1 %) nasal QPM \n10. Cetirizine 10 mg PO DAILY \n11. ClonazePAM ___ mg PO QHS:PRN agitation \n12. Diazepam 5 mg PO Q12H:PRN m spasm \n13. Digoxin 0.125 mg PO DAILY \n14. DULoxetine 120 mg PO DAILY \n15. flaxseed oil ___ units oral DAILY \n16. Gabapentin 2400 mg PO QHS \n17. melatonin 10 mg oral QHS:PRN \n18. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n19. nicotine (polacrilex) 4 mg buccal DAILY:PRN \n20. Omeprazole 40 mg PO DAILY \n21. PredniSONE 5 mg PO DAILY \n22. Sucralfate 1 gm PO QID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAtrial Fibrillation/Flutter\nBasal Cell Carcinoma\nCervical Spine Disease\nChronic Obstructive Pulmonary Disease, ___ O2 requirement\nChronic Pain \nDepression\nDiabetes Mellitus Type II\nFibromyalgia \nGastroesophageal Reflux Disease\nHypertension \nInsomnia\nLung Nodule, left\nSkin Cancer\nSleep apnea \nSystemic Lupus Erythematous\nUveitis, wears glasses\nPast Surgical History:\nRight thoracotomy and upper lobectomy \nC5-6 fusion\nL3-S1 decompression laminectomy/hardware\nrotator cuff repair \n\n \nDischarge Condition:\nAlert and oriented x3, non-focal\n Ambulating, gait steady\n pain managed with oral analgesics\n Thoracotomy Incision - healing well, no erythema or drainage\n\nEdema- trace\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\n Please - NO lotion, cream, powder or ointment to incisions\n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n No driving for approximately one month and while taking \nnarcotics\n\nClearance to drive will be discussed at follow up appointment \nwith surgeon\n No lifting more than 10 pounds for 10 weeks\n\nEncourage full shoulder range of motion, unless otherwise \nspecified\n **Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I481", "J439", "Z9981", "E119", "E7800", "F329", "Z781", "M797", "I10", "G8929", "M488X2", "G4733", "M3219", "Z87891", "Z7901", "Z8674", "Z9181", "Z85828", "Z902" ]

[ "I481: Persistent atrial fibrillation", "J439: Emphysema, unspecified", "Z9981: Dependence on supplemental oxygen", "E119: Type 2 diabetes mellitus without complications", "E7800: Pure hypercholesterolemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z781: Physical restraint status", "M797: Fibromyalgia", "I10: Essential (primary) hypertension", "G8929: Other chronic pain", "M488X2: Other specified spondylopathies, cervical region", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M3219: Other organ or system involvement in systemic lupus erythematosus", "Z87891: Personal history of nicotine dependence", "Z7901: Long term (current) use of anticoagulants", "Z8674: Personal history of sudden cardiac arrest", "Z9181: History of falling", "Z85828: Personal history of other malignant neoplasm of skin", "Z902: Acquired absence of lung [part of]" ]

[ "E119", "F329", "I10", "G8929", "G4733", "Z87891", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ntofu / moxifloxacin\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo F with medical history notable for atrial\nfibrillation (not on Coumadin due to recurrent fall history, s/p\nwatchman ___, COPD on O2 (5L at rest), and frequent falls\nwho presented with shortness of breath and dizziness.\n\nPer PCP notes patient was discharged from ___ ___\nafter being admitted 1 week previously with a severe flare of \nher\nadvanced COPD. Unfortunately, no records available on BID\ncommunity link in OMR. She was recommended to go to rehab but\napparently did not want to do this. Per note PCP started her on\n___ mg Lasix PO on ___ due to cocern for volume overload. \n\nIn the last few days since discharge from the hospital she has\nhad significant worsening of her baseline shortness of breath.\nNormally when she gets up from lying down to sitting her\nsaturations will drop to mid ___ and then recover to low ___.\nThis week she has been dropping to the ___ with significant\nshortness of breath. Today she became extremely dyspneic when\ngoing to the bathroom, got dizzy, and fell down. Denies striking\nher head. She crawled to her bedroom and was able to call for an\nambulance. \n\nIn the ED: \nInitial vitals: \n-98.6 90 115/82 26 92% 5L NC \n\n- Labs notable for: \nWBC 15.8, Hb 9.7, Cr 1.3, pBNP 3155, trop <0.1, INR 1.0, pH 7.51\n\n- Imaging notable for: CTA with extensive segmental and\nsubsegmental PE, right ventricular prominence and pHTN noted\n\n- Pt given: \n___ 02:37 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 02:37 IH Ipratropium Bromide Neb 1 NEB \n___ 02:51 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 02:51 IH Ipratropium Bromide Neb 1 Neb \n___ 03:40 IH Albuterol 0.083% Neb Soln 1 Neb \n___ 03:40 IH Ipratropium Bromide Neb 1 Neb \n___ 06:52 IV Azithromycin \n___ 06:52 IV CefTRIAXone \n___ 06:52 IV Heparin 7000 UNIT \n___ 06:52 IV Heparin \n___ 07:03 IV CefTRIAXone 1 gm \n___ 07:37 IV Azithromycin 500 mg \n\n- Vitals prior to transfer: \nHR 90 BP 105/65 RR 20 SPO2 87% 5L NC\n\nOf note, patient was also admitted to ___ in ___ for Watchman\nocclusion device, however the procedure was aborted due to\nrecurrent device dislodgements. During the procedure she had an\nepisode of severe hypotension and bradycardia requiring two\nminutes of CPR until her condition stabilized. After This was\nthought to be secondary to an air embolism. Dr. ___ was \nconsulted\nfor left atrial appendage ligation, went to operating Room on\n___ where she underwent exclusion of left atrial appendage\nvia left mini thoracotomy with Dr. ___. She was on warfarin but\ndue to multiple falls and appendage surgery, this was stopped at\nsome point in ___.\n\nUpon arrival to the floor, the patient denies chest pain or\ndizziness. She reports mild shortness of breath. \n \nPast Medical History:\n1. HTN\n2. Hypercholesterolemia\n3. chronic back pain\n4. COPD/emphysema\n5. C spine disc disease\n6. Depression\n7. pneumonia ___. Right brachial plexus neuropathy\n9. Right eye with decreased vision, ? macular degeneration\n10. SLE (severe ophthalmopathy, diffuse arthropathy)\n11. OSA/cpap\n12. MVP\n13. Fibromyalgia\nPSH\n1. S/P B/L cataracts\n2. S/P C4-5 fusion\n3. S/P multiple skin Ca exc both squamous and basal cell\n\n \nSocial History:\n___\nFamily History:\nNo family history of premature coronary artery disease,\ncardiomyopathy, congestive heart failure, or sudden death.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n___ 1506 Temp: 97.8 PO BP: 117/67 R Lying HR: 87 RR:\n20 O2 sat: 90% O2 delivery: 5 L \nGeneral: Lying in bed, on 5L NC \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, Right\npupil fixed 6mm, Left pupil 5-4mm\nCV: Irregular, no murmurs, rubs, gallops \nLungs: Globally decreased breath sounds, no wheezes, rales,\nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present,\nno organomegaly, no rebound or guarding \nExt: Warm, well perfused, 2+ pulses; 1+ edema to the ankles b/l \n\nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII intact (pupil exam as above), ___ strength\nupper/lower extremities, grossly normal sensation, \n \nDISCHARGE PHYSICAL EXAM: \nVITALS: Afebrile, HR ___, BP 127/79, RR ___, satting 96% \non hi flow NC, 40L with 50% FiO2\nGENERAL: Resting in bed, overall appears comfortable\nHEENT: Sclera anicteric\nCARDIAC: Tachycardic, distant heart sounds, no murmurs\nPULMONARY: Significant diffuse wheezing w/ reduced breath sounds\nABDOMEN: Soft, nt, nd\nEXTREMITIES: Warm with lower extremity ecchymoses, no ___ edema\nSKIN: Warm and dry\nNEURO: A&O x3\n \nPertinent Results:\n___ 11:09PM BLOOD WBC-15.8* RBC-3.64* Hgb-9.7* Hct-32.4* \nMCV-89 MCH-26.6 MCHC-29.9* RDW-14.7 RDWSD-48.0* Plt ___\n___ 07:09AM BLOOD WBC-16.3* RBC-3.08* Hgb-8.3* Hct-28.3* \nMCV-92 MCH-26.9 MCHC-29.3* RDW-15.7* RDWSD-51.7* Plt ___\n___ 05:03AM BLOOD WBC-15.3* RBC-2.82* Hgb-7.7* Hct-25.9* \nMCV-92 MCH-27.3 MCHC-29.7* RDW-15.6* RDWSD-51.1* Plt ___\n___ 04:40AM BLOOD WBC-11.5* RBC-2.58* Hgb-7.0* Hct-23.3* \nMCV-90 MCH-27.1 MCHC-30.0* RDW-15.4 RDWSD-49.4* Plt ___\n___ 11:09PM BLOOD Glucose-277* UreaN-17 Creat-1.3* Na-143 \nK-4.4 Cl-95* HCO3-29 AnGap-19*\n___ 05:10PM BLOOD Glucose-285* UreaN-18 Creat-1.0 Na-136 \nK-4.2 Cl-96 HCO3-25 AnGap-15\n___ 04:40AM BLOOD Glucose-253* UreaN-30* Creat-1.0 Na-139 \nK-3.7 Cl-102 HCO3-27 AnGap-10\n___ 07:09AM BLOOD cTropnT-<0.01 proBNP-2778*\n___ 06:30PM BLOOD Digoxin-0.9\n___ 06:09PM BLOOD ___ pO2-22* pCO2-43 pH-7.43 \ncalTCO2-29 Base XS-2\n\nCTA CHESTStudy Date of ___ 5:15 AM\n1. Extensive filling defects in the pulmonary vascular tree \ncompatible with\npulmonary emboli. These are seen as proximal as the right \nintralobar artery. \nEmboli are seen at both the segmental and subsegmental level \ninvolving nearly\nevery lobe, but predominantly in the lower lobes.\n2. There is mild prominence of the right ventricle. Clinical \ncorrelation for\nright heart strain is recommended.\n3. Dilation of the main pulmonary and right and left pulmonary \narteries\ncompatible with pulmonary hypertension.\n4. Severe emphysematous changes. Ground-glass opacification is \nseen\nbilaterally which suggests interstitial pneumonitis. However, \nin the superior\nleft upper lobe there is a more consolidative appearance favored \nto represent\ninfection with atelectasis and infarction also considerations.\n5. Trace left pleural effusion.\n \nTransthoracic Echocardiogram Report\nName: ___ ___ MRN: ___ Date: ___ 09:45\nThe left atrium is mildly elongated. The estimated right atrial \npressure is ___ mmHg. The left ventricle has a\nnormal cavity size. Overall left ventricular systolic function \nis normal. Mildly dilated right ventricular cavity\nwith moderate global free wall hypokinesis. Intrinsic right \nventricular systolic function is likely lower due to the\nseverity of tricuspid regurgitation. The mitral valve leaflets \nappear structurally normal. There is trivial mitral\nregurgitation. There is moderate to severe [3+] tricuspid \nregurgitation. There is SEVERE pulmonary artery\nsystolic hypertension. In the setting of at least moderate to \nsevere tricuspid regurgitation, the pulmonary\nartery systolic pressure may be UNDERestimated.\nIMPRESSION: Right ventricular cavity dilation with free wall \nhypokinesis. Severe pulmonary artery\nsystolic hypertension. Moderate to severe tricuspid \nregurgitation.\n \nBrief Hospital Course:\n___ is a ___ year old woman a history of atrial \nfibrillation s/p Watchman procedure in ___ (with prior \nWatchman issues with device dislodgments and a cardiac arrest \n___ possible air embolism in ___, not on home \nanticoagulation due to frequent falls, COPD (5L O2 at home), who \nwas admitted to ___ on ___ for a submassive pulmonary \nembolism. She was treated in the medical ICU until ___ for \nthis, along with pneumonia, copd exacerbation, and pulmonary \nedema before being discharged directly to ___ \n___. \n\nACUTE ISSUES: \n===================\n#ACUTE RESPIRATORY FAILURE: \n#SUBMASSIVE PULMONARY EMBOLISM: \n#PULMONARY EDEMA:\n#COPD WITH EXACERBATION\n#HOSPITAL ACQUIRED PNEUMONIA: \nAdmitted to medicine initially, treated on the floor initially \nwith a heparin gtt, stable O2, transitioned to apixaban. She was \ntransferred to the MICU when she developed worsening hypoxemia \nas well as tachcyardia and hemoptysis. She maintained that she \nwas DNR/DNI and was managed with non-invasive oxygenation \nmethods. Failure of anticoagulation was considered unlikely, but \nshe was transitioned to enoxaparin BID. Her acute respiratory \nfailure was felt to be from pulmonary edema, copd exacerbation, \nand possible pneumonia. She improved with treatment of all three \nand was weaned to <10 L/hr oxymizer, sats ok on NRB mask for \ntransfer to rehab. \n- Discharged with azithromycin as well as a slow prednisone \ntaper, finishing vancomycin and cefepime (D7/last day = \n___\n- Restarted home furosemide at discharge\n\n#GOALS OF CARE: \nSpoke at length with the team and palliative care. She very \nclearly wants to be in the hospital as little as possible. \nRemains DNR/DNI. She was OK with a short stay at rehab to \nmaximize her chances of doing well at home, very important for \nher to return there to be with her cats. Her mother does not \nknow that wants to be DNR/DNI and is even considering hospice \ncare, but her friend/sister-in-law/HCP ___ ___ \nis in the loop.\n\n#STEROID INDUCED ANXIETY: \nPrednisone taper significantly affecting the patient's anxiety, \nwell known issue for the patient. She was given large doses of \nclonazepam here without respiratory drive depression, and it is \nOK and actually preferable to continue controlling her anxiety \nat rehab with this medication. Please call PCP if any concerns. \n\nCHRONIC ISSUES: \n=====================\n#ATRIAL FIBRILLATION: \nNow on anticoagulation, but for PEs. Continued metoprolol and \ndigoxin.\n\n#DIABETES MELLITUS: \nContinued insulin \n\n#DEPRESSION/ANXIETY: \nContinued home antidepressants and anxiety medications\n\n#GERD: \nContinued home PPI, sucralfate\n\n#CHRONIC PAIN: \nContinued home gabapentin, oxycodone\n\nTRANSITIONAL ISSUES: \n===================== \n- Last day of vanc/cefepime is ___. OK to continue vancomycin \nat 750 mg BID without checking levels. \n- Last day of azithromycin is ___\n- OK for patient to get significant doses of clonazepam, \nespecially while on prednisone taper. Please call PCP if any \nconcerns. \n- Please consult palliative care and social work if available\n- Prednisone taper, written out in discharge orders \n- OK to use IV pain medication if needed, please avoid sending \npatient back to hospital for pain management if possible\n\nCODE STATUS: DNR/DNI\nHCP: ___ (___) \n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob \n2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob \n3. Cetirizine 10 mg PO DAILY \n4. ClonazePAM 1.5 mg PO QHS:PRN insomnia and agitation \n5. Digoxin 0.125 mg PO DAILY \n6. DULoxetine 120 mg PO DAILY \n7. Gabapentin 2400 mg PO QHS \n8. Omeprazole 40 mg PO DAILY \n9. PredniSONE 10 mg PO DAILY \nTapered dose - DOWN \n10. Sucralfate 1 gm PO QID:PRN GI upset \n11. Diazepam 5 mg PO Q12H:PRN m spasm \n12. melatonin 10 mg oral QHS:PRN \n13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n14. nicotine (polacrilex) 4 mg buccal DAILY:PRN \n15. Aspirin EC 81 mg PO DAILY \n16. Furosemide 20 mg PO DAILY \n17. ClonazePAM 0.5 mg PO DAILY:PRN anxiety \n18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of \nbreath/wheezing \n19. Metoprolol Succinate XL 100 mg PO DAILY \n20. GlipiZIDE XL 5 mg PO DAILY \n21. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain \n- Moderate \n22. ipratropium bromide 0.03 % nasal DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \n2. Azithromycin 250 mg PO DAILY Duration: 4 Doses \nLast day ___. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line \n4. CefePIME 2 g IV Q8H \nLast day ___. Enoxaparin Sodium 80 mg SC Q12H \n6. Glargine 8 Units Bedtime\nHumalog 4 Units Breakfast\nHumalog 4 Units Lunch\nHumalog 4 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H \n8. Metoprolol Tartrate 25 mg PO Q6H \n9. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*12 Tablet Refills:*0 \n10. PredniSONE 10 mg PO DAILY Duration: 3 Days \nStart after the patient finishes 3 days of pred 20 mg Qd, and \nthen stop prednisone completely. \nTapered dose - DOWN \n11. Ramelteon 8 mg PO QHS:PRN insomnia \nShould be given 30 minutes before bedtime \n12. Senna 8.6 mg PO BID:PRN Constipation - First Line \n13. Vancomycin 750 mg IV Q 12H \nLast day ___. ClonazePAM 0.5 mg PO BID:PRN anxiety \nRX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*6 \nTablet Refills:*0 \n15. PredniSONE 60 mg PO DAILY Duration: 2 Days \n16. PredniSONE 50 mg PO DAILY Duration: 3 Doses \nThis is dose # 1 of 5 tapered doses \n17. PredniSONE 40 mg PO DAILY Duration: 3 Doses \nThis is dose # 2 of 5 tapered doses \n18. PredniSONE 30 mg PO DAILY Duration: 3 Doses \nThis is dose # 3 of 5 tapered doses\nTapered dose - DOWN \n19. PredniSONE 20 mg PO DAILY Duration: 3 Doses \nThis is dose # 4 of 5 tapered doses\nTapered dose - DOWN \n20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob \n21. Aspirin EC 81 mg PO DAILY \n22. ClonazePAM 1.5 mg PO QHS:PRN insomnia and agitation \nRX *clonazepam 1 mg 1.5 tablet(s) by mouth at bedtime Disp #*5 \nTablet Refills:*0 \n23. Digoxin 0.125 mg PO DAILY \n24. DULoxetine 120 mg PO DAILY \n25. Furosemide 20 mg PO DAILY \n26. Gabapentin 2400 mg PO QHS \n27. nicotine (polacrilex) 4 mg buccal DAILY:PRN \n28. Omeprazole 40 mg PO DAILY \n29. Sucralfate 1 gm PO QID:PRN GI upset \n30. HELD- Albuterol Inhaler 2 PUFF IH Q4H:PRN sob This \nmedication was held. Do not restart Albuterol Inhaler until you \ngo home\n31. HELD- Cetirizine 10 mg PO DAILY This medication was held. \nDo not restart Cetirizine until you need it\n32. HELD- Diazepam 5 mg PO Q12H:PRN m spasm This medication was \nheld. Do not restart Diazepam until you need it\n33. HELD- GlipiZIDE XL 5 mg PO DAILY This medication was held. \nDo not restart GlipiZIDE XL until you go home\n34. HELD- HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN \nPain - Moderate This medication was held. Do not restart \nHYDROcodone-Acetaminophen (5mg-325mg) until you go home\n35. HELD- Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of \nbreath/wheezing This medication was held. Do not restart \nIpratropium Bromide Neb until you go home\n36. HELD- ipratropium bromide 0.03 % nasal DAILY This \nmedication was held. Do not restart ipratropium bromide until \nyou go home\n37. HELD- melatonin 10 mg oral QHS:PRN This medication was \nheld. Do not restart melatonin until you go home\n38. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO DAILY This \nmedication was held. Do not restart MetFORMIN XR (Glucophage XR) \nuntil you go home.\n39. HELD- Metoprolol Succinate XL 100 mg PO DAILY This \nmedication was held. Do not restart Metoprolol Succinate XL \nuntil you go home. Right now you are getting a short acting \nversion of this while in the hospital/rehab.\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nSubmassive pulmonary embolism\nCOPD exacerbation\nPneumonia\nPulmonary edema\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ because you were having trouble \nbreathing. You were diagnosed with a blood clot in your lungs \nand given blood thinners to treat this, while being closely \nmonitored in the intensive care unit. \n\nYou were also treated for pneumonia, a COPD exacerbation, and \ndiuresed to get extra fluid out of your lungs. \n\nNow that you are breathing with much less oxygen support, we are \nable to discharge you to a rehabilitation center so that you can \nget stronger before going home. \n\nIt was a pleasure caring for you,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "I2699", "J189", "J810", "J9621", "J440", "Z66", "J441", "N179", "I824Z3", "I482", "Y95", "G8929", "M549", "G4733", "M797", "E7800", "F329", "F419", "K219", "G4700", "F17210", "E119", "T380X5A", "I10", "I341", "M329", "G540", "Z981", "Z8701", "Z95818", "Z9181", "Z9981", "Z85828", "Z87891" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "J189: Pneumonia, unspecified organism", "J810: Acute pulmonary edema", "J9621: Acute and chronic respiratory failure with hypoxia", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "Z66: Do not resuscitate", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "N179: Acute kidney failure, unspecified", "I824Z3: Acute embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral", "I482: Chronic atrial fibrillation", "Y95: Nosocomial condition", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M797: Fibromyalgia", "E7800: Pure hypercholesterolemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G4700: Insomnia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "E119: Type 2 diabetes mellitus without complications", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "I10: Essential (primary) hypertension", "I341: Nonrheumatic mitral (valve) prolapse", "M329: Systemic lupus erythematosus, unspecified", "G540: Brachial plexus disorders", "Z981: Arthrodesis status", "Z8701: Personal history of pneumonia (recurrent)", "Z95818: Presence of other cardiac implants and grafts", "Z9181: History of falling", "Z9981: Dependence on supplemental oxygen", "Z85828: Personal history of other malignant neoplasm of skin", "Z87891: Personal history of nicotine dependence" ]

[ "Z66", "N179", "G8929", "G4733", "F329", "F419", "K219", "G4700", "F17210", "E119", "I10", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \npollen extracts\n \nAttending: ___.\n \nChief Complaint:\nright knee pain\n \nMajor Surgical or Invasive Procedure:\n___: right total knee replacement \n\n \nHistory of Present Illness:\n___ year old female with right knee osteoarthritis which has \nfailed conservative management and has elected to proceed with a \nright total knee replacement on ___\n \nPast Medical History:\n___: CAD s/p cardiac stenting, hyperlipidemia, HTN, prostate cx, \nrectal bleeding, dermatitis, diastolic CHF on lasix, GERD, gout\n\nPSHx: Radical prostatectomy in ___, cardiac stents ___, \nherniorrhaphy, bilateral;, cardiac cath\n \nSocial History:\n___\nFamily History:\nnon contributory \n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Incision healing well with staples \n* Scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n\n \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:\n******\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications.. The patient received Lovenox for DVT \nprophylaxis starting on the morning of POD#1. The foley was \nremoved and the patient was voiding independently thereafter. \nThe surgical dressing was changed on POD#2 and the surgical \nincision was found to be clean and intact without erythema or \nabnormal drainage. The patient was seen daily by physical \ntherapy. Labs were checked throughout the hospital course and \nrepleted accordingly. At the time of discharge the patient was \ntolerating a regular diet and feeling well. The patient was \nafebrile with stable vital signs. The patient's hematocrit was \nacceptable and pain was adequately controlled on an oral \nregimen. The operative extremity was neurovascularly intact and \nthe wound was benign. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity.\n \nMr. ___ is discharged to home with services in stable \ncondition\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atenolol 50 mg PO DAILY \n2. Atorvastatin 20 mg PO DAILY \n3. Xtandi (enzalutamide) 40 mg oral take 4 capsules by mouth \ndaily \n4. Furosemide 20 mg PO 3X/WEEK (___) \n5. Nitroglycerin SL 0.4 mg SL 1 TABLET SL Q1 H PRN CHEST PAIN \nchest pain \n6. Leuprolide Acetate 22.5 mg IM EVERY 3 MONTHS \n7. Aspirin 81 mg PO DAILY \n8. Cyanocobalamin ___ mcg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nright knee osteoarthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \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).\n \n8. ANTICOAGULATION: Please continue your Lovenox for four (4) \nweeks to help prevent deep vein thrombosis (blood clots). If \nyou were taking aspirin prior to your surgery, it is OK to \ncontinue at your previous dose while taking this medication. \n \n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed 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.\n\nPhysical Therapy:\nWBAT RLE\nROMAT\nMobilize frequently\nwean from assistive devices when appropriate\nTreatment Frequency:\ndaily dressing changes as needed for drainage\ninspect incision daily for erythema/drainage \nice and elevation of operative limb\nremove staples and replace with steri-strips at follow up visit \nin clinic.\n\n \nFollowup Instructions:\n___\n" ]

[ "M1711", "I110", "I5032", "I2510", "E785", "K219", "M109", "Z955" ]

[ "M1711: Unilateral primary osteoarthritis, right knee", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "Z955: Presence of coronary angioplasty implant and graft" ]

[ "I110", "I5032", "I2510", "E785", "K219", "M109", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nadhesive tape / seasonal allergies\n \nAttending: ___.\n \nChief Complaint:\nvomiting, fever\n \nMajor Surgical or Invasive Procedure:\nERCP\n \nHistory of Present Illness:\n___ year old male with new dx pancreatic CA (unresectable) s/p\nbiliary stent placed ___ at ___, with Atrial fibrillation on\nCoumadin, presented to initiate FOLFIRINOX today but referred in\nfor leukocytosis, elevated LFTs, bilious vomiting, and some\nincreased confusion. Note that he had port placed ___ ___XR today ___ at ___ showed mild bibasilar opacity R>L may\nbe ___ microaspiration but appeared improved compared to CXR one\nday prior reportedly. RUQ u/s at ___ today also read as:\n 1. Hypoechoic mass the head of the pancreas with pancreatic \nduct\n dilatation upstream, consistent with the patient's known\npancreatic carcinoma 2. Cyst with a thin internal septation in\nthe liver. \n\nOn my interview he states he has been feeling well other than\nmild cough (disclosed only specifically on prompting) since his\nEUS on ___ at time of biopsy which is productive of mucous, \nhas\nno pain at all, but today vomiting some greenish slimy material,\nnonbloody, once. Has had 1 episode roughly of looser stool daily\nfor past several days but no watery diarrhea and no blood or\nmelena. Did not have fever or chills until noted today in the ED\nas below. Has been feeling reasonably well and very disappointed\nand frustrated he didn't get chemotherapy. He remembers that he\nwas a bit confused earlier today but he feels this was due to\nfrustration over the plan not going as expected. NO dysuria,\nrash, chest pain, dyspnea, back pain, all other 10 point ROS \nneg.\n\nED COURSE:\nT 101/7 HR 83 --> 108 BP 116/75 RR 22 --> 18 99%RA\nLabs with ALT 147 AST 237 Tbili 1.9 AP 279, Mg 1.4, P 2.6, chem\nreassuring. WBC 16, Hct 30, plts 294, pmns 90%, lactate 1.5. UA\nreassuring. Na down to 130 on second draw. \nCT a/p without evidence of fluid collection or acute abd \nprocess.\nPt received 1L nS, 2g cefepime, 650 mg APAP.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nHe first\npresented to Oncology in ___ for evaluation of anemia. \nHe had routine blood work done on ___, which demonstrated\nhemoglobin of 13.2 g/dL with a normal white count, normal\nplatelet count, and normal MCV. The differential of this white\ncount was normal and his baseline hemoglobin had been in the 14\nand 15 range with an MCV of 89 to 90. Repeat CBC on ___\nshowed hemoglobin of 11.9 again with the rest of his cell counts\nbeing normal. However, his creatinine had risen at that point \nto\n1.9 on ___, thought to be medication-induced. It had\nreturned to 1.2 by ___. Iron studies and CRP were normal,\nalthough I do not have copies of those numbers with myself. He\nalso describes significant fatigue and increased dyspnea on\nexertion. Labs on the day of the consult on ___\nshowed a white count of 5.9, hemoglobin at 12.3, platelets of\n308,000, MCV of 85 and a reticulocyte count of 2.6. He also had\nlabs from ___ and on those labs there were 2% circulating\nmetamyelocytes described. So Dr. ___ recommended \na\nbone marrow biopsy and this was performed on ___ to\nevaluate for MDS. ___ bone marrow biopsy was ___ cellular\nwith an M:E ratio of 2.5:1. There is no significant dysplasia. \nFlow cytometry was unremarkable. Cytogenetics and MDS _____ \nFISH\nwere still pending at the time of his followup with Hematology,\nbut it was overall felt that the bone marrow was unremarkable. \nHe was advised to simply follow his creatinine for any evidence\nof persistent renal insufficiency as the possible cause for his\nsymptoms. He was then referred to the emergency room on\n___, so approximately six weeks later because he\nhad blood work done that showed an INR of 7.4, he was also noted\nat that time to be jaundiced. Labs at that time showed a\nbilirubin of 6.7 and AST of 196, ALT of 562 and an alkaline\nphosphatase of 466, creatinine was 2.1. He was described as\nbeing very fatigued and reporting a 65-pound weight loss over \nthe\ncourse of the year. He had a decreased appetite and generally\nfelt weak and tired. He denied any fevers or abdominal pain. \nHe\ndenied any nausea, vomiting or diarrhea. He was admitted to\n___. He had a urinalysis performed, which showed a\nlittle bit of protein and red blood cells in his urine, but was\notherwise unremarkable. He was given vitamin K to reverse his\nINR. He was given IV fluids to try to bring his creatinine \ndown.\n The patient reported that the jaundice has been present for\napproximately two to three weeks and then in addition, he\ndeveloped pruritus. His stool had also become light and his\nurine had become dark. Upon admission additional labs were \nsent.\n He had a white count of 5.73, hemoglobin of 15, hematocrit of\n43.0, MCV of 84, platelet count of 317,000 with normal\ndifferential 74% polys, 19% lymphocytes, 6% monocytes, 1\neosinophil and 1 basophil. Lipase was normal at 45, CA ___\nreturned elevated at 355, direct bilirubin was 4.3. He \nunderwent\nan ultrasound on the ___, which showed fatty changes in the\nliver. He had a subcapsular cyst with septation in the \nposterior\ninferior right hepatic lobe measuring 13 x 13 x 10 mm. There is\nno ascites. The hepatic artery was patent with normal arterial\nwaveforms and the main left and right portal veins were all\npatent with normal hepatopetal flow. The middle, right, and \nleft\nhepatic veins are patent with normal direction of flow towards\nthe IVC. There was intrahepatic biliary dilatation present. \nCommon duct was 9 mm. The spleen was 12 cm in size with normal\nechotexture. The kidneys were fairly symmetric in size. There\nwas no hydronephrosis. He had a simple cyst in the lower pole \nof\nthe left kidney. There is also pancreatic ductal dilatation \nseen\nmeasuring up to 8 mm with hypoattenuated region and the head to\nthe pancreas measuring 3.4 cm, suspicious for a mass. He then\nunderwent a CT of the chest and abdomen with contrast and that\nshowed that he had scattered pulmonary micronodules as well as\nill-defined hypodense mass involving the pancreatic head that \nwas\n3.9 x 3.8 cm concerning for a primary pancreatic neoplasm. The\npancreatic duct was markedly dilated with pancreatic parenchymal\natrophy where calcifications within the pancreatic parenchyma\nsuggested a prior inflammation of pancreatitis. At the level of\nthe pancreatic neck, the pancreatic duct measured up to 1.3 cm. \nIt contacted the SMA circumferentially and resulted in\nsignificant narrowing, but without complete occlusion. He\ncontacted 180 degrees of the SMV without significant narrowing \nor\nocclusion. The portal vein and splenic vein were not felt to be\ninvolved nor was the celiac trunk or splenic artery. The common\nhepatic artery and GDA contacted peripancreatic adenopathy, but\nnot the mass. There is also loss of a fat plane between the\nsecond portion of the duodenum and the pancreatic mass. In the\nliver, there was moderate intra and extrahepatic biliary ductal\ndilatation. There were no suspicious liver lesions. There was \na\n1.5 cm hypodensity in segment VI, which was thought to represent\na cyst. He then underwent an ERCP on ___. _____ this \nwas\nperformed on ___. He underwent an endoscopic ultrasound\nand ERCP on ___ by GI at ___ and they were able to\nbiopsy the pancreatic head mass and that was positive for\nmalignant cells consistent with an adenocarcinoma. There was\nabundant necrosis noted in the background. We do not have the\nreport of the ERCP, unfortunately, but by the patient's report,\nthey did place a stent and after doing that, his bilirubin was\nable to trend down. While in the hospital, he saw Dr. ___ of the ___ oncology team, who recommended a surgical\nconsultation, but thought that based on the encasement of the \nSMA\nthat this was an unresectable pancreatic cancer and recommended\nchemotherapy. Surgery by report also felt that this was not a\nresectable pancreatic cancer and thus the recommendation was for\ndefinitive chemotherapy and radiation. Dr. ___ met with the\npatient upon discharge and stated that he would like to proceed\nwith FOLFIRINOX with a reassessment of the disease after two\nmonths. He thought that the likelihood that he would be\nconverted into a surgical candidate would be slim but that could\nbe reassessed after two months. If it seems that he is still \nnot\na surgical candidate, then at that time, they could make plans\nfor stereotactic radiation. Due to the distance that he would\nhave to travel to get to ___, the patient opted to switch his\ncare to ___\n\nPAST MEDICAL HISTORY: Fairly unremarkable. He has diabetes,\nwhich he states he has had for many years, probably \napproximately\n___ years, hypertension, atrial fibrillation.\n\nPAST SURGICAL HISTORY: He had surgery on his shoulder in ___,\narthroscopy with rotator cuff repair, he has had an \nappendectomy,\narthroscopy on his knee and a cholecystectomy.\n\n \nSocial History:\n___\nFamily History:\nHis father died of colon cancer as did his\nbrother. His mother had breast cancer diagnosed late in life. \nShe also had kidney cancer by the ___ reports.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITAL SIGNS: 99.0 122/77 85 18 98%RA\nGeneral: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary adenopathy, no thyromegaly\nCV: irregularly irregular, NL S1S2 no S3S4 MRG\nPULM: CTAB\nGI: BS+, soft, NTND, no masses or hepatosplenomegaly\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 Physical Exam:\nVS: AF 100s-130s/70s-90s ___ 18 95-99% on RA\nHEENT: NC/AT, sclera anicteric, conjunctiva noninjected, PER, \nEOMI, MMMs\nCV: RRR no m/r/g\nPulm: CTAB no c/r/w\nAbd: S NT ND BS+ no HSM or masses\nExtr: wwp no edema, distal pulses intact\nNeuro: alert and interactive; strength, sensation, and CNs \ngrossly intact/symmetric\nSkin: no lesions noted on limited exam\nPsych: normal range of affect\n \nPertinent Results:\nAdmission data\n===================\nLABORATORY ANALYSIS:\nWBC: a) 17.3*; b) 16.0*. RBC: a) 3.51*; b) 3.76*. HGB: a) 10.1*;\nb) 10.9*. HCT: a) 28.6*; b) 30.0*. MCV: a) 82; b) 80*. RDW: a)\n13.3; b) 12.9. Plt Count: a) 294; b) 310. \nNeuts%: 90.7*. Lymphs: 4.6*. MONOS: 3.6*. Eos: 0.0*. BASOS: 0.2. \n\n___: 13.9*. INR: 1.3*. \nNa: a) 130*; b) 136. K: a) 3.7; b) 3.5. Cl: a) 92*; b) 99. CO2:\na) 22; b) 24. BUN: a) 15; b) 18. Creat: a) 0.9; b) 1.0. Ca: 9.9.\nMg: 1.4*. PO4: 2.6*. \nAST: 237*. ALT: 147*. Alk Phos: 279*. Total Bili: 1.9*. \n\nSubsequent data:\n===================\n\nCT ___. Approximately 2.8 cm ill-defined hypodense mass within the \nhead of the \npancreas is consistent with known pancreatic cancer. The mass \ncompletely \nencases and attenuates the SMA and abuts 180 degrees of the \nposterior aspect of the SMV. Loss of fat plane between the \nmass and the second and third portions of the duodenum is also \ndemonstrated along with multiple enlarged peripancreatic lymph \nnodes. There is associated upstream pancreatic ductal \ndilatation and atrophy of the pancreatic parenchyma. \n2. Peripancreatic stranding and fluid about the head and \nuncinate process may reflect acute pancreatitis. Recommend \ncorrelation with lipase levels. \n3. Multiple ill-defined nodules at the lung bases concerning for \nmetastatic disease. \n4. Ill-defined subcentimeter hypodensity in segment 8 of the \nliver is \nconcerning for metastatic disease. Additional focal hypodense \narea with \nsubtle capsular retraction in segment 4B could possibly be due \nto an \nunderlying metastatic lesion as well. \n5. Biliary stent appears to be patent with expected pneumobilia. \n No \nintrahepatic biliary dilatation. \n6. Mild periportal edema, mild pulmonary edema, and small amount \nof pelvic \nfree fluid. \n7. Prostatomegaly. \n8. Colonic diverticulosis. \n\nERCP ___:\nImpression: •Limited exam of the esophagus was normal\n•Limited exam of the stomach was normal\n•Limited exam of the duodenum was normal\n•The scout film revealed a metal stent in the RUQ. \n•A metal stent was emerging from the major ampulla. \n•The stent was successfully cannulated with an extraction \nballoon catheter. \n•A 0.025in guidewire was advanced into the biliary tree. \n•The stent was swept several times with sucessful removal of \nsmall amounts of sludge material. \n•Careful contrast injection revealed excellent flow throught the \nstent. \n•There was excellent spontaneous flow of bile and contrast at \nthe end of the procedure.\n•The PD was not injected or cannulated. \nRecommendations: •Return to ward under ongoing care.\n•Clear fluids when awake then advance diet as tolerated.\n•Continue with antibiotics to complete course for cholangitis.\n•Repeat ERCP as needed for suspected stent occlusion. \n•Follow for response and complications. If any abdominal pain, \nfever, jaundice, gastrointestinal bleeding please call ERCP \nfellow on call ___\n \nPost port placement CXR\nSuccessful placement of a single lumen chest power Port-a-cath \nvia the right internal jugular venous approach. The tip of the \ncatheter terminates in the right atrium. The catheter is ready \nfor use. Successful removal of existing right subclavian \napproach chest port. \n\nDay of discharge labs\n===================\n\n___ 05:19AM BLOOD WBC-5.6 RBC-3.02* Hgb-8.5* Hct-24.7* \nMCV-82 MCH-28.1 MCHC-34.4 RDW-13.2 RDWSD-38.9 Plt ___\n___ 05:19AM BLOOD Glucose-133* UreaN-15 Creat-1.0 Na-136 \nK-3.5 Cl-101 HCO3-20* AnGap-19\n___ 05:19AM BLOOD ALT-54* AST-21 AlkPhos-175* TotBili-1.0\n___ 05:19AM BLOOD Mg-1.___ year old male with new dx pancreatic CA (unresectable) s/p \nbiliary stent placed ___ at ___, with Atrial fibrillation on \nCoumadin, presented to care to initiate FOLFIRINOX but was \nreferred to ED for leukocytosis, fever, elevated LFTs, bilious \nvomiting, and some increased confusion. Presentation c/f \ncholangitis, although quickly improved with unrevealing ERCP, so \nremains somewhat unclear. \n\n#Suspected cholangitis:\n#?aspiration vs PNA\nPatient presented with the above symptoms, c/f cholangitis in \nthe setting of biliary stent. He was treated with fluids and \ncefepime/flagyl. However his symptoms, labs findings, and vitals \nrapidly improved, and the ERCP did not reveal significant \nobstruction or pus. It is also possible that he had these \nsymptoms from pneumonia or an aspiration event given the imaging \nfindings suggestive of such and his recent cough, although the \nXR on day of admission actually appeared improved, and his cough \nhad nearly completely resolved by the day of admission, so this \nseems somewhat unlikely. He will complete 8 more days of \naugmentin for a total 10 day cholangitis course. He was \ncounseled to ___ w/ recurrent symptoms.\n\nThe day after ERCP he was continued NPO for port replacement. \nSubsequently his diet was advanced for successfully and he was \ndischarged home. \n \n\n# Pancreatic cancer\nPatient will follow-up with onc provider to reschedule \nchemotherapy. \n\n# Port placement:\nPort was replaced during admission due to proximal location of \ncatheter. R IJ catheter, and prior R subclavian was removed. \n\n# Hyponatremia \nMild hyponatremia on presentation that improved with fluids. \n\n# Diabetes \nHeld home meds and started sliding scale. Discharged back on \nhome meds with instructions to start with a low lantus dose and \ngradually increase based on glucose levels given his reduced PO \nintake. \n\n# HypoMg \nKept on home repletion and received additional IV repletion\n\n# Afib\nStopped Coumadin ___ ___ procedure and was told to hold until \n___. Continued to hold, will defer to outpatient providers for \nrestarting. may need reduced dose if starting while still on \nabx. Continued home dilt. \n\n>30 minutes spent in face to face time and coordination of \ndischarge\n\n=================================\nTransitional issues:\n(1) f/u final blood cultures\n(2) determine starting time for chemo \n(3) consider restarting time of Coumadin\n(4) continue monitoring magnesium levels \n(5) completing 8 more days of augmentin for cholangitis course\n=================================\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Benzonatate 100 mg PO TID:PRN cough \n2. Diltiazem Extended-Release 180 mg PO DAILY \n3. Glargine 28 Units Bedtime\n4. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit \noral TID \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. LORazepam 0.5 mg PO QHS:PRN insomnia \n7. Ondansetron 8 mg PO Q8H:PRN nausea \n8. Tamsulosin 0.4 mg PO QHS \n9. Warfarin 5 mg PO DAILY16 \n10. Magnesium Oxide 400 mg PO DAILY \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO BID Duration: 8 Days \nRX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 \ntablet by mouth twice daily Disp #*16 Tablet Refills:*0 \n2. Glargine 28 Units Bedtime \n3. Benzonatate 100 mg PO TID:PRN cough \n4. Diltiazem Extended-Release 180 mg PO DAILY \n5. LORazepam 0.5 mg PO QHS:PRN insomnia \n6. Magnesium Oxide 400 mg PO DAILY \n7. MetFORMIN (Glucophage) 1000 mg PO BID \n8. Ondansetron 8 mg PO Q8H:PRN nausea \n9. Tamsulosin 0.4 mg PO QHS \n10. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 \nunit oral TID \n11. HELD- Warfarin 5 mg PO DAILY16 This medication was held. Do \nnot restart Warfarin until instructed by your outpatient doctors\n\n \n___:\nHome\n \nDischarge Diagnosis:\nCholangitis\nPancreatic cancer\nPort replacement\nAtrial fibrillation\nDiabetes Mellitus\nHypomagnesemia\n\n \nDischarge Condition:\nPatient hemodynamically stable and afebrile with baseline \ncognitive and functional status. \n\n \nDischarge Instructions:\nYou were admitted to the hospital because of a fever and concern \nfor an infection related to your bile duct stent. Fortunately \nyour condition improved quickly and the ERCP procedure did not \nshow any significant problems. We still recommend taking \nantibiotics for the next 8 days because of the concern for \ninfection. You should contact your oncologist to determine when \nyou will restart chemo. You also had your port replaced to fix \nthe positioning of it.\n\nWe also recommend touching base with your outpatient providers \nabout when to restart your Coumadin. If you restart the Coumadin \nwhile you are still taking the antibiotics then you may need a \nlower dose. \n\nRegarding your insulin, as we discussed, you should start at a \nlower dose than normal and gradually increase back to normal \nbased on how much you are eating and what your glucose levels \nare at home. \n \nFollowup Instructions:\n___\n" ]

[ "K830", "C259", "E871", "I4891", "E8342", "I10", "N400", "E806", "E119", "Z794", "Z7901", "Z23" ]

[ "K830: Cholangitis", "C259: Malignant neoplasm of pancreas, unspecified", "E871: Hypo-osmolality and hyponatremia", "I4891: Unspecified atrial fibrillation", "E8342: Hypomagnesemia", "I10: Essential (primary) hypertension", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E806: Other disorders of bilirubin metabolism", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "Z7901: Long term (current) use of anticoagulants", "Z23: Encounter for immunization" ]

[ "E871", "I4891", "I10", "N400", "E119", "Z794", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nTetracycline Analogues / amoxicillin / iodopropynl / \nglutaraldehyde\n \nAttending: ___.\n \nChief Complaint:\nMorbid obesity\n \nMajor Surgical or Invasive Procedure:\n___: laparoscopic sleeve gastrectomy\n\n \nHistory of Present Illness:\nPer Dr. ___ has class III morbid obesity with \nweight of 286.9 pounds as of ___ with her initial screen \nweight of 285.1 pounds on ___, height of 63.25 inches and BMI \nof 50.4. Her previous weight loss efforts have included Weight \nWatchers multiple times, calorie counting, low carbohydrate diet \n___, ___ diet, prescription weight loss \nmedications, over-the-counter dietary ___ visits \nas well as counseling with obesity specialist Dr. ___ \n___ at ___. She stated \nthat her lowest weight was in the 180s in her teenage years and \nher highest weight was 297 pounds. She stated that she has been \nstruggling with weight since puberty and cites as factors \ncontributing to her excess weight convenience eating, lack \nportions, emotional eating ___ times a\nmonth, genetics, eating too many carbohydrates and lack of \nexercise although she does walk for 60 minutes ___ times per \nweek and does track her progress via a pedometer. She denied \nhistory of eating disorders - no anorexia, bulimia, diuretic or \nlaxative abuse and she denied binge eating. She does not have a \ndiagnosis of depression but does have anxiety with history of \npanic\nattacks. She has not been followed by a therapist and she has\nnot been hospitalized for mental health issues and she is not on\nany psychotropic medications.\n\n \nPast Medical History:\nHer medical history includes:\n\n1) hyperlipidemia with elevated triglycerides\n2) hypertension not a medication\n3) vitamin D deficiency\n4) iron deficiency with saturation of 16%\n5) acne\n6) eczema\n7) ___ fracture of the right foot (inversion plantar flexion \n after tripping down stairs at ___ at a ___)\n\nShe has no surgical history.\n\n \nSocial History:\nWorks as ___ at ___.\n\n \nPhysical Exam:\nVS: T 98.3 P 76 BP 135/81 RR 18 02 100%RA\nConstitutional: NAD\nNeuro: Alert and oriented x 3\nCardiac: Regular rate and rhythm, no murmurs appreciated\nResp: Clear to auscultation, bilaterally\nAbdomen: Soft, non-tender, non-distended, no rebound \ntenderness/guarding\nWounds: Abd lap sites, CDI; no periwound erythema or drainage\nExt: no lower extremity edema\n \nPertinent Results:\nLABS:\n___ 05:50AM BLOOD Hct-39.8\n___ 10:32AM BLOOD Hct-40.4\n\nIMAGING:\nBAS/UGI W/KUB: \nNo evidence of leak or obstruction.\n \nBrief Hospital Course:\nThe patient presented to pre-op on ___. Pt was \nevaluated by anaesthesia and taken to the operating room for \nlaparoscopic sleeve gastrectomy. There were no adverse events in \nthe operating room; please see the operative note for details. \nPt was extubated, taken to the PACU until stable, then \ntransferred to the ward for observation. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a PCA and then \ntransitioned to oral oxycodone once tolerating a stage 2 diet. \nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \nGI/GU/FEN: The patient was initially kept NPO with a \n___ tube in place for decompression. On POD1, the NGT \nwas removed and an upper GI study was negative for a leak, \ntherefore, the diet was advanced sequentially to a Bariatric \nStage 3 diet, which was well tolerated. Patient's intake and \noutput were closely monitored. \nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a stage 3 \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. levonorgestrel 20 mcg/24 hr ___ years) intrauterine DAILY \n2. Spironolactone 50 mg PO QHS \n3. Multivitamins W/minerals 1 TAB PO DAILY \n4. Imipramine 50 mg PO AS DIRECTED \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium 50 mg/5 mL 10 ml by mouth twice a day \nRefills:*0 \n2. OxycoDONE Liquid 5 mg PO Q6H:PRN Pain - Moderate \nRX *oxycodone 5 mg/5 mL 5 ml by mouth q 6 hours Refills:*0 \n3. Ranitidine (Liquid) 150 mg PO BID \nRX *ranitidine HCl 15 mg/mL 10 ml by mouth twice a day \nRefills:*0 \n4. Imipramine 50 mg PO AS DIRECTED \n5. levonorgestrel 20 mcg/24 hr ___ years) intrauterine DAILY \n6. Multivitamins W/minerals 1 TAB PO DAILY \n7. HELD- Spironolactone 50 mg PO QHS This medication was held. \nDo not restart Spironolactone until you discuss with Dr. ___.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nObesity\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: Please call your surgeon or return to \nthe emergency department if you develop a fever greater than \n101.5, chest pain, shortness of breath, severe abdominal pain, \npain unrelieved by your pain medication, severe nausea or \nvomiting, severe abdominal bloating, inability to eat or drink, \nfoul smelling or colorful drainage from your incisions, redness \nor swelling around your incisions, or any other symptoms which \nare concerning to you.\n\nDiet: Stay on Stage III diet until your follow up appointment. \nDo not self advance diet, do not drink out of a straw or chew \ngum.\n\nMedication Instructions:\nResume your home medications, CRUSH ALL PILLS.\nYou will be starting some new medications:\n1. You are being discharged on medications to treat the pain \nfrom your operation. These medications will make you drowsy and \nimpair your ability to drive a motor vehicle or operate \nmachinery safely. You MUST refrain from such activities while \ntaking these medications.\n2. You should begin taking a chewable complete multivitamin with \nminerals. No gummy vitamins.\n3. You will be taking Zantac liquid ___ mg twice daily for one \nmonth. This medicine prevents gastric reflux.\n4. You should take a stool softener, Colace, twice daily for \nconstipation as needed, or until you resume a normal bowel \npattern.\n5. You must not use NSAIDS (non-steroidal anti-inflammatory \ndrugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and \nNaproxen. These agents will cause bleeding and ulcers in your \ndigestive system.\n\nActivity:\nNo heavy lifting of items ___ pounds for 6 weeks. You may \nresume moderate exercise at your discretion, no abdominal \nexercises.\n\nWound Care:\nYou may shower, no tub baths or swimming. \nIf there is clear drainage from your incisions, cover with \nclean, dry gauze. \nYour steri-strips will fall off on their own. Please remove any \nremaining strips ___ days after surgery.\nPlease call the doctor if you have increased pain, swelling, \nredness, or drainage from the incision sites. \n\n \nFollowup Instructions:\n___\n" ]

[ "E6601", "E559", "I10", "Z6843", "E780", "L709", "K660", "D509", "L309", "F419", "R000", "R110" ]

[ "E6601: Morbid (severe) obesity due to excess calories", "E559: Vitamin D deficiency, unspecified", "I10: Essential (primary) hypertension", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "E780: Pure hypercholesterolemia", "L709: Acne, unspecified", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "D509: Iron deficiency anemia, unspecified", "L309: Dermatitis, unspecified", "F419: Anxiety disorder, unspecified", "R000: Tachycardia, unspecified", "R110: Nausea" ]

[ "I10", "D509", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nlidocaine\n \nAttending: ___.\n \nChief Complaint:\nelevated BP\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ G3P3 POD4 from primary LTCS for arrrest of dilation and\nfetal intolerance to augmentation of labor c/b gestational\nhypertension now with severe BP at home. Reports assymetric calf\nswelling (R>L) starting this morning. Has intermittent shortness\nof breath, but none now. Endorse + chest pressure which started\non arrival to the ED, also comes and goes. Denies substernal\nchest pain, arm pain, jaw pain, heart pain. Breast nt, feeding\nand pumping well. incisional pain will controlled at home on\ntylenol/oxy/ibuprofen with normal lochia. Infant is at home with\ngrandma.\n\nDenies headache, vision changes, RUQ pain (subcostal cheat\ndiscomfort as above). Remainder of ROS as per HPI.\n \nPast Medical History:\nOBHx:\n- G1: SVD term, 5#15, pre eclampsia at 40 weeks\n- G2: SVD term, 9#10oz, gHTN\n- G3: pLTCS as above\n\nGynHx:\n- No h/o abnormal Pap, fibroids, Gyn surgery, STIs\n\nPMH: none\nPSH: wisdom teeth, cesarean delivery\nMeds: PNV\nAll: lidocaine (difficulty breathing)\n \nSocial History:\nSHx: denies T/E/D\n \nPhysical Exam:\nGeneral: NAD\nCV: RRR\nLungs: Nonlabored breathing, CTAB\nAbd: soft, fundus firm at umbilicus, appropriate fundal\ntenderness\nIncision: clean/dry/intact, no erythema/induration\nLochia: minimal\nExtremities: no calf tenderness, 1+ edema\n\n \nPertinent Results:\n___ 01:15PM cTropnT-<0.01\n___ 11:04AM ___ PTT-33.7 ___\n___ 10:10AM GLUCOSE-91 UREA N-9 CREAT-0.7 SODIUM-143 \nPOTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12\n___ 10:10AM ALT(SGPT)-45* AST(SGOT)-45* ALK PHOS-97 TOT \nBILI-0.3\n___ 10:10AM cTropnT-<0.01\n___ 10:10AM proBNP-257*\n___ 10:10AM ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-3.6 \nMAGNESIUM-1.8\n___ 10:10AM URINE HOURS-RANDOM\n___ 10:10AM URINE UCG-POSITIVE*\n___ 10:10AM URINE UHOLD-HOLD\n___ 10:10AM WBC-11.0* RBC-3.67* HGB-10.0* HCT-31.3* \nMCV-85 MCH-27.2 MCHC-31.9* RDW-16.7* RDWSD-50.5*\n___ 10:10AM NEUTS-83.1* LYMPHS-11.7* MONOS-3.6* EOS-0.1* \nBASOS-0.3 IM ___ AbsNeut-9.14* AbsLymp-1.29 AbsMono-0.40 \nAbsEos-0.01* AbsBaso-0.03\n___ 10:10AM PLT COUNT-245\n___ 10:10AM URINE COLOR-Yellow APPEAR-Hazy* SP ___\n___ 10:10AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-100* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 \nLEUK-LG*\n___ 10:10AM URINE RBC-5* WBC-107* BACTERIA-MOD* YEAST-NONE \nEPI-4 TRANS EPI-2\n \nBrief Hospital Course:\nMs. ___ was readmitted on ___ with elevated blood \npressures, found to have pre-eclampsia severe by blood \npressures. \n\nShe presented to the ED on post-operative day 4 from primary low \ntransverse cesarean section. She received 20mg IV labetalol was \nstarted on 24 hours of magnesium. Her home nifedipine was \ncontinued and labetalol was added for better control of her \nblood pressures. \n\nIn the ED, she also complained of chest pressure w/ bilateral \nleg sweeling, bedside echocardiogram was within normal limit and \nEKG demonstrated NSR. CTA demonstrated no evidence of pulmonary \nembolism or aortic abnormalities, however ground-glass \nopacities in dependent areas were noted, that may have \nrepresented fluid overload.\n\nDuring her hospital course, she continued to have persistent HA \n(___). MRI/MRA obtained showed no evidence of ischemia, \nhemorrhage, or edema. She received acetaminophen, ibuprofen, \nfioricet, and Compazine. She had elevated liver enzymes which \ndowntrended prior to her discharge. Her anti-hypertensive \nmedications were uptitrated to labetalol 600 q8h and nifedipine \n30 mg daily. \n \nBy hospital day 5, she was stable for discharge. Discussed \nreturn precautions included severe range blood pressures and \npersistent headache. She was discharged home with outpatient \nfollow-up. \n \nMedications on Admission:\nprenatal vitamins\n \nDischarge Medications:\n1. Labetalol 600 mg PO Q8H \nRX *labetalol 300 mg 2 tablet(s) by mouth three times a day Disp \n#*120 Tablet Refills:*1 \n2. NIFEdipine (Extended Release) 30 mg PO DAILY hypertension \nhold if bp below 110/70 \nRX *nifedipine 30 mg 1 tablet(s) by mouth q day Disp #*20 Tablet \nRefills:*1 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\npost partum pre ecclampsia with headache symptoms\npulmonary edema\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nrest. take meds. no heavy lifting, exercise, for 4 weeks\n \nFollowup Instructions:\n___\n" ]

[ "O1415", "O99215", "E669", "R0789", "O9989" ]

[ "O1415: Severe pre-eclampsia, complicating the puerperium", "O99215: Obesity complicating the puerperium", "E669: Obesity, unspecified", "R0789: Other chest pain", "O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium" ]

[ "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillins / Zofran\n \nAttending: ___\n \nChief Complaint:\nNausea and vomiting\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ w hx remote colon cancer ___ s/p sigmoid resection c/b leak\nrequiring reoperation/diverting colostomy, s/p takedown, with\nlong-standing incisional hernia, who presents to the ED with 4\ndays of nausea and bilious emesis, found on CT to have recurrent\nSBO. Patient reports 4 days ago she noticed cramping abdominal\npain associated with nausea, had several episodes of bilious\nemesis. Did not have any bowel movements for 3 days/flatus x 2\ndays, however initially tried managing by increasing her stool\nsofteners and starting lactulose 2 days ago. However her\nnausea/vomiting did not resolve prompting her to present today. \nA\nCT scan was done, results detailed below, demonstrating an\nincarcerated ___ hernia for which we are consulted. \n\nOnly prior hospitalization for this issue was in ___, at which\ntime she was admitted to ___ service w obstructive symptoms - \nACS\nwas consulted several days into her hospital stay but at that\npoint her symptoms had already improved and CT demonstrated\npartial SBO at most. Given her recurrent lymphoma and plans to\nperform repeat aSCT she deferred definitive surgical repair - \nher\nsymptoms resolved with non operative management, did not follow\nup with surgery as outpatient. Successfully underwent repeat \naSCT\nand has been in remission for ___ years, with last scans ___\nshowing no evidence of disease recurrence.\n\nNo recurrent SBO's in the subsequent ___ years until her\npresentation today. Last colonoscopy ___ which noted several\nadenomatous polyps, plans for repeat in ___. \n\nROS:\n(+) per HPI\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY\n1. Recurrent marginal zone lymphoma, stage IIIA. \n--Initially treated with R-CVP, completed in ___\n--Relapsed in ___ with extensive adenopathy, treated with\ntotal 6 cycles of Rituxan/Bendamustine, completed in ___\n--Increasing left breast lesion and skin nodule. Biopsy on\n___ showed diffuse large B-cell lymphoma and \ntransformation\nin the background of a marginal zone lymphoma\n--4 cycles of DA-EPOCH, followed by high dose Cytoxan and\nautologous stem cell transplantation(D 0 ___. \n2. Colon cancer, status post surgery in ___. She does not\nremember the stage of her disease, but she did not receive any\nadjuvant treatment. Colonoscopy needs to be repeated.\n\nPAST MEDICAL HISTORY: \n Osteoarthritis. \n Adnexal cyst.\n Hypertension\n Chemotherapy induced pneumonitis, on steroids with taper.\n \nSocial History:\n___\nFamily History:\nAdopted. Family history unknown.\n \nPhysical Exam:\nAdmission physical exam\n=======================\nVitals: T98 HR110 BP 130/80 RR 18 ___ 92RA\nGEN: A&O, NAD, non-toxic appearing\nHEENT: No scleral icterus, mucus membranes dry\nCV: mild tachycardia, reg rhythm\nPULM: unlabored respirations\nABD: Soft, morbidly obsese, nondistended, large palpable\nincisional hernia just to the left of umbilicus with gas-filled\nsmall bowel. Tender to palpation over hernia but no diffuse\nabdominal tenderness, no rebound or guarding. \nExt: No ___ edema, ___ warm and well perfused\n\nDischarge physical exam\n========================\nVS: 98.2, 135/75, 87, 20, 95 RA\nGen: A&O x3. Ambulatory. In NAD.\nCV: HRR\nPulm: LS CTAB\nAbd: soft, obese, + large hernia. nontender to palp.\nExt: WWP, trace edema \n \nPertinent Results:\nAdmission labs\n==============\n___ 10:00AM BLOOD WBC-10.5* RBC-5.57* Hgb-16.5* Hct-50.0* \nMCV-90 MCH-29.6 MCHC-33.0 RDW-13.5 RDWSD-44.5 Plt ___\n___ 10:00AM BLOOD Neuts-74.5* Lymphs-14.2* Monos-9.5 \nEos-0.7* Baso-0.5 Im ___ AbsNeut-7.81* AbsLymp-1.49 \nAbsMono-0.99* AbsEos-0.07 AbsBaso-0.05\n___ 10:00AM BLOOD ___ PTT-27.8 ___\n___ 10:00AM BLOOD Plt ___\n___ 10:00AM BLOOD Glucose-252* UreaN-17 Creat-0.9 Na-141 \nK-3.8 Cl-97 HCO3-26 AnGap-18\n___ 10:00AM BLOOD Calcium-9.7 Phos-2.7 Mg-1.9\n___ 11:03AM BLOOD Lactate-3.2*\n___ 01:48AM BLOOD Lactate-1.2\n___ 06:13AM BLOOD Lactate-1.5\n\nDischarge labs:\n___ 05:30AM BLOOD WBC-8.9 RBC-4.13 Hgb-12.4 Hct-40.0 MCV-97 \nMCH-30.0 MCHC-31.0* RDW-14.3 RDWSD-50.4* Plt ___\n___ 04:50AM BLOOD WBC-10.4* RBC-4.48 Hgb-13.3 Hct-42.9 \nMCV-96 MCH-29.7 MCHC-31.0* RDW-14.5 RDWSD-50.2* Plt ___\n___ 04:09AM BLOOD WBC-18.9* RBC-4.89 Hgb-14.7 Hct-46.4* \nMCV-95 MCH-30.1 MCHC-31.7* RDW-14.1 RDWSD-48.9* Plt ___\n___ 05:30AM BLOOD Glucose-124* UreaN-10 Creat-0.6 Na-143 \nK-3.7 Cl-105 HCO3-31 AnGap-7*\n___ 04:50AM BLOOD Glucose-167* UreaN-12 Creat-0.6 Na-143 \nK-3.9 Cl-103 HCO3-30 AnGap-10\n\nImaging\n========\nCXR ___\nPA and lateral views of the chest provided. Port-A-Cath resides \nover the \nright chest wall with catheter tip in the mid SVC region. The \nlungs are clear bilaterally. There is no focal consolidation, \nlarge effusion, pneumothorax or signs of edema. \nCardiomediastinal silhouette appears stable. Bony structures \nare intact. No free air below the right hemidiaphragm. \n\nCT A/P ___\n1. Small-bowel obstruction due to a left periumbilical small \nbowel containing hernia. Please correlate for reducibility. No \nfree fluid, free air or bowel wall thickening. \n2. Multiple additional fat containing abdominal wall hernias. \n3. Right adnexal cystic lesion, previously characterized as \nhydrosalpinx. \n4. Thickened endometrium, measuring up to 2.8 cm, consider \nnonemergent pelvic ultrasound to further assess. \n\n___ KUB: Multiple air-filled, mildly dilated loops of small \nand large bowel, compatible with ileus. \n\n___ KUB: Interval decrease in mildly dilated loops of small \nand large bowel, compatible with improving ileus. \n\n___ CHEST/ABD/PELVIS CT:\n1. Left periumbilical incisional hernia with a 4.___ontaining loops of small bowel with interval slight \nimprovement of upstream small bowel dilatation. The oral \ncontrast material has passed through the trapped loops of \nsmall-bowel in the incisional hernia, however, given the \ncontinued upstream dilation, there appears to be an element of \npersisting partial obstruction. \n2. Thickened endometrium measures 0.9 cm as noted on pelvic \nultrasound dated ___. Please correlate with prior \nendometrial biopsy. \n3. Unchanged right hydrosalpinx. \n4. Please refer to separate report of CT chest performed on the \nsame day for description of the thoracic findings. \n\n \nBrief Hospital Course:\n___ y/o F hx marginal zone lymphoma s/p alloSCT x 2, remote colon \ncancer s/p resection with incisional hernia, admitted to the \nGeneral Surgical Service on ___ for evaluation and treatment of \nabdominal pain, nausea and vomiting. Admission abdominal/pelvic \nCT revealed a small-bowel obstruction due to a left \nperiumbilical small bowel containing hernia. The patient was \nhemodynamically stable. She was treated non-operatively with \nbowel rest, IV fluids, nasogastric tube for decompression, and \nclose monitoring or lab work and abdominal exam.\n\nSerial abdominal x-rays showed gradual improvement. The patient \neventually began passing consistent flatus. On ___, a repeat CT \nscan showed no bowel obstruction. NGT was removed and diet was \nprogressively advanced as tolerated to a regular diet with good \ntolerability. \n\nDuring this hospitalization, the patient ambulated early and \nfrequently, was adherent with respiratory toilet and incentive \nspirometry, and actively participated in the plan of care. The \npatient received subcutaneous heparin and venodyne boots were \nused during this stay.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home without services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan. She would follow-up as an outpatient to \ndiscuss an elective hernia repair. \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acyclovir 400 mg PO Q8H \n2. Hydrochlorothiazide 25 mg PO DAILY \n3. Vitamin D ___ UNIT PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Senna 8.6 mg PO BID \n6. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Polyethylene Glycol 17 g PO DAILY \n2. Acyclovir 400 mg PO Q8H \n3. Docusate Sodium 100 mg PO BID \n4. Hydrochlorothiazide 25 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*0 \n6. Senna 8.6 mg PO BID \n7. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nDistal small-bowel obstruction due to a left periumbilical \nhernia \ncontaining multiple small bowel loops \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 recurrent small bowel \nobstruction and irreducible small-bowel containing incisional \nhernia. You were managed non-operatively with bowel rest, IV \nfluids, and nasogastric tube for stomach decompression. A repeat \nCT scan was done which showed resolution of the obstruction, and \nyou also had begun to have reliable return of bowel function. \nYou have been tolerating a regular diet now, passing flatus and \nhaving bowel movements. You are ready to be discharged home to \ncontinue your recovery. You can follow-up in clinic to discuss \nelective hernia repair. \n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids\n \nFollowup Instructions:\n___\n" ]

[ "K430", "C8580", "Z9484", "Z85038", "Z9049", "I10", "Z87891", "E860" ]

[ "K430: Incisional hernia with obstruction, without gangrene", "C8580: Other specified types of non-Hodgkin lymphoma, unspecified site", "Z9484: Stem cells transplant status", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z9049: Acquired absence of other specified parts of digestive tract", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "E860: Dehydration" ]

[ "I10", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms / propofol\n \nAttending: ___\n \nChief Complaint:\nGeneralized Weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ male with a past medical history significant for\nliver transplant in ___ for PBC, hemorrhagic pericarditis in\n___ s/p pericardial window, MI x2 in ___, IBS vs Crohn's\ndisease, osteoporosis with multiple pathological fractures who\npresents for generalized weakness.\n\nNotably, the pt was admitted recently to ___ \n___,\nat which time his presenting symptoms was also weakness. Work up\nwas significant for ___, adrenal insufficiency, and CMV viremia.\nHe underwent a colonoscopy and EGD that were unrevealing. The pt\nwas treated w/ steroids and valganciclovir and his Cr improved \nto\nbaseline by time of discharge.\n\nThe pt now complains of about 2 days of generalizes weakness and\nfatigue. Prior to that, he was in his usual state of health. \nAlso\nendorses low appetite, nausea, and some abdominal discomfort\nwithout vomiting or change in bowel movements. The pt was\ninitially seen at ___ where labs, flu swab, UA, and\nCXR were reportedly unremarkable with the exception of elevated\nCr to 1.8. He was given 100 mg of Hydrocort for concerns of\nadrenal insufficiency. The pt was then transferred to ___ for\ncontinued care.\n\nIn the ED, initial VS were T 96.7, HR 64, BP 140/70, RR 16, O2\n98% on RA.\n\nExam was notable for diffuse abdominal tenderness. \n\nLabs were significant for:\n- Pancytopenia with WBC 2.7, Hbg 9.0, Plts 89\n- Otherwise normal chemistry panel (Cr 1.2) LFTs, coags, \nlactate,\nand U/A negative\n\nStudies included:\n- CT A&P with no acute intra-abdominal process\n- RUQ US w/ doppler with high resistance waveform in the main\nhepatic artery with diminished antegrade diastolic flow as well\nas interval decrease in peak systolic velocity (31.3 cm/s);\nnonvisualization of the right or left hepatic arteries; patent\nportal veins; and splenomegaly\n\nThe pt was continued on his home medications. He was transferred\nto the Heparorenal service for further management.\n\nOn arrival to the floor, the pt endorsed the above history. \nAside\nfrom the weakness, nausea, and abdominal pain, the pt denied\nhaving and fevers, chills, vomiting, cough, or urinary \nfrequency.\nHe also denied any new medications, recent travel, or sick\ncontacts.\n\nREVIEW OF SYSTEMS:\n==================\nPer HPI, otherwise, 10-point review of systems was within normal\nlimits.\n \nPast Medical History:\n- Attention deficit hyperactivity disorder\n- Bipolar disorder\n- Hemorrhoids\n- History of alcohol abuse\n- History of deep vein thrombosis in ___\n- History of hemorrhagic pericarditis complicated by cardiac \ntamponade status post pericardial window in ___, recurrent \npericarditis in ___\n- History of neutropenia complicated by neutropenic fever\n- History of positive tuberculin skin test status post INH \n- Hyperlipidemia \n- Osteoporosis \n- Primary biliary cirrhosis status post orthotopic liver\ntransplant \n- Pulmonary nodule\n- COPD\n- Alternating constipation/diarrhea, ? IBS vs Crohn's Disease \n\n\n- CAD s/p MI x 2 in ___\n- T1 compression fx, T6 burst fracture \n\n- T4-8 FUSION (___) \n- LIVER TRANSPLANT (___) \n \nSocial History:\n___\nFamily History:\nNoncontributory to the patients current admission,\nFather passed away from head and neck cancer \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: T 97.9, BP 137/90, HR 75, RR 18, O2 98% on RA\nGENERAL: Alert and interactive, NAD\nCARDIAC: RRR, no m/r/g\nLUNGS: CTAB, no wheezes or crackles\nABDOMEN: Soft, tenderness to palpation diffusely, worse in\nmidline, nor rebound or guarding, BS+\nEXTREMITIES: Trace edema in ___\nSKIN: Warm, no rashes\nNEUROLOGIC: AOx3, CNII-XII intact, moving extremities, gait\ndeferred\n\nDISCHARGE PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 812)\n Temp: 97.5 (Tm 98.6), BP: 138/97 (114-139/83-97), HR: 67\n(61-74), RR: 18 (___), O2 sat: 98% (97-98), O2 delivery: Ra \nHEENT: NC/AT EOMI sclera nonicteric MMM no oropharyngeal \nerythema\n\nNeck: No thyromegaly, no thyroid nodules \nCV: RRR S1/S2 normal\nRESP: CTAB\nABD: TTP periumbilical. soft, nondistended. \nBACK: Diffuse tenderness to palpation at flanks, paraspinal,\nspinous processes inferior to rib borders\nEXT: No C/C/E\n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 05:40AM tacroFK-3.2*\n___ 03:04AM LACTATE-1.1\n___ 03:00AM CK(CPK)-38*\n___ 03:00AM cTropnT-<0.01\n___ 03:00AM TSH-3.2\n___ 03:00AM T4-3.9* T3-68*\n___ 01:30AM ___ PTT-26.8 ___\n___ 12:05AM URINE HOURS-RANDOM\n___ 12:05AM URINE UHOLD-HOLD\n___ 12:05AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 12:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 10:30PM GLUCOSE-95 UREA N-15 CREAT-1.2 SODIUM-143 \nPOTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-26 ANION GAP-10\n___ 10:30PM estGFR-Using this\n___ 10:30PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-106 TOT \nBILI-0.3\n___ 10:30PM LIPASE-18\n___ 10:30PM cTropnT-<0.01\n___ 10:30PM ALBUMIN-3.8 CALCIUM-8.9 PHOSPHATE-3.0 \nMAGNESIUM-1.9\n___ 10:30PM WBC-2.7* RBC-4.11* HGB-9.0* HCT-31.4* MCV-76* \nMCH-21.9* MCHC-28.7* RDW-16.6* RDWSD-45.4\n___ 10:30PM NEUTS-48.9 ___ MONOS-12.5 EOS-1.1 \nBASOS-1.1* IM ___ AbsNeut-1.33* AbsLymp-0.98* AbsMono-0.34 \nAbsEos-0.03* AbsBaso-0.03\n___ 10:30PM PLT COUNT-89*\n\nPERTINENT STUDIES:\n==================\n___ DOPP ABD/PEL\n\n1. High resistance waveform in the main hepatic artery with \ndiminished\nantegrade diastolic flow as well as interval decrease in peak \nsystolic\nvelocity (31.3 cm/s), represents a change from ultrasound of ___ and is concerning for possible occlusion. \nRecommend clinical correlation with LFTs and CT angiogram.\n2. Patent portal veins.\n3. Splenomegaly.\n\n___ ABD & PELVIS WITH CO\n1. No acute intra-abdominal process.\n2. Unremarkable appearance of the liver transplant. The \ntransplant main\nhepatic artery appears patent to level of the liver hilum. \nSuboptimal\nevaluation of the hepatic arterial vasculature on this non \ndedicated study.\n3. Splenomegaly.\n\n___ ABD & PELVIS\n\n1. Main, left and right hepatic arteries are patent and appear \nsimilar to CTA\nfrom ___ with no evidence of focal stenosis.\n2. Stable pancreatic cystic lesion is likely a side-branch IPMN \nand can be\nre-evaluated at next follow-up.\n \nBrief Hospital Course:\n___ is a ___ year-old male w/ hx of PBC s/p liver \ntransplant (___), hemorrhagic pericarditis s/p window, CAD c/b \nMI x 2 (___), IBS vs Crohn's disease, OA, and pancytopenia who \npresented with generalized weakness, malaise, and dyspnea on \nexertion. Of note this is his second hospitalization for similar \npresentation in the last several months. Workup here as detailed \nbelow was largely unremarkable, with greatest suspicion for \nendocrine or psychosomatic etiology of his weakness. \n\nTRANSITIONAL ISSUES:\n====================\n\n[ ] Consider broader endocrine workup for fatigue including \ntestosterone testing, FSH/LH\n\n[ ] If workup for other organic causes is negative, consider \npsychiatric etiology given recent life stressors and possible \nreferral to psychiatry \n\n[ ] We were unable to provide an appointment with cardiology \nwhile inpatient; please ensure patient follows up with \ncardiology for his history of pericarditis and reported MI \nhistory \n\n[ ] Recommend ___ week follow-up of thyroid function tests\n\n[ ] For sick day dosing, recommend prednisone increase from 5 to \n10mg dosing for ___ days, after which he can be tapered back to \n5mg. \n\nACUTE ISSUES:\n=============\n#Fatigue\nPatient presented with several weeks of worsening fatigue \nwithout frank weakness, associated with vague diffuse aching and \ntenderness across his torso. This is his second admission in \nseveral months for similar complaints. During his prior \nadmission, there were concerns for adrenal insufficiency given \nlow AM cortisol and ACTH levels although these were checked at \nsuboptimal timings around the time of steroid administration. \nFor this hospitalization, he presented to ___ where \ndue to concern of adrenal insufficiency he was given 100mg \nhydrocortisone and transferred to ___ for further management \nand continuity of care. Workup here notable for low repeat AM \ncortisol (although now in setting of hydrocortisone \nadministration), normal TSH with low T3/T4, negative CMV viral \nload and culture data. He additionally had CTA abdomen to \nevaluate hepatic vasculature (admission RUQ US with decreased \nvelocities) which was unremarkable. Other endocrine etiologies \nwere currently left unexplored. He has had prior cardiac \ncoronary cath in ___ which was unremarkable. Of note, \npatient's father recently passed away ~3 months ago which has \nbeen a significant life stressor and associated with \nsubjectively depressed mood, anhedonia, sleep disturbance, and \ndecreased energy levels. \n- Started on prednisone 10mg on date of admission for sick day \ndosing. He was told to taper back to 5mg over two days at \ndischarge. \n\n#Acute Kidney Injury\nPatient with baseline serum creatinine of 1.0, increased to 1.6 \nwhich resolved with IV albumin administration, and subsequently \nagain to 1.3 with IVF administration. Likely in setting of poor \nPO intake and unrelated to ongoing above pathology. Not on \ndiuretics. \n\n#Primary Biliary Cirrhosis s/p Deceased Donor Liver Tx ___\nMaintained on tacrolimus 1mg BID. Prednisone dosing as above. \n\nCHRONIC ISSUES:\n===============\n# H/o pericarditis \nPt found to have hemorrhagic pericarditis c/b tamponade s/p \npericardial window in ___ with recurrent pericarditis in ___ \nand moderate pericardial effusion seen on TTE in ___. \nResolved on recent TTE ___.\n- Continue home colchicine 0.6mg BID\n- Continue home ASA (full dose)\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 10 mg PO QPM \n2. BuPROPion (Sustained Release) 300 mg PO QAM \n3. Colchicine 0.6 mg PO BID \n4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate \n\n5. Pantoprazole 40 mg PO Q24H \n6. Ranitidine 150 mg PO DAILY \n7. Tacrolimus 1 mg PO QAM \n8. Tacrolimus 1 mg PO QPM \n9. Senna 8.6 mg PO BID \n10. DICYCLOMine 20 mg PO BID diarrhea \n11. Gabapentin 800 mg PO BID \n12. Naloxone Nasal Spray 4 mg IH ONCE MR1 \n13. Aspirin 325 mg PO DAILY \n14. PredniSONE 5 mg PO DAILY \n15. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n\n16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n17. DICYCLOMine 10 mg PO DAILY:PRN Abd pain/cramping \n\n \nDischarge Medications:\n1. Ursodiol 500 mg PO BID \n2. Aspirin 325 mg PO DAILY \n3. Atorvastatin 10 mg PO QPM \n4. BuPROPion (Sustained Release) 300 mg PO QAM \n5. Colchicine 0.6 mg PO BID \n6. DICYCLOMine 20 mg PO BID diarrhea \n7. DICYCLOMine 10 mg PO DAILY:PRN Abd pain/cramping \n8. Gabapentin 800 mg PO BID \n9. Naloxone Nasal Spray 4 mg IH ONCE MR1 \n10. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First \nLine \n11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n12. Pantoprazole 40 mg PO Q24H \n13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n14. PredniSONE 5 mg PO DAILY \nPlease start this on ___. Ranitidine 150 mg PO DAILY \n16. Tacrolimus 1 mg PO QAM \n17. Tacrolimus 1 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n#Fatigue\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nThank you for coming to ___ for your care. Please read the \nfollowing instructions carefully:\n\nWhy was I admitted to the hospital?\n-You were admitted to the hospital because you have been having \nshortness of breath with activities, general feelings of \nweakness, and pain throughout her back and abdomen.\n\nWhat was done for me while I was here?\n-We performed several blood tests and a CAT scan to ensure that \nthere are no serious or life-threatening causes of your symptoms\n-We believe that the issues you are currently having will be \nbetter addressed with the doctors in ___\n\nWhat do I need to do when I leave the hospital?\n-Please take your medications as listed below\n-Tomorrow, please take 7.5mg of prednisone, and you can resume \nyour normal dose of 5mg daily on ___\n-Please keep your appointments as listed below\n-It is very important that you continue to follow with the \ncardiologist due to your history of pericarditis. The \ninformation to contact their office is below\n\nWe wish you the best with your care!\n- Your ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "R5383", "Z944", "D61818", "N179", "I252", "I2510", "Z634", "K589", "M810", "Z87310", "F909", "F319", "F1021", "Z86718", "E7849", "R911", "J449", "Z981", "Z87891", "I509", "R9431", "D509" ]

[ "R5383: Other fatigue", "Z944: Liver transplant status", "D61818: Other pancytopenia", "N179: Acute kidney failure, unspecified", "I252: Old myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z634: Disappearance and death of family member", "K589: Irritable bowel syndrome without diarrhea", "M810: Age-related osteoporosis without current pathological fracture", "Z87310: Personal history of (healed) osteoporosis fracture", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F319: Bipolar disorder, unspecified", "F1021: Alcohol dependence, in remission", "Z86718: Personal history of other venous thrombosis and embolism", "E7849: Other hyperlipidemia", "R911: Solitary pulmonary nodule", "J449: Chronic obstructive pulmonary disease, unspecified", "Z981: Arthrodesis status", "Z87891: Personal history of nicotine dependence", "I509: Heart failure, unspecified", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "D509: Iron deficiency anemia, unspecified" ]

[ "N179", "I252", "I2510", "Z86718", "J449", "Z87891", "D509" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms\n \nAttending: ___\n \nChief Complaint:\nchest pain, difficulty swallowing\n \nMajor Surgical or Invasive Procedure:\nEGD with esophageal and gastric biopsies (___) \n\n \nHistory of Present Illness:\n___ yo M primary biliary cirrhosis s/p orthotopic liver\ntransplant, prior hemorrhagic pericarditis with tamponade\nrequiring pericardial window ___, gastritis, prior DVT, HLD,\nand bipolar disorder, who presents with pain with swallowing for\nthe past 4 days.\n\nFour days prior to presentation, the patient was eating a\ncheesesteak when he noticed a stabbing pain in his mid-chest \nwith\nswallowing both liquids and solids. He describes the pain as a\nstabbing sensation worse with hot things that spreads throughout\nhis chest bilaterally and radiates to his right arm.\nMaalox/Benadryl/lidocaine makes the pain somewhat better. The\npain is not worse with lying down. He reports that he has woken\nup with chest pain in the middle of the night before, but not\nwithin the last 4 days. He says that this pain is distinctly\ndifferent than his pain with his pericarditis and his MIs, and\ndoes not remember ever having experienced anything like this\npreviously. He takes a PPI daily. He has been able to tolerate\nPO with difficulty. He denies foreign body sensation. He\ncontacted his transplant hepatologist who recommended he present\nto the ED. Of note, he does report increase in SOB. Normally he\nis able to walk up several flights without difficulty, however\nrecently he becomes winded with 1 flight. Patient reports he has\na history of COPD but does not take any medications for it\nbecause he does not like them. He reports a history of CHF but\nhas not had any exacerbations since his liver transplant. \nPatient\nreports compliance with his immunosuppressives and denies oral\nthrush.\n\nAlso of note, about 2 weeks prior to presentation, he had a fall\nwhen he slipped on the floor. He does not remember having a\nheadstrike. Per patient, his PCP increased his prednisone to 60\nmg/day after this incident, with a taper of 5 days of 60, 5 days\nof 40, 5 days of 20. His last dose of 20 mg was the day prior to\npresentation, and he is now taking 5 mg daily. Per chart review,\nhe picked up 20 mg of Prednisone from his pharmacy on ___.\nHe denies fever, chills, cough, and N/V, though he had an\nelevated temp of 99.9 on the evening prior to presentation. He\nhas chronic non-bloody diarrhea that he reports as pudding to\nwatery, and has ___ bowel movements/day normally. No recent\nchanges in bowel movements.\n\nCardiology clinic outpatient notes significant for a\nhospitalization in ___ for sharp, tight chest pain\nthat radiated to L shoulder not associated with exertion with\nendoscopy showing diffuse gastritis. At that time, his ASA was\nstopped, and he was discharged on PPI and sucralfate with an\nincrease in his colchicine. \n\nIn the ED:\nInitial vital signs were notable for: \nPain ___ T 97.4 HR 100 BP 147/84 RR 20 100% RA \n \nExam notable for:\nDry mucous membranes\nNontender neck on palpation\n\nLabs were notable for:\nCrea of 1.5 (baseline 1.2-1.5), BUN 15\nAlt 20; Ast 19; AP 203; Tbili 1.3; Alb 3.7\nWBC 6.5 (N79.0; L11.0) ; H/H ___ platelets 60\n___ 11.4; PTT 23.9; INR 1.1\n\nStudies performed include:\n___ CXR\nFINDINGS:Streaky left basilar opacities are most likely due to\natelectasis and/or scarring. The lungs are otherwise clear\nwithout consolidation, effusion, or pneumothorax. There is\nbiapical scarring again noted. Cardiomediastinal silhouette is\nstable noting prominent fat along the mediastinum superiorly. \nThere is no pneumomediastinum. No free intraperitoneal air. No\nacute osseous abnormalities. \nIMPRESSION:No acute cardiopulmonary process. \n\nPatient was given: 1L NS bolus and 1L LR\nStarted on full liquid diet\n\nConsults: Hepatology \nRecommended\n - Labs\n - please obtain barium study (Esophagus) to evaluate for\nstrictures\n - CXR\n - If above work-up is negative will likely need EGD tomorrow\n - Will need daily tacro levels\n - Please admit to ET under Dr. ___\n\n___ on transfer: T97.8 BP 117 / 80 HR 74 RR16 99 RA \n\nUpon arrival to the floor, the patient was eating dinner\ncomfortably, NAD. He reports increased pain with hot liquids. \n\n \nPast Medical History:\n-Primary biliary cirrhosis: s/p orthotopic liver transplant \n-Neutropenia c/b neutropenic fever \n-DVT ___ \n-Prior Alcohol abuse \n-Hemorrhagic pericarditis: c/b tamponade s/p pericardial window\n___, recurrent pericarditis ___. \n-Positive PPD, s/p INH\n-Hyperlipidemia \n-Osteoporosis \n-Bipolar disorder \n-ADHD \n-Hemorrhoids \n \nSocial History:\n___\nFamily History:\nMother- thyroid disease\nFather- head and neck cancer (deceased)\n\n \nPhysical Exam:\nAdmission Physical\n==================\nVITALS:97.8 PO 117 / 80 HR 74 RR16 99 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,\nedentulous. Oropharynx is clear.\nNECK: No cervical lymphadenopathy. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. Tenderness to palpation at the xyphoid\nprocess and the right lower ribs.\nLUNGS: Clear to auscultation bilaterally in apices, crackles in\nthe bases bilaterally that clear with deep breaths. No wheezes,\nrhonchi or rales. No increased work of breathing.\nBACK: No CVA tenderness.\nABDOMEN: Normal bowels sounds, non distended, tenderness to\npalpation in the epigastrium. \nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. No rash.\nNEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal\nsensation. \n\nDischarge Physical\n==================\nVITALS: ___ 0740 Temp: 98.0 PO BP: 111/78 HR: 91 RR: 18 O2\nsat: 96% O2 delivery: Ra \nGENERAL: Laying in bed, NAD, pleasant\nHEENT: sclerae anicteric, MMM, poor dentition\nCARDIAC: RRR, nl s1/s2, no m/r/g/t\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi, \nor\nrales. No increased work of breathing.\nABDOMEN: Normal bowel sounds, non distended, non-tender. \nEXTREMITIES: warm, well-perfused, no clubbing, cyanosis, or \nlower\nextremity edema. \nNEUROLOGIC: AOx3, no facial asymmetry, moving all extremities \n \nPertinent Results:\nADMISSION LABS\n___ 09:00AM BLOOD WBC-6.5 RBC-5.38 Hgb-15.2 Hct-45.2 MCV-84 \nMCH-28.3 MCHC-33.6 RDW-15.1 RDWSD-45.4 Plt Ct-60*\n___ 09:00AM BLOOD Neuts-79.0* Lymphs-11.0* Monos-8.2 \nEos-0.6* Baso-0.3 Im ___ AbsNeut-5.10 AbsLymp-0.71* \nAbsMono-0.53 AbsEos-0.04 AbsBaso-0.02\n___ 09:00AM BLOOD ___ PTT-23.9* ___\n___ 09:00AM BLOOD Glucose-101* UreaN-15 Creat-1.5* Na-136 \nK-4.0 Cl-98 HCO3-24 AnGap-14\n___ 09:00AM BLOOD ALT-20 AST-19 AlkPhos-203* TotBili-1.3\n___ 09:00AM BLOOD Albumin-3.7\n___ 11:55PM BLOOD Calcium-8.0* Phos-2.1* Mg-2.5\nPERTINENT INTERVAL LABS\n___ 05:17AM BLOOD ALT-15 AST-12 LD(LDH)-250 AlkPhos-167* \nTotBili-0.7\n___ 05:17AM BLOOD CK-MB-<1 cTropnT-<0.01\n___ 02:41PM URINE bnzodzp-NEG opiates-NEG cocaine-NEG \namphetm-NEG oxycodn-NEG mthdone-NEG\nDISCHARGE LABS\n___ 05:30AM BLOOD WBC-2.9* RBC-4.47* Hgb-12.7* Hct-37.0* \nMCV-83 MCH-28.4 MCHC-34.3 RDW-15.5 RDWSD-45.8 Plt Ct-78*\n___ 05:30AM BLOOD Neuts-46.3 ___ Monos-9.0 Eos-2.8 \nBaso-1.0 Im ___ AbsNeut-1.34* AbsLymp-1.12* AbsMono-0.26 \nAbsEos-0.08 AbsBaso-0.03\n___ 05:30AM BLOOD Glucose-81 UreaN-12 Creat-1.2 Na-139 \nK-3.6 Cl-104 HCO3-24 AnGap-11\n\n___ 05:30AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.0\n___ 05:30AM BLOOD 25VitD-20*\n___ 05:30AM BLOOD tacroFK-5.1\nMICROBIOLOGY\nBlood Culture ___: No Growth (Final)\nIMAGING AND STUDIES \n___ CXR\nStreaky left basilar opacities are most likely due to \natelectasis and/or \nscarring. The lungs are otherwise clear without consolidation, \neffusion, or pneumothorax. There is biapical scarring again \nnoted. Cardiomediastinal silhouette is stable noting prominent \nfat along the mediastinum superiorly. There is no \npneumomediastinum. No free intraperitoneal air. No acute \nosseous abnormalities. \n\n___ EGD\nGastritis (biopsied)\nUlcers in distal esophagus (biopsied)\n\n___ CXR PA and LAT\nComparison to ___. New subtle parenchymal opacities \nat the left and the right lung basis could reflect recent or \ndeveloping pneumonia.\nStable normal size of the heart. Moderate widening and \nrelatively dense\nmediastinum is likely caused by a mild degree of mediastinal \nlipomatosis, as documented on a previous CT examination from ___.\nNo pleural effusions. No pneumothorax.\n\n \nBrief Hospital Course:\nPATIENT SUMMARY\n___ yo M primary biliary cirrhosis s/p orthotopic liver \ntransplant, prior hemorrhagic pericarditis with tamponade \nrequiring pericardial window ___, gastritis, prior DVT, HLD, \nand bipolar disorder, who presented with pain with swallowing, \nfound to have HSV esophagitis. \n\nACUTE ISSUES\n============\n# HSV Esophagitis \nPresented with several days of pain with swallowing, with prior \nepisode of central chest pain that was thought to be a \ncostochondritis flare but my have been esophagitis. Per EGD, \nesophageal mucosa demonstrated evidence of friable with punched \nout lesions. Given recent prednisone burst two weeks prior to \nadmission, patient was likely even more immunocompromised than \nbaseline. Preliminary pathology was consistent with HSV \nesophagitis, so the patient was started on acyclovir with plan \nto complete a course for 3 weeks with outpatient transplant ID \nfollowup. Of note, gastric mucosa also showed non-specific \ninflammation and was biopsied. Final pathology results are \npending.\n\n# Acute Kidney Injury \n# Moderate Malnutrition\nLikely difficulty swallowing over past few weeks has caused \ndecreased PO intake and contributed to moderately malnourished \nstate as well as ___. Patient's ___ was prerenal and improved \nwith fluid administration. \n\n# Thrombocytopenia\nChronic and stable during hospitalization.\n\n# s/p Liver Transplant\nPatient with PBC status post liver transplant in ___ \ncomplicated by recurrent pericarditis requiring pericardial \nwindow. Alk phos elevated consistent with outpatient levels and \nelevated anti-mitochondrial Ab. Patient currently stable on \ntacrolimus and prednisone. \n\nCHRONIC ISSUES\n==============\n# Gastroparesis \nPatient with history of gastroparesis per chart. He initially \ndenied nausea and vomiting but was thought to contribute to the \npatients esophageal pain as above. \n\n# Bipolar Disorder\nContinued on home wellbutrin.\n\n# History of Pericarditis\nNo rub on exam. No positional change in chest pain. Holding home \nASA in setting of esophagitis/gastritis. Home colchicine \ninitially decreased to daily instead of BID given ___. \n\n# Hypercholesterolemia\nContinued home atorvastatin. \n\nTRANSITIONAL ISSUES\n[ ]HSV Esophagitis: patient to take acyclovir 800mg TID for 3 \nweeks ending on ___\n[ ]New Meds: See Med sheet.\n[ ]Consider outpatient evaluation for esophageal dysmotility if \ncontinuing to have symptoms of nausea and vomiting \n[ ]Patient to have twice weekly CBC to monitor leukopenia, \ncoordinated through liver clinic\n\n#CODE: Full (presumed)\n#CONTACT: ___ - Sister - ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 650 mg PO DAILY \n2. Colchicine 0.6 mg PO BID hx of pericarditis \n3. Tacrolimus 1 mg PO Q12H \n4. PredniSONE 5 mg PO DAILY \n5. Gabapentin 600 mg PO BID \n6. Atorvastatin 10 mg PO QPM \n7. Vitamin D ___ UNIT PO 1X/WEEK (FR) \n8. DICYCLOMine 20 mg PO QID \n9. Ranitidine 150 mg PO BID \n10. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID:PRN \nodynophagia \n11. Ondansetron 4 mg PO Q8H:PRN nausea secondary to \ngastroparesis \n12. BuPROPion XL (Once Daily) 150 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Acyclovir 800 mg PO Q8H \nRX *acyclovir 800 mg 1 tablet(s) by mouth three times a day Disp \n#*55 Tablet Refills:*0 \n3. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n4. Sucralfate 1 gm PO QID \nRX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp \n#*120 Tablet Refills:*0 \n5. TraMADol 25 mg PO BID:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth twice a day \nDisp #*3 Tablet Refills:*0 \n6. Ursodiol 300 mg PO TID \nRX *ursodiol 300 mg 1 capsule(s) by mouth three times a day Disp \n#*90 Capsule Refills:*0 \n7. Atorvastatin 10 mg PO QPM \n8. BuPROPion XL (Once Daily) 150 mg PO DAILY \n9. Colchicine 0.6 mg PO BID hx of pericarditis \n10. DICYCLOMine 20 mg PO QID \n11. Gabapentin 600 mg PO BID \n12. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID:PRN \nodynophagia \n13. Ondansetron 4 mg PO Q8H:PRN nausea secondary to \ngastroparesis \n14. PredniSONE 5 mg PO DAILY \nRX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n15. Ranitidine 150 mg PO BID \n16. Tacrolimus 1 mg PO Q12H \nRX *tacrolimus [Astagraf XL] 1 mg 1 capsule(s) by mouth every \ntwelve (12) hours Disp #*60 Capsule Refills:*0 \n17. Vitamin D ___ UNIT PO 1X/WEEK (FR) \n18. HELD- Aspirin 650 mg PO DAILY This medication was held. Do \nnot restart Aspirin until you you discuss further with your PCP\n\n \n___:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses\n=================\nHSV esophagitis\n___\ns/p Liver transplant\n\nSecondary Diagnoses\n===================\nBipolar Disorder\nPericarditis\nHypercholesterolemia\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!\n\nWHY DID YOU COME TO THE HOSPITAL?\n-You were having pain with swallowing\n\nWHAT HAPPENED TO YOU DURING YOUR HOSPITAL STAY?\n-We checked your esophagus (the tube that brings food from your \nmouth to your stomach) and found that it was infected\n-We gave you medication to help control the pain from the \ninfection, as well as to treat the virus and to assist in \nhealing\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?\n-Take all of your medications as prescribed\n-Keep all of your appointments as schedule\n\nWe wish you the best!\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K208", "N179", "D696", "E440", "Z944", "I319", "B0089", "E7800", "F319", "K3184", "Z6823", "K2970", "F1011", "F909", "M810", "J449", "I509", "Z86718", "Z9181", "Z87891" ]

[ "K208: Other esophagitis", "N179: Acute kidney failure, unspecified", "D696: Thrombocytopenia, unspecified", "E440: Moderate protein-calorie malnutrition", "Z944: Liver transplant status", "I319: Disease of pericardium, unspecified", "B0089: Other herpesviral infection", "E7800: Pure hypercholesterolemia, unspecified", "F319: Bipolar disorder, unspecified", "K3184: Gastroparesis", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "K2970: Gastritis, unspecified, without bleeding", "F1011: Alcohol abuse, in remission", "F909: Attention-deficit hyperactivity disorder, unspecified type", "M810: Age-related osteoporosis without current pathological fracture", "J449: Chronic obstructive pulmonary disease, unspecified", "I509: Heart failure, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z9181: History of falling", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "D696", "J449", "Z86718", "Z87891" ]

[]