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rntc

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mm-icd-visit

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nVisual hallucinations\n \nMajor Surgical or Invasive Procedure:\nN/A\n\n \nHistory of Present Illness:\n___ male with ___ disease, dyslipidemia, and a\nhistory of prostate cancer (s/p prostatectomy) who was referred\nto the ED by his neurologist for worsening gait, falls, and\nvisual hallucinations. \n\nThe following history is taken from chart review: \n\nThe patient was seen by his neurologist on ___ at which time he\nwas noted to have visual hallucinations and worsening gait\nfreezing. For his gait freezing, his mirapex was increased by\n0.125 mg every week to a goal dose of 0.75 mg t.i.d. He\nsuccessfully up-titrated the medicine to 0.75/0.625/0.625 but\nbegan to have visual hallucinations and confusion so on ___ his\nneurologist recommended decreasing the dose to 0.625 TID. \nDespite\nthe changes to his Mirapex, the patient's daughter has noted\nprogressive gait stiffness and increased difficulty standing.\nThis has resulted in difficulty with simply getting to the\nbathroom leading to episodes of incontinence. A UA performed on\n___ was reassuring. \n\nOn the day of presentation to the hospital, the patient began to\nexperience visual hallucinations of a motor cross race in his\nbackyard. He subsequently had a fall while transferring from the\ncouch to a chair. His wife was unable to get him off the floor.\nThe fall was witnessed and there was no head strike. Per the\npatient's wife, his gait has acutely worsened over the past 24\nhours to the point where he has been unable to ambulate on his\nown. The patient's daughter called his neurologist who\nrecommended presentation to the ED. \n\nIn the ED, the patient was afebrile, HRs ___, normotensive, and\nSpO2 100% RA. On exam he was noted to have cogwheeling of upper\nextremities and decrease ___ strength. Labs were remarkable for a\nnegative urine and serum tox, Na 132, K 5.8 (hemolyzed and no \nEKG\nchanges), negative troponin, normal LFTs, unremarkable CBC. \nChest\nXray showed no acute process and CTH was reassuring. He was\nevaluated by neurology who recommended admission to medicine for\nfailure to thrive, to continue the patient's home medications,\nand complete a toxo-metabolic workup. The patient was given his\nhome pramipexole and pravastatin before he was admitted. \n\nOn arrival to the floor, the patient is comfortable in bed. He \nis\nnot accompanied by family on my interview. He knows that he is \nin\nthe hospital and that it is ___. He is not sure why he is here\nand begins to tell me about a party in his house with a motor\ncross race in his backyard. When I asked him about his fall, he\nmentions that he has not had a fall for ___ years. He denies any\nfevers, chills, cough, chest pain, abdominal pain, nausea,\ndiarrhea, or dysuria. \n\nREVIEW OF SYSTEMS:\n==================\nPer HPI, otherwise, 10-point review of systems was within normal\nlimits.\n\n \nPast Medical History:\n___ disease\n___ Body Dementia \ndyslipidemia \nprostate cancer (s/p prostatectomy)\n \nSocial History:\n___\nFamily History:\nHis mother died at age ___ of \"old age.\"\nHis father died of prostate cancer at ___. He has an older \nsister\n(age ___ and a younger sister (age ___. He has a younger \nbrother\n(age ___. As noted, he has 2 daughters. There is no family\nhistory of neurologic illness or dementia. There is no family\nhistory of neurodevelopmental mental disorders such as learning\ndisability or ADHD. There is no family history of psychiatric\nproblems.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: reviewed in OMR \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. No\nmurmurs/rubs/gallops.\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. cogwheel UE b/l. Increased tone\nin LEs, ___ strength b/l ___. Normal sensation.\n\nDISCHARGE PHYSICAL EXAM\n======================\n24 HR Data (last updated ___ @ 2340)\n Temp: 97.7 (Tm 98.4), BP: 130/80 (130-153/80-90), HR: 80\n(80-104), RR: 18 (___), O2 sat: 100% (95-100), O2 delivery: Ra \n\n\nGENERAL: In no acute distress. Talking very quietly.\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.\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: AOx3. CN2-12 intact. cogwheel UE b/l. Increased tone\nin LEs, ___ strength b/l ___. Normal sensation.\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 10:30PM BLOOD WBC-8.6 RBC-4.03* Hgb-12.8* Hct-38.2* \nMCV-95 MCH-31.8 MCHC-33.5 RDW-13.0 RDWSD-45.2 Plt ___\n___ 10:30PM BLOOD Neuts-48.1 ___ Monos-15.9* \nEos-2.0 Baso-0.6 Im ___ AbsNeut-4.13 AbsLymp-2.86 \nAbsMono-1.36* AbsEos-0.17 AbsBaso-0.05\n___ 10:30PM BLOOD ___ PTT-23.4* ___\n___ 10:30PM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-132* \nK-5.8* Cl-98 HCO3-19* AnGap-15\n___ 10:30PM BLOOD ALT-18 AST-38 AlkPhos-39* TotBili-0.4\n___ 10:30PM BLOOD Lipase-47\n___ 10:30PM BLOOD cTropnT-<0.01\n___ 10:30PM BLOOD Albumin-4.0 Calcium-9.9 Phos-3.7 Mg-2.0\n___ 10:30PM BLOOD VitB12-570\n___ 10:30PM BLOOD TSH-1.4\n___ 07:00AM BLOOD Trep Ab-NEG\n___ 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\nIMAGING:\n========\n___ Imaging CT HEAD W/O CONTRAST \nFINDINGS: \nThere is no evidence of infarction, hemorrhage, edema, or mass. \nThere is \nprominence of the ventricles and sulci suggestive of \ninvolutional changes. \nThere is no evidence of fracture. The visualized portion of the \nremaining \nparanasal sinuses and middle ear cavities are clear. The \nvisualized portion of the orbits are unremarkable apart from \nbilateral lens replacements. \nIMPRESSION: \n1. No acute intracranial abnormality. No hydrocephalus. \n\n___ Imaging CHEST (PA & LAT) \nIMPRESSION: \nMild atelectasis in the lung bases without focal consolidation. \n\nAge-indeterminate moderate to severe compression deformity of a \nlow thoracic vertebral body. \n\nDISCHARGE LABS:\n===============\n___ 06:21AM BLOOD WBC-7.0 RBC-4.02* Hgb-12.9* Hct-38.1* \nMCV-95 MCH-32.1* MCHC-33.9 RDW-12.8 RDWSD-44.4 Plt ___\n___ 06:21AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-140 \nK-4.0 Cl-104 HCO3-24 AnGap-12\n___ 06:21AM BLOOD Calcium-9.5 Phos-3.2 Mg-1.___ male with ___ disease, dyslipidemia, and a\nhistory of prostate cancer (s/p prostatectomy) who was referred\nto the ED by his neurologist for worsening gait, falls, and\nvisual hallucinations concerning for progression of his\nneurologic disorder. \n\nACUTE/ACTIVE ISSUES:\n====================\n___ disease\n___ Body Dementia \n#Visual Hallucinations \nThe patient appears to have acute on chronic progression of his\n___ disease. Unclear if this is disease progression or\nunderlying medical cause. Continued mirapex, rasagiline, and \nrivastigmine. Neurology recommended started Seroquel for his \nhallucinations.\n\nHe was evaluated by physical therapy who recommended rehab. This \nrecommendation was discussed with the family who opted for \ndischarge to home with home physical therapy as this was in line \nwith the patient's goals of care.\n\nTRANSITIONAL ISSUES:\n[] f/u visual hallucination symptoms on Seroquel\n[] f/u physical therapy at home\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Rasagiline 1 mg PO DAILY \n2. Pramipexole 0.625 mg PO TID \n3. rivastigmine 9.5 mg/24 hr transdermal DAILY \n4. Pravastatin 40 mg PO QPM \n5. Cyanocobalamin Dose is Unknown PO DAILY \n6. Loratadine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. QUEtiapine Fumarate 25 mg PO QHS \nRX *quetiapine 25 mg 1 tablet(s) by mouth AT NIGHT Disp #*30 \nTablet Refills:*0 \n2. Loratadine 10 mg PO DAILY \n3. Pramipexole 0.625 mg PO TID \n4. Pravastatin 40 mg PO QPM \n5. Rasagiline 1 mg PO DAILY \n6. rivastigmine 9.5 mg/24 hr transdermal DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n___ Dementia\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were sent to the emergency room by your neurologist who \nwas concerned that you were having visual hallucinations.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were started on a new medication to help treat your \nsymptoms.\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" ]

[ "G3183", "F0280", "R441", "R296", "E785", "Z8546" ]

[ "G3183: Dementia with Lewy bodies", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "R441: Visual hallucinations", "R296: Repeated falls", "E785: Hyperlipidemia, unspecified", "Z8546: Personal history of malignant neoplasm of prostate" ]

[ "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nomeprazole\n \nAttending: ___.\n \nChief Complaint:\ndysphagia \n \nMajor Surgical or Invasive Procedure:\nUpper endoscopy ___\n\n \nHistory of Present Illness:\n ___ w/ anxiety and several years of dysphagia who p/w worsened \nforeign body sensation. \n\nShe describes feeling as though food gets stuck in her neck when \nshe eats. She put herself on a pureed diet to address this over \nthe last 10 days. When she has food stuck in the throat, she \nalmost feels as though she cannot breath, but she denies trouble \nbreathing at any other time. She does not have any history of \nfood allergies or skin rashes. \n \nIn the ED, initial vitals: 97.6 81 148/83 16 100% RA \nImaging showed: CXR showed a prominent esophagus\nConsults: GI was consulted.\n\nPt underwent EGD which showed a normal appearing esophagus. \nBiopsies were taken.\n\nCurrently, she endorses anxiety about eating. She would like to \ntry eating here prior to leaving the hospital. \n\n \nPast Medical History:\n- GERD \n - Hypercholesterolemia \n - Kidney stones \n - Mitral valve prolapse \n - Uterine fibroids \n - Osteoporosis \n - Migraine headaches \n \nSocial History:\n___\nFamily History:\n+ HTN - father \n+ Dementia - father \n \n \nPhysical Exam:\n=================\nADMISSION/DISCHARGE EXAM\n=================\nVS: 97.9 PO 109 / 71 70 16 97 ra \nGEN: Thin anxious woman, lying in bed, no acute distress \nHEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI \nNECK: Supple without LAD, no JVD \nPULM: CTABL no w/c/r\nCOR: RRR (+)S1/S2 no m/r/g \nABD: Soft, non-tender, non-distended, +BS, no HSM \nEXTREM: Warm, well-perfused, no ___ edema \nNEURO: CN II-XII grossly intact, motor function grossly normal, \nsensation grossly intact \n \nPertinent Results:\n=============\nADMISSION LABS\n=============\n\n___ 08:27AM BLOOD WBC-5.0 RBC-4.82 Hgb-14.9 Hct-44.4 MCV-92 \nMCH-30.9 MCHC-33.6 RDW-12.1 RDWSD-41.3 Plt ___\n___ 08:27AM BLOOD ___ PTT-28.6 ___\n___ 08:27AM BLOOD Glucose-85 UreaN-8 Creat-0.9 Na-142 K-3.6 \nCl-104 HCO3-22 AnGap-20\n___ 08:27AM BLOOD ALT-11 AST-16 LD(LDH)-154 AlkPhos-63 \nTotBili-1.0\n___ 08:27AM BLOOD Albumin-4.8\n=============\nIMAGING\n=============\n\nCXR ___: \nIMPRESSION: \n \nProminent esophagus on lateral view, without air-fluid level. \nGiven the patient's history and radiographic appearance, barium \nswallow is indicated either now or electively. \n \nNECK X-ray ___:\nIMPRESSION: \n \nWithin the limitation of plain radiography, no evidence of \nprevertebral soft tissue swelling or soft tissue mass in the \nneck. \n \n\nEGD: ___\n Impression: Hiatal hernia\nAngioectasia in the stomach\nAngioectasia in the duodenum\n (biopsy, biopsy)\nOtherwise normal EGD to third part of the duodenum \n\nRecommendations: - no obvious anatomic cause for the patient's \nsymptoms\n- follow-up biopsy results to rule out eosinophilic esophagitis\n- follow-up with Dr. ___ if biopsies show eosinophilic \nesophagitis \n\n \nBrief Hospital Course:\nMs. ___ is a ___ with history of GERD who presents with \nsubacute worsening of dysphagia and foreign body sensation. This \nhad worsened to the point where she placed herself on a pureed \ndiet for the last 10 days. She underwent CXR which showed a \nprominent esophagus but was otherwise normal. She was evaluated \nby Gastroenterology and underwent an upper endoscopy on ___. \nThis showed a normal appearing esophagus. Biopsies were taken. \n\nTRANSITIONAL ISSUES:\n-f/u biopsies from EGD\n-if results show eosinophilic esophagitis, follow-up with Dr. ___. \n___ for management\n-pt should undergo barium swallow as an outpatient for further \nworkup of her dysphagia\n-f/u with ENT as planned\n#Code: Full (presumed) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO BID \n\n \nDischarge Medications:\n1. Omeprazole 20 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n-dysphagia and foreign body sensation\n\nSECONDARY DIAGNOSIS:\n-GERD \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 at ___.\n\nYou came in due to difficulty swallowing. You had an endoscopy \nto look for any abnormalities in the esophagus. Thankfully, this \nwas normal. They took biopsies, and you will be called with the \nresults. You should have a test called a barium swallow as an \noutpatient.\n\nWe wish you all the best!\n-Your ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "R1310", "R0989", "K31819", "K219", "K449", "F419", "I341", "M810", "Z87891" ]

[ "R1310: Dysphagia, unspecified", "R0989: Other specified symptoms and signs involving the circulatory and respiratory systems", "K31819: Angiodysplasia of stomach and duodenum without bleeding", "K219: Gastro-esophageal reflux disease without esophagitis", "K449: Diaphragmatic hernia without obstruction or gangrene", "F419: Anxiety disorder, unspecified", "I341: Nonrheumatic mitral (valve) prolapse", "M810: Age-related osteoporosis without current pathological fracture", "Z87891: Personal history of nicotine dependence" ]

[ "K219", "F419", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nomeprazole / Iodine and Iodide Containing Products / \nhallucinogens\n \nAttending: ___.\n \nChief Complaint:\nLeft hip pain \n \nMajor Surgical or Invasive Procedure:\nStatus post left CRPP ___, ___\n\n \nHistory of Present Illness:\nREASON FOR CONSULT: Femur fracture\n\nHPI: ___ female presents with the above fracture s/p mechanical\nfall. This morning, pt was walking ___, when dog\npulled on leash. Pt fell on L hip. Immediate pain. ___ ___ with movement. Denies Head strike, LOC or blood thinners.\nDenies numbness or weakness in the extremities. \n \nPast Medical History:\n- GERD \n - Hypercholesterolemia \n - Kidney stones \n - Mitral valve prolapse \n - Uterine fibroids \n - Osteoporosis \n - Migraine headaches \n \nSocial History:\n___\nFamily History:\n+ HTN - father \n+ Dementia - father \n \n \nPhysical Exam:\nGeneral: Well-appearing female in no acute distress.\n\nLeft Lower extremity:\n- Skin intact\n- No deformity, edema, ecchymosis, erythema, induration\n- Soft, non-tender thigh and leg\n- Full, painless ROM knee, and ankle\n- Fires ___\n- SILT S/S/SP/DP/T distributions\n- 1+ ___ pulses, WWP\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 valgus impacted femoral neck fracture and was \nadmitted to the orthopedic surgery service. The patient was \ntaken to the operating room on ___ for left closed reduction \nand percutaneous pinning of hip, which the patient tolerated \nwell. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications by POD#1. \nThe patient was given ___ antibiotics and \nanticoagulation per routine. The patient's home medications were \ncontinued throughout this hospitalization. The patient worked \nwith ___ who determined that discharge to home with services was \nappropriate. The ___ hospital course was otherwise \nunremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nweightbearing as tolerated in the left lower extremity, and will \nbe discharged on Lovenox for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. A thorough discussion \nwas had with the patient regarding the diagnosis and expected \npost-discharge course including reasons to call the office or \nreturn to the hospital, and all questions were answered. The \npatient was also given written instructions concerning \nprecautionary instructions and the appropriate follow-up care. \nThe patient expressed readiness for discharge.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lactaid (lactase) 3,000 unit oral DAILY:PRN \n2. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 \nmg-unit oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n3. Docusate Sodium 100 mg PO BID \n4. Enoxaparin Sodium 40 mg SC QHS \nRX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously Nightly Disp \n#*30 Syringe Refills:*0 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth q4 PRN Disp #*25 Tablet \nRefills:*0 \n6. Senna 8.6 mg PO BID \n7. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 \nmg-unit oral DAILY \n8. Lactaid (lactase) 3,000 unit oral DAILY:PRN \n9. Multivitamins 1 TAB PO DAILY \n10. Vitamin D 400 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft valgus impacted femoral neck fracture\n\n \nDischarge Condition:\nAVSS\nNAD, A&Ox3\nLLE: Incision well approximated. Dressing clean and dry. Fires \nFHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP \npulse, wwp distally.\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 \nFollowup Instructions:\n___\n" ]

[ "S72012A", "W010XXA", "Y93K1", "Y92480", "K219", "E7800", "I341", "G43909", "Z87891", "Z87442", "F419", "M810", "Z7901" ]

[ "S72012A: Unspecified intracapsular fracture of left femur, initial encounter for closed fracture", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y93K1: Activity, walking an animal", "Y92480: Sidewalk as the place of occurrence of the external cause", "K219: Gastro-esophageal reflux disease without esophagitis", "E7800: Pure hypercholesterolemia, unspecified", "I341: Nonrheumatic mitral (valve) prolapse", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "Z87891: Personal history of nicotine dependence", "Z87442: Personal history of urinary calculi", "F419: Anxiety disorder, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "Z7901: Long term (current) use of anticoagulants" ]

[ "K219", "Z87891", "F419", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nshortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPatient is a ___ with history of coronary artery disease c/b\nischemic MR ___ DES to LCX ___, TTE ___ with mild regional LV\nsystolic dysfunction), heart failure with preserved ejection\nfraction (LVEF 50% ___, peripheral vascular disease, chronic\nkidney disease (stage IV), prior unprovoked DVT c/b severe UGIB\nwhile on AC, HTN, dyslipidemia, and T2DM who presents with\nseveral days of shortness of breath. \n\nPatients says that she first noticed rather acute onset dyspnea\nstarting ___ when trying to walk up the stairs in her home. \n\nShe had to sit down and catch her breath, whereas just days \nprior\nshe was able to mount ___ of stairs without difficulty. \nPatient denies any associated chest pain or palpitations. No\ndizziness or lightheadedness. Patient further denies any cough,\nfevers/chills, or pleuritic chest discomfort. She has not\nexperienced any symptoms consistent with orthopnea or PND. No\nincreased ___ swelling, patient notes that she has experienced\nthis in the past. \n\nPatient takes her weight nearly every day, 7lbs reported weight\ngain over the past week (154lbs -> 161lbs), which she attributes\nto eating more over the ___. She is currently\ntaking torsemide 40mg qd, no missed doses. No issues with\nabdominal bloating or constipation. No recent travel. \nPatient's\nhusband just recovered from a viral URI. \n\nIn the ED, initial VS were: 97.2 90 186/87 22 100% RA \n\nExam notable for:\nObvious bilateral wheezing.\nNo overt volume overload. \n\nEKG: NSR (92bpm), normal axis, normal PR/QRS intervals, QTc 479,\nq-waves III/aVF, TWIs III/aVF/V3/V6, submm lateral STDs, no \nSTEs.\n\nLabs showed: \nCBC 6.0>9.0/27.8<176 (PMNs 75.2%, MCV 97)\nBMP 142/4.8/105/___/2.4/189\nTrop <.01\nproBNP 4512\nVBG 7.33/40\nUA: 1.010 SG, pH 6.0, urobilinogen NEG, bilirubin NEG, leuk NEG,\nblood NEG, nitrite NEG, protein 100, glucose NEG, ketones NEG,\nRBC 1, WBC 1, few bacteria\n\nImaging showed: \nCXR ___\nFINDINGS: \nLungs are moderately well-expanded. There is an asymmetric right\nlower lung opacity, new from ___. The heart appears mildly\nenlarged and there is mild pulmonary vascular congestion. No\npleural effusion or pneumothorax. \nIMPRESSION: \nRight lower lobe opacity could represent pneumonia in the right\nclinical setting, although atelectasis or asymmetric pulmonary\nedema could account for this finding. Dedicated PA and lateral\nviews could be helpful for further assessment. \n \nConsults: NONE \n\nPatient received: \n___ 21:45 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 22:08 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 22:08 IH Ipratropium Bromide Neb 1 NEB \n___ 22:47 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 22:47 IH Ipratropium Bromide Neb 1 NEB \n___ 22:51 IV Azithromycin \n___ 22:51 IV CefTRIAXone\n___ 22:51 PO PredniSONE 60 mg\n___ 22:51 IV Furosemide 80 mg \n___ 23:01 IV CefTRIAXone 1 gm \n___ 00:13 IV Azithromycin 500 mg\n___ 00:23 PO/NG Atorvastatin 80 mg\n___ 00:23 PO/NG Carvedilol 25 mg\n___ 00:23 PO NIFEdipine (Extended Release) 60 mg \n___ 00:23 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 00:23 IH Ipratropium Bromide Neb 1 NEB\n___ 00:26 PO/NG Gabapentin 100 mg\n___ 00:44 SC Insulin 4 Units\n\nTransfer VS were: 98.2 77 141/76 18 100% 2L NC \n \nOn arrival to the floor, patient recounts the history as above. \nShe says that she feels improved after treatment in the ED, no\nongoing SOB. \n \n10-point ROS is otherwise NEGATIVE.\n\n \nPast Medical History:\nCoronary artery disease\nPeripheral vascular disease\nType II Diabetes Mellitus c/b diabetic retinopathy\nObesity\nEsophageal ring\nHypertension\nDyslipidemia\nBilateral unprovoked posterior tibial DVTs (___) off AC given\nsevere UGIB\nCKD Stage IV iso DM/HTN, secondary hyperparathyroidism\nAnemia\nGout\n \nSocial History:\n___\nFamily History:\nNiece had some sort of cancer. Father died in his ___ due to \nlung disease. Mother died in her ___ due to an unknown cause. \nNo early CAD or sudden cardiac death. No other known history of \ncancer. \n \nPhysical Exam:\n==============================\n ADMISSION PHYSICAL EXAM\n==============================\nVS: 97.5 162/93 78 16 100RA \nGENERAL: Pleasant female appearing younger than her stated age,\ntaking deep breaths while speaking \nHEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. \nNECK: JVD 10 CM. \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs. \nLUNGS: CTAB, no wheezes. \nABDOMEN: Obese abdomen, normoactive BS throughout, nondistended,\nnontender in all quadrants, no rebound/guarding, no\nhepatosplenomegaly. \nEXTREMITIES: No cyanosis, clubbing, or edema. \nPULSES: 2+ radial pulses bilaterally. \nNEURO: A&Ox3, moving all 4 extremities with purpose. \nSKIN: Warm and well perfused, no excoriations or lesions, no\nrashes. \n \n==============================\nDISCHARGE PHYSICAL EXAM\n==============================\nVS: Afeb, 144/78, HR 57, 97% RA, RR 12\nGEN: Well appearing in NAD\nNeck: No JVD appreciated\nCV: RRR no m/r/g, no carotid bruits appreciated\nPULM: CTAB no wheezes, rales, or crackles. Symmetric expansion\nEXT: warm well perfused, no pitting edema \n \nPertinent Results:\n==============================\n ADMISSION LABS\n==============================\n___ 09:37PM BLOOD WBC-6.0 RBC-2.88* Hgb-9.0* Hct-27.8* \nMCV-97 MCH-31.3 MCHC-32.4 RDW-15.1 RDWSD-52.0* Plt ___\n___ 09:37PM BLOOD Neuts-75.2* Lymphs-17.6* Monos-4.4* \nEos-1.8 Baso-0.3 Im ___ AbsNeut-4.49 AbsLymp-1.05* \nAbsMono-0.26 AbsEos-0.11 AbsBaso-0.02\n___ 06:40AM BLOOD ___ PTT-25.9 ___\n___ 09:37PM BLOOD Glucose-189* UreaN-38* Creat-2.4* Na-142 \nK-4.8 Cl-105 HCO3-20* AnGap-17\n___ 09:37PM BLOOD proBNP-4512*\n___ 09:37PM BLOOD cTropnT-<0.01\n___ 06:40AM BLOOD CK-MB-6 cTropnT-0.05*\n___ 02:01PM BLOOD CK-MB-5 cTropnT-0.04*\n___ 09:37PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.3\n___ 09:41PM BLOOD ___ pO2-30* pCO2-40 pH-7.33* \ncalTCO2-22 Base XS--5\n \n==============================\n IMAGING\n==============================\nTTE ___: The left atrial volume index is mildly increased. \nThe estimated right atrial pressure is ___ mmHg. Left \nventricular wall thicknesses and cavity size are normal. There \nis mild regional left ventricular systolic dysfunction with \nbasal inferoseptal, inferior, inferolateral as well as mid \ninferior/inferoseptal wall motion abnormalities. Doppler \nparameters are most consistent with Grade II (moderate) left \nventricular diastolic dysfunction. 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) are mildly thickened but aortic stenosis is \nnot present. There is no aortic valve stenosis. Trace aortic \nregurgitation is seen. The mitral valve leaflets are moderately \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 IMPRESSION: 1) Mild regional LV systolic dysfunction c/w \nprior myocardial infarction in the RCA territory. 2) Grade II \nLV diastolic dysfunction.\n Compared with the prior study (images reviewed) of ___, LV \nsytolic function appears mildly less vigorous. Regional wall \nmotion abnormalities encompassess slightly greater territory. \n\nCXR PA & LAT ___: No focal consolidation or pulmonary \nedema.\n\nBILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND ___: \n1. Nonocclusive thrombosis of one of the paired posterior tibial \nveins in the bilateral lower extremities which appears grossly \nunchanged compared to bilateral lower extremity ultrasound ___. No new deep venous thrombosis in either \nextremity. \n2. Right ___ cyst measuring up to 1.8 cm across maximal \ndiameter is \nunchanged in size compared to ___. \n \n==============================\n MICROBIOLOGY\n==============================\n URINE CULTURE ___: ENTEROCOCCUS SP.. >100,000 CFU/mL.\n BLOOD CULTURE ___: Blood Culture: PENDING \n BLOOD CULTURE ___: Blood Culture: PENDING \n\n==============================\n DISCHARGE LABS\n==============================\n___ 05:45AM BLOOD WBC-5.1 RBC-2.57* Hgb-7.9* Hct-24.5* \nMCV-95 MCH-30.7 MCHC-32.2 RDW-15.0 RDWSD-51.8* Plt ___\n___ 05:45AM BLOOD Glucose-144* UreaN-49* Creat-2.6* Na-147 \nK-4.0 Cl-105 HCO3-24 AnGap-___ yo F PMH CAD c/b ischemic MR ___ DES to ___ ___, TTE ___ \nwith mild regional LV systolic dysfunction), HFpEF (LVEF 50% \n___, PAD, CKD (stage IV), prior DVT c/b severe UGIV on AC, \nT2DM presents with subacute SOB, weight gain, c/f acute heart \nfailure exacerbation. She underwent diuresis with IV Lasix 80 \nmg, 120mg IV x2 with rapid improvement in subjective dyspnea. \n___ showed no acute DVT, CXR without sign of consolidation. \nGiven her improvement in dyspnea, no supplemental O2 \nrequirement, the patient was discharged w/o medication changes.\n\n# Shortness of breath\n# Hypoxia\n# acute exacerbation of chronic diastolic heart failure with \npreserved LVEF (50%)\nDry weight per pt 154 lbs. Admission weight above baseline, BNP \nelevated. Regarding trigger, suspect dietary vs uncontrolled \nBP. No EKG changes for ACS, trop negative, repeat TTE showed \nmild regional LV systolic dysfunction c/w prior myocardial \ninfarction in the RCA territory, as well as Grade II LV \ndiastolic dysfunction and similar to prior ___ TTE. Doubt PNA \ngiven CXR and lack of cough/fever, doubt PE given low Wells' \nscore 1.5, and stable repeat ___. Underwent diuresis with IV \nLasix 80 mg, 120mg IV x2 with rapid improvement in subjective \ndyspnea. Resumed home torsemide 40mg, nifedipine 60mg BID and \ncarvedilol 25mg BID. Was stable on RA prior to discharge.\n\n# Hypertension - Patient missed her antiHTN medications earlier \nday of admission. Continued home carvedilol 25mg BID and \nnifedipine 60mg BID with holding parameters. Appears that a \ntrial of ___ or spironolactone would be limited by \nhyperkalemia, so this was deferred.\n \n# Urinary frequency/urge incontinence: occurred in setting of \ndiuresis, however UCx ordered in ED did grow enterococci, likely \ncolonization. If symptoms persists would revaluate/treat.\n \nCHRONIC STABLE ISSUES\n\n# Normocytic anemia (recent baseline Hb 9.4 ___ - Hb was at \nbaseline, no signs of active bleeding. Likely multifactorial, \nanemia of chronic disease as well as decreased erythropoiten \nproduction iso CKD.\n \n# Non anion gap metabolic acidosis - Patient has intermittently \nhad a NAGMA in the past. No recent diarrhea. ___ suspect Type \nIV RTA given advanced age and history of T2DM (both of which can \ncause hyporeninemia).\n\n# Stage IV Chronic Kidney Disease (baseline Cr 2.3-2.8) - CKD \niso HTN and T2DM, Cr is currently at baseline. Low K/Phos/Na \ndiet. Continued home calcitriol, avoided nephrotoxins and \nrenally dosed all medications.\n\n# Coronary artery disease ___ DES to LCX ___: troponins were \ntrended from < 0.01 to 0.05 to 0.04 then stopped. CK-MB was \nflat. Patient deneied any chest pain. A TTE showed mild \nregional LV systolic dysfunction c/w prior myocardial infarction \nin the RCA territory and similar to prior ___ TTE. Continued \nhome aspirin 81mg qd, home carvedilol 25mg BID with holding \nparameters, home atorvastatin 80mg qHS.\n \n# Type II Diabetes Mellitus (last HbA1C 6.4% ___ - Under \nexcellent control, most recently in the pre-diabetic range.\n- Continue home 70/30 sliding scale (___t dinner if \nblood sugar over 130, 10 units 90-130, none if blood sugar under \n90) \n\n# Dyslipidemia: continued home atorvastatin\n\n# Insomnia: continued home gabapentin\n\n# Gout: continued home allopurinol\n \n==============================\n TRANSITIONAL ISSUES\n==============================\n- Discharge weight: 69.2kg\n- Discharge creatinine: 2.6\n- Discharge oral diuretic: torsemide 40mg daily\n- Transitional issue: consider outpatient epo with renal \n- Transitional issue: BP goal of 140/90 per accord or even \n130/80 per ACC/AHA ___ guidelines however anticipate difficulty \nin adding additional agents iso CKD (limits use of clonidine) \nand baseline potassium (would likely limit ___ or \nspironolactone) \n- TTE showed prior LV hypokinesis, could consider MIBI or \noutpatient pharmacological stress test\n- had some urinary retention/incontinence while undergoing IV \ndiuresis would assess for recurrent symptoms at routine \noutpatient visits\n\n#CODE: Full (confirmed) \n#CONTACT: ___ (husband) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Atorvastatin 80 mg PO QPM \n3. Calcitriol 0.5 mcg PO DAILY \n4. Carvedilol 25 mg PO BID \n5. Gabapentin 100 mg PO QHS \n6. NIFEdipine (Extended Release) 60 mg PO BID \n7. Torsemide 40 mg PO DAILY \n8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n10. Aspirin 81 mg PO DAILY \n11. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using 70/30 Insulin\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. Allopurinol ___ mg PO EVERY OTHER DAY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Calcitriol 0.5 mcg PO DAILY \n6. Carvedilol 25 mg PO BID \n7. Gabapentin 100 mg PO QHS \n8. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using 70/30 Insulin \n9. NIFEdipine (Extended Release) 60 mg PO BID \n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n11. Torsemide 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n- Acute on chronic diastolic congestive heart failure\n\nSECONDARY DIAGNOSES\n- Hypertension\n- History of prior DVT\n- Anemia, NOS\n- Chronic Kidney Disease stage IV\n- Coronary Artery Disease ___ drug eluting stent\n- Diabetes Mellitus Type 2 controlled\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nYou were admitted to the hospital with shortness of breath and \nweight gain. This was likely caused by an exacerbation of your \nheart failure possibly from salty foods over the holiday. \n\nWhile you were in the hospital:\n- we gave you IV diuretics to help remove extra fluid\n- we checked for pneumonia with a chest x-ray, there was no sign \nof a pneumonia\n- we checked for signs on new clots in your legs, there was no \nnew clot\n\nNow that you are going home:\n- continue to take all of your medications as prescribed\n- monitor your salt intake, this should be no more than 2 grams \nevery day, ask your doctors for help with this if you do not \nknow how to keep track of your salt\n- continue to weigh yourself every morning, call your doctor if \nweight goes up more than 3 lbs.\n- follow-up with your primary care doctor regarding your blood \npressure and blood sugar control\n\nIt was a pleasure taking care of you!\n\nYour ___ Inpatient Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "E872", "N184", "E1122", "N2581", "I2510", "E11319", "D6489", "E785", "Z955", "Z86718", "I252", "Z2239", "G4700", "M1A9XX0", "R0902", "E1151", "Z794", "E669", "Z6831" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "E872: Acidosis", "N184: Chronic kidney disease, stage 4 (severe)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N2581: Secondary hyperparathyroidism of renal origin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "D6489: Other specified anemias", "E785: Hyperlipidemia, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "Z86718: Personal history of other venous thrombosis and embolism", "I252: Old myocardial infarction", "Z2239: Carrier of other specified bacterial diseases", "G4700: Insomnia, unspecified", "M1A9XX0: Chronic gout, unspecified, without tophus (tophi)", "R0902: Hypoxemia", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "Z6831: Body mass index [BMI] 31.0-31.9, adult" ]

[ "I130", "E872", "E1122", "I2510", "E785", "Z955", "Z86718", "I252", "G4700", "Z794", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nfatigue, anemia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a past medical \nhistory of type-2 DM, hypertension, stage IV CKD, CAD s/p \ndistant MI and bare metal stent, stroke, recent unprovoked DVTs \non Coumadin, and recent upper GI bleeding, who was sent to ___ \nby her physician for anemia (Hgb 6.5).\n\nThe patient was admitted to ___ in ___ with unprovoked \nbilateral lower extremity DVTs. She was started on heparin as an \ninpatient, but anticoagulation was complicated by severely \nelevated PTT (>150) and upper GI bleed. Endoscopy was notable \nfor significant erythema, superficial ulceration, and gastritis \nwithout active bleeding. She was placed on BID PPI prophylaxis. \nShe was eventually bridged to Coumadin for a planned 6 month \ncourse. Her INR is managed by her rehab facility, and she is \nfollowed by Dr. ___ in ___ clinic. \n\nFor the last two weeks she has noted increasing fatigue along \nwith shortness of breath, exertional sub-sternal chest pain \nrelieved with rest, and symmetrical lower extremity swelling. \nDuring this period she reports that her appetite remained good, \nand he bowel function was normal. She denies bloody stools or \ndark stool. On ___ she presented to her PCP office from rehab \nreporting increasing shortness of breath and fatigue. She was \nfound to have a Hgb of 6.5, with an unconcerning CXR. She was \nsent to the ___ ED.\n\nIn the ED, her initial vitals were T: 97.5 P: 60 BP: 156/76 RR: \n16 SPO2: 100% RA. Exam was notable for guiac negative stool. \nImaging was notable for:\n \"1. Nonocclusive deep vein thrombosis of one of the paired \nposterior tibial veins bilaterally. The extent of thrombus \nbilaterally has decreased. No new deep venous thrombosis in \neither lower extremity. \n 2. Right complex ___ cyst.\"\n\nThe patient was transfused with 2 units of pRBCs, with \nappropriate increase in Hgb to 9.0. Following transfusion, a \nrepeat CXR was notable for pulmonary edema with bilateral \npleural effusions. She was given 20mg PO Lasix and 40mg IV Lasix \nin the ED. The decision was made to admit the patient for anemia \nand flash pulmonary edema. \n\nOn the floor, vitals notable for T: 97.9 BP: 154/75 P: 65 R: 20 \nO2: 99RA FSBG: 76. She reports no acute complaints, and that her \nshortness of breath has resolved. She denies chest pain, \ndizziness, lightheadedness.\n \nPast Medical History:\n- hypertension \n- diabetes \n- hx CVA (cerebellar-medullary stroke in ___ \n- CAD (hx of MI in ___ BMS to circumflex and POBA ___ \n- peripheral arterial disease- claudication, followed by \nvascular, managed conservatively\n- stage IV CKD (baseline 2.1-2.6) \n- GERD/esophageal rings\n \nSocial History:\n___\nFamily History:\nNiece had some sort of cancer. Father died in his ___ due to \nlung disease. Mother died in her ___ due to an unknown cause. \nNo early CAD or sudden cardiac death. No other known history of \ncancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: T: 97.9 BP: 154/75 P: 65 R: 20 O2: 99RA FSBG: ___ \nGeneral: Overweight woman, alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated \nLungs: Crackles to the mid-lungs bilaterally \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs or \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 2+ \npitting edema in dependent areas to the buttocks \nSkin: no rashes noted\nNeuro: ___ strength in deltoids, biceps, triceps, wrist \nextensors, finger extensors, hip flexors, hamstrings, \nquadriceps, gastrocs, tibialis anterior, bilaterally. Sensation \nintact bilaterally. \nPSYCH: Alert and fully oriented; normal mood and affect.\nsometimes slow to respond and responding with repetitive answers\nbut otherwise appropriate\n\nDISCHARGE PHYSICAL EXAM:\nVS: T: 97.6 BP: 150s-160s/70s-80s P: 60s-70s RR: 18 SPO2: 100RA\nGeneral: Overweight woman, alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated \nLungs: Clear to auscultation bilaterally\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs or \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing or cyanosis. 1+ \npitting edema in shins bilaterally\nSkin: no rashes noted\n\n \nPertinent Results:\nLABORATORY STUDIES ON ADMISSION\n=============================================\n___ 12:30PM WBC-4.4 RBC-2.03* HGB-6.5* HCT-20.6* \nMCV-102*# MCH-32.0 MCHC-31.6* RDW-16.3* RDWSD-59.6*\n___ 12:30PM ___\n___ 12:30PM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-4.7* \nIRON-61\n___ 12:30PM calTIBC-303 FERRITIN-155* TRF-233\n___ 12:30PM UREA N-42* CREAT-2.3* SODIUM-142 \nPOTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-15\n___ 04:50PM LD(___)-247 TOT BILI-0.2\n___ 04:50PM HAPTOGLOB-188\n\nIMAGING: \n==============================================\nLENIs (___)\n1. Nonocclusive deep vein thrombosis of one of the paired \nposterior tibial veins bilaterally. The extent of thrombus \nbilaterally has decreased. No new deep venous thrombosis in \neither lower extremity. \n2. Right complex ___ cyst. \n\nCXR (___): \n1. New mild pulmonary edema with persistent small bilateral \npleural effusions. \n2. Severe cardiomegaly is likely accentuated due to low lung \nvolumes and patient positioning. \n\nCXR (___):\nAs compared to ___, the lung volumes have slightly \ndecreased. Signs of mild overinflation and moderate pleural \neffusions persist. Moderate cardiomegaly. Elongation of the \ndescending aorta. No pneumonia. \n\nLABORAROTY STUDIES ON DISCHARGE\n==============================================\n___ 05:45AM BLOOD WBC-3.4* RBC-2.93* Hgb-8.9* Hct-28.0* \nMCV-96 MCH-30.4 MCHC-31.8* RDW-17.5* RDWSD-59.7* Plt ___\n___ 05:45AM BLOOD ___ PTT-30.6 ___\n___ 05:45AM BLOOD Glucose-116* UreaN-41* Creat-2.1* Na-144 \nK-4.0 Cl-108 HCO3-25 AnGap-15\n___ 04:50PM BLOOD LD(LDH)-247 TotBili-0.2\n___ 05:45AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with a past medical \nhistory of type-2 DM, hypertension, stage IV CKD, CAD s/p \ndistant MI and bare metal stent, stroke, recent unprovoked DVTs \non Coumadin, and recent upper GI bleed, who was sent to ___ by \nher physician for anemia. \n\n# Anemia: \nPatient presented with Hgb of 6.5, down from her recent baseline \nof ~7.5 since her ___ hospitalization. Upon presentation she \nhad a new macrocytic anemia. Hemolysis labs were negative. She \nreceived two units of packed red cells with an appropriate rise \nin her Hgb to 9.0. Stool was guiac negative, with no reports of \ndark stool or blood in stool. Her hemoglobin remained stable at \nthis level, there was no overt bleeding, and her stool was guiac \nnegative. After transfusion the patient reported significant \nimprovement in her shortness of breath and fatigue. Given her \nhistory of gastritis and diverticulosis, a GI bleed was believed \nresponsible for her anemia. Patient should receive an \nEGD/colonoscopy as an outpatient. \n\n# Acute exacerbation of heart failure with preserved ejection \nfraction: \nThe patient was also found to be slightly volume overloaded, and \nwas treated with 2x40mg IV Lasix, with good urine output and \nsymptomatic improvement. Her pulmonary edema and peripheral \nedema resolved with diuresis.\n\nCHRONIC ISSUES:\n# Gastic ulceration: \nContinued on home pantoprazole BID\n\n# Hypertension:\nContinued on home nifedipine, carvadilol, lisinopril.\n\n# Stage IV Chronic Kidney Disease: \nCreatinine remained at baseline (b/l Cr 2.1-2.6) during \nadmission.\n\nTRANSITIONAL ISSUES\n======================\n--Patient's Anemia is thought to be due to slow GI bleed given \nhistory of gastritis and diverticulosis. Please schedule \nEGD/colonoscopy within the next month\n--Patient continued on Coumadin for bilateral DVTs; please \ncontinue to weigh the risks and benefits of anticoagulation \ngiven history of bleed.\n--Discharge weight: 167.7\n\n# CONTACT: ___ ___\n# CODE: full, confirmed\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Carvedilol 12.5 mg PO BID \n5. Lisinopril 40 mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. NIFEdipine CR 30 mg PO BID \n8. Vitamin D ___ UNIT PO DAILY \n9. Docusate Sodium 100 mg PO BID \n10. Gabapentin 100 mg PO QHS neuropathic pain \n11. Pantoprazole 40 mg PO Q12H \n12. Senna 8.6 mg PO BID constipation \n13. Warfarin 4 mg PO 3X/WEEK (___) \n14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n15. Furosemide 20 mg PO DAILY \n16. Polyethylene Glycol 17 g PO DAILY \n17. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever \n18. Warfarin 3 mg PO 4X/WEEK (___) \n19. 70/30 30 Units Dinner\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever \nRX *acetaminophen 325 mg ___ tablet(s) by mouth Q6H:PRN Disp \n#*120 Tablet Refills:*0\n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n3. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet \nRefills:*0\n4. Carvedilol 12.5 mg PO BID \nRX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0\n5. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0\n6. Gabapentin 100 mg PO QHS neuropathic pain \nRX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30 \nCapsule Refills:*0\n7. Lisinopril 40 mg PO DAILY \nRX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n8. Multivitamins 1 TAB PO DAILY \nRX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule \nRefills:*0\n9. NIFEdipine CR 30 mg PO BID \nRX *nifedipine 30 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0\n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \nRX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually \nQ5MIN:PRN Disp #*10 Tablet Refills:*0\n11. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12) \nhours Disp #*60 Tablet Refills:*0\n12. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth \ndaily Refills:*0\n13. Senna 8.6 mg PO BID constipation \nRX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day \nDisp #*60 Capsule Refills:*0\n14. Vitamin D ___ UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n15. Warfarin 4 mg PO 3X/WEEK (___) \nRX *warfarin 4 mg 1 tablet(s) by mouth 3X/WEEK Disp #*30 Tablet \nRefills:*0\n16. Warfarin 3 mg PO 4X/WEEK (___) \nRX *warfarin 3 mg 1 tablet(s) by mouth 4X/WEEK Disp #*30 Tablet \nRefills:*0\n17. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n18. Allopurinol ___ mg PO EVERY OTHER DAY \nRX *allopurinol ___ mg 1 tablet(s) by mouth EVERY OTHER DAY Disp \n#*30 Tablet Refills:*0\n19. 70/30 30 Units Dinner\nRX *insulin NPH and regular human [Humulin 70/30 KwikPen] 100 \nunit/mL (70-30) 30 units SC Take 30 Units before DINER Disp #*2 \nPackage Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\nAnemia\nCongestive heart failure exacerbation\n\nSecondary diagnosis:\nHypertension \nDMII on insulin \nCoronary artery disease \nStage IV chronic kidney disease\nDeep vein thrombosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure caring for you. You were admitted to the \nhospital with fatigue, chest pain, and shortness of breath. You \nwere found to have too few red blood cells (anemia). We gave you \nblood, and your symptoms improved. Additionally, you were found \nto have too much fluid in your legs and lungs. We treated you \nwith a diuretic, which helped eliminate the fluid. \n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "D500", "I5023", "N184", "E118", "K2970", "Z23", "K259", "K5730", "I2510", "Z87891", "I252", "Z955", "I129", "Z794", "Z8673", "R0789", "Z86718", "R791", "T45515A", "I70218", "K222", "K219" ]

[ "D500: Iron deficiency anemia secondary to blood loss (chronic)", "I5023: Acute on chronic systolic (congestive) heart failure", "N184: Chronic kidney disease, stage 4 (severe)", "E118: Type 2 diabetes mellitus with unspecified complications", "K2970: Gastritis, unspecified, without bleeding", "Z23: Encounter for immunization", "K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z794: Long term (current) use of insulin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "R0789: Other chest pain", "Z86718: Personal history of other venous thrombosis and embolism", "R791: Abnormal coagulation profile", "T45515A: Adverse effect of anticoagulants, initial encounter", "I70218: Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity", "K222: Esophageal obstruction", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "I2510", "Z87891", "I252", "Z955", "I129", "Z794", "Z8673", "Z86718", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ndyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with a history of of HTN, CAD s/p DES with ischemic MR and \nsystolic dysfunction, ___ on torsemide, hx of DVT, who presents \nwith 4 days of dyspnea on exertion, leg swelling, and 10 weight \ngain.\n\nOf note, patient was seen in the Heart Failure Clinic with Dr. \n___ on ___ where she noted that she has had \npersistent dyspnea on exertion and PND after a lengthy prior \nhospitalization for DVT/GIB. At that time she was started on \n40mg po torsemide which initially improved her symptoms. \n\nOver the holiday she indulged in a high salt diet and developed \nslow-onset dyspnea on exertion. Denies any medication \nnoncompliance, chest pain, palpitations, palpitations. Describes \nPND, worsening exercise tolerance (unable to walk >50 feet) and \northopnea. \n\nIn the ED, patient was found to have 1+ bilateral lower \nextremity edema, and have bibasilar crackles on exam. Patient \nunderwent CXR, BNP, and was given one dose of IV 40mg Lasix. In \nthe ED initial vitals were: 97.8 73 199/100 18 95% RA. Prior to \ntransfer, vitals were 74 188/95 18 100% RA. Patient's labs were \nremarkable for sodium 146, Chloride 115, K 5.4, Bicarb 19, BUN \n39, Creatinine 2.3. Patient had CK 229, with MB 6, Trop < 0.01. \nPatient had BNP of 10,180. Patient also had Hgb 8.1, Hct 26.8, \nPlatelet 168, WBC 5.4. Urinalysis still pending upon discharge. \n\nEKG: notable for SR 76, with LAD, TWI in the inferior leads \nwhich appears unchanged from prior on ___\n\nOn the floor she is symptomatically improved since coming to the \nED. \n \nPast Medical History:\n- hypertension \n- diabetes \n- hx CVA (cerebellar-medullary stroke in ___ \n- CAD (hx of MI in ___ BMS to circumflex and POBA ___ \n- peripheral arterial disease- claudication, followed by \nvascular, managed conservatively\n- stage IV CKD (baseline 2.1-2.6) \n- GERD/esophageal rings\n \nSocial History:\n___\nFamily History:\nFather died in his ___ due to lung disease. Mother died in her \n___ due to an unknown cause. No early CAD or sudden cardiac \ndeath. No other known history of cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS: T=98.0 BP: 168/96 HR=67 RR=16 O2 sat=100% on 2L NC \nAdmission weight 178lbs\nGENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. \nMood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa.\nNECK: Supple with JVP of 8cm. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No \nthrills, lifts. \nLUNGS: Resp were unlabored, no accessory muscle use, dyspneic at \nthe end of a long sentence. Bibasilar crackles ___ up thorax, \ndiffuse wheezing. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: 2+ edema to shins. No femoral bruits. \nPULSES: Distal pulses palpable and symmetric\n\nDISCHARGE PHYSICAL EXAMINATION: \nVS: T=98.0 BP: 135/72 HR=67 RR=16 O2 sat=100% on RA\nweight: 74kg\nGENERAL: WDWN, obese, sitting upright in bed, in NAD. AOx3. \nMood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa.\nNECK: Supple with JVP of 7cm. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2, +S3. No murmurs/rubs/gallops. No \nthrills, lifts. \nLUNGS: Resp were unlabored, no accessory muscle use. Bibasilar \ncrackles trace, diffuse wheezing. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: dry. No femoral bruits. \nPULSES: Distal pulses palpable and symmetric\n \nPertinent Results:\nADMISSION LABS\n___ 11:55AM BLOOD WBC-5.4 RBC-2.63* Hgb-8.1* Hct-26.8* \nMCV-102*# MCH-30.8 MCHC-30.2* RDW-17.2* RDWSD-64.7* Plt ___\n___ 11:55AM BLOOD Neuts-80.6* Lymphs-11.2* Monos-5.0 \nEos-2.4 Baso-0.2 Im ___ AbsNeut-4.38 AbsLymp-0.61* \nAbsMono-0.27 AbsEos-0.13 AbsBaso-0.01\n___ 12:45PM BLOOD ___ PTT-32.9 ___\n___ 07:30AM BLOOD Ret Aut-2.4* Abs Ret-0.06\n___ 11:55AM BLOOD Glucose-153* UreaN-39* Creat-2.3* Na-146* \nK-5.4* Cl-115* HCO3-19* AnGap-17\n___ 11:55AM BLOOD CK-MB-6 cTropnT-<0.01 ___\n___ 07:38PM BLOOD CK-MB-6 cTropnT-<0.01\n___ 11:55AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8\n\nDISCHARGE LABS\n=====\n___ 07:10AM BLOOD WBC-3.9* RBC-2.81* Hgb-8.6* Hct-26.7* \nMCV-95 MCH-30.6 MCHC-32.2 RDW-16.0* RDWSD-56.4* Plt ___\n___ 07:10AM BLOOD ___\n___ 07:10AM BLOOD Glucose-100 UreaN-37* Creat-1.9* Na-144 \nK-3.9 Cl-105 HCO3-29 AnGap-14\n___ 07:10AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8\n\nIMAGING\n=====\n___ CXR\nFINDINGS: \nThere is mild pulmonary edema with superimposed region of more \nconfluent consolidation in the left upper lung. There are \npossible small bilateral pleural effusions. Moderate \ncardiomegaly is again seen as well as tortuosity of the \ndescending thoracic aorta. No acute osseous abnormalities.\n \nIMPRESSION: \nMild pulmonary edema with superimposed left upper lung \nconsolidation, potentially more confluent edema versus \nsuperimposed infection.\n\n \nBrief Hospital Course:\n___ year-old female with history of hypertension, CAD s/p DES \nwith ischemic MR and systolic dysfunction, ___, hx of DVT, who \nadmitted for CHF exacerbation.\n\n# Acute on chronic decompensated heart failure: presented in the \nsetting of high salt diet with dyspnea on exertion, decreased \nexercise tolerance, ___ edema, crackles on exam, elevated BNP to \n10K, 8lbs above dry weight and pulmonary congestion on CXR. \nLater discovered on pharmacy review that patient had not filled \ntorsemide after last outpatient Cardiology appointment where she \nwas instructed to start taking it. Troponins cycled and \nnegative. On admission, she was placed on a salt and fluid \nrestricted diet. She was diuresed with IV Lasix 80mg for 2 days \nand then transitioned to po torsemide 40mg with steady weight \ndecline and net negative fluid balance of goal -___ and \nstable renal function. Electrolytes repleted for goal Mg>2 and \nK>4. She was continued on home carvedilol 12.5mg BID, \natorvastatin 80mg daily and lisinopril 40mg daily for blood \npressure control and increased home nifedipine CR from 30 to \n60mg BID to achieve goal SBP <140. Discharged with close PCP and \n___ to monitor weights and blood pressure \ncontrol.\n\n# Hypertension: She was continued on home carvedilol 12.5mg BID, \natorvastatin 80mg daily and lisinopril 40mg daily for blood \npressure control and increased home nifedipine CR from 30 to \n60mg BID to achieve goal SBP <140. \n\n# Positive U/A: patient asymptomatic but with 32WBCs, ___, \n+bacteria (although 3 epis). Asymptomatic with no \nfevers/dysuria/malaise. Urine culture negative.\n\n# Left upper lung consolidation: infiltrate per Radiology read \non admission CXR. No cough, fevers, leukocytosis. Rereviewed \nwith on-call radiologist who favored pulmonary edema with no \nneed for repeat imaging or PNA treatment unless clinically \nindicated. Monitored without any significant clinical findings.\n\n# DVT: anticoagulated on Coumadin goal 2.0-3.0, no signs of \nthrombus on exam. Daily INR trended and continued on home \nCoumadin 5mg daily. \n\n# Anemia: no signs of external loss, specifically denying any \nmelena. Chronically anemic with baseline ___, presented with Hgb \n8. Likely ___ renal disease and ACD however elevated MCV \nindicates possible reticulocytosis. Altogether low suspicion for \nGIB so Coumadin was continued. Reticulocytes 2.4 which is \ninappropriate arguing against acute loss. Trended daily CBC with \nnoted uprising by discharge.\n\n# Chronic kidney disease, stage IV- baseline ___, likely ___ \nHTN and DM. Renally dosed medications and trended Cr with no \nsignificant change. \n# HLD: continued home atorvastatin\n# DM: held home 25U 70/30. Patient maintained on aspart ISS and \nglargine qHS with good glycemic control.\n\nTRANSITIONAL ISSUES\n==================\nCHF: diuresed with IV lasix, transitioned to po diuretics, \ndischarged home on 40mg po torsemide, to take in the AM and take \na banana. Pt complained of unilateral R-sided incomplete hearing \nloss on day of discharge- was not felt to be related to \ndiuretics but would ___.\nHTN: increased nifedipine CR to 60mg BID given elevated SBPs. \nPlease f/u at next appointments.\nAnemia: multiple prior workups showing ACD. Hgb 8s during \nadmission\nPrior DVT/PE: continued on warfarin, will need continued \nmonitoring\nDM: stopped home 70/30 while in-house and put on \naspart/glargine, discharged on home regimen\n\nDischarge weight: 74kg\nDischarge Cr: 1.9\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Carvedilol 12.5 mg PO BID \n5. Docusate Sodium 100 mg PO BID \n6. Gabapentin 100 mg PO QHS neuropathic pain \n7. Lisinopril 40 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. NIFEdipine CR 30 mg PO BID \n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n11. Pantoprazole 40 mg PO Q12H \n12. Polyethylene Glycol 17 g PO DAILY \n13. Senna 8.6 mg PO BID constipation \n14. Vitamin D ___ UNIT PO DAILY \n15. Warfarin 5 mg PO DAILY16 \n16. Allopurinol ___ mg PO EVERY OTHER DAY \n17. Torsemide 40 mg PO DAILY \n18. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL \n(70-30) subcutaneous 25 units with dinner \n\n \nDischarge Medications:\n1. HumuLIN 70/30 (insulin NPH and regular human) 100 unit/mL \n(70-30) subcutaneous 25 units with dinner \n2. Warfarin 5 mg PO DAILY16 \n3. Vitamin D ___ UNIT PO DAILY \n4. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever \n5. Allopurinol ___ mg PO EVERY OTHER DAY \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Docusate Sodium 100 mg PO BID \n9. Gabapentin 100 mg PO QHS neuropathic pain \n10. Lisinopril 40 mg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n13. Polyethylene Glycol 17 g PO DAILY \n14. Senna 8.6 mg PO BID constipation \n15. Torsemide 40 mg PO DAILY \nRX *torsemide 20 mg 2 tablet(s) by mouth once daily Disp #*60 \nTablet Refills:*0\n16. Pantoprazole 20 mg PO Q12H \n17. Carvedilol 25 mg PO BID \n18. NIFEdipine CR 60 mg PO BID \nRX *nifedipine 20 mg 3 capsule(s) by mouth twice daily Disp \n#*180 Capsule Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses:\nAcute on chronic decompensated congestive Heart Failure\nHypertension\n\nSecondary Diagnoses:\nAnemia\nDiabetes mellitus\nPrior deep vein thrombosis\nChronic Kidney Disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMrs. ___, \n\n___ were admitted to ___ for treatment of your congestive \nheart failure and hypertension. ___ were given IV diuretics with \nimprovement in your symptoms, labs and exam. We increased one of \nyour blood pressure medications and continued your other home \nmedicines. \n\nIt was a pleasure taking care of ___ during your stay- we wish \n___ all the best!\n\n- Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I5023", "N184", "D631", "E1121", "Z86718", "I129", "Z955", "I2510", "Z7901", "Z794", "I340", "I252", "Z8673", "Z87891", "Z91128", "E785" ]

[ "I5023: Acute on chronic systolic (congestive) heart failure", "N184: Chronic kidney disease, stage 4 (severe)", "D631: Anemia in chronic kidney disease", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "Z86718: Personal history of other venous thrombosis and embolism", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z955: Presence of coronary angioplasty implant and graft", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "I340: Nonrheumatic mitral (valve) insufficiency", "I252: Old myocardial infarction", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "Z91128: Patient's intentional underdosing of medication regimen for other reason", "E785: Hyperlipidemia, unspecified" ]

[ "Z86718", "I129", "Z955", "I2510", "Z7901", "Z794", "I252", "Z8673", "Z87891", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nBladder cancer\n \nMajor Surgical or Invasive Procedure:\nrobotic anterior exenteration and open ileal conduit\n\n \nHistory of Present Illness:\n___ with invasive bladder cancer, pelvic MRI concerning for \ninvasion into anterior vaginal wall, now s/p robotic anterior \nexent (Dr ___ and open ileal conduit (Dr ___.\n \nPast Medical History:\nHypertension, laparoscopic cholecystectomy\nsix months ago, left knee replacement six to ___ years ago,\nlaminectomy of L5-S1 at age ___, two vaginal deliveries.\n\n \nSocial History:\n___\nFamily History:\nNegative for bladder CA.\n\n \nPhysical Exam:\nA&Ox3\nBreathing comfortably on RA\nWWP\nAbd S/ND/appropriate postsurgical tenderness to palpation\nUrostomy pink, viable\n \nPertinent Results:\n___ 06:50AM BLOOD WBC-7.6 RBC-3.41* Hgb-10.6* Hct-32.5* \nMCV-95 MCH-31.1 MCHC-32.6 RDW-14.4 RDWSD-50.2* Plt ___\n___ 06:50AM BLOOD Plt ___\n___ 06:45AM BLOOD Glucose-117* UreaN-23* Creat-0.6 Na-136 \nK-4.4 Cl-104 HCO3-23 AnGap-13\n___ 06:45AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0\n \nBrief Hospital Course:\nMs. ___ was admitted to the Urology service after \nundergoing [robotic anterior exenteration with ileal conduit]. \nNo concerning intrao-perative events occurred; please see \ndictated operative note for details. Patient received \n___ intravenous antibiotic prophylaxis and deep vein \nthrombosis prophylaxis with subcutaneous heparin. The \npost-operative course was notable for several episodes of emesis \nprompting NGT placement on ___. Pt self removed the NGT on ___, \nbut nausea/emesis resolved thereafter and pt was gradually \nadvanced to a regular diet with passage of flatus without issue. \n With advacement of diet, patient was transitioned from IV pain \nmedication to oral pain medications. The ostomy nurse\nsaw the patient for ostomy teaching. At the time of discharge \nthe wound was healing well with no evidence of erythema, \nswelling, or purulent drainage. Her drain was removed. The \nostomy was perfused and patent, and one ureteral stent had \nfallen out spontaneously. ___ was consulted and recommended \ndisposition to rehab. Post-operative follow up appointments \nwere arranged/discussed and the patient was discharged to rehab \nfor further recovery.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Heparin 5000 UNIT SC ONCE \nStart: in O.R. Holding Area \n2. Losartan Potassium 50 mg PO DAILY \n3. Atorvastatin 10 mg PO QPM \n4. Levothyroxine Sodium 175 mcg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \ntake while taking narcotic pain meds \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*50 Capsule Refills:*0 \n3. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \nRX *enoxaparin 40 mg/0.4 mL 40 mg sc daily Disp #*28 Syringe \nRefills:*0 \n4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY \ntake while ureteral stents are in place \nRX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 \ncapsule(s) by mouth daily Disp #*14 Capsule Refills:*0 \n5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*30 Tablet \nRefills:*0 \n6. Atorvastatin 10 mg PO QPM \n7. Levothyroxine Sodium 175 mcg PO DAILY \n8. Losartan Potassium 50 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nBladder cancer\n\n \nDischarge Condition:\nWdWn, NAD, AVSS\nAbdomen soft, appropriately tender along incision\nIncision is c/d/I (steris)\nStoma is well perfused; Urine color is yellow\nUreteral stent noted via stoma\nJP drain has been removed\nBilateral lower extremities are warm, dry, well perfused. There \nis no reported calf pain to deep palpation. No edema or pitting\n\n \nDischarge Instructions:\n-Please also refer to the handout of instructions provided to \nyou by your Urologist\n-Please also refer to the instructions provided to you by the \nOstomy nurse specialist that details the required care and \nmanagement of your Urostomy\n-You will be sent home with Visiting Nurse ___ \nservices to facilitate your transition to home care of your \nurostomy\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-___ you have been prescribed IBUPROFEN, please note that you may \ntake this in addition to the prescribed NARCOTIC pain \nmedications and/or tylenol. FIRST, alternate Tylenol \n(acetaminophen) and Ibuprofen for pain control.\n-REPLACE the Tylenol with the prescribed narcotic if the \nnarcotic is combined with Tylenol (examples include brand names \n___, Tylenol #3 w/ codeine and their generic \nequivalents). ALWAYS discuss your medications (especially when \nusing narcotics or new medications) use with the pharmacist when \nyou first retrieve your prescription if you have any questions. \nUse the narcotic pain medication for break-through pain that is \n>4 on the pain scale.\n-The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 4 grams (from \nALL sources) PER DAY and remember that the prescribed narcotic \npain medication may also contain Tylenol (acetaminophen) so this \nneeds to be considered when monitoring your daily dose and \nmaximum.\n-If you are taking Ibuprofen (Brand names include ___ \nthis should always be taken with food. If you develop stomach \npain or note black stool, stop the Ibuprofen.\n-Please do NOT drive, operate dangerous machinery, or consume \nalcohol while taking narcotic pain medications.\n-Do NOT drive and until you are cleared to resume such \nactivities by your PCP or urologist. You may be a passenger\n-Colace may have been prescribed to avoid post surgical \nconstipation and constipation related to narcotic pain \nmedication. Discontinue if loose stool or diarrhea develops. \nColace is a stool-softener, NOT a laxative.\n-You may shower 2 days after surgery, but do not tub bathe, \nswim, soak, or scrub incision for 2 weeks\n-If you had a drain or skin clips (staples) removed from your \nabdomen; bandage strips called “steristrips” have been applied \nto close the wound OR the site was covered with a gauze \ndressing. Allow any steristrips/bandage strips to fall off on \ntheir own ___ days). PLEASE REMOVE any \"gauze\" dressings within \ntwo days of discharge. Steristrips may get wet.\n-No heavy lifting for 4 weeks (no more than 10 pounds). Do \"not\" \nbe sedentary. Walk frequently. Light household chores (cooking, \nfolding laundry, washing dishes) are generally “ok” but AGAIN, \navoid straining, pulling, twisting (do NOT vacuum).\n\n \nFollowup Instructions:\n___\n" ]

[ "C675", "I10", "D259", "Z87891", "E785", "E890" ]

[ "C675: Malignant neoplasm of bladder neck", "I10: Essential (primary) hypertension", "D259: Leiomyoma of uterus, unspecified", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "E890: Postprocedural hypothyroidism" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\n dyspnea on exertion \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPatient is a ___ year old woman s/p robotic radical cystectomy \n___ (with ileal conduit creation) with postop course \ncomplicated by bacteremia and abscess, LLE DVT (on prophylactic \ndosing lovenox) who presents with dyspnea on exertion for past 3 \ndays. \n\nBriefly, patient was initially admitted to the Urology service \nfrom ___ for robotic anterior exenteration with ileal \nconduit. She was discharged to rehab on prophylactic dosing \nlovenox for 1 month. She was then readmitted from ___ for \nileus requiring NGT decompression, TPN. BCx grew Citrobacter, \nfor which CTX was started. CT showed intra-abdominal, interloop, \nsimple fluid collection and LLQ drain was placed by ___. Patient \nimproved, passing BMs and tolerating PO, and was discharged on \ncipro/flagyl. She was also discharged on PO Bactrim for presumed \nUTI, though unclear if she actually took this. During this \nadmission, she was noted to have new bilateral ___ edema. LENIs \nat the time showed aute deep vein thrombosis of the duplicated \nmid and distal left femoral veins. She was discharged on \nEnoxaparin Sodium 40 mg SC daily. She reports that her PCP \nstarted PO ___ 20mg daily and since then there has been \nimprovement of the swelling. Per her report, a repeat ___ at \nthe rehab facility (___) was negative for DVT.\n\nPatient reports that she recovered well post-operatively and was \ndoing well at her assisted living facility up until a week ago \nwhen she began experiencing dyspnea on exertion. She states that \nshe typically is able to ambulate a block before stopping to \ncatch her breath, however in the past week she has been unable \nto take more than a few steps. She states that it has become \nincreasingly more difficult to ambulate from her bedroom to the \nbathroom. When visited by the NP her ambulatory saturation was \nnoted to be in the ___ with associated tachycardia to 110, \npallor and diaphoresis. She endorses associated leg swelling \nleft worse than right, and she states that her thighs \"feel \nheavy\". She denies any associated chest pain, fever, chills, \npain with deep inspiration, abdominal pain, rashes, dizziness, \nlightheadedness. \n\nIn the ED, initial VS were: 97.7 72 136/93 20 100% Nasal Cannula \n\nED physical exam was recorded as patient resting comfortably \nwith NC, pursed lip breathing, unable to speak in full sentences \nbefore becoming short of breath, urostomy pouch in RLQ, stoma \npink, 2+ edema to bilateral lower extremities L>R. \n\nED labs were notable for: Hb 9, Hct 29, plt 479, UA: large ___, \n>182 WBC, many bact 0 epi. Trop neg x1, proBNP normal\n\nCTA chest showed:\n1. Extensive pulmonary embolism with thrombus seen extending \nfrom the right main pulmonary artery into the segmental and \nsubsegmental right upper, middle, and lower lobe pulmonary \narteries. No right heart strain identified. 2. Additionally, \nthere are smaller pulmonary emboli seen in the segmental and \nsubsegmental branches of the left upper and lower lobes. 3. \nSeveral pulmonary nodules are noted, as noted previously, with \nthe largest appearing spiculated and measuring up to 1 cm in the \nright middle lobe, suspicious for malignancy on the previous \nPET-CT. 4. Re- demonstration of 2 left breast nodules for which \ncorrelation with mammography and ultrasound is suggested.\n\nEKG showed NSR with frequent PAC\n\nPatient was given:\n___ 20:26 PO/NG Ciprofloxacin HCl 500 mg \n___ 20:26 IV Heparin 6600 UNIT \n___ 20:26 IV Heparin \n\nTransfer VS were: 98.1 77 145/63 20 99% Nasal Cannula \n When seen on the floor, she reports significant dyspnea with \nminimal exertion. Denies chest pain, palpitations, \nlightheadedness.\nA ten point ROS was conducted and was negative except as above \nin the HPI.\n \nPast Medical History:\nHypertension, laparoscopic cholecystectomy, left knee \nreplacement six to ___ years ago, laminectomy of L5-S1 at age \n___, two vaginal deliveries.\n\ns/p ___: \n1. Robot-assisted laparoscopic bilateral pelvic lymph node \ndissection.\n2. Robot-assisted hysterectomy and bilateral oophorectomy for \nlarge uterus, greater than 300 grams, with large fibroid.\n3. Laparoscopic radical cystectomy and anterior vaginectomy with \nvaginal reconstruction.\n\n \nSocial History:\n___\nFamily History:\nNegative for bladder CA.\n\n \nPhysical Exam:\nADMISSION EXAM:\n Gen: NAD, speaking in 3 word sentences, pursed lip breathing, \nno accessory muscle use, lying in bed\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n Cardiovasc: RRR, no MRG, full pulses, 1+ edema bilaterally with \ncompression stockings in place, no JVD \n Resp: normal effort, no accessory muscle use, lungs CTA ___ to \nanterior auscultation.\n GI: soft, NT, ND, BS+. Urostomy site does not appear infected\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\nDISCHARGE EXAM:\nvitals: 98.3 140/42 90 24 96% 1L\nGen: Lying in bed in no apparent distress\nHEENT: Anicteric, MMM\nCardiovascular: RRR normal S1, S2, no right sided heave, ___ \nsystolic murmur \nPulmonary: Lung fields clear to auscultation throughout. No \ncrackles or wheezing. \nGI: Soft, distended, nontender, bowel sounds present, urostomy \nin place.\nExtremities: no edema, though left leg appears larger than right \nleg, warm, well perfused with motor function intact. Her left \nlower leg is wrapped. \n\n \nPertinent Results:\nLABS:\n==========================\nAdmission labs:\n___ 02:40PM GLUCOSE-101* UREA N-22* CREAT-0.7 SODIUM-136 \nPOTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-22 ANION GAP-20\n___ 02:40PM cTropnT-<0.01\n___ 02:40PM proBNP-567\n___ 02:40PM WBC-7.7 RBC-3.07* HGB-9.0* HCT-29.1* MCV-95 \nMCH-29.3 MCHC-30.9* RDW-14.9 RDWSD-52.1*\n___ 02:40PM PLT COUNT-479*\n___ 02:40PM ___ PTT-33.4 ___\n\nDischarge labs:\n___ 06:55AM BLOOD WBC-11.0* RBC-2.60* Hgb-7.5* Hct-24.5* \nMCV-94 MCH-28.8 MCHC-30.6* RDW-14.8 RDWSD-51.4* Plt ___\n___ 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.5 Na-141 \nK-4.3 Cl-105 HCO3-26 AnGap-14\n___ 06:55AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0\n___ 07:15AM BLOOD calTIBC-134* Ferritn-507* TRF-103*\n___ 07:15AM BLOOD Iron-18*\n\nMICROBIOLOGY\n==========================\n___ 4:30 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n ENTEROCOCCUS SP.. >100,000 CFU/mL. \n PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ <=2 S\nNITROFURANTOIN-------- <=16 S\nTETRACYCLINE---------- <=1 S\nVANCOMYCIN------------ 1 S\n\nIMAGING\n==========================\n___ CXR\nIMPRESSION: Hilar congestion without frank edema. No convincing \nsigns of pneumonia.\n\n___ CTA chest showed:\n1. Extensive pulmonary embolism with thrombus seen extending \nfrom the right main pulmonary artery into the segmental and \nsubsegmental right upper, middle, and lower lobe pulmonary \narteries. No right heart strain identified. 2. Additionally, \nthere are smaller pulmonary emboli seen in the segmental and \nsubsegmental branches of the left upper and lower lobes. 3. \nSeveral pulmonary nodules are noted, as noted previously, with \nthe largest appearing spiculated and measuring up to 1 cm in the \nright middle lobe, suspicious for malignancy on the previous \nPET-CT. 4. Re- demonstration of 2 left breast nodules for which \ncorrelation with mammography and ultrasound is suggested.\n\n___ ___:\nIMPRESSION:\n1. Interval progression of deep vein thrombosis in the left \nlower extremity, with occlusive thrombus involving the entire \nfemoral vein, previously only involving the mid and distal \nfemoral vein. There is additional nonocclusive thrombus in the \ndeep femoral vein. The left common femoral and popliteal veins \nare patent.\n2. The bilateral calf veins were not visualized due to an \noverlying dressing. Otherwise no evidence of deep venous \nthrombosis in the right lower extremity.\n\n___ TTE:\nConclusions\nThe left atrium is normal in size. The estimated right atrial \npressure is ___ mmHg. Left ventricular wall thickness, cavity \nsize, and global systolic function are normal (LVEF>55%). \nDoppler parameters are most consistent with Grade I (mild) left \nventricular diastolic dysfunction. Right ventricular chamber \nsize and free wall motion are normal. The aortic valve leaflets \nare mildly thickened (?#). There is no aortic valve stenosis. \nTrivial mitral regurgitation is seen. There is mild pulmonary \nartery systolic hypertension. \n\n___ CXR\nIMPRESSION: \nCompared to chest radiographs ___ through ___. \nHeart size top-normal. Lungs grossly clear. No pleural \nabnormality or evidence of central lymph node enlargement.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman s/p robotic radical cystectomy \n___omplicated by bacteremia and \nabscess, LLE DVT, currently on daily lovenox who presents with \ndyspnea on exertion and dyspnea on exertion and found to have \nlarge PE and progression of DVT.\n\n# PE/DVT: Likely due to undertreatment of known LLE DVT with \nprophylactic dosing of lovenox. Given underdosing of lovenox, \nthis was not thought to be treatment failure and IVC filter was \ndeferred. She had no signs of right heart strain on imaging, \nEKG, exam. TTE showed no evidence of right heart strain. She was \ntreated with a heparin gtt, then transitioned to treatment dose \nlovenox given malignancy associated thrombosis as noted in CLOT \ntrial. She is quite symptomatic and requires oxygen \nsupplementation, though improved during hospitalization. Please \nwean oxygen as tolerated.\n\n# Pulmonary nodules: Known spiculated masses that were noted on \nCT in ___, concerning for primary lung malignancy vs mets. \nCurrent CT showed stable nodules still concerning for \nmalignancy. She was evaluated by the thoracic team who \nrecommended CT biopsy vs. surveillance. Given her current \nPE/DVT, the family and the patient decided for surveillance at \nthis time. They will follow up with her primary care provider. \n\n# Enterococcal UTI\nShe was noted to have rising WBC in the setting of UCX from \nurostomy growing Enterococcus. Given her rising leukocytosis, we \nproceeded with treatment. She was started on IV Ampicillin and \ntransitioned to macrobid, based on sensitivies. Leukocytosis \nimproved on antibiotics. She should complete a 7 day course (day \n1: ___, day 7: ___. \n\n# Normocytic Anemia: No signs of bleeding, or hemolysis. Hb \ndropped to nadir of 7.3, stable at discharge at 7.5. Iron \nstudies consistent with likely combination iron deficiency \nanemia and anemia of chronic disease with low iron but elevated \nferritin and low TIBC. Would recommend checking again as \noutpatient and work-up as needed.\n\n# ___ swelling: Likley multifactorial including venous \ninsufficiency, as well as known LLE DVT. She responded quite \nwell with compression stockings.\n\n# Hx of bladder cancer: s/p ___ TURBT, high-grade TCC, T1 \n(no muscle identified). Then in ___, pelvic MRI showed \nbladder mass invasion, perivesical soft tissue, anterior vaginal \nwall on right (C/W T4 lesion). In ___, underwent robotic \nTAH-BSO, lap radical cystectomy and anterior vaginectomy with \npathology showing pT2b, node and margins negative. No plan for \nany further therapy at this time per Dr ___.\n\nThe patient is safe to discharge today, and >30min were spent on \ndischarge day management services.\n\nTransitional issues:\n- She will need follow up chest CT for pulmonary nodules in 3 \nmonths (___)\n- To complete 7 day course for UTI with macrobid (day 7: ___\n- Continue oxygen therapy and wean as tolerated to maintain O2 \nsat > 92% \n- Please check CBC on ___ to ensure stability of h/h \nand demonstrate resolution of leukocytosis\n- HCP: son, Dr. ___ ___\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 650 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \n3. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n4. Levothyroxine Sodium 175 mcg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Losartan Potassium 50 mg PO DAILY \n7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate \n\n8. LORazepam 0.25 mg PO BID:PRN anxiety \n9. Senna 8.6 mg PO BID \n\n \nDischarge Medications:\n1. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H \nLast day: ___. Enoxaparin Sodium 90 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n3. LORazepam 0.25 mg PO QHS:PRN insomnia \nRX *lorazepam 0.5 mg 0.5 (One half) tab by mouth QHS:prn Disp \n#*3 Tablet Refills:*0 \n4. Acetaminophen 650 mg PO Q6H \n5. Atorvastatin 10 mg PO QPM \n6. Docusate Sodium 100 mg PO BID \n7. Levothyroxine Sodium 175 mcg PO DAILY \n8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q8H:prn Disp #*3 Tablet \nRefills:*0 \n9. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPE\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:\nMs. ___ it was a pleasure taking care you during your \nadmission to ___. You were admitted for a clot in your lungs \nand leg. You were treated with a blood thinner. You will need to \ncontinue the blood thinner. You were also treated for a urinary \ntract infection. For your pulmonary nodules, you should follow \nup with your primary care doctor. \n \nFollowup Instructions:\n___\n" ]

[ "I2699", "I82412", "N390", "I471", "I10", "I872", "R918", "B952", "E039", "E785", "E876", "E8342", "G4700", "K5900", "Z66", "N63", "D509", "D638", "Z7901", "Z8551", "Z906", "Z87891", "Z96652" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "I82412: Acute embolism and thrombosis of left femoral vein", "N390: Urinary tract infection, site not specified", "I471: Supraventricular tachycardia", "I10: Essential (primary) hypertension", "I872: Venous insufficiency (chronic) (peripheral)", "R918: Other nonspecific abnormal finding of lung field", "B952: Enterococcus as the cause of diseases classified elsewhere", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "E876: Hypokalemia", "E8342: Hypomagnesemia", "G4700: Insomnia, unspecified", "K5900: Constipation, unspecified", "Z66: Do not resuscitate", "N63: Unspecified lump in breast", "D509: Iron deficiency anemia, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "Z7901: Long term (current) use of anticoagulants", "Z8551: Personal history of malignant neoplasm of bladder", "Z906: Acquired absence of other parts of urinary tract", "Z87891: Personal history of nicotine dependence", "Z96652: Presence of left artificial knee joint" ]

[ "N390", "I10", "E039", "E785", "G4700", "K5900", "Z66", "D509", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, distention, nausea\n \nMajor Surgical or Invasive Procedure:\nInterventional radiology placement of abdominal abscess drain\n\n \nHistory of Present Illness:\n___ F with h/o muscle invasive bladder cancer, returning to \nthe ED POD 15 with abdominal pain, nausea, and distension. She \nhas been obstipated for nearly three days. KUB and CT scan \nnotable for dilated loops, air fluids, and tapering small bowel \nwithout an obvious transition point. Labwork notable for ___ \nand\nleukocytosis. Concerned for small bowel obstruction or an ileus \nin presence ___ and leukocytosis she was re-admitted for IVF, \nbowel rest, NGT decompression. \n \nPast Medical History:\nHypertension, laparoscopic cholecystectomy, left knee \nreplacement six to ___ years ago, laminectomy of L5-S1 at age \n___, two vaginal deliveries.\n\ns/p ___: \n1. Robot-assisted laparoscopic bilateral pelvic lymph node \ndissection.\n2. Robot-assisted hysterectomy and bilateral oophorectomy for \nlarge uterus, greater than 300 grams, with large fibroid.\n3. Laparoscopic radical cystectomy and anterior vaginectomy with \nvaginal reconstruction.\n\n \nSocial History:\n___\nFamily History:\nNegative for bladder CA.\n\n \nPhysical Exam:\nWdWn, NAD, AVSS\nAbdomen soft, appropriately tender along incision\nIncision is c/d/I\nStoma is well perfused; Urine color is yellow\nBilateral lower extremities are warm, dry, well perfused. There \nis no reported calf pain to deep palpation. Bilateral lower \nextremities have 2+ pitting edema but no erythema, callor, pain. \n\nPigtail drain has been removed - dressing c/d/i\n \nPertinent Results:\n___ 05:58AM BLOOD WBC-9.9 RBC-2.76* Hgb-8.2* Hct-26.2* \nMCV-95 MCH-29.7 MCHC-31.3* RDW-13.9 RDWSD-47.3* Plt ___\n___ 06:45AM BLOOD WBC-10.3* RBC-2.87* Hgb-8.7* Hct-27.7* \nMCV-97 MCH-30.3 MCHC-31.4* RDW-14.0 RDWSD-49.4* Plt ___\n___ 05:13AM BLOOD WBC-11.6* RBC-3.27* Hgb-9.8* Hct-31.0* \nMCV-95 MCH-30.0 MCHC-31.6* RDW-13.6 RDWSD-47.5* Plt ___\n___ 07:06PM BLOOD WBC-22.5*# RBC-3.58* Hgb-10.9* Hct-34.0 \nMCV-95 MCH-30.4 MCHC-32.1 RDW-13.9 RDWSD-47.9* Plt ___\n___ 07:06PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3* \nEos-0 Baso-0 ___ Metas-1* Myelos-0 Hyperse-1* AbsNeut-20.48* \nAbsLymp-1.13* AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00*\n___ 01:04PM BLOOD ___ PTT-30.9 ___\n___ 05:58AM BLOOD Glucose-106* UreaN-26* Creat-0.4 Na-136 \nK-4.6 Cl-107 HCO3-26 AnGap-8\n___ 06:45AM BLOOD Glucose-114* UreaN-32* Creat-0.4 Na-137 \nK-4.1 Cl-106 HCO3-25 AnGap-10\n___ 06:00AM BLOOD Glucose-121* UreaN-39* Creat-0.4 Na-140 \nK-3.6 Cl-107 HCO3-26 AnGap-11\n___ 07:06PM BLOOD Glucose-117* UreaN-60* Creat-1.7*# Na-133 \nK-5.0 Cl-96 HCO3-21* AnGap-21*\n___ 08:30AM BLOOD ALT-20 AST-19 AlkPhos-77\n\n___ 05:58AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.2\n___ 06:45AM BLOOD Calcium-7.7* Phos-2.4* Mg-2.1\n\n___ 08:30AM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.5 Mg-2.1 \nIron-23*\n___ 07:06PM BLOOD Calcium-8.0* Phos-5.5* Mg-2.2\n___ 08:30AM BLOOD calTIBC-116* Ferritn-789* TRF-89*\n___ 05:09AM BLOOD Triglyc-106\n___ 08:30AM BLOOD Triglyc-89\n\n___ 07:06PM BLOOD Lactate-1.5\n\n___ 03:00PM ASCITES Creat-0.4 Amylase-18 Triglyc-29 \nLipase-8\n___ 03:00PM OTHER BODY FLUID Creat-0.5\n\n___ 7:12 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n CITROBACTER KOSERI. FINAL SENSITIVITIES. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n CITROBACTER KOSERI\n | \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\n Aerobic Bottle Gram Stain (Final ___: \n GRAM NEGATIVE ROD(S). \n Reported to and read back by ___ ___, @14:35 ON \n___. \n\n___ 3:00 pm ABSCESS . PELVIC ASPIRATION. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n\n WOUND CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Final ___: \n BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. \n BETA LACTAMASE POSITIVE. \n\n___ 10:52 am STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n C. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Illumigene DNA\n amplification assay. \n (Reference Range-Negative). \n\n \nBrief Hospital Course:\nMs. ___ was admitted to Dr. ___ service for \nmanagement of ileus. Upon admission, a nasogastric tube was \nplaced for decompression. On ___, PICC was placed and TPN \nstarted. Blood cultures grew gram negative rods and ceftriaxone \nwas started. On ___, pt started to pass small amount of \nflatus. ___ CT scan demonstrated improving ileus, but concern \nfor possible urine leak and increased free fluid. On ___, a \nLLQ drain was placed by interventional radiology. on ___, pt \npassed clamp trial and NGT was removed. Pt continued to pass \nflatus and also started to have bowel movements. On ___, pt \nwas advanced to a clear liquid diet. Repeat blood cultures were \nnegative and positive blood culture from admission grew \ncitrobacter. Diet was gradually advanced and ensure added. IV \nmedications were gradually converted to PO and she was \nre-evaluated by physical therapy for rehabilitative services. \nShe was ambulating with walker assistance and prepared for \ndischarge to her ___ facility (___). TPN was \ncontinued up until day before discharge. At time of discharge, \nshe was tolerating regular diet, passing flatus regularly and \nhaving bowel movements. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 10 mg PO QPM \n2. Levothyroxine Sodium 175 mcg PO DAILY \n3. Losartan Potassium 50 mg PO DAILY \n4. Acetaminophen 650 mg PO Q6H \n5. Docusate Sodium 100 mg PO BID \n6. Enoxaparin Sodium 40 mg SC DAILY \n7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY \n8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate \n\n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days \nLast dose ___ \n2. MetroNIDAZOLE 500 mg PO Q6H Duration: 7 Days \nLast dose ___ \n3. Senna 8.6 mg PO BID \n4. Acetaminophen 650 mg PO Q6H \n5. Atorvastatin 10 mg PO QPM \n6. Docusate Sodium 100 mg PO BID \n7. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n8. Levothyroxine Sodium 175 mcg PO DAILY \n9. LORazepam 0.25 mg PO BID:PRN anxiety \n10. Losartan Potassium 50 mg PO DAILY \n11. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY \n12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nbladder cancer, post-operative ileus, bacteremia (CITROBACTER \nKOSERI) and abdominal-pelvic abscess (BACTEROIDES FRAGILIS \nGROUP) requiring ___ drainage\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n-Please also refer to the instructions provided to you by the \nOstomy nurse specialist that details the required care and \nmanagement of your Urostomy\n\n-Resume your pre-admission/home medications except as noted. \nAlways call to inform, review and discuss any medication changes \nand your post-operative course with your primary care doctor\n\n-___ (acetaminophen) and Ibuprofen for pain control.\n\n-Ciprofloxacin and Metronidazole are new ANTIBIOTIC medications \nto treat your infection. Continue for 7 days through ___.\n\n-The MAXIMUM dose of Tylenol (ACETAMINOPHEN) is 3 grams (from \nALL sources) PER DAY \n\n-If you are taking Ibuprofen (Brand names include ___ \nthis should always be taken with food. If you develop stomach \npain or note black stool, stop the Ibuprofen.\n\n-Please do NOT drive, operate dangerous machinery, or consume \nalcohol while taking narcotic pain medications.\n\n-Do NOT drive and until you are cleared to resume such \nactivities by your PCP or urologist. You may be a passenger\n\n-Colace may have been prescribed to avoid post surgical \nconstipation and constipation related to narcotic pain \nmedication. Discontinue if loose stool or diarrhea develops. \nColace is a stool-softener, NOT a laxative.\n\n-No heavy lifting for 4 weeks (no more than 10 pounds). Do \"not\" \nbe sedentary. Walk frequently. Light household chores (cooking, \nfolding laundry, washing dishes) are generally “ok” but AGAIN, \navoid straining, pulling, twisting (do NOT vacuum).\n\n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "K651", "N179", "I82412", "C679", "I10", "B966", "R7881", "Y838", "Y9289", "F17210", "Z436", "Z90710", "D72829", "Z96652" ]

[ "T814XXA: Infection following a procedure", "K651: Peritoneal abscess", "N179: Acute kidney failure, unspecified", "I82412: Acute embolism and thrombosis of left femoral vein", "C679: Malignant neoplasm of bladder, unspecified", "I10: Essential (primary) hypertension", "B966: Bacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhere", "R7881: Bacteremia", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y9289: Other specified places as the place of occurrence of the external cause", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z436: Encounter for attention to other artificial openings of urinary tract", "Z90710: Acquired absence of both cervix and uterus", "D72829: Elevated white blood cell count, unspecified", "Z96652: Presence of left artificial knee joint" ]

[ "N179", "I10", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nFevers and chills\n \nMajor Surgical or Invasive Procedure:\n___ -- stent exchange\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with the past\nmedical history notable for history of bladder cancer status \npost\nrobotic TAH-BSO, lap radical cystectomy with ileal loop \ndiversion\nand anterior vaginectomy in ___ complicated by abdominal\nfluid requiring placement of drainage catheters, further\ncomplicated by a severe bilateral hydronephrosis requiring\nbilateral urostomy tube placement and then ultimately ureteral\nstent placements with improvement who presented to the hospital\nfor routine stent exchange and cystoscopy. The patient \nunderwent\nan uncomplicated procedure but then postoperatively in the PACU\nshe developed a fever to 102.4 and was tachycardic 105 and as\nsuch was felt to need admission for treatment of sepsis. At \nthat\ntime she was given ampicillin and gentamicin given her history \nof\ndrug resistant organisms. She reported at that time she was\nfeeling feverish and chills with nausea and vomiting x1. She\nreceived IV fluids and her IV antibiotics and her symptoms\nimproved. She was admitted to the medical service for further\nevaluation and management\n\nOn the floor the patient reports that she continues to have\npersistent chills. She feels slightly nauseous. She denies any\nabdominal pain. She otherwise reports that she is feeling \nbetter\nthan she did immediately postprocedural but is still\nsignificantly off of her baseline. She reports that she has a\nhistory of urinary tract infections and was most recently on\nciprofloxacin and ___. She reports that she was on\nthis medication for 7-day course. No ___ acute complaints.\n\n \nPast Medical History:\n- Hypertension \n - s/p lap chole \n - s/p left knee replacement \n - s/p laminectomy of L5-S1 at age ___ \n - Bladder Cancer high grade TCC, T1 diagnosed in ___, then \n___ pelvic MRI w/invasion into bladder wall, perivesical \nsoft tissue and anterior vaginal wall c/w T4 staging \n - s/p hysterectomy and bilateral oophorectomy for large uterus \nw/fibroid, s/p laparascopic b/l pelvic lymph node resection, s/p \n\nradical cystectomy and anterior vaginectomy with vaginal \nreconstruction with ileal conduit creation ___, course \ncomplicated by bacteremia and development of intra-abdominal \nfluid collection, no s/p drain placement by ___ ___ \n - h/o LLE DVT and PE no longer on anticoagulation. \n \nSocial History:\n___\nFamily History:\nNegative for bladder CA.\n\n \nPhysical Exam:\nADMISSION EXAM:\n\nVITALS: ___ 2227 Temp: 99.3 PO BP: 119/54 HR: 80 RR: 16 O2\nsat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \nGENERAL: Alert and in no apparent distress, facial twitches\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation, foley\ncatheter in place\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\n\nAVSS, ambulating comfortably at baseline. Urostomy bag in place \nwith no surround erythema or pain.\n \nPertinent Results:\nLABORATORY RESULTS:\n\n___ 05:30AM BLOOD WBC-16.5* RBC-3.23* Hgb-9.8* Hct-31.8* \nMCV-99* MCH-30.3 MCHC-30.8* RDW-14.5 RDWSD-52.3* Plt ___\n___ 06:09AM BLOOD WBC-14.1* RBC-3.39* Hgb-10.2* Hct-33.2* \nMCV-98 MCH-30.1 MCHC-30.7* RDW-14.6 RDWSD-52.7* Plt ___\n___ 06:10AM BLOOD WBC-10.0 RBC-3.55* Hgb-10.5* Hct-33.6* \nMCV-95 MCH-29.6 MCHC-31.3* RDW-14.1 RDWSD-49.9* Plt ___\n___ 05:30AM BLOOD Glucose-115* UreaN-34* Creat-1.6* Na-142 \nK-4.2 Cl-106 HCO3-22 AnGap-14\n___ 06:10AM BLOOD Glucose-99 UreaN-29* Creat-1.3* Na-141 \nK-3.8 Cl-104 HCO3-23 AnGap-14\n___ 05:30AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8\n\nMICROBIOLOGY:\n\n___ 3:00 pm URINE Site: CYSTOSCOPY RIGHT KIDNEY \nWASH. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ENTEROCOCCUS FAECIUM. >10,000 CFU/ML. \n ___ (___) REQUESTS SUSCEPTIBILITY TESTING \n___. \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1,000 - 10,000 \nCFU/ML. \n CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). 1,000 - 10,000 \nCFU/ML. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS FAECIUM\n | \nAMPICILLIN------------ 8 S\nNITROFURANTOIN-------- <=16 S\nTETRACYCLINE---------- =>16 R\nVANCOMYCIN------------ 2 S\n\nBlood cultures NGTD\n \nBrief Hospital Course:\nMs. ___ was admitted with sepsis from a urinary tract \ninfection after her stent exchange. She was placed empirically \non vancomycin and cefepime (narrowed to vanc/ceftriaxone on \nHD#1), because of her history of resistant organisms. She \nrapidly improved. Her urine grew E. faecium, sensitive to \nampicillin. Therefore, a PICC line was placed, and she will \ncomplete two weeks total of ampicillin for a complicated urinary \ntract infection (additional day days). She will follow up with \nDr. ___ as an outpatient. She will stop her prophylactic TMP \nwhile on ampicillin, but then resume after finishing her course.\n- ampicillin 500 mg TID x 9 additional days\n- restart TMP 100 mg daily for ppx after antibiotic course\n- follow up with Dr. ___\n\n___ problems addressed this hospitalization:\n\n1. ___. Ms. ___ initially had an ___, likely prerenal from \nher sepsis. She received IV fluids and antibiotics as above, and \nher creatinine down-trended. Losartan was initially held, but \nrestarted on discharge.\n\n2. Hyperlipidemia: continued atorvastatin 10 mg daily\n\n3. Hypothyroidism: continue levothyroxine 175 mcg daily\n\n> 30 minutes spent on discharge activities.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Atorvastatin 10 mg PO QPM \n3. Cyanocobalamin 1000 mcg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Levothyroxine Sodium 175 mcg PO DAILY \n6. LORazepam 0.5 mg PO Q12H:PRN anxiety \n7. Losartan Potassium 50 mg PO BID \n8. Multivitamins 1 TAB PO DAILY \n9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n10. Trimethoprim 100 mg PO Q24H \n\n \nDischarge Medications:\n1. Ampicillin 500 mg IV Q8H \nRX *ampicillin sodium 500 mg 500 mg IV Every eight hours Disp \n#*15 Vial Refills:*0\nRX *ampicillin sodium 500 mg 500 mg IV Every eight hours Disp \n#*27 Vial Refills:*0 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n3. Atorvastatin 10 mg PO QPM \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Levothyroxine Sodium 175 mcg PO DAILY \n7. LORazepam 0.5 mg PO Q12H:PRN anxiety \n8. Losartan Potassium 50 mg PO BID \n9. Multivitamins 1 TAB PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n11. HELD- Trimethoprim 100 mg PO Q24H This medication was held. \nDo not restart Trimethoprim until after you finish your \nampicillin.\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nComplicated E. faecium UTI\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nYou were admitted to the hospital after you developed fevers and \nchills after you developed fevers and chills from your stent \nexchange. Your urine grew the enterococcus species -- the source \nof your infection. Because it was enterococcus, a PICC line was \nplaced and you will finish a total 14-day course of IV \nampicillin.\n\nYou also had kidney injury, likely from infection, that resolved \nwith antibiotics and fluids. It was a pleasure taking care of \nyou!\n \nFollowup Instructions:\n___\n" ]

[ "T8140XA", "A4181", "R6520", "N179", "N1330", "N12", "T8144XA", "Z936", "I10", "E785", "E039", "Z87891", "Z8551", "Z86718", "Y848", "Y92239" ]

[ "T8140XA: Infection following a procedure, unspecified, initial encounter", "A4181: Sepsis due to Enterococcus", "R6520: Severe sepsis without septic shock", "N179: Acute kidney failure, unspecified", "N1330: Unspecified hydronephrosis", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "T8144XA: Sepsis following a procedure, initial encounter", "Z936: Other artificial openings of urinary tract status", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "Z87891: Personal history of nicotine dependence", "Z8551: Personal history of malignant neoplasm of bladder", "Z86718: Personal history of other venous thrombosis and embolism", "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" ]

[ "N179", "I10", "E785", "E039", "Z87891", "Z86718" ]

[]

[ " \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:\nsubjective fevers, lethargy, and bloody drain output \n \nMajor Surgical or Invasive Procedure:\n___: For the large pelvic fluid collections, CT-guided \nrepositioning of existing drain and placement of an additional \ndrain.\n\n___: Removal of more recently placed drain \n\n \nHistory of Present Illness:\nMs. ___ is an ___ with PMH of hypertension and bladder \ncancer (high grade invasive urothelial carcinoma pT2b) s/p \nTAH/BSO, radical cystectomy w/ileal conduit c/b intra-abdominal \ninfection and pelvic fluid collection s/p ___ guided drain \nplacement ___ who presents with 2 days of generalized \nmalaise and 1 day of fevers. \n Patient underwent ___ guided JP drain placement for \nintra-abdominal fluid collection and infection, thought to be \ncomplicated of recent TAH/BSO, radical cystectomy and pelvic \nlymph node biopsy. This procedure was done on ___. Over the \npast 2 days she had noticed generalized malaise and 1 day of \nfever w/rigors to Tmax 101.5 at home. She notes that the \ndrainage from her intra-abdominal drain is darker, but her \nurostomy output has been unchanged. She notes some associated \nmild LLQ pain. She denies diarrhea, BRBPR, rash, cough, \nheadache, neck stiffness. She presented initially to OSH, where \nshe was evaluated with BCx and drain culture and was started on \nzosyn and vancomycin and given 650mg acetaminophen. She was \ntransferred to ___ for further management. \n\n \nPast Medical History:\n- Hypertension \n - s/p lap chole \n - s/p left knee replacement \n - s/p laminectomy of L5-S1 at age ___ \n - Bladder Cancer high grade TCC, T1 diagnosed in ___, then \n___ pelvic MRI w/invasion into bladder wall, perivesical \nsoft tissue and anterior vaginal wall c/w T4 staging \n - s/p hysterectomy and bilateral oophorectomy for large uterus \nw/fibroid, s/p laparascopic b/l pelvic lymph node resection, s/p \nradical cystectomy and anterior vaginectomy with vaginal \nreconstruction with ileal conduit creation ___, course \ncomplicated by bacteremia and development of intra-abdominal \nfluid collection, no s/p drain placement by ___ ___ \n - h/o LLE DVT and PE on lovenox \n\n \nSocial History:\n___\nFamily History:\nNegative for bladder CA.\n\n \nPhysical Exam:\nADMISSION EXAM:\n===============\n Vital Signs: 100.9 PO 130 / 54 L Lying 80 24 95 RA \n General: Alert, oriented, no acute distress \n HEENT: Sclerae anicteric, MMM, oropharynx clear \n CV: RRR, normal S1 S2, systolic murmur RUBS, no rubs, gallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \n+ileal conduit drain in RLQ, with pigtail drain in LLQ draining \ndark/sang fluid \n GU: No foley \n Ext: Warm, well perfused, 1+ nonpitting edema LLE \n Neuro: CN2-12 grossly intact, moving all extremities \nspontaneously\n\nDISCHARGE EXAM: \n===============\n Vital signs: 98.3 134/64 71 20 96 RA \n General: AxO x3\n HEENT: Sclera anicteric\n Neck: supple \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi on anterior auscultation \n CV: Regular rate and rhythm, normal S1 + S2, III/VI SEM\n Abdomen: +BS, ileal conduit draining clear yellow urine. Has \none LLQ drain in place draining serosanguinous fluid. \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 07:10PM BLOOD WBC-19.4*# RBC-2.53* Hgb-6.9* Hct-22.9* \nMCV-91 MCH-27.3 MCHC-30.1* RDW-15.1 RDWSD-49.5* Plt ___\n___ 07:10PM BLOOD Neuts-81.4* Lymphs-9.4* Monos-7.4 \nEos-0.0* Baso-0.1 Im ___ AbsNeut-15.77*# AbsLymp-1.81 \nAbsMono-1.43* AbsEos-0.00* AbsBaso-0.02\n___ 07:10PM BLOOD ___ PTT-33.4 ___\n___ 07:10PM BLOOD Ret Aut-2.9* Abs Ret-0.07\n___ 07:10PM BLOOD Glucose-118* UreaN-25* Creat-1.1 Na-133 \nK-5.0 Cl-97 HCO3-23 AnGap-18\n___ 07:10PM BLOOD ALT-9 AST-9 AlkPhos-56 TotBili-0.3\n___ 07:10PM BLOOD Lipase-9\n___ 07:10PM BLOOD Albumin-2.5* Iron-6*\n___ 07:10PM BLOOD calTIBC-170* Hapto-518* Ferritn-489* \nTRF-131*\n___ 07:13PM BLOOD Lactate-1.0\n\nDISCHARGE LABS:\n===============\n___ 06:00AM BLOOD WBC-6.9 RBC-2.92* Hgb-8.3* Hct-26.8* \nMCV-92 MCH-28.4 MCHC-31.0* RDW-15.4 RDWSD-52.4* Plt ___\n___ 06:00AM BLOOD ___ PTT-31.2 ___\n___ 06:00AM BLOOD Plt ___\n___ 06:00AM BLOOD Glucose-86 UreaN-8 Creat-0.8 Na-143 K-3.6 \nCl-106 HCO3-25 AnGap-16\n___ 06:00AM BLOOD Calcium-7.5* Phos-3.7 Mg-2.3\n\nMICROBIOLOGY:\n=============\nBlood cultures x3 pending\n\n___ 4:35 pm pelvic aspiration\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\nPERTINENT IMAGING:\n==================\nCT ABD&PEL W/ CONTRAST \n___\n1. Interval decrease in size of the right hemipelvis fluid \ncollection (7.0 x 6.5 x 11.3 cm, previously 10.0 x 12.7 x 14.8 \ncm) with the anterior approach pigtail catheter unchanged in \nposition. The pigtail is again located partly within the \ncollection and partly outside its wall. \n2. Interval increase in size of the left pelvic fluid \ncollection, now \nmeasuring 14.7 x 16.2 x 23.3 cm (previously 13.6 x 13.9 x 23.0 \ncm). Increased peripheral enhancement may suggest superimposed \ninfection. \n3. No new fluid collection identified. \n \nCTA ABD & PELVIS\n___\n1. Decrease in size of right lower quadrant fluid collection \nthat has \npercutaneous drain within it, with areas of high attenuation on \nnoncontrast exam consistent with blood products, and associated \nhyperemia which is likely inflammatory, but without evidence of \ncontrast extravasation. \n2. There is large stable fluid collection in the low left \nabdomen, pelvis with mild linear peripheral enhancement, \ninfection cannot be excluded. \n3. There is severe left, and moderate to severe right \nhydroureteronephrosis, with delayed left nephrogram, stable from \ntoday. Mass effect about anastomosis between distal ureters and \nneobladder has resolved all since ___, and while \nhydronephrosis may be from residual edema, if this does not \nresolve, alternative etiologies including stenosis, tumor \ninfiltration should be excluded. \n4. Tiny hepatic lesion segment ___, attention to this area on \nsubsequent \nfollowups recommended. \n\nCT INTERVENTIONAL PROCEDURE\n___ \n1. Complete collapse the patient has recently drained left \nlower quadrant \ncollection. The catheter from this collection was removed. \n2. Near complete collapse of the patient is originally drained \ncollection in the mid pelvis, with pigtail catheter in place. \n3. Left lower quadrant and deep pelvic collections as above. \nThese findings were discussed with the team. Given the \npatient's improving clinical status, the decision was made to \npursue no further collection drainage at this time. \n4. Severe bilateral hydronephrosis, as on prior examinations. \nRECOMMENDATION: Given persistence of severe hydronephrosis, \npercutaneous \nnephrostomy tubes should be considered. \n\n \nBrief Hospital Course:\nBRIEF SUMMARY:\n==============\n___ year old women with a history of bladder cancer s/p \ncystectomy, hysterectomy, and BSO now with ileal conduit, whose \npost operative course has been complicated by DVT/PE, ileus, and \npelvic fluid collections w/ one LLQ drain presented with \nsubjective fevers, lethargy, and bloody drain output. She was \nfound to have worsening anemia and was given 2 units of pRBC \nwith appropriate increase in hemoglobin noted. She was also \nfound on CT imaging to have an interval increase in size of a \nleft abdominal fluid collection. Decision was made to place a \ndrain per ID. Fluid was sent and revealed: negative cultures, \nnegative malignant cells, no evidence of lymphatic or urinary \nfluid. This new drain was subsequently removed per ___ as fluid \ncollection was completely drained. The prior drain was still \ndraining serosanguinous fluid and was kept in but repositioned. \nID was consulted for the fevers, leukocytosis and fluid \ncollections and was deemed to need antibiotics and tranisitioned \nfrom broad spectrum to IV ertapenem at discharge. Will require \nmultiple follow ups and imaging as specified in the transitional \nissues. \n \nACUTE ISSUES:\n=============\n#Pelvic fluid collections: patient arrived with one anterior \ndrain putting out serosanguinous fluid. CT abdomen/pelvis \nrevealed enlarging left fluid collection, and decision was made \nto place a drain per ___. The fluid was negative for malignant \ncells. The fluid had Cr 1 and triglycerides <9 suggesting that \nfluid collection is neither urine nor lymphatic fluid. Fluid \nculture was negative for bacteria. On interval imaging, the new \nenlarging fluid collection had completely collapsed and the \ndrain was removed. As for the other fluid collection that \nalready had a drain putting out serosanguinous fluid, it \ncontinued to drain serosanguinous fluid but at a lower rate than \nprior to admission. The drain was left in place as the fluid \ncollection on imaging had not completely collapsed. BID - N \ncultures for the aforementioned fluid collection came back \npositive for MSSA but per ID, does not reflect rue \nintra-abdominal infection. Given that patient had a fever at OSH \nand a leukocytosis, she was placed on broad spectrum antibiotics \nwith vanc, ceftaz and flagyl. This was tapered per ID team to IV \nzosyn. On discharge, ID recommended ertapenem for approximately \n4 weeks with final length of treatment to be determined by fluid \ncollection changes on repeat imaging on outpatient basis. Mrs. \n___ remained afebrile, and leukocytosis resolved. \n\n#Pulmonary embolism: Likely developed in the setting of being \ndiagnosed with a post-op DVT. She was placed on lovenox. She \nwas transitioned to heparin ggt as she needed ___ procedures and \nwas transitioned back to lovenox but at a lower dose per weight \ndosing to 70mg q12H upon discharge. \n\n#Acute renal injury: SCr has been steadily rising from a \nbaseline of around 0.04-0.06 in ___ to 1.1, likely \n___ obstructed uropathy ___ large pelbic fluid collections. ___ \nresolved over the course of her hospital stay with final Cr 0.8. \n\n\n#Hydronephrosis: bilateral and worsening on interval imaging \nfrom prior studies. Given patient's age, adequate urinary \noutput, adequate creatinine clearance, and no significant \nelectrolyte abnormalities, patient likely would not \nsignificantly benefit from intervention at this time. Per \nurology consult, deemed stable for discharge and recommended \noutpatient urology followup. \n\n#Anemia: likely a combination of anemia of chronic inflammation \nand acute blood loss ___ to anterior abdominal drain showing \nserosanguinous fluid. Labs not consistent with hemolysis. \nReceived 2 units of pRBC with appropriate response. Patient was \ndischarged with Hgb of 8.3 per hem/onc recommendation for \nthreshold Hgb>8 as patient feels and functionally performs \nbetter with higher blood counts. \n\n#Hypokalemia: was hypokalemic and was repleted with oral KCl \nPRN. \n\nCHRONIC ISSUES:\n===============\n#Invasive high-grade urothelial carcinoma, involving the deep \nmuscularis propria\nS/p cystectomy, hysterectomy, and BSO now with ileal conduit, \nwhose post operative course has been complicated by DVT/PE, \nileus, and pelvic fluid collections. Patient stating that there \nis no plan for chemo and radiation, her PET scan does show \nconcerning foci of metastatic disease in the lung and \nperitoneum. Per patient's son, Mrs. ___ has seen a doctor \nto work up the lung mass. Will need ongoing discussion with \noutpatient hem/onc regarding how to best manage concerning \nlesions. \n\n#Breast mass ___ mammogram showing BI-RADS 5, Solid mass \nin the 3 o'clock left breast with features of a highly \nsuspicious for malignancy. Per patient's son, she has seen a \ndoctor for evaluating the new breast mass. Would recommend \nongoing discussion with aforementioned doctor and outpatient \nhem/onc about plan to manage.\n\n# HLD: continued atorvastatin without changes. Consider \nevaluation regarding stopping atorvastatin on outpatient basis \n \n# Hypothyroidism: continued levothyroxine without changes. \n \n#HCP: Dr. ___ (son, ___ physician) ___\n#Code status: full code (confirmed with patient on ___ \n\nTRANSITIONAL ISSUES:\n====================\n[ ] Will need infectious disease follow up. If ID has not \ncontacted Mrs ___ by ___, she should call ___ \nto set up an appointment. The ID appointment needs to be AFTER \nher CT abdomen/pelvis has already been done \n[ ] Assure that Mrs ___ has her CT abdomen & pelvis with \ncontrast in the week of ___\n[ ] She should get weekly lab draws of the following: CBC with \ndifferential, BUN, Cr, AST, ALT, TB, ALK PHOS. ALL LAB REQUESTS \nSHOULD BE ANNOTATED WITH: **ATTN: ___ CLINIC - FAX: \n___\n[ ] If possible, please give ertapenem at night-time so it does \nnot interfere with her daily activities. Tentatively, she will \nbe receiving ertapenem for ___ weeks but with final treatment \nlength determined by the infectious disease team. \n[ ] Will need ongoing discussion with outpatient PCP and hem/onc \nregarding how to manage new breast lesion and lung/peritoneum \nlesions. \n[ ] Reevaluate need for atorvastatin\n[ ] Will need outpatient follow up with urology, Dr. ___ \nhis team regarding worsening hydronephrosis\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H \n2. Atorvastatin 10 mg PO QPM \n3. Enoxaparin Sodium 90 mg SC Q12H \nStart: ___, First Dose: Next Routine Administration Time \n4. Levothyroxine Sodium 175 mcg PO DAILY \n5. LORazepam 0.25-0.5 mg PO DAILY:PRN anxiety \n\n \nDischarge Medications:\n1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose \nplease give ertapenem daily, preferably at nighttime to not \ninterfere with her daily activities \n2. Milk of Magnesia 30 mL PO Q6H:PRN constipation \n3. Enoxaparin Sodium 70 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n4. Acetaminophen 650 mg PO Q6H \n5. Atorvastatin 10 mg PO QPM \n6. Levothyroxine Sodium 175 mcg PO DAILY \n7. LORazepam 0.25-0.5 mg PO DAILY:PRN anxiety \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis: Pelvic fluid collection infection, ___, acute \nblood loss anemia\n\nSecondary diagnosis: acute renal failure, acute on chronic \nanemia, recent pulmonary embolism, invasive high-grade \nurothelial carcinoma, left breast mass (BIRADS 5), \nhypothyroidism \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___,\n\n___ did you come to the hospital?\n- You were feeling tired and your drain output was bloody. \n\nWhat happened at the hospital?\n- A CT scan showed very large fluid collections in your pelvis \n- The radiologists placed another drain and removed it once it \nappeared that the large fluid collection was gone\n- You were given a blood transfusion\n- We placed a PICC (a long IV) so that you can receive \nantibiotics after you get discharged from the hospital\n\nWhat needs to happen when you leave the hospital?\n- Please continue seeing the doctors that are ___ your \nlung and breast lesions and follow their recommendations. \n- Continue taking Lovenox every day to treat the blood clot in \nyour lung. \n- If the infectious disease doctor has not contacted you by ___, please call the following number to set up an appointment: \n___. \n- Please make sure you have a repeat CT scan done BEFORE your \nappointment with the infectious disease doctor\n- You will be getting IV antibiotics for several weeks. The \ninfectious disease doctor ___ determine how long you will need \nto be on it. \n\nIt was a pleasure taking care of you. \nYour ___ team \n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "A419", "K651", "N179", "N1330", "D62", "I2782", "N138", "C679", "I10", "E785", "E039", "K439", "K435", "E876", "Y838", "Y929", "Z96652", "Z86718", "N63", "Z7901", "Z87891" ]

[ "T814XXA: Infection following a procedure", "A419: Sepsis, unspecified organism", "K651: Peritoneal abscess", "N179: Acute kidney failure, unspecified", "N1330: Unspecified hydronephrosis", "D62: Acute posthemorrhagic anemia", "I2782: Chronic pulmonary embolism", "N138: Other obstructive and reflux uropathy", "C679: Malignant neoplasm of bladder, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "K439: Ventral hernia without obstruction or gangrene", "K435: Parastomal hernia without obstruction or gangrene", "E876: Hypokalemia", "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", "Z96652: Presence of left artificial knee joint", "Z86718: Personal history of other venous thrombosis and embolism", "N63: Unspecified lump in breast", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "D62", "I10", "E785", "E039", "Y929", "Z86718", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nHematuria, weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ y/o female with h/o PE (on lovenox), bladder cancer s/p \nRobotic TAH-BSO, lap radical cystectomy with ileal loop \ndiversion and anterior vaginectomy in ___ c/b abdominal \nfluid requiring placement of drainage catheters. Recent \nabdominal imaging noted worsening of her bilateral severe \nhydronephrosis and her Cr was noted to have risen from 0.8 to \n1.3(outside lab value). Patient recently underwent bilateral \nnephrostomy tube placement by ___ on ___.\n\nShe first started feeling weak during ___ yesterday doing the \nexercises. Had palpitations with ambulation. Has tightness in \nchest with ambulating since yesterday. Felt light headed with \nambulation. SNF noticed increased hematuria with R bag darker \nthan L bag since yesterday. Her Urostomy (placed in ___ \nalso positive for hematuria. She was transferred to ___ ED for \nfurther management.\n\nIn the ED, initial vitals were: \n\nTemp. 98.1, HR 72, BP 139/56, RR 16, 99% RA\n \n- Labs notable for: \nWBC 5.9, Hg 8.1, platelets 374. Na 140, K 4.3, Cl 103, biacrb \n22, BUN 29, Cr 1.0\n\nUA from bilateral nephrostomy tubes with > 100 WBC, moderate \nleukocytes, and large blood.\n\n- Imaging was notable for: \nCT abd/pelvis w/o contrast:\nInterval placement of bilateral percutaneous nephroureterostomy \ntubes with resolved hydroureteronephrosis. No RP hematoma.\n \n- Patient was given: \nLR\n\nUpon arrival to the floor, patient reports that she noticed \nshortness of breath today with walking in conjunction with \nbloody output from her ostomy tubes. She notes that the output \nfrom her nephrostomy tubes was pink tinged when she left the \nhospital 2 days ago. She also endorses associated chest \ntightness but no pain or pressure. She denies cough, fever, \nchills, abdominal pain, or diarrhea. She notes that she has an \nostomy and nephroureterostomy without sensation of dysuria. \nPatient notes feeling dizzy and lightheaded previously though is \ncurrently asymptomatic. \n\n \nPast Medical History:\n- Hypertension \n - s/p lap chole \n - s/p left knee replacement \n - s/p laminectomy of L5-S1 at age ___ \n - Bladder Cancer high grade TCC, T1 diagnosed in ___, then \n___ pelvic MRI w/invasion into bladder wall, perivesical \nsoft tissue and anterior vaginal wall c/w T4 staging \n - s/p hysterectomy and bilateral oophorectomy for large uterus \nw/fibroid, s/p laparascopic b/l pelvic lymph node resection, s/p \nradical cystectomy and anterior vaginectomy with vaginal \nreconstruction with ileal conduit creation ___, course \ncomplicated by bacteremia and development of intra-abdominal \nfluid collection, no s/p drain placement by ___ ___ \n - h/o LLE DVT and PE on lovenox \n\n \nSocial History:\n___\nFamily History:\nNegative for bladder CA.\n\n \nPhysical Exam:\n=========================\nADMISSION PHYSICAL EXAM: \n========================= \nVITAL SIGNS: Temp. 98.1 PO BP 158 / 66 HR 72 RR 18 Spo2 95 RA \nGENERAL: well-appearing elderly woman in no acute distress \nCARDIAC: RRR, no murmurs\nLUNGS: clear to auscultation bilaterally \nABDOMEN: soft, non-tender to palpation, normal bowel sounds. \nOstomy draining brown stool. Nephroureterostomy draining dark \nred bloody urine. Bilateral nephrostomy tubes draining blood \nurine. \nEXTREMITIES: No edema, warm and well-perfused.\n\n=========================\nDISCHARGE PHYSICAL EXAM: \n========================= \nVS - 98.3 PO 139/67 71 18 94 RA \nGENERAL: well-appearing elderly woman in no acute distress \nCARDIAC: RRR, no murmurs\nLUNGS: clear to auscultation bilaterally \nABDOMEN: soft, non-tender to palpation, normal bowel sounds. \nNephroureterostomy draining dark red bloody urine. Bilateral \nnephrostomy tubes capped. \nEXTREMITIES: No edema, warm and well-perfused\n\n \nPertinent Results:\n================\nADMISSION LABS\n================\n___ 05:20PM BLOOD WBC-5.9 RBC-2.90* Hgb-8.1* Hct-26.6* \nMCV-92 MCH-27.9 MCHC-30.5* RDW-15.4 RDWSD-51.2* Plt ___\n___ 05:48AM BLOOD WBC-4.6 RBC-2.46* Hgb-7.0* Hct-22.6* \nMCV-92 MCH-28.5 MCHC-31.0* RDW-15.3 RDWSD-51.7* Plt ___\n___ 05:20PM BLOOD Neuts-56.3 ___ Monos-12.6 Eos-1.5 \nBaso-0.3 Im ___ AbsNeut-3.29# AbsLymp-1.69 AbsMono-0.74 \nAbsEos-0.09 AbsBaso-0.02\n___ 05:20PM BLOOD Glucose-101* UreaN-29* Creat-1.0 Na-140 \nK-4.3 Cl-103 HCO3-22 AnGap-19\n\n=================\nIMAGING/STUDIES\n=================\n\n___ CT Abd/Pel w/o Contrast: \nIMPRESSION: \n1. Interval placement of bilateral percutaneous \nnephroureterostomy tubes with resolved hydroureteronephrosis. \nNo RP hematoma. \n2. Partially imaged nodular opacity in the right middle lobe \nwhich can be \nfurther assessed on a nonemergent dedicated CT chest. \n\n___ CXR\nAP portable upright view of the chest. Right upper extremity \naccess PICC \nline is seen with its tip in the upper SVC. Overlying EKG leads \nare present. Lungs are clear. Cardiomediastinal silhouette is \nstable. Bony structures are intact. \n\n==============\nMICROBIOLOGY\n==============\n___ 6:35 pm URINE LEFT NEPHROSTOMY TUBE. \n **FINAL REPORT ___\n URINE CULTURE (Final ___: NO GROWTH. \n\n================\nDISCHARGE LABS\n================\n___ 05:08AM BLOOD WBC-5.4 RBC-2.86* Hgb-8.2* Hct-26.5* \nMCV-93 MCH-28.7 MCHC-30.9* RDW-15.3 RDWSD-51.8* Plt ___\n___ 05:08AM BLOOD Glucose-94 UreaN-29* Creat-0.9 Na-143 \nK-4.0 Cl-106 HCO3-26 AnGap-15\n___ 05:08AM BLOOD Calcium-8.8 Phos-5.2* Mg-2.1\n \nBrief Hospital Course:\nMs. ___ is an ___ year old woman with history of provoked \nDVT/PE (on lovenox), bladder cancer s/p Robotic TAH-BSO, lap \nradical cystectomy with ileal loop diversion and anterior \nvaginectomy in ___ c/b abdominal fluid requiring \nplacement of drainage catheters, and recent hydronephrosis \nrequiring placement of bilateral PCN tubes on ___, presenting \nfrom rehab with hematuria and weakness.\n\nOn arrival, pt had evidence of frank hematuria in her urostomy \nbag and PCN tubes. Her hemoglobin was initially 8.1, which \nsubsequently dropped to 7.0 Her lovenox was held, and she was \ntransfused with 1 U PRBC with an appropriate hemoglobin bump to \n8.2. Hematuria was likely caused by recent instrumentation in \nthe setting of anticoagulation. Her hematuria improved, as did \nher dizziness/weakness. ___ was consulted and recommending \ncapping her PCN tubes. After discussion with the patient's \nhematologist, it was decided to stop her lovenox treatment given \nthat her DVT/PE were provoked in the setting of her recovery \nfrom surgery, and that she had received almost 6 months of \ntreatment.\n\nSecondary Issues:\n\n# Asymptomatic bacteruria: Patient with asymptomatic bacteruria \nin setting of recent procedural manipulation. She was afebrile \nand without leukocytosis, so treatment with antibiotics was \ndeferred.\n\n# Hyperlipidemia: continued atorvastatin 10 mg daily\n\n# Hypothyroidism: continue levothyroxine 175 mcg daily\n\n===================\nTRANSITIONAL ISSUES\n===================\nMedication Changes: Lovenox stopped \n[ ] CT Abdomen/Pelvis showed partially imaged nodular opacity in \nthe right middle lobe which can be further assessed on a \nnonemergent dedicated CT chest. \n[ ] Pt's PCN tubes were capped per ___ recommendation during her \nhospitalization; she was discharged with scheduled followup to \ndecide on long term management\n[ ] If pt develops hematuria and/or lightheadedness or other \nsymptoms of anemia, a CBC should be rechecked to assess for \nbleeding\n[ ] Hemoglobin/Hematocrit on discharge: 8.2/26.5\n\n# CODE: presumed full\n# CONTACT: ___ (MD) ___ (cell) \n___ (home) \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 10 mg PO QPM \n2. Enoxaparin Sodium 70 mg SC Q12H \nStart: ___, First Dose: Next Routine Administration Time \n3. Levothyroxine Sodium 175 mcg PO DAILY \n4. Multivitamins 1 TAB PO DAILY \n5. Probiotic-Digestive Enzymes (L. acidophilus-dig ___ 5) \n___ mg oral daily \n\n \nDischarge Medications:\n1. Atorvastatin 10 mg PO QPM \n2. Levothyroxine Sodium 175 mcg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Probiotic-Digestive Enzymes (L. acidophilus-dig ___ 5) \n___ mg oral daily \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses: Hematuria, anemia\n\nSecondary Diagnoses: Bladder cancer, hydronephrosis, \nhypothyroidism, DVT/PE\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was a pleasure taking care of you at ___. \n\nWHY DID YOU COME TO THE HOSPITAL?\nYou noticed blood in your urine, and you were feeling \nweak/lightheaded.\n\nWHAT HAPPENED WHILE YOU WERE HERE?\nWe did not give you your blood thinner medication (Lovenox), and \nwe gave you a unit of blood. The blood in your urine cleared up. \n\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?\nAlong with your oncologist Dr. ___ have decided that you \nno longer need to take any Lovenox. You should continue to \nfollow up with your doctors, and take all of your medications as \nprescribed. Your followup appointments are listed below.\n\nAgain, it was a pleasure taking care of you!\n\nSincerely, \n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "N99820", "E43", "R310", "N131", "D62", "R8271", "E039", "E785", "N9989", "I10", "Z86718", "Z936", "Z7902", "Z86711", "Z87891", "Z6822", "Z8551", "Z96652", "Y848", "Y833", "Y929" ]

[ "N99820: Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure", "E43: Unspecified severe protein-calorie malnutrition", "R310: Gross hematuria", "N131: Hydronephrosis with ureteral stricture, not elsewhere classified", "D62: Acute posthemorrhagic anemia", "R8271: Bacteriuria", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "N9989: Other postprocedural complications and disorders of genitourinary system", "I10: Essential (primary) hypertension", "Z86718: Personal history of other venous thrombosis and embolism", "Z936: Other artificial openings of urinary tract status", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z86711: Personal history of pulmonary embolism", "Z87891: Personal history of nicotine dependence", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "Z8551: Personal history of malignant neoplasm of bladder", "Z96652: Presence of left artificial knee joint", "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", "Y833: Surgical operation with formation of external stoma as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]

[ "D62", "E039", "E785", "I10", "Z86718", "Z7902", "Z87891", "Y929" ]

[]

[ " \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:\nslurred speech\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ year old right-handed woman with hx of Atrial fibrillation on \nEliquis (only once daily), hypertension, hyperlipidemia, CHF\npresents as transfer from OSH after she had acute onset \ndysarthria and CTA showed possible partial thrombus or stenosis \nin superior division of L MCA. Transferred here for closer \nmonitoring and possible thrombectomy if her exam acutely \nworsens.\n\nHistory obtained from patient and daughter at bedside. Patient \nis an excellent historian. \n\nOn ___, she had dinner with friends and then returned to her \napartment and was fooling around on her computer. Last known \nwell\nwas around 8:00 ___. Then, she had an odd sensation and started \nthrowing her arms around. She went to living room to sit down \nand\ntried to read but could not see the words very clearly. Then, \ntwo family members were knocking at the door and she had a tough \ntime\nstanding up to open door. She was able to eventually stand up \nwith great difficulty and walked with her walker. She usually \nwalks with a walker because of knee replacement. Finally, got up \nout of chair with walker and walked to the door to unlock. She \nnoticed problems talking to family members. She had difficulty \nforming words and pronouncing words. Denies word finding \ndifficulty. She could tell it was slurred like a person who had \ntoo much to drink. EMTs asked if she was intoxicated but she was \nnot. She was very aware of her dysarthria and told her daughters \nthat she thinks she's having a stroke. Then, she said she had \ntrouble sitting down but has no idea why she thought that. When \nshe was standing, she was able to walk with walker but she felt \nunsteady and almost fell. No visual changes. No numbness or \ntingling. Denies focal weakness; she just had trouble standing \nup. She was able to unlock her door without issue but she felt \nshaky. \n\nShe was brought by EMS to ___ where NIHSS was 1 for \nslurred speech. There, she felt the same but her symptoms \nstarted to improve when she started to be transferred. \nParamedics said her speech was improving rapidly en route. \n\nLast month, started needing naps. Her hearing is poor at \nbaseline and she normally uses hearing aids. \n\nFor the past ___ months, she has had ___ nocturia nightly. No \ndysuria. \n\nShe has noticed more frequent headaches lately in the past ___ \nmonths. Last headache was yesterday. She takes tramadol and \nacetaminophen up to a couple times a night. She reports \nheadaches at night which wake her up. She denies that the \nheadache is\npositional; it is the same sitting up or lying down. She has had \nsome gradual weight loss over the past ~12 months; ___ year ago \nshe was almost 140 lbs, and now she is ___ lbs. Her appetite is \nstill good and she enjoys eating but she is less hungry that she \nused to be. \n\nDaughter says that she has had marked decline in memory in past \n___ weeks. Over past few years, she has been forgetting plans, \ntimes for pickpup, and dinner plans, which has become normal. \nOver the past ___ weeks, family has noticed dramatic worsening. \nShe doesn't remember which grandkids were coming to visit when \nshe bought the plane tickets herself.\n\nShe endorses 2 pillow orthopnea. \n \nPast Medical History:\nDivertoculosis\nAtrial fibrillation on Eliquis\nCHF\nHypercholesterolemia\nHypertension\n \nSocial History:\n___\nFamily History:\nFather - severe alcoholic, schizophrenia\nMother - CHF\nBrother - stroke, carotid stenosis\n \nPhysical Exam:\nADMISSION EXAM:\nVitals: T:97.9 HR: 79 BP: 164/121 RR: 19 SaO2: 94% on RA\n\nGeneral: Awake, cooperative elderly woman, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx.\nNeck: Supple. No nuchal rigidity.\nPulmonary: Normal work of breathing.\nCardiac: RRR, warm, well-perfused.\nAbdomen: Soft, non-distended.\nExtremities: No ___ edema.\nSkin: ecchymoses in L shin, more extensive on R shin. \n \nNeurologic:\n-Mental Status: Alert, oriented ___.\nAble to relate history without difficulty. Attentive, able to\nname ___ backward without difficulty. Language is fluent with\nintact repetition and comprehension. Normal prosody. There were\nno paraphasic errors. Able to name both high and low frequency\nobjects. Able to read without difficulty. No dysarthria. Able \nto\nfollow both midline and appendicular commands. There was no\nevidence of apraxia or neglect.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. \nV: Facial sensation intact to light touch and pinprick.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing intact to finger snapping b/l. Did not bring her\nhearing aids. \nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk and tone throughout. No pronator drift. No\nadventitious movements, such as tremor or asterixis noted.\n [___]\nL 5 5 5 5 5 5 5 5 5 5 5 5\nR 5 5 5 5 5 5 5 5 5 5 5 5\n\n-Sensory: No deficits to light touch, pinprick, temperature\nthroughout. Decreased vibratory sense in b/l feet up to ankles.\nJoint position sense intact in b/l great toes. No extinction to\nDSS. Romberg absent.\n\n-Reflexes:\n [Bic] [Tri] [___] [Pat] [Ach]\nL 2+ 2 2 2+ 0\nR 2+ 2 2 2+ 0 \nPlantar response was flexor bilaterally.\n\n-Coordination: No intention tremor. No dysmetria on FNF\nbilaterally. HKS with L heel without dysmetria. Unable to bend R\nknee due to knee surgery. \n\n-Gait: unable to assess as patient needs a walker at baseline\n\nDISCHARGE EXAM:\n24 HR Data (last updated ___ @ 419)\nTemp: 97.4 (Tm 98.6), BP: 146/76 (116-155/65-94), HR: 53 \n(53-86),\nRR: 17 (___), O2 sat: 96% (92-97), O2 delivery: Ra\n\nGeneral: Awake, cooperative elderly woman, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx.\nNeck: Supple. No nuchal rigidity.\nPulmonary: Normal work of breathing.\nCardiac: NR, RR, warm, well-perfused.\nAbdomen: Soft, non-distended.\nExtremities: No ___ edema.\nSkin: ecchymoses in L shin, more extensive on R shin. \n \nNeurologic:\n-Mental Status: Alert, oriented to person and situation. Able to\nrelate history without difficulty. Attentive to examiner.\nLanguage is fluent with intact comprehension. Normal prosody.\nThere were no paraphasic errors. No dysarthria. Able to follow\nboth midline and appendicular commands. There was no evidence of\napraxia or neglect.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades.\nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing intact to conversation.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions.\n\n-Motor: Normal bulk and tone throughout. No pronator drift. No\nadventitious movements, such as tremor or asterixis noted.\n [Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]\nL 5 5 5 5 5 5 5 5 5 5 5 \nR 5 5 5 5 5 5 5 * * 5 5 \n*Knee cannot bend after prior surgery\n\n-Sensory: No deficits to light touch throughout.\n\n-Coordination: No intention tremor. No dysmetria on FNF\nbilaterally. \n\n-Gait: needs a walker at baseline\n \nPertinent Results:\n___ 01:50AM BLOOD WBC-7.2 RBC-4.75 Hgb-14.6 Hct-45.5* \nMCV-96 MCH-30.7 MCHC-32.1 RDW-13.2 RDWSD-46.5* Plt ___\n___ 01:50AM BLOOD Neuts-53.1 ___ Monos-8.2 Eos-1.5 \nBaso-0.3 Im ___ AbsNeut-3.81 AbsLymp-2.63 AbsMono-0.59 \nAbsEos-0.11 AbsBaso-0.02\n___ 01:50AM BLOOD ___ PTT-29.7 ___\n___ 01:50AM BLOOD Glucose-97 UreaN-18 Creat-0.7 Na-139 \nK-4.3 Cl-102 HCO3-26 AnGap-11\n___ 07:35AM BLOOD CK-MB-4 cTropnT-<0.01\n___ 07:35AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.8 Cholest-207*\n___ 07:35AM BLOOD Triglyc-62 HDL-69 CHOL/HD-3.0 LDLcalc-126\n___ 10:57AM BLOOD %HbA1c-5.5 eAG-111\n___ 05:22AM BLOOD VitB12-249\n___ 05:22AM BLOOD TSH-5.8*\n___ 05:22AM BLOOD Trep Ab-NEG\n___ 03:12AM URINE Color-Straw Appear-Clear Sp ___\n___ 03:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n\n___ OSH CTA head/neck ___ opinion (___)\nIMPRESSION: \n1. Segmental left vertebral artery occlusion of indeterminate \nchronicity. No evidence of ischemia.\n2. Somewhat small caliber attenuated left M2 inferior branch, \nwithout evidence of focal occlusion.\n3. No acute intracranial abnormality on noncontrast CT head.\n\n___ MRI head w/o contrast\nIMPRESSION:\n1. No acute intracranial abnormality. Specifically, no large \nterritory infarction or hemorrhage.\n2. Scattered foci of T2/high-signal intensity in the subcortical \nand periventricular white matter are nonspecific and may reflect \nchanges due to chronic small vessel disease.\n\n___ TTE\nIMPRESSION: No structural source of thromboembolism identified \n(underlying rhythm predisposes to thrombus formation). Preserved \nleft ventricular systolic function in the setting of \nbeat-to-beat variability due to arrhythmia. Mild to moderate \nmitral and tricuspid regurgitation. Normal pulmonary pressure. \nVery small pericardial effusion\n \nBrief Hospital Course:\nMs. ___ is a ___ year old female with AFib on Eliquis, CHF, \nHLD, HTN who presented w/ sudden onset dysarthria, abnormal arm \nmovements, and poor balance (walker at baseline). NIHSS 1 for \nslurred speech at OSH. There, a CTA head and neck was completed, \nand there was concern for left M2 branch attenuation concerning \nfor stenosis or occlusion, and she was subsequently transferred \nfor consideration of thrombectomy but NIHSS 0 on arrival so she \nwas not deemed a candidate. She was admitted to the Neurology \nstroke service for further evaluation of possible TIA vs stroke. \nNo further symptoms noted during admission. MRI head w/o \ncontrast were without evidence of stroke. Reports recent \nechocardiogram per outpatient PCP/cardiologist, reported as no \nacute findings and so this was not repeated. She mentioned \nconcern about worsening memory, but able to perform ADLs w/ \nmeals/cleaning provided by ALF (moved 10 months ago); it appears \nthere has been no acute change. She was taking apixiban 2.5mg \nonce daily (unclear why as this is a BID medication), and so her \ndose was increased to 2.5mg BID (she was not a candidate for 5mg \nBID due to her age and weight). She was started on atorvastatin \nfor her hyperlipidemia (LDL 126). EP cardiology was consulted \nfor frequent sinus pauses noted on telemetry that persisted \ndespite holding home atenolol, recommending discontinuing home \ndigoxin and close cardiology ___. Discharged to home w/ \n___ & ___ and close PCP ___.\n\n#Transient slurred speech and instability, c/f TIA\n- ___ consult - cleared for home with home services\n- Started on atorvastatin for HLD and increased home apixaban to \ntherapeutic level\n- ___ with stroke neurology after discharge\n\nHer stroke risk factors include the following:\n1) DM: A1c 5.5%\n2) Likely chronic segmental left vertebral artery occlusion and \nsomewhat small caliber attenuated left M2 inferior branch\n3) Hyperlipidemia: LDL 126\n4) Obesity\n5) No concern noted for sleep apnea - she does not carry the \ndiagnosis\nAn echocardiogram did not show a PFO on bubble study.\n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack\n1. Dysphagia screening before any PO intake? (X) Yes, confirmed \ndone - () Not confirmed () No\n2. DVT Prophylaxis administered? (X) Yes - () No\n3. Antithrombotic therapy administered by end of hospital day 2? \n(X) Yes - () No\n4. LDL documented? (X) Yes (LDL = 126) - () No\n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if \nLDL if LDL >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]\n6. Smoking cessation counseling given? () Yes - (X) No [reason \n(X) non-smoker - () unable to participate]\n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given (verbally or \nwritten)? (X) Yes - () No\n8. Assessment for rehabilitation or rehab services considered? \n(X) Yes - () No\n9. Discharged on statin therapy? (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\n10. Discharged on antithrombotic therapy? (X) Yes [Type: () \nAntiplatelet - (X) Anticoagulation] - () No\n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? (X) Yes - () No - () N/A\n\n#Cognitive complaints\n- B12 249 - one time IM supplementation, then start oral B12 \nsupplementation\n- Treponemal antibodies negative\n- consider cognitive neurology referral as outpatient for memory \ndifficulties not appreciated on our examination\n\n#Afib\n#frequent sinus pauses\n- stopped digoxin, will ___ closely w/ otpt cardiologist \n(also PCP)\n- increased to appropriate therapeutic dosing at Eliquis 2.5 mg \nBID (reduced dose given age and weight <60 kg)\n\n#HLD\n- started atorvastatin\n\n#HTN\n- continue home antihypertensives\n\n#elevated troponin (RESOLVED)\n- Troponin elevated at OSH, negative on admission\n\n#elevated TSH\n- should recheck as otpt w/ PCP ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atenolol 50 mg PO DAILY \n2. Apixaban 2.5 mg PO DAILY \n3. Losartan Potassium 50 mg PO DAILY \n4. Digoxin 0.125 mg PO DAILY \n5. LevoFLOXacin 500 mg PO Q24H \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth once daily at \nbedtime Disp #*30 Tablet Refills:*5 \n2. Cyanocobalamin 500 mcg PO DAILY \nRX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) by mouth \nonce daily Disp #*30 Tablet Refills:*5 \n3. Apixaban 2.5 mg PO BID \n4. Atenolol 50 mg PO DAILY \n5. LevoFLOXacin 500 mg PO Q24H \n6. Losartan Potassium 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\ntransient dysarthria not secondary to TIA or stroke\nMild Vitamin B12 deficiency\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were hospitalized due to symptoms of slurred speech due to \nconcern for an ACUTE ISCHEMIC STROKE, a condition where a blood \nvessel providing oxygen and nutrients to the brain is blocked by \na clot. 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. However, the MRI of your brain did not show \nevidence of stroke or TIA. Your symptoms could have been related \nto blood pressure, dehydration, alcohol use, or a combination of \nthese factors.\n\nWe are changing your medications as follows:\nIncrease apixaban to 2.5mg twice daily\nStart Vitamin B12 daily supplement\n\nPlease take your other medications as prescribed.\n\nPlease follow up with your primary care physician as listed \nbelow. You should also follow up with your cardiologist as you \nwere noted to have occasional pauses on cardiac monitoring.\n\nIf you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, please pay attention to \nthe sudden onset and persistence of these 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 \nFollowup Instructions:\n___\n" ]

[ "R471", "I5030", "E538", "Z66", "I4891", "Z7902", "I110", "E7849", "K5790", "Z87891", "R946", "I455", "R413" ]

[ "R471: Dysarthria and anarthria", "I5030: Unspecified diastolic (congestive) heart failure", "E538: Deficiency of other specified B group vitamins", "Z66: Do not resuscitate", "I4891: Unspecified atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I110: Hypertensive heart disease with heart failure", "E7849: Other hyperlipidemia", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "Z87891: Personal history of nicotine dependence", "R946: Abnormal results of thyroid function studies", "I455: Other specified heart block", "R413: Other amnesia" ]

[ "Z66", "I4891", "Z7902", "I110", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIV Dye, Iodine Containing Contrast Media / Oxycodone / \ncilostazol / Varenicline\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with hx COPD on home O2, atrial \nfibrillation on apixaban, hypertension, CAD, and hyperlipidemia, \nwith recurrent hospitalizations for COPD exacerbations, who \npresented with dyspnea.\n \nShe has had multiple prior admissions for dyspnea. She was \nrecently discharged on ___ after 3 day inpatient admission for \nCOPD exacerbation. She was discharged on extended prednisone \ntaper with plan for 5d 40mg Prednisone (to finish ___ followed \nby 10mg taper every 5 days (35mg from ___, 30mg ___, \netc...). \n\nOn the evening prior to presentation, patient experienced \nworsening shortness of breath, nonproductive cough and wheezing \nc/w prior COPD exacerbations. She reported taking inhalers as \ndirected, without relief. The patient reported that this is \nalmost identical to her last presentation. She also felt that \nshe was taking too many medications and does not wish to \ncontinue to take prednisone. The patient was also noted to have \nincreased O2 requirement and she was referred to the ___ ED \nfor further management. Of note, please see prior admission note \nfor details regarding prior admission. \n \nIn the ED, initial vital signs were: 88 143/105 26 94% RA. Labs \nwere notable for normal BNP and a creatinine of 1.2. Patient was \ngiven azithromycin and duoneb. Patient was scheduled to have \nmethylpred but did not have it administered until arrival to the \nfloor. \n Upon arrival to the floor, she complained of wheezing and SOB. \nShe otherwise felt well. She agreed to take the methyprednisone \nbut does not wish to take prednisone any more. \n \nREVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, \npharyngitis, fevers, chills, sweats, weight loss, chest pain, \nabdominal pain, nausea, vomiting, diarrhea, constipation, \nhematochezia, dysuria, rash, paresthesias, and weakness.\n \nPast Medical History:\n- COPD/Asthma on home 2L O2\n- Atypical Chest Pain\n- Hypertension\n- Hyperlipidemia\n- Osteroarthritis\n- Atrial Fibrillation on Apixaban\n- Anxiety\n- Cervical Radiculitis\n- Cervical Spondylosis\n- Coronary Artery Disease\n- Headache\n- Herpes Zoster\n- GI Bleeding\n- Peripheral Vascular Disease s/p bilateral iliac stents\n- s/p hip replacement\n \nSocial History:\n___\nFamily History:\nMother with asthma and hypertension. Father with colon cancer. \nBrother with leukemia.\n\n \nPhysical Exam:\nPHYSICAL EXAMINATION ON ADMISSION:\n==================================\n VITALS: 97.3 159/91 75 16 94% on 2L \n GENERAL: Pleasant, well-appearing, in no apparent distress. \n HEENT: Normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear. \n NECK: Supple, no LAD, no thyromegaly, JVP flat. \n CARDIAC: Normal S1/S2, no murmurs rubs or gallops. \n PULMONARY: Mild expiratory wheezes in all lung fields \n ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \n EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema. \n SKIN: Without rash. \n NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n\nPHYSICAL EXAMINATION ON DISCHARGE:\n==================================\n VITALS: 98.6 127-150/50-60 70-90'S 16 98% on 3L \n GENERAL: Pleasant, well-appearing, in no apparent distress. \n HEENT: Normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear. \n NECK: Supple, no LAD, no thyromegaly, JVP flat. \n CARDIAC: Normal S1/S2, no murmurs rubs or gallops. \n PULMONARY: Minimally decreased bilateral air entry, no wheezes \nin all lung fields \n ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \n EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema. \n SKIN: Without rash. \n NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n \nPertinent Results:\nLABS ON ADMISSION:\n==================\n___ 06:15PM BLOOD WBC-7.7 RBC-4.92 Hgb-13.5 Hct-42.4 MCV-86 \nMCH-27.4 MCHC-31.8* RDW-19.6* RDWSD-61.2* Plt ___\n___ 06:15PM BLOOD Neuts-87.4* Lymphs-5.7* Monos-6.1 \nEos-0.0* Baso-0.1 Im ___ AbsNeut-6.72* AbsLymp-0.44* \nAbsMono-0.47 AbsEos-0.00* AbsBaso-0.01\n___ 06:15PM BLOOD ___ PTT-29.6 ___\n___ 06:15PM BLOOD Plt ___\n___ 06:15PM BLOOD Glucose-122* UreaN-21* Creat-1.2* Na-136 \nK-3.4 Cl-92* HCO3-31 AnGap-16\n___ 06:15PM BLOOD ALT-52* AST-34 AlkPhos-69 TotBili-0.3\n___ 06:15PM BLOOD Lipase-28\n___ 06:15PM BLOOD cTropnT-<0.01 proBNP-325\n___ 06:15PM BLOOD Albumin-4.2\n\nLABS ON DISHCHARGE:\n===================\n___ 06:40AM BLOOD WBC-10.3* RBC-4.20 Hgb-11.8 Hct-37.0 \nMCV-88 MCH-28.1 MCHC-31.9* RDW-19.9* RDWSD-65.1* Plt ___\n___ 06:40AM BLOOD Plt ___\n___ 06:40AM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-137 \nK-3.6 Cl-96 HCO3-28 AnGap-17\n___ 06:40AM BLOOD Calcium-9.5 Phos-2.6* Mg-2.1\n\nIMAGING:\n========\n___ CXR:\nNo acute cardiopulmonary process.\n\n \nBrief Hospital Course:\n___ yo F with history of COPD on home O2, atrial fibrillation on \napixaban, hypertension, CAD, hyperlipidemia, and recurrent \nhospitalization for COPD exacerbation over the last 4 months, \nwho presented with dyspnea and increased wheezing secondary to \nsevere COPD.\n \n#Recurrent COPD exacerbation: Patient presented with increased \ndyspnea and diffuse wheezing, likely secondary to COPD \nexacerbation. She has a history of multiple recurrent COPD \nhospitalizations. According to Pulmonary, patient has severe \nCOPD based on her obstructive deficits on PFTs as well as her \nsevere symptoms even at rest, as well as her more frequent \nexacerbations and is likely approaching end-stage disease. We \ncontinued Advair 500/50 BID, Spiriva, standing nebulizers, and \ntheophylline. Pulmonary recommended additional budesonide \ninhalers to allow reduction of PO prednisone dose. Prednisone \ndose was increased back to 40mg (where patient was better) with \na plan for slow wean by 5mg every 2 weeks. Also, patient was \nstarted on chronic azithromycin for chronic anti-inflammation; \nafter discussion with Dr. ___ was agreed to stop \nazithromycin on discharge due to inability to monitor QT the \nweek after discharge, with plan to restart azithromycin once Dr. \n___ is able to see the patient. Patient did not want to go to \npulmonary rehab. She was seen by Palliative Care who recommended \ninitiation of morphine liquid suspension as needed for shortness \nof breath.\n\n# Acute kidney injury: Creatinine was slightly elevated to 1.2 \nfrom a baseline of 1.0. She likely had poor PO intake. \nCreatinine on discharge was 0.9.\n \nCHRONIC ISSUES: \n================== \n# Anxiety/Insomnia: We continued home lorazepam.\n \n# Atrial fibrillation: We continued diltiazem for rate control \nand apixaban for anticoagulation. \n \n# Hypertension: We continued home imdur, hydrochlorothiazide, \nand diltiazem. \n \n# CAD: Cardiac catheterization in ___ showed no evidence of \nsignificant stenosis of coronaries. ECHO on ___ showed EF > \n55% and no regional or global wall motion abnormalities. We \ncontinued home aspirin and atorvastatin.\n \n# Anemia: We continued home iron supplements. \n\n***TRANSITIONAL ISSUES:*** \n- Continue Advair 500/50 BID, Spiriva, and theophylline \n- Make sure patient receives standing nebulizers \n- Added additional budesonide inhalers to allow reduction of PO \nprednisone dose \n- Start chronic azithromycin for chronic anti-inflammation. \n(Patient was started on azithromycin in the hospital and QTc on \n___ was 472 ms. ___ discussion with Dr. ___ was agreed \nto stop azithromycin on discharge due to inability to monitor QT \nthe week after discharge, with the plan to restart azithromycin \nonce Dr. ___ is able to see the patient.)\n- Would recommend audiology testing at some point while patient \nis on chronic azithromycin\n- Continue supplemental oxygen for comfort\n- Follow up with Dr. ___ discharge \n- Continue Bactrim PPX (1 tab SS daily) given extended courses \nof steroids \n- Patient was discharged on prednisone 40 mg with plan for taper \nby 5mg every 2 weeks:\n Prednisone 40 mg for two weeks (Day 1= ___ end \n___\n Prednisone 35 mg for two weeks (Day 1= ___ end \n___\n Prednisone 30 mg for two weeks (Day 1= ___ end \n___\n etc...\n# CONTACT: ___ (husband/HCP) ___ \n# CODE STATUS: Full confirmed \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325 mg PO Q4H:PRN Pain \n2. albuterol sulfate 90 mcg/actuation inhalation Q4H \n3. Apixaban 5 mg PO BID \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Diltiazem Extended-Release 240 mg PO BID \n7. Docusate Sodium 100 mg PO BID \n8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n9. Ferrous Sulfate 325 mg PO DAILY \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n12. Guaifenesin ___ mL PO Q4H:PRN cough \n13. Hydrochlorothiazide 50 mg PO DAILY \n14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n16. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo \n17. Multivitamins 1 TAB PO DAILY \n18. PredniSONE 30 mg PO DAILY \nTapered dose - DOWN \n19. Ranitidine 300 mg PO DAILY \n20. Theophylline SR 300 mg PO BID \n21. Tiotropium Bromide 1 CAP IH DAILY \n22. Levofloxacin 750 mg PO DAILY \n23. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for \nlong term steroid use \n24. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - \n200 units oral DAILY \n25. cod liver oil 1 capsule oral BID \n26. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing \n\n \nDischarge Medications:\n1. Acetaminophen 325 mg PO Q4H:PRN Pain \n2. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - \n200 units oral DAILY \n3. Tiotropium Bromide 1 CAP IH DAILY \n4. Theophylline SR 300 mg PO BID \n5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for long \nterm steroid use \n6. Ranitidine 300 mg PO DAILY \n7. PredniSONE 40 mg PO DAILY \n8. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo \n9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n11. Ipratropium Bromide Neb 1 NEB IH Q6H Wheezing \n12. Hydrochlorothiazide 50 mg PO DAILY \n13. Guaifenesin ___ mL PO Q4H:PRN cough \n14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n15. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n16. Ferrous Sulfate 325 mg PO DAILY \n17. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n18. albuterol sulfate 90 mcg/actuation inhalation Q4H \n19. Apixaban 5 mg PO BID \n20. Aspirin 81 mg PO DAILY \n21. Atorvastatin 10 mg PO QPM \n22. Diltiazem Extended-Release 240 mg PO BID \n23. Docusate Sodium 100 mg PO BID \n24. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal discomfort \nRX *sodium chloride 0.65 % ___ spray QID nasal congestion Disp \n#*1 Spray Refills:*0\n25. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q4H:PRN \nshortness of breath \nRX *morphine 10 mg/5 mL 2.5 mL by mouth every four (4) hours \nDisp ___ Milliliter Milliliter Refills:*0\n26. Budesonide Nasal Inhaler 180 mcg Other DAILY \nRX *budesonide [Pulmicort Flexhaler] 180 mcg/actuation (160 mcg \ndelivered) 1 puff INH DAILY Disp #*1 Inhaler Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nSevere COPD\n\nSECONDARY DIAGNOSES:\nCAD\nHypertension\nAtrial fibrillation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\n___ was a great pleasure taking care of you at ___ \n___. You came to the hospital because you \nwere experiencing worsening shortness of breath. Pulmonary team \nsaw you and reviewed your condition, and your symptoms are \nthought to be related to severe COPD. We did some changes in \nyour medications and increased the dose of prednisone. The \nPalliative Care team was consulted and started you on morphine \nliquid suspension to help with your breathing symptoms.\n\nPlease take all your medications on time and follow up with your \ndoctors as ___.\n\nBest regards,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "J441", "N179", "Z9981", "I4891", "D649", "I10", "E785", "G5622", "I2510", "M1990", "Z96649", "Z87891", "J45909", "F419", "G4700", "R040", "I739" ]

[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "N179: Acute kidney failure, unspecified", "Z9981: Dependence on supplemental oxygen", "I4891: Unspecified atrial fibrillation", "D649: Anemia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "G5622: Lesion of ulnar nerve, left upper limb", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M1990: Unspecified osteoarthritis, unspecified site", "Z96649: Presence of unspecified artificial hip joint", "Z87891: Personal history of nicotine dependence", "J45909: Unspecified asthma, uncomplicated", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "R040: Epistaxis", "I739: Peripheral vascular disease, unspecified" ]

[ "N179", "I4891", "D649", "I10", "E785", "I2510", "Z87891", "J45909", "F419", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIV Dye, Iodine Containing Contrast Media / Oxycodone / \ncilostazol / Varenicline\n \nAttending: ___.\n \nChief Complaint:\nShortness of Breath\n\n \nMajor Surgical or Invasive Procedure:\nN/A\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with history of \nCOPD on home O2, atrial fibrillation on apixaban, hypertension, \nCAD, and hyperlipidemia who presents with shortness of breath, \ncough, and wheezing for one day.\n\nThe patient reports shortness of breath, increased cough \nproductive of ___ red-flected sputum, and wheezing since \nyesterday evening. She has been using albuterol IH more \nfrequently (___) with ipratropium nebs every 4 hours with \nminimal relief. She had to increase her O2 flow up to 4L without \nsignificant improvement. She was currently taking 10mg of \nprednisone. She has also been taking tiotropium IH, \ntheophylline, advair IH at home as prescribed. She denies sick \ncontacts. She quit smoking approximately 1 month ago.\n\nShe reports an episode of chest pain in waiting room while \nsitting down, non-exertional, resolved after 2 minutes. She \ndenies fever/chills, abdominal pain, nausea/vomiting, \npalpitations, and diaphoresis. \n\nShe was recently admitted from ___ to ___ for dyspnea that \nwas thought to be secondary to steroid taper for recent COPD \nexacerbation with a component of anxiety (not an acute COPD \nexacerbation) and was treated with steroids and duonebs but no \nantibiotics. She had a CT that showed emphysema but no evidence \nof infection such as ___. Pulmonary was consulted and \nrecommended increasing her Advair dose to 500/50 (which was \ndone) and switching from theophylline to \nroflumilast and initiation of long-term azithromycin therapy \n(which was deferred for outpatient follow-up) She was initiated \non a steroid \ntaper on ___ of prednisone 30 mg for 3 days, then 20 mg for 3 \ndays, then 10 mg until outpatient follow-up.\n\nIn the ED, initial vital signs were: 97.6 67 132/82 22 97% 4L. \nExam was notable for limited air movement with wheezing \nbilaterally. Labs were notable for WBC 7.1, H/H 12.8/41.1, Plt \n233, Na 133, K 3.6, BUN/Cr ___, trop < 0.01, BNP 181, lactate \n1.5, VBG 7.43/___. Imaging with CXR showed mild basilar \natelectasis without definite focal consolidation. The patient \nwas given Duonebs and solumedrol 125mg IV. Vitals prior to \ntransfer were:\n\nUpon arrival to the floor, she reports her breathing is \nimproved.\n\nREVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, \npharyngitis, rhinorrhea, nasal congestion, fevers, chills, \nsweats, weight loss, abdominal pain, nausea, vomiting, diarrhea, \nconstipation, hematochezia, dysuria, rash, paresthesias, and \nweakness.\n \nPast Medical History:\n- COPD/Asthma on home 2L O2\n- Atypical Chest Pain\n- Hypertension\n- Hyperlipidemia\n- Osteroarthritis\n- Atrial Fibrillation on Apixaban\n- Anxiety\n- Cervical Radiculitis\n- Cervical Spondylosis\n- Coronary Artery Disease\n- Headache\n- Herpes Zoster\n- GI Bleeding\n- Peripheral Vascular Disease s/p bilateral iliac stents\n- s/p hip replacement\n \nSocial History:\n___\nFamily History:\nMother with asthma and hypertension. Father with colon cancer. \nBrother with leukemia.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==========================\nVITALS: Temp 97.3, HR 76, O2 sat 160/80, RR 20, O2 sat 94% 4L\nGENERAL: AOx3, speaking in full sentences, NAD, resting in bed \ncomfortably.\nHEENT: NCAT. PERRL. EOMI. Sclera anicteric and not injected. \nMMM. Oropharynx is clear.\nNECK: Supple. No LAD. JVP not appreciated at 45 degrees.\nCARDIAC: Irregularly irregular, normal rate. ___ systolic murmur \n\nat the RUSB. No rubs or gallops.\nLUNGS: Expiratory wheezes throughout with poor air movement.\nABDOMEN: +BS, soft, nontender, and nondistended.\nEXTREMITIES: Warm and well-perfused. No edema. 2+ DP pulses \nbilaterally. \nNEUROLOGIC: A&Ox3, CNII-XII intact, strength and sensation \ngrossly intact bilaterally.\n\nDISCHARGE PHYSICAL EXAM:\n===========================\nVITALS: Tm 99.1, 146/69 (143-159/69-77), 94, 22, 94-95%% 2L\nGENERAL: speaking in full sentences, NAD, resting in bed \ncomfortably.\nCARDIAC: rrr, normal rate. ___ systolic murmur at the RUSB\nLUNGS: +mild wheezes throughout\nABDOMEN: +BS, soft, nontender, and nondistended.\nEXTREMITIES: Warm and well-perfused. 1+ b/l ___ edema. \nNEUROLOGIC: grossly nonfocal, aaox3\n \nPertinent Results:\nADMISSION LABS: \n=========================\n___ 05:54PM BLOOD WBC-7.1 RBC-4.74 Hgb-12.8 Hct-41.1 MCV-87 \nMCH-27.0 MCHC-31.1* RDW-22.6* RDWSD-69.0* Plt ___\n___ 05:54PM BLOOD Neuts-81.8* Lymphs-9.6* Monos-7.6 \nEos-0.3* Baso-0.1 Im ___ AbsNeut-5.82 AbsLymp-0.68* \nAbsMono-0.54 AbsEos-0.02* AbsBaso-0.01\n___ 06:35AM BLOOD Calcium-9.9 Phos-4.1 Mg-2.0\n___ 05:54PM BLOOD ___ pO2-52* pCO2-49* pH-7.43 \ncalTCO2-34* Base XS-6\n___ 05:54PM BLOOD Lactate-1.5\n___ 05:54PM BLOOD proBNP-181\n___ 05:54PM BLOOD cTropnT-<0.01\n\nSTUDIES: \n=========================\n+ CXR (___): Mild basilar atelectasis without definite focal \nconsolidation.\n+ EKG: Sinus rhythm at 69, left bundle branch block, no acute ST \nor T wave changes.\n\nDISCHARGE LABS: \n=========================\n___ 06:38AM BLOOD WBC-14.4*# RBC-4.34 Hgb-11.8 Hct-37.6 \nMCV-87 MCH-27.2 MCHC-31.4* RDW-22.5* RDWSD-69.4* Plt ___\n___ 06:38AM BLOOD Glucose-113* UreaN-18 Creat-0.8 Na-137 \nK-3.1(repleted)* Cl-94* HCO3-31 AnGap-15\n\n \nBrief Hospital Course:\nMs. ___ is a ___ female with history of \nCOPD on home O2, atrial fibrillation on apixaban, hypertension, \nCAD, and hyperlipidemia who presents with shortness of breath, \ncough, and wheezing for one day. Pt recently DC'd from hospital \nfor dyspnea, treated only w/nebs and steroids as not thought ___ \ntrue COPD exacerbation, c/f anxiety component. Pt re-admitted \nw/similar Sx, thought ___ COPD exacerbation, received nebs, \nsteroids, azithromycin. Pt's wheezing, cough, SOB improved \nshortly after admission, O2 titrated down & satting well on 2L \nin mid-90s which is baseline. Evaluated by ___, recommended DC to \npulmonary rehab, pt was agreeable. \n\nACTIVE ISSUES\n=================\n# Shortness of Breath: Patient with history of COPD and recent \nadmission for dyspnea in the setting of steroid taper. Her \nsymptoms on presentation were consistent with severe COPD given \ndiffuse wheezing and poor air movement. She likely had an \nexacerbation in the setting of a decrease in her steroids. There \nmay also be a component of anxiety. She underwent CT last \nadmission that was negative for infections such as ___. She was \ncontinued on home spiriva, theophylline, advair. She was started \non standing duonebs q6h and albuterol q2h prn and prednisone was \nstarted at 40mg daily with slow taper. She was also given \nazithromycin to complete 5 day course. She had improvement in \nher wheezing and returned to baseline O2 requirement after 48 \nhours. She was seen by ___ who felt that she would benefit from \ndischarge to inpatient pulmonary rehabilitation program. On DC \nto ___ rehab, recommended continued Prendisone 40mg \ndaily for 1x week with slow taper by 5mg every 5 days. ___ also \nconsider starting bactrim ppx with extended duration of steroids \nif unable to wean less than 20mg qd. Will also f/u as outpatient \nwith pulm.\n\nCHRONIC ISSUES: \n==================\n# Anxiety/Insomnia: Continued home lorazepam. Consider starting \nSRRI as an outpatient. \n# Atrial Fibrillation: Continued dilt for rate control and \napixaban for anticoagulation.\n# Hypertension: Continued home imdur, hydrochlorothiazide, and \ndiltiazem.\n# CAD: Cardiac catheterization in ___ without evidence of \nsignificant stenosis of coronaries. ECHO on ___ with EF > \n55% and no regional or global wall motion abnormalities. \nContinued home aspirin and atorvastatin.\n# Anemia: Continued home iron supplements.\n\nTRANSITIONAL ISSUES:\n==========================\n[] For pt's continued COPD exacerbations, recommend finishing 5d \ncourse of Azithromycin, 250mg qd until ___\n[] Recommend extended prednisone taper for pt, 5d 40mg \nPrednisone (to finish ___ followed by 10mg taper every 5 days \n(35mg from ___, 30mg ___, etc...). \n[] Would consider PCP prophylaxis with ___ if unable to wean \nprednisone to less than 20mg daily. \n[] Pt's SOB may have an anxiety component, may benefit from \nstarting SSRI in addition to home benzos already prescribed\n\n# CONTACT: Full Code\n# CODE STATUS: ___ (husband/HCP) ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325 mg PO Q4H:PRN Pain \n2. Apixaban 5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 10 mg PO QPM \n5. Diltiazem Extended-Release 240 mg PO BID \n6. Docusate Sodium 100 mg PO BID \n7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n8. Ferrous Sulfate 325 mg PO DAILY \n9. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n10. Hydrochlorothiazide 50 mg PO DAILY \n11. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n13. Multivitamins 1 TAB PO DAILY \n14. PredniSONE 10 mg PO DAILY \n15. Ranitidine 300 mg PO DAILY \n16. Theophylline SR 300 mg PO BID \n17. Tiotropium Bromide 1 CAP IH DAILY \n18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing \n19. cod liver oil 1 capsule oral BID \n20. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - \n200 units oral DAILY \n21. albuterol sulfate 90 mcg/actuation inhalation Q4H \n22. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n23. Lorazepam 0.5 mg PO Q8H:PRN Anxiety \n24. Guaifenesin ___ mL PO Q4H:PRN cough \n\n \nDischarge Medications:\n1. Acetaminophen 325 mg PO Q4H:PRN Pain \n2. albuterol sulfate 90 mcg/actuation inhalation Q4H \n3. Apixaban 5 mg PO BID \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Diltiazem Extended-Release 240 mg PO BID \n7. Docusate Sodium 100 mg PO BID \n8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n9. Ferrous Sulfate 325 mg PO DAILY \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n12. Guaifenesin ___ mL PO Q4H:PRN cough \n13. Hydrochlorothiazide 50 mg PO DAILY \n14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n16. Lorazepam 0.5 mg PO Q8H:PRN Anxiety \n17. Multivitamins 1 TAB PO DAILY \n18. Ranitidine 300 mg PO DAILY \n19. Theophylline SR 300 mg PO BID \n20. Tiotropium Bromide 1 CAP IH DAILY \n21. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - \n200 units oral DAILY \n22. cod liver oil 1 capsule oral BID \n23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing \n24. Nicotine Patch 7 mg TD DAILY \n25. Azithromycin 250 mg PO Q24H Duration: 4 Doses \nplease take until ___. PredniSONE 40 mg PO DAILY Duration: 5 Days \n40mg until ___ \nTapered dose - DOWN \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nPRIMARY:\nCOPD Exacerbation\n\nSECONDARY:\nAfib\nAnxiety\nHTN\nCAD\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 ___ after you developed \nshortness of breath and wheezing at home shortly after your last \ndischarge. You were treated for a COPD exacerbation and your \nbreathing quickly got better. Our physical therapists evaluated \nyou and recommended that you have a short stay at Pulmonary \n___ before going home to improve your breathing. \n\nWe wish you all the best at rehab and send our condolences to \nyour family on your recent loss.\n\nIt was truly a pleasure taking care of you.\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "J441", "Z9981", "I4891", "J45909", "Z7901", "I10", "I2510", "E785", "M1990", "F419", "I739", "G4700", "D649", "Z96649", "Z87891" ]

[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "Z9981: Dependence on supplemental oxygen", "I4891: Unspecified atrial fibrillation", "J45909: Unspecified asthma, uncomplicated", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "F419: Anxiety disorder, unspecified", "I739: Peripheral vascular disease, unspecified", "G4700: Insomnia, unspecified", "D649: Anemia, unspecified", "Z96649: Presence of unspecified artificial hip joint", "Z87891: Personal history of nicotine dependence" ]

[ "I4891", "J45909", "Z7901", "I10", "I2510", "E785", "F419", "G4700", "D649", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nIV Dye, Iodine Containing Contrast Media / Oxycodone / \ncilostazol / Varenicline\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nIntubation & Mechanical Ventilation (Extubated)\nTemporary Pacer Placement\nCVL Insertion\n\n \nHistory of Present Illness:\n___ with COPD who has been admitted 9 times since ___ for \ndyspnea, CAD, atrial fibrillation on apixaban who presented with \nshortness of breath since being discharged on ___. She was \ndischarged home with services. \n \nMrs. ___ has significant COPD, with recent PFTs on ___ \nshowing severely reduced FEV1 and moderately reduced FEV1/FVC. \nShe was generally feeling better since discharged on ___, \ncontinuing her prednisone (at 40mg today) until the day prior to \npresentation. She subsequently began to become short of breath, \nespecially with exertion, and developed a cough productive of \nbrown sputum. No fever, chills, nausea, vomiting, diarrhea. She \nsleeps with three pillows laying on her side, which is stable. \nHer secondary concern is that she is having trouble walking due \nto pain in her R-hip to R-thigh with weight bearing. This was \nnew. No falls or trauma. No loss of sensation, numbness, \nweakness, urinary or fecal incontinence or difficulty urinating. \n \n \nIn the ED, initial vital signs were: 99.0 80 116/66 24 98% Nasal \nCannula \n - Exam was notable for: diffuse ronchi worst in the RLL, \ntripoding \n - Labs were notable for: flu swab negative, WBC 7.5 with left \nshift, CBC otherwise WNL, BNP 425, lactate 3.0, U/A cloudy with \n30 protein but otherwise negative, BUN/Cr ___ \n - Imaging: CXR with mild bibasilar atelectasis, though ED \nphysicians concerned for pneumonia on lateral view \n - The patient was given: 1g Vancomycin, 2g cefepime, 500 mg PO \nazithromycin, 1 duoneb, 20 mg prednisone (total 60 mg that day) \n\n - Consults: none \n Vitals prior to transfer were: 98.2 87 148/76 18 92% RA \n \nUpon arrival to the floor, Mrs. ___ stated her breathing \nwas slightly better, but she continued to have shortness of \nbreath. She felt as though her ears are clogged up, and this was \nher as well. She stated she has been taking all her medications \nas prescribed. \n \nPast Medical History:\n- COPD/Asthma on home 2L O2\n- Atypical Chest Pain\n- Hypertension\n- Hyperlipidemia\n- Osteroarthritis\n- Atrial Fibrillation on Apixaban\n- Anxiety\n- Cervical Radiculitis\n- Cervical Spondylosis\n- Coronary Artery Disease\n- Headache\n- Herpes Zoster\n- GI Bleeding\n- Peripheral Vascular Disease s/p bilateral iliac stents\n- s/p hip replacement\n \nSocial History:\n___\nFamily History:\nMother with asthma and hypertension. Father with colon cancer. \nBrother with leukemia.\n\n \nPhysical Exam:\nPHYSICAL EXAMINATION ON ADMISSION:\n==================================\n VITALS: 98.4 140/83 77 22 94% RA \n GENERAL: breathing somewhat heavily with audible wheeze \n HEENT - no pallor or icterus, no oropharyngeal lesion, no sinus \ntenderness \n NECK: Supple, JVP flat \n CARDIAC: RRR, unable to appreciate any m/r/g due to breathing \n PULMONARY: diffuse wheezes and ronchi \n ABDOMEN: NT/ND, +BS \n EXTREMITIES: 1+ lower extremity edema up shins, patient is \nsitting ___ style and I do not appreciate tenderness at the R \nhip \n SKIN: Without rash. \n NEUROLOGIC: A&Ox3, moving all extremities with purpose \n \nPHYSICAL EXAMINATION ON DISCHARGE:\n==================================\n HR and RR went to zero on continuous telemetry. Patient did not \nrespond to vocal or tactile stimuli. Pupils were non-reactive to \nlight. She had no heart or lung sounds for > 1 minute on \nauscultation. She was pronounced dead at 0515. Family was \nnotified, they had previously declined an autopsy. \n \nPertinent Results:\nLABS ON ADMISSION:\n==================\n___ 04:38PM BLOOD WBC-7.5 RBC-4.39 Hgb-12.3 Hct-38.6 MCV-88 \nMCH-28.0 MCHC-31.9* RDW-18.0* RDWSD-56.9* Plt ___\n___ 04:38PM BLOOD Neuts-92.1* Lymphs-3.9* Monos-3.5* \nEos-0.0* Baso-0.0 Im ___ AbsNeut-6.91* AbsLymp-0.29* \nAbsMono-0.26 AbsEos-0.00* AbsBaso-0.00*\n___ 04:38PM BLOOD Plt ___\n___ 04:38PM BLOOD Glucose-143* UreaN-20 Creat-1.1 Na-135 \nK-3.5 Cl-91* HCO3-29 AnGap-19\n___ 04:38PM BLOOD ALT-50* AST-41* AlkPhos-73 TotBili-0.3\n___ 04:38PM BLOOD proBNP-425\n___ 04:38PM BLOOD Albumin-4.4 Calcium-10.3 Phos-3.6 Mg-2.0\n___ 10:40AM BLOOD ___ pO2-130* pCO2-41 pH-7.42 \ncalTCO2-28 Base XS-2 Comment-GREEN TOP\n___ 04:44PM BLOOD Lactate-3.0*\n\nLABS ON DISCHARGE:\n==================\n___ 04:15AM BLOOD WBC-13.4* RBC-2.42* Hgb-7.0* Hct-22.9* \nMCV-95 MCH-28.9 MCHC-30.6* RDW-17.5* RDWSD-56.8* Plt ___\n___ 04:15AM BLOOD Glucose-94 UreaN-15 Creat-0.6 Na-138 \nK-4.2 Cl-97 HCO3-37* AnGap-8\n___ 04:15AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0\n\nSELECT IMAGING:\n===============\n___ CXR: \nCOMPARISON: ___ \nFINDINGS: \n Heart size is mildly enlarged. There is mild unfolding of the \nthoracic aorta. Cardiomediastinal silhouette and hilar contours \nare otherwise unremarkable. There is mild bibasilar atelectasis. \nLungs are otherwise clear. Pleural surfaces are clear without \neffusion or pneumothorax. Focus of air seen under the right \nhemidiaphragm, likely represents colonic interposition. \nIMPRESSION:No acute cardiopulmonary abnormality. \n\n___ RUE U/S:\n IMPRESSION: 4 cm acute deep vein thrombosis noted within the \nmid right brachial vein as detailed above. \n\n___ CXR:\n IMPRESSION: The endotracheal tube tip is 6 cm above the carina. \n Nasogastric tube tip is beyond the GE junction and off the edge \nof the film. A left central line is present in the tip is in \nthe mid SVC. A pacemaker is noted on the right in the lead \nprojects over the right ventricle. There is probable scarring \nin both lung apices. There are no new areas of consolidation. \nThere is upper zone redistribution and cardiomegaly suggesting \npulmonary venous hypertension. There is no pneumothorax. \n \nBrief Hospital Course:\n___ hx severe COPD, AFib, CAD, HTN, HLD, recent hospitalizations \nfor recurrent COPD exacerbations over the last several months, \nwho presented with dyspnea and increased wheezing secondary to \nsevere COPD. \n\nShe was treated for her COPD with nebulizers and steroids, but \ncontinued to decline eventually suffering a PEA arrest thought \ndue to hypoxemia requiring endotracheal intubation and \nmechanical ventilation. A temporary pacemaker was placed for \nperiods of bradycardia that may also have contributed to her PEA \narrest (versus being a manifestation of severe hypoxemia/severe \nhypercarbia preceding her arrest). She made a cognitive recovery \nbut was unable to be successfully weaned from her ventilator. \nShe had capacity and was able to make it understand that she did \nnot wish: continued intubation & mechanical ventilation; \nre-intubation and mechanical ventilation once extubated; or, \npositive non-invasive pressure ventilation. After extensive \ndiscussions with her and her family, she was transitioned to \nDNR/DNI and comfort-oriented care. She was extubated to spend \nquality time with her family before passing from respiratory \nfailure on the morning of ___ at 0515. Autopsy was declined \nby family.\n\nShe was incidentally found to have a RUE DVT that was treated \nwith heparin gtt (which was also used for anticoagulation for \nher atrial fibrillation; she was temporarily transitioned to \nargatroban for concern of HIT, but PF4 antibodies returned at \nvery low OD, making this diagnosis unlikely). She was also \ntreated for an acute sinusitis with Augmentin during her \nhospital stay. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325 mg PO Q4H:PRN Pain \n2. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - \n200 units oral DAILY \n3. Tiotropium Bromide 1 CAP IH DAILY \n4. Theophylline SR 300 mg PO BID \n5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for long \nterm steroid use \n6. Ranitidine 300 mg PO DAILY \n7. PredniSONE 40 mg PO DAILY \n8. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo \n9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n11. Ipratropium Bromide Neb 1 NEB IH Q6H Wheezing \n12. Hydrochlorothiazide 50 mg PO DAILY \n13. Guaifenesin ___ mL PO Q4H:PRN cough \n14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n15. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n16. Ferrous Sulfate 325 mg PO DAILY \n17. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n18. albuterol sulfate 90 mcg/actuation inhalation Q4H \n19. Apixaban 5 mg PO BID \n20. Aspirin 81 mg PO DAILY \n21. Atorvastatin 10 mg PO QPM \n22. Diltiazem Extended-Release 240 mg PO BID \n23. Docusate Sodium 100 mg PO BID \n24. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal discomfort \n25. Morphine Sulfate (Oral Solution) 2 mg/mL 5 mg PO Q4H:PRN \nshortness of breath \n26. Budesonide Nasal Inhaler 180 mcg Other DAILY \n\n \nDischarge Medications:\nNone.\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\ns/p PEA Arrest \nRespiratory Failure\nCOPD\nSinusitis\nRUE DVT\n\nSECONDARY DIAGNOSES:\nAtrial fibrillation\nHypertension\nCAD\n \nDischarge Condition:\nDeceased. \n \nDischarge Instructions:\nN/A\n \nFollowup Instructions:\n___\n" ]

[ "J441", "K7200", "R579", "J9602", "J9601", "I442", "I82621", "I4891", "D696", "I469", "I10", "E785", "Z7901", "M47892", "I7389", "I2510", "Z87891", "Z96641", "J0190", "F419", "G4700", "R609", "D509", "R509", "M1990", "Y92239", "Z7952", "Z825", "Z781", "Z515", "Z66", "Z9981", "J45909", "I447", "M7981", "T45515A" ]

[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "K7200: Acute and subacute hepatic failure without coma", "R579: Shock, unspecified", "J9602: Acute respiratory failure with hypercapnia", "J9601: Acute respiratory failure with hypoxia", "I442: Atrioventricular block, complete", "I82621: Acute embolism and thrombosis of deep veins of right upper extremity", "I4891: Unspecified atrial fibrillation", "D696: Thrombocytopenia, unspecified", "I469: Cardiac arrest, cause unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z7901: Long term (current) use of anticoagulants", "M47892: Other spondylosis, cervical region", "I7389: Other specified peripheral vascular diseases", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "Z96641: Presence of right artificial hip joint", "J0190: Acute sinusitis, unspecified", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "R609: Edema, unspecified", "D509: Iron deficiency anemia, unspecified", "R509: Fever, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Z7952: Long term (current) use of systemic steroids", "Z825: Family history of asthma and other chronic lower respiratory diseases", "Z781: Physical restraint status", "Z515: Encounter for palliative care", "Z66: Do not resuscitate", "Z9981: Dependence on supplemental oxygen", "J45909: Unspecified asthma, uncomplicated", "I447: Left bundle-branch block, unspecified", "M7981: Nontraumatic hematoma of soft tissue", "T45515A: Adverse effect of anticoagulants, initial encounter" ]

[ "J9601", "I4891", "D696", "I10", "E785", "Z7901", "I2510", "Z87891", "F419", "G4700", "D509", "Z515", "Z66", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIV Dye, Iodine Containing Contrast Media / Oxycodone / \ncilostazol / Varenicline\n \nAttending: ___.\n \nChief Complaint:\nAnemia, Melena, SOB\n \nMajor Surgical or Invasive Procedure:\nUpper endoscopy ___\n\n \nHistory of Present Illness:\n___ yo female with history of Afib on Xarelto, COPD, HTN, PAD who \npresents for abnormal labs. She noted dark, tarry, stool on \n___ and presented to PCP ___ ___, where H/H was noted \nto be 8.8/28.6 from prior 11.___.6 (baseline Hct about 38). She \nhas also been experiencing bright red blood with wiping, she \nbelieves from her hemorrhoids. PCP called pt who agreed to come \nto ED. She had colonoscopy in ___ with showed a benign polyp, \ninternal hemorrhoids, and diverticulosis. Her last BM was ___, \nwas reportedly \"regular.\" She currently complains of increased \nexertional fatigue and has been feeling more SOB than her \nbaseline. Over the last 6 months she has noticed she becomes \nincreasingly out of breath, walking or climbing stairs. She \nbecomes SOB after 6 stairs or less than 1 block, requiring her \nto stop, and at times use albuterol inhaler. She used to use her \nonly use her inhaler ___ times per day, now she uses it over \nfour times a day and nebulizers twice a day. \n\nShe denies any fevers, chills, nausea/vomit, diarrhea, dysuria, \nrash, unintentional weight loss. \n \n \nIn the ED, initial vitals: 0 98 64 149/85 20 98% RA \nLabs significant for:\nWBC 5.0 HGB 8.8 HCT 28.4( Last baseline of 11.___/34.6 in \n___ MCV PLT 240 \n___ 16.7 INR 1.5 PTT 38.8\nChem 7 was normal\n\nShe was given albuterol nebs and started on IV normal saline\n \nOn transfer, vitals were: T:98.4 BP: 152/60 P:68 R:18 18 \nO2:97%RA \nOn arrival to the floor patient was stable and in good spirits. \nShe notes that she had some blood per rectum on her underwear. \n\n \nPast Medical History:\nASTHMA/COPD/Tobacco use, Peripheral Arterial disease s/p recent \ncommon iliac stenting, ATRIAL TACHYCARDIA, ATYPICAL CHEST PAIN, \nCERVICAL RADICULITIS, CERVICAL SPONDYLOSIS, CORONARY ARTERY \nDISEASE \nHEADACHE, HIP REPLACEMENT, HYPERLIPIDEMIA, HYPERTENSION, \nOSTEOARTHRITIS, HERPES ZOSTER, TOBACCO ABUSE, ATRIAL \nFIBRILLATION \nANXIETY,GASTROINTESTINAL BLEEDING, OSTEOARTHRITIS, \nATHEROSCLEROTIC CARDIOVASCULAR DISEASE, PERIPHERAL VASCULAR \nDISEASE, CATARACT SURGERY ___ \nSurgery: \nBILATERAL COMMON ILIAC ARTERY STENTING ___ \nBUNIONECTOMY \nHIP REPLACEMENT \nPRIOR CESAREAN SECTION \nGANGLION CYST\n \nSocial History:\n___\nFamily History:\nMother: ___, HTN \nFather: ___ CA \nBrother: CA? \nBrother: ___ \n \nPhysical ___:\nADMISSION PHYSICAL EXAM:\nVitals: T:98.4 BP: 152/60 P:68 R:18 18 O2:97%RA \nGENERAL: Well nourished, well appearing AA female, sitting up in \nbed Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally though decreased air \nmovement. No no wheezes, rales, rhonchi \nCV: Irregularly irregular rate and rhythm, normal S1 S2, ___ \nsystolic murmur heard best at RUSB, no rubs or gallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nRectum: No obvious hemorrhoids \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: clear\nNEURO: No gross deficits.\n\nDISCHARGE PHYSICAL EXAM:\nVitals: T: 98.2, BP: 146-152/67-78, P:57-60, ___, O2:97%RA \nGENERAL: Well nourished, well appearing, sitting up in bed, NAD\nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Scattered wheezes bilaterally but no resp distress \nCV: Irregularly irregular rate and rhythm, normal S1 S2, ___ \nsystolic murmur heard best at RUSB, no rubs or gallops\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\nNEURO: No gross deficits. \n \nPertinent Results:\nADMISSION LABS:\n================\n___ 12:28PM BLOOD WBC-5.0 RBC-3.28* Hgb-8.8* Hct-28.4* \nMCV-87 MCH-26.8 MCHC-31.0* RDW-16.1* RDWSD-50.4* Plt ___\n___ 02:28PM BLOOD ___ PTT-38.8* ___\n___ 12:28PM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-137 \nK-3.6 Cl-98 HCO3-28 AnGap-15\n\nPERTINENT FINDINGS:\n====================\nEGD negative for evidence of bleeding\n\nDISCHARGE LABS:\n================\n___ 06:35AM BLOOD WBC-4.7 RBC-3.38* Hgb-9.1* Hct-29.1* \nMCV-86 MCH-26.9 MCHC-31.3* RDW-16.1* RDWSD-50.5* Plt ___\n___ 06:35AM BLOOD ___ PTT-37.1* ___\n___ 06:35AM BLOOD Glucose-99 UreaN-8 Creat-0.9 Na-137 \nK-3.2* Cl-98 HCO3-30 AnGap-12\n___ 06:35AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.___ PMH of CAD, PVD, and COPD and history of recurrent chest \npain present with drop in HCT and progressive SOB. \n\nACTIVE PROBLEMS\n#GI Bleed: Presented to PCP with melena and wiping BRBPR. CBC \nwas taken and Hgb found to drop from 11.3->8.8. Two large bore \nIVs were placed, started on IV PPI, and she was type and \nscreened. Vitals remained stable, so patient was continued on \nhome rivaroxaban. She was evaluated by GI who recommended upper \nGI endoscopy, which showed no evidence of bleeding. She remained \nhemodynamically stable throughout the admission. Hgb 9.1 on day \nof discharge. She was discharged home on both her Xarelto and \nASA.\n\n#SOB: Long standing history of smoking and COPD. Progressive \nexertional dyspnea despite use of Spiriva, advair, fluticasone \nnasal spray, theophylline, and albuterol nebulizers. Has \nincreased rescue inhaler use. Etiology unclear, does not appear \nto be infectious given chronicity. Most likely is progression of \nunderlying COPD. PFT's were obtained while in-house. Smoking \ncessation was also discussed. Will need continued outpatient f/u \nre: her COPD.\n\nCHRONIC PROBLEMS\n#Afib: Continued home amiodarone and diltiazem. Continued \nrivaroxaban for anticoagulation, as discussed above.\n\n#HTN: Stable, continued on home diltiazem, Imdur, HCTZ\n\n#Anxiety/insomnia: stable, continued home lorazepam QHS PRN for \ninsomnia/anxiety.\n\n#Dry eyes: History of glaucoma. Continued home latanoprost \nophthalmic drops.\n\n#PAD: Stable, continued on home atorvastatin, s/p iliac stent. \nOK to continue aspirin as well.\n\nTRANSITIONAL ISSUES:\n- Should consider outpatient colonoscopy to potentially identify \nany source of lower GI Bleed.\n- Given stable hemoglobin/hematocrit while inpatient as well as \nno evidence of bleeding on EGD, her Xarelto and Aspirin were \ncontinued on discharge\n- Was treated with IV PPI while inpatient, but given no evidence \nof active bleeding, was discharged on home Ranitidine 300mg PO \ndaily\n- Continue to encourage smoking cessation\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Rivaroxaban 20 mg PO QPM \n2. Acetaminophen 325 mg PO Q6H:PRN pain \n3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Diltiazem Extended-Release 180 mg PO BID \n7. Fluticasone Propionate NASAL 2 SPRY NU BID nasal congestion \n8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n9. Hydrochlorothiazide 50 mg PO DAILY \n10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n11. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS \n12. Lorazepam 0.5 mg PO QHS:PRN insomnia \n13. Multivitamins W/minerals 1 TAB PO DAILY \n14. Ranitidine 300 mg PO DAILY \n15. Theophylline ER 300 mg PO BID \n16. Tiotropium Bromide 1 CAP IH BID \n17. TraMADOL (Ultram) 50 mg PO BID pain \n18. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN \nirritation \n19. Amiodarone 200 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 325 mg PO Q6H:PRN pain \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB \n3. Amiodarone 200 mg PO DAILY \n4. Atorvastatin 10 mg PO QPM \n5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN \nirritation \n6. Diltiazem Extended-Release 180 mg PO BID \n7. Fluticasone Propionate NASAL 2 SPRY NU BID nasal congestion \n8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n9. Hydrochlorothiazide 50 mg PO DAILY \n10. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n11. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS \n12. Lorazepam 0.5 mg PO QHS:PRN insomnia \n13. Rivaroxaban 20 mg PO QPM \n14. Theophylline ER 300 mg PO BID \n15. Ranitidine 300 mg PO DAILY \n16. TraMADOL (Ultram) 50 mg PO BID pain \n17. Tiotropium Bromide 1 CAP IH BID \n18. Multivitamins W/minerals 1 TAB PO DAILY \n19. Aspirin 81 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\n- Anemia\n\nSecondary:\n- Afib\n- CAD\n- HTN\n- COPD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted to ___ due to \na decrease in blood count on laboratory testing. Because we were \nconcerned for a bleed in your GI tract, you underwent an upper \nendoscopy. Fortunately, this did not show any evidence of \nbleeding. Your blood counts remained stable while in the \nhospital. You were discharged with plan for outpatient follow up \nwith GI for colonoscopy in the future. Pulmonary function \ntesting was done as well while you were here. You will also \nfollow up with Dr. ___ in his clinic.\n\nIt was a pleasure taking care of your at ___. If you have any \nquestions about the care you received, please do not hesitate to \nask.\n\nSincerely,\nYour Inpatient ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K921", "D62", "I4891", "J449", "I10", "F17210", "D649", "I2510", "F419", "E785", "I739", "M47892", "R0602", "G4700", "H409", "K449", "K2970", "Z7982", "Z7901", "Z96649" ]

[ "K921: Melena", "D62: Acute posthemorrhagic anemia", "I4891: Unspecified atrial fibrillation", "J449: Chronic obstructive pulmonary disease, unspecified", "I10: Essential (primary) hypertension", "F17210: Nicotine dependence, cigarettes, uncomplicated", "D649: Anemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F419: Anxiety disorder, unspecified", "E785: Hyperlipidemia, unspecified", "I739: Peripheral vascular disease, unspecified", "M47892: Other spondylosis, cervical region", "R0602: Shortness of breath", "G4700: Insomnia, unspecified", "H409: Unspecified glaucoma", "K449: Diaphragmatic hernia without obstruction or gangrene", "K2970: Gastritis, unspecified, without bleeding", "Z7982: Long term (current) use of aspirin", "Z7901: Long term (current) use of anticoagulants", "Z96649: Presence of unspecified artificial hip joint" ]

[ "D62", "I4891", "J449", "I10", "F17210", "D649", "I2510", "F419", "E785", "G4700", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIV Dye, Iodine Containing Contrast Media / Oxycodone / \ncilostazol / Varenicline\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ with hx COPD on home O2, atrial \nfibrillation on apixaban, hypertension, CAD, and hyperlipidemia \nwho presented with dyspnea. \nShe has had multiple prior admissions for dyspnea. She was \nrecently discharged on ___ after 3 day inpatient admission for \nCOPD exacerbation. She was discharged on extended prednisone \ntaper with plan for 5d 40mg Prednisone (to finish ___ followed \nby 10mg taper every 5 days (35mg from ___, 30mg ___, \netc...). She initially went to rehab and subsequently went home \n2 days prior to admission. \nUpon arrival at home she subsequently had recrudescence of \nfatigue, wheezing, dyspnea. She also had increased O2 \nrequirements (up to 3L, using oxygen 24hr instead of during day \nonly). Also with new cough, non-productive. Denies f/c, CP. No \nn/v, no myalgias. Decreased hearing in right ear with fullness \nfor past 4 days. She was seen by PCP ___ noted to have \ninspiratory/expiratory wheezes, as well as decreased hearing and \nbulging TM right ear. She was referred to the ___ ED for \nfurther management. \nIn the ED, initial vital signs were: 98.4 74 142/69 16 100%(2L \nNC) \n- Labs were notable for: \n 136 95 17 140 \n 3.5 29 1.0 \n BNP 254 \n CBC within normal limits, but with neutrophil predominance \n UA with 30 protein \n VBG: pH 7.45, pCO2 43, pO2 59, HCO3 31 \n Flu PCR negative \n- Imaging: \n CXR notable for no acute cardiopulmonary process. \n- The patient was given: \n ___ 16:03 IH Albuterol 0.083% Neb Soln 1 NEB \n ___ 16:03 IH Ipratropium Bromide Neb 1 NEB \n ___ 17:12 IH Albuterol 0.083% Neb Soln 1 NEB \n ___ 17:12 IH Ipratropium Bromide Neb 1 NEB \n ___ 18:12 IH Albuterol 0.083% Neb Soln 1 NEB \n ___ 18:12 IH Ipratropium Bromide Neb 1 NEB \n ___ 21:05 IH Albuterol 0.083% Neb Soln 1 NEB \n ___ 21:05 PO PredniSONE 60 mg \n ___ 21:05 IV Magnesium Sulfate 2 gm \n ___ 21:33 IH Albuterol 0.083% Neb Soln 1 NEB \n Vitals prior to transfer were: \n 98.8 87 131/83 16 97% (2L) \nUpon arrival to the floor, she complained of wheezing and SOB, \nand persistent decreased hearing with fullness in right ear. \n \nREVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, \npharyngitis, rhinorrhea, nasal congestion, cough, fevers, \nchills, sweats, weight loss, dyspnea, chest pain, abdominal \npain, nausea, vomiting, diarrhea, constipation, hematochezia, \ndysuria, rash, paresthesias, and weakness.\n \nPast Medical History:\n- COPD/Asthma on home 2L O2\n- Atypical Chest Pain\n- Hypertension\n- Hyperlipidemia\n- Osteroarthritis\n- Atrial Fibrillation on Apixaban\n- Anxiety\n- Cervical Radiculitis\n- Cervical Spondylosis\n- Coronary Artery Disease\n- Headache\n- Herpes Zoster\n- GI Bleeding\n- Peripheral Vascular Disease s/p bilateral iliac stents\n- s/p hip replacement\n \nSocial History:\n___\nFamily History:\nMother with asthma and hypertension. Father with colon cancer. \nBrother with leukemia.\n\n \nPhysical Exam:\nPHYSICAL EXAMINATION ON ADMISSION:\n==================================\nVITALS: 98.1 139/79 78 22 98RA \nGENERAL: Pleasant, well-appearing, in no apparent distress. \nHEENT - normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear. \nNECK: Supple, no LAD, no thyromegaly, JVP flat. \nCARDIAC: Normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Inspiratory and expiratory wheezes in all lung fields \n \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema. \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n\nPHYSICAL EXAMINATION ON DISCHARGE:\n==================================\nVITALS: 98.2 130-140/70'S 70-80's 20 98RA \nGENERAL: Pleasant, well-appearing, in no apparent distress. \nHEENT - normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear. \nNECK: Supple, no LAD, no thyromegaly, JVP flat. \nCARDIAC: Normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Decreased inspiratory and expiratory wheezes in all \nlung fields \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema. \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n\n \nPertinent Results:\nLABS ON ADMISSION:\n==================\n___ 04:00PM BLOOD Neuts-92.1* Lymphs-4.5* Monos-2.7* \nEos-0.0* Baso-0.0 Im ___ AbsNeut-5.51 AbsLymp-0.27* \nAbsMono-0.16* AbsEos-0.00* AbsBaso-0.00*\n___ 04:00PM BLOOD Plt ___\n___ 04:00PM BLOOD Glucose-140* UreaN-17 Creat-1.0 Na-136 \nK-3.5 Cl-95* HCO3-29 AnGap-16\n___ 04:00PM BLOOD proBNP-254\n___ 03:58PM BLOOD ___ pO2-59* pCO2-43 pH-7.45 \ncalTCO2-31* Base XS-4\n\nLABS ON DISCHARGE:\n==================\n___ 08:00AM BLOOD WBC-5.8 RBC-4.37 Hgb-11.9 Hct-38.2 MCV-87 \nMCH-27.2 MCHC-31.2* RDW-20.4* RDWSD-65.6* Plt ___\n___ 08:00AM BLOOD Plt ___\n___ 08:00AM BLOOD Glucose-156* UreaN-21* Creat-0.9 Na-134 \nK-3.4 Cl-92* HCO3-30 AnGap-15\n___ 08:00AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.0\n\nSTUDIES:\n========\nCXR ___: No acute cardiopulmonary process \nEKG: NSR rate 72, QTC 469, LBBB\n \nBrief Hospital Course:\n___ yo F with history of COPD on home O2, atrial fibrillation on \napixaban, hypertension, CAD, hyperlipidemia, and recurrent \nhospitalization for COPD exacerbation over the last 4 months, \nwho presented with dyspnea consistent with COPD exacerbation, \npossibly secondary to acute viral URI with concurrent sinusitis \n/ Eustachian tube dysfunction\n\n# COPD exacerbation: \nPatient has been experiencing recurrent COPD exacerbations over \nthe last 4 months. She presented with dyspnea consistent with \nCOPD exacerbation, possibly secondary to acute viral URI with \nconcurrent sinusitis / Eustachian tube dysfunction. We continued \nhome spiriva, theophylline, and advair. We continued her steroid \ntherapy at 30mg prednisone daily with a slow taper (5mg every 2 \nweeks). We also treated her with levofloxacin (Day ___ \nwith plan for 5-day course given COPD exacerbation with \nconcurrent concern for sinusitis / bulging right tympanic \nmembrane.\n\nCHRONIC ISSUES: \n================== \n# Anxiety/Insomnia: We continued home lorazepam. \n\n# Atrial Fibrillation: We continued diltiazem for rate control \nand apixaban for anticoagulation.\n \n# Hypertension: We continued home imdur, hydrochlorothiazide, \nand diltiazem. \n \n# CAD: Cardiac catheterization in ___ without evidence of \nsignificant stenosis of coronaries. ECHO on ___ with EF > \n55% and no regional or global wall motion abnormalities. We \ncontinued home aspirin and atorvastatin. \n \n# Anemia: We continued home iron supplements.\n\n***TRANSITIONAL ISSUES:*** \n- Continue levofloxacin with plan for 5-day course (Day \n___ end ___\n- Patient was started Bactrim PPX (1 tab SS daily) given \nextended courses of steroids, stop after discontinuation of \nsteroids\n- Patient was discharged on prednisone 30 mg with plan for taper \nby 5mg every 2 weeks:\n Prednisone 30 mg for two weeks (Day 1= ___ end \n___\n Prednisone 25 mg for two weeks (Day 1= ___ end \n___\n Prednisone 20 mg for two weeks (Day 1= ___ end \n___\n etc...\n# CONTACT: ___ (husband/HCP) ___ \n# CODE STATUS: Full confirmed \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325 mg PO Q4H:PRN Pain \n2. albuterol sulfate 90 mcg/actuation inhalation Q4H \n3. Apixaban 5 mg PO BID \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Diltiazem Extended-Release 240 mg PO BID \n7. Docusate Sodium 100 mg PO BID \n8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n9. Ferrous Sulfate 325 mg PO DAILY \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n12. Guaifenesin ___ mL PO Q4H:PRN cough \n13. Hydrochlorothiazide 50 mg PO DAILY \n14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n16. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo \n17. Multivitamins 1 TAB PO DAILY \n18. Ranitidine 300 mg PO DAILY \n19. Theophylline SR 300 mg PO BID \n20. Tiotropium Bromide 1 CAP IH DAILY \n21. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - \n200 units oral DAILY \n22. cod liver oil 1 capsule oral BID \n23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing \n24. PredniSONE 30 mg PO DAILY \nTapered dose - DOWN \n\n \nDischarge Medications:\n1. Acetaminophen 325 mg PO Q4H:PRN Pain \n2. albuterol sulfate 90 mcg/actuation inhalation Q4H \n3. Apixaban 5 mg PO BID \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Diltiazem Extended-Release 240 mg PO BID \n7. Docusate Sodium 100 mg PO BID \n8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n9. Ferrous Sulfate 325 mg PO DAILY \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n12. Guaifenesin ___ mL PO Q4H:PRN cough \n13. Hydrochlorothiazide 50 mg PO DAILY \n14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n16. Lorazepam 0.5 mg PO Q8H:PRN Insomnia, anxiety, vertigo \n17. Multivitamins 1 TAB PO DAILY \n18. PredniSONE 30 mg PO DAILY \nPlease decrease dose by 5mg every 2 weeks \nTapered dose - DOWN \nRX *prednisone 10 mg 3 tablets(s) by mouth once a day Disp #*45 \nDose Pack Refills:*0\n19. Ranitidine 300 mg PO DAILY \n20. Theophylline SR 300 mg PO BID \n21. Tiotropium Bromide 1 CAP IH DAILY \n22. Levofloxacin 750 mg PO DAILY Duration: 5 Days \nRX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4 \nTablet Refills:*0\n23. Sulfameth/Trimethoprim SS 1 TAB PO DAILY prophylaxis for \nlong term steroid use \nRX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by \nmouth once a day Disp #*30 Tablet Refills:*0\n24. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - \n200 units oral DAILY \n25. cod liver oil 1 capsule oral BID \n26. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nCOPD exacerbation\n\nSECONDARY DIAGNOSES:\nCAD\nHypertension anxiety\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear ___,\n\n___ was a great pleasure taking care of you at ___ \n___. You came here because you were \nexperiencing worsening shortness of breath as well as nasal \ncongestion and decreased hearing. Your symptoms are likely \nrelated to an upper respiratory tract infection and exacerbation \nof your COPD. We started you on antibiotics and continued your \nprednisone.\n\nThe dose of prednisone will be decreased by 5 mg every two \nweeks; please take your prednisone as follows:\n- Prednisone 30 mg for two weeks (Day 1= ___ end \n___\n- Prednisone 25 mg for two weeks (Day 1= ___ end \n___\n- Prednisone 20 mg for two weeks (Day 1= ___ end \n___\n- Discuss with Dr. ___ further taper at f/u \n\nPlease take all your medications on time and follow up with your \ndoctors as ___.\n\nBest regards,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "J441", "J45909", "H6991", "F419", "G4700", "I4891", "Z7901", "I10", "I2510", "D649", "E785", "Z87891", "Z006" ]

[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "J45909: Unspecified asthma, uncomplicated", "H6991: Unspecified Eustachian tube disorder, right ear", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "J45909", "F419", "G4700", "I4891", "Z7901", "I10", "I2510", "D649", "E785", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIV Dye, Iodine Containing Contrast Media / Oxycodone / \ncilostazol / Varenicline\n \nAttending: ___.\n \nChief Complaint:\ncough, dyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHPI: ___ year old female with history of COPD (on home O2), HTN, \nAfib admitted with dyspnea and cough. \n Pt states inc dyspnea since this am, also one episode of \nretrosternal chest pressure lasting 2minuts on way to ED. No cp \ncurrently. on home O2. no fevers/chills or abd sx. \n Patient was recently admitted from ___ with COPD flare \nand afib with RVR. She could not receive azithromycin due to \nconcern for QTc prolongation and so was treated with \nceftriaxone/cefpodoxime. She was treated with 60mg PO prednisone \nand discharged with a prednisone taper of 10 mg decrease q3d \nuntil at 10 mg, then stay at 10 mg until pulm follow up. She was \nalso counseled to do pulmonary rehab and follow up with Dr. \n___. She was discharged on 2L supplemental O2 to be worn at \nall times. He theophylline was decreased from 300 mg BID to ___ \nmg BID due to her afib with RVR. \n She was also seen in the ED on ___ and ___ due to dyspnea \nwhich was felt to be a continuation of her COPD flare in the \nsetting of patient not taking her home medications. She was \ngiven nebulizers and improved. She was DCed home with ___ for \nassistance with medications. She declined pulmonary rehab \nfacility disposition. \n\nIn the ED, initial vitals: \n- Exam notable for: diffuse insp/esp wheezing, dry oropharynx \n- Labs notable for: nl WBC. Trop X1 neg. EKG in sinus.\n- Imaging notable for: CXR no acute process. \n- Pt given: duoneb X 3. methylpred 125mg. Aspirin 325mg, 1L NS, \nand azithromycin 500mg. Peak flow 150, baseline per pt. Symptoms \noverall improved after nebs. \n- Vitals prior to transfer: 98.2 76 138/72 20 97NC. \n\nOn arrival to the floor, pt reports feeling much improved and \nminimal wheezing.\n\nROS: \nNo fevers, chills, night sweats, or weight changes. No changes \nin vision or hearing, no changes in balance. No cough, no \nshortness of breath, no dyspnea on exertion. No chest pain or \npalpitations. No nausea or vomiting. No diarrhea or \nconstipation. No dysuria or hematuria. No hematochezia, no \nmelena. No numbness or weakness, no focal deficits. \n\n \nPast Medical History:\nASTHMA/COPD \n ATYPICAL CHEST PAIN \n CERVICAL RADICULITIS \n CERVICAL SPONDYLOSIS \n CORONARY ARTERY DISEASE \n HEADACHE \n HIP REPLACEMENT \n HYPERLIPIDEMIA \n HYPERTENSION \n OSTEOARTHRITIS \n HERPES ZOSTER \n ATRIAL FIBRILLATION \n ANXIETY \n GASTROINTESTINAL BLEEDING \n OSTEOARTHRITIS \n ATHEROSCLEROTIC CARDIOVASCULAR DISEASE \n PERIPHERAL VASCULAR DISEASE\n \nSocial History:\n___\nFamily History:\nMother: ___, HTN \nFather: ___ CA \nBrother: CA? \nBrother: ___ \n \nPhysical ___:\nAdmission\n\nVitals: 99 142/80 77 20 95/2L \nGeneral: Alert, oriented, no acute distress, appears very calm \nand can talk in full sentences \nHEENT: Sclerae anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: scattered wheezing \nCV: II/VI RUSB systolic murmur, Nl S1, S2, No MRG \nAbdomen: soft, NT/ND bowel sounds present, no rebound tenderness \nor guarding, no organomegaly \nGU: no foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ \nedema b/l\nNeuro: CN2-12 intact, no focal deficits \n\nVitals: 98.5 122/69(130-150) 76(70s) 18 100/2L \nGeneral: Alert, oriented, no acute distress, appears very calm \nand can talk in full sentences \nHEENT: Sclerae anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: scattered wheezing \nCV: II/VI RUSB systolic murmur, Nl S1, S2, No MRG \nAbdomen: soft, NT/ND bowel sounds present, no rebound tenderness \nor guarding, no organomegaly \nGU: no foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ \nedema b/l\nNeuro: CN2-12 intact, no focal deficits\n \nPertinent Results:\nAdmission\n\n___ 01:46PM BLOOD WBC-8.3 RBC-4.52 Hgb-10.8* Hct-36.2 \nMCV-80* MCH-23.9* MCHC-29.8* RDW-21.6* RDWSD-52.4* Plt ___\n___ 01:46PM BLOOD Neuts-93.4* Lymphs-4.0* Monos-1.8* \nEos-0.1* Baso-0.1 Im ___ AbsNeut-7.77* AbsLymp-0.33* \nAbsMono-0.15* AbsEos-0.01* AbsBaso-0.01\n___ 01:46PM BLOOD ___ PTT-31.9 ___\n___ 01:46PM BLOOD Glucose-121* UreaN-19 Creat-1.1 Na-134 \nK-3.7 Cl-91* HCO3-31 AnGap-16\n___ 01:46PM BLOOD cTropnT-<0.01\n___ 01:46PM BLOOD Calcium-10.1 Phos-2.7 Mg-2.1\n___ 01:58PM BLOOD Lactate-1.6\n\nDISCHARGE\n\n___ 05:52AM BLOOD WBC-14.1*# RBC-3.81* Hgb-9.4* Hct-30.8* \nMCV-81* MCH-24.7* MCHC-30.5* RDW-22.5* RDWSD-58.1* Plt ___\n___ 05:52AM BLOOD Glucose-107* UreaN-26* Creat-0.9 Na-136 \nK-3.5 Cl-94* HCO3-35* AnGap-11\n\nCXR ___\n\nIMPRESSION: \n \nNo acute cardiopulmonary process. \n\n \nBrief Hospital Course:\n___ year old female with history of COPD (on home O2), HTN, Afib \nadmitted with dyspnea and cough. \n\n# COPD exacerbation: Presenting with cough, significant \nwheezing and poor air movement initially consistent with COPD \nexacerbation. No PNA on CXR. No ischemic EKG changes. Symptoms \nimproved with duonebs, prednisone and doxycycline. Evaluated by \n___ and discharged to rehab facility for physical strengthening \nand respiratory rehab. Discharged on home COPD meds and steroid \ntaper and abx course.\n\n# pAfib: currently rate well controlled. on apixaban\n\n- continued diltiazam\n- continued apixaban\n- continued amiodarone\n\n# Anemia: Fe def anemia on recent admission, discharged on Fe, \ncontinued iron supplement\n\n# CAD: continue aspirin, atorvastatin\n# Constipation: continue home bowel reg\n# Anxiety: continued home meds\n\nTRANSITIONAL \n\n- Discharged on steroid taper with maintenance dose of 10mg \ndaily until she sees PCP\n* Take ___-\n\n- Doxycycline 100mg BID to ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Amiodarone 200 mg PO DAILY \n3. Apixaban 5 mg PO BID \n4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB \n5. Artificial Tears ___ DROP BOTH EYES PRN irritation \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 10 mg PO QPM \n8. Diltiazem Extended-Release 180 mg PO BID \n9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n10. Fluticasone Propionate NASAL 1 SPRY NU BID \n11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n12. Hydrochlorothiazide 50 mg PO DAILY \n13. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n14. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS \n15. Lorazepam 0.5 mg PO QHS:PRN insomnia \n16. Multivitamins W/minerals 1 TAB PO DAILY \n17. Ranitidine 300 mg PO DAILY \n18. Tiotropium Bromide 1 CAP IH DAILY \n19. Theophylline SR 200 mg PO BID \n20. Ferrous Sulfate 325 mg PO DAILY \n21. Docusate Sodium 100 mg PO BID \n22. Polyethylene Glycol 17 g PO DAILY \n23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB \n24. PredniSONE 30 mg PO DAILY \nStart: ___, First Dose: Next Routine Administration Time \nThis is dose # 1 of 2 tapered doses\n25. PredniSONE 20 mg PO DAILY \nStart: After 30 mg DAILY tapered dose \nThis is dose # 2 of 2 tapered doses\n26. PredniSONE 10 mg PO DAILY \nStart: After last tapered dose completes \nThis is the maintenance dose to follow the last tapered dose\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Amiodarone 200 mg PO DAILY \n3. Apixaban 5 mg PO BID \n4. Artificial Tears ___ DROP BOTH EYES PRN irritation \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 10 mg PO QPM \n7. Diltiazem Extended-Release 180 mg PO BID \n8. Docusate Sodium 100 mg PO BID \n9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n10. Ferrous Sulfate 325 mg PO DAILY \n11. Fluticasone Propionate NASAL 1 SPRY NU BID \n12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n13. Hydrochlorothiazide 50 mg PO DAILY \n14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n15. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS \n16. Lorazepam 0.5 mg PO QHS:PRN insomnia \n17. Multivitamins W/minerals 1 TAB PO DAILY \n18. Polyethylene Glycol 17 g PO DAILY \n19. Ranitidine 300 mg PO DAILY \n20. Theophylline SR 200 mg PO BID \n21. Tiotropium Bromide 1 CAP IH DAILY \n22. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB \n23. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB \n24. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB \n25. Doxycycline Hyclate 100 mg PO Q12H Duration: 2 Days \nto end ___ \n26. PredniSONE 10 mg PO ASDIR \nTake ___- \nTapered dose - DOWN \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary\n\nCOPD exacerbation\n\nSecondary\n\n CORONARY ARTERY DISEASE \n HYPERLIPIDEMIA \n HYPERTENSION \n OSTEOARTHRITIS \n ATRIAL FIBRILLATION \n ANXIETY \n GASTROINTESTINAL BLEEDING \n 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:\nDear ___,\n\n ___ were admitted with exacerbation of your COPD. We gave \n___ some treatments and ___ improved. ___ were evaluated by the \nphysical therapy team who recommended a rehab stay for \nstrengthening and improve your breathing. Please take your \nmedications as prescribed and follow up with your providers.\n\nSincerely,\n___ medical team\n \nFollowup Instructions:\n___\n" ]

[ "J441", "I4892", "Z9981", "I480", "J45998", "Z87891", "I2510", "Z96649", "I10", "E785", "D509", "I739", "F419", "K5900", "M1990", "Z825", "Z8249", "Z7901" ]

[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "I4892: Unspecified atrial flutter", "Z9981: Dependence on supplemental oxygen", "I480: Paroxysmal atrial fibrillation", "J45998: Other asthma", "Z87891: Personal history of nicotine dependence", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z96649: Presence of unspecified artificial hip joint", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "D509: Iron deficiency anemia, unspecified", "I739: Peripheral vascular disease, unspecified", "F419: Anxiety disorder, unspecified", "K5900: Constipation, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z825: Family history of asthma and other chronic lower respiratory diseases", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "Z7901: Long term (current) use of anticoagulants" ]

[ "I480", "Z87891", "I2510", "I10", "E785", "D509", "F419", "K5900", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIV Dye, Iodine Containing Contrast Media / Oxycodone / \ncilostazol / Varenicline\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo woman with a PMH notable for COPD on \nhome O2(hospitalized ___, multiple recent ED visits), Afib on \napixaban, HTN, CAD, and HLD who presents with several days of \nworsening dyspnea.\n\nPatient has had several ED visits for dyspnea and a recent \nhospitalization for a COPD exacerbation in ___. She has \nbeen on steroid therapy with several attempts to taper over the \nlast several months. After her most recent ED visit on ___ \nshe was on placed on 60 mg PO prednisone with a taper down by 10 \nmg each day. Her SOB worsened with the taper and she was seen on \n___ by her PCP who started her on a course of prednisone 30 mg \nPO to be tapered down by 5 mg every 3 days. With the taper she \nis currently on prednisone 25 mg QD.\n\nShe reports that her SOB improved slightly after starting the \nsteroids on ___. However, last night it acutely worsened and she \nwas unable to sleep. She usually uses 3 pillows to sleep but was \nonly comfortable seated upright last night. This morning she \nincreased her oxygen to 3L and felt better. She is usually on 2L \nNC at home. She reports that for the last several months she has \nbeen using two different albuterol inhalers each every ___ \nhours. She knows that this is more than they are prescribed for \nbut it makes her comfortable. She mostly stays put on the second \nfloor of her home. She states that she can walk to the bathroom \nwithout being short of breath, but does not use the stairs \nunless she has to leave the house because it worsens her \nbreathing. She endorses a cough occasionally productive of ___ \nsputum. This is consistent with her baseline. She endorses one \nepisode of non-exertional chest pain today that spontaneously \nresolved. She denies fever, chills, recent sick contacts, and \nlower extremity edema.\n\nIn the ED, initial vital signs were: T 98.5 P 80 BP 154/97 R 20 \nO2 sat 97% NC. \n- Exam notable for: Diffuse expiratory wheezing, prolonged \nexpiratory phase, left inspiratory crackles, irregularly \nirregular rhthym, minimal pedal edema \n- Labs were notable for CBC wnl, proBNP 235, Trop 0.02, chem \nnotable for bicarb 31, AG 13, UA notable for 40 RBCs \n- Studies performed include CXR with stable mild/moderate \ncardiomegaly, atelectasis at bases, otherwise clear lung fields\n- Patient was given Albuterol neb x 1, ipratropium neb x 1, \nAzithromycin 500 mg PO, Prednisone 25 mg PO\n\nUpon arrival to the floor, the patient states that she is doing \nwell. She says that her SOB has improved since this morning and \nis better than last night when she could not sleep. \n \nReview of Systems: \n (+) per HPI \n (-) fever, chills, night sweats, headache, vision changes, \nrhinorrhea, congestion, sore throat, abdominal pain, nausea, \nvomiting, diarrhea, constipation, BRBPR, melena, hematochezia, \ndysuria, hematuria. \n \nPast Medical History:\nASTHMA/COPD \nATYPICAL CHEST PAIN \nCERVICAL RADICULITIS \nCERVICAL SPONDYLOSIS \nCORONARY ARTERY DISEASE \nHEADACHE \nHIP REPLACEMENT \nHYPERLIPIDEMIA \nHYPERTENSION \nOSTEOARTHRITIS \nHERPES ZOSTER \nATRIAL FIBRILLATION \nANXIETY \nGASTROINTESTINAL BLEEDING \nOSTEOARTHRITIS \nPERIPHERAL VASCULAR DISEASE (s/p bilateral iliac stents)\n \nSocial History:\n___\nFamily History:\nMother: ___, HTN \nFather: ___ CA \nBrother: CA? \nBrother: ___ \n \nPhysical ___:\n=================\nADMISSION EXAM:\n=================\nVitals- T 98.0 BP 148/70 HR 70 RR 24 O2Sat 96% on 2L NC \nGENERAL: AOx3, NAD, sitting up in bed\nHEENT: Normocephalic, atraumatic. Pupils equal, round, and \nreactive bilaterally, extraocular muscles intact. No \nconjunctival pallor or injection, sclera anicteric and without \ninjection. Moist mucous membranes, good dentition. Oropharynx \nis clear.\nNECK: Supple. JVD not visualized.\nCARDIAC: Irregularly irregular, ___ systolic murmur best at the \nLSB, no rubs or gallops.\nLUNGS: Poor air movement throughout. Mild diffuse inspiratory \nand expiratory wheezes. No use of accessory muscles of \nbreathing. No rhonchi or rales.\nBACK: No CVA tenderness \nABDOMEN: Normal bowels sounds, non distended, non-tender to \ndeep palpation in all four quadrants. No organomegaly.\nEXTREMITIES: No clubbing or cyanosis. Bilateral pitting edema to \nthe mid shin. Pulses DP/Radial 2+ bilaterally.\nSKIN: No rash or ulcers\nNEUROLOGIC: CN2-12 intact. Moves all extremities spontaneously. \n Normal sensation. \n=================\nDISCHARGE EXAM:\n=================\nVitals- T 98.7 BP 154/85 HR 77 RR 18 O2Sat 99% on 3L NC \nGENERAL: AOx3, NAD, sitting up in bed\nHEENT: NCAT. PERRL. EOMI. Sclera anicteric and not injected. \nMMM. Oropharynx is clear.\nNECK: Supple. No LAD. JVP not appreciated at 45 degrees.\nCARDIAC: Irregularly irregular, normal rate. ___ systolic murmur \nat the RUSB. No rubs or gallops.\nLUNGS: Poor air movement throughout all zones of the lungs. No \nwheezes. No prolonged expiratory phase. No rhonchi or rales. \nDoes typically sit cross legged in the bed with forearms on her \nlegs in a tripod position.\nBACK: No CVA tenderness. \nABDOMEN: +BS, soft, nontender, nondistended\nEXTREMITIES: Trace pitting edema to the mid shin. 2+ DP pulses \nbilaterally. No TTP.\nSKIN: No rash or ulcers.\nNEUROLOGIC: CN2-12 intact. Moves all extremities spontaneously. \n Normal sensation. \n \nPertinent Results:\n==================\nADMISSION LABS:\n==================\n___ 02:27PM BLOOD WBC-7.4 RBC-4.57 Hgb-12.3 Hct-39.3 MCV-86 \nMCH-26.9 MCHC-31.3* RDW-23.6* RDWSD-70.9* Plt ___\n___ 02:27PM BLOOD Neuts-86.5* Lymphs-6.1* Monos-6.6 \nEos-0.0* Baso-0.0 Im ___ AbsNeut-6.38* AbsLymp-0.45* \nAbsMono-0.49 AbsEos-0.00* AbsBaso-0.00*\n___ 02:27PM BLOOD Glucose-132* UreaN-17 Creat-1.0 Na-137 \nK-3.7 Cl-93* HCO3-31 AnGap-17\n==================\nPERTINENT RESULTS:\n==================\nLABS:\n==================\n___ 12:15AM BLOOD ___ pO2-103 pCO2-49* pH-7.42 \ncalTCO2-33* Base XS-5\n===\n___ 02:27PM BLOOD cTropnT-0.02* proBNP-235\n___ 09:05PM BLOOD CK-MB-6 cTropnT-<0.01\n___ 07:45AM BLOOD CK-MB-6 cTropnT-0.02*\n===\n___ 07:45AM BLOOD THEOPHYLLINE-17.3 (10.0-20.0)\n==================\nIMAGING:\n==================\nCXR (___): PA and lateral views the chest provided. Biapical \npleural parenchymal scarring noted. No focal consolidation \nconcerning for pneumonia. No effusion or pneumothorax. No signs \nof congestion or edema. Cardiomediastinal silhouette is stable \nwith an unfolded thoracic aorta and top-normal heart size. Bony \nstructures are intact.\n===\nCT Chest (___):\n1. Moderate upper lobe predominant centrilobular and paraseptal \nemphysema.\n2. New left lower lobe nodule, potentially measuring as large \nas 6 x 8 mm, warrants close follow-up. Stable to slightly \nsmaller 4 mm right middle lobe nodule.\n3. Severe coronary artery calcifications. Aortic valve \ncalcifications. \n4. Enlargement of the main and right pulmonary arteries is \nsuggestive of chronic pulmonary arterial hypertension. \n5. Fusiform aneurysmal dilatation of the abdominal aorta \nmeasuring up to 3.7 cm has progressed compared to prior \nexamination.\n==================\nDISCHARGE LABS:\n==================\n___ 07:45AM BLOOD WBC-7.8 RBC-4.74 Hgb-12.7 Hct-41.0 MCV-87 \nMCH-26.8 MCHC-31.0* RDW-23.7* RDWSD-71.7* Plt ___\n___ 07:45AM BLOOD Glucose-94 UreaN-18 Creat-1.0 Na-135 \nK-3.3 Cl-93* HCO3-31 AnGap-14\n___ 07:45AM BLOOD Calcium-9.8 Phos-2.8 Mg-2.0\n \nBrief Hospital Course:\nMs. ___ is a ___ y/o woman with a PMH notable for COPD on \nhome O2 (hospitalized ___, multiple recent ED visits), Afib \non apixaban, HTN, CAD, and HLD who presented with dyspnea and \northopnea in the setting of a steroid taper for recent COPD \nexacerbation. Her dyspnea was thought to be multifactorial due \nto her severe COPD and with a component of anxiety. The patient \nwas not thought to be having an acute COPD exacerbation.\n\n================\nACTIVE ISSUES:\n================\n\n# Dyspnea: Patient was admitted after one night of worsened \northopnea and dyspnea in the setting of a steroid taper from 30 \nmg to 25 mg. Her dyspnea was thought to be multifactorial due to \nher severe COPD and with a component of anxiety. The patient was \nnot thought to be having an acute COPD exacerbation. The patient \nwas treated with occasional duonebs and lorazepam 0.5 mg PRN \nthat helped relieve her dyspnea. Pulmonology was consulted. The \npatient underwent CT that showed emphysema but no evidence of \ninfection such as ___. The patient was initiated on a steroid \ntaper on ___ of prednisone 30 mg for 3 days, then 20 mg for 3 \ndays, then 10 mg until outpatient follow-up. Pulmonology \nrecommended increasing her Advair dose to 500/50, which was \ndone. They also recommended switching from theophylline to \nroflumilast and initiation of long-term azithromycin therapy \nprovided the patient's QTc was not prolonged; this was deferred \nto the outpatient setting. Throughout her admission she had O2 \nsats greater than 95% on 2L NC. She did not desaturate on \nambulation. \n\n# Anxiety/Insomnia: Patient with a history of anxiety and \ninsomnia, thought to be contributing to her experience of \ndyspnea. The patient was discharged with lorazepam Q8H as needed \nfor anxiety. The patient would likely benefit from therapy with \nan SSRI.\n\n# Demand Ischemia: Patient with troponin 0.02, <0.01, then 0.02. \nECG without acute ischemic changes.\n\n# Microscopic hematuria: On admission the patient had a UA with \n40 RBCs. Occasional UAs over the last year in OMR with \nmicroscopic hematuria. Would recommend repeat UA as an \noutpatient or work-up for microscopic hematuria.\n\n================\nCHRONIC ISSUES:\n================\n\n# Smoking: Patient recently quit smoking one month ago. Patient \nwas provided with a nicotine patch 7 mg while in house; could \nconsider continuing as an outpatient if patient endorses \ncravings.\n\n# Atrial fibrillation: Patient continued on diltiazem 240 mg PO \nBID and apixaban 5 mg BID.\n\n# HTN: Patient with a history of hypertension. Blood pressure \nwell-controlled. Continued on isosorbide mononitrate ER 240 mg \nPO daily and hydrochlorothiazide 50 mg PO daily.\n\n# CAD: Cardiac catheterization in ___ without evidence of \nsignificant stenosis of coronaries. ECHO on ___ with EF>55% \nand no regional or global wall motion abnormalities. The patient \nwas continued on aspirin 81 mg daily and atorvastatin 10 mg QPM.\n\n===================\nTRANSITIONAL ISSUES:\n===================\n#New Medications:\n-Prednisone 30 mg PO QD through ___, then on ___ mg for 3 \ndays, then on ___ mg until outpatient follow-up\n-Increased Advair (Fluticasone-Salmeterol) to 500/50 dose\n-Lorazepam 0.5 mg PO Q8H PRN for anxiety\n\n#Follow-up:\n-Appointment arranged with PCP, ___ ___\n-Appointment arranged with Pulmonologist, Dr. ___, ___\n\n#COPD: Patient was seen by pulmonology during admission who had \nthe following recommendations to consider as an outpatient.\n-Switch to roflumilast from theophylline\n-Daily azithromycin for treatment of chronic inflammation \nprovided QTc within normal limits.\n-Patient may benefit from treatment of anxiety with an SSRI, as \nher anxiety is likely contributing to her experience of dyspnea.\n-In the future, palliative care consult for consideration of \nopioid treatment of dyspnea\n\n#Microscopic hematuria: Patient had a UA with 40 RBCs on \nadmission \n-Recommend repeat UA as an outpatient or work-up for microscopic \nhematuria\n\n#Lung nodule: New left lower lobe nodule, potentially measuring \nas large as 6 x 8 mm, warrants close follow-up. Stable to \nslightly smaller 4 mm right middle lobe nodule. Follow-up CT in \n___ months as per ___ guidelines for evaluation \nof new left lower lobe pulmonary nodule.\n\n#Code Status: Full code\n#Emergency Contact/HCP: ___ (HUSBAND) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 5 mg PO DAILY \nTapered dose - DOWN \n2. Acetaminophen 325 mg PO Q4H:PRN Pain \n3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing \n4. Tiotropium Bromide 1 CAP IH DAILY \n5. Guaifenesin 1 teaspoon PO Q3H:PRN cough \n6. Lorazepam 0.5 mg PO QHS vertigo/insomnia \n7. Diltiazem Extended-Release 240 mg PO BID \n8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n9. Docusate Sodium 100 mg PO BID \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n11. Apixaban 5 mg PO BID \n12. Ranitidine 300 mg PO DAILY \n13. Atorvastatin 10 mg PO QPM \n14. Ferrous Sulfate 325 mg PO DAILY \n15. Multivitamins 1 TAB PO DAILY \n16. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n18. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n19. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - \n200 units oral DAILY \n20. Theophylline SR 300 mg PO BID \n21. Aspirin 81 mg PO DAILY \n22. albuterol sulfate 90 mcg/actuation inhalation Q4H \n23. Hydrochlorothiazide 50 mg PO DAILY \n24. cod liver oil 1 capsule oral BID \n\n \nDischarge Medications:\n1. Acetaminophen 325 mg PO Q4H:PRN Pain \n2. Apixaban 5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 10 mg PO QPM \n5. Diltiazem Extended-Release 240 mg PO BID \n6. Docusate Sodium 100 mg PO BID \n7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n8. Ferrous Sulfate 325 mg PO DAILY \n9. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n10. Hydrochlorothiazide 50 mg PO DAILY \n11. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n13. Multivitamins 1 TAB PO DAILY \n14. PredniSONE 30 mg PO DAILY \nRX *prednisone 10 mg 3 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*0\n15. Ranitidine 300 mg PO DAILY \n16. Theophylline SR 300 mg PO BID \n17. Tiotropium Bromide 1 CAP IH DAILY \n18. Guaifenesin 1 teaspoon PO Q3H:PRN cough \n19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Wheezing \n20. cod liver oil 1 capsule oral BID \n21. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315 mg - \n200 units oral DAILY \n22. albuterol sulfate 90 mcg/actuation inhalation Q4H \n23. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \nRX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/dose 1 \ndose Inhaled Twice a day Disp #*1 Disk Refills:*1\n24. Lorazepam 0.5 mg PO Q8H:PRN Anxiety \nRX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth Every 8 \nhours Disp #*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nChronic obstruction pulmonary disease exacerbation\n\nSecondary Diagnoses:\nTobacco use disorder\nAtrial fibrillation\nHypertension\nAnxiety\nCoronary Artery Disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a privilege taking care of you during your admission to \n___. You were admitted to the hospital for \nshortness of breath and concern that you were having a flare of \nyour COPD.\n\nWhile in the hospital we increased your dose of steroids to help \nyour breathing. You also received several nebulizer treatments \nthat helped your breathing. You were also expressing some \nanxiety that may have been contributing to your shortness of \nbreath. You were given a medication called Ativan for your \nanxiety that also seemed to help your breathing.\n\nDuring your admission you were seen by the pulmonary \nspecialists. They recommended a CT scan that showed that you \nhave extensive COPD but did not show any infection. They also \nsuggested increasing the dose of your Advair inhaler, which we \ndid.\n\nIf you feel short of breath, first please check your oxygen \nlevel. If it is less than 90, you can use oxygen and your \ninhaler. If not, try to wait a few minutes, take a few deep \nbreaths and see if your shortness of breath improves. You can \nuse the medication called Ativan(lorazepam) to help with the \nshortness of breath(no more than three times a day). If still \nnot improved, you can use one of the inhalers/oxygen. \n\nPlease follow-up with all your appointments as listed below and \ncontinue to take all of your medications as prescribed. If you \nexperience any of the danger signs listed you should call your \ndoctor immediately or go to the Emergency Room.\n\nWe wish you the best!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "J441", "I4892", "I248", "J45909", "Z87891", "I4891", "F419", "G4700", "E780", "I2510", "E876", "R312", "I739", "Z7952", "Z9981" ]

[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "I4892: Unspecified atrial flutter", "I248: Other forms of acute ischemic heart disease", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "I4891: Unspecified atrial fibrillation", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "E780: Pure hypercholesterolemia", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E876: Hypokalemia", "R312: Other microscopic hematuria", "I739: Peripheral vascular disease, unspecified", "Z7952: Long term (current) use of systemic steroids", "Z9981: Dependence on supplemental oxygen" ]

[ "J45909", "Z87891", "I4891", "F419", "G4700", "I2510" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIV Dye, Iodine Containing Contrast Media / Oxycodone / \ncilostazol / Varenicline\n \nAttending: ___\n \nChief Complaint:\nDyspnea, Atrial Fibrillation\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ F with pmhx of COPD (nighttime O2), htn, afib who presents \nwith dyspnea, currently being treated for COPD and admitted for \nAfib with RVR. \n The patient went to the ED on ___ and was diagnosed with a \nCOPD flare. She was discharged with a prednisone taper \n(currently on 60mg) and azithromycin. This AM she initially felt \nwell, then developed dyspnea at rest, worsening with exertion. \nHer inhalers improved her SOB. She felt that these symptoms were \nconsistent with her COPD. She saw her PCP ___ today in \nclinic where she was found to be in Afib w/ RVR, rate around \n110-120. She has a history of afib. He referred her to the ED \nfor persistent SOB and afib with RVR. She states she been \ncompliant with nebs and steroid/azithro regimen. She denies any \n___ edema, orthopnea. She denies recent travel, surgeries. She \nhad an episode of chest tightness this AM that felt like her \nCOPD flares. Denies fevers or coughing or production of sputum, \nhemomptysis. \n \nPast Medical History:\nASTHMA/COPD \n ATYPICAL CHEST PAIN \n CERVICAL RADICULITIS \n CERVICAL SPONDYLOSIS \n CORONARY ARTERY DISEASE \n HEADACHE \n HIP REPLACEMENT \n HYPERLIPIDEMIA \n HYPERTENSION \n OSTEOARTHRITIS \n HERPES ZOSTER \n ATRIAL FIBRILLATION \n ANXIETY \n GASTROINTESTINAL BLEEDING \n OSTEOARTHRITIS \n ATHEROSCLEROTIC CARDIOVASCULAR DISEASE \n PERIPHERAL VASCULAR DISEASE\n \nSocial History:\n___\nFamily History:\nMother: ___, HTN \nFather: ___ CA \nBrother: CA? \nBrother: ___ \n \nPhysical ___:\nADMISSION PHYSICAL EXAM:\nVS: 98.14 154/74 71 24 98% 2L \n GENERAL: Well appearing, NAD, no accessory muscle use. \n HEENT: NCAT. Sclera anicteric. PERRL, EOMI. \n NECK: No JVD \n CARDIAC: Irregular rhythm, normal rate. Normal S1, S2. No \nmurmurs/rubs/gallops. \n LUNGS: Moving air well bilaterally. Trace inspiratory wheezing \nand louder expiratory wheezing in all lung fields. No \ncrackles/rhonchi. \n ABDOMEN: Soft, NTND. No HSM or tenderness. \n EXTREMITIES: No c/c/e. No femoral bruits. \n\nDISCHARGE PHYSICAL EXAM:\nVS: Tm 98.8 Tc 98.4 ___ RA\nGENERAL: NAD\nHEENT: NCAT. Sclera anicteric. Conjunctivae noninjected. OM \nclear.\nNECK: No JVD \nCARDIAC: RRR. Normal S1, S2. No murmurs/rubs/gallops. \nLUNGS: Mildly reduced air movement, significant wheezing \nbilaterally, +rhonchi, no crackles \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. \n \nPertinent Results:\nADMISSION LABS:\n___ 03:38PM BLOOD WBC-7.2 RBC-4.06 Hgb-9.4* Hct-31.4* \nMCV-77* MCH-23.2* MCHC-29.9* RDW-16.9* RDWSD-47.2* Plt ___\n___ 03:38PM BLOOD Neuts-93.8* Lymphs-4.2* Monos-1.3* \nEos-0.0* Baso-0.0 Im ___ AbsNeut-6.74*# AbsLymp-0.30* \nAbsMono-0.09* AbsEos-0.00* AbsBaso-0.00*\n___ 03:38PM BLOOD ___ PTT-30.3 ___\n___ 03:38PM BLOOD Glucose-141* UreaN-20 Creat-1.0 Na-133 \nK-3.8 Cl-93* HCO3-30 AnGap-14\n___ 03:38PM BLOOD Calcium-9.9 Phos-2.8 Mg-2.1\n\nPERTINENT LABS:\n___ 03:58PM BLOOD cTropnT-<0.01\n___ 06:50AM BLOOD CK-MB-4 cTropnT-<0.01\n___ 06:50AM BLOOD calTIBC-398 Ferritn-16 TRF-306\n___ 06:50AM BLOOD TSH-4.5*\n___ 09:31AM BLOOD ___ pO2-73* pCO2-58* pH-7.35 \ncalTCO2-33* Base XS-3 \n___ 07:15AM BLOOD T4, FREE, DIRECT DIALYSIS-Test \n\nDISCHARGE LABS: \n___ 05:30AM BLOOD WBC-13.2* RBC-3.97 Hgb-9.0* Hct-31.1* \nMCV-78* MCH-22.7* MCHC-28.9* RDW-17.4* RDWSD-48.7* Plt ___\n___ 05:30AM BLOOD Glucose-85 UreaN-23* Creat-0.9 Na-136 \nK-3.9 Cl-95* HCO3-30 AnGap-15\n___ 06:30AM BLOOD Calcium-9.7 Phos-3.0 Mg-2.0\n\nIMAGING:\n___ Chest X ray: Relative increase in opacity over the lung \nbases bilaterally felt due to overlying soft tissue rather than \nconsolidation. Lateral view may be helpful for confirmation.\n\n___ Chest X ray: There is hyperinflation. There is no \npneumothorax, effusion, consolidation or CHF. There is probable \nosteopenia.\n \nBrief Hospital Course:\n___ is a ___ with a history of CAD, PVD, and \nCOPD and history of recurrent chest pain who presented with afib \nwith RVR and COPD exacerbation. \n \nACUTE PROBLEMS:\n\n#COPD exacerbation: Ms. ___ had had two recent ED visits \nfor COPD exacerbation, most recently ___ when she was started \non prednisone 60 mg. She presented to her PCP's office with \nworsening dyspnea despite this therapy and was also complaining \nof nasal congestion, suggesting a viral URI trigger. In clinic \nshe was also noted to be in afib with RVR so was referred to the \nED where she was admitted after control of her heart rate (see \nbelow). On admission to the floor, she was noted to have \nwheezing, increased work of breathing, and poor air movement. \nShe was treated with 125 mg solumedrol and maintained on 60 mg \nPO prednisone daily. Her home theophylline was decreased from \n400 mg BID to ___ mg BID due to concerns it was contributing to \nher tachyarrhythmia. She was placed on ipratropium nebs q6h, \nalbuterol nebs q2h, and fluticasone-salmeterol. Pulmonary was \nconsulted and recommended a trial of diuresis so she received 10 \nmg IV Lasix as well. Azithromycin was not given due to concerns \nfor QT prolongation with theophylline and amiodarone (QTc was \n460). She was started on a 5 day course of ceftriaxone instead, \nand discharged to finish the course with cefpodoxime. She was \ndischarged with a prednisone taper (10 mg decrease q3d until at \n10 mg, then stay at 10 mg until pulm follow up) as well as \nfollow up with pulmonary rehab and a pulmonologist she \npreviously followed with, Dr. ___. She was also discharged on \n2L supplemental O2 to be worn at all times. \n\n#Atrial fibrillation: Ms. ___ has known atrial \nfibrillation for which she was on amiodarone and apixaban but \nwas found to have HR in the 120s in her PCP's office, prompting \nher referral to the ED. Her COPD exacerbation was the likely \nprecipitant, with medications also possibly contributing, \nparticularly theophylline. She was started on a diltiazem gtt in \nthe ED to control her rates than transitioned to diltiazem 90 mg \nq6h. After arrival to the floor, her rates remained controlled. \nHer amiodarone and apixaban were continued. Her theophylline was \ndecreased to 200 mg BID from 400 mg BID.\n\n#Iron deficiency anemia. Patient was found to have microcytic \nanemia with low iron and ferritin. She was started on IV iron \n125 mg ferric gluconate x4 doses and wasdischarged on PO iron \nwith a bowel regimen. Her H/H was stable throughout the \nhospitalized; there was no evidence of bleeding.\n\nTransitional issues:\n- patient discharged on prednisone taper: decrease by 10 mg \nevery 3 days until at 10 mg, then keep at 10 mg until seen by \npulmonology\n- patient discharged with plan to follow up with pulmonology and \npulmonary rehab. Can call ___ to schedule appointment \nwith pulmonary rehab.\n- patient discharged on with 2 days of cefpodoxime to complete 5 \nday course of antibiotics for severe COPD exacerbation\n- patient discharged with O2 concentrator for continuous home O2\n- patient's theophylline decreased from 300 mg BID to ___ mg BID \ndue to her afib with RVR; may want to consider further \ntheophylline wean, and addition of azithromycin (if QTc is \ndecreased as patient also on amiodarone), and/or roflumilast \ntherapy\n- patient found to be iron deficient, started on IV iron \nrepletion, discharged on PO iron\n- patient found to have elevated TSH, please follow up free T4 \nwhich was pending on discharge\n- Code: full\n- Emergency Contact ___ (Husband) ___ \nDaughter ___: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Apixaban 5 mg PO BID \n3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of \nbreath \n4. Amiodarone 200 mg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Artificial Tears ___ DROP BOTH EYES PRN irritation \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS \n8. Diltiazem Extended-Release 180 mg PO BID \n9. Fluticasone Propionate NASAL 1 SPRY NU BID \n10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n11. Hydrochlorothiazide 50 mg PO DAILY \n12. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n13. Lorazepam 0.5 mg PO QHS:PRN insomnia \n14. Theophylline ER 300 mg PO BID \n15. Ranitidine 300 mg PO DAILY \n16. Tiotropium Bromide 1 CAP IH DAILY \n17. Multivitamins W/minerals 1 TAB PO DAILY \n18. Aspirin 81 mg PO DAILY \n19. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n\n \nDischarge Medications:\n1. Home O2\n2 Liters continuous nasal cannula with exertion\nDiagnosis: chronic obstructive pulmonary disease (J44.9)\nLength of Needs: ongoing (years)\n2. Acetaminophen 650 mg PO Q6H:PRN pain \n3. Amiodarone 200 mg PO DAILY \n4. Apixaban 5 mg PO BID \n5. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of \nbreath \n6. Artificial Tears ___ DROP BOTH EYES PRN irritation \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 10 mg PO QPM \n9. Diltiazem Extended-Release 180 mg PO BID \n10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n11. Fluticasone Propionate NASAL 1 SPRY NU BID \n12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n13. Hydrochlorothiazide 50 mg PO DAILY \n14. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY \n15. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS \n16. Lorazepam 0.5 mg PO QHS:PRN insomnia \n17. Multivitamins W/minerals 1 TAB PO DAILY \n18. Ranitidine 300 mg PO DAILY \n19. Tiotropium Bromide 1 CAP IH DAILY \n20. Theophylline SR 200 mg PO BID \nRX *theophylline 200 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0\n21. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Days \nRX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*4 \nTablet Refills:*0\n22. Ferrous Sulfate 325 mg PO DAILY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n23. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0\n24. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth \ndaily Refills:*0\n25. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea, wheezing \nRX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb INH Every six \nhours Disp #*30 Nebule Refills:*0\n26. PredniSONE 10 mg PO ASDIR \n50 mg ___, then \n40 mg ___, then\n30 mg ___, then\n20 mg ___, then\n10 mg ongoing \nTapered dose - DOWN \nRX *prednisone 10 mg 1 to 5 tablet(s) by mouth As directed Disp \n#*50 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnoses:\nChronic obstructive pulmonary disease\nAtrial fibrillation with rapid ventricular response\n\nSecondary diagnoses:\nHypertension\nCoronary artery disease\nPeripheral vascular disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were hospitalized at ___ \nbecause you were having difficulty breathing and were found in \nclinic to have a fast heart rate. Your difficulty breathing was \ndue to your COPD flaring. Your fast heart rate was due to your \natrial fibrillation, which is an irregular heart rate that can \nsometimes cause the heart to beat very quickly. Medications that \nyou were taking, such as theophylline, were likely contributing. \nYour heart rate was lowered using the same medication that you \ntake at home, diltiazem, given through your IV. \n\nYour COPD was likely worsened because of a cold. However, your \nflare was very serious requiring IV steroids and many inhaled \ntreatments. You should follow up with the lung doctors as ___ \nas with pulmonary rehab to make sure your lung disease is being \ntreated as well as possible to prevent you from coming into the \nhospital as often. Please call ___ to schedule an \nappointment with them.\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" ]

[ "I4891", "J441", "Z9981", "Z7901", "I10", "E785", "F419", "I739", "I2510", "Z87891", "D509", "R079", "G4700", "H409" ]

[ "I4891: Unspecified atrial fibrillation", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "Z9981: Dependence on supplemental oxygen", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F419: Anxiety disorder, unspecified", "I739: Peripheral vascular disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z87891: Personal history of nicotine dependence", "D509: Iron deficiency anemia, unspecified", "R079: Chest pain, unspecified", "G4700: Insomnia, unspecified", "H409: Unspecified glaucoma" ]

[ "I4891", "Z7901", "I10", "E785", "F419", "I2510", "Z87891", "D509", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLocally advanced gastric carcinoma\n \nMajor Surgical or Invasive Procedure:\nCystoscopy for foley catheter placement; Laparoscopy with \nbiopsy; Gastroscopy\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old male with locally advanced gastric \ncancer (stage II [T3N2]) who arrives to ___ for \ncurative-intent surgical resection after completion of induction \nchemotherapy. \n\nHe was started on neoadjuvant chemotherapy with FLOT4 on\n___. Overall he tolerated the chemotherapy well without any \nsignificant side effects. However, last\nmonth he developed right upper extremity edema and was noted to\nhave a thrombosis in the R SVC. He was started on Lovenox 1 \nmg/kg\nBID, which he is compliant with. Denies any fever, nausea,\nemesis, chills, weight loss, melena, hematochezia or hematuria. \n\nHe comes after recent repeat staging (___) with torso CT\nscan demonstrating no evidence of disease. He is now now taken\nto the operating room for minimally invasive and possibly open\nradical distal gastrectomy with lymphadenectomy. The risks\nand benefits of surgery have been described with the patient\nin detail and are documented by Dr. ___ in a separate\nnote.\n \nPast Medical History:\nPast Medical History: Prostate cancer, Thyroid nodule,\nHypothyroid, GERD mild, Diverticulosis on colonoscopy ___\nanemia iron def. anemia which resolved and no workup\n\nPast Surgical History: Prostate cancer external beam ___,\nAchilles tendon repair ___, Shattered right tibia and fibula,\nTonsillectomy age ___.\n \nSocial History:\n___\nFamily History:\nFather died at ___ from Lymphoma. Mother died at ___ with type II \nDM, Dementia. \n \nPhysical Exam:\nVS: 24 HR Data (last updated ___ @ 1118)\n Temp: 98.1 (Tm 98.9), BP: 116/73 (108-118/59-77), HR: 79 \n(77-86), RR: 18 (___), O2 sat: 99% (97-99), O2 delivery: Ra \nGEN: A&Ox3, NAD, resting comfortably \nHEENT: NCAT, EOMI, sclera anicteric\nCV: RRR\nPULM: no respiratory distress\nABD: soft, NT, ND, no rebound or guarding \nEXT: warm, well-perfused, no edema \nPSYCH: normal insight, memory, and mood\nWOUND(S): Incision c/d/i\n \nBrief Hospital Course:\nMr. ___ is a ___ year old Male who presented on ___ for \na planned minimally invasive and possibly open radical distal \ngastrectomy with lymphadenectomy for locally advanced gastric \ncarcinoma after chemotherapy. After placement of the Right upper \nquadrant port, insufflation revealed the right upper quadrant \nport to be penetrating the omentum. It appeared to miss the \ntransverse mesocolon as well as the colon itself. During the \nsurgery, there were visually obvious peritoneal deposits on all \nperitoneal surfaces in all four quadrants, which demonstrated \nundetected carcinomatosis, poorly -differentiated adenocarcinoma \ninvolving the peritoneum. For this reason, the procedure was \nthen aborted. Post-operatively the patient was taken to the PACU \nuntil stable and then transferred to the wards until stable to \ngo home. \n\n#NEURO: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with dilaudid PCA \nwhich he was not using and then transitioned to tramadol which \nhe got only one dose. Pain was very well controlled.\n\n#CV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. \n\n#PULMONARY: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \n\n#GI/GU/FEN: Before the procedure started, OR nurse was unable to \npass Foley after attempt with standard and coude type. PA \n___, with usual sterile technique, re-attempted foley \nplacement after 10cc urojet application with ___ and ___ \ncoude-type catheters but was also unable to get passed the \nprostate. Urology was consulted and they performed a flexible \ncystoscope demonstrating a normal urethra. Using a flexible \nguidewire, cystoscope was advanced into the bladder. The scope \nwas withdrawn and a ___ council was advanced over the wire, \npassed the prostate and into the bladder. The patient was \ndischarged with the Foley in place with instructions to \nfollow-up with urology as outpatient in 5 to 7 days for a \nvoiding trial. No antibiotics were administered. The patient was \ntolerating a regular diet prior to discharge. \n\n#ID: The patient's fever curves were closely watched for signs \nof infection, of which there were none. \n\n#HEME: Patient received BID SQH for DVT prophylaxis, in addition \nto encouraging early ambulation and Venodyne compression \ndevices. On POD1 the patient was restarted on his home \nenoxaparin before discharge.\n\n#TRANSITIONAL ISSUES\n--------------------\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating diet as \nabove per oral, ambulating, and pain was well controlled. The \npatient was discharged home with the Foley catheter with \nappropriate teaching for care. The patient received discharge \nteaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan.\n \nMedications on Admission:\nMedications - Prescription\nBIO-THROID - Bio-Throid . 65 mg. once a day - (Prescribed by \nOther Provider)\nENOXAPARIN - enoxaparin 120 mg/0.8 mL subcutaneous syringe. 120 \nmg SC daily\nOMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 \ncapsule(s) by mouth twice daily\nUBIQUINOL - ubiquinol . (100 mg) 2 tabs mouth twice a day - \n(Prescribed by Other Provider)\n \nMedications - OTC\nFERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1 \ntablet(s) by mouth twice a day - (Prescribed by Other Provider)\nLACTOBACILLUS COMBINATION NO.4 [PROBIOTIC] - Dosage uncertain - \n(Prescribed by Other Provider; daily)\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO TID \n2. Docusate Sodium 100 mg PO BID \n3. Senna 8.6 mg PO BID:PRN Constipation - First Line \n4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \nThis medication is a low dose narcotic and may cause \nconstipation. \nRX *tramadol 50 mg 1 (One) tablet(s) by mouth every six (6) \nhours Disp #*20 Tablet Refills:*0 \n5. Enoxaparin Sodium 120 mg SC DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMetastatic gastric cancer (stage IV [T3N2M1])\nUrethral stricture\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 here at ___ \n___. You were admitted to our hospital for \ngastric cancer. You had an attempted Robot-assisted laparoscopic \npartial gastrectomy and gastroscopy on ___ without \ncomplications. You tolerated the procedure well and are \nambulating, stooling, tolerating a regular diet, and your pain \nis controlled by pain medications by mouth. You are now ready to \nbe discharged to home. Please follow the recommendations below \nto ensure a speedy and uneventful recovery. \n\nACTIVITY:\n- Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\n- You may climb stairs. You should continue to walk several \ntimes a day. \n- You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit. \n- You may start some light exercise when you feel comfortable. \nSlowly increase your activity back to your baseline as \ntolerated.\n- Heavy exercise may be started after 6 weeks, but use common \nsense and go slowly at first. \n- No heavy lifting (10 pounds or more) until cleared by your \nsurgeon, usually about 6 weeks. \n- You may resume sexual activity unless your doctor has told you \notherwise.\n\nHOW YOU MAY FEEL: \n- You may feel weak or \"washed out\" for 6 weeks. You might want \nto nap often. Simple tasks may exhaust you.\n- You may have a sore throat because of a tube that was in your \nthroat during the surgery.\n\nYOUR BOWELS:\n- Constipation is a common side effect of narcotic pain medicine \nsuch as oxycodone. If needed, you may take a stool softener \n(such as Colace, one capsule) or gentle laxative (such as milk \nof magnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\n- If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon.\n- After some operations, diarrhea can occur. If you get \ndiarrhea, don't take anti-diarrhea medicines. Drink plenty of \nfluids and see if it goes away. If it does not go away, or is \nsevere and you feel ill, please call your surgeon.\n\nPAIN MANAGEMENT:\n- You are being discharged with a prescription for **oxycodone \nfor pain control. You may take Tylenol as directed, not to \nexceed 3500mg in 24 hours. Take regularly for a few days after \nsurgery but you may skip a dose or increase time between doses \nif you are not having pain until you no longer need it. You may \ntake the oxycodone for moderate and severe pain not controlled \nby the Tylenol. You may take a stool softener while on narcotics \nto help prevent the constipation that they may cause. Slowly \nwean off these medications as tolerated. \n- Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\n\nIf you experience any of the following, please contact your \nsurgeon: \n- sharp pain or any severe pain that lasts several hours\n- chest pain, pressure, squeezing, or tightness\n- cough, shortness of breath, wheezing\n- pain that is getting worse over time or pain with fever\n- shaking chills, fever of more than 101\n- a drastic change in nature or quality of your pain\n- nausea and vomiting, inability to tolerate fluids, food, or \nyour medications\n- if you are getting dehydrated (dry mouth, rapid heart beat, \nfeeling dizzy or faint especially while standing)\n-any change in your symptoms or any symptoms that concern you\n\nAdditional: \n*- pain that is getting worse over time, or going to your chest \nor back\n*- urinary: burning or blood in your urine or the inability to \nurinate\n\nMEDICATIONS:\n- Take all the medicines you were on before the operation just \nas you did before, unless you have been told differently.\n- If you have any questions about what medicine to take or not \nto take, please call your surgeon. \n\nWOUND CARE: \n- dressing removal:\n- You may remove your dressings tomorrow ___ and shower that \nsame day with any bandage strips that may be covering your \nwound. Do not scrub and do not soak or swim, and pat the \nincision dry. If you have steri strips, they will fall off by \nthemselves in ___ weeks. If any are still on in two weeks and \nthe edges are curling up, you may carefully peel them off.\n Do not take baths, soak, or swim for 6 weeks after surgery \nunless told otherwise by your surgical team. \n-Notify your surgeon is you notice abnormal (foul smelling, \nbloody, pus, etc) or increased drainage from your incision site, \nopening of your incision, or increased pain or bruising. Watch \nfor signs of infection such as redness, streaking of your skin, \nswelling, increased pain, or increased drainage. \n\nPlease call with any questions or concerns. Thank you for \nallowing us to participate in your care. We hope you have a \nquick return to your usual life and activities.\n\nHome with ___:\nYou had a Foley catheter in your bladder placed by urology on \nthe day of your surgery after difficulty trying to place it.\nYou will keep the catheter until your appointment with Urology \nin 5 days (please call the number below to schedule your \nappointment), who will decide if you need it longer or attempt \nto remove it and see if you are able to void.\n Empty the bag as needed and as shown to you by nursing staff. \nYou will be given a leg bag before your discharge, that you may \nuse for short trips. This is a smaller bag that straps to your \nleg, to take home and wear if you are traveling outside your \nhome. This holds a smaller amount than the bag you have now, so \nit needs to be emptied more often. Some people find it easier to \nuse the larger bad when they are at home or carry it with them. \n\n-- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "C169", "C786", "I82621", "K9171", "Y838", "Y92234", "N359", "E039", "K219", "Z7901", "Z8546" ]

[ "C169: Malignant neoplasm of stomach, unspecified", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "I82621: Acute embolism and thrombosis of deep veins of right upper extremity", "K9171: Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "N359: Urethral stricture, unspecified", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7901: Long term (current) use of anticoagulants", "Z8546: Personal history of malignant neoplasm of prostate" ]

[ "E039", "K219", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlisinopril\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nCardiac cath (___)\n\n \nPast Medical History:\n-COPD\n-CAD s/p BMS proximal-LAD ___, DES to mid LAD ___, DES to edge \nISR of mid LAD DES and stenosis distal to stent ___, DES to OM1 \n___, s/p 3 v CABG LIMA-LAD, SVG-OM1, \n___ \n-HFpEF\n-Depression \n-DM \n-GERD \n-Hypertension\n-Migraines\n-Chronic shoulder pain on narcotics\n-OSA\n-Peripheral neuropathy\n-Restless leg\n \nSocial History:\n___\nFamily History:\nPatient was ward of the state, doesn't know full details of \nfamily history. Mother with possible alcohol abuse. Father \ndeceased at ___ from Hodgkin's Disease per old records.\n \nPhysical Exam:\nADMISSION EXAM\n==============\nGENERAL:NAD AOx3 Pleasant woman. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no \npallor or cyanosis of the oral mucosa\nNECK: Supple with no JVD\nCARDIAC: RRR normal S1/S2. No thrills, lifts. \nLUNGS: CTAB. No crackles, wheezes or rhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No ___ edema\nPULSES: ___ and DP palpable on the right side. Did not take \nbandage down for exam as podiatry had just dressed. \n \n\nDISCHARGE EXAM\n==============\nVITALS: ___ 0412 Temp: 97.8 PO BP: 105/67 R Lying HR: 71\nRR: 18 O2 sat: 97% O2 delivery: Ra \nGENERAL:NAD AOx3 Pleasant woman. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no\npallor or cyanosis of the oral mucosa\nNECK: Supple with no JVD\nCARDIAC: RRR normal S1/S2. No thrills, lifts. \nLUNGS: CTAB. No crackles, wheezes or rhonchi. \nABDOMEN: Soft, NTND. \nEXTREMITIES: No ___ edema\nPULSES: ___ and DP palpable on the right side. Did not take\nbandage down for exam as podiatry had just dressed.\n\nPer podiatry exam (___) [See attached picture on OMR]\n___ pulses palpable b/l. CFT <3 sec to digits\nbilaterally. There is a L hallux wound present at the medial\naspect of the toe at the level of the IPJ. Wound has eschar over\ntop of the base w/ surrounding hyperkeratotic skin and\nsurrounding erythema. There is no malodor or proximal streaking\npresent. Once the wound was debrided and the eschar was \nderoofed,\nthere is fibrotic skin at the base of the wound. It does not\nprobe deep to bone. 2cc of purulent drainage was expressed from\nwound. Wound is extremely TTP. Gross sensation is intact to b/l\nlower extremities. MMT ___ to all ___ muscle groups crossing the\nankle jt. No gross deformities noted. \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 12:50AM BLOOD WBC-12.7* RBC-4.34 Hgb-14.4 Hct-41.7 \nMCV-96 MCH-33.2* MCHC-34.5 RDW-11.8 RDWSD-41.3 Plt ___\n___ 12:50AM BLOOD Glucose-318* UreaN-21* Creat-1.1 Na-134* \nK-4.2 Cl-92* HCO3-19* AnGap-23*\n___ 12:50AM BLOOD cTropnT-<0.01\n___ 06:00AM BLOOD cTropnT-<0.01\n___ 11:40AM BLOOD cTropnT-<0.01\n___ 05:20PM BLOOD CK-MB-1 cTropnT-<0.01\n___ 05:20PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.6 Mg-1.8\n___ 05:20PM BLOOD %HbA1c-12.0* eAG-298*\n___ 12:50AM BLOOD CRP-36.4*\n___ 12:50AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG\n\nSTUDIES\n=======\n___ Coronary Angiogram\nCoronary Anatomy\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is.\n* Left Anterior Descending\nThe LAD has diffuse 60% in-stent restenosis with patent LIMA to \ndistal vessel.\nThe ___ Diagonal is small and diffusely diseased.\n* Circumflex\nThe Circumflex is occluded after a small OM1. There is a patent \nSVG to OM2.\n* Right Coronary Artery\nThe RCA has focal mid 50% stenosis.\nSVG to OM patent.\nLIMA to LAD patent.\nIntra-procedural Complications: None\nImpressions:\n1. three vessel CAD.\n2. Patent SVG to OM and LIMA to LAD.\nRecommendations\n1. Medical therapy.\n\nPharmacological MIBI ___\nIMPRESSION: \n \n1. Reversible, medium sized, moderate severity perfusion defect \ninvolving the \nLAD territory. \n \n2. Normal left ventricular cavity size and systolic function. \n \nCompared to the prior study of ___, the perfusion defect \nis new. \n \n\nECHO ___\nLEFT ATRIUM: Normal LA volume index. \n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and \nregional/global systolic function (biplane LVEF>55%). Doppler \nparameters are most consistent with normal LV diastolic \nfunction. \n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. \nParadoxic septal motion consistent with prior cardiac surgery. \n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch \nlevels. \n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. \n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. \n___ mitral valve supporting structures. No MS. \n\n___ VALVE: Normal tricuspid valve leaflets with trivial \nTR. Normal PA systolic pressure. \n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. \nNo PS. Physiologic PR. \n\nPERICARDIUM: No pericardial effusion. \nConclusions \n The left atrial volume index is normal. Normal left ventricular \nwall thickness, cavity size, and regional/global systolic \nfunction (biplane LVEF = 63 %). Doppler parameters are most \nconsistent with normal left ventricular diastolic function. \nRight ventricular chamber size and free wall motion are normal. \nThe diameters of aorta at the sinus, ascending and arch levels \nare normal. The aortic valve leaflets (3) appear structurally \nnormal with good leaflet excursion and no aortic stenosis or \naortic regurgitation. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. The estimated \npulmonary artery systolic pressure is normal. There is no \npericardial effusion. \n\n IMPRESSION: \n 1) Normal biventricular regional/global systolic function. \n\n Compared with the prior study (images reviewed) of ___, \nno clinically significant change noted \n\nDISCHARGE LABS\n==============\n___ 06:10AM BLOOD WBC-7.7 RBC-3.53* Hgb-11.6 Hct-33.8* \nMCV-96 MCH-32.9* MCHC-34.3 RDW-11.7 RDWSD-40.6 Plt ___\n___ 06:10AM BLOOD Glucose-245* UreaN-12 Creat-1.0 Na-140 \nK-4.3 Cl-101 HCO3-25 AnGap-14\n___ 02:45AM BLOOD ALT-14 AST-17 AlkPhos-50 TotBili-0.4\n___ 06:10AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.___ year old female with CAD(s/p BMS proximal-LAD ___, DES to \nmid LAD ___, DES to edge ISR of mid LAD DES and stenosis distal \nto stent ___, DES to ___, s/p 3 v CABG LIMA-LAD, \nSVG-OM1, SVG-D1(occluded) ___, HFpEF, IDDM, HTN who \npresented with several days atypical chest pain both with \nexertion and at rest, with mild T wave deepening but no other \nEKG changes or troponin. She also presented with mild DKA and \ndiabetic foot ulcer. She had a stress test with reversible \nischemia in the LAD territory (___) and went to cardiac \ncatheterization ___ which showed stable disease and no new \nobstructive lesions. Overall her chest pain was felt to have \nbeen either musculoskeletal or demand in the setting of DKA and \ndiabetic foot ulcer. She was discharged on ASA 81, atorvastatin \n80, Metoprolol XL 100mg daily. \n\n#DKA/IDDM: Patient presented with anion gap metabolic acidosis \nand felt to be in mild DKA. She had insulin gtt in the ED but \nwas rapidly switched to subcutaneous insulin. Her A1c returned \nat 12%, which is the highest it has been recorded for her in our \nrecords. She had followed with ___ previously and was \non canagliflozin and glipizide as well as SC insulin prior to \nadmission. However, she reported intermittent adherence to her \nmedications and this was the likely reason for her DKA. While \nshe was in house the ___ followed along and she met \nwith a diabetes educator. Her canagliflozin was stopped at \ndischarge due to increased risk of amputation. \n\n#Diabetic foot ulcer: Present for at least 3 weeks prior to \nadmission. She underwent bedside debridement by Podiatry in ED. \nXR suggested presence of osteomyelitis . She was maintained on \nvanc/cefepime/flagyl in house, and was switched to cipro/clinda \nat discharge per podiatry recs with plans for close follow up. \nHer wound swab at time of discharge was polymicrobial but was \ngrowing Group B strep (sensitivities pending) and klebsiella \n(pan sensitive). \n\n#Med noncompliance: She reported intermittent medication \ncompliance related to difficulty remembering to take her \nmedications as well as periods of depression and stress where \ntaking her medication was not a priority. She has recently \nobtained a pillbox and her granddaughter is helping her with \nremembering to take her medications. \n\n#HFpEF: Metoprolol as above, continued torsemide 20mg and she \nappeared euvolemic throughout admission. \n#HL: Continued atorvastatin\n#HTN: Metoprolol lowered to XL 100mg daily, losartan kept at \n25mg daily. Imdur stopped.\n#COPD: Duonebs q6h in house, continued home inhalers on \ndischarge. \n#Restless legs: continued ropinerole \n\nTransitional issues: \n- Please follow up her diabetic foot ulcer in ___ clinic. \nPlan at time of discharge was to take to OR for further surgical \ndebridement, patient was discharged with cipro/clinda until \nPodiatry follow up \n- Please review her blood sugars at home and continue to \nreinforce compliance with diabetes medications. Her \nCanagliflozin was stopped due to increased risk of amputation. \nConsider reintroducing metformin as this was stopped ___ years ago \nfor diarrhea but may be a better option for her. \n- Follow up blood pressures and heart rate on the current \nregimen. Suspect that due to noncompliance her medications were \nuptitrated to higher doses than she actually needs. We cut back \nher Metoprolol and stoped her imdur\n- Can restart imdur if requiring for chest pain on outpatient \nbasis\n- Please continue to work with patient on med compliance and \npossible barriers. She denied depression with our social worker \nbut does endorse that stress makes it hard to take her \nmedications. \n- f/u final wound swab cultures \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 25 mg PO DAILY \n2. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea \n3. Gabapentin 300 mg PO QHS:PRN Headache \n4. Metoprolol Succinate XL 250 mg PO DAILY \n5. linaGLIPtin 5 mg oral DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Furosemide 20 mg PO DAILY \n8. Isosorbide Mononitrate 120 mg PO DAILY \n9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina \n10. rOPINIRole 0.5 mg PO QHS restless leg syndrome \n11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - \nSevere \n12. Fluticasone Propionate 110mcg 2 PUFF IH BID \n13. Pantoprazole 40 mg PO BID \n14. Aspirin 325 mg PO DAILY \n15. TraZODone 50 mg PO QHS:PRN insomnia \n16. canagliflozin 100 mg oral DAILY \n17. albuterol sulfate 90 mcg/actuation inhalation Q8H:PRN \n18. Lidocaine 5% Patch 1 PTCH TD QPM \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*14 Tablet Refills:*0 \n2. Clindamycin 300 mg PO Q6H \nRX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times per \nday Disp #*28 Capsule Refills:*0 \n3. Glargine 50 Units Bedtime\nHumalog 18 Units Breakfast\nHumalog 18 Units Lunch\nHumalog 18 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n4. Metoprolol Succinate XL 100 mg PO DAILY \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n5. albuterol sulfate 90 mcg/actuation inhalation Q8H:PRN \n6. Aspirin 325 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Fluticasone Propionate 110mcg 2 PUFF IH BID \n9. Furosemide 20 mg PO DAILY \n10. Gabapentin 300 mg PO QHS:PRN Headache \n11. linaGLIPtin 5 mg oral DAILY \n12. Losartan Potassium 25 mg PO DAILY \n13. MetronidAZOLE Topical 1 % Gel 1 Appl TP BID:PRN Rosacea \n14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina \n15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain \n- Severe \nRX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth \nthree times daily Disp #*15 Tablet Refills:*0 \n16. Pantoprazole 40 mg PO BID \n17. rOPINIRole 0.5 mg PO QHS restless leg syndrome \n18. TraZODone 50 mg PO QHS:PRN insomnia \n19. HELD- canagliflozin 100 mg oral DAILY This medication was \nheld. Do not restart canagliflozin until you speak with your \nendocrinologist\n20. HELD- Lidocaine 5% Patch 1 PTCH TD QPM This medication was \nheld. Do not restart Lidocaine 5% Patch until you speak with \nyour PCP\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY\n=======\nDiabetic foot ulcer\nDiabetic ketoacidosis \nChest pain \n\nSECONDARY\n=========\nDIABETES MELLITUS (INSULIN DEPENDENT)\nCOPD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n - You were admitted because you had chest pain. \n - You also had a process called DKA from not taking enough \ninsulin \n - You also had a bad infection in your foot. \n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n - We did several tests to figure our if your chest pain was \ncaused by a heart attack. The first was a stress test, which had \na positive results. We then did a procedure called a cardiac \ncath, which showed that you did NOT have a heart attack. \n - Our podiatrists did a debridement of your foot. \n - We gave you antibiotics for your foot. \n - We adjusted your insulin levels. \n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Take all of your medications: \n - Ciproflocaxin and Clindamycin are antibiotics you need to \ntake until the podiatrists tell you to stop. You are scheduled \nto see them ___\n - Your insulin regimen will be slightly different from your \nold regimen. \n - You need to take aspirin and Atorvastatin every day to \nprevent blockages in your heart from forming. \n - You will have many appointments in the next week. It is very \nimportant that you go to all of these, to help get your health \non track! \n - Your weight at discharge is 79.1 kg (174.38 lb) . Please \nweigh yourself today at home and use this as your new baseline \n -Please weigh yourself every day in the morning. Call your \ndoctor if your weight goes up by more than 3 lbs. \n - Seek medical attention if you have new or concerning symptoms \nor you develop swelling in your legs, abdominal distention, or \nshortness of breath. If you have worsening pain or redness in \nyour foot, urinating frequently or very thirsty, or if your \nblood sugar is consistently above 300 or below 70 please cal \nyour doctor. \n \nIt was a pleasure participating in your care. We wish you the \n___! \n -Your ___ Care Team \n \n \nFollowup Instructions:\n___\n" ]

[ "I25110", "E1110", "E1122", "E11319", "M869", "I5032", "I130", "T82855A", "E11621", "E1142", "E1165", "E1169", "L97529", "N183", "J449", "B961", "B951", "F329", "K219", "G4733", "Z87891", "Z951", "Z794", "Z9114", "G2581", "Z955", "Y840", "Y929" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "E1110: Type 2 diabetes mellitus with ketoacidosis without coma", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "M869: Osteomyelitis, unspecified", "I5032: Chronic diastolic (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", "T82855A: Stenosis of coronary artery stent, initial encounter", "E11621: Type 2 diabetes mellitus with foot ulcer", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E1169: Type 2 diabetes mellitus with other specified complication", "L97529: Non-pressure chronic ulcer of other part of left foot with unspecified severity", "N183: Chronic kidney disease, stage 3 (moderate)", "J449: Chronic obstructive pulmonary disease, unspecified", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "B951: Streptococcus, group B, as the cause of diseases classified elsewhere", "F329: Major depressive disorder, single episode, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z87891: Personal history of nicotine dependence", "Z951: Presence of aortocoronary bypass graft", "Z794: Long term (current) use of insulin", "Z9114: Patient's other noncompliance with medication regimen", "G2581: Restless legs syndrome", "Z955: Presence of coronary angioplasty implant and graft", "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", "Y929: Unspecified place or not applicable" ]

[ "E1122", "I5032", "I130", "E1165", "J449", "F329", "K219", "G4733", "Z87891", "Z951", "Z794", "Z955", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlisinopril\n \nAttending: ___.\n \nChief Complaint:\nLeft diabetic foot ulcer\n \nMajor Surgical or Invasive Procedure:\nLeft partial hallux amputation\n\n \nHistory of Present Illness:\n___ with poorly controlled diabetes (complicated by retinopathy,\nneuropathy, PAD, foot ulcer L hallux), CAD with ___ s/p \nCABG,\nand narcotics agreement, presenting with 3 days subjective \nfever,\nchills, increased pain in L great toe. Pt recently had ulcer\ndebrided by podiatry on ___, ulcer had healed to the size of a\npin, but within the span of a week enlarged to size of a tennis\nball. Presented to ___ urgent care in ___, found to be\nfebrile to ___, given Tylenol, sent to ER and was afebrile and\nnormotensive upon arrival, though sustained tachycardia to low\n100s. Podiatry consulted in ER, wound to left medial hallux\nprobes to bone w/ high c/f osteomyelitis. X-rays show bony\nerosion but no subcutaneous gas. Plan for IV antibiotics and\npartial amputation of left great toe tomorrow (___). ___ n/v,\nabd pain, diarrhea, excessive urination, orthostasis, dyspnea,\nchest pain.\n\nIn the ED:\n\nInitial vital signs were notable for: afebrile, tachycardia to\n118, normotensive\n\nExam notable for:\nPE: warm, slightly diaphoretic\nCV: RRR, +S1/S2\nResp :lungs clear b/l\nMSK: erythema involving L big toe, tracking along inferior base.\nTenderness tracking along path of great saphenous on L calf.\nLimited dorsiflexion and plantar flexion. Limited ROM of ankle\nand toe.\nMental Status: A&ox4\nLines & Drains: 20g L hand\n\nLabs were notable for:\n\n136 98 26* AGap=20 \n------------<266* \n4.2 18* 1.6* \n\nLactate elevated: 2.4\nWhites elevated: 23.4, neut predominance\n\nStudies performed include:\n\nXray Foot Ap,Lat & Obl Left (prelim read): Re-demonstration of\nulceration along the medial distal aspect of the great toe and\nerosion along the medial base of the distal phalanx of the great\ntoe perhaps slightly progressed in the interval. Findings again\nremain concerning \nfor osteomyelitis and MRI with contrast could be obtained for\nfurther \nassessment. \n\nPatient was given:\nPiperacillin-Tazobactam \nVancomycin\n\nConsults: Podiatry\n\nVitals on transfer: T100.5, BP 154/80, HR117, RR18, 99 Ra \n\nUpon arrival to the floor, patient resting comfortably in bed,\ncomplains of chills, which resolve with blankets. Left foot\nwrapped in gauze dressing, very tender up to midcalf.\n\nREVIEW OF SYSTEMS:\n\nComplete ROS obtained and is otherwise negative\n \nPast Medical History:\n-COPD\n-CAD s/p BMS proximal-LAD ___, DES to mid LAD ___, DES to edge \nISR of mid LAD DES and stenosis distal to stent ___, DES to OM1 \n___, s/p 3 v CABG LIMA-LAD, SVG-OM1, \n___ \n-HFpEF\n-Depression \n-DM \n-GERD \n-Hypertension\n-Migraines\n-Chronic shoulder pain on narcotics\n-OSA\n-Peripheral neuropathy\n-Restless leg\n \nSocial History:\n___\nFamily History:\nPatient was ward of the ___, doesn't know full details of \nfamily history. Mother with possible alcohol abuse. Father \ndeceased at ___ from Hodgkin's Disease per old records.\n \nPhysical Exam:\nADMISSION EXAM\n==============\nVITALS: T100.5, BP 154/80, HR117, RR18, 99 Ra \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: NCAT. MMM.\nCARDIAC: RRR, no MRG\nLUNGS: Normal WOB, CTA B/L\nABDOMEN: Soft, nontender to deep palpation, nondistended,\nnormoactive bowel sounds.\nEXTREMITIES: left foot wrapped in gauze dressing, mildly\nerythematous and very tender up to lower calf, RLE no edema,\nthready DP pulses\nNEUROLOGIC: Sensory and motor function grossly intact.\n\nDISCHARGE EXAM\n==============\nVS: 98.5, 134 / 75,75, 18, 97% RA\nGeneral Appearance: Well-groomed, in NAD.\nHEENT: Atraumatic, normocephalic. Sclera anicteric b/l. MMM. No\noropharyngeal lesions. No LAD.\nLungs: Equal chest rise. Good air movement. No increased work of\nbreathing. Decreased breath sounds in LLL. Rales in left base. \nNo\nwheezes or rhonchi.\nCV: RRR. Normal S1, S2. No murmurs, gallops, or rubs. No carotid\nbruits b/l. +2 carotid pulses b/l, +2 radial pulses b/l, +1\ndorsalis pedis pulse on right, unable to palpate on left due to\nsurgical bandage.\nAbdomen: Non-distended. Bowel sounds present. Soft, non-tender \nto\npalpation throughout. \nExtremities: No clubbing or cyanosis. Left foot dressing clean\ntoday. Erythema and edema around margin of surgical site is\nimproved today. Suture site is clean with no pus.\nSkin: No rashes or lesions besides surgical site.\nNeuro: A+O to person, place, and time. CN III-XII grossly \nintact.\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 05:50PM BLOOD WBC-23.4* RBC-4.01 Hgb-13.3 Hct-37.9 \nMCV-95 MCH-33.2* MCHC-35.1 RDW-12.0 RDWSD-42.1 Plt ___\n___ 05:50PM BLOOD Neuts-81.4* Lymphs-10.5* Monos-7.1 \nEos-0.0* Baso-0.3 Im ___ AbsNeut-19.09* AbsLymp-2.47 \nAbsMono-1.66* AbsEos-0.00* AbsBaso-0.06\n___ 05:50PM BLOOD Glucose-266* UreaN-26* Creat-1.6* Na-136 \nK-4.2 Cl-98 HCO3-18* AnGap-20*\n___ 05:50PM BLOOD CRP-180.1*\n___ 07:45PM BLOOD ___ pO2-22* pCO2-44 pH-7.32* \ncalTCO2-24 Base XS--4\n___ 05:50PM BLOOD Lactate-2.4*\n___ 07:40PM URINE Color-Straw Appear-Clear Sp ___\n___ 07:40PM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-1000* Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0 \nLeuks-SM*\n___ 07:40PM URINE RBC-4* WBC-7* Bacteri-FEW* Yeast-NONE \nEpi-1 TransE-<1\n___ 07:40PM URINE Mucous-RARE*\n\nPERTINENT INTERVAL LABS\n=======================\n___ 09:48AM BLOOD ALT-25 AST-29 LD(LDH)-210 AlkPhos-130* \nTotBili-0.8\n\nDISCHARGE LABS\n==============\n___ 07:17AM BLOOD WBC-9.9 RBC-3.07* Hgb-9.8* Hct-30.4* \nMCV-99* MCH-31.9 MCHC-32.2 RDW-12.3 RDWSD-44.2 Plt ___\n___ 07:29AM BLOOD Glucose-109* UreaN-18 Creat-1.2* Na-140 \nK-4.0 Cl-100 HCO3-25 AnGap-15\n___ 07:29AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.8\n___ 07:29AM BLOOD CRP-44.6*\n\nIMAGING\n=======\nLEFT FOOT XRAY (___)\nIMPRESSION: \n \nRe-demonstration of ulceration along the medial distal aspect of \nthe great toe\nand erosion along the medial base of the distal phalanx of the \ngreat toe, the\nlatter of which is perhaps slightly progressed in the interval. \nFindings again\nremain concerning for osteomyelitis and MRI with contrast could \nbe obtained\nfor further assessment.\n\nNIAS (___)\n---------------\nFINDINGS: \n \nOn the right side, triphasic Doppler waveforms are seen in the \nright femoral,\npopliteal, and dorsalis pedis arteries. Absent waveform in the \nposterior\ntibial artery.\nThe right ABI was 1.6, artifactually elevated due to \nnoncompressible vessels.\n \nOn the left side, triphasic Doppler waveforms are seen at the \nleft femoral and\npopliteal arteries. Monophasic waveforms are seen in the \nposterior tibial and\ndorsalis pedis arteries.\nThe left ABI could not be calculated\n \nPulse volume recordings showed decreased amplitudes at the level \nthe right\ncalf, ankle and metatarsal.\n \nIMPRESSION: \n \nSignificant bilateral tibial arterial insufficiency to the lower \nextremities\nat rest, more significant on the right side.\n\nCXR (___)\n--------------\nIMPRESSION: \n \nComparison to ___. No relevant change is noted. \nAlignment of the\nsternal wires is unremarkable. Mild elongation of the \ndescending aorta. \nBorderline size of the heart. No pleural effusions. No \npneumonia, no\npulmonary edema.\n\nMRI LEFT FOOT (___)\nIMPRESSION:\n \n \n1. Nonenhancing stump soft tissue and the plantar fat pad under \nthe middle\nphalanges, concerning for devitalized tissue. No evidence of \ndrainable\nabscess.\n2. 4 mm focus of low T1 signal with edema at the most distal \ncortex of the\nfirst metatarsal. This is nonspecific as there was no \ncomparison study and\nfocus of osteomyelitis cannot be excluded.\n3. 2 sinus tracts medial to the head of the first metatarsal, \nstatus post\namputation at the first MTP with postsurgical changes.\n4. Dorsal swelling and diffuse skin edema.\n\nCXR PICC PLACEMENT (___)\nIMPRESSION: \n \nNew right PICC with tip projecting over the junction of the \nsuperior vena cava\nand right atrium. No pneumothorax. Clear lungs.\n\nPATHOLOGY\n==========\nSURGICAL TISSUE (___)\n- Bone with reparative changes, consistent with chronic \nosteomyelitis.\n- There is no evidence of acute osteomyelitis. \n\nSURGICAL TISSUE (___)\n1. LEFT GREAT TOE, EXCISION:\n- Acute osteomyelitis, focal.\n- Bone with reparative changes.\n- Skin and subcutis with ulceration and acute inflammation.\n- Atherosclerosis, severe.\n2. PROXIMAL PHALANX BASE MARGIN, LEFT, EXCISION:\n- Bone with reparative changes.\n- There is no evidence of acute osteomyelitis.\n3. PROXIMAL PHALANX, LEFT, EXCISION:\n- Bone with reparative changes.\n- There is no evidence of acute osteomyelitis.\n\nMICROBIOLOGY\n============\n___ 10:00 am TISSUE PROXIMAL PHALYNX. \n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN \nPAIRS. \n Reported to and read back by ___ (___) ON \n___ AT\n 1:20PM. \n\n TISSUE (Final ___: \n STAPH AUREUS COAG +. SPARSE GROWTH. \n Susceptibility testing performed on culture # ___ \n___. \n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n__________________________________________________________\n___ 7:00 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 5:38 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 12:34 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 11:00 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 12:18 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 10:53 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n \nBrief Hospital Course:\n=============\nSUMMARY\n=============\n\n___ yo F with hx of DMII, HTN who presented with diabetic foot \nulcer on her left hallux complicated by osteomyelitis. She \nunderwent surgical debridement and partial tissue and bone \nremoval on ___. However the infection persisted, and she \nunderwent left hallux amputation on ___. She was started \non IV nafcillin for MSSA infection with plan to continue home \ninfusions of nafcillin until at least ___\n\nACTIVE ISSUES\n=============\n#Osteomyelitis of left hallux: Due to diabetic ulcer of left \nhallux. Patient underwent partial left hallux amputation on ___ \nby podiatry. She was initially placed on IV Vancomycin, Flagyl, \nand cefepime. Initial surgical cultures came back positive for \nMSSA, so was changed to IV nafcillin. Patient continued to be \nafebrile, but her left foot continued to have erythema, edema, \npain, and the ulcer was not healing well. There was concern for \npoor arterial blood flow and therefore underwent noninvasive \narterial studies on bilateral lower extremities. The studies \nshowed mild atherosclerotic disease in her left leg and foot, \nand severe atherosclerotic disease in her right leg and foot. \nVascular surgery was consulted for potential intervention, but \nthey felt that no further vascular intervention was warranted \nprior to podiatric surgery. The patient was brought back to the \nOR by podiatry on ___ for total left hallux amputation \ngiven lack of clinical improvement. Her ___ blood cell count \ncontinued to down trend. The pathology report showed clean \nmargins. However, patient was continuing to have pain, and there \nwas increased erythema and swelling around surgical site. An MRI \nof the left foot was done, which showed devitalization of the \nsurgical flap, some edema, and a hyperintense focal spot at the \nsite of the surgery. There were no signs of abscess or fluid \ncollection. Podiatry team felt patient did not need any acute \nsurgical intervention and will have close follow-up on \n___. A PICC line was placed in the right arm \n___ with tentative plan to complete a two-week course of IV \nnafcillin on ___. For the wound, podiatry recommends daily \ndressing changes to left foot surgical site: Betadine moistened \ngauze, 4x4 gauze, and kerlix.\n\n#Cough: During her stay the patient developed cough that was \nnonproductive. It was thought to be due to atelectasis after \nsurgery, especially since her rales on exam would clear with \ncoughing. A repeat chest x-ray was negative for any acute \ncardiopulmonary processes and on comparison to previous chest \nx-ray during this hospital stay there were no changes. Will \nrestart home Lasix at discharge.\n\n#Hypertension: Patient's antihypertensives were held upon \nadmission given that her blood pressures were low with systolic \nblood pressures in the ___ likely due to sepsis in the \nsetting of her osteomyelitis from her diabetic foot ulcer. After \nher first debridement, patient's blood pressures increase to \n160s-170s so we restarted her losartan and furosemide. However \nher blood pressure dipped back down again to the ___ systolic \nand her creatinine bumped up to 1.8 so we discontinued her \nlosartan and furosemide. Her metoprolol was continued with \nholding parameters, and it was held when her systolic blood \npressure was less than 110. Her ___ resolved, and she became \nhypertensive again, so we restarted her losartan while in the \nhospital and instructed the patient to restart her Lasix upon \ndischarge from the hospital.\n\n#Acute Kidney Injury: Her baseline creatinine is 1.0. It bumped \nup to 1.8 in the setting of sepsis, restarting her losartan and \nfurosemide, and hypotension. We gave her IV fluids and stopped \nher losartan and furosemide. Her creatinine continued to improve \nwith these measures and upon discharge it was 1.1-1.2, which is \naround her baseline.\n\nCHRONIC ISSUES\n==============\n#Diabetes Mellitus Type 2: Upon admission, patient was started \non 80% of home insulin doses. Her Lantus inpatient dose was 32 \nunits, and her Humalog inpatient dose was 12 units 3 times \ndaily. Patient's blood sugars were hard to control while she was \ninpatient. Working with the ___ diabetes consult team we \nadjusted her insulin doses as needed. ___ recommended \ndischarging the patient on 48 units of Toujeo and 18 units of \nNovolog with meals as well as resuming her Trajenta and \nJardiance.\n\n#CODE STATUS: Full (presumed)\n#CONTACT: ___ (grandson's girlfriend) ___\n\nTRANSITIONAL ISSUES\n===================\n[ ] Patient is on oxycodone 5 mg Q8H for her foot pain from the \nsurgery. She was given enough to get her to her PCP appointment, \nwhich is ___. Please re-assess pain management.\n\n[ ] Osteomyelitis, infected diabetic foot ulcer: Surgical margin \nfrom total left hallux amputation on ___ was negative for \nosteomyelitis. Patient to complete a 2 week course of nafcillin \nfor ongoing soft tissue infection and will follow up with ID \nprior to completion of antibiotics to ensure resolution. Will be \ndischarged on q4 hour nafcillin to be infused via a pump. Once \nfinished an antibiotic should also have right arm PICC line \nremoved. For the wound, podiatry recommends daily dressing \nchanges to left foot surgical site: Betadine moistened gauze, \n4x4 gauze, and kerlix\n\n[ ] Diabetes mellitus type 2: Patient's blood sugars were very \nlabile. Given that she came in with a diabetic foot ulcer \nsuggesting that her blood sugars are not well-controlled at \nhome, she needs close follow-up to optimize her diabetic \nmedication regimen. She is being discharged on reduced dose \nToujeo and regular home Novolog along with her usual Trajenta \nand Jardiance with close follow-up with ___ provider on \n___, ___ at 1 ___. Please reassess patient's need for \nJardiance given history of recurrent AKIs\n\n[ ] Cough: Patient developed non-productive cough while in \nhospital but afebrile, no leukocytosis, CXR no signs of pleural \neffusion or consolidation. Suspect due to atelectasis in post-op \nperiod after foot surgery. Will discharge on incentive \nspirometer and restarting home Lasix as outpatient. If not \nimproved once back on outpatient Lasix, would consider further \nworkup.\n\n[ ] Hypertension: Patient was discharged on her regular home \nmedications. While she was an inpatient, she became hypotensive \nwhen we restarted her on all of her antihypertensives. Please \nfollow her blood pressure to ensure that she is on the right \nregimen. If too low, might consider removing furosemide.\n\n[ ] ___: Discharge creatinine 1.2 on ___. Suspect patient will \nhave a slight bump in creatinine after restarting losartan on \n___. Patient had weekly labs checked with IV antibiotic \ninfusions. If continues to rise, may be due to nafcillin and \nwould consider switching antibiotic to cefazolin.\n\n#CODE STATUS: Full (presumed)\n#CONTACT: ___ (grandson's girlfriend) ___\n\n>30 minutes spent on complex discharge \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. canagliflozin 100 mg oral DAILY \n2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina \n3. rOPINIRole 0.5 mg PO QHS restless leg syndrome \n4. TraZODone 50 mg PO QHS:PRN insomnia \n5. Pantoprazole 40 mg PO BID \n6. Gabapentin 400 mg PO QHS:PRN Neuropathic pain \n7. Atorvastatin 80 mg PO QPM \n8. Fluticasone Propionate 110mcg 2 PUFF IH BID \n9. linaGLIPtin 5 mg oral DAILY \n10. Losartan Potassium 25 mg PO DAILY \n11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain - \nSevere \n12. Lidocaine 5% Patch 1 PTCH TD QPM \n13. Furosemide 20 mg PO DAILY \n14. Metoprolol Succinate XL 150 mg PO DAILY \n15. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \n16. Aspirin EC 325 mg PO DAILY \n17. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY Rosacea \n18. nystatin 100,000 unit/gram topical DAILY:PRN \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth Every 8 hours for \nfoot pain Disp #*60 Tablet Refills:*0 \n2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \nRX *bisacodyl 5 mg 2 tablet(s) by mouth Once a day as needed for \nconstipation Disp #*60 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day \nDisp #*30 Capsule Refills:*0 \n4. Nafcillin 2 g IV Q4H \nRX *nafcillin in dextrose iso-osm 2 gram/100 mL 2 g IV Every \nfour hours Disp #*84 Intravenous Bag Refills:*0 \n5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 capsule(s) by mouth Once every 8 hours as \nneeded for severe foot pain. Disp #*15 Capsule Refills:*0 \n6. Senna 8.6 mg PO BID:PRN Constipation - First Line \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth Twice a day as \nneeded for constipation Disp #*30 Tablet Refills:*0 \n7. Novolog 18 Units Breakfast\nNovolog 18 Units Lunch\nNovolog 18 Units Dinner \n8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \n9. Aspirin EC 325 mg PO DAILY \n10. Atorvastatin 80 mg PO QPM \n11. canagliflozin 100 mg oral DAILY \n12. Fluticasone Propionate 110mcg 2 PUFF IH BID \n13. Furosemide 20 mg PO DAILY \n14. Gabapentin 400 mg PO QHS:PRN Neuropathic pain \n15. Lidocaine 5% Patch 1 PTCH TD QPM \n16. linaGLIPtin 5 mg oral DAILY \n17. Losartan Potassium 25 mg PO DAILY \n18. Metoprolol Succinate XL 150 mg PO DAILY \n19. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY Rosacea \n20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina \n21. nystatin 100,000 unit/gram topical DAILY:PRN \n22. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain \n- Severe \n23. Pantoprazole 40 mg PO BID \n24. rOPINIRole 0.5 mg PO QHS restless leg syndrome \n25. ___ SoloStar U-300 Insulin (insulin glargine) 300 \nunit/mL (1.5 mL) subcutaneous QHS \nInject 48U QHS \n26. TraZODone 50 mg PO QHS:PRN insomnia \n27.Outpatient Lab Work\nICD-10: E11.621 \nDATE: weekly: draw on ___ and ___\nLAB TEST: CBC with differential, BUN, Cr, AST, ALT, Total\nBili, ALK PHOS, ESR, CRP\nPLEASE FAX RESULTS TO: ATTN: ___ CLINIC - FAX: \n___\n28.Rolling Walker\nEQUIPMENT: Rolling Walker\nDIAGNOSIS: Left hallux amputation\nICD-10: ___ \nPX: Good\n___: 13 months\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nOsteomyelitis of left hallux\n\nSECONDARY DIAGNOSES\n===================\nHypertension\nType 2 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 Ms. ___,\n\nIt was a pleasure taking care of you.\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\nYou had a diabetic foot ulcer on your left toe that was very \ninfected and had caused an infection in your bone.\n\nWHAT WAS DONE WHILE I WAS HERE?\nYour big left toe was removed because you had a bad bone \ninfection. You were treated with antibiotics to fight the \ninfection and will need to go home on IV antibiotics.\n\nWHAT DO I NEED TO DO WHEN I LEAVE?\nPlease continue to take your medications as directed. You will \ngo home with an antibiotic infusion pump and will have a \nvisiting nurse come to your house to teach you how to use it. \nYou will need to administer antibiotics through the pump every 4 \nhours. We changed your diabetic medication regimen, so please \nfollow along as instructed below and keep close track of your \nsugars at home. Check your sugars 4 times a day and log the \nresults. Bring the results in with you to your ___ \nappointment on ___ at 1:00 pm so that they can \nadjust your medication regimen appropriately. Please follow-up \nwith Dr. ___ team on ___ at 11:00 am. Please \nfollow up with Dr. ___ your antibiotic regimen on \n___ at 10:30 am. Please follow-up with Dr. ___ \nin ___ ___ on ___ at 1:00 pm.\n\nBe well,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "A419", "M86672", "M86172", "N179", "L03116", "J9811", "I5032", "I130", "E1152", "I96", "E1169", "L97524", "E11621", "B9561", "J449", "E11319", "E1142", "E1165", "I2510", "I252", "G4733", "K219", "G2581", "N189", "E1122", "Z794", "Z951", "Z955", "Z87891" ]

[ "A419: Sepsis, unspecified organism", "M86672: Other chronic osteomyelitis, left ankle and foot", "M86172: Other acute osteomyelitis, left ankle and foot", "N179: Acute kidney failure, unspecified", "L03116: Cellulitis of left lower limb", "J9811: Atelectasis", "I5032: Chronic diastolic (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", "E1152: Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene", "I96: Gangrene, not elsewhere classified", "E1169: Type 2 diabetes mellitus with other specified complication", "L97524: Non-pressure chronic ulcer of other part of left foot with necrosis of bone", "E11621: Type 2 diabetes mellitus with foot ulcer", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "J449: Chronic obstructive pulmonary disease, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K219: Gastro-esophageal reflux disease without esophagitis", "G2581: Restless legs syndrome", "N189: Chronic kidney disease, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z794: Long term (current) use of insulin", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "I5032", "I130", "J449", "E1165", "I2510", "I252", "G4733", "K219", "N189", "E1122", "Z794", "Z951", "Z955", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlisinopril\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with extensive cardiac history \nincluding multivessel vessel CAD S/P stenting of the LAD with \nin-stent restenosis and stenting of the CX, S/P CABG in ___ with known occluded SVG-D1 with patent LIMA-LAD and SVG-OM \nin ___, poorly controlled type 2 diabetes mellitus, \nhypertension, COPD, GERD, now presenting with new chest pain.\n At 5 pm on the day of presentation, she was resting at home \nwhen she had onset of severe stabbing pain left of the sternum. \nThis pain radiated across her chest but not to the arm or jaw. \nShe took 1 nitroglycerin, which improved her pain slightly. She \nreports that the pain came in waves lasting 5 minutes. She also \nendorsed left chest wall tenderness. She did not remember when \nshe last had chest pain prior to this. The pain was not clearly \nexertional. The sharp pains occurred when she was lying down. \nShe says the area is very tender. Lying on the left side causes \npain. She did have nausea the past 3 mornings which resolved. \nShe denied vomiting, diaphoresis, fevers or chills. She had an \nepisode of diarrhea yesterday, but no abdominal pain. She \nalready took a full dose aspirin on the day of presentation. \n In the ED, initial vitals were: T 98.0, HR 88, BP 127/65, RR \n16, SaO2 100% on RA. FSBG 302->94. Labs notable for Troponin-T < \n0.01, CK-MB < 1, D-Dimer 268, Cr 1.2, Mg 1.4. Normal LFTs; CBC, \nChem 7, coags WNL. CXR showed no acute cardiopulmonary \nabnormality. Bedside echocardiogram showed no substantial \npericardial effusion or tamponade. Patient was given fluticasone \npropionate inhaled, OxyCODONE--Acetaminophen (5mg-325mg), \nMagnesium Sulfate 2 gm IV. \n\nOn arrival to the cardiology ward, the patient reported that her \npain was still there but it felt \"slow\" ___ but at its worse \nwas ___. The area was tender. She had no breathing complaints. \nShe felt a little congested this evening when the pain started.\n \nPast Medical History:\n-COPD\n-CAD s/p CABG and stenting, as above\n-Depression \n-DM \n-GERD \n-Hypertension\n-Migraines\n-Chronic shoulder pain on narcotics\n-OSA\n-Peripheral neuropathy\n-Restless leg\n \nSocial History:\n___\nFamily History:\nPatient was ward of the ___, doesn't know full details of \nfamily history. Mother with possible alcohol abuse. Father \ndeceased at ___ from Hodgkin's Disease per old records.\n \nPhysical Exam:\nOn admission\nGeneral: Obese middle aged ___ woman, alert, oriented, in no \nacute distress\nVital Signs: T 98.7, BP 98/65, HR 79, RR 18, SaO2 95% on RA\nWeight: 89 kg\nHEENT: Sclera anicteric, mucous membranes moist, oropharynx \nclear\nNECK: difficult to appreciate JVP\nCV: Regular rate and rhythm, normal S1 + S2; no murmurs, rubs, \ngallops\nChest: Tenderness to palpation of the left anterior chest wall\nLungs: Clear to auscultation bilaterally--no wheezes, rales, \nrhonchi\nAbdomen: Soft, non-tender, non-distended, obese\nGU: No Foley\nExt: Warm, well perfused; no clubbing, cyanosis or edema\n\nExam unchanged at discharge, left chest wall tender with \npalpation with pain after change in position\n \nPertinent Results:\n___ 10:31PM BLOOD WBC-9.4 RBC-3.51* Hgb-12.0 Hct-34.3 \nMCV-98 MCH-34.2* MCHC-35.0 RDW-11.8 RDWSD-42.3 Plt ___\n\n___ 10:31PM BLOOD Glucose-105* UreaN-21* Creat-1.2* Na-137 \nK-3.4 Cl-97 HCO3-24 AnGap-19\n___ 10:31PM BLOOD ALT-15 AST-16 CK(CPK)-39 AlkPhos-53 \nTotBili-0.3\n___ 10:31PM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.4 Mg-1.4*\n\n___ 10:57PM BLOOD D-Dimer-268\n___ 10:31PM BLOOD CK-MB-1 cTropnT-<0.01\n___ 06:00AM BLOOD CK-MB-<1 cTropnT-<0.01\n\n___ 06:00AM BLOOD WBC-9.3 RBC-3.44* Hgb-11.8 Hct-33.1* \nMCV-96 MCH-34.3* MCHC-35.6 RDW-11.9 RDWSD-41.3 Plt ___\n___ 06:00AM BLOOD Glucose-147* UreaN-21* Creat-1.2* Na-139 \nK-3.0* Cl-99 HCO3-24 AnGap-19\n___ 06:00AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.0\n\nECG ___ 8:33:29 ___\nBaseline artifact. Sinus rhythm. Borderline P-R interval \nprolongation. Prominent voltage in leads I and aVL but does not \nmeet criteria for left ventricular hypertrophy. There are marked \nST segment depressions and T wave inversions in leads I, II, aVL \nand apical lateral leads. Compared to the previous tracing of \n___ the rate then was faster. ST-T wave abnormalities were \nsimilar. Consider left ventricular hypertrophy as before. \nClinical correlation is suggested.\n\nCXR ___\nPatient is status post median sternotomy and CABG. Heart size is \nnormal. Mediastinal and hilar contours are unchanged. Pulmonary \nvasculature is normal. No focal consolidation, pleural effusion \nor pneumothorax is seen. No acute osseous abnormality is \ndetected.\nIMPRESSION: No acute cardiopulmonary abnormality.\n\nDipyridamole-MIBI Stress test ___\n___ yp woman with HL, HTN, DM, PVD and diastolic CHF; s/p MI and \nmultiple PCIs f/b CABG x 3 in ___ with known SVG-OM occlusion \nwas referred to evaluate an atypical chest discomfort. The \npatient was administered 0.142 mg/kg/min of Persantine over 4 \nminutes. Prior to the procedure the patient reported an isolated \nleft-sided chest discomfort that had been present since \nadmission and was tender to mild palpation; ___. This \ndiscomfort did not change in intensity during the procedure. In \nthe presence of diffuse ST-T wave changes, no additional ECG \nchanges were noted during the procedure. The hemodynamic \nresponse to the Persantine infusion was appropriate. \nPost-infusion, the patient was administered 125 mg Aminophylline \nIV.\nIMPRESSION: Non-anginal type symptoms with no additional ST \nsegment changes from baseline.\nImaging:\n Left ventricular cavity size is normal.\n Rest and stress perfusion images reveal uniform tracer uptake \nthroughout the left ventricular myocardium. The previously \nnoted perfusion defect involving the inferolateral wall has \nresolved.\n Gated images reveal normal wall motion. The calculated left \nventricular ejection fraction is 64%.\nIMPRESSION: Normal myocardial perfusion study. Interval \nnormalization of prior LCx territory perfusion defect.\n \nBrief Hospital Course:\nThis is a ___ with type 2 diabetes mellitus on insulin, CAD s/p \nMI, S/P multiple PCIs and CABG ___ (LIMA-LAD, SVG-OM1; also \nSVG-D1 known occluded ___ with chronic stable angina \nadmitted with atypical, stabbing, focal chest pain.\n\n# Chest pain: Initially the patient was started on a heparin \ndrip and other ACS protocol medications. Her home losartan and \nfurosemide were held due to low blood pressures. Suspicion for \ncardiac etiology of chest pain was ultimately not high. She had \nan isolated ongoing ___ left-sided chest discomfort exacerbated \nby changes in position and with chest wall tenderness to light \npalpation. Despite prolonged chest pain, troponin-T and CK-MB \nnegative x2 and EKGs mostly unchanged from prior. Given known \nH/O CAD, a vasodilator nuclear stress test was performed and was \nreassuring. Her discomfort did not change in intensity during \nthe stress test drug infusion. In the presence of diffuse ST-T \nwave changes, no additional ECG changes were noted during the \nprocedure. The hemodynamic response to the Persantine infusion \nwas appropriate. Her perfusion study was normal with interval \nnormalization of prior LCx territory perfusion defect. Given the \nstabbing quality and tenderness to palpation of the area of \ndiscomfort, her symptoms were most likely related to \ncostochondritis or other musculoskeletal causes. She was started \non aspirin 650 mg q6h with plans to trial for 2 days and \ncontinue through the week if symptoms improve.\n\nChronic medical problems:\n# Diabetes mellitus: Continued levemir and was switched to a \nsliding scale of Humalog.\n# Hypertension: Losartan was held as above due to hypotension \nand once daily isosorbide mononitrate was switched temporarily \nto isosorbide dinitrate TID. \n# For her hyperlipidemia, COPD and GERD, her home regimens were \ncontinued. \n\nTRANSITIONAL ISSUES:\n- Patient had low blood pressures initially (88-92 systolic). \nWould benefit from close monitoring and titration of blood \npressure medications as an outpatient\n- She was hypokalemic (K 3.0) during admission (with ___ and \nfurosemide already held). Please recheck CHEM-10 at ___ ___ \nvisit on ___ to determine whether she might benefit from K \nsupplementation\n- Cr elevated to 1.2 on discharge (up from most recent 1.1.1). \nPlease recheck at ___ office on ___\n- Full code\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain \n2. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain \n3. Metoprolol Succinate XL 250 mg PO DAILY \n4. Levemir Flexpen (insulin detemir) 90 units subcutaneous in \nthe evening \n5. albuterol sulfate 90 mcg/actuation inhalation q4hrs wheezing \n6. Vitamin D 1000 UNIT PO DAILY \n7. TraZODone 100 mg PO HS \n8. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY \n9. Aspirin 325 mg PO DAILY \n10. Atorvastatin 80 mg PO HS \n11. Fluticasone Propionate 110mcg 2 PUFF IH BID \n12. Pantoprazole 40 mg PO Q12H \n13. Ropinirole 0.5 mg PO QPM \n14. HumaLOG KwikPen (insulin lispro) 0 SUBCUTANEOUS AS \nDIRECTED \n15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze \n16. Methocarbamol 500 mg PO TID:PRN muscle pain \n17. Losartan Potassium 25 mg PO DAILY \n18. Furosemide 20 mg PO DAILY \n19. diclofenac sodium 1 % topical TID:PRN pain\n \nDischarge Medications:\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze \n2. Atorvastatin 80 mg PO HS \n3. Fluticasone Propionate 110mcg 2 PUFF IH BID \n4. Methocarbamol 500 mg PO TID:PRN muscle pain \n5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN pain \n6. Pantoprazole 40 mg PO Q12H \n7. Ropinirole 0.5 mg PO QPM \n8. TraZODone 100 mg PO HS \n9. Vitamin D 1000 UNIT PO DAILY \n10. albuterol sulfate 90 mcg/actuation INHALATION Q4HRS wheezing\n11. diclofenac sodium 1 % topical TID:PRN pain \n12. Furosemide 20 mg PO DAILY \n13. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY \n14. Metoprolol Succinate XL 250 mg PO DAILY \n15. HumaLOG KwikPen (insulin lispro) 0 SUBCUTANEOUS AS \nDIRECTED \n16. Levemir Flexpen (insulin detemir) 90 units subcutaneous in \nthe evening \n17. Losartan Potassium 25 mg PO DAILY \n18. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain \n19. Aspirin 650 mg PO Q6H \nRX *aspirin 650 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*28 Tablet Refills:*0\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n- Chest wall pain atypical for angina\n- Musculoskeletal pain\n- Known native coronary artery and bypass graft disease\n- Type 2 Diabetes mellitus, with\n- Chronic kidney disease, stage 3\n- Acute kidney injury\n- Chronic obstructive pulmonary disease\n- Hypertension\n- Hypotension\n- Hypokalemia\n- Chronic shoulder pain on narcotics\n- Obstructive sleep apnea\n- Gastroseophageal reflux disease\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\nIt was our pleasure participating in your care here at ___. \nYou were admitted with severe chest pain. You underwent a stress \ntest that showed the pain is unlikely from a big blockage in the \narteries that feed your heart. Your lab work also did not \nsuggest injury to the heart.\n\nThe pain you are experiencing is most likely musculoskeletal and \nshould hopefully improve with supportive measures such as \nTylenol (maximum 3 grams per day) and time. You will also be \nprescribed high dose aspirin (650mg). Please try this for two \ndays and if there is improvement in your symptoms continue it \nfor the week. \n\nIf your symptoms worsen, you develop shortness of breath or any \nother concerning symptom, please let your doctor know right \naway.\n\nAgain, it was our pleasure participating in your care.\n\nWe wish you the very ___,\nYour ___ Cardiology Team\n \nFollowup Instructions:\n___\n" ]

[ "R0789", "E876", "I25119", "I25709", "Z951", "Z955", "E1122", "E1165", "I129", "N183", "E785", "J449", "K219", "E1140", "F329", "E669", "Z6837", "G8929", "M25519", "G4733", "Z794", "I252", "Z87891" ]

[ "R0789: Other chest pain", "E876: Hypokalemia", "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "I25709: Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "G8929: Other chronic pain", "M25519: Pain in unspecified shoulder", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z794: Long term (current) use of insulin", "I252: Old myocardial infarction", "Z87891: Personal history of nicotine dependence" ]

[ "Z951", "Z955", "E1122", "E1165", "I129", "E785", "J449", "K219", "F329", "E669", "G8929", "G4733", "Z794", "I252", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Dilantin Kapseal / Zofran (as hydrochloride)\n \nAttending: ___.\n \nChief Complaint:\nRight hip pain \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ y/o F with PMHx CHF, Afib not on \nanticoagulation, severe advanced Alzheimer's dementia, \nosteoporosis, HTN, who presents from assisted living facility \nwith R hip pain.\n\nThe patient has severe dementia, with short term memory loss so \nis unable to provide history. Much of the history is obtained \nfrom multiple family members in the room. She has multiple \nfamily members who live close by and are involved intimately in \nher care. They were called from the assisted living facility \nthis morning when the patient was in ___ right hip pain. This \noccurred suddenly. No trauma. No reported falls. She was not \ncomplaining of other symptoms. She was brought to the ED. \n\nDiscussing with the patient, she moved into the Assisted living \nfacility in ___ in ___ given worsening of her \ndementia. She was in her USOH, bowling weekly and very social, \nuntil ___ when she developed acute SOB with ambulation \nprompting admission to ___ where she was noted \nto be in Afib. She had a week long hospital stay complicated by \nan ICU course for an allergic reaction to a medication (family \nthinks Zofran). Since returning from this hospitalization, she \nhas not been back to baseline and has deteriorated. She has \nspent much of her time wheelchair bound given deconditioning. \nShe has worsening memory function, now with severe short term \nmemory loss. Decreased appetite and PO intake. She was recently \nseen in ___ clinic by Dr. ___ new diagnosis of CHF. She \nunderwent an TTE at ___ yesterday ___ to evaluate her \nsystolic function. \n \nIn the ED, initial vitals were: \n98.7, 96, 122/48, 20, 96% RA. \n\nExam was significant for: \nR hip TTP greater trochanter, neg straight leg raise. ___ \npulses 2+\nLLE 2+ edema, unknown duration\nLabs were significant for : \nK 2.8 \nCr 0.8\nCBC: 13.9/12.5/39.2/168\nUA: WBC 22, moderate leuks, negative nitrites \n\nStudies: \nLower extremity ultrasound: 1. Deep vein thrombosis of the left \ncommon femoral vein extending into at least the popliteal vein. \nLeft calf veins were not clearly identified and possibly also \noccluded.\n2. No DVT in the right lower extremity.\n\nCXR\nBilateral pleural effusions, large on the right and small on the \nleft. No definite focal consolidation identified, although \nevaluation is limited secondary to these effusions. \n\nShe was given 80 mEq of K and 60mg Enoxaparin Sodium. \n \nVitals on transfer were: 97.9, 79, 125/53, 18, 100% Nasal \nCannula. \n \nOn the floor, she is resting comfortably in bed. History is \nobtained as above with family members. She sleeps with 2 pillows \nat home and has DOE. She has not had a bowel movement in 2 days. \n\n\nReview of systems: \n(+) Per HPI \n(-) Denies fever, chills, night sweats. denies headache, sinus \ntenderness, rhinorrhea or congestion. Denies cough. Denies \nnausea, vomiting, diarrhea, constipation or abdominal pain. No \ndysuria. Denies arthralgias or myalgias. \n\n \nPast Medical History:\nHypertension\nDementia\nOsteoporosis\nIrritable bowel syndrome\nMacrocytosis of unclear etiology\nLeft ear hearing loss\nStatus post hysterectomy\nStatus post appendectomy\nStatus post ovarian cyst removal\nCataract surgery\nGlaucoma\n \nSocial History:\n___\nFamily History:\nNot relevant to the current admission.\n \nPhysical Exam:\nADMISSION EXAM \n==============\nVital Signs: 98.3, 107/43, 72, 16, 99 2L NC \nGeneral: AOx1, pleasant, smiling, at baseline per family members \nat bedside \n___: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, soft ___ systolic \nmurmur. \nLungs: Moderate inspiratory effort, decreased breath sounds \nbilaterally at bases L>R. No wheezes, rales, rhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, L>R lower extremity \nswelling with left leg erythematous and tender to palpation, 2+ \npitting edema tender, right lower extremity with e/o chronic \nvenous stasis changes, 1+ pitting edema non tender. \nNeuro: AOx1, strength ___ upper and lower exteremities, all \nfacial movements in tact, sensation grossly in tact, gait \ndeferred. \n \nDISCHARGE EXAM \n==============\nVitals: T:97.9, 144/59, 72, 20, 93 RA \n\nGeneral: AOx1, pleasant, smiling, at baseline per family members \nat bedside \n___: Sclera anicteric, MMM \nCV: Irregularly irregular, normal S1 + S2, soft ___ systolic \nmurmur. \nLungs: Moderate inspiratory effort, decreased breath sounds \nbilateral bases \nExt: Warm, well perfused, 2+ pulses, L>R lower extremity \nswelling with left leg erythematous and minimal tender to \npalpation, 2+ pitting edema tender, right lower extremity with \ne/o chronic venous stasis changes, 1+ pitting edema non tender. \n\nNeuro: AOx1 \n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 11:35AM URINE RBC-2 WBC-22* BACTERIA-NONE YEAST-NONE \nEPI-<1 TRANS EPI-<1\n___ 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-MOD\n___ 12:00PM PLT COUNT-168\n___ 12:00PM NEUTS-81.1* LYMPHS-10.8* MONOS-6.7 EOS-0.1* \nBASOS-0.2 IM ___ AbsNeut-11.29* AbsLymp-1.51 AbsMono-0.94* \nAbsEos-0.02* AbsBaso-0.03\n___ 12:00PM WBC-13.9* RBC-3.78* HGB-12.5 HCT-39.2 \nMCV-104* MCH-33.1* MCHC-31.9* RDW-13.6 RDWSD-51.9*\n___ 12:00PM CALCIUM-7.8* PHOSPHATE-3.7 MAGNESIUM-1.6\n___ 12:00PM cTropnT-0.03* proBNP-8428*\n___ 12:00PM GLUCOSE-118* UREA N-26* CREAT-0.8 SODIUM-144 \nPOTASSIUM-2.8* CHLORIDE-95* TOTAL CO2-38* ANION GAP-14\n\nSTUDIES\n=======\n\nCXR \nBilateral pleural effusions, large on the right and small on the \nleft. No \ndefinite focal consolidation identified, although evaluation is \nlimited \nsecondary to these effusions. \n\nPelvis Xray \nThere is no acute fracture or dislocation. No focal lytic or \nsclerotic \nosseous lesion is seen. There is no radiopaque foreign body. \nVascular \ncalcifications are noted. The visualized bowel gas pattern is \nnonobstructive. \n \nIMPRESSION: No acute fracture or dislocation. \n\nLower extremity ultrasound \n1. Deep vein thrombosis of the left common femoral vein \nextending into at \nleast the popliteal vein. Left calf veins were not clearly \nidentified, \npossibly also occluded. \n2. No right DVT. \n\nLAST LABS BEFORE DISCHARGE \n===============================\n___ 06:55AM BLOOD WBC-14.9* RBC-3.51* Hgb-11.5 Hct-36.8 \nMCV-105* MCH-32.8* MCHC-31.3* RDW-13.8 RDWSD-53.1* Plt ___\n___ 06:55AM BLOOD Glucose-109* UreaN-32* Creat-0.9 Na-144 \nK-3.7 Cl-96 HCO3-37* AnGap-15\n___ 06:55AM BLOOD Albumin-2.5* Calcium-8.0* Phos-3.2 \nMg-1.5*\n \nBrief Hospital Course:\n___ is a ___ y/o F with PMHx CHF, Afib not on \nanticoagulation, severe advanced Alzheimer's dementia, \nosteoporosis, HTN, who presents from assisted living facility \nwith R hip pain, found to have DVT left common femoral vein with \nvolume overload. During a meeting with patient and her family, \ndecision was made to transition care to comfort-directed \nmeasures only and to pursue hospice services on discharge. \n\nACTIVE ISSUES \n=============\n# CMO. The team had a family meeting on ___ and decision was \nmade to transition care to CMO and pursue 24 hour hospice \nservices on discharge. Family did not want to pursue active \ntreatments such as Lasix, which would make her uncomfortable \ngiven incontinence or shots such as lovenox for treatment of \nDVT. Home medications metoprolol, donepezil and Memantine were \ncontinued for comfort. She was discharged to an ___ \n___ facility. \n\nOTHER HOSPITAL ISSUES \n=====================\n\n# DVT. Deep vein thrombosis of the left common femoral vein \nextending into at least the popliteal vein diagnosed on \nultrasound on admission. This was likely acquired in the setting \nof immobility, as the patient had been restricted to her \nwheelchair at her assisted living for greater than 1 month due \nto deconditioning. She was initially started on Lovenox for \ntreatment but this was discontinued in the setting of transition \nto care to CMO as above. \n\n# Acute CHF. Patient was volume overloaded on presentation with \npleural effusions. She was diuresed with IV Lasix. Home \nmetoprolol was continued at a decreased dose. In the setting of \ntransition to care to CMO, Lasix was discontinued. She was \ncontinued on metoprolol for comfort. She remained on room air \nwithout respiratory distress. \n\n# Afib. She presented in sinus rhythm, rate controlled on \nmetoprolol. Metoprolol was continued at a decreased dose for \ncomfort. \n\n# Hip pain. The right hip pain that she presented with was \nresolved by the time of admission. Pelvic xray was without \nfracture. She was treated with Tylenol scheduled for pain \ncontrol. \n\n# Al___ Dementia. She was AOx1 at her baseline per family \nmembers. She was continued on Aricept/Namenda. \n\nTRANSITIONAL ISSUES \n===================\n\n- ___ facility to continue writing orders for \npain/anxiety/secretions and other symptoms. \n- Continued metoprolol succinate and Memantine and donepezil on \ndischarge for comfort. Continuation of these medications can be \nfurther decided at inpatient hospice. \n- MOLST form: DNR/DNI, do not re-hospitalize \n\n# CODE: DNR/DNI, CMO \n# CONTACT: HCP ___ (daughter) ___ Primary, \nsecondary ___ (son) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 150 mg PO BID \n2. Torsemide 40 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Donepezil 10 mg PO QHS \n5. raloxifene 60 mg oral DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. Namenda XR (MEMAntine) 21 mg oral DAILY \n8. Ascorbic Acid ___ mg PO DAILY \n9. Calcium Carbonate 1500 mg PO DAILY \n10. Vitamin D 1000 UNIT PO DAILY \n11. Fish Oil (Omega 3) 1000 mg PO DAILY \n\n \nDischarge Medications:\n1. Donepezil 10 mg PO QHS \n2. Metoprolol Succinate XL 200 mg PO DAILY \n3. Namenda XR (MEMAntine) 21 mg oral DAILY \n4. Acetaminophen 1000 mg PO TID \n5. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions \n6. Hyoscyamine 0.125 mg SL QID:PRN excess secretions \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis \n--------------- \nDeep Vein Thrombosis \n \nSecondary Diagnosis \n------------------ \nCongestive heart failure \nAtrial fibrillation \nConstipation \nMalnutrition \nHypertension \nAlzheimer's dementia \n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear ___, \n\nIt was a pleasure taking care of you during your \nhospitalization. Briefly, you were hospitalized with right hip \npain. We did Xrays of your hip which did not show any fractures. \nWe also found a blood clot in your left leg and noticed that \nyour heart wasn't pumping very efficiently. We talked with you \nand your family, who shared with us many of your wishes about \nbeing hospitalized and the type of care you would like to \nreceive. We decided to focus on your comfort. Because of this, \nyou are being discharged to ___ for hospice care. \n\nWe wish you and your family the ___, \n\nYour ___ Treatment Team \n \nFollowup Instructions:\n___\n" ]

[ "I82412", "I5033", "E873", "E46", "I482", "G309", "I82432", "F0280", "I10", "E876", "M810", "Z66", "Z515", "Z993", "H9192", "H409", "M25551", "K5900", "Z6827", "Z85828" ]

[ "I82412: Acute embolism and thrombosis of left femoral vein", "I5033: Acute on chronic diastolic (congestive) heart failure", "E873: Alkalosis", "E46: Unspecified protein-calorie malnutrition", "I482: Chronic atrial fibrillation", "G309: Alzheimer's disease, unspecified", "I82432: Acute embolism and thrombosis of left popliteal vein", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "I10: Essential (primary) hypertension", "E876: Hypokalemia", "M810: Age-related osteoporosis without current pathological fracture", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z993: Dependence on wheelchair", "H9192: Unspecified hearing loss, left ear", "H409: Unspecified glaucoma", "M25551: Pain in right hip", "K5900: Constipation, unspecified", "Z6827: Body mass index [BMI] 27.0-27.9, adult", "Z85828: Personal history of other malignant neoplasm of skin" ]

[ "I10", "Z66", "Z515", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nCodeine / Augmentin / Topamax\n \nAttending: ___.\n \nChief Complaint:\nleft knee osteoarthritis/pain\n \nMajor Surgical or Invasive Procedure:\n___: left total knee arthroplasty\n\n \nHistory of Present Illness:\n___ year old female w/left knee osteoarthritis/pain who failed \nconservative measures, now admitted for left total knee \narthroplasty. \n \nPast Medical History:\nDyslipidemia, varicose veins (R>L) s/p ligation, COPD, OSA \n(+CPap), recent URI (received course of Zithromax), bilateral \nPEs (___), antiphospholipid antibody syndrome (on lifelong \nanticoagulation), T2DM (last A1C 6.2 on ___, cerebral \naneurysm (followed by Dr. ___, unchanged), GERD, \ndiverticulosis, h/o colon polyps, depression, s/p right CMC \njoint arthroplasty, b/l rotator cuff repair, excision right ___ \ndigit mass, CCY w/stone & pancreatic duct exploration (___), \nhysterectomy, tonsillectomy \n \nSocial History:\n___\nFamily History:\nNo family hx of DVT or PE, two sisters have atrial fibrillation. \n \n\n \nPhysical Exam:\nWell appearing in no acute distress \n Afebrile with stable vital signs \n Pain well-controlled \n Respiratory: CTAB \n Cardiovascular: RRR \n Gastrointestinal: NT/ND \n Genitourinary: Voiding independently \n Neurologic: Intact with no focal deficits \n Psychiatric: Pleasant, A&O x3 \n Musculoskeletal Lower Extremity: \n * Aquacel dressing with scant serosanguinous drainage \n * Thigh full but soft \n * No calf tenderness \n * ___ strength \n * SILT, NVI distally \n * Toes warm \n \nPertinent Results:\n___ 06:30AM BLOOD WBC-6.8 RBC-2.69* Hgb-8.3* Hct-25.3* \nMCV-94 MCH-30.9 MCHC-32.8 RDW-13.0 RDWSD-44.0 Plt ___\n___ 06:10AM BLOOD WBC-6.4 RBC-2.77* Hgb-8.6* Hct-26.0* \nMCV-94 MCH-31.0 MCHC-33.1 RDW-13.1 RDWSD-44.7 Plt ___\n___ 06:22AM BLOOD WBC-7.6 RBC-3.31* Hgb-10.2*# Hct-30.5*# \nMCV-92 MCH-30.8 MCHC-33.4 RDW-12.8 RDWSD-42.6 Plt ___\n___ 06:30AM BLOOD Plt ___\n___ 06:30AM BLOOD ___\n___ 06:10AM BLOOD Plt ___\n___ 06:10AM BLOOD ___\n___ 06:22AM BLOOD Plt ___\n___ 06:22AM BLOOD ___\n___ 10:55AM BLOOD ___\n___ 06:22AM BLOOD Glucose-136* UreaN-8 Creat-0.7 Na-138 \nK-3.7 Cl-96 HCO3-27 AnGap-15\n___ 06:22AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.7\n \nBrief Hospital Course:\nThe patient was admitted to the Orthopaedic 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, patient was administered 500ml bolus of IV fluids for \nhypotension ___, which she responded to appropriately. She \nreported nausea on oxycodone and was switched to dilaudid with \nno reported adverse effects.\nPOD #2, patient had INR of 1.8 and lovenox was discontinued. \nPatient will continue Coumadin 5mg daily. Next INR check day \nafter discharge. Please direct results and all questions to PCP \nfor INR monitoring/Coumadin dosing.\nPOD #3, INR 2.0 and patient will be due for 5mg Coumadin upon \narrival to rehab facility.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Coumadin starting on \nPOD#0 with a Lovenox bridge starting on POD#1. Lovenox to be \ncontinued until INR > 1.5 and discontinued on POD #2 with INR \n1.8. Coumadin was dosed daily based on her INR levels. The \nsurgical dressing will remain on until POD#7 after surgery. The \npatient was seen daily by physical therapy. Labs were checked \nthroughout the hospital course and repleted accordingly. At the \ntime of discharge the patient was tolerating a regular diet and \nfeeling well. The patient was afebrile with stable vital signs. \n The patient's hematocrit was acceptable and pain was adequately \ncontrolled on an oral regimen. The operative extremity was \nneurovascularly intact and the dressing was intact.\n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity. Please use walker or 2 \ncrutches, wean as able.\n\nMs. ___ is discharged to rehab in stable condition.\n\n**Patient will be in rehab facility for less than 30 days**\n \nMedications on Admission:\n1. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN wheezing, cough \n2. Atorvastatin 40 mg PO QPM \n3. econazole 1 % topical BID \n4. Enoxaparin Sodium 110 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n5. Furosemide ___ mg PO DAILY:PRN leg swelling \n6. MetFORMIN (Glucophage) 500 mg PO QPM \n7. Omeprazole 20 mg PO BID \n8. Sertraline 100 mg PO DAILY \n9. TraZODone 50 mg PO QHS:PRN insomnia \n10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN \nrash/itching \n11. Warfarin ___ mg PO DAILY16 \n12. Aspirin 81 mg PO DAILY \n13. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \n2. Gabapentin 100 mg PO TID \n3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate \ndo NOT drink alcohol or drive while taking med \n4. Senna 8.6 mg PO BID \n5. Acetaminophen 1000 mg PO Q8H \n6. Warfarin 5 mg PO TO BE DOSED DAILY PER PCP \nDOSED DAILY PER PCP, GOAL INR 1.8-2.2 \n7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath \n8. Aspirin 81 mg PO DAILY \n9. Atorvastatin 40 mg PO QPM \n10. econazole 1 % topical BID \n11. Furosemide ___ mg PO DAILY:PRN leg swelling \n12. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n13. Omeprazole 20 mg PO BID \n14. Sertraline 100 mg PO DAILY \n15. TraZODone 50 mg PO QHS:PRN insomnia \n16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN \nrash/itching \n17. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft knee osteoarthritis/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:\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: Lovenox discontinued on ___ due to INR \n1.8. INR goal is 1.8-2.2. Please continue Coumadin 5mg daily. \nINR to be checked day after discharge. Please direct all INR \nresults to patient's PCP. You may continue your dose of Aspirin \n81mg daily.\n \n9. WOUND CARE: Please remove Aquacel dressing on POD#7 after \nsurgery. It is okay to shower after surgery after 5 days but no \ntub baths, swimming, or submerging your incision until after \nyour four (4) week checkup. Please place a dry sterile dressing \non the wound after aqaucel is removed each day if there is \ndrainage, otherwise leave it open to air. Check wound regularly \nfor signs of infection such as redness or thick yellow drainage. \n \n\n10. ___ (once at home): Home ___, dressing changes as \ninstructed, and wound checks.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Two crutches or walker. Wean assistive device as \nable. Mobilize. ROM as tolerated. No strenuous exercise or \nheavy lifting until follow up appointment. \n\nPhysical Therapy:\nWBAT LLE\nNo range of motion restrictions\nWean assistive devices as able\nMobilize frequently\nTreatments Frequency:\nremove aquacel POD#7 after surgery\napply dry sterile dressing daily if needed after aquacel \ndressing is removed\nwound checks daily after aquacel removed\n\n \nFollowup Instructions:\n___\n" ]

[ "M1712", "D6861", "J449", "G4733", "F329", "E119", "M4696", "E785", "K219", "E669", "Z7901", "Z87891", "Z6837", "Z86711" ]

[ "M1712: Unilateral primary osteoarthritis, left knee", "D6861: Antiphospholipid syndrome", "J449: Chronic obstructive pulmonary disease, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F329: Major depressive disorder, single episode, unspecified", "E119: Type 2 diabetes mellitus without complications", "M4696: Unspecified inflammatory spondylopathy, lumbar region", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "Z86711: Personal history of pulmonary embolism" ]

[ "J449", "G4733", "F329", "E119", "E785", "K219", "E669", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCodeine / Augmentin / Topamax\n \nAttending: ___.\n \nChief Complaint:\nRLE pain and swelling\n \nMajor Surgical or Invasive Procedure:\nUltrasound guided steroid injection of the right trochanteric \nbursa (right hip)\n\n \nHistory of Present Illness:\nThis is a ___ woman with a history of breast cancer with\nBRCA1 gene mutation, COPD, cerebral aneurysm, sleep apnea,\ndepression, hyperlipidemia, antiphospholipid syndrome with hx\nDVT/PE ___ ago on warfarin who presents for evaluation of severe\nright lower extremity pain.\n\nShe was just admitted to the hospital for lumpectomy\n(infiltrating ductal carcinoma of left breast) and sentinel \nlymph\nnode biopsy on ___, complicated by hematoma status post\nevacuation on ___. Prior to these procedures, she had \nsevere\nright lower extremity pain similar to today and underwent a DVT\nultrasound on ___ which was negative. Her anticoagulation was\nheld in the hospital due to the hematoma, and she had DVT\nprophylaxis with pneumoboots.\n\nDuring her postoperative hematoma her anticoagulation was held.\nShe did not have extremity pain during her time in the hospital.\nHowever, upon returning home, she developed severe pain which \nshe\ndescribes as cramps in her mid calf on the right. She also has\npain that intermittently occurs in the right thigh which she\ndescribes as spasms. She has not had numbness, tingling, or\nweakness on that side. She was seen in breast clinic today where\nshe complained of this pain, and was referred to the ED for\nfurther evaluation. She initially triggered as a pulseless\nextremity because of nonpalpable pulses in the right foot. She\nhas been taking Tylenol as well as tramadol with minimal pain\nrelief. \n\nOf note, she resumed her warfarin without any enoxaparin bridge\nthis past ___. She has been wearing compression stockings and\nelevating her leg in an attempt to relieve the pain. \n\nIn the ED, initial vitals: \nT 98.7 HR 85 BP 175/77 RR 20 O2 Sat 98% RA \n\n- Exam notable for: \nRight lower extremity with dopplerable pulses, palpable pulses \nin\nthe left lower extremity. The right lower extremity is warm.\nThere is tenderness to palpation of the right calf. Tenderness \nto\npalpation of the right thigh.\n\n- Labs notable for: \nChem panel: Unremarkable with Cr 0.8\nCK 67\nCBC: WBC 5.6, Hgb 10.8 with MCV 93, Plt 264\nCoags: ___ 14.8, PTT 28.2, INR 1.4\nLactate 1.1\nUA: Mod Leuk, few bacteria\n\n- Imaging notable for: \n\nRLE Ultrasound ___\nRight calf veins not visualized. Otherwise, no evidence of deep\nvenous\nthrombosis in the right lower extremity veins.\n\nCT Lower Extremity Right ___\nUnremarkable contrast enhanced CT of the right calf with a two\nvessel runoff to the foot.\nThe veins of the lower extremity are not opacified therefore\ncannot be\nassessed for patency. Consider repeat ultrasound to more fully\nevaluate.\nNo focal collection or obvious muscular abnormality identified \nby\nCT.\n\n- Pt given: \nIV Morphine 4mg\nIV APAP 1g\nIV NS\nIV Dilaudid 5 mg total (1mg x 5)\nWarfarin 7.5mg\nAtorvastatin 40mg\nOmeprazole 20mg\n\nSurgery was consulted: Recommend vascular surgery consult for\npossible dvt with history of multiple vein stripping procedures\nand DVTs. Also recommend admission to medicine for pain control. \n\n\nVascular surgery was consulted: There is no clear vascular\netiology for her pain.\n\n- Vitals prior to transfer: \nT 98.3 HR 83 BP 140/55 RR 20 O2 Sat 100% RA \n\nUpon arrival to the floor, the patient reports the pain is ___.\nShe reports again that this pain is similar to the pain she had\non ___ but even then an ultrasound showed no DVT. She is able \nto\nmove her toes but has pain with lifting her leg. She has never\nhad this kind of pain before, even with the vein stripping that\nshe had in the past (age ___. She has no chest pain or shortness\nof breath. She has had no recent travel or trauma to her leg. \n\n \nPast Medical History:\nDyslipidemia, \nVaricose veins (R>L) s/p ligation, \nCOPD, \nOSA (+CPap), \nrecent URI (received course of Zithromax), \nbilateral PEs (___), \nantiphospholipid antibody syndrome (on lifelong \nanticoagulation),\n\nT2DM (last A1C 6.2 on ___, \ncerebral aneurysm (followed by Dr. ___, unchanged), \nGERD, \ndiverticulosis, \nh/o colon polyps, \ndepression, \ns/p right CMC joint arthroplasty, \nb/l rotator cuff repair, \nexcision right ___ digit mass, \nCCY w/stone & pancreatic duct exploration (___), \nhysterectomy, \ntonsillectomy \n\n \nSocial History:\n___\nFamily History:\nMother ___ ___ OVARIAN CANCER dx age ___ \nFather ___ ___ BRAIN CANCER \nPGM OVARIAN CANCER \nAunt OVARIAN CANCER paternal aunt in \n ___ \nMGM ENDOMETRIAL CANCER \nMGF PROSTATE CANCER \nBrother ___ ___ KIDNEY CANCER \n RENAL FAILURE \n CONGESTIVE HEART \n FAILURE \n DIABETES MELLITUS \n TOBACCO ABUSE \n ALCOHOL ABUSE \nSister ___ ___ OVARIAN CANCER dx age ___ \nBrother ___ THROAT CANCER dx age ___, died in \n ___ \nSister BRCA1 MUTATION, BREAST CANCER \nDaughter Living ___ ABNORMAL PAP SMEAR ___\n SUBSTANCE ABUSE \nSon Died ___ SUBSTANCE ABUSE ___ - heroin overdose on ___.\n \nPhysical Exam:\nADMISSION EXAM:\n==================\nVITALS: T 97.9 BP 125 / 80 HR 82 RR 16 O2 Sat 94 RA \nGeneral: Alert, oriented, no acute distress \nHEENT: MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not\nelevated\nChest: L breast incisions well healed. S/p L axilla surgical\ndrain removal.\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs\nLungs: Clear to auscultation bilaterally, no wheezes or crackles\nAbdomen: Soft, non-tender, non-distended, bowel sounds present\nExt: Warm, well perfused, right lower extremity is tender to\npalpation and movement limited by pain. Swelling of RLE > LLE.\nPalpable 2+ ___ pulses bilaterally.\nSkin: Warm, dry, varicose veins noted in lower extremities. \nNeuro: CNII-XII intact, grossly normal strength and sensation \nand\nsymmetric bilaterally\n\nDISCHARGE EXAM:\n================\nVITALS: Temp: 98.2 (Tm 98.9), BP: 133/74 (127-147/72-83), HR: 76\n(76-91), RR: 18, O2 sat: 99% (90-99), O2 delivery: Ra \nGeneral: Alert, oriented, no acute distress \nHEENT: MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP not\nelevated\nChest: L breast incisions well healed. S/p L axilla surgical\ndrain removal.\nCV: RRR, no murmurs\nLungs: Clear\nAbdomen: Soft, non-tender, non-distended, bowel sounds present\nExt: Warm, well perfused. No asymmetric swelling. Minimally\ntender to palpation along the right trochanteric bursa and\nminimally tender to palpation along the right tibia. Normal ROM\nthough pain elicited with knee flexion; improves with leg raise\nand extension. Palpable 2+ ___ pulses bilaterally.\nSkin: varicose veins noted in lower extremities. \nNeuro: lower extremity sensation is equal on both sides to light\ntouch. Normal bilateral lower extremity strength. Negative\nbabinsky. Ambulating in hallway independently though it \nprecipitates \nright tibial pain\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 12:00PM BLOOD WBC-5.6 RBC-3.48* Hgb-10.8* Hct-32.3* \nMCV-93 MCH-31.0 MCHC-33.4 RDW-14.7 RDWSD-48.6* Plt ___\n___ 12:00PM BLOOD Neuts-73.6* ___ Monos-4.9* \nEos-0.9* Baso-0.7 Im ___ AbsNeut-4.09 AbsLymp-1.08* \nAbsMono-0.27 AbsEos-0.05 AbsBaso-0.04\n___ 12:00PM BLOOD ___ PTT-28.2 ___\n___ 12:00PM BLOOD Glucose-107* UreaN-7 Creat-0.8 Na-139 \nK-4.0 Cl-100 HCO3-26 AnGap-13\n___ 05:40AM BLOOD Calcium-8.6 Phos-4.8* Mg-2.2 Iron-36\n___ 05:40AM BLOOD calTIBC-291 VitB12-331 Ferritn-50 TRF-224\n___ 07:15AM BLOOD 25VitD-45\n___ 12:25PM BLOOD Lactate-1.1\n\nDISCHARGE LABS:\n================\n___ 04:41AM BLOOD WBC-5.6 RBC-3.36* Hgb-10.1* Hct-31.1* \nMCV-93 MCH-30.1 MCHC-32.5 RDW-14.5 RDWSD-48.7* Plt ___\n___ 04:41AM BLOOD ___\n___ 04:41AM BLOOD Glucose-132* UreaN-15 Creat-0.7 Na-140 \nK-5.0 Cl-103 HCO3-26 AnGap-11\n___ 04:41AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.4\n\nIMAGING:\n===================\nUnilat lower extremity vein- R ___\nRight calf veins not visualized. Otherwise, no evidence of deep\nvenous thrombosis in the right lower extremity veins.\n\nCT RLE ___\nUnremarkable contrast enhanced CT of the right calf with a two \nvessel runoff to the foot. \nThe veins of the lower extremity are not opacified therefore \ncannot be assessed for patency. Consider repeat ultrasound to \nmore fully evaluate. \nNo focal collection or obvious muscular abnormality identified \nby CT\n\n___:\n1.. Uneventful ultrasound-guided injection of long-acting \nanesthetic and\nsteroid into theright greater trochanteric bursa.\n2. Prior injection, small amount of fluid in the right greater \ntrochanteric\nbursa and dystrophic calcification within the bursal space. \nFindings raise\nsuspicion for chronic trochanteric bursitis.\n \nBrief Hospital Course:\nSUMMARY:\n==================\nMs. ___ is a ___ with a PMH significant for \nantiphospholipid syndrome with DVTs and PEs on Coumadin, recent \nL-sided breast cancer s/p lumpectomy, who presented to the ED \nwith acute on chronic right lower extremity and right hip pain, \nmaking it difficult to ambulate. Right lower extremity U/S and \nCT did not reveal a DVT though calf veins were not well \nvisualized. \n\nACTIVE ISSUES:\n==================\n# Right trochanteric bursitis\n# Right anterior lower leg pain\n# Right sided varicose veins\nPt endorsed >4mths of pain in RLE that became acutely worse over \nthe last few wks. Her initial exam was most consistent with \nsevere trochanteric bursitis on the right. She also has some \nfocal pain along the right tibia which she felt was most \nconsistent with pain from her varicose veins. The XRs of her \ntibia/fibula and right hip were without obvious pathology. There \nare no concerning neurologic symptoms to suggest a \nradiculopathy, no weakness or numbness though she may have some \ndegree of chronic sciatica. Mildly decreased patellar reflex on \nthe right as compared to left may have been in the setting of \npain and guarding; strength was normal bilaterally as was her \nsensation. \nShe underwent U/S guided steroid injection of her trochanteric \nbursa w/ significant improvement in symptoms; ___ stated that \nthere was some fluid near the bursa, suggestive of acute on \nchronic trochanteric bursitis. Her anterior shin pain improved \nwith initiation of gabapentin and lidocaine patch in addition to \nher home tylenol and an increase in the frequency of her home \ntramadol (q8h PRN to q4h PRN). Pt was not given her home \nhydromorphone PRN, though she did require one dose of 0.5 mg IV \nhydromorphone following her injection in the setting of an acute \npain episode. She was discharged with Tramadol 50mg x15 tablets \ngiven increased requirement. By discharge, she was able ambulate \nand was felt safe for discharge home with a cane per ___ \nevaluation. Pt was eager to leave and will reach out to her \nvascular surgeon for an appointment early in the new year for \ntreatment of her painful varicose veins.\n\n# Iron deficiency anemia:\nAnemia is new since ___. Normocytic. Downtrended overnight to \n8.9 from 10.8. No concern for active bleeding. Per iron studies, \nshe is iron deficient with a ferritin of 50. She endorses \nfatigue and restless leg syndrome. Etiology is unclear, though \nit may be related to the recent left breast hematoma of her \nbreast (unlikely though the timing fits). Prior EGD with \ngastritis (___) for which she is on a BID PPI; prior \ncolonoscopy ___ with findings that may be suggestive of \nceliac disease, though ttg at that time was normal with a normal \nIgA. She also had two polyps biopsied and were normal. On this \nadmission, a vitamin D level was obtained to assess for evidence \nof malabsorption iso daily supplementation: level was 45. She \nwas given ferric gluconate IV x1 on ___. TTG was repeated and \npending at discharge. \n\nCHRONIC ISSUES:\n===================\n# History of DVT/PE on warfarin:\n# Antiphospholipid antibody syndrome:\n# Subtherapeutic INR:\nLupus anticoagulant positive in ___. She has been taking her \nhome dose of warfarin (5 mg ___ and 7.5 mg other days). Her \nwarfarin was held last ___ iso hematoma and she was not \nbridged with Lovenox upon reinitiation. INR on this admission \nwas subtherapeutic at 1.4. Bridged during this hospitalization \nwith Lovenox for goal INR ___. She was given an increased dose \nof warfarin, 7.5 mg daily while in house. INR at discharge was \n1.9, with plan to continue home warfarin regimen. Patient will \nget repeat INR on ___. \n\n# Vitamin D deficiency: pt takes 2,000 U vitamin D daily. Repeat \nlevel IS 45 which suggests against malabsorption to account for \nher iron deficiency. \n\nTRANSITIONAL ISSUES:\n====================\nCode status: Full, presumed\nHCP: ___, granddaughter - ___.\n\n- Right trochanteric bursitis:\n[] Consider repeat injection\n[] Consider physical therapy\n\n- Right anterior leg pain\n[] discharged on gabapentin 600 mg three times daily\n[] discharged with tramadol 50mg, home regimen is Q8hrs and \nrequired Q4hrs during hospitalization. Will give two day supply \nof increased dose. Plan to see PCP next week.\n[] Consider outpatient MRI of the lumbar spine for chronic pain \n[] Consider EMG\n[] Vascular surgery follow up as outpt for treatment of painful \nveins\n\n- Iron deficiency anemia:\n[] Consider repeat IV iron infusion\n[] F/u pending TTG\n[] Consider further work up (though may be related to left \nbreast hematoma)\n\n- History of DVT/PE, antiphospholipid antibody syndrome, \nsubtherapeutic INR:\n[] F/u ___ clinic on ___. Patient can continue home \nWarfarin regimen\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Docusate Sodium 100 mg PO BID \n3. Omeprazole 20 mg PO BID \n4. Senna 8.6 mg PO HS \n5. Sertraline 150 mg PO DAILY \n6. TraZODone 50 mg PO QHS:PRN sleep \n7. TraMADol 50 mg PO Q8H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\n8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n10. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze \n12. Vitamin D ___ UNIT PO DAILY \n13. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID \n14. Furosemide 20 mg PO DAILY:PRN Leg swelling \n15. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe \n16. Warfarin 7.5 mg PO 2X/WEEK (___) \n17. Warfarin 5 mg PO 5X/WEEK (___) \n\n \nDischarge Medications:\n1. Gabapentin 600 mg PO TID \nRX *gabapentin 600 mg 1 tablet(s) by mouth three times daily \nDisp #*90 Tablet Refills:*0 \n2. Lidocaine 5% Patch 1 PTCH TD QAM right hip \nRX *lidocaine 5 % Apply ___ patches daily Disp #*12 Patch \nRefills:*0 \n3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \nRX *tramadol 50 mg 1 tablet(s) by mouth Every six hours as \nneeded Disp #*15 Tablet Refills:*0 \n4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze \n6. Atorvastatin 40 mg PO QPM \n7. Docusate Sodium 100 mg PO BID \n8. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID \n9. Furosemide 20 mg PO DAILY:PRN Leg swelling \n10. Omeprazole 20 mg PO BID \n11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n13. Senna 8.6 mg PO HS \n14. Sertraline 150 mg PO DAILY \n15. TraZODone 50 mg PO QHS:PRN sleep \n16. Vitamin D ___ UNIT PO DAILY \n17. Warfarin 5 mg PO 2X/WEEK (___) \n18. Warfarin 7.5 mg PO 5X/WEEK (___) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n=================\nRight trochanteric bursitis\nRight anterior leg pain\nRight sided varicose veins \n\nSECONDARY:\n=================\nIron deficiency anemia\nHistory of DVT/PE on warfarin\nAntiphospholipid antibody syndrome\nSubtherapeutic INR\nVitamin D deficiency\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___, \n\nYou were admitted because you were having a lot of leg pain, \nmaking it difficult to walk. \n\nIn the hospital, we gave you a steroid injection near your right \nthigh for a condition called, Trochanteric Bursitis. We also \ngave you a medication called Gabapentin to help with your leg \npain lower down. \n\nWe also started you on a medication called Lovenox in order to \nbridge you back to your warfarin - currently, your warfarin dose \nis 7.5 mg daily and your INR was 1.9 at discharge (goal ___. \n\nFinally, you received 1 dose of intravenous iron because you are \niron deficient which may be why you are more fatigued than \nusual.\n\nWhen you go home, please take your medications as prescribed and \nmake an appointment with your primary care doctor. We do not \nknow what exactly is causing the lower leg pain, so you may want \nto talk to your doctor about having an MRI of your spine. You \ncan also ask your doctor about prescribing a medication called \nDICLOFENAC GEL, also called VOLTAREN. This is essentially Motrin \nor Advil in a topical form and may help your pain.\n\nAdditionally, please talk to your doctor about why you may be \niron deficient. \n\nIt was a pleasure taking part in your care. We wish you all the \nbest with your health.\n\nSincerely,\nThe team at ___\n\n \nFollowup Instructions:\n___\n" ]

[ "M7061", "D6861", "D509", "E559", "Z87891", "Z86711", "Z7901", "C50912", "G4733", "E785", "E119", "K219", "K5790", "F329", "J449", "I83811" ]

[ "M7061: Trochanteric bursitis, right hip", "D6861: Antiphospholipid syndrome", "D509: Iron deficiency anemia, unspecified", "E559: Vitamin D deficiency, unspecified", "Z87891: Personal history of nicotine dependence", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "C50912: Malignant neoplasm of unspecified site of left female breast", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "K219: Gastro-esophageal reflux disease without esophagitis", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "F329: Major depressive disorder, single episode, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "I83811: Varicose veins of right lower extremity with pain" ]

[ "D509", "Z87891", "Z7901", "G4733", "E785", "E119", "K219", "F329", "J449" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine / Augmentin / Topamax\n \nAttending: ___\n \n___ Complaint:\nleft breast swelling and pain\n \nMajor Surgical or Invasive Procedure:\nEvacuation of hematoma \n\n \nHistory of Present Illness:\n___ woman on anticoagulation with L breast IDC Grade 3 \nnow s/p L breast lumpectomy and SLNB with left breast swelling \nand pain concerning for a hematoma. \n \nPast Medical History:\nDyslipidemia, varicose veins (R>L) s/p ligation, COPD, OSA \n(+CPap), recent URI (received course of Zithromax), bilateral \nPEs (___), antiphospholipid antibody syndrome (on lifelong \nanticoagulation), T2DM (last A1C 6.2 on ___, cerebral \naneurysm (followed by Dr. ___, unchanged), GERD, \ndiverticulosis, h/o colon polyps, depression, s/p right CMC \njoint arthroplasty, b/l rotator cuff repair, excision right ___ \ndigit mass, CCY w/stone & pancreatic duct exploration (___), \nhysterectomy, tonsillectomy \n \nSocial History:\n___\nFamily History:\nNo family hx of DVT or PE, two sisters have atrial fibrillation. \n \n\n \nPhysical Exam:\nPhysical Exam:\nVS: ___ 0313 Temp: 98.2 PO BP: 98/62 HR: 79 RR: 18 O2 sat:\n95% O2 delivery: RA \nGEN: NAD, pleasant, conversant \nHEENT: NCAT, EOMI, sclera anicteric\nCV: RRR\nPULM: no increased work of breathing, comfortable on RA\nBREAST: L breast with dependent ecchymosis, mildly ttp inferior\nbreast, incision C/D/I. JP drain with serosanguineous output. \nABD: soft, non-tender, non-distended, no masses or hernia\nEXT: Warm, well-perfused, no edema, no tenderness \nNEURO: A&Ox3, no focal neurologic deficits\nPSYCH: normal judgment/insight, normal memory, normal \nmood/affect\n \nPertinent Results:\n___ 07:33AM BLOOD WBC-4.8 RBC-2.86* Hgb-8.6* Hct-27.2* \nMCV-95 MCH-30.1 MCHC-31.6* RDW-14.7 RDWSD-48.7* Plt ___\n___ 07:33AM BLOOD ___ PTT-26.2 ___\n___ 07:33AM BLOOD Glucose-130* UreaN-7 Creat-0.8 Na-141 \nK-4.2 Cl-101 HCO3-31 AnGap-9*\n___ 07:33AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.0\n\nEXAMINATION: CTA CHEST WITH CONTRAST \nCOMPARISON: Chest CT dated ___. \n \nFINDINGS: \n \nHEART AND VASCULATURE: There is no central pulmonary embolism. \nThe thoracic \naorta is normal in caliber without evidence of dissection or \nintramural \nhematoma. The heart, pericardium, and great vessels are within \nnormal limits. \nNo pericardial effusion is seen. \n \nAXILLA, HILA, AND MEDIASTINUM: There is a 8.8 x 5.8 x 9.8 cm \ncollection in the \nleft breast, with density measuring 39 Hounsfield units, \nconsistent with \nhematoma. There are few foci of air within the collection, \nlikely from prior \naspiration, as well as few punctate hyperdensities at the \nperiphery. No \naxillary, mediastinal, or hilar lymphadenopathy is present. The \nright axilla \nis not included on the study. No mediastinal mass. \n \nPLEURAL SPACES: No pleural effusion or pneumothorax. \n \nLUNGS/AIRWAYS: Partially visualized lungs are clear without \nmasses or areas of \nparenchymal opacification. The airways are patent to the level \nof the \nsegmental bronchi bilaterally. \n \nBASE OF NECK: Visualized portions of the base of the neck show \nno abnormality. \n \nBONES: No suspicious osseous abnormality is seen.? There is no \nacute fracture. \n \nIMPRESSION: \n \n8.8 x 5.8 x 9.8 cm left breast hematoma, with no evidence of \nactive bleed. \nPlease note, timing was suboptimal as the patient needed to be \nre-scanned due \nto incomplete field-of-view on initial images, however, the \ndensity of the \ncollection was unchanged on all series. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman who was admitted to the \nbreast service following a left breast lumpectomy for invasive \ncarcinoma performed on ___. She presented with a recurrent \nleft breast hematoma after it was evacuated by needle aspiration \nin clinic on ___. She was admitted for observation and \nsurgical evacuation of her hematoma. \n\nOn ___ she was brought to the operating room for evacuation \nof the left ___ hematoma and placement of a surgical drain. \nHospital course as detailed below:\n\nNeuro: pain was controlled with oral pain medication including \nacetaminophen and tramadol. \n\n___: Vital signs were monitored per protocol. She was continued \non her home medications. \n\nResp: she was continued on her home albuterol medications\n\nFEN/GI: she was continued on a regular diet throughout her \nadmission. She was briefly made NPO for the operating room and \nhydrated with IV fluids in the perioperative period. \n\nGU: She voided without issue throughout her hospital course\n\nHeme: H/H was closely monitored with daily labs and found to be \nstable. Her home anticoagulation was held during her hospital \ncourse. She was resumed on her home dose of warfarin on \ndischarge without a lovenox bridge. She remained on compression \nboots during her hospital course to prevent DVTs.\n\nID: She was given ancef 2gm IV Q8hrs for prophylaxis, she \nremained afebrile and did not develop a leukocytosis during her \nhospital course. \n\nEndo: Due to a history of metabolic syndrome and pre-diabetes \nshe was kept on a constant carbohydrate diet. \n\nOn the day of discharge she was tolerating a regular diet w/o \nnausea or emesis. She was ambulating independently. Her pain was \ncontrolled with oral pain medications. She was afebrile and did \nnot have a leukocytosis, all antibiotics were discontinued. She \nwas discharged home with ___ for drain management and close \nfollow up with Dr. ___ in clinic for drain removal. She \nwill also follow up with Dr. ___ in clinic in early ___ \nfor routine follow up. \n\n \nMedications on Admission:\nActive Medication list as of ___:\n \nMedications - Prescription\nALBUTEROL SULFATE - albuterol sulfate 2.5 mg/3 mL (0.083 %)\nsolution for nebulization. 3 ml inhalation four times a day as\nneeded for cough, wheeze\nALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation\naerosol inhaler. 2 puffs inhalation q4-6 hours as needed for\ncough/wheeze\nATORVASTATIN - atorvastatin 40 mg tablet. 1 (One) tablet(s) by\nmouth at bedtime - (Prescribed by Other Provider; Dose\nadjustment - no new Rx)\nENOXAPARIN - enoxaparin 100 mg/mL subcutaneous syringe. 100 mg \nSC\ntwice daily approximately 12 hours apart (will start ___,\nlast dose ___ AM). - (Prescribed by Other Provider; Dose\nadjustment - no new Rx)\nERYTHROMYCIN - erythromycin 5 mg/gram (0.5 %) eye ointment. \nApply\n___ inch affected eye four times a day\nFUROSEMIDE - furosemide 20 mg tablet. ___ tablet(s) by mouth\nonce a day as needed for leg swelling\nHYDROMORPHONE - hydromorphone 2 mg tablet. ___ tablet(s) by\nmouth every four (4) hours as needed for severe pain do not \ndrink\nalcohol or drive while taking this medication\nNEBULIZER AND COMPRESSOR [PORTABLE NEBULIZER SYSTEM] - Portable\nNebulizer System. Use with albuterol nebulizer soln four times a\nday as needed for cough/wheeze\nOMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE 1\nCAPSULE TWICE DAILY FOR GASTROESOPHAGEAL REFLUXDISEASE\nSERTRALINE - sertraline 100 mg tablet. 1.5 tablet(s) by mouth\nonce a day\nTRAMADOL - tramadol 50 mg tablet. one tablet(s) by mouth three\ntimes a day\nTRAZODONE - trazodone 50 mg tablet. 1 tablet(s) by mouth at\nbedtime as needed for insomia\nWARFARIN - warfarin 5 mg tablet. 1 (One) tablet(s) by mouth 2\ntimes a ___, ___ tabs po 5 times a week (last dose per\n___ clinic ___ - (Prescribed by Other Provider; Dose\nadjustment - no new Rx)\n \nMedications - OTC\nACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by \nmouth\n3 times daily as needed for pain - ___ DC med rec)\nCHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) \n2,000\nunit tablet. 1 tablet(s) by mouth once a day - (OTC)\nPOLYETHYLENE GLYCOL 3350 [MIRALAX] - Miralax 17 gram/dose oral\npowder. 1 powder(s) by mouth once a day as needed for\nconstipation - (Prescribed by Other Provider; Dose adjustment -\nno new Rx)\nSENNOSIDES [SENNA] - senna 8.6 mg tablet. 1 tablet(s) by mouth\nonce a day as needed for constipation - (OTC)\n\n \nDischarge Medications:\n1. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *tramadol 50 mg 1 tablet(s) by mouth Q4hr prn Disp #*7 Tablet \nRefills:*0 \n2. Atorvastatin 40 mg PO QPM \n3. Docusate Sodium 100 mg PO BID \n4. Omeprazole 20 mg PO BID \n5. Senna 17.2 mg PO HS \n6. Sertraline 150 mg PO DAILY \n7. TraZODone 50 mg PO QHS:PRN sleep \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nbreast hematoma \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. Do not shower while your drain is in place. \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. \n\nANTICOAGULATION:\nYou should begin taking your home warfarin dose this evening \n(___) and resume taking warfarin at your regular scheduled \ndoses. You will not need a bridge therapy to begin warfarin. \n\nDRAIN DISCHARGE INSTRUCTIONS \nYou are being discharged with drains in place. Drain care is a \nclean procedure. Wash your hands thoroughly with soap and warm \nwater before performing drain care. Perform drainage care twice \na day. Try to empty the drain at the same time each day. Pull \nthe stopper out of the drainage bottle and empty the drainage \nfluid into the measuring cup. Record the amount of drainage \nfluid on the record sheet. Reestablish drain suction. \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\n \nFollowup Instructions:\n___\n" ]

[ "L7632", "C50912", "D6861", "K760", "K219", "G4733", "E785", "I671", "J449", "E119", "Y838", "F329", "Z7901", "Z86711", "Z87891", "Z803", "Z8041", "Z9012" ]

[ "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "C50912: Malignant neoplasm of unspecified site of left female breast", "D6861: Antiphospholipid syndrome", "K760: Fatty (change of) liver, not elsewhere classified", "K219: Gastro-esophageal reflux disease without esophagitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E785: Hyperlipidemia, unspecified", "I671: Cerebral aneurysm, nonruptured", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "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", "F329: Major depressive disorder, single episode, unspecified", "Z7901: Long term (current) use of anticoagulants", "Z86711: Personal history of pulmonary embolism", "Z87891: Personal history of nicotine dependence", "Z803: Family history of malignant neoplasm of breast", "Z8041: Family history of malignant neoplasm of ovary", "Z9012: Acquired absence of left breast and nipple" ]

[ "K219", "G4733", "E785", "J449", "E119", "F329", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nCodeine / Augmentin / Topamax\n \nAttending: ___.\n \nChief Complaint:\nLow back pain with radiation down the right leg \n \nMajor Surgical or Invasive Procedure:\nDECOMPRESSION L2-S1, FUSION L4-L5, DURAPLASTY on ___\n \nHistory of Present Illness:\nMs. ___ is a ___ female with a past medical \nhistory significant for cerebral aneurysm, abdominal aortic \naneurysm, antiphospholipid syndrome w/ multiple DVTs and one \nevent of bilateral large PEs on warfarin, BRCA1 mutation w/ \nL-sided breast cancer s/p lumpectomy, who presents with over one \nmonth of right lower back pain with radicular pain down the \nright leg pain. She had recent admission ___ for acute \nworsening of RLE pain and swelling in background of about 4 \nmonths right leg pain. RLE US did not show evidence of DVT. Exam \nwas most consistent with right trochanteric bursitis and pt \nreceived a steroid injection. Her right tibia pain was felt to \nbe ___ to her varicose veins. On this admission Imaging notable \nfor: Normal CT A/P with no e/o nephrolithiasis, MR ___ spine with \ndisc bulge at L2-L3 and L3-4 cause severe narrowing of the \nspinal canal with crowding of the traversing cauda equina.\n\n \nPast Medical History:\nDyslipidemia, \nVaricose veins (R>L) s/p ligation, \nCOPD, \nOSA (+CPap), \nrecent URI (received course of Zithromax), \nbilateral PEs (___), \nantiphospholipid antibody syndrome (on lifelong \nanticoagulation),\n\nT2DM (last A1C 6.2 on ___, \ncerebral aneurysm (followed by Dr. ___, unchanged), \nGERD, \ndiverticulosis, \nh/o colon polyps, \ndepression, \ns/p right CMC joint arthroplasty, \nb/l rotator cuff repair, \nexcision right ___ digit mass, \nCCY w/stone & pancreatic duct exploration (___), \nhysterectomy, \ntonsillectomy \n\n \nSocial History:\n___\nFamily History:\nMother ___ ___ OVARIAN CANCER dx age ___ \nFather ___ ___ BRAIN CANCER \nPGM OVARIAN CANCER \nAunt OVARIAN CANCER paternal aunt in \n ___ \nMGM ENDOMETRIAL CANCER \nMGF PROSTATE CANCER \nBrother ___ ___ KIDNEY CANCER \n RENAL FAILURE \n CONGESTIVE HEART \n FAILURE \n DIABETES MELLITUS \n TOBACCO ABUSE \n ALCOHOL ABUSE \nSister ___ ___ OVARIAN CANCER dx age ___ \nBrother ___ THROAT CANCER dx age ___, died in \n ___ \nSister BRCA1 MUTATION, BREAST CANCER \nDaughter Living 40 ABNORMAL PAP SMEAR ___\n SUBSTANCE ABUSE \nSon Died ___ SUBSTANCE ABUSE ___ - heroin overdose on ___.\n \nPhysical Exam:\nPhysical Exam On Admission:\nVITALS: ___ 1104 Temp: 97.9 PO BP: 129/79 R Lying HR: 82\nRR: 16 O2 sat: 96% O2 delivery: Ra \n\nGeneral: Tearful, expressing right back and leg pain with spasms \n\n\nChest: L breast incisions well healed. S/p L axilla surgical\ndrain removal.\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs\nLungs: Clear to auscultation bilaterally, no wheezes or crackles\nAbdomen: Soft, non-tender, non-distended, bowel sounds present\nExt: Warm, well perfused, right lower extremity is tender to\npalpation and movement limited by pain. Swelling of RLE > LLE.\nPalpable 2+ ___ pulses bilaterally.\nSkin: Warm, dry, varicose veins noted in lower extremities. \nNeuro: Grossly oriented\nMSK exam: Right SI Joint tenderness. Radicular pain worsened \nwith\nback flexion and relieved with extension. ___ strength\nbilaterally w/ hip flexion and extension, knee flexion and\nextension, foot plantar and dorsiflexion, sensation in tact\nbilaterally \n\n___ Ortho Spine Exam\n\nPE: \nVS\n___ ___ Temp: 98.7 PO BP: 135/66 R Lying HR: 99 RR: 18 O2\nsat: 94% O2 delivery: Ra \n___ ___ Temp: 98.7 PO BP: 135/66 R Lying HR: 99 RR: 18 O2\nsat: 94% O2 delivery: Ra \n\nNAD, A&Ox4\nnl resp effort\nRRR\n \nSensory:\nUE \n C5 C6 C7 C8 T1\n (lat arm) (thumb) (mid fing) (sm finger) (med arm)\nR SILT SILT SILT SILT SILT\nL SILT SILT SILT SILT SILT\n\nT2-L1 (Trunk) \n SILT\n\n___ \n L2 L3 L4 L5 S1 S2\n (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)\nR SILT SILT SILT SILT SILT SILT \nL SILT SILT SILT SILT SILT SILT \n\nMotor:\nUE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)\nR 5 5 5 5 5 5 5\nL 5 5 5 5 5 5 5\n\n___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___\nR 5 5 5 5 5 5 5 \nL 5 5 5 5 5 5 5\n\nReflexes \n Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1)\nR 2 2 2 2 2\nL 2 2 2 2 2\n \n___: Negative\nBabinski: Downgoing\nClonus: No beats\n\n \nPertinent Results:\nIMAGING:\nMR THORACIC SPINE W/O CONTRAST; MR ___ SPINE W/O CONTRAST ___\nIMPRESSION:\n1. Severe central canal narrowing at L4-5 level from \ndegenerative changes.\n2. Large right paramedian, superior disc extrusion L4-5 level, \nextends into\nright L4 lateral recess, mass effect on exiting right L4, \ntraversing L5\nnerves, severe right L4-5 foraminal narrowing..\n3. Advanced degenerative changes lumbar spine.\n4. Moderate central canal narrowing L2-L3, moderate to severe at \nL3-L4 levels.\n5. Multilevel significant foraminal narrowing lumbar spine, as \nabove.\n6. Degenerative changes thoracic spine, mild-to-moderate central \ncanal\nnarrowing, foraminal narrowing.\n\nCT ABD & PELVIS WITH CONTRAST ___\nIMPRESSION:\n \n1. No acute CT findings in the abdomen or pelvis to correlate \nwith patient's\nreported symptoms. Specifically, no evidence of obstructive \nrenal stone or\npyelonephritis.\n2. Sigmoid diverticulosis without evidence of acute \ndiverticulitis.\n\nAdmission Labs:\n___ 12:49PM BLOOD WBC-6.3 RBC-3.97 Hgb-11.9 Hct-37.2 MCV-94 \nMCH-30.0 MCHC-32.0 RDW-14.3 RDWSD-49.1* Plt ___\n___ 12:49PM BLOOD ___ PTT-34.3 ___\n___ 12:49PM BLOOD Glucose-117* UreaN-11 Creat-0.8 Na-143 \nK-4.3 Cl-106 HCO3-26 AnGap-11\n\n___ 10:06AM BLOOD WBC-5.8 RBC-2.81* Hgb-8.5* Hct-26.1* \nMCV-93 MCH-30.2 MCHC-32.6 RDW-14.0 RDWSD-47.6* Plt ___\n___ 05:53AM BLOOD WBC-6.6 RBC-2.88* Hgb-8.9* Hct-27.6* \nMCV-96 MCH-30.9 MCHC-32.2 RDW-14.4 RDWSD-50.4* Plt ___\n___ 04:30AM BLOOD WBC-6.9 RBC-3.40* Hgb-10.2* Hct-32.6* \nMCV-96 MCH-30.0 MCHC-31.3* RDW-14.4 RDWSD-50.3* Plt ___\n___ 10:06AM BLOOD Plt ___\n___ 04:30AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-142 \nK-4.8 Cl-105 HCO3-25 AnGap-12\n___ 04:30AM BLOOD Glucose-147* UreaN-12 Creat-0.9 Na-142 \nK-4.8 Cl-99 HCO3-28 AnGap-15\n___ 08:49AM BLOOD Glucose-128* UreaN-10 Creat-0.9 Na-141 \nK-4.3 Cl-102 HCO3-28 AnGap-11\n___ 04:30AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.0\n___ 08:49AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.1\n___ 04:30AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.1\n \nBrief Hospital Course:\nInitial Admission: \nACTIVE ISSUES:\n==================\n# R Low Back pain and Leg Pain\n# Radiculopathy\nPatient presents with severe right lower back pain with \nprominent\nlancinating component. CT A/P with no evidence of visceral\npathology or nephrolithiasis. MRI L spine with significant disc\nbulge at L2-L3 and L3-4 cause severe narrowing of the spinal\ncanal and extrusion at L4-5 with significant L4 nerve root\ncompression, likely the cause of patient's pain. She was \nrecently\nadmitted with right leg pain, with exam notable for trochanteric\nbursitis, now s/p injection of corticosteroid. Currently\nneruovascularly intact, with no evidence of cord compression by\nhistory or on exam. Per ortho spine, would benefit from\ndecompression. She had a DECOMPRESSION L2-S1, FUSION L4-L5, \nDURAPLASTY on ___ w/ ortho-spine once her INR was 1.2. She \nwas started on a heparin bridge on ___ when her INR dropped \nbelow 2.0 and transitioned to lovenox bridge to coumadin on \n___\n\n# Dysuria (resolved)\n# UTI\nStates she has been having burning pain with urination recently.\nShe also feels that she needs to push on her abdomen to urinate.\nMost concerning for UTI. UA demonstrating large leukocytes and 8\nWBC. However, urine culture showing mixed bacterial flora\nconsistent with contamination. Will treat given symptoms.\nAbdominal pain could also be from constipation in the setting of\nopioid use. Reports resolution of symptoms on ___. Was treated \nwith bactrim DS BID for 3 days starting ___ and ending ___. \n\nCHRONIC ISSUES:\n===================\n# History of DVT/PE\n# Antiphospholipid antibody syndrome:\nLupus anticoagulant positive in ___. Had bilateral PE in ___.\nShe has been taking her home dose of warfarin (7.5 mg ___ and \n5\nmg other days). Warfarin held on admission for procedure with \nheparin drip until procedure. \n\n# AAA\nHas a reported history of AAA in chart, but does not follow up\nwith anyone for surveillance and CT abd/pelvis did not show an\nabdominal aortic aneurysm.\n\n# Vitamin D deficiency:\n- Continued Vitamin D ___ daily\n\n# OSA\n- Remained on CPAP \n\n#Other Home Meds:\n- Continued omeprazole 20mg BID for GERD\n- Continued sertraline 150mg PO daily for depression\n- Continued Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough,\nwheeze\n- Held ProAir\n- Held trazadone while getting opioids\n- Held furosemide 20mg PO daily PRN: takes rarely \n- d/c gabapentin: not helping and not taking\n- d/c erythromycin- no longer taking\n\nAdmission to Ortho spine:\n\nMs. ___ is a ___ female with a past medical \nhistory significant for OSA, cerebral aneurysm, abdominal aortic \naneurysm, antiphospholipid syndrome w/ multiple DVTs and one \nevent of bilateral large PEs on warfarin, BRCA1 mutation w/\nL-sided breast cancer s/p lumpectomy, who presents with over one \nmonth of right lower back pain with radicular pain down the \nright leg pain found to have significant disc herniations at \nL2-L5. She is now s/p L2-5 lami, L4-5 discectomy, and \nnon-instrumented fusion c/b durotomy s/p ___, ___\n \n\nPost op course: \nPatient was admitted to the ___ Spine Surgery Service and \ntaken to the Operating Room for the above procedure.Refer to the \ndictated operative note for further details.The surgery was \nwithout complication and the patient was transferred to the PACU \nin a stable condition.\n\nPostoperative DVT ___ drip post \nop with trasition back to lovenox bridge to coumadin on ___. \nActivity remained flat/bedrest for dural tear precautions for 48 \nhours. \n\nActivity was advanced after 48 hours. Intravenous antibiotics \nwere continued for 24hrs postop per standard protocol.\n\nInitial postop pain was controlled with oral and IV pain \nmedication.Diet was advanced as tolerated.Foley was removed on \nPOD#3. Physical therapy and Occupational therapy were consulted \nfor mobilization OOB to ambulate and ADL's.\n\nPost op course was notable for acute blood loss anemia, \nconstipation, pain and hypokalemia. Acute blood loss anemia is \nstable and did not require intervention. She was treated with \nImmediate release morphine, Valium and Tylenol for pain control. \nOral Potassium was given for hypokalemia of 3.3 on ___. Vitals \nand labs are otherwise stable. \n\nHospital course was otherwise unremarkable.On the day of \ndischarge the patient was afebrile with stable vital signs, \ncomfortable on oral pain control and tolerating a regular diet.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze \n3. Atorvastatin 40 mg PO QPM \n4. Docusate Sodium 100 mg PO BID \n5. Omeprazole 20 mg PO BID \n6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n7. Senna 8.6 mg PO HS \n8. Sertraline 150 mg PO DAILY \n9. TraZODone 50 mg PO QHS:PRN sleep \n10. Vitamin D ___ UNIT PO DAILY \n11. Warfarin 7.5 mg PO 2X/WEEK (___) \n12. Lidocaine 5% Patch 1 PTCH TD QAM right hip \n13. Furosemide 20 mg PO DAILY:PRN Leg swelling \n14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n15. Warfarin 5 mg PO 5X/WEEK (___) \n16. Gabapentin 600 mg PO TID \n17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Diazepam 5 mg PO Q8H:PRN pain/spasm \nmay cause drowsiness \nRX *diazepam 5 mg 1 tablet by mouth every eight (8) hours Disp \n#*25 Tablet Refills:*0 \n2. Enoxaparin Sodium 110 mg SC Q12H Antiphospholipid Syndrome \nTreatment Bridge Dosing \n3. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Severe \nplease do not operate heavy machinery, drink alcohol or drive \nRX *morphine 15 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*30 Tablet Refills:*0 \n4. Furosemide 10 mg PO DAILY:PRN Leg swelling \n5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN cough, wheeze \n7. Atorvastatin 40 mg PO QPM \n8. Docusate Sodium 100 mg PO BID \n9. Lidocaine 5% Patch 1 PTCH TD QAM right hip \n10. Omeprazole 20 mg PO BID \n11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n13. Senna 8.6 mg PO HS \n14. Sertraline 150 mg PO DAILY \n15. TraZODone 50 mg PO QHS:PRN sleep \n16. Vitamin D ___ UNIT PO DAILY \n17. Warfarin 5 mg PO 5X/WEEK (___) \n18. Warfarin 7.5 mg PO 2X/WEEK (___) \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n-Lumbar spinal stenosis.\n-Spondylolisthesis, L4-L5.\n-UTI\n-Constipation\n\nSecondary Diagnoses:\n- History of DVT/PE\n- Antiphospholipid antibody syndrome\n- AAA\n- OSA on CPAP \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:\nIt was a pleasure to care for you at the ___ \n___. \n\nWhy did you come to the hospital? \n- You came to the hospital because you were having worsening \nback pain with pain radiating down your right leg. This pain \nstarted about a month ago and progressively got worse, making it \ndifficult to walk. You also had burning pain with urination.\n\nWhat did you receive in the hospital? \n- You had an MRI that showed significant disc herniation in your \nlower back, which was the cause of your pain. The spine surgeons \nfelt that you would benefit from surgery given that your pain \nwas constant and worsening over the past month. We gave you pain \nmedications and stopped your warfarin until it was safe for you \nto have surgery. You had a spinal decompression on ___. We \nalso gave you antibiotics for your burning pain with urination, \nwhich we believe was caused by a urinary tract infection. \n\nWhat should you do once you leave the hospital? \n\nLumbar Decompression With Fusion:\n\nYou have undergone the following operation: Lumbar Decompression \nWith Fusion\n\nImmediately after the operation:\n\n• Activity:You should not lift anything greater \nthan 10 lbs for 2 weeks.You will be more comfortable if you do \nnot sit or stand more than~45 minutes without getting up and \nwalking around.\n\n• Rehabilitation/ Physical ___ times a \nday you should go for a walk for ___ minutes as part of your \nrecovery.You can walk as much as you can tolerate.Limit any kind \nof lifting.\n\n• Diet: Eat a normal healthy diet.You may have \nsome constipation after surgery.You have been given medication \nto help with this issue.\n\n• Brace:You may have been given a brace.If you \nhave been given a brace,this brace is to be worn when you are \nwalking.You may take it off when sitting in a chair or while \nlying in bed.\n\n• Wound Care:Please keep the incision covered \nwith a dry dressing on until your follow up appointment. Do not \nsoak the incision in a bath or pool.If the incision starts \ndraining at anytime after surgery,do not get the incision \nwet.Call the office at that time.\n\n• You should resume taking your normal home \nmedications.\n\n• You have also been given Additional Medications \nto control your pain.Please allow 72 hours for refill of \nnarcotic prescriptions,so please plan ahead.You can either have \nthem mailed to your home or pick them up at the clinic located \non ___.We are not allowed to call in or fax narcotic \nprescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In \naddition,we are only allowed to write for pain medications for \n90 days from the date of surgery.\n\n• Follow up:\n\n Please Call the office and make an appointment \nfor 2 weeks after the day of your operation if this has not been \ndone already.\n\n At the 2-week visit we will check your \nincision,take baseline X-rays and answer any questions.We may at \nthat time start physical therapy\n\n We will then see you at 6 weeks from the day of \nthe operation and at that time release you to full activity.\n\nPlease call the office if you have a fever>101.5 degrees \nFahrenheit and/or drainage from your wound.\n\nPhysical Therapy:\n1)Weight bearing as tolerated.2)Gait,balance training.3)No \nlifting >10 lbs.4)No significant bending/twisting. \nTreatments Frequency:\nPlease keep the incision covered with a dry dressing on until \nyour follow up appointment. Do not soak the incision in a bath \nor pool.If the incision starts draining at anytime after \nsurgery,do not get the incision wet.Call the office at that \ntime.\n \nFollowup Instructions:\n___\n" ]

[ "M5116", "D6861", "N390", "D62", "I83811", "D509", "Z87891", "Z86711", "Z7901", "E559", "C50912", "E785", "G4733", "E119", "K219", "K5790", "F329", "J449", "I671", "M48061", "K5900", "E876" ]

[ "M5116: Intervertebral disc disorders with radiculopathy, lumbar region", "D6861: Antiphospholipid syndrome", "N390: Urinary tract infection, site not specified", "D62: Acute posthemorrhagic anemia", "I83811: Varicose veins of right lower extremity with pain", "D509: Iron deficiency anemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "E559: Vitamin D deficiency, unspecified", "C50912: Malignant neoplasm of unspecified site of left female breast", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E119: Type 2 diabetes mellitus without complications", "K219: Gastro-esophageal reflux disease without esophagitis", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "F329: Major depressive disorder, single episode, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "I671: Cerebral aneurysm, nonruptured", "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "K5900: Constipation, unspecified", "E876: Hypokalemia" ]

[ "N390", "D62", "D509", "Z87891", "Z7901", "E785", "G4733", "E119", "K219", "F329", "J449", "K5900" ]

[]

[ " \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:\nHeadaches\n \nMajor Surgical or Invasive Procedure:\n___ - Suboccipital craniotomy for resection of cerebellar \nlesion\n\n \nHistory of Present Illness:\n___ is a ___ female with hx cerebral aneurysm \nclipping in ___ who presents from OSH with left cerebellar \nhypodensity concerning for underlying lesion. Patient reports \nthat three weeks ago she started having headaches, which is \nabnormal for her. She describes the headaches to be global and \nresolve with Tylenol, but at the worst was an ___. She also \nreports having difficulty walking, which also started about \nthree weeks ago. She describes her walking as \"staggering side \nto side.\" She denies any vision changes, nausea, vomiting, \nconfusion, or word finding difficulty. She saw her eye doctor \nthis morning for routine visit, who referred her to the ED for \nevaluation of these symptoms. OSH CT showed an area of \nhypodensity in the left cerebellum, concerning for underlying \nlesion. She was subsequently transferred to ___. \n\nOf note, patient reports her aneurysm clip is not MRI \ncompatible.\n\n \nPast Medical History:\n- ___ \n- Hypertension \n- S/p aneurysm clipping ___ at ___ by Dr. ___\n \nSocial History:\n___\nFamily History:\nNo known history of stroke, cancer, aneurysm. \n\n \nPhysical Exam:\nON ADMISSION: \nO: T: 97.9 BP: 130/62 HR: 64 R 16 O2Sats 98% RA\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: L ___, R ___ EOMs full\nNeck: Supple.\nExtrem: Warm and well-perfused.\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: Left pupil 5-4mm, right 4-3mm, both equally reactive to\nlight. \nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\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. Slight left upward \ndrift\n\nSensation: Intact to light touch\n\nCoordination: normal on finger-nose-finger and heel to shin\n\n======================================================\n\nON DISCHARGE: \nExam:\n\nOpens eyes: [x]Spontaneous [ ]To voice [ ]To noxious\n\nOrientation: [x]Person [x]Place [x]Time\n\nFollows commands: [ ]Simple [x]Complex [ ]None\n\nPupils: Right 4-3mm Left 5-4mm - chronic\n\nEOM: [ ]Full [x]Restricted - chronic, most prominent left \nlateral\n\nFace Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No\n\nPronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No\n\nComprehension Intact: [x]Yes [ ]No\n\nMotor:\nTrapDeltoid BicepTricepGrip\nRight 5 5 5 5 5\nLeft 5 5 5 5 5\n\nIPQuadHamATEHLGast\nRight5 5 5 5 5 5\nLeft5 5 5 5 5 5\n\n[x]Sensation intact to light touch\n\n \nPertinent Results:\nPlease see OMR for pertinent lab and imaging results.\n \nBrief Hospital Course:\n#Brain lesion\nPatient was found to have cerebellar hypodensity on NCHCT from \nOSH. CT w/wo contrast was obtained while in the ED at ___ \nwhich was concerning for underlying mass lesion and \nhydrocephalus. (Of note, she was unable to get MRI due to \nreportedly having a non-compatible aneurysm clip that was placed \nin ___ at ___. Patient was admitted to the ___ for close \nmonitoring and surgical planning. She was started on \ndexamethasone 4mg Q6hr for mass effect. CT torso was obtained \nwhich showed two lung nodules, see below for more information. \nNeuro and radiation oncology were consulted. Plan was made for \nsurgical resection of the lesion. On ___, it was determined \nthat her aneurysm clip was MRI compatible and she was able to \nhave a MRI Brain for surgical planning. She went to the OR the \nevening of ___ for a suboccipital craniotomy for resection of \nher cerebellar lesion. Postoperatively she was monitored in \nNeuro ICU, where she remained neurologically and hemodynamically \nstable. She was transferred to the ___ on POD#2 and made floor \nstatus. Her Dexamethasone was ordered to taper down to a \nmaintenance dose of 2mg BID over the course of one week. Her \npathology finalized as small cell lung carcinoma. \n\n#Lung lesions\nCT torso was obtained which showed two lung nodules, one in the \nleft paramedian abutting the aortic arch and the other in the \nright upper lobe. Pulmonary was consulted and stated that no \nfurther intervention was indicated until final pathology was \nback. Heme-Onc was also consulted, and made recommendations that \nno further lung imaging or separate lung biopsy was needed. Both \nPulmonary and Heme-Onc stated that staging and treatment could \nbe determined based on the tissue pathology from resection of \nthe brain lesion. Her final pathology came back as small cell \nlung carcinoma. She will follow-up with the thoracic oncologist \non ___. \n\n#Steroid-induced hyperglycemia\nThroughout her admission, the patient intermittently required \nsliding scale Insulin for elevated blood sugars while on \nDexamethasone. She was evaluated by the ___ inpatient team on \n___, who decided that she did not need to go home on Insulin. \nThey recommended discharging her with a glucometer so that she \ncould check her blood sugars daily with a goal blood sugar less \nthan 200. She was advised to record her readings and follow-up \nwith her PCP and ___. \n\n#Bradycardia\nShe was due to transfer out to the ___ on POD1, however was \nkept in the ICU for asymptomatic bradycardia to the ___. She \nremained asymptomatic, and her heartrate improved with fluids, \nand administration of her levothyroxine. She intermittently \ndipped to the ___, however remained asymptomatic.\n\n#Bell's palsy\nThe patient was resumed on her home Valacyclovir and Prenisolone \ngtts. \n\n#Urinary urgency\nOn POD 2, the patient complained of urinary urgency and \nincreased frequency. U/A was negative and culture was negative. \nHer symptoms had resolved at the time of discharge.\n\n#Dispo \nThe patient was evaluated by ___ and OT who cleared her for home \nwith services. She was discharged on ___ in stable condition. \nShe will follow up in ___ on ___. \n \nMedications on Admission:\n- ASA 81mg\n- Alendronate 70mg weekly\n- Vitamin D3 ___ units daily\n- Levothyroxine 88mcg daily\n- Lisinopril 20mg daily\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Bisacodyl 10 mg PO/PR DAILY \n3. Dexamethasone 3 mg PO Q8H Duration: 6 Doses \nstart ___: 3tabsq8hrs x2, 2tabsq8hrs x6, 2tabsq12hrs \nmaintenance dose. \nThis is dose # 2 of 3 tapered doses\nRX *dexamethasone 1 mg 3 tablet(s) by mouth every eight (8) \nhours Disp #*120 Tablet Refills:*1 \n4. Docusate Sodium 100 mg PO BID \n5. Famotidine 20 mg PO Q24H \nRX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*1 \n6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n7. Senna 17.2 mg PO HS \n8. Levothyroxine Sodium 88 mcg PO DAILY \n9. Lisinopril 20 mg PO DAILY \n10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID \n11. ValACYclovir 1000 mg PO Q8H \n12. Vitamin D ___ UNIT PO DAILY \n13. HELD- Alendronate Sodium 70 mg PO 1X/WEEK (___) This \nmedication was held. Do not restart Alendronate Sodium until POD \n___ - ___\n14. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until POD 14 - ___\n___ glucometer\n___ Freestyle glucometer. Check blood sugars ___ hours after a \nstarchy meal. Record numbers and show to your Oncologist. \n___ test strips\n#50. Check blood sugars QD. 3 refills. \n___ Lancets\n#50. Check blood sugars QD. 3 refills. \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nBrain tumor\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid.\n\n \nDischarge Instructions:\nSurgery:\n\n- You underwent surgery to remove a brain lesion from your \nbrain. \n\n- A sample of tissue from the lesion in your brain was sent to \npathology for testing. \n\n- Please keep your incision dry until your sutures are removed. \n\n- You may shower at this time but keep your incision dry.\n\n- It is best to keep your incision open to air but it is ok to \ncover it when outside. \n\n- Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity:\n\n- We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n\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\n- No driving while taking any narcotic or sedating medication. \n\n- If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n\n- No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications:\n\n- Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \nWe held your Aspirin 81mg daily. You are cleared to resume this \nmedication on POD 14 (___). \n\n- We held your home Alendronate during this admission. You are \ncleared to resume this medication on POD 14 (___). \n\n- You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\n- You were started on Dexamethasone, a steroid that treats \nintracranial swelling. This Dexamethasone is being tapered down \nto a maintenance dose of 2mg BID. Please take this medication as \nprescribed.\n\n- While admitted, you had elevated blood glucose levels that \nneeded to be treated by Insulin. You should continue to check \nyour blood sugars daily at home with the prescribed glucometer. \nYou visiting nurse should teach you how to use this device at \nhome. Please record your blood sugars and follow-up with your \nPCP and ___ regarding the results. Your goal blood sugar \nis less than 200. \n\nWhat You ___ Experience:\n\n- You may experience headaches and incisional pain. \n\n- You may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n\n- You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n\n- Feeling more tired or restlessness is also common.\n\n- Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n\n- Severe pain, swelling, redness or drainage from the incision \nsite. \n\n- Fever greater than 101.5 degrees Fahrenheit\n\n- Nausea and/or vomiting\n\n- Extreme sleepiness and not being able to stay awake\n\n- Severe headaches not relieved by pain relievers\n\n- Seizures\n\n- Any new problems with your vision or ability to speak\n\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\n- Sudden numbness or weakness in the face, arm, or leg\n\n- Sudden confusion or trouble speaking or understanding\n\n- Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n\n- Sudden severe headaches with no known reason\n\n \nFollowup Instructions:\n___\n" ]

[ "C7931", "G935", "G936", "G911", "C3490", "F05", "I10", "F17210", "G510", "M21372", "E039", "M810", "Z781", "R001", "R739", "T380X5A", "Y92239", "D72829", "R3915" ]

[ "C7931: Secondary malignant neoplasm of brain", "G935: Compression of brain", "G936: Cerebral edema", "G911: Obstructive hydrocephalus", "C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung", "F05: Delirium due to known physiological condition", "I10: Essential (primary) hypertension", "F17210: Nicotine dependence, cigarettes, uncomplicated", "G510: Bell's palsy", "M21372: Foot drop, left foot", "E039: Hypothyroidism, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "Z781: Physical restraint status", "R001: Bradycardia, unspecified", "R739: Hyperglycemia, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "D72829: Elevated white blood cell count, unspecified", "R3915: Urgency of urination" ]

[ "I10", "F17210", "E039" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nmeropenem / Penicillins\n \nAttending: ___.\n \nChief Complaint:\nBRBPR\n \nMajor Surgical or Invasive Procedure:\naborted flexible sigmoidoscopy attempt (due to stool in vault) \n___\nFlexible sigmoidoscopy ___\n\n \nHistory of Present Illness:\nThis is an ___ year old female with past medical history of\nsjogrens, hypothyroidism, recent diagnosis of L1 compression\nfracture, prior cdiff infection, presenting with bright red \nblood\nper rectum. Patient reports that on morning of presentation, \nshe\nawoke in her normal state of health. Her home health aid helped\nher to the commode and she suddenly had a large volume over \nblood\nper rectum. Over the next ___ minutes she then had 2 subsequent\nepisodes. Home health aid consulted with family and then called\n___. \n\nIn the ED VS were 97.2 98 158/89 14 98%RA ___ 99. Labs were\nnotable for WBC 10.1, Hgb 9.8, Plt 245; K 4.4, Cr 0.6; lactate\n1.0; UA neg leuk, nitr. Exam reported as tachycardia, grossly\nblood rectum without large hemorrhoids. PEG lavage reported as\nnegative for blood.\n\nGI note on the ED dashboard stated ___ with C.diff on flagyl,\npresenting with maroon colored GIB. HDS. HCT 30.7 with normal\nCoag. Please continue with supportive care with fluids and\ntransfusion as needed. If on-going bleeding or hemodynamic\nchanges, please get CTA. If concern of upper GI bleeding, can\nlavage via PEG. Please give PPI if positive.\"\n\nPatient was given 1L normal saline and was admitted to medicine.\nOn arrival to the floor patient reported above. Reported recent\ndiagnosis of L1 compression fracture and intermittent difficulty\nwith flushing her PEG tube at home. Full 10 point review of\nsystems positive where noted, otherwise negative. \n\n \nPast Medical History:\nSjogrens\nHypothyroidism\nh/o severe Cdiff\nProtein calorie malnutrition s/p PEG\nOsteoporosis s/p L1 compression fracture\nDepression\nHemorrhoids\nNormocytic anemia \nBronchiectasis \nh/o Shingles \nDementia (___ ___ \nMitral regurgitation \n \nSocial History:\n___\nFamily History:\nHas 2 children. Father had hemorrhoids. No history of cancer,\nGI bleeding. \n \nPhysical Exam:\nADMISSION\nVS: 187-106 (128/78 on recheck) 112 16 96%RA\nGen - supine in bed, comfortable, pale\nEyes - EOMI\nENT - OP clear, MMM\nHeart - regularly tachycardic; II/VI systolic murmur loudest at\naxilla; \nLungs - CTA bilaterally\nAbd - soft nontender, normoactive bowel sounds; PEG in place\nRectum - dark maroon blood in vault, no large hemorrhoids\npalpated\nExt - trace edema to mid-shin\nSkin - +pale; no rashes\nVasc - 2+ DP/radial pulses\nNeuro - AOx2-3 (full name, ___\", ___,\nmoving all extremities\nPsych - appropriate\n\nDISCHARGE\nVS: 98.1 135/64 103 20 95%RA\nGen - supine in bed, comfortable appearing\nEyes - EOMI\nENT - OP clear, MMM\nHeart - RRR, II/VI systolic murmur loudest at axilla; \nLungs - CTA bilaterally, unchanged from day prior\nAbd - soft nontender, normoactive bowel sounds; PEG in place; \nunchanged from yesterday \nExt - no edema \nSkin - no rashes\nVasc - 2+ DP/radial pulses\nNeuro - AOx3 (full name, ___, ___, \nmoving all extremities\nPsych - appropriate\n \nPertinent Results:\nADMISSION\n___ 10:37AM BLOOD WBC-10.1* RBC-3.15* Hgb-9.8* Hct-30.7* \nMCV-98 MCH-31.1 MCHC-31.9* RDW-13.6 RDWSD-48.4* Plt ___\n___ 10:37AM BLOOD Glucose-96 UreaN-27* Creat-0.6 Na-136 \nK-4.4 Cl-97 HCO3-30 AnGap-13\n___ 06:00AM BLOOD ALT-12 AST-19 AlkPhos-81 TotBili-0.3\n\nDISCHARGE\n___ 06:20AM BLOOD WBC-8.9 RBC-3.35* Hgb-10.5* Hct-32.7* \nMCV-98 MCH-31.3 MCHC-32.1 RDW-13.4 RDWSD-47.7* Plt ___\n___ 06:20AM BLOOD Glucose-106* UreaN-18 Creat-0.7 Na-137 \nK-3.8 Cl-100 HCO3-28 AnGap-13\n\nFlexible Sigmoidoscopy - ___\nMucosa: Normal mucosa was noted in the rectum and sigmoid colon. \n \nOther No bleeding sources or blood identified, though extent of \nsigmoid colon evaluated was limited by poor prep. \nImpression: Normal mucosa in the rectum and sigmoid colon\nNo bleeding sources or blood identified, though extent of \nsigmoid colon evaluated was limited by poor prep.\nOtherwise normal sigmoidoscopy to sigmoid colon at 25 cm \nRecommendations: If bleeding recurs, would recommend full \ncolonoscopy with prep. \n\n \nBrief Hospital Course:\nThis is an ___ year old female with past medical history of \nsjogrens, hemorrhoids, prior cdiff infection, admitted ___ \nwith bright red blood per rectum thought to be acute lower GI \nbleed, subsequently stabilizing without intervention, status \npost flexible sigmoidoscopy without identifiable source, \nremaining stable x greater than 4 days, able to be discharged to \nrehab facility.\n\n# Acute GI Bleed NOS - Patient presented with acute episode of \nBRBPR concerning for lower GI source. Patient subsequently \nmonitored without new or worsening anemia. After discussion \nwith family and patient regarding whether or not to further \nworkup, they opted for flexible sigmoidoscopy (felt colonoscopy \nmight be too invasive). Patient underwent aborted flexible \nsigmoidoscopy on ___ due to pressence of copious stool in \nrectal vault, and then underwent successful flexible \nsigmoidoscopy on ___ without identifiable source for her \nbleeding. From admission Hgb 9.8, discharge hemoglobin was \n10.5. Per GI, could consider outpatient colonoscopy if \nconsistent with patient's wishes. \n\n# Osteoporosis / chronic L1 compression fracture / \ndeconditioning - patient with recent L1 compression fracture as \noutpatient prior to admission; patient noted to be significantly \ndeconditioned this admission, requiring assistance with ADLs; \npatient seen by ___ and recommended for rehab. Continued home \nCalcium 500 + vitamin D, calcitonin. Placed on Tylenol and \ntramadol for pain control with good effect \n\n# Chronic Severe Protein Calorie Malnutrition - per discussion \nwith family and review of chart, patient has lost weight despite \nPEG placement and bolus tube feeds (has had difficulty \nmaintaining PO intake due to her Sjogrens). At home patient has \nnot be using full recommended 2 cans of Nutren 2.0, 500 \nCal/250ml BID. Here patient seen by nutrition, continued on \nabove 2 cans, and was given oral supplementation with her PO \nmeals as well. \n\n# Depression - continued home BuPROPion and mirtazapine \n\n# Hypothryoidism - continued levothyroxine \n\nTransitional Issues\n- Code status - DNR/DNI\n- Discharged to rehab\n- No source for bleeding identified this admission; can consider \nfuture colonoscopy to look for source of bleeding, but would \nfirst discuss if consistent with patient's goals of care\n- Would consider encouragement of PO intake and PEG-tube \nsupplementation given her malnutrition \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BuPROPion XL (Once Daily) 150 mg PO DAILY \n2. Calcium 500 + D (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -400 unit oral DAILY \n3. Levothyroxine Sodium 75 mcg PO DAILY \n4. Mirtazapine 30 mg PO QHS \n5. TraMADol 50 mg PO BID:PRN back pain \n6. Acetaminophen 500 mg PO Q6H:PRN back pain \n7. Alendronate Sodium 70 mg PO QSUN \n8. Calcitonin Salmon 200 UNIT NAS DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. TraMADol 100 mg PO QHS:PRN back pain \n11. Artificial Tears ___ DROP BOTH EYES QID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN pain \n2. BuPROPion XL (Once Daily) 150 mg PO DAILY \n3. Calcitonin Salmon 200 UNIT NAS DAILY \n4. Levothyroxine Sodium 75 mcg PO DAILY \n5. Mirtazapine 30 mg PO QHS \n6. Multivitamins 1 TAB PO DAILY \n7. TraMADol 50 mg PO BID:PRN back pain \n8. Alendronate Sodium 70 mg PO QSUN \n9. Calcium 500 + D (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -400 unit oral DAILY \n10. TraMADol 100 mg PO QHS:PRN back pain \n11. Artificial Tears ___ DROP BOTH EYES QID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n# Acute GI Bleed NOS \n# Depression\n# Osteoporosis / chronic L1 compression fracture\n# Hypothryoidism\n# Chronic Severe Protein Calorie Malnutrition\n# Dementia\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nMs. ___: \n\nIt was a pleasure caring for you at ___. You were admitted \nwith gastrointestinal bleeding. You were seen by GI specialists \nand underwent a flexible sigmoidiscopy without signs of a source \nof your bleeding. You were monitored and your blood levels were \nstable. You are now ready for discharge home.\n\nIn the future you may wish to consider a colonoscopy to look for \nthe source of your bleeding, especially if it occurs again. You \nshould discuss with your family and primary care doctor \nregarding if this is within your goals of care.\n \nFollowup Instructions:\n___\n" ]

[ "K922", "E43", "M8008XA", "F0390", "Z681", "R000", "I10", "F329", "E039", "Z66", "Z931", "M3500", "Z5309", "I340" ]

[ "K922: Gastrointestinal hemorrhage, unspecified", "E43: Unspecified severe protein-calorie malnutrition", "M8008XA: Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture", "F0390: Unspecified dementia without behavioral disturbance", "Z681: Body mass index [BMI] 19.9 or less, adult", "R000: Tachycardia, unspecified", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "Z66: Do not resuscitate", "Z931: Gastrostomy status", "M3500: Sicca syndrome, unspecified", "Z5309: Procedure and treatment not carried out because of other contraindication", "I340: Nonrheumatic mitral (valve) insufficiency" ]

[ "I10", "F329", "E039", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nCorgard / Vasotec\n \nAttending: ___\n \nChief Complaint:\nleg edema\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS: \n Mr. ___ is an ___ year old gentleman with history of CAD \n(s/p 3V CABG ___, LM PCI ___, pulmonary HTN, AFib on \nanticoagulation, ___ (EF 50%) who presents with volume overload \nand new found RV dilation on office echocardiogram. \n Patient reports he has had 10 days of waking up feeling nervous \nand jittery. He also endorses weight gain, and new onset lower \nextremity swelling. He has not had chest pain, palpitations, \northopnea, or PND. He has not had any fevers, cough, recent \ntravel, medication non compliance, increased salty food intake. \nHe also has not had dyspnea on exertion and rides 4 miles per \nday on a stationary bike and does 6 minutes of weight lifting. \n He presented to Dr. ___ today for evaluation. There \nhe had a TTE that showed new RV dilation and was referred to the \n___ ED for further evaluation with concern for pulmonary \nembolism. \n \n In the ED, initial vitals were: \n T98. HR 70, BP 166/65, RR 16, 100% RA. \n Exam in ED notable for bilateral pitting edema to knees. Labs \nnotable for mild hyponatremia, Cr 1.1. ALT/AST mildly elevated \nat 81/64. WBC 4, Hgb 11.3, INR 1.3. DDimer <150. UA \nunremarkable. \n CXR with mild cardiomegaly but no evidence of consolidation or \npulmonary edema. CTA was negative for PE, showed severe \nemphysema and dilated pulmonary artery. \n Patient received 20 mg IV Lasix with significant urine output \nper patient. He was then admitted to the heart failure service \nfor acute heart failure exacerbation and further workup of RV \ndilation. \n Vitals on transfer: Afebrile, HR 66, BP 129/54, RR 19, 95%RA. \n \n On review of systems, he denies any prior history of stroke, \nTIA, deep venous thrombosis, pulmonary embolism, bleeding at the \ntime of surgery, myalgias, joint pains, cough, hemoptysis, black \nstools or red stools. He denies recent fevers, chills or rigors. \nHe denies exertional buttock or calf pain. All of the other \nreview of systems were negative. \n \n Cardiac review of systems is notable for absence of chest pain, \nparoxysmal nocturnal dyspnea, orthopnea, palpitations, syncope \nor presyncope. \n \n\n \nPast Medical History:\nPast Medical History:\nBILATERAL MODERATE CAROTID DISEASE \nCONGESTIVE HEART FAILURE \nCORONARY ARTERY DISEASE \nGASTROESOPHAGEAL REFLUX \nHYPERTENSION \nSEVERE EMPHYSEMA \nPULMONARY HYPERTENSION \nRIGHT BUNDLE BRANCH BLOCK \nBENIGN PROSTATIC HYPERTROPHY \nHYPERLIPIDEMIA \nPAROXYSMAL ATRIAL FIBRILLATION \nH/O HISTIOPLASMOSIS \n\nPast Surgical History:\nCARDIOVERSION ___ \nRIGHT LOWER LOBE LOBECTOMY ___ \nCORONARY BYPASS SURGERY ___ \n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION\nVitals: 98 159/62 16 98% on RA weight 143 lbs (bed scale) \n General: very pleasant older gentleman lying in bed speaking in \nfull sentences in NAD \n HEENT: PERRL, EOMI, no scleral icterus, oropharynx clear \n Neck: supple, JVP at 6cm, no adenopathy \n CV: regular rate and rhythm, normal S1, physiologic split S2, \n___ systolic murmur at LLSB. No rubs or gallops. \n Lungs: CTAB, no crackles, wheezes, or rhonchi \n Abdomen: soft, non distended, non tender to deep palpation, +BS \n \n GU: no CVA tenderness, no foley \n Extr: warm, well perfused, 2+ pulses in radial and DP, 2+ edema \nin bilateral lower extremities to knees \n Neuro: aoxo3, CN2-12 grossly intact, moving all 4 extremities \nwithout deficit, stable gait \n Skin: warm, well perfused, dry, no rashes or lesions \n\nDISCHARGE\nVitals: 98.3 100-121/49-59 54-62 18 96RA\nTele: no tele\nLast 8 hours I/O: ___\nLast 24 hours I/O: 1200/3150\nWeight on admission: 64.3\nToday's weight: 63.1\n\nGeneral: elderly, NAD \nNeck: JVP at base of clavicle when 90 degrees\nLungs: CTAB no crackles\nCV: RRR, split S2\nAbdomen: slightly obese, soft, NTND, NABS\nExt: no edema\n \nPertinent Results:\nADMISSION\n___ 04:02PM BLOOD WBC-4.0 RBC-4.32* Hgb-11.3* Hct-35.1* \nMCV-81* MCH-26.2 MCHC-32.2 RDW-16.3* RDWSD-48.3* Plt ___\n___ 04:02PM BLOOD ___ PTT-35.8 ___\n___ 04:02PM BLOOD Glucose-93 UreaN-17 Creat-1.1 Na-131* \nK-3.8 Cl-93* HCO3-27 AnGap-15\n___ 04:02PM BLOOD ALT-81* AST-64* AlkPhos-89 TotBili-0.7\n___ 04:02PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-1284*\n___ 04:02PM BLOOD Albumin-4.2 Calcium-9.7 Mg-2.2\n___ 04:34PM BLOOD D-Dimer-<150\n___ 04:02PM BLOOD TSH-3.0\n\nDISCHARGE\n___ 04:04AM BLOOD WBC-6.5# RBC-4.57* Hgb-12.2* Hct-36.8* \nMCV-81* MCH-26.7 MCHC-33.2 RDW-16.4* RDWSD-47.8* Plt ___\n___ 04:04AM BLOOD ___ PTT-34.1 ___\n___ 04:04AM BLOOD Glucose-113* UreaN-32* Creat-1.4* Na-133 \nK-3.9 Cl-94* HCO3-26 AnGap-17\n___ 04:04AM BLOOD ALT-79* AST-57* AlkPhos-83 TotBili-0.6\n___ 04:04AM BLOOD Calcium-10.0 Phos-4.4 Mg-2.0\n\nECHO ___\nThe left atrium is moderately dilated. The right atrium is \nmoderately dilated. No atrial septal defect is seen by 2D or \ncolor Doppler. Left ventricular wall thicknesses and cavity size \nare normal. There is mild regional left ventricular systolic \ndysfunction with hypokinesis of the mid-anterior and mid-distal \ninferior wall. The estimated cardiac index is normal \n(>=2.5L/min/m2). Doppler parameters are indeterminate for left \nventricular diastolic function. The right ventricular cavity is \nmildly dilated with depressed free wall contractility (RV free \nwall is not well seen). The aortic valve leaflets (3) are mildly \nthickened but aortic stenosis is not present. The mitral valve \nleaflets are mildly thickened. There is no mitral valve \nprolapse. Trivial mitral regurgitation is seen. The tricuspid \nvalve leaflets are mildly thickened. Moderate [2+] tricuspid \nregurgitation is seen. There is moderate pulmonary artery \nsystolic hypertension. The pulmonic valve leaflets are \nthickened. There is no pericardial effusion. \n\nIMPRESSION: Mild regional left ventricular dysfunction c/w \nmultivessel CAD, with overall mildly depressed global systolic \nfunction. Mildly dilated right ventricle with depressed free \nwall systolic function. Moderate tricuspid regurgitation with \nmoderate pulmonary hypertension. \n \nBrief Hospital Course:\nMr. ___ is an ___ year old gentleman with history of CAD \n(s/p CABG and PCI), pAF, PAH, diastolic CHF who presents with \nweight gain, leg swelling and new evidence of right ventricle \ndilation concerning for acute on chronic heart failure \nexacerbation. \n\n#Acute on Chronic Diastolic Heart Failure Exacerbation: with \ncomponent of RV failure by report of OSH echo. Likely primary \nprocess is lung disease causing elevated RV pressures and \nsubsequent poor filling of LV. He diuresed quite well with 20 \nIV Lasix which is consistent with RV failure. Started on \ntorsemide 10 daily but this is likely too aggressive. We \nobtained an echo but read PND at time of discharge. We sent him \nhome on a diuretic regimen on torsemide 5 mg daily (and \ndiscontinued home triamterene-HCTZ). Close follow up with Dr. \n___ ensured.\n\n#Elevated Transaminases: Patient with mildly elevated AST and \nALT. Most likely etiologies in this patient include amiodarone \ntoxicity and congestive hepatopathy. Encouraged outpatient \ntrending. \n\n#Pulmonary disease: patient with extensive emphysema on CTA \nthough patient has no history of smoking. As this may be \ndriving R heart failure, Dr. ___ requested pulmonology \nconsult prior to discharge but patient was insistent on leaving. \n Instead scheduled outpatient appointment. \n \n#Atrial Fibrillation: Continue home amiodarone 200mg daily, \nApixaban 5mg BID \n\n#CAD: Continue ASA 81mg, rosuvastatin 40mg qHS \n\n#HTN: continue home losartan 25mg qD.\n\nTRANSITIONAL ISSUES\n[] New medication: Torsemide 5 mg daily\n[] Discontinued triamterene/HCTZ in favor of above\n[] LFTs mild elevated in house; consider possible \ndiscontinuing/changing amiodarone\n[] Please check LFT's and Creatinine at follow up appointment as \nthese were elevated while hospitalized\n[] Follow up appointment with cardiology, Dr. ___\n[] Follow up appointment with pulmonology\n[] Follow up appointment with PCP\n\n***Discharge weight 63.1 kg*** \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amiodarone 200 mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Losartan Potassium 25 mg PO DAILY \n6. Omeprazole 10 mg PO DAILY \n7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY \n8. Senna 17.2 mg PO HS \n9. Align (bifidobacterium infantis) 4 mg oral DAILY \n10. coenzyme Q10 100 mg oral DAILY \n11. Rosuvastatin Calcium 40 mg PO QPM \n12. Vitamin D 1000 UNIT PO DAILY \n13. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Medications:\n1. Amiodarone 200 mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Losartan Potassium 25 mg PO DAILY \n6. Rosuvastatin Calcium 40 mg PO QPM \n7. Senna 17.2 mg PO HS \nRX *sennosides [senna] 8.6 mg 1 capsule by mouth once a day Disp \n#*30 Capsule Refills:*0\n8. Vitamin D 1000 UNIT PO DAILY \n9. Torsemide 5 mg PO DAILY \nRX *torsemide 5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0\n10. Align (bifidobacterium infantis) 4 mg oral DAILY \n11. coenzyme Q10 100 mg oral DAILY \n12. Omeprazole 10 mg PO DAILY \n13. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nAcute on chronic diastolic congestive heart failure\nCor pulmonale\n\nSecondary:\nPulmonary hypertension\nParoxysmal atrial fibrillation\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 Mr. ___,\n\nYou were hospitalized for progressive leg swelling over the past \nweek and a half. We started you on a new medication here that \nshould help prevent this from happening. Of note, Dr. ___ was \nconcerned about a clot in your lungs, but our scans showed NO \nclot. With this news, you were discharged home with PCP and \ncardiology follow up.\n\nPlease continue to take your torsemide in order to maintain your \nweight. Please weight yourself everyday and call your \ncardiologist if you weight changes by three pounds.\n\nYou also have \"pulmonary hypertension,\" which may be due to your \nunderlying lung disease. Amiodarone can also cause lung changes \nand we recommend following up with the lung doctors as ___ \noutpatient to see if this may be contributing. \n\nIt was a pleasure taking care of you!\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "I5033", "I281", "I272", "I480", "E871", "J449", "I2781", "I2510", "K219", "I10", "N400", "E785", "Z902", "Z7982", "Z9861", "Z87891" ]

[ "I5033: Acute on chronic diastolic (congestive) heart failure", "I281: Aneurysm of pulmonary artery", "I272: Other secondary pulmonary hypertension", "I480: Paroxysmal atrial fibrillation", "E871: Hypo-osmolality and hyponatremia", "J449: Chronic obstructive pulmonary disease, unspecified", "I2781: Cor pulmonale (chronic)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E785: Hyperlipidemia, unspecified", "Z902: Acquired absence of lung [part of]", "Z7982: Long term (current) use of aspirin", "Z9861: Coronary angioplasty status", "Z87891: Personal history of nicotine dependence" ]

[ "I480", "E871", "J449", "I2510", "K219", "I10", "N400", "E785", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nCorgard / Vasotec\n \nAttending: ___.\n \nChief Complaint:\nDyspnea on Exertion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n ======================================================= \n ___ FAILURE ADMISSION NOTE \n ======================================================= \nOUTPATIENT CARDIOLOGIST: ___., MD ___\ncardiology), ___ ___., MD(CHF)\nPCP: ___., MD \n\nCHIEF COMPLAINT: Dyspnea on Exertion\nHISTORY OF PRESENTING ILLNESS: \nMr. ___ is a ___ gentleman with a past medical\nhistory pertinent for HFrEF (35% ___ CAD s/p CABG and\nsubsequent PCI, moderate tricuspid regurgitation, right\nventricular dysfunction, moderate pulmonary hypertension, and\nparoxysmal atrial fibrillation on apixaban, stage III chronic\nkidney disease (Baseline Cr 2.0-2.1), cerebrovascular disease,\nand metastatic melanoma of unknown primary on checkpoint\ninhibitor pembrolizumab who was found volume overloaded with\nincreased DOE, admitted to ___ for IV diuresis. \n\nPer most recent outpatient CHF notes:\n\nHe was seen by his primary car primary Cardiologist, Dr. ___ increased fatigue and exertional dyspnea. Dr. ___ \na\n___ and felt his LVEF was ~30% and reduced from prior. He was\nstarted on low-dose Entresto, but couldn't tolerate it from a BP\nprospective. He was previously on losartan which was stopped\ndue to this lightheadedness, dizziness and worsening renal\nfunction. Dr. ___ concern about the possibility of\nmyocarditis secondary to the checkpoint inhibitor. When he\nfollowed up with the Oncology team on ___, his symptoms were\nsomewhat improved. Cardiac biomarkers were notable for a rising\nNTproBNP to >10K but normal CK-MB and minimally elevated \ntroponin\nT of 0.03, which is not unexpected in the setting\nof decompensated ___ failure and chronic kidney disease. He \nwas\nplanned to receive immunotherapy on ___, but treatment was\nheld due to elevated Cr. Recheck showed improvement. The patient\nrestarted pembrolizumab on ___. Pembrolizumab was again \nheld\nin ___ for diarrhea and elevated LFTs \n\nIn addition, he also received intravenous hydration.\nSubsequently, he was noted to be more volume overloaded, at \nwhich\ntime Torsemide from 20 mg daily to 30 mg daily then 40 mg daily.\nTroponin testing showed Trop-T of 0.04, attributed to renal\ninsufficiency. The patient was also noted to have mild\nhyperkalemia (K 5.7) for which potassium supplementation was\nstopped and torsemide dose increased. He was also seen in the\nEmergency room in the ___ ___ due to a\nfall with resultant scalp laceration. CT head and neck was\nunremarkable. \n\nHe presented this morning ___ for his scheduled visit at\n___ clinic where he noted that his weight had been 126 lbs most\nrecently on his home scale. He also reported decreased appetite\nthat he attributes to eating a different diet. He currently has \na\n___ care taker that makes ___ food for him, adhering\nto a low sodium diet, that he does not like as much as his\nregular diet. He drinks ___ glasses of water or juice daily. He\nwas taking torsemide 40 mg daily, that he decreased to 30 mg\ndaily several days ago as he felt he was urinating too\nfrequently. He also ran out of tamsulosin several days ago so\nstopped taking this around the same time. He noted becoming \nshort\nof breath after taking 20 steps or less. Due to his volume\noverloaded noted on exam he was recommended for admission to ___\nfor IV diuresis\n\nOn the floor, he endorses the above history. He noted that his\nSOB has progressive gotten worse. Mostly occurs with activity.\nNone at rest. He noted that his weight has been slowly \ndecreasing\ndue lack of appetite and him being to lazy. He has a home health\naid everyday from 11am-7pm, who helps him with ADL. He endorses\nabdominal bloading. \n\nCardiac review of systems is notable for absence of chest pain,\nparoxysmal nocturnal dyspnea, orthopnea, palpitations, syncope,\nor presyncope.\n\nROS otherwise negative, unless otherwise noted above \n\n \nPast Medical History:\nPast Medical History:\nBILATERAL MODERATE CAROTID DISEASE \nCONGESTIVE ___ FAILURE \nCORONARY ARTERY DISEASE \nGASTROESOPHAGEAL REFLUX \nHYPERTENSION \nSEVERE EMPHYSEMA \nPULMONARY HYPERTENSION \nRIGHT BUNDLE BRANCH BLOCK \nBENIGN PROSTATIC HYPERTROPHY \nHYPERLIPIDEMIA \nPAROXYSMAL ATRIAL FIBRILLATION \nH/O HISTIOPLASMOSIS \n\nPast Surgical History:\nCARDIOVERSION ___ \nRIGHT LOWER LOBE LOBECTOMY ___ \nCORONARY BYPASS SURGERY ___ \n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION:\n===============================\n24 HR Data (last updated ___ @ 1335)\n Temp: 97.4 (Tm 97.4), BP: 115/66, HR: 61, RR: 18, O2 sat:\n99%, O2 delivery: ra, Wt: 130.73 lb/59.3 kg \n\nGENERAL: Well developed, well nourished male in NAD. Oriented \nx3.\nMood, affect appropriate. \nHEENT: Scalp laceration noted. Sclera slightly icteric. PERRL.\nEOMI. Conjunctiva were pink. No pallor or cyanosis of the oral\nmucosa. No xanthelasma. \nNECK: Supple. JVP ~ 20 cm with positive hepatojugular reflex. \nCARDIAC: Regular rate and rhythm. Normal S1, S2. ___ \nholosystolic\nmurmur at the LLSB and the apex, no rubs, or gallops. No thrills\nor lifts. \nLUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. Bibasilar crackles \nABDOMEN: mildly distended; normoactive bowel sounds; soft and\nnon-tender to palpation; there is no appreciable organomegaly or\nmass\nEXTREMITIES: Cool, 1+ pitting edema to knee caps. bilateral\nstatus dermatitis. \nSKIN: Eccymosis noted on left hand, Multiple open biopsy \nexcision\nsites on left shin and right calf\nPULSES: Distal pulses palpable and symmetric. \n\nDischarge Physical exam\n=======================\n24 HR Data (last updated ___ @ 751)\n Temp: 98.2 (Tm 98.6), BP: 110/61 (100-121/54-63), HR: 72\n(60-99), RR: 16 (___), O2 sat: 91% (91-95), O2 delivery: Ra \n\nGeneral: elderly gentleman in NAD\nHEENT: dressing in place on scalp from recent fall/scalp\nlaceration/c/d/i. Sclera mildly icteric, pupils equally round,\nMMM \nNECK: JVP~10cm, with positive hepatojugular reflex\nCV: irregularly irregular ; the precordium is quiet without RV\nheave; normal S1 with fixed split S2; there is a soft ___\nholosystolic\nmurmur at the LLSB and the apex;\nLUNGS: Normal effort. Fine Bibasilar crackles\nAbd: soft, mildy distended, no guarding / rebound. \nEXT: 1+ pitting edema to the mid-calf L leg > R leg\nSKIN: Multiple excision biopsy wounds on legs, covered with\ndressing c/d/i\nNEURO: Speech fluent, strength grossly intact \n\n \nPertinent Results:\n___ 01:00PM ___ PTT-34.4 ___\n___ 01:00PM PLT COUNT-169\n___ 01:00PM NEUTS-81.6* LYMPHS-6.6* MONOS-10.4 EOS-0.1* \nBASOS-0.1 IM ___ AbsNeut-6.00 AbsLymp-0.49* AbsMono-0.77 \nAbsEos-0.01* AbsBaso-0.01\n___ 01:00PM WBC-7.4 RBC-3.02* HGB-9.1* HCT-30.2* MCV-100* \nMCH-30.1 MCHC-30.1* RDW-16.4* RDWSD-59.2*\n___ 01:00PM calTIBC-352 FERRITIN-111 TRF-271\n___ 01:00PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.8* \nIRON-88\n___ 01:00PM CK-MB-4 cTropnT-0.01 ___\n___ 01:00PM ALT(SGPT)-56* AST(SGOT)-52* LD(LDH)-277* ALK \nPHOS-135* TOT BILI-0.7\n___ 01:00PM estGFR-Using this\n___ 01:00PM GLUCOSE-100 UREA N-52* CREAT-2.1* SODIUM-135 \nPOTASSIUM-5.4 CHLORIDE-100 TOTAL CO2-24 ANION GAP-11\n___ 04:54PM URINE HYALINE-1*\n___ 04:54PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE \nEPI-<1\n___ 04:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 04:54PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 07:53AM BLOOD WBC-6.5 RBC-2.70* Hgb-8.2* Hct-26.5* \nMCV-98 MCH-30.4 MCHC-30.9* RDW-16.0* RDWSD-56.3* Plt ___\n___ 07:53AM BLOOD Plt ___\n___ 07:53AM BLOOD Glucose-105* UreaN-43* Creat-2.2* Na-140 \nK-4.2 Cl-102 HCO3-27 AnGap-11\n___:04AM BLOOD ALT-45* AST-42* AlkPhos-113 TotBili-0.6\n___ 07:53AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.4\n___ 01:00PM BLOOD calTIBC-352 Ferritn-111 TRF-271\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES \n==================== \nDISCHARGE WEIGHT: 55.6 kg (122.57 lb) \nDISCHARGE Cr/BUN: Cr 2.2, BUN 43\nDISCHARGE DIURETIC: 40 Torsemide daily\nMEDICATION CHANGES: Decreased daily potassium to 40 mEq daily \n(from 30 mEq twice dailye)\n\n[] Please obtain repeat Chem10 within 2 weeks and after 4 weeks. \nAdjust electrolyte repletion accordingly.\n[] Please follow up weight and volume status and adjust \ntorsemide accordingly. \n\n#CODE STATUS: Presumed full\nHealth care proxy chosen: Yes \nName of health care proxy: ___ \n___: son \nPhone number: ___ \n\n==================== \nPATIENT SUMMARY: \n==================== \nMr. ___ is a ___ gentleman with PMHx of CAD s/p \nCABG\nand subsequent PCI, HFrEF (35% ___, moderate tricuspid\nregurgitation, right ventricular dysfunction, moderate pulmonary\nhypertension, and paroxysmal atrial fibrillation on apixaban,\nstage III chronic kidney disease (Baseline Cr 2.0-2.1),\ncerebrovascular disease, and metastatic melanoma of unknown\nprimary on checkpoint inhibitor pembrolizumab who was found\nvolume overloaded with increased DOE, admitted to acute ___ \nfailure for IV diuresis, now transitioned to oral duiretics. \n\n# CORONARIES: Left Main and two vessel coronary disease (___).\n# PUMP: 35% ___ \n# RHYTHM: Ectopic rhythm, PR prolongation, left axis deviation, \nRBBB\n\nACTIVE ISSUES: \n============== \n# ___ Failure with reduced ejection fraction\n# Right ventricular dysfunction, TR, pulm HTN\n# Volume overload\nHis ___ failure exacerbation is likely secondary to his recent\nadministration of IV fluids in addition to his self down\ntitration of his torsemide over the last week. In addition, he\ndoes not follow a restricted fluid intake and drinks ___ glasses\nof water or juice daily. Furthermore, he has not tolerated\nguideline directed medical therapy due to recurrent issues with\nacute kidney injury and elevated transaminitis while on\npembrolizumab therapy. He was clinically volume overloaded with\nelevated BNP 16020. We initiated IV lasix 160 bolus and put him \non a lasix gtt with good response, however he his Cr increased \nfrom 2.1-->2.7. His Cr. improved with transition to PO Torsemide \n40 mg daily. We monitored and aggressively repleted his \npotassium. No afterload reduction or neural hormonal blockade \nwas added.\n\n# Chronic Kidney Disease: Baseline 2.1-2.3 . \nCr 2.1 on admission(Stable )- Cr on discharge:2.2\nCr initially uptrended above baseline from 2.1---> 2.7. Felt \nlikely due to increased diuretic usage as it improved with \nstopping diuretics. Less likely cardiorenal syndrome. In \naddition,patient was recently seen in follow-up by nephrology. \nThey felt his CKD was less likely to be related to pembrolizumab \nand more likely related to age-related decline in renal \nfunction. Creatinine 2.2 on discharge (stable).\n\n# Metastatic Melanoma \nHe is followed by Dr. ___. He was previously on\nPembrolizumab which was held due diarrhea, elevated LFTs and\nworsening kidney function. Negative troponin and CK MB, no \nconcern\nfor drug-induced myocarditis at this point. Followup in \n___ clinic in 2weeks after discharge\n\n# Elevated transaminiatis\nStable. Statin and ___ had previously been held. No changes made \nduring admission. \n\n# Urinary frequency\nLikely due to diuretic use. Afebrile and asx otherwise\n-Continued home tamsulosin\n\n# Coronary artery disease, s/p CABG and LAD PCI.\n-Continued aspirin 81 mg daily\n-Statin stopped prior to admission due to elevated LFTs. \nContinued holding. \n\nCHRONIC ISSUES: \n============== \n\n# Paroxysmal Atrial fibrillation\nRythym: Continue amiodarone 200mg for rhythm control strategy\n(monitoring safety labs)\n-Continued anticoagulation with apixaban 2.5mg twice daily\n\n# Hypertension: Stable. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Amiodarone 200 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. Senna 17.2 mg PO HS \n5. Vitamin D 1000 UNIT PO DAILY \n6. Align (bifidobacterium infantis) 4 mg oral DAILY \n7. coenzyme Q10 100 mg oral DAILY \n8. Tamsulosin 0.4 mg PO QHS \n9. Torsemide 40 mg PO DAILY \n10. Ferrous Sulfate 325 mg PO DAILY \n11. Sertraline 50 mg PO DAILY \n12. Potassium Chloride 30 mEq PO BID \n13. Apixaban 2.5 mg PO BID \n14. Cephalexin 500 mg PO Q6H \n\n \nDischarge Medications:\n1. Potassium Chloride 40 mEq PO DAILY \nRX *potassium chloride 20 mEq 2 packet(s) by mouth once a day \nDisp #*60 Tablet Refills:*0 \n2. Align (bifidobacterium infantis) 4 mg oral DAILY \n3. Amiodarone 200 mg PO DAILY \n4. Apixaban 2.5 mg PO BID \n5. Aspirin 81 mg PO DAILY \n6. coenzyme Q10 100 mg oral DAILY \n7. Docusate Sodium 100 mg PO BID \n8. Ferrous Sulfate 325 mg PO DAILY \n9. Senna 17.2 mg PO HS \n10. Sertraline 50 mg PO DAILY \n11. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin 0.4 mg 1 capsule(s) by mouth nightly Disp #*30 \nCapsule Refills:*0 \n12. Torsemide 40 mg PO DAILY \n13. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis\n=================\nHFrEF excerterbation\n\nSecondary diagnosis\n===================\nTransaminitis\nMetastatic melanoma\nCKD\nCoronary artery disease, s/p CABG and LAD PCI\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n========================= \nDISCHARGE INSTRUCTIONS \n========================== \n\nDear Mr. ___ , \n\nIt was a pleasure taking care of you at ___ \n___. \n \nWHY WAS I ADMITTED TO THE HOSPITAL? \nYou were feeling short of breath because you had fluid in your \nlungs. This was caused by a condition called ___ failure, \nwhere your ___ does not pump hard enough and fluid backs up \ninto your lungs. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL? \nYou were given medications to help get the fluid out. Your \nbreathing got better and were ready to leave the hospital. \n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Weigh yourself every morning. Your weight on discharge is \n122.57 lbs. Call your doctor if your weight goes up more than 3 \npounds.\n- Call you doctor if you notice any of the \"danger signs\" below. \n \n \nWe wish you the best! \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5023", "N179", "C799", "N183", "Z87891", "J439", "Z951", "Z955", "I071", "I2720", "I480", "Z7902", "Z8673", "C439", "I6523", "K219", "I4510", "N400", "E7849", "Z902", "R740", "I255" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "C799: Secondary malignant neoplasm of unspecified site", "N183: Chronic kidney disease, stage 3 (moderate)", "Z87891: Personal history of nicotine dependence", "J439: Emphysema, unspecified", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "I071: Rheumatic tricuspid insufficiency", "I2720: Pulmonary hypertension, unspecified", "I480: Paroxysmal atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "C439: Malignant melanoma of skin, unspecified", "I6523: Occlusion and stenosis of bilateral carotid arteries", "K219: Gastro-esophageal reflux disease without esophagitis", "I4510: Unspecified right bundle-branch block", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E7849: Other hyperlipidemia", "Z902: Acquired absence of lung [part of]", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "I255: Ischemic cardiomyopathy" ]

[ "I130", "N179", "Z87891", "Z951", "Z955", "I480", "Z7902", "Z8673", "K219", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nCorgard / ___\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 12:48AM BLOOD WBC-10.3* RBC-3.71* Hgb-10.6* Hct-36.6* \nMCV-99* MCH-28.6 MCHC-29.0* RDW-18.6* RDWSD-55.8* Plt ___\n___ 12:48AM BLOOD ___ PTT-82.4* ___\n___ 12:48AM BLOOD Glucose-128* UreaN-47* Creat-2.2* Na-144 \nK-3.8 Cl-105 HCO3-22 AnGap-17\n___ 12:48AM BLOOD ALT-75* AST-55* AlkPhos-150* TotBili-1.1\n___ 12:48AM BLOOD ___\n___ 12:48AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.3\n___ 01:19AM BLOOD ___ pO2-59* pCO2-42 pH-7.34* \ncalTCO2-24 Base XS--2\n\nRELEVANT LABS:\n==============\n___ 12:48AM BLOOD ___\n\nIMAGING:\n========\nCXR: ___\nNo comparison. The lung volumes are low. Moderate cardiomegaly \nis present. Normal alignment of the sternal wires after CABG. \nMild bilateral pleural effusions. Signs of moderate pulmonary \nedema. Retrocardiac atelectasis, no evidence of pneumonia. \n\nCXR: ___\nThere are stable postsurgical changes following wedge resection \nthe right \nlower lobe. Small bilateral effusions right greater than left \nare unchanged. Cardiomediastinal silhouette is stable. There is \nmoderate cardiomegaly. No pneumothorax. Mild pulmonary edema \nis unchanged. \n\nDISCARHGE LABS:\n===================\n___ 08:00AM BLOOD WBC-5.4 RBC-3.54* Hgb-10.3* Hct-34.1* \nMCV-96 MCH-29.1 MCHC-30.2* RDW-19.0* RDWSD-65.7* Plt ___\n___ 08:00AM BLOOD Glucose-94 UreaN-44* Creat-2.0* Na-140 \nK-3.6 Cl-99 HCO3-27 AnGap-14\n___ 08:00AM BLOOD ALT-38 AST-46* LD(LDH)-198 AlkPhos-108 \nTotBili-0.5\n___ 08:00AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n====================\n[] Consider discontinuing amiodarone given persistence of AF \ndespite this medication\n[] Consider starting beta blocker, if BP is able to tolerate. \nPatient previously did not tolerate this medication while on \npembrolizumab (dizziness and ___, but patient has been off of \npembrolizumab since ___\n[] Consider starting spironolactone and ___ pending blood \npressures; trialed losartan and spironolactone during this \nadmission, but ultimately held due to hypotension. \n[] His LFTs should be rechecked ~2 weeks after discharge \n(___). He has a history of transaminitis attributed in part \nto statin use in the past; he was restarted on rosuvastatin this \nadmission (given history of CAD s/p CABG), and LFTs on day of \nadmission were ALT 38, AST 46, Alk phos 108, Tbili 0.5.\n[] Follow up with Oncology regarding melanoma.\n[] Monitor for resolution of supplemental O2 requirement after \ndischarge. He was requiring ___ of O2 by NC at time of \ndischarge, in the setting of recovering from pneumonia.\n\nDISCHARGE WT: 116.18 lbs\nDISCHARTE Cr: 2.0\nDISCHARGE DIURETIC: torsemide 60 mg PO BID\n\nSUMMARY:\n===============\nMr. ___ is a ___ man with PMH of HFrEF (35% \n___,\nCAD s/p 3v CABG (___) and subsequent PCI to the LAD (___),\nmoderate tricuspid regurgitation, right ventricular dysfunction,\nmoderate pulmonary hypertension, and paroxysmal atrial \nfibrillation on apixaban, stage III chronic kidney disease \n(Baseline Cr 2.0-2.1), cerebrovascular disease, and metastatic \nmelanoma of unknown primary on Pembrolizumab (on hold since \n___ iso worsening transaminitis and concern for \ncardiotoxicity). He was admitted with volume overload from heart \nfailure exacerbation and pneumonia with high oxygen \nrequirements. He initially required CCU admission for high flow \noxygen, weaned to nasal cannula after aggressive IV diuresis and \ntreatment of pneumonia with 5 day course of Zosyn after \nreceiving vancomycin at OSH. He was transferred to cardiology \nfloor where he continued to diurese well and his oxygen \nrequirement was weaned to ___. He was transitioned to 60 mg \ntorsemide PO BID which adequately maintained euvolemia. \n\nACUTE ISSUES: \n============= \n# Acute on chronic systolic heart failure exacerbation\nPatient with history of heart failure with etiology likely \nischemic cardiomyopathy given history of CAD s/p CABG and PCI. \nAdmitted with fluid overload and pleural effusion. Trigger for \ncurrent exacerbation could be infectious given evidence of \npneumonia in left lower lobe on admission. Patient with high \noxygen requirements prior to admission but responded \nappropriately to diuresis with Lasix. After IV diuresis, patient \nwas transitioned PO torsemide and maintained at euvolemia. With \neffective diuresis, the patient's oxygen requirement gradually \nlowered from 4L NC to ___ NC. He was discharged on torsemide 60 \nmg PO BID. He was unable to tolerate afterload reducing agents \nor neurohormonal blockade agents due to hypotension. \n\n# Lower left lobe pneumonia\nPatient with evidence of pneumonia in the left lower lobe, \nreceived vanc/zosyn at outside hospital and continued on Zosyn \nhere for a total of 5 day course with resolution of symptoms. We \nsuspect that his lingering O2 requirement is at least in part \ndue to slowly resorbing consolidation left over from his \ninfection. He was requiring ___ of supplemental O2 by NC at \ntime of discharge.\n\n# Pleural effusion, bilateral\nPatient with evidence of right pleural effusion. Etiology likely \nfluid overload given heart failure with reduced ejection \nfraction. Pleural effusion resolved improved with diuresis and \nhis oxygen requirement trended down to ___ NC. Given this, \nthoracentesis was deferred. \n\n# Atrial fibrillation\nPatient with chronic history of atrial fibrillation. In afib \nthroughout this admission. Continued amiodarone and apixaban. \nRates appropriately controlled.\n\nCHRONIC ISSUES\n================\n# Coronary artery disease s/p CABG\nPatient with history of 3 vessel CABG on ___ (___) and\nsubsequent PCI to LAD (___). Continued home aspirin. Patient \nwas started on low dose rosuvastatin 5 mg daily. On review, it \nappears he had been on this medication at this dose in the past \nbut it was discontinued due to transamnitis; however, at the \ntime it was unclear whether this was an effect of the statin or \npembrolizumab. Given that the patient has not had his checkpoint \ninhibitor therapy since ___, the decision was to restart \nrosuvastatin. \n\n# Chronic kidney disease\nBaseline Cr appears to be 2.1-2.2 over past year. Cr remained \nbetween 1.8-2.4 throughout admission. \n\n# Anemia\nChronic, although worsening since ___. On admission \nhemoglobin\n10.6 and remained stable. \n\n# Thrombocytopenia\nUncertain etiology, appears subacute/chronic. On admission\nplatelets 130 down-trended to 100s. No concern for bleeding \nthroughout admission. \n\n# Melanoma\nPatient with history of metastatic melanoma with unknown \nprimary.\nOn treatment with pembrolizumab, but held since ___ iso\ntoxicity. \n\nCODE: DNR/DNI\nCONTACT: ___ (___)\nRelationship: Son \nPhone number: ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amiodarone 200 mg PO DAILY \n2. Apixaban 2.5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Senna 17.2 mg PO HS \n7. Sertraline 50 mg PO DAILY \n8. Tamsulosin 0.4 mg PO QHS \n9. Torsemide 40 mg PO DAILY \n10. coenzyme Q10 100 mg oral DAILY \n11. Align (bifidobacterium infantis) 4 mg oral DAILY \n12. Potassium Chloride 40 mEq PO DAILY \n\n \nDischarge Medications:\n1. Rosuvastatin Calcium 5 mg PO QPM \n2. Vitamin D 1000 UNIT PO DAILY \n3. Torsemide 60 mg PO BID \n4. Align (bifidobacterium infantis) 4 mg oral DAILY \n5. Amiodarone 200 mg PO DAILY \n6. Apixaban 2.5 mg PO BID \n7. Aspirin 81 mg PO DAILY \n8. coenzyme Q10 100 mg oral DAILY \n9. Docusate Sodium 100 mg PO BID \n10. Ferrous Sulfate 325 mg PO DAILY \n11. Potassium Chloride 40 mEq PO DAILY \n12. Senna 17.2 mg PO HS \n13. Sertraline 50 mg PO DAILY \n14. Tamsulosin 0.4 mg PO QHS \n\n___ and mineralocorticoid receptor antagonist held in the \nsetting of hypotension and CKD. Patient is intolerant of beta \nblockers due to dizziness/hypotension previously.\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\n=====================\nAcute on chronic systolic heart failure exacerbation\nLower left lobe pneumonia\nBilateral pleural effusion\nAtrial fibrillation\n\nSecondary diagnosis:\n=====================\nCoronary artery disease status post CABG\nChronic kidney disease\nAnemia\nThrombocytopenia\nMetastatic melanoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at the ___ \n___. \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n- You were admitted because of you were short of breath \n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- You were found to have fluid on your lungs. This was because \nyou have a medical condition called heart failure, where your \nheart does not pump hard enough and fluid backs up into your \nlungs. \n- You were given a diuretic medication to help get the fluid \nout. You improved considerably and are ready to leave the \nhospital. \n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Be sure to take all your medications and attend all of your \nappointments listed below. \n- Your weight at discharge is 116.18 lbs. Please weigh yourself \ntoday at home and use this as your new baseline \n- Please weigh yourself every day in the morning. Call your \ndoctor or the HeartLine at ___ if your weight goes up \nby more than 3 lbs or you experience significant chest pain and \nshortness of breath. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nSincerely,\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I5023", "J189", "J9691", "C7951", "J90", "N179", "I255", "I480", "Z7902", "I2720", "I079", "I2510", "Z951", "N183", "D638", "D696", "C439", "Z87891" ]

[ "I5023: Acute on chronic systolic (congestive) heart failure", "J189: Pneumonia, unspecified organism", "J9691: Respiratory failure, unspecified with hypoxia", "C7951: Secondary malignant neoplasm of bone", "J90: Pleural effusion, not elsewhere classified", "N179: Acute kidney failure, unspecified", "I255: Ischemic cardiomyopathy", "I480: Paroxysmal atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I2720: Pulmonary hypertension, unspecified", "I079: Rheumatic tricuspid valve disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "N183: Chronic kidney disease, stage 3 (moderate)", "D638: Anemia in other chronic diseases classified elsewhere", "D696: Thrombocytopenia, unspecified", "C439: Malignant melanoma of skin, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "I480", "Z7902", "I2510", "Z951", "D696", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nCorgard / Vasotec\n \nAttending: ___.\n \nChief Complaint:\nincarcerated inguinal hernia\n \nMajor Surgical or Invasive Procedure:\nLeft inguinal hernia repair\n \nHistory of Present Illness:\n___ with afib on apixiban, CAD s/p CABG, b/l carotid disease, \nCOPD/emphysema with recent pneumonia presents for elective left \ninguinal hernia repair (large, with incarcerated sigmoid colon)\n\n \nPast Medical History:\nPast Medical History:\nBILATERAL MODERATE CAROTID DISEASE \nCONGESTIVE HEART FAILURE \nCORONARY ARTERY DISEASE \nGASTROESOPHAGEAL REFLUX \nHYPERTENSION \nSEVERE EMPHYSEMA \nPULMONARY HYPERTENSION \nRIGHT BUNDLE BRANCH BLOCK \nBENIGN PROSTATIC HYPERTROPHY \nHYPERLIPIDEMIA \nPAROXYSMAL ATRIAL FIBRILLATION \nH/O HISTIOPLASMOSIS \n\nPast Surgical History:\nCARDIOVERSION ___ \nRIGHT LOWER LOBE LOBECTOMY ___ \nCORONARY BYPASS SURGERY ___ \n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nGen: Awake and alert\nCV: Irregularly irregular rhythm, normal rate\nResp: CTAB\nGI: Soft, appropriately tender near incision, non-distended\nIncision clean, dry, and intact with no erythema\nExt: Warm and well perfused\n \nPertinent Results:\n \n \nBrief Hospital Course:\nMr. ___ was admitted to ___ \n___ on ___ after undergoing repair of a left \nincarcerated inguinal hernia. For details of the procedure, \nplease refer to the operative report. His postoperative course \nwas uncomplicated. After a brief stay in the PACU, he was \ntransferred to the regular nursing floor. His pain was \ncontrolled with IV medication. On POD #1, he was started on a \nregular diet, and his pain was controlled with PO pain \nmedication. He voided without issue. He was ambulating \nindependently in the halls. He was given a bowel regimen, and \npassed flatus. On POD #2, he continued to tolerate his diet, his \npain was well-controlled on oral medication, and he continued to \nambulate independently. He was discharged home in stable \ncondition on POD #2 with plans to follow-up with Dr. ___. \n \nDischarge Medications:\n1. Amiodarone 200 mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Losartan Potassium 25 mg PO DAILY \n6. Omeprazole 10 mg PO DAILY \n7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY \n8. Acetaminophen 1000 mg PO Q6H:PRN pain or fever \nDo not exceed 4 grams per day. \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*60 Tablet Refills:*0\n9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp \n#*40 Tablet Refills:*0\n10. Senna 17.2 mg PO HS \nTake this while you are taking oxycodone. \nRX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 capsule by \nmouth daily Disp #*30 Tablet Refills:*0\n11. Align (bifidobacterium infantis) 4 mg oral DAILY \n12. coenzyme Q10 100 mg oral DAILY \n13. Rosuvastatin Calcium 40 mg PO QPM \n14. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nInguinal hernia\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\nIt was a pleasure taking care of you here at ___ \n___. You were admitted to our hospital \nafter undergoing repair of your inguinal hernia. You have \nrecovered from surgery and are now ready to be discharged home. \nPlease follow the recommendations below to ensure a speedy and \nuneventful recovery. \n \nACTIVITY:\n- Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\n- You may climb stairs. \n- You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\n- Don't lift more than 10 lbs for 6 weeks. (This is about the \nweight of a briefcase or a bag of groceries.) This applies to \nlifting children, but they may sit on your lap.\n- You may start some light exercise when you feel comfortable.\n- You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n- Heavy exercise may be started after 6 weeks, but use common \nsense and go slowly at first.\n- You may resume sexual activity unless your doctor has told you \notherwise.\n \nHOW YOU MAY FEEL: \n- You may feel weak or \"washed out\" for 6 weeks. You might want \nto nap often. Simple tasks may exhaust you.\n- You may have a sore throat because of a tube that was in your \nthroat during surgery.\n- You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\n- You could have a poor appetite for a while. Food may seem \nunappealing.\n- All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\n- Your incision may be slightly red around the edges. This is \nnormal.\n- If you have steri strips, do not remove them for 2 weeks. \n(These are the thin paper strips that are on your incision.) But \nif they fall off before that that's okay).\n- You may gently wash away dried material around your incision.\n- It is normal to feel a firm ridge along the incision. This \nwill go away.\n- Avoid direct sun exposure to the incision area.\n- Do not use any ointments on the incision unless you were told \notherwise.\n- You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\n- You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n- Over the next ___ months, your incision will fade and become \nless prominent.\n \nYOUR BOWELS:\n- Constipation is a common side effect of medicine such as \nPercocet or codeine. If needed, you may take a stool softener \n(such as Colace, one capsule) or gentle laxative (such as milk \nof magnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\n- If you go 48 hours without a bowel movement, or have pain \nmoving your bowels, call your surgeon.\n- After some operations, diarrhea can occur. If you get \ndiarrhea, don't take anti-diarrhea medicines. Drink plenty of \nfluids and see if it goes away. If it does not go away, or is \nsevere and you feel ill, please call your surgeon.\n \nPAIN MANAGEMENT:\n- It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \n- Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\n-You will receive a prescription from your surgeon for pain \nmedicine to take by mouth. It is important to take this medicine \nas directed. \n- Do not take it more frequently than prescribed. Do not take \nmore medicine at one time than prescribed.\n- Your pain medicine will work better if you take it before your \npain gets too severe. \n- If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\nIf you experience any of the folloiwng, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\n- Take all the medicines you were on before the operation just \nas you did before, unless you have been told differently.\n- If you have any questions about what medicine to take or not \nto take, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K4030", "I480", "I272", "I509", "I2510", "I10", "K219", "N400", "E785", "J439", "I4510", "Z7982", "Z951", "Z87891" ]

[ "K4030: Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent", "I480: Paroxysmal atrial fibrillation", "I272: Other secondary pulmonary hypertension", "I509: Heart failure, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "E785: Hyperlipidemia, unspecified", "J439: Emphysema, unspecified", "I4510: Unspecified right bundle-branch block", "Z7982: Long term (current) use of aspirin", "Z951: Presence of aortocoronary bypass graft", "Z87891: Personal history of nicotine dependence" ]

[ "I480", "I2510", "I10", "K219", "N400", "E785", "Z951", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\n___ - bedside pericardiocentesis at ___\n\n \nHistory of Present Illness:\n HISTORY OF PRESENTING ILLNESS: Mr. ___ is a ___\nmale with rheumatoid arthritis, DMARD holiday, and recent, brief\nhospitalization for presumptive pericarditis, returned to \noutside\nhospital with probable cardiac tamponade now post-bedside\npericardiocentesis with drain placement prior to transfer.\nImportantly, patient was hospitalized at ___ on ___ with acute pleuritic chest pain of two-day duration in the\ncontext of constellation of fatigue, malaise, upper respiratory\nsymptoms, and non-productive cough. While CTA exonerated\npulmonary embolism, thickened pericardium and small effusion \nwere\nnoted, suggesting pericarditis. ECG revealed subtle diffuse ST\nelevations in keeping with pericarditis. Echocardiogram \nconfirmed\nsaid effusion, though no features of tamponade were appreciated.\nHe was discharged the same day with ibuprofen 600 mg TID and\ncolchicine 0.6 mg BID. He had persistence of minor residual \nchest\npain, which began to worsen two days later, but was tolerable\nuntil yesterday evening when it evolved to severe, unrelenting\npain across his precordium likened to \"wearing shoulder pads\nbearing down on him.\" He notes a new concurrent substernal chest\npain that \"goes straight to his back.\" He then became dyspneic,\nprompting him to seek care. He arrived at ___ hypotensive\nwith SBP in the 80-range. He was borderline tachycardic and in\nmild respiratory distress, but oxygenation was acceptable. He\nrapidly received three liters of fluid for presumptive tamponade\nwithin the confines of poor windows on bedside echocardiogram.\nPericardiocentesis yielded 400 cc or more of serous fluid and a\npericardial drain was placed. Hemodynamics rapidly improved. On\narrival to ___ ED, patient was indeed hemodynamically stable\nbut was then in moderate respiratory distress, requiring\nnon-rebreather. He was given Lasix 20 mg IV. Bedside\nechocardiogram was limited, but preliminarily suggestive of \nsmall\nresidual effusion. In the CCU, patient notes resurgence of said\nchest pain. His dyspnea is improving. An additional 250 cc was\ndrained. \n \nPast Medical History:\nPAST MEDICAL HISTORY: \n Cardiac History: \n-Pericarditis, as above.\n-Hypertension.\n-Dyslipidemia. \n \n Other PMH: \n-Rheumatoid arthritis. \n-Remote traumatic DVT.\n-Cholecystectomy.\n-Appendectomy.\n-Tonsillectomy.\n-Left wrist reconstruction.\n-Right rotator cuff reconstruction.\n\n \nSocial History:\n___\nFamily History:\npaternal history of ureothelial carcinoma.\nMaternal history of diabetes. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n=================================\n VS: T 96.7, HR 81, BP 136/81, O2 94% 6L \n GENERAL: obese male in mild to moderate respiratory distress. \n HEENT: anicteric sclerae. Oropharynx clear. \n NECK: JVP at mandibular angle. \n CARDIAC: tachycardic, regular with rare ectopy, S1/S2 within \nthe\nconfines of body habitus. Subtle pericardial rub. Pericardial\ndrain with serosanguinous fluid. Sternal tenderness. \n LUNGS: Conversational dyspnea but tachypnea is slowing. Diffuse\nwheezing and crackles in bilateral lung fields. \n ABDOMEN: obese, soft, non-tender.\n EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees. \n SKIN: Chronic bilateral venous stasis dermatitis. \n PULSES: Distal pulses palpable and symmetric. \n NEURO: non-focal.\n\nDISCHARGE PHYSICAL EXAMINATION: \n=================================\nGENERAL: obese male in mild to moderate respiratory distress. \n HEENT: anicteric sclerae. Oropharynx clear. \n NECK: JVP not appreciated. \n CARDIAC: normal rate and rhythm, S1/S2 within the confines of\nbody habitus. No pericardial rub appreciated. \n LUNGS: Decreased respiratory effort compared to yesterday.\nExpiratory wheezing and bibasilar crackles.\n ABDOMEN: obese, soft, non-tender, non-distended.\n EXTREMITIES: Warm, well perfused, 1 to 2+ pitting edema to\nknees. \n SKIN: Chronic venous stasis dermatitis. \n PULSES: Distal pulses palpable and symmetric. \n NEURO: non-focal.\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 10:57PM WBC-16.9* RBC-4.63 HGB-14.2 HCT-43.1 MCV-93 \nMCH-30.7 MCHC-32.9 RDW-13.1 RDWSD-44.1\n___ 10:57PM NEUTS-85.5* LYMPHS-4.3* MONOS-9.4 EOS-0.1* \nBASOS-0.2 IM ___ AbsNeut-14.43* AbsLymp-0.72* AbsMono-1.58* \nAbsEos-0.01* AbsBaso-0.04\n___ 10:57PM ___ PTT-27.2 ___\n___ 10:57PM GLUCOSE-269* UREA N-20 CREAT-0.9 SODIUM-135 \nPOTASSIUM-5.3 CHLORIDE-106 TOTAL CO2-18* ANION GAP-11\n___ 10:57PM CALCIUM-7.4* PHOSPHATE-3.1 MAGNESIUM-1.6\n___ 10:57PM cTropnT-<0.01\n___ 11:03PM LACTATE-2.0\n___ 01:05AM PLEURAL FLUID STUDIES ___ \nPolys-94* Lymphs-2* Monos-4*\n\nIMAGING:\n========\n___ TTE\nThe left atrium is normal in size. The inferior vena cava is \ndilated (>2.5 cm). There is normal left ventricular\nwall thickness with a normal cavity size. There is suboptimal \nimage quality to assess regional left ventricular\nfunction. Overall left ventricular systolic function is normal. \nQuantitative biplane left ventricular ejection\nfraction is 66 %. Left ventricular cardiac index is normal (>2.5 \nL/min/m2). No ventricular septal defect is\nseen. Normal right ventricular cavity size with normal free wall \nmotion. There is abnormal interventricular\nseptal motion. The aortic sinus diameter is normal for gender \nwith normal ascending aorta diameter for\ngender. The aortic arch diameter is normal. There is no evidence \nfor an aortic arch coarctation. The aortic\nvalve leaflets (?#) appear structurally normal. There is no \naortic valve stenosis. There is no aortic\nregurgitation. The mitral valve is not well visualized. The \ntricuspid valve is not well seen. The pulmonary\nartery systolic pressure could not be estimated. There is no \npericardial effusion.\n\nMICRO:\n======\n___ 1:05 am FLUID,OTHER PERICARDIAL FLUID. \n\n GRAM STAIN (Final ___: \n 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n\n FLUID CULTURE (Preliminary): \n Reported to and read back by ___ ___ \n1:53PM. \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1 \nPLATE. \n\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. \n\n FUNGAL CULTURE (Preliminary): \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n\nDISCHARGE LABS:\n===============\n___ 04:01AM BLOOD WBC-13.0* RBC-4.05* Hgb-12.3* Hct-37.3* \nMCV-92 MCH-30.4 MCHC-33.0 RDW-13.0 RDWSD-43.8 Plt ___\n___ 03:30PM BLOOD Glucose-115* UreaN-22* Creat-0.6 Na-138 \nK-4.1 Cl-100 HCO3-24 AnGap-14\n___ 04:01AM BLOOD ALT-43* AST-27 AlkPhos-99 TotBili-0.5\n___ 03:30PM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9\n___ 10:57PM BLOOD proBNP-110\n___ 03:29AM BLOOD TSH-0.93\n___ 11:04AM BLOOD ___ pO2-82* pCO2-42 pH-7.34* \ncalTCO2-24 Base XS--2\n \nBrief Hospital Course:\nSUMMARY: \n===================== \n___ male with rheumatoid arthritis, DMARD holiday, and\nrecent, brief hospitalization for presumptive pericarditis,\nreturned to outside hospital with pericardial effusion with \npossible tamponade physiology now post-bedside \npericardiocentesis prior to transfer, with persistent \npericardial effusion now s/p drain placement with course \ncomplicated by acute hypercapneic respiratory distress. \n\n#CORONARIES: unknown.\n#PUMP: normal biventricular structure and function. \n#RHYTHM: NSR. pAF ___\n\nTRANSITIONAL ISSUES:\n====================\n[] He was discharged on ibuprofen 600mg TID and colchicine 0.6mg \nBID for his inflammatory pericarditis. He should continue \ncolchicine for 3 months. He should have his ibuprofen tapered \nweekly following resolution of his symptoms over 3 weeks to \nreduce the risk of recurrence. \n[] He was discharged on a PPI and should continue this while on \nibuprofen. \n[] Strongly recommend that patient receive outpatient PFTs given \nhigh suspicion for baseline obstructive/restrictive pulmonary \ndisease \n[] Patient developed paroxysmal afib with RVR during this \nadmission which is a new diagnosis. CHADSVASC 2 for hypertension \nand diabetes. Anticoagulation was not started during this \nadmission given that he was felt to have relatively low risk for \nCVA, however please make a note of this new diagnosis and \nreassess need for anticoagulation as medically appropriate. \n[] He was newly diagnosed with DM (HbA1c 7.9 at ___ \nand will be discharged on metformin 500 BID. Will require \noutpatient follow-up for this and can consider uptitration in \nthe outpatient setting. \n[] Please reassess need for diuretic in the outpatient setting. \nHe had no echocardiographic evidence of heart failure during \nthis admission so was not discharged on diuretics. \n\nNew medications:\nMetformin 500mg BID\nMetoprolol XL 50mg QD \nOmeprazole 20mg QD \n\nContinued medications:\nAtorvastatin 10mg QPM\nColchicine 0.6mg BID\nIbuprofen 600mg TID\nFolic acid 1mg PO QD\nSertraline 100mg PO QD\n\nStopped medications: \nMethotrexate 20mg PO\nFamotidine 20mg QD\n\nACUTE ISSUES: \n=============\n#) Acute pericarditis\n#) Cardiac tamponade, now s/p pericardiocentesis and drain\nplacement \nHe presented with inflammatory pericarditis of probable viral \nnature in the context of viral-like prodrome versus rheumatic \npericarditis, given serologic positive active disease in the \nabsence of DMARD. Pericardial fluid cultures from ___ \nnegative, cultures here with 1 colony on 1 plate of coag \nnegative staph felt to be contaminant, negative acid fast smear. \nNo biochemical evidence of myocardial injury on admission, \nunlikely to have concurrent myocarditis or cardiac event \nsequelae. At ___ was initially noted to have SBPs in \nthe ___ and received fluid resuscitation and pericardiocentesis \ngiven concern for tamponade physiology. Hemodynamics \nsubsequently stabilized and remained so throughout the duration \nof his admission here. TTE on ___ showed no pericardial \neffusion. Pericardial drain was initially left to gravity due to \ncontinued output, and was removed ___. He was treated with \ncolchicine 0.6mg BID which he will continue for 3 months after \ndischarge. He also received ibuprofen 600mg PO TID and will be \ndischarged on a slow taper; he received PPI while receiving \nNSAIDs. \n\n#) Acute hypercapnic respiratory failure - resolving\nProbable flash pulmonary edema from rapid large-volume fluid \nadministration on tamponade, as evidenced by radiographic \npulmonary edema. Earlier echocardiogram otherwise not suggestive \nof ventricular dysfunction and BNP is within normal limits. TTE \non ___ was without evidence of cardiac etiology for his \npulmonary edema/respiratory failure.\nPatient likely has unappreciated restrictive pulmonary \nphysiology. Additionally, no emphysematous changes noted on CT \none week ago, but\nbackground obstructive defect is conceivable, given compelling\nsmoking history. He had a negative CTA one week prior to \nadmission. Patient had leukocytosis on admission without clear \nradiographic consolidation suggestive of pneumonia - one dose of \nempiric azithromycin was given overnight and discontinued on \n___. He received IV diuresis with significant improvement in \nhis respiratory status. O2 weaned ___ morning. He was breathing \ncomfortably on RA at the time of discharge with ambulatory \nsaturations >90%. \n\n#) Paroxysmal AFib, new diagnosis \nPatient went into Afib with RVR on ___, and subsequently \nreceived metoprolol. He subsequently flipped back into NSR. His \nCHADsVASC = 2 (DM, HTN). Anticoagulation was discussed but \nultimately deferred at the time of discharge given the patient's \nlower overall risk for CVA and concerns regarding medication \nadherence/cost. He was discharged on metoprolol. He should have \nhis need for anticoagulation reassessed as an outpatient as \nmedically appropriate. \n\n#) Type II diabetes: \nHe was newly diagnosed with DM with a A1C of 7.9% during this \nadmission. He was maintained on an insulin sliding scale during \nthis admission and will be discharged on metformin 500mg BID. \n\nCHRONIC/STABLE ISSUES:\n====================\n#) Rheumatoid arthritis: \nRF and anti-CCP positive per outpatient rheumatology. Not\ncurrently endorsing sx suggestive of RA flare. Per discussion\nwith OP rheumatologist, deferred restarting MTX and/or other\nDMARD until outpatient.\n\n#) HTN\nHis home BP meds were held initially due to soft BPs and were \nstopped at the time of discharge as he remained normotensive. \n\nCORE MEASURES: \n============== \n#CODE: DNR/DNI.\n#CONTACT/HCP: ___, ex-wife (___) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 10 mg PO QPM \n2. Colchicine 0.6 mg PO BID \n3. Ibuprofen 600 mg PO TID \n4. Famotidine 20 mg PO DAILY \n5. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n6. Methotrexate 20 mg PO 1X/WEEK (___) \n7. Sertraline 100 mg PO DAILY \n8. FoLIC Acid 1 mg PO DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of \nbreath \nRX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs ih every 6 \nhours as needed Disp #*1 Inhaler Refills:*0 \n2. MetFORMIN (Glucophage) 500 mg PO BID \nRX *metformin 500 mg 1 tablet(s) by mouth Twice a day Disp #*60 \nTablet Refills:*2 \n3. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp \n#*30 Tablet Refills:*2 \n4. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30 \nCapsule Refills:*2 \n5. Atorvastatin 10 mg PO QPM \n6. Colchicine 0.6 mg PO BID \nRX *colchicine 0.6 mg 1 capsule(s) by mouth Twice a day Disp \n#*60 Capsule Refills:*2 \n7. FoLIC Acid 1 mg PO DAILY \n8. Ibuprofen 600 mg PO TID \n9. Sertraline 100 mg PO DAILY \n10. HELD- lisinopril-hydrochlorothiazide ___ mg oral DAILY \nThis medication was held. Do not restart \nlisinopril-hydrochlorothiazide until instructed by your primary \ncare doctor or cardiologist\n11. HELD- Methotrexate 20 mg PO 1X/WEEK (___) This medication \nwas held. Do not restart Methotrexate until a doctor tells you \nto\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis: inflammatory pericarditis\nSecondary Diagnosis: rheumatoid arthritis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n \nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You were admitted to the hospital with chest pain. \n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- You were found to have inflammation and a build up of fluid \nin the lining of the heart.\n- You had a procedure to remove the fluid from the lining of the \nheart and a temporary drain placed. This was removed before you \nleft the hospital. \n- You received medication to help you pee off the excess fluid \nin your body. \n- You developed an abnormal heart rhythm (afib) while in the \nhospital. You were started on a new medication for this \n(metoprolol).\n- You were diagnosed with diabetes during this admission. You \nwere started on a new medication for this (metformin). \n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Weigh yourself every morning, seek medical attention if your \nweight goes up more than 3 lbs. \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\nPlease see below for more information on your hospitalization. \nIt was a pleasure taking part in your care here at ___! \n\nWe wish you all the best! \n - Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I309", "J9602", "I314", "I480", "E119", "Z66", "I10", "M069", "E785", "Z86718", "Z87891" ]

[ "I309: Acute pericarditis, unspecified", "J9602: Acute respiratory failure with hypercapnia", "I314: Cardiac tamponade", "I480: Paroxysmal atrial fibrillation", "E119: Type 2 diabetes mellitus without complications", "Z66: Do not resuscitate", "I10: Essential (primary) hypertension", "M069: Rheumatoid arthritis, unspecified", "E785: Hyperlipidemia, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z87891: Personal history of nicotine dependence" ]

[ "I480", "E119", "Z66", "I10", "E785", "Z86718", "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:\ncardiogenic ___, NSTEMI\n \nMajor Surgical or Invasive Procedure:\n- cardiac catheterization with DES to mid-LAD occlusion via R \nradial access\n- IABP placement and removal\n \nHistory of Present Illness:\nMr. ___ is a ___ M with HTN, HLD, DMII, and prior MI with \nmedical management w/o cath presented to ___ with ___ \ntransferred to ___ for catheterization for concern for STEMI. \n\nPatient has long standing angina pain w/ exertion. On ___ night \nhad acute onset b/l non-radiating ___ CP not resolved with SL \nNTG that persisted on ___ morning. In addition had 3 episodes \nof diarrhea and weakness/malaise so he went to ___. No \northopnea, PND, ___ edema, palpitations, or SOB. \n\nIn the ED, initial vitals were: \nExam: Chest pain ___ nonradiating\nLabs: Trop I 1.14, WBC 29.6, Hct 38.7, Plt 148, INR 1.25, Na \n127, K+ 4.6, BUN 30/Cr1.86\nImaging: EKG showed ST elevations in AVR (2mm), borderline \nelevation in V1, and otherwise diffuse ST depressions. Bedside \nECHO w/ septal wall motion abnormalities. CXR w/o any acute \nabnormalities. \nPatient was given: Heparin gtt, Nitro gtt, ASA 324mg, Ticagrelor \n180mg @ 1500, Vanco 125mg PO, ___\n\nTransferred to ___ for cardiac cath. Vitals on transfer were: \n106/64, 86, 100% on 2L, afebrile\nCath lab where he still had ___ pain on heparin and nitro gtt. \nCatheterization showed mid-LAD septal occlusion, diffuse disease \nthroughout RCA, complete occlusion of circumflex w/ collaterals, \nand 20% stenosis of L main. DES to mid-LAD occlusion via R \nradial access. Hypotensive throughout so given 750cc IVF. \nCoughing post-procedure with LVEDP 25 so given Lasix 20mg IV. \nWas then hypertensive to 150 so given further Lasix 40mg IV.\n\nAdmitted to CCU for hypotension throughout procedure, WBC 30, \nand lack of ___ beds. In the CCU, patient reports no chest pain \nbut continues to have productive cough and diarrhea.\n\nOf note, two weeks ago had endoscopy and diagnosed with H \nPylori. Currently on clarithromycin and amoxicillin. On ___ \nnight developed diarrhea. Also had 15lb weight loss in past 4 \nmonths.\n\n \nPast Medical History:\n1) HTN\n2) HLD\n3) DMII\n4) CAD s/p MI - medically managed\n5) H. Pylori\n6) Spinal stenosis\n \nSocial History:\n___\nFamily History:\nFather: possible dilated cardiomyopathy\nNo family history of early MI, arrhythmia, or sudden cardiac \ndeath; otherwise non-contributory. \n \nPhysical Exam:\nOn admission:\n---------------\nVS: afebrile, 160/80, 114, 94% on 15L Non-rebreather\nWeight: 69kg\nTele: NSR\nGen: Slightly tachypneic older man audibly wheezing but \ncomfortably finishing sentences \nHEENT: EOMI, PERRLA,\nNECK: No JVD\nCV: Tachycardic, difficult to appreciate heart sounds due to \nsignificant rhonchi \nLUNGS: b/l rhonchi throughout w/ mild end expiratory wheezing \nand R base crackles\nABD: Soft, Non-tender, non-distended\nEXT: 2+ L radial pulses, R arm w/ band in place and normal \nmotor/sensory function intact distally, RLE non-palpable DP but \ndopplerable, 1+ LLE DP. b/l ___ slightly cold but normal \nsensation w/ full motor strength and ROM\nSKIN: No rashes or chronic edematous changes\nNEURO: Alert and attentive, AOX3, Moving all extremities\n\nAt discharge:\n--------------\nWeight: 63.7kg (63.4) \nI/O: 980/800\nT 98.4 BP 123/68 (102-133/62-87) P 86 (71-100) RR 20 O2 99% RA \n \nGen: awake, alert, oriented to self, date, hospital\nHEENT: EOMI, PERRLA,\nNECK: No JVD\nCV: Tachycardic, difficult to appreciate heart sounds \nLUNGS: Bibasilar crackles\nABD: Soft, Non-tender, non-distended\nEXT: 2+ b/l radial pulses, R arm normal motor/sensory function \nintact distally, RLE non-palpable DP but dopplerable, trace \nedema b/l. b/l ___ slightly cold but normal sensation w/ full \nmotor strength and ROM\nSKIN: No rashes or chronic edematous changes\nNEURO: Alert and attentive, AOX3, Moving all extremities\n\n \nPertinent Results:\nLabs on Admission:\n-------------------\n___ 09:23PM WBC-36.8* RBC-4.40* HGB-14.0 HCT-40.6 MCV-92 \nMCH-31.8 MCHC-34.5 RDW-12.5 RDWSD-41.8\n___ 09:23PM PLT SMR-NORMAL PLT COUNT-176\n___ 09:23PM NEUTS-81* BANDS-10* LYMPHS-3* MONOS-6 EOS-0 \nBASOS-0 ___ MYELOS-0 AbsNeut-33.49* AbsLymp-1.10* \nAbsMono-2.21* AbsEos-0.00* AbsBaso-0.00*\n___ 09:23PM ___ PTT-49.6* ___\n___ 09:23PM GLUCOSE-264* UREA N-30* CREAT-1.4* \nSODIUM-129* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-14* ANION \nGAP-23*\n___ 09:23PM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.7 \nCHOLEST-157\n___ 09:23PM %HbA1c-5.9 eAG-123\n___ 09:23PM CK-MB-44* cTropnT-0.69*\n___ 09:23PM TRIGLYCER-90 HDL CHOL-42 CHOL/HDL-3.7 \nLDL(CALC)-97\n___ 09:23PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ \nMACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-1+\n\nLabs at Discharge:\n-------------------\n___ 05:50AM BLOOD WBC-11.2* RBC-3.59* Hgb-11.2* Hct-34.7* \nMCV-97 MCH-31.2 MCHC-32.3 RDW-13.2 RDWSD-46.7* Plt ___\n___ 05:50AM BLOOD Neuts-76* Bands-0 Lymphs-16* Monos-5 \nEos-2 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-8.51* \nAbsLymp-1.79 AbsMono-0.56 AbsEos-0.22 AbsBaso-0.00*\n___ 05:50AM BLOOD ___ PTT-27.3 ___\n___ 05:50AM BLOOD Glucose-165* UreaN-43* Creat-1.1 Na-136 \nK-4.3 Cl-103 HCO3-22 AnGap-15\n___ 05:50AM BLOOD ALT-38 AST-32 LD(LDH)-481* AlkPhos-99 \nTotBili-0.4\n___ 05:50AM BLOOD Albumin-3.3* Calcium-8.4 Phos-3.6 Mg-2.4\n\nRelevant Imaging:\n-----------------\nTTE ___:\nThe left atrium is mildly dilated. The estimated right atrial \npressure is ___ mmHg. Left ventricular wall thicknesses and \ncavity size are normal. Overall left ventricular systolic \nfunction is moderately depressed (LVEF= ? 35-40% - assessment \nlimited by suboptimal image quality and significant beat to beat \nvariability). There is hypokinesis of the mid-distal LV segments \nand apex. There is no ventricular septal defect. Right \nventricular chamber size and free wall motion are normal. The \nascending aorta is mildly dilated. The number of aortic valve \nleaflets cannot be determined. There is mild aortic valve \nstenosis (valve area 1.2-1.9cm2). No aortic regurgitation is \nseen. The mitral valve appears structurally normal with trivial \nmitral regurgitation. The pulmonary artery systolic pressure \ncould not be determined. There is a trivial/physiologic \npericardial effusion. \n\nCompared with the prior focused study (images reviewed) of \n___, left ventricular systolic function is probably \nsimilar, although suboptimal image quality of both studies \nprecludes definite comparison. \n\n___ CXR\n \nIMPRESSION: \n \nGeneralized improvement in both lungs is probably due to \ndecrease in pulmonary \nedema, now mild, and decrease in previous moderate right pleural \neffusion. \nThere is still substantial consolidation in the right upper lobe \nprobably \npneumonia but the bilateral lower lobe components have improved. \n Heart size \ntop-normal. No pneumothorax. \n\nMICRO\n========\nFINAL REPORT ___\n\n C. difficile DNA amplification assay (Final ___: \n CLOSTRIDIUM DIFFICILE. \n Positive for toxigenic C. difficile by the Illumigene \nDNA\n amplification. (Reference Range-Negative). \n\n___ 12:53 pm SPUTUM Source: Expectorated. \n\n GRAM STAIN (Final ___: \n <10 PMNs and <10 epithelial cells/100X field. \n 2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). \n 2+ ___ per 1000X FIELD): BUDDING YEAST. \n QUALITY OF SPECIMEN CANNOT BE ASSESSED. \n\n RESPIRATORY CULTURE (Preliminary): \n Further incubation required to determine the presence or \nabsence of\n commensal respiratory flora. \n KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n GRAM NEGATIVE ROD #2. SPARSE GROWTH. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n KLEBSIELLA PNEUMONIAE\n | \nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n \nBrief Hospital Course:\nMr. ___ is a ___ M w/ HTN, HLD, DMII, and old MI transferred \nfrom ___ w/ NSTEMI w/ diffuse 3 vessel disease s/p DES to \nmid-LAD occlusion found to have severe Cdiff.\n\nACTIVE ISSUES\n==============\n# NSTEMI \nNSTEMI based on STE aVR and V1 but o/w ST depressions w/ \nsignificant multi vessel disease but significant stenosis in LAD \ns/p DES that occluded diagnonal. Repeat cath unchanged. He was \nstarted on plavix, atorvastatin, ACE-I, and metoprolol. Echo \nshowed LVEF 35-40% with hypokinesis of mid-distal LV segments \nand apex. He was started on warfarin for his hypokinetic LV as \nwell as his atrial fibrillation as discussed below.\n\n# ___\nPossibly mixed cardiogenic/distributive given mixed venous O2 \n65%, CI 2.1, PCWP 25. He initially required pressors and balloon \npump and was then successfully weaned off both. He remained \nhemodynamically stable during rest of hospital course. \n\n# Atrial Fibrillation\nPatient with a reported history of paroxysmal afib per his PCP \nfor which he was maintained on digoxin as well as aspirin 325mg \nPO daily prior to admission. He was found to be in atrial \nfibrillation during admission and the decision was made to \nanticoagulate with Coumadin. He was continued on home dose \ndigoxin. His home dose aspirin was decreased as discussed above \nwith initiation of Coumadin.\n\n# Hematuria: \nLikely traumatic in setting of systemic anticoagulation, as \npatient pulled at ___. Cytology was negative. He will followup \noutpatient with urology.\n\n# Dyspnea: \nPatient had acute episodes of dyspnea. This was mainly \nattributed to pulmonary edema and improved with diruesis. \nAdditionally, CXR showed possible consolidation of RUL, \nconcerning for aspiration pneumonia. However, treatment was \ndeferred as he had no other focal signs of infectious pna. He \ndid have sputum cultures which grew Klebsiella pneumonia but on \ndiscussion with ID, felt this did not warrant any treatment as \nhe was asymptomatic. He was discharged on po lasix 20 mg daily \nwith next electrolytes to be checked ___. \n \n# C diff, severe: \nHad loose stool in setting of antibiotic tx for Hpylori \n(initiated outpatient). Given WBC >15, ___, age >___ treated as \nsevere. Patient was started on vancomycin 125mg PO qid for 14 \nday course (day ___, last day ___. \n \n# GASTROESOPHAGEAL REFLUX DISEASE (GERD): \nEndoscopy confirmed H Pylori treated with PPI + \nclarithromycin/amoxicillin since ___ for 14 days. Omeprazole \nwas continued. Antibiotics held in setting of c.diff infection. \n\n# Delirium: \nPatient with frequent sundowning during hospitalization \nrequiring Seroquel po.\n\nCHRONIC ISSUES\n===============\n# Spinal Stenosis: Continued gabapentin, d/ced naproxen. Did \nnot complain of pain throughout hospital course. Explained he \nshould not take any more NSAIDS in setting of recent ACS and now \non Coumadin, Plavix and asa. \n# DM: maintained on ISS during admission and discharged on home \nglipizide and metformin\n# HTN: Home dose metoprolol uptitrated. Home dose lisinopril \ndecreased. Home dose imdur discontinued.\n# HLD: Transitioned home dose simvastatin to atorvastatin\n\nTRANSITIONAL ISSUES\n=====================\n- Discharge weight: 63.7kg \n- patient will require urology followup given hematuria during \nadmission. Urine cytology negative.\n- patient will need to be treated for hpylori once he completes \na course of PO Vancomycin for Severe CDiff\n- Please check electrolytes on ___ on lasix\n- Coumadin initiated given atrial fibrillation, ASA decreased \nfrom 325 mg to 81 mg daily\n- Started on Plavix given recent stent placement, atorvastatin \n80 mg (stopped simvastatin), and Lasix 20 mg po daily\n- Home metoprolol was increased from 25 mg XL to 50 mg XL daily, \nlisinopril decreased to 2.5 mg po daily and home imdur was \ndiscontinued\n- patient will need to continue a 14 day course of PO Vanc (day \n___- ___ last day ___ for cdiff infection\n- Patient instructed to not take any NSAIDS\n- SLP treatment at rehab for pharyngeal strengthening exercises\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 600 mg PO TID \n2. Naproxen 500 mg PO DAILY \n3. MetFORMIN (Glucophage) 500 mg PO BID \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. GlipiZIDE 2.5 mg PO BID \n6. Simvastatin 40 mg PO QPM \n7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \n8. Lisinopril 10 mg PO DAILY \n9. Digoxin 0.125 mg PO DAILY \n10. Aspirin 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin EC 81 mg PO DAILY \n2. Digoxin 0.125 mg PO DAILY \n3. Metoprolol Succinate XL 50 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Warfarin 4 mg PO DAILY16 \n6. GlipiZIDE 2.5 mg PO BID \n7. Clopidogrel 75 mg PO DAILY \n8. Omeprazole 20 mg PO BID \n9. Vancomycin Oral Liquid ___ mg PO Q6H \n10. MetFORMIN (Glucophage) 500 mg PO BID \n11. Gabapentin 600 mg PO TID \n12. Lisinopril 2.5 mg PO DAILY \n13. Furosemide 20 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nNSTEMI s/p ___, likely mixed cardiogenic/distributive \nHematuria\nDyspnea\nC. dif, severe\nGERD\nDelirium\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ because you were experiencing chest \npain due to a heart attack. In the cath lab you were found to \nhave blockage of your arteries, and a stent was placed. We also \nmanaged your low blood pressure, infectious diarrhea, and trauma \nfrom foley placement. You responded well. \n\nPlease continue taking your medications as prescribed. You are \nbeing started on coumadin. Please do not take any non-steroidal \nantiinflammatory drugs (NSAIDS) such as ibuprofen, advil, \nmotrin, aleve, naproxen. Please also follow-up with your \ncardiology and PCP appointments as scheduled\n\nIt was a pleasure taking care of you,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I214", "R570", "I509", "R578", "A047", "N179", "S3730XA", "I2510", "E118", "X58XXXA", "Y92239", "I10", "E785", "T45515A", "Z86718", "Z7901", "R310", "Z7902", "I480", "Z23", "K2960", "B9681", "Z87891", "I252", "R410", "K219" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "R570: Cardiogenic shock", "I509: Heart failure, unspecified", "R578: Other shock", "A047: Enterocolitis due to Clostridium difficile", "N179: Acute kidney failure, unspecified", "S3730XA: Unspecified injury of urethra, initial encounter", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E118: Type 2 diabetes mellitus with unspecified complications", "X58XXXA: Exposure to other specified factors, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "T45515A: Adverse effect of anticoagulants, initial encounter", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "R310: Gross hematuria", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I480: Paroxysmal atrial fibrillation", "Z23: Encounter for immunization", "K2960: Other gastritis without bleeding", "B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere", "Z87891: Personal history of nicotine dependence", "I252: Old myocardial infarction", "R410: Disorientation, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "N179", "I2510", "I10", "E785", "Z86718", "Z7901", "Z7902", "I480", "Z87891", "I252", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \namoxicillin\n \nAttending: ___.\n \nChief Complaint:\nWeakness and lethargy \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPatient is a ___ year old female with history of chronic\nabdominal pain and anemia w/ recent Fe sucrose infusion (___)\ncomplicated by infusion reaction (mottling and discoloration of\nfeet) s/p IV steroids who presents with increasing lethargy and\nheadache.\n\nHistory per ___ records and per her Aunt as patient cannot\nprovide much history. Per her aunt, ___ has been doing well\nrecently without any illness, behavioral change. She had a cold\nshe was getting over but otherwise doing well. She had an Fe\ntransfusion on ___ around 3:30P at ___ and the aunt\naccompanied her to the visit. Towards the end of the infusion,\n___ developed mottle purple lower extremities and was having\nnausea, heart racing. She was sent to ___ where she had SBP\nup to 144. Her exam per ___ records notable for \"shivering...\ndoesn't open her eyes...mottled hands and feet\". There was no\nconcern for respiratory distress. She was given 50 mg IV\nBenadryl, 100 mg IV hydrocortisone and observed for 5 hours and\nthen discharged. At that time ___ was reportedly \"lethargic\"\nmeaning sleeping frequently but able to sit up and walk without\nissue. They arrived home and ___ went to bed. Around 6:00 AM\non ___, ___ aunt check on her and she was still sleeping.\nShe was reporting a headache (which the transfusion place said\nwould happen) but did not mention other characteristic. \n___\naunt gave her acetaminophen and water and ___ went back to\nsleep. Over the next few hours, she heard ___ awake several\ntimes and use the bathroom. Then as it got later and later into\nthe day and ___ was not up and about yet, her aunt became\nworried. She told ___ to call the ___ which she\nwas able to do. She reportedly said she continued to have a\nheadache and felt sleepy. She was instructed to go to the ED. \n\nShe went to the ED at ___ for evaluation. At ___ she\nhad T 99.5, P 58, RR 15 and sat 100%. BP 110/67. She was\nreportedly drowsy and arousing to voice, \"alert oriented x3\",\nconsistent eye fluttering, pupils reactive to light and\nextraocular eye movements full, with reportedly \"non focal \nexam\".\nLab work notable for WBC 7.2, Hgb 13.2, Na 142, bicarb 26, Cr\n0.9, Ca 9.4, normal LFTs, Fe 360, Ferritin 438. VBG pH was 7.43,\nPCO2 was 45.She had a normal ___ and LP with WBC 2, 100%\nmonocytes glucose 57, protein 24, no xanthochromia. She\nultimately had MRA and MRV which showed no thrombus or venoous\nthrombosis. She was transferred to ___ for further management.\n\nOn my interview she cannot provide much history other than to \nsay\nshe is here because \"I'm tired\". She keeps her eyes closed \nduring\nquestioning. She reports headache but cannot describe where it \nis\nor features other than +photophobia. She is unable to \nparticipate\nin other questioning, often getting tearful and saying \"the\nquestions are hard\". \n\nPer her father and aunt, she has no history of seizures, or CNS\ninfection. She did have a concussion at ___ years old. \n \nPast Medical History:\nAnemia \n \nSocial History:\n___\nFamily History:\nMother with a celiac disease and autoimmune hypothyroidism. Dad\nis healthy. She has a cousin with seizures.\n \nPhysical Exam:\nAdmission exam:\n98.1 76 130/78 14 96% RA \nGeneral: appears to be sleeping, occasional eye lid fluttering,\nlip movements, occasional slow movements of head from side to\nside\nHEENT: no trauma, no jaundice, no lesions of oropharynx \nCV: RRR, wwp\nPulm: breathing comfortably on RA \nExt: clammy, warm and no rash\n\nNeurologic:\n\n-Mental Status: She frequently gets upset during exam and is\ntearful at times, then abulic at other times. Eyes open only\nbriefly to voice. She is oriented to ___ but not full\ndate. Knows she is in a \"hospital\" but not the name. She says \nshe\nis in the hospital because, \"I'm tired\". She is unable to \nprovide\nhistory. Speech is not dysarthric, says ___ words when asked\nquestions, no spontaneous speech output. Follows simple commands\nlike open eyes, lift legs. She is able to name \"key\" and\n\"feather\" on stroke card but then stops naming and closes her\neyes. She reads the first sentence on stroke card but then no\nmore and closes her eyes. When asked to describe stroke card\npicture she says, \"dishes\". She does not participate in further\nexam.\n\n-Cranial Nerves:\n II, III, IV, VI: Pupils 8 mm->6 mm. EOMI without nystagmus. \nVFF\nto confrontation. Fundoscopic exam revealed no papilledema,\nexudates, or hemorrhages.\n VII: No facial droop, facial musculature symmetric with \ngrimace.\n VIII: Hearing intact to exam\n IX, X: Palate elevates symmetrically.\n XII: Tongue protrudes in midline.\n\n-Motor: Normal bulk, tone throughout. She says she cannot move\nher arms. When arms placed over her head, her arms slowly miss\nher face and slowly drops to the bed in a controlled fashion. \nShe\ndoes lift her arms to hold the side rails of the bed\nspontaneously. She lifts her legs antigravity and holds them\nwithout drift.\n\n-Sensory: slightly withdrawals in upper extremities and says\n\"ouch\", briskly withdrawals in lower extremities to noxious\nstimuli and says \"ouch\"\n\n-DTRs:\n ___ Tri ___ Pat Ach\n L 2 2 0 3 2\n R 2 2 0 3 2\n Plantar response was flexor bilaterally.\n\n-Coordination: patient could not participate\n\n-Gait: could not assess as patient would not get out of bed\n\nDischarge Exam:\nGeneral: sitting up in her chair with eyes closed\nHEENT: no trauma, no jaundice, no lesions of oropharynx \nCV: sinus bradycardia, no m/r/g\nPulm: Breathing comfortably on RA \nExt: Warm and well perfused, no rash or mottling\n\nNeurologic:\n\n-Mental Status: Answering questions with slow short sentence.\nMore humor and complex sentences observed today.\nEyes intermittently close while she is talking. Speech\nis not dysarthric, no spontaneous speech output. Follows\nsimple commands.\n\n-Cranial Nerves:\nII, III, IV, VI: Pupils 8 mm->4 mm. EOMI without nystagmus. \nV: facial sensation intact throughout\nVII: No facial droop, facial musculature symmetric with grimace\nbut limited facial movements.\nIX, X, XII: palate elevates symmetrically, tongue midline\n\n-Motor: Normal bulk, tone throughout. Lifting arms and legs\nagainst gravity but not against resistance (___)\n\n-Sensory: Sensation intact to touch and temperature throughout\n\n-DTRs: 1+ patellar, biceps, brachioradialis throughout\n\n-Coordination: No dysmetria or tremor. \n\n-Gait: Ambulated well with a ___.\n \nPertinent Results:\nAdmission labs:\n===============\n___ 12:59PM GLUCOSE-77 UREA N-8 CREAT-0.7 SODIUM-142 \nPOTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14\n___ 12:59PM ALT(SGPT)-9 AST(SGOT)-13 ALK PHOS-39 TOT \nBILI-0.3\n___ 12:59PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-1.7\n___ 12:59PM tTG-IgA-7\n___ 12:59PM WBC-5.0 RBC-3.89* HGB-11.5 HCT-34.4 MCV-88 \nMCH-29.6 MCHC-33.4 RDW-12.4 RDWSD-39.8\n___ 12:59PM PLT COUNT-235\n___ 05:11AM URINE HOURS-RANDOM\n___ 05:11AM URINE UCG-NEGATIVE\n___ 05:11AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 05:11AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 05:11AM URINE BLOOD-LG* NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 05:11AM URINE RBC-5* WBC-1 BACTERIA-FEW* YEAST-NONE \nEPI-0\n___ 05:11AM URINE MUCOUS-RARE*\n___ 04:34AM ___ PTT-27.2 ___\n___ 04:28AM WBC-6.4 RBC-4.17 HGB-12.6 HCT-37.4 MCV-90 \nMCH-30.2 MCHC-33.7 RDW-12.4 RDWSD-40.8\n___ 04:28AM NEUTS-58.2 ___ MONOS-7.1 EOS-0.2* \nBASOS-0.6 IM ___ AbsNeut-3.70 AbsLymp-2.14 AbsMono-0.45 \nAbsEos-0.01* AbsBaso-0.04\n___ 04:28AM PLT COUNT-246\n___ 04:11AM ___ PO2-50* PCO2-34* PH-7.44 TOTAL \nCO2-24 BASE XS-0 COMMENTS-GREEN TOP\n___ 04:10AM GLUCOSE-84 UREA N-7 CREAT-0.8 SODIUM-143 \nPOTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14\n___ 04:10AM estGFR-Using this\n___ 04:10AM ALT(SGPT)-9 AST(SGOT)-14 CK(CPK)-67 ALK \nPHOS-41 TOT BILI-0.3\n___ 04:10AM CK-MB-<1\n___ 04:10AM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-2.9 \nMAGNESIUM-1.8\n___ 04:10AM VIT B12-227*\n___ 04:10AM TSH-2.7\n___ 04:10AM TSH-2.6\n___ 04:10AM ___ TITER-1:1280* CRP-3.4 \ndsDNA-NEGATIVE\n___ 04:10AM C3-121 C4-27\n___ 04:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \ntricyclic-NEG\n\nEEG ___:\n==============\nIMPRESSION: This telemetry captured no pushbutton activations. \nThe background showed normal waking and sleep patterns. There \nwere no focal abnormalities, epileptiform features, or \nelectrographic seizures. A bradycardia was noted. \n\nIMAGING:\n========\nMRI BRAIN WITH/WITHOUT CONTRAST ___\n\nFINDINGS: \n \nA 5 mm FLAIR hypointense and T1 isointense lesion at midline \nbetween the \nanterior and posterior pituitary is noted. There is no evidence \nof \nhemorrhage, edema, mass effect, midline shift or infarction. The \nventricles and sulci are normal in caliber and configuration. \nThere is no abnormal enhancement after contrast administration. \n \nIMPRESSION: \n \nA 5 mm FLAIR hypointense and T1 isointense lesion at midline \nbetween the \nanterior and posterior pituitary likely represents a Rathke's \ncleft cyst. \nFurther evaluation is needed, dedicated pituitary MR may be \nobtained. \n \n\n \nBrief Hospital Course:\nSee worksheet\n \nMedications on Admission:\nfamotidine 40 mg daily\nbirth control per her aunt\n \n___:\n1. ___ 250 mcg PO DAILY \n2. Famotidine 40 mg PO DAILY \n3. Metoprolol Tartrate 12.5 mg PO DAILY \n4. Multivitamins W/minerals 1 TAB PO DAILY \n5. Nortriptyline 10 mg PO QHS \n6. ___ 1 item miscellaneous ONCE \nPrognosis: Good\n___: 13 months \nRX ___ Once Disp #*1 Each Refills:*0 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nFunctional neurological syndrome \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___ \n___.\n\nYou were in the hospital because of headache, lethargy, and \nweakness after an iron infusion.\n\nYou had a number of tests performed in the hospital, all of \nwhich were reassuring. An MRI of your brain showed no evidence \nof stroke or inflammation. An EEG to monitor your brain waves \nshowed no evidence of seizure. Your weakness gradually improved \nover the course of your hospitalization and will continue to \nimprove after you leave the hospital. \n\nAfter leaving the hospital, you should continue to work on \nimproving your strength. It will improve as long as you work \nhard!\n\nWe wish you the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "F4489", "R29818", "I7300", "I951", "R000", "F410", "E869", "K219", "D509", "D519", "F329" ]

[ "F4489: Other dissociative and conversion disorders", "R29818: Other symptoms and signs involving the nervous system", "I7300: Raynaud's syndrome without gangrene", "I951: Orthostatic hypotension", "R000: Tachycardia, unspecified", "F410: Panic disorder [episodic paroxysmal anxiety]", "E869: Volume depletion, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "D509: Iron deficiency anemia, unspecified", "D519: Vitamin B12 deficiency anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified" ]

[ "K219", "D509", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \namoxicillin / iron\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 10:45PM PLT COUNT-244\n___ 10:45PM NEUTS-55.7 ___ MONOS-10.8 EOS-0.7* \nBASOS-0.9 IM ___ AbsNeut-2.99 AbsLymp-1.70 AbsMono-0.58 \nAbsEos-0.04 AbsBaso-0.05\n___ 10:45PM WBC-5.4 RBC-4.19 HGB-13.4 HCT-41.2 MCV-98 \nMCH-32.0 MCHC-32.5 RDW-12.4 RDWSD-44.2\n___ 10:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \ntricyclic-NEG\n___ 10:45PM ALBUMIN-4.8 CALCIUM-9.6 PHOSPHATE-3.0 \nMAGNESIUM-2.1\n___ 10:45PM LIPASE-31\n___ 10:45PM ALT(SGPT)-20 AST(SGOT)-26 ALK PHOS-48 TOT \nBILI-0.4\n___ 10:45PM GLUCOSE-128* UREA N-15 CREAT-1.1 SODIUM-137 \nPOTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-14\n___ 03:17AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.5 \nLEUK-NEG\n___ 03:17AM URINE COLOR-Straw APPEAR-CLEAR SP ___\n___ 03:17AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 03:17AM URINE UCG-NEGATIVE\n___ 03:17AM URINE HOURS-RANDOM\n\nPERTINENT LABS:\n===============\n___ 05:45AM BLOOD VitB12-956*\n___ 05:45AM BLOOD TSH-0.99\n___ 05:45AM BLOOD Free T4-1.3\n___ 05:45AM BLOOD VITAMIN B1-WHOLE BLOOD-PND\n\nMICRO:\n======\n___ 3:17 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nIMAGING:\n========\nnone\n\nDISCHARGE LABS:\n===============\nno labs on day of discharge\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: ___ 1136 Temp: 98.1 PO BP: 107/68 R lying HR: 68 \nRR: 18 O2\nsat: 100% O2 delivery: RA \nGENERAL: NAD, sitting up in chair, smiling, moving head around\nEYES: Sclera anicteric and without injection. \nCARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.\nRESP: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender.\nEXTREMITIES: Pulses DP/Radial 2+ bilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: Speech slow but markedly improved today and speaks \nin simple\nsentences. Sitting in a chair and able to move all extremities, \nfollow commands such as moving fingers/toes on command and \nsticking thumb up.\nPSYCH: Alert and awake, pleasant, smiling \n\n \nBrief Hospital Course:\nBRIEF HOSPITAL SUMMARY:\n=======================\n___ female with history of disordered eating, PTSD, GAD \nwith panic disorder, depression and functional neurological \ndisorder presenting from a therapy session with weakness, \nabnormal movement, and aphasia concerning for an acute \nfunctional neurological episode. She was evaluated by neurology \nand psychology who felt this was consistent with functional \nneurological disorder, similar to her prior presentation. She \nbegan working with ___ and OT and had made great improvement at \ntime of discharge to acute rehab. \n\nTRANSITIONAL ISSUES:\n====================\nFor rehab:\n[] Please continue aggressive ___ and OT for further improvement \nin functional status. \n[] On discharge, please ensure patient has follow up with her \nPCP and her therapist. \n[] Patient was having some intermittent nausea as appetite \nimproved. Please continue Zofran TID prn. QTc was 441 on EKG on \n___. If continuing Zofran use for >1 week, please recheck QTc \non ___ and d/c medication if prolonged.\n[] Patient has a history of disordered and restrictive eating. \nShe does well eating with encouragement and did not show any \nevidence of eating disorder while inpatient. Please continue \nensure supplements TID with meals. \n\nFor PCP/therapist:\n[] Please refer patient to psychiatrist for further titration of \npsychiatric medications, given report of previous sensitivity to \nmedications and concern for possible bipolar disorder diagnosis. \n\n[] Please follow up pending thiamine level. \n\nACUTE ISSUES:\n=============\n# GAD/Panic disorder\n# Depression\n# PTSD\n# Functional neurological disorder\nPatient presented from a therapy session where she had acute \nonset of weakness, abnormal movement and aphasia in the setting \nof potential trigger of seeing shadows outside the door. Per her \ntherapist, over the past several weeks she has been increasingly \nmore hypervigilant and stressed about going home for the \nholidays to see her mom, which is a major trigger for her PTSD. \nHer therapist also reports a history of sexual/physical/verbal \nabuse but patient is very guarded about it and will not discuss \nit. On presentation to the ___ had significant and acute \nfunctional neurological symptoms, including weakness, abnormal \nmovement, and aphasia, resulting in impaired functioning. There \nwas concern for catatonia and she improved after 1 mg IV ativan \nin the ER. She endorsed significant anxiety, but denied SI and, \nper Psychiatry, she did not meet ___ criteria. She had a \nsimilar episode in ___ after IV iron infusion and was \nadmitted to the neurology service, where she was diagnosed with \nfunctional neurological disorder and she improved with ___ and \nrehab. She was also started on nortriptyline 10 mg QHS at that \ntime. Per her therapist, she is sensitive to medications and \nwhen she was on SSRIs she became manic, although she has not \nformally been diagnosed with bipolar disorder. Once admitted, \nshe was re-evaluated by neuro and psychiatry who determined this \nwas not consistent with catatonia and instead was likely \nfunctional neurological disorder. She was recommended for acute \nrehab to continue aggressive ___. She was continued on home \nnortriptyline 10mg qhs.\n\n#Disordered eating\n#Restrictive eating\n#Over-exercising \nShe has a history of restrictive eating and over-exercising and \nin the past she has had bradycardia and electrolyte \nabnormalities. Per her therapist, her disordered eating has \nbecome much worse over the past few months in the setting of \ntraveling a lot for work. She started an intensive outpatient \nprogram at ___ Eating ___ on ___. Per her \ntherapist, she restricts her calories to about 1,000 or less a \nday and over-exercises and is good at hiding it from people. \nFrom review of OMR, her BMI seems to be normal (between ___ \nand she currently does not have any electrolyte abnormalities \nbut she has been intermittently bradycardic with HR in the ___. \nHer appetite improved as her neurological symptoms began \nresolving. Per nutrition evaluation, no need for eating disorder \nprotocol while inpatient. She received Ensure supplements. Heart \nrates were stable, bradycardic in ___. Electrolytes were \nmonitored. TSH, T4 and B12 levels were all normal. She received \nthiamine supplementation. She received Zofran PRN for nausea \n(QTc 441).\n\nCORE MEASURES\n=============\n#CODE: full code \n#CONTACT: Per patient's request, do not contact her mother\n(___)\n -Emergency Contacts: ___ (___) ___ and ___ (Uncle) ___ \n -Therapist: ___, ___ ___ and coordinates\nall of her care and available for questions/calls at anytime\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Nortriptyline 10 mg PO QHS \n\n \nDischarge Medications:\n1. Multivitamins W/minerals 1 TAB PO DAILY \n2. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n \n3. Thiamine 100 mg PO DAILY \n4. Nortriptyline 10 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n#Functional neurological disorder\n#GAD/depression\n#PTSD\n#H/o disordered eating \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n===================================\n-You came to the hospital because you acutely had trouble moving \nand speaking. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n-You were seen by the neurologists who diagnosed you with \nfunctional neurological disorder. \n-You worked with physical and occupational therapists.\n-Your symptoms began to improve.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n============================================ \n- Please continue to take all your medications and follow up \nwith your doctors at your ___ appointments. \n- Please continue to work with your physical and occupational \ntherapists.\n\nWe wish you all the best!\n\nSincerely, \n \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "R29818", "F411", "F329", "F4310", "F5082", "Z6822", "D649" ]

[ "R29818: Other symptoms and signs involving the nervous system", "F411: Generalized anxiety disorder", "F329: Major depressive disorder, single episode, unspecified", "F4310: Post-traumatic stress disorder, unspecified", "F5082: Avoidant/restrictive food intake disorder", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "D649: Anemia, unspecified" ]

[ "F329", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nPercocet / cucumber / Tegaderm\n \nAttending: ___.\n \nChief Complaint:\ncracked tooth, s/p fall\n \nMajor Surgical or Invasive Procedure:\ntooth extraction\n \nHistory of Present Illness:\nPatient is a ___ year old G1P0 at ___ by U/S w/ h/o breast CA \non DDAC chemotherapy in pregnancy and thyroid CA who presents \nafter transfer from ED for tooth pain and for evaluation after a \nfall two days ago when she tripped on the ice and hit her \nshoulder. \n\nShe reports progressive dental pain in the right lower molar. \nShe has been unable to get dental treatment of her fractured \nmolar in the outpatient setting due to concerns about pregnancy \nand medical complexity. She was therefore referred to the ED. \nOMFS was consulted while she was in the ED w/ plan for removal \nin the OR tomorrow. Findings included cracked tooth #29 w/ \ncarriers extending to pulp. The patient was sent to OB triage \ngiven the mechanical fall. \n\nThe patient denies any abdominal trauma or bruising. She has \nbeen having very irregular cramping, no contractions. She also \nreports intermittent sharp shooting pain from the groin to her \nbelly button. Not exacerbated by anything. Pain cannot be \nreproduced. She denies and VB or LOF.\n \nPast Medical History:\nPNC:\n- ___ ___ by US\n- Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown\n- Genetics: LR ERA\n- FFS: wnl \n- GLT: wnl\n- US: ___, 67%, breech, ___, nl fluid, anterior placenta\n- Issues:\n*) breast cancer in pregnancy: unilateral mastectomy w/ sentinel\nLN biopsy, s/p chemotherapy completed ___, plan for PP \ntamoxifen\n\n*) mild asthma\n*) History of papillary thyroid cancer x 2, on levothyroxine\n175mcg daily; labs ___ - TSH 4.3 (elevated) but normal FT4 \n(1.1)\n\nROS: per hpi \n\nGYNHx: h/o breast cancer\n\nOBHx: G1, current\n \nPMH: h/o breast cancer, mild asthma, h/o papillary\n \nPSH: s/p unilateral mastectomy w/ sentinel LN biopsy\n \nSocial History:\n___\nFamily History:\nFamily history: Aunt and mother with ALS. Mother, aunt,\ngrandmother: ___. Father--prostate cancer (age ___\n \nPhysical Exam:\nOn admission:\n___ 19:03Temp.: 98.0°F\n___ 19:03BP: 121/65 (76)\n___ ___: 69\n___ ___: 67\nGEN: NAD\nRespiratory: no increased WOB\nAbdomen: no bruising, non-tender, gravid\nSVE: LCP\nTAUS: vtx, anterior placenta, no sonographic evidence of \nabruption, MVP 5.4 \nFHT: 130/moderate/+accels/ no decels\n\nOn discharge:\nVS: 98.0, 114/71, 73, 16, O2 96% \nGen: [x] NAD\nResp: [x] No evidence of respiratory distress\nAbd: [x] soft [x] non-tender \nExt: [x] no edema [x] non-tender\n \nDate: ___ Time: ___\nFHT: 120s, mod var, +accels, no decels reactive\nToco: occ ctx\n \nPertinent Results:\nn/a\n \nBrief Hospital Course:\nPatient is a ___ year old G1 with hx of breast CA on DDAC \nchemotherapy in pregnancy and thyroid CA admitted at 34w2d after \na fall. On admission, she had no evidence of abruption or \npreterm labor. She reported mild cramping and her cervix was \nLCP. Fetal testing was reassuring. She also had a painful, \ncracked tooth and had been evaluated by OMFS in the emergency \nroom. A plan was made for extraction in the OR. On HD#2, she \nunderwent an uncomplicated tooth extraction under local \nanesthesia. Her pain resolved. She continued to have some \nintermittent cramping and pink discharge, however, she had no \nevidence of preterm labor. She was discharged to home in stable \ncondition on HD#3 and will have close outpatient follow up.\n \nMedications on Admission:\nalbuterol, levothyroxine\n \nDischarge Medications:\nAcetaminophen 1000 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*50 Tablet Refills:*0 \nLevothyroxine Sodium 200 mcg PO DAILY\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCracked tooth\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___, \nYou were admitted to the ___ service for monitoring after \na fall and prior to your procedure with the oral surgeons for a \ntooth extraction. You procedure went well and your baby was \nmonitored before and after the procedure. You are now stable to \nbe discharged home. Please see instructions below. \n\nYou should continue biting down on a piece of gauze for 30 \nminute interval. You may stop after ___ gauze changes. \nYou should NOT have any hot/solid foods for the time being. You \nmay continue drinking cool liquids.\nYou may transition to soft foods (eggs, pasta, pancake) tonight.\nFor pain control, you may take Tylenol as needed (do not take \nmore than 4000mg in 24 hours). \n\nPlease call your primary dentist with any questions or concerns. \n\n\n Please call the office for: \n - Worsening, painful or regular contractions \n - Vaginal bleeding \n - Leakage of water or concern that your water broke \n - Abdominal pain \n - Nausea/vomiting \n - Fever, chills \n - Decreased fetal movement \n - Other concerns \n \nFollowup Instructions:\n___\n" ]

[ "O99613", "K029", "Z3A34", "O99513", "J45998", "O9989", "O99013", "O99283", "E890", "Y836", "M170", "M479", "Z853", "Z85850", "Z87891", "K219" ]

[ "O99613: Diseases of the digestive system complicating pregnancy, third trimester", "K029: Dental caries, unspecified", "Z3A34: 34 weeks gestation of pregnancy", "O99513: Diseases of the respiratory system complicating pregnancy, third trimester", "J45998: Other asthma", "O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium", "O99013: Anemia complicating pregnancy, third trimester", "O99283: Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester", "E890: Postprocedural hypothyroidism", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "M170: Bilateral primary osteoarthritis of knee", "M479: Spondylosis, unspecified", "Z853: Personal history of malignant neoplasm of breast", "Z85850: Personal history of malignant neoplasm of thyroid", "Z87891: Personal history of nicotine dependence", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "Z87891", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPercocet / cucumber\n \nAttending: ___\n \nChief Complaint:\nLeft breast invasive ductal carcinoma\n \nMajor Surgical or Invasive Procedure:\nLEFT BREAST TOTAL MASTECTOMY W/ SENTINEL LYMPH NODE BIOPSY \n___\n\n \nHistory of Present Illness:\nMs ___ is a ___ year old pregnant female with breast\ncancer. She had a palpable left breast lump, underwent\nultrasound, MRI, and core biopsy that showed a grade 2 invasive\nductal carcinoma, ER positive, PR positive, HER2 negative. She\nlater was found to be pregnant. She\nis currently feeling fine apart from tiredness. She reports that\nher levothyroxine dose was increased earlier this week. She also\nnotes some left nipple crusting, that there initially (after the\nbiopsy) was some bloody output that has since declined and \nbecome\nmild and crusty. Otherwise no changes. \n \nPast Medical History:\nPAST MEDICAL HISTORY: thyroid CA, postsurgical hypothyroidism,\nIBS, ovarian cysts, PID, spine arthritis, asthma,\nmononucleosisreported history of Lyme disease status post 3 \nweeks\nof antibiotic therapy. Hashimotos negative prior to surgery per\nher report\n\n \nSocial History:\n___\nFamily History:\nFamily history: Aunt and mother with ALS. Mother, aunt,\ngrandmother: ___. Father--prostate cancer (age ___.\n\n \nPhysical Exam:\nVS: Refer to flowsheet\nGEN: WD, WN in NAD\nCV: RRR\nPULM: no respiratory distress\nBREAST: L breast - No evidence of hematoma, seroma. Small amount\nof ecchymoses. Mildly tender to palpation. Incision healing \nwell.\nABD: soft, NT, ND\nEXT: WWP\nNEURO: A&Ox3\n \nBrief Hospital Course:\nThe patient was admitted on ___ with left breast invasive \nductal carcinoma for left total mastectomy and left axillary \nsentinel lymph node biopsy with Dr. ___. Please see \noperative note. The patient tolerated the procedure well. There \nwere no immediate complications. She was awoken from general\nanesthesia in the operating room and transferred to the\nrecovery room in stable condition. On post-operative check, she \nreported pain at the site of the incision and nausea, and had an \nepisode of emesis. The OB/GYN team recommended pain control with \nDilaudid. She was placed on subQ heparin and compression devices \nfor prophylaxis. She tolerated a regular diet. On ___, the \npain continued to have pain, which was discussed with OB/GYN, \nand her dosage of Dilaudid was increased. She was given stool \nsoftener given the usage of narcotics. She reported some mild \npink spotting, which was discussed with OB, and they performed \nan ultrasound which showed a strong fetal heart rate of 158. Per \ntheir report, she has been spotting since earlier in the \npregnancy as well. The dressing on the incision site continued \nto be clean dry and intact. There was no ecchymoses or hematoma \non the chest wall. Drain output was serosanguineous. At the \ntime of discharge on ___, vitals were stable, pain \nwell-controlled, and patient felt ready for discharge to home \nwith ___, with follow up appointments in place.\n \nMedications on Admission:\nMeds/Allergies: reviewed in OMR and medications listed here\nALBUTEROL SULFATE [PROAIR HFA] - Dosage uncertain - (Prescribed\nby Other Provider)\nLEVOTHYROXINE - levothyroxine 175 mcg tablet. 1 tablet(s) by\nmouth daily in the morning on empty stomach, 90 minutes prior to\nany food or other meds\nPNV ___ FUMARATE-FA [PRENATAL] - Dosage uncertain - \n(Prescribed by Other Provider)\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \n3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Severe \n4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, dyspnea \n5. Levothyroxine Sodium 175 mcg PO DAILY \n6. Prenatal Vitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft breast invasive ductal carcinoma\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. ___,\nYou were admitted to ___ for LEFT BREAST TOTAL MASTECTOMY W/ \nSENTINEL LYMPH NODE BIOPSY. You are now stable for discharge.\n\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. \n\nDRAIN DISCHARGE INSTRUCTIONS \nYou are being discharged with drains in place. Drain care is a \nclean procedure. Wash your hands thoroughly with soap and warm \nwater before performing drain care. Perform drainage care twice \na day. Try to empty the drain at the same time each day. Pull \nthe stopper out of the drainage bottle and empty the drainage \nfluid into the measuring cup. Record the amount of drainage \nfluid on the record sheet. Reestablish drain suction. \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\n \nFollowup Instructions:\n___\n" ]

[ "O9A112", "C50412", "O99512", "Y836", "E890", "O99282", "O26852", "Z3A14", "Z170", "J45909", "Z85850", "Z87891" ]

[ "O9A112: Malignant neoplasm complicating pregnancy, second trimester", "C50412: Malignant neoplasm of upper-outer quadrant of left female breast", "O99512: Diseases of the respiratory system complicating pregnancy, second trimester", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "E890: Postprocedural hypothyroidism", "O99282: Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester", "O26852: Spotting complicating pregnancy, second trimester", "Z3A14: 14 weeks gestation of pregnancy", "Z170: Estrogen receptor positive status [ER+]", "J45909: Unspecified asthma, uncomplicated", "Z85850: Personal history of malignant neoplasm of thyroid", "Z87891: Personal history of nicotine dependence" ]

[ "J45909", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PLASTIC\n \nAllergies: \ncucumber / Tegaderm\n \nAttending: ___\n \nChief Complaint:\nSurgical absence of L breast\n \nMajor Surgical or Invasive Procedure:\n1) ___ - Right prophylactic mastectomy, bilateral ___ \nreconstruction\n2) ___ - take back to OR for exploration of left flap \nvessels\n \nHistory of Present Illness:\n___ is a ___ year old female with history of L breast\ncancer (Stage I IDC and Paget's) and previous left sided \nmastectomy & SLNB. She was admitted to the hospital after her \nprophylactic R mastectomy with ___ reconstruction on \n___. She was taken back to the OR on ___ for flap \nexploration due to declining Vioptix recordings. \n \nPast Medical History:\nPNC:\n- ___ ___ by US\n- Labs: Rh+/ab neg/RPRNR/RI/HBsAg neg/HIV neg/ GBS unknown\n- Genetics: LR ERA\n- FFS: wnl \n- GLT: wnl\n- US: ___, 67%, breech, ___, nl fluid, anterior placenta\n- Issues:\n*) breast cancer in pregnancy: unilateral mastectomy w/ sentinel\nLN biopsy, s/p chemotherapy completed ___, plan for PP \ntamoxifen\n\n*) mild asthma\n*) History of papillary thyroid cancer x 2, on levothyroxine\n175mcg daily; labs ___ - TSH 4.3 (elevated) but normal FT4 \n(1.1)\n\nROS: per hpi \n\nGYNHx: h/o breast cancer\n\nOBHx: G1, current\n \nPMH: h/o breast cancer, mild asthma, h/o papillary\n \nPSH: s/p unilateral mastectomy w/ sentinel LN biopsy\n \nSocial History:\n___\nFamily History:\nFamily history: Aunt and mother with ALS. Mother, aunt,\ngrandmother: ___. Father--prostate cancer (age ___\n \nPhysical Exam:\nGen: Well-appearing F in no acute distress. \nHEENT: Normocephalic. Sclerae anicteric. \nCV: RRR\nR: Breathing comfortably on room air. No wheezing.\n\nBreasts: Bilateral reconstructed breasts soft and without\npalpable fluid collection, right mastectomy flap with lateral\necchymosis, ___ skin paddles warm bilaterally with good\ncapillary refill, JP drains x 2 to bulb suction draining\nserosanguinous fluid\n\nAbdomen: Soft, non-distended; umbilicus viable; lower abdominal\nincision without erythema or drainage; JP drains x2 to bulb\nsuction draining serosanguinous fluid \nExt: No cyanosis or edema\n \nPertinent Results:\n___ 04:38AM BLOOD WBC-12.0* RBC-2.88* Hgb-8.8* Hct-26.3* \nMCV-91 MCH-30.6 MCHC-33.5 RDW-13.2 RDWSD-44.3 Plt ___\n___ 03:44AM BLOOD WBC-11.3* RBC-3.32* Hgb-10.2* Hct-29.5* \nMCV-89 MCH-30.7 MCHC-34.6 RDW-13.0 RDWSD-42.0 Plt ___ - OR - Right prophylactic mastectomy, bilateral ___ \nreconstruction. Per protocol, patient stayed in PACU overnight. \n\n___ - OR - Patient was recovering well in PACU, with morning \nplan of clear liquid diet, out of bed to chair, and transfer to \nfloor. However, Vioptix signal of Left breast with declining \nvalues, so patient taken back to OR for exploration of L breast \nflap. Again stayed in PACU overnight per protocol\n\n___ - Recovering well. Febrile overnight to \"103\" but nurse \nremoved BAIR hugger and re-measured temperature at 99. clear \nliquid diet, out of bed to chair, transfer to floor\n\nShe was admitted to the plastic surgery service, where she was \nbegan the ___ postoperative pathway. She was given ASA 121.5 \ndaily (to be continued at discharge), Ancef (transitioned to \nDuricef at discharge), and SCH during her stay. She will \ndischarge home 4 with drains in place, to be removed at office \nvisit. She will daily bacitracin BID application to right \nmastectomy flap necrosis site. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 175 mcg PO DAILY \n2. BuPROPion XL (Once Daily) 300 mg PO DAILY \n3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN \n\n \nDischarge Medications:\nResume taking your previous home prescriptions, including \n1. Levothyroxine Sodium 175 mcg PO DAILY \n2. BuPROPion XL (Once Daily) 300 mg PO DAILY \n3. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN \n4. LIDOCAINE-PRILOCAINE - lidocaine-prilocaine 2.5 %-2.5 % \ntopical\ncream. Apply thick layer to port-a-cath site at least 30 minutes\nprior to port access. C___ - (Not Taking as Prescribed)\n5. OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 \ncapsule\nby mouth daily for heartburn symptoms - (Not Taking as\nPrescribed)\n6. TAMOXIFEN - tamoxifen 20 mg tablet. 1 tablet(s) by mouth \ndaily\n\nIn addition, patient discharged with these new medications:\n1. Aspirin 121.5 mg QD for 1 month\n2. Duricef 500mg PO BID x7 days w/ 1 refill\n2. Oxycodone ___ tablets, q4-6 hours #50\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSurgical absence of left breast; breast cancer\n \nDischarge Condition:\nAwake, alert, oriented. Stable\n \nDischarge Instructions:\nPersonal Care: \n1. You may keep your incisions open to air or covered with a \nclean, ___\nile gauze that you change daily. If \nany areas develop blistering, you will need to apply Bactroban \ncream\n twice a day. \n2. Clean around the drain site(s), where the tubing exits the \nskin, w\nith soap and water. \n3. Strip drain tubing, empty bulb(s), and record output(s) ___ \ntimes \nper day. \n4. A written record of the daily output from each drain should \nbe broug\nht to every follow-up \nappointment. your drains will be removed as soon as possible \nwhen\n the daily output tapers off to an \nacceptable amount. \n5. DO NOT wear a normal bra for 3 weeks. You may wear a soft, \nloose \ncamisole for comfort. \n6. You may shower daily with assistance as needed. Be sure to \nsecure\n your upper drains to a lanyard that \nhangs down from your neck so they don't hang down and pull out. \nY\n___ may secure your lower drains to \na fabric belt tied around your waist. \n7. The Dermabond skin glue will begin to flake off in about ___\n days. \n8. No pressure on your chest or abdomen \n9. Okay to shower, but no baths until after directed by your \ndoctor. \n. \nActivity: \n1. You may resume your regular diet. \n2. Keep hips flexed at all times, and then gradually stand \nupright \nas tolerated. \n3. DO NOT lift anything heavier than 5 pounds or engage in \nstrenuous\n activity for 6 weeks following \nsurgery. \n. \nMedications: \n1. Resume your regular medications unless instructed otherwise \nand\n take any new meds as ordered . \n2. You may take your prescribed pain medication for moderate to \nsevere ___\nn. You may switch to Tylenol \nor Extra Strength Tylenol for mild pain as directed on the \npackaging\n3. Take prescription pain medications for pain not relieved by \ntyleno\nl. \n4. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescript\nion pain medication. You \nmay use a different over-the-counter stool softener if you wish. \n\n5. Do not drive or operate heavy machinery while taking any \nnarcotic pain m\nedication. You may have \nconstipation when taking narcotic pain medications (oxycodone, \npercocet, vicodin, hydrocodone, dilaudid, \netc.); you should continue drinking fluids, you may take stool \nsoften\ners, and should eat foods that are \nhigh in fiber. \n. \nCall the office IMMEDIATELY if you have any of the following: \n1. Signs of infection: fever with chills, increased redness, sw\n___, warmth or tenderness at the surgical \nsite, or unusual drainage from the incision(s). \n2. A large amount of bleeding from the incision(s) or drain(s). \n3. Fever greater than 101.5 oF \n4. Severe pain NOT relieved by your medication. \n. \nReturn to the ER if: \n* If you are vomiting and cannot keep in fluids or your \nmedications.\n* If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) ___\nes, increased redness, \nswelling or discharge from incision, chest pain, shortness of\n breath, or anything else that is troubling you. \n* Any serious change in your symptoms, or any new symptoms that \nconcern \nyou. \n. \nDRAIN DISCHARGE INSTRUCTIONS \nYou are being discharged with drains in place. Drain care is a c\nlean procedure. Wash your hands \nthoroughly with soap and warm water before performing drain \ncare. Perfo\nrm drainage care twice a day. \nTry to empty the drain at the same time each day. Pull the \nstopper out of \nthe drainage bottle and empty \nthe drainage fluid into the measuring cup. Record the amount of \nd\nrainage fluid on the record sheet. \nReestablish drain suction. \n\n \nFollowup Instructions:\n___\n" ]

[ "Z421", "Z4001", "T85898A", "Y834", "Y92238", "J4520", "E890", "F329", "R509", "Z9012", "Z853", "Z85850" ]

[ "Z421: Encounter for breast reconstruction following mastectomy", "Z4001: Encounter for prophylactic removal of breast", "T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter", "Y834: Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92238: Other place in hospital as the place of occurrence of the external cause", "J4520: Mild intermittent asthma, uncomplicated", "E890: Postprocedural hypothyroidism", "F329: Major depressive disorder, single episode, unspecified", "R509: Fever, unspecified", "Z9012: Acquired absence of left breast and nipple", "Z853: Personal history of malignant neoplasm of breast", "Z85850: Personal history of malignant neoplasm of thyroid" ]

[ "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"I'm still hearing the voices\"\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nPlease see psychiatry consult notes by Drs ___, and \n___ dated ___ for details of HPI, past psychiatric, \nmedical, family, and social histories. Additionally, please \nrefer to medicine discharge summary dated ___ for details of \nmedicine ICU and floor course.\n\nBriefly, this is a ___ y/o homeless ___ F with PMH of\nTBI, HIV (not on HAART), HCV (not treated), and past psychiatric\nhx of polysubstance abuse (EtOH, crack cocaine, and heroin),\nunspecified mood disorder (MDD with psychotic features vs.\n___ mood disorder), and chronic AH who presented \nto\nthe ED from ___ station with tangential thoughts and complaint of\nrepeat head strikes after multiple falls. She was found to be\nexhibiting signs of severe EtOH withdrawal and was admitted to\nthe ICU where she was initiated on the phenobarb protocol. She\nwas transferred to the medical \n\nOn arrival to Deac 4: Pt stated that she was continuing to hear\nvoices and have suicidal thoughts. She declined to give details\nregarding her SI, stating, \"why would I tell you about it? I\nwould just do it.\" She also notes, \"and obviously you guys are\nnot gonna give me a razor to shave with or anything.\" \n\nShe reported that the voices she hears are both male and female.\nThey are not voices that she recognizes, and she cannot make out\nwhat they are saying. They are frequently worse as she tries to\nfall asleep. She has a difficult time discerning whether they\nhave been bothering her more frequently during the past several\nweeks, because she has been drinking and \"maybe doing crack.\" \nShe\nbecomes fixated on a story about smoking a crack pipe and\nthrowing it onto the ground \"where any kid could pick it up and\nlight it and smoke it,\" and she retells this multiple times.\n\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY: Per Dr. ___ note (___),\nconfirmed with ___ and updated as relevant:\n- Diagnosis on discharge from ___ 4 on ___: MDD with\npsychotic features vs. ___ mood disorder\n- Hospitalizations: ___ reports many prior hospitalizations\n(>10, including Arbour; >20 detox admissions per OMR). Most\nrecent hospitalization at ___ with discharge one day prior to\nED presentation (___).\n- Suicide ___ stated she ODed on\nAmitriptyline ___ years ago, per prior records stated she took\n___ pills, went to sleep on a park bench, and then woke up and\nwent to her shelter, did not go to the hospital. In the past she\nhas also reported ingestion of alcohol as a possible suicide\nattempt and a suicide attempt in ___ by overdose on unknown\npills to ED staff. ___ 4 discharge summary dated ___: \"Per\npt, OD on Ultram \"probably to hurt [her]self\" ___ yrs ago)\"\n- Violence: ___\n- Medication Trials: Reports h/o successful treatment with \nZoloft\n(denies knowledge of when). Also reports being txed with Haldol\n\"once\" and states she \"took too much, and my jaw was locked for\n___ hours.\" Past documentation from ___ 4 discharge summary\ndated ___ stated h/o treatment with Elavil. BEST indicated\nprevious reported treatment with Risperdal. OMR reveals past tx\nwith Risperdal and Zoloft (last filled ___. Stabilized on\nDeac 4 during most recent hospitalization with Amitriptyline and\nSeroquel.\n- Treaters: Denies past or present outpatient psychiatric\ntreaters. Per records, last had pending appointment at ___ \nfor\npsychiatry (Dr. ___, ___ at 9 AM). Currently states she\ndoesn't remember last time she saw psych.\n-Access to weapons: Denies\n\nPAST MEDICAL HISTORY:\nPCP: ___, MD\n- HIV (not currently taking antiretrovirals) - today denies that\nshe has HIV at all.\n- Hepatitis C\n- H/o head injury (Per ___ 4 ___ summary ___: \"pt reports she\nwas \"assaulted\" and subsequently received 300 stitches, was\nhospitalized x 2wks, and underwent rehab at ___ she \ndenies\nLOC or persistent deficits but receives SSDI for this injury\")\n\nHOME MEDICATIONS: \nNot currently taking any medications.\n\nPer Deac 4 Discharge Summary dated ___:\n1. Amitriptyline 50 mg PO QHS \n2. QUEtiapine Fumarate 50 mg PO QHS\n \nSocial History:\nSUBSTANCE ABUSE HISTORY: Per Dr. ___ note (___),\nconfirmed with ___ and updated as relevant:\n- Alcohol: ___ reports starting drinking age ___ due to\nconflict with parents. Reports numerous detox admissions (>20 \nper\nOMR). States that she was sober from ___ and only involved\nwith AA for 1 week of that time, which she stopped because she\n\"did not like it\". Most recent drink was 13 nips of vodka today.\nCurrently states she drinks about 1x/week. Denies history of \ncomplicated alcohol withdrawal but has required benzodiazepines\nduring detox admissions.\n- Benzodiazepines: Denies lifetime illicit use. Reports only use\nin detox when prescribed.\n- Marijuana: Reports remote use in high school, denies recent\nuse.\n- Crack cocaine: Denies current use, though say she has used in\nthe past.\n- Heroin: Reports h/o IVDU w/ heroin ___ years, previously\nreported ending ___ yrs ago. Denies current use.\n- Tobacco: past smoker, but denies currently.\n\nFORENSIC HISTORY:\nSays \"not lately\" and can't remember last time.\n\nPer Dr. ___ note (___): Inconsistent history: said\nshe spent ___ yrs\" in jail for \"shoplifting, drug related \nissues.\"\nThen states she was last in jail \"probably in early ___\n \nFamily History:\nStates she doesn't know.\n \nPhysical Exam:\n VS: T:98.4 P:106 BP:137/90 RR:16 SpO2: 100%(RA)\n * General: ___, in no apparent\ndistress. Appears stated age. \n * HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear.\n * Neck: Supple, trachea midline. No adenopathy or thyromegaly.\n * Back: No significant deformity, no focal tenderness.\n * Lungs: Clear to auscultation; no crackles or wheezes.\n * CV: Regular rate and rhythm; no murmurs/rubs/gallops; 2+ \npedal\n pulses.\n * Abdomen: Soft, nontender, nondistended; no masses or\n organomegaly.\n * Extremities: No clubbing, cyanosis, or edema.\n * Skin: Warm and dry, no rashes, scars, or lesions.\n\n \nNeurological:\n *Cranial Nerves-\n I: Not tested.\n II: Pupils equally round and reactive to light\nbilaterally. Visual fields are full to confrontation.\n III, IV, VI: Extraocular movements intact bilaterally;\nsignificant horizontal nystagmus (>7 beats) bilaterally.\n V, VII: Facial strength and sensation intact and\nsymmetric.\n VIII: Hearing intact to voice.\n IX, X: Palatal elevation symmetrical.\n XI: Sternocleidomastoid and trapezius normal bilaterally.\n XII: Tongue midline without fasciculations.\n *Motor- Normal bulk and tone bilaterally. No abnormal\nmovements, no tremor. Strength full power ___ throughout. No\ngross focal motor or sensory deficits, normal gait.\n *Coordination- Normal on ___.\n *Deep tendon reflexes- 2+ and symmetrical, toes downgoing.\n *Sensation- intact to light touch, position sense intact.\n *Gait- steady, no truncal ataxia, normal stance and posture.\n *Romberg- negative.\n\n \nPertinent Results:\n___ 06:05AM ___ \n___\n___ 06:05AM ___ \n___ IM ___ \n___\n___ 06:05AM PLT ___\n___ 06:05AM ___ ___ ABS ___ ABS \n___ ABS ___ ABS ___\n \nBrief Hospital Course:\nSAFETY: ___ was placed on 15 minute checks on admission and \nremained here on that level of observation throughout. She was \nunit restricted. There were no acute safety issues during this \nhospitalization.\n\nLEGAL: ___\nPSYCHIATRIC:\n\n___ is a ___ year old ___ female with a \nhistory of TBI, HIV (not on HAART therapy), HCV (not treated), \npolysubstance use (EtOH, crack cocaine, and heroin), unspecified \nmood disorder, and chronic auditory hallucinations who presented \nto the emergency department on ___ with alcohol \nintoxication, tangential thoughts, and complaints of repeated \nhead strikes, now s/p ICU/medicine course for alcohol withdrawal \nwith phenobarbital taper. On the unit, ___ was started on \nquetiapine (uptitrated to 300 mg BID) and on sertraline 25 mg \ndaily to good effect. ___ did well on the unit and attended \ngroups regularly. She recognized effect illicit drugs and \nalcohol have had on her mental health, social situation, and \ninterpersonal relationships. Although she has a history of \nmultiple relapses, failing to ___, and medication \nnonadherence, she kept repeating that this admission was \ndifferent and that she wants to maintain her sobriety. She \nshowered daily and had no issues with sleep or appetite. On the \nday of discharge, ___ endorsed/exhibited \"good\" mood and \neuthymic affect. Denied SI/HI and AVH. She expressed continued \nmotivation to maintain her sobriety, do 90 AA meetings in 90 \ndays, and desire to ___ at ___. A ___ application was \nsubmitted. Her PCP was updated on the plan and ___ \nappointments were coordinated. \n\nMEDICAL:\n\n#HIV: ___ not currently taking HAART. Most recent CD4 count \n42\non ___. \n- Continued Bactrim DS 1 tab daily for PCP ppx\n- ___ has appointment with Dr. ___ on ___ \non ___\nto discuss reinitiation of HAART\n\n#Hepatitis C: HCV Ab positive on ___. Not treated. \n- ___ has appointment with Dr. ___ on ___ \non ___\nto discuss treatment \n\nPSYCHOSOCIAL:\n\n#) GROUPS/MILIEU: ___ was encouraged to participate in \nunit’s groups, milieu, and therapy opportunities. Usage of \ncoping skills, mindfulness, and relaxation methods were \nencouraged. Therapy addressed family, social, work, and housing \nissues. The ___ enjoyed groups and participated. She also \nparticipated in AA meetings on the unit. \n\n#) COLLATERAL CONTACTS:\n\n-Treaters- PCP (Dr. ___\n\n-Records- Per OMR\n\n-Family- ___ refused family meetings\n\n#) FAMILY INVOLVEMENT:\n\nDespite encouragement from the team throughout her admission, \n___ refused family meetings. \n\n#) INTERVENTIONS:\n\n-D___ Referral: The team submitted a DMH application for the \n___ to receive services and ___ support.\n-Pharmacological treatment: Quetiapine and sertraline as above.\n-Individual/group/milieu therapy\n-Coordinated aftercare with SW\n\nINFORMED CONSENT:\n\n-Quetiapine, sertraline \n\nThe Team discussed the indications for, intended benefits of, \nand possible side effects and risks of this medication, and \nrisks and benefits of possible alternatives, including not \ntaking the medication, with this ___. We discussed the \n___ right to decide whether to take this medication as \nwell as the importance of the ___ actively participating \nin the treatment and discussing any questions about medications \nwith the treatment team, and I answered the ___ questions. \nThe ___ appeared able to understand and consented to begin \nthe medication. \n\nRISK ASSESSMENT:\n\nLow imminent risk of harm/violence to self/others.\n \n#) Chronic/Static Risk Factors:\n\nChronic mental illness, chronic medical illness, single, ongoing \nhomelessness.\n\n#) Modifiable Risk Factors:\n\n-Acute major mood episode with suicidal ideation - Modified by \nmedication adjustments and psychotherapeutic interventions as \nabove. \n\n-Active polysubstance misuse - Modified by phenobarbital taper \nwhile on medical floor for alcohol withdrawal and detox; \nattendance to AA meetings on the unit; list of free substance \nuse recovery resources in the community. \n\n-Limited outpatient/social support - Modified by aftercare \nplanning with SW; outpatient appointments; list of community \nresources. \n\n-___ - Modified by counseling on the unit. ___ \nwas adherent with medications on the unit. \n\n#) Protective Factors:\n\nProtective factors include current outpatient \nproviders/treatment, knowledge of community resources, \nmotivation to maintain sobriety, ___, and \n___ behaviors. \n\nPROGNOSIS:\n\nGood: ___ was engaged on the unit, adherent with \nmedications, and attended groups regularly. She has outpatient \nappointments and community resources. Current risk is low for \nintentional ___ given that ___ denies suicidal \nideation, intent and plan, is accepting of treatment, is \ncurrently sober and is ___ with plans. \n\n \nMedications on Admission:\n___ was not taking medications prior to admission. \n\nPer Deac 4 Discharge Summary dated ___:\n1. Amitriptyline 50 mg PO QHS \n2. QUEtiapine Fumarate 50 mg PO QHS\n\n \nDischarge Medications:\n1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \nRX ___ [Bactrim DS] 800 ___ mg 1 \ntablet(s) by mouth once a day Disp #*30 Tablet Refills:*0\n2. QUEtiapine Fumarate 300 mg PO BID \nRX *quetiapine [Seroquel] 100 mg 3 tablet(s) by mouth twice a \nday Disp #*180 Tablet Refills:*0\n3. Sertraline 25 mg PO DAILY \nRX *sertraline [Zoloft] 25 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUnspecified psychotic disorder ___ vs.\nschizophrenia spectrum)\nEtOH use disorder\nCocaine use disorder\nHeroin use disorder (in full sustained remission)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\nMental Status Examination:\n*Appearance: Woman who appears older than stated age, wearing\njeans and a sweater, tattoo on neck, hair in a bun, appropriate \nhygiene, no acute distress. \n Behavior: Good eye contact, cooperative, engaged. No\npsychomotor agitation/retardation. \n *Mood and Affect: 'Good' / Mostly euthymic, some smiling. \n *Speech: Normal rate, volume, rhythm, prosody, articulation.\nFluent in ___. \n *Thought process: Linear and ___. No loosening of\nassociations. \n *Thought Content: Denies SI/HI and AVH. Focused on maintaining\nher sobriety. \n *Judgment and Insight: Fair/Fair. ___ recognizes effect\ndrug use has had on her mental health, social situation, and\ninterpersonal relationships. She has a history of multiple\nrelapses, failing to ___, and medication nonadherence but\nkeeps repeating that this admission is different and that she\nwants to maintain her sobriety.\n Cognition: Awake, alert, attentive throughout interview. \nMemory\nintact to recent and remote history.\n\n \nDischarge Instructions:\nYou were hospitalized at ___ for alcohol detox, depressed \nmood, and suicidal ideation. We adjusted your medications, and \nyou are now ready for discharge and continued treatment on an \noutpatient basis. \n\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n-Please continue all medications as directed.\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\n\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n\n \nFollowup Instructions:\n___\n" ]

[ "F1994", "B20", "F1490", "F1099", "F209", "Z87820", "B1920", "Z87891" ]

[ "F1994: Other psychoactive substance use, unspecified with psychoactive substance-induced mood disorder", "B20: Human immunodeficiency virus [HIV] disease", "F1490: Cocaine use, unspecified, uncomplicated", "F1099: Alcohol use, unspecified with unspecified alcohol-induced disorder", "F209: Schizophrenia, unspecified", "Z87820: Personal history of traumatic brain injury", "B1920: Unspecified viral hepatitis C without hepatic coma", "Z87891: Personal history of nicotine dependence" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nalcohol intoxication\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ y/o ___ homeless F with PMH of TBI, HIV+, HCV, \npolysubstance abuse (alcohol, crack cocaine, and heroin), \nunspecified mood disorder (MDD with psychotic features vs. \nsubstance-induced mood disorder), and chronic AH who presented \nfrom ___ station via EMS with complaint of multiple head strikes \nfound to have EtOH intoxication and SI admitted to MICU for EtOH \nwithdrawal and CIWA monitoring.\n\nPatient is noted to be a poor historian; however she reports she \nhit her head \"multiple\" times today ___ falling asleep. Of note, \nshe reports active EtOH use and states her last drink was at \n1200 on ___. She is unsure if she used other drugs/medications. \nIn addition, she reports concern that she is having auditory \nhallucinations with the voices increasing in frequency. In \naddition, patient reports active SI although she does not have a \nplan.\n\nIn the ED, initial vitals: 98.2 88 150/98 16 100% RA. During \ntime in ED, patient became febrile to 101; a urinalysis/urine \ncx, CXR, and blood cultures were sent. \n- Exam notable for: pleasant patient with poor hygiene/dress, \ntangential and appearing to respond to internal stimuli, neuro \nintact, no clear HEENT trauma, mild upper thoracic tenderness, \n(+) tongue fasiculation\n- Labs were notable for:\n2.9>9.9/33.6<168 \nNa 140 K 3.5 Cl 103 HCO3 24 BUN 15 Cr 0.6 Gluc 111 AGap=17 \nALT 77 AST 196 AP 98 Tbili 0.6 Alb 3.9 \nSerum EtOH 21 \nSerum ASA, Acetmnphn, ___, Tricyc Negative \nLactate 1.0\nU/A with ketones, 6 WBCs, few bacteria, negative leuks, negative \nnitrites\n- Imaging showed:\nNCHCT (___): 1. No acute intracranial abnormality. 2. Stable \nleft parietal encephalomalacia.\nCXR (___): No acute cardiopulmonary abnormality or fracture.\n- Patient was given: \n40mg diazepam\n100mg thiamine\nMVI\n1mg folic acid\n30mg ketorolac\n2L NS\n1gm Tylenol\n- Psychiatry was consulted who felt patient was disorganized and \nendorsing AH and SI (no plan). Per their recommendations, \npatient was placed on a ___ with a 1:1 sitter with \nadmission to medicine for EtOH withdrawal\n\nOn arrival to the MICU, she was sleeping comfortably. Would open \neyes to voice and answer questions, but was overall very sleepy. \nDenies pain. Cannot articulate when last drink was, says \n\"yesterday.\" Denies taking anything else.\n\n \nPast Medical History:\nPer Dr. ___ (___), confirmed\nwith patient and updated as relevant:\n- HIV\n- Hepatitis C\n- H/o head injury (Per Deac 4 DC summary ___: \"pt reports she\nwas \"assaulted\" and subsequently received 300 stitches, was\nhospitalized x 2wks, and underwent rehab at ___ she \ndenies\nLOC or persistent deficits but receives SSDI for this injury\"\n\n \nSocial History:\nPer Dr. ___ (___), \nconfirmed with patient and updated as relevant: \n\"The patient reports that she was born and raised in ___ \nand that her parents were separated while she was growing up. \nShe \nstates that she lives with her grandmother her whole life until \n___ \nyears ago when her mother died and that she has been living in \nthe ___ since. She states that she has 2 daughters (age \n___ and ___, named ___ and ___ who are both enrolled at \n___ and that she also has 2 grandchildren. Denies contact with \n\nparents, whom she reports are not supportive. \" \nOn today's interview patient reports no contact with her family, \n\nreports having 3 living children (2 daughters and 1 son) and 1 \ndead son. She has no contact with her children. She did not wish \n\nto elaborate further. Confirms living at ___. \n\n \nFamily History:\nUnknown (pt refused to answer in past)\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n=========================== \nVitals: 98.2 103 138/77 22 99% ra\nGEN: lying in bed, somnolent, but wakes to voice, NAD\nHEENT: no scleral icterus, PERRL, mmm, nl OP\nNECK: supple, no JVD\nCV: tachycardic, regular rhythm, II/VI systolic murmur\nPULM: nl wob on ra, LCAB, no wheezes or crackles\nABD: soft, mild distension, normal bs, nontender\nEXT: warm, trace bilateral edema, 2+ DP pulses\nSKIN: no rashes or visible track marks\nNEURO: sleepy, oriented to person, didn't answer re place or \ntime, answering questions then falls asleep, moving all 4 \nextremities\nACCESS: PIV\n\nDISCHARGE PHYSICAL EXAM:\n===========================\n\nstable vital signs\nlying comfortably in bed.\nbilateral knee ecchymosis.\n \nPertinent Results:\nADMISSION LABS:\n===========================\n___ 03:27PM BLOOD WBC-2.9* RBC-3.81* Hgb-9.9* Hct-33.6* \nMCV-88 MCH-26.0 MCHC-29.5* RDW-17.9* RDWSD-56.8* Plt ___\n___ 03:27PM BLOOD Neuts-74.0* ___ Monos-4.5* \nEos-0.7* Baso-0.3 AbsNeut-2.16 AbsLymp-0.60* AbsMono-0.13* \nAbsEos-0.02* AbsBaso-0.01\n___ 03:27PM BLOOD Glucose-111* UreaN-15 Creat-0.6 Na-140 \nK-3.5 Cl-103 HCO3-24 AnGap-17\n___ 03:27PM BLOOD ALT-77* AST-196* AlkPhos-98 TotBili-0.6\n___ 03:27PM BLOOD Albumin-3.9\n___ 03:27PM BLOOD Osmolal-295\n___ 03:27PM BLOOD ASA-NEG Ethanol-21* Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n\nMICRO:\n===========================\n-Blood cx pending\n-Urine cx pending\n\nIMAGING/STUDIES:\n===========================\n-NCHCT (___): 1. No acute intracranial abnormality. 2. Stable \nleft parietal encephalomalacia.\n\n-CXR (___): No acute cardiopulmonary abnormality or fracture. \n\n\nDISCHARGE LABS:\n===========================\n\n \nBrief Hospital Course:\n___ y/o ___ homeless F with PMHx of TBI, HIV+, HCV, \npolysubstance abuse (alcohol, crack cocaine, and heroin), \nunspecified mood disorder (MDD with psychotic features vs. \nsubstance-induced mood disorder), and chronic AH who presented \nfrom ___ station via EMS with complaint of multiple head strikes \nfound to have EtOH intoxication and SI admitted to MICU for EtOH \nwithdrawal and CIWA monitoring, now stabilized and transferred \nto the floor, now medically stable for discharge to psychiatric \nfacility\n\nACTIVE ISSUES:\n========================\n# EtOH intoxication/withdrawal: on phenobarbital withdrawal \nprotocol. Last drink ___. Patient was loaded with \nphenobarbital, which may continue if the accepting psychiatric \nfacility is okay with administering, however there is no \ncontraindication to discontinuing.\n-Phenobarb protocol while inpatient, stopped at discharge\n-Continued MVI, thiamine, folate\n-Hydroxyzine PRN for additional agitation\n-seen by psychiatry and social work - appreciated.\n\n# Suicidal ideation: patient repeatedly stating \"I have suicidal \nthoughts\" and \"I'm depressed,\" though is unable to fully \nelaborate. Psychiatry saw the patient and had the following \nrecommendations: -Patient meets ___ criteria for \ninvoluntary admission, may not leave AMA, should continue 1:1 \nobservation.\n-Would hold on any psychiatric medications given acute alcohol \nwithdrawal.\n-If chemical restraint necessary, please call psychiatry for \nspecific recs. Please be aware that patient has cited \"jaw \nlocking\" with Haldol administration in the past, thus would \nconsider alternative antipsychotic.\n- seen by psychiatry - recommended inpatient psychiatric \nplacement, and transferred to deac 4.\n\n# FEVER: Patient febrile to 101 in the ED. No localizing signs \nof symptoms of infection. Suspect that this was likely related \nto acute ingestion, however given her murmur which has not been \ndocumented previously, obtained TTE which showed no evidence of \nvegetation or endocarditis.\n\n# Psychosis: suspect this is part of underlying psych disorder \nand not necessarily alcoholic hallucinosis. Will defer to \npsychiatry.\n-Appreciate Psychiatry recs\n\nCHRONIC STABLE ISSUES:\n========================\n# HIV: not on HAART, started Bactrim for PCP prophylaxis given \nlast CD4 count was <200, will send repeat CD4 count on ___ if \nstill inpatient. Patient was previously not taking her HAART \nmedications, will defer to outpatient.\n\n# HCV: not on active treatment\n- Monitor LFTs, as above\n\nTransitioanl issues:\nShould see PCP re HIV and HCV once psychiatrically stabilized.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Amitriptyline 25 mg PO QHS \n2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID \n3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY (not taking)\n4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY (not taking)\n5. Darunavir 600 mg PO BID (not taking)\n6. RiTONAvir 100 mg PO DAILY (not taking)\n\n \nDischarge Medications:\n1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. Thiamine 100 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPolysubstance abuse\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\nYou were admitted to ___ for evaluation of numerous falls, \nalcohol and substance abuse. While you were here you were \nbriefly in the intensive care unit where you were started on \nphenobarbital to help you withdrawal from alcohol and prevent \ndelirium tremens. You also disclosed that you were not taking \nany of your HIV medications. You were started on Bactrim as \nprophylaxis for opportunistic infections, and should follow up \nwith your outpatient providers regarding restarting your HIV \nmedications and for evaluation of your hepatitis C. You were \ndeemed medically stable for discharge to a psychiatric facility.\n \nFollowup Instructions:\n___\n" ]

[ "F10239", "F1110", "R45851", "Z87820", "B1920", "Z23", "Z590", "F1410", "R509", "F29", "Z21", "Z9114", "D72819" ]

[ "F10239: Alcohol dependence with withdrawal, unspecified", "F1110: Opioid abuse, uncomplicated", "R45851: Suicidal ideations", "Z87820: Personal history of traumatic brain injury", "B1920: Unspecified viral hepatitis C without hepatic coma", "Z23: Encounter for immunization", "Z590: Homelessness", "F1410: Cocaine abuse, uncomplicated", "R509: Fever, unspecified", "F29: Unspecified psychosis not due to a substance or known physiological condition", "Z21: Asymptomatic human immunodeficiency virus [HIV] infection status", "Z9114: Patient's other noncompliance with medication regimen", "D72819: Decreased white blood cell count, unspecified" ]

[]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nRagweed\n \nAttending: ___.\n \nChief Complaint:\nshortness of breath\n \n\n \nMajor Surgical or Invasive Procedure:\ns/p TRANSCATHETER MITRAL VALVE REPAIR on ___\n \nHistory of Present Illness:\n___ year old male with a past medical history of\nhyperlipidemia, congestive heart failure (EF 61%), mitral\nregurgitation, lymphoma, sarcoidosis, and obstructive sleep \napnea\nwho has been experiencing progressive dyspnea on exertion over\nthe last several months. His most recent echo showed moderate to\nsevere mitral regurgitation. He presented for planned mitraclip.\n \n\n \nPast Medical History:\nCHF\nMitral regurgitation\nCKD\nHyperlipidemia\nOSA\nAsthma\nDuodenal ulcer\nLymphoma\nGERD\nSarcoidosis with pulmonary and intestinal involvement\nBPH\nInflammatory bowel disease\nHard of hearing with cochlear implants\n \n PSH:\ncochlear implants\ncataract surgery\nknee surgery\nsplenectomy\nhernia repair\ntonsillectomy\nappendectomy\nrotator cuff repair \n?brain biopsy \nvasectomy \n \nSocial History:\n___\nFamily History:\nMother: ___, cardiac disease. \nFather: diverticulosis, peptic ulcer disease, died at age ___. \nMaternal grandfather: ___ cancer. \nTwo siblings, living and healthy. \n\n \nPhysical Exam:\nAdmission PE: \nVS: 103/51, HR 63 SR, O2 sat 99% RA \nGen: alert, not oriented but answers to name and asking\nappropriate questions. NAD. \nNeuro: PERLA, CN ___ intact. MAE, strengths ___. speech\nclear. \nNeck: no JVD lying flat. \nCV: RRR, ___ diastolic course murmur at ___. \nChest: clear ant \nABD: soft, NT \nExtr: no edema, feet warm, pulses palp \nSkin: intact, warm and dry\nAccess sites: right fem: DSD with no hematoma or ecchymosis. \nGU: condom cath with clear urine \nWeight: \nEKG: ___: SR, LAD, nl intervals \nTele: SR \n.\nDC:\nGen: alert, talkative, mildly confused \nNeuro: PERLA, CN ___ intact. MAE, strengths ___. speech\nclear. \nNeck: supple\nCV: RRR, ___ diastolic course murmur at LUSB. \nChest: clear ant \nABD: soft, NT \nExtr: no edema, feet warm, pulses palp \nSkin: intact, warm and dry\nAccess sites: right fem: DSD with no hematoma or ecchymosis. \n \n\n \nPertinent Results:\nAdmission labs:\n___ 12:53PM BLOOD WBC-10.1* RBC-3.44* Hgb-10.6* Hct-32.0* \nMCV-93 MCH-30.8 MCHC-33.1 RDW-14.4 RDWSD-48.7* Plt ___\n___ 12:53PM BLOOD ___ PTT-150* ___\n___ 12:53PM BLOOD Glucose-94 UreaN-21* Creat-1.2 Na-142 \nK-4.3 Cl-106 HCO3-24 AnGap-12\n___ 09:15AM BLOOD GGT-41\n___ 12:53PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.6\n___ 09:15AM BLOOD Albumin-3.5\n\nTRANSCATHETER MITRAL VALVE REPAIR ___\nTransfemoral Extreme Risk MITRAL REGURGITATION\nProcedures: TransSEPTAL transcatheter MITRAL valve repair \nCatheter Placement, Mitraclip sheath\nright femoral vein Percutaneous mitral Valve\ncase complexity required a multidisciplinary approach with \nCardiac Surgery and Interventional Cardiology. Vascular access \nwas obtained in the right femoral veinusing vascular ultrasound \ntechniques.\nRHC and LHC performed by transeptal approach and showed \nsignificant V waves\nTranseptal Puncture was done Using Lamp 45 and needle under \nfluoro and TEE guidance to ensure 4 cm\nclearance from annulus Unfractionated heparin was given to \nachieve an ACT> 250 seconds.\nA 0.035\" confida wire was advanced through sheath and used to \nadvance the Pascal Guide system The\nPascal was advanced through the guide and positioned across A2 \nand P2 under fluoro and TEE guidance. First Grab resulted in \nonly modest reduction in MR therefore, the leaflets were \nreleased and\nindependently grabbed again with reduction in MR to ___, and \ngreat hemodynamics (no V waves). An additional device was placed \nwith resultant 1+ MR and gradient of 2 mmHg The clip were \nreleased and sheath pulled to RA. No significant shunting seen, \ntherefore, sheath removed\nafter proglide in preclose fashion and applying skin suture \nThere was no evidence of complications following the procedure. \nThe patient was transported to PACU the in stable condition\n\nTransesophageal echocardiogram on ___: \nEjection Fraction:55-100%(nl M:52-72;F:54-74)\nFINDINGS:\nADDITIONAL FINDINGS: No TEE related complications.\nPRE-OPERATIVE STATE: Pre-bypass assessment.\nLeft Atrium ___ Veins: Dilated ___. No spontaneous \necho contrast is seen in the ___. No ___ mass/thrombus\nRight Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): \nDIlated RA. No spontaneous echo\ncontrast is seen in the RA/RA appendage. Lipomatous interatrial \nseptum. No atrial septal defect by 2D/color\nflow Doppler.\nLeft Ventricle (LV): Normal cavity size. Normal regional & \nglobal systolic function Normal ejection fraction.\nNo resting LV outflow tract gradient. No mass/thrombus.\nRight Ventricle (RV): Normal cavity size. Normal free wall \nmotion.\nAorta: Normal sinus diameter. Normal ascending diameter. Normal \ndescending aorta diameter. No dissection.\nSimple sinus atheroma. Siimple atheroma of ascending aorta. \nSimple arch atheroma.\nAortic Valve: Mildly thickened (3) leaflets. Minimal leaflet \ncalcification. No stenosis. Trace regurgitation.\nCentral jet.\nMitral Valve: Mildly thickened/myxomatous leaflets. No stenosis. \nMild annular calcification. SEVERE [4+]\nregurgitation. Eccentric jet.\nTricuspid Valve: Mildly thickened leaflets. Trace regurgitation.\nPericardium: No effusion.\nPOST-OP STATE: The post-bypass TEE was performed at 13:18:00. \nSinus rhythm.\nPost-op Comments ___ guidance provided for \ntrans-septal puncture and positioning\nand deployment of the two PASCAL devices\nSupport: Vasopressor(s): none.\nInteratrial Septum: Small residual secundum atrial septal defect \non color Doppler.\nLeft Ventricle: Similar to preoperative findings. SImilar \nregional function. Global ejection fraction\nis normal.\nRight Ventricle: No change in systolic function.\nAorta: Intact. No dissection.\nAortic Valve: No change in aortic valve morphology from \npreoperative state. Unchanged gradient.\nNo change in aortic regurgitation.\nMitral Valve: MitraClip(s). MitraClip(s) attached to both \nleaflets. Post-bypass, mean mitral valve\ngradient = 1.75mmHg. Similar gradient to preoperative state. \nMild [1+] valvular regurgitation.\nTricuspid Valve: No change in tricuspid valve morphology vs. \npreoperative state. No change in\nregurgitation vs preoperative state.\nPericardium: No effusion.\n.\nDC:\n\n___ 08:13AM BLOOD WBC-10.1* RBC-3.48* Hgb-10.8* Hct-32.8* \nMCV-94 MCH-31.0 MCHC-32.9 RDW-14.6 RDWSD-49.9* Plt ___\n___ 08:13AM BLOOD Glucose-86 UreaN-19 Creat-1.2 Na-141 \nK-4.7 Cl-106 HCO3-24 AnGap-11\n___ 12:53PM BLOOD Calcium-8.6 Phos-3.4 Mg-1.___ yo M with PMH of severe MR, HFpEF, OSA,\nsarcoid, BPH s/p Mitraclip using Pascal system. \n\n# Severe mitral regurgitation: s/p Mitraclip with no\ncomplications. Full report above. MR now dec to ___. right \ngroin site without sig ecchymosis or hematoma. \nMetoprolol restarted before discharge but lisinopril will be \nheld because of soft blood pressures on day of discharge. Please \nconsider restarting low-dose lisinopril at follow-up \nappointments. Anticoagulation is aspirin and Plavix for the \nmitral clip. He will return in 1 month for an echocardiogram to \nassess positioning of the mitral clips and will see Dr ___ in \napproximately 2 months\n\n# Chronic diastolic heart failure: looks euvolemic on exam. Pt's\nmain symptom was SOB. holding BB and ACEI for lowish BP after\nanesthesia. As noted above restarted metoprolol before discharge \nbut lisinopril was held. Started on Lasix 20 mg and low-dose \npotassium which is standard post mitral clip. His weight at \ndischarge is 154 pounds. \n\n# sarcoidosis: w/pulmonary and intestinal involvement. Good O2\nsats on RA. Unknown if he has cardiac involvement. \n- cont prednisone 1mg\n\n# hyperlipidemia: LDL 130, TC 212, HDL 57. on simva 20. Patient \ncould benefit from an increased dose of simvastatin if he has \nbeen tolerating at home.\n\n# asthma: no wheezes on exam and nl O2 sats. Continued Advair\n\n# GERD: change omeprazole to pantoprazole because of new Plavix.\n\n# BPH: currently on no meds, no trouble with urinary retention \nafter the procedure.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK (___) \n2. PredniSONE 1 mg PO DAILY \n3. Lisinopril 2.5 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. Simvastatin 20 mg PO QPM \n6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n7. Omeprazole 20 mg PO DAILY \n8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB \n9. FLUoxetine 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Clopidogrel 75 mg PO DAILY \n3. Furosemide 20 mg PO DAILY \n4. Pantoprazole 40 mg PO Q24H \n5. Potassium Chloride 20 mEq PO DAILY \n6. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN SOB \n7. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK (___) \n8. FLUoxetine 40 mg PO DAILY \n9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n10. Metoprolol Succinate XL 25 mg PO DAILY \n11. PredniSONE 1 mg PO DAILY \n12. Simvastatin 20 mg PO QPM \n13. HELD- Lisinopril 2.5 mg PO DAILY This medication was held. \nDo not restart Lisinopril until after you see Dr ___\n\n \n___ Disposition:\nHome\n \nDischarge Diagnosis:\nSevere mitral regurgitation s/p Mitraclip\nHypertension\nHyperlipidemia\nchronic diastolic heart failure\nSleep apnea\nSarcoid\nGERD\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted for your mitral valve clip procedure. By \nrepairing the valve your heart can pump blood more easily and \nyour shortness of breath should improve. \nIt is very important to take all of your heart healthy \nmedications. In particular, you are now taking Aspirin and \nClopidogrel (Plavix). These medications help to prevent blood \nclots from forming in/around the heart valve. If you stop these \nmedications or miss ___ dose, you risk causing a blood clot \nforming on your heart valve. This could cause it to malfunction \nand it may be life threatening. Please do not stop taking \nAspirin or Plavix without taking to your heart doctor, even if \nanother doctor tells you to stop the medications. \n \nYou will need prophylactic antibiotics prior to any dental \nprocedure. Please obtain a prescription for a one-time dose of \nantibiotics prior to procedures, and inform your dentist about \nyour recent cardiac procedure. \n \nPlease weigh yourself every day in the morning after you go to \nthe bathroom and before you get dressed. If your weight goes up \nby more than 3 lbs in 1 day or more than 5 lbs in 3 days, please \ncall your heart doctor or your primary care doctor and alert \nthem to this change. Your weight at discharge is 154 pounds. \n \nWe have made changes to your medication list, so please make \nsure to take your medications as directed. You will also need to \nhave close follow up with your heart doctor and your primary \ncare doctor. \n\nIf you were given any prescriptions on discharge, any future \nrefills will need to be authorized by your outpatient providers, \nprimary care or cardiologist.\n \nIf you have any urgent questions that are related to your \nrecovery from your procedure or are experiencing any symptoms \nthat are concerning to you and you think you may need to return \nto the hospital, please call the ___ Heart Line at \n___ to speak to a cardiologist or cardiac nurse \npractitioner. \nIt has been a pleasure to have participated in your care and we \nwish you the best with your health. \n\n \nFollowup Instructions:\n___\n" ]

[ "I340", "I5032", "Z006", "D8689", "E785", "J45909", "K219", "N400", "Z8042", "G4733", "Z8572", "Z87891", "Z9621", "H9190" ]

[ "I340: Nonrheumatic mitral (valve) insufficiency", "I5032: Chronic diastolic (congestive) heart failure", "Z006: Encounter for examination for normal comparison and control in clinical research program", "D8689: Sarcoidosis of other sites", "E785: Hyperlipidemia, unspecified", "J45909: Unspecified asthma, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z8042: Family history of malignant neoplasm of prostate", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8572: Personal history of non-Hodgkin lymphomas", "Z87891: Personal history of nicotine dependence", "Z9621: Cochlear implant status", "H9190: Unspecified hearing loss, unspecified ear" ]

[ "I5032", "E785", "J45909", "K219", "N400", "G4733", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIodine-Iodine Containing\n \nAttending: ___.\n \nChief Complaint:\ndifficulty with swallowing\npainful swallowing\ndiarrhea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with history of stage\nIIIA squamous cell carcinoma of lung undergoing chemoradiation\ncompleted at end of ___, multiple strokes, hypertension,\nhyperlipidemia, DMII, and prior colon cancer s/p hemicolectomy\nwho presents with throat pain and difficulty swallowing.\n\nShe was recently seen in the ED on ___ after a fall with head\nstrike. Imaging was negative and she was discharged home. K was\nnoted to be 3.2 so she was called back to the ED. Her K was\nrepleted and she was discharged home. Since then she has had\nsignificant odynophagia with difficulty swallowing leading to\npoor appetite, weakness, poor PO intake, and continued weight\nloss. She has also been having diarrhea that is occasionally\nbloody. She also notes persistent dry cough. She called her\nOncologist who recommended she present to the ED for further\nevaluation.\n\nOn arrival to the ED, initial vitals were 96.8 84 ___ 18 100%\nRA. Exam was notable for fatigued-appearing woman. Labs were\nnotable for WBC 2.9, H/H 10.5/31.9, Plt 178, Na 145, K 3.0,\nBUN/Cr ___, and lactate 1.1. Blood cultures were done. No\nimaging obtained. Patient was given 40mEq IV potassium. Prior to\ntransfer vitals were 98.1 72 134/69 20 100% RA.\n\nOn arrival to the floor, patient endorses the above history. She\nhas no acute issues or concerns. She denies fevers/chills, night\nsweats, headache, vision changes, dizziness/lightheadedness,\nweakness/numbnesss, shortness of breath, hemoptysis, chest pain,\npalpitations, abdominal pain, nausea/vomiting, hematemesis,\ndysuria, hematuria, and new rashes.\n\nREVIEW OF SYSTEMS: A complete 10-point review of systems was\nperformed and was negative unless otherwise noted in the HPI.\n\nPAST ONCOLOGIC HISTORY:\nBriefly, patient initially presented to care in ___ with\nhemoptysis. She was subsequently admitted for workup of same and\nhad a CT of the chest which showed a right infrahilar mass with\ncomplete occlusion of the right middle lobe bronchus and\natelectasis of the right middle lobe with high suspicion for \nlung\ncancer; there was evidence of bilateral intrathoracic \nadenopathy.\nDuring her hospital admission, she was seen by the \ninterventional\npulmonary team and scheduled for outpatient bronchoscopy.\n\nShe underwent bronchoscopy with EBUS under Dr. ___ care on\n___. FNA of the right middle lobe mass showed findings\nconsistent with squamous cell carcinoma; there was biopsy-proven\ninvolvement of the level 4L lymph node; sampling of the 11 L\nlymph node showed no malignant cells.\n\nPatient underwent staging PET scan on ___. This showed an \nFDG\navid 3.2 cm mass in the right infrahilar region with evidence of\nocclusion of the right middle lobe bronchus and atelectasis of\nthe right middle lobe. FDG avid subcarinal adenopathy measuring\nup to 1.3 cm was noted; additionally enlarged mediastinal and \nand\nhilar lymph nodes are also noted. A 2.2 cm left lower lobe\nsubpleural FDG avid lesion was also noted. No other distant\nmetastatic sites of disease were noted.\n\n___: Weekly ___ and radiation started.\n \nPast Medical History:\n- prior paramedian pontine infarct (___) \n- right-sided lenticulostriate territory infarct ___\n- Hypertension as per prior medical records(patient denies)\n- Dyslipidemia \n- Colon cancer 2/p right colectomy in ___ with prolonged\nstuttering course of adjuvant chemotherapy (diagnosed in setting\nof GI bleeding)\n- Cholecystectomy for chronic cholecystitis and gallstones in\n___\n- Diverticulosis\n- Hemorrhoids\n\n \nSocial History:\n___\nFamily History:\nMother had stroke in her ___ or ___. Her paternal \ngrandfather,\nfather, and brother all had colon cancer. Sister had ovarian\ncancer and has prostate cancer in her family.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n===========================\nVS: Temp 98.3, BP 110/62, HR 66, RR 18, O2 sat 100% RA.\nGENERAL: Pleasant woman, in no distress, lying in bed\ncomfortably.\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.\nABD: Soft, non-tender, 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.\nACCESS: Right chest wall port without erythema.\n\nDISCHARGE PHYSICAL EXAM:\n===========================\nVS: 24 HR Data (last updated ___ @ 2327)\n Temp: 98.3 (Tm 98.4), BP: 127/66 (115-131/53-69), HR: 66\n(58-73), RR: 18 (___), O2 sat: 97% (97-99%), O2 delivery: Ra \n\nGENERAL: Pleasant woman, in no distress, lying in bed\ncomfortably.\nHEENT: Anicteric, PERLLA, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: CTAB, no increased work of breathing\nABD: Soft, non-tender, non-distended, normoactive BS\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, alert and interactive thought, CN II-XII intact.\nStrength full throughout. Sensation to light touch intact.\nSKIN: No significant rashes.\n \nPertinent Results:\nADMISSION LABS:\n==================\n___ 05:30PM BLOOD WBC-2.9* RBC-4.03 Hgb-10.5* Hct-31.9* \nMCV-79* MCH-26.1 MCHC-32.9 RDW-25.4* RDWSD-70.9* Plt ___\n___ 05:30PM BLOOD Neuts-54.0 ___ Monos-21.1* \nEos-0.0* Baso-0.3 NRBC-1.0* Im ___ AbsNeut-1.56* \nAbsLymp-0.69* AbsMono-0.61 AbsEos-0.00* AbsBaso-0.01\n___ 05:30PM BLOOD Glucose-99 UreaN-7 Creat-0.6 Na-145 \nK-3.0* Cl-107 HCO3-27 AnGap-11\n___ 05:30PM BLOOD Calcium-9.7 Phos-2.8 Mg-1.8\n\nDISCHARGE LABS:\n==================\n___ 05:33AM BLOOD WBC-6.0 RBC-3.75* Hgb-9.6* Hct-29.6* \nMCV-79* MCH-25.6* MCHC-32.4 RDW-25.7* RDWSD-71.3* Plt ___\n___ 05:33AM BLOOD Glucose-81 UreaN-4* Creat-0.7 Na-141 \nK-4.0 Cl-105 HCO3-26 AnGap-10\n___ 05:33AM BLOOD Calcium-9.3 Phos-2.2* Mg-1.9\n\nMICROBIO:\n==============\n___ urine culture: MIXED BACTERIAL FLORA ( >= 3 COLONY \nTYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.\n\n___ blood culture: final, no growth\n\nC. difficile PCR (Final ___: \n NEGATIVE. \n (Reference Range-Negative). \n\n___ 12:20 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 (Pending): \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n No E. coli O157:H7 found. \n\n Cryptosporidium/Giardia (DFA) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n\nIMAGING AND STUDIES:\n===================\nNone\n\n \nBrief Hospital Course:\nSUMMARY:\n=============\nMs. ___ is a ___ woman with stage IIIA squamous cell \ncarcinoma of lung undergoing chemoradiation completed on \n___, history of multiple strokes and prior colon cancer s/p \nhemicolectomy who presents with odynophagia x several weeks, \nattributed to radiation esophagitis. \n\nACUTE ISSUES:\n====================\n# Odynophagia/Dysphagia \n#Radiation Esophagitis\nManaged with oral liquid lidocaine formulation, which improved \npatient's ability to tolerate PO. Speech and language pathology \nconsutled, recommended soft ground diet and thin liquids, which \nwas advanced to regular solids. Nutrition consulted as well. If \nsymptoms fail to improve with liquid lidocaine and with a time \ncourse consistent with radiation esophagitis, will need further \nworkup as outpatient, such as barium swallow or EGD. Patient was \nstarted on lansoprazole for any contribution of GERD, should \ncontinue to assess need for PPI as an outpatient.\n\n# Hypernatremia\nPatient with rising Na this admission, up to 149. Likely poor \noral intake iso radiation esophagitis. Patient received 1L D5W \nwith improvement of Na to 141 on day of discharge. She was \nencouraged to maintain liquids throughout the day.\n\n# Severe Malnutrition\nPatient with poor PO intake and weight loss. Nutrition was \nconsulted, and per their recommendations she received Carnation \nsupplements with soy milk with meals, as well as Ensure Clear \nwith meals and multivitamins. PO intake was encouraged. SW was \nconsulted due to concern about her having adequate resources at \nhome (but she denies having issues with resources). ___ assessed \nher and recommended home, where she already has a walker. OOB \nwith assistance was encouraged during the admission.\n\n# Vitamin B12 deficiency\nB12 was noted to be low this admission, so the patient received \ncyanocobalamin 1000 mcg IM on ___ and was started on PO \ncyanocobalamin daily. MMA was obtained, which was pending at \ntime of discharge. CBC was obtained daily.\n\n# Stage IIIA Squamous Cell Lung Carcinoma\nUndergoing concurrent chemoradiation. Will follow up with Dr. \n___ as outpatient.\n\nCHRONIC ISSUES:\n=================\n# Hypokalemia, chronic\nHypokalemia has been chronic. Etiology unclear as patient is not \non diuretics. Other etiologies include kidney dysfunction such \nas rental tubular acidosis. Reportedly does not take potassium \nas often as necessary at home d/t difficulty swallowing pill. \nUrine\nelectrolytes notable for >20 K which seems inappropriate in \nsetting of hypokalemia. Potassium powder was trialed during the \nadmission.\n\n# Diarrhea, stable\nPatient reports loose stool since radiation. On admission did \nreport blood in stool that is streaky and superficial; patient \ndenied tarry stools or frank blood. The most concerning etiology \nwould be recurrence of colorectal carcinoma (s/p hemicolectomy),\nalthough more likely causes include diverticulosis flare or \nhemorrhoidal bleeding. Cdiff negative. Hb stable throughout this \nadmission.\n\n# Tobacco Abuse: Managed inpatient with nicotine patch. \n\nTRANSITIONAL ISSUES:\n===========================\n[] Ensure that patient is eating and drinking without difficulty\n[] Continue to assess for presence of blood in stools\n[] Should repeat CBC and BMP at next PCP visit to ensure stable \nHb and Na/K\n[] Previously on potassium tablets, but discharged on potassium \npowder given odynophagia, will need to follow up with ability to \ntolerate this.\n[] Patient was started on lansoprazole for any contribution of \nGERD, should continue to assess need for PPI as an outpatient.\n[] Found to have B12 deficiency anemia during this admission, \nreceived cyanocobalamin 1000 mcg IM on ___ and was started on \nPO cyanocobalamin daily, which she should continue.\n[] Follow up on lab tests that were pending at time of \ndischarge: campylobacter stool culture, stool ova + parasites, \nfecal culture r/o Yersinia, methylmalonic acid.\n[] Patient was scheduled for outpatient CT chest ___, unable to \ncomplete as an inpatient, will need to be rescheduled by her \noncology team\n\n==========================\nCODE: Full Code (confirmed)\nEMERGENCY CONTACT HCP: ___ (daughter)\n___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain \n2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n3. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n4. Potassium Chloride 20 mEq PO DAILY \n5. Nicotine Patch 7 mg/day TD DAILY \n\n \nDischarge Medications:\n1. Cyanocobalamin ___ mcg PO DAILY \nRX *cyanocobalamin (vitamin B-12) 2,500 mcg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*3 \n2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \nRX *lansoprazole 30 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*3 \n3. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN throat \npain \n4. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*3 \n5. Potassium Chloride (Powder) 20 mEq PO DAILY \nRX *potassium chloride 20 mEq 1 packet(s) by mouth daily Disp \n#*30 Packet Refills:*3 \n6. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain \n7. Nicotine Patch 7 mg/day TD DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnoses:\nRadiation Esophagitis\nstage IIIA squamous cell carcinoma of lung \nSevere Malnutrition\n\nSecondary diagnoses:\nB12 deficiency\nChronic hypokalemia\nDiarrhea\nTobacco abuse\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for you at ___ \n___.\n\nWHY WAS I IN THE HOSPITAL?\n- You were having pain with swallowing and difficulty eating \nenough food.\n- You were having diarrhea.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL?\n- You received medication that decreased throat discomfort.\n- You were seen by speech and swallow specialists who made \nrecommendations for your diet. You received a soft liquid diet \ninitially, which was advanced to regular solid foods as \ntolerated.\n- Studies were done on your stool to make sure that your \ndiarrhea wasn't caused by an infection.\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" ]

[ "K208", "E870", "C342", "E46", "Y842", "Y92009", "D519", "E876", "R197", "F17210", "Z85038", "E119", "Z8673", "E785", "Z6822", "R32", "R1310" ]

[ "K208: Other esophagitis", "E870: Hyperosmolality and hypernatremia", "C342: Malignant neoplasm of middle lobe, bronchus or lung", "E46: Unspecified protein-calorie malnutrition", "Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "D519: Vitamin B12 deficiency anemia, unspecified", "E876: Hypokalemia", "R197: Diarrhea, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z85038: Personal history of other malignant neoplasm of large intestine", "E119: Type 2 diabetes mellitus without complications", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E785: Hyperlipidemia, unspecified", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "R32: Unspecified urinary incontinence", "R1310: Dysphagia, unspecified" ]

[ "F17210", "E119", "Z8673", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIodine-Iodine Containing\n \nAttending: ___.\n \nChief Complaint:\nhematemesis\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with medical history notable for DM2,\nHTN, HLD, multiple strokes on Plavix and aspirin, inferior MI,\ntobacco use, primary hyperparathyroidism, and colon cancer s/p\ncolectomy and chemotherapy who presented with hemoptysis. \n Patient was initially seen for hemoptysis at ___ on ___ HPI\nreported \"She first noticed coughing and hemoptysis\napproximately ___ weeks ago, and noticed very small blood clots\nat that time. She saw her PCP in clinic on ___ for this, and \nCT\nwith contrast was ordered, but has not yet been scheduled (note,\nshe has allergy to contrast). Over the past 3 days, she has\nnoticed worsening of her cough, sputum production, and\nhemoptysis, with large clots on the order of teaspoons. No \nfevers\nor chills, shortness of breath, chest pain, or lightheadedness.\nHas some weight loss. No night sweats, homelessness, or prison\nexposure. No recent travel, surgery, immobility, ___\nswelling/pain. Notes some LUQ abdominal pain that began last\nnight, that is worsened by cough. \n It is not associated with food, and she has no \n n/v/d/constipation, and has regular BMs with no hematochezia or\nmelena.\" \n A CT chest was obtained which was notable for infrahilar mass\nwith complete occlusion of the right middle lobe. She was not\nable to connect with her PCP to discuss the results. \n\n In the ED, initial VS: \nPain 0 Temp 97.7 HR 78 BP 170/88 RR 16 POx 97% RA\n \n Exam: \nO: lung mild wheeze in the RLL.\n\n Work-up: \nLeukocytosis to 16, \nElevated Ca ___\n\n She received: \nPO Oxybutynin 5 mg \nPO Azithromycin 500 mg \nIV CefTRIAXone (1 g ordered) \n\n Consults: \nIP: Decision was made to admit for expedited oncology work-up. \n\n\n On arrival to the floor, the patient the endorsed the history\nper above. In addition, she clarified that she has lost 3 pounds\nin the past month. She denies any decrease PO intake or \nabdominal\npain. She denies SOB. She says she feels a lot better after\nreceiving medications in the ED.\n\n \nPast Medical History:\n- prior paramedian pontine infarct (___) \n- right-sided lenticulostriate territory infarct ___\n- Hypertension as per prior medical records(patient denies)\n- Dyslipidemia \n- Colon cancer 2/p right colectomy in ___ with prolonged\nstuttering course of adjuvant chemotherapy (diagnosed in setting\nof GI bleeding)\n- Cholecystectomy for chronic cholecystitis and gallstones in\n___\n- Diverticulosis\n- Hemorrhoids\n\n \nSocial History:\n___\nFamily History:\nMother had stroke in her ___ or ___. Her paternal \ngrandfather,\nfather, and brother all had colon cancer. Sister had ovarian\ncancer and has prostate cancer in her family.\n\n \nPhysical Exam:\nAdmission:\nGeneral: Older woman who appears stated ago, NAD, lying flat on\nbed\n HEENT: EOMI, PERRLA, MMM\n Neck: No JVD, no JVP elevation, neck supple, no cervical\nlymphadenopathy\n Lungs: Decreased breath sounds on R side, L side CTAB @ bases,\nb/l ronchi in b/l upper lobes\n CV: RRR, distant heart sounds, bradycardic, no murmurs/rubs/or\ngallops\n Lymph: 0.5 cm x 2 R enlarged supraclaviular node, 0.5 cm x1 L\nenlarged supraclavicular node\n GI: Soft, nondistended, nonrigid, nontender to palpation\n Ext: No lower extremity swelling, distal pulses b/l intact in\nUE and ___\n ___: CNII-XII intact, L eyebrow lower than R eyebrow, no\nlower facial droop, ___ strength R grip strength, RUE flexion \nand\nextension @ elbow, RLE ___ strength on plantar flexion and\ndorsiflexion, RUE +antigravity, L grip strength ___, LUE ___\nflexion and extension @ elbow joint, LLE +antigravity, LLE\nplantar and dorsiflexion ___, A&O grossly\n\nDischarge:\nNo significant changes\n \nPertinent Results:\nAdmission:\n\n___ 06:57AM PTH-106*\n___ 06:57AM WBC-13.3* RBC-4.63 HGB-12.1 HCT-36.7 MCV-79* \nMCH-26.1 MCHC-33.0 RDW-14.5 RDWSD-41.5\n___ 06:57AM PLT COUNT-275\n___ 12:05AM ___ PTT-30.5 ___\n___ 10:18PM GLUCOSE-110* UREA N-12 CREAT-1.1 SODIUM-146 \nPOTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14\n___ 10:18PM estGFR-Using this\n___ 10:18PM ALT(SGPT)-7 AST(SGOT)-15 LD(LDH)-362* ALK \nPHOS-107* TOT BILI-<0.2\n___ 10:18PM ALBUMIN-3.4* CALCIUM-10.5* PHOSPHATE-3.0 \nMAGNESIUM-2.3 URIC ACID-6.7*\n___ 10:18PM WBC-16.9* RBC-4.99 HGB-13.3 HCT-39.5 MCV-79* \nMCH-26.7 MCHC-33.7 RDW-14.7 RDWSD-41.8\n___ 10:18PM NEUTS-75.3* LYMPHS-18.1* MONOS-5.8 EOS-0.2* \nBASOS-0.2 IM ___ AbsNeut-12.72* AbsLymp-3.05 AbsMono-0.98* \nAbsEos-0.04 AbsBaso-0.03\n___ 10:18PM PLT COUNT-348\n\nImaging:\nCT Chest ___: \nIMPRESSION: \nRight infrahilar mass with complete occlusion of the right \nmiddle\nlobe bronchus with complete atelectasis of the right middle lob,\nconcerning for bronchogenic carcinoma mediastinal bilateral \nhilar\nadenopathy. Diffuse enlargement the thyroid with multiple\nhypodense areas within it which most likely represent goiter.\n \nBrief Hospital Course:\nMrs. ___ is a ___ female with a medical history notable for \nDM2,\nHTN, HLD, multiple strokes, inferior MI, tobacco use, and colon \ncancer, who presented with 3 weeks of increasing hemoptysis \ni/s/o a R hilar lung mass found on CT.\n\n#Hemoptysis, R hilar mass\nHer hemoptysis and R hilar mass is concerning for bronchogenic \ncarcinoma given her history of smoking, colon cancer, and weight \nloss. She was stable without hypoxia or respiratory distress. \nHer home Plavix and aspirin were held, and her hemoptysis \nimproved. IP consulted and planned for biopsy \nelectrocautery/cryo +/- stent placement on ___, ___. She \nhad a brain MRI on the evening of discharge that showed nothing \nacute, though follow-up on final read will be needed. She will \nalso need a PET-CT for complete staging. She has been told to \nhold home Plavix until further notice (last dose ___ but \ncontinue her home aspirin. \n\n#Hypercalcemia\nShe has a history of primary hyperparathyroidism, but an \nelevated calcium level can also be seen as paraneoplastic \nsyndrome. Her Ca was 10.5 on admission, in the same range as has \nbeen historically. She received her home Vitamin D, but no \nspecific treatment was started.\n\n# CVA\nWe held her home Plavix and aspirin per above.\n\n# T2DM\nShe was on SSI, but did not require any.\n\n# HLD\nWe continued her home statin.\n\n# Tobacco use\nShe was given a Nicotine patch.\n\nTRANSITIONAL ISSUES:\n====================\n[] MRI wet read negative for acute pathology, will need to be \nfollowed up for final read\n[] PET/CT scan to complete staging\n[] ___, ___ flex and rigid bronchoscopy + EBUS TBNA and \npossible stenting\n[] Discuss restarting Plavix post-procedurally\n[] Smoking cessation discussion\n-------------\nCODE: Full (confirmed)\nCONTACT: ___ (Daughter) ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 325 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Clopidogrel 75 mg PO DAILY \n4. Oxybutynin 5 mg PO DAILY \n5. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 325 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Oxybutynin 5 mg PO DAILY \n4. Vitamin D ___ UNIT PO DAILY \n5. HELD- Clopidogrel 75 mg PO DAILY This medication was held. \nDo not restart Clopidogrel until you have spoken with your \ndoctors and it is safe to resume. Certainly, not before ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: Hemoptysis\nSecondary: Hypercalcemia\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 ___ was a pleasure taking part in your ___ here at ___! \n\nWhy was I admitted to the hospital?\nYou were admitted because you were on blood thinners and were \ncoughing up blood.\n\nWhat was done for me while I was in the hospital?\n- We were concerned about the blood that you were coughing up, \nso we did a number of tests. We also stopped your Plavix, a \nmedicine that can make you bleed easier - and that helped to \nreduce the amount of blood that you were coughing up. \n- The lung doctors spoke with ___ about the results of your \nrecent lung CT, and explained that they will need to get a \nsample of tissue in order to find out what is in your lungs. \n- You also got a head MRI to look for any changes in your brain. \nSince you were stable and did not need to be in the hospital for \nany other tests, it was decided that you could go home safely.\n\nWhat should I do when I leave the hospital?\n-You have a bronchoscopy schedule for ___. Please \nDO NOT eat after 11:59PM on ___ and do not eat breakfast \nor lunch. You can take your morning medicines with water.\n-Your appointments are as below\n-Please DO NOT TAKE Plavix (clopidogrel) UNTIL after your \nprocedure with the pulmonary doctors\n-___ call Health ___ Associates to make a follow-up \nappointment with your primary ___ doctor about this \nhospitalization (number below)\n\nSincerely,\nYour ___ ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R042", "E210", "R918", "Z8673", "E119", "E785", "F17210", "I252", "Z85038", "J9819" ]

[ "R042: Hemoptysis", "E210: Primary hyperparathyroidism", "R918: Other nonspecific abnormal finding of lung field", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I252: Old myocardial infarction", "Z85038: Personal history of other malignant neoplasm of large intestine", "J9819: Other pulmonary collapse" ]

[ "Z8673", "E119", "E785", "F17210", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nIodine-Iodine Containing\n \nAttending: ___.\n \nChief Complaint:\nThroat Pain, confusion, worsening L hemiparesis \n \nMajor Surgical or Invasive Procedure:\n___ and biopsy \n\n \nHistory of Present Illness:\nMs. ___ is a ___ w/ stage IIIA squamous cell carcinoma\nof lung, s/p completion of concurrent ___ ___,\nalso w/ a h/o multiple strokes w/ residual left hemiparesis, \nHTN,\nDL, and prior colon cancer s/p hemicolectomy who is transferred\nfrom ___ for continuity of care. \n\nDr ___, the oncology service resident, called me for\nsignout. She presented there on ___ with subacute worsening \nof\nher chronic L-sided hemiparesis and confusion. She was seen by\nneurology and her head CT and brain MRI did not reveal any\nnew/acute stroke or other acute process. The neurologic symptoms\nwere therefore felt to be recrudescence of prior stroke symptoms\nin the setting of dehydration, deconditioning, malnutrition. She\nhad a CXR that was concerning for pneumonia. She had a Chest CT\nwhich revealed no pneumonia but did reveal b/l scapular mets. \nHer\nconfusion resolved with some maintenance fluids and her lue\nweakness improved. Nutrition and ___ saw her as well. \n\nHer symptoms of poor po intake and esophagitis are known to her\noncology team and they have been working closely together,\nrespecting her wishes to remain independent at home. She was \neven\nrecently admitted ___ and her sx improved w/ oral liquid\nlidocaine formulation. She states this helps and is not taking \nit\nbecause she doesn't have it at home. \n\nI spoke w/ her daughter, who is her HCP and she noted that her\nmom has been having increased confusion for weeks now at least.\nShe thinks she may have dementia. She notes that she does have a\nnew bottle of lidocaine at home. She notes worsening PO intake.\n \nREVIEW OF SYSTEMS: A complete 10-point review of systems was\nperformed and was negative unless otherwise noted in the HPI.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nBriefly, patient initially presented to care in ___ with\nhemoptysis. She was subsequently admitted for workup of same and\nhad a CT of the chest which showed a right infrahilar mass with\ncomplete occlusion of the right middle lobe bronchus and\natelectasis of the right middle lobe with high suspicion for \nlung\ncancer; there was evidence of bilateral intrathoracic \nadenopathy.\nDuring her hospital admission, she was seen by the \ninterventional\npulmonary team and scheduled for outpatient bronchoscopy.\n\nShe underwent bronchoscopy with EBUS under Dr. ___ care on\n___. FNA of the right middle lobe mass showed findings\nconsistent with squamous cell carcinoma; there was biopsy-proven\ninvolvement of the level 4L lymph node; sampling of the 11 L\nlymph node showed no malignant cells.\n\nPatient underwent staging PET scan on ___. This showed an \nFDG\navid 3.2 cm mass in the right infrahilar region with evidence of\nocclusion of the right middle lobe bronchus and atelectasis of\nthe right middle lobe. FDG avid subcarinal adenopathy measuring\nup to 1.3 cm was noted; additionally enlarged mediastinal and \nand\nhilar lymph nodes are also noted. A 2.2 cm left lower lobe\nsubpleural FDG avid lesion was also noted. No other distant\nmetastatic sites of disease were noted.\n\n-___: weekly ___ and radiation started\n-___ completed weekly ___ + RT\n-___ ED visit for fall, head scrape\n-___ ED visit for hypokalemia\n-___ Admission for esophagitis\n\nPAST MEDICAL HISTORY:\n- H/o paramedian pontine infarct in ___\n- H/o right-sided lenticulostriate territory infarct in ___\n- Hypertension \n- Dyslipidemia \n- Colon cancer, s/p right hemicolectomy in ___\n- Cholecystectomy for chronic cholecystitis and gallstones in\n___\n- Diverticulosis\n- Hemorrhoids\n- Tobacco Abuse\n \nSocial History:\n___\nFamily History:\nMother had stroke in her ___ or ___. Her\npaternal grandfather, father, and brother all had colon cancer.\nTwo brothers had gastric cancer. Sister had ovarian cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: Temp 98.3, 74, 140/64, 100% on RA \nGENERAL: Pleasant woman, in no distress, lying in bed \nomfortably.\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.\nABD: Soft, non-tender, non-distended, normal bowel sounds.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, L temporal field deficit, CN XI weak, ___ LUE, \ngood\nattention and linear thought, CN III-XII otherwise intact but \nshe\nhas a mild R facial drop but symmetric smile. Strength ___ RUE\nand RLE, but 3+/5 proximal LLE with ___ on plantar flexion and\ndorsiflexion. No nystagmus. gait not assessed\nSKIN: xerosis on upper extremities \nACCESS: Right chest wall port without erythema, accessed,\ndressing c/d/i\n\nDISCHARGE PHYSICAL EXAM:\nVS: ___ 0740 Temp: 99.0 PO BP: 133/79 HR: 96 RR: 18 O2 sat:\n100% O2 delivery: RA \nGENERAL: Pleasant, in no distress, lying in bed comfortably\nHEENT: Anicteric sclera, EOMI\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, strength ___ RLE&RUE, ___ LLE&LUE\nSKIN: xerosis on upper extremities \nACCESS: Right chest wall port without erythema, accessed,\ndressing c/d/i\n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 05:39AM BLOOD WBC-21.5* RBC-3.78* Hgb-9.6* Hct-29.9* \nMCV-79* MCH-25.4* MCHC-32.1 RDW-23.9* RDWSD-69.0* Plt ___\n___ 05:39AM BLOOD Neuts-89.5* Lymphs-5.0* Monos-3.9* \nEos-0.2* Baso-0.3 Im ___ AbsNeut-18.96* AbsLymp-1.07* \nAbsMono-0.83* AbsEos-0.04 AbsBaso-0.06\n___ 05:39AM BLOOD ___ PTT-30.1 ___\n___ 05:39AM BLOOD Glucose-174* UreaN-5* Creat-0.6 Na-145 \nK-3.6 Cl-107 HCO3-23 AnGap-15\n___ 05:39AM BLOOD ALT-21 AST-15 LD(LDH)-343* AlkPhos-240* \nTotBili-0.4\n___ 05:39AM BLOOD Albumin-2.5* Calcium-9.2 Phos-3.2 Mg-2.0\n\nMICRO:\n======\n___ c diff stool test - negative\n\nIMAGING/STUDIES:\n===============\n___ second opinion CT Torso:\n1. Within the confines of a motion limited, unenhanced study, \nthe known,\napproximately 1.8 cm right hilar mass appears stable.\n2. Stable postobstructive collapse of the right middle lobe in \nthe setting of\nright hilar mass.\n3. Stable 3 mm left upper lobe pulmonary nodule. No definite \nnew or growing\npulmonary nodules.\n4. Moderate paraseptal emphysema.\n\n___ right upper extremity US:\n1. Nonocclusive thrombus is seen in the right internal jugular \nvein.\n2. The remaining visualized veins of the right upper extremity \nare patent.\n\n___ EGD:\n- erythema in middle third of esophagus, consistent with \nnon-erosive esophagitis\n- esophageal hiatal hernia\n- erythema and erosion in gastric antrum and stomach body \nconsistent with non-erosive gastritis\n- duodenitis\n- ring in the distal esophagus\n\n___ x-rays of pelvis and femurs:\nNo evidence of lytic or sclerotic lesions within either femur or \npelvis.\n\nDISCHARGE LABS:\n==============\n\n___ 05:21AM BLOOD WBC-22.4* RBC-3.44* Hgb-8.8* Hct-27.3* \nMCV-79* MCH-25.6* MCHC-32.2 RDW-23.0* RDWSD-65.7* Plt ___\n___ 05:21AM BLOOD Plt ___\n___ 05:21AM BLOOD Glucose-178* UreaN-8 Creat-0.6 Na-147 \nK-3.6 Cl-109* HCO3-25 AnGap-13\n___ 04:40AM BLOOD ALT-17 AST-13 AlkPhos-242* TotBili-0.4\n___ 05:21AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.5\n \nBrief Hospital Course:\nSUMMARY:\n=========\n___ w/ stage IIIA squamous cell carcinoma of lung, s/p \ncompletion of concurrent ___ ___, also w/ a h/o \nmultiple strokes w/ residual left hemiparesis, HTN, DL, and \nprior colon cancer s/p hemicolectomy who is transferred from \n___ for continuity of care after presenting \nthere w/ confusion and worsening LUE weakness. \n\nACTIVE ISSUES:\n============\n#Odynophagia/Dysphagia: Most likely radiation esophagitis, \nreflux esophagitis. ___ EGD with esophagitis, gastritis, \nduodenitis. Gastric biopsy showed H. pylori. She was given \nviscous lidocaine with meals, BID PPI, fluids as needed, and a \nregular diet. We had long discussions about her goals of care \nwith both her outpatient oncology team as well as her palliative \ncare team (detailed below) and it was ultimately decided to not \npursue full antibiotic therapy for H. pylori as her primary \nsymptom of odynophagia is most likely primarily related to \nstrictures and radiation esophagitis. \n\n#Failure to thrive\nSeems like most likely etiology is poor po intake. Felt to be \ndue to progressive esophagitis (presumably radiation induced). \nShe has odynophagia. TSH wnl. No e/o pulmonary infection. UA neg \nat OSH. C diff negative this admission. Geriatrics was involved \nin the patient's care during this admission. Her throat and body \npain was controlled with IV morphine, and she received viscous \nlidocaine to help her eat/drink more comfortably. She was \nsupported with IVF as needed. ___ and OT evaluated her and \nrecommended rehab placement however after long discussions of \nher GOC and it was decided that she would not want tube feeding \nand would like to go home on hospice. \n\n#Nonocclusive thrombus in right IJ\nIn the setting of being hypercoagulable from malignancy. \nHAS-BLED score is 3 (HTN, stroke Hx, age she is at high risk for \nmajor bleeding, but is hypercogulable iso malignancy. The \ndefinitive treatment for her hypercoagulable state is treatment \nof her malignancy, if within GOC. Her home ASA/Plavix were \ncontinued, and she was started on enoxaparin 80 mg SC daily, \nwith the plan to treat for 1 month.\n\n#Stage IIIA Squamous Cell Lung Carcinoma\n#Bilateral lytic scapular lesions\nMost recent imaging, CT chest on ___, revealed substantial \ndecrease in size of the pre-existing right hilar mass, which now \nmeasures 20 x 20 mm in diameter. However CT abd revealed \"new \n1.3 cm hepatic segment VII lesion ... suspicious for \nmetastasis.\" ___ elevated this admission, consistent with liver \ninvolvement. Now CT from ___ revealed new bilateral lytic \nscapular lesions.\nOutpatient team arranging PET scan in ___, with future \ncancer treatment directed therapies to be determined. Her \noutpatient oncology team (Drs ___ was contacted \nwith updates. Hip/femur x-rays were obtained to eval for \nosseous/lytic lesions (because of delays with scheduling a bone \nscan).\n\n#Encephalopathy \nShe's been having episodes of confusion for some time now per \ndaughter. She locked herself in the bathroom last week. \n\"Thetiles have me locked in the bathroom and I can't get out.\" \nBut the bathroom was not locked. A few weeks ago, she had left \nthe stove on during a hot day, and she stated she was heating \nfood for her son (who was murdered ___. Daughter is \nconcerned\nabout dementia. MRI brain did not reveal mets or new stroke. \nalthough pt is oriented x 3, she seems to have poor insight into \nreason for admission and her hospitalization. Confusion possibly \nalso due to impaired sleep (sleeps during day, as lives with her \nson who works nights), dehydration, pain from malignancy. \nGeriatrics was consulted and assisted with her care. Her \nnutrition and hydration status were optimized and her pain was \ncontrolled with IV morphine. She received high dose thiamine for \npossible Wernicke's encephalopathy. She received folic acid \nrepletion for severe protein calorie malnutrition.\n\nCHRONIC/RESOLVED ISSUES:\n========================\n#Worsening LUE and LLE weakness - stable\n#History of CVA w/ residual hemiparesis\nLikely recrudescence from prior CVA and improved w/ hydration \nand nutrition. Her home aspirin, Plavix, and atorvastatin were \ncontinued. Her neurologic status was checked daily. She was \nstarted on Lovenox ___aily.\n\n#Severe protein calorie malnutrition: \n- Nutrition was consulted. She received a regular diet, high \ndose thiamine, folic acid and MVI. Her electrolytes were \nmonitored daily and repleted as needed.\n\n#Tobacco Abuse: Continued nicotine patch.\n\nTRANSITIONAL ISSUES:\n====================\n[] Due to esophageal spasms seen during EGD, outpatient \nesophageal mannometry should be considered to further work up \nher dysphagia/odynophagia.\n[] Consider starting a bisphosphonate, if osseous metastases are \nconfirmed through bone scan/bone biopsy.\n\nCode status: DNR/DNI\n\nEMERGENCY CONTACT HCP: ___ (daughter)\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. Nicotine Patch 21 mg/day TD DAILY \n2. Cyanocobalamin ___ mcg PO DAILY \n3. Multivitamins W/minerals 1 TAB PO DAILY \n4. Lidocaine Viscous 2% 15 mL PO QID:PRN throat pain \n5. Potassium Chloride (Powder) 20 mEq PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 40 mg PO QPM \n8. Oxybutynin 5 mg PO DAILY \n9. Clopidogrel 75 mg PO DAILY \n\n \nDischarge Medications:\n1. Enoxaparin Sodium 80 mg SC DAILY \nRX *enoxaparin 80 mg/0.8 mL 80 mg SC daily Disp #*30 Syringe \nRefills:*3 \n2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 10 mg \nPO Q4H:PRN Pain - Severe \nRX *morphine concentrate 100 mg/5 mL (20 mg/mL) 10 mg by mouth \nq4hrs PRN Refills:*0 \n3. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose \nRX *naloxone [Narcan] 4 mg/actuation 1 spray nasal once AS \nNEEDED Disp #*1 Spray Refills:*0 \n4. Omeprazole 40 mg PO DAILY \nRX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*3 \n5. Lidocaine Viscous 2% 15 mL PO QID:PRN throat pain \n6. Nicotine Patch 21 mg/day TD DAILY \n7. Oxybutynin 5 mg PO DAILY \n8. Potassium Chloride (Powder) 20 mEq PO DAILY \nHold for K > 4.0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis \n==================\n1) Odynophagia/Dysphagia\n2) Failure to Thrive\n3) H pylori gastritis \n4) Stage IIA squamous cell carcinoma of the lung \n5) Non-occlusive thrombus of the right IJ \n6) Severe protein calorie malnutrition\n\nSecondary Diagnosis\n===================\n1) History of CVA \n2) Tobacco Abuse \n\n \nDischarge Condition:\nLevel of Consciousness: Alert and interactive.\nMental Status: Clear and coherent.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for you at ___ \n___.\n\nWHY WAS I IN THE HOSPITAL?\n- You were having pain in your throat and body. You were not \ngetting enough to eat and drink. Because of this, you were \nweaker than usual, which made your old stroke symptoms seem \nworse. Your children were concerned that you were more confused \nthan usual.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL?\n- You received scans to make sure that you did not have a new \nstroke.\n- You were watched closely for signs of infection.\n- You were supported with fluids and nutritious food.\n- You underwent an endoscopy procedure, which showed a lot of \ninflammation that is probably causing your swallowing pain. You \nwere given liquid lidocaine for throat pain, as well as an acid \nblocker medicine. \n- Your body pain was treated with morphine.\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" ]

[ "K208", "E43", "I82C11", "C342", "D6869", "E512", "I69354", "R627", "K2950", "B9681", "E860", "K222", "I10", "K224", "K449", "K2980", "F17210", "Z66", "Z6822", "Y842", "Y92009", "Z9221", "Z7901", "Z85038", "Z9049" ]

[ "K208: Other esophagitis", "E43: Unspecified severe protein-calorie malnutrition", "I82C11: Acute embolism and thrombosis of right internal jugular vein", "C342: Malignant neoplasm of middle lobe, bronchus or lung", "D6869: Other thrombophilia", "E512: Wernicke's encephalopathy", "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "R627: Adult failure to thrive", "K2950: Unspecified chronic gastritis without bleeding", "B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere", "E860: Dehydration", "K222: Esophageal obstruction", "I10: Essential (primary) hypertension", "K224: Dyskinesia of esophagus", "K449: Diaphragmatic hernia without obstruction or gangrene", "K2980: Duodenitis without bleeding", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z66: Do not resuscitate", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "Z9221: Personal history of antineoplastic chemotherapy", "Z7901: Long term (current) use of anticoagulants", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z9049: Acquired absence of other specified parts of digestive tract" ]

[ "I10", "F17210", "Z66", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nIodine-Iodine Containing\n \nAttending: ___.\n \nChief Complaint:\nleft leg weakness, falls\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ RH female with a PMHx of\nparamedian pontine infarct (___), right-sided lenticulostriate\nterritory infarct (___), multiple strokes in the right \nposterior\nMCA/PCA watershed region (thought to be cardioembolic but no\nsource identified, ___, followed by Dr. ___, on\nPlavix and ASA), hypertension, hyperlipidemia, prior MI, colon\ncancer s/p resection and chemotherapy in ___, extensive tobacco\nuse, recent DM diagnosis, and recent diagnosis of B12 deficiency\nwho presents with ___ weeks of frequent falls and 4 weeks of \nleft\nleg weakness. \n\nThe left leg weakness was gradual in onset and began about 4\nweeks ago; it has remained relatively stable. She now needs help\ngetting off a toilet or up off of chairs. The falls occur when\nshe is pivoting while using her cane, and she has had 5 falls in\nthe last week including once into her bathtub. Her legs feel \nlike\n\"they get tangled up.\" She has only landed on her bottom; no\nheadstrikes or LOC. No prodrome prior to falls. She also has\nbaseline LUE weakness that remains unchanged since her strokes \nin\n___ she has trouble twisting caps and opening jars, but \nshe\ndoes not have trouble reaching up. Denies missing Plavix doses.\nMissed ___ doses of atorvastatin since starting it.\n\nShe has also had urinary and fecal incontinence (3 months per\nprior notes; since last stroke in ___ per patient); per\nprior notes, she loses control just after getting the urge to\nurinate or move her bowels; today, she says she sometimes does\nnot get the urge to go. She sometimes does not have time to make\nit to the bathroom, but this is not the chief reason for\nincontinence. Reports 2 days of lower back pain (midline). \nDenies\nsaddle anesthesia. \n\nShe was seen by her PCP ___ she was noted to be dragging her\nleft foot on the ground and she was noted to have left ankle\ndorsiflexion>plantarflexion, knee flexion/extension, and hip\nflexion/extension weakness with more brisk reflexes on that \nside.\nPer ED, she was noted to have ___ left hip flexion, 4+ hip\nextension, 4+ knee extension, upgoing toes on left, left arm.\" \n\nOf note, she last saw Dr. ___ in ___ in clinic. \nAt\nthat time, she was noted to have SCM weakness, mild L pronation\nwith upward drift, and ___ left deltoid strength. She had brisk\nreflexes at left biceps and patella, and her plantar response \nwas\nmute bilaterally. She also had a broad-based gait with small\nsteps that was safe. She was continued on Plavix 75mg daily, and\na stronger statin was recommended, but the patient preferred to\nstay on rosuvastatin (Crestor).\n\n+:Left facial droop noticed during sleep by daughter one week\nwhich subsequently resolved (date of resolution unknown), per\npatient\nOn neuro ROS, the pt denies headache, loss of vision, blurred\nvision, diplopia, dysarthria, dysphagia, lightheadedness,\nvertigo, tinnitus, and hearing difficulty. Denies difficulties\nproducing or comprehending speech. Denies focal numbness and\nparasthesiae. \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 abdominal pain. No dysuria. Denies arthralgias or myalgias.\nDenies rash.\n\n \nPast Medical History:\n- prior paramedian pontine infarct (___) \n- right-sided lenticulostriate territory infarct ___\n- Hypertension as per prior medical records(patient denies)\n- Dyslipidemia \n- Colon cancer 2/p right colectomy in ___ with prolonged\nstuttering course of adjuvant chemotherapy (diagnosed in setting\nof GI bleeding)\n- Cholecystectomy for chronic cholecystitis and gallstones in\n___\n- Diverticulosis\n- Hemorrhoids\n\n \nSocial History:\n___\nFamily History:\nMother had stroke in her ___ or ___. Her paternal \ngrandfather,\nfather, and brother all had colon cancer. Sister had ovarian\ncancer and has prostate cancer in her family.\n\n \nPhysical Exam:\nAdmission Exam:\nVitals: T: 97.4 P: 65 R: 16 BP: 153/70 SaO2: 97%RA\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity\nPulmonary: Lungs CTA bilaterally without R/R/W\nCardiac: RRR, nl. S1S2, no M/R/G noted\nAbdomen: soft, NT/ND, normoactive bowel sounds, no masses or\norganomegaly noted.\nExtremities: No C/C/E bilaterally, 2+ radial, DP pulses\nbilaterally.\nSkin: no rashes or lesions noted.\n\nNeurologic:\nNIHSS as above.\n\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive, able to name ___ backward without\ndifficulty. Language is fluent with intact repetition and\ncomprehension. Normal prosody. There were no paraphasic errors.\nPt was able to name both high and low frequency objects. Able \nto\nread without difficulty. Speech was not dysarthric. Able to\nfollow both midline and appendicular commands. Pt was able to\nregister 3 objects and recall ___ at 5 minutes ___ with\nprompting). There was no evidence of apraxia or neglect. No\ncortical sensory loss.\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, or hemorrhages.\nV: Facial sensation intact to light touch.\nVII: Mild L NLFF.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline.\n\n-Motor: Normal bulk and tone. Subtle LUE pronation without \ndrift.\nRUE orbiting around left. No adventitious movements, such as\ntremor, noted. No asterixis noted. \n[___] \n [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] \n L 5- 5 5 5 5 5 4+ 5 5 5- 5 5 \n R 5 5 5 5 5 5 5 5 5 5 5 5\n\n-Sensory: No deficits to light touch, pinprick, cold sensation,\nvibratory sense. ___ errors to proprioception in LLE. No\nextinction to DSS. No spinal sensory level. \n\n-DTRs: brisk diffusely L>R. Left toe upgoing, right downgoing.\n\n-Coordination: Missed target mildly with RUE on FNF. RAM slow\nbilaterally. FNF ok. HKS ok. \n\n-Gait: Dragging left leg when ambulating with some \ncircumduction.\n\n******************\nDischarge exam:\nVitals: T: 97.4 P: 65 R: 16 BP: 164/70 SaO2: 97%RA\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity\nPulmonary: Lungs CTA bilaterally without R/R/W\nCardiac: RRR, nl. S1S2, no M/R/G noted\nAbdomen: soft, NT/ND, normoactive bowel sounds, no masses or\norganomegaly noted.\nExtremities: No C/C/E bilaterally, 2+ radial, DP pulses\nbilaterally.\nSkin: no rashes or lesions noted.\n\nNeurologic:\nNIHSS as above.\n\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive, able to name ___ backward without\ndifficulty. Language is fluent with intact repetition and\ncomprehension. Normal prosody. There were no paraphasic errors.\nPt was able to name both high and low frequency objects. Able \nto\nread without difficulty. Speech was not dysarthric. Able to\nfollow both midline and appendicular commands. There was no \nevidence of apraxia or neglect. \n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. Visual acuity\n___ bilaterally. \nV: Facial sensation intact to light touch.\nVII: 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 and tone. Subtle LUE pronation without \ndrift.\nRUE orbiting around left. No adventitious movements, such as\ntremor, noted. No asterixis noted. \n[___] \n [C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5] \n L 5- 5 5 5 4 5 5 5 5 ___ \n R 5 5 5 5 5 5 5 5 5 5 5 5\n\n-Sensory: No deficits to light touch, pinprick, cold sensation,\nvibratory sense. Intact proprioception b/l. No\nextinction to DSS. No spinal sensory level. \n\n-DTRs: brisk diffusely L>R. Left toe upgoing, right downgoing.\n\n-Coordination: Missed target mildly with RUE on FNF. RAM slow\nbilaterally. FNF ok. HKS ok. \n\n-Gait: Dragging left leg but stable with cane\n\n \nPertinent Results:\n___ 01:10PM GLUCOSE-125* UREA N-9 CREAT-0.9 SODIUM-144 \nPOTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-17\n___ 01:10PM estGFR-Using this\n___ 01:10PM ALT(SGPT)-18 AST(SGOT)-30 ALK PHOS-97 TOT \nBILI-0.5\n___ 01:10PM ALBUMIN-3.7 CALCIUM-11.2* PHOSPHATE-3.4 \nMAGNESIUM-2.3\n___ 01:10PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG \nbarbitrt-NEG tricyclic-NEG\n___ 01:10PM WBC-9.4 RBC-4.87 HGB-13.4 HCT-41.0 MCV-84 \nMCH-27.5 MCHC-32.7 RDW-14.4 RDWSD-44.0\n___ 01:10PM NEUTS-64.6 ___ MONOS-5.8 EOS-0.5* \nBASOS-0.2 IM ___ AbsNeut-6.06 AbsLymp-2.68 AbsMono-0.54 \nAbsEos-0.05 AbsBaso-0.02\n___ 01:10PM PLT COUNT-276\n\nCT head \nIMPRESSION: \n1. Small right caudate hypodensity/lacunar infarct is new from \n___, but \notherwise appears chronic to possibly subacute, lacunar infarct. \n Correlate \nwith clinical symptoms. MRI is more sensitive in detecting \nacute ischemia. \n2. Sequelae of prior right frontal lobe infarct and left pontine \ninfarct. \n3. Nonspecific bilateral white matter changes are similar the \nprior exam and \nconsistent with sequelae of chronic small vessel ischemic \ndisease. \n4. No acute intracranial hemorrhage. \n5. Cortical atrophy. \n\nCXR \nIMPRESSION: \nNo focal consolidation to suggest pneumonia. Possible minimal \npulmonary \nvascular congestion. Stable mild cardiomegaly. \n\nMRI/MRA brain and neck\nIMPRESSION: \n1. Substantially motion limited exam. \n2. Punctate, likely subacute infarcts of the right frontal \nperiventricular \nwhite matter, posterior limb of the right internal capsule or \nright thalamus , \nand right periatrial white matter. \n3. Chronic right frontal cortical infarct is again seen. \nExtensive \nsupratentorial white matter signal abnormalities, similar to \nprior, \nnonspecific but likely sequela of chronic small vessel ischemic \ndisease in \nthis age group. \n4. Nondominant left vertebral artery is diminutive and not \nadequately assessed \non this motion limited exam. 0 \n5. Atherosclerosis of the proximal right internal carotid artery \nis again seen \nbut could be exaggerated by artifact. Apparent irregularity of \nthe left \nproximal internal carotid artery, of the V2 and V3 segments of \nthe right \nvertebral artery, of the left greater than right carotid \nsiphons, and of the \ndistal M1 and M2 segments of the left middle cerebral artery \nprobably \nrepresents a combination of atherosclerosis and artifacts. \n\n \nBrief Hospital Course:\n___ RH female with a PMHx of paramedian pontine infarct (___), \nright-sided lenticulostriate territory infarct (___), multiple \nstrokes in the right posterior MCA/PCA watershed region (thought \nto be cardioembolic but no source identified, ___ \nPlavix and ASA, HTN, HLD, prior MI, colon cancer s/p resection \nand chemotherapy in ___, extensive tobacco use, recent DM \ndiagnosis, and recent diagnosis of B12 deficiency presents with \n4 week hx of progressively worsening left leg weakness and \nfalls. On exam she had no signs of neuropathy, intact sensation \nto light touch, temperature and Pin Prick as well as intact \nproprioception. CT Head with right caudate hypodensity of \nindeterminate age, but appears subacute/chronic. MRI/MRA brain \nand neck with punctate, likely subacute infarcts of the right \nfrontal periventricular white matter, posterior limb of the \nright internal capsule or right thalamus and right periatrial \nwhite matter. \nEtiology most likely secondary to known intracranial athero seen \non imaging vs. small vessel disease. Patient already on \nappropriate secondary stroke prophylaxis and thus no changes to \nher medications were made. She was evaluated by physical therapy \nwho recommended home ___.\nStroke risk factors: LDL 48, A1C6.6 \n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack\n1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed () No\n2. DVT Prophylaxis administered? (x) Yes - () No\n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes - () No\n4. LDL documented? (x) Yes (LDL =48 ) - () No\n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if \nLDL >100, reason not given: ]\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(x) Yes - () No\n9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, \nreason not given: ]\n10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - () Anticoagulation] - () No\n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - (x) N/A\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Oxybutynin 5 mg PO DAILY \n3. MetFORMIN (Glucophage) 500 mg PO DAILY \n4. Vitamin D 1000 UNIT PO DAILY \n5. Clopidogrel 75 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Clopidogrel 75 mg PO DAILY \n4. MetFORMIN (Glucophage) 500 mg PO DAILY \n5. Oxybutynin 5 mg PO DAILY \n6. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nIschemic stroke\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 ___ were hospitalized due to symptoms of left leg weakness and \nfalls resulting from an ACUTE ISCHEMIC STROKE, a condition where \na blood vessel providing oxygen and nutrients to the brain is \nblocked by a clot. The brain is the part of your body that \ncontrols and directs all the other parts of your body, so damage \nto the brain from being deprived of its blood supply can result \nin a variety of symptoms.\nStroke can have many different causes, so we assessed ___ for \nmedical conditions that might raise your risk of having stroke. \nIn order to prevent future strokes, we plan to modify those risk \nfactors. Your risk factors are:\nHTN\natherosclerotic disease\n\nNo changes to your medications were made since ___ are already \non the appropriate secondary stroke prevention.\n\nPlease take your other medications as prescribed.\n\nPlease follow up with Neurology and your primary care physician \nas listed below.\n\nIf ___ experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms:\n- Sudden partial or complete loss of vision\n- Sudden loss of the ability to speak words from your mouth\n- Sudden loss of the ability to understand others speaking to \n___\n- Sudden weakness of one side of the body\n- Sudden drooping of one side of the face\n- Sudden loss of sensation of one side of the body\n\nSincerely,\nYour ___ Neurology Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I639", "G8194", "E119", "I672", "Z8673", "I10", "E785", "I252", "Z85038", "E538", "Z9181", "F17210", "I6529", "I2510", "R32", "R159", "M8580", "Z7902" ]

[ "I639: Cerebral infarction, unspecified", "G8194: Hemiplegia, unspecified affecting left nondominant side", "E119: Type 2 diabetes mellitus without complications", "I672: Cerebral atherosclerosis", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I252: Old myocardial infarction", "Z85038: Personal history of other malignant neoplasm of large intestine", "E538: Deficiency of other specified B group vitamins", "Z9181: History of falling", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I6529: Occlusion and stenosis of unspecified carotid artery", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "R32: Unspecified urinary incontinence", "R159: Full incontinence of feces", "M8580: Other specified disorders of bone density and structure, unspecified site", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "E119", "Z8673", "I10", "E785", "I252", "F17210", "I2510", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nCelexa\n \nAttending: ___.\n \nChief Complaint:\nAdrenal Mass\n \nMajor Surgical or Invasive Procedure:\n1. Laparoscopic right adrenalectomy with removal of large \nadrenal mass (12cm).\n2. Percutaneous liver biopsy.\n\n \nHistory of Present Illness:\n___ yo F with right 10 cm nonfunctional adrenal mass. \n \nPast Medical History:\nPast medical history of hypertension, denies history of MI or\nstroke. 3 vaginal deliveries, appendectomy\n \nSocial History:\n___\nFamily History:\nFamily history is negative for adrenal issues\n\n \nPhysical Exam:\nWdWn, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, appropriately tender along incisions\nIncisions otherwise c/d/i\nExtremities w/out edema or pitting and there is no reported calf \npain to deep palpation\n\n \nPertinent Results:\n___ 12:50PM BLOOD WBC-6.4 RBC-2.72*# Hgb-7.6*# Hct-23.8*# \nMCV-88 MCH-27.9 MCHC-31.9* RDW-15.8* RDWSD-50.2* Plt ___\n___ 12:50PM BLOOD Glucose-91 UreaN-7 Creat-0.6 Na-137 K-4.1 \nCl-103 HCO3-23 AnGap-11\n___ 12:50PM BLOOD Calcium-7.7* Mg-1.7\n \nBrief Hospital Course:\nMs. ___ was admitted to Urology with right adrenal mass and \nunderwent laparoscopic right adrenalectomy with percutaneous \nliver biopsy. No concerning intraoperative events occurred; \nplease see dictated operative note for details. The patient \nreceived perioperative antibiotic prophylaxis. The patient was \ntransferred to the floor from the PACU in stable condition. On \nPOD0, pain was well controlled on PCA, hydrated for urine output \n>30cc/hour, provided with pneumoboots and incentive spirometry \nfor prophylaxis, and ambulated once. On POD1, the patient was \nrestarted on home medications, basic metabolic panel and \ncomplete blood count were checked, pain control was transitioned \nfrom PCA to oral analgesics, diet was advanced to a clears/toast \nand crackers diet. Urethral Foley catheter was removed without \ndifficulty and on POD2, diet was advanced as tolerated. The \nremainder of the hospital course was relatively unremarkable. \nThe patient was discharged in stable condition, eating well, \nambulating independently, voiding without difficulty, and with \npain control on oral analgesics. On exam, incision was clean, \ndry, and intact, with no evidence of hematoma collection or \ninfection. The patient was given explicit instructions to \nfollow-up in clinic in four weeks.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n2. Omeprazole 20 mg PO DAILY \n3. raloxifene 60 mg oral DAILY \n4. Simvastatin 20 mg PO QPM \n5. Citracal + D3 (calcium phos) (calcium phosphate-vitamin D3) \n250 mg calcium- 500 unit oral DAILY \n6. Vitamin D 1000 UNIT PO DAILY \n7. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg \niron-400 mcg-300 mcg oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \nRX *ibuprofen 600 mg ONE tablet(s) by mouth Q8hrs Disp #*25 \nTablet Refills:*0 \n3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg HALF to ONE FULL tablet by mouth Q4hrs Disp \n#*30 Tablet Refills:*0 \n4. Senna 8.6 mg PO BID Duration: 4 Doses \nRX *sennosides [Senokot] 8.6 mg ONE tab by mouth ___ x daily \nDisp #*30 Tablet Refills:*0 \n5. Centrum Silver Women (multivit-min-iron-FA-lutein) 8 mg \niron-400 mcg-300 mcg oral DAILY \n6. Citracal + D3 (calcium phos) (calcium phosphate-vitamin D3) \n250 mg calcium- 500 unit oral DAILY \n7. lisinopril-hydrochlorothiazide ___ mg oral DAILY \n8. Omeprazole 20 mg PO DAILY \n9. raloxifene 60 mg oral DAILY \n10. Simvastatin 20 mg PO QPM \n11. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPREOPERATIVE DIAGNOSIS: Right adrenal mass.\n\nPOSTOPERATIVE DIAGNOSIS: Right adrenal mass with possible\nliver fibrosis.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-Please also refer to the provided “handout” that details \ninstructions and expectations for your post-operative phase as \nmade available by your urologist. \n\n-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" ]

[ "D497", "K740", "I10", "K219", "K660", "Z87891" ]

[ "D497: Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system", "K740: Hepatic fibrosis", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "Z87891: Personal history of nicotine dependence" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___ / ___\n \nAttending: ___\n \nChief Complaint:\nperianal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPatient is a ___ man with history of hypertension who \npresents with perianal pain and purulent discharge.\n\nPatient states that he has had longstanding problems with \n\"hemorrhoids\". He reports that for the past ___ years, he has \nhad intermittent sensation of \"swelling\" and \"rectal pain\" with \ndefecation. This lasted for a few weeks followed by drainage of \npus from the rectal areas, followed by some asymptomatic months. \nHowever for the past month, he has felt significant pain and \nirritation, worse with sitting. He also see bloody drainage \noccasionally from the anal area. In the past, he was seen at \n___ ED in ___ for possibly possibly thrombosed painful \ninternal hemmorhoid. He reports he has tried Anusol HC \nsuppository without relief. He works using computers and \ntherefore is quite sedentary at work. He was recently seen by \nhis PCP ___ ___ due to worsening pain and purulent discharge. His \ndoctor prescribed him augmentin and mupriocin, as well as derm \nreferral. HIV and RPR negative at that time. The patient states \nthat the symptoms have not improved. He denies any history of \nreceptive anal intercourse, Crohn's disease, ulcerative colitis, \nfevers, chills, abdominal pain, dysuria, hematuria, diarrhea. \nPatient denies any similar pustules in his inguinal region or \narmpits. No family history of Crohn's disease. Patient reports \nexquisite pain with defecation.\n\n In the ED, initial VS were: 99.9 96 148/102 16 100% RA \n \n ED physical exam was recorded as multiple pustules along the \nleft buttock crease\n\nED labs were notable for WBC 13.7\n CT pelvis showed soft tissue thickening in the perianal region \nand extending along the left buttock, without fluid collection.\n\n Patient was given 1g Tylenol and vancomycin 1gm\n\nTransfer VS were 98.0 67 141/91 18 100% RA \n \nREVIEW OF SYSTEMS: \n A ten point ROS was conducted and was negative except as above \nin the HPI.\n\n \nPast Medical History:\nHYPERTENSION \nSICKLE CELL TRAIT \nASTHMA \nHEMORRHOIDS \nOBESITY \nKELOID \nH/O TOBACCO ABUSE \nH/O ACL TEAR \nH/O BACK PAIN \n \nSocial History:\n___\nFamily History:\n-Mother: ___\n-Grandmother: Lung Cancer (still alive)\n \nPhysical Exam:\nADMISSION & DISCHARGE EXAM:\n\n Gen: NAD, lying in bed\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n Cardiovasc: RRR, no MRG, full pulses, no edema \n Resp: normal effort, no accessory muscle use, lungs CTA ___.\n GI: soft, NT, ND, BS+\n MSK: No significant kyphosis. No palpable synovitis.\n Skin: Multiple nodular/pustular lesions on the left ___ \nregion extending to the gluteal folds. Some of these are \nerythematous and draining pus. On the right perianal region at 6 \no clock, there is also an area of condylomatous lesions, with no \npus. No anal fissures observed. No external hemorrhoid \nobserved. There are keloid lesions in the pubic area\n Neuro: AAOx3. No facial droop.\n \nPertinent Results:\n___ 12:10AM URINE HOURS-RANDOM\n___ 12:10AM URINE UHOLD-HOLD\n___ 12:10AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 12:10AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 12:10AM URINE MUCOUS-RARE\n___ 11:24PM estGFR-Using this\n\n CT\nSoft tissue thickening in the perianal region and extending \nalong the left buttock, without fluid collection. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ man with history of hypertension \nwho presents with perianal pain and purulent discharge. He has \nhad a history of multiple ___ lesions for ___ years \n(pustules with some drainage and warts) and discussed this with \nhis PCP for the first time last week. He was prescribed a \ncourse of augmentin, which he nearly completed, and referred to \nDermatology urgently for consideration of biopsy and further \nevaluation. Given the weather, his outpatient appointment was \ncanceled so presented to the ED and was admitted. He had no \nworsening symptoms from the ___ years of his chronic lesions, with \nthe exception of pain relieved with ibuprofen. He denied any \nfevers, chills, or sweats. His exam did not reveal s/s \ncellulitis and CT was negative for an abscess. His dermatology \nappt was rescheduled for the following morning, so he was \ndischarged a few hours after admission in stable condition with \ninstructions to keep his Dermatology appointment. No changes \nwere made to his medications. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Lisinopril 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n___ lesions, chronic\nHTN\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 for ongoing pain due to the lesions in the \n___ area. You have an appointment with Dermatology \ntomorrow AM - it is very important you keep this appointment so \nthese lesions can be evaluated. \n\nPlease complete the antibiotics Dr. ___ for you last \nweek. \n\nNo other changes were made to your medications.\n\nWe wish you the best,\n___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K629", "L910", "I10", "D573", "E669", "Z6831", "Z87891" ]

[ "K629: Disease of anus and rectum, unspecified", "L910: Hypertrophic scar", "I10: Essential (primary) hypertension", "D573: Sickle-cell trait", "E669: Obesity, unspecified", "Z6831: Body mass index [BMI] 31.0-31.9, adult", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "E669", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nSacral ulcer\n \nMajor Surgical or Invasive Procedure:\nUretropelvic junction stent replacement\nIntubation\nPICC line placement\nRight Chest tube placement\n \nHistory of Present Illness:\nMs. ___ is a ___ year-old woman a PMH significant for AFib on \ncoumadin, UPJ obstruction s/p stent placement in ___ c/b \nchronic Klebsiella bacturia, IgG myeloma on lenolidamide, and \nadenocarcinoma of the anal canal (followed by Dr. ___ \nadmitted to ___ for evaluation of anemia (Hgb 8.6) \nwith course complicated by atrial fibrillation with RVR \nrequiring ICU admission for dilt gtt, Acute of chronic kidney \ninjury osteomyelitis from sacral decubitus ucler who was \ntransferred to ___ for debridement of sacral ulcer. \n In the ED she developed afib with RVR with hypotension where \nshe briefly required a dilt gtt. She was then transferred to the \nfloor. \n Hospital course thus far has included an MRI without \nosteomyelitis, abdominal distension w/ NGT placement draining \nbilious contents, CBI and urology procedure for evaluation of \nhematuria. She underwent cystoscopy ___ to exchange ureteral \nstent and found purulence behind stent. There was no etiology of \nhematuria seen. She was started on vanc and zosyn and kept on \nfluconazole started pre-procedure. Culture significant for \n___ albicans and MDR pseudomonas SN to Gentamicin which was \nheld ___ ___.\n Following cystoscopy, were unable to extubate and couldn't get \noff pressors. Per report, black colored liquid was coming out of \nNGT. \n \nRequired FICU transfer\nFICU Course Significant for: Extubation and starting on tube \nfeeding.\nWas restabilized and discharged from the FICU where CT Torso \nrevealed\nNew retroperitoneal soft tissue mass encasing the aorta and \ncommon iliac vessels in comparison to the ___ \nexamination. The mass abuts the second and third portion of the \nduodenum and pancreatic head. Suspected involvement of the \npancreatic head and distal CBD with new intra and extrahepatic \nbile duct dilation. \nEncasement of both ureters, with new left and worsened right \nmoderate hydronephrosis in comparison to the ___ \n Transferred to ___ where course was complicated by hypotension \nand worsening of anemia in the setting of gross hematuria. Her \nVS were 85/Doppler and HR of high ___. She received one unit \nprbc at the time of initial assessment and 2nd unit being hung.\n\nPrior to transfer: hung 2nd unit prbc (first at about 3). \n-Obtained ABG.\n-Guiac positive\n\nOn arrival to the CCU, pt in respiratory distress with shallow \nbreathing. Intermittently responsive, able to follow some \ncommands. Felt \"ok\" but increasingly somnolent.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n\n#ANAL ADENOCA: Per Dr. ___: Admitted to ___ ___ for\nBRBPR. Found to have anal adenocarcinoma, T2N0 based on MRI and\nCT. Seen by Dr ___ in the hospital from surgery but has\nbeen noncompliant with f/u with her despite multiple outreaches\nfrom her office.\n\n#MM: ___ woman who presented with anemia in ___. Further testing demonstrated an M-spike of\napproximately 3.3 g/dL, IgG was 5800 mg/dL. Eventually, the\npatient was referred to Hematology, IgG increased to 7100mg/dL \nat\nthe start of treatment. Initial Hematology consult was ___. Bone marrow biopsy revealed 60% of her bone marrow\noccupied by plasma cells, cytogenetics demonstrated \ntranslocation\nof chromosomes 11 and 14, also monosomy 13. Skeletal survey was\nnegative. Initial beta 2 microglobulin was 4.08, she started\ncycle 1 of Revlimid and dexamethasone on ___, \nRevlimid\nat 25 mg. She was admitted to ___ on ___,\nwith pneumonia, she was also coagulopathic and quite leukopenic. \n\nShe was discharged on ___. On\n___, she presented with severe back pain, and she has\nsustained a compression fracture of L3 vertebra. Her white \nblood\ncell count was still low, the Revlimid was held, and restarted \non\n___ at a lower dose of 15 mg, in combination with\nweekly dexamethasone at 20 mg. She was started on Zometa. The\npatient did well on this lower dose of Revlimid with a nice\nimprovement in her IgG and M-spike, M-spike going down to 1.0\ng/dL by ___, and her IgG going into the normal range \nat\nthe same time, she continued on Revlimid 15 mg every days ___,\nwith weekly dexamethasone at 20 mg, repeated every month, with\nZometa every 3 months, for quite some time, although by ___, the patient was becoming more leukopenic. At the start of\ncycle 19 of Revlimid and dexamethasone, in ___, the\nM-spike was down to 0.6 g/dL, and the Revlimid was reduced to 10\nmg per day because of severe neutropenia. Unfortunately by\n___ timeframe, the M-spike started to creep up, to 0.8\ng/dL fairly consistently through the ___, and by \n___, at her ___ cycle of Revlimid and dexamethasone, the\nM-spike increased to 0.9 g/dL. She was increased to Rev 15 mg \nand\nher counts are holding. She reports she missed a month of Rev \ndue\nto her hospitalization in ___ Cycle #27 Rev 15mg -Dex\n___ Clinic appt start Biaxin\n___ Cycle #28 Rev-Dex\n___ Clinic appt reviewed labs M-spike 0.8g/dL\n___ Cycle #29 Rev-Dex\n___ Admitted for hematuria, elevated INR\nattributed to Ultram-warfarin interaction\n___ Clinic appt Zometa, on cycle #29\n___ Cycle #30 Rev-Dex\n___ Cycle #31-- decided to continue without a clinic \nappt,\nshe was having a great time visiting family in ___\n___ Cycle #31 day #19\n___ Cycle #32\n___ Cycle #33 and Zometa\n___ Cycle #34 start on ___ end ___. \n___ Cycle #35 start ___ end ___. M-spike 0.9g/dL\n___ Cycle #36, start ___ or ___, Zometa, end ___. \nM-spike 0.8g/dL\n___ Cycle ___ M-spike 0.9g/dL. Now ___ years on \nRev-dex\n(first cycle was ___ Cycle ___ M-spike 0.9g/dL IgG stable. Start Rev ___\n___ finish ___ See me in clinic before cycle #39\nstart ___ finish ___ See me in clinic, Zometa, cycle #40\nwill start ___ ( I am out of office ___\n___ Admitted ___ obstructive uropathy and\nenterococcal UTI discharged ___ to rehab\n___ ___ \ndischarged\n___ Touched base by phone, hold Revlimid until next \nfollow\nup\n___ Cycle #41 start ___ end ___ Stent change scheduled\n___ Cycle #42 planned start\n___ Zometa, Previously followed in hem/onc by Dr \n___ today to establish care with me.\n___ Cycle 44\n___ Cycle 45, zometa\n___ Cycle 46\n___ Cycle 47, zometa\n___ Cycle 48 Rev\n___ Cycle 49 rev, zometa\n___ Cycle 50 rev\n___ Cycle 51 rev\n___ Anal cancer - adeno diagnosed\n\nPAST MEDICAL HISTORY:\nHypertension \nAtrial fibrillation on coumadin \nObesity \nMyeloma \nOsteoarthritis of right knee \nUPJ obstruction s/p stent placement ___ c/b persistent \nKlebsiella bacteruria \nAnal adenocarcinoma (dx ___ \n? Perirectal cyst drainage in 1980s \n\nPSH: \n___ - EUA, biopsy of ___ lesion\n___ - cystoscopy and R ureteral stent exchange\n___ - lap CCY\nHysterectomy\n___ - unknown ___ procedure\n\n \nSocial History:\n___\nFamily History:\nHer parents died in their ___ or ___ of \"old age.\" Her parents \nand multiple siblings have hypertension. Sibling with \nAlzheimer's disease. No family history of significant arrhythmia \nor premature coronary disease.\n\n \nPhysical Exam:\nAdmission Physical Exam:\n Vitals: 97.8 120/77 118 20 100RA \n GENERAL: Elderly woman, lying in bed, NAD \n HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM \n NECK: nontender supple neck, no LAD, no JVD \n CARDIAC: Irregularly irregular, +S1/S2, no murmurs, gallops, or \nrubs \n LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \n ABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly. Anus with friable \nmucosa. Ostomy in place \n EXTREMITIES: 2 piting edema up through shins bilaterally, no \ncyanosis or clubbing \n PULSES: 2+ DP pulses bilaterally \n NEURO: CN II-XII and motor grossly intact intact \n SKIN: warm and well perfused, no excoriations or lesions, no \nrashes\n\nDischarge Physical Exam:\ndeceased\n \nPertinent Results:\nAdmission Labs:\n---------------\n___ 04:38AM BLOOD WBC-4.3 RBC-2.88* Hgb-8.6* Hct-25.9* \nMCV-90 MCH-29.9 MCHC-33.2 RDW-15.9* RDWSD-52.1* Plt ___\n___ 04:38AM BLOOD Neuts-53 Bands-0 Lymphs-14* Monos-25* \nEos-3 Baso-0 ___ Metas-2* Myelos-3* AbsNeut-2.28 \nAbsLymp-0.60* AbsMono-1.08* AbsEos-0.13 AbsBaso-0.00*\n___ 04:38AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL \nMacrocy-NORMAL Microcy-NORMAL Polychr-NORMAL\n___ 04:38AM BLOOD ___ PTT-27.0 ___\n___ 04:38AM BLOOD Glucose-101* UreaN-35* Creat-2.0*# Na-134 \nK-4.9 Cl-98 HCO3-27 AnGap-14\n___ 04:38AM BLOOD ALT-6 AST-18 LD(LDH)-182 AlkPhos-75 \nTotBili-0.4\n___ 04:38AM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.6 Mg-2.1\n___ 04:38AM BLOOD Vanco-14.6\n\nIMAGES: \n-------\n___ CXR\nPort-A-Cath catheter tip is at the level of the right \nventricular outflow tract. The double tube has been removed. \nThere is substantial distension of the stomach that might \npotentially benefit from the NG tube insertion. What appears to \nbe a E ureteral stent is partially imaged. Bilateral pleural \neffusions, right more than left are present. Vascular congestion \nis noted, borderline with mild interstitial pulmonary edema. \n\n___ KUB\n1. A right double J stent projects over the expected location of \nthe right renal pelvis and bladder. The stent is unchanged in \nposition since ___. \n2. The stomach is distended with air. \n\n___ TTE\nThe left atrium is moderately dilated. Left ventricular wall \nthicknesses and cavity size are normal. Regional left \nventricular wall motion is normal. Overall left ventricular \nsystolic function is low normal (LVEF 50-55%). The estimated \ncardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging \nsuggests a normal left ventricular filling pressure \n(PCWP<12mmHg). The right ventricular cavity is mildly dilated \nwith normal free wall contractility. The aortic valve leaflets \n(3) are mildly thickened but aortic stenosis is not present. \nTrace aortic regurgitation is seen. The mitral valve leaflets \nare structurally normal. There is no mitral valve prolapse. Mild \nto moderate (___) mitral regurgitation is seen. There is mild \nto moderate pulmonary artery systolic hypertension. There is no \npericardial effusion. \n\nCompared with the prior study (images reviewed) of ___, the \nfindings are similar. \n\n___ Renal US\n1. Moderate hydronephrosis and cortical thinning on the right. \nMild \nhydronephrosis on the left. These findings are unchanged from \nCT ___. \n2. A large pleural effusion is unchanged from ___. \n\n___ CXR\nAs compared to the previous radiograph, the right sided J-stent \nis unchanged. The previously severe gastric over distension has \nfurther increased in severity and is now massive. \n\n___ CXR\nAs compared to ___, the patient has received a new \nnasogastric tube. The tube is located in the middle parts of \nthe stomach. The previous overinflation of the stomach is no \nlonger present. The lung volumes remain low. Moderate \ncardiomegaly. Moderate bilateral areas of atelectasis and mild \nto moderate right pleural effusion. \n\n___ MRI Sacrum\nPND - preliminary read is no osteomylelitis\n\nDischarge Labs: N/A\n---------------\n \nBrief Hospital Course:\nMs. ___ is a ___ year-old woman a PMH significant for AFib on \ncoumadin, UPJ obstruction s/p stent placement in ___ c/b \nchronic Klebsiella bacturia, IgG myeloma on lenolidamide, and \nadenocarcinoma of the anal canal (followed by Dr. ___ \nadmitted to ___ for evaluation of anemia (Hgb 8.6) with \ncourse complicated by atrial fibrillation with RVR requiring ICU \nadmission for dilt gtt, Acute of chronic kidney injury, \n?osteomyelitis from sacral decubitus ulcer now transferred to \n___ for debridement of sacral ulcer. Became hypotensive and \nquite anemic on the floor with H/H of ___ and was transferred \nto the MICU ___. \n She peacefully passed away with her family and family pastor \npresent in the room at ___ on ___. \n \n#Hypercarbic respiratory failure: The pt consistently required \nnasal cannula up to 6 L while on the floor. This was thought to \nbe due to volume overload and increased work of breathing. While \nin the CCU pt became more lethargic and an ABG showed \nhypercarbic respiratory failure. She was intubated by \nanesthesia. CXR showed large bilateral pleural effusions and \nshe was grossly anasarcic. IP placed a right chest tube to \ndrain the effusion which showed that it was malignant with \ncytology showing adenocarcinoma. She was extubated successfully \non ___ and was weaned down to room air thereafter. She was \nable to be comfortable on room air for the rest of her \nadmission.\n\n# Encephalopathy: although the pt's mental status had noticed to \nbe declining on the floor, she was still able to answer \nappropriately. After extubation, the pt was noted to be very \nlethargic and minimally responsive. EEG was done which showed \ntriphasic waves consistent with an encephalopathy. The pt was \ntrialed on Ativan and Keppra. Her mental status remained very \npoor in spite of continued Keppra. Neuro signed off after head \nimaging was unrevealing. Mental status continued to wax and \nwane through the rest of her time. \n\n# Stage IV surgical dehiscence: Patient had correction of \nabdominoperineal resection defect with a right vertical rectus \nabdominis muscular cutaneous flap in ___ following \nresection of anal cancer. She presented to the hospital with \nstage IV, MRSA + sacral ulcer with concern for osteomyelitis, as \nwound probes to bone. CT scan with no mention of sacral \nosteomyelitis. GI deferred to plastics as they did flap surgery. \nPlastics does not recommend surgical intervention at this time. \nMRI shows no signs of osteomyelitis. This wound remained stable \nduring her hospital course. \n\n# ___: Baseline Creatinine 0.8. Creatinine on admission was 2.1 \nin setting of diuresis but also possible hypotension from afib \nwith RVR. Pt is grossly volume overloaded with hypoalbumenemia. \nConcern for prerenal vs. intrinsic with possible multiple \nmyeloma involvement vs obstructive. Creatinine remains above 2.0 \ntoday. Renal consulted and believed that her ___ was \npredominantly secondary to obstruction. After stent exchange by \nurology ___, renal function improved with a Cr to 1.5 with IV \nfluids and remained stable. \n \n# Gastric Distension: Patient developed nausea and 1 episode of \nvomiting ___ with increasing distention. And xray ___ \nshowed significant gastric distension. NG tube was placed and \n>1L was drawn off. Patient's reported symptomatic improvement. \nPatient continued to have ostomy output throughout episode. No \nmass appreciated on exam though obese abdomen. Patient not on \nnarcotic medication. On ___, NG tube was clamped without \nrecurrence of distention, patient denies nausea or distension. \nUnable to get CT abd due to poor kidney function, but got OSH CT \nread by our radiologists. It was notable for new retroperitoneal \nmass encasing aorta throughout abdomen. It is touching and \npossibly invading ___ and ___ portion of duodenum, potentially \nexplaining gastric obstruction symptoms. Invades pancreatic \nhead, explaining ductal dilatation. Also surrounding common \niliac vessels, and both ureters (hydronephrosis worse since \n___. Speech and swallow was consulted who said the pt \nshould be strict NPO. Tube feeds were started. \n\n# Tube feeds: On ___ Ms. ___ was no longer tolerating \nher tube feeds due to very high residuals. Tube feeds were \nstopped and she was given nutrition with D5NS at 75/hr. ___ \nattempted to place the Dobhoff tube post-pyloric but they were \nunable to pass the tube through the pylorus and noted contrast \nbarely trickles through ___ obstruction. In family meetings the \nfamily was informed that the feeding tube could not be advanced, \nand that other options such as TPN would likely harm the pt more \nthan help her because of her risk for bloodstream infection and \nmetabolic derangements. \n\n# Metastatic anal adenocarcinoma: large retroperitoneal mass \ncompressing the abdomen and constricting the aorta at the level \nof the iliacs noted on CT from OSH, thought to be metastasis \nfrom her known anal adenocarcinoma. Per onc, not a candidate for \nchemotherapy, so likely not worth biopsying even though \ndefinitive diagnosis would not otherwise be reached. Recommend \ngetting palliative care involved and having goals of care \ndiscussion with family. First family meeting was ___ and \nson, ___, wanted us to do everything we could to help Ms. \n___. This continued to be a theme during her hospital stay, \nand several meetings were held with the family to discuss goals \nof care. On ___ it was decided to switch to focusing on her \ncomfort only.\n\n# Volume overload: Likely from diastolic heart failure but will \nneed to rule out hypoalbuminemic state, and cirrhosis. Patient \nwith gross volume overload with 2+ ___ edema, bilateral effusions \nand CT with anasarca on abdominal imaging. TTE unchanged from \nprevious with EF 55% and no gross valvular dysfunction. TSH \nelevated, T4 WNLs. Patient given albumin ___ with good \nresponse. However, patient still significantly overloaded. On \n___ she was anuric and hypotensive despite having \nsignificant lower extremity and abdominal edema. She was \ntransferred to the MICU on this day. While in the MICU she was \nstabilized and pressors were downtitrated. Poor response to \nLasix alone but given Lasix and Chlorothiazide with good UOP. \n \n# Hematuria: Unclear cause but patient was on anticoagulation. \nConcern would be primarily for tumor infiltration. Hematuria \nintermittent, but seems to recur during transport. Potential \nmechanical irritation. Patient continues to pass dime sized \nclots. Stent exchange done ___ by urology, with improvement in \nher hematuria. Hematuria with clots returned on ___. \nUrology recommended CBI which was started ___. She had \nCBI intermittently throughout her stay to relieve foley \nobstructions. \n \n# Normocytic Anemia: Hgb at ___ 8.6. No evidence of \nbleeding. She does have stage III CKD. MCV within normal range \nand iron studies not particularly suggestive of iron deficiency \nanemia with ferritin of 781. Folate level of 7.4 and B12 of 411. \nConcern could possibly be for chronic low grade bleed from gut \nor hematuria. (transfused evening of ___. Hgb remained \nstable in the 7's until ___ when H/H dropped to ___. \nThis same day she triggered for hypotension of 86/Doppler. As \nshe was anuric at this time there was concern of intraabdominal \nbleeding and was one of the indications for MICU transfer. Pt \nhad episode of gross hematuria requiring CBI and pRBC \ntransfusion for BP control. Pt required Vasopressin and \nPhenylephrine while in the MICU but was able to be weaned off. \nShe required intermittent pRBC transfusions during her time in \nthe MICU.\n \n# AFib on coumadin: CHADS 2 of 3. Hemodynamically unstable with \nRVR upon arrival, but controlled with diltiazem and metoprolol. \nShe remained in AFib during her hospital stay. Due to her \nhematuria and dropping H/H, blood pressure medications and \nultimately SQH were discontinued on ___. Pt put on an \nesmolol gtt as she had afib with RVR into the 130s on her first \nday in the ICU. She was taken off the esmolol drip and \nthereafter controlled with IV metoprolol and achieved good \ncontrol on PO metoprolol with heart rates in the ___. \n\n# Hypertension: Currently normotensive. See above for issues \nwith hypotension and reason for MICU transfer ___. \n \n# IgG Myeloma: Patient with longstanding IgG MM, followed by \n___ Oncology. Currently not on revlimid or dexamethasone. \nKappa:lamba increase, but can be seen in kidney disease. Atrius \noncology followed patient throughout hospital stay.\n\n====================\nTRANSITIONAL ISSUES:\n====================\n- Family Bereavement Counseling \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen (Liquid) 1000 mg PO TID \n2. Diltiazem 30 mg PO QID \n3. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush \n\n4. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes \n5. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port \n6. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain \n7. Dexamethasone 4 mg PO 1X/WEEK (TH) \n8. Calcium Carbonate 500 mg PO BID:PRN heart burn \n9. Collagenase Ointment 1 Appl TP DAILY \n10. Escitalopram Oxalate 5 mg PO DAILY \n11. Metoprolol Succinate XL 200 mg PO DAILY \n12. Mirtazapine 7.5 mg PO QHS \n13. Pantoprazole 40 mg PO Q24H \n14. Furosemide 80 mg PO DAILY \n\n \nDischarge Medications:\nN/A\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPatient Expired \n \nDischarge Condition:\nPatient Expired\n\n \nDischarge Instructions:\nPatient Expired\n \nFollowup Instructions:\n___\n" ]

[ "T8131XA", "R6521", "J9601", "N179", "A419", "G9340", "C9000", "J910", "K5660", "C786", "C7889", "C211", "E46", "Q620", "T814XXA", "T8359XA", "N12", "B3749", "K311", "I5032", "D62", "Z66", "Z515", "E8809", "I482", "Z7901", "M179", "I129", "B9562", "N183", "Z433", "R310", "E669", "Z6838", "Y848", "Y92239", "B965", "D696" ]

[ "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter", "R6521: Severe sepsis with septic shock", "J9601: Acute respiratory failure with hypoxia", "N179: Acute kidney failure, unspecified", "A419: Sepsis, unspecified organism", "G9340: Encephalopathy, unspecified", "C9000: Multiple myeloma not having achieved remission", "J910: Malignant pleural effusion", "K5660: Unspecified intestinal obstruction", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C7889: Secondary malignant neoplasm of other digestive organs", "C211: Malignant neoplasm of anal canal", "E46: Unspecified protein-calorie malnutrition", "Q620: Congenital hydronephrosis", "T814XXA: Infection following a procedure", "T8359XA: Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system", "N12: Tubulo-interstitial nephritis, not specified as acute or chronic", "B3749: Other urogenital candidiasis", "K311: Adult hypertrophic pyloric stenosis", "I5032: Chronic diastolic (congestive) heart failure", "D62: Acute posthemorrhagic anemia", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "I482: Chronic atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "M179: Osteoarthritis of knee, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "N183: Chronic kidney disease, stage 3 (moderate)", "Z433: Encounter for attention to colostomy", "R310: Gross hematuria", "E669: Obesity, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "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", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "D696: Thrombocytopenia, unspecified" ]

[ "J9601", "N179", "I5032", "D62", "Z66", "Z515", "Z7901", "I129", "E669", "D696" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nChloroquine\n \nAttending: ___\n \nChief Complaint:\nL2 fracture, back pain\n \nMajor Surgical or Invasive Procedure:\n___: L2 corpectomy (retroperitoneal approach) and \nrevision of posterior L1-L3 fusion \n\n \nHistory of Present Illness:\nMr. ___ is a ___ Ph.D. researcher at ___ who was \nin ___ for\nresearch projects in ___. He had to jump out of a \nsecond-floor window secondary to a terrorist attack and broke \nhis leg and fractured his L2 vertebrae. He initially received \ncare for this in ___. The patient continued to have back \npain and after exhausting medical treatment, remained \nsymptomatic. The decision was made to proceed with L2 corpectomy \nwith a revision\nof posterior instrumentation and fusion.\n\n \nPast Medical History:\nMitral valve prolapse\nheadaches \nGERD\n\nPast Surgical:\n___: L ankle ORIF\n___ L1-L3 fusion\n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nUPON DISCHARGE: \nAfebrile \nVital sigs stable \nNo apparent distress \nHeart rate regular \nRespirations non-labored \nAbdomen, soft, non-tender, non-distended \n\nBack incision clean, dry and intact with staples place \n___ strength throughout \nSensation intact throughout \n\n \nPertinent Results:\n___: Portable abdomen xray\nIMPRESSION: \nDiffuse dilatation of the large bowel in a pattern most \nconsistent with ileus. No pneumoperitoneum or pneumatosis. \n\n___: Ultrasound Bilateral ___ veins\nIMPRESSION: \nNo evidence of deep venous thrombosis in the right or left lower \nextremity \nveins. \n\n___: CTA Chest\nIMPRESSION: \n1. No evidence of pulmonary embolism or aortic abnormality. \n2. Bilateral small nonhemorrhagic pleural effusions and adjacent \nbibasilar \natelectasis. \n\n___: Xray abdomen\nIMPRESSION: \n1. Interval improvement of colonic ileus. \n2. Left loculated pleural effusion, better assessed on CT chest \nfrom the same day. \n\n___ Lumbosacral spine xray\nIMPRESSION: \nPostsurgical changes. No acute fracture. \n\n___ KUB **\n\n \nBrief Hospital Course:\nOn ___, the patient was admitted for elective L2 corpectomy \n(retroperitoneal approach) and revision of posterior L1-L3 \nfusion. He underwent this procedure with Dr. ___ was \nsubsequently transferred out of the OR to the PACU for \npost-anesthesia care and monitoring. \n\nOn ___ Patient was neurologically stable. He continued to \ncomplain of uncontrolled back pain so pain regimen was adjusted.\n\nOn ___, the patient continued with back pain which he states \nwas mildly improved. He complained of abdominal pain and \ndistention and KUB showed large bowel ileus. His bowel regimen \nwas increased and he received enema with no immediate BM,but \nlarge amount of flatus. The patient underwent workup for \ntachycardia, EKG showed sinus tach and Trops were negative. \nLENIs were negative for any DVTs and tachycardia improved to 110 \nafter pain improved.\n\nOn ___, overnight the patient's oxygen saturation dipped down \nto 80% while sleeping, and he was therefore placed on 1L NC. In \nthe morning, his neurological and motor exam was stable. When \nworking with ___ he had tachyacardia with a heart rate of 100 \nthat increased to 140 when he rose from sitting to standin. He \nalso had a correlating O2 drop to the ___. A CTA was ordered and \nwas negative for PE, though it revealed some atelectasis. A \nfollow-up KUB was ordered for investigation of resolution of \nileus, as he had a BM overnight. It showed interval improvement \nof colonic ileus. \n\nOn ___, the patient remained neurologically stable. While \ntrying to reposition himself in bed he reports he \"snapped\" his \nlow back and has new posterior right sided lumbar pain. He \ndenies numbness, tingling in his lower extremities. He is full \nstrength bilaterally. A repeat AP/LAT xray are stable. Per CPS \nhis diazepam was d/c'd and he was started on Tizanidine. Diet \nchanged to full liquids.\n\nOn ___ the patient remained neurologically stable, and was \nawaiting a rehab bed. He continued to endorse right lower back \npain, although continued on pain medication as needed. \n \nOn ___ the patient remained neurologically and hemodynamically \nstable. The patient was awaiting a rehab bed. \n\nOn ___, the patient remained neurologically and hemodynamically \nstable. Patient complaining of diarrhea with intermittent \nabdominal pain. Ordered repeat KUB to evaluate previous ileus \nwhich showed resolving ileus. Diet was advanced as patient \ntolerates. \n\nAt the time of discharge on ___ the patient's pain was well \ncontrolled with oral medications, incisions were \nclean/dry/intact, and the patient was voiding/moving bowels \nspontaneously. The patient will follow up with Dr. ___ \nroutine. The patient expressed readiness for discharge.\n\n \nMedications on Admission:\nGabapentin 300mg PO TID\nlansoprazole 15mg PO daily\noxycodone prn\ntramadol prn\nCialis 20mg q72 hours\n \nDischarge Medications:\n1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth Every four (4) hours \nas needed Disp #*60 Tablet Refills:*0\n2. Gabapentin 600 mg PO TID \nRX *gabapentin 600 mg 1 tablet(s) by mouth three times a day \nDisp #*42 Tablet Refills:*0\n3. Calcium Carbonate 1000 mg PO QID:PRN indisgestion \n4. Acetaminophen 650 mg PO Q6H \n5. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth Twice daily Disp \n#*28 Tablet Refills:*0\n6. Tizanidine 2 mg PO TID:PRN muscle spasm \nRX *tizanidine 2 mg 1 tablet(s) by mouth Three times daily as \nneeded Disp #*42 Tablet Refills:*0\n7. Cyanocobalamin 1000 mcg PO DAILY \n8. FoLIC Acid ___ mcg PO DAILY \n9. lansoprazole 15 mg oral DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nL2 fracture, back pain\n\n \nDischarge Condition:\nStable\n\n \nDischarge Instructions:\nSurgery\n•Your dressing was removed on the second day after surgery. The \nwound may remain uncovered. \n•Your incision is closed with staples. You will need to have \nstaple removal. \n•Do not apply any lotions or creams to the site. \n•Please keep your incision dry until removal of your staples.\n•Please avoid swimming for two weeks after staple removal.\n•Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n•You must wear your brace at all times when out of bed. You may \napply your brace sitting at the edge of the bed. You do not need \nto sleep with it on. \n•We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n•You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n•No driving while taking any narcotic or sedating medication. \n•No contact sports until cleared by your neurosurgeon. \n•Do NOT smoke. Smoking can affect your healing and fusion.\n\nMedications\n•Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n•Do not take any anti-inflammatory medications such as Motrin, \nAdvil, Aspirin, and Ibuprofen etc… until cleared by your \nneurosurgeon.\n•You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n•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\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite. \n•Fever greater than 101.5 degrees Fahrenheit\n•New weakness or changes in sensation in your arms or legs.\n\n \nFollowup Instructions:\n___\n" ]

[ "M4856XA", "K913", "T8489XA", "M5136", "Y831", "Y92239", "Y838", "Y92009" ]

[ "M4856XA: Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture", "K913: Postprocedural intestinal obstruction", "T8489XA: Other specified complication of internal orthopedic prosthetic devices, implants and grafts, initial encounter", "M5136: Other intervertebral disc degeneration, lumbar region", "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", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nnifedipine / Amitriptyline / Prilosec OTC / Terazosin / \nAmlodipine / Atenolol / Oxybutynin / Hydrochlorothiazide / \nspironolactone / furosemide\n \nAttending: ___.\n \nChief Complaint:\nFall, bradycardia.\n \nMajor Surgical or Invasive Procedure:\nNone.\n \nHistory of Present Illness:\n___ YO F w/ PMH significant for CAD, mild AS, afib/flutter on \ndabigatran, HFpEF, HTN, HLD, chronic hyponatremia, who presents \nafter a fall at her nursing home. \n\nPt unable to provide history, but per nursing home and OSH \nnotes, in early AM on ___, pt fell and was discovered by nursing \nhome RN. RN at that time noted that pt was confused and \nlethargic. HR at that time per report was in the ___. EMS was \nactivated and pt brought to OSH ER. En route, EMS report \nindicates that heart rates were labile, but there are no EKG \nstrips and unclear if pt received any cardiac medications. At \nOSH ER, pt's EKG revealed bradycardia to 20 with ventricular \nescape and no signs of atrial activity. The pt was then given 1 \nmg of atropine with no effect and then transcutaneously paced \nfor 1 hour. She was then noted to have HRs in the ___ and atrial \nactivity. She was then transferred to ___ for possible PPM. \n\nHere at ___, noted to be intermittently lethargic and poorly \nresponsive. CT head and neck negative. EP was consulted for \npossible PPM and initially recommended admission to ___, \ndeferred PPM for the time being. She continued to be \nintermittently bradycardic to the ___ in the ED, but given that \nshe has a history of previous bradycardia and has been \nasymptomatic with her episodes, she was felt to be stable for \nthe floor. However, after this she had increasing respiratory \ndistress requiring a NRB. Due to this she was admitted to the \nCCU. Received Lasix 60mg IV x1.\n \n Of note, pt's HCP reports that she had been more altered over \nthe last week in the setting of higher doses of seroquel that \nthe nursing home had started for increased agitation. \n\nIn the ED initial vitals were: 98.3, HR 90, 142/73, 18, 93% RA \nEKG: \nLabs/studies notable for: Na 140, K 4.6, Cl 98 HCO3 35 BUN 58 Cr \n1.2 glu 125, WBC 7 Hct 34.8 AST 219 ALT 178 Trop 0.05 ___: 14.8 \nPTT: 42.4 INR: 1.4 AGap=12 BNP 2900 Lactate 1.5. ABG: \n___\n\nOn arrival to the CCU: Awake but not answering questions. Pt \ndoes not speak ___, per report. On NRB. \n \nPast Medical History:\n1. CARDIAC RISK FACTORS\n- Hypertension\n- Dyslipidemia\n2. CARDIAC HISTORY\n- CAD (100% LAD occlusion). MI ___ year ago. Unclear history of \nPCI.\n- Afib/flutter on dabigatran \n- Mild aortic stenosis\n3. OTHER PAST MEDICAL HISTORY \n- Chronic hyponatremia \n- Dementia\n\n \nSocial History:\n___\nFamily History:\nMother deceased at ___ yo from breast cancer. Father deceased at \n___ yo. Son deceased at ___ yo from heart attack. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: T 97.6 BP 132/103 HR 80 RR 21 O2 SAT 100% NRB\nGENERAL: Ill appearing. Not answering questions. \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \nNo xanthelasma.\nNECK: Supple. JVP unable to assess due to restlessness.\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. Irregularly irregular. Normal S1, S2. II/VI systolic \nmurmur at R sternal border. \nLUNGS: No chest wall deformities or tenderness. Tachypneic but \nwithoug increased work of breathing. Faint crackles.\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: T 97.6 BP 144/75 HR 54 RR 22 O2 SAT 92% 2 L NC \n\nGENERAL: Skinny, somewhat anxious. Oriented to self only. \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \nNo xanthelasma.\nNECK: Supple. JVP unable to assess due to restlessness.\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. Irregularly irregular. Normal S1, S2. II/VI systolic \nmurmur at R sternal border. \nLUNGS: No chest wall deformities or tenderness. Tachypneic no \nsigns respiratory distress. Lungs clear to auscultation \nbilaterally. \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___ 12:45PM BLOOD WBC-10.0 RBC-3.55* Hgb-10.5* Hct-34.8 \nMCV-98 MCH-29.6 MCHC-30.2* RDW-13.1 RDWSD-46.9* Plt ___\n___ 12:45PM BLOOD Neuts-87.3* Lymphs-5.0* Monos-7.0 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-8.76* AbsLymp-0.50* \nAbsMono-0.70 AbsEos-0.00* AbsBaso-0.02\n___ 12:45PM BLOOD ___ PTT-42.4* ___\n___ 12:45PM BLOOD Glucose-125* UreaN-58* Creat-1.2* Na-140 \nK-4.6 Cl-98 HCO3-35* AnGap-12\n___ 12:45PM BLOOD proBNP-2915*\n___ 12:45PM BLOOD cTropnT-0.05*\n___ 05:51AM BLOOD CK-MB-9 cTropnT-0.13*\n___ 05:51AM BLOOD Calcium-10.1 Phos-4.6* Mg-2.5\n___ 08:10PM BLOOD ___ pO2-23* pCO2-79* pH-7.29* \ncalTCO2-40* Base XS-6\n___ 12:52PM BLOOD Lactate-1.5\n\nPERTINENT RESULTS:\n___ 12:45PM BLOOD cTropnT-0.05*\n___ 05:51AM BLOOD CK-MB-9 cTropnT-0.13*\n___ 12:52PM BLOOD Lactate-1.5\n___ 11:47PM BLOOD Lactate-1.0\n___ 06:04AM BLOOD Lactate-2.9*\n\nDISCHARGE LABS:\n\n___ 05:51AM BLOOD WBC-7.8 RBC-3.90 Hgb-11.3 Hct-37.7 MCV-97 \nMCH-29.0 MCHC-30.0* RDW-13.2 RDWSD-46.2 Plt ___\n___ 05:51AM BLOOD ___ PTT-36.7* ___\n___ 05:51AM BLOOD Glucose-89 UreaN-56* Creat-1.2* Na-141 \nK-4.1 Cl-97 HCO3-31 AnGap-17\n___ 05:51AM BLOOD CK-MB-9 cTropnT-0.13*\n\nIMAGING:\nCHEST XRAY ___: Large right and moderate left pleural \neffusions and severe bibasilar atelectasis are unchanged. \nCardiac silhouette is obscured. No pneumothorax. Pulmonary edema \nis mild, obscured radiographically by overlying abnormalities. \n\nMICROBIOLOGY:\nNone.\n\n \nBrief Hospital Course:\nMs. ___ is ___ year old female with a past medical history \nsignificant for CAD, mild AS, afib/flutter on dabigatran, HTN, \nHLD, chronic hyponatremia, who presented to ___ on transfer \nfrom OSH after a fall and headstrike when subsequently found to \nbe bradycardic to the ___. She was transferred here externally \npaced and was seen by our EP physicians. After discussion with \npatient's healthcare proxy, it was decided not to purse \npacemaker placement and to withdraw external pacemaker. She \ninitially became profoundly bradycardic from ___ beats per \nminute but stabilized to the ___ overnight. She was made \nDNR/DNI/DNH and sent back to senior living facility \nhemodynamically stable. Of note CT head at outside facility was \nnegative. \n\nTRANSITIONAL ISSUES\n====================\n- Per discussion with patient's sister, ___, \npatient was made DNH in addition to her DNR/DNI. She will need a \nnew MOLST signed by her sister and the doctors at ___ \n___\n- She will also need a palliative care consult with possible \nescalation to hospice care as needed.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Artificial Tears ___ DROP BOTH EYES BID \n2. Aspirin 81 mg PO DAILY \n3. Dabigatran Etexilate 75 mg PO BID \n4. Vitamin D ___ UNIT PO EVERY 3 WEEKS \n5. Escitalopram Oxalate 15 mg PO DAILY \n6. Losartan Potassium 37.5 mg PO DAILY \n7. QUEtiapine Fumarate 12.5 mg PO QHS \n8. Senna 17.2 mg PO QHS \n9. Sodium Chloride Nasal ___ SPRY NU BID:PRN congestion \n10. Torsemide 60 mg PO DAILY \n11. OxyCODONE (Immediate Release) 2.5 mg PO QAM \n12. LORazepam 0.5 mg PO Q6H:PRN anxiety \n13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Artificial Tears ___ DROP BOTH EYES BID \n3. Dabigatran Etexilate 75 mg PO BID \n4. Escitalopram Oxalate 15 mg PO DAILY \n5. LORazepam 0.5 mg PO Q6H:PRN anxiety \n6. Losartan Potassium 37.5 mg PO DAILY \n7. OxyCODONE (Immediate Release) 2.5 mg PO QAM \n8. QUEtiapine Fumarate 12.5 mg PO QHS \n9. Senna 17.2 mg PO QHS \n10. Sodium Chloride Nasal ___ SPRY NU BID:PRN congestion \n11. Torsemide 60 mg PO DAILY \n12. Vitamin D ___ UNIT PO EVERY 3 WEEKS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nBradycardia\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___.\n\nWhy was I here?\n- You originally went to another hospital because you fell and \nhit your head.\n- You were found to have a very slow heart rate and transferred \nhere to ___ for further management\n\nWhat was done while I was in the hospital?\n- A CT scan of your head and neck at the outside hospital was \ndone and was normal.\n- You were transferred here with an external pacemaker to bring \nyour heart rate up but we eventually decided to withdraw this \ndevice. \n- You were seen by our electrophysiologists, who did not decided \nto put in a pacemaker at this time.\n\nWhat should I do when I get home?\n- Take your old medications as prescribed.\n\nAll the best,\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "R001", "I5033", "F0391", "I2582", "E871", "Z9181", "I2510", "I252", "I10", "I350", "I4891", "Z7902", "E785", "Z66" ]

[ "R001: Bradycardia, unspecified", "I5033: Acute on chronic diastolic (congestive) heart failure", "F0391: Unspecified dementia with behavioral disturbance", "I2582: Chronic total occlusion of coronary artery", "E871: Hypo-osmolality and hyponatremia", "Z9181: History of falling", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "I10: Essential (primary) hypertension", "I350: Nonrheumatic aortic (valve) stenosis", "I4891: Unspecified atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E785: Hyperlipidemia, unspecified", "Z66: Do not resuscitate" ]

[ "E871", "I2510", "I252", "I10", "I4891", "Z7902", "E785", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlisinopril\n \nAttending: ___.\n \nChief Complaint:\nHypotension\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ hx of ischemic cardiomyopathy sent from ___ clinic \nwhen his BP was noted to be systolic ___. Patient reports that \nat 9am his vision was a little blurry and he felt diffusely weak \nand tired, the subjective feelings completely resolved prior to \nadmission. He states he had been taking his blood pressure \nmedication regularly and drinking only about one small bottle of \nwater daily. He reports over the last year his blood pressure \nhas been regularly with systolic in the ___. He denies fevers or \nrecent illness. Had perirectal abscess drained in ___, site \nlooked well at evaluation today in clinic. No chest pain, \npalpitations, or cough. No abd pain/n/v/d/urinary symptoms. \n \n In the ED, initial vitals were: HR 82 BP79/42 RR16 SaO298% RA \n Exam notable for \n Labs notable for BNP 5890, Cr 2.8, WBC 13.4 \n Imaging notable for ___ CXR: No acute cardiopulmonary \nabnormality. \n Patient was given: 500 cc IVF \n Decision was made to admit for hypotension and ___ \n Vitals prior to transfer: HR 73 BP101/57 RR20 SaO2 100% RA \n On the floor, Patient was resting comfortably in bed and \nasymptomatic. \n \n ROS: \n (+) Per HPI \n (-) Denies fever, chills, night sweats. \n Denies headache, sinus tenderness, rhinorrhea or congestion. \nDenies cough, shortness of breath. Denies chest pain or \ntightness, palpitations. Denies nausea, vomiting, diarrhea, \nconstipation or abdominal pain. No recent change in bowel or \nbladder habits. No dysuria. Denies arthralgias or myalgias. \n \nPast Medical History:\n*Cards: HTN, HLD, CAD c/b MI s/p PCI/stent and CABG, CHF with \nreduced EF (LVEF 27%), Single lead ICD pacemaker\n*Neuro: L MCA ischemic stroke \n*GI: Perirectal abscess s/p I&D (___), Anal \nfistula, s/p EUA, ___ placement \n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nADMISSION EXAM: \nVital Signs: T97.9 PO, BP97/50, HR60 RR16 SaO2: 100% RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera 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, cyanosis or \nedema \nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation \n\nDISCHARGE EXAM: \nVital Signs: Tmax 98.2 T97.4 BP 102/67 HR 71 RR 18 O2 100%RA\nGeneral: No acute distress \nHEENT: Sclera anicteric, conjunctiva without injection. PERRLA. \nOropharynx clear with MMM. Neck supple, no JVP elevation. \nLungs: Clear to auscultation bilaterally with no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops. Left-sided AICD. \nAbdomen: Soft, non-tender, non-distended. Bowel sounds present \nwith no renal bruits. No rebound tenderness or guarding, no \norganomegaly, no pulsatile mass. \nExt: Warm, well perfused with no cyanosis of the toes or \nfingers. No calf tenderness or edema.\nSkin: Without rashes or lesions on gross exam. Tattoos over the \nforearm bilaterally. \nNeuro: Alert and oriented. Face symmetric. Speech is fluent and \nlogical with no evidence of dysarthria. Moves all extremities \npurposefully. \n\n \nPertinent Results:\nADMISSION LABS: \n___ 02:05PM WBC-13.4*# RBC-4.11*# HGB-12.1*# HCT-35.6*# \nMCV-87 MCH-29.4 MCHC-34.0 RDW-14.0 RDWSD-43.9\n___ 02:05PM NEUTS-72.3* LYMPHS-13.0* MONOS-12.7 EOS-1.2 \nBASOS-0.4 IM ___ AbsNeut-9.68* AbsLymp-1.74 AbsMono-1.70* \nAbsEos-0.16 AbsBaso-0.05\n___ 02:05PM PLT COUNT-223\n___ 02:21PM ___ PTT-34.1 ___\n___ 02:05PM GLUCOSE-143* UREA N-78* CREAT-2.8*# \nSODIUM-133 POTASSIUM-3.7 CHLORIDE-89* TOTAL CO2-23 ANION GAP-25*\n___ 02:05PM CALCIUM-10.4* PHOSPHATE-4.6* MAGNESIUM-2.4\n___ 02:05PM CK(CPK)-59\n___ 02:05PM cTropnT-0.04*\n___ 02:05PM CK-MB-2 proBNP-5890*\n___ 07:30PM URINE HOURS-RANDOM\n___ 07:30PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 07:30PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE \nEPI-0\n___:30PM URINE MUCOUS-RARE\n___ 07:30PM URINE HYALINE-13*\n\nDISCHARGE LABS: \n___ 07:35AM BLOOD WBC-7.7 RBC-3.84* Hgb-11.3* Hct-33.8* \nMCV-88 MCH-29.4 MCHC-33.4 RDW-14.1 RDWSD-44.8 Plt ___\n___ 07:35AM BLOOD Plt ___\n___ 07:35AM BLOOD ___ PTT-34.7 ___\n___ 07:35AM BLOOD Glucose-105* UreaN-91* Creat-2.6* Na-134 \nK-3.5 Cl-91* HCO3-25 AnGap-22*\n___ 03:14PM BLOOD Glucose-96 UreaN-84* Creat-1.8* Na-134 \nK-3.4 Cl-95* HCO3-22 AnGap-20\n___ 07:35AM BLOOD CK-MB-4 cTropnT-0.03*\n___ 07:35AM BLOOD Calcium-9.6 Phos-5.1* Mg-2.6\n___ 03:14PM BLOOD Digoxin-0.2*\n\nDIAGNOSTICS:\nECHO (CHA ___\nCONCLUSIONS \n1. LV ejection fraction is 27%. \n2. The apical portion of the anterior wall and the LV apex are \nakinetic. \n3. The left atrium is mildly dilated. \n4. There is mild-to-moderate mitral regurgitation. \n5. Estimated RV systolic pressure is moderately elevated at 55 \nmmHg. \n6. Compared to the previous echo of ___, there is no \nsignificant change.\n\nCXR ___\nFINDINGS: \nPatient is status post median sternotomy and CABG. Left-sided \nAICD is noted with single lead terminating in the right \nventricle. Heart size is normal. Mediastinal and hilar contours \nare normal. Lungs are clear. No pleural effusion or \npneumothorax. No acute osseous abnormalities are detected. \nIMPRESSION: No acute cardiopulmonary abnormality. \n\n \nBrief Hospital Course:\n___ M with h/o ischemic cardiomyopathy (s/p PCI/stent, CABG, \nICD pacemaker) c/b systolic CHF (LVEF 27%), L MCA stroke, and \nperirectal abscess who presents with hypotension and new ___ in \nthe setting fluid restriction while taking multiple diuretics \nand anti-hypertensives. \n\n#Hypotension: Pt presented with a baseline SBP in ___ over past \nyear, was fluid restricting given history of pulmonary edema, \npresented with SBP in 60-70s in ED. After 500cc fluid bolus, SBP \nreturned to baseline and pt was asymptomatic. Patient was not \northostatic. Bolused additional 1L NS. Hypotension seemed likely \nattributable to self fluid restriction in the setting of \nmultiple diuretic and anti-hypertensive medications. Losartan, \nSpironolactone, Carvedilol and Torsemide were held on discharge. \nPatient was instructed to schedule primary care to have \nfollow-up of his laboratory values.\n\n___: Rise in pt's Cr to 2.8 from baseline of 1.1 with \nassociated BUN/Cr >20. UA was unremarkable. Pt was maintaining \nUOP, w/ no history to suggest post-renal obstruction. Elevated \npro-BNP suggestive of ventricular overload c/w history of \nischemic cardiomyopathy, possible cardiorenal contribution to \n___. Overall findings were pre-renal ___, likely ___ decreased \neffective circulating volume in the setting of hypotension and \nfluid restriction in pt with underlying ischemic cardiomyopathy. \nHe responded well to 1.5L IVFs, with a creatinine of 1.8 at time \nof discharge. He was instructed to improve his PO intake to 1.5L \nper day (has hx of CHF exacerbations). Antihypertensives were \nheld at time of discharge. \n\n#Hyperphosphatemia: Phos to 5.1 on ___. Likely ___ renal \ninsufficiency. He was given a low phosphate diet for one day.\n\n#Normocytic Anemia: H/H down to 11.3/33.8 on ___ AM. Had low \nsuspicion for hemolysis or acute blood loss. Was thought to be \nlikely dilutional after fluids and was consistent with pt's \nnormal range.\n\nRESOLVED ISSUES: \n#Leukocytosis: Patient presented with transient leukocytosis, \nwhich downtrended to wnl ___ AM, likely ___ acute stress \nreaction. CXR/UA was not concerning for infection. Further \ninfectious workup was not pursued.\n\nCHRONIC ISSUES: \n#Ischemic Cardiomyopathy: s/p L ICD placement. No evidence of \nvolume overload on exam ___. Losartan, Spironolactone, \nTorsemide, Carvedilol in were held in the setting of hypotension \nand ___, and also held on discharge.\n#Hypertension: Losartan, Spironolactone, Torsemide, Carvedilol \nwere held as above. \n#Hyperlipidemia: atorvastatin was continued without issue.\n#History of MCA stroke: continued home warfarin without issue.\n\nTRANSITIONAL ISSUES:\n-patient was instructed to drink 1.5 L of fluid per day\n-patient's home antihypertensives were held at time of \ndischarge.\n-patient was instructed to follow-up with his PCP within one \nweek\n-patient may benefit from a repeat Na, K, Cl, bicarb, BUN, Cr at \ntime of follow-up\n-consideration of when to restart home antihypertensives can be \nconsidered at follow-up.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Warfarin 4 mg PO DAILY16 \n3. Atorvastatin 80 mg PO QPM \n4. Carvedilol 12.5 mg PO BID \n5. Digoxin 0.125 mg PO DAILY \n6. Ferrous Sulfate uncertain mg PO DAILY \n7. Losartan Potassium 25 mg PO DAILY \n8. Spironolactone 25 mg PO DAILY \n9. Torsemide 20 mg PO BID \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Digoxin 0.125 mg PO DAILY \n4. Ferrous Sulfate uncertain mg PO DAILY \n5. Warfarin 4 mg PO DAILY16 \n6. HELD- Carvedilol 12.5 mg PO BID This medication was held. Do \nnot restart Carvedilol until following up with your primary care \ndoctor\n7. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until following up with \nyour primary care doctor\n8. HELD- Spironolactone 25 mg PO DAILY This medication was \nheld. Do not restart Spironolactone until following up with your \nprimary care doctor\n9. HELD- Torsemide 20 mg PO BID This medication was held. Do \nnot restart Torsemide until following up with your primary care \ndoctor\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n-------------------\nHypotension\n___\n\nSecondary Diagnosis\nCongestive Heart Failure\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital when it was discovered that \nyou had low blood pressures and evidence of kidney injury after \nhaving reduced fluid intake while still taking your \nantihypertensives. You were evaluated with bloodwork and \nimaging, and given intravenous fluids. Your blood pressure \nmedications were held and we have not restarted these on \ndischarge from the hospital.\n\nPlease follow-up with your primary care doctor with ___ visit in \nthe next week before resuming your home antihypertensives. \nPlease continue to drink 1.5L of fluids per day.\n\nIt was a pleasure to be involved with your care!\n-___ Team\n \nFollowup Instructions:\n___\n" ]

[ "N179", "I5022", "I959", "E8339", "I2510", "Z951", "Z950", "Z8673", "D649", "F17210", "I10", "E785", "I255" ]

[ "N179: Acute kidney failure, unspecified", "I5022: Chronic systolic (congestive) heart failure", "I959: Hypotension, unspecified", "E8339: Other disorders of phosphorus metabolism", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z950: Presence of cardiac pacemaker", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "D649: Anemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I255: Ischemic cardiomyopathy" ]

[ "N179", "I2510", "Z951", "Z8673", "D649", "F17210", "I10", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nlisinopril\n \nAttending: ___.\n \nChief Complaint:\nperianal fistula and abscess\n \nMajor Surgical or Invasive Procedure:\nExamination under anesthesia, incision and drainage of abscess, \nplacement of Malecot drain\n\n \nHistory of Present Illness:\n___ with PMH significant for fistula in ano with rectal abscess\ns/p 3 OR drainages, CAD, CHF, hx of stroke and ___ s/p CABG &\npacemaker who presents with rectal pain. The patient states that \nhe has been having worsening rectal pain for the past week. \n\nPatient first noticed pain on ___ and described as mild. He\ndid his typical routine of warm shower which in the past has\nworked for rectal pain with mild abscess. On ___ he was\nadmitted to ___ with cough c/w pulmonary edema \nand\nwas treated with lasix. He was discharged on ___ with\ncontinuing worsening rectal pain. On presentation, he describes \nhis pain as\n___, with warm baths helping the pain. He had taken no\nmedications to improve his pain. He felt a palpable mass on his\ninner right buttock and feels it has gotten larger. He had been\nbedridden with pain for several days. His last bowel movement \nwas\nthe morning of presentation. His last urine output was also that \nmorning. He\nendorsed trouble passing stool and urine since this morning \n(even\nif he were to try he is unable). He endorsed that all 3 times he\nhas required OR intervention, he has had these same set of\nsymptoms. He denied fever, chills, abdominal pain, nausea,\nvomitting, diarrhea, constipation, bloody bowel movements, or\nblood from his rectal mass. \n\nIn the ED, his temp max was 99.5. Lactate is 2.1. WBC 15.8 and\nH/H is 10.3/32.3. \n\n \nPast Medical History:\nIllness: HTN, HLD, CAD c/b MI s/p PCI/stent (___), Hx \nperirectal\nabscess s/p I&D (___)\n\n___: I&D perirectal abscess (___), EUA, ___ placement\n(___)\n\nMedications: ASA 81', metoprolol succinate ER 25'\n\nAllergies: NKDA\n\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nDischarge PE:\n\nVS: AVSS\nGen: well appearing male, NAD\nHEENT: no lymphadenopathy, moist mucous membranes\nLungs: CTAB\nHeart: rrr\nAbd: soft, nt, nd\nIncisions: cdi\nExtremities: wwp\n\n \nPertinent Results:\n___ 11:43PM ___ PTT-32.4 ___\n___ 05:30PM URINE HOURS-RANDOM\n___ 05:30PM URINE GR HOLD-HOLD\n___ 05:30PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 05:30PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 05:30PM URINE HYALINE-1*\n___ 05:30PM URINE MUCOUS-RARE\n___ 01:02PM LACTATE-2.1*\n___ 11:30AM GLUCOSE-103* UREA N-37* CREAT-1.6* SODIUM-135 \nPOTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-22 ANION GAP-21*\n___ 11:30AM estGFR-Using this\n___ 11:30AM WBC-15.8*# RBC-3.37* HGB-10.3* HCT-32.3* \nMCV-96 MCH-30.6 MCHC-31.9* RDW-14.7 RDWSD-52.4*\n___ 11:30AM NEUTS-78.2* LYMPHS-9.6* MONOS-11.3 EOS-0.3* \nBASOS-0.2 IM ___ AbsNeut-12.33* AbsLymp-1.51 AbsMono-1.79* \nAbsEos-0.05 AbsBaso-0.03\n___ 11:30AM PLT COUNT-183\n \nBrief Hospital Course:\nPatient was taken to the OR on ___ for an examination under \nanesthesia, drainage of abscess, and placement of Malecot drain \nfor perianal fistula and abscess. He tolerated the procedure \nwell and was transferred to the floor with no issue. \n\nNeuro: Pain was well controlled on oxycodone 5 mg q6 hours. \nCV: Vital signs were routinely monitored during the patient's \nlength of stay. \nPulm: The patient was encouraged to ambulate, sit and get out \nof bed, use the incentive spirometer, and had oxygen saturation \nlevels monitored as indicated.\nGI: The patient was initially kept NPO after the procedure. The \npatient was later advanced to and tolerated a regular diet at \ntime of discharge. \nGU: Patient had a Foley catheter that was removed at time of \ndischarge. Urine output was monitored as indicated. At time of \ndischarge, the patient was voiding without difficulty. \nID: The patient's vital signs were monitored for signs of \ninfection and fever. The patient was started on/continued on \nantibiotics as indicated.\nHeme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding. The \npatient had vital signs, including heart rate and blood \npressure, monitored throughout the hospital stay. \nOn ___, the patient was discharged to home. At discharge, he \nwas tolerating a regular diet, passing flatus, stooling, \nvoiding, and ambulating independently. He will follow-up in the \nclinic in ___ weeks. This information was communicated to the \npatient directly prior to discharge. \n\n \nMedications on Admission:\nATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth\nonce a day\nCARVEDILOL - carvedilol 12.5 mg tablet. 1 tablet(s) by mouth\ntwice a day - (Prescribed by Other Provider)\nDIGOXIN - digoxin 125 mcg tablet. 1 tablet(s) by mouth daily - \n(Prescribed by Other Provider)\nLOSARTAN - losartan 25 mg tablet. 1 tablet(s) by mouth daily - \n(Prescribed by Other Provider)\nSPIRONOLACTONE - spironolactone 25 mg tablet. 1 tablet(s) by\nmouth daily - (Prescribed by Other Provider)\nTORSEMIDE - torsemide 20 mg tablet. 2 tablet(s) by mouth daily - \n\n(Prescribed by Other Provider)\nWARFARIN [COUMADIN] - Coumadin 5 mg tablet. 1 tablet(s) by mouth\ndaily x 5 days per week, 3mg on M and F - (Prescribed by Other\nProvider)\n \nMedications - OTC\nASPIRIN [ASPIR-81] - Aspir-81 81 mg tablet,delayed release. 1\ntablet(s) by mouth once a day - (Prescribed by Other Provider)\nIRON - Dosage uncertain - (Prescribed by Other Provider) (Not\nTaking as Prescribed)\n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. sodium chloride 0.9 % 0.9 % mallencot drain irrigation BID \nRX *sodium chloride [Saline Wound Wash] 0.9 % please irrigate \nrectal mallenot drain with 60cc of sterile normal saline twice a \nday Refills:*3 \n3. Tamsulosin 0.4 mg PO QHS \nplease take for 10 days \nRX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*10 \nCapsule Refills:*0 \n4. Atorvastatin 80 mg PO QPM \n5. Carvedilol 12.5 mg PO BID \n6. Digoxin 0.125 mg PO DAILY \n7. Losartan Potassium 25 mg PO DAILY \n8. Spironolactone 25 mg PO DAILY \n9. Torsemide 20 mg PO DAILY \n10. Warfarin 6 mg PO 1X/WEEK (FR) \n11. Warfarin 4 mg PO 6X/WEEK (___) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPerianal fistula and 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 ___ on ___ for a perianal \nfistula with abscess. You underwent an examination under \nanesthesia with incision and drainage and placement of a drain. \nYou have recovered from the procedure well and are ready to \nreturn home. \n\nYou were seen by cardiology while you were here prior to your \nsurgery. They recommended that you have close follow up with \nyour cardiologist once you are discharged from the hospital. You \nrequired diuresis with Lasix several times during your hospital \nstay with good improvement in your shortness of breath. Please \nensure that you make an appointment with both your PCP and your \ncardiologist once you are discharged for management of your \ndiuretic regimen.\n\nThe drain placed in your abscess site should remain until you \nfollow up with Dr. ___ in his clinic. You will receive ___ to \nhelp you flush the drain twice daily.\n\n \nFollowup Instructions:\n___\n" ]

[ "K611", "I2582", "I509", "I2510", "I252", "Z950", "Z951", "Z8673", "E785", "I255", "F17210" ]

[ "K611: Rectal abscess", "I2582: Chronic total occlusion of coronary artery", "I509: Heart failure, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "Z950: Presence of cardiac pacemaker", "Z951: Presence of aortocoronary bypass graft", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E785: Hyperlipidemia, unspecified", "I255: Ischemic cardiomyopathy", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "I2510", "I252", "Z951", "Z8673", "E785", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlisinopril\n \nAttending: ___\n \nMajor Surgical or Invasive Procedure:\n___: Right heart catheterization\n___: Anal exam under anesthesia with anal fistuolotomy\n___: Bronchoscopy with EBUS and lymph node biopsies\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:49PM BLOOD WBC-9.0 RBC-3.71* Hgb-11.3* Hct-34.3* \nMCV-93 MCH-30.5 MCHC-32.9 RDW-16.9* RDWSD-56.8* Plt ___\n___ 05:49PM BLOOD Glucose-112* UreaN-69* Creat-1.9* Na-140 \nK-4.5 Cl-102 HCO3-24 AnGap-14\n___ 05:49PM BLOOD Calcium-10.1 Phos-3.3 Mg-2.3 Iron-65\n\nPERTINENT INTERVAL LABS:\n========================\n___ 05:49PM BLOOD calTIBC-300 Ferritn-246 TRF-231\n\nMICRO:\n======\n___ 11:12 am BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE. \n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ CLUSTERS. \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 SMEAR REVIEWED; RESULTS CONFIRMED. \n\n RESPIRATORY CULTURE (Final ___: \n 10,000-100,000 CFU/mL Commensal Respiratory Flora. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n Test cancelled by laboratory. \n PATIENT CREDITED. \n This is a low yield procedure based on our ___ \nstudies. \n if pulmonary Histoplasmosis, Coccidioidomycosis, \nBlastomycosis,\n Aspergillosis or Mucormycosis is strongly suspected, \ncontact the\n Microbiology Laboratory (___). \n\n ACID FAST CULTURE (Pending): \n\n___ 11:44 am TISSUE MEDIASTINAL LYMPH NODE. \n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n TISSUE (Preliminary): RESULTS PENDING. \n\n ANAEROBIC CULTURE (Preliminary): \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Preliminary): \n\nSTUDIES:\n========\n___: CT chest w/o contrast\nMediastinal and hilar lymphadenopathy could be reactive ___ \nnature or sequela of the evident prior granulomatous infection, \nhowever, a lymphoproliferative disorder such as lymphoma cannot \nbe excluded. A PET-CT scan is recommended for further \nassessment. \nModerate cardiomegaly with associated extensive coronary artery \natherosclerotic disease and CABG postsurgical changes. \nModerate pulmonary edema. \n\n___: Right heart cath\n• Normal right heart filling pressure. Mildly elevated left \nheart filling pressure.\n• Mild pulmonary hypertension (mPA 24mmHg) with hemodynamic \nfeatures consistent with\npredominant post-capillary PH (TPG 8, DPG 3, PVR 1.35 ___.\n• Normal systemic blood pressure and SVR.\n• Normal cardiac output/index as estimated by both the indirect \nFick method and by thermodilution.\n\nDISCHARGE LABS:\n===============\n___ 07:33AM BLOOD WBC-8.8 RBC-2.92* Hgb-9.0* Hct-28.1* \nMCV-96 MCH-30.8 MCHC-32.0 RDW-17.9* RDWSD-62.1* Plt ___\n___ 07:33AM BLOOD Glucose-102* UreaN-53* Creat-2.1* Na-139 \nK-4.4 Cl-101 HCO3-22 AnGap-16\n___ 07:33AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.0\n \nBrief Hospital Course:\nPATIENT SUMMARY:\n================\nMr. ___ is a ___ with CAD/MI s/p PCIs and CABG ___, HFrEF\n(EF 28%) s/p ___ ICD ___ and cardiomems ___,\npAF on apixaban, HTN, DLD, prior L MCA CVA, CKD, and recurrent\nperirectal abscesses who presented as direct admit from home for\nheparin gtt bridge for planned procedures including RHC and anal\nfistulotomy. Chest CT was also performed which demonstrated \nenlarged lymph nodes, now s/p bronchoscopy with biopsies. He was \nactively diuresed for slight volume overload until euvolemic and \nthen discharged on his home diuretic regimen. \n\n# CORONARIES: Unknown; needs repeat stress\n___ RHC: RA 5, PA ___ (24), PCWP 16 CO 5.89 CI 2.92 SVR 1005\n# PUMP: TTE ___ showed ___. IVS 1.0, PW 1.0. LVEDD 6.1, LVEF\n___. RV normal size/function. No AS/AR. 1+ MR. ___+ TR. Mild\npHTN. \n# RHYTHM: NSR w/ non-specific intraventricular delay\n\nTRANSITIONAL ISSUES:\n====================\nDischarge Weight: 195.8 lbs\nDischarge Creatinine: 2.1\nDischarge diuretic: Home torsemide 60mg BID\n\n[ ] Tooth extraction: According to OMFS, it is appropriate to \ncontinue apixaban prior to outpatient extraction. If his primary \ndentist has concerns, he can be referred to our oral surgeons by \ncalling ___. Recommend not holding apixaban for given \nhis prior stroke.\n[ ] Stress testing: Recommend another CPET (cardiopulmonary \nstress test) now that he is euvolemic and optimized. \n[ ] Interventional pulmonology: Pt will follow up with IP ___ 2 \nweeks, where he will review the results from his \nbronchoscopy/biopsy. \n[ ] Cardiology: Outpatient notes had said his spironolactone was \nincreased from 25mg to 50mg PO daily but patient only reports \ntaking 25mg per day. He was continued on 25mg daily of \nspironolactone while inpatient.\n\nACTIVE ISSUES: \n============== \n# Chronic HFrEF s/p ICD and cardiomems (EF ___ \nHistory of dilated ischemic cardiomyopathy, ___ Class II, EDW \npreviously documented as 185-187lbs, but likely closer to \n190-195lbs given relatively dry RHC at this weight. On \npresentation he was well compensated. RHC was performed while \ninpatient which had largely normal pressures and it was \ndiscovered that his cardiomems was not calibrated correctly and \nstill is reporting falsely elevated numbers. He had a few days \noff diuretics due to NPO status for procedures and mild \nhypotension, then restarted on his home dosing at discharge. He \npreviously had a CPET that demonstrated poor function. This \nshould be repeated now that he is optimized to reassess his need \nfor LVAD/transplant.\n- PRELOAD: Torsemide 60mg PO BID \n- AFTERLOAD: Entresto 97-103mg PO BID, Carvedilol 12.5/18.75mg \nPO BID\n- NHBK: Spironolactone 25mg PO daily, Carvedilol as above\n- Ionotrope: Digoxin 0.125mcg PO daily\n- ICD: s/p ___ ICD placement ___ ___ \n- Transplant/VAD: undergoing workup\n\n# Transplant workup\nEvaluation for advanced therapies for VAD/transplant started \n___.\n- Dental/OMFS were consulted for teeth removal. He was found to \nhave no acute dental infections requiring intervention. \nTherefore, extractions were not performed during this admission. \nDental/OMFS recommended pursuing extraction of mobile tooth #9 \nas an outpatient with an outpatient dentist with no need to hold \napixaban. If there are concerns from his primary dentist, he can \nbe referred to our outpatient ___ clinic for extraction. \n- Underwent right heart catheterization on ___ which \ndemonstrated only mildly elevated filling pressures including a \nmildly elevated PASP, which is significantly improved from \nprior. Vasodilator study was not performed given low pulmonary \npressures. \n- CT chest was performed as part of workup, found asymmetric \npulmonary edema (R>L) and enlarged mediastinal/hilar lymph \nnodes. Given these findings, IP was consulted and he underwent \nbronchoscopy w/ EBUS and lymph node biopsies on ___. Per \npulmonology, unclear etiology of the lymph nodes. Initially \nthought to be just pulmonary edema but RHC showed he was fairly \neuvolemic. Other possibilities include prior granulomatous \ndisease or, less likely, lymphoma.\n\n# Perianal fistula\nInitially presented ___ s/p multiple exams under anesthesia, \nI&D, most recently ___ abscess was drained and malecot \ncatheter placed. Evaluated by ___ ___ ___ clinic after \nreferral from cardiology for pre-transplant evaluation. They \nnoted no evidence of abscess but recommended exam under \nanesthesia with management of fistula ___ ano. He underwent anal \nfistulotomy with colorectal surgery on ___. The procedure was \nwithout complications and he had a cutting ___ placed that \nwill remain until outpatient follow up. \n- Outpatient CRS follow up on ___. At that visit they will \nschedule further follow up with Dr. ___.\n\nCHRONIC ISSUES: \n============== \n# CAD c/b MI s/p PCI and subsequent CABG\n- Continued ASA 81mg\n- Continued atorvastatin 80mg \n\n# Paroxysmal atrial fibrillation\n# Hx CVA \n- Continued ASA 81, atorvastatin 80\n- Continued carvedilol, digoxin per above\n- Resumed home apixaban 5mg BID\n\n# History of GI bleed\n- Continued omeprazole\n\n# ___ on CKD stage ___ \nB/l 1.3-1.6. Cr 1.9 on admission, had been up to 2.2 as\noutpatient. Fluctuated throughout admission, 2.1 on discharge, \nwhich may be new baseline. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID \n2. Allopurinol ___ mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. CARVedilol 12.5 mg PO BID \n5. CARVedilol 6.25 mg PO QPM \n6. Digoxin 0.125 mg PO DAILY \n7. Omeprazole 40 mg PO BID \n8. Spironolactone 25 mg PO DAILY \n9. Torsemide 60 mg PO BID \n10. Apixaban 5 mg PO BID \n11. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. CARVedilol 12.5 mg PO BID \n6. CARVedilol 6.25 mg PO QPM \n7. Digoxin 0.125 mg PO DAILY \n8. Omeprazole 40 mg PO BID \n9. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID \n10. Spironolactone 25 mg PO DAILY \n11. Torsemide 60 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nChronic heart failure with reduced ejection fraction\nParoxysmal atrial fibrillation\nPerianal fistula\nMediastinal/hilar lymphadenopathy\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to the hospital for heparin (a blood thinner \nsimilar to the apixaban you take at home) while getting multiple \nprocedures done. Please see below for more information on your \nhospitalization. It was a pleasure participating ___ your care! \n \nWhat happened while you were ___ the hospital? \n- We held your apixaban and started you on a heparin drip for \ncontinued anticoagulation for your atrial fibrillation\n- You underwent multiple procedures while you were \nhospitalized; this includes a right heart catheterization, an \nanal fistulotomy, and a bronchoscopy with lymph node biopsies\n- We gave you a little extra diuretics while you were ___ the \nhospital to help keep fluid off you. \n\nWhat should you do after leaving the hospital? \n- Please take your medications as listed below and follow up at \nthe listed appointments. We have made NO changes to your \nmedications.\n - You have an appointment with the lung doctors ___ ___. They \nwill go over the results of your biopsy then.\n- Your weight at discharge is 195.8 lbs. Please weigh yourself \ntoday at home and use this as your new baseline. \n- Please weigh yourself every day ___ the morning. Call your \ndoctor if your weight goes up or down by more than 3 lbs ___ one \nday or 5 lb ___ one week\n\nWe wish you the best! \n \n- Your ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K603", "I130", "I5022", "N179", "N183", "E785", "I2510", "I480", "Z7682", "I255", "R590", "I2722", "I252", "Z7901", "Z8673", "Z95810", "Z951", "Z955", "Z87891" ]

[ "K603: Anal fistula", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5022: Chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I480: Paroxysmal atrial fibrillation", "Z7682: Awaiting organ transplant status", "I255: Ischemic cardiomyopathy", "R590: Localized enlarged lymph nodes", "I2722: Pulmonary hypertension due to left heart disease", "I252: Old myocardial infarction", "Z7901: Long term (current) use of anticoagulants", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z87891: Personal history of nicotine dependence" ]

[ "I130", "N179", "E785", "I2510", "I480", "I252", "Z7901", "Z8673", "Z951", "Z955", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / nitrofurantoin\n \nAttending: ___.\n \nChief Complaint:\nFall from wheelchair\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ female with a history of peripheral vascular \ndisease, hypertension, coronary artery disease, emphysema, \npelvic fracture s/p hip replacement presents to the ED after a \nfall and a head CT from OSH showing ___ for neurosurgery \nevaluation.\n\nPatient was in her usual state of health until today when she \nfell from her wheelchair at home. Patient has a laceration to \nher forehead. Per report from outside hospital, patient was \ngetting up from her wheelchair when she tripped and fell forward \nhitting her head. Patient denies any chest pain and there is no \nnausea or vomiting\n\n \nPast Medical History:\nPast medical history:\n- Peripheral vascular disease\n- Hypertension\n- Coronary artery disease\n- Emphysema \n- Pelvic fracture \n\nPast surgical history:\n- Right hip replacement\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nADMISSION:\nVital signs: reviewed\nGeneral: alert and oriented x3, cooperative, speaks in full\nsentences \nHEENT: EOMI PERLA, left periorbital ecchymosis, left forehead\nlaceration sutured by ED team. Neck supple.\nPulmonary: clear to auscultation bilaterally\nCardiovascular: regular rate and rhythm, no murmurs\nAbdomen: soft, nontedner, nondistended.\nExtremities: warm and well perfussed. Normal ___ 2+\n\nDISCHARGE\nVitals: 97.5 122/58R Lying 87 18 95 Ra \nGen: Calm, alert, NAD\nHEENT: Ecchymosis surrounding the left eye, improving, no\nconjunctival hemorrhage\nCV: RRR, ___ harsh systolic murmur with radiation to the \ncarotids\nResp: Lungs clear to auscultation bilaterally, no w/r/r\nAbd: Soft, NTND\nExt: warm, no edema, L calf > R calf \nMSK: ecchymosis of L shoulder, mild ttp and with movement, large\nhematoma on lateral L hip/buttock\nNeuro: alert, oriented to self and place, not date\n \nPertinent Results:\nADMISSION:\n___ 10:30PM BLOOD WBC-23.6* RBC-2.90* Hgb-9.4* Hct-29.5* \nMCV-102* MCH-32.4* MCHC-31.9* RDW-15.0 RDWSD-55.3* Plt ___\n___ 10:30PM BLOOD Neuts-79.6* Lymphs-8.2* Monos-10.3 \nEos-0.6* Baso-0.5 Im ___ AbsNeut-18.76* AbsLymp-1.92 \nAbsMono-2.42* AbsEos-0.15 AbsBaso-0.12*\n___ 10:30PM BLOOD ___ PTT-25.3 ___\n___ 10:30PM BLOOD Glucose-134* UreaN-16 Creat-0.5 Na-136 \nK-4.7 Cl-98 HCO3-26 AnGap-12\n___ 10:44AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.6\n\nDISCHARGE:\n___ 05:57AM BLOOD WBC-9.9 RBC-2.42* Hgb-7.7* Hct-24.8* \nMCV-103* MCH-31.8 MCHC-31.0* RDW-17.2* RDWSD-61.1* Plt ___\n\nMICRO:\n___ BLOOD CULTURE Blood Culture, \nRoutine-PENDING EMERGENCY WARD \n___ BLOOD CULTURE Blood Culture, \nRoutine-PENDING \n___ 1:52 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ 8 S\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nIMAGING\n___ CT C/A/P:\n1. Severe T12 compression fracture with slight retropulsion of \nthe superior T2 endplate, indeterminate age. \n2. Multiple fractures of posterior and lateral ___ ribs, \nsome of which demonstrate developing callus, suggesting subacute \nchronicity. \n3. Acute appearing right L1 transverse process fracture, and \nprobable T10 and T11 spinous process fractures. \n4. Status post aortic bifemoral bypass with complete occlusion \nof right bypass graft. \n5. 3.5 cm fluid collection encasing the left bypass graft in the \nleft lower quadrant, likely representing a seroma. \n6. Apparent filling defect in the left common femoral vein, \nlikely mixing \nartifact. However, ultrasound is recommended to evaluate for \npossible DVT. \n7. UIP pattern of pulmonary fibrosis in the bilateral lung \nbases. \n8. Diverticulosis without evidence of acute diverticulitis. \n9. 4.2 cm abdominal aortic aneurysm at the level of the aortic \nhiatus. \n\n___ L ___:\nIMPRESSION: \nNo evidence of deep venous thrombosis in the left lower \nextremity veins. \n\n___ CT head:\n1. Mild left frontal subarachnoid hemorrhage. No prior studies \navailable for comparison. \n2. Presumed arachnoid cyst in the left middle cranial fossa. \n\n___ TTE:\nThe left atrial volume index is normal. There is no evidence for \nan atrial septal defect by 2D/color Doppler.\nThe estimated right atrial pressure is ___ mmHg. There is mild \n(non-obstructive) hypertrophy of the basal\nseptum with a normal cavity size. There is normal regional left \nventricular systolic function. Global left\nventricular systolic function is normal. The visually estimated \nleft ventricular ejection fraction is 60%. Left\nventricular cardiac index is normal (>2.5L/min/m2) No \nventricular septal defect is seen. There is no resting\nleft ventricular outflow tract gradient. Normal right \nventricular cavity size with normal free wall motion. The\naortic sinus diameter is normal with normal ascending aorta \ndiameter. The aortic arch diameter is normal.\nThere are simple atheroma in the abdominal aorta. The aortic \nvalve leaflets (3) are mildly thickened. There is\nmoderate aortic valve stenosis (valve area 1.0-1.5 cm2). There \nis no aortic regurgitation. The mitral leaflets\nare mildly thickened with no mitral valve prolapse. There is \nmoderate mitral annular calcification. There is no\nmitral valve stenosis. There is mild [1+] mitral regurgitation. \nDue to acoustic shadowing, the severity of mitral\nregurgitation could be UNDERestimated. The tricuspid valve \nleaflets appear structurally normal. There is trivial\ntricuspid regurgitation. The estimated pulmonary artery systolic \npressure is normal. There is no pericardial\neffusion.\nIMPRESSION: Adequate image quality. Moderate low gradient aortic \nstenosis. Normal biventricular systolic\nfunction.\n\n___ XR shoulder/humerus:\n1. No fracture or dislocation. \n2. Multiple focal lucencies in the left humeral shaft could \nreflect osteopenia but raise concern for multiple myeloma or \ndiffuse metastatic disease, which could be further evaluated \nwith MRI, SPEP, and UPEP. \n3. Moderate to severe degenerative changes of the \nacromioclavicular \nglenohumeral joints. \n\n \nBrief Hospital Course:\n___ is an ___ with history of dementia, PAD, HTN, \nCAD, COPD, prior pelvic fracture s/p hip replacement who \npresented to an OSH with an unwitnessed fall and was transferred \nto ___ due to CT head showing SAH. Transferred to the medicine \nservice for encephalopathy. \n\n# Encephalopathy, toxic/metabolic: Patient was acutely altered \non admission with waxing and waning mental status consistent \nwith delirium on baseline of mild dementia. Found to have \nsymptomatic UTI which was a like contributor as well as \npain/trauma from her fall. She was started on antibiotics and \nimproved back to baseline.\n\n# Small left frontal traumatic SAH: Sustained in her fall. She \nhad repeat head CT that showed stability. She was evaluated by \nneurosurgery who felt no surgical intervention was needed. Her \nhome aspirin and prophylactic subcutaneous heparin were started \non ___. Her goal blood pressure was under 160 and was maintained \nthroughout her hospitalization. Per neurosurgery she did not \nneed seizure prophylaxis and did not need neurosurgery follow up \nas an outpatient. Sutures were placed for her head laceration \nand can be removed on ___. \n \n# T12 compression fracture\n# L1 transverse fracture: Per orthospine, likely chronic and \nunrelated to recent fall. She worked with ___ who recommended \nrehab. She is weight bearing as tolerated and ROM as tolerated. \nShe should follow up with spine clinic 2 weeks after discharge. \nPain control was with lidocaine patch and Tylenol. Her home \ntramadol was restarted on discharge at reduced dose. \n\n# Fall: She suffered an unwitnessed fall and had poor memory of \nthe event. She is on a number of medications that could \npre-dispose to falls including multiple antihypertensives (and \nhad positive orthostatics in-house) and sedating/pain \nmediations. Symptomatic UTI likely contributer as well. A TTE \nrevealed moderate AS. Telemetry revealed rare short runs of \nself-terminating SVT. Low suspicion overall for cardiac cause of \nher fall. Her antihypertensives were held with acceptable blood \npressures throughout (SBPs < 160). Her tramadol and gabapentin \n(which had been newly started/uptitrated) were also held. \nTramadol was restarted at a lower dose on the day of discharge \nand well tolerated.\n \n# Urinary tract infection: patient with urinary frequency and \npansensitive E coli in her urine culture. She was treated with \nceftriaxone starting ___ and discharged with one day of \ncefpodoxime to complete a ___nemia: She was found to be anemic on admission around 7s with \na small drop to 6.4 for which she received 1U pRBC with \nappropriate increase. Her H/H remained stable thereafter. Per \nher family she has chronic anemia. She may have element of MDS \nas she has borderline thrombocytopenia as well. She has a \nhip/buttock hematoma that remained stable. Iron studies showed \nan elevated ferritin and normal Fe, consistent with ACD. \n\nTRANSITIONAL ISSUES:\n[] Patient discharged on cefpodoxime for 400 mg q12h for one day \nto complete a 5 day course of antibiotics for UTI\n[] Patient with sutures in place; can be removed ___\n[] Patient found to be anemic with unknown baseline; if not \npreviously evaluated could consider further work up\n[] Xray of the L humerus revealed: \"Multiple focal lucencies in \nthe left humeral shaft could reflect osteopenia but raise \nconcern for multiple myeloma or diffuse metastatic disease, \nwhich could be further evaluated with MRI, SPEP, and UPEP.\"\n[] Patients antihypertensives (atenolol and lisinopril) were \nstopped on admission due to fall and orthostatic hypotension. If \nshe develops hypertension, can consider restarting.\n[] Patient started on metoprolol succinate 25 mg daily for \ncardiac protection as atenolol was stopped\n[] Patient's tramadol was decreased to 50 mg TID PRN\n[] Patient's gabapentin was held on discharge\n\n**The patient was seen and examined today and is stable for \ndischarge. Greater than 30 minutes were spent on discharge \ncoordination and counseling.**\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atenolol 25 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Calcium 500 + D (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -200 unit oral DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Donepezil 5 mg PO QHS \n7. Bisacodyl ___AILY:PRN constipation \n8. DULoxetine 60 mg PO DAILY \n9. Florastor (Saccharomyces boulardii) 250 mg oral BID \n10. Gabapentin 100 mg PO QHS \n11. Lisinopril 10 mg PO DAILY \n12. Loratadine 10 mg PO DAILY \n13. Milk of Magnesia 30 mL PO PRN constipation \n14. Multivitamins 1 TAB PO DAILY \n15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n16. Omeprazole 20 mg PO BID \n17. Senna 17.2 mg PO BID \n18. TraMADol 100 mg PO TID \n19. Acetaminophen 1000 mg PO Q8H \n20. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n21. Ondansetron 4 mg PO Q8H:PRN nausea \n\n \nDischarge Medications:\n1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 2 Doses \nGive on ___. Metoprolol Succinate XL 25 mg PO DAILY \n3. TraMADol 50 mg PO TID:PRN Pain - Moderate \n4. Acetaminophen 1000 mg PO Q8H \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 40 mg PO QPM \n7. Bisacodyl ___AILY:PRN constipation \n8. Calcium 500 + D (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -200 unit oral DAILY \n9. Docusate Sodium 100 mg PO BID \n10. Donepezil 5 mg PO QHS \n11. DULoxetine 60 mg PO DAILY \n12. Florastor (Saccharomyces boulardii) 250 mg oral BID \n13. Loratadine 10 mg PO DAILY \n14. Milk of Magnesia 30 mL PO PRN constipation \n15. Multivitamins 1 TAB PO DAILY \n16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n17. Omeprazole 20 mg PO BID \n18. Ondansetron 4 mg PO Q8H:PRN nausea \n19. Senna 17.2 mg PO BID \n20. HELD- Gabapentin 100 mg PO QHS This medication was held. Do \nnot restart Gabapentin until talking with your PCP\n21. HELD- Lisinopril 10 mg PO DAILY This medication was held. \nDo not restart Lisinopril until talking with your PCP\n\n \n___:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nSmall left frontal SAH\nT12 compression fracture\nUrinary tract infection\nAcute right L1 transverse process fracture and T10/T11 spinous \nprocess fractures. \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital after you fell and hit your \nhead. You had a bleed in your brain but did not need surgery. \nYou were found to have a small fracture in one of the small \nbones in your back but this was thought to have been present \nbefore you fell. You will follow up with spine doctors after ___ \nleave the hospital for this. You also hit your arm and hip but \ndid not have any broken bones. \n\nYou were found to have a urinary tract infection and treated \nwith antibiotics. This may have contributed to your fall. You \nalso were found to have low blood pressure when you stand up, so \nyour blood pressure medications stopped. You can discuss \nrestarting them with your primary care doctor.\n\nYou were found to be anemic (to have low blood counts) and got a \nblood transfusion. Your blood counts were stable after this. You \nmay need further evaluation of your anemia by your primary care \ndoctor unless this has already been done.\n\nIt was a pleasure participating in your care. We wish you all \nthe best in the future!\n\nSincerely,\n\nYour ___ team\n\n \nFollowup Instructions:\n___\n" ]

[ "S066X0A", "G92", "N390", "W050XXA", "Y92009", "I2510", "I10", "I739", "J439", "Z96641", "B9620", "F0390", "I350", "D649", "D469", "S0181XA", "M4854XD", "J8410", "Z66", "M8448XD", "S7002XA", "R402142", "R402362", "R402252" ]

[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "G92: Toxic encephalopathy", "N390: Urinary tract infection, site not specified", "W050XXA: Fall from non-moving wheelchair, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "I739: Peripheral vascular disease, unspecified", "J439: Emphysema, unspecified", "Z96641: Presence of right artificial hip joint", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "F0390: Unspecified dementia without behavioral disturbance", "I350: Nonrheumatic aortic (valve) stenosis", "D649: Anemia, unspecified", "D469: Myelodysplastic syndrome, unspecified", "S0181XA: Laceration without foreign body of other part of head, initial encounter", "M4854XD: Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with routine healing", "J8410: Pulmonary fibrosis, unspecified", "Z66: Do not resuscitate", "M8448XD: Pathological fracture, other site, subsequent encounter for fracture with routine healing", "S7002XA: Contusion of left hip, initial encounter", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "R402252: Coma scale, best verbal response, oriented, at arrival to emergency department" ]

[ "N390", "I2510", "I10", "D649", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nSeizures, Headaches, left frontal cavernous Malformation\n \nMajor Surgical or Invasive Procedure:\n___ craniotomy for RSX of Cavernous malformation \n \nHistory of Present Illness:\nMr. ___ is a very pleasant ___ Caucasian male who was \ndiagnosed with a left inferolateral frontal lobe cavernous \nmalformation approximately ___ years ago in around ___. He \nhas had an episode where he had twitching of the right side of \nhis tongue, some dysarthria and that resulted into more \nextensive simple partial seizures. Now, this past ___, he \nagain had a similar episode where he had twitching of the right \nside of his tongue and he had difficulty speaking. He is \ncurrently taking Keppra 1000 mg once a day at night. \n\nA recent CT shows some hyperdensity within the lesion that is \nindicative of recent hemorrhage. Given the fact that he has \ncontinuous seizures despite management of antiepileptic drugs \nand the vicinity of the small cavernoma to the brain surface, we \nthink it is reasonable to remove it surgically. We will set him \nup for surgical resection to a preresection Wand Brain Lab MRI \nprior. He reviewed the risks and benefits of this operation and \nhe is okay with preceding.\n\n \nPast Medical History:\nLeft frontal cavernous malformation w/seizures & headaches \n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nOn Discharge:\nalert, oriented x3. PERRL. Face symmetric. Tongue midline. EOM \nintact.\nStrength ___ throughout. Sensation intact to light touch.\nNo pronator drift.\nIncision c/d/I with staples - no erythema. Mild L facial \nswelling \n\n \nPertinent Results:\n MR HEAD W/ CONTRAST Study Date of ___ 5:16 AM \n \nIMPRESSION: \n 1. Unchanged appearance of a left temporal operculum 1.0 cm \nlesion compatible with a cavernoma with associated large \ndevelopmental venous anomaly. \n \n2. Unchanged appearance of a right posterior parasagittal 0.8 cm \nmeningioma. \n\n \nBrief Hospital Course:\n___ Caucasian male who was diagnosed with a left \ninferolateral frontal lobe cavernous malformation approximately \n___ years ago, with recent recurrent seizure activity, who \npresents for elective left craniotomy for Cav Mal resection.\n\n#Inferolateral frontal lobe cavernous malformation: The patient \nwas taken to the OR on ___ for a left craniotomy for \nfrontal lobe cavernous malformation resection with Dr. ___. \nThe procedure was uncomplicated, the patient was extubated and \nrecovered in the PACU. He was closely monitored and then was \ntransferred to the step down unit when stable. He remained \nneurologically intact. No postop imaging was indicated. Keppra \nwas increased to 500 mg qAM and 1000 mg q ___. Foley was removed \nand he was urinating without retention. His diet was advanced \nand well tolerated, he was ambulating, and pain was well \ncontrolled with PO medications. He was discharged home on POD#2. \n\n \nMedications on Admission:\nKeppra 1gm Daily, lorazepam (PRN seizures), isotretinoin \n \nDischarge Medications:\n1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache \nno not take >4g acetaminophen in 24 hours from any source \nRX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ \ncapsule(s) by mouth every 6 hours as needed Disp #*30 Capsule \nRefills:*0 \n2. Docusate Sodium 100 mg PO BID \n3. LevETIRAcetam 500 mg PO QAM \nRX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth every \nmorning Disp #*30 Tablet Refills:*0 \n4. LevETIRAcetam 1000 mg PO QHS \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed \nDisp #*30 Tablet Refills:*0 \n6. Senna 8.6 mg PO BID:PRN Constipation \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ncavernous malformation \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions\nBrain Tumor\n\nSurgery\n• You underwent surgery to remove a Cavernous Malformation from \nyour brain. \n• Please keep your incision dry until your staples are removed. \n• You may shower at this time but keep your incision dry.\n• It is best to keep your incision open to air but it is ok to \ncover it when outside. \n• Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n• We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n• You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n• No driving while taking any narcotic or sedating medication. \n• If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n• No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n• Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n• You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication as indicated on your discharge instruction. It is \nimportant that you take this medication consistently and on \ntime. \n• You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n• You may experience headaches and incisional pain. \n• You may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n• You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n• Feeling more tired or restlessness is also common.\n• Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n• Severe pain, swelling, redness or drainage from the incision \nsite. \n• Fever greater than 101.5 degrees Fahrenheit\n• Nausea and/or vomiting\n• Extreme sleepiness and not being able to stay awake\n• Severe headaches not relieved by pain relievers\n• Seizures\n• Any new problems with your vision or ability to speak\n• Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n• Sudden numbness or weakness in the face, arm, or leg\n• Sudden confusion or trouble speaking or understanding\n• Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n• Sudden severe headaches with no known reason\n\n \nFollowup Instructions:\n___\n" ]

[ "D1802", "I619", "G40909" ]

[ "D1802: Hemangioma of intracranial structures", "I619: Nontraumatic intracerebral hemorrhage, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nSulfamethoxazole / Penicillins\n \nAttending: ___.\n \nChief Complaint:\narrest of descent, gHTN, incisional cellulitis with wound \nabscess\n \nMajor Surgical or Invasive Procedure:\nprimary low transverse cesarean section\n\n \nHistory of Present Illness:\nPatient is a ___ year-old G3P0 with EDC = ___ (EGA = 37w1d on\n___ with elevated blood pressures in the office as\nhigh as 140/70 over the past week. Repeat BP in OB triage =\n142/70, 141/72, 139/85. PIH labs on ___ showed:\nCBC 15.6 > 10.6 / 30.3 < 312\nALT 21\nCr 0.5\nUric Acid 5.0 \nUP:C 0.1\n\nShe currently denies headache, visual changes,\nepigastric or RUQ pain. Denies ctx, VB, LOF. +FM\n\n \nPast Medical History:\nMEDICAL HISTORY\nAllergies (Last Verified ___ by ___:\nPenicillins \n\nSulfamethoxazole \n\n--------------- --------------- --------------- ---------------\nActive Medication list as of ___:\n \nMedications - Prescription\nALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation\naerosol inhaler. 2 puffs every four (4) hours PRN\nBUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5\nmcg/actuation HFA aerosol inhaler. 2 puffs inh twice a day\nPNV WITH CALCIUM ___ [PRENATAL VITAMINS LOW IRON] -\nDosage uncertain - (Prescribed by Other Provider)\n \nMedications - OTC\nDOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s) \nby\nmouth once per day, as needed, for constipation\n--------------- --------------- --------------- ---------------\n\nProblems (Last Verified ___ by ___, MD):\nASTHMA, EXTRINSIC W/ ACUTE EXACERBATION \n493.02 \n\nECZEMATOUS DERMATITIS \n\nH/O TOBACCO USE \n305.1 \n\nSurgical History (Last Verified ___ by ___, \nMD):\nSurgical History updated, no known surgical history. \n\nFamily History (Last Verified ___ by ___, MD):\nRelative Status Age Problem Comments \nOther ASTHMA V17.5 \n F/H GI MALIGNANCY V16.0 \n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nVSS\nGen: NAD\nLungs: CTA\nCV: RRR\nAbd: 2cm opening on right side of incision with packing, \nerythema improved from prior, no pus\nExt: 1+ pitting edema bilaterally with no calf tenderness\n \nBrief Hospital Course:\nThe patient is a ___ G3, P0 at 37 weeks\n4 days admitted for induction of labor due to gestational\nhypertension. After a prolonged induction, the patient\nprogressed to fully dilated and +2 station. However, after 5\nhours fully dilated and ___ hours pushing, there was no\ndescent of the fetal head and significant caput was noted. The\npatient was recommended to undergo delivery via cesarean\nsection.\n\nShe experienced a PPH with EBL 1200cc from cervical extension, \nbut remained stable postpartum. In terms of her gestational \nhypertension, she had normal labs. She was started on labetalol \n200mg BID on ___, which was increased to 300mg BID on \n___ for elevated pressures. During her postpartum course she \ndeveloped an incisional cellulitis with wound abscess. She was \nnoted to have erythema and induration on right side of incision \nand extending to mons. She was started on IV gent/clinda -> PO \nclindamycin started ___ ___, 10d course. She incision was \nopened at bedside ___ and she underwent BID wet to dry \ndressing changes. She had a wound culture with mixed flora, a \nnegative urine culture, and blood cultures with no growth.\n\nPatient also experienced bilateral lower extremity edema during \nher stay that she found very bothersome. She received Lasix 20mg \nPO x1, with improvement of symptoms. She was also maintained on \nLovenox 40mg daily.\n\nShe was discharged on ___ in stable condition with plan for \noutpatient ___ for BID dressing changes and blood pressure \nmonitoring.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Prenatal Vitamins 1 TAB PO DAILY \n2. Docusate Sodium 100 mg PO DAILY:PRN constipation \n3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation 2 puffs bid \n4. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 puffs \nQ4H:PRN wheezing \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma \n2. Docusate Sodium 100 mg PO BID:PRN Constipation \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*40 Capsule Refills:*1\n3. Ibuprofen 600 mg PO Q6H:PRN Pain \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*30 Tablet Refills:*0\n4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n5. Clindamycin 450 mg PO Q6H Duration: 10 Days \nRX *clindamycin HCl 150 mg 3 capsule(s) by mouth every 6 hrs \nDisp #*108 Capsule Refills:*0\n6. Ferrous Sulfate 325 mg PO BID \nRX *ferrous sulfate 140 mg (45 mg iron) 1 tablet(s) by mouth \ntwice a day Disp #*60 Tablet Refills:*1\n7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain \nRX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hrs \nDisp #*30 Tablet Refills:*0\n8. Labetalol 300 mg PO BID \nRX *labetalol 300 mg 1 tablet(s) by mouth twice a day Disp #*40 \nTablet Refills:*0\n9. Prenatal Vitamins 1 TAB PO DAILY \n10. ProAir HFA (albuterol sulfate) 90 mcg/actuation 2 PUFFS \nQ4H:PRN wheezing \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nprimary low transverse cesarean section\ngestational hypertension\nasthma\narrest of descent\nendometritis, cellulitis, wound infection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\npelvic rest x 6 weeks until postpartum visit\nno heavy lifting or driving x 2 weeks\nkeep incision clean and dry\n \nFollowup Instructions:\n___\n" ]

[ "O133", "O722", "O8612", "O639", "L03311", "L02211", "O324XX0", "O99334", "O9952", "R609", "J45909", "O860", "Z3A37", "Z370" ]

[ "O133: Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester", "O722: Delayed and secondary postpartum hemorrhage", "O8612: Endometritis following delivery", "O639: Long labor, unspecified", "L03311: Cellulitis of abdominal wall", "L02211: Cutaneous abscess of abdominal wall", "O324XX0: Maternal care for high head at term, not applicable or unspecified", "O99334: Smoking (tobacco) complicating childbirth", "O9952: Diseases of the respiratory system complicating childbirth", "R609: Edema, unspecified", "J45909: Unspecified asthma, uncomplicated", "O860: Infection of obstetric surgical wound", "Z3A37: 37 weeks gestation of pregnancy", "Z370: Single live birth" ]

[ "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:\nAltered Mental Status\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ year old male with history of \nschizophrenia with most recent ED visit ___, COPD, DM, \nmechanical falls most recently in ___ and s/p negative \nsyncope workup in ___, history of urinary retention s/p \nindwelling foley in ___, admission in ___ for sepsis \nfrom pneumonia, presenting with complaints of fever and altered \nmental status.\n\n___ presented to the ED from his group home after reportedly \nbeing febrile yesterday. The group home care staff changed his \nfoley yesterday and noted that he his mental status was altered \nthis morning.\n\nSeen in ___ on ___ by Dr. ___ \nfor evaluation of need for chronic foley which was placed in \nlate ___ after ___ presented to the ED after a fall and \nwas found to be in ___ (prior to this, he had no problems \nvoiding) and have obstructive uropathy. Noted to have a \nhypersensitive bladder with normal compliance, terminal detrusor \noveractivity, no obstruction, and was able to empty bladder \ncompletely despite over activity. The plan was to leave the \nfoley catheter out and monitor PVRs ___ times daily with foley \nre-insertion if PVR>400-450cc and to continue tamsulosin.\n\nIn the ED, initial vital signs were: T99.1 HR112 BP91/58 RR16 \nSaO2 95% on RA\n- Exam notable for: lethargy, arousable only to pain, oriented \nx1\n- Labs were notable for: \n1) Chem 10 -\n134|94|28\n---------<159\n4.2|20|1.5\n2) CBC - 27.3>10.5/32.5<376\nDiff - 85.6%, 4.5%, Monos 8.7%\n3) LFTs - ALP 167 (ALT 5, AST 14, Tbili 0.5, Alb 3.8)\n4) U/A - hazy appearance with large leuks (WBC>182), small \namount of blood (RBC>10), Few bacteria, Negative Nitrites, 30 \nProteins\n5) FluAPCR and FluBPCR - negative\n6) Lactate - 1.6\n7) Blood cx - pnd\n8) Urine cx - pnd\n- Studies performed include:\n1) CT C-spine w/o contrast: No acute fracture or malalignment of \nthe cervical spine. \n2) NCHCT: No acute intracranial process\n3) CXR: No acute cardiopulmonary process. No focal consolidation \nto suggest pneumonia. \n- Patient was given:\n1) IV NS \n2) Ceftriaxone 2 gm\n- Vitals on transfer: \n___, 99.2F, HR111(106-113), BP135/67 (91-135/55-67), RR25 \n(___), SaO2 100% on RA\n\nUpon arrival to the floor, the patient was somnolent but \narousable, oriented to name only. History could not be completed \nas patient could not answer questions. \n \nREVIEW OF SYSTEMS: \n(+) per HPI \n(-) chills, night sweats, headache, vision changes, rhinorrhea, \ncongestion, sore throat, cough, shortness of breath, chest pain, \nabdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, \nmelena, hematochezia, dysuria, hematuria. \n \nPast Medical History:\n1. Paranoid schizophrenia, well-controlled on Clozaril \n- Previous auditory and visual hallucinations, none \"for awhile\"\nper patient\n2. Mechanical falls with negative syncope workup (___)\n3. T2DM (last HbA1c 7.1 in ___\n4. COPD (last FEV1 unknown)\n5. GERD/Reflux Esophagitis\n6. CAD\n7. HTN\n8. Hyperlipidemia\n \nSocial History:\n___\nFamily History:\nUnknown to patient\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: 98.9, 109bpm, BP129/66, RR18, SaO2 96% on RA\nGENERAL: A&Ox1 (name only), somnolent, responsive to voice and \ngentle touch but quickly falls asleep, unable to answer \nquestions comprehensibly\nHEENT: Normocephalic, atraumatic. Pupils equal (3mm), round, \nand unreactive bilaterally. No conjunctival pallor or \ninjection, sclera anicteric and without injection. Moist mucous \nmembranes, good dentition. Oropharynx is clear.\nNECK: Thyroid is normal in size and texture, no nodules. No \ncervical lymphadenopathy.\nCARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. \nNo JVD.\nLUNGS: Clear to auscultation bilaterally w/appropriate breath \nsounds appreciated in all fields. No wheezes, rhonchi or rales. \n\nBACK: Skin. no spinous process tenderness. no CVA tenderness. \nABDOMEN: Normal bowels sounds, non distended, non-tender to \ndeep palpation in all four quadrants though difficult to assess \ngiven patient's altered sensorium. Tympanic to percussion. No \norganomegaly. well-healed mid-line incision measuring ___ inches\nEXTREMITIES: No clubbing, cyanosis, or edema, no sign of \natrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.\nSKIN: No evidence of ulcers, rash or lesions suspicious for \nmalignancy\nNEUROLOGIC: could not complete due to lack of patient \ncooperation\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: 98.0PO, Tmax 98.1, 156/79 (149-156/79-87), 83 (71-85), 18, \nSaO2 95% on RA \nGENERAL: A&Ox2 (name and place), able to engage in conversation \nand keep eyes open\nHEENT: Normocephalic, atraumatic. Pupils equal (3mm), round, \nand unreactive bilaterally. No conjunctival pallor or \ninjection, sclera anicteric and without injection. Moist mucous \nmembranes, good dentition. Oropharynx is clear.\nNECK: Thyroid is normal in size and texture, no nodules. No \ncervical lymphadenopathy.\nCARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. \nNo JVD.\nLUNGS: Clear to auscultation bilaterally w/appropriate breath \nsounds appreciated in all fields. No wheezes, rhonchi or rales. \n\nBACK: Skin. no spinous process tenderness. no CVA tenderness. \nABDOMEN: Normal bowels sounds, soft, non-tender/non-distended. \nTympanic to percussion. No organomegaly. well-healed mid-line \nincision measuring ___ inches\nEXTREMITIES: No clubbing, cyanosis, or edema, no sign of \natrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.\nSKIN: No evidence of ulcers, rash or lesions suspicious for \nmalignancy\nNEUROLOGIC: could not complete due to lack of patient \ncooperation\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 12:54PM PLT SMR-NORMAL PLT COUNT-376\n___ 12:54PM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL \nPOLYCHROM-NORMAL OVALOCYT-OCCASIONAL\n___ 12:54PM NEUTS-85.6* LYMPHS-4.5* MONOS-8.7 EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-23.37*# AbsLymp-1.23 AbsMono-2.36* \nAbsEos-0.00* AbsBaso-0.05\n___ 12:54PM WBC-27.3*# RBC-3.75* HGB-10.5* HCT-32.5* \nMCV-87 MCH-28.0 MCHC-32.3 RDW-14.2 RDWSD-44.6\n___ 12:54PM ALBUMIN-3.8\n___ 12:54PM ALT(SGPT)-5 AST(SGOT)-14 ALK PHOS-167* TOT \nBILI-0.5\n___ 12:54PM estGFR-Using this\n___ 12:54PM GLUCOSE-159* UREA N-28* CREAT-1.5* SODIUM-134 \nPOTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-20* ANION GAP-24*\n___ 01:19PM LACTATE-1.6\n___ 01:53PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 03:00PM URINE MUCOUS-RARE\n___ 03:00PM URINE HYALINE-4*\n___ 03:00PM URINE RBC-10* WBC->182* BACTERIA-FEW \nYEAST-NONE EPI-<1\n___ 03:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-LG\n___ 03:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___\n___ 03:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \noxycodn-NEG\n___ 03:00PM URINE UHOLD-HOLD\n___ 03:00PM URINE HOURS-RANDOM\n___ 09:32PM PLT COUNT-334\n___ 09:32PM WBC-19.8* RBC-3.39* HGB-9.4* HCT-29.7* MCV-88 \nMCH-27.7 MCHC-31.6* RDW-14.5 RDWSD-46.8*\n___ 09:32PM GLUCOSE-123* UREA N-24* CREAT-1.2 SODIUM-139 \nPOTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-21* ANION GAP-21*\n\nDISCHARGE/PERTINENT LABS:\n=========================\n___ 07:05AM BLOOD WBC-8.9 RBC-3.32* Hgb-9.2* Hct-27.7* \nMCV-83 MCH-27.7 MCHC-33.2 RDW-13.9 RDWSD-42.4 Plt ___\n___ 07:05AM BLOOD Glucose-118* UreaN-6 Creat-0.6 Na-140 \nK-3.5 Cl-101 HCO3-24 AnGap-19\n___ 07:00AM BLOOD ___ PTT-35.2 ___\n___ 07:00AM BLOOD ALT-6 AST-14 LD(LDH)-176 AlkPhos-127 \nTotBili-0.4\n___ 07:05AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.7\n\nMICROBIOLOGY:\n==============\n___ 3:00 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. 10,000-100,000 CFU/mL. \n Fosfomycin Susceptibility testing requested by ___. ___ \n___\n (___) ON ___. FOSFOMYCIN = 24MM = SUSCEPTIBLE. \n FOSFOMYCIN sensitivity testing performed by ___ \n___. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMIKACIN-------------- 8 S\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- =>32 R\nCEFAZOLIN------------- =>64 R\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ =>16 R\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nTOBRAMYCIN------------ =>16 R\nTRIMETHOPRIM/SULFA---- =>16 R\n\nIMAGING:\n========\n___ Imaging ABDOMEN (SUPINE & ERECT)\nNonobstructive bowel gas pattern in the stomach, small bowel and \ncolon. No evidence of pneumoperitoneum. \n\n___ Imaging CHEST (SINGLE VIEW)\nNo acute cardiopulmonary process. No focal consolidation to \nsuggest \npneumonia. \n \n___-SPINE W/O CONTRAST\nNo acute fracture or malalignment of the cervical spine.\n\n___ Imaging CT HEAD W/O CONTRAST \nNo acute intracranial process.\n \nBrief Hospital Course:\nMr. ___ is a ___ man with history of paranoid \nschizophrenia, COPD, Type 2 DM, urinary retention s/p indwelling \nfoley catheter placement in ___, who presented from his \ngroup home with report of 1 day of fever prior to admission and \naltered mental status on the day of presentation to the ED \n(___). \n\n# Altered mental status/catheter associated urinary tract \ninfection:\nPatient hemodynamically stable on admission, but drowsy and not \noriented. Afebrile, but WBC count of 27. Urinalysis consistent \nwith infection in the setting of indwelling foley catheter. Head \nand neck imaging without acute abnormalities. He was without \nheadaches, photophobia, or neck stiffness to suggest \nmeningoencephalitis. Patient initially started on ceftriaxone; \nhowever, urine culture revealed ESBL E. coli resistant to \nceftriaxone. Patient switched to meropenem, which he received \nfrom ___ to ___. Patient was switched to fosfomycin (1 dose) \non discharge to complete a full antibiotic course. Foley \ncatheter was replaced.\n\n# Acute kidney injury:\nPatient also noted to have acute kidney injury with Cr 1.5, \nlikely prerenal in etiology, that resolved with IV fluids. Cr on \ndischarge 1.0.\n\n# Paranoid schizophrenia:\nPatient's clozapine was held on admission, given altered mental \nstatus. He was seen by the psychiatry service for assistance \nwith management. Clozapine was resumed at the suggestion of \npsychiatry at 100mg PO QHS, with plan for outpatient uptitration \nby primary psychiatrist.\n\n# Normocytic anemia: \nHe was found to have Hgb of 8.8-10.5 as compared to most recent \nbaseline of 11.8. He was without signs of overt bleeding. There \nwas low suspicion for hemolysis in the setting of normal TBili \nand lack of schistocytes on manual smear.\n\n# Abdominal pain:\nHe experienced transient abdominal pain with benign abdomen, \npossibly related to urinary tract infection, though not \nspecifically suprapubic. KUB was without signs of obstruction or \nperforation. Abdominal pain resolved prior to discharge.\n\n# T2DM\nHe received long-acting insulin with sliding scale as needed. \nHome metformin was held throughout admission and resumed at \ndischarge.\n\n# COPD\nHome fluticasone and tiotropium inhaler were held throughout \nadmission and resumed at discharge.\n\n# GERD/Reflux esophagitis\nHe received omeprazole in place of home ranitidine in the \ninpatient setting.\n\n# CAD\nHome ASA was continued.\n\n# Hyperlipidemia\nHome gemfibrozil was held throughout admission and resumed at \ndischarge.\n\n# Orthostatic hypotension \nHome fludrocortisone was continued.\n\nTRANSITIONAL ISSUES:\n====================\n# Patient's clozapine was stopped on admission and restarted at \n100mg PO QHS by recommendation from psychiatry. Patient should \nfollow up with outpatient psychiatrist for uptitration.\n# Patient was found to have anemia with Hgb of 9.2. He should \nhave a follow-up CBC with differential within 1 week and should \nbe worked-up for iron-deficiency or other causes anemia if not \nimproved; downtrending monocyte count, likely elevated on \nadmission in the setting of infection, also should be ensured.\n# Follow-up of coagulation studies to ensure downtrending INR \n(elevated to 1.4 on this admission likely in the setting of \ninfection and poor PO intake, without overt signs of DIC) also \nadvised.\n# Patient found to have 10 RBC on urinalysis on this admission, \nlikely in the setting of urinary tract infection; please assess \nfor resolution of hematuria following resolution of urinary \ntract infection, though may be confounded if ongoing foley \ncatheter needed.\n# Patient should follow up with urology for foley catheter care \nand to assess whether ongoing foley catheter is needed. \nAppointment was made for ___.\n\n# CODE: Full\n# CONTACT: ___ (___) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n3. Aspirin 81 mg PO DAILY \n4. Clozapine 200 mg PO BID \n5. Clozapine 75 mg PO QHS \n6. Docusate Sodium 100 mg PO BID \n7. Fluticasone Propionate 110mcg 2 PUFF IH BID \n8. Gemfibrozil 600 mg PO BID \n9. Levemir (insulin detemir) 32 units subcutaneous BREAKFAST \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. Ranitidine 150 mg PO BID \n12. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Medications:\n1. Clozapine 100 mg PO QHS \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n3. Aspirin 81 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension \n6. Fluticasone Propionate 110mcg 2 PUFF IH BID \n7. Gemfibrozil 600 mg PO BID \n8. Levemir (insulin detemir) 32 units subcutaneous BREAKFAST \n9. MetFORMIN (Glucophage) 1000 mg PO BID \n10. Ranitidine 150 mg PO BID \n11. Tiotropium Bromide 1 CAP IH DAILY \n12. HELD- Clozapine 200 mg PO BID This medication was held. Do \nnot restart Clozapine until until you see your psychiatrist\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n==================\nToxic Metabolic Encephalopathy\nCatheter-associated UTI\nAcute Kidney Injury\n\nSECONDARY DIAGNOSES:\n====================\nParanoid Schizophrenia\nType 2 Diabetes\nCOPD\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you. You were admitted to the \n___ because you were confused \nand had a fever. You were found to have a urinary tract \ninfection and you were started on IV antibiotics and your mental \nstatus improved significantly. Your Clozaril was also stopped \nand restarted at a lower dose because of your confusion.\n\nYou should follow-up with your PCP and outpatient psychiatrist \nwithin ___ weeks of discharge.\n\nWishing you a speedy recovery,\n___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "T83511A", "G92", "I10", "B9620", "J449", "E119", "F200", "N390", "Y846", "Y929", "Z87891", "K210", "I2510", "E785", "D649" ]

[ "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "G92: Toxic encephalopathy", "I10: Essential (primary) hypertension", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "F200: Paranoid schizophrenia", "N390: Urinary tract infection, site not specified", "Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z87891: Personal history of nicotine dependence", "K210: Gastro-esophageal reflux disease with esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "D649: Anemia, unspecified" ]

[ "I10", "J449", "E119", "N390", "Y929", "Z87891", "I2510", "E785", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nWEAKNESS\n \nMajor Surgical or Invasive Procedure:\nN/A\n \nHistory of Present Illness:\n___ is a ___ year-old M (poor historian) with a PMH of\npsychosis, mechanical falls with negative syncope w/u in ___,\nT2DM (last HbA1c unknown, on metformin and insulin), and COPD\n(last FEV1 unknown), who presents with a 2-week history of\nweakness and cough with sputum production. \n\nHe was in his usual state of health until 2 weeks ago, when he\nbegan to feel weak and short of breath. Of note, he has had\nsimilar episodes in the past that last for several days and said\ndirectly that \"this feels like pneumonia to me.\" This was\nassociated with a frequent cough productive of yellow-green\nsputum and anorexia with poor PO intake. He denies hemoptysis,\nfevers, chills, and night sweats. He denies orthopnea and PND. \nHe\ndenies nausea, vomiting, diarrhea, constipation, hematochezia,\nmelena, dysuria, and hematuria. Yesterday, he experienced\nworsening lightheadedness and he had frequent episodes of\ntripping. He denies falls, LOC, or head strike with these\nepisodes. \n\nThis morning, he had an episode of chest pain that was\nmidsternal, sharp, and pleuritic without radiation into the arm\nor neck or worsened SOB. Concurrently, he was too weak to rise\nfrom his chair. Last FSG 138. Given his weakness and worsening\nrespiratory status, he presented to the ED. \n\n___ ED\n--------\n+ Initial Vitals: \n 97.5 91 126/81 17 100% RA \n\n+ Exam was notable for: \n Dry MM, R tonsillar fullness. No focality to pulmonary exam. \n \n+ Labs were significant for:\n BUN 33, Cr 1.5, AGAP 21\n WBC 13, Hgb 12.4, Plt 341\n Trop <0.01\n\n+ Imaging:\n- CT head showed no acute process.\n- CXR showed streaky posteroinferior left lobe opacity may\nreflect atelectasis, though infection cannot be entirely\nexcluded.\n- EKG showed NSR, rate 90.\n\n+ Interventions: 1L IVF, azithromycin 500mg IV x1, CTX 1g x1.\n\n+ Vitals Prior to Transfer: \n 97.9 84 132/78 17 99% RA \n\nCurrently, he continues to have a cough with intermittent sputum\nproduction. His appetite has returned and he was eating dinner \nat\nthe time of the exam. He denies any other complaints. \n \n \nPast Medical History:\n1. Paranoid schizophrenia, well-controlled on Clozaril \n- Previous auditory and visual hallucinations, none \"for awhile\"\nper patient\n2. Mechanical falls with negative syncope workup (___)\n3. T2DM (last HbA1c 7.1 in ___\n4. COPD (last FEV1 unknown)\n \n \nSocial History:\n___\nFamily History:\nUnknown to patient. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS: T 97.7 BP 137/80 HR 98 RR 20 SaO2 100% RA Wt 78.88kg \nGEN: Man appearing older than stated age, alert, lying in bed\nwatching TV, no acute distress. \nHEENT: Dry MM, anicteric sclerae, no conjunctival pallor. +R\ntonsillar fullness. \nNECK: Supple without LAD. \nPULM: Globally decreased breath sounds with intermittent\nexpiratory wheeze, no rhonchi or rales, symmetric air movement,\nno increased work of breathing. \nCOR: RRR (+)S1/S2 no m/r/g \nABD: Soft, non-tender, non-distended, +bowel sounds. \nEXTREM: Warm, well-perfused, no edema. +2 ___ pulses. \nNEURO: A&Ox3. CN II-XII grossly intact, motor function grossly\nnormal. Diminished sensation in bilateral distal ___ (although\ndifficult to pinpoint given intermittent compliance with the\nexam). \n\nDISCHARGE PHYSICAL EXAM\nVS: 97.2 141/86 83 18 97 RA \nOrthostatics ___:\n 154/77 82 (lying)\n 143/78 90 (sitting)\n 120/86 97 (standing) \nGEN: Elderly gentleman lying in bed, arousable but falls asleep \nquickly, NAD.\nHEENT: Chapped lips, anicteric sclerae. Multiple missing teeth \nof front lower jaw.\nNECK: Supple without LAD. \nPULM: Breath sounds clearer than ___ bilaterally but general \npoor air movement decreased, intermittent expiratory wheeze, no \nincreased work of breathing. No egophony. \nCOR: RRR (+)S1/S2 no m/r/g, heart sounds distant. \nABD: Soft, non-tender, non-distended, +bowel sounds. \nEXTREM: Warm, well-perfused, no edema. +2 ___ pulses. \nNo e/o diabetic foot ulcers.\nNEURO: Refused to answer orientation Qs this AM. Gait deferred.\n \nPertinent Results:\nADMISSION LABS\n------------------\n\n___ 12:30PM BLOOD WBC-13.0* RBC-4.26* Hgb-12.4* Hct-36.5* \nMCV-86 MCH-29.1 MCHC-34.0 RDW-13.8 RDWSD-42.5 Plt ___\n___ 12:30PM BLOOD Neuts-77.3* Lymphs-16.1* Monos-5.3 \nEos-0.5* Baso-0.2 Im ___ AbsNeut-10.01* AbsLymp-2.08 \nAbsMono-0.69 AbsEos-0.06 AbsBaso-0.03\n___ 12:30PM BLOOD Glucose-139* UreaN-33* Creat-1.5* Na-136 \nK-4.2 Cl-97 HCO3-22 AnGap-21*\n\nOTHER LABS\n------------------\n___ 06:55AM BLOOD Cortsol-13.0\n___ 06:33AM BLOOD Triglyc-379* HDL-25 CHOL/HD-8.8 \nLDLcalc-120\n___ 07:25AM BLOOD WBC-7.2 RBC-3.77* Hgb-10.9* Hct-32.7* \nMCV-87 MCH-28.9 MCHC-33.3 RDW-13.9 RDWSD-43.2 Plt ___\n___ 06:33AM BLOOD %HbA1c-7.1* eAG-157*\n___ 06:33AM BLOOD Triglyc-379* HDL-25 CHOL/HD-8.8 \nLDLcalc-120\n___ 06:33AM BLOOD HBsAg-Negative HBsAb-Negative IgM \nHBc-Negative\n___ 06:33AM BLOOD HIV Ab-Negative\n___ 06:33AM BLOOD HCV Ab-Negative\n___ 10:07AM BLOOD ___ pO2-195* pCO2-33* pH-7.43 \ncalTCO2-23 Base XS-0\n___ 12:30PM BLOOD cTropnT-<0.01\n\nDISCHARGE LABS\n___ 06:13AM BLOOD WBC-9.3 RBC-4.19* Hgb-11.9* Hct-36.5* \nMCV-87 MCH-28.4 MCHC-32.6 RDW-13.7 RDWSD-43.2 Plt ___\n___ 06:13AM BLOOD Glucose-114* UreaN-16 Creat-1.1 Na-137 \nK-4.3 Cl-99 HCO3-21* AnGap-21*\n\nIMAGING\n---------\n+ CXR (___)\nStreaky left lobe opacity may reflect atelectasis, though\ninfection cannot be entirely excluded. \n\n+ CT Head (___)\nNo acute intracranial abnormalities. Specifically, no evidence\nof intra-axial or extra-axial hemorrhage. \n\n+ EKG (___)\n NSR, rate 90\n\n \nBrief Hospital Course:\n___ is a ___ year-old M (poor historian) with a PMH of \npsychosis, mechanical falls with negative syncope w/u in ___, \nT2DM (last HbA1c 7.1 in ___, on metformin and insulin), and \nCOPD (last FEV1 unknown), who presents with a 2-week history of \nweakness and cough with sputum production concerning for CAP as \nwell as orthostatic hypotension. \n\n# Cough: Likely CAP given leukocytosis (13k), malaise, sputum \nproduction, and LLL infiltrate on CXR. Never met SIRS criteria \nduring hospitalization. He always saturated well on RA with no \nevidence of increased work of breathing. SputumCx indeterminate, \nurine legionella negative. He received a 5-day course of \nantibiotics with ceftriaxone/azithromycin (___). On \ndischarge, he was feeling significantly better with no \ncomplaints of cough. \n\n# Dizziness/Weakness: The patient presented with orthostatic \nhypotension thought secondary hypovolemia in the setting of poor \nPO intake, given positive orthostatics and BUN/Cr > 20:1 \nsuggestive of dehydration. Patient relies on cane at home. ECG \nNSR, trops neg. CT Head with no acute process. Electrolytes WNL. \nDespite brisk fluid resuscitation and now likely euvolemic \nstatus, orthostatics remain positive and he has a persistent \nunsteady gait. Underlying etiology unclear, possibly autonomic \ndysfunction ___ DM versus medication (on clozapine). Per \noutpatient psychiatrist Dr. ___ has been on the same dose \nof clozapine for ___ years. Adrenal insufficiency unlikely as \n___ AM cortisol level 13.0. ___ evaluated him on ___ and \nrecommended rehab. On discharge, his orthostatic vital signs \nremained positive and he continued to require assistance with \nwalking. He was initiated on fludrocortisone 0.1mg QD on ___ \nwith some symptom relief. \n\n# ___: Likely due to hypovolemia in the setting of poor PO \nintake given BUN/Cr > 20:1. Last baseline 0.95 in ___. We \ngave him IVF as above with resolution of his ___ to Cr 0.9. On \ndischarge, his BUN/Cr were ___.\n\n# Prior IVDU: Patient reports prior history of heroin use and \n\"other drugs.\" He gave consent for HIV testing. HIV, HepB, HepC \nwere all negative. \n\nCHRONIC ISSUES: \n===============\n# Psychosis: Continued clozapine. \n# Diabetes: RISS, held home metformin. Repeat HbA1c 7.2. FSGs \n120s-180s here. No evidence of diabetic foot ulcers. \n# COPD: Continued home fluticasone and tiotropium inhaler. \n# GERD: Continued home ranitidine. \n# CAD: Continued home ASA. \n# HTN: Held home lisinopril given orthostatic hypotension. \n# HL: Continued home gemfibrozil. Total Chol 221 Triglycerides \n379* elevated. HDL low at 25. Chol/HD 8.8, LDL calc 120. \n\nTRANSITIONAL ISSUES\n=================== \n# Fludrocortisone: The patient was initiated on Fluricil on ___ \nat 0.1mg daily. This can be uptitrated at a rate of 0.1mg per \nweek to a maximum of 0.3mg daily. \n\n# Transthoracic echo: The patient was scheduled for an \noutpatient echo. ECHO office will call patient to make \nappointment. He should follow up with a cardiologist to review \nthe results.\n\n# Nutrition: The patient arrived with evidence of dehydration. \nPlease ensure that he is reminded to drink water and other \nfluids throughout the day, especially if he is feeling ill. \n\n# Former IVDU: HIV, HepC, HepB found to be negative on this \nadmission. No evidence of active IVDU.\n\n# ? Diabetic neuropathy: The patient intermittently reported \nreduced sensation and proprioception in bilateral distal \nextremities. His HbA1c was 7.2 on admission, which is mildly \nelevated. His orthostatic hypotension may also be an effect of \nautonomic neuropathy. His primary care physician should \nreevaluate this at their next appointment. \n\n# Orthostatic hypotension: He will be scheduled for an \noutpatient follow-up appointment with neurology to evaluate for \npotential causes of autonomic neuropathy. If negative, his \npsychiatrist should consider redosing of his clozapine to \nminimize potential side effects. His primary care physician \nshould continue to work closely with him to ensure his diabetes \nmellitus is being treated adequately. \n\n# Blood cultures: Negative since ___, final result pending at \ndischarge. If any growth observed, the patient will be notified. \n\n\n# Lipid panel: Total Chol 221 Triglycerides 379* elevated. HDL \nlow at 25. Chol/HD 8.8, LDL calc 120. He should have a repeat \nlipid panel performed with his primary care physician and \nconsider alternative agents/dosing to better manage his low HDL \nand high triglycerides.\n\n===========================\n# CODE STATUS: Full (unconfirmed) \n# CONTACT: ___ ___ or ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. Clozapine 200 mg PO BID \n4. Clozapine 75 mg PO HS \n5. Docusate Sodium 100 mg PO BID \n6. Fluticasone Propionate 110mcg 2 PUFF IH BID \n7. Gemfibrozil 600 mg PO BID \n8. Lisinopril 5 mg PO DAILY \n9. Ranitidine 150 mg PO BID \n10. Tiotropium Bromide 1 CAP IH DAILY \n11. MetFORMIN (Glucophage) 1000 mg PO BID \n12. Detemir 32 Units Breakfast\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. Clozapine 200 mg PO BID \n4. Clozapine 75 mg PO HS \n5. Docusate Sodium 100 mg PO BID \n6. Fluticasone Propionate 110mcg 2 PUFF IH BID \n7. Gemfibrozil 600 mg PO BID \n8. Lisinopril 5 mg PO DAILY \n9. Ranitidine 150 mg PO BID \n10. Tiotropium Bromide 1 CAP IH DAILY \n11. MetFORMIN (Glucophage) 1000 mg PO BID \n12. Detemir 32 Units Breakfast\n\n \nDischarge Medications:\n1. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension \n2. Acetaminophen 650 mg PO Q6H:PRN pain \n3. Aspirin 81 mg PO DAILY \n4. Clozapine 200 mg PO BID \n5. Clozapine 75 mg PO HS \n6. Docusate Sodium 100 mg PO BID \n7. Fluticasone Propionate 110mcg 2 PUFF IH BID \n8. Gemfibrozil 600 mg PO BID \n9. Detemir 32 Units Breakfast \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. Ranitidine 150 mg PO BID \n12. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\nCOMMUNITY-ACQUIRED PNEUMONIA \nDEHYDRATION \nACUTE KIDNEY INJURY \nORTHOSTATIC HYPOTENSION \n\nSECONDARY DIAGNOSES:\nTYPE II DIABETES MELLITUS\nHYPERTENSION\nHYPERLIPIDEMIA\nCHRONIC OBSTRUCTIVE PULMONARY DISEASE\nPARANOID SCHIZOPHRENIA \nCORONARY ARTERY DISEASE \nGASTROESOPHAGEAL REFLUX DISORDER \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital for weakness and cough. We \nfound that you had a pneumonia (infection of the lungs) and gave \nyou antibiotics. We also found that you were very dehydrated and \ngave you IV fluids. Our physical therapists also evaluated you \nand decided you were strong enough to go home. \n\nYou will need to continue your antibiotics until _____. It is \nvery important not to stop your antibiotics early as this can \nlead to repeated or worse infections. \n\nPlease make sure to drink enough water (at least 8 cups a day) \nand eat three meals a day. \n\nIt was a pleasure taking care of you, and we hope you continue \nto feel better.\n\nSincerely,\nYour Team at ___\n \nFollowup Instructions:\n___\n" ]

[ "J189", "F200", "N179", "E1143", "J449", "Z794", "Z87891", "I951", "K219", "I2510", "I10", "E785", "Z9181" ]

[ "J189: Pneumonia, unspecified organism", "F200: Paranoid schizophrenia", "N179: Acute kidney failure, unspecified", "E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy", "J449: Chronic obstructive pulmonary disease, unspecified", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence", "I951: Orthostatic hypotension", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z9181: History of falling" ]

[ "N179", "J449", "Z794", "Z87891", "K219", "I2510", "I10", "E785" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nPenicillins / Tetracycline Analogues / Amoxicillin / IV Dye, \nIodine Containing Contrast Media / Lactose / Statins-Hmg-Coa \nReductase Inhibitors / metoprolol\n \nAttending: ___.\n \nChief Complaint:\nAsymptomatic carotid stenosis\n \nMajor Surgical or Invasive Procedure:\n___ RIGHT CAROTID ENDARTERECTOMY\n\n \nHistory of Present Illness:\nThe patient is a ___ male with progressive carotid \nstenosis, now greater than 80%. In addition, he is intolerant \nof statin, so we discussed elective preventative repair. He \nunderstood the risks including stroke, cranial nerve injury, \nrestenosis, and bleeding. \n\n \nPast Medical History:\nCAD (s/p DES to LAD in ___ \nProstate cancer s/p prostatectomy ___\nHodgkin's Lymphoma ___ s/p splenectomy, chemotherapy and\nradiation,\nGout\nTonsillectomy\nSpontaneous subarachnoid hemorrhage ___, treated conservatively \n\nHemorrhoids\nHerpes zoster and simplex\nHyperlipidemia\nasthma\npeptic ulcer disease\n\n \nSocial History:\n___\nFamily History:\nFather had an MI at age ___, died at age ___.\n\n \nPhysical Exam:\nPhysical Exam as of **** ___\n\n132 / 76, 107, 18 93 RA \nGen: NAD, AOx3 \nHEENT: PEERLA, no neck masses, right neck incision clean, dry \nand intact / flat - his trachea is mobile \nPULM: unlabored breathing, normal chest excursion \nCV: RRR, no m/r/g \nAbd: soft, non-distended, non-tender, no masses \nExt: no edema\n\n \nPertinent Results:\n___ 05:01AM BLOOD WBC-8.0 RBC-3.78* Hgb-12.2* Hct-37.8* \nMCV-100* MCH-32.3* MCHC-32.3 RDW-15.6* RDWSD-57.1* Plt ___\n___ 06:00AM BLOOD ___ PTT-25.3 ___\n___ 05:01AM BLOOD Plt ___\n___ 05:01AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-141 \nK-4.3 Cl-105 HCO3-26 AnGap-10\n___ 05:01AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.8\n \nBrief Hospital Course:\nNeuro: Pain was well controlled on Tylenol and oxycodone\n\nCV: Vital signs were routinely monitored during the patient's \nlength of stay. \n \nPulm: The patient was encouraged to ambulate, sit and get out of \nbed, use the incentive spirometer, and had oxygen saturation \nlevels monitored as indicated. \n\nGI: The patient was initially kept NPO after the procedure. The \npatient was later advanced to and tolerated a regular diet at \ntime of discharge. \n\nGU: Patient had a Foley catheter that was removed at time of \ndischarge. Urine output was monitored as indicated. At time of \ndischarge, the patient was voiding without difficulty. \n\nID: The patient's vital signs were monitored for signs of \ninfection and fever. The patient was started on/continued on \nantibiotics as indicated. \n\nHeme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding. The \npatient had vital signs, including heart rate and blood \npressure, monitored throughout the hospital stay. \n\nHe was seen and evaluated by Physical Therapy - The pt has a \nhistory of Tremor/postural tremor and felt unsteady on his feet. \n ___ deemed him an appropriate rehab candidate. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Testosterone Cypionate 300 mg sc Q3 WEEKS \n2. Fish Oil (Omega 3) 1000 mg PO BID \n3. Niacin 100 mg PO BID \n4. Diltiazem Extended-Release 120 mg PO DAILY \n5. Budesonide Nasal Inhaler (*NF*) 90 mcg Other DAILY \n6. lysine ___ mg oral TID \n7. Vitamin E 400 UNIT PO DAILY \n8. Vitamin D ___ UNIT PO TID \n9. Aspirin 325 mg PO DAILY \n10. Clindamycin 600 mg PO ONE HOUR BEFORE DENTAL CLEANING \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze \n3. Docusate Sodium 100 mg PO BID \n4. Levalbuterol Neb 0.63 mg NEB Q4H:PRN sob \n5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg 1 tablet(s) by mouth Q 4 HOURS Disp #*10 \nTablet Refills:*0 \n6. Pulmicort Flexhaler (budesonide) 180 mcg/actuation \ninhalation PRN \n7. Senna 17.2 mg PO QHS \n8. Aspirin 325 mg PO DAILY \n9. Budesonide Nasal Inhaler (*NF*) 90 mcg Other DAILY \n10. Clindamycin 600 mg PO ONE HOUR BEFORE DENTAL CLEANING \n11. Diltiazem Extended-Release 120 mg PO DAILY \n12. Fish Oil (Omega 3) 1000 mg PO BID \n13. lysine ___ mg oral TID \n14. Niacin 100 mg PO BID \n15. Testosterone Cypionate 300 mg sc Q3 WEEKS \n16. Vitamin D ___ UNIT PO TID \n17. Vitamin E 400 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nASYMPTOMATIC CAROTID STENOSIS\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nCarotid Endarterectomy Surgery Discharge Instructions \n\nWHAT TO EXPECT: \n1. Surgical Incision: \n• It is normal to have some swelling and feel a firm ridge along \nthe incision \n• Your incision may be slightly red and raised, it may feel \nirritated from the staples \n2. You may have a sore throat and/or mild hoarseness \n• Try warm tea, throat lozenges or cool/cold beverages \n3. You may have a mild headache, especially on the side of your \nsurgery \n• Try ibuprofen, acetaminophen, or your discharge pain \nmedication \n• If headache worsens, is associated with visual changes or \nlasts longer than 2 hours- call vascular surgeon’s office \n4. 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• You 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! \n5. 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 all of your medications as prescribed in your discharge \n\nACTIVITIES: \n• No driving until post-op visit and you are no longer taking \npain medications \n• No excessive head turning, lifting, pushing or pulling \n(greater than 5 lbs) until your post op visit \n• You may shower (no direct spray on incision, let the soapy \nwater run over incision, rinse 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 \n\nCALL THE OFFICE FOR: ___ \n• Changes in vision (loss of vision, blurring, double vision, \nhalf vision) \n• Slurring of speech or difficulty finding correct words to use \n• Severe headache or worsening headache not controlled by pain \nmedication \n• A sudden change in the ability to move or use your arm or leg \nor the ability to feel your arm or leg \n• Trouble swallowing, breathing, or talking \n• Temperature greater than 101.5F for 24 hours \n• Bleeding, new or increased drainage from incision or white, \nyellow or green drainage from incisions \n\n \nFollowup Instructions:\n___\n" ]

[ "I6521", "I2510", "Z955", "Z8546", "Z8571", "E785", "Z951", "I081", "Z952", "G4733" ]

[ "I6521: Occlusion and stenosis of right carotid artery", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z8546: Personal history of malignant neoplasm of prostate", "Z8571: Personal history of Hodgkin lymphoma", "E785: Hyperlipidemia, unspecified", "Z951: Presence of aortocoronary bypass graft", "I081: Rheumatic disorders of both mitral and tricuspid valves", "Z952: Presence of prosthetic heart valve", "G4733: Obstructive sleep apnea (adult) (pediatric)" ]

[ "I2510", "Z955", "E785", "Z951", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nWeakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with past medical\nhistory notable for hypertension, prior small intestinal bleed\n(sounds like distal upper AVM), recent hospitalization for\nseizures in the setting of gallstone pancreatitis status post\ncholecystectomy who was discharged on ___ who presents to\nthe hospital with several days of weakness. She reports that\ninitially following discharge she was feeling well. She reports\nthat after several days at home she started to feel increasingly\nfatigued. She reports that she felt similar to when she was\nbleeding in ___ and required the upper GI which found a\nlikely AVM. She reports the records from that hospitalization \nor\nat ___ in ___. She reports that at that \ntime\nher bowel movements were normal. She reports that on the \nevening\nprior to admission she developed diarrhea with black stools. \nShe\nreports that this is the exact same happened last time she had\nthe upper GI bleed. She reports that she continue to feel\nfurther fatigue. She touch base with her primary care doctor \nwho\nreferred her into the emergency department for further\nevaluation. She also reports that while at home she had a\ndecreased appetite. Per her daughter she started to look\nincreasingly pale. She became lightheaded and dizzy in the\nshower on several occasions. She also reports that she had\nurinary symptoms from around the time she got home. She reports\nthat over the last 6 days she has had increased lower abdominal\npain, burning on urination, pressure. She reports that she \nfeels\nlike it got so bad she decreased her p.o. intake to reduce the\namount that she would have to urinate. She also reports that \nshe\nhad some blood in the urine.\n\nIn the emergency department she was seen and evaluated. Her\ninitial vital signs were unremarkable. She was afebrile with a\nheart rate of 81, blood pressure 157/94, respiratory rate of 18. \n\nHer H&H was notable for 11.3/35.3 which is up from her discharge\nhemoglobin and hematocrit of 8.7/26.8. She had a UA that was\nchecked which unfortunately contained 9 epithelial cells. It \ndid\nhave positive nitrates, large leukocyte esterase, greater than\n184 white blood cells as well as few bacteria. She received 1 g\nof IV ceftriaxone, 2 L of normal saline, and was admitted to the\nmedical service for further evaluation and management. She was\nalso evaluated by the surgery service while in the emergency\ndepartment he felt like if she had anything was likely a slow GI\nbleed and would not require acute surgical intervention and \nwould\nrecommend admission to medicine for a GI workup.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n \nPast Medical History:\nGallstone pancreatitis status post cholecystectomy ___\nSeizures in the setting of the above gallstone pancreatitis\nHypertension due to renal artery stenosis, difficult to control\nPrior history of upper GI bleed from a likely AVM\nPrior history of DVT no longer on anticoagulation\n \nSocial History:\n___\nFamily History:\n___ and found to be not relevant to this\nillness/reason for hospitalization. She specifically denies any\nfamily history of seizures or strokes.\n \nPhysical Exam:\nADMISSION EXAM\n--------------\nVITALS: 98.4 PO 147 / 72 60 18 100 RA \nGENERAL: Alert and in no apparent distress, laying in bed\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 JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, tender to palpation over the\nsuprapubic region. Laparoscopic cholecystectomy incisions\nhealing well. Bowel sounds present. No HSM. No CVA tenderness\nGU: No suprapubic fullness but significant tenderness to\npalpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM\n--------------\nVS: Reviewed\nGENERAL: Alert and in no apparent distress, laying in bed\nEYES: Anicteric, pupils equally round\nCV: Heart regular, no murmur. \nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, tender to palpation over the\nsuprapubic region. Laparoscopic cholecystectomy incisions\nhealing well. Bowel sounds present. \nGU: No suprapubic fullness but significant tenderness to\npalpation\nPSYCH: pleasant, appropriate affect \n \nPertinent Results:\nADMISSION LABS\n--------------\n___ 03:46PM BLOOD WBC-10.6*# RBC-3.78*# Hgb-11.5# Hct-35.3# \nMCV-93 MCH-30.4 MCHC-32.6 RDW-14.0 RDWSD-47.6* Plt ___\n___ 03:46PM BLOOD Neuts-71.9* Lymphs-17.5* Monos-6.9 \nEos-2.6 Baso-0.7 Im ___ AbsNeut-7.65* AbsLymp-1.86 \nAbsMono-0.73 AbsEos-0.28 AbsBaso-0.07\n___ 02:22PM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-145 \nK-4.8 Cl-104 HCO3-24 AnGap-17\n___ 02:22PM BLOOD ALT-18 AST-17 AlkPhos-121* TotBili-0.5\n\nMICROBIOLOGY\n------------\n___ 4:55 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n PREDOMINATING ORGANISM. INTERPRET RESULTS WITH \nCAUTION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ <=2 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\nDISCHARGE LABS\n--------------\n___ 08:10AM BLOOD WBC-5.6 RBC-2.92* Hgb-8.9* Hct-27.2* \nMCV-93 MCH-30.5 MCHC-32.7 RDW-13.3 RDWSD-45.4 Plt ___\n___ 08:10AM BLOOD Glucose-101* UreaN-11 Creat-1.0 Na-142 \nK-4.6 Cl-101 HCO3-30 AnGap-11\n___ 07:10AM BLOOD ALT-16 AST-17 AlkPhos-91 TotBili-0.4\n___ 07:45AM BLOOD Calcium-9.7 Phos-3.8 Mg-1.7\n___ 03:46PM BLOOD calTIBC-411 Ferritn-___-___\n___ 02:35PM BLOOD Lactate-1.8\n\nKUB: \nIMPRESSION: \nNormal bowel gas pattern.\n \nBrief Hospital Course:\n___ female with past medical history notable for \nhypertension, prior small intestinal bleed (sounds like distal \nupper AVM), recent hospitalization for seizures in the setting \nof gallstone pancreatitis status post cholecystectomy who was \ndischarged on ___ who presents to the hospital with \nseveral days of weakness. \n\n# Possible upper GI bleed\n# Gastritis: Patient reported several episodes of black stools, \nbut none during admission. Hemoglobin downtrended over the \ncourse of admission. Awaiting records from ___ \nin ___. GI following patient, but did not plan on \nEGD/colonoscopy. H. pylori antigen was sent. She was placed on \nPO pantoprazole, as well as home famotidine and simethicone, \ngiven complaints of indigestion, as well as antiemetics.\n\n# Urinary tract infection: Patient reported approximately five \ndays of urinary tract symptoms with pain on urination, burning \non urination, and suprapubic fullness. Pan-sensitive E.coli on \nurine specimen, placed on ceftriaxone and switched to \nciprofloxacin for 7-day course. She was also placed on three \nday course of pyridium.\n\n# Weakness: suspect related to UTI and possible slow GI bleed, \nsee above. ___ consulted. She progressed and was able to be \ndischarged home. \n\n#Constipation\nPatient noted to constipated likely ___ to opioids and decreased \nmobility. KUB without obstruction. She received bowel regimen. \nShe had a bowel movement prior to discharge.\n\n# HTN due to\n# RAS: Patient has renal artery stenosis as documented on her \nprior admission. She has difficult to control blood pressures. \nShe was stabilized on a regimen during her prior \nhospitalization. Continued home antihypertensive regimen of \namlodipine, labetalol, lisinopril.\n\n# Seizure Disorder: Patient had generalized tonic-clonic seizure \nduring her prior hospitalization in the setting of her gallstone \npancreatitis. She was seen by neurology during her prior \nhospitalization and is now on antiseizure medication with \noutpatient follow-up. She was continued on her home Keppra.\n\n# GERD: continued on home famotidine and added PO pantoprazole.\n\nI updated her son and daughter with the plan of care. \n\nTRANSITIONS OF CARE\n-------------------\n# Follow-up: patient will follow up with her PCP.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY hypertension \n2. Atorvastatin 40 mg PO QPM \n3. LevETIRAcetam 1500 mg PO Q12H \n4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n5. Lisinopril 40 mg PO DAILY \n6. Famotidine 20 mg PO BID \n7. Aspirin 81 mg PO DAILY \n8. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe \n9. Labetalol 400 mg PO BID Hypertension \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*30 Capsule Refills:*0 \n2. Ondansetron 4 mg PO Q8H \nRX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*30 Tablet Refills:*0 \n3. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe \n\nRX *oxycodone 5 mg 1 capsule(s) by mouth every eight (8) hours \nDisp #*6 Capsule Refills:*0 \n4. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n5. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by \nmouth once a day Disp #*30 Packet Refills:*0 \n6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n7. amLODIPine 10 mg PO DAILY hypertension \n8. Aspirin 81 mg PO DAILY \n9. Atorvastatin 40 mg PO QPM \n10. Famotidine 20 mg PO BID \n11. Labetalol 400 mg PO BID Hypertension \n12. LevETIRAcetam 1500 mg PO Q12H \n13. Lisinopril 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUrinary tract infection\nGastritis/peptic ulcer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for you during your recent admission at \n___. You came for further evaluation of weakness, pain when \nurinating and black stools. \n\nIt is important that you continue to take your medications as \nprescribed and follow up with the appointments listed below.\n\nPlease follow up with your PCP ___. \nPlease arrange to have you labs checked.\n\nGood luck!\n \nFollowup Instructions:\n___\n" ]

[ "N390", "K2971", "N179", "F05", "I701", "G40409", "I10", "D500", "I739", "Z720", "K219", "B9620", "K5903", "T402X5A", "Y92230", "Z86718" ]

[ "N390: Urinary tract infection, site not specified", "K2971: Gastritis, unspecified, with bleeding", "N179: Acute kidney failure, unspecified", "F05: Delirium due to known physiological condition", "I701: Atherosclerosis of renal artery", "G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus", "I10: Essential (primary) hypertension", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "I739: Peripheral vascular disease, unspecified", "Z720: Tobacco use", "K219: Gastro-esophageal reflux disease without esophagitis", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "K5903: Drug induced constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "N390", "N179", "I10", "K219", "Y92230", "Z86718" ]

[]

[ " \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:\nPresyncope, Fall\n \nMajor Surgical or Invasive Procedure:\nEGD ___\nCapsule endoscopy ___\nColonoscopy ___\n\n \nHistory of Present Illness:\n___ with history of CVA, seizures, upper GI AVM's with chronic \nanemia, HTN, presents after presyncopal fall. \n\nOn ___ she was at home and went to linen closet to grab \nsomething. Then felt presyncopal, dizzy, warm feeling, and fell \nbackwards, hitting her head first against a bedroom door which \ngave way, and then against the floor. No LOC. Daughter came to \nher aid. She did not want to go to the hospital. The next day \nshe went to ___. CT head and CT C-spine \nnegative for\nacute bleed or fracture. Today she went to her GI appointment \nand was referred to ___. Last ___ she reported a seizure \nepisode where her arms were shaking and she was in a daze. This \nlasted for a few minutes. Consistent with prior seizures \nepisodes.\n\nIn the ___, initial VS were: \n- 98.3 77 147/45 19 100% RA \n- Exam: diffuse mild abd tenderness, scant brown stool in rectal\nvault +guaiac, \n- Labs: Hgb 7.4, Creatinine 1.1, Lactate 1.3, urine WBC 35, lg\nleuk, hazy, few bac\n- Imaging: CXR clear. CT A/P no acute process.\n\nOn interview she reports acute on chronic \"soreness\" in neck, \nback, hips, for which she takes oxycodone at home. Otherwise no \nacute complaints.\n \nREVIEW OF SYSTEMS: \n+tinnitus; all other positives per HPI\notherwise 10 point ROS reviewed and negative except as per HPI \n \nPast Medical History:\n- Hypertension\n- Renal Artery Stenosis\n- Seizures\n- CVA\n- Gallstone pancreatitis\n- Iron deficiency anemia\n- AVM's in stomach and duodenum\n- Lumbar radiculopathy\n- Chronic opioid use, with pain contract\n- Hypothyroidism\n- Hyperlipidemia\n- COPD\n- Neuropathic pain\n- GERD\n- DVT \n \nSocial History:\n___\nFamily History:\nMother had dementia.\nFather had asbestosis and mesothelioma.\n\n \nPhysical Exam:\nADMISSION PHYSICAL\n================== \nVS: 98.3 130 / 55 58 18 99 ra \nGENERAL: NAD \nHEENT: PERRL, EOMI, no nystagmus, tongue moist\nNECK: +L carotid bruit\nHEART: RRR, S1, S2, no murmurs\nLUNGS: LCAB\nABDOMEN: s, lower abdominal tenderness\nGU: suprapubic tenderness\nEXTREMITIES: no edema\nNEURO: A&Ox3, moving all 4 extremities with purpose, RLE \nweakness\n\nDISCHARGE PHYSICAL\n==================\n___ ___ Temp: 97.9 PO BP: 162/62 HR: 56 RR: 18 O2\nsat: 97% O2 delivery: Ra \nGENERAL: NAD, sitting in bed\nNECK: +bilateral carotid bruits \nHEART: RRR, S1, S2, no murmurs \nPULM: CTABL \nABDOMEN: soft, mildly distended without tenderness, +BS\nEXTREMITIES: warm, 1+ ___ pulses bilaterally, no edema \nNEURO: A&Ox3, no facial asymmetry, moving all 4 extremities with\npurpose\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 05:50PM BLOOD WBC-5.5 RBC-2.49* Hgb-7.4* Hct-22.3* \nMCV-90 MCH-29.7 MCHC-33.2 RDW-15.3 RDWSD-50.4* Plt ___\n___ 05:50PM BLOOD Neuts-47.5 ___ Monos-8.9 Eos-7.5* \nBaso-0.5 Im ___ AbsNeut-2.60 AbsLymp-1.94 AbsMono-0.49 \nAbsEos-0.41 AbsBaso-0.03\n___ 05:50PM BLOOD ___ PTT-34.2 ___\n___ 05:50PM BLOOD Glucose-101* UreaN-12 Creat-1.1 Na-138 \nK-4.2 Cl-99 HCO3-24 AnGap-15\n___ 05:50PM BLOOD ALT-14 AST-13 AlkPhos-43 TotBili-0.3\n___ 05:50PM BLOOD Lipase-22\n___ 05:50PM BLOOD proBNP-78\n___ 05:50PM BLOOD cTropnT-<0.01\n___ 05:50PM BLOOD Albumin-4.8 Calcium-9.6 Phos-3.7 Mg-1.8\n\nPERTINENT INTERVAL LABS\n=======================\n___ 09:10AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.8 Iron-16*\n___ 09:10AM BLOOD calTIBC-382 VitB12-318 Folate-14 \nFerritn-14 TRF-294\n___ 06:48AM BLOOD TSH-3.6\n___ 06:48AM BLOOD Free T4-0.9*\n\nDISCHARGE LABS\n==============\n___ 05:35AM BLOOD WBC-5.0 RBC-3.62* Hgb-10.7* Hct-34.0 \nMCV-94 MCH-29.6 MCHC-31.5* RDW-15.5 RDWSD-53.1* Plt ___\n___ 05:35AM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-144 \nK-4.5 Cl-104 HCO3-24 AnGap-16\n___ 05:35AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.0\n\nMICROBIOLOGY\n============\nUrine Culture ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), \nCONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION\n\nIMAGING AND STUDIES\n===================\n___ CXR\nAP upright and lateral views of the chest provided.\nThere is no focal consolidation, effusion, or pneumothorax. The\ncardiomediastinal silhouette is normal. Imaged osseous \nstructures are intact. \nNo free air below the right hemidiaphragm is seen.\n\n___ CT ABD/PEVLIS W CON\n1. Colonic diverticulosis without evidence of diverticulitis. \nNo signs of\ncolitis or bowel obstruction. Normal appendix.\n2. Status post cholecystectomy with stable mild prominence of \nthe intrahepatic\nand extrahepatic biliary tree.\n3. Extensive aortoiliac atherosclerotic calcification with \nstents in the\nbilateral external iliac arteries which appear patent.\n4. Atrophic right kidney.\n5. Trace free pelvic fluid, nonspecific.\n\n___ ECHO (TTE)\nThe left atrial volume index is normal. The estimated right \natrial pressure is ___ mmHg. Left ventricular wall thickness, \ncavity size and regional/global systolic function are normal \n(LVEF >55%). There is no left ventricular outflow obstruction at \nrest or with Valsalva. There is no ventricular septal defect. \nRight ventricular chamber size and free wall motion are normal. \nThe aortic valve leaflets (3) are mildly thickened but aortic \nstenosis is not present. No aortic regurgitation is seen. The \nmitral valve appears structurally normal with trivial mitral \nregurgitation. There is no mitral valve prolapse. The estimated \npulmonary artery systolic pressure is normal. There is no \npericardial effusion. \n\nIMPRESSION: Normal biventricular cavity size and global/regional \nsystolic function. No pathological valvular flow identified. No \nstructural cause for syncope identified. \n\n___ CAROTID ULTRASOUND\nModerate-to-marked predominantly heterogeneous soft plaque \nwithin the\nbilateral carotid arteries most profound within the mid ICAs, \nright greater\nthan left, resulting in hemodynamically significant stenosis \nestimated to be 80-99% bilaterally.\n\n___ EGD\nMucosa suggestive of ___ Esophagus\nErosion in pylorus\nAngioectasias in stomach and second part of duodenum (Thermal \nTherapy applied)\nCapsule released in duodenum\n\n___ COLONOSCOPY \nAborted due to high residue material\n\n___ pMIBI\nFINDINGS: There was soft tissue attenuation. \nLeft ventricular cavity size is within normal limits. \nRest and stress perfusion images reveal uniform tracer uptake \nthroughout the left ventricular myocardium. \n \nGated images reveal normal wall motion. \nThe calculated left ventricular ejection fraction is 71%. \n \nIMPRESSION: 1. No evidence of myocardial perfusion defect. 2. \nNormal left \nventricular cavity size with normal systolic function. \n\n___ KUB\nEndoscopy capsule in the proximal descending colon.\n\n___ KUB\nEndoscopy pill capsule has migrated since ___, now \npossibly in the sigmoid colon. \n \nBrief Hospital Course:\n___ with history of CVA, seizures, upper GI AVM's with chronic \nanemia, HTN, peripheral vasculopathy, who presented after \npresyncopal fall. \n\nACUTE ISSUES \n============\n# Acute on Chronic Blood Loss Anemia \n# Upper GI Bleed\nPresented with ongoing intermittent melena and known gastric and \nduodenal AVMs per prior EGD's s/p single balloon enteroscopy \nwith APC to small bowel AVMs. Stool guaiac positive in ___. \nRequired 2u pRBCs during her hospitalization. EGD showed several \nduodenal/gastric AVMs that were cauterized, as well as likely \n___ esophagus. Patient was iron deficient and was given 2 \n125mg IV infusions of ferric gluconate. Patient was continued \non PPI prophylaxis.\n\n# Seizures\nPatient reported that her last seizure 1 week prior to admission \nand involved extremity shaking and AMS that lasted several \nminutes, consistent with previous episodes. Neurology was \nconsulted for optimization of her AEDs. EEG was performed and \nthe patient was continued on Keppra with plans for outpatient \nfollowup in neurology clinic. She had no seizures in house.\n\n# Severe, Bilateral Carotid Artery Stenosis\nCarotid US done as part of pre-syncope work-up revealed severe \nbilateral carotid artery stenosis (80-99%). She was seen by \nvascular surgery in house, who recommended no urgent treatment. \nThis could certainly contribute to pre-syncope, however vascular \nsurgery will followup with patient for CEA consideration. \n\n# Presyncope\nPresented 4 days after presyncopal episode at home with fall and \nhead trauma. CT head and c-spine were negative at OSH. Signs and \nsymptoms not consistent with prior seizures. Initial ddx \nincluded CNS process (TIA, carotid stenosis), cardiac (had old \nRBBB on EKG, and new LBBB on this admission), orthostasis (had \npreviously documented orthostatic hypotension), vasovagal event, \nperipheral vertigo (has tinnitus), or symptomatic anemia. \n\n# Concern for Cardiac Conduction Disease\nNoted patient has HRs usually in ___, even when standing and \nlightheaded. There was concern that she was not adequately \naugmenting her cardiac output with exertion due to conduction \ndisease and this blunted response was contributing to her \npre-syncope. Also noted to initially have RBBB on EKG, but then \nLBBB on EKG done later in the same day (in ___ on presentation). \nUnusual and concerning for conduction disease, so cardiology was \nconsulted and beta-blocker (home med) was held. pMIBI revealed \nno overt ischemia and ambulatory telemetry revealed that \npatients heart rates increased to ___. Cardiology felt that this \nwas an appropriate response and the patient did not require \nfurther electrophysiologic evaluation during this \nhospitalization.\n\n# Hypertension\nPatient has history of hypertension (renal artery stenosis) with \northostatic hypotension. Antihypertensives were held in the \nsetting of GI bleed but were restarted once her GI bleed was \naddressed. She was continued on home doses of blood pressure \nmedications and was also started on chlorthalidone 12.5mg daily \nfor better control. \n\n# Chronic Back and Neck Pain\nHas narcotics contract w PCP for oxycodone 5mg BID since \n___. Review of MassPMP indicates pt also prescribed \nvicodin in OSH ___ three days prior to presentation. Likely that \npain is exacerbated by recent fall, so increased pain regimen \nwhile in-house. \n\nCHRONIC ISSUES\n==============\n# Neuropathic pain: continued gabapentin 300mg TID. \n# GERD: continued PPI and famotidine. \n# Chronic nausea: continued ondansetron PRN. \n\nTRANSITIONAL ISSUES\n===================\n[]Ensure passage of capsule, on discharge KUB ___ noted to be \nin sigmoid colon/rectum. Consider repeat KUB to assess if \nconcerned. Per GI, very unlikely to cause obstruction once in \ncolon.\n[]Labetalol/Beta-Blockade: Recommend avoiding all beta-blockade \ngiven heart rates in the ___. Patient's labetalol was \ndiscontinued to avoid negative chronotrope effect\n[]Chlorthalidone: titrate dose as needed for adequate blood \npressure control\n[]ASA 81: discharged on ASA 81 given stroke risk in the setting \nof severe carotid disease, if GI bleed recurs, risk/benefit \nshould be discussed with patient (okay to hold per inpatient \ncardiology recommendations but neurology would recommend \ncontinuing)\n[]Atorvastatin: increased to 80mg (although less data in \nsecondary prevention) due to severe vascular disease\n___ esophagus: Noted on EGD. Will have follow up \nendoscopy with plan for biopsy in ___ \n[]Labs: Repeat CBC at clinic visit to ensure stability, \ndischarge Hgb 9.9\n[]Vascular Followup: Has appointment with Dr. ___ ___ for \nCEA evaluation\n[]Neurology Followup: Has appointment for further management of \nanti-seizure medications\n\n# Contact/HCP: ___ (daughter) ___ \n# Code status: Full, presumed\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY hypertension \n2. Atorvastatin 40 mg PO QPM \n3. LevETIRAcetam 1500 mg PO Q12H \n4. Lisinopril 40 mg PO DAILY \n5. Simethicone 40-80 mg PO QID:PRN abd pain \n6. Famotidine 20 mg PO BID \n7. Ondansetron 4 mg PO Q8H:PRN nausea \n8. Pantoprazole 40 mg PO Q12H \n9. Aspirin 81 mg PO DAILY \n10. Ferrous Sulfate 325 mg PO BID \n11. Ascorbic Acid ___ mg PO BID \n12. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH \nPAIN \n13. Labetalol 200 mg PO BID \n14. Gabapentin 300 mg PO TID \nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY hypertension \n2. Atorvastatin 40 mg PO QPM \n3. LevETIRAcetam 1500 mg PO Q12H \n4. Lisinopril 40 mg PO DAILY \n5. Simethicone 40-80 mg PO QID:PRN abd pain \n6. Famotidine 20 mg PO BID \n7. Ondansetron 4 mg PO Q8H:PRN nausea \n8. Pantoprazole 40 mg PO Q12H \n9. Aspirin 81 mg PO DAILY \n10. Ferrous Sulfate 325 mg PO BID \n11. Ascorbic Acid ___ mg PO BID \n12. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH \nPAIN \n13. Labetalol 200 mg PO BID \n14. Gabapentin 300 mg PO TID \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \nRX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Chlorthalidone 12.5 mg PO DAILY \nRX *chlorthalidone 25 mg 0.5 (One half) tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID constipation \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily \nDisp #*30 Capsule Refills:*0 \n4. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n5. Polyethylene Glycol 17 g PO DAILY constipation \nRX *polyethylene glycol 3350 [PEG___] 17 gram/dose 17 g by \nmouth daily Refills:*0 \n6. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*30 \nTablet Refills:*0 \n7. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth at nightime Disp \n#*30 Tablet Refills:*0 \n8. amLODIPine 10 mg PO DAILY hypertension \n9. Ascorbic Acid ___ mg PO BID \n10. Aspirin 81 mg PO DAILY \n11. Famotidine 20 mg PO BID \n12. Ferrous Sulfate 325 mg PO BID \n13. Gabapentin 300 mg PO TID \n14. LevETIRAcetam 1500 mg PO Q12H \n15. Lisinopril 40 mg PO DAILY \n16. Ondansetron 4 mg PO Q8H:PRN nausea \n17. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH \nPAIN \n18. Pantoprazole 40 mg PO Q12H \n19. Simethicone 40-80 mg PO QID:PRN abd pain \n20.Rolling Walker\nPlease provide rolling walker.\nDx: Seizure Disorder (ICD-9: 780.39)\nPrognosis: Good\n___: 13 Months\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses\n=================\nAcute on chronic upper GI bleed\nSevere, bilateral coronary artery stenosis\nSeizure disorder\nOrthostatic hypotension\n\nSecondary Diagnoses\n===================\nBipolar Disorder\nHepatitis B\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___, \n\n___ was a pleasure taking care of you in the hospital.\n\nWHY DID YOU COME TO THE HOSPITAL?\n-You felt lightheaded and suffered a fall\n\nWHAT HAPPENED TO YOU DURING YOUR HOSPITAL STAY?\n-You were given blood to increase your blood counts\n-Your bloody bowel movements were evaluated and treated by the \ngastroenterologists\n-You were evaluated for seizures by the neurologists and was \nstarted on a medication to prevent seizures \n-You were found to have severe blockages in both arteries \nsupplying blood to brain and need to follow-up with the vascular \nsurgeons in vascular surgery clinic to discuss surgical \ncorrection of these blockages\n-Your heart was evaluated by the cardiologists who do not \nrecommend any further testing at this time\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?\n–please take all of your medications as prescribed, details \nbelow\n–Please keep all of your appointments as scheduled\n-Please keep track of whether you have passed the capsule in \nyour bowel movement. If you have not passed the capsule in 2 \ndays since discharge, you should be seen in clinic by your PCP. \nPlease call your PCP right away if you have any symptoms such as \nconstipation, vomiting, anorexia, and if you are not passing any \ngas.\n\nWe wish you the very best!\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K31811", "B1910", "S0990XA", "G629", "D62", "F1120", "I452", "I6523", "G40909", "I951", "F319", "Q2733", "I10", "W01198A", "Y92008", "I701", "M5416", "E039", "E785", "J449", "K219", "Z86718", "Z87891", "K2270", "R110", "T402X5A", "Y929", "I739", "I69398", "R531", "R42", "N3090", "R079", "I459", "K5900" ]

[ "K31811: Angiodysplasia of stomach and duodenum with bleeding", "B1910: Unspecified viral hepatitis B without hepatic coma", "S0990XA: Unspecified injury of head, initial encounter", "G629: Polyneuropathy, unspecified", "D62: Acute posthemorrhagic anemia", "F1120: Opioid dependence, uncomplicated", "I452: Bifascicular block", "I6523: Occlusion and stenosis of bilateral carotid arteries", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I951: Orthostatic hypotension", "F319: Bipolar disorder, unspecified", "Q2733: Arteriovenous malformation of digestive system vessel", "I10: Essential (primary) hypertension", "W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter", "Y92008: Other place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "I701: Atherosclerosis of renal artery", "M5416: Radiculopathy, lumbar region", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z86718: Personal history of other venous thrombosis and embolism", "Z87891: Personal history of nicotine dependence", "K2270: Barrett's esophagus without dysplasia", "R110: Nausea", "T402X5A: Adverse effect of other opioids, initial encounter", "Y929: Unspecified place or not applicable", "I739: Peripheral vascular disease, unspecified", "I69398: Other sequelae of cerebral infarction", "R531: Weakness", "R42: Dizziness and giddiness", "N3090: Cystitis, unspecified without hematuria", "R079: Chest pain, unspecified", "I459: Conduction disorder, unspecified", "K5900: Constipation, unspecified" ]

[ "D62", "I10", "E039", "E785", "J449", "K219", "Z86718", "Z87891", "Y929", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nGI bleed\n \nMajor Surgical or Invasive Procedure:\nEndoscopy ___\nCapsule Endoscopy ___\n \nHistory of Present Illness:\n___ with history of GI bleed with unidentified etiology, \ngallstone pancreatitis requiring lap CCY (course c/b seizures \nthought triggered by pancreatitis and possible prior stroke) who \npresents from home with dark stools, abd pain, dysuria, \npolyuria.\nIn the ED, initial VS were: 98.5 76 179/62 18 100% RA\nExam notable for:\nTTP RLQ, LLQ, suprapubic region\nLabs showed:\nHgb 7.9\nUA with few bacteria, lg leuk, 2 WBC\nLactate 1.5\nImaging showed:\nCTA ABD/PELVIS\n1. No evidence of active contrast extravasation into the bowel.\n2. Colonic diverticulosis without diverticulitis.\n3. Interval increased extrahepatic and central intrahepatic \nbiliary dilation is likely due to post cholecystectomy status. \nCorrelation with LFTs is Recommended and if there is continued \nconcern for biliary obstruction, consider MRCP for further \nassessment.\nPatient received:\n___ 15:00 IV Morphine Sulfate 4 mg\n___ 16:39 IV Esomeprazole sodium 40 mg\n___ 17:59 IV Morphine Sulfate 4 mg\n___ 20:19 IV Morphine Sulfate 4 mg\n___ 21:54 IV CefTRIAXone\n___ 22:23 PO/NG Atorvastatin 40 mg\n___ 22:23 PO/NG Labetalol 200 mg\n___ 22:23 PO LevETIRAcetam 1500 mg\n___ 23:30 IV Ondansetron 4 mg ___\n***1 unit PRBCs ___ @ 1752***\nGI was consulted:\nH/H down from discharge at 7.9/24.5. Discharged on ___ at \n8.9/27.2.\nRecommend:\n- 2 large bore IVs\n- Trend CBC q12h\n- IV PPI BID\n- NPO at midnight\n- Transfuse for hgb >7\n- Plan for EGD in AM\nTransfer VS were: 98.3 67 164/70 16 100% RA\nOn arrival to the floor, patient reports that she simply does \nnot feel well. She has been unable to sleep, feeling weak upon \nstanding, melena x 2 days, diffuse abdominal pain, and dysuria. \nShe typically knows when she has a UTI, and these symptoms are \nconsistent. She denies fevers, weight change, chest pain, \nshortness of breath.\nRecently hospitalized ___ for weakness, thought ___ UTI \nand possible slow GI bleed. UTI grew pan-sensitive E coli \ntreated with CTX -> ciprofloxacin. H/H trended, H pylori \nserology came back negative, patient did not undergo endoscopy. \nDischarge Hgb 8.9.\nREVIEW OF SYSTEMS:\n10 point ROS reviewed and negative except as per HPI\n \nPast Medical History:\nGallstone pancreatitis status post cholecystectomy ___\nSeizures in the setting of the above gallstone pancreatitis\nHypertension due to renal artery stenosis, difficult to control\nPrior history of upper GI bleed from a likely AVM\nPrior history of DVT no longer on anticoagulation\n \nSocial History:\n___\nFamily History:\n___ and found to be not relevant to this\nillness/reason for hospitalization. She specifically denies any\nfamily history of seizures or strokes.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: 98.2 162/75 63 18 96% RA\nGENERAL: NAD\nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM\nNECK: supple, no LAD, no JVD\nHEART: RRR, S1/S2, no murmurs, gallops, or rubs\nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles\nABDOMEN: slightly TTP diffusely\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ DP pulses bilaterally\nNEURO: A&Ox3, moving all 4 extremities with purpose\nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes\n\nDISCHARGE EXAM:\nVS: 98.4 ___\nGENERAL: NAD , pale\nHEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM \nNECK: supple \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB\nABDOMEN: Soft nondistended, tender over umbilicus, no \nrebound/guarding.\nEXTREMITIES: no cyanosis, clubbing, or edema. Warm \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \nPSYCH: Appropriate affect \n \nPertinent Results:\nADMISSION LABS:\n___ 01:49PM BLOOD WBC-7.6 RBC-2.70* Hgb-7.9* Hct-24.5* \nMCV-91 MCH-29.3 MCHC-32.2 RDW-13.2 RDWSD-43.4 Plt ___\n___ 01:49PM BLOOD Neuts-58.9 ___ Monos-6.2 Eos-5.4 \nBaso-0.4 Im ___ AbsNeut-4.48 AbsLymp-2.19 AbsMono-0.47 \nAbsEos-0.41 AbsBaso-0.03\n___ 01:49PM BLOOD ___ PTT-30.9 ___\n___ 01:49PM BLOOD Glucose-106* UreaN-15 Creat-1.0 Na-143 \nK-4.3 Cl-103 HCO3-22 AnGap-18\n___ 01:49PM BLOOD ALT-15 AST-15 LD(LDH)-136 AlkPhos-62 \nTotBili-0.2\n___ 05:05AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.9\n___ 02:09PM BLOOD Lactate-1.5\n\nIMAGING:\n\nKUB ___:\n1. Enteric capsule in the small bowel of the left lower abdomen \nin similar position to the study 2 days ago.\n2. Nonobstructive bowel gas pattern.\n\nKUB ___:\nEnteric capsule in the left lower abdomen.\n\nGI Endoscopy ___:\nAngioectasias in the body (thermal therapy)\nOtherwise normal EGD to third part of the duodenum\n\nCTA ABD/PELVIS ___:\n1. No evidence of active contrast extravasation into the bowel.\n2. Colonic diverticulosis without diverticulitis.\n3. Interval increased extrahepatic and central intrahepatic\nbiliary dilation is likely due to post cholecystectomy status.\nCorrelation with LFTs is Recommended and if there is continued\nconcern for biliary obstruction, consider MRCP for further\nassessment.\n\nDISCHARGE LABS:\n___ 05:15AM BLOOD WBC-4.8 RBC-2.66* Hgb-7.8* Hct-24.7* \nMCV-93 MCH-29.3 MCHC-31.6* RDW-13.2 RDWSD-44.8 Plt ___\n___ 05:00AM BLOOD Glucose-93 UreaN-9 Creat-1.0 Na-144 K-4.7 \nCl-105 HCO3-26 AnGap-13\n___ 05:15AM BLOOD ___ PTT-31.1 ___\n___ 05:00AM BLOOD ALT-10 AST-9 AlkPhos-55 TotBili-0.3\n___ 05:00AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.___ with history of recurrent GIB of unidentified source who \npresents with melena, drop in H/H, and abdominal pain also with \nUTI and GPC bactermia.\n\n#Acute blood loss anemia\n#Melena,Upper GI bleeding: suspect recurrence of prior GIB. Has \nhad reported extensive workup in past at hospital in ___ \nincluding capsule study. Required 3 transfusions in ___. No \nendoscopy in our system. Prior thought to be AVM in small bowel. \nEGD showed angiectasias in the body of the stomach. No further \nbleeding while inpatient. Capsule endoscopy ___ was \ncomplicated by poor transit time through the stomach and poor \nbowel prep. Capsule remained in colon by day of discharge, will \nneed visualization in stool or KUB ___ to ensure passage. Will \nneed to be repeated as an outpatient.\n \n#Staph bacteremia, contaminant:\nCoag negative staph and staph hemolyticus growing out of initial \ncultures. Unclear if contaminant however as affecting 2 out of 2 \nbottles. Patient without white count or systemic symptoms of \ninfection and no further positive cultures. Treated with \nvancomycin until preantibiotic repeat cultures resulted \nnegative. Overall thought to be contaminant.\n \n#UTI/Dysuria/suprapubic pain: in setting of recent E coli in \nurine, dysuria, and suprapubic tenderness, concern for UTI \ndespite equivocal urine. Initial urine culture was contaminated. \nPostvoid residual was 0. Pain was managed with Tylenol and \noxycodone. S/p ceftriaxone x 3 days for presumed UTI.\n\n#Abdominal pain: Patient had some gassy abdominal pain following \nMoviPrep. Treated with simethicone. She subsequently had \nabdominal pain following jerking with subcu heparin injection; \nabdominal exam benign.\n\n#History of seizure: per neuro notes, thought triggered by \npancreatitis vs prior stroke. Continued Keppra\n\n#HA: Likely related to SBPs in 190s. Pain management with \nTylenol/oxycodone. Avoided NSAIDs given GIB. Trialed fioricet. \n\n#Dizziness, bradycardia: Patient endorsed significant dizziness \nduring hospitalization. Was bradycardic to the ___ on home \nlabetalol. Labetalol was discontinued and patient was treated \nwith IV fluids.\n\n#HTN: HTN to 190s inpatient. Restarted home amlodipine, \nlisinopril. \n\n#HLD: atorvastatin. Restarted Asa on discharge. \n\n#Chronic pain in bilateral legs: no longer takes oxycodone at \nhome. Not a complaint here. \n\n#CTA findings of intrahepatic biliary dilation: likely ___ \npost-CCY state. LFTs negative. No RUQ pain. \n\nTRANSITIONAL ISSUES:\n====================\n[] Outpatient follow up with Dr. ___ on ___ as already \nscheduled to determine whether EGD for capsule placement is \nneeded\n[] Titrate antihypertensives \n[] Labetalol was held for bradycardia\n[] Needs KUB ___ to ensure passage of capsule \n\n#CODE: Full (confirmed) \n#CONTACT: ___ (daughter) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY hypertension \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. LevETIRAcetam 1500 mg PO Q12H \n5. Labetalol 400 mg PO BID Hypertension \n6. Famotidine 20 mg PO BID \n7. Ondansetron 4 mg PO Q8H:PRN nausea \n8. Pantoprazole 40 mg PO Q12H \n9. Lisinopril 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Simethicone 40-80 mg PO QID:PRN abd pain \nRX *simethicone 80 mg 1 tab by mouth four times a day Disp #*80 \nTablet Refills:*0 \n2. amLODIPine 10 mg PO DAILY hypertension \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Famotidine 20 mg PO BID \n6. LevETIRAcetam 1500 mg PO Q12H \n7. Lisinopril 40 mg PO DAILY \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. Pantoprazole 40 mg PO Q12H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUpper GI bleed\nUTI\nBacteremia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were seen at ___ for gastrointestinal bleed. You \nunderwent an endoscopic procedure that showed a small blood \nvessel abnormality in your stomach. We suspected that a similar \nabnormality in your small bowel could be the cause of your \nbleed. We tried to verify this with the capsule endoscopy, \nhowever the images were of poor quality. You may need to have \nthis capsule study repeated as an outpatient. You may require \nfurther transfusions in the future.\n\nYou also had some burning pain in her lower abdomen that was \nlikely due to a urinary tract infection. You were treated with \nantibiotics for this.\n\nYour initial blood cultures showed growth of some bacteria. \nGiven that you did not have symptoms of a bloodstream infection, \nit is likely that these were a contaminant. You were treated \nwith antibiotics while we waited for these bacterial colonies to \ngrow enough to be identified as contaminants from your skin. \n\nPlease take all your medications as prescribed and follow-up at \nyour outpatient appointments.\n\nIt was a pleasure taking care of you,\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K31811", "E440", "R569", "D62", "I150", "Z681", "N390", "E785", "I739", "I69398", "R531", "R2681", "R51", "R001", "T448X5A", "Y92230", "R109", "F1011", "Z86718", "Z87891" ]

[ "K31811: Angiodysplasia of stomach and duodenum with bleeding", "E440: Moderate protein-calorie malnutrition", "R569: Unspecified convulsions", "D62: Acute posthemorrhagic anemia", "I150: Renovascular hypertension", "Z681: Body mass index [BMI] 19.9 or less, adult", "N390: Urinary tract infection, site not specified", "E785: Hyperlipidemia, unspecified", "I739: Peripheral vascular disease, unspecified", "I69398: Other sequelae of cerebral infarction", "R531: Weakness", "R2681: Unsteadiness on feet", "R51: Headache", "R001: Bradycardia, unspecified", "T448X5A: Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R109: Unspecified abdominal pain", "F1011: Alcohol abuse, in remission", "Z86718: Personal history of other venous thrombosis and embolism", "Z87891: Personal history of nicotine dependence" ]

[ "D62", "N390", "E785", "Y92230", "Z86718", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nseizures, abdominal pain\n \nMajor Surgical or Invasive Procedure:\nmechanical intubation\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with HTN who presents with \nseizure. Around ___ on ___, daughter received a text from her \ncousin that the patient was vomiting. The patien't daughter then \ngot back from work in the morning of ___ when she found her \nmother sleeping on her R side facing opposite direction. She \nthen did a full turn out of bed and fell on the floor face \nfirst. Per the daughter, the patient had positive head strike on \nthe night stand on her way down to the floor. Daughter turned \nher over and saw pt's bottom jaw retracted and top part of mouth \nsticking out, eyes open, arms straight out stiffly. Tongue was \nstarting to come out, and pt was \"banging up against the bed.\" \nAfter ___ min, convulsions stopped, and pt developed heavy \nbreathing/snoring. Her eyes kind of cracked open but she was not \nresponsive to daughter. EMS came and brought her outside, but \nhead was flopping around as they were transporting her. When \nthey got close to ___, pt started to \"come to\" and kept \ntaking off the O2 mask. Seemed to go \"in and out\" of \nconsciousness per daughter. She would get intermittently \nagitated, pupils were dilated, and she would have episodes of \nintermittent staring where she did not seem to be registering \nthings. No further shaking. Reportedly got 2mg IV Ativan at \n___ and transferred to ___. Once she arrived at ___, the \npatient was complaining of abdominal pain. CT abd/pelvis showed \nacute pancreatitis. Patient was then intubated given her \nagitation and need for diagnostic procedures. LP was completed. \nNicardipine gtt was initated at OSH for SBP >220. She is now \nadmitted to the neuro ICU, remains intubated on nicardipine gtt \nfor further workup and management.\n\nOf note, about 1mo ago, pt was sitting with daughter's cousin. \nThere was a yell, so daughter went to go find her mother. At \nthat time, pt was sitting up with a \"deer caught in headlights \nlook.\" Cousin who witnessed the episode said that she sat \nupright, then started falling backwards and became stiff. Was \nshaking. Lasted a few seconds, then came out of it. After the \nepisode, she said she was thirsty and did not remember the \nepisode happening at all. \n \nPer son at bedside, she did have a seizure ___ years ago without \nany clear cause. She was living in ___ alone at that time. \nShe was taking a lot of Klonopin, vicodin, and Percocet along \nwith antidepressants, so unclear if this was a trigger. He does \nnot know any further information about the seizure. Also unclear \nif she ever had strokes before. She had fallen ___ months ago in \n___, but son does not think she had any brain hemorrhages \nfrom that. She came back to ___ about 5 months ago to live \nwith her daughter. Since that time, she has only been taking \nlisinopril. No other pain medications. Patient's daughter \ndenies any further drug use over the past 5 months.\n\n \nPast Medical History:\nHTN, DVTs\n-internal bleed from small intestine \n- tubes tied \n- plantar wart removed \n- procedure in groin \n- colonoscopies \n \nSocial History:\n___\nFamily History:\nno history of seizures or strokes \n \nPhysical Exam:\n===ADMISSION EXAM===\nGeneral: agitated, refusing to participate in exam\nHEENT: contusions on forehead with a few scrapes\n___: tachycardic\nPulmonary: breathing comfortably on RA\nAbdomen: Soft, NT, ND\nExtremities: Warm, no edema\nNeurologic Examination:\n- Mental status: awake, agitated, oriented to ___ and ___. Able to name \"thumb\" and \"watch\" and \"green.\" Speech is\nclear and not dysarthric. No gibberish.\n- Cranial Nerves: PERRL 6->5mm brisk. BTT bilaterally. Face\nappears symmetric. Looks around the room fully. Unable to \nperform\nmore dedicated CN exam ___ pt's agitation \n- Motor: moves all extremities spontaneously and equally\n- Reflexes: unable to obtain, pt moving too much and is not\nrelaxing\n- Sensory: withdraws to light touch in all extremities\n- Coordination: no ataxia when reaching for bed rails or trying\nto pull out foley catheter\n- Gait: unable to assess\n\nDISCHARGE EXAM\nVS: 98.8 PO 100 / 56 53 18 97 RA\nGENERAL: Pleasant elderly woman, sitting up in bed, appears\ncomfortable in no acute distress. Persistent paranoid delusions.\nHEENT: Sclerae anicteric, EOMI, moist mucous membranes\nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, or\nrhonchi. Good inspiratory effort.\nHEART: Regular rate and rhythm, normal S1 and S2, no murmurs,\nrubs, gallops, or thrills\nABDOMEN: Normal bowel sounds. Soft, non-distended. Mild\nimproving tenderness and hyperesthesia around lap port incision\nsites. No organomegaly. No rebound tenderness or guarding.\nEXTREMITIES: Warm and well perfused. No clubbing, cyanosis, or\nlower extremity edema.\nNEURO: A&Ox3, moving all 4 extremities with purpose\n \nPertinent Results:\nADMISSION LABS\n___ 12:00PM BLOOD WBC-15.7* RBC-5.35* Hgb-16.2* Hct-48.4* \nMCV-91 MCH-30.3 MCHC-33.5 RDW-13.6 RDWSD-45.3 Plt ___\n___ 12:00PM BLOOD Neuts-91.3* Lymphs-3.8* Monos-4.1* \nEos-0.1* Baso-0.2 Im ___ AbsNeut-14.36* AbsLymp-0.59* \nAbsMono-0.65 AbsEos-0.01* AbsBaso-0.03\n___ 12:00PM BLOOD ___ PTT-29.7 ___\n___ 12:00PM BLOOD Glucose-228* UreaN-13 Creat-1.3* Na-132* \nK-8.4* Cl-93* HCO3-21* AnGap-18*\n___ 06:30PM BLOOD ALT-523* AST-333* AlkPhos-252* \nTotBili-1.7*\n___ 06:30PM BLOOD Lipase-1222*\n___ 06:30PM BLOOD Calcium-9.6 Phos-2.7 Mg-1.7\n___ 12:00PM BLOOD Osmolal-287\n___ 12:00PM BLOOD TSH-3.5\n___ 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 12:11PM BLOOD Lactate-3.4* K-4.5\n\nPERTINENT LABS\n___ 01:55PM BLOOD Lactate-1.1\n___ 01:45PM BLOOD WBC-10.5* RBC-3.25* Hgb-9.8* Hct-30.3* \nMCV-93 MCH-30.2 MCHC-32.3 RDW-14.4 RDWSD-49.2* Plt ___\n___ 05:25AM BLOOD WBC-7.0 RBC-3.04* Hgb-9.1* Hct-28.1* \nMCV-92 MCH-29.9 MCHC-32.4 RDW-14.3 RDWSD-48.3* Plt ___\n___ 04:45PM BLOOD Glucose-93 UreaN-5* Creat-0.7 Na-139 \nK-3.6 Cl-100 HCO3-24 AnGap-15\n___ 09:45AM BLOOD Glucose-144* UreaN-8 Creat-0.9 Na-138 \nK-3.7 Cl-100 HCO3-22 AnGap-16\n___ 01:36AM BLOOD ALT-177* AST-50* AlkPhos-110* \nAmylase-149* TotBili-0.6\n___ 02:32AM BLOOD ALT-139* AST-38 AlkPhos-131* Amylase-302* \nTotBili-0.9\n___ 03:58AM BLOOD Lipase-442*\n___ 01:36AM BLOOD Lipase-67*\n___ 02:32AM BLOOD Lipase-40\n\nDISCHARGE LABS\n___ 05:41AM BLOOD WBC-7.0 RBC-2.81* Hgb-8.7* Hct-26.8* \nMCV-95 MCH-31.0 MCHC-32.5 RDW-14.0 RDWSD-48.2* Plt ___\n___ 05:41AM BLOOD Glucose-98 UreaN-7 Creat-0.9 Na-140 K-4.4 \nCl-101 HCO3-28 AnGap-11\n\nIMAGING/STUDIES\nCT A/P: ___- 1. Mild to moderate intra and extrahepatic \nbiliary ductal dilatation with\nprobable calculus in the distal common bile duct indicative of \ncholedocholithiasis. If needed, MRCP can provide further \nconfirmation and assessment.\n2. Edematous pancreas with peripancreatic fat stranding and \nfluid most suggestive of acute interstitial edematous \npancreatitis. In the setting of probable choledocholithiasis, \nconstellation of findings likely indicate gallstone \npancreatitis. Correlation with serum amylase and lipase levels \nare\nrecommended.\n3. Cholelithiasis. Pericholecystic fluid and stranding may be \nsecondary to pancreatitis.\n4. Extensive atherosclerotic disease with severe stenosis of the \nSMA and right renal artery with resultant atrophy of the right \nkidney.\n5. Bilateral nodular adrenal glands which are incompletely \ncharacterized.\n6. 0.5 cm pulmonary nodule in the right upper lobe. Please see \nrecommendations section.\n\nMRI Brain w/ and w/o: ___: 1. Motion limited exam.\n2. No evidence for acute infarction.\n3. Nonmasslike FLAIR signal abnormality within the right \nposteriorperiventricular white matter, with discontiguous foci \nof cystic encephalomalacia and no evidence for blood products. \nThese may represent sequela of prior infarction, demyelination, \ninfection, or other insult.\n4. Small chronic infarcts in the left cerebellar hemisphere. \nPunctate cortical FLAIR hyperintensity in the right frontal lobe \nmay also represent a chronic infarct.\n5. Small area of FLAIR hyperintensity and contrast enhancement \nin the right occipital cortex, with associated chronic blood \nproducts, and with questionable involvement of the adjacent \nsulci. This may represent a chronic infarct with hemorrhagic \ntransformation or sequela of amyloid angiopathy.\n6. Small chronic microhemorrhage in the right posterior internal \ncapsule, most likely hypertensive.\n7. 6 mm round structure in the region of the left petroclival \nconfluence, with diagnostic considerations including a \ncholesterol granuloma, another type of lesion, or an aberrant \nblood vessel. Partial left mastoid air cell opacification.\n \nBrief Hospital Course:\n================\nPATIENT SUMMARY:\n================\n___ year old woman who presented with generalized tonic-clonic \nseizure in the setting of gallstone pancreatitis who was found \nto have right side renal artery stenosis. Seizures were \ncontrolled with keppra and patient underwent cholecystectomy and \npatients blood pressure was well controlled with medical \nmanagement.\n\n=============\nACUTE ISSUES:\n=============\n\n#Generalized tonic clonic seizures: \nPatient presented after a witnessed generalized tonic-clonic \nseizures. She presented to the emergency room and seizures were \ninitially controlled with ativan in the emergency room. \nNeurology followed the patient during this hospitalization for \nworkup of seizures. Patient was found to have gallstone induced \npancreatitis which is believed to have caused seizures in a \npatient with underlying susceptibility given history of CVA. She \nunderwent cholecystectomy. Infectious workup was negative. LP \nwas preformed which was bland. MRI demonstrated existing \ninfarcts, but no evidence of acute infarction or intracranial \nprocess. The patient was maintained on Keppra 1500 BID and had \nno further seizures during hospitalization. Neurology recommends \nthat the patient continue keppra 1500 BID indefinitely until \npotential modification by outpatient neurology in 6 months. If \nthere is concern for mild encephalopathy and gait unsteadiness, \nKeppra could be decreased to 1250 mg twice daily prior to \nfollow-up. She was started on atorvastatin and aspirin for \nprimary prevention of CVA. \n\n#Renal artery stenosis:\nPatient was found to have right sided renal artery stenosis on \nCT during hospitalization. Systolic blood pressure were \ninitially 170 systolic. Her blood pressure was controlled with \nnicardipine drip. Vascular surgery evaluated the patient and \nrecommended no surgical intervention. She was medically managed \nwith oral antihypertensive regime and blood pressure was \nsuccessfully controlled to the 100-160s systolic. she should \ncontinue lisinopril, amlodapine and labetalol as an outpatient.\n\n#Gallstone pancreatitis \nPatient was found to have choledocolithiasis induced \npancreatitis. She underwent cholecystectomy and had an \nuneventful postoperative course. Pain was well controlled with \noral oxycodone in the postoperative period. The patient will \nfollow with acute care surgery two weeks after discharge.\n\n===============\nCHRONIC ISSUES:\n===============\n#GERD: Home famotidine was continued\n\n====================\nTRANSITIONAL ISSUES:\n====================\n[ ] Please recheck patient blood pressure and adjust blood \npressure medications accordingly as an outpatient\n[ ] Neurology recommends that the patient continue keppra 1500 \nBID indefinitely until potential modification by outpatient \nneurology in 6 months. If there is concern for mild \nencephalopathy and gait unsteadiness, Keppra could be decreased \nto 1250 mg twice daily prior to follow-up. She was started on \natorvastatin and aspirin for primary prevention of CVA. \n[ ] Follow up with surgery for post-operative check after \ncholecystectomy\n[ ] Follow up with new PCP to establish care and also for \ncardiology referral for her known peripheral vascular disease \nfor which she was on aspirin and Plavix, but were stopped for GI \nbleeding in ___.\n[ ] given recent seizure, patient should not drive until cleared \nby her Neurologist\n\nFULL CODE\nHCP daughter ___ ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 20 mg PO BID \n2. Famotidine 20 mg PO BID \n3. Acetaminophen 500 mg PO Q12H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. amLODIPine 10 mg PO DAILY hypertension \nRX *amlodipine [Norvasc] 10 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n3. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n4. Labetalol 400 mg PO BID Hypertension \nRX *labetalol 200 mg 2 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n5. LevETIRAcetam 1500 mg PO Q12H \nRX *levetiracetam 1,000 mg 1.5 tablet(s) by mouth every twelve \n(12) hours Disp #*90 Tablet Refills:*0 \n6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe \n\nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*8 Tablet Refills:*0 \n7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n8. Lisinopril 40 mg PO DAILY \nRX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n9. Famotidine 20 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n=================\nPrimary diagnosis\n=================\nGeneralized tonic-Clonic Seizures\ncholecystitis\n===================\nSecondary diagnosis\n===================\nRight Renal Artery Stenosis\nHypertension\nGallstone Pancreatitis\nEncephalopathy \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDISCHARGE WORKSHEET INSTRUCTIONS:\n\nDear Ms. ___,\n\nIt was a pleasure caring for you at ___ \n___!\n\nWHY WERE YOU ADMITTED?\nYou were admitted to the hospital because you had seizures.\n\nWHAT HAPPENED IN THE HOSPITAL?\nYour seizures were controlled with medication. You were found to \nhave abdominal pain caused by inflammation in your gallbladder \nand pancreas. Your gallbladder was removed and this helped the \ninflammation. We think that your seizures were caused by the \ninflammation in your gallbladder and pancreas. You were also \nfound to have hypertension caused by a partial blockage to the \nartery for your right kidney. You were started on new \nmedications to treat your blood pressure and your blood pressure \nimproved.\n\nWHAT SHOULD YOU DO AT HOME?\nYou should continue the new medications for your seizures and \nblood pressure and follow up with the surgeons and neurologist \nat your next scheduled appointment. You also have a primary care \nphysician appointment scheduled for you to follow up and \nestablish care. You will have to discuss with the new PCP about \ncardiologist referral for your peripheral vascular disease that \nwas treated with aspirin, Plavix, and procedures in your lower \nextremity arteries in ___ last year. As you know, your \nPlavix was stopped due to GI bleeding that occurred in ___ \nlast year. You need a new cardiologist to continue to manage \nyour antiplatelet agents.\n\nBecause you had a seizure, please do not drive a car until you \nare cleared by your Neurologist. \n\nPlease work on switching your insurance to ___ so that \nyou can continue to get care here. \n\nThank you for allowing us be involved in your care, we wish you \nall the best!\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "G40409", "K8510", "G9340", "K8064", "E871", "I701", "I10", "I160", "K219", "I739", "E785", "F17210", "Z95820", "Z86718", "Z8673" ]

[ "G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus", "K8510: Biliary acute pancreatitis without necrosis or infection", "G9340: Encephalopathy, unspecified", "K8064: Calculus of gallbladder and bile duct with chronic cholecystitis without obstruction", "E871: Hypo-osmolality and hyponatremia", "I701: Atherosclerosis of renal artery", "I10: Essential (primary) hypertension", "I160: Hypertensive urgency", "K219: Gastro-esophageal reflux disease without esophagitis", "I739: Peripheral vascular disease, unspecified", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z95820: Peripheral vascular angioplasty status with implants and grafts", "Z86718: Personal history of other venous thrombosis and embolism", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "E871", "I10", "K219", "E785", "F17210", "Z86718", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPercocet\n \nAttending: ___.\n \nChief Complaint:\nRight leg/foot pain\n \nMajor Surgical or Invasive Procedure:\n___ Right lower extremity angiogram, angioJet mechanical \nthrombectomy of occluded bypass graft, balloon angioplasty of \noutflow stenosis. \n___ Right lower extremity angiogram, angioJet mechanical \nthrombectomy of occluded bypass graft, balloon angioplasty of \noutflow stenosis. \n\n \nHistory of Present Illness:\n___ w Rt AK pop to ___ bypass with NRGSV for a thrombosed \npopliteal aneurysm in ___ present with worsening new onset \nright foot claudication. \n \nPast Medical History:\nPMH: DVT R pop v (___), asthma, Rt pop artery thrombus with \nnegative hypercoagulable workup \n \nPSH: Rt AK pop to ___ bypass with NRGSV ___ \n\n \nPhysical Exam:\nPhysical Exam:\nAlert and oriented x 3 \nVS:BP 104/54 HR 72 RR 16\nResp: Lungs clear\nAbd: Soft, non tender\nExt: Pulses: palp throughout. \nFeet warm, well perfused. No open areas\nLeft groin puncture site: Dressing clean dry and intact. Soft, \nno hematoma or ecchymosis.\n \n\n \nPertinent Results:\n___ 05:45AM BLOOD WBC-9.0 RBC-3.91 Hgb-11.5 Hct-34.2 MCV-88 \nMCH-29.4 MCHC-33.6 RDW-12.9 RDWSD-40.8 Plt ___\n___ 05:45AM BLOOD Plt ___\n___ 05:45AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-141 \nK-3.7 Cl-107 HCO3-26 AnGap-12\n___ 05:45AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.0\n\nArterial Duplex:\nFindings. Doppler evaluation was performed of both lower \nextremity arterial \nsystems at rest. \nOn the right the tibial waveforms are monophasic and there is no \naudible \nWaveforms are flat. \nThe left all waveforms are triphasic. The ankle-brachial index \nis 1.3. \nImpression severe ischemia right lower extremity \n\n \nBrief Hospital Course:\n___ sp Rt AK pop to ___ bypass with NRGSV ___ for arterial \nthrombosis presents with worsening right leg pain that occurred \nover predictable distances and acute change over past 24 hours \nwith fullness in her right leg. Her motor and\nsensation are intact with no signs of limb threat. A heparin \ninfusion was started.\n\nArterial duplex showed occluded right popliteal to posterior \ntibial artery bypass. She was taken to the OR for right lower \nextremity angiogram, angioJet mechanical \nthrombectomy of occluded bypass graft, balloon angioplasty of \noutflow stenosis. A tpa catheter was left in place overnight. \nShe return the next day for right lower extremity angiogram, \nangioJet mechanical thrombectomy of occluded bypass graft and \nballoon angioplasty of outflow stenosis. At that session, we \nwere able to remove residual thrombus in the native right \npopliteal artery and bypass with good outflow to the foot via \nthe anterior tibial, and peroneal arteries. At this point she \nwas pain free with a palpable graft AT and DP pulse. \n\nThe next morning, we discontinued the heparin infusion and \nstarted xarelto. She was ambulatory ad lib, voiding qs and \ntolerating a regular diet. She was discharged to home. We will \nsee her again in followup in one month with surveillance duplex.\n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clobetasol Propionate 0.05% Soln 1 Appl TP BID \n2. Fluocinolone Acetonide 0.01% Solution 1 Appl TP Q24H PRN \n3. metroNIDAZOLE 0.75 topical BID \n4. ALPRAZolam 0.5 mg PO TID:PRN anxiety \n5. Lovastatin 10 mg ORAL DAILY \n6. Montelukast 10 mg PO DAILY \n7. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY \n8. Pantoprazole 40 mg PO Q24H \n9. Aspirin 81 mg PO DAILY \n10. Loratadine 10 mg PO BID \n\n \nDischarge Medications:\n1. Rivaroxaban 15 mg PO/NG BID \nFOR THE NEXT 3 WEEKS ONLY. \nRX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice daily \nDisp #*42 Tablet Refills:*0\n2. Clopidogrel 75 mg PO DAILY \nFor the next ___ days. \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n3. metroNIDAZOLE 0.75 topical BID \n4. Fluocinolone Acetonide 0.01% Solution 1 Appl TP Q24H PRN \n5. Clobetasol Propionate 0.05% Soln 1 Appl TP BID \n6. ALPRAZolam 0.5 mg PO TID:PRN anxiety \n7. Aspirin 81 mg PO DAILY \n8. Fluticasone-Salmeterol Diskus (500/50) 2 INH IH DAILY \n9. Loratadine 10 mg PO BID \n10. Montelukast 10 mg PO DAILY \n11. Pantoprazole 40 mg PO Q24H \n12. Rivaroxaban 20 mg PO DAILY \nStart ___ after loading dose of 15 mg twice daily. \nRX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*3\n13. Lovastatin 10 mg ORAL DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPeripheral Arterial Disease\nRight Posterior Tibial Deep Vein Thrombosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\nIt was a pleasure taking care of you at ___ \n___. You were admitted to the hospital with right \nleg pain that we found was secondary to a blockage in your \nbypass graft. We also noted a clot in a vein in your calf. We \ndid a peripheral angiogram to open up the graft with special \ncatheter and balloons. To do the procedure, a small puncture \nwas made in one of your arteries. The puncture site heals on \nits own: there are no stitches to remove. You tolerated the \nprocedure well and are now ready to be discharged from the \nhospital. Please follow the recommendations below to ensure a \nspeedy and uneventful recovery.\n\nPeripheral Angiography\nPuncture Site Care\nFor one week:\n•Do not take a tub bath, go swimming or use a Jacuzzi or hot \ntub.\n•Use only mild soap and water to gently clean the area around \nthe puncture site. \n•Gently pat the puncture site dry after showering. \n•Do not use powders, lotions, or ointments in the area of the \npuncture site. \n\nYou may remove the bandage and shower the day after the \nprocedure. You may leave the bandage off. \nYou may have a small bruise around the puncture site. This is \nnormal and will go away one-two weeks. \nActivity \nFor the first 48 hours: \n•Do not drive for 48 hours after the procedure\nFor the first week:\n•Do not lift, push , pull or carry anything heavier than 10 \npounds\n•Do not do any exercises or activity that causes you to hold \nyour breath or bear down with abdominal muscles. Take care not \nto put strain on your abdominal muscles when coughing, sneezing, \nor moving your bowels.\nAfter one week:\n•You may go back to all your regular activities, including \nsexual activity. We suggest you begin your exercise program at \nhalf of your usual routine for the first few days. You may \nthen gradually work back to your full routine.\nMedications:\nBefore you leave the hospital, you will be given a list of all \nthe medicine you should take at home. If a medication that you \nnormally take is not on the list or a medication that you do not \ntake is on the list please discuss it with the team! \n\n \nFollowup Instructions:\n___\n" ]

[ "T82868A", "I82441", "Y832", "Y92009", "I70411", "Z86718", "J45909" ]

[ "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "I82441: Acute embolism and thrombosis of right tibial vein", "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", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "I70411: Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, right leg", "Z86718: Personal history of other venous thrombosis and embolism", "J45909: Unspecified asthma, uncomplicated" ]

[ "Z86718", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Haldol\n \nAttending: ___\n \n___ Complaint:\ns/p cardiac arrest \n \nMajor Surgical or Invasive Procedure:\nchest thoracostomy tube placement\nintubation \ncentral venous catheter placement\n \nHistory of Present Illness:\n___ with PMHx significant for schizophrenia, hypertension and \nanemia who p/w from nursing home with cardiac arrest.\n\nPer EMS, he choked while sitting in his chair eating, found \nslumped over in chair without e/o trauma, turned blue. Found \ncyanotic without pulses. Heimelich productive of large food \nbolus. ROSC ___ s/p CPR and epi x2 and intubated w/ IO placed. \nIn ___, became bradycardic transitioning to Asystole \n1330. Given Epi, further CPR, obtained ROSC. His SBP of ___, \nstarted on levo. \n\nIn ED initial VS: T 34.9 HR 83 BP 111/63 RR 14 100% ra\n\nExam: Tube in place, some secretions suctioned, No e/o trauma or \nprolonged down time, Psoriatic plaques, 2mm minimally responsive \npupils, Unresponsive, No spontaneous limb movements\nLabs were notable for: wbc 16.1, hgb 12.4, plt 635, Na 134, K \n4.2, cr 0.3, TnT 0.47, AP 164, normal ALT/AST, INR 1.4, ABG \n___, lactate 2.6->1.3\n\nImaging notable for: NCCTH w/o hemorrhage, CXR w/ possible LLL \nPNA. \n\nEKG 88 NS NA No STTW changes concerning for ischemia\n\nPatient was given: RIJ placed, given rocuronium 80 mg, \nnorepinephrine gtt, midazolam gtt, fentanyl gtt\n\nConsults: Post-arrest response team recommended TTM at 35 \ndegrees for 24 hours w/ EEG in ICU. TTM was initiated. He \ndeveloped a CTX after the RIJ was placed that required chest \ntube placement.\n\nVS prior to transfer: T 34.9 HR 87 BP 137/76 RR 20 99% RA \n\nOn arrival to the MICU: Patient is intubated and sedated, chest \ntube in place.\n\n \nPast Medical History:\nBasal cell carcinoma\nSchizophrenia\nAnemia\nCataracts\nConstipation\nHyponatremia\nTobacco abuse\nOsteoporosis\nPsoriasis\nActinic keratosis\nDupuytrens\nSquamous cell carcinoma\nHypertension\nAllergic rhinitis\n \nSocial History:\n___\nFamily History:\nMother: deceased, old age\nFather: prostate cancer\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM \n============================\nVITALS: Reviewed in metavision.\nGENERAL: Intubated and sedated\nHEENT: Sclera anicteric, PERRLA, ETT in place\nNECK: supple, right CVL\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: Cool, well perfused, 2+ pulses, no edema \nSKIN: Artic sun in place\n \nPertinent Results:\nLABS ON ADMISSION \n==========================\n___ 06:38PM TYPE-CENTRAL VE PO2-40* PCO2-31* PH-7.45 \nTOTAL CO2-22 BASE XS-0\n___ 06:38PM LACTATE-1.5\n___ 06:38PM O2 SAT-72\n___ 06:10PM GLUCOSE-182* UREA N-13 CREAT-0.3* SODIUM-134 \nPOTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-20* ANION GAP-17*\n___ 06:10PM ALT(SGPT)-14 AST(SGOT)-31 CK(CPK)-279 ALK \nPHOS-164* TOT BILI-0.6\n___ 06:10PM ALBUMIN-3.0* CALCIUM-8.5 PHOSPHATE-2.8\n___ 06:10PM NEUTS-86.9* LYMPHS-5.1* MONOS-6.7 EOS-0.1* \nBASOS-0.2 IM ___ AbsNeut-14.01* AbsLymp-0.83* \nAbsMono-1.08* AbsEos-0.01* AbsBaso-0.04\n___ 06:10PM ___ PTT-29.3 ___\n\nPERTIENT LABS \n===============\nTrops \n___ 06:10PM BLOOD cTropnT-0.47*\n___ 12:30AM BLOOD CK-MB-41* MB Indx-13.4* cTropnT-0.41*\n___ 07:32AM BLOOD CK-MB-29* MB Indx-12.0* cTropnT-0.30*\n___ 02:29PM BLOOD CK-MB-27* MB Indx-13.6* cTropnT-0.22*\n\nMICRO\n===========\nBCx ___ pending \n\nGRAM STAIN (Final ___: \n>25 PMNs and >10 epithelial cells/100X field. \n\n___ MRSA SCREEN (Final ___: No MRSA isolated.\n\nIMAGING\n==================\n\n___ MRI Head \nDiffusion abnormalities along the cortex of both cerebral \nhemispheres predominantly in the parieto-occipital lobes are \nsuggestive of early ischemic brain injury. \n\n___ LENIs \n1. Limited examination, but no evidence of deep vein thrombosis \nin the right upper extremity. \n2. Probable hematoma in the upper inner arm as described. \nCorrelate with \nphysical examination for chronicity, and advise clinical \nfollow-up to ensure resolution over time. \n\n___ TTE \nThe left atrial volume index is normal. Normal left ventricular \nwall thickness, cavity size, and regional/global systolic \nfunction (biplane LVEF = 64 %). Tissue Doppler imaging suggests \na normal left ventricular filling pressure (PCWP<12mmHg). Right \nventricular chamber size and free wall motion are normal. The \ndiameters of aorta at the sinus, ascending and arch levels are \nnormal. The aortic valve leaflets (?#) appear structurally \nnormal with good leaflet excursion. There is no aortic valve \nstenosis. No aortic regurgitation is seen. The mitral valve \nappears structurally normal with trivial mitral regurgitation. \nThe estimated pulmonary artery systolic pressure is high normal. \nThere is no pericardial effusion. \n\n IMPRESSION: Normal biventricular cavity sizes with preserved \nregional and global biventricular systolic function. No valvular \npathology or pathologic flow identified. No pericardial \neffusion. \n\n___ EEG \nThis is an abnormal ICU continuous video EEG monitoring study \ndue to the presence of a burst suppression pattern, indicative \nof a severe ecphalopathy. By the late afternoon, overall \namplitudes began to diminish, and more prolonged background \nattenuation was seen, with plentiful artifact. By the end of the \nrecording, definitive activity of cerebral origin was not \nclearly seen. These findings are indicative of worsening of the \nsevere encephalopathy, which could be related to medication \neffects, toxic/metabolic disturbances or progression of \nneurologic injury. There were no clear epileptiform discharges \nor electrographic seizures in this recording. \n\n___ Shoulder ___ views \nDisplaced humeral head fracture corresponding to given history, \nwith exact relation of fracture fragments difficult to identify \ngiven limited included two views. \n\n___ CXR \nAP portable supine view of the chest. The endotracheal tube is \npositioned with its tip 3.8 cm above the carina. There is a \nvague opacity in the right lower lung which could reflect a \nfocus of pneumonia though attention on followup advised. There \nis mild retrocardiac opacity likely atelectasis. No large \neffusion or pneumothorax is seen. The cardiomediastinal \nsilhouette appears grossly unremarkable. There is a \ndextroscoliotic curvature of the thoracic spine. No acute bony \nabnormalities. \n \n\n \nBrief Hospital Course:\nMr ___ was admitted to the MICU at ___ for post-cardiac \narrest management. He received 5 rounds of CPR prior to ROSC. \nUnfortunately, despite obtaining ROSC, he suffered a devastating \nbrain injury likely ___ anoxia. This was confirmed on MRI as \nwell as with consult from the neurology team. After speaking \nwith his HCP, we agreed to progress to CMO. He was extubated and \nexpired on ___. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO DAILY \n2. Calcium Carbonate 500 mg PO BID \n3. Citalopram 10 mg PO DAILY \n4. Apixaban 5 mg PO BID \n5. OLANZapine 20 mg PO DAILY \n6. Divalproex (DELayed Release) 500 mg PO TID \n7. Ketoconazole Shampoo 1 Appl TP ASDIR \n8. Docusate Sodium 100 mg PO DAILY \n9. Hydrocortisone Cream 2.5% 1 Appl TP BID \n\n \nDischarge Medications:\nExpired \n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nExpired\n \nDischarge Condition:\nExpired\n \nDischarge Instructions:\nN/A\n \nFollowup Instructions:\n___\n" ]

[ "J690", "G931", "I82621", "Z8674", "J95811", "I959", "J9600", "I10", "D638", "Y848", "Y92238", "Z66", "Z515", "Z781", "F209", "S42291D", "W1830XD", "Z9181", "Z85828", "H269", "Z720", "L409", "M810", "L570", "M720", "J309", "F1021", "Z7902", "H6120" ]

[ "J690: Pneumonitis due to inhalation of food and vomit", "G931: Anoxic brain damage, not elsewhere classified", "I82621: Acute embolism and thrombosis of deep veins of right upper extremity", "Z8674: Personal history of sudden cardiac arrest", "J95811: Postprocedural pneumothorax", "I959: Hypotension, unspecified", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "I10: Essential (primary) hypertension", "D638: Anemia in other chronic diseases classified elsewhere", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92238: Other place in hospital as the place of occurrence of the external cause", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z781: Physical restraint status", "F209: Schizophrenia, unspecified", "S42291D: Other displaced fracture of upper end of right humerus, subsequent encounter for fracture with routine healing", "W1830XD: Fall on same level, unspecified, subsequent encounter", "Z9181: History of falling", "Z85828: Personal history of other malignant neoplasm of skin", "H269: Unspecified cataract", "Z720: Tobacco use", "L409: Psoriasis, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "L570: Actinic keratosis", "M720: Palmar fascial fibromatosis [Dupuytren]", "J309: Allergic rhinitis, unspecified", "F1021: Alcohol dependence, in remission", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "H6120: Impacted cerumen, unspecified ear" ]

[ "I10", "Z66", "Z515", "Z7902" ]

[]

[ " \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\n \nMajor Surgical or Invasive Procedure:\n___\nUrgent coronary artery bypass graft x3, left internal\n mammary artery to left anterior descending artery,\n saphenous vein graft to diagonal and distal right\n coronary arteries.\n2. Endoscopic harvesting of long saphenous vein.\n\n \nHistory of Present Illness:\n___ old male hx of CAD, underwent PCI ___ ago BMS to left circ\nand balloon angioplasty to diagonal branch. At that time was \nnote\nto have RCA and LAD disease. He reports that over the past few\nmonths he has been having worsening chest discomfort, described\nas burning sensation mid chest that radiates down both arms. He\nhas pain with exertion, relieved with rest. Yesterday he\ndeveloped chest pain and took SL nitro,pain reslved. He was seen\nby his PCP today who referred him to ___. His EKG was\nunremarkable, troponin 0.22. He underwent cardiac cath today\nwhich revealed significant multivessel disease. He was\ntransferred to ___ for CABG evaluation. \n\n \nPast Medical History:\nPast Medical History:\nCAD,\nHTN,\nHypercholesterolemia\nPast Surgical History:\nPCI ___\ns/p T+A\n\n \nSocial History:\n___\nFamily History:\nunremarkable\n\n \nPhysical Exam:\n___:\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [] grade ______ \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+[x]\n\nExtremities: Warm [x] well-perfused [x] Edema [] _____\nVaricosities: None [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: 2+ Left: 2+\nDP Right: 1+ Left: 1+\n___ Right: 1+ Left: 1+\nRadial Right: cath site Left: 2+\n\nCarotid Bruit: Right: no Left: no\n\n \nPertinent Results:\nCardiac Catheterization: Date: ___ Place: ___\nLM 90% stenosis\nLAD ___ 90% stenosis\nCirc: 100% stenosis, existing stent unknown, instent stenosis, \nno\nthrombosis\nRCA: mid ___ 60% stenosis, mid 70%\n\nLeft heart cath revealed: EF 65% grade 2 MR, aortic valve Ok\nCardiac Echocardiogram:\n\n___ ECHOCARDIOGRAPHY REPORT\n\n___ ___ MRN: ___ TEE \n(Complete) Done ___ at 9:24:37 AM FINAL \nReferring Physician ___ \n___ of Cardiothoracic Surg\n___ ___\n___ Status: Inpatient DOB: ___ \nAge (years): ___ M Hgt (in): 70 \nBP (mm Hg): 127/60 Wgt (lb): 143 \nHR (bpm): 68 BSA (m2): 1.81 m2 \nIndication: Intraoperative TEE for CABG \nDiagnosis: I25.9, I34.0 \n___ Information \nDate/Time: ___ at 09:24 ___ MD: ___, \nMD \n___ Type: TEE (Complete) Sonographer: ___, MD \nDoppler: Full Doppler and color Doppler ___ Location: \nAnesthesia West OR cardiac \nContrast: None Tech Quality: Adequate \n Machine: \nEchocardiographic Measurements \n\nResults \n\nMeasurements \n\nNormal Range \n\nLeft Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm \n \nLeft Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 \ncm \nLeft Ventricle - Ejection Fraction: 60% to 65% >= 55% \n \nFindings \nLEFT ATRIUM: Dilated LA. \n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. \n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and \nglobal systolic function (LVEF>55%). Normal regional LV systolic \nfunction. \n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. \n\nAORTA: Normal ascending aorta diameter. Normal aortic arch \ndiameter. Focal calcifications in aortic arch. Normal descending \naorta diameter. Simple atheroma in descending aorta. Focal \ncalcifications in descending aorta. \n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. \n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. \n___ (1+) MR. \n\n___ VALVE: Normal tricuspid valve leaflets with trivial \nTR. No TS. \n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. \nNo PS. Physiologic PR. \n\nPERICARDIUM: Very small pericardial effusion. \n\n___ COMMENTS: Written informed consent was obtained from the \n___. The ___ was under ___ anesthesia throughout the \nprocedure. No TEE related complications. The ___ appears to \nbe in sinus rhythm. Results were personally reviewed with the MD \ncaring for the ___. See Conclusions for post-bypass data \nConclusions \nPRE-BYPASS: \n\n The left atrium is dilated. The right atrium is dilated. Left \nventricular wall thickness, cavity size, and global systolic \nfunction are normal (LVEF>55%). Regional left ventricular wall \nmotion is normal. Right ventricular chamber size and free wall \nmotion are normal. The aortic valve leaflets (3) appear \nstructurally normal with good leaflet excursion and no aortic \nstenosis or aortic regurgitation. The mitral valve leaflets are \nmildly thickened. There is billowing of the anterior mitral \nleaflet. Mild (1+) mitral regurgitation is seen. Trace tricuspid \nregurgitation is seen. There is a very small pericardial \neffusion. \n\n POST-BYPASS: \n\n The ___ is in sinus rhythm and receiving a phenylephrine \ninfusion.\n Biventricular function remains preserved. There are no regional \nwall motion abnormalities.\n Valvular function is unchanged.\n The thoracic aorta is intact following decannulation.\n\n \nBrief Hospital Course:\nMr. ___ was transferred to ___ on ___. On ___ he \nunderwent a coronary artery bypass grafting times three. Please \nsee operative note for full details. He tolerated the procedure \nwell and was transferred to the CVICU in stable condition for \nrecovery and invasive monitoring. He was weaned from sedation, \nawoke neurologically intact, and was extubated on post-operative \nday one. He weaned from inotropic and vasopressor support. Beta \nblocker was initiated and he was diuresed toward his \npreoperative weight. Mr. ___ remained hemodynamically \nstable and was transferred to the telemetry floor for further \nrecovery. Chest tubes and epicardial wires were removed per \nprotocol. He was evaluated by the physical therapy service for \nassistance with strength and mobility. On the evening of \npost-operative day two he had about two hours of atrial \nfibrillation and therefore was placed on oral amiodarone. His \nbeta blockade was up-titrated as tolerated. By the time of \ndischarge on post-operative day four he was ambulating freely, \nhis wounds were healing well, and his pain was controlled with \noral analgesics. He was discharged to home in good condition \nwith appropriate follow up instructions.\n\n \nMedications on Admission:\nASA 81mg daily\natenolol 25mg daily\natorvastatin 80mg daily \n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO/PR QID:PRN pain or temperature \n>38.0 \n2. Amiodarone 200 mg PO BID \ntake 200mg twice daily for one week, then decrease to 200mg \ndaily ongoing \nRX *amiodarone 200 mg one tablet(s) by mouth twice daily Disp \n#*120 Tablet Refills:*2 \n3. Metoprolol Succinate XL 150 mg PO DAILY \nRX *metoprolol succinate 50 mg three tablet(s) by mouth daily \nDisp #*90 Tablet Refills:*2 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp \n#*40 Tablet Refills:*0 \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary Artery Disease\nHypertension\nHTN,\nHypercholesterolemia\n\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 \nLeg Right/Left - healing well, no erythema or drainage. \nEdema trace\n\n \nDischarge Instructions:\n Please shower daily including washing incisions gently with \nmild soap, no baths or swimming until cleared by surgeon. Look \nat your incisions daily for redness or drainage\nPlease NO lotions, cream, powder, or ointments to incisions \n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the 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 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\n \nFollowup Instructions:\n___\n" ]

[ "I2510", "I959", "I4891", "D649", "I10", "E7800", "Z955", "Z87891", "R0902" ]

[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I959: Hypotension, unspecified", "I4891: Unspecified atrial fibrillation", "D649: Anemia, unspecified", "I10: Essential (primary) hypertension", "E7800: Pure hypercholesterolemia, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "Z87891: Personal history of nicotine dependence", "R0902: Hypoxemia" ]

[ "I2510", "I4891", "D649", "I10", "Z955", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nMalignant transformation of endometriosis - final pathology \nreport pending.\n \nMajor Surgical or Invasive Procedure:\nexploratory laparotomy, total abdominal hysterectomy, left \nsalingo-oophrectomy, omentectomy, para-aortic lymph node biopsy, \nliver resection, cystoscopy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ G0 with a history of fibroids and\nendometriosis who presents today for consultation regarding a\nlarge left adnexal mass identified on imaging. In ___ \nshe\nunderwent an abdominal myomectomy with left ovarian cystectomy\nfor 27 fibroids and a 15-cm endometrioma. She reports recovering\nwell until around ___, when she started to experience\nepigastric discomfort and occasional shortness of breath. She\nunderwent CTA of the chest to evaluate for PE, which was \nnegative\nand there was no lymphadenopathy or suspicious nodule seen. In\n___, she got the heaviest period she has had since her\nMirena IUD was placed. She underwent endometrial biopsy on\n___, which showed chronic endometritis. She was already\ntaking doxycycline for a positive Lyme titer while awaiting\nconfirmatory testing, but continued to have vaginal bleeding. \nHer\nfollowup Lyme testing was negative.\n\nShe continued to feel quite fatigued and noted abdominal pain\nepigastrically as well as in the LLQ, back pain, and decreased\nappetite and constipation which got progressively more \nbothersome\nduring ___. She ultimately went to the ED on ___ where\nshe underwent CT scan of the abdomen and pelvis, which showed a\nlarge 10-cm left complex adnexal cystic mass with septations and\nirregular solid components. Additionally, there were multiple\nsubcapsular hepatic lesions and peritoneal implants, as well as\nretroperitoneal lymphadenopathy. Findings \nwere concerning for a metastatic primary ovarian neoplasm, such\nas cystadenocarcinoma, versus atypical distribution of\nendometriotic implants. \n\nOn ___ patient underwent an MRI of the abdomen and pelvis\nlower thorax showed clear lung bases no focal consolidations no\npleural or pericardial effusion. Liver showed multiple\nnonenhancing cystic subcapsular implants likely representing\nhemorrhage. The largest right arises from the right lobe of the\nliver and measured 4.1 x 2.8 cm. There was no associated\nenhancement likely represent adherent clot. There were no\nsuspicious enhancing lesions intrinsic to the hepatic \nparenchyma.\nAgain, in regard to the pelvis, there was a large cystic\nmultiloculated left adnexal structure measuring up to 10.8 x \n10.1\ncm. The septations were thin without significant enhancement or\nnodular components. The loculations demonstrated fluid-filled\nareas correction fluid-filled levels also likely representing\nhemorrhage. Within one of the loculations, there was a dark spot\nsign a finding that could be consistent with endometriosis. A\nsmaller right adnexal cystic structure was seen measuring 3.5 x\n3.0 cm. Uterus was enlarged with multiple small fibroids and \nIUD\nwas seen within the endometrial cavity at. There was a trace\nfree fluid within the pelvis multiple cystic anterior peritoneal\nimplants were visualized with fluid-filled levels likely\nrepresenting hemorrhage. There was peripheral enhancement, \nwhich\nmay be reactive in nature. One of these peritoneal implants\nappeared to have significant surrounding fat stranding. A left\nperiaortic retroperitoneal lesion had a similar appearance. \nMultiple subcentimeter periaortic lymph nodes were nonspecific.\nThere was no inguinal or pelvic lymphadenopathy.\n\nShe saw Dr. ___ in the office on ___ and received a\n1-month dose of Lupron. She was referred to ___ Oncology for\nfurther evaluation given atypical imaging findings. \n\nOf note, she had a CA125 checked on ___, which was 108,\ndecreased from 209 in ___. CEA was 0.9 on ___.\n\nToday she reports abdominal bloating, constipation, decreased\nappetite and increased abdominal girth. She noted decreased\nvaginal spotting since her Lupron shot, but it has been\npersistent. She also reports continued fatigue and occasional\nnausea. She denies chest pain, shortness of breath, diarrhea or\ndysuria. \n\n \nPast Medical History:\nGYN HX: \nG0\n- LMP ___, only minor spotting while IUD in place except\nwhen bleeding began in ___\n- Currently sexually active with female partner\n- ___ history of abnormal Pap smears; last Pap ___\n- Denies history of pelvic infections or sexually transmitted\n infections\n- Known history of fibroids and ovarian cysts\n- Known endometriosis\n\nPMH:\n- allergic rhinitis\n- depression\n- pseudocholinesterase deficiency\n- Denies hypertension, diabetes, asthma, thromboembolic disease\n\nPSH: \n- ___ knee surgery\n- ___ abdominal myomectomy\n- ___ RSO, L ov cystectomy -> Path: endometriotic cyst with\nfocal metaplastic/reactive changes\n- ___ abdominal myomectomy, LOA, L ovarian cystectomy -> Path:\nleiomyomata with degenerative changes, endometriotic cyst\n\n \nSocial History:\n___\nFamily History:\nFHx: \n- Father living, hx of bladder, prostate, skin, and throat \ncancer\n(non-smoker)\n- Mother died age ___ of colon cancer, also had DM and glaucoma\n- Brother is healthy\n- Niece with cystic fibrosis\n- No known family history of breast, uterine, ovarian, or\ncervical\n\n \nPhysical Exam:\nOn day of discharge:\nAfebrile, vitals stable\nNo acute distress\nCV: regular rate and rhythm\nPulm: clear to auscultation bilaterally\nAbd: soft, appropriately tender, nondistended, incision \nclean/dry/intact, no rebound/guarding\n___: nontender, nonedematous\n \nBrief Hospital Course:\nMs. ___ was admitted to the gynecologic oncology service \nafter undergoing exploratory laparaotomy, total abdominal \nhysterectomy, left salpingo-oophorectomy, omentectomy, \npara-aortic lymph node biopsy, liver resection and cystoscopy \nfor malignant transformation of endometriosis. Please see the \noperative report for full details. \n\nHer post-operative course is detailed as follows. Immediately \npostoperatively, her pain was controlled with an epidural and \nDilaudid PCA with toradol. Her diet was gradually advanced \nwithout difficulty and she was transitioned to oral oxycodone, \nTylenol and ibuprofen. On post-operative day #2, her urine \noutput was adequate so her Foley catheter was removed and she \nvoided spontaneously. \n\nBy post-operative day 5, 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:\nduloxetine 60mg daily\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \ndo not exceed 4000mg in 24 hours \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp \n#*60 Tablet Refills:*2 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily \nDisp #*60 Capsule Refills:*2 \n3. Enoxaparin Sodium 30 mg SC Q12H \nStart: ___, First Dose: Next Routine Administration Time \nTake this medication for a total of 28 days after your surgery, \nending ___. \nRX *enoxaparin 30 mg/0.3 mL 30 mg SC twice a day Disp #*50 \nSyringe Refills:*0 \n4. Ferrous GLUCONATE 324 mg PO DAILY \nRX *ferrous gluconate 324 mg (36 mg iron) 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*2 \n5. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate \ntake with food \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*60 Tablet Refills:*1 \n6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \ndo not drive or drink alcohol, causes sedation \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp \n#*50 Tablet Refills:*0 \n7. DULoxetine 60 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nmalignant transformation of endometriosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n.\nYou were admitted to the gynecologic oncology service after \nundergoing the procedures listed below. You have recovered well \nafter your operation, and the team feels that you are safe to be \ndischarged home. Please follow these instructions: \n.\nAbdominal instructions: \n* Take your medications as prescribed. We recommend you take \nnon-narcotics (i.e. Tylenol, ibuprofen) regularly for the first \nfew days post-operatively, and use the narcotic as needed. As \nyou start to feel better and need less medication, you should \ndecrease/stop the narcotic first.\n* Do not drive while taking narcotics. \n* Do not combine narcotic and sedative medications or alcohol. \n* Do not take more than 4000mg acetaminophen (tylenol) in 24 \nhrs. \n* No strenuous activity until your post-op appointment. \n* Nothing in the vagina (no tampons, no douching, no sex) for 12 \nweeks. \n* No heavy lifting of objects >10 lbs for 6 weeks. \n* You may eat a regular diet.\n* It is safe to walk up stairs. \n.\nIncision care: \n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No bath tubs for 6 weeks. \n* If you have staples, they will be removed at your follow-up \nvisit. \n.\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___. \n\n.\nCall your doctor at ___ for: \n* fever > 100.4 \n* severe abdominal pain \n* difficulty urinating \n* vaginal bleeding requiring >1 pad/hr \n* abnormal vaginal discharge \n* redness or drainage from incision \n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication \n* chest pain or difficulty breathing \n* onset of any concerning symptoms \n\n \nFollowup Instructions:\n___\n" ]

[ "C562", "C786", "C772", "C787", "E669", "F419", "F329", "Z6836" ]

[ "C562: Malignant neoplasm of left ovary", "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "E669: Obesity, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult" ]

[ "E669", "F419", "F329" ]

[]

[ " \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:\nsymptomatic fibroid uterus, left ovarian cyst\n \nMajor Surgical or Invasive Procedure:\nexploratory laparotomy, lysis of adhesions, multiple myomectomy, \nleft ovarian cystectomy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ gravida 0 with a long history of \nrecurrent ovarian cyst and endometriosis who on ___, underwent a right salpingo-oophorectomy, left ovarian \ncystectomy for endometriomas. In ___, she had a multiple \nmyomectomies for symptomatic fibroid uterus. The patient \npresents today for followup of unknown left adnexal cyst.\n\nThe patient notes that she has no abdominal pain. She is simply \nexperiencing increased bloatedness and pelvic pressure. New \nsymptoms, she has developed stress urinary incontinence with \nsneezing. We discussed that this certainly can be related to \nthis large adnexal cyst in addition to her overweightedness.\n\nOn ___, she had an ultrasound, which showed an \nanteverted uterus that measured 14.3 x 6.7 x 9.2 cm, slightly \nsmaller than previous measurement on ___, where it \nmeasured 15.2 x 7.4 x 10.4 cm. Multiple masses were consistent \nwith uterine fibroids. The dominant fibroid was seen at the\nfundus and measured 3.3 x 3.3 x 3.5 cm. The endometrium was \ndistorted due to fibroids and not well evaluated. An IUD was \ndemonstrated within the endometrial cavity. The patient is \nstatus post right oophorectomy, previously seen 10.7 cm left \nadnexal cyst again visualized and now measuring slightly larger \nat 10.8 x 10 cm. It predominantly was thin walled; however,\nthere was one area with the appearance of an incomplete \nseptation. This either represented a hydrosalpinx or peritoneal \ninclusion cyst, less likely a cystadenoma. There was no free \npelvic fluid. These findings were discussed with the patient. \n \nPast Medical History:\nPast OB/GYN: The patient has regular menses. She has never had a \npregnancy. She does have a history of genital warts. The patient \nhas a long history of uterine fibroids, endometriosis, \nendometriomas. She is in a monogamous relationship with a female \npartner.\n\nPMH:\n___ rhinitis\nDepression\nUterine fibroids\nEndometriosis\nEndometriomas\nPseudocholinesterase deficiency\n\nPSH:\nMedial collateral ligament release – ___\nAbdominal MMY\n \nSocial History:\n___\nFamily History:\nHer mother had hypertension and died of colon cancer. Her father \nhas hypertension and prostate cancer.\n \nPhysical Exam:\nDischarge Physical Exam:\nAVSS\nGen NAD\nCV RRR\nP CTAB\nAbd soft, nondistended, appropriately tender to palpation, \nincision c/d/I\nExt WWP\n \nPertinent Results:\n___ 07:25AM WBC-5.9 RBC-4.30 HGB-13.4 HCT-40.5 MCV-94 \nMCH-31.2 MCHC-33.1 RDW-11.9 RDWSD-41.6\n___ 07:25AM PLT COUNT-268\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service \nafter undergoing an exploratory laparotomy, lysis of adhesions, \nleft ovarian cystectomy, abdominal myomectomy for symptomatic \nfibroid uterus and left ovarian cyst. Please see the operative \nreport for full details.\n\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV dilaudid and toradol. \nOn post-operative day 1, her urine output was adequate so her \nfoley was removed and she voided spontaneously. Her diet was \nadvanced without difficulty and she was transitioned to PO \noxycodone, Tylenol and ibuprofen (pain meds).\n\nBy post-operative day 2, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n\n \nMedications on Admission:\nDuloxetine 60mg QD\n \nDischarge Medications:\n1. DULoxetine 60 mg PO DAILY \n2. Ibuprofen 600 mg PO Q6H:PRN pain \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*50 Tablet Refills:*0\n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN severe pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*40 Tablet Refills:*0\n4. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*3\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nfibroid uterus, ovarian cyst\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your \nprocedure. You have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ \noffice with any questions or concerns. Please follow the \ninstructions below.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Do not drive while taking narcotics.\n* Take a stool softener such as colace while taking narcotics to \nprevent constipation.\n* Do not combine narcotic and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* No heavy lifting of objects >10 lbs for 6 weeks.\n* You may eat a regular diet.\n* You may walk up and down stairs.\n\nIncision care:\n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No tub baths for 6 weeks.\n* If you have steri-strips, leave them on. They will fall off on \ntheir own or be removed during your followup visit.\n* If you have staples, they will be removed at your follow-up \nvisit.\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 \nFollowup Instructions:\n___\n" ]

[ "D259", "E8809", "N3289", "N8320", "N736", "Z90721", "Z9079", "N393", "Z975", "J309", "F329", "Z800", "Z8042" ]

[ "D259: Leiomyoma of uterus, unspecified", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "N3289: Other specified disorders of bladder", "N8320: Unspecified ovarian cysts", "N736: Female pelvic peritoneal adhesions (postinfective)", "Z90721: Acquired absence of ovaries, unilateral", "Z9079: Acquired absence of other genital organ(s)", "N393: Stress incontinence (female) (male)", "Z975: Presence of (intrauterine) contraceptive device", "J309: Allergic rhinitis, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z800: Family history of malignant neoplasm of digestive organs", "Z8042: Family history of malignant neoplasm of prostate" ]

[ "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 \n___ Surgical or Invasive Procedure:\n___: Redo TIPS\n___: Redo TIPS\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n\n___ 07:30AM BLOOD WBC-4.2 RBC-4.29* Hgb-12.1* Hct-37.9* \nMCV-88 MCH-28.2 MCHC-31.9* RDW-14.7 RDWSD-47.1* Plt Ct-63*\n___ 07:30AM BLOOD ___\n___ 07:30AM BLOOD Plt Ct-63*\n___ 06:11PM BLOOD ___\n___ 07:30AM BLOOD UreaN-21* Creat-1.0 Na-142 K-4.6 Cl-109* \nHCO3-22 AnGap-11\n___ 07:30AM BLOOD ALT-75* AST-88* AlkPhos-487* TotBili-1.0\n___ 06:11PM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.7 Mg-1.9\n\nDISCHARGE LABS:\n___ 04:54AM BLOOD WBC-5.1 RBC-3.97* Hgb-11.2* Hct-35.4* \nMCV-89 MCH-28.2 MCHC-31.6* RDW-14.7 RDWSD-48.1* Plt Ct-71*\n___ 12:07PM BLOOD PTT-83.3*\n___ 04:54AM BLOOD Plt Ct-71*\n___ 03:22PM BLOOD ___ 04:54AM BLOOD Glucose-95 UreaN-24* Creat-1.0 Na-140 \nK-4.4 Cl-109* HCO3-19* AnGap-12\n___ 04:54AM BLOOD ALT-501* AST-660* LD(LDH)-696* \nAlkPhos-428* TotBili-2.7*\n___ 04:54AM BLOOD Albumin-3.6 Calcium-8.3* Phos-3.0 Mg-1.9\n\nMICRO:\nn/a\n\nIMAGING:\n___ REDO TIPS \nSuccessful right internal jugular access with direct \ntransjugular intrahepatic portosystemic shunt revision with \nextension of the TIPS cranially. \n \nNew direct TIPS aspiration thrombectomy. \n \nThrombolysis catheter placement through the right IJ sheath for \novernight \nthrombolysis \n\n___BD & PELVIS W & W/O \n1. Interval redo TIPS procedure, with persistent thrombus in the \nTIPS shunt. \nThe new TIPS shunt lies parallel to the superior most aspect of \nthe \npre-existing stent, with its upper portion approximately 1 cm \nbelow the \ncavoatrial junction. The tPA infusion catheter localizes in the \nlower right atrium, with the lowest radiopaque marker overlying \nthe lower cavoatrial junction. \n2. There is increased burden of nonocclusive thrombus in the \nmain portal vein. \n3. Interval development of trace ascites. \n4. Stable cirrhosis with secondary changes representing the \nsequela of portal hypertension including perisplenic, \nperigastric and periesophageal varices, and splenomegaly. \n\n___ REDO TIPS \n \nSuccessful revision of occluded TIPS and thrombosed portal vein \nwith a \npostprocedural portosystemic gradient of 11 mm Hg. \n \nTechnically successful coronary variceal embolization and \nsclerotherapy. \n\n \nBrief Hospital Course:\n___ male with congenital hepatic fibrosis complicated by \nportal hypertension and variceal bleeding s/p TIPS ___ who \npresented to the MICU s/p TIPS revision with thrombolysis \ncomplicated by hypoxia. \n\nACUTE ISSUES \n======================= \n#Hypoxic respiratory failure: \nPatient developed new oxygen requirement after ___ TIPS revision. \nUnclear if VTE or atelectasis\nor just some orthodeoxia but responded to oxygen and remained on \nroom air for the majority of his ICU course. \n\n# Congenital Hepatic Fibrosis c/b portal hypertension and\nvariceal bleeding:\n# S/p TIPS ___ and revision ___\nPt with congenital hepatic fibrosis c/b portal HTN and variceal \nbleeding. TIPS revision complicated by hypoxia. He had a right \nIJ sheath with lysis catheter placed. He underwent CTV with \npersistent thrombus in TIPS shunt. Now s/p revision of occuled \nTIPS and thrombosed portal vein with a postprocedural \nportosystemic gradient of 11 mm Hg. He also had successful \ncoronary variceal embolization and sclerotherapy. He was placed \non a heparin drip post TIPS and transitioned to lovenox on \ndischarge.\n- GIB/VARICES: EGD ___ which showed scarring at GE junction, \nproximal grade 2 EVs s/p esophageal band ligation x4 and large \ngastric varices. Pt also presented to an outside ED in ___ \nwith acute UGIB/variceal bleed. Not able to be banded/embolized; \nconsidered for future procedure. On nadolol at home which was \ncontinued while inpatient.\n- ASCITES: no history of ascites, not on diuretics, he was not \noverloaded on exam.\n\n#Transminitis\nLikely due to liver disease and TIPS procedure\n\n# Thrombocytopenia\nLikely ___ to liver disease and sequestration \n\nCHRONIC ISSUES \n======================= \n# Hyperlipidemia:\n- Continued Pravastatin 40 mg QHS \n\nTRANSITIONAL ISSUES: \n======================= \n[ ] please recheck LFTs in 1 week to ensure downtrending \n[ ] check CBC within 1 week as on anticoagulation and patient \nhas bleeding history \n[ ] f/u US of TIPS shunt in 1 week\n[ ] continue lovenox for one month \n[ ] follow up with ___ in 1 month \n#CODE STATUS: Presumed FULL \n#CONTACT: ___ - wife - ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Nadolol 40 mg PO DAILY \n2. Pravastatin 40 mg PO QPM \n3. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Medications:\n1. Enoxaparin Sodium 90 mg SC Q12H \n2. Nadolol 40 mg PO DAILY \n3. Pantoprazole 40 mg PO Q24H \n4. Pravastatin 40 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIANGOSIS:\nHypoxic respiratory failure \nCongenital Hepatic Fibrosis c/b portal hypertension and variceal \nbleeding\nTIPS occlusion\nPortal vein thrombosis occlusion\n\nSECONDARY DIAGNOSIS:\nTransaminitis\nThrombocytopenia\nHyperlipidemia \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\nYou were admitted because you had a blood clot in your TIPS and \nyour oxygen was low. \n\nWHAT WAS DONE WHILE I WAS HERE?\nWe opened up the vessels/TIPS. We started you on a blood \nthinner. We watched your breathing closely. \n\nWHAT SHOULD I DO NOW?\nYou should take your medications as instructed. \nYou should go to your doctor's appointments as below. \n\nWe wish you the best!\n-Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "J95821", "I81", "T82868A", "K766", "I8510", "K740", "I864", "D6959", "E785", "Y838", "K7460", "Y92238" ]

[ "J95821: Acute postprocedural respiratory failure", "I81: Portal vein thrombosis", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "K766: Portal hypertension", "I8510: Secondary esophageal varices without bleeding", "K740: Hepatic fibrosis", "I864: Gastric varices", "D6959: Other secondary thrombocytopenia", "E785: Hyperlipidemia, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "K7460: Unspecified cirrhosis of liver", "Y92238: Other place in hospital as the place of occurrence of the external cause" ]

[ "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:\npost TIPS monitoring\n \nMajor Surgical or Invasive Procedure:\nTIPS ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with congenital hepatic\nfibrosis complicated by portal hypertension and variceal \nbleeding\nwho presents to the medicine floor s/p TIPS procedure for TIPS\nmonitoring. \n \nThe patient recently presented to the ED on ___ with severe\nvariceal bleeding requiring blood/plasma transfusion as well as\nendoscopic banding of his esophageal/gastric varices. He\nultimately elected to undergo a TIPS placement by ___ on ___.\nPer sign out, the TIPS procedure was quite complicated, lasting \na\ntotal of 6 hours. The HVPG was reduced to 10. His\nesophageal/gastric were not embolized though he did receive tPA\nfor his portal vein thrombosis.\n\n \nPast Medical History:\n- Congenital hepatic fibrosis\n-- Portal hypertension\n-- Gastric and esophageal varices s/p band ligation \n- Hyperlipidemia \n \nSocial History:\n___\nFamily History:\nnon contributory to this admission\n \nPhysical Exam:\nVS: 24 HR Data (last updated ___ @ 1213)\n Temp: 97.9 (Tm 98.5), BP: 133/78 (129-146/75-78), HR: 71\n(71-82), RR: 16 (___), O2 sat: 98% (95-98), O2 delivery: RA,\nWt: 203.7 lb/92.4 kg \n\nGENERAL: well appearing man in no acute distress\nHEENT: anicteric sclera, right neck access site bandaged &\nclean. no active bleeding\nHEART: RRR, no murmurs, rubs, gallops\nLUNGS: clear bilaterally \nABDOMEN: soft, mildly distended, non-tender to palpation but\nsubjective discomfort, RUQ dressing c/d/I without surrounding\nerythema, drainage, bleeding\nEXTREMITIES: wwp, no edema\nNEURO: A&Ox3, moving all 4 extremities with purpose, no\nasterixis. Able to say months of the year backwards.\n\n \nPertinent Results:\n___ 06:47AM BLOOD WBC-4.2 RBC-3.93* Hgb-11.0* Hct-33.8* \nMCV-86 MCH-28.0 MCHC-32.5 RDW-15.2 RDWSD-47.3* Plt Ct-29*\n___ 06:47AM BLOOD Glucose-109* UreaN-15 Creat-1.0 Na-141 \nK-3.8 Cl-104 HCO3-23 AnGap-14\n___ 06:47AM BLOOD ALT-824* AST-556* LD(LDH)-289* \nAlkPhos-360* TotBili-1.8*\n\n \nBrief Hospital Course:\nMr. ___ is a ___ male with congenital hepatic \nfibrosis complicated by portal hypertension and variceal \nbleeding who presents to the medicine floor for post TIPS \nmonitoring. Mild ___ post-op s/p 25gm albumin; otherwise \nuncomplicated course. Surgical wounds stable; dressing clean and \ndry. Patient able to tolerate PO without issue. No evidence of \nhepatic encephalopathy prior to discharge. No further planned \nintervention by ___ this hospitalization; they will see him in \nfollow-up in ___ weeks.\n\nTRANSITIONAL ISSUES:\n====================\n[ ] please obtain repeat LFTs on ___ with results faxed to \n___ (f: ___\n[ ] consider repeat hepatitis A and B serologies to ensure \nimmunization (non immune as of ___ in ___ records) \n[ ] consider repeat AFP as last AFP in BID system is from ___ \n[ ] please consider stopping lactulose that was continued on \ndischarge depending on post-op course regarding HE \n\nACTIVE ISSUES\n=============\n# Congenital Hepatic Fibrosis c/b portal hypertension:\n# S/p TIPS ___: \nAs above, patient presented in ___ with variceal bleeding \nrequiring transfusions and banding of his esophageal/gastric \nvarices, now s/p elective TIPS placement on ___ with ___ (10 x 6 \nand 10 x 8 R TIPS placed). He has no history of HE or ascites. \nPer ___ team, the TIPS procedure was complicated, lasting 6 \nhours. His post-TIPS HVPG is between ___ mmHg (pre-tips HVPG \nnot documented). His varices were not embolized though he did \nreceive tPA for his portal vein thrombosis. Tentatively may need \nanother procedure in the near future. He was discharged on \nlactulose with instructions to titrate to two BMs daily. \nConsider stopping this at his follow-up appointment.\n\nPost-op, his vitals have remained stable. His neck and abdominal \naccess sites appear to be healing appropriately. His LFTs are up \nbut expected post-op changes, downtrending by discharge. \nTelemetry and foley were dc'd. Patient has been able to urinate \nand has had multiple bowel movements with lactulose. His MELD-NA \npost-op on ___ was 16. Pain control with acetaminophen + \nhot/cold packs. He post-op course was uncomplicated except for a \nmild ___ discussed below which resolved with albumin.\n\nDischarge MELD-NA: 11\nDischarge HgB: 11\n\n___\nSCR 1.1 --> 1.4 ---> 1.0\nMost likely related to NPO prior to procedure and prolonged \noperation. HRS very unlikely has patient has no ascites or \nhepatic hydrothorax (on exam or history of). Urine lytes were \nunremarkable with UNa <20 which is an appropriate response to \npre-renal dehydration. UA and sediment unremarkable. Discharge \nCreatinine: 1.0\n\n# Thrombocytopenia: \nPlts in the ___, at baseline. Secondary to cirrhosis, \nsplenomegaly. SQH was held ___ thrombocytopenia. Patient had no \ne/o bleeding or petichiae during his hospital course. \nDischarge platelets: 29\n\nCHRONIC ISSUES\n==============\n# Hyperlipidemia:\nContinued Pravastatin 40 mg QHS\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Nadolol 40 mg PO DAILY \n2. Pravastatin 40 mg PO QPM \n\n \nDischarge Medications:\n1. Lactulose 30 mL PO DAILY \nRX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth once a day \nDisp #*1 Bottle Refills:*2 \n2. Nadolol 40 mg PO DAILY \n3. Pravastatin 40 mg PO QPM \n4.Outpatient Lab Work\nDX: Elevated Liver Enzymes\nICD-10: R94.5\nTests: AST, ALT, ALP, Total Bili, Direct Bili\n\nPlease fax results to ___ at ___.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\nCongenital hepatic fibrosis\nPortal hypertension\nCirrhosis\n\nSECONDARY:\nHistory of esophageal and gastric varices\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. ___, \nIt was a pleasure taking care of you at the ___ \n___! \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n- You were admitted because you had a TIPS procedure and needed \nroutine monitoring afterwards\n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- You had a TIPS procedure performed\n- Post-procedure, your mental status, liver/kidney tests, and \nblood counts were monitored\n- You received a medicine to help you have regular bowel \nmovements\n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Be sure to take all your medications and attend all of your \nappointments listed below.\n- Take your lactulose enough times daily to have two bowel \nmovements every day.\n- If you notice black or bloody stool or if you are vomiting \nblood, please go to the ER right away\n- Interventional Radiology will call you with an appointment in \n___ weeks. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nYour ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K7460", "I81", "N179", "K766", "I8510", "K740", "D6959", "E785", "I864" ]

[ "K7460: Unspecified cirrhosis of liver", "I81: Portal vein thrombosis", "N179: Acute kidney failure, unspecified", "K766: Portal hypertension", "I8510: Secondary esophageal varices without bleeding", "K740: Hepatic fibrosis", "D6959: Other secondary thrombocytopenia", "E785: Hyperlipidemia, unspecified", "I864: Gastric varices" ]

[ "N179", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nmorphine / Demerol\n \nAttending: ___.\n \nChief Complaint:\nRight femoral neck fracture\n \nMajor Surgical or Invasive Procedure:\nClosed reduction, internal fixation with cannulated screws of \nRight femoral neck fracture\n\n \nHistory of Present Illness:\n___ M presents with right femoral neck fracture s/p mechanical \nfall. He fell on his right side earlier this morning, with \nimmediate right hip pain and inability to ambulate. He denies \npain elsewhere. He ambulates without assistance at baseline, \nbut reports he does not walk as much as he used to due to \nantecedent bilateral hip pain. He is fairly active and enjoys \nfishing regularly.\n\n \nPast Medical History:\nPMH/PSH:\nDM\nHTN \nCOPD\nClaudication\nCarotid stenosis\nS/p L carotid endarterectomy ___\n \nSocial History:\n___\nFamily History:\nFather CAD/PVD; Diabetes - Type II \nMother chf [OTHER] \nSister ___ \n\n \nPhysical ___:\nRight lower extremity:\n- Skin intact\n- Fires ___\n- SILT S/S/SP/DP/T distributions\n- 1+ ___ pulses, WWP\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 right femoral neck fracture and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ for closed reduction and cannulated \nscrew fixation, which the patient tolerated well. For full \ndetails of the procedure please see the separately dictated \noperative report. The patient was taken from the OR to the PACU \nin stable condition and after satisfactory recovery from \nanesthesia was transferred to the floor. The patient was \ninitially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications by POD#1. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ who \ndetermined that discharge to rehab was appropriate. 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 \nNVI distally in the right extremity, and will be discharged on \nlovenox for DVT prophylaxis. The patient will follow up with Dr. \n___ routine. A thorough discussion was had with the \npatient regarding the diagnosis and expected post-discharge \ncourse including reasons to call the office or return to the \nhospital, and all questions were answered. The patient was also \ngiven written instructions concerning precautionary instructions \nand the appropriate follow-up care. The patient expressed \nreadiness for discharge.\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Calcium Carbonate 500 mg PO QID:PRN indigestion \n3. Docusate Sodium 100 mg PO BID \n4. Enoxaparin Sodium 40 mg SC QPM Duration: 4 Weeks \nStart: Today - ___, First Dose: Next Routine Administration \nTime \nRX *enoxaparin 40 mg/0.4 mL 40 mg SC QPM Disp #*28 Syringe \nRefills:*0\n5. Lisinopril 2.5 mg PO DAILY \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q4H: PRN Disp #*60 \nTablet Refills:*0\n8. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nRight femoral neck fracture\n\n \nDischarge Condition:\nAOX3, OOB with assistance of ___, overall stable\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- Touchdown weight bearing 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\nANTICOAGULATION:\n- Please take Lovenox 40mg 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- No dressing is needed if wound continues to be non-draining.\nPhysical Therapy:\nActivity: Activity: Out of bed w/ assist\n Right lower extremity: Touchdown weight bearing\n Left lower extremity: Full weight bearing\nEncourage turning, deep breathing and coughing qhour when awake.\n\nTreatments Frequency:\nDSD as needed. Sutures/staples removed at clinic. Elevation as \ntolerated.\n \nFollowup Instructions:\n___\n" ]

[ "S72001A", "E119", "J449", "I10", "W1839XA", "Y92009", "Z87891", "I70209", "Z23" ]

[ "S72001A: Fracture of unspecified part of neck of right femur, initial encounter for closed fracture", "E119: Type 2 diabetes mellitus without complications", "J449: Chronic obstructive pulmonary disease, unspecified", "I10: Essential (primary) hypertension", "W1839XA: Other fall on same level, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "Z87891: Personal history of nicotine dependence", "I70209: Unspecified atherosclerosis of native arteries of extremities, unspecified extremity", "Z23: Encounter for immunization" ]

[ "E119", "J449", "I10", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nright ankle fracture dislocation\n \nMajor Surgical or Invasive Procedure:\nright ankle surgical fixation\n\n \nHistory of Present Illness:\n___ healthy female who sustained a right ankle injury \nfollowing a mechanical slip and fall down stairs. She states \nshe was packing to fly home tomorrow morning when she was going \nto load up her suitcase down stairs, slipped on the last step, \ntwisting and injuring her ankle. Denied head strike or loss of \nconsciousness. She is not currently on anticoagulation. She \ndenies any numbness or paresthesias in the right foot. She \ndenies any previous injury to the right ankle. Notably she is \ncurrently in town visiting her son. She lives in ___ \ncurrently. She is here with her husband and son.\n\n \nPast Medical History:\nnone\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nRight lower exam\n-splint c/d/I\n-grossly moves exposed toes\n-silt in exposed toes\n-toes WWP \n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a right ankle fracture dislocation and was admitted to \nthe orthopedic surgery service. The patient was taken to the \noperating room on ___ for open reduction internal fixation of \nright ankle fracture, which the patient tolerated well. For full \ndetails of the procedure please see the separately dictated \noperative report. The patient was taken from the OR to the PACU \nin stable condition and after satisfactory recovery from \nanesthesia was transferred to the floor. The patient was \ninitially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications by POD#1. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ who \ndetermined that discharge to home was appropriate. The ___ \nhospital course was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nnonweightbearing in the right lower extremity in a splint, and \nwill be discharged on Lovenox for DVT prophylaxis. The patient \nwill follow up with Dr. ___ routine. Alternatively, \nsince she is from ___ she may choose to follow-up \nwith an orthopedic provider ___. She was instructed to \nfollow-up in 2 weeks. A thorough discussion was had with the \npatient regarding the diagnosis and expected post-discharge \ncourse including reasons to call the office or return to the \nhospital, and all questions were answered. The patient was also \ngiven written instructions concerning precautionary instructions \nand the appropriate follow-up care. The patient expressed \nreadiness for discharge.\n\n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \n3. Enoxaparin Sodium 40 mg SC QHS \nRX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28 \nSyringe Refills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \ndon't drink or drive while taking \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nPRN Disp #*30 Tablet Refills:*0 \n5. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nright ankle fracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDischarge Instructions:\n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n-Nonweightbearing right lower extremity in splint\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add oxycodone as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 tablet every 3 hours as needed x 1 day,\nthen 1 tablet every 4 hours as needed x 1 day,\nthen 1 tablet every 6 hours as needed x 1 day,\nthen 1 tablet every 8 hours as needed x 2 days, \nthen 1 tablet every 12 hours as needed x 1 day,\nthen 1 tablet every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \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- If you have a splint in place, splint must be left on until \nfollow up appointment unless otherwise instructed. Do NOT get \nsplint wet.\n\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\n \nFollowup Instructions:\n___\n" ]

[ "S82851A", "W108XXA", "Y92009" ]

[ "S82851A: Displaced trimalleolar fracture of right lower leg, initial encounter for closed fracture", "W108XXA: Fall (on) (from) other stairs and steps, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[]

[]

[ " \nName: ___ ___ 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\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ male, history of cervical fusion in ___, ETOH \nabuse, and HTN presenting with nausea, hematemesis/coffee-ground \nemesis and ? melena. \n He was in his usual state of health, consuming ___ shot \nglasses per night of ETOH (last night however ___ shots), and \nalso using NSAIDS 1600 mg/day and Tylenol ___ mg/day for his \nneck pain after the surgery. On ___, he began having \nintermittent abdominal discomfort with food intake. He also had \nnausea and vomiting, with hematemesis on day prior to \npresentation and 2 episodes of coffee-ground emesis on day of \npresentation. He reports lightheadedness with standing. In the \nED, noted to have a dark tarry BM with subsequent dizziness. \n He reports no chest pain, shortness of breath, abdominal pain, \ndiarrhea. \n In ED, vital signs were notable for tachycardia 110s-120s, BP \n130s/70s-80s, satting well on RA. Labs are notable for Hgb 12.9, \nwhich is above his baseline of ___. He had elevated \ntransaminases to 169/257, elevated from prior with normal AP, \nTbili, and lipase. He has ___ with Cr of 1.2 from baseline of \n0.5 and BUN of 29. Chemistry notable for K 5.0, Cl 82, and anion \ngap of 26. INR was 1.2. GI was consulted and recommended IV PPI, \nNPO, transfusion goal of ___, anti-emetic, and potential EGD. He \nwas given NS, pantoprazole, ondansetron, and morphine. \n \n On arrival to the floor, patient reports severe pain in his \nneck at the site of his recent surgery. Otherwise feels well \nwithout complaints. \n \n REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as \nper HPI \n \nPast Medical History:\nETOH abuse \nHTN \nS/p posterior cervical decompression and fusion ___ \nC. diff \n \nSocial History:\n___\nFamily History:\nNo family history of liver disease\n \nPhysical Exam:\nADMISSION PHYSICAL\n==================\nVS: 97.7 PO 177 / 92L Lying ___ Ra \nGENERAL: NAD \nHEENT: anicteric sclera, pink conjunctiva, MMM \nNECK: supple, no LAD, no JVD \nHEART: tachycardia, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly on exam \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes\n\nDISCHARGE PHYSICAL\n==================\n___ 0720 Temp: 98.3 PO BP: 107/56 R Lying HR: 67 RR: 16\nO2 sat: 97% O2 delivery: Ra \nGENERAL: NAD \nHEENT: anicteric sclera, pink conjunctiva, MMM \nHEART: normal S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly on exam \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 04:00PM BLOOD WBC-8.4 RBC-4.51* Hgb-12.9* Hct-38.4* \nMCV-85 MCH-28.6 MCHC-33.6 RDW-16.7* RDWSD-48.5* Plt ___\n___ 04:00PM BLOOD Neuts-85.4* Lymphs-7.9* Monos-5.4 \nEos-0.5* Baso-0.4 Im ___ AbsNeut-7.15* AbsLymp-0.66* \nAbsMono-0.45 AbsEos-0.04 AbsBaso-0.03\n___ 04:11PM BLOOD ___ PTT-27.5 ___\n___ 04:00PM BLOOD Glucose-109* UreaN-29* Creat-1.2 Na-138 \nK-5.0 Cl-82* HCO3-30 AnGap-26*\n___ 04:00PM BLOOD ALT-169* AST-257* AlkPhos-112 TotBili-0.6\n___ 04:00PM BLOOD Lipase-30\n___ 04:00PM BLOOD Albumin-4.8 Calcium-11.2* Phos-4.1 Mg-1.6\n___ 09:48PM URINE Hours-RANDOM Creat-200 Na-81\n\nPERTINENT LABS\n==============\n___ 08:57AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 08:57AM BLOOD HCV Ab-NEG\n___ 01:52PM STOOL HELICOBACTER ANTIGEN DETECTION, STOOL-PND\n\nMICRO\n=====\nNone\n\nSTUDIES\n=======\nUS Liver ___. Echogenic liver consistent with steatosis. Mildly nodular \nsuggests\ncirrhosis.\n2. No cholelithiasis, evidence of cholecystitis, or biliary \ndilation.\n3. Patent portal vein.\n\nDISCHARGE LABS\n==============\n___ 04:47AM BLOOD WBC-3.7* RBC-2.81* Hgb-8.2* Hct-25.3* \nMCV-90 MCH-29.2 MCHC-32.4 RDW-15.6* RDWSD-51.0* Plt Ct-96*\n___ 04:47AM BLOOD Glucose-82 UreaN-10 Creat-0.8 Na-141 \nK-3.7 Cl-99 HCO3-29 AnGap-13\n___ 04:47AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.___ male, history of cervical fusion in ___, ETOH \nabuse, and HTN presenting with hematemesis and coffee-ground \nemesis as well melena concerning for UGIB likely ___ alcoholic \ngastritis vs. esophagitis vs ___ tear.\n\n# UGIB\nPatient presented after having two episodes of \nhematemesis/coffee-ground emesis, and then proceeded to have \nlarge melena in ED. Hgb at presentation was 12.9 but \nsubsequently dropped to 9.5 and then 8.9 in the setting of \ngetting 2L IVF. Possible etiologies include ___ Tear, \nesophagitis, alcoholic gastritis, and NSAID use. Patient was \nplanned to undergo EGD on ___ but unfortunately, given \nspinal fusion, anesthesia felt that it would be safest to \nperform procedure in the OR. Patient was hemodynamically stable \nfor 48 hours since admission and had no major changes in his \nhemoglobin. Multiple conversations were had with the patient and \nthe inpatient GI team about our preference of having him stay \nand undergo EGD in the OR given possible evidence of cirrhotic \nchanges on liver US. Patient preferred to leave due to multiple \nlife stressors outside of the hospital (including significant \nwork issues with his boss) and the patient's presentation was \nthought to be less concerning for acute variceal bleed. This \nplan was discussed with GI consultants. Patient was educated \nabout danger signs that should prompt an immediate return to the \nED, and otherwise was encouraged to attend his scheduled follow \nup liver clinic where the EGD could be setup as an outpatient.\n\n# ___\nCr was elevated to 1.2 at presentation from baseline 0.5. Likely \npre-renal in setting of ongoing nausea limiting PO intake and \nvomiting. Patient received 2L IVF and Cr downtrended.\n\n# Cirrhosis\n# Transaminitis\nPatient's liver enzymes were elevated on admission, AST/ALT \n100s-200s. Baseline abnormal likely due to ongoing alcohol use \nvs. fatty liver disease. He was also found to be leukopenic and \nthrombocytopenic. No stigmata of chronic liver disease on exam. \nRUQ U/S demonstrated stigmata of cirrhosis. Hepatitis serologies \n(HBV, HCV) were obtained and were all negative. Patient was \nstarted on hepatitis B vaccination series and received the first \nimmunization on ___.\n\n# Alcohol abuse\nPatient formerly frank ten shots a night every night and drank \ncontinuously on weekends. He has since cut down and now drinks \n___ shots ___ nights a week. No history of withdrawal seizures \nthough did require phenobarb during prior admission. At his \nreduced level of drinking, he did not have withdrawal on this \nadmission. \n___ w/ EtOH abuse admitted w/ hematemesis and melena. Imaging \nand labs c/w a new diagnosis of cirrhosis. \nThe patient was advised that even though he has cut down his \ndrinking, his liver is now much more fragile than before and \neven small amounts of alcohol can cause further damage. He was \neducated on the life-threatening complications of cirrhosis and \nhow he may not have any symptoms until it has become too late to \nundo the damage. He verbalized understanding of this, but does \nnot feel quite ready to quit drinking. He was educated about \nnaltrexone and other resources and agrees to readdress sobriety \nat his follow up visit. \n\n# H/o cervical fusion in ___\nPain was controlled with Tylenol, tizanadine, gabapentin, and \noxycodone PRN.\n\nTRANSITIONAL ISSUES\n===================\n[]EGD: Prompt outpatient EGD is recommended to clarify the cause \nof bleeding. Even if he has no further bleeding, the patient \nstill needs to complete an EGD to screen for esophageal varices. \n\n[]Pending Labs: f/u h pylori stool antigen\n[]Hepatology: Close followup in liver clinic given new diagnosis \nof cirrhosis\n[]___ Screening: Patient will require q6 month ___ screening \nwith abdominal ultrasound\n[]Hepatitis B, non-immune: Patient was found to be hepatitis B \nnon-immune, received first vaccine on ___, followup with \ncourse per recommended schedule\n[]PPI: Discharged on PPI BID which should be continued until \npatient has GI follow up at ___\n[] NO NSAIDS.\n[] Continue discussion regarding alcohol cessation. He is \npotentially interested in naltrexone.\n\n#CODE: Full (presumed)\n#CONTACT: ___ ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q6H \n2. Gabapentin 300 mg PO Q8H \n3. Tizanidine 4 mg PO TID:PRN neck pain \n4. Ibuprofen 400 mg PO Q6H \n\n \nDischarge Medications:\n1. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Gabapentin 300 mg PO Q8H \n3. 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 \n4. Omeprazole 40 mg PO BID \nRX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*0 \n5. Thiamine 200 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0 \n6. Tizanidine 4 mg PO TID:PRN neck pain \n7. HELD- Acetaminophen 1000 mg PO Q6H This medication was held. \nDo not restart Acetaminophen until you really need it, and this \nshould be no more than 2 grams per day\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses\n=================\nUpper GI bleed\nAlcoholic cirrhosis\n___\n\nSecondary Diagnoses\n===================\nAlcohol abuse\nNicotine dependence\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 in the hospital. \n\nWHY WERE YOU ADMITTED:\n- You were having bloody vomit and dark stools which concerned \nus that you were having a bleed from somewhere in your \nesophagus, stomach, or intestines. \n\nWHAT HAPPENED IN THE HOSPITAL:\n- We gave you fluids\n- We took lab tests to see if you were bleeding quickly\n- We had the GI doctors ___ by and ___ you, and they \nrecommended that you get a procedure in which we look with a \ncamera into your stomach. However, because of your neck \nsurgeries, this would have to be done in the operating room. You \ndecided that you did not want to wait and have this done so you \nwere discharged with strict instructions to return if you start \nfeeling ANY symptoms or experienced ANY bleeding\n- You had imaging that suggested that you had cirrhosis in your \nliver. This needs follow up and further work up and it will be \nextremely important for you to follow up with a liver \nspecialist.\n- Importantly, you should NOT take any further ibuprofen, advil, \nnaproxen, aleve. You should STOP drinking and consider a \ndetoxification center.\n\nWHAT SHOULD I DO AFTER LEAVING:\n- Please take all of your medications as prescribed including a \nnew medication:\n 1.) Pantoprazole 40mg twice daily\n- Please follow-up with your primary care doctor within the next \n___ weeks to have a repeat blood draw. \n- Please return to the hospital if you develop the following \nsigns:\n 1.) More bloody or dark vomiting\n 2.) More black, tarry stools\n 3.) New lightheadedness or shortness of breath\n\nThank you for allowing us to participate in your care.\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K920", "N179", "F1010", "I10", "F17200", "E8352", "E876", "E8342", "K7030", "D6959" ]

[ "K920: Hematemesis", "N179: Acute kidney failure, unspecified", "F1010: Alcohol abuse, uncomplicated", "I10: Essential (primary) hypertension", "F17200: Nicotine dependence, unspecified, uncomplicated", "E8352: Hypercalcemia", "E876: Hypokalemia", "E8342: Hypomagnesemia", "K7030: Alcoholic cirrhosis of liver without ascites", "D6959: Other secondary thrombocytopenia" ]

[ "N179", "I10" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nneck fracture\n \nMajor Surgical or Invasive Procedure:\n___ C5/6 corpectomy, C4-C7 ACDF\n___ C2-T2 posterior cervical fusion, C4-6 cervical \nlaminectomy\n\n \nHistory of Present Illness:\n___ year-old male who presents s/p intoxicated fall from ___\nstory balcony. He denies LOC, but sustained a laceration to his\nface. He complaining of neck, chest and right shoulder pain. CT\nof the cervical spine demonstrated comminuted C5-C7 fractures, \nT2\nsuperior endplate fracture. He also sustained a sternal \nfracture.\nHe denies numbness, tingling, weakness, or loss of bowel or\nbladder function. \n \nPast Medical History:\nETOH abuse\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nPHYSICAL EXAMINATION:\n\nGeneral: laceration/abrasions to face, Alert and interacting, \nbut\nappears intoxicated\nnl resp effort\nRRR\n \nSensory:\nUE \n C5 C6 C7 C8 T1\n (lat arm) (thumb) (mid fing) (sm finger) (med arm)\nR SILT SILT SILT SILT SILT\nL SILT SILT SILT SILT SILT\n\nT2-L1 (Trunk) \n SILT\n\n___ \n L2 L3 L4 L5 S1 S2\n (Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)\nR SILT SILT SILT SILT SILT SILT \nL SILT SILT SILT SILT SILT SILT \n\nMotor:\nUE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)\nR 5 5 5 5 5 5 5\nL 5 5 5 5 5 5 5\n\n___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___\nR 5 5 5 5 5 5 5 \nL 5 5 5 5 5 5 5\n\nReflexes \n Bic(C4-5) BR(C5-6) Tri(C6-7) Pat(L3-4) Ach(L5-S1)\nR 2 2 2 2 2\nL 2 2 2 2 2\n \n___: Negative\nBabinski: Downgoing\nClonus: No beats\n\nPostop:\ngen: awake, pleasant, Dressings with staining\nskin: warm and dry, incision are intact\n___: normal breathing\nabd: soft, nt\nextr: no c/c/e\nNeurologic: \nMotor Strength:\n Delt Bi Tri BR WF/WE HI\nRight 5 5 5 5 5 5 \nLeft 4+ 4+ 4- 4 4 4\n \n\n IP Quad Ham TA Gas ___\nRight 5 5 5 5 5 5 \nLeft 5 5 5 5 5 5\n\nSensation: dyesthesia bilateral C7/C8 distribution\n\n \nPertinent Results:\nTrauma Pelvis XR\n___\nIMPRESSION: \n \n1. No acute cardiopulmonary process. No obvious rib fractures. \n\n2. No fracture or dislocation involving the ___, hips, and \npartially imaged \nfemurs. \n\n___\nC/A/P CT\nIMPRESSION: \n \n \n1. Comminuted and displaced sternal fracture with surrounding \nhematoma and \nunderlying pulmonary contusion in the right middle lobe. \n2. Subtle focal irregularity of the superior T12 vertebral body \nwith subtle \nsuperior endplate depression, suspicious for T12 compression \nfracture. \n3. No additional acute fracture is identified. \n4. Small amount of hyperdense material between the right kidney \nand psoas \nmuscle most likely representing hematoma without active \nextravasation. \nAdjacent ureter appears patent but with short-segment luminal \nnarrowing. \nClose follow-up is recommended. \n5. No additional traumatic organ injury in the chest, abdomen, \nor pelvis. \n\nCt c-spine ___\n1. Multiple mildly displaced comminuted fractures through the \nC5, C6, and C7 \nvertebral bodies as described above, with traumatic kyphotic \nangulation at \nC5-C6 and extension into the spinal canal with fractures \ninvolving the C4, C5, \nC6 spinous processes, lamina and multiple levels, and right \nC5-C6 facet joint \nand possibly right C6-C7 facet joint. Additional acute \nanterosuperior \nendplate fracture of T2 is also noted. \n2. Extensive prevertebral edema from C2-C3 through T1-T2. \n\nCT head ___\n1. Large scalp hematoma over the vertex with skin laceration. \nNo underlying \ncalvarial fracture. No evidence of acute intracranial \nhemorrhage. \n\nCT Head angiogram ___\n1. Patent intracranial and cervical vasculature without \nhigh-grade stenosis, \nocclusion, or dissection. \n2. Numerous known comminuted fractures involving the mid to \nlower cervical \nspine are better delineated on the separately reported CT \ncervical spine \nexamination. \n3. For description of the intracranial parenchymal findings \nplease see the \nseparate CT head examination performed earlier on the same day. \n\nCervical spine MRI ___\n. Redemonstrated acute to subacute compression deformities of \nthe C5, C6 and \nC7 vertebral bodies with associated unchanged traumatic kyphotic \ndeformity at \nC5-C6. There is also evidence of acute to subacute compression \ndeformities of \nthe superior endplates of the T2 and T3 vertebral bodies with \nminimal loss of \nvertebral body height. \n2. Redemonstrated multilevel mildly displaced cervical spine \nfractures \nextending from C4 through C7, better described on the recent CT \ncervical spine \nstudy. \n3. Evidence of increased interspinous interval and ligamentum \nflavum \ndisruption at C4-C5 with findings suspicious for CSF leak at \nthis level. \n4. Extensive edema of the posterior paraspinal musculature \nextending from C2 \nthrough T1. \n5. Unchanged traumatic kyphotic angulation at C5-C6. \n6. Moderate prevertebral edema is likely trauma related. \n7. Degenerative changes of the cervical spine most significant \nat C5-C6 where \nsuperimposed traumatic kyphotic deformity results in mild spinal \ncanal \nnarrowing and flattening of the ventral cord without evidence of \nabnormal cord \nsignal. \n\npCXR ___\nIn comparison with the study of ___, the bilateral \nlayering pleural \neffusions are no longer seen. However, this appearance could \nmerely reflect a \nmore upright position of the patient. \nNo pneumonia, vascular congestion, or other abnormality. \nCervical fusion device is again seen. \n\n \nBrief Hospital Course:\nPatient was admitted to Orthopedic Spine Service on ___ in \nthe trauma ICU for further management. He underwent the above \nstated procedure on ___ and ___. Patient tolerated the \nprocedures well without complication. Please review dictated \noperative report for details. Patient remained intubated \npostoperative for respiratory failure and delirium tremens. He \nwas started on folate/thiamine IV and phenobarb for agitation \nand DTs. His neuro exam was monitored closely. \n\nHis ICU course is as follows:\n\n___- paresthesias in bilateral thumbs, consented to remain \nintubated x2d for procedures if needed > to OR for ACDF EBL 2.2L \n___, 2u pRBC, 4u FFP remained intubated (easy with \n___, lactate downtrending. plan for OR likely ___. started \nphenobarb load postop. BPs with MAPS in ___, UOP trending down > \ngave albumin bolus, expect Hct to continue slow downtrend for \nnow but holding off on blood. \n\n___- \n Neuro exam improved, only mild numbness in left ___ digit. \n Hct stable 23.7->24. \n Sedation increased and phenobarb rescue dosed for \nagitation/tremors. \n Hypercarbic on ASV with increased sedation. Switched to CMV but \nhypoxic with paO2 75-> PEEP increased to 8. CXR without \ncongestion or consolidation. \n TTE: LVEF 74%. Grade I (mild) left ventricular diastolic \ndysfunction. \n \n\n___: pt intermittently agitated, will write midaz PRN; pt to go \nto the OR today for posterior fusion, EBL 3.5 L, 6U PRBC, 2U \nPlts, 1U FFP; post op Hct 28, pt HDS and has to be flat for CSF \nleak. Pt anemic preop, got 1UPRBC. ankle XR showed ankle sprain, \ncan immobilize if uncomfortable/consult ortho. \n\n___: Og tube replaced. stays flat for 24h, until ___ on ___. \nwean propofol, add precedex. repeat CBC is 8.8/26.4. per spine, \nSQH restarted. concern for ? CSF leak on the blanket, ortho \nspine consulted- discussed with ___. will monitor. does not \nthink it is csf leak. \n\n___: \n Pt extubated in the AM, doing well from resp standpoint, good \nO2 sat on RA. NGT out, A-line out, +gas, -BM, Still agitated on \nprecedex, being weaned off. HLIV, foley still in, Neurochecks \nQ4H, lactulose added to bowel regimen, worked with ___: \nrecommending rehab \n\n___: pt continues on dex intermittently, was interactive and \nappropriate with friend today. will continue to monitor for \nagitation \n\n___: febrile with leukocytosis. plan is for fever workup with \nCdiff, UA, Blood culture, CXR. gabapentin TID. speech and \nswallow consult. plan to transfer to spine, no longer has ICU \nneeds. \n\nHe was transferred to floor in stable condition on ___. \nDuring the patient's course ___ were used for \npostoperative DVT prophylaxis. Diet was advanced as tolerated. \nFoley was removed in routine fashion and patient voided without \nincident. Hemovac was removed in routine fashion once the \noutput per 8 hours became minimal. \n\nHe was complicated by diarrhea on ___ and CDIFF was sent. \nOn ___, patient + for CDIFF and was started on flagyl po for \n10 days. His diarrhea improved as of ___. Neurologically he \nhad dysesthesia and numbness. He had LUE weakness secondary to \nspinal cord injury and jumped facet. Physical therapy and \nOccupational therapy were consulted for mobilization OOB to \nambulate and ADL's. \n\nNow, Day of Discharge, patient is afebrile, VSS, and neuro \nstable s/p SCI. He had LUE weakness and bilateral ulnar \nweaknessPatient tolerated a good oral diet and pain was \ncontrolled on oral pain medications. Patient ambulated without \nissues. Patient's wound is clean, dry and intact. Patient is \nset for discharge to home in stable condition.\n\n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \nRX *acetaminophen 650 mg ___ tablet(s) by mouth every eight (8) \nhours Disp #*120 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n3. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4. Gabapentin 300 mg PO Q8H \nRX *gabapentin 300 mg 1 capsule(s) by mouth every eight (8) \nhours Disp #*90 Capsule Refills:*1 \n5. MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days \nRX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three \ntimes a day Disp #*21 Tablet Refills:*0 \n6. OxycoDONE Liquid 5 mg PO Q3H:PRN Pain - Moderate \nRX *oxycodone 5 mg 1 tab by mouth Q4-6h Disp #*40 Tablet \nRefills:*0 \n7. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nc5 fx\nC6 fx\njumped facet fx\nCSF leak\nDelirium Tremens\nD-diff colitis\nspinal cord injury\nrespiratory failure\n\nalcohol abuse\nrespiratory failure\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent with Hard collar on at \nall times\n\n \nDischarge Instructions:\nACDF:\n You have undergone the following operation: Anterior Cervical \nDecompression and Fusion.\n1.When you are discharged from the hospital and settled at \nhome/rehab, if you do not have an appointment, please call to \nschedule two appointments: \n1.a wound check visit for 8 -14 days after surgery\n2.a post-operative visit with your surgeon for ___ weeks after \nsurgery. \n1.You can reach the office at ___ and ask to speak \nwith staff to schedule or confirm your appointments. \n\nWound Care\n•If not already done in the hospital, remove the incision \ndressing on day 2 after surgery. Keep the incision dry for the \nfirst two days after surgery. \n•There will often be small white strips of tape over the \nincision (steri-strips). These should be left alone and may get \nwet in the shower on day 3. \n•Starting on the third day, you should be washing your incision \nDAILY. While holding the head and neck still, gently clean the \nincision and surrounding area with mild soap and water, rinse \nand then pat dry. \n•Do not put any lotion, ointments, alcohol, or peroxide on the \nincision.\n•If you have a multi-level fusion and require a hard cervical \ncollar, this may be removed for showering, and often sleeping \nand eating. The collar will typically be removed at the week 4 \nvisit.\n•You may remove the compression stockings when you leave the \nhospital\n\n \n\n \n•Have someone look at the incision daily for 2 weeks. Call the \nsurgeon’s office if you notice any of the following: \n___ redness along the length of the incision \n___ swelling of the area around your incision \n___ from the incision \n___ of your extremities greater than before surgery \n \n___ of bowel or bladder control \n \n___ of severe headache \n___ swelling or calf tenderness \n \n \n___ above 101.5\n\n•At your wound check visit, the Nurse Practitioner or ___ \n___, will check your wound and remove any sutures or \nstaples or steri-strips. \n•Do not soak or immerse your incision in water for 1 month. For \nexample, no tub baths, swimming pools or jacuzzi.\n\n \n\nMedications\n• You will be given prescriptions for pain medications and stool \nsofteners upon discharge from the hospital.\n•Pain medications should be taken as prescribed by your surgeon \nor nurse practitioner/ physician ___. You are allowed to \ngradually reduce the number of pills you take when the pain \nbegins to subside. \n•If you are taking more than the recommended dose, please \ncontact the office to discuss this with a practitioner ___ \nmedication may need to be increased or changed).\n\n \n•Constipation: Pain medications (narcotics) may cause \nconstipation (difficulty having a bowel movement). It is \nimportant to be aware of your bowel habits so you ___ develop \nsevere constipation. Call the office if this occurs for more \nthan 3 days or if you have stomach pain.\n\n \n•Most prescription pain medications cannot be called into the \npharmacy for renewal. \n\n The following are 2 options you may explore to obtain a \nrenewal of your narcotic medications:\n1.Call the office ___ days before your prescription runs out and \nspeak with our office staff about mailing a prescription to your \nhome/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS) \n2.Call the office 24 hours in advance and speak with office \nstaff about coming into the office to pick up a prescription.\n\n \n•If you continue to require medications, you may be referred to \na pain management specialist or your medical doctor for ongoing \nmanagement of your pain medications. \n\n \n•Avoid NSAIDS for 12 weeks post-operative. These medications \ninclude, but are not limited to the following:\n•Non-Steroidal Anti-Inflammatory Agents: Advil, Aleve, Cataflam, \nClinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin, \nMedipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen, \nTolectin, Toradol, Trilisate, Voltarin\n\n \n\nActivity Guidelines\n•If you have a multi-level cervical fusion, you will be asked to \nwear a hard cervical collar. This is typically removed at week \n4 after surgery. You may not drive while wearing the collar.\n•You may remove your cervical collar for eating, sleeping, and \nwhen showering.\n•Avoid strenuous activity, bending, pushing, or reaching \noverhead. For example, you should not vacuum, do large loads of \nlaundry, walk the dog, wash the car, etc. until your follow-up \nvisit with your surgeon.\n•Avoid heavy lifting. Do not lift anything over ___ pounds for \nthe first few weeks that you are home from the hospital.\n•Increase your activities a little each day. Walking is a form \nof exercise. Exercise should not cause pain. Limit yourself to \nthings that you can do comfortably and plan rest periods \nthroughout the day.\n•You are not unless you are not taking narcotic medication and \nare not required to wear a collar. You may ride in a car for \nshort distances and avoid sitting in one position for too long. \n\n•You may resume sexual activity ___ weeks after surgery, \navoiding stress on the neck and shoulders. \n\n \n\nPhysical Therapy\n•Outpatient Physical Therapy (if appropriate) will not begin \nuntil after your post-operative visit with your surgeon. A \nprescription is needed for formal outpatient therapy. \n•You may be given simple stretching exercises or a prescription \nfor formal outpatient physical therapy, based on what your needs \nare after surgery.\n\n \n\nBlood Clots in the Leg \n1.It is not uncommon for patients who recently had surgery to \ndevelop blood clots in leg veins. \n•Symptoms include low-grade fever, and/or redness, swelling, \ntenderness, and/or an aching/cramping pain in your calf. \n•You should call your doctor immediately if you have these \nsymptoms. \n•To prevent blood clots in legs, try walking and/or pumping \nankles several times during the day. \n•If the blood clot breaks free from the leg vein, it can travel \nto the lungs and cause severe breathing difficulty and/or chest \npain. If you experience this, call ___ immediately.\n\n \n\nQuestions\n•Any questions may be directed to your surgeon or nurse \npractitioner/ physician ___. \n1.During normal business hours (8:30am- 5:00pm), you can call \nour office directly at ___. If no one picks up, \nplease leave a message and someone will get back to you. \n•If you are calling with an urgent medical issue, please go to \nnearest emergency room (i.e. pain unrelieved with medications, \nwound breakdown/infection, or new neurological symptoms).\n\n \n\nRigid Collar Instructions\n\n \n•How to put collar on:\n\n ___ collar is labeled front and back with arrows \nindicating top and bottom.\n___ the back section on your neck first. Apply the \nfront section placing your chin in the chin rest.\n___ securing the Velcro, make sure the front overlaps \nthe back section. This allows more Velcro to be exposed giving \nthe collar a more secure fit.\n___ the collar as tight as you can while remaining \ncomfortable. The tighter it is worn, the more immobilization of \nyour spine is obtained and the less likely you will move your \nneck.\n\n \n\n•Care for/during use:\n\n ___ alert to pressures under your chin. Some pressure \nis necessary but do not allow a blister or pressure sore to \ndevelop.\n___ provide comfort, you should wear the collar liners \nprovided between the brace and your chin to absorb perspiration \nand lessen irritation. We recommend that these liners be hand \nwashed. \n___ collar can be washed with mild soap and water, then \ndried with a towel and/or hair dryer on the lowest setting. \nHand washing is recommended.\n\n \n\n \n\nPosterior Cervical Fusion\n\nYou have undergone the following operation: Posterior Cervical \nDecompression and Fusion\n\nImmediately after the operation:\n\n• Activity:You should not lift anything greater \nthan 10 lbs for 2 weeks.You will be more comfortable if you do \nnot sit in a car or chair for more than~45 minutes without \ngetting up and walking around.\n\n• Rehabilitation/ Physical ___ times a \nday you should go for a walk for ___ minutes as part of your \nrecovery.You can walk as much as you can tolerate.Limit any kind \nof lifting. \n\n• Cervical Collar / Neck Brace:You need to wear \nthe brace at all times until your follow-up appointment which \nshould be in 2 weeks.You may remove the collar to take a \nshower.Limit your motion of your neck while the collar is \noff.Place the collar back on your neck immediately after the \nshower.\n\n• Wound Care:Remove the dressing in 2 days.If the \nincision is draining cover it with a new sterile dressing.If it \nis dry then you can leave the incision open to the air.Once the \nincision is completely dry (usually ___ days after the \noperation) you may take a shower.Do not soak the incision in a \nbath or pool.If the incision starts draining at anytime after \nsurgery,do not get the incision wet.Call the office at that \ntime.If you have an incision on your hip please follow the same \ninstructions in terms of wound care.\n\n• You should resume taking your normal home \nmedications\n\n• You have also been given Additional Medications \nto control your pain.Please allow 72 hours for refill of \nnarcotic prescriptions, so please plan ahead.You can either have \nthem mailed to your home or pick them up at the clinic located \non ___ 2.We are not allowed to call in narcotic \nprescriptions (oxycontin,oxycodone,percocet) to the pharmacy.In \naddition,we are only allowed to write for pain medications for \n90 days from the date of surgery.\n\n• Follow up:\n\n___ Please Call the office and make an \nappointment for 2 weeks after the day of your operation if this \nhas not been done already.\n\n___ At the 2-week visit we will check your \nincision, take baseline x rays and answer any questions.\n\n \n\nPlease call the office if you have a fever>101.5 degrees \nFahrenheit,drainage from your wound,or have any questions.\n\n \n\n \nFollowup Instructions:\n___\n" ]

[ "S12390A", "J9690", "S27321A", "S14109A", "S2220XA", "F10121", "A0472", "G960", "S22020A", "S12490A", "S12590A", "S12690A", "S93409A", "W109XXA", "Y9289", "S0101XA", "F17210", "F1290", "D649", "M5382" ]

[ "S12390A: Other displaced fracture of fourth cervical vertebra, initial encounter for closed fracture", "J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia", "S27321A: Contusion of lung, unilateral, initial encounter", "S14109A: Unspecified injury at unspecified level of cervical spinal cord, initial encounter", "S2220XA: Unspecified fracture of sternum, initial encounter for closed fracture", "F10121: Alcohol abuse with intoxication delirium", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "G960: Cerebrospinal fluid leak", "S22020A: Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture", "S12490A: Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture", "S12590A: Other displaced fracture of sixth cervical vertebra, initial encounter for closed fracture", "S12690A: Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture", "S93409A: Sprain of unspecified ligament of unspecified ankle, initial encounter", "W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "S0101XA: Laceration without foreign body of scalp, initial encounter", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1290: Cannabis use, unspecified, uncomplicated", "D649: Anemia, unspecified", "M5382: Other specified dorsopathies, cervical region" ]

[ "F17210", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nHigh blood sugars, labs showing acute on chronic kidney injury\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with a h/o renal transplant, CHF, AFib on \nCoumadin, DM who presented to the ED on ___ with \nhyperglycemia (600s) and worsening kidney function on routine \ntests at PCP. On ___, her blood glucose was 665, and her Hgb A1c \nwas found to be 12.7. Her creatinine was 2.1, up from 1.4 in \n___ (most recent value). Had been taking her home \nGlipizide as prescribed. She had been urinating frequently and \nhad a cold a few days prior to admission, but otherwise had no \nsymptomatic complaints. \n \nPast Medical History:\nATRIAL FIBRILLATION \nCHRONIC KIDNEY DISEASE \nDIABETES TYPE II \nHYPERLIPIDEMIA \nHYPERTENSION \nGALLSTONE PANCREATITIS S/P SPHINCTEROTOMY \nS/P RENAL TRANSPANT \nSYSTOLIC CONGESTIVE HEART FAILURE EF ___ \nSHINGLES - FOREHEAD \nDIABETES MELLITUS \nMITRAL REGURGITATION \nURINARY TRACT INFECTION \nRENAL TRANSPLANT ___ \nBILATERAL NEPHRECTOMIES ___ \nSPHINCTEROTOMY \nBREAST AUGMENTATION\n \nSocial History:\n___\nFamily History:\nSister RENAL TRANSPLANT\nDaughter POLYCYSTIC KIDNEYS\n \nPhysical Exam:\nPHYSICAL EXAM upon admission:\nVitals: 97.4 PO, 160 / 55, 71, 20, 97 Ra \nIntake: 480, outs not recorded\nGeneral: alert, oriented, no acute distress \nHEENT: sclera anicteric, slightly dry mucus membranes, \noropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Irregularly irregular rhythm, normal S1 + S2, no murmurs, \nrubs, gallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nGU: no foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNs2-12 intact, motor function grossly normal \n\nPHYSICAL EXAM upon discharge:\nVitals: 97.4 PO, 160 / 55, 71, 20, 97 Ra \nIntake: 480, outs not recorded\nGeneral: alert, oriented, no acute distress \nHEENT: sclera anicteric, slightly dry mucus membranes, \noropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Irregularly irregular rhythm, normal S1 + S2, no murmurs, \nrubs, gallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nGU: no foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNs2-12 intact, motor function grossly normal \n \nPertinent Results:\nLABS UPON ADMISSION\n___ 05:42PM BLOOD UreaN-46* Creat-2.1* Na-127* K-4.0 Cl-86* \nHCO3-22 AnGap-23*\n___ 05:42PM BLOOD Glucose-665*\n___ 05:42PM BLOOD WBC-7.9 RBC-3.54* Hgb-9.8* Hct-29.1* \nMCV-82 MCH-27.7 MCHC-33.7 RDW-14.1 RDWSD-41.6 Plt ___\n___ 05:42PM BLOOD %HbA1c-12.7* eAG-318*\n\n___ 12:15PM BLOOD Glucose-548* UreaN-47* Creat-1.9* Na-122* \nK-3.8 Cl-85* HCO3-21* AnGap-20\n___ 12:15PM BLOOD WBC-11.2* RBC-3.64* Hgb-10.1* Hct-30.0* \nMCV-82 MCH-27.7 MCHC-33.7 RDW-14.1 RDWSD-41.8 Plt ___\n___ 12:15PM BLOOD Neuts-90.2* Lymphs-6.1* Monos-2.1* \nEos-0.2* Baso-0.2 Im ___ AbsNeut-10.14* AbsLymp-0.68* \nAbsMono-0.24 AbsEos-0.02* AbsBaso-0.02\n\nLABS UPON DISCHARGE:\n___ 11:19AM BLOOD Glucose-221* UreaN-42* Creat-1.8* Na-130* \nK-3.1* Cl-91* HCO3-22 AnGap-20\n___ 05:56PM BLOOD Glucose-356* UreaN-43* Creat-1.9* Na-126* \nK-4.0 Cl-89* HCO3-23 AnGap-18\n___ 11:19AM BLOOD WBC-11.4* RBC-3.64* Hgb-10.1* Hct-30.1* \nMCV-83 MCH-27.7 MCHC-33.6 RDW-14.1 RDWSD-41.7 Plt ___\n___ 11:19AM BLOOD ___ PTT-35.5 ___\n\nIMAGING:\nRENAL US ___\nIMPRESSION: \n1. Patent renal transplant vasculature.\n2. Borderline to minimally elevated intrarenal resistive \nindices measuring up to 0.79 in the interpolar region.\n\nCXR ___\nIMPRESSION: \nPersistent small left and trace right pleural effusions and \ncardiomegaly. No pulmonary edema.\n\n \nBrief Hospital Course:\n___ with a history of renal transplant, CHF, AFib on Coumadin, \nDM who was admitted on ___ after she was found to have \nhyperglycemia (600s) and worsening renal function on routine lab \ntests at PCP (Cr 2.1 on ___, up from most recent 1.4 on \n___.\n\n# Hyperglycemia / T2DM: \nPt presented with significant hyperglycemia with ___ and \nelevated serum osms (but not meeting criteria for HHS). Treated \nwith insulin in ED and developed low K. Given her significantly \nelevated glucose and HbA1c, the patient requires insulin therapy \nfor glucose control. ___ was consulted and recommended the \nfollowing regimen: NPH 10 Units fixed dose in the morning and \nHumalog sliding scale at meals (see discharge paperwork for \nscale). Her electrolyte abnormalities resolved with repletion \nand intravenous fluids. Her home glipizide was held. \n\n# Acute on chronic kidney disease s/p renal transplant: She \npresented with Cr 2.1, though her Cr has been baseline 1.2-1.3 \nfor many years. Her acute presentation is likely due to \nhypovolemia in setting of hyperglycemia and gradual decline in \nkidney function. She was given intravenous fluids, and her \ncreatinine was followed closely. Her Lasix and Losartan were \nheld during admission due to her dehydration and ___. Her home \ncyclosporine, prednisone, and MMF were continued. Cr was not \nback to baseline upon discharge. Losartan and Lasix held at \ndischarge.\n\n# UTI: She was also found to have a urinalysis suggestive of \nUTI, culture pending. This infection likely developed in setting \nof acute on chronic hyperglycemia. Endorsed urinary sx. She was \ntreated with ceftriaxone 1g IV once daily and transitioned to \ncefpoxodime 500mg twice a day for a 7 day course (last dose \n___. Urine cultures were pending at the time of discharge.\n\n#Extensive discussions were had with patient and husband \nregarding discharge plan. We requested that the patient stay \novernight given the elevated Cr, pending urine cultures, \nelectrolyte abnormalities, and need for additional fluid \nrepletion and patient education. Patient insisted on discharge \nand agreed to help ensure very close follow-up.\n\nCHRONIC:\n# A-fib\nContinued home warfarin at 0.5 and 1mg alternating (note was \njust changed on ___ per ___ clinic because INR was high. \nContinued diltiazem, metoprolol and digoxin.\n\n# CHF\nECHO ___ with normal regional/global systolic function. \nMild-to-moderate mitral regurgitation. Moderate pulmonary \nhypertension. EF >55%. Per hx and exam, she was volume down. \nLasix was held.\n\n# Anxiety\nContinued home lorazepam\n\n# HTN\nLosartan held in setting of ___. Furosemide held in setting of \n___.\n\n# HLD\nContinued home atorvastatin and zetia.\n\n**TRANSITIONAL ISSUES**\n\nNEW MEDICATIONS:\nInsulin NPH 10 units at breakfast\nInsulin sliding scale Humalog (see discharge medications)\nCefpodoxime 100 mg PO BID, end date ___\n\nSTOPPED MEDICATIONS:\nGlipizide\nFurosemide (Lasix)\nLosartan\n\n-Pt needs close f/u with PCP, ___, and ___. PCP is \n___. Discussed with patient and family\n-Pt should have repeat labs on ___, chem 10 and INR. If her \ncreatinine is improved and she does not appear hypovolemic, \nplease restart her losartan and furosemide. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 5 mg PO DAILY \n2. Losartan Potassium 25 mg PO DAILY \n3. LORazepam 0.5 mg PO QHS:PRN anxiety \n4. Metoprolol Succinate XL 100 mg PO BID \n5. Diltiazem Extended-Release 120 mg PO DAILY \n6. Ezetimibe 10 mg PO DAILY \n7. Warfarin 1 mg PO EVERY OTHER DAY \n8. Atorvastatin 10 mg PO QPM \n9. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H \n10. Mycophenolate Mofetil 250 mg PO BID \n11. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \n12. Furosemide 60 mg PO BID \n13. Multivitamins 1 TAB PO DAILY \n14. GlipiZIDE XL 5 mg PO DAILY \n15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n16. Warfarin 0.5 mg PO EVERY OTHER DAY \n\n \nDischarge Medications:\n1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 10 Days \nRX *cefpodoxime 100 mg 1 tablet(s) by mouth twice per day Disp \n#*18 Tablet Refills:*0 \n2. NPH 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin \n3. Atorvastatin 10 mg PO QPM \n4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n5. CycloSPORINE (Neoral) MODIFIED 25 mg PO Q12H \n6. Diltiazem Extended-Release 120 mg PO DAILY \n7. Ezetimibe 10 mg PO DAILY \n8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \n9. LORazepam 0.5 mg PO QHS:PRN anxiety \n10. Metoprolol Succinate XL 100 mg PO BID \n11. Multivitamins 1 TAB PO DAILY \n12. Mycophenolate Mofetil 250 mg PO BID \n13. PredniSONE 5 mg PO DAILY \n14. Warfarin 1 mg PO EVERY OTHER DAY \n15. Warfarin 0.5 mg PO EVERY OTHER DAY \n16. HELD- Furosemide 60 mg PO BID This medication was held. Do \nnot restart Furosemide until you see your PCP or your kidney \ndoctor\n17. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until you see your PCP \nor kidney doctor\n18.Outpatient Lab Work\nChem 10, ___\nfax to:\n___, MD\n___, MD\n___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \nHYPERGLYCEMIA\nAcute kidney injury on chronic kidney injury\nComplicated urinary tract infection\nHyponatremia\nHypokalemia\nSECONDARY DIAGNOSIS: \nAtrial fibrillation\nRenal transplant\nCongestive heart failure\nAnxiety\nHypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou came to the hospital because you had very high blood sugar \nand bloodwork showing that your kidneys were not working as \nwell.\n\nWhile you were in the hospital, you were given insulin and \nintravenous fluids. Your Lasix and Losartan medications were \nheld because you were very dehydrated. Your electrolyte levels \nwere abnormal, which were repleted. You were also found to have \na urinary tract infection, which was treated with antibiotics. \n\nSince your blood sugars were so high, it is very important that \nyou take insulin every day, as prescribed. When you leave the \nhospital, you will also need to continue taking antibiotics \n(cefpodoxime 100 mg PO twice per day for 10 days) with last dose \non ___. \n\nNEW MEDICATIONS:\nInsulin NPH 10 units at breakfast\nInsulin sliding scale Humalog (see discharge medications)(we \nhave provided you with a chart that)\nCefpodoxime 100 mg PO twice a day through ___\n\nSTOPPED MEDICATIONS:\nGlipizide \nFurosemide (Lasix)\nLosartan\n\nMAKE AN APPOINTMENT WITH YOUR NEPHROLOGIST FOR WITHIN ONE WEEK - \nDr. ___ AN APPOINTMENT WITH YOUR PRIMARY CARE DOCTOR - Call \n___\nPLEASE ATTEND YOUR ___ APPOINTMENT\n\nPlease get your labs checked next ___.\n\nIt was a pleasure taking care of you.\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "E1165", "N179", "E1122", "I130", "N189", "I5022", "N390", "E871", "E876", "I482", "F419", "Z940", "Z794", "Z7901", "E785" ]

[ "E1165: Type 2 diabetes mellitus with hyperglycemia", "N179: Acute kidney failure, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "I5022: Chronic systolic (congestive) heart failure", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "E876: Hypokalemia", "I482: Chronic atrial fibrillation", "F419: Anxiety disorder, unspecified", "Z940: Kidney transplant status", "Z794: Long term (current) use of insulin", "Z7901: Long term (current) use of anticoagulants", "E785: Hyperlipidemia, unspecified" ]

[ "E1165", "N179", "E1122", "I130", "N189", "N390", "E871", "F419", "Z794", "Z7901", "E785" ]

[]

[ " \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:\nweakness, hypoxia secondary to superior vena cava syndrome\n \nMajor Surgical or Invasive Procedure:\nintubation ___\nLeft femoral line placement ___\nR femoral line placement\nLeft chest tube placement\nRadiation Therapy\nLeft PICC placement\n \nHistory of Present Illness:\n___ h/o COPD, CAD s/p CABG, pAfib on xarelto, CKD, HTN, HLD, L \nsupraclaviular mass dx as neuroendocrine tumor, who presented to \n___ on ___ for dehydration and failure to thrive. He did \nreport scapular pain and dyspnea on exertion x 4 weeks starting \nabout 2 months prior to presentation. Outpatient CT showed \nmediastinal lymphadenopathy and a supraclavicular mass. Biopsy \non ___ showed poorly differentiated neuroendocrine tumor. \nInitial plan was to start chemotherapy of etoposide and \ncarbaplantiunum x 3 days, as well as additioning to PET scan to \n___, however patient was unable to tolerate lying flat and PET \nscan was not performed. The patient was sent by his outpatient \noncologist to ___ on ___ for failure to thrive and \nhypotension with SBPs in the ___. CT scan on ___ showed \nmediastinal adenopathy and SVC compromise and rec'd radiation \nbut this was not done due to clinical decompensation. However, \nonce the disease is staged, if the patient has no sign of \nmetastatic disease, than chemotherapy would be curative. \n\nDuring his time at ___, his hospital course was notable for \nincreased upper extremity swelling, facial swelling, and \nincreased hypoxia. RUE ultrasound was negative for DVT. He had \nan increasing oxygen requirement from 2L to 7L. Given concern \nfor airway compromise, the patient was transferred to the \n___ ICU on ___. Due to lack of surgical backup at \n___, the patient was not intubated at ___ and \nsubsequently transferred here for further airway evaluation. \n\nOf note, the patient had a recent admission at ___ on \n___ for pneumonia, at which time he was treated with \nlevaquin.\n\nVital signs at the time of transfer were 97.6 80 160/76 19 96% \non high flow NC 8L.\nPhysical exam notable for facial flushing, able to speak in full \nsentences, RUE swelling.\nLabs prior to transfer notable for a WBC of 12.6, H/H ___, \nplatelets WNL. VBG 7.40/___. Cr 1.7. Lactate 3.8 -> 2.2. \nProcalcitonin <0.05 (undetectable).\n\nOn arrival to the MICU, the patient was hemodynamically stable \nwith pulse of 76 are blood pressure of 127/64. He had an \nincreased work of breathing using his abdominal muscles. He was \nsitting upright, unable to tolerate laying flat.\n \nPast Medical History:\n- Coronary artery disease w/LAD stent; now s/p CABG x3:\nLeft internal mammary artery to left anterior descending artery,\nsaphenous vein graft to diagonal and obtuse marginal arteries\n- Chronic obstructive pulmonary disease\n- hypertension\n- Congestive heart failure EF 40-45%.\n- Diabetes mellitus\n- Rectal Cancer ___ - treated w Chemo/ Rad followed by a \nsurgical\nprocedure to remove residual tumor via the rectum\n- Post traumatic stress disorder (pt is ___ veteran)\n- atrial fibrillation\n- CKD\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: No premature coronary artery disease, or \nneuroendocrine carcinomas\n \nPhysical Exam:\nMICU ADMISSION \n============================\nVitals: T 97.7 HR 76 BP 127/64 R 20 93% 6L NC\nGENERAL: fatigued, no acute distress\nHEENT: Sclera anicteric, noted ___ swelling with \nrightsided facial fullness. Difficult to visualize posterior \noropharynx\n___: Regular without murmurs\nRESP: Increased work of breathing with abnormal muscles. No \nstridor. RLL crackles\nABD: Non-tender, non-distended\nEXT: Warm, no edema ___, Mild edema RUE\nNEURO: CN II-XII intact. Strength ___ UE and ___ b/l\n\nDEATH EXAM ___ - ___)\n============================\nPupils non-reactive to light\nNo cardiac sounds auscultated\nNo respiratory effort seen\nTelemetry without cardiac electrical activity\n \nPertinent Results:\nADMISSION LABS: \n==============================\n___ 10:30PM WBC-12.1*# RBC-3.67*# HGB-10.9*# HCT-33.4* \nMCV-91 MCH-29.7 MCHC-32.6 RDW-14.0 RDWSD-46.3\n___ 10:30PM PLT COUNT-359#\n___ 10:30PM GLUCOSE-190* UREA N-48* CREAT-1.6* SODIUM-138 \nPOTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19\n___ 10:51PM freeCa-1.11*\n___ 10:30PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-2.4 URIC \nACID-8.3*\n___ 10:51PM LACTATE-2.3*\n\nDISCHARGE LABS: \n==============================\n___ 01:02PM BLOOD WBC-9.8 RBC-3.06* Hgb-8.9* Hct-26.2* \nMCV-86 MCH-29.1 MCHC-34.0 RDW-14.6 RDWSD-44.7 Plt ___\n___ 05:00AM BLOOD ___ PTT-67.6* ___\n___ 11:14AM BLOOD Glucose-161* UreaN-102* Creat-2.7* \nNa-131* K-3.9 Cl-89* HCO3-28 AnGap-18\n___ 05:00AM BLOOD ALT-27 AST-55* LD(LDH)-925* AlkPhos-93 \nTotBili-0.4\n___ 11:14AM BLOOD Calcium-7.0* Phos-6.0* Mg-1.8\n\nMICROBIOLOGY: \n==============================\n___ FLUID RECEIVED IN BLOOD CULTURE BOTTLES \nFluid Culture in Bottles-PRELIMINARY INPATIENT \n___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID \nCULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT \n___ URINE URINE CULTURE-FINAL INPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nINPATIENT \n___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY \nCULTURE-FINAL {YEAST} INPATIENT \n___ URINE URINE CULTURE-FINAL INPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ STOOL C. difficile DNA amplification \nassay-FINAL INPATIENT \n___ BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; \nRESPIRATORY CULTURE-FINAL {YEAST}; POTASSIUM HYDROXIDE \nPREPARATION-FINAL; FUNGAL CULTURE-PRELIMINARY {YEAST} INPATIENT \n___ MRSA SCREEN MRSA SCREEN-FINAL {STAPH AUREUS \nCOAG +} INPATIENT \n___ PLEURAL FLUID GRAM STAIN-FINAL; FLUID \nCULTURE-FINAL; ANAEROBIC CULTURE-FINAL \n\nPATHOLOGY: \n===============================\nPLEURAL FLUID, LATERALITY NOT SPECIFIED:\nPOSITIVE FOR MALIGNANT CELLS.\nConsistent with metastatic poorly-differentiated non-small cell \nneuroendocrine carcinoma.\nA few small groups of and scattered single atypical epithelioid \ncells are seen on the cell block\npreparation. Immunohistochemical stains show the atypical cells \nto be focally, weakly positive for\nsynaptophysin, and CK5/6. No immunoreactive cells for \nchromogranin are seen. The patient's prior\nslides of lymph node biopsy (___) were not available for \ncomparison. Drs. ___ and ___ were informed of the diagnosis via e-mail by Dr. ___ \non ___\n\nSTUDIES: \n===============================\n+ TTE ___: The left atrium is mildly dilated. There is \nmild symmetric left ventricular hypertrophy. The left \nventricular cavity size is normal. Due to suboptimal technical \nquality, a focal wall motion abnormality cannot be fully \nexcluded. Overall left ventricular systolic function is normal \n(LVEF = 65%). Right ventricular chamber size and free wall \nmotion are normal. The diameters of aorta at the sinus, \nascending and arch levels are normal. The aortic valve is not \nwell seen. There is no aortic valve stenosis. No aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. Trivial mitral regurgitation is seen. The left \nventricular inflow pattern suggests impaired relaxation. There \nis mild pulmonary artery systolic hypertension. There is a small \npericardial effusion. There are no echocardiographic signs of \ntamponade. \n \nBrief Hospital Course:\nMr. ___ is a ___ year-old man with recently-diagnosed \nmetastatic poorly-differentiated high-grade neuroendocrine \ncarcinoma (likely of pulmonary origin), with bulky \nretroperitoneal/common iliac/mediastinal lymphadenopathy \nconcerning for metastatic disease, who was admitted to ___ on \n___ with progressive dyspnea and hypoxemia thought to be at \nleast partially related to ___ syndrome from an enlarging \nchest/neck mass, which was treated with external radiotherapy. \nHospital course was been complicated by hypoxemic respiratory \nfailure requiring prolonged mechanical intubation, sepsis ___ \nobstructive pneumonia, acute kidney injury ___ acute tubular \nnecrosis, malignant pleural effusions requiring bilateral chest \ntube placement and hemodynamically unstable atrial fibrillation. \nMr. ___ was followed closely by numerous consulting services \n(Heme-Onc, Pulmonary, Radiation Oncology, Nephrology, Infectious \nDisease). He developed progressive multi-system organ failure \ndespite aggressive supportive care. Given his progressive \ndecline and based on family wishes, his care was transitioned to \na comfort focus and he was extubated with family at the bedside \nin accordance with his goals of care. He expired soon thereafter \nwith official time of death being ___ @ 18:36. Autopsy was \ndeferred. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 80 mg PO QPM \n2. Carvedilol 12.5 mg PO BID \n3. Diltiazem Extended-Release 240 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Fenofibrate 160 mg PO DAILY \n6. Levothyroxine Sodium 50 mcg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Rivaroxaban 15 mg PO DAILY \n9. SAXagliptin 2.5 mg oral DAILY \n10. GlipiZIDE XL 10 mg PO QAM \n11. GlipiZIDE XL 5 mg PO QPM \n12. LamoTRIgine 100 mg PO DAILY \n13. Omeprazole 20 mg PO DAILY \n14. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain \n- Moderate \n15. QUEtiapine Fumarate 25 mg PO QHS \n16. Fentanyl Patch 75 mcg/h TD Q72H \n17. Midodrine 5 mg PO TID \n\n \nDischarge Medications:\npatient expired\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\n- Superior Vena Cava Syndrome\n- Poorly differentiated neuroendocrine tumor \n- Acute Hypoxemic Respiratory failure \n- Healthcare associated pneumonia\n- Malignant Pleural Effusions\n- Acute tubular necrosis \n- Tumor lysis syndrome\n- New onset atrial fibrillation/flutter with rapid ventricular \nresponse.\n \nDischarge Condition:\nPatient expired\n\n \nDischarge Instructions:\nPatient expired\n \nFollowup Instructions:\n___\n" ]

[ "J9621", "J910", "J189", "N170", "E883", "I82412", "C7B8", "I5022", "I871", "C7A8", "J449", "I2510", "F17210", "Z951", "Z955", "E119", "Z85048", "F4310", "I4891", "Z515", "I129", "N189", "R410", "Z9981", "Z7902" ]

[ "J9621: Acute and chronic respiratory failure with hypoxia", "J910: Malignant pleural effusion", "J189: Pneumonia, unspecified organism", "N170: Acute kidney failure with tubular necrosis", "E883: Tumor lysis syndrome", "I82412: Acute embolism and thrombosis of left femoral vein", "C7B8: Other secondary neuroendocrine tumors", "I5022: Chronic systolic (congestive) heart failure", "I871: Compression of vein", "C7A8: Other malignant neuroendocrine tumors", "J449: Chronic obstructive pulmonary disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "E119: Type 2 diabetes mellitus without complications", "Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus", "F4310: Post-traumatic stress disorder, unspecified", "I4891: Unspecified atrial fibrillation", "Z515: Encounter for palliative care", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "R410: Disorientation, unspecified", "Z9981: Dependence on supplemental oxygen", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "J449", "I2510", "F17210", "Z951", "Z955", "E119", "I4891", "Z515", "I129", "N189", "Z7902" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PLASTIC\n \nAllergies: \nAspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee \nSting Kit / adhesive bandage / Caffeine\n \nAttending: ___.\n \nChief Complaint:\nSymptomatic macromastia\n \nMajor Surgical or Invasive Procedure:\nMAMMOPLASTY REDUCTION BILATERAL\n\n \nHistory of Present Illness:\n___ yo morbidly obese woman with multinodular goiter, sarcoid, \nHTN, SPinal stenosis, B TKAs, lami and fusion with symptomatic \nmacromastia. She is here today for bilateral breast reduction.\n \nPast Medical History:\nARTHRITIS \nBRAIN ANEURYSM \nHYPOTHYROIDISM \nMULTINODULAR GOITER \nLOW BACK PAIN \nHYPERSENSITIVITY \nRASH \nFRONTAL LOBE SYNDROME \nHEADACHE \nOBESITY \nROTATOR CUFF INJURY \nLYMPHADENOPATHY \nPULMONARY NODULE \nSARCOID \nRIGHT WRIST PAIN \n\n \nSocial History:\n___\nFamily History:\nPositive for breast cancer in the patient's mother. Brother and \nfather both status post CABG. Brother with type ___ diabetes.\n\n \nPhysical Exam:\nPhysical exam per PRS post op check ___ 1516 Temp: 97.7 PO BP: 112/72 L Lying HR: 66 RR: 16 O2\nsat: 94% O2 delivery: RA \n___ 1520 Dyspnea: 0 RASS: -1 Pain Score: ___ Pedal Pulses:\nLeft DPP: + Right DPP: + \n___ 1521 IV Solution: OR/PACU IVF IV Amt Infused: 1613ml \n___ 1521 Urine Amt: No Foley DTV@1600 \nGeneral: Sleepy, NAD\nMental/psych: A+Ox3\nchest: bilateral breasts soft, no evidence of hematoma. \nBilateral\nIMF incisions intact with small amount of bleeding around\nxeroform strip. Nipples intact with xeroform dressings. \nSurgibra\nin place.\nHeart: RRR\nLungs: CTAB\nAbd: Large, round and soft, NT.\nBLE: No ankle edema. Pneumoboots in place.\n\n \nBrief Hospital Course:\nThe patient was admitted to the plastic surgery service on \n___ and had a bilateral breast reduction. The patient \ntolerated the procedure well. \n .\n Neuro: Post-operatively, the patient was heavily sedated and \ndifficult to arouse. She was given narcan with good effect in \nthe PACU and then transferred to floor. Upon further assessment \non the floor, the patient, again, became difficult to arouse and \nwas given a repeat dose of narcan with good result. She became \nmuch more alert and responsive. Patient was monitored with \ncontinuous oxygen monitoring overnight for safety. \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. Her diet was advanced when appropriate, \nwhich was tolerated well. Intake and output were closely \nmonitored. \n .\n Prophylaxis: The patient was encouraged to get up and ambulate \nas early as possible. \n .\n At the time of discharge on POD#1, the patient was doing well, \nafebrile with stable vital signs, tolerating a regular diet, \nambulating with cane and assistance, voiding without assistance, \nand pain was well controlled. Bilateral breasts soft without \nevidence of hematoma, bilateral nipples warm, pink and viable. \n+ ___ ecchymosis about IMF incisions bilaterally. \nIncisions intact. Surgibra in place. Patient discharged to \nrehab facility due to inability to safely go up and down stairs. \n She lives alone and needs to be able to go up and down stairs. \nShe will continue work with ___ at rehab. \n\n \n \nMedications on Admission:\n1. Acetaminophen 650 mg PO Q6H pain \n2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n3. Calcium Carbonate 1000 mg PO BID \n4. Levothyroxine Sodium 50 mcg PO DAILY \n5. Minocycline 100 mg PO Q12H \n6. Multivitamins 1 TAB PO DAILY \n7. Pramipexole 0.25 mg PO TID \n8. Topiramate (Topamax) 50 mg PO BID \n9. trospium 60 mg oral DAILY \n10. Venlafaxine 200 mg PO QHS \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H pain \n2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n3. Calcium Carbonate 1000 mg PO BID \n4. Levothyroxine Sodium 50 mcg PO DAILY \n5. Minocycline 100 mg PO Q12H \n6. Multivitamins 1 TAB PO DAILY \n7. Pramipexole 0.25 mg PO TID \n8. Topiramate (Topamax) 50 mg PO BID \n9. trospium 60 mg oral DAILY \n10. Venlafaxine 200 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nsymptomatic macromastia\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 on ___ for a bilateral breast reduction. \nPlease follow these discharge instructions.\n .\n Personal Care: \n 1. You may remove any dressings from your incision sites 48 \nhours after surgery.\n2. You may shower 48 hours after surgery. \n 3. You should keep your surgibra in place. You may remove for \nlaundering and showering.\n 4. You may expect some drainage from your incisions for up to 1 \nmonth. \nTIP: You may pad your bras with clean ___ to absorb any \ndrainage. This provides a clean and absorbent dressing!\n . \n Activity: \n 1. You may resume your regular diet. \n 2. DO NOT lift anything heavier than 5 pounds or engage in \nstrenuous activity until instructed by Dr. ___. \n . \n Medications: \n 1. Resume your regular medications unless instructed otherwise \nand take any new meds as ordered. \n 2. You may take your prescribed pain medication for moderate to \nsevere pain. You may switch to Tylenol or Extra Strength Tylenol \nfor mild pain as directed on the packaging. \n 3. Take Colace, 100 mg by mouth 2 times per day, while taking \nthe prescription pain medication. You may use a different \nover-the-counter stool softener if you wish. \n 4. Do not drive or operate heavy machinery while taking any \nnarcotic pain medication. You may have constipation when taking \nnarcotic pain medications (oxycodone, percocet, vicodin, \nhydrocodone, dilaudid, etc.); you should continue drinking \nfluids, you may take stool softeners, and should eat foods that \nare high in fiber. \n 5. Do not take any medicines such as Motrin, Aspirin, Advil or \nIbuprofen, unless instructed to do so by Dr. ___.\n . \n Call the office IMMEDIATELY if you have any of the following: \n 1. Signs of infection: fever with chills, increased redness, \nswelling, warmth or tenderness at the surgical site, or unusual \ndrainage from the incision(s). \n 2. A large amount of bleeding from the incision(s) or drain(s). \n\n 3. Fever greater than 101.5 oF \n 4. Severe pain NOT relieved by your medication. \n . \n Return to the ER if: \n * If you are vomiting and cannot keep in fluids or your \nmedications. \n * If you have shaking chills, fever greater than 101.5 (F) \ndegrees or 38 (C) degrees, increased redness, swelling or \ndischarge from incisions, chest pain, shortness of breath, or \nanything else that is troubling you. \n * Any serious change in your symptoms, or any new symptoms that \nconcern you. \n\n \nFollowup Instructions:\n___\n" ]

[ "N62", "N6082", "N6081", "E6601", "Z6842", "E039", "E042", "G8929", "D869", "I10", "G4733", "M4802", "K589", "M170", "M545", "F329", "M25531", "R7303", "Z96653", "Z8679", "Z833", "Z8249", "Z803" ]

[ "N62: Hypertrophy of breast", "N6082: Other benign mammary dysplasias of left breast", "N6081: Other benign mammary dysplasias of right breast", "E6601: Morbid (severe) obesity due to excess calories", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "E039: Hypothyroidism, unspecified", "E042: Nontoxic multinodular goiter", "G8929: Other chronic pain", "D869: Sarcoidosis, unspecified", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M4802: Spinal stenosis, cervical region", "K589: Irritable bowel syndrome without diarrhea", "M170: Bilateral primary osteoarthritis of knee", "M545: Low back pain", "F329: Major depressive disorder, single episode, unspecified", "M25531: Pain in right wrist", "R7303: Prediabetes", "Z96653: Presence of artificial knee joint, bilateral", "Z8679: Personal history of other diseases of the circulatory system", "Z833: Family history of diabetes mellitus", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "Z803: Family history of malignant neoplasm of breast" ]

[ "E039", "G8929", "I10", "G4733", "F329" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAspirin / Adhesive Tape / Percocet / Erythromycin Base / Bee \nSting Kit / adhesive bandage / Caffeine\n \nAttending: ___.\n \nChief Complaint:\n20 lb weight gain, DOE\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old F w/ history of hypertension,\nobesity, osteoarthritis, hypothyroidism, and sarcoidosis\npresenting for evaluation of a 20 lb weight gain in 1 week, DOE,\nand lower extremity edema. She was seen by Cognitive Neurology\ntoday who sent her in for evaluation. She reports that she woke\nup approximately 3 days before admission with new lower \nextremity\nswelling, DOE, bendopnea, and orthopnea. She also endorses chest\npain while walking that stops with slowing down. On ___, she \nwas\n265 pounds and today her weight is 293. She denies any chest\npain. She also has had three weeks of rhinorrhea, sore throat,\nand a productive cough. \n\nIn the ED, initial vital signs were T 99 HR 87 BP 135/106 RR 22\nSPO2 96% RA. Her exam was notable for volume overload with\nbilateral crackles and lower extremity edema. proBNP was only\n221. TSH was normal. Hgb was newly decreased to 10.7. Urine\nalb/Cr ratio was high at 109 and she had a low total protein of\n5.8. ECG was unchanged from prior with sinus rhythm and\nborderline LVH. Bedside cardiac ultrasound reportedly performed,\nbut not documented anywhere. CXR in the ED showed pulmonary\nvascular congestion, so she was given 40 mg IV Lasix. \n\nUpon arrival to the floor, the patient reports the above story.\nShe is currently chest pain free, although notes dyspnea with\nwalking to the bathroom. Her legs feel lighter than before since\nshe received IV Lasix. This reminds her exactly of when she had\nstrep-induced nephritis at ___ years old. \n\nREVIEW OF SYSTEMS:\n==================\nCardiac review of systems is notable for absence of paroxysmal\nnocturnal dyspnea, palpitations, syncope, or presyncope. On\nfurther review of systems, denies any prior history of stroke,\nTIA, deep venous thrombosis, pulmonary embolism, bleeding at the\ntime of surgery, myalgias, hemoptysis, black stools or red\nstools. Denies exertional buttock or calf pain. Denies recent\nfevers, chills or rigors. All of the other review of systems \nwere\nnegative.\n \nPast Medical History:\n1. CARDIAC RISK FACTORS\n- Hypertension\n- Obesity \n\n2. CARDIAC HISTORY\n- CABG: None\n- PERCUTANEOUS CORONARY INTERVENTIONS: None\n- PACING/ICD: None\n- Mitral valve prolapse \n\n3. OTHER PAST MEDICAL HISTORY\n- Hypothyroidism, s/p partial thyroidectomy for multinodular\ngoiter \n- Sarcoidosis\n- Acute nephritis diagnosed at age ___\n- Urinary incontinence\n- Spinal stenosis, lumbar region with neurogenic claudication,\ns/p 3. Laminectomy lumbar L2-5, fusion I3-I5, instrumentation,\nbone\ngraft, ___ S.viridans PJI of right knee (___)\n- Chronic bilateral knee pain s/p bilateral total knee\nreplacement, ___\n- Cerebral aneurysm s/p clips \n- Pulmonary nodule \n- Irritable bowel syndrome \n- Hx of CCY, APPY, TAH/RSO \n- S/p remote CTS release \n \nSocial History:\n___\nFamily History:\nMother - breast cancer\nBrother - type ___ DM, CAD s/p CABG\nFather - CAD s/p CABG, iCM \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: 98.7 PO 154 / 84 74 20 92 ra \nGENERAL: Obese elderly woman sitting up in bed in no acute\ndistress\nHEENT: PERRL, EOMI, anicteric sclera, MMM, no oropharyngeal\nerythema or exudates, no rhinorrhea \nNECK: supple, no LAD, JVP @ 12 cm\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen obese, soft, multiple surgical scar, nontender in \nall\nquadrants, no rebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis or clubbing. 1+ pitting ___ to knees.\nBruising on knees \nPULSES: 1+ radial pulses bilaterally\nBACK: Buffalo hump present \nNEURO: Alert although sometimes forgetful when asked questions,\nCN intact, strength ___ x4 extremities, sensation to LT intact \nDERM: warm and well perfused, no excoriations or lesions, no\nrashes\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: 24 HR Data (last updated ___ @ 722)\n Temp: 97.7 (Tm 98.3), BP: 124/63 (117-142/63-75), HR: 64\n(64-75), RR: 16 (___), O2 sat: 96% (92-98), O2 delivery: RA,\nWt: 264.33 lb/119.9 kg \nGENERAL: Obese elderly woman, NAD\nHEENT: anicteric sclera\nNECK: supple, JVP not appreciated\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no increased work of breathing\nGI: abdomen obese, soft, nontender\nEXTREMITIES: No ___ edema\nPULSES: palpable distal pulses\nBACK: Buffalo hump present \nNEURO: alert, moves all four extremities with purpose\nDERM: warm and well perfused, no excoriations or lesions, no\nrashes\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 03:00PM BLOOD WBC-9.6 RBC-4.07 Hgb-10.7* Hct-35.6 \nMCV-88 MCH-26.3 MCHC-30.1* RDW-16.4* RDWSD-52.0* Plt ___\n___ 03:00PM BLOOD Neuts-77.9* Lymphs-12.4* Monos-7.1 \nEos-1.6 Baso-0.4 Im ___ AbsNeut-7.47* AbsLymp-1.19* \nAbsMono-0.68 AbsEos-0.15 AbsBaso-0.04\n___ 03:00PM BLOOD ___ PTT-28.2 ___\n___ 03:00PM BLOOD Glucose-97 UreaN-18 Creat-0.9 Na-147 \nK-4.6 Cl-110* HCO3-29 AnGap-8*\n___ 03:00PM BLOOD ALT-13 AST-20 AlkPhos-97 TotBili-0.2\n___ 03:00PM BLOOD cTropnT-<0.01 proBNP-221\n___ 03:00PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.4 Mg-2.0 \nCholest-188\n___ 03:00PM BLOOD VitB12-713\n___ 03:00PM BLOOD Triglyc-114 HDL-71 CHOL/HD-2.6 LDLcalc-94\n___ 03:00PM BLOOD TSH-0.84\n\nMICROBIOLOGY:\n=============\n___ 3:00 pm SEROLOGY/BLOOD\n\n **FINAL REPORT ___\n\n RAPID PLASMA REAGIN TEST (Final ___: \n NONREACTIVE. \n Reference Range: Non-Reactive. \n\nINTERVAL LABS:\n==============\n___ C1 ESTERASE INHIBITOR PROTEIN, Result 34, Ref ___ \nmg/dL\n___ COMPLEMENT, TOTAL (CH50), Result >60 H, Ref ___ U/mL\n\n___ 06:18AM BLOOD cTropnT-<0.01\n___ 01:18AM BLOOD %HbA1c-5.3 eAG-105\n___ 03:10PM BLOOD C3-134 C4-28\n\nIMAGING AND REPORTS:\n====================\nCHEST (PA & LAT) ___\nPulmonary vascular congestion without overt edema or focal \nconsolidation.\n\nTransthoracic Echo Report ___\nThe left atrial volume index is mildly increased. The right \natrium is moderately enlarged. There is no evidence for an \natrial septal defect by 2D/color Doppler\n. The estimated right atrial pressure is ___ mmHg. There is mild \nsymmetric left ventricular hypertrophy with a normal cavity \nsize. There is normal regional and global left ventricular \nsystolic function. Quantitative biplane left ventricular \nejection fraction is 56 %.\nThere is no resting left ventricular outflow tract gradient. No \nventricular septal defect is seen. Diastolic parameters are \nindeterminate. Normal right ventricular cavity size with mild \nglobal free wall hypokinesis. The aortic sinus diameter is \nnormal for gender with normal ascending aorta diameter for \ngender\n. The aortic arch diameter is normal. There is no evidence for \nan aortic arch coarctation. The aortic valve leaflets (3) are \nmildly thickened. There is no aortic valve stenosis. There is\nno aortic regurgitation. The mitral valve leaflets are mildly \nthickened with no mitral valve prolapse.\nThere is trivial mitral regurgitation. The tricuspid valve \nleaflets appear structurally normal. There is physiologic \ntricuspid regurgitation. The estimated pulmonary artery systolic \npressure is borderline elevated. There is a trivial pericardial \neffusion.\nIMPRESSION: Biatrial enlargement. Mild symmetric left \nventricular hypertrophy\n. Preserved biventricular systolic function. Borderline \npulmonary hypertension.\nCompared with the prior TTE ___, the findings are similar\n.\n\nDISCHARGE LABS:\n===============\n___ 08:14AM BLOOD WBC-7.6 RBC-4.39 Hgb-11.6 Hct-38.5 MCV-88 \nMCH-26.4 MCHC-30.1* RDW-16.5* RDWSD-52.8* Plt ___\n___ 08:14AM BLOOD Glucose-98 UreaN-34* Creat-1.0 Na-143 \nK-4.3 Cl-100 HCO3-32 AnGap-11\n___ 08:14AM BLOOD Calcium-9.7 Phos-4.1 Mg-2.2\n \nBrief Hospital Course:\nMs. ___ is a ___ year old F w/ history of hypertension,\nobesity, osteoarthritis, hypothyroidism, and sarcoidosis\nwho presented for evaluation of a 20 lb weight gain in 1 week, \nDOE,\nand lower extremity edema which improved after diuresis.\n\nACUTE PROBLEMS:\n===============\n# HFpEF\n# Volume overload\nPatient with 20 lb weight gain in one week, new ___ edema, DOE,\northopnea, and bendopnea. TTE w/ LVEF 56% and biatrial \nenlargement. Diastolic parameters were indeterminate, but \nclinical suspicion is for diastolic failure likely ___ obesity. \nDiastolic CHF likely given her symptoms. Renal disease or DI \nunlikely with unremarkable studies. Unlikely hypothyroidism \ngiven normal TSH, or liver disease given normal LFTs and no \nstigmata on exam. Euvolemic and back to baseline weight s/p \nLasix diuresis. Transitioned to Lasix 20 mg PO.\nAdmission Weight: 133.6 kg, 294.53 lb.\nDischarge Weight: 119.9 kg, 264.33 lb\n\n# Chest pain\nPatient endorsed exertional chest pain. Unclear if this is\nsimilar to pain she has had in the past when she had stress\ntests. ECG unchanged and trops negative x1. ___ be stable angina\nvs. severe DOE vs. pulmonary HTN vs. MSK. No evidence of\nmyocarditis or active ischemia. CP resolved. Should consider \npMIBI.\n\n# Acute normocytic anemia\n___ be secondary to dilution from acute volume overload. No\nhistory of bleeding. Hgb increased with diuresis.\n\nCHRONIC PROBLEMS:\n=================\n# Hypothyroidism\nContinued levothyroxine.\n\n# Hx of spinal hardware infection\nContinued home suppressive minocycline.\n\n# Memory loss\nSeeing Cognitive Neurology for poor short term memory. B12 and\nTSH normal. RPR negative. Continued topiramate.\n\n# GERD\nContinued omeprazole.\n\n# Restless legs\nContinued Pramipexole.\n\n# Insomnia\nContinued trazodone, venlafaxine.\n\n# Dry Eyes\nHeld home restasis; substituted for artificial tears.\n\n# Urinary urgency\nHeld home mirabegron and trospium given non-formulary\n\nTRANSITIONAL ISSUES:\n====================\n[] Consider pMIBI to further evaluate etiology of her chest \npain.\n[] Started on Lasix 20 mg PO on discharge. Titrate as needed and \nplease ensure the patient monitors her weight.\n[] Consider initiation of a statin.\n[] Please weigh yourself every day in the morning. Call your \ndoctor at if your weight goes up by more than 3 lbs. PCP: Dr. \n___ ___.\n[] Discharge Weight: 119.9 kg, 264.33 lb\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Calcium Carbonate 1000 mg PO BID \n2. L-Lysine (lysine) 500 mg oral BID \n3. Multivitamins 1 TAB PO DAILY \n4. Restasis 0.05 % ophthalmic (eye) BID \n5. Minocycline 100 mg PO Q12H \n6. Omeprazole 20 mg PO BID \n7. Pramipexole 0.25 mg PO TID \n8. Topiramate (Topamax) 50 mg PO BID \n9. TraZODone 100 mg PO QHS \n10. trospium 60 mg oral DAILY \n11. Venlafaxine 200 mg PO QHS \n12. mirabegron 25 mg oral DAILY \n13. Levothyroxine Sodium 50 mcg PO DAILY \n\n \nDischarge Medications:\n1. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*90 \nTablet Refills:*2 \n2. Calcium Carbonate 1000 mg PO BID \n3. L-Lysine (lysine) 500 mg oral BID \n4. Levothyroxine Sodium 50 mcg PO DAILY \n5. Minocycline 100 mg PO Q12H \n6. mirabegron 25 mg oral DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Omeprazole 20 mg PO BID \n9. Pramipexole 0.25 mg PO TID \n10. Restasis 0.05 % ophthalmic (eye) BID \n11. Topiramate (Topamax) 50 mg PO BID \n12. TraZODone 100 mg PO QHS \n13. trospium 60 mg oral DAILY \n14. Venlafaxine 200 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nHeart failure with preserved ejection fraction\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital for rapid weight gain and \nleg swelling.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You were given medication to remove fluid from your body. You \nshould continue to take this medication after you leave the \nhospital.\n- You got imaging of your heart. The study showed normal pumping \nfunction but part of the results were indeterminate. You should \nfollow-up with your PCP and cardiologist to review these \nresults.\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 weigh yourself every day in the morning. Call your \ndoctor at ___ if your weight goes up by more than 3 \nlbs. \n\nWe wish you the best!\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I5031", "Z6843", "R079", "D649", "E669", "E039", "R413", "K219", "G2581", "G4700", "H04129", "R3915" ]

[ "I5031: Acute diastolic (congestive) heart failure", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "R079: Chest pain, unspecified", "D649: Anemia, unspecified", "E669: Obesity, unspecified", "E039: Hypothyroidism, unspecified", "R413: Other amnesia", "K219: Gastro-esophageal reflux disease without esophagitis", "G2581: Restless legs syndrome", "G4700: Insomnia, unspecified", "H04129: Dry eye syndrome of unspecified lacrimal gland", "R3915: Urgency of urination" ]

[ "D649", "E669", "E039", "K219", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNeurontin\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___ Exploratory laparotomy\n___ EGD\n___ EGD nasojejeunal placed and bridled (removed ___ CT-guided placement of an ___ pigtail catheter into \nthe lesser sac collection. (removed ___\nPICC placement. \n\n \nHistory of Present Illness:\n___ man with multiple recent admissions for waxing\nand waning abdominal pain, history of EtOH/hep C cirrhosis, now\npresents with 24 hours of acutely worsening epigastric pain\nassociated with multiple episodes of emesis and dark stools. \nPatient states that his abdominal pain was at its baseline\nyesterday at which point he noticed an acute worsening of his\npain that he describes as sharp and in his upper abdomen. He\nalso had several episodes of emesis, reporting his vomit as \nbeing\ndark brown in character. Decided to re-present to ED for\nreevaluation of abdominal pain given acute worsening status. \nMost recently presented to the ED over the weekend where he got \na\nCT abdomen pelvis that did not show any acute interval changes\ncompared to prior scans. Was discharged home with expectant\nmanagement, transplant surgery was not consulted at that time. \nNow, underwent repeat CT scan showing free air and fluid in the\nlesser sac concerning for gastric perforation. Transplant\nsurgery is consulted for surgical management of this disease.\n\nROS:\n(+) per HPI\n\n \nPast Medical History:\n - Hepatitis C (genotype 3) \n - Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic \nencephalopathy, portal hypertension with ascites and esophageal \nvarices, portal hypertensive gastropathy \n - Gastric & Duodenal ulcers \n - Insomnia \n - Umbilical hernia \n - Sacral osteoarthritis \n \nPast Surgical History: \n - Umbilical hernia repair (___) \n -SBO requiring Ex lap & repair of ruptured umbilical hernia \nwith lysis of adhesions (___)\n - Abdominal Hematoma evacuation (___) \n - Abdominal incision opened, wound vac placed (___) \n \nSocial History:\n___\nFamily History:\nSister and brother both with \"collapsed lungs.\" No family \nhistory of liver disease.\n \nPhysical Exam:\nAdmission Physical Exam:\n=========================\nVitals: T 97.8 HR 96 BP 145/79 RR 20 100 RA\nGEN: A&O, uncomfortable appearing\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR\nPULM: No respiratory distress\nABD: Firm, tender to percussion in the epigastric region,\nguarding present, moderately distended, no fluid wave \nDRE: Deferred\nNeuro: CSM grossly intact x 4\nExt: No ___ edema, UE and ___ warm and well perfused bilat\n\nDischarge Physical Exam:\n=========================\nVS:97.5 95/56 65 18 99 Ra \nGENERAL: cachectic appearing older male, sitting up in bed, more\nconversant and interactive today. \nHEENT: anicteric sclera, temporal muscle wasting \nNeck: supple \nHEART: irregular rhythm, no m/r/g\nLUNGS: CTAB on anterior exam \nABDOMEN: protuberant but soft, +BS, tenderness to palpation\nin right upper quadrant, midline surgical incision with staples\nremoved, well healed, dressing over RLQ with drain place \ndraining\ndark brown serosanguineous fluid \nEXTREMITIES: no lower extremity edema, no clubbing or cyanosis\nSKIN: no jaundice, warm and dry \nNEURO: alert, oriented, no asterixis, moving all extremities \n\n \nPertinent Results:\nAdmission Labs: ___ 02:35AM \n================\nWBC-15.9*# RBC-3.39* Hgb-11.7* Hct-35.5* MCV-105* MCH-34.5* \nMCHC-33.0 RDW-14.7 RDWSD-56.3* Plt ___ PTT-29.5 ___\nGlucose-122* UreaN-15 Creat-0.5 Na-134* K-4.3 Cl-97 HCO3-22 \nAnGap-15\nALT-24 AST-63* AlkPhos-92 TotBili-2.5*\nLipase-24\nCalcium-6.8* Phos-3.7 Mg-1.7\nTriglyc-36\n\nMicrobiology\n============\nBlood Culture, Routine (Final ___: NO GROWTH. \nHELICOBACTER PYLORI ANTIBODY TEST (Final ___: NEGATIVE BY \nEIA.(Reference Range-Negative). \n \n___ 7:44 pm PERITONEAL FLUID PERITONEAL FLUID. \n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\nImaging:\n=========\nCT Abdomen Pelvis ___\nIMPRESSION: \n1. Free air and increased fluid within the lesser sac concerning \nfor \nperforated viscus, which could be from the stomach based on \nlocation. \n2. Mildly dilated small bowel bowel a transition point. This \ncould represent ileus versus partial small bowel obstruction. \nNo initial in of the bowel or pneumatosis. \n3. Cirrhotic liver with findings of portal hypertension \nincluding varices and ascites. \n\nUpper GI Contrast Study: ___\nIMPRESSION: Leak of contrast from the posterior antrum of the \nstomach. \n\nCXR: ___\nCOMPARISON: ___ \nIMPRESSION: Pulmonary edema has slightly worsened. \nCardiomediastinal silhouette is stable. Left-sided PICC line is \nunchanged the NG tube projects below the left hemidiaphragm. \nSmall bilateral effusions left greater than right are \nunchanged. No pneumothorax is seen \n\nCT Abdomen Pelvis ___\nIMPRESSION:\n1. A 8.5 x 5.9 cm loculated fluid collection with rim \nenhancement in the \nlesser sac is identified. Compared to ___, the fluid \ncollection \ndemonstrates thicker and more discrete wall. \n2. Small ascites and peritonitis is similar to before. \n3. Liver cirrhosis with mild splenomegaly and portosystemic \nshunt. \n4. Small bilateral pleural effusions.\n \nCT Abdomen for Interventional Procedure: ___\nIMPRESSION: Successful CT-guided placement of an ___ \npigtail catheter into the lesser sac collection. Samples were \nsent for microbiology evaluation. \n\nAbdominal Ultrasound ___:\nIMPRESSION: No fluid pocket amenable to percutaneous sampling. \nA diagnostic paracentesis was not performed. \n \n\nTransfer Labs: ___ 06:32AM\n===============\nWBC-5.0 RBC-2.99* Hgb-9.7* Hct-31.0* MCV-104* MCH-32.4* \nMCHC-31.3* RDW-17.1* RDWSD-64.6* Plt ___ PTT-28.8 ___\nGlucose-108* UreaN-15 Creat-0.5 Na-137 K-4.5 Cl-106 HCO3-24 \nAnGap-7*\nALT-18 AST-58* AlkPhos-194* TotBili-1.2\nAlbumin-2.2* Calcium-7.3* Phos-2.6* Mg-1.8\n\nDischarge Labs: ___ 05:55AM\n===============\nWBC-4.2 RBC-2.72* Hgb-9.0* Hct-28.7* MCV-106* MCH-33.1* \nMCHC-31.4* RDW-16.6* RDWSD-65.1* Plt ___\nGlucose-97 UreaN-14 Creat-0.5 Na-136 K-4.8 Cl-105 HCO3-21* \nAnGap-10\nALT-19 AST-59* AlkPhos-198* TotBili-1.2\nAlbumin-2.1* Calcium-7.3* Phos-2.6* Mg-1.8\n\n \nBrief Hospital Course:\nSummary: \n---------\nMr ___ is a ___ man with alcoholic and hepatitis C \ncirrhosis who presented with abdominal pain, and was found to \nhave a perforated inoperable duodenal and stomach ulcer. \n\nActive Issues:\n--------------\n# DUODENAL AND GASTRIC ULCERS with\n# ___ GUIDED DRAINAGE OF LESSER SAC COLLECTION:\nThe patient presented to the ___ Emergency Department with \nabdominal pain. There was evidence of perforated ulcer on both \nCT abdomen and upper GI series (posterior antral leak to lesser \nsac). Initially he was kept NPO with IV hydration and placed on \nbroad-spectrum antibiotics with pip-tazo and fluconazole from \n___. \nHe underwent EGD on ___ with the following finding: large \nulcer measuring approximately 5-6cm was seen in the first part \nof the duodenum. There was likely perforation around the edge \nof the ulcer measuring 2-3cm -This appeared contained. The \nperforation was too large for endoscopic intervention. There was \nalso moderate to severe esophagitis in the distal esophagus with \nportal hypertensive gastropathy seen. H. pylori was negative. He \nwas put on the maximum dose of PPI. A NG was in place. \nHe underwent exploratory laparotomy by Dr. ___, but \nwas found to have a frozen abdomen thus unable to see perforated \nstomach. Postop, he was transferred to the SICU for management \nas he was hypotensive and hematocrit had decreased. He was given \nalbumin and 4 units of PRBC. Hct stabilized, but on ___, he \nhad brief episode of SVT with rate of 160 without blood pressure \ndrop; afib with intermittent RVR that was treated with \nmetoprolol IV x 2 with decrease in BP. The patient required \npressors and amiodarone was started (please see #Afib below). \n\nHe transferred out of the SICU and was started on TPN. Afib was \nmanaged with metoprolol. Metoprolol dose was increased and he \nwas given intermittent doses of Lasix for volume control and \npulmonary edema seen on CXR. \n\nHis diet was initially advanced to clears then full liquids. \nHowever, he did not tolerate advancement to a regular diet. He \nexperienced a lot of abdominal pain. Diet was changed to just \nsips of clears and pain was managed with a Dilaudid PCA. His \ndiet was eventually changed to tube feeds and then regular diet \nas per an initial goals of care discussion. An abdominal CT \n___ an 8cm loculated fluid collection in lesser \nsac. He then underwent ___ placement of a drain in the \nfluid collection. Microbiology evaluation of the fluid \ncollection did not grow any organisms, so antibiotics were \ndiscontinued on ___. ___ continued to follow the drain until \noutput was < 5cc for 2 consecutive days, at which point the \ndrain was pulled. Diet was advanced slowly for comfort, with \nsupplemental nutrition from nasogastric tube feeds. After a \ngoals of care meeting on ___, Pt endorsed a desire to \ntransition towards measures that would improve his comfort. In \nlight of this, his NGT was pulled ___ and he was permitted a \nregular PO diet, which he tolerated well. Patient was continued \non sucralfate for continued gastric coating and comfort. PPI \nand other unnecessary medicines were held.\n\n# GOALS OF CARE DISCUSSION:\nPt with poor prognosis due to his perforated viscus, surgically \nfrozen abdomen, and non-transplant candidacy. A goals of care \nmeeting was held on ___ with the patient and his friend, as \nwell as newly-chosen HCP, ___. At this meeting, Pt \nacknowledged the severity of his illness and endorsed a \nwillingness to transition his course more towards \ncomfort-focused care. Medicines that would not contribute to \nhis comfort were discontinued. Unnecessary tubes and lines, \nincluding his NGT and PICC line, were removed prior to \ndischarge. Patient was discharged to a ___ facility for \nhousing and further titration of his care.\n\n# ETOH/HCV CIRRHOSIS with\n# ASCITES and\n# NEED FOR SBP PPX:\nPreviously complicated by hepatic encephalopathy, ascites, grade \nI esophageal varices. Pt without significant hepatic \nencephalopathy or large ascites during his hospital stay; he was \ninitially put on oral diuretics to minimize the ascites and risk \nof wound dehiscence, but these were held in the setting of \nsignificant weight loss while on tube feeds and overall hypo- to \neuvolemic appearance on exam. Patient was continued on Bactrim \nfor SBP prophylaxis. He was continued on lactulose to keep his \nmental status clear. Given goals of care discussion as above, \nvitamins such as thiamine and multivitamin were discontinued.\n\n# ATRIAL FIBRILLATION:\nHad one episode of Afib on ___, for which he was amiodarone \nloaded and started on amio gtt. He was stable on PO metoprolol \nin-house, though sometimes limited due to soft blood pressures. \nHe had a CHADS-VASC of 0. Given his goals of care discussion at \ndischarge, PO metoprolol was discontinued. Anticoagulation was \ndeferred given recent surgery as well as goals of care \ndiscussion as above.\n\n# NUTRITION:\nInitially requiring TPN, then tube feeds by ___. He \ncontinued to lose muscle mass despite optimal nutrition on TF's. \n After goals of care discussion ___, patient was provided with \na regular diet - which he tolerated well. \n\nTRANSITIONAL ISSUES:\n--------------------\n# CODE STATUS: DNR/DNI, CMO, Do not Hospitalize\n# CONTACT: Friend/HCP, ___ (___)\n\n[ ] GOALS OF CARE:\n- Pt transitioned to DNR/DNI and comfort measures only, given \nhis poor prognosis and lack of surgical alternatives for his \nmedical conditions.\n\n[ ] PAIN MANAGEMENT:\n- If patient is requiring more than 3 daily doses of oxycodone \nfor breakthrough pain, consider uptitrating his TID oxyconTIN \nfor further long-lasting pain relief.\n\n[ ] MEDICATION CHANGES:\n- Added: Oxycodone 10mg PO q2h:PRN breakthrough pain, \nacetaminophen 500mg Q6H, Bactrim DS 1 tab daily, lidocaine \npatch, oxyconTIN 20mg PO TID, sucralfate 1gm PO QID, \npolyethylene glycol 17g daily\n- Changed: Lactulose (QID -> TID), Bactrim (1 SS tab -> 1 DS \ntab for SBP Ppx)\n- Stopped: Metoprolol, Vitamins, furosemide, lansoprazole\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Famotidine 20 mg PO BID \n2. Furosemide 20 mg PO DAILY \n3. Lactulose 30 mL PO QID \n4. Spironolactone 50 mg PO DAILY \n5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis \n6. Polyethylene Glycol 17 g PO DAILY \n7. Bisacodyl ___AILY:PRN constipation \n8. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Potassium Chloride 20 mEq PO DAILY \n11. Simethicone 40-80 mg PO TID:PRN gas pain \n12. Thiamine 100 mg PO DAILY \n13. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - \nModerate \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg NG Q6H \n2. Lidocaine 5% Patch 1 PTCH TD QAM \napply to abdomen\nremove in pm \n3. OxyCODONE SR (OxyconTIN) 20 mg PO TID abdominal pain \nRX *oxycodone 5 mg/5 mL 20 mL by mouth three times a day \nRefills:*0 \n4. Simethicone 40-80 mg PO TID:PRN gas pain \n5. Sucralfate 1 gm PO QID \n6. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY \n7. OxyCODONE (Immediate Release) 10 mg PO Q2H:PRN BREAKTHROUGH \nPAIN \nRX *oxycodone 5 mg/5 mL 10 mL by mouth every 2 hours Refills:*0 \n8. Bisacodyl ___AILY:PRN constipation \n9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n10. Lactulose 30 mL PO TID \n11. Multivitamins 1 TAB PO DAILY \n12. Polyethylene Glycol 17 g PO DAILY \n13. Thiamine 100 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\nGastric perforation, frozen abdomen.\nDuodenal ulcer\nEsophagitis\n\nSECONDARY DIAGNOSES:\nportal hypertensive gastropathy\nanemia\nmalnutrition\nCirrhosis\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were having pain in your abdomen. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You were found to have a hole in your intestine (perforated \nulcer), that could not be repaired due to scarred down tissue in \nyour abdomen (frozen abdomen)\n- You were given antibiotics to prevent infection\n- You had a temporary drain placed in your abdomen to drain an \ninfection, and this was removed. \n- You initially were given a feeding tube to bypass the hole, \nbut as it healed from the inside, you were able to eat regular \nfood. \n- Because you were so sick and there was no cure for your \nadvance liver disease and holes in your stomach and intestines, \nyou chose hospice care. \n\nWHAT SHOULD I DO WHEN I GO HOME\n-Take medications to help your pain\n-Eat for comfort\n\nThank you for letting us be a part of your care!\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K265", "E43", "J811", "D688", "K766", "D6959", "D62", "I471", "I959", "K255", "I4891", "K209", "B182", "K7031", "F1011", "K660", "K3189", "Z5309", "G8929", "I8510", "Z66", "Z515", "R0902", "D638", "Z590", "Z6824", "K449", "Z720" ]

[ "K265: Chronic or unspecified duodenal ulcer with perforation", "E43: Unspecified severe protein-calorie malnutrition", "J811: Chronic pulmonary edema", "D688: Other specified coagulation defects", "K766: Portal hypertension", "D6959: Other secondary thrombocytopenia", "D62: Acute posthemorrhagic anemia", "I471: Supraventricular tachycardia", "I959: Hypotension, unspecified", "K255: Chronic or unspecified gastric ulcer with perforation", "I4891: Unspecified atrial fibrillation", "K209: Esophagitis, unspecified", "B182: Chronic viral hepatitis C", "K7031: Alcoholic cirrhosis of liver with ascites", "F1011: Alcohol abuse, in remission", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "K3189: Other diseases of stomach and duodenum", "Z5309: Procedure and treatment not carried out because of other contraindication", "G8929: Other chronic pain", "I8510: Secondary esophageal varices without bleeding", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "R0902: Hypoxemia", "D638: Anemia in other chronic diseases classified elsewhere", "Z590: Homelessness", "Z6824: Body mass index [BMI] 24.0-24.9, adult", "K449: Diaphragmatic hernia without obstruction or gangrene", "Z720: Tobacco use" ]

[ "D62", "I4891", "G8929", "Z66", "Z515" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nTylenol / Neurontin\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ man presents for evaluation of abdominal pain. \nPatient recently hospitalized for acute exacerbation of his\nchronic abdominal pain, likely partial bowel obstruction. \nDischarged yesterday after undergoing conservative management of\nlikely partial bowel obstruction; of note at the time of\ndischarge he was pain-free and tolerating a regular diet, as \nwell\nas having bowel function. Also had repeat ultrasound of liver\nwhich showed resolution of prior portal vein partially occlusive\nthrombus. Patient reports arriving to his daughter's home, \nhaving\na cup of tea and dinner without issue. However overnight his\nabdominal pain recurred and he decided to come back in for\nevaluation. He denies any nausea or vomiting, has not had a\nbowel movement since leaving the hospital yesterday. Denies any\nfevers, chills, dysuria, chest pain, shortness of breath,\nnumbness, tingling. Transplant surgery is consulted to evaluate\nfor surgical causes of recurrent abdominal pain.\n\nROS:\n(+) per HPI\n\n \nPast Medical History:\n - Hepatitis C (genotype 3) \n - Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic \nencephalopathy, portal hypertension with ascites and esophageal \nvarices, portal hypertensive gastropathy \n - Gastric & Duodenal ulcers \n - Insomnia \n - Umbilical hernia \n - Sacral osteoarthritis \n \nPast Surgical History: \n - Umbilical hernia repair (___) \n -SBO requiring Ex lap & repair of ruptured umbilical hernia \nwith lysis of adhesions (___)\n - Abdominal Hematoma evacuation (___) \n - Abdominal incision opened, wound vac placed (___) \n \nSocial History:\n___\nFamily History:\nSister and brother both with \"collapsed lungs.\" No family \nhistory of liver disease.\n \nPhysical Exam:\nAdmission Exam:\n==================\nVITAL SIGNS: 97.9 65 165/75 16 99% RA \nGENERAL: AAOx3 NAD\nHEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no \nLAD\nCARDIOVASCULAR: R/R/R\nPULMONARY: CTA ___, No crackles or rhonchi\nGASTROINTESTINAL: protuberant, soft, more distended than usual,\ntender to palpation in right hemi-abdomen, left hemi-abdomen\nmildly tender, No guarding, rebound, or peritoneal signs.\nEXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion.\nNEUROLOGICAL: Reflexes, strength, and sensation grossly intact\n.\nDischarge Exam:\n===================\nVS: 97.8 123/72 70 18 98% RA \nGENERAL: NAD, patient appears chronically ill, sunken temples,\nA&Ox3 \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nadentulous\nNECK: supple, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: protuberant abdomen, not tense, decreased bowel sounds.\nTender to moderate palpation, mostly on R side. Multiple \nsurgical\nscars appearing c/d/i.\nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4\nextremities with purpose \nPULSES: 2+ DP pulses bilaterally \nNEURO: CN II-XII intact \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes\n \nPertinent Results:\nLabs on admission:\n========================\n___ 07:00AM BLOOD WBC-5.7 RBC-3.43* Hgb-11.5* Hct-35.6* \nMCV-104* MCH-33.5* MCHC-32.3 RDW-14.9 RDWSD-57.2* Plt ___\n___ 07:45AM BLOOD WBC-5.9 RBC-3.49* Hgb-11.7* Hct-36.4* \nMCV-104* MCH-33.5* MCHC-32.1 RDW-14.7 RDWSD-57.0* Plt ___\n___ 07:00AM BLOOD ___ PTT-35.6 ___\n___ 07:45AM BLOOD ___\n___ 04:42AM BLOOD Glucose-90 UreaN-4* Creat-0.7 Na-136 \nK-4.6 Cl-102 HCO3-26 AnGap-8*\n___ 04:42AM BLOOD ALT-17 AST-50* AlkPhos-110 TotBili-2.4*\n.\nMicrobiology:\n========================\n \n___ 7:31 am PERITONEAL FLUID PERITONEAL FLUID. \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.. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n.\n\n___ 07:31AM ASCITES TNC-37* RBC-92* Polys-1* Lymphs-30* \nMonos-8* Basos-1* Macroph-60*\n___ 07:31AM ASCITES TotPro-0.4 Glucose-101\n.\n.\nReports/imaging:\n========================\nRUQ ultrasound:\nIMPRESSION: \n1. Cirrhotic liver, without evidence of focal lesion. \n2. Mild to moderate ascites and a right pleural effusion. \n3. Patent main and right portal vein with appropriate direction \nof flow. \n.\nAbdominal XR:\nIMPRESSION: \nBorderline diameter of a single loop of small bowel with a few \nsmall \nnonspecific small bowel air-fluid levels and air seen in the \ncolon. Findings are nonspecific, but a very early/very mild \npartial small bowel obstruction is not entirely excluded in the \nappropriate clinical setting. \n.\nCT abd and pelvis with contrast\nIMPRESSION: \n1. Redemonstration cirrhotic liver with sequela of portal \nhypertension. New branching hypoattenuation in segments VIII \nand ___ may be due to periportal edema or inflammation along \nintrahepatic biliary ducts, the latter possibly related to \ncholangitis. The main portal vasculature is patent. \n2. Moderate amount of ascites, as on prior. Mild peritoneal \nenhancement \nwithout free air or drainable fluid collections, could represent \nperitonitis or secondary to recent paracentesis. \n.\nLabs on discharge:\n========================\n___ 06:32AM BLOOD WBC-6.6 RBC-2.84* Hgb-9.8* Hct-29.5* \nMCV-104* MCH-34.5* MCHC-33.2 RDW-14.2 RDWSD-54.1* Plt ___\n___ 06:32AM BLOOD Glucose-109* UreaN-7 Creat-0.7 Na-133* \nK-4.3 Cl-100 HCO3-24 AnGap-9*\n___ 06:32AM BLOOD ALT-17 AST-50* AlkPhos-104 Amylase-110* \nTotBili-1.7*\n___ 07:00AM BLOOD Lipase-42\n___ 06:32AM BLOOD Lipase-32\n___ 06:32AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.___ with Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic \nencephalopathy, portal hypertension with ascites and esophageal \nvarices, portal hypertensive gastropathy; hx numerous abdominal \nsurgeries with suspected frozen abdomen, chronic abdominal pain \nwith subacute worsening. Patient had recent admission with small \nbowel obstruction that was treated conservatively with NG tube \nand bowel rest and resolved, who went home with decreased pain \nmed regimen, and who is now returning with worsening abdominal \npain. \n.\n#Abdominal pain\nCT abd pain pelvis showed no obstruction or extravasation of \ncontrast. Patient was first placed on home pain regiment (oxy \n10mg q6hr) with improvement of pain, but given increased pain at \n4hours after oxy dose, chronic pain service recommended a \nregimen of 7.5mg oxy every 4 hours, which better controlled \npain. Lidocaine patch attempted for back pain but without \nnoticeable change. Patient was eating regular diet and with \nongoing ___ pain but appearing comfortable, walking, \neating and passing soft stool.\n.\n#Cirrhosis\nWith regards to cirrhosis, Child's Class C due EtOH and HCV, \nwith past hepatic\nencephalopathy, portal hypertension with ascites and esophageal \nvarices, portal hypertensive gastropathy. No evidence of \ndecompensation during this hospitalization. Para was done that \ndid not show SBP.\n.\nTRANSITIONAL ISSUES:\n[] CHANGED oxycodone 10mg q6hr to 7.5mg q4hr with improvement in \npain control\n[] STARTED miralax, thiamine\n[] Please consider outpatient pain consult if worsening pain\n[] CONTACT: ___ (HCP, sister) ___\n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Famotidine 20 mg PO BID \n2. Furosemide 20 mg PO DAILY \n3. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain \n4. Spironolactone 50 mg PO DAILY \n5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis \n6. Simethicone 40-80 mg PO TID:PRN gas pain \n7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n8. Lactulose 30 mL PO QID \n9. Multivitamins 1 TAB PO DAILY \n10. Potassium Chloride 20 mEq PO DAILY \n11. Bisacodyl ___AILY:PRN constipation \n\n \nDischarge Medications:\n1. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 scoop \npowder(s) by mouth daily Disp #*1 Package Refills:*0 \n2. Simethicone 40-80 mg PO TID:PRN gas pain \n3. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0 \n4. OxyCODONE (Immediate Release) 7.5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone [Oxaydo] 7.5 mg 1 tablet(s) by mouth every 4 hours \nDisp #*42 Tablet Refills:*0 \n5. Bisacodyl ___AILY:PRN constipation \n6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n7. Famotidine 20 mg PO BID \n8. Furosemide 20 mg PO DAILY \n9. Lactulose 30 mL PO QID \nTitrate to ___ bowel movements daily \n10. Multivitamins 1 TAB PO DAILY \n11. Potassium Chloride 20 mEq PO DAILY \n12. Spironolactone 50 mg PO DAILY \n13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\n=============\nCirrhosis\nIntermittent abdominal pain of unknown origin\nIntraabdominal bowel adhesions\n.\nSecondary:\n=============\nHistory of multiple abdominal surgeries\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 at ___ \n___. You were seen for increasing abdominal \npain. A number of tests, including laboratory and a CT scan were \nreassuring. You were initially on the surgical service, but the \nsurgical team did not feel there was any problem requiring \nsurgery. You were seen by the chronic pain service that made an \nadjustment to the dose and timing of your pain medication. \nPlease take this new dose as prescribed. Please take the new \nmedications as prescribed.\n.\nPlease call the surgery doctor, ___ office at \n___ if you are having increasing abdominal pain, \ninability to tolerate diet, not passing gas or having bowel \nmovements, nausea, vomiting or any other concerning GI \ncomplaints.\n.\nYou are likely to be having intermittent abdominal pain. Please \nwork with your primary care physician regarding your pain \nmanagement strategies.\n.\nNo driving if taking narcotic pain medication.\n.\nTry to eat small frequent meals, using no additional salt, stay \nhydrated.\n.\nWe wish you the best,\nYour ___ care team\n\n \nFollowup Instructions:\n___\n" ]

[ "K660", "E43", "K766", "Z720", "K7031", "Z6820", "R1084" ]

[ "K660: Peritoneal adhesions (postprocedural) (postinfection)", "E43: Unspecified severe protein-calorie malnutrition", "K766: Portal hypertension", "Z720: Tobacco use", "K7031: Alcoholic cirrhosis of liver with ascites", "Z6820: Body mass index [BMI] 20.0-20.9, adult", "R1084: Generalized abdominal pain" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nTylenol / Neurontin\n \nAttending: ___\n \nChief Complaint:\nRUQ abdominal pain, vomiting, diarrhea\n \nMajor Surgical or Invasive Procedure:\n-diagnostic para ___\n\n \nHistory of Present Illness:\nMr ___ is a ___ year old man with cirrhosis (EtOH/HCV \nuntreated, genotype 3)Child Class C, complicated by esophageal \nvarices, ascites, and encephalopathy, chronic abdominal pain and \nmultiple prior abdominal surgeries, presenting with 3 days of \nmore severe RUQ pain, vomiting, and diarrhea. \n\nAfter a several month stay in rehab in ___ following his \nlast ___ hospitalization in ___, the patient has been doing \nwell at home. In his usual state of health, he has chronic RUQ \nabdominal pain, and is followed by his PCP and hepatologist; \npatient states that his pain has been attributed to possibly \nscar tissue from his several abdominal surgeries. He was \npreviously on fentanyl patch for this but is now on oxycodone \n10mg QID. ___ checked ___. Last filled oxycodone 10mg 30 \nday supply (120 pills) ___. \n\nHe has Child's class C cirrhosis but overall his ascites and \nhepatic encephalopathy are well controlled with \nLasix/spironolactone and lactulose. Prior paracentesis was \n\"Several years ago.\" \n\nHe developed his present symptoms 3 days ago, with the subacute \nonset of worsening RUQ pain (stabbing, constant with waves of \nmore severe pain, worse with vomiting, no change with \neating/position/movement). For the past 3 days he has also had \n___ episodes per day of vomiting (clear/yellow fluid, no blood \nor coffee-ground emesis), and has been unable to tolerate food, \nor fluids, and thinks he has also vomited pills (although has \nbeen trying to stay compliant with his regimen). He has also \nbeen having multiple episodes per day of watery/yellow fluid \ndiarrhea (no blood or melena). \n\nHis ROS is positive for chills/sweats, and fatigue. His \nabdominal distention is moderate but stable. But he denies \nfevers, myalgia/arthralgias, HA, URI symptoms, visual complaint, \nchest pain/pressure, dyspnea, cough, rash, bruising, lower \nextremity edema. No recent travel, sick contacts, or recent \nraw/uncooked/spoiled food.\n\nHe presented to the ED for further evaluation. \n\nIn the ED, initial vitals were: Temp. 98.0, HR 82, BP 157/82, RR \n22, 100% RA \n- Exam notable for: RUQ tenderness to palpitation, abdomen \ndistended but soft \n--Bedside abdominal ultrasound showed small volume of ascites \nwithout a pocket amenable to paracentesis. \n\n- Labs notable for: \n--WBC 5.4, Hgb 14.0, plt 181 \n--Na 130, K 4.8, HCO3 15, creatinine 0.8, glucose 144, BUN 9 \n--ALT 32, AST 127, alk phos 145, Tbili 4.7, albumin 2.8 \n--lactate 2.6, repeat lactate 1.7 \n--INR 1.4, PTT 38.7 \n\n- Imaging was notable for: \nCT abdomen ___: \n1. Cirrhosis with evidence of portal hypertension with moderate \nvolume ascites partially loculated in the right upper quadrant, \nextensive portosystemic varices. ***Partially occlusive thrombus \nin the main portal vein. *** \n2. Small bowel distention without obstruction may reflect ileus. \nMild thickening of the proximal colon may reflect portal \ncolopathy. \n3. Trace right pleural effusion with chronic appearing \natelectasis in the right lower lung. \n4. Extensive atherosclerotic disease of the aorta. \n \nLiver US ___: \n1. There is a new nonocclusive thrombus within the main portal \nvein with extension into the left and right portal vein \nbranches. There is normal hepatopetal flow within the main \nportable vein and evidence of sluggish flow within the left and \nright portal vein branches. \n2. Large volume ascites. \n3. Worsening splenomegaly measuring 13.7 cm today, previously \nmeasuring 12 cm ___.\n4. New 1.6 cm focus within the right hepatic lobe is \nincompletely characterized. Follow-up MR for further evaluation \nis recommended.\n\n- Patient was given: \n--morphine 4mg IV x2 \n--ondansetron 4mg IV \n--1L normal saline \n--started on heparin drip \n\nUpon arrival to the floor, patient reports continued abdominal \npain in the RUQ, and being very thirsty and a little hungry. \n\nREVIEW OF SYSTEMS: \n (+) Per HPI \n (-) 10 point ROS reviewed and negative unless stated above in \nHPI\n \nPast Medical History:\n - Hepatitis C (genotype 3) \n - Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic \nencephalopathy, portal hypertension with ascites and esophageal \nvarices, portal hypertensive gastropathy \n - Gastric & Duodenal ulcers \n - Insomnia \n - Umbilical hernia \n - Sacral osteoarthritis \n \nPast Surgical History: \n - Umbilical hernia repair (___) \n -SBO requiring Ex lap & repair of ruptured umbilical hernia \nwith lysis of adhesions (___)\n - Abdominal Hematoma evacuation (___) \n - Abdominal incision opened, wound vac placed (___) \n \nSocial History:\n___\nFamily History:\nSister and brother both with \"collapsed lungs.\" No family \nhistory of liver disease.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==============================\nVITAL SIGNS: BP 115 / 77 hr 64 RR18 SPO2 98 Ra \nGENERAL: chronically ill appearing man, resting in bed in \nmoderate discomfort. Able to move around in bed without obvious \nincrease in pain. Alert, fully conversant, very pleasant. \nHEENT: NCAT. Dry oral mucosa. No scleral icterus. Conjunctivae \nwhite. No JVD. \nNECK: full ROM, no masses \nCARDIAC: RRR, no murmurs, no lower extremity edema \nLUNGS: CTAB, unlabored breathing on ambient air \nABDOMEN: moderately distended, but soft. Moderately tender in \nRUQ. Umbilical hernia site intact, non-tender. Dull to \npercussion, no fluid wave. Normal bowel sounds. Collateral \nvessels faintly visible in abdominal wall \nEXTREMITIES: warm, no edema. No asterixis \nNEUROLOGIC: alert, fully oriented. CN exam normal. \nStrength/sensation intact. Gait not tested. No asterixis or \ntremor. \nSKIN: no rashes, no jaundice \n\nDISCHARGE PHYSICAL EXAM:\n==============================\nVS: 98.1 PO 106 / 68 R Lying 68 18 96 Ra \nGENERAL: chronically ill appearing man, resting in bed in \nmoderate discomfort. \nHEENT: NCAT. MMM. No scleral icterus\nCARDIAC: RRR, no murmurs, no lower extremity edema \nLUNGS: CTAB, unlabored breathing on ambient air \nABDOMEN: moderately distended, but soft. Moderately tender in \nRUQ. Umbilical hernia site intact, non-tender. Normal bowel \nsounds. Collateral vessels faintly visible in abdominal wall \nEXTREMITIES: warm, no edema. No asterixis \nNEUROLOGIC: alert, fully oriented. CN exam normal. \nStrength/sensation intact. Gait not tested. No asterixis or \ntremor. \nSKIN: no rashes, no jaundice\n \nPertinent Results:\nADMISSION LABS:\n==========================\n___ 09:36AM BLOOD WBC-5.4 RBC-3.97* Hgb-14.0 Hct-42.2 \nMCV-106* MCH-35.3* MCHC-33.2 RDW-14.2 RDWSD-56.4* Plt ___\n___ 09:36AM BLOOD Neuts-65.3 ___ Monos-10.4 Eos-1.9 \nBaso-1.7* Im ___ AbsNeut-3.51 AbsLymp-1.08* AbsMono-0.56 \nAbsEos-0.10 AbsBaso-0.09*\n___ 11:21AM BLOOD ___ PTT-38.7* ___\n___ 09:36AM BLOOD Glucose-144* UreaN-9 Creat-0.8 Na-130* \nK-4.8 Cl-101 HCO3-15* AnGap-19\n___ 09:36AM BLOOD ALT-32 AST-127* AlkPhos-145* TotBili-4.7*\n___ 09:36AM BLOOD Albumin-2.8*\n___ 05:00AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.4*\n___ 09:44AM BLOOD Lactate-2.6*\n\nDISCHARGE LABS:\n==========================\n___ 04:46AM BLOOD WBC-5.1 RBC-3.46* Hgb-12.3* Hct-37.0* \nMCV-107* MCH-35.5* MCHC-33.2 RDW-14.2 RDWSD-55.5* Plt ___\n___ 04:46AM BLOOD ___ PTT-36.8* ___\n___ 04:46AM BLOOD Glucose-93 UreaN-9 Creat-0.9 Na-133 K-4.2 \nCl-99 HCO3-26 AnGap-12\n___ 04:46AM BLOOD ALT-21 AST-63* AlkPhos-159* TotBili-2.3*\n___ 04:46AM BLOOD Albumin-2.4* Calcium-8.0* Phos-3.6 Mg-1.6\n\nPERTINENT RESULTS:\n==========================\n___ 01:55PM ASCITES TNC-64* RBC-650* Polys-1* Lymphs-48* \nMonos-6* Mesothe-2* Macroph-43* Other-0\n___ 01:55PM ASCITES TotPro-1.7 Glucose-103 LD(LDH)-104 \nAlbumin-0.7 Cholest-19\n___ 08:58PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE\n\nMICROBIOLOGY:\n==========================\n___ 1:55 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES\n PERITONEAL FLUID. \n\n Fluid Culture in Bottles (Preliminary): NO GROWTH.\n\n___ 1:48 pm PERITONEAL FLUID PERITONEAL FLUID. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.\n\nIMAGING:\n==========================\n___\nIMPRESSION:\n1. Cirrhosis with new partially occlusive thrombus within the \nmain portal \nvein.\n2. Large volume ascites. \n3. Worsening splenomegaly measuring 13.7 cm today, previously \nmeasuring 12 cm ___.\n4. New 1.6 cm focus within the right hepatic lobe is \nincompletely characterized. Follow-up MR for further evaluation \nis recommended.\n\n___\nIMPRESSION:\nTiny right pleural effusion, otherwise unremarkable exam.\n\n___\nIMPRESSION:\n1. Cirrhosis with evidence of portal hypertension with moderate \nvolume ascites partially loculated in the right upper quadrant, \nextensive portosystemic varices. Partially occlusive thrombus \nin the main portal vein.\n2. Small bowel distention without obstruction may reflect ileus. \n Mild thickening of the proximal colon may reflect portal \ncolopathy.\n3. Trace right pleural effusion with chronic appearing \natelectasis in the right lower lung.\n4. Extensive atherosclerotic disease of the aorta.\n \nBrief Hospital Course:\n___ year old man with cirrhosis (EtOH/HCV untreated, genotype 3) \nChild Class C, complicated by esophageal varices, ascites, and \nencephalopathy, chronic abdominal pain and multiple prior \nabdominal surgeries, presenting with 3 days of acute on chronic \nRUQ pain, vomiting, and diarrhea likely ___ viral \ngastroenteritis. C.diff negative, norovorius negative. \nDiagnostic para w/ no e/o SBP. Stool Cx pending at time of \ndischarge. Patient was given IV fluids with spontaneous \nresolution (though persistent chronic RUQ pain).\n\nHospital course complicated by new non-occlusive PVT, lactate \nslightly elevated on initial presentation normalized with IVF \nless c/f ischemia. Outpatient hepatologist (Dr. ___ was \ncontacted who recommended against anticoagulation given \nnon-occlusive, and concerns with patient compliance.\n\nOtherwise no changes to home medications.\n\n======================\nACUTE ISSUES\n======================\n\n#Abdominal pain, vomiting, diarrhea: presented with 3 days of \nacute on chronic RUQ pain, vomiting, and diarrhea likely ___ \nviral gastroenteritis. C.diff negative, norovorius negative. \nDiagnostic para w/ no e/o SBP. Stool Cx pending at time of \ndischarge. Patient was given IV fluids with spontaneous \nresolution (though persistent chronic RUQ pain). Of note RUQ U/S \nand CT A/P w/ e/o non-occlusive PVT, though unlikely explanation \nfor presentation as non-occlusive w/ down-trending lactate. \n\n#Partially occlusive portal vein thrombosis: iso decompensated \ncirrhosis; RUQ ultrasound and CT abdomen with contrast \ndemonstrated partially occlusive portal vein thrombus, new since \n___ ultrasound. Lactate slightly elevated on initial \npresentation normalized with IVF less c/f ischemia. Outpatient \nhepatologist (Dr. ___ was contacted who recommended against \nanticoagulation given non-occlusive, and concerns with patient \ncompliance.\n \n\n#Hyponatremia : Admitted w/ serum sodium 130. Per history, \nmultiple days of low fluid intake, diarrhea, vomiting, while \ncontinuing to take diuretics suggested he was intravascularly \ndepleted. Resolved s/p 1L IVF, and resolution of gastroenteritis \nw/ improved PO intake. Home diuretics restarted upon discharge.\n\n#Cirrhosis: Child's Class C, complicated by ascites, hepatic \nencephalopathy, prior SBP, esophageal varices. \n -volume: home Lasix/spironolactone initially held iso n/v/d, \nresumed upon discharge.\n -hepatic encephalopathy - cont home lactulose after resolution \nof diarrhea\n -SBP ppx - cont home Bactrim \n -esophageal varices - last EGD in ___ no evidence of bleeding \non this presentation;\n\nTransitional Issues:\n==========================\n-On RUQ U/S: There is a 1.6 cm echogenic focus within the mid \nright hepatic lobe, peripherally, for which follow-up MR for \nfurther evaluation is recommended.\n-Patient w/ new non-occlusive PVT. Would recommend f/u CT in 3 \nmonths to eval for progression of PVT thrombus.\n-Stool cultures pending at time of discharge, please follow up\n\n # CODE: full \n # CONTACT: sister/HCP ___ ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Furosemide 20 mg PO DAILY \n2. Lactulose 30 mL PO TID \n3. Spironolactone 50 mg PO DAILY \n4. Famotidine 20 mg PO Q12H \n5. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN Pain - \nModerate \n6. Multivitamins 1 TAB PO DAILY \n7. Potassium Chloride 10 mEq PO DAILY \n8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n\n \nDischarge Medications:\n1. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n2. Famotidine 20 mg PO Q12H \n3. Furosemide 20 mg PO DAILY \n4. Lactulose 30 mL PO TID \n5. Multivitamins 1 TAB PO DAILY \n6. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 10 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*8 Tablet Refills:*0 \n7. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n8. Potassium Chloride 10 mEq PO DAILY \nHold for K > \n9. Spironolactone 50 mg PO DAILY \n10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n=======================\n-viral gastroenteritis\n\nSecondary Diagnosis:\n======================\n-ETOH/HCV Cirrhosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr ___,\n\nIt was a pleasure being involved in your care.\n\nWhy you were here:\n-You came in for nausea/vomiting/diarrhea.\n\nWhat we did while you were here :\n-We gave you some fluids through your IV because you were \ndehydrated. We believe that you had a viral illness, which \ncleared on its own.\n-We also took some fluid out of your abdomen to make sure you \nwere not having an infection, and this was negative for any \ninfection.\n\nYour next steps:\n-please take all your medications as indicated below\n-please keep all of your appointments\n\nWe wish you well,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "A084", "I81", "R188", "E872", "K766", "E871", "K7469", "K7290", "Z720" ]

[ "A084: Viral intestinal infection, unspecified", "I81: Portal vein thrombosis", "R188: Other ascites", "E872: Acidosis", "K766: Portal hypertension", "E871: Hypo-osmolality and hyponatremia", "K7469: Other cirrhosis of liver", "K7290: Hepatic failure, unspecified without coma", "Z720: Tobacco use" ]

[ "E872", "E871" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nTylenol / Neurontin\n \nAttending: ___.\n \nChief Complaint:\nAcute Abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThis patient is a ___ year old male, with ETOH and Hep C\ncirrhosis, child's class B (MELD 16) presenting to the ED with\nacute abdominal pain concerning for recurrent bowel obstruction.\nPatient is now being seen by Transplant surgery in consultation.\n\nAs above, the patient has a history of cirrhosis secondary to\nboth ethanol and Hep C. Currently compensated. Last paracentesis\nperformed ___ years ago. His surgical history is pertinent for a\nprior umbilical repair, and an exploratory laparotomy for a\nclosed loop obstruction requiring lysis of an internal hernia.\nThe patient was in his usual state of health until last night\nwhen he developed an acute abdominal pain. He describes the pain\nas stabbing in nature and constant. The pain is located in his\nright flank. He has had around 10 episodes of bilious emesis.\nDenies hematemesis. Last episode of vomiting was this morning at\n10:00. He has not felt better after the emesis triggering this \nED\nvisit. He describes this pain similar in nature as prior one \nlast\nyear when he required exploration. The patient endorses chills\nbut denies any fever, chest pain, SOB, dysuria, or urinary\nurgency or frequency. He last passed gas this morning and has\nnot had a bowel movement in the last two days.\n\nIn the ED, VSS. Patient with persistent nausea. No NG in place.\nAbdomen soft but tender to right flank. No peritoneal. Labs w/o\nleukocytosis or acidosis. Imaging studies c/w distal ileum bowel\nobstruction. No signs of bowel ischemia. Moderate ascites. \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:\n - Hepatitis C (genotype 3) \n - Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic \nencephalopathy, portal hypertension with ascites and esophageal \nvarices, portal hypertensive gastropathy \n - Gastric & Duodenal ulcers \n - Insomnia \n - Umbilical hernia \n - Sacral osteoarthritis \n \nPast Surgical History: \n - Umbilical hernia repair (___) \n -SBO requiring Ex lap & repair of ruptured umbilical hernia \nwith lysis of adhesions (___)\n - Abdominal Hematoma evacuation (___) \n - Abdominal incision opened, wound vac placed (___) \n \nSocial History:\n___\nFamily History:\nSister and brother both with \"collapsed lungs.\" No family \nhistory of liver disease.\n \nPhysical Exam:\nVitals: 98.1, 121/70, 57, 18, 98% 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, tender to deep palpation to right flank. No rebound.\nAscites. Dull to percussion.\nExt: No ___ edema, ___ warm and well perfused\n.\nWeight at discharge: 64.5 kg\n \nPertinent Results:\nLabs on Admission: ___\nWBC-6.1 RBC-4.29* Hgb-14.8 Hct-44.0 MCV-103* MCH-34.5* MCHC-33.6 \nRDW-15.7* RDWSD-56.9* Plt ___ PTT-38.3* ___\nGlucose-121* UreaN-9 Creat-0.7 Na-138 K-4.4 Cl-100 HCO3-24 \nAnGap-14\nALT-27 AST-102* AlkPhos-135* TotBili-4.1*\nAlbumin-3.1* Calcium-8.5 Phos-4.2 Mg-1.6\n.\nLabs at Discharge: ___\nWBC-5.8 RBC-3.88* Hgb-13.3* Hct-39.9* MCV-103* MCH-34.3* \nMCHC-33.3 RDW-15.7* RDWSD-58.6* Plt ___\nGlucose-145* UreaN-6 Creat-0.8 Na-136 K-5.3* Cl-105 HCO3-23 \nAnGap-8\nALT-18 AST-54* AlkPhos-94 TotBili-3.8*\nCalcium-7.6* Phos-3.7 Mg-1.___ y/o male with HCV, ETOH cirrhosis with prior ex-lap who now \npresents with acute abdominal pain.\n\nOn admission the patient had a CT done with findings suspicious \nfor partial small bowel obstruction with adhesive disease in the \nright lower quadrant involving loops of ileum with alternating \nareas of luminal narrowing and dilatation. Overall, the \nappearance of the small bowel is similar to the previous CT from \n___. \nOf note there is liver cirrhosis with small to moderate ascites, \nmild splenomegaly, and portosystemic varices. There is also a \nnonocclusive small thrombus in the main portal vein which is \nslightly smaller compared to ___. \n\nAn NG tube was placed, and he was having bilious output from the \nNG tube. He reported passing some flatus, and the abdominal pain \nwas present but stable on exam.\n\nOn hospital day two, he was reporting an increase in abdominal \npain. A KUB was done showing that there was no evidence of free \nair. The abdominal exam still showed him to be soft, and serial \nexams over the next ___ hours showed him to be less tender.\n\nA suppository was given resulting in a loose bowel movement and \nhe was reporting passing some flatus still. The NG tube output \nwas lightening in colr and less volume. Prior to the NG tube \nbeing discontinued, another KUB was obtained, with no evidence \nof obstruction. \n\nThe NG tube was removed and he was kept NPO for the next ___ \nhours. He had no nausea with tube removed, and so he was started \non a clear diet which he tolerated without nausea or vomiting. \nThe abdominal exam was significantly improved so he was deemed \nsafe for discharge with plan for clears for three days.\n\nLiver function tests were slightly improved at discharge. \n\nAdditionally the patient has a follow up appointment with his \nhepatologist this week which the patient was advised to keep. \nHome medications including diuretics were resumed at discharge. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Famotidine 20 mg PO BID \n2. Fentanyl Patch 50 mcg/h TD Q72H \n3. Furosemide 20 mg PO DAILY \n4. Lactulose 30 mL PO QID \n5. Lidocaine 5% Patch 1 PTCH TD QAM \n6. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - \nModerate \n7. Potassium Chloride 20 mEq PO DAILY \n8. Spironolactone 50 mg PO DAILY \n9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n10. Bisacodyl 10 mg PR QHS:PRN constipation \n11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n12. Polyethylene Glycol 17 g PO DAILY \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PR QHS:PRN constipation \n2. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n3. Famotidine 20 mg PO BID \n4. Fentanyl Patch 50 mcg/h TD Q72H \n5. Furosemide 20 mg PO DAILY \n6. Lactulose 30 mL PO QID \n7. Lidocaine 5% Patch 1 PTCH TD QAM \n8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - \nModerate \n9. Polyethylene Glycol 17 g PO DAILY \n10. Potassium Chloride 20 mEq PO DAILY \n11. Spironolactone 50 mg PO DAILY \n12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSmall bowel obstruction: Resolved\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPlease call Dr. ___ office at ___ if you have fever \ngreater than 101, chills, nausea, vomiting, constipation, you \nare not passing gas, you have a lot of hiccupping or burping, \nyour abdomen is becoming more distended, you have pain in your \nabdomen or any other concerning symptoms.\n\nContinue all your home medications as they have been prescribed \nto you. Follow up with your primary providers if you have \nquestions about those medications.\n\nTo help your bowel heal and not become obstructed again, you \nshould continue a clear diet through ___. This means \nliquids you can see through, clear sodas, water, clear juices, \njello and broth.\n\n \nFollowup Instructions:\n___\n" ]

[ "K565", "K7031", "I8510", "K766", "F17210", "Z6823", "B1920", "I81", "E43" ]

[ "K565: Intestinal adhesions [bands] with obstruction (postinfection)", "K7031: Alcoholic cirrhosis of liver with ascites", "I8510: Secondary esophageal varices without bleeding", "K766: Portal hypertension", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "B1920: Unspecified viral hepatitis C without hepatic coma", "I81: Portal vein thrombosis", "E43: Unspecified severe protein-calorie malnutrition" ]

[ "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nTylenol / Neurontin\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, nausea, vomiting\n \nMajor Surgical or Invasive Procedure:\nParacentesis, ___\n\n \nHistory of Present Illness:\n___ year old male, with ETOH and Hep C cirrhosis,\nchild's class B (MELD 16) presenting to the ED with acute\nabdominal pain concerning for recurrent bowel obstruction. His\nsurgical history is pertinent for a prior umbilical repair, and\nan exploratory laparotomy for a closed loop obstruction \nrequiring\nlysis of an internal hernia. \n\nThe patient was in his usual state of health until 5 days ago\nwhen he started having mild diffuse abdominal pain associated\nwith nausea and multiple episodes of emesis. Denies bilious or\nbloody emesis. Last episode of emesis was 2 days ago but still\ncomplains of nausea and abdominal pain. He also mentions that \nhis\nlast bowel movement was 2 days ago, same time when he last \npassed\nflatus. He also mentions some subjective fevers, but denies\ntaking his temperature. Off note, on ___ this year he \npresented\nto the ED with similar symptoms which required hospitalization\nfor SBO that was managed conservatively. Other than that he\ndenies shortness of breath, palpitations, night sweats,\nunexplained weight loss, fatigue/malaise/lethargy, changes in\nappetite, trouble with sleep, dysuria.\n\nIn the ED, VSS. Patient with persistent nausea and abdominal\npain. No NG tube in place. Abdomen soft but tender to palpation\nin right hemi-abdomen. No peritoneal. Labs w/o leukocytosis or\nacidosis. Imaging studies suggestive of SBO with transition in\nright hemi-abdomen. No signs of bowel ischemia. Moderate \nascites.\n\n \nPast Medical History:\n - Hepatitis C (genotype 3) \n - Cirrhosis, Child's Class C due EtOH and HCV d/b hepatic \nencephalopathy, portal hypertension with ascites and esophageal \nvarices, portal hypertensive gastropathy \n - Gastric & Duodenal ulcers \n - Insomnia \n - Umbilical hernia \n - Sacral osteoarthritis \n \nPast Surgical History: \n - Umbilical hernia repair (___) \n -SBO requiring Ex lap & repair of ruptured umbilical hernia \nwith lysis of adhesions (___)\n - Abdominal Hematoma evacuation (___) \n - Abdominal incision opened, wound vac placed (___) \n \nSocial History:\n___\nFamily History:\nSister and brother both with \"collapsed lungs.\" No family \nhistory of liver disease.\n \nPhysical Exam:\nVITAL SIGNS: T97.7, BP 156/76, HR 58, RR 18, SpO2 97%RA\nGENERAL: AAOx3 NAD\nHEENT: NCAT, no scleral icterus\nCARDIOVASCULAR: rrr, S1S2\nPULMONARY: CTABL, non-labored respirations\nGASTROINTESTINAL: soft, minimally distended per baseline, mildly \nTTP over R abdomen - much improved from admission and consistent \nwith baseline. No guarding, rebound, or peritoneal signs.\nEXT/MS/SKIN: No cyanosis, clubbing, or edema\nNEUROLOGICAL: Strength and sensation grossly intact\n \nPertinent Results:\nAdmission labs:\n\n___ 06:10PM BLOOD WBC-7.8 RBC-3.46* Hgb-12.0* Hct-35.9* \nMCV-104* MCH-34.7* MCHC-33.4 RDW-15.6* RDWSD-58.6* Plt ___\n___ 06:10PM BLOOD Glucose-99 UreaN-5* Creat-0.6 Na-134* \nK-3.6 Cl-98 HCO3-25 AnGap-11\n___ 06:10PM BLOOD ALT-16 AST-44* AlkPhos-122 TotBili-2.7*\n___ 06:10PM BLOOD Albumin-2.7* Calcium-8.1* Phos-2.9 \nMg-1.4*\n___ 06:10PM BLOOD Lipase-___ year old male with ETOH and Hep C cirrhosis, child's class \nB, presented to the ED with acute abdominal pain, nausea and \nvomiting concerning for recurrent bowel obstruction. His initial \nCT abdomen showed slightly dilated loops of jejunum with \nrelative transition point right hemiabdomen followed by \ndecompressed bowel, distal small bowel loops were normal in \ncaliber with air and stool present. No pneumatosis, bowel wall \nthickening, or pneumoperitoneum were seen. He was admitted to \nTransplant surgery and kept NPO with IV fluid. Serial abdominal \nexams were done noting increased distension and tenderness. No \nfree air was seen on KUB. A nasogastric tube was placed to \ndecompress the stomach and a Foley catheter was placed to \nclosely monitor urine output. He was given a dulcolax \nsuppository with passage of a BM. \n\nLactate increased the next day to 2.1 then 3.1. A CT was done \nthat showed colonic thickening but no obstruction. He continued \nto require IV fluid bolus for low u/o.Lactate decrease to 1.9. \nBy hospital day 4, exam was improved and lactate had decreased. \nThe foley was removed. On ___, he tolerated NG clamp trials \nand the NG was removed. \n\nOn ___, a clear diet was tolerated and this advanced to \nregular diet that he also tolerated. However, over night, he c/o \nsudden right hemi-abdominal pain and gas pain. Simethicone was \nadministered with relief. He was moving his bowels without \ndifficulty. \n\nHepatology was consulted and recommended a paracentesis. This \ndone on ___ with 0.4 liter removed. Cell count was notable for \nWBC-TNC and zero polys. Culture of ascites was negative. \n\nOn ___, he felt ready for discharge to home. His home Nadolol \nwas held as his heart rates were in the ___. SBP ranged \nbetween 104-160s. \n\nOn ___, t.bili increased from 2.0 to 2.4. A liver duplex was \ndone to evaluate his portal vein given h/o portal vein thrombus. \nU/S demonstrated patent main and right portal vein, small \nascites and small right pleural effusion. \n\nHe was discharged to home in stable condition. \n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Famotidine 20 mg PO BID \n2. Furosemide 20 mg PO DAILY \n3. Lactulose 30 mL PO QID \n4. Lidocaine 5% Patch 1 PTCH TD QAM \n5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain \n6. Potassium Chloride 20 mEq PO DAILY \n7. Spironolactone 50 mg PO DAILY \n8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis \n9. Bisacodyl ___AILY:PRN constipation \n10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n11. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Simethicone 40-80 mg PO TID:PRN gas pain \n2. Bisacodyl ___AILY:PRN constipation \n3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral DAILY \n4. Famotidine 20 mg PO BID \n5. Furosemide 20 mg PO DAILY \n6. Lactulose 30 mL PO QID \n7. Multivitamins 1 TAB PO DAILY \n8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain \ncontinue to follow up with your outpatient provider for \nmanagement \n9. Potassium Chloride 20 mEq PO DAILY \nHold for K > 5.0 \n10. Spironolactone 50 mg PO DAILY \n11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCirrhosis\nAbdominal pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPlease call Dr. ___ office at ___ for fever > 101, \nchills, nausea, vomiting, diarrhea, constipation, increased \nabdominal pain, pain not controlled by your pain medication, \nswelling of the abdomen or ankles, yellowing of the skin or \neyes, inability to tolerate food, fluids or medications, or any \nother concerning symptoms.\n\nYou may return to your usual healthy diet. If your abdomen \nbecomes distended, you stop passing gas, or you begin burping, \ngo back to having only sips of clear liquids. If your symptoms \nworsen or do not resolve, call the clinic number above or come \nto the ED.\n\nNo driving if taking narcotic pain medications.\n\nYou did not have surgery on this admission and do not need a \nsurgical follow-up visit. However, please keep the appointment \nwe have made for you with your usual hepatologist Dr. ___ to \nmonitor your liver function.\n\n \nFollowup Instructions:\n___\n" ]

[ "K56600", "K766", "I8510", "K7031", "F17210", "M47818" ]

[ "K56600: Partial intestinal obstruction, unspecified as to cause", "K766: Portal hypertension", "I8510: Secondary esophageal varices without bleeding", "K7031: Alcoholic cirrhosis of liver with ascites", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M47818: Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region" ]

[ "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbd pain\n \nMajor Surgical or Invasive Procedure:\n___: ex-lap and LOA \n___: hematoma evacuation\n___: Incision opened and VAC placed\n\n \nHistory of Present Illness:\n___ with HCV, ETOH cirrhosis (MELD 13, MELD-Na 18)p/w 5 days of \nnausea, vomiting, abdominal pain and melena. His symptoms \nstarted 5 days ago and he has not been able to maintain adequate \nPO intake since. His pain was initially diffuse but is now \nlocalized to the RLQ. Denies fevers or chills. No prior similar \nepisodes in the past. The patient is followed by Dr. ___ at\n___. Per patient report his liver disease has \nbeen stable in the past ___ years and his ascites has been well \ncontrolled with medical\ntherapy (last paracenthesis over one year ago per pt report). \nLast EGD on file done in ___, significant for 2 bleeding \ngastric ulcers and one duodenal ulcer.\n\n \nPast Medical History:\nHCV, cirrhosis,lumbar and sacral osteoarthritis, FTT, gastric \nand\nduodenal ulcers\n \nSocial History:\n___\nFamily History:\nNon-Contributory\n \nPhysical Exam:\nTemp: 98.5; P: 89; BP: 109/69; RR: 18; O2: 100% RA\nGeneral: alert, OrientedX3; in no acute distress\nHEENT: atraumatic, normocephalic; oral mucosa moist\nResp: clear breath sounds bilaterally\nCV: RRR; no murmurs, rubs, or gallops\nAbd: soft, protuberant, mid-line vac intact \nVac measurement: 5cm long x2cm wide x1cm deep; low suction, \n-75mm Hg\nExtr: atraumatic, skin intact \n \nPertinent Results:\n___ 05:00AM BLOOD WBC-7.2 RBC-2.11* Hgb-7.2* Hct-22.2* \nMCV-105* MCH-34.1* MCHC-32.4 RDW-19.5* RDWSD-73.1* Plt ___\n___ 07:30AM BLOOD WBC-7.3 RBC-3.44* Hgb-11.9* Hct-35.3* \nMCV-103* MCH-34.6* MCHC-33.7 RDW-14.8 RDWSD-55.3* Plt ___\n___ 05:20AM BLOOD ___ PTT-41.5* ___\n___ 05:00AM BLOOD Glucose-86 UreaN-10 Creat-0.5 Na-131* \nK-3.8 Cl-103 HCO3-22 AnGap-10\n___ 04:40AM BLOOD ALT-14 AST-38 AlkPhos-83 TotBili-3.4*\n___ 07:30AM BLOOD Lipase-126*\n___ 05:00AM BLOOD Albumin-2.2* Calcium-7.2* Phos-2.4* \nMg-1.7\n\n \n\n___\nCT ABD & PELVIS WITH CO\nIMPRESSION: \n \n \n1. Large right rectus sheath hematoma measuring 9 x 5.9 x 8.5 cm \nwith evidence of active extravasation. Given patient's history \nof cirrhosis and portal hypertension and venous collaterals, it \nis unclear whether the source of this hematoma is arterial or \nvenous. \n2. Moderate right-sided pleural effusion. \n3. Cirrhotic appearing liver, extensive esophageal, perigastric, \nand \nperisplenic varices, and large volume ascites. \n\n___\nPARACENTESIS DIAG/THERA\nIMPRESSION: \n \nTechnically successful ultrasound-guided diagnostic and \ntherapeutic \nparacentesis removing 0.8 L of serosanguineous ascitic fluid. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with a history of HCV cirrhosis \nwho presented to ___ on ___ with the chief complaint of \nabdominal pain; evaluation in the ED by surgery revealed \nlocalized abdominal pain, with clinical and radiological signs \nof an acute abdomen with concern for an internal hernia. The \npatient was taken to the OR for a lysis of adhesions and relief \nof obstruction due to multiple adhesions into the pelvis causing \nan internal loop obstruction. The patient tolerated the \nprocedure well, please refer to the operative report for further \ndetails. Post-procedure the patient was extubated in PACU due to \nprolonged sedation, which went unremarkably. He did receive 24 \nhours of cefazolin after surgery, in addition to 5% albumin for \na total of 500cc for volume support. \n\nOn POD1: The patient was kept NPO, with a NG tube in place. He \nelectrolytes were closely monitored and repleted as necessary. \nHis pain was further managed with IV and PO pain medications.\n\nPOD2: a NGT clamp trial was performed, and the patient was \nstarted on glutamine supplementation. His electrolytes were \ncontinued to be closely monitored and repleted. There was a \nconcern for a RUE DVT due to difficult CVL placement in the OR; \nhowever, a repeat RUE/neck US showed no evidence of a DVT. \n\nPOD3: the patient underwent a KUB, which did not show signs of \nobstruction or ileus. NGT was dc'd, and the patient was kept \nNPO. He electrolytes were repleted as per protocol. His foley \ncatheter was removed at mid-night, and the patient voided \nspontaneously.\n\nPOD4: the patient complained of a cough with intermittent sputum \nproduction, he was given a PRN nebulizer therapy and a PA/LAT \ncxr was consistent with clearing of a prior mucous plug. The \npatient was started on a clear liquid diet, and his IVF were \nstopped once he was taking in a good amount PO. His home Lasix \ndose was continued as well. The patient's expected \npost-operative pain and transient electrolyte abnormalities were \nfollowed and corrected.\n\nPOD5: overnight the patient complained of ___ \nerythema, along with fluctuance and increased pain/tenderness. \nAn Abd/Pelv CT scan without contrast revealed a large right \nrectus sheath hematoma measuring 9 x 5.9 x 8.5 cm with evidence \nof active extravasation; given those findings, several wound \nstaples were removed at bed-side with the plan to take to OR as \nsoon as possible. The patient received a ___ in the \ninterim due to continuous oozing from his abdominal wound. A \nfoley was placed due to urinary retention. The patient was taken \nto the OR and a rectus sheath hematoma was evacuated, and any \nactive bleeders were treated with argon beam laser. A wound vac \nwas placed in the OR for wound management. Post-op the patient's \nmedications were resumed, and he was started on a clear liquid \ndiet. \n\nPOD6: the patient tolerated his clear diet well and was advanced \nto a regular diet, while his IVF were dc'd. His diuretics were \nrestarted and he was given 1U of FFP due to a high INR and \nanticipation of a paracentesis. The patient's levaquin for \npresumed pneumonia was changed to vanc, cefepime for broader \ncoverage; in addition, he underwent a nasal MRSA screen which \nwas negative, along with sputum cx which grew commensal flora. \nThe patient under paracentesis due to abdominal distention, \nwhere 0.8L were removed, and cell count was not consistent with \nSBP. The patient received 12.5 grams of albumin for repletion. \n\nPOD7: the patient was restarted on his lactulose, his foley \ndc'd, and a vac placed. \n\nPOD8: the patient was managed for his routine pain control, \nelectrolyte repletion, along with ambulation.\n\nPOD9: a physical therapy consult was placed, and the patient \nresumed his PO levaquin to complete a 7-day course. \n\nPOD10-11: an occupation therapy consult was placed, and the \npatient was discharged to rehab. \nThe patient's vac was changed on ___ its measurements are \n5cmX2cmX1cm deep, and the vac is set on min suction at -75 mmHg\n\nAt the time of discharge, the patient was comfortable with the \ndischarge plan and recommendations. \n\n \nMedications on Admission:\nSpironolactone 50 mg daily\nFurosemide 20 mg daily\nLactulose 20 GM/30 ML solution 30 mLs by mouth 3 (three) times \ndaily. \nLidocaine 5 % patch\nMVI\nPotassium chloride ___ MEQ tablet1 tablet by mouth daily. \n\n \nDischarge Medications:\n1. Furosemide 20 mg PO DAILY \n2. Lactulose 30 mL PO TID \nTitrate to ___ bowel movements daily \n3. Spironolactone 50 mg PO DAILY \n4. Famotidine 20 mg PO Q12H \n5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \n6. Lidocaine 5% Patch 1 PTCH TD QAM \n7. Multivitamins 1 TAB PO DAILY \n8. Potassium Chloride 10 mEq PO DAILY \nHold for K > 5 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nETOH Cirrhosis\nSmall bowel obstruction\nRectus sheath hematoma\nPneumonia\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:\nPlease contact Dr. ___ office at ___ if the patient \ndevelops fever > 101, chills, bleeding from the wound, nausea, \nvomiting, diarrhea, constipation, inability to tolerate food, \nfluids or medications, increased abdominal pain, jaundice ; \nyellowing of the skin or eyes, VAC fails to hold suction or any \nother concerns\n\nNo lifting more than 10 pounds\n\nVAC dressing change to abdominal wound q 3 days using black foam \nand 75 mmHG continuous suction. If VAC fails, wound may be \ntemporarily dressed with a NS damp to dry dressing.\n\n \nFollowup Instructions:\n___\n" ]

[ "K565", "E43", "J189", "J952", "K766", "M96831", "D62", "T814XXA", "L03311", "K7031", "M47817", "Z6823", "F17210", "D696", "Y838", "Y92239", "T17990A", "R339" ]

[ "K565: Intestinal adhesions [bands] with obstruction (postinfection)", "E43: Unspecified severe protein-calorie malnutrition", "J189: Pneumonia, unspecified organism", "J952: Acute pulmonary insufficiency following nonthoracic surgery", "K766: Portal hypertension", "M96831: Postprocedural hemorrhage of a musculoskeletal structure following other procedure", "D62: Acute posthemorrhagic anemia", "T814XXA: Infection following a procedure", "L03311: Cellulitis of abdominal wall", "K7031: Alcoholic cirrhosis of liver with ascites", "M47817: Spondylosis without myelopathy or radiculopathy, lumbosacral region", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "F17210: Nicotine dependence, cigarettes, uncomplicated", "D696: Thrombocytopenia, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "T17990A: Other foreign object in respiratory tract, part unspecified in causing asphyxiation, initial encounter", "R339: Retention of urine, unspecified" ]

[ "D62", "F17210", "D696" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \namoxicillin\n \nAttending: ___.\n \nChief Complaint:\n___ Syndrome\n \nMajor Surgical or Invasive Procedure:\n___ Thrombolysis, mechanical thrombectomy\n___ IVC filter placement\nRepeat mechanical thrombectomy, angiojet\nCommon iliac wall stent x2\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with hx of hypothyroidism presenting with \nleft\nleg swelling and pain. She was in her usual state of health \nuntil\nlast night when she noted progressive left leg swelling and \npain.\nOver the night she developed worsening pain in her left groin\npain radiating down her leg which prompted her to present to\n___ for further evaluation in the morning. On\nvenous duplex, she was found to extensive left leg DVT. She was\nstarted on a heparin gtt with a loading bolus and transferred to\n___ for further management. She denies recent long periods of\nimmobility, travel history, or history of DVT. No recent surgery\nor leg trauma. Denies shortness or breath or leg weakness,\nparasthesias or loss of sensation. No known hypercoaguability\ndisorder. Her mother notes a possible GSV aneurysm which was\nresected after a pregnancy many years ago. Her father had a DVT\nafter a prolonged ICU course. Vascular surgery was consulted for\nfurther management. \n \nPast Medical History:\nHypothyroidism, depression\n \nSocial History:\n___\nFamily History:\nNo family history of hypercoagulability disorders. Father had\nhistory of DVT while hospitalized in the ICU. \n\n \nPhysical Exam:\nPhysical Exam on Discharge:\nVitals: 99 100 122/74 24 100%RA\nGEN: AOx3, 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\nExt: LLE mildly swollen, wrapped with ace wrap, no RLE swelling, \nno evidence of phlegmasia, strength and sensation equal\nPulses: R: p/p/p/p L: p/p/p/p\n \nPertinent Results:\n___ 07:14AM BLOOD WBC-13.1* RBC-2.88* Hgb-8.5* Hct-26.6* \nMCV-92 MCH-29.5 MCHC-32.0 RDW-13.5 RDWSD-45.2 Plt ___\n___ 07:14AM BLOOD Plt ___\n___ 07:14AM BLOOD ___ PTT-84.5* ___\n___ 07:14AM BLOOD Glucose-92 UreaN-6 Creat-0.6 Na-140 K-3.3 \nCl-104 HCO3-25 AnGap-14\n___ 07:14AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9\n___ 07:14AM BLOOD\n \nBrief Hospital Course:\nThe patient was admitted on ___ for left lower extremity \nswelling. CTA demonstrated right iliac artery compression of the \nleft iliac vein, and the patient was started on heparin. The \npatient was brought to the operating room on ___ and underwent \nIVC filter placement and catheter-directed thrombolysis, which \nwas the patient had no evidence of hematoma and was transferred \nto the PACU for recovery, where she remained hemodynamically \nstable. Hematocrit q6hrs remained stable, and the patient \ncomplained of mild back pain, which improved with pain \nmanagement.\n \nThe patient was closely monitored in the ICU and remained \nstable. She was brought back to the OR on ___ for mechanical \nthrombectomy and placement of left CIV wall stent. The procedure \nwas without complications. The patient did well intraoperatively \nand was transferred back to the ICU, where she continued to \nrecover. On ___, her diet was advanced and foley was \nd/c'ed. She was discharged to home on POD#2 in stable condition \nwith rivaroxaban 15mg BID for first 3 weeks, followed by 20mg \ndaily. Follow-up has been arranged with Dr. ___ in clinic \nwith surveillance with LLE duplex in 3 wks.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, thrombectomy incisions were \nclean/dry/intact, and the patient was voiding/moving bowels \nspontaneously. The patient will follow up with a LLE duplex and \nDr. ___ in three weeks. She will be discharged on xarelto. A \nthorough discussion was had with the patient regarding the \ndiagnosis and expected post-discharge course including reasons \nto 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:\nThe Preadmission Medication list is accurate and complete.\n1. DULoxetine 120 mg PO DAILY \n2. Levothyroxine Sodium 75 mcg PO DAILY \n3. ClonazePAM 0.5 mg PO BID \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four hours Disp \n#*30 Tablet Refills:*0 \n3. Rivaroxaban 15 mg PO BID \nfor first three weeks only \nRX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day \nDisp #*42 Tablet Refills:*0 \n4. Rivaroxaban 20 mg PO DAILY \nafter first 3 weeks \nRX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*2 \n5. ClonazePAM 0.5 mg PO BID \n6. DULoxetine 120 mg PO DAILY \n7. Levothyroxine Sodium 75 mcg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n___ syndrome - DVT in LLE\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nLower Extremity Angioplasty/Stent Discharge Instructions\n\nMEDICATION:\n• Take Aspirin 325mg (enteric coated) once daily \n• If instructed, take Plavix (Clopidogrel) 75mg once daily\n• Continue all other medications you were taking before surgery, \nunless otherwise directed\n• You make take Tylenol or prescribed pain medications for any \npost procedure pain or discomfort\nWHAT TO EXPECT:\nIt is normal to have slight swelling of the legs:\n• Elevate your leg above the level of your heart with pillows \nevery ___ hours throughout the day and night\n• Avoid prolonged periods of standing or sitting without your \nlegs elevated\n• It is normal to feel tired and have a decreased appetite, your \nappetite will return with time \n• Drink plenty of fluids and eat small frequent meals\n• It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing\n• To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication\n\nACTIVITIES:\n• When you go home, you may walk and use stairs\n• You may shower (let the soapy water run over groin incision, \nrinse and pat dry)\n• Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing or \nband aid over the area \n• No heavy lifting, pushing or pulling (greater than 5 lbs) for \n1 week (to allow groin puncture to heal)\n• After 1 week, you may resume sexual activity\n• After 1 week, gradually increase your activities and distance \nwalked as you can tolerate\n• No driving until you are no longer taking pain medications\n\nCALL THE OFFICE FOR: ___\n• Numbness, coldness or pain in lower extremities \n• Temperature greater than 101.5F for 24 hours\n• New or increased drainage from incision or white, yellow or \ngreen drainage from incisions\n• Bleeding from groin puncture site\n\nSUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)\n• Lie down, keep leg straight and have someone apply firm \npressure to area for 10 minutes. If bleeding stops, call \nvascular office ___. If bleeding does not stop, call \n___ for transfer to closest Emergency Room. \n \nFollowup Instructions:\n___\n" ]

[ "I82422", "I871", "I9751", "Y838", "Y92234" ]

[ "I82422: Acute embolism and thrombosis of left iliac vein", "I871: Compression of vein", "I9751: Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___\n \nChief Complaint:\nHypotension, ___ on CKD\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history metastatic\nRCC, locally advanced cholangiocarcinoma s/p six months of\ngemcitabine and cisplatin, and recent diagnosis of pancreatic\nacinar cell carcinoma receiving liposomal irinotecan and\n___ who presents with hypotension and acute on\nchronic renal failure.\n\nHe reports that he checks his blood pressure using a machine at\nhome every morning. His BP this morning was 79/44 about 15\nminutes after taking amlodipine, atenolol, and lisinopril. This\nwas associated with dizziness. Later in the morning repeat check\nwas 110/70. He notes decreased appetite. He had one loose small\nbowel movement yesterday but otherwise no diarrhea.\n\nHe presented to clinic for follow-up His vitals were Temp 97.3,\nBP 125/58, HR 72, RR 16, and O2 sat 100% RA. Labs were notable\nfor Cr 2.7 from baseline Cr 1.7-1.8. He was given 2L NS and\nreferred for direct admission to 11 ___.\n\nOn arrival to the floor, patient reports shortness of breath \nwith\nexertion, mild nausea without vomiting, and tingling in his\nhands. He denies fevers/chills, night sweats, headache, vision\nchanges, weakness, cough, hemoptysis, chest pain, palpitations,\nabdominal pain, nausea/vomiting, hematemesis,\nhematochezia/melena, dysuria, hematuria, and new rashes.\n\nREVIEW OF SYSTEMS: A complete 10-point review of systems was\nperformed and was negative unless otherwise noted in the HPI.\n\nPAST ONCOLOGIC HISTORY:\n- ___: Presented with acute onset of gross hematuria\naccompanied with some mild flank pain. During his workup, he was\nfound to have a 4.8 cm mass on a CAT scan dated ___,\nspecifically the scan describes a left renal mass with internal\nenhancement measuring 4.1 x 4.8 cm in size in the mid and upper\npole of the left kidney. Also described was the fat-containing\nleft inguinal hernia and left perinephric stranding. There was \nno\nadenopathy or other suspicious lesions. There is also an old\nsclerotic right ilial lesion and left sacral lesion. \n- ___: Underwent a laparoscopic hand assisted radical right\nnephrectomy by Dr. ___ pathology showed a \nrenal\ncell carcinoma, clear cell type, ___ grade II/IV measuring 4\ncm extending but not invading through the renal capsule or\nGerota's fascia margins were questionably positive at the renal\nvein and otherwise negative. On review of pathology here at ___, the margins are described as negative including the \nrenal\nvein margin. A background of global glomerulosclerosis is\ndescribed. Overall, this was a T3bNxMx lesion. Postoperative\nimaging on ___ which was a CT torso showed no evidence of\nrecurrent or metastatic disease.\n- ___: CT chest showed interval increase in prominence of\nmediastinal lymph nodes and minimal interval increase in \nmultiple\nb/l pulmonary nodules, concerning for progression\n- ___: Fine needle aspirate of 11R and 11L lymph nodes, \nwhich\nwas consistent with metastatic RCC\n- ___: CT Torso - mediastinal and hilar nodes and pulmonary\nlesions increased in size. No definite intra-abdominal sites of\ndisease \n- ___: C1D1 ___, randomized to sunitinib\n- ___: Multiple grade ___ adverse events including\nthrombocytopenia (grade 2; platelet 52,000), leukopenia (grade \n2;\nWBC 2.9), elevated lipase (grade 1), elevated amylase (grade 1;\nelevated at baseline), elevated ALT (grade 1), and \nhypothyroidism\n(grade 1). Mild symptoms with treatment. Continued sunitinib at\n50mg daily per protocol.\n- ___: CT Torso: Response of mediastinal lymphadenopathy,\nbilateral hilar lymphadenopathy, and numerous parenchymal\nmetastases. Stable disease by RECIST (decrease 19.1% from\nbaseline).\n- ___: Sunitinib reduced to 37.5 mg daily due to \nerythematous\nrash and blistering on palms and sole of right foot.\n- ___: CT Torso: Decrease in pulmonary and mediastinal\nlesions. Stable disease by RECIST 1.1 (decrease 22.5% from\nbaseline).\n- ___: CT Torso: Partial response by RECIST 1.1 (decrease\n39.8% from baseline).\n- ___: CT Torso: Partial response by RECIST 1.1 (decrease\n46.3% from baseline).\n- ___: CT Torso: Partial response by RECIST 1.1 (decrease\n40.3% from baseline).\n- ___: CT Torso: Partial response by RECIST 1.1 (decrease\n42.6% from baseline).\n- ___: CT Torso: Partial response by RECIST 1.1 (decrease\n47.7% from baseline).\n- ___: CT torso: Ongoing partial response comments: No\nsignificant change compared to prior scan. No new lesions. \n- ___: CT Torso: PR by RECIST 1.1 \n- ___: CT Torso: PR by RECIST 1.1: -54.22% change from\nbaseline and -10.29% change from last scan. \n-___: CT Torso: Partial response: -57.79% from baseline,\n-7.79% from nadir\n- ___: CT Torso shows continued partial response, no\nsignificant change compared to prior\n- ___: C25D1 held, admitted for biliary stricture\n- ___: Resumed cycle 25 day 1\n- ___: Admitted for biliary stricture and\ncholangitis, diagnosed with pancreatobiliary adenocarcinoma and\ntaken off study. ERCP x2 with placement of plastic, then metal\nbiliary stent. EUS/biopsy of CBD mass showed new \npancreatobiliary\nadenocardinoma. \n- ___: C1D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: C2D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: C3D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: CT torso showed stable disease \n- ___: C4D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: C5D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 D1,___: MR liver showed ongoing inoperable disease but\nstable\n- ___: C6D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 \nD1,15\ndose modified for low counts\n- ___: CT torso showed stable disease\n- ___: C7D1 Gemcitabine 1000mg/m2 Cisplatin 25 mg/m2 \nD1,15\n\n- ___: C8D1 Gemcitabine 1000mg/m2 Cisplatin 18.75 mg/m2\nD1,15 reduced for CKD\n- ___: CT torso showed possible liver lesion and\npancreatic lesion. Biopsy of liver lesion suggests poorly\ndifferentiated carcinoma. Biopsy of pancreas lesion suggests\nacinar cell carcinoma.\n- ___: C1D1 nanoliposomal irinotecan / ___ / leucovorin\n___ I)\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\n-___: presented with acute onset of gross hematuria\naccompanied with some mild flank pain. During his workup, he was\nfound to have a 4.8 cm mass on a CAT scan dated ___,\nspecifically the scan describes a left renal mass with internal\nenhancement measuring 4.1 x 4.8 cm in size in the mid and upper\npole of the left kidney. Also described was the fat-containing\nleft inguinal hernia and left perinephric stranding. There was \nno\nadenopathy or other suspicious lesions. There is also an old\nsclerotic right ilial lesion and left sacral lesion. \n-___: underwent a laparoscopic hand assisted radical right\nnephrectomy by Dr. ___ pathology showed a \nrenal\ncell carcinoma, clear cell type, ___ grade II/IV measuring 4\ncm extending but not invading through the renal capsule or\nGerota's fascia margins were questionably positive at the renal\nvein and otherwise negative. On review of pathology here at ___, the margins are described as negative including the \nrenal\nvein margin. A background of global glomerulosclerosis is\ndescribed. Overall, this was a T3bNxMx lesion. Postoperative\nimaging on ___ which was a CT torso showed no evidence of\nrecurrent or metastatic disease.\n-___: CT chest showed interval increase in prominence of\nmediastinal lymph nodes and minimal interval increase in \nmultiple\nb/l pulmonary nodules, concerning for progression\n-___: Fine needle aspirate of 11R and 11L lymph nodes, which\nwas consistent with metastatic RCC\n-___: CT Torso - mediastinal and hilar nodes and pulmonary\nlesions increased in size. No definite intra-abdominal sites of\ndisease \n-___: C1D1 ___, randomized to sunitinib\n-___: Multiple grade ___ adverse events including\nthrombocytopenia (grade 2; platelet 52,000), leukopenia (grade \n2;\nWBC 2.9), elevated lipase (grade 1), elevated amylase (grade 1;\nelevated at baseline), elevated ALT (grade 1), and \nhypothyroidism\n(grade 1). Mild symptoms with treatment. Continued sunitinib at\n50mg daily per protocol.\n-___: CT Torso: Response of mediastinal lymphadenopathy,\nbilateral hilar lymphadenopathy, and numerous parenchymal\nmetastases. Stable disease by RECIST (decrease 19.1% from\nbaseline).\n-___: Sunitinib reduced to 37.5 mg daily due to erythematous\nrash and blistering on palms and sole of right foot.\n-___: CT Torso: Decrease in pulmonary and mediastinal\nlesions. Stable disease by RECIST 1.1 (decrease 22.5% from\nbaseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n39.8% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n46.3% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease \n40.3%\nfrom baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n42.6% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n47.7% from baseline).\n-___: CT torso: Ongoing partial response comments: No\nsignificant change compared to prior scan. No new lesions. \n-___: CT Torso: PR by RECIST 1.1 \n-___: CT Torso: PR by RECIST 1.1: -54.22% change from\nbaseline and -10.29% change from last scan. \n-___: CT Torso: partial response: -57.79% from baseline,\n-7.79% from nadir\n-___: CT Torso shows continued partial response, no\nsignificant change compared to prior\n\nPAST MEDICAL HISTORY (per OMR):\n1. Clear cell kidney cancer as above.\n2. Benign prostatic hypertrophy.\n3. Diabetes mellitus.\n4. Hypertension.\n5. Hyperlipidemia.\n6. History of anxiety.\n\n \nSocial History:\n___\nFamily History:\nColorectal cancer - mother\n___ cancer - sister (dx at age ___\nLiver cancer - brother\n___ cell leukemia - brother\n___ - father\n\n \nPhysical ___:\nADMISSION PHYSICAL EXAM:\nVS: Temp 97.9, BP 150/74, HR 71, RR 20, O2 sat 100% RA.\nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\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.\nABD: Soft, non-tender, non-distended, normal bowel sounds.\nEXT: Warm, well perfused, no lower extremity edema.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Gross strength and sensation intact.\nSKIN: No significant rashes.\nACCESS: Right chest wall port without erythema.\n\nDISCHARGE PHYSICAL EXAM:\nVS: ___ 1623 Temp: 98.1 PO BP: 148/78 HR: 76 RR: 18 O2 sat: \n97% O2 delivery: RA \nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\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.\nABD: Soft, non-tender, non-distended, normal bowel sounds.\nEXT: Warm, well perfused, no lower extremity edema.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII \nintact. Gross strength and sensation intact.\nSKIN: No significant rashes.\nACCESS: Right chest wall port without erythema.\n \nPertinent Results:\nADMISSION LABS:\n___ 12:45PM BLOOD WBC-5.6 RBC-3.04* Hgb-9.1* Hct-28.6* \nMCV-94 MCH-29.9 MCHC-31.8* RDW-14.6 RDWSD-49.4* Plt ___\n___ 12:45PM BLOOD Neuts-72.3* Lymphs-17.0* Monos-8.0 \nEos-2.0 Baso-0.2 Im ___ AbsNeut-4.05 AbsLymp-0.95* \nAbsMono-0.45 AbsEos-0.11 AbsBaso-0.01\n___ 12:45PM BLOOD Plt ___\n___ 12:45PM BLOOD UreaN-48* Creat-2.7* Na-135 K-4.7 Cl-102 \nHCO3-18* AnGap-15\n___ 12:45PM BLOOD ALT-24 AST-31 LD(LDH)-667* AlkPhos-173* \nTotBili-0.4\n___ 12:45PM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.1 Mg-2.1\n___ 05:54AM BLOOD Hapto-271*\n___ 10:41PM URINE Color-Straw Appear-Clear Sp ___\n___ 10:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 10:41PM URINE Hours-RANDOM Creat-78 Na-34\n\nDISCHARGE LABS:\n___ 05:47AM BLOOD WBC-5.2 RBC-2.74* Hgb-8.3* Hct-26.1* \nMCV-95 MCH-30.3 MCHC-31.8* RDW-14.6 RDWSD-49.2* Plt ___\n___ 05:47AM BLOOD Plt ___\n___ 05:47AM BLOOD Glucose-120* UreaN-26* Creat-1.7* Na-141 \nK-4.9 Cl-106 HCO3-23 AnGap-12\n___ 05:47AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.0\n\nPERTINENT STUDIES:\nRadiology Report RENAL U.S. Study Date of ___ 8:18 AM \nCOMPARISON: CT abdomen and pelvis ___ \n \nFINDINGS: \n \nThe left kidney is surgically absent. A cortical defect is \nre-demonstrated in \nthe interpolar region of the right kidney. There is a 1.3 cm \nexophytic simple \ncyst arising from the lower pole of the right kidney, stable \nfrom the prior \nCT. There is no hydronephrosis or stones bilaterally. Normal \ncortical \nechogenicity and corticomedullary differentiation are seen \nbilaterally. \nRight kidney: 11.5 cm \n \nThe bladder is moderately well distended and normal in \nappearance. \n \nIMPRESSION: \n \nNo hydronephrosis. Normal cortical echogenicity and \ncorticomedullary \ndifferentiation within the remaining right kidney. \n\nRadiology Report CHEST (PORTABLE AP) Study Date of ___ \n7:22 ___ \nCOMPARISON: CT is available from ___. \n \nFINDINGS: \n \nPort terminates in the mid superior vena cava. Cardiac, \nmediastinal and hilar \ncontours appear stable. There is no pleural effusion or \npneumothorax. Lungs \nappear clear. \n \nIMPRESSION: \n \nNo evidence of acute cardiopulmonary process.\n\nMICROBIOLOGY:\n___ 10:41 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\nURINE CULTURE (Final ___: NO GROWTH. \n\n \nBrief Hospital Course:\nBrief hospital summary:\n=======================\nMr. ___ is a ___ male with history metastatic \nRCC, locally advanced cholangiocarcinoma s/p six months of \ngemcitabine and cisplatin, and recent diagnosis of pancreatic \nacinar cell carcinoma receiving liposomal irinotecan and \n___ who presents with hypotension and acute on \nchronic renal failure. Hypotension and ___ resolved with IVFs \nand holding BP medications. He was discharged in stable \ncondition. \n\nTransitional issues:\n==============\n[] Hgb on discharge 8.3.\n[] Held home lisinopril, atenolol, and amlodipine given concern \nfor dehydration and hypotension. BPs improved during course of \nhospital stay.\n[] Please titrate BP medications on outpatient basis as \nclinically indicated \n[] Cr on discharge 1.7 (baseline appears to be 1.4-1.7). Please \nrecheck BMP within one week of discharge to trend Cr.\n[] Glipizide held on discharge due to increase risk of \nhypoglycemia. Would consider d/c vs restart based on renal \nfunction\n\nAcute issues:\n==========\n# Hypotension: Likely combination of poor PO intake and \ndehydration in setting of poor appetite and nausea from new \nchemotherapy regimen while continuing multiple home BP \nmedications. Given IVF and held BP medications with resolution \nof hypotension. Orthostatics prior to discharge unremarkable. \n\n# ___ on CKD: Likely prerenal in setting of poor PO intake. FeNa \n<1% consistent with diagnosis. Held lisinopril which we will \ncontinue to hold upon discharge. Renal ultrasound without \nevidence of hydronephrosis. \n\n# Anemia: Likely secondary to chemotherapy and malignancy. \nHemolysis labs reassuring. No clinical evidence of bleeding. Hgb \non discharge 8.3.\n\nChronic issues:\n===============\n# Fatigue: Likely from anemia and chemotherapy side effect. \nStable during course of hospitalization\n\n# Pancreatic Acinar Cell Carcinoma:\n# Cholangiocarcinoma:\n# Secondary Neoplasm of Liver: Currently on palliative liposomal \n___. Follow-up with Dr. ___\n\n# Metastatic Renal Cell Carcinoma:\n# Secondary Neoplasm of Lung: He is on a treatment hold due to \nthe management of his cholangiocarcinoma and now pancreatic \ncancer.\n\n# Portal Vein Thrombus: continued home rivaroxaban\n\n# BPH: continued home Flomax\n\n# Hypothyroidism: continued home levothyroxine\n\n# Diabetes: continued home lantus, started humalog ISS, and held \nhome glipizide while in house and on discharge.\n\n# Anxiety: continued home citalopram\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Ascorbic Acid ___ mg PO DAILY \n3. Atenolol 50 mg PO DAILY \n4. Levothyroxine Sodium 100 mcg PO DAILY \n5. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia \n6. Multivitamins 1 TAB PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n9. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting \n10. Tamsulosin 0.4 mg PO QHS \n11. Vitamin D 5000 UNIT PO DAILY \n12. GlipiZIDE 2.5 mg PO BID \n13. Lisinopril 10 mg PO DAILY \n14. Fenofibrate 48 mg PO DAILY \n15. Amoxicillin ___ mg PO PREOP \n16. Citalopram 20 mg PO DAILY \n17. Glargine 16 Units Bedtime\n18. Rivaroxaban 10 mg PO DAILY \n19. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever \n20. Cyanocobalamin 1000 mcg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever \n2. Ascorbic Acid ___ mg PO DAILY \n3. Citalopram 20 mg PO DAILY \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Fenofibrate 48 mg PO DAILY \n6. Glargine 16 Units Bedtime \n7. Levothyroxine Sodium 100 mcg PO DAILY \n8. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia \n9. Multivitamins 1 TAB PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n12. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting \n13. Rivaroxaban 10 mg PO DAILY \n14. Tamsulosin 0.4 mg PO QHS \n15. Vitamin D 5000 UNIT PO DAILY \n16. HELD- amLODIPine 10 mg PO DAILY This medication was held. \nDo not restart amLODIPine until you discuss with your primary \ncare doctor.\n17. HELD- Atenolol 50 mg PO DAILY This medication was held. Do \nnot restart Atenolol until you discuss with your primary care \ndoctor.\n18. HELD- GlipiZIDE 2.5 mg PO BID This medication was held. Do \nnot restart GlipiZIDE until you follow up with your PCP.\n19. HELD- Lisinopril 10 mg PO DAILY This medication was held. \nDo not restart Lisinopril until you discuss with your primary \ncare doctor.\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nAcute Issues:\n==========\nHypotension\nAcute on chronic CKD\n\nSecondary Issues:\n=============\nHypertension\nCKD\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. ___,\n \nIt was a pleasure caring for you at ___ \n___. \n \nWHY WAS I IN THE HOSPITAL? \n - You were admitted for low blood pressures \n \nWHAT HAPPENED TO ME IN THE HOSPITAL? \n - We gave you fluids through an IV, and we held your blood \npressure medications. Your blood pressures eventually improved \nto normal range. \n - We monitored your kidney function which improved with fluids \nand holding your blood pressure medications. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n - Continue to take all your medicines and keep your \nappointments. \n - Do not take any of your blood pressure medications until you \ndiscuss with your primary care doctor.\n\nWe wish you the best! \n \nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "N179", "C221", "C259", "C7802", "C7801", "I10", "E785", "F419", "N400", "I129", "E1122", "N189", "Z7984", "Z87891", "T464X5A", "Y929", "D6481", "T451X5A", "E039", "Z794", "Z905", "I959", "E860", "Z7901" ]

[ "N179: Acute kidney failure, unspecified", "C221: Intrahepatic bile duct carcinoma", "C259: Malignant neoplasm of pancreas, unspecified", "C7802: Secondary malignant neoplasm of left lung", "C7801: Secondary malignant neoplasm of right lung", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F419: Anxiety disorder, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z87891: Personal history of nicotine dependence", "T464X5A: Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounter", "Y929: Unspecified place or not applicable", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "E039: Hypothyroidism, unspecified", "Z794: Long term (current) use of insulin", "Z905: Acquired absence of kidney", "I959: Hypotension, unspecified", "E860: Dehydration", "Z7901: Long term (current) use of anticoagulants" ]

[ "N179", "I10", "E785", "F419", "N400", "I129", "E1122", "N189", "Z87891", "Y929", "E039", "Z794", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmirtazapine\n \nAttending: ___.\n \nChief Complaint:\nNausea and vomiting\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a pleasant ___ w/ ID-T2DM, HTN, DL, BPH, and \nthree concurrent cancers (1) metastatic clear cell RCC, s/p \nradical L nephrectomy in ___, found to have pulmonary, \nmediastinal, and hilar mets ___ (now off sunitinib w/o \ndisease progression), (2) metastatic cholangiocarcinoma s/p 6 \nmonths gem/cisplatin, who subsequently had new (3) acinar cell \ncarcinoma of the pancreas, now on ___ I regimen of liposomal \nirinotecan and ___, last dose ___, p/w nausea/vomiting that \nstarted last evening. \n\nPatient was interviewed with his daughter at bedside and she \nhelped provide collateral. \n\nThey note that he has had n/v the past few weeks, especially \nwith chemo. He had poor appetite as well since chemo. The \nvomiting seemed to be intermittent, sometimes able to tolerate \nPO. Last night he developed abdominal pain and vomiting. He had \nregular bowel movements last night. This morning he had \ndiarrhea but no further episodes of vomiting and his abdominal \npain improved and nausea improved. He had special K cereal with \nskim milk today and tolerated it well. \n\nHe called into his ___ clinic where he was seen this am. There \nhe had 2L NS and obtained a KUB which suggested SBO. He is only \na little tender in the epigastrium on exam. He was then admitted \nto 12R to the oncology service.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\n-___: presented with acute onset of gross hematuria\naccompanied with some mild flank pain. During his workup, he was\nfound to have a 4.8 cm mass on a CAT scan dated ___,\nspecifically the scan describes a left renal mass with internal\nenhancement measuring 4.1 x 4.8 cm in size in the mid and upper\npole of the left kidney. Also described was the fat-containing\nleft inguinal hernia and left perinephric stranding. There was \nno\nadenopathy or other suspicious lesions. There is also an old\nsclerotic right ilial lesion and left sacral lesion. \n-___: underwent a laparoscopic hand assisted radical right\nnephrectomy by Dr. ___ pathology showed a \nrenal\ncell carcinoma, clear cell type, ___ grade II/IV measuring 4\ncm extending but not invading through the renal capsule or\nGerota's fascia margins were questionably positive at the renal\nvein and otherwise negative. On review of pathology here at ___, the margins are described as negative including the \nrenal\nvein margin. A background of global glomerulosclerosis is\ndescribed. Overall, this was a T3bNxMx lesion. Postoperative\nimaging on ___ which was a CT torso showed no evidence of\nrecurrent or metastatic disease.\n-___: CT chest showed interval increase in prominence of\nmediastinal lymph nodes and minimal interval increase in \nmultiple\nb/l pulmonary nodules, concerning for progression\n-___: Fine needle aspirate of 11R and 11L lymph nodes, which\nwas consistent with metastatic RCC\n-___: CT Torso - mediastinal and hilar nodes and pulmonary\nlesions increased in size. No definite intra-abdominal sites of\ndisease \n-___: C1D1 ___, randomized to sunitinib\n-___: Multiple grade ___ adverse events including\nthrombocytopenia (grade 2; platelet 52,000), leukopenia (grade \n2;\nWBC 2.9), elevated lipase (grade 1), elevated amylase (grade 1;\nelevated at baseline), elevated ALT (grade 1), and \nhypothyroidism\n(grade 1). Mild symptoms with treatment. Continued sunitinib at\n50mg daily per protocol.\n-___: CT Torso: Response of mediastinal lymphadenopathy,\nbilateral hilar lymphadenopathy, and numerous parenchymal\nmetastases. Stable disease by RECIST (decrease 19.1% from\nbaseline).\n-___: Sunitinib reduced to 37.5 mg daily due to erythematous\nrash and blistering on palms and sole of right foot.\n-___: CT Torso: Decrease in pulmonary and mediastinal\nlesions. Stable disease by RECIST 1.1 (decrease 22.5% from\nbaseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n39.8% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n46.3% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease \n40.3%\nfrom baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n42.6% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n47.7% from baseline).\n-___: CT torso: Ongoing partial response comments: No\nsignificant change compared to prior scan. No new lesions. \n-___: CT Torso: PR by RECIST 1.1 \n-___: CT Torso: PR by RECIST 1.1: -54.22% change from\nbaseline and -10.29% change from last scan. \n-___: CT Torso: partial response: -57.79% from baseline,\n-7.79% from nadir\n-___: CT Torso shows continued partial response, no\nsignificant change compared to prior\n\nPAST MEDICAL HISTORY (per OMR):\n1. Clear cell kidney cancer as above.\n2. Benign prostatic hypertrophy.\n3. Diabetes mellitus.\n4. Hypertension.\n5. Hyperlipidemia.\n6. History of anxiety.\n\n \nSocial History:\n___\nFamily History:\nColorectal cancer - mother\n___ cancer - sister (dx at age ___\nLiver cancer - brother\n___ cell leukemia - brother\n___ - father\n\n \nPhysical ___:\nADMISSION EXAM:\nVITAL SIGNS: 98.4 PO 112 / 71 89 18 97 Ra\nGeneral: NAD, Resting in bed comfortably with daughter at \nbedside\n___: + xerostomia, + healing dried cold sore the L lower lip\nCV: RR, NL S1S2 no S3S4 No MRG\nPULM: CTAB, No C/W/R, No respiratory distress\nABD: scant bowel sounds, mostly tympanic, soft, minimally tender \nin epigastrium, no peritoneal signs, no significant distention\nLIMBS: WWP, no ___, no tremors\nSKIN: No notable rashes on trunk nor extremities\nNEURO: Face symmetric, speech clear and fluent, strength b/l \n___ intact\nPSYCH: Thought process logical, linear, future oriented\nACCESS: R Chest port site intact w/o overlying erythema, \naccessed and dressing C/D/I \n\nDISCHARGE EXAM:\n___ 0910 Temp: 97.4 PO BP: 136/89 HR: 102 RR: 18 O2 sat: \n95%\nO2 delivery: RA FSBG: 269 \n___ 0918 Pain Score: ___ \nGENERAL: appears uncomfortable, weaker and pale.\nEYES: Anicteric\nENT: MMM, no lesions noted\nCV: RRR, no murmur. Right chest port.\nRESP: anterior exam, quiet lungs, normal respiratory effort.\nGI: Abdomen soft, mild distention, G-tube in place.\nMSK: no edema or swelling\nNEURO: sleepy, but awakens with gentle touch, face symmetric, \nspeech fluent, moves all limbs, answers all questions, fully\noriented.\nPSYCH: Pleasant, appropriate affect\n \nPertinent Results:\nADMISSION LABS:\n___ 01:15PM BLOOD WBC-3.5* RBC-2.83* Hgb-8.4* Hct-26.9* \nMCV-95 MCH-29.7 MCHC-31.2* RDW-17.2* RDWSD-58.1* Plt ___\n___ 01:15PM BLOOD Neuts-74* Lymphs-12* Monos-13 Eos-0* \n___ Metas-1* AbsNeut-2.59 AbsLymp-0.42* AbsMono-0.46 \nAbsEos-0.00* AbsBaso-0.00*\n___ 05:41AM BLOOD ___ PTT-25.9 ___\n___ 01:15PM BLOOD UreaN-26* Creat-1.8* Na-132* K-4.4 Cl-95* \nHCO3-22 AnGap-15\n___ 01:15PM BLOOD ALT-20 AST-28 LD(___)-861* AlkPhos-150* \nTotBili-0.4\n___ 01:15PM BLOOD Albumin-3.3* Calcium-9.1 Phos-3.9 Mg-2.2\n=======================\nDISCHARGE LABS:\n___ 06:25AM BLOOD WBC-19.0* RBC-3.27* Hgb-9.4* Hct-31.4* \nMCV-96 MCH-28.7 MCHC-29.9* RDW-17.6* RDWSD-59.2* Plt ___\n___ 06:25AM BLOOD Glucose-176* UreaN-35* Creat-1.5* Na-141 \nK-4.8 Cl-100 HCO3-22 AnGap-19*\n___ 06:25AM BLOOD ALT-24 AST-79* LD(LDH)-1713* AlkPhos-184* \nTotBili-0.8\n___ 06:25AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.1\n=======================\nMICROBIOLOGY:\n___ 3:07 am STOOL CONSISTENCY: LOOSE Source: \nStool. \n **FINAL REPORT ___\n C. difficile PCR (Final ___: \n NEGATIVE. \n___ 3:07 am STOOL CONSISTENCY: LOOSE Source: \nStool. \n FECAL CULTURE - R/O E.COLI 0157:H7 (Pending): \n=======================\nABDOMINAL X-RAY ___:\nFINDINGS: \nThere are multiple centrally located distended loops of small \nbowel, concerning for small bowel obstruction. There is no free \nintraperitoneal air. Osseous structures are unremarkable. \nRe-demonstrated is a common bile duct extent in grossly \nunchanged position compared to the prior study given differences \nin techniques. Two small linear\nhyperdensities noted over the midline adjacent to the biliary \nstent, likely surgical clips.\nIMPRESSION: Imaging findings concerning for small-bowel \nobstruction. Further evaluation with CT abdomen and pelvis, \nwith iv contrast, is recommended.\n\nCT ABDOMEN/PELVIS WITH ORAL CONTRAST ___:\n1. Interval increase in size of pancreatic head mass, now \nmeasuring up to 8.0 cm, previously 6.0 cm.\n2. Numerous metastatic lesions throughout the liver, increased \nin size and number.\n3. Interval worsening of retroperitoneal lymphadenopathy.\n4. Wall thickening of an approximately 20 cm segment of distal \nand terminal ileum with adjacent fat stranding, compatible with \ninfectious or inflammatory ileitis. No small bowel obstruction. \n Oral contrast is seen to the rectum.\n5. New 3 mm pulmonary nodule in the left lower lobe.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with type 2 diabetes, \nhypertension, hyperlipidemia, BPH, and three concurrent cancers: \n(1) metastatic clear cell renal cell carcinoma, s/p radical L \nnephrectomy in ___, found to have pulmonary,\nmediastinal, and hilar metastases ___ (now off sunitinib \nwithout disease progression), (2) metastatic cholangiocarcinoma \ns/p 6 months gem/cisplatin, who subsequently had new (3) acinar \ncell carcinoma of the pancreas, now on ___ I regimen of \nliposomal irinotecan and ___, last dose ___, who went to \n___ clinic with nausea, vomiting, abdominal pain and was \nfound to have possible SBO on KUB. This led to direct admission \nfor workup. CT abdomen/pelvis with oral contrast showed no \nevidence of bowel obstruction, but showed findings of ileitis, \nas well as increasing pancreatic mass size and new hepatic \nlesions all concerning for progression of his cancer. While \nhospitalized, he developed recurrent symptoms of nausea, \nvomiting after an initial improvement, and then developed signs \nand symptoms of frank obstruction likely related to his \npancreatic mass or peritoneal carcinomatosis. No further \nimaging was pursued. An NG tube was placed for decompression \nand he had significant improved symptoms. He subsequently \nunderwent palliative venting G-tube is a transition to hospice.\n\nACUTE/ACTIVE PROBLEMS:\n# Abdominal pain\n# Nausea and vomiting, with malignant obstruction, in setting of \nprogressive acinar cell cancer, and large pancreatic mass\n# Acinar cell pancreatic cancer\nHe has been off sutinib as his other cancers are being managed \nand his pulm/hepatic mets have been stable. He is not yet due \nfor restaging imaging. He is due for\n___, LV, liposomal irinotecan. His oncologists are Dr ___ \n___ Dr ___ seen on ___. CT abdomen/pelvis showed \nincreased size of pancreatic head mass (from 6.0 to 8.0 cm), \nnumerous metastatic liver lesions (increased in size and \nnumber), interval worsening of retroperitoneal lymphadenopathy, \nand new 3 mm pulmonary nodule in the left lower lobe. He had \nbeen having nausea and vomiting likely related to chemo for \nseveral weeks, but then developed diarrhea, vomiting, and \nabdominal pain the night prior to presentation. His symptoms \nhave resolved. He had 2 watery bowel movements after admission. \n KUB had showed multiple centrally located distended loops of \nsmall bowel, concerning for small bowel obstruction. He has not \nhad prior bowel obstruction. Since he has only 1 kidney with a \nCr of 1.6, initial CT was done without IV contrast. CT \nabdomen/pelvis with oral contrast showed no evidence of bowel \nobstruction, but showed wall thickening of distal and terminal \nileum with adjacent fat stranding, compatible with infectious or \ninflammatory ileitis. Since he was afebrile with improved \nsymptoms, empiric antibiotics were not started. C. difficile \nwas negative as was ecoli. He was initially treated with bowel \nrest and IV fluids, then diet was advanced. The CT scan also \nshowed increasing size of pancreatic mass, enlarging and new \nhepatic lesions, new left lung nodule, worsening retroperitoneal \nlymphadenopathy, all concerning for progression of disease. \nGiven this new complication of his pancreatic cancer, family \nmeeting was held on ___, with a decision to pursue hospice \ncare at home given no other therapeutic options. His prognosis \nwas given as weeks. He was transitioned to liquid concentrated \nmorphine for pain, as well as lorazepam for anxiety, and \ndexamethasone for nausea. Oral medications were given after his \nPEG was placed, with clear instructions on how to take them. \nThis included dexamethasone, concentrated morphine, and \nolanzapine. Other home medications were continued at this time, \nwith decisions to stop these medications going forward to occur \nwith hospice services and Dr. ___, patient's \noncologist. MOLST form was completed.\n\n# Acute on chronic anemia: Baseline hemoglobin is ___. \nHemoglobin was low at 6.7 on ___, so he was transfused 1 unit \nPRBCs with improvement to 8.3. He had no obvious signs of acute \nblood loss anemia and stool has not appeared grossly bloody or \nsigns of melena evident. His blood count remained stable. Labs \nwere not checked after goals of care were changed.\n\nCHRONIC/STABLE PROBLEMS:\n# Chronic kidney disease: Creatinine is 1.4-1.6 at baseline. He \nhad recent ___ with Cr of 2.2 on ___ and 1.8 on admission, \nlikely due to dehydration. Renal function returned to baseline \nafter getting IV fluids then rose after he likely developed \nrecurrent dehydration. As stated above labs were not rechecked \nafter goals of care change.\n\n# History of Portal Vein Thrombus: He was continued on home \nRivaroxaban 10mg daily, except for initially being held while \nNPO. This was continued for now, but should be stopped if \ndecided not consistent with comfort going forward.\n\n# Severe protein-calorie malnutrition: He has low albumin and \nreported low oral intake due to nausea, vomiting, and abdominal \npain, which has been ongoing off/on for weeks, likely due to \nchemo and his known cancers. Consulted nutrition who \nrecommended low fiber diet with Ensure Clear early in \nhospitalization, but given transition to hospice, he was \nrecommended to have diet as tolerated.\n\n# Type 2 diabetes: His glargine was initially decreased while \nNPO on IV D5LR, then stopped and treated with sliding scale \ninsulin only and Glipizide was held. On discharge, glipizide \nwas continued.\n\nTRANSITIONS OF CARE\n-------------------\n# Follow-up: patient is being discharged to hospice. Dr. ___ \n___ be the physician responsible for decisions going \nforward.\n\n# Code status: DNR/DNI, comfort-focused care\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever \n2. Citalopram 20 mg PO DAILY \n3. Levothyroxine Sodium 100 mcg PO DAILY \n4. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia \n5. Multivitamins 1 TAB PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting \n8. Rivaroxaban 10 mg PO DAILY \n9. Tamsulosin 0.4 mg PO QHS \n10. Vitamin D 5000 UNIT PO DAILY \n11. Ascorbic Acid ___ mg PO DAILY \n12. Cyanocobalamin 1000 mcg PO DAILY \n13. Fenofibrate 48 mg PO DAILY \n14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n15. GlipiZIDE 2.5 mg PO BID \n16. Abreva (docosanol) 10 % topical ___ times daily prn cold \nsore \n\n \nDischarge Medications:\n1. Dexamethasone 4 mg PO DAILY \nRX *dexamethasone 4 mg 1 tablet(s) by mouth once a day Disp #*5 \nTablet Refills:*0 \n2. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___ \nmg PO Q2H:PRN Breakthrough pain \nRX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.25-0.75 ml by \nmouth q2h Refills:*0 \n3. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN nausea \nnot addressed by ondansetron \nRX *olanzapine 5 mg 1 tablet(s) by mouth twice a day Disp #*10 \nTablet Refills:*0 \n4. Abreva (docosanol) 10 % topical ___ times daily prn cold \nsore \n5. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever \n6. Ascorbic Acid ___ mg PO DAILY \n7. Citalopram 20 mg PO DAILY \n8. Cyanocobalamin 1000 mcg PO DAILY \n9. Fenofibrate 48 mg PO DAILY \n10. Levothyroxine Sodium 100 mcg PO DAILY \n11. LORazepam 0.5 mg PO DAILY:PRN anxiety/insomnia \n12. Multivitamins 1 TAB PO DAILY \n13. Omeprazole 20 mg PO DAILY \n14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n15. Prochlorperazine 5 mg PO Q8H:PRN nausea/vomiting \n16. Rivaroxaban 10 mg PO DAILY \n17. Tamsulosin 0.4 mg PO QHS \n18. HELD- GlipiZIDE 2.5 mg PO BID This medication was held. Do \nnot restart GlipiZIDE until someone tells you to\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nAbdominal pain\nNausea with vomiting\nDiarrhea\nIleitis\nMetastatic cholangiocarcinoma\nAcinar cell pancreatic cancer\nMetastatic renal cell carcinoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were hospitalized with abdominal pain. Despite the fact \nthat you initially improved, you subsequently worsened and the \nsymptoms were all related to progressive cancer. We talked \nabout the meaning of this with you and your family and you are \nopting to go home with hospice care. We put a gastric tube in \nto help alleviate any symptoms of obstruction. You should keep \nthe gastric tube hooked up to low suction overnight and when you \nare not doing anything during the day. When you are active, and \nfor ___ minutes after taking oral medications, you should \nclamp the tube.\n\nYou were continued on most of your oral medications that you \ntake at home. Over time, you may decide to discontinue these \nmedications if they are not necessary for your comfort (for \ninstance, your vitamin supplements), and can discuss this with \nyour hospice team.\n\nThe hospice team will help you manage your symptoms at home.\n\nWe wish you the best of luck going forward. \n\nThanks,\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "C786", "E43", "C250", "C787", "C781", "C771", "N179", "E871", "G893", "K8681", "Z85528", "Z8589", "Z905", "Z66", "Z515", "E1122", "I129", "N189", "Z794", "E7849", "N400", "K529", "Z87891", "K117", "D630", "E860", "Z6826", "Z7902", "B001", "F419", "G4700", "R739", "T380X5A", "Y92230", "K5900" ]

[ "C786: Secondary malignant neoplasm of retroperitoneum and peritoneum", "E43: Unspecified severe protein-calorie malnutrition", "C250: Malignant neoplasm of head of pancreas", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C781: Secondary malignant neoplasm of mediastinum", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "N179: Acute kidney failure, unspecified", "E871: Hypo-osmolality and hyponatremia", "G893: Neoplasm related pain (acute) (chronic)", "K8681: Exocrine pancreatic insufficiency", "Z85528: Personal history of other malignant neoplasm of kidney", "Z8589: Personal history of malignant neoplasm of other organs and systems", "Z905: Acquired absence of kidney", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "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", "Z794: Long term (current) use of insulin", "E7849: Other hyperlipidemia", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "K529: Noninfective gastroenteritis and colitis, unspecified", "Z87891: Personal history of nicotine dependence", "K117: Disturbances of salivary secretion", "D630: Anemia in neoplastic disease", "E860: Dehydration", "Z6826: Body mass index [BMI] 26.0-26.9, adult", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "B001: Herpesviral vesicular dermatitis", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "R739: Hyperglycemia, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "K5900: Constipation, unspecified" ]

[ "N179", "E871", "Z66", "Z515", "E1122", "I129", "N189", "Z794", "N400", "Z87891", "Z7902", "F419", "G4700", "Y92230", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nFatigue\n \nMajor Surgical or Invasive Procedure:\n___: ERCP and EUS\n \nHistory of Present Illness:\nMr. ___ is a ___ male with IDDM, HTN, BPH,\nand clear cell RCC s/p radical L nephrectomy (___) metastatic \nto\nthe lungs, mediastinum, and hilum currently on chemotherapy\n(experimental trial; on sunitinib), with recent admission\n(___) for biliary stricture s/p ERCP with plastic stent\nplacement (CBD brushing cytology non-diagnostic) and\nnon-occlusive portal vein thrombus started on enoxaparin who\npresented to the ED with fever, jaundice, and confusion.\n\nThe CBD brushing cytology from his prior admission was\nnon-diagnostic. His imaging was reviewed at multidisciplinary\npancreas conference and no mass lesion was visualized in the \nhead\nof the pancreas but there was some peripancreatic stranding\naround the head of the pancreas noted. There was some concern \nfor\na potential primary pancreatobiliary tumor (rather than rare RCC\nmetastasis to pancreas), so he was planned for a repeat ERCP and\nEUS in ___ weeks (planned for the week of ___ off sunatinib).\n\nHe last followed up in ___ clinic with Dr. ___ on \n___.\nHe was complaining of a week of increased fatigue, nausea, and\npoor PO intake. His sunatinib was held due to concern for side\neffects. Over the past week since then, he has had worsening\njaundice and fatigue. Last night, he developed chills,\nrestlessness, mild confusion, and fevers to 101, which prompted\nhis wife to bring him to ___. He was\ntransferred from there to the ___ ED.\n\nRight now, he feels ok, just a little tired. He feels like his\nthinking is foggy. No fevers/chills since he presented to the\nhospital. No nausea, vomiting, abdominal pain. He has had loose\nstools, which he associates with the sunatinib. No bloody, \nblack,\nor ___ stools. His urine has been \"tea colored.\" He has\nhad poor appetite. No chest pain, shortness of breath, or\npalpitations. \n\nED COURSE:\nVS: Tmax 98.6, HR ___, BP 100s-110s/60s, RR 16, SpO2 98-100%\non RA\nLabs: WBC 3.4, AST/ALT 71/97, AP 214, Tbili 7.6, lipase 148,\nlactate 1.4\nExam: jaundiced, abdomen benign, guaiac negative brown stool\nImaging: RUQ US: persistent left intrahepatic biliary dilation,\npersistent GB sludge\nInterventions: None\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\n-___: presented with acute onset of gross hematuria\naccompanied with some mild flank pain. During his workup, he was\nfound to have a 4.8 cm mass on a CAT scan dated ___,\nspecifically the scan describes a left renal mass with internal\nenhancement measuring 4.1 x 4.8 cm in size in the mid and upper\npole of the left kidney. Also described was the fat-containing\nleft inguinal hernia and left perinephric stranding. There was \nno\nadenopathy or other suspicious lesions. There is also an old\nsclerotic right ilial lesion and left sacral lesion. \n-___: underwent a laparoscopic hand assisted radical right\nnephrectomy by Dr. ___ pathology showed a \nrenal\ncell carcinoma, clear cell type, ___ grade II/IV measuring 4\ncm extending but not invading through the renal capsule or\nGerota's fascia margins were questionably positive at the renal\nvein and otherwise negative. On review of pathology here at ___, the margins are described as negative including the \nrenal\nvein margin. A background of global glomerulosclerosis is\ndescribed. Overall, this was a T3bNxMx lesion. Postoperative\nimaging on ___ which was a CT torso showed no evidence of\nrecurrent or metastatic disease.\n-___: CT chest showed interval increase in prominence of\nmediastinal lymph nodes and minimal interval increase in \nmultiple\nb/l pulmonary nodules, concerning for progression\n-___: Fine needle aspirate of 11R and 11L lymph nodes, which\nwas consistent with metastatic RCC\n-___: CT Torso - mediastinal and hilar nodes and pulmonary\nlesions increased in size. No definite intra-abdominal sites of\ndisease \n-___: C1D1 ___, randomized to sunitinib\n-___: Multiple grade ___ adverse events including\nthrombocytopenia (grade 2; platelet 52,000), leukopenia (grade \n2;\nWBC 2.9), elevated lipase (grade 1), elevated amylase (grade 1;\nelevated at baseline), elevated ALT (grade 1), and \nhypothyroidism\n(grade 1). Mild symptoms with treatment. Continued sunitinib at\n50mg daily per protocol.\n-___: CT Torso: Response of mediastinal lymphadenopathy,\nbilateral hilar lymphadenopathy, and numerous parenchymal\nmetastases. Stable disease by RECIST (decrease 19.1% from\nbaseline).\n-___: Sunitinib reduced to 37.5 mg daily due to erythematous\nrash and blistering on palms and sole of right foot.\n-___: CT Torso: Decrease in pulmonary and mediastinal\nlesions. Stable disease by RECIST 1.1 (decrease 22.5% from\nbaseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n39.8% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n46.3% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease \n40.3%\nfrom baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n42.6% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n47.7% from baseline).\n-___: CT torso: Ongoing partial response comments: No\nsignificant change compared to prior scan. No new lesions. \n-___: CT Torso: PR by RECIST 1.1 \n-___: CT Torso: PR by RECIST 1.1: -54.22% change from\nbaseline and -10.29% change from last scan. \n-___: CT Torso: partial response: -57.79% from baseline,\n-7.79% from nadir\n-___: CT Torso shows continued partial response, no\nsignificant change compared to prior\n\nPAST MEDICAL HISTORY (per OMR):\n1. Clear cell kidney cancer as above.\n2. Benign prostatic hypertrophy.\n3. Diabetes mellitus.\n4. Hypertension.\n5. Hyperlipidemia.\n6. History of anxiety.\n\n \nSocial History:\n___\nFamily History:\nColorectal cancer - mother\n___ cancer - sister (dx at age ___\nLiver cancer - brother\n___ cell leukemia - brother\n___ - father\n\n \nPhysical ___:\nADMISSION EXAM:\nVITALS: T 97.6, HR 68, BP 115/76, RR 16, SpO2 98% on RA\n___: Alert, NAD, breathing room air comfortably\nEYES: Icteric sclera, PERRL\nENT: MMM, sublingual jaundice, OP clear\nCV: NR/RR, no m/r/g\nRESP: CTAB, no wheezes, crackles, or rhonchi\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM.\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: Jaundiced\nNEURO: Alert, oriented to hospital, city, date; able to recite\nthe days of the week backwards, face symmetric, gaze conjugate\nwith EOMI, speech fluent, moves all limbs\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\nT 97.9, HR 70, BP 143/79, RR 18, SpO2 97% on RA\n___: Alert, NAD, breathing room air comfortably\nEYES: Icteric sclera\nENT: MMM, OP clear\nCV: NR/RR, no m/r/g\nRESP: CTAB, no wheezes, crackles, or rhonchi\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present.\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: Jaundiced (but improved)\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI, speech fluent, moves all limbs\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\nADMISSION LABS:\n___ 05:43AM BLOOD WBC-3.4* RBC-2.48* Hgb-8.4* Hct-24.9* \nMCV-100* MCH-33.9* MCHC-33.7 RDW-16.8* RDWSD-61.6* Plt ___\n___ 05:43AM BLOOD Glucose-95 UreaN-24* Creat-1.5* Na-138 \nK-4.4 Cl-106 HCO3-18* AnGap-14\n___ 05:55AM BLOOD Albumin-2.5* Calcium-8.1* Phos-3.5 Mg-1.9 \nIron-18*\n___ 05:43AM BLOOD Albumin-2.8*\n___ 05:55AM BLOOD calTIBC-160* Hapto-230* Ferritn-990* \nTRF-123*\n___ 05:43AM BLOOD ALT-97* AST-71* AlkPhos-214* TotBili-7.6* \nDirBili-5.6* IndBili-2.0\n\nMICRO:\nBCx ___: NGTD\nBlood culture (___):\nSTREPTOCOCCUS ANGINOSUS (___) GROUP\n | \nCEFTRIAXONE----------- 0.5 S\nCLINDAMYCIN-----------<=0.25 S\nERYTHROMYCIN----------<=0.12 S\nPENICILLIN G----------<=0.06 S\nVANCOMYCIN------------ 0.5 S\n\nPATHOLOGY/CYTOLOGY:\nBiliary mass biopsy (___): Minute fragment of highly \natypical cells with sclerotic stroma consistent with \nadenocarcinoma\nCommon bile duct stricture brushings (___):\nPOSITIVE FOR MALIGNANT CELLS. - Adenocarcinoma.\n\nIMAGING:\nRUQ US (___):\nIMPRESSION: \n1. Persistent mild left intrahepatic biliary dilation in \npresence\nof a partially visualized CBD stent raises concern for stent\nmalfunction. Compared to the prior ultrasound, the degree of\nintrahepatic biliary dilation has not changed significantly. \n2. Persistent gallbladder sludge. \n\nERCP ___:\nremoval of the old stent and placement of a new stent over a 2cm \nmalignant-appearing stricture\nof the distal CBD. Cytology brushings were sampled.\n\nEUS ___:\n1.8 x 1.1 cm ill-defined hypoechoic area around the distal CBD. \nFNB was performed x3\n\nCT torso ___:\nIMPRESSION: \nNon obstructive pneumonia, left upper lobe.\nMinimal residual pulmonary edema and pleural effusions \nattributable to heart failure.\nAtherosclerotic coronary calcification.\nLeft PICC line ends just above the superior cavoatrial junction.\nIMPRESSION:\n1. No evidence of local recurrence or metastatic disease in the \nabdomen and\npelvis.\n2. Mild intrahepatic and extrahepatic biliary ductal dilatation, \nwith CBD\nstent in place.\n3. Known nonocclusive main portal vein thrombus appears \nincreased in size,\nthough difficult to directly compare to MR due to differences in \nimaging\ntechnique.\n\nERCP ___: Biliary plastic stent removed with a snare. A \nmetal stent was placed over 2cm long malignant appearing \nstricture in the distal CBD. \n\nTTE ___:\nIMPRESSION: Adequate image quality. Mild symmetric left \nventricular hypertrophy with normal cavity size and \nregional/global left ventricular systolic function. No 2D \nechocardiographic evidence for endocarditis. If clinically \nsuggested, the absence of a discrete vegetation on \nechocardiography does not exclude the diagnosis of endocarditis.\n\n \nBrief Hospital Course:\nSUMMARY/ASSESSMENT: \nMr. ___ is a ___ male with IDDM, HTN, BPH, and \nmetastatic clear cell RCC s/p radical L nephrectomy (___) on \nchemotherapy (sunitinib), with recent admission (___) for \nbiliary stricture s/p ERCP with plastic stent placement (CBD \nbrushing cytology non-diagnostic) and non-occlusive portal vein \nthrombus started on enoxaparin who presented to the ED with \nfever, jaundice, and confusion, found to have persistent \nintrahepatic biliary dilation and gallbladder sludge on ___ US \ns/p ERCP x2 with placement of plastic, then metal biliary stent \nand EUS with pathology from FNB of CBD mass consistent with new \npancreatobiliary adenocardinoma. \n\nACUTE/ACTIVE PROBLEMS:\n# Cholangitis\n# Strep spp. (likely Enterococcus) bacteremia\n# Adenocarcinoma pancreaticobiliary origin\nHe presented with fever, jaundice, and mental status changes. \nRUQ US also showed persistent left intrahepatic biliary dilation \nand gallbladder sludge despite the presence of CBD stent, \nsuggesting that the stent was non-functioning/occluded or there \nwas some other source of obstruction. The CBD brushing cytology \nfrom his prior ERCP was non-diagnostic. He had no apparent mass \nin the head of the pancreas on imaging but there remained some \nconcern for a primary pancreatobiliary tumor so he was planned \nto have a repeat ERCP and EUS the week he was admitted.\nBlood culture at ___ is growing Strep spp. He was treated with \nUnasyn for cholangitis as well as Strep bacteremia. BCx here \ngrew Strep anginosus. He had an ERCP on ___ with removal of the \nold stent and placement of a new stent over a 2cm \nmalignant-appearing stricture of the distal CBD. Cytology \nbrushings were sampled. EUS was completed on which they \nvisualized a 1.8 x 1.1 cm ill-defined hypoechoic area around the \ndistal CBD. FNB was performed x3. Pathology was consistent with \nadenocarcinoma. \nAfter the plastic stent placement, his LFTs did not improve and \nbilirubin continued to rise. A repeat ERCP was done on ___ with \nremoval of the plastic stent and placement of a metal stent. \nAfter this, his LFTs started to improve. His Unasyn was changed \nto ceftriaxone and metronidazole for ease of dosing to complete \na 2 week course ___ - ___. A PICC was placed prior to \ndischarge. TTE did not show evidence of endocarditis.\n\n# ___ on CKD\nCr peaked at 1.8 from baseline 1.2. Most likely this was \nprerenal in the setting of cholangitis. It improved after ERCP, \nantibiotics, and fluid resuscitation. \n\n# PVT\nHe was found to have a non-occlusive portal vein thrombus on \nMRCP during his recent hospital admission and was started on \nenoxaparin. HIs home enoxaparin was initially held for ERCP, \nthen resumed. \n\n# Macrocytic anemia\nMacrocytic anemia is chronic. Baseline H/H appears to be ___, \nso he is lower than baseline. He had no signs of bleeding. \nRecent TSH, folate, B12, ferritin, and TIBC were wnl. Bilirubin \nis predominantly direct, so less likely hemolysis. Other \nhemolysis labs were not consistent with hemolysis. Acute on \nchronic anemia is perhaps ___ bone marrow suppression from \nsepsis. He was given 1 unit pRBCs for Hgb 7.6. \n\n# Metastatic clear cell RCC on chemotherapy\nHe is followed at ___ by Dr. ___. He was diagnosed in \n___ in workup of gross hematuria and flank pain. He underwent a \nlaparoscopic radical right nephrectomy in ___. He was found \nto have metastases to the lungs, mediastinal lymph nodes, and \nhilar lymph nodes in ___. In ___ he was enrolled in an \nexperimental trial and started on sunatinib. His most recent CT \nshowed clinical response. He is currently in his regularly\nscheduled two weeks off on sunatinib. He had a surveillance CT \non ___ which showed no evidence of local recurrence of \nmetastatic disease in the abdomen/pelvis. \n\n# LUL pneumonia\nHe was found to have LUL opacity on CT chest ordered for \nsurveillance. He was also complaining of cough. He was on Unasyn \nwhile inpatient, then transitioned to ceftriaxone and \nmetronidazole for 2 weeks total, which should cover him for \npneumonia.\n\n# HTN\nInitially his home atenolol dose was halved due to concern for \ncholangitis/impending sepsis. His home amlodipine 10 mg and \nlisinopril 40 mg daily were also initially held. These were \nresumed prior to or at discharge. \n\n# Insulin-dependent DM type II\nAt home he takes glargine 16 units qhs if his FSBG is <170 and \nhe takes 18 units qhs if his FBSG is >170. While inpatient, he \nwas given glaring 8 units qhs as he was not taking much PO as \nwell as lispro SSI. \n\nCHRONIC/STABLE PROBLEMS:\n# Hypothyroidism - continued home levothyroxine\n\n# Depression and anxiety - continued home fluoxetine; held home\ncariprazine as it is non-formulary\n\nMr. ___ is clinically stable for discharge. The total time \nspent today on discharge planning, counseling and coordination \nof care was greater than 30 minutes.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Enoxaparin Sodium 120 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n2. amLODIPine 10 mg PO DAILY \n3. Ascorbic Acid ___ mg PO DAILY \n4. Atenolol 100 mg PO DAILY \n5. cariprazine 1.5 mg oral DAILY \n6. FLUoxetine 20 mg PO DAILY \n7. Gabapentin 100 mg PO BID \n8. GlipiZIDE 2.5 mg PO BID \n9. Glargine 16 Units Bedtime\n10. Levothyroxine Sodium 100 mcg PO DAILY \n11. Lisinopril 40 mg PO DAILY \n12. LORazepam 0.5 mg PO DAILY:PRN anxiety \n13. Omeprazole 20 mg PO DAILY \n14. Ondansetron 4 mg PO Q8H:PRN nausea \n15. Prochlorperazine 5 mg PO Q8H:PRN nausea \n16. Tamsulosin 0.4 mg PO QHS \n17. Vitamin D 5000 UNIT PO DAILY \n18. Multivitamins 1 TAB PO DAILY \n19. Fenofibrate 48 mg PO DAILY \n\n \nDischarge Medications:\n1. CefTRIAXone 2 gm IV Q24H \nRX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV once a \nday Disp #*9 Intravenous Bag Refills:*0 \n2. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*27 Tablet Refills:*0 \n3. Glargine 16 Units Bedtime \n4. amLODIPine 10 mg PO DAILY \n5. Ascorbic Acid ___ mg PO DAILY \n6. Atenolol 100 mg PO DAILY \n7. cariprazine 1.5 mg oral DAILY \n8. Enoxaparin Sodium 120 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n9. Fenofibrate 48 mg PO DAILY \n10. FLUoxetine 20 mg PO DAILY \n11. Gabapentin 100 mg PO BID \n12. GlipiZIDE 2.5 mg PO BID \n13. Levothyroxine Sodium 100 mcg PO DAILY \n14. Lisinopril 40 mg PO DAILY \n15. LORazepam 0.5 mg PO DAILY:PRN anxiety \n16. Multivitamins 1 TAB PO DAILY \n17. Omeprazole 20 mg PO DAILY \n18. Ondansetron 4 mg PO Q8H:PRN nausea \n19. Prochlorperazine 5 mg PO Q8H:PRN nausea \n20. Tamsulosin 0.4 mg PO QHS \n21. Vitamin D 5000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nCholangitis \nBacteremia \nAdenocarcinoma \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 after you were found to have a \nblockage of your bile ducts causing a serious infection called \ncholangitis. You were also found to have bacteria in your blood \nstream. You underwent an ERCP with a plastic stent placed. \nAfter the procedure your bilirubin continued to rise and you \nunderwent a second ERCP to place a metal stent. \n\nFor your serious infection you were started on IV antibiotics \nand will need to continue this for two weeks. \n\nThis blockage in the bile duct was caused by a stricture. \nSamples of the stricture were taken and found to be cancer \n(adenocarcinoma). You were seen by the oncology team and have \nfollow up with them in a few days to talk about treatment \noptions. \n\nIt was a pleasure caring for you,\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "A408", "K831", "I81", "J189", "K830", "C7802", "C7801", "C771", "N179", "C249", "R6520", "F419", "N400", "Z85528", "E785", "Z87891", "D539", "F329", "E039", "E1122", "I129", "N189", "Z794" ]

[ "A408: Other streptococcal sepsis", "K831: Obstruction of bile duct", "I81: Portal vein thrombosis", "J189: Pneumonia, unspecified organism", "K830: Cholangitis", "C7802: Secondary malignant neoplasm of left lung", "C7801: Secondary malignant neoplasm of right lung", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "N179: Acute kidney failure, unspecified", "C249: Malignant neoplasm of biliary tract, unspecified", "R6520: Severe sepsis without septic shock", "F419: Anxiety disorder, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z85528: Personal history of other malignant neoplasm of kidney", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "D539: Nutritional anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "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", "Z794: Long term (current) use of insulin" ]

[ "N179", "F419", "N400", "E785", "Z87891", "F329", "E039", "E1122", "I129", "N189", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___\n \nChief Complaint:\nanbormal lfts\n \nMajor Surgical or Invasive Procedure:\nERCP ___\n\n \nHistory of Present Illness:\nPRIMARY ONCOLOGIST: Dr ___ \n___: Metastatic clear cell renal cell carcinoma \nTREATMENT: ___, randomized to sunitinib 50 mg PO daily x 4\nweeks followed by 2 weeks off. Dose reduced sunitinib to 37.5 mg\ndaily. Cycle 25, Week 1.\nCHIEF COMPLAINT: Abnormal LFTs \n\nHISTORY OF PRESENT ILLNESS:\nMr. ___ is a pleasant ___ w/ ID-T2DM, HTN, DL, BPH, and\nmetastatic clear cell RCC, s/p radical L nephrectomy in ___,\nfound to have pulmonary, mediastinal, and hilar mets ___, now\non ___, randomized to sunitinib, dose-reduced, currently 2\nweeks off sunitinib per protocol, who is directly admitted from\nclinic for abnormal LFTs found on routine lab screening. \n\nHe feels tired but has no localizing symptoms. He did not have\nany F/C, no abd pain, no N/V. Appeared mildly lethargic today\nafter he took his Ativan today for anxiety related coming into\n___. His family reported ___ episodes of confusion since his\nlast clinic visit. He states he's had greasy foods lately \nwithout\nany n/v, no abd pain. He drinks a couple beers a week during his\nweeks off sunitinib. No new meds. No apap/nsaids. No recent\ntravel. No camping. \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):\n-___: presented with acute onset of gross hematuria\naccompanied with some mild flank pain. During his workup, he was\nfound to have a 4.8 cm mass on a CAT scan dated ___,\nspecifically the scan describes a left renal mass with internal\nenhancement measuring 4.1 x 4.8 cm in size in the mid and upper\npole of the left kidney. Also described was the fat-containing\nleft inguinal hernia and left perinephric stranding. There was \nno\nadenopathy or other suspicious lesions. There is also an old\nsclerotic right ilial lesion and left sacral lesion. \n-___: underwent a laparoscopic hand assisted radical right\nnephrectomy by Dr. ___ pathology showed a \nrenal\ncell carcinoma, clear cell type, ___ grade II/IV measuring 4\ncm extending but not invading through the renal capsule or\nGerota's fascia margins were questionably positive at the renal\nvein and otherwise negative. On review of pathology here at ___, the margins are described as negative including the \nrenal\nvein margin. A background of global glomerulosclerosis is\ndescribed. Overall, this was a T3bNxMx lesion. Postoperative\nimaging on ___ which was a CT torso showed no evidence of\nrecurrent or metastatic disease.\n-___: CT chest showed interval increase in prominence of\nmediastinal lymph nodes and minimal interval increase in \nmultiple\nb/l pulmonary nodules, concerning for progression\n-___: Fine needle aspirate of 11R and 11L lymph nodes, which\nwas consistent with metastatic RCC\n-___: CT Torso - mediastinal and hilar nodes and pulmonary\nlesions increased in size. No definite intra-abdominal sites of\ndisease \n-___: C1D1 ___, randomized to sunitinib\n-___: Multiple grade ___ adverse events including\nthrombocytopenia (grade 2; platelet 52,000), leukopenia (grade \n2;\nWBC 2.9), elevated lipase (grade 1), elevated amylase (grade 1;\nelevated at baseline), elevated ALT (grade 1), and \nhypothyroidism\n(grade 1). Mild symptoms with treatment. Continued sunitinib at\n50mg daily per protocol.\n-___: CT Torso: Response of mediastinal lymphadenopathy,\nbilateral hilar lymphadenopathy, and numerous parenchymal\nmetastases. Stable disease by RECIST (decrease 19.1% from\nbaseline).\n-___: Sunitinib reduced to 37.5 mg daily due to erythematous\nrash and blistering on palms and sole of right foot.\n-___: CT Torso: Decrease in pulmonary and mediastinal\nlesions. Stable disease by RECIST 1.1 (decrease 22.5% from\nbaseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n39.8% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n46.3% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease \n40.3%\nfrom baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n42.6% from baseline).\n-___: CT Torso: Partial response by RECIST 1.1 (decrease\n47.7% from baseline).\n-___: CT torso: Ongoing partial response comments: No\nsignificant change compared to prior scan. No new lesions. \n-___: CT Torso: PR by RECIST 1.1 \n-___: CT Torso: PR by RECIST 1.1: -54.22% change from\nbaseline and -10.29% change from last scan. \n-___: CT Torso: partial response: -57.79% from baseline,\n-7.79% from nadir\n-___: CT Torso shows continued partial response, no\nsignificant change compared to prior\n\nPAST MEDICAL HISTORY (per OMR):\n1. Clear cell kidney cancer as above.\n2. Benign prostatic hypertrophy.\n3. Diabetes mellitus.\n4. Hypertension.\n5. Hyperlipidemia.\n6. History of anxiety.\n\n \nSocial History:\n___\nFamily History:\nMother: Died of rectal/colon cancer.\nFather: No cancers, history of diabetes.\nOther: He has a sister with ovarian cancer diagnosed at age ___\nand a brother with liver cancer at age ___ and another brother\nwith hairy cell leukemia, which is in remission.\n \nPhysical Exam:\nVITAL SIGNS: 97.5 PO 160 / 89 R Sitting 71 18 99 ra\nGeneral: NAD, Resting in bed comfortably with daughter at \nbedside \n___: MMM, no OP lesions, no cervical/supraclavicular\nadenopathy, no icterus\nCV: RR, NL S1S2 no S3S4 No MRG\nPULM: CTAB, No C/W/R, No respiratory distress\nABD: BS+, soft, NTND, no palpable masses or HSM\nLIMBS: WWP, trace b/l pitting edema at the distal ___, no tremors\nSKIN: No rashes on the extremities\nNEURO: Grossly normal, speech clear, AOx3\nACCESS: No port\n \nPertinent Results:\n___ 06:55AM BLOOD WBC-3.9* RBC-3.12* Hgb-10.5* Hct-33.5* \nMCV-107* MCH-33.7* MCHC-31.3* RDW-16.8* RDWSD-65.9* Plt ___\n___ 07:25AM BLOOD WBC-3.0* RBC-3.03* Hgb-10.2* Hct-32.2* \nMCV-106* MCH-33.7* MCHC-31.7* RDW-16.9* RDWSD-66.0* Plt ___\n___ 11:30AM BLOOD WBC-3.6* RBC-3.21* Hgb-10.8* Hct-34.9* \nMCV-109* MCH-33.6* MCHC-30.9* RDW-17.0* RDWSD-68.3* Plt ___\n___ 06:55AM BLOOD Glucose-121* UreaN-14 Creat-1.2 Na-147 \nK-4.5 Cl-106 HCO3-27 AnGap-14\n___ 07:25AM BLOOD Glucose-204* UreaN-18 Creat-1.3* Na-140 \nK-4.3 Cl-103 HCO3-25 AnGap-12\n___ 11:30AM BLOOD UreaN-19 Creat-1.4* Na-139 K-5.3 Cl-101\n___ 06:55AM BLOOD ALT-101* AST-47* LD(___)-239 AlkPhos-188* \nTotBili-1.5 DirBili-0.7* IndBili-0.8\n___ 09:45PM BLOOD ALT-123* AST-57* LD(LDH)-274* CK(CPK)-106 \nAlkPhos-241* TotBili-2.3*\n___ 11:30AM BLOOD ALT-133* AST-71* LD(___)-289* \nAlkPhos-259* Amylase-210* TotBili-3.0* DirBili-1.8* IndBili-1.2\n___ 09:45PM BLOOD cTropnT-<0.01\n___ 11:30AM BLOOD Lipase-252*\n___ 06:55AM BLOOD Lipase-63*\n___ 06:55AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.7 Mg-2.0\n___ 09:45PM BLOOD calTIBC-306 VitB12-356 Folate->20 \n___ Ferritn-597* TRF-235\n___ 09:45PM BLOOD Triglyc-207* HDL-30* CHOL/HD-4.7 \nLDLcalc-70\n___ 11:30AM BLOOD Free T4-1.2\n___ 09:45PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 09:45PM BLOOD Smooth-NEGATIVE\n___ 09:45PM BLOOD ___\n___ 09:45PM BLOOD IgG-666* IgA-165 IgM-120\n___ 09:45PM BLOOD HCV Ab-NEG\n___ 09:46PM BLOOD Lactate-0.7\n___ 11:30AM BLOOD FREE T3-Test \n___ 11:30AM BLOOD Free T4-1.2\n \nBrief Hospital Course:\nIMAGING: \n\nRUQ US ___: \n1. Biliary sludge without evidence of gallbladder-wall \nthickening\nor intrahepatic biliary dilatation. \n2. No evidence of focal liver lesions\n\nMRCP ___:\n1. Moderate intra and extrahepatic biliary ductal dilatation \nwith\nduct penetrating sign suggestive of inflammatory rather than\nneoplastic stricture. Correlation with ERCP may be considered. \nNo\nevidence of choledocholithiasis or definite obstructing mass. 2.\nShort-segment (11 mm) eccentric filling defect within the main\nportal vein, suspicious for nonocclusive thrombus. 3. Sludge\nwithin the gallbladder lumen. 4. Status post left nephrectomy\nwith stable soft tissue within the left nephrectomy bed. 5.\nMultiple pancreatic cystic lesions, likely small side branch\nIPMNs, measuring up to 10 mm.\n\nASSESSMENT AND PLAN:\n___ w/ ID-T2DM, HTN, DL, BPH, and metastatic clear cell RCC, s/p\nradical L nephrectomy in ___, found to have pulmonary,\nmediastinal, and hilar mets ___, now on ___, randomized \nto\nsunitinib, dose-reduced, currently 2 weeks off sunitinib per\nprotocol, who is directly admitted from clinic for abnormal LFTs\nfound on routine lab screening. \n\n# Elevated LFTs\nNon-specific elevations. US did not reveal any focal lesions nor\nany biliary dilatation nor stones. Lipase elevated at 252 but in\nabsence of any abd pain, unlikely pancreatitis. Unlikely\nsunitinib effect per oncology. Pt did appear to be lethargic per\noncologist but is AOx3 and no asterixis, but cannot rule out \nsome\nelement of encephalopathy. Found on MRCP to have moderate\nintra/extrahepatic biliary ductal dilatation suggestive of\nstricture. Hepto wnl and anemia stable, so unlikely hemolysis.\nSPEP largely wnl. \n\nERCP on ___ revealed stricture in bile duct and had plastic \nbiliary\nstent placed. He tolerated procedure well. Had no infectious \nsymptoms\nnor any signs of post-ercp pancreatitis. He was advanced to full \ndiet \nand instructed to f/u with oncology for the results of the \nbrushings \ndone during ERCP. Their team will coordinate a repeat ERCP in 4 \nwks. \n\n# Portal Vein THrombus\nMRCP revealed a small non-occlusive filling defect within the\nmain portal vein suspicious for thrombus. Due to risk of \nprogression,\npatient was started on once daily dosing lovenox at 1.5 mg/kg.\nDue to sphincterotomy during the ERCP, patient was instructed to \n\nwait 5 days after ercp to start the lovenox. He was provided \nteaching\non how to inject and warning signs while he was here.\n\n# Pancreatic cysts \nFound on MRCP, per radiology, felt to be to be small side branch\nIntraductal papillary mucinous neoplasm. \n- f/u in ___ year\n\n# ___\nCT scans from ___ revealed partial response to sunitinib. \n- sunitinib is currently on hold\n- will f/u w/ Dr ___ \n\n# Macrocytic Anemia\nChronic and at baseline. TSH WNL as well as VIt B12, Folate,\nspep, and ferritin/TIBC.\n\n# Depressed mood/anxiety\n- hold cariprazine ___ lfts\n- cont fluoxetine\n\n# T2DM: cont home insulin, glipizide \n# HTN: cont amlodipine, atenolol, lisinopril\n# DL: hold statin/fibrate\n# CKD: cr baseline \n# Hypothyroidism: cont levothyroxine (TSH WNL)\n# BPH: cont flomax\n\nFEN: Regular low fat diabetic diet\nDVT PROPHYLAXIS: HSQ\nACCESS: PIV \nCODE STATUS: Full code, presumed\nPCP: ___, MD\nDISPO: Home w/o services\nBILLING: 45 min spent coordinating care for discharge\n________________\n___, D.O.\nHeme/Onc Hospitalist\np: ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Atenolol 100 mg PO DAILY \n3. cariprazine 1.5 mg oral DAILY \n4. Fenofibrate 48 mg PO DAILY \n5. FLUoxetine 20 mg PO DAILY \n6. Gabapentin 100 mg PO DAILY \n7. GlipiZIDE 2.5 mg PO BID \n8. Lantus Solostar U-100 Insulin (insulin glargine) ___ units \nsubcutaneous QPM \n9. Levothyroxine Sodium 100 mcg PO DAILY \n10. LORazepam 0.5 mg PO DAILY:PRN anxiety \n11. Ondansetron 4 mg PO Q8H:PRN nausea \n12. Prochlorperazine 5 mg PO Q8H:PRN nausea \n13. Simvastatin 40 mg PO QPM \n14. Tamsulosin 0.4 mg PO QHS \n15. Ascorbic Acid ___ mg PO DAILY \n16. Vitamin D 5000 UNIT PO DAILY \n17. Omeprazole 20 mg PO DAILY \n18. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n19. Lisinopril 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Enoxaparin Sodium 120 mg SC DAILY \nStart: Future Date - ___, First Dose: First Routine \nAdministration Time \nRX *enoxaparin 120 mg/0.8 mL 120 mg sc daily Disp #*30 Syringe \nRefills:*0 \n2. amLODIPine 10 mg PO DAILY \n3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n4. Ascorbic Acid ___ mg PO DAILY \n5. Atenolol 100 mg PO DAILY \n6. cariprazine 1.5 mg oral DAILY \n7. FLUoxetine 20 mg PO DAILY \n8. Gabapentin 100 mg PO DAILY \n9. GlipiZIDE 2.5 mg PO BID \n10. Lantus Solostar U-100 Insulin (insulin glargine) ___ \nunits subcutaneous QPM \n11. Levothyroxine Sodium 100 mcg PO DAILY \n12. Lisinopril 40 mg PO DAILY \n13. LORazepam 0.5 mg PO DAILY:PRN anxiety \n14. Omeprazole 20 mg PO DAILY \n15. Ondansetron 4 mg PO Q8H:PRN nausea \n16. Prochlorperazine 5 mg PO Q8H:PRN nausea \n17. Tamsulosin 0.4 mg PO QHS \n18. Vitamin D 5000 UNIT PO DAILY \n19. HELD- Fenofibrate 48 mg PO DAILY This medication was held. \nDo not restart Fenofibrate until discussed with your oncologist\n20. HELD- Simvastatin 40 mg PO QPM This medication was held. Do \nnot restart Simvastatin until discussed with your oncologist\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBiliary Stricture\nPortal Vein Thrombus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___\n\n___ were admitted to the hospital because ___ had abnormal liver \nenzymes. MRI of your liver (MRCP) revealed a narrowing in your \nbile duct, also known as a stricture. ___ had an ERCP (endoscopy \nand a camera into your bile duct) which confirmed a stricture. \nThese improved after ___ had an ERCP. ___ had a plastic stent \nplaced in your bile duct and ___ tolerated this well. Your liver \nenzymes are already improving. ERCP team will call ___ to \nschedule another ERCP in 4 weeks or so to possibly remove the \nstent. ___ will follow up on the biopsy results with your \noncology team. ___ were also found to have a clot in one of your \nveins (portal vein) which will need to be treated with a blood \nthinner. ___ will start this ___. Call your oncology team if \nthere are any issues or questions. \n\nRegards,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K831", "I81", "C7800", "K862", "C771", "E785", "I129", "E1122", "N189", "F419", "N400", "D539", "F329", "E039", "Z85528", "Z905", "Z87891", "Z800", "Z807", "Z8041" ]

[ "K831: Obstruction of bile duct", "I81: Portal vein thrombosis", "C7800: Secondary malignant neoplasm of unspecified lung", "K862: Cyst of pancreas", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "E785: Hyperlipidemia, unspecified", "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", "F419: Anxiety disorder, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "D539: Nutritional anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "Z85528: Personal history of other malignant neoplasm of kidney", "Z905: Acquired absence of kidney", "Z87891: Personal history of nicotine dependence", "Z800: Family history of malignant neoplasm of digestive organs", "Z807: Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues", "Z8041: Family history of malignant neoplasm of ovary" ]

[ "E785", "I129", "E1122", "N189", "F419", "N400", "F329", "E039", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nEGD\nColonoscopy\nBiopsy during colonoscopy\nLumbar puncture\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n___ 11:00AM WBC-10.0 RBC-4.66 HGB-8.4* HCT-30.9* MCV-66* \nMCH-18.0* MCHC-27.2* RDW-20.1* RDWSD-45.3\n___ 11:00AM NEUTS-85.1* LYMPHS-6.6* MONOS-7.7 EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-8.47* AbsLymp-0.66* AbsMono-0.77 \nAbsEos-0.00* AbsBaso-0.02\n___ 11:00AM PLT COUNT-225\n___ 11:00AM GLUCOSE-111* UREA N-15 CREAT-1.0 SODIUM-128* \nPOTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-18* ANION GAP-15\n___ 11:00AM ALT(SGPT)-13 AST(SGOT)-20 ALK PHOS-80 TOT \nBILI-1.0\n___ 11:00AM ALBUMIN-4.9\n___ 07:20AM BLOOD Hypochr-1+* Anisocy-1+* Macrocy-1+* \nMicrocy-1+* Polychr-1+* Tear Dr-1+* RBC Mor-SLIDE REVI\n\n___ 11:42AM BLOOD Ret Aut-3.1* Abs Ret-0.13*\n___ 07:20AM BLOOD calTIBC-371 VitB12-293 Folate-8 \nFerritn-5.6* TRF-285\n___ 11:42AM BLOOD Hapto-208*\n___ 07:20AM BLOOD TSH-1.1\n___ 07:20AM BLOOD 25VitD-17*\n___ 03:30AM BLOOD IgA-162\n\n___ 03:40PM CEREBROSPINAL FLUID (CSF) TNC-146* RBC-7* \nPOLYS-1 ___ MONOS-12 BASOS-1 OTHER-0\n___ 03:40PM CEREBROSPINAL FLUID (CSF) TNC-141* RBC-2 \nPOLYS-1 ___ MONOS-3 OTHER-0\n___ 03:40PM CEREBROSPINAL FLUID (CSF) PROTEIN-100* \nGLUCOSE-57\n___ 11:00AM Lyme Ab-NEG\n___ 04:45PM BLOOD Trep Ab-NEG\n___ 07:20AM BLOOD HIV Ab-NEG\n___ 03:05PM BLOOD Parst S-NEGATIVE\n \nMICRO:\n___ 3:40 pm CSF;SPINAL FLUID \nSite: LUMBAR PUNCTURE\n TUBE #3. \n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\nHSV CSF HSV2 + low positive\n\nIMAGING:\nCT head w/o acute intracranial process\n\nDischarge Labs:\n\n___ 06:00AM BLOOD WBC-5.6 RBC-3.79* Hgb-7.2* Hct-27.1* \nMCV-72* MCH-19.0* MCHC-26.6* RDW-22.1* RDWSD-56.4* Plt ___\n___ 06:00AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-143 \nK-3.9 Cl-111* HCO3-21* AnGap-11\n___ 06:00AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7\n___ 05:45AM BLOOD Hapto-126\n___ 07:20AM BLOOD TSH-1.1\n___ 05:50AM BLOOD CEA-1.9\n___ 03:30AM BLOOD IgA-162\n\nColonoscopy:\nCircumferential mass of malignant appearance was found in the \ndistal rectum completely encircling the rectal verge. There were \nlocal ulcerations in the 12 o'clock position. Multiple cold \nforceps biopsies were performed for histology in the rectal \nmass.\n\nEGD:\nNormal erythema in the whole esophagus. Erythema in the antrum \nwith gastritis. Erythema in the duodenum compatible with \nduodenitis.\n \nBrief Hospital Course:\nHospital Medicine Attending Progress Note\n\nTime patient seen and examined today\n\nHPI on Admission:\nMr. ___ is a ___ male with a PMHX of partial aortic \ndissection, HTN, who presents w/ HA & fever x2d concerning for \nmeningitis.\n\nPatient reports that 3 days ago, he developed malaise and \nterrible headache: constant, dull, diffuse. The following day, \nheadache was relenting ___ pain. Also had fever of 102 and \ntook tylenol/ibuprofen without relief of symptoms. He reports \nnausea and decreased PO intake. Denies vision changes, \nsensitivity to light, syncope, URI sx, chest pain, shortness of \nbreath, abd pain, diarrhea/constipation, sick contacts. Has mild \nneck stiffness as well. He lives in ___, does a lot of\nyardwork. Has had exposure to ticks, mosquitoes, but none he \nmemorably recalls recently. No recent travel hx. No rash. He was \nfeeling entirely well prior to onset of these symptoms. Given \nterrible headache and fever, he presented to the ED. \n\nHospital Course to Date:\n\nThe pt was admitted for acute onset headache and fever. LP \nshowed a cell count of 141 with lymphocytic predominance and \nelevated protein to 100. He was initially started on bacterial \nmeningitis coverage, then narrowed to acyclovir based on \nnegative CSF stain and cultures. Doxycycline was added to cover \npotential lyme\nmeningitis. The pt's CSF came back positive for HSV PCR. Per ID \nrecommendations from ___: \"Would recommend continuing on \nAcyclovir for now but when safe for discharge can change to \nValtrex 1 gram po three times per day to complete 14 day course.\nIn setting of only low positive HSV 2 PCR and extensive outdoor \nactivity would also complete 14 day course of doxycycline even \nthough lyme is less likely.\" The pt improved dramatically. His \nheadache resolved. Throughout his hospitalization, he had no \nconfusion or neurologic deficits. He was transitioned to oral \nacyclovir the day before discharge and discharged on PO \nacyclovir + PO doxycycline for a total 14 day course.\n\nOf note, the pt was incidentally found to have an abnormally low \nHb on admission. He required 1u PRBC transfusion ___. He denies \nany known bleeding. GI was consulted and recommended EGD + \ncolonoscopy, performed ___. EGD showed diffuse erythema of \nthe mucosa with no bleeding noted in the antrum, consistent with \ngastritis. Colonoscopy showed a circumferential mass of \nmalignant appearance in the distal rectum completely encircling \nthe rectal verge. There were local ulcerations in the 12:00 \nposition. Colorectal surgery was consulted. They recommended \nfollow up at the colorectal cancer clinic. Follow up was \narranged prior to discharge and the pt was aware of the \ndiagnosis and need for follow up. The clinic and colorectal \nsurgery asked for a baseline CEA which was normal. They asked \nfor a staging MRI pelvis which did not show any spread of the \npresumed cancer. Pathology was sent by GI. Initial pathology \nshowed superficial fragments of tubulovillous adenoma. This was \npending at the time of discharge, though initial reports had \nshown the same diagnosis, so the pt was instructed to follow up \nwith GI. The GI phone number was shared with the patient and he \nwas instructed to call them directly if he did not hear from the \nclinic within 24 hours. The pt received a total of 2u PRBCs this \nhospitalization. Hb was 7.2 on the morning of discharge and the \npt received 1u PRBCs (the second unit this stay) on the day of \ndischarge after the Hb of 7.2 in order to ensure that his Hb did \nnot drop below 7.0 at home. Close follow up was arranged prior \nto discharge. The pt had no active bleeding at the time of \ndischarge. Return to ER precautions such as dizziness and \nincreased bleeding were reviewed with the patient.\n\nThe pt's BP meds were held on admission but restarted prior to \ndischarge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. TraZODone 50 mg PO QHS:PRN insomnia \n2. Citalopram 20 mg PO DAILY \n3. Lisinopril 20 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n2. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day \nDisp #*12 Capsule Refills:*0 \n3. Pantoprazole 40 mg PO DAILY \nRX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n4. ValACYclovir 1000 mg PO TID \nRX *valacyclovir [Valtrex] 1,000 mg 1 tablet(s) by mouth three \ntimes a day Disp #*18 Tablet Refills:*0 \n5. Citalopram 20 mg PO DAILY \n6. Lisinopril 20 mg PO DAILY \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. TraZODone 50 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nViral meningitis ___ HSV\nIron deficiency anemia\nRectal cancer\n\n \nDischarge Condition:\nStable for outpatient follow up\n\n \nDischarge Instructions:\nDear ___,\n\nYou came to the hospital with severe headache and fevers. You \nwere found to have a viral meningitis with testing showing \nherpes simplex virus to be the cause. Please continue taking \nValtrex and doxycycline until ___ to treat this infection.\n\nWhen you were in the hospital, you were found to have iron \ndeficiency anemia. You were seen by the Gastroenterologists. \nYou underwent an EGD and a colonoscopy. The EGD showed a little \nstomach irritation. Avoid ibuprofen, higher dose aspirin, and \nnaproxen. Take pantoprazole to help with the irritation. There \nwas no cancer found in the stomach. The colonoscopy showed a \nrectal cancer. Please follow up as instructed with \ngastroenterology for a better pathology sample and with the \nmulti-disciplinary colorectal cancer team as instructed.\n\nYour appointment with the multi-disciplinary team has already \nbeen set up.\n\nCall the ___ clinic to set up an appointment \nwith them, in order for them to get a better sample of the \ntumor. This is needed for the pathologists and oncologists. If \nyou do not hear from the office within 48 hours, call them at: \n___.\n\nWe wish you the best in your recovery.\n-- Your medical team\n \nFollowup Instructions:\n___\n" ]

[ "B003", "C20", "K626", "K2960", "K2980", "I10", "F329", "D508" ]

[ "B003: Herpesviral meningitis", "C20: Malignant neoplasm of rectum", "K626: Ulcer of anus and rectum", "K2960: Other gastritis without bleeding", "K2980: Duodenitis without bleeding", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "D508: Other iron deficiency anemias" ]

[ "I10", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex\n \nAttending: ___\n \nChief Complaint:\nabd pain\n \nMajor Surgical or Invasive Procedure:\n___: EUS was performed using a linear echoendoscope at ___ MHz \nfrequency. Celiac Plexus Neurolysis was performed. The take-off \nof the celiac artery was identified. A 22-gauge EUS needle was \nprimed with saline and advanced adjacent to the Aorta, just \nsuperior to the celiac artery take-off. The celiac plexus was \nvisualized. This was aspirated to assess for vascular injection. \nNo blood was noted. Bupivacaine 0.25% x 10 cc was injected \nbilaterally. Dehydrated 98% alcohol x 10 cc was injected. The \nneedle was then withdrawn.\n \nHistory of Present Illness:\n============================================================= \nONCOLOGY HOSPITALIST ADMISSION NOTE ___\n============================================================= \nPRIMARY ONCOLOGIST: ___\nPRIMARY DIAGNOSIS: Metastatic pancreatic cancer\nTREATMENT REGIMEN: C7D1 Gemcitabine ___\n \nCC: ___ pain\n\nHISTORY OF PRESENTING ILLNESS: \n___ is a ___ year old woman with metastatic pancreatic\ncancer on palliative gemcitabine who is admitted with one week \nof\nprogressive epigastric abdominal pain. Patient is deaf and uses\nASL; interview conducted with the aid of her son translating.\n\nPatient developed insidious onset of progressive epigastric\nabdominal pain after chemotherapy on ___. Her pain progressed,\nand was associated with nausea, dry heaves, and poor po intake.\nOlanzapine was prescribed for her worsening nausea on ___, \nwhich\nmade her very sleepy. By ___ she was not tolerating po intake\nwith emesis x2 and her pain was up to ___. She discusse with\nher oncologist, and presented to the ___ ED.\nThere, her lipase was 2800. CT a/p reportedly showed 'large\ninfiltrative pancreatic head tumor along with tumor infiltrate\nand/or pancreatitis in the lesser sac and about the celiac \naxis'.\nShe was transferred to ___ ED.\n\nIn the ED, initial VS were pain 10, T 99.6, HR 94, BP 115/75, RR\n16, O2 97%RA. Initial labs notable for Na 137, K 4.4, HCO3 24, \nCr\n0.5, Ca 9.6, Mg 2.0, P 2.9, ALT 14, AST 14, ALP 138, TBili 0.6,\nAlb 3.3, Lipase 508, INR 1.2, lactate 1.2. Patient was given IV\nlR along with IV Zofran and IV morphine. VS prior to transfer\nwere T 98.4, HR 80, BP 121/57, RR 16, O2 98%RA. \n\nOn arrival to the floor, patient reports progressive epigastric\npain, up to ___ with occaisional radiation into RUQ and LUQ. \nIt\nis worse with any po intake. Minimal relief with home oxycodone\nand tramadol. She has mild intermittent abdominal pain but\nnothing like this. She has associated poor appetite and nausea.\nNo fevers or chills. No dysphagia or odynophagia. No UTRI\nsymptoms. No SOB, cough, or chest pian. No dysuria, although has\nhad low UOP. No BM in last two days and no diarrhea. No new \njoint\npains, rashes, or leg swelling.\n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n___ has a history of hypertension,\ncongenital deafness, and GERD, and presented in ___ to\n___ with painless jaundice. At the time, \nshe\nalso noted several weeks of nausea, vomiting, postprandial\nabdominal pain and a 20-pound weight loss. She was referred to\n___ where she underwent ERCP. This study identified a\nstricture in the common bile duct due to external compression. \nBrushings were atypical. Her CA ___ was elevated at 180 U/mL. \nShe underwent endoscopic ultrasound ___, which identified a 1.8 x 1.6 cm pancreatic head mass\nwithout vascular involvement. Biopsy by ___ showed\nadenocarcinoma. CT angiogram also showed a 1.6 x 1.4 x 1.4 cm\npancreatic head mass with stranding but no definite involvement\nat the SMA and SMV. There was no evidence of distant \nmetastases.\nMs. ___ was diagnosed with borderline resectable PDA and\ninitiated chemotherapy with neoadjuvant FOLFIRINOX ___.\nC1D15 was dose reduced for N/V/D. She was hospitalized\n___ with diarrhea, nausea, anorexia, and\nneutropenia. Her C2D15 treatment was held. With cycle 3 she\ntransitioned to mFOLFOX. She completed five infusion and was\ntaken to the OR ___. Liver metastases were identified\nintraoperatively, and plans for resection were aborted. She\ninitiated palliative chemotherapy with gemcitabine ___. \nThe dose was reduced to 750mg/m2 on C1D8 due to neutropenia. \nWith cycle 2 she transitioned to day 1 and 15 schedule. \nFollowing six cycles there was further progression, and she was\nreferred for combination gemcitabine/nab-paclitaxel.\n\n \nPAST MEDICAL HISTORY: \n1. Hypertension.\n2. Congenital deafness.\n3. GERD.\n4. Goiter.\n5. History of nephrolithiasis.\n6. Hypercholesterolemia.\n7. Status post C-section x 2.\n \nSocial History:\n___\nFamily History:\nThe patient's father died of an MI at ___ years.\nHer mother died with type 2 diabetes mellitus. A sister died \nwith\ncolon cancer at ___ years. Another sister died of ___\ndisease. She has two sons without health concerns.\n \nPhysical Exam:\nVITAL SIGNS: 97.9 PO 108 / 66 Lying 70 18 95 RA\n___: NAD\nHEENT: MMM\nCV: RR, NL S1S2 no S3S4, no MRG\nPULM: CTAB, respirations unlabored \nABD: BS+, S, less TTP epigastric area\nLIMBS: No ___\nSKIN: No rashes on extremities\nNEURO: Grossly WNL\n\n \nPertinent Results:\n___ 05:19AM BLOOD WBC-12.0* RBC-3.41* Hgb-9.6* Hct-30.0* \nMCV-88 MCH-28.2 MCHC-32.0 RDW-14.7 RDWSD-46.3 Plt ___\n___ 05:19AM BLOOD Glucose-69* UreaN-4* Creat-0.4 Na-135 \nK-3.6 Cl-98 HCO3-25 AnGap-12\n___ 05:19AM BLOOD ALT-9 AST-14 LD(LDH)-127 AlkPhos-109* \nTotBili-0.5\n___ 04:46AM BLOOD Lipase-293*\n___ 05:19AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.1* Mg-1.7\n___ 04:46AM BLOOD Triglyc-73\n \nBrief Hospital Course:\nIMAGING: \n___BDOMEN (___)\n- Image loaded into PACS. Read in chart:\n\" Large infiltrative pancreatic head tumor. There is tumor\ninfiltrate and/or pancreatitis in the lesser sac and about the\nceliac axis/SMA. Attenuation of the portal vein and splenic vein\ndue to tumor. Multiple liver metastases. Large amount stool in\nthe right colon \"\n\nASSESSMENT AND PLAN: \n___ w/ metastatic pancreatic cancer on palliative gemcitabine \nwho\nis admitted with one week of progressive epigastric abdominal\npain\n\n# Pancreatitis\n# Abdominal pain: \nPatient with one week of progressive worsening of epigastric\nabdominal pain/nausea. Found to have elevated lipase and OSH\nimaging suggestive of acute inflammation c/w pancreatitis flare\n(although difficult to interpret given her pancreatic cancer). \nNo\nelevation in LFT's to suggest acute obstruction. Pain has been\nlargely insidious since diagnosis of pancreatic ca so possibly\nacute pancreatitis but largely pain is due to the tumor hence\nceliac plexus block ___. Symptoms cont to improve slowly. \n\n- low fat diet\n- appreciate Pal care c/l for sx control\n- started on oxycontin 10 mg bid w/ modicum of improvement of \nher sx\n- cont oxycodone prn (uses rarely)\n\n# Metastatic pancreatic cancer: Initially thought locally\nadvanced and went to OR for Whipple after neoadjuvant\nchemotherapy, unfortunately found to have metastatic liver\ndisease intraoperatively. Recently progressive after 6C\npalliative gemcitabine. Plan has been to initiate nab-paclitaxel\nfor C7D15 however she noted several times she is not interested\nin receiving any more chemo until she regains her strength. \n\n- chemo on hold for this week\n- f/u Onc arranged\n- f/u w/ palliative care being arranged\n\n# Hypertension: now hypotensive, hence dc'd home acei w/ SBP \n___ \n\n# GERD: cont PPI\n\nCODE: DNR/DNI\nCOMMUNICATION: Patient \nEMERGENCY CONTACT HCP:\nHealth care proxy chosen: Yes\nName of health care proxy: ___ \nCell phone: ___ phone) \nDISPO: Home w/ ___\nBILLING: >30 min spent coordinating care for discharge\n______________\n___, D.O.\nHeme/Onc Hospitalist\n___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 20 mg PO DAILY \n2. OLANZapine 5 mg PO BID:PRN nausea \n3. Omeprazole 20 mg PO DAILY \n4. Ondansetron 8 mg PO Q8H:PRN nausea \n5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate \n\n6. Prochlorperazine 10 mg PO Q6H:PRN nausea \n7. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate \n8. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area \nRX *lidocaine 5 % ___ patches daily to LUQ daily, 12 hrs on, 12 \nhrs off Disp #*30 Patch Refills:*0 \n2. Magnesium Citrate 300 mL PO ONCE Duration: 1 Dose \nRX *magnesium citrate 300 ml by mouth q3 days Refills:*0 \n3. Milk of Magnesia 30 mL PO Q6H:PRN constipation \nRX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 ml by \nmouth q6h prn Refills:*0 \n4. Multivitamins W/minerals 1 TAB PO DAILY \n5. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H \nRX *oxycodone 10 mg 1 tablet(s) by mouth q12 Disp #*60 Tablet \nRefills:*0 \n6. Polyethylene Glycol 17 g PO DAILY constipation \nRX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily \nDisp #*30 Packet Refills:*0 \n7. Senna 17.2 mg PO BID constipation \nRX *sennosides [senna] 8.6 mg 17.2 mg by mouth twice a day Disp \n#*120 Tablet Refills:*0 \n8. Ondansetron ODT ___ mg PO Q8H:PRN nausea \nRX *ondansetron 4 mg ___ tablet(s) by mouth every eight (8) \nhours Disp #*60 Tablet Refills:*0 \n9. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n10. OLANZapine 5 mg PO BID:PRN nausea \n11. Omeprazole 20 mg PO DAILY \n12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nAcute Pancreatitis\nPancreatic Cancer\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear ___,\n\n___ was a pleasure caring for ___ in the hospital. ___ were \nadmitted because of worsening abdominal pain. ___ had a celiac \nplexus block and were started on oxycontin with improvement of \nyour pain. ___ will need to continue a low fat diet. ___ were \nseen by the nutritionist who recommended eating small frequent \nmeals. Please eat high protein, nutrient-dense diets that \ninclude fruits, vegetables, whole grains, low fat dairy, and \nother lean protein sources. Abstinence from alcohol and greasy \nor fried foods is important in helping to prevent malnutrition \nand pain. \n\nBest,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "G893", "Z66", "K8580", "E43", "C250", "C787", "C7900", "I959", "K219", "Z681", "I10", "E049", "E7800", "K5900" ]

[ "G893: Neoplasm related pain (acute) (chronic)", "Z66: Do not resuscitate", "K8580: Other acute pancreatitis without necrosis or infection", "E43: Unspecified severe protein-calorie malnutrition", "C250: Malignant neoplasm of head of pancreas", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7900: Secondary malignant neoplasm of unspecified kidney and renal pelvis", "I959: Hypotension, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z681: Body mass index [BMI] 19.9 or less, adult", "I10: Essential (primary) hypertension", "E049: Nontoxic goiter, unspecified", "E7800: Pure hypercholesterolemia, unspecified", "K5900: Constipation, unspecified" ]

[ "Z66", "K219", "I10", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex\n \nAttending: ___.\n \nChief Complaint:\nNausea, anorexia, abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ PMH of Deafness (uses ASL), GERD, HTN, Metastatic Pancreatic\nCancer (mets to liver, recently on palliative gemcitabine), CBD\nobstruction (s/p sphincerotomy and metal stent placement) who\nrecently was admitted for pain control and possible pancreatitis\n(s/p celiac plexus block and increased pain regimen), now \nreturns\nwith nausea, vomiting, abdominal pain and decreased PO intake\n\nPt was last discharged on ___ after being admitted for possible\npancreatitis vs pain ___ progression of malignancy. She had\nceliac nerve plexus block and had oxycontin initiated. As a\nresult pain was improved and patient was discharged with\noutpatient oncology followup\n\nOF note, patient is deaf and uses ASL to communicate for complex\ndecision making, but was able to communicate by writing and with\nlip reading for purposes of this interview. Pt noted that since\ndischarge she has had intermittent abdominal pain which is\nepigastric and radiating to the back, which comes on in spasms,\nwith sharp stabbing sensation. She noted that her pain may be \nslightly improved compared to prior though. However, she is more\nconcerned with nausea/vomiting at home with yellow colored\nvomitus and lack of po intake ___ decreased appetite. Denied\nfever, chills, sore throat, dysuria, rash, significant diarrhea. \n\n\nIn the ED, initial vitals: 98.1 107 122/87 18 99% RA. Labs\nrevealed WBC of 23 (recent baseline was 12), Hgb 11.9 (baseline\n9.5), plt 585 (baseline 268). Chem wnl, LFTs unchanged since \nlast\nadmission. Lipase 123 down from 500 on last admit. Lactate\nnormal. She was given IVF, Zofran, and dilaudid. She noted that\nshe felt unsafe going home as did not feel remarkably improved \nso\nwas admitted to oncology for further care. \n \nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \nAs per OMR\n\"presented in ___ to\n___ with painless jaundice. At the time, \nshe\nalso noted several weeks of nausea, vomiting, postprandial\nabdominal pain and a 20-pound weight loss. She was referred to\n___ where she underwent ERCP. This study identified a\nstricture in the common bile duct due to external compression. \nBrushings were atypical. Her CA ___ was elevated at 180 U/mL. \nShe underwent endoscopic ultrasound ___, which identified a 1.8 x 1.6 cm pancreatic head mass\nwithout vascular involvement. Biopsy by ___ showed\nadenocarcinoma. CT angiogram also showed a 1.6 x 1.4 x 1.4 cm\npancreatic head mass with stranding but no definite involvement\nat the ___ and ___. There was no evidence of distant \nmetastases.\nMs. ___ was diagnosed with borderline resectable PDA and\ninitiated chemotherapy with neoadjuvant FOLFIRINOX ___.\nC1D15 was dose reduced for N/V/D. She was hospitalized\n___ with diarrhea, nausea, anorexia, and\nneutropenia. Her C2D15 treatment was held. With cycle 3 she\ntransitioned to mFOLFOX. She completed five infusion and was\ntaken to the OR ___. Liver metastases were identified\nintraoperatively, and plans for resection were aborted. She\ninitiated palliative chemotherapy with gemcitabine ___. \nThe dose was reduced to 750mg/m2 on C1D8 due to neutropenia. \nWith cycle 2 she transitioned to day 1 and 15 schedule. \nFollowing six cycles there was further progression, and she was\nreferred for combination gemcitabine/nab-paclitaxel\"\n \nPAST MEDICAL HISTORY: \n1. Hypertension.\n2. Congenital deafness.\n3. GERD.\n4. Goiter.\n5. History of nephrolithiasis.\n6. Hypercholesterolemia.\n7. Status post C-section x 2.\n8. CBD obstruction s/p sphincerotomy and metal stent placement\nvia ERCP\n\n \nSocial History:\n___\nFamily History:\nThe patient's father died of an MI at ___ years.\nHer mother died with type 2 diabetes mellitus. A sister died \nwith\ncolon cancer at ___ years. Another sister died of ___\ndisease. She has two sons without health concerns.\n \nPhysical Exam:\nVitals: 98.3 134/84 104 18 98RA\n___: Sitting in bed, appears comfortable, no acute distress\nEYES: PERRLA\nHEENT: Moist mucous membranes, oropharynx clear\nNECK: Supple\nLUNGS: Clear to auscultation bilaterally no wheezes rales or\nrhonchi, normal respiratory rate\nCV: Regular rate and rhythm without any murmurs rubs or gallops\nABD: Slight epigastric tenderness to moderate palpation,\nnondistended, normoactive bowel sounds, no ascites\nEXT: Normal bulk/tone, no deformity\nSKIN: Warm/dry, no rash\nNEURO: Alert and oriented ×3, fluent speech but has difficulty\nwith correct pronunciation as is deaf, but reads lips and writes\nto communicate\nACCESS: chest port with dressing c/d/i\n \nPertinent Results:\n___ 02:10PM WBC-23.0*# RBC-4.30# HGB-11.9 HCT-37.1 MCV-86 \nMCH-27.7 MCHC-32.1 RDW-16.1* RDWSD-48.4*\n___ 02:10PM PLT COUNT-585*#\n___ 02:10PM cTropnT-0.05*\n___ 02:10PM ALT(SGPT)-10 AST(SGOT)-18 ALK PHOS-153* TOT \nBILI-0.5\n___ 02:10PM LIPASE-123*\n___ 02:10PM GLUCOSE-132* UREA N-10 CREAT-0.4 SODIUM-138 \nPOTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-18*\n___ 02:53PM LACTATE-1.7\n \nBrief Hospital Course:\nMs ___ is a pleasant ___ year-old female with deafness \nadmitted with recurrent abdominal pain, nausea, and poor \nappetite attributed to her pancreatic cancer. Her anti-nausea \nand pain medications were adjusted to achieve better symptom \ncontrol, including increase of her oxycontin dose from bid to \ntid, and adding baclofen to address some element of back spasm. \nHer appetite remained minimal, but she was able to tolerate \nfluids throughout her stay. She met with Dr ___ our \n___ Care service and discussed options for home hospice, \nthough at the time of discharge she remains uncertain whether \nshe may pursue palliative chemotherapy instead. Her ___ agency \nhas the ability to deliver hospice care and will continue to \noffer information on this option after she arrives home. \nThroughout her admission she was seen at least daily with the \nassistance of our ASL interpreter.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Ondansetron ODT ___ mg PO Q8H:PRN nausea \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate \n\n4. Omeprazole 20 mg PO DAILY \n5. Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area \n6. Milk of Magnesia 30 mL PO Q6H:PRN constipation \n7. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H \n8. Polyethylene Glycol 17 g PO DAILY constipation \n9. Senna 17.2 mg PO BID constipation \n10. OLANZapine 5 mg PO BID:PRN nausea \n11. Magnesium Citrate 300 mL PO ONCE \n12. Multivitamins W/minerals 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Baclofen 5 mg PO Q8H:PRN Back Pain \nRX *baclofen 10 mg 0.5 (One half) tablet(s) by mouth every eight \n(8) hours Disp #*90 Tablet Refills:*2 \n2. lidocaine 5 % topical QAM \nRX *lidocaine [Lidoderm] 5 % apply to left upper abdomen qam \nDisp #*30 Patch Refills:*3\nRX *lidocaine 5 % apply to left upper abdomen qam Disp #*30 \nPatch Refills:*2 \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*60 Tablet Refills:*0 \n4. OxyCODONE SR (OxyconTIN) 10 mg PO Q8H abdominal pain \n5. Lidocaine 5% Patch ___ PTCH TD QAM to LUQ area \n6. Magnesium Citrate 300 mL PO ONCE \n7. Milk of Magnesia 30 mL PO Q6H:PRN constipation \n8. Multivitamins W/minerals 1 TAB PO DAILY \n9. OLANZapine 5 mg PO BID:PRN nausea \n10. Omeprazole 20 mg PO DAILY \n11. Ondansetron ODT ___ mg PO Q8H:PRN nausea \n12. Polyethylene Glycol 17 g PO DAILY constipation \n13. Senna 17.2 mg PO BID constipation \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nMetastatic pancreatic cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nPlease take your medications as prescribed.\n \nFollowup Instructions:\n___\n" ]

[ "C250", "C787", "E860", "H903", "K219", "I10", "D473", "D72829", "E861", "R112", "Z66", "G893", "Z800", "R634", "Z6821" ]

[ "C250: Malignant neoplasm of head of pancreas", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "E860: Dehydration", "H903: Sensorineural hearing loss, bilateral", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "D473: Essential (hemorrhagic) thrombocythemia", "D72829: Elevated white blood cell count, unspecified", "E861: Hypovolemia", "R112: Nausea with vomiting, unspecified", "Z66: Do not resuscitate", "G893: Neoplasm related pain (acute) (chronic)", "Z800: Family history of malignant neoplasm of digestive organs", "R634: Abnormal weight loss", "Z6821: Body mass index [BMI] 21.0-21.9, adult" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex\n \nAttending: ___\n \nChief Complaint:\nPainless jaundice, nausea\n \nMajor Surgical or Invasive Procedure:\nEUS\n\n \nHistory of Present Illness:\nMs. ___ is a ___ PMHx HTN and congenital deafness who was \ninitially admitted to ___ on ___ for \npainless\njaundice/biliary obstruction associated with n/v, post-prandial \nabdominal pain and unintentional weight loss over the past \nmonth. \n\nHistory is obtained with assistance of her son who is fluent in \n___ sign language. She had an MRCP as an outpatient which \nshowed concern for possible lesion at uncinated process. She \nwas then sent to ___ on ___ for ERCP evaluation; ERCP \nshowed stricture with post-obstructive dilation with severely \ndilated proximal CBD. These findings were compatible with \nextrinsic compression of malignant pancreatic lesion at the \nhead/uncinate process of the pancreas. She underwent \nsphincterotomy with stent placement; brushings showed atypical \ncells on cytology. She was transferred back to ___ \n___. Post-ERCP, the patient has had ongoing obstructive \nsymptoms of n/v, abdominal pain and very limited PO tolerance \n(barely tolerating a liquid diet). EUS was performed on ___ \nwhich was\nwnl, but her CA ___ level was elevated to 180. She has been \nafebrile, and labs have shown improvement of her LFTs with \nAST46, ALT 86, alkphos 376 at admission to 303 today. Tbili 18 \nat admission to 10.1 today. WBC nml. Transfer is requested for \nrepeat ERCP evaluation and further work-up for malignancy.\n\nUpon arrival to the floor, the patient feels overall well and \nendorses just some mild epigastric and RUQ abdominal soreness. \nShe has been only on liquids for the past 2 weeks without any \nsignificant PO intake.\n \nROS: \n(+) Per HPI \n(-) Denies fever, chills, night sweats. Denies headache, sinus \ntenderness, rhinorrhea or congestion. Denies cough, shortness of \nbreath. Denies chest pain or tightness, palpitations. No recent \nchange in bowel or bladder habits. No dysuria. Denies \narthralgias or myalgias. \n\n \nPast Medical History:\nHTN \ncongenital deafness\nGERD\nGoiter\n \nSocial History:\n___\nFamily History:\nFather passed away from complications of gangrenous colitis.\nMother with T2DM.\nSister with colon CA.\nSister deceased, ___.\n \nPhysical Exam:\nVital Signs: 98.3, 158/92, 71, 18, 99% on RA \n___: Well-appearing elderly jaundiced female, oriented, no \nacute distress \nHEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL, neck \nsupple, 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, obese, nondistended, mild TTP of epigastrium and \nRUQ, normal bowel sounds\nGU: No foley \nExt: Warm, well perfused, 2+ pulses, trace pitting edema of BLE \nNeuro: AOX3, moving all extremities spontaneously, nml gait. \nCan read lips, responding to all commands \n\nOn discharge:\nGEN: Lying in bed, in NAD, jaundiced\nHEENT: EOMI, sclerae anicteric, MMM, OP clear \nNECK: No LAD, no JVD\nCARDIAC: RRR, no M/R/G\nPULM: normal effort, no accessory muscle use, LCAB\nGI: soft, NT, ND, NABS\nMSK: No visible joint effusions or deformities.\nDERM: No visible rash. No jaundice.\nNEURO: AAOx3. No facial droop, moving all extremities.\nPSYCH: Full range of affect\nEXTREMITIES: WWP, trace edema\n \nPertinent Results:\n___ OSH labs\nWBC 7.6\nHgb 11.1 (down from 14.8 at admission on ___\nPlt 260\nMCV 77\nNa 142\nK 4.1\nCl 107\nCO2 28\nCr 0.672\nTbili 10.1\nAST 46\nALT 86\nAP 303\nCEA 112\nCA ___ 180.6 \n\nOn Admission:\n\n___ 06:50AM BLOOD WBC-8.2 RBC-3.78* Hgb-10.2* Hct-29.4* \nMCV-78* MCH-27.0 MCHC-34.7 RDW-18.1* RDWSD-48.0* Plt ___\n___ 06:50AM BLOOD ___ PTT-26.9 ___\n___ 06:50AM BLOOD Glucose-110* UreaN-6 Creat-0.7 Na-142 \nK-4.1 Cl-106 HCO3-31 AnGap-9\n___ 06:50AM BLOOD ALT-69* AST-56* AlkPhos-277* TotBili-8.8*\n___ 06:50AM BLOOD calTIBC-177* Ferritn-755* TRF-136*\n\nOn Discharge:\n\n___ 06:44AM BLOOD WBC-9.1 RBC-3.81* Hgb-10.1* Hct-30.4* \nMCV-80* MCH-26.5 MCHC-33.2 RDW-18.6* RDWSD-50.7* Plt ___\n___ 06:44AM BLOOD Glucose-144* UreaN-6 Creat-0.5 Na-141 \nK-3.3 Cl-104 HCO3-29 AnGap-11\n___ 06:44AM BLOOD ALT-61* AST-51* AlkPhos-257* TotBili-6.1*\n___ 06:44AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9\n___ 06:15AM BLOOD IGG SUBCLASSES 1,2,3,4-Test \n\nIMAGING & STUDIES\n================= \n___ ERCP\nFindings: \nEsophagus: Limited exam of the esophagus was normal \n \nStomach: Limited exam of the stomach was normal \n \nDuodenum: Limited exam of the duodenum was normal \n \nMajor Papilla: Normal major papilla was noted. \n\nCannulation: Cannulation of the biliary duct was successful and \ndeep with a sphincterotome using a free-hand technique. Contrast \nmedium was injected resulting in complete opacification. The \nprocedure was not difficult. \n \nBiliary Tree/Fluoroscopy Interpretation: The scout film was \nnormal. A single 1.5 cm stricture was seen at the lower third of \nthe common bile duct. There was post-obstructive dilation with \nseverely dilated proximal CBD. with both CBD. These findings are \ncompatible with extrinsic compression of malignant pancreatic \nlesion at the head/uncinate process of pancreas. A \nsphincterotomy was performed in the 12 o'clock position using a \nsphincterotome over an existing guidewire. No evidence of post \nsphincterotomy bleeding was noted. Cytology samples were \nobtained for histology using a brush in the lower third of the \ncommon bile duct for final diagnosis. Due to obstructive pattern \na ___ biliary plastic stent was placed into the distal \ncommon bile duct. Post stent deployment a good contrast and bile \ndrainage was noted both endoscopically and fluoroscopically. I \nsupervised the acquisition and interpretation of the fluoroscopy \nimages. The quality of the images was good. \n\nImpression: •The scout film was normal. \n•Normal major papilla was noted.\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•A single 1.5 cm stricture was seen at the lower third of the \ncommon bile duct. \n•There was post-obstructive dilation with severely dilated \nproximal CBD. \n•These findings are compatible with extrinsic compression of \nmalignant pancreatic lesion at the head/uncinate process of \npancreas. \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•Cytology samples were obtained for histology using a brush in \nthe lower third of the common bile duct for final diagnosis. \n•Due to obstructive pattern a ___ biliary plastic stent was \nplaced into the distal common bile duct. \n•Post stent deployment a good contrast and bile drainage was \nnoted both endoscopically and fluoroscopically.\n•Otherwise normal ercp to third part of the duodenum\n\n___: Tissue biopsy pancreas: Adenocarcinoma\n\n___ CT Chest\nIMPRESSION: \n \nNo evidence of metastasis. \n \nLarge goiter, substantially narrows the trachea at the thoracic \ninlet and \ncould contribute to malacia, though not assessed by this study. \nUltrasound recommended to exclude concurrent thyroid nodules. \n \nSmall bilateral pleural effusions. Severe bibasilar relaxation \natelectasis. \n\n___ CT A/P Pancreas Protocol\n1. Patient is now status post biliary stenting, with the stent \nextending from the common hepatic duct to the duodenum. There \nis associated pneumobilia, the but interval reduction in the \nintra and extrahepatic biliary dilatation. \n2. A approximately 1.6 cm x 1.4 cm x 1.4 cm poorly-defined \nhypoenhancing \nlesion is seen at the head of the pancreas. \n3. Peripancreatic fluid and fat stranding, particularly \nsurrounding the head of the pancreas, SMA and SMV. This may \nrepresent pancreatitis in the \nappropriate clinical setting. \n4. Subcentimeter hypodensity in segment 4B of the liver likely \nrepresents a biliary hamartoma versus simple cyst. \n5. Multiple bilateral subcentimeter renal hypodensities are too \nsmall to \ncharacterize but likely represent simple renal cysts. \n6. 1.7 cm homogeneously enhancing lesion in the uterus, likely a \nfibroid. \n7. Please see separate report of CT chest performed on the same \ndate. \n\n___ Thyroid US\nMultinodular goiter. Dominant solid nodules arising from the \nisthmus and \nright lower pole measuring 3.2 cm and at least 4.9 cm, \nrespectively, are \nrecommended for biopsy. \n \nRECOMMENDATION(S): Thyroid biopsy of the dominant isthmic and \nright lower \npole nodules, as above. \n\n \n \nBrief Hospital Course:\nMs. ___ is a ___ PMHx HTN and congenital deafness who was \ninitially admitted to ___ on ___ for \npainless jaundice/biliary obstruction associated with n/v, \npost-prandial abdominal pain and unintentional weight loss s/p \nERCP with sphincterotomy and stent placement for CBD dilation, \ntransferred for repeat ERCP evaluation for likely ongoing \nobstruction.\n\n# Pancreatic adenocarcinoma: Resulting in painless jaundice and \nnausea. She underwent ERCP with sphincterotomy on ___ with \nplastic stent placement to relieve the obstruction. Her LFTs \nsubsequently downtrended and her nausea improved. CT pancreas \nnotable for 1.6 cm x 1.4 cm x 1.4 cm poorly-defined \nhypoenhancing lesion is seen at the head of the pancreas. \nStaging CT of the chest was negative for metastases. She was \nseen by the surgery team and is scheduled for follow up in the \nsurgery clinic on ___ to discuss the next steps in surgical \nmanagement. \n\n# Goiter: Patient has known goiter and reportedly has an \noutpatient endocrinologist. Staging CT of the chest noted this \nlarge goiter and advised for further evaluation with ultrasound. \nUltrasound revealed multinodular goiter. Dominant solid nodules \narising from the isthmus and right lower pole measuring 3.2 cm \nand at least 4.9 cm, respectively, are recommended for biopsy. \nOn discussion of these findings with the patient she revealed \nthat she has in fact recently undergone biopsy of her thyroid \nand has follow up with her endocrinologist in the near future.\n\n# Pruritis: Likely secondary to elevated bilirubin. She found \nmost symptomatic relief with sarna lotion (rather than \ncholestyramine) and was discharged with a prescription. \n \n# HTN: Continued home lisinopril\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 20 mg PO DAILY \n2. Omeprazole 40 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \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 #*30 Capsule Refills:*0 \n2. Polyethylene Glycol 17 g PO DAILY \nDo not take if you are having loose stools \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by \nmouth daily Disp #*15 Packet Refills:*0 \n3. Sarna Lotion 1 Appl TP QID:PRN pruritus \nRX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to \naffected area Four times daily Refills:*0 \n4. Senna 8.6 mg PO BID \nPlease do not take this if you are having loose stools \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp \n#*30 Tablet Refills:*0 \n5. Aspirin 81 mg PO DAILY \n6. Cholestyramine 4 gm PO DAILY \n7. Lisinopril 20 mg PO DAILY \n8. Omeprazole 40 mg PO DAILY \n9. Ondansetron 4 mg PO Q4H:PRN nausea \n10. zaleplon 5 mg oral QHS:PRN \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nPancreatic adenocarcinoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital because of an inability to \ntolerate food. This is likely from compression of part of your \nGI tract by a mass. Fortunately, your symptoms improved during \nyour hospitalization. You underwent imaging to help further \ncharacterize what may be going on in your GI tract to cause \nthese symptoms. You are scheduled for follow up with the surgery \nteam to discuss the next steps in your diagnosis and treatment \nplan.\n\nOf note, your CT scan revealed a large goiter. The \nrecommendation was to obtain an ultrasound to determine the \npresence of nodules. The ultrasound did reveal some nodules that \nwere recommended for biopsy. However, it appears that you have \nrecently undergone a thyroid nodule biopsy. Please continue to \nfollow up with your thyroid specialist as previously scheduled. \n\nPlease follow up with your primary care doctor as previously \nscheduled. \n\nIt was a pleasure to be a part of your care!\nYour ___ treatment team\n \nFollowup Instructions:\n___\n" ]

[ "C250", "H905", "I10", "E042", "K838", "L298", "K219", "D509", "G4700", "Z800" ]

[ "C250: Malignant neoplasm of head of pancreas", "H905: Unspecified sensorineural hearing loss", "I10: Essential (primary) hypertension", "E042: Nontoxic multinodular goiter", "K838: Other specified diseases of biliary tract", "L298: Other pruritus", "K219: Gastro-esophageal reflux disease without esophagitis", "D509: Iron deficiency anemia, unspecified", "G4700: Insomnia, unspecified", "Z800: Family history of malignant neoplasm of digestive organs" ]

[ "I10", "K219", "D509", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex\n \nAttending: ___.\n \nChief Complaint:\ndiarrhea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ w/ HTN, DL, congenital\ndeafness, and recently diagnosed borderline resectable \npancreatic\nhead adenocarcinoma, on neoadjuvant C1D21 Folfirinox who \npresents\nfor diarrhea for two days.\n\nShe had ERCP with stent placement done yesterday. No\ncomplications with that. She reports multiple episodes of watery\nbrown non-bloody diarrhea for the past two days. She reports not\neating or drinking as much over the past several months. Also\nsome nausea on and off over the same time period. She reports\nmild gas pain but denies abdominal pain and vomiting.\n\nIn ED, initial vitals were Temp 97.7, HR 91, BP 102/65, RR 15, \nO2\nsat 98% RA. She received 1L NS. CXR was negative for infection.\nVitals prior to transfer were Temp 98.1, HR 77, BP 106/66, RR \n16,\nO2 sat 100% RA.\n\nOn arrival to the floor, she reports that she is feeling well.\nShe denies fevers/chills, headache, dizziness/lightheadedness,\nshortness of breath, cough, chest pain, palpitations, abdominal\npain, vomiting, constipation, dysuria, and rashes.\n\n \nPast Medical History:\nHTN \ncongenital deafness\nGERD\nGoiter\n \nSocial History:\n___\nFamily History:\nFather passed away from complications of gangrenous colitis.\nMother with T2DM.\nSister with colon CA.\nSister deceased, ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: Temp 97.3, BP 125/89, HR 69, RR 18, O2 sat 100% RA.\nGENERAL: Pleasant woman, in no distress, lying in bed\ncomfortably.\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.\nABD: Normal bowel sounds, soft, nontender, nondistended, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: Alert, oriented, good attention and linear thought, CN\nII-XII intact. Strength full throughout.\nSKIN: No significant rashes.\n \n \nBrief Hospital Course:\n___ is a pleasant ___ w/ HTN, DL, congenital deafness, and \nrecently diagnosed borderline resectable pancreatic head \nadenocarcinoma, on neoadjuvant C1D21\nFolfirinox who presents for diarrhea for two days. \n\nDiarrhea- She has 2 loose watery diarrhea everyday mostly at AM. \nHer stool c diff was negative. She was started on Imodium and \nthe dose was titrated up to 4mg TID but she still continued to \nhave loose watery diarrhea. Her diarrhea is most likely from \nIrinotecan. She was also started on peptobismol to help her \ndiarrhea\n\nElevated Lipase- She had a mild elevation of lipase levels but \nthis is likely from her having a ERCP on the day prior to \nadmission. She does not have any epigastric abdominal pain or \nlipase levels high enough to suspect pancreatitis.\n\n Her blood and urine cultures were negative during this \nadmission. She was discharged home in a stable condition.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 20 mg PO DAILY \n2. Omeprazole 20 mg PO DAILY \n3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n4. LORazepam 0.5 mg PO BID:PRN anxiety,nausea \n5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n6. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate \n7. Dexamethasone 4 mg PO BID \n\n \nDischarge Medications:\n1. Bismuth Subsalicylate 30 mL PO TID \n___ cause black discoloration of stool \nRX *bismuth subsalicylate [Bismatrol] 525 mg/15 mL 15 ml by \nmouth three times daily Refills:*0 \n2. LOPERamide 4 mg PO Q8H \nRX *loperamide 2 mg 2 tablets by mouth three times daily Disp \n#*50 Capsule Refills:*1 \n3. Dexamethasone 4 mg PO BID \ntake for 2 days after chemotherapy \n4. Lisinopril 20 mg PO DAILY \n5. LORazepam 0.5 mg PO BID:PRN anxiety,nausea \nRX *lorazepam 0.5 mg 1 tablet by mouth twice daily Disp #*30 \nTablet Refills:*1 \n6. Omeprazole 20 mg PO DAILY \n7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n8. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n9. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nDiarrhea-likely from Irinotecan.\nPancreatic cancer\n\n \nDischarge Condition:\nstable\nalert and oriented to time place and person\nindependent ambulation\n\n \nDischarge Instructions:\nDear ___,\n\n It was a pleasure taking care of you. You were admitted since \nyou developed loose stools. We found out that you had no \ninfections causing the diarrhea. It is likely a adverse reaction \nfrom chemotherapy agent.\n\n Please take Imodium and Peptobismol as directed until your \ndiarrhea is controlled.\n\n Please follow up for your appointment with ___ on \n___.\n\nSincerely,\n___ MD\n \nFollowup Instructions:\n___\n" ]

[ "K521", "K831", "C250", "D6959", "E860", "I10", "K219", "R110", "T451X5A", "Y929" ]

[ "K521: Toxic gastroenteritis and colitis", "K831: Obstruction of bile duct", "C250: Malignant neoplasm of head of pancreas", "D6959: Other secondary thrombocytopenia", "E860: Dehydration", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "R110: Nausea", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "I10", "K219", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlatex\n \nAttending: ___.\n \nChief Complaint:\nNausea/vomting, diarrhea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with with HTN, DL,\ncongenital deafness, and borderline resectable pancreatic head\nadenocarcinoma on neoadjuvant C2D12 Folfirinox who presents with\nnausea/vomiting, diarrhea, and inability to tolerate POs.\n\nPatient reports continued diarrhea as well as nausea/vomiting\nthat has not been controlled with home medications. She was seen\nin clinic on ___ where she noted diarrhea for one week and\nwas given immodium, Zofran, and 1L NS. She had been taking Pepto\nBismal. Stool studies were ordered however patient unable to \ngive\na sample and attempted to be done at outside facility but not\nprocessed. She continued to have diarrhea and poor PO intake due\nto nausea and poor appetite. She tried immodium without\nsignificant improvement. She wants to stop chemo due to the side\neffects.\n\nOf note, she was recently admitted ___ to ___ with\ndiarrhea. Stool studies were negative. She was started on\nimmodium and pepto bismal.\n\nOn arrival to the ED, initial vitals were 97.9 80 118/71 16 100%\nRA. Labs were notable for WBC 3.0, H/H 13.0/39.8, Plt 248, Na\n134, K 3.5, BUN/Cr ___, LFTs wnl, INR 1.2, and UA bland. CT\nabdomen was negative for acute process. Patient was given Zofran\n4mg IV x 2 and 1L Ns at 100 cc/hr. Vitals prior to transfer were\n98.0 99 117/90 18 99% RA.\n\nOn arrival to the floor, patient reports that she is feeling\nbetter. She is able to drink without nausea. She denies\nfevers/chills, headache, dizziness/lightheadedness, vision\nchanges, weakness/numbness, shortness of breath, cough, chest\npain, palpitations, and dysuria.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n___ has a history of hypertension, congenital\ndeafness, and GERD, and presented in early ___ to ___ with painless jaundice. At the time, she also\nnoted several weeks of nausea, vomiting, postprandial abdominal\npain and a 20-pound weight loss. She was referred to ___ where\nshe underwent ERCP. This study identified a stricture in the\ncommon bile duct due to external compression. Brushings were\natypical. Her CA ___ was elevated at 180 U/mL. She underwent\nendoscopic ultrasound ___. This study identified a \n1.8\nx 1.6 cm pancreatic head mass without vascular involvement.\nBiopsy by ___ showed adenocarcinoma. CT angiogram also\nshowed a 1.6 x 1.4 x 1.4 cm pancreatic head mass with stranding\nbut no definite involvement at the SMA and SMV. There was no\nevidence of distant metastases. Ms. ___ was diagnosed with\nborderline resectable PDA and initiated chemotherapy with\nneoadjuvant FOLFIRINOX ___. C1D15 dose reduced for N/V/D.\nShe underwent biliary stent change and was then hospitalized\n___ with persistent diarrhea and leukocytosis. \n \nPAST MEDICAL HISTORY:\n1. Hypertension\n2. Congenital deafness\n3. GERD\n4. Goiter\n5. History of nephrolithiasis\n6. Hypercholesterolemia\n7. Status post C-section x 2\n \nSocial History:\n___\nFamily History:\nThe patient's father died of an MI at ___ years.\nHer mother died with type 2 diabetes mellitus. A sister died \nwith\ncolon cancer at ___ years. Another sister died of ___\ndisease. She has two sons without health concerns.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: Temp 97.2, BP 154/84, HR 99, RR 18, O2 sat 98% RA.\n___: Pleasant woman, in no distress, lying in bed\ncomfortably.\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.\nABD: Normal bowel sounds, soft, nontender, nondistended, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: Alert, oriented, good attention and linear thought, CN\nII-XII intact. Strength full throughout.\nSKIN: No significant rashes.\n\nDischarge PE:\n97.7 142 / 80 82 18 97 RA \n___: Well appearing, lying in bed in NAD\nEyes: PERLL, EOMI, sclera anicteric\nENT: MMM, oropharynx clear without exudate or lesions \nRespiratory: CTAB without crackles, wheeze, rhonchi, though\nbreath sounds reduced at bases. \nCardiovascular: RRR, normal S1 and S2, no murmurs, rubs or\ngallops\nGastrointestinal: Soft, nontender, nondistended, +BS, no masses\nor HSM\nExtremities: Warm and well perfused, no peripheral edema \nSkin: warm, no rashes/no jaundice/no skin ulcerations noted\nNeurological: Alert and oriented x3\n \nPertinent Results:\nADMISSION LABS:\n\n___ 10:35AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 10:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 10:35AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE \nEPI-1\n___ 04:29AM GLUCOSE-103* UREA N-10 CREAT-0.5 SODIUM-134 \nPOTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-20* ANION GAP-19\n___ 04:29AM ALT(SGPT)-29 AST(SGOT)-22 ALK PHOS-60 TOT \nBILI-0.4\n___ 04:29AM LIPASE-33\n___ 04:29AM ALBUMIN-3.0* CALCIUM-8.1* PHOSPHATE-2.3* \nMAGNESIUM-1.6\n___ 04:29AM WBC-3.0*# RBC-4.66 HGB-13.0 HCT-39.8 MCV-85 \nMCH-27.9 MCHC-32.7 RDW-15.0 RDWSD-45.9\n___ 04:29AM NEUTS-41 BANDS-3 ___ MONOS-21* EOS-2 \nBASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-1.32* AbsLymp-0.99* \nAbsMono-0.63 AbsEos-0.06 AbsBaso-0.00*\n___ 04:29AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-3+ \nMACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-1+ \nSCHISTOCY-OCCASIONAL BURR-3+ TEARDROP-OCCASIONAL\n___ 04:29AM ___ PTT-22.7* ___\n\nDISCHARGE LABS:\n___ 06:17AM BLOOD WBC-7.6 RBC-4.35 Hgb-12.0 Hct-36.5 MCV-84 \nMCH-27.6 MCHC-32.9 RDW-15.4 RDWSD-46.3 Plt ___\n___ 06:17AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-137 K-4.0 \nCl-99 HCO3-29 AnGap-13\n___ 06:17AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7\n\nMICRO: \nURINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n___ C diff, stool studies negative\n\nIMAGING:\n\n___ CXR\nIMPRESSION: \nIn comparison with the study of ___, there is little \ninterval change. The cardiac silhouette remains within normal \nlimits with no evidence of vascular congestion or acute focal \npneumonia. There is blunting of the left costophrenic angle on \nthe lateral view, suggesting small interval pleural effusion. \nThe right Port-A-Cath again extends to the lower SVC.\n\n___ CT A/P\nIMPRESSION:\n1. No evidence of acute intra-abdominal process.\n2. Pancreatic head hypodensity is unchanged and associated \nperipancreatic soft\ntissue density is less conspicuous, potentially due to interval \nimprovement or\ndifferences in technique.\n3. Left pelvic vein engorgement and left gonadal vein \nenlargement are\nnonspecific findings but may be seen in the setting of pelvic \ncongestion\nsyndrome.\n \nBrief Hospital Course:\n___ female with with HTN, congenital deafness, and\nborderline resectable pancreatic head adenocarcinoma on\nneoadjuvant C2D12 Folfirinox who presents with nausea/vomiting,\ndiarrhea, and inability to tolerate POs.\n\n# Diarrhea/Nausea/Vomiting: Most likely due to side effects of\nFOLFIRINOX. Abdominal CT without acute process and exam benign.\nSimilar symptoms in past after chemotherapy. Less likely\ninfection especially given negative stool studies. C. diff\nnegative so after consultation with outpatient oncologist,\ntreated with typical antidiarrheal regimen of loperamide and\nlomotil with resolution of diarrhea. Beginning to improve, \nmildly increased PO intake but solid foods still limited. \nDiarrhea largely resolved. After discussion with patient and \noutpatient oncologist was started on Decadron 2 mg PO daily to \nhelp improve appetite/reduce nausea in order to allow adequate \nPO intake for safe discharge. \n- Continue 2mg dexamethasone daily, likely will stop after 7 day \ncourse if continued improvement\n- Continue anti-emetic regimen \n- Continue PPI \n\n#Cough: Having cough intermittently productive of yellow sputum. \n Lung exam reassuring, CXR shows no evidence of pneumonia, \nafebrile without leukocytosis. \n-Monitor off antibiotics, if symptoms worsening consider repeat \nchest imaging\n-Cont IS\n-Encourage ambulation\n\n# Pancreatic Cancer/neutropenia: s/p FOLFIRINOX cycle 2 on ___.\nGI sx likely ___ further plans \nfor\nadministration of this drug. Neutropenic with ANC ___,\nlikely ___ recent chemotx, no fevers to date, WBC now improved\nwith ANC >2800. Will follow with Dr. ___. \n- Continue tramadol for pain\n\n# HTN:\n- Lisinopril was held initially, restarted on discharge\n\n# Anxiety: She reports having anxiety about leaving the hospital \nas after multiple recent discharges she quickly went to a local \nED. She was counseled extensively that she had made gradual \nimprovement and there was no further treatment recommended in \nthe hospital at this time. \n-Consider outpatient social work or palliative care referral to \nhelp with anxiety and symptom management. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LORazepam 0.5 mg PO BID:PRN anxiety,nausea \n2. Omeprazole 20 mg PO DAILY \n3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n4. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate \n5. Bismuth Subsalicylate 30 mL PO TID:PRN \ndiarrhea/nausea/abdominal pain \n6. LOPERamide 4 mg PO TID:PRN diarrhea \n7. Dexamethasone 4 mg PO BID \n8. Lisinopril 20 mg PO DAILY \n9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n10. ___ ___ UNIT PO QID \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n2. Senna 8.6 mg PO BID:PRN constipation \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Dexamethasone 2 mg PO DAILY Duration: 7 Days \nRX *dexamethasone 2 mg 1 tablet(s) by mouth once a day Disp #*7 \nTablet Refills:*0 \n4. Bismuth Subsalicylate 30 mL PO TID:PRN \ndiarrhea/nausea/abdominal pain \n5. Lisinopril 20 mg PO DAILY \n6. LOPERamide 4 mg PO TID:PRN diarrhea \n7. LORazepam 0.5 mg PO BID:PRN anxiety,nausea \n8. ___ ___ UNIT PO QID \n9. Omeprazole 20 mg PO DAILY \n10. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n12. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nPrimary: Chemotherapy-related nausea\n\nSecondary: Pancreatic adenocarcinoma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ for nausea/vomiting/diarrhea and \ninability to tolerate food after your recent chemotherapy. You \nwere given medicine which resolved your diarrhea and helped with \nnausea. Since you continued to have difficulty eating, you were \nstarted on a course of steroids. \n\nPlease follow up with your oncologist to determine your ongoing \nchemotherapy plans. \n\nIt was a pleasure caring for you, \n\nYour ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "E860", "C250", "K521", "D701", "H905", "I10", "K219", "R112", "T451X5A", "Z6823", "R630", "E7800", "F419", "Y929" ]

[ "E860: Dehydration", "C250: Malignant neoplasm of head of pancreas", "K521: Toxic gastroenteritis and colitis", "D701: Agranulocytosis secondary to cancer chemotherapy", "H905: Unspecified sensorineural hearing loss", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "R112: Nausea with vomiting, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "R630: Anorexia", "E7800: Pure hypercholesterolemia, unspecified", "F419: Anxiety disorder, unspecified", "Y929: Unspecified place or not applicable" ]

[ "I10", "K219", "F419", "Y929" ]

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