MRN: Name:  Age: 70 y.o. Admit Date: 7/14/2022  3:58 PM Discharge Date:  7/21/2022  Admitting Physician: Dr.  Discharge Physician: MD   Discharge Diagnosis: Principal Problem:   Acute blood loss anemia Active Problems:   Acute on chronic respiratory failure with hypoxia   COVID-19       HPI AND HOSPITAL COURSE   History of Present Illness:  As per admission H&P, "Patient is a 70 y.o. male with a history below admitted for Acute blood loss anemia. Pt came in with complaints of abnormal labs. Had been having several weeks of poor po intake, nausea, diarrhea, black stools, general weakness. Nothing made better / worse. Recently completed chemo 2+ weeks ago. States he has required blood transfusions several times. Discussed with er and will admit "   Hospital Course: Patient, is a 70 y.o. male who presented with anemia.  He was managed for the following:   * Acute blood loss anemia Anemia - Hgb 5.6 on admission, improved s/p RBC transfusions.  Now stable 7-8 g/dL.  EGD showed duodenal erosions, no active bleeding.  Hematology was consulted.  Probable multifactorial, from recent chemotherapy, possible blood loss.   Hgb was fluctuating 7-8 g/dL. He was transfused one additional unit of blood before discharge home.  Will need reevaluated outpatient for possible colonoscopy.  Holding eliquis.       Acute on Chronic Hypoxic Respiratory Failure - due to COVID-19 pneumonia and symptomatic anemia.  CT thorax with loculated left pleural effusion, left lung atelectasis.  Home O2 requirement 3L.  Pulmonary medicine involved.  Completed remdesivir, decadron 5 days. He improved to his baseline 3L.   CTS consulted, recommended against drainage of loculated fluid.    Oncology following.  On outpatient chemo.     Acute metabolic encephalopathy - due to acute UTI, hospital delirium.  CT head no acute pathology. . Avoid sedating meds.  Mental status improved, no longer confused.     Acute UTI -E.coli on urine culture.  Complete ceftin on discharge.     History atrial flutter - hold eliquis due to anemia and thrombocytopenia.  Follow-up outpatient.      Left chest wall fluid collection - present since previous surgery.  CTS consulted and recommended against drainage.  Patient also declined any drainaged.  Non tender, no erythema.       Physical Exam on the Date of Discharge: Blood pressure (!) 91/63, pulse (!) 128, temperature 98.1 °F (36.7 °C), temperature source Oral, resp. rate 17, height 6' (182.9 cm), weight 116.7 kg (257 lb 3.2 oz), SpO2 96 %. General - NAD, appears stated age, obese HEENT - EOMI, PER, MMM,  Chest - lungs clear bilaterally,  Heart - RRR, NS1S2,  Abdomen - Soft, non-tender, n Extremities - warm, Psych - AAOx3, affect appropriate Skin - dry   Discharge Condition: improved   Disposition: home   CONSULTS DURING ADMISSION:  IP CONSULT TO ONCOLOGY/HEMATOLOGY IP CONSULT TO ONCOLOGY/HEMATOLOGY IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK IP CONSULT TO PULMONOLOGY IP CONSULT TO CARDIOTHORACIC SURGERY IP CONSULT TO SOCIAL WORK   IMAGING / PROCEDURES / RESULTS:     CT Head WO Contrast   Result Date: 7/18/2022 PROCEDURE INFORMATION: Exam: CT Head Without Contrast Exam date and time: 7/18/2022 5:02 AM Age: 70 years old Clinical indication: Altered mental status/memory loss; Confusion or disorientation; Patient HX: AMS, confusion. No contrast. HX dm, hld, lung cancer, HTN. Ct2. Bi TECHNIQUE: Imaging protocol: Computed tomography of the head without contrast. Total images: 372 Radiation optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction. COMPARISON: CT HEAD WO CONTRAST 5/27/2022 10:20 AM FINDINGS: Brain: Global brain atrophy is present. Cerebral ventricles: No ventriculomegaly. Paranasal sinuses: Visualized sinuses are unremarkable. No fluid levels. Mastoid air cells: Visualized mastoid air cells are well aerated. Bones/joints: Unremarkable. No acute fracture. Soft tissues: Unremarkable. Other findings: Benign appearing dural calcifications are present. Dense paranasal sinusitis.    IMPRESSION: 1. Dense paranasal sinusitis. 2. Global brain atrophy is present. No acute intracranial abnormality. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 07/18/2022 05:10 AM   CT Thorax WO   Result Date: 7/19/2022 PROCEDURE INFORMATION: Exam: CT Chest Without Contrast; Diagnostic Exam date and time: 7/19/2022 10:06 PM Age: 70 years old Clinical indication: Abnormal findings; Abnormal radiologic exam of lung or chest; Patient HX: Pneumonia complication. HX, copd, mediastinal mass, nonsmall cell carcinoma lt lung TECHNIQUE: Imaging protocol: Diagnostic computed tomography of the chest without contrast. Radiation optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction. COMPARISON: CT THORAX WO 6/24/2022 8:24 AM FINDINGS: Tubes, catheters and devices: Right internal jugular port-type catheter terminates at the cavoatrial junction. Lungs: This appears situated in the fluoro space although an infected left upper lobe bulla cannot be entirely excluded. Remainder of the left lung is severely atelectatic. There is elevation of the left hemidiaphragm compatible with atelectasis in the left lung. Centrilobular and paraseptal emphysema is evident. No airspace disease in the right lung. There is narrowing the left upper and lower lobe bronchi. Pleural spaces: In the left upper chest, there is a thin-walled cavity which contains fluid, not significantly changed from the prior exam. Low volume left pleural effusion demonstrates features multifocal loculation. Trace right pleural effusion is new from prior. Heart: Extensive coronary artery hyperdensity could be calcification and/or stent material. Mediastinal surgical clips and vascular markers suggest prior myocardial revascularization. Low-attenuation intra cardiac blood pool is concerning for severe anemia. Heart is enlarged and displaced into the left lower chest. Lymph nodes: Unremarkable. No enlarged lymph nodes. Vasculature: Mild to moderate thoracic aortic calcification is evident. Adrenal glands: Normal adrenals bilaterally. Bones/joints: Unremarkable. No acute fracture. Soft tissues: Deep to the left pectoral muscle, there is a thick walled fluid collection measuring 10.5 x 8.8 x 2.7 cm. No convincing communication with the pleural space is evident. There is also edema in the left chest wall which is somewhat progressed from prior.    IMPRESSION: 1. Exam demonstrates persistent loculated left pleural fluid predominantly in the superior posterior chest. There has been interval worsening of atelectasis in the left lung with elevation of the left hemidiaphragm and translation of the heart into the left lower chest. Bronchi appeared narrowed but no definite endobronchial occlusion appreciated. 2. There is an increasing left subpectoral fluid collection with edema in the left chest wall. Communication with the pleural space is not identified. Correlate with clinical circumstances. Aspiration of this collection may be helpful for diagnosis. 3. Severe background centrilobular and paraseptal emphysema. 4. Probable severe anemia. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 07/19/2022 10:56 PM   CT Thorax WO   Result Date: 6/25/2022 PROCEDURE INFORMATION: Exam: CT Chest Without Contrast; Diagnostic Exam date and time: 6/24/2022 8:24 AM Age: 70 years old Clinical indication: Malignant neoplasm of overlapping sites of unspecified bronchus and lung; Condition or disease; Lung condition and disease; Cancer of the lung; Left; Follow-up oncological assessment; Prior surgery; Surgery date: 6+ months; Surgery type: Cabg; Patient HX: Lung cancer TECHNIQUE: Imaging protocol: Diagnostic computed tomography of the chest without contrast. Radiation optimization: All CT scans at this facility use at least one of these dose optimization techniques: automated exposure control; mA and/or kV adjustment per patient size (includes targeted exams where dose is matched to clinical indication); or iterative reconstruction. COMPARISON: CT THORAX WO 5/27/2022 10:25 AM FINDINGS: Tubes, catheters and devices: Right jugular MediPort terminates at the atrial caval junction. Thyroid: Thyroid gland is heterogenous and appears to contain several nodules. Follow-up with thyroid ultrasound. Lungs: Left medial apical mass measures 7.3 x 3.0 cm on today's exam; 6.0 x 3.7 cm on the prior study. These differences are likely due to slight alterations technique. Visibly, the lesion is not appear to be substantively changed. Portions of lingula and left lower lobe are surgically absent. Diffuse ground-glass infiltrates of the bilateral lungs show no interval improvement. Pleural spaces: Left pleural effusion is diminished in volume. There is consolidation with air bronchograms in the left lower lobe with evidence of developing central necrosis at this time. Heart: Heart is enlarged. Lymph nodes: Unremarkable. No enlarged lymph nodes. Vasculature: Prominence of the main pulmonary trunk, right and left pulmonary arteries suggesting an element of chronic pulmonary hypertension. Calcifications within thoracic aorta, carotid and coronary arteries. There appears to be a stent within the abdominal aorta. Diaphragm: Sliding hiatal hernia. Gallbladder and bile ducts: Calcific stones and sludge within the lumen of the gallbladder. No worrisome dilation of the biliary tree. Bones/joints: Prior median sternotomy wires. Degenerative spondylosis, rotoscoliosis and facet arthropathy are identified within the spine. Soft tissues: Unremarkable. Other findings: Multiple cystic spaces especially toward the apices are once again seen.    IMPRESSION: 1. Left medial apical mass measures 7.3 x 3.0 cm on today's exam; 6.0 x 3.7 cm on the prior study. These differences are likely due to slight alterations in technique. Visibly, the lesion is not appear to be substantively changed. 2. Portions of lingula and left lower lobe appear to be surgically absent. 3. Left pleural effusion is diminished in volume. 4. Consolidation with air bronchograms in the left lower lobe with evidence of developing central necrosis at this time. 5. Diffuse ground-glass infiltrates of the bilateral lungs show no interval improvement. 6. Multiple cystic spaces especially toward the apices are once again seen. 7. Right jugular MediPort terminates at the atrial caval junction. 8. Thyroid gland is heterogenous and appears to contain several nodules. Follow-up with thyroid ultrasound. 9. Prominence of the main pulmonary trunk, right and left pulmonary arteries suggesting an element of chronic pulmonary hypertension. 10. Cholelithiasis. 11. Cardiomegaly. 12. Stent within the abdominal aorta. COMMENTS: Consistent with the Agency paper: In patients aged 35 years and older with an incidental thyroid nodule equal to or greater than 1.5 cm detected on CT, MRI or extrathyroidal US, further evaluation with dedicated thyroid US is recommended for patients with normal life expectancy and without comorbidities. For smaller nodules without suspicious features, no further evaluation or follow up is recommended. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 06/25/2022 02:54 PM   XR Portable Chest   Result Date: 7/21/2022                                                             Radiology  PATIENT NAME:                   MR#:   PROCEDURE DATE:  07/21/2022                       ACCOUNT#:  ACCESSION #:                           ROOM#:  ORDERING PHYS:  MD   EXAM:  Single portable view of the chest, 07/21/2022.  COMPARISON:  07/18/2022, 07/14/2022.  INDICATION:  Worsening of hypoxia, COVID positive  FINDINGS: Single portable view of the chest demonstrates stable appearance of the mediastinal and cardiac size.  Evidence of prior median sternotomy is noted.  Atherosclerotic calcification is seen at the aortic knob.  Right IJ single-lumen power port is noted.  Near complete opacification of the left hemithorax is again noted with slight improvement of aeration as compared to a prior exam.  The right lung is clear.  Pulmonary vasculatures are stable in appearance.  No acute osseous or soft tissue abnormality is identified.  Impression: 1.  Near complete opacification left hemithorax with slight interval improvement of aeration as compared to a prior exam.                  THIS IS AN ELECTRONICALLY VERIFIED REPORT                 7/21/2022 12:42 PM:  MD   MD  DD:  07/21/2022 TD:  07/21/2022 JOB #:                                      Radiology Page 1    of   1                                                          COPY   XR Portable Chest   Result Date: 7/18/2022 PROCEDURE INFORMATION: Exam: XR Chest Exam date and time: 7/18/2022 2:14 AM Age: 70 years old Clinical indication: Shortness of breath; Additional info: SOB, AMS TECHNIQUE: Imaging protocol: Radiologic exam of the chest. Views: 1 view. Total images: 2774 COMPARISON: CR XR PORTABLE CHEST 7/14/2022 5:16 PM FINDINGS: Tubes, catheters and devices: Port-A-Cath present. Lungs: Worsened opacification of nearly the entire left hemithorax, minimal apical aeration remaining. Question intervening partial pneumonectomy since CT of 06/24/2022. Otherwise, central airway obstructive process would be strongly favored, possibly mucous plug. Pulmonary vascular congestion of the right lung is worsened. Pleural spaces: Unremarkable. No pleural effusion. No pneumothorax. Heart/Mediastinum: Mediastinum shifted the left. Bones/joints: Changes of sternotomy are noted.    IMPRESSION: 1. Worsened opacification of nearly the entire left hemithorax, minimal apical aeration remaining. Question intervening partial pneumonectomy since CT of 06/24/2022. Otherwise, central airway obstructive process would be strongly favored, possibly mucous plug. 2. Pulmonary vascular congestion of the right lung is worsened. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 07/18/2022 03:20 AM   XR Portable Chest   Result Date: 7/14/2022 PROCEDURE INFORMATION: Exam: XR Chest Exam date and time: 7/14/2022 5:16 PM Age: 70 years old Clinical indication: Other: HX lung CA on chemo TECHNIQUE: Imaging protocol: Radiologic exam of the chest. Views: 1 view. COMPARISON: CT THORAX WO 6/24/2022 8:24 AM FINDINGS: Tubes, catheters and devices: Right-sided MediPort catheter identified with tip SVC RA junction. Tip is in good position. Lungs: Volume loss within the left hemithorax likely a combination of postsurgical changes from prior left lung resection in combination with probable partial collapse of the left mid and lower lung zone. There is evidence for perihilar and interstitial edema within the visualized right lung. Pleural spaces: Large left knee pleural effusion. There is no evidence for pneumothorax. Heart/Mediastinum: Heart size difficultTo assess . Bones/joints: Median sternotomy wires are identified.    IMPRESSION: Volume loss within the left hemithorax likely a combination of postsurgical changes from prior left lung resection in combination with probable partial collapse of the left mid and lower lung zone. There is evidence for perihilar and interstitial edema within the visualized right lung. THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY MD on 07/14/2022 06:21 PM     Procedure(s) (LRB): EGD (N/A)       LABS AT TIME OF DISCHARGE:   Lab Results Component Value Date   WBC 3.1 (L) 07/21/2022   HGB 7.6 (L) 07/21/2022   HCT 23.1 (L) 07/21/2022   MCV 90.3 07/21/2022     Lab Results Component Value Date   SODIUM 137 07/21/2022   POTASSIUM 5.1 (H) 07/21/2022   MAGNESIUM 1.6 (L) 07/14/2022   PHOSPHORUS 2.6 07/14/2022   CHLORIDE 104 07/21/2022   CO2 28 07/21/2022   GLUCOSE 102 07/21/2022   BUN 18 07/21/2022   CREATININE 1.0 07/21/2022   CALCIUM 8.7 07/21/2022   TBILIRUBIN 0.4 07/21/2022   DBILIRUBIN 0.1 05/26/2022   ALP 57 07/21/2022   AST 11 07/21/2022   ALBUMIN 2.8 (L) 07/21/2022     Lab Results Component Value Date   INR 1.3 (H) 07/21/2022   INR 4.6 (HH) 05/27/2022     Microbiology Results (last 14 days)    Procedure Component Value Units Date/Time   Urine Culture  (Abnormal)  (Susceptibility) Collected: 07/18/22 0448   Order Status: Completed Specimen: Reflexed from UA Updated: 07/20/22 0716     URINE CULTURE COLONY COUNT: >100K cfu/ml Escherichia coli.     URINE CULTURE Escherichia coli   Narrative:     NO KNOWN ALLERGIES   SARS-CoV-2, QL, PCR (Rapid) (Abnormal) Collected: 07/14/22 1839   Order Status: Completed Specimen: Throat Updated: 07/14/22 1937     SARS-CoV-2 RNA Detected      Comment:   Reference value:  Undetected   Testing was performed using the System.   Fact sheets for this Emergency Use Authorization (EUA) assay can be found at the following links:      Test Performed by: Lab Director: D.O.      Narrative:     Symptomatic?->No Indications (select all that apply)->Admission NO KNOWN ALLERGIES Called to and read back at 19:36 on 07/14/2022,    SARS-CoV-2, QL, PCR (Rapid)  (Abnormal) Collected: 07/14/22 1712   Order Status: Completed Specimen: Throat Updated: 07/14/22 1817     SARS-CoV-2 RNA Detected      Comment:   Reference value:  Undetected   Testing was performed using the System.   Fact sheets for this Emergency Use Authorization (EUA) assay can be found at the following links:        Test Performed by: Lab Director: D.O.      Narrative:     Symptomatic?->No Indications (select all that apply)->Admission NO KNOWN ALLERGIES Called to and read back at 18:17 on 07/14/2022,    SARS-CoV-2, QL, PCR (Rapid)  Collected: 07/14/22 1430   Order Status: Sent Specimen: Throat         MEDICATIONS AND ORDERS   Current Discharge Medication List   START taking these medications   Details pantoprazole (PROTONIX) 40 mg DR tablet Take 1 Tablet by mouth Twice a day. Qty: 60 Tablet, Refills: 1   Associated Diagnoses: Acute blood loss anemia   cefUROXime (CEFTIN) 250 mg tablet Take 1 Tablet by mouth Twice a day for 3 days. Indications: inflammation of the bladder Qty: 6 Tablet, Refills: 0   Associated Diagnoses: Acute cystitis without hematuria     CONTINUE these medications which have CHANGED   Details amiodarone (CORDARONE) 200 mg tablet Take 1 Tablet by mouth Once Daily. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: Atypical atrial flutter     CONTINUE these medications which have NOT CHANGED   Details magnesium chloride (SLOW-MAG) 64 mg DR tablet Take 2 Tabs by mouth Twice a day for 30 days. Qty: 120 Tablet, Refills: 1   Associated Diagnoses: Hypomagnesemia   metoprolol (TOPROL XL) 50 mg Take 1 Tablet by mouth Once Daily. Qty: 30 Tablet, Refills: 0   Associated Diagnoses: S/P CABG (coronary artery bypass graft)   furosemide (LASIX) 40 mg tablet Take 1 Tablet by mouth Once daily as needed (if greater than 5lbs weight gain in 1-2 days.  increase lower extremity swelling.). Take along with scheduled morning dose of lasix. Qty: 30 Tablet, Refills: 0   Associated Diagnoses: Acute on chronic respiratory failure with hypoxia and hypercapnia   mupirocin calcium (BACTROBAN) 2 % Apply to each nostril twice a day for 5 days. Qty: 1 Each, Refills: 0   Associated Diagnoses: MRSA (methicillin resistant Staphylococcus aureus) colonization   midodrine (PROAMATINE) 5 mg tablet Take 1 Tablet by mouth Three times a day as needed (for systolic blood pressure less than 90). Qty: 30 Tablet, Refills: 0   Associated Diagnoses: Hypotension   nystatin (MAGIC MOUTHWASH) Take 10 mL by mouth Four times a day. Qty: 480 mL, Refills: 1   Associated Diagnoses: Non-small cell cancer of left lung   aspirin 81 mg chewable tablet Take 1 Tablet by mouth Once Daily. Qty: 90 Tablet, Refills: 3   Associated Diagnoses: S/P CABG (coronary artery bypass graft)   lidocaine-diphenhyd-al-mag-sim (FIRST MOUTHWASH) 200-25-400-40 mg/30 mL suspension Take 10 mL by mouth Four times a day. Qty: 480 mL, Refills: 3   Associated Diagnoses: Non-small cell cancer of left lung   rosuvastatin (CRESTOR) 20 mg tablet Take 1 Tablet by mouth At bedtime. Qty: 90 Tablet, Refills: 3   ondansetron HCL (ZOFRAN) 8 mg tablet Take 1 Tablet by mouth As directed. Take 1 tablet twice a day for 3 days following chemotherapy, then every 8 hours as needed for nausea. Qty: 60 Tablet, Refills: 5   Associated Diagnoses: Non-small cell cancer of left lung; Encounter for antineoplastic chemotherapy   prochlorperazine (COMPAZINE) 10 mg tablet Take 1 Tablet by mouth Every 6 hours as needed for Nausea or Vomiting. Use 1st Qty: 120 Tablet, Refills: 2   Associated Diagnoses: Non-small cell cancer of left lung; Encounter for antineoplastic chemotherapy   lidocaine-prilocaine (EMLA) cream Apply dime size amount to site 1 hour prior to appointment time. Qty: 30 g, Refills: 5   Associated Diagnoses: Non-small cell cancer of left lung; Encounter for antineoplastic chemotherapy   ipratropium-albuteroL (DUO-NEB) 0.5 mg-3 mg(2.5 mg base)/3 mL nebulizer solution Take 3 mL by nebulization Every 4 hours while awake. Qty: 90 Each, Refills: 0   Associated Diagnoses: Acute exacerbation of chronic obstructive pulmonary disease (COPD)   ferrous sulfate 325 mg (65 mg iron) DR tablet Take 325 mg by mouth Daily.   nitroglycerin (NITROSTAT) 0.4 mg SL tablet Take 1 Tablet sublingually As needed. Qty: 25 Tablet, Refills: 3   Associated Diagnoses: Coronary artery disease involving native coronary artery of native heart without angina pectoris   umeclidinium 62.5 mcg/actuation DsDv Take 1 Puff by inhalation Daily.   mometasone/formoterol (DULERA IN) Take 2 Puffs by inhalation Twice a day.   albuterol sulfate (PROAIR RESPICLICK) 90 mcg/actuation inhaler Take 2 Puffs by inhalation Every 4 hours as needed.   albuterol (PROVENTIL) 2.5 mg /3 mL (0.083 %) nebulization Take 0.5 Vials by nebulization Every 4 hours as needed for Wheezing.   Fexofenadine (ALLEGRA) 180 mg tablet Take 180 mg by mouth Daily.   latanoprost (XALATAN) 0.005 % 1 Drop At bedtime.   roflumilast (DALIRESP) 500 mcg tablet Take 500 mcg by mouth Daily.   tamsulosin (FLOMAX) 0.4 mg capsule Take 1 capsule by mouth every day.   Associated Diagnoses: HLD (hyperlipidemia); HTN (hypertension); Dizzy; CAD (coronary artery disease); Other specified forms of chronic ischemic heart disease; Other dyspnea and respiratory abnormality   pioglitazone-metFORMIN 15-850 mg Tab Take 1 Tab by mouth Twice a day.     STOP taking these medications     apixaban (ELIQUIS) 5 mg tablet Comments:  Reason for Stopping:        omeprazole (PRILOSEC) 20 mg DR capsule Comments:  Reason for Stopping:        cefdinir (OMNICEF) 300 mg capsule Comments:  Reason for Stopping:            Discharge Procedure Orders CBC Standing Status: Future Standing Exp. Date: 07/21/23   Follow up with your PCP,   Order Specific Question Answer Comments Follow up when? 1 week     Follow-Up with Cardiology; 2 weeks   Order Specific Question Answer Comments Follow up with whom? Cardiology   Follow up when? 2 weeks     Follow-Up with Oncology; 1 week   Order Specific Question Answer Comments Follow up with whom? Oncology   Follow up when? 1 week     Follow-Up with GI; 1 week   Order Specific Question Answer Comments Follow up with whom? GI   Follow up when? 1 week     Follow-Up with Pulmonary; 1 week   Order Specific Question Answer Comments Follow up with whom? Pulmonary   Follow up when? 1 week       PCP PCP:   DO    Future Appointments Date Time Provider Department Center 8/19/2022  9:10 AM MD CARDA None 8/22/2022  2:45 PM APRN CARDA None 10/24/2022  2:00 PM APRN None