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rntc

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mm-icd-visit

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nMorphine Sulfate / Codeine / Dilaudid (PF) / lisinopril / \nlisinopril\n \nAttending: ___\n \nChief Complaint:\nhypoglycemia\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nPatient is a ___ year old woman with history of NIDDM on \nglipizide, hx of pericarditis, HTN, hyperlipidemia, \nnephrolithiasis who presents from home with weakness and found \nto have hypoglycemia.\n\nShe is on glipizide and metformin for diabetes mellitus. Her AM \n___ range from ___, the highest ___ she usually has are in the \nevenings, up to 150s. She has noted a few lows this month, as \nlow as 60 in the AM. She reports she was in her usual state of \nhealth until this AM when she experienced severe fatigue where \nshe could not get out of the sofa. Reports feeling cold and \nclammy. No fall. She called EMS and on arrival BS ___, given \noral glucose, improved to 30, BIBEMS, no IV access could be \nobtained. No cough, ST, rhinorrhea, abd pain, naus, vom, \ndiarrhea, dysuria, frequency, CP, SOB, or leg swelling. No \nfevers or chills. No visual changes, blurry vision, or headache. \nNo history of antecedent trauma. Of note, she was started on \nindomethacin on ___ for a presumed gout flare at first MTP \njoint.\n\nIn ED, VS: 97.0 104 182/97 18 99% RA \n___ 36 on arrival\nOn exam, Alert, pleasant, conversant, oriented x3, no distress\nLabs showed H/H ___, Cr 1.7 (baseline ___, last checked \n___, lactate 2\nShe was given dextrose 50%\n\n___ 36-->34--> 177-->218-->216--> 204--> 182\n\nTransfer VS: 82 132/77 20 100% RA \nOn arrival to floor, reports feeling back to baseline. Her right \ntoe pain (from recent gout flare) is resolved.\n \nPast Medical History:\nPmHX: \nDMII - ___ years, complicated with neuropathy and retinopathy. \npericarditis \nHTN\nHyperlipidemia \nabd pain, s/p ___ ___, unrevealing; appendectomy \nETT ___ with small anterior defect (likely artifact). EF 73%. \n \nNephrolithiasis\nALL: Codeine, morphine, dilaudid - all cause nausea, vomiting, \nitching \n\n \nSocial History:\n___\nFamily History:\nNo family history of neurologic disease including stroke, \nseizures, movement disorders, demyelinating diseases, or \nmigraines. \n# Mother: ___ \n# Father: Fatal MI at age ___. \n# Siblings: Three sisters and one brother, all well. \n\n \nPhysical Exam:\n Gen: NAD, pleasant, cooperative, 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: No visible rash. No jaundice.\n Neuro: AAOx3. No facial droop.\n Psych: Full range of affect\n\ndischarge exam:\n\nVS: 97.9 135/85 70 18 100 Ra \notherwise unchanged from prior\nGen: NAD, pleasant, cooperative, lying in bed\nEyes: EOMI, sclerae anicteric \nENT: MMM, OP clear\nCardiovasc: RRR, no MRG, full pulses, no edema \nResp: lungs CTA ___.\nGI: soft, NT, ND, BS+\nMSK: No significant kyphosis. No palpable synovitis.\nSkin: No visible rash. No jaundice.\nNeuro: AAOx3. No facial droop. Mild RUE weakness which is \nbaseline post CVA\nPsych: Full range of affect\n\n \nPertinent Results:\n___ 01:29AM ___ TOP\n___ 01:29AM ___\n___ 01:25AM URINE ___\n___ 01:25AM URINE ___\n___ 01:25AM URINE ___ SP ___\n___ 01:25AM URINE ___ \n___\n___ 01:25AM URINE ___ \n___ TRANS ___\n___ 01:25AM URINE ___\n___ 01:25AM URINE ___\n___ 01:15AM ___ UREA ___ \n___ TOTAL ___ ANION ___\n___ 01:15AM ___ this\n___ 01:15AM ___ \n___\n___ 01:15AM ___ \n___ IM ___ \n___\n\nRenal US ___:\nThe right kidney measures 10.7 cm. The left kidney measures 11.0 \ncm. There is \na nonobstructing 3 mm stone in the right kidney. There is no \nhydronephrosis \nor masses bilaterally. Normal cortical echogenicity and \ncorticomedullary \ndifferentiation are seen bilaterally. \n \nThe bladder is moderately well distended and normal in \nappearance. \n \nIMPRESSION: \n \nNonobstructing stone in the right kidney. No hydronephrosis. \n\nD/C Labs: \n\n___ 08:40AM BLOOD ___ \n___ Plt ___\n___ 07:35AM BLOOD ___ \n___\n___ 07:35AM BLOOD ___\n___ 01:15AM BLOOD ___ w/h/o NIDDM (c/b neuropathy and retinopathy, most recent \nHbA1c=8), hx of pericarditis, ischemic CVA ___ with residual \nLUE weakness, s/p post left carotid endarterectomy ___, \nHTN, hyperlipidemia, nephrolithiasis, active smoking and ETOH, \non glipizide and metformine for her diabetes who was admitted on \n___ with severe hypoglycemia in the setting ___ (Cr 1.7 from \n___ baseline) after starting indomethacin on ___ for a \npresumed gout flare at first MTP joint. Oral antidiabetic meds \nand NSAIDS held on admission. Renal functions improved and \nfinger stick glucose trended up. Metformin was restarted on \n___. Glipizide was not restarted. \n\nProblem Summary\n\n- Hypoglycemia: likely due to reduced clearance of glipizide and \nit's metabolites in the setting of ___. \n- ___: possibly ___ recent indomethacin use. Resolved with IVF. \nUA showed WBC with few bacteria. No UTI symptoms. Ucx grew alpha \nhemolytic colonies consistent with alpha streptococcus or \nLactobacillus sp. likely representing vaginal contamination. No \nantibiotics were given. \n\n- Recent gout flair: ___ flares per year at baseline. most \nrecently ___ resolved with 3 day course of indomethacin. \n\n- normocytic anemia: stable here. unclear etiology. \n\n- Nephrolithiasis: renal US ___: incidental finding of \n___ stone in the right kidney. No hydronephrosis.\n\nChronic: \n\n- Type 2 diabetes complicated by nephropathy, retinopathy and \nneuropathy, last hgbA1c is 8.4% (___), worsened from 6.9% in \n___. \n- moderate nonproliferative retinopathy bilaterally (___). \n- microalbuminuria (124 on ___. \n- HTN: currently not on meds. previously on metoprolol which was \nswitched to lisinopril, which was then stopped due to \nhyperkalemia. Normal BP's during this admission. \n- Carpal Tunnel syndrome \n- h/o left CVA ___eficit. \n- hyperlipidemia\n- ETOH 4 drinks per day \n\nPatient is doing well clinically and is stable for discharge \nhome with the following plan:\n \n \n\n- f/u at PCP's office for FBG and HbA1c check and further \nadjustment of diabetic meds. Metformin restarted ___ and \nGlipizide continued to be held at discharge. BG well controlled \nat d/c on metformin alone.\n- f/u with PCP for recheck of renal functions\n- other preadmission meds continued without change \n- Avoid NSAID's in the future \n- counseled to reduce alcohol intake \n- Continue to monitoring BP's, mostly WNL in house\n- Consideration of allopurinol deferred to outpatient\n- normocytic anemia ___ by PCP\n- renal function f/u with PCP \n\n \n___ on ___:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 1000 mg PO BID \n2. Atorvastatin 80 mg PO QPM \n3. Aspirin 325 mg PO DAILY \n4. GlipiZIDE 2.5 mg PO DAILY \n5. Nortriptyline 20 mg PO QHS \n6. Cyanocobalamin 1000 mcg IM/SC ONCE \n7. Vitamin B Complex 1 CAP PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 325 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Cyanocobalamin 1000 mcg IM/SC ONCE \n4. MetFORMIN (Glucophage) 1000 mg PO BID \n5. Nortriptyline 20 mg PO QHS \n6. Vitamin B Complex 1 CAP PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHypoglycemia\n___\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 low blood sugar which were likely \nrelated to poor clearance of one of your ___ \nmedications (glipizide) in the setting of kidney dysfunction. \nYour kidney dysfunction may have been caused by indomethacin. \nYour glipizide was stopped and you should discuss with your PCP \nwhether you should restart it or replace it with a different \nmedications. In the future you should avoid indomethacin and \nother medications of the same class (NSAIDS like ibuprofen and \nnaproxen). Do not use any pain or ___ medication \nwithout first discussing with your doctor. \n\nYou should also ___ with your PCP to make sure your \ndiabetes is well controlled. \n \nFollowup Instructions:\n___\n" ]

[ "N179", "I69351", "E1121", "E1140", "E11649", "E113393", "I10", "E785", "D649", "F17210", "Z7984", "N141", "T39395A", "Y929" ]

[ "N179: Acute kidney failure, unspecified", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E113393: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateral", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "D649: Anemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z7984: Long term (current) use of oral hypoglycemic drugs", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "T39395A: Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounter", "Y929: Unspecified place or not applicable" ]

[ "N179", "I10", "E785", "D649", "F17210", "Y929" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nnephrolithiasis, acute kidney injury\n \nMajor Surgical or Invasive Procedure:\nCystoscopy, left ureteral stent placement.\n\n \nHistory of Present Illness:\n___ yo diabetic male, found to have at least 2 separate left \nureteral stones, 4 mm at left UVJ and 6 mm at proximal ureter. \nHis UA is unremarkable and he is without fevers. His creatinine \nis elevated to 1.4 on arrival and 1.5 on recheck after fluids. \nDiscussed this with the patient, and ultimately recommended\ncystoscopy and placement of left ureteral stent for \ndecompression given his elevated creatinine.\n \nPast Medical History:\nProblems (Last Verified - None on file):\nDIABETES TYPE II \nNEPHROLITHIASIS \n\nSurgical History (Last Verified - None on file):\nNo Surgical History currently on file. \n \nSocial History:\n___\nFamily History:\nNo Family History currently on file. \n\n \nPhysical Exam:\nWdWn male, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, Nt/Nd\nLower extremities w/out edema or pitting and no report of calf \npain\n\n \nPertinent Results:\n___ 10:36PM BLOOD WBC-10.1* RBC-5.54 Hgb-14.2 Hct-44.0 \nMCV-79* MCH-25.6* MCHC-32.3 RDW-12.9 RDWSD-36.7 Plt ___\n\n___ 10:36PM BLOOD Neuts-64.3 ___ Monos-6.9 Eos-2.9 \nBaso-0.4 Im ___ AbsNeut-6.50* AbsLymp-2.49 AbsMono-0.70 \nAbsEos-0.29 AbsBaso-0.04\n\n___ 06:28AM BLOOD Glucose-193* UreaN-13 Creat-1.4* Na-143 \nK-4.9 Cl-107 HCO3-24 AnGap-12\n___ 05:39AM BLOOD Glucose-91 UreaN-15 Creat-1.5* Na-139 \nK-4.8 Cl-102 HCO3-24 AnGap-13\n___ 10:36PM BLOOD Glucose-260* UreaN-18 Creat-1.4* Na-135 \nK-4.6 Cl-99 HCO3-18* AnGap-18\n\n___ 10:36PM BLOOD ALT-23 AST-14 AlkPhos-93 TotBili-0.2\n\n___ 06:28AM BLOOD Calcium-8.8 Mg-2.0\n\n___ 10:36PM BLOOD Albumin-4.0\n\n___ 03:16AM BLOOD Lactate-1.6\n\n___ 12:35AM URINE Color-Yellow Appear-Clear Sp ___\n___ 12:35AM URINE Blood-SM* Nitrite-NEG Protein-TR* \nGlucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 \nLeuks-NEG\n___ 12:35AM URINE RBC-14* WBC-3 Bacteri-FEW* Yeast-NONE \nEpi-<1\n___ 12:35AM URINE Mucous-RARE*\n\n___ 01:05PM OTHER BODY FLUID STONE ANALYSIS-PND\n\n___ 12:35 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. 10,000-100,000 CFU/mL. \n PRESUMPTIVE IDENTIFICATION. \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------------ 4 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n \nBrief Hospital Course:\nMr. ___ is known to Dr. ___ previous treatment of \nuric acid renal stones. He has had ___ days of vomiting and left \nflank pain and came to the emergency room last night. CT scan \nrevealed proximal and distal left ureteral stones. His \ncreatinine was elevated from baseline of ___. Based on his \nconstellation of\nsymptoms and the acute kidney injury, we decided to bring him to \nthe operating room today for left ureteral stent placement. He \nwas taken urgently for obstructing left ureteral stones with \nacute kidney injury and underwent cystoscopy, left ureteral \nstent placement. He tolerated the procedure well and recovered \nin the PACU before transfer to the general surgical floor. See \nthe dictated operative note for full details. Overnight, the \npatient was hydrated with intravenous fluids and received \nappropriate perioperative prophylactic antibiotics. Intravenous \nfluids and Flomax were given to help facilitate passage of \nstones but toradol was held given his acute kidney injury. On \nPOD1 his creatinine bumped to 1.6 from 1.4. At discharge on \nPOD1, patient’s pain was controlled with oral pain medications, \ntolerating regular diet, ambulating without assistance, and \nvoiding without difficulty. He was explicitly advised to follow \nup for future procedures to include ureteral stent \nremoval/exchange, definitive stone management. He was \ndischarged with antibiotics and sodium bicarb tablets and \nadvised to have a recheck of his lab work in ___ days after \ndischarge. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. MetFORMIN (Glucophage) 1000 mg PO BID \n2. GlipiZIDE 20 mg PO DAILY \n3. Januvia (SITagliptin) 100 mg oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Cephalexin 250 mg PO Q6H Duration: 7 Days \nRX *cephalexin 250 mg ONE tablet(s) by mouth Q6hrs Disp #*28 \nTablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg ONE capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ONE tablet(s) by mouth Q4hrs Disp #*10 Tablet \nRefills:*0 \n5. Pravastatin 80 mg PO DAILY \n6. Sodium Bicarbonate 650 mg PO TID \nRX *sodium bicarbonate 650 mg ONE tablet(s) by mouth three times \na day Disp #*28 Tablet Refills:*0 \n7. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin 0.4 mg ONE capsule(s) by mouth DAILY Disp #*30 \nCapsule Refills:*0 \n8. amLODIPine 10 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. GlipiZIDE 20 mg PO DAILY \n11. Januvia (SITagliptin) 100 mg oral DAILY \n12. MetFORMIN (Glucophage) 1000 mg PO BID \n13.Outpatient Lab Work\nPlease have repeat lab work (Chem 7) through your PCP ___ ___ \ndays after discharge (to check your kidney function). Call to \narrange when you get home today. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nnephrolithiasis; Obstructing left ureteral stones\nacute kidney injury\nurinary tract infection (E.Coli)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-You can expect to see occasional blood in your urine and to \npossibly experience some urgency and frequency over the next \nmonth; this may be related to the passage of stone fragments or \nthe indwelling ureteral stent.\n\n-The kidney stone may or may not have been removed AND/or there \nmay fragments/others still in the process of passing.\n\n-You may experience some pain associated with spasm of your \nureter.; This is normal. Take the narcotic pain medication as \nprescribed if additional pain relief is needed.\n\n-Ureteral stents MUST be removed or exchanged and therefore it \nis IMPERATIVE that you follow-up as directed. \n\n-Do not lift anything heavier than a phone book (10 pounds) \n\n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. \n\n-For pain control, try TYLENOL FIRST, then ibuprofen, and then \ntake the narcotic pain medication as prescribed if additional \npain relief is needed.\n\n-You may be given “prescriptions” for a stool softener and/or a \ngentle laxative. These are over-the-counter medications that \nmay be “health care spending account reimbursable.” \n\n-Colace (docusate sodium) may have been prescribed to avoid \npost-surgical constipation or constipation related to use of \nnarcotic pain medications. Discontinue if loose stool or \ndiarrhea develops. Colace is a stool-softener, NOT a laxative.\n\n-Senokot (or any gentle laxative) may have been prescribed to \nfurther minimize your risk of constipation. \n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n \nFollowup Instructions:\n___\n" ]

[ "N136", "B9620", "N179", "E119", "Z794" ]

[ "N136: Pyonephrosis", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "N179: Acute kidney failure, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin" ]

[ "N179", "E119", "Z794" ]

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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:\nFever, left ankle and knee pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ ___ speaking man with history of gout and\ndiabetes presenting with two days of left ankle and knee pain \nand\nsubjective fevers. He has previously had gout in his ankles. He\nreports fevers to 101 at home. He denies trauma to the area,\ndysuria, penile discharge and rash. He denies IV drug use. He \nhas\nbeen taking large doses of NSAIDs for pain over last 2 days. \n\nIn the ED: \n\n - Initial vital signs were notable for: T97.2 HT119 BP126/82\nRR17 SpO2 98% RA \n \n - Exam notable for: tachycardia, warm and swollen left ankle \nand\nleft knee without redness, able to range both joints however the\nknee hurts when ranged. \n\n - Labs were notable for: \n Cr 1.8->1.5 \n Cl 109 \n HCO3 21->20 \n WBC 11.0 (7.12 absolute PMNs) \n BUN 32 \n CRP 253 \n\n - Studies performed include: \n Joint fluid: slightly cloudy yellow fluid WBC ___ RBC 17 Poly\n97% Lymph ___ Mono ___ Macro 2 Crystal Moderate, Needle I/E,\nNegatively birefringent \n\n GRAM STAIN \n 2+ ___ per 1000X FIELD): /POLYMORPHONUCLEAR LEUKOCYTES \n NO MICROORGANISMS SEEN \n\nLeft Ankle Mortise XRay: \nIMPRESSION: \n1. No acute fracture dislocation. \n2. Degenerative changes most prominent the medial malleolus and\ntibiofibular joint, which may reflect sequela from prior \ninjury.\n\n3. Moderate plantar calcaneal spur. \n \nLeft Knee XRay \nIMPRESSION: No acute fractures. Moderate left knee joint\neffusion. \n\n- Patient was given: \n ___ 22:40 IV Morphine Sulfate 4 mg \n ___ 00:01 IVF NS 1000 mL \n ___ 02:09 PO Acetaminophen 1000 mg \n ___ 02:09 PO Pravastatin 80 mg \n ___ 07:26 PO/NG amLODIPine 10 mg \n ___ 07:26 PO/NG Aspirin 81 mg \n ___ 07:26 PO/NG Lisinopril 20 mg \n ___ 07:26 PO PredniSONE 40 mg \n ___ 09:45 IV Morphine Sulfate 4 mg \n ___ 09:45 IV Morphine Sulfate 4 mg \n ___ 14:25 PO Acetaminophen 1000 mg \n - Consults: None \n\nUpon arrival to the floor, patient appears comfortable. Endorses\n___ pain in his L knee and ___ pain in his left ankle,\ndescribed as burning. Pain first started ___ days ago, was at \nits\nworst last night. Denies any recent injury to his knee or ankle.\nReports history of gout with similar symptoms to previous gout\nattacks, although has not had it in his knee before only his\nankles. Patient also reports history of nephrolithiasis w prior\nprocedures for stone removal. Took 500mg Motrin TID at home,\nhowever he was told to avoid NSAIDs because of his ___, and says\nice also helps. Denies fever at this time, felt fever-ish at \nhome\nyesterday but did not take his temp. Otherwise denies chest \npain,\nshortness of breath, abdominal pain, dysuria,\nconstipation/diarrhea. \n\nREVIEW OF SYSTEMS: Complete ROS obtained and is otherwise\nnegative. \n\n \nPast Medical History:\n Type II Diabetes \n Nephrolithiasis \n ___ \n Gout \n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVITALS: T 98.0 BP 116/78 HR 94 RR 16 98% RA \nGENERAL: Alert and interactive. In no acute distress. \n HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without\ninjection. MMM. Ears with small tophi on earlobes\n NECK: No cervical lymphadenopathy. No JVD. \n CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. \n LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi \nor\nrales. No increased work of breathing. \n BACK: No CVA tenderness. \n ABDOMEN: Large, non distended, non-tender to palpation in all\nfour quadrants. No organomegaly. \n EXTREMITIES: L knee is warm and swollen compared to R, TTP, no\nerythema or skin changes, active ROM ___. L ankle also warm and\nswollen, no erythema or skin changes, decent ROM. No clubbing or\ncyanosis. Pulses DP/Radial 2+ bilaterally. \n SKIN: Warm. Cap refill <2s. No rash. \n NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal\nsensation. Gait is normal. AOx3. \n\nDISCHARGE PHYSICAL EXAM\n24 HR Data (last updated ___ @ 1157)\n Temp: 98.7 (Tm 98.7), BP: 131/77 (116-143/77-96), HR: 103\n(88-103), RR: 21 (___), O2 sat: 96% (96-98), O2 delivery: Ra,\nWt: 211.4 lb/95.89 kg \n\nGENERAL: Alert and interactive. In no acute distress. \nHEENT: NCAT. PERRL, EOMI. Sclera anicteric and without \ninjection.\nMMM. Ears with small tophi on earlobes\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: Large, non distended, non-tender to palpation in all\nfour quadrants. No organomegaly. \nEXTREMITIES: L knee is warm and swollen compared to R, TTP, no\nerythema or skin changes. L ankle also warm and swollen, no\nerythema or skin changes. No clubbing or cyanosis. Pulses\nDP/Radial 2+ bilaterally. \nSKIN: Warm. Cap refill <2s. No rash. \nNEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal\nsensation. Gait is normal. AOx3. \n \n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 09:15PM BLOOD WBC-11.0* RBC-5.76 Hgb-14.6 Hct-46.9 \nMCV-81* MCH-25.3* MCHC-31.1* RDW-13.5 RDWSD-39.7 Plt ___\n___ 09:15PM BLOOD Neuts-64.8 ___ Monos-8.6 Eos-1.4 \nBaso-0.5 Im ___ AbsNeut-7.12* AbsLymp-2.67 AbsMono-0.94* \nAbsEos-0.15 AbsBaso-0.05\n___ 09:15PM BLOOD Glucose-165* UreaN-32* Creat-1.8* Na-140 \nK-5.0 Cl-102 HCO3-21* AnGap-17\n___ 09:15PM BLOOD CRP-253.0*\n___ 05:54AM BLOOD UricAcd-8.5*\n___ 11:58PM JOINT FLUID ___ RBC-17 Polys-97* \n___ Macro-2\n___ 11:58PM JOINT FLUID Crystal-MOD Shape-NEEDLE \nLocatio-I/E Birefri-NEG Comment-c/w calciu\n\nDISCHARGE LABS:\n===============\n___ 05:46AM BLOOD Glucose-125* UreaN-26* Creat-1.2 Na-141 \nK-4.7 Cl-103 HCO3-23 AnGap-15\n\nMICROBIOLOGY:\n=============\n___ 11:58 pm JOINT FLUID RIGHT KNEE. \n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Preliminary): NO GROWTH. \n\nIMAGING:\n========\n___ Ankle X-Ray\nIMPRESSION: \n \n \n1. No acute fracture dislocation. \n2. Degenerative changes most prominent the medial malleolus and \ntibiofibular \njoint, which may reflect sequela from prior injury. \n3. Moderate plantar calcaneal spur. \n\n___ L Knee X-Ray\nIMPRESSION: \n \nNo acute fractures. Moderate left knee joint effusion. \n\n \nBrief Hospital Course:\nBRIEF HOSPTIAL COURSE:\n======================\n___ ___ speaking man with history of gout and uric \nacid nephrolithiasis (followed by urology) and T2DM who \npresented with two days of left ankle and knee pain consistent \nwith acute gout flare, treated with prednisone, IVF, and \nmorphine for pain management. \n\nTRANSITIONAL ISSUES:\n====================\n[] Consider allopurinol for gout prevention when acute flare \nresolved\n\n#Gout Flare \nInitial exam was notable for warm and swollen left ankle and \nleft knee without redness, able to range both joints however \nknee was painful with ROM. Studies performed in the ED included \nL knee and ankle XR that were unremarkable. Arthrocentesis was \nperformed with synovial fluid analysis showing needle shaped \nnegatively birefringent crystals consistent with gout. He was \nstarted on a 5 day course of prednisone 40mg. He also received \nIVF and morphine in the ED. Once on the floor he was continued \non the prednisone and had appropriate PO fluid intake. He was \ndischarged with remaining 3d course of prednisone.\n\n___ on ___: \nCr initially 1.8 in ED BUN 32, up from baseline 1.2-1.3. Likely \n___ dehydration and possibly NSAID use at home. He was given IV \nfluid in the ED with improvement to 1.5. His creatinine was \nchecked again ___ prior to discharge home.\n\nCHRONIC ISSUES: \n=============== \n#Type II Diabetes: \nOn sliding scale insulin while inpatient. Home medications \nrestarted at discharge. Instructed to call PCP if finger sticks \nat home > 300 while on prednisone. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. GlipiZIDE 20 mg PO DAILY \n2. Januvia (SITagliptin) 100 mg oral DAILY \n3. MetFORMIN (Glucophage) 1000 mg PO BID \n4. amLODIPine 10 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 40 mg PO QPM \n7. Vitamin D ___ UNIT PO DAILY \n8. Lisinopril 40 mg PO DAILY \n9. liraglutide 1.8 mg subcutaneous DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. PredniSONE 40 mg PO DAILY Duration: 3 Doses \nRX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*6 \nTablet Refills:*0 \n3. amLODIPine 10 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. GlipiZIDE 20 mg PO DAILY \n7. Januvia (SITagliptin) 100 mg oral DAILY \n8. liraglutide 1.8 mg subcutaneous DAILY \n9. Lisinopril 40 mg PO DAILY \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute Gout Flare\n___ \n___\nType 2 Diabetes\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at the ___ \n___.\n\nWhy did you come to the hospital?\nYou had severe pain in your left knee and ankle that was found \nto be due to gout.\n\nWhat did you receive in the hospital?\nYou received steroids to treat the gout flare, as well as IV \nfluids and pain medication.\n\nWhat should you do once you leave the hospital?\n- Try to drink >3L/day of fluids\n- Please take your medications as prescribed and go to your \nfuture appointments which are listed below.\n- Check your blood sugar daily while on steroids and call your \nprimary care physician if your sugar is > 300\n\nWe wish you all the best!\n- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "M10072", "N179", "M10062", "E1122", "N189", "E860", "Z87442", "Z794" ]

[ "M10072: Idiopathic gout, left ankle and foot", "N179: Acute kidney failure, unspecified", "M10062: Idiopathic gout, left knee", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "E860: Dehydration", "Z87442: Personal history of urinary calculi", "Z794: Long term (current) use of insulin" ]

[ "N179", "E1122", "N189", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nBactrim / adhesive tape / chlorhexidine / lactose / seasonal\n \nAttending: ___.\n \nChief Complaint:\nPost-procedure monitoring\n \nMajor Surgical or Invasive Procedure:\nRight hepatic artery embolization (___)\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with a past medical\nhistory of IBS, LPR, eczema, thyroid nodules, severe menstrual\ncramps on OCP since age ___, insulin resistance, fibromyalgia,\ninterstitial cystitis, and depression/anxiety, who who was found\nto have large hepatic adenoma now admitted for monitoring after\nembolization.\n\nPatient was found to have a very large 21 cm hepatic adenoma \nwith\nsatellite adenomas in the beginning of ___. She was \nreferred\nto the multidisciplinary liver clinic who recommended that she\nhave an embolization by interventional radiology and stop all\nestrogen based therapy.\n\nShe underwent the embolization today with interventional\nradiology they did an embolization of the right lobe via the\nright radial access. After the procedure she was noted to have\nsome mild chest tightness that they thought was likely\ndiaphragmatic irritation. She was also noted to have a mild rash\non her upper chest that had not been noted prior to the\nprocedure. She got a dose of IV Benadryl. Her heart rate at \nthe\ntime was 80 and her systolic blood pressure was 147. She got a\ndose of Toradol a dose of Decadron and was admitted to the floor\nfor further monitoring. \n\nOn arrival to the floor:\nPt reports her rash has resolved. \nShe continues to report ___ CP which radites to epigastrum with\nperiodic waves. Not clearly worse by exertion. No associated \nSOB,\npalpations. She reports stable fibromyalgia pain of multiple\njoints as well. \nNotably she recently underwent an hysterectomy approx 1 month\nprior and \n\n14 point review of systems reviewed with patient and negative\nexcept HPI\n\n \nPast Medical History:\nasthma\nobesity\nIBS\nGERD\ninterstitial cystitis on yearly bladder infusion therapy\nglucose resistance\nfibromyalgia\nGERD/LPR\nADHD\nanxiety/depression\nLactose intolerance\nThyroid nodules\neczema/hidradinitis suppuritiva\nmigraines\njaundiced as a baby, went home normally\n \nSocial History:\n___\nFamily History:\nPositive for UC. \nMaternal great aunt with liver cancer. Second\ncousins with liver cancer. \nPAternal side without liver disease.\nHTN, DM run in the family. \nSomeone has bladder cancer.\n\n \nPhysical Exam:\nADMISSION EXAM:\nVS: ___ 1721 Temp: 97.5 PO BP: 169/98 HR: 82 RR: 18 O2 sat: \n94%\nO2 delivery: ra \nGeneral Appearance: pleasant, comfortable, no acute distress\nEyes: PERLL, EOMI, no conjuctival injection, anicteric\nENT: no sinus tenderness, MMM, oropharynx without exudate or\nlesions, no supraclavicular or cervical lymphadenopathy, no JVD,\nno carotid bruits, no thyromegaly or palpable thyroid nodules\nRespiratory: CTA b/l with good air movement throughout\nCardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops.\nGastrointestinal: Mild epigastric TTP which reproduces pts chest\npain. \nOtherwise Nd, +b/s, soft, no masses or HSM.\n3 well-healed port sites from prior/recent hysterectomy\nExtremities: no cyanosis, clubbing or edema\nSkin: warm, no rashes/no jaundice/no skin ulcerations noted\nNeurological: Alert, oriented to self, time, date, reason for\nhospitalization. Cn II-XII intact. \nPsychiatric: pleasant, appropriate affect, at times anxious\nappearing\nGU: no catheter in place\n\nDISCHARGE EXAM:\nVS: ___ 0802 Temp: 97.8 PO BP: 150/84 R Lying HR: 85 RR: 22 \nO2 sat: 95% O2 delivery: RA FSBG: 115 \nGeneral Appearance: NAD, appears well\nEyes: PERRL\nENT: mmm, OP clear\nRespiratory: CTAB\nCardiovascular: NR/RR, no m/r/g\nGastrointestinal: Soft, obese, non-distended, epigastric TTP \nwithout guarding or rebound tenderness, normoactive bowel sounds\nExtremities: no cyanosis, clubbing or edema, good peripheral \npulses\nSkin: warm, no rashes/no jaundice/no skin ulcerations noted\nNeurological: Alert, oriented, CN grossly intact, grossly \nnonfocal\nPsychiatric: pleasant, normal affect\n\n \nPertinent Results:\nADMISSION LABS:\n___ 07:30AM BLOOD WBC-7.7 RBC-4.65 Hgb-13.3 Hct-42.2 MCV-91 \nMCH-28.6 MCHC-31.5* RDW-14.7 RDWSD-48.8* Plt ___\n___ 07:30AM BLOOD ___\n___ 01:10PM BLOOD Glucose-123* UreaN-8 Creat-0.6 Na-140 \nK-4.6 Cl-100 HCO3-22 AnGap-18\n___ 01:10PM BLOOD Calcium-9.9 Phos-3.8 Mg-2.0\n___ 01:10PM BLOOD ALT-194* AST-92* AlkPhos-973* TotBili-0.3\n___ 01:10PM BLOOD cTropnT-<0.01\n\nDISCHARGE LABS:\n___ 10:37AM BLOOD WBC-8.1 RBC-4.59 Hgb-13.2 Hct-40.9 MCV-89 \nMCH-28.8 MCHC-32.3 RDW-14.6 RDWSD-47.3* Plt ___\n___ 10:37AM BLOOD Glucose-121* UreaN-8 Creat-0.6 Na-136 \nK-4.0 Cl-95* HCO3-26 AnGap-15\n___ 06:55AM BLOOD ALT-1429* AST-___* LD(LDH)-2091* \nAlkPhos-1362* TotBili-0.4\n___ 06:55AM BLOOD Albumin-4.4\n\nSTUDIES/REPORTS:\n\nEmbolization:\nFINDINGS: \n1. Conventional hepatic arterial anatomy .\n2. Pre-embolization arteriogram showing an area of blush in the \nright lobe\ncorresponding to the large known right hepatic adenoma.\n3. Cone-beam CT showing supply to the vast majority of the \nadenoma from the\nbranches to segments 5, 7 and 8\n4. Post-embolization showing stasis in the embolized branches \nof the right\nhepatic artery.\nIMPRESSION: \nSuccessful left trans radial approach trans-arterial bland \nembolization of the\nlarge, right lobe hepatic adenoma.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ with a past medical history of IBS, LPR, \neczema, thyroid nodules, severe menstrual cramps on OCP since \nage ___, insulin resistance, fibromyalgia, interstitial cystitis, \nand depression/anxiety, who who was found to have large hepatic \nadenoma now admitted for monitoring after embolization.\n\nAcute problems:\n==============\n# Hepatic adenoma status post embolization\nShe was monitored overnight after the procedure without \nsignificant events. Her pain was treated with oxycodone and IV \nmorphine for breakthrough pain. She was discharged with a few \ndays worth of oxycodone and instructed to taper down as she is \nable and as the pain improves. She will follow up in ___ clinic \nin about a week to determine if she needs another procedure. \n\n# Chest pain \nEKG without concerning findings and troponin negative. Likely \nfrom diaphragmatic irritation from large embolization. \n\n# DM: \nHeld metformin. Blood glucose controlled on sliding scale \ninsulin.\n\n# Elevated liver labs: \nAP Elevated to 973 from 647 in ___. GGT at that time 129\nALT 194 (41) AST 92 (30) also elevated compared to ___.\nLFTs predictably increased further after embolization. Pt has \nalready undergone considerable serologic workup (AMA, \nAnti-SMooth muscle, ___, AFP) 1 month prior so will hold on \nfurther workup for now.\nTRANSITIONAL ISSUE:\n[ ] Consider repeating LFTs at follow up ___ appointment in 1 \nweek to ensure they are trending down after embolization. \n\nChronic issues:\n==============\n#Fibromylagia: Home duloxetine, gabapntin\n#IBS: Home amitriptyline,\n#Anxiety: Home clonazepam\n#Obesity: Hold Phenteremine\n#GERD: Home ranitidine\n#Insomnia: Home trazodone\n\n>30 minutes spent on discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amitriptyline 10 mg PO QHS \n2. ClonazePAM 1 mg PO BID:PRN Anxiety \n3. darifenacin 15 mg oral BID \n4. DULoxetine ___ 30 mg PO DAILY \n5. Gabapentin 600 mg PO BID \n6. MetFORMIN (Glucophage) 1000 mg PO BID \n7. phentermine 37.5 mg oral QAM \n8. Ranitidine 150 mg PO BID \n9. TraZODone 50 mg PO QHS:PRN Insomnia \n10. Cetirizine 10 mg PO DAILY Allergies \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever \n2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - \nSevere \nRX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours \nDisp #*16 Tablet Refills:*0 \n3. Amitriptyline 10 mg PO QHS \n4. Cetirizine 10 mg PO DAILY Allergies \n5. ClonazePAM 1 mg PO BID:PRN Anxiety \n6. darifenacin 15 mg oral BID \n7. DULoxetine ___ 30 mg PO DAILY \n8. Gabapentin 600 mg PO BID \n9. MetFORMIN (Glucophage) 1000 mg PO BID \n10. phentermine 37.5 mg oral QAM \n11. Ranitidine 150 mg PO BID \n12. TraZODone 50 mg PO QHS:PRN Insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHepatic adenomas s/p right hepatic artery embolization\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 the hospital for monitoring after \nembolization for hepatic adenomas. You will be discharged with a \nlimited supply of oxycodone but your pain should improve with \ntime. You will follow up with interventional radiology in clinic \nin about 1 week - they will call you to make an appointment.\nBest wishes for your continued healing.\nTake care,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "D134", "G8918", "R112", "R0789", "Z800", "E119", "Z794", "R748", "M797", "K589", "F419", "E669", "K219", "G4700" ]

[ "D134: Benign neoplasm of liver", "G8918: Other acute postprocedural pain", "R112: Nausea with vomiting, unspecified", "R0789: Other chest pain", "Z800: Family history of malignant neoplasm of digestive organs", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "R748: Abnormal levels of other serum enzymes", "M797: Fibromyalgia", "K589: Irritable bowel syndrome without diarrhea", "F419: Anxiety disorder, unspecified", "E669: Obesity, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G4700: Insomnia, unspecified" ]

[ "E119", "Z794", "F419", "E669", "K219", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___ - Percutaneous coronary intervention with thrombectomy \nand no stent \n\n \nHistory of Present Illness:\nMr. ___ is a healthy ___ year-old male who presented with \nback pain and chest pain following a crossfit work-out and was \nfound to have a dissection of the abdominal aorta in addition to \nnew q waves on EKG and a mildly elevated troponin. The patient \nreports that he had a strenuous work-out the morning of \nadmission. At home, shortly following the work-out, he \nexperienced acute onset back pain across his back below the \nclavicle. This was associated with a cold sweat. The pain did \nnot subside and when the patient tried to climb his stairs at \nhome, he felt extremely week and thus presented to the ___ at \n___. Upon presentation his back pain began to subside \nbut he did begin to experience some mild central chest pain. \n\nAt the ___, he was hemodynamically stable. An EKG was \nobtained which demonstrated new inferior q waves and a troponin \nwas measured at 0.04. A CTA was obtained which demonstrated an \nabdominal aortic dissection of the infrarenal aorta. He was \ntherefore transferred to ___ for further care. \n\nHere CT repeated – still no ascending dissection. Overnight \nechocardiogram poor quality, no obvious WMA. This morning’s \necho showed slight inferior HK. Cardiac biomarkers rising and \npt noted to have Q waves with slight STEs inferiorly. \n\nHe went to cath and was found to have a RCA lesion. He had a \nthrombectomy with no stent and has a 50% residual distal RCA \nstenosis. Admitted to the CCU for further monitoring.\n\nVitals on transfer were: T 98.2, HR 63, BP 123/71, RR 21, 99% \nRA.\n\nOn the floor, patient reports that he feels \"great\" with no \nchest pain, back pain, shoulder pain or SOB. Only complaint is \nof mild lower abdominal dull pain.\n\n \nPast Medical History:\nPCP ___ ___ EKG with first-degree heart block sinus \nbradycardia, pt is asymptomatic, no further actions\nGERD \nL4/L5 microdiscectomy \nOtherwise healthy\n \nSocial History:\n___\nFamily History:\nFather: angioplasty, afib\nMother: afib\n___ grandfather may have had MI\nOtherwise mainly history of cancer (lung)\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: T 98.2, HR 63, BP 123/71, RR 21, 99% RA\nGen: Pleasant gentleman, NAD\nHEENT: MMM\nNECK: no JVP elevation\nCV: RRR, no murmurs, rubs, gallops\nLUNGS: CTAB, no wheezes\nABD: soft, +BS, mild tenderness in mid lower quadrant\nEXT: warm, well-perfused, +pulses\nSKIN: warm, dry, no rashes or lesions\nNEURO: A&Ox3, CNII-XII grossly intact\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: T 98.2, HR 60-70s, BP 120s/70s, RR ___, 97-99% RA\nGen: Pleasant gentleman, NAD\nHEENT: MMM\nNECK: no JVP elevation\nCV: RRR, no murmurs, rubs, gallops\nLUNGS: CTAB, no wheezes\nABD: soft, +BS, mild tenderness in mid lower quadrant\nEXT: warm, well-perfused, +pulses\nSKIN: warm, dry, no rashes or lesions\nNEURO: A&Ox3, CNII-XII grossly intact\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 06:15PM BLOOD WBC-11.3* RBC-4.61 Hgb-13.4* Hct-40.5 \nMCV-88 MCH-29.1 MCHC-33.1 RDW-12.9 RDWSD-41.2 Plt ___\n___ 06:15PM BLOOD Neuts-76.8* Lymphs-15.5* Monos-7.2 \nEos-0.0* Baso-0.2 Im ___ AbsNeut-8.67* AbsLymp-1.75 \nAbsMono-0.81* AbsEos-0.00* AbsBaso-0.02\n___ 06:15PM BLOOD ___ PTT-27.9 ___\n___ 06:15PM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-137 \nK-4.1 Cl-102 HCO3-27 AnGap-12\n___ 12:19AM BLOOD CK(CPK)-2278*\n___ 06:15PM BLOOD CK-MB-52*\n___ 12:19AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0\n\nDischarge Labs:\n===============\n___ 06:40AM BLOOD WBC-6.1 RBC-4.14* Hgb-11.9* Hct-37.3* \nMCV-90 MCH-28.7 MCHC-31.9* RDW-12.8 RDWSD-42.0 Plt ___\n___ 06:40AM BLOOD ___ PTT-28.4 ___\n___ 06:40AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-138 \nK-4.1 Cl-101 HCO3-26 AnGap-15\n___ 10:45AM BLOOD CK(CPK)-713*\n___ 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.0\n___ 04:55AM BLOOD %HbA1c-5.2 eAG-103\n___ 11:26AM BLOOD Triglyc-627* HDL-65 CHOL/HD-2.6 \nLDLmeas-73\n___ 04:24AM BLOOD CRP-2.8\n\nTroponin Trend:\n===============\n___ 06:15PM BLOOD cTropnT-0.21*\n___ 12:19AM BLOOD CK-MB-157* MB Indx-6.9* cTropnT-0.70*\n___ 03:58AM BLOOD CK-MB-178* MB Indx-7.3* cTropnT-1.37*\n___ 09:58AM BLOOD CK-MB-171* MB Indx-6.7* cTropnT-1.82*\n___ 04:24AM BLOOD cTropnT-2.77*\n___ 11:26AM BLOOD CK-MB-3 cTropnT-<0.01\n\nCK Trend:\n=========\n___ 12:19AM BLOOD CK(CPK)-2278*\n___ 03:58AM BLOOD CK(CPK)-2432*\n___ 09:58AM BLOOD CK(CPK)-2562*\n___ 11:26AM BLOOD CK(CPK)-74\n\nMicro:\n=======\nRPR: \n\nImaging:\n=========\nCTA ___:\n1. Infrarenal abdominal aortic aneurysm as detailed above \noriginating at the level of the ___ and extending into the \nproximal right common iliac artery. No significant change \ncompared to recent CT. \n2. Normal thoracic aorta without dissection. \n\nCXR ___:\nLungs are fully expanded and clear. Cardiomediastinal and hilar \nsilhouettes and pleural surfaces are normal. \n\nEKG (___): \nNSR, nl axis, no ST changes \n\nTTE (___): \nThe left atrium is mildly dilated. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thickness, \ncavity size and regional/global systolic function are normal \n(LVEF >55%). There is no ventricular septal defect. Right \nventricular chamber size and free wall motion are normal. An \naortic dissection cannot be excluded. The aortic valve leaflets \n(3) appear structurally normal with good leaflet excursion and \nno aortic stenosis or aortic regurgitation. The mitral valve \nleaflets are structurally normal. Mild (1+) mitral regurgitation \nis seen. The pulmonary artery systolic pressure could not be \ndetermined. There is no pericardial effusion. \n\nCARDIAC CATH (___): RCA occluded with thrombus in mid- to \ndistal-vessel. LAD and circumflex free of disease.\n\n \nBrief Hospital Course:\n___ y/o previously healthy gentleman presenting with a type B \naortic dissection complicated by an NSTEMI in the context of a \ncross-fit workout.\n\n# CORONARIES: 50% distal RCA occlusion, LAD and circumflex \nclean \n# PUMP: EF > 55%\n# RHYTHM: normal\n\n#) TYPE B AORTIC DISSECTION: Mr. ___ is a healthy ___ \nyear-old male who presented with back pain and chest pain \nfollowing a crossfit work-out and was found to have a dissection \nof the abdominal aorta. The dissection was located just beneath \nthe takeoff of the ___, and terminating at the proximal most \naspect of the right\ncommon iliac artery. Although he is a male he has no other clear \nrisk factors, including HTN, age, CAD, vasculitis, bicuspid \naortic valve, family history, h/o AVR, or cocaine use. We \ncontinued tight BP control - SBP<140 with IV/PO BB. He had no \nevidence on exam or imaging of end-organ or lower extremity \nischemia. Therefore, the is no indication for emergent vascular \nsurgery intervention. He will need f/u imaging in 6 months and \nwill follow up with ___. His ESR and CRP were \nwithin normal limits and his RPR was not reactive.\n\n#) ACUTE CORONARY SYNDROME: \nHe went to cath and was found to have a RCA lesion. He had a \nthrombectomy with no stent and has a 50% residual distal RCA \nstenosis. Admitted to the CCU for further monitoring after \nthrombectomy and we continued heparin 24h after procedure \n(starting\nit 4 hours after procedure). The patient is a Killip Class I \nindicating 6% mortality based on an updated study in JAMA \nperformed at ___ and ___ published in \n___. We continued aspirin 81mg daily, ticagrelor 90 BID, \natorvastatin 10mg daily.\n\nTRANSITIONAL ISSUES:\n=========================\n[] f/u aortic imaging in 6 months\n\n \nMedications on Admission:\nNone.\n \nDischarge Medications:\n1. TiCAGRELOR 90 mg PO BID \nRX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*6\n2. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*6\n3. Aspirin EC 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*6\n4. Metoprolol Succinate XL 12.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*6\n5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \nRX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min Disp \n#*15 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\n- TYPE B AORTIC DISSECTION \n- ACUTE CORONARY SYNDROME\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou came to the hospital because you were having chest pain. We \nfound that you were having a heart attack and we broke down a \nclot from one of your hearts blood vessels to treat that. Other \nimaging found that the wall of your large blood vessel, the \naorta had formed a slit called a dissection. The vascular \nsurgeons and did not think you needed to have a surgical repair \nat this time. It will be very important for you to keep good \ncontrol of your blood pressure, and follow-up with the vascular \nsurgeons, your PCP, and your new cardiologist (Drs. ___ \nand ___. \n\nShould you have any chest pain, please use the nitroglycerin \npills we have prescribed for you. Take up to three pills, spaced \n5 minutes apart. If the pain does not go away after this, call \n___. If your pain does go away, call either Dr. ___ Dr. \n___ an appointment.\n\nFinally, we have started you on several new medications because \nof your heart attack. These are very important, and must be \ntaken every day. They are:\n\n1) Ticagrelor (Brillinta) 90 mg twice a day. This will be \ncontinued for at least 3 months, and potentially as long as 9 \nmonths. The duration of this will be decided in follow-up \nappointments with Dr. ___\n2) Aspirin 81 mg daily, likely for the forseeable future\n3) Metoprolol succinate 12.5 mg daily, on an ongoing basis\n4) Atorvastatin 80 mg daily, on an ongoing basis\n\nIt was a pleasure taking care of you!\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I214", "I7102", "K219", "Z23", "Z7902", "Z7982" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I7102: Dissection of abdominal aorta", "K219: Gastro-esophageal reflux disease without esophagitis", "Z23: Encounter for immunization", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z7982: Long term (current) use of aspirin" ]

[ "K219", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___\n \nChief Complaint:\nLeft chest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man who was sleeping lying on a \ndriveway and was run over by backing out car, causing 3 left \nribs fracture.\n \nPast Medical History:\nDM (not treated) \n? head aneurysm ___ years ago, seen in ___\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nPHYSISCAL EXAM ON ADIMSSION (___)\n\nConstitutional: Comfortable, intoxicated\nHEENT: Pupils equal, round and reactive to light,\nNormocephalic, atraumatic\nCcollar in place\nChest: Clear to auscultation, diffuse tenderness, L crepitus\nCardiovascular: Regular Rate and Rhythm\nAbdominal: Soft, Nontender\nExtr/Back: No cyanosis, clubbing or edema\nSkin: abrasions to anterior chest wall\nNeuro: GCS 14 ( -1 for spont eye opening), otherwise intact\nPsych: Normal mood\n\nPHYSISCAL EXAM ON DISCHARGE (___)\n\nConstitutional: Comfortable, AAOX3\nHEENT: Pupils equal, round and reactive to light, normocephalic\nChest: Clear to auscultation, mild diffuse tenderness on \nanterior chest wall\nCardiovascular: Regular Rate and Rhythm, no m/r/g\nAbdominal: Soft, Nontender, non-distended, no organomegaly\nExtr/Back: No cyanosis, clubbing or edema\nSkin: abrasions to anterior chest wall\nNeuro: GCS 15, strength ___\nPsych: Normal mood\n \nPertinent Results:\nLAB RESULTS\n\n___ 08:45AM BLOOD WBC-7.6 RBC-4.12* Hgb-13.3* Hct-40.4 \nMCV-98 MCH-32.3* MCHC-32.9 RDW-15.5 RDWSD-55.6* Plt ___\n___ 06:02AM BLOOD WBC-7.9 RBC-4.02* Hgb-13.1* Hct-38.1* \nMCV-95 MCH-32.6* MCHC-34.4 RDW-14.7 RDWSD-51.2* Plt ___\n___ 08:47AM BLOOD WBC-7.2 RBC-4.13* Hgb-13.3* Hct-39.5* \nMCV-96 MCH-32.2* MCHC-33.7 RDW-14.8 RDWSD-51.8* Plt ___\n___ 05:35AM BLOOD WBC-7.8 RBC-3.99* Hgb-12.9* Hct-38.7* \nMCV-97 MCH-32.3* MCHC-33.3 RDW-14.6 RDWSD-52.1* Plt ___\n___ 05:35AM BLOOD Plt ___\n___ 08:47AM BLOOD Plt ___\n___ 08:45AM BLOOD Plt ___\n___ 05:35AM BLOOD Glucose-159* UreaN-5* Creat-0.6 Na-132* \nK-3.5 Cl-94* HCO3-26 AnGap-16\n___ 08:47AM BLOOD Glucose-126* UreaN-8 Creat-0.7 Na-130* \nK-3.9 Cl-91* HCO3-22 AnGap-21*\n___ 06:02AM BLOOD Glucose-149* UreaN-8 Creat-0.6 Na-132* \nK-3.7 Cl-92* HCO3-26 AnGap-18\n___ 05:35AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8\n___ 08:47AM BLOOD Calcium-8.9 Phos-1.2* Mg-2.0\n\n___ 08:45AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8\n\nIMAGING\n\nCXR (___)\nIMPRESSION: \nSmall amount of subcutaneous emphysema along the mid left \nlateral chest wall with concern for nondisplaced fracture of the \nleft sixth and seventh ribs. CT pending \n\nCT SPINE (___)\n1. No acute traumatic abnormality. \n2. Severe paraseptal emphysema. \n3. Small left thyroid nodule could be further evaluate dedicated \nultrasound, if clinically indicated. \n\nCT HEAD (___)\nIMPRESSION: \n1. Left lamina papyracea probable chronic fracture. \n2. No intracranial hemorrhage. \n\nCT TORSO (___)\nIMPRESSION:\n1. Small left pneumothorax with adjacent anterolateral left \nfifth through \nseventh rib fractures and small amount of adjacent subcutaneous \nemphysema. \n2. Small foci of cortical regularity in the anterior right ribs \nmay reflect a nutrient foramen. If pain is present in this \nlocation, however, subtle nondisplaced fractures could be \nconsidered. \n3. Severe paraseptal emphysema with a significant component of \ncentrilobular emphysema. \n4. Scattered calcified pulmonary granulomas likely reflect prior \ngranulomatous infection. \n\nCXR (___)\nIMPRESSION: \nSmall left pneumothorax, more fully assessed by recent CT. \n\nCXR (___)\nIMPRESSION: \nResolution of pneumothorax. Unchanged left sixth and seventh \nrib fractures. \nNo other acute cardiopulmonary process. \n\n \nBrief Hospital Course:\nThe patient presented to Emergency Department on ___. Upon \narrival to ED the patient was evaluated for anterior chest pain. \nSeveral imaging studies were done including CXR, CT scan of \nTorson, spine and head showing only left ___ ribs fracture and \na small apical pneumothorax which did not need placement of a \nchest tube. He was admitted to the floor for pain control. \nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a dilaudid PCA \nand then transitioned to oral oxycodone, ketorolac and a \nlidocaine patch. \nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \nGI/GU/FEN: Patient was always on a regular diet and with \nbathroom privileges. \nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\nOxyCODONE (Immediate Release) ___ mg PO/NG Q3H:PRN Pain - \nModerate\nLidocaine 5% Patch 1 PTCH TD QAM \nKetorolac 30 mg IV Q8H \nDocusate Sodium 100 mg PO/NG BID\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft ___ rib fracture\nLeft small apical pneumothorax\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ for \nrib fractures and were treated conservatively. You are \nrecovering well and are now ready for discharge. Please follow \nthe instructions below to continue your recovery:\n\n* Your injury caused 3 rib fractures which can cause severe pain \nand subsequently cause you to take shallow breaths because of \nthe pain.\n \n* You should take your pain medication as directed to stay ahead \nof the pain otherwise you won't be able to take deep breaths. If \nthe pain medication is too sedating take half the dose and \nnotify your physician.\n \n* Pneumonia is a complication of rib fractures. In order to \ndecrease your risk you must use your incentive spirometer 4 \ntimes every hour while awake. This will help expand the small \nairways in your lungs and assist in coughing up secretions that \npool in the lungs.\n \n* You will be more comfortable if you use a cough pillow to hold \nagainst your chest and guard your rib cage while coughing and \ndeep breathing.\n \n* Symptomatic relief with ice packs or heating pads for short \nperiods may ease the pain.\n \n* Narcotic pain medication can cause constipation therefore you \nshould take a stool softener twice daily and increase your fluid \nand fiber intake if possible.\n \n* Do NOT smoke\n \n* If your doctor allows, non-steroidal ___ drugs \nare very effective in controlling pain ( ie, Ibuprofen, Motrin, \nAdvil, Aleve, Naprosyn) but they have their own set of side \neffects so make sure your doctor approves.\n \n* Return to the Emergency Room right away for any acute \nshortness of breath, increased pain or crackling sensation \naround your ribs (crepitus).\n\n \nFollowup Instructions:\n___\n" ]

[ "S270XXA", "S2242XA", "Y33XXXA", "Y92481", "Z590", "F1010", "F1210", "Z720" ]

[ "S270XXA: Traumatic pneumothorax, initial encounter", "S2242XA: Multiple fractures of ribs, left side, initial encounter for closed fracture", "Y33XXXA: Other specified events, undetermined intent, initial encounter", "Y92481: Parking lot as the place of occurrence of the external cause", "Z590: Homelessness", "F1010: Alcohol abuse, uncomplicated", "F1210: Cannabis abuse, uncomplicated", "Z720: Tobacco use" ]

[]

[]

[ " \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:\nVolume overload \n \nMajor Surgical or Invasive Procedure:\nParacentesis ___\nParacentesis ___\nParacentesis ___\nParacentesis ___\nParacentesis ___\nParacentesis ___\nCardiac catheterization\nHD line placement\nCVL placement\nA-line placement\n\n \nHistory of Present Illness:\n___ year old with CAD, hypertension, atrial fibrillation not on \nCoumadin, type 2 DM, and ___ Class C cirrhosis secondary \nto non-alcoholic steatohepatitis complicated by recurrent \nascites, no reported varices, ?GI bleed, and hepatic \nencephalopathy presenting from clinic with volume overload.\n\nPt was initially seen by Dr. ___ in clinic ___ for \nconsideration of TIPS. He was subsequently sent to transplant \nclinic for workup of possible transplant given the risk of \ndecompensation secondary to a TIPS procedure. Today, he \npresented to clinic to see Dr. ___ was noted to be volume \noverloaded with massive ascites and failure to thrive. He was \nsubsequently admitted directly from clinic to the ET service \nwith plans for aggressive volume management and TIPS.\n\nOn presentation to the floor, pt reports that over the past few \nmonths he has had increasing ascites, and overall general \nworsening with fatigue and weakness. Since ___ he has been \nhaving regular paracenteses, first biweekly and now up to one \ntime per week. His last paracentesis was 4 days ago, and 6 \nliters were drained. He has had no recent confusion, no nausea \nor vomiting, no melena. His bowel movements are normal (loose). \n \n \nPast Medical History:\nChild C cirrhosis ___ nonalcoholic steatohepatitis\nAtrial fibrillation: off Coumadin after having a \nsupratherapeutic INR and ?blood loss in ___\nT2DM on insulin\nCAD\nHTN\n \nSocial History:\n___\nFamily History:\nUnknown\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS: T97.5 BP119/69 HR62 RR18 O2100 RA\nGeneral: lying in bed, appears tired, NAD.\nHEENT: anicteric sclerae; MMM.\nNeck: no appreciable JVD.\nCV: regular rate and rhythm (not in afib), normal S1 and S2\nLungs: CTAx2 with good air movement \nAbdomen: distended, tense, nontender, +fluid wave\nExt: nonedematous; nontender.\nNeuro: AOx3, no asterixis\nSkin: no jaundice\n\nDISCHARGE PHYSICAL EXAM\nPatient deceased\n\n \nPertinent Results:\nADMISSION LABS\n___ 07:36PM BLOOD WBC-8.6 RBC-3.82* Hgb-11.7* Hct-35.6* \nMCV-93 MCH-30.6 MCHC-32.9 RDW-15.3 RDWSD-52.3* Plt ___\n___ 07:36PM BLOOD ___ PTT-38.5* ___\n___ 07:36PM BLOOD Glucose-230* UreaN-68* Creat-2.0* Na-125* \nK-5.2* Cl-93* HCO3-21* AnGap-16\n___ 07:36PM BLOOD ALT-22 AST-45* AlkPhos-84 TotBili-1.2\n___ 07:36PM BLOOD Albumin-3.6 Calcium-9.6 Phos-3.6 Mg-2.1\n\nPERTINENT INTERMITTENT LABS\n___ 03:10AM BLOOD Lipase-131*\n___ 11:54AM BLOOD CK-MB-1 cTropnT-0.02*\n___ 02:05PM BLOOD CK-MB-1 cTropnT-<0.01\n___ 10:17PM BLOOD Hapto-22*\n___ 07:21AM BLOOD D-Dimer-GREATER TH\n___ 03:55AM BLOOD Triglyc-174*\n___ 03:10AM BLOOD Triglyc-188*\n___ 09:41AM BLOOD TSH-0.92\n___ 01:01PM BLOOD PTH-17\n___ 09:41AM BLOOD T4-2.5*\n___ 06:14AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE \nHBcAb-NEGATIVE\n___ 10:42AM BLOOD PEP-NO SPECIFI IgG-762 IgA-319 IgM-59 \nIFE-NO MONOCLO\n___ 04:30AM BLOOD HIV Ab-Negative\n___ 06:14AM BLOOD HCV Ab-NEGATIVE\n\nDISCHARGE LABS\n___ 03:10AM BLOOD WBC-12.2* RBC-UNABLE TO Hgb-UNABLE TO \nHct-36.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO \nRDW-UNABLE TO RDWSD-UNABLE TO Plt Ct-72*\n___ 03:10AM BLOOD ___\n___ 03:10AM BLOOD Glucose-317* UreaN-49* Creat-2.4* Na-132* \nK-3.8 Cl-92* HCO3-20* AnGap-24\n___ 03:10AM BLOOD ALT-29 AST-121* AlkPhos-105 TotBili-34.5*\n___ 03:10AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.7*\n\nMICRO:\n\n___ 3:09 pm PERITONEAL FLUID PERITONEAL FLUID. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n\n___ 4:30 am Blood (EBV)\n\n **FINAL REPORT ___\n\n ___ VIRUS VCA-IgG AB (Final ___: POSITIVE \nBY EIA. \n\n ___ VIRUS EBNA IgG AB (Final ___: POSITIVE \nBY EIA. \n\n___ 8:00 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n ESCHERICHIA COLI. FINAL SENSITIVITIES. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n AZTREONAM REQUESTED PER ___ ___ (___) \n___. \n SENSITIVE TO AZTREONAM sensitivity testing performed by \n___\n ___. \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\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___ 12:55 am URINE Site: NOT SPECIFIED\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n SERRATIA MARCESCENS. >100,000 ORGANISMS/ML.. \n This organism may develop resistance to third \ngeneration\n cephalosporins during prolonged therapy. Therefore, \nisolates that\n are initially susceptible may become resistant within \nthree to\n four days after initiation of therapy. For serious \ninfections,\n repeat culture and sensitivity testing may therefore be \nwarranted\n if third generation cephalosporins were used. \n Piperacillin/tazobactam sensitivity testing available \non request. \n AZTREONAM Susceptibility testing requested by ___. \n___ ___\n ___. SENSITIVE TO AZTREONAM. \n AZTREONAM sensitivity testing performed by ___. \n\n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n SERRATIA MARCESCENS\n | \nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- 256 R\nTOBRAMYCIN------------ 2 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___ 2:19 am SPUTUM Source: Endotracheal. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n ___ PMNs and <10 epithelial cells/100X field. \n 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH \nPSEUDOHYPHAE. \n\n RESPIRATORY CULTURE (Final ___: \n Commensal Respiratory Flora Absent. \n Due to mixed bacterial types ( >= 3 colony types) an \nabbreviated\n workup will be performed appropriate to the isolates \nrecovered from\n this site. \n YEAST. SPARSE GROWTH. \n GRAM NEGATIVE ROD(S). RARE GROWTH. \n STAPH AUREUS COAG +. RARE GROWTH. \n This isolate is presumed to be resistant to clindamycin \nbased on\n the detection of inducible resistance . \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN----------- R\nERYTHROMYCIN---------- R\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- =>8 R\nOXACILLIN-------------<=0.25 S\nTETRACYCLINE---------- <=1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\n\n___ 6:29 pm BRONCHOALVEOLAR LAVAGE\n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 1+ (<1 per 1000X FIELD): BUDDING YEAST. \n\n RESPIRATORY CULTURE (Final ___: \n Commensal Respiratory Flora Absent. \n YEAST. 10,000-100,000 ORGANISMS/ML.. \n\n FUNGAL CULTURE (Preliminary): \n YEAST. \n\n NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. \n\n\nDIAGNOSTICS AND IMAGING\nRUQ w/ Doppler ___: \nIMPRESSION: \nCirrhotic appearing liver with large ascites and splenomegaly. \nNo suspicious masses. Patent hepatic vasculature. \nCholelithiasis. \n\nRenal US ___:\nIMPRESSION: \n1. No evidence of hydronephrosis. \n2. Cirrhosis with large amount of intra-abdominal ascites. \n\nCXR ___:\nIMPRESSION: \nIn comparison with the study of ___, there are again low \nlung volumes that accentuate the transverse diameter of the \nheart. Continued increased opacification at the left base, \nconsistent with pleural effusion and compressive basilar \natelectasis. Mild indistinctness of pulmonary vessels could \nreflect some elevated pulmonary venous pressure. The ___ \ntube appears unchanged\n\nCT A/P ___. 24 cm right retroperitoneal hematoma secondary to a right \ncommon femoral artery pseudoaneurysm measuring 2.2 cm with a \nneck of 0.2 cm and another component of the pseudoaneurysm just \nsuperiorly measuring 3 cm. \n2. Cirrhosis, ascites and splenomegaly. \n3. Cholelithiasis. \n4. Moderate right pleural effusion and bibasilar atelectasis. \n\n___ Arteriogram\n1. Punctate foci of active extravasation from the right L3 and \nL4 lumbar \narteries, treated with Gelfoam and coil embolization, with good \nangiographic result. \n2. The right lateral circumflex artery was in proximity to the \nknown area of bleeding, and was Gel-Foam and coil embolized, \nwith good angiographic result. \n3. The previously identified right common femoral artery \npseudoaneurysm \nremains thrombosed, with a tiny area (2-3 mm) of residual \npseudoaneurysm, too small to treat. This will likely thrombose \non its own. \n4. A small 4 mm pseudoaneurysm identified arising from the left \nSFA on left CFA angiography at the site of the arterial pressure \nline entry was too small to treat, and appeared thrombosed with \nultrasound at the conclusion of the case. \n\n___ CT A/P\nIMPRESSION: \n \n1. Stable size of large right retroperitoneal hematoma status \npost coil \nembolization of right lumbar arteries and right lateral \ncircumflex artery. No evidence of active extravasation. \n2. Cirrhosis with sequelae of portal hypertension including \nsplenomegaly, \nascites and perigastric varices. \n3. No drainable fluid collection identified. No evidence of \nbowel ischemia. \n4. Tiny 6 mm pseudoaneurysm arising from the left superficial \nfemoral artery just distal to its origin. The pseudoaneurysm is \nsuperior to the site of active extravasation seen on ___. \n\n___ CT Chest\nIMPRESSION: \n1. Small bilateral pleural effusions with adjacent \nconsolidation, which \nappears to be predominantly atelectasis. A component of \ninfection may also be present. \n2. CT abdomen/pelvis reported separately. \n\n___ CT Head\n1. Severely motion limited examination demonstrating no acute \nlarge \nintracranial abnormality. \n2. Fluid in the posterior nasopharynx and mastoid air cells \nbilaterally.\n\n___ CT A/P\nIMPRESSION: \n1. Large right retroperitoneal hematoma is similar in appearance \nto prior \nexamination given redistribution. No evidence of active bleed. \n2. No findings to suggest infection in the abdomen or pelvis. \n\n___ CT Chest\nIMPRESSION: \nNo evidence of active intrathoracic infection or malignancy. \nSmall bilateral effusions with persistent left left lower lobe \ncollapse and right basal atelectasis with increasing \nendobronchial secretions in the lower lobes. \n\n \n\n \nBrief Hospital Course:\n___ year old with ___ Class C cirrhosis secondary to NASH \npresenting from clinic with volume overload, sarcopenia, and \nquestion of possible TIPS for refractory ascites.\n\nFLOOR COURSE:\nPatient was admitted with diuretic refractory ascites. He was \nadmitted for paracenteses and evaluation for TIPS and future \ntransplant. The transplant team made the initial decision that \nthe patient is not a TIPS or transplant candidate because of \nsevere malnutrition, and goal became to improve nutritional \nstatus and then proceed.\n\nThe patient's renal function began to worsen, and workup was \nconsistent with hepatorenal syndrome. Nephrology was consulted, \nand agreed with HRS as the diagnosis, and he was started on \nmidodrine, octreotide and daily albumin. As his renal failure \nprogressed, he required dialysis and had a dialysis line placed \n___. His worsening renal function led to the decision to \nexpedite his transplant eligibility. Because he has a history of \nCAD and is s/p 2 stents from ___, he had to undergo a cardiac \ncatheterization for evaluation of CAD and transplant \neligibility. He went for cardiac cath on ___, which found no \ninterventional lesions. However, the day after the procedure he \ndeveloped a retroperitoneal bleed, which led to transfer to the \nICU.\n\nMICU COURSE:\n\n# Shock: Initially secondary to hemorrhagic shock due to \nretroperitoneal bleed requiring massive transfusion protocol on \narrival to the MICU. He was resuscitated though subsequently had \nongoing septic shock physiology requiring pressor support. \nEtiology of septic shock was secondary to new infections \nincluding serratia UTI, E.coli bacteremia, MSSA VAP. Despite \ncompleting a course of antibiotics (Vanc/Meropenem) for all of \nthese infections by ___ he had a persistent and rising \nleukocytosis. Infectious disease was consulted for assistance \nwith workup and management. Micafungin was added for empiric \nfungal coverage. His HD line (placed in the setting of renal \nfailure as below) was removed. Pus was noted around the \ninsertion site, suggesting a line infection as a possible \ncontributing source. Blood cultures, however, remained negative. \nPeritoneal fluid was also not suggestive of infection. Note is \nmade of peritoneal fluid from ___, which appears inflammatory, \ndespite correction for RBC count. Cultures were negative, \nhowever and subsequent pleural fluid did not suggest spontaneous \nor secondary bacterial peritonitis. Alternative etiology \npotentially secondary to persisent gut translocation into the \nperitoneal space. His leukocytosis downtrended without a clear \nsource of ongoing infection. \n\n# Respiratory failure: Mr. ___ was initially intubated in the \nsetting of hemorrhagic shock and metabolic acidosis. His course \nwas then complicated by MSSA VAP. After correction of metabolic \nacidosis he remained intubated in the setting of altered mental \nstatus, volume overload, and impaired lung dynamics in the \nsetting of ascites. Yet, despite clearing of his mental status, \nimprovement of volume status with HD, and large volume \nparacenteses it was not possible to wean him off of the \nventilator. He remained intubated for more than two weeks with a \nlikely contribution from respiratory muscle weakness in the \nsetting of prolonged intubation. He had ongoing thick secretions \nrequiring repeated bronchoscopies for clearance of mucous \nplugging and LLL collapse. Tracheostomy was discussed with the \npatient and family. The patient clearly indicated that he did \nnot want a tracheostomy, nor did he want to remain intubated. \nRather, he made it clear that he wanted to be extubated to \ncomfort care. He was extubated on the evening of ___ and \npassed within a few hours. Family was at bedside. \n\n# Renal failure: Mr. ___ was noted to have progressively \nworsening renal function prior to MICU transfer, consistent with \nhepatorenal syndrome. He was started on midodrine and octreotide \nas well as albumin. His renal failure progressed requiring \ndialysis and a dialysis line was placed ___. He continued on \nCVVH while in the ICU and was ultimately transitioned to \nintermittent HD. His HD line was removed as noted above in the \nsetting of persistent leukocytosis for a line holiday. A \ntemporary line was replaced given ongoing dialysis needs. He \nrequired pressors in the ICU in order to tolerate fluid removal \nwith HD. \n \n# MSSA pneumonia: Noted to have MSSA pneumonia from sputum \nculture on ___. He was initially treated with Vancomycin \npending sensitivities. However, he was continued on Vancomycin \ndespite penicillin sensitivity in order to prevent inducible \nserratia resistance in the setting of serratia UTI, as below. He \ncompleted a course of antibiotics on ___, though antibiotics \nwere continued as noted above in the setting of ongoing \nleukocytosis. \n\n# E.coli bacteremia: E.coli noted on blood culture on ___. He \nwas initially treated with Meropenem for GNR bacteremia and \ncompleted a 2 week course of meropenem on ___, though \nantibiotics were continued in the setting of persistent \nleukocytosis as above and concern for ongoing gut translocation. \n\n\n# Serratia UTI: Noted on urine culture on ___. He was treated \nwith a course of meropenem.\n\n# Atrial flutter/fib: MICU course was complicated by recurrent \nepisodes of atrial fibrillation and flutter. This initially \noccurred in the setting of volume removal with CVVH and \nresponded well to doses of metoprolol or diltiazem. He developed \natrial fibrillation with hypotension requiring pressors later in \nhis ICU course during bronchoscopy, requiring amiodarone. He was \ncontinued on amiodarone until his he was transitioned to comfort \nmeasures. \n\n# Ileus: Mr. ___ malnutrition was noted while he was on the \nfloor and prior to MICU transfer. After intubation an NGT was \nplaced and tube feeds were initiated. He had high residuals that \nprecluded goal tube feeding. CT A/P did not reveal obstructive \npathology. Concern for potential peritonitis causing ileus, \nthough ileus persisted despite negative peritoneal cultures. \nIleus did not improve with reglan. He was started on TPN. A \ndophoff was placed, advanced post-pyloric by ___. \n\n# Decompensated Cirrhosis: Mr. ___ had worsening liver failure \nwith rising bilirubin and MELD score throughout his hospital \nstay in the setting of multiple complications as noted below. \nAlso with renal failure requiring HD. MICU team and liver \nattending had ongoing family meetings regarding potential for \nliver/kidney transplant. As his hospital course progressed it \nbecame increasingly clear that he would not recover to be well \nenough for a transplant. His family struggled to come to terms \nwith this. Ultimately he indicated that he wanted to be \nextubated to CMO and passed within a few hours. Family was at \nbedside. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Loratadine 10 mg PO DAILY PRN allergic symptoms \n2. Rifaximin 550 mg PO BID \n3. Nadolol 10 mg PO DAILY \n4. Sodium Polystyrene Sulfonate 15 gm PO 2X/WEEK (___) \n5. Methimazole 15 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Fenofibrate 200 mg PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. Humalog ___ 20 Units Bedtime\n10. Vitamin D 1000 UNIT PO DAILY \n11. Fish Oil (Omega 3) 1000 mg PO DAILY \n12. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\nPatient deceased\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\nDiuretic refractory ascites\nSevere malnutrition\n\nSECONDARY DIAGNOSES\nNASH cirrhosis \nAtrial fibrillation \nType 2 Diabetes\nCoronary Artery Disease\nHyperthyroidism\nRenal insufficiency \n\n \nDischarge Condition:\nPatient deceased\n \nDischarge Instructions:\nPatient Deceased\n \nFollowup Instructions:\n___\n" ]

[ "K7469", "K767", "J9600", "A4151", "N179", "K661", "R571", "R6521", "K659", "N183", "E43", "K7201", "T8119XA", "K7200", "D684", "J95851", "R188", "D62", "I4892", "K766", "E871", "N390", "K567", "E872", "J9811", "I97610", "T80219A", "K7581", "I129", "D638", "I25118", "Z955", "E119", "Z794", "R627", "I4891", "B9689", "B9561", "Y848" ]

[ "K7469: Other cirrhosis of liver", "K767: Hepatorenal syndrome", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "A4151: Sepsis due to Escherichia coli [E. coli]", "N179: Acute kidney failure, unspecified", "K661: Hemoperitoneum", "R571: Hypovolemic shock", "R6521: Severe sepsis with septic shock", "K659: Peritonitis, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "E43: Unspecified severe protein-calorie malnutrition", "K7201: Acute and subacute hepatic failure with coma", "T8119XA: Other postprocedural shock, initial encounter", "K7200: Acute and subacute hepatic failure without coma", "D684: Acquired coagulation factor deficiency", "J95851: Ventilator associated pneumonia", "R188: Other ascites", "D62: Acute posthemorrhagic anemia", "I4892: Unspecified atrial flutter", "K766: Portal hypertension", "E871: Hypo-osmolality and hyponatremia", "N390: Urinary tract infection, site not specified", "K567: Ileus, unspecified", "E872: Acidosis", "J9811: Atelectasis", "I97610: Postprocedural hemorrhage of a circulatory system organ or structure following a cardiac catheterization", "T80219A: Unspecified infection due to central venous catheter, initial encounter", "K7581: Nonalcoholic steatohepatitis (NASH)", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "D638: Anemia in other chronic diseases classified elsewhere", "I25118: Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "R627: Adult failure to thrive", "I4891: Unspecified atrial fibrillation", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of 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" ]

[ "N179", "D62", "E871", "N390", "E872", "I129", "Z955", "E119", "Z794", "I4891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nshellfish derived\n \nAttending: ___.\n \nChief Complaint:\nEnlargement of pararenal abdominal aortic aneurysm with \nimpingement on the para-visceral segment.\n \nMajor Surgical or Invasive Procedure:\nEndovascular repair of abdominal aortic aneurysm using \nphysician-modified fenestrated ___.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ gentleman with history of small \nbowel obstructions, last occurring in ___, coronary \nartery disease, hypertension and atrial fibrillation on Coumadin \nwho presents for repair of a pararenal abdominal aortic \naneurysm. Mr. ___ has a vascular history to include \nbilateral popliteal artery aneurysms repaired via above-knee to \nbelow-knee popliteal artery bypass. Recently, his aneurysm had \ngrown and had impinged on the para-visceral segment. He was \ntherefore referred to Dr. ___ risks, benefits, \nand alternatives to open versus endovascular repair were \nexplained to the patient in detail and he elected to pursue \nphysician-modified ___. The risks, benefits and \nalternatives to this treatment were explained to the patient in \ndetail and he consented to proceed.\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n- Abdominal aortic aneurysm \n- Bilateral popliteal artery aneurysms\n- Small-bowel obstruction.\n- Atrial fibrillation - (Coumadin) \n- Coronary artery disease \n- Hypertension \n- Arthritis \n- Gastroesophageal reflux disease \n\nPAST SURGICAL HISTORY: \n- Incarcerated incisional hernia repair with mesh (___)\n- L3-L4 revision decompression with foraminotomy and discectomy\nin ___, \n- Exploratory laparotomy (___). \n- Lumbar laminectomy L2 through L5 (___)\n- Left total knee replacement (___) \n- Multiple trigger finger releases \n- Coronary artery bypass graft x 3 at ___ (___) \n- Anterior cervical discectomy at C3 and C4, anterior body \nfusion\n(___) \n- Ligation of popliteal artery aneurysm with AK to BK popliteal\nartery bypass (___). \n- Ligation of a right popliteal artery aneurysm with AK to BK\npopliteal artery bypass (___) \n- Partial medial meniscectomy left knee (___). \n- Left shoulder revision arthroscopy with repair of the rotator\ncuff (___) \n- Right shoulder revision and arthroscopy with primary repair of\nthe rotator cuff in ___. \n- Umbilical hernia repair \n- Right total knee replacement (___) \n- Partial meniscectomy and debridement arthritis right knee\n(___) \n- Ankle arthroscopy and ___ \n- Appendectomy.\n \nSocial History:\n___\nFamily History:\nFather: ___ ___, colon cancer. \nMother: ___ at ___ years old, coronary artery disease. \nSister #1: Deceased at ___ years old, lung carcinoma. \nSister #2: Deceased at ___, uterine cancer.\n \nPhysical Exam:\nVitals: T97.7, HR76, 148/84, 20RR, 96%RA\nGeneral: NAD, comfortable\nHEENT: NCAT, PERRL, MMM\nChest/CV: RRR, no MRG\nPulmonary: CTAB\nABD: SNT/ND, normoactive BS, no palpable masses\nNeuro: A/O, CN II-XII intact, steady gait with walker\nExtremities: palpable DP and ___ pulses, no edema, motor and \nsensation intact in bilateral lower extremities; no erythema, \nwarmth, or swelling at wound sites on R ___. Minimal back pain \nand. Resolved Right groin pain.\n \nBrief Hospital Course:\nMr. ___ arrived to ___ on ___ \nfor an elective fenestrated endovascular aneurysm repair after \nenlargement of a pararenal abdominal aortic aneurysm with \nimpingement on the para-visceral segment. The patient presented \nto pre-operative admission and was evaluated by anesthesia. The \npatient was taken to the operating room for an endovascular \nrepair of abdominal aortic aneurysm using ___-modified \nfenestrated ___. Both rentals and SMA were stunted and had \nbilateral percutaneous access. At the completion of this, the \npatient had soft groins without any evidence of hematoma or \nbleeding. Pulses in the feet were checked and all pedal pulses, \nwhich had been palpable preoperatively, were still palpable. 40 \nmg of Protamine were administered and the patient was extubated \nin the operating room and taken to the PACU for further \nrecovery. There were no adverse events in the operating room; \nplease see the operative note for more details. After a brief \nstay in PACU, the patient was transferred to the vascular \nsurgery floor where he remained through the rest of the \nhospitalization.\n\nPost-operatively he did well without any groin swelling and \nneurological exams were intact following his surgery. He was \nable to tolerate a regular diet, get out of bed and ambulate \nwith assistance. On POD1 he did complain of pain in his back \nwhich was later on well controlled with PO Dilaudid. He \npreferred to stay in ___ that night due to pain control. On \nPOD2, Mr. ___ began complaining of severe back pain and \ninability to lift his legs secondary to pain in his groins. A \nCTA of torso was ordered which showed no evidence of endoleak, \nretroperitoneal hematoma, or groin access complications. Later \nthat day, symptoms subsided and the patient was able to get out \nof bed to chair and ambulate and reported absence of pain in \nboth groins and minimal back pain. Previous dose of Coumadin was \nrestarted. Mr. ___ was deemed ready for discharge, and was \ngiven the appropriate discharge and follow-up instructions.\n \nMedications on Admission:\nMedications - Prescription\nDILTIAZEM HCL - diltiazem ER 360 mg capsule,extended release. 1\ncapsule(s) by mouth q am - (Prescribed by Other Provider)\nESOMEPRAZOLE MAGNESIUM [NEXIUM] - Nexium 40 mg capsule,delayed\nrelease. 1 capsule(s) by mouth q am - (Prescribed by Other\nProvider)\nMETOPROLOL SUCCINATE - metoprolol succinate ER 100 mg\ntablet,extended release 24 hr. 1 tablet(s) by mouth twice a day \n-\n(Prescribed by Other Provider)\nNITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet. 1\ntablet(s) sublingually as directed for chest pain - (Prescribed\nby Other Provider)\nPRAVASTATIN - pravastatin 10 mg tablet. 1 tablet(s) by mouth q \nhs\n- (Prescribed by Other Provider)\nRANITIDINE HCL - ranitidine 150 mg capsule. 1 capsule(s) by \nmouth\nq hs - (Prescribed by Other Provider)\nWARFARIN - warfarin 5 mg tablet. 1 tablet(s) by mouth qd on a\nsliding scale based on INR results - (Prescribed by Other\nProvider)\nZALEPLON - zaleplon 10 mg capsule. 1 capsule(s) by mouth q hs - \n(Prescribed by Other Provider)\n \nMedications - OTC\nASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by\nmouth once a day - (Prescribed by Other Provider)\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 (One) tablet(s) by mouth once a day Disp \n#*30 Tablet Refills:*0 \n3. Diltiazem Extended-Release 360 mg PO DAILY \n4. Metoclopramide 10 mg PO QIDACHS \n5. Metoprolol Succinate XL 100 mg PO BID \n6. Omeprazole 40 mg PO DAILY \nAlternatively you can take Esomeprazole - Nexium 40mg capsule - \n1 capsule by mouth q am \n7. Pravastatin 10 mg PO QPM \n8. Ranitidine 150 mg PO QHS \n9. Warfarin 5 mg PO 5X/WEEK (___) \n10. Warfarin 2.5 mg PO 2X/WEEK (MO,TH) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal aortic aneurysm status post Fenestrated Endovascular \nAneurysm Repair.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ and \nunderwent a FENESTRATED ENDOVASCULAR ANEURYSM REPAIR. You have \nnow recovered from surgery and are ready to be discharged. \nPlease follow the instructions below to continue your recovery:\n\nMEDICATIONS:\n• Please stop taking your Aspirin while taking Plavix. Resume \nAspirin 81mg in one(1) month when you stop taking your Plavix. \n• Take Plavix 75mg once daily for one month.\n• Please restart your Coumadin at your usual dose. 5 mg ___, \n___, and ___. 2.5 mg ___ and \n___.\n• Continue all other medications you were taking before surgery, \nunless otherwise directed\n• You make take Tylenol or prescribed pain medications for any \npost procedure pain or discomfort\n\nWHAT TO EXPECT AT HOME:\n It is normal to have slight swelling of the legs:\n• Elevate your leg above the level of your heart (use ___ \npillows or a recliner) every ___ hours throughout the day and at \nnight\n• Avoid prolonged periods of standing or sitting without your \nlegs elevated\n It is normal to feel tired and have a decreased appetite, your \nappetite will return with time \n• Drink plenty of fluids and eat small frequent meals\n• It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing\n• To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication\n\nACTIVITIES:\n• When you go home, you may walk and go up and down stairs\n• You may shower (let the soapy water run over groin incision, \nrinse and pat dry)\n• Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing or \nband aid over the area that is draining, as needed\n• No heavy lifting, pushing or pulling (greater than 5 lbs) for \n1 week (to allow groin puncture to heal)\n• After 1 week, you may resume sexual activity\n• After 1 week, gradually increase your activities and distance \nwalked as you can tolerate\n• No driving until you are no longer taking pain medications\n\nCALL THE OFFICE FOR: ___\n• Numbness, coldness or pain in lower extremities \n• Temperature greater than 101.5F for 24 hours\n• New or increased drainage from incision or white, yellow or \ngreen drainage from incisions\n• Bleeding from groin puncture site\n\nFOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or \nincision)\n• Lie down, keep leg straight and have someone apply firm \npressure to area for 10 minutes. If bleeding stops, call \nvascular office. If bleeding does not stop, call ___ for \ntransfer to closest Emergency Room. \n\n \nFollowup Instructions:\n___\n" ]

[ "I714", "I482", "I10", "I2510", "M549", "Z7901", "Z006", "Z951", "K219", "M1990", "Z96651", "Z87891", "E669", "Z6837" ]

[ "I714: Abdominal aortic aneurysm, without rupture", "I482: Chronic atrial fibrillation", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M549: Dorsalgia, unspecified", "Z7901: Long term (current) use of anticoagulants", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z951: Presence of aortocoronary bypass graft", "K219: Gastro-esophageal reflux disease without esophagitis", "M1990: Unspecified osteoarthritis, unspecified site", "Z96651: Presence of right artificial knee joint", "Z87891: Personal history of nicotine dependence", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult" ]

[ "I10", "I2510", "Z7901", "Z951", "K219", "Z87891", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nshellfish derived / hydromorphone / oxycodone / trazodone\n \nAttending: ___\n \nMajor Surgical or Invasive Procedure:\nCoronary Angiogram ___\n\nattach\n \nPertinent Results:\nDISCHARGE PHYSICAL EXAMINATION\n==============================\n VS: reviwed in MetaVision \n GENERAL: Well developed, well nourished, appears uncomfortable\nwhile laying in bed\n HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. \nEOMI.\n NECK: Supple. JVP ~9-10cm \n CARDIAC: irregular rate. No murmurs, rubs, or gallops. \n LUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. LCTA\n ABDOMEN: Soft, non-tender, non-distended. No palpable\nhepatomegaly \n EXTREMITIES: cool extremities, mild lower extremity edema to\nshins b/l \n SKIN: No significant lesions or rashes, no hematoma at either\nradial access sites, normal capillary refill b/l, no extr\ndiscoloration \n PULSES: Distal pulses palpable and symmetric both radial and \nDP.\n\n NEURO: alert, oriented x3, moving all extremities \n\nADMISSION LABS\n==============\n___ 08:30AM BLOOD WBC-5.9 RBC-5.16 Hgb-11.8* Hct-38.5* \nMCV-75* MCH-22.9* MCHC-30.6* RDW-21.3* RDWSD-55.6* Plt ___\n___ 09:52PM BLOOD Glucose-108* UreaN-20 Creat-1.2 Na-137 \nK-5.6* Cl-105 HCO3-18* AnGap-14\n___ 09:52PM BLOOD Calcium-8.9 Phos-3.5 Mg-2.0\n___ 09:52PM BLOOD ALT-15 AST-40 LD(LDH)-450* CK(CPK)-172 \nAlkPhos-58 TotBili-0.8\n___ 08:30AM BLOOD ___\n\nPERTINENT STUDIES\n=================\n___ 09:52PM BLOOD CK-MB-13* MB Indx-7.6* cTropnT-0.21* \nproBNP-840\n___ 04:19AM BLOOD CK-MB-46* MB Indx-13.2* cTropnT-0.44*\n___ 12:30PM BLOOD CK-MB-55*\n___ 06:28PM BLOOD CK-MB-44*\n___ 12:23AM BLOOD CK-MB-33*\n___ 08:18AM BLOOD CK-MB-21*\n\nDISCHARGE LABS\n==============\n___ 08:18AM BLOOD WBC-6.0 RBC-4.54* Hgb-10.5* Hct-33.8* \nMCV-74* MCH-23.1* MCHC-31.1* RDW-21.4* RDWSD-56.6* Plt Ct-99*\n___ 08:18AM BLOOD ___ PTT-48.6* ___\n___ 08:18AM BLOOD Glucose-90 UreaN-18 Creat-1.1 Na-138 \nK-4.2 Cl-106 HCO3-19* AnGap-13\n___ 08:18AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.1\n\nIMAGING/OTHER STUDIES\n=====================\nCoronary angiography ___\nFindings\n• Three vessel coronary artery disease.\n• Succesful RCA CTO PCI with 5 DES complicated with proximal \nRCA/aortic dissection\n(succesfully stented). Distal edge wire-induced dissection that \nwill most likely heal normally.\nRecommendations\n• Maximize medical therapy\n• DAPT for at least 12 months; 30 months prefered if no bleeding \nissues. OBS tonight. CTA\n\nTTE ___\nIMPRESSION: Suboptimal image quality. Mild symmetric left \nventricular hypertrophy with normal cavity size and mild \nregional systolic dysfunction consistent with known CAD. \nModerately dilated right ventricle with moderate systolic \ndysfunction. Mild mitral, tricuspid, and aortic regurgitation. \nNormal estimated pulmonary artery systolic pressure. Mildly \ndilated ascending aorta. Tomorrow if Cr stable. Aggresive IVFs \ntonight. Maximize medical therapy.\n \nBrief Hospital Course:\nPatient Summary: \n================ \nMr. ___ is ___ male with HTN, HLD, AF on coumadin, \nCAD s/p CABG ___ (with LIMA-LAD, SVG-OM, and SVG-RCA), AAA s/p \nendovascular repair, dilated ascending aorta (4.2cm), CKD stage \nIII, who underwent complex PCI with 5 DES to a chronically \noccluded RCA for persistent stable angina. The procedure was \ncomplicated by aortic root/proximal RCA dissection. He was \ntransferred to the CCU for monitoring post procedure and had \nimprovement of his chest pain and stabilization of his blood \npressure. Medical therapy was titrated on the floor prior to \ndischarge. \n\n#CORONARIES: CABG ___ with LIMA-LAD, SVG-OM, and SVG-RCA, s/p \n___ 5 to RCA CTO ___ c/b aortic root/RCA dissection \n#PUMP: EF 51%, 1+ MR/TR/AR, mod RV dilation\n#RHYTHM: atrial fibrillation \n\nTransitional Issues:\n==================== \n[] Patient reported interest in switching over to a DOAC, though \nwas hesitant to do so without speaking to his outpatient \ncardiologist. Would consider transition from warfarin to a DOAC. \n\n[] He was started on triple therapy due to ___. He \nshould be continued on this for 1 month with plan to discontinue \nthe ASA at that point. In one year, his Plavix should be \nreplaced by ASA\n[] Should consider cardiac rehab program after discharge\n[] He was transitioned from pravastatin 20mg to atorvastatin \n80mg. \n\nACUTE ISSUES:\n===============\n# CAD s/p CABG \n# s/p ___ 5 to RCA CTO ___ c/b aortic root/RCA dissection\nPatient with history of CAD with CABG in ___ (LIMA-LAD, SVG-OM, \nand SVG-RCA). On his most recent cath, patient was noted to have \nCTO of mid LAD, LIMA-LAD patent, occluded SVG-OM and RCA, and \nCTO of the RCA. Due to ongoing chest pain despite 3 antianginal \nmedications, he underwent elective revascularization of his \nknown CTO RCA. During this hospitalization, his coronary \nangiogram showed severe tortuosity beginning in the mid segment \nof the RCA, with 70% stenosis with a TIMI flow grade of 0 in the \nproximal and mid segments, a 100% stenosis in the mid and distal \nsegments, and significant collaterals. During initial access to \nthrough R radial catheter was kinked and angiogram showed a \nsmall perforation in the brachial artery that was closed with a \nFr. guide and a BP cuff. Access was then obtained through L \nradial, 5 stents total were placed to the RCA. Angiogram during \ncath showed distal dissection into the RPDA/RPL (wire induced \nmost likely, no intervention performed) with TIMI 3 flow, as \nwell as an aortic root/proximal RCA dissection at the origin \nrequiring ___. Final angiogram showed no residual, \nstable ___ RCA/ aortic dissection as well as distal RPDA \ndissection and TIMI 3 flow. Following the procedure, he \ncontinued to report chest pain and was started on an IV nitro \ndrip with a brief drop of his blood pressure when he was given \nmorphine. He was admitted to the CCU on the nitro drip and his \nBP stabilized and his chest pain resolved. His CK-MB was trended \nand peaked prior to discharge. Focused TTE showed overall \npreserved left ventricular systolic function and normal right \nventricle free wall motion, no pericardial effusion. He was \ndischarged on atorvastatin 80mg, ASA, Plavix, and warfarin with \nplan to continue triple therapy for 1 month and then continue \nwith Plavix and warfarin. His anti-anginal medications were not \nchanged during this admission. \n\n# A fib: \nHe was started on a heparin drip while inpatient and started on \nwarfarin 5mg two days prior to discharge. He was given \ninstructions to take warfarin 5mg the night of discharge and \nthen to resume his home regimen of 2.5 mg x 6 days and 5 mg on \n___. He is managed by Dr. ___ has an INR check \nfor ___. He was continued on his home metoprolol 100mg BID.\n\n# HTN: \nHis amlodipine was held while his blood pressures were low and \nwas restarted on the day of discharge as his blood pressure \nimproved. He was continued on his home nitrate and metoprolol. \n\n# HLD:\nHe was transitioned from pravastatin 20mg to atorvastatin 80mg \nfollowing his procedure. \n\n# CKD stage III\nPatient with baseline Cre ~1.2-1.3. His Cr remained close to \nbaseline during this admission. \n\n#GERD\nHe was continued on his home omeprazole. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 100 mg PO BID \n2. Ranolazine ER 1000 mg PO BID \n3. Warfarin 2.5 mg PO 6X/WEEK (___) \n4. Warfarin 5 mg PO 1X/WEEK (TH) \n5. amLODIPine 5 mg PO DAILY \n6. Ranitidine 150 mg PO QHS \n7. Pravastatin 20 mg PO QPM \n8. Isosorbide Mononitrate (Extended Release) 60 mg PO BID \n9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n10. esomeprazole magnesium 40 mg oral DAILY \n11. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 80 mg PO QPM \n2. Clopidogrel 75 mg PO DAILY \n3. amLODIPine 5 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. esomeprazole magnesium 40 mg oral DAILY \n6. Isosorbide Mononitrate (Extended Release) 60 mg PO BID \n7. Metoprolol Succinate XL 100 mg PO BID \n8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n9. Ranitidine 150 mg PO QHS \n10. Ranolazine ER 1000 mg PO BID \n11. Warfarin 5 mg PO 1X/WEEK (TH) \n12. Warfarin 2.5 mg PO 6X/WEEK (___) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnoses:\nCoronary Artery disease s/p CABG, RCA CTO s/p ___ 5 \nPersistent angina\n\nSecondary diagnoses:\nAtrial Fibrillation\nHTN\nHLD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nHi Mr. ___,\n\nWHY WERE YOU ADMITTED TO THE HOSPITAL?\nYou were admitted following your cardiac catheterization in \nwhich 5 drug coated stents were placed to open a blockage in \nyour right coronary artery. Procedure was complicated by tearing \nin the right coronary artery which was fixed with a stent. Echo \ndid not show any complications.\n\nInstructions regarding care of the access site are included with \nyour discharge information. \n\nWHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? \n Please continue your current medications with the following \nchanges: \n - continue Aspirin 81mg daily for one month, then STOP. You \nwill go back on aspirin after one year when you come off Plavix. \n\n - Start Plavix 75mg daily, you should take this for a minimum \nof one year and ONLY stop when told by a cardiologist \nspecifically. \n - Stop Pravastatin and start Atorvastain 80 mg daily \n - Continue to to take Coumadin (Warfarin) per Dr. ___ \n___ \n - Continue all other medications without any change. \n\n It is very important to take all of your heart healthy \nmedications. In particular, aspirin and clopidogrel (Plavix) \nhelp to keep the stents in the vessels of the heart open and \nhelp reduce your risk of having a future heart attack. If you \nstop these medications or miss ___ dose, you risk causing a blood \nclot forming in your heart stents which could cause a life \nthreatening heart attack. Please do not stop taking either \nmedication without talking to your heart doctor, even if another \ndoctor tells you to stop the medications. \n\n It is strongly recommended that you attend a cardiac rehab \nprogram in the near future. A referral form was provided to you \nthat lists the locations of these programs. Please bring this \nwith you to your follow up visit with your cardiologist, and \nthey will inform you when it is safe to begin a program. \n\n If you were given any prescriptions on discharge, any future \nrefills will need to be authorized by your outpatient providers, \nprimary care or cardiologist.\n\n If you have any urgent questions that are related to your \nrecovery from your hospitalization or are experiencing any \nsymptoms that are concerning to you and you think you may need \nto return to the hospital, please call the ___ HeartLine at \n___ to speak to a cardiologist or cardiac nurse \npractitioner. \n\n It has been a pleasure to have participated in your care and we \nwish you the best with your health! \n\n Your ___ Cardiac Care Team \n \n\n \nFollowup Instructions:\n___\n" ]

[ "I25118", "I9751", "I25718", "N183", "I129", "I2582", "I480", "E785", "K219", "Y658", "Y713", "Y92238", "Z87891", "Z951", "Z7902" ]

[ "I25118: Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris", "I9751: Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure", "I25718: Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris", "N183: Chronic kidney disease, stage 3 (moderate)", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I2582: Chronic total occlusion of coronary artery", "I480: Paroxysmal atrial fibrillation", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Y658: Other specified misadventures during surgical and medical care", "Y713: Surgical instruments, materials and cardiovascular devices (including sutures) associated with adverse incidents", "Y92238: Other place in hospital as the place of occurrence of the external cause", "Z87891: Personal history of nicotine dependence", "Z951: Presence of aortocoronary bypass graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I129", "I480", "E785", "K219", "Z87891", "Z951", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nphenobarbital / Zonegran / Demerol\n \nAttending: ___.\n \nChief Complaint:\nPelvic pain, limp on R\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old male with severe\ndevelopmental delay, nonverbal, history of seizures, presents as\na transfer from ___ for orthopedics evaluation. This\nmorning he began having difficulty walking with apparent limp. \nNo\ninjuries or trauma reported by group home staff. The patient\npreviously has had unexplained injuries including a broken leg,\ngash in his leg and gash over the eye. All of these incidents\nwere reported to the ___. The patient initially went to\n___ where CT scan showed comminuted fracture of the right\nilium. At ___ initial labs showed H/H 13.5/40.2 which trended\nto 11.1/34 after fluids. Patient transiently soft blood pressure\nin the high ___, responded to single bolus of saline 500 mL. He\nalso had a fever at ___. \n\nIn the ED, initial VS were: 99.2F, HR 99, 125/77, RR 20, 96% on\nRA\n\nExam notable for: Hematoma and bruising on the right hip and\nbilateral elbows. Pain with right straight leg raise. \n\nLabs showed:\n-Negative flu \n-Unremarkable BMP except for Cl 109\n-CK 122\n-WBC 6.8, Hb 11.1, Platelets 203\n-INR 1.2\n-Urinalysis - bland \n\nImaging showed: CXR: Lung volumes still remain quite low.\nHeterogeneous opacification at the lung bases, particularly the\nright, could be due to pneumonia, especially aspiration. Upper\nlungs are clear. No pleural effusion. \n\nConsults: \n-Ortho: Injury is closed; right lower extremity is\nneurovascularly intact. Follow up in ___ clinic in 2\nweeks. Ok for activity as tolerated. Secondary survey negative\nfor pain elsewhere when palpated throughout his extremities and\ndown spine. \n-SW: Filed ___ report for abuse/neglect of a disabled person. \n-___: Recommended d/c to rehab. \n-CM: Multiple rehab referrals placed with no rehab bed offered \nas\nof 540pm. \n\nPatient received:\n-Home medications\n-Ceftriaxone, azithromycin, flagyl \n\nTransfer VS were: 98.1F (Tmax 100.6), HR 99, BP 110/80, RR 18,\n99% on RA\n\nOn arrival to the floor, patient unable to provide further\nhistory but mother at bedside. She does report that the patient\ncan become aggressive (biting, hitting) with over stimulation.\nShe says he has a high tolerance for pain and does want him\ngetting anything more than Tylenol for now. She is unaware of \nany\nfevers at the group home. Denies recent cough or difficulty\nbreathing. \n\n \nPast Medical History:\n1. Intellectual disability, non-verbal \n2. Asthma \n3. Constipation \n4. Dysphagia (on regular diet with thin liquids) \n5. Epilepsy / Myoclonic seizure disorder\n6. Osteoporosis \n7. Mood disorder with aggression and psychosis \n \nSocial History:\n___\nFamily History:\nFather died from complications of alcoholism,\nalso with history of HTN and bladder cancer. Mother with basal\ncell carcinoma. Brother is healthy. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: 98.1F, 116/91, RR91, RR 20, 95%RA \nGENERAL: NAD, mother holding arms to prevent patient from \nhitting\nduring exam \nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no edema, cries in pain with straight leg raise on\nthe right, hematoma on right hip\n\nDISCHARGE PHYSICAL EXAM:\nGENERAL: NAD, caregiver holding arms to prevent patient from\nhitting during exam. Patient smiling and appeared very\ncomfortable.\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no edema, hematoma on right hip improving.\n\n \nPertinent Results:\nADMISSION LABS: \n\n___ 06:01PM BLOOD WBC-6.8 RBC-3.47* Hgb-11.1* Hct-34.3* \nMCV-99* MCH-32.0 MCHC-32.4 RDW-12.8 RDWSD-45.8 Plt ___\n___ 06:01PM BLOOD ___ PTT-28.6 ___\n___ 06:01PM BLOOD Glucose-82 UreaN-11 Creat-0.8 Na-145 \nK-4.0 Cl-109* HCO3-25 AnGap-11\n___ 03:40AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.5\n\nDISCHARGE LABS: None\n\nIMAGING: \nPelvic X-ray: Study is read in conjunction with pelvis CT \n___. \nThere has been no change in minimal displacement of the \nvertically oriented fracture of the lateral right iliac wing. \nPelvis and hips are otherwise intact. \n\n \nBrief Hospital Course:\nSUMMARY:\n___ with severe developmental delay, nonverbal, history of \nseizures, presents with limping and found to have a fracture of \nthe right ilium. No report of fall but has history of them due \nto unsteady gait.\n\nACUTE ISSUES:\n===============\n#Hip hematoma/Non-displaced fracture of the right ilium:\nOrtho consult decided to non-surgically treat the patient with \npain management and physical therapy. There was an unknown \nsource of trauma however patient has had other injuries in the \npast at group home that\nwere unexplained, possibly secondary to longstanding spastic \ngait\nand impulsivity. Group home stated he is unsteady on feet at \nbaseline\nand has not had any witnessed syncopal episodes. Pelvic x-rays\nshowed no interval change from prior CT showing minimal\ndisplacement of fracture. Hematoma was improving on discharge. \nHe will follow up at the ___ on ___. He was \ndischarged to group home after being cleared by physical \ntherapy.\n\n#Hypernatremia:\nHe was intermittently hypernatremic in the setting of poor \nintake of water. He was able to maintain himself without use of \nIV fluids and encouraged to drink more water.\n\n#Fever:\nPreviously had low grade fevers and had no clear localizing\nsource of infection with urinalysis and culture and flu both \nnegative. Chest x-ray did show heterogeneous opacification at \nthe lung bases, particularly the right was concerning for \naspiration pneumonia, but had no cough and hypoxia and was \nmonitored throughout his admission during which he remained well \nclinically and hemodynamically stable. \n\nCHRONIC ISSUES:\n===============\n#Seizure disorder\nContinued on home keppra and LevoCARNitine \n\n#Aggression \nContinued on home Fluvoxamine and ClonazePAM, which was recently \nuptitrated to TID)\n-Nuedexta is NF, mother does not have medications here in the\nhospital but will ask her to bring it \n\n#Osteoporosis\nContinued on weekly Alendronate, Vit D, and Calcium Carbonate \nwhile he was in house.\n\n#Constipation\nContinued home docusate. \n\n#Asthma\nContinued home Montelukast. \n\nMEDICATION CHANGES: NONE\n\nTRANSITIONAL ISSUES:\n[] Ensure patient following orthopedics recommendations \n(follow-up appointment on ___\n[] Please get BMP at first follow up: Monitor his Na as he \ntended to be mildly hypernatremic while he was inpatient, \nencourage good PO water intake\n[] Follow-up on pain/mobility at group home: Ensure he walks \nwith one to one assistance as he has required while in patient\n[] OK to return to adult day care program when able to walk on \nown without assistance\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Alendronate Sodium 70 mg PO QMON \n2. ClonazePAM 1 mg PO TID \n3. Fluvoxamine Maleate 100 mg PO TID \n4. Nuedexta (dextromethorphan-quinidine) ___ mg oral TID \n5. Boost (food supplemt, lactose-reduced) 0.04 gram- 1 kcal/mL \noral DAILY \n6. Calcium Carbonate 600 mg PO BID \n7. LevoCARNitine 200 mg PO TID \n8. Docusate Sodium 100 mg PO BID \n9. LevETIRAcetam 1500 mg PO BID \n10. Multivitamins 1 TAB PO DAILY \n11. Montelukast 10 mg PO DAILY \n12. Vitamin D 400 UNIT PO DAILY \n13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Alendronate Sodium 70 mg PO QMON \n3. Boost (food supplemt, lactose-reduced) 0.04 gram- 1 kcal/mL \noral DAILY \n4. Calcium Carbonate 600 mg PO BID \n5. ClonazePAM 1 mg PO TID \n6. Docusate Sodium 100 mg PO BID \n7. Fluvoxamine Maleate 100 mg PO TID \n8. LevETIRAcetam 1500 mg PO BID \n9. LevoCARNitine 200 mg PO TID \n10. Montelukast 10 mg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. Nuedexta (dextromethorphan-quinidine) ___ mg oral TID \n13. Vitamin D 400 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\nNon-displaced fracture of the Right Ilium\nHypernatremia\n\nSECONDARY DIAGNOSES\nSeizure disorder\nOsteoporosis\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n \nIt was a pleasure taking part in your care here at ___! \n\nWhy was I admitted to the hospital? \n- You were admitted for a fall and were found to have a fracture \nin your right hip.\n \nWhat was done for me while I was in the hospital? \n- You were treated medically for your fracture with pain \nmanagement and underwent physical therapy to help you regain \nyour mobility.\n- We continued your home medications.\n\nWhat should I do when I leave the hospital? \n- Attend all your follow-up appointments and take all of your \nmedications as prescribed.\n- Follow-up at the orthopedics clinic as scheduled below.\n- Continue to walk with assistance as much as you can to help \nthe healing process.\n \nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "S32391A", "E870", "F72", "G40909", "R509", "J45909", "M810", "R2681", "X58XXXA", "Y92098", "K5900" ]

[ "S32391A: Other fracture of right ilium, initial encounter for closed fracture", "E870: Hyperosmolality and hypernatremia", "F72: Severe intellectual disabilities", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "R509: Fever, unspecified", "J45909: Unspecified asthma, uncomplicated", "M810: Age-related osteoporosis without current pathological fracture", "R2681: Unsteadiness on feet", "X58XXXA: Exposure to other specified factors, initial encounter", "Y92098: Other place in other non-institutional residence as the place of occurrence of the external cause", "K5900: Constipation, unspecified" ]

[ "J45909", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nnaproxen / latex\n \nAttending: ___.\n \nChief Complaint:\ncavernous malformation \n \nMajor Surgical or Invasive Procedure:\n___: Left temporal craniectomy for cavernous malformation \n\n \nHistory of Present Illness:\n___ year old female known to the Neurosurgical Service who has \nbeen conservatively monitored for known cavernous malformation. \nRecently, she has had more seizures related to her cavernous \nmalformation slowly bleeding thus elected to now have it \nresected. \n \nPast Medical History:\nthyroid cancer\ncavernous malformation\nseizures\n \nSocial History:\n___\nFamily History:\nnc\n \nPhysical Exam:\nEXAM UPON DISCHARGE: \n\nGen: WD/WN, comfortable, NAD.\n\nHEENT: \nPupils: PERRL ___ \nEOMs: Intact\n\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: Pupils equally round and reactive to light, 2 to 1mm \nbilaterally.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift\n\nSensation: Intact to light touch\n \nPertinent Results:\n___ CT HEAD W/O CONTRAST\nIMPRESSION: \n \n1. Status post resection of the left mesial temporal lobe mass, \nlikely a \ncavernous malformation, with expected postsurgical changes, \nincluding \ninvolving blood products and bilateral pneumocephalus. \n \n2. No shift of normally midline structures. The basal cisterns \nare patent. No unexplained intracranial hemorrhage. \n\n \nBrief Hospital Course:\nPatient was electively admitted for cavernous malformation \nresection. OR was uneventful and patient was extubated in the OR \nand brought to the PACU for immediate post-operative care. In \nthe PACU, patient complains of headache and nausea however \nnausea improving after medications. Patient will remain ICU \nlevel of care overnight. \n\nOn ___, patient is neurologically and hemodynamically stable. \nPatient complains of intermittent nausea and incisional pain. \nMedications adjusted. Patient transferred to the floor with \nphysical therapy consult. \n\nOn ___, patient is neurologically and hemodynamically \nstable. Patient states nausea is improved and is slowly \nincreasing diet. Case management saw the patient and set the \npatient up for services at home. Patient to be discharged \ntomorrow. \n\nOn ___, the patient remained neurologically and hemodynamically \nstable. She did not have any issues overnight. She was stable \nand deemed safe for discharge homw with services and appropriate \nfollow-up. \n \nMedications on Admission:\nkeppra 750mg BID, Armour 90mg daily \n\n \nDischarge Medications:\n1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache \nDo not exceed 6 tab/day. Each tablet contains: Acetaminophen \n325mg, Butalbital 50mg, Caffeine 40mg \nRX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ \ntablet(s) by mouth every 6 hours as needed Disp #*45 Tablet \nRefills:*0\n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID \n4. LevETIRAcetam 750 mg PO BID \nRX *levetiracetam 750 mg 1 tablet(s) by mouth twice a day Disp \n#*45 Tablet Refills:*0\n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours as \nneeded Disp #*45 Tablet Refills:*0\n6. Senna 17.2 mg PO QHS \n7. Thyroid 90 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\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:\nSurgery\n\n· You underwent a surgery called a craniotomy to have left \ncavernous malformation resection. \n\n· Please keep your sutures along your incision dry until they \nare removed.\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\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 \nmedication. \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. \n\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\n· You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n\n· You may have difficulty paying attention, concentrating, and \nremembering new information.\n\n· Emotional and/or behavioral difficulties are common. \n\n· Feeling more tired, restlessness, irritability, and mood \nswings are also common.\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· Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nHeadaches:\n\n· Headache is one of the most common symptoms after a brain \nbleed. \n\n· Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n\n· Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n\n· There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/meditation, massage, acupuncture, heat or ice packs. \n\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" ]

[ "D1802", "G40909", "Z85850" ]

[ "D1802: Hemangioma of intracranial structures", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z85850: Personal history of malignant neoplasm of thyroid" ]

[]

[]

[ " \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:\nFall\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\n___ w/ PMHx notable for HTN and remote head injury 40+ years \nprior now seen in consultation following a presumed syncopal \nepisode. Pt cannot describe any inciting events leading to the \nfall and reports becoming aware that he had fallen after his \nwife awakened him. He reports LOC immediately surrounding the \nevents of the fall, but has had no difficulty with memory, \nmotor/sensation, vision, or speech since. He was taken to \n___ where workup there included labs which were normal and \na CT head and c-spine which demonstrated bifrontal subacute on \nchronic SDHs with a small, acute right lateral-posterior\ncomponent. CT cspine consistent with chronic degenerative \nchanges, but no acute traumatic injury. He was transferred to \n___ for further workup and evaluation.\n \nPast Medical History:\nPMHx: HTN, hepatitis B\n\nPSHx: L leg/hip surgery distantly while in ___ war, repair \nof L scalp laceration ~ ___ year ago\n \nSocial History:\n___\nFamily History:\nbrother with colon cancer at young age, otherwise unknown\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nPE:\n97.9 88 132/70 16 99% RA \nGen: NAD, comfortable, superficial abrasions over left cheek and\nchin\nHEENT: EOMI, pupils equal and reactive ___, left neck pain on\nlateral side which pt reports is chronic and muscular in nature,\nno deformities noted and no motor/sensory loss; no cspine\ntenderness, no thoracic or lumbar spine tenderness or deformity;\nhead with abrasions as noted above, otherwise atraumatic\nCV: RRR\nR: CTAB\nAbd: soft, NT/ND, no masses, no surgical incisions, no hernias,\nno bruising\nExt: moves all extremities x4 equally and with full sensation \nand\nstrength, no bruising or e/o traumatic injury\n\n=========================\n=========================\nDISCHARGE PHYSICAL EXAMINATION\nDischarge:\n97.6 PO 135 / 76 66 18 96 Ra \nGen: NAD, comfortable, superficial abrasions over left cheek and\nchin\nHEENT: EOMI, PERRLA\nCV: RRR\nR: CTAB\nAbd: soft, NT/ND, no masses, no surgical incisions, no hernias,\nno bruising\nExt: moves all extremities x4 equally and with full sensation \nand\nstrength, no bruising or e/o traumatic injury\n\n \nPertinent Results:\nIMAGING STUDIES\n\n___ CT Cspine: No cervical vertebral fracture or traumatic\nsubluxation. Multilevel degenerative changes with asymmetric\nmultifocal neural foraminal stenosis\n\n=========================\n\nLABS\n___ 07:21PM BLOOD WBC-8.9 RBC-4.33* Hgb-14.1 Hct-40.2 \nMCV-93 MCH-32.6* MCHC-35.1 RDW-11.7 RDWSD-40.0 Plt ___\n___ 07:21PM BLOOD Neuts-52.8 ___ Monos-5.7 Eos-1.6 \nBaso-0.7 Im ___ AbsNeut-4.69 AbsLymp-3.48 AbsMono-0.51 \nAbsEos-0.14 AbsBaso-0.06\n___ 07:21PM BLOOD Glucose-106* UreaN-22* Creat-1.0 Na-139 \nK-3.8 Cl-104 HCO3-21* AnGap-14\n___ 09:19AM BLOOD CK(CPK)-49\n___ 02:12AM BLOOD CK-MB-1 cTropnT-<0.01\n \nBrief Hospital Course:\nMs. ___ is an ___ yo M who was admitted to the Acute Care Trauma \nsurgery service after sustanging a fall with bifrontal subacute \non chronic subdural hemorrhages and small acute right lateral \ncomponent. He was admitted to the acute care surgery service for \ncontinuous cardiac monitoring given possible syncope episode. \nThe patient was seen and evaluated by neurosurgery who \nrecommended a repeat CT scan which was stable and seizure \nprophylaxis with keppra for 7 days. The patient remained \nhemodynamically stable with no events on continuous telemetry \nand negative cardiac enzymes. Physical and occupational therapy \nassessed the patient and recommend discharge to home with \ncontinued physical therapy which the patient and daughter \nagreed. \n\nOn HD2, the patient was doing well, afebrile with stable vital \nsigns. The patient was tolerating a regular diet, ambulating, \nvoiding without assistance, and pain was well controlled. The \npatient was discharged home with home ___ services. The patient \nreceived discharge teaching and follow-up instructions with \nunderstanding verbalized and agreement with the discharge plan.\n\n \nMedications on Admission:\nHCTZ 25', losartan 100', omeprazole 20'\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \n3. LevETIRAcetam 500 mg PO Q12H Duration: 7 Days \nRX *levetiracetam 500 mg 1 tablet(s) by mouth every twelve (12) \nhours Disp #*12 Tablet Refills:*0 \n4. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n5. Hydrochlorothiazide 25 mg PO DAILY \n6. Losartan Potassium 100 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute on chronic right and chronic appearing left subdural \nhematomas \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 Acute Care Surgery Service on ___nd found to have a bleed in your head. You had a \nrepeat CT scan that showed the bleed was stable. You were \nevaluated by the neurosurgery team who recommended that you take \na medication called Keppra to prevent seizures for the next 7 \ndays. You were seen and evaluated by physical and occupational \ntherapy who cleared you for discharge to home with home physical \ntherapy.\n\nYou are now doing better, tolerating a regular diet, and ready \nto be discharged to home to continue your recovery. \n\nPlease note the following discharge instructions: \n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. \n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\n===============================\nSigns and symptoms of a concussion may include:\n•Headache or a feeling of pressure in the head\n•Temporary loss of consciousness\n•Confusion or feeling as if in a fog\n•Amnesia surrounding the traumatic event\n•Dizziness or \"seeing stars\"\n•Ringing in the ears\n•Nausea\n•Vomiting\n•Slurred speech\n•Delayed response to questions\n•Appearing dazed\n•Fatigue\n\nYou may have some symptoms of concussions immediately. Others \nmay be delayed for hours or days after injury, such as:\n•Concentration and memory complaints\n•Irritability and other personality changes\n•Sensitivity to light and noise\n•Sleep disturbances\n•Psychological adjustment problems and depression\n•Disorders of taste and smell\n\n \nFollowup Instructions:\n___\n" ]

[ "S065X9A", "S0081XA", "W19XXXA", "Y92009", "R55", "I10", "M542", "R531" ]

[ "S065X9A: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter", "S0081XA: Abrasion of other part of head, initial encounter", "W19XXXA: Unspecified fall, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R55: Syncope and collapse", "I10: Essential (primary) hypertension", "M542: Cervicalgia", "R531: Weakness" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillinase\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain and bulge\n \nMajor Surgical or Invasive Procedure:\nVentral hernia repair\n\n \nHistory of Present Illness:\n___ year old female presenting with longstanding history of \nhaving a reducible hernia (at least ___ years). It caused no pain \nand she was always able to manually reduce it. Last month, she \npresented to the ED with abdominal\ndiscomfort and inability to reduce the hernia. She denies any \nsevere pain at the time, nausea, vomiting, skin changes, \nobstipation. She did note a decreased in frequency of her bowel \nmovements to every other day. \n\nA CT scan demonstrated incarcerated transverse colon within the\nventral hernia, with no evidence of obstruction or bowel\ncompromise. She opted for outpatient referral for surgical\nrepair. She has continued to have only mild abdominal discomfort\nand is unable to reduce the hernia. She is tolerating PO intake,\nhaving bowel movements, and otherwise feels well\n \nPast Medical History:\nHTN, ovarian dermoid cyst, fibroids\n \nSocial History:\n___\nFamily History:\nFather has CAD s/p heart transplant, multiple myeloma, and \nkidney cancer\n\n \nPhysical Exam:\nVS: T: 97.3 HR: 77 BP: 123/69 RR: 18 O2Sat: 95%RA\n GEN: AA&O x 3, NAD, calm, cooperative. \n HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI \n CHEST: Clear to auscultation bilaterally, (-) cyanosis. \n ABDOMEN: soft, diffuse tenderness, incision sites are c/d/i \ncovered with steri-strips. JP drain in place with scant \nserosanguineous drainage\n EXTREMITIES: Warm, well perfused, no edema \n \nPertinent Results:\n___ 02:44PM BLOOD Hct-41.8\n___ 05:45AM BLOOD Hct-41.0\n\n \nBrief Hospital Course:\nThe patient presented to pre-op on ___. Pt was evaluated by \nanaesthesia and was taken to the operating room for open ventral \nhernia repair with mesh. There were no adverse events in the \noperating room; please see the operative note for details. Pt \nwas extubated, taken to the PACU until stable, then transferred \nto the ward for observation. \nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a morphine PCA \nand IV dilaudid and then transitioned to oral Tylenol and ultram \nonce tolerating a diet. \nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \nGI/GU/FEN: The patient was initially kept NPO. On ___ the diet \nwas advanced sequentially to a Regular diet, which was well \ntolerated. Patient's intake and output were closely monitored\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nLisinopril 10 mg tablet\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Cyclobenzaprine 10 mg PO TID:PRN pain \nRX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day \nDisp #*30 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*20 Capsule Refills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*10 Tablet Refills:*0 \n5. Lisinopril 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ns/p ventral hernia repair\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nIt was a pleasure taking care of you here at the ___ \n___. You were admitted to our hospital for \nyour abdominal pain. You had a ventral hernia repair on ___. \nYou tolerated the procedure well and have recovered well from \nsome mild \npost-operative issues, that resolved prior to your discharge. \nYou are now ambulating, stooling, tolerating a regular diet, and \n\nyour pain is controlled by pain medications by mouth. You are \nnow ready to be discharged to home. Please follow the \nrecommendations below to ensure a speedy and uneventful \nrecovery. \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 \n\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- If needed, you may take a stool softener(such as Colace, one \ncapsule) or gentle laxative (such as milk of magnesia, 1 tbs) \ntwice a day. You can get both of these medicines without a \nprescription.\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 \nCyclobenzaprine\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 \n\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- You are being discharged with a JP drain. Please empty when \nhalfway full and record daily output.\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- You are going home on metoprolol 12.5mg every 12 hours. Please \n\ncontinue until follow up in clinic. (1 week following \ndischarge). \n\nWOUND CARE: \n-You may shower with any bandage strips that may be covering \nyour wound. Do not scrub and do not soak or swim, and pat the \nincision dry. If you have steri strips, they will fall off by \nthemselves in ___ weeks. If any are still on in two weeks and \nthe edges are curling up, you may carefully peel them off. *** \nYour staples will be removed by your surgeon at your follow up \nappointment. \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, \n\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\n-- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K436", "I10", "F17210" ]

[ "K436: Other and unspecified ventral hernia with obstruction, without gangrene", "I10: Essential (primary) hypertension", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "I10", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nibuprofen\n \nAttending: ___.\n \nChief Complaint:\nL thumb near complete amputation\n \nMajor Surgical or Invasive Procedure:\n___ ___:\n1. Irrigation and debridement down to necrotic bone.\n2. Primary IP joint arthrodesis with autograft.\n3. Repair of the radial digital nerve.\n4. Repair of the ulnar digital nerve.\n5. Repair of the ulnar digital artery with a 3 cm vein\n graft from the foot.\n6. Full thickness skin graft measuring 5x1.5cm\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old male with past medical history\nsignificant for HCV who presents from outside hospital with a\nnear complete amputation of his left thumb at the \ninterphalangeal\njoint. Patient states he was using a table saw at work and cut\nthrough his thumb. He denies any other injuries. He has no\nsensation distal to the cut.\n \nPast Medical History:\nHepatitis C virus \n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nNAD\nNo respiratory distress\nRRR\nsplint c/d/i, decreased sensation in the distal thumb, some \nsensation over dorsal nailbed, cap refill ___\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic Hand surgery team. The patient was \nfound to have L thumb near complete amputation and was admitted \nto the orthopedic surgery service. The patient was taken to the \noperating room on ___ for:\n1. Irrigation and debridement down to necrotic bone.\n2. Primary IP joint arthrodesis with autograft.\n3. Repair of the radial digital nerve.\n4. Repair of the ulnar digital nerve.\n5. Repair of the ulnar digital artery with a 3 cm vein\n graft from the foot.\n6. Full thickness skin graft measuring 5x1.5cm\n\n, which the patient tolerated well. For full details of the \nprocedure please see the separately dictated operative report. \nThe patient was taken from the OR to the PACU in stable \ncondition and was monitored for 24hours there w/ q1h NV exams to \nhis L thumb. After 24h he was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications \nincluding a supraclavicular nerve catheter. He was initially \nkept NPO in case there was a need to potentially take him back \nto the OR for a revision. He progressed to a regular diet and \noral medications by POD#2. The patient was given ___ \nantibiotics and anticoagulation per routine and antibiotics were \ncontinued while he was in house. The patient's home medications \nwere continued throughout this hospitalization. The patient was \ndischarged home with followup in 1 week. The ___ hospital \ncourse was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nNWB on the LUE, and will be discharged on ASA 162mg for DVT \nprophylaxis. The patient will follow up in Hand Clinic per \nroutine. A thorough discussion was had with the patient \nregarding the diagnosis and expected post-discharge course \nincluding reasons to call the office or return to the hospital, \nand all questions were answered. The patient was also given \nwritten instructions concerning precautionary instructions and \nthe appropriate follow-up care. The patient expressed readiness \nfor discharge.\n \nMedications on Admission:\nMethadone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Aspirin 162 mg PO DAILY \n3. Docusate Sodium 100 mg PO BID \n4. Gabapentin 300 mg PO TID \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \n6. Senna 8.6 mg PO BID \n7. Methadone (Concentrated Oral Solution) 10 mg/1 mL 63 mg PO \nDAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nL thumb near complete amputation\n\n \nDischarge Condition:\nStable\n\n \nDischarge Instructions:\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- Non weight bearing L upper extremity\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take Aspirin 162mg 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- Splint must be left on until follow up appointment unless \notherwise instructed\n- Do NOT get splint wet\n\nPhysical Therapy:\nNWB LUE\nTreatments Frequency:\nWound monitoring\nPin care:\nThe initial dressing may have Xeroform wrapped at the pin site \nwith surrounding gauze.\nOften, the Xeroform is used in the immediate post-op phase to \nallow for control of the bleeding. The Xeroform can be removed \n___ days after surgery.\nIf the pin sites are clean and dry, keep them open to air. If \nthey are still draining slightly, cover with clean dry gauze \nuntil draining stops.\nIf they need to be cleaned, use ___ strength Hydrogen Peroxide \nwith a Q-tip to the site.\n\nCall your surgeon's office with any question\n \nFollowup Instructions:\n___\n" ]

[ "S68522A", "B182", "W312XXA", "Y9269", "F1290" ]

[ "S68522A: Partial traumatic transphalangeal amputation of left thumb, initial encounter", "B182: Chronic viral hepatitis C", "W312XXA: Contact with powered woodworking and forming machines, initial encounter", "Y9269: Other specified industrial and construction area as the place of occurrence of the external cause", "F1290: Cannabis use, unspecified, uncomplicated" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nN/A\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old male with past medical history\nsignificant for ischemic cardiomyopathy with LVEF 35%, coronary\nartery disease ___ silent anterior MI of indeterminate age\n(presumed to be years ago), permanent AF w/ CHB ___ BiV-ICD\nimplant, mild-moderate MR, CKD, hyperlipidemia who presents to\nthe emergency department today with complaint of chest and\nepigastric pain. Pain occurred in middle of night and awoke\npatient from his sleep. Pain is associated with nausea, dyspnea,\nand diaphoresis. Denies any pain similar to this in the past.\nDenies any pain in his back, fevers, chills, or emesis. \n \nIn the ED initial vitals were: T 96.7, HR 57, BP 99/57, RR 18,\nSpO2 99% RA\n\n \nPast Medical History:\n(per chart, unable to confirm with patient):\nhypertension\nhyperlipidemia\nAFib\nCAD\nCHF\nhearing loss \nCORONARY ARTERY DISEASE \nGOUT \nHYPERLIPIDEMIA \nMEMORY LOSS \nPACEMAKER \nCHRONIC KIDNEY DISEASE \nHYPERTENSION \nISCHEMIC CARDIOMYOPATHY \n \nSocial History:\n___\nFamily History:\nNoncontributory to patient's presentation\n \nPhysical Exam:\nAdmission\n___ Temp: 97.7 PO BP: 108/67 R Lying HR: 60 RR: 16 O2\nsat: 96% O2 delivery: 2LNC \nGENERAL: lying in bed, interactive but hard of hearing. \nHEENT: PERRL. EOMI. No pallor or cyanosis of the oral mucosa. \nNECK: Supple. JVP 14-15cm\nCARDIAC: Normal S1, S2. No murmurs, rubs, or gallops. \nLUNGS: Bibasilar crackles and dullness at bases. \nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: 1+ bilateral edema. WWP. \nPULSES: 2+ peripheral pulses. \n\nDischarge\n___ 0710 Temp: 97.5 PO BP: 115/61 R Lying HR: 60 RR: 16 O2\nsat: 100% O2 delivery: Ra \n___ Total Intake: 1570ml PO Amt: 1570ml \n___ Total Output: 650ml Urine Amt: 650ml \n\nGENERAL: NAD\nHEENT: PERRL. MMM. \nNECK: JVP noted at the clavicle with patient at 30 degrees\nCARDIAC: Normal S1, S2. Grade ___ systolic murmur\nLUNGS: Clear to auscultation bilaterally \nEXTREMITIES: No ___ edema noted. Warm and well perfused. \nPULSES: 2+ peripheral pulses. \n\n \nPertinent Results:\nAdmission\n\n___ 04:05AM BLOOD WBC-7.3 RBC-3.39* Hgb-10.4* Hct-31.8* \nMCV-94 MCH-30.7 MCHC-32.7 RDW-14.5 RDWSD-49.7* Plt ___\n___ 04:05AM BLOOD Neuts-73.4* Lymphs-14.6* Monos-9.6 \nEos-1.6 Baso-0.4 Im ___ AbsNeut-5.36 AbsLymp-1.07* \nAbsMono-0.70 AbsEos-0.12 AbsBaso-0.03\n___ 04:05AM BLOOD ___ PTT-39.0* ___\n___ 04:05AM BLOOD Glucose-118* UreaN-34* Creat-1.8* Na-137 \nK-4.5 Cl-102 HCO3-20* AnGap-15\n___ 04:05AM BLOOD ALT-34 AST-48* CK(CPK)-153 AlkPhos-59 \nTotBili-0.6\n___ 04:05AM BLOOD CK-MB-6 ___\n___ 04:05AM BLOOD Albumin-4.0 Calcium-8.8 Phos-3.2\n___ 04:05AM BLOOD D-Dimer-2200*\n___ 07:40AM BLOOD TSH-2.2\n___ 07:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*\n___ 07:50AM BLOOD HBV VL-NOT DETECT\n___ 07:30AM BLOOD HCV Ab-NEG\n\nDischarge\n\n___ 07:50AM BLOOD WBC-6.2 RBC-3.24* Hgb-10.2* Hct-31.4* \nMCV-97 MCH-31.5 MCHC-32.5 RDW-15.6* RDWSD-55.2* Plt ___\n___ 07:50AM BLOOD Neuts-67.8 Lymphs-16.0* Monos-11.3 \nEos-3.9 Baso-0.2 Im ___ AbsNeut-4.21 AbsLymp-0.99* \nAbsMono-0.70 AbsEos-0.24 AbsBaso-0.01\n___ 07:50AM BLOOD Plt ___\n___ 07:50AM BLOOD Glucose-92 UreaN-68* Creat-2.5* Na-140 \nK-5.8* Cl-100 HCO3-27 AnGap-13\n___ 07:50AM BLOOD ALT-86* AST-63* LD(LDH)-285* AlkPhos-68 \nTotBili-0.5\n___ 06:50AM BLOOD ___\n___ 07:50AM BLOOD Calcium-9.1 Phos-5.4* Mg-2.7*\n___ 06:17AM BLOOD Hapto-154\n\nStudies\n___ RUQ US\n1. Cholelithiasis. \n2. Mild gallbladder wall edema is significantly improved \ncompared to recent CT \nfrom ___. No other evidence of cholecystitis. \n \n___ ECHO\nThe left atrial volume index is SEVERELY increased. The right \natrium is moderately enlarged. The\nestimated right atrial pressure is >15mmHg. There is normal left \nventricular wall thickness with a\nmoderately increased/dilated cavity. The apex is aneurysmal. A \nleft ventricular thrombus/mass cannot be\nexcluded. Overall left ventricular systolic function is severely \ndepressed secondary to akinesis of the\nanterior septum and apex with focal apical dyskinesis, severe \nhypokinesis with focal basal akinesis of\nthe inferior septum and inferior free wall, and hypokinesis of \nthe anterior ftree wall and lateral wall.\nQuantitative biplane left ventricular ejection fraction is 27 %. \nThe right ventricular free wall is\nhypertrophied. Dilated right ventricular cavity with low normal \nfree wall motion. Intrinsic right\nventricular systolic function is likely lower due to the \nseverity of tricuspid regurgitation. The aortic sinus\ndiameter is normal for gender with mildly dilated ascending \naorta. The aortic arch diameter is normal.\nThe aortic valve leaflets (3) are mildly thickened. There is no \naortic valve stenosis. There is moderate\n[2+] aortic regurgitation. The mitral valve leaflets are mildly \nthickened with no mitral valve prolapse.\nThere is moderate to severe [3+] mitral regurgitation. The \ntricuspid valve leaflets appear structurally\nnormal. There is moderate to severe [3+] tricuspid \nregurgitation. Due to acoustic shadowing, the severity\nof tricuspid regurgitation may be UNDERestimated. There is \nmild-moderate pulmonary artery systolic\nhypetension. In the setting of at least moderate to severe \ntricuspid regurgitation, the pulmonary artery\nsystolic pressure may be UNDERestimated. There is no pericardial \neffusion. A left pleural effusion is\npresent.\nCompared with the prior TTE ___, left ventricular \nejection fraction is further reduced, with\nincreased mitral and tricuspid regurgitation.\nEMR\n\n___ CTA\n1. 7 mm penetrating plaque in the distal portion of the aortic \narch, without \nprior imaging for 2 studies acuity. A short-segment focal \ndissection in the \nmid aortic arch, appears chronic. \n2. Signs of heart failure with cardiomegaly, pulmonary edema, \nbilateral \npleural effusions greater on the right, as well as \ngallbladder-wall edema. \n3. Infrarenal aortic aneurysm and left common iliac aneurysm. \nPlease note \nthat the prior study was done without IV contrast however based \non wall \ncalcifications in overall diameter it is grossly unchanged. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with PMH significant for \nischemic cardiomyopathy (LVEF 27% on ___ ECHO), CAD ___ \nsilent anterior MI of indeterminate age), permanent AF w/ CHB \n___ BiV-ICD implant (on apixaban), CKD, hyperlipidemia who \npresented for chest/epigastric pain. He was found to have \nelevated troponins and decompensated heart failure. He was \nmedically treated for NSTEMI with heparin drip and continuation \nof home medications including aspirin, statin, and beta blocker. \nHe was diuresed with Lasix drip. He was also managed for ___ \nduring this time, which was improving at time of discharge. \nWhile inpatient he had a reaction to likely hydralazine that \nresulted in a morbilliform drug rash. The drug was discontinued \nand his rash improved. Corresponding to that rash he had \nelevated LFTs that were downtrending by time of admission. He \nwas found to have isolated hepatitis B antibody. \n\n# CORONARIES: CAD ___ silent anterior MI\n# PUMP: HFrEF (EF 35%)\n# RHYTHM: permanent AF and CHB ___ BiV-ICD\n\nACTIVE ISSUES: \n============== \n#Acute decompensated HFrEF (EF 35%)\n#Ischemic Cardiomyopathy\n#LBBB ___ CRT-D \nThe patient presented with clinical evidence of volume overload \nwith rales, elevated JVP, mild pulmonary edema on CXR, and \ncongestive gallbladder and ascending colon on CT. BNP >50000. \nDiuresed on a Lasix drip at 10cc/hr. \n- Admission weight 51 kg, discharge dry weight 45.4 kg\n- Preload: 10 mg furosemide daily\n- Afterload: Imdur 90 mg daily (previous intolerance to ACE + he \nhas hyperkalemia) \n- Neurohormonal blockade: metoprolol 50 mg XL\n- Digoxin was discontinued w/ supratherapeutic level, worsening \nrenal failure, and stable cardiac function after diuresis \n\n#NSTEMI\n#CAD with prior silent MI\nInitial trop elevated with peak to 2.60, without clear new ECG \nchanges. Unclear if initial presentation was Type 1 NSTEMI \nversus demand in the setting of severe decompensated CHF. He \nreceived 48 hour heparin drip, aspirin, and rosuvastatin. After \ndiscussion with the patient and family, it was determined that \nhe did not desire any invasive intervention such as cardiac \ncatheterization. He will continue on aspirin, rosuvastatin 20 \nmg, and metoprolol succinate 50 mg qD at home. \n\n___ on CKD\nBaseline appears to be ___ and was at baseline at \npresentation, but increased to a peak of 3.4 with diuresis. It \nwas not clear the etiology of his ___, but possibly prerenal in \nthe setting of his low flow state. No urinalysis sediment \nevidence of ATN. No post-renal obstruction. Renal function was \nimproving at the time of discharge, with creatinine down to 2.5. \nWe did suspend apixaban for some time, but it was restarted once \nrenal function improved. \n\n#Hyperkalemia\nPersistently hyperkalemic during the admission. Likely a \ncombination of both diet and acute renal failure. Patient was \nfound to have pile of bananas in his room. He likes eating them \nbecause they are soft. Patient and patient's family education on \nlow potassium foods. He was not discharged on any potassium \nelevating agents at the time of discharge. His levels will need \nto be followed closely as ___ outpatient. \n\n# Transaminitis\nMild transaminitis of unclear etiology. Initially thought to be\ndue to vascular congestion, but has remained elevated even after\ndiuresis. RUQ without evidence for cholecystitis. Possibly \nhypersensitivity\nto hydralazine, as LFTs increased after drug was introduced. Was \nalso Hep B core Ig positive without Ag or Ab positive, which is \nnonspecific. LFTs were downtrending at time of discharge. \nHepatitis B viral load pending at time of discharge. He should \nreceive a fibroscan to follow up for possible cirrhosis \nsecondary to possible chronic disease. \n\n# Morbilliform Drug Eruption\nPatient with erythematous itchy macular rash that started on \nback and\nthighs and since spread to abdomen anteriorly. Derm consulted, \nbelieves to be drug eruption, but unclear which drug. Patient \nstarted on hydralazine, furosemide, isosorbide mononitrite at \nthe same time. Hydralazine was held at is was believed to be \nlikely culprit, and rash improved. He was started on 14 day \ncourse of betamethasone steroid cream, per derm.\n\n#Ulceration of aortic arch\n#Aortic dissection\nFound on CT in ED. Cardiac surgery was consulted and recommended \nmedical management with blood pressure control with systolic \nblood pressures < 120 mmHg. This should be continued as ___ \noutpatient. \n\n# Anemia\nStable between ___ without any further acute drops. No \nevidence for\nhemolysis or active bleeding at this time. \n\nCHRONIC ISSUES:\n===============\n#AF ___ BiV-ICD: \n Patient continued home metoprolol, as above, and will be able \nto continue apixaban for anticoagulation. He has a BiV-ICD in \nplace. \n\nTransitional Issues:\n====================\n[ ] Persistent hyperkalemia while inpatient, please follow at \nnext appointment (lab slip provided on discharge). \n[ ] Patient with elevated transaminases during admission. \nImproving on discharge. Please follow with repeat LFTs at PCP \n___\n[ ] Follow up hepatitis B viral load (to r/o active Hep B \ninfection). Currently pending in OMR. \n[ ] Due to prior hepatitis B infection, patient may benefit from \nfibroscan. \n[ ] Follow weights to ensure proper diuretic dose on furosemide \n10 mg qD\n[ ] Follow blood pressures to ensure adequate afterload \nreduction (ideally systolic < 120 mmHg), previously intolerant \nto ACE inhibitors (and hyperkalemic) thus not initiated on \ndischarge \n[ ] Discuss with patient whether or not to inactivate ICD given \nDNR/DNI code status\n\nCr: 2.5\nWt: 45.4 kg\nCODE STATUS: DNR/DNI\nCONTACT: \n___ \nRelationship: Daughter \nPhone number: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. Rosuvastatin Calcium 20 mg PO QPM \n4. ipratropium bromide 0.03 % nasal Other \n5. Loratadine 10 mg PO DAILY \n6. Mirtazapine 45 mg PO QHS \n7. Digoxin 0.25 mg PO DAILY \n8. Colchicine 0.6 mg PO TID:PRN joint pain \n9. Apixaban 2.5 mg PO BID \n10. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Betamethasone Dipro 0.05% Oint 1 Appl TP BID \nRX *betamethasone dipropionate 0.05 % Apply to affected areas \n(not on face, groin, axilla) twice a day Refills:*0 \n2. Furosemide 10 mg PO DAILY \nRX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth once a \nday Disp #*15 Tablet Refills:*3 \n3. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY \nRX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth once a day \nDisp #*90 Tablet Refills:*3 \n4. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals [Multi-Vitamin HP/Minerals] 1 \ncapsule(s) by mouth once a day Disp #*30 Capsule Refills:*12 \n5. Allopurinol ___ mg PO DAILY \nRX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n6. Apixaban 2.5 mg PO BID \nRX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n7. Aspirin 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \nonce a day Disp #*30 Tablet Refills:*0 \n8. ipratropium bromide 0.03 % nasal Other \nRX *ipratropium bromide 21 mcg (0.03 %) 1 spray nasal once a day \nDisp #*1 Spray Refills:*0 \n9. Loratadine 10 mg PO DAILY \nRX *loratadine [Claritin] 10 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n10. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n11. Mirtazapine 45 mg PO QHS \nRX *mirtazapine 45 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n12. Rosuvastatin Calcium 20 mg PO QPM \nRX *rosuvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n13.Outpatient Lab Work\nICD 10 N17.9: acute kidney injury \nR74.0 transaminitis\n\nPlease obtain CMP, lytes, and LFTs (ALT/ALT/LDH/TBili/Albumin) \nand provide to outpatient PCP ___ \n___ Fax ___. \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: Acute Decompensated Systolic Heart Failure\nNon-ST Elevation MI\n\nSecondary:\nAcute Kidney Injury\nTransaminitis \nHyperkalemia \nAtrial fibrillation \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr ___\n\n You were admitted to ___ \nbecause you had a small heart attack. You had extra fluid that \ncaused weight gain. This is called heart failure. \n\nWhile you were here we gave you a medication to help you urinate \nmore and remove fluid. \n\nWhat to do when you go home: \n\n* Please weigh yourself every daily. Do this in the morning \nafter you go to the bathroom and before you get dressed. \n* If your weight goes up by more than 3 lbs in 1 day or more \nthan 5 lbs in 3 days, please call your heart doctor or your \nprimary care doctor and alert them to this change. \n* We have made changes to your medication list, so please make \nsure to take your medications as listed below \n* You will also need to have close follow up with your heart \ndoctor and your primary care doctor. \n\n It was a pleasure to take care of you. We wish you the best \nwith your health! \n\n Your ___ Cardiac Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I214", "I5023", "I7101", "I130", "N179", "I252", "I2510", "I5084", "N189", "R627", "E875", "I482", "Z7901", "L270", "I255", "G629", "D649", "R7989", "Z66", "Z95810", "T465X5A", "Y92230" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I5023: Acute on chronic systolic (congestive) heart failure", "I7101: Dissection of thoracic aorta", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N179: Acute kidney failure, unspecified", "I252: Old myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I5084: End stage heart failure", "N189: Chronic kidney disease, unspecified", "R627: Adult failure to thrive", "E875: Hyperkalemia", "I482: Chronic atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "I255: Ischemic cardiomyopathy", "G629: Polyneuropathy, unspecified", "D649: Anemia, unspecified", "R7989: Other specified abnormal findings of blood chemistry", "Z66: Do not resuscitate", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "T465X5A: Adverse effect of other antihypertensive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "I130", "N179", "I252", "I2510", "N189", "Z7901", "D649", "Z66", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath \n \nMajor Surgical or Invasive Procedure:\nCoronary angiogram ___\n \nHistory of Present Illness:\n___ w/ hx of HLD, CAD c/b remote anteroseptal MI, ischemic \ncardiomyopathy HFrEF (EF=27%) mild/mod MR/TR, CKD, and permanent \nafib w/ CHB s/p BiV ICD who presented with respiratory distress, \nfound to be in cardiogenic shock c/b possible demand STEMI.\n\nPer report from family and EMS, patient has been feeling weak \nand short of breath progressively for the last 2 days. EMS was \neventually called on evening of presentation due to worsening \ndyspnea. EMS evaluation notable for RR between 40 and 60 \nbreaths/min, and mild hypotension. He was placed on BiPAP prior\nto arrival to the ___ ED.\n\nIn the ED, initial vitals were T 97.6, BP 99/66, RR 37, O2 96% \non BiPAP. Exam notable for tachypnea and diffuse bibasilar \npulmonary wheezes, though no peripheral edema. \n\nLabs notable for: \n- K 5.7, BUN/Cr 59/3.3\n- Trop 0.15\n- proBNP 28,546\n- VBG pH 7.27, pCO2 45, lactate 3.6\n\nHe was was given 20mg IV Lasix, 150mg IV amiodarone bolus \nfollowed by gtt, 600mg PR ASA, and 2mg IV Ca gluconate.\n\nInitial EKG showed afib/flutter w/ V-paced complexes HR 115. \nHowever subsequent EKGs over the course of 1hr showed the \ndevelopment SVT w/ ST elevations in anteroseptal leads followed \nby episodes of nonsustained polymorphic VT requiring ICD shocks.\n\nCXR showed mild pulmonary vascular congestion and edema.\n\nThe pt was intubated shortly after arrival for worsening \nrespiratory status. He also became progressively hypotensive to \n69/52. A code STEMI was called given the EKGs findings as \ndescribed. \n\nHe was taken to the cath lab where coronary angiography revealed\n100% ostial LAD and distal LM of unclear chronicity, with R to L\ncollaterals. PCI was deferred given the complexity of lesions. A\nswan was placed via R fem vein revealing for RA 13, RV 52/2, PA\n___ (34), PCWP 24, CI 1.7, CO 3.0. An impella was placed via R\nfem artery for mechanical support. \n \nOn arrival to the CCU, the pt was intubated and sedated. \n\n \nPast Medical History:\nCardiac History: \n1. Ischemic cardiomyopathy (LVEF 27%)\n2. Coronary artery disease s/p anterior MI\n3. Permanent atrial fibrillation, complete heart block, s/p\nBiV-ICD\n4. Mild-moderate MR\n5. HFrEF (EF 27% as of ___\n \nOther PMH: \n1. Chronic kidney disease \n2. Dyslipidemia\n3. Gout\n \nSocial History:\n___\nFamily History:\nUnable to obtain given intubation\n \nPhysical Exam:\nADMISSION EXAM\n==============\nVS: T 97.5, HR 78, BP ___ (91), RR 24, O2 100% on 50% FiO2\nventilated \nGENERAL: Intubated, sedated \nNECK: Supple, JVP\nCARDIAC: RRR, S1/S2, ___ holosystolic murmur, prominent PMI\nLUNGS: CTAB anteriorly\nABDOMEN: Soft, non-tender, non-distended, BS+\nEXTREMITIES: Warm, well perfused, no edema, R fem/arterial \naccess\nsites cleanly dressed w/o surrounding hematoma or induration\nSKIN: No significant lesions or rashes \nPULSES: Distal pulses palpable and symmetric \nNEURO: Sedated\n\nDISCHARGE EXAM\n==============\nPatient expired\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 01:05AM BLOOD WBC-7.4 RBC-4.12* Hgb-12.2* Hct-39.8* \nMCV-97 MCH-29.6 MCHC-30.7* RDW-14.6 RDWSD-51.8* Plt Ct-88*\n___ 01:05AM BLOOD Neuts-75.6* Lymphs-14.2* Monos-8.7 \nEos-0.8* Baso-0.3 Im ___ AbsNeut-5.58 AbsLymp-1.05* \nAbsMono-0.64 AbsEos-0.06 AbsBaso-0.02\n___ 01:05AM BLOOD ___ PTT-30.3 ___\n___ 01:05AM BLOOD Glucose-196* UreaN-59* Creat-3.3* Na-142 \nK-9.4* Cl-110* HCO3-17* AnGap-15\n___ 01:05AM BLOOD ALT-<5 AST-105* AlkPhos-60 TotBili-0.4\n___ 01:05AM BLOOD ___\n___ 01:05AM BLOOD cTropnT-0.15*\n___ 01:05AM BLOOD Albumin-4.0 Calcium-8.4 Phos-5.4* Mg-2.6\n___ 05:43AM BLOOD Hapto-103\n___ 01:11AM BLOOD ___ pO2-37* pCO2-45 pH-7.27* \ncalTCO2-22 Base XS--6 Comment-GREEN TOP\n___ 03:37AM BLOOD Glucose-170* Lactate-2.2* Creat-3.2* \nNa-142 K-5.3 Cl-115*\n\nREPORTS\n=======\nCHEST (PORTABLE AP) Study Date of ___ \n1. Mild pulmonary vascular congestion and edema. \n2. Stable cardiomegaly. \n\nCHEST (PORTABLE AP) Study Date of ___ \nThe endotracheal tube terminates 35 mm above the carina. The \nenteric tube \nterminates within the proximal stomach in the side-port of the \nprojects within the proximal stomach. The tip of the Swan-Ganz \ncatheter projects over the right hilum. The Impella projects \nover the aorta and left ventricle. The left-sided pacemaker \nterminates in the right ventricle. \n \nThere cardiomediastinal silhouette is moderately enlarged. \nThere are mild \nbibasilar opacifications. No pneumothorax. Trace left pleural \neffusion. \nVisualized osseous structures unchanged. \n\nCORONARY ANGIOGRAPHY ___\nFINDINGS:\nElevated left heart filling pressure.\n• Cardiogenic shock.\n• Mild pulmonary hypertension.\n• Three vessel coronary artery disease.\n• Three vessel epicardial CAD suggestive of chronic total \nocclusion in the LAD vs. subtotal chronic occlusion (functional \nCTO) with acute occlusion. Collaterals from the RPDA are highly \ndeveloped and presentation was cardiogenic shock and not chest \npain/ST elevations (first ECG) and there is evidence of old \nanterior MI on TTE and old ECGs. There is a proximal RCA\nstenosis and mild epicardial disease in the LCx. Cardiogenic \nshock now s/p succesful Impella CP placement.\n\nRecommendations\n• Family meeting with goals of care including long-term \ndialysis, rehab and revascularization vs. medical management or \neven comfort care. CABG vs. high risk PCI evaluation if \ncompatible with goals of care. Impella care per protocolCycle \nTrop/MBTripple therapy (heparin,ASA/Ticag)\nfor now.\n\nTTE ___\nThe right atrial pressure could not be estimated. There is \nsuboptimal image quality to assess regional left ventricular \nfunction. The visually estimated left ventricular ejection \nfraction is ___. The aortic\nvalve leaflets (3) are mildly thickened. The Impella catheter \ninlet is positioned close to aortic valve. There is mitral \nregurgitation (cannot be qualified). Due to acoustic shadowing, \nthe severity of mitral regurgitation could be UNDERestimated. \nThere is tricuspid regurgitation present (could not be \nqualified). Due to acoustic shadowing, the severity of tricuspid \nregurgitation may be UNDERestimated. There is a trivial \npericardial effusion.\nIMPRESSION: Focused study. The Impella catheter is positioned \ntoo close to the aortic valve. Severely depressed left \nventricular systolic function.\n\nTTE ___\nThere is SEVERE global left ventricular hypokinesis. The \nvisually estimated left ventricular ejection fraction is ___. \nThe Impella catheter is correctly positioned with respect to the \naortic valve. There\nis mitral regurgitation (cannot be qualified). There is mild \npulmonary artery systolic hypertension.\nIMPRESSION: Focused study/limited views. Correctly positioned \nImpella catheter. Depressed left ventricular systolic function. \nMitral regurgitation present (not quantified).\n \nBrief Hospital Course:\nSUMMARY:\n========\n___ w/ hx of HLD, CAD c/b remote anteroseptal MI, ischemic \ncardiomyopathy HFrEF (EF=27%) mild/mod MR/TR, CKD, and permanent \nafib w/ CHB s/p BiV ICD who presented with respiratory distress, \nfound to be in cardiogenic shock c/b possible demand STEMI. He \nwas intubated shortly after arrival to the ED for respiratory \ndistress. While he was in the ED, his rhythm changed from sinus \nto a narrow complex tachycardia and ST segment elevations \ndeveloped over the course of an hour on serial EKGs. He also had \npolymorphic VT during this time for which amiodarone drip was \ninitiated. Code STEMI was called, he was given ASA and \nticagrelor load and he was taken to the cath lab where he was \nfound to have 95% distal LM disease, 100% ___ LAD stenosis with \ncollateralization from RCA distribution, 40% ___, and 70% \nostial RCA disease. No intervention was performed due to \ncomplexity and unclear goals of care; and impella CP was placed \nthrough right femoral access while heparin drip initiated; a \nSwan-ganz catheter was placed in the R femoral vein, and later \non an A-line was placed in the right arm. Goals of care \ndiscussion was held, as the patient was previously DNR/DNI and \nPCI would put him at high risk for needing dialysis given his \nCKD; there was concern this would not be consistent with his \ngoals as someone who preferred to avoid being in the hospital. \nThe recovery process would additionally likely necessitate a \nlong rehab stint. Meanwhile, he was treated broadly with \nvancomycin and Cefepime for fever, likely secondary to lung \nsource. Due to his Impella he developed complications of \nhemolysis and hyperkalemia, so was temporized with IV insulin \nand dextrose. He was not making significant urine so Lasix was a \npoor option and dialysis was not within goals of care. Repeat \nfamily meeting was held discussing CPR, and it was decided that \nthis would be against the patient's wishes. At that time, \npatient was made DNR and ICD was disabled. HCP wished to \ncontinue with medical management including impella and \nventilator support until family was able to visit the patient. \nOvernight on ___, patient had increasingly downtrending MAPs \nand began alarming for low flow on the impella. Exam at that \npoint in time was notable for R surgical pupil, L fixed dilated \npupil, no corneal reflex, no gag or cough reflex, no withdraw to \npainful stimuli. Cardiac exam with very faint S1/S2 with weak \ncarotid pulses. Patient was triggering spontaneous breaths on \nventilator. Upon discussion with family at that time, the \npreference was to wait to discontinue life support until arrival \nof the daughter. After that conversation, patient then developed \nloss of all arterial pulsations on A-line and lost his pulse on \nexam. He also was noted to be asystolic on telemetry so all \nsupportive measures were withdrawn. He was pronounced disease at \n0405 on ___. Family members were immediately contacted and \ncame to bedside. His HCP declined autopsy. \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Mirtazapine 45 mg PO QHS \n2. Allopurinol ___ mg PO DAILY \n3. Colchicine 0.6 mg PO TID:PRN joint pain \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Apixaban 2.5 mg PO BID \n6. Rosuvastatin Calcium 20 mg PO QPM \n7. Furosemide 10 mg PO DAILY \n8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. Loratadine 10 mg PO DAILY \n11. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Medications:\nPatient deceased \n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPatient deceased\n \nDischarge Condition:\nPatient deceased\n \nDischarge Instructions:\nPatient deceased\n \nFollowup Instructions:\n___\n" ]

[ "I2109", "J9601", "I5023", "I442", "R570", "I2510", "I255", "I482", "Z7901", "N189", "E785", "M109", "N400", "M1990", "Z66", "E875", "D649", "R34", "I252", "I081", "Z4502", "I2720", "Z781" ]

[ "I2109: ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall", "J9601: Acute respiratory failure with hypoxia", "I5023: Acute on chronic systolic (congestive) heart failure", "I442: Atrioventricular block, complete", "R570: Cardiogenic shock", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I255: Ischemic cardiomyopathy", "I482: Chronic atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "N189: Chronic kidney disease, unspecified", "E785: Hyperlipidemia, unspecified", "M109: Gout, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M1990: Unspecified osteoarthritis, unspecified site", "Z66: Do not resuscitate", "E875: Hyperkalemia", "D649: Anemia, unspecified", "R34: Anuria and oliguria", "I252: Old myocardial infarction", "I081: Rheumatic disorders of both mitral and tricuspid valves", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator", "I2720: Pulmonary hypertension, unspecified", "Z781: Physical restraint status" ]

[ "J9601", "I2510", "Z7901", "N189", "E785", "M109", "N400", "Z66", "D649", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nacute encephalopathy\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr ___ is a ___ year-old male with a past medical history of \nhyperlipidemia, CAD, anterior MI, ischemic cardiomyopathy with \nLVEF 35%, mild- moderate MR, CKD,\nand AF with CHB s/p BiVICD implant, here with failure to thrive, \nlightheadedness, and mild confusion. History is very limited \ndue to patient being deaf and confused. Pt is also ___ \nspeaking however does seem to understand some ___ and is \nable to read ___ when I write down questions. I was also \nunable to reach family members by phone. Per ED records, pt has \nhad poor PO intake for weeks, however in the past week it has \ndecreased even more and he has had bilious small amounts of \nvomit in the AMs. Denies fevers, chills, sweats, cough, \nshortness of breath. Endorses incontinence x about 1 week. \nPatient's daughter also endorses mild confusion. In the ED, \npatient was able to recognize daughters and knows his own name, \nhowever was unsure what date it was - which is not his baseline. \n\n\nIn the ED, initial vitals were: 98.6 60 96/51 16 100% RA. Labs \nwere notable for trop of 0.15--)0.13-->>0.11, LDH 373, Na 130, \ncreatinine 3.4, bland UA, plts 48. CT head showed no acute \nprocess, CXR was nl. Pt was given 2 L NS. \n\nOn the floor, pt states that he is tired but is unable to answer \nany other questions, I think due to a combination of confusion \nand difficulty hearing. When I write my questions on paper, he \nreads the first part however then becomes confused. He states \nhe is not on any pain. Provides phone numbers for his \ngranddaughter however one of them is not a valid number.\n\nReview of systems: unable to obtain due to confusion and HOH\n\n \nPast Medical History:\n(per chart, unable to confirm with patient):\nhypertension\nhyperlipidemia\nAFib\nCAD\nCHF\nhearing loss \nCORONARY ARTERY DISEASE \nGOUT \nHYPERLIPIDEMIA \nMEMORY LOSS \nPACEMAKER \nCHRONIC KIDNEY DISEASE \nHYPERTENSION \nISCHEMIC CARDIOMYOPATHY \n \nSocial History:\n___\nFamily History:\nunknown\n\n \nPhysical Exam:\n97.8 116 / 56 60 16 99 Ra\nConstitutional: Alert, confused, NAD\nEYES: Sclera anicteric, EOMI, PERRL\nENT: MMD, oropharynx clear,\nNeck: Supple, no LAD\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nRespiratory: Clear to auscultation bilaterally, no wheezes, \nrales, rhonchi\nGI: Soft, non-tender, non-distended, bowel sounds present, no \norganomegaly, no rebound or guarding\nGU: No foley\nEXT: Warm, well perfused, no CCE\nNEURO: unable to assess, responds to questioning but answers are \nunclear, moves all extermities, CNS grossly intact\nSKIN: no rashes or lesions\n \nPertinent Results:\n___ 06:30PM LD(LDH)-373* TOT BILI-0.6\n___ 06:30PM cTropnT-0.11*\n___ 06:30PM CK-MB-6 cTropnT-0.13*\n___ 06:30PM HAPTOGLOB-241*\n___ 02:14PM ___ PTT-34.6 ___\n___ 01:30PM URINE HOURS-RANDOM\n___ 01:30PM URINE UHOLD-HOLD\n___ 01:30PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 01:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 01:30PM URINE RBC-4* WBC-<1 BACTERIA-FEW YEAST-NONE \nEPI-0\n___ 01:30PM URINE AMORPH-RARE\n___ 01:30PM URINE MUCOUS-RARE\n___ 12:45PM GLUCOSE-99 UREA N-140* CREAT-3.4*# \nSODIUM-130* POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-13* ANION \nGAP-25*\n___ 12:45PM estGFR-Using this\n___ 12:45PM ALT(SGPT)-29 AST(SGOT)-44* CK(CPK)-248 ALK \nPHOS-71 TOT BILI-0.6\n___ 12:45PM LIPASE-132*\n___ 12:45PM cTropnT-0.15*\n___ 12:45PM CK-MB-6\n___ 12:45PM ALBUMIN-4.1\n___ 12:45PM WBC-7.2 RBC-3.78* HGB-11.3* HCT-32.3* MCV-85# \nMCH-29.9 MCHC-35.0 RDW-15.1 RDWSD-46.9*\n___ 12:45PM NEUTS-74.0* LYMPHS-8.5* MONOS-16.3* EOS-0.4* \nBASOS-0.1 IM ___ AbsNeut-5.33 AbsLymp-0.61* AbsMono-1.17* \nAbsEos-0.03* AbsBaso-0.01\n___ 12:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ \nMACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ \nSCHISTOCY-OCCASIONAL BURR-1+ ELLIPTOCY-OCCASIONAL\n___ 12:45PM PLT COUNT-48*#\n___ 12:45PM RET AUT-1.0 ABS RET-0.04\n\nMICRO: urine cxs pending\n\nSTUDIES:\nCT head: No acute intracranial process.\nCXR: no acute process\n\nEKG: paced rhythm with underlying afib, TWI in V1, V2, LVH, LAD\n\n___ 06:25AM BLOOD WBC-5.7 RBC-3.40* Hgb-10.2* Hct-28.6* \nMCV-84 MCH-30.0 MCHC-35.7 RDW-15.1 RDWSD-46.4* Plt Ct-47*\n___ 06:25AM BLOOD Plt Ct-47*\n___ 06:25AM BLOOD ___\n___ 06:25AM BLOOD Glucose-137* UreaN-110* Creat-3.0* Na-137 \nK-3.2* Cl-106 HCO3-12* AnGap-20\n___ 06:30PM BLOOD cTropnT-0.11*\n___ 06:30PM BLOOD CK-MB-6 cTropnT-0.13*\n___ 12:45PM BLOOD cTropnT-0.15*\n___ 06:25AM BLOOD TSH-1.3\n___ 06:25AM BLOOD calTIBC-241* VitB12-862 Folate->20 \nFerritn-706* TRF-185*\n___ 06:30PM BLOOD Hapto-241*\n___ 06:25AM BLOOD Digoxin-1.6\n___ 06:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 06:25AM BLOOD COPPER (SERUM)-PND\n\nC \nIMPRESSION: \n \n \n1. Fusiform and saccular aneurysmal dilatation of the infrarenal \nabdominal \naorta measuring up to 3.9 cm extending into both common iliac \narteries and the \nright external iliac artery. Linear areas of calcification \nwithin the \naneurysm sac at the level of the third portion of the duodenum \nis suspicious \nfor dissection which is limited in the absence of intravenous \ncontrast. The \naneurysm sac exerts mass effect on the third portion of the \nduodenum which is \ndecompressed. There is no upstream dilatation of the duodenum to \nsuggest \nobstruction. The distance between the anterior aspect of the \naortic aneurysm \nto the anterior wall peritoneal is approximately 1.5 cm. \n2. Colonic diverticulosis without CT evidence of acute \ndiverticulitis. \n3. Cholelithiasis without CT evidence of acute cholecystitis. \n4. Asymmetric sclerosis and narrowing of the right SI joint \nlikely reflecting \nprior sacroiliitis. \n5. Mild-to-moderate cardiomegaly with at least right and \npossibly biatrial \nenlargement. Stable size of a known left ventricular aneurysm \nwith increased \ninterval calcifications since ___. \n6. Two 2 mm pulmonary micro nodules in the right lung base. In a \npatient with \nno known risk factors for lung cancer, these are presumed to be \nbenign and no \nfollow-up is recommended. In a patient with risk factors for \nlung cancer, ___ \nyear follow-up is recommended. \nT abdomen/pelvis:\n\n \nBrief Hospital Course:\n___ y.o male with h.o HL, CAD, MI, ___ with EF 35%, CKD,\nafib with CHF s/p biVICD who presented with weight loss,\ninability to tolerate PO, confusion, weakness found to have\nacidosis and ___ on CKD. \n\n#weight loss\n#inability to tolerate PO\n#nausea with vomiting\n#severe protein calorie malnutrition\nSymptoms are concerning for underlying malignancy. Pt with signs\nof dehydration and weight loss. No apparent prior w/u for these\nsymptoms and pt has yet to see PCP. Unknown if prior \ncolonoscopy.\nCT scan without revealing cause. Nutrition consulted and pt \ngiven IVF. \n\nHowever, pt and family after much discussion with ___ \n___ present and again with pt's PCP on speaker phone, pt \nand family elected to leave AMA accepting risks of dehydration, \nmalnutrition, undiagnosed illness, cancer, electrolyte abn, \nworsening renal function, risk of falls and injury due to \nweakness. \n\nPt advised to f/u with PCP ___. \n\n#acute encephalopathy-likely due to metabolic derangements. Head\nCT without acute process. Tox screen neg. TSH, LFts, b12/folate\nWNL. IVF given. Held mirtazapine.\n\n___ on CKD, baseline appears to be Cr 2.4-2.5. Likely prerenal\ndue to above. Pt given some IVF. \n\n#thrombocytopenia-b12/folate WNL. Iron studies c/w ACD.\nHaptoglobin elevated, less likely hemolysis. Outpt f/u given AMA \ndischarge.\n\n#anemia-most likely AOCD. Outpt f/u given AMA discharge. \n\n#hyponatremia-improved\n\n#AGMA-likely due to ___. Lactate WNL. Outpt f /u given AMA \ndischarge. \n\n#HTN, HL, afib, CAD, chronic systolic CHF\n-continued home meds (BB, statin, held dig and eliquis given\ntpenia. Currently hypovolemic.\n#gout-no e/o acute flare. Continue appropriately dosed\nallopurinol. HOld colchicine given CKD. \n\nPt was never able to see ___ as he left AMA before consult. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 2.5 mg PO BID \n3. Colchicine 0.6 mg PO TID:PRN joint pain \n4. Digoxin 0.25 mg PO DAILY \n5. ipratropium bromide 0.03 % nasal Other \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Mirtazapine 30 mg PO QHS \n8. Rosuvastatin Calcium 20 mg PO QPM \n9. Aspirin 81 mg PO DAILY \n10. Loratadine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO EVERY OTHER DAY \n2. ipratropium bromide 0.03 % nasal Other \n3. Loratadine 10 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Rosuvastatin Calcium 20 mg PO QPM \n6. HELD- Apixaban 2.5 mg PO BID This medication was held. Do \nnot restart Apixaban until you discuss with your doctor due to \nyour low platlet count \n7. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until you discuss with your doctor due to \nyour low platelet count \n8. HELD- Colchicine 0.6 mg PO TID:PRN joint pain This \nmedication was held. Do not restart Colchicine until you discuss \nwith your doctor \n9. HELD- Digoxin 0.25 mg PO DAILY This medication was held. Do \nnot restart Digoxin until you discuss with your doctor\n10. HELD- Mirtazapine 30 mg PO QHS This medication was held. Do \nnot restart Mirtazapine until you discuss with your doctor\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nweakness\ndehydration\nnausea with vomiting\nweight loss \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nYou were admitted for monitoring and further work up of weight \nloss, nausea, vomiting, dehydration, kidney failure and \nweakness. For this, you had lab testing and were given IV fluids \nand had a CT scan. Due to the unexplained dehydration and weight \nloss as well as weakness, renal failure, electrolyte \nabnormalities, and concern for falls and fractures due to \nweakness we recommended that you stay inpatient for further work \nup and monitoring but you declined. Risks of leaving against \nmedical advice include infection, worsened renal failure, \nelectrolyte abnormalities, undiagnosed cancer and including \ndeath. We recommend that you see your PCP ___ for ongoing care. \n\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "N179", "G9341", "E43", "E872", "D696", "I130", "I4891", "I5022", "E871", "Z681", "E860", "E785", "I2510", "I252", "I255", "N189", "M109", "R627", "Z7902", "D638" ]

[ "N179: Acute kidney failure, unspecified", "G9341: Metabolic encephalopathy", "E43: Unspecified severe protein-calorie malnutrition", "E872: Acidosis", "D696: Thrombocytopenia, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I4891: Unspecified atrial fibrillation", "I5022: Chronic systolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "Z681: Body mass index [BMI] 19.9 or less, adult", "E860: Dehydration", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "I255: Ischemic cardiomyopathy", "N189: Chronic kidney disease, unspecified", "M109: Gout, unspecified", "R627: Adult failure to thrive", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "D638: Anemia in other chronic diseases classified elsewhere" ]

[ "N179", "E872", "D696", "I130", "I4891", "E871", "E785", "I2510", "I252", "N189", "M109", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nepigastric abdominal pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history AML s/p \n7+3 induction now s/p 3C of HiDAC. Developed FN after C2 of \nHiDAC with no obvious infectious source found now presenting \nwith abdominal pain.\n\nSUBJECTIVE: Patient c/o slight epigastric pain hx of this with \nprevious chemotherapy cycles feels similar to prior. No fevers \nsince last admission, denies chills/rigors/uri sx. pain ___ on \npain scale feels \"gas pains\". no recent n/v/d. He denies \nshortness of breath, cough, chest pain, rashes, and dysuria.\n\n \nPast Medical History:\nPast Medical History:\n\nPatient presented to ___ with a 3 week history of \nweakness on ___. CBC revealed leukocytosis with blasts for \n\nwhich he was transferred to ___. Bone marrow biopsy confirmed \nacute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. \nPatient was started on 7+3 on ___. Day 14 bone marrow with \n\naplasia but persistent t(8;21) in 40% of cells per karyotype and \n\nRUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made \nnot to re-induce. Day 21 bone marrow on ___ was with no \nmorphologic or cytogenetic evidence of residual disease.\n\nTreatment History:\n- ___: 7+3\n- ___: BMB with ___\n- ___: C1D1 HiDAC\n- ___: C2D1 HiDAC\n- ___: C3D1 HiDAC\n \nSocial History:\n___\nFamily History:\nBoth mother and father died of old age. He denies any family \nhistory of malignancy or blood disorders.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITAL SIGNS: Temp 98.2 BP 123/74 HR 96 RR 16 O2 sat 100% RA.\n___: NAD.\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, \naxillary\nadenopathy, no thyromegaly.\nCV: RR, NL S1S2 no S3S4 MRG.\nPULM: CTAB.\nGI: BS+, soft, slight pain on palpation of epigastric region. no\nmasses or hepatosplenomegaly.\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal\nadenopathy.\nSKIN: No rashes or skin breakdown port site intact w/o erythema.\nPt does have darker brown skin lesions over anterior foreleg on\nleft but states chronic.\nNEURO: A&Ox3. Cranial nerves II-XII are within normal limits.\nGross strength and sensation intact. no nystagmus, rapid hand\nmovements and tandem gait intact.\n\nDISCHARGE PHYSICAL EXAM:\nVITAL SIGNS: TC 98.3 ___ 20 99-100%RA\nGEN: NAD, awake and alert, non-toxic in appearance.\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, \naxillary\nadenopathy, no thyromegaly.\nCV: RR, NL S1S2 no S3S4 MRG.\nPULM: Non-labored. CTAB.\nGI: BS+, soft. Pain on palpation of epigastric region resolved.\nNo rebound tenderness. No palpable masses or hepatosplenomegaly.\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal\nadenopathy.\nSKIN: No rashes or skin breakdown; port site intact w/o \nerythema,\ndischarge or swelling. Does have darker brown skin lesions over\nanterior foreleg on left but states chronic.\nNEURO: A&Ox3. Cranial nerves II-XII are within normal limits.\nGross strength and sensation intact. No nystagmus, rapid hand\nmovements and tandem gait intact.\n \nPertinent Results:\nLABS:\n\n___ 09:45AM PLT SMR-RARE PLT COUNT-9*#\n___ 09:45AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ \nMACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL \nOVALOCYT-OCCASIONAL TEARDROP-1+ BITE-OCCASIONAL\n___ 09:45AM NEUTS-4* BANDS-0 LYMPHS-96* MONOS-0 EOS-0 \nBASOS-0 ___ MYELOS-0 AbsNeut-0.01* AbsLymp-0.19* \nAbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 09:45AM WBC-0.2* RBC-2.37* HGB-7.7* HCT-21.5* MCV-91 \nMCH-32.5* MCHC-35.8 RDW-14.5 RDWSD-48.2*\n___ 09:45AM CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-2.0\n___ 09:45AM LIPASE-21\n___ 09:45AM ALT(SGPT)-62* AST(SGOT)-30 ALK PHOS-82 TOT \nBILI-0.5\n___ 09:45AM GLUCOSE-128* UREA N-13 CREAT-0.8 SODIUM-140 \nPOTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-21* ANION GAP-19\n___ 12:15PM PLT COUNT-46*#\n___ 11:45PM BLOOD WBC-0.4*# RBC-2.49* Hgb-8.2* Hct-22.4* \nMCV-90 MCH-32.9* MCHC-36.6 RDW-14.6 RDWSD-47.3* Plt Ct-21*\n___ 11:45PM BLOOD Neuts-14* Bands-0 Lymphs-66* Monos-16* \nEos-0 Baso-0 Atyps-4* ___ Myelos-0 AbsNeut-0.06* \nAbsLymp-0.28* AbsMono-0.06* AbsEos-0.00* AbsBaso-0.00*\n___ 11:45PM BLOOD Plt Ct-21*\n___ 11:45PM BLOOD Glucose-121* UreaN-12 Creat-0.7 Na-134 \nK-4.0 Cl-100 HCO3-24 AnGap-14\n___ 11:45PM BLOOD ALT-48* AST-23 LD(LDH)-106 AlkPhos-75 \nTotBili-0.7\n___ 11:45PM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.8 Mg-2.2\n\nECG ___\n\nClinical indication for EKG: R___.31 - Abnormal electrocardiogram \n[ECG] \n[EKG] \n \nSinus rhythm. Possible inferior wall myocardial infarction. \nSomewhat early R wave progression. Compared to the previous \ntracing of ___ the rate is now somewhat slower. Otherwise, \nunchanged. \n \nBrief Hospital Course:\nASSESSMENT AND PLAN: Mr. ___ is a ___ male \nwith history AML s/p 7+3 and C3 HiDAC consolidation presenting \nwith epigastric pain.\n\nC3D17 ___\n\n#Epigastric pain: (resolved), described as mild in nature and \nwas minimal on exam, etiology likely GERD vs. gastritis related. \nAdded protonix and simethicone on admission with improvement. \nReceived IVF ___ overnight. No fevers throughout hospital \ncourse so no further workup necessitated as etiology of pain \nunlikely infectious in origin although we had a low threshold \nfor initiating empiric antimicrobial given neutropenia. No \nnausea, vomiting or diarrhea. Patient eating and drinking well. \nLipase WNL. CMV/EBV PCR pending at discharge. \n\n#AML: Favorable genetics given t(8.21) s/p 7+3 and now s/p C3 \nHiDAC consolidation. Bone marrow biopsy, FISH, and cytogenetics \non day 21 of 7+3 indicate complete response. Will continue \nacyclovir, fluconazole and ciprofloxacin. Received neulasta \ngiven ___ and expect counts recovery soon. Follow up \narranged for lab check on ___ at ___ and ___ with \nprimary team\n\n#Panyctopenia (anemia, thrombocytopenia, neutropenia): counts at \nnadir secondary to recent cycle of HiDAC but showing signs of \nrecovery. No e/o clinical blood loss currently. Likely all \nconsequence of chemotherapy and underlying malignancy and \ninflammatory block. However, given downtrend of H/H on ___, \nreceived 1U of PRBCs on ___. Transfuse for hgb <7 and/or plt \n<10K. Will RTC to ___ on ___ for lab check as above. \n\nProphylaxes:\n# Access: POC\n# Contact: ___\n# Disposition: Discharged ___ RTC on ___ at ___ for \nlabs and ___ for provider visit and labs\n# Code Status: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Ciprofloxacin HCl 500 mg PO Q12H \n3. Fluconazole 400 mg PO Q24H \n4. Montelukast 10 mg PO DAILY \n5. Simethicone 40-80 mg PO QID:PRN gas pain \n\n \nDischarge Medications:\n1. Pantoprazole 40 mg PO Q24H \n2. Acyclovir 400 mg PO Q12H \n3. Ciprofloxacin HCl 500 mg PO Q12H \n4. Fluconazole 400 mg PO Q24H \n5. Montelukast 10 mg PO DAILY \n6. Simethicone 40-80 mg PO QID:PRN gas pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAML\nAbdominal pain likely GERD/Gastritis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nMr. ___,\n\nYou were admitted due to dehydration and abdominal upset which \nimproved with IV fluids time and adding a medication for \nheartburn. You will be discharged home and follow up as stated \nbelow. Please do not hesitate to call in the meantime with any \nquestions or concerns. It was a pleasure taking care of you.\n \nFollowup Instructions:\n___\n" ]

[ "K2960", "D61810", "C92Z0", "K219", "E860", "T451X5A", "Y9289", "Z79899" ]

[ "K2960: Other gastritis without bleeding", "D61810: Antineoplastic chemotherapy induced pancytopenia", "C92Z0: Other myeloid leukemia not having achieved remission", "K219: Gastro-esophageal reflux disease without esophagitis", "E860: Dehydration", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "Z79899: Other long term (current) drug therapy" ]

[ "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nplanned admission for HiDAC\n \nMajor Surgical or Invasive Procedure:\nNone. \n\n \nHistory of Present Illness:\nMr. ___ is a ___ gentleman without any past medical\nhistory, and recent diagnosis of acute myeloid leukemia s/p\nrecent admission for 7+3 starting ___, who presents for\ninitiation of HiDAC consolidation therapy. The patient had\nfavorable genetics given t(8;21). Bone marrow biopsy, FISH, and\ncytogenetics on day 21 indicated complete response to 7+3.\nBecause of this, the plan per outpatient oncology team, was for\nconsolidation with ___ cycles of HiDAC. Patient was recently \nseen\nin follow up on ___, during which time, there was a discussion\nof the potential adverse effect of this regimen, particularly\ncytopenias requiring close follow-up, as well as cerebellar\ndegeneration. After a discussion of risks, patient signed an\ninformed consent to initiate cycle 1 of HiDAC on ___, with\nplan to have port placed.\n\nPatient says that he has felt will since his recent admission \nfor\n7+3 (discharge on ___. He denies fatigue (presenting complaint\non recent admission for AML diagnosis) any fevers, chills, night\nsweats. He denies headache, lightheadedness, chest pain,\nshortness of breath, URI sx, nausea/vomiting,\ndiarrhea/constipation, or dysuria/urinary incontinence. \n\nReview of Systems: \n(+) Per HPI.\nDenies fever, chills, night sweats, headache, vision changes,\nrhinorrhea, congestion, sore throat, cough, shortness of breath,\nchest pain, abdominal pain, nausea, vomiting, diarrhea,\nconstipation, BRBPR, melena, hematochezia, dysuria, hematuria. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nPatient presented to ___ with a 3 week history of\nweakness associated with dyspnea on exertion and chest pain on\n___ and was transferred to ___ for further evaluation by\nheme/onc when a CBC revealed leukocytosis with blasts. Bone\nmarrow biopsy confirmed acute myeloid leukemia, t(8;21),\nRUNX1/RUNX1T1 rearrangement. Patient was started on 7+3 on\n___. Day 14 bone marrow with aplasia but persistent \nt(8;21)\nin 40% of cells per karyotype and RUNX1/RUNX1T1 rearrangement in\n16% per FISH. Decision was made not to re-induce. Day 21 bone\nmarrow on ___ was with no\nmorphologic or cytogenetic evidence of residual disease. \n\nPAST MEDICAL/SURGICAL HISTORY: \nHe is in excellent health and has had no past problems.\n\n \nSocial History:\n___\nFamily History:\nBoth mother and father died of old age. He denies any family\nhistory of malignancy or blood disorders.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=============================\nVitals: T 97.9 BP 122/70 HR 72 RR 18 O2Sat 100% RA\nGen: Pleasant, calm, appropriately interactive \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP 4 cm above sternal angle at 45 degr. Normal carotid\nupstroke without bruits. \nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3.\nLINES: PIV\n\nDISCHARGE PHYSICAL EXAM\n=============================\nVitals: T 97.9 BP 122/70 HR 72 RR 18 O2Sat 100% RA\nGen: Pleasant, calm, appropriately interactive \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP 4 cm above sternal angle at 45 degr. Normal carotid\nupstroke without bruits. \nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3.\nLINES: Port\n \nPertinent Results:\nADMISSION LABS\n==============================\n___ 10:12AM GLUCOSE-107* UREA N-12 CREAT-0.7 SODIUM-138 \nPOTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-15\n___ 10:12AM ALT(SGPT)-22 AST(SGOT)-18 LD(LDH)-167 ALK \nPHOS-68 TOT BILI-0.2\n___ 10:12AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-3.5 \nMAGNESIUM-2.1 URIC ACID-5.6\n___ 10:12AM WBC-7.4 RBC-3.16* HGB-10.3* HCT-30.6* MCV-97 \nMCH-32.6* MCHC-33.7 RDW-18.4* RDWSD-63.4*\n___ 10:12AM NEUTS-77* BANDS-0 LYMPHS-9* MONOS-9 EOS-2 \nBASOS-2* ___ METAS-1* MYELOS-0 AbsNeut-5.70 AbsLymp-0.67* \nAbsMono-0.67 AbsEos-0.15 AbsBaso-0.15*\n___ 10:12AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ \nMACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ \nBURR-OCCASIONAL TEARDROP-OCCASIONAL\n___ 10:12AM PLT SMR-NORMAL PLT COUNT-340\n___ 10:12AM ___ PTT-28.4 ___\n___ 10:12AM ___\n\nMICROBIOLOGY\n==============================\nN/A\n\nIMAGING\n==============================\nN/A\n\nDISCHARGE AND PERTINENT LABS\n==============================\n___ 12:00AM BLOOD WBC-2.9*# RBC-3.12* Hgb-10.0* Hct-30.1* \nMCV-97 MCH-32.1* MCHC-33.2 RDW-16.9* RDWSD-59.1* Plt ___\n___ 12:00AM BLOOD Neuts-97.0* Lymphs-1.4* Monos-1.0* \nEos-0.0* Baso-0.3 Im ___ AbsNeut-2.81# AbsLymp-0.04* \nAbsMono-0.03* AbsEos-0.00* AbsBaso-0.01\n___ 12:00AM BLOOD Plt ___\n___ 12:00AM BLOOD Glucose-212* UreaN-10 Creat-0.5 Na-135 \nK-4.0 Cl-100 HCO3-24 AnGap-15\n___ 12:00AM BLOOD ALT-62* AST-48* LD(___)-154 AlkPhos-47 \nTotBili-0.5\n___ 12:00AM BLOOD Albumin-3.9 Calcium-8.8 Phos-2.8 Mg-2.1\n \nBrief Hospital Course:\nMr. ___ is a ___ with recent dx of AML t(8;21), RUNX1/RUNX1T1 \nrearrangement, s/p 7+3 on ___, with day 21 bone marrow \nbiopsy on ___ notable for no morphologic or cytogenetic \nevidence of residual disease, now admitted for first cycle of \nHiDAC consolidation therapy (D1: ___ and port placement. \n\n#AML: The patient has a recent dx of AML, t(8;21), RUNX1/RUNX1T1 \nrearrangement and is s/p recent admission for 7+3 on ___. \nDay 14 bone marrow biopsy showed aplasia, but persistent t(8;21) \nin 40% of cells per karyotype and RUNX1/RUNX1T1 rearrangement in \n16% per FISH, and decision was made at that time not to \nre-induce. Day 21 bone marrow on ___ was notable for no \nmorphologic or cytogenetic evidence of residual disease, and \ndecision was made to initiate HiDAC consolidation therapy (D1: \n___, D3: ___, D5: ___ for a total of 6 doses. On \nadmission on ___, WBC 7.4, H&H 10.3/30.6, plt 340, ANC 5700, \nALT/AST ___. Baseline cerebellar exam prior to 1st dose was \nnotable for slight intention tremor on bilateral finger to nose \ntesting. There was no change in cerebellar exam with subsequent \ndoses of chemotherapy and exam was stable at time of discharge. \nAt time of discharge on ___, WBC 2.9, H&H 10.0/30.1, plt 228, \nANC 2810. ALT/AST 62/48. Patient also had port placed on ___. \n\nTRANSITIONAL\n=========================\n- Patient received first cycle of HiDAC consolidation therapy \n(D1: ___, D3: ___, D5: ___ for a total of 6 doses.\n- Patient had port placed on ___. \n- Patient has outpatient appointment with primary oncologist, \nDr. ___ on ___ at 10:00 AM, phone# ___. \n \nMedications on Admission:\nNone. \n \nDischarge Medications:\n1. Ondansetron ODT 4 mg PO Q8H:PRN Nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth Q8H: prn Disp #*42 \nTablet Refills:*0 \n2. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID \nRX *prednisolone acetate 1 % 1 drop ophthalmic three times a day \nRefills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n======================\nAcute myeloid leukemia \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure taking care of you!\n\nWhy you were admitted\n- For consolidation chemotherapy for your cancer. \n\nWhat we did for you\n- We continued treatment for your leukemia. You tolerated the \nchemotherapy very well.\n- We placed a port to facilitate your future treatments. \n\nWhat you should do when you go home:\n- Please take your medications as prescribed. \n- Please attend your follow-up appointment with your primary \noncologist, Dr. ___ on ___, ___ at 10:00 \nAM.\n \n\nWe wish you the best,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C9200" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C9200: Acute myeloblastic leukemia, not having achieved remission" ]

[]

[]

[ " \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:\nFever\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with recent diagnosis AML on HiDAC (recent admit \n___ for second cycle HiDAC consolidation after \npreviously receiving 7+3) presenting as a transfer from ___ with \nfever in setting of neutropenia.\n\nNote that after his first cycle of HiDAC he was admitted ___ \nwith neutropenic fever. Initially on vanc cefepime, cefepime \ncontinued for duration of his stay though vanc stopped on admit, \nno cultures showed documented infection, and it's not clear from \n___ summary that any specific source was suspected as it seems he \ndidn't even have any localizing symptoms.\n\nPt reports on my interview today that he has been feeling fine \nbut maybe with slight mild nonproductive cough over the last \nweek (extremely minimal he reports on being pressed further) and \nthis morning around 7 Am noted fever at home to 100.0 and \nsubsequently 100.4 so went to ___. He reports that he had a \nsharp pleuritic right sided pain at the time of the fever and \nmild headache, but that these resolved very rapidly when his \ntemperature returned to normal and he hasn't experienced these \nsince. He denies significant sore throat or rhinorrhea neck \nstiffness, dysuria, diarrhea, or pain anywhere else. No SOB or \nchest pain specifically and no ___ edema.\n\nOn review of ___ records from ___, he reported there mild \nsore throat, mild congestion and subjective fever/chills. Denied \nsick contacts and stated had flu shot this year. At ___ pt was \nin SR without EKG changes c/f ischemia. He presented with temp \nto 100.0. BP there was 146/72, HR 94, RR 18 98.6 temp. 100% RA. \nLabs with normal serum chem WBC 0.2 hct 19.3 plts 25. trop I \nwas 0.049 (ref range <0.046). UA reassuring. Given \nvanc/cefepime. was given 324mg aspirin for slightly positive \ntrop, but had no chest pain or ekg changes.\n\nNote he was seen in clinic ___ and received 1u plts for plts \n11, now 25. Hct was in the 19 range but did not receive blood.\n\nED COURSE at BI:\nT 98.9 HR 87 136/81 18 100% RA. lactate 1.4. trop neg. WBC \n0.3, Hct 19.4, plts 25, chem pending at time of transfer from \nED, UA reassuring, flu swab pending.\n\nOn arrival to the floor interview as above conducted in ___, \npt reports he feels quite well with most of the above symptoms \ncompletely resolved. All other 10 point ROS except as noted \nabove negative.\n \nPast Medical History:\nPatient presented to ___ with a 3 week history of \nweakness on ___. ___ revealed leukocytosis with blasts for \nwhich he was transferred to ___. Bone marrow biopsy confirmed \nacute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. \nPatient was started on 7+3 on ___. Day 14 bone marrow with \naplasia but persistent t(8;21) in 40% of cells per karyotype and \nRUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made \nnot to re-induce. Day 21 bone marrow on ___ was with no \nmorphologic or cytogenetic evidence of residual disease.\n\nTreatment History:\n- ___: 7+3\n- ___: BMB with ___\n- ___: C1D1 HiDAC\n- ___: C2D1 HiDAC\n \nSocial History:\n___\nFamily History:\nBoth mother and father died of old age. He denies any family \nhistory of malignancy or blood disorders.\n \nPhysical Exam:\n========================\nAdmission Physical Exam:\n========================\nVITAL SIGNS: 98.8 122/76 108 16 93% RA\n___: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or \naxillary adenopathy, no thyromegaly.\nCV: RR, NL S1S2 no S3S4 MRG.\nPULM: CTAB.\nGI: BS+, soft, NTND, no masses or hepatosplenomegaly.\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal \nadenopathy.\nSKIN: No rashes or skin breakdown port site intact w/o erythema. \nPt does have darker brown skin lesions over anterior foreleg on \nleft but states chronic.\nNEURO: Oriented x3. Cranial nerves II-XII are within normal \nlimits excluding visual acuity which was not assessed, no \nnystagmus; strength is ___ of the proximal and distal upper and \nlower extremities; reflexes are 2+ of the biceps, triceps, \npatellar, and Achilles tendons, toes are down bilaterally; gait \nis normal, coordination is intact.\n\n========================\nDischarge Physical Exam:\n========================\nVS: 97.9 118/70 75 18 100RA \nGEN: NAD\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, \naxillary\nadenopathy, no thyromegaly\nCV: RR, NL S1S2 no S3S4 MRG\nPULM: CTAB\nABD: BS+, soft, NTND, no masses or hepatosplenomegaly\nEXT: No edema, clubbing, tremors, or asterixis; no inguinal \nadenopathy\nSKIN: No rashes or skin breakdown port site intact w/o erythema; \npt does have darker brown skin lesions over anterior foreleg on \nleft but states chronic.\nNEURO: A&Ox3; Cranial nerves II-XII are within normal limits; \nGross strength and sensation intact.\n \nPertinent Results:\n===============\nAdmission Labs:\n===============\n___ 08:50AM BLOOD WBC-0.2* RBC-2.24* Hgb-7.4* Hct-21.1* \nMCV-94 MCH-33.0* MCHC-35.1 RDW-15.6* RDWSD-53.3* Plt Ct-11*#\n___ 08:50AM BLOOD Neuts-0 Bands-0 Lymphs-99* Monos-1* Eos-0 \nBaso-0 ___ Myelos-0 AbsNeut-0.00* AbsLymp-0.20* \nAbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 08:50AM BLOOD UreaN-16 Creat-0.9 Na-138 K-4.1 Cl-103 \nHCO3-23 AnGap-16\n___ 08:50AM BLOOD ALT-41* AST-26 AlkPhos-77 TotBili-0.2\n___ 08:50AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9\n___ 04:45PM BLOOD cTropnT-<0.01\n___ 05:48AM BLOOD cTropnT-<0.01\n___ 04:45PM BLOOD Lipase-23\n___ 04:56PM BLOOD Lactate-1.4\n\n===============\nDischarge Labs:\n===============\n___ 12:00AM BLOOD WBC-4.1 RBC-2.64* Hgb-8.3* Hct-24.6* \nMCV-93 MCH-31.4 MCHC-33.7 RDW-14.8 RDWSD-50.4* Plt ___\n___ 12:00AM BLOOD Neuts-29* Bands-2 Lymphs-16* Monos-42* \nEos-0 Baso-0 Atyps-1* Metas-5* Myelos-5* NRBC-3* AbsNeut-1.27* \nAbsLymp-0.70* AbsMono-1.72* AbsEos-0.00* AbsBaso-0.00*\n___ 12:00AM BLOOD ___ PTT-28.1 ___\n___ 12:00AM BLOOD Glucose-144* UreaN-13 Creat-0.6 Na-137 \nK-3.8 Cl-102 HCO3-25 AnGap-14\n___ 12:00AM BLOOD ALT-70* AST-47* LD(LDH)-200 AlkPhos-89 \nTotBili-<0.2\n___ 12:00AM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.3 Mg-2.1\n\n========\nImaging:\n========\nCXR ___ at ___\nFindings: There has been interval placement of a Mediport on the \nright side, the tip of which projects over the SVC/right atrial \njunction. No focal consolidation. No pleural effusion. No \npneumothorax. Unchanged cardiomediastinal silhouette.\nImpression: No acute pulmonary process.\n\n=============\nMicrobiology:\n=============\n___ 4:11 pm BLOOD CULTURE Source: Line-port. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH.\n\n___ 10:14 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n **FINAL REPORT ___\n\n Respiratory Viral Culture (Final ___: \n No respiratory viruses isolated. \n Culture screened for Adenovirus, Influenza A & B, \nParainfluenza type\n 1,2 & 3, and Respiratory Syncytial Virus.. \n Detection of viruses other than those listed above will \nonly be\n performed on specific request. Please call Virology at \n___\n within 1 week if additional testing is needed. \n\n Respiratory Viral Antigen Screen (Final ___: \n Negative for Respiratory Viral Antigen. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza A, B,\n and RSV by immunofluorescence. \n Refer to respiratory viral culture and/or Influenza PCR \n(results\n listed under \"OTHER\" tab) for further information.. \n\n___ 6:30 pm BLOOD CULTURE 2 OF 2. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n \n \n___ 4:45 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH.\n\n___ 4:45 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH.\n \nBrief Hospital Course:\nMr. ___ is a ___ male with history AML on \nHiDAC (recent admit ___ for second cycle HiDAC \nconsolidation after previously receiving 7+3) who presented as a \ntransfer from ___ with fever in setting of neutropenia.\n\n# Febrile Neutropenia: The patient was febrile and seen first at \n___, where cultures were drawn and a CXR was \nnegative. He was then transferred to ___ where he was again \nfebrile and cultured, then started on vanco/cefepime. Subsequent \nto this we was afebrile and all cultures were negative with no \nlocalizing signs of infection. Vancomycin and cefepime were \nstopped after ANC>5400 and patient had been afebrile >24h after \nabx. stopped. Dr. ___ was consulted and stopped his cipro \nand fluconazole prophylaxis after count recovery, and the \npatient was fit for discharge. He will be seen in clinic ___ \nand have planned admission ___.\n\n# AML: Favorable genetics given t(8.21) s/p 7+3 and C2D1 HiDAC \nconsolidation was ___. Bone marrow biopsy, FISH, and \ncytogenetics on day ___ indicate complete response to 7+3. \nBecause of this, he is currently undergoing consolidation with \n___ cycles of HiDAC, first cycle c/b admit for neutropenic \nfever, cytopenias. He presented for a similar picture, \nneutropenia with ANC<500 and fever. He was treated as above. \nUltimately the patient's counts sufficiently recovered to be \nsent home, and he will return to be seen by Dr. ___ as an \noutpatient.\n\n# Panyctopenia (anemia, thrombocytopenia, neutropenia): Likely \nall consequence of chemotherapy and underlying malignancy and \ninflammatory block. His counts recovered by the time of \ndischarge.\n\nTRANSITIONAL ISSUES:\n- continue to trend LFTs while outpatient, slight rise thought \nto be medication effect\n- continue to monitor ANC and counts\n- plan for next HiDAC cycle\n- Contact: ___son) ___\n- Code: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. Ciprofloxacin HCl 500 mg PO Q12H \n3. Fluconazole 400 mg PO Q24H \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q8H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n- fever and neutropenia\n- acute myeloid leukemia\n- pancytopenia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you while you were at ___. You \ncame from ___ with fevers and low blood counts, which has \nhappened to you before when you have gotten chemotherapy. We \nfound no infection but kept you on antibiotics to prevent any \ninfection from taking hold. You never had any symptoms while you \nwere here, and once your counts recovered antibiotics were \nstopped and you were discharged home.\n\nThank you for allowing us to participate in your care!\n\nBest regards,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "D701", "C9200", "T451X5A", "R5081", "Y92009", "D61818" ]

[ "D701: Agranulocytosis secondary to cancer chemotherapy", "C9200: Acute myeloblastic leukemia, not having achieved remission", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "R5081: Fever presenting with conditions classified elsewhere", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "D61818: Other pancytopenia" ]

[]

[]

[ " \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:\nHiDAC\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history AML s/p \n7+3 induction now s/p 3C of HiDAC. Developed FN after C2 of \nHiDAC with no obvious infectious source found now presenting for \nC4 of HiDAC.\n \nPast Medical History:\nPast Medical History:\n\nPatient presented to ___ with a 3 week history of \nweakness on ___. ___ revealed leukocytosis with blasts for \n\nwhich he was transferred to ___. Bone marrow biopsy confirmed \nacute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. \nPatient was started on 7+3 on ___. Day 14 bone marrow with \n\naplasia but persistent t(8;21) in 40% of cells per karyotype and \n\nRUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made \nnot to re-induce. Day 21 bone marrow on ___ was with no \nmorphologic or cytogenetic evidence of residual disease.\n\nTreatment History:\n- ___: 7+3\n- ___: BMB with ___\n- ___: C1D1 HiDAC\n- ___: C2D1 HiDAC\n- ___: C3D1 HiDAC\n \nSocial History:\n___\nFamily History:\nBoth mother and father died of old age. He denies any family \nhistory of malignancy or blood disorders.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITAL SIGNS: Temp 97.9 BP 130/70 HR 72 RR 16 O2 sat 98% RA.\n___: NAD.\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, \naxillary\nadenopathy, no thyromegaly.\nCV: RR, NL S1S2 no S3S4 MRG.\nPULM: CTAB.\nGI: BS+, soft, slight pain on palpation of epigastric region. no\nmasses or hepatosplenomegaly.\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal\nadenopathy.\nSKIN: No rashes or skin breakdown port site intact w/o erythema.\nPt does have darker brown skin lesions over anterior foreleg on\nleft but states chronic.\nNEURO: A&Ox3. Cranial nerves II-XII are within normal limits.\nGross strength and sensation intact. no nystagmus, rapid hand\nmovements and tandem gait intact.\n\nDISCHARGE PHYSICAL EXAM:\nVITAL SIGNS: 97.8 PO ___ 20 98 RA \n___: NAD.\nHEENT: MMM.\nCV: RR, NL S1S2 no S3S4 MRG.\nPULM: CTAB.\nABD: soft/nt/nd, no HSM\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal\nadenopathy.\nSKIN: No new rashes\nNEURO: A&Ox3. Cranial nerves II-XII are within normal limits.\nGross strength and sensation intact. no nystagmus, rapid hand\nmovements and tandem gait intact. FNF intacdt and negative \nromberg\n \nPertinent Results:\nADMISSION LABS:\n\n___ 09:05AM BLOOD WBC-4.4 RBC-3.23* Hgb-10.8* Hct-32.4* \nMCV-100* MCH-33.4* MCHC-33.3 RDW-20.2* RDWSD-72.9* Plt ___\n___ 09:05AM BLOOD Neuts-50.8 ___ Monos-17.3* \nEos-0.5* Baso-0.7 Im ___ AbsNeut-2.23 AbsLymp-1.34 \nAbsMono-0.76 AbsEos-0.02* AbsBaso-0.03\n___ 09:05AM BLOOD Glucose-112*\n___ 09:05AM BLOOD UreaN-12 Creat-0.7 Na-139 K-4.2 Cl-102 \nHCO3-25 AnGap-16\n___ 09:05AM BLOOD ALT-117* AST-64* AlkPhos-83 TotBili-0.4\n___ 09:05AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1\n\nDISCHARGE LABS:\n\n___ 12:00AM BLOOD WBC-3.8* RBC-3.11* Hgb-10.4* Hct-31.0* \nMCV-100* MCH-33.4* MCHC-33.5 RDW-18.5* RDWSD-67.1* Plt ___\n___ 12:00AM BLOOD Neuts-97.0* Lymphs-1.9* Monos-0.5* \nEos-0.0* Baso-0.3 Im ___ AbsNeut-3.67 AbsLymp-0.07* \nAbsMono-0.02* AbsEos-0.00* AbsBaso-0.01\n___ 12:00AM BLOOD Glucose-133* UreaN-15 Creat-0.6 Na-136 \nK-4.2 Cl-102 HCO3-23 AnGap-15\n___ 12:00AM BLOOD ALT-104* AST-56* LD(LDH)-172 AlkPhos-65 \nTotBili-0.8\n \nBrief Hospital Course:\nMr. ___ is a ___ male with history AML s/p \n7+3 and C3 HiDAC consolidation presenting for C4\n\nC4D6 ___\n\n# AML: Favorable genetics given t(8.21) s/p 7+3 and now s/p C3\nHiDAC consolidation. Bone marrow biopsy, FISH, and cytogenetics\non day 21 of 7+3 indicate complete response. He received \nCytarabine 5940 mg IV Q12H on Days 1, 3 and 5. ___, \n___ and ___ mg/m2). Neuro checks prior to each \nchemotherapy were performed and did nto show signs of cerebellar \ntoxicity. He also received the following:\n- antiemetics/IVF per protocol\n- Continue acyclovir, fluc and cipro while neutropenic\n- neulasta to be given ___\n- f/u set for clinic ___\n\n#epigastric pain: mild in nature and minimal on exam, likely \nGERD/gastritis related. had w/u inhouse last admission, lipase \nWNL, afebrile. Improved with protonix, simethicone.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Montelukast 10 mg PO DAILY \n3. Pantoprazole 40 mg PO Q24H \n4. Simethicone 40-80 mg PO QID:PRN gas pains \n5. Ciprofloxacin HCl 500 mg PO Q12H \n6. Fluconazole 400 mg PO Q24H \n\n \nDischarge Medications:\n1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID \n2. Acyclovir 400 mg PO Q12H \nRX *acyclovir 400 mg 1 tablet(s) by mouth q 12 hours Disp #*28 \nTablet Refills:*0 \n3. Montelukast 10 mg PO DAILY \n4. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n5. Simethicone 40-80 mg PO QID:PRN gas pains \n6. HELD- Ciprofloxacin HCl 500 mg PO Q12H This medication was \nheld. Do not restart Ciprofloxacin HCl until outpatient team \ntells you to restart\n7. HELD- Fluconazole 400 mg PO Q24H This medication was held. \nDo not restart Fluconazole until outpatient team tells you to \nrestart\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAML\n\n \nDischarge Condition:\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\nMental Status: Clear and coherent.\n\n \nDischarge Instructions:\nMr. ___,\n\nYou were admitted to receive HiDAC chemotherapy. You tolerated \nthis well and will be discharged home. You will follow up in \nclinic as stated below. Please do not hesitate to call in the \nmeantime with any questions or concerns. It was a pleasure \ntaking care of you.\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C92Z0", "K760", "K219", "K2970" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C92Z0: Other myeloid leukemia not having achieved remission", "K760: Fatty (change of) liver, not elsewhere classified", "K219: Gastro-esophageal reflux disease without esophagitis", "K2970: Gastritis, unspecified, without bleeding" ]

[ "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ncycle 3 of hidac\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history AML s/p \n7+3 induction now presenting for C3 of HiDAC. Developed FN after \nC2 of chemotherapy with no infectious source found and no \nfurther complications.\n\nSUBJECTIVE: Patient is feeling well. No fevers since last \nadmission, denies chills/rigors/uri sx. no recent n/v/d. did c/o \ngas pains a few days prior to admission that improved with \nsimethicone prn. He denies shortness of breath, cough, chest \npain, abdominal pain, rashes, and dysuria\n \nPast Medical History:\nPast Medical History:\n\nPatient presented to ___ with a 3 week history of \nweakness on ___. CBC revealed leukocytosis with blasts for \n\nwhich he was transferred to ___. Bone marrow biopsy confirmed \nacute myeloid leukemia, t(8;21), RUNX1/RUNX1T1 rearrangement. \nPatient was started on 7+3 on ___. Day 14 bone marrow with \n\naplasia but persistent t(8;21) in 40% of cells per karyotype and \n\nRUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made \nnot to re-induce. Day 21 bone marrow on ___ was with no \nmorphologic or cytogenetic evidence of residual disease.\n\nTreatment History:\n- ___: 7+3\n- ___: BMB with ___\n- ___: C1D1 HiDAC\n- ___: C2D1 HiDAC\n- ___: C3D1 HiDAC\n \nSocial History:\n___\nFamily History:\nBoth mother and father died of old age. He denies any family \nhistory of malignancy or blood disorders.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITAL SIGNS: Temp 97.8 BP 121/70 HR 77 RR 18, O2 sat 100%RA.\nGEN: NAD.\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, \naxillary\nadenopathy, no thyromegaly.\nCV: RR, NL S1/S2 no S3S4 MRG.\nPULM: CTAB.\nGI: BS+, soft, NTND, no masses or hepatosplenomegaly.\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal \nadenopathy.\nSKIN: No rashes or skin breakdown port site intact w/o erythema.\nPt does have darker brown skin lesions over anterior foreleg on\nleft but states chronic.\nNEURO: A&Ox3. Cranial nerves II-XII are within normal limits.\nGross strength and sensation intact. no nystagmus, rapid hand\nmovements and tandem gait intact.\n\nDISCHARGE PHYSICAL EXAM:\nVITAL SIGNS: TC 97.7 PO 110/62 97 18 96%RA\nGEN: NAD, awake and alert x 3\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, \naxillary\nadenopathy; no thyromegaly.\nCV: RR, NL S1/S2 no S3/S4 MRG.\nPULM: No increased WOB. CTAB.\nGI: BS+, soft, NT/ND, no masses or hepatosplenomegaly.\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal \nadenopathy.\nSKIN: No rashes or skin breakdown. Has darker brown skin lesions\nover anterior foreleg on left which are chronic\nNEURO: A&Ox3. Cranial nerves II-XII are within normal limits.\nGross strength and sensation intact. no nystagmus, rapid hand\nmovements and tandem gait intact. Cerebellar testing WNL\nACCESS: POC deaccessed at discharge\n \nPertinent Results:\n___ 06:03AM BLOOD WBC-2.7*# RBC-2.96* Hgb-9.7* Hct-28.7* \nMCV-97 MCH-32.8* MCHC-33.8 RDW-16.5* RDWSD-58.8* Plt ___\n___ 09:45AM BLOOD WBC-4.3 RBC-3.09* Hgb-10.1* Hct-30.3* \nMCV-98 MCH-32.7* MCHC-33.3 RDW-18.3* RDWSD-63.3* Plt ___\n___ 06:03AM BLOOD Neuts-97.0* Lymphs-2.6* Monos-0.0* \nEos-0.0* Baso-0.0 Im ___ AbsNeut-2.63# AbsLymp-0.07* \nAbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 09:45AM BLOOD Neuts-54.9 Lymphs-18.8* Monos-23.5* \nEos-0.2* Baso-1.2* NRBC-1.2* Im ___ AbsNeut-2.34# \nAbsLymp-0.80* AbsMono-1.00* AbsEos-0.01* AbsBaso-0.05\n___ 06:03AM BLOOD Plt ___\n___ 09:45AM BLOOD Plt Smr-NORMAL Plt ___\n___ 06:03AM BLOOD Glucose-144* UreaN-15 Creat-0.6 Na-138 \nK-4.1 Cl-100 HCO3-24 AnGap-18\n___ 09:45AM BLOOD UreaN-10 Creat-0.8 Na-140 K-4.0 Cl-103 \nHCO3-25 AnGap-16\n___ 06:03AM BLOOD ALT-122* AST-71* LD(LDH)-186 AlkPhos-57 \nTotBili-0.6\n___ 09:45AM BLOOD ALT-83* AST-54* AlkPhos-72 TotBili-0.2\n___ 06:03AM BLOOD Albumin-4.0 Calcium-8.8 Phos-4.1 Mg-2.3 \nUricAcd-5.0\n___ 09:45AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.___SSESSMENT AND PLAN: Mr. ___ is a ___ male \nwith history AML s/p 7+3 presenting for C3 HiDAC consolidation.\n\nC3D6 ___\n\n#AML: Favorable genetics given t(8.21) s/p 7+3 and now \npresenting for C3 HiDAC consolidation. Bone marrow biopsy, FISH, \nand cytogenetics on day 21 of 7+3 indicate complete response. \nTolerated this cycle w/o acute complications. Cerebellar exam \nwas stable throughout all doses. Initiated on fluconazole and \nciprofloxacin at discharge per primary team. Remains on \nacyclovir. Will continue on prednisolone eye drops until \n___. Has appointment on ___ with Dr. ___. \n\n#Pancytopenia (anemia, thrombocytopenia, neutropenia): stable \nnow but expect to downtrend. Likely all consequence of \nchemotherapy and underlying malignancy and inflammatory block. \nTrend CBC with diff outpatient. \n\n#Transaminitis: Elevation in AST and ALT. No hyperbilirubinemia. \nLikely chemotherapy effect, continue to monitor and trend \noutpatient, consider RUQ U/S if worsens. \n\n#Constipation: on bowel regimen, stooling daily prior to \ndischarge\n\nProphylaxes:\n# Access: POC\n# Contact: ___\n# Disposition: Discharged on ___. RTC on ___ with Dr. \n___\n\n# Code Status: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Ciprofloxacin HCl 500 mg PO Q12H \n3. Fluconazole 400 mg PO Q24H \n4. Montelukast 10 mg PO DAILY \n5. Simethicone 40-80 mg PO QID:PRN gas pain \n\n \nDischarge Medications:\n1. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID \nContinue this eye drop until ___ \n2. Acyclovir 400 mg PO Q12H \n3. Ciprofloxacin HCl 500 mg PO Q12H \n4. Fluconazole 400 mg PO Q24H \n5. Montelukast 10 mg PO DAILY \n6. Simethicone 40-80 mg PO QID:PRN gas pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAML\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___, \n\nYou were admitted to receive your third cycle of chemotherapy \n(high dose cytarabine) for your leukemia. You tolerated this \nwell and will be discharged today. Please restart your oral \nantibiotics (ciprofloxacin and fluconazole) to help prevent \ninfection.\n\nPlease refer below for your outpatient appointment.\n\nIt was a pleasure taking care of you.\n\nSincerely,\nYour ___ TEAM\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "D61810", "C92Z0", "R740", "K5903", "T451X5A", "Y92230" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "D61810: Antineoplastic chemotherapy induced pancytopenia", "C92Z0: Other myeloid leukemia not having achieved remission", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "K5903: Drug induced constipation", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nWeakness\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr ___ is a ___ gentleman with no significant past\nmedical history who presents with weakness and found to have\nfindings concerning for acute leukemia. \n\nThe patient reports he has been having increasing weakness over\nthe past 3 weeks, which is what prompted him to the ED today. He\nnotes increased dyspnea on exertion, chest pain, associated with\nfatigue. He denies any hematuria, dysuria, blood in the stool, \nor\ndiarrhea. No fevers, no chills, no cough.\n\nHe initially presented to ___. He was found to have\nelevated WBC with increased Blasts and was transferred to ___ for\nfurther evaluation by Heme/Onc. ECG with no ischemic changes. CT\nabdomen and CXR were done at OSH. Prior to arrival he received 1\nunit of PRBC. \n\nIn the ED, initial VS were pain 0, T 97.9, HR 70, BP 124/67, RR\n18, O2 97%RA. Na 135, K 4.0, HCO3 24, Cr 0.7, WBC 8.6 (ANC 690,\n70% Other), HCT 24.6, PLT 29, Urate 6.1, LDH 392, lactate ___\nFibrinogen 466, INR 1.2, nlf LFT's, trop <0.01. CXR and CT a/p\nfrom OSH were uploaded to LifeImage. Bone marrow bx was \nperformed\nand patient was given 2g IV cefepime. \n \nOn arrival to the floor, patient has no complaints. He is chest\npain free and breathing comfortably. \n\n \nPast Medical History:\nHe is in excellent health and has had no past problems.\n\n \nSocial History:\n___\nFamily History:\nBoth mother and father died of old age. He denies any family\nhistory of malignancy or blood disorders.\n \nPhysical Exam:\nON ADMISSION\n===============\nVS: 98.1 112/60 69 18 97 RA \n___: Pleasant, lying in bed comfortably\nHEAD: NCAT\nEyes: sclera anicteric\nENT: MMM, no oral lesions\nNECK: supple, no cervical lymphadenopathy \nCARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi\nABD: Normal bowel sounds, soft, nontender, nondistended\nEXT: Warm, well perfused, no lower extremity edema\nNEURO: Alert, oriented, CN II-XII intact, motor and sensory\nfunction grossly intact\nSKIN: No significant rashes\n\nON DISCHARGE\n===================\nVITAL SIGNS: 97.8 (97.4-98.3) 113/76 (104-120/60-72) 66 (65-79) \n20 95-100% RA\n24hr I/O: 950/233\n___: Pleasant male well appearing in NAD\nHEENT: MMM, mucositis over anterior hard palate. no cervical or \nsupraclavicular LAD\nCV: RRR. Normal S1, S2. No murmurs, or gallops. \nPULM: CTA b/l. No increase work of breathing. \nABD: +BS. soft, nondistended, nontender. No organomegaly \nappreciated\nEXTREMITIES: WWP. No ___ edema. 2+ Dp pulses. \nSKIN: brown/black verrucuous papules/plaques over anterior LLE \nstable. \nNEURO: CN II-XII grossly intact. ___ strength throughout. Steady \ngait\nLINE: Right CVL. Erythema around insertion site stable. No \ntenderness, swelling, or fluctuance\n \nPertinent Results:\nON ADMISSION\n===================\n___ 06:00PM ___\n___ 06:00PM ___ PTT-26.9 ___\n___ 06:00PM WBC-8.9 RBC-2.46* HGB-8.1* HCT-24.2* MCV-98 \nMCH-32.9* MCHC-33.5 RDW-17.7* RDWSD-62.5*\n___ 06:00PM LACTATE-0.9\n___ 06:00PM ALBUMIN-4.0 URIC ACID-6.1\n___ 06:00PM cTropnT-<0.01\n___ 06:00PM LIPASE-27\n___ 06:00PM ALT(SGPT)-14 AST(SGOT)-17 ALK PHOS-58 TOT \nBILI-0.4\n___ 06:00PM GLUCOSE-104* UREA N-12 CREAT-0.7 SODIUM-135 \nPOTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-14\n___ 09:25PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE \nEPI-0 TRANS EPI-<1\n___ 09:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n\nMICROBIOLOGY\n===================\nBlood Culture, Routine (Final ___: NO GROWTH. \nURINE CULTURE (Final ___: NO GROWTH. \n\nSkin tissue bx (___):\nGRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES \nSEEN. NO MICROORGANISMS SEEN. \nTISSUE (Final ___: NO GROWTH. \nANAEROBIC CULTURE (Final ___: NO GROWTH. \nPOTASSIUM HYDROXIDE PREPARATION (Final ___: NO FUNGAL \nELEMENTS SEEN. \nFUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED. \nACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON \nDIRECT SMEAR. \nACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. \n\nBlood Culture, Routine (Final ___: NO GROWTH.\nBlood Culture, Routine (Final ___: NO GROWTH. \nURINE CULTURE (Final ___: < 10,000 CFU/mL.\nBlood Culture, Routine (Final ___: NO GROWTH. \nBlood Culture, Routine (Final ___: NO GROWTH.\nURINE CULTURE (Final ___: NO GROWTH. \n\nC. difficile DNA amplification assay (Final ___: Negative \nfor toxigenic C. difficile by the Illumigene DNA amplification \nassay. \n\nBlood Culture, Routine (Final ___: NO GROWTH. \nBlood Culture, Routine (Final ___: NO GROWTH. \n\nURINE CULTURE (Final ___: NO GROWTH.\n\nBlood Culture, Routine (___): Pending \nBlood Culture, Routine (___): Pending \n\nURINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING\n===================\nCT pelvis w/contrast (___):\nIMPRESSION: \n1. No evidence of acute process in the pelvis. Specifically, no \nevidence of infection or hematoma. \n2. Mildly enlarged prostate. \n\nCARDIAC STUDIES\n===================\nTTE (___): \nFINDINGS: \nThe left atrium is elongated. No atrial septal defect is seen by \n2D or color Doppler. The estimated right atrial pressure is ___ \nmmHg. Left ventricular wall thickness, cavity size and \nregional/global systolic function are normal (LVEF >55%). Right \nventricular chamber size and free wall motion are normal. The \ndiameters of aorta at the sinus, ascending and arch levels are \nnormal. The aortic valve leaflets (3) appear structurally normal \nwith good leaflet excursion and no aortic stenosis or aortic \nregurgitation. The mitral valve appears structurally normal with \ntrivial mitral regurgitation. The estimated pulmonary artery \nsystolic pressure is normal. There is no pericardial effusion. \nIMPRESSION: Preserved biventricular systolic function. No \nclinically significant valvular disease. Normal pulmonary artery \nsystolic pressure. \n\nPATHOLOGY\n===================\nSkin bx, left lower leg (1A) (___):\n- Mild papillary epidermal hyperplasia, compact hyperkeratosis, \npapillary dermal hyalinized deposits, and superficial and \nmid-dermal perivascular and periappendageal lymphocytic \ninflammation with numerous dermal melanophages, see note.\n- Focal follicular hyperkeratosis with perifollicular fibrosis \nand chronic inflammation.\n\nNote: The findings are consistent with a late stage of a \nlichenoid dermatitis such as lichen planus. There are clusters \nof colloid bodies and hyalinized papillary dermal deposits \nsuggestive of lichen amyloidosis. The deposits stain with CK5/6 \nand focally with PAS. Due to the finding of ___ \ninflammation, the histopathologic differential diagnosis \nincludes a late stage of lichen striatus, but this is considered \nless likely. GMS and PAS stains are negative for fungi. The \nfindings are not suggestive of infection. Initial and level \nsections are examined.\n\nBM Bx (___):\nDIAGNOSIS: HYPOCELLULAR BONE MARROW WITH LYMPHOCYTES, PLASMA \nCELLS, STROMAL CELLS AND INTERSTITIAL EOSINOPHILIC DEBRIS \nCONSISTENT WITH CHEMOTHERAPY INDUCED MARROW ABLATION. SEE NOTE.\nNOTE: Correlation with clinical flow cytometry, and cytogenetics \nis recommended.\nMICROSCOPIC DESCRIPTION\nPeripheral blood smear:\nThe smear is adequate for evaluation. Erythrocytes are markedly \ndecreased, normochromic and normocytic and have marked \nanisopoikilocytosis including frequent echinocytes and \noccasional dacryocytes. The white blood cell count is markedly \ndecreased. Platelet count appears markedly\ndecreased. Rare large and giant platelets are seen. A 100 cell \ndifferential shows 1% neutrophils, 97% lymphocytes, 2% \nmonocytes, 0% eosinophils, 0% basophils.\nBone marrow aspirate: The aspirate material is inadequate for \nevaluation due to lack of spicules and hemodilution.\nClot section and biopsy slides:\nThe core biopsy material is adequate for evaluation. It consists \nof a 1.1 cm long core biopsy of trabecular marrow and periosteum \nwith a cellularity of ___. The interstitium consists of plasma \ncells, lymphocytes and stromal cells with eosinophilic debris \nconsistent with chemotherapy induced\nbone marrow ablation.\n\nFLOW CYTOMETRY REPORT \nFLOW CYTOMETRY IMMUNOPHENOTYPING \nThe following tests (antibodies) were performed: \n___, cCD3, cCD22, and CD antigens 11b, 16, \n19,33,34,45,64, and 117. \nRESULTS:\n10-color analysis with linear side scatter vs. CD45 gating is \nused to evaluate lymphocytes and blasts.\nA subset of the acquired events are in the low light scatter \ncell debris/lysed cell region with non-debris cells comprising \n53% of total acquired events.\nThe viability of the analyzed non-debris events, done by 7-AAD \nis 95.8%. \nCD45-bright, low side-scatter gated lymphocytes comprise 75.2% % \nof total analyzed events. \n\nCell marker analysis demonstrates that a small subset of the \ncells isolated from this bone marrow are in the CD45-dim/low \nside-scatter \"blast\" region. They express immature antigens \nCD34, ___, and myelomonocytic associated antigens CD117, \nCD33, CD13 (dim), CD14, CD64, CD11b. They lack B (cCD22, cCD79) \nand T cell (cCD3) associated antigens and are negative for nTdT, \ncMPO. \n\nBlast cells comprise 3.5% of total analyzed events. \nINTERPRETATION\nImmunophenotypic findings show the presence of a small \npopulation of myeloblasts (~3.5%). Correlation with clinical \nfindings and morphology (see separate pathology report \n___ and other ancillary findings is recommended. Flow \ncytometry immunophenotyping may not detect all abnormal \npopulations due to topography, sampling or artifacts of sample \npreparation. \n\nSPECIMEN: BONE MARROW\nCLINICAL HISTORY: t(8;21) positive acute myeloid leukemia, s/p \n7+3, day 14 bone marrow\nCYTOGENETICS PROCEDURE: Unstimulated culture for Giemsa-banded \nchromosome analysis.\nFINDINGS: An abnormal 45,X,-Y,t(8;21)(q22;q22) chromosome \ncomplement with the Y chromosome missing and a translocation \ninvolving the long arms of a chromosome 8 and a chromosome 21 \nwas observed in 8 cells. 12 cells had an apparently normal 46,XY \nmale chromosome complement. A total of 20 mitotic cells were \nexamined in detail. Chromosome band resolution was 400-425. A\nkaryogram was prepared on 4 cells.\nCYTOGENETIC DIAGNOSIS: 45,X,-Y,t(8;21)(q22;q22)[8]/\n46,XY[12]\nINTERPRETATION/COMMENT: 40% of the metaphase cells examined had \nthe previously observed (___) abnormal karyotype with the Y \nchromosome missing and a translocation involving the long\narms of chromosomes 8 and 21. FISH has demonstrated that the \nRUNX1/RUNX1T1 gene rearrangement brought about by this \ntranslocation is in 16% of the cells in this bone marrow \naspirate\nsample (see below).\nFISH: POSITIVE for RUNX1/RUNX1T1. 16% of the interphase bone \nmarrow cells examined had a probe signal pattern consistent with \nthe previously observed (___) RUNX1/RUNX1T1 gene \nrearrangement brought about by the t(8;21)(q22;q22) \ntranslocation associated with acute myeloid\nleukemia with neutrophilic maturation.\nUncultured cells for fluorescence in situ hybridization (FISH) \nanalysis with the ___ Molecular RUNX1/RUNX1T1 dual color dual \nfusion translocation probe set: SpectrumOrange directly labeled \nprobe for the RUNX1T1 (ETO) gene on ___ and SpectrumGreen \ndirectly labeled probe for the RUNX1 (AML1) gene on ___. This \nprobe combination detects the\nRUNX1/RUNX1T1 gene rearrangement brought about by the \nt(8;21)(q22;q22) translocation associated with acute myeloid \nleukemia with neutrophilic maturation.\nFINDINGS: A total of 200 interphase nuclei were examined with \nthe RUNX1T1 and RUNX1dual color dual fusion probe set and \nfluorescence microscopy. 168 cells (84%) had 2 red signals and 2 \ngreen signals. 32 cells (16%) had ___ yellow (red-green fusion) \nsignals, 1 red signal and 1 green signal. Normal cut-off values \nfor this probe set include: 91% for a normal 2 red and 2 green \nprobe signal pattern and 1% for a ___ yellow (red-green fusion), 1 \nred and 1 green signal pattern. nuc ish(RUNX1T1,RUNX)x3,(RUNX1 \ncon RUNX1T1x2)[32/200].\n\nBM Bx (___): pending\n\nDISCHARGE AND PERTINENT LABS \n======================\n___ 12:11AM BLOOD WBC-7.7# RBC-2.63* Hgb-8.1* Hct-24.3* \nMCV-92 MCH-30.8 MCHC-33.3 RDW-15.0 RDWSD-49.1* Plt ___\n___ 12:11AM BLOOD Neuts-56 Bands-5 Lymphs-7* Monos-21* \nEos-0 Baso-0 ___ Metas-11* Myelos-0 NRBC-1* AbsNeut-4.70 \nAbsLymp-0.54* AbsMono-1.62* AbsEos-0.00* AbsBaso-0.00*\n___ 12:11AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL \nMacrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL\n___ 12:11AM BLOOD Plt Smr-HIGH Plt ___\n\n___ 12:00AM BLOOD ___\n\n___ 12:11AM BLOOD Glucose-95 UreaN-7 Creat-0.8 Na-136 K-4.5 \nCl-99 HCO3-25 AnGap-17\n\n___ 12:11AM BLOOD ALT-35 AST-23 LD(LDH)-243 AlkPhos-62 \nTotBili-0.2\n___ 12:00AM BLOOD Lipase-18\n___ 12:11AM BLOOD Albumin-3.5 Calcium-8.8 Phos-4.3 Mg-2.3\n\n___ 06:25AM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative\n___ 06:25AM BLOOD HIV Ab-Negative\n___ 06:25AM BLOOD HCV Ab-Negative\n___ 12:00AM BLOOD PML/RARA T(15:17), QUANTITATIVE PCR-Test \n \n___ 11:15AM BLOOD HLA TYPING SENT TO ARC-TEST \n___ 01:47PM BLOOD QUANTIFERON-TB GOLD-Test \n\n___ 12:00PM BLOOD C-KIT D816, MUTATION ANALYSIS \n(MASTOCYTOSIS)-Test\n \n___ 01:00AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test \n \n___ 01:00AM BLOOD B-GLUCAN-Test \n\n___ 04:15PM URINE Color-Yellow Appear-Clear Sp ___\n___ 04:15PM URINE Blood-TR Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 04:15PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE \nEpi-___ without significant PMHx admitted found to have newly \ndiagnosed AML(8:21 translocation), and underwent induction with \n7+3. \n\n#Acute myelongenous leukemia:\nPatient presenting with increasing fatigue, dyspnea over the \npast 3 weeks with smear and bone marrow biopsy consistent with \nAML 8:21 translocation. RUNX1/RUNX1T1 rearrangement; C-Kit \nnegative. Rapid Heme panel negative. Patient underwent induction \nwith 7+3. Tolerated well without significant complications. He \nwas started on acyclovir, fluconazole, and cipro for \nprophylaxis. D14 BMBx w/ aplasia, but still w/ t(8;21) in 40% by \nkaryotype and 16% RUNX1 rearrangement by FISH. Discussed at \n___ conference and decided not to re-induce. Pt recovered \nhis counts, w/ANC 1540 and plt 444 on ___ and was able to d/c \nacyclovir and fluconazole on ___. BmBx also performed on ___ \ngiven recovery of counts, which on preliminary analysis revealed \nno morphologic or cytogenetic evidence of residual disease. Will \nplan for HDAC consolidation therapy for ___ wks post-discharge. \nPatient will also need port placed at time of next admission. \n\n#Rigors/fever\nRigors on ___. Was afebrile and VSS. Blood/Ucx negative without \nlocalizing symptoms. He was started on empiric cefepime. Did \nwell until he had fever on ___ with associated chills. Again no \nlocalizing symptoms, but suspect likely in the setting of marrow \nrecovery. ___ 1540 on ___ from 780 on ___. ___ 4700 on ___. \nGiven recovery of counts, d/c'ed cefepime on ___. \n\n#Pleuritic chest pain\nPt complaining of chest pressure with deep breaths. No \npericardial fluid seen on echo. ?rub on exam vs coarse crackles \nanteriorly. ___ be mild pericarditis or pleuritis. Symptoms \ngradually improved throughout admission. \n\n#Chronic LLE skin lesion\nVerrucous papules/plaques on anterior LLE that were ongoing for \npast ___ years and asymptomatic. Skin biopsy was consistent with \nlichen amyloidosis that did not require any intervention. \n\n#Dizziness\nReports lightheaded upon getting up, relieved when laying down \nconcerning for orthostatic hypotension. Although orthostatics \nnegative. This was stable throughout admission.\n\nTRANSITIONAL ISSUES:\n====================\n- Patient has appointment with his primary oncologist, Dr. \n___ on ___, ___. Patient should call \n___ if he has not heard from the office within three \ndays of discharge. \n- Patient had bone marrow biopsy on ___, with final results \npending at time of discharge. \n- Patient will need to be readmitted for HiDAC consolidation \ntherapy ___ weeks following discharge, likely in the week of \n___. He will also need port placed during next admission. \n- Patient may f/u with ___ clinic (___) \nregarding lichen amyloidosis.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\nNone. \n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY: \nAcute Myeloid Leukemia\nLichen Amyloidosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you.\n\nWhy you were admitted\n- You were found to have leukemia, a cancer in your blood. \n\nWhat we did for you\n- We started treatment of your leukemia with chemotherapy. Your \ncounts went down and then recovered. Bone marrow biopsy after \nyour first cycle of chemotherapy showed you had no more cancer \ncells in your bone marrow. \n\nWhat you should do when you go home:\n- Pleas attend your follow-up appointment with your primary \noncologist, Dr. ___ on ___, ___. The \noffice will call you to schedule the exact time. If you have not \nheard from the office within three days of discharge, please \ncall the office at ___. \n\nWe wish you the best,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "C9200", "E854", "D701", "K1230", "L99", "K219", "R0781", "R42", "R300", "R197", "T451X5A", "R5081", "Y92239" ]

[ "C9200: Acute myeloblastic leukemia, not having achieved remission", "E854: Organ-limited amyloidosis", "D701: Agranulocytosis secondary to cancer chemotherapy", "K1230: Oral mucositis (ulcerative), unspecified", "L99: Other disorders of skin and subcutaneous tissue in diseases classified elsewhere", "K219: Gastro-esophageal reflux disease without esophagitis", "R0781: Pleurodynia", "R42: Dizziness and giddiness", "R300: Dysuria", "R197: Diarrhea, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "R5081: Fever presenting with conditions classified elsewhere", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nfebrile neutropenia\n \nMajor Surgical or Invasive Procedure:\nPOC removal ___\n\n \nHistory of Present Illness:\nHPI: \n___ with history of AML on HiDAC C4D13 presenting to the ED \nwith fever and submandibular swelling. The patient reports he \nhad a small \"bump\" under his chin for over a week. This morning \nhe awoke and found the bump had dramatically enlarged, became \ntender to touch, and he developed fevers. He then presented to \nthe hospital. He denies CP, SOB, N/V/D, abdominal pain.\n\nIn the ED: \nVS: T 102.9 | HR120 | BP 137/87 | 20 | 100% RA \nHis evam was notable for: Small pustule on R scalp, palpable \nfluctuant 3cm diameter ? abscess in submandibular region.\nLabs Notable for WBC 0.1, HGB of 8.4 and plt of 14. Also sodium \nof 131.\n\nHe was given:\n13:22 IVF NS \n14:19 PO Acetaminophen 1000 mg \n14:37 IV Vancomycin\n16:21 IV CefePIME 2 g \n\nOn the floor, he arrived in stable condition, still febrile and \nconfirmed the above story\n \nPast Medical History:\nPast Medical History:\nOther than his malignancy, he has no medical conditions.\n \nPast Onc History:\nInitial presentation of AML on ___ to ___, \ntransferred to ___ for Leukocyotosis with blastsand Bone \nmarrow confirmed. Bone marrow biopsy confirmed acute myeloid \nleukemia, t(8;21), RUNX1/RUNX1T1 rearrangement.\n\nPatient was started on 7+3 on ___. Day 14 bone marrow with \n\naplasia but persistent t(8;21) in 40% of cells per karyotype and \n\nRUNX1/RUNX1T1 rearrangement in 16% per FISH. Decision was made \nnot to re-induce. Day 21 bone marrow on ___ was with no \nmorphologic or cytogenetic evidence of residual disease.\n\nTreatment History:\n- ___: 7+3\n- ___: BMB with ___\n- ___: C1D1 HiDAC\n- ___: C2D1 HiDAC\n- ___: C3D1 HiDAC\n- ___: C4D1 HiDAC \n \nSocial History:\n___\nFamily History:\nBoth mother and father died of old age. He denies any family \nhistory of malignancy or blood disorders.\n \nPhysical Exam:\nAdmission Physical Exam:\nVitals: 98.8 | PO 130/69 | 87 | 18 | 100% RA \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: 2cm fluctuant nodule in left submandibular region with \nsmall central lesion. No JVP appreciated. \nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses other than \nnoted above\nNEURO: A&Ox3.\nLINES: Left Portacath heparin dependent\n\nDischarge Physical Exam:\nVS: TC 97.7 ___ 94-99%RA\nGen: pleasant & conversant, NAD. \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: submandibular swelling and erythema resolved. No \nfluctuance\nor tenderness appreciated.\nCV: Normocardic, regular. Normal S1/S2. No MRG. \nLUNGS: No increased WOB. CTAB. \nABD: +BS, soft, NT/ND \nEXT: WWP. No ___ edema. \nSKIN: Except as described above. No other petechiae/purpura\necchymoses.\nNEURO: A&Ox3, grossly non-focal\n \nPertinent Results:\nADMISSION LABS:\n___ 09:00AM BLOOD WBC-0.2*# RBC-2.51* Hgb-8.5* Hct-24.4* \nMCV-97 MCH-33.9* MCHC-34.8 RDW-15.9* RDWSD-56.5* Plt Ct-10*#\n___ 09:00AM BLOOD Neuts-23* Bands-0 Lymphs-75* Monos-0 \nEos-1 Baso-1 ___ Myelos-0 AbsNeut-0.05* \nAbsLymp-0.15* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 09:00AM BLOOD UreaN-14 Creat-0.7 Na-134 K-4.0 Cl-101 \nHCO3-24 AnGap-13\n___ 09:00AM BLOOD ALT-99* AST-41* AlkPhos-85 TotBili-0.4\n___ 09:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9\n\nMicrobiology:\n___ 1:15 pm BLOOD CULTURE positive x2\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n STAPH AUREUS COAG +. \n FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in \nMCG/ML\n ________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN-----------<=0.25 S\nERYTHROMYCIN----------<=0.25 S\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- 0.25 S\nOXACILLIN-------------<=0.25 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN CLUSTERS. \n Reported to and read back by ___ ___ (___), \n@11:10 ON\n ___. \n\nIMAGING:\n___ CT Neck IMPRESSION: \n1. There are a few prominent, though nonenlarged, cervical lymph \nnodes. 1 of which may correspond to the clinical area of \nconcern, but is not pathologically enlarged or necrotic. No \nmass or abscess is identified. \n2. Mild, nonspecific soft tissue stranding in the subcutaneous \ntissues \ninferior to the chin. \n3. Moderate mucosal thickening in the left maxillary sinus. \n\n___ CT Neck IMPRESSION:\n1. Left greater than right submental subcutaneous edema, \nconsistent with known cellulitis in this area, demonstrates mild \nprogression compared to 3 days earlier on ___. No \nfree fluid or abscess. \n2. Multiple small right upper lobe lung nodules measuring up to \n5 mm are new compared ___. In the setting of \nbacteremia, these may represent septic emboli. Atypical \ninfection may also be considered as the patient is neutropenic \n(Nocardia, etc). \n3. Moderate polypoid mucosal thickening in the left maxillary \nsinus with \nocclusion of the left ostiomeatal unit and a mucous retention \ncyst in the right maxillary sinus, similar to prior. Given the \nsmall periapical lucency involving ___ 14 or 15, as detailed \nabove, please correlate clinically whether there may be \nodontogenic etiology of sinus disease. \n\n___ CT Chest IMPRESSION: \n1. Numerous bilateral pulmonary nodules appear increased in \nnumber at least in the upper lobes since the prior neck CT and \nfavor infectious etiology, likely fungal in the setting of \nfebrile neutropenia. Correlate with clinical assessment. If \nthe patient's symptoms persist despite treatment, consider \nrepeat Chest CT in ___ weeks to reevaluate. \n2. Anemia. \n3. Minimal colonic diverticulosis. \n\n___ US Neck IMPRESSION: \n1. No drainable fluid collection. No abnormal lymph nodes. \n2. Mild skin thickening and subcutaneous edema of the submental \narea, \nconsistent with patient's known cellulitis. \n\n___ MANDIBLE PANOREX\n\nIMPRESSION: No periapical lucency. \n\n___ LIVER U/S\n\nIMPRESSION: \n \nEchogenic liver consistent with steatosis. Other forms of liver \ndisease \nincluding steatohepatitis, hepatic fibrosis, or cirrhosis cannot \nbe excluded on this examination. Unchanged from prior. \n \nCT CHEST ___\n\nIMPRESSION: \n \nMultiple scattered pulmonary nodules are minimally decreased in \nsize as \ncompared to chest CT ___. No new pulmonary nodules \nidentified. \n\nDISCHARGE LABS:\n___ 08:15AM BLOOD WBC-2.8* RBC-2.80* Hgb-9.4* Hct-28.3* \nMCV-101* MCH-33.6* MCHC-33.2 RDW-20.9* RDWSD-76.9* Plt ___\n___ 08:15AM BLOOD Neuts-42.9 ___ Monos-25.9* \nEos-0.4* Baso-0.7 NRBC-1.4* Im ___ AbsNeut-1.21* \nAbsLymp-0.83* AbsMono-0.73 AbsEos-0.01* AbsBaso-0.02\n___ 08:15AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+ \nMacrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-1+ Tear \nDr-1+\n___ 08:15AM BLOOD Plt Smr-NORMAL Plt ___\n___ 08:15AM BLOOD Glucose-103* UreaN-6 Creat-0.8 Na-140 \nK-4.2 Cl-103 HCO3-28 AnGap-13\n___ 08:15AM BLOOD ALT-51* AST-58* LD(LDH)-204 AlkPhos-82 \nTotBili-0.3\n___ 08:15AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.9 Mg-2.1\n___ 08:15AM BLOOD\n \nBrief Hospital Course:\nASSESSMENT/PLAN: Mr. ___ is a ___ year old male with AML s/p C4 \nof HiDAC (___) who presents with febrile neutropenia found to \nhave MSSA bacteremia and new pulmonary nodules.\n\nC4D38 ___\n\n#Febrile Neutropenia:\n#MSSA bacteremia: Likely source is skin and soft tissue \ninfection\nfrom an ingrown hair/folliculitis. MSSA growing from first set \nof\nblood cultures on ___, was on vancomycin and meropenem but\nnarrowed to cefazolin x 4 week course from POC removal\n(___). Patient has completed mandatory 2 weeks \ncourse\nof IV ABX with cefazolin in-house with NTD surveillance \ncultures.\nHowever, given concern for medical contraindication for central\nline access to provide intravenous antibiotics at home, we\nrecommend changing from cefazolin to linezolid PO as there is no\nbetter alternative for patient. Patient transitioned to \nlinezolid\non ___ and will continue until ___\n-surveillance cultures have been negative to date as above.\n-CT Neck negative for abscess\n-TTE no significant findings\n-ID consulted, recs appreciated--felt more comfortable tx as\nendovascular infection for extended course, per ___ team will\ntreat 4 week course from POC removal (___)\n - Chest CT concerning for fungal infection, see below\n - F/U panorex for abscess - negative\n - F/U b-glucan/galactomannan - negative on ___, see below \nfor repeat on ___\n\n#Lung Nodules: concerning for fungal infection, found \nincidentally on neck CT that were new and worsening on repeat \nimaging. Patient was switched from fluconazole to posaconazole \non ___ given these findings. However, due to elevated LFTs,\ndiscontinued posaconazole (___) which was thought to be \nthe likely culprit as well as ciprofloxacin. Per ID, patient \nwill require repeat CT chest in 4 weeks to monitor nodules but \nmay obtain earlier per primary oncologist. Repeat CT chest on \n___ showed multiple scattered pulmonary nodules that are \nminimally decreased in size as compared to chest CT ___. Although no new pulmonary nodules were identified, patient \nnow has elevated BD glucan and given his AML, he is at a high \nrisk for fungal PNA so initiated on voriconazole (d1: ___ with \nplan to follow up radiographically as above. He will likely need \na 6WK course.\n-Beta glucan 61 on ___ (was negative on ___\n-Asp galactomannan negative on ___ \n\n#Transaminitis: (improving). Thought to be secondary to \nmedication-effect (posaconazole likely culprit which was \ndiscontinued on ___. Liver ultrasound on ___ showed \nechogenic liver consistent with steatosis. Other forms of liver\ndisease including steatohepatitis, hepatic fibrosis, or \ncirrhosis cannot be excluded on this examination. Hep serologies \nwere unremarkable on ___. Re-consulted ID on ___ in light \nof worsening transaminitis to consider switch from cefazolin to\nvancomycin. ID thinks that his transaminitis is potentially from \nposaconazole which has been discontinued, as above, and would \nnot expect his LFTs to plateau until ___ days after \ndiscontinuing the offending agent. We will continue to monitor \nand trend LFTs closely particularly given initiation of \nvoriconaozle.\n\n#AML on HiDAC: s/p 4C of HIDAC. Patient counts now recovered, \ncontinue with Acyclovir 400mg BID prophylactically. \n\n#Pancytopenia: now recovered although noted some mild \ndowntrending of his WBC and ANC, etiology most likely secondary \nto chemotherapy. He had a positive hemoocult test on ___ and \n___. Repeat CBC/COAGS stable. Coombs negative. Will need GI \nconsult for further work-up \n-stopped filgrastim ___ \n-Singulair 10mg daily for history or mild urticarial reaction to \nplts transfusions\n\n#ACCESS: POC removed. No access. \n#CODE: Presumed Full\n#Contact: ___\n#DISPO: Discharged ___. RTC next week on ___ or ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Pantoprazole 40 mg PO Q24H \n3. Simethicone 40-80 mg PO QID:PRN gas pains \n4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES TID \n5. Ciprofloxacin HCl 500 mg PO Q12H \n6. Fluconazole 400 mg PO Q24H \n7. Montelukast 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Linezolid ___ mg PO Q12H \nyou will continue this medication until ___ \nRX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*30 \nTablet Refills:*0 \n2. Voriconazole 200 mg PO Q12H \n3. Acyclovir 400 mg PO Q12H \n4. Montelukast 10 mg PO DAILY \n5. Pantoprazole 40 mg PO Q24H \n6. Simethicone 40-80 mg PO QID:PRN gas pains \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nFebrile Neutrapenia\nMSSA Bacteremia\nPeripheral Pulmonary Nodules\n\nSecondary Diagnosis:\nAML\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\n\nYou were admitted due to fever when your blood counts were very \nlow. You were found to have a blood infection and you were \ntreated with IV antibiotics. Your fever has now resolved so we \ntransitioned you to an oral regimen of antibiotics with plan of \ncompleting on ___.\n\nPlease refer below for your appointment with Dr. ___\n\n___ was a pleasure taking care of you.\n\nSincerely\n\nYour ___ TEAM\n \nFollowup Instructions:\n___\n" ]

[ "A4101", "D61810", "L03221", "E871", "C92Z1", "L731", "R5081", "T451X5A", "Y92009", "R918", "R740", "T50995A", "Y92230" ]

[ "A4101: Sepsis due to Methicillin susceptible Staphylococcus aureus", "D61810: Antineoplastic chemotherapy induced pancytopenia", "L03221: Cellulitis of neck", "E871: Hypo-osmolality and hyponatremia", "C92Z1: Other myeloid leukemia, in remission", "L731: Pseudofolliculitis barbae", "R5081: Fever presenting with conditions classified elsewhere", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R918: Other nonspecific abnormal finding of lung field", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "T50995A: Adverse effect of other drugs, medicaments and biological substances, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "E871", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nFever.\n \nMajor Surgical or Invasive Procedure:\nNone.\n \nHistory of Present Illness:\nMr ___ is a ___ year old man with recently diagnosed AML with \nRUNX1/RUNX1T1 rearrangement, s/p induction with 7+3 (D1 ___ \nand s/p HiDAC consolidation (D1: ___, D3: ___, D5: \n___, who presented to clinic today for labs and was found \nto be febrile and\nneutropenic.\n\nFrom clinic note: \"Called to ___ 7 by nurse for fever to \n100.8. On interview, patient is feeling well with the exception \nof fever, chills, and mild right-sided chest pain. Otherwise, \nfeeling well. He denies shortness of breath, cough, abdominal \npain, nausea, vomiting, and diarrhea. Right-sided port is \nwithout pain or irritation.\"\n\nUpon arrival to the floor, he states that his temperature was \nactually 99.8 last night (although he told the nurse in clinic \ntoday that it was 100.8 last night). He woke up feeling slightly \nsweaty this morning, but states that this was due to using too \nmany blankets overnight. Otherwise, he has been feeling well. He \ndid note a couple days of RUQ pain upon moving or swallowing, \nbut this has since resolved. Finally, he stated that his calves \nhave been slightly sore recently when walking. Otherwise no \ncomplaints. No recent travel. Had a friend with a cold last \nweek, otherwise no sick contacts.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nPatient presented to ___ with a 3 week history of\nweakness associated with dyspnea on exertion and chest pain on\n___ and was transferred to ___ for further evaluation by\nheme/onc when a CBC revealed leukocytosis with blasts. Bone\nmarrow biopsy confirmed acute myeloid leukemia, t(8;21),\nRUNX1/RUNX1T1 rearrangement. Patient was started on 7+3 on\n___. Day 14 bone marrow with aplasia but persistent \nt(8;21)\nin 40% of cells per karyotype and RUNX1/RUNX1T1 rearrangement in\n16% per FISH. Decision was made not to re-induce. Day 21 bone\nmarrow on ___ was with no\nmorphologic or cytogenetic evidence of residual disease. \n\nPAST MEDICAL/SURGICAL HISTORY: \nHe is in excellent health and has had no past problems.\n\n \nSocial History:\n___\nFamily History:\nBoth mother and father died of old age. He denies any family\nhistory of malignancy or blood disorders.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n===========================\nVitals: T98.1 BP 110/64 P 98 RR 21 O2 100% RA\nGen: Pleasant, calm, ___ speaking gentleman \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nNECK: JVP flat. Normal carotid upstroke without bruits. \nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. On L foreleg, few scattered raised \npatches with superficial scale. No cords/redness in b/l calves. \n \nNEURO: A&Ox3.\nLINES: R POC: c/d/I\n\nDISCHARGE PHYSICAL EXAM:\n===========================\nVitals: Tm 98.6 BP ___ P ___ RR 20 O2 95-100% RA\nGen: Pleasant, calm, ___ speaking gentleman. \nHEENT: No icterus. MMM. OP clear. \nNECK: JVP flat. Normal carotid upstroke without bruits. \nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. On L foreleg, few scattered raised \npatches with superficial scale. No cords/redness in b/l calves. \n \nNEURO: A&Ox3.\nLINES: R POC: c/d/I\n \nPertinent Results:\nADMISSION LABS:\n========================\n___ 08:55AM BLOOD WBC-1.1*# RBC-2.35* Hgb-7.6* Hct-21.7* \nMCV-92 MCH-32.3* MCHC-35.0 RDW-15.0 RDWSD-50.4* Plt Ct-34*\n___ 08:55AM BLOOD Neuts-3* Bands-0 ___ Monos-67* \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-0.03* \nAbsLymp-0.33* AbsMono-0.74 AbsEos-0.00* AbsBaso-0.00*\n___ 08:55AM BLOOD Glucose-122* UreaN-13 Creat-0.9 Na-135 \nK-3.7 Cl-100 HCO3-22 AnGap-17\n___ 08:55AM BLOOD ALT-32 AST-20 AlkPhos-68 TotBili-0.2\n___ 08:55AM BLOOD CK-MB-<1 cTropnT-<0.01\n___ 08:55AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.8\n___ 10:00AM URINE Color-Yellow Appear-Clear Sp ___\n___ 10:00AM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 10:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE \nEpi-<1\n___ 10:00AM URINE CastHy-5*\n___ 10:00AM URINE Mucous-MOD\n\nIMAGING:\n========================\nCXR ___: \nComparison to ___. No relevant change is noted. No \nevidence of pneumonia. Normal size of the cardiac silhouette. \nNormal hilar and \nmediastinal contours. No pulmonary edema. No pleural \neffusions. \n\nMICROBIOLOGY:\n========================\n___ 5:29 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n Respiratory Viral Culture (Pending): \n Respiratory Viral Antigen Screen (Pending): \n \n___ 12:00 am BLOOD CULTURE Source: Line-PORT. \n Blood Culture, Routine (Pending):\n\n___ 10:00 am URINE ___. \n **FINAL REPORT ___\n URINE CULTURE (Final ___: NO GROWTH. \n \n___ 9:25 am BLOOD CULTURE\n Blood Culture, Routine (Pending): \n\nPERTINENTS LABS:\n========================\nN/a\n\nDISCHARGE LABS:\n========================\n___ 12:28AM BLOOD WBC-4.4 RBC-2.66* Hgb-8.4* Hct-24.7* \nMCV-93 MCH-31.6 MCHC-34.0 RDW-16.4* RDWSD-54.5* Plt ___\n___ 12:28AM BLOOD Neuts-37 Bands-10* ___ Monos-25* \nEos-0 Baso-0 Atyps-1* Metas-6* Myelos-0 Blasts-2* NRBC-3* \nAbsNeut-2.07 AbsLymp-0.88* AbsMono-1.10* AbsEos-0.00* \nAbsBaso-0.00*\n___ 12:28AM BLOOD Glucose-111* UreaN-10 Creat-0.6 Na-137 \nK-4.2 Cl-102 HCO3-25 AnGap-14\n___ 12:28AM BLOOD ALT-41* AST-30 LD(LDH)-181 AlkPhos-79 \nTotBili-0.2\n___ 12:28AM BLOOD Albumin-3.8 Calcium-9.0 Phos-4.3 Mg-2.1\n \nBrief Hospital Course:\nMr ___ is a ___ year old man with recently diagnosed AML with \nRUNX1/RUNX1T1 rearrangement, s/p induction with 7+3 (D1 ___ \nand s/p HiDAC consolidation (D1: ___, D3: ___, D5: \n___, who presented to clinic for labs and was found to be \nfebrile and neutropenic.\n\n# Febrile neutropenia. Pt self-reports fever to 100.8 prior to \nadmission. He had 2 fevers during admission, with last one on \n___ (to 100.6). Otherwise no infectious or localizing \nsymptoms. He was well appearing and non-toxic on exam. No \nhemodynamic instability or other signs to suggest severe \ninfection/sepsis. He received a dose of both Vancomycin and \nCefepime in clinic prior to being admitted. Vancomycin was \nstopped on admission due to his benign clinical status. Cefepime \nwas continued for the duration of admission (Day 1: ___, \nand stopped upon discharge. UA, UCx, CXR did not show evidence \nof infection. Blood and Port cultures were obtained and remained \nnegative during admission, with blood cultures still pending at \ntime of discharge. \n\n# AML. S/p induction with 7+3 (D1 ___ and s/p 1 cycle of \nHiDAC consolidation. Has a history of transfusion reaction \n(hives) in setting of platelet transfusion, without respiratory \ndistress. Last transfusion ___. CBC, chemistry, LFTs \nmonitored daily. He did not require any transfusions, and his \ncounts improved to ANC >1000 prior to discharge (see above). His \nprophylactic medications were held upon discharge due to his \nrecovering counts, but he was instructed to hold onto these \nmedications as he will need them in the future.\n\n# RUQ pain. Unclear etiology of pain, although suspicion for ACS \nis very low given pain is now resolved and Troponin negative. \nThis did not re-occur during admission.\n\n# Calf pain. Pt states he has had b/l calf pain for days-weeks. \nNo palpable cord, redness, warmth on exam to suggest DVT in \neither leg. No further work-up was implemented. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 4 mg PO Q8H:PRN nausea \n2. Acyclovir 400 mg PO Q12H \n3. Ciprofloxacin HCl 500 mg PO Q12H \n4. Fluconazole 400 mg PO Q24H \n5. Montelukast 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Ondansetron 4 mg PO Q8H:PRN nausea \n2. HELD- Acyclovir 400 mg PO Q12H This medication was held. Do \nnot restart Acyclovir until instructed to do so by your doctor.\n3. HELD- Ciprofloxacin HCl 500 mg PO Q12H This medication was \nheld. Do not restart Ciprofloxacin HCl until instructed to do so \nby your doctor.\n4. HELD- Fluconazole 400 mg PO Q24H This medication was held. \nDo not restart Fluconazole until instructed to do so by your \ndoctor.\n5. HELD- Montelukast 10 mg PO DAILY This medication was held. \nDo not restart Montelukast until instructed to do so by your \ndoctor.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\nFebrile neutropenia\n\nSECONDARY:\nAcute myelogenous leukemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___.\n\nWhy was I in the hospital?\nYou were in the hospital because you had a fever at home, and \nyour blood counts are very low.\n\nWhat happened to me in the hospital?\nWe gave you antibiotics to fight infection. We did tests of your \nblood and urine to look for infection, but did not find any.\n\nWhat should I do when I leave the hospital?\nYou should go to your follow up appointment at 8am on ___. \nYou do not need to take any medicines for now.\n\nBest wishes,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "D709", "C9200", "R5081", "R1011", "M79662", "M79661", "L729" ]

[ "D709: Neutropenia, unspecified", "C9200: Acute myeloblastic leukemia, not having achieved remission", "R5081: Fever presenting with conditions classified elsewhere", "R1011: Right upper quadrant pain", "M79662: Pain in left lower leg", "M79661: Pain in right lower leg", "L729: Follicular cyst of the skin and subcutaneous tissue, unspecified" ]

[]

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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:\nAdmit for Cycle 2 HIDAC\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo M with no past medical history and recent diagnosis of\nacute myeloid leukemia s/p 7+3 admitted for cycle 2 of HiDAC.\n\nCommunicated with patient using interpretor (in person). Pt \nfeels well. Denies any sort of infectious symptoms. He mentions \nthat he worked as a ___ and in ___. He \ndenies all ROS.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nPatient presented to ___ with a 3 week history of\nweakness associated with dyspnea on exertion and chest pain on\n___ and was transferred to ___ for further evaluation by\nheme/onc when a CBC revealed leukocytosis with blasts. Bone\nmarrow biopsy confirmed acute myeloid leukemia, t(8;21),\nRUNX1/RUNX1T1 rearrangement. Patient was started on 7+3 on\n___. Day 14 bone marrow with aplasia but persistent \nt(8;21)\nin 40% of cells per karyotype and RUNX1/RUNX1T1 rearrangement in\n16% per FISH. Decision was made not to re-induce. Day 21 bone\nmarrow on ___ was with no\nmorphologic or cytogenetic evidence of residual disease. \n\nPAST MEDICAL/SURGICAL HISTORY: \nHe is in excellent health and has had no past problems.\n\n \nSocial History:\n___\nFamily History:\nBoth mother and father died of old age. He denies any family\nhistory of malignancy or blood disorders.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n___: NAD\nVITAL SIGNS:97.4 PO ___ 20 98 RA \nHEENT: MMM, no OP lesions, \nCV: RRR, NL S1S2 no S3S4 MRG\nPULM: CTAB. No crackles or wheezes\nABD: BS+, soft, NTND, \nLIMBS: No edema, clubbing, tremors, or asterixis; \nSKIN: No rashes or skin breakdown\nNEURO: No focal deficits observed.\n\nDISCHARGE PHYSICAL EXAM:\nT 98.0 BP 116/68 HR 85 RR 18 O2 98%RA\n___: Pleasant, well appearing. NAD\nHEENT: Anicteric. MMM, no OP lesions, \nCV: RRR, NL S1S2 no S3S4 MRG.\nPULM: CTAB. No crackles or wheezes\nGI: BS+, soft, NTND. No HSM.\nMSK: No edema, clubbing, tremors, or asterixis; Normal bulk\nSKIN: No rashes or skin breakdown\nNEURO: CN II-XII intact. AAOx3. FTN intact without dysmetria. \nNo DDK. No truncal ataxia. Tandem gait intact.\n\n \nPertinent Results:\n___ 05:45PM BLOOD WBC-4.0 RBC-2.67* Hgb-8.8* Hct-25.9* \nMCV-97 MCH-33.0* MCHC-34.0 RDW-19.1* RDWSD-64.4* Plt ___\n___ 12:00AM BLOOD WBC-4.3 RBC-3.02* Hgb-9.6* Hct-29.6* \nMCV-98 MCH-31.8 MCHC-32.4 RDW-19.2* RDWSD-66.9* Plt ___\n___ 12:00AM BLOOD WBC-10.4*# RBC-2.71* Hgb-8.9* Hct-26.7* \nMCV-99* MCH-32.8* MCHC-33.3 RDW-19.5* RDWSD-68.8* Plt ___\n___ 02:00AM BLOOD WBC-3.4*# RBC-2.84* Hgb-9.2* Hct-27.8* \nMCV-98 MCH-32.4* MCHC-33.1 RDW-18.9* RDWSD-67.4* Plt ___\n___ 12:20AM BLOOD WBC-4.8 RBC-2.66* Hgb-9.8* Hct-28.9* \nMCV-109*# MCH-36.8*# MCHC-33.9 RDW-14.6 RDWSD-58.0* Plt ___\n\n___ 05:45PM BLOOD Glucose-109* UreaN-12 Creat-0.9 Na-139 \nK-4.0 Cl-103 HCO3-27 AnGap-13\n___ 12:00AM BLOOD Glucose-157* UreaN-13 Creat-0.7 Na-137 \nK-4.5 Cl-104 HCO3-24 AnGap-14\n___ 12:00AM BLOOD Glucose-182* UreaN-15 Creat-0.6 Na-137 \nK-3.6 Cl-103 HCO3-24 AnGap-14\n___ 02:00AM BLOOD Glucose-156* UreaN-10 Creat-0.6 Na-135 \nK-3.8 Cl-102 HCO3-25 AnGap-12\n___ 12:20AM BLOOD Glucose-131* UreaN-15 Creat-0.8 Na-137 \nK-3.8 Cl-101 HCO3-25 AnGap-15\n___ 10:21PM BLOOD Glucose-125* UreaN-12 Creat-0.5 Na-138 \nK-3.9 Cl-103 HCO3-26 AnGap-13\n\n___ 05:45PM BLOOD ALT-51* AST-36 AlkPhos-64 TotBili-0.2\n___ 12:00AM BLOOD ALT-52* AST-37 AlkPhos-68 TotBili-0.2\n___ 12:00AM BLOOD ALT-40 AST-25 AlkPhos-73 TotBili-0.3\n___ 02:00AM BLOOD ALT-39 AST-25 AlkPhos-52 TotBili-0.5\n___ 12:20AM BLOOD ALT-14 AST-22 AlkPhos-62 TotBili-0.2\n \nBrief Hospital Course:\nPRINCIPLE REASON FOR ADMISSION:\nMr ___ is a ___ year old man with recently diagnosed AML with\nt(8,21)/RUNX1/RUNX1T1 rearrangement, s/p induction with 7+3 (D1\n___ and s/p HiDAC consolidation, here for C2 HiDAC. \n\n# AML: Favorable genetics given t(8;21). Bone marrow biopsy, \nFISH, and cytogenetics on day 21 indicate complete response to \n7+3. Because of this, he is currently undergoing consolidation \nwith ___ cycles of HiDAC. Admitted for Cycle 2 of HiDAC; ___. Tolerated well without significant complaint. Of note, \nafter discussion with outpatient oncology team will hold off on \nppx anti-infectives on discharge (has been on acyclovir, cipro, \nand fluconazole). He will be seen in clinic on ___ for further \nre-evaluation. \n\nTransitional issues:\n- ___ eval on ___ for count check and re-eval\n- Consider restarting ppx anti-infectives.\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\nNone\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute myeloid leukemia\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. You admitted for HiDAC \nchemotherapy for your AML. You tolerated the infusion well. \nPlease note we have stopped several medications that help \nprevent infection (acyclovir, fluconazole, and ciprofloxacin). \nPlease discuss with Dr. ___ during your follow up \nappointments if you should restart these medications.\n\nYou will need to follow up in clinic to have your blood counts \nmonitored. These appointments have been scheduled as below. It \nhas been a pleasure taking care of you,\n\nSincerely,\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C9200", "Z91048" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C9200: Acute myeloblastic leukemia, not having achieved remission", "Z91048: Other nonmedicinal substance allergy status" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Topamax / Reglan\n \nAttending: ___.\n \nChief Complaint:\nLow back pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old woman with history of pudendal neuralgia s/p \nintrathecal pump placement in ___ and with ongoing narcotic \nuse, hypothyroidism and history of an arrhythmia who presents \nwith pain at the site of her intrathecal pain pump catheter and \nurinary retention, transferred from ___ on ___ for \nrule-out of cord compression. She was reportedly unable to \nundergo MRI due to pump. CT L spine revealed no signs of \ninfection. However, where catheter bends and overlaps the L2 \nspinous process is quite superficial and had some mild \nsurrounding inflammatory stranding of the soft tissue. Per ___ \nPain Service, this inflammation could be causing the pain. Pt \nwas seen by Neurology service who felt cord compression \nunlikely. Ultimately urinary retention was thought to be due to \nincreased ziconotide in pump, and she was discharged with a \nFoley. She returns now for worsening pain overlying the pump. \n Of note, the patient's opioids are managed by an outpt provider \nin ___, and pump is managed by a provider in ___. Her visiting \nnurse contacted her spine surgeon in ___, who reportedly \ngave the nurse the order to shut off her pump (unclear reasons). \nThe pump was shut off, resulting in worsening back pain which \nprompted the pain to come to the ED. She notes she took 5mg \nmethadone as well as smoked marijuana for the pain prior to \ncoming in. She also notes buttock's paresthesias, which are new. \nShe had one reported fall when getting out of her car in the ED \nbut was able to stand back up and walk. Denies any fevers. She \ncontinues to have foley in. \n In the ED, initial vital signs were: 97.7 74 102/57 16 98% RA \n - Exam was notable for: very uncomfortable female, no visible \nevidence of infection overlying lumbar incision site; poor \neffort with motor exam due to pain but grossly intact, \nperirectal sensation intact, able to increase rectal tone \n - Labs were notable for: ___ ct 3.5, CRP: 0.4 \n - Imaging: none \n - The patient was given: 1g IV dilaudid \n - Consults: none \n Upon arrival to the floor, pt continues to have severe lower \nback pain as well as buttocks paresthesias. She also notes \nhaving a migraine HA. \n \nPast Medical History:\nHYPOTHYROIDISM \nARRHYTHMIA \nPUDENDAL IMPINGEMENT SYNDROME s/p INTRATHECAL PUMP PLACEMENT\nSOMATIZATION DISORDER\n\n \nSocial History:\n___\nFamily History:\nNo cardiac or cancer history in either parent. Mother and sister \nwith depression. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: 98.9, 115/76, 94, 20, 100% on RA \n GENERAL: uncomfortable female, lying on R side in bed \n HEENT: NC/AT, no scleral icterus, PERRLA, EOMI \n CARDIAC: RRR, normal S1/S2, no murmurs \n PULMONARY: clear to auscultation bilaterally \n ABDOMEN: normal bowel sounds, soft, non-tender, non-distended \n EXTREMITIES: no edema \n NEUROLOGIC: TTP to palpation over lumbar incision site \n where pump catheter is. Rectal tone intact, mild decreased \nsensation over buttocks to gross touch (R>L) but intact by \npinprick, ___ sensation intact, ___ dorsiflexion and \nplantar flexion, hip flexion limited by pain \n\nDISCHARGE PHYSICAL EXAM:\nVITALS: 98, 122/68, 78, 18, 98% on RA\nGENERAL: uncomfortable female, lying on R side in bed \nHEENT: NC/AT, no scleral icterus, PERRLA, EOMI. R tympanic \nmembrane with mild inferior bulge and apparent purulence in \nmiddle ear. \nCARDIAC: RRR, normal S1/S2, no murmurs \nPULMONARY: clear to auscultation bilaterally \nABDOMEN: normal bowel sounds, soft, non-tender, non-distended \nEXTREMITIES: no edema \nNEUROLOGIC: TTP to palpation over lumbar incision site where \npump catheter is. Gait slow but normal.\n \nPertinent Results:\nRELEVANT LABS:\n___ 05:52AM BLOOD WBC-2.7* RBC-3.65* Hgb-10.9* Hct-31.7* \nMCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 RDWSD-38.8 Plt ___\n___ 10:05PM BLOOD Calcium-9.4 Phos-4.6* Mg-1.8\n___ 10:05PM BLOOD Glucose-94 UreaN-8 Creat-0.6 Na-142 K-3.9 \nCl-106 HCO3-28 AnGap-12\n___ 07:38AM BLOOD WBC-3.3* RBC-4.13 Hgb-12.2 Hct-36.2 \nMCV-88 MCH-29.5 MCHC-33.7 RDW-12.5 RDWSD-39.8 Plt ___\n___ 07:38AM BLOOD Glucose-86 UreaN-7 Creat-0.6 Na-141 K-3.7 \nCl-104 HCO3-25 AnGap-16\n___ 10:05PM BLOOD CRP-0.4\n___ 07:38AM BLOOD Calcium-9.5 Phos-5.4* Mg-1.8\n___ 05:58PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 05:58PM URINE Color-Straw Appear-Clear Sp ___\n\nMICROBIOLOGY:\n___ BLOOD CULTURE PENDING\n \nBrief Hospital Course:\n___ with chronic pudendal impingement syndrome s/p intrathecal \npump for ziconotide infusion with recent admission ___ for \nacute urinary retention and pain at intrathecal pump catheter \nsite who now presented one day after discharge with continued \npain at intrathecal pump. \n \nACUTE ISSUES: \n#Low back pain - Pt with recent admission for acute pain over \nintrathecal catheter site for her chronic pudendal impingement \nsyndrome. CT of the lumbar spine at that time revealed no signs \nof infection. However, where catheter bends and overlaps the L2 \nspinous process is superficial and had some mild surrounding \ninflammatory stranding of the soft tissue. Per ___ Pain \nService, this inflammation could be causing the pain. Neurology \nalso saw the patient during last admission and there were no \nconcerns for cord compression. She was discharged home on ___ \nand woke on ___ with worsening pain and buttocks paresthesias, \nwhich actually occurred prior to her intrathecal pump being \nturned off. History of paresthesias and report of falling \nconcerning for acute cord syndrome however she was again seen by \nthe Neurology consult service and exam was not concerning for \ncord compression. Pain Service was consulted again and \nincreased her methadone to 7.5mg TID, and replaced her \nshort-acting hydromorphone with oxycodone to avoid development \nof narcotic tolerance. She was started on a methylprednisolone \ntaper with improvement in her pain. She was continued on her \nother pain medications with the exception of Exalgo, which was \nsubstituted with hydromorphone short-acting 4mg q6h (Exalgo is \nnon-formulary at ___. Neurosurgery was consulted and \ndeclined to intervene surgically on the pump catheter site; they \nrecommended she follow up with the physician who manages her \npump, Dr. ___. ___, a representative from \n___, the company which adjusts the patient's intrathecal pump \nsettings, confirmed on day of discharge by phone that she would \nbe visiting the patient at home to empty the pump of ziconotide \nand replace with saline, per Dr. ___ order. Patient \nstated she would seek another pain specialist in ___ \nto manage her Prometra pump.\n\n#Acute urinary retention - Noted last hospital admission, felt \nto be secondary to recent increase in ziconotide dose on ___. \nPump was unable to be decreased last hospital admission due to \nlack of legal permission for pump company to provide inpatient \nservices at ___, and pt was discharged with Foley. Now that \npump was turned off, Foley catheter was removed on ___ and \npatient passed voiding trial. She had no further urinary \nretention during this admission.\n\n#Otitis media - Patient complained of right ear pain and \nfullness on day of discharge. She had been having symptoms for \nseveral days prior to this admission and reported a URI in the \nfew weeks prior to admission. Exam revealed otitis media of the \nright ear. She was started on azithromycin for a 5-day course \ngiven her penicillin allergy.\n\nCHRONIC ISSUES: \n#Orthostatic hypotension - Patient was again noted to have \northostatic lightheadedness intermittently. She received IV \nfluids with improvement in her BP and symptoms. She was \ninstructed to monitor her BP at home and call her PCP or seek \nmedical attention if her orthostatic symptoms returned. \n\n#Migraine: continued on sumatriptan prn.\n \n#HYPOTHYROIDISM: continued levothyroxine.\n \n#HX OF HTN/CARDIAC ARRHYTHMIA: Continued home Verapamil.\n \n#PSYCH: Continue home medications, including buspirone, Ativan, \ntrazadone, duloxetine, abilify, lyrica \n\n#Constipation: chronic in setting of opioids. Continued home \nmiralax daily. \n\n#GERD: continued home ranitidine and PPI.\n \nTRANSITIONAL ISSUES:\n- Patient discharged with methylprednisolone taper, with last \nday ___.\n- Patient discharged with azithromycin for otitis media, with \nlast day ___.\n- Hydromorphone (short-acting) was stopped and oxycodone 10mg \nq8h prn pain was started. \n- Patient had mild leukopenia (WBC 2.8) and anemia (Hgb ___ \nthat was stable during this admission. Consider outpatient \nworkup.\n- Patient has had chronic orthostatic lightheadedness. Consider \nadjusting her antihypertensive medications and further \noutpatient workup. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BusPIRone 15 mg PO TID \n2. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN PAIN \n3. Levothyroxine Sodium 150 mcg PO DAILY \n4. LORazepam 1 mg PO Q4H:PRN anxiety \n5. Methadone 5 mg PO TID \n6. Ondansetron 4 mg PO Q8H:PRN nausea \n7. Polyethylene Glycol 17 g PO DAILY \n8. Pregabalin ___ mg PO DAILY \n9. Ranitidine 300 mg PO QHS \n10. Tizanidine 2 mg PO TID \n11. TraZODone 100 mg PO QHS:PRN insomnia \n12. Verapamil SR 120 mg PO Q24H \n13. DULoxetine 120 mg PO DAILY \n14. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR \n15. NexIUM (esomeprazole magnesium) 40 mg oral DAILY \n16. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain \n17. Sumatriptan Succinate 6 mg SC ONCE:PRN HA \n18. ARIPiprazole 5 mg PO DAILY \n19. Albuterol 0.083% Neb Soln 1 NEB IH BID \n20. Elmiron (pentosan polysulfate sodium) 100 mg oral TID \n21. Exalgo ER (HYDROmorphone) 16 mg oral DAILY \n\n \nDischarge Medications:\n1. Albuterol 0.083% Neb Soln 1 NEB IH BID \n2. ARIPiprazole 5 mg PO DAILY \n3. BusPIRone 15 mg PO TID \n4. DULoxetine 120 mg PO DAILY \n5. Levothyroxine Sodium 150 mcg PO DAILY \n6. LORazepam 1 mg PO Q4H:PRN anxiety \n7. Methadone 7.5 mg PO TID \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. Polyethylene Glycol 17 g PO DAILY \n10. Pregabalin ___ mg PO DAILY \n11. Ranitidine 300 mg PO QHS \n12. Tizanidine 2 mg PO TID \n13. TraZODone 100 mg PO QHS:PRN insomnia \n14. Verapamil SR 120 mg PO Q24H \n15. Azithromycin 250 mg PO Q24H Duration: 4 Days \nLast day ___ \nRX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*4 \nTablet Refills:*0\n16. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain \nRX *oxycodone 10 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*21 Tablet Refills:*0\n17. Phenazopyridine 100 mg PO TID Duration: 3 Days \nRX *phenazopyridine [Pyridium] 100 mg 1 tablet(s) by mouth three \ntimes a day Disp #*5 Tablet Refills:*0\n18. Elmiron (pentosan polysulfate sodium) 100 mg oral TID \n19. Exalgo ER (HYDROmorphone) 16 mg oral DAILY \n20. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR \n21. NexIUM (esomeprazole magnesium) 40 mg oral DAILY \n22. Sumatriptan Succinate 6 mg SC ONCE:PRN HA \n23. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain \n24. Methylprednisolone 6 mg PO TID Duration: 1 Day \nRX *methylprednisolone 4 mg 1 tablets(s) by mouth four times a \nday Disp #*1 Dose Pack Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses:\nLow back pain\nAcute urinary retention\nOtitis media\n\nSecondary Diagnoses:\nHypertension\nMigraine\nOrthostatic hypotension\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 for worsening back pain. Your \nexam and blood work were not concerning for any neurological \nchanges. We changed one of your pain medications, increased \nyour methadone dose, and started you on a steroid taper and your \nsymptoms improved. Please complete the steroid taper after \ndischarge and follow up with your pain doctor. \n\nWe removed your Foley catheter and your urinary retention \nresolved.\n\nWhile you were here, you were also diagnosed with a middle ear \ninfection of your right ear. Please finish taking 5 days total \nof azithromycin. \n\nBest wishes,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "G588", "I10", "R338", "R202", "Z9689", "G43909", "E039", "F459", "H6691", "I951", "K219", "K5900" ]

[ "G588: Other specified mononeuropathies", "I10: Essential (primary) hypertension", "R338: Other retention of urine", "R202: Paresthesia of skin", "Z9689: Presence of other specified functional implants", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "E039: Hypothyroidism, unspecified", "F459: Somatoform disorder, unspecified", "H6691: Otitis media, unspecified, right ear", "I951: Orthostatic hypotension", "K219: Gastro-esophageal reflux disease without esophagitis", "K5900: Constipation, unspecified" ]

[ "I10", "E039", "K219", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Topamax / Reglan\n \nAttending: ___.\n \nChief Complaint:\n============================\nHMED Admission H&P\n============================\n\nCC: Back pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a history of \ndebilitating pudendal neuralgia who was admitted in ___ and \n___ with worsening back pain, who presented to the ED \ntoday with subacutely worsening back pain. She had an \nintrathecal ziconotide pump for placed in ___ in ___ \nand had presented to ___ in ___ with worsened back pain at \nthe site of the pump as well as urinary retention. Cord \ncompression was ruled out at that time and her ziconotide was \nstopped (this was suspected as the cause of her urinary \nretention), and she was also started on prednisone for her pain \nwhich was attributed to inflammation around the site of her pump \ncatheter where it passes by the L2 spinous process. She has \nalso been managed on multiple chronic narcotics and other agents \nfor her pain. During the prior admission she was seen by \nneurology, neurosurgery, and pain service. \n\nShe reports that initially the steroids were extremely helpful \nat controlling her pain but that she has been completing a slow \ntaper. The plan had been tapering to 15 mg in ___ and 10 mg \nin ___, but in recent weeks she has had worsening control \nof her pain, similar to its prior location and quality. The pain \nis most severe over the lumbar incision site and is severe to \nthe point of limiting basic daily function - has been using \ncommode d/t difficulty ambulating ___ pain. She is followed \nclosely by her PCP, who increased the steroids back to 40 mg \ndaily and attempted a rapid taper with 4 days of 40mg, 4 days of \n30, and 4 days of 20. She noted some slight improvement with the \nincrease to 40 mg but subsequently returned to severe pain when \nthis was reduced to 30 and then 20. She also notes that she no \nlonger sees the doctor in ___ who placed her pump. She reports \nthat her PCP obtained an MRI in recent days, although she is \nunsure what the results showed. Her PCP recommended presenting \nto the ED given her worsening pain control. She denies any \nurinary retention, changes in bowel patterns, weakness, or \nnumbness. \n\nReview of systems: \nConst: no fevers, chills\nHEENT: + HA x 2 weeks, bilateral, constant non-pulsating \"not \nmigraine\"\nCV: + intermittent palpitations, no CP\nPulm: + occasional dyspnea associated with palpitations, \notherwise no dyspnea or cough\nGI: +RUQ pain for past week intermittently, no n/v, no changes \nin PO intake, no changes in BMs\nGU: no retention or urinary changes\nMSK: no new myalgias/arthralgias except as per HPI\nNeuro: no new focal weakness or numbness\nDerm: no new rashes\nHem: no new bleeding/bruising\nEndo: no hot/cold intolerance\nPsych: no recent mood changes\n\n \nPast Medical History:\nHYPOTHYROIDISM \nARRHYTHMIA \nPUDENDAL IMPINGEMENT SYNDROME s/p INTRATHECAL PUMP PLACEMENT\nSOMATIZATION DISORDER\n\n \nSocial History:\n___\nFamily History:\nNo cardiac or cancer history in either parent. Mother and sister \nwith depression. \n \nPhysical Exam:\nAdmission Physical Exam:\nVital signs: 98 120/72 68 18 99% RA\ngen: pt in NAD, lying in bed\nHEENT: nc/at, sclera anicteric, conjunctiva noninjected, PER, \nEOMI, MMMs\nCV: RRR no m/r/g\nPulm: CTAB No c/r/w\nAbd/GI: S NT ND BS+, no masses/HSM palpated (except pump)\nBack: tenderness over lumbar incision site\nExtr: wwp, distal pulses intact, no edema\nGU: no Foley\nNeuro: alert and interactive, strength, sensation, CNs grossly \nintact, reflexes brisk throughout all 4 extremities\nSkin: no rashes on limited skin exam\nPsych/MS: normal range of affect\n\nDischarge PE:\nVS: 98.0 132 / 84 86 18 100 RA \nGen: NAD, occasionally tearful, resting on her side\nHEENT: EOMI, PERRLA, MMM\nCV: RRR nl s1s2 no m/r/g\nResp: CTAB no w/r/r\nAbd: Soft, NT, ND +BS\nExt: no c/c/e\nBack: pump site c/d/I, no erythema or swelling, diffuse lower\nback tenderness to even light palpation of skin\nNeuro: CN II-XII intact, ___ strength throughout\nSkin: warm, dry no rashes\n \nPertinent Results:\nCBC: 6.0>12.6<227\nBMP: ___\nUA wnl\n\nMRI lumbar spine w/o contrast ___:\nImpression\nThere has been interval placement of hardware since the prior \nexam as further discussed above. This results in extensive \nartifact including regions of signal loss and distortion of the \nanatomy. Allowing for this limitation, there is persistent \nchanges of mild lumbar spondylosis but no definitive limiting \ncentral canal or foraminal stenosis at any level in the lumbar \nspine. \nExtrahepatic biliary ductal dilation.\n\nMRI thoracic spine w/o contrast ___:\nImpression\nMild chronic T6 and T9 compression fracture deformities. No \nlimiting central canal or foraminal stenosis at any level in the \nthoracic spine.\nExtrahepatic biliary duct dilation to 7.5 mm.\n\nRUQ ___: \n \nIMPRESSION: \nUnremarkable abdominal ultrasound. No evidence of biliary tree \ndilation. \nNormal CBD. \n\n \nBrief Hospital Course:\n___ year old woman with pudendal neuralgia status post \nintrathecal pump catheter placement in ___ treated with \nziconotide infusion complicated by urinary retention (pump \ncurrently not in use) presenting with worsening of chronic back \npain.\n\n#Pudendal neuralgia with severe subacute on chronic pain: \nNo significant change in character of pain, no fevers, chills, \nweakness, numbness, incontinence, retention or other concerning \nfindings. MRI T/L spine on ___ showing no concerning findings, \nno evidence of infection or significant spinal stenosis. \nChronic pain service was consulted. She reports she had \nsignificant benefit from her intrathecal pump prior to \ndeveloping side effect of urinary retention and having it \nstopped, she is interested in trialing another medication \nthrough the pump. On discharge in ___ she was counselled to \nfind a physician to manage the pump but has not done so, \nrecommended that she work on seeing an outpatient doctor who can \nmanage her Prometra intrathecal pump, given name and office \ninformation of a local physician who is certified to manage the \nPrometra pump. Concern that there is significant anxiety and/or \npossible somatization disorder contributing to symptoms. \n - Started Lidoderm patch, recommend following up with Dr. \n___ to manage her intrathecal pump.\n - Home ___\n - continuing home medication regimen, which is as follows:\n - methadone 5 tid prn\n - percocet 10 tid prn\n - pregabalin 150 AM 300 HS\n - Exalgo 16 mg daily (in hospital placed on hydromorphone 4 \nmg PO q6H as Exalgo non-formulary)\n - tizanidine 2 tid prn\n - ativan 1 q4h prn\n - duloxetine 120\n - elmiron (will use home med) and miralax for constipation\n - topical lidocaine PRN\n - increasing prednisone to 40 mg daily with taper of 10 mg \ndaily.\n - Recommend that she establish care with a psychiatrist and \ntherapist to help manage her anxiety and psychiatric disorders \nwhich are likely contributing significantly to her symptoms. \n\n#Abdominal pain\n#Biliary ductal dilation on MRI\nShe denies any current abdominal pain, n/v, pruritus, jaundice. \nLFTs normal and RUQ unremarkable without ductal dilation.\n\n#History of supraventricular arrhythmia\n-cont verapimil 120\n\n#HA:\nHistory of migraine headaches.\n - Continue home PRN Imitrex\n\n#Other home meds:\n - cont albuterol PRN for wheezing \n - cont abilify 5 for mood\n - cont buspar 15 TID for anxiety\n - cont synthroid ___ for hypothyroidis\n - cont PRN zofran for nausea\n - cont PRN trazodone for insomnia\n - cont home ranitidine and substitute omeprazole for protonix\nfor GERD\n\n# FEN: regular diet \n# Prophylaxis: Subcutaneous heparin \n# Access: peripherals \n# Communication: Patient \n# Code: Full (discussed with patient) \n# ___: home with home ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol 0.083% Neb Soln 1 NEB IH BID \n2. ARIPiprazole 5 mg PO DAILY \n3. BusPIRone 15 mg PO TID \n4. DULoxetine 120 mg PO DAILY \n5. Levothyroxine Sodium 125 mcg PO DAILY \n6. LORazepam 1 mg PO Q4H:PRN anxiety \n7. Methadone 5 mg PO TID \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. Polyethylene Glycol 17 g PO DAILY \n10. Pregabalin ___ mg PO DAILY \n11. Ranitidine 300 mg PO QHS \n12. Tizanidine 2 mg PO TID \n13. TraZODone 100 mg PO QHS:PRN insomnia \n14. Verapamil SR 120 mg PO Q24H \n15. Elmiron (pentosan polysulfate sodium) 100 mg oral TID \n16. Exalgo ER (HYDROmorphone) 16 mg oral DAILY \n17. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR \n18. NexIUM (esomeprazole magnesium) 40 mg oral DAILY \n19. Sumatriptan Succinate 6 mg SC ONCE:PRN HA \n20. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain \n21. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO TID \n22. Linzess (linaclotide) 290 mcg oral DAILY \n23. PredniSONE 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Lidocaine 5% Patch 1 PTCH TD QAM \nRX *lidocaine 5 % Apply one patch to lower back Daily Disp #*30 \nPatch Refills:*0 \n2. PredniSONE 40 mg PO DAILY \n40 mg daily x 1 week, 30 mg daily x 1 week, 20 mg PO daily x 1 \nweek then 10 mg PO daily x 1 week. \nTapered dose - DOWN \nRX *prednisone 10 mg As directed tablet(s) by mouth Daily Disp \n#*70 Tablet Refills:*0 \n3. Albuterol 0.083% Neb Soln 1 NEB IH BID \n4. ARIPiprazole 5 mg PO DAILY \n5. BusPIRone 15 mg PO TID \n6. DULoxetine 120 mg PO DAILY \n7. Elmiron (pentosan polysulfate sodium) 100 mg oral TID \n8. Exalgo ER (HYDROmorphone) 16 mg oral DAILY \n9. Levothyroxine Sodium 125 mcg PO DAILY \n10. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR \n11. Linzess (linaclotide) 290 mcg oral DAILY \n12. LORazepam 1 mg PO Q4H:PRN anxiety \n13. Methadone 5 mg PO TID \n14. NexIUM (esomeprazole magnesium) 40 mg oral DAILY \n15. Ondansetron 4 mg PO Q8H:PRN nausea \n16. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO TID \n17. Polyethylene Glycol 17 g PO DAILY \n18. Pregabalin ___ mg PO DAILY \n19. Ranitidine 300 mg PO QHS \n20. Sumatriptan Succinate 6 mg SC ONCE:PRN HA \n21. Tizanidine 2 mg PO TID \n22. TraZODone 100 mg PO QHS:PRN insomnia \n23. Verapamil SR 120 mg PO Q24H \n24. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute on chronic back pain\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:\nYou were admitted with worsening of your chronic back pain. You \nhad a recent MRI of your spine which did not show any \nsignificant abnormalities. You were seen by the chronic pain \nservice, you were started on a lidocaine patch. We recommend \nthat you follow-up with a pain physician who specializes in your \nPrometra pump. \n \nFollowup Instructions:\n___\n" ]

[ "G588", "E039", "F419", "K828", "I498", "K219", "Z9689", "F450" ]

[ "G588: Other specified mononeuropathies", "E039: Hypothyroidism, unspecified", "F419: Anxiety disorder, unspecified", "K828: Other specified diseases of gallbladder", "I498: Other specified cardiac arrhythmias", "K219: Gastro-esophageal reflux disease without esophagitis", "Z9689: Presence of other specified functional implants", "F450: Somatization disorder" ]

[ "E039", "F419", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Topamax / Reglan\n \nAttending: ___.\n \nChief Complaint:\nUrinary retention, pain at intrathecal pump catheter site\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThis is a ___ year old woman with history of pudendal neuralgia \ns/p intrathecal pump placement in ___ and with ongoing \nnarcotic use, hypothyroidism and history of an arrhythmia who \npresents with pain at the site of her intrathecal pain pump \ncatheter and urinary retention, transferred from ___ \nfor rule-out of cord compression. \n\nPatient has had several years of pain so disabling that she \"has \nnot been able to get out of bed for ___ years.\" She trialed many \ndifferent pain regimens (see pain management notes from this \ninstitution) and ultimately was seen by a pain management \nphysician in ___ for placement of an intrathecal pain pump in \n___. Since then, she has been able to get out of bed on at \nleast two occasions, though her pain is only moderately \nimproved. This week she developed new back pain at the site of \nthe pump's insertion and urinary retention. Also with one \nepisode of fecal incontinence in the setting of new nausea, \nvomiting X ___ yesterday and multiple episodes of watery diarrhea \nover the past week. No other incontinence during this time. No \nfevers, chills, chest pain, shortness of breath, melena, BRBPR. \n\n\nGiven the pain at the insertion site, she presented to ___ \n___ where she was reportedly neurologically stable and a CT \nwith IV contrast was unremarkable. She was bladder scanned there \nfor 800 cc urine, Foley was placed and she put out 1200cc urine. \nRequired 4mg IV dilaudid for pain control. She was then \ntransferred to ___ to rule out cord compression given pain and \nnew urinary retention. \n \nUpon arrival to the floor, she complains the light is bothering \nher eyes. She also details the history above. \n \nREVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes, \ncough, fevers, chills, dyspnea, chest pain, abdominal pain, \nnausea, vomiting, diarrhea, constipation, dysuria, rash and \nweakness. \n\n \nPast Medical History:\nHYPOTHYROIDISM \nARRHYTHMIA \nPUDENDAL IMPINGEMENT SYNDROME s/p INTRATHECAL PUMP PLACEMENT\nSOMATIZATION DISORDER\n\n \nSocial History:\n___\nFamily History:\nNo cardiac or cancer history in either parent. Mother and sister \nwith depression. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVITALS: 97.9F 113/68 76 18 96% on RA \nGENERAL: no acute distress, lying in bed \nHEENT: NC/AT, no scleral icterus, PERRLA, EOMI \nNECK: supple \nCARDIAC: RRR, normal S1/S2, no murmurs \nPULMONARY: clear to auscultation bilaterally \nABDOMEN: normal bowel sounds, soft, non-tender, non-distended \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema. Mild tenderness to palpation over lumbar incision site \nwhere pump catheter is. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, strength normal and \nsymmetric in the bilateral UE and ___ \n\nDISCHARGE PHYSICAL EXAM:\nVITALS: 98.3F 116/85 77 18 97% on RA\nGENERAL: no acute distress, lying in bed \nHEENT: NC/AT, no scleral icterus, PERRLA, EOMI \nNECK: supple \nCARDIAC: RRR, normal S1/S2, no murmurs \nPULMONARY: clear to auscultation bilaterally \nABDOMEN: normal bowel sounds, soft, non-tender, non-distended \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or edema \n \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, strength normal and \nsymmetric in the bilateral UE and ___ \n \nPertinent Results:\nADMISSION LABS:\n___ 12:20AM BLOOD WBC-3.2* RBC-3.84* Hgb-11.5 Hct-33.4* \nMCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 RDWSD-38.7 Plt ___\n___ 12:20AM BLOOD Neuts-28.9* Lymphs-56.1* Monos-12.5 \nEos-1.6 Baso-0.9 AbsNeut-0.93* AbsLymp-1.80 AbsMono-0.40 \nAbsEos-0.05 AbsBaso-0.03\n___ 12:20AM BLOOD Glucose-96 UreaN-10 Creat-0.7 Na-142 \nK-3.9 Cl-107 HCO3-27 AnGap-12\n___ 12:20AM BLOOD CK(CPK)-80\n___ 12:49AM URINE Type-RANDOM Color-Yellow Appear-Clear Sp \n___\n___ 12:49AM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG\n___ 12:49AM URINE RBC-4* WBC-1 Bacteri-FEW Yeast-NONE Epi-0\n___ 12:49AM URINE Mucous-RARE\n___ 12:14PM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE\n\nDISCHARGE LABS:\n___ 05:52AM BLOOD WBC-2.7* RBC-3.65* Hgb-10.9* Hct-31.7* \nMCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 RDWSD-38.8 Plt ___\n\nMICROBIOLOGY:\n**FINAL REPORT ___\n URINE CULTURE (Final ___: NO GROWTH. \n\n**FINAL REPORT ___\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 FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n NO E.COLI 0157:H7 FOUND.\n\n \nECG Study Date of ___ 7:51:52 AM \n \nClinical indication for EKG: ___.___ - QT interval for \nmedication \nmonitoring \n \nSinus rhythm. Normal tracing. \n \nRead by: ___. \n \n Intervals Axes \nRate PR QRS QT QTc (___) P QRS T \n83 ___ 426 54 63 55 \n \nIMAGING:\nSECOND OPINION READ OF CT (___) L-SPINE\nFINDINGS: \nThere is normal alignment of the lumbar spine. Mild ligamentum \nflavum \nthickening is seen at L3-4, L4-5 and L5-S1. No significant \nspinal canal or neural foraminal stenosis is seen. There is no \nacute fracture or \nmalalignment. \n \nThere is an intrathecal catheter which courses from the pump, \nwhich is not \nvisualized, through the left subcutaneous soft tissues of the \nback, between the L2-3 spinous process and into the thecal sac. \nTwo linear hyperdensities are noted within the soft tissues at \nthe level of the L3 spinous process, consistent with surgical \nsutures. Minimal stranding is noted within the posterior soft \ntissues, at the level of the L3 spinous process, likely \nsecondary to postsurgical changes. No fluid collection or soft \ntissue mass is identified along the course of the catheter. The \ncatheter extends from the through the T11- L2 spinal canal. No \ndiscontinuity is noted in the visualized catheter. \n \nA fluid-filled distended bladder is seen. Multiple sub cm \nhypodensities are noted in the kidneys, which are too small to \ncharacterize and likely represent simple cysts. \n \nIMPRESSION: \n1. Minimal soft tissue stranding in the posterior soft tissues \nof the back, at the L2-3 level, consistent with postsurgical \nchanges. No fluid collection or abscess identified along the \ncourse of the visualized catheter. \n \nBrief Hospital Course:\n___ with chronic pudendal impingement syndrome s/p intrathecal \npump for ziconotide infusion who was admitted for acute urinary \nretention and pain at intrathecal pump catheter site.\n\n#Acute urinary retention - Timing seems to coincide with recent \nincrease in ziconotide dose on ___. ___ Pain service was \nconsulted and recommended decreasing the ziconotide dose 20%, to \nprevious dose. However, ___ Pain service only has equipment \nfor ___ pumps and were not able to interrogate or adjust \nthe Flowonix Prometra pump, which the patient has. \nAdministrative approval was obtained for Pentec, the company who \nmanages patient's pump in the outpatient setting, to provide \nservices as inpatient. Given delay in ability of pump service \nagency to provide adjustment in the inpatient setting, patient \nwas discharged with Foley catheter with plan for decrease in \nziconotide dose as an outpatient, followed by Foley removal and \nvoiding trial.\n\n#Acute pain over intrathecal pump catheter site - Developed over \nthe ___ weeks prior to admission. CT L spine revealed no signs \nof infection. However, where catheter bends and overlaps the L2 \nspinous process is quite superficial and had some mild \nsurrounding inflammatory stranding of the soft tissue. Per \n___ Pain Service, this inflammation could be causing the pain. \n Pressure on the site over time from supine position (patient \nspends most of her time in bed due to debilitating pain) could \nexplain the timing of the pain 6 months after pump was placed. \nThe pain was partially relieved by lidocaine patches. Patient \nwas discharged with lidocaine ointment and Voltaren gel. Dr. \n___ at the ___ in ___, \nwho placed the pump, was contacted by phone on ___ regarding \nthis issue, and did not feel the catheter was causing the pain \nbut was willing to see the patient in followup. He recommended \nthat the patient find a local pain specialist in ___ \nwho could manage the pump and the ziconotide but was unable to \nprovide a referral to a specific specialist. ___ Pain was \nalso unable to provide this referral as the Flowonix brand of \nintrathecal pumps is essentially never used in the ___ of \n___. Patient will contact the vendor to request a \nreferral to an appropriate local provider. \n\n#Chronic low back pain and pelvic pain: Patient has been \ndebilitated by this pain for several years despite multiple \nprocedures. Her current narcotics are managed by Dr. ___ \n___ in ___ and her pump is managed by Dr. ___ \n___ in ___. She was continued on her home pain regimen, \nwhich was confirmed per phone conversation with Dr. ___ on \n___, with the exception of substituting regular release \nhydromorphone for her extended release hydromorphone due to it \nbeing non-formulary at ___.\n\n#Orthostatic hypotension: Pt had been having loose stools and \ndecreased PO intake, likely due to a viral gastroenteritis. She \nwas also on higher doses of hydromorphone at the beginning of \nthe hospitalization for acute on chronic pain. The orthostasis \nresolved with IV fluids, weaning of narcotics, and improvement \nin her gastroenteritis. Stool studies were negative for \ninfectious source.\n \nCHRONIC ISSUES:\n#HYPOTHYROIDISM: Continued levothyroxine.\n \n#HX OF HTN/CARDIAC ARRHYTHMIA: Continued home Verapamil.\n\n#PSYCH: Continued home medications.\n\nTRANSITIONAL ISSUES:\n- Patient will require routine Foley care\n- Voiding trial to be performed after intrathecal ziconotide \ndose is decreased by 20%. If no void within 8 hours, seek urgent \nmedical attention.\n- Patient will require ongoing followup with pain specialist and \nevaluation of intrathecal pump catheter incision site.\n- Patient had mild leukopenia (WBC 2.8) and anemia (Hgb ___ \nthat was stable during this admission. Consider outpatient \nworkup.\n- Consider routine periodic monitoring of CK levels while \npatient is on ziconotide.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN PAIN \n2. LORazepam 1 mg PO Q4H:PRN anxiety \n3. Methadone 5 mg PO TID \n4. DULoxetine 60 mg PO BID \n5. Pregabalin ___ mg PO DAILY \n6. NexIUM (esomeprazole magnesium) 40 mg oral DAILY \n7. Levothyroxine Sodium 137 mcg PO DAILY \n8. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n9. BusPIRone 15 mg PO TID \n10. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR \n11. Tizanidine 2 mg PO TID \n12. TraZODone 150 mg PO QHS:PRN insomnia \n13. Verapamil SR 120 mg PO Q24H \n14. Polyethylene Glycol 17 g PO DAILY \n15. Ranitidine 300 mg PO QHS \n16. Ondansetron 4 mg PO Q8H:PRN nausea \n17. Dilaudid (HYDROmorphone) 16 mg oral QAM \n18. ziconotide 8.01 mcg/day injection INFUSION \n\n \nDischarge Medications:\n1. BusPIRone 15 mg PO TID \n2. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN PAIN \n3. Levothyroxine Sodium 137 mcg PO DAILY \n4. LORazepam 1 mg PO Q4H:PRN anxiety \n5. Methadone 5 mg PO TID \n6. Ondansetron 4 mg PO Q8H:PRN nausea \n7. Polyethylene Glycol 17 g PO DAILY \n8. Pregabalin ___ mg PO DAILY \n9. Ranitidine 300 mg PO QHS \n10. Tizanidine 2 mg PO TID \n11. TraZODone 150 mg PO QHS:PRN insomnia \n12. Verapamil SR 120 mg PO Q24H \nDo not take this medication if your systolic blood pressure in \nthe morning is below 100. \n13. DULoxetine 60 mg PO BID \n14. Lidocaine 5% Ointment 1 Appl TP ONCE ASDIR \n15. NexIUM (esomeprazole magnesium) 40 mg oral DAILY \n16. Vitamin D ___ UNIT PO 1X/WEEK (WE) \n17. HYDROmorphone (Dilaudid) (HYDROmorphone) 16 mg ORAL QAM \n18. Voltaren (diclofenac sodium) 1 % topical QID:PRN pain \nRX *diclofenac sodium [Voltaren] 1 % Apply to painful site of \nlower back 4 times per day Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\nAcute urinary retention\nAcute viral gastroenteritis\n\nSECONDARY DIAGNOSES:\nPostsurgical pain of incision site\nChronic pudendal impingement syndrome\nHypothyroidism\nUnspecified cardiac arrhythmia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ for \nurinary retention and pain over your intrathecal pump catheter \nincision site. \n\nWe believe the urinary retention was due to the recent increase \nin the ziconotide dose running through your pump. We were able \nto get administrative approval for the company who adjusts your \npump settings to come provide their services in the inpatient \nsetting, however they are able to visit you in your home to \nadjust the settings sooner. You will have additional nursing \nservices to care for your new Foley catheter. Once your \nziconotide dose is decreased, the Foley catheter should be \nremoved to allow a trial of urination. If you are still unable \nto urinate, you should return to the hospital immediately.\n\nOur radiologists and pain specialists reviewed the CT images of \nyour lumbar spine and we believe that the pain you are \nexperiencing is due to the superficial placement of the pump \ncatheter, which has some mild inflammatory changes around it. \nPlease continue lidocaine ointment or patches and Voltaren gel \nto relieve the pain in that area until you can see a pain \nspecialist who can manage this type of intrathecal pump.\n\nIt was a pleasure taking care of you.\n\nBest wishes,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "R338", "A084", "T398X5A", "G588", "E039", "F450", "M545", "I951", "Z9689", "Y929" ]

[ "R338: Other retention of urine", "A084: Viral intestinal infection, unspecified", "T398X5A: Adverse effect of other nonopioid analgesics and antipyretics, not elsewhere classified, initial encounter", "G588: Other specified mononeuropathies", "E039: Hypothyroidism, unspecified", "F450: Somatization disorder", "M545: Low back pain", "I951: Orthostatic hypotension", "Z9689: Presence of other specified functional implants", "Y929: Unspecified place or not applicable" ]

[ "E039", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNSAIDS, ASA, statins\n \nAttending: ___\n \nChief Complaint:\nNew Afib \n \nMajor Surgical or Invasive Procedure:\nECHO on ___ \n\n \nHistory of Present Illness:\nMs. ___ is an ___ F with h/o CAD, severe aortic stenosis, \nCOPD on 2 L NC, ESRD on HD MWF, hypothyroidism, chronic pain \ntransferred from ___ for new onset Afib. She was \napparently found to have new Afib at dialysis on ___ did \nnot receive dialysis). She reports new SOB on morning of ___ \nthat was so severe she had to sit on ___ couch and draw in deep \nbreaths for 30 mins. SOB worse was with activity, and the \npatient stated she could not walk from bed to door without SOB. \nPatient denied chest pain, lightheadedness, cough, nausea, abd \npain, urinary sx, diarrhea. \n\nOf note she had a recent hospitalization at OSH from ___ \nfor SOB thought to be secondary to acute CHF. She had bibasilar \ninfiltrates on CXR and a troponin elevated to 0.19, thought to \nbe demand ischemia. ECHO showed >50% LVEF, critical AS with 0.5 \ncm2, moderate MR. ___ cardiologist recommended cath in the \noutpatient setting, followed by TAVR evaluation, and she had an \nappointment to see him on ___. She reports at that appointment \nshe decided she did not want to pursue procedures/surgery (she \ndidn't know what a TAVR meant when asked though) and wanted to \n\"live life as best I can.\" \n\nOn day of admission, she had a CXR at OSH that showed a \nquestionable right sided PNA, and was treated with a dose of \nlevofloxacin and CTX. She was initially hypotensive at the \noutside hospital and was given 1 L IVF, but then became volume \noverloaded. \n\nIn the ED initial vitals were: ___ F, BP 136/68, HR 126, RR 22, \n99% 3 L NC. \n\nEKG: Atrial fibrillation with left bundle branch block (LBBB is \nold)\n\nLabs/studies notable for: \nCBC: WBC 8.7, Hgb 9.1 (baseline unknown), plts 135. \nchem 10: Na 139, K 5.4, Cr 6.4\nlactate 1.4 \nCK 103 \nINR 1.2 \ntrop 0.33\nMB 12\nbnp >70,000\n\nPatient was given: 500 cc IVF, as well as calcium \ngluconate/insulin for K 5.4. \n\nOn the floor patient was comfortable with HR in the 100-110s max \n120. BP 100s/60s. She reported feeling like she was not SOB. \n \nPast Medical History:\n1. CARDIAC RISK FACTORS: HLD \n\n2. CARDIAC HISTORY\n- CAD: reported CAD, although no cath reports here \n- Pump: diastolic dysfunction with EF >50%, severe AS, moderate \nMR ___ ECHO below) \n- Rhythm: new afib, preexisting LBBB \n \n3. OTHER PAST MEDICAL HISTORY\naortic stenosis (aortic valve area of 0.6 cm2 and mild mitral \nstenosis and moderate mitral regurgitation) \nbradycardia \nESRD MWF, initiated ___ \nCOPD, baseline 2 L NC \nAnemia of chronic disease \nHypothyroidism \nCarotid stenosis \nChronic pain (back and left shoulder) \nL humerus fracture ___\nCarpal tunnel \n \nSocial History:\n___\nFamily History:\nFather had died of an MI at age ___.\n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION:\n\nVS: 97.4 F, BP 100/60s, HR 100-110s, RR 20, 100% 2 l nc \nGENERAL: Well developed, A/Ox3, pleasant elderly woman \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \nNo xanthelasma.\nNECK: Supple. JVP not elevated, around 8 cm. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. Harsh systolic murmur and tachycardia, difficult to \nappreciate irregularity. \nLUNGS: No chest wall deformities or tenderness. Mild bibasilar \ncrackles, very soft expiratory wheezes. \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly.\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or \nperipheral edema. Right arm AVF (failed 2x fistulas on left, \nmaybe had a graft on left arm too?) \nSKIN: No significant skin lesions or rashes.\nPULSES: Distal pulses palpable and symmetric.\n\nPHYSICAL EXAM ON DISCHARGE:\n\nVS: 98.5, BP 108-131/47-59, HR 69-72, RR 18, 98-99% 2L NC \nGENERAL: Well developed, A/Ox3, pleasant elderly woman \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \nNo xanthelasma.\nNECK: Supple. JVP not elevated. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. Harsh systolic murmur and tachycardia.\nLUNGS: No chest wall deformities or tenderness. Mild bibasilar \ncrackles, with soft expiratory wheezes. \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly.\n \nPertinent Results:\nLABS ON ADMISSION: \n\n___ \nLactate-1.4\nT4-4.7\nTSH-4.7\nCalcium-8.5\nPhos-5.2 \nMg-2.2\nCK-MB-12 \nMB Indx-11.7 \ncTropnT-0.33\nCK(CPK)-103\nGlucose-108 \nUreaN-49 \nCreat-6.4 \nNa-139 \nK-5.4 \nCl-96 \nHCO3-30 \nAnGap-18\n___ \nPTT-28.9 \n___\nWBC-8.7 \nRBC-2.82 \nHgb-9.1 \nHct-30.5 \nMCV-108 \nMCH-32.3 \nMCHC-29.8 \nRDW-13.3 \nRDWSD-52.4 \nPlt ___\n\nLABS ON DISCHARGE:\n\n___:\nCalcium-8.5 \nPhos-5.3 \nMg-2.0\nCK-MB-6\ncTropnT-1.03\nGlucose-102 \nUreaN-40 \nCreat-5.3 \nNa-134 \nK-4.3 \nCl-93 \nHCO3-29 \nAnGap-16\n___\nPTT-33.3 \n___\nWBC-6.4 \nRBC-2.80 \nHgb-8.8 \nHct-29.5 \nMCV-105 \nMCH-31.4 \nMCHC-29.8 \nRDW-13.1 \nRDWSD-50.9 \nPlt ___\n\nMICRO: \nBlood culture: pending\n\nIMAGING STUDIES:\n\nCXR (___):\n\nFINDINGS: \n \nThere are moderate bilateral pleural effusions with overlying \natelectasis. The cardiac silhouette is mild to moderately \nenlarged. There is prominence of the bilateral central \npulmonary vasculature worrisome for pulmonary edema. Right \ninfrahilar opacity may be due to combination of pleural effusion \nand atelectasis, but underlying consolidation or other pulmonary \nlesion not excluded. Recommend follow-up chest imaging \nfollowing acute episode/diuresis. The aorta is calcified. \n \nIMPRESSION: \n \nModerate bilateral pleural effusions with overlying atelectasis. \n Pulmonary edema. Cardiomegaly. Constellation of findings \nsuggest CHF. \n \nRight infrahilar opacity may be secondary to the above findings, \nbut \nunderlying consolidation or other pulmonary lesion not excluded. \n Recommend follow-up chest imaging after acute episode/ \ndiuresis. \n\nCXR (___):\n\nFINDINGS: \n \nThere are persisting small to moderate bilateral pleural \neffusions with \nsubjacent atelectasis as well as pulmonary vascular engorgement \nand mild \ninterstitial septal thickening. The right infrahilar opacity is \nunchanged. \n \nThere is enlargement of the cardiac silhouette, unchanged. \nCalcification of the aortic arch is present. \n \nIMPRESSION: \n \nFindings are suggestive of pulmonary edema. \n \nPersisting right infrahilar opacity. \n\nECHO (___):\n\nThe left atrium is moderately dilated. No atrial septal defect \nis seen by 2D or color Doppler. There is mild symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. There is mild global left ventricular hypokinesis (LVEF \n= 45-50 %). No masses or thrombi are seen in the left ventricle. \nThere is no ventricular septal defect. The right ventricular \ncavity is mildly dilated with normal free wall contractility. \nThe ascending aorta is mildly dilated. The aortic valve leaflets \nare moderately thickened. There is severe aortic valve stenosis \n(valve area <1.0cm2). The mitral valve leaflets are mildly \nthickened. Mild to moderate (___) mitral regurgitation is seen. \nThe tricuspid valve leaflets are mildly thickened. Tricuspid \nregurgitation is present but cannot be quantified. The pulmonary \nartery systolic pressure could not be determined. There is no \npericardial effusion. \n\n \nBrief Hospital Course:\n___ F with h/o CAD, severe aortic stenosis, COPD on 2 L NC, ESRD \non HD MWF, hypothyroidism, chronic pain transferred from ___ \n___ for new onset afib. \n\n#New onset Afib - various potential etiologies were considered \nfor the patient's Afib, including infection, ischemia, CHF, \nthyroid dysfunction. TSH was 4.7 and FT4 at 4.7. Patient was \nstarted on metoprolol tartrate 6.25 mg BID and patient was not \nstarted on anticoagulation. ECHO revealed mild symmetric left \nventricular hypertrophy with normal left ventricular cavity and \nmild global left ventricular hypokinesis (LVEF = 45-50 %). There \nwere No masses or thrombi seen in the left ventricle. The \npatient was in SR with Metoprolol 6.25 mg BID and was discharged \non ___ with 25 mg Metoprolol succinate daily. ___ Afib was \nthought likely ___ infection (right lobe PNA) for which we \ntreated with an 8-day course of levofloxacin.\n\n#Right infrahilar opacity - the patient had a CXR showing a \nquestionable right-sided PNA at an OSH for which she received a \ndose of CTX and levofloxacin. Given persisting right infrahilar \nopacity on CXR here, the patient was continued on a \nrenally-dosed 8-day course of levofloxacin (500 mg Q48H) for \ncommunity acquired PNA. The patient was afebrile without \nproductive cough during ___ admission, though she did report \nmild shortness of breath during the first morning of ___ \nhospital stay that was alleviated with albuterol. \n\n#Elevated troponin level - the patient presented with elevated \ntroponin to 0.33 and CKMB 12. There was no overt ischemic \nchanges on EKG, and the patient had a known h/o LBBB. Though \ntroponin levels increased from 0.33 --> 0.46 --> 1.03 during the \n___ hospital stay, the patient had no CP during ___ \nadmission, and elevated troponin's were thought to be likely ___ \nESRD. \n\n#ESRD - patient had HD on ___ and ___ during ___ \nhospital stay. \n\n#COPD - patient was continued on oxygen and albuterol prn \n\n#Hypothyroidism - patient was continued on home synthroid \n\n#Chronic pain - patient reported being on methadone, has \nself-titrated dose to 5 mg BID. She was additionally continued \non home Tylenol and gabapentin. \n\nTRANSITIONAL ISSUES: \n====================\nNew Medications: Metoprolol, Levofloxacin\nStopped Medications: None\n- after risk/benefit discussion, deferred starting AC with \nwarfarin, consider as outpatient.\n- patient will resume HD on regular ___ schedule\n- please monitor clinically for resolution of PNA. \n# CODE: full, confirmed \n# CONTACT: ___, ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Nephrocaps 1 CAP PO DAILY \n2. Docusate Sodium 100 mg PO DAILY \n3. Gabapentin 300 mg PO QHS \n4. Gabapentin 100 mg PO QAM \n5. Levothyroxine Sodium 100 mcg PO DAILY \n6. Methadone 5 mg PO BID \n7. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \n8. Rosuvastatin Calcium 20 mg PO 5X/WEEK (___) \n\n \nDischarge Medications:\n1. Levofloxacin 500 mg PO Q48H \nFirst dose on ___, last dose on ___ \nRX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth every \nother day Disp #*2 Tablet Refills:*0 \n2. Metoprolol Succinate XL 25 mg PO DAILY \nRX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \n4. Docusate Sodium 100 mg PO DAILY \n5. Gabapentin 300 mg PO QHS \n6. Gabapentin 100 mg PO QAM \n7. Levothyroxine Sodium 100 mcg PO DAILY \n8. Methadone 5 mg PO BID \n9. Nephrocaps 1 CAP PO DAILY \n10. Rosuvastatin Calcium 20 mg PO 5X/WEEK (___) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNew onset Afib\nSevere aortic stenosis \nCOPD on 2 L NC\nESRD on HD MWF\nHypothyroidism\nChronic pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you during your stay at ___ \n___. While you were in the hospital, \nyou were evaluated for an abnormal heart rhythym (atrial \nfibrillation) for which we started a new medication (metoprolol) \nfor with good control of your heart rate and blood pressures. \nSince then, your heart rhythm has been in normal sinus rhythm. \nWe also performed an echocardiogram of your heart which showed \ngood contractility of your heart. \n\nDuring your hospital stay, a chest x-ray was obtained which \nshowed an opacity in an area of your right lung for which we are \ntreating for pneumonia. We recommend completing your course of \nantibiotics for 4 more days through ___.\n\nIf you have any fevers, chills, worsening chest pain, shortness \nof breath, nausea, vomiting, or diarrhea, please return to the \nhospital for further care. \n\nWe wish you all the best!\n\nSincerely,\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I4891", "N186", "J189", "Z7682", "I248", "J449", "Z992", "I2510", "I350", "I340", "D631", "E039", "M5489", "M25512", "Z79891", "G8929" ]

[ "I4891: Unspecified atrial fibrillation", "N186: End stage renal disease", "J189: Pneumonia, unspecified organism", "Z7682: Awaiting organ transplant status", "I248: Other forms of acute ischemic heart disease", "J449: Chronic obstructive pulmonary disease, unspecified", "Z992: Dependence on renal dialysis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I350: Nonrheumatic aortic (valve) stenosis", "I340: Nonrheumatic mitral (valve) insufficiency", "D631: Anemia in chronic kidney disease", "E039: Hypothyroidism, unspecified", "M5489: Other dorsalgia", "M25512: Pain in left shoulder", "Z79891: Long term (current) use of opiate analgesic", "G8929: Other chronic pain" ]

[ "I4891", "J449", "I2510", "E039", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNSAIDS, ASA, statins\n \nAttending: ___.\n \nChief Complaint:\ns/p cardiac arrest\n \nMajor Surgical or Invasive Procedure:\n___: RHC \n \nHistory of Present Illness:\n___ y/o F with h/o severe aortic stenosis, ESRD on HD, paroxysmal \natrial fibrillation, and PPM for LBBB/syncope presents following \nacute LOC while at HD with pulselessness. Patient underwent \n___ minutes of CPR (no epi or defibrillation per ED report) \nbefore ROSC was achieved. Initial rhythm during the event is \nunclear. Of note, she was in dialysis for 1 hour and only 140 cc \nwere removed prior to event. Patient was subsequently \ntransferred to ___ where she was started on heparin gtt \nfor possible NSTEMI given ST depressions on EKG and initial \ntroponin of 0.08. While at A-J, SBP dropped to 35 and patient \nwent into rapid atrial fibrillation. 12-lead EKG showed a left \nbundle branch block, which she is known to have and occurs \nintermittently. Patient was subsequently cardioverted and \nreceived 2 L NS and IV digoxin, prior to returning to NSR\n \nAt A-J, she underwent CT angiogram which did not show aortic \ndissection or pulmonary embolus. Patient was awake and talking \nand denied CP or SOB, though she endorsed significant ongoing \nback pain, which has been a chronic issue. BP subsequently \nimproved with initiation of Levophed. Cardiology was consulted \ndue to concern for posterior STEMI given EKG findings; posterior \nMI was felt to be unlikely and ischemic findings were thought to \nbe ___ hypotension and severe AS. She was subsequently \ntransferred to ___ for CVVHD and further management. \n\nREVIEW OF SYSTEMS: She endorses back pain. She endorses dyspnea \non exertion prior to HD sessions, which is relieved following \nHD. Otherwise review of systems was negative.\n\nIn the ED initial vitals were: \nHR 82 BP 84/42 RR21 95% Nasal Cannula \nLabs/studies notable for: BNP >32000, Troponin 0.74, MB 136, WBC \n18.9, H/H ___, Lactate 2.8, Cr 6.6, ALT 64, AST 119\nCXR with marked enlargement of the central pulmonary vasculature \nsuggesting severe pulmonary edema, underlying pulmonary \nhemorrhage/contusion not excluded. Small pleural effusions. \nModerate to marked enlargement of the cardiac silhouette. \nMultiple bilateral rib fractures. No radiographic evidence of \npneumothorax, but a small pneumothorax would be difficult to \nexclude. \nPatient was started on heparin gtt, levophed gtt, dilaudid IV \n0.125 mg x 5 doses\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n-ESRD on the basis of hypertension, on hemodialysis with R AV \nfistula \n-Hypertension\n-Severe aortic stenosis, ___ 0.8. Declined TAVR due to age and \nco-morbidities, though unclear if discussion was fully \naddressed/understood\n-Mixed systolic/diastolic HF\n-Pacemaker (left-sided, single chamber) placed for syncope ___ \ntransient heart block (has intermittent left bundle branch \nblock)\n-Dyslipidemia.\n-Nonobstructive coronary artery disease.\n-Hypothyroidism.\n-Anemia of renal disease.\n-Venous insufficiency.\n-COPD, on home ___ L\n-Chronic upper back pain for which she takes methadone.\n-Left humerus fracture ___ after falling.\n-Bilateral fibular fractures in ___.\n-Right carpal tunnel syndrome.\n-Carotid stenosis.\n-Bradycardia.\n\n \nSocial History:\n___\nFamily History:\nFather had died of an MI at age ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVITALS: 97.5 93 139/79 19 96%\nGENERAL APPEARANCE: Elderly woman, AAOx3, pleasant\nHEENT: Neck supple. PERRLA. JVP is distended to mid-neck.\nLUNGS: Bibasilar crackles with diffuse wheezing\nCARDIAC: Heart sounds faint, ___ crescendo-descrendo systolic \nmurmur at LUSB.\nABDOMEN: Soft, nontender, and nondistended.\nEXTREMITIES: 1+ pitting edema. RLE > LLE (chronic) without \nerythema or tenderness. Distal extremities cool to touch. Patent \nright upper extremity AV fistula. \nNEUROLOGIC: Purposely moving all extremities and following \ncommands.\n\nDISCHARGE PHYSICAL EXAM\n=======================\nPatient died. \n \nPertinent Results:\nADMISSION LABS\n==============\n\n___ 05:30PM BLOOD WBC-18.9*# RBC-3.43* Hgb-11.0* Hct-36.2 \nMCV-106* MCH-32.1* MCHC-30.4* RDW-13.9 RDWSD-53.3* Plt ___\n___ 05:30PM BLOOD ___ PTT-84.2* ___\n___ 05:30PM BLOOD Plt ___\n___ 05:30PM BLOOD Glucose-215* UreaN-49* Creat-6.6*# Na-140 \nK-4.3 Cl-96 HCO3-24 AnGap-24*\n___ 05:30PM BLOOD ALT-64* AST-119* AlkPhos-75 TotBili-0.5\n___ 11:58PM BLOOD CK(CPK)-3034*\n___ 05:30PM BLOOD CK-MB-136* ___\n___ 05:30PM BLOOD cTropnT-0.74*\n___ 05:30PM BLOOD Albumin-3.4*\n___ 11:58PM BLOOD TSH-6.6*\n___ 11:58PM BLOOD T4-5.2\n___ 05:30PM BLOOD Lactate-2.8*\n\nIMAGING\n=======\n\nCATH:\nImpressions:\n1. Moderate three vessel CAD.\n2. Preserved cardiac ouput.\n3. Elevated left sided filling pressure with prominent V waves.\n\nECHO:\nThe left atrium is moderately dilated. There is moderate \nsymmetric left ventricular hypertrophy. Overall left ventricular \nsystolic function is severely depressed (LVEF = 25%) secondary \nto akinesis of the inferior wall, hypokinesis of the posterior \nwall, and pacing-induced dyssynchrony. Tissue Doppler imaging \nsuggests an increased left ventricular filling pressure \n(PCWP>18mmHg). Doppler parameters are most consistent with Grade \nIII/IV (severe) left ventricular diastolic dysfunction. The \nright ventricular free wall thickness is normal. Right \nventricular chamber size is normal with borderline normal free \nwall function. The aortic valve is not well seen. There is \nsevere aortic valve stenosis (valve area = 0.5 cm2). No aortic \nregurgitation is seen. The mitral valve leaflets are severely \nthickened/deformed. There is severe mitral annular \ncalcification. There is mild functional mitral stenosis (mean \ngradient 5 mmHg) due to mitral annular calcification. Severe \n(4+) mitral regurgitation is seen. The tricuspid valve leaflets \nare mildly thickened. Moderate [2+] tricuspid regurgitation is \nseen. [Due to acoustic shadowing, the severity of tricuspid \nregurgitation may be significantly UNDERestimated.] There is \nmoderate pulmonary artery systolic hypertension. There is no \npericardial effusion. \n\nDISCHARGE LABS:\nPatient died. \n \nBrief Hospital Course:\n___ y/o F with h/o severe aortic stenosis, ESRD on HD, paroxysmal \natrial fibrillation, and PPM for LBBB/syncope who presents \nfollowing cardiac arrest, transferred to ___ for further \nmanagement of hypotension associated with HD sessions and for \npost cardiac arrest care.\n\n#Goals of care. Given worsening clinical condition over the \ncourse of the hospital stay and inability to tolerate HD with \nnecessity of pressors, discussions about patient’s outcome were \nongoing with her daughter/HCP ___. Confirmed with daughter \nthat quality of life is of great importance to the patient. \nPatient was eventually on higher O2 requirements, two pressors, \nand became increasingly somnolent. Patient's daughter agreed \nthat they should focus on her comfort. She was transitioned to \nCMO on ___ and died later in the day on ___. For \nhospital course by problem see below.\n\n#s/p cardiac arrest\n#Elevated lactate\n#Leukocytosis: Patient transferred to ___ after pulselessness, \nrequiring ___ minutes of CPR before achieving ROSC. Etiology \nof arrest remained unclear. Most likely I/s/o low flow state due \nto hypotension during HD and severe AS ___ 0.8 in ___. \nEtiology unlikely to be ___ arrhythmia (PPM interrogation with \nlongest AF episode to be 5 seconds). CTA negative for PE. \n\n#Hypotension. was likely multifactorial, related to severe AS, \nMR, and Afib iso moderate to diffuse CAD. Patient was difficult \nto wean from pressors, and difficult to manage AS, MR, and Afib \neffectively given that patient is not candidate for CABG. \nPressor requirement increased over course and included midodrine \n10mg TID.\n\n#NSTEMI: OSH EKG with ST depressions prominent in V2-V4, with \nelevated troponins to 0.08, in the setting of pulseless arrest, \nconcerning for likely type II NSTEMI in the setting of low flow \nstate from severe AS and hypotension with HD. Trop peaked at \n7.31 and MB peaked at 506. TTE shows preserved LVEF >55%, \nsimilar severe AS, new severe MR, elevated pulmonary/right sided \npressures. Cath ___ showed moderate to diffuse dz, non-critical \nlesions.\n\n#Severe AS: AS likely contributing to pulselessness and LOC. TTE \nin ___ with ___ 0.8 and elevated peak velocity/peak \ngradient. She had RHC in preparation for TAVR, but patient \ndecompensated. See above. \n \n \n#Paroxysmal Atrial Fibrillation: s/p cardioversion prior to \nadmission. Onset noted in ___ in the setting of PNA, for \nwhich she was started on Metoprolol succinate 25 mg daily. \nCHA2DS2-VASc 5. Anticoagulation was deferred during previous \nadmission after risks/benefits discussion. She was placed on AC \nhere and was loaded with amio and digoxin with some benefit.\n\n#Mixed systolic, diastolic HF: LVEF 45-50% on TTE in ___. \nBNP elevated to 32,000. Pt tried to have HD as above for fluid \nremoval and did not tolerate as above.\n\n#Positive blood cultures: Pt w/ ___ bottles growing GPC in pairs \nand clusters. Afebrile, but w/slight leukocytosis. ___ blood \ncx- ___ coag-neg Staph<10,000, and started empiric vanc ___ and \nremoved femoral line and replaced w/IJ. Repeat cx- NGTD >48hrs \nand empiric vanc was discontinued.\n\nCHRONIC ISSUES\n=============\n#COPD on home O2 (2L): Not on any inhalers per patient. Continue \n2L O2. Continued on nebulizer treatment.\n\n#GERD: Continued omeprazole.\n\n#Chronic Back Pain: Continued gabapentin and methadone\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Gabapentin 300 mg PO DAILY \n2. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \nPRN \n3. Levothyroxine Sodium 100 mcg PO DAILY \n4. Methadone 30 mg PO DAILY \n5. Omeprazole 40 mg PO DAILY \n6. Nephrocaps 1 CAP PO DAILY \n7. Rosuvastatin Calcium 20 mg PO 5X/WEEK (___) \n8. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Medications:\nPatient deceased\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nAortic stenosis\nCongestive heart failure\ns/p cardiac arrest\nhypotension\natrial fibrillation with rapid ventricular response\ntransiminitis\nend stage renal disease on hemodialysis\nrib fractures\n\nSECONADRY DIAGNOSIS\nChronic obstructive pulmonary disease\ngastroesophageal reflux disease\nchronic back pain\nhypothyroidism\n\n \nDischarge Condition:\ndeceased\n \nDischarge Instructions:\nN/a deceased\n \nFollowup Instructions:\n___\n" ]

[ "I214", "N186", "I462", "J9690", "I5033", "S2243XA", "I959", "R7881", "I132", "I480", "Z9981", "J449", "I080", "I447", "E785", "I2510", "E039", "M5489", "Z87891", "K219", "Z45018", "D631", "Z992", "Y848", "Y9289", "R740", "Z515", "M7981", "T45515A", "Y92239" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "N186: End stage renal disease", "I462: Cardiac arrest due to underlying cardiac condition", "J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia", "I5033: Acute on chronic diastolic (congestive) heart failure", "S2243XA: Multiple fractures of ribs, bilateral, initial encounter for closed fracture", "I959: Hypotension, unspecified", "R7881: Bacteremia", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I480: Paroxysmal atrial fibrillation", "Z9981: Dependence on supplemental oxygen", "J449: Chronic obstructive pulmonary disease, unspecified", "I080: Rheumatic disorders of both mitral and aortic valves", "I447: Left bundle-branch block, unspecified", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E039: Hypothyroidism, unspecified", "M5489: Other dorsalgia", "Z87891: Personal history of nicotine dependence", "K219: Gastro-esophageal reflux disease without esophagitis", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "D631: Anemia in chronic kidney disease", "Z992: Dependence on renal dialysis", "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", "Y9289: Other specified places as the place of occurrence of the external cause", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z515: Encounter for palliative care", "M7981: Nontraumatic hematoma of soft tissue", "T45515A: Adverse effect of anticoagulants, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "I480", "J449", "E785", "I2510", "E039", "Z87891", "K219", "Z515" ]

[]

[ " \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:\nSI\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThe patient is a ___ y/o F with PMHx of complex PTSD,\nborderline PD, endorses anxiety and depression, with multiple\npsych admissions and prior SA, who initially presented to the ED\non ___ after making statements to friends concerning for\nsuicidal ideation, now found to have flu.\n\nAccording to ED notes on initial presentation: \"She was looking\nfor razors, stating she wanted to cut herself, and she did want\nto cut herself but did not want to kill herself. She denies\nSI/HI/AVH. She reports that in therapy this week she started\nremembering previous trauma that she had not previously\nremembered. Today this all came \"flooding\" back, and it set off\nthis episode today. She states she had one drink today, denies\nany more alcohol use and denies drug use.\"\n\nDuring her initial ED stay, she was diagnosed with flu and was\nstarted on Tamiflu. She was also placed on Macrobid for possible\nUTI. She was ultimately placed in an inpatient psych unit.\nHowever, when she arrived there, she was sent back to the ED\ngiven + flu.\n\nED Course:\nInitial VS: 97.9 79 96/69 12 99% RA \nNo new labs during most recent ED stay. Labs during initial ED\nstay notable for negative serum and urine tox screens. UA with \n11\nWBCs and few bacteria. Flu B positive.\nMeds given:\n___ 02:08 PO Acetaminophen 1000 mg \n___ 02:08 PO Ibuprofen 600 mg \n___ 08:12 PO/NG OSELTAMivir 75 mg \n___ 08:12 PO Nitrofurantoin Monohyd (MacroBID) 100 mg \n___ 16:14 PO Acetaminophen 1000 mg \n___ 16:14 PO Ibuprofen 600 mg \n___ 19:52 PO/NG OSELTAMivir 75 mg \n___ 19:52 PO Nitrofurantoin Monohyd (MacroBID) 100 mg \n___ 07:41 PO/NG OSELTAMivir 75 mg \n___ 07:41 PO Nitrofurantoin Monohyd (MacroBID) 100 mg \n___ 10:45 PO Acetaminophen 1000 mg \n___ 20:06 PO/NG OSELTAMivir 75 mg \n___ 20:06 PO Nitrofurantoin Monohyd (MacroBID) 100 mg \n\nVS prior to transfer: 97.7 78 99/60 16 98% RA \n\nOn arrival to the floor, the patient endorses the above story.\n\nRegarding her psychiatric symptoms, she denies having any true\nSI. She states that the told her friends that she wanted to cut\nherself but not kill herself. She feels that some statements she\nhad made in the past were mistaken as statements made on the day\nof presentation. She reports that her mood is \"good.\" She denies\nany current SI, anxiety.\n\nOtherwise, she endorses fevers, myalgias, cough (productive of\nclear sputum), headache that began the day prior to her ED\npresentation. Her roommate was recently sick with the flu. The\npatient reports that her symptoms have largely resolved at this\ntime, with only mild lingering aches and headache. Her last \nfever\nappears to have been on the evening of ___ in the ED (101.6).\nRegarding potential UTI, the patient reports that the only\nurinary symptom she has had is dark urine. She denies any \ndysuria\nor urinary frequency.\n\n \nPast Medical History:\nPt denies PHMx to me.\nPer psych note:\n-complex PTSD, borderline PD; patient also endorses anxiety and\ndepression \n-Hospitalizations: Multiple, at least 4- ___ in ___\nin ___ after attempting to hang herself. ___ @ ___ after\n___ by suffocation. ___ ___. ___ ___. \n-Psychiatrist: denies having one, reports she is waiting for one\nat ___, previously seeing Dr. ___ @ ___ \n-Therapist: ___ ___ and ECT trials: sertraline, fluoxetine, clonidine,\nprazosin\n-Self-injury/Suicide attempts: history of cutting and burning\nsince age ___. Multiple SAs by hanging, overdosing, drowning\n-Harm to others: denies\n-Trauma: history of emotional and physical abuse from father\nwhile growing up.\n \nSocial History:\n___\nFamily History:\nSignificant for cancer and psychiatric illness. Pt unaware of\nfurther details.\n \nPhysical Exam:\nADMISSION EXAM:\n\nVS - ___ 0230 Temp: 99.5 PO BP: 109/67 HR: 83 RR: 16 O2 \nsat:\n97% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \nGEN - Alert, NAD\nHEENT - NC/AT, MMM\nNECK - Supple\nCV - RRR, no m/r/g\nRESP - Breathing appears comfortable, no w/r/r appreciated\nABD - S/NT/ND, BS present\nEXT - No ___ edema or calf tenderness\nSKIN - No apparent rashes\nNEURO - MAE\nPSYCH - Flat affect\n\nDISCHARGE EXAM:\n\nAfebrile in the AM, with SBP 94. Lungs clear with normal \nsymmetric chest rise.\n \nPertinent Results:\nLABORATORY RESULTS:\n\n___ 02:30AM BLOOD WBC-6.0 RBC-4.15 Hgb-12.1 Hct-36.5 MCV-88 \nMCH-29.2 MCHC-33.2 RDW-13.4 RDWSD-43.2 Plt ___\n___ 02:30AM BLOOD Neuts-64.8 Lymphs-12.3* Monos-20.2* \nEos-1.5 Baso-0.5 Im ___ AbsNeut-3.86 AbsLymp-0.73* \nAbsMono-1.20* AbsEos-0.09 AbsBaso-0.03\n___ 02:30AM BLOOD Plt ___\n___ 02:30AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-138 \nK-3.8 Cl-103 HCO3-24 AnGap-11\n___ 02:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n \nBrief Hospital Course:\nOn admission, the patient's influenza symptoms had resolved. She \nwill need to finish one additional day of oseltamavir, and \notherwise has no contraindication to returning to her dorm. \n\nShe was followed up by our psychiatry team. I am quoting their \nrecommendations here: \n\n- PTSD\n- Borderline personality d/o\n- Chronic: eczema\n\nComplex case of young ___ freshman with trauma hx, recently\nadmitted to ___, brought to ED after making further \nstatements\nabout killing herself to her roommate, c/w dissociative\nstate based on information in OMR and from therapist. Patient \nhas\nbenefited from the contained environment in the ED and has not\nbeen suicidal or had any dissociative episodes since ___. Risk\nassessment complex; certainly remains at chronic elevated risk\ngiven both family hx of suicide attempts and personal hx of\nsuicide attempts, but insight/judgment have been improving\nsteadily, and she is engaged in treatment planning. At this \npoint\nappears at low acute risk of harm to self; hopeful, forward\nlooking, caring for self here throughout stay, motivated for\nschool and keeping up grades, has not been cutting, agreeable to\nmore intensive supports. Cannot r/o some sort of ongoing trauma\nin community, although patient adamantly denies, given continued\ndissociative events with no obvious trigger (usually triggers\nhave been impending contact with family); outpatient therapist\ncontinuing to work with patient on this. Unfortunately, \ninpatient\npsychiatric admission continues to present elevated risk of\nregression in that more intensive setting. In terms of \ntreatment,\ngiven patient not willing to consider additional medications at\nthis time, I don't think an inpatient unit would be useful; she\nwould benefit more from additional outpatient supports eg The\nTrauma Center in ___ (therapist will refer for DBT). She \nis\nalso wlling to consider an IOP. Both would be most likely way to\ndecrease her long term risk. \n\nRECOMMEND:\n- No psychiatric contraindication to d/c\n- ED social worker working on referral to IOP (she will call\npatient with appointment if obtained after pt is discharged)\n- Re:entry meeting today at 11 am ___, ___\n- Pt should f/u with her therapist ___\n- Patient should return to the ED if any thoughts of self-harm \nor\nany further dissociative episodes\n- Therapist making referral for psychiatry through her clinic \nand\nwill also likely refer to additional trauma based resources\n- ___ requesting call from medicine if patient is\ngoing to be discharged to discuss flu precautions needed for \ndorm\nif any ___\n\nAfter discussion with ___ health, she was discharged back \nto ___ health. \n\n> 30 minutes spent on complex discharge.\n\n \nDischarge Medications:\n1. OSELTAMivir 75 mg PO BID Duration: 5 Days \nRX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*2 \nCapsule Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nInfluenza\nSuicidal ideation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the medical ward with influenza. You \nreceived four days of Tamiflu; you will need to finish one final \nday. You were closely followed by our psychiatry team, and you \nwill transfer back to BU to continue your care there.\n \nFollowup Instructions:\n___\n" ]

[ "J111", "R45851", "F4310", "F603", "L309", "F329", "F39" ]

[ "J111: Influenza due to unidentified influenza virus with other respiratory manifestations", "R45851: Suicidal ideations", "F4310: Post-traumatic stress disorder, unspecified", "F603: Borderline personality disorder", "L309: Dermatitis, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F39: Unspecified mood [affective] disorder" ]

[ "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nTEE/DCCV (___)\nLeft knee athrocentesis (___)\n\n \nHistory of Present Illness:\nMr. ___ is an ___ y/o ___ man with history of CAD \ns/p MI s/p POBA ___ ___, NSTEMI s/p PCI to LCx (___), UA \ns/p DES to LAD (___), and UA with unsuccessful attempt at POBA \nof D2 (___), HTN, HLD who presents with chest pressure and \nshortness of breath.\n\nThe patient reports that he noticed the symptoms (chest pressure \nand sob) when taking out the trash approx. 1 week ago. Patient \nnotes that he has had episodes of chest pressure and sob with \nwalking. Patient has to walk 15 steps up the stairs to his home \nand last night, while walking these steps, patient felt chest \npressure and sob. Denies any heart palpitations. Does not sleep \nwith any pillows propping him up. No previous history of Afib.\n\nIn the ED, he was triggered for HR 140 on arrival, noted to be \nin afib. No known history of afib. No current CP, only with \nexertion, also DOE. \n\nIn the ED initial vitals were: ___ HR140 bp132/93 RR20 96%O2sat \nRA \nEKG: RAD, atrial fibrillation at 153 bpm, Q waves in V4\nLabs/studies notable for: \n- BMP ___\n- CBC 9.7/12.0/36.7/282; INR 1.2; trop-T <0.01.\n- CXR: Moderate pulmonary edema with small bilateral pleural \neffusions and bibasilar atelectasis.\nPatient was given:\n___ 10:36 PO Aspirin 243 mg \n___ 10:36 IV BOLUS Diltiazem 10 mg \n___ 10:57 IV BOLUS Diltiazem 10 mg \n___ 12:44 IV DRIP Diltiazem ___ mg/hr ordered) \n___ 13:29 IV Heparin 3700 UNIT \n___ 13:29 IV Heparin\n \nVitals on transfer: HR125 bp132/94 RR16 96% O2sat on 3L O2 NC \n \nOn the floor, HR ranged from 112-130s on telemetry in Afib, bp \n133/67, RR 22, 98% O2sat on 2L O2 NC\nWeight= 62.9 kg (Per the family, usual weight is 54.4-56.7kg)\n\nPatient denied any chest pressure currently (last chest pressure \nand sob was this morning with walking). \n\nREVIEW OF SYSTEMS: 10-point ROS otherwise negative. \n \nPast Medical History:\n- Hypertension\n- Dyslipidemia\n- CAD s/p MI s/p POBA ___ ___\n- NSTEMI s/p PCI to LCx (___)\n- UA s/p DES to LAD (___)\n- UA with unsuccessful attempt at POBA of D2 (___)\n- Osteoporosis\n- Arthritis\n- Vitamin B 12 deficiency\n- Left hip fracture requiring surgery\n \nSocial History:\n___\nFamily History:\nNo family cardiac history.\n \nPhysical Exam:\n======================\nADMISSION EXAM\n======================\nVS: HR ranged from 112-130s on telemetry in Afib, bp 133/67, RR \n22, 98% O2sat on 2L O2 NC\nWeight= 62.9 kg (Per the family, usual weight is 54.4-56.7kg)\n\nGENERAL: Awake, alert, in no acute distress, resting comfortably \nin bed\nHEENT: NC/AT, PERRLA, clear conjunctiva b/l, MMM\nNECK: Supple with JVP of approx. 12 cm.\nCARDIAC: Tachycardia, regular rhythm, S1, S2, no murmurs\nLUNGS: Bibasilar crackles with dullness on percussion at \nbilateral bases, good aeration throughout \nABDOMEN: Soft, obese, non-distended, +BS, non-tender to \npalpation in all four quadrants \nEXTREMITIES: Warm, 2+ peripheral pulses, no edema \nSKIN: No lesions or rashes \nPULSES: Distal pulses palpable and symmetric \n\n======================\nDISCHARGE EXAM\n======================\nVS: ___, bp 136/69 (100-164/59-72), HR58-71, RR18-20, \nO2sast 91-95% on RA\nWt: 58kg (58.7kg on ___\nI/O: ___, 958/905+(24h)\nTelemetry: NSR with few single PACs\n\nGENERAL: Awake, alert, in no acute distress, resting comfortably \nin bed\nHEENT: NC/AT, PERRLA, clear conjunctiva b/l, MMM\nNECK: Supple with JVP of approx. 10 cm.\nCARDIAC: RRR, S1, S2, no murmurs\nLUNGS: Faint bibasilar crackles, good aeration throughout \nABDOMEN: Soft, obese, non-distended, +BS, non-tender to \npalpation in all four quadrants \n \nPertinent Results:\n=================\nADMISSION LABS\n=================\n___ 10:29AM BLOOD WBC-9.7 RBC-3.75* Hgb-12.0* Hct-36.7* \nMCV-98 MCH-32.0 MCHC-32.7 RDW-13.2 RDWSD-47.0* Plt ___\n___ 10:29AM BLOOD Neuts-74.2* Lymphs-14.6* Monos-10.1 \nEos-0.5* Baso-0.2 Im ___ AbsNeut-7.18* AbsLymp-1.41 \nAbsMono-0.98* AbsEos-0.05 AbsBaso-0.02\n___ 10:29AM BLOOD ___ PTT-28.0 ___\n___ 10:29AM BLOOD Glucose-115* UreaN-24* Creat-1.3* Na-141 \nK-4.6 Cl-103 HCO3-21* AnGap-22*\n___ 10:20PM BLOOD ALT-25 AST-26 LD(LDH)-175 AlkPhos-149* \nTotBili-0.6\n___ 06:58PM BLOOD CK-MB-4 cTropnT-<0.01\n___ 10:29AM BLOOD cTropnT-<0.01\n___ 10:20PM BLOOD Calcium-8.4 Phos-3.9 Mg-2.3\n\n===================\nPERTINENT RESULTS\n===================\nEKG (___): RAD, atrial fibrillation at 153 bpm, Q waves in \nV4\n\n=======\nLABS\n=======\n___ 03:45PM JOINT FLUID ___ RBC-129* Polys-91* \n___ ___ 03:45PM JOINT FLUID Crystal-NONE\n___ 03:45PM JOINT FLUID TotProt-3.9\n___ 07:35AM BLOOD UricAcd-9.8*\n\n================\nMICROBIOLOGY\n================\n___ 3:42 pm JOINT FLUID Source: Knee. \n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Preliminary): NO GROWTH. \n\n===============\nIMAGING\n===============\nCXR (___): Moderate pulmonary edema with small bilateral \npleural effusions and bibasilar atelectasis.\n\n___\nLeft knee, 2 view limited Xray\n EXAMINATION: KNEE (2 VIEWS) LEFT\n \nINDICATION: ___ year old man with new onset left knee \ntenderness, concern for\ninflammatory process. Consulting service Rheumatology requested \nL knee XRay. \n// Concern for any contributing factors for inflammatory process\n \nTECHNIQUE: Two views.\nCOMPARISON: None.\n\nFINDINGS: \nThere is severe osteoarthritis involving the femorotibial \ncompartments of the\nleft knee. Mild patellofemoral degenerative changes. Moderate \nknee joint\neffusion. No acute fracture is seen. No concerning bone \nlesion. There is\nvascular calcification. Some degenerative bodies are seen along \nthe medial\nand to a lesser extent lateral femorotibial joint margins.\n \nIMPRESSION:\nSevere degenerative change with moderate effusion. No acute \nfracture is seen.\n\n====================\nDISCHARGE LABS\n====================\n___ 09:00AM BLOOD WBC-9.9 RBC-4.29* Hgb-13.3* Hct-42.2 \nMCV-98 MCH-31.0 MCHC-31.5* RDW-13.1 RDWSD-46.2 Plt ___\n___ 09:00AM BLOOD Plt ___\n___ 09:00AM BLOOD ___\n___ 09:00AM BLOOD Glucose-270* UreaN-37* Creat-1.5* Na-136 \nK-4.3 Cl-96 HCO3-25 AnGap-19\n___ 09:00AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.6\n \nBrief Hospital Course:\nMr. ___ is an ___ y/o ___ man with history of CAD \ns/p MI s/p POBA ___ ___, NSTEMI s/p PCI to LCx (___), UA \ns/p DES to LAD (___), and UA with unsuccessful attempt at POBA \nof D2 (___), HTN, HLD who presents with exertional chest \ndiscomfort, found to have atrial fibrillation with RVR. Now in \nNSR s/p TEE/DCCV on ___. Patient was started on Amiodarone 400 \nmg BID (___), then Amiodarone 200 mg daily ___- onwards) \nfor maintenance therapy. He was initially started on metoprolol \nbut was briefly bradycardic on day of discharge and this was \ndiscontinued.\n\nOf note, patient's Plavix was discontinued as DES was placed \nmore than ___ year ago and patient was started on Warfarin.\n\nPatient also developed acute left knee edema, pain and \ntenderness. Rheumatology was consulted and synovial fluid was \ndrawn which showed no crystals, ___ wbcs, 91 polys, 129 rbcs, \n3.9 total protein; gram stain with no organisms; serum Uric acid \nwas elevated to 9.8. Left knee X-ray showed severe degenerative \nchanges with moderate effusion. IV Medrol was injected in the \nknee joint with resolved symptoms. There remains concern for \ngout for which he will need outpatient follow-up.\n\nOf note, patients Cr at discharge was 1.5 (baseline 1.2 with \npeak Cr of 1.9 during this admission). Acute kidney injury most \nlikely secondary to pre-renal etiology with diuresis. Will \ncontinue to monitor Cr on discharge as below.\n\nTRANSITIONAL ISSUES:\n- Discharge weight 58.4kg\n- Discharge Cr 1.5\n- NEW/CHANGED MEDICATIONS:\n-- Started amiodarone 400 mg BID (___), then Amiodarone \n200 mg daily ___- onwards)\n-- Warfarin 2.5 mg daily, with goal INR ___. INR day of \ndischarge 2.8.\n-- Stopped Plavix\n-- Held lisinopril due to ___ please restart when kidney \nfunction recovers. Favor lisinopril for blood pressure control \nover amlodipine given reduced LVEF.\n-- Stopped Metoprolol due to low heart rates.\n---\n- Check INR and Cr level on ___ FAX to ___, \nMD, fax: ___. Patient will be referred to \n___ clinic. \n- Please refer to outpatient Rheumatology for concern for gout \nin left knee; if patient has recurrence of gout he may benefit \nfrom uric acid lowering therapy\n- Discharge weight: 58.4 kg\n- Discharge Creatinine: 1.5\n# CODE: Full Code (confirmed with patient)\n# CONTACT: ___ (son): ___ cell; Son ___ \n___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 2.5 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Clopidogrel 75 mg PO DAILY \n4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n5. Lisinopril 5 mg PO DAILY \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. Multivitamins W/minerals 1 TAB PO DAILY \n8. Ferrous Sulfate 325 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Cyanocobalamin 250 mcg PO DAILY \n11. Calcium Carbonate 500 mg PO DAILY \n12. Alendronate Sodium 70 mg PO QSAT \n13. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Amiodarone 400 mg PO BID Duration: 9 Doses \nPlease take Amiodarone 400 mg two times daily, start taking 1 \ntablet ___ and continue until ___. \nRX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*9 \nTablet Refills:*0 \n2. Amiodarone 200 mg PO DAILY Duration: 30 Days \nTake Amiodarone 200 mg daily from ___ onwards. \nRX *amiodarone 200 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*2 \n3. Warfarin 2.5 mg PO DAILY \nRX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n4. Alendronate Sodium 70 mg PO QSAT \n5. amLODIPine 2.5 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Calcium Carbonate 500 mg PO DAILY \n9. Cyanocobalamin 250 mcg PO DAILY \n10. Ferrous Sulfate 325 mg PO DAILY \n11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n12. Multivitamins W/minerals 1 TAB PO DAILY \n13. Vitamin D 1000 UNIT PO DAILY \n14. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do \nnot restart Lisinopril until you see your PCP (primary care \ndoctor).\n15.Outpatient Lab Work\n427.31, PCP: ___, MD, fax: ___\nINR, Creatinine\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\n- Atrial fibrillation\n- Acute on chronic systolic heart failure\n\nSECONDARY:\n- Acute kidney injury\n- Gout flare\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you. You came to the hospital \nbecause you were having shortness of breath. We found that your \nheart was in an abnormal rhythm called atrial fibrillation. You \nhad a procedure to zap your heart back into a normal rhythm. You \ndid well with the procedure, and it was a success. We started \nyou on some new medicines to help your heart.\n\nWe also found that your knee was swollen, likely due to a flare \nof gout. We put steroids into the knee, and you felt better.\n\nWe wish you the best of health.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I481", "I5023", "N179", "I130", "I2510", "E785", "M06042", "M06041", "M109", "M810", "E559", "D649", "I255", "M19012", "M19011", "Z955", "Z7902", "Z87891" ]

[ "I481: Persistent atrial fibrillation", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "M06042: Rheumatoid arthritis without rheumatoid factor, left hand", "M06041: Rheumatoid arthritis without rheumatoid factor, right hand", "M109: Gout, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "E559: Vitamin D deficiency, unspecified", "D649: Anemia, unspecified", "I255: Ischemic cardiomyopathy", "M19012: Primary osteoarthritis, left shoulder", "M19011: Primary osteoarthritis, right shoulder", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "I130", "I2510", "E785", "M109", "D649", "Z955", "Z7902", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \ngluten\n \nAttending: ___.\n \nChief Complaint:\nRight scapula pain \n \nMajor Surgical or Invasive Procedure:\n___: ___ Fr right chest tube placement \n\n \nHistory of Present Illness:\n___ s/p MVC in ___ during which she had a SAH, C7 facet fx, \nT4/5 transverse process, T4/6 spinus fx, T7 fx, L2 transverse \nprocess fx, right hemothorax. At the time, she had a right \npigtail placed and underwent C6-7 ACDF, C6-7 posterior\nlami/fusion, T3-T11 lami/fusion. She recovered well from her \ninjuries and surgeries and was discharged to ___ on ___ \nto continue her recovery. She was discharged 2 days ago and \nreports feeling well without difficulty doing her ADLs. Now p/w \n1 day of severe, pleuritic R scapula pain limiting her mobility. \n+HA, but no nausea/vomiting, no fevers/chills. No new trauma. \nTransferred\nfor trauma surgery evaluation.\n\n \nPast Medical History:\nPast Medical History:\n-hx of thyroid nodules \n-hx of mild persistsant asthma, previously on proair and \nfluticasone, but no script since ___ \n-hx of migraines \n\nPSH: C6-7 ACDF ___, ___, C6-7 posterior lami/fusion\n___, ___, T3-T11 lami/fusion ___, ___\n\n \nSocial History:\n___\nFamily History:\nnon-contributory \n \nPhysical Exam:\nAdmission Physical Exam:\n\nVS: 99.3 84 128/68 18 97% RA\nGen: GCS 15, A&Ox3\nHEENT: NCAT. No septal hematoma, no hemotympanum, OP wnl\nCV: 2+ radial pulses, 2+ DP pulses b/l. RRR, no M/R/G\nResp: BS equal b/l, R chest wall tenderness, no crepitus\nAbd: soft, nontender, nondistended\nMSK: FROM without pain throughout. Joints non-tender\nthroughout. Pelvis stable\nNeuro: PERRL, EOMI. Motor ___ throughout, sensation\nintact throughout. No midline spinal tenderness, step-offs\n\nDischarge Physical Exam:\nVS: T: 99.4, HR: 87, BP: 113/51, RR: 16, O2: 99% RA\nGENERAL: A+Ox3, NAD\nCV: RRR\nCHEST: right upper chest with old chest tube site, healing well, \nno s/s infection. dry sterile dressing with tegaderm intact \nwithout drainage. \nPULM: CTA b/l, no crepitus, symmetric chest expansion\nNEURO: + sensation in all extremities\nEXTREMITIES: +2 palpable pulses b/l, warm, well-perfused, trace \nedema b/l ___. \n\n \nPertinent Results:\nIMAGING: \n\n___:\nSinus rhythm. Normal ECG. Compared to the previous tracing of \n___ the \nheart rate has increased. \n \n___: Pleural fluid pathology:\nPLEURAL FLUID (SIDE NOT SPECIFIED):\nNEGATIVE FOR MALIGNANT CELLS.\nMesothelial cells, histiocytes, and lymphocytes.\nNote: Immunostains for B72.3 and ___ are negative, supporting \nthe above diagnosis.\n\n___: CXR: \nInterval placement of right-sided pigtail catheter. No gross \neffusion. No pneumothorax detected. \n \n___: CXR:\nPossible minimal fluid at the right costophrenic angle, grossly \nunchanged.\n\n___: CXR:\nComparison to ___. The right chest tube was removed. \nThere is no \nevidence for the presence of an right pneumothorax. Stable \nappearance of the left hemi thorax and of the heart. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year-old F s/p MVC in ___ during which \nshe had a SAH, C7 facet fx, T4/5 transverse process, T4/6 spinus \nfx, T7 fx, L2 transverse process fx, right hemothorax. At the \ntime, she had a right pigtail placed and underwent C6-7 ACDF, \nC6-7 posterior lami/fusion, T3-T11 lami/fusion. She recovered \nwell and was discharged to ___ rehab on ___ to \ncontinue her recovery. She was recently discharged from rehab, \nand then presented to ___ this admission with severe, \npleuritic right scapula pain limiting her mobility. Imaging \nrevealed a right pleural effusion and she was admitted to the \nAcute Care Surgery service for further medical care. \n\nInterventional Pulmonology was consulted for chest tube \nplacement and a ___ Fr chest tube was placed on ___. The \npatient tolerated this procedure well and the chest tube was \nplaced to suction. The Chronic pain service was consulted to \nhelp prescribe an appropriate oral pain regimen. On ___, \nthe chest tube was placed to waterseal. On ___, the chest \ntube was removed and post-pull chest x-ray was stable. \n\nThe patient was alert and oriented throughout hospitalization. \nShe remained stable from a cardiovascular standpoint; vital \nsigns were routinely monitored. Good pulmonary toilet, early \nambulation and incentive spirometry were encouraged throughout \nhospitalization. The patient tolerated a regular diet. Patient's \nintake and output were closely monitored. The patient's fever \ncurves were closely watched for signs of infection, of which \nthere were none. There were no signs of bleeding. The patient \nreceived subcutaneous heparin and ___ dyne boots were used \nduring this stay and she was encouraged to get up and ambulate \nas early as possible. The patient worked with Physical Therapy \nwho recommended she be discharged to rehab to continue her \nrecovery. \n\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Zolpidem Tartrate 5 mg PO QHS \n2. Baclofen 10 mg PO Q12H \n3. Baclofen 15 mg PO DAILY \n4. Gabapentin 400 mg PO DAILY \n5. HYDROmorphone (Dilaudid) ___ mg PO Q2H:PRN pain \n6. Pregabalin 100 mg PO TID \n7. Bisacodyl 10 mg PR QHS:PRN constipation \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H Pain \n2. Baclofen 10 mg PO BID \n3. Bisacodyl 10 mg PR QHS:PRN constipation \n4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain \n5. Pregabalin 100 mg PO TID \n6. Zolpidem Tartrate 5 mg PO QHS \n7. Docusate Sodium 100 mg PO BID \nplease hold for loose stool \n8. Heparin 5000 UNIT SC BID \n9. Senna 8.6 mg PO BID:PRN constipation \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n11. Morphine SR (MS ___ 30 mg PO Q8H \ndo NOT drink alcohol or drive while taking this medication \n12. Diazepam 5 mg PO Q6H:PRN anxiety \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight nonhemorrhagic pleural effusion\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital with right scapula pain and \nwere found to have a right pleural effusion. You had a chest \ntube placed to drain the fluid collection and the tube was later \nremoved as the pleural effusion was appropriately drained. You \nhave worked with Physical Therapy who now recommend you be \ndischarged to rehab to continue your recovery.\n\nPlease note the following discharge instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n \n\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Check your incisions daily and report any increased redness or \ndrainage. Cover the area with a gauze pad if it is draining.\n\n* Your chest tube dressing may be removed in 48 hours. If it \nstarts to drain, cover it with a clean dry dressing and change \nit as needed to keep site clean and dry.\n\n * You will continue to need pain medication once you are home \nbut you can wean it over a few weeks as the discomfort resolves. \nMake sure that you have regular bowel movements while on \nnarcotic pain medications as they are constipating which can \ncause more problems. Use a stool softener or gentle laxative to \nstay regular.\n\n* No driving while taking narcotic pain medication.\n\n* Take Tylenol ___ mg every 6 hours in between your narcotic. \n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n \nFollowup Instructions:\n___\n" ]

[ "J90", "I272", "M25511", "Z981", "Z87820", "V8609XS", "Y92488", "J45909", "E041", "G43909", "F1210" ]

[ "J90: Pleural effusion, not elsewhere classified", "I272: Other secondary pulmonary hypertension", "M25511: Pain in right shoulder", "Z981: Arthrodesis status", "Z87820: Personal history of traumatic brain injury", "V8609XS: Driver of other special all-terrain or other off-road motor vehicle injured in traffic accident, sequela", "Y92488: Other paved roadways as the place of occurrence of the external cause", "J45909: Unspecified asthma, uncomplicated", "E041: Nontoxic single thyroid nodule", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "F1210: Cannabis abuse, uncomplicated" ]

[ "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nsingle car ___\n \nMajor Surgical or Invasive Procedure:\n___ Posterior Fusion Laminectomy C6-C7 \n___ FUSION CERVICAL ANTERIOR WITH INSTRUMENTATION C6-C7 \n\n \nHistory of Present Illness:\n___ s/p transferred to ___ from ___, where she was \noriginally brought in by EMS due to MVC. Patient was found \nunrestrained and lethargic in a single vehicle collision the \nmorning of ___, found wedged between the dashboard and steering \nwheel; no report of prolonged extrication or ejection. VSS on \nEMS transfer, but upon presentation to ___, intubated in ED \nfor combativeness, altered mental status, and airway protection. \nInitial CT scanning at ___ showed a CT head with SAH, and \nnumerous injuries including superior facet fx at C7; widened \nfacet at C6-7, R side pleural hemothorax; multiple T-spine \nfractures with T4/5 transverse process, T3/6 - spinus process \nfx; T7 with small amount of retropulsion, L2 transverse process \nfx. Laboratory evaluation notable for stable CBC, chemistries \nbut urine tox positive methamphetamines, TCH, and serum ETOH \n180. Patient transferred to ___ for trauma, neurosurgery, \nspine evaluation. Noted to be moving all extremities at ___ \n___, but on initial evaluation in ___ with decreased \nsedation, difficult ability to assess lower extremity movement. \nNo report at OSH or in ___ ED of additional external injuries on \nexam. In addition to prior injuries found on CT the MRI revealed \na small ventral epidural hematoma at C5-T1 with no significant \nmass effect on the spinal canal, and abnormal high signal within \nthe thoracic spinal cord at T6-7, consistent with contusion and \nedema. \n\n \nPast Medical History:\n-hx of thyroid nodules \n-hx of mild persistsant asthma, previously on proair and \nfluticasone, but no script since ___ \n-hx of migraines \n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nPHYSICAL EXAMINATION upon admission: ___\n \nConstitutional: intubated sedated\nHEENT: Pupils equal, round and reactive to light 3->2 bilat.\nSmall abrasion and contusion right scalp\nccollar in place. intubated\nChest: Clear to auscultation\nCardiovascular: Regular Rate and Rhythm, Normal first and\nsecond heart sounds\nAbdominal: Soft, Nontender, Nondistended\nExtr/Back: No cyanosis, clubbing or edema. Contusion to R\nforearm. Back nontender, no stepoff, no skin changes.\nSkin: Normal\nNeuro: 3T sedated. Noted to move BUE spontaneously.\nPsych: unable to assess\n\nPhysical examination: upon discharge: ___:\n\nvital signs: t=99.5, hr=102, bp=143/83, rr=16, oxygen \nsaturation=99% room air\n\nCV: ns1,s2, -s3, -s4\nLUNGS: clear\nABDOMEN: soft, non-tender\nEXT: + dp bil., left foot cool, muscle st. left leg 0, right \nleg +5/+5., + dp right foot, + radial pulse bil., PICC line \nwith DSD right antecubital\nSKIN: intact, steri strips intact ant and post aspect of neck\nNEURO: sleepy, opens eye to name, follows ___\n \n\n \n___ Results:\nChest x-ray: ___:\n\nET tube tip is 4.5 cm above the carinal. Right PICC line tip is \nin the right atrium and should be pulled back approximately 2 \ncm. NG tube tip is in the stomach \n\nIMPRESSION: \n \nThere is an endotracheal tube whose distal tip is 3.8 cm above \nthe carina. \nHeart size is upper limits of normal. There are low lung volumes \nwithout focal consolidation. There is some atelectasis at the \nlung bases. No \npneumothoraces are seen. There is an air-filled stomach. \n\nPELVIS (AP ONLY) \n\nIMPRESSION: \n \nNo acute fractures or dislocations are seen. Bilateral hip joint \nspaces are preserved. The visualized lower lumbar spine is \nwithin normal limits. There is contrast seen within the bladder \nand a Foley catheter is also seen. \n\nFOREARM (AP & LAT) RIGH\n\nIMPRESSION: \n \nNo acute fractures or dislocations are seen. Joint spaces are \npreserved \nwithout significant degenerative changes. There is normal \nosseous \nmineralization. There are no radiopaque foreign densities. \n\nMR CERVICAL SPINE W/O CONTRAST\n\nIMPRESSION: \n \n \n1. Focal disruption of the anterior longitudinal ligament, \nposterior \nlongitudinal ligament and ligamentum flavum at C6-7 with \nprobable interspinous and supraspinous ligamentous strain/tear. \n2. Small ventral epidural hematoma at C5-T1 with no significant \nmass effect on the spinal canal or spinal canal stenosis. \n3. Widening and fluid in the right C6-7 facet, suggestive of \ncapsular injury. \n4. Abnormal high signal within the thoracic spinal cord at T6-7, \nconsistent with contusion and edema. \n5. Mild widening and small amount of fluid in the left T6-7 \nfacet suggestive of capsular injury. \n6. Perched right T6-7 facet with left T7 superior articular \nfacet fracture \nbetter seen on the prior CT. Recommend a dedicated CT of the \nthoracic spine for further evaluation. \n7. High-signal in the T6-7 interspinous space and ligamentum \nflavum, \nsuggestive of strain/tear. \n8. STIR signal hyperintensity paralleling the superior endplates \nof T10, T11, and perhaps T9, without height loss raising the \npossibility of contusions. \n9. Partially visualized 4.6 cm right adnexal lesion, likely \nrepresenting a \nsimple cyst. \n10. Large right pleural effusion with layering dependent \nhemorrhage. \n \nRECOMMENDATION(S): Thoracic spine CT for further evaluation \n\nCT HEAD W/O CONTRAST Study Date of ___ 10:11 AM \n\nIMPRESSION: \n \nStable appearance of subarachnoid hemorrhage, punctate \nhemorrhagic contusions and subdural hematoma along the falx and \ntentorium. No significant mass effect. \n\n___ 08:34AM BLOOD WBC-10.1* RBC-3.21* Hgb-8.8* Hct-28.1* \nMCV-88 MCH-27.4 MCHC-31.3* RDW-14.0 RDWSD-42.9 Plt ___\n___ 04:57AM BLOOD WBC-11.1* RBC-3.16* Hgb-8.7* Hct-28.1* \nMCV-89 MCH-27.5 MCHC-31.0* RDW-14.0 RDWSD-44.3 Plt ___\n___ 01:48AM BLOOD WBC-10.4* RBC-2.98* Hgb-8.2* Hct-26.4* \nMCV-89 MCH-27.5 MCHC-31.1* RDW-13.9 RDWSD-44.4 Plt ___\n___ 07:55AM BLOOD WBC-14.7* RBC-3.94 Hgb-11.0* Hct-35.8 \nMCV-91 MCH-27.9 MCHC-30.7* RDW-13.8 RDWSD-45.6 Plt ___\n___ 02:01AM BLOOD Neuts-71.3* Lymphs-17.2* Monos-9.0 \nEos-1.4 Baso-0.2 Im ___ AbsNeut-6.43* AbsLymp-1.55 \nAbsMono-0.81* AbsEos-0.13 AbsBaso-0.02\n___ 08:34AM BLOOD Plt ___\n___ 04:57AM BLOOD Glucose-112* UreaN-10 Creat-0.5 Na-140 \nK-3.9 Cl-105 HCO3-25 AnGap-14\n___ 01:48AM BLOOD Glucose-112* UreaN-9 Creat-0.5 Na-139 \nK-4.0 Cl-103 HCO3-26 AnGap-14\n___ 04:57AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.3\n___ 01:58AM BLOOD TSH-1.6\n___ 01:58AM BLOOD T4-5.9\n___ 02:36PM BLOOD Vanco-9.5*\n___ 07:55AM BLOOD ASA-NEG ___ Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 02:18AM BLOOD Type-ART pO2-116* pCO2-41 pH-7.43 \ncalTCO2-28 Base XS-3\n___ 02:18AM BLOOD Lactate-0.7\n___ 02:18AM BLOOD freeCa-1.11*\n \nBrief Hospital Course:\nMs. ___ presented as a transfer from ___ to ___ s/p \nMVC intubated and sedated with +etoh/marijuana, SAH w/ C7 facet \nfx, T4/5 transverse process, T4/6 spinus fx, T7 fx, L2 \ntransverse process fx, and a right hemothorax on ___. She \nwas triaged as stat trauma and subsequently admitted to the \nTrauma ICU. Spine/Neurosurgery were emergently consulted. \n\n ___: Admitted to TICU, intubated, sedated. Interval hcts \nstable and MRI C/T/L spine performed notable for unstable \nligamentous injury at level of prior noted facet injuries, and \nsmall mid thoracic syrinx. Given her hemothorax, a right pigtail \nwas placed with 470cc bloody output. No further injuries \nidentified.\n \n ___: She was taken to the OR for anterior fusion C6-7 which \nwas uncomplicated. She was noted to be agitated, and \nsubsequently started on precedex. \n ___: Given concern of increased secretions and increased PEEP, \npt. underwent a bronchoscopy and subsequent mini BAL which was \nnegative for organisms. \n ___: Pt. was taken to OR for posterior fusion of cervical \nspine with minimal EBL and returned off pressors. Spine surgery \nfurther recommended non operative management for T-spine \ninjuries that included a TLSO. \n ___: Pt. noted to be increasingly agitated, and was started on \nclonidine patch and Seroquel. \n ___ : Pt. was more comfortable after medication change. \nHowever was noted to have more secretions and elevated temps \nwith a CXR consistent with LLL colapse. After a series of \nbronchoscopies and subsequent BAL, she was noted to be positive \nfor GPCs/GPRs/GNRS and was therefore started on Vanc/cefepime. \nShe subsequently improved from a ventilation standpoint, as well \nas agitation. \n ___: She was then extubated and per report of concerns for \na suicidal attempt, psychiatry was consulted and pt. was placed \non a 1:1 sitter pending collateral pending evaluation. Per \nrecommendation she was placed on prn Haldol which was \nsubsequently weaned, and her clonidine was discontinued. A \nfeeding tube that was placed upon admission was subsequently \nremoved and she passed a bedside speech and swallow. She was \ntransitioned to PO medications and transferred to the floor. \n\nThe patient transferred to the surgical floor on ___. She was \nevaluated by physical and occupational therapy in preparation \nfor discharge. Her vital signs have been stable and she has \nbeen afebrile. She has been tolerating a regular diet and \nvoiding without difficulty. She has been getting out of bed \nwith the ___ brace with the assistance of physical therapy. \nThere was concern for aspiration on Colace and the patient was \nevaluated by Speech and Swallow. She was cleared for thin \nliquids and ground solids, 1:1 supervision, and aspiration \nprecautions. Her oral intake has been about 700cc. On ___ she \nwas noted to have dark urine and a urine specimen was sent which \nshowed no bacteria growth. The patient had difficulty voiding \nand was retaining, for that reason a foley catheter was placed. \nShe will be discharged with the foley catheter in place and \nattempts to remove to be made at rehab. ___ brace to be \ndonned while in bed, prior to getting out of bed. \n\nThe patient was discharged to rehab on ___ in stable condition. \nShe will need follow-up appointments with the acute care surgery \nservice and with the spine service. \n\n*****\n\nThe patient will be discharged with the PICC line and foley \ncatheter. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PR QHS:PRN constipation \n2. Docusate Sodium 100 mg PO BID \n3. Famotidine 20 mg PO Q12H \n4. Heparin 5000 UNIT SC TID \n5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush \n\n6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H PRN wheeze \n7. LORazepam 0.5-1 mg PO Q6H:PRN anxiety \n8. OxycoDONE Liquid 15 mg PO Q3H:PRN pain \n9. Polyethylene Glycol 17 g PO DAILY:PRN constiaption \n10. Senna 8.6 mg PO BID \n11. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\ns/p MVC\nSAH \nC7 facet fracture\nT4/5 transverse process fracture\nT4/6 spinous process fracture\nT7 fracture \nL2 transverse process fracture\nRight hemothorax\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 (with brace for neck and back support)\n\n \nDischarge Instructions:\nYou were admitted to the hospital after you were involved in a \nmotor vehicle crash. You sustained injuries to your neck and \nback, as well as a small bleed in your head and a fluid \ncollection in your lung. You were taken to the operating room \nfor a neck fusion or stabilization. You were fitted for a brace \nfor support of your upper and lower back. You will need to place \nthe brace on when in bed before you get up. Your pain has been \ncontrolled with oral analgesia. Your vital signs have been \nstable and you are preparing for discharge to a rehabilitation \ncenter to further regain your strength and mobility. \n \nFollowup Instructions:\n___\n" ]

[ "S12600A", "S271XXA", "S066X0A", "J9600", "S240XXA", "F05", "S22049A", "S22059A", "S22069A", "S32029A", "Z6841", "D62", "J95851", "R339", "F10129", "F1290", "E669", "F329", "Z781", "V270XXA", "Y929", "S8012XA", "Z23", "Y848", "Y92239", "F419" ]

[ "S12600A: Unspecified displaced fracture of seventh cervical vertebra, initial encounter for closed fracture", "S271XXA: Traumatic hemothorax, initial encounter", "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "S240XXA: Concussion and edema of thoracic spinal cord, initial encounter", "F05: Delirium due to known physiological condition", "S22049A: Unspecified fracture of fourth thoracic vertebra, initial encounter for closed fracture", "S22059A: Unspecified fracture of T5-T6 vertebra, initial encounter for closed fracture", "S22069A: Unspecified fracture of T7-T8 vertebra, initial encounter for closed fracture", "S32029A: Unspecified fracture of second lumbar vertebra, initial encounter for closed fracture", "Z6841: Body mass index [BMI]40.0-44.9, adult", "D62: Acute posthemorrhagic anemia", "J95851: Ventilator associated pneumonia", "R339: Retention of urine, unspecified", "F10129: Alcohol abuse with intoxication, unspecified", "F1290: Cannabis use, unspecified, uncomplicated", "E669: Obesity, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z781: Physical restraint status", "V270XXA: Motorcycle driver injured in collision with fixed or stationary object in nontraffic accident, initial encounter", "Y929: Unspecified place or not applicable", "S8012XA: Contusion of left lower leg, initial encounter", "Z23: Encounter for immunization", "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", "F419: Anxiety disorder, unspecified" ]

[ "D62", "E669", "F329", "Y929", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \ngluten\n \nAttending: ___.\n \nChief Complaint:\nunstable thoracic spine fractures with left lower extremity \nmotor deficits\n \nMajor Surgical or Invasive Procedure:\n1. T3 to T11.\n2. Multiple thoracic laminotomies.\n3. Laminectomy T6 and 7.\n4. Instrumentation T3 to 11.\n5. Autograft.\n\n \nHistory of Present Illness:\n___ s/p recent MVC w/ multiple T-spine fxs & LLE motor deficits. \nCT in ___ revealed fxs of T3 SP, T4 R TP, T5 SP, T6 SP, \nand T7 vertebral body. She recently had repeat imaging showing \ninterval displacement of her T-spine fxs. She was seen by. Dr \n___ who is planning for posterior T3-12 fusion for stability. \nShe endorses persistent LLE motor deficits. Denies neck pain or \nUE sxs. Denies bowel or bladder sxs.\n \nPast Medical History:\n-hx of thyroid nodules \n-hx of mild persistsant asthma, previously on proair and \nfluticasone, but no script since ___ \n-hx of migraines \n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nOn examination the patient is well developed, well nourished, \nA&O x3 in NAD. AVSS.\nRange of motion of the thoracolumbar spine is somewhat limited \non flexion, extension and lateral bending due to pain.\nAmbulating with the assistance of a walker and ___, with TLSO \nbrace and soft cervical collar for support.\nGross motor examination reveals ___ strength throughout the \nbilateral upper extremities and right lower extremity. \nPersistent weakness in left lower extremity unchanged as \ncompared to pre operative examination.\nSensation is grossly intact throughout all affected dermatomes.\nThe thoracic incision is clean, dry and intact without erythema, \nedema or drainage.\nFoley catheter in place to gravity.\n\n \nPertinent Results:\n___ 09:15AM BLOOD WBC-8.9 RBC-3.40* Hgb-9.2* Hct-29.7* \nMCV-87 MCH-27.1 MCHC-31.0* RDW-13.3 RDWSD-42.5 Plt ___\n___ 09:15AM BLOOD Glucose-125* UreaN-6 Creat-0.5 Na-140 \nK-3.7 Cl-103 HCO3-29 AnGap-12\n___ 09:15AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.___riefly, ___ was admitted to the ___ Spine Surgery \nService and taken to the Operating Room on ___ for the above \nprocedure. Refer to the dictated operative note for further \ndetails. The surgery was performed without complication, the \npatient tolerated the procedure well, and was transferred to the \nPACU in a stable condition. TEDs/pneumoboots/SC heparin were \nused for postoperative DVT prophylaxis. Intravenous antibiotics \nwere continued for 24hrs postop per standard protocol. \nInitially, postop pain was controlled with a PCA. Diet was \nadvanced as tolerated. The patient was transitioned to oral \npain medication when tolerating PO diet. Foley catheter \nremained in place to gravity. Post-operative labs were grossly \nstable. A hemovac drain that was placed at the time of surgery \nwas removed on POD#2. Physical therapy was consulted for \nmobilization OOB. A TLSO brace was fitted for the patient. \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 \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Diazepam 5 mg PO Q6H:PRN pain/anxiety \nRX *diazepam [Valium] 5 mg 1 tab by mouth every six (6) hours \nDisp #*90 Tablet Refills:*0\n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Gabapentin 300 mg PO TID \nRX *gabapentin [Neurontin] 300 mg 1 capsule(s) by mouth three \ntimes a day Disp #*90 Capsule Refills:*0\n5. Heparin 5000 UNIT SC BID \n6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain \nRX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every \nfour (4) hours Disp #*90 Tablet Refills:*0\n7. Morphine SR (MS ___ 30 mg PO Q8H \nRX *morphine [MS ___ 30 mg 1 tablet(s) by mouth every eight \n(8) hours Disp #*90 Tablet Refills:*0\n8. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n T6 and 7 fractures, kyphosis.\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:\nACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks. \n\n___ times a day you should go for a walk for ___ minutes as \npart of your recovery. You can walk as much as you can tolerate. \n\nYou will be more comfortable if you do not sit or stand more \nthan ~45 minutes without changing positions.\n\nBRACE: You have been given a TLSO brace and soft cervical \ncollar. Both braces should be worn when you are walking. You may \ntake it off when sitting in a chair or while lying in bed.\n\nWOUND: Remove the external dressing in 2 days. If your incision \nis draining, cover it with a new dry sterile dressing. If it is \ndry then you may leave the incision open to air. Once the \nincision is completely dry, (usually ___ days after the \noperation) you may shower. Do not soak the incision in a bath or \npool until fully healed. If the incision starts draining at any \ntime after surgery, cover it with a sterile dressing. Please \ncall the office. \nPlease call the office if you have a fever>101.5 degrees \nFahrenheit and/or drainage from your wound.\n\nMEDICATIONS: You should resume taking your normal home \nmedications. Refrain from NSAIDs immediately post operatively.\n\nYou have also been given Additional Medications to control your \npost-operative pain. Please allow our office 72 hours for refill \nof narcotic prescriptions. Please plan ahead. You can either \nhave them mailed to your home or pick them up at ___ Spine \nSpecialists, ___. We are not able \nto call or fax narcotic prescriptions to your pharmacy. In \naddition, per practice policy, we only prescribe pain \nmedications for 90 days from the date of surgery.\n\n \nFollowup Instructions:\n___\n" ]

[ "S22059A", "F329", "S22069A", "V499XXA", "Y929", "E669", "Z6833", "Z981", "J45909", "G43909", "F1910", "M40209" ]

[ "S22059A: Unspecified fracture of T5-T6 vertebra, initial encounter for closed fracture", "F329: Major depressive disorder, single episode, unspecified", "S22069A: Unspecified fracture of T7-T8 vertebra, initial encounter for closed fracture", "V499XXA: Car occupant (driver) (passenger) injured in unspecified traffic accident, initial encounter", "Y929: Unspecified place or not applicable", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "Z981: Arthrodesis status", "J45909: Unspecified asthma, uncomplicated", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "F1910: Other psychoactive substance abuse, uncomplicated", "M40209: Unspecified kyphosis, site unspecified" ]

[ "F329", "Y929", "E669", "J45909" ]

[]

[ " \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:\nFacial trauma\n \nMajor Surgical or Invasive Procedure:\n___: Open reduction internal fixation left mandibular \nfracture left angle placement of IMF screws and wiring of \njawextraction of left upper third tooth (Number 16). \n\n \nHistory of Present Illness:\nMr. ___ is a ___ male prisoner patient with no \nsignificant past medical history who presents to the ED after \nbeing assaulted. He reports that he was assaulted there was no \nloss of consciousness. Given his trauma he underwent laboratory \ntesting which was significant for white cell count of 17.8 but a \nnormal CBC, coags, and electrolytes. He\nunderwent CT scan of the head, and torso which showed a left 10 \n- 11 posterior rib fracture and a left comminuted mandible \nfracture. We are consulted for management.\n\nPatient reports that he has left chest pain and mandible \ntenderness. He denies chills, fevers, palpitations, and SOB. A \n10+ review of systems is otherwise negative.\n\n \nPast Medical History:\nPMH \nnone\n\nPSH \nnone\n \nSocial History:\n___\nFamily History:\nNon-contributory. \n \nPhysical Exam:\nAdmission Physical Exam:\n\nVS: Temp 98.8, HR 97, BP 150/76, RR 16, O2 sat 97% on RA\nGeneral: NAD, AAOx3\nHEENT: PERRL, EOMI, anicteric sclera, left mandible edematous \nand\ndeformed\nChest: tender to palpation in the right chest\nCardiovascular: Regular rate and rhythm\nPulmonary: Clear to auscultation bilaterally, no respiratory\ndistress\nAbdominal: Soft, nondistended, non-tender\nExtremities: Warm, well-perfused, without edema\n\nDischarge Physical Exam:\nVS: T: 98.5 PO BP: 131/66 HR: 73 RR: 18 O2: 98% Ra \nGEN: A+Ox3, NAD \nHEENT: left facial edema. Left eye injected. \nCV: RRR, no m/r/g\nPULM: CTA b/l\nCHEST: left mid-axillary chest wall tenderness c/w known rib \nfractures. No crepitus, symmetric chest wall expanxion. \nABD: wwp, no edema b/l\nEXT:\n\n \nPertinent Results:\nIMAGING:\n\nCT head ___\nLeft comminuted mandible fxr\n\nCT Torso ___ posterior rib fractures\n\nLABS:\n\n___ 01:40AM GLUCOSE-139* UREA N-16 CREAT-1.2 SODIUM-140 \nPOTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14\n___ 01:40AM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-1.6\n___ 01:40AM WBC-17.8* RBC-4.22* HGB-13.5* HCT-40.3 MCV-96 \nMCH-32.0 MCHC-33.5 RDW-12.9 RDWSD-45.2\n___ 01:40AM NEUTS-85.7* LYMPHS-6.8* MONOS-6.9 EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-15.27* AbsLymp-1.21 AbsMono-1.22* \nAbsEos-0.00* AbsBaso-0.03\n___ 01:40AM PLT COUNT-221\n___ 01:40AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 01:40AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-300* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 01:40AM URINE RBC-5* WBC-8* BACTERIA-FEW* YEAST-NONE \nEPI-<1\n___ 01:40AM URINE MUCOUS-RARE*\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male who presents as a transfer \nfrom an outside hospital s/p an assault to the left side of the \nface as well as trauma to the torso. Found to have a left \nmandibular comminuted fracture, left 10& 11th rib fractures. He \nwas admitted to the Trauma/Acute Care Surgery service and the \nOral Maxillofacial (OMFS) service was consulted to address the \nmandible fracture. On HD1, the patient underwent ORIF of the \nleft mandible fracture. This procedure went well (reader, \nplease refer to operative note for further details). After \nremaining hemodynamically stable in the PACU, the patient was \ntransferred to the surgical floor. He initially received IV \nhydromorphone for pain control and he was then written for \nliquid acetaminophen and ibuprofen as well as lidocaine patches \nfor pain control. He received cefazolin post-operatively and was \nlater transitioned to a course of oral Keflex. Diet was advanced \nto full liquids which the patient tolerated well. \n\nThe patient remained stable from a cardiopulmonary standpoint; \nvital signs were routinely monitored. Good pulmonary toilet and \nearly ambulation were encouraged throughout hospitalization. The \npatient received subcutaneous heparin and ___ dyne boots were \nused during this stay and he was encouraged to get up and \nambulate as early as possible.\n\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever \nRX *acetaminophen 650 mg/20.3 mL 20.3 ml by mouth every six (6) \nhours Disp #*473 Milliliter Refills:*1 \n2. Cephalexin 500 mg PO Q6H Duration: 5 Days \nRX *cephalexin 250 mg/5 mL 10 mL(s) by mouth every six (6) hours \nRefills:*0 \n3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID \nswish and spit \nRX *chlorhexidine gluconate 0.12 % 15 mL(s) every eight (8) \nhours Refills:*0 \n4. Ibuprofen Suspension 400 mg PO Q6H:PRN Pain - Mild \nDo not take on an empty stomach. \nRX *ibuprofen 100 mg/5 mL 20 ml by mouth every six (6) hours \nRefills:*0 \n5. Lidocaine 5% Patch 1 PTCH TD QAM left rib pain \nApply patch and leave on for 12 hours, then remove and leave off \nfor 12 hours. \nRX *lidocaine 5 % Apply to area of left-sided rib pain Every \nmorning Disp #*15 Patch Refills:*0 \n6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth \nonce a day Disp #*5 Packet Refills:*0 \n7. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \nWean as tolerated. \nRX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*15 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n-Left mandibular fracture\n-Left ___ posterior rib fractures \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital with a left jaw fracture as \nwell as left-sided rib fractures. Your rib fractures will heal \non their own with time and it is important that you continue to \ntake deep breaths to keep your lungs expanded. The Oral \nMaxillofacial Surgery service took you to the operating room for \nsurgical repair of your left jaw fracture. Please remain on a \nfull liquid diet until your follow-up appointment in the Oral \nSurgery clinic. \n\nYou are now ready to be discharged from the hospital. Please \nfollow the discharge instructions below:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n\nDischarge Instructions Regarding your Rib Fractures:\n\n* Your injury caused left-sided rib fractures which can cause \nsevere pain and subsequently cause you to take shallow breaths \nbecause of the pain.\n \n* You should take your pain medication as directed to stay ahead \nof the pain otherwise you won't be able to take deep breaths. If \nthe pain medication is too sedating take half the dose and \nnotify your physician.\n \n* Pneumonia is a complication of rib fractures. In order to \ndecrease your risk you must use your incentive spirometer 4 \ntimes every hour while awake. This will help expand the small \nairways in your lungs and assist in coughing up secretions that \npool in the lungs.\n \n* You will be more comfortable if you use a cough pillow to hold \nagainst your chest and guard your rib cage while coughing and \ndeep breathing.\n \n* Symptomatic relief with ice packs or heating pads for short \nperiods may ease the pain.\n \n* Narcotic pain medication can cause constipation therefore you \nshould take a stool softener twice daily and increase your fluid \nand fiber intake if possible.\n \n* Do NOT smoke\n \n* If your doctor allows, non-steroidal ___ drugs \nare very effective in controlling pain ( ie, Ibuprofen, Motrin, \nAdvil, Aleve, Naprosyn) but they have their own set of side \neffects so make sure your doctor approves.\n \n* Return to the Emergency Room right away for any acute \nshortness of breath, increased pain or crackling sensation \naround your ribs (crepitus).\n\n \nFollowup Instructions:\n___\n" ]

[ "S02652A", "S2242XA", "Y09", "Y929", "Z23", "Z87891" ]

[ "S02652A: Fracture of angle of left mandible, initial encounter for closed fracture", "S2242XA: Multiple fractures of ribs, left side, initial encounter for closed fracture", "Y09: Assault by unspecified means", "Y929: Unspecified place or not applicable", "Z23: Encounter for immunization", "Z87891: Personal history of nicotine dependence" ]

[ "Y929", "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:\nR IF pain \n \nMajor Surgical or Invasive Procedure:\nPROCEDURE: Irrigation, washout and debridement right index\nfinger distal interphalangeal joint.\n \nHistory of Present Illness:\n___ year-old right-hand dominant nurse at ___ with severe RA on methotrexate who underwent excision \nof\ndistal right IF mass just proximal to eponychial fold concerning\nfor mucus cyst on ___ at ___. She noted some drainage \nfrom\nthe incision starting in the past ___, she had worsening pain\ntherefore went to ___ earlier today where they\ncultured purulent discharge and GPCs in clusters and pairs were\nobserved on gram stain, gave vancomycin and zosyn, and was\nsuperficially washed out and digital block performed for pain\ncontrol. She was transferred to ___ for further management. \nShe\ndenies fevers or chills, only increasing pain, drainage, and\nswelling of the digit. \n \nPast Medical History:\nRA\n \nSocial History:\n___\nFamily History:\nnon contributory \n \nPhysical Exam:\n***\n \nPertinent Results:\n___ 02:26PM WBC-8.9 RBC-3.94 HGB-12.5 HCT-37.7 MCV-96 \nMCH-31.7 MCHC-33.2 RDW-13.1 RDWSD-45.1\n \nBrief Hospital Course:\nThis is a delightful ___ female nurse ___ \n___ who is on immunosuppressants for rheumatoid \narthritis. She underwent excision of a draining mucous cyst by \nDr. ___ ___ unfortunately she developed an infection at \nthe surgical site. She was admitted to the hospital yesterday \nand underwent bedside I&D x2. \n\nThe patient was formally admitted to hand service for ongoing \nobservation as well as IV antibiotic\ntreatment. She was placed on vancomycin and Unasyn. Her \ncultures from the OSH grew pan sensitive enterococcus and MSSA \n(resistant to b lactams) she was discharged on levofloxacin. She \nwill follow up with Dr. ___ in clinic as \nscheduled. \n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Levofloxacin\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nR IF wound infection \n\n \nDischarge Condition:\nAVSS, AOx3\n\n \nDischarge Instructions:\nYou were admitted to the ED with a wound infection. Please \nfollow this instructions for postoperative care: \n\n1. Soak your wound four times daily in warm soapy water. After \nthis, replace the dressing. \n\n2. Take your antibiotics as prescribed\n\n3. Only take narcotic pain medications for sever pain and do not \ndrive while taking these medications \n \nFollowup Instructions:\n___\n" ]

[ "T814XXA", "L0889", "B952", "B9561", "Y838", "Y92018", "L608", "M069", "I10", "K219", "L820", "M6289" ]

[ "T814XXA: Infection following a procedure", "L0889: Other specified local infections of the skin and subcutaneous tissue", "B952: Enterococcus as the cause of diseases classified elsewhere", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "L608: Other nail disorders", "M069: Rheumatoid arthritis, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "L820: Inflamed seborrheic keratosis", "M6289: Other specified disorders of muscle" ]

[ "I10", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \n___: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nPalpitations\n \nMajor Surgical or Invasive Procedure:\nAblation \n\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS: Mr. ___ is a very pleasant\n___ man with PMHx PUD,HTN, HLD, possible hx of\n\"arrhythmia\" and recent hospital stay from ___ for AMS and\npalpitations felt to be ___ syncope and orthostasis who presents\nto the ED with palpitations. \n\nPatient was seen for a similar complaint in the ED on ___. Per\nreview of record, at that time patient was on ___ and\nfelt lightheaded and generally weak. He was given adenosine for\nSVT en route to ED. In the ED HR was in the 170s and rhythm\n\"likely atrial tachycardia\" per report. HR was controlled on IV\ndiltiazem and pt was discharged on metoprolol succinate 25 mg\ndaily per cardiology recommendation. Patient states that he took\none dose last night and one dose this morning. He states that he\nwoke up this morning feeling very lightheaded and weak and\nsensation of rapid heartbeat in his chest. He also felt like his\nvision was closing in and he was \"in a haze or a dream\" (but did\nnot pass out) sensation of SOB and chest tightness at which \npoint\nhe presented to the ED.\n\nIn the ED, initial VS were: Temp 97.6 HR 98 (66-180) BP 95/54 RR\n28 SaO2 100% \n\nExam notable for: Thready rapid pulse, diaphoresis, hypotension\nto 65/40\n\nLabs showed: Glu 108 WBC 6.4 Hb 13.8 \n\nPatient received:\n___ 09:50IVFNS___\n___ 10:50IVFNS 1000 mLRancourt,___ (1h ___\n___ 10:56IVFNSRancourt,___\n___ 11:56IVFNS 1000 mLRan___ (1h ___\n___ 21:03POFlecainide Acetate 100 ___\n* Per report, patient's heart rate improved to sinus in the high\n___ with a blood pressure of approximately 100/60 after\n1.5 L of normal saline\n\nEP was consulted. After review of strips, patient likely had\nAVNRT that is not well tolerated hemodynamically.\n \nWould do the following:\n-Admit to EP Nurse Practitioner ___ flecainide 100mg BID (first dose this evening at 7PM)\n-Obtain TTE\n\nTransfer VS were: Temp 98.5 HR 58 BP 108/68 RR 14 SaO2 96% RA \n\nOn arrival to the floor, patient reports the above history. He \nis\ncurrently without SOB, CP, palpitations, dizziness,\nlight-headedness, N/V/D, constipation, leg swelling, \nparasthesia,\nfocal weakness, visual changes, abdominal pain. As stated in the\nEP note, ___ years ago, he was diagnosed with \"arrhythmia\" in\n___ after episodes of dizziness, palpitations, and tachycardia\nthough a\n?TIA was also considered. At the time, diagnosis was made based\non an EKG. He has had episodes of tachycardia since then\noccurring several times per year and lasting seconds to minutes.\nHe recently moved to the ___ and had 2 more similar episodes (see\nrecent discharge on ___ and recent ED visit ___ as above).\n\n \nPast Medical History:\n? PUD\nPsoriasis\nHTN\nHLD\n? TIA\n? CAD\n? \"arrhythmia\"\n \nSocial History:\n___\nFamily History:\nmother- uterine cancer\nfather- kidney cancer\nmaternal grandmother kidney cancer\nno family history of strokes or seizure\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: Temp 99 BP 111 / 66 HR 69 RR 18 97%RA \nGeneral: Well-appearing man, NAD. Pleasant and conversational.\nAAOx3. \nHEENT: Sclerae anicteric, MMM, oropharynx clear\nNeck: supple, no LAD \nLungs: normal WOB on room air\nCV: RRR, no murmur, no gallop\nAbdomen: soft, NT/ND\nExt: warm, no edema\nNeuro: Moving all extremities. Able to walk the halls with a \nnormal gait.\nSkin: No rash or lesion. plaques/discolorations visible on ___\n\nDISCHARGE PHSYICAL EXAM\n98.1PO 112 / 74 R Sitting 54 18 99 RA \nGeneral: Well-appearing man, NAD. Pleasant and conversational.\nAAOx3. \nHEENT: Sclerae anicteric, MMM, oropharynx clear\nNeck: supple, no LAD \nLungs: normal WOB on room air\nCV: RRR, no murmur, no gallop\nAbdomen: soft, NT/ND\nExt: warm, no edema. b/l groin dressings clean/dry/intact\nNeuro: Moving all extremities. Able to walk the halls with a \nnormal gait.\nSkin: No rash or lesion. plaques/discolorations visible on ___\n \nPertinent Results:\nADMISSION LABS\n\n___ 09:54AM BLOOD WBC-6.4 RBC-4.63 Hgb-13.8 Hct-40.7 MCV-88 \nMCH-29.8 MCHC-33.9 RDW-12.7 RDWSD-40.7 Plt ___\n___ 09:54AM BLOOD Glucose-108* UreaN-19 Creat-0.7 Na-139 \nK-4.2 Cl-103 HCO3-17* AnGap-19*\n___ 07:45AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.2\n\nDSICAHRGE LABS\n___ 07:30AM BLOOD Glucose-93 UreaN-19 Creat-0.8 Na-134* \nK-4.2 Cl-99 HCO3-22 AnGap-13\n___ 07:30AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.3\n\nIMAGING\nECHO\nThe left atrial volume index is normal. Normal left ventricular \nwall thickness, cavity size, and regional/global systolic \nfunction (biplane LVEF = 59%). The estimated cardiac index is \nnormal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal \nleft 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 (3) appear structurally normal \nwith good leaflet excursion and no aortic stenosis. Trace aortic \nregurgitation is seen. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. The estimated \npulmonary artery systolic pressure is normal. There is no \npericardial effusion. \n\n IMPRESSION: Normal biventricular cavity sizes with preserved \nglobal biventricular systolic function. \n \nBrief Hospital Course:\nASSESSMENT AND PLAN: Mr. ___ is a ___ man with PMHx\nPUD,HTN, HLD, possible hx of \"arrhythmia\" and recent hospital\nstay from ___ for AMS and palpitations felt to be ___\nsyncope and orthostasis who presented to the ED with \ntachycardia,\npalpitations, and hypotension and was found to have a narrow\ncomplex tachycardia most consistent with AVNRT. \n\nACUTE ISSUES:\n=============\n# AVNRT. Patient presented with recurrent episodes of \npalpitations and lightheadness, most recently ___ HR in 170s \nand EKG showing a regular, narrow complex tachycardia most \nconsistent with AVNRT vs atrial tachycardia. No episodes since \nthat time. Patient was brought to the cath lab for potential \nablation on ___, no abnormalities found to ablate. Regimen \nincreased to 50mg Metoprolol XL. TTE was obtained which showed \nno structural abnormalities. \n\nCHRONIC ISSUES:\n===============\n# HLD. Continued Atorva 20mg daily \n# HTN. Was on 5mg amlodipine but held prior to admission iso \northostasis. \n# CAD (per report). Continued home Aspirin 81mg\n# GERD. Continued home omeprazole 40mg daily\n\nTRANSITIONAL ISSUES \n=================\n[ ] NO HEALTH INSURANCE at the time of discharge. Patient is \nhaving ongoing discussions with the Financial Department at \n___ for arranging insurance. Once insurance arranged, he will \nbe contacted by ___ Associates to schedule \nappointment for PCP\n[ ] incidental Right MCA aneurysm measuring 5x4x3mm found on CTA \nof Head and Neck\n[ ] mild normocytic anemia with normal iron studies, B12, \nFolate. Follow up as outpatient.\n\n#Medication change\n-Metoprolol succinate XL increased from 25mg daily to 50mg daily\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Omeprazole 40 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth every day \nDisp #*30 Tablet Refills:*0 \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. Omeprazole 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary\nAVNRT\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWhy was I admitted to the hospital? \n-You were admitted because you had an abnormal heart rate. \n\nWhat happened while I was in the hospital? \n- Your heart was monitored ___ to look for any more episodes, \nand you had no more episodes during the admission. \n- The electrophysiology (EP) doctors were ___ to help with \nfurther management. \n- You had a procedure done by the ___ doctors to ___ at your \nheart to find the cause of your fast heart rates, but no \nabnormalities were found.\n- You were started on 50mg of Metoprolol Succinate Daily to help \ncontrol your heart rate and prevent further episode.\n\nWhat should I do after leaving the hospital? \n- Please take your medications as listed in discharge summary \nand follow up at the listed appointments. \n- One of your home meds, Metoprolol, was increased from 25mg to \n50mg daily. Please take this new dose.\n- The Financial Department at ___ will continue working with \nyou \nto arrange health insurance. Once this is arranged, you will be \ncontacted to schedule a Primary Care Appointment. \n-In the meantime, if you do develop any new or concerning \nsymptoms, you will need to report to the ED.\n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\n Your ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "I471", "I671", "I10", "I2510", "K219", "I951", "D649", "Z598", "E785" ]

[ "I471: Supraventricular tachycardia", "I671: Cerebral aneurysm, nonruptured", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "I951: Orthostatic hypotension", "D649: Anemia, unspecified", "Z598: Other problems related to housing and economic circumstances", "E785: Hyperlipidemia, unspecified" ]

[ "I10", "I2510", "K219", "D649", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with HTN, HLD, & recurrent SVT on Flecainade/Toprol p/w \nCP/SOB and lightheadedness, found to be hypotensive with \nintermittent SVT without ischemic EKG changes or positive \nbiomarkers, now admitted to the CCU for planned EP ablation.\n\nHis SVT was initially diagnosed in ___, when he was admitted \nfor palpitations associated with tachycardia and hypotension, \nand was\nfound to have a narrow complex tachycardia consistent with AVNRT\nvs. atrial tachycardia, which was not able to be induced on EP\nstudy. Therefore, he was treated medically with metoprolol, but\ndue to recurrence of arrhythmia, flecainide was added as of\n___. He had a routine f/u visit to his cardiologist on \n___, during which he was in NSR and asymptomatic.\n\nPer patient, chest pain started at 8 am this morning. Describes \nthe pain as a pressure sensation which was non-radiating. He has \nhad this pain before with prior arrhythmia episodes, but says \nthis was stronger. He reports associated dyspnea, palpitations, \nand dizziness. \n\n---------\nED Course\n---------\nInitial VS: T 97.5 HR 71 BP 98/51 RR 18 SpO2 98% RA\n*Later SBP decreased to low ___, placed on 2LNC for SaO2 \ndecreased to low ___\n\nExam notable for: heart rhythm irreg, clear lungs, no JVD or leg \nedema \n\nEKG: notable for intermittent runs of atrial tachycardia with \n2:1 conduction. \n\nLabs/studies notable for: \nCBC: 5.4 > 12.6/27.0 < 172\nTrop-T: <0.01 \nproBNP: 186\nLactate: 1.1\n\nCXR: No acute intrathoracic process\n\nPatient was given: \n- ___ 15:34PO/NG Aspirin 325 mg\n1L IVF\n\nConsult:\n- Cardiology: Please order proBNP, TSH and urgent TTE.\n\nOn arrival to the CCU: \nPatient continues to feel tightness in his chest and \nlightheadedness, as though he were going to pass out. His BPs \nremain 80-90s/60s, heart rhythm fluctuating between runs of SVT \n(to 130s), bouts of sinus bradycardia (30s), and runs of \nsinus/PVC bigeminy (70s)\n\nROS: Positive per HPI. Remaining 10 point ROS reviewed and \nnegative.\n \nPast Medical History:\nPER PRIOR DISCHARGE SUMMARY, confirmed as much as possible:\n- Peptic ulcer disease: was on omeprazole, self-discontinued\n- Psoriasis\n- HTN\n- HLD\n- TIA\n- CAD (reported, no history of cardiac catheterization)\n? \"arrhythmia\"\n \nSocial History:\n___\nFamily History:\nPer prior discharge summary:\nmother- uterine cancer\nfather- kidney cancer\nmaternal grandmother kidney cancer\nno family history of strokes or seizure\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVS: T 98.5 HR ___, BP ___, SaO2 96% RA \nGENERAL: Well developed, well nourished, Oriented x3. Mood, \naffect appropriate. \nHEENT: Normocephalic, atraumatic. \nCARDIAC: Irregular rhythm without murmurs \nLUNGS: Breath sounds equal b/l without crackles or wheezes \nABDOMEN: Soft, ND, NT \nEXTREMITIES: Warm, no edema \n\nDISCHARGE PHYSICAL EXAM: \n========================\nVS: 24 HR Data (last updated ___ @ 650)\n Temp: 98.1 (Tm 98.2), BP: 97/62 (93-109/50-67), HR: 53\n(51-59), RR: 16 (___), O2 sat: 97% (90-97), O2 delivery: Ra,\nWt: 150.57 lb/68.3 kg \nGeneral: well appearing, pleasant, in no acute distress.\nHEENT: sclerae anicteric, mucous membranes moist\nCHEST: Lungs clear to auscultation bilaterally, no wheezes, \nrales\nor rhonchi, no dullness to percussion\nCARDIAC: regular rhythm, bradycardic, normal S1/S2, no rubs,\ngallops or murmurs, no RV heave, non-displaced PMI\nABDOMEN: Soft, nontender, nondistended\nEXT/VASC: warm and well perfused, no clubbing, cyanosis or edema\nNEURO: grossly non focal. AOx3\n\n \nPertinent Results:\nADMISSION LABS\n=======================\n___ 02:25PM BLOOD WBC-5.4 RBC-4.13* Hgb-12.6* Hct-37.0* \nMCV-90 MCH-30.5 MCHC-34.1 RDW-13.2 RDWSD-43.4 Plt ___\n___ 02:25PM BLOOD Glucose-118* UreaN-17 Creat-0.8 Na-137 \nK-4.3 Cl-106 HCO3-21* AnGap-10\n___ 02:25PM BLOOD CK-MB-2 proBNP-186*\n___ 02:25PM BLOOD cTropnT-<0.01\n___ 02:25PM BLOOD Calcium-8.3* Phos-3.3 Mg-2.2\n___ 02:25PM BLOOD TSH-2.5\n___ 02:32PM BLOOD Lactate-1.1\n\nDISCHARGE LABS\n==============\n___ 05:03AM BLOOD WBC-6.2 RBC-4.05* Hgb-12.4* Hct-36.9* \nMCV-91 MCH-30.6 MCHC-33.6 RDW-13.4 RDWSD-45.0 Plt ___\n___ 05:03AM BLOOD ___ PTT-31.1 ___\n___ 05:03AM BLOOD Glucose-106* UreaN-19 Creat-0.8 Na-145 \nK-3.8 Cl-111* HCO3-21* AnGap-13\n___ 05:03AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.2\n\nIMAGING\n========================\nTTE (___): There is normal left ventricular wall thickness \nwith a normal cavity size. There is suboptimal image quality to \nassess regional left ventricular function. Overall left \nventricular systolic function is low normal. There is \nbeat-to-beat variability in the left ventricular contractility \ndue to the irregular rhythm. The visually estimated left \nventricular ejection fraction is 50-55%. There is no resting \nleft ventricular outflow tract gradient. No ventricular septal \ndefect is seen. Tissue Doppler suggests a normal left \nventricular filling pressure (PCWP less than 12mmHg). Normal \nright ventricular cavity size with\nnormal free wall motion. The aortic valve leaflets (?#) are \nmildly thickened. There is no aortic regurgitation. The mitral \nvalve leaflets are mildly thickened with no mitral valve \nprolapse. There is trivial mitral regurgitation. The tricuspid \nvalve leaflets appear structurally normal. There is physiologic \ntricuspid regurgitation. The estimated pulmonary artery systolic \npressure is normal. There is a trivial pericardial effusion. \nThere is a prominent anterior fat pad.\nIMPRESSION: Suboptimal image quality. Low-normal global left \nventricular sysotlic function in the setting of beat-to-beat \nvariability secondary to arrhythmia. Compared with the prior TTE \n___ , the left ventricular systolic function may be less \nvigorous (?beat-to-beat variability), but the suboptimal image \nquality of the studies precludes definitive omparison.\n\nCXR (___) IMPRESSION: No acute findings. \n\nMICROBIOLOGY\n============\n___ 3:30 pm BLOOD CULTURE #1. \n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 6:50 pm BLOOD CULTURE 2 OF 2. \n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 3:10 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE:\n======================\n___ with HTN, HLD, & recurrent SVT on Flecainade/Toprol who \npresented with CP/SOB and lightheadedness, found to be \nhypotensive with intermittent SVT without ischemic EKG changes \nor positive biomarkers, admitted to the CCU for planned EP \nablation. Patient was evaluated by EP and started on verapamil \nwith plan to arrange outpatient EP study/ablation. \n\nACUTE ISSUES: \n============= \n#Atrial Tachycardia\nHe presented to the ER with chest pain and was found to be in an \natrial arrhythmia, likely 2:1 atrial tachycardia. BPs were soft \nto 80-100/50-60s. He was in no acute distress and was having \n___ chest pain. Urgent TTE performed showed low-normal LV \nfunction with beat to beat variability ___ to the arrhythmia. \nLactate was 1.1. Second hospitalization for symptomatic \nnarrow-complex tachycardia c/w atrial tachycardia with variable \nconduction, with likely location of AT coming from high RA vs \nthe RUPV per EP. Previous EP study negative for ablatable focus \nin ___. He was started on phenylephrine for the tachycardia \nwhich was discontinued on ___ for bradycardia to the ___. \nHome metoprolol and flecainide were held during the admission \nand discontinued on discharge. He was started on verapamil 40 mg \nTID, consolidated to 120mg ER daily on discharge with plan to \narrange EP study/ablation as an outpatient with likely need for \ntrans-septal access for ablation.\n\n#Hypotension - resolved\nAdmitted with symptomatic hypotension to ___ with \nlightheadedness, likely ___ impaired diastolic filling I/s/o \nSVT. While in the ED received 500cc IVF without effect. In the \nCCU was started on phenylephrine but was stopped due to \nreflexive bradycardia to the ___. He was then given an \nadditional 2L IVF with improvement in blood pressures. He was \nencouraged to increase his PO intake of fluids. \n\n#Chest pain\nNegative initial troponin in ED, several hours into chest \ntightness sx, and no obvious ischemic EKG changes (either in ED \nor in CCU) to suggest ACS. Trop and CK-MB flat. Likely ___ \narrhythmia, as similar symptom during last hospitalization for \nthe same problem. During hospitalization did complain of some \nchest discomfort that would occur during episodes of sadness \nwhen thinking of his wife and ___ young children who are still in \n___ - these episodes would self-resolve. \n\nCHRONIC ISSUES: \n=============\n#HLD: Continued home atorvastatin and ASA\n\n#HTN: Held home metoprolol succinate while admitted and on \ndischarge\n\n#PUD: Had \"stomach ulcers\" ___ years ago per patient report, \ntook omeprazole 20mg/day but decided to stop a few months ago \nbecause it was giving him discomfort in other parts of his body. \nDuring hospitalization was held but he was advised to restart it \nas an outpatient pending further discussion with his PCP. \n\nTRANSITIONAL ISSUES\n===================\n[] Outpatient EP study/ablation for atrial tachycardia, to be \nscheduled. \n[] Started on verapamil 120 mg daily for atrial tachycardia, \nhome metoprolol and flecainide stopped; EP to follow-up for \nplanned duration \n[] Patient recently stopped PPI on his own which he was on for \nhistory of stomach ulcers ~ ___ years ago. Advised that he should \ncontinue to take this and discuss with PCP plan for the course \nof omeprazole. Consider H. Pylori stool study if not previously \ndone for further workup of PUD \n[] While here, was reporting episodes of feeling very sad \naccompanied by some chest discomfort. He reported missing his \nwife and 3 small children who are still in ___ and would have \nepisodes of extreme sadness because of this. Would consider \noffering ___/SW services for counseling, and possible assessment \nfor depression. \n\nCORE MEASURES: \n============== \n#CODE: Full (presumed) \n#CONTACT/HCP: ___, cell ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. Flecainide Acetate 50 mg PO Q12H \n3. Atorvastatin 20 mg PO QPM \n4. Aspirin 81 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY PUD \n\n \nDischarge Medications:\n1. Verapamil SR 120 mg PO Q24H \nRX *verapamil 120 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. Omeprazole 20 mg PO DAILY PUD \n5. HELD- Flecainide Acetate 50 mg PO Q12H This medication was \nheld. Do not restart Flecainide Acetate until instructed by your \ncardiologist\n6. HELD- Metoprolol Succinate XL 25 mg PO DAILY This medication \nwas held. Do not restart Metoprolol Succinate XL until \ninstructed by your cardiologist\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nAtrial tachycardia\n\nSECONDARY DIAGNOSIS:\n==================== \nHypertension\nHyperlipidemia \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nEstimado Sr. ___,\n \nConsulte a continuación para obtener más información ___ \nhospitalización. ¡Fue un placer ___ aquí en \n___!\n\n¿POR QUÉ ___ ADMITÓ ___ HOSPITAL?\n- Fue ingresado ___ hospital porque tenía un ritmo cardíaco \nmuy rápido ___ estaba causando dolor en el pecho.\n \n¿QUÉ ___ HIZO MIENTRAS ESTAS ___ HOSPITAL?\n- Mientras estuvo ___ hospital, ___ inició un nuevo medicamento \nllamado verapamilo. Usted fue atendido por el ___ de \nelectrofisiología y ___ programó un seguimiento para un \nestudio y un procedimiento para ___ más \n___ del corazón ___ está causando el aumento de \n___ cardíaca. En el momento en ___ estaba listo para \nir a casa, tenía más ___ cardíaca normal.\n \n¿QUÉ NECESITAS HACER CUANDO SALES ___ HOSPITAL?\n- COMIENZO a tomar verapamilo.\n- Deje de tomar metoprolol y flecainida a menos ___ \ncardiólogo ___ lo contrario.\n- ___ un seguimiento con sus médicos como ___ indica a \ncontinuación\n- Pésese ___ mañana, ___ atención médica ___ peso sube más \nde 3 libras.\n- - ___ atención médica ___ tiene síntomas nuevos o relativos, \no ___ presenta dolor en el pecho, sentimientos de ___ corazón \nestá latiendo muy rápido y no desaparece por sí solo, hinchazón \nen las piernas, distensión abdominal o falta de aire ___ \n___.\n\n___ deseamos todo lo mejor!\n- ___ de atención ___\n\n=========================== \n\nDear Mr. ___,\n \nPlease see below for more information on your hospitalization. \nIt was a pleasure taking part in your care here at ___!\n\nWHY WERE YOU ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital because you were having very \nfast heart rates that was causing your chest pain. \n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- While you were in the hospital a new medication called \nverapamil was started. You were seen by the electrophysiology \nteam and were scheduled for follow up for a study and procedure \nto more permanently fix the part of your heart that is causing \nthe elevated heart rates. At the time that you were ready to go \nhome you were having more normal heart rates. \n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- START taking verapamil.\n- STOP taking metoprolol and flecanide unless instructed \notherwise by your cardiologist. \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 chest pain, feelings that your heart is beating \nvery quickly that does not go away on its own, swelling in your \nlegs, abdominal distention, or shortness of breath at night. \n\nWe wish you all the best!\n- Your ___ Care Team\n \n\n \nFollowup Instructions:\n___\n" ]

[ "I471", "E785", "I959", "I10", "Z8711", "I2510", "Z8673", "L409" ]

[ "I471: Supraventricular tachycardia", "E785: Hyperlipidemia, unspecified", "I959: Hypotension, unspecified", "I10: Essential (primary) hypertension", "Z8711: Personal history of peptic ulcer disease", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "L409: Psoriasis, unspecified" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nSyncope, Visual Changes, Tinnitus\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ yo M ___ M with history of ?TIA, HTN, HLD, who\npresents with episodes of altered consciousness.\n\nOccurred ___ in the morning while sitting, he describes\nfeeling out-of-body in that his perception was \"off,\" and then\nhis vision in both eyes narrowed circumferentially and then\nexpanded. He sat down in a chair, and continued to have series \nof\nabout 6 brief episodes of this. He then loses memory of what\nhappened. Per sister, her other brother witnessed this and \nstated\nhe was not speaking but remained sitting up without fall or\nconvulsions, loss of bowel or bladder function. Directly prior \nto\nthese episodes he could hear a \"whooshing sound\" in his ear. He\nrecovered quickly from the events without any weakness numbness\nor balance issues. He does say his chest felt \"tight\" prior to\nthe episodes. He did have palpitations, lightheadedness, chest\npain, shortness of breath.\n\nHe reports they also occurred about 4 months ago, and again 6 \nmonths prior to that. They did occur in the setting of poor PO \nintake and possibly taking an extra dose of his Amlodipine. \nThere was no clear positional component to his symptoms.\n\nHe denies melena, hematochezia. He does have a history of\n\"ulcers\" diagnosed 6 weeks ago in ___. He had an EGD there. He\ndoes not recall being told if he had H. pylori. He was put on\nseveral medications, he believes antibiotics for a total of 3\nweeks to which he was compliant. also reports he intermittently\nnotices blood on his toilet paper and that a lump extrudes at\ntimes when he strains when having bowel movements.\n\nHe recently moved to ___ from ___ within the last two weeks.\nHe is living with his sister. He used to drink heavily but has\nnot had alcohol in \"many years.\" He denies other drug use.\n\nHe denies fevers, chills, nausea, diaphoresis, any recent cough,\nabdominal pain, shortness of breath. He denies dyspnea on\nexertion. \n\nIn the ED, initial VS were: 98.1 67 115/70 19 100% RA \n\nImaging showed: \nNCTH with no acute intracranial abnormality\nCXR wnl\n\nNeuro were consulted and recommended to admit to medicine for \nsyncopal/cardiac\nwork-up\n\nOn arrival to the floor, patient reports he is feeling well. He\nis concerned that he had a small amount of blood on the toilet\npaper when having a bowel movement upon arrvial. He is very\nworried about this. He does strain when having bowel movements.\n \nPast Medical History:\n? PUD\nPsoriasis\nHTN\nHLD\n? TIA\n? CAD\n? \"arrhythmia\"\n \nSocial History:\n___\nFamily History:\nmother- uterine cancer\nfather- kidney cancer\nmaternal grandmother kidney cancer\nno family history of strokes or seizure\n \nPhysical Exam:\nEXAM ON ADMISSION\n======================\ntele sinus, rates ___\nVS: 96.4 AdultAxillary 91 / 58 60 18 94 Ra \nGENERAL: NAD, laying comfortably in bed. barrel-chested\nHEENT: AT/NC, EOMI, PERRL,pink conjunctiva, MMM\nNECK: no JVD \nHEART: Distant heart sounds, RRR, S1/S2, no murmurs, gallops, or\nrubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nRectal: deferred per patient\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, CNII-XII, strength, sensation grossly intact \nSKIN: warm and well perfused, no excoriations. hyperpigmented\npatches to back. \n\nEXAM ON DISCHARGE\n===========================\nVitals: 98.0, 130/76, hr 64, RR 17, 97 Ra \nTelemetry: sinus with rates 50-60's\nGeneral: Alert, oriented, no acute distress, well appearing\nHEENT: Sclerae anicteric, MMM, oropharynx clear\nNeck: supple, no LAD \nLungs: normal WOB on room air\nCV: RRR, no murmur, no gallop\nAbdomen: soft, NT/ND\nExt: warm, no edema\nNeuro: Moving all extremities. Able to walk the halls with a \nnormal gait.\nSkin: No rash or lesion\n \nPertinent Results:\nADMISSION LABS\n=========================\n___ 03:14PM BLOOD WBC-6.3 RBC-4.38* Hgb-13.2* Hct-39.8* \nMCV-91 MCH-30.1 MCHC-33.2 RDW-12.3 RDWSD-40.7 Plt ___\n___ 03:14PM BLOOD Glucose-101* UreaN-13 Creat-0.7 Na-142 \nK-4.2 Cl-106 HCO3-20* AnGap-16\n___ 04:28PM BLOOD ___ PTT-31.1 ___\n___ 03:14PM BLOOD cTropnT-<0.01\n___ 05:28AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 03:14PM BLOOD CK(CPK)-102\n___ 05:28AM BLOOD ALT-27 AST-21 AlkPhos-96 TotBili-0.6\n___ 05:28AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.3\n___ 03:14PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG \nBarbitr-NEG Tricycl-NEG\n___ 04:34PM BLOOD Lactate-0.8\n___ 04:45PM URINE Blood-TR* Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 04:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n\nDISCHARGE LABS\n===========================\n___ 05:12AM BLOOD WBC-5.5 RBC-4.40* Hgb-13.2* Hct-40.8 \nMCV-93 MCH-30.0 MCHC-32.4 RDW-12.3 RDWSD-42.5 Plt ___\n___ 05:12AM BLOOD Glucose-104* UreaN-16 Creat-0.8 Na-140 \nK-4.6 Cl-103 HCO3-27 AnGap-10\n___ 05:12AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.3 Iron-115\n\nMICROBIOLOGY\n===========================\n___ 4:45 pm URINE\n URINE CULTURE (Preliminary): \n GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL\n\nREPORTS\n===========================\nCTA Head and Neck ___\nRight MCA aneurysm measuring 5 x 4 x 3 mm. The aneurysm has a \nslightly \nlobulated/irregular appearance.\nNo significant ICA stenosis by NASCET criteria. \nThere is poor opacification of the left vertebral artery at its \norigin, this may be secondary to its tortuous origin or be \nrelated stenosis. Rest of the vertebral arteries and basilar \nartery are widely patent with no significant stenosis. \nLobular/tubular structure just posterior to the suprasternal \nnotch which seems to connect to the left brachiocephalic vein \nwhich most likely represents an anomalous venous structure. \nHowever correlation with neck ultrasound is advised. \n\nNCCT Head ___\nNo acute intracranial abnormality.\n\nCXR ___\nNo acute cardiopulmonary abnormality. \n\nEEG ___\nThis is a normal awake and asleep EEG with no epileptiform \ndischarges or features.\n\nEKG ___\nSinus Bradycardia\n \nBrief Hospital Course:\n___ from ___, reported hx of possible CAD, possible hx of TIA, \npossible hx of \"arrhythmia,\" HTN, HLD, who presented to the ED \nwith transient episode of alteration in consciousness, visual \nchanges, and tinnitus.\n\nHe reports episodes of symptoms similar to this occurring about \n6 months ago, and again a few months before that, while in ___. \nNo etiology had previously been identified.\n\nOn arrival to the floor, orhostatics were positive. He received \nIV fluid and Amlodipine was stopped. Even after stopping \nAmlodipine, blood pressures remained low-normal, so it was \ndiscontinued.\n\nHe had a workup for this while in house, including telemetry \nmonitoring (no tachy- or bradyarrthymia was seen), CT of the \nHead, EEG, and EKG, all of which were normal or unremarkable. \nNeurology was consulted in the Emergency Room, and recommended a \nCTA of the Head and Neck. This was negative for acute pathology \nin the posterior circulation to explain his presenting symptoms, \nbut did show an incidental Right MCA aneurysm measuring 5 x 4 x \n3 mm.\n\nHe had no further symptoms or episodes while in house, and was \nfeeling well on the day of discharge. Ultimately, given the lack \nof other etiology identified, his symptoms were felt to most \nlikely be due to orthostatic hypotension in the setting of \nAmlodipine, but he will need further monitoring as an outpatient \nfor recurrence of symptoms and consideration of further workup.\n\nCHRONIC ISSUES\n========================\n# HLD - Atorva 20mg daily\n# HTN - holding amlodipine given hypotension and positive \northostatics, as above\n# CAD (per report) - Aspirin 81mg\n# GERD - omeprazole 40mg daily\n\nTRANSITIONAL ISSUES\n========================\n[ ] NO HEALTH INSURANCE at the time of discharge. Patient is \nhaving ongoing discussions with the Financial Department at \n___ for arranging insurance. Once insurance arranged, he will \nbe contacted by ___ Health Care Associates and see Dr. ___ \n___ in clinic\n[ ] have STOPPED Amlodipine given orthostatic hypotension on \nadmission and normal BP's without it\n[ ] incidental Right MCA aneurysm measuring 5x4x3mm found on CTA \nof Head and Neck\n[ ] mild normocytic anemia with normal iron studies, B12, \nFolate. Follow up as outpatient.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 20 mg PO QPM \n2. Aspirin 81 mg PO DAILY \n3. amLODIPine 5 mg PO DAILY \n4. Omeprazole 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Omeprazole 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSyncope - likely from antihypertensive medication\nIncidental finding of R MCA Aneurysm\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nMr. ___,\n\nIt was a pleasure meeting you at ___. You were admitted to \nour hospital after developing dizziness, passing out, visual \nsymptoms, and ear ringing. We did multiple tests.\n\nWe found that your blood pressure was low, and for this we gave \nyou IV fluids and stopped your Amlodipine.\n\nThe EEG of the brain did not show any seizures. Your Head CT \ndid not show anything to explain your symptoms. It did show a \nfinding of an aneurysm in one of the arteries of your brain. \nThis was NOT what was causing your symptoms, but you will need \nto follow up on this as an outpatient to for further monitoring.\n\nPlease stop your Amlodipine, and continue your other \nmedications.\n\nIt was a pleasure, we wish you the best,\n___ Medicine Team\n \nFollowup Instructions:\n___\n" ]

[ "R55", "H539", "H9319", "I10", "K625", "I720", "L409", "K219", "I951" ]

[ "R55: Syncope and collapse", "H539: Unspecified visual disturbance", "H9319: Tinnitus, unspecified ear", "I10: Essential (primary) hypertension", "K625: Hemorrhage of anus and rectum", "I720: Aneurysm of carotid artery", "L409: Psoriasis, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I951: Orthostatic hypotension" ]

[ "I10", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PSYCHIATRY\n \nAllergies: \npcn / sulfa / phenobarbital / labetalol / ampicillin / \namoxicillin\n \nAttending: ___.\n \nChief Complaint:\n\"I'm jittery from the risperidone\" \n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with self-reported psychiatric \nhistory of OCD, anxiety, depression, and somatization disorder, \nrecently hospitalized on Deac4 for an unspecified psychotic \nepisode that was possibly substance-induced (___), who \nself-presented to the ED due to concerns that his risperidone \nwas making him increasingly restless and anxious. Psychiatry was \nconsulted for evaluation due to ED resident concern of possible \nSI.\n.\nPlease also see Dr. ___ comprehensive discharge \nsummary dated ___ for full details of last Deac4 hospital \ncourse. Briefly, at that time patient was hospitalized after \nfor possible substance-induced psychosis. There was also \nconcern for polypharmacy, as pt has history of somatic symptom \ndisorder and had a box filled with numerous prescriptions that \nhe took for unclear reasons. Medication regimen during that \nhospitalization was drastically simplified, and patient's mental \nstatus had improved.\n.\nSince that hospitalization, patient reports that he broke up \nwith his ex-wife, and is living with his son in-law. States \nthat he has been feeling increasingly \"depressed.\" Cites \nnumerous neurovegetative symptoms of depression, including poor \nsleep (sleeping 4h/night), increasing anxiety, decreased \nappetite, weight loss (states 40 pounds over past several \nmonths), and difficulty with concentration.\n.\nPt presents today because of concern that risperidone has been \nmaking him anxious. Pt states he became akathitic secondary to \nhaloperidol in the past, and does not feel that he is quite at \nthat level yet. Pt reports that his restless symptoms started on \nthe inpatient unit approx. 1 week after starting the med. Pt is \nasking to discontinue risperidone and instead use Ativan. Pt \nreports Vistaril has not helped with his restlessness. Pt \nthinks his previous psychotic episode is a \"statistical \nanomaly,\" states that, \"I don't have a chronic psychotic \ndisorder, I don't need that med.\" Pt states that he has been \nmedication compliant. Of note, pt reports that his outpatient \npsychiatrist recently started him on selegiline 5mg po BID to \ntreat his depression.\n.\nHe denies AVH. Patient denies HI. When asked about symptoms of \nmania, pt reported, \"no, I'm not manic.\"\n.\nIn terms of SI, patient initially denied. However, on repeat \nquestion, patient stated, \"it's a philosophical difference. If \nyou were in my SES, you'd have these thoughts too.\" Pt then \nacknowledged passive SI, worsened over the past several weeks, \nwith no intent or plan. Upon further questioning, pt began to \nsob, and cried, \"I just need a break. I can't do it anymore.\" He \nstates that he has no hope for the future, and spends his time \nisolated at home. Pt is requesting inpatient hospitalization at \nthis time for stabilization.\n.\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\nAs per Dr. ___ ___ note and Dr. ___ \n___ discharge summary, updated with patient today:\nDiagnoses: Per patient: OCD, anxiety, depression, somatization \ndisorder\nHospitalizations: \"too many\" first was in the late 1990s, last \non Deac4 discharged ___\nCurrent treaters and treatment: Psychiatrist Dr. ___, \nat ___ through CHA\nMedication and ECT trials: lithium, Depakote, risperidone, \nHaldol, prazosin\nSelf-injury: reported burning self (patient was vague), reported \n2 suicide attempts, once when he was \"too young to know better\" \nand does not remember details of that attempt; second attempt in \nearly ___ when he tried to overdose on medications\nHarm to others: denied\nAccess to weapons: denied\n.\nPAST MEDICAL HISTORY:\nPCP: Dr. ___ at ___ through CHA\nHTN\nDiverticulitis s/p colonic resection in ___\nasthma\narthritis\ncarpal tunnel syndrome\n\nHistory of head injuries with LOC as a child\n\nHistory of febrile seizures as a child\n.\n \nSocial History:\nSUBSTANCE ABUSE HISTORY:\nAlcohol: \"couple beers a week\"\nMJ: \"a little bit a couple times a week,\" would not specify what \n\"little bit\" meant, stated it helps with anxiety\n.\nFORENSIC HISTORY:\nAs per Dr. ___ ___ note and Dr. ___ \n___ discharge summary, updated with patient today:\nArrests: 3, does not remember details\nConvictions and jail terms: 1 month in ___\nCurrent status (pending charges, probation, parole): none\n.\n\nSOCIAL HISTORY:\n___\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\nPatient does not know, stated he was adopted\n \nPhysical Exam:\nAdmission Physical Examination:\nVS: BP: 134/78 HR: 90 temp: 97.6 resp: 18 O2 sat: 94 \nGeneral- NAD, anxious\nSkin- Warm, dry\nHEENT- No scleral icterus. MMM. \nLungs- CTAB. No wheezes/crackles/rales.\nCV- RRR. No m/r/g.\nAbdomen: +BS, soft, nondistended, nontender. No \norganomegaly/masses.\nExtremities- No edema/clubbing/cyanosis.\nNeuro- EOMI. No ptosis, no facial asymmetry. Normal gait. Normal \nstrength in upper/lower extremities. Sensation intact to LT. \n.\nNeuropsychiatric Examination:\n *Appearance: Overweight male in hosital gown.\n Behavior: Mostly cooperative, withheld info at times, poor \neye-contact.\n *Mood and Affect: \"Very anxious.\" Constricted affect. \n *Thought process: Linear and goal-directed. No loosening of \nassociations.\n *Thought Content: Passive SI and hopelessness with no \nintent/plan. Did not want to elaborate on specific content of \nSI. Reported possible obsessions/compulsions but did not to \nelaborate. No delusions. No AVH. No HI. \n *Judgment and Insight: Impaired\n Cognition:\n *Attention: Able to name months of the year backwards\n *Memory: ___ recognition and ___ recall\n *Fund of knowledge: Appropriate\n *Speech: Normal rate, volume, prosody\n *Language: ___\n.\n \nPertinent Results:\n___ 12:48PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 12:48PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 12:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 11:30AM GLUCOSE-113* UREA N-10 CREAT-1.0 SODIUM-139 \nPOTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-23 ANION GAP-18\n___ 11:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 11:30AM WBC-7.1 RBC-5.53 HGB-16.3 HCT-47.9 MCV-87 \nMCH-29.5 MCHC-34.0 RDW-12.6 RDWSD-39.8\n___ 11:30AM NEUTS-63.2 ___ MONOS-7.4 EOS-1.5 \nBASOS-0.4 IM ___ AbsNeut-4.50 AbsLymp-1.89 AbsMono-0.53 \nAbsEos-0.11 AbsBaso-0.03\n___ 11:30AM PLT COUNT-___rief Hospital Course:\n SAFETY: The pt. was placed on 15 minute checks on admission \nand remained here on that level of observation throughout. He \nwas unit-restricted. There were no acute safety issues during \nthis hospitalization.\n.\n LEGAL: ___\n PSYCHIATRIC:\nOn admission interview, patient confirmed much of the initial \npresentation detailed above. He reported increased anxiety, and \nworsening mood over several weeks, with intermittent SI. He \ndenied any specific plan. He also reported a general \"jittery\" \nfeeling, particularly in his legs, which he attributed to his \nrisperidone. Patient's clinical presentation is quite complex, \nbut overall seems to be most consistent with his history of OCD, \nas well as an unspecified anxiety disorder, and unspecified \ndepressive disorder. His general subjective sense of \nrestlessness could represent akathisia secondary to his dose of \nrisperidone. To address this, patient was started on Cogentin, \nwhich was uptitrated to 1mg po BID, and his dose of risperidone \nwas decreased from 6mg po qHS to risperidone 1mg po qHS. After \na few days of treatment with Cogent and decreased dose of \nrisperidone, patient felt that his restlessness had markedly \nimproved. To target anxiety, patient was treated with lorazepam \n0.5mg po q4h prn anxiety, agitation, Vistaril 25mg po q4h prn \nanxiety or insomnia, as well as Benadryl 50mg po qHS. To target \nmood, patient reported that his outpatient psychiatrist had \nstarted him on selegiline, but patient reported that he was \ntaking po selegiline as he was unable to obtain prior ___ for \ntransdermal selegiline. Patient was initially continued on his \npo selegiline, but this was transitioned to transdermal Emsam \n9mg q24hour patch while inpatient. Patient was advised and \neducated on importance to remain on tyramine-free diet while on \npo selegiline, and this dietary restriction was ordered as well \nthrough our dining services. \n.\nAfter several days on this adjusted medication regimen, patient \nreported markedly decreased anxiety level and improved mood. \nWhile inpatient, he consistently denied SI, denied HI, and \ndenied AVH. Inpatient treatment team applied for prior \nauthorization for transdermal selegiline, which was approved by \npatient's insurance. On day of discharge, patient denied SI and \nremained future oriented, with plans to attend follow-up \nappointments and become more active in hi community. Upon \ndischarge, patient was provided with prescriptions for Cogentin \n1mg po BID, Emsam 9mg transdermal patch to be changed every 24 \nhours (prior ___ ___, has been approved for one year, \nexpires ___, lorazepam 0.5mg po BID prn anxiety (28 tabs), \nrisperidone 1mg po qHS, as well as prescriptions for his \nlevothyroxine and losartan (see Medical section below). Patient \nwas scheduled for follow-up appointments with his outpatient \npsychiatrist and therapist. Patient was in good understanding \nand agreement with this aftercare plan.\n.\n GENERAL MEDICAL CONDITIONS:\n #.HTN: Patient was continued on his home antihypertensive \nregimen of losartan 50mg po daily. Patient remained \nhemodynamically stable and normotensive throughout this \nadmission. Patient will continue to require outpatient \nfollow-up by PCP to monitor HTN and adjust antihypertensive \nregimen as clinically appropriate.\n.\n#.Hypothyroidism: Patient was continued on his home regimen of \nlevothyroxine 112mcg po daily. On this regimen, thyroid labs \nwere within normal limits: TSH was 1.4, T4 8.7, T3 119. Patient \nwill continue to require outpatient follow-up by PCP to monitor \nhis thyroid.\n.\n#.Asthma: Patient was continued on his home regimen of albuterol \ninhaler 2puff in q4h prn SOB/wheezing, and ipratropium bromide 2 \npuff in q6h prn SOB/wheezing. Patient's asthma remained \nasymptomatic throughout this admission. Patient will continue \nto require outpatient follow-up by PCP to monitor his asthma.\n.\n PSYCHOSOCIAL:\n #) GROUPS/MILIEU: Pt was encouraged to participate in unit’s \ngroups/milieu/therapy opportunities as appropriate. He was \nvisible in the unit and had conversations with peers. He \nattended groups as tolerated. She never engaged in any unsafe \nbehaviors. He ate all meals in the milieu, slept well, and \ncooperated with group rules. Therapy addressed \nfamily/social/work issues. \n.\n #) COLLATERAL CONTACTS: Patient's outpatient psychiatrist, Dr. \n___, was contacted during this admission and provided \nwith a clinical update. Dr. ___ that he saw the \npatient once as an embedded CL psychiatrist on his PCP's team, \nand does not routinely follow his own outpatients at this \npractice. However, he was willing to see the patient once more \nupon discharge while patient is being referred to more longterm \noutpatient treaters.\n.\n #) INTERVENTIONS:\n - Medications: risperidone, Cogentin, lorazepam, Emsam\n - Psychotherapeutic Interventions: Individual, group, and \nmilieu therapy.\n - Behavioral Interventions (e.g. encouraged DBT skills, ect): \nPatient was encouraged to continue to participate in groups as \ntolerated, with particular emphasis on identifying positive \ncoping mechanisms\n.\n INFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nstarting these medications, and risks and benefits of possible \nalternatives, including not taking the medication, with this \npatient. We discussed the patient's right to decide whether to \ntake this medication as well as the importance of the patient's \nactively participating in the treatment and discussing any \nquestions about medications with the treatment team, and I \nanswered the patient's questions. The patient appeared able to \nunderstand and consented to begin the medication.\n. \n RISK ASSESSMENT:\n #) Chronic/Static Risk Factors:\n-history of chronic mental illness with multiple \nhospitalizations\n-history of prior suicide attempts\n-history of chronic medical illness\n \n #) Modifiable Risk Factors:\n-acute stress of recent separation from wife\n-minimal interpersonal supports\n\n #) Protective Factors:\n-patient is help seeking\n-patient is medication compliant\n.\n PROGNOSIS: Patient has potential for fair longterm prognosis, \nas he has numerous strengths, including the fact that he is \nintelligent, educated, help seeking, medication compliant, and \nhas been established with outpatient treaters. Patient will \ncontinue to require longterm outpatient psychopharmacology \nmanagement closely monitored by his outpatient treaters.\n.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 112 mcg PO DAILY \n2. HydrOXYzine 25 mg PO Q4H:PRN anxiety/insomnia \n3. Losartan Potassium 50 mg PO DAILY \n4. RISperidone (Disintegrating Tablet) 6 mg PO DAILY \n5. DiphenhydrAMINE 50 mg PO QHS \n6. Selegiline HCl 5 mg PO BID \n7. Ipratropium Bromide MDI 2 PUFF IH Q6H SOB/wheezing \n8. Albuterol Inhaler 2 PUFF IH Q4H SOB/wheezing \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q4H SOB/wheezing \n2. DiphenhydrAMINE 50 mg PO QHS \n3. Levothyroxine Sodium 112 mcg PO DAILY \nRX *levothyroxine 112 mcg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n4. RISperidone (Disintegrating Tablet) 1 mg PO QHS \nRX *risperidone 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n5. Losartan Potassium 50 mg PO DAILY \nRX *losartan 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n6. Ipratropium Bromide MDI 2 PUFF IH Q6H SOB/wheezing \n7. Benztropine Mesylate 1 mg PO BID EPS \nRX *benztropine 1 mg 1 tablet(s) by mouth twice a day Disp #*30 \nTablet Refills:*0\n8. Emsam (selegiline) 9 mg/24 hr transdermal QAM \nRX *selegiline [Emsam] 9 mg/24 hour apply one patch daily once \nevery 24 hours Disp #*30 Patch Refills:*0\n9. Lorazepam 0.5 mg PO BID:PRN anxiety \nRX *lorazepam 0.5 mg 1 by mouth twice a day Disp #*28 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nOCD, unspecified depressive disorder, unspecified anxiety \ndisorder\n\n \nDischarge Condition:\nNeurological:\n *station and gait: normal gait and station\n *tone and strength: moves all 4 extremities spontaneously\nantigravity\n cranial nerves: CN II-XII grossly intact\n abnormal movements: none observed \n *Appearance: fair appearing man who appears stated age, \nwearing\ncasual clothing. Sitting up in chair, in no acute distress.\n Behavior: calm, cooperative with interview, answers questions\nappropriately. Good eye contact. No PMA/PMR\nobserved\n *Mood and Affect: 'Better' / overall euthymic, less anxious \nappearing, mood\ncongruent, normal range and intensity\n *Thought process (including whether linear, tangential,\ncircumstantial and presence or absence of loose *associations):\nLinear, goal oriented, somewhat rigid and concrete at times\n *Thought Content (including presence or absence of\nhallucinations, delusions, homicidal and suicidal ideation, with\ndetails if present): Denies SI, denies HI, denies AVH. \n *Judgment and Insight: Fair / fair\n Cognition:\n *Attention, *orientation, and executive function: Alert,\noriented to interview at hand\n *Memory: grossly intact to recent and remote events\n *Fund of knowledge: adequate, appropriate\n *Speech: Normal rate, normal rhythm, normal prosody, normal\nvolume\n *Language: Native ___ speaker, fluent without \nparaphrasic\nerrors\n\n \nDischarge Instructions:\nDischarge Instructions\n\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n\n-Please continue all medications as directed.\n\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\n\n \n\n*It was a pleasure to have worked with you, and we wish you the \nbest of health.*\n\n \n \nFollowup Instructions:\n___\n" ]

[ "F339", "R45851", "I10", "F42", "F419", "F459", "Z9049", "J45909", "G4700", "E039", "E663", "Z6837" ]

[ "F339: Major depressive disorder, recurrent, unspecified", "R45851: Suicidal ideations", "I10: Essential (primary) hypertension", "F42: Obsessive-compulsive disorder", "F419: Anxiety disorder, unspecified", "F459: Somatoform disorder, unspecified", "Z9049: Acquired absence of other specified parts of digestive tract", "J45909: Unspecified asthma, uncomplicated", "G4700: Insomnia, unspecified", "E039: Hypothyroidism, unspecified", "E663: Overweight", "Z6837: Body mass index [BMI] 37.0-37.9, adult" ]

[ "I10", "F419", "J45909", "G4700", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\ndental pain, facial swelling\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___, previously healthy, who presented with\nleft lower dental abscess. He noticed tooth pain 2 weeks ago, \nbut\nput off seeing his dentist. Experienced progressive swelling and\nworsening pain since, and saw dentist 3 days ago. An xray was\nperformed and showed abscess. He was prescribed a course of\namoxicillin, which he has been taking for 3 days, but his\nsymptoms have continued to progress. He has been taking \nibuprofen\nfor the pain, but says it is not helpful. Last ibuprofen dose \nwas\n___ AM. He went to ___ ___ AM where a CT was\nperformed. He was given 900mg IV clindamycin and transferred to\n___ for ENT evaluation.\n\nIn the ED he reported minimal pain, localized to left mandible\nwithout radiation. No dyspnea, stridor. No numbness. Reported\nsome pain with chewing and odynophagia, no dysphagia. No fever,\nchills, sweats. \n\n \nPast Medical History:\nnone\n \nSocial History:\n___\nFamily History:\nReviewed and determined to be non-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n___ Temp: 98.1 PO BP: 133/68 Lying HR: 67 RR: 18 O2\nsat: 99% O2 delivery: Ra \nWeight: 174.21 (Standing Scale) (Entered in Nursing IPA). BMI:\n27.3. \nGENERAL: WD/WN male, NAD \nHEENT: tender fluctuant and mobile mass below the left jaw that\nextends posteriorly, able to open mouth fully, swallowing\nsecretions, no oral lesions or trauma. \nRESP: Normal lung sounds bilaterally, no wheezes or rales, no\ndullness to percussion \nCV: RRR, + S1/S2, no M/R/G \nABD: + BS, soft, non tender, non distended, no rebound or\nguarding \nNEURO and EXTR: CN II-XII grossly intact, ___ strength and \nnormal\ntone in extremities bilaterally \n\nDISCHARGE PHYSICAL EXAM:\n___ ___ Temp: 98.2 PO BP: 129/81 L Lying HR: 63 RR: 18 O2\nsat: 98% O2 delivery: Ra \nGENERAL: NAD, lying in bed, cooperative\nHEENT: \n Head: atraumatatic and normocephalic\n Eyes: EOMI, PERRL\n Ears: right ear normal, left ear normal, no external \ndeformities\n Nose: straight septum, non-tender, no epistaxis\n Teeth/Mouth: left lower submandibular area swelling, poor\ndentition\nNECK: No LA\nCARDIAC: Regular rate and rhythm, Normal S1 and S2, no murmurs\nRESPIRATORY: CTAB with no crackles\nABDOMEN: Soft, nondistended, nontender\nEXTREMITIES: Warm and well perfused, no edema\nSKIN: No rashes\nNEURO: CN ___ intact, moving bilateral extremities \nspontaneously\n\n \nPertinent Results:\nADMISSION LABS:\n\n___ 02:50PM BLOOD WBC-7.4 RBC-4.05* Hgb-13.2* Hct-37.1* \nMCV-92 MCH-32.6* MCHC-35.6 RDW-11.7 RDWSD-39.0 Plt ___\n___ 02:50PM BLOOD Neuts-69.2 Lymphs-17.2* Monos-12.2 \nEos-0.7* Baso-0.4 Im ___ AbsNeut-5.10 AbsLymp-1.27 \nAbsMono-0.90* AbsEos-0.05 AbsBaso-0.03\n___ 02:50PM BLOOD Glucose-67* UreaN-10 Creat-0.6 Na-141 \nK-4.5 Cl-103 HCO3-24 AnGap-14\n___ 03:21PM BLOOD Lactate-1.1\n\nDISCHARGE LABS:\n\n___ 07:25AM BLOOD WBC-6.3 RBC-4.14* Hgb-13.8 Hct-38.2* \nMCV-92 MCH-33.3* MCHC-36.1 RDW-11.6 RDWSD-39.3 Plt ___\n___ 07:25AM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-142 \nK-4.5 Cl-104 HCO3-23 AnGap-15\n___ 07:25AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.___ previously healthy male with a left lower dental abscess, \nadmitted for Unasyn administration and to be assessed by ___ \nfor possible surgery.\n\nACTIVE ISSUES:\n#Dental Abscess. Unclear etiology. ___ be due to poor dental \nhygiene given poor dentition on exam. He also has had history of \ntobacco use which may predispose him to infection from long-term \ndamage to mucosa. Oral maxillofacial surgery evaluated the \npatient and advised to give IV Unasyn 3g q6hrs. They evaluated \nhim on the morning of ___ and felt that he could get his tooth \nextraction and incision and drainage completed as an outpatient. \nThey recommended a 10 day course of PO Augmentin 875mg BID. At \ntime of discharge, blood cultures ___ were pending from ___. \nPatient was instructed to return to the ED immediately if he had \nany worsening pain, swelling, new stridor or voice changes, or \nany other concerning symptoms.\n\nCore Measures \n# CODE: full \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amoxicillin 500 mg PO Q8H \n2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth twice a day Disp #*21 Tablet Refills:*0 \n2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nDental 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\nWhat brought you to the hospital?\nYou came in with a tooth infection and were admitted for IV \nantibiotics and evaluation by the oral surgery team.\n\nWhat did we do for you in the hospital?\nYou received IV antibiotics. The oral surgery team felt that you \ncould get the dental extraction procedure done as an outpatient.\n\nWhat should you do after leaving the hospital?\n-Call ___ at 7AM to set up an appointment for the tooth \nextraction.\n-Continue your antibiotics as prescribed below.\n\nWe wish you the very best.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K047", "F17210" ]

[ "K047: Periapical abscess without sinus", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "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:\nHypoxia \n \nMajor Surgical or Invasive Procedure:\nintubation ___\n \nHistory of Present Illness:\n___ with PMHx of left CVA with right hemiplegia and dysphagia, \nHTN, CAD, HLD, Raynaud's and depression who is BIBA after \nconcern for aspiration at home. Per report, patient chronically \naspirates and has been aspirating more over the past 2 days. She \nlives with her daughter. Her other daughter, ___ who lives in \n___ worked in life ___ and has some medical experience so is \ntypically called in setting of medical issues. Patients daughter \ncalled ___, given increased secretions and concern for \naspiration. Family tried chest ___ overnight and patient seemed \nto improve. She was refusing transport to hospital at that time. \nThis morning, patient was increasingly SOB and had difficulty \nwith breathing. There was concern that she had swallowed a piece \nof ___ several days ago that may have been too large and that \nshe sneaks water even though she is on nectar thick liquids. \nShe called her daughter this morning reporting feeling more SOB. \nDaughter called EMS who found patient to be coughing and \ndesaturating. She was brought to the ED, initially stable on \nminimal 02 but acutely decompensated requiring intubation. \n\nRecent admission from ___ for sucidial ideation. Patient \nrecently lost her husband in ___ and has had worsening \ndepression since that time. She was discharged to a ___ \nfacility but appears that she now lives with one of her children \nat home, with 24 hr nurse. \n \nIn the ED, initial vitals: 110, 202/90, 78% RA \nOn exam pt desaturated and required intubation. Intubation was \ndifficult, eventually a 6.5ETT was placed, significant \nsecretions were also noted. She was placed on propofol/fentanyl \nfor intubation and shortly after became hypotensive. Peripheral \nlevophed was started briefly and she received 2L IVF. Prop was \ndiscontinued. Hypotension improved. Midazolam gtt was started \nfor sedation. \n \nLabs were significant for: \n- CBC: 10.9/13.6/43/268\n- Chem 7: ___\n- INR 1.0\n- VBG: 7.___\n- Lactate 2.1 \n\nPatient was given: Vancomycin/Zosyn/Propofol/Fentanyl, 2L IVF\nImaging was significant for:\n- CXR: Notable for Right main stem bronchus intubation \n- EKG: Sinus rhythm, LBBB (seen on past EKG from ___ \n \nOn arrival to the MICU, patient was intubated and sedated. \nInitially normotensive but became acutely hypotensive, got 1L NS \nwith improvement in BP. Placed on peripheral levophed. \n\nPatients HCP was called via phone and updated. Initially said \nthat patient was Full Code for short term reversible causes but \nthen came into the hospital with a MOLST form that had been \nfilled out previously stating that the patient was DNR/DNI. POE \norder was changed to reflect this. \n\nReview of systems: \n(+) Per HPI \n(-) Unable to assess in setting of intubation/sedation \n\n \nPast Medical History:\n1. Right basal ganglia stroke without known residual symptoms.\nleft basal ganglia stroke (putamen and caudate) in ___ with\nresidual right arm and leg spasticity and weakness, and \ndyarthria\nand hypophonia. Etiology unclear but thought to be most likely\nsmall vessel as vessel imaging at that time unrevealing. \n2. Hypertension.\n3. Raynaud's phenomenon.\n4. History of hormonal replacement therapy, currently not taking \n\nany.\n5. Hypercholesterolemia.\n6. Gait disturbance, status post CVA.\n7. Spotting (?vaginal)\n8. Depression\n9. Avulsion fracture left metatarsal ___\n10. Constipation\n \nSocial History:\n___\nFamily History:\nMother \"heart attack\" in ___, father \"heart attack\" in ___. \nMother died of a stroke at age ___. Father died at age ___ \nsecondary to tuberculosis.\n \nPhysical Exam:\nADMISSION:\nVitals: T:98.6 BP:124/46 P:102 R:20 O2:100% Intubated \nGENERAL: Intubated, sedated, thin appearing \nHEENT: Sclera anicteric, PERRL, ETT in place \nLUNGS: Coarse breath sounds anteriorally bilaterally. \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present\nEXT: Warm, well perfused, ___ reticulated erythema L>R lower \nextremity, palpable pulses peripherally, no edema \nNEURO: Not responding to commands on sedation, not opening eyes \n \nACCESS: PIVs x3\n\n \nPertinent Results:\nADMISSION:\n\n___ 12:30PM BLOOD WBC-10.9*# RBC-4.62 Hgb-13.6 Hct-43.0 \nMCV-93 MCH-29.4 MCHC-31.6* RDW-13.7 RDWSD-46.8* Plt ___\n___ 12:30PM BLOOD Neuts-80.4* Lymphs-12.0* Monos-5.8 \nEos-0.7* Baso-0.5 Im ___ AbsNeut-8.75*# AbsLymp-1.31 \nAbsMono-0.63 AbsEos-0.08 AbsBaso-0.05\n___ 05:44AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ \nMacrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ \nAcantho-1+\n___ 12:30PM BLOOD ___ PTT-27.8 ___\n___ 12:30PM BLOOD Glucose-170* UreaN-10 Creat-0.7 Na-135 \nK-4.5 Cl-97 HCO3-20* AnGap-23*\n___ 05:44AM BLOOD ALT-30 AST-44* AlkPhos-42 TotBili-0.6\n___ 12:30PM BLOOD Calcium-9.2 Phos-4.1 Mg-2.1\n___ 01:28PM BLOOD ___ pO2-44* pCO2-62* pH-7.27* \ncalTCO2-30 Base XS-0\n___ 01:28PM BLOOD Lactate-2.1*\n___ 01:28PM BLOOD O2 Sat-69\n\nDISCHARGE:\n___ 03:50AM BLOOD Plt Smr-NORMAL Plt ___\n___ 03:50AM BLOOD Glucose-185* UreaN-17 Creat-0.6 Na-134 \nK-3.7 Cl-100 HCO3-20* AnGap-18\n___ 03:50AM BLOOD WBC-13.4* RBC-3.60* Hgb-10.8* Hct-32.0* \nMCV-89 MCH-30.0 MCHC-33.8 RDW-14.7 RDWSD-47.3* Plt ___ with PMHx of left CVA with right hemiplegia and dysphagia, \nHTN, CAD, HLD and depression who is BIBA with acute hypoxic \nrespiratory failure, requiring intubation likely in the setting \nof aspiration. Patient found to be coughing with acute \ndesaturation requiring intubation, with h/o dysphagia following \nCVA, c/f aspiration event. CTA on admission in ED negative for \nPE but notable for partial esophageal obstruction. GI was \nconsulted, no intervention was done, and food passed on its own \nbased on ability for team to pass OG tube. Patient was started \non vancomycin/cefepime for aspiration pneumonia. Prior to \nextubation on ___, patient expressed that she would want to be \nre-intubated although this contraindicated previous code status \nand discussion with son and primary care doctor. She was \nextubated on ___, but had to be reintubated the same day due to \ncopious secretions. Bronchoscopy revealed irritated airways \nthroughout and copious secretions in the bilat lower lobes that \nwere aspirated therapeutically. Family meeting was held on ___, \nand patient was made DNR/DNI with plan for extubation and for \nhome hospice. Patient was diuresed and had repeat bronchoscopy \nto optimize extubation. Patient was extubated on ___ with focus \non comfort measures. Due to concern that she would not survive \nambulance ride, she remained inpatient. She passed away on ___ \nat 0020 with family present at bedside. \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Aspirin 325 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. biotin 1 mg oral DAILY \n4. Calcium Carbonate 1500 mg PO DAILY \n5. Vitamin D 1000 UNIT PO DAILY \n6. Citalopram 20 mg PO DAILY \n7. Estradiol 0.1 mg PO 2X/WEEK (MO,FR) \n8. Lisinopril 20 mg PO DAILY \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n12. trospium 20 mg oral BID \n\n \nDischarge Medications:\nN/A\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nHypoxemic Respiratory Failure\nAspiration Pneumonia\nHistory of cerebrovascular accident\nDysphagia\nHypertension\n \nDischarge Condition:\nDeceased\n \n ___ MD ___\n \nCompleted by: ___\n" ]

[ "A419", "J9601", "J690", "R6521", "J189", "R64", "R1312", "I69351", "I4891", "N390", "Z681", "Z66", "Z515", "Z781", "T18128A", "X58XXXA", "Y929", "I69391", "I10", "I2510", "E785", "F329", "I447", "I69322", "I7300", "E7800", "K5900", "I69398", "R2689", "Z87891", "B9620", "N3941" ]

[ "A419: Sepsis, unspecified organism", "J9601: Acute respiratory failure with hypoxia", "J690: Pneumonitis due to inhalation of food and vomit", "R6521: Severe sepsis with septic shock", "J189: Pneumonia, unspecified organism", "R64: Cachexia", "R1312: Dysphagia, oropharyngeal phase", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "I4891: Unspecified atrial fibrillation", "N390: Urinary tract infection, site not specified", "Z681: Body mass index [BMI] 19.9 or less, adult", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z781: Physical restraint status", "T18128A: Food in esophagus causing other injury, initial encounter", "X58XXXA: Exposure to other specified factors, initial encounter", "Y929: Unspecified place or not applicable", "I69391: Dysphagia following cerebral infarction", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I447: Left bundle-branch block, unspecified", "I69322: Dysarthria following cerebral infarction", "I7300: Raynaud's syndrome without gangrene", "E7800: Pure hypercholesterolemia, unspecified", "K5900: Constipation, unspecified", "I69398: Other sequelae of cerebral infarction", "R2689: Other abnormalities of gait and mobility", "Z87891: Personal history of nicotine dependence", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "N3941: Urge incontinence" ]

[ "J9601", "I4891", "N390", "Z66", "Z515", "Y929", "I10", "I2510", "E785", "F329", "K5900", "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:\nsuicidal ideation\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ y/o woman with right hemiplegia s/p left \nCVA c/b dysphagia, HTN, CAD, HLD, and depression who was brought \nin to ED after calling 911 and telling police she was feeling \nsuicidal \n The patient reports that she has been having thoughts of \nsuicide after the recent loss of husband on ___. In ED, \nstated she wanted to die to be close to him. Denies plan, but \ntearful. No ingestions. In the ED, she was also denying any \nauditory or visual hallucinations or homicidal ideation. \n The patient has been in the Emergency Department awaiting a \ngeriatric psych bed since ___. The psych and geriatric teams \nwere made aware of this patient and there will likely not be a \nbed available until ___, so decision was made to admit to a \nmedicine bed until a psych bed was found. \n In the ED, initial vitals: 98.6 81 180/74 16 97% RA \n - Labs notable for: positive UA, normal Chem 7, negative Utox, \nTSH 4.4, normal CBC. \n - Patient was started on Macrobid ___ mg bid and started on her \nhome medications: Aspirin 325 mg, atorvastatin 80 mg, metoprolol \nsuccinate 25 mg, citalopram 20 mg, duloxetine 20 mg \n - Vitals prior to transfer: 98.7 77 167/92 18 94% RA \n On arrival to the floor, pt reports no SI/HI. She acknowledges \ngoing through a rough time with her husband dying and ___ \n___ being elected. She notes she felt particularly stressed a \nfew days ago and was feeling suicidal but no longer feels this \nway. \n \nPast Medical History:\n1. Status post left CVA with right hemiplegia.\n2. Hypertension.\n3. Raynaud's phenomenon.\n4. History of hormonal replacement therapy, currently not taking \nany.\n5. Hypercholesterolemia.\n6. Gait disturbance, status post CVA.\n7. Spotting (?vaginal)\n8. Depression\n9. Avulsion fracture left metatarsal ___\n10. Constipation\n \nSocial History:\n___\nFamily History:\nMother \"heart attack\" in ___, father \"heart attack\" in ___. \nMother died of a stroke at age ___. Father died at age ___ \nsecondary to tuberculosis. \n \nPhysical Exam:\n==========\nADMISSION \n==========\nVitals: 98.7 147/75 77 18 93% RA \nGeneral: Alert, oriented, Thin elderly woman in no acute \ndistress \nHEENT: Sclera anicteric, Dry MM with crusting, oropharynx clear \n\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, no cyanosis or edema \nNeuro: A&Ox3. RUE contracted with deformity. Loss of R \nnasolabial fold. Chronic per records. \n\n==========\nDISCHARGE\n==========\nGeneral: Alert, oriented, Thin elderly woman in no acute \ndistress \nHEENT: Sclera anicteric, Dry MM with crusting, oropharynx clear \n\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, no cyanosis or edema \nNeuro: A&Ox3. RUE contracted with deformity. Loss of R \nnasolabial fold. Chronic per records. \n \nPertinent Results:\n===============\nADMISSION LABS\n===============\n___ 08:40PM BLOOD WBC-6.8 RBC-4.10 Hgb-11.9 Hct-37.5 MCV-92 \nMCH-29.0 MCHC-31.7* RDW-13.7 RDWSD-46.5* Plt ___\n___ 08:40PM BLOOD Neuts-60.4 ___ Monos-9.3 Eos-5.9 \nBaso-0.7 Im ___ AbsNeut-4.11 AbsLymp-1.59 AbsMono-0.63 \nAbsEos-0.40 AbsBaso-0.05\n___ 08:40PM BLOOD Glucose-144* UreaN-16 Creat-0.5 Na-143 \nK-3.5 Cl-102 HCO3-26 AnGap-19\n___ 08:40PM BLOOD TSH-4.4*\n___ 08:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n\n=========\nIMAGING\n=========\nCXR ___: In comparison with the study of ___, there is \nlittle change and no evidence of acute cardiopulmonary disease. \nThere is continued elevation of the right hemidiaphragmatic \ncontour, but no evidence of acute pneumonia, vascular \ncongestion, or pleural effusion. Scoliosis of the thoracic spine \nconvex to the right\n\nEKG ___: Sinus rhythm. Consider left atrial abnormality. \nLeft bundle-branch block. Compared to the previous tracing of \n___ left bundle-branch block is new.\n\n \nBrief Hospital Course:\n___ F with history of depression, CVA c/b right hemiplegia and \ndysphagia, and HTN who presents with SI in the setting of recent \ndeath of her husband, transferred to ___ facility for \nfurther management.\n\n==============\nACTIVE ISSUES \n==============\n# Suicidal Ideation: Patient presenting with suicidal ideation \nin the setting of recent loss of her husband. She felt suicidal \non the day of admission, called ___, and was brought to the \nemergency department. Psychiatry was consulted and recommended \nadmission to ___ program. \n\n# UTI: Patient found to have UA consistent for possible UTI. She \ncompleted a three day course of nitrofurantoin. Urine culture \nremained negative. \n\n===============\nCHRONIC ISSUES\n===============\n#Dysphagia: Patient with residual dysphagia from prior CVA. \nSpeech and swallow evaluated the patient and recommended \ncontinuing current diet. \n \n#HTN: Remained normotensive. Continued home metoprolol and \nlisinopril. \n \n#HLD: Continued statin.\n \n#Hx of CAD/CVA: Continued ASA 325 mg, metoprolol XL. \n \n#Urge incontinence: Held trospium while inpatient as \nnon-formulary. \n\n====================\nTRANSITIONAL ISSUES\n====================\n*Please consider neurocognitive testing.\n*Patient should follow up with her primary care doctor within 1 \nweek of discharge from ___ facility.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Aspirin 325 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Citalopram 20 mg PO DAILY \n4. Lisinopril 20 mg PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n7. Vitamin D 1000 UNIT PO DAILY \n8. biotin 1 mg oral DAILY \n9. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -200 unit oral DAILY \n10. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 2X/WEEK \n11. Metoprolol Succinate XL 25 mg PO DAILY \n12. trospium 20 mg oral BID \n\n \nDischarge Medications:\n1. Aspirin 325 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. biotin 1 mg oral DAILY \n4. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) \n600 mg(1,500mg) -200 unit oral DAILY \n5. Citalopram 20 mg PO DAILY \n6. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 2X/WEEK \n7. Lisinopril 20 mg PO DAILY \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n11. trospium 20 mg oral BID \n12. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nSuicidal Ideation\nDepression\n\nSecondary Diagnosis:\nDysphagia\nHypertension\nHyperlipidemia\nUrge Incontinence\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:\nMs. ___,\n\nYou were admitted to the hospital because you called ___ and \nwere feeling suicidal. While you were in the Emergency \nDepartment, you were found to have a urinary tract infection \nwhich was treated with antibiotics.\n\nYou were seen by psychiatry who recommended inpatient treatment \nof your underlying depression.\n\nIt was a pleasure meeting and taking care of you while you were \nin the hospital.\n\n-Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "F322", "I69351", "R45851", "N390", "Z681", "I10", "N3941", "I69391", "R1310", "E7800", "I252", "I2510", "I69322", "R634" ]

[ "F322: Major depressive disorder, single episode, severe without psychotic features", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "R45851: Suicidal ideations", "N390: Urinary tract infection, site not specified", "Z681: Body mass index [BMI] 19.9 or less, adult", "I10: Essential (primary) hypertension", "N3941: Urge incontinence", "I69391: Dysphagia following cerebral infarction", "R1310: Dysphagia, unspecified", "E7800: Pure hypercholesterolemia, unspecified", "I252: Old myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I69322: Dysarthria following cerebral infarction", "R634: Abnormal weight loss" ]

[ "N390", "I10", "I252", "I2510" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \noptiflux dialyzer\n \nAttending: ___.\n \nChief Complaint:\nAltered mental status, weakness\n \nMajor Surgical or Invasive Procedure:\nTherapeutic paracentesis\n\n \nHistory of Present Illness:\nMrs. ___ is a ___ y/o F with PMHx EtOH cirrhosis c/b HE and\nascites (no SBP or varices) and ESRD recently initiated on HD\nTThS ___ hepatorenal syndrome who presented to the ED after her\nhusband called an ambulance due to two days of poor PO intake \nand\nweakness.\n\nPer a phone conversation with her husband, Mrs. ___ was weak\nand barely able to walk and was not eating or drinking much. \nThis\nbegan yesterday ___. He reports she only ever wants to eat\nfruit. She does drink ___ of her NuPro shakes daily although she\nis reportedly supposed to drink 5 daily. He reports she rarely\ntakes her lactulose unless \"she feels like it\" but adheres to \nher\nother medicines including rifaximin. During this phone call the\nmedication list was also reviewed.\n\nMrs. ___ herself reports much of the same. She has had trouble\nwith balance for the past two days. She also feels her abdomen \nis\nmore distended than usual. She originally reports that she\nundergoes large-volume paracentesis every 3 weeks but then\nrestated she was confused and goes to dialysis 3 times a week \nbut\nactually goes for LVP every week on ___. Her last \ndialysis\nrun was ___ which she attended. She reports no missed\nsessions. She reports ___ bowel movements a day although she\nstopped taking her lactulose because she felt \"like she was \ngoing\ntoo much.\" She does not report any specific event leading up to\nher weakness such as a fall, loss of consciousness or recent\nillness. No numbness, slurred speech, or weakness. She reports \nno\nnausea/vomiting, black or bloody stool, no shortness of breath,\nchest pain, abdominal pain, itching or fevers/chills. \n\nIn the ED:\n- Initial vital signs were notable for: Temp 97.9, HR 87, BP\n118/59, O2 sats 100% on RA\n\n- Exam notable for: No acute distress, regular rate and rhythm,\nclear lungs, soft non-tender grossly distended abdomen,\nasterixis, no lower extremity edema\n\nGeneral: in NAD\nCardiac: RRR\nChest: CTAB\nAbd: soft, non-tender, grossly distended\nNeuro: moving all 4 extremities, asterixis noted b/l, sensation\ngrossly intact in all 4 extremities\nExtremities: no pedal edema \n\n- Labs were notable for: \nWBC 12.6 w 82% neutrophils Hgb 11.3 Plt 63\n\nNa 140 Cl 99 K 3.4 BUN 63 SCr 3.4 HCO3 20 AG 21, Glucose 118\n\nAST 40 ALT 31 AlkPhos 135 Tbili 2.4 Alb 3.6 INR 1.6\n\nLactate 1.9\n\nUA notable for 55 WBC, no bacteria\n\n- Studies performed include:\n\nDiagnostic Para: ___ 27 (2% polys) ___ & culture pending\n\nChest x-ray PA/LAT: Low lung volumes but clear lungs without e/o\neffusion or pneumothorax. No acute cardiopulmonary disease.\n\n- Patient was given: Lactulose 30 mL\n\n- Consults: \n\nHepatology was consulted who recommended lactulose q2h until\nclear, diagnostic para (above), a renal consult to consider\ndialysis, RUQUS w doppler, a full infectious w/u including UA,\ncultures, CXR, and admission to ET for further care.\n\nVitals on transfer: Temp 98.2 BP 114/75 HR 80 RR 16 O2 sat 98% \non\nRA\n\nUpon arrival to the medicine floor, the patient reports the \nabove\nstory. Currently, she has no complaints. Asks if she will need a\nfeeding tube.\n\nREVIEW OF SYSTEMS: Complete ROS obtained and is otherwise\nnegative.\n \nPast Medical History:\n- CV: HLD, HTN\n- GI: Esophageal stricture, GERD, Childs B EtOH Cirrhosis \n(MELD-Na 15) decompensated by encephalopathy, ascites\n- MSK: arthritis \n\nPast Surgical History \n- Appendectomy \n\n \nSocial History:\n___\nFamily History:\n- No family history of liver disease\n- Father had a cancer of unknown origin\n- Mother is in her ___ \n- No family history of liver disease\n- Father had a cancer of unknown origin\n- Mother is in her ___ \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: Temp 98.2 BP 114/75 HR 80 RR 16 O2 sat 98% on\nRA\nGENERAL: Alert and interactive. In no acute distress.\nEYES: NCAT. PERRL, EOMI. Sclera anicteric. \nENT: MMM. JVP not able to be visualized\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nRESP: Clear to auscultation bilaterally. No crackles. No\nincreased WOB.\nABDOMEN: Soft, distended. Non-tender to deep palpation in all\nfour quadrants. Small reducible umbilical hernia.\nMSK: No clubbing, cyanosis, or edema.\nSKIN: Warm. No rash. \nNEUROLOGIC: AOx3. Able to say months of the year backwards with\none mistake. Slow to respond during the interview. CN2-12 \nintact.\n___ strength throughout. Normal sensation. Asterixis noted\nbilaterally.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: T 98.8 BP 105/60 HR 90 RR 18 O2 98% RA\nGENERAL: Thin woman in no acute distress, alert and interactive\nEYES: NCAT. PERRL, EOMI. Sclera anicteric. \nENT: MMM. JVP not able to be visualized\nCARDIAC: Regular rate and rhythm. S1, S2 normal. No \nmurmurs/rubs/gallops.\nRESP: Clear to auscultation bilaterally. No crackles. No \nincreased WOB.\nABDOMEN: Soft, distended but improved compared to yesterday. \nNon-tender to deep palpation in all four quadrants. Small \nreducible umbilical hernia.\nMSK: No clubbing, cyanosis, or edema.\nSKIN: Warm. No rash. \nEXTREMITIES: No edema. R ___ DIP edematous, warm to touch, \ntender to palpation.\nNEUROLOGIC: AOx3. Response time to questions has improved. Able \nto say months of the year backwards with one mistake. CN2-12 \nintact. ___ strength throughout. Sensation grossly intact. No \nasterixis.\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 03:15PM ___ PTT-28.5 ___\n___ 03:15PM WBC-12.6* RBC-3.34* HGB-11.3 HCT-35.3 \nMCV-106* MCH-33.8* MCHC-32.0 RDW-22.0* RDWSD-84.4*\n___ 03:15PM NEUTS-82.6* LYMPHS-10.5* MONOS-5.5 EOS-0.5* \nBASOS-0.3 IM ___ AbsNeut-10.43* AbsLymp-1.32 AbsMono-0.70 \nAbsEos-0.06 AbsBaso-0.04\n___ 03:15PM ALBUMIN-3.6 CALCIUM-9.5 PHOSPHATE-6.4* \nMAGNESIUM-2.0\n___ 03:15PM ALT(SGPT)-31 AST(SGOT)-40 ALK PHOS-135* TOT \nBILI-2.4*\n___ 03:15PM GLUCOSE-118* UREA N-63* CREAT-3.4*# \nSODIUM-140 POTASSIUM-3.4* CHLORIDE-99 TOTAL CO2-20* ANION \nGAP-21*\n___ 03:21PM LACTATE-1.9\n___ 05:40PM ASCITES TNC-27* RBC-55* POLYS-2* LYMPHS-8* \n___ MESOTHELI-4* MACROPHAG-86*\n___ 05:40PM ASCITES TOT PROT-0.7 GLUCOSE-129\n___ 07:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 \nLEUK-LG*\n\nINTERVAL LABS\n=============\n___ 10:30AM BLOOD WBC-12.5* RBC-3.26* Hgb-11.2 Hct-34.8 \nMCV-107* MCH-34.4* MCHC-32.2 RDW-21.8* RDWSD-84.3* Plt Ct-63*\n___ 10:30AM BLOOD Glucose-190* UreaN-72* Creat-4.2* Na-142 \nK-3.0* Cl-100 HCO3-17* AnGap-25*\n___ 05:47AM BLOOD ALT-30 AST-40 AlkPhos-113* TotBili-2.7*\n___ 10:30AM BLOOD DirBili-1.0*\n___ 10:30AM BLOOD Calcium-9.2 Phos-7.8* Mg-2.3\n___ 10:30AM BLOOD 25VitD-21*\n\nDISCHARGE LABS\n===============\n___ 06:36AM BLOOD WBC-11.0* RBC-2.69* Hgb-9.3* Hct-28.9* \nMCV-107* MCH-34.6* MCHC-32.2 RDW-20.7* RDWSD-81.5* Plt Ct-43*\n___ 06:36AM BLOOD Glucose-153* UreaN-45* Creat-3.4*# \nNa-134* K-3.8 Cl-95* HCO3-20* AnGap-19*\n___ 07:00AM BLOOD ALT-26 AST-32 TotBili-2.3* DirBili-0.9* \nIndBili-1.4\n___ 06:36AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.3\n\nIMAGING\n=======\n___ LIVER OR GALLBLADDER US (SINGLE ORGAN)\n1. Patent hepatic vasculature. No portal vein thrombosis \nidentified. \n2. Cirrhotic liver with sequelae of portal hypertension \nincluding moderate \nvolume ascites, and splenomegaly. \n3. Cholelithiasis without definite acute cholecystitis. \nNonspecific \ngallbladder wall thickening, likely secondary to third spacing \nfrom known \nliver disease. \n\n___ CHEST X-RAY PA & LAT\nNo evidence of acute cardiopulmonary disease.\n\n___ CHEST X-RAY PORTABLE\nLeft-sided 8 minutes catheter is unchanged. Lungs are low \nvolume with \nbibasilar atelectasis. Heart size is normal. There is no \npleural effusion. \nNo pneumothorax. \n\nSTUDIES/PROCEDURES\n====================\nTHERAPEUTIC PARACENTESIS\n\nMICROBIOLOGY\n=============\n___ BLOOD CULTURE: NO GROWTH\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\n___ 7:25 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n YEAST. >100,000 CFU/mL. \n\n___ 4:51 pm JOINT FLUID Source: right ___ DIP. \n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Preliminary): NO GROWTH. \n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n====================\n[ ]It is very important that the patient continues taking her \nlactulose regularly.\n[ ]The patient had a gout flare in her right index DIP during \nadmission. She was started on a prednisone taper. The patient \ndeclined to follow-up outpatient with the ___ \n___ as it is too far away from where she lives. The patient \nwill need to set up a Rheumatology follow-up after discharge \nwith her PCP to initiate allopurinol therapy.\n[ ]PREDNISONE TAPER: Today (___), you received 30mg of \nprednisone. Tomorrow (___), take 30 mg (3 tablets) by \nmouth. Then, take 20 mg (2 tablets) by mouth daily for 2 days. \nThen, take 10 mg (1 tablet) by mouth daily for 2 days. Then \nstop, the steroid course is completed.\n[ ]The patient should continue with her ___ schedule \nof hemodialysis.\n[ ]The patient should continue with her weedkly paracentesis \nsessions on ___. \n[] Vitamin D 50000U PO weekly course finished ___. Vitamin D \nlevel on ___ was 21. Discuss further high dose repletion vs \nmaintenance dosing. \n\nACUTE ISSUES:\n=============\n# Fatigue, weakness\n# Altered mental status (improved)\n# Malnutrition\n# Leukocytosis (improved)\nMain differential for patient's confusion and weakness includes \nhepatic vs. uremic vs. infectious. She reported a history of \nintermittently taking lactulose and decreased PO in the past ___ \ndays prior to admission. Her slowness during conversation, and \nasterixis on exam is consistent with acute on chronic grade II \nhepatic encephalopathy exacerbated by poor PO intake. WBC 12.6 \non admission but she reports no fevers and was afebrile during \nadmission. Diagnostic paracentesis was negative for SBP. Her UA \nshowed sterile pyuria; reflex urine culture grew yeast but \npatient was asymptomatic. RUQ US was negative for PVT or acute \ncholecystitis. CXR was unremarkable. Blood cultures showed no \ngrowth. Per patient and dialysis center staff, she has been \nregularly attending dialysis without missing any appointments. \nShe was AOx3 without other symptoms (itching) to suggest uremia. \nThere was no evidence of active bleeding; Hgb improved from \nprior baseline. She was started on lactulose q2h. Home rifaximin \n550mg BID, thiamine, nephrocaps were continued. She received \ndialysis during her admission consistent with her regular \nschedule. Chemistries were monitored daily. On discharge, the \npatient's WBC is 11.0. Her speech and response rate has \nnormalized and she does not have asterixis. \n\n# EtOH cirrhosis\n# Thrombocytopenia\n# Coagulopathy \n# History of hepatic encephalopathy\n# Ascites\nMELD-Na 28 on admission. ___ B. See above for discussion \nof HE. She has no history of SBP or varices. Her abdomen was \nfairly distended on exam although there was no tenderness to \npalpation. Diagnostic paracentesis was negative for SBP. Patient \ngets weekly therapeutic paracentesis (~5L) every week at \n___. She makes a bit of urine but is not currently \ntaking diuretics; furosemide/spironolactone held - unclear \nbenefit given low urine output. She received dialysis during her \nadmission consistent with her regular schedule. She received a \n5L therapeutic paracentesis during her admission. On discharge, \nher abdominal distention is improved. She was given explicit \ninstruction to return to the hospital/emergency room if she \nexperienced abdominal pain, fevers, bleeding.\n\n#Joint pain, swelling\nOn admission day 2, pt's R ___ DIP was red, swollen, warm, and \npainful. A similar episode occurred during her last admission \nwith suspicion for gout, where she was seen by rheum and given \nsteroids, with good resolution. Rheum performed arthrocentesis, \nwhich improved the pt's pain and ROM in her finger. Joint fluid \nstudies showed neg birefringence monosodium urate crystals, \nconsistent with gout. Patient was started on a steroid taper and \nwill continue prednisone outpatient (total course: prednisone \n40mg x2 days, 20mg x2 days, 10mg x2 days). Pt declined outpt \nRheum f/u here at ___ and would prefer to have her own PCP set \nup ___ Rheum appointment in ___.\n\n#Disposition\nThe patient originally had wanted to be discharged to rehab. \nPhysical therapy had evaluated the patient and recommended her \nto be discharged home with home ___. Patient then mentioned that \nit would be hard to coordinate her dialysis and paracentesis \nsessions with rehab. At discharge, the patient prefers to be \ndischarged home. \n\nCHRONIC ISSUES:\n===============\n#ESRD on HD TThS\nPatient does make some urine. Renal/dialysis followed her during \nadmission, and she received dialysis while admitted. Called her \ndialysis center, which confirmed pt has not missed any sessions. \nMidodrine dose noted to be quite high but correct per PAML and \nprior discharge summary.\n- Electrolytes monitored daily with chem10\n- Continued sevelamer 800 mg TIDAC\n- Continued midodrine 30 mg TID\n\n#Hyperlipidemia\n- Continue home simvastatin 20 mg\n\n#Code status\nDuring admission, in the patient's confused state, she mentioned \nthat she had wanted to be DNR but not DNI. Patient has been full \ncode based on prior records and required brief intubation during \nher last hospitalization. On discharge, code status was \ndiscussed with the patient once again. She stated that for now, \nshe is full code. She understands that she may change this code \nstatus in the future.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Thiamine 100 mg PO DAILY \n2. sevelamer CARBONATE 800 mg PO TID W/MEALS \n3. rifAXIMin 550 mg PO BID \n4. Mirtazapine 15 mg PO QHS \n5. Simvastatin 20 mg PO QPM \n6. Vitamin D ___ UNIT PO 1X/WEEK (FR) \n7. Nephrocaps 1 CAP PO DAILY \n8. Midodrine 30 mg PO TID \n9. Lactulose 30 mL PO TID:PRN confusion \n\n \nDischarge Medications:\n1. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. PredniSONE 10 mg PO DAILY TAKE 3 TABLETS BY MOUTH DAILY FOR \n1 DAYS (BEGIN ___. \nTapered dose - DOWN \nRX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*9 \nTablet Refills:*0 \n3. Lactulose 30 mL PO TID \nRX *lactulose 20 gram/30 mL 30 ml by mouth three times a day \nDisp #*90 Packet Refills:*0 \n4. Midodrine 30 mg PO TID \n5. Mirtazapine 15 mg PO QHS \n6. Nephrocaps 1 CAP PO DAILY \n7. rifAXIMin 550 mg PO BID \n8. sevelamer CARBONATE 800 mg PO TID W/MEALS \n9. Simvastatin 20 mg PO QPM \n10. Thiamine 100 mg PO DAILY \n11. HELD- Vitamin D ___ UNIT PO 1X/WEEK (FR) This medication \nwas held. Do not restart Vitamin D until you speak with your \ndoctor. \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnoses: hepatic encephalopathy, toxic metabolic \nencephalopathy, decompensated alcohol cirrhosis, ascites, gout\nSecondary diagnoses: end-stage kidney disease on hemodialysis, \nhyperlipidemia\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 Dear ___, \n It was a pleasure taking care of you at the ___ \n___! \n\n WHY WAS I IN THE HOSPITAL? \n ========================== \n - You came to the hospital because you were not eating and you \nwere feeling weak and confused.\n - Your right index finger became swollen and painful during \nyour hospital stay.\n\n WHAT HAPPENED IN THE HOSPITAL? \n ============================== \n - You received lactulose regularly to help clear toxins from \nyour system. Your mental status and strength improved. \n - Your blood counts and electrolytes were monitored daily.\n - You received a therapeutic paracentesis to remove ascites \nfrom your abdomen.\n - You were evaluated by the Rheumatology team and they started \nyou on a short course of steroids to treat the gout flare in \nyour finger. \n\n WHAT SHOULD I DO WHEN I GO HOME? \n ================================ \n - Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs. Your discharge weight is 59.15kg (130.4 lb).\n - Please continue to take all of your medications as directed.\n\n***Instructions for your prednisone: Today (___), you \nreceived 30mg of prednisone in the hospital. Tomorrow \n(___), take 30 mg (3 tablets) by mouth. Then, take 20 mg \n(2 tablets) by mouth daily for 2 days. Then, take 10 mg (1 \ntablet) by mouth daily for 2 days. Then stop, the steroid course \nis completed.***\n\n - Please follow up with all the appointments scheduled with \nyour doctor.\n\n - PLEASE RETURN TO THE HOSPITAL OR GO TO THE EMERGENCY ROOM IF \nYOU EXPERIENCE:\n * worsening abdominal pain\n * fevers\n * nausea or vomiting; blood in your vomit\n * bloody or black bowel movements\n * lightheadedness or dizziness\n * any other new or concerning symptoms\n\n Thank you for allowing us to be involved in your care, we wish \nyou all the best! \n Your ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "K7040", "N186", "K767", "I120", "E440", "K7031", "M109", "K219", "D6959", "D631", "F1010", "Z992", "Z6825" ]

[ "K7040: Alcoholic hepatic failure without coma", "N186: End stage renal disease", "K767: Hepatorenal syndrome", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "E440: Moderate protein-calorie malnutrition", "K7031: Alcoholic cirrhosis of liver with ascites", "M109: Gout, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "D6959: Other secondary thrombocytopenia", "D631: Anemia in chronic kidney disease", "F1010: Alcohol abuse, uncomplicated", "Z992: Dependence on renal dialysis", "Z6825: Body mass index [BMI] 25.0-25.9, adult" ]

[ "M109", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \noptiflux dialyzer / lisinopril\n \nAttending: ___\n \nChief Complaint:\nDislodged HD line\nEncephalopathy\nSepsis\n \nMajor Surgical or Invasive Procedure:\n___ CVL Insertion Note \n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS:\n===========================\nMs. ___ is a ___ year old F w/ EtOH cirrhosis complicated by\nhepatic encephalopathy, recurrent ascites with weekly large\nvolume paracentesis, and hepatorenal syndrome on TuThSa HD who\nwas transferred from ___ for a dislodged \ncentral\nline and imaging showing free air in the peritoneal space. She\npresented there after waking up with blood in her bed overnight. \n\nCXR showed air in her peritoneum. Her HD line was found to be\ndislodge and was removed. She was given vancomycin and cefepime\nand transferred to ___ for further evaluation. \n\nOf note, she was recently admitted to BI for altered mental\nstatus. It was felt that she had hepatic encephalopathy.\nInfectious workup was negative. She was started on lactulose and\nrifaximin with improvement in her mental status. She was also\ndiagnosed with gout in her R ___ DIP and started on a prednisone\ntaper. It was recommended that she go to rehab, but was \ndischarge\nhome with ___ on ___. \n\nIn the ED, vitals were notable for hypotension with BPs in\n___. Exam was notable for an unwell-appearing woman with\nbibasilar crackles, bilateral lower extremity edema, an \nabdominal\nfluid wave, asterixis, and disorientation. Labs were notable for\nhypotatremia, anemia, thrombocytopenia, and coagulopathy. CXR \nwas\nnormal. CT abd/pelvis showed \"The air appears to communicates\nwith an umbilical defect. No portal venous gas or pneumatosis to\nsuggest bowel ischemia. In the setting of recent paracentesis \nand\nlack of convincing evidence of bowel ischemia, the\npneumoperitoneum could be secondary to the paracentesis and less\nlikely from bowel perforation. No acute processes.\" She was\nstarted on Zosyn and Flagyl. Transplant Surgery was consulted \nwho\nhad low suspicion for intraabdominal process. Hepatology\nrecommended treatment with antibiotics, lactulose, and rifaxmin.\nThey also recommended diagnostic paracentesis, which was not\nperformed as there was reportedly no tappable pocket. \n\nUpon arrival to the floor, she feels well. She denies any \nfevers,\nchills, night sweats, headaches, N/V, diarrhea, black or red\nstools, abdominal pain, chest pain, easy bleeding, or confusion.\nShe is unsure of her home medications. \n\n \nPast Medical History:\n- CV: HLD, HTN\n- GI: Esophageal stricture, GERD, Childs B EtOH Cirrhosis \n(MELD-Na 15) decompensated by encephalopathy, ascites\n- MSK: arthritis \n\nPast Surgical History \n- Appendectomy \n\n \nSocial History:\n___\nFamily History:\n- No family history of liver disease\n- Father had a cancer of unknown origin\n- Mother is in her ___ \n- No family history of liver disease\n- Father had a cancer of unknown origin\n- Mother is in her ___ \n \nPhysical Exam:\nVS: 97.___\nGENERAL: Chronically ill-appearing woman laying in bed. Alert \nand\ninteractive in no acute distress\nHEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM\nCHEST: HD line site C/D/I with line removed\nHEART: RRR, S1/S2, no murmurs, gallops, or rubs\nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nABDOMEN: soft, mild distention, non-tender, normoactive bowel\nsounds, +fluid wave\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ DP and radial pulses bilaterally\nNEURO: Alert and oriented to place, year, date; states month is\n___. CN II-XII intact. Moving all 4 extremities with purpose,\nno asterixis\nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes\n \nPertinent Results:\nADMISSION Labs:\n\n___ 09:05PM BLOOD WBC-10.8* RBC-2.51* Hgb-8.7* Hct-27.0* \nMCV-108* MCH-34.7* MCHC-32.2 RDW-20.1* RDWSD-79.3* Plt Ct-52*\n___ 09:05PM BLOOD ___ PTT-30.4 ___\n___ 09:05PM BLOOD Glucose-133* UreaN-72* Creat-4.6*# \nNa-129* K-4.0 Cl-95* HCO3-16* AnGap-18\n___ 09:05PM BLOOD ALT-28 AST-33 AlkPhos-112* TotBili-1.5\n___ 09:05PM BLOOD Albumin-3.0*\n___ 05:24AM BLOOD calTIBC-222* Ferritn-262* TRF-171*\n\nDISCHARGE Labs:\n\n___ 06:13AM BLOOD WBC-5.8 RBC-2.68* Hgb-8.8* Hct-28.1* \nMCV-105* MCH-32.8* MCHC-31.3* RDW-23.2* RDWSD-88.3* Plt Ct-58*\n___ 02:24AM BLOOD Neuts-83.4* Lymphs-9.0* Monos-6.7 \nEos-0.0* Baso-0.2 NRBC-0.7* AbsNeut-3.35 AbsLymp-0.36* \nAbsMono-0.27 AbsEos-0.00* AbsBaso-0.01\n___ 06:13AM BLOOD Glucose-134* UreaN-35* Creat-4.5*# Na-135 \nK-3.9 Cl-96 HCO___ AnGap-16\n\nMICROBIOLOGY:\n___ 10:51 am BLOOD CULTURE Source: Venipuncture. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n ENTEROCOCCUS FAECIUM. \n Identification and susceptibility testing performed on \nculture # \n ___ (___). \n\n Aerobic Bottle Gram Stain (Final ___: \n Reported to and read back by ___. ___ ON ___ AT \n0540. \n GRAM POSITIVE COCCI IN PAIRS AND CHAINS. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN PAIRS AND CHAINS. \n\n___ 10:51 am BLOOD CULTURE Source: Line-tlcl. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. \n Daptomycin MIC OF 2 MCG/ML test result performed by \nEtest. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS FAECIUM\n | \nAMPICILLIN------------ =>32 R\nDAPTOMYCIN------------ S\nLINEZOLID------------- 2 S\nPENICILLIN G---------- =>64 R\nVANCOMYCIN------------ =>32 R\n\nHD Line Report ___:\nFINDINGS: \n \nPatent left internal jugular vein. Final fluoroscopic image \nshowing catheter \nwith tip terminating in the right atrium. \n\nINDICATION: ___ year old woman with etoh cirrhosis HRS on line \nholiday for vre \nbacteremia, needs ___ dialysis on ___, can she get line on \n___ AM, thank \nyou // can she get tunneled line in am of ___ for pm dialysis \non ___, \nthanks \n\nFLUOROSCOPY TIME AND DOSE: 2:01 min, 7.7 mGy \n \nPROCEDURE: PROCEDURE DETAILS: Following the explanation of the \nrisks, \nbenefits and alternatives to the procedure, written informed \nconsent was \nobtained from the patient. The patient was then brought to the \nangiography \nsuite and placed supine on the exam table. A pre-procedure \ntime-out was \nperformed per ___ protocol. The left upper chest was prepped \nand draped in \nthe usual sterile fashion. \nUnder continuous ultrasound guidance, the patent left internal \njugular vein \nwas compressible and accessed using a micropuncture needle. \nPermanent \nultrasound images were obtained before and after intravenous \naccess, which \nconfirmed vein patency. Subsequently a Nitinol wire was passed \ninto the right \natrium using fluoroscopic guidance. The needle was exchanged \nfor a \nmicropuncture sheath. The Nitinol wire was removed and a short \nAmplatz wire \nwas advanced to make appropriate measurements for catheter \nlength. The wire \nwas then passed distally into the IVC. \nNext, attention was turned towards creation of a tunnel over the \nupper \nanterior chest wall. After instilling superficial and deeper \nlocal anesthesia \nusing lidocaine mixed with epinephrine, a small skin incision \nwas made at the \ntunnel entry site. A 23cm tip-to-cuff length catheter was \nselected. The \ncatheter was tunneled from the entry site towards the venotomy \nsite from where \nit was brought out using a tunneling device. The venotomy tract \nwas dilated \nusing the introducer of the peel-away sheath supplied. Following \nthis, the \npeel-away sheath was placed over the ___ wire through which \nthe catheter was \nthreaded into the right side of the heart with the tip in the \nright atrium. \nThe sheath was then peeled away. The catheter was sutured in \nplace with 0 silk \nsutures. Steri-strips were also used to close the venotomy \nincision site. \nFinal spot fluoroscopic image demonstrating good alignment of \nthe catheter and \nno kinking. The tip is in the right atrium. The catheter was \nflushed and both \nlumens were capped. Sterile dressings were applied. The patient \ntolerated the \nprocedure well. \n \nFINDINGS: \n \nPatent left internal jugular vein. Final fluoroscopic image \nshowing catheter \nwith tip terminating in the right atrium. \n \n\n \nIMPRESSION: \n \nSuccessful placement of a 23cm tip-to-cuff length tunneled \ndialysis line. \nThe tip of the catheter terminates in the right atrium. The \ncatheter is ready \nfor use. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ y/o female with a history of ETOH cirrhosis \nc/b HE, recurrent ascites with weekly large and hepatorenal \nsyndrome on HD (___), undergoing transplant work up, who was \ntransferred from ___ on ___ for a dislodged \nHD line that was removed, hospital course c/b encephalopathy, \nVRE bacteremia and concern for endocarditis. Patient was \nadmitted to ___, at which time she was started on daptomycin. \nRepeat blood cultures were obtained, and the last positive blood \nculture was on ___ growing enterococcus that was resistant to \nvancomycin. The patient continued on IV therapy, and she was \nclinically improving, denying any fevers, chills, chest pain, \npalpitations, and throughout her hospitalization had no stigmata \nof endocarditis. The source of the infection was likely due to \nher HD line.\n\nID was consulted, and the recommendations included continuing \ndaptomycin, removing her HD line, and getting a TEE to determine \nthe course of antibiotic therapy. The patient had her HD line \nremoved, was on a line holiday, with replacement of her HD line \n48 hours after removal. Patient had no issues with removal, \nblood cultures were persistently negative, and her TEE did not \nshow any evidence of endocarditis. She was stable throughout her \ntime in the hospital. The patient had initially NG tube \nplacement, but prior to discharge given intolerance of NG tube \nthe patient and care team elected to remove the NG tube. The \npatient tolerated oral feedings well, with the caveat that her \nnutrition will have to be closely monitored. Patient was \ndischarged after her dialysis on ___, needing 2 additional \ndoses of daptomycin for her VRE bacteremia.\n\nTI:\nVRE Bacteremia \n[]last 2 dapto doses on ___ and ___ after HD\n\nCirrhosis/transplant w/u \n[]will need q6month HCC screening\n[] please schedule pt to have eval for fistula\n[] Continue to assess nutritional status and p.o. intake. \nPatient briefly on NG tube while in hospital. Patient did not \nwant NG tube as outpatient.\n\nPCP:\n[] recheck vitamin d levels \n\nACUTE ISSUES:\n==============\n#Septic shock\n#VRE bacteremia, stable \nThe patient was admitted with septic shock with VRE bacteremia \nwith 4 out of 4 blood cultures positive, requiring \nnorepinephrine/vasopressin. Patient was hemodynamically stable, \nand transferred to the floor. Her last blood culture was \npositive on ___ growing enterococcus resistant to \nvancomycin sensitive to daptomycin. The source of the infection \nwas likely line infection although diarrheal illness was \ninitially considered. TTE was initially performed with a \npossible vegetation, although later TEE was reassuring for no \nsigns of endocarditis. ID was consulted this hospitalization and \nprovided recommendations for infection management. She had a \nline holiday for her HD line, with replacement of her HD line on \n___, for which she continue daptomycin with dialysis. Her CK \nlevels were unremarkable. The patient was maintained on \nMidodrine. She was scheduled to complete 2 weeks of daptomycin \ntreatment, with the last 2 courses to be infused via her midline \nas an outpatient.\n\n#Dislodged HD catheter\n#ESRD on ___ HD\n#Hepatorenal syndrome\nThe patient had HD line placed upon arrival to the ICU, was \nstable on hemodialysis. She was maintained on midodrine, \ncontinued hemodialysis through her tunneled HD line, and was \ncontinued on her home Nephrocaps and sevelamer.\n\n#Encephalopathy, resolved \nThe patient's encephalopathy was likely multifactorial although \nthere was a large component from her VRE bacteremia. \nEncephalopathy improved with antibiotics and lactulose, the \npatient was awake and alert oriented x3 and did not have any \nasterixis on exam. Her mental status was stable over the course \nof his hospitalization.\n\n#ETOH Cirrhosis\nC/b HE, recurrent ascites with weekly large and hepatorenal \nsyndrome on HD (___), undergoing transplant work up. MELD \n27, Childs Class B. Currently decompensated by ascites. \n- V: Moderate ascites on exam. paracetensis on ___ removed 4.3 \nliters of fluid \n- I: VRE treatment as above, otherwise no new infections\n- B: No signs of acute bleeding, continued pantoprazole\n- E: None on exam. Continued rifaximin and lactulose\n- S: will need q6month ___ screening \n\n#Acute on chronic macrocytic anemia\nBaseline Hgb ___, downtrended <7 requiring 1u pRBC. OSH EGD in \n___ showed no varices. No evidence of active bleeding. Likely \nmultifactorial from chronic illness and cirrhosis. \n- Trended CBC\n- Continued home pantoprazole \n- Maintained active T&S\n- Transfused for Hgb <7 or HD instability \n\n#Concern for pneumoperitoneum\nSeen on outside hospital CXR. CT shows improvement in free air\nand tracking to umbilical deficit. Per Surgery and Radiology, \nmost likely secondary to recent paracentesis. Abdominal exam has \nremained benign throughout her hospitalization.\n- Trended abdominal exam\n\n#Malnutrition \n- Nutrition consulted \n-The patient was initially on tube feeds while she was on the \nfloor, she was tolerating p.o. intake well and her NG tube was \nDC'd the night prior to her discharge. The patient tolerated \ndinner and breakfast well.\n\nCHRONIC ISSUES:\n================\n#Thrombocytopenia\nLikely ___ underlying cirrhosis. \n\n# Vitamin D deficiency\n- Continued vitamin D supplements \n- Recheck vitamin D level as outpatient \n\nCORE MEASURES: \n# FEN: No IVF, replenish electrolytes, regular diet \n# PPX: Subcutaneous heparin (hold for plt <50), lactulose \n# ACCESS: PIV, HD line \n# CODE: Full code\n# CONTACT: ___ (Husband) ___ \n# DISPO: ET pending abx plan, TEE, line holiday\n \nMedications on Admission:\n1. Vitamin B Complex w/C 1 TAB PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. Lactulose 30 mL PO TID \n4. Midodrine 30 mg PO TID \n5. Mirtazapine 15 mg PO DAILY \n6. PredniSONE 10 mg PO DAILY \n7. rifAXIMin 550 mg PO BID \n8. sevelamer CARBONATE 800 mg PO TID W/MEALS \n9. Thiamine 100 mg PO DAILY \n10. Vitamin D ___ UNIT PO 1X/WEEK (___) \n11. Simvastatin 20 mg PO QPM \n\n \nDischarge Medications:\n1. Daptomycin 350 mg IV QTUTHUR (___) \nRX *daptomycin 350 mg 350 mg IV on ___ and ___ Disp #*2 \nVial Refills:*0 \n2. Midodrine 25 mg PO Q6H \n3. FoLIC Acid 1 mg PO DAILY \n4. Lactulose 30 mL PO TID \n5. Mirtazapine 15 mg PO DAILY \n6. rifAXIMin 550 mg PO BID \n7. sevelamer CARBONATE 800 mg PO TID W/MEALS \n8. Simvastatin 20 mg PO QPM \n9. Thiamine 100 mg PO DAILY \n10. Vitamin B Complex w/C 1 TAB PO DAILY \n11. Vitamin D ___ UNIT PO 1X/WEEK (___) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nVRE bacteremia\nDislodged HD catheter\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 because your dialysis line was \ndislodged, and you were found to have a bacterial infection. \nWhile you were in the hospital, you had IV antibiotics started, \nand your blood cultures eventually showed that there was no \nbacterial growth and you started to feel better. You also had a \nparacentesis performed to take fluid from your belly.\n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?\n- You must never drink alcohol, and you should try to keep your \nliver as healthy as possible. See below for all our recommended \nstrategies. \n- Please enroll in AA and work with your primary care doctor to \ndetermine the best strategy to help you stay sober\n- Take all of your medications as prescribed (listed below)\n- Keep your follow up appointments with your doctors\n- Weigh yourself every morning, before you eat or take your \nmedications. Call your doctor if your weight changes by more \nthan 3 pounds\n- Please stick to a low salt diet and monitor your fluid intake\n- If you experience any of the danger signs listed below please \ncall your primary care doctor or come to the emergency \ndepartment immediately.\n\nIt was a pleasure participating in your care. Best wishes to you \nand your family. \n- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "T80211A", "A4181", "R6521", "N186", "K767", "G9341", "T8242XA", "Z1622", "D684", "E871", "I120", "E440", "D61818", "Y718", "Y929", "Z992", "K7031", "D638", "D696", "E559", "E785", "Z6823", "K219", "M109", "K668", "I9589", "Z781", "E876", "K7040" ]

[ "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "A4181: Sepsis due to Enterococcus", "R6521: Severe sepsis with septic shock", "N186: End stage renal disease", "K767: Hepatorenal syndrome", "G9341: Metabolic encephalopathy", "T8242XA: Displacement of vascular dialysis catheter, initial encounter", "Z1622: Resistance to vancomycin related antibiotics", "D684: Acquired coagulation factor deficiency", "E871: Hypo-osmolality and hyponatremia", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "E440: Moderate protein-calorie malnutrition", "D61818: Other pancytopenia", "Y718: Miscellaneous cardiovascular devices associated with adverse incidents, not elsewhere classified", "Y929: Unspecified place or not applicable", "Z992: Dependence on renal dialysis", "K7031: Alcoholic cirrhosis of liver with ascites", "D638: Anemia in other chronic diseases classified elsewhere", "D696: Thrombocytopenia, unspecified", "E559: Vitamin D deficiency, unspecified", "E785: Hyperlipidemia, unspecified", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "K668: Other specified disorders of peritoneum", "I9589: Other hypotension", "Z781: Physical restraint status", "E876: Hypokalemia", "K7040: Alcoholic hepatic failure without coma" ]

[ "E871", "Y929", "D696", "E785", "K219", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \noptiflux dialyzer\n \nAttending: ___.\n \nChief Complaint:\n___ \n \nMajor Surgical or Invasive Procedure:\nDiagnostic paracentesis ___ \nLeft chest tunneled HD line placement \n\n \nHistory of Present Illness:\n___ with a history of EtOH cirrhosis, complicated by hepatic\nencephalopathy and ascites requiring paracentesis, CKD,\nhypertension, hyperlipidemia, and GERD, who initially presented\nto ___ after she was found to have an elevated\ncreatinine on outpatient labs, subsequently transferred to ___\nfor further evaluation.\n\nRecent admission ___ for UTI, hepatic encephalopathy, \nand\nleaking from her paracentesis site. Urine culture was positive\nfor pan-sensitive E. coli for which she completed a seven day\ncourse of antibiotics (ceftrixaone initially before \ntransitioning\nto ciprofloxacin 500mg BID). Trigger for hepatic encephalopathy\nwas felt to be UTI, with improvement in her mental status with\ntreatment of same and initiation of lactulose/rifaximin.\nHospitalization was otherwise notable for mild ___ felt to\npre-renal in etiology, which improved by the time of discharge.\n\nSince discharge, patient has overall not been doing well.\nReported persistent issues with fatigue and poor appetite, which\nhave been present for almost one month. She had not been taking\nin much PO intake over the same time period, and feels this has\nbeen impacting her energy levels. On a number of occasions, she\nhas dropped an item she has been carrying due to this \n\"weakness\".\nDenies focal neurological deficits, including motor or sensory\nsymptoms, confusion, memory issues, or headaches. She has been\ntaking all her medications as prescribed, including furosemide,\ndespite not taking in adequate PO intake. She had labs drawn \nwith\nher PCP yesterday which showed a creatinine of 3.2, prompting\nreferral to ___. UA demonstrated 4+ calcium\noxalate crystals, suggesting component of hypovolemia to ___.\nDecision was made to transfer to ___ for further evaluation as\nshe is followed here by hepatology.\n\nIn the ED, initial vital signs were notable for;\nTemp 97.0 HR 92 BP 108/64 RR 16 SaO2 100% RA\n\nExamination notable for;\nA/O x3, comfortable, jaundiced, scleral icterus present, RRR,\nnormal S1 and S2, clear lungs bilaterally, no CVAT,\nsoft/non-tender abdomen, distended, no lower extremity edema, no\nsensorimotor deficits, fluent speecg\n\nLabs were notable for;\nWBC 6.3 Hgb 8.6 Plt 67\n___ 15.2 PTT 29.7 INR 1.4\nNa 137 K 4.5 Cl 109 HCO3 12 BUN 78 Cr 3.0 Gluc 120 AnGap\n16\nALT 20 AST 36 ALP 97 Tbili 1.0 Alb 3.1\nLactate 1.2\nSerum tox screen negative\n\nUrine studies notable for moderate leuks (7 WBC), negative\nnitrites, few bacteria, and 4 epithelial cells.\n\nPleural fluid analysis notable for 110 WBC 17 RBC, protein 0.9,\nglucose 118, LDG 39, creatinine 3.0, amylase 22, Tbili 0.2, and\nalbumin 0.5.\n\nRenal US demonstrated no hydornephrosis and moderate volume\nascites.\n\nHepatology were consulted; recommended 1g/kg/day IV albumin 25%\nfor 48 hours for ___, admit to ___ for ___ work-up and\nmanagement.\n\nPatient was given;\n- IV albumin 25% 50g\n\nTransfer vital signs were notable for;\nTemp 98.3 HR 87 BP 106/52 RR 12 SaO2 100% RA\n\nUpon arrival to the floor, patient repeats the above story.\nCurrently she denies any symptoms, with the exception of \nfatigue.\nStates she has not been sleeping well. Denies confusion, feels \nat\nher baseline mental status.\n\n10-point review of systems otherwise negative.\n\n \nPast Medical History:\n- CV: HLD, HTN\n- GI: Esophageal stricture, GERD, Childs B EtOH Cirrhosis \n(MELD-Na 15) decompensated by encephalopathy, ascites\n- MSK: arthritis \n\nPast Surgical History \n- Appendectomy \n\n \nSocial History:\n___\nFamily History:\n- No family history of liver disease\n- Father had a cancer of unknown origin\n- Mother is in her ___ \n \nPhysical Exam:\nADMISSION EXAM:\n==================\n\nVS: Temp: 98.3 BP: 109/60 HR: 86 RR: 18 SaO2 100% RA\n\nGENERAL: sitting comfortably in bed, no acute distress\nHEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM\nNECK: supple, non-tender, no JVP elevation\nCV: RRR, S1 and S2 normal, no murmurs/rubs/gallops\nRESP: CTAB, no wheezes/crackles\n___: soft, non-tender, distended but not firm, BS normoactive\nEXTREMITIES: warm, well perfused, no lower extremity edema\nNEURO: A/O x3, moving all four extremities with purpose, CNs\ngrossly intact \n\nDISCHARGE EXAM:\n=====================\n\nGeneral: NAD, alert, Alert/oriented x4, pleasant and interactive \n\nHEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck supple. Tunneled line in place.\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 \nExt: Warm, well perfused, 2+ pulses, some trace edema in the\nbilateral lower extremities \nNeuro: A/O X4 with No asterixis.\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 07:58PM URINE HOURS-RANDOM\n___ 07:58PM URINE UHOLD-HOLD\n___ 07:58PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 07:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-MOD*\n___ 07:58PM URINE RBC-1 WBC-7* BACTERIA-FEW* YEAST-NONE \nEPI-4 TRANS EPI-1\n___ 07:58PM URINE HYALINE-5*\n___ 07:58PM URINE MUCOUS-RARE*\n___ 07:14PM LACTATE-1.2\n___ 06:20PM ASCITES TOT PROT-0.9 GLUCOSE-118 CREAT-3.0 \nLD(LDH)-39 AMYLASE-22 TOT BILI-0.2 ALBUMIN-0.5\n___ 06:20PM ASCITES TNC-110* RBC-17* POLYS-15* LYMPHS-26* \nMONOS-31* MACROPHAG-28* OTHER-0\n___ 04:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \ntricyclic-NEG\n___ 01:00PM GLUCOSE-120* UREA N-78* CREAT-3.0*# \nSODIUM-137 POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-12* ANION \nGAP-16\n___ 01:00PM estGFR-Using this\n___ 01:00PM ALT(SGPT)-20 AST(SGOT)-36 ALK PHOS-97 TOT \nBILI-1.0\n___ 01:00PM ALBUMIN-3.1*\n___ 01:00PM WBC-6.3 RBC-2.78* HGB-8.6* HCT-27.2* MCV-98 \nMCH-30.9 MCHC-31.6* RDW-14.8 RDWSD-53.0*\n___ 01:00PM NEUTS-80.3* LYMPHS-11.3* MONOS-6.2 EOS-1.4 \nBASOS-0.3 IM ___ AbsNeut-5.03 AbsLymp-0.71* AbsMono-0.39 \nAbsEos-0.09 AbsBaso-0.02\n___ 01:00PM PLT COUNT-67*\n___ 01:00PM ___ PTT-29.7 ___\n\nIMAGING:\n=========\n\n___ renal US:\nIMPRESSION: \n \n \n1. No hydronephrosis. \n2. Moderate volume ascites. \n\n___ X-ray feet bilateral\nIMPRESSION: \n \nNo previous images. On the left, there is soft tissue \nprominence at the first \nMTP joint containing areas of opacification, consistent with a \ntophus. In \naddition, there is an erosion of the medial aspect of the base \nof the proximal \nphalanx of the great toe, all consistent with the clinical \ndiagnosis of gout. \nOn the right, there is soft tissue prominence at the first MTP \njoint, but no \nevidence of calcification in soft tissues or erosive changes. \nThere are inferior and posterior calcaneal spurs bilaterally. \n \nNOTIFICATION: Dr. ___ states that the patient in the \npast has been \ntreated for gout. \n\nRENAL US: ___\n\nIMPRESSION: \n \n \n1. No hydronephrosis. \n2. Partially imaged cirrhotic liver and ascites. \n\n___\n\nEXAMINATION: DUPLEX DOPP ABD/PEL\n \nINDICATION: eval for ascites, portal vein trhombus,or other \netiology for\ndecompensated cirrhosis\n \nTECHNIQUE: Gray scale, color, and spectral Doppler evaluation \nof the abdomen\nwas performed.\n \nCOMPARISON: Prior liver ultrasound from ___.\n \nFINDINGS: \n \nLiver: The hepatic parenchyma is coarsened and nodular.. No \nfocal liver\nlesions are identified. There is mild ascites.\nBile ducts: There is no intrahepatic biliary ductal dilation.\n CHD: 5 mm\nGallbladder: There is cholelithiasis and biliary sludge without \nevidence of\ncholecystitis.\nPancreas: The imaged portion of the pancreas appears within \nnormal limits,\nwith portions of the pancreatic tail obscured by overlying bowel \ngas.\nSpleen: The spleen is enlarged and demonstrates normal \nechotexture.\n Spleen length: 15.6 cm\nKidneys: No stones, masses, or hydronephrosis are identified in \neither kidney.\n Right kidney: 10.1 cm\n Left kidney: 10.1 cm\n \nDoppler evaluation:\n \nThe main portal vein is patent, with flow in the appropriate \ndirection.\nMain portal vein velocity is 19.1 cm/sec.\nRight and left portal veins are patent, with antegrade flow.\n \nIMPRESSION: \n \nPatent hepatic venous vasculature with no evidence of portal \nvein thrombosis. \nRedemonstration of a cirrhotic liver associated to splenomegaly \nand mild\nascites.\n___\nRight second finger radiographs, two views.\nINDICATION: Mono arthritis of the right distal interphalangeal \njoint. Gout\nversus septic arthritis.\n \nCOMPARISON: None available.\n \nFINDINGS: \n \nThere is marked soft tissue swelling about the second distal \ninterphalangeal\njoint. Lytic bone destruction is noted along the radial sides \nof the middle\nand distal phalanges near the joint space. Joint space appears \nnarrowed. \nVague subchondral lucency along the lateral sided of the middle \nphalanx.\n \nIMPRESSION: \n \nLytic changes and narrowing at the joint space with marked soft \ntissue\nswelling. This is concerning for septic arthritis. Locations \nand pattern of\nbone erosions are less typical for gout.\n \n\nTTE : ___ \nCONCLUSION:\nThe left atrial volume index is normal. The estimated right \natrial pressure is ___ mmHg. There is\nnormal left ventricular wall thickness with a normal cavity \nsize. There is normal regional and global left\nventricular systolic function. Quantitative biplane left \nventricular ejection fraction is 66 % (normal\n54-73%). Left ventricular cardiac index is normal (>2.5 \nL/min/m2). There is no resting left ventricular\noutflow tract gradient. No ventricular septal defect is seen. \nNormal right ventricular cavity size with\nnormal free wall motion. Tricuspid annular plane systolic \nexcursion (TAPSE) is normal. The aortic valve\nleaflets (3) are mildly thickened. There is no aortic valve \nstenosis. There is no aortic regurgitation. The\nmitral valve leaflets are mildly thickened with no mitral valve \nprolapse. There is trivial mitral\nregurgitation. The pulmonic valve leaflets are normal. The \ntricuspid valve leaflets appear structurally\nnormal. There is mild [1+] tricuspid regurgitation. The \nestimated pulmonary artery systolic pressure is\nnormal. There is no pericardial effusion.\nIMPRESSION: Preserved biventricular systolic function. Mild \ntricuspid regurgitation. Normal\npulmonary pressure.\n\nMICROBIOLOGY:\n================\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n STAPH AUREUS COAG +. >100,000 CFU/mL. \n Oxacillin RESISTANT Staphylococci MUST be reported as \nalso\n RESISTANT to other penicillins, cephalosporins, \ncarbacephems,\n carbapenems, and beta-lactamase inhibitor combinations. \n\n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- =>8 R\nNITROFURANTOIN-------- <=16 S\nOXACILLIN------------- =>4 R\nTETRACYCLINE---------- <=1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ 1 S\n\nDISCHARGE LABS:\n===============\n\nTest NameValueR___ RangeUnitsPerforming Site\n___ 06:30\nCOMPLETE BLOOD COUNT\nWhite Blood Cells4.94.0 - 10.0K/uLW\nRed Blood Cells2.70*3.9 - 5.2m/uLW\nHemoglobin8.3*11.2 - 15.7g/dLW\nHematocrit27.2*34 - 45%W\nMCV101*82 - 98fLW\nMCH30.726 - 32pgW\nMCHC30.5*32 - 37g/dLW\nRDW21.4*10.5 - 15.5%W\nRDW-SD77.8*35.1 - 46.3fLW\nBASIC COAGULATION ___, PTT, PLT, INR)\nPlatelet Count61*150 - 400K/uLW\n\nTest Name___ RangeUnitsPerforming Site\n___ 06:30\nReport Comment:\nADD ON\nRENAL & GLUCOSE\nGlucose9070 - 100mg/dLW\n If fasting, 70-100 normal, >125 provisional diabetes\nUrea Nitrogen37*6 - 20mg/dLW\nCreatinine2.2*0.4 - 1.1mg/dLW\nSodium141135 - 147mEq/LW\nPotassium4.13.5 - 5.4mEq/LW\nChloride___ - 108mEq/LW\nBicarbonate2822 - 32mEq/LW\nAnion Gap1510 - 18mEq/LW\nENZYMES & BILIRUBIN\nAlanine Aminotransferase (ALT)250 - 40IU/LW\nAsparate Aminotransferase (AST)48*0 - 40IU/LW\nAlkaline Phosphatase121*35 - 105IU/LW\nBilirubin, Total2.4*0 - 1.5mg/dLW\nBilirubin, Direct0.9*0 - .3mg/dLW\nBilirubin, Indirect1.5 mg/dLW\nCHEMISTRY\nAlbumin3.63.5 - 5.2g/dLW\nCalcium, Total9.28.4 - 10.3mg/dLW\nPhosphate3.22.7 - 4.5mg/dLW\nMagnesium2.01.6 - 2.6mg/dLW\n\n \nBrief Hospital Course:\nSUMMARY:\n------------\n___ female PMH EtOH cirrhosis c/b HE, ascites, CKD, HTN, \nHLD, and GERD who was transferred from OSH for ___ on CKD. \nEtiology was thought to be due to pre-renal from HRS. She was \nstarted on midodrine, octreotide, and received albumin but renal \nfunction did not improve. She required intubation and brief ICU \nstay for uremic encephalopathy for which she received CRRT and \nwas transitioned to HD. Course was complicated by aspiration \npneumonia and gout flare requiring steroids. She started \ntransplant evaluation and needs to engage in relapse prevention \nfor at least 3 months as an outpatient which was arranged at \n___. \n\nTRANSITIONAL ISSUES:\n======================\n[] Outpatient HD center below \n___ Dialysis Center \n___. \n___\nPhone: ___\nNephrologist: Dr. ___\n\n___ forward ___ set dialysis treatment schedule will be \nevery\n___ and ___ at 6:00am, unless instructed\notherwise.\n\n[] Held home furosemide/spironolactone on discharge given \npatient is on HD TTS.\n[] Nutrition: initially received tube feeds but dobhoff removed. \nContinue 2 Nepros TID w/ meals. \n[] Recommend Rheumatology follow-up given history of recurrent \ngout flares. \n[] Transplant evaluation: nuclear stress test, ENT evaluation, \nPFTs, CT A/P for surgical planning, OMFS to extract tooth #19\n[] Last therapeutic paracentesis ___ with 3.5 L removed. \n[] Vitamin D 50000U PO weekly (___) to continue for 8-week \ncourse finishing ___. Please transition to daily vitamin D \nsupplementation after this. \n\nACUTE ISSUES:\n==============\n# ___ on CKD\n# Metabolic acidosis:\nBaseline Cr 1.2-1.3. Creatinine 3.0 on admission which \nultimately progressed to uremic encephalopathy requiring CRRT in \nICU before being transitioned to HD TTS. Etiology pre-renal, \nlikely HRS v. ATN. Started and will continue midodrine 30 mg PO \nTID for hemodynamic support. \n\n#MRSA UTI\nUrine cultures sent in the setting of altered mental status, \nwhich resulted positive for MRSA. Febrile overnight of ___ to \nTmax 100.9. Treated with vancomycin as above for adequate \ncourse.\n\n# Nutrition\nPatient is s/p ___ placement with tube feedings for \nnutrition. She will be discharged with Nepro shakes and advised \nto drink ___ per day to help with her moderate to severe \nmalnutrition. \n\n# Subacute monoarthritis (R index finger):\n# Bilateral MTP pain:\n# Gout:\nPatient noted to have R index finger redness, swelling at DIP \njoint which she had noticed for the last few weeks. Also with \ndorsal foot pain bilaterally. She notably has a history of gout \nflares affecting these areas. She underwent finger x-rays and \nankle x-rays which were consistent with gout. MSK radiology and \nrheumatology were consulted. Rheumatology had recommended tap, \nhowever on review with radiology, unlikely any area to tap on \nthe R index finger and clinical picture most consistent with \ngout. We initiated therapy with steroids for 2 days with \nimprovement of symptoms. She may need allopurinol (renally \ndosed) as outpatient if her pain recurs.\n\n# EtOH cirrhosis\n# Thrombocytopenia\n# Coagulopathy \n# History of ascites and hepatic encephalopathy MELD-Na 22. \nPreviously decompensated by ascites requiring paracentesis (last \n___ and hepatic encephalopathy. Not a candidate for \ntransplant due to lack of relaspse prevention for at least 3 \nmonths as an outpatient. She was set up with Adcare to follow up \nas an outpatient. Home diuretics held on discharge since she was \non HD. \n\n# Anemia\nBaseline hemoglobin ___ per OMR records. Hemoglobin on admission\n8.6. Most likely etiology is macrocytic anemia secondary to EtOH\nuse and cirrhosis. No overt evidence of bleeding on this \nadmission. Required 4 units of prbc which was likely secondary \nto her ESLD and CKD. \n\n#sleep: started mirtazapine qhs for sleep\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 20 mg PO QPM \n2. Furosemide 20 mg PO DAILY \n3. Spironolactone 50 mg PO DAILY \n4. Lactulose 30 mL PO TID \n\n \nDischarge Medications:\n1. Midodrine 30 mg PO Q8H \nRX *midodrine 10 mg 3 tablet(s) by mouth every eight (8) hours \nDisp #*90 Tablet Refills:*0 \n2. Mirtazapine 15 mg PO QHS \nRX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n3. Nephrocaps 1 CAP PO DAILY \nRX *B complex with C 20-folic acid [Renal Caps] 1 mg 1 \ncapsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 \n4. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth q24h Disp #*30 \nTablet Refills:*0 \n5. rifAXIMin 550 mg PO BID \nRX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n6. sevelamer CARBONATE 800 mg PO TID W/MEALS \nRX *sevelamer carbonate 800 mg 1 tablet(s) by mouth TID with \nmeals Disp #*90 Tablet Refills:*0 \n7. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n8. Vitamin D ___ UNIT PO 1X/WEEK (FR) Duration: 8 Weeks \nTake for five more weeks. \nRX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by \nmouth once a week Disp #*5 Capsule Refills:*0 \n9. Lactulose 30 mL PO TID \nRX *lactulose 10 gram/15 mL 30 ml by mouth three times a day \nRefills:*0 \n10. Simvastatin 20 mg PO QPM \nRX *simvastatin 20 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet \nRefills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n# Acute renal failure requiring HD \n# Urinary tract infection\n# Severe malnutrition \n# Gout flare \n# Cirrhosis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was a pleasure taking care of you on this hospital admission \nat ___. \n\nWhy was I admitted to the hospital?\n\n- You were admitted for a kidney injury due to being dehydrated\n\nWhat happened while I was in the hospital?\n\n- You received IV fluids to try and improve your kidney failure. \nYou ultimately required dialysis and were started on this. \n- You were started on vancomycin to treat a urinary tract \ninfection\n- You had a gout flare and were started on treatment \n\nWhat do I need to do one I leave the hospital?\n\n- It is very important that you take all of your medications as \nprescribed \n- You should eat a low sodium diet \n- See your doctor within ___ weeks\n\nWe wish you the best!\n\nSincerely,\n\nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K767", "J690", "E43", "A419", "R6521", "E872", "N390", "E871", "N179", "K7040", "N189", "I129", "K7031", "K219", "B9562", "M109", "D6959", "D631", "D539", "E785", "F1021", "Z6823" ]

[ "K767: Hepatorenal syndrome", "J690: Pneumonitis due to inhalation of food and vomit", "E43: Unspecified severe protein-calorie malnutrition", "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "E872: Acidosis", "N390: Urinary tract infection, site not specified", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "K7040: Alcoholic hepatic failure without coma", "N189: Chronic kidney disease, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "K7031: Alcoholic cirrhosis of liver with ascites", "K219: Gastro-esophageal reflux disease without esophagitis", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "M109: Gout, unspecified", "D6959: Other secondary thrombocytopenia", "D631: Anemia in chronic kidney disease", "D539: Nutritional anemia, unspecified", "E785: Hyperlipidemia, unspecified", "F1021: Alcohol dependence, in remission", "Z6823: Body mass index [BMI] 23.0-23.9, adult" ]

[ "E872", "N390", "E871", "N179", "N189", "I129", "K219", "M109", "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:\nLeaking paracentesis site \nConfusion \n\n \nMajor Surgical or Invasive Procedure:\nDiagnostic paracentesis ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a history of \nalcoholic\ncirrhosis decompensated by ascites who presents with confusion,\nascites and leaking ascites from a prior paracentesis site. \n\nShe states that on ___ she presented to ___\nwith worsening ascites and had a paracentesis. Since then, she's\nhad draining at her paracentesis site requiring dressing changes\nabout ___. She denies any abdominal pain or history of SBP.\nShe doesn't feel that her abdomen has reaccumulated fluid since\nthen. She had therapeutic paracenteses here on ___ and ___\n(5L). \n\nShe's also had some increased forgetfulness and possibly\nconfusion as well. She noticed that she couldn't open the\nsteering wheel lock on her car the other day, but wasn't sure if\nit was just the lock acting up. She doesn't think she's been\novertly confused otherwise, but may be more forgetful for the\npast few days. She typically has 1 bowel movement daily,\nsometimes up to 3, and does not use lactulose. \n\nShe has not had fevers. She sometimes has chills at night. No\nnausea, vomiting, hematochezia, melena, dysuria, hematuria,\nabdominal pain, weakness, headache, vision change, dyspnea, \nchest\npain. She endorses significant fatigue. \n\nHer last drink was around ___. She denies any alcohol since\nthen. \n\nToday she met with Dr. ___ the above, she was sent \nto\nthe ED. \n\nRegarding her history of cirrhosis, she reports being diagnosed\nabout ___ years ago. She was drinking ___ cocktails daily since \nher\nteenage years. She started drinking again this ___ and then\nwas hospitalized at ___ and had a 5L paracentesis. She may have\nhad an EGD in ___ without EV. She has never had SBP. She's been\nseen in nephrology at ___ due to CKD and the concern is for\nhepatorenal syndrome as an etiology. \n\nEMERGENCY DEPARTMENT COURSE\nInitial vital signs were notable for: \n- T 98.7, HR 106, BP \"102/859\", RR 18, O2 98% RA \n \nExam notable for: \n- General: Appearing stated age\n- HEENT: NCAT, PEERL, MMM \n- Neck: Supple, trachea midline\n- Heart: RRR, no MRG. No peripheral edema. \n- Lungs: CTAB. No wheezes, rales, or rhonchi.\n- Abd: Soft, NTND. Bandage applied to RLQ is clean and dry. \n- MSK: No obvious limb deformities.\n- Derm: Skin warm and dry\n- Neuro: Awake, alert, moves all extremities. Asterixis present.\nA&O x3.\n- Psych: Appropriate affect and behavior\n\nLabs were notable for: \n- Cr 1.3, BUN 31\n- Bicarbonate 18\n- Tbili 1.6\n- Hb 8.6, PLT 79\n- INR 1.5 \n\nPatient was given: \n- Lactulose 30mL \n\nConsults: \n- Hepatology\n\nVital signs prior to transfer: \n- 98.4, HR 98, BP 105/63, RR 20, O2 100% RA \n\nUpon arrival to the floor: \n- She reports some cramping abdominal pain after taking \nlactulose\n\n \nPast Medical History:\n- CV: HLD, HTN\n- GI: Esophageal stricture, GERD, Childs B EtOH Cirrhosis \n(MELD-Na 15) decompensated by encephalopathy, ascites\n- MSK: arthritis \n\nPast Surgical History \n- Appendectomy \n\n \nSocial History:\n___\nFamily History:\n- No family history of liver disease\n- Father had a cancer of unknown origin\n- Mother is in her ___ \n \nPhysical Exam:\nADMISSION EXAM\n====================\nVITALS: 24 HR Data (last updated ___ @ 005)\n Temp: 98.0 (Tm 98.3), BP: 120/75 (120-123/74-75), HR: 99\n(91-104), RR: 18, O2 sat: 100%, O2 delivery: Ra \nGENERAL: Comfortable appearing, sitting up in bed speaking to me\nin no distress\nHEENT: Pupils equal and reactive, no scleral icterus, moist\nmucous membranes\nCARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4 \nLUNGS: Clear bilaterally\nABDOMEN: Soft, distended, no pain to palpation. Bandage on RLQ\nparacentesis site appears clean and dry. Small reducible\numbilical hernia. \nEXTREMITIES: No lower extremity edema. \nNEUROLOGIC: A+Ox3 though was confused about the day of the week\nand occasionally very mildly forgetful during our conversation.\n___ intact. She has bilateral asterixis. \n\nDISCHARGE EXAM\n====================\nVITALS:T: 99, BP 102/65, HR 93, RR 16, O2 Sat 98% on RA \nGENERAL: Comfortable appearing, sitting up in bed speaking to me \nin no distress\nHEENT: Pupils equal and reactive, no scleral icterus, moist \nmucous membranes\nCARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4 \nLUNGS: Clear bilaterally, no wheezes or crackles. \nABDOMEN: soft, NTND, +BS throughout \nEXTREMITIES: No lower extremity edema. \nNEUROLOGIC: A+Ox3, able to state day of week, location, name. \n___ intact. No asterixis on exam \n \nPertinent Results:\nADMISSION LABS\n====================\n___ 12:20PM BLOOD WBC-5.4 RBC-2.73* Hgb-8.6* Hct-27.9* \nMCV-102* MCH-31.5 MCHC-30.8* RDW-13.9 RDWSD-51.0* Plt Ct-79*\n___ 12:20PM BLOOD ___ PTT-28.5 ___\n___ 12:20PM BLOOD Glucose-116* UreaN-31* Creat-1.3* Na-141 \nK-4.6 Cl-105 HCO3-18* AnGap-18\n___ 12:20PM BLOOD ALT-15 AST-24 AlkPhos-97 TotBili-1.6*\n___ 12:20PM BLOOD Lipase-76*\n___ 06:27AM BLOOD calTIBC-411 VitB12-1429* Folate->20 \nFerritn-27 TRF-316\n\nDISCHARGE LABS \n====================\n___ 06:43AM BLOOD WBC-5.2 RBC-2.40* Hgb-7.7* Hct-24.4* \nMCV-102* MCH-32.1* MCHC-31.6* RDW-13.5 RDWSD-50.4* Plt Ct-66*\n___ 06:43AM BLOOD Glucose-117* UreaN-28* Creat-1.2* Na-138 \nK-3.8 Cl-108 HCO3-15* AnGap-15\n___ 06:43AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.7\n\nMICROBIOLOGY\n=====================\n___ URINE CULTURE\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ 8 S\nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n___: BLOOD CULTURE: pending, no growth to date \n___: BLOOD CULTURE: pending, no growth to date \n\n___ 11:56 am PERITONEAL FLUID PERITONEAL. \n GRAM STAIN (Final ___: \n THIS IS A CORRECTED REPORT (___). \n Reported to and read back by ___ (___) AT 3:53 \n___\n ___. \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, if \napplicable. \n PREVIOUSLY REPORTED AS (___). \n 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). \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 Reported to and read back by ___ ___ 15:06. \n\n FLUID CULTURE (Preliminary): pending, no growth to date \n\n ANAEROBIC CULTURE (Preliminary): pending, no growth to date\n\nIMAGING \n=====================\n___ RUQ U/S:\n1. Cirrhotic liver with no evidence of portal vein thrombosis. \n2. Small-to-moderate amount of ascites. \n\n___ ___ DIAGNOSTIC PARACENTESIS:\n1. Technically successful ultrasound guided diagnostic \nparacentesis. \n2. 20 cc of fluid were removed and sent for requested analysis. \n\n \nBrief Hospital Course:\nPATIENT SUMMARY\n============== \nMs. ___ is a ___ woman w/ Child's B decompensated EtOH \ncirrhosis (MELD-Na 15) w/ ascites necessitating recurrent \nparacentesis (last ___, admitted to ___ on ___ for further \nevaluation and management of urinary symptoms, confusion \nconcerning for hepatic encephalopathy and leaking ascites from \nparacentesis site. With regards to the urinary symptoms, she was \nfound to have a UTI, and was started on antibiotics with \nimprovement, with plan for completion of 7-day course of \nciprofloxacin. With regards to the confusion concerning for \nhepatic encephalopathy, this was assessed and felt most likely \nto be precipitated by the urinary infection. Her mental status \ncleared with initiation of lactulose/rifaximin, and she was \ndischarged with plan for continued lactulose therapy to reduce \nthe chance of future episodes of hepatic encephalopathy. With \nregards to the paracentesis site, it was no longer leaking upon \narrival to the floor. It was monitored closely and her abdomen \nwas assessed by ___ for tappable pocket given concern for \npossible SBP, with small pocket of straw-colored fluid obtained. \nThe fluid analyses showed evidence of portal HTN (SAAG 2.5), low \ntotal protein (0.9), and negative neutrophil criteria for SBP \n(PMNs 235), without any culture growth to date at the time of \ndischarge.\n\nACTIVE ISSUES: \n============== \n#Decompensated EtOH cirrhosis c/b volume refractory ascites \n#Concern for spontaneous bacterial peritonitis \nThe patient has a history of refractory ascites secondary to her \ncirrhosis which has historically required frequent LVP (~5L, \n___. When the patient reported to her outpatient \nhepatology office following her most recent paracentesis (___), \nshe reported ongoing leakage of yellow fluid from her \nparacentesis site necessitating ___ dressing changes/day, \nwithout any ascites reaccumulation. Per patient, this has \nhappened once before with a prior paracentesis and self-resolved \nafter ___ days, nonetheless, her outpatient hepatologist Dr. \n___ was concerned that she might have an evolving complication \nat the site of the paracentesis and sent her to the emergency \nroom for further evaluation. By the time the patient arrived at \nthe ___ ED on ___, the drainage from the paracentesis site \nhad dramatically decreased; and by the time she reached the \nfloor on the morning of ___, the drainage had entirely stopped, \nwith only scant yellow drainage appreciable on the gauze \npadding. Despite the cessation in drainage and quiescent \nappearance of paracentesis site w/o erythema or induration or \npurulence, given the potential for clinically silent SBP she \nunderwent ___ assessment for tappable pocket, during which 20 mL \nof straw-colored fluid were obtained. The fluid analyses showed \nevidence of portal HTN (SAAG 2.5), low total protein (0.9), and \nnegative neutrophil criteria for SBP (PMNs 235), negative gram \nstain, without any culture growth to date at the time of \ndischarge, and thus low concern for SBP at this point.\n\n#UTI:\nThe patient's UA on admission showed nitrites and rare bacteria, \nand subsequently grew out pan-sensitive E-coli. Despite absence \nof urinary symptoms (dysuria, hematuria, suprapubic discomfort, \nflank tenderness), given altered mental status and laboratory \nfindings was treated for presumed UTI, initially with CTX (___) \nwith subsequent transfer to ciprofloxacin 500 mg BID with plan \nto complete seven day course. \n\n___: \nThe patient was noted to have a Cr bump to 1.3 from admission \n(up from baseline 1, has been as high as 1.7 in past). She has \nknown b/l renal cysts demonstrated on US imaging as recently as \n___. Her change in Cr this admission was felt to be most \nlikely pre-renal in the setting of volume depletion from the \nUTI. She did not meet criteria for further evaluation for HRS, \ngiven no evidence of ascites, and Cr <1.5. Her Cr remained \nstable at 1.2-1.3 during the admission; she was discharged with \nclose outpatient hepatology follow-up. \n\n#Hepatic Encephalopathy: \nPrior to this admission, the patient had no history of hepatic \nencephalopathy and reported regular BM ___ without \nlactulose. However, on days preceding this admission she became \nmore forgetful, and was noted to have b/l asterixis on admission \nexam and to have confusion about day of the week, concerning for \nfirst-episode of hepatic encephalopathy, likely triggered by her \nurinary tract infection. She was evaluated with US and lab w/u \nfor concomitant clot or bleed trigger, and this work-up was \nnegative. She was treated with lactulose/rifaximin and her \nmental status cleared, with concomitant improvement in her \nasterixis. She was discharged on maintenance lactulose taken as \nneeded with titration for goal ___ BMs/day, with plan for close \nhepatology follow-up. \n\n#Screening/Maintenance \nThe patient's status with regards to screening and surveillance \nwas assessed as a component of routine inpatient cirrhosis care \nto ensure ongoing optimization. With regards to vaccination, she \nwas noted to have had both pneumococcal vaccines (completed \n___ influenza this year (___), HAV vaccination \n(___), and HBV immunity by serologies (___), with the \nmajority of this information documented in the ___ \nsystem. With regards to malignancy screenings, her last ___ \nscreening was ___, and showed coarsened hepatic echotexture \nwith nodular capsular contour, and no masses concerning for ___. \nWith regards to behaviors mediating her cirrhosis, she reported \nno current alcohol use, with last drink ___ months ago. \n\n#GERD:\n- The patient reported she had not been taking the omeprazole on \nher PAML recently due to issues with insurance coverage of \nomeprazole. She experienced some GERD symptoms during the \nadmission, predominantly burning in chest, w/o frank sense of \nacid refluxing back to her throat or other symptoms, which she \nassociated temporally with the initiation of the \nlactulose/rifaximin. She was treated symptomatically with \ncalcium carbonate for these symptoms and improved; we recommend \nthat she follow up with her primary care provider about \nalternate GERD medication if her symptoms continue to be \nbothersome, as detailed in transitional issues. \n\nCHRONIC ISSUES \n============== \n#HLD: \n- The patient's home simvastatin was continued during the \nadmission without issue. \n\nTRANSITIONAL ISSUES \n============== \n-NEW MEDICATIONS: The patient was started on one new long term \nmedication this admission, lactulose 30 mL PO/NG TID with goal \nto titrate to ___ daily. She was also discharged on a seven \nday course of ciprofloxacin, which she is due to complete on \n___.\n\n-PRIMARY CARE: \n[] Follow-up on the patient's Cr at the next scheduled visit, as \nthis remained mildly elevated at 1.2 ___ 1.0) at the time of \ndischarge. She was discharged on her home diuretic regimen.\n[] We recommend further discussion of alternate medications for \nGERD management that might be covered by the patient's insurance \nat the next routine primary care appointment if the patient is \ncontinuing to report significant and ongoing GERD symptoms. \n[] We also recommend follow-up regarding to the patient's \nurinary symptoms, to ensure resolution after completion of the \nantibiotic course. \n\n-HEPATOLOGY: \n[] We recommend follow-up on the final peritoneal fluid \ncultures, which were pending at the time of discharge.\n[] Follow up ascites and need for repeat paracentesis and need \nfor long-term lactulose therapy.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 20 mg PO QPM \n2. Spironolactone 50 mg PO DAILY \n3. Furosemide 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H Urinary tract infection \nDuration: 10 Doses \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*10 Tablet Refills:*0 \n2. Lactulose 30 mL PO TID \nTake as needed once daily with goal of having ___ bowel \nmovements a day. \nRX *lactulose 10 gram/15 mL 30 mL by mouth three times a day \nDisp #*___ Milliliter Milliliter Refills:*0 \n3. Furosemide 20 mg PO DAILY \n4. Simvastatin 20 mg PO QPM \n5. Spironolactone 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: \n-UTI\n-Hepatic encephalopathy \n-Leakage from paracentesis site \nSecondary diagnosis: \n-EtOH Cirrhosis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\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 part in your care here at ___! \n\nWhy was I admitted to the hospital? \nYou were admitted for further evaluation of confusion and fluid \nthat was continuing to leak from your paracentesis site (the \nsite where your outpatient providers had used a needle to take \n5L of fluid out of your belly on ___. \n\nWhat was done for me while I was in the hospital? \n-We treated you with medications called LACTULOSE and RIFAXIMIN \nto help you remove the toxins which might have been contributing \nyour confusion, and you improved with this treatment. \n-We found on laboratory testing of your urine that you had a \nurinary tract infection, which also could have contributed to \nyour confusion. We treated you with antibiotics for this \ninfection. \n-We evaluated your paracentesis site to further evaluate why it \nhad been leaking. Fortunately, by the time you were brought up \nto the ___ hospital floors, the site was not leaking \nanymore, so we watched the site closely but did not need to do \nany further treatment. \n-We used special imaging techniques to look for pockets of fluid \nin your belly, we found a small pocket of fluid which was \nsampled. The sample did not show any signs of bacteria growing \nat the time of your discharge. \n\nWhat should I do when I leave the hospital? \n- You should follow-up with your outpatient providers as \nscheduled. \n- You should take your medications as prescribed for the \nduration of time specified on the prescription, including the \nnew antibiotic medication to treat your urinary tract infection \n(CIPROFLOXACIN), as well as the new medication to help you avoid \nfurther episodes of confusion by removing out more of the \ncontributing toxins (LACTULOSE)\n- You should watch for new/or worsening symptoms, especially \nthose listed below in the section entitled \"Danger Signs\". If \nyou do not feel like you are getting better or have any other \nconcerns, please call your doctor to discuss or return to the \nemergency room. \n\nSincerely, \n\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "K7040", "N179", "K766", "N390", "K9181", "N281", "K7031", "I129", "N189", "B9620", "E869", "E785", "K219", "Y848", "Y92530" ]

[ "K7040: Alcoholic hepatic failure without coma", "N179: Acute kidney failure, unspecified", "K766: Portal hypertension", "N390: Urinary tract infection, site not specified", "K9181: Other intraoperative complications of digestive system", "N281: Cyst of kidney, acquired", "K7031: Alcoholic cirrhosis of liver with ascites", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "E869: Volume depletion, unspecified", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92530: Ambulatory surgery center as the place of occurrence of the external cause" ]

[ "N179", "N390", "I129", "N189", "E785", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nleg pain, rash\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPCP:\nName: ___ \nLocation: ___ \nGROUP \nAddress: ___, ___ \nPhone: ___ \nFax: ___ \n\n___ yo M with eczema well controlled, hypothyroidism, who \npresents with acute LLE rash, pain, and fever. The patient \nfirst noticed the onset of redness in inner thigh with the \nfeeling of a muscle pull. Over the next day he noticed a rash \nin his LLE at the shin, punctate, which then became more \nconfluent. This was assoc with a sharper pain. He describes HA \nand feeling hazy as well. He also reports fever to 102. He \ndenies recent trauma to leg or bug bite. He denies recent \ntravel. He otherwise has felt well and denies vision change, \nCP, SOB, cough, n/v/d, bloody stool, dysuria, or leg swelling,=.\n\nHe saw his PCP and was referred to dermatology. The lower rash \nwas biopsied but derm was concerned about cellulitis. He was \ntherefore referred into the hospital for more aggressive \ntreatment. He currently feels better and notes that his rash \nhas stopped spreading.\n\n10 point review of systems reviewed otherwise negative except as \nlisted above\n \nPast Medical History:\nECZEMA \n___'S THYROIDITIS \nORTHOSTATIC HYPOTENSION \nADRENAL FATIGUE \nBENIGN PROSTATIC HYPERTROPHY \n \nSocial History:\n___\nFamily History:\nFather with prostate cancer. mother with COPD and renal failure\n \nPhysical Exam:\nVS: T96.8, BP 151/101, HR 98, RR 14, 100%RA\nGEN: well appearing in NAD\nHEENT: MMM OP clear anicteric sclera\nNECK: supple no LAD\nHEART: RRR no mrf\nLUNG: CTAB\nABD: soft NT/ND +BS no rebound or guarding\nEXT: Mild blanching erythema in inner thigh of RLE, mildly \ntender. No tender LAD or fluctuance or drainage. Distal ___ at \nshin with non-blanching confluent erythema, tender to touch, no \ndischarge. Connecting the two is a mild erythematous cord. \nMild eczematous change in RLE\nSKIN: as above\nNEURO: no focal deficits\n \nPertinent Results:\n___ 04:30AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 04:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 02:44AM ___ PTT-31.6 ___\n___ 12:42AM LACTATE-2.4*\n___ 12:30AM GLUCOSE-96 UREA N-21* CREAT-0.9 SODIUM-137 \nPOTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-28 ANION GAP-18\n___ 12:30AM WBC-5.9 RBC-4.71 HGB-14.8 HCT-43.2 MCV-92 \nMCH-31.4 MCHC-34.3 RDW-12.6 RDWSD-42.3\n___ 12:30AM NEUTS-54.1 ___ MONOS-16.0* EOS-0.0* \nBASOS-0.5 IM ___ AbsNeut-3.20 AbsLymp-1.72 AbsMono-0.95* \nAbsEos-0.00* AbsBaso-0.03\n___ 12:30AM PLT COUNT-___ with hypothyroidism presents with acute RLE erythema c/w \nacute cellulitis with lymphangitis.\n\nAcute RLE cellulitis: \nExam most consistent with acute cellulitis of distal RLE with \nlymphatic spread to upper RLE. There is no tender LAD or \nfluctuance to suggest abscess. There is no discharge. portal \nof entry likely eczema on leg. Vasculitis is also to be \nconsidered though less likely. There is no characteristic \nfeature of Lyme disease. Strep is the most likely cause. He \nwas started on IV with stabilization and improvement in his \noverall condition. The derm biopsy results were reviewed. \nDermatology here was consulted for a second opinion and agreed \nthat this was likely related to cellulitis, strep. After 48 hrs \nof IV Vanco, he was transitioned to Dicloxacillin to complete a \n10 day course. His Doxycycline was stopped on discharge. Lyme \nnegative. Blood cultures pending on discharge.\n\nHypothyroidism: Continued home pork thyroid\n\n \nMedications on Admission:\nPork Thyroid ___ daily\n \nMedications - OTC\nASCORBATE CALCIUM-BIOFLAVONOID [___] - Dosage uncertain - \n(Prescribed by Other Provider; ___)\nBETA CISTEROL - Dosage uncertain - (Prescribed by Other\nProvider; ___)\nCALCIUM CITRATE - Dosage uncertain - (Prescribed by Other\nProvider; ___)\nCOENZYME Q10 - Dosage uncertain - (Prescribed by Other \nProvider;\n___)\nGARLIC - Dosage uncertain - (Prescribed by Other Provider; ___)\nGRAPE SEED EXTRACT - Dosage uncertain - (Prescribed by Other\nProvider; ___)\nGUGGALIPID - Dosage uncertain - (OTC)\nMAGNESIUM CITRATE - Dosage uncertain - (Prescribed by Other\nProvider; ___)\nMULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth once a\nday - (OTC)\nOMEGA-3 FATTY ACIDS [FISH OIL CONCENTRATE] - Dosage uncertain - \n(Prescribed by Other Provider)\nPANTETHINE - Dosage uncertain - (OTC)\nPSYLLIUM HUSK [FIBER (PSYLLIUM HUSK)] - Dosage uncertain - \n(Prescribed by Other Provider; ___)\nPYCNOGENAL - Dosage uncertain - (___)\nSAW ___ - Dosage uncertain - (OTC)\nVITAMIN A-VITAMIN C-VIT E-MIN [ANTIOXIDANT FORMULA] - Dosage\nuncertain - (Prescribed by Other Provider)\nVITAMIN B COMPLEX [B-50 COMPLEX] - Dosage uncertain - \n(Prescribed by Other Provider; ___)\nVITAMIN E - Dosage uncertain - (Prescribed by Other Provider;\n___)\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain fever \n2. thyroid (pork) 162.5 mg oral DAILY \n3. DiCLOXacillin 500 mg PO Q6H \nRX *dicloxacillin 500 mg 1 capsule(s) by mouth four times a day \nDisp #*32 Capsule Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute RLE cellulitis\nHypothyroidism\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted for evaluation of right leg rash, likely \ncaused by infection in your skin (cellulitis). Please complete \nyour doxycycline given to you previously (subtract the last 2 \ndays worth), and complete the course of Dicloxicillin given to \nyou. please follow up with your PCP in the next ___ days.\n\nYou can use Vaseline to your wound with dry gauze dressing \nchange daily\n \nFollowup Instructions:\n___\n" ]

[ "L03115", "B955", "E039", "L309" ]

[ "L03115: Cellulitis of right lower limb", "B955: Unspecified streptococcus as the cause of diseases classified elsewhere", "E039: Hypothyroidism, unspecified", "L309: Dermatitis, unspecified" ]

[ "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlisinopril\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nCardiac Catheterization ___\nTEE ___\n\nattach\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 05:04PM BLOOD WBC-6.1 RBC-4.03 Hgb-12.3 Hct-38.0 MCV-94 \nMCH-30.5 MCHC-32.4 RDW-13.6 RDWSD-46.5* Plt ___\n___ 05:04PM BLOOD Neuts-62.5 ___ Monos-5.7 Eos-3.1 \nBaso-1.0 Im ___ AbsNeut-3.80 AbsLymp-1.64 AbsMono-0.35 \nAbsEos-0.19 AbsBaso-0.06\n___ 05:04PM BLOOD ___ PTT-36.0 ___\n___ 05:04PM BLOOD Glucose-84 UreaN-12 Creat-0.6 Na-141 \nK-5.0 Cl-104 HCO3-24 AnGap-13\n___ 10:07PM BLOOD ALT-16 AST-33 AlkPhos-99 TotBili-2.3* \nDirBili-0.4* IndBili-1.9\n___ 05:14AM BLOOD Calcium-9.4 Phos-4.7* Mg-1.7\n\nOTHER PERTINENT LABS\n====================\n___ 05:14AM BLOOD ___\n___ 05:42AM BLOOD ___ PTT-150* ___\n___ 04:55AM BLOOD ___ PTT-62.0* ___\n___ 05:03AM BLOOD ___ PTT-45.4* ___\n___ 05:05PM BLOOD ___\n___ 05:50AM BLOOD ___ PTT-105.1* ___\n___ 05:10AM BLOOD ___\n___ 05:14AM BLOOD LD(LDH)-452*\n___ 05:04PM BLOOD cTropnT-0.19*\n___ 08:29PM BLOOD CK-MB-9 cTropnT-0.25*\n___ 10:07PM BLOOD CK-MB-7 cTropnT-0.29*\n___ 05:14AM BLOOD CK-MB-5 cTropnT-0.16*\n___ 05:19PM BLOOD CK-MB-3 cTropnT-0.06*\n___ 05:14AM BLOOD Hapto-<10*\n___ 05:42AM BLOOD CRP-4.0\n___ 06:16AM BLOOD SED RATE-Test \n\nDISCHARGE LABS\n=============== \n___ 05:10AM BLOOD WBC-3.8* RBC-3.76* Hgb-11.6 Hct-36.0 \nMCV-96 MCH-30.9 MCHC-32.2 RDW-13.9 RDWSD-48.8* Plt ___\n___ 05:10AM BLOOD ___\n___ 05:10AM BLOOD Glucose-100 UreaN-19 Creat-0.8 Na-138 \nK-4.9 Cl-103 HCO3-24 AnGap-11\n___ 05:10AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9\n\nMICRO\n=====\n___ 7:33 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\nIMAGING\n=======\n___ CXR\nModerate pulmonary vascular congestion/edema. More focal \nnodular opacity at \nthe right lung base could be due to volume overload, but \npulmonary nodule or \nconsolidation is not excluded. Recommend repeat chest \nradiographs after \ndiuresis. \n\n___ TTE\nTTE ___. Probable large thrombus on the left atrial aspect of \nthe bileaflet mitral valve adjacent to the posterior annulus \nwith no significant mitral regurgitation and normal \ntransvalvular gradients. Moderate global left ventricular \nhypokinesis.\n\n___ TEE\nNormally functioning mechanical mitral prosthesis. No \nthrombus/mass. The\ninteratrial septum is intact, but may have had prior repair or \nchairi attachments to the right atrial side of the septum (see \nclips ___.\n\n___ Cardiac Cath\nNo angiographically apparent coronary artery disease. Normal \nleft-side filling pressures.\n\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES\n===================\n[ ] Discharge Weight: 71.9kg\n[ ] Discharge INR 2.6\n[ ] Please repeat lab to check INR this week by ___, given \nlab script.\n[ ] Patient presented with atypical chest pain and NSTEMI, \nunderwent LHC which showed no lesions. Her chest pain is quite \natypical so she was trialed on GI cocktails and pain medications \nwith little effect. She was ultimately trialed on Isurdil which \nstrangely resolved her chest pain. She was discharged on Imdur. \n[ ] Patient presented with subtherapeutic INR. She was bridged \nwith heparin and ultimately resumed her home warfarin regimen. \nINR seems to be labile as an outpatient. Please continue to \nmonitor INR closely.\n[ ] Patient with TTE showing reduced EF 35-40% down from 60% in \n___. She presented with fluid overload requiring IV diuresis. \nShe was not transitioned to PO diuretics as she was euvolemic \nand not net positive without its addition. Advised patient to \nweigh herself daily. Please follow weights as patient may need \naddition of PO Lasix as an outpatient.\n\nBRIEF HOSPITAL COURSE\n======================\nMs. ___ is a ___ woman with a history of mechanical \nmitral valve replacement(on Coumadin) in ___ rheumatic \ndisease c/b MSSA endocarditis in ___, HTN, HLD, non-ischemic CM \nw/ EF 45%, and long-standing history of atypical chest pain, who \npresents with recurrent chest pain, also with evidence of volume \noverload and elevated troponins. In terms of chest pain, patient \nultimately underwent LHC on ___ showing no lesions. She \ncontinued to have chest pain despite GI cocktail and pain \nregimen. She was trialed on Isurdil which actually resolved her \npain. In terms of fluid overload, patient was treated with IV \ndiuresis and discharged in euvolemic condition. In addition, \npatient's course was complicated by subtherapeutic INR and \nconcern for mitral valve thrombus, however, TEE showed no \nthrombus and she was bridged with heparin to goal INR on \ndischarge.\n\nCORONARIES: ___ clean coronaries/ ___ with clean \ncoronaries. \nPUMP: EF 35-40% as of ___\nRHYTHM: NSR\n\n=============== \nACTIVE ISSUES: \n=============== \n#NSTEMI\n#Atypical Chest pain\nPatient has a longstanding history of atypical chest pain for \nwhich she has undergone previous work-up including diagnostic \nLHC in ___ showing clean coronaries and no obstructive CAD. Her \n___ stress test revealed a poor exercise tolerance, resting \nhypertension, and a blunted blood pressure response, as well as \na decrease in her heart rate (90s to ___ but no ischemic ECG \nchanges or wall motion abnormalities were appreciated. Her \ncurrent symptoms are consistent with prior presentations. EKG \ndoes show similar STD in lateral leads and TWI in V4-V6 which \nare stable compared to prior EKGs. However, the big difference \nis that she had significantly elevated troponins on admission \ntrending up to 0.25 and since downtrending. Initially, this was \nthought to be possibly a type II MI iso decompensated heart \nfailure but unusually high\ntroponins and normal renal function. It was less likely a type I \nNSTEMI given such clean coronaries on LHC in ___. Now with TTE \nshowing global hypokinesis, decreased EF to 35-40%. Therefore, \npatient underwent repeat LHC on ___ given continuing ___ \nchest pain which again showed no angiographically apparent \ncoronary artery disease and normal left-side filling pressures. \nPatient failed GI cocktails and typical pain regimens. \nTherefore, she was trialed on Isurdil 10mg TID which did relieve \nher pain. This could represent microvascular changes given her \nhistory of rheumatic heart disease, however is still atypical. \nWill discharge on Imdur given its success and tolerance.\n\n#Heart Failure with Reduced Ejection Fraction (35-40%) \n#Hypoxemia\nPatient had a most recent EF of 45%, although repeat TTE in \n___ stress echo showing recovered EF of 60%. Echo this \nadmission showed EF of 35-40%. CXR showed moderate pulmonary \nvascular congestion also with BNP ___. Possible trigger was \ndietary indiscretion given high salt diet. Patient received IV \ndiuresis. She was not transitioned to a standing oral regimen as \nshe was improved to baseline euvolemic, not reaccumulating fluid \noff diuretics. Patient continued on home losartan and \nmetoprolol. Patient euvolemic and saturating well on room air \nupon discharge. Weight on discharge 71.9kg. Please continue to \nmonitor weights and volume exam. ___ need addition of loop \ndiuretic in future. \n\n#History of Mitral Valve Replacement\n#Indirect Hyperbilirubinemia\nPatient has a mechanical bileaflet mitral valve replacement \nsecondary to rheumatic mitral stenosis ___, later complicated \nby Staph aureus endocarditis ___ TR. Patient presented \nsubtherapeutic on coumadin, INR 1.6 (goal 2.5-3.5). She has been \nsubtherapeutic recently as an outpatient as well. Patient with \npositive hemolysis labs. TTE showed concern for MV thrombus, but \nTEE shows confirmed no thrombus. She was bridged with heparin \nuntil her INR was therapeutic and she was discharged on her home \nregimen. Please ensure INRs are checked regularly and warfarin \ndosing is titrated accordingly. \n\n================ \nCHRONIC ISSUES: \n================ \n#HLD\nPatient continued on home atorvastatin 80mg PO QPM\n\n#Depression \nPatient continued on home celexa 20mg PO QD. Please monitor QTc \nas was elevated at start of admission. QTc on discharge 449. \n\n# CODE STATUS: Full Code \n# CONTACT: Name of health care proxy: ___ \nRelationship: boyfriend Phone number: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Warfarin 4 mg PO 6X/WEEK (___) \n2. Warfarin 6 mg PO 1X/WEEK (___) \n3. Atorvastatin 80 mg PO QPM \n4. Metoprolol Succinate XL 300 mg PO DAILY \n5. Losartan Potassium 50 mg PO DAILY \n6. Citalopram 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \nRX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n2. Atorvastatin 80 mg PO QPM \n3. Citalopram 20 mg PO DAILY \n4. Losartan Potassium 50 mg PO DAILY \n5. Metoprolol Succinate XL 300 mg PO DAILY \n6. Warfarin 4 mg PO 6X/WEEK (___) \n7. Warfarin 6 mg PO 1X/WEEK (___) \n8.Outpatient Lab Work\nZ95.2\nlab: INR \nwhen: any day between ___. \nPlease fax results to ___ attn: ___ \n___, MD \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n=================\nAtypical Chest Pain\nAcute on Chronic Heart Failure with Reduced Ejection Fraction\n\nSECONDARY DIAGNOSES\n===================\nSubtherapeutic INR with mechanical heart valve\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 privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You had chest pain\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You had imaging of your heart.\n- You were given medications for your chest pain\n- You had a procedure to look at your valve replacement better \nwhich was normal\n- You had a procedure to look at the blood vessels of your heart \nwhich was normal \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n-Please continue to take all of your medications and follow-up \nwith your appointments as listed below. \n-Please weigh yourself every morning. Call your doctor if you \ngain more than 3 lbs in one day.\n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I214", "I110", "I5023", "I428", "R0789", "E785", "R0902", "F329", "R300", "R9431", "E806", "R791", "Z7901", "Z952", "Z87891" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I110: Hypertensive heart disease with heart failure", "I5023: Acute on chronic systolic (congestive) heart failure", "I428: Other cardiomyopathies", "R0789: Other chest pain", "E785: Hyperlipidemia, unspecified", "R0902: Hypoxemia", "F329: Major depressive disorder, single episode, unspecified", "R300: Dysuria", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "E806: Other disorders of bilirubin metabolism", "R791: Abnormal coagulation profile", "Z7901: Long term (current) use of anticoagulants", "Z952: Presence of prosthetic heart valve", "Z87891: Personal history of nicotine dependence" ]

[ "I110", "E785", "F329", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Sulfa (Sulfonamide Antibiotics) / Tylenol / \nTetracyclines\n \nAttending: ___.\n \nChief Complaint:\nchronic nausea/vomiting/diarrhea of unclear etiology that\nfailed outpatient management\n \nMajor Surgical or Invasive Procedure:\nColonoscopy \n\n \nHistory of Present Illness:\nMs. ___ is a ___ year-old lady with history of liver\ncirrhosis ___ alcohol use and Hepatitis C s/p treatment \n(followed\nby Dr. ___, breast cancer in ___ in remission, depression,\nvertebral\ncompression fractures presenting for worsening of chronic loss \nof\nappetite/nausea/vomiting/diarrhea/weight loss of unclear \netiology\nthat have failed outpatient management.\n\nPatient presents with her friend/HCP ___ who helped with\nhistory. \n\nSymptoms started in ___ with decreased appetite.\n___ says she would not finish her meal and would take leftovers\nhome, which was not typical of her. At that time, patient \nstarted\nexperiencing vomiting and diarrhea. Diarrhea started as loose\nstool and progressed into diarrhea around ___. Describes\nher\nstool as yellow/green color that is oily and floats. ___ bowel\nmovements a day. Patient reports accidents of fecal incontinence\nand that's why she wears diapers now. \n\nIn regards to her vomiting, per patient cannot keep food down.\nInitially used to vomit ___ times a day and now she vomits\nwhenever she eats. Vomitus is usually food material. Patient\ndenies presyncope, syncope, falling, or decreased urine output.\nPatient smokes marijuana once a week. Takes oxycodone and\ngabapentin for chronic pain. She is also on abilify and\nvenlafaxine for depression. \n\nPatient's weight dropped from almost 140 lbs in ___ to\n116 lbs this month (~25lbs weight loss in ___ months).\n\nDenies fevers, shortness of breath, history of recent\ntravel, hematochezia, melena or contact with sick person. States\nshe has been completely sober since ___ and is not using \nIV\ndrugs\nsince ___.\n\nRegarding her 6 months of diarrhea that may be steatorrhea,\nreview of her records revealed that chronic pancreatitis had\nappeared on her list of diagnoses near the end of ___, however\npatient denies ever receiving a diagnosis of acute or chronic\npancreatitis. CT abdomen and pelvis in ___ without evidence\nof chronic pancreatitis. Also MRI from ___ did not show\nevidence of pancreatic pathology. \n\nRegarding her cyclical vomiting syndrome, patient never\nexperienced dizziness, presyncope or syncope. CT scan from ___\ndid not show evidence of obstruction or malignancy. Patient\ndenies dysphagia to solids or liquids. Uses marijuana (smokes,\neats as brownies) 2x/week.\n\nPatient had several recent visits for the same complaints,\nincluding ED on ___, ___ clinic on ___, and ___\nurgent care on ___. \n\nEGD was done on ___, scheduled from the ED visit, which \nshowed\ngastritis without esophageal varices. Patient tested positive \nfor\nH. pylori. Did not start treatment because pt saw that\ntetracycline had been prescribed and she refused to take because\nof hx of hearing loss/ototoxicity when she took it in past. Pt\ntried reaching out to GI clinic to see if there was an\nalternative regimen, but never heard back. \n\nDuring clinic visit plan was to send stool studies to work up \nher\nsteatorrhea however patient did not deliver stool samples as she\nis not making stool because she is not eating. Was prescribed\nZofran and compazine for her vomited, of which she reported \nlater\nthat compazine helped her more than the zofran. \n\nFollowing clinic visit pt's HCP/friend ___ called and reported\nthat he was concerned as she was not eating/drinking and \nbecoming\nweaker and dizzy. Patient advised to go to nearest ED for\nrehydration. Pt refused to go to ED unless she knew she would be\nadmitted, and so presented to urgent care instead. \n\nAt urgent care she received a liter of fluids but didn't feel \nany\nbetter. \n\nPCP arranged for GI referral (Dr. ___ for functional study\nfor gastroparesis (gastric emptying study). Has appt with him on\n___.\n\nOn the floor, patient feels fatigued, weak, but is able to\nconverse and ambulate normally. Accompanied by her HCP/friend,\n___. Still having intermittent N/V though this has improved. Has\nnot had a bowel movement since 3 weeks ago, only passing gas. \nHas\nbecome able to tolerate PO liquids as of a few days ago. Hasn't\nused marijuana since about 3 weeks ago. For all of her\nmedications, she had either been taking them for many years or\nthey were started well after her symptoms started. Notes she's\nalso been having stomach pain/cramping that started in ___ \n___.\n\nComplete ROS obtained and is otherwise negative.\n\n \nPast Medical History:\nPPH: \nOutpatient psychiatrist, Dr. ___,\nbeing treated for alcohol dependence and mood disorder with\nEffexor XR, Abilify, and Trazodone.\n\nPMH:\n-hepatitis C\n-cirrhosis due to alcohol abuse and hepatitis C\n-recently diagnosed breast cancer s/p lumpectomy ___, currently \nundergooing XRT \n-asthma\n \nSocial History:\n___\nFamily History:\n-Mother reported +CAD with first event at age ___, second event \nin ___. Also with h/o DM.\n-Father with CAD - at age ___\n\nFamily psychiatric history: no history of suicide, substance \nabuse, or major mental illness.\n\n \nPhysical Exam:\nAdmission Exam:\n==============\nVITALS: T 98.7 PO, BP 146 / 95 L Sitting, HR 116, RR 18, O2 97 \nRa\nGEN: NAD\nCARDIAC: tachycardic, reg rhythm, no MRG\nLUNGS: Normal WOB, CTAB \nABD: soft, NT, ND, normoactive bowel sounds\nEXT: no ___\nNEUROLOGIC: AAOx3, CN2-12 grossly intact, moves all 4 \nextremities\n\nDischarge Exam:\n==============\nVITALS: ___ 0753 Temp: 98.3 PO BP: 131/88 L Lying HR: 119\nRR: 16 O2 sat: 99% O2 delivery: Ra \nGEN: NAD\nHEENT: Normocephalic, atraumatic, PERLA, 2cm erythematous non\nblanching, non-raised, well circimsucribed rash adjacent to L\nnasolabial fold. Very mild acneiform eruption on cheeks.\nCARDIAC: tachycardic, reg rhythm, no MRG\nLUNGS: Normal WOB, CTAB \nABD: soft, NT, ND, normoactive bowel sounds\nEXT: no ___\nNEUROLOGIC: AAOx3, CN2-12 grossly intact, moves all 4 \nextremities\n \nPertinent Results:\nAdmission:\n\n___ 09:00PM ___ PTT-28.7 ___\n___ 09:00PM WBC-4.9 RBC-3.74* HGB-12.0 HCT-35.1 MCV-94 \nMCH-32.1* MCHC-34.2 RDW-12.5 RDWSD-42.9\n___ 09:00PM tTG-IgA-6\n___ 09:00PM IgA-355\n___ 09:00PM CALCIUM-9.2 PHOSPHATE-2.8 MAGNESIUM-1.7\n___ 09:00PM ALT(SGPT)-20 AST(SGOT)-44* ALK PHOS-76 TOT \nBILI-0.4\n___ 09:00PM GLUCOSE-100 UREA N-10 CREAT-0.6 SODIUM-142 \nPOTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15\n\nDischarge:\n\n___ 06:50AM BLOOD WBC-4.7 RBC-3.84* Hgb-12.1 Hct-36.5 \nMCV-95 MCH-31.5 MCHC-33.2 RDW-12.8 RDWSD-43.8 Plt ___\n___ 08:42AM BLOOD Glucose-208* UreaN-11 Creat-0.6 Na-144 \nK-4.1 Cl-104 HCO3-24 AnGap-16\n___ 08:53AM BLOOD ALT-21 AST-44* AlkPhos-82 TotBili-0.4\n___ 08:42AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.1\n___ 08:53AM BLOOD TSH-0.51\n___ 04:00PM BLOOD 25VitD-46\n___ 06:56AM BLOOD Cortsol-22.0*\n___ 08:53AM BLOOD CRP-47.5*\nPrealbumin 10, Zinc and copper normal\n\nMicrobiology:\n___ 2:13 am STOOL CONSISTENCY: FORMED\n\n CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. \n\n MICROSPORIDIA STAIN (Pending): \n\n Cryptosporidium/Giardia (___) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n\n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n No E. coli O157:H7 found. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\nAlpha 1 Antitrypsin, Feces \n Test Result Reference \nRange/Units\nALPHA-1-ANTITRYPSIN, FECES <25 <55 mg/dL\n \nTHIS TEST WAS PERFORMED AT:\n___, ___ \n___\nComment: Source: Stool\n \nCALPROTECTIN, STOOL \n Test Result Reference \nRange/Units\nCALPROTECTIN, STOOL <15.6 mcg/g\n \n \n \n<15.625 - 50 mcg/g Normal\n>50 - 120 mcg/g Borderline\n>120 mcg/g Abnormal\n \nCalprotectin in Crohn's disease and ulcerative colitis can\nbe five to several thousand times above the reference\npopulation (50 mcg/g or less). Levels are usually 50 mcg/g\nor less in healthy patients and with irritable bowel\nsyndrome. Repeat testing in ___ weeks is suggested for\nborderline values.\nTHIS TEST WAS PERFORMED AT:\n___, ___ ___ \n___\nComment: Source: Stool\n \nPANCREATIC ELASTASE 1, STOOL \n Test Result Reference \nRange/Units\nPANCREATIC ELASTASE-1 <15 L mcg/g\n \n \nAdult and Pediatric Reference Ranges for\n Pancreatic Elastase-1:\n \n Normal: >200 mcg/g\nModerate Pancreatic\n Insufficiency: 100-200 mcg/g\n Severe Pancreatic\n Insufficiency: <100 mcg/g\n \nElastase-1 (E-1) assay results are expressed\nin mcg/g, which represent mcg E1/g feces.\n \nIt is not necessary to interrupt enzyme\nsubstitution therapy.\nTHIS TEST WAS PERFORMED AT:\n___ ___, ___ ___ \n___\nComment: Source: Stool\n \n\n \n Test Result Reference \nRange/Units\nPOTASSIUM, FECES 15 mEq/L\n \n \nReference ranges have not been established.\nHowever, Fecal Osmotic Gap in mOsm/kg can be\ncalculated using the following equation:\nFecal Osmotic Gap = 290-2x([Na] + [K]).\nA Fecal Osmotic gap of 125 mOsm/kg or greater\nis indicative of osmotic diarrhea, whereas a\nresult of 50 mOsm/kg or less indicates a\nsecretory diarrhea.\n \nTHIS TEST WAS PERFORMED AT:\n___, ___ \n___\nComment: Source: Stool\n \n\nFECAL FAT, TOTAL, QUANTITATIVE, TIMED Results Pending \n\nGastric emptying study ___:\nFINDINGS: Residual tracer activity in the stomach is as \nfollows: \n \nAt 2 hours 39% of the ingested activity remains in the stomach \nAt 3 hours 14% of the ingested activity remains in the stomach \nAt 4 hours 1.4% of the ingested activity remains in the stomach \n \nThere is rapid emptying for the duration of the study. \n \nIMPRESSION: No evidence of abnormal gastric emptying. Of note, \nthe patient \nexperienced symptoms throughout the course of the study. \nAdditionally, the \npatient did not consume the entirety of the standardized meal \nand therefore \ncomparison to normal values should be made with caution. \n\nCT Head ___\nFINDINGS: \n \nThere is no evidence of infarction, hemorrhage, edema, or mass \neffect. The \nventricles and sulci are normal in size and configuration. \n \nPlate fixation of prior right maxillary frontal and lateral wall \nfractures are \npartially visualized. Surgical screws are also noted over the \nright zygoma. \nThe visualized portion of the paranasal sinuses, mastoid air \ncells, and middle \near cavities are clear. The visualized portion of the orbits \nare \nunremarkable. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year-old lady with history of liver \ncirrhosis ___ alcohol use and Hepatitis C s/p treatment, breast \ncancer in ___ in remission, depression, vertebral compression \nfractures presenting for worsening of chronic loss of \nappetite/nausea/vomiting/diarrhea/weight loss of unclear \netiology that has failed outpatient management. \n\nACUTE ISSUES:\n=============\n#Chronic Diarrhea\n#Nausea/Vomiting \n#Poor PO intake\n#Weight Loss\n#Failure to thrive \n#Severe protein calorie malnutrition\nPatient reported several months of diarrhea, which she said \nwould float at times. She states she has also lost over 20 \npounds since ___. Patient has also had chronic vomiting \nwhich has worsened over the last few weeks. She stated that it \nhad been occurring with liquids and solids, and it would occur \njust seconds to minutes after starting to eat. Does smoke \nmarijuana but not daily and vomiting not associated with use, \ncyclical vomiting less likely. Given her history of chronic \nalcohol use and mild epigastric tenderness, pancreatic \ndysfunction was thought to be a possibility. Her recent MRI \nliver and CT abdomen pelvis showed no signs of acute or chronic \npancreatitis, although this does not rule out exocrine \npancreatic insufficiency. Her EGD on ___ had normal biopsies \nand no structural abnormalities, but positive for H pylori. \nImaging and EGD with no abnormal masses, making \nGIST/VIPoma/Carcinoid tumor less likely. GI was consulted, \nrecommended the following studies. Stool studies showed negative \nO&P, culture. Elastase, calprotectin, and alpha-1-antitrypsin \nwere low but per GI not diagnostic of EPI given her very poor PO \nintake precding this. Stool K and Na suggested mixed \nsecretory/osmotic diarrhea, which could also be in carbohydrate \nmalabsorption. Fecal fat was pending at time of discharge. \nVitamin D was normal, although she is on supplementation for \nosteoporosis. Anti-TTG IgA was not elevated and total IgA was \nnormal, so less likely Celiac. HIV antibodies were negative. TSH \nwas normal. CT head showed no acute intracranial pathology. She \nhad a colonoscopy on ___ which showed a few benign appearing \nsessile polyps which were biopsied. She had a gastric emptying \nstudy ___ which showed no evidence of gastroperisis. Her CRP \nwas mildly elevated at 47.5, making an acute flair of IBD less \nlikely. She also denied any bloody diarrhea or focal pain in the \nLLQ. She has a history of one oral lesion, which is most likely \nrelated to her dentures. From a nutrition standpoint, her \nprealbumin was low at 10, Zinc was low (likely falsely low in \nthe setting of high CRP) and Copper was normal. Her weight on \nadmission was 114, and she says her baseline a few months ago is \n140. Her weight on the day of discharge was 116. Nutrition \nconsulted. For management of her nausea, she was given Compazine \nfor nausea control prior to meals. Reglan was added standing in \naddition and she was able to tolerate good PO intake by day of \ndischarge, with discharge weight 116. Despite her history of \ndiarrhea, patient developed constipation during admission, \npossibly contributing to her nausea and abd pain, increased \nbowel reg and had BMs by day of discharge. She still endorsed \nnausea and ___ abd pain at discharge. She was treated for H \npylori gastritis as below. She should have outpatient breath \ntesting for H pylori eradication and SIBO breath testing with GI \nfor follow up.\n\n#H. pylori gastritis\nPatient had an EGD on ___ which demonstrated gastritis and \nbiopsy evidence of H. pylori. This could contribute to her \nnausea and vomiting and abdominal pain. Based on these findings, \nshe was initially recommended bismuth quadruple therapy. \nHowever, the patient reported an adverse effect of hearing loss \nsecondary to prior tetracycline use. Additionally, she reports a \nhistory of anaphylaxis to penicillin and sulfa drug use in the \npast. She was started on a two week course of triple therapy \nwith ___ with metronidazole 500mg TID, clarithromycin 500 BID, \nand pantoprazole 40mg BID (D1 of antibiotics ___. She was also \ninstructed to avoid NSAID use to prevent worsening of her \ngastritis, and her home celecoxib for back pain was \ndiscontinued. \n\n#Tachycardia \nPt had a persistently elevated heart rate throughout her \nadmission in the 100-120's. It would decrease slightly to fluid \nbolus or valvsalva maneuvers (120 -->105). EKGs showed no signs \nof atrial arrhythmia and appeared to be sinus tachycardia. \nTelemetry showed mostly sinus tachycardia with one short \npossible asymptomatic bout of SVT. She received electrolyte \nrepletion and no further arrhythmias were seen on telemetry. She \ndid not exhibit any infectious symptoms. Per her friend ___, she \nhas had a \"fast heart for years\". Pt denies prior cardiac \ndysfunction. Says she can feel her heart race sometimes, but \ndenies any chest pain. Outside records show her HR has \nfluctuated b/w 80-110 on clinic visits. She should have a follow \nup EKG done at her next primary care appointment.\n\n#Headache\nPt had R-sided headache with photophobia and nausea on night of \n___. She described it as a ___ and denied it being the worst \nheadache of her life. Her neuro exam at that time was non-focal. \nThis was thought to be most consistent with a migraine. Her \nheadache resolved with Compazine and oxycodone. She had a head \nCT performed earlier in her admission (per above), which did not \nshow any obvious underlying causes of possible mass effect. Her \nneuro exam remained non-focal throughout her admission. She \ndenied a history of migraines, and possible triggers for this \nepisode could be her acute illness, new medication \n(metronidazole and clarithromycin although not common causes of \nmigraines). In terms of management if this recurs, she should \navoid NSAIDs due to her gastritis, and the patient states she \nhas an allergy to Tylenol, which she reports as an episode of \nacute severe pain after trying Tylenol. She can try caffeine in \nthe future and should follow up with her primary care if this \ncontinues to be an issue. \n\n#Rash\nOn ___, patient endorsed a new itchy rash. She had a 2cm \nerythematous, non raised, well circumscribed, non blanching, \nitch rash on the left nasloabial fold with very mild small \nacneiform papules on her cheeks. No signs of anaphylaxis and no \nrash seen on other areas of skin. Itchiness responded to \nBenadryl, and rash improved with topical steroids.\n\nCHRONIC ISSUES:\n===============\n#Cirrhosis, likely compensated\nPatient has a history of cirrhosis, thought to be secondary to a \ncombination of chronic alcohol use and hepatitis C. The patient \nreports discontinuing alcohol since ___ and she has been \ntreated for her HCV in ___ (HCV genotype 3, treated with DAA \n___ with good response in reducing her viral load. \nHer most recent MRI of her liver and CT abdomen/pelvis show no \nmention of ascites. Her most recent EGD on ___ was negative \nfor varices. She should continue to follow with her GI team.\n\n#Depression\n#Insomnia\n#Anxiety\nHer home Abilify, Venlafaxine, Mirtazapine, Lorazepam, and \nDiphenhydramine were continued throughout her admission.\n\n#Breast Cancer \nShe has a history of ER+/PR+/HER2- breast cancer which was \nresected in ___ and treated with hormonal risk reduction with \nanastrozole/Lupron for ___ years. This was then complicated by \nosteoporosis and compression fractures in T4, T12, and L1 seen \nin ___. Her last breast MRI was in ___ which was unremarkable. \nShe should continue to follow with her oncologists and stay up \nto date with her breast cancer screening. \n\n#Chronic back pain from vertebral compression fractures\nPatient has a history of T4, T12, and L1 vertebral compression \nfractures thought to be secondary to hormonal risk reduction \ntherapy following resection of her breast cancer. She is written \nfor oxycodone ___ q6:prn as her home dose, although the patient \nstates she usually takes it ___ while home to manage pain. \nShe continued her home gabapentin during her stay. Her celcoxib \nwas discontinued, due to concern for possible worsening of her \ngastritis. She was also given lidocaine topical patches for pain \ncontrol.\n\n#HTN\nHer home amlodipine was continued throughout admission.\n\n#Asthma\nHer home albuterol inhaler was available to her but sparingly \nused throughout her admission.\n\nTRANSITIONAL ISSUES:\n===================\nDischarge weight: 116 lbs\nDischarge QTC: 469\n\n[] F/u colonoscopy biopsies and repeat colonoscopy in ___ years \npending biopsy results\n[] f/u pending fecal fat studies\n[] Triple therapy for 2 week course through ___, then \ncontinue pantoprazole for at least 8 weeks for gastritis\n[] F/u for H pylori eradication in 3 months\n[] Consider outpatient SIBO breath testing vs empiric rifaximin, \nhas GI follow up\n[] continue to monitor ECGs at outpatient follow up given many \nQTC prolonging meds. QTC on day of discharge \n[] She should avoid NSAID use to prevent worsening of her \ngastritis, including her home celecoxib. This may require \nre-optimization of her pain control for her spinal compression \nfractures.\n[] F/u polyp histology in ___ ___ need f/u colonoscopy in \n___ years pending pathology results\n[] continue to recommend avoidance of marijuana\n[] Patient' Amphetamine-Dextroamphetamine 15 mg PO BID held for \nduration of admission and on discharge, no notable effects from \nwithholding, consider resuming as outpatient if indicated.\n[] She should have a f/u EKG to monitor her tachycardia and \nscreen for QT prolongation at her next PCP ___\n\n#CODE: FC (presumed)\n#CONTACT: Name of health care proxy: ___\nRelationship:friend\nPhone ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amphetamine-Dextroamphetamine 15 mg PO BID \n2. Mirtazapine 15 mg PO QHS \n3. LORazepam 1 mg PO BID:PRN anxiety \n4. ARIPiprazole 15 mg PO QAM \n5. Venlafaxine XR 75 mg PO DAILY \n6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate \n\n7. DiphenhydrAMINE 50 mg PO TID:PRN anxiety/insomnia \n8. amLODIPine 5 mg PO HS \n9. Celecoxib 200 mg oral BID:PRN back pain from compression \nfractures \n10. Gabapentin 600 mg PO TID \n11. Prochlorperazine 5 mg PO TID:PRN Nausea/Vomiting - First \nLine \n12. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing \n\n \nDischarge Medications:\n1. Clarithromycin 500 mg PO Q12H Duration: 2 Weeks \nRX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day Disp \n#*24 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*0 \n3. Hydrocortisone Cream 1% 1 Appl TP QID:PRN Facial rash \n4. Metoclopramide 5 mg PO TID \nRX *metoclopramide HCl 5 mg 1 tablet by mouth three times a day \nDisp #*90 Tablet Refills:*0 \n5. MetroNIDAZOLE 500 mg PO TID Duration: 2 Weeks \nRX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three \ntimes a day Disp #*36 Tablet Refills:*0 \n6. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n7. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n8. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth once \na day Refills:*2 \n9. Senna 8.6 mg PO BID:PRN Constipation - First Line \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n10. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing \n11. amLODIPine 5 mg PO HS \n12. ARIPiprazole 15 mg PO QAM \n13. DiphenhydrAMINE 50 mg PO TID:PRN anxiety/insomnia \n14. Gabapentin 600 mg PO TID \n15. LORazepam 1 mg PO BID:PRN anxiety \n16. Mirtazapine 15 mg PO QHS \n17. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n18. Prochlorperazine 5 mg PO TID:PRN Nausea/Vomiting - First \nLine \n19. Venlafaxine XR 75 mg PO DAILY \n20. HELD- Amphetamine-Dextroamphetamine 15 mg PO BID This \nmedication was held. Do not restart \nAmphetamine-Dextroamphetamine until you see your PCP\n\n \n___:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis\n=================\nFailure to thrive\nH. Pylori gastritis\nChronic diarrhea\n\nSecondary Diagnosis\n===================\natrial tachycardia\nHeadache\nchronic back pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n======================\nDISCHARGE INSTRUCTIONS\n======================\nDear Ms. ___,\nIt was a pleasure caring for you at ___ \n___.\n\nWHY WAS I IN THE HOSPITAL?\n- You came to the hospital because you had trouble eating and \nkeeping your food down.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL?\n- You were given fluids and anti-nausea medicine to help you \neat. \n- You had a colonoscopy which showed a few benign polyps (NOT \ncancerous appearing), and the confirmatory biopsy results will \nbe sent to you when they are available\n- Your gastric emptying study showed no signs of delayed gastric \nemptying.\n- You were started on two antibiotics for your H. pylori \ninfection\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n- Continue to take all your medicines and keep your \nappointments.\n- continue to take your anti-nausea meds prior to meals to help \nyou to eat more\n- please avoid all marijuana as this may contribute to your \nsymptoms\n\nWe wish you the best! \nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R627", "E43", "Z681", "A048", "K7030", "B1920", "F1011", "Z853", "K2970", "F1911", "F1290", "J45909", "E785", "M810", "I10", "Z880", "Z882", "Z888", "K529", "G4700", "R000", "H53141", "R51", "L539", "M549", "Z87311", "K5900" ]

[ "R627: Adult failure to thrive", "E43: Unspecified severe protein-calorie malnutrition", "Z681: Body mass index [BMI] 19.9 or less, adult", "A048: Other specified bacterial intestinal infections", "K7030: Alcoholic cirrhosis of liver without ascites", "B1920: Unspecified viral hepatitis C without hepatic coma", "F1011: Alcohol abuse, in remission", "Z853: Personal history of malignant neoplasm of breast", "K2970: Gastritis, unspecified, without bleeding", "F1911: Other psychoactive substance abuse, in remission", "F1290: Cannabis use, unspecified, uncomplicated", "J45909: Unspecified asthma, uncomplicated", "E785: Hyperlipidemia, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "I10: Essential (primary) hypertension", "Z880: Allergy status to penicillin", "Z882: Allergy status to sulfonamides", "Z888: Allergy status to other drugs, medicaments and biological substances", "K529: Noninfective gastroenteritis and colitis, unspecified", "G4700: Insomnia, unspecified", "R000: Tachycardia, unspecified", "H53141: Visual discomfort, right eye", "R51: Headache", "L539: Erythematous condition, unspecified", "M549: Dorsalgia, unspecified", "Z87311: Personal history of (healed) other pathological fracture", "K5900: Constipation, unspecified" ]

[ "J45909", "E785", "I10", "G4700", "K5900" ]

[]

[ " \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:\nSeizure\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThe patient is a ___\nright-handed woman with a history of complex partial seizures \nwas\nbrought to the ED by EMS due to concern for seizure at home.\n\nShe reports that her father passed away 2 weeks ago after a\nfairly lengthy illness. This is caused her a great deal of\nstress and other social difficulties. Since that time she has\nbeen having several episodes per day, which are of a new\nsemiology for her. She describes these as follows: A feeling of\nswelling and numbness of the tongue, which is accompanied by\ndifficulty forming words. She feels that she is able to think \nof\nthe words she wants to say but is unable to get her mouth to\nproduce them. She is able to understand people if they did \nspeak\nto her. She feels quite certain that the tongue\nnumbness/swelling as well as the difficulty speaking come on at\nthe same time. Episodes last between 1 and 2 minutes, after\nwhich she is completely back to normal. Her husband has\napparently seen his episodes, and there is no associated \nabnormal\neye movements, oral or facial automatism, or abnormal movement \nof\nthe limbs. She has had the episodes while seated, and has been\nable to maintain her posture; she is unsure if she is ever had\nthem while standing. These episodes have been happening between\n5 and 10 times per day for the last 2 weeks. She is unable to\nidentify any particular triggers, and feels that they come on\nrandomly.\n\nThese episodes actually started at rehab, where she has been for\nthe last several days after she tripped and fell and sustained a\nleft ankle injury at home. Other than this, there have not been\nany recent changes to her medical status. She is not certain of\nthe medicine she takes, but denies any changes in the doses or\nfrequency of her antiseizure medications. Her medications are\ncurrently administered by visiting nurse. She reports that she\nwas not sleeping very well at rehab, but denies any significant\nloss of sleep. She also denies any recent infections fevers,\netc.\n\nToday, her visiting nurse apparently noted her to have one or\nmore of these episodes, and recommended she be brought to the ED\nfor evaluation.\n\nRegarding her seizure history, she has been followed by Dr.\n___ quite some time. Seizure started in the ___. Her\ntypical semiology consists of a visual aura of flashing lights,\nfollowed by a head deviation to the right lasting a minute or \nso.\nThis is been followed by a postictal cry as well as difficulty\nspeaking for several minutes. Apparently, there also sometimes\nstrange behaviors such as starting to make a pot of coffee. She\nhas never had a generalized seizure. Prior medications include\nDilantin, which was stopped for unclear reasons. She is\ncurrently on a regimen of levetiracetam, phenobarbital, and\nlamotrigine which she reports she tolerates well. She feels \nlike\nher last seizure was around ___ years ago.\n\nOn neurologic review of systems, the patient denies headache,\nlightheadedness, or confusion. Denies loss of vision, blurred\nvision, diplopia, vertigo, tinnitus, hearing difficulty,\ndysarthria, or dysphagia. Denies focal muscle weakness, \nnumbness,\nparasthesia. Denies loss of sensation. Denies bowel or bladder\nincontinence or retention. Denies difficulty with gait.\n\nOn general review of systems, the pt denies recent fever or\nchills. No night sweats or recent weight loss or gain. Denies\ncough, shortness of breath. Denies chest pain or tightness,\npalpitations. Denies nausea, vomiting, diarrhea, constipation \nor\nabdominal pain. No recent change in bowel or bladder habits. \nNo\ndysuria. Denies arthralgias or myalgias. Denies rash.\n \nPast Medical History:\n- COPD \n- Epilepsy, complex-partial; followed by Dr. ___ seizures \ncharacterized by head turn to the right with impaired ability to \n speak but maintains awareness; this lasts for ___ minutes, \nfollowed by emotional crying, and then headache and nausea. Last \n seizure was > ___ years ago. \n- AVM, Left frontal, s/p Proton beam radiation at ___ in ___ \nand again ___ \n- PCom aneurysm s/p clipping at ___ in ___ \n- HLD \n- Lumbar disc herniation, presented with left sciatic pain but \nnone recently \n- Anemia (iron deficiency)\n- Eosinophilia\n \nSocial History:\n___\nFamily History:\nNo family history of neurologic disease. \nBoth parents had COPD. Father had colon cancer. \n\n \nPhysical Exam:\nAdmission Physical Examination:\nVitals: T: 98.2 p: 79 R: 18 BP: 137/66 SaO2: 94% room air\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: Breathing comfortably on room air\nCardiac: RRR, nl. S1S2, no M/R/G noted\nAbdomen: soft, NT/ND.\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Spells WORLD backward as DLOW. Language is\nfluent with intact repetition and comprehension. Normal prosody.\nThere were no paraphasic errors. Pt was able to name both high\nand low frequency objects. Able to follow both midline and\nappendicular commands. There was no evidence of apraxia or\nneglect.\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 finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline.\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally.\nNo adventitious movements, such as tremor, noted. No asterixis\nnoted.\n Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc \nL 5- ___ ___- 5 5 5 5 \nR 5- ___ ___- 5 5 5 5 \n-Sensory: There is a circumferential, length dependent loss of\npinprick and temperature sensation below the upper shin. No\nextinction to DSS.\n-DTRs:\n Bi Tri ___ Pat Ach\nL 1 1 1 0 0\nR 1 1 1 0 0\nPlantar response was mute bilaterally.\n-Coordination: No intention tremor, no dysdiadochokinesia noted.\nNo dysmetria on finger to nose bilaterally.\n-Gait: Not tested\n\n=================================================\nDischarge Physical Exam:\n24 HR Data (last updated ___ @ 500)\n Temp: 97.3 (Tm 98.3), BP: 166/75 (119-166/72-80), HR: 64\n(64-74), RR: 18 (___), O2 sat: 94% (94-97), O2 delivery: 2 L \n\n\nGeneral: elderly woman lying comfortably in recliner, NAD\nHEENT: NC/AT, EEG leads in place\nCardiac: warm, well-perfused\nPulmonary: no increased work of breathing\nAbdomen: soft, ND\nExtremities: wwp, CAM boot on LLE\nSkin: no rashes or lesions noted. \n\nNeurologic: \n- Mental status: Awake, alert, oriented to self, ___, date.\nAble to relate history without difficulty. Attentive to\ninterview. Speech is fluent with full sentences, intact\nrepetition, and intact verbal comprehension. Naming intact. No\nparaphasias. No dysarthria. Normal prosody. No evidence of\nhemineglect. No left-right confusion. Able to follow both \nmidline\nand appendicular commands.\n\n- Cranial Nerves: PERRL 4->2 brisk. EOMI, no nystagmus. V1-V3\nwithout deficits to light touch bilaterally. No facial movement\nasymmetry. Hearing intact to voice. Trapezius strength ___\nbilaterally. Tongue midline.\n\n- Motor: Normal bulk and tone. No drift. No tremor or \nasterixis.\n [Delt] [Bic] [Tri] [ECR] [FEx] [IP] [Quad] [Ham] [TA] [Gas]\n L 5 5 5 5 5 5 5 5 * * \n\n\n R 5 5 4- 5 5 5 5 5 3+ 5\nL wrapped in dressing in CAM boot\n\n- Sensory: No deficits to light touch bilaterally. \n\n- Reflexes: deferred \n\n- Coordination: No dysmetria with finger to nose testing\nbilaterally. \n\n- Gait: unable to assess\n \nPertinent Results:\nAdmission Labs: \n\n___ 05:59PM BLOOD WBC-9.8 RBC-3.65* Hgb-10.7* Hct-34.1 \nMCV-93 MCH-29.3 MCHC-31.4* RDW-13.9 RDWSD-47.3* Plt ___\n___ 05:59PM BLOOD Neuts-65.5 Lymphs-16.4* Monos-5.9 \nEos-11.2* Baso-0.7 Im ___ AbsNeut-6.40* AbsLymp-1.61 \nAbsMono-0.58 AbsEos-1.10* AbsBaso-0.07\n___ 06:45PM BLOOD ___ PTT-28.4 ___\n___ 05:59PM BLOOD Glucose-87 UreaN-24* Creat-1.4* Na-139 \nK-4.8 Cl-100 HCO3-24 AnGap-15\n___ 05:59PM BLOOD ALT-6 AST-7 AlkPhos-160* TotBili-0.3\n___ 05:59PM BLOOD Calcium-9.5 Phos-4.3 Mg-2.0\n\nDischarge Labs: \n\n___ 06:00AM BLOOD WBC-9.9 RBC-3.23* Hgb-9.3* Hct-30.3* \nMCV-94 MCH-28.8 MCHC-30.7* RDW-13.4 RDWSD-46.5* Plt ___\n___ 06:00AM BLOOD ___ PTT-27.9 ___\n___ 09:39AM BLOOD Glucose-90 UreaN-32* Creat-1.3* Na-142 \nK-5.4 Cl-104 HCO3-25 AnGap-13\n___ 09:39AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.1\n___ 06:05AM BLOOD calTIBC-218* Ferritn-76 TRF-168*\n___ 05:59PM BLOOD Phenoba-26.0\n\nCXR AP Lat ___: FINDINGS: \n \nNo focal consolidation is seen. There is minimal basilar \natelectasis. Left upper hemithorax scarring is noted. There is \nmild pulmonary vascular \ncongestion. No pleural effusion or pneumothorax is seen. \nCardiac silhouette as mildly enlarged. There is mild prominence \nthe main pulmonary artery, would suggest a component of \nunderlying pulmonary hypertension. \n \nIMPRESSION: \n \nMild pulmonary vascular congestion. Mild prominence of the main \npulmonary \nartery suggest component of underlying pulmonary hypertension. \n\nCTA Head Neck ___: IMPRESSION: \n \n \n1. No evidence of acute infarction or intracranial hemorrhage. \n2. Stable large left frontal AVM with arterial feeders from the \nleft MCA and venous drainage into the superior sagittal sinus. \n3. Approximately 20% stenosis by NASCET criteria of the proximal \nbilateral \ninternal carotid arteries. \n4. Mild-to-moderate multifocal atherosclerotic calcifications of \nthe head and \nneck vasculature with no evidence of occlusion. \n\nTIB/FIB (AP AND LAT) LEFT ___: \nIMPRESSION: \n \nDiffuse osteopenia is noted. There is a healing subacute spiral \nfracture \nthrough the distal tibial metadiaphysis, which demonstrates \nfibroosseous \nbridging and callus formation. There is a healed fracture \nthrough the distal fibular diaphysis. Multiple well corticated \nossific densities inferior to the medial malleolus most likely \nrepresent sequela from remote trauma. There are mild \ndegenerative changes of the medial patellofemoral compartment \nand \ntibiotalar joint. \n\nFOOT AP,LAT & OBL LEFT PORT ___: FINDINGS: \n \nDiffuse osteopenia is noted. No acute fracture or dislocation \nis seen. There are sclerotic changes along the second, third \nand fourth metatarsal necks, \nwhich most likely represent subacute/chronic fractures. Mild \ndegenerative \nchanges are seen in the hindfoot and midfoot. There is a small \nplantar \ncalcaneal spur. There is a small skin defect along the \nposterior aspect of the calcaneus. There is no adjacent \ncortical erosion, focal osteopenia or \nperiosteal reaction. \n \nIMPRESSION: \n \n1. Small skin defect along the posterior aspect of the \ncalcaneus. No \nradiographic evidence of osteomyelitis. If there is high \nclinical concern for osteomyelitis, further evaluation may be \nperformed with MRI with contrast or nuclear medicine bone scan. \n2. Sclerotic changes along the second, third and fourth \nmetatarsal necks, \nwhich most likely represent subacute/chronic fractures. \n3. Please see separate report from concurrently performed \nradiographs of the left tibia and fibula for additional \nfindings. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with a history of epilepsy, \nwas well controlled on levetiracetam/lamotrigine/phenobarbital \nwho presented with new onset of episodes of tongue \nnumbness/swelling sensation, as well as aphasia. EEG shows \nmultiple left frontal brief seizures ___ long. Patient may be \nhaving breakthrough seizures due to UTI and soft tissue \ninfections. She also has a L heel ulcer and a R groin abscess \ns/p I&D by ACS. \n\n#Epilepsy \n-cvEEG monitoring showed numerous of electrographic seizures \ndaily (>80-90). Did not improve on addition of Ativan bridge, \nvimpat, klonopin. However, there was decrease in clinical \nseizures on fycompa 6mg such that there were no further clinical \nevents x24 hours prior to discharge.\n\n- Continued home AEDs (LEV 1000mg BID, PHB 97.2mg BID, LTG 200mg \nTID)\n- vimpat 250mg BID (started ___ - ineffective - weaned off. \n- trialed ativan bridge which was not improving EEG, so it was \nstopped after 2 days\n- stopped klonopin on ___ after short, ineffective trial\n- prednisone 60 mg on ___, 40 mg on ___, 20 mg ___. Back to \nhome dose of 5 mg daily on ___. per outpatient epileptologist, \nDr. ___\n- started Fycompa at 2 mg QHS and uptitrated to 6 mg QHS. Plan \nto increase to 8mg QHS in 1 week as outpatient. \n\n#R groin abscess- with purulent drainage\n- consulted ACS; s/p I+D\n- doxycycline and Keflex on ___ to complete 10 day course\n- BID wet to dry dressing changes per ACS\n\n#Heel ulcer, R buttock ulcer\n- wound care consulted\n- podiatry consulted\n- please see wound recs\n\n#multiple L tibia/fibula fractures, subacute in ___\n- x-ray shows multiple subacute healing fractures\n- spoke with patient's outpatient ortho, Dr. ___\n- weight bearing as tolerated if CAM boot in place with walker \nper OP ortho\n- ___ consulted; recommended rehab\n\n#UTI\n- urine culture grew E. coli resistent to cipro and ampicillin. \nsensitive to cephalosporins\n- s/p ceftriaxone x1 in ED\n- macrobid stopped; covered by Keflex and doxy for ulcers\n- repeat UA negative \n\n#Gross hematuria - painless, 2 episodes\n- UA negative for blood, 1 RBC\n- recommended outpatient follow-up with Urology\n\nChronic Issues: \n#HTN\n- Lisinopril 10 mg held. BPs mostly 120s-140s. Please restart as \nappropriate. \n\n===========================================\nTransitional Issues:\n[] f/u on healing of R groin ulcers/abscesses, R buttock ulcer, \nL heel ulcer. \n[] Continue daily/BID wound dressing changes\n[] antibiotics through ___ unless continuing concern for \ninfection\n[] increase Fycompa to 8 mg QHS on ___\n[] follow-up in 1 week with ___ RN\n[] follow up with Dr. ___ surgeon) within 2 weeks \nof discharge. \n[] follow up with urology for painless hematuria within 1 month\n[] monitor blood pressure and restart home lisinopril 10 mg as \nappropriate. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. sevelamer CARBONATE 800 mg PO TID W/MEALS \n2. PredniSONE 5 mg PO DAILY \n3. Famotidine 20 mg PO DAILY \n4. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of Breath \n5. LevETIRAcetam 1000 mg PO BID \n6. LamoTRIgine 200 mg PO TID \n7. PHENObarbital 97.2 mg PO BID \n8. LORazepam 1 mg PO DAILY:PRN anxiety \n9. Ferrous Sulfate 325 mg PO BID \n10. HydrOXYzine 25 mg PO Q6H:PRN anxiety \n11. Lisinopril 10 mg PO DAILY \n12. Gabapentin 400 mg PO TID \n13. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID \n\n \nDischarge Medications:\n1. Cephalexin 500 mg PO QID \nRX *cephalexin 500 mg 1 capsule(s) by mouth four times a day \nDisp #*9 Capsule Refills:*0 \n2. Collagenase Ointment 1 Appl TP DAILY \n3. Doxycycline Hyclate 100 mg PO BID \nRX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day \nDisp #*5 Tablet Refills:*0 \n4. Fycompa (perampanel) 6 mg oral QHS \nRX *perampanel [Fycompa] 6 mg 1 tablet(s) by mouth at bedtime \nDisp #*30 Tablet Refills:*0\nRX *perampanel [Fycompa] 8 mg 1 tablet(s) by mouth at bedtime \nDisp #*30 Tablet Refills:*3 \n5. Polyethylene Glycol 17 g PO DAILY \n6. Pramipexole 0.125 mg PO QHS \n7. Sarna Lotion 1 Appl TP DAILY:PRN itching \n8. Gabapentin 100 mg PO TID:PRN pain \n9. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of Breath \n10. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID \n\n11. Famotidine 20 mg PO DAILY \n12. Ferrous Sulfate 325 mg PO BID \n13. HydrOXYzine 25 mg PO Q6H:PRN anxiety \n14. LamoTRIgine 200 mg PO TID \n15. LevETIRAcetam 1000 mg PO BID \n16. PHENObarbital 97.2 mg PO BID \n17. PredniSONE 5 mg PO DAILY \n18. sevelamer CARBONATE 800 mg PO TID W/MEALS \n19. HELD- Lisinopril 10 mg PO DAILY This medication was held. \nDo not restart Lisinopril until necessary for high blood \npressure. \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nSeizure disorder\n\nSecondary diagnoses: \nUrinary tract infection\nRight groin abscess\nLeft heel ulcer\nCOPD\nLeft tibia/fibular fractures\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 ___ due to \nnew episodes of tongue heaviness and difficulty speaking. \nYou were monitored on EEG, which showed that these episodes are \nseizures. In addition, you had dozens of subclinical seizures \neach day, which you do not notice.\n\nWe think you are having more seizures due to infections. You \nwere found to have a urinary tract infection which has been \ntreated with antibiotics. \n\nYou also had ulcers on your left heel and your right buttock. An \nabscess was found in your right groin which needed to be lanced \nand drained by the surgery team. \n\nYou were treated for 7 days with antibiotics called Keflex and \nDoxycycline. \n\nTake your medications as prescribed. \nYou were started on an additional anti-seizure medication: \nFycompa (perampanel) 6 mg at bedtime. On ___, increase to 8 \nmg at bedtime.\n\nYou are being treated on antibiotics through ___. \nKeep taking cephalexin 500 mg four times a day. Stop after ___. \n\nKeep taking doxycycline 100 mg twice a day. Stop after ___. \n\nYour Lisinopril 10 mg daily was held temporarily while in the \nhospital. Please see your PCP about whether you should restart \nit for your blood pressure. \n\nContinue all your other medications as prescribed.\n\nFollow up with your PCP ___ ___ weeks of discharge. \nYou had a couple episodes of painless blood in your urine. This \nmay be completely benign but there is a possibility that \nsometimes it is an early sign of bladder or kidney cancer. You \nshould see your PCP or ___ urologist within the next month to \nfollow up on blood in your urine.\n\nFollow up with your orthopedic surgeon (Dr. ___ in 2 weeks. \nHe suggests calling his office to make an appointment. \n\nFollow up with your neurologist within 2 months. \n\nThank you for the opportunity to care for you. \n\nSincerely, \n\nThe ___ Neurology Team\n \nFollowup Instructions:\n___\n" ]

[ "G40802", "L89623", "L02214", "N390", "L03314", "B9620", "R310", "I10", "J449", "D509", "Z87891", "L98419" ]

[ "G40802: Other epilepsy, not intractable, without status epilepticus", "L89623: Pressure ulcer of left heel, stage 3", "L02214: Cutaneous abscess of groin", "N390: Urinary tract infection, site not specified", "L03314: Cellulitis of groin", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "R310: Gross hematuria", "I10: Essential (primary) hypertension", "J449: Chronic obstructive pulmonary disease, unspecified", "D509: Iron deficiency anemia, unspecified", "Z87891: Personal history of nicotine dependence", "L98419: Non-pressure chronic ulcer of buttock with unspecified severity" ]

[ "N390", "I10", "J449", "D509", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nfloctafenine\n \nAttending: ___.\n \nChief Complaint:\nAcute pancreatitis \n \nMajor Surgical or Invasive Procedure:\n___: Laparoscopic cholecystectomy \nLaparoscopic cholecystectomy - Dr. ___ ___\n\n \nHistory of Present Illness:\nPt.is ___ y/o male with hx of hypertriglyceridemia, HTN, OSA, \nDMII, neuropathy, essential tremor, and prior diagnosis of acute \npancreatitis 3 weeks ago at ___ in ___ after experience abdominal pain, nausea/vomiting, and \nseveral episodes of loose stools ___. CT at that time was \nnotable for mild acute pancreatitis/duodenitis, a high density \nfluid collection posterior to the pancreatic tail, and a small \nnonocclusive filling defect in SMV suspicious for thrombus. \nPatient underwent IVF resuscitation and with an ___ \nhospital course and was subsequently discharged home. \n\nSince discharge pt. states he as been unable to tolerate Po \nintake eating solid food once in the past 10 days. While \ntraveling for a funeral the past couple of day his emesis, \nabdominal pain, and diarrhea have intensified culminating in\nevaluation at ___ where CT findings were again notable \nfor edema and inflammation around the pancreas, fluid collection \nin both the tail(5.7x3.1cm) and head(2.9x2.2cm) of the pancreas, \nas well fluid extending down the right abdomen.\n\nOn presentation, pt is not in acute distress, persistently \nhypotensive 80-90 systolic despite receiving 3L at the OSH \nendorsing continued abdominal pain, dry mouth, diarrhea, a \nfrustrating lack of PO intake. Pt denies nausea/vomiting today, \nchest pain, LOC, prior MI, melena, or headache. \n\n \nPast Medical History:\nPast Medical History:\n-DMII\n-HTN\n-HLD\n-Acute Pancreatitis\n-Neuropathy \n-OSA\n-Essential Tremor \n\nPast Surgical History:\n-Spinal Stimulator Placement\n-C-spine Fusion \n\n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nAdmission Physical Exam:\n\nVitals:98.5 PO 142 / 90 R Lying 92 18 98 RA \nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: hypotensive, regular rhythm \nPULM: Clear to auscultation b/l, No wheezin\nABD: Soft,obese, nondistended, mild epigastric tenderness, no\nrebound or guarding,\nnormoactive bowel sounds,\nExt: No ___ edema, ___ warm and well perfused\n\nDischarge Physical Exam:\n\nVS: 97.5 PO 141 / 83 104 20 97 RA \nGen: NAD, AxOx3\nCard: RRR, no m/r/g\nPulm: CTAB, no respiratory distress\nAbd: Soft, non-tender, non-distended, normal bs. NJT in place \nWounds: c/d/i\nExt: No edema, warm well-perfused\n \nPertinent Results:\nIMAGING:\n\n___: DUPLEX DOPP ABD/PEL PORT:\n\n1. Patent hepatic vasculature. \n2. Limited evaluation of the splenic vein and superior \nmesenteric vein. The visualized portions of the splenic and \nsuperior mesenteric veins appear patent. \n3. Diffusely echogenic liver suggestive of a degenerative cyst \nor intrinsic liver disease. \n4. Heterogeneous collections adjacent to the spleen as on the \nprior CT, likely sequela of known pancreatitis. \n5. Cholelithiasis, without evidence of acute cholecystitis. \n\n___: CTA Abdomen/Pelvis:\n1. Multiple peripancreatic collections are unchanged from recent \nprior. \n2. Nonocclusive thrombus in the splenic vein. A second order \njejunal branch of the SMV is narrowed however remains patent. \n\n___: Upper Endoscopic Ultrasound:\n-Normal mucosa in the whole esophagus \n-Normal mucosa in the whole stomach\n-Multiple shallow nonbleeding clean-based ulcers in the examined \nduodenum, expected in setting of acute pancreatitis\n-EUS: markedly edematous and distorted pancreatic parenchyma in \nsetting of acute pancreatitis. Several acute pancreatic and \nperipancreatic fluid collections identified. The CBD could not \nbe assessed due to distorted in anatomy in setting of acute \npancreatitis.\n-Nasojejunal tube placed at the end of the procedure. \n\n___: Portable Abdominal x-ray:\n \nThere is a nasojejunal tube which terminates in the expected \nregion of the \nproximal jejunum in the left hemiabdomen. There are no \nabnormally dilated \nloops of large or small bowel. There is no free intraperitoneal \nair, although evaluation is limited by supine technique. A \nspinal cord stimulator device projects over the right side of \nthe abdomen. No acute osseous abnormalities are identified. \n \n___: CT Interventional Radiology Procedure:\n1. Sample 1: 3 cc of milky fluid was aspirated from the right \nparacolic gutter collection. \n2. Sample 2: 5 cc of straw-colored, blood tinged fluid was \naspirated from the peripancreatic collection. \n \nIMPRESSION: \n \nTechnically successful CT-guided aspiration of the collections \nas described above. \n\nLABS:\n\n___ 03:14AM LACTATE-0.7\n___ 02:59AM GLUCOSE-108* UREA N-35* CREAT-1.5* \nSODIUM-132* POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-23 ANION GAP-14\n___ 02:59AM ALT(SGPT)-12 AST(SGOT)-14 LD(LDH)-150 ALK \nPHOS-50 TOT BILI-0.2\n___ 02:59AM LIPASE-150*\n___ 02:59AM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-3.1 \nMAGNESIUM-1.5*\n___ 02:59AM TRIGLYCER-412*\n___ 02:59AM WBC-15.2* RBC-3.53* HGB-10.3* HCT-31.6* \nMCV-90 MCH-29.2 MCHC-32.6 RDW-15.2 RDWSD-50.1*\n___ 02:59AM NEUTS-83* LYMPHS-15* MONOS-1* EOS-1 BASOS-0 \nAbsNeut-12.62* AbsLymp-2.28 AbsMono-0.15* AbsEos-0.15 \nAbsBaso-0.00*\n___ 02:59AM HYPOCHROM-1+* ANISOCYT-1+* MACROCYT-1+*\n___ 02:59AM PLT SMR-HIGH* PLT COUNT-587*\n___ 02:59AM ___ PTT-27.7 ___\n___ 08:50PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 08:50PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 08:50PM URINE RBC-6* WBC-1 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 08:50PM URINE HYALINE-5*\n___ 08:49PM LACTATE-1.0\n___ 08:39PM GLUCOSE-100 UREA N-39* CREAT-1.7* SODIUM-131* \nPOTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-21* ANION GAP-15\n___ 08:39PM ALT(SGPT)-12 AST(SGOT)-16 ALK PHOS-52 TOT \nBILI-0.2\n___ 08:39PM LIPASE-168*\n___ 08:39PM ALBUMIN-3.6\n___ 08:39PM WBC-17.5* RBC-3.53* HGB-10.4* HCT-31.2* \nMCV-88 MCH-29.5 MCHC-33.3 RDW-15.3 RDWSD-49.2*\n___ 08:39PM NEUTS-68 ___ MONOS-3* EOS-3 BASOS-0 \nMYELOS-1* AbsNeut-11.90* AbsLymp-4.38* AbsMono-0.53 AbsEos-0.53 \nAbsBaso-0.00*\n___ 08:39PM RBCM-WITHIN NOR\n___ 08:39PM RBCM-WITHIN NOR\n \nBrief Hospital Course:\nMr. ___ is a ___ y/o male with hx of hypertriglyceridemia, \nHTN, OSA, DMII, neuropathy, essential tremor, and recent \ndiagnosis of acute pancreatitis at ___ in \n___ after experiencing abdominal pain, \nnausea/vomiting, and several episodes of loose stools ___. \nHe was discharged from ___ and then later \npresented at ___ in ___ with \nabdominal pain and emesis. CT findings at ___ were \nagain notable\nfor edema and inflammation around the pancreas, fluid collection \nin both the tail(5.7x3.1cm) and head(2.9x2.2cm) of the pancreas, \nas well fluid extending down the right abdomen. The patient was \ntransferred to ___ in hypovolemic shock and was \nadmitted to the Acute Care Surgery service on ___. Blood \nculture from ___ grew staphylococcus coagulase negative and \nhe was started on vancomycin. Repeat blood cultures were sent \nwhich were negative and vancomycin was discontinued. \n\nThe patient was transferred to the ICU and was made NPO with IVF \nfor hydration. Gastroenterology was consulted for endoscopy. \nAbdominal ultrasound revealed gallstones and his pancreatitis \nwas thought to be due to gallstone pancreatitis. On ___, \nCTA was done to evaluate for SMV thrombus and a nonocclusive \nthrombus was seen in the splenic vein. The patient was started \non a heparin drip which was later transitioned to warfarin with \nlovenox bridging. \n\nOn ___, the patient went for upper endoscopy with \nGastroenterology which revealed multiple shallow nonbleeding \nclean-based ulcers in the examined duodenum, a markedly \nedematous and distorted pancreatic parenchyma in the setting of \nacute pancreatitis, several acute pancreatic and peripancreatic \nfluid collections. The CBD could not be assessed due to \ndistorted anatomy in the setting of acute pancreatitis. A \nnasojejunal tube was placed so that the patient could receive \ntube feedings. Tube feeds were initiated on ___ which the \npatient tolerated. Tube feeds were later changed from \ncontinuous to cycled. \n\nOn ___, the patient was taken to the operating room where he \nunderwent laparoscopic cholecystectomy. This procedure went \nwell (reader, please refer to operative note for details). \nAfter remaining hemodynamically stable in the PACU, the patient \nwas transferred to the surgical floor. Pain was managed with a \nhydromorphone PCA initially. On POD #2, the PCA was d/c'd and \noxycodone and acetaminophen were prescribed. The patient \ncontinued on tube feeds which he tolerated.\n\nGiven that the patient lives in ___, follow-up care \nappointments were arranged in his home state. Please see \ndischarge worksheet for further details. INR check ___ ___. All other INR check with primary care doctor in \n___ Dr. ___. \n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating Tube feeds, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home with ___ services \nfor tube feeds. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. atenolol-chlorthalidone 50-25 mg oral DAILY \n2. DULoxetine 60 mg PO DAILY \n3. Fenofibrate 145 mg PO DAILY \n4. Gabapentin 600 mg PO TID \n5. Lisinopril 10 mg PO DAILY \n6. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n7. Nortriptyline 25 mg PO QHS \n8. PrimiDONE 50 mg PO TID \n9. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*30 Capsule Refills:*0 \n2. Enoxaparin Sodium 90 mg SC Q12H \nRX *enoxaparin 100 mg/mL 90 mg sc every twelve (12) hours Disp \n#*30 Syringe Refills:*0 \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every four (4) \nhours Disp #*6 Tablet Refills:*0 \n4. Warfarin 5 mg PO ONCE Duration: 1 Dose \nRX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once a day \nDisp #*8 Tablet Refills:*0 \n5. atenolol-chlorthalidone 50-25 mg oral DAILY \n6. DULoxetine 60 mg PO DAILY \n7. Fenofibrate 145 mg PO DAILY \n8. Gabapentin 600 mg PO TID \n9. Lisinopril 10 mg PO DAILY \n10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n11. Nortriptyline 25 mg PO QHS \n12. PrimiDONE 50 mg PO TID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n-Non-occlusive thrombus in the splenic vein- 3 months Lovenox \nand Warfarin\n-___ fluid collections- negative gram stain on \naspiration\n-Cholelithaisis \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 ___ and \nunderwent laparoscopic cholecystectomy. During your \nhospitalization ___ also had the interventional radiology team \naspirate a sample of the ___ fluid collections seen \non the CT scan. These cultures were negative. ___ are recovering \nwell and are now ready for discharge. Please follow the \ninstructions below to continue your recovery:\n\n*****ANTICOAGULATION: ___ have a partial splenic thrombus seen \non the CT scan. ___ are on a Lovenox bridge until your INR is \ngoal ___. ___ also need to take Warfarin for 3 months. Follow up \nwith primary care doctor ___ in ___ \n. Your PCPC will monitor your anticoagulation in the office for \nINR checks .Avoid changes in diet with foods rich in Vit.K \n(broccoli, spinach, cauliflower & ___ sprouts)\n\n****Your health records were sent to Dr. ___ \n___ surgery clinic (___) )office at the \nMedical ___. ___ is Dr. \n___ assistant. The office will review your record \nthen contact ___ in the next ___ days to be assigned to Dr. \n___ another surgeon for your post operative \nappointment(s). ___ can call ___ if ___ have any \nquestions. This arrangement was coordinated on your behalf due \nto preference to follow up in ___. \n\n***VISITING NURSES***\n___ will have ___ services for 1 week in ___ for \nnutrition feeding education and supplies. This company will \nconnect ___ with ___ services in ___ if still \nneeded. \n\n******FOLLOW UPS:\n1) Primary care doctor- INR blood test goal INR (___), blood \nsugar and medication reconciliation . Please go to your primary \ncare doctor ___.\n2) ___- post operative \ncheck from laparoscopic cholecystectomy and splenic vein \nthrombus\n3) ___ ___ at 3:30pm- post operative \nand a one time INR check. Your primary care doctor will be \nfollowing all additional INR checks. Please go the ___ \nblood lab before your clinic appointment to have labs drawn. \nClinic number ___. \n\nACTIVITY:\n \no Do not drive until ___ have stopped taking pain medicine and \nfeel ___ could respond in an emergency.\no ___ may climb stairs. \no ___ may go outside, but avoid traveling long distances until \n___ see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no ___ may start some light exercise when ___ feel comfortable.\no ___ will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when ___ \ncan resume tub baths or swimming.\n \nHOW ___ MAY FEEL: \no ___ may feel weak or \"washed out\" for a couple of weeks. ___ \nmight want to nap often. Simple tasks may exhaust ___.\no ___ may have a sore throat because of a tube that was in your \nthroat during surgery.\no ___ might have trouble concentrating or difficulty sleeping. \n___ might feel somewhat depressed.\no ___ could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow ___ may shower and remove the gauzes over your \nincisions. o Your incisions may be slightly red around the \nstitches. This is normal.\no ___ may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless ___ were told \notherwise.\no ___ may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no ___ may shower. As noted above, ask your doctor when ___ may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, ___ may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. ___ can get both of these \nmedicines without a prescription.\no If ___ go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If ___ find the pain \nis getting worse instead of better, please contact your surgeon.\no ___ will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if ___ take it before your \npain gets too severe.\no Talk with your surgeon about how long ___ will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If ___ are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when ___ \ncough or when ___ are doing your deep breathing exercises.\nIf ___ experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines ___ were on before the operation just as \n___ did before, unless ___ have been told differently.\nIf ___ have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K8510", "E43", "N179", "D684", "I82890", "K8010", "E861", "K269", "I10", "G4733", "E1140", "Z7984", "F17210", "G250", "E8342", "D6959", "E781", "Z6822", "B957" ]

[ "K8510: Biliary acute pancreatitis without necrosis or infection", "E43: Unspecified severe protein-calorie malnutrition", "N179: Acute kidney failure, unspecified", "D684: Acquired coagulation factor deficiency", "I82890: Acute embolism and thrombosis of other specified veins", "K8010: Calculus of gallbladder with chronic cholecystitis without obstruction", "E861: Hypovolemia", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "Z7984: Long term (current) use of oral hypoglycemic drugs", "F17210: Nicotine dependence, cigarettes, uncomplicated", "G250: Essential tremor", "E8342: Hypomagnesemia", "D6959: Other secondary thrombocytopenia", "E781: Pure hyperglyceridemia", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "B957: Other staphylococcus as the cause of diseases classified elsewhere" ]

[ "N179", "I10", "G4733", "F17210" ]

[]

[ " \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:\nSubsternal Chest pain; ST Elevation myocardial infarction \ncomplicated by complete heart block. \n \nMajor Surgical or Invasive Procedure:\n___: Cardiac catheterization via right radial artery with \nPCI; \nPercutaneous Coronary Intervention: Percutaneous coronary \nintervention (PCI) was performed on an ad hoc basis based on the \ncoronary angiographic findings from the diagnostic portion of \nthis procedure. A 6 ___ JR4 guide provided adequate support. \nCrossed with a Choice ___ wire into the distal PDA.\nPredilated with a 2.0 mm balloon. A 3.0 mm x 15 mm DES was \ndeployed. The stent was post dilated again with a 3.5 NC \nballoon. Final angiography revealed normal flow, no dissection \nand 0% residual\nstenosis.\n \nHistory of Present Illness:\nMr. ___ is a ___ y/o M w/ HTN, GERD, treated HCV, and \npre-diabetes, presenting ___ for chest pain, found to have \nanterolateral STEMI complicated by complete heart block. \n\nPatient was in his usual state of health until ___ afternoon. \nHe states early in the afternoon he started to notice some \nabdominal pain after eating, around 17:00. He took a few tums, \nand then took a nap. After the nap, he noted no improvement in \nhis pain, and had new, substernal chest pressure. The pain did \nnot radiate, but gradually worsened, and he became more \ndiaphoretic. This\nprompted him to call EMS who transported him here. \n\nWhile in transport, he was found to have EKG findings concerning \nfor a STEMI and 3rd degree heart block, however he remained \nnormotensive, with HR ___. He was given a full dose ASA and \nfentanyl.\n\nIn the ED, \n- Initial vitals were: HR: 56 BP: 129/81 Resp: 12 O2 Sat: 100 on\nRA\n- Exam notable for: Patient appeared ill, was diaphoretic. Noted\nto be bradycardic. \n- Labs notable for: Trop <0.1 and CK-MB 4 \n- Studies notable for: EKG with complete heart block, ST\nelevation in II, III, aVF, V3-V6 \n- Patient was given: Atorvastatin, Ticagrelor loading dose, and\nstarted on Heparin ggt \n\nPatient was immediately taken to the cath lab where the culprit \nlesion was felt to be a 100% stenosis of the proximal RCA, for \nwhich a DES was placed. He was also noted to have 80% stenosis \nof the mid segment of the LAD, which was not intervened upon. \nThe procedural course was complicated by worsening bradycardia \nand hypotension, thought likely to be a vagal response given \nincreased sensitivity in the setting of his RCA lesion. \nFollowing intervention, his EKG returned to normal sinus rhythm, \nwith symptomatic and hemodynamic improvement. \n\nOn arrival to the CCU, patient reiterates story as above. His \nbiggest complaint is nausea, but notes his chest pain has \nimproved markedly. \n\n \nPast Medical History:\nCardiac History: \n- HTN \nOther PMH: \n- GERD\n- HCV treated with ribavirin and interferon in ___. Neg VL in\n___, no evidence of cirrhosis \n \nSocial History:\n___\nFamily History:\nFather who passed away from an MI in his ___. Mother with MI in\nher ___. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS: Reviewed in Metavision \nGENERAL: Fatigued appearing male in no acute distress \nHEENT: Normocephalic, atraumatic. No JVD appreciated. \nCARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or\ngallops. \nLUNGS: No increased work of breathing, clear to auscultation\nbilaterally \nABDOMEN: Soft, non-tender, non-distended.\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. TR band in place over right wrist, small\nhematoma directly proximal. Larger hematoma near antecubital\nfossa \nNEURO: CNII-XII grossly intact \n \nDISCHARGE PHYSICAL EXAMINATION:\n117/73, 58, 16, 94%ra, 97.9 \nGeneral: no acute distress, well appearing \nCardiovascular: Regular rate/rhythm, no murmur\nRespiratory: Lungs clear bilaterally, breathing non-labored\nAbdomen: Soft, Non-tender, +BS \nExtremities: BLE warm, no ___ edema \nSkin: Warm, dry and intact \nNeuro: Alert, oriented, appropriate, no focal deficits\nAccess site: Right radial access site with fading bruising, area \nis soft to palpation with intact radial pulse and distal \nsensation. \n\n \nPertinent Results:\nCARDIAC CATHETERIZATION ___:\nThe coronary circulation is right dominant.\nLM: The Left Main, arising from the left cusp, is a large \ncaliber vessel. This vessel bifurcates into the Left Anterior \nDescending and Left Circumflex systems.\nLAD: The Left Anterior Descending artery, which arises from the \nLM, is a large caliber vessel. There is an 80% stenosis in the \nmid segment.\nThe Diagonal, arising from the proximal segment, is a medium \ncaliber vessel.\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel. There is a 30% stenosis in the mid segment.\nThe ___ Obtuse Marginal, arising from the proximal segment, is a \nmedium caliber vessel.\nThe ___ Obtuse Marginal, arising from the mid segment, is a \nmedium caliber vessel.\nRCA: The Right Coronary Artery, arising from the right cusp, is \na large caliber vessel. There is a 100% stenosis in the proximal \nsegment. There is a 40% stenosis in the mid segment.\nThe Right Posterior Descending Artery, arising from the distal \nsegment, is a medium caliber vessel.\nThe Right Posterolateral Artery, arising from the distal \nsegment, is a medium caliber vessel.\n\nPercutaneous Coronary Intervention: Percutaneous coronary \nintervention (PCI) was performed on an ad hoc basis based on the \ncoronary angiographic findings from the diagnostic portion of \nthis procedure. A 6\n___ JR4 guide provided adequate support. Crossed with a \nChoice ___ wire into the distal PDA. Predilated with a 2.0 mm \nballoon. A 3.0 mm x 15 mm DES was deployed. The stent was post \ndilated again with a 3.5 NC balloon. Final angiography revealed \nnormal flow, no dissection and 0% residual\nstenosis.\n\nTRANSTHORACIC ECHOCARDIOGRAM ___: \nCONCLUSION:\nThe left atrial volume index is normal. There is normal left \nventricular wall thickness with a normal cavity size.\nThere is moderate regional left ventricular systolic dysfunction \nwith basal inferoseptal and inferior akinesis as well as basal \nto mid inferolateral hypokinesis (see schematic). Overall left \nventricular systolic function is mildly depressed. Quantitative \nbiplane left ventricular ejection fraction is 55 % (normal \n54-73%). Left ventricular cardiac index is normal (>2.5 \nL/min/m2). There is no resting left ventricular outflow tract \ngradient. There is Grade I diastolic dysfunction. Normal right \nventricular cavity size with mild global free wall hypokinesis. \nThe aortic sinus diameter is normal for gender with normal \nascending aorta diameter for gender. The aortic valve leaflets \n(3) appear structurally normal. There is no aortic valve \nstenosis. There is no aortic regurgitation. The mitral valve \nleaflets appear structurally normal with no mitral valve \nprolapse. There is trivial mitral regurgitation. The pulmonic \nvalve leaflets are normal. The tricuspid valve leaflets appear \nstructurally normal. There is mild to moderate [___] tricuspid \nregurgitation. The estimated pulmonary artery systolic pressure \nis normal. There is no pericardial effusion.\nIMPRESSION: 1) Mild global and moderate focal LV systolic \ndysfunction c/w prior myocardial infarction in RCA territory \nwith large PLV branch to supply inferolateral wall.\n\nADMISSION LABS:\n___ 07:49PM BLOOD WBC-11.1* RBC-5.04 Hgb-14.0 Hct-45.2 \nMCV-90 MCH-27.8 MCHC-31.0* RDW-13.1 RDWSD-42.5 Plt ___\n___ 07:49PM BLOOD Neuts-67.3 ___ Monos-7.3 Eos-1.4 \nBaso-0.3 Im ___ AbsNeut-7.48* AbsLymp-2.57 AbsMono-0.81* \nAbsEos-0.15 AbsBaso-0.03\n___ 07:49PM BLOOD Glucose-186* UreaN-16 Creat-1.1 Na-140 \nK-3.6 Cl-104 HCO3-20* AnGap-16\n___ 07:49PM BLOOD ALT-44* AST-50* LD(___)-208 CK(CPK)-175 \nAlkPhos-65 TotBili-0.4\n___ 07:49PM BLOOD Albumin-4.2 Calcium-8.8 Phos-3.8 Mg-1.9\n___ 07:49PM BLOOD cTropnT-<0.01\n___ 07:49PM BLOOD CK-MB-4 proBNP-69\n___ 06:20AM BLOOD %HbA1c-5.5 eAG-111\n___ 11:27PM BLOOD Triglyc-54 HDL-39* CHOL/HD-3.3 LDLcalc-80\n\nDISCHARGE LABS:\n___ 06:09AM BLOOD WBC-10.1* RBC-4.99 Hgb-13.8 Hct-43.2 \nMCV-87 MCH-27.7 MCHC-31.9* RDW-13.2 RDWSD-41.0 Plt ___\n___ 06:09AM BLOOD UreaN-16 Creat-1.2 Na-141 K-4.4 Cl-106 \nHCO3-23 AnGap-12\n___ 06:09AM BLOOD ALT-48* AST-77*\n\nLiver Function Tests\n--------------------\n___ 07:49PM BLOOD ALT-44* AST-50* LD(___)-208 CK(CPK)-175 \nAlkPhos-65 TotBili-0.4\n___ 06:20AM BLOOD ALT-74* AST-251* AlkPhos-52 TotBili-0.9\n___ 07:58AM BLOOD ALT-56* AST-124* AlkPhos-52 TotBili-1.2\n___ 06:09AM BLOOD ALT-48* AST-77*\n \nBrief Hospital Course:\n ___ s/p STEMI c/b complete heart block s/p PCI to 100% \nproximal RCA occlusion with additional findings of 80% mid LAD \ndisease. \n\n#CORONARIES: LAD 80%, LCx 30%, RCA 100% stenosis s/p ___ 1 \n#PUMP: EF 55% \n#RHYTHM: Sinus \n\n#. Inferior STEMI: Initial EKG with inferolateral STE (III>II) \nwith ST depressions in aVL and complete heart block. EKG on \ndischarge with t wave inversions and Q waves II, III and AvF and \nTWI V3-V6. Sinus rhythm rate 65 normal intervals. \n Now s/p revascularization as above. \n- Aspirin 81mg daily \n- Ticagrelor loaded, continue at 90mg BID \n- Atorvastatin 80mg daily \n- Metoprolol Succinate 25mg daily \n- Losartan home dose 50mg daily resumed on ___ \n- Needs PCI for 80% mid LAD disease, recommended to be done this\nadmission however patient strongly prefers to go home and return\nfor planned PCI at a later date ***** \n- Outpt cardiac rehab once LAD revascularized\n\n#. Complete Heart Block, resolved \nNew onset in setting of inferolateral STEMI ___ RCA occlusion.\nResolved following revascularization \n\n#. Transaminitis: Improved during recovery \n\n#. Hypertension: \n- Home Losartan resumed on ___ \n- Metoprolol added as noted \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 50 mg PO DAILY \n2. Clindamycin 1% Solution 1 Appl TP BID \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Metoprolol Succinate XL 25 mg PO DAILY \n4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n5. TiCAGRELOR 90 mg PO BID \n6. Clindamycin 1% Solution 1 Appl TP BID \n7. Losartan Potassium 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCoronary Artery Disease \nSTEMI \nHypertension \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\nVS: 117/73, 58, 16, 94%ra, 97.9 \nGeneral: Alert, no acute distress \nCardiovascular: Regular rate/rhythm, no murmur\nRespiratory: Lungs clear bilaterally, breathing non-labored\nAbdomen: Soft, Non-tender, +BS \nExtremities: BLE warm, no ___ edema \nSkin: Warm, dry and intact \nNeuro: Alert, oriented, appropriate \nAccess site: Right radial access site with surrounding bruising, \narea is soft to palpation with intact radial pulse and distal \nsensation. \n\n \nDischarge Instructions:\n You were admitted to the hospital because you had a heart \nattack. \n \n You had an urgent cardiac catheterization procedure in which a \ndrug coated stent was placed to open a blockage (100%) in your \nright coronary artery (RCA). Your heart also went into a \ndangerous rhythm, complete heart block, which resolved following \nthis procedure. \n\n It was also found that you have a blockage (80%) in your left \nanterior descending (LAD) heart artery and this needs to be \nstented to prevent you from having another heart attack. It was \nstrongly recommended that this be done now, however you have \ndecided to go home and return at a later time for this \nprocedure. Please keep your appointment with ___ \n___ bellow.\n\n A number of medications have been given to you and should be \ncontinued, these include: \n#1. Aspirin 81mg daily, you should take this for life \n#2. Ticagrelor 90mg twice a day, you should take this for a \nminimum of one year and ONLY stop when told by a cardiologist \nspecifically. Ticagrelor and Aspirin are extremely important \nmedications taken to prevent blood clots from forming in the \nstents in your heart. Stopping either of these medications too \nearly puts you at high risk for a life threatening heart attack. \n \n#3. Atorvastatin, 80mg, daily (best absorbed when taken in the \nevening), this medication not only reduces cholesterol, but has \nbeen shown to help decrease risk of heart attack in the future \nfor people who have coronary artery (heart) disease. \n#4. Metoprolol - This medication belongs to a class of \nmedications known as Beta Blockers. Beta blockers slow the \nheart down and can lower blood pressure. They help reduce the \namount of work the heart has to do, and can reduce risk of \nfuture heart attack. \n#5. Losartan 50mg daily - you were taking this at home and you \nshould continue taking it as prescribed. \n#6. Nitroglycerin - Nitroglycerin is a medication that is used \nas needed for chest pain. If you develop chest pain, place 1 \ntablet under the tongue and allow it to dissolve. If after 5 \nminutes you are still having chest pain, you can repeat this \nevery 5 minutes for UP TO 3 doses.\n\n It was a pleasure to have participated in your care. \n \n *Because we know that you have a coronary lesion (blockage) \nthat has not yet been stented, it is extremely important that \nyou return to the hospital right away (call ___ for evaluation \nif you develop recurrent symptoms. If you have other questions \nrelated to recovery from your procedure, you can call the ___ \nHeart line at ___ to page us and receive a call back \nfrom a cardiologist or cardiac nurse practitioner. \n\n \nFollowup Instructions:\n___\n" ]

[ "I2119", "I442", "I10", "K219", "I2510", "R001", "I9589", "Z87891", "R740" ]

[ "I2119: ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall", "I442: Atrioventricular block, complete", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "R001: Bradycardia, unspecified", "I9589: Other hypotension", "Z87891: Personal history of nicotine dependence", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]" ]

[ "I10", "K219", "I2510", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nshellfish derived\n \nAttending: ___\n \nChief Complaint:\ndizziness, gait unsteadiness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with history of chronic\nleft ear pulsatile tinnitus of unclear etiology and GERD who\npresents with 1 day history of dizziness and gait unsteadiness,\nfor whom neurology is consulted due to question of posterior\ncirculation etiology. History provided by patient.\n\nMs. ___ reports she was in her usual state of health until 4\n___ yesterday. At that time, she got out of her car on the way\nhome from work, and felt significant dizziness. Reports that\nthis started suddenly. She describes her dizziness as a\ncombination of feeling disequilibrium, off-balance, and with \nsome\nroom spinning sensation. She reported that when she tried to\nwalk, it felt like she \"drank 20 beers.\" She struggled walking\nback into the house, but eventually was able to do so, and\nimmediately went to lie down the couch. She right on the couch\nand rested for 1 hour, and then felt back to her baseline. Last\nnight, she spent most of the night with her father who was\nhospitalized at ___ and felt fine. During that time\nshe was able to ambulate without any symptoms.\n\nThe patient woke up this morning feeling in her usual state of\nhealth. She got to ___ at 10 AM for a tour of the\nstadium, and felt fine walking around the park. She had a\nbreakfast sandwich and 2 beers with breakfast. Shortly after \nthe\ngame started at 1 ___, she went to the bathroom. After standing\nfor a few minutes after using the restroom, while washing her\nhands, she felt the dizziness come back. Dizziness was similar\nto yesterday, described as a combination of disequilibrium, gait\nunsteadiness, with some room spinning component. It was more\nsevere than usual. She sat down and put her head in her hands,\ncovering her eyes. She felt significantly nauseous but did not\nvomit. She sat in the chair but that it did not help. There \nwas\nno difference or change positions. She tried to stand up, but\nwas swaying back and forth, not in any particular direction, and\nunable to take steps. EMS was called and she was transferred to\n___ emergency department for further\nevaluation.\n\nOn the emergency department evaluation, vitals were notable for\nelevated blood pressures with systolic blood pressures \n180s-190s.\nShortly after being in triage, she took a 20 minute nap and felt\nsome transient improvement, but by 5:30 ___, symptoms resumed.\n\nCurrently, patient reports low-grade dizziness and room spinning\nvertigo. When she sits upright or tries to walk, it becomes\nunbearable. She cannot ambulate unless she has significant\nassistance, which is far from her baseline. Her blood pressures\ncontinue to be elevated to 170s-180s.\n\nOf note, the patient has baseline, chronic left ear pulsatile\ntinnitus. She reports her left ear always feels blocked. This\nhas been worked up in the past with MRI head and MRA's, which \nshe\nreports been overall unrevealing. She believes that over the\nlast day, this left ear sensation has been somewhat more\nprominent than usual. She otherwise denies any new symptoms,\nincluding denying focal weakness, sensory changes, visual\nchanges, difficulties understanding or expressing speech.\n\nPrior to the above, the only change to her routine is that she\nhas had significant stress recently due to her father being ill\nwith pneumonia. She stayed up late last night overnight in the\nhospital caring for him. She otherwise denies any recent\nillnesses, denies fevers/chills, denies any new or missed\nmedications.\n \nOn neuro ROS, the pt reports dizziness and gait unsteadiness. \nDenies headache, loss of vision, blurred vision, diplopia,\ndysarthria, dysphagia. Denies difficulties producing or\ncomprehending speech. Denies focal weakness, numbness,\nparasthesiae. No bowel or bladder incontinence or retention. \n \nOn general review of systems, the pt reports nausea. Denies\nrecent fever or chills. No night sweats or recent weight loss \nor\ngain. Denies cough, shortness of breath. Denies chest pain or\ntightness, palpitations. Denies vomiting, diarrhea, \nconstipation\nor abdominal pain. No recent change in bowel or bladder habits. \n\nNo dysuria. Denies arthralgias or myalgias. Denies rash.\n\n \nPast Medical History:\n-Chronic pulsatile tinnitus of the left ear\n-GERD\n \nSocial History:\n___\nFamily History:\nDenies any family history of stroke or neurologic\nconditions\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=========================\nVitals: 97.3F, heart rate ___, blood pressure 178-191/94-109, RR\n18, O2 94% RA \n\nOrthostatic vital signs in ED: \nSupine HR 74, BP 181/104\nSitting HR 81, BP 178/109\nStanding HR 73, BP 180/108 \n\nGeneral: Awake, cooperative, 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: no rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive, able to name ___ backward without\ndifficulty. Language is fluent with intact repetition and\ncomprehension. Normal prosody. There were no paraphasic errors.\nPt was able to name both high and low frequency objects. Able \nto\nread without difficulty. Speech was not dysarthric. Able to\nfollow both midline and appendicular commands. 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. No skew. Head impulse test indeterminate. Normal\nsaccades. VFF to confrontation. Visual acuity ___ bilaterally. \n\nV: Facial sensation intact to light touch.\nVII: Mild left nasolabial fold flattening at rest, symmetric \nupon\nactivation. Obtained previous license photos and photos from\nphone; difficult to appreciate if this was present previously.\nSymmetric smile after hearing a joke. Symmetric forehead wrinkle\nand eyeclosure. Facial musculature symmetric.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally. No adventitious movements, such as tremor, noted. \nNo\nasterixis noted.\n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 5 ___ ___ 5 5 5 5\nR 5 ___ ___ 5 5 5 5 \n\n-Sensory: No deficits to light touch, pinprick, proprioception\nthroughout. No extinction to DSS.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 3 2+ 2+ 3 2+\nR 3 2+ 2+ 3 2+\nPectoralis jerks and crossed adductors present b/l \nPlantar response was flexor bilaterally.\n\n-Coordination: When attempting to sit up, there appears to be\ntruncal ataxia, more prominent upon standing. No intention\ntremor. Normal finger-tap bilaterally. No dysmetria on FNF or \nHKS\nbilaterally. No overshoot on cerebellar mirroring. \n\n-Gait: Stands without assistance, but sways back and forth with \na\nwide base at rest. Falls backward when attempting to do\nUnteberger testing. Requires one person assistance to ambulate.\nGait is wide-based, normal stride and arm swing. Cannot walk in\ntandem. \n\nDISCHARGE PHYSICAL EXAM\n==========================\nGeneral: no acute distress\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx, Tympanic membranes with no infection or effusion. \nNeck: Supple, No nuchal rigidity\nPulmonary: Normal work of breathing\nCardiac: RRR, warm, well-perfused\nAbdomen: soft, non-distended\nExtremities: no cyanosis, clubbing, edema.\nSkin: no rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive. Language is fluent with intact \nrepetition 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. R gaze nystagmus. No \nskew. Head impulse test indeterminate. Normal saccades. VFF to \nconfrontation.\nV: Facial sensation intact to light touch.\nVII: No nasolabial fold flattening. Smile symmetric.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally. No adventitious movements, such as tremor, noted. \nNo\nasterixis noted.\n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 5 ___ ___ 5 5 5 5\nR 5 ___ ___ 5 5 5 5 \n\n-Sensory: No deficits to light touch, pinprick, proprioception\nthroughout. No extinction to DSS.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 3 2+ 2+ 3 2+\nR 3 2+ 2+ 3 2+\nPectoralis jerks and crossed adductors present b/l \nPlantar response was flexor bilaterally.\n\n-Coordination: When attempting to sit up, there appears to be\ntruncal ataxia, more prominent upon standing. No intention\ntremor. Normal finger-tap bilaterally. No dysmetria on FNF or \nHKS\nbilaterally. No overshoot on cerebellar mirroring. \n\n-Gait: Stands without assistance, veers to left with eyes \nclosed. Requires one person assistance to ambulate.\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 05:00PM BLOOD WBC-10.6* RBC-4.45 Hgb-13.7 Hct-40.7 \nMCV-92 MCH-30.8 MCHC-33.7 RDW-12.8 RDWSD-41.7 Plt ___\n___ 05:00PM BLOOD Neuts-76.7* Lymphs-17.6* Monos-4.7* \nEos-0.3* Baso-0.4 Im ___ AbsNeut-8.11* AbsLymp-1.86 \nAbsMono-0.50 AbsEos-0.03* AbsBaso-0.04\n___ 05:00PM BLOOD Plt ___\n___ 05:00PM BLOOD Glucose-114* UreaN-10 Creat-0.6 Na-142 \nK-4.3 Cl-105 HCO3-21* AnGap-16\n___ 05:00PM BLOOD ALT-18 AST-21 AlkPhos-97 TotBili-0.3\n___ 05:00PM BLOOD Lipase-29\n___ 05:00PM BLOOD cTropnT-<0.01\n___ 05:00PM BLOOD Albumin-4.5 Cholest-243*\n___ 05:00PM BLOOD Triglyc-312* HDL-47 CHOL/HD-5.2 \nLDLcalc-134*\n___ 05:00PM BLOOD TSH-2.8\n___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\nDISCHARGE LABS\n=================\n___ 04:25AM BLOOD WBC-7.0 RBC-4.01 Hgb-12.3 Hct-37.0 MCV-92 \nMCH-30.7 MCHC-33.2 RDW-12.7 RDWSD-43.3 Plt ___\n___ 04:25AM BLOOD Neuts-40.8 ___ Monos-7.8 Eos-3.4 \nBaso-0.3 Im ___ AbsNeut-2.87 AbsLymp-3.34 AbsMono-0.55 \nAbsEos-0.24 AbsBaso-0.02\n___ 04:25AM BLOOD Plt ___\n___ 04:25AM BLOOD ___ PTT-27.3 ___\n___ 04:25AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-144 \nK-4.1 Cl-108 HCO3-25 AnGap-11\n___ 04:25AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0\n\nIMAGING\n===========\nCT HEAD W/O CONTRAST Study Date of ___ \nFINDINGS:\nThere is no evidence of acute large territorial infarction, \nhemorrhage, edema,or mass effect. The ventricles and sulci are \nnormal in size and configuration.There is no evidence of \nfracture. Minimal mucosal thickening is seen within the right \nsphenoid sinus posteriorly. The visualized portion of the \nremaining paranasal sinuses, mastoid air cells, and middle ear \ncavities are clear. The visualized portion of the orbits are \nunremarkable. \nIMPRESSION: \nNo acute intracranial abnormality.\n\nMR HEAD W/O CONTRAST Study Date of ___ \nFINDINGS:\nThere is no evidence of hemorrhage, edema, masses, mass effect, \nmidline shift or infarction. The ventricles and sulci are normal \nin caliber and \nconfiguration. Normal flow voids are demonstrated bilaterally. \nIMPRESSION:\n1. Normal brain MRI.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with history of chronic left \near pulsatile tinnitus of unclear etiology and GERD who \npresented with 1 day history of dizziness and gait unsteadiness. \nShe was ruled out for acute stroke.\n\n#Vestibulopathy of unclear etiology:\nInitially presented with intermittent dizziness, described as a \ncombination of dysequilibrium, gait unsteadiness and room \nspinning over one day. Her dizziness was positional and worse \nwith standing, she was unable to ambulate independently which is \na change from her baseline. She also developed new left ear \n\"fullness\". Initial exam notable for unremarkable HINTS exam, \nhowever did have truncal ataxia. Interval repeat examination was \nnotable for persistent gait unsteadiness (veered to left), and \nright beating nystagmus on right gaze. Tympanic membranes had no \nevidence of infection or effusion. Head CT and MRI with no \nevidence of stroke. Etiology of her symptoms is unclear, has \nmixed features. Peripheral vestibulopathy possible, lower \nsuspicion for vestibular neuritis (no preceding viral symptoms, \nnausea, or vomiting), BPPV (negative ___, Menieres \n(late age of onset). Stroke risk factors were checked: LDL 134, \nA1C 5.9. Initiated atorvastatin 40 mg daily. At the time of \ndischarge, patient felt subjectively better although still \nrequired some assistance with walking. ___ recommended discharge \nhome with ___ rehab.\n\nTRANSITIONAL ISSUES:\n=====================\n[] A1C 5.9, prediabetic range, continue to monitor and consider \nmetformin initiation\n[] LDL 134, started atorvastatin 40 mg daily\n[] noted to be hypertensive throughout admission (in ED SBP \n180s-190s, on floor 140-160s/60-70s), consider addition of \nantihypertensive\n[] please perform outpatient audiogram, consider VNG pending \naudiogram results and evolution of symptoms (Scheduled for ENT) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 40 mg PO DAILY \n2. Cetirizine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n2. Cetirizine 10 mg PO DAILY \n3. Omeprazole 40 mg PO DAILY \n4.Outpatient Physical Therapy\n___ rehab\nICD-10: H81.90 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n#Vestibulopathy of unclear etiology\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\nIt was a pleasure to care for you at the ___ \n___.\n\nYou came to the hospital because you developed dizziness, ear \nfullness, and unsteadiness when walking at home. These symptoms \nwere concerning for a stroke. We performed blood tests and \nimaging of your brain and determined that you did not have a \nstroke. We also performed examinations of your ears and found no \nabnormalities. We believe your symptoms are related to a problem \nin your inner ears, which is an area of your body that controls \nbalance. It is safe for you to return home. ENT also evaluated \nyou and recommended you follow up in their clinic on ___ \nat ___:30 AM for a hearing test. \n\nWhile in the hospital, we found that your cholesterol levels \nwere high and we started you on a medication to lower your \ncholesterol (\"atorvastatin\"). You will also have ___ \nrehab\" sessions which will help you regain and improve your \nbalance.\n\nPlease continue to take your medications as prescribed and to \n___ with your doctors as ___.\n\nWe wish you all the best,\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "H81399", "K219", "H93A2", "Z79899" ]

[ "H81399: Other peripheral vertigo, unspecified ear", "K219: Gastro-esophageal reflux disease without esophagitis", "H93A2: Pulsatile tinnitus, left ear", "Z79899: Other long term (current) drug therapy" ]

[ "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \ntree nut\n \nAttending: ___\n \nChief Complaint:\nback pain\n \nMajor Surgical or Invasive Procedure:\n___ - pamidronate\n___ - Velcade\n\n \nHistory of Present Illness:\nMr. ___ is a very pleasant ___ with history of IgG Multiple \nMyeloma diagnosed last week in the workup of non-traumatic \nT-spine fracture who presents with acute on chronic back pain \nand new foot numbness. \n\nMr. ___ recent medical history is notable for presenting to \nhis PCP ___ ___ with one month of mid back pain. At that visit \nhe reported that while he has a history of low back pain he had \nstarted to have pain in his mid back that was not getting \nbetter. On exam he was noted to have point tenderness along his \nthoracic spine with pain raditating across his rib cage. He \nreports the pain was better with rest and while supine on a hard \nsurface. Was worse with activity and worse with wearing a \nbackpack. He had a thoracic spine Xray which showed loss of \nheight of T7 vertabrae and was referred to orthopaedics. An MRI \nT spine was obtained which showed:\n \n\"1. Multiple compression fractures, the most severe at T7 \nwithout definite paraspinal or bone marrow edema to suggest \nacute fractures \n2. The visualized bone marrow signal intensity is diffusely \nabnormal with increased in STIR signal which could be related to \nhematopoietic marrow hyperplasia or an infiltrative process.\n3. Slight retropulsion of fragments at the superior aspect of T7 \nindents the spinal cord minimally. Dorsally the subarachnoid \nspace is widely patent. Rostral to this level there is a ___ \nhydromyelia likely secondary to the slight mass effect on the \nspinal cord.\"\n\nHe was then referred to Dr. ___ evaluation. He had a iliac \nbone marrow biopsy on ___ the results of which are still \npending. Blood tests showed an elevated IgG thus the presumed \ndiagnosis of multiple myeloma was made and it was recommended \nthat he start RVD + Zometa on ___. \n\nHe reports that he was doing well up until yesterday when he was \nbending down to pick something up and had acute worsening of his \npain. He reported that he also began to feel numbness over toes \nbilaterally. He had continued pain overnight and in the morning \nwas unable to get OOB tonight and was unable due to pain. He \ncalled ___ and was taken to ED. \n\nIn the ED, initial VS were: 03:32 3 98.4 92 132/78 18 99% RA \nExam notable for: Normal rectal tone, Normal perianal sensation\nLabs were notable for: normal WBC, Na of 126. \nImaging included: CT L spine with diffuse bony disease. MRI of \nC/T/L spine was obtained.\nConsults called: none, though was asked by primary team to get \nSpine consult in ED.\nTreatments received:\n___ 03:56 IV Morphine Sulfate 5 mg \n___ 03:56 IV Ondansetron 4 mg \n___ 05:31 IV Morphine Sulfate 5 mg \n___ 05:31 IV Diazepam 5 mg \nVitals prior to transfer were: Today ___ 136/72 20 99% \nRA \nToday ___ 83 109/66 18 97% Nasal Cannula \n \nOn arrival to the floor, patient stable. Lying flat in bed. Wife \nat bedside. Pain increasing as last morphine dose about 6 hrs \nprior.\n\nNo urinary incontinence or retention. No saddle anesthesia. No \nIVDA. Denies any trauma. No fevers or chills.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY \nMultiple Myeloma (Diagnosed ___, initiated RVD) \n\nPAST MEDICAL HISTORY: \nDe Quervain's tenosynovitis, right \nColon polyp \nVitamin D deficiency \nAnemia \n \n \nSocial History:\n___\nFamily History:\nFather CAD/PVD - Early; Stroke \nMaternal Grandmother ___ \nMother ___ - Unknown Type \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n\nVS: 98.4 118/70 92 18 95RA ___ \nGen: well appearing man in mild distress lying flat in bed. \nHEENT: OP clear. No scleral icterus. EOMI\nCV: RR, normal S1, S2. No m/r/g\nPulm: CTAB\nAbd: Soft, ND, NT, NAB \nGU: no foley. \nGI: Normal anal sphincter tone. \nExt: no evidence of clubbing cyanosis or edema. pulses 2+ \nradial and dp, warm well perfused\nSkin: without rashes, wounds or lesions suspicious for \nmalignancy.\nNeuro: AOx3 CN II-XII in tact\nExtremities: UE b/l normal strength and sensation\n ___ b/l strength ___ with flexion and extension of \nhip, knee, ankle, great toe. Normal sensation to light touch and \ntemperature. No level identified. \nSphincter tone normal.\nNegative Babinski. No clonus. \nReflexes 2+ b/l patellar, achillies. \nPsych: not currently depressed. good insight. \n\nAccess: #20 RUE\n\nDISCHARGE PHYSICAL EXAM: \n\nVS: 98.2 ___ 116 94%RA\n\nGen: AOx3 non-ill appearing male. Sitting upright without brace \nin no discomfort.\nHEENT: EOMI, OP clear w/MMM\nCV: normal S1, S2. No m/r/g\nPulm: Lungs CTA b/l without w/r/r\nAbd: Active BS. ND, NT.\nGU: no foley. \nExt: no edema. pulses 2+ radial and dp, warm well perfused\nSkin: without rashes, wounds or lesions suspicious for \nmalignancy or infection.\nNeuro: AOx3 CN II-XII intact\nExtremities: \nNo evidence of mm atrophy. \nROM deferred ___ pain on prior exams with motion.\nReflexes: bilateral patellar 2+ Achilles 2+\nPsych: Possible adjustment related depression. \nAccess: #20 RUE\n \nPertinent Results:\nADMISSION LABORATORY VALUES: \n\n___ 03:57AM WBC-3.4* RBC-2.57* HGB-8.2* HCT-25.0* MCV-97 \nMCH-31.9 MCHC-32.8 RDW-15.1 RDWSD-53.3*\n___ 03:57AM NEUTS-61.6 ___ MONOS-3.8* EOS-0.9* \nBASOS-0.0 IM ___ AbsNeut-2.08 AbsLymp-1.13* AbsMono-0.13* \nAbsEos-0.03* AbsBaso-0.00*\n___ 03:57AM PLT COUNT-195\n___ 03:57AM OSMOLAL-285\n___ 03:57AM GLUCOSE-74 UREA N-28* CREAT-1.0 SODIUM-128* \nPOTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-26 ANION GAP-11\n___ 03:57AM CALCIUM-8.7 PHOSPHATE-5.6* MAGNESIUM-2.0\n___ 03:57AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 03:57AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 03:57AM URINE U-PEP-NO PROTEIN OSMOLAL-343\n___ 03:57AM URINE HOURS-RANDOM UREA N-572 CREAT-46 \nSODIUM-21 POTASSIUM-27 CHLORIDE-35 TOT PROT-<6 PROT/CREA-<0.1\n\nPERTINENT IMAGING: \n\n+ SKELETAL SURVEY: Skull: ___ rounded lucency over the \nanterior parietal bone is non-specific and could represent a \nvascular channel. Otherwise, no suspicious lytic lesions \nidentified. \n \nThoracic spine: Right convex scoliosis and severe osteopenia, \nwith \ncompression of multiple upper thoracic vertebral bodies, more \ncompletely \nvisualized on ___ spine MRI. Background \ndegenerative changes \npresent. \n \nLumbar spine: No osteopenia, degenerative change common very \nmild left convex curvature. Mild endplate scalloping at L2 and \nL5. These abnormalities are better depicted on the L-spine CT \nand MRI from ___. \n \nPelvis and hips: The sacrum is considerably obscured by \noverlying bowel gas. Allowing for this, there is an equivocal \n___ rounded lucency at the lateral border of the right a \nischial tuberosity, measuring approximately 6 mm. Otherwise, no \nsuspicious focal lytic lesion is identified. Mild degenerative \nspurring of both hips is noted. \n \nRight and left femur: No obvious focal lytic lesions detected. \n \nRight and left humerus: Equivocal tiny (<4 mm) scattered \nlucencies in the \nproximal and mid humerus on both sides. Mild degenerative \nchanges noted in both shoulders. \n \nIMPRESSION: \n1. Diffuse osteopenia. \n2. No large lytic lesions identified. Equivocal ___ lucencies \nin the skull and bilateral humeri. Note is made that there was \ndiffuse marrow abnormality on the L-spine MRI from ___, raising the question of diffuse marrow infiltration. \n3. Compression fractures in the thoracic spine and vertebral \nbody endplate \nscalloping in the lumbar spine, more completely depicted on the \nrecent CT and MRI studies. \n4. Degenerative changes of the thoracic and lumbar spine noted. \nMild \ndegenerative changes of the shoulders and hips are also present. \n\n \nDISCHARGE LABORATORY VALUES: \n\n___ 07:32AM BLOOD WBC-2.3* RBC-2.78* Hgb-8.8* Hct-26.7* \nMCV-96 MCH-31.7 MCHC-33.0 RDW-16.7* RDWSD-58.5* Plt ___\n___ 07:32AM BLOOD Neuts-43.1 ___ Monos-7.8 Eos-0.9* \nBaso-0.0 Im ___ AbsNeut-0.99* AbsLymp-1.10* AbsMono-0.18* \nAbsEos-0.02* AbsBaso-0.00*\n___ 07:32AM BLOOD Plt ___\n___ 07:32AM BLOOD ALT-164* AST-85* AlkPhos-76 TotBili-0.2\n___ 07:32AM BLOOD Albumin-2.3* Calcium-6.8* Phos-2.3* \nMg-2.9*\n___ 07:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE \nHBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE\n \nBrief Hospital Course:\n ___ with history of IgG Multiple Myeloma diagnosed week prior \nto admission during the workup of non-traumatic T-spine fracture \nwho presented with acute on chronic back pain. Spinal MRI on \nadmission showed no evidence of spinal cord compression but with \nnumerous osteolytic lesions of the spine. Long bone survey with \nminimal osteolytic involvement. He was seen by Orthopaedic who \nrecommended a TLSO brace when OOB for comfort and safety. He was \nstarted on Bortezomib (Velcade) and Dexamethasone on ___ and \nreceived second dose on ___. He was given pamidronate on ___. \nDuring admission he was noted to have low neutrophil count and \nbecame neutropenic (ANC 500) and febrile without localizing \nsource. He was started on cefepime and had resolution of fevers \nand neutropenia and then was transitioned to levofloxacin for \nseven day antibiotic course for presumed pneumonia. He was \nfollowed by physical therapy and cleared to return home with \nphysical therapy and occupational therapy services at home. He \nwill be seen in clinic on ___ to receive third dose of \nbortezomib. Additionally, at time of d/c started Revlimid and \nASA 81mg (___).\n\n#Back Pain\nPatient with known diffuse spinal involvement of MM and known T7 \ncompression fracture. Acute worsening concerning for further \ncompression, however MRI C/T/L spine was reassuring for lack of \ncord impingement. Persistent uncontrolled pain localized to \nlumbar mid spine. Mr. ___ had been declining PRN pain \nmedication. Discussion with patient to help him better \nunderstand current physical state and that it is okay to need \npain medications right now. He agreed that would have a better \nquality of life if we control his pain presently.\nPatient was seen by ortho ___, MD, who \nrecommended use of TLSO brace with activity. This alleviated a \ndegree of his pain. \n\nPatient course was complicated by constipation most likely \nsecondary to both inability to get to bathroom prn as well as \npain when defecating limiting effort. In turn constipation \ncontributed to lower back pain. With PRN use of pain medication \nand support brace his pain was controlled to degree patient \nwilling to tolerate sedentary side effects of opiates. \n\n#Febrile Neutropenia: \nFirst spiked fevers ___ as high as 102.7. Subsequently \ndeveloped Neutropenia. Admission ___: 1300; Nadir ANC 510 \n(___). Unclear etiology. Initiation of Velcade and \nDexamethasone scheduled for ___ were held at this time. No \nobvious precipitating factor. Started on Cefepime for febrile \nneutropenia. \n\n Results of recent marrow tap not finalized, however per \nconversation with primary oncology team some samples showing \nrange of 40-90% plasma cell predominance. Patient w/MM puts at \nrisk for infection given functional hypogammaglobulinemia. Bone \nmarrow crowding is possible, however is now s/p two doses of \nbortezomib which usually has a more rapid marrow response. \nPossible other etiologies include viral etiology such as CMV and \nEBV as patient has concordant transaminitis. No other known \nrecent sick contacts prior to hospitalization. Did not at \npresent have any localizing symptoms. TLS not common in MM. CXR \nat time of fever w/o evidence of consolidation however cannot \nrule out pneumonia and not aspiration risk or concern for \npneumonitis. No abdominal pain or diarrhea suggestive of noro or \nc diff. Had one large formed BM yesterday to great relief. No \nrecent proceduralization. \n\n Fevers broke ___. All infectious studies and imaging to date \nof discharge negative. Given transaminitis specific viral \netiologies considered EBV, CMV. Also negative. RUQUS revealed no \nconcerning biliary or hepatic pathology. ANC at d/c: ~1000. Plan \nwas to continue empiric course of 7 days levofloxacin until \ncompletion.\n\n# Constipation\nHad sparse use of pain medications at home PTA. No use of \nopioids. Had been having intermittent BM. Since admission and \nuse of opioids has not had significant BM. Abdominal exam is \nsoft, but full. Pain has limited ability to physically make it \nto toilet initially. Since initation of brace has felt he cannot \nvalsalva well, however pain has limited effort as well. \n\nDiscussed need to continue to use opioids despite their \ncontribution to constipation as they will enable ability to \npush. Trial with polyethylene glycol did not produce BMs. \nResponded immediately with sips of ___ Mag Citrate:Ginger Ale. \n\n# Transaminitis\nNoted elevation of LFTs ___ ALT: 108 AST: 71 now ___: ALT: 362 \nAST: 356. Alk phos and TBili wnl and unchanged during this time \nperiod. INR stably 1.2. \n\n Likely ___ medication side effect from acetaminophen \nresponsible for uptrending transaminiases. Responded to d/c of \nacetominophen. No other current medications w/known \nhepatotoxicity. Bortezomib not typically associated with liver \ntoxicity. No other recent illness or localizing symptoms. \nPossible viral etiologies include: hepatidities, CMV, EBV, HIV. \nNo hx hiv, no current clinical suspicion for hiv. All other \nstudies negative to date at time of d/c. Recomment vaccination \nas above. \n\n# Multiple Myeloma: \n IgG Multiple Myeloma diagnosed last week in the workup of \nnon-traumatic T-spine fracture. Symptoms concerning for possible \nprogression of disease involving L-Spine with pathologic \nfracture sustained when bent over to clean cat litter box. \nOriginally due for initation of RVD treatment this coming ___ \n___ as outpatient but initiated on ___. \n Skeletal survey showing: \n1. Diffuse osteopenia. \n2. No large lytic lesions identified. Equivocal ___ lucencies \nin the skull and bilateral humeri. Note is made that there was \ndiffuse marrow abnormality on the L-spine MRI from ___, raising the question of diffuse marrow infiltration. \n3. Compression fractures in the thoracic spine and vertebral \nbody endplate scalloping in the lumbar spine, more completely \ndepicted on the recent CT and MRI studies. \n4. Degenerative changes of the thoracic and lumbar spine noted. \nMild \ndegenerative changes of the shoulders and hips are also present. \n\n\nPatient was intended to begin Velcade and Dexamethasone ___. \nHeld for febrile neutropenia. Fever resolved and chemo started \n___. First dose Revlimid and ASA 81mg ___.\n\n# Hyponatremia: \n Currently ASx and AOx3. Probable contribution of \npseudohyponatremia secondary to hyperproteinemia (IgG) as urine \nosmolarity is inappropriately normal and we would expect \nincreased urine osmolarity. \n\n*****TRANSITION ISSUES*****\n#CODE STATUS: FULL (CONFIRMED)\n#HCP: WIFE: ___ Spouse ___ \n1. F/up PCP, primary oncology and ortho spine as outpatient\n2. Patient at higher risk for dvt/pe; would consider outpatient \nlovenox \n3. Pain regimen\n4. Bowel Regimen\n5. Depression/Coping follow up\n6. Hepatitidies, viral negative; Recommend Revaccination with \nHep A, B \n7. F/up ANC outpt\n8. Avoid Tylenol prn pain/fevers-hx precipitating transaminitis \n9. patient discharged on levofloxacin to complete 7 day \nantibiotic course for neutropenia. Course to end ___. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 8 mg PO Q8H:PRN nausea \n2. Prochlorperazine 10 mg PO Q6H:PRN nausea \n3. Omeprazole 20 mg PO DAILY \n4. Vitamin D ___ UNIT PO 1X/WEEK (___) \n5. Dexamethasone 20 mg PO ONCE \n6. Dexamethasone 40 mg PO ONCE \n7. Acyclovir 400 mg PO Q12H \n8. Lorazepam 0.5-1 mg PO Q6H:PRN anixety, insomnia \n9. TraMADOL (Ultram) 50-100 mg PO Q8H:PRN pain \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Lorazepam 0.5-1 mg PO Q6H:PRN anixety, insomnia \n3. Omeprazole 20 mg PO DAILY \n4. Prochlorperazine 10 mg PO Q6H:PRN nausea \n5. TraMADOL (Ultram) 50-100 mg PO Q8H:PRN pain \nRX *tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*100 Tablet Refills:*0\n6. Bortezomib 2.3 mg SC Days 1, 4, 8 and 11. ___, \n___ and ___\n (1.3 mg/m2 (Weight used: Actual Weight = 65.32 kg BSA: 1.74 \nm2)) \n7. Ondansetron 8 mg PO Q8H:PRN nausea \n8. Vitamin D ___ UNIT PO 1X/WEEK (___) \n9. Equipment\nStandard Cane\nLength of Need: 13 months\nPrognosis: Good\nICD10: R26.2\n___: ___\n10. Equipment\nRolling Walker\nLength of Need: 13 months\nPrognosis: Good\nICD10: R26.2\n___: ___\n11. Docusate Sodium 100 mg PO BID \n12. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n13. Senna 8.6 mg PO BID \n14. Levofloxacin 500 mg PO DAILY Duration: 3 Doses \nRX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily \nDisp #*3 Tablet Refills:*0\n15. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN breakthrough \npain \nRX *oxycodone 5 mg ___ capsule(s) by mouth every six (6) hours \nDisp #*120 Capsule Refills:*0\n16. Aspirin 81 mg PO DAILY \n17. Lenalidomide 25 mg PO DAILY \nFor each cycle (3 weeks):\nTake one tablet daily for d1-14 and none day ___. \"2 weeks on \n1 off.\" \n18. Dexamethasone 20 mg PO ASDIR \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY: Back pain, Pathologic Fracture of T5 and T7 Vertebral \nBodies, Febrile Neutropenia\nSECONDARY: Multiple Myeloma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Please wear TLSO brace when out of bed.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure meeting you and taking care of you. You were \nadmitted with severe back pain caused by your multiple myeloma. \nWe obtained imaging that showed no compression of your spine \ncord, which was reassuring. \n\nYou were started on treatment for your multiple myeloma and you \nwe were able to find a balance of pain medication that you felt \nwas appropriate enough to decrease pain without limiting your \ndaily function further.\n\nYou were found to possibly have an infection, and will need to \nfinish your course of antibiotics.\n\nBest,\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "M8448XA", "J189", "C9000", "D801", "D709", "E559", "E871", "R5081", "G8929", "M8580", "D649", "M5135", "K5900", "T391X5A" ]

[ "M8448XA: Pathological fracture, other site, initial encounter for fracture", "J189: Pneumonia, unspecified organism", "C9000: Multiple myeloma not having achieved remission", "D801: Nonfamilial hypogammaglobulinemia", "D709: Neutropenia, unspecified", "E559: Vitamin D deficiency, unspecified", "E871: Hypo-osmolality and hyponatremia", "R5081: Fever presenting with conditions classified elsewhere", "G8929: Other chronic pain", "M8580: Other specified disorders of bone density and structure, unspecified site", "D649: Anemia, unspecified", "M5135: Other intervertebral disc degeneration, thoracolumbar region", "K5900: Constipation, unspecified", "T391X5A: Adverse effect of 4-Aminophenol derivatives, initial encounter" ]

[ "E871", "G8929", "D649", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \ntree nut / Bactrim\n \nAttending: ___.\n \nChief Complaint:\nauto transplant with melphalan prep\n \nMajor Surgical or Invasive Procedure:\nCVC placement ___\nCVC removal ___\n\n \nHistory of Present Illness:\n___ year old male with multiple myeloma and known compression \nfractures s/p 4 cycles RVD now admitted for autologous \ntransplant w/ melphalan prep\n\n \nPast Medical History:\nONCOLOGIC HISTORY: (per Atrius Records)\n- ___ ___ was seen with mid thoracic back pain of ___ weeks\nduration. This was worse with walking or carrying his backpack \nto\nwork. ___ noted dyspnea with exertion but no angina or shortness\nof breath at rest. ___ had no lower extremity weakness nor\nparethesis and no bowel or bladder dysfunction. ___ had plain\nfilms of this thoracic spine which showed dextroscoliosis\ncentered at T7. Subtle loss of height of the right side of the\nsuperior endplate of T7 of indeterminate age. Scattered endplate\ndegenerative spurs. ___ was advised to take ibuprofen\n- ___ ___ had a thoracic spine MRI. This showed multiple\ncompression fractures, the most severe at T7 without\ndefinite paraspinal or bone marrow edema to suggest acute\nfractures. The visualized bone marrow signal intensity is\ndiffusely abnormal with increased in STIR signal which could be\nrelated to hematopoietic marrow hyperplasia or an infiltrative\nprocess. Slight retropulsion of fragments at the superior aspect\nof T7 indents the spinal cord minimally. Dorsally the\nsubarachnoid space is widely patent. Rostral to this level there\nis a small hydromyelia likely secondary to the slight mass \neffect\non the spinal cord.\n- ___ ___ was seen by Dr ___ the ___ service\nand started on tramadol 50 mg every 8 hr as needed but ___ has \nnot\ntaken this medication.\n- ___ ___ had labs obtained. These showed: CBC with WBC of\n2.4, hemoglobin 8.7, hct 26.2, plts 226,000. ANC 1450. ESR 120,\nretic 1.8, Cr 1.01, Na 131, calcium 8.8, total protein 14.2, \nalb\n2.8, PTH 11, LFTs normal, ferritin 43.6 and Ig G of 9190. His \nIgA\nand IgM were both <10. Free kappa: lambda light chains were\n117.7:<1.30 for a ratio >90.54\n- ___: Bone Marrow Bx performed by Dr. ___ of ___\nand showed that the bone marrow biopsy was extensively\ninfiltrated with plasma cells which occupied about 80% of the\nmarrow seen. The aspirate showed about 50% plasma cells. Plasma\ncells were kappa restricted. Cytogenetics demonstrated an\nabnormal 53, X,-Y, +3, +4, +5, add (6) (q13), +9, add (10) \n(q25),\n+11, der (13)t(1;13)(q21;p11.2), add (13) (p11.2), +15, +19(1).\nFISH was positive for gain of chromosomes 5, 9, and 15 and extra\ncopy of 1 q. There was no evidence of rearrangement of the IgH\ngene, deletion 13 q monosomy 13, deletion of TP53 or monosomy \n16.\n- ___ and ___ ___ was given dexamethasone 20 mg a day x 2\ndays\n- ___ ___ was admitted to the ___ with increased \nin\nhis back pain. ___ had MRIs of his spine which demonstrated\nextensive involvement by myeloma as well as disc bulges but no\nevidence of epidural disease. ___ had T5/T7 compression \nfractures.\n___ was seen by Dr ___ orthopedics and was given TLSO \nbrace\nto use while awake. ___ received pamidronate 90 mg x 1 dose on\n___. ___ developed one temperature to 103 on ___ and then\nbecame neutropenic. ___ was treated empirically with cefepime \nthen\ntransitioned to levaquin once his WBC improved. ___ had negative\ncultures and no further temps. ___ had a Chest CT which showed no\npneumonia. The bones were abnormal consistent with diagnosis of\nmyeloma. \n- ___ started velcade (dose of 1.3 mg/m2 and dexamethasone 10 mg\non ___ and then received C1D5 on ___ with velcade dose\nreduced to 1.0 mg/m2 for his low WBC and dexamethasone 20 mg po.\n___ developed increased LFTs (AST and ALT) and had a liver\nultrasound which was negative as were hepatitis serologies. ___\nwas told to hold acetaminophen and his LFTs trended downward by\nthe time of discharge. \n- At the time of discharge on ___ ___ was told to start\nrevlimid (which ___ did on ___ and ASA 81 mg a day. ___ was\ngiven 2 additional days of levaquin to complete an 8 day course\nof antibiotics. ___ was given tramadol and oxycodone for pain\ncontrol but used these minimally during his final days of\nadmission. ___ was cleared by ___ to go home and not to a \nrehab\nfacility. Additional evaluation at the ___ included a negative\nUPEP and a skeletal series with possible small lytic lesions in\nhumeri and skull but no other worrisome findings outside of the\nspine. ___ was transfused one unit of PRBCs.\n- ___: Started C2 RVD\n- Developed a rash on bactrim during Cycle 2, ___ after \nabout\n3 days was switched to atovoquone\n- ___: Zometa\n- ___: Started C3 RVD\n- ___: Started C4 RVD + Zometa \n- ___: HD Cytoxan \n- ___: Started neupogen shots for collection\n- ___: at total of 17 million CD34 cells were\ncollected\n\nPAST MEDICAL HISTORY: LBP\n \nPAST SURGICAL HISTORY:\n- Tonsillectomy; eye surgery for lazy eye\n- right hand surgery\n \nSocial History:\n___\nFamily History:\nSiblings: Brother with soft tissue sarcoma on knee\nMother: No known history of cancer or blood disorders\nFather: No known history of cancer or blood disorders; still\nalive, ___ year old\nAunts: No known history of cancer or blood disorders\nUncles: No known history of cancer or blood disorders\nMaternal Grandmother: No known history of cancer or blood\ndisorders; died of unknown type\nMaternal Grandfather: No known history of cancer or blood\ndisorders; lived to ___\nPaternal Grandmother: No known history of cancer or blood\ndisorders\nPaternal Grandfather: No known history of cancer or blood\ndisorders\nChildren: No known history of cancer or blood disorders\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nECOG: 1\nVS: TC 97.9 ___ 20 97%RA; WEIGHT: 149.7LBS\nPain (___): 0\nGEN: Pleasant and cooperative, well appearing \nHEENT: PERRL, Anicteric sclerae. Oropharynx clear without \nerythema, oral ulcerative lesions, or thrush. \nNeck: Supple without thyromegaly or adenopathy. \nLymphatics: No cervical, supraclavicular, infraclavicular, or \naxillary adenopathy.\nCV: Regular rate and rhythm. Normal S1/S2. No S3/S4. No murmurs, \nrubs, or gallops. \nLungs: Non-labored. Clear to auscultation bilaterally without \nrhonchi, rales, or wheezes. \nAbdomen: Soft, nontender, nondistended, normoactive bowel sounds\nthroughout. No hepatosplenomegaly. \nSkin: Warm, dry and intact. No new rashes or lesions \nMS: No pain on palpation to spine or parasacral region.\nExtremities: No BLE edema.\n\nDISCHARGE PHYSICAL EXAM:\nECOG: 1\nVS: TC 98.5 102/64 86 18 99%RA\nI/O: ___ own)/2525 BM x 1\nPain (___): 0 \nGEN: NAD, appear anxious but well appearing \nHEENT: PERRL, Anicteric sclera. Oropharynx clear without \nerythema, oral ulcerative lesions or thrush. \nNeck: Supple without thyromegaly or adenopathy. \nLymphatics: No cervical, supraclavicular, infraclavicular, or \naxillary adenopathy.\nCV: Regular rate and rhythm. Normal S1/S2. No S3/S4. No murmurs, \nrubs, or gallops. \nLungs: Non-labored. Clear to auscultation bilaterally without \nrhonchi, rales, or wheezes. \nAbdomen: Soft, nontender, nondistended, normoactive bowel sounds \nthroughout. No hepatosplenomegaly. \nSkin: Dry. Unable to assess scrotum [patient reports pruritus, \nimproving]. ~ dime size macular rash on RLQ unchanged. No \nerythema or pain. Otherwise, no new lesions or rashes. \nMS: No pain on palpation to spine or parasacral region.\nExtremities: No upper or lower extremity edema.\nLINE: R CVC removed, 2x2 gauze and tegaderm applied on site. No \npain or discharge\n \nPertinent Results:\nADMISSION LABS:\n\n___ 12:10PM PLT COUNT-176\n___ 12:10PM NEUTS-67.9 LYMPHS-16.7* MONOS-10.4 EOS-3.6 \nBASOS-1.1* IM ___ AbsNeut-2.48 AbsLymp-0.61* AbsMono-0.38 \nAbsEos-0.13 AbsBaso-0.04\n___ 12:10PM WBC-3.7* RBC-3.72* HGB-12.0* HCT-35.5* MCV-95 \nMCH-32.3* MCHC-33.8 RDW-15.5 RDWSD-54.6*\n___ 12:10PM TOT PROT-7.6 ALBUMIN-4.1 GLOBULIN-3.5 \nCALCIUM-9.2 PHOSPHATE-4.1 MAGNESIUM-2.3 URIC ACID-4.4\n___ 12:10PM ALT(SGPT)-14 AST(SGOT)-16 LD(LDH)-131 ALK \nPHOS-47 TOT BILI-0.3\n___ 12:10PM UREA N-17 CREAT-0.8 SODIUM-139 POTASSIUM-4.1 \nCHLORIDE-101 TOTAL CO2-28 ANION GAP-14\n___ 12:10PM GLUCOSE-76\n___ 05:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 05:52PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 12:00AM PLT COUNT-174\n___ 12:00AM NEUTS-60.3 ___ MONOS-12.7 EOS-3.4 \nBASOS-1.2* IM ___ AbsNeut-2.46 AbsLymp-0.91* AbsMono-0.52 \nAbsEos-0.14 AbsBaso-0.05\n___ 12:00AM WBC-4.1 RBC-3.51* HGB-11.2* HCT-33.6* MCV-96 \nMCH-31.9 MCHC-33.3 RDW-15.6* RDWSD-54.3*\n___ 12:00AM ALBUMIN-3.8 CALCIUM-8.7 PHOSPHATE-3.5 \nMAGNESIUM-2.3\n___ 12:00AM ALT(SGPT)-12 AST(SGOT)-15 LD(LDH)-128 ALK \nPHOS-44 TOT BILI-0.3\n___ 12:00AM GLUCOSE-101* UREA N-18 CREAT-0.9 SODIUM-138 \nPOTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-29 ANION GAP-11\n\nDISCHARGE LABS:\n\n___ 12:12AM BLOOD WBC-4.2 RBC-2.98* Hgb-9.5* Hct-27.7* \nMCV-93 MCH-31.9 MCHC-34.3 RDW-13.6 RDWSD-43.7 Plt ___\n___ 12:12AM BLOOD Neuts-61 Bands-4 Lymphs-6* Monos-22* \nEos-0 Baso-1 Atyps-2* Metas-4* Myelos-0 AbsNeut-2.73 \nAbsLymp-0.34* AbsMono-0.92* AbsEos-0.00* AbsBaso-0.04\n___ 12:12AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ \nMacrocy-1+ Microcy-1+ Polychr-1+ Spheroc-OCCASIONAL Ovalocy-1+ \nSchisto-1+ Stipple-OCCASIONAL Tear Dr-OCCASIONAL\n___ 12:12AM BLOOD Plt Smr-LOW Plt ___\n___ 12:12AM BLOOD Glucose-92 UreaN-13 Creat-0.7 Na-136 \nK-3.9 Cl-99 HCO3-29 AnGap-12\n___ 12:12AM BLOOD ALT-18 AST-18 LD(LDH)-169 AlkPhos-64 \nTotBili-0.2\n___ 12:12AM BLOOD Albumin-3.5 Calcium-8.8 Phos-4.9* Mg-2.4\n\nIMAGING:\n\nCVC PLACEMENT CXR ___\n\nIMPRESSION: \n \nIn comparison with the study of ___, there has been \nplacement of a right subclavian catheter that extends to the mid \nportion of the SVC. No evidence of pneumothorax or interval \nchange. No pneumonia or vascular congestion. \n \nCXR ___\n\nIMPRESSION: \n \nRight subclavian central line unchanged in position. Lung \nvolumes remain \nslightly diminished with streaky patchy opacities in the bases \nsuggestive of atelectasis or scarring. No developing airspace \nconsolidation is seen to suggest pneumonia. No pulmonary edema. \nOld right-sided rib fracture. Stable cardiac and mediastinal \ncontours. \n \nBrief Hospital Course:\nASSESSMENT AND PLAN: ___ year old male with multiple myeloma s/p \n4 cycles RVD now\nadmitted for autologous transplant w/ melphalan prep\n\nD+16 = ___\n\n#Diarrhea: Acute onset ___ evening. No abdominal cramping or \nfever but has had low grade temps which also have improved, \nnone > 72hrs. Etiology likely due to chemotherapy (melphalan) \nbut obtained sample to r/o c-diff which was negative.\nInitiated Imodium ATC, changed to BID dosing on ___ and further \nchanged to PRN on ___ due to improvement. Stooling ___ \ntimes/daily, more formed\n\n#CVC Discomfort: Reported pain likely from line placement post \nprocedure. Resolved after several days and did not require \noxycodone for pain management\n\n#Multiple Myeloma: His presentation was notable for a history of\nworsening back pain for ~1 month, which when worked up by MRI\ndemonstrated multiple compression fractures and a BM signal\nintensity c/f myeloma. BM biopsy on ___ demonstrated\ninfiltrate with 80% plasma cells, c/w with a Dx of Stage III \n(IgG\n> 7g/dl and Advanced lytic lesions) ISS Stage III (Beta 2\n>5.5mg/dL). ___ was started on RVD by Dr. ___ on ___\nand completed 4 cycles w/o major complications. Underwent HD\ncytoxan on ___ and stem cell collection on ___ and ___,\ncollecting 17 million CD34. ___ now presents for auto transplant\nw/ melphalan prep. D0 = ___\n-Melphalan 175 mg IV Q24H on Days -3 and -2. ___ and\n___ mg/m2) \n-Cryotherapy PO 1 unit Q24H on Days -3 and -2. \n-Furosemide 20 mg IV Q24H Duration: 2 Days \n-Antiemetics/IVF protocol\n-D+4 Neupogen [started ___ -discontinued ___ with counts \nrecovery]\n-Discontinued ciprofloxacin PPX ___ w/ counts recovery\n\n#Scrotal Itching: Noted to start during count nadir, likely \nsecondary to fungal\ninfection, improved with miconazole powder. Added Benadryl cream \nand nystatin cream on ___ after exacerbated itching after \nshower. Discharged w/ miconazole, f/u outpatient \n\n#Anorexia/Nausea: Distaste for food early during transplant. \nEtiology likely secondary to chemotherapy (melphalan). Rec \nensures, patient trialing now. Drinking 2L of fluids on own \nprior to discharge. Solid intake much improved\n\n#Back Pain: Chronic, history of compression fractures at T5/T7. \nPreviously using TLSO brace which was recommended by Ortho but \nnot needing now, see Ortho note on ___. No acute \nexacerbations during hospitalization\n\n#History of Constipation: Attributed to RVD cycles and opioids \nuse (although using sparingly now). Held stool regimen on \nadmission as expect diarrhea w/\nchemotherapy initiation, see above. \n\n#Infectious Prophylaxis:\n- PCP: ___ to Bactrim, defer to outpatient provider for \nanother PCP PPX\n- HSV/VZV: Acyclovir BID\n\nProphylaxes:\n# Access: R CVC placed ___, removed ___ prior to \ndischarge\n\n# FEN: Low bacteria diet\n\n# Pain control: oxycodone prn\n\n# Contact: WIFE: ___ Spouse ___ \n\n# Disposition: Discharged ___ with follow up appointment on \n___ with Dr. ___\n\n# Code Status: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Docusate Sodium 100 mg PO DAILY \n3. LORazepam 0.5 mg PO Q6H:PRN nausea/insomnia/anxiety \n4. Ondansetron 8 mg PO Q8H:PRN nausea \n5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain \n6. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n7. Senna 8.6 mg PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \nRX *acyclovir 400 mg 1 tablet(s) by mouth Q12hrs Disp #*60 \nTablet Refills:*2\n2. LORazepam 0.5 mg PO Q6H:PRN nausea/insomnia/anxiety \nRX *lorazepam 0.5 mg 1 by mouth every 6 hours Disp #*30 Tablet \nRefills:*0\n3. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 6hrs Disp #*30 \nTablet Refills:*0\n4. Vitamin D 1000 UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half) \ntablet(s) by mouth daily Disp #*30 Tablet Refills:*1\n5. Senna 8.6 mg PO DAILY:PRN constipation \nHOLD IF YOU HAVE DIARRHEA \nRX *sennosides 8.6 mg 1 tab by mouth daily Disp #*30 Tablet \nRefills:*1\n6. Polyethylene Glycol 17 g PO DAILY:PRN constipation \nHOLD IF YOU HAVE DIARRHEA \nRX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily \nDisp #*30 Packet Refills:*1\n7. Ondansetron 8 mg PO Q8H:PRN nausea \nRX *ondansetron 8 mg 1 tablet(s) by mouth every 8 hours Disp \n#*60 Tablet Refills:*1\n8. Docusate Sodium 100 mg PO DAILY:PRN constipation \nHOLD IF YOU HAVE DIARRHEA \nRX *docusate sodium 100 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*1\n9. Miconazole 2% Cream 1 Appl TP TID \nRX *miconazole nitrate 2 % 1 application three times a day \nRefills:*0\n10. Atovaquone Suspension 1500 mg PO DAILY \n___. ___ WILL LET YOU KNOW WHEN TO START TAKING THIS \nMEDICATION AGAIN \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMultiple Myeloma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted for an autologous stem cell transplant. \n\nYou developed nausea, diarrhea and loss of appetite while you \nwere admitted. These are common side effects after transplant \nand your symptoms continue to improve.\n\nYour nausea medications are as follows:\n1 zofran\n2 ativan\n\nYou will continue to take acyclovir to prevent infection. Your \noutpatient provider ___ let you know when to restart your \natovaquone. \n\nPlease take your temperature twice a day, and call us if it goes \nabove 100.4. Please be sure to drink at least 2L (64oz) of \nfluid daily. Call if you are unable to do so, or if you have \nworsening nausea or watery stools.\n\nIt has been a pleasure taking care of you. \n \nFollowup Instructions:\n___\n" ]

[ "C9000", "K521", "D709", "D696", "B356", "R630", "R110", "G8929", "M545", "T451X5A", "Z006", "Z6825", "Y92230" ]

[ "C9000: Multiple myeloma not having achieved remission", "K521: Toxic gastroenteritis and colitis", "D709: Neutropenia, unspecified", "D696: Thrombocytopenia, unspecified", "B356: Tinea cruris", "R630: Anorexia", "R110: Nausea", "G8929: Other chronic pain", "M545: Low back pain", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "D696", "G8929", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \ntree nut / Bactrim\n \nAttending: ___\n \nChief Complaint:\nadmit for HD Cytoxan prior to stem cell\nmobilization\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old male with MM s/p 4 cycles RVD now admitted for\nCytoxan stem cell mobilization. Bone marrow biopsy ___ showed 4%\nof aspirate plasma cells, significant reduction compared to \nprior\n(was 48% of aspirate).\n\nStates ___ previously had leg swelling on dex but none currently,\notherwise no headaches, cough, sore throat, fevers, rash, abd\npain, diarrhea, chest pain/SOB, constipation, BRBPR, melena. All\nother 10 point ROS neg.\n\nREVIEW OF SYSTEMS:\nGENERAL: No fever, chills, night sweats, recent weight changes.\nHEENT: No sores in the mouth, painful swallowing, intolerance to\nliquids or solids, sinus tenderness, rhinorrhea, or congestion.\nCARDS: No chest pain, chest pressure, exertional symptoms, or\npalpitations.\nPULM: No cough, shortness of breath, hemoptysis, or wheezing.\nGI: No nausea, vomiting, diarrhea, constipation or abdominal\npain. No recent change in bowel habits, hematochezia, or melena.\nGU: No dysuria or change in bladder habits.\nMSK: No arthritis, arthralgias, myalgias, or bone pain.\nDERM: Denies rashes, itching, or skin breakdown.\nNEURO: No headache, visual changes, numbness/tingling,\nparesthesias, or focal neurologic symptoms.\nPSYCH: No feelings of depression or anxiety. All other review of\nsystems negative.\n\n \nPast Medical History:\nONC HISTORY:\nRegarding his myeloma:\nHis presentation\nis notable for a history of worsening back pain for ~1 month,\nwhich when worked up by MRI demonstrated multiple compression\nfractures and a BM signal intensity c/f myeloma. W/u revealed\nleukopenia (WBC 2.4), Anemia (Hgb 8.7), Cr 1.01, Ca 8.8, Alb \n2.8,\nIgG of 9190, M spike with 7.2g/dL, IgA and IgM <10 with Kappa:\nLambda ratio of >90.5, B2 Microglobulin of 6.38 BMBx on ___\ndemonstrated infiltrate with 80% plasma cells, c/w with a Dx of\nStage III (IgG > 7g/dl and Advanced lytic lesions) ISS Stage III\n(Beta 2 >5.5mg/dL). ___ was started on RVD by Dr. ___ on\n___. ___ has tolerated it fairly well and has completed 4 \ncycles.\n\nPAST MEDICAL HISTORY:\nlower back pain\n\nPAST SURGICAL HISTORY:\n- Tonsillectomy; eye surgery for lazy eye\n- right hand surgery\n\n \nSocial History:\n___\nFamily History:\nSiblings: Brother with soft tissue sarcoma on knee\nMother: No known history of cancer or blood disorders\nFather: No known history of cancer or blood disorders; still\nalive, ___ year old\nAunts: No known history of cancer or blood disorders\nUncles: No known history of cancer or blood disorders\nMaternal Grandmother: No known history of cancer or blood\ndisorders; died of unknown type\nMaternal Grandfather: No known history of cancer or blood\ndisorders; lived to ___\nPaternal Grandmother: No known history of cancer or blood\ndisorders\nPaternal Grandfather: No known history of cancer or blood\ndisorders\nChildren: No known history of cancer or blood disorders\n\n \nPhysical Exam:\nVITAL SIGNS: 98.4 102/60 80 18 95% RA\nGeneral: NAD\nHEENT: MMM, no OP lesions\nCV: RR, NL S1S2 no S3S4 MRG\nPULM: CTAB\nGI: BS+, soft, NTND, no masses or hepatosplenomegaly\nLIMBS: No edema, clubbing, tremors\nSKIN: No rashes or skin breakdown\nNEURO: Oriented x3. Non-focal\n \nPertinent Results:\n___ 08:33AM BLOOD WBC-5.2 RBC-3.96* Hgb-12.5* Hct-37.1* \nMCV-94 MCH-31.6 MCHC-33.7 RDW-14.0 RDWSD-48.8* Plt ___\n\n___ 04:40PM BLOOD Na-141\n___ 09:00PM BLOOD Na-129*\n___ 05:30PM BLOOD Na-126*\n___ 11:01AM BLOOD Na-127*\n\n___ 07:38AM BLOOD Glucose-120* UreaN-17 Creat-0.6 Na-129* \nK-3.7 \n___ 01:00PM BLOOD Glucose-101* UreaN-22* Creat-0.8 Na-138 \nK-3.8 \n\n___ 06:24AM BLOOD Glucose-76 UreaN-16 Creat-0.7 Na-138 \nK-4.1 Cl-103 HCO3-29 AnGap-___ w/ MM s/p 4 cycles RVD admitted for Cytoxan stem cell \nmobilization c/b mod-severe hyponatremia. \n\n# Hyponatremia \nNa dropped from 138 to 127 within 24 hrs with associated HA but \nno MS changes. ___ was seen by nephrology. Considering the \nelevated UNa and Osms, along with clinical history of Cytoxan \ninduced nausea and ongoing aggressive IVF\nadministration, it was thought that this was ADH induced \nhyponatremia from Cytoxan related nausea. ___ was placed on 1L PO \nfluid restriction and salt tabs and Na improved to back to 141 \nwithin 24 hrs. His symptoms improved and ___ was monitored \novernight without PO restrictions and NaCL tabs and his Na \nremained normal on 138. ___ will need to have his sodium \nmonitored carefully if ___ will receive Cytoxan again. \n\n# MM \nCompleted RVD, Bm BX ___ with 4% plasma cells in aspirate and \n___ in marrow, significant reduction from 48%. ___ was admitted \nfor Cytoxan mobilization and completed it with the complication \nof hyponatremia and nausea. \n\n- ___ started cipro and zarxio, has scripts and zarxio at home\n- SC collection in 10 days\n- c/w zometa as outpatient\n- plan for upcoming auto transplant per ___\n- monitor for nausea with chemo, anti-emetics prn\n- ppx: cont acyclovir, pt taking BID ___ reports\n\n# Lower back pain\n# H/o compression fractures at T5/T7 - chronic \n- cont prn oxy/tramadol\n\n____________________\n___, D.O.\nHeme/___ Hospitalist\n___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. LORazepam 0.5 mg PO Q8H:PRN nausea/insomnia/anxiety \n3. Ondansetron 8 mg PO Q8H:PRN nausea \n4. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n5. Vitamin D 1000 UNIT PO DAILY \n6. Senna 8.6 mg PO DAILY \n7. Docusate Sodium 100 mg PO DAILY \n8. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Docusate Sodium 100 mg PO DAILY \n3. Ciprofloxacin HCl 500 mg PO Q12H \nstart ___, for 10 days \n4. LORazepam 0.5 mg PO Q8H:PRN nausea/insomnia/anxiety \n5. Ondansetron 8 mg PO Q8H:PRN nausea \n6. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n7. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n8. Senna 8.6 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Filgrastim 300 mcg SC Q24H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMultiple Myeloma\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted for high dose Cytoxan for stem cell \nmobilization. \n\nPlease follow the instructions given to you by your nurse \n___. In brief this includes taking \nciprofloxacin (antibiotic) and neupogen injections until you are \ntold to stop.\n\nYou also had low sodium levels. This was most likely due to a \nside effect from the chemotherapy and nausea. You improved with \ntime, salt tablets, and fluid restriction. You do not have to be \non any further restrictions. \n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C9000", "E871", "M8458XA", "Z808", "R112", "T451X5A", "Y92230" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C9000: Multiple myeloma not having achieved remission", "E871: Hypo-osmolality and hyponatremia", "M8458XA: Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture", "Z808: Family history of malignant neoplasm of other organs or systems", "R112: Nausea with vomiting, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "E871", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nStatus post left thyroid lobectomy with follicular thyroid \ncarcinoma.\n\n \nMajor Surgical or Invasive Procedure:\nCompletion right thyroidectomy.\n\n \nHistory of Present Illness:\nThis elderly patient has undergone resection of a very large \nleft substernal goiter last year and the pathology showed widely \ninvasive follicular carcinoma, and completion was recommended.\n\n \nPast Medical History:\nPMH:- Toxic multinodular goiter causing tracheal stenosis and \ndeviation,Mild mitral regurg, moderate pulm HTN,HLD,DM2\n,Paroxysmal afib on lovenox, DVT L arm ___ now on lovenox, \npulm embolism in ___ s/p lower extremity bypass \ngraft, COPD,Gout,Prior stroke, possibly with neurogenic bladder \nnow s/p suprapubic catheter,ongoing tobacco use as of ___\n\n \nSocial History:\n___\nFamily History:\nMother, aunt, and uncle all had CHF, unknown cause; no known hx \nof CAD in her family. Daughter with heart arrhythmia \n \nPhysical Exam:\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nNeck incision w/ staples c/d/I, no erythema/ecchymosis or \ndrainage\nCV: RRR, No M/G/R\nPULM: clear to auscultation b/l, No W/R/R\nABD: soft, nondistended, nontender, no rebound or guarding\nGU: suprapubic catheter w/clear yellow urine \nExt: No ___ edema, ___ warm and well perfused\n\n \nPertinent Results:\n___ 06:50AM BLOOD WBC-10.1* RBC-4.46 Hgb-11.2 Hct-36.8 \nMCV-83 MCH-25.1* MCHC-30.4* RDW-15.0 RDWSD-45.5 Plt ___\n___ 06:50AM BLOOD Glucose-93 UreaN-20 Creat-0.8 Na-140 \nK-4.2 Cl-101 HCO3-27 AnGap-16\n___ 06:50AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.8\n \nBrief Hospital Course:\nMs. ___ is a ___ F with hx of multinodular goiter and \nfollicular thyroid carcinoma s/p prior left thyroid lobectomy \nand resection of medial aspect of right lobe now s/p complete \nright thyroidectomy. Surgery was uncomplicated; reader is \nreferred to operative report for details of surgery. She was \nadmitted overnight for observation.\n\nFollowing admission her calcium level was monitored and was \nfound to be appropriate. Postoperatively she had adequate urine \noutput via her suprapubic catheter. Her diet was advanced and \nwell tolerated. She ambulated and was able to achieve adequate \npain control on oral medications. Her surgical site remained \nc/d/I and without evidence of hematoma or drainage. Once she met \nthe appropriate criteria she was discharged home on POD1 with \nscheduled follow up with Dr. ___ postoperative care. \nAdditionally, thyroid hormone replacement, calcium and vitamin D \nsupplementation were added to her medication regimen, as well as \npain medication. \nIn regards to her anticoagulation for h/o Afib/DVT, which was \nheld ___ patient has been instructed to restart \nLovenox on ___. She was discharged home on POD 1, with \ndetailed follow-up instructions and verbalized good \nunderstanding.\n \nMedications on Admission:\nMedications:\n- Amlodipine 5 mg PO DAILY \n- Atorvastatin 40 mg PO QPM \n- Lisinopril 15 mg PO DAILY \n- Aspirin 81 mg PO DAILY \n- Enoxaparin Sodium 80 mg SC QD \n- HCTZ 12.5mg daily\n- Methimazole 1.25mg daily\n- Metoprolol XR 25 qdaily\n- Ferrous sulfate 325 daily\n- MVI daily\n- Calcium 500 + D 500 mg (1,250 mg)-200 unit tablet\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO TID \n2. Calcitriol 0.25 mcg PO DAILY \nRX *calcitriol 0.25 mcg 1 capsule(s) by mouth once a day Disp \n#*10 Capsule Refills:*0 \n3. Levothyroxine Sodium 112 mcg PO DAILY \nRX *levothyroxine 112 mcg 1 tablet(s) by mouth once a day Disp \n#*30 Tablet Refills:*3 \n4. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -200 unit oral QID \n5. amLODIPine 5 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 40 mg PO QPM \n8. Docusate Sodium 100 mg PO BID \n9. Enoxaparin Sodium 80 mg SC DAILY \nStart: Tomorrow - ___, First Dose: First Routine \nAdministration Time \n10. Ferrous Sulfate 325 mg PO DAILY \n11. Hydrochlorothiazide 12.5 mg PO DAILY \n12. Lisinopril 15 mg PO DAILY \n13. Metoprolol Succinate XL 25 mg PO DAILY \n14. Multivitamins 1 TAB PO DAILY \n15. Senna 17.2 mg PO HS \n16. Vitamin D 200 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nStatus post left thyroid lobectomy with follicular thyroid \ncarcinoma.\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 being involved in your care at ___.\n \nYou were admitted to the inpatient general surgery unit after \nyour completion thyroidectomy. You have adequate pain control \nand have tolerated a regular diet and may return home to \ncontinue your recovery. \nYou will be discharged home on thyroid hormone replacement, \ncalcium and vitamin D supplement, please take as prescribed. For \nyour calcium supplement please purchase Oscal(chewable tablets \nare acceptable) over the counter at the pharmacy and take 1 \ntablet FOUR times a day. Please go to any ___ lab \non ___ Before 12:00 pm, and have your calcium level \ndrawn. If there is a need to change your calcium dosage your \nendocrinologist will give you further instructions. \nPlease monitor for signs and symptoms of low Calcium such as \nnumbness or tingling around mouth/fingertips or muscle cramps in \nyour legs. If you experience any of these signs or symptoms \nplease call Dr. ___ for advice or if you have \nsevere symptoms go to the emergency room. \nPlease restart your LOVENOX on THURS ___ as prescribed. You \nmay restart all regular home medications, and take any new \nmedications as prescribed. You will be given a prescription for \nnarcotic pain medication, take as prescribed. You may take \nacetaminophen (Tylenol) as directed, but do not exceed 3000 mg \nin one day. Please get plenty of rest, continue to walk several \ntimes per day, and drink adequate amounts of fluids. \nPlease call your surgeon or go to the emergency department if \nyou have increased pain, swelling, redness, or drainage from the \nincision site. You may shower and wash incisions with a mild \nsoap and warm water. Avoid swimming and baths until cleared by \nyour surgeon. Gently pat the area dry. Your neck incision has \nbeen closed with staples, please call the office and schedule an \nappointment for staples to be removed by ___.\nThank you for allowing us to participate in your care.\n\nYour ___ care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "C73", "N319", "I480", "Z7902", "I340", "I272", "I10", "E785", "E119", "J449", "F17210", "I739", "Z95820", "Z8673", "Z86718", "Z86711" ]

[ "C73: Malignant neoplasm of thyroid gland", "N319: Neuromuscular dysfunction of bladder, unspecified", "I480: Paroxysmal atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I340: Nonrheumatic mitral (valve) insufficiency", "I272: Other secondary pulmonary hypertension", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "J449: Chronic obstructive pulmonary disease, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I739: Peripheral vascular disease, unspecified", "Z95820: Peripheral vascular angioplasty status with implants and grafts", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z86718: Personal history of other venous thrombosis and embolism", "Z86711: Personal history of pulmonary embolism" ]

[ "I480", "Z7902", "I10", "E785", "E119", "J449", "F17210", "Z8673", "Z86718" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nToxic large substernal multinodular goiter.\n\n \nMajor Surgical or Invasive Procedure:\nResection of left substernal goiter and resection of medial \naspect right lobe.\n\n \nHistory of Present Illness:\nThis is a ___ year old woman who lady presented with a \nchronically toxic multinodular goiter that was however,enlarging \ncausing tracheal deviation and stenosis. FNA of a nodule on the \nleft side, also was suspicious for papillary\ncancer. Consequently, we arranged to do a total thyroidectomy \nbut the possibility of a staged operation had been raised \npreoperatively.\n\n \nPast Medical History:\nToxic multinodular goiter causing tracheal stenosis and \ndeviation,Mild mitral regurg, moderate pulm HTN,HLD, DM2, \nParoxysmal afib on lovenox, DVT L arm ___ now on lovenox, \npulm embolism in ___, HTN, PAD s/p lower extremity bypass \ngraft, COPD, Gout,Prior stroke, possibly with neurogenic bladder \nnow s/p suprapubic catheter,ongoing tobacco use as of ___\n\nPSH: Cataracts,Fem-pop BPG,Hysterectomy,Suprapubic urinary \ncatheter ___\n\n \nSocial History:\n___\nFamily History:\nMother, aunt, and uncle all had CHF, unknown cause; no known hx \nof CAD in her family. Daughter with heart arrhythmia on \namiodarone \n \nPhysical Exam:\nGeneral: AA&O, pleasant,no distress\nCardiac: irreg irreg rate and rhythm, normal S1 S2\nPulm:clear, no stridor\nAbd:soft, NT/ND\nINC:neck soft, incision c/d/I, no erythema/drainage\nEXT:warm well perfused, no ___ edema\n \nBrief Hospital Course:\n___ with massive multinodular goiter with FNA suspicious for \npapillary thyroid cancer. She presented to ___ on ___ and \nunderwent left thyroid lobectomy. Initially postoperatively, she \nwas hypertensive and received IV Labetalol and responded \nappropriately. She was transferred to the surgical ward \novernight for observation.\nPostoperatively she was able to tolerate regular diet, ambulate, \nand achieve adequate pain control on oral medications. Her \nsurgical site remained c/d/I and without evidence of hematoma or \ndrainage. Once she met the appropriate criteria she was \ndischarged home on POD1 with scheduled follow up with Dr. \n___ postoperative care. She was given instructions \non wound care as well as symptoms of complications to look out \nfor, of which she expressed understanding.\n \nMedications on Admission:\n- Amlodipine 5' QAM\n- Atorvastatin 40' QHS\n- Lovenox 80mg SQ QAM\n- Lisinopril 30' QHS\n- Methimazole 2.5' QAM\n- ASA 81'\n- Calcium + vitD QD\n- Iron 325'\n- MVI\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Amlodipine 5 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Lisinopril 30 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \nplease restart your aspirin 48 hours after surgery on ___. \n6. Enoxaparin Sodium 80 mg SC QD \nStart: Tomorrow - ___, First Dose: First Routine \nAdministration Time \nPlease restart your Lovenox 48 hours after your surgery. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nToxic multinodular goiter\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. ___,\nYou were admitted to the inpatient general surgery unit after \nyour left thyroid lobectomy. You have adequate pain control and \nhave tolerated a regular diet and may return home to continue \nyour recovery. \nMonitor for signs and symptoms of low Calcium such as numbness \nor tingling around mouth/fingertips or muscle cramps in your \nlegs. If you experience any of these signs or symptoms please \ncall Dr. ___ for advice or if you have severe \nsymptoms go to the emergency room. \nPlease note that your Methimazole has been discontinued. You may \nrestart your Aspirin and Lovenox on ___ (48 hours after your \nsurgery). You may take acetaminophen (Tylenol) as directed, but \ndo not exceed 4000 mg in one day. Please get plenty of rest, \ncontinue to walk several times per day, and drink adequate \namounts of fluids. \nPlease call your surgeon or go to the emergency department if \nyou have increased pain, swelling, redness, or drainage from the \nincision site. You may shower and wash incisions with a mild \nsoap and warm water. Avoid swimming and baths until cleared by \nyour surgeon. Gently pat the area dry. You have a neck incision \nwith steri-strips in place, do not remove, they will fall off on \ntheir own.\nThank you for allowing us to participate in your care.\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "C73", "E0520", "I10", "I272", "E785", "E119", "J449", "I480", "Z7901", "Z86711", "I739", "F17210", "Z8673", "Z86718" ]

[ "C73: Malignant neoplasm of thyroid gland", "E0520: Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm", "I10: Essential (primary) hypertension", "I272: Other secondary pulmonary hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "J449: Chronic obstructive pulmonary disease, unspecified", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "Z86711: Personal history of pulmonary embolism", "I739: Peripheral vascular disease, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "I10", "E785", "E119", "J449", "I480", "Z7901", "F17210", "Z8673", "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:\nHypoxic and Hypercarbic Respiratory Failure, deep vein \nthromboses\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ y/o F with atrial fibrillation on warfarin, PE, CKD III, PVD, \nmultinodular goiter s/p biopsy w/ possible follicular neoplasm \nin ___ who was sent to ___ ED after being found to have L \njugular and subclavian venous thrombosis despite therapeutic INR \non warfarin. Patient found to have airway stenosis on CT \nimaging, and s/s of hypercarbic respiratory failure, w/ABG \nconsistent w/acute on chronic hypercapnic respiratory failure, \nsent to ICU for monitoring and further workup. \n\n \nPast Medical History:\n- T2DM (HbA1c 6.1% in ___, diet controlled)\n- HLD\n- CKD III\n- PVD\n- OA\n- iron deficiency anemia\n- paroxysmal atrial fibrillation\n- pulmonary embolism\n- stroke\n- diverticulosis\n- goiter (nontoxic multinodular)\n- AAA (3.3 cm in ___, no further eval)\n- cholelithiasis\n- obesity\n- lung nodules (as above)\n- neurogenic bladder\n- prolonged QT \n \nSocial History:\n___\nFamily History:\nMother, aunt, and uncle all had CHF, unknown cause; no known hx \nof CAD in her family. Daughter with heart arrhythmia on \namiodarone \n \nPhysical Exam:\nAdmission Physical Exam \n======================\nGENERAL: Patient pleasant and cooperative w/exam, and AAOx3, \nfalls asleep intermittently during exam. \nHEENT: Sclera anicteric w/evidence of slight proptosis, MMM, \noropharynx clear \nNECK: Large multinodular goiter on exam \nLUNGS: Clear to auscultation bilaterally, no stridor at the \nthroat, no wheezes, rales, rhonchi \nCV: Irregularly irregular rate and rhythm, normal S1 S2, ___ SEM \nloudest at the mitral valve, no rubs, gallops \nABD: Soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, left upper extremity \nw/increased edema versus right \nSKIN: No visible rashes upper/lower extremities\nNEURO: as noted above, patient sleepy during exam\n\nDISCHARGE PHYSICAL EXAM\n========================\nVital Signs: 98.7 130/58 57 18 99% on 1L\nGENERAL: Patient pleasant and cooperative w/exam, and AAOx3, \nHEENT: Sclera anicteric w/evidence of slight proptosis, MMM, \noropharynx clear \nNECK: Large multinodular goiter on exam \nLUNGS: Clear to auscultation bilaterally, no stridor at the \nthroat, no wheezes, rales, rhonchi \nCV: Irregularly irregular rate and rhythm, normal S1 S2, ___ SEM \nloudest at apex, no rubs, gallops \nABD: Soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, left upper extremity \nw/increased edema versus right. \nSKIN: No visible rashes upper/lower extremities \nNEURO: A&O x 3\n\n \nPertinent Results:\nADMISSION LABS:\n===============================\n___ 04:05AM BLOOD WBC-5.2 RBC-3.79* Hgb-9.3* Hct-32.2* \nMCV-85 MCH-24.5* MCHC-28.9* RDW-19.9* RDWSD-58.3* Plt ___\n___ 04:05AM BLOOD Neuts-70.9 Lymphs-12.6* Monos-13.0 \nEos-2.1 Baso-0.8 Im ___ AbsNeut-3.65 AbsLymp-0.65* \nAbsMono-0.67 AbsEos-0.11 AbsBaso-0.04\n___ 04:05AM BLOOD ___ PTT-77.1* ___\n___ 04:05AM BLOOD Glucose-113* UreaN-16 Creat-0.9 Na-143 \nK-3.8 Cl-105 HCO3-31 AnGap-11\n___ 04:05AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.9\n___ 08:51PM BLOOD TSH-3.1\n___ 08:51PM BLOOD T4-7.5\n___ 01:52AM BLOOD Type-ART pO2-77* pCO2-74* pH-7.29* \ncalTCO2-37* Base XS-5\n___ 08:56PM BLOOD Lactate-1.0\n\nOTHER PERTINENT/DISCHARGE LABS\n=================================\n___ 07:53PM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)- \nNegative\n___ 04:05AM BLOOD Triglyc-35\n___ 08:51PM BLOOD TSH-3.1\n___ 08:51PM BLOOD T4-7.5\n___ 07:53PM BLOOD TotProt-6.3*\n___ 07:53PM BLOOD Lupus-NEG\n___ 07:53PM BLOOD Thrombn-19.3*\n___ 06:40PM BLOOD IPT-DONE\n\nDISCHARGE LABS\n=================\n___ 07:40AM BLOOD WBC-4.6 RBC-3.84* Hgb-9.3* Hct-32.3* \nMCV-84 MCH-24.2* MCHC-28.8* RDW-18.2* RDWSD-54.6* Plt ___\n___ 07:40AM BLOOD ___ PTT-29.2 ___\n___ 07:40AM BLOOD Glucose-80 UreaN-10 Creat-0.8 Na-142 \nK-4.5 Cl-99 HCO3-36* AnGap-12\n\nIMAGING\n===================\n___ LENIs\nNo evidence of deep venous thrombosis in the left lower \nextremity veins.\n\n___ CT Chest w and wout\n1. No evidence of pulmonary embolism or acute aortic \nabnormality. \n2. Multiple pulmonary nodules, the largest of which measures 7 \nmm. If \nclinically indicated, follow-up chest CT is suggested at ___ \nmonths. If there \nis no change, a second follow-up in ___ months and then at 24 \nmonths is \nrecommended if there is no change. \n3. Dilated main pulmonary artery likely reflective of pulmonary \narterial \nhypertension. \n4. Markedly enlarged thyroid gland with mediastinal extension \nand severe \nnarrowing of the trachea. \n5. Mild centrilobular emphysema. \n\nCXR ___\n1. Moderate pulmonary congestion and mild interstitial edema is \nincreased, \nmoderate right pleural effusion is new, and moderate left \nbasilar atelectasis is increased since ___, consistent \nwith acute CHF exacerbation. Large goiter, unchanged. \n\nAnkle XR ___\nFINDINGS: \nNo acute fracture or dislocation is detected about the left \nankle. There is minimal spurring about the distal tibia, but no \nother evidence of tibiotalar joint osteoarthritis. The mortise \njoint is congruent, without talar dome OCD. There is prominent \nenthesophytic spurring along the posterior and inferior \ncalcaneus. An ovoid density projects inferior to the fibula \nmeasures 5 mm, of unclear etiology, potentially sequelae of \nprior trauma. Differential diagnosis could include a early \nleft, focus hydroxyapatite, or calcified lymph node. No \nsuspicious lytic or sclerotic lesion is identified. Vascular \ncalcifications are noted. \n\nCT abdomen ___\n \n1. No evidence of malignancy or metastatic disease within the \nabdomen or \npelvis although residual high-density oral contrast and \nassociated artifact moderately limits evaluation of the large \nbowel and pelvis. \n2. Cholelithiasis without evidence of cholecystitis. \n3. Intrahepatic and extrahepatic biliary dilation, which may \nrepresent \nprevious gallstone passage. \n4. Extensive atherosclerosis and infrarenal abdominal aortic \nectasia measuring maximally 31 mm. \n5. Diverticulosis. \n\n \nBrief Hospital Course:\n___ y/o F with atrial fibrillation on warfarin, PE, CKD III, PVD, \nmultinodular goiter s/p biopsy w/ possible follicular neoplasm \nin ___ who was sent to ___ ED after being found to have L \njugular and subclavian venous thrombosis despite therapeutic INR \non warfarin. \n\n#Hypoxemia and Hypercapnic Respiratory Failure (Acute on \nChronic):\nPatient w/new O2 requirement, hx of OSA, and ABG was consistent \nwith acute on chronic respiratory failure. Likely the patient's \nstenosis of her airway from large goiter contributing. Also, may \nhave undiagnosed COPD given emphysematous changes on her CT scan \nalong with untreated OSA. Her elevated bicarbonate is suggestive \nof a chronic process. She was transferred to the ICU on ___ \nfor monitoring w/continuous O2 (88-92%) due to concerns about \nairway compression and increasing oxygen requirement shortly \nafter her admission. ENT was consulted on ___ for evaluation \nof any airway compromise and did not feel that any intervention \nwas warranted. She did not demonstrate any respiratory distress \nat any time during her hospital stay. She was transferred to the \nfloor on the ___ and had continuous O2 monitoring. She also \ncontinued to use BiPap with good effect at night. Bipap settings \nwere: EPAP 5 IPAP 15 O2 flow: 6\n\n#LUE DVTs: Patient w/new onset DVTs despite therapeutic \nwarfarin. This is concerning for a coagulopathy. It is unclear \nif this is inherited or acquired perhaps in the setting of \nmalignancy. No clear provoking symptoms. CT abdomen/pelvis was \nnegative for overt malignancy or metastases. Imaging did show \npulmonary nodules that will need to be followed up with repeat \nimaging. Also, there is concern for malignancy related to her \nmultinodular thyroid. She is scheduled to follow up with her \nendocrinologist regarding this. She was placed on enoxaparin 80 \nmg q12hr per hematology recommendations. Hematology/Oncology was \nfollowing her throughout admission as well.\n\n#Gout. Patient had some left foot/ankle pain which impaired her \nability to walk. It improved after colchicine administration. \nXRay of left foot was negative. \n\n#Atrial Fibrillation: Has chronic atrial fibrillation, and \nwarfarin was discontinued as she developed upper extremity DVTs \nwith therapeutic INR. Lovenox was initiated. Amiodarone was at \nfirst discontinued in the ICU, and then restarted on the floor. \nShe was discharged on her home dose of 100 daily. Her PR \ninterval was >200 and she was not considered a good candidate \nfor a beta blocker while in house.\n\n#Coronary Artery Disease: Stable. Continued atorvastatin, \naspirin\n\n#Hypertension: Stable. Continued home amlodipine, lisinopril\n\n#Thyroid disease:Patient w/large goiter, and questionable effect \non trachea. Followed by ___ endocrinology. IP and ENT at ___ \nwill consider intervention pending whether there is malignancy \nwithin goiter, and overall patient prognosis. Methimazole was \ncontinued. Thyroglobulin pending at discharge. Abd/pelvic CT \nwithout evidence of malignancy.\n\n#MGUS: monoclonal IgG kappa represents only 1% of total protein. \nThe rest of it, and IgA, are polyclonal. Free kappa and lambda \nlight chains both slightly elevated, not worrisome for myeloma. \nNo further evaluation needed. \n\nTRANSITIONAL ISSUES:\n#She was followed by hem/onc atrius as inpatient: PCP can refer \nher to Dr ___, ___ Heme, for further follow-up if deemed \nappropriate.\n\n# For the PCP: IP can offer her a joint procedure with ENT \nregarding her large multinodular goiter and its impingement on \nthe trachea when it is clear whether there is malignancy present \nor not, and what the overall prognosis of patient is. They can \ncertainly stent her trachea if it starts to compromise her \nairway if that is within the patient goals of care. An \nappointment in interventional pulmonology/compromised ___ \nclinic is being made for her at ___ to follow up this issue.\n\n#Multiple pulmonary nodules, the largest of which measures 7 mm. \nIf clinically indicated, follow-up chest CT is suggested at ___ \nmonths. If there is no change, a second follow-up in ___ months \nand then at 24 months is recommended if there is no change. \n\n#Repeat FNA in 2 weeks with endocrinology. thyroglobulin pending \nat discharge\n\n#nightly bipap: EPAP 5 IPAP 15 O2 flow: 6\n\n#Patient started on Lovenox 80 mg sc BID for UE DVT which \noccurred while on warfarin\n\n#Consider starting allopurinol for prevention of gout\n\n-HCP: ___ (___) - ___\n-Code: Full confirmed\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amiodarone 100 mg PO DAILY \n2. Amlodipine 5 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Calcium Carbonate 500 mg PO DAILY \n6. Ferrous Sulfate 325 mg PO DAILY \n7. Lisinopril 30 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n___ MD to order daily dose PO DAILY16 \n10. Methimazole 2.5 mg PO DAILY \n\n \nDischarge Medications:\n1. Amiodarone 100 mg PO DAILY \n2. Amlodipine 5 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Calcium Carbonate 500 mg PO DAILY \n6. Lisinopril 30 mg PO DAILY \n7. Methimazole 2.5 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Enoxaparin Sodium 80 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n10. Ferrous Sulfate 325 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nDeep vein thrombosis\nhypoxemic and hypercapnic respiratory failure secondary \ngout flare\n\nSecondary Diagnosis\n====================\natrial fibrillation\ncoronary artery disease\nhypertension\nmultinodular thyroid \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 \nswollen arms, and you were found to have clots in your arms even \nthough you were on Coumadin. Your medication, Coumadin was \nchanged to lovenox 80 mg twice a day. You were also started on \nBiPAP at night to help your breathing at night. You should \ncontinue to use this. You were also treated for a gout flare and \nyour foot feels improved. \n\nPlease keep your appointments with your urologist, \nendocrinologist, and primary care physician. You will also need \nto follow up with the lung doctors who were following you as an \ninpatient.\n\nIt was a pleasure taking part in your care.\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I82622", "J9621", "I480", "N319", "J449", "D472", "J9622", "I129", "N183", "I739", "E042", "E119", "D509", "Z6829", "I714", "M1000", "J398", "K5790", "E669", "G4733", "F17210", "K8020", "M19072", "E780", "M109", "I2510", "Z7982", "Z86711", "Z7901", "Z8673" ]

[ "I82622: Acute embolism and thrombosis of deep veins of left upper extremity", "J9621: Acute and chronic respiratory failure with hypoxia", "I480: Paroxysmal atrial fibrillation", "N319: Neuromuscular dysfunction of bladder, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "D472: Monoclonal gammopathy", "J9622: Acute and chronic respiratory failure with hypercapnia", "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)", "I739: Peripheral vascular disease, unspecified", "E042: Nontoxic multinodular goiter", "E119: Type 2 diabetes mellitus without complications", "D509: Iron deficiency anemia, unspecified", "Z6829: Body mass index [BMI] 29.0-29.9, adult", "I714: Abdominal aortic aneurysm, without rupture", "M1000: Idiopathic gout, unspecified site", "J398: Other specified diseases of upper respiratory tract", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "E669: Obesity, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "M19072: Primary osteoarthritis, left ankle and foot", "E780: Pure hypercholesterolemia", "M109: Gout, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z7982: Long term (current) use of aspirin", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "I480", "J449", "I129", "E119", "D509", "E669", "G4733", "F17210", "M109", "I2510", "Z7901", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nComplete Heart Block\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is an ___ female with history of A. fib on \nCoumadin, chronic kidney disease, COPD on 2L O2, severe \npulmonary hypertension who is presenting as a transfer from ___ \n___ for concern for 3rd degree heart block. \n\nThe patient was recently admitted to ___ in ___ for \nsyncope. She was walking through a store to buy medications for \nher constipation and she became lightheaded, weak, and she fell \nto the floor and hit her head. She endorsed epigastric pain \nprior to event but no other prodrome of diaphoresis, nausea, or \ntunnel vision. The event was thought to be due to pulmonary HTN \nfrom\nchronic COPD as her TTE showed elevated PA pressures as well as \na possible orthostatic component. She was given gentle fluids \nand her Lasix was held but resumed at a decreased dose prior to \ndischarge. She was also given prednisone 30mg PO daily, \nlevaquin 250mg daily, and started on albuterol nebulizers. She \nwas discharged on 2L NC with plan to get outpatient PFTs. \n\nShe states that she has not been the same since discharge. She \nused to be able to walk her dog around the block multiple times \nbut in the past month, she has been so short of breath she has \nnot been able to walk her dog at all. The most activity she is \nable to perform is chores around the house. She has noticed \nlower extremity swelling but no orthopnea, PND, nausea, or \nvomiting.\nShe does not weigh herself as she does not have a scale but she \ndoes not think she has gained weight. She manages all of her \nmedications on her own and does not think she missed any doses. \n\nThe patient was cooking dinner for herself the night prior to \nadmission when she developed a sharp chest pressure in the left \nside of her chest. The pain progressed so she called EMS. She \ndenied any palpitations, shortness of breath, nausea, or \nvomiting. The pain lasted about one hour. When EMTs arrived, \nshe was bradycardic to the ___. \n\nOn arrival to ___, her blood pressure was 82/39 with a heart \nrate of ___. EKG was concerning for complete heart block. She \nhad minimal response to atropine so was started on transvenous \npacing without capture. She was then given pushes of \nepinepherine then started on an epinepherine drip. Her lowest \nblood pressure was 70/40. Labs were notable for a creatinine of \n3.1, potassium of\n6.2, ph on the VBG of 7.10 with a pCO2 of 34 and a bicarbonate \nof 10. She was then given IVF boluses and started on a \nbicarbonate drip. She was also given 1 amp of calcium gluconate \nand 3mg of glucagon given concern for AV nodal blockage \noverdose. \n\nThe patient was transferred to ___ for further management of \ncomplete heart block. Blood pressure was 90/40 on transfer and \nshe was placed on epinepherine and norepinephrine. In the ED, \nepinephrine and norepinephrine were weaned off and she was \nplaced on dopamine 2.5 mcg/kg/min. \n\nIn the ED, \n - Initial vitals were: \n97.3 66 100/58 12 96% 3L NC \n \n - Exam notable for: \nNone documented \n\n - Labs notable for: \nWBC of 27.6, hgb of 8.5, plt of 338\n\nNa of 141, K of 5.9, Cl of 115, HCO3 of 13, BUN 46, Cr of 2.8 \n\nALT of 21, AST of 51, ALP of 89, Tbili of 0.4\n\nVBG with ___\nlactate of 1.9\n\n - Studies notable for: \nCXR with Apparent opacities projecting over the right lower lung \nmay partially be due to costochondral calcifications but cannot \nexclude possible lung parenchymal opacities.\n\n - Patient was given: \n IV DRIP DOPamine 2.5 mcg/kg/min \n500 cc IVF\nIV Calcium Gluconate 1 gm \n\nOn arrival to the CCU, the patient endorses shortness of breath \nmildly improved from prior. She denies any chest pain, nausea, \nvomiting, palpitations, dysuria, urgency, frequency, or \ndiarrhea. She has been eating and drinking normally over the \npast few days.\n\nIn speaking with renal this morning, they recommended 1L of \nNabicarb for his acidosis. \n\n \nPast Medical History:\nCardiac History: \n - type 2 diabetes\n - hypertension\n - dyslipidemia\n - atrial fibrillation\n - HFpEF \nOther PMH: \n - CKD stage III\n - COPD\n\n \nSocial History:\n___\nFamily History:\nFATHER, ___ Cause: CVA (cerebral vascular accident).\nMOTHER, ___ Cause: Colon cancer.\nDAUGHTER, ___, Age ___ Cause: Diabetes mellitus.\nSON, ___, Age ___ Cause: ___ syndrome.\nSON, ___, Age ___ Cause: Hydrocephalus.\n \nPhysical Exam:\nADMISSION EXAM\n===============\nVS: Reviewed in Metavision \nGENERAL: Well developed, well nourished in NAD. Oriented x3.\nMood, affect appropriate. \nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. \n\n\nNECK: Supple. JVP at 11 cm at 90 degrees. \nCARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or\ngallops. \nLUNGS: No chest wall deformities or tenderness. scattered \nwheezes\nthroughout both lung fields \nABDOMEN: Soft, non-tender, non-distended. No palpable\nhepatomegaly or splenomegaly. \nEXTREMITIES: Warm, well perfused. 2+ pitting edema of both lower\nextremities bilaterally \nSKIN: No significant lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE EXAM\n================\n24 HR Data (last updated ___ @ 516)\n Temp: 97.6 (Tm 98.0), BP: 149/70 (109-149/43-70), HR: 83\n(___), RR: 20 (___), O2 sat: 90% (84-93), O2 delivery: 3L,\nWt: 168.21 lb/76.3 kg \nGENERAL: Well developed, well nourished in NAD. Oriented x3.\nMood, affect appropriate. \nCARDIAC: RRR. No murmurs, rubs, or gallops. \nLUNGS: Decreased breath sounds. No wheezing, no increased WOB or\nuse of accessory muscles\nABDOMEN: Soft, NTND. No palpable hepatomegaly or splenomegaly. \nEXTREMITIES: 1+ pitting edema of both lower extremities\nbilaterally to mid shin. \nPULSES: Distal pulses palpable and symmetric. \nNEURO: Alert, conversant, no gross focal deficits\n \nPertinent Results:\nADMISSION LABS \n================\n___ 11:59PM BLOOD WBC-27.6* RBC-3.71* Hgb-8.5* Hct-30.3* \nMCV-82 MCH-22.9* MCHC-28.1* RDW-21.0* RDWSD-59.8* Plt ___\n___ 11:59PM BLOOD Neuts-85.5* Lymphs-6.9* Monos-6.2 \nEos-0.0* Baso-0.3 NRBC-0.3* Im ___ AbsNeut-23.60* \nAbsLymp-1.90 AbsMono-1.72* AbsEos-0.01* AbsBaso-0.08\n___ 11:59PM BLOOD ___ PTT-27.4 ___\n___ 11:59PM BLOOD ALT-21 AST-51* CK(CPK)-67 AlkPhos-89 \nTotBili-0.4\n___ 11:59PM BLOOD Albumin-3.4*\n\nINTERVAL LABS\n===============\n___ 12:05AM BLOOD ___ pO2-72* pCO2-36 pH-7.16* \ncalTCO2-14* Base XS--15 Comment-GREEN TOP\n___ 07:46AM BLOOD ___ pO2-133* pCO2-37 pH-7.37 \ncalTCO2-22 Base XS--3 Comment-GREEN TOP\n___ 05:37AM BLOOD Cortsol-15.3\n___ 11:59PM BLOOD TSH-2.1\n___ 05:55AM BLOOD calTIBC-300 Ferritn-31 TRF-231\n___ 11:59PM BLOOD cTropnT-<0.01\n___ 05:37AM BLOOD CK-MB-3 cTropnT-<0.01\n\nMICROBIOLOGY \n=============\n___ 12:05 am BLOOD CULTURE\n\n Blood Culture, Routine (Preliminary): \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. \n Isolated from only one set in the previous five days. \n\n___ BLOOD CULTURE \nNO GROWTH \n\n___ URINE CULTURE \nNO GROWTH - FINAL \n\nMRSA SWAB - PENDING \n\n___ BLOOD CULTURE \nNO GROWTH TO DATE (PENDING)\n\n___ BLOOD CULTURE \nNO GROWTH TO DATE (PENDING)\n\nIMAGING \n==========\nTTE (___) \nThe left atrial volume index is normal. The right atrium is \nmildly enlarged. There is no evidence for an atrial\nseptal defect by 2D/color Doppler. The estimated right atrial \npressure is ___ mmHg. There is normal leftventricular wall \nthickness with a normal cavity size. There is normal regional \nand global left ventricular systolic\nfunction. Quantitative biplane left ventricular ejection \nfraction is 73 %. Left ventricular cardiac index is depressed \n(less than 2.0 L/min/m2). There is no resting left ventricular \noutflow tract gradient. Diastolic\nparameters are indeterminate. Mildly dilated right ventricular \ncavity with moderate global free wall hypokinesis. Tricuspid \nannular plane systolic excursion (TAPSE) is depressed. There is \nabnormal interventricular septal motion c/w right ventricular \npressure and volume overload. The aortic sinus diameter is \nnormal for gender with normal ascending aorta diameter for \ngender. The aortic arch diameter is normal with a normal \ndescending aorta diameter. The aortic valve leaflets (3) appear \nstructurally normal. There is no aortic valve stenosis. There is \nno aortic regurgitation. The mitral valve leaflets appear \nstructurally normal with no\nmitral valve prolapse. There is trivial mitral regurgitation. \nThe pulmonic valve leaflets are not well seen. The tricuspid \nvalve leaflets appear structurally normal. There is moderate \n[2+] tricuspid regurgitation. There is moderate to severe \npulmonary artery systolic hypertension. There is no pericardial \neffusion.\n\nIMPRESSION: Moderate to severe pulmonary artery systolic \nhypertension. Right ventricular cavity dilation with free wall \nhypokinesis. Moderate tricuspid regurgitation.\n\nRENAL U.S. Study Date of ___ 6:20 ___ \n1. Atrophic kidneys bilaterally. No hydronephrosis. \n2. Small right pleural effusion. \n\nCXR (___)\nHeart size is top-normal. Mediastinum is stable. Right basal \nopacities are minimal and unchanged, unlikely to represent \ninfectious process but attention on the subsequent radiographs \nis recommended to this area. No pleural effusion or \npneumothorax is seen \n\n___: CT chest w/o contrast:\n\n1. No evidence of interstitial lung disease. \n2. Moderate upper lobe predominant centrilobular emphysema. \n3. Small bilateral pleural effusions with minor associated \natelectasis. '' \n4. Coronary calcification. \n5. Cholelithiasis without evidence of acute cholecystitis. \n6. Few small lung nodules measuring up to at most 4 mm. These \nare very \nlikely benign, but noting emphysema may be appropriate to \nconsider follow-up \nchest CT for surveillance in ___ year. \n \nRECOMMENDATION(S): Follow-up chest CT is recommended for \nsurveillance of very \nsmall, probably benign, lung nodules in ___ year.3. \n\n___: RUQUS with duplex \n\n1. Patent hepatic vasculature. No evidence for portal vein \nthrombosis \n2. Loss of diastolic flow in the main hepatic artery is likely \nsecondary to \nhepatic congestion. \n3. Cholelithiasis without cholecystitis. \n4. Small right pleural effusion. \n\nV/Q Scan: \nFINDINGS:\n \nVentilation images demonstrate irregular tracer distribution in \nboth lung\nfields.\n \nPerfusion images demonstrate irregular tracer uptake in both \nlung fields, worse\non the left compared to the right. All perfusion images are \nmatched but less\napparent than the defects noted on ventilation imaging.\n \nChest x-ray shows bibasilar infiltrates and pulmonary \ncongestion.\n \nIMPRESSION: Ventilation images more apparent than perfusion \nimages, most\nconsistent with COPD/airways disease. No clear evidence of \npulmonary\nthromboembolism.\n \n\nDISCHARGE LABS \n===============\n___ 06:19AM BLOOD WBC-9.8 RBC-3.47* Hgb-8.1* Hct-28.6* \nMCV-82 MCH-23.3* MCHC-28.3* RDW-22.3* RDWSD-65.3* Plt ___\n___ 06:19AM BLOOD ___\n___ 06:19AM BLOOD Plt ___\n___ 06:19AM BLOOD Glucose-80 UreaN-44* Creat-1.7* Na-139 \nK-4.7 Cl-107 HCO3-22 AnGap-10\n___ 06:10AM BLOOD ALT-12 AST-17 LD(LDH)-242 AlkPhos-100 \nTotBili-0.4\n___ 06:00AM BLOOD ___\n___ 05:37AM BLOOD CK-MB-3 cTropnT-<0.01\n___ 06:19AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.1\n___ 05:55AM BLOOD calTIBC-300 Ferritn-31 TRF-231\n___ 06:47AM BLOOD ANCA-PND\n___ 06:47AM BLOOD RheuFac-<10 ___ Cntromr-NEGATIVE\n___ 06:47AM BLOOD C3-110 C4-23\n___ 06:47AM BLOOD HIV Ab-NEG\n___ 05:55AM BLOOD Vanco-13.6\n \nBrief Hospital Course:\nMs. ___ is an ___ female with history of A. fib on \nCoumadin, chronic kidney disease, COPD on 2L O2, severe \npulmonary hypertension who is presenting as a transfer from ___ \n___ for bradycardia likely due to metabolic disturbances in \nthe setting ___ from right sided heart failure/HFpEF, thought \nrelated to new severe pulmonary hypertension. \n\nDischarge Cr: 1.7\nDischarge Weight: 168.21 lb (76.3 kg)\nDischarge Diuretic: Furosemide 10 mg daily\nDischarge Hgb: 8.1\n\nACUTE ISSUES: \n============= \n#Bradycardia\nThe patient presented with bradycardia in the setting of \nelectrolyte disturbance and acidosis as transfer from ___ \n___. Reportedly at the OSH her ECG was concerning for \npossible atrial fibrillation w/ complete heart block and both \natropine and transcutaneous pacing were attempted prior to \ntransfer. Of note, on arrival to ___ she was noted to be in \natrial fibrillation w/ slow ventricular response and rates \n___. Sequence of causality is unclear: ie, if patient was \nbradycardic leading to decreased renal perfusion and thus an \nacidosis or if patient was acidotic due to renal failure (or \nother cause) leading to bradycardia. However, given lack of \nother end organ damage, more likely the latter. Her troponins \nwere negative so unlikely to be ischemic in etiology. She is on \nhigh doses of metoprolol and Diltiazem at home and denies taking \nmore medications than prescribed. On arrival, the pt was briefly \non a dopamine drip. In this setting, her metoprolol and \ndilitiazem were held and her metoprolol was slowly reintroduced. \nHer Bradycardia resolved. \n\n#Pulmonary Hypertension \nThe patient had evidence of volume overload with elevated JVP \nand lower extremity edema consistent with right sided heart \nfailure exacerbation. However with diuresis, the patient became \northostatic. RHC showed severe pulmonary hypertension. Likely \ngroup III iso oxygen dependent COPD but evaluation for other \ncauses was recommended by pulmonary. Group I work up included \n___, ANCA, CCP, anti-centromere pending at time of discharge, \nC3: 110, C4: 23, RF: <10, anti-RNP: negative, HIV: negative. She \nis s/p RUQUS with doppler for portopulmonary HTN: No evidence of \nporto-pulmonary HTN. Group III work up: was unable to acquire \nfull PFTs - (spirometry, DLCO, lung volumes), has appointment on \n___. A Non con CT chest: demonstrated emphysema. Regarding \ngroup IV workup, a VQ scan was performed without evidence of PE. \n\n\n#HFpEF\nPatient with new diagnosis of HFpEF with evidence of right-sided \nHF likely secondary to COPD given elevated RV pressures on her \nTTE, right axis deviation/low limb lead voltage on her EKG. She \nis chronically on 3L but had an increased oxygen requirement \nintitially. She was initially diuresed with IV Lasix but this \nwas ultimately held given mild ___. TTE this admission notable \nfor RV dilation w free wall hypokinesis. She was diuresed with \nIV Lasix transitioned to torsemide. Held ACEi in the setting of \n___. Received metoprolol as above, continued to hold diltiazem. \nImdur was discontinued given absence of angina. Continued with \nIV Lasix lead to orthostatic hypotension and RHC was done to \nevaluate for volume overload. PCWP was normal at 10 and CI was \nnormal at 2.82. PA pressure was ___ (47) consistent for severe \npulmonary hypertension as above. At discharge, diuretic was her \nhome dose of furosemide 10mg PO. \n\n#Atrial Fibrillation\nCHADS2VASC of 5 on warfarin. INR supratherapeutic on admission, \ninitially held diltiazem and metoprolol iso of bradycardia. High \ndoses of AV nodal blocking agents suggest that she has difficult \nto control rates. She had intermittent bouts of AF w/ RVR to \n150s while her nodal agents were being held. We restarted her \nmetoprolol and uptitrated to metoprolol tartrate 25mg q6H (her \nhome dose of metop) and consolidated to 100mg succinate prior to \ndischarge. Anticoagulation was continued with warfarin 3 mg \nafter correction of coagulopathy. \n\n#Coagulopathy\nOn arrival pt's INR was supratherapeutic to 6.0 with prolonged \nPTT and decreasing platelets. Possibly in the setting of \ncongestive hepatopathy vs. due to changes in her PO intake prior \nto arrival. She was given PO vitamin K for three days, w/ \nnormalization of her INR. Fibrinogen normal, blood smear showed \n1+ schistocytes. Warfarin was restarted as above. \n\n#Iron Deficiency Anemia \nPt w/ Hgb ___ this admission. Required intermittent pRBC. Her \niron studies are consistent w/ Fe deficiency anemia (Ferritin \n31, TIBC 300, Fe 17). Stool guaiac positive, but brown. Likely \nslow lower GI bleed iso supratherapeutic INR. INR reversed with \nvitamin K and Hgb stabilized. She should undergo EGD and a \ncolonoscopy as an outpatient, but had adamantly refused \ninpatient evaluation. She received IV iron repletion x3 days. \n\n#Non-Anion Gap Metabolic Acidosis: \nPatient with non anion gap metabolic acidosis with respiratory \nacidosis. Bicarbonate is chronically around 18 but ph was 7.16 \non presentation. Non anion gap metabolic acidosis likely due to \nrenal failure from worsening heart failure or injury due to \nhypotensive event. She required small quantities of bicarb \ninitially before her pH normalized. Renal was consulted while \nshe was inpatient and improved without intervention.\n\n___ on CKD: Patient has been seen by nephrologist with workup \nnotable for negative spep, upep. Baseline creatinine in ___ \n~1.5. Give exertional dyspnea, lower extremity dyspnea, and \nvolume overload, likely pre-renal from decreased effective \ncirculatory volume. Cr was 2.8 on admission and improved \ninitially with diuresis. Diuresis was restarted with increase in \nCr. on discharge Cr was 1.7. \n\n#Positive blood cultures \n#Leukocytosis \n#Possible Cellulitis\nShe was briefly on vancomycin for possible GPC bactermia, but \ngiven speciation as CoNS only in one bottle, suspect this may \nhave been contaminant. She had a full infectious workup which \nwas negative and we transitioned her to Keflex to complete a 5 \nday course for cellulitis (___). \n\nCHRONIC ISSUES:\n===============\n#Diabetes mellitus: on levemir 10U SQ qhs so switched to \nglargine 10mg qhs with sliding scale insulin while inpatient.\n\n#COPD: Baseline 3L of home O2 with extensive smoking history. \nContinued Advair.\n\n#gout: continued allopurinol, dose reduced to every other day in \nsetting of worsening renal function. \n\n#CODE: DNR/okay to intubate \n#CONTACT/HCP: ___ ___ (son) \n\nTRANSITIONAL ISSUES \n=====================\n[] Recommend performance of Full PFTs - spirometry, DLCO, lung \nvolumes, which are scheduled at ___ on ___. \n[] Recommend follow up with a pulmonologist (she preferred to \nsee a provider closer to home as outpatient follow up in ___ \nwill be challenging for her to keep.) If possible outpatient \nfollow-up should involve a local Pulmonologist (at ___) and PH \nspecialist at ___. She has had relatively extensive pulmonary \nhypertension workup however still needs PFTs. We have scheduled \nan appointment for her on ___ at ___ with a pulmonary \nhypertension specialist. \n[] Recommend referral to a cardiologist given her bradycardia \nwith heart block on admission and further titration of nodal \nblockers.\n[] Few small lung nodules measuring up to at most 4 mm. These \nare very likely benign, but noting emphysema may be appropriate \nto consider follow-up chest CT for surveillance in ___ year. \n[] Pt w/ iron deficiency anemia this admission w/ Hgb ___. Her \nstool was guaic positive, but pt did not have any BRBPR or \nmelena, so suspecting slow ooze. She was repleted with IV iron. \nConsider EGD/Colonscopy as an outpatient.\n[] Consider transition from colesevelam to a statin.\n[] Consider continuing iron repletion as an outpatient. \n[] Diuretic management: she was discharged on lasix 10mg PO with \nnotable lower extremity edema, further attempts at diuresis were \nmade during her hospital course with worsening of her kidney \nfunction, absent of resolution of her edema and orthostasis. \n[] INR management: She was supratherapeutic with INR of 6 on \nadmission please continue to monitor INR closely on discharge. \nShe was ultimately continued on her home dose of 3 mg daily. \n[] Reduced allopurinol to every other day dosing due to \ndecreased CrCl, if Cr improves can consider increasing dose. \n[] Monitor BP. Stopped ACE because she was normotensive at rest \nand intermittently orthostatic. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of \nbreath \n2. fosinopril 10 mg oral DAILY \n3. levemir 10 Units Bedtime\n4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n5. WelChol (colesevelam) 1875 mg oral BID \n6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY \n7. Omeprazole 40 mg PO DAILY \n8. Allopurinol ___ mg PO DAILY \n9. Metoprolol Succinate XL 100 mg PO DAILY \n10. Diltiazem Extended-Release 240 mg PO DAILY \n11. Warfarin 3 mg PO DAILY16 \n12. Vitamin D 1000 UNIT PO DAILY \n13. Aspirin 81 mg PO DAILY \n14. Furosemide 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO EVERY OTHER DAY \nRX *allopurinol ___ mg 1 tablet(s) by mouth every other day Disp \n#*15 Tablet Refills:*0 \n2. levemir 10 Units Bedtime \n3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of \nbreath \n4. Aspirin 81 mg PO DAILY \n5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n6. Furosemide 10 mg PO DAILY \n7. Metoprolol Succinate XL 100 mg PO DAILY \n8. Omeprazole 40 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Warfarin 3 mg PO DAILY16 \n11. WelChol (___) 1875 mg oral BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\nBradycardia\nPulmonary hypertension \n\nSECONDARY DIAGNOSIS:\n====================\nAtrial fibrillation \nAnemia \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\nThank you for allowing us to participate in your care. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- Your heart rates were extremely slow.\n\nWHAT DID YOU DO FOR ME WHILE I WAS HERE?\n- Your heart rates were monitored closely.\n- We slowly restarted some your medications to control your \nheart rates.\n- You were treated with antibiotics for a possible skin \ninfection. \n- Your blood was too thin, so we held a few doses of your blood \nthinner until it normalized. \n- You had a right heart catheterization which showed severe \npulmonary hypertension so you were seen by lung doctors . \n\nAfter you leave:\n================\n- Please take your medications as prescribed.\n- Please attend any outpatient follow-up appointments you have \nupcoming.\n- Your primary care doctor ___ refer you to a local \npulmonologist. We would also recommend that you follow up with a \npulmonary hypertension specialist here at ___. We have made an \nappointment for you (see below) and there are pulmonary function \ntests scheduled for the same day. If you feel that you do not \nwant to keep this appointment, please call the clinic to cancel. \n\n- Please work with your primary care provider to monitor your \nwarfarin level or INR closely, if the level is too high it can \ncause bleeding. If it is too low, it can increase your risk of a \nstroke. \n- Please ask your primary care doctor to assist you in finding a \npulmonologist close to your home. They can help further evaluate \nthe causes of your shortness of breath. \n\nIt was a pleasure participating in your care! We wish you the \nvery best!\n\nSincerely,\n\nYour ___ HealthCare Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I2729", "I5033", "I130", "N184", "E874", "D62", "K921", "L0390", "N179", "R001", "E875", "Z66", "J439", "Z9981", "I482", "Z7901", "E7849", "Z87891", "I952", "T501X5A", "Y92230", "R791", "D509", "D72829", "M109", "L89151" ]

[ "I2729: Other secondary pulmonary hypertension", "I5033: Acute on 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", "N184: Chronic kidney disease, stage 4 (severe)", "E874: Mixed disorder of acid-base balance", "D62: Acute posthemorrhagic anemia", "K921: Melena", "L0390: Cellulitis, unspecified", "N179: Acute kidney failure, unspecified", "R001: Bradycardia, unspecified", "E875: Hyperkalemia", "Z66: Do not resuscitate", "J439: Emphysema, unspecified", "Z9981: Dependence on supplemental oxygen", "I482: Chronic atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "E7849: Other hyperlipidemia", "Z87891: Personal history of nicotine dependence", "I952: Hypotension due to drugs", "T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R791: Abnormal coagulation profile", "D509: Iron deficiency anemia, unspecified", "D72829: Elevated white blood cell count, unspecified", "M109: Gout, unspecified", "L89151: Pressure ulcer of sacral region, stage 1" ]

[ "I130", "D62", "N179", "Z66", "Z7901", "Z87891", "Y92230", "D509", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCelebrex / Excedrin Migraine / Fluzone / glyburide / ibuprofen / \nmetformin / tizanidine\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\nChest tightness\n \nMajor Surgical or Invasive Procedure:\nCardiac Catheterization ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a history of HTN, \nDM2, dyslipedia, and non-ischemic cardiomyopathy with EF of 20% \nwho was recently admitted to ___ for ___ with RCA occlusion \ns/p DES and who presents today for worsening dyspnea on exertion \nand chest discomfort at home. \n\nPatient was hospitalized at ___ from ___ to ___. She \npresented for that hospitalization with epigastric \npain/discomfort and shortness of breath. She was found to have \nST elevation in inferior leads II,III, AVF with lateral anterior \ndepressions.The patient had a DES placed to the RCA with LCx \ndisease as well, and course complicated by transient heart \nblock that resolved prior to discharge. \n\nSince being discharged patient reports that she has felt \nincreasing discomfort. She states that she gets short of breath \nand has increasing epigastric discomfort. Because of the \nworsening of her symptoms she decided to re-present for care. Of \nnote, patient had been seen by her cardiologist on ___. At that \ntime there was concern that she was not taking her medications \nappropriately. She brought her medications and did have \naspirin/Plavix with her. However, it was noted that there was a \nlot of uncertainty about her medications. \n\nPatient denies palpiations, orthopnea ___ edema. She does \nreport increasing pain in her feet bilaterally. She endorses \n\"turning feeling\" in her stomach. No nausea/vomiting. \n\nPatient presented to ___ where she was found to have \nelevated troponin-I of 21.35. She was given aspirin and started \non heparin gtt and transferred to ___ because she had her \nrecent cath here. \n\nIn the ___ initial vitals were: 99 105/52 16 100% RA \nEKG: SR at 74bpm, <0.5mm STE in III and aVF. Subtle STD in \nV4-V6. LVH. \nLabs/studies notable for: Trop of 1.74, MB 26\nPatient was given: SL nitro x1 and started on IV heparin \nVitals on transfer: 98.3 97 112/64 18 99% RA \n\nOn the floor, patient was interviewed with ___ \ninterpreter and confirmed the above history. \n\nREVIEW OF SYSTEMS: As per HPI, otherwise negative in detail\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n-Nonischemic cardiomyopathy (LVEF ___ \n3. OTHER PAST MEDICAL HISTORY\n-Chronic low back pain \n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n\nBrother with HTN, mother died in ___\n \nPhysical Exam:\nAdmission Physical Exam:\n=======================\nVS: 98.4 PO 116/72 101 18 98 ra \nGENERAL: WDWN woman in NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple with JVD at 10cm \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills, \nlifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\nDischarge Physical Exam:\n========================\nGENERAL: pleasant, lying in bed. Oriented x3. \nHEENT: NCAT. Sclera anicteric. PERRLA, EOMI. no conjunctival \npallor. \nNECK: JVP 8cm at 45 deg. no cervical lad. \nCARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. \nLUNGS: good inspiratory effort. CTABL. No wheezes or rhonchi. \n\nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: no peripheral edema. +ttp in ___ b/l stable. pain on\npalpation of AC joint stable. full ROM and intact strength in UE\nand ___.\nSKIN: No stasis dermatitis, ulcers \nPULSES: 2+ Distal pulses b/l, warm and well perfused\n \nPertinent Results:\nAdmission Labs:\n==============\n___ 09:15AM BLOOD WBC-6.1 RBC-3.59* Hgb-8.8* Hct-28.9* \nMCV-81* MCH-24.5* MCHC-30.4* RDW-19.0* RDWSD-54.4* Plt ___\n___ 09:15AM BLOOD Neuts-55.2 ___ Monos-8.1 Eos-1.3 \nBaso-0.3 NRBC-0.5* Im ___ AbsNeut-3.35# AbsLymp-2.10 \nAbsMono-0.49 AbsEos-0.08 AbsBaso-0.02\n___ 09:15AM BLOOD ___ PTT-94* ___\n___ 09:15AM BLOOD Glucose-144* UreaN-23* Creat-1.3* Na-139 \nK-4.8 Cl-99 HCO3-26 AnGap-14\n___ 09:15AM BLOOD CK(CPK)-1040*\n___ 09:15AM BLOOD CK-MB-26* MB Indx-2.5 proBNP-5390*\n___ 09:15AM BLOOD cTropnT-1.74*\n___ 02:45PM BLOOD cTropnT-1.39*\n___ 02:45PM BLOOD CK-MB-18* MB Indx-2.2\n___ 09:15AM BLOOD Calcium-9.5 Phos-4.5 Mg-2.4\n___ 09:15AM BLOOD Digoxin-<0.4*\n\nImaging:\n=======\nCardiac catheterization ___\nImpressions:\nTwo-vessel CAD with patent RCA stent and diffuse 80% LCx disease \nand subtotal OM2 unchanged from\nbefore.\nElevated left-side filling pressures\n\nDischarge Labs:\n===============\n___ 06:15AM BLOOD WBC-7.1 RBC-4.22 Hgb-9.9* Hct-32.3* \nMCV-77* MCH-23.5* MCHC-30.7* RDW-18.2* RDWSD-49.9* Plt ___\n___ 06:15AM BLOOD Glucose-112* UreaN-33* Creat-1.1 Na-141 \nK-4.1 Cl-96 HCO3-30 AnGap-15\n___ 06:15AM BLOOD Mg-2.1\n___ 06:30AM BLOOD %HbA1c-8.7* eAG-203*\n \nBrief Hospital Course:\n___ year old woman with a sig PMHx of HTN, DM2, and non-ischemic \ncardiomyopathy (EF of 20%) who was recently admitted to ___ \nfor ___ with RCA occlusion s/p DES and who presents with \nworsening dyspnea, chest discomfort and positive biomarkers \nconcerning for new NSTEMI. \n\nAcute Issues:\n=============\n#NSTEMI: The patient presented with worsening dyspnea, chest \ndiscomfort, and had positive biomarkers, concerning NSTEMI. \nCardiac catheterization on ___ revealed worsening LCx lesion \n(70-80%) as well as a subtotal occlusion of a small OM2 with \nTIMI 1 flow, likely the culprit lesion. The thrombus was \nmedically managed, and the patient was already on dual \nantiplatelet therapy, given recent stent placement. We continued \nher home aspirin and Plavix, rosuvastatin, and metoprolol. \n\n#Decompensated Systolic Heart Failure: The patient has a history \nof non ischemic cardiomyopathy with baseline EF ___. She was \nvolume overloaded during her hospitalization and was diuresed \nwith Lasix 10mg/hr, which improved her symptomatically. After \nbecoming euvolemic, she was changed to PO torsemide 40mg BID. \nShe was also changed to isosorbide mononitrate 30mg daily from \nisosorbide dinitrate 10mg TID. Her ACE inhibitor was held in the \nsetting of hyperkalemia on admission. \n\n#Type II Diabetes: The patient experienced labile glucose levels \nthroughout her hospital stay. At admission, she was started on \nher home insulin regimen. Throughout her stay however, she \nbecame hyperglycemic (BG ~400) but was asymptomatic. ___ was \nconsulted and her insulin regimen was altered to an optimal \nlevel. Of note, her A1C on ___ was 8.7. Her glucose control \nimproved on her new regimen as listed below. Lantus 35U AM, 20U \n___, 14U Humalog TID with meals with ISS. \n\nChronic Issues:\n===============\n#Right shoulder pain: The patient described having shoulder pain \nthat was tender at her A/C joint. Her symptoms improved with \nLidoderm patches and Tylenol ___ TID. \n\n#2:1 AV block: The patient had a 2:1 AV block ___ during \nher last hospitalization. She was in sinus rhythm throughout \nthis hospital stay. \n\n#Hypertension: Isosorbide Mononitrate (Extended Release) 30 mg \nPO DAILY.\n\n#Hyperlipidemia: The patient was continued on her home \nrosuvastatin 40mg \n\n#Chronic Pain: The patient was continued on her home Tramadol, \nand Tylenol\n\n#GERD: The patient was continued on pantoprazole 40mg daily\n\nTransitional Issues:\n====================\n[] Continue to monitor for symptoms of volume overload\n[] Follow up K and restart Lisinopril, discharge K 4.1 \n[] Continue Torsemide 40mg BID \n[] Consider decreasing pantoprazole dosage \n\nDischarge Weight: 68.7kg\nDischarge Cr: 1.1\nHbA1c 8.7%\n\nMedication Changes:\n===================\n**Medications that were changed in the hospital:\n1. INSULIN REGIMEN \nGlargine 35 Units Breakfast\nGlargine 20 Units Bedtime\nHumalog 14 Units Breakfast\nHumalog 14 Units Lunch\nHumalog 14 Units Dinner\nInsulin SC Sliding Scale \n2. Metoprolol Succinate XL 150 mg PO DAILY\n3. Torsemide 40 mg PO/NG BID \n4. Omeprazole 40mg PO daily\n\n***New medications that were started in the hospital:\n1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n2. Lidocaine 5% Patch 1 PTCH TD QPM \n\n***Medications that were stopped:\n1. HydrALAZINE 10 mg PO TID \n\n#Code: Full \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 75 mg PO DAILY \n2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n3. Aspirin 81 mg PO DAILY \n4. Gabapentin 600 mg PO TID \n5. Omeprazole 40 mg PO BID \n6. Rosuvastatin Calcium 40 mg PO QPM \n7. Torsemide 20 mg PO DAILY \n8. TraMADol 50 mg PO Q8H:PRN Pain - Moderate \n9. Tizanidine 8 mg PO Q8H:PRN spasm \n10. Clopidogrel 75 mg PO DAILY \n11. HydrALAZINE 10 mg PO TID \n12. Isosorbide Dinitrate 10 mg PO TID \n13. Glargine 50 Units Bedtime\nHumalog 10 Units Breakfast\nHumalog 10 Units Lunch\nHumalog 10 Units Dinner\n\n \nDischarge Medications:\n1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \nRX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n2. Lidocaine 5% Patch 1 PTCH TD QPM \nRX *lidocaine-menthol [LidoPatch] 4 %-1 % 1 patch over area once \ndaily Disp #*30 Patch Refills:*0 \n3. Glargine 35 Units Breakfast\nGlargine 20 Units Bedtime\nHumalog 14 Units Breakfast\nHumalog 14 Units Lunch\nHumalog 14 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n4. Metoprolol Succinate XL 150 mg PO DAILY \nRX *metoprolol succinate [Toprol XL] 100 mg 1.5 tablet(s) by \nmouth daily Disp #*45 Tablet Refills:*0 \n5. Omeprazole 40 mg PO DAILY \n6. Torsemide 40 mg PO BID \nRX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*120 \nTablet Refills:*0 \n7. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n8. Aspirin 81 mg PO DAILY \n9. Clopidogrel 75 mg PO DAILY \n10. Gabapentin 600 mg PO TID \n11. Rosuvastatin Calcium 40 mg PO QPM \n12. Tizanidine 8 mg PO Q8H:PRN spasm \n13. TraMADol 50 mg PO Q8H:PRN Pain - Moderate \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nPrimary Diagnoses:\n==================\nNSTEMI\nDecompensated systolic heart failure\nInsulin dependent diabetes mellitus\n \nSecondary Diagnoses:\n====================\nAV block\nHTN\nHLD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for you at ___. \n\nYou were admitted to the hospital because you had chest \ndiscomfort and shortness of breath. You were found to have had a \nheart attack. Your heart arteries were examined (cardiac \ncatheterization) which showed a blockage of one of the arteries. \nIt was however decided that you did not need a stent. Rather, \nyou were given medications to prevent future blockages. \n\nYou also were experiencing worsening shortness of breath. and \nyou were found to have fluid on your lungs. This was felt to be \ndue to a condition called heart failure, where your heart does \nnot pump hard enough and fluid backs up into your lungs. You \nwere given a diuretic medication through the IV to help get the \nfluid out. You improved considerably and were ready to leave the \nhospital.\n\nFinally, your blood sugar levels were going high and low. ___ \nor the endocrine service was consulted to help guide management. \nWe changed your insulin regimen to the following (see below) and \nyou felt better. Please continue these as written below:\n\nNEW INSULIN REGIMEN:\nGlargine: 35 units morning and 20 units bedtime\nHumalog: 14 units for breakfast, lunch, and dinner\nContinue sliding scale as you were at home. \n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- It is very important to take your aspirin and clopidogrel \n(also known as Plavix) every day. These medications reduce your \nchance for having a heart attack in the future. \n- If you stop these medications or miss ___ dose, you risk causing \na blood clot forming in your heart vessels, and you may die from \na massive heart attack.\n- Weigh yourself every morning, seek medical attention if your \nweight goes up more than 3 lbs. Your discharge weight is 153lb \nor 69.4kg. \n- Take all of your medications as prescribed. \n- Follow up with your doctors as listed below. \n- Seek medical attention if you have new or concerning symptoms \nor you develop chest pain, swelling in your legs, abdominal \ndistention, or shortness of breath at night, blurry vision or \nheadaches. \n \nWe are happy to see you feeling better.\n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I222", "I5023", "I428", "E1142", "E1165", "I213", "I110", "I2510", "M25511", "E785", "G8929", "K219", "M79672", "M79671", "Z955", "Z7902", "Z794" ]

[ "I222: Subsequent non-ST elevation (NSTEMI) myocardial infarction", "I5023: Acute on chronic systolic (congestive) heart failure", "I428: Other cardiomyopathies", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I213: ST elevation (STEMI) myocardial infarction of unspecified site", "I110: Hypertensive heart disease with heart failure", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M25511: Pain in right shoulder", "E785: Hyperlipidemia, unspecified", "G8929: Other chronic pain", "K219: Gastro-esophageal reflux disease without esophagitis", "M79672: Pain in left foot", "M79671: Pain in right foot", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z794: Long term (current) use of insulin" ]

[ "E1165", "I110", "I2510", "E785", "G8929", "K219", "Z955", "Z7902", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCelebrex / Excedrin Migraine / Fluzone / glyburide / ibuprofen / \nmetformin / tizanidine\n \nAttending: ___\n \nChief Complaint:\nRight-sided weakness, aphasia\n \nMajor Surgical or Invasive Procedure:\nMechanical thrombectomy\nPEG\n\n \nHistory of Present Illness:\n___ is a ___ woman ___\nspeaking with a history of diabetes, dilated cardiomyopathy,\nhypertension, hyperlipidemia who presented initially to an\noutside hospital with acute onset right-sided weakness and\naphasia. \nAnd most of it is provided by EMS run sheets as well as the\nhistory is limited, outside hospital records. Patient was\notherwise last known well at 0835 this a.m. when she was talking\non the phone with a relative. She got off the phone at that\ntime. Unclear how she was discovered, however she was noted to\nhave right-sided weakness right facial droop, and a aphasia. \nShe\nwas initially taken to an outside hospital. Initial ___ stroke\nscale was 27 for the findings as above. She was given TPA at\n1005, after CT confirmed no hemorrhage. Initial blood pressures\nwere less than 110. She was subsequently transferred to ___\nfor consideration for endovascular clot retrieval.\n\nPer daughter, the patient lives alone without assistance.\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n-Nonischemic cardiomyopathy (LVEF ___ \n3. OTHER PAST MEDICAL HISTORY\n-Chronic low back pain \n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n \nPhysical Exam:\nADMISSION EXAMINATION:\n======================\nGeneral: Drowsy but awakens to voice\nHEENT: NCAT, no oropharyngeal lesions, neck supple\n___: RRR, no M/R/G\nPulmonary: CTAB, no crackles or wheezes\nAbdomen: Soft, NT, ND, +BS, no guarding\nExtremities: Warm, no edema\nNeurologic Examination:\n- Mental status: Eyes open to voice. Does not follow commands. \nno spontaneous speech output \n- Cranial Nerves: PERRL 3->2 brisk. There is significant left\ngaze deviation but the patient is able to cross her eyes to the\nright. There is right facial droop. Visual fields difficult to\nassess, no significant blink to threat on either side.\n- Sensorimotor: Left upper extremity is antigravity for at least\n10 seconds. Left lower extremity briskly withdraws to noxious\nbut does not clearly give good antigravity effort. Right lower\nextremity withdraws slightly against gravity to noxious. Right\nupper extremity slightly withdraws off of the bed to noxious.\n- Reflexes: Plantar response flexor bilaterally \n- Coordination/gait deferred\n\nDISCHARGE PHYSICAL EXAMINATION:\n===============================\nGENERAL: Elderly female sitting in chair, NAD.\nHEAD: NC/AT. Leftward gaze preference. \nNECK: Supple.\nCARDIAC: RRR, S1S2 w/o m/r/g.\nRESPIRATORY: Normal effort, CTABL. \nABODMEN: Soft, NT, +BS. \nEXTREMITIES: Warm, non-pitting edema of feet and lower shins,\nintact pulses. \nNEUROLOGIC: Moves limbs spontaneously. \n\n \nPertinent Results:\nADMISSION LABS:\n===============\nLabs:\n___ 06:35AM BLOOD WBC:12.2* RBC:4.23 Hgb:10.0* Hct:33.3*\nMCV:79* MCH:23.6* MCHC:30.0* RDW:18.8* RDWSD:52.8* Plt Ct:282\n___ 06:35AM BLOOD Glucose:319* UreaN:47* Creat:1.2* Na:156*\nK:4.0 Cl:113* HCO3:27 AnGap:16\n___ 06:35AM BLOOD Calcium:8.7 Phos:2.1* Mg:2.8*\n___ 02:12PM BLOOD Type:ART pO2:81* pCO2:35 pH:7.49*\ncalTCO2:27 Base XS:3 Intubat:NOT INTUBA\n___ 01:28PM TSH-2.6\n___ 01:28PM %HbA1c-8.6* eAG-200*\n___ 01:28PM TRIGLYCER-151* HDL CHOL-42 CHOL/HDL-2.5 \nLDL(CALC)-35\n\nDISCHARGE LABS:\n===============\n___ 06:33AM BLOOD WBC-6.9 RBC-4.36 Hgb-9.6* Hct-33.3* \nMCV-76* MCH-22.0* MCHC-28.8* RDW-20.3* RDWSD-54.4* Plt ___\n___ 06:33AM BLOOD Glucose-322* UreaN-36* Creat-1.0 Na-138 \nK-4.7 Cl-93* HCO3-29 AnGap-16\n\nMICROBIOLOGY:\n=============\n___ URINE URINE CULTURE-FINAL NEG\n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nNEG\nURINE (___)\nBETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL. \n\nIMAGING:\n========\nCHEST XRAY (___)\nLeft lower lobe atelectasis has improved substantially. Small \nbilateral pleural effusions are smaller. Moderate to severe \ncardiomegaly and pulmonary vascular engorgement have both \nimproved. No pulmonary edema. No pneumothorax. Compared to \nprevious chest radiographs\n\nTTE (___)\nMild to moderately dilated left ventricle with severe global \nhypokinesis. No intracardiac thrombi identified (cardiac MRI may \nbe more specific for left ventricular thrombi and TEE for left \natrial appendage thrombus if this would change clinical \nmanagement). Severe mitral regurgitation. At least moderate \ntricuspid regurgitation. Moderate to severe pulmonary \nhypertension.\n\nMR HEAD W/O CONTRAST (___)\n1. Acute infarction involving the left MCA territory, ASPECTS of \n1. There is involvement of the left occipital lobe. Evidence \nof cortical micro hemorrhage on gradient images only within the \nparietal, occipital, and temporal lobe. No evidence of \nparenchymal hematoma\n2. Chronic small right frontal lobe infarct.\n\nLIVER OR GALLBLADDER US (___)\nUnremarkable abdominal ultrasound.\n\nCHEST (PORTABLE ___\nModerate cardiomegaly is chronic. Large heart obscures the left \nlower lobe where there is at least some atelectasis. Lateral \nview would be helpful to decide if there is pneumonia, and to \nassess pleural effusions probably small to moderate on both \nsides. No pulmonary edema. Pulmonary vasculature mildly \nengorged. \n\n___ UNILAT LOWER EXT VEINS\nIMPRESSION: \nNo evidence of deep venous thrombosis in the left lower \nextremity veins.\n\n___ CXR\nIMPRESSION:\nSmall bilateral pleural effusions and mild pulmonary edema.\n \n___ ___\nIMPRESSION: \nStable distribution of infarcts, with large left MCA late \nsubacute to chronic infarct, with areas of predominant cortical \nmineralization, with possible smaller components of cortical \nmicrohemorrhage, and interval volume loss. There is no gyral \nexpansion or edema. There is no parenchymal hematoma\n \nBrief Hospital Course:\nBRIEF SUMMARY:\n==============\nMs. ___ is a ___ ___ speaking woman \nwith a history notable for IDDM, HTN, HLD, recent MI s/p stent \n(___), and HFrEF (EF=20%)transferred from ___ \nafter presenting with right-sided weakness and altered mental \nstatus (LKW ___ am ___. t-PA administered at OSH at 10:05 AM \nprior to transfer to ___. On arrival to ___ angiogram \nrevealed occlusion of the left MCA at the M2 bifurcation, \nfollowed by mechanical thrombectomy with TICI 2b reperfusion of \nthe left MCA territory after 3 passes at 11:00 AM. Following \nadmission to Neuro ICU, exam was notable for somnolence and \nbradypnea, prompting NCHCT that revealed diffuse left MCA \nhyperdensity likely related to contrast administration. \nFollow-up MRI 24 hours after t-PA administration revealed \nmicrohemorrhages within the infarct bed affecting the parietal, \noccipital, and temporal lobes. Given patient's recent MI s/p \nDES, dual antiplatelets were subsequently resumed. ICU course \notherwise notable for period of sinus tachycardia, ascribed to \nbeta blocker withdrawal effect and somewhat improved on resuming \nhome metoprolol dose, as well as pulmonary edema which responded \nto IV furosemide. She was transferred to the floor. Floor course \ncomplicated by aspiration PNA requiring antibiotic treatment & \nhyperglycemia requiring frequent adjustments in insulin regimen. \nPEG placed ___ for long-term nutrition.\n\nTRANSITIONAL ISSUES:\n===================\n[ ] CRITICAL TO DO: Please follow this insulin regimen, as \npatient has been prone to significant hyperglycemia: \n[ ] NPH 60U given at 7PM (NEEDS TO BE GIVEN EXACTLY 1 HOUR \nBEFORE TUBE FEEDS ARE GIVEN) \n[ ] Sliding scale at breakfast, lunch, dinner, and before \nbedtime as written. \n[ ] Fasting sugar should be checked before each meal & sliding \nscale insulin should be administered based on this sugar value. \n[ ] If fasting sugar is > 400 or < 70 please call the MD on call \nto review insulin regimen. \n[ ] If tube feeds are held, start D10 at same rate of tube feeds\n\n[ } CRITICAL FOLLOW-UP: Needs ongoing titration of insulin \nregimen. Please arrange follow up with her endocrinologist Dr. \n___ who is her primary endocrinologist for many years \n(daughter will arrange appointment). Pt used to be on Victoza in \nthe past and per daughter she had achieved good glycemic control \non that. Victoza is an outapatient treatment to consider if her \nhyperglycemia cannot be controlled despite titration of insulin \ndoses. \n\n[ ] Diuretic regimen: torsemide 40mg BID, D/C Weight: 65.1 kg, \n143.52 lb on standing scale. Please weigh daily and call MD if \nchange in weight by 3 lbs.\n[ ] CAD regimen: aspirin 81mg daily, clopidogrel 75mg daily, \nrosuvastatin 40mg daily, isosorbide dinitrate 10mg 3x/day, \nmetoprolol succinate 150mg daily \n[ ] D/C diet: pureed solids w/ nectar pre-thickened liquids & \naspiration precautions\n[ ] Tube feeds as written\n\nContinuous tubefeeding: Start ___ Glucerna 1.5 Cal; Full \nstrength\nTube Type: Percutaneous gastrostomy (PEG); Placement confirmed.\nStarting rate: 90 ml/hr; Do not advance rate Goal rate: 90 ml/hr\nCycle?: Yes Cycle start: ___ Cycle end: 0800\nResidual Check: Q4H Hold feeding for residual >= : 200ml\nFlush w/ 30 mL water Per standard\nFree water amount: 50 mL; Free water frequency: Q6H\n\nISSUES ADDRESSED:\n=================\n# Left MCA stroke: \nMRI: \"Acute infarction involving the left MCA territory. There \nis involvement of the left occipital lobe. Evidence of cortical \nmicrohemorrhage on gradient images only within the parietal, \noccipital, and temporal lobe. No evidence of parenchymal \nhematoma. Chronic small right frontal lobe infarct.\" Received \nt-PA administration & mechanical thrombectomy. Suffered residual \ndeficits and required daily work w/ ___ & OT. Has Neurology f/u \n___. \n\n# Aspiration PNA c/b sepsis, resolved:\n# Recurrent aspiration:\n___ placed for TF. PEG ___. On medical floor, febrile w/ \nleukocytosis. Initial concern for UTI, started on empiric \namp-sulb ___. CXR suspicious for aspiration PNA, switched to \nvancomycin and ceftriaxone. Ceftriaxone changed to ceftazidime \n___, course was completed on ___. Repeat aspiration PNA w/ \ndiet advancement required further treatment w/ ceftazadime for \ncourse completed ___. No further PNA or anti-infectives since \nthat time. On d/c, PEG in place, diet on d/c pureed solids w/ \nnectar pre-thickened liquids & aspiration precautions w/ plans \nto advance as tolerated at rehab. \n\n# IDDM:\nHospital course complicated by hyperglycemia and difficult \ncontrol given intermittent tube feeds & NPO status. ___ \nfollowed. \n\n# HFrEF, last EF 20% ___: Home diuretic is torsemide 20mg \nBID, she suffered fluid overload when on ICU service & required \nIV diuretics. Maintained on furosemide 40mg PO QD until appeared \noverloaded on exam w/ lower extremity edema ___. Weight noted \nto be 10-lb increased from ___ (no weights charted in \nbetween). She was diuresed w/ furosemide 40mg IV (___) \nw/ adequate response but creatinine increased to 1.2 on ___ \n(from baseline 0.9). Diuresis was held ___ given creatinine \nincrease to 1.2, creatinine remained @ 1.2 by ___, gave gentle \nhydration w/ improvement in creatinine to 1.0 ___. \n-Preload: D/c diuretic torsemide 40mg BID, d/c weight 65.1 kg, \n143.52 lb. \n-Afterload: Did not initiate b/c of previous attempts w/ \nhyperkalemia. \n-NHBK: Was on metoprolol tartrate 25mg Q6H, increased to \nmetoprolol tartrate 37.5mg PO Q6H given ST, plan to continue w/ \nmetoprolol succinate 150mg daily on d/c. \n-Inotropy: None. \n\n# CAD s/p recent RCA STEMI with DES: Continued DAPT + statin + \nBB & isosorbide dinitrate. \n\n# Normocytic anemia: Stable, monitored H/H, did not require \ntransfusions. \n\n# Glaucoma: Continued home eye drops. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspart 10 Units Breakfast\nAspart 10 Units Lunch\nAspart 10 Units Dinner\nGlargine 20 Units Bedtime\n2. Torsemide 20 mg PO BID \n3. Vitamin D 1000 UNIT PO DAILY \n4. Aspirin EC 81 mg PO DAILY \n5. Rosuvastatin Calcium 40 mg PO QPM \n6. Isosorbide Dinitrate 10 mg PO TID \n7. Clopidogrel 75 mg PO DAILY \n8. Gabapentin 600 mg PO TID \n9. Omeprazole 40 mg PO BID \n10. Metoprolol Succinate XL 75 mg PO DAILY \n11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n12. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n13. Tizanidine 2 mg PO Q8H:PRN muscle spasm \n14. liraglutide 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous DAILY \n15. Lidocaine 5% Patch 3 PTCH TD QAM \n16. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n\n \nDischarge Medications:\n1. Metoprolol Tartrate 150 mg PO DAILY \n2. Multivitamins W/minerals Liquid 15 mL PO DAILY \n3. NPH 60 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n4. Metoprolol Succinate XL 150 mg PO DAILY \n5. Aspirin EC 81 mg PO DAILY \n6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n7. Clopidogrel 75 mg PO DAILY \n8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n9. Isosorbide Dinitrate 10 mg PO TID \n10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n11. Rosuvastatin Calcium 40 mg PO QPM \n12. Torsemide 40 mg PO BID \n13. Vitamin D 1000 UNIT PO DAILY \n14. HELD- Omeprazole 40 mg PO BID This medication was held. Do \nnot restart Omeprazole until until directed by your phsyician. \n15. HELD- Tizanidine 2 mg PO Q8H:PRN muscle spasm This \nmedication was held. Do not restart Tizanidine until directed by \nyour physician. \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\nLeft MCA Stroke\n___ Acquired Pneumonia\nInsulin Dependent Diabetes\nCoronary Artery Disease, s/p STEMI with DES\nAcute on Chronic Systolic Heart Failure\nAcute on Chronic Kidney Disease\n\nSECONDARY DIAGNOSES\nChronic systolic heart failure\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. ___ and family, \n\nIt was a pleasure to care for you at the ___ \n___. \n \nWHY WERE YOU ADMITTED:\n-You had weakness on the right side of your body and trouble \nspeaking. \n\nWHAT HAPPENED WHEN YOU WERE HERE:\n-We found you had a stroke. We gave you medication to dissolve \nthe clot and you had a procedure to remove it too.\n-You had an infection in your lungs that we treated with \nantibiotics.\n-We put a feeding tube in your stomach because we found you were \nunable to swallow food safely. \n\nWHAT SHOULD YOU DO WHEN YOU LEAVE:\n-Please take all of your medications as below. \n-Please make sure to follow up with your cardiologist for \nongoing monitoring of your heart at the appointment listed \nbelow. \n-Please weigh yourself or have someone weigh you every morning \non a standing scale. If your weight changes by 3 pounds then \ncall your doctor because this might mean you are gaining too \nmuch fluid in your body. \n-If you notice worsening shortness of breath, chest pain, leg \nswelling, dizziness, or any other symptoms that concern you \nplease let us know right away. \n\nWe wish you the best! \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I63412", "I618", "J690", "E43", "I5023", "G9340", "J159", "N179", "G8191", "E870", "I130", "I429", "I248", "R4701", "N183", "E1165", "R0681", "R29810", "E1122", "B951", "Z794", "I2510", "Z955", "I252", "E785", "M545", "G8929", "E875", "D649", "H409", "R000", "I959", "E861", "Z6825" ]

[ "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "I618: Other nontraumatic intracerebral hemorrhage", "J690: Pneumonitis due to inhalation of food and vomit", "E43: Unspecified severe protein-calorie malnutrition", "I5023: Acute on chronic systolic (congestive) heart failure", "G9340: Encephalopathy, unspecified", "J159: Unspecified bacterial pneumonia", "N179: Acute kidney failure, unspecified", "G8191: Hemiplegia, unspecified affecting right dominant side", "E870: Hyperosmolality and hypernatremia", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I429: Cardiomyopathy, unspecified", "I248: Other forms of acute ischemic heart disease", "R4701: Aphasia", "N183: Chronic kidney disease, stage 3 (moderate)", "E1165: Type 2 diabetes mellitus with hyperglycemia", "R0681: Apnea, not elsewhere classified", "R29810: Facial weakness", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "B951: Streptococcus, group B, as the cause of diseases classified elsewhere", "Z794: Long term (current) use of insulin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction", "E785: Hyperlipidemia, unspecified", "M545: Low back pain", "G8929: Other chronic pain", "E875: Hyperkalemia", "D649: Anemia, unspecified", "H409: Unspecified glaucoma", "R000: Tachycardia, unspecified", "I959: Hypotension, unspecified", "E861: Hypovolemia", "Z6825: Body mass index [BMI] 25.0-25.9, adult" ]

[ "N179", "I130", "E1165", "E1122", "Z794", "I2510", "Z955", "I252", "E785", "G8929", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCelebrex / Excedrin Migraine / Fluzone / glyburide / ibuprofen / \nmetformin / tizanidine\n \nAttending: ___.\n \nChief Complaint:\nEpigastric pain\n \nMajor Surgical or Invasive Procedure:\n___ Cardiac Catheterization with DES to RCA\n\n \nHistory of Present Illness:\nMs. ___ is a ___ speaking ___ y/o female \nwith a history of DMII on insulin, HLD, HTN, systolic heart \nfailure EF 20% who presents with ___ days of epigastric and \nsubsternal CP as well as GI upset. Patient started having \nepigastric pain and fatigue on ___ night about 3 days ago per \nthe patient and her daughter. She says that she was out with her \nfriends coming home from church when she started having \nsymptoms. She was walking home but had to take the T given her \nfatigue and epigastric pain. She tried drinking some Tea at home \nbut continued having pain. She then was home and could not get \nout of bed due to worsening symptoms. Patient denies worsening \npain with exertion but does endorse feeling malaise with her \npain. \n\nThe pain persisted and began to be more retrosternal in \nlocation, and she presented to ___. \n\nAt CHA TnI was ___ and she was found the be in second degree \nheart block so was transferred. In the ED the cardiac fellow was \nconsulted. EKGs in the ED demonstrated ST elevations in II, III, \nAVF which evolved on multiple EKGs. There were also noted \nreciprocal lateral anterior depressions. Trop T 2.97 on arrival. \n \n\nPatient was taken to the cath lab where she was found to have a \n100% RCA occlusion which was stented with a DES, she also had \nLeft Cx occlusion of 80% but was not intervened upon. During the \nprocedure she was intermittently in variable block and 2:1 \nblock. \n\nShe was transferred to the CCU for further observation and \nmanagement of her heart block. \n\nIn the ED initial vitals were: 98.8 100 ___ 98% RA \n\n\nEKG: ST Elevations in inferior leads II,III, AVF with reciprocal \nlater and anterior depressions. Also noted to have 2:1 heart \nblock. \n\nLabs/studies notable for:\nWBC-14.3 HgB-10.0 Plt-292 \n\n133 93 27 AGap=17 \n\n-------------<201\n\n5.0 23 1.3 \n\nTrop-T: 2.97 \nCK: 1415 MB: 59 MBI: 4.2 \nDig: 0.9 \n\nPatient was given: \n-Atorvastatin 80 mg PO/NG QPM \n-Aspirin 243 mg PO ONCE \n-Heparin IV \n\nVitals on transfer: \n97.8 86 128/55 16 100% RA \n\nOn arrival to the CCU: the patient appears comfortable. She \ndenies any chest pain, shortness of breath, lightheadedness or \ndizziness. \n\n \n\n \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n-Nonischemic cardiomyopathy (LVEF ___ \n3. OTHER PAST MEDICAL HISTORY\n-Chronic low back pain \n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n\nBrother with HTN, mother died in ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n========================\nVS: Temp: 98.1 HR: 56 BP:115/81 RR:18 02: 92% RA\nGENERAL: Well developed, well nourished in NAD. Oriented x3. \nMood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva \nwere pink. No pallor or cyanosis of the oral mucosa. No \nxanthelasma. \nNECK: Supple. JVP of suprclavicularly about 5-6cm. \nCARDIAC: bradycardic rate, regular rhythm. Normal S1. No \nmurmurs, rubs, or gallops. \nLUNGS: No chest wall deformities or tenderness. Respiration is \nunlabored with no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, trace \nedema bilaterally. \nSKIN: No significant skin lesions or rashes. \n\nDISCHARGE PHYSICAL EXAM\n========================\nVITALS: Reviewed in OMR. \nI/O: Reviewed in OMR.\nGEN: Well appearing woman, laying in bed, no pain or distress\nHEENT: EOMI, MMM\nNECK: supple, JVP mid-neck augments with Hepatojugular Reflex \nCV: RRR, S1/S2, no m/r/g\nPULM: unlabored, mild crackles in right lung base \nGI: soft, NT, ND, no organomegaly\nEXT: warm, well perfused\nNEURO: non-focal\n\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 10:30AM WBC-14.3* RBC-4.04 HGB-10.0* HCT-32.5* \nMCV-80* MCH-24.8* MCHC-30.8* RDW-18.7* RDWSD-53.1*\n___ 10:30AM NEUTS-79.3* LYMPHS-13.3* MONOS-6.5 EOS-0.1* \nBASOS-0.2 IM ___ AbsNeut-11.30* AbsLymp-1.90 AbsMono-0.92* \nAbsEos-0.01* AbsBaso-0.03\n___ 10:30AM GLUCOSE-201* UREA N-27* CREAT-1.3* SODIUM-133 \nPOTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-23 ANION GAP-17*\n___ 10:30AM CK(CPK)-1415*\n___ 10:30AM cTropnT-2.97*\n___ 10:30AM CK-MB-59* MB INDX-4.2\n___ 10:30AM DIGOXIN-0.9\n\nINTERVAL LABS\n==============\n___ 08:56AM BLOOD TSH-0.92\n___ 03:13AM BLOOD CK-MB-18* cTropnT-5.09*\n___ 08:56AM BLOOD CK-MB-4 cTropnT-5.71*\n\nDISCHARGE LABS\n===============\n___ 07:35AM BLOOD WBC-5.3 RBC-3.54* Hgb-8.7* Hct-27.8* \nMCV-79* MCH-24.6* MCHC-31.3* RDW-18.4* RDWSD-52.2* Plt ___\n___ 07:35AM BLOOD Plt ___\n___ 07:35AM BLOOD Glucose-111* UreaN-22* Creat-1.1 Na-144 \nK-5.0 Cl-105 HCO3-23 AnGap-16\n___ 07:35AM BLOOD Calcium-9.3 Phos-4.7* Mg-2.0\n\nMICROBIOLOGY\n=============\nNone.\n\nIMAGING\n========\n___ TTE\n2:1 atrioventricular conduction block was present during this \nstudy. The left atrial volume index is severely increased. There \nis mild symmetric left ventricular hypertrophy. The left \nventricular cavity is moderately dilated. There is severe global \nleft ventricular hypokinesis (LVEF = 20 %). The right \nventricular free wall thickness is normal. Right ventricular \nchamber size is normal with depressed free wall contractility. \nThe aortic valve leaflets (3) are mildly thickened but aortic \nstenosis is not present. No aortic regurgitation is seen. The \nmitral valve leaflets are mildly thickened. Moderate (2+) mitral \nregurgitation is seen. The left ventricular inflow pattern \nsuggests a restrictive filling abnormality, with elevated left \natrial pressure. There is moderate pulmonary artery systolic \nhypertension. There is no pericardial effusion. \n\n___ Cardiac Cath\nLeft main normal\nLAD mild disease\nLCX 70-80% mid\nRCA occluded mid-->crossed, dilated and stented with 0% residual \nand normal flow\n\n \nBrief Hospital Course:\nPatient is a ___ year old female with a history of DMII, HTN, \nHLD, and systolic heart failure (EF 20%), who presented to ___ \n___ with acute onset epigastric/retrosternal chest pain and \ntroponemia with ST elevations in the inferior leads so was \ntransferred to ___ for cath. The patient had a DES placed to \nthe RCA with LCx disease as well, and course complicated by \ntransient heart block. Following her cath the patient had 2:1 AV \nblock. The patient was transferred to the ICU for monitoring. In \nthe CCU her course was uncomplicated and she was subsequently \ntransferred to the floor for further monitoring. For a brief \nperiod her block became more high grade but did evolve to 4:3 \nblock and eventually 1:1 conduction. During her stay we \nrestarted her home metoprolol with good tolerance. We did hold \noff on starting back her ACEi due to hyperkalemia. \n\n#STEMI s/p DES to RCA: Patient presented with elevated troponin \nat ___ and upon evaluation at ___ was found to have \nECG changes with ST elevation in inferior leads II,III, AVF with \nlateral anterior depressions. She was taken to the cath lab, \nloaded with Plavix and ASA, and received a DES to RCA for 100% \nocclusion. LCx had 80% stenosis and was not intervened upon. \nCK-MB continued to trend down and the pt was continued on daily \nASA, Plavix, and statin and a beta blocker. She was not started \non an ACE inhibitor due to borderline hyperkalemia.\n\n#AV Block: The patient with 2:1 block in setting of RCA \nocclusion. EKGs demonstrated prolonged PR with dropped QRS \nindicating possible second degree type 1 heart block. Her rhythm \ntransitioned to complete heart block, but she remained \nasymptomatic and normotensive. It again changed back to 2:1 \nblock before converting back to sinus rhythm. Heart rates were \nstable > 60 on discharge.\n\n#Systolic Heart Failure EF 20%: The patient has a history of non \nischemic cardiomyopathy with baseline EF ___. A TTE at ___ \ndemonstrated stable ventricular function EF=205. She was not \nvolume overloaded appearing on exam, so home diuretics were \nheld. \n \n___: The patient's baseline Cr. is 1.2 per outside record, was \nincreased to 1.3 on admission. The small increase may be simple \ndue to normal lab variation or from cardiac cath contrast. \nCreatinine was monitored daily.\n\n#Leukocytosis: She also had an elevated WBC on admission, likely \nin the setting of MI stress induced. There were no signs of \ninfection and the patient remained afebrile. CBC was trended \ndaily.\n\n#Elevated LFTs at OSH: AST/ALT were measured to be 273/40 in \nsetting of ACS. No signs of volume overload to suggest \ncongestive hepatopathy. Given history of HLD and DM, NAFLD also \na possibility. \n\n#Microcytic Anemia: Hgb 10 on admission with iron studies at \noutside hospital suggestive of chronic iron deficiency anemia. \n\n#DMII: The patient was placed on ISS while in house.\n\n#HTN: The patient's home BP meds were initially held due to \nconcern for heart block and normotensive BPs.\n \n#HLD: She was continued on home rosuvastatin 40mg daily.\n\n#Chronic Pain: She was continued on home tramadol and Tylenol.\n\nTRANSITIONAL ISSUES\n====================\n[ ] Please review all medication changes.\n[ ] Patient was started on DAPT (clopidogrel and aspirin) given \n___ in RCA. She should continue uninterrupted \nclopidogrel use for at least ___ year.\n[ ] Patient previously on digoxin although indication unclear. \nWas held in acute setting. Decision to restart at the discretion \nof primary cardiologist.\n[ ] Patient previously on spironolactone that was held in the \nacute setting. It should be restarted within 1 week of discharge \nwith follow-up labs to ensure stable potassium.\n[ ] Patient not on ACE inhibitor ___ despite EF of 20%. This \nwas not started given hyperkalemia and presumed intolerability. \nShould be on ___ if the patient can tolerate it. Decision \nto start at the discretion of primary cardiologist.\n[ ] Please continue to uptitrate metoprolol with target HR of \n60.\n[ ] Patient will need follow-up with EP regarding ICD placement \ngiven her current HFrEF (20%). \n[ ] Patient should have follow-up labs (CHEM10) on ___ and \nshould be faxed to her primary cardiologist Dr. ___ \n(___). Script was provided to patient.\n[] Patient will need ICD implantation post discharge \n[] Consider Fe supplementation\n[] Consider Hepatitis serologies given elevated LFTs \n\n# CODE: FULL CODE\n# CONTACT/HCP: ___: ___\n ___: ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 40 mg PO BID \n2. Gabapentin 600 mg PO TID \n3. Digoxin 0.125 mg PO DAILY \n4. Rosuvastatin Calcium 40 mg PO QPM \n5. Tizanidine 8 mg PO Q8H:PRN spasm \n6. Aspirin 81 mg PO DAILY \n7. Spironolactone 25 mg PO DAILY \n8. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n9. TraMADol 50 mg PO Q8H:PRN Pain - Moderate \n10. Torsemide 20 mg PO DAILY \n11. Metoprolol Succinate XL 200 mg PO DAILY \n12. Glargine 50 Units Bedtime\nHumalog 10 Units Breakfast\nHumalog 10 Units Lunch\nHumalog 10 Units Dinner\n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*5 \n2. HydrALAZINE 10 mg PO TID \nRX *hydralazine 10 mg 1 tablet(s) by mouth three times a day \nDisp #*90 Tablet Refills:*0 \n3. Isosorbide Dinitrate 10 mg PO TID \nRX *isosorbide dinitrate 10 mg 1 tablet(s) by mouth three times \na day Disp #*90 Tablet Refills:*0 \n4. Glargine 50 Units Bedtime\nHumalog 10 Units Breakfast\nHumalog 10 Units Lunch\nHumalog 10 Units Dinner \n5. Metoprolol Succinate XL 75 mg PO DAILY \nRX *metoprolol succinate [Toprol XL] 25 mg 3 tablet(s) by mouth \ndaily Disp #*90 Tablet Refills:*0 \n6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n7. Aspirin 81 mg PO DAILY \n8. Gabapentin 600 mg PO TID \n9. Omeprazole 40 mg PO BID \n10. Rosuvastatin Calcium 40 mg PO QPM \n11. Tizanidine 8 mg PO Q8H:PRN spasm \n12. Torsemide 20 mg PO DAILY \n13. TraMADol 50 mg PO Q8H:PRN Pain - Moderate \n14. HELD- Digoxin 0.125 mg PO DAILY This medication was held. \nDo not restart Digoxin until you are instructed by your \ncardiologist.\n15. HELD- Spironolactone 25 mg PO DAILY This medication was \nheld. Do not restart Spironolactone until you are instructed by \nyour cardiologist.\n16.Outpatient Lab Work\n___.11\nPlease check CHEM10 on ___ and fax results to Dr. ___ at \n___ \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nPRIMARY DIAGNOSIS\nSTEMI\nHigh Degree AV block\nAcute on Chronic Systolic Heart Failure\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nIt was a pleasure taking care of you during your hospitalization \nat ___.\n\nYou came to the hospital because you were having chest pain. We \ndid tests that showed you were having a heart attack. You \nunderwent a procedure called a cardiac catheterization which \nshowed a blockage in one of the vessels that brings blood to \nyour heart which was the cause of your heart attack. A stent was \nplaced to keep the blood vessel open. Your hospital course was \ncomplicated by a slow heart rate which is often seen after the \ntype of heart attack you had.\n\nWe started you on medications called blood thinners to prevent \nthe stent placed in your heart from getting clogged. It is very \nimportant that you take this medicine every day. We also gave \nyou medicines to prevent another heart attack.\n\nYour medications and discharge follow up appointments are \ndetailed below.\n\nWe wish you the best!\n\nYour ___ Care team\n \nFollowup Instructions:\n___\n" ]

[ "I2111", "N170", "I5023", "I959", "I429", "I441", "I110", "K760", "E871", "E119", "D509", "N141", "E785", "E861", "M545", "E875", "G8929", "Z794", "T508X5A", "Y92238" ]

[ "I2111: ST elevation (STEMI) myocardial infarction involving right coronary artery", "N170: Acute kidney failure with tubular necrosis", "I5023: Acute on chronic systolic (congestive) heart failure", "I959: Hypotension, unspecified", "I429: Cardiomyopathy, unspecified", "I441: Atrioventricular block, second degree", "I110: Hypertensive heart disease with heart failure", "K760: Fatty (change of) liver, not elsewhere classified", "E871: Hypo-osmolality and hyponatremia", "E119: Type 2 diabetes mellitus without complications", "D509: Iron deficiency anemia, unspecified", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "E785: Hyperlipidemia, unspecified", "E861: Hypovolemia", "M545: Low back pain", "E875: Hyperkalemia", "G8929: Other chronic pain", "Z794: Long term (current) use of insulin", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "Y92238: Other place in hospital as the place of occurrence of the external cause" ]

[ "I110", "E871", "E119", "D509", "E785", "G8929", "Z794" ]

[]

[ " \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:\nHypertension \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with hx of HTN (prescribed unknown medication in ___ and \nrecently ran out) who was sent in to the ED for hypertension \nfound to have sternal fracture. Patient established care at ___ \ntoday and was noted to be significantly hypertensive to 190s \nsystolic. While the patient did not have any overt symptoms, she \nwas sent to the ED for evaluation of hypertensive \nurgency/emergency and initiation of antihypertensives. She \nreports that he was taking a medication for his hypertension but \nran out 4 days ago. \n\nOn arrival to the ED, initial vitals notable for afebrile, HR \n120, BP 175/106, RR 16, 98% RA. Labs notable for Chem 7 with \nmild hypernatremia to 148, normal CBC, bland UA without \nproteinuria, negative troponin. EKG sinus tach with LVF and no \nevidence of ischemia. CXR with concern for sternal fracture. CT \nchest then performed which confirmed minimally displaced lower \nsternal fracture and atelectasis. Trauma surgery consulted and \npatient reports fall/blunt trauma several days PTA (tripped \nwalking over a curb and fell onto an elevated concrete structure \nwith her chest. No head strike no LOC. First fall, denies prior \nhistory) however trauma service did not feel patient required \nadmission for the fracture, but rec f/u in clinic in ___ weeks. \nPatient given 1gm tylenol 2.5mg oxycodone, amlodipine 5mg and \nIVF. Given the patient's labile BP and HR, she was admitted to \nmedicine for pain control and further monitoring. \n\nUpon arrival to the floor, patient is resting in bed. She \nreports pain only with movement and deep inspiration. She also \nreports that her BP generally is in the 170s to 180s at \nbaseline. No other acute complaints. \n \nPast Medical History:\nHypertension \n \nSocial History:\n___\nFamily History:\nSister has hypertension. No family history of heart attack, \nstroke, or cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n\nVITALS: 98.5; 190/110; 110; 20; 96RA; Pain ___ \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 \n CARDIAC: tachycardic with occasional PVCs \n PULMONARY: decreased breath sounds at bilateral bases ___ poor \neffort. \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\nDISCHARGE PHYSICAL EXAM \n\nVitals: 98.5 | 158/99 | 18 | 96% on RA\n General: lying in bed, pleasant, alert, oriented, no acute \ndistress \n HEENT: sclera anicteric, moist mucous membranes, oropharynx \nclear \n Lungs: clear to auscultation bilaterally, no wheezes, rales, \nronchi \n CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Abdomen: soft, non-tender, non-distended, bowel sounds present\n Ext: warm, well perfused, no evidence of edema \n Neuro: CNs2-12 intact, motor function normal \n \nPertinent Results:\nCOMPLETE BLOOD COUNT\n=====================\n\n___ 05:24AM BLOOD WBC-6.4 RBC-4.05 Hgb-11.5 Hct-36.2 MCV-89 \nMCH-28.4 MCHC-31.8* RDW-13.7 RDWSD-45.1 Plt ___\n___ 04:20PM BLOOD WBC-7.3 RBC-4.66 Hgb-13.1 Hct-41.3 MCV-89 \nMCH-28.1 MCHC-31.7* RDW-13.8 RDWSD-44.4 Plt ___\n___ 04:20PM BLOOD Neuts-53.9 ___ Monos-6.1 Eos-1.4 \nBaso-0.4 Im ___ AbsNeut-3.96 AbsLymp-2.78 AbsMono-0.45 \nAbsEos-0.10 AbsBaso-0.03\n\nCHEMISTRIES\n===========\n\n___ 05:24AM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-142 \nK-4.0 Cl-104 HCO3-28 AnGap-14\n___ 04:20PM BLOOD Glucose-103* UreaN-18 Creat-1.0 Na-148* \nK-3.9 Cl-103 HCO3-30 AnGap-19\n___ 05:24AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.8\n\nURINE STUDIES\n============\n\n___ 04:00PM URINE Color-Straw Appear-Clear Sp ___\n___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n\nTROPONIN\n========\n\n___ 04:20PM BLOOD cTropnT-<0.01\n\nIMAGING\n=======\n\n___ ImagingCHEST (PA & LAT)\n1. Minimal cortical step-off involving the lower sternum is \nsuspicious for a\nminimally displaced sternal fracture.\n2. Bibasilar atelectasis.\n\n___HEST W/O CONTRAST\n1. Minimally displaced lower sternal fracture with adjacent \nsmall hematoma. \nNo other fractures identified.\n2. Bibasilar atelectasis.\n \n \nBrief Hospital Course:\n___ ___ female with history of chronic hypertension who \npresents to the hospital after being found to be hypertensive to \nthe 190s and found to have sternal fracture.\n\n#Hypertension\nAt presentation patient had BP 175/106 and asymptomatic. She \nreports taking an unknown medication for hypertension \n(prescribed by provider in ___ and having been off the \nmedication for the past 4 days because she ran out of it. \nPatient denied any vision changes, headaches, shortness of \nbreath, or palpitations while interviewed in ___. \nInitial workup showed no evidence of proteinuria on UA or \ncardiac ischemia on ECG. Radiograph was notable for sternal \nfracture which was confirmed on CT (see below). Patient is \nthought to have elevation of baseline chronic hypertension which \nwas triggered by pain from sternal fracture and being off \nmedication.\n\n#Sternal Fracture\nPatient experienced mechanical fall without evidence of loss of \nconsciousness or head strike on ___. Patient found to have \nsome sternal tenderness on exam. Fracture is depressed but \nstable on palpation. CXR revealed minimal cortical step-off \ninvolving the lower sternum is suspicious for a minimally \ndisplaced sternal fracture and atelectasis. CT confirmed these \nresults. Acute Care Surgery evaluated patient in the ED and \nrecommended ambulatory follow up in ___ weeks. Patient was \nstarted on tramadol and acetaminophen for pain management. \n\nTRANSITIONAL ISSUES\n#Hypertension: Given 1-month supply of amlodipine, please \ntitrate as appropriate\n#Concern for Osteopenia/Osteoporosis:\nRecommend getting outpatient DEXA scan as an outpatient. \nPatient started on Vitamin 1000U daily and Calcium Carbonate \n1000mg daily given concern for osteoporosis/osteopenia. \n#ACS follow-up: Voice mail to arrange appointment with ACS for \nfollow-up left at ___, please ensure that appointment \nis made. \n#Pain management: Discharged with prescription for 10-day course \nof tramadol 50mg q6h:prn\n \nMedications on Admission:\nUnknown antihypertensive prescribed in ___ \n \nDischarge Medications:\n1. amLODIPine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0\n2. Calcium Carbonate 1000 mg PO DAILY osteoporosis \nRX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by \nmouth once a day Disp #*60 Tablet Refills:*0\n3. traMADol-acetaminophen 37.5-325 mg oral Q6H:PRN Duration: 10 \nDays \nRX *tramadol-acetaminophen 37.5 mg-325 mg 1 tablet(s) by mouth \nevery six (6) hours Disp #*40 Tablet Refills:*0\n4. Vitamin D ___ UNIT PO DAILY osteoporosis \nRX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth \nonce a day Disp #*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n- Chronic Hypertension\n- Sternal Fracture\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 after being seen at ___ \n___ on ___ with an elevated blood pressure. In the \nEmergency Department you where evaluated and also were found to \nhave experienced a fall on ___ causing you to experience \nincreased pain. Imaging showed that you have a sternal fracture. \nIt is likely that your blood pressure was elevated in the \nsetting of not taking your medication and stress caused by pain. \nWe started you on amlodipine for your blood pressure and \ntramadol and Tylenol for your pain. It is likely that you have \nsome bone mineral deficiency so we are also recommending that \nyou take Vitamin D and Calcium at home. Acute Care Surgery (ACS) \nevaluated you while you were in the Emergency Department and \nrecommend that you follow up in ___ clinic in ___ weeks. Please \nalso follow up with your primary care physician.\nIt was a pleasure taking care of you. We wish you well.\n\nSincerely,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I10", "S2220XA", "W01198A", "Y92480", "I517", "I471" ]

[ "I10: Essential (primary) hypertension", "S2220XA: Unspecified fracture of sternum, initial encounter for closed fracture", "W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter", "Y92480: Sidewalk as the place of occurrence of the external cause", "I517: Cardiomegaly", "I471: Supraventricular tachycardia" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nchest pain, dyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\n___: ___ Cardioversion: TEE revealed no atrial thrombus. \nSuccessful cardioversion to sinus rhythm. \n\n \nHistory of Present Illness:\n___ hx AF on Coumadin (s/p DCCV ___, recurrence ___ \nrestarted on AC), DM2 on Insulin, R BKA with prosthetic joint, \nMRSA Cellulitis (recent adm ___ for stump infection), HTN, \nHLD, chronic pain syndrome, transferred to ___ for CP and \nelevated troponin. \n Pt called Atrius triage today with DOE and CP on exertion for \nthe past several days. He had been getting this with just moving \naround, such as when he puts on his prosthesis. There was some \nassociated LUE numbness. He had been diagnosed with recurrent \nAFib on ___ and was having his labs checked at the ___. \nHe was referred there for further evaluation. \n In their ED, initial VS were: 98.8 F, 64, 115/82, 20, 98% RA. \nLabs there were significant for WBC 10.9, Trop 0.08 (Cr 1.1) and \nINR 1.87. For reported AFib with RVR he received IV diltiazem. \nHe was also given ASA and Lovenox per report. He was transferred \nto ___ for further cardiology evaluation. \n In the ___ ED initial vitals were: 98.0 110 118/70 18 95% RA. \n \n EKG was read as: AFib 81, qwave III (old). no STE. CWP. \n CTA Chest: No evidence of pulmonary embolism or aortic \nabnormality. \n Labs/studies notable for: WBC 12, BUN/Cr ___ (at baseline), \nTrop 0.07 & 0.07, PTT 56.6, INR 1.9. \n Patient was given: 2L NS and Morphine 5mg IV x1. \n Vitals on transfer: 97.3 106 126/90 16 94%RA \n On the floor, pt reports that he had a stress/ECHO through the \n___ on ___ (orders appear through Atrius system, but not the \nresults). He confirms that he's been having 1wk of L parasternal \nCP with associated shoulder pain, L arm numbness and SOB with \nslight exertion such as placing/removing his prosthetic. He uses \na motorized wheelchair to get around. The pain is not associated \nwith meals, is not pleuritic. He has felt hot, but not feverish \nnor has had chills. He has had occ palpitations. There has been \nno cough, congestion, post-nasal drip, wheeze, abdominal pain, \nn/v/d, incontinence of urine. \n\n \nPast Medical History:\nPMH: \n- Neuropathy \n- Insomnia \n- Hypercholesteremia \n- Hypertension \n- Type II diabetes mellitus with neurological manifestations \n- Chronic pain syndrome \n- Pain medication agreement \n- Adenomatous colon polyp \n- S/P R BKA (below knee amputation) unilateral \n- Diabetic ulcer of left foot \n- MRSA cellulitis \n- 1 episode of Afib resolved with cardioversion \nPSH: \n- R BKA \n- I&D of wound above R BKA at bedside \n- L shoulder surgery \n- Open appendectomy (pediatric) \n- Tonsillectomy (pediatric) \n\n \nSocial History:\n___\nFamily History:\nMother with CAD in ___, s/p 3v CABG, passed from cancer \n \nPhysical Exam:\nAdmission Exam\n==================\nPHYSICAL EXAM: \n VS: T= 97.8 BP= 138/79 HR= 115 RR=18 O2 sat=98%RA \n GENERAL: Well-appearing middle-aged male, NAD \n HEENT: NCAT. EOMI, PERRLA, anicteric sclera, clear OP, MMM, no \nLAD \n NECK: Supple with JVP of 7cm. \n CARDIAC: Irregularly irregular, no r/g/m \n LUNGS: CTAB \n ABDOMEN: Obese, soft, NT, ND, +BS \n EXTREMITIES: R BKA w/o lesions. L foot without ulcers, few open \nskin cuts. \n SKIN: Multiple tattoos on upper body, extremity findings as \nabove. \n\nDischarge Exam\n================\nVS: T=97.9 BP=129/86(111-131/61-82) HR=85 (81-99)RR=20 O2 \nsat=99% RA \nTele: Sinus rhythm. \nLast 24 hours I/O: 1560/2250\nWeight today: 144.7kg (143.1 on ___. \nGENERAL: Well-appearing middle-aged male, NAD \nHEENT: NCAT. EOMI, anicteric sclera, clear OP, MMM, no LAD \nNECK: Supple with JVP of 7cm. \nCARDIAC: RRR, no m/r/g \nLUNGS: CTAB \nABDOMEN: Obese, soft, NT, ND, +BS \nEXTREMITIES: R BKA w/o lesions. L foot without ulcers, few open \nskin cuts. \nSKIN: Multiple tattoos on upper body.\nPulses: L DP pulse 2+ \n\n \nPertinent Results:\nAdmission Labs\n=================\n___ 03:05PM BLOOD WBC-12.0*# RBC-5.16 Hgb-14.8 Hct-44.7 \nMCV-87 MCH-28.7 MCHC-33.1 RDW-13.2 RDWSD-41.1 Plt ___\n___ 03:05PM BLOOD Neuts-70.7 ___ Monos-6.4 Eos-1.0 \nBaso-0.3 Im ___ AbsNeut-8.46*# AbsLymp-2.54 AbsMono-0.76 \nAbsEos-0.12 AbsBaso-0.04\n___ 03:05PM BLOOD Plt ___\n___ 03:05PM BLOOD Glucose-160* UreaN-22* Creat-1.4* Na-136 \nK-4.7 Cl-102 HCO3-23 AnGap-16\n___ 03:05PM BLOOD CK(CPK)-186\n___ 06:50AM BLOOD ALT-16 AST-18 AlkPhos-68 TotBili-0.7\n___ 03:05PM BLOOD cTropnT-0.07*\n___ 09:20PM BLOOD cTropnT-0.07*\n___ 06:50AM BLOOD CK-MB-9 cTropnT-0.08*\n___ 06:50AM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.5\n\nMicrobiology\n=========\nUrine culture ___: no growth\nBlood culture ___: no growth\n\nImaging\n===========\nCTA chest ___\nIMPRESSION: \nNo evidence of pulmonary embolism or aortic abnormality. \n\nTTE ___\nThe left atrium is normal in size. There is mild symmetric left \nventricular hypertrophy with normal cavity size and global \nsystolic function (LVEF>55%). Regional left ventricular wall \nmotion is probably normal. Diastolic function could not be \nassessed. Right ventricular chamber size and free wall motion \nare normal. The number of aortic valve leaflets cannot be \ndetermined. There is no aortic valve stenosis. No aortic \nregurgitation is seen. The mitral valve leaflets are \nstructurally normal. No mitral regurgitation is seen. The \nestimated pulmonary artery systolic pressure is normal. There is \nan anterior space which most likely represents a prominent fat \npad. \n\nCompared with the report of the prior study (images unavailable \nfor review) of ___, the findings are probably similar.\n\nTEE ___\nNo spontaneous echo contrast or thrombus is seen in the body of \nthe left atrium/left atrial appendage or the body of the right \natrium/right atrial appendage. There is a small PFO visualized \nby color flow Doppler imaging. Overall left ventricular systolic \nfunction is normal (LVEF>55%). Right ventricular chamber size \nand free wall motion are normal. There are simple atheroma in \nthe ascending aorta and the descending thoracic aorta. The \naortic valve leaflets (3) appear structurally normal with good \nleaflet excursion. No masses or vegetations are seen on the \naortic valve. No aortic regurgitation is seen. The mitral valve \nleaflets are structurally normal. No mass or vegetation is seen \non the mitral valve. Mild (1+) mitral regurgitation is seen. The \npulmonary artery systolic pressure could not be determined. No \nvegetation/mass is seen on the pulmonic valve. There is no \npericardial effusion. \n\nIMPRESSION: No spontaneous echo contrast or ___ \nthrombus identified. Normal biventricular systolic function. \nMild mitral regurgitation. Small PFO. \n\nProcedures\n=============\nCardioversion ___\nIMPRESSION:\nSuccessful electrical cardioversion of atrial fibrillation to \nsinus rhythm.\n\nDischarge Labs\n===============\n___ 07:52AM BLOOD WBC-8.6 RBC-4.92 Hgb-13.9 Hct-42.7 MCV-87 \nMCH-28.3 MCHC-32.6 RDW-13.1 RDWSD-40.5 Plt ___\n___ 07:52AM BLOOD Plt ___\n___ 07:52AM BLOOD ___ PTT-73.8* ___\n___ 07:52AM BLOOD Glucose-218* UreaN-12 Creat-1.0 Na-137 \nK-4.3 Cl-103 HCO3-25 AnGap-13\n___ 07:52AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.___ hx AF on Coumadin (s/p DCCV ___, recurrence ___ \nrestarted on AC), DM2 on Insulin, R BKA with prosthetic joint, \nMRSA Cellulitis, HTN, HLD, chronic pain syndrome, transferred to \n___ for chest pain, worsening dyspnea on exertion and elevated \ntroponin, concerning for NSTEMI.\n \n#NSTEMI: Patient presented with chest pain in setting of \nelevated troponin, concerning for Type I NSTEMI. However, \npatient had stress echo at ___ on ___, which showed no \nevidence of ischemia. Patient in atrial fibrillation with \nintermittent RVR throughout admission, so troponin elevation \nfelt to be secondary to Type I NSTEMI in setting of demand. \nTroponin stabilized and then downtrended. Patient underwent TEE \non ___ which showed no thrombus and he was subsequently \ncardioverted. He remained in sinus rhythm for the remainder of \nhospitalization. Patient's Warfarin discontinued and he was \nplaced on Rivaroxaban post cardioversion. He was discharged to \nhome with Cardiology follow up. \n \n# Atrial Fibrillation: Patient in atrial fibrillation with rates \nin 90-100s during admission. Given negative stress echo, \npatient's symptoms thought to be triggered by persistent atrial \nfibrillation. Patient on Metoprolol XL 200mg daily for rate \ncontrol, and he was continued on equivalent fractionated dose. \nHis home Warfarin was held prior to cardioversion and patient \nbridged with heparin drip. He underwent successful cardioversion \non ___ and remained in sinus rhythm for the remainder of \nadmission. Warfarin was not re-started and patient started on \nRivaroxaban for anticoagulation. He was discharged on \nRivaroxaban and Metoprolol with cardiology follow up. \n\n# Leukocytosis: WBC was 10.9 on admission. Infectious work up \nwas negative. Thought to be stress response in setting of \npersistent atrial fibrillation. Leukocytosis resolved without \nintervention. \n\n# Type 2 Diabetes: continued on home glargine and insulin \nsliding scale. Metformin held during admission but resumed upon \ndischarge.\n\n# HTN: continued Lisinopril.\n \n# HLD: continued Atorvastatin.\n \n# Chronic Pain Syndrome/Psych: Continued home gabapentin, \noxycodone and acetaminophen.\n\n# Urinary Incontinence: continued Oxybutynin\n\nTransitional Issues:\n-Medications ADDED during this hospitalization: Rivaroxaban 20mg \ndaily with dinner\n-Medications STOPPED during this hospitalization: Warfarin 2mg \ndaily\n-Patient to follow up with Cardiologist Dr. ___ on \n___ who will determine length of anticoagulation. \n-Patient has small cut on plantar aspect of R foot. Does not \nappear infected. Patient instructed to apply bacitracin and keep \nthe wound covered. PCP should follow until healed. \n-CODE: Full (confirmed) \n-CONTACT: wife ___ ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 1000 mg PO BID \n2. Glargine 66 Units Bedtime\nNovolog 18 Units Breakfast\nNovolog 18 Units Lunch\nNovolog 18 Units Dinner\n3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain \n4. Warfarin 2.5 mg PO DAILY16 \n5. Vitamin D 1000 UNIT PO DAILY \n6. Gabapentin 900 mg PO TID \n7. Atorvastatin 20 mg PO DAILY \n8. Lisinopril 20 mg PO DAILY \n9. Metoprolol Tartrate 100 mg PO BID \n10. nystatin 100,000 unit/gram topical TID \n11. urea 40 % topical BID \n12. oxybutynin chloride 5 mg oral DAILY \n\n \nDischarge Medications:\n1. Rivaroxaban 20 mg PO DINNER \nDaily with the evening meal. \nRX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0\n2. Gabapentin 900 mg PO TID \n3. Glargine 66 Units Bedtime\nNovolog 18 Units Breakfast\nNovolog 18 Units Lunch\nNovolog 18 Units Dinner\n4. Lisinopril 20 mg PO DAILY \n5. Metoprolol Tartrate 100 mg PO BID \n6. Vitamin D 1000 UNIT PO DAILY \n7. MetFORMIN (Glucophage) 1000 mg PO BID \n8. nystatin 100,000 unit/gram topical TID \n9. oxybutynin chloride 5 mg oral DAILY \n10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain \n11. urea 40 % topical BID \n12. Atorvastatin 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nAtrial Fibrillation with rapid ventricular response\nType 2 NSTEMI\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 caring for you at ___ \n___. You were admitted because of chest pain and \nshortness of breath. Our testing revealed that you did not have \na heart attack. Your heart was found to be in an abnormal \nrhythm, called atrial fibrillation, which was the likely cause \nof your symptoms. You underwent a cardioversion, a procedure to \nshock your heart back into a normal rhythm. The procedure was \nsuccessful and you did well. \n\nYou were started on a medication called Rivaroxaban, which thins \nyour blood and prevents clots. You should continue taking this \nmedication for one month after your discharge. Please STOP \ntaking warfarin. \n\nYou should follow up with your PCP and ___ (see \nappointments below).\n\nWe wish you all the best in your recovery.\n\nSincerely, \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I4891", "I248", "E1140", "Z7901", "I10", "Z87891", "Z794", "G4700", "G894", "Z8614", "E785", "R32" ]

[ "I4891: Unspecified atrial fibrillation", "I248: Other forms of acute ischemic heart disease", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin", "G4700: Insomnia, unspecified", "G894: Chronic pain syndrome", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection", "E785: Hyperlipidemia, unspecified", "R32: Unspecified urinary incontinence" ]

[ "I4891", "Z7901", "I10", "Z87891", "Z794", "G4700", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nabd pain, nausea\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ w/ hx of Afib, CVA on coumadin, prior SBO s/p ex-lap w/ LOA\n___ who now p/w abd pain, with questionable partial SBO, \npassing flatus & loose stools \n\n \nPast Medical History:\nHigh Cholesterol\nStroke\nafib on Coumadin\nCHF\n\nPast Surgical History:\n___'s lateral R ankle ___\nEx-lap, LOA ___ (___)\nCecal polyp removal \nC-section x2\n \nFamily History:\nnon contributory \n \nPhysical Exam:\nVitals: 24 HR Data (last updated ___ @ 021)\n Temp: 97.5 (Tm 98.5), BP: 118/52 (118-160/52-70), HR: 48\n(48-59), RR: 16, O2 sat: 96% (93-96), O2 delivery: RA \nFluid Balance (last updated ___ @ 2143) \n Last 8 hours Total cumulative 124ml\n IN: Total 124ml, IV Amt Infused 124ml\n OUT: Total 0ml, Urine Amt 0ml\n Last 24 hours Total cumulative 124ml\n IN: Total 124ml, IV Amt Infused 124ml\n OUT: Total 0ml, Urine Amt 0ml \nPhysical exam:\nGen: NAD, AxOx3\nCard: RRR, no m/r/g\nPulm: no respiratory distress\nAbd: Soft, non tender, non-distended\nExt: No edema, warm well-perfused\n \nPertinent Results:\nEXAMINATION: CT ABD AND PELVIS WITH CONTRAST \n \nFINDINGS: \n \nLOWER CHEST: Visualized lung fields are within normal limits. \nThere is no \nevidence of pleural or pericardial effusion. \n \nABDOMEN: \n \nHEPATOBILIARY: The liver demonstrates homogenous attenuation \nthroughout. \nThere is no evidence of focal lesions. There is no evidence of \nintrahepatic or \nextrahepatic biliary dilatation. The gallbladder is within \nnormal limits. \n \nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence of \nfocal lesions or pancreatic ductal dilatation. There is no \nperipancreatic \nstranding. \n \nSPLEEN: The spleen shows normal size and attenuation throughout, \nwithout \nevidence of focal lesions. \n \nADRENALS: The right and left adrenal glands are normal in size \nand shape. \n \nURINARY: Mild cortical thinning bilaterally. Small cortical \nhypodensities \nbilaterally are too small to characterize. Otherwise, the \nkidneys are of \nnormal and symmetric size with normal nephrogram. There is no \nevidence of \nfocal renal lesions or hydronephrosis. There is no perinephric \nabnormality. \n \nGASTROINTESTINAL: There is a small hiatal hernia. The stomach \ndistended with \nair and fluid. The duodenum and proximal jejunum are normal in \ncaliber. \nThere is circumferential wall thickening involving a segment of \njejunum in the \nleft upper quadrant (series 601, image 39). There are several \nloops of mildly \ndilated small bowel with suspected transition points in the left \nmid abdomen \nand pelvis (series 2, image 32/58). These loops are distal to \nthe segment of \njejunal thickening. There is fecalization in the terminal ileum \nbut the \ndistal bowel is otherwise normal in caliber. There is no \npneumoperitoneum, or \norganized fluid collection. \n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is \ntrace free fluid in the pelvis. \n \nREPRODUCTIVE ORGANS: The visualized reproductive organs are \nunremarkable. \n \nLYMPH NODES: There is no retroperitoneal or mesenteric \nlymphadenopathy. There \nis no pelvic or inguinal lymphadenopathy. \n \nVASCULAR: There is no abdominal aortic aneurysm. Mild \natherosclerotic disease \nis noted. \n \nBONES: Multilevel degenerative changes of the lumbar spine with \na similar \nappearance of the compression deformity involving the L2 \nvertebral body. \nThere is no evidence of worrisome osseous lesions or acute \nfracture. \n \nSOFT TISSUES: The abdominal and pelvic wall is within normal \nlimits. \n \nIMPRESSION: \n \n1. Low-grade small-bowel obstruction with at least ___ssociated short segments of circumferential wall \nthickening. \n2. No pneumoperitoneum or fluid collections. \n\n \nBrief Hospital Course:\n___ w/ hx of Afib, CVA on coumadin, prior SBO s/p ex-lap w/ LOA \n___ who now p/w abd pain. She was admitted to the ACS service \nfollowing her CT scan which was concerning for partial small \nbowel obstruction. She was kept NPO with IV fluids overnight. \nShe did well overnight on HD 1 and continued to pass flatus and \nhave bowel movements. Her abdominal pain resolved and she was \ngiven a regular diet which was well tolerated. \n\nOn the day of discharge the patient was tolerating a regular \ndiet without nausea or emesis, she was passing flatus and having \nBMs. Her abdominal pain had resolved and she was not nauseated. \nShe was ambulating at her baseline and was deemed medically \nappropriate for discharge home. She should follow up with her \nprimary care physician and resume all home medications following \nher discharge from the hospital. \n \nMedications on Admission:\nLasix 20 mg QD\nCoumadin (2 mg x 6x weekly, 1 mg 1x weekly)\nAlprazolam 0.25 mg TID:PRN\nSimvastatin 80mg\nDorzolamide-Timolol eye drops BID\n \nDischarge Medications:\n1. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n3. ALPRAZolam 0.25 mg PO TID \n4. Aspirin 81 mg PO DAILY \n5. Atenolol 25 mg PO DAILY \n6. FoLIC Acid 1 mg PO DAILY \n7. Furosemide 20 mg PO DAILY \n8. Simvastatin 40 mg PO QPM \n9. Vitamin D 1000 UNIT PO DAILY \n10. vits A-C-E-B complx-min-lutein 5,000 unit- 120 mg-60 unit \noral unknown \n11. ___ MD to order daily dose PO DAILY16 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSmall Bowel Obstruction\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ \nevaluation of your abdominal pain and were diagnosed with a \nsmall bowel obstruction. You are recovering well and are now \nready for discharge. Please follow the instructions below to \ncontinue your recovery:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n \nFollowup Instructions:\n___\n" ]

[ "K56600", "I4891", "Z7901", "E7800", "I509", "Z8673", "Z86010" ]

[ "K56600: Partial intestinal obstruction, unspecified as to cause", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "E7800: Pure hypercholesterolemia, unspecified", "I509: Heart failure, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z86010: Personal history of colonic polyps" ]

[ "I4891", "Z7901", "Z8673" ]

[]

[ " \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 \n___ Complaint:\nAbdominal pain, constipation and large bowel obstruction\n \nMajor Surgical or Invasive Procedure:\nLaparotomy and total colonic resection with proximal proctectomy \nwith end ileostomy.\n\n \nHistory of Present Illness:\n___ MEDICINE ATTENDING ADMISSION NOTE .\n.\n___\nTime: 0256\n.\n_\n________________________________________________________________\n\nPCP: Name: ___ \n___: ___ \nAddress: ___ \nPhone: ___ \nFax: ___ \n\nCC: ___ pain and constipation\n\n_\n________________________________________________________________\n\nHPI:\nThe patient is a ___ year old male with h/o BPAD self treated \nwith marijuana, who has never had a colonoscopy who presents \nwith abdominal distension, abdominal pain and decreased stool \noutput -> no stool output x 10 days. This was initially thought \nto represent constpation, for which meds were attempted without \nimprovement. He reports that in the past ___ days he has not \nstooled, and may not have had flatus. He was sent for CT scan \nyesterday, where he was told that he had new colon ca. He was \nreferred to the ED given the finding of bowel obstruction on \nimaging.\n.\n \nIn ER: (Triage Vitals: 3 |98.4 |113 |135/92 |20 |98% RA ) \nMeds Given: None\nFluids given: 1L NS \nRadiology Studies: abdominal CT/consults called- GI-ERCP for \nplacement of sigmoid stent and ACS\n.\nREVIEW OF SYSTEMS:\nCONSTITUTIONAL: As per HPI- denies fevers or chills and he has \nhad a 20 lb intentional weight loss over the past year\nHEENT: [X] All normal\nRESPIRATORY: [+] cough which he states is secondary to the air \nin the ED being dry\nCARDIAC: [X] All normal\nGI: As per HPI\nGU: [X] All normal\nSKIN: [X] All normal\nMUSCULOSKELETAL: [X] All normal\nNEURO: [X] All normal\nENDOCRINE: [X] All normal\nHEME/LYMPH: [X] All normal\nPSYCH: [X] All normal\nAll other systems negative except as noted above\n \n\n \nPast Medical History:\nPMH:\nVaricose veins\n? Bipolar affective disorder\nPSH:\nMicrophlebectomy\n \nSocial History:\n___\nFamily History:\nFather died of metastatic melanoma at age ___. Mother is alive \nand lives independently at age ___. \n \nPhysical Exam:\nVitals: T 97.7 P 88 BP 148/79 RR 20 SaO2 97% on RA\nGEN: NAD, chronically ill appearing who appears older than his \nstated age\nHEENT: ncat anicteric MMM \nCV: s1s2 rr no m/r/g \nRESP: b/l ae no w/c/r \nABD: no bowel sounds, distended, soft-> firm, with no rebound. \nMild tenderness with deep palpation throughout. \n\nEXTR:? increased LLE edema compared to R \nDERM: no rash \nNEURO: face symmetric speech fluent \nPSYCH: calm, cooperative \n\nAt discharge:\nNAD\nRRR\nEWOB\nAb soft, slightly tender, ostomy pink, output WNL, surgical \nincisions clean dry and intact\nNeuro grossly intact\n\n \nPertinent Results:\n___ 09:01PM LACTATE-1.6\n___ 08:50PM GLUCOSE-89 UREA N-16 CREAT-0.9 SODIUM-138 \nPOTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-23 ANION GAP-21*\n___ 08:50PM estGFR-Using this\n___ 08:50PM CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-2.4\n___ 08:50PM WBC-10.9* RBC-4.74 HGB-13.8 HCT-42.1 MCV-89 \nMCH-29.1 MCHC-32.8 RDW-13.9 RDWSD-44.9\n___ 08:50PM NEUTS-64.3 ___ MONOS-8.5 EOS-0.1* \nBASOS-0.5 IM ___ AbsNeut-6.99* AbsLymp-2.82 AbsMono-0.92* \nAbsEos-0.01* AbsBaso-0.05\n___ 08:50PM PLT COUNT-427*\n============================\nADMISSION ABDOMINAL CT SCAN:\n Large bowel obstruction - Narrowing/collapse of the large bowel \nlumen in \nat the site of focal apple core wall thickening in the region of \nthe distal \nsigmoid/rectum junction which may correspond to the known colon \ncancer \nresulting in proximal large bowel dilation with stool. No free \nair or \nevidence of pneumatosis. Wall enhancement is normal. No evidence \nof \nlymphadenopathy. \n \n2. 8-mm right adrenal nodule of uncertain etiology. This could \nbe further \nevaluated with MR or CT with adrenal protocol. \n=================================================\n___\nABDOMINAL CT SCAN IN ATRIUS\nObstructing mass in the rectosigmoid with large and small bowel \ndilatation\n\nproximally. Adjacent involvement of the pararectal soft \ntissues. Enlarged\n\nright pararectal lymph node and mild free fluid in the pelvis.\n\nSmall right pleural effusion.\n\n1 cm indeterminate nodule in the right adrenal.\n\nOn discharge:\n___ 07:20AM BLOOD WBC-8.2 RBC-3.09* Hgb-8.9* Hct-28.2* \nMCV-91 MCH-28.8 MCHC-31.6* RDW-14.1 RDWSD-47.3* Plt ___\n___ 07:20AM BLOOD Plt ___\n___ 06:40AM BLOOD Glucose-88 UreaN-12 Creat-0.6 Na-140 \nK-3.4 Cl-105 HCO3-25 AnGap-13\n___ 06:40AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.1\n___ 07:20AM BLOOD calTIBC-160* TRF-123*\n \nBrief Hospital Course:\n___ presented to pre-op holding at ___ on ___ \n\nfor a proctocolectomy w/ end ilesotomy. He tolerated the \nprocedure well \nwithout complications (Please see operative note for further \ndetails). After a brief and uneventful stay in the PACU, the \npatient was transferred to the floor for further post-operative \nmanagement. On ___, he was bolused 1L of fluid for low urine \noutput. On ___, his foley was discontinued. On ___, he was \ntolerating PO and voided independently. On ___, his malecot \nwas discontinued, was started on a regular diet, and was started \non loperamide for high ostomy output. On ___, he received \nostomy teaching. On ___, his loperamide was increased for high \nostomy output. He also received ostomy teaching. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a PCA. Pain was \n\nvery well controlled. The patient was then transitioned to oral \npain medication once tolerating a diet. \n \nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. \n\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \n\ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \n\nGI/GU/FEN: The patient was initially kept NPO. The patient had \nemesis that later resolved. She was then advanced to clears then \n\nto a regular diet, which was tolerated. \n\nID: The patient's fever curves were closely watched for signs of \n\ninfection, of which there were none. \n\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none. \n\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible. \n\nOn ___, the patient was discharged to home with services. \nAt discharge, \nhe was 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\nInclude in Brief Hospital Course for Every Patient and check of \nboxes that apply: \nPost-Surgical Complications During Inpatient Admission: \n[ ] Post-Operative Ileus resolving w/o NGT \n[ ] Post-Operative Ileus requiring management with NGT \n[ ] UTI \n[ ] Wound Infection \n[ ] Anastomotic Leak \n[ ] Staple Line Bleed \n[ ] Congestive Heart failure \n[ ] ARF \n[ ] Acute Urinary retention, failure to void after Foley D/C'd \n[ ] Acute Urinary Retention requiring discharge with Foley \nCatheter \n[ ] DVT \n[ ] Pneumonia \n[ ] Abscess \n[ X] None \nSocial Issues Causing a Delay in Discharge: \n[ ] Delay in organization of ___ services \n[ ] Difficulty finding appropriate rehabilitation hospital \ndisposition. \n[ ] Lack of insurance coverage for ___ services \n[ ] Lack of insurance coverage for prescribed medications. \n[ ] Family not agreeable to discharge plan. \n[ X] Patient knowledge deficit related to ileostomy delaying \ndischarge. \n[ ] No social factors contributing in delay of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN pain \nDo not take over 3000 mg per day \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*50 Tablet Refills:*0\n2. LOPERamide 2 mg PO TID ostomy output \nplease continue to monitor ileostomy output \nRX *loperamide 2 mg 1 tablet by mouth three times a day Disp \n#*100 Tablet Refills:*0\n3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \ndo not drink alcohol or drive a car while taking this medication \n\nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*25 Tablet Refills:*0\n4. Nicotine Patch 14 mg TD DAILY \nplease take until ___, and then taper to lower dose patch \nRX *nicotine 14 mg/24 hour 1 patch daily Disp #*10 Patch \nRefills:*0\n5. Nicotine Patch 7 mg TD DAILY Duration: 14 Days \nplease take for two weeks after finishing 14mg patch \nRX *nicotine 7 mg/24 hour 1 patch daily Disp #*14 Patch \nRefills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLarge bowel resections secondary to upper rectal cancer with \nimpending perforation.\n\n \nDischarge Condition:\nActivity Status: Ambulatory - Independent.\nLevel of Consciousness: Alert and interactive.\nMental Status: Clear and coherent.\n\n \nDischarge Instructions:\n___ were admitted to the hospital after a proctocolectomy with \nend ilesotomy. ___ have recovered from this procedure well and \n___ are now ready to return home. Samples from your colon were \ntaken and this tissue has been sent to the pathology department \nfor analysis. ___ will receive these pathology results at your \nfollow-up appointment. If there is an urgent need for the \nsurgeon to contact ___ regarding these results they will contact \n___ before this time. ___ have tolerated a regular diet, are \npassing gas and your pain is controlled with pain medications by \nmouth. ___ may return home to finish your recovery. \n \nPlease monitor your bowel function closely. ___ may or may not \nhave had a bowel movement prior to your discharge which is \nacceptable, however it is important that ___ have a bowel \nmovement in the next ___ days. After anesthesia it is not \nuncommon for patient’s to have some decrease in bowel function \nbut ___ should not have prolonged constipation. Some loose stool \nand passing of small amounts of dark, old appearing blood are \nexpected. However, if ___ notice that ___ are passing bright red \nblood with bowel movements or having loose stool without \nimprovement please call the office or go to the emergency room \nif the symptoms are severe. If ___ are taking narcotic pain \nmedications there is a risk that ___ will have some \nconstipation. Please take an over the counter stool softener \nsuch as Colace, and if the symptoms do not improve call the \noffice. If ___ have any of the following symptoms please call \nthe office for advice or go to the emergency room if severe: \nincreasing abdominal distension, increasing abdominal pain, \nnausea, vomiting, inability to tolerate food or liquids, \nprolonged loose stool, or extended constipation. \n \n___ have ___ laparoscopic surgical incisions on your abdomen \nwhich are closed with internal sutures and a skin glue called \nDermabond. These are healing well however it is important that \n___ monitor these areas for signs and symptoms of infection \nincluding: increasing redness of the incision lines, \nwhite/green/yellow/malodorous drainage, increased pain at the \nincision, increased warmth of the skin at the incision, or \nswelling of the area. Please call the office if ___ develop any \nof these symptoms or a fever. ___ may go to the emergency room \nif your symptoms are severe. \n___ may shower; pat the incisions dry with a towel, do not rub. \nThe small incisions may be left open to the air. If closed with \nsteri-strips (little white adhesive strips) instead of \nDermabond, these will fall off over time, please do not remove \nthem. Please no baths or swimming for 6 weeks after surgery \nunless told otherwise by your surgical team.\n \n___ will be prescribed narcotic pain medication. This medication \nshould be taken when ___ have pain and as needed as written on \nthe bottle. This is not a standing medication. ___ should \ncontinue to take Tylenol for pain around the clock and ___ can \nalso take Advil. Please do not take more than 3000mg of Tylenol \nin 14 hours. Do not drink alcohol while taking narcotic pain \nmedication or Tylenol. Please do not drive a car while taking \nnarcotic pain medication.\n\n \nNo heavy lifting greater than 6 lbs for until your first \npost-operative visit after surgery. Please no strenuous activity \nuntil this time unless instructed otherwise. \n \nThank ___ for allowing us to participate in your care! Our hope \nis that ___ will have a quick return to your life and usual \nactivities. Good luck! \n \n\n___ have a new ileostomy. The most common complication from a \nnew ileostomy placement is dehydration. The output from the \nstoma is stool from the small intestine and the water content is \nvery high. The stool is no longer passing through the large \nintestine which is where the water from the stool is reabsorbed \ninto the body and the stool becomes formed. ___ must measure \nyour ileostomy output for the next few weeks. The output from \nthe stoma should not be more than 1200cc or less than 500cc. If \n___ find that your output has become too much or too little, \nplease call the office for advice. The office nurse or nurse \npractitioner can recommend medications to increase or slow the \nileostomy output. Keep yourself well hydrated, if ___ notice \nyour ileostomy output increasing, take in more electrolyte drink \nsuch as Gatorade. Please monitor yourself for signs and symptoms \nof dehydration including: dizziness (especially upon standing), \nweakness, dry mouth, headache, or fatigue. If ___ notice these \nsymptoms please call the office or return to the emergency room \nfor evaluation if these symptoms are severe. ___ may eat a \nregular diet with your new ileostomy. However it is a good idea \nto avoid fatty or spicy foods and follow diet suggestions made \nto ___ by the ostomy nurses. \n \nPlease monitor the appearance of the ostomy and stoma and care \nfor it as instructed by the wound/ostomy nurses. ___ stoma \n(intestine that protrudes outside of your abdomen) should be \nbeefy red or pink, it may ooze small amounts of blood at times \nwhen touched and this should subside with time. The skin around \nthe ostomy site should be kept clean and intact. Monitor the \nskin around the stoma for bulging or signs of infection listed \nabove. Please care for the ostomy as ___ have been instructed by \nthe wound/ostomy nurses. ___ will be able to make an appointment \nwith the ostomy nurse in the clinic 7 days after surgery. ___ \nwill have a visiting nurse at home for the next few weeks \nhelping to monitor your ostomy until ___ are comfortable caring \nfor it on your own. \n\n \nFollowup Instructions:\n___\n" ]

[ "C188", "K5669", "F17210", "F419", "F1290", "F319", "Z808", "R05" ]

[ "C188: Malignant neoplasm of overlapping sites of colon", "K5669: Other intestinal obstruction", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F419: Anxiety disorder, unspecified", "F1290: Cannabis use, unspecified, uncomplicated", "F319: Bipolar disorder, unspecified", "Z808: Family history of malignant neoplasm of other organs or systems", "R05: Cough" ]

[ "F17210", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old male with history of CAD s/p PCI to the LAD \n(___), atrial fibrillation s/p PPM, diabetes, hypertension, \nhyperlipidemia, and recent diagnosis of testicular cancer \npresenting with chest pain. \n\nPatient notes sudden onset chest pain at 5:30 ___. He notes this \npain is similar to prior pain at time of MI in ___, \ndescribed as crushing, burning substernal chest pain (like a \n\"fist \ninto the chest\"), radiating to left arm. He took 325 mg ASA \nprior to presentation to ___. He reported to the nurse at \n___ that the pain was since ___, but reported to the MD \nat ___ that it was since ~2 hours PTA to ___ (time of \npresentation ~ 9 pm), progressively worsening. EKG there \nreportedly in NSR, narrow complex, without ST elevations. Chest \nX ray reportedly unremarkable. \n\nPatient was given 4 of morphine, and 0.3 Nitroglycerin SL with \nsome improvement in pain. The plan at ___ was to admit for \nobservation with telemetry and trending with cardiac troponins, \nhowever patient requested transfer to ___ as he had received \nprevious care here. \n \nOf note, patient was recently diagnosed with testicular cancer \nat ___ with recent surgery ___ with urology at ___. His Plavix \nwas held for 10 days prior to the surgery and then restarted one \nday after. \n\nIn addition, ___ and ___ notes that patient has \nhad history of drug seeking behavior, with frequent requests for \nbenzodiazepines and opiates, pain contract in place, and note to \n\"not administer any narcotics in ER, due to hx ED visits that \nare triggered by drug seeking behavior.\" \n\nIn the ED initial vitals were: \nTemp. 98.4, HR 85, BP 137/86, RR 18, 97% RA \nEKG: Sinus rhythm, HR 56. \nLabs/studies notable for: \ntrop < 0.01 \nWBC 12, Hg 9.9, platelets 237 \nPatient was given: \nIV Lorazepam .5 mg \nIV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min ordered) \nIV Morphine Sulfate 2 mg \nIV Morphine Sulfate 2 mg \nHYDROmorphone (Dilaudid) .25 mg \n \nVitals on transfer: \nHR 62, BP 122/54, RR 14, SpO2 97% RA \n\nOn the floor, patient notes notes ongoing ___ substernal chest \npain with radiation to the left arm. Patient states that since \nhis PCI in ___ he has not had any more chest pain until \nnow, states patient (however, per chart review was admitted in \n___ for chest pain). He was requesting to eat, and states \nthat his pain medication of choice is IV dilaudid. We explained \nthat if concerned for cardiac cause would not want to mask his \nchest pain and if there were any potential intervention would \nwant to keep him NPO. His chest pain improved to ___. \n\nPatient notes he is very anxious over receiving diagnosis of \naggressive testicular cancer on ___. He notes he is \nscheduled for a pan-scan on ___ to evaluate for metastasis. \nHe notes severe anxiety over this with support from his son and \nwife. Patient notes he would be ok with SW consult for coping. \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n- Coronary artery disease s/p DES to LAD in ___ \n- Atrial fibrillation s/p PPM \n3. OTHER PAST MEDICAL HISTORY \n- CLL \n- Stroke in ___ \n \nSocial History:\n___\nFamily History:\n- No cancer or stroke\n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION/DISCHARGE:\n======================================\nVS: 98.3-98.8 ___ RA\nGENERAL: WDWN male in NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple with JVP flat \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. ___ SEM LSB. No thrills, lifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\n \nPertinent Results:\nLAB RESULTS ON ADMISSION:\n=========================\n___ 02:43AM BLOOD WBC-12.0* RBC-3.86* Hgb-9.9* Hct-31.4* \nMCV-81* MCH-25.6* MCHC-31.5* RDW-13.9 RDWSD-40.6 Plt ___\n___ 02:43AM BLOOD Neuts-52.8 ___ Monos-6.9 Eos-4.4 \nBaso-0.5 Im ___ AbsNeut-6.33* AbsLymp-4.16* AbsMono-0.82* \nAbsEos-0.53 AbsBaso-0.06\n___ 02:43AM BLOOD Glucose-122* UreaN-10 Creat-0.9 Na-135 \nK-4.2 Cl-98 HCO3-25 AnGap-16\n___ 09:25AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.1\n\nPERTINENT INTERVAL LABS:\n=========================\n___ 02:43AM BLOOD cTropnT-<0.01\n___ 09:25AM BLOOD CK-MB-2 cTropnT-<0.01\n\n___ CARDIAC PERFUSION PHARM\n==================================\nSUMMARY FROM THE EXERCISE LAB:\nFor pharmacologic stress dipyridamole was infused intravenously \nfor\napproximately 4 minutes at a dose of 0.142 \nmilligram/kilogram/min. 1 to 2\nminutes after the cessation of infusion, the stress dose of the \nradiotracer was\ninjected.\n \nFINDINGS: Calculated end-diastolic volume is 133 cc, however \nvisual observation\nsuggests that the left ventricular cavity size is normal.\n \nThere is a small fixed defect within the inferior wall that is \nconsistent with attenuation and does not appear on the \nattenuation correction images..\nOtherwise, rest and stress perfusion images reveal uniform \ntracer uptake\nthroughout the left ventricular myocardium.\n \nGated images reveal normal wall motion.\n \nThe calculated left ventricular ejection fraction is 65%.\n \nIMPRESSION: Normal myocardial perfusion study\n \nBrief Hospital Course:\n___ year old male with history of CAD s/p PCI to the LAD, atrial \nfibrillation s/p PPM, diabetes, hypertension, hyperlipidemia and \nrecent diagnosis of testicular cancer presenting with chest pain \nwith no ischemic ST changes, negative troponins x 3, and normal \nmyocardial perfusion study, likely in setting of anxiety. \n\n# Atypical chest pain: \nPatient with known CAD and recent PCI to LAD in ___ with recent \nholding of clopidogrel in setting of orchiectomy (although > 3 \nmonths post stent). Patient notes abrupt onset of chest pain \ninitially reported as similar in character to prior MI but later \nreported that he thought this was most likely secondary to \nanxiety and was much improved with benzodiazepines. EKG without \nischemic ST changes, atrially paced. Troponin I negative at \n___ x 1, troponin T negative x 2 here. Patient was initially \nplaced on nitro gtt and continued on home rivaroxaban given \nhistory of known coronary artery disease. Given history of CAD, \npatient underwent p-MIBI with dipyridamole stress. No anginal \ntype symptoms or significant ST segment changes. Nuclear report- \nnormal myocardial perfusion study with calculated LVEF 65%. \nSuspect that chest pain may be secondary to anxiety given recent \ndiagnosis of testicular cancer. \n\nTRANSITIONAL ISSUES:\n====================\n- Troponins negative x 3, nuclear stress test without evidence \nof ischemia\n[] Chest pain most likely related to anxiety, please consider \nsocial work for coping as an outpatient\n- No changes were made to patient's home medications\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Acyclovir 400 mg PO Q8H \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Senna 8.6 mg PO DAILY:PRN constipation \n5. Losartan Potassium 50 mg PO DAILY \n6. TraZODone 300 mg PO QHS \n7. Multivitamins 1 TAB PO DAILY \n8. Furosemide 20 mg PO DAILY \n9. Metoprolol Tartrate 12.5 mg PO BID \n10. Atorvastatin 80 mg PO QPM \n11. MetFORMIN (Glucophage) 1000 mg PO BID \n12. Levothyroxine Sodium 25 mcg PO DAILY \n13. melatonin 2.5 mg oral QHS:PRN \n14. ibrutinib 420 oral DAILY \n15. Gabapentin 300 mg PO TID \n16. Acetaminophen 500 mg PO Q8H \n17. Magnesium Oxide 400 mg PO BID \n18. ZIPRASidone Hydrochloride 40 mg PO BID \n19. FLUoxetine 20 mg PO DAILY \n20. Pantoprazole 40 mg PO Q24H \n21. Cyanocobalamin 1000 mcg PO DAILY \n22. Neomycin-Polymyxin-Bacitracin 1 Appl TP TID \n23. Rivaroxaban 10 mg PO DAILY \n24. Clopidogrel 75 mg PO DAILY \n25. Divalproex (EXTended Release) 500 mg PO BID \n26. Divalproex (EXTended Release) 250 mg PO QPM \n27. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n28. Milk of Magnesia 30 mL PO QHS:PRN constipation \n29. Glargine 56 Units Breakfast\nGlargine 56 Units Dinner\n\n \nDischarge Medications:\n1. Glargine 56 Units Breakfast\nGlargine 56 Units Dinner \n2. Acetaminophen 500 mg PO Q8H \n3. Acyclovir 400 mg PO Q8H \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. Clopidogrel 75 mg PO DAILY \n7. Cyanocobalamin 1000 mcg PO DAILY \n8. Divalproex (EXTended Release) 500 mg PO BID \n9. Divalproex (EXTended Release) 250 mg PO QPM \n10. Docusate Sodium 100 mg PO BID:PRN constipation \n11. FLUoxetine 20 mg PO DAILY \n12. Furosemide 20 mg PO DAILY \n13. Gabapentin 300 mg PO TID \n14. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n15. ibrutinib 420 oral DAILY \n16. Levothyroxine Sodium 25 mcg PO DAILY \n17. Losartan Potassium 50 mg PO DAILY \n18. Magnesium Oxide 400 mg PO BID \n19. melatonin 2.5 mg oral QHS:PRN \n20. MetFORMIN (Glucophage) 1000 mg PO BID \n21. Metoprolol Tartrate 12.5 mg PO BID \n22. Milk of Magnesia 30 mL PO QHS:PRN constipation \n23. Multivitamins 1 TAB PO DAILY \n24. Neomycin-Polymyxin-Bacitracin 1 Appl TP TID \n25. Pantoprazole 40 mg PO Q24H \n26. Rivaroxaban 10 mg PO DAILY \n27. Senna 8.6 mg PO DAILY:PRN constipation \n28. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nAtypical chest pain\nAnxiety\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___!\n\nYou came to us after sudden onset of chest pain at rest, which \ninitially reminded you of your prior heart attack.\n\nWhile you were here with us, we performed multiple EKGs and sent \nout blood tests to look for a heart attack. Good news- this did \nnot demonstrate anything that was concerning for a heart attack. \nDue to your history of a stent in ___, we ordered a nuclear \nstress test, which DID NOT demonstrate any heart damage!\n\nAs you had been under significant stress recently in the setting \nof new diagnosis of testicular cancer, we would like to \nencourage you to talk to social work as an outpatient. \n\nPlease take care, we wish you the best!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "R0789", "F419", "C6292", "I2510", "Z955", "I252", "Z950", "E119", "Z794", "I10", "E785", "Z7902", "Z8673", "C9110", "H409", "R569", "E039", "K219", "I4891" ]

[ "R0789: Other chest pain", "F419: Anxiety disorder, unspecified", "C6292: Malignant neoplasm of left testis, unspecified whether descended or undescended", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction", "Z950: Presence of cardiac pacemaker", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "H409: Unspecified glaucoma", "R569: Unspecified convulsions", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I4891: Unspecified atrial fibrillation" ]

[ "F419", "I2510", "Z955", "I252", "E119", "Z794", "I10", "E785", "Z7902", "Z8673", "E039", "K219", "I4891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses\n \nAttending: ___.\n \nChief Complaint:\nRectal bleeding noted on night prior to admission\n \nMajor Surgical or Invasive Procedure:\nColonoscopy ___ & ___: aborted due to poor bowel prep\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of CLL on\nibrutinib, non-seminoma testicular GCT (T2N2M1a, stage IIIA) s/p\nEP x4 completed ___ with normalization of markers and \nresidual\nLAD <1 cm (now on surveillance), CAD s/p LAD PCI in ___, SSS\ns/p PPM, paroxysmal atrial fibrillation on rivaroxaban, CVA,\nDMII, depression who presents for BRBPR.\n\nPatient reports BRBPR since 5PM on Wednessday. He first noticed\nthe bleeding when he took off his bathrobe to take a shower. He\nwiped the area with a towel and noted to have dark red blood. He\nreports having a colonoscopy about ___ years ago. He notes\ncontinued rectal bleeding. He also noticed increasing bruising\nover his forearms. He denies any other symptoms.\n\nOn arrival to the ED, initial vitals were 97.4 100 122/80 22 98%\nRA. Exam notable for red blood on rectal. Labs were notable for\nWBC 31.8, H/H 10.1/30.6 (at baseline), Plt 156, INR 0.9, Na 133,\nK 3.9, BUN/Cr ___, lactate 1.1, and UA negative. Urine \nculture\nwas sent. No imaging obtained. No medications given. GI was\nconsulted and recommended admission and prep for colonoscopy.\nPrior to transfer vitals were 97.5 67 149/60 18 97% RA.\n\nOn arrival to the floor, patient reports feeling like his blood\nsugar is low. He also notes pain on his tailbone due to a fall \n___\nyears ago and lying in bed all day. He denies fevers/chills,\nnight sweats, headache, vision changes,\ndizziness/lightheadedness, shortness of breath, cough,\nhemoptysis, chest pain, palpitations, abdominal pain,\nnausea/vomiting, diarrhea, hematemesis, dysuria, and hematuria.\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 (per OMR):\nCLL (17p-) and Stage IIIA Mixed germ cell tumor of the testis\n-___: Lymphocytosis incidentally found during a psychiatric\nhospitalization.\n-___: CT scan showed a slightly enlarged spleen at 14.5 cm \nand\nno adenopathy.\n-___: He met with Dr. ___ in ___ at\n___. WBC was 15.0 with 49.6% lymphocytes, Hgb 11.9,\nand platelets 260,000. Flow cytometry was consistent with CLL,\nand B-cell gene rearrangement confirmed clonality. CLL FISH \npanel\nshowed a p53 mutation. He was asymptomatic at the time of\ndiagnosis and followed with Dr. ___. \n-WBC gradually uptrended to 22.7 in ___, 37.3 in ___, \n51.3\nin ___, and 50.4 on ___. Hgb has decreased slightly to\n10.9 and Hct 34.4 with platelets 234,000 on the ___ labs. \n-___: Hematology care transitioned to Dr. ___\nafter Dr. ___. He also started having nightly sweats. \n\n-___: CT Chest without lymphadenopathy or other notable\nfindings.\n-___: Initial ___ Hematology evaluation for second\nopinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood\nflow cytometry and cytogenetics confirmed CLL with TP53 \ndeletion.\n-___: CT Abdomen/Pelvis without lymphadenopathy or other\nnotable findings.\n-___: Started ibrutinib 420 mg daily.\n-___: Ibrutinib held for vitreous bleed\n-___: Ibrutinib restarted\n-___: Per OSH records, underwent scrotal U/S showing\nheterogeneous left testicle, prominent rete testis on right.\n-___: Presented to his outpatient hematologist, Dr. \n___ a painful swollen left testicle (swelling over ~8 months,\nworsening pain). This had been evaluated on ___ with an\nultrasound that did not demonstrate torsion but did show\nheterogeneous morphology of the left testicle. HCG was \npositive.\nReferred to Dr. ___.\n-___: ibrutinib held for surgery\n-___: Underwent left radical orchiectomy. Pathology\nrevealed 3.9 cm malignant mixed germ cell tumor of the testis,\n95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1%\nchoriocarcinoma, invading hilar statin ___ vaginalis, with\nlymphatic vascular invasion and metastatic tumor nodules in the\nspermatic cord. pT2NxS1 (although no post-orch levels, beta hCG\n64 on ___, up from 21 on ___ AFP 3, LDH normal).\n-___: CT torso showing new 8 mm nodule in the left lower\nlobe, and comparison with CT ___.\nLeft para-aortic lymphadenopathy up to 2.8 cm and a 3.5 cm fluid\ncollection in the left inguinal region/scrotum, felt to be \nlikely\npostsurgical.\n-___: C1D1 EP\n-___: C2D1 EP \n\nPAST MEDICAL HISTORY:\n-Sick sinus syndrome s/p PPM ___ Revo DDD, \nMRI-compatible,\n___\n-CAD s/p DES to mid-LAD in ___. Preserved LVEF in ___.\n-Stroke ___\n-Diabetes mellitus type II on insulin\n-Hypertension\n-Hyperlipidemia\n-Morbid obesitys/p Gastric bypass surgery ___\n-Obstructive sleep apnea - not on CPAP\n-Pancreatitis ___ related to alcohol\n-s/p Cholecystectomy\n-Hypothyroidism\n-Osteoarthritis\n-s/p Bilateral shoulder surgery, chronic pain\n-Major depression with psychotic features (vs schizoaffective\ndisorder per patient) (Dr. ___ name unknown, affiliated\nwith ___)\n-Anxiety\n-Conversion disorder\n-Benign paroxysmal positional vertigo\n-Glaucoma, cataract (Dr. ___ at ___)\n\n \nSocial History:\n___\nFamily History:\nNo known history of malignancies.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: Temp 97.7, BP 159/76, HR 62, RR 18, O2 sat 96% 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: Obese, soft, non-tender, non-distended, normal bowel \nsounds.\nEXT: Warm, well perfused, 1+ bilateral lower extremity edema.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Strength full throughout. Sensation to light touch\nintact.\nSKIN: Bruising on bilateral upper extremities.\nACCESS: Right chest wall port without erythema.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS - Reviewed in E flowsheets\nGENERAL - in no distress \nEYES - anicteric \nENT - moist mucous membranes \nCV - regular, normal S1/S2\nRESPIRATORY - lungs clear bilaterally, breathing comfortably \nGI - soft, non-tender \nMUSCULOSKELETAL - no edema \nNEUROLOGIC - face symmetric, gaze conjugate, speech fluent,\noriented x4\nPSYCHIATRIC - pleasant but flattened \nINTEGUMENTARY - pale \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 11:00AM BLOOD WBC-29.0* RBC-3.73* Hgb-10.8* Hct-31.6* \nMCV-85 MCH-29.0 MCHC-34.2 RDW-13.7 RDWSD-42.4 Plt ___\n___ 09:40PM BLOOD ___ PTT-36.0 ___\n___ 11:00AM BLOOD UreaN-15 Creat-1.1 Na-132* K-3.9 Cl-93* \nHCO3-26 AnGap-13\n___ 11:00AM BLOOD Albumin-4.2 Calcium-8.9 Phos-4.4 Mg-1.7\n___ 11:00AM BLOOD %HbA1c-7.8* eAG-177*\n\nRELEVANT INTERVAL LABS\n======================\n___ 04:13AM BLOOD Glucose-175* UreaN-3* Creat-0.9 Na-125* \nK-3.9 Cl-85* HCO3-26 AnGap-14\n___ 03:36AM BLOOD Cortsol-8.2\n___ 04:13AM BLOOD Osmolal-266*\n\nSTUDIES\n=======\n___ CT ABDOMEN/PELVIS W/ CONTRAST\n1. Fluid in the colon can be correlated with diarrhea. No \nimaging findings of colitis or bowel obstruction. \nRedemonstration of findings of gastrogastric fistula. \n2. No new lymphadenopathy or definite evidence of metastatic \ndisease. \n\n___ COLONSCOPY\nAborted due to poor preparation\n\n___ Colonoscopy:\nPolyps in the cecum and descending colon (polypectomy)\nDiffuse melanosis noted throughout the colon.\nInternal hemorrhoids\nOtherwise normal colonoscopy to cecum \n\nDISCHARGE LABS\n==============\n___ 10:47AM BLOOD WBC-14.3* RBC-3.11* Hgb-9.0* Hct-27.0* \nMCV-87 MCH-28.9 MCHC-33.3 RDW-14.5 RDWSD-44.5 Plt ___\n \nBrief Hospital Course:\nMr. ___ is a ___ male with history of CLL on \nibrutinib, non-seminoma testicular GCT (T2N2M1a, stage IIIA) s/p \nEP x4 completed ___ with normalization of markers and \nresidual LAD <1 cm (now on surveillance), CAD s/p LAD PCI in \n___, SSS s/p PPM, paroxysmal atrial fibrillation on \nrivaroxaban, CVA, DMII, depression who presented with BRBPR.\n\nACUTE ISSUES:\n# GI Bleed:\n# Acute on chronic normocytic anemia with acute blood loss: Hgb \nremained stable during hospitlization, without any transfusion \nrequirement. Vitals remained stable as well. No significant \nbleeding observed while hospitalized. Patient required extremely \nprolonged colonoscopy preparation (>4 days, with 15+ MoviPrep & \nmagnesium citrate, with 2 colonoscopies with inadequate \npreparation. Colonsocopy ultimately revealed two benign \nappearing polyps which were biopsied as well as internal \nhemorrhoids. Clopidogrel stopped, after discussion with \ncardiologist, as >12 months after PCI/stenting. Ibrutinib & \nrivaroxaban held, per discussion with oncologist, Dr. ___, \n___ restarted at discharge. Aspirin dose decreased to 81 mg \ndaily\n\n# Hyponatremia: developed during bowel preparation. Improved \nwith IV NS\n\nCHRONIC ISSUES:\n# CLL: WBC remained mostly stable. Ibrutinib held, as above, and \nrestarted at discharge. Continued home acyclovir. \n\n# Testicular Cancer: He is s/p treatment with \netoposide/cisplatin with plan for surveillance. Follow-up with \nDr. ___ as scheduled. \n\n# DMII complicated by\n# Hypoglycemia: Unclear etiology. Long acting insulin was \ntransiently held during limited po intake with bowel prep and \nadjusted during hospitalization. Discharged on lantus 50 units \nBID but will require close monitoring (and likely uptitration) \nas an outpatient\n\n# CAD s/p PCI:\n# Chronic Diastolic Heart Failure: Per d/w pt's cardiologist Dr. \n___ on ___, ok to decrease home ASA from 243 to 81mg daily \nand to discontinue clopidogrel altogether as it has been >12 \nmonths since last PCI. Continued home atorvastatin and \nfenofibrate. Held home Lasix and losartan in setting of GI \nbleed. Home dose metoprolol initially held but restarted ___\n\n# Paroxysmal Atrial Fibrillation:\n# History of CVA:\n# SSS s/p PPM:\nHeld home rivaroxaban in setting of GI bleed. Resumed home-dose \nmetoprolol ___ ___, resumed rivaroxaban at discharge\n\n# Depression/Anxiety\nContinued home trazodone, ziprasidone, fluoxetine, clonidine, \nand divalproex. Added PRN low-dose lorazepam for increased \nanxiety while hospitalized, discontinued at discharge\n\n# Hypothyroidism\nContinued home levothyroxine\n\n# Chronic Back/Shoulder Pain\nContinue home Vicodin, gabapentin, and lidocaine. Pt received \nPRN one-time doses of IV morphine for breakthrough pain with \ngood effect\n\nTransitional Issues:\n====================\n- biopsy results from colonoscopy pending at discharge\n- clopidogrel stopped\n- ASA decreased to 81mg daily\n- persistently hypoglycemic requiring D10W drip though this was \nin the setting of NPO and colonoscopy prep. Lantus decreased to \n50 units BID, please increase as an outpatient prn\n\n> 30 minutes spent on discharge coordination and planning\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acyclovir 400 mg PO Q8H \n2. Aspirin 243 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. CloNIDine 0.1 mg PO TID \n5. Clopidogrel 75 mg PO DAILY \n6. Divalproex (EXTended Release) 500 mg PO QAM \n7. Divalproex (EXTended Release) 750 mg PO QPM \n8. Docusate Sodium 100 mg PO BID constipation \n9. Fenofibrate 150 mg PO DAILY \n10. FLUoxetine 20 mg PO DAILY \n11. Furosemide 20 mg PO DAILY \n12. Gabapentin 300 mg PO TID \n13. Levothyroxine Sodium 25 mcg PO DAILY \n14. Losartan Potassium 50 mg PO DAILY \n15. Magnesium Oxide 400 mg PO BID \n16. Metoprolol Tartrate 12.5 mg PO BID \n17. Pantoprazole 40 mg PO Q24H \n18. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n19. Rivaroxaban 10 mg PO DAILY \n20. Senna 8.6 mg PO BID:PRN constipation \n21. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n22. TraZODone 300 mg PO QHS \n23. ZIPRASidone Hydrochloride 40 mg PO BID \n24. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n25. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n26. melatonin 2.5 mg oral QHS:PRN \n27. MetFORMIN (Glucophage) 1000 mg PO BID \n28. Glargine 75 Units Breakfast\nGlargine 75 Units Bedtime\n29. ibrutinib 420 mg oral DAILY \n30. Lidocaine 5% Patch 3 PTCH TD QAM \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Glargine 50 Units Breakfast\nGlargine 50 Units Bedtime \n3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n4. Acyclovir 400 mg PO Q8H \n5. Atorvastatin 80 mg PO QPM \n6. CloNIDine 0.1 mg PO TID \n7. Divalproex (EXTended Release) 500 mg PO QAM \n8. Divalproex (EXTended Release) 750 mg PO QPM \n9. Docusate Sodium 100 mg PO BID constipation \n10. Fenofibrate 150 mg PO DAILY \n11. FLUoxetine 20 mg PO DAILY \n12. Furosemide 20 mg PO DAILY \n13. Gabapentin 300 mg PO TID \n14. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n15. ibrutinib 420 mg oral DAILY \n16. Levothyroxine Sodium 25 mcg PO DAILY \n17. Lidocaine 5% Patch 3 PTCH TD QAM \n18. Losartan Potassium 50 mg PO DAILY \n19. Magnesium Oxide 400 mg PO BID \n20. melatonin 2.5 mg oral QHS:PRN \n21. MetFORMIN (Glucophage) 1000 mg PO BID \n22. Metoprolol Tartrate 12.5 mg PO BID \n23. Pantoprazole 40 mg PO Q24H \n24. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n25. Rivaroxaban 10 mg PO DAILY \n26. Senna 8.6 mg PO BID:PRN constipation \n27. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n28. TraZODone 300 mg PO QHS \n29. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nGI bleed, likely lower\nAcute blood-loss anemia\nType-2 insulin-dependent diabetes mellitus complicated by \nhypoglycemia\nDifficult bowel prep\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 are admitted to the hospital for evaluation of bleeding from \nthe rectum. You are on a number of medications that can increase \nyour risk of bleeding. We contacted your cardiologist Dr. ___ \n___ agrees with stopping Plavix (clopidogrel), since it has been \nmore than 12 months since you had a stent placed.\n\nYou required a very prolonged preparation for your colonoscopy, \nwhich showed 2 polyps. They were removed.\n\nPlease monitor your blood sugars very closely at home, and call \nyour primary doctor if you have any sugars over 300 or lower \nthan 70. Your sugars were very low here so we decreased your \nlantus to 50 units twice a day, but once you restart your \nregular diet you may need to increase your insulin back to 75 \nunits twice a day. \n\n***Please note the adjustments to your medications on the \nmedication reconciliation sheet***\n\nIt was a pleasure taking care of you!\n-Your ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K625", "D62", "C9110", "I5032", "E11649", "I481", "E871", "E1136", "I2510", "Z950", "Z7901", "K648", "K635", "Z9884", "G4733", "E039", "H409", "Z8547", "F329", "F419", "M549", "M25519", "G8929", "R791", "I129", "K6389", "E669", "Z6835" ]

[ "K625: Hemorrhage of anus and rectum", "D62: Acute posthemorrhagic anemia", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "I5032: Chronic diastolic (congestive) heart failure", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "I481: Persistent atrial fibrillation", "E871: Hypo-osmolality and hyponatremia", "E1136: Type 2 diabetes mellitus with diabetic cataract", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z950: Presence of cardiac pacemaker", "Z7901: Long term (current) use of anticoagulants", "K648: Other hemorrhoids", "K635: Polyp of colon", "Z9884: Bariatric surgery status", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E039: Hypothyroidism, unspecified", "H409: Unspecified glaucoma", "Z8547: Personal history of malignant neoplasm of testis", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "M549: Dorsalgia, unspecified", "M25519: Pain in unspecified shoulder", "G8929: Other chronic pain", "R791: Abnormal coagulation profile", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "K6389: Other specified diseases of intestine", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult" ]

[ "D62", "I5032", "E871", "I2510", "Z7901", "G4733", "E039", "F329", "F419", "G8929", "I129", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nPenicillins\n \nAttending: ___\n \nChief Complaint:\nleft leg weakness and numbness\ns/p tPA\n \nMajor Surgical or Invasive Procedure:\nIV tPA prior to admission\n \nHistory of Present Illness:\nMr. ___ is a ___ yo man with CLL, DM, HTN, HLD and right\nsubcortical stroke in ___ who presents s/p tPA from OSH for \nleft\nleg numbness and weakness.\n\nToday he went into the bedroom to put on pajamas at 4:45 pm. \nWhen\nhe sat down, his left leg went numb. When he stood up to pull up\nhis pants, he almost fell to the left. He sat down and called\n___. He was taken to ___, where he was given tPA at\n6:51 pm. Since receiving tPA, he feels that his symptoms are\nunchanged.\n\nIn ___, he had left face/arm/leg paresis and numbness due to\nstroke. He recovered with the exception of Left thigh weakness,\nthough he was still able to move his leg. He walks with a cane.\nThis leg weakness/numbness today felt similar to his previous\nstroke.\n\nHe has chronic right shoulder pain.\n\n On neuro ROS, the pt denies headache, loss of vision, blurred\nvision, diplopia, dysarthria, dysphagia, lightheadedness,\nvertigo, tinnitus or hearing difficulty. Denies difficulties\nproducing or comprehending speech. No bowel or bladder\nincontinence or retention.\n \n On general review of systems, the pt denies recent fever or\nchills. No night sweats or recent weight loss or gain. Denies\ncough, shortness of breath. Denies chest pain or tightness,\npalpitations. Denies nausea, vomiting, diarrhea, constipation \nor\nabdominal pain. No recent change in bowel or bladder habits. \nNo\ndysuria. Denies arthralgias or myalgias. Denies rash.\n \nPast Medical History:\nCLL\nPPM for bradycardia\nStroke in ___\nHTN\nHLD\nDM\n \nSocial History:\n___\nFamily History:\n- no cancer or stroke\n \nPhysical Exam:\n==============================\nADMISSION EXAM:\nVitals: 98.2 63 118/49 16 97% RA \n \n General: Awake, cooperative, NAD.\n HEENT: NC/AT, MMM\n Neck: Supple, no nuchal rigidity.\n Pulmonary: CTABL\n Cardiac: RRR, no murmurs\n Abdomen: soft, nontender, nondistended\n Extremities: mild edema, pulses palpated\n \n Neurologic:\n -Mental Status: Alert, oriented x 3. Able to relate history \nwithout difficulty. Language is fluent with intact repetition \nand comprehension. Normal prosody. There were no paraphasic \nerrors. Pt. was able to name both high and low frequency \nobjects. Speech was not dysarthric. Able to follow both \nmidline and appendicular commands. Attentive, able to name ___ \nbackward without difficulty. There was no evidence of neglect.\n\n-Cranial Nerves:\n I: Olfaction not tested.\n II: PERRL 3 to 2mm, both directly and consentually; brisk \nbilaterally. VFF to confrontation.\n III, IV, VI: EOMI without nystagmus. Normal saccades.\n V: Facial sensation intact to light touch in all distributions\nVII: No facial droop, facial musculature symmetric and ___ \nstrength in upper and lower distributions, bilaterally \n VIII: Hearing intact to finger-rub bilaterally.\n IX, X: Palate elevates symmetrically.\n XI: ___ strength in trapezii and SCM bilaterally.\n XII: Tongue protrudes in midline.\n\n -Motor: Normal bulk, paratonia throughout. No pronator drift \nbilaterally. No adventitious movements, such as tremor, noted. \nNo asterixis noted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ \n L ___ ___ 5 0 0 0 4- 5 3 \n R ___ ___ ___ 5 5 5 5 \n \n -DTRs:\n Bi Tri ___ Pat Ach\n L 2 1 1 0 0\n R 2 1 1 0 0\n\n- Plantar response was extensor bilaterally.\n- Pectoralis Jerk was absent, and Crossed Adductors are absent. \n \n -Sensory: Left thigh and calf decreased FT and pin, normal \nsensation in left foot. Mildly decreased proprioception \nbilaterally.\n\n-Coordination: Mild intention tremor on L FNF. No dysmetria on \nFNF. Normal R HKS.\n\n-Gait: not tested.\n\n==============================\nDISCHARGE EXAM:\n-Mental Status: Alert, oriented x 3. Language is fluent with \nintact repetition and comprehension. Normal prosody. There \nwere no paraphasic errors. Pt. was able to name both high and \nlow frequency objects. Speech was not dysarthric. Able to \nfollow both midline and appendicular commands. Attentive with \nno evidence of neglect.\n\n-Cranial Nerves:\n PERRL, EOMI without nystagmus, no facial asymmetry , palate \nelevates symmetrically and tongue in midline \n -Motor: Full strength in the UE. \n IP Quad Ham TA ___ ___ \n L 4+ ___ 4+ 4 \n R 4+ ___ 5 5 \n \n -DTRs:\n Bi Tri ___ Pat Ach\n L 2 2 1 0 0\n R 2 2 1 0 0\n\n-Sensory: Left leg mild decrease sensation to light touch , no \ndermatomal pattern.\n\n==============================\n \nPertinent Results:\nADMISSION LABS: ___\nWBC-74.2* RBC-3.36* Hgb-9.2* Hct-30.0* Plt ___\nNeuts-7* Bands-0 Lymphs-90* Monos-2* Eos-1 Baso-0 Atyps-0 \n___ Myelos-0\nAbsNeut-5.19 AbsLymp-66.78* AbsMono-1.48* AbsEos-0.74* \nAbsBaso-0.00*\n\n___ PTT-32.5 ___\n\nGlucose-214* UreaN-14 Creat-1.2 Na-137 K-4.0 Cl-100 HCO3-23 \nAnGap-18\nALT-14 AST-28 AlkPhos-32* TotBili-0.2\nCalcium-8.8 Phos-3.9 Mg-1.8 \n\ncTropnT-<0.01\n\nSTox: negative\nUTox: +opioids\nUA: bland\n\nStroke Risk Factors:\nCholest-100 Triglyc-230* HDL-24 CHOL/HD-4.2 LDLcalc-30\n%HbA1c-7.4* eAG-166*\nTSH-20* T3-PND Free T4-PND\n\nImaging:\nCTA Head/Neck ___\nIMPRESSION: \n1. Patent circle of ___. \n2. Patent vasculature in the neck with no evidence of internal \ncarotid artery stenosis by NASCET criteria. \n3. No acute intracranial abnormality. \n4. At least moderate spinal canal stenosis at C2-C3 and C3-C4 \nsecondary to ossifications of the posterior longitudinal \nligaments. \n\nCT Head ___ post-tPA: no hemorrhagic transformation or \nevolving infarct noted\n\nEchocardiogram: The left atrium is normal in size. The \nestimated right atrial pressure is ___ mmHg. Agitated saline \ninjected at rest but suboptimal image quality precludes adequate \nvisualization of bubbles. There is mild symmetric left \nventricular hypertrophy with normal cavity size and \nregional/global systolic function (LVEF>55%). There is no \nventricular septal defect. The aortic root is mildly dilated at \nthe sinus level. The ascending aorta is mildly dilated. The \naortic valve leaflets (3) are mildly thickened but aortic \nstenosis is not present. Mild (1+) aortic regurgitation is seen. \nThe mitral valve appears structurally normal with trivial mitral \nregurgitation. There is no mitral valve prolapse. There is mild \npulmonary artery systolic hypertension. There is no pericardial \neffusion. \nIMPRESSION: Bubble study at rest performed but inadequate to \nexclude a PFO/ASD due to very suboptimal image quality. Mild \nsymmetric left ventricular hypertrophy with preserved regional \nand global systolic function (contrast used for better \nendocardial definition). Mild aortic regurgitation. Mild \npulmonary artery systolic hypertension. \n \nBrief Hospital Course:\nMr. ___ presented to OSH with acute onset left leg numbness and \nweakness. He received IV tPA and was transferred to ___ for \nmonitoring. \n\n# NEURO\nAt ___, he was found to have proximal>distal weakness of the \nleft lower extremity with some improvement in his sensory \ndeficit. His lower extremity exam had some functional overlay \nand was variable from day to day. He was monitored in the ICU \nfor 24 hours without change in his examination and there was no \nevidence hemorrhagic transformation on his CT head. The \netiology of his symptoms remained unclear. CTA head and neck was \ndifficult to interpret given timing of contrast, possibly with a \ncutoff in R ACA territory, but there was no evidence of evolving \ninfarct within the limits of CT on repeat scan. An echo was \ndone, but was of poor quality. \n\nHis stroke risk factors were assessed and include: 1) \ndyslipidemia, 2) IDDM, 3) HTN, 4) Obesity. Lipid panel revealed \nlow LDL and HDL and elevated triglycerides with a high \ntriglyceride to LDL ratio. Diabetes management is discussed \nbelow. His blood pressure was in good control ranging between \n130-160's/50's-70's. His home aspirin was restarted and his \nsimvastatin and fenofibrates were continued. No meds were \nchanged.\n\n# HEME/ONC\nHis outpatient oncologist recommended holding is ibrutinib for \n24 hours after tPA due to elevated bleeding risk. This will be \nrestarted as outpatient.\n\n# THYROID\nHe was continued on his home levothyroxine. His thyroid function \ntests were notable for an elevated TSH at 30 T3-93. \n\n# DIABETES\nHis A1c was elevated at 7.4% and his metformin was initially \nheld after contrast. He was maintained on insulin glargine and \nsliding scale. His ___ were elevated and that was the result of \ngiving him 50 ___ at bedtime when he typically has it \ntwice a day. At discharge, his diabetes regimen was restarted \nas per his home regimen given that his blood glucose was well \ncontrolled ___ that regiment and this was confirmed with ___ \nDiabetes consult team. \n\n# MUSKULOSKELETAL\nHe complained of Left shoulder pain with a remote hx of trauma, \nwe had a shoulder X-ray that was negative and pain was well \ncontrolled on Ibuprofen and Vicodin which he sues at home \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amlodipine 5 mg PO DAILY \n2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n3. Divalproex (EXTended Release) 500 mg PO QAM \n4. Divalproex (EXTended Release) 750 mg PO QPM \n5. Fenofibrate 150 mg PO DAILY \n6. Fluoxetine 10 mg PO DAILY \n7. Furosemide 20 mg PO DAILY \n8. Gabapentin 200 mg PO TID \n9. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain \n10. ibrutinib 420 mg oral DAILY \n11. Glargine 50 Units Breakfast\nGlargine 50 Units Bedtime\n12. Levothyroxine Sodium 50 mcg PO DAILY \n13. Losartan Potassium 50 mg PO DAILY \n14. MetFORMIN (Glucophage) 1000 mg PO BID \n15. RISperidone 0.5 mg PO DAILY \n16. Simvastatin 20 mg PO QPM \n17. ZIPRASidone Hydrochloride 40 mg PO BID \n18. Aspirin EC 81 mg PO DAILY \n19. Calcium Carbonate 1000 mg PO DAILY \n20. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral \nDAILY \n21. Senna 8.6 mg PO BID:PRN cosntipation \n22. TraZODone 300 mg PO QHS \n\n \nDischarge Medications:\n1. Aspirin EC 81 mg PO DAILY \n2. Divalproex (EXTended Release) 500 mg PO QAM \n3. Divalproex (EXTended Release) 750 mg PO QPM \n4. Fenofibrate 150 mg PO DAILY \n5. Gabapentin 200 mg PO TID \n6. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain \n7. Levothyroxine Sodium 50 mcg PO DAILY \n8. RISperidone 0.5 mg PO DAILY \n9. Senna 8.6 mg PO BID:PRN cosntipation \n10. Simvastatin 20 mg PO QPM \n11. ZIPRASidone Hydrochloride 40 mg PO BID \n12. Amlodipine 5 mg PO DAILY \n13. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n14. Calcium Carbonate 1000 mg PO DAILY \n15. Furosemide 20 mg PO DAILY \n16. ibrutinib 420 mg oral DAILY \n17. Losartan Potassium 50 mg PO DAILY \n18. MetFORMIN (Glucophage) 1000 mg PO BID \n19. Vitamin D3 (cholecalciferol (vitamin D3)) 400 unit oral \nDAILY \n20. Fluoxetine 10 mg PO DAILY \n21. Glargine 50 Units Breakfast\nGlargine 50 Units Bedtime\n22. TraZODone 300 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft leg weakness\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to ___ after being treated with a blood \nthinning intravenous medication called tPA for concerns of an \nacute stroke as you presented with worsening left leg weakness \nand numbness. We found no stroke on repeated brain imaging, the \nweakness and numbness has been improving. You also complained \nof left shoulder pain for which we obtained an x-ray and that \nwas normal. You should continue your home medications.\n \nFollowup Instructions:\n___\n" ]

[ "I69354", "C9110", "G8194", "Z9282", "E785", "I10", "M25512", "E0865", "J449", "E6601", "F329", "E039", "Z950", "Z9884", "H409", "G629" ]

[ "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "G8194: Hemiplegia, unspecified affecting left nondominant side", "Z9282: Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "M25512: Pain in left shoulder", "E0865: Diabetes mellitus due to underlying condition with hyperglycemia", "J449: Chronic obstructive pulmonary disease, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "Z950: Presence of cardiac pacemaker", "Z9884: Bariatric surgery status", "H409: Unspecified glaucoma", "G629: Polyneuropathy, unspecified" ]

[ "E785", "I10", "J449", "F329", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses soft, ___, cottage, cream cheese\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNONE\n\n \nHistory of Present Illness:\n___ with history of CLL on ibrutinibm metastatic testicular\ncancer, CAD s/p LAD PCI in ___, SSS s/p PPM, pAF on \nrivaroxaban,\nand DM presenting with midsternal chest pain admitted for \nnuclear\nstress test.\n\nHe woke up this morning with 9 out of 10 midsternal chest pain\nradiating to both shoulders. He felt like \"a fist was pushing\nagainst my chest and putting pressure down \". He notes that \nthis\npain was re-created by pushing on his chest, made it difficult\nfor him to breathe in secondary to worsening of his pain, and \nwas\nworse than his prior chest pains. He notes no nausea, vomiting,\ndizziness, lightheadedness, abdominal pains, or changes in bowel\nor bladder movements. He states that this was at 4 in the\nmorning, he thinks he should have called EMS at that time \nhowever\nhe waited to see if it would pass. While he was eating\nbreakfast, the pain was so unbearable that he push the Lifeline\nbutton and had been transferred him to ___ for further evaluation.\n\nOf note, in ___ he had an admission for the exact same\npresentation and history provided. At that time, he was treated\nwith morphine and nitroglycerin drip with improvement of\nsymptoms. No further escalation was done as patient has a\nhistory of drug-seeking behavior in the past. Workup at that\ntime was pan negative. A stress MIBI was performed that\ndemonstrated no signs of acute ischemia or exertional ischemia.\n\nHe has a history of CLL with high risk cytogenetics (17p)\ntreating with ibrutinib course c/b metastatic GCT s/p EP in\n___. He notes that he travelled from ___ in the last\nseveral weeks. Denies leg swelling, hemoptysis. \n\nHe was last admitted from ___ to ___ for LGIB likely\n___ internal hemorrhoids and two benign polyps while on ___, ibrutinib. His ___ was discontinued and he was\ndischarged without further issue.\n\nIn the ED, he was evaluated with a well score of 1 and a heart\nscore of 4. Troponin was negative and PE was ruled out. He was\ngiven IV morphine, low-dose aspirin, and started on Percocet. \nSublingual nitroglycerin reportedly caused worsening of \nsymptoms.\n\nPharmocologic Stress ___ neg\n\nIn the ED initial vitals were:\nPain: ___, 83, 159/105, 20, 98% on RA. \n \nEKG: Normal sinus rhythm, normal axis, enlarged LA, LVH by aVL\ncriteria. PR 228 narrow QRS, normal QTC, no STEMI\n\nLabs/studies notable for: \nWBC: 25.6* Hgb: 10.4* Plt Ct: 196 \nNeuts: 30* Bands: 1 Lymphs: 67* Monos: 2* Eos: 0 Baso: 0 Atyps: \n___\nMetas: ___ Myelos: 0 AbsNeut: 7.94* AbsLymp: 17.15* AbsMono: 0.51\nAbsEos: 0.00* AbsBaso: 0.00* \nPTT: 43.0* \ncTropnT: <0.01 \nD-Dimer: 135 \nUreaN: 15 Creat: 1.1 \n\nCXR ___\nNo definite acute cardiopulmonary abnormality\n\nPatient was given: \n___ 324 mg.\nIV Morphine Sulfate 4 mg \nSL Nitroglycerin SL .4 mg\nPO Oxycodone-Acetaminophen (5mg-325mg) 2 TAB \n\nVitals on transfer: \nPain: 7 80, 148/65, 15, 100% RA \n\nOn the floor he verifies the above history. He notes that he is\nstill having 9 out of 10 chest pain radiating to both shoulders. \n\nHe notes that he has difficulty taking deep inspiration \nsecondary\nto the pain. He denies nausea, vomiting, abdominal pain, or\nincrease in lower extreme swelling.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\nCLL (17p-) and Stage IIIA Mixed germ cell tumor of the testis\n-___: Lymphocytosis incidentally found during a psychiatric\nhospitalization.\n-___: CT scan showed a slightly enlarged spleen at 14.5 cm \nand\nno adenopathy.\n-___: He met with Dr. ___ in ___ at\n___. WBC was 15.0 with 49.6% lymphocytes, Hgb 11.9,\nand platelets 260,000. Flow cytometry was consistent with CLL,\nand B-cell gene rearrangement confirmed clonality. CLL FISH \npanel\nshowed a p53 mutation. He was asymptomatic at the time of\ndiagnosis and followed with Dr. ___. \n-WBC gradually uptrended to 22.7 in ___, 37.3 in ___, \n51.3\nin ___, and 50.4 on ___. Hgb has decreased slightly to\n10.9 and Hct 34.4 with platelets 234,000 on the ___ labs. \n-___: Hematology care transitioned to Dr. ___\nafter Dr. ___. He also started having nightly sweats. \n\n-___: CT Chest without lymphadenopathy or other notable\nfindings.\n-___: Initial ___ Hematology evaluation for second\nopinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood\nflow cytometry and cytogenetics confirmed CLL with TP53 \ndeletion.\n-___: CT Abdomen/Pelvis without lymphadenopathy or other\nnotable findings.\n-___: Started ibrutinib 420 mg daily.\n-___: Ibrutinib held for vitreous bleed\n-___: Ibrutinib restarted\n-___: Per OSH records, underwent scrotal U/S showing\nheterogeneous left testicle, prominent rete testis on right.\n-___: Presented to his outpatient hematologist, Dr. \n___ a painful swollen left testicle (swelling over ~8 months,\nworsening pain). This had been evaluated on ___ with an\nultrasound that did not demonstrate torsion but did show\nheterogeneous morphology of the left testicle. HCG was \npositive.\nReferred to Dr. ___.\n-___: ibrutinib held for surgery\n-___: Underwent left radical orchiectomy. Pathology\nrevealed 3.9 cm malignant mixed germ cell tumor of the testis,\n95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1%\nchoriocarcinoma, invading hilar statin ___ vaginalis, with\nlymphatic vascular invasion and metastatic tumor nodules in the\nspermatic cord. pT2NxS1 (although no post-orch levels, beta hCG\n64 on ___, up from 21 on ___ AFP 3, LDH normal).\n-___: CT torso showing new 8 mm nodule in the left lower\nlobe, and comparison with CT ___.\nLeft para-aortic lymphadenopathy up to 2.8 cm and a 3.5 cm fluid\ncollection in the left inguinal region/scrotum, felt to be \nlikely\npostsurgical.\n-___: C1D1 EP\n-___: C2D1 EP \n\nPAST MEDICAL HISTORY:\n-Sick sinus syndrome s/p PPM ___ Revo DDD, \nMRI-compatible,\n___\n-CAD s/p DES to mid-LAD in ___. Preserved LVEF in ___.\n-Stroke ___\n-Diabetes mellitus type II on insulin\n-Hypertension\n-Hyperlipidemia\n-Morbid obesitys/p Gastric bypass surgery ___\n-Obstructive sleep apnea - not on CPAP\n-Pancreatitis ___ related to alcohol\n-s/p Cholecystectomy\n-Hypothyroidism\n-Osteoarthritis\n-s/p Bilateral shoulder surgery, chronic pain\n-Major depression with psychotic features (vs schizoaffective\ndisorder per patient) (Dr. ___ name unknown, affiliated\nwith ___)\n-Anxiety\n-Conversion disorder\n-Benign paroxysmal positional vertigo\n-Glaucoma, cataract (Dr. ___ at ___)\n\n \nSocial History:\n___\nFamily History:\nNo known history of malignancies.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: 97.9°F, 88, 184/80, 18, 98% on room air.\nGENERAL: Obese man laying in bed wearing home pajamas in no \nacute\ndistress. Able to speak in full sentences without gasping for\nair. Does not appear to have increased work of breathing.\nHEENT: Pupils equal round reactive to light and accommodation,\nextraocular muscles intact, non-erythematous oropharynx.\nNECK: Supple with JVD to 8 cm\nCARDIAC: Regular rate and rhythm with 2 out of 6 systolic\nejection murmur best appreciated at the base. \nLUNGS: Poor inspiratory effort however clear to auscultation\nbilaterally in anterior and posterior fields with no wheezes\ncrackles or rhonchi. Pain reproduced with palpation at right\nchest wall at site of ___ costochondral joint.\nABDOMEN: Obese, soft, NTND. No HSM or tenderness. Port present\non right chest wall with bandages clean dry and intact.\nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: 98.5 PO 117/62 L Lying 71 16 99 Ra \nGENERAL: Obese man sitting in chair in NAD\nHEENT: Pupils equal round reactive to light and accommodation,\nextraocular muscles intact, non-erythematous oropharynx.\nNECK: Supple with JVP not visible\nCARDIAC: Regular rate and rhythm with 2 out of 6 systolic\nejection murmur best appreciated at the base. No pericardial rub\nappreciated. No evidence of pulsus paradoxus with 5 mmHg \ndecrease\nin systolic BP with inspiration. \nLUNGS: Poor inspiratory effort however clear to auscultation\nbilaterally in anterior and posterior fields with no wheezes\ncrackles or rhonchi. \nABDOMEN: Obese, soft, NTND. No HSM or tenderness. Port present\non right chest wall with bandages clean dry and intact.\nEXTREMITIES: Trace to 1+ edema ___. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 07:26PM GLUCOSE-198* UREA N-14 CREAT-1.0 SODIUM-136 \nPOTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-26 ANION GAP-12\n___ 07:26PM CK-MB-1 cTropnT-<0.01\n___ 07:26PM CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-1.8\n___ 07:26PM WBC-25.9* RBC-3.39* HGB-9.9* HCT-30.1* MCV-89 \nMCH-29.2 MCHC-32.9 RDW-14.9 RDWSD-48.4*\n___ 07:26PM PLT COUNT-181\n___ 02:48PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 02:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-70* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 02:48PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 02:48PM URINE HYALINE-1*\n___ 10:46AM D-DIMER-135\n___ 09:55AM GLUCOSE-186* UREA N-15 CREAT-1.1 SODIUM-135 \nPOTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-24 ANION GAP-14\n___ 09:55AM estGFR-Using this\n___ 09:55AM cTropnT-<0.01\n___ 09:55AM proBNP-98\n___ 09:55AM WBC-25.6* RBC-3.58* HGB-10.4* HCT-31.6* \nMCV-88 MCH-29.1 MCHC-32.9 RDW-14.7 RDWSD-47.2*\n___ 09:55AM NEUTS-30* BANDS-1 LYMPHS-67* MONOS-2* EOS-0 \nBASOS-0 ___ MYELOS-0 AbsNeut-7.94* AbsLymp-17.15* \nAbsMono-0.51 AbsEos-0.00* AbsBaso-0.00*\n___ 09:55AM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL \nELLIPTOCY-1+*\n___ 09:55AM PLT SMR-NORMAL PLT COUNT-196\n___ 09:55AM ___ PTT-43.0* ___\n\nDISCHARGE LABS:\n===============\n\n___ 05:20AM BLOOD WBC-15.4* RBC-3.02* Hgb-9.0* Hct-26.5* \nMCV-88 MCH-29.8 MCHC-34.0 RDW-14.5 RDWSD-46.0 Plt ___\n\nPORTABLE CXR ___:\n===================\nFINDINGS: \n \nStreaky opacity at the right lung base likely represents \natelectasis. No \ndense consolidative opacity, pleural effusion, or pneumothorax \nidentified on single view. Right-sided chest port is seen with \ntip likely terminating over the right atrium. A left-sided \npacemaker is seen. Mild cardiomegaly appears similar. \n \nIMPRESSION: \n \nNo definite acute cardiopulmonary abnormality. \n\nTTE ___:\n==========\nThe left atrium is mildly dilated. There is mild symmetric left \nventricular hypertrophy with normal cavity size and global \nsystolic function (LVEF>55%). Due to suboptimal technical \nquality, a focal wall motion abnormality cannot be fully \nexcluded. The aortic root is mildly dilated at the sinus level. \nThe aortic valve leaflets are mildly thickened (?#). The mitral \nvalve appears structurally normal with trivial mitral \nregurgitation. The estimated pulmonary artery systolic pressure \nis normal. There is a trivial/physiologic pericardial effusion. \n\nIMPRESSION: Suboptimal image quality. Trivial pericardial \neffusion. Preserved global left ventricular systolic function. \nMildly dilated aortic sinus. \n\nCompared with the prior study (images reviewed) of ___, \nthe estimated PA systolic pressure is now lower/normal. \n\nCARDIAC PERFUSION ___:\n========================\nSUMMARY FROM THE EXERCISE LAB: \nFor pharmacologic stress 0.4 mg of regadenoson (0.08 mg/ml) was \ninfused \nintravenously over 20 seconds followed by a saline flush. \n \nFINDINGS: Computer calculated end-diastolic volume is \nborderline at 114 cc, however, left ventricular cavity size \nvisually appears normal. \n \nRest and stress perfusion images again reveal a small inferior \nfixed defect, likely secondary to attenuation artifact. \nOtherwise, there is uniform tracer uptake throughout the left \nventricular myocardium. \n \nGated images reveal normal wall motion. \n \nThe calculated left ventricular ejection fraction is 62 %. \n \nIMPRESSION: Normal myocardial perfusion study. \n \nSTRESS TEST ___:\n==================\nINTERPRETATION: This ___ year old man with a history of \nhypertension, diabetes, dyslipidemia, coronary artery disease \n(s/p LAD PCI ___, referred as an inpatient for the evaluation \nof chest pain after serial negative cardiac biomarkers. He \nunderwent pharmacologic vasodilator perfusion study with \n0.4mg/5ml of regadenason over 20 seconds prior to tracer \ninjection. There was no report of any chest, back, arm, jaw, or \nneck discomfort throughout the study. There were no significant \nSTTW changes. The vasodilator effect was reversed with 125mg of \naminophylline IV. The rhythm was atrial fibrillation with \noccasional ventricular paced beats and no ectopy. There was an \nappropriate hemodynamic response to regadenason. \n\nIMPRESSION: No anginal symptoms or significant STTW changes. \nNuclear \nreport sent separately. \n\n \nBrief Hospital Course:\nPATIENT SUMMARY:\n================\n___ male with PMH of CAD s/p drug-eluting stent in ___, \nsick sinus syndrome status post pacemaker in ___, paroxysmal \natrial fibrillation, diabetes, hypertension, and CLL who \npresented with midsternal chest pain and\ndiffuse ST-segment elevations consistent with pericarditis. \n\n#CORONARIES: Mid LAD stent \n#PUMP: >55% \n#RHYTHM: Paroxysmal atrial fibrillation \n\nACUTE ISSUES: \n============\n\n#CHEST PAIN\n#PERICARDITIS\nPatient presented with ___ mid-sternal chest pain. Patient's \ntroponins were negative X4 and d-dimer also negative which \nprovided reassurance of non-ACS and non-PE event. Recreation of \npatient's chest\npain with palpation of his chest wall was initially thought to \nbe most consistent with a costochondritis. However, EKG \nobtained upon admission showed diffuse ST elevations consistent \nwith pericarditis and the patient was treated empirically for \npericarditis. TTE showed a trivial pericardial effusion and \npreserved global left ventricular systolic function with a \nmildly dilated aortic sinus. As the patient was unable to \nreceive NSAIDs due to known CAD and questionable GI bleed on \nlast admission, he was started on colchicine and prednisone. \nThis combination improved his chest pain overall, though he \ncontinued to have occasional episodes of midsternal pain leading \nup to discharge. These episodes were all self-limiting and were \nnot associated with any new EKG changes or troponin elevations. \nThe patient underwent a stress test to ensure no ischemic \ndisease. He had no anginal symptoms or significant STTW changes \nduring the pharmacological stress and myocardial perfusion was \nnormal. The patient will be discharged on colchicine (0.6 mg \nBID) and a prednisone taper.\n\n___\nPatient's creatinine bumped from 1.1 on admission to 2.2 on \n___. Patient had been NPO prior to myocardial perfusion study \nand the etiology of the ___ was thought to be pre-renal. This \nwas supported by urine electrolytes studies which revealed a \nurine Na < 20 and urine Cl also < 20, consistent with sodium \navid state. The patient was treated with a 1.5 liter fluid bolus \nand his creatinine rapidly downtrended. The patient's creatinine \nwas 1.2 on discharge. \n\n#DM\nPatient's blood sugars were monitored closely during this \nadmission. He initially was very poorly controlled with blood \nsugars in the mid ___. This was likely due to a delay in \nrestarting his home dose of Lantus 75 units BID (he had been \ninitially placed on 50 units BID). Metformin was held on \nadmission and the patient was placed on a sliding scale short \nacting insulin in addition to above metformin. Given the \npatient's need for 2 weeks of prednisone therapy to treat his \npericarditis, ___ was consulted to provide input regarding \nadequate glucose control while on steroids during this time. The \n___ team recommended adding 5 units of Homolog with a \nHumalog pen before meals. This dose was deemed appropriate to \nhelp control blood sugars while on prednisone and also safe \nenough to be continued after the steroid taper has finished. \n\n#Paroxysmal Atrial Fibrillation\nPatient in sinus rhythm upon admission. The patient's home \nmetoprolol was continued for rate control. The patient's home \nrivaroxaban was 10 mg. Unclear why patient on this dose but he \nhas been maintained on 10 mg daily since at least the end of \n___. Given the patient's normal kidney function at baseline, \nthe dose was increased to 20 mg daily prior to discharge in \norder to ensure adequate anticoagulation for atrial \nfibrillation.\n\nCHRONIC ISSUES:\n==============\n\n#CLL\nPatient presented with leukocytosis to 25.6 the setting of his \nunderlying CLL. He takes ibrutinib as an outpatient which has \nbeen controlling his symptoms. This medication was unfortunately \nnot on formulary at ___. His wife was able to bring in his \nhome ibrutinib to take while hospitalized. Acyclovir was \ncontinued at his home dose.\n\n#CHRONIC PAIN\nPatient is taking a number of medications at home to treat \nchronic pain in the shoulders as well as in his back. We \ncontinued all of these medications while he is in the hospital.\n\n#HYPOTHYROIDISM\nContinued home levothyroxine\n\n#INSOMNIA\nContinued home ramelteon, trazodone, ziprasidone\n\n#HLD\nContinued home atorvastatin and fenofibrate.\n\nTRANSITIONAL ISSUES:\n==================\n\nPatient hospitalized for chest pain without evidence of ischemic \ndisease. Troponin and stress test both unremarkable. EKG notable \nfor diffuse STE consistent with presumptive diagnosis of \nidiopathic acute pericarditis. Patient placed on prednisone \ntaper rather than NSAIDs given history of CAD and possible \nhistory of GIB. He was also started on colchicine which will be \ncontinued as an outpatient. Patient seen by ___ team for \nbetter blood sugar control and they recommended starting 5 units \nof Humalog before meals. Rivaroxaban dose increased to 20 mg \ndaily from 10 mg daily given no contraindication to do so and 10 \nmg subtherapeutic anticoagulation for patient's with atrial \nfibrillation. Needs to have CBC monitored closely after \ndischarge to make sure H/H stable on higher dose.\n\nNEW MEDICATIONS:\n- Homolog pen 5 units prior to meals\n- Colchicine 0.6 mg PO/NG BID for 3 months\n- Prednisone taper as follows: 40 mg daily on the day of \ndischarge, and the following day (___), then 30 mg daily for 3 \ndays, then 20 mg daily for 3 days, then 10 mg daily for 3 days, \nthen off\n\nCHANGED MEDICATIONS:\n- Rivaroxaban changed from 10 mg daily to 20 mg daily\n\nSTOPPED MEDICATIONS:\n- None\n\nRELEVANT LAB VALUES ON DISCHARGE:\n=================================\nWBC: 15.4\nHgB: 9.0\nCre: 1.2\nBUN: 33\nNa: 127\nGlu: 302\n\nCONTACT: ___ (son): ___\nCODE STATUS: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n2. Acyclovir 400 mg PO Q8H \n3. Atorvastatin 80 mg PO QPM \n4. Divalproex (EXTended Release) 500 mg PO QAM \n5. Divalproex (EXTended Release) 750 mg PO QPM \n6. Docusate Sodium 100 mg PO BID constipation \n7. Fenofibrate 150 mg PO DAILY \n8. FLUoxetine 20 mg PO DAILY \n9. Gabapentin 300 mg PO TID \n10. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n11. Levothyroxine Sodium 25 mcg PO DAILY \n12. Lidocaine 5% Patch 3 PTCH TD QAM \n13. Losartan Potassium 50 mg PO DAILY \n14. Metoprolol Tartrate 12.5 mg PO BID \n15. Pantoprazole 40 mg PO Q24H \n16. Senna 8.6 mg PO BID:PRN constipation \n17. ZIPRASidone Hydrochloride 40 mg PO BID \n18. melatonin 2.5 mg oral QHS:PRN \n19. Magnesium Oxide 400 mg PO BID \n20. MetFORMIN (Glucophage) 1000 mg PO BID \n21. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n22. Furosemide 20 mg PO DAILY \n23. Aspirin 81 mg PO DAILY \n24. CloNIDine 0.1 mg PO TID \n25. ibrutinib 420 mg oral DAILY \n26. Rivaroxaban 10 mg PO DAILY \n27. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n28. Multivitamins 1 TAB PO DAILY \n29. Fluticasone Propionate NASAL 1 SPRY NU BID \n30. Belsomra (suvorexant) 4 oral QHS:PRN insomnia \n31. TraZODone 200 mg PO QHS:PRN Insomnia \n32. Glargine 75 Units Breakfast\nGlargine 75 Units Bedtime\n\n \nDischarge Medications:\n1. Colchicine 0.6 mg PO BID\nRX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n2. Glargine 75 Units Breakfast\nGlargine 75 Units Bedtime\nHumalog 5 Units Breakfast\nHumalog 5 Units Lunch\nHumalog 5 Units Dinner\nRX *insulin glargine [Lantus] 100 unit/mL AS DIR 75 SC 75 Units \nbefore BKFT; 75 Units before BED; Disp #*5 Vial Refills:*0\nRX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 5 SC 5 \nUnits before BKFT; 5 Units before LNCH; 5 Units before DINR; \nDisp #*5 Syringe Refills:*0 \n3. PredniSONE 40 mg PO DAILY Duration: 1 Dose \nYou will take your last 40 mg tablet of prednisone the day after \nleaving the hospital \nThis is dose # 1 of 4 tapered doses\nRX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*4 \nTablet Refills:*0 \n4. PredniSONE 30 mg PO DAILY Duration: 3 Doses \nTake this dose after finishing the last 40 mg tablet. \nThis is dose # 2 of 4 tapered doses\nRX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*9 \nTablet Refills:*0 \n5. PredniSONE 20 mg PO DAILY Duration: 3 Doses \nTake this dose after finishing the last 30 mg tablet. \nThis is dose # 3 of 4 tapered doses\nRX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*6 \nTablet Refills:*0 \n6. PredniSONE 10 mg PO DAILY Duration: 3 Doses \nTake this dose after finishing the last 20 mg tablet. \nThis is dose # 4 of 4 tapered doses\nRX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*3 \nTablet Refills:*0 \n7. Rivaroxaban 20 mg PO DINNER \nRX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n8. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n9. Acyclovir 400 mg PO Q8H \n10. Aspirin 81 mg PO DAILY \n11. Atorvastatin 80 mg PO QPM \n12. Belsomra (suvorexant) 4 oral QHS:PRN insomnia \n13. CloNIDine 0.1 mg PO TID \n14. Divalproex (EXTended Release) 500 mg PO QAM \n15. Divalproex (EXTended Release) 750 mg PO QPM \n16. Docusate Sodium 100 mg PO BID constipation \n17. Fenofibrate 150 mg PO DAILY \n18. FLUoxetine 20 mg PO DAILY \n19. Fluticasone Propionate NASAL 1 SPRY NU BID \n20. Furosemide 20 mg PO DAILY \n21. Gabapentin 300 mg PO TID \n22. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n23. ibrutinib 420 mg oral DAILY \n24. Levothyroxine Sodium 25 mcg PO DAILY \n25. Lidocaine 5% Patch 3 PTCH TD QAM \n26. Losartan Potassium 50 mg PO DAILY \n27. Magnesium Oxide 400 mg PO BID \n28. melatonin 2.5 mg oral QHS:PRN \n29. MetFORMIN (Glucophage) 1000 mg PO BID \n30. Metoprolol Tartrate 12.5 mg PO BID \n31. Multivitamins 1 TAB PO DAILY \n32. Pantoprazole 40 mg PO Q24H \n33. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n34. Senna 8.6 mg PO BID:PRN constipation \n35. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n36. TraZODone 200 mg PO QHS:PRN Insomnia \n37. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\n========\nAcute pericarditis\n___\nType 2 DM\n\nSECONDARY:\n==========\nCLL\nSick sinus syndrome s/p pacemaker\nCAD s/p DES ___\nHTN\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___ was a pleasure taking care of you at ___ \n___!\n\nWHY WERE YOU IN THE HOSPITAL?\n- You came to the hospital because of chest pain in the center \nof your chest.\n- This pain became severe enough to make it difficult for you to \nbreathe.\n\nWHAT HAPPENED IN THE HOSPITAL?\n- You had laboratory tests which showed that you were not having \na heart attack.\n- You had an EKG to look at the electrical activity of your \nheart. This showed that you may have inflammation of the lining \naround the heart (called the pericardium).\n- You were given medications to control your pain and started on \nsteroids to reduce the inflammation of the pericardium.\n- You were seen by the diabetes doctor in order to better \ncontrol your blood sugar while on the steroids. \n- Your kidney's were injured while in the hospital. This was \nlikely caused by taking off too much fluid. Your kidney function \nimproved by the time you left the hospital.\n- You also had a stress test to assess the blood vessels \nsurrounding your heart muscle. This was normal. \n\nWHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?\n- You should take all of your medications as prescribed \n- You should follow up with your primary care doctor\n- You should follow up with ___ at Dr. ___ \noffice on ___ at 10:00 am.\n\nWe wish you the best!\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I309", "C9110", "N179", "E1142", "I480", "E860", "E871", "G4733", "E039", "G8929", "I2510", "Z955", "Z7984", "I10", "Z7901", "E785", "G4700", "Z6836", "Z9884", "F419", "F329", "E669" ]

[ "I309: Acute pericarditis, unspecified", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "N179: Acute kidney failure, unspecified", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "I480: Paroxysmal atrial fibrillation", "E860: Dehydration", "E871: Hypo-osmolality and hyponatremia", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E039: Hypothyroidism, unspecified", "G8929: Other chronic pain", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z7984: Long term (current) use of oral hypoglycemic drugs", "I10: Essential (primary) hypertension", "Z7901: Long term (current) use of anticoagulants", "E785: Hyperlipidemia, unspecified", "G4700: Insomnia, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "Z9884: Bariatric surgery status", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified" ]

[ "N179", "I480", "E871", "G4733", "E039", "G8929", "I2510", "Z955", "I10", "Z7901", "E785", "G4700", "F419", "F329", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses soft, ___, cottage, cream cheese\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 02:30AM BLOOD WBC-10.0 RBC-3.49* Hgb-9.1* Hct-29.8* \nMCV-85 MCH-26.1 MCHC-30.5* RDW-16.9* RDWSD-50.8* Plt ___\n___ 02:30AM BLOOD Neuts-51 ___ Monos-7 Eos-0* Baso-1 \nAbsNeut-5.10 AbsLymp-4.10* AbsMono-0.70 AbsEos-0.00* \nAbsBaso-0.10*\n___ 02:30AM BLOOD Glucose-384* UreaN-19 Creat-1.1 Na-135 \nK-4.4 Cl-100 HCO3-21* AnGap-14\n___ 07:45AM BLOOD ALT-41* AST-41* AlkPhos-110 TotBili-0.2\n___ 03:04AM BLOOD Lactate-2.5*\n___ 07:49AM BLOOD Lactate-1.6\n___ 11:02PM URINE Color-Yellow Appear-Clear Sp ___\n___ 11:02PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 \nLeuks-NEG\nURINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING:\n========\nCT ABD & PELVIS WITH CO ___\nLOWER CHEST: ICD leads were demonstrated within the right \nventricle and \natrium. Moderate calcification of the coronary arteries. The \nvisualized lung fields are within normal limits. There is no \nevidence of pleural or \npericardial effusion. \n \nHEPATOBILIARY: Normal attenuation of the liver. There is no \nevidence of focal lesions. There is no evidence of intrahepatic \nbiliary dilatation. The common hepatic duct measures up to 9 mm \nwhich is likely secondary to post cholecystectomy changes. The \ngallbladder is surgically absent. \n \nPANCREAS: The pancreas is atrophic and fatty replaced. There is \nno \nperipancreatic stranding. \n \nSPLEEN: The spleen shows normal size and attenuation throughout, \nwithout \nevidence of focal lesions. \n \nADRENALS: The right and left adrenal glands are normal in size \nand shape. \n \nURINARY: The kidneys are of normal and symmetric size with \nnormal nephrogram. There is no evidence of solid renal lesions \nor hydronephrosis. There is no perinephric abnormality. \n \nGASTROINTESTINAL: Small hiatal hernia, the stomach is \nunremarkable. A \nsurgical clip is adjacent lesser curvature of the stomach, \npossibly secondary a dropped clip during prior cholecystectomy. \nSmall bowel loops demonstrate normal caliber, wall thickness, \nand enhancement throughout. Diverticulosis of the sigmoid colon \nis noted, without evidence of wall thickening or fat stranding. \nThe appendix is not visualized. \n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \nThere is no free fluid in the pelvis. \n \nREPRODUCTIVE ORGANS: The prostate and seminal vesicles are \ngrossly \nunremarkable. \n \nLYMPH NODES: There is no retroperitoneal or mesenteric \nlymphadenopathy. There is no pelvic or inguinal \nlymphadenopathy. \n \nVASCULAR: There is no abdominal aortic aneurysm. Moderate \natherosclerotic \ndisease is noted. \n \nBONES: There is no evidence of worrisome osseous lesions or \nacute fracture. Moderate multilevel degenerative changes of the \nlower thoracic and lumbar spine included vertebral disc space \nnarrowing osteophytosis and vacuum phenomena. \n \nSOFT TISSUES: The abdominal and pelvic wall is within normal \nlimits. \n \nIMPRESSION: No finding to explain the patient's symptoms. \n\nDISCHARGE LABS:\n===============\n___ 12:00AM BLOOD WBC-8.2 RBC-3.42* Hgb-8.7* Hct-29.2* \nMCV-85 MCH-25.4* MCHC-29.8* RDW-17.1* RDWSD-52.9* Plt ___\n___ 12:00AM BLOOD Neuts-32* Lymphs-54* Monos-6 Eos-4 Baso-0 \nOther-4* AbsNeut-2.62 AbsLymp-4.43* AbsMono-0.49 AbsEos-0.33 \nAbsBaso-0.00*\n___ 12:00AM BLOOD Hypochr-2+* Anisocy-1+* Poiklo-2+* \nMicrocy-1+* Polychr-1+* Spheroc-2+* Ovalocy-2+* Tear Dr-1+* \nAcantho-1+* RBC Mor-SLIDE REVI\n___ 12:00AM BLOOD Glucose-299* UreaN-16 Creat-1.0 Na-139 \nK-4.2 Cl-103 HCO3-24 AnGap-12\n___ 12:00AM BLOOD ALT-41* AST-47* LD(LDH)-246 AlkPhos-100 \nTotBili-0.2\n___ 12:00AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.9 Mg-1.8\n \nBrief Hospital Course:\nPATIENT SUMMARY\n=================\n___ with CLL (on venetoclax) with history of depression with \npsychotic features, T2DM, stroke, s/p gastric bypass and \ncholecystectomy who presented with lower abdominal pain and \ndifficulty urinating. Patient was able to void normally with \nPVRs < 50 cc without intervention. Workup for cause of abdominal \npain was unrevealing.\n\nACUTE ISSUES\n=============\n#Acute Abdominal Pain\nPatient reported severe lower abdominal pain which he stated was \nsimilar to his most recent admission during which he was treated \nfor a UTI. UA, however, revealed no evidence of infection. In \naddition, CT AP was performed which also did not reveal a cause \nfor the patient's pain. Recent CTA revealed no evidence of \nmesenterich ischemia. Recent EGD revealed a healing duodenal \nulcer for which the patient had been placed on BID PPI. He \nstated this pain was unlike his ulcer pain. He remained \nhemodynamically stable and pain was well-controlled with his \nhome regimen of oxycodone, PPI, and Carafate prior to discharge.\n\n#Urinary retention\nPatient reported suprapubic tenderness and had a temperature of \n100.2. He was initially treated empirically with cefepime. UA \nhowever, had no evidence of infection and antibiotics were \nstopped. In addition, the patient was able to void spontaneously \nand had PVRs < 50 mls. \n\nCHRONIC ISSUES\n===============\n#CLL: Patient had recurrence of night sweats and noted to have \nan increase in his white blood cell count with prominent \nlymphocytosis, consistent with relapsing disease. Given these \nchanges, he was started on ibrutinib. However, given multiple\nsignificant bleeding events (GI bleeding and pericardial bleed), \nfurther ibrutinib therapy was deferred and venetoclax was \ninitiated. In the setting of active infection concern, \nvenetoclax was held but now restarted on ___ per primary\noncologist. \n- Continued venetoclax 400mg daily\n- Continued acyclovir for infectious prophylaxis\n\n# Paroxysmal Afib\n- Continued home Metoprolol and rivaroxaban \n\n#T2DM: Continues on ___ with SS per ___ recommendations \nfrom previous admission. \n- Held metformin on admission. \n\n#History of depression with psychotic features: \n- Continued risperdal, melatonin, hydroxyzine, Topamax\n\n#SSS status post PPM: Atrial paced per EKG in ED\n- Continued rivaroxaban 20mg daily\n- Continued Metoprolol \n\n#History of Gout: \n-Continued allopurinol ___ daily\n\n#Hypothyroidism: \n- Continued synthroid ___ ___\n\n#History of Jejunal Ulcer: \n- Continued sucralfate and pantoprazole\n\n#History of CVA: Had right-sided subcortical lacunar infarcts in\n___ with residual mild left-sided weakness, but does not have \nan effect on mobility. \n- Continued ASA \n\nThis patient was prescribed, or continued on, an opioid pain \nmedication at the time of discharge (please see the attached \nmedication list for details). As part of our safe opioid \nprescribing process, all patients are provided with an opioid \nrisks and treatment resource education sheet and encouraged to \ndiscuss this therapy with their outpatient providers to \ndetermine if opioid pain medication is still indicated.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever \n2. Acyclovir 400 mg PO Q8H \n3. Allopurinol ___ mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Escitalopram Oxalate 20 mg PO DAILY \n7. Gabapentin 100 mg PO TID \n8. Levothyroxine Sodium 125 mcg PO DAILY \n9. Lidocaine 5% Patch 3 PTCH TD QPM \n10. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - \nModerate \n11. Pantoprazole 40 mg PO Q12H \n12. Rivaroxaban 20 mg PO DINNER \n13. Senna 8.6 mg PO BID \n14. Sucralfate 1 gm PO BID \n15. Atorvastatin 40 mg PO QPM \n16. Fenofibrate 54 mg PO DAILY \n17. HydrOXYzine 10 mg PO Q6H:PRN anxiety \n18. Magnesium Oxide 400 mg PO BID \n19. melatonin 6 mg oral qhs \n20. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n21. RisperiDONE 3 mg PO QHS \n22. Topiramate (Topamax) 50 mg PO DAILY \n23. Venetoclax 400 mg PO DAILY \n24. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n25. Metoprolol Succinate XL 150 mg PO DAILY \n\n \nDischarge Medications:\n1. ___ 70 Units Breakfast\n___ 50 Units Lunch\n___ 30 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever \n3. Acyclovir 400 mg PO Q8H \n4. Allopurinol ___ mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 40 mg PO QPM \n7. Docusate Sodium 100 mg PO BID \n8. Escitalopram Oxalate 20 mg PO DAILY \n9. Fenofibrate 54 mg PO DAILY \n10. Gabapentin 100 mg PO TID \n11. HydrOXYzine 10 mg PO Q6H:PRN anxiety \n12. Levothyroxine Sodium 125 mcg PO DAILY \n13. Lidocaine 5% Patch 3 PTCH TD QPM \n14. Magnesium Oxide 400 mg PO BID \n15. melatonin 6 mg oral qhs \n16. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \nDo Not Crush \n17. Metoprolol Succinate XL 150 mg PO DAILY \n18. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - \nModerate \n19. Pantoprazole 40 mg PO Q12H \n20. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n21. RisperiDONE 3 mg PO QHS \n22. Rivaroxaban 20 mg PO DINNER \n23. Senna 8.6 mg PO BID \n24. Sucralfate 1 gm PO BID \n25. Topiramate (Topamax) 50 mg PO DAILY \n26. Venetoclax 400 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\n- Acute Abdominal Pain\n\nSecondary Diagnoses: \n- CLL\n- Hypothyroidism\n- Insulin dependent diabetes mellitus \n- Depression with psychotic features, in remission \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a privilege taking care of you at ___ \n___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were having abdominal pain and trouble urinating\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You had a CT scat of your abdomen which did not reveal any \ncause for your pain. \n- You were able to urinate normally. We performed an ultrasound \nof your bladder which showed that you were able to empty your \nbladder normally and there was only a small amount of urine left \nafterwards.\n- We performed a lab test on your urine and found that there was \nno infection there.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Please attend your upcoming appointment with Dr. ___ on \n___ at 1:50 ___. He will continue to work \nwith you to control your pain.\n- If you have another flare in your abdominal pain, please call \nDr. ___\n- ___ attend your urology appointment on ___ at 1:15 \n___. \n\nWe wish you the best.\n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "R1030", "C9110", "I69354", "F323", "R339", "I495", "D696", "E039", "I480", "Z7901", "Z950", "M109", "D638", "E1142", "Z794", "I2510", "E785", "G4733", "M1990", "R600", "E669", "G8929", "M549", "R509", "Z6837", "Z955", "Z8547", "Z9884" ]

[ "R1030: Lower abdominal pain, unspecified", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "F323: Major depressive disorder, single episode, severe with psychotic features", "R339: Retention of urine, unspecified", "I495: Sick sinus syndrome", "D696: Thrombocytopenia, unspecified", "E039: Hypothyroidism, unspecified", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "Z950: Presence of cardiac pacemaker", "M109: Gout, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "Z794: Long term (current) use of insulin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M1990: Unspecified osteoarthritis, unspecified site", "R600: Localized edema", "E669: Obesity, unspecified", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "R509: Fever, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "Z955: Presence of coronary angioplasty implant and graft", "Z8547: Personal history of malignant neoplasm of testis", "Z9884: Bariatric surgery status" ]

[ "D696", "E039", "I480", "Z7901", "M109", "Z794", "I2510", "E785", "G4733", "E669", "G8929", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses soft, ___, cottage, cream cheese\n \nAttending: ___.\n \nChief Complaint:\nL sided weakness and numbness in face, arm, leg \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with\nCLL on Venclexta, hx testicular cancer, diabetes, hypertension,\nhyperlipidemia, obesity, right subcortical stroke in ___ with\nresidual left leg weakness (ambulates with a cane), remote BPV,\nsick sinus syndrome status post pacemaker, depression with\npsychotic features, presenting with vertigo, near falls, vision\nchanges.\n\nHe describes near-constant vertigo, worse with position changes,\nand several near syncopal events, starting ___ morning ___. \n\nSymptoms initially improved that evening, but when he woke up on\n___ felt significantly worse. He had no associated nausea or\nvomiting, but was taking reduced p.o. (water only minimal food)\ndue to concern that he would become nauseous and be at risk for\nfalling while going to the bathroom. \n\nOn ___, he called the on-call physician for his insurance, \nand\nwas advised to go to the ED to be evaluated; however, he did \nnot,\nbecause he had just put in a freestyle ___ monitor and was\nworried that they would take it out if he needed a scan (he paid\nfor this out of pocket). He did however call his wife, from \nwhom\nhe is separated, and went to stay with her. Due to continuing\nsymptoms on ___, he went to ___ urgent care.\n\nHis vitals were unremarkable, and his exam was notable for \nalmost\nfalling off of his chair with extraocular movement check. His\nfinger-nose-finger was notable for past pointing bilaterally, \nand\nhe had binocular double vision. He was sent to the ___ ED by\nambulance for further work-up.\nHe reports that\n\nWhile getting into the ambulance from ___, he developed left\narm and leg weakness and numbness. On arrival to the emergency\nroom a rapid response was called due to concern for stroke. He\nhad hypoglycemia to 50. A an amp of dextrose, after his blood\nsugar improved to 126 and left arm weakness and numbness\nimproved, however, his leg still is \"paralyzed\". CT head was\nnegative for an acute bleed; CTA head and neck had no thrombus. \n\n\nLabs notable for: \nWBC 8.9, hemoglobin 10.7, platelets 198\nINR 1.6, ___ 17.2, PTT 46.3\nBUN 21; hold blood: Sodium 138, K3.6, chloride 103, bicarb 25,\ncreatinine 1.1\nTroponin negative, lactate 1.6\nAST 42, ALT 38, alk phos 107, T bili 0.3, albumin 4.2\nNegative serum tox for ASA, ethanol, acetaminophen, TCA.\n\n___ Imaging notable for negative CTA head and CT brain\nperfusion scan, copied below, wet read.\n\nThe patient was given: \n-1 amp dextrose\n-Hydrocodone-acetaminophen ___ p.o. x2, which she reports was\nineffective\n\nVitals prior to transfer: Heart rate 73, blood pressure 136/65,\nrespiratory rate 16, satting 98% on room air, glucose 124.\n\nUpon arrival to the floor, the patient confirms the above\nhistory. He additionally describes some dyspnea on exertion \nthat\nhas been long-standing and which he attributes to his wife's\n___ smoke.\n\nA complete REVIEW OF SYSTEMS was negative except for as noted in\nthe HPI. Specifically, he denies lightheadedness, headache,\nchest pain, palpitations, abdominal pain, constipation, dysuria,\nrash, joint pain.\n\nOf note, in ___ and ___ he had an external work-up for\nleft arm weakness concerning for possible TIAs, unrevealing for\nan embolic disorders.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nCLL (17p-) and Stage IIIA Mixed germ cell tumor of the testis\n- ___ Lymphocytosis incidentally found during a psychiatric\nhospitalization.\n- ___ CT scan showed a slightly enlarged spleen at 14.5 cm\nand no adenopathy.\n- ___ He met with Dr. ___ in ___ at\n___. WBC was 15.0 with 49.6% lymphocytes, Hgb 11.9,\nand platelets 260,000. Flow cytometry was consistent with CLL,\nand B-cell gene rearrangement confirmed clonality. CLL FISH \npanel\nshowed a p53 mutation. He was asymptomatic at the time of\ndiagnosis and followed with Dr. ___. \n- WBC gradually uptrended to 22.7 in ___, 37.3 in ___,\n51.3 in ___, and 50.4 on ___. Hgb has decreased slightly\nto 10.9 and Hct 34.4 with platelets 234,000 on the ___ \nlabs.\n- ___ Hematology care transitioned to Dr. ___\nafter Dr. ___. He also started having nightly sweats. \n\n- ___ CT Chest without lymphadenopathy or other notable\nfindings.\n- ___ Initial ___ Hematology evaluation for second\nopinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood\nflow cytometry and cytogenetics confirmed CLL with TP53 \ndeletion.\n- ___ CT Abdomen/Pelvis without lymphadenopathy or other\nnotable findings.\n- ___ Started ibrutinib 420 mg daily.\n- ___ Ibrutinib held for vitreous bleed\n- ___ Ibrutinib restarted\n- ___ Per OSH records, underwent scrotal U/S showing\nheterogeneous left testicle, prominent rete testis on right.\n- ___ Presented to his outpatient hematologist, Dr.\n___ a painful swollen left testicle (swelling over \n~8 months, worsening pain). This had been evaluated on ___\nwith\nan ultrasound that did not demonstrate torsion but did show\nheterogeneous morphology of the left testicle. HCG was positive.\nReferred to Dr. ___.\n- ___ Underwent left radical orchiectomy. Pathology\nrevealed 3.9 cm malignant mixed germ cell tumor of the testis,\n95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1%\nchoriocarcinoma, invading hilar statin ___ vaginalis, with\nlymphatic vascular invasion and metastatic tumor nodules in the\nspermatic cord. pT2NxS1 (although no post-orch levels, beta hCG\n64 on ___, up from 21 on ___ AFP 3, LDH normal).\n- ___ CT torso showing new 8 mm nodule in the left lower\nlobe, and comparison with CT ___. Left para-aortic\nlymphadenopathy up to 2.8 cm and a 3.5 cm fluid collection in \nthe left inguinal region/scrotum, felt to be likely \npostsurgical.\n- ___ C1D1 EP\n- ___ C2D1 EP (delayed 1 week after nasal infection\n- ___ Admitted for weakness, fall\n- ___ Admitted for parainfluenza pneumonia, symptomatic\nanemia, palpitations, developed nausea/vomiting in hospital\n- ___ C3D1 EP (delayed 1 week, added palonosetron)\n- ___ C4D1 EP\n- ___ CT torso with significant decrease in size of the\npreviously seen left para-aortic lymph node which now measures 6\nmm, previously 28 mm. Otherwise no LAD.\n- ___ Restarted ibrutinib for recurrent CLL (night sweats,\nlymphocytosis)\n\nPAST MEDICAL HISTORY:\n- Sick sinus syndrome s/p PPM ___ Revo DDD,\nMRI-compatible, ___\n- CAD s/p DES to mid-LAD (___)\n- Stroke ___ (with recovering motor function, though still with\nsome left thigh sensory decrease)\n- Type II DM (on insulin)\n- Hypertension\n- Hyperlipidemia\n- Morbid Obesity status post gastric bypass surgery ___\n- OSA (not on CPAP)\n- Pancreatitis secondary to alcohol (___)\n- Cholecystectomy\n- Hypothyroidism\n- Osteoarthritis\n- Bilateral shoulder surgery, chronic pain right shoulder\n- Major depression with psychotic features\n- Anxiety\n- Conversion Disorder\n- Benign Paroxysmal Positional Vertigo\n- Glaucoma\n \nSocial History:\n___\nFamily History:\nNo known history of malignancies.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVS: 98.2, pulse 57/83, heart rate 69, respiratory rate 20,\nsatting 99% on room air\nGENERAL: Obese man, sitting comfortably in bed, fully \nconversant,\nHEENT: Pupils 2 mm, reactive to light; no scleral icterus; moist\nmucous membranes without any lesions. \nNECK: no lymphadenopathy\nCV: Regular rate and rhythm without murmurs\nPULM: Clear to auscultation bilaterally with good air movement\nthroughout and no adventitious sounds\nABD: Obese, nondistended, nontender; cannot assess organomegaly;\nseveral ecchymoses at insulin sites\nEXT: Warm, well-perfused, 1+ pitting edema to knees bilaterally\nSKIN: No concerning rashes or lesions\nNEURO: Alert, oriented, telling cogent history, no speech\nabnormalities. \nCranial nerves:\n - Left homonymous hemianopia on visual field testing. Did not\nassess blink to threat. \n - UNABLE to do left lateral gaze with either eye when asked. \n - Symmetric V1 through V3 sensation bilaterally, symmetric eyes\nsqueeze, bite, puffed cheeks. \n - Hearing normal, hearing aids in place\n - Tongue midline, no palate deviation\n - Shrug symmetric\nStrength: Moving left arm against gravity; 4+ out of 5 strength\nin all muscle groups compared to 5 out of 5 on the right. \nUnable\nto lift left leg against gravity on command. \nSensation of upper extremities symmetric. Reports absent\nsensation to light touch in all fields of the left leg compared\nto right; does not feel pinprick on the left leg. \nTrouble following command for finger-nose-finger, but no obvious\ndysmetria.\nPSYCH: slightly odd affect, but overall appropriate. \nACCESS: Port\n\nDISCHARGE PHYSICAL EXAM\n=======================\n\nPHYSICAL EXAM: \n24 HR Data (last updated ___ @ 721)\n Temp: Pt. refused Vitals. (Tm 98.2), BP: 124/73\n(105-151/57-73), HR: 78 (69-78), RR: 16 (___), O2 sat: 98%\n(97-99), O2 delivery: Ra, Wt: 296.2 lb/134.36 kg \n\nGENERAL: Obese man, sitting comfortably in chair, conversant\nNEURO: Alert, with fluent speech; EOMI; no scleral icterus; \nmoist\nmucous membranes without any lesions. Symmetric smile. Pronator\ndrift on L with eyes closed. ___ UE strength and\nsensation. ___ motor at hip, ___ motor elsewhere + no sensation\nat LLE; ___ motor, + sensation RLE. Was observed to walk from \nbathroom later in the morning, stable but slow gait.\nNECK: no lymphadenopathy, no subclav LAD\nCV: Regular rate and rhythm, distant heart sounds\nPULM: Clear to auscultation bilaterally with good air movement, \ndistant \nABD: Obese, nondistended, nontender, excoriations on R side\nEXT: Warm, well-perfused, 2+ ___ edema to mid-shin\nSKIN: No concerning rashes or lesions\nPSYCH: linear thought, mood anxious \nACCESS: Port\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 03:20PM BLOOD WBC-8.9 RBC-4.01* Hgb-10.7* Hct-34.8* \nMCV-87 MCH-26.7 MCHC-30.7* RDW-15.0 RDWSD-47.3* Plt ___\n___ 03:20PM BLOOD Neuts-44.9 ___ Monos-10.0 Eos-1.2 \nBaso-0.3 Im ___ AbsNeut-4.01 AbsLymp-3.86* AbsMono-0.89* \nAbsEos-0.11 AbsBaso-0.03\n___ 03:20PM BLOOD ___ PTT-46.3* ___\n___ 03:20PM BLOOD UreaN-21*\n___ 03:20PM BLOOD ALT-38 AST-42* AlkPhos-107 TotBili-0.3\n___ 03:20PM BLOOD cTropnT-<0.01\n___ 03:20PM BLOOD Albumin-4.2\n___ 01:00AM BLOOD VitB12-513\n___ 01:00AM BLOOD TSH-28*\n___ 01:00AM BLOOD Free T4-0.7*\n___ 03:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 03:23PM BLOOD Glucose-50* Lactate-1.6 Creat-1.1 Na-138 \nK-3.6 Cl-103 calHCO3-25\n\nPERTINENT IMAGING AND MICRO\n===========================\n1. Head CT: No evidence for acute intracranial hemorrhage or \nacute major \nvascular territorial infarction. \n2. CT perfusion: 6 ml area of T-max > 6 seconds and mismatch \nproject over the left periatrial white matter and left lateral \nventricle, possibly an artifact. If clinically indicated, MRI \nwould be more sensitive for the detection of acute infarct. \n3. CTA: No carotid stenosis by NASCET criteria. Atherosclerosis \nof \nintracranial carotid and intracranial vertebral arteries without \nflow-limiting stenosis. \n4. Ossification of the posterior longitudinal ligament in the \nupper cervical spine narrows the spinal canal, as seen on the \nprior cervical spine CT from ___. \n\nMRI Head w wo Contrast\n1. No evidence of infarction, hemorrhage, mass, or edema. \n\nDISCHARGE LABS\n==============\n___ 12:00AM BLOOD WBC-9.6 RBC-3.62* Hgb-9.7* Hct-31.3* \nMCV-87 MCH-26.8 MCHC-31.0* RDW-15.1 RDWSD-47.3* Plt ___\n___ 12:00AM BLOOD Glucose-181* UreaN-22* Creat-1.2 Na-138 \nK-3.9 Cl-101 HCO3-21* AnGap-16\n___ 12:00AM BLOOD ALT-32 AST-39 LD(LDH)-229 AlkPhos-94 \nTotBili-0.3\n___ 12:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0 UricAcd-7.5*\n\n \nBrief Hospital Course:\nMr. ___ is a ___ man with high risk CLL on venetoclax, \ninsulin-dependent type 2 diabetes, history of left sided \ncerebrovascular accident, depression with psychotic features, \nreported history of conversion disorder, hypothyroidism, \nhypertension, who was admitted with left-sided weakness and \ndiminished sensation in the setting of hypoglycemia and 3 days \nof vertigo. CT head negative, CTA head and neck with no thrombus \non admission. MRI Brain performed without acute findings. His \nsymptoms gradually resolved over the course of his stay and he \nwas discharged with outpatient ___. \n\nTRANSITIONAL ISSUES\n==================\n[ ] Follow up hypothyroidism. Levothyroxine dose increase ___ \nfrom 75mcg to 100mcg, after lab findings of elevated TSH (28) \nand low free T4 (0.7). Needs repeat TSH/FT4 in ___ weeks \n[ ] Follow up on neurological symptoms. His L sided weakness and \nsensory deficits had resolved by time of discharge \n[ ] F/u blood glucose, he was discharged on his home ___ \n___ at meals with ISS per ___\n[ ] For his MRI, his freestyle ___ was removed. He may require \nreplacement as an outpatient. \n[ ] Follow up re: BPPV symptoms. \n[ ] Follow up re: L forearm-hand peripheral neuropathy, \nalleviated by capsaicin cream. He was continued on gabapentin \n600mg BID as an inpatient. \n[ ] Follow up on joint/tailbone pain, exacerbated by poor \nweather. \n[ ] Follow up uric acid level. He was given 1 dose of \nallopurinol at discharge after his AM labs showed uric acid 7.5. \nWill need repeat level at next appointment. \n[] Discharge weight 296lbs (134Kg), increased throughout \nhospitalization. Follow up weight, consider increasing dose of \ndaily Lasix if needed\n\nACUTE ISSUES\n============\n#L sided weakness, numbness\n#L homonymous hemianopsia\n#H/o prior CVA\nPresented with left-sided weakness and diminished sensation. No \nacute stroke was seen on CT/CTA imaging, despite what would be a \nlarge territory infarct given profound ipsilateral facial and \nupper and lower extremity symptoms. Neurology was consulted and \nhad low suspicion for new event. Hypoglycemia was considered, as \nthis can cause recrudescence of stroke symptoms; however, his \nsymptoms persisted even with correction of blood sugar. B12 and \nTSH/T4 were also obtained; he was noted to be somewhat \nhypothyroid, even with medications, and we increased his dosage \nfrom 75mcg to 100mcg. He was placed on telemetry; no events were \nnoted. With approval from our EP team and his outpatient \ncardiologist, an MRI brain was performed, with read notable for \nno evidence of infarction, hemorrhage, mass, or edema. He \ncontinued to work with our ___ team. His symptoms gradually \nresolved throughout his stay, with full upper extremity strength \nat discharge and waxing/waning ability to walk on his LLE. There \nwas low concern for an acute stroke or TIA; the primary team, \nneurology, and psychiatry found that his presentation is most \nconsistent with functional neurologic disorder, with possible \nrecrudescence of stroke symptoms given hypoglycemia and low \nthyroid. He should follow up as an outpatient for further \nmanagement of symptoms. \n\n#Hypoglycemia in setting of Insulin-dependent Type 2 Diabetes \nMellitus \nHis A1c in ___ was 8.7%. His home insulin regimen is 70/30, \n100 units 3 times daily. He was reportedly taking in much less \np.o. in the setting of his persistent vertigo, which may explain \nhis hypoglycemia. No symptoms of other common causes of \nhypoglycemia, eg infection or adrenal insufficiency, were found. \nNo insulin was given on admission, and he was started on 50% of \nhis dose the next morning. ___ was consulted \nand his insulin regimen was adjusted per their recommendations. \nHis home metformin was held but restarted on discharge. His \ndischarge regimen was home ___ ___ at meals with ISS \nper ___. \n\n#Anxiety\nPsychiatry was consulted regarding his increasing anxiety, and \nwere also made aware of his ongoing symptoms, potentially \ncontributing to his anxiety. He was given lorazepam prn for \nacute anxiety events. \n\n#Diabetic neuropathy\nHe noted exacerbation of L sided neuropathy from fingers to mid \nforearm. He was given capsaicin cream prn to good effect, and \ndid not note further symptoms throughout the rest of his stay. \nHe also continued on his home gabapentin. \n\n#BPPV\nHe noted worsening vertigo the day prior to discharge, similar \nbut reduced in intensity as compared to previous events. He \nnoted that he had been given meclizine prior to good effect. He \nstated that he felt okay to move around, with the main symptom \nbeing that he saw double if something was held close to his \nface. He was given meclizine. He was able to ambulate without \nissues at time of discharge. \n\nCHRONIC ISSUES\n==============\n#Depression\nHe was continued on home ziprasidone.\n\n#CLL\nHe brought in his venetoclax from home, and was continued on his \nregimen. He was given allopurinol on discharge given a slight \nincrease in uric acid levels. \n\n#HTN\nContinued on home losartan and metoprolol. He was also continued \non home furosemide with furosemide prn for ___ edema and increase \nweight. He should follow up as an outpatient for weight check \nand possible uptitration of Lasix. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 \n2. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever \n3. Losartan Potassium 50 mg PO DAILY \n4. Magnesium Oxide 400 mg PO BID \n5. Gabapentin 600 mg PO BID \n6. Colchicine 0.6 mg PO DAILY \n7. Venetoclax 400 mg PO DAILY \n8. Lidocaine 5% Patch 3 PTCH TD QAM \n9. HydrOXYzine 10 mg PO Q6H:PRN anxiety \n10. ZIPRASidone Hydrochloride 40 mg PO BID \n11. Metoprolol Succinate XL 150 mg PO DAILY \n12. Docusate Sodium 100 mg PO BID \n13. Senna 8.6 mg PO BID:PRN Constipation - First Line \n14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY \n15. Rivaroxaban 20 mg PO DAILY \n16. Carbamide Peroxide 6.5% ___ DROP BOTH EARS DAILY \n17. Fenofibrate 54 mg PO DAILY \n18. Atorvastatin 40 mg PO QPM \n19. Furosemide 20 mg PO DAILY \n20. Acyclovir 400 mg PO Q8H \n21. melatonin 6 mg oral qhs \n22. Nystatin-Triamcinolone Cream 1 Appl TP BID \n23. Sucralfate 1 gm PO BID \n24. Pantoprazole 40 mg PO Q24H \n25. Aspirin 325 mg PO DAILY \n26. Levothyroxine Sodium 75 mcg PO DAILY \n27. ___ 100 Units Breakfast\n___ 100 Units Lunch\n___ 100 Units DinnerMax Dose Override Reason: home regimen\n\n28. Topiramate (Topamax) 50 mg PO DAILY \n\n \nDischarge Medications:\n1. Capsaicin 0.025% 1 Appl TP TID:PRN neuropathy \n2. Levothyroxine Sodium 100 mcg PO DAILY \nRX *levothyroxine [Euthyrox] 100 mcg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever \n4. Acyclovir 400 mg PO Q8H \n5. Aspirin 325 mg PO DAILY \n6. Atorvastatin 40 mg PO QPM \n7. Carbamide Peroxide 6.5% ___ DROP BOTH EARS DAILY \n8. Colchicine 0.6 mg PO DAILY \n9. Docusate Sodium 100 mg PO BID \n10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 \n11. Fenofibrate 54 mg PO DAILY \n12. Furosemide 20 mg PO DAILY \n13. Gabapentin 600 mg PO BID \n14. HydrOXYzine 10 mg PO Q6H:PRN anxiety \n15. ___ 100 Units Breakfast\n___ 100 Units Lunch\n___ 100 Units DinnerMax Dose Override Reason: home regimen\n \n16. Lidocaine 5% Patch 3 PTCH TD QAM \n17. Losartan Potassium 50 mg PO DAILY \n18. Magnesium Oxide 400 mg PO BID \n19. melatonin 6 mg oral qhs \n20. Metoprolol Succinate XL 150 mg PO DAILY \n21. Nystatin-Triamcinolone Cream 1 Appl TP BID \n22. Pantoprazole 40 mg PO Q24H \n23. Rivaroxaban 20 mg PO DAILY \n24. Senna 8.6 mg PO BID:PRN Constipation - First Line \n25. Sucralfate 1 gm PO BID \n26. Topiramate (Topamax) 50 mg PO DAILY \n27. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY \n28. Venetoclax 400 mg PO DAILY \n29. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nNeuropathy\nWeakness/numbness \n\nSECONDARY DIAGNOSIS \n===================\nHypoglycemia in the setting of Insulin-dependent type 2 diabetes\nInsomnia\nDepression \nChronic lymphocytic leukemia\nBenign paroxysmal positional vertigo\nHypertension \nHypothyroidism \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a privilege to care for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \nYou noted that your left arm, leg, and face were paralyzed. You \nalso noted that you weren't able to appreciate sensation on the \nleft side of your face and your left arm and leg. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You received CT scans and an MRI of your brain; in other \nwords, we took pictures of your head. These pictures did not \nshow an acute reason for your weakness and loss of sensation, \nwhich was reassuring. Your symptoms resolved over the course of \nyour stay, and you worked with our physical therapists to help \nwith the symptoms. \n- We gave you a cream to treat the neuropathy you endorsed in \nyour left forearm. \n- We gave you more Lasix medication to help with the swelling in \nyour lower legs. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \nContinue to take all your medicines and keep your appointments. \n\n- Continue taking your insulin as you were prior to the \nhospitalization, you should check your blood sugar at least 4 \ntimes a day\n- Your levothyroxine (synthroid) dose was increased, you will \nneed repeat labs in ___ weeks to monitor levels \n\nWe wish you the ___. \n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "F447", "C9110", "I495", "E11649", "E1142", "H53462", "I10", "E785", "E669", "I2510", "I69344", "Z45018", "G4733", "E039", "H409", "H8110", "F419", "G4700", "R2240", "G8929", "D649", "R740", "F325", "F09", "L299", "Z6837", "Z8547", "Z955", "Z794", "Z9884" ]

[ "F447: Conversion disorder with mixed symptom presentation", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "I495: Sick sinus syndrome", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "H53462: Homonymous bilateral field defects, left side", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I69344: Monoplegia of lower limb following cerebral infarction affecting left non-dominant side", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E039: Hypothyroidism, unspecified", "H409: Unspecified glaucoma", "H8110: Benign paroxysmal vertigo, unspecified ear", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "R2240: Localized swelling, mass and lump, unspecified lower limb", "G8929: Other chronic pain", "D649: Anemia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "F325: Major depressive disorder, single episode, in full remission", "F09: Unspecified mental disorder due to known physiological condition", "L299: Pruritus, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "Z8547: Personal history of malignant neoplasm of testis", "Z955: Presence of coronary angioplasty implant and graft", "Z794: Long term (current) use of insulin", "Z9884: Bariatric surgery status" ]

[ "I10", "E785", "E669", "I2510", "G4733", "E039", "F419", "G4700", "G8929", "D649", "Z955", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\nFall, weakness, fatigue\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ year-old gentleman with history of CAD s/p DES, \nSSS s/p PPM, pAF on rivaroxaban in addition to Rai III CLL on \nibrutinib and Stage IIIA NSGCT s/p radical orchiectomy and now \non C2D7 of EP who presents with generalized weakness, a fall and \nabdominal discomfort. \n\nMr. ___ was in his usual state of health until 2 days prior to \nadmission when he began having generalized fatigue and malaise \nthat has progressively worsened since then. On the day of \nadmission he was walking back to the bathroom and felt his legs \ngive out falling forward on his knees and hands. He denies loss\nof consciousness, dizziness/lightheadedness, head strike. He is \nhaving some vague upper gastrointestinal upset over the past 2 \ndays along with some intermittent dyspnea. He denies having \nnausea/vomiting, diarrhea or constipation. He has not had chest \ndiscomfort, palpitations, pleuritic chest pain. He has been able \nto tolerate POs. \n \nED initial vitals were 97.3 80 138/78 18 99% RA \nPrior to transfer vitals were 98.5 82 142/78 18 100% RA \n\nExam in the ED showed : \"pale gentleman, without acute distress. \nbreathing comfortably on room air, shallow respirations \nbilaterally, without ronchi or wheezing, no murmurs, power port \nto R SCV, without overlying erythema, drainage,\ntenderness, abd: soft, no RUQ tenderness. nontender extremities: \nno swelling, no tenderness to palpation bilaterally neuro: \na+ox3.\"\n\nED work-up were significant for:\n-CBC: WBC: 52.2* HGB: 8.8*. Plt Count: 289. Neuts%: 76*. \n-Chemistry: Na: 137. K: 3.8. Cl: 100. CO2: 25. BUN: 26*. Creat:\n1.3*. Ca: 8.3*. Mg: 2.0. PO4: 3.3. \n-Lactate:1.8\n-Coags: INR: 1.0. PTT: 29.1. \n-LFTs: ALT: 20. AST: 17. Alk Phos: 77. Total Bili: <0.2. \n-Lipase: 159\n-Cards: EKG non-ischemic, TnT<0.01\n-UA: WBC 1, RBC 1, Prot 100, Glu 100\n-CXR: no acute process\n\nPatient was given: AlOH/simethicone 30mL, viscous lidocaine 2% \n10mL, ondansetron 4mg IV x1, NS @ 150mL/h\n\nOn arrival to the floor, patient reports concern about his \nelevated lipase and white blood cell count, he thinks his cancer \nmay have extended to his pancreas and that his CLL has worsened \nfor being off the ibrutinib. He continues to feel tired, the \nnausea he felt in the emergency room has improved with \nondansetron. He is afraid that his kidneys are failing and he \nwould not like to be on dialysis. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n-___: Lymphocytosis incidentally found during a psychiatric\nhospitalization.\n-___: CT scan showed a slightly enlarged spleen at 14.5 cm \nand\nno adenopathy.\n-___: He met with Dr. ___ in ___ at\n___. WBC was 15.0 with 49.6% lymphocytes, Hgb 11.9,\nand platelets 260,000. Flow cytometry was consistent with CLL,\nand B-cell gene rearrangement confirmed clonality. CLL FISH \npanel\nshowed a p53 mutation. He was asymptomatic at the time of\ndiagnosis and followed with Dr. ___. \n-WBC gradually uptrended to 22.7 in ___, 37.3 in ___, \n51.3\nin ___, and 50.4 on ___. Hgb has decreased slightly to\n10.9 and Hct 34.4 with platelets 234,000 on the ___ labs. \n-___: Hematology care transitioned to Dr. ___\nafter Dr. ___. He also started having nightly sweats. \n\n-___: CT Chest without lymphadenopathy or other notable\nfindings.\n-___: Initial ___ Hematology evaluation for second\nopinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood\nflow cytometry and cytogenetics confirmed CLL with TP53 \ndeletion.\n-___: CT Abdomen/Pelvis without lymphadenopathy or other\nnotable findings.\n-___: Started ibrutinib 420 mg daily.\n-___: Ibrutinib held for vitreous bleed\n-___: Ibrutinib restarted\n-___: Per OSH records, underwent scrotal U/S showing\nheterogeneous left testicle, prominent rete testis on right.\n-___: Presented to his outpatient hematologist, Dr. \n___ a painful swollen left testicle (swelling over ~8 months,\nworsening pain). This had been evaluated on ___ with an\nultrasound that did not demonstrate torsion but did show\nheterogeneous morphology of the left testicle. HCG was \npositive.\nReferred to Dr. ___.\n-___: ibrutinib held for surgery\n-___: Underwent left radical orchiectomy. Pathology\nrevealed 3.9 cm malignant mixed germ cell tumor of the testis,\n95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1%\nchoriocarcinoma, invading hilar statin ___ vaginalis, with\nlymphatic vascular invasion and metastatic tumor nodules in the\nspermatic cord. pT2NxS1 (although no post-orch levels, beta hCG\n64 on ___, up from 21 on ___ AFP 3, LDH normal).\n-___: CT torso showing new 8 mm nodule in the left lower\nlobe, and comparison with CT ___.\nLeft para-aortic lymphadenopathy up to 2.8 cm and a 3.5 cm fluid\ncollection in the left inguinal region/scrotum, felt to be \nlikely\npostsurgical.\n-___: C1D1 EP\n-___: C2D1 EP \n\nPAST MEDICAL HISTORY: \n-Sick sinus syndrome s/p PPM ___ Revo DDD, \nMRI-compatible,\n___\n-CAD s/p DES to mid-LAD in ___. Preserved LVEF in ___.\n-Stroke ___\n-Diabetes mellitus type II on insulin\n-Hypertension\n-Hyperlipidemia\n-Morbid obesitys/p Gastric bypass surgery ___\n-Obstructive sleep apnea - not on CPAP\n-Pancreatitis ___ related to alcohol\n-s/p Cholecystectomy\n-Hypothyroidism\n-Osteoarthritis\n-s/p Bilateral shoulder surgery, chronic pain\n-Major depression with psychotic features (vs schizoaffective\ndisorder per patient) (Dr. ___ name unknown, affiliated\nwith ___ ___)\n-Anxiety\n-Conversion disorder\n-Benign paroxysmal positional vertigo\n-Glaucoma, cataract (Dr. ___ at ___)\n \nSocial History:\n___\nFamily History:\nNo cancer or stroke\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: 99.0 PO 171 / 79 79 20 97 RA \nGENERAL: Chronically-ill appearing gentleman, in emotional\ndistress lying in bed.\nHEENT: Anicteric, PERLL, Mucous membranes dry, OP clear.\nCARDIAC: Regular rate and rhythm, normal heart sounds, no\nmurmurs, rubs or gallops. JVP 1cm above clavicle.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Non-distended, bowel sounds increased in frequency and\nvolume but normal tone, soft, non-tender, no guarding, no\npalpable masses, no organomegaly.\nEXT: Warm, well perfused. No lower extremity edema. No erythema\nor tenderness.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Strength full throughout. Sensation to light touch\nintact.\nPSYCH: Anxious mood and affect. \nSKIN: No significant rashes.\n\nDISCHARGE PHYSICAL EXAM:\nVitals: 98.2 150 / 76 77 18 99 RA \nGENERAL: Chronically-ill appearing gentleman, sitting up in \nchair eating breakfast\nHEENT: Anicteric sclera, PERLL, MMM, OP clear.\nCARDIAC: Regular rate and rhythm, normal heart sounds, no\nmurmurs, rubs or gallops. \nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Non-distended, soft, non-tender, no guarding, no palpable \nmasses, no organomegaly.\nEXT: Warm, well perfused. Trace to 1+ lower extremity edema \nbilaterally. No erythema or tenderness.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Strength full throughout. Sensation to light touch\nintact.\nPSYCH: calm and cooperative. \nSKIN: No significant rashes. \n\n \nPertinent Results:\n==============\nADMISSION LABS\n==============\n___ 07:00PM BLOOD WBC-52.2*# RBC-3.31* Hgb-8.8* Hct-26.8* \nMCV-81* MCH-26.6 MCHC-32.8 RDW-17.9* RDWSD-47.8* Plt ___\n___ 07:00PM BLOOD Neuts-76* Bands-0 ___ Monos-1* \nEos-1 Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-39.67* \nAbsLymp-11.48* AbsMono-0.52 AbsEos-0.52 AbsBaso-0.00*\n___ 07:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ \nMacrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear \nDr-1+ Acantho-1+\n___ 07:00PM BLOOD ___ PTT-29.1 ___\n___ 07:00PM BLOOD Glucose-158* UreaN-26* Creat-1.3* Na-137 \nK-3.8 Cl-100 HCO3-25 AnGap-16\n___ 07:00PM BLOOD ALT-20 AST-17 AlkPhos-77 TotBili-<0.2\n___ 07:00PM BLOOD Lipase-159*\n___ 07:00PM BLOOD Albumin-3.8 Calcium-8.3* Phos-3.3 Mg-2.0\n___ 05:11AM BLOOD TSH-4.0\n___ 07:00PM BLOOD Lactate-1.8\n\n==============\nMICROBIOLOGY\n==============\n\n___ 10:30 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n Respiratory Viral Culture (Pending): \n\n Respiratory Viral Antigen Screen (Final ___: \n Negative for Respiratory Viral Antigen. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza A, B,\n and RSV by immunofluorescence. \n Refer to respiratory viral culture and/or Influenza PCR \n(results\n listed under \"OTHER\" tab) for further information.. \n\n===============\nIMAGING/STUDIES\n===============\n\n___ CXR\nIMPRESSION: \nNo acute cardiopulmonary process. \n\n==============\nDISCHARGE LABS\n==============\n___ 05:30AM BLOOD WBC-30.3* RBC-3.20* Hgb-8.3* Hct-26.2* \nMCV-82 MCH-25.9* MCHC-31.7* RDW-17.7* RDWSD-48.7* Plt ___\n___ 05:30AM BLOOD Glucose-104* UreaN-17 Creat-0.8 Na-138 \nK-4.8 Cl-104 HCO3-25 AnGap-14\n___ 05:30AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.7\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old gentleman with history of CAD s/p DES, \nSSS s/p PPM, pAF on rivaroxaban in addition to Rai III CLL on \nibrutinib (currently on hold) and Stage IIIA NSGCT s/p radical \norchiectomy and now s/p initiation of cycle 2 (___) of \nCisplatin/Etoposide who presents with generalized weakness, poor \nPO intake, a fall and abdominal discomfort. \n\n#Weakness:\n#Hypovolemia:\n#Acute Kidney Injury:\nWeakness and fatigue are similar to what he experienced for a \nweek during his first cycle of chemotherapy. Volume depleted on \nadmission due to poor PO intake and ongoing use of furosemide. \nCr elevated to 1.3 on admission, was given 1 L IVF with \nimprovement in Cr to 0.9. Flu swab negative, respiratory viral \npanel negative for Adeno, Parainfluenza 1, 2, 3, Influenza A, B, \nand RSV; viral culture pending at the time of discharge. Held \nfurosemide and losartan during this admission, but will resume \non discharge. \n\n#S/P Fall: \nSuspect that fall was due to orthostatic factors, owing to \nvolume depletion. Low suspicion for arrhythmia. No suspicion for \nACS or seizure. No secondary injuries on exam. Patient was \nambulatory in the hospital and did not need ___ evaluation.\n\n#Epigastric discomfort \n#Nausea\n#Hyperlipasemia:\nPatient had significant upper GI upset and nausea after previous \ncycle of chemotherapy so likely attributable to chemotherapy. \nMildly elevated lipase very unlikely to represent pancreatitis \ngiven absence of significant abdominal pain or tenderness. \nContributing factors for hyperlipasemia in this patient are \nfurosemide, renal failure, valproate, narcotics, RYGB. Continued \nOndansetron, and added prochlorperazine and Ativan. Continued \nhome pantoprazole and added sucralfate. Lipase trended down. \nPt's diet was advanced without issue.\n\n#Stage IIIA Non-seminoma testicular cancer\n#Leukocytosis with Neutrophilia: \nWith low risk features. Has completed C2 ___ C2D1) of \ncisplatin/etoposide. Received pegfilgrastim on ___ which \nexplains his leukocytosis with neutrophilia. Did not receive any \nchemotherapy while in-house.\n\n#Rai Stage III Chronic Lymphocytic Leukemia: \nLymphocytosis to 11.48 on differential up from 3.39 on ___. \nLikely reactive and not reflecting recurrence or acceleration of \nCLL. Did not receive ibrutinib while inpatient, as this is being \nheld while he is on chemo for his testicular cancer.\n\n#Coronary artery disease\n#Chronic diastolic heart failure\n#History of CVA:\nNo symptoms suggestive of acute ischemia during this admission. \nEKG non-ischemic and initial TnT<0.01. No acute neurologic \nsymptoms. Unclear why on atypical dose of 243mg of ASA but no \nevidence supporting this especially while anticoagulated and on \nclopidogrel with a history of vitreal bleed, so treated with ASA \n81. Continued home Plavix, atorva, metoprolol. Held home \nfurosemide while inpatient \n\n#Paroxysmal Atrial Fibrillation\n#Sick Sinus Syndrome:\nCurrently in sinus rhythm. Warrants continuation of \nanticoagulation given CHADSVaSC 6 (NNT 12). Continued dose \nreduced rivaroxaban 10mg with dinner. PPM active in DDD mode.\n\n#Type 2 Diabetes Mellitus c/b nephropathy: \nLast A1c 7.4%. Held metformin in setting of ___. Continued home \nglargine 56sc bid. Humalog sliding scale.\n\n#Depressive Disorder with Psychotic features\n#Anxiety: \nAppropriately anxious affect while hospitalized, no positive or \nnegative psychotic symptoms. Continued home psychiatric \nmedications.\n\n#Chronic back and shoulder pain: \nNot exacerbated. Continued acetaminophen-hydrocodone tid prn.\n\n===================\nTRANSITIONAL ISSUES\n===================\n-Respiratory viral culture pending at the time of discharge.\n-He has been on triple anticoagulation with aspirin, \nclopidogrel, and rivaroxaban. Ibrutinib adds additional bleeding \nrisk (though he is not currently on this). Patient will \nfollow-up with his cardiologist for discussion of continuing \nclopidogrel (for LAD stent placed in ___.\n-Nausea: added Compazine during this admission. ___ benefit from \naddition of Ativan or olanzapine to his anti-emetic regimen for \nthe next round of chemotherapy\n\n#CODE: Full Code, presumed. Not addressed in setting of marked \nanxiety. No urgency given clinical stability. \n#EMERGENCY CONTACT / HCP: ___ (son)\nPhone number: ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO Q8H:PRN Headache \n2. Aspirin 243 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Clopidogrel 75 mg PO DAILY \n5. Metoprolol Tartrate 12.5 mg PO BID \n6. Divalproex (EXTended Release) 500 mg PO BID \n7. Divalproex (EXTended Release) 250 mg PO QPM \n8. Docusate Sodium 100 mg PO BID constipation \n9. FLUoxetine 20 mg PO DAILY \n10. Furosemide 20 mg PO DAILY \n11. Gabapentin 300 mg PO TID \n12. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n13. Levothyroxine Sodium 25 mcg PO DAILY \n14. Losartan Potassium 50 mg PO DAILY \n15. Magnesium Oxide 400 mg PO BID \n16. melatonin 2.5 mg oral QHS:PRN \n17. MetFORMIN (Glucophage) 1000 mg PO BID \n18. Pantoprazole 40 mg PO Q24H \n19. Rivaroxaban 10 mg PO DAILY \n20. Senna 8.6 mg PO DAILY constipation \n21. Glargine 56 Units Breakfast\nGlargine 56 Units Bedtime\n22. TraZODone 300 mg PO QHS \n\n \nDischarge Medications:\n1. Prochlorperazine 10 mg PO Q6H:PRN nausea \nRX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth q6h:prn \nDisp #*30 Tablet Refills:*0 \n2. Sucralfate 1 gm PO TID:PRN upset stomach with meals \nRX *sucralfate 1 gram/10 mL 10 mL by mouth TID:PRN Refills:*0 \n3. Acetaminophen 500 mg PO Q8H:PRN Headache \n4. Aspirin 243 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. Clopidogrel 75 mg PO DAILY \n7. Divalproex (EXTended Release) 500 mg PO BID \n8. Divalproex (EXTended Release) 250 mg PO QPM \n9. Docusate Sodium 100 mg PO BID constipation \n10. FLUoxetine 20 mg PO DAILY \n11. Furosemide 20 mg PO DAILY \n12. Gabapentin 300 mg PO TID \n13. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n14. Glargine 56 Units Breakfast\nGlargine 56 Units Bedtime \n15. Levothyroxine Sodium 25 mcg PO DAILY \n16. Losartan Potassium 50 mg PO DAILY \n17. Magnesium Oxide 400 mg PO BID \n18. melatonin 2.5 mg oral QHS:PRN \n19. MetFORMIN (Glucophage) 1000 mg PO BID \n20. Metoprolol Tartrate 12.5 mg PO BID \n21. Pantoprazole 40 mg PO Q24H \n22. Rivaroxaban 10 mg PO DAILY \n23. Senna 8.6 mg PO DAILY constipation \n24. TraZODone 300 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\nVolume depletion\nAcute Kidney Injury\nTesticular Cancer\n\nSecondary diagnoses:\nChronic lymphocytic leukemia\nCoronary artery disease\nDiabetes mellitus type 2\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure taking care of you at ___. \n\nWHY DID YOU COME TO THE HOSPITAL?\nYou were feeling weak and tired, and you had a fall at home. \nThis was likely due to dehydration. \n\nWHAT HAPPENED WHILE YOU WERE HERE?\nWe treated you with IV fluids, and started some new medicines \nfor nausea.\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?\nPlease continue to take all of your medications as directed, and \nfollow up with all of your doctors. \n\nAgain, it was a pleasure taking care of you!\n\nSincerely, \n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "N179", "C9110", "E1121", "C6212", "E861", "I110", "I5032", "I480", "I2510", "Z955", "Z7902", "Z8673", "E785", "Z9884", "E039", "F329", "F419", "F449", "E1136", "G8929", "T451X5A", "Y92009", "T501X5A", "E6601", "Z6834", "Z794" ]

[ "N179: Acute kidney failure, unspecified", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "C6212: Malignant neoplasm of descended left testis", "E861: Hypovolemia", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "I480: Paroxysmal atrial fibrillation", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E785: Hyperlipidemia, unspecified", "Z9884: Bariatric surgery status", "E039: Hypothyroidism, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "F449: Dissociative and conversion disorder, unspecified", "E1136: Type 2 diabetes mellitus with diabetic cataract", "G8929: Other chronic pain", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter", "E6601: Morbid (severe) obesity due to excess calories", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "Z794: Long term (current) use of insulin" ]

[ "N179", "I110", "I5032", "I480", "I2510", "Z955", "Z7902", "Z8673", "E785", "E039", "F329", "F419", "G8929", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses soft, ___, cottage, cream cheese\n \nAttending: ___.\n \nChief Complaint:\nabdominal ___\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ PMH CLL (on venetoclax), Depression with psychotic features,\nT2DM, CVA, presented from OSH with malaise, abdominal pain, left\nleg pain, found to have ___, UTI, Hypotension, admitted to\noncology ward for further care. \n\nOn arrival to medical ward patient was lethargic but arousable \nto\nvoice and clearly oriented. However, he had difficulty staying\nawake during the interview, as he had received 1mg of IV \nDilaudid\nin ED several hours prior. He noted that he did not feel\nlethargic prior to receiving IV Dilaudid. As a result of his\nsedation, a full history and PAML could not be obtained. \n\nHe was able to state that he initially presented to OSH with\nmalaise, lower abdominal pain, which he felt radiated to his \nleft\nleg, that was a/w difficulty urinating. He denied fever, chills,\ncough, sore throat, nausea, vomiting, diarrhea/constipation.\nNoted that he had decreased appetite/intake at home. Noted that\nsince foley was placed his abdominal and leg pain is resolved.\nReported that he was tired but asymptomatic on admission to\noncology ward. \n\nPer review of outside hospital records, patient had elevated Cr\nof 2.2, and BP to mid ___ during stay. He was given IVF and \nblood\npressure rebounded and stayed normal thereafter. Bladder scan\nrevealed >500cc so foley was placed and UA was not consistent\nwith infection. Lower extremity duplex performed on both legs \nand\nwas negative for DVT. CTH performed for questions of altered\nmental status and was without acute intracranial pathology. \nGiven\nthat he gets his care at ___, wife requested transfer. \n\nIn our ED, initial vitals: 98.6 72 125/62 18 100% RA. WBC 14.4,\nHgb 9.1, plt 146, BNP 311, ALT 67, AST 57, Ca/Mg/Phos wnl, HCO3\n18, BUN/Cr ___, lactate 2.8, UA with 182 WBC/RBC, mod bact, \nlg\nleuk, mod bld. Urine Na was 35, Osm 377\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n-___: found to have CLL incidentally on labs performed during\npsych admission. \n- Followed for several years until ___ when he noted night\nsweats and progressive fatigue.\n- Ibrutinib ___. Complicated by multiple bleeding events \nIncluding retinal bleed. Ibrutinib was held, lymph node. \nIbrutinib was restarted, c/b GI and pericardial bleeding\n- Ventoclax initiated ___\n\nPAST MEDICAL HISTORY: \n-Non-seminoma testicular GCT sp 4 cycles EP ___\n-Chronic lymphocytic leukemia as above.\n-Sick sinus syndrome s/p PPM ___ Revo DDD, \nMRI-compatible,\n___.\n-CAD s/p DES to mid-LAD in ___\n-Cerebrovascular accident (___) with residual left weakness.\n-Diabetes mellitus type II on insulin\n-pAF on xarelto\n-Hypertension.\n-Hyperlipidemia.\n-Morbid obesity.\n-Obstructive sleep apnea - not on CPAP.\n-Pancreatitis.\n-Hypothyroidism.\n-Peripheral neuropathy.\n-Chronic pain.\n-Osteoarthritis.\n-Major depression with psychotic features (vs schizoaffective\ndisorder per patient).\n-Anxiety.\n-Conversion disorder.\n-Benign paroxysmal positional vertigo.\n-Glaucoma.\n\n-s/p Cholecystectomy.\n-s/p Bilateral shoulder surgery.\n-s/p Gastric bypass surgery ___.\n\n \nSocial History:\n___\nFamily History:\nFather and mother with cardiovascular disease; mother died of\nunknown malignancy.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: ___ 2221 Temp: 97.2 PO BP: 124/66 HR: 70 RR: 20 O2\nsat: 98% O2 delivery: RA \nGENERAL: laying in bed, appears calm/comfortable, lethargic,\nopens eyes to voice then quickly falls back asleep\nEYES: right eye dilated chronically s/p cataract surgery (per\npatient), anicteric\nHEENT: OP clear but dry MM\nNECK: supple, normal ROM\nLUNGS: CTA anteriorly as is too lethargic to sit forward\nCV: RRR no m/r/g, normal distal perfusion \nABD: SOFT, protruberant, no tenderness elicited, no guarding\nGENITOURINARY: + foley with dark yellow urine + significant\namount of brown sediment\nEXT: warm, no deformity, no e/o trauma of left leg, no \nasymmetry,\nno tenderness to palpation \nSKIN: warm, dry, no rash\nNEURO: AOX3, (name, year, trump, nurses name), quickly falls\nasleep but awakens to voice\nACCESS: PORT in right chest dressing c/d/I\n\nDISCHARGE PHYSICAL EXAM:\nVSS\nGENERAL: Sitting in chair with eyes closed, appears comfortable, \n\nEYES: Right eye dilated chronically s/p cataract surgery (per\npatient), anicteric\nHEENT: OP clear. Dry MM\nNECK: Supple, normal ROM\nLUNGS: CTA b/l. No increased WOB. \nCV: RRR no m/r/g, normal distal perfusion \nABD: Soft, very protuberant, tenderness on palpation of lower\nquadrants bilaterally, no rebound tenderness or guarding\nGENITOURINARY: No foley since ___\nEXT: Warm, no deformity or evidence trauma of left leg. No\nasymmetry or tenderness to palpation \nSKIN: warm, dry, no rash\nNEURO: AOX3\nPSYCH: Irritable with ROS. Prolonged latency of speech, not\nfrankly psychotic\nACCESS: POC w/ no bleeding, erythema or discharge. \n \n \nPertinent Results:\nADMISSION LABS:\n\n___ 05:30PM BLOOD WBC-14.4* RBC-3.60* Hgb-9.1* Hct-31.0* \nMCV-86 MCH-25.3* MCHC-29.4* RDW-16.8* RDWSD-52.3* Plt ___\n___ 05:30PM BLOOD Neuts-47 ___ Monos-7 Eos-0* Baso-0 \nAtyps-1* AbsNeut-6.77* AbsLymp-6.62* AbsMono-1.01* AbsEos-0.00* \nAbsBaso-0.00*\n___ 05:03AM BLOOD ___ PTT-31.8 ___\n___ 05:30PM BLOOD Glucose-132* UreaN-23* Creat-1.7* Na-137 \nK-4.4 Cl-104 HCO3-18* AnGap-15\n___ 05:30PM BLOOD ALT-67* AST-57* AlkPhos-100 TotBili-0.2\n___ 05:30PM BLOOD Albumin-3.6 Calcium-8.7 Phos-3.8 Mg-2.0\n___ 05:43PM BLOOD Lactate-2.8*\n___ 08:48PM BLOOD Lactate-1.1\n\nDISCHARGE LABS:\n\n___ 06:35AM BLOOD WBC-10.9* RBC-3.44* Hgb-8.7* Hct-29.3* \nMCV-85 MCH-25.3* MCHC-29.7* RDW-17.0* RDWSD-51.5* Plt ___\n___ 06:35AM BLOOD Neuts-29* Lymphs-62* Monos-5 Eos-3 Baso-0 \nMetas-1* AbsNeut-3.16 AbsLymp-6.76* AbsMono-0.55 AbsEos-0.33 \nAbsBaso-0.00*\n___ 06:35AM BLOOD Glucose-160* UreaN-14 Creat-1.1 Na-141 \nK-4.4 Cl-105 HCO3-23 AnGap-13\n___ 06:35AM BLOOD ALT-56* AST-53* LD(LDH)-317* AlkPhos-112 \nTotBili-0.2\n___ 06:35AM BLOOD Albumin-3.6 Calcium-9.4 Phos-3.0 Mg-2.___ year old male with CLL (on venetoclax) with\nPMH significant for depression with psychotic features, T2DM, \nCVA\nwho presented from OSH with malaise, abdominal pain, left leg\npain, found to have ___, presumed UTI and hypotension.\n\nACUTE CONDITIONS\n========================\n\n#Acute Abdominal Pain (Improved):\n#Presumed Complicated UTI:\n#Urinary Retention (resolved)\n___ (resolved)\n#Hematuria:\nPatient with suprapubic tenderness at OSH, occurred in setting \nof\nacute urinary retention which corresponds to location of lower\nabdominal pain. Significant improvement after foley placement.\nHowever, noted worsening of abdominal pain on ___ which\nprompted further imaging with CT A/P. Alternate cause could be\ndue to recent jejunal ulcer vs. known gastric fistula causing\nintra-abdominal complication that was diagnosed via CT scan and\nEGD last admission on ___ (less likely as abdomen is benign\ncurrently). Urinalysis grossly positive from ___ therefore,\ninitiated ceftriaxone. However, culture negative. Given UA\nresults on admission, presenting symptoms and high risk for\ninfection in s/o CLL and treatment, decision was made to \ncontinue\na course of ceftriaxone but extended to a ___s would\nbe a complicated UTI. CT A/P ___ does not show an acute\nintra-abdominal process but noted gastrogastric fistula or \nbypass\nreversal (not new and unlikely to cause his pain). Also, \nconsider\nrole of constipation as possible cause of abdominal discomfort \nand retention. \n-Lactate unremarkable at 0.9. \n-Renal U/S negative ___\n-Completed ceftriaxone x7D (D1: ___\n-constipation relief after BM ___\n-GI prophylaxis: protonix and carafate\n-will schedule outpatient urology appointment to further work up \nhematuria and cause of urinary retention\n\n#LLE Pain: Most likely ___ neuropathy or referred pain ___ acute\nurinary retention. U/S at OSH did not show DVT. No tenderness or\ndeformity to warrant x-ray or cross sectional imaging. Restarted\nhome gabapentin 100mg TID on ___ with improvement. ___\nfollowing. Plan to resume ___ services at discharge \n\n#Constipation: currently resolved, rec continuing bowel regimen \non discharge \n\nCHRONIC/RESOLVED/STABLE CONDITIONS\n=========================================\n\n#Lethargy: Resolved. Likely over-medication with dilaudid in ED\non admission ___. CTH at OSH negative for acute ICH.\nOver-sedation ___ psych medications also possible but less \nlikely\nas presented with normal alertness while on home meds versus \nUTI.\nFSG wnl on admission. Resumed home psychiatry medications that\nwas originally held due to sedation including topomax,\nhydroxyzine, and risperidone ___. Monitor for reoccurrence \n\n#Hypotension: Resolved. Likely ___ hypovolemia as appears dry on\nexam. Anti-HTN meds + diuretics likely contributing factors\n-IVF prn\n-Hold losartan and lasix (as above)\n-Trend BPs, restart metoprolol if becomes hypertensive\n\n___: Likely ___ hypovolemia-related as improved Cr with fluids.\n-Renally dose medications, holding Lasix & losartan\n-Foley discontinued ___ and no issues voiding since\n-U/S negative for hydronephrosis\n\n#CLL: Patient had recurrence of night sweats and noted to have \nan\nincrease in his white blood cell count with prominent\nlymphocytosis, consistent with relapsing disease. Given these\nchanges, he was started on ibrutinib. However, given multiple\nsignificant bleeding events (GI bleeding and pericardial bleed),\nfurther ibrutinib therapy was deferred and venetoclax was\ninitiated. In the setting of active infection concern, \nvenetoclax\nwas held but now restarted on ___ per primary oncologist. \n-Continue venetoclax 400mg daily\n-Continue acyclovir for infectious prophylaxis\n\n#Transaminitis & HLD: Stable. Uptrending as of ___ ALT 75\n(previously 64 on ___ and AST 84 (previously 69 on ___.\nPresent on prior admits, thought to be ___ drug-induced liver\ninjury of low level, though unclear causative agent as is on so\nmany agents which could potentially lead to transaminitis. Hep\nserologies in ___ were negative. Given strong indication for\ncurrent medications, will continue except for fenofibrate/statin\n-Trend LFTs daily\n\n#T2DM: Continues on ___ with SS per ___ recommendations \nfrom\nlast admission. Held metformin on admission. \n-When not eating, give sliding scale only\n-Trend FSG, consider re-consulting ___ if trend worsens\n\n#Anemia: Noted on last hospitalization to be due to iron\ndeficiency and likely contribution from CLL/Venetoclax\n-Continue CBC daily\n-Maintain type and screen\n-Transfuse Hgb<7\n\n#Thrombocytopenia: Stable. Likely ___ treatment vs. disease. \n-Trend daily\n-Transfuse for plt <10\n-Maintain type and screen\n\n#History of depression with psychotic features: On last\nhospitalization, had fluctuating mental state, was followed by\npsychiatry who adjusted his medications by stopping ziprasidone \n&\namitriptyline, decreasing gabapentin, and continuing\nescitalopram, risperidone, and topirimate\n-Continue psychiatric medications, resumed sedating medications\nas above (ex Risperdal, melatonin, hydroxyzine, Topamax)\n-Trend mental status closely, re-consult psych as needed\n\n#SSS status post PPM: Atrial paced per EKG in ED\n-Continue rivaroxaban 20mg daily\n-Hold Metoprolol in s/o hypotension as above, restart PRN\n\n#History of Gout: Holding colchicine in s/o renal injury. \n-Continues on allopurinol ___ daily\n\n#Hypothyroidism: Dose was adjusted on most recent admission. He\ncontinues on synthroid ___ daily, next re-check ___\n\n#History of Jejunal Ulcer: Continues sucralfate/pantoprazole\n\n#History of CVA: Had right-sided subcortical lacunar infarcts in\n___ with residual mild left-sided weakness, but does not have \nan\neffect on mobility. Continues on ASA.\n\nCORE MEASURES\n====================== \n#FEN: IVF, replete electrolytes, regular diet \n#Prophylaxis: \n-DVT: rivaroxaban as above\n#Access: PORT\n#HCP: ___ Relationship: son; Phone number: ___ \n#Code: Full presumed\n\n#Disposition: home with services\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever \n2. Acyclovir 400 mg PO Q8H \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Docusate Sodium 100 mg PO BID \n6. Escitalopram Oxalate 20 mg PO DAILY \n7. Fenofibrate 54 mg PO DAILY \n8. Gabapentin 100 mg PO TID \n9. Levothyroxine Sodium 125 mcg PO DAILY \n10. Lidocaine 5% Patch 3 PTCH TD QPM \n11. Magnesium Oxide 400 mg PO BID \n12. Metoprolol Succinate XL 150 mg PO DAILY \n13. Nystatin-Triamcinolone Cream 1 Appl TP BID \n14. Pantoprazole 40 mg PO Q12H \n15. RisperiDONE 3 mg PO QHS \n16. Rivaroxaban 20 mg PO DINNER \n17. Topiramate (Topamax) 50 mg PO DAILY \n18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY \n19. Venetoclax 400 mg PO DAILY \n20. Allopurinol ___ mg PO DAILY \n21. Carbamide Peroxide 6.5% ___ DROP BOTH EARS DAILY \n22. Colchicine 0.6 mg PO DAILY \n23. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 \n24. Furosemide 20 mg PO DAILY \n25. melatonin 6 mg oral qhs \n26. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n27. Losartan Potassium 50 mg PO DAILY \n28. HydrOXYzine 10 mg PO Q6H:PRN anxiety \n29. Sucralfate 1 gm PO BID \n30. Senna 8.6 mg PO BID:PRN Constipation - First Line \n31. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - \nModerate \n32. ___ 70 Units Breakfast\n___ 50 Units Lunch\n___ 30 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n2. ___ 70 Units Breakfast\n___ 50 Units Lunch\n___ 30 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n3. Senna 8.6 mg PO BID \n4. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever \n5. Acyclovir 400 mg PO Q8H \n6. Allopurinol ___ mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 40 mg PO QPM \n9. Docusate Sodium 100 mg PO BID \n10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 \n11. Escitalopram Oxalate 20 mg PO DAILY \n12. Fenofibrate 54 mg PO DAILY \n13. Gabapentin 100 mg PO TID \n14. HydrOXYzine 10 mg PO Q6H:PRN anxiety \n15. Levothyroxine Sodium 125 mcg PO DAILY \n16. Lidocaine 5% Patch 3 PTCH TD QPM \n17. Magnesium Oxide 400 mg PO BID \n18. melatonin 6 mg oral qhs \n19. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n20. Metoprolol Succinate XL 150 mg PO DAILY \n21. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - \nModerate \n22. Pantoprazole 40 mg PO Q12H \n23. RisperiDONE 3 mg PO QHS \n24. Rivaroxaban 20 mg PO DINNER \n25. Sucralfate 1 gm PO BID \n26. Topiramate (Topamax) 50 mg PO DAILY \n27. Venetoclax 400 mg PO DAILY \n28. HELD- Colchicine 0.6 mg PO DAILY This medication was held. \nDo not restart Colchicine until outpatient team tells you to \nrestart\n29. HELD- Furosemide 20 mg PO DAILY This medication was held. \nDo not restart Furosemide until outpatient team tells you to do \nso\n30. HELD- Losartan Potassium 50 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until outpatient team \ntells you to do so\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses: \nUTI\n___\nCLL\nConstipation\nAcute Abdominal Pain\n\nSecondary Diagnoses: \nJejunal Ulcer\nGastro-gastric Fistula \nLethargy\nHypothyroidism\nDelirium\nInsulin dependent diabetes mellitus \nDepression with psychotic features, in remission \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking part in your care here at ___! \n\nWhy was I admitted to the hospital? \n- You were admitted for abdominal pain, urinary retention, and \nacute kidney injury.\n\nWhat was done for me while I was in the hospital? \n- We gave you antibiotics for your urinary tract infection\n- We gave you pain medications as needed\n\nWhat should I do when I leave the hospital? \n- please check your blood sugars before meals and at bedtime \neveryday, and bring a log of your readings to your next doctors \n___.\n- Take all of your medications as prescribed\n- Follow-up with all of your physicians as directed \n\nSincerely, \n\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "N179", "N390", "C9110", "I69354", "Z950", "I2510", "Z955", "E1142", "Z794", "I480", "Z7901", "E785", "E6601", "G4733", "E039", "F419", "Z9884", "I10", "G8929", "D696", "D509", "F329", "I495", "M109", "K289", "R339", "I959", "Z8547", "R319", "R740", "R5383", "T402X5A", "K5900", "E861" ]

[ "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "Z950: Presence of cardiac pacemaker", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "Z794: Long term (current) use of insulin", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "E785: Hyperlipidemia, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E039: Hypothyroidism, unspecified", "F419: Anxiety disorder, unspecified", "Z9884: Bariatric surgery status", "I10: Essential (primary) hypertension", "G8929: Other chronic pain", "D696: Thrombocytopenia, unspecified", "D509: Iron deficiency anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I495: Sick sinus syndrome", "M109: Gout, unspecified", "K289: Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "R339: Retention of urine, unspecified", "I959: Hypotension, unspecified", "Z8547: Personal history of malignant neoplasm of testis", "R319: Hematuria, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "R5383: Other fatigue", "T402X5A: Adverse effect of other opioids, initial encounter", "K5900: Constipation, unspecified", "E861: Hypovolemia" ]

[ "N179", "N390", "I2510", "Z955", "Z794", "I480", "Z7901", "E785", "G4733", "E039", "F419", "I10", "G8929", "D696", "D509", "F329", "M109", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses soft, ___, cottage, cream cheese\n \nAttending: ___.\n \nChief Complaint:\nInitiation of venetoclax\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with a background history of CLL, previously on ibrutinib, \nstatus post EP x4 cycles, and now planned for venetoclax, SSS \nstatus post PPM placement, AF on rivaroxaban, CAD status post \nstent, recurrent pericarditis, HFpEF, stroke, HTN/HLD, and \nhypothyroidism, presenting for initiation of venetoclax therapy.\n\nPatient with recent admission ___ with viral \nrespiratory illness, and negative infectious work-up. Admission \nwas complicated by atrial flutter with RVR, requiring ICU \nadmission for IV amiodarone load, ___ which was likely pre-renal \nin origin in the setting of hypovolemia and hypotension, and \nyeast urinary tract infection for which he was prescribed a two \nweek course of fluconazole. Also completed course of \nlevofloxacin for CAP prophylaxis. Unfortunately he left against \nmedical advice the night prior to discharge.\n\nSince discharge, patient has been doing well. All symptoms from \nprevious viral respiratory illness have resolved, except for \npersistence of non-productive cough. Recalls ___ episodes of \nloose stools over the weekend, but this has now resolved. Does \nreport anxiety regarding starting new chemotherapy regimen,\nespecially regarding kidney dysfunction and future need for \ndialysis. Had long discussion with Dr. ___ same.\n\nDenies fevers, chills, headache, light-headedness, dizziness, \nsore throat, nasal congestion, sputum production, wheeze, chest \npain, palpitations, abdominal pain/discomfort, diarrhea, \nconstipation, PR blood loss, joint pains or skin rashes. Does \nhave chronic right shoulder pain. \n\n10-point review of systems negative, except as noted above.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nCLL (17p-) and Stage IIIA Mixed germ cell tumor of the testis\n- ___ Lymphocytosis incidentally found during a psychiatric\nhospitalization.\n- ___ CT scan showed a slightly enlarged spleen at 14.5 cm\nand no adenopathy.\n- ___ He met with Dr. ___ in ___ at\n___. WBC was 15.0 with 49.6% lymphocytes, Hgb 11.9,\nand platelets 260,000. Flow cytometry was consistent with CLL,\nand B-cell gene rearrangement confirmed clonality. CLL FISH \npanel\nshowed a p53 mutation. He was asymptomatic at the time of\ndiagnosis and followed with Dr. ___. \n- WBC gradually uptrended to 22.7 in ___, 37.3 in ___,\n51.3 in ___, and 50.4 on ___. Hgb has decreased slightly\nto 10.9 and Hct 34.4 with platelets 234,000 on the ___ \nlabs.\n- ___ Hematology care transitioned to Dr. ___\nafter Dr. ___. He also started having nightly sweats. \n\n- ___ CT Chest without lymphadenopathy or other notable\nfindings.\n- ___ Initial ___ Hematology evaluation for second\nopinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood\nflow cytometry and cytogenetics confirmed CLL with TP53 \ndeletion.\n- ___ CT Abdomen/Pelvis without lymphadenopathy or other\nnotable findings.\n- ___ Started ibrutinib 420 mg daily.\n- ___ Ibrutinib held for vitreous bleed\n- ___ Ibrutinib restarted\n- ___ Per OSH records, underwent scrotal U/S showing\nheterogeneous left testicle, prominent rete testis on right.\n- ___ Presented to his outpatient hematologist, Dr.\n___ a painful swollen left testicle (swelling over \n~8 months, worsening pain). This had been evaluated on ___\nwith\nan ultrasound that did not demonstrate torsion but did show\nheterogeneous morphology of the left testicle. HCG was positive.\nReferred to Dr. ___.\n- ___ Underwent left radical orchiectomy. Pathology\nrevealed 3.9 cm malignant mixed germ cell tumor of the testis,\n95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1%\nchoriocarcinoma, invading hilar statin ___ vaginalis, with\nlymphatic vascular invasion and metastatic tumor nodules in the\nspermatic cord. pT2NxS1 (although no post-orch levels, beta hCG\n64 on ___, up from 21 on ___ AFP 3, LDH normal).\n- ___ CT torso showing new 8 mm nodule in the left lower\nlobe, and comparison with CT ___. Left para-aortic\nlymphadenopathy up to 2.8 cm and a 3.5 cm fluid collection in \nthe left inguinal region/scrotum, felt to be likely \npostsurgical.\n- ___ C1D1 EP\n- ___ C2D1 EP (delayed 1 week after nasal infection\n- ___ Admitted for weakness, fall\n- ___ Admitted for parainfluenza pneumonia, symptomatic\nanemia, palpitations, developed nausea/vomiting in hospital\n- ___ C3D1 EP (delayed 1 week, added palonosetron)\n- ___ C4D1 EP\n- ___ CT torso with significant decrease in size of the\npreviously seen left para-aortic lymph node which now measures 6\nmm, previously 28 mm. Otherwise no LAD.\n- ___ Restarted ibrutinib for recurrent CLL (night sweats,\nlymphocytosis)\n\nPAST MEDICAL HISTORY:\n- Sick sinus syndrome s/p PPM ___ Revo DDD,\nMRI-compatible, ___\n- CAD s/p DES to mid-LAD (___)\n- Stroke ___ (with recovering motor function, though still with\nsome left thigh sensory decrease)\n- Type II DM (on insulin)\n- Hypertension\n- Hyperlipidemia\n- Morbid Obesity status post gastric bypass surgery ___\n- OSA (not on CPAP)\n- Pancreatitis secondary to alcohol (___)\n- Cholecystectomy\n- Hypothyroidism\n- Osteoarthritis\n- Bilateral shoulder surgery, chronic pain right shoulder\n- Major depression with psychotic features\n- Anxiety\n- Conversion Disorder\n- Benign Paroxysmal Positional Vertigo\n- Glaucoma\n \nSocial History:\n___\nFamily History:\nNo known history of malignancies.\n \nPhysical Exam:\n===============================\nADMISSION PHYSICAL EXAMINATION:\n===============================\n\nVS: Temp 98.2 BP 145/90 HR 146 (88 manual) RR 22 SaO2 98% \nRA\nGENERAL: sitting comfortably in chair, no acute distress\nHEENT: AT/NC, EOMI, PERRLA, no conjunctival pallor, anicteric \nsclera, MMM, oropharynx without lesions\nNECK: supple, non-tender, no LAD, no JVD\nCV: RRR, S1 and S2 normal, no murmurs/rubs/gallops\nRESP: CTAB, no wheezes/crackles, breathing comfortably without \nuse of accessory muscles of respiration\n___: obese, soft, non-tender, distention with body habitus, BS \nnormoactive\nEXTREMITIES: warm/well perfused, 1+ lower extremity edema\nNEURO: A/O x3, CN II-XII intact, strength ___ in all \nextremities, sensation intact\nSKIN: no skin rashes/lesions\nACCESS: right sided port clean, dry and intact, without \nsurrounding erythema\n\n===============================\nDISCHARGE PHYSICAL EXAMINATION:\n===============================\n\nVS: Temp: 98.7 (Tm 99.8), BP: 126/60 (104-150/60-75), HR: 68\n(68-70), RR: 18 (___), O2 sat: 98% (96-98), O2 delivery: RA\n\nGENERAL: sitting comfortably in chair, no acute distress\nHEENT: no conjunctival pallor, anicteric sclera, MMM, oropharynx \nwithout lesions\nNECK: supple, non-tender, no LAD, no JVD\nCV: RRR, S1 and S2 normal, no murmurs/rubs/gallops\nRESP: decreased air entry at left base (present previously), no \nclear crackles, breathing comfortably without use of accessory \nmuscles of respiration\n___: obese, soft, non-tender, distention with body habitus, BS \nnormoactive\nEXTREMITIES: warm/well perfused, ___ lower extremity edema\nNEURO: A/O x3, grossly intact\nSKIN: no skin rashes/lesions\nACCESS: right sided port clean, dry and intact, without \nsurrounding erythema\n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n\n___ 12:30PM BLOOD WBC-21.4* RBC-3.27* Hgb-8.9* Hct-28.2* \nMCV-86 MCH-27.2 MCHC-31.6* RDW-15.3 RDWSD-48.4* Plt ___\n___ 12:30PM BLOOD Neuts-50 Bands-0 ___ Monos-3* Eos-1 \nBaso-0 ___ Myelos-0 AbsNeut-10.70* AbsLymp-9.84* \nAbsMono-0.64 AbsEos-0.21 AbsBaso-0.00*\n___ 12:30PM BLOOD UreaN-10 Creat-1.1 Na-133* K-4.3 Cl-93* \nHCO3-26 AnGap-14\n___ 12:30PM BLOOD ALT-12 AST-16 LD(LDH)-278* CK(CPK)-124 \nAlkPhos-81 TotBili-0.2\n___ 12:30PM BLOOD Albumin-3.2* Calcium-8.7 Phos-4.5 Mg-1.9 \nUricAcd-5.3\n___ 12:30PM BLOOD %HbA1c-8.3* eAG-192*\n\n=====================\nOTHER PERTINENT LABS:\n=====================\n\n___ 12:00AM BLOOD ___\n___ 12:00AM BLOOD ___\n___ 08:04AM BLOOD TSH-19*\n___ 08:04AM BLOOD Free T4-1.0\n___ 08:04AM BLOOD Osmolal-256*\n___ 08:12PM BLOOD Osmolal-257*\n___ 08:14AM BLOOD ___\n___ 08:14AM BLOOD Osmolal-253*\n___ 08:14AM BLOOD Cortsol-11.2\n___ 12:48PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN - 0.12 \n(negative)\n___ 12:48PM BLOOD B-GLUCAN - 50 (negative)\n___ 06:00AM BLOOD ___\n___ 01:02PM BLOOD Bnzodzp-NEG\n___ 01:02PM BLOOD Acetmnp-NEG\n___ 12:05PM BLOOD G6PD-NORMAL\n___ 12:05PM BLOOD Ret Aut-1.8 Abs Ret-0.05\n___ 12:05PM BLOOD LMWH-0.77\n___ 02:05PM BLOOD Heparin-1.03*\n___ 09:30AM BLOOD Cortsol-13.3\n\n======\nMICRO:\n======\n\n___ Urine culture x3 - no growth\n___ Blood culture x4 - no growth\n___ Respiratory viral screen/culture - negative\n\n================\nIMAGING/REPORTS:\n================\n\n___ CXR\nLungs are low volume with bibasilar atelectasis. Left-sided \npacemaker is \nunchanged. Right-sided Port-A-Cath tip projects to the \ncavoatrial junction. Small left pleural effusion stable. No \npneumothorax is seen. There is subsegmental atelectasis in the \nleft lung base.\n\n___ CT CHEST WITHOUT CONTRAST\nBilateral pleural effusions left greater than right slightly \nincreased in \nvolume since the prior study. Moderate-sized pericardial \neffusion. Also slightly increased in volume since the prior \nstudy. Left-sided pacemaker and right-sided central line \nunchanged. Bibasilar atelectasis.\n\n___ RENAL US\nNo hydronephrosis on either side. Corticomedullary \ndifferentiation is \nwell-maintained. \n\n___ CT HEAD WITHOUT CONTRAST\nNo acute intracranial process.\n\n___ TTE\nDue to suboptimal technical quality, a focal wall motion \nabnormality cannot be fully excluded. Overall left ventricular \nsystolic function is normal (LVEF>55%). There is a small \npericardial effusion. The effusion is echo dense, consistent \nwith blood, inflammation or other cellular elements. \n\n===============\nDISCHARGE LABS:\n===============\n\n___ 08:00AM BLOOD WBC-19.6* RBC-3.10* Hgb-8.6* Hct-26.9* \nMCV-87 MCH-27.7 MCHC-32.0 RDW-15.9* RDWSD-47.3* Plt ___\n___ 08:00AM BLOOD Neuts-35 Bands-0 Lymphs-54* Monos-6 Eos-2 \nBaso-1 ___ Myelos-0 Other-2* AbsNeut-6.86* \nAbsLymp-10.58* AbsMono-1.18* AbsEos-0.39 AbsBaso-0.20*\n___ 08:00AM BLOOD ___ PTT-42.8* ___\n___ 08:00AM BLOOD Glucose-372* UreaN-12 Creat-1.2 Na-129* \nK-4.4 Cl-86* HCO3-30 AnGap-13\n___ 08:00AM BLOOD ALT-6 AST-11 LD(LDH)-216 AlkPhos-67 \nTotBili-0.2\n___ 08:00AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9 UricAcd-4.___ with a background history of CLL, previously on ibrutinib, \nstatus post EP x4 cycles, and now planned for venetoclax, SSS \nstatus post PPM placement, AF on rivaroxaban, CAD status post \nstent, recurrent pericarditis, HFpEF, stroke, HTN/HLD, and \nhypothyroidism, presenting for initiation of venetoclax therapy.\n\n====================\nACUTE/ACTIVE ISSUES:\n====================\n\n# Hyponatremia\nPatient with a known history of chronic hyponatremia, previously \nthought to contain a component of SIADH. Sodium levels remained \nan issue throughout admission. Acutely decreased in the setting \nof IVF administration, reaching a nadir of 119. Urine/serum \nlytes and osmolality consistent with SIADH. Of note, patient is \non several psychiatric medications which may contribute to \nchronic hyponatremia. Rapid correction of sodium with IV \nfurosemide, with daily diuresis required to maintain sodium \n>130. AM cortisol was within normal limits. As patient required \nIVF during initiation of venetoclax, sodium was closely \nmonitored and high dose IV furosemide administered twice daily. \nPatient was also fluid restricted and placed on a low sodium \ndiet. Weight down-trended over the course of the admission but \nwas still elevated at discharge. Will increase home regimen of \nfurosemide to 20mg PO daily from every other day. Sodium 129 \nprior to discharge, but this lab was drawn prior to last dose of \nIV furosemide 80mg.\n\n# CLL\nDiagnosed in ___, unfavorable cytogenetics by virtue of \ndeletion(17p), previously on ibrutinib, but now off ibrutinib \ntherapy given recent admission for pericardial effusion and \nhypotension. Presented on this occasion to initiate venetoclax, \nhowever starting same was delayed in the setting of \nhyponatremia, ___ and altered mental status. Eventually started \nvenetoclax 20mg daily on ___, without issue or evidence of \nTLS. Dose was increased to 50mg on ___, and 100mg on ___, \nwithout any issues. Continued allopurinol (renally dosed during \n___ to prevent hyperuricemia. Also continued acyclovir for HSV \nprophylaxis. \n\n# Bradycardia\nPatient with a known history of sick-sinus syndrome, with a PPM \nin place, and atrial fibrillation, on metoprolol succinate 150mg \ndaily. Soon after admission, patient was noted to have heart \nrates in ___ on monitor, which persisted for several hours. EKG \nat the time with normal heart rate in ___. Patient was \nasymptomatic, with the exception of a \"mechanical fall\" without \ninjury. Initially rates recovered to ___, but following \nadministration of metoprolol tartrate 37.5mg, rates dropped back \ndown to ___. EP were consulted; interrogation of the PPM \nrevealed a well functioning device, with no documented \nbradycardic episodes. Subsequent telemetry with high PVC burden \nand ventricular bigeminy, but no recurrence of bradycardia. \nThese episodes likely represented monitoring error rather than \ntrue bradycardia.\n\n# Fever\nPatient with temperature of 100.3, and subsequently 101 on \n___. Remained asymptomatic and denied all symptoms. CT chest \ndemonstrated bilateral pleural effusions, left greater than \nright, but no evidence of consolidation/infiltration. Urine \nculture was negative. Beta glucan and galactomannan were not \ndetected. Respiratory screen and culture also negative. Unclear \nexact etiology but given absence of recurrent fevers and \nhemodynamic stability, antibiotics were not initiated. \n\n# ___\nPatient with apparent baseline creatinine ~1.1. Over the course \nof admission, creatinine fluctuated, reaching a max of 1.9 on \n___. Most likely etiology was venous congestion in the setting \nvolume overload. Creatinine returned to baseline on each \noccasion following aggressive diuresis, consistent with this \nhypothesis. \n\n# Somnolence\nIntermittent somnolence noted by nursing staff over the course \nof admission. Unclear etiology; initial concern was for osmotic \ndemyelination in setting of rapid\nhyponatremia correction, but this was unlikely given normal \nneurological examination and periods of time when he was alert, \nawake and orientated. Another concern was patient \nself-medicating with Vicodin, as was found on two occasions with \nVicodin on his person, although patient denied same, serum APAP \nlevel was negative and no respiratory depression was noted. Most \nlikely etiology was delirium in setting of metabolic \nderangements. \n\n# LUE swelling\nPatient noted to have left greater than right upper extremity \nswelling by nursing. Unclear exact chronicity, but a small \ndifference was notable on examination. Had been anticoagulated \non rivaroxaban at home, and before transitioning to enoxaparin \nwhile an inpatient. Factor Xa levels were therapeutic. Patient \nrefused US Doppler. There was no further change in swelling \nthroughout admission, making DVT less likely.\n\n======================\nCHRONIC/STABLE ISSUES:\n======================\n\n# Type II Diabetes Mellitus\nContinued home insulin glargine, with a Humalog insulin sliding \nscale. Adjustments had to be made on a number of occasions, \ngiven patient's reluctance to eat a restricted diet. Will be \ndischarged on admission regimen. \n\n# HFrEF\nIssues with volume persisted throughout admission, and were \ncontributors to both ___ and hyponatremia. Home furosemide was \nreplaced with IV furosemide as needed. Ultimately the patient \nwas transitioned to an oral regimen of furosemide 20mg daily. \nWeight was not at admission weight at discharge, but as it was \nthe patient's birthday and he was stable, we were happy to \ndischarge him with close follow-up. Losartan was held in the \nsetting of ___, and will be held on discharge. The decision \nif/when to restart is deferred to outpatient providers. \nMetoprolol, fractionated from home dose, was continued, except \nas noted above. \n\n# Atrial Fibrillation\nRivaroxaban was held given potential interaction with \nvenetoclax, and therapeutic enoxaparin started in its place. \nHome metoprolol was fractionated, and continued at 37.5mg Q6H, \nexcept as noted above. Following discussion, the decision was \nmade to restart rivaroxaban on discharge, as the risk of further \nthromboembolism was felt to outweigh the risk of bleeding.\n\n# CAD status post LAD PCI\n# Hyperlipidemia\nContinues aspirin 81mg daily. On previous admission, both statin \nand fenofibrate were held. Decision if/when to restart these \nmedications is deferred to outpatient provider. \n\n# Pericarditis\nColchicine was discontinued, given theoretical interaction with \nvenetoclax.\n\n# Hypertension\nHome losartan 25mg daily was held in the setting of labile renal \nfunction during the course of admission. It was held on \ndischarge; decision if/when to restart is deferred to outpatient \nproviders. \n\n# Schizoaffective Disorder\nCotninued home divalproex, fluoxetine, and ziprasidone. \nDiscussion should be had with outpatient psychiatrist if these \nmedications may be contributing to chronic hyponatremia.\n\n# Anemia\nChronic issue, which remained stable during admission. Required \ntwo blood transfusions while an inpatient. Most likely etiology \nis malignancy induced.\n\n# Hypothyroidism\nContinued levothyroxine 50mcg daily. Repeat TSH was 19, with a \nnormal free T4. Discussed with endocrinology, who recommended \nrepeating TSH after ___ to obtain an accurate reflection if \ncurrent dosing is correct. \n\n# Chronic pain\nContinued gabapentin 300mg TID, dose adjusted during times of \nacute kidney injury. Home vicodin was replaced with APAP and \noxycodone while an inpatient. Will be discharged on gabapentin \n300mg BID (renally dosed)\n\n====================\nTRANSITIONAL ISSUES:\n====================\n\n- discharge WBC 19.6\n- discharge Hgb 8.6\n- discharge Plt 210\n- discharge Na 129 \n- discharge K 4.4\n- discharge creatinine 1.2\n- discharge calcium 8.5\n- discharge phosphate 3.7\n- discharge uric acid 4.6\n\n- Admission weight 270.1lbs \n- Discharge weight 278.9lbs\n\nMEDICATION CHANGES:\n[] started allopurinol ___ daily\n[] started venetoclax 100mg daily (dose will be changed by Dr. \n___\n[] started ondansetron 4mg Q8H:PRN (30 tablets)\n[] changed gabapentin to 300mg twice a day\n[] changed furosemide to 20mg daily\n[] held losartan as your blood pressures were normal\n[] stopped colchicine given interaction with venetoclax\n[] stopped fluconazole as it was no longer needed\n\n[] Repeat TSH after ___ to determine if levothyroxine is \nadequately dosed\n[] Discuss if chronic SIADH may be attributable to psychiatric \nmedications\n[] Held losartan at discharge as blood pressures were within \nnormal limits; decision if/when to restart deferred to \noutpatient providers\n[] Follow patient's weight closely as not at baseline on \ndischarge\n[] Decision if/when to restart atorvastatin/fenofibrate is \ndeferred to outpatient providers\n\n============================================\n# CODE STATUS: Full\n# CONTACT: ___, HCP/son, ___\n \nMedications on Admission:\n1. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN back pain \n2. Acyclovir 400 mg PO Q8H \n3. Aspirin 81 mg PO DAILY \n4. Colchicine 0.6 mg PO DAILY \n5. Divalproex (EXTended Release) 500 mg PO QAM \n6. Divalproex (EXTended Release) 750 mg PO QPM \n7. FLUoxetine 20 mg PO DAILY \n8. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN Nasal \ncongestion \n9. Furosemide 20 mg PO EVERY OTHER DAY \n10. Gabapentin 300 mg PO TID \n11. Levothyroxine Sodium 50 mcg PO DAILY \n12. Losartan Potassium 25 mg PO DAILY \n13. Metoprolol Succinate XL 150 mg PO DAILY \n14. Multivitamins 1 TAB PO DAILY \n15. Pantoprazole 40 mg PO Q24H \n16. Rivaroxaban 20 mg PO DINNER \n17. Senna 8.6 mg PO BID:PRN constipation \n18. ZIPRASidone Hydrochloride 40 mg PO BID \n19. Fluconazole 200 mg PO Q24H \n20. Docusate Sodium 100 mg PO BID \n21. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n22. Magnesium Oxide 400 mg PO BID \n23. Glargine 75 Units Breakfast\nGlargine 30 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \nRX *allopurinol ___ mg 1 tablet(s) by mouth DAILY Disp #*30 \nTablet Refills:*0 \n2. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet \nRefills:*0 \n3. Ondansetron 4 mg PO Q8H:PRN Nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*30 \nTablet Refills:*0 \n4. venetoclax 100 mg oral DAILY \n5. Gabapentin 300 mg PO BID \n6. Glargine 75 Units Breakfast\nGlargine 30 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n7. Acyclovir 400 mg PO Q8H \n8. Aspirin 81 mg PO DAILY \n9. Divalproex (EXTended Release) 500 mg PO QAM \n10. Divalproex (EXTended Release) 750 mg PO QPM \n11. Docusate Sodium 100 mg PO BID \n12. FLUoxetine 20 mg PO DAILY \n13. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN Nasal \ncongestion \n14. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n15. Levothyroxine Sodium 50 mcg PO DAILY \n16. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN back pain \n17. Magnesium Oxide 400 mg PO BID \n18. Metoprolol Succinate XL 150 mg PO DAILY \n19. Multivitamins 1 TAB PO DAILY \n20. Pantoprazole 40 mg PO Q24H \n21. Rivaroxaban 20 mg PO DINNER \n22. Senna 8.6 mg PO BID:PRN constipation \n23. ZIPRASidone Hydrochloride 40 mg PO BID \n24. HELD- Losartan Potassium 25 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until informed by your \noutpatient provider\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n==================\nPRIMARY DIAGNOSES:\n==================\n\nChronic lymphocytic leukemia \nHypervolemic hyponatremia\nAcute kidney injury\nAcute on chronic anemia\n\n====================\nSECONDARY DIAGNOSES:\n====================\n\nType II diabetes mellitus\nHeart failure with reduced ejection fraction\nAtrial fibrillation\nCoronary artery disease status post percutaneous coronary \nintervention\nHyperlipidemia\nRecurrent pericarditis\nHypertension\nSchizoaffective disorder\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 Mr. ___,\n\nWHY YOU CAME TO THE HOSPITAL\nYou were admitted to start chemotherapy for your CLL\n\nWHAT HAPPENED WHILE YOU WERE IN HOSPITAL\n- You had problems with low sodium levels due to excess fluid in \nyour body\n- We restricted your salt/fluid intake and gave you diuretics to \nremove the extra fluid\n- You were confused for several days, likely due to your low \nsodium levels\n- You also had a fever, but all this was negative and they did \nnot recur\n- We started your chemotherapy and increased the dose to 100mg \nwithout issue\n\nWHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL\n- You need to follow-up with Dr. ___ ...\n- Please take all your medications as prescribed\n- It is important to try to limit your fluid intake to 2L a day \nand eat a low salt diet\n- It is also important you measure your weight daily to assess \nfor fluid retention\n\nIt was a pleasure taking care of you!\n\nYour ___ Healthcare Team\n\nMEDICATION CHANGES:\n[] started allopurinol ___ daily\n[] started venetoclax 100mg daily (dose will be changed by Dr. \n___\n[] started ondansetron 4mg every 8 hours as needed for nausea\n[] changed gabapentin to 300mg twice a day\n[] changed furosemide to 20mg daily\n[] held losartan as your blood pressures were normal\n[] stopped colchicine given interaction with venetoclax\n[] stopped fluconazole as it was no longer needed\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "I5023", "N179", "C9110", "E222", "D630", "C6290", "F05", "E1142", "I4891", "I110", "F259", "I2510", "E039", "E785", "Z955", "G4733", "Z7901", "Z794", "Z45018", "R509", "G8929", "I493", "E875", "M7989" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "D630: Anemia in neoplastic disease", "C6290: Malignant neoplasm of unspecified testis, unspecified whether descended or undescended", "F05: Delirium due to known physiological condition", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "I4891: Unspecified atrial fibrillation", "I110: Hypertensive heart disease with heart failure", "F259: Schizoaffective disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "R509: Fever, unspecified", "G8929: Other chronic pain", "I493: Ventricular premature depolarization", "E875: Hyperkalemia", "M7989: Other specified soft tissue disorders" ]

[ "N179", "I4891", "I110", "I2510", "E039", "E785", "Z955", "G4733", "Z7901", "Z794", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses soft, ___, cottage, cream cheese\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ with H/O CLL on ibrutinib, metastatic \ntesticular cancer, CAD s/p mid LAD PCI in ___, SSS s/p \npacemaker, paroxysmal atrial fibrillation on rivaroxaban, and \ndiabetes mellitus with recent pericarditis (admission from \n___ who presented with chest pain and was found to be \nhypotensive requiring ICU admission. \n\nPrior to presentation to the ___ on ___, he had ___ substernal \nchest pain. He was taken to the ___. Imaging \nincluding bedside echocardiogram unremarkable. CTA without \nevidence of pulmonary embolus. His systolic blood pressure \ndropped to 80's, and he was transferred to the ___ ___. In the \n___, he was seen by cardiology who felt his picture was most \nconsistent with septic shock given fever of 102. He had relative \nhypotension in this setting which was fluid responsive. He had \ncontinued tachycardia while in the ___ so he was admitted to the \nICU.\n\nIn the ICU, he was weaned off BiPAP and breathing on room air. \nHis blood pressure recovered, and tachycardia improved with \nreintroduction of metoprolol at home dose of 12.5 mg TID. Blood \nand urine cultures sent and given fever, he was empirically \nstarted on vancomycin+cefepime while awaiting culture results. \nHis rivaroxaban was held in the setting of worsening kidney \nfunction.\n \nOf note, during his recent admission from ___, he had \nmidsternal chest pain with diffuse ST elevations. Echocardiogram \ndemonstrated trivial pericardial effusion, so a presumptive \ndiagnosis of pericarditis. He was treated with colchicine and \nprednisone with improvement in his chest pain, although the \npatient continued to have episodes of pain up to discharge. He \nwas discharged on colchicine with prednisone taper.\n\nHe also had a recent admission in ___ where he had a GI \nbleed thought to be due to combination of ibrutinib, \nclopidogrel, and rivaroxaban. His clopidogrel was ultimately \ndiscontinued. There is also a remark about a vitreous hemorrhage \noccurring due to ibrutinib.\n\nOn transfer, patient noted ongoing stable chest pain improved \nwith oxycodone. He had mild shortness of breath but no new \ncough. He had no acute complaints and denied fever, chills, \nabdominal pain, constipation, ___ swelling.\n \nPast Medical History:\nPAST ONCOLOGICAL HISTORY:\nCLL (17p-) and Stage IIIA Mixed germ cell tumor of the testis\n- ___: Lymphocytosis incidentally found during a psychiatric \nhospitalization.\n- ___: CT scan showed a slightly enlarged spleen at 14.5 cm \nand no adenopathy.\n- ___: He met with Dr. ___ in ___ at \n___. WBC was 15.0 with 49.6% lymphocytes, Hgb 11.9, \nand platelets 260,000. Flow cytometry was consistent with CLL, \nand B-cell gene rearrangement confirmed clonality. CLL FISH \npanel showed a p53 mutation. He was asymptomatic at the time of \ndiagnosis and followed with Dr. ___.\n- ___ gradually uptrended to 22.7 in ___, 37.3 in ___, \n51.3 in ___, and 50.4 on ___. Hgb has decreased slightly \nto 10.9 and Hct 34.4 with platelets 234,000 on the ___ \nlabs.\n- ___: Hematology care transitioned to Dr. ___ \nafter Dr. ___. He also started having nightly sweats.\n- ___: CT Chest without lymphadenopathy or other notable \nfindings.\n- ___: Initial ___ Hematology evaluation for second \nopinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood \nflow cytometry and cytogenetics confirmed CLL with TP53 \ndeletion.\n- ___: CT Abdomen/Pelvis without lymphadenopathy or other \nnotable findings.\n- ___: Started ibrutinib 420 mg daily.\n- ___: Ibrutinib held for vitreous bleed\n- ___: Ibrutinib restarted\n- ___: Per OSH records, underwent scrotal U/S showing \nheterogeneous left testicle, prominent rete testis on right.\n- ___: Presented to his outpatient hematologist, Dr. \n___ a painful swollen left testicle (swelling over \n~8 months, worsening pain). This had been evaluated on ___ \nwith an ultrasound that did not demonstrate torsion but did show \nheterogeneous morphology of the left testicle. HCG was positive. \nReferred to Dr. ___.\n- ___: Underwent left radical orchiectomy. Pathology \nrevealed 3.9 cm malignant mixed germ cell tumor of the testis, \n95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1% \nchoriocarcinoma, invading hilar statin ___ vaginalis, with \nlymphatic vascular invasion and metastatic tumor nodules in the \nspermatic cord. pT2NxS1 (although no post-orch levels, beta hCG \n64 on ___, up from 21 on ___ AFP 3, LDH normal).\n- ___: CT torso showing new 8 mm nodule in the left lower \nlobe, and comparison with CT ___. Left para-aortic \nlymphadenopathy up to 2.8 cm and a 3.5 cm fluid collection in \nthe left inguinal region/scrotum, felt to be likely \npostsurgical.\n- ___: C1D1 EP\n- ___: C2D1 EP (delayed 1 week after nasal infection\n- ___: Admitted for weakness, fall\n- ___: Admitted for parainfluenza pneumonia, symptomatic \nanemia, palpitations, developed nausea/vomiting in hospital\n- ___: C3D1 EP (delayed 1 week, added palonosetron)\n- ___: C4D1 EP\n- ___: CT torso with significant decrease in size of the \npreviously seen left para-aortic lymph node which now measures 6 \nmm, previously 28 mm. Otherwise no LAD.\n- ___: Restarted ibrutinib for recurrent CLL (night sweats, \nlymphocytosis)\n\nOther PMH:\n-Sick sinus syndrome s/p PPM ___ Revo DDD, \nMRI-compatible, ___\n-CAD s/p DES to mid-LAD in ___. Preserved LVEF in ___.\n-Stroke ___\n-Diabetes mellitus type II, on insulin\n-Hypertension\n-Hyperlipidemia\n-Morbid obesity s/p Gastric bypass surgery ___\n-Obstructive sleep apnea - not on CPAP\n-Pancreatitis ___ related to alcohol\n-Hypothyroidism\n-Osteoarthritis\n-Major depression with psychotic features (vs schizoaffective \ndisorder per patient) (Dr. ___ name unknown, affiliated \nwith ___)\n-Anxiety\n-Conversion disorder\n-Benign paroxysmal positional vertigo\n-Glaucoma, cataract (Dr. ___ at ___)\n-s/p Cholecystectomy\n-s/p Bilateral shoulder surgery, chronic pain\n \nSocial History:\n___\nFamily History:\nNo known family history of malignancies.\n \nPhysical Exam:\nOn transfer to OMed Service\nGENERAL: Middle aged white man sitting up in chair comfortably, \nA&OX3 \nVITALS: T 98.8 HR 90 BP 145/90 RR 26 O2 sat 97% on RA\nHEENT: Sclera anicteric, MMM, oropharynx clear\nNECK: JVP not elevated, no LAD\nLUNGS: Clear to auscultation bilaterally--no wheezes, rales, \nrhonchi\nCV: irregularly irregular, normal S1 S2, no murmurs, rubs, \ngallops\nCHEST: moderate tenderness with palpation of sternum\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: no ras\nNEURO: patient responding to questions appropriately and is able \nto move all four extremities\n\nAt discharge\nGENERAL: in NAD, sitting in chair\nVITALS: T 97.9F BP 137/90 HR 70 RR 20 O2 Sat 97% on RA\nDischarge Weight: 119.9 kg (264.5 lb)\nHEENT: NC/AT, sclera anicteric, MMM, oropharynx clear. JVP \nelevation not appreciated\nLUNGS: CTAB--no wheezing\nCV: regular, normal S1 S2, no murmurs, rubs, gallops.\nChest: Right-sided port in place\nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly\nEXT: bilateral 1+ pitting edema (R>L up to knees), 1+ pulses\nNEURO: A&Ox3, moving all extremities with purpose\n \nPertinent Results:\n___ 02:55AM BLOOD WBC-40.7* RBC-3.40* Hgb-9.8* Hct-30.5* \nMCV-90 MCH-28.8 MCHC-32.1 RDW-15.2 RDWSD-49.2* Plt ___\n___ 02:55AM BLOOD Neuts-47 Bands-0 ___ Monos-3* Eos-0 \nBaso-0 ___ Myelos-0 AbsNeut-19.13* AbsLymp-20.35* \nAbsMono-1.22* AbsEos-0.00* AbsBaso-0.00*\n\n___ 02:55AM BLOOD Glucose-216* UreaN-41* Creat-1.9* Na-128* \nK-5.9* Cl-93* HCO3-20* AnGap-15\n\n___ 09:25PM BLOOD proBNP-6636*\n___ 02:55AM BLOOD Calcium-7.6* Phos-5.0* Mg-2.0 UricAcd-6.1\n___ 01:33PM BLOOD Osmolal-288\n___ 02:55AM BLOOD TSH-5.4*\n\n___ CXR\nNew left pleural effusion with subjacent opacities which may \nreflect atelectasis and/or consolidation.\n\n___ CT chest w/out contrast\n1. New small bilateral pleural effusions and adjacent \nconsolidations at the lung bases, left greater than right, \nlikely representing atelectasis, however superimposed infection \nis difficult to exclude.\n2. New moderate pericardial effusion.\n\n___ Echocardiogram\nThe estimated right atrial pressure is at least 15 mmHg. Due to \nsuboptimal technical quality, a focal wall motion abnormality \ncannot be fully excluded. Overall left ventricular systolic \nfunction is normal (LVEF>55%). There is beat-to-beat variability \nof the left ventricular ejection fraction due to an irregular \nrhythm/premature beats. The aortic valve leaflets are mildly \nthickened (?#). Trace aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. There is moderate pulmonary \nartery systolic hypertension. There is a trivial/physiologic \npericardial effusion. \nIMPRESSION: Focused study. Suboptimal image quality. LV function \nappears preserved. Moderate pulmonary hypertension. Trivial \npericardial effusion. \n Compared with the prior study (images reviewed) of ___ \nthe rhythm is now afib and HR higher. Pericardial effusion very \nslighlty larger however still trivial.\n\n___ Echocardiogram\nThe left ventricular cavity size is normal. Overall left \nventricular systolic function is normal (LVEF>55%). The aortic \nvalve leaflets are mildly thickened (?#). There is a small to \nmoderate sized circumferential pericardial effusion. There is \nright ventricular diastolic collapse, consistent with impaired \nfillling/tamponade physiology but no respiratory eccentuatlon of \ntransmitral flow. A left pleural effusion is present. \n Compared with the prior study (images reviewed) of ___, \nthe pericardial effusion is now larger and increased pericardial \npressure is now suggested. \n\n___ Pericardiocentesis\nUnder US, fluoro, ECG and hemo guidance, and after local \nanesthesia, the pericardial space was entered using 17 Tuhioy \nneedle. Initial pericardial pressure was markedly elevated and \nafter removing 470 ml of bloody fluid, pressure became negative \nwith improvement in BP and rapid wean of pressors.\n___ Pericardial Fluid \n-Negative for malignant cells \n-Abundant blood. \n-Lymphocytes, histiocytes, and mesothelial cells \n\n___ Head CT\n Study is mildly to moderately motion degraded despite multiple \nacquisitions. Within this confine, there is no evidence of acute \ninfarction,hemorrhage,edema,or mass effect. There is prominence \nof the ventricles and sulci suggestive of involutional changes. \nMultiple periventricular hypodensities, probably sequela of \nchronic small vessel disease. There are atherosclerotic \ncalcifications of the carotid siphon and the vertebral arteries \nbilaterally.\n There is no evidence of fracture. The visualized portion of \nthe paranasal sinuses is unremarkable. There is mild \nopacification of the mastoid air cells. The middle ear cavities \nare remarkable. The visualized portion of the orbits are \nunremarkable.\nIMPRESSION:\n1. Within confines of a mildly to moderately motion degraded \nexamination, no evidence of acute intracranial abnormality on \nnoncontrast head CT. Specifically, no large territory infarct or \nintracranial hemorrhage.\n2. Additional findings described above.\n\n___ Echocardiogram\nLIMITED STUDY/FOCUSED VIEWS/SUBOPTIMAL IMAGE QUALITY: Overall \nleft ventricular systolic function is normal (LVEF>55%). There \nis abnormal septal motion/position. The number of aortic valve \nleaflets cannot be determined. Trace aortic regurgitation is \nseen. The mitral valve leaflets are mildly thickened. There is a \ntrivial/physiologic pericardial effusion. \nCompared with the prior study (images reviewed) of ___, \nthe pericardial effusion has nearly resolved. \n\n___ Echocardiogram\nVery limited study due to suboptimal image quality. There is a \nvery small posterior pericardial effusion. There are no \nechocardiographic signs of tamponade.\n Compared with the prior study (images reviewed) of ___, \nno obvious change but the technically suboptimal nature of both \nstudies precludes definitive comparison. \n\nOther Pertinent labs:\n___ 03:36AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-5810*\n___ 09:19AM BLOOD CRP-38.5*\n___ 02:33PM BLOOD CRP-16.0*\n___ 12:40PM BLOOD ___\n\nMicro:\nAll blood and urine cultures were negative \n\nDischarge labs:\n___ 05:08AM BLOOD WBC-22.1* RBC-3.00* Hgb-8.6* Hct-26.8* \nMCV-89 MCH-28.7 MCHC-32.1 RDW-14.8 RDWSD-47.2* Plt ___\n___ 05:08AM BLOOD Plt ___\n___ 05:08AM BLOOD Glucose-177* UreaN-20 Creat-1.1 Na-133* \nK-5.0 Cl-96 HCO3-26 AnGap-11\n___ 05:08AM BLOOD ALT-988* AST-100* AlkPhos-74 TotBili-0.3\n___ 05:08AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.9\n \nBrief Hospital Course:\nThis is a ___ yo man with H/O CLL on ibrutinib, metastatic \ntesticular cancer, CAD s/p mid LAD DES in ___, SSS now s/p \npacemaker, paroxysmal atrial fibrillation on rivaroxaban, \ndiabetes mellitus and recent admissions for GI bleed and \nsubsequently pericarditis (___) discharged on prednisone, \nwho re-presented with chest pain. He was admitted to F-ICU for \natrial fibrillation with rapid ventricular rate, fever and \nhypotension. He was treated with cefepime for HAP and was \ntransferred to cardiology for treatment of ongoing pericarditis. \nHe was started on high-dose aspirin which improved his \npericarditis pain. Unfortunately, this was complicated by \nhemopericardium and hypotension for which he required CCU \ntransfer and pericardial drainage. He was then transferred back \nto the cardiology service on prednisone for his pericarditis and \nprior to discharge anticoagulation was resumed. His ibrutinib \nwas not restarted per his outpatient oncologist.\n\nACTIVE ISSUES:\n# Pericarditis/pericardial effusion: Patient with recent \nhospitalization for pericarditis ___ on \ncolchicine and prednisone taper, returned with ongoing chest \npain with exertion, which was same in quality. Etiology of \neffusion presumed viral vs. malignancy. He was started on \nAspirin 650 mg TID. This was complicated by pericardial effusion \nfor which he was admitted to CCU. Following pericardiocentesis, \n500 cc bloody fluid was removed via the pericardial drain. Chest \npain resolved by end of admission and on discharge. In \ndiscussion with patient's oncologist, Dr. ___ ibrutinib \nwas discontinued as it increased his bleeding risk while on \naspirin and rivaroxaban. Patient was continued on colchicine and \nprednisone. Continued pantoprazole 40 mg daily for GI \nprophylaxis. Colchicine should be continued for 3 months after \n___. Patient will need prednisone taper. Recommend tapering to \n5 mg for ___ weeks before stopping after patient sees \ncardiologist on ___.\n\n# Transaminitis: Unclear etiology of abnormal LFTs in the 2000s \nthat developed in CCU. No new medications. Viral hepatitis panel \nnegative. These could represent decreased perfusion vs. shock \nliver. His acetaminophen, fenofibrate, and statin were held. His \ntransaminases improved but remained elevate and will need \nmonitoring as outpatient to confirm values normalize.\n\n# ___: Baseline creatinine 0.9-1.0, but increased to 2.0. This \nlikely reflects pre-renal physiology in the setting of \nhypotension and improved after pericardial fluid drained. \nCreatinine improved to 1.1 at discharge.\n\n# Acute on chronic diastolic heart failure: Repeat echo with \nintact LVEF >55% and evidence of pulmonary hypertension likely \nsecondary to OSA. Bilateral pulmonary effusions on CT chest with \nlikely dry weight of ~270, increased to 278 on\nadmission. Patient continued on home furosemide 20 mg daily then \nreduced to furosemide 20 mg every other day as his weight \nremained stable. Home losartan was restarted at a reduced dose \nof 25 mg daily. Discharge weight: 119.9 kg (264.5 lb). \n\n# Atrial fibrillation: Patient developed atrial fibrillation \nwith rapid ventricular rate increased to 120s. Metoprolol was \nincreased to 37.5 q6hr then consolidated to metoprolol succinate \nXL 150 mg daily. After ibrutinib was stopped, patient was \nrestarted on rivaroxaban 20 mg daily.\n\n# CAD s/p LAD PCI: Aspirin was held in setting of hemorrhagic \npericardial effusion. Aspirin 81 mg daily restarted after \nibrutinib was stopped for prevention of stent thrombosis (mid \nLAD DES from ___ on ___. Held atorvastatin given elevated \nLFTs. \n\n# Polyuria: Unclear precipitant, no recent changes in \nmedications. Patient reports\nhe has recently begun drinking copious amounts of H2O upon \ninitiation of Ibrutinib. Ibrutinib was stopped. Unlikely \ndiabetes insipidus given concentrated urine electrolytes \n(osmolol 459). This also this occurred in the setting of \nhyperglycemia with some glycosuria, ___ was consulted for \nimproved glucose control (see below).\n\n# Diabetes mellitus: ___ followed. While patient was on \nhospital diet, he was managed with lantus 75 Units qAM with \nHumalog coverage with meals and ISS per ___ recommendations. \nDischarged on home diabetic regimen. This was communicated with \nElderly Services. \n\n# OSA: Patient reports he has a CPAP mask at night for OSA but \ndoes not use it. He was given BiPAP in ___. VBG at the time was \n7.37/43. Oxygen saturations improved to high ___ on RA. Sats \nremained normal without CPAP at night. \n\n# Schizoaffective disorder: Continued divalproic acid, \nfluoxetine, ziprosadone. Followed QTc.\n\n# CLL: Per oncologist, stopped ibrutinib. Patient has follow-up \nwith oncology. \n\nRESOLVED ISSUES \n# Altered mental status: This occurred in the setting of \nhypotension, however high risk of CVA given anticoagulation. \nStat head CT head negative. Mental status improved. \n\n# Hyponatremia: Component of hyperglycemia as well as true \nhyponatremia, suspect related to hypervolemia. Improved with \nfluid restriction.\n\n# Hospital acquired pneumonia: CT chest with bilateral pleural \neffusions as well as\nconsolidations concerning for HAP in setting of fever and \nhypotension on presentation. He was treated with cefepime ___ \n- ___.\n\nTRANSITIONAL ISSUES:\n# Patient's ibrutinib was stopped. CLL management per \noncologist. \n# Patient needs repeat TTE to re-evaluate pericardial effusion \nwithin ___ weeks. \n# Patient's home losartan was restarted at lower dose, please \nmonitor BP and uptitrate as tolerated \n# Patient's home metoprolol tartrate was switched to metoprolol \nsuccinate XL 150 mg daily\n# Patient's home clonidine, 0.1 mg TID, was stopped due to \nhypotension and altered mental status. Please monitor \nanxiety/agitation and resume as needed. \n# Patient restarted on aspirin 81 mg to prevent thrombosis of \nhis mid LAD drug-eluting stent and rivaroxaban 20 mg daily for \nembolic prevention in setting of paroxysmal atrial fibrillation. \nPlease continue to monitor for bleeding. \n# Patient's home furosemide was adjusted to 20 mg every other \nday. Please monitor volume status and weight, increase as \nneeded. \n# Patient discharged on prednisone 10 mg daily and colchicine \n0.6 mg BID for pericarditis. He was not continued on high dose \nNSAIDs (aspirin) because of bleeding while on aspirin 625 mg \nTID. He should continue the colchicine for 3 months after ___ \n(start date) and prednisone until follow up with his \ncardiologist on ___. At that time, recommend \ntapering to prednisone 5 mg for ___ weeks before stopping. \n# Please monitor LFTs and confirm they normalize. Patient's \natorvastatin, fenofibrate, acetaminophen were held on discharge \nin the setting of elevated LFTs. Please recheck liver function \ntests at next follow up appointment and restart his atorvastatin \nand fenofibrate if they are normal. \n# Please continue to monitor patient's CBC. WBC and Hgb abnormal \nlikely due to CLL but remained stable on discharge. \n\nADMISSION WEIGHT: 126.2 kg\nDISCHARGE WEIGHT: 119.98 kg \n\nAbnormal labs on discharge: \nALT 988\nAST 100 \nWBC 22.1 \nHgb 8.6 \n\n#CODE STATUS: Full code\n#CONTACT: Name of health care proxy: ___ (SON) - Phone: \n___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Divalproex (EXTended Release) 500 mg PO QAM \n5. Divalproex (EXTended Release) 750 mg PO QPM \n6. Docusate Sodium 100 mg PO BID constipation \n7. Fenofibrate 150 mg PO DAILY \n8. Fluticasone Propionate NASAL 1 SPRY NU BID \n9. Gabapentin 300 mg PO TID \n10. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n11. Levothyroxine Sodium 25 mcg PO DAILY \n12. Lidocaine 5% Patch 3 PTCH TD QAM \n13. Losartan Potassium 50 mg PO DAILY \n14. Magnesium Oxide 400 mg PO BID \n15. Metoprolol Tartrate 12.5 mg PO TID \n16. Multivitamins 1 TAB PO DAILY \n17. Pantoprazole 40 mg PO Q24H \n18. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n19. Rivaroxaban 20 mg PO DINNER \n20. Senna 8.6 mg PO BID:PRN constipation \n21. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n22. TraZODone 200 mg PO QHS:PRN Insomnia \n23. ZIPRASidone Hydrochloride 40 mg PO BID \n24. Colchicine 0.6 mg PO BID \n25. PredniSONE 40 mg PO DAILY \nThis is dose # 1 of 4 tapered doses\n26. PredniSONE 30 mg PO DAILY \nThis is dose # 2 of 4 tapered doses\n27. PredniSONE 20 mg PO DAILY \nThis is dose # 3 of 4 tapered doses\n28. PredniSONE 10 mg PO DAILY \nThis is dose # 4 of 4 tapered doses\n29. Furosemide 20 mg PO DAILY \n30. ibrutinib 420 mg oral DAILY \n31. melatonin 2.5 mg oral QHS:PRN \n32. FLUoxetine 20 mg PO DAILY \n33. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n34. Glargine 75 Units Breakfast\nGlargine 75 Units Bedtime\nHumalog 5 Units Breakfast\nHumalog 5 Units Lunch\nHumalog 5 Units Dinner\n35. CloNIDine 0.1 mg PO TID \n \nDischarge Medications:\n1. Metoprolol Succinate XL 150 mg PO DAILY \n2. Furosemide 20 mg PO EVERY OTHER DAY \n3. Losartan Potassium 25 mg PO DAILY \n4. Acyclovir 400 mg PO Q8H \n5. Aspirin 81 mg PO DAILY \n6. Colchicine 0.6 mg PO BID \n7. Divalproex (EXTended Release) 500 mg PO QAM \n8. Divalproex (EXTended Release) 750 mg PO QPM \n9. Docusate Sodium 100 mg PO BID constipation \n10. FLUoxetine 20 mg PO DAILY \n11. Fluticasone Propionate NASAL 1 SPRY NU BID \n12. Gabapentin 300 mg PO TID \n13. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n14. Glargine 75 Units Breakfast\nGlargine 75 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n15. Levothyroxine Sodium 25 mcg PO DAILY \n16. Lidocaine 5% Patch 3 PTCH TD QAM \n17. Magnesium Oxide 400 mg PO BID \n18. melatonin 2.5 mg oral QHS:PRN \n19. Multivitamins 1 TAB PO DAILY \n20. Pantoprazole 40 mg PO Q24H \n21. PredniSONE 10 mg PO DAILY \nPlease continue until follow-up with your PCP \n___ is dose # 4 of 4 tapered doses \n22. Rivaroxaban 20 mg PO DINNER \n23. Senna 8.6 mg PO BID:PRN constipation \n24. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n25. TraZODone 200 mg PO QHS:PRN Insomnia \n26. ZIPRASidone Hydrochloride 40 mg PO BID \n27. HELD- Acetaminophen 500 mg PO Q8H:PRN Pain - Mild This \nmedication was held. Do not restart Acetaminophen until you \nfollow-up with your PCP\n28. HELD- Atorvastatin 80 mg PO QPM This medication was held. \nDo not restart Atorvastatin until you follow up with PCP\n29. HELD- CloNIDine 0.1 mg PO TID This medication was held. Do \nnot restart CloNIDine until you follow up with your PCP\n30. HELD- Fenofibrate 150 mg PO DAILY This medication was held. \nDo not restart Fenofibrate until you follow up with your PCP\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n-Healthcare associated pneumonia\n-Pericarditis \n-Hemorrhage pericardial effusion with tamponade physiology\n-Paroxysmal atrial fibrillation\n-Long term use of anticoagulants\n-Acute on chronic left ventricular diastolic heart failure\n-Polyuria\n-Type 2 diabetes mellitus, on insulin, with\n-Acute kidney injury\n-Chronic lymphocytic leukemia\n-Delirium\n-Coronary artery disease with prior stenting\n-Elevated hepatic transaminases\n-Hyponatremia\n-Obstructive sleep apnea\n-Schizoaffective disorder\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of your ___ \n___.\n\nWHY were you in the hospital?\n-He will brought to the emergency room due to low blood \npressures.\n-You were also found to have a fever and there was concern that \nyou had an infection.\n\nWHAT happened in the hospital?\n-Because of your low blood pressures, you were initially brought \nto the intensive care unit. There, your breathing improved and \nyour blood pressure came up. You were started on antibiotics \nfor possible infection.\n-You were also found to have extra fluid, likely due to heart \nfailure.\n-You were given IV medications to remove this extra fluid, and \nyour breathing improved. The swelling in your legs also \nimproved.\n-___ transferred to the cardiology floor for further treatment \nof your pericarditis (inflammation around your heart).\n-For this, you were treated with high-dose aspirin and your pain \nin the chest greatly improved. Unfortunately, you had some \nbleeding in the sac around your heart and you had to go to the \nICU again to have a drain placed in that sac to remove the \nfluid. \n- When the drain was removed, you returned to the cardiology \nfloor and we continued your prednisone for your pericarditis, \nyou had no more chest pain and your rivaroxaban and aspirin were \nrestarted \n- In discussion with your oncologist, Dr. ___ decision \nwas made to stop your ibrutinib. \n\nWHAT should you do after leaving the hospital?\n-You should take all of your medications as prescribed.\n-You should weigh yourself when you get home and then daily, and \ncall your doctor if you note weight gain more than 3 pounds.\n-You should follow-up with your doctors as listed below.\n\nWe wish you the best,\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "J189", "R570", "I314", "I5033", "N179", "I480", "C9110", "I4892", "E871", "I313", "E11649", "E1142", "G4733", "I2510", "Z955", "F259", "Z950", "Z8547", "Z8673", "Z9884", "E785", "E039", "R740", "M940" ]

[ "J189: Pneumonia, unspecified organism", "R570: Cardiogenic shock", "I314: Cardiac tamponade", "I5033: Acute on chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "I480: Paroxysmal atrial fibrillation", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "I4892: Unspecified atrial flutter", "E871: Hypo-osmolality and hyponatremia", "I313: Pericardial effusion (noninflammatory)", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "F259: Schizoaffective disorder, unspecified", "Z950: Presence of cardiac pacemaker", "Z8547: Personal history of malignant neoplasm of testis", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z9884: Bariatric surgery status", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "M940: Chondrocostal junction syndrome [Tietze]" ]

[ "N179", "I480", "E871", "G4733", "I2510", "Z955", "Z8673", "E785", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / codeine / acetaminophen / oxycodone\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo M with CLL on ibrutinib, HTN, T2DM, SSS s/p PPM (A-paced, \nLRL appears ~50), hx of AF on Xarelto, CAD s/p ___ LHC with \nDES (? x2) placed in mid-LAD, now presenting with constant \n___ chest pain on left radiating down arm. Chest pain is \ndescribed as a central substernal chest \"pressure\", like a \"fist \ninto the chest\". Patient did not have nitroglycerin at home. \nChest pain was precipitated by him walking his dog at around \n___ on ___. Pain was accompanied by shortness of breath. \nReports he feels worse than the chest pain that brought him in \nwith the LAD occlusion. Received ASA 325mg via EMS. Given 2 \nnitro by EMS as well with some improvement in his chest pain. \nEMS stated he had one episode ___ beat run of NSVT in ambulance. \n \n In the ED, initial vitals: T 97.9, HR 62, BP 145/63, 16, 95%RA \n\n - Later vitals in the ED notable for bradycardia (with \nintermittent A-pacing dependency) between 50-65. \n - Exam notable for: RRR, no murmurs, clear lungs, trace edema\n - Labs notable for: Trop <.01 x2, Na 128, WBC 11.9, Hgb 8.9 \n(9.9)\n - Imaging notable for: unremarkable CXR\n - Patient given: ASA 325 by EMS\n___ 00:23 IV HYDROmorphone (Dilaudid) .5 mg \n___ 01:38 IV HYDROmorphone (Dilaudid) .5 mg \n___ 03:24 PO/NG Gabapentin 300 mg \n___ 03:24 PO/NG TraZODone 300 mg \n___ 03:24 IV Heparin Started 1000 \n___ 03:24 IV DRIP Nitroglycerin (0.35-3.5 mcg/kg/min \nordered) Started 0.35 mcg/kg/min \n___ 05:19 IV DRIP Nitroglycerin Stopped - Unscheduled \n___ 06:16 IV Heparin Confirmed No Change in Rate, rate \ncontinued at 1000 units/hr \n___ 08:44 PO Divalproex (EXTended Release) 250 mg \n___ 08:44 IV Heparin Stopped (5h ___ \n___ 09:24 IV HYDROmorphone (Dilaudid) .5 mg \n\n - Vitals prior to transfer: 98.0 50 119/56 12 100% RA \n \nOn arrival to the floor, pt reports chest pain ___ from ___ \nwith dilaudid .5 adm in ED 45 minutes ago. Denies associated sx, \nn/v, headache, shortness of breath, palpitations. Reports \nfeeling well after stent, no pain or shortness of breath until \n___. Pain has persisted since onset with only slight relief \nfrom nitro or dilaudid.\n \nPast Medical History:\nCLL\nPPM for bradycardia\nStroke in ___\nHTN\nHLD\nDM\n \nSocial History:\n___\nFamily History:\n- no cancer or stroke\n \nPhysical Exam:\nVitals: 97.6 175/34 55 16 96RA BP re-check 120/70\n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, \nJVP not elevated \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n CV: Bradycardic, regular, normal S1 + S2, II/VI systolic murmur \nbest heard \n Abdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \n Ext: Warm, well perfused, no cyanosis, 1+ edema to mid-shins \n Skin: Without rashes or lesions \n Neuro: A&Ox3. Grossly intact. \n\n \nPertinent Results:\n___ 11:05PM BLOOD WBC-11.9* RBC-3.25* Hgb-8.9* Hct-27.1* \nMCV-83 MCH-27.4 MCHC-32.8 RDW-14.2 RDWSD-42.9 Plt ___\n___ 11:05PM BLOOD Neuts-45.0 ___ Monos-7.0 Eos-1.4 \nBaso-0.5 Im ___ AbsNeut-5.36 AbsLymp-5.41* AbsMono-0.83* \nAbsEos-0.17 AbsBaso-0.06\n___ 11:05PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ \nMacrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Tear \n___\n___ 11:05PM BLOOD ___ PTT-38.7* ___\n___ 11:05PM BLOOD Glucose-122* UreaN-9 Creat-0.9 Na-128* \nK-3.9 Cl-91* HCO3-23 AnGap-18\n___ 11:05PM BLOOD ALT-17 AST-18 AlkPhos-45 TotBili-<0.2\n___ 11:05PM BLOOD Lipase-62*\n___ 06:32AM BLOOD cTropnT-<0.01\n___ 11:05PM BLOOD cTropnT-<0.01\n___ 06:32AM BLOOD CK-MB-3\n___ 11:05PM BLOOD Albumin-3.6 Calcium-8.9 Phos-4.6* Mg-1.6\n___ 11:05PM BLOOD Osmolal-263*\n \nBrief Hospital Course:\n___ with CLL, HTN, HLD, T2DM, CAD s/p stenting to LAD on \n___, presenting with ___ chest pain concerning for unstable \nangina.\n \n # Chest Pain / Hx CAD: Clinical history is concerning for ACS. \nS/p 2x DES to the LAD on ___ for a 70% stenosis. Patient was \nreportedly out walking when the pain started and he clearly \ndescribes ___ chest pressure like a \"fist into his chest\". \nPartially responsive to nitro gtt and dilaudid, but also \nreproducible on exam. Heparin gtt started initially, but \ncardiology consultant recommended discontinuation. Recent cath \nwith single vessel disease now s/p PCI. No biomarker elevation \nor EKG change to raise concern for stent thrombosis. Patient has \nno untreated disease to cause ischemic symptoms. No indication \nto re-cath. Reproducible pain points toward non-cardiac \netiology. Discussion with outpatient provider indicates pain \ncontract and possible history of drug-seeking behavior. He was \ngiven home medications, re-assured about the non-cardiac nature \nof his chest pain and discharged home. \n\n # SSS s/p Pacemaker: A-paced in ___ this admission. \nNormotensive at this rate off nitro gtt. \n\n # H/o AFib: \n - continued home xeralto\n\n # Hypertension: \n - continued home metoprolol and losartan\n \n # CLL: \n - Patient should continue ibrutinib at home \n\n # T2DM: \n - Home insulin continued and metformin held while inpatient. No \nchanges to home regimen on discharge\n\n # Depression & Cognitive Impairment: \n - Continued home ziprasidone, fluoxetine and divalproex \n \n CHRONIC ISSUES \n # Hyperlipidemia: Continue atorvastatin 80mg QHS \n # Depression: Continue high dose trazodone which is his home \nmedication. \n # Hypothyroidism: Continue home levothyroxine. \n # R Hip Pain due to bursitis: Has required Vicodin BID as well \nas gabapentin and Depakote. \n\n CORE MEASURES \n # CODE STATUS: Presumed Full \n # CONTACT: ___ (___)\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Divalproex (EXTended Release) 500 mg PO BID \n6. Divalproex (EXTended Release) 250 mg PO QHS \n7. FLUoxetine 30 mg PO DAILY \n8. Furosemide 20 mg PO DAILY \n9. Gabapentin 300 mg PO TID \n10. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID \n11. Levothyroxine Sodium 50 mcg PO DAILY \n12. Losartan Potassium 50 mg PO DAILY \n13. Magnesium Oxide 400 mg PO BID \n14. Metoprolol Tartrate 12.5 mg PO BID \n15. Pantoprazole 40 mg PO Q24H \n16. Senna 17.2 mg PO BID:PRN constipation \n17. TraZODone 300 mg PO QHS \n18. MetFORMIN (Glucophage) 1000 mg PO BID \n19. Fenofibrate 150 mg PO DAILY \n20. dextrose-maltodextrin 10 gram/11.5 gram oral DAILY:PRN \n21. Capsaicin 0.025% 1 Appl TP QID shoulder pain \n22. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation QID:PRN \n23. Multivitamins 2 TAB PO DAILY \n24. Vitamin D ___ UNIT PO EVERY MONTH \n25. ZIPRASidone Hydrochloride 40 mg PO BID \n26. ibrutinib 420 mg oral DAILY \n27. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion \n28. Clopidogrel 75 mg PO DAILY \n29. Rivaroxaban 10 mg PO DAILY \n30. Glargine 56 Units Breakfast\nGlargine 56 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation QID:PRN \n\n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H \n5. Capsaicin 0.025% 1 Appl TP QID shoulder pain \n6. Clopidogrel 75 mg PO DAILY \n7. Cyanocobalamin 1000 mcg PO DAILY \n8. dextrose-maltodextrin 10 gram/11.5 gram oral DAILY:PRN \n9. Divalproex (EXTended Release) 500 mg PO BID \n10. Divalproex (EXTended Release) 250 mg PO QHS \n11. Fenofibrate 150 mg PO DAILY \n12. FLUoxetine 30 mg PO DAILY \n13. Furosemide 20 mg PO DAILY \n14. Gabapentin 300 mg PO TID \n15. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID \n16. ibrutinib 420 mg oral DAILY \n17. Glargine 56 Units Breakfast\nGlargine 56 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n18. Levothyroxine Sodium 50 mcg PO DAILY \n19. Losartan Potassium 50 mg PO DAILY \n20. Magnesium Oxide 400 mg PO BID \n21. MetFORMIN (Glucophage) 1000 mg PO BID \n22. Metoprolol Tartrate 12.5 mg PO BID \n23. Multivitamins 2 TAB PO DAILY \n24. Pantoprazole 40 mg PO Q24H \n25. Rivaroxaban 10 mg PO DAILY \n26. Senna 17.2 mg PO BID:PRN constipation \n27. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion \n28. TraZODone 300 mg PO QHS \n29. Vitamin D ___ UNIT PO EVERY MONTH \n30. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: Atypical chest pain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou came to ___ because you were having chest pain. We \nevaluated you very carefully and determined that you were not \nhaving a heart attack and that your pain is very likely not \ncoming from your heart. Your symptoms are probably coming from \nyour ribs and the muscles of your chest. We recommend Tylenol \nand your home pain medication for this. You can follow up with \nyour usual doctor to see if there is anything else that can be \ndone to help this pain. \n\nBest wishes,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "R0789", "I2510", "I10", "Z955", "Z7902", "E785", "C9110", "E119", "Z794", "I4891", "E039", "F329", "M7071", "F0390", "G4733", "Z8673", "Z950" ]

[ "R0789: Other chest pain", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E785: Hyperlipidemia, unspecified", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "I4891: Unspecified atrial fibrillation", "E039: Hypothyroidism, unspecified", "F329: Major depressive disorder, single episode, unspecified", "M7071: Other bursitis of hip, right hip", "F0390: Unspecified dementia without behavioral disturbance", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z950: Presence of cardiac pacemaker" ]

[ "I2510", "I10", "Z955", "Z7902", "E785", "E119", "Z794", "I4891", "E039", "F329", "G4733", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses soft, ___, cottage, cream cheese\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with PMHx coronary artery disease (status post stent), heart\nfailure with preserved ejection fraction, atrial fibrillation on\nrivaroxaban, and a recent admission for pericarditis who \npresents\nwith a chief complaint of substernal chest pain that began\nsuddenly at 5:30 in the morning on ___. It is similar to his\nprevious presentation of pericarditis.\n\nPatient was recently in the hospital for 3 weeks for a\npericarditis flare. He was discharged on ___, and felt\nvery well throughout the weekend. On ___, he was getting up\nfrom bed to go to the bathroom when he felt the sudden onset of\nsharp substernal chest pain, with radiation around to both\nshoulders and through to the back. Patient describes the pain \nas\nsimilar to his prior pericarditis flare. The patient had been\ntaking Vicodin and a prednisone taper at home; this did not help\nwith his pain. His pain is exacerbated by taking a deep breath;\nit is not made worse by positional changes. He denies any\nassociated symptoms of shortness of breath or syncope. He did\nreport palpitations on ___, and for this reason he called EMS\nto return to the emergency department.\n\nIn the ED, initial VS were: T 97.7 BP 105/70 HR 98 RR 16 O2 96%\non RA\nExam notable for:\nGA: NAD, sitting up in bed\nPulm: CTAB\nCV: nl S1S2, RRR, no m/r/g, 2+ peripheral pulses b/l\nAbd: soft, nt, nd, no masses\nExt: 1+ non pitting LLE \nEKG: NSR71, nl axis, nl intervals, non specific st changes\nLabs showed: Negative troponin ×1, leukocytosis to 16.9 \n(baseline\nin the ___ to mid teens), urinary glucose greater than 1000,\nsodium 120 (up to 125 on recheck).\nImaging showed: \nCXR PA AND LATERAL (___):\nSmall left pleural effusion with overlying atelectasis, left \nbase\nconsolidation is difficult to exclude. \nConsults:\nCardiology -recommended 40 mg p.o. prednisone, to continue home\ncolchicine, and admit to ___.\nPatient received: 4 mg morphine sulfate, Tylenol 1 g, prednisone\n40 mg, normal saline 1 L, Zofran 4 mg IV.\n \nTransfer VS were: \nT 98.2 BP 121/54 HR 70 RR 18 O2 90% on RA\n\nOn arrival to the floor, patient reports the above history. He\nis very uncomfortable, and would like a shot of morphine again \nas\nit \"works faster for the pain.\" He denies any fevers, chills,\nabdominal pain, dysuria, hematuria, and focal weakness.\n \nREVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as\nper HPI \n\n \nPast Medical History:\n-Sick sinus syndrome s/p PPM ___ Revo DDD, \n MRI-compatible, \n ___ \n -CAD s/p DES to mid-LAD in ___. Preserved LVEF in ___. \n -Stroke ___ (with recovering motor function, though still with\nsome left thigh sensory decrease)\n -Diabetes mellitus type II on insulin \n -Hypertension \n -Hyperlipidemia \n -Morbid obesity s/p Gastric bypass surgery ___ \n -Obstructive sleep apnea - not on CPAP \n -Pancreatitis ___ related to alcohol \n -s/p Cholecystectomy \n -Hypothyroidism \n -Osteoarthritis \n -s/p Bilateral shoulder surgery, chronic pain \n -Major depression with psychotic features (vs schizoaffective \n disorder per patient) (Dr. ___ name unknown, affiliated \n\n with ___) \n -Anxiety \n -Conversion disorder \n -Benign paroxysmal positional vertigo \n -Glaucoma, cataract (Dr. ___ at ___ \n___)\n\n \nSocial History:\n___\nFamily History:\nNo known history of malignancies.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS: ___ ___ Temp: 98.1 PO BP: 115/78 HR: 71 RR: 20 O2 \nsat:\n98% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___ \nGENERAL: Obese Caucasian male, sitting up in bed and responsive. \n\nPleasant and cooperative, though appears somewhat uncomfortable.\nHEENT: Sclerae anicteric, mucous members moist.\nHEART: Distant heart sounds, but regular rate and rhythm. \nNormal\nS1-S2. No murmurs/gallops/rubs.\nTHORAX: Put in place in right upper chest wall.\nLUNGS: Patient takes short shallow breaths. No wheezes, rales,\nrhonchi.\nABDOMEN: Abdomen is soft, protuberant, nontender in all\nquadrants, no rebound/guarding. \nEXTREMITIES: no cyanosis, clubbing. Trace pretibial edema one\nthird of the way up the shin.\nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose.\nSKIN: warm and well perfused. Patient has a 1 cm x 1 cm brown\nraised flat lesion in between his shoulder blades on the back. \nHe states this was \"from a mole being lanced when I was a\nteenager.\" Now surrounding skin changes.\n\nDISCHARGE PHYSICAL EXAM\nVS: \n24 HR Data (last updated ___ @ 1543)\n Temp: 98.1 (Tm 99.0), BP: 112/67 (112-150/67-86), HR: 71 \n(68-75), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: ra, \nWt: 261.02 lb/118.4 kg \nGENERAL: Obese Caucasian male, sitting in chair, pleasant, \neating breakfast\nHEENT: Sclerae anicteric, mucous members moist.\nHEART: Distant heart sounds, but regular rate and rhythm. \n+pre-cordial rub. pain reproducible on palpation\nLUNGS: breathing comfortably on RA, CTAB\nABDOMEN: Abdomen is soft, protuberant, nontender in all \nquadrants, no rebound/guarding. \nEXTREMITIES: no cyanosis, clubbing. 1+ pitting edema bilaterally\nNEURO: A&Ox3, moving all 4 extremities with purpose.\nSKIN: Patient has a 1 cm x 1 cm brown raised flat lesion in \nbetween his shoulder blades on the back. He states this was \n\"from a mole being lanced when I was a teenager.\" Now \nsurrounding skin changes.\n \nPertinent Results:\nADMISSION LABS\n--------------\n\n___ 11:03PM BLOOD WBC-16.9* RBC-2.93* Hgb-8.3* Hct-25.8* \nMCV-88 MCH-28.3 MCHC-32.2 RDW-15.5 RDWSD-49.1* Plt ___\n___ 11:03PM BLOOD Neuts-33.3* Lymphs-57.6* Monos-7.2 \nEos-1.0 Baso-0.2 Im ___ AbsNeut-5.61# AbsLymp-9.72* \nAbsMono-1.22* AbsEos-0.17 AbsBaso-0.03\n___ 11:03PM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL\n___ 11:03PM BLOOD ___ PTT-32.1 ___\n___ 11:03PM BLOOD Glucose-245* UreaN-17 Creat-1.0 Na-120* \nK-4.9 Cl-89* HCO3-23 AnGap-8*\n___ 05:59AM BLOOD ALT-188* AST-27 AlkPhos-68 TotBili-0.4\n___ 11:03PM BLOOD cTropnT-<0.01\n___ 05:59AM BLOOD CK-MB-3 cTropnT-<0.01\n___ 05:59AM BLOOD Albumin-3.6 Calcium-8.2* Phos-3.2 Mg-1.8\n___ 05:59AM BLOOD Cortsol-3.0\n___ 05:59AM BLOOD TSH-4.9*\n___ 05:59AM BLOOD Osmolal-266*\n___ 11:11PM BLOOD Lactate-1.5\n\nDISCHARGE PHYSICAL EXAM\n\n___ 04:36AM BLOOD WBC-16.6* RBC-3.01* Hgb-8.4* Hct-26.0* \nMCV-86 MCH-27.9 MCHC-32.3 RDW-15.0 RDWSD-47.7* Plt ___\n___ 04:36AM BLOOD ___ PTT-41.7* ___\n___ 04:36AM BLOOD Glucose-137* UreaN-20 Creat-1.0 Na-128* \nK-4.5 Cl-89* HCO3-26 AnGap-13\n___ 04:36AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0\n\nSTUDIES\n-------\n___ TTE\nSuboptimal image quality. Trivial posterior pericardial effusion \nwithout echo evidence of tamponade. Aortic regurgitation is \npresent. Mildly dilated thoracic aorta. Mild left ventricular \nhypertrophy with normal biventricular systolic function. \nFindings c/w hypertensive heart disease. A left pleural effusion \nis present. \n\nCompared with the prior study (images reviewed) of ___ \nthe pericardial effusion is likley similar. This was a complete \nstudy with additional findings as noted, but still limited by \nimage quality. \n \nBrief Hospital Course:\n___ gentleman with a history of coronary artery disease \n(status post mid LAD PCI in ___, sick sinus syndrome status \npost pacemaker, paroxysmal atrial fibrillation on rivaroxaban, \ntype 2 diabetes mellitus on insulin, and recent admission for \npericarditis who presented with substernal chest pain similar to \nhis most recent admission with pericarditis. Patient's exam \ngenerally unremarkable, with normal blood pressures and good \nmentation. Labs notable for a negative troponin and EKG without \nacute changes. Hospital course complicated by hyponatremia, \nhyperkalemia, and hyperglycemia.\n\nACTIVE ISSUES\n=============\n\n#Chest pain\n#Pericarditis\nHis chest pain on presentation was very similar to his most \nrecent presentation of pericarditis. In the absence of troponin \nelevation and EKG changes, this was likely a recurrent \npericarditis flare. No evidence of recurrent pericardial \neffusion on TTE ___. He was recently discharged on a \nprednisone taper and taking 10 mg daily prior to admission. The \npatient received prednisone 40 mg in the emergency room on ___ \nwith plan to continue prednisone 40 mg daily for 7 days followed \nby a slower steroid taper. Pantoprazole was continued for GI \nprophylaxis. Given persistently recurring chest pain and \ninability to give NSAIDs in the setting of CAD status post PCI \n___, aspirin was increased to 320 mg daily for 2 weeks with \nplan for subsequent decrease back to 81 mg daily (the patient \nmay continue taking 320 mg daily for pain as needed). Colchicine \ntwice daily was continued. Chest pain resolved within 1 day of \nadmission. Follow up with cardiology is recommended.\n\n#Hyponatremia\nThe patient presented with hypoosmolar hyponatremia to 120 which \nwas asymptomatic (exacerbated by initial blood glucose of 220. \nUrine lytes were notable for Na of 43. Given euvolemia on exam \nhis hyponatremia was most likely secondary to SIADH in the \nsetting of acute pain from pericarditis. A.m. cortisol level low \nin the setting of current treatment with prednisone as above. \nTSH not significantly elevated. Patient was placed on fluid \nrestriction of 1.5 L daily and his sodium subsequently increased \nto 128. The patient was educated to continue with the daily \nfluid restriction until he follows up with his primary care \nphysician. Follow up within ___ weeks is recommended to ensure \nnormalization of hyponatremia.\n-Discharge serum sodium: 128\n\n#Hyperkalemia\nThe patient's potassium during his hospital stay was increased \nto 5.7, asymptomatic. Etiology remains unclear, hyperlipidemia \nas below possibly contributing. No evidence of acute kidney \ninjury. Potassium normalized to his baseline with treatment of \nhypoglycemia as below.\n-Discharge serum potassium: 4.5\n\n#Type II diabetes mellitus, insulin dependent\n#Hyperlipidemia\nPatient was initially continued on his home insulin regimen with \n75 units of glargine twice daily plus an insulin sliding scale. \nHowever, his blood sugars are persistently elevated to 260-360 \nwith the increased prednisone dose. ___ was consulted to \nassist with further management recommended an increase of his \ninsulin sliding scale. His glargine was changed to 75 qAM and \n30qHS (due to hypoglycemia) with sliding scale with meals. He \nreceived diabetes education and was discharged with a glucometer \n(his home one was broken) for daily blood sugar measurement and \ninstructions to monitor his BG closely as his prednisone \ntapered.\n\n#Acute on chronic diastolic heart failure\nMildly hyperkalemic on presentation. He was given an additional \ndose of 20 mg IV Lasix with good urine output. His home Lasix \nwas increased to 20 mg every day. Discharge weigth 118.4kg \n(261.02 lbs).\n-Increased Lasix 20 mg to daily.\n-Continued Metoprolol Succinate XL 150 mg PO DAILY \n-Continued Rivaroxaban 20 mg p.o. with dinner.\n\nCHRONIC/STABLE ISSUES:\n======================\n\n#CAD status post LAD PCI\n-Continue baby aspirin\n\n#Obstructive sleep apnea\n\n#History of schizoaffective disorder\n-Home divalproex, fluoxetine, ziprasidone.\n\n#CLL:\nHis ibrutinib was stopped on the last hospital stay given \nbleeding risk and pericardial effusion. \n-Continued to hold ibrutinib\n\nTRANSITIONAL ISSUES\n===================\n\n[] Aspirin increased to 320 mg daily for pain control plan to \ndecrease back to 81 mg daily 2 weeks after discharge\n[] Discharge serum sodium: 128 - uptrending. Discharged on fluid \nrestriction. Please follow up within ___ weeks after discharge \nto ensure resolution\n[] Discharge potassium: 4.5\n[] Increased Lasix to 20mg daily. Discharge weigth 118.4kg \n(261.02 lbs)\n[] Increased insulin sliding scale and decreased ___ glargine to \n30U. Patient given glucometer for daily blood sugar measurement. \nPlease follow up and adjust insulin regimen accordingly\n\n#CODE: Full (confirmed) \n#CONTACT: \nWife, ______)\nSon and listed HCP, ___ (___)\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Colchicine 0.6 mg PO BID \n2. Divalproex (EXTended Release) 500 mg PO QAM \n3. Divalproex (EXTended Release) 750 mg PO QPM \n4. Docusate Sodium 100 mg PO BID constipation \n5. FLUoxetine 20 mg PO DAILY \n6. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal \ncongestion \n7. Gabapentin 300 mg PO TID \n8. Levothyroxine Sodium 25 mcg PO DAILY \n9. Lidocaine 5% Patch 3 PTCH TD QAM \n10. Multivitamins 1 TAB PO DAILY \n11. Pantoprazole 40 mg PO Q24H \n12. Senna 8.6 mg PO BID:PRN constipation \n13. ZIPRASidone Hydrochloride 40 mg PO BID \n14. Acyclovir 400 mg PO Q8H \n15. Aspirin 81 mg PO DAILY \n16. Furosemide 20 mg PO EVERY OTHER DAY \n17. Rivaroxaban 20 mg PO DINNER \n18. TraZODone 200 mg PO QHS:PRN Insomnia \n19. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n20. melatonin 2.5 mg oral QHS:PRN \n21. Magnesium Oxide 400 mg PO BID \n22. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n23. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n24. PredniSONE 10 mg PO DAILY \nThis is dose # 4 of 4 tapered doses\n25. Metoprolol Succinate XL 150 mg PO DAILY \n26. Losartan Potassium 25 mg PO DAILY \n27. Glargine 75 Units Breakfast\nGlargine 75 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. PredniSONE 40 mg PO DAILY Duration: 4 Days \ntake for four days starting ___ \nRX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*8 Tablet \nRefills:*0 \n2. PredniSONE 30 mg PO DAILY Duration: 7 Days \ntake for 7 days starting ___ \nRX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*21 Tablet \nRefills:*0 \n3. PredniSONE 20 mg PO DAILY Duration: 7 Days \ntake for 7 days starting ___ \nRX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet \nRefills:*0 \n4. PredniSONE 10 mg PO DAILY Duration: 7 Days \ntake for 7 days starting ___ \nRX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*7 Tablet \nRefills:*0 \n5. PredniSONE 5 mg PO DAILY Duration: 7 Days \ntake for 7 days starting ___ \nRX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*7 Tablet \nRefills:*0 \n6. Aspirin 325 mg PO DAILY \nRX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*14 Tablet \nRefills:*0 \n7. Glargine 75 Units Breakfast\nGlargine 30 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n8. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n9. Acyclovir 400 mg PO Q8H \n10. Colchicine 0.6 mg PO BID \n11. Divalproex (EXTended Release) 500 mg PO QAM \n12. Divalproex (EXTended Release) 750 mg PO QPM \n13. Docusate Sodium 100 mg PO BID constipation \n14. FLUoxetine 20 mg PO DAILY \n15. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal \ncongestion \n16. Furosemide 20 mg PO EVERY OTHER DAY \n17. Gabapentin 300 mg PO TID \n18. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n19. Levothyroxine Sodium 25 mcg PO DAILY \n20. Lidocaine 5% Patch 3 PTCH TD QAM \n21. Losartan Potassium 25 mg PO DAILY \n22. Magnesium Oxide 400 mg PO BID \n23. melatonin 2.5 mg oral QHS:PRN \n24. Metoprolol Succinate XL 150 mg PO DAILY \n25. Multivitamins 1 TAB PO DAILY \n26. Pantoprazole 40 mg PO Q24H \n27. Rivaroxaban 20 mg PO DINNER \n28. Senna 8.6 mg PO BID:PRN constipation \n29. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n30. TraZODone 200 mg PO QHS:PRN Insomnia \n31. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\n#Pericarditis\n\nSecondary diagnoses:\n#Hyponatremia\n#Acute on chronic diastolic heart failure\n#CAD status post LAD PCI\n#Type 2 diabetes mellitus\n#Obstructive sleep apnea\n#History of schizoaffective disorder\n#CLL\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr ___,\n\nIt was a pleasure taking care of you at ___!\n\nWhy was I admitted to the hospital?\n- you had worsening of your chest pain from the pericarditis. \nYour steroid dose and your aspirin were increased. Imaging of \nyour heart did not show any evidence of recurrent fluid around \nyour heart.\n- your salt level was low. This was likely because of you were \ndrinking a lot of water. The amount of water you were drinking \nper day was decreased and your salt levels increased\n- your blood sugar was high and therefore your insulin was \nincreased.\n\nWhat should I do after discharge?\n- please take all the medications as detailed below. \nSpecifically, take 325mg aspirin daily for the next two weeks. \nAfter that you should go back to 81mg daily (a baby aspirin) but \nyou can take 325 daily if you still have pain (for up to two \nmore weeks)\n- please do not drink more than 1.5l of fluid per day until you \nsee your PCP to keep your salt levels steady\n- please use the glucometer to measure your blood sugar daily \nand record the results. Please show them to your PCP when you \nfollow up with him\n- please call your PCP if your blood sugars are <80 or >200 for \nassistance with changing your insulin dose. \n- please follow up with your PCP and your cardiologist as below.\n\nAll the best,\n\nYour ___ care team!\n \nFollowup Instructions:\n___\n" ]

[ "I319", "E871", "C9110", "I110", "I5032", "I2510", "Z955", "Z7901", "E785", "E039", "E119", "Z794", "G4733", "F259", "E875", "E1165", "I480", "E669", "Z6837" ]

[ "I319: Disease of pericardium, unspecified", "E871: Hypo-osmolality and hyponatremia", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z7901: Long term (current) use of anticoagulants", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F259: Schizoaffective disorder, unspecified", "E875: Hyperkalemia", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I480: Paroxysmal atrial fibrillation", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult" ]

[ "E871", "I110", "I5032", "I2510", "Z955", "Z7901", "E785", "E039", "E119", "Z794", "G4733", "E1165", "I480", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / codeine / acetaminophen / oxycodone\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nImpressions:\nleft main normal\nLAD with 70% mid diffuse disease\nLCX mild disease\nRCA mild disease\nRecommendations\nmed tx\n\n \nHistory of Present Illness:\n___ yo M with HTN, HLD, AF on Xarelto (last dose ___ who \npresented to ___ on ___ with chest pain and \nmarginal trop leak. He was transferred to ___ holding area for \ncardiac catheterization for ongoing chest pain. \n\n \nPast Medical History:\nCLL\nPPM for bradycardia\nStroke in ___\nHTN\nHLD\nDM\n \nSocial History:\n___\nFamily History:\n- no cancer or stroke\n \nPhysical Exam:\nADMISSION EXAM:\nVS:\nTemp: afeb\nHR: 63 SR\nRR: 18, comfortable\nBP: 146/65 \nO2 sat: 100% 2L \nECG: NA \nGeneral: lying on stretcher, anxious but cooperative\nHEENT: MM dry \nNeck: no LAD, no JVD\nCV: RRR, no M/R/G\nChest: LS clear bilat\nABD: soft, NT\nExt: no edema, DP and ___ pulses dopplerable\n.\nDISCHARGE EXAM: \nVS:98.2, 126/67, HR 58, RR 20, 02 sat 96% RA. \nTele: Sinus rhythem, 12 beats SVT overnight, asymptomatic, labs \nWNL.\nECG: SB @ 58 bpm.\nLABS: Hct 27.5, Plts 167, INR 0.9, BUN 16, Creat 1.3, Na 135, \nK+4.5, Trop <0.01 , CK-MB 2, Mag 2.3. \nPE:\nGeneral: lying on stretcher, anxious but cooperative\nNeuro: Awake, alert and oriented x3, vague but appropriate. MAE. \nAmbulating with cane in halls. Speech clear, appropriate and \ncomprehensible. \nHEENT: MM dry \nNeck: no LAD, no JVD\nCV: RRR, no M/R/G\nChest: LS clear bilat\nABD: soft, NT\nExt: no edema, DP and ___ pulses dopplerable. Access site without \nbleeding, hematoma or bruit. \n\n \nPertinent Results:\n___ 11:00AM BLOOD WBC-11.3*# RBC-3.62* Hgb-9.9* Hct-31.2* \nMCV-86 MCH-27.3 MCHC-31.7* RDW-14.9 RDWSD-46.3 Plt ___\n___ 04:15AM BLOOD Hct-27.5* Plt ___\n___ 04:15AM BLOOD Plt ___\n___ 04:15AM BLOOD ___\n___ 02:00AM BLOOD Plt ___\n___ 10:55AM BLOOD PTT-54.9*\n___ 12:26AM BLOOD PTT-23.9*\n___ 11:00AM BLOOD Plt ___\n___ 04:15AM BLOOD UreaN-16 Creat-1.3* Na-135 K-4.5\n___ 02:00AM BLOOD K-4.1\n___ 04:20AM BLOOD UreaN-17 Creat-1.2 Na-135 K-4.0\n___ 11:00AM BLOOD Glucose-313* UreaN-12 Creat-1.1 Na-131* \nK-4.9 Cl-95* HCO3-23 AnGap-18\n___ 04:15AM BLOOD CK(CPK)-71\n___ 04:15AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 02:00AM BLOOD cTropnT-<0.01\n___ 07:30PM BLOOD cTropnT-<0.01\n___ 04:20AM BLOOD cTropnT-<0.01\n___ 06:50PM BLOOD cTropnT-<0.01\n___ 11:00AM BLOOD cTropnT-<0.01\n___ 04:15AM BLOOD Mg-2.3\n \nBrief Hospital Course:\nThis is a ___ year old male with a history of dementa, CVA, \nhyperlipidemia, hypertension and OSA transferred for cardiac \ncatheterization following presentation to ___ for chest pain \nand a mildly elevated troponin. He underwent repeat \ncatheterization ___ and received a DES to the LAD. \nPost-procedure he is doing well and is looking forward to being \ndischarged. His access sites were dry and intact, with no \nerythema, excess warmth, bleeding or bruit noted. He will be \ndischarged home with home services and support as prior to \nadmission, with addition of ___ services for home evaluation, \nsafety and will hopefully transition to cardiac rehab when \nappropriate. Referral discussed and given. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete. \n(Verified per outside documents. Patient not sure what he is on \nat home.)\n1. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H \n2. Losartan Potassium 50 mg PO DAILY \n3. Magnesium Oxide 400 mg PO BID \n4. Divalproex (EXTended Release) 500 mg PO BID \n5. Divalproex (EXTended Release) 250 mg PO QHS \n6. Gabapentin 300 mg PO TID \n7. ibrutinib 420 mg oral DAILY \n8. ZIPRASidone Hydrochloride 40 mg PO BID \n9. Metoprolol Tartrate 12.5 mg PO BID \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. dextrose-maltodextrin 10 gram/11.5 gram oral DAILY:PRN \n12. Senna 17.2 mg PO BID:PRN constipation \n13. Fenofibrate 150 mg PO DAILY \n14. Atorvastatin 80 mg PO QPM \n15. Glargine 56 Units Breakfast\nGlargine 56 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n16. Furosemide 20 mg PO DAILY \n17. Multivitamins 2 TAB PO DAILY \n18. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID \n19. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate \n20. Pantoprazole 40 mg PO Q24H \n21. Aspirin 81 mg PO DAILY \n22. Vitamin D ___ UNIT PO EVERY MONTH \n23. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation QID:PRN \n24. FLUoxetine 20 mg PO DAILY \n25. TraZODone 300 mg PO QHS \n26. Capsaicin 0.025% 1 Appl TP QID shoulder pain \n27. Levothyroxine Sodium 50 mcg PO DAILY \n28. Cyanocobalamin 1000 mcg PO DAILY \n29. Rivaroxaban 10 mg PO DAILY \n30. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion \n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY \nFor 3 months following drug eluding stent \nRX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*5 \n2. Glargine 56 Units Breakfast\nGlargine 56 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n3. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation QID:PRN \n\n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE Q8H \n7. Capsaicin 0.025% 1 Appl TP QID shoulder pain \n8. Cyanocobalamin 1000 mcg PO DAILY \n9. dextrose-maltodextrin 10 gram/11.5 gram oral DAILY:PRN \n10. Divalproex (EXTended Release) 500 mg PO BID \n11. Divalproex (EXTended Release) 250 mg PO QHS \n12. Fenofibrate 150 mg PO DAILY \n13. FLUoxetine 30 mg PO DAILY \n14. Furosemide 20 mg PO DAILY \n15. Gabapentin 300 mg PO TID \n16. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID \n17. Levothyroxine Sodium 50 mcg PO DAILY \n18. Losartan Potassium 50 mg PO DAILY \n19. Magnesium Oxide 400 mg PO BID \n20. Metoprolol Tartrate 12.5 mg PO BID \n21. Multivitamins 2 TAB PO DAILY \n22. Pantoprazole 40 mg PO Q24H \n23. Rivaroxaban 10 mg PO DAILY \n24. Senna 17.2 mg PO BID:PRN constipation \n25. Sodium Chloride Nasal ___ SPRY NU QID:PRN congestion \n26. TraZODone 300 mg PO QHS \n27. Vitamin D ___ UNIT PO EVERY MONTH \n28. ZIPRASidone Hydrochloride 40 mg PO BID \n29. HELD- ibrutinib 420 mg oral DAILY This medication was held. \nDo not restart ibrutinib until ___. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication \nwas held. Do not restart MetFORMIN (Glucophage) until ___ \n___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nNSTEMI, Coronary artery disease\nDiabetes\nHypertension\nHyperlidpidemia\n\n \nDischarge Condition:\nHPI: \nThis is a ___ year old male with a history of dementa, CVA, \nhyperlipidemia, hypertension and OSA transferred for cardiac \ncatheterization following presentation to ___ for chest pain \nand a mildly elevated troponin. He underwent repeat \ncatheterization ___ and received a DES to the LAD. \nPost-procedure he is doing well and is looking forward to being \ndischarged. His access sites were dry and intact, with no \nerythema, excess warmth, bleeding or bruit noted.\n\nVS:98.2, 126/67, HR 58, RR 20, 02 sat 96% RA. \nTele: Sinus rhythem, 12 beats SVT overnight, asymptomatic, labs \nWNL.\nECG: SB @ 58 bpm.\nLABS: Hct 27.5, Plts 167, INR 0.9, BUN 16, Creat 1.3, Na 135, \nK+4.5, Trop <0.01 , CK-MB 2, Mag 2.3. \n\nPE:\nGeneral: lying on stretcher, anxious but cooperative\nNeuro: Awake, alert and oriented x3, vague but appropriate. MAE. \nAmbulating with cane in halls. Speech clear, appropriate and \ncomprehensible. \nHEENT: MM dry \nNeck: no LAD, no JVD\nCV: RRR, no M/R/G\nChest: LS clear bilat\nABD: soft, NT\nExt: no edema, DP and ___ pulses dopplerable. Access site without \nbleeding, hematoma or bruit. \n\nA/P:\n___ M with hx of dementia, CVAHLD, HTN and OSA admitted for\nchest pain with mildly elevated trop. \n\n#1: CAD: S/P coronary angiogram: no PCI initial cath, then \nreturned to ___ lab on ___ and a DES was placed to LAD. \n- cont atorvastatin 80 mg and ASA 81 mg\n- Plavix 75mg daily.\n- Continue Metoprolol, Losarten\n\n#2 HTN: clinically stable\n- Continue LOsarten, Metoprolol, Isosorbide\n\n#3 HLD: cont atorvastatin 80 mg\n\n#4 SSS s/p pacer: tele stable. History of AFIB, on Xarelto\n - Now needs triple therapy\n - Reviewed with team best plan, given CLL and risk for bleeding \nand best evidence. Fellow recommending to continue Xarelto with \nASA and Plavix and for his Cardiologist to determine whether to \nconvert to Coumadin longer term\n\n#5 CLL: currently on ibutinib po daily. Per OMR notes pt has\nmissed some doses lately. This medicine can lead to bleeding,\nthrombycytopenia and neutropenia. Appears to be tol well so far.\nWBC was 50 when initiated. Of note, no interaction with \nclopidogrel. ___ restart three days post-procedure. \n\n#6 Cognitive impairment: unclear how severe this is as he\nremembers most of his meds and seems oriented at present. has\nhomemaker and social services. Extensive medication list\nconcerning depending on supports \n- daily supports at home; will have services and home ___\n\n#7 Depression: on high dose trazadone\n- continue medication regimen\n\n#8 Right hip pain ___ bursitis: on multiple non narcotic pain\nmedicines/treatments and getting weekly scripts for vicodin from\nPCP ___. Unable to perform history of medicines.\n- vicodin BID only. \n- Con gabapentin and Depakote for hip pain. No ibuprofen given \nrisk for bleeding\n\nDISPO:\n Home with daily services as confirmed by CM. \n \n\n \nDischarge Instructions:\nYou were transferred from ___ following \npresentation there with chest pain and heart attack. You \nunderwent an initial cardiac catheterization on ___ and had a \nstent placement on ___. You were started on a new \nmedication called Plavix which is taken to help prevent \nrethrombosis or clotting off of your stent. Given that you are \ncurrently on Xarelto and there is a high risk of bleeding with \nXarelto, Aspirin and Plavix, you will continue Plavix for \nminimum if three months and then consider stopping per \ninstructions from your cardiologist. You will continue Aspirin \n81 mg Daily lifelong. You should not stop either of these \nmedications unless instructed to do so by your Cardiologist. \n\nYou will resume your Xarelto tonight per your home regimen. \n\nYou should follow up with your Cardiologist in ___ weeks. At \nthat time, you will be referred for Cardiac Rehab; a referral \nwas provided. Until that time, avoid strenuous exercise. It is \nokay for you to walk. Specific instructions concerning your \naccess sites are provided separately, along with weight bearing \nrestrictions.\n\nContinue to follow a heart healthy carbohydrate consistent diet. \nYour Metformin was held and may be resumed on ___, \n___. Additionally, you should follow up with your PCP \n___ ___ weeks.\n\nYou may resume your ibrutinib on ___. It was held for three \ndays post-procedure per the recommendation of the oncologist due \nto the bleeding risk concern during your procedure. \n\nYou were seen by Physical Therapy prior to discharge and \nrecommended independent walking inside of house and cane use for \noutside activity. You will continue ___ after discharge in the \nhome setting. A cardiac rehab referral was given and will be \ndiscussed at follow-up appointment with cardiology.\n \nFollowup Instructions:\n___\n" ]

[ "I214", "C9110", "E119", "I10", "E785", "F329", "G3184", "I2510", "G4733", "Z7902", "M719" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "G3184: Mild cognitive impairment, so stated", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "M719: Bursopathy, unspecified" ]

[ "E119", "I10", "E785", "F329", "I2510", "G4733", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses soft, ___, cottage, cream cheese\n \nAttending: ___.\n \nChief Complaint:\nFever/Cough\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of CLL, \natrial fibrillation on rivaroxaban, CAD s/p stent, recurrent \npericarditis, and HFpEF who presents cough and fever.\n\nPatient awoke at 4AM on ___ morning with fever to 103, \nsweats, and a non-productive cough. Took Tylenol and fever \nimproved to 99, but in the afternoon spiked another fever. He \nalso reports associated sore throat. He reports good PO intake. \nHe notes shortness of breath as well as right lateral rib pain \nwith\ncoughing. His wife was sick with similar symptoms recently but \nno other sick contacts. He had his flu shot this year. He \nreports he was originally scheduled to be admitted ___ to \nstart his new chemotherapy but he was postponed till ___ \ndue to difficulty getting the new medication. He called his \nOncologist who recommended he come to the ED for evaluation.\n \nOn arrival to the ED, initial vitals were 100.2 106 142/73 20 \n99% RA. Exam notable for anxious-appearing, lung clear without \naccessory muscle use, and benign abdomen. Labs were notable for \nWBC 18.0, H/H 10.1, Plt 31.7, Na 132, K 4.4, BUN/Cr ___, and \nlactate 1.8. Influenza PCR negative. Blood cultures were sent. \nCXR was negative for pneumonia. Patient was given Tylenol ___\nPO. Prior to transfer vitals were 98.5 108 144/88 16 99% 2L.\n\nOn arrival to the floor, patient reports an mild headache. He \ndenies vision changes, dizziness/lightheadedness, \nweakness/numbness, hemoptysis, chest pain, palpitations, \nabdominal pain, nausea/vomiting, diarrhea, hematemesis,\nhematochezia/melena, dysuria, hematuria, and new rashes.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nCLL (17p-) and Stage IIIA Mixed germ cell tumor of the testis\n- ___: Lymphocytosis incidentally found during a psychiatric\nhospitalization.\n- ___: CT scan showed a slightly enlarged spleen at 14.5 cm\nand no adenopathy.\n- ___: He met with Dr. ___ in ___ at\n___. WBC was 15.0 with 49.6% lymphocytes, Hgb 11.9,\nand platelets 260,000. Flow cytometry was consistent with CLL,\nand B-cell gene rearrangement confirmed clonality. CLL FISH \npanel\nshowed a p53 mutation. He was asymptomatic at the time of\ndiagnosis and followed with Dr. ___. \n- WBC gradually uptrended to 22.7 in ___, 37.3 in ___,\n51.3 in ___, and 50.4 on ___. Hgb has decreased slightly\nto 10.9 and Hct 34.4 with platelets 234,000 on the ___ \nlabs.\n- ___: Hematology care transitioned to Dr. ___\nafter Dr. ___. He also started having nightly sweats. \n\n- ___: CT Chest without lymphadenopathy or other notable\nfindings.\n- ___: Initial ___ Hematology evaluation for second\nopinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood\nflow cytometry and cytogenetics confirmed CLL with TP53 \ndeletion.\n- ___: CT Abdomen/Pelvis without lymphadenopathy or other\nnotable findings.\n- ___: Started ibrutinib 420 mg daily.\n- ___: Ibrutinib held for vitreous bleed\n- ___: Ibrutinib restarted\n- ___: Per OSH records, underwent scrotal U/S showing\nheterogeneous left testicle, prominent rete testis on right.\n- ___: Presented to his outpatient hematologist, Dr.\n___ a painful swollen left testicle (swelling over \n~8\nmonths, worsening pain). This had been evaluated on ___ with\nan ultrasound that did not demonstrate torsion but did show\nheterogeneous morphology of the left testicle. HCG was positive.\nReferred to Dr. ___.\n- ___: Underwent left radical orchiectomy. Pathology\nrevealed 3.9 cm malignant mixed germ cell tumor of the testis,\n95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1%\nchoriocarcinoma, invading hilar statin ___ vaginalis, with\nlymphatic vascular invasion and metastatic tumor nodules in the\nspermatic cord. pT2NxS1 (although no post-orch levels, beta hCG\n64 on ___, up from 21 on ___ AFP 3, LDH normal).\n- ___: CT torso showing new 8 mm nodule in the left lower\nlobe, and comparison with CT ___. Left para-aortic\nlymphadenopathy up to 2.8 cm and a 3.5 cm fluid collection in \nthe\nleft inguinal region/scrotum, felt to be likely postsurgical.\n- ___: C1D1 EP\n- ___: C2D1 EP (delayed 1 week after nasal infection\n- ___: Admitted for weakness, fall\n- ___: Admitted for parainfluenza pneumonia, symptomatic\nanemia, palpitations, developed nausea/vomiting in hospital\n- ___: C3D1 EP (delayed 1 week, added palonosetron)\n- ___: C4D1 EP\n- ___: CT torso with significant decrease in size of the\npreviously seen left para-aortic lymph node which now measures 6\nmm, previously 28 mm. Otherwise no LAD.\n- ___: Restarted ibrutinib for recurrent CLL (night sweats,\nlymphocytosis)\n\nPAST MEDICAL HISTORY:\n- Sick sinus syndrome s/p PPM ___ Revo DDD,\nMRI-compatible, ___\n- CAD s/p DES to mid-LAD in ___. Preserved LVEF in ___\n- Stroke ___ (with recovering motor function, though still with\nsome left thigh sensory decrease)\n- Diabetes mellitus type II on insulin\n- Hypertension\n- Hyperlipidemia\n- Morbid Obesity s/p Gastric bypass surgery ___\n- Obstructive Sleep Apnea - not on CPAP\n- Pancreatitis ___ related to alcohol\n- s/p cholecystectomy\n- Hypothyroidism\n- Osteoarthritis\n- s/p bilateral shoulder surgery, chronic pain\n- Major depression with psychotic features (vs schizoaffective\ndisorder per patient) (Dr. ___ name unknown, affiliated\nwith ___)\n- Anxiety\n- Conversion Disorder\n- Benign Paroxysmal Positional Vertigo\n- Glaucoma, cataract (Dr. ___ at ___ \n___)\n \nSocial History:\n___\nFamily History:\nNo known history of malignancies.\n \nPhysical Exam:\n===============================\nADMISSION PHYSICAL EXAMINATION:\n===============================\n\nVS: Temp 97.7, BP 155/80, HR 96, RR 19, O2 sat 99% RA.\nGENERAL: Pleasant man, in no distress, sitting up in chair \ncomfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, decreased breath \nsounds.\nABD: Obese, soft, non-tender, non-distended, positive bowel \nsounds.\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\n===============================\nDISCHARGE PHYSICAL EXAMINATION:\n===============================\n\nVS: Temp: 97.6 (Tm 98.5), BP: 123/78 (108-156/68-85), HR: 70\n(70-111), RR: 20 (___), O2 sat: 100% (97-100), O2 delivery: RA \n\nGENERAL: sitting comfortably in chair, no acute distress\nHEENT: no conjunctival pallor, anicteric sclera, MMM, oropharynx\nclear\nNECK: supple, non-tender, JVP just above clavicle\nCV: RRR, S1 and S2 normal, no murmurs/rubs/gallops\nRESP: CTAB, no wheezes/crackles, breathing comfortably\n___: soft, non-tender, obese, non-distended, BS normoactive\nEXTREMITIES: warm/well perfused, trace lower extremity edema\nNEURO: A/O x3, grossly intact\nSKIN: no skin rashes/lesions\nACCESS: right sided port clean, dry and intact, without\nsurrounding erythema\n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n\n___ 07:50PM BLOOD WBC-18.0* RBC-3.65* Hgb-10.1* Hct-31.7* \nMCV-87 MCH-27.7 MCHC-31.9* RDW-15.4 RDWSD-49.1* Plt ___\n___ 07:50PM BLOOD Neuts-37 Bands-0 Lymphs-55* Monos-7 Eos-1 \nBaso-0 ___ Myelos-0 AbsNeut-6.66* AbsLymp-9.90* \nAbsMono-1.26* AbsEos-0.18 AbsBaso-0.00*\n___ 07:50PM BLOOD Glucose-191* UreaN-13 Creat-0.9 Na-132* \nK-4.4 Cl-95* HCO3-21* AnGap-16\n___ 07:50PM BLOOD Lactate-1.8\n\n======\nMICRO:\n======\n\n___ Flu A/B PCR - Negative\n\n___ BLOOD CULTURE\n Blood Culture: \n\n___ Rapid Respiratory Viral Screen & Culture\n Respiratory Viral Culture: Negative\n Respiratory Viral Antigen Screen: \n Negative for Respiratory Viral Antigen. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza \n A, B, and RSV by immunofluorescence. \n\n___ BLOOD CULTURE Source: Line-poc. \n Blood Culture: \n\n___ URINE CULTURE\n Urine Culture: Yeast >100,000 CFU/ml\n\n================\nIMAGING/REPORTS:\n================\n\n___ CXR\nRight-sided Port-A-Cath tip terminates in the low SVC. \nLeft-sided \ndual-chamber pacemaker device is again noted with leads in \nunchanged \npositions. Cardiac silhouette size remains mildly enlarged. The \nmediastinal and hilar contours are unchanged. Pulmonary \nvasculature is normal. No focal consolidation, pleural effusion, \nor pneumothorax is demonstrated. Previously noted small left \npleural effusion appears resolved. No acute osseous \nabnormalities demonstrated. \n\n___ TTE\nThe left atrium is normal in size. The estimated right atrial \npressure is ___ mmHg. There is mild symmetric left ventricular \nhypertrophy with normal cavity size. Due to suboptimal technical \nquality, a focal wall motion abnormality cannot be fully \nexcluded. There is mild global left ventricular hypokinesis \n(LVEF = 40 %). Right ventricular chamber size is normal with \nmild global free wall hypokinesis. The aortic root is mildly \ndilated at the sinus level. The ascending aorta is mildly \ndilated. The aortic valve leaflets are mildly thickened (?#). \nThere is no aortic valve stenosis. Mild (1+) aortic \nregurgitation is seen. The mitral valve leaflets are not well \nseen. There is mild pulmonary artery systolic hypertension. \nThere is a small pericardial effusion. The effusion is echo \ndense, consistent with blood, inflammation or other cellular \nelements. There are no echocardiographic signs of tamponade or \nconstriction.\n\n___ CXR\nIn comparison with the study of ___, there are slightly \nlower lung \nvolumes. Continued enlargement the cardiac silhouette with dual \nchannel pacer in place. Right IJ Port-A-Cath is unchanged. Note \nfocal pneumonia, vascular congestion, or pleural effusion. \n\n===========\nOTHER LABS:\n===========\n\n___ 05:45AM BLOOD IgG-537*\n___ 08:30AM BLOOD Lactate-1.9\n___ 08:22AM BLOOD proBNP-6621*\n___ 12:35PM BLOOD Osmolal-267*\n___ 08:22AM BLOOD TSH-7.4*\n___ 12:56PM BLOOD Lactate-1.3\n\n===============\nDISCHARGE LABS:\n===============\n\n___ 11:28PM BLOOD WBC-10.3* RBC-2.95* Hgb-7.9* Hct-25.3* \nMCV-86 MCH-26.8 MCHC-31.2* RDW-15.0 RDWSD-46.7* Plt ___\n___ 11:28PM BLOOD Neuts-62 Bands-0 ___ Monos-5 Eos-0 \nBaso-0 Atyps-4* ___ Myelos-0 AbsNeut-6.39* AbsLymp-3.40 \nAbsMono-0.52 AbsEos-0.00* AbsBaso-0.00*\n___ 11:28PM BLOOD Glucose-77 UreaN-20 Creat-1.1 Na-133* \nK-4.7 Cl-95* HCO3-22 AnGap-16\n___ 11:28PM BLOOD ALT-12 AST-14 LD(LDH)-224 AlkPhos-81 \nTotBili-<0.2\n___ 11:28PM BLOOD Calcium-7.7* Phos-2.8 Mg-2.___ with a background history of CLL, previously on ibrutinib, \nstatus post EP x4 cycles, and now planned for venetoclax, SSS \nstatus post PPM placement, AF on rivaroxaban, CAD status post \nstent, recurrent pericarditis, HFpEF, stroke, HTN/HLD, and \nhypothyroidism, presenting with cough and fever. \n\n====================\nACUTE/ACTIVE ISSUES:\n====================\n\n# Fever\n# Non-productive cough\nPresented with one day history of fever (103), sore throat, \nintermittent dry cough, general body aches and mild shortness of \nbreath. Wife with similar symptoms in the days preceding \nsymptoms, which had subsequently resolved. Patient had flu \nvaccine this season. Took Tylenol with some improvement in \nfever, but given persistence greater than 100.3F, presented to \nED. Examination with clear lungs bilaterally and no evidence of \nfluid overload. Labs were unremarkable. CXR without evidence of \ninfiltrates/consolidation. As symptoms were most likely \nconsistent with a viral syndrome, patient was treated \nsymptomatically and started on five day course of levofloxacin \nto prevent bacterial superinfection. Total IgG levels >500. \nInfluenza swab negative and respiratory viral culture negative. \nSymptoms gradually improved and resolved over the course of the \nadmission. Patient left AMA, understanding all risks to him \nleaving.\n\n# UTI\n# ___\nBaseline creatinine ~1.0. Acute rise prior to transfer to FICU, \nwith poor urine output over the previous 12 hours. Most likely \netiology included pre-renal vs. ATN, in the setting of \nhypovolemia and hypotension. However, patient was on many \nmedications which could have precipitated ___, including \ncolchicine, losartan and acyclovir. These medications were held, \nbut restarted prior to discharge, as creatinine returned to \nbaseline following administration of 2L IVF in FICU. Patient \nalso noted to have dirty UA, with subsequent urine culture \npositive for yeast >100,000 CFU/ml. Started fluconazole 200mg \ndaily for 14 days. Patient left AMA, understanding all risks to \nhim leaving.\n\n# Atrial flutter\nPatient with a background history of atrial fibrillation/flutter \nwith RVR. On previous admission required transfer to CCU for \nrate management in the setting of pericardial effusion, and \nsubsequent tamponade requiring pericardiocentesis. Flipped into \natrial flutter with rates 140-150s on ___. Minimal response to \nPO/IV diltiazem and PO metoprolol. Patient remained asymptomatic \nbut given hypotension, with systolic blood pressure readings in \nthe ___, patient was transferred to ICU for rate control. Here \nhe received 2L IVF and was loaded with IV amiodarone, with \nsubsequent normalization of rates and pressures. Remained stable \non the floor, on fractionated metoprolol 37.5mg Q6H, before \ntransitioning to home regimen of metoprolol succinate 150mg \ndaily prior to discharge. \n\n# CLL\n# Lymphocytosis\nDiagnosed in ___, unfavorable cytogenetics by virtue of \ndeletion(17p), previously on ibrutinib and has completed four \ncycles of EP, but now off ibritnib therapy given recent \nadmission for pericardial effusion and hypotension. Patient was \nscheduled for admission ___ to initiate therapy with \nvenetoclax. This was deferred given current infective process \nand will be commenced at a later date. Continued home acyclovir \nfor prophylaxis.\n\n======================\nCHRONIC/STABLE ISSUES:\n======================\n\n# Type II Diabetes Mellitus\nContinued home insulin glargine regimen, but eased back on \nHumalog ISS on admission. Blood sugars remained controlled. \n\n# HFrEF\nContinued furosemide 20mg every other day initially for preload \nreduction and losartan 25mg daily for afterload reduction, \nhowever given acute rise in creatinine on ___, furosemide and \nlosartan were both held. NHBK was initially achieved with \nfractionated metoprolol, but given atrial flutter changes were \nmade as above. Given normalization of creatinine and heart \nrates, patient was transitioned back to the above medications \nprior to discharge.\n\n# Atrial Fibrillation\nContinued rivaroxaban while inpatient. Temporarily transitioned \nto heparin drip given acute rise in creatinine, but restarted \nrivaroxaban with improvement in renal function. Rate control \nmanagement was achieved with control of atrial flutter as above, \nbefore transitioning back to home regimen of metoprolol. \n\n# CAD status post LAD PCI\n# Hyperlipidemia\nPatient was transitioned back to aspirin 81mg daily from aspirin \n325mg daily, given resolution of pericarditis symptoms. \nAtorvastatin and fenofibrate had been held on a previous \nadmission. The decision if/when to restart these is deferred to \noutpatient providers. \n\n# Pericarditis\nContinued prednisone taper, but changed colchicine BID to daily \ndosing. \n\n# Hypertension\nContinued home losartan initially, before it was held in the \nsetting of ___. Restarted prior to discharge.\n\n# Schizoaffective Disorder\nContinued home divalproex, fluoxetine, and ziprasidone.\n\n# Hyponatremia\nStable and chronic. Thought to be some component of SIADH. \nSodium levels were closely monitored during admission, and \npatient was maintained on a low sodium diet. \n\n# Anemia\nChronic and stable. Likely due to malignancy.\n\n# Hypothyroidism\nContinued home levothyroxine 50mcg daily.\n\n====================\nTRANSITIONAL ISSUES:\n====================\n\n- discharge WBC 10.3\n- discharge Hgb 7.9\n- discharge Plt 185\n- discharge Na 133\n- discharge K 4.7\n- discharge creatinine 1.1\n\nMEDICATION CHANGES:\n[] fluconazole 200mg daily for 14 days\n[] levofloxacin 750mg one dose\n[] changed aspirin to 81mg daily\n[] changed colchicine to 0.6mg daily\n\n[] Follow-up with oncologist, Dr. ___ week\n[] Follow-up when to start venetoclax\n[] Re-check TFTs in six weeks to ensure correct dose of \nlevothyroxine\n[] Decide if/when to restart atorvastatin/fenofibrate\n[] Repeat EKG with PCP at next visit, to assess rhythm \n[] Discuss chronic pain management at next PCP visit, given \nconcern patient is pain is not adequately controlled\n[] Patient left AMA\n\n============================================\n# CODE STATUS: Full\n# CONTACT: ___, HCP/son, ___\n \nMedications on Admission:\n1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever \n2. Acyclovir 400 mg PO Q8H \n3. Aspirin 81 mg PO DAILY \n4. Colchicine 0.6 mg PO BID \n5. Divalproex (EXTended Release) 500 mg PO QAM \n6. Divalproex (EXTended Release) 750 mg PO QPM \n7. FLUoxetine 20 mg PO DAILY \n8. Furosemide 20 mg PO EVERY OTHER DAY \n9. Gabapentin 300 mg PO TID \n10. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN back pain \n11. Multivitamins 1 TAB PO DAILY \n12. Pantoprazole 40 mg PO Q24H \n13. Rivaroxaban 20 mg PO DINNER \n14. Senna 8.6 mg PO BID \n15. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n16. Losartan Potassium 25 mg PO DAILY \n17. Magnesium Oxide 400 mg PO BID \n18. Metoprolol Succinate XL 150 mg PO DAILY \n19. PredniSONE 5 mg PO DAILY \n20. Glargine 75 Units Breakfast\nGlargine 30 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n21. Docusate Sodium 100 mg PO BID \n22. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN Nasal \ncongestion \n23. melatonin 2.5 mg oral QHS:PRN \n24. Levothyroxine Sodium 25 mcg PO DAILY \n25. TraZODone 200 mg PO QHS:PRN Insomnia \n26. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Medications:\n1. Fluconazole 200 mg PO Q24H Duration: 14 Doses \nRX *fluconazole 200 mg 1 tablet(s) by mouth Daily Disp #*14 \nTablet Refills:*0 \n2. Levofloxacin 750 mg PO Q24H Duration: 1 Dose \nRX *levofloxacin 750 mg 1 tablet(s) by mouth ONCE Disp #*1 \nTablet Refills:*0 \n3. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*0 \n4. Colchicine 0.6 mg PO DAILY \nRX *colchicine 0.6 mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*0 \n5. Glargine 75 Units Breakfast\nGlargine 30 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n6. Acyclovir 400 mg PO Q8H \n7. Divalproex (EXTended Release) 500 mg PO QAM \n8. Divalproex (EXTended Release) 750 mg PO QPM \n9. Docusate Sodium 100 mg PO BID \n10. FLUoxetine 20 mg PO DAILY \n11. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN Nasal \ncongestion \n12. Furosemide 20 mg PO EVERY OTHER DAY \n13. Gabapentin 300 mg PO TID \n14. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n15. Levothyroxine Sodium 50 mcg PO DAILY \n16. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN back pain \n17. Losartan Potassium 25 mg PO DAILY \n18. Magnesium Oxide 400 mg PO BID \n19. Metoprolol Succinate XL 150 mg PO DAILY \n20. Multivitamins 1 TAB PO DAILY \n21. Pantoprazole 40 mg PO Q24H \n22. PredniSONE 5 mg PO DAILY Duration: 3 Doses \nTapered dose - DOWN \n23. Rivaroxaban 20 mg PO DINNER \n24. Senna 8.6 mg PO BID:PRN constipation \n25. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nViral bronchitis \nAcute kidney injury\nYeast urinary tract infection\nAtrial flutter with RVR and hypotension\nCLL \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 decided to leave the hospital AGAINST MEDICAL ADVICE. We \nwanted you to stay as you had evidence of a yeast urinary tract \ninfection, but you were not willing to do this. You understood \nthe risks, including death and severe infection, but still \nwanted to leave. Although you are leaving AGAINST MEDICAL \nADVICE, it is important you follow the below instructions. \n\n- We will give you a prescription, and you must pick these up in \nthe morning\n- If you develop fevers, burning when you urinate, pain in your \nabdomen, racing heart, chest pain or shortness of breath, you \nshould return to the ED.\n\nWHY YOU CAME TO THE HOSPITAL\nYou were admitted to the hospital with fevers, cough, \ngeneralized body aches and right sided rib pain.\n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL\n- You tested negative for flu, so your symptoms likely \nrepresented a viral infection\n- We treated you with antibiotics to prevent pneumonia\n- You developed a rapid heart rate and low blood pressures, \nrequiring transfer to the ICU for management of same\n- When your heart rate and blood pressure returned to normal, \nyou were transferred back to the floor\n- You were found to have a urinary tract infection, which you \nwill need to take medication to treat when you are discharged\n\nWHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL\n- You need to take all your medications as prescribed\n- Follow-up with Dr. ___ as arranged \n- You will start your CLL treatment at a later date\n- Keep a close eye on your weight, and restrict your salt and \nfluid intake\n\nYour ___ Team\n\nMEDICATION CHANGES:\n[] fluconazole 200mg daily for 14 days\n[] levofloxacin 750mg one dose\n[] changed aspirin to 81mg daily\n[] changed colchicine to 0.6mg daily\n \nFollowup Instructions:\n___\n" ]

[ "J208", "C9110", "N179", "E222", "I480", "F259", "I110", "I5032", "I4892", "I4891", "B3749", "E861", "E119", "D630", "E039", "I2510", "Z955", "I69398", "E785", "G4733", "Z7901", "G8929", "Z794", "R339", "E669", "Z6836" ]

[ "J208: Acute bronchitis due to other specified organisms", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "N179: Acute kidney failure, unspecified", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "I480: Paroxysmal atrial fibrillation", "F259: Schizoaffective disorder, unspecified", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "I4892: Unspecified atrial flutter", "I4891: Unspecified atrial fibrillation", "B3749: Other urogenital candidiasis", "E861: Hypovolemia", "E119: Type 2 diabetes mellitus without complications", "D630: Anemia in neoplastic disease", "E039: Hypothyroidism, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I69398: Other sequelae of cerebral infarction", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z7901: Long term (current) use of anticoagulants", "G8929: Other chronic pain", "Z794: Long term (current) use of insulin", "R339: Retention of urine, unspecified", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult" ]

[ "N179", "I480", "I110", "I5032", "I4891", "E119", "E039", "I2510", "Z955", "E785", "G4733", "Z7901", "G8929", "Z794", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base / cheeses soft, ___, cottage, cream cheese\n \nAttending: ___.\n \nChief Complaint:\nEpigastric Pain\n \nMajor Surgical or Invasive Procedure:\nEndoscopy (___)\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with CLL on venetoclax, hx\ntesticular cancer, IDDM, hypertension, hyperlipidemia, obesity,\nright subcortical stroke in ___ with residual left leg weakness\n(ambulates with a cane), sick sinus syndrome status post\npacemaker, depression with psychotic features, presenting with\nsudden onset of epigastric abdominal pain.\n\nPatient states he ate dinner at 4:30PM yesterday evening, and an\nhour later at 5:30pm, he began experiencing epigastric pain.\nDescribed pain as sharp and stabbing, 9.5/10. Reported \nassociated\nnausea, but no emesis. States pain radiated \"straight to my\nback\". Denies any alleviating or exacerbating factors. Did not\ntry to take any medications, and instead called an ambulance to\nbring him to the hospital. Stated he had never felt this pain\nbefore. Reportedly had a history of GERD and takes a PPI daily.\nWhen asked if this pain resembled his reflux symptoms, he states\nit's hard to say as he very rarely has reflux symptoms on this\nregimen. Denies any diarrhea, constipation, obstipation, \ndysuria,\nfoul smelling urine, hematochezia, melena. Reports last BM the\nday prior to admission which was normal. No history of\ngallstones.\n\nIn the ED, initial vitals: 75 | 180/74 | 18 | 98% RA. Labs\nsignificant for WBC 10.6, Plts 149, Hgb 10.0. Na 133, BUN 21, \nGlu\n391. AST 42, ALT 57. T bili 0.2. AP 115, lipase 25, trop <0.01\nx2, Lactate 2.0. UA with glucose, but no signs of infection. \n\nEKG with sinus tachycardia, no acute ischemic changes, QTc 505.\n\nPatient underwent CTA abd/pelvis ___ which showed (prelim) no\nacute intra-abdominal process. Specifically, no evidence of\nmesenteric ischemia.\n\nPatient got IV morphine 4mg x2, Maalox, foamotidine, viscous\nlidocaine. Patient admitted to oncology for additional\nmanagement. On arrival to floors, patient confirms history as\nabove and states his pain improved after getting IV morphine in\nthe ED, now down to a ___.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n-___: found to have CLL incidentally on labs performed during\npsych admission. \n- Followed for several years until ___ when he noted night\nsweats and progressive fatigue.\n- Ibrutinib ___. Complicated by multiple bleeding events \nIncluding retinal bleed. Ibrutinib was held, lymph node. \nIbrutinib was restarted, c/b GI and pericardial bleeding\n- Ventoclax initiated ___\n\nPAST MEDICAL HISTORY: \n-Non-seminoma testicular GCT sp 4 cycles EP ___\n-Chronic lymphocytic leukemia as above.\n-Sick sinus syndrome s/p PPM ___ Revo DDD, \nMRI-compatible,\n___.\n-CAD s/p DES to mid-LAD in ___\n-Cerebrovascular accident (___) with residual left weakness.\n-Diabetes mellitus type II on insulin\n-pAF on xarelto\n-Hypertension.\n-Hyperlipidemia.\n-Morbid obesity.\n-Obstructive sleep apnea - not on CPAP.\n-Pancreatitis.\n-Hypothyroidism.\n-Peripheral neuropathy.\n-Chronic pain.\n-Osteoarthritis.\n-Major depression with psychotic features (vs schizoaffective\ndisorder per patient).\n-Anxiety.\n-Conversion disorder.\n-Benign paroxysmal positional vertigo.\n-Glaucoma.\n\n-s/p Cholecystectomy.\n-s/p Bilateral shoulder surgery.\n-s/p Gastric bypass surgery ___.\n\n \nSocial History:\n___\nFamily History:\nFather and mother with cardiovascular disease; mother died of\nunknown malignancy.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n=========================\nVitals: 24 HR Data (last updated ___ @ 428)\n Temp: 97.6 (Tm 97.6), BP: 137/75, HR: 71, O2 sat: 97%, O2\ndelivery: RA, Wt: 287.5 lb/130.41 kg\nGENERAL: Sitting in chair comfortably, eyes closed \nintermittently\nthroughout interview, NAD, obese\nHEENT: Clear OP without lesions or thrush\nEYES: PERRL, anicteric\nNECK: supple, no JVD\nRESP: No increased WOB, no wheezing, rhonchi or crackles\n___: RRR, no murmurs/rubs/gallops\nGI: obese, soft, distended. tympanic to percussion over\nepigastrum. When asked if palpation over epigastrum causes pain\nduring gentle palpation, patient says yes and jumps. However,\nwhen palpating the same region without asking if he's tender,\npatient without pain. No rebound or guarding. \nEXT: RLE edema 2+, trace pedal edema in LLE, warm.\nSKIN: dry, no obvious rashes\nNEURO: alert though closes eyes throughout interview. Responds \nin\nshort ___ word answers. PERRL, EOMI.\nACCESS: POC\n\nDISCHARGE PHYSICAL EXAM: \n=========================\nVitals: 24 HR Data (last updated ___ @ 428)\n Temp: 98, 126/77, 71, 20, 98% RA\nGENERAL: Sitting in chair comfortably, pleasant, conversant\nHEENT: Clear OP without lesions or thrush\nEYES: PERRL, anicteric\nNECK: supple, no JVD\nRESP: No increased WOB, no wheezing, rhonchi or crackles\n___: RRR, no murmurs/rubs/gallops\nGI: obese, soft, distended. Non tender to palpation\nEXT: RLE edema 2+, trace pedal edema in LLE, warm.\nSKIN: dry, no obvious rashes\nNEURO: AOx3, answering questions appropriately.\nACCESS: POC\n\n \nPertinent Results:\nADMISSION LABS: \n===============\n___ 10:23PM BLOOD WBC-10.6* RBC-3.93* Hgb-10.0* Hct-32.8* \nMCV-84 MCH-25.4* MCHC-30.5* RDW-15.7* RDWSD-47.3* Plt ___\n___ 10:23PM BLOOD Neuts-45 ___ Monos-3* Eos-0* Baso-0 \nAbsNeut-4.77 AbsLymp-5.51* AbsMono-0.32 AbsEos-0.00* \nAbsBaso-0.00*\n___ 04:48AM BLOOD ___ PTT-33.6 ___\n___ 10:23PM BLOOD Glucose-391* UreaN-17 Creat-1.0 Na-133* \nK-4.3 Cl-98 HCO3-21* AnGap-14\n___ 10:23PM BLOOD ALT-57* AST-42* AlkPhos-115 TotBili-0.2\n___ 10:23PM BLOOD Albumin-3.7 UricAcd-7.0\n___ 10:23PM BLOOD Lipase-25\n___ 10:23PM BLOOD cTropnT-<0.01\n___ 11:33PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 \nLeuks-NEG\n\nRELEVANT INTERVAL LABS:\n=======================\n___ 05:21AM BLOOD Glucose-332* UreaN-28* Creat-1.5* Na-141 \nK-4.4 Cl-103 HCO3-22 AnGap-16\n___ 05:32AM BLOOD ALT-41* AST-44* LD(___)-409* AlkPhos-98 \nAmylase-24 TotBili-0.2\n___ 05:32AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.4 UricAcd-9.2*\n___ 05:21AM BLOOD VitB12-551 Folate-14\n___ 05:21AM BLOOD 25VitD-13*\n\nDISCHARGE LABS: \n===============\n___ 05:08AM BLOOD WBC-8.7 RBC-3.76* Hgb-9.6* Hct-31.8* \nMCV-85 MCH-25.5* MCHC-30.2* RDW-15.9* RDWSD-48.7* Plt ___\n___ 05:08AM BLOOD Neuts-40 ___ Monos-10 Eos-1 Baso-0 \nAbsNeut-3.48 AbsLymp-4.26* AbsMono-0.87* AbsEos-0.09 \nAbsBaso-0.00*\n___ 04:51AM BLOOD Hypochr-2+* Anisocy-1+* Poiklo-2+* \nMicrocy-1+* Polychr-1+* Spheroc-2+* Ovalocy-2+* Schisto-1+* Tear \nDr-1+* RBC Mor-SLIDE REVI\n___ 05:08AM BLOOD ___ PTT-41.7* ___\n___ 05:08AM BLOOD Glucose-108* UreaN-18 Creat-1.1 Na-143 \nK-4.0 Cl-109* HCO3-20* AnGap-14\n___ 05:08AM BLOOD ALT-34 AST-42* LD(___)-247 AlkPhos-91 \nTotBili-0.3\n___ 05:08AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.3 UricAcd-7.6*\n\nIMAGING: \n========\nCTA A/P (___): No acute intra-abdominal process. Specifically, \nno evidence of mesenteric ischemia. The appendix is not \nvisualized, however, there are no secondary signs to suggest \nappendicitis. \n\nEGD (___): Normal mucosa of esophagus. ___ fistula \nwith mild erythema and food debris. Esophageal hiatal hernia. \nHealing ulcer of proximal jejunum. \n\nEKG:\nA-paced, V sensed, mod critera for LVH\n\nPATHOLOGY: \n==========\nGastric pouch, biopsy:\n-Corpus type mucosa within normal limits.\n\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE \n================================= \nMr. ___ is a ___ gentleman w/ history of CLL (on venetoclax), \ndepression with psychotic features, GERD, single remote episode \nof pancreatitis, IDDM, CAD s/p PCI, roux-en-y gastric bypass & \ncholecystectomy, & hypothyroidism who presented with acute \nonset, severe epigastric pain. CTA A/P, lab work & cardiac \nworkup were all unrevealing. Mr. ___ was evaluated by GI and \nunderwent EGD, which revealed a healing jejunal ulcer as well as \na ___ fistula. His home PPI was made BID and Mr. ___ \nwas provided with low dose oxycodone prn for pain management. \nCourse was complicated by periods of lethargy and delirium. His \nlevothyroxine was titrated up as his recent TSH was elevated and \nconcern this was contributing to his lethargy. Mr. ___ was also \nseen by psychiatry, who assisted in medication adjustments. Over \nthe course of his hospitalization, Mr. ___ mental status \nwaxed and waned, likely due to his underlying medical issues and \nmedication titration, however at discharge his mental status was \nback to baseline and clear. Course was further complicated by \n___, that was deemed contrast induced nephropathy. Mr. ___ was \nseen by renal, and upon discharge his Cr was 1.1. Mr. ___ was \nfollowed by ___ throughout his hospitalization for assistance \nin managing his IDDM. \n\nTRANSITIONAL ISSUES: \n================================= \n___: \n[] please continue to follow Mr. ___ for his IDDM \n\nPCP: \n[] please check a repeat TSH on ___ and titrate his \nlevothyroxine dose accordingly. he is being discharged on \nlevothyroxine 125mcg daily. \n\nGI:\n[] please follow-up with Mr. ___ after he completes 8 weeks of \nBID PPI therapy to ensure resolution of epigastric abdominal \npain. at that point in time please continue him on daily PPI. \n\nPSYCHIATRY: \n[] please continue to titrate Mr. ___ medications \n\nBARIATRIC SURGERY: \n[] please follow-up with Mr. ___ regarding the ___ \nfistula that was found on ___ EGD \n\nOTHER ISSUES: \n- Discharge Hemoglobin: 9.6\n- Discharge Cr: 1.1\n- Discharge weight: 290.78lbs\n\n# CODE: Full presumed\n# CONTACT: Son ___ (___) is his primary proxy,\nwife (separated) is his alternate\n\nACTIVE PROBLEMS:\n======================\n# Contrast Induced Nephropathy\nMr. ___ with ___, seen by renal and deemed likely ___ contrast \ninduced nephropathy. We held his colchicine, losartan, and \nfurosemide. We renally dosed his medications. However these were \nresumed on discharge as his renal function recovered. Cr on \ndischarge of 1.1. \n\n#Epigastric Abd Pain\n#Jejunal Ulcer \nSuspect abd pain ___ healing jejunal ulcer seen on EGD ___. CTA \nA/P with no concerning findings at this time for infectious, \nischemic, or pancreatic etiologies. ECG & trop unremarkable for \nACS. Initiated on BID PPI for ___ontinued home mag \nox & sucralfate. Provided low dose oxycodone intermittently for \npain relief. He should follow up with GI as an outpatient.\n\n#Lethargy\n#AMA Request\nUnclear etiology but possibly polypharmacy vs. other TME vs. \nhypothyroidism vs. delirium. Waxing & waning disorientation most \nc/f superimposed delirium. TSH persistently elevated therefore \npossible that poorly managed hypothyroidism contributing. Seen \nby psychiatry, who recommended stopping ziprasidone & \namitriptyline & decreasing his gabapentin. Agreed to discharge \nwith home ___.\n\n# Insulin-dependent type 2 diabetes: \nComplicated by peripheral neuropathy. A1c 8.7% in ___ Home \ninsulin regimen is 70/30, 100 units 3 times daily. Followed by \n___ & held metformin while inpatient. Will be discharged on \nregimen of 70/30 insulin, 70 units at breakfast, 60 units at \nlunch, and 55 units at dinner. Resume metformin at home. \n\n#Hx Roux-en-y\n___ fistula\nFistula seen by EGD ___. Bariatric surgery favor no surgical \nintervention at current time. GI also favors deferring EGD \nclipping as unlikely contributing to current presentation. \nVitamin studies wnl. Added thiamine supplementation. \nTI: follow up with Dr. ___ after discharge\n\n# Elevated LFTs\nMild elevations. Has had intermittently elevated LFTs in past. \nLikely drug induced liver injury, but unclear precipitant. These \nresolved upon discharge.\n\n# Normocytic Anemia: \n# Thrombocytopenia:\nAppears stable. Recent Fe studies indicate ___. Possibly r/t hx \ngastric bypass vs. colon cancer.\nLast c-scope ___ w/ tubular adenoma & serrated adenoma. GI at \nthat time rec ___ f/up screen w/ stool based testing d/t \ndifficulty w/ GI prep. \nTI: colon cancer screening \n\n#Hx Depression w/ psychotic features\nSeen by psychiatry. D/c ziprasidone & amitriptyline per above. \nContinued escitalopram, risperidone, and topirimate. Decreased \ndose of gabapentin. \n\n#Hypothyroidism \nRecent TSH elevated at 17 & fT4 low at 0.7. Unclear dose of \nlevothyroxine at home, but increased to 125mcg per day, per \n___ recs. \nTI: repeat TSH 6weeks (___)\n\n#Hyperuricemia\n#Hx of Gout\nHeld home colchicine in s/o renal injury. Initiated allopurinol \n___ daily. Home meds were resumed at time of discharge.\n\nCHRONIC ISSUES: \n================\n___ swelling\nPer pt at baseline. Held furosemide in s/o renal injury. \n\n#CLL\nStable. Patient continued on home venetoclax & acyclovir ppx. \n\n#Chronic Back Pain \nStable. Continued lidocaine patches. \n\n#Skin Care\nHx xerosis. Possibly ___ hypothyroid. Nystatin & triamcinolone \ncreams. \n\n#CAD s/p PCI \n#CVA w/ residual left sided weakness\n#HTN \nECG & trops w/o e/o ACS. Continued ASA, atorvastatin, metop \nsucc. Held home losartan ___ renal injury. Resumed upon \ndischarge.\n\n#HLD\n#Hypertriglyceridemia\n___ cholesterol 334, ___ 1475, HDL 24, LDL 151. Continued home \natorvastatin & fenofibrate. \n\n#pAF\nRate controlled (metop suc) & on OAC (rivaroxaban)\n\n#Hx Gout\nNothing acute. Held home colchicine ___ renal injury. Started \nrenally dosed allopurinol. \n\nd/c planning > 30 min\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. Atorvastatin 40 mg PO QPM \n3. Fenofibrate 54 mg PO DAILY \n4. Furosemide 20 mg PO DAILY \n5. Gabapentin 300 mg PO BID \n6. Levothyroxine Sodium 100 mcg PO DAILY \n7. Lidocaine 5% Patch 3 PTCH TD QAM \n8. Losartan Potassium 50 mg PO DAILY \n9. Pantoprazole 40 mg PO Q24H \n10. Rivaroxaban 20 mg PO DAILY \n11. Senna 8.6 mg PO BID:PRN Constipation - First Line \n12. Sucralfate 1 gm PO BID \n13. Topiramate (Topamax) 50 mg PO DAILY \n14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY \n15. Carbamide Peroxide 6.5% ___ DROP BOTH EARS DAILY \n16. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 \n17. HydrOXYzine 10 mg PO Q6H:PRN anxiety \n18. Magnesium Oxide 400 mg PO BID \n19. melatonin 6 mg oral qhs \n20. Metoprolol Succinate XL 150 mg PO DAILY \n21. Nystatin-Triamcinolone Cream 1 Appl TP BID \n22. Venetoclax 400 mg PO DAILY \n23. Docusate Sodium 100 mg PO BID \n24. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever \n25. Aspirin 81 mg PO DAILY \n26. Colchicine 0.6 mg PO DAILY \n27. Amitriptyline 10 mg PO QHS \n28. Escitalopram Oxalate 20 mg PO DAILY \n29. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n30. ___ 100 Units Breakfast\n___ 100 Units Lunch\n___ 100 Units BedtimeMax Dose Override Reason: as per ___\n\n31. RisperiDONE 3 mg PO DAILY \n32. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \nRX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. Gabapentin 100 mg PO TID \nRX *gabapentin 100 mg 1 capsule(s) by mouth three times a day \nDisp #*90 Capsule Refills:*0 \n3. ___ 70 Units Breakfast\n___ 50 Units Lunch\n___ 30 Units Dinner\nInsulin SC Sliding Scale using HUM InsulinMax Dose Override \nReason: home regimen\n \n4. Levothyroxine Sodium 125 mcg PO DAILY \nRX *levothyroxine [Euthyrox] 125 mcg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n5. Lidocaine 5% Patch 3 PTCH TD QPM \n6. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - \nModerate \n7. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n8. RisperiDONE 3 mg PO QHS \n9. Rivaroxaban 20 mg PO DINNER \n10. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever \n11. Acyclovir 400 mg PO Q8H \n12. Aspirin 81 mg PO DAILY \n13. Atorvastatin 40 mg PO QPM \n14. Carbamide Peroxide 6.5% ___ DROP BOTH EARS DAILY \n15. Colchicine 0.6 mg PO DAILY \n16. Docusate Sodium 100 mg PO BID \n17. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 \n18. Escitalopram Oxalate 20 mg PO DAILY \n19. Fenofibrate 54 mg PO DAILY \n20. Furosemide 20 mg PO DAILY \n21. HydrOXYzine 10 mg PO Q6H:PRN anxiety \n22. Losartan Potassium 50 mg PO DAILY \n23. Magnesium Oxide 400 mg PO BID \n24. melatonin 6 mg oral qhs \n25. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \nDo Not Crush \n26. Metoprolol Succinate XL 150 mg PO DAILY \n27. Nystatin-Triamcinolone Cream 1 Appl TP BID \n28. Senna 8.6 mg PO BID:PRN Constipation - First Line \n29. Sucralfate 1 gm PO BID \n30. Topiramate (Topamax) 50 mg PO DAILY \n31. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY \n32. Venetoclax 400 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: \nJejunal Ulcer \n\nSecondary: \n___ fistula \nLethargy\nHypothyroidism\nInsulin dependent diabetes mellitus \nDelirium\nContrast induced nephropathy\nDepression with psychotic features, in remission \nHyperuricemia\nElevated LFTs \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 taking part in your care here at ___! \n\nWhy was I admitted to the hospital? \n- You were admitted for abdominal pain\n \nWhat was done for me while I was in the hospital? \n- We took pictures of your abdomen to determine what was causing \nyour abdominal pain\n- We used a camera to look into your stomach (endoscopy) and saw \na healing ulcer in your small intestine \n- We gave you pain medications & anti-acid medications to treat \nthe ulcer\n- We had diabetes doctors ___ help manage your blood sugars\n- We had psychiatrists see you to help manage your medications\n- We had the kidney doctors ___ because your kidney levels \nwere high\n\nWhat should I do when I leave the hospital? \n- please note that your acid reducing medication (Pantoprazole) \nshould be taken twice a day for the next 8 weeks. \n- please check your blood sugars before meals and at bedtime \neveryday, and bring a log of your readings to your next doctors \n___.\n- Take all of your medications as prescribed\n- Follow-up with all of your physicians as directed \n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K289", "K9589", "K316", "N179", "I5032", "F05", "C9110", "Z6841", "F3340", "N141", "I129", "N183", "E1122", "E1142", "E1165", "I480", "E039", "T508X5A", "Y92238", "K219", "K449", "E781", "E6601", "D649", "R5383", "I69344", "M109", "M160", "M19012", "M19011", "G4733", "R7989", "L853", "F419", "I252", "Z7901", "Z794", "Z8547", "Z950" ]

[ "K289: Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "K9589: Other complications of other bariatric procedure", "K316: Fistula of stomach and duodenum", "N179: Acute kidney failure, unspecified", "I5032: Chronic diastolic (congestive) heart failure", "F05: Delirium due to known physiological condition", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "Z6841: Body mass index [BMI]40.0-44.9, adult", "F3340: Major depressive disorder, recurrent, in remission, unspecified", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "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)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I480: Paroxysmal atrial fibrillation", "E039: Hypothyroidism, unspecified", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "Y92238: Other place in hospital as the place of occurrence of the external cause", "K219: Gastro-esophageal reflux disease without esophagitis", "K449: Diaphragmatic hernia without obstruction or gangrene", "E781: Pure hyperglyceridemia", "E6601: Morbid (severe) obesity due to excess calories", "D649: Anemia, unspecified", "R5383: Other fatigue", "I69344: Monoplegia of lower limb following cerebral infarction affecting left non-dominant side", "M109: Gout, unspecified", "M160: Bilateral primary osteoarthritis of hip", "M19012: Primary osteoarthritis, left shoulder", "M19011: Primary osteoarthritis, right shoulder", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R7989: Other specified abnormal findings of blood chemistry", "L853: Xerosis cutis", "F419: Anxiety disorder, unspecified", "I252: Old myocardial infarction", "Z7901: Long term (current) use of anticoagulants", "Z794: Long term (current) use of insulin", "Z8547: Personal history of malignant neoplasm of testis", "Z950: Presence of cardiac pacemaker" ]

[ "N179", "I5032", "I129", "E1122", "E1165", "I480", "E039", "K219", "D649", "M109", "G4733", "F419", "I252", "Z7901", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / \nerythromycin base\n \nAttending: ___.\n \nChief Complaint:\nFever\n \nMajor Surgical or Invasive Procedure:\nN/A\n \nHistory of Present Illness:\n___ yo male with a history of CLL and more recently testicular\ncancer who is admitted with fevers, cough, and sore throat. The\npatient states his symptoms started about two days ago but the\nfever just started today and has been as high as 100.6. He \ndenies\nany associated shortness of breath. He has had some intermittent\nnausea. He denies any diarrhea, dysuria, or rashes. Of note he\nhas had some mild dyspnea on exertion and palpitations that was\nthought by his outpatient team to be possibly symptomatic anemia\nand he was going to have an outpatient red blood cell \ntransfusion\nbut it had not been done yet.\nIn the ED a chest x-ray and urinalysis were unremarkable. His\nlabwork was notable for WBC 37.7, Hgb 7.8, and platelets 92. A\nrapid flu test was negative. He was given cefepime. \nOf note he was recently hospitalized from ___ - ___ with\nweakness, ___, and falls which was thought to be due to poor PO\nintake after his recent chemotherapy.\n\nREVIEW OF SYSTEMS:\n- All reviewed and negative except as noted in the HPI.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\nCLL (17p-) and Stage IIIA Mixed germ cell tumor of the testis\n-___: Lymphocytosis incidentally found during a psychiatric\nhospitalization.\n-___: CT scan showed a slightly enlarged spleen at 14.5 cm \nand\nno adenopathy.\n-___: He met with Dr. ___ in ___ at\n___. ___ was 15.0 with 49.6% lymphocytes, Hgb 11.9,\nand platelets 260,000. Flow cytometry was consistent with CLL,\nand B-cell gene rearrangement confirmed clonality. CLL FISH \npanel\nshowed a p53 mutation. He was asymptomatic at the time of\ndiagnosis and followed with Dr. ___. \n-WBC gradually uptrended to 22.7 in ___, 37.3 in ___, \n51.3\nin ___, and 50.4 on ___. Hgb has decreased slightly to\n10.9 and Hct 34.4 with platelets 234,000 on the ___ labs. \n-___: Hematology care transitioned to Dr. ___\nafter Dr. ___. He also started having nightly sweats. \n\n-___: CT Chest without lymphadenopathy or other notable\nfindings.\n-___: Initial ___ Hematology evaluation for second\nopinion. WBC 50.7, Hgb 10.5, Hct 33.2, Plt 226. Peripheral blood\nflow cytometry and cytogenetics confirmed CLL with TP53 \ndeletion.\n-___: CT Abdomen/Pelvis without lymphadenopathy or other\nnotable findings.\n-___: Started ibrutinib 420 mg daily.\n-___: Ibrutinib held for vitreous bleed\n-___: Ibrutinib restarted\n-___: Per OSH records, underwent scrotal U/S showing\nheterogeneous left testicle, prominent rete testis on right.\n-___: Presented to his outpatient hematologist, Dr. \n___ a painful swollen left testicle (swelling over ~8 months,\nworsening pain). This had been evaluated on ___ with an\nultrasound that did not demonstrate torsion but did show\nheterogeneous morphology of the left testicle. HCG was \npositive.\nReferred to Dr. ___.\n-___: ibrutinib held for surgery\n-___: Underwent left radical orchiectomy. Pathology\nrevealed 3.9 cm malignant mixed germ cell tumor of the testis,\n95% embryonal carcinoma, 2% teratoma, 2% yolk sac tumor, 1%\nchoriocarcinoma, invading hilar statin ___ vaginalis, with\nlymphatic vascular invasion and metastatic tumor nodules in the\nspermatic cord. pT2NxS1 (although no post-orch levels, beta hCG\n64 on ___, up from 21 on ___ AFP 3, LDH normal).\n-___: CT torso showing new 8 mm nodule in the left lower\nlobe, and comparison with CT ___.\nLeft para-aortic lymphadenopathy up to 2.8 cm and a 3.5 cm fluid\ncollection in the left inguinal region/scrotum, felt to be \nlikely\npostsurgical.\n-___: C1D1 EP\n-___: C2D1 EP \n\nPAST MEDICAL HISTORY:\n-Sick sinus syndrome s/p PPM ___ Revo DDD, \nMRI-compatible,\n___\n-CAD s/p DES to mid-LAD in ___. Preserved LVEF in ___.\n-Stroke ___\n-Diabetes mellitus type II on insulin\n-Hypertension\n-Hyperlipidemia\n-Morbid obesitys/p Gastric bypass surgery ___\n-Obstructive sleep apnea - not on CPAP\n-Pancreatitis ___ related to alcohol\n-s/p Cholecystectomy\n-Hypothyroidism\n-Osteoarthritis\n-s/p Bilateral shoulder surgery, chronic pain\n-Major depression with psychotic features (vs schizoaffective\ndisorder per patient) (Dr. ___ name unknown, affiliated\nwith ___)\n-Anxiety\n-Conversion disorder\n-Benign paroxysmal positional vertigo\n-Glaucoma, cataract (Dr. ___ at ___)\n\n \nSocial History:\n___\nFamily History:\nNo known history of malignancies.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nGeneral: NAD\nVITAL SIGNS: T 98.2 BP 178/74 HR 63 RR 18 O2 99%RA\nHEENT: MMM, no OP lesions\nCV: RR, NL S1S2\nPULM: CTAB\nABD: Soft, NTND, no masses or hepatosplenomegaly\nLIMBS: Trace bilateral lower extremity edema.\nSKIN: No rashes or skin breakdown\nNEURO: Alert and oriented, no focal deficits.\n\nDISCHARGE PHYSICAL EXAM:\nGeneral: Pleasant man, sitting up in chair in NAD\nVITAL SIGNS: T 98.4 BP 146/76 HR 52 RR 18 O2 98%RA\nHEENT: MMM, no OP lesions, erythema, or purulence. No LAD.\nCV: RR, NL S1S2. ___ SEM.\nPULM: Nonlabored appearing. CTAB. No cough this morning.\nABD: Obese. Soft, NTND, no masses or hepatosplenomegaly\nLIMBS: ___ bilateral lower extremity edema, L>R\nSKIN: No rashes or skin breakdown\nNEURO: Alert and oriented, no focal deficits.\n\n \nPertinent Results:\nADMISSION LABS:\n==============\n\n___ 08:20PM BLOOD WBC-37.7* RBC-2.77* Hgb-7.8* Hct-23.7* \nMCV-86 MCH-28.2 MCHC-32.9 RDW-20.5* RDWSD-61.8* Plt Ct-92*#\n___ 08:20PM BLOOD Neuts-57 Bands-12* ___ Monos-3* \nEos-2 Baso-1 ___ Metas-2* Myelos-1* NRBC-2* AbsNeut-26.01* \nAbsLymp-8.29* AbsMono-1.13* AbsEos-0.75* AbsBaso-0.38*\n___ 08:20PM BLOOD ___ PTT-30.6 ___\n___ 08:20PM BLOOD Glucose-213* UreaN-8 Creat-0.9 Na-140 \nK-3.5 Cl-104 HCO3-25 AnGap-15\n___ 02:48AM BLOOD ALT-15 AST-22 AlkPhos-122 TotBili-0.2\n___ 02:48AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.4*\n___ 02:48AM BLOOD IgG-544* IgA-101 IgM-28*\n\nDISCHARGE LABS:\n===============\n\n___ 12:00AM BLOOD WBC-26.6* RBC-2.98* Hgb-8.3* Hct-25.4* \nMCV-85 MCH-27.9 MCHC-32.7 RDW-19.9* RDWSD-58.8* Plt ___\n___ 12:00AM BLOOD Neuts-73* Bands-7* Lymphs-13* Monos-2* \nEos-1 Baso-2* ___ Metas-1* Myelos-1* AbsNeut-21.28* \nAbsLymp-3.46 AbsMono-0.53 AbsEos-0.27 AbsBaso-0.53*\n___ 12:00AM BLOOD Glucose-114* UreaN-8 Creat-0.8 Na-128* \nK-4.4 Cl-92* HCO3-24 AnGap-16\n___ 12:00AM BLOOD Albumin-3.2* Calcium-8.0* Phos-3.6 Mg-1.8\n\nTROP TREND:\n===========\n\n___ 09:19AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 05:00PM BLOOD CK-MB-2 cTropnT-<0.01\n\nNA\n==\n___ 12:00AM BLOOD Glucose-114* UreaN-8 Creat-0.8 Na-128* \nK-4.4 Cl-92* HCO3-24 AnGap-16\n___ 12:00AM BLOOD Osmolal-272*\n___ 05:11AM URINE Hours-RANDOM Na-34\n___ 05:11AM URINE Osmolal-154\n___ 11:00AM BLOOD Na-131*\n\nIMAGING:\n========\n___ Imaging UNILAT LOWER EXT VEINS \nNo evidence of deep venous thrombosis in the visualized right \nlower extremity veins. Right peroneal veins not visualized. \n\n___ Imaging CTA CHEST \n1. New opacities in the right lower lobe are concerning for \ninfection versus aspiration. \n2. No evidence of pulmonary embolism or aortic abnormality. \n3. There has been interval resolution of the previously seen 8 \nmm nodule in the left lower lobe from ___. \n\n___ Imaging CHEST (PA & LAT) \nPersistent low lung volumes, without focal consolidation. \nStable mild \ncardiomegaly without overt pulmonary edema. \n\nMICRO:\n======\n___ URINE Legionella Urinary Antigen -FINAL INPATIENT \n___ Rapid Respiratory Viral Screen & Culture Respiratory \nViral Culture-FINAL {PARAINFLUENZA VIRUS TYPE 3}; Respiratory \nViral Antigen Screen-FINAL INPATIENT \n___ URINE URINE CULTURE-FINAL EMERGENCY WARD \n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nEMERGENCY WARD \n___ BLOOD CULTURE Blood Culture, Routine-PENDING \n\n \nBrief Hospital Course:\nPRINCIPLE REASON FOR ADMISSION:\n___ yo male with a history of CLL and more recently testicular \ncancer who is admitted with fevers, cough, and sore throat. \nCourse notable for nausea, vomiting, and intermittent \npalpitations.\n\n# Fever: \n# Parainfluenza bronchitis/pharyngitis: Patient febrile to \narrival, but no fever noted in the hospital. Blood and urine \ncultures remain negative. Most prominent symptoms were sore \nthroat, dry cough, and nausea/vomiting. He was treated \nsymptomatically and slowly improved during his course. \nNasopharyngeal swab obtained on admission eventually grew \nparainfluenza type 3. Of note, CTA showed\nmild area of possible infection in RLL, and he was empirically \nstarted\non clindamycin for aspiration PNA (has PCN allergy). However, \nthis was discontinued\nafter one day given concern it was worsening his nausea. \nAdditionally, noted to have low IgG/IgM, we discussed with his \noutpatient oncology team and decided against IVIG.\n\n# Nausea/vomiting - Patient developed marked nauasea and \nvomiting on hospital days 2 and 3. Abdomen was benign on exam \nand LFT/chemistry panel generally unremarkable. He did have \nelevated white count but no diarreha to suggest CDiff. Somewhat \nunclear etiology, but ultimately felt related to parainfluenzae. \nGreatly improved after reducing dietary allowance, and slowly \nadvanced back to full diet. He was treated supportively \ntreatment with IV zofran, compazine, ativan and olanzapine as \nneeded\n\n# Palpitations\n# Dyspnea on exertion: Patient reported several weeks of DOE and \npalpitations with exertion. He continued to have these during \nhis stay, although no VS derangements were noted during \nepisodes. Had been thought that symptomatic anemia was playing a \nrole, but no significant improvement with 2 units pRBC. He was \nmonitored on telemetry, and ACS ruled out with serial troponins. \nCTA was negative for PE. Cardiology was consulted interrogate \nPPM, and no significant arrhythmias were noted. \n\n# Left lower extremity swelling - Likely worsened in setting of \nholding home Lasix and providing IVF for nausea/vomiting. ___ \nwas negative for DVT.\n\n# Hyponatremia: Na was noted to be 128 on day of discharge. Felt \nlikely due to nausea and vomiting and decreased po intake day \nprior. Urine was appropriately dilute, and was given 500cc \nadditional fluid. Na improved to 131 prior to discharge.\n\n# Anemia, chemotherapy induced: No signs of active bleeding. SP \n2 units pRBC.\n\n# Leukocytosis: Most likely due to recent neulasta and less\nlikely from CLL given profound left shift. No clear bacterial\ninfection, as above, and antibiotics were held, aside from one \nday of clindamycin. \n\n# Testicular Cancer: Received C2D1 etoposide and cisplatin on \n___. Received\nneulasta on ___. Next cycle planned for ___, ultimately \ndeferred to next week. \n\n# CLL: Treatment on hold while the patient is being treated for\ntesticular cancer. Continued home acyclovir.\n\n# DM: Continued home lantus. Held home metformin while in house \nand maintained HISS.\n\n# CAD: Continued home aspirin, atorvastatin, clonidine, Plavix, \nLasix,\nand losartan.\n\n# Depression/Anxiety: Continued home trazadone, ziprasidone, \nfluoxetine, and\ndivalproex.\n\n# Hypothyroidism: Continued home levothyroxine.\n\n# Atrial Fibrillation: Continue home metoprolol and rivaroxaban.\n\nFEN: \n- Electrolytes per oncology scales\n- Regular diet\nPAIN:\n- Continue home gabapentin. Oxycodone PRN. Avoid Tylenol acutely\nto avoid masking fevers.\nBOWEL REGIMEN:\n- Continue home Colace and senna.\nDVT PROPHYLAXIS:\n- Continue home rivaroxaban.\nACCESS: \n- Port\n\nBILLING: >30 minutes spend planning and executing this discharge \nplan.\n\nTRANSITIONAL ISSUES:\n- Please follow up in clinic on ___ to consider next cycle chemo\n- Please recheck Na to monitor hyponatremia\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO Q8H:PRN Headache \n2. Atorvastatin 80 mg PO QPM \n3. Clopidogrel 75 mg PO DAILY \n4. Divalproex (EXTended Release) 500 mg PO BID \n5. Divalproex (EXTended Release) 250 mg PO QPM \n6. Docusate Sodium 100 mg PO BID constipation \n7. FLUoxetine 20 mg PO DAILY \n8. Gabapentin 300 mg PO TID \n9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain - \nModerate \n10. Levothyroxine Sodium 25 mcg PO DAILY \n11. Magnesium Oxide 400 mg PO BID \n12. Metoprolol Tartrate 12.5 mg PO BID \n13. Pantoprazole 40 mg PO Q24H \n14. Rivaroxaban 10 mg PO DAILY \n15. Senna 8.6 mg PO DAILY constipation \n16. TraZODone 300 mg PO QHS \n17. Prochlorperazine 10 mg PO Q6H:PRN nausea \n18. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n19. Furosemide 20 mg PO DAILY \n20. Losartan Potassium 50 mg PO DAILY \n21. melatonin 2.5 mg oral QHS:PRN \n22. MetFORMIN (Glucophage) 1000 mg PO BID \n23. Aspirin 243 mg PO DAILY \n24. Glargine 56 Units Breakfast\nGlargine 56 Units Bedtime\n25. Acyclovir 400 mg PO Q8H \n26. CloNIDine 0.1 mg PO TID \n27. Fenofibrate 150 mg PO DAILY \n28. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Medications:\n1. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat \nRX *benzocaine-menthol [Cepacol Sore Throat ___ 15 \nmg-2.6 mg 2 lozenge q4 hours Disp #*30 Lozenge Refills:*0 \n2. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough \nRX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth \nq4 hours Refills:*0 \n3. Acetaminophen 500 mg PO Q8H:PRN Headache \n4. Acyclovir 400 mg PO Q8H \n5. Aspirin 243 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. CloNIDine 0.1 mg PO TID \n8. Clopidogrel 75 mg PO DAILY \n9. Divalproex (EXTended Release) 500 mg PO BID \n10. Divalproex (EXTended Release) 250 mg PO QPM \n11. Docusate Sodium 100 mg PO BID constipation \n12. Fenofibrate 150 mg PO DAILY \n13. FLUoxetine 20 mg PO DAILY \n14. Furosemide 20 mg PO DAILY \n15. Gabapentin 300 mg PO TID \n16. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Moderate \n17. Glargine 56 Units Breakfast\nGlargine 56 Units Bedtime \n18. Levothyroxine Sodium 25 mcg PO DAILY \n19. Losartan Potassium 50 mg PO DAILY \n20. Magnesium Oxide 400 mg PO BID \n21. melatonin 2.5 mg oral QHS:PRN \n22. MetFORMIN (Glucophage) 1000 mg PO BID \n23. Metoprolol Tartrate 12.5 mg PO BID \n24. Pantoprazole 40 mg PO Q24H \n25. Prochlorperazine 10 mg PO Q6H:PRN nausea \n26. Rivaroxaban 10 mg PO DAILY \n27. Senna 8.6 mg PO DAILY constipation \n28. Sucralfate 1 gm PO TID:PRN upset stomach with meals \n29. TraZODone 300 mg PO QHS \n30. ZIPRASidone Hydrochloride 40 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nParainfluenzae virus 3\nNausea/Vomiting\nPalpitations\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 for fevers. ___ were found to have a viral \ninfection, called parainfluenza 3 virus. Your symptoms, \nincluding fever, cough, sore throat, nausea, and vomiting \nimproved with time. ___ also had a blood transfusion to help \nimprove your breathing and energy. ___ tolerated it well. We had \nour cardiologists evaluate your pacemaker given your \npalpitations, and we found no evidence of concerning heart \nrhythms. ___ will need to follow up with your oncology team as \nscheduled.\n\nRegards,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "B348", "C9110", "E1136", "D6481", "E871", "C6292", "E785", "I2510", "Z955", "Z8673", "I10", "Z9884", "E039", "G8929", "F329", "F419", "H409", "Z794", "Z950", "R002", "M7989", "E669", "Z6834" ]

[ "B348: Other viral infections of unspecified site", "C9110: Chronic lymphocytic leukemia of B-cell type not having achieved remission", "E1136: Type 2 diabetes mellitus with diabetic cataract", "D6481: Anemia due to antineoplastic chemotherapy", "E871: Hypo-osmolality and hyponatremia", "C6292: Malignant neoplasm of left testis, unspecified whether descended or undescended", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I10: Essential (primary) hypertension", "Z9884: Bariatric surgery status", "E039: Hypothyroidism, unspecified", "G8929: Other chronic pain", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "H409: Unspecified glaucoma", "Z794: Long term (current) use of insulin", "Z950: Presence of cardiac pacemaker", "R002: Palpitations", "M7989: Other specified soft tissue disorders", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult" ]

[ "E871", "E785", "I2510", "Z955", "Z8673", "I10", "E039", "G8929", "F329", "F419", "Z794", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Penicillins / fluconazole / \nStrawberry\n \nAttending: ___.\n \nChief Complaint:\nWheezing, Shortness of Breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nThis is an ___ female with a history of asthma, CHF and \nhypertension presenting to the emergency department for \nproductive cough of yellow sputum and increased wheezing since \n___. The patient also states that ___ night she woke \nup with chills. She has not had another episode of chills. The\npatient is already on a Z-Pak ___ \nchronically. The patient called her PCP and was prescribed \nsteroids on ___. The patient has been taking her inhaler \nand nebulizers every 4 hours and her pro-air 2 times a day. The \npatient states she is still wheezing and coughing. The patient \nstates her voice has become raspy. The patient has not measured \nany fevers at home, her p.o. appetite has been okay, no chest \npain, no nausea, no vomiting, no, no history of blood clots, no \nhistory of DVT, no hemoptysis.\n\nThe patient states she is not having any more trouble than \nnormal laying flat. She has not noticed increased swelling in \nher legs. \n\nInitial VS: T 97.1, HR 82, BP 121/60, RR 16 98% RA \n\nExam: \nRespiratory: Mild respiratory distress, no accessory muscle use, \nequal chest rise, wheezes in all fields with good air movement \nthroughout.\nCV: RRR with S1 and S2. No S3, S4, murmurs, heaves, thrills, \nrubs appreciated. (-) JVD. Trace peripheral edema. Radial and \nPedal\npulses 2+ bilaterally. \n\nPertinent labs/imaging studies:\nCXR: Low lung volumes. No acute cardiopulmonary abnormality. \nCBC: WNL\n\nPatient received: Duonebs x3, methylpred 125, mag sulfate\n\nOn arrival to the floor, she confirms the above story. No sick \ncontacts at home, 2 days of increased wheezing, some SOB that is \nnow improved, but mostly just concerned about the wheezing. No \nfevers or chills, a mild headache. No abdominal, nausea, \nvomiting, diarrhea, or constipation.\n\n \nPast Medical History:\n- Asthma\n- Hypertension\n- GERD\n\n \nSocial History:\n___\nFamily History:\nMother & maternal grandmother with stroke. Father and daughter \nwith cancer. Grandmother with CAD/PVD.\n\n \nPhysical Exam:\nADMISSION\n=========\nVitals: Temp: 98.3 PO BP: 108/70 HR: 94 RR: 18 O2 sat: 100% O2 \ndelivery: RA \nGeneral: Alert and oriented x3, no acute distress\nHEENT: NC/AT, MMM, EOMI\nNeck: Supple, non-tender\nLungs: Diffuse wheezing bilaterally, good air movement, no \ncrackles or consolidations\nCV: RRR, no murmurs, rubs, or gallops\nGI: Soft, non-tender and non-distended, BS+\nExt: Warm and well perfused, non-edematous\nNeuro: Alert and oriented x3, CNII-XII grossly intact, no focal \nneurologic deficit.\n\nDISCHARGE\n=========\nVitals: Temp: 98.1 (Tm 98.1), BP: 115/64 (115-134/63-77), HR: 74 \n(74-89), RR: 20 (___), O2 sat: 96%, O2 delivery: Ra \nGeneral: Alert and oriented x3, no acute distress\nHEENT: NC/AT, MMM, EOMI\nNeck: Supple, non-tender\nLungs: Diffuse wheezing bilaterally, good air movement, no \ncrackles or consolidations\nCV: RRR, no murmurs, rubs, or gallops\nGI: Soft, non-tender and non-distended, BS+\nExt: Warm and well perfused, non-edematous\nNeuro: Alert and oriented x3, CNII-XII grossly intact, no focal \nneurologic deficit.\n \nPertinent Results:\nADMISSION\n=========\n___ 02:25PM GLUCOSE-142* UREA N-20 CREAT-1.0 SODIUM-139 \nPOTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-10\n___ 02:25PM estGFR-Using this\n___ 02:25PM cTropnT-<0.01 proBNP-447\n___ 11:33AM VoidSpec-SPECIMEN R\n___ 11:33AM WBC-9.0 RBC-4.52 HGB-12.7 HCT-40.0 MCV-89 \nMCH-28.1 MCHC-31.8* RDW-16.3* RDWSD-52.3*\n___ 11:33AM NEUTS-85.9* LYMPHS-7.7* MONOS-5.5 EOS-0.3* \nBASOS-0.2 IM ___ AbsNeut-7.71* AbsLymp-0.69* AbsMono-0.49 \nAbsEos-0.03* AbsBaso-0.02\n___ 11:33AM PLT COUNT-298\n\nDISCHARGE\n=========\n___ 07:45AM BLOOD WBC-6.5 RBC-4.42 Hgb-12.2 Hct-38.7 MCV-88 \nMCH-27.6 MCHC-31.5* RDW-15.7* RDWSD-50.5* Plt ___\n___ 07:45AM BLOOD Glucose-117* UreaN-21* Creat-0.9 Na-139 \nK-4.2 Cl-102 HCO3-26 AnGap-11\n\nIMAGING\n=======\n___ CXR:\nHeart size is top-normal. The mediastinal and hilar contours \nare unremarkable apart from minimal tortuosity of the thoracic \naorta and mild atherosclerotic calcifications at the aortic \nknob. The pulmonary vasculature is normal. Lung volumes are \nlow, but the lungs are clear. No pleural effusion or \npneumothorax is seen. There are no acute osseous abnormalities. \n \nIMPRESSION: Low lung volumes. No acute cardiopulmonary \nabnormality. \n\n \nBrief Hospital Course:\nThis is an ___ year old female with past medical history of \nasthma, GERD, recently diagnosed fungal laryngitis, admitted \n___ with acute asthma exacerbation, treated with steroids \nwith slow improvement, able to be discharged home on prednisone \ntaper with outpatient follow up.\n\n# Moderate persistent asthma with acute exacerbation\nPatient with PFTs with evidence of asthma but no obstructive \ndisease, also undergoing workup with ENT with recent \nlaryngoscopy showing fungal laryngitis, who presented with \nseveral days of increased wheezing. CXR reassuring no \npneumonia. She was treated with IV solumedrol 125MG in the ED \nand then transitioned to PO prednisone 60MG on admission with \nstanding and prn nebulizers, as well as her home asthma/allergy \nmedications. Unclear trigger for her symptoms. Over 72 hours \npatient slowly improved back to baseline, was able to ambulate \nwithout symptoms and peakflow returned to baseline (she reported \nbaseline as 300-350). Per discussion with outpatient \npulmonologist, discharged with prednisone taper and planned PCP, \n___, and ENT follow up for ongoing treatment and workup \nof \nher recurrent respiratory issues.\n\n# Fungal laryngitis \nRecently diagnosed by ENT 2 weeks ago, unclear how/if this may \nrelate to her chronic respiratory symptom burden. Continued on \nnystatin with plan for previously scheduled close ENT follow-up. \n \n\n#GERD: Continued home omeprazole and ranitidine\n#HTN: Continued home triamterene-HCTZ, amlodipine \n\nTRANSITIONAL ISSUES\n# Emergency contact: ___ (___) ___\n# Code: Full with limited trial of life sustaining measures \n\n> 30 minutes spent on discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze \n3. Montelukast 10 mg PO DAILY \n4. Omeprazole 20 mg PO BID \n5. ZyrTEC (cetirizine) 10 mg Oral qd \n6. Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral \nDAILY \n7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n8. amLODIPine 2.5 mg PO DAILY \n9. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze \n10. Calcium Carbonate 500 mg PO DAILY \n11. Vitamin D 1000 UNIT PO DAILY \n12. Fluticasone Propionate NASAL 1 SPRY NU BID \n13. Nystatin Oral Suspension 5 mL PO QID \n14. Azithromycin 250 mg PO 3X/WEEK (___) \n15. Ranitidine 150 mg PO BID \n\n \nDischarge Medications:\n1. PredniSONE 40 mg PO DAILY Duration: 2 Doses \nStart: Today - ___, First Dose: Next Routine Administration \nTime \nThis is dose # 1 of 3 tapered doses\nRX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*14 \nTablet Refills:*0 \n2. PredniSONE 20 mg PO DAILY Duration: 2 Doses \nStart: After 40 mg DAILY tapered dose \nThis is dose # 2 of 3 tapered doses \n3. PredniSONE 10 mg PO DAILY Duration: 2 Doses \nStart: After 20 mg DAILY tapered dose \nThis is dose # 3 of 3 tapered doses \n4. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze \n5. amLODIPine 2.5 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Azithromycin 250 mg PO 3X/WEEK (___) \n8. Calcium Carbonate 500 mg PO DAILY \n9. Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral \nDAILY \n10. Fluticasone Propionate NASAL 1 SPRY NU BID \n11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze \n12. Montelukast 10 mg PO DAILY \n13. Nystatin Oral Suspension 5 mL PO QID \n14. Omeprazole 20 mg PO BID \n15. Ranitidine 150 mg PO BID \n16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n17. Vitamin D 1000 UNIT PO DAILY \n18. ZyrTEC (cetirizine) 10 mg Oral qd \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY\n=======\nAsthma\n\nSECONDARY\n=========\nGastroesophageal Reflux Disease\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. ___, \nIt was a pleasure caring for you at ___ \n___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were wheezing and short of breath.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You got IV and oral steroids and nebulizer treatments to \nimprove your breathing.\n\n- You felt better and continued to have good oxygen levels \nwithout needing extra oxygen so you were discharged home.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- You should complete your prednisone taper and follow up with \nyour pulmonologist and ENT doctor regarding ongoing workup \nsurrounding your asthma and cough. \n\nWe wish you the best! \n\nSincerely, \n\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "J4541", "K219", "Z87891", "J040", "I10" ]

[ "J4541: Moderate persistent asthma with (acute) exacerbation", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "J040: Acute laryngitis", "I10: Essential (primary) hypertension" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Penicillins / fluconazole / \nStrawberry\n \nAttending: ___.\n \nChief Complaint:\ndyspnea\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with asthma and\nbronchiectasis who presents with dyspnea, cough, and weakness,\nadmitted for asthma exacerbation. \n\nPatient has been on Mass Health as her primary insurance. Over\nthe past ___ years, she has lost coverage at the beginning of the\nyear for various reasons and in the setting of being unable to\nafford and obtain her maintenance medications, she has had\ndecomepnsation of her respiratory status. She lost her insurance\nin ___, and between then and sometime in the last 3 weeks\nwhen she was able to get it back, she has been unable to obtain\nher long acting inhalers (initially Breo --> Symbicort). She has\nhad a number of ER visits to ___ due to respiratory\ndecompensation. In addition, she has been seen by Dr. ___\nprimary care physician and has been started on two courses of\nsteroids and antibiotics in the past month. Her most recent\ncourse was started on ___ with a course of 18 days of\nlevofloxacin and prednisone. \n\nPatient reported progressive dyspnea and weakness over the past\nfew days. Denies fevers or chills. She reports cough productive\nof clear sputum. Had musculoskeletal chest pain triggered by\ncough. She denies sick contacts. She does have a young grandson\nwho is pre-___ in the home. She came to the ED for\nevaluation. \n\nIn the ED, patient's vitals were as follows: T98.3, HR 81, RR \n21,\nBP 132/69, SpO2 100% on RA. CBC without leukocytosis. BMP wnl.\nBNP slightly elevated at 148. Flu PCR negative. She was given\nduoneb x 1, 80 mg methylpred, and 500 cc LR. She was admitted to\nmedicine for further work up and management. \n \n\nOn arrival to the floor, patient reports interval improvement\nwith ED interventions. Less coughing. Able to complete sentences\nnow. \n \nPast Medical History:\nAsthma: secondary to second-hand smoke\nHTN\nHypercholesterolemia (? reported in Atrius but denied by \npatient)\nGERD\nVertigo: had one episode one year ago, CT was negative, improved\nwith meclizine\nOsteoarthritis of knee \nDermatitis, eczematous \nMitral valve insufficiency \n\n \nSocial History:\n___\nFamily History:\nMother & maternal grandmother with stroke. Father\nand daughter with cancer. Grandmother with CAD/PVD.\n\n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVS - ___ 2207 Temp: 98.2 PO BP: 154/80 HR: 87 RR: 18 O2 \nsat:\n95% O2 delivery: RA \nGEN - NAD, speaking in hoarse voice but in complete sentences\nHEENT - NCAT\nNECK - supple, no LAD\nCV - rrr, no r/m/g\nRESP - diffuse expiratory wheezing with poor air movement\nABD - soft, nt/nd, +bs\nEXT - no edema\nSKIN - no rashes\nNEURO - alert and oriented x 3\n\nDischarge Physical Exam:\n========================\nVS: see Eflowsheets\nGEN - NAD, speaking in complete sentences\nHEENT - NCAT\nNECK - supple, no LAD\nCV - rrr, no r/m/g\nRESP - diffuse expiratory wheezing with good air movement\nABD - soft, nt/nd, +bs\nEXT - no edema\nSKIN - no rashes\nNEURO - alert and oriented x 3\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 01:40PM BLOOD WBC-9.3 RBC-4.76 Hgb-13.1 Hct-40.9 MCV-86 \nMCH-27.5 MCHC-32.0 RDW-15.6* RDWSD-48.2* Plt ___\n___ 01:40PM BLOOD Neuts-79.9* Lymphs-15.2* Monos-3.3* \nEos-0.2* Baso-0.2 Im ___ AbsNeut-7.45* AbsLymp-1.42 \nAbsMono-0.31 AbsEos-0.02* AbsBaso-0.02\n___ 01:40PM BLOOD Glucose-122* UreaN-25* Creat-0.9 Na-139 \nK-4.5 Cl-101 HCO3-29 AnGap-9*\n___ 05:26AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.2\n\nImaging:\n========\nCXR:\nNo acute cardiopulmonary process.\n\nCT Chest:\nVery mild bronchiectasis in the right lower lobe.\nResidual secretions are noted inside the subsegmental bronchi in \nthe left\nlower lobe.\n\nDischarge Labs:\n===============\n___ 06:15AM BLOOD WBC-16.0* RBC-4.46 Hgb-12.2 Hct-38.0 \nMCV-85 MCH-27.4 MCHC-32.1 RDW-15.7* RDWSD-48.6* Plt ___\n___ 06:15AM BLOOD Glucose-107* UreaN-25* Creat-0.8 Na-140 \nK-4.7 Cl-98 HCO3-29 AnGap-13\n___ 06:15AM BLOOD Calcium-9.6 Phos-3.8 Mg-2.___ year old woman with a history of asthma and bronchiectasis \nwho is here with exacerbation of respiratory issues.\n\n# Dyspnea:\nPresented with acute worsening of dyspnea. She has had multiple \nED visits recently for the same issue, thought to be due to \nasthma exacerbations.\nOn admission, CXR was negative for acute abnormalities. BNP was \nnormal.\nShe was noted to have a diffuse wheeze and was started on a \nsteroid course (prednisone 60mg, as she had been taking 10mg \ndaily at home as part of a taper).\nShe was seen by pulmonology, who felt that the diagnosis of \nasthma was questionable given the lack of obstruction on PFTs \n(see pulmonary note from ___ for full details).\nThey suspect that she may have vocal cord dysfunction. There may \nalso be an element of GERD/aspiration, and post-nasal drip \ncontributing to her symptoms, particularly since she reports \nthat her cough is worse at night.\nIn addition, pulmonary felt that there was a significant \ncomponent of anxiety contributing to her dyspnea, which patient \nacknowledged may be the case.\nShe also carries a diagnosis of bronchiectasis, but this was \nfound to be very mild on CT chest.\nShe was discharged on a rapid prednisone taper. She was \ncontinued on home Zyrtec, Montelukast, and flonase as well as \nsymbicort. Omeprazole was increased to BID.\n___, ANCA, and IgE sent per pulmonary recommendations and were \npending at time of discharge.\nPulmonary recommended outpatient ENT evaluation for vocal cord \ndysfunction, outpatient video swallowing study, and repeat \noutpatient PFTs. Patient reported that she would like to follow \nup with ___ pulmonary. An appointment was pending at time of \ndischarge.\n\n# Leukocytosis: developed leukocytosis to 16 with no fever or \ninfectious signs. Likely steroid effect\n\n# HTN : continued dyazide and amlodipine \n\n# GERD: continued omeprazole, which was increased to BID per \npulmonary recommendations\n\n> 30 minutes spent on discharge coordination and planning\n\nTransitional Issues:\n====================\n- discharged on rapid prednisone taper\n- omeprazole and flonase increased to BID\n- ___, ANCA, and IgE pending at time of discharge\n- pulmonology recommending outpatient ENT evaluation for vocal \ncord dysfunction, video swallow, and repeat PFTs\n- patient reported that she wanted to follow up with ___ \npulmonology. Appointment pending at time of discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Vitamin D 1000 UNIT PO DAILY \n3. Calcium Carbonate 500 mg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n5. ZyrTEC (cetirizine) 10 mg Oral qd \n6. Montelukast 10 mg PO DAILY \n7. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze \n8. Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral \nDAILY \n9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze \n10. amLODIPine 2.5 mg PO DAILY \n11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n12. LevoFLOXacin 750 mg PO Q24H \n13. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n\n \nDischarge Medications:\n1. PredniSONE 60 mg PO DAILY \nTapered dose - DOWN \nRX *prednisone 10 mg 6 tablet(s) by mouth once a day Disp #*32 \nTablet Refills:*0 \n2. Fluticasone Propionate NASAL 1 SPRY NU BID \nRX *fluticasone propionate 50 mcg/actuation 1 spry NAS twice a \nday Disp #*1 Bottle Refills:*0 \n3. Omeprazole 20 mg PO BID \nRX *omeprazole 20 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n4. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze \n5. amLODIPine 2.5 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Calcium Carbonate 500 mg PO DAILY \n8. Dyazide (triamterene-hydrochlorothiazid) 37.5-25 mg oral \nDAILY \n9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze \n10. Montelukast 10 mg PO DAILY \n11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n12. Vitamin D 1000 UNIT PO DAILY \n13. ZyrTEC (cetirizine) 10 mg Oral qd \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\nDyspnea\nGERD\nAsthma\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 in because your breathing was becoming worse. You were \nseen by the pulmonary doctors, who felt that there were several \ndifferent things contributing to your breathing problems. They \nrecommended increasing your omeprazole to twice a day. This \nmedication treats acid reflux and acid reflux can sometimes \ncause breathing issues.\n\nYou will also need to see an ear, nose and throat doctor as an \noutpatient and will need to have a video swallowing study.\n\nWe are sending you home on a prednisone taper:\n___: take 6 tabs (60mg)\n___: take 6 tabs (60mg)\n___: take 6 tabs (60mg)\n___: take 4 tabs (40mg)\n___: take 4 tabs (40 mg)\n___: take 2 tabs (20mg)\n___: take 2 tabs (20mg)\n___: take 1 tab (10mg)\n___: take 1 tab (10mg)\n___: stop prednisone\n\nIt was a pleasure taking care of you, and we are happy that \nyou're feeling better!\n \nFollowup Instructions:\n___\n" ]

[ "K219", "I10", "J479", "D72829", "R0600", "R531", "T380X5A", "Y92230", "Z87891", "Z7722" ]

[ "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "J479: Bronchiectasis, uncomplicated", "D72829: Elevated white blood cell count, unspecified", "R0600: Dyspnea, unspecified", "R531: Weakness", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z87891: Personal history of nicotine dependence", "Z7722: Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)" ]

[ "K219", "I10", "Y92230", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nMagnesium Citrate / Shellfish Derived\n \nAttending: ___\n \nChief Complaint:\nRight knee pain\n \nMajor Surgical or Invasive Procedure:\n___: Right total knee replacement\n\n \nHistory of Present Illness:\n___ healthy female with right knee OA presenting for total knee \nreplacement.\n \nPast Medical History:\ncongenital hip dysplasia, scoliosis, ocular migraines\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Incision healing well with staples \n* Scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n \nPertinent Results:\n___ 07:25AM BLOOD WBC-5.2 RBC-3.20* Hgb-10.0* Hct-30.6* \nMCV-96 MCH-31.3 MCHC-32.7 RDW-13.2 RDWSD-46.2 Plt ___\n___ 07:45AM BLOOD WBC-6.4 RBC-3.36* Hgb-10.2* Hct-32.2* \nMCV-96 MCH-30.4 MCHC-31.7* RDW-13.2 RDWSD-46.5* Plt ___\n___ 07:30AM BLOOD WBC-7.4# RBC-3.57* Hgb-10.9* Hct-33.6* \nMCV-94 MCH-30.5 MCHC-32.4 RDW-13.2 RDWSD-45.5 Plt ___\n___ 07:25AM BLOOD Plt ___\n___ 07:45AM BLOOD Plt ___\n___ 07:30AM BLOOD Plt ___\n___ 07:30AM BLOOD Glucose-108* UreaN-15 Creat-0.6 Na-136 \nK-3.9 Cl-100 HCO3-27 AnGap-13\n___ 07:30AM BLOOD estGFR-Using this\n___ 07:30AM BLOOD\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:\nOn postop day #2 the patient complained of uncontrolled pain. A \nbrief course of toradol was added with adequate improvement. \n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Lovenox for DVT \nprophylaxis starting on the morning of POD#1. The patient was \nunable to void post-operatively. She had to be straight cath'ed \nx1. The patient was able to void after being straight cath'ed \nx1. The surgical dressing was changed and the Silverlon dressing \nwas removed on POD#2. The surgical incision was found to be \nclean and intact without erythema or abnormal drainage. 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 wound was benign\n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity. Please use walker or 2 \ncrutches at all times for 6 weeks.\n \nMs. ___ is discharged to home with services in stable \ncondition.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ibuprofen 600 mg PO BID:PRN Pain - Mild \n2. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp \n#*100 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp \n#*60 Tablet Refills:*0 \n3. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: First Routine Administration Time \nRX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe \nRefills:*0 \n4. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp \n#*60 Tablet Refills:*0 \n5. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \nRX *tramadol 50 mg 1 tablet by mouth every ___ hours Disp #*60 \nTablet Refills:*0 \n6. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n7. HELD- Ibuprofen 600 mg PO BID:PRN Pain - Mild This \nmedication was held. Do not restart Ibuprofen until cleared by \nsurgeon to resume NSAIDs\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight knee osteoarthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc).\n \n8. ANTICOAGULATION: Please continue your Lovenox for four (4) \nweeks to help prevent deep vein thrombosis (blood clots). If \nyou were taking aspirin prior to your surgery, it is OK to \ncontinue at your previous dose while taking anticoagulation \nmedication. ___ STOCKINGS x 6 WEEKS.\n \n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed by at follow-up \nappointment approximately two weeks after surgery.\n\n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks, and staple removal at two weeks after \nsurgery.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Two crutches or walker at all times for 6 weeks. \nMobilize. ROM as tolerated. No strenuous exercise or heavy \nlifting until follow up appointment. \nPhysical Therapy:\nWeight bearing as tolerated right lower extremity\nNo range of motion restrictions\nMobilize frequently\nambulate with assistive device (2 crutches or walker) x 6 weeks\nTreatments Frequency:\n- wound checks for erythema/drainage\n- dry dressing changes as needed\n- staples to be removed at first ___ clinic visit\n- Lovenox teaching\n\n \nFollowup Instructions:\n___\n" ]

[ "M179", "M419", "E669", "Z6833", "G43B0", "K589", "L719", "Q6589", "G4700", "Z87891" ]

[ "M179: Osteoarthritis of knee, unspecified", "M419: Scoliosis, unspecified", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "G43B0: Ophthalmoplegic migraine, not intractable", "K589: Irritable bowel syndrome without diarrhea", "L719: Rosacea, unspecified", "Q6589: Other specified congenital deformities of hip", "G4700: Insomnia, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "E669", "G4700", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLipitor / Penicillins / Claritin / Statins-Hmg-Coa Reductase \nInhibitors\n \nAttending: ___\n \nChief Complaint:\nDVT/Renal failure\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with PMH of NASH vs cryptogenic cirrhosis, HTN, \nhyperlipidemia, hypothyroidism who presents from ___ \n___ with DVT and renal failure.\n\nHistory obtained from wife and daughter over phone, OSH records, \nand nephrology consult note. The patient's health has \nprogressively declined since ___. He has been hospitalized \nmultiple times since then. He has been bouncing back between \nhospitalization and rehab, at home for only a couple weeks. Most \nrecently at ___ for confusion. He was discharged \nlast ___ and per his wife, his mental status was \nsignificantly improved. He first noted leg pain on ___ and his \nwife encouraged pt to be evaluated. At OSH, VS: P 77, RR 16, BP \n76-103/55-67, 96% on RA. Labs there significant for Na 132, K \n3.6, Cl 92, HCO3 17, BUN 91, Cr 8.9, Glu 104, AST 38, ALT 27, AP \n164, lipase 133, TB 1.4, Alb 3.1, INR 1.4. \n\nPt was transferred to ___ for further management of DVT and \nrenal failure. \n\nIn the ED, initial vitals were T98.5, HR 75, BP 94/58, RR 18, O2 \n97% on RA. He denies chest pain, dyspnea, lightheadedness, \nabdominal pain, nausea, vomiting.\n- Labs showed Na 135, K 3.2, Cl 95, HCO3 14, BUN 97, Cr 9.1, Ca \n8.9, Mg 2.8, Phos 9.5; ALT 33, AST 42, AP 163, Lip 143, Alb 3.1; \nWBC 6.5, Hgb .8, HCT 26.2, Plt 154; Lactate 3.2 improved to 2.3 \n\n- Peritoneal Fluid: WBC 41, (11% polys, 78% macroph), RBC 3825 \n CXR ___ \n- CXR showed low lung volumes \n- Abd US showed cirrhotic liver with splenomegaly and large \nvolume ascites, no hydronephrosis \n- B/l ___: extensive RLE venous thrombosis \nPatient was treated with heparin 5300U, albumin 5%, lorazepam \n0.5mg \n\nRenal consulted and spun urine with no evidence of muddy brown \ncasts. Recommended expansion with albumin. \nHepatology consult- start heparin ggt and admit to liver \nservice. \n\nOn the floor, the patient reports no specific complaints. States \nhis belly has been distended for years. No pain. Appears to be \nslightly confused, but can tell me his wife and daughter will \nknow more about his medical care. \n\nDaughter ___ called and notified of patients admission and \ncurrent severity of illness with chronic liver failure and acute \nkidney failure. Described we need to obtain further records. \n\nROS: \nAs per HPI all other ROS negative\n \nPast Medical History:\n___ Cirrhosis \nHyperlipidemia \nHypertension \nGERD \nAllergic Rhinitis \nHypothyroidism \nHiatal Hernia \nOsteopenia \nCarpal Tunnel Syndrome \nArthritis \nDental disease \nVision Loss \nChronic Kidney Disease\nPAST SURGICAL HISTORY: \nAppendectomy \nHernia repair \nColonoscopy ___ \nHydrocelectomy, scrotal approach (left) ___ \nEGD ___ \nEGD ___ \n\n \nSocial History:\n___\nFamily History:\nnon-contributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: 97.6 94/57 88 17 97%RA\nGEN: alert, lying in bed, thin, ill appearing malnourished with \ntemporal wasting\nHEENT: dry MM, anicteric sclera, no conjunctival pallor \nNECK: Supple \nPULM: Clear, no wheeze, rales, or rhonchi \nCOR: RRR, normal S1/S2, no murmurs \nABD: tense, distended abdomen, fluid wave, umbilical hernia with \nfluid, reproducible, no rebound or guarding, difficult to \npalpate livers edge given ascities\nEXTREM: Warm, 3+ edema in right lower extremity, no edema in \nleft lower extremity\nNEURO: AOx2-3, + asterixis on exam \n\nDISCHARGE PHYSICAL EXAM:\nVS: 97.8 111/71 86 24 98% shovel mask\nGEN: opening eyes but not speaking, lying in bed, thin, ill \nappearing malnourished\nHEENT: dry MM\nPULM: upper airway sounds\nCOR: RRR, normal S1/S2, no murmurs \nABD: tense, distended abdomen, fluid wave, umbilical hernia with \nfluid, reproducible\nEXTREM: Warm, 1+ edema in right lower extremity, no edema in \nleft lower extremity\nNEURO: AOx0, opening eyes , not following commands\n\n \nPertinent Results:\nADMISSION LABS\n===============\n___ 01:15AM BLOOD WBC-6.6 RBC-3.34* Hgb-9.0* Hct-28.1* \nMCV-84 MCH-26.9 MCHC-32.0 RDW-22.2* RDWSD-66.1* Plt ___\n___ 01:15AM BLOOD Neuts-64.1 Lymphs-15.3* Monos-14.7* \nEos-4.3 Baso-1.1* Im ___ AbsNeut-4.22 AbsLymp-1.01* \nAbsMono-0.97* AbsEos-0.28 AbsBaso-0.07\n___ 01:15AM BLOOD ___ PTT-33.6 ___\n___ 01:15AM BLOOD Glucose-99 UreaN-97* Creat-9.1* Na-135 \nK-3.2* Cl-95* HCO3-14* AnGap-29*\n___ 01:15AM BLOOD ALT-33 AST-42* AlkPhos-163* TotBili-1.1\n___ 01:15AM BLOOD Lipase-143*\n___ 01:15AM BLOOD Albumin-3.1* Calcium-8.9 Phos-9.5* \nMg-2.8*\n___ 01:26AM BLOOD Lactate-3.3*\n___ 12:10AM ASCITES WBC-41* RBC-3825* Polys-11* Lymphs-9* \nMonos-1* Eos-1* Macroph-78*\n___ 12:10AM ASCITES TotPro-0.6 Glucose-129\n\nPERTINENT LABS\n=================\n\n___ 06:47AM BLOOD WBC-4.5 RBC-2.68* Hgb-7.2* Hct-21.5* \nMCV-80* MCH-26.9 MCHC-33.5 RDW-21.3* RDWSD-61.6* Plt ___\n___ 10:28AM BLOOD ___ PTT-57.4* ___\n___ 06:47AM BLOOD Glucose-83 UreaN-110* Creat-10.4*# Na-134 \nK-3.3 Cl-97 HCO3-12* AnGap-28*\n___ 06:47AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE\n___ 06:47AM BLOOD ___\n___ 08:43AM BLOOD Lactate-2.3*\n___ 03:06PM URINE Color-Red Appear-Hazy Sp ___\n___ 03:06PM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-TR\n___ 03:06PM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-1 \nTransE-<1\n___ 03:06PM URINE CastHy-24*\n___ 03:06PM URINE Mucous-RARE\n___ 03:06PM URINE Hours-RANDOM Creat-227 Na-LESS THAN K-20 \nCl-26\n___ 03:06PM URINE Osmolal-324\n\nDISCHARGE LABS\n================\n___ 06:41AM BLOOD WBC-5.5 RBC-2.92* Hgb-7.7* Hct-23.3* \nMCV-80* MCH-26.4 MCHC-33.0 RDW-21.6* RDWSD-61.9* Plt ___\n___ 06:47AM BLOOD Neuts-59.6 Lymphs-17.9* Monos-16.5* \nEos-4.0 Baso-1.6* Im ___ AbsNeut-2.67 AbsLymp-0.80* \nAbsMono-0.74 AbsEos-0.18 AbsBaso-0.07\n___ 06:41AM BLOOD ___ PTT-40.0* ___\n___ 06:41AM BLOOD Glucose-107* UreaN-121* Creat-11.2* \nNa-137 K-3.0* Cl-99 HCO3-12* AnGap-29*\n\nIMAGING\n=================\n\n___ (PA & LAT)\nFINDINGS: \nLung volumes are low. The cardiac silhouette is unremarkable. \nThe pulmonary\nvasculature is normal. There is no pleural effusion or \npneumothorax. No\nfocal consolidation is identified.\n \nIMPRESSION: \n\nNo acute intrathoracic abnormality. Specifically, no evidence \nof edema.\n\n___ US (COMPLETE ST\n\nFINDINGS: \n \nLIVER: The hepatic parenchyma is heterogeneous. The contour of \nthe liver is\nnodular. There is no focal liver mass. The main portal vein is \npatent with\nhepatopetal flow. There is large volume ascites.\n \nBILE DUCTS: There is no intrahepatic biliary dilation. The CBD \nmeasures 4 mm.\n \nGALLBLADDER: The gallbladder is collapsed and contain a large \namount of\nsludge.\n \nPANCREAS: Imaged portion of the pancreas appears within normal \nlimits, without\nmasses or pancreatic ductal dilation, with portions of the \npancreatic tail\nobscured by overlying bowel gas.\n \nSPLEEN: Normal echogenicity, measuring 13 cm.\n \nKIDNEYS: The right kidney measures 10.7 cm. The left kidney \nmeasures 10.6 cm.\nNormal cortical echogenicity and corticomedullary \ndifferentiation is seen\nbilaterally. There is no evidence of masses, stones, or \nhydronephrosis in the\nkidneys.\n \nRETROPERITONEUM: Visualized portions of aorta and IVC are within \nnormal\nlimits.\n \nIMPRESSION: \n \n1. Cirrhotic liver with splenomegaly and large volume ascites. \nPortal vein\nis patent.\n2. No evidence of hydronephrosis.\n \n\n___ LOWER EXT VEINS\n\nFINDINGS: \n \nThere is normal compressibility, flow, and augmentation of the \nleft common\nfemoral, femoral, and popliteal veins. Normal color flow and \ncompressibility\nare demonstrated in the left posterior tibial and peroneal \nveins. On the\nright, there is normal compressibility and flow in the common \nfemoral vein. \nHowever, extensive, occlusive thrombus is seen extending from \nthe right calf\nveins into the right popliteal vein and the right femoral vein.\n \nThere is normal respiratory variation in the common femoral \nveins bilaterally.\n \nNo evidence of medial popliteal fossa (___) cyst.\n \nIMPRESSION: \n \nExtensive right lower extremity venous thrombosis extending from \nthe right\ncalf veins into the popliteal vein and femoral vein. No left \nlower extremity\ndeep venous thrombus.\n \n\nMICRO\n=============\nClose\n___ 3:06 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\n___ 1:15 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n___ 12:10 am PERITONEAL FLUID PERITONEAL FLUID. \n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Preliminary): NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n \nBrief Hospital Course:\n___ year old man with with PMH of cirrhosis, HTN, hyperlipidemia, \nhypothyroidism who presents from ___ with DVT and \nrenal failure. Per the patients family the patient's health has \nprogressively declined since ___. He has been hospitalized \nmultiple times since then. Most recently admitted to ___ \n___ for confusion. The patient reported leg pain on ___ at \nhome and his wife encouraged pt to be evaluated. At the outside \nhospital he was noted to have BUN 91, Cr 8.9. He was transferred \nto ___ ED for a further level of care. Patient had right lower \nextremity swelling and had ultrasound that showed DVT. Patient \nwas initially started on heparin ggt. He had a diagnostic \nparacentesis that was negative for SBP.\n\n___ with PMH of NASH vs cryptogenic cirrhosis, HTN, \nhyperlipidemia, hypothyroidism who presents from ___ \n___ with DVT and renal failure to Creatinine of 9. \n\n#Acute on Chronic Kidney Injury - patient presents with Cr of \n9.1. Review of records show Cr of 5 on ___. He had a Cr of 3 \nback in ___. Likely has component of acute injury \nalthough it was unclear why. Abdominal ultrasound showed no \nevidence of hydronephrosis. Patient was admitted for further \nwork up. Renal was consulted and analyzed urine sediment that \nshowed no evidence of ATN. Outside hospital records were \nobtained and it was noted that the patient had been having \nworsening renal failure for months. His Cr 1 week prior to \nadmission had been approx 5. He was treated for hepatorenal \nsyndrome and fluid challenged with albumin and given octreotide \nand midodrine. The patients urine output was minimal. Ongoing \ndiscussion with the family, it was made clear that invasive \nprocedures would not be in the patients interest. Given the \npatient was persistently hypotensive it was unlikely that he \nwould tolerate hemodialysis well. Also given his malnutrition \nand severe illness evaluating for liver transplant would be \ndifficult. Decision was made to pursue hospice care. Patient was \nenrolled in hospice and discharged home as per family wishes. \n\n# Cirrhosis: Patient with ascities, varicies and hx of SBP. \nChilds C. MELD Na 23. Per report of records NASH vs cryptogenic. \nUnclear how much this has been worked up. ___, AMA were \nnegative. Patient acutely ill and malnourished with severe \ntemporal wasting. Unclear if he would've been a candidate for \nliver transplant. Patient had a diagnostic paracentesis that was \nnegative for SBP. \n\n# Lower extremity DVT: likely coaguloapthic in setting of liver \ndisease. The patient reported leg pain on ___ at home and his \nwife encouraged pt to be evaluated.He was transferred to ___ \nED for a further level of care. Patient had right lower \nextremity swelling and had ultrasound that showed DVT. Patient \nwas initially started on heparin ggt. It was discontinued when \nthe patient had a dropping H/H ___ to concern for possible GI \nbleed. \n\n# Encephalopathy: Patient was continued on lactulose and \nrifaximin. Initially he was AO2-3 with asterixsis. This worsened \nas his uremia and kidney injury worsened. Patient had no \nevidence of infection on work up. Decision was made to stop \nmedications ___ to concern for aspiration and he was enrolled in \nhospice. \n\n#Goals of care- Discussion with family that patients preference \nis to be comfortable and not have too many invasive \ninterventions. Wife would like to get him home on hospice. \nFamily agreeable that resuscitation would be harmful/painful to \npatient. Agree to DNR/DNI. Given patient would not tolerate \ndialysis the decision was made to enroll patient into hospice \ncare. Wife and daughter would like patient to make it home. He \nwas discharge home with hospice.\n\nTRANSITIONAL ISSUES\n==============\n- patient enrolled in hospice care and discharged home\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Cyanocobalamin 500 mcg PO DAILY \n2. Lactulose 15 mL PO Frequency is Unknown \n3. Omeprazole 20 mg PO DAILY \n4. Levothyroxine Sodium 150 mcg PO DAILY \n5. Thiamine 100 mg PO DAILY \n6. Gabapentin 100 mg PO Frequency is Unknown \n7. cetirizine 10 mg oral DAILY \n8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n9. Rifaximin 550 mg PO Frequency is Unknown \n10. OxycoDONE (Immediate Release) 5 mg PO Frequency is Unknown \n11. Multivitamins 1 TAB PO DAILY \n12. Lorazepam 0.5 mg PO Frequency is Unknown \n13. Albuterol Inhaler Dose is Unknown IH Frequency is Unknown \n14. nadolol 20 mg oral unknown \n\n \nDischarge Medications:\n1. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain \nRX *hydromorphone 2 mg ___ tablet(s) by mouth every 3 hours Disp \n#*15 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: Acute Kidney Failure, Deep Vein Thrombosis\nSECONDARY DIAGNOSIS: Cirrhosis, Hepatic Encephalopathy, Ascities \n\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic and not arousable.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at the ___ \n___. You were transferred to our hospital \nfor a deep vein thrombosis (clot in your leg) and renal failure. \nYou were seen by our renal doctors and liver ___ to \nyour severe renal failure, liver disease and low blood pressures \nit was determined that you would not be a good candidate for \ndialysis. Decision was made to enroll you in hospice care. You \nwere discharged home with hospice. \n\nSincerely,\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I824Z1", "E43", "N179", "R188", "I8500", "K7581", "K7290", "R64", "E785", "E039", "M8580", "K219", "I129", "N189", "Z66" ]

[ "I824Z1: Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity", "E43: Unspecified severe protein-calorie malnutrition", "N179: Acute kidney failure, unspecified", "R188: Other ascites", "I8500: Esophageal varices without bleeding", "K7581: Nonalcoholic steatohepatitis (NASH)", "K7290: Hepatic failure, unspecified without coma", "R64: Cachexia", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "M8580: Other specified disorders of bone density and structure, unspecified site", "K219: Gastro-esophageal reflux disease without esophagitis", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z66: Do not resuscitate" ]

[ "N179", "E785", "E039", "K219", "I129", "N189", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nVancocin / Zosyn / ceftriaxone / Meropenem / Tigecycline / \namoxicillin-pot clavulanate / Gentamicin\n \nAttending: ___\n \nChief Complaint:\nknee pain\n \nMajor Surgical or Invasive Procedure:\nORIF, washout, debridement \n\n \nHistory of Present Illness:\n___ with PMH of ___ year old man with a history of severe aortic \ninsufficiency with left ventricular dilatation s/p Bentall with \nCABGx3 on ___, b/l TKA with R chronic knee infection on \nmoxifloxacin and fluconazole who presents with acute onset R \nknee pain. \n\nPatient started feeling knee pain overnight on ___. Patient was \nwoken up in the middle of the night by the pain. Pain was ___. \nTried to get up out of bed, but was unable to get out of bed or \nput weight on it. Noticed joint swelling. Pain is worse today. \nHurts when moves or puts weight on it. No other joints joints. \nNo fevers, chills, shortness of breath. No fevers, chills, SOB. \nNo dysuria, hematuria. Feels pain and numbness. \n\nIn review of recent surgical history, patient had TURP on ___ \nthat was uneventful. He also states that he had a dental \nprocedure in the last month for replacement of his dentures. He \nwas given prophylactic antibiotics prior to the procedure. \n\nIn review of his R chronic knee infection: \nHe received his initial knee replacement in ___, but \ndeveloped acutely septic right TKA later in the month. In the \nnext few months, knee cultures grew proteus and staph species; \nhe was treated with several operations including a liner \nexchange. He was eventually revised to remove his entire \nprosthesis in ___, at which time a GMRS prothesis was placed. \nHe was last admitted to ___ on ___ and received 8 \nstaged irrigation and debridements with VAC changes and eventual \nuse of an antibiotic spacer before final reconstruction on ___. \nEarly cultures of his wound from ___ grew E. coli, \nEnterococcus sp., Bacteroides, and ___ parapsilosis. \nHowever, later wound cultures and gram stains from ___ \nwere negative. After his latest reconstruction with rectus free \nflap and skin graft on ___, he was maintained on \npiperacillin-tazobactam and rifampin. \n\nIn the ED, initial vitals were: T 98.6 HR 94 BP 116/67 16 100% \nRA \n\nExam notable for R knee warmth and tenderness to palpation. \nSwelling difficult to assess given post-operative anatomy. ROM \nlimited due to pain. Sensation intact bilaterally. Statis \ndermatitis changes present b/l. \n Labs notable for WBC 16, Cr 1.6 (bl 1.0), CRP 101 (last 52 in \n___ \n Imaging notable for \n -Renal u/s w no hydronephrosis \n -R knee XR: hardware loosening of the tibial component that is \nchronic but increased posterior and varus angulation. Extensive \noverlying soft tissue swelling, no definite superimposed osseous \nfracture. \n\nOrtho was consulted and recommended: admit for pain control, ___ \nconsult, continue suppressive abx, follow up in clinmic w Dr. \n___ week. Recommend further w/u of elevated Cr and WBC. \n\nPatient was given: 1g Tylenol, 2L IVF, 5 mg po oxycodone \n \nDecision was made to admit for ___ and leukocytosis \nVitals prior to transfer: \nT 98.6 BP 139/75 RR 16 100% RA \nOn the floor, pt reports feeling chills and minimal pain in R \nknee \n \nPast Medical History:\nPMH:\nHTN, Glaucoma, \nb/l TKA ___ and ___ L TKA c/b\npolymicrobial infection - currently on suppressive\nMoxifloxacin/Fluconazole\n\nPSxH:\n-___ - Bentall Procedure with 27 mm Medetronic root valve \n\nand coronary artery bypass grafting x 3 (Ao valve, root, ascAo \ngraft replacement with coronary artery reimplantation onto \ngraft): left internal mammary \nartery to left anterior descending artery; saphenous vein graft \nto obtuse marginal branch; saphenous vein graft to \nposterolateral branch\n-___ - Bilateral laminectomy L1-L5 with proximal \nforaminotomies \n-b/l TKA ___ and ___\n \nSocial History:\n___\nFamily History:\nThere is no family history of strokes or significant heart \ndisease per patient \n \nPhysical Exam:\nDischarge Physical Exam:\n========================\nVital Signs: afeb 120/64 69 18 98% RA \nGeneral: Alert, oriented, NAD \nHEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated \nCV: RRR, I/VI systolic murmur best at LSB, normal S1 + S2, + \nsternotomy \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding . Abdominal scar noted \nGU: No foley \nExt: multiple scars, brace, staples C/D/I, wound imtact\nNeuro: CNII-XII intact, ___ strength upper/lower extremities ___ \nlimited by pain). 1+ DPs bilaterally \n\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 01:25PM BLOOD WBC-16.5*# RBC-4.66 Hgb-10.3* Hct-35.4* \nMCV-76* MCH-22.1* MCHC-29.1* RDW-17.3* RDWSD-47.8* Plt ___\n___ 05:15AM BLOOD ___\n___ 01:25PM BLOOD Glucose-128* UreaN-23* Creat-1.6* Na-136 \nK-4.3 Cl-99 HCO3-23 AnGap-18\n___ 05:15AM BLOOD ALT-21 AST-21 LD(LDH)-188 AlkPhos-80 \nTotBili-0.4\n___ 10:45AM BLOOD CK(CPK)-143\n___ 05:15AM BLOOD Albumin-3.5 Calcium-8.5 Phos-3.0 Mg-1.8\n___ 01:25PM BLOOD CRP-101.1*\n___ 05:15AM BLOOD CRP-261.3*\n___ 01:25PM BLOOD Lactate-1.9\n\nDischarge labs:\n++++++++++++++++++\n___ 05:50AM BLOOD WBC-10.0 RBC-2.91* Hgb-7.7* Hct-24.0* \nMCV-83 MCH-26.5 MCHC-32.1 RDW-18.0* RDWSD-54.4* Plt ___\n___ 05:24AM BLOOD UreaN-15 Creat-1.2 Na-135 K-3.9 Cl-103 \nHCO3-24 AnGap-12\n___ 05:24AM BLOOD CK(CPK)-262\n___ 06:40AM BLOOD Phos-3.4 Mg-1.9\n___ 05:49AM BLOOD CRP-278.2*\n\nImaging:\n========\n___ Xray Knee:\nHardware loosening of the tibial component was also present in \n___ but there is increased posterior and varus angulation. \nExtensive overlying soft tissue swelling. No definite \nsuperimposed osseous fracture.\n\n___ Renal US:\n1. No hydronephrosis. \n2. Debris in the bladder, and possible 4 mm bladder stone. \n3. Postvoid bladder volume measured 429 cc. \n\n___ CXR:\nNo radiographic evidence of acute cardiopulmonary disease.\n\nMicrobiology:\n=============\n___ 1:25 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. \n BETA LACTAMASE NEGATIVE. \n HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml \nof\n gentamicin. Screen predicts NO synergy with penicillins \nor\n vancomycin. Consult ID for treatment options. \n HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to \n1000mcg/ml of\n streptomycin. Screen predicts possible synergy with \nselected\n penicillins or vancomycin. Consult ID for details.. \n Daptomycin MIC: 0.50 MCG/ML (SENSITIVE). \n Daptomycin Sensitivity testing performed by Etest. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS FAECALIS\n | \nAMPICILLIN------------ <=2 S\nDAPTOMYCIN------------ S\nPENICILLIN G---------- 2 S\nVANCOMYCIN------------ 1 S\n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN PAIRS AND CHAINS. \n Reported to and read back by ___ ___, @08:10 ON \n___. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN PAIRS AND CHAINS. \n\n \nBrief Hospital Course:\n___ yo man with complicated PMH including AI/CAD s/p CABG, h/o \nbilateral TKAs c/b infection on chronic suppressive antibiotics \nwho presented with R knee pain and ___, found to have high grade \nenterococcal bacteremia and septic arthritis. \n\n# R knee pain s/p TKR, and h/o R knee prosthetic joint \ninfection: presented with acute knee pain with a warm and red \njoint. CRP was > 200. He was also found to have high grade \nenterococcal bacteremia. He was started on daptomycin given \nmultiple antibiotic allergies and continued on chronic \nsuppressive antibiotics (levofloxacin rather than moxifloxacin, \nthen back to moxifloxacin on recommendation of ID team due to \nbetter coverage of his previously grown bacteroides). He \nunderwent ___ guided arthrocentesis on ___ which was \nsignificant for WBC count of 12,000 (on antibiotic therapy X 2 \ndays) with 90% PMNs. Culture later grew enterococcus. He was \nevaluated by orthopedic surgery, who recommended placement of an \nantibiotic spacer. This was placed on ___, with repeat I&D and \nORIF ___. Intra op cultures grew enterococcus as well. \n\nFinal ID regimen.\n\"Now that the prosthesis is explanted, our plan is to treat with \n6\nweeks for all bacteria previously found in the knee, inc dapto\n~6mg/kg for VSE (but pcn allergic) BSI & septic arthritis s/p\nexplantation, fluc for ___, and moxifloxacin for GNR &\nanaerobes. This was intended as curative, \"mop up\" therapy.\nConsideration for d/c abx if no concern persistent infxn at the\nend of the course. We also Rx'd treating 14days Bactrim for new \nE coli in urine\nculture, esp as pt had recent TURP.\"\n\nFinal ortho plan to be discussed at follow-up. Please do not \nremove sutures until follow-up as wound closure was tenuous. \nDaily dressing changes by RN. \n\nLong term plan unclear. Hope is that if infection is effectively \ncleared than there is a possibility of a new knee implant. \nHowever, given the long term nature of the infection, loss of \nviable bone, that eventually he may need an above the knee \namputation.\n\n# blood loss anemia: had 1L blood loss after procedure on ___, \nrequiring 3U PRBCs, IVF, FFP. Remained intubated \nprophylactically and admitted to ICU, but did quite well and was \nquickly extubated and returned to medical floor. He then had a \nvery slow drop in hgb through ___. There was a \nreticulocytosis, but insufficient. We attributed this to blood \ndraws and anemia of chronic disease (infection). We transfused 1 \nuni on ___ without incident.\n\n# Bacteremia: blood cultures from ___ and ___ positive for \nenterococcus. He remained hemodynamically stable without signs \nof shock. He was started on daptomycin. Given his history of \naortic valve replacement there was high suspicion for \nendocarditis. As above he was also found to have septic \narthritis. TTE and TEE both unrevealing for endocarditis. \nantibiotics as above.\n\n# femur fracture: noted post op, Went for ORIF ___ \n\n# UTI: UA with pyuria, urine culture grew E. coli. Per ID \nguidance he was started on nitrofurantoin BID given his multiple \nantibiotic allergies, but when ___ was resolved this was \nswitched to Bactrim for planned prolonged course.\n\n# ___: mild ___ on admission, resolved with IVF. Likely \npre-renal. \n\nCHRONIC ISSUES \n#CAD/AI s/p CABG, Bentall procedure (___): continued \nmetoprolol, asa 81 (these were held briefly after blood loss) \nbut restarted. \n\n#HTN: held home lisinopril 5 mg in s/o ongoing infection and \nlower bp.\n\n#BPH s/p TURP ___: pt recently passed voiding trial in ___ \nat outpatient urology follow up. Patient reports no longer \ntaking tamsulosin at home.\n\n# Multiple drug allergies: patient has previously seen allergy \nbut no plans for desensitization per patient/daughter. Would \nconsider going forward.\n\nTransitional Issues:\n- may benefit from antibiotic desensitization\n- Bactrim through ___ for complex UTI\n- please follow Hgb, he refused a transfusion on ___ because \nof slow drift down in hgb which we are attributing to frequent \nblood draws and anemia of chronic disease. \n- Outpatient labs weekly\n- please keep sutures in until f/u ortho appointment. closure \nwas tenuous.\n- Blood pressure meds were decreased or dropped during \nhospitalization. If BP rises at rehab, can re-add lisinopril 5mg \nand increase metoprolol to 150 total. \n- we have continued LMWH to prevent DVT given his relative \nimmobility and the explant of knee. would recommend until \ncompletion of antibiotics though usual course is 3 weeks\n- he can return to his home if there is sufficient social \nsupport. his goal is to be able to transfer to wheelchair to \ncommode to bed. ___, his daughter, is involved in care and \nmay move in with him at discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fluconazole 100 mg PO Q24H \n2. Metoprolol Tartrate 50 mg PO TID \n3. Pravastatin 20 mg PO QPM \n4. Docusate Sodium 100 mg PO BID \n5. Aspirin 81 mg PO DAILY \n6. Lisinopril 5 mg PO DAILY \n7. Moxifloxacin 400 mg Other DAILY \n8. Lumigan (bimatoprost) 0.01 % ophthalmic QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nprosthetic joint infection\nbacteremia\nacute kidney injury\nurinary tract infection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___,\nIt was a pleasure caring for you. You were admitted because you \nhad a fever, which we believe was caused by bacteria in your \nknee and blood. This got better with antibiotics and the removal \nof your prosthetic joint. You also got blood after your \noperation because of how much you lost as well as another \ntransfusion when your blood count was low. You received fluids \nfor a mild kidney injury which has resolved. \n \nFollowup Instructions:\n___\n" ]

[ "T8453XA", "S72301A", "A4181", "N179", "N390", "M00861", "D62", "I9742", "Y792", "Z951", "I10", "Y92009", "B9620", "Z96653", "Y831", "N401", "R338", "D638" ]

[ "T8453XA: Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter", "S72301A: Unspecified fracture of shaft of right femur, initial encounter for closed fracture", "A4181: Sepsis due to Enterococcus", "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "M00861: Arthritis due to other bacteria, right knee", "D62: Acute posthemorrhagic anemia", "I9742: Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating other procedure", "Y792: Prosthetic and other implants, materials and accessory orthopedic devices associated with adverse incidents", "Z951: Presence of aortocoronary bypass graft", "I10: Essential (primary) hypertension", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z96653: Presence of artificial knee joint, bilateral", "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", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "D638: Anemia in other chronic diseases classified elsewhere" ]

[ "N179", "N390", "D62", "Z951", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nVancocin / Zosyn / ceftriaxone / Meropenem / Tigecycline / \namoxicillin-pot clavulanate / Gentamicin\n \nAttending: ___.\n \nChief Complaint:\nRight knee periprostethic joint infection \n \nMajor Surgical or Invasive Procedure:\nRight complex revision total knee arthroplasty ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old male w/ history of bilateral TKA \nwith complex history of right periprostethic joint infection now \ns/p R revision TKA. \n \nPast Medical History:\nPMH:\nHTN, Glaucoma, b/l TKA ___ and ___ L TKA c/b polymicrobial \ninfection - currently on suppressive Moxifloxacin/Fluconazole\n\nPSxH:\n-___ - Bentall Procedure with 27 mm Medetronic root valve \n\nand coronary artery bypass grafting x 3 (Ao valve, root, ascAo \ngraft replacement with coronary artery reimplantation onto \ngraft): left internal mammary artery to left anterior descending \nartery; saphenous vein graft to obtuse marginal branch; \nsaphenous vein graft to posterolateral branch\n-___ - Bilateral laminectomy L1-L5 with proximal \nforaminotomies \n-b/l TKA ___ and ___\n \nSocial History:\n___\nFamily History:\nThere is no family history of strokes or significant heart \ndisease per patient \n \nPhysical Exam:\nWell appearing in no acute distress \n Afebrile with stable vital signs \n Pain well-controlled \n Respiratory: CTAB \n Cardiovascular: RRR \n Gastrointestinal: NT/ND \n Genitourinary: Voiding independently \n Neurologic: Intact with no focal deficits \n Psychiatric: Pleasant, A&O x3 \n Musculoskeletal Lower Extremity: \n * Incision healing well with staples \n * 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___ 05:43AM BLOOD WBC-6.8 RBC-3.67* Hgb-9.2* Hct-30.1* \nMCV-82 MCH-25.1* MCHC-30.6* RDW-18.1* RDWSD-53.9* Plt ___\n___ 07:10AM BLOOD WBC-9.0 RBC-3.73* Hgb-9.4* Hct-30.8* \nMCV-83 MCH-25.2* MCHC-30.5* RDW-17.8* RDWSD-53.2* Plt ___\n___ 06:55AM BLOOD WBC-8.5 RBC-3.57* Hgb-9.0* Hct-28.2* \nMCV-79* MCH-25.2* MCHC-31.9* RDW-17.1* RDWSD-48.9* Plt ___\n___ 03:48PM BLOOD WBC-8.4 RBC-3.04*# Hgb-7.5* Hct-24.2*# \nMCV-80* MCH-24.7* MCHC-31.0* RDW-17.4* RDWSD-49.9* Plt ___\n___ 08:00AM BLOOD WBC-12.1*# RBC-4.06*# Hgb-9.8*# \nHct-32.5*# MCV-80* MCH-24.1* MCHC-30.2* RDW-17.2* RDWSD-50.0* \nPlt ___\n___ 05:43AM BLOOD Plt ___\n___ 07:10AM BLOOD Plt ___\n___ 06:55AM BLOOD Plt ___\n___ 03:48PM BLOOD Plt ___\n___ 08:00AM BLOOD Plt ___\n___ 05:43AM BLOOD Glucose-100 UreaN-12 Creat-1.2 Na-143 \nK-3.9 Cl-107 HCO3-25 AnGap-15\n___ 07:10AM BLOOD Glucose-102* UreaN-13 Creat-1.4* Na-140 \nK-4.1 Cl-106 HCO3-24 AnGap-14\n___ 09:35AM BLOOD Glucose-147* UreaN-18 Creat-1.5* Na-140 \nK-4.2 Cl-108 HCO3-25 AnGap-11\n___ 06:55AM BLOOD Glucose-141* UreaN-20 Creat-1.6* Na-140 \nK-4.2 Cl-110* HCO3-24 AnGap-10\n___ 03:48PM BLOOD Glucose-118* UreaN-24* Creat-1.9* Na-136 \nK-4.0 Cl-103 HCO3-23 AnGap-14\n___ 08:00AM BLOOD Glucose-192* UreaN-25* Creat-1.7* Na-138 \nK-4.7 Cl-104 HCO3-18* AnGap-21*\n___ 05:00PM BLOOD CK(CPK)-784*\n___ 09:35AM BLOOD CK(CPK)-918*\n___ 03:48PM BLOOD CK(CPK)-1211*\n___ 07:10AM BLOOD CK-MB-4 cTropnT-0.18*\n___ 05:00PM BLOOD CK-MB-11* MB Indx-1.4 cTropnT-0.16*\n___ 09:35AM BLOOD CK-MB-14* MB Indx-1.5 cTropnT-0.17*\n___ 10:45PM BLOOD CK-MB-12* cTropnT-0.08___ 03:48PM BLOOD CK-MB-10 MB Indx-0.8 cTropnT-0.05*\n___ 05:43AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.1\n___ 07:10AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.8\n___ 09:35AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.7\n___ 06:55AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.7\n___ 08:00AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.5*\n \nBrief Hospital Course:\nThe patient was admitted to the orthopedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nOvernight on POD#0, the patient had low urine output and was \ngiven a bolus of fluid (1.5 liters). On POD#1, the patient \nagain required a bolus of fluid ___ mL) for low urine output \nand his maintenance fluids were increased. He triggered on \nPOD#1 as well. Maintenance fluids were continued. His repeat \nhematocrit was 24.2, therefore he was given 2 units of blood. \nHis post-transfusion hematocrit was 28.2\nMedicine was consulted for co-management due to his persistent \nlow blood pressures. Medicine recommended an additional \none-liter fluid bolus and to check an EKG and cardiac enzymes. \nThe EKG was unchanged from pre-op and his cardiac enzymes were \nelevated, but were trended. The cardiac enzymes continued to \nrise. Medicine discussed case with Cardiology. Given less than \n5% rise in CK-MB index and lack of symptoms or chest pain, \nelevated cardiac enzymes likely elevated due to demand ischemia \nin the setting of hypotension post-op and underlying CAD. Case \ndiscussed with cardiology fellow ___ and ECGs reviewed \nwith cardiology. ECGs with LVH w/secondary repolarization, no \nacute ischemia noted. Outpatient cardiologist emailed who will \nfollow him as outpatient for further evaluation if indicated. \nHis Metoprolol was initially held due to hypotension, but was \nrestarted at 25mg q8H with blood pressure parameters. The \npatient had acute kidney injury with creatinine to 1.9, likely \ndue to hypovolemia, his kidney function normalized to 1.2 at \ndischarge with fluid repletion. \n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Lovenox for DVT \nprophylaxis starting on the morning of POD#1. The foley was \nremoved and the patient was voiding independently thereafter. \nThe surgical dressing was changed on POD#2 and the surgical \nincision was found to be clean and intact without erythema or \nabnormal drainage. The patient was seen daily by physical \ntherapy. Labs were checked throughout the hospital course and \nrepleted accordingly. At the time of discharge the patient was \ntolerating a regular diet and feeling well. The patient was \nafebrile with stable vital signs. The patient's hematocrit was \nacceptable and pain was adequately controlled on an oral \nregimen. The operative extremity was neurovascularly intact and \nthe wound was benign. \n\nThe patient's weight-bearing status is partial weight bearing \n(50%) on the operative extremity. No range of motion of the \nknee, knee immobilizer on at all times (can remove daily for \nskin checks).\n\nMr. ___ is discharged to home with services in stable \ncondition.\n\nTRANSITIONAL ISSUES:\nOutpatient follow up with Cardiologist regarding elevated \ncardiac enzymes, hypotension, and possible peripheral vascular \ndisease.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Tartrate 50 mg PO Q8H \n2. Pravastatin 20 mg PO QPM \n3. Aspirin 81 mg PO DAILY \n4. Lumigan (bimatoprost) 0.01 % ophthalmic QHS \n5. Iron Polysaccharides Complex ___ mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Docusate Sodium 100 mg PO BID \n3. Enoxaparin Sodium 40 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain \n5. Senna 8.6 mg PO BID \n6. Aspirin 81 mg PO DAILY \n7. Iron Polysaccharides Complex ___ mg PO DAILY \n8. Lumigan (bimatoprost) 0.01 % ophthalmic QHS \n9. Metoprolol Tartrate 50 mg PO Q8H \n10. Pravastatin 20 mg PO QPM \n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight knee periprostethic joint infection \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n \n8. ANTICOAGULATION: Please continue your Lovenox for four (4) \nweeks to help prevent deep vein thrombosis (blood clots). If \nyou were taking Aspirin prior to your surgery, it is OK to \ncontinue at your previous dose while taking this medication. \n \n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed at your follow-up \nappointment in two weeks.\n \n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks.\n \n11. ACTIVITY: Partial weight bearing (50%) right lower \nextremity. Please make sure knee immobilizer is on at all times \nup to the hip (can take off daily for skin checks). Mobilize. \nNo range of motion. No strenuous exercise or heavy lifting \nuntil follow up appointment.\n\nPhysical Therapy:\nPartial (50%) weight bearing on right leg\nNo range of motion of right knee (knee immobilizer on at all \ntimes, but can remove daily for skin checks)\nMobilize frequently\n\nTreatments Frequency:\nDSD daily prn drainage \nIce and elevate\n*Staples and stitches will be removed at your first \npost-operative visit*\nKeep knee immobilizer on at all times up to the hip (can take \noff daily for skin checks)\n \nFollowup Instructions:\n___\n" ]

[ "Z4733", "N170", "I248", "E861", "D62", "I2510", "I878", "M89351", "M89361", "I10", "H409", "M5416", "E785", "M4800", "I9581", "I739", "N400", "Z96652", "Z8673", "Z951", "Z954" ]

[ "Z4733: Aftercare following explantation of knee joint prosthesis", "N170: Acute kidney failure with tubular necrosis", "I248: Other forms of acute ischemic heart disease", "E861: Hypovolemia", "D62: Acute posthemorrhagic anemia", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I878: Other specified disorders of veins", "M89351: Hypertrophy of bone, right femur", "M89361: Hypertrophy of bone, right tibia", "I10: Essential (primary) hypertension", "H409: Unspecified glaucoma", "M5416: Radiculopathy, lumbar region", "E785: Hyperlipidemia, unspecified", "M4800: Spinal stenosis, site unspecified", "I9581: Postprocedural hypotension", "I739: Peripheral vascular disease, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z96652: Presence of left artificial knee joint", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z951: Presence of aortocoronary bypass graft", "Z954: Presence of other heart-valve replacement" ]

[ "D62", "I2510", "I10", "E785", "N400", "Z8673", "Z951" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nVancocin / Zosyn / ceftriaxone / Meropenem / Tigecycline / \namoxicillin-pot clavulanate / Gentamicin\n \nAttending: ___\n \nChief Complaint:\nDyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\n___ - ___ Procedure with 27 mm Medetronic root valve \nand coronary artery bypass grafting x 3: left internal mammary \nartery to left anterior descending artery; saphenous vein graft \nto obtuse marginal branch; saphenous vein graft to \nposterolateral branch\n \nHistory of Present Illness:\nMr. ___ is a very pleasant ___ year old man with a history of \nsevere aortic insufficiency with left ventricular dilatation. \nHis history is also significant for chronic right knee infection \nrelated to prosthetic joint. He is closely followed for this by \nDr. ___ infectious disease. He has been stabilized from an \ninfectious disease perspective. He returns for consultation with\nDr. ___.\n\nHe continues to have dyspnea on exertion. He otherwise denied \nfatigue, dizziness, lightheadedness, shortness of breath at \nrest, chest pain, palpitation, orthopnea, paroxysmal nocturnal \ndyspnea, or lower extremity edema.\n\nIn preparation for surgery, he was admitted for cardiac \ncatheterization. The study demonstrated left main and \nmultivessel coronary artery disease. \n\n \nPast Medical History:\nAortic Insufficiency\nBPH\nChronic Right Knee Infection \nGlaucoma\nHypertension\nOsteoarthritis \nProsthetic Joint Infections \nSpinal Stenosis\n\n \nSocial History:\n___\nFamily History:\nMother died of cancer at age ___\nFather died from an myocardial infarction at age ___\n\n \nPhysical Exam:\nBP: 170/59 (left arm). Heart Rate: 69. O2 Saturation%: 100 RA.\nHeight: 70\" Weight: 210 lbs\n\nGeneral: Pleasant elderly gentleman, NAD, ambulating with a \ncane.\n\nSkin: Warm, dry, intact \nHEENT: NCAT, PERRLA, EOMI, OP benign\nNeck: Supple, full ROM\nChest: Lungs clear bilaterally \nHeart: Regular rate and rhythm, III/VI blowing diastolic murmur\nAbdomen: Well healed abdominal scar. Normal BS, soft, \nnon-tender,\nnon-distended \nExtremities: Warm, well-perfused, trace to 1+ edema bilaterally. \n\nRight knee with significant scarring. \nVaricosities: Chronic venous stasis changes below knee\nbilaterally. Right leg at knee significant scarring. No evidence\nof infection. \nNeuro: Grossly intact \nPulses: + Water hammer pulse\nFemoral Right: 2+ Left: 2+\nDP Right: 1+ Left: 1+\n___ Right: 1+ Left: 1+\nRadial Right: 2+ Left: 2+\n\nCarotid Bruit: Transmitted\n\n \nPertinent Results:\nCardiac Catheterization ___\nDominance: Right\nLMCA: eccentric 60% ostial narrowing\nLAD: 70% stenosis after D2\nLCK: large vessel with 90% stenosis distally before the origin \nof a moderately large posterolateral branch.\nRCA: diffuse <50% mid narrowing with no significant lesions.\n\nCarotid Ultrasound ___\nRight ICA less than 40% stenosis. Left ICA no stenosis.\n\nTransesophageal Echocardiogram ___\nPre-bypass\n\nThe left atrium is mildly dilated. No mass/thrombus is seen in \nthe left atrium or left atrial appendage. No atrial septal \ndefect is seen by 2D or color Doppler. The left ventricular \ncavity is moderately dilated, with mild to moderate global left \nventricular hypokinesis (LVEF = 35-40%). Right ventricular \nchamber size and systolic function are normal. The aortic root \nis moderately dilated at the sinus level (4.6 cm). The proximal \nascending aorta and aortic arch mildy dilated. The aortic valve \nis trileaflet with deformation and malcoaptation of leaflets. \nThere is no aortic valve stenosis. There is severe (4+) aortic \nregurgitation, with an eccentric jet directed toward the \nanterior mitral leaflet. There is holodiastolic flow reversal in \nthe descending aorta. The mitral valve leaflets are mildly \nthickened. Mild (1+) mitral regurgitation is seen. There is no \npericardial effusion. \n\nPost-bypass\n\nThe patient is in sinus rhythm and receiving phenylephrine, \nepinephrine (0.03 mcg/kg/min) and milrinone (0.125 mcg/kg/min) \ninfusions.\nLeft ventricular function is stable at 35-40% on inotropic \nsupport. Global hypokinesis remains, with slightly more anterior \nhypokinesis. Septal bounce is visualized.\nRight ventricular systolic function is normal.\nThe aortic valve and root have been replaced. There is normal \nopening of the bioprosthesis (27 mm Freestyle). There is \nhematoma/edema at the site of graft consistent with \npost-surgical state. The distal end of the graft is not well \nvisualized. There is no evidence of aortic dissection.\nMitral regurgitation is trace; tricuspid regurgitation is mild.\n\n___\nThere is mild regional left ventricular systolic dysfunction \nwith septal hypokinesis. The remaining segments contract \nnormally (LVEF = 45-50%). Right ventricular chamber size and \nfree wall motion are normal. There is no pericardial effusion. \nThere is an anterior space which most likely represents a \nprominent fat pad.\n\nIMPRESSION: No pericardial effusion seen. Mild regional left \nventricular systolic dysfunction, c/w CAD. Well-seated aortic \nvalve bioprosthesis.\n\n___ 01:23AM BLOOD WBC-9.1 RBC-3.14* Hgb-9.0* Hct-27.2* \nMCV-87 MCH-28.7 MCHC-33.1 RDW-14.7 RDWSD-46.3 Plt ___\n___ 05:30PM BLOOD Hct-28.5*\n___ 07:05AM BLOOD WBC-8.3 RBC-2.84* Hgb-8.3* Hct-25.0* \nMCV-88 MCH-29.2 MCHC-33.2 RDW-14.6 RDWSD-46.8* Plt ___\n___ 09:14PM BLOOD WBC-10.0 RBC-2.43*# Hgb-7.0*# Hct-21.1*# \nMCV-87 MCH-28.8 MCHC-33.2 RDW-14.6 RDWSD-46.0 Plt ___\n___ 08:08PM BLOOD WBC-6.8 RBC-1.70*# Hgb-5.0*# Hct-15.0*# \nMCV-88 MCH-29.4 MCHC-33.3 RDW-14.9 RDWSD-46.7* Plt Ct-86*\n___ 01:23AM BLOOD Glucose-105* UreaN-30* Creat-1.5* Na-136 \nK-3.5 Cl-101 HCO3-23 AnGap-16\n___ 05:17PM BLOOD Na-135 K-3.8 Cl-101\n___ 07:05AM BLOOD Glucose-107* UreaN-32* Creat-1.8* Na-135 \nK-4.1 Cl-101 HCO3-23 AnGap-15\n___ 09:00PM BLOOD Glucose-125* UreaN-29* Creat-1.8* Na-136 \nK-4.4 Cl-103 HCO3-23 AnGap-14\n___ 12:00PM BLOOD Glucose-131* UreaN-28* Creat-1.9* Na-137 \nK-4.4 Cl-102 HCO3-25 AnGap-14\n___ 02:03AM BLOOD Glucose-145* UreaN-23* Creat-1.9* Na-136 \nK-4.7 Cl-102 HCO3-25 AnGap-14\n___ 06:39AM BLOOD Glucose-115* UreaN-17 Creat-1.0 Na-139 \nK-4.5 Cl-110* HCO3-21* AnGap-13\n___ 01:12AM BLOOD UreaN-18 Creat-1.1 Na-142 K-3.9 Cl-110* \nHCO3-22 AnGap-14\n___ 03:50PM BLOOD UreaN-21* Creat-1.2 Na-139 K-3.5 Cl-108 \nHCO3-19* AnGap-16\n___ 10:14AM BLOOD Glucose-100 UreaN-22* Creat-1.3* Na-140 \nK-3.8 Cl-105 HCO3-24 AnGap-15\n___ 07:20AM BLOOD WBC-7.6 RBC-3.35* Hgb-9.8* Hct-29.8* \nMCV-89 MCH-29.3 MCHC-32.9 RDW-14.9 RDWSD-47.5* Plt ___\n___ 01:23AM BLOOD ___ PTT-26.7 ___\n___ 07:20AM BLOOD Glucose-120* UreaN-26* Creat-1.3* Na-140 \nK-3.7 Cl-103 HCO3-26 AnGap-15\n \nBrief Hospital Course:\n___ was admitted on ___ for routine preoperative \ntesting and evaluation. He was cleared for surgery by the dental \nservice. He remained hemodynamically stable and was taken to the \noperating room on ___. Upon intraoperative evaluation, he \nwas noted to have a large and abnormal aortic root. He underwent \na Bentall procedure and coronary artery bypass grafting x 3. \nPlease see operative note for full details. He tolerated the \nprocedure well and was transferred to the CVICU in stable \ncondition for recovery and invasive monitoring. After a few \nhours, he suddenly started draining\nincreasing amount of blood from the chest tubes, especially the \nleft pleural chest tube with a hematocrit and a chest x- ray \nshowing left pleural collection. He remained hemodynamically \nstable. He was taken back to the operating room for \nreexploration. After removing the clots, a single left internal \nmammary artery pedicle bleeder was found which was actively \nbleeding, and this was controlled with a Ligaclip. After \nclearing all the clots from the left chest and washing out, the \nchest tubes were repositioned, and after 1 further inspection of \nall the surgical sites, no other bleeding was found. He was \nagain transferred to the CVICU in stable condition for recovery \nand invasive monitoring. He weaned from sedation, awoke somewhat \ndelirious but was extubated on POD 1. He was weaned from \ninotropic and vasopressor support. He was treated for delirium \nin the ICU with Haldol and this slowly resolved. POD2 he had a \nrepeat echo due to a hematocrit drop and this showed no \npericardial effusion or collection. Beta blocker was initiated \nand he was diuresed toward his preoperative weight. He was \ntransfused a unit of RBC for a Hct 21 and this remained stable \nthroughout the remainder of his hospital course. Pacing wires \nwere removed. He remained hemodynamically stable and was \ntransferred to the telemetry floor for further recovery. Chest \ntubes remained in until POD4 due to copious serous drainage. \nThese were removed without complication. He was evaluated by the \nphysical therapy service for assistance with strength and \nmobility. By the time of discharge on POD #6 he was ambulating \nwith assistance, the wound was healing, and pain was controlled \nwith oral analgesics. He remained on his chronic antibiotics for \na previous right knee infection. He was discharged to ___ \n___ rehab in good condition with appropriate follow up \ninstructions.\n \nMedications on Admission:\nFluconazole 100 mg tablet daily \nHydrochlorothiazide 25 mg tablet daily \nLisinopril 10 mg tablet daily\nMoxifloxacin 400 mg tablet daily \n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN pain \n2. Aspirin EC 81 mg PO DAILY \n3. DiphenhydrAMINE ___ mg PO Q6H:PRN itching \n4. Docusate Sodium 100 mg PO BID \n5. Fluconazole 100 mg PO Q24H \n6. Heparin 5000 UNIT SC BID \n7. Metoprolol Tartrate 50 mg PO Q8H \n8. Moxifloxacin 400 mg OTHER DAILY \n9. Pravastatin 20 mg PO QPM \n10. Sarna Lotion 1 Appl TP QID:PRN itching \n11. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAortic Insufficiency\nAortic Root Aneurysm\nCoronary Artery Disease\n\nBPH\nChronic Right Knee Infection \nGlaucoma\nHypertension\nOsteoarthritis \nProsthetic Joint Infections \nSpinal Stenosis\n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\nPlease NO lotions, cream, powder, or ointments to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I351", "J942", "F05", "I97411", "D62", "L97229", "I712", "I2510", "I10", "T8453XD", "Y92009", "Y832", "Y92234", "N401", "H409", "M4800", "M1990", "Z9889", "Z8669", "Z8614", "R339" ]

[ "I351: Nonrheumatic aortic (valve) insufficiency", "J942: Hemothorax", "F05: Delirium due to known physiological condition", "I97411: Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating a cardiac bypass", "D62: Acute posthemorrhagic anemia", "L97229: Non-pressure chronic ulcer of left calf with unspecified severity", "I712: Thoracic aortic aneurysm, without rupture", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "T8453XD: Infection and inflammatory reaction due to internal right knee prosthesis, subsequent encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "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", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "H409: Unspecified glaucoma", "M4800: Spinal stenosis, site unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z9889: Other specified postprocedural states", "Z8669: Personal history of other diseases of the nervous system and sense organs", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection", "R339: Retention of urine, unspecified" ]

[ "D62", "I2510", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nVancocin / Zosyn / ceftriaxone / Meropenem / Tigecycline / \namoxicillin-pot clavulanate / Gentamicin / daptomycin / rifampin\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\nCough\n \nMajor Surgical or Invasive Procedure:\nThoracentesis with chest tube placement ___\n\n \nHistory of Present Illness:\n___ with h/o HTN, HLD, CAD s/p CABG, severe AR s/p prosthetic\nAVR, CKD, recurrent knee prosthetic joint infections s/p AKA,\nprostate cancer who presented to the ED with ___ weeks of\nnon-productive cough. He was in his usual state of health when \nhe\nbegan to have slowly progressive non-productive cough and\ndyspnea. He feels a \"rattling\" sensation in his chest. He denies\nany chest discomfort or pressure, difficulty lying flat, or\nweight gain. He denies any subjective fever, abdominal pain, \nN&V,\ndiarrhea, or dysuria. He denies any recent travel or smoking\nhistory. He was seen by his PCP last week who recommended that \nif\nthe cough did not improve in one week he should come to the ED\nfor further evaluation.\n\nIn the ED, initial VS 96.9 78 176/109 20 100% RA. Labs showed \nINR\n1.3 and Hgb 12.9; otherwise unremarkable. CXR showed moderate R\npleural effusion, loculated laterally with associated R basilar\natelectasis. \n\nEKG - sinus, left axis, HR 70, QRS 92, QTc 463, worsening LV\nstrain but no ischemic or T-wave changes, more pronounced \nS-waves\nin I-III\n\nCXR:\nModerate right pleural effusion which is loculated laterally \nwith\nassociated right basilar atelectasis. \n\nIP was consulted and recommended admission to medicine for \nworkup\nof loculated pleural effusion. \n\nUpon arrival to the floor, the patient confirms the above\nhistory. He denies current SOB, stating that he is only SOB when\nhe coughs. No phlegm. Never smoker, no sick contacts, no recent\ntravel. He confirms his choice to be DNR/DNI.\n\n \nPast Medical History:\nPMH: HTN, Glaucoma, b/l TKA ___ and ___ L TKA c/b \npolymicrobial infection - was discharged on ___ w/no antibiotics \n \n\nPSxH: \n-___ - Bentall Procedure with 27 mm Medetronic root valve \nand coronary artery bypass grafting x 3 (Ao valve, root, ascAo \ngraft replacement with coronary artery reimplantation onto \ngraft): left internal mammary artery to left anterior descending \nartery; saphenous vein graft to obtuse marginal branch; \nsaphenous vein graft to posterolateral branch \n-___ - Bilateral laminectomy L1-L5 with proximal \nforaminotomies \n-b/l TKA ___ and ___ \n \n\n \nSocial History:\n___\nFamily History:\nThere is no family history of strokes or significant heart \ndisease per patient \n \nPhysical Exam:\nADMISSION EXAM:\nVITAL SIGNS: ___ 0752 Temp: 98.1 PO BP: 129/81 L Lying HR:\n80 RR: 16 O2 sat: 96% O2 delivery: RA \nGENERAL: Alert and interactive. Breathing comfortably in NAD, \nnot\non O2\nHEENT: NCAT. Sclera anicteric and without injection.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally, although decreased\nbreath sounds in RLL. On room air breathing comfortably without\nthe use of accessory muscles. S/p chest tube removal, site with\ndressing c/d/i\nABDOMEN: Large abdomen, +BS, nontender \nEXTREMITIES: LLE with chronic venous stasis changes. RLL is\nprosthetic. \nSKIN: Warm. No rash.\nNEUROLOGIC: A&O\n\nDISCHARGE EXAM:\nVITAL SIGNS: ___ 0752 Temp: 98.1 PO BP: 129/81 L Lying HR:\n80 RR: 16 O2 sat: 96% O2 delivery: RA \nGENERAL: Alert and interactive. Breathing comfortably in NAD, \nnot\non O2\nHEENT: NCAT. Sclera anicteric and without injection.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally, although decreased\nbreath sounds in RLL. On room air breathing comfortably without\nthe use of accessory muscles. S/p chest tube removal, site with\ndressing c/d/i\nABDOMEN: Large abdomen, +BS, nontender \nEXTREMITIES: LLE with chronic venous stasis changes. RLL is\nprosthetic. \nSKIN: Warm. No rash.\nNEUROLOGIC: A&O\n \nPertinent Results:\n___ 01:56PM ___ PTT-32.4 ___\nADMISSION LABS:\n___ 11:34AM LACTATE-1.1\n___ 11:25AM GLUCOSE-119* UREA N-16 CREAT-1.1 SODIUM-138 \nPOTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-24 ANION GAP-13\n___ 11:25AM estGFR-Using this\n___ 11:25AM cTropnT-<0.01\n___ 11:25AM proBNP-212\n___ 11:25AM WBC-4.8 RBC-4.80 HGB-12.9* HCT-40.2 MCV-84 \nMCH-26.9 MCHC-32.1 RDW-12.6 RDWSD-38.5\n___ 11:25AM NEUTS-65.9 LYMPHS-14.1* MONOS-10.5 EOS-7.2* \nBASOS-1.9* IM ___ AbsNeut-3.13 AbsLymp-0.67* AbsMono-0.50 \nAbsEos-0.34 AbsBaso-0.09*\n___ 11:25AM PLT COUNT-286\n\n___ 05:08PM PLEURAL TNC-789* Hct,Fl-4.0* Polys-27* \nLymphs-49* Monos-13* Eos-6* Macro-5*\n___ 05:08PM PLEURAL TotProt-4.5 Glucose-43 LD(LDH)-761 \nCholest-49 Triglyc-37 proBNP-505.7\nPleural fluid culture ___ no growth to date, no acid fast seen \non smear\n\n___ 06:30AM BLOOD WBC-4.5 RBC-5.40 Hgb-14.4 Hct-45.2 MCV-84 \nMCH-26.7 MCHC-31.9* RDW-12.4 RDWSD-37.5 Plt ___\n___ 11:25AM BLOOD Neuts-65.9 Lymphs-14.1* Monos-10.5 \nEos-7.2* Baso-1.9* Im ___ AbsNeut-3.13 AbsLymp-0.67* \nAbsMono-0.50 AbsEos-0.34 AbsBaso-0.09*\n___ 06:30AM BLOOD Plt ___\n___ 06:30AM BLOOD Glucose-119* UreaN-17 Creat-1.1 Na-139 \nK-4.9 Cl-97 HCO3-25 AnGap-17\n___ 11:25AM BLOOD cTropnT-<0.01\n___ 11:25AM BLOOD proBNP-212\n___ 06:50AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.___ with h/o HTN, HLD, CAD s/p CABG, severe AR s/p Bentall,\nprostate CA, who presents with ___ weeks of non-productive cough \nfound to have loculated effusion on CXR. \n\nACUTE ISSUES:\n=============\n#Complicated, R-sided loculated pleural effusion\nThe patient presented with dry cough and increased dyspnea. A \nloculated pleural effusion was seen on CXR. He underwent \nthoracentesis with chest tube placement by IP. The pleural \nfluid appeared bloody and was exudative by protein and \ncholesterol levels but LDH was not very elevated. This picture \nwas thought to be consistent with an old bleed that became \nloculated. PFA not consistent with infection and the patient \nlacked infectious symptoms. Cytology and cultures were pending \nat the time of discharge. Gram stain had 1+ PMNs with no \norganisms, preliminary culture negative, pleural fluid in blood \nculture bottle NGTD. Chest tube removed after 1 day of drainage, \nconfirming resolution with CT. The patient will follow-up with \nIP and with his PCP for final results of pending pleural fluid \nstudies.\n\nCHRONIC ISSUES:\n===============\n# Hx of recurrent R knee prosthetic joint infections\nPreviously enterococcus bacteremia, MRSA, serratia treated with \nlinezolid + cipro.\n\n#History of AI, s/p AVR\n#CAD\nContinued home carvedilol, aspirin\n\n#HTN/HLD\nContinued home meds\n\n#Anemia\nAppears to be chronic. Stable.\n\n#Prostate Cancer\n___ 3+4 = 7, last seen in clinic in ___ where PSA was\nstable. At that time patient elected to proceed with active \nsurveillance. Outpatient MRI due in ___, repeat bx \n___ or sooner\nper outpatient notes\n\nTRANSITIONAL ISSUES: \n[ ] Will need follow up chest x-ray with IP and followup, to be \narranged by IP\n[ ] Cytology and final pleural fluid cultures pending on \ndischarge \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Carvedilol 12.5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Carvedilol 12.5 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPleural effusion\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ with fluid around your lung called a \npleural effusion. \n\nWe drained this fluid out which allowed you to breath more \neasily. \n\nWhen you leave the hospital, please follow up with your doctors \nand note any medication changes below. \n\nIt was a pleasure caring for you!\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "J90", "J9811", "D689", "I2510", "Z951", "E785", "C61", "Z23", "Z89611", "Z96652", "Z952", "D649", "I129", "N189", "Z66" ]

[ "J90: Pleural effusion, not elsewhere classified", "J9811: Atelectasis", "D689: Coagulation defect, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "E785: Hyperlipidemia, unspecified", "C61: Malignant neoplasm of prostate", "Z23: Encounter for immunization", "Z89611: Acquired absence of right leg above knee", "Z96652: Presence of left artificial knee joint", "Z952: Presence of prosthetic heart valve", "D649: Anemia, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z66: Do not resuscitate" ]

[ "I2510", "Z951", "E785", "D649", "I129", "N189", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nVancocin / Zosyn / ceftriaxone / Meropenem / Tigecycline / \namoxicillin-pot clavulanate / Gentamicin\n \nAttending: ___\n \nChief Complaint:\nL hand weakness\n\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old ___ man with a history of \nsevere aortic insufficiency with left ventricular dilatation s/p \nBentall with CABGx3 on ___, discharged ___, b/l TKA with R \nchronic knee infection, presents with 2 days of L hand weakness \nand progressive L hand sensory loss. \n\nHe notes that he woke with these symptoms 2 days prior to his ED \nvisit ___ AM) feeling like he couldn't write with his L \nhand. He had numbness in his L fingers at the time (from tip to \nwhere they meet the palm, both dorsal and palmar surfaces) that \nhe feels has gradually progressed circumferentially up his L arm \nsince then. \n\nHe presents to the ED today concerned about he gradual sensory \nloss. No pain, tingling, pins/needles. No speech slurring or \nword finding difficulty. No other focal neurologic symptoms. \nAmbulating at his baseline with a walker. \n\nOn neuro ROS, notable for the above. Otherwise, the pt denies \nheadache, loss of vision, blurred vision, diplopia, dysarthria, \ndysphagia, lightheadedness, vertigo, tinnitus or hearing \ndifficulty. Denies difficulties producing or comprehending \nspeech. Denies focal weakness, numbness, parasthesiae except as \nabove. No bowel or bladder incontinence or retention. Denies \ndifficulty with gait.\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 recent change in bowel or bladder habits. \n No dysuria. Denies arthralgias or myalgias. Denies rash.\n\n \nPast Medical History:\nPMH:\nHTN, Glaucoma, \nb/l TKA ___ and ___ L TKA c/b\npolymicrobial infection - currently on suppressive\nMoxifloxacin/Fluconazole\n\nPSxH:\n-___ - Bentall Procedure with 27 mm Medetronic root valve \n\nand coronary artery bypass grafting x 3 (Ao valve, root, ascAo \ngraft replacement with coronary artery reimplantation onto \ngraft): left internal mammary \nartery to left anterior descending artery; saphenous vein graft \nto obtuse marginal branch; saphenous vein graft to \nposterolateral branch\n-___ - Bilateral laminectomy L1-L5 with proximal \nforaminotomies \n-b/l TKA ___ and ___\n \nSocial History:\n___\nFamily History:\nThere is no family history of strokes or significant heart \ndisease per patient \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVitals: T:97.7 P:89 R: 18 BP:110/64 SaO2:100% RA\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted\nNeck: Supple\nPulmonary: Regular respirations\nCardiac: RRR\nAbdomen: soft\nSkin: Midline sternotomy c/d/I, ___ scarring (R>L) from TKA.\n\nNeurologic:\n\n-Mental Status: Alert, oriented to BI, name, and ___ \n(thought ___ or ___. Able to relate history without \ndifficulty. Named ___ through ___ only. Language is fluent \nwith intact repetition and comprehension. Poor prosody. There \nwere no paraphasic errors. Pt was able to name both high and low \nfrequency objects. Speech was not dysarthric but was \nhypophonic. Able to follow both midline and appendicular \ncommands. Pt was able to register 3 objects and recall ___ at 5 \nminutes (despite category and choice cues). \n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: PERRL 4 to 2mm and brisk. VFF to confrontation. \nIII, IV, VI: EOMI without nystagmus. No diplopia.\nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline.\n\n-Motor: Normal bulk, tone throughout. L hand with pronation and \nfinger curl. No adventitious movements, such as tremor, noted. \nNo asterixis noted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5 ___ ___- 5 5 5 5 5 5 5\nR 5 ___ ___ * 5 5 5 5 5 5\nAbductor pollicis longus, extensor pollicus longus 4-\nOpponens pollicis 4+\nFlexor carpi ulnaris 5- \n*patient notes he is unable to lift this since his R knee \ninfection\n\n-Sensory: Diminished pinprick, light touch, temperature \nsensation worst at L fingers and then gradually improving up to \nshoulders. Patient notes light touch is worst at the palmar and \ndorsal services of all of his fingers. On pinprick testing, \nmildly worse on ___ and ___ digit palmar surfaces, but diffusely \ndiminished primarily across hand palmar surface and dorsal \naspect of digits ___. No propriception deficits in L fingers. No \ndeficits to light touch, pinprick, cold sensation, \nproprioception throughout otherwise. \n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 0 0\nR 2 2 2 0 0\nPlantar response was flexor bilaterally.\n\n-Coordination: No intention tremor on R, FNF limited on L.\n\n-Gait: Patient asked to defer as walker was not readily \navailable (patient uses walker to ambulate at home)\n====================================================\n\nDISCHARGE PHYSICAL EXAM:\nL finger extensors 4-, L finger flexors 5-. L IO 4-. L hand > \nforearm > arm diminished sensation to pinprick/cold/light touch \n(but intact to proprioception). \n\n \nPertinent Results:\nADMISSION LABS:\n___ 08:53PM BLOOD WBC-8.3 RBC-3.04* Hgb-8.6* Hct-27.8* \nMCV-91 MCH-28.3 MCHC-30.9* RDW-14.6 RDWSD-48.8* Plt ___\n___ 08:53PM BLOOD Neuts-69.0 Lymphs-9.9* Monos-8.7 Eos-9.7* \nBaso-1.9* Im ___ AbsNeut-5.71# AbsLymp-0.82* AbsMono-0.72 \nAbsEos-0.80* AbsBaso-0.16*\n___ 06:00AM BLOOD ___ PTT-28.5 ___\n___ 08:53PM BLOOD Glucose-95 UreaN-26* Creat-1.5* Na-135 \nK-3.7 Cl-99 HCO3-23 AnGap-17\n___ 08:53PM BLOOD ALT-31 AST-43* AlkPhos-82 TotBili-0.3\n___ 06:00AM BLOOD GGT-32\n___ 06:00AM BLOOD CK-MB-2 cTropnT-0.03*\n___ 08:53PM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8\n___ 06:00AM BLOOD Triglyc-68 HDL-32 CHOL/HD-3.3 LDLcalc-58\n___ 08:53PM BLOOD TSH-1.3\n___ 06:00AM BLOOD CRP-52.6*\n___ 08:53PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG \nBarbitr-NEG Tricycl-NEG\n\nIMAGING:\nCXR ___:\nNo acute cardiopulmonary process. No focal consolidation to \nsuggest \npneumonia. \n\nCT HEAD ___:\nNo acute intracranial abnormality including no acute \nintracranial hemorrhage. Note that MR is more sensitive for the \ndetection of early stroke.\n\nMRI C-SPINE ___:\n1. No evidence of bony or ligamentous injury. \n2. Moderate spinal stenosis at C3-4 and C5-6 levels. Spinal \nfusion at C4-5 level. \n3. Mild extrinsic indentation on the spinal cord by disc bulging \nand \nthickening of the ligaments at C3-4 and C5-6 levels without \nabnormal increased signal within the spinal cord. \n4. Foraminal changes as described above. \n\nMRI/A BRAIN ___:\nSubacute appearing infarcts in the left periatrial white matter. \n No definite acute infarct. Chronic left-sided watershed \nfrontoparietal infarcts. Mild changes of small vessel disease. \nNo significant abnormalities are seen on MRA of the head and \nneck. \n\nDISCHARGE LABS: \n___ 07:07AM BLOOD WBC-6.8 RBC-3.17* Hgb-8.6* Hct-28.0* \nMCV-88 MCH-27.1 MCHC-30.7* RDW-14.4 RDWSD-46.3 Plt ___\n___ 07:07AM BLOOD Plt ___\n___ 07:07AM BLOOD Glucose-107* UreaN-17 Creat-1.1 Na-138 \nK-3.5 Cl-102 HCO3-28 AnGap-12\n___ 07:07AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.6\n \nBrief Hospital Course:\n___ is a ___ year old ___ man with a history of severe aortic \ninsufficiency with left ventricular dilatation s/p Bentall with \nCABGx3 on ___, discharged ___, history of lumbar stenosis s/p \nL1-L5 laminectomies, presents with 2 days of L hand weakness and \nprogressive L hand sensory loss. CT/A, MRI brain negative for \nacute stroke. MRI brain DID show a small subacute stroke in the \nleft posterior periventricular white matter which may have been \nrelated to his prior cardiac intervention, although it is \nimpossible to tell. There were also tiny chronic left parietal \ncortical infarcts that do no correlate with symptoms. MRA was \nnormal. MRI C-spine with diffuse mild degenerative changes, C4-5 \nand C5-6 discs that abut the cord and mild neural foraminal \nnarrowing at C6 and C7 bilaterally. Though the disease appears \ndiffuse on MRI, clinically the etiology of symptoms most \nconsistent with C7 radiculopathy.\n\n====================\nTRANSITIONAL ISSUES:\n====================\n-soft collar at night\n-outpatient OT as needed\n-no need for surgery referral\n-continue home aspirin for stroke prevention\n-neurology follow-up to be arranged\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Docusate Sodium 100 mg PO BID \n3. Fluconazole 100 mg PO Q24H \n4. Metoprolol Tartrate 50 mg PO Q8H \n5. Moxifloxacin 400 mg Other DAILY \n6. Pravastatin 20 mg PO QPM \n7. Tamsulosin 0.4 mg PO QHS \n8. Sarna Lotion 1 Appl TP QID:PRN itching \n9. DiphenhydrAMINE 25 mg PO Q6H:PRN itching \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Docusate Sodium 100 mg PO BID \n3. Fluconazole 100 mg PO Q24H \n4. Metoprolol Tartrate 50 mg PO Q8H \n5. Pravastatin 20 mg PO QPM \n6. Sarna Lotion 1 Appl TP QID:PRN itching \n7. Tamsulosin 0.4 mg PO QHS \n8. DiphenhydrAMINE 25 mg PO Q6H:PRN itching \n9. Moxifloxacin 400 mg OTHER DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nsubacute left parietal lobe stroke\nC7 radiculopathy\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to the hospital with left sided arm numbness \nand mild hand weakness. We have imaged your brain and vessels \nwith CT/CTA and MRI which did not show evidence of an acute \nstroke. However, we did find evidence of 1 small subacute stroke \n(at least ___ weeks old) and very small older chronic strokes on \nthe left side of your brain which are not the cause of your \nsymptoms. We imaged your spinal cord at the level of your neck \nwhich showed chronic disc disease that abut the spinal cord. We \nbelieve your symptoms are coming from a mild impingement of one \nof the nerve roots coming from your neck, known as \"C7 \nRADICULOPATHY.\" This does not need to be treated with surgery, \nbut you may benefit from outpatient occupational therapy. You \nshould continue on your baby aspirin for stroke prevention. You \nmay also wear a soft collar at night to help keep your neck in \nalignment. You can buy this from any pharmacy. \n\nYou should follow-up with stroke neurology as an outpatient. \n\nIt was a pleasure taking care of you, \nYour ___ Neurologists\n\nInstructions: \n1. Please continue to take all your medications as directed.\n2. Please follow up with your primary care doctor.\n3. Please call with any questions. \n \nFollowup Instructions:\n___\n" ]

[ "M5412", "I639", "I351", "Z951", "Z7982", "Z96653", "H409" ]

[ "M5412: Radiculopathy, cervical region", "I639: Cerebral infarction, unspecified", "I351: Nonrheumatic aortic (valve) insufficiency", "Z951: Presence of aortocoronary bypass graft", "Z7982: Long term (current) use of aspirin", "Z96653: Presence of artificial knee joint, bilateral", "H409: Unspecified glaucoma" ]

[ "Z951" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nVancocin / Zosyn / ceftriaxone / Meropenem / Tigecycline / \namoxicillin-pot clavulanate / Gentamicin / daptomycin\n \nAttending: ___.\n \nChief Complaint:\nsurgical site infection s/p right knee reimplantation on ___\n \nMajor Surgical or Invasive Procedure:\n___: I&D right knee, wound vac application\n___: right leg above the knee amputation\n___: Local muscle advancement and closure of\nright above-knee amputation site\n\n \nHistory of Present Illness:\n___ male with a history of right knee arthroplasty \ncomplicated by multiple prior polymicrobial right knee \nprosthetic joint infections, most\nrecently status post enterococcal right knee PJI complicated by \nhigh-grade bacteremia in ___, status post resection \narthroplasty and antibiotic therapy at that time. Now most \nrecently status post right knee reimplantation on ___. Also \nwith a history of aortic valve replacement and Bentall with\naortic graft, with concern for surgical site infection and new \narea of\n?fluctuance/abscess despite Bactrim for 5days and VAC dressing \nsince ___ with superficial culture + MRSA.\n \nPast Medical History:\nPMH: HTN, Glaucoma, b/l TKA ___ and ___ L TKA c/b \npolymicrobial infection - was discharged on ___ w/no antibiotics \n \n\nPSxH: \n-___ - Bentall Procedure with 27 mm Medetronic root valve \nand coronary artery bypass grafting x 3 (Ao valve, root, ascAo \ngraft replacement with coronary artery reimplantation onto \ngraft): left internal mammary artery to left anterior descending \nartery; saphenous vein graft to obtuse marginal branch; \nsaphenous vein graft to posterolateral branch \n-___ - Bilateral laminectomy L1-L5 with proximal \nforaminotomies \n-b/l TKA ___ and ___ \n \n\n \nSocial History:\n___\nFamily History:\nThere is no family history of strokes or significant heart \ndisease per patient \n \nPhysical Exam:\nWell appearing in no acute distress \n Afebrile with stable vital signs \n Pain well-controlled \n Respiratory: CTAB \n Cardiovascular: RRR \n Gastrointestinal: NT/ND \n Genitourinary: Voiding independently \n Neurologic: Intact with no focal deficits \n Psychiatric: Pleasant, A&O x3 \n Musculoskeletal Lower Extremity: \n * Incision healing well with ***\n * Scant serosanguinous drainage \n * Thigh full but soft \n * ___ strength \n * NVI distally \n\n \nPertinent Results:\n___ 08:50AM BLOOD WBC-3.2* RBC-2.80* Hgb-7.9* Hct-23.8* \nMCV-85 MCH-28.2 MCHC-33.2 RDW-15.8* RDWSD-49.2* Plt ___\n___ 10:13AM BLOOD WBC-5.3 RBC-3.14* Hgb-8.8* Hct-26.3* \nMCV-84 MCH-28.0 MCHC-33.5 RDW-15.6* RDWSD-47.3* Plt ___\n___ 10:25AM BLOOD WBC-5.3 RBC-2.83* Hgb-7.8* Hct-23.7* \nMCV-84 MCH-27.6 MCHC-32.9 RDW-16.1* RDWSD-49.4* Plt ___\n___ 07:10AM BLOOD WBC-7.1 RBC-3.28* Hgb-9.1* Hct-27.7* \nMCV-85 MCH-27.7 MCHC-32.9 RDW-16.2* RDWSD-50.4* Plt ___\n___ 10:45AM BLOOD WBC-5.9 RBC-3.32* Hgb-9.1* Hct-27.7* \nMCV-83 MCH-27.4 MCHC-32.9 RDW-16.2* RDWSD-49.6* Plt ___\n___ 03:40AM BLOOD WBC-6.1 RBC-2.93* Hgb-8.0* Hct-24.1* \nMCV-82 MCH-27.3 MCHC-33.2 RDW-16.3* RDWSD-48.3* Plt ___\n___ 07:37PM BLOOD WBC-7.3 RBC-2.90* Hgb-7.9*# Hct-23.9* \nMCV-82 MCH-27.2 MCHC-33.1 RDW-16.3* RDWSD-49.1* Plt ___\n___ 07:50AM BLOOD WBC-6.8 RBC-2.32*# Hgb-6.1*# Hct-19.4*# \nMCV-84 MCH-26.3 MCHC-31.4* RDW-17.8* RDWSD-53.6* Plt ___\n___ 09:25AM BLOOD WBC-9.1 RBC-3.31* Hgb-8.5* Hct-27.2* \nMCV-82 MCH-25.7* MCHC-31.3* RDW-17.4* RDWSD-51.4* Plt ___\n___ 07:40PM BLOOD WBC-6.2 RBC-3.24* Hgb-8.5* Hct-26.2* \nMCV-81* MCH-26.2# MCHC-32.4 RDW-17.0* RDWSD-49.2* Plt ___\n___ 06:48AM BLOOD WBC-4.2 RBC-3.40* Hgb-7.9* Hct-26.7* \nMCV-79* MCH-23.2* MCHC-29.6* RDW-16.4* RDWSD-46.4* Plt ___\n___ 06:30AM BLOOD WBC-4.2 RBC-3.49* Hgb-8.1* Hct-27.1* \nMCV-78* MCH-23.2* MCHC-29.9* RDW-16.4* RDWSD-45.8 Plt ___\n___ 07:48AM BLOOD WBC-4.8 RBC-4.09* Hgb-9.4* Hct-32.2* \nMCV-79* MCH-23.0* MCHC-29.2* RDW-16.1* RDWSD-46.0 Plt ___\n___ 10:55AM BLOOD WBC-4.8 RBC-3.56* Hgb-8.1* Hct-28.0* \nMCV-79* MCH-22.8* MCHC-28.9* RDW-16.0* RDWSD-45.5 Plt ___\n___ 06:30AM BLOOD WBC-4.2 RBC-3.34* Hgb-7.7* Hct-25.9* \nMCV-78* MCH-23.1* MCHC-29.7* RDW-16.0* RDWSD-45.1 Plt ___\n___ 03:08PM BLOOD WBC-5.6 RBC-3.45* Hgb-8.3* Hct-26.6* \nMCV-77* MCH-24.1* MCHC-31.2* RDW-15.9* RDWSD-44.6 Plt ___\n___ 07:10AM BLOOD Neuts-83.8* Lymphs-7.6* Monos-7.0 \nEos-0.6* Baso-0.6 Im ___ AbsNeut-5.95 AbsLymp-0.54* \nAbsMono-0.50 AbsEos-0.04 AbsBaso-0.04\n___ 10:45AM BLOOD Neuts-80.7* Lymphs-8.5* Monos-6.6 Eos-3.2 \nBaso-0.3 Im ___ AbsNeut-4.76# AbsLymp-0.50* AbsMono-0.39 \nAbsEos-0.19 AbsBaso-0.02\n___ 08:50AM BLOOD Plt ___\n___ 10:13AM BLOOD Plt ___\n___ 10:25AM BLOOD Plt ___\n___ 07:10AM BLOOD Plt ___\n___ 10:45AM BLOOD Plt ___\n___ 03:40AM BLOOD Plt ___\n___ 07:37PM BLOOD Plt ___\n___ 07:50AM BLOOD Plt ___\n___ 09:25AM BLOOD Plt ___\n___ 07:40PM BLOOD Plt ___\n___ 06:48AM BLOOD Plt ___\n___ 06:30AM BLOOD Plt ___\n___ 07:48AM BLOOD Plt ___\n___ 10:55AM BLOOD Plt ___\n___ 06:30AM BLOOD Plt ___\n___ 03:08PM BLOOD Plt ___\n___ 03:08PM BLOOD ___ PTT-39.2* ___\n___ 03:40AM BLOOD Glucose-108* UreaN-16 Creat-1.1 Na-134 \nK-4.0 Cl-101 HCO3-21* AnGap-16\n___ 07:50AM BLOOD Glucose-118* UreaN-19 Creat-1.3* Na-133 \nK-3.6 Cl-100 HCO3-22 AnGap-15\n___ 09:25AM BLOOD Glucose-142* UreaN-16 Creat-1.1 Na-139 \nK-4.3 Cl-104 HCO3-21* AnGap-18\n___ 07:40PM BLOOD Glucose-114* UreaN-16 Creat-1.0 Na-141 \nK-4.1 Cl-109* HCO3-20* AnGap-16\n___ 06:48AM BLOOD Glucose-113* UreaN-19 Creat-1.2 Na-142 \nK-4.1 Cl-108 HCO3-22 AnGap-16\n___ 10:35AM BLOOD UreaN-20 Creat-1.5*\n___ 06:30AM BLOOD Glucose-95 UreaN-17 Creat-1.6* Na-141 \nK-4.7 Cl-108 HCO3-23 AnGap-15\n___ 07:48AM BLOOD Glucose-129* UreaN-18 Creat-1.4* Na-142 \nK-4.3 Cl-105 HCO3-22 AnGap-19\n___ 06:30AM BLOOD Glucose-114* UreaN-14 Creat-1.1 Na-138 \nK-4.9 Cl-103 HCO3-25 AnGap-15\n___ 03:08PM BLOOD Glucose-85 UreaN-19 Creat-1.3* Na-137 \nK-4.7 Cl-102 HCO3-24 AnGap-16\n___ 03:40AM BLOOD estGFR-Using this\n___ 07:50AM BLOOD estGFR-Using this\n___ 07:40PM BLOOD ALT-13 AST-18 AlkPhos-63 TotBili-1.3\n___ 03:40AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.7\n___ 07:40PM BLOOD Calcium-8.2* Phos-3.5 Mg-1.7\n___ 06:48AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8\n___ 06:30AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8\n___ 07:48AM BLOOD Calcium-9.5 Phos-3.4 Mg-1.9\n___ 06:30AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9\n___ 03:40AM BLOOD\n___ 07:50AM BLOOD\n___ 09:25AM BLOOD\n___ 07:40PM BLOOD\n___ 06:48AM BLOOD\n___ 10:35AM BLOOD\n___ 06:30AM BLOOD\n___ 07:48AM BLOOD\n___ 06:30AM BLOOD\n___ 03:08PM BLOOD\n___ 09:07PM URINE Color- Appear-Clear Sp ___\n___ 09:07PM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 09:07PM URINE ___ Bacteri-FEW Yeast-NONE \n___ 09:07PM URINE ___ 09:07PM URINE\n___ 10:22AM URINE Hours-RANDOM Creat-103 Na-86\n___ 04:13PM URINE Hours-RANDOM Creat-62 Na-86\n___ 04:52PM JOINT FLUID ___ Polys-98* \n___ Monos-0\nURINE CULTURE (Final ___: NO GROWTH\n___ 3:00 pm TISSUE RIGHT LEG TISSUE. \n\n GRAM STAIN (Final ___: \n 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n TISSUE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH.\n\n___ 3:50 pm TISSUE RIGHT KNEE DEEP TISSUE # 2. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n TISSUE (Final ___: \n SERRATIA MARCESCENS. \n Isolated from broth media only, INDICATING VERY LOW \nNUMBERS OF\n ORGANISMS. \n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # \n___\n (___). \n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n___ 9:50 pm BLOOD CULTURE: Blood Culture, Routine \n(Pending): \n\n \nBrief Hospital Course:\nThe patient was admitted to the orthopedic surgery service from \nInfectious Disease clinic. He was placed on IV Linezolid per ID \nrecommendations. He was taken to the OR on ___ for incision and \ndrainage and wound vac application of his knee. Please see \nseparately dictated operative report for details. The surgery \nwas uncomplicated and the patient tolerated the procedure well. \n\nPostoperative course was remarkable for the following:\nIn the early morning of POD#1, the patient was unable to void. \nHis foley was replaced and was discontinued the morning of POD#2 \nand he was able to void independently. He was started on \nAztreonam on POD#2 per ID recommendations since gram negative \nrods and gram positive cocci were identified in the OR cultures. \n On POD#3, his drain was discontinued and his wound vac was \nchanged. On POD#4, the patient's cultures grew Serratia. Per \nID recommendations Aztreonam was discontinued and Cipro 500mg PO \nBID was started. Linezolid was continued at this time. On \nPOD#5 the patient had an elevated creatinine to 1.4. He was \ngiven 1L NS bolus with minimal effect. On POD#5, his creatinine \nrose to 1.6 but given overall hospital stay his fluid balance is \n~ 4L negative. He was given a repeat bolus. On POD#7, he \nreturned to the OR for a left above the knee amputation. \nCultures showed no growth. Post-operatively, his creatinine was \nstable at 1.1. On POD#9, his hematocrit was 19.4. He was given \ntwo units of blood. Upon re-check, his hematocrit was 24.1 and \nhe was transfused with another unit of blood. He returned to \nthe OR on ___ with Plastics for local muscle advancement and \nclosure of right above-knee amputation site. ID saw him and \nrecommended discontinuing linezolid and ciprofloxacin and \ntransitioning to oral DS Bactrim given thrombocytopenia. His \nlast dose of ciprofloxacin was on ___ and his last dose of \nlinezolid was ___. PO Bactrim commenced on ___. On ___, a \nurine culture was obtained given multiple foley placements \nduring his hospitalization which was negative for a UTI. \n\nOtherwise, pain was controlled with oral pain medications. The \npatient received ASA 325 twice daily for DVT prophylaxis \nstarting on the morning of POD#1. The patient was seen by \nphysical therapy. Labs were checked throughout the hospital \ncourse and repleted accordingly. At the time of discharge the \npatient was tolerating a regular diet and feeling well. The \npatient was afebrile with stable vital signs. The patient's \nhematocrit was acceptable and pain was adequately controlled on \nan oral regimen. The operative extremity was neurovascularly \nintact and the wound was benign. \n\nThe patient's weight-bearing status is non weight bearing.\n\nMr. ___ is discharged to home with services in stable \ncondition.\n \nMedications on Admission:\n1. Aspirin 81 mg PO DAILY \n2. Metoprolol Tartrate 50 mg PO Q8H \n3. Pravastatin 20 mg PO QPM \n4. Acetaminophen 1000 mg PO Q8H \n5. Docusate Sodium 100 mg PO BID \n6. Enoxaparin Sodium 40 mg SC DAILY \n7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain \n8. Senna 8.6 mg PO BID \n9. Iron Polysaccharides Complex ___ mg PO DAILY \n10. Lumigan (bimatoprost) 0.01 % ophthalmic QHS \n\n \nDischarge Medications:\n1. Aspirin 325 mg PO BID \nRX *aspirin [Ecotrin] 325 mg 1 tablet(s) by mouth twice a day \nDisp #*56 Tablet Refills:*0 \n2. Pantoprazole 40 mg PO Q24H \nTake for 4 weeks while on Aspirin 325 mg. \nRX *pantoprazole [Protonix] 40 mg 1 tablet(s) by mouth daily \nDisp #*28 Tablet Refills:*0 \n3. Rifampin 300 mg PO Q12H \nRX *rifampin 300 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*0 \n4. Sulfameth/Trimethoprim DS 2 TAB PO BID \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by \nmouth twice a day Disp #*120 Tablet Refills:*0 \n5. TraMADol 25 mg PO Q6H:PRN pain \nRX *tramadol [Ultram] 50 mg 0.5 (One half) tablet(s) by mouth \nevery 6 hours as needed Disp #*84 Tablet Refills:*0 \n6. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp \n#*84 Tablet Refills:*0 \n7. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen [Acetaminophen Pain Relief] 500 mg 2 tablet(s) \nby mouth every 8 hours Disp #*100 Tablet Refills:*0 \n8. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*2 \n9. Iron Polysaccharides Complex ___ mg PO DAILY \n10. Lumigan (bimatoprost) 0.01 % ophthalmic QHS \n11. Metoprolol Tartrate 50 mg PO Q8H \n12. Pravastatin 20 mg PO QPM \n13. Senna 8.6 mg PO BID \nRX *sennosides 8.6 mg 2 tablets by mouth twice a day Disp #*60 \nTablet Refills:*2 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nsurgical site infection s/p right knee reimplantation on ___\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 extremity 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. \n\n8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice \ndaily for four (4) weeks to help prevent deep vein thrombosis \n(blood clots). Continue Pantoprazole daily while on Aspirin 325 \nmg (x 4 weeks) to prevent GI upset. You can resume your home \ndose of Aspirin once you have completed your full 4 week course \nof 325mg BID.\n\n9. WOUND CARE: ***Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Dressing changes are as follows: \nxeroform, krilix, and an Acewrap. Please leave JP drain in place \nuntil follow up with plastic surgery. \n\n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks. DRESSING CHANGES ARE XEROFORM, KRILIX, \nAND ACEWRAP. DO NOT REMOVED STAPLES OR SUTRES. \n\n11. ACTIVITY: No strenuous exercise or heavy lifting until \nfollow up appointment. mobilize frequently. \n\n13. WEEKLY LABS: draw on ___ and send result to ID RNs \nat: ___ R.N.s at ___. \n - CHEM 7\nMonthly labs: \n - CBC/DIFF\n - LFTS\n - ESR/CRP\n\n**All questions regarding outpatient parenteral antibiotics \nshould be directed to the ___ R.N.s at \n___ or to the on-call ID fellow when the clinic is \nclosed.**\nPhysical Therapy:\nAmbulate with assistive device\nMobilize frequently\nROMAT\nNWB RLE\nTreatments Frequency:\ndaily dressing changes: xeroform, krilix, and an ACE wrap\nwound checks daily\nice\n*****please leave JP drain in place until follow up appointment \nwith plastic surgery****\n*****DO NOT REMOVE STAPLES OR SUTURE. THIS WILL BE DONE BY \nPLASTIC SURGERY IN CLINIC****\n\n \nFollowup Instructions:\n___\n" ]

[ "T8453XA", "D62", "N179", "D709", "B9562", "D696", "I10", "E785", "I2510", "E860", "H409", "B9689", "N400", "Z951", "Z8673", "Z96652", "Z954", "Y792", "Y929" ]

[ "T8453XA: Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter", "D62: Acute posthemorrhagic anemia", "N179: Acute kidney failure, unspecified", "D709: Neutropenia, unspecified", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "D696: Thrombocytopenia, unspecified", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E860: Dehydration", "H409: Unspecified glaucoma", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z951: Presence of aortocoronary bypass graft", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z96652: Presence of left artificial knee joint", "Z954: Presence of other heart-valve replacement", "Y792: Prosthetic and other implants, materials and accessory orthopedic devices associated with adverse incidents", "Y929: Unspecified place or not applicable" ]

[ "D62", "N179", "D696", "I10", "E785", "I2510", "N400", "Z951", "Z8673", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nVancocin / Zosyn / ceftriaxone / Meropenem / Tigecycline / \namoxicillin-pot clavulanate / Gentamicin\n \nAttending: ___.\n \nChief Complaint:\nUrinary retention\n \nMajor Surgical or Invasive Procedure:\nTransurethral resection of prostate\n\n \nHistory of Present Illness:\n___ BPH c/b urinary retention on CIC, PSA 10.8\n \nPast Medical History:\nPMH:\nHTN, Glaucoma, \nb/l TKA ___ and ___ L TKA c/b\npolymicrobial infection - currently on suppressive\nMoxifloxacin/Fluconazole\n\nPSxH:\n-___ - Bentall Procedure with 27 mm Medetronic root valve \n\nand coronary artery bypass grafting x 3 (Ao valve, root, ascAo \ngraft replacement with coronary artery reimplantation onto \ngraft): left internal mammary \nartery to left anterior descending artery; saphenous vein graft \nto obtuse marginal branch; saphenous vein graft to \nposterolateral branch\n-___ - Bilateral laminectomy L1-L5 with proximal \nforaminotomies \n-b/l TKA ___ and ___\n \nSocial History:\n___\nFamily History:\nThere is no family history of strokes or significant heart \ndisease per patient \n \nPhysical Exam:\nA&Ox3\nBreathing comfortably on RA\nWWP\nAmbulating independently\n \nPertinent Results:\n___ 09:20AM BLOOD WBC-3.2* RBC-5.15 Hgb-11.5* Hct-38.7* \nMCV-75* MCH-22.3* MCHC-29.7* RDW-18.9* RDWSD-50.8* Plt ___\n___ 09:20AM BLOOD Glucose-145* UreaN-13 Creat-1.0 Na-137 \nK-4.2 Cl-102 HCO3-24 AnGap-15\n \nBrief Hospital Course:\nPt was admitted to Dr. ___ service after bipolar \ntransurethral resection of prostate. No concerning \nintraoperative events occurred; please see dictated operative \nnote for details. He patient received ___ antibiotic \nprophylaxis. The patient's postoperative course was \nuncomplicated. He received intravenous antibiotics and \ncontinuous bladder irrigation overnight. On POD1 the CBI was \ndiscontinued and Foley catheter was removed with an active \nvodiding trial. Pt voided, but with high PVRs up to 900s. \nHence, a ___ coude foley was replaced. He remained a-febrile \nthroughout his hospital stay. At discharge, the patient had \npain well controlled with oral pain medications, was tolerating \nregular diet, ambulating without assistance. He was given oral \npain medications on discharge and a course of antibiotics along \nwith explicit instructions to follow up in clinic with Dr. \n___ a void trial.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Docusate Sodium 100 mg PO BID \n3. Fluconazole 100 mg PO Q24H \n4. Metoprolol Tartrate 50 mg PO Q8H \n5. Pravastatin 20 mg PO QPM \n6. Sarna Lotion 1 Appl TP QID:PRN itching \n7. Tamsulosin 0.4 mg PO QHS \n8. DiphenhydrAMINE 25 mg PO Q6H:PRN itching \n9. Amoxicillin 400 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO ONCE Duration: 1 \nDose \ntake morning of foley removal \nRX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 \ncapsule(s) by mouth once Disp #*1 Capsule Refills:*0 \n3. 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 \n4. Amoxicillin 400 mg PO DAILY \n5. DiphenhydrAMINE 25 mg PO Q6H:PRN itching \n6. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*40 Capsule Refills:*0 \n7. Fluconazole 100 mg PO Q24H \n8. Metoprolol Tartrate 50 mg PO Q8H \n9. Pravastatin 20 mg PO QPM \n10. Sarna Lotion 1 Appl TP QID:PRN itching \n11. Tamsulosin 0.4 mg PO QHS \n12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until your follow up appointment\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBPH\n\n \nDischarge Condition:\nA&Ox3\nAbd S/ND/NT\nWWP\nAmbulating independently\nFoley in place\n\n \nDischarge Instructions:\n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor.  \n\nShould you HOLD ASPIRIN? Unless otherwise advised;  If the urine \nis still pink, hold the aspirin until it has been clear/yellow \nfor at least three days. \n\n-If prescribed; complete the full course of antibiotics.\n\n-You may be discharged home with a medication called PYRIDIUM \nthat will help with the \"burning\" pain you may experience when \nvoiding. This medication may turn your urine bright orange.\n\n-Colace has been prescribed to avoid post surgical constipation \nand constipation related to narcotic pain medication. \nDiscontinue if loose stool or diarrhea develops. Colace is a \nstool softener, NOT a laxative\n\n- AVOID STRAINING for bowel movements as this may stir up \nbleeding.\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\n\n-Do not lift anything heavier than a phone book (10 pounds) or \nparticipate in high intensity physical activity for a minimum of \nfour weeks or until you are cleared by your Urologist in \nfollow-up\n\n-Tylenol should be your first line pain medication, a narcotic \npain medication has been prescribed for breakthrough pain >4. \nReplace Tylenol with narcotic pain medication.\n\n-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL \nsources, note that narcotic pain medication also contains \nTylenol\n\n-Do not drive or drink alcohol while taking narcotics and do not \noperate dangerous machinery. Also, if the Foley catheter and Leg \nBag are in place--Do NOT drive (you may be a passenger).\n\nWHEN YOU ARE DISCHARGED WITH A FOLEY CATHETER:\n-Please also reference the nursing handout and instructions on \nroutine care and hygiene\n\n-Your Foley should be secured to the catheter secure on your \nthigh at ALL times until your follow up with the surgeon.\n\n-IF YOU HAVE A PRESCRIPTION FOR DITROPAN/OXYBUTININ: YOU MUST \nSTOP at least 24hours before planned foley removal and void \ntrial.\n\n-DO NOT have anyone else other than your Surgeon or your \nsurgeon's representative remove your Foley for any reason.\n\n-Wear Large Foley bag for majority of time; the leg bag is only \nfor short-term periods for when leaving the house.\n\n-Do NOT drive if you have a Foley in place (for your safety)\n\n \nFollowup Instructions:\n___\n" ]

[ "C61", "R339", "E785", "I10", "I2510", "Z951", "Z952", "Z8673", "H409", "T8453XD", "Y831" ]

[ "C61: Malignant neoplasm of prostate", "R339: Retention of urine, unspecified", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z952: Presence of prosthetic heart valve", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "H409: Unspecified glaucoma", "T8453XD: Infection and inflammatory reaction due to internal right knee prosthesis, subsequent encounter", "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" ]

[ "E785", "I10", "I2510", "Z951", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \noxycodone / Omnipaque / adhesive tape\n \nAttending: ___\n \n___ Complaint:\nLeft total knee replacement\n \nMajor Surgical or Invasive Procedure:\n___: Left total knee replacement\n\n \nHistory of Present Illness:\n___ w/ DM2 (A1C 8.5%), CHF (exercise stress ___ with ___ METS; \nsevere global LV systolic dysfunction mixed \nischemic/non-ischemic cardiomyopathy), CAD, OSA s/p L TKA (Dr. \n___, ___.\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes Type II\n- Hypertension \n- Dyslipidemia \n\n2. CARDIAC HISTORY \nCORONARIES: mid LAD 60% stenosis, lesion on mid CX 30% stenosis; \nlesion on mid RCA 50% stenosis; lesion on R PDA 90% stenosis \nPUMP: LVEF 34% with RWMA on TTE, 20% on RHC, dilated LV chamber; \nLAE; 2 to 3+ MR; 2+ TR est SPAP 31 mmhg\nRHYTHM: Sinus \n\n3. OTHER PAST MEDICAL HISTORY \nChronic Kidney Disease\nTAH\nTotal Knee replacement RT\nRotator cuff R\nMiniscus tear R \n \nSocial History:\n___\nFamily History:\n- Mother: History of MI at age ___ remote colorectal cancer;\nvalve replacement\n- Father: Fatal MI age ___\n- Siblings: Sister with sinus issues, arthritis; \n- Sister with a mild arrhythmia (possibly atrial fibrillation)\n- Paternal grandmother with a valve replacement and an enlarged\nheart\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* 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___ 05:22AM BLOOD WBC-9.6 RBC-3.33* Hgb-9.5* Hct-29.5* \nMCV-89 MCH-28.5 MCHC-32.2 RDW-12.8 RDWSD-41.1 Plt ___\n___ 05:13AM BLOOD WBC-11.2* RBC-3.25* Hgb-9.2* Hct-29.0* \nMCV-89 MCH-28.3 MCHC-31.7* RDW-12.7 RDWSD-41.8 Plt ___\n___ 05:36AM BLOOD WBC-9.8 RBC-3.53* Hgb-10.2* Hct-31.5* \nMCV-89 MCH-28.9 MCHC-32.4 RDW-12.8 RDWSD-41.2 Plt ___\n___ 05:22AM BLOOD Creat-1.1\n___ 05:13AM BLOOD Creat-1.3*\n___ 05:36AM BLOOD Glucose-175* UreaN-27* Creat-1.2* Na-147 \nK-4.6 Cl-104 HCO3-27 AnGap-16\n___ 05:36AM BLOOD Calcium-9.0 Phos-4.9* Mg-1.6\n___ 11:46AM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 11:46AM URINE Blood-NEG Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM*\n___ 11:46AM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-RARE* \nEpi-9\n___ 11:46AM URINE CastHy-13*\n___ 11:46AM URINE Mucous-RARE*\n \nBrief Hospital Course:\nThe patient was admitted to the orthopedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nPOD #1, patient was triggered for hypotension, BP ___ with \ncomplaint of slight dizziness. BPs improved to 95/60 without \nfurther intervention. Patient was not administered IV fluids \nsecondary to history of CHF with EF ___.\nPOD #2, a urinalysis was obtained due to slight increase in WBC \nof 11.2 from 9.8. Results showed urine hazy, small leukocytes, \nepi 9, negative nitrites.\nUrine cultures were pending at the time of discharge and patient \nwill be contacted if further treatment is needed. \nPOD #3, WBC downtrended to 9.6 and patient remained afebrile.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 325 mg twice \ndaily for DVT prophylaxis starting on the morning of POD#1. The \nsurgical dressing 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. \n \nMs. ___ is discharged to home with services in stable \ncondition.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Lantus U-100 Insulin (insulin glargine) 100 unit/mL \nsubcutaneous BID \n4. Metoprolol Succinate XL 75 mg PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. Ranitidine 150 mg PO BID \n7. Sertraline 100 mg PO DAILY \n8. Torsemide 10 mg PO DAILY \n9. Valsartan 80 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Docusate Sodium 100 mg PO BID \n3. Gabapentin 300 mg PO TID \n4. Pantoprazole 40 mg PO Q24H \n5. Senna 8.6 mg PO BID \n6. TraMADol 50-100 mg PO Q4H:PRN Pain - Moderate \n7. Aspirin 325 mg PO BID \nTake for 4 weeks after surgery to prevent blood clots. \n8. Atorvastatin 80 mg PO QPM \n9. Lantus U-100 Insulin (insulin glargine) 100 unit/mL \nsubcutaneous BID \n10. Metoprolol Succinate XL 75 mg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. Ranitidine 150 mg PO BID \n13. Sertraline 100 mg PO DAILY \n14. Torsemide 10 mg PO DAILY \n15. Valsartan 80 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft knee osteoarthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\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 in three (3) weeks.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n \n8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice \ndaily with food for four (4) weeks to help prevent deep vein \nthrombosis (blood clots). Continue Pantoprazole daily while on \nAspirin to prevent GI upset (x 4 weeks). If you were taking \nAspirin prior to your surgery, take it at 325 mg twice daily \nuntil the end of the 4 weeks, then you can go back to your \nnormal dosing.\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 Staples will be removed by your doctor at follow-up appointment \napproximately 3 weeks after surgery.\n \n10. ___ (once at home): Home ___, dressing changes as \ninstructed, and wound checks.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Mobilize with assistive devices (___) if \nneeded. Range of motion at the knee as tolerated. No strenuous \nexercise or heavy lifting until follow up appointment.\n\nPhysical Therapy:\nWeight bearing as tolerated on the operative extremity. Mobilize \nwith assistive devices (___) if needed. Range of \nmotion at the knee as tolerated. No strenuous exercise or heavy \nlifting until follow up appointment.\n\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\nstaple removal and replace with steri-strips at follow up visit \nin clinic\n\n \nFollowup Instructions:\n___\n" ]

[ "M1712", "E1122", "I428", "I130", "I5020", "E119", "E785", "I2510", "G4733", "N189", "Z96651", "Z794", "I252", "E669", "Z6834", "F419", "F329", "I951" ]

[ "M1712: Unilateral primary osteoarthritis, left knee", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I428: Other cardiomyopathies", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5020: Unspecified systolic (congestive) heart failure", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "G4733: Obstructive sleep apnea (adult) (pediatric)", "N189: Chronic kidney disease, unspecified", "Z96651: Presence of right artificial knee joint", "Z794: Long term (current) use of insulin", "I252: Old myocardial infarction", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "I951: Orthostatic hypotension" ]

[ "E1122", "I130", "E119", "E785", "I2510", "G4733", "N189", "Z794", "I252", "E669", "F419", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \noxycodone / Omnipaque\n \nAttending: ___.\n \nChief Complaint:\nLeg swelling, dyspnea on exertion, orthopnea \n \nMajor Surgical or Invasive Procedure:\nNone\n(Left Heart Catheterization at ___\n \nHistory of Present Illness:\n___ is a ___ year old woman with HTN, HLD, DM2, \nobesity who presents as a transfer from ___ \n___ for management of acute systolic heart failure. \n\nMs. ___ developed a productive cough in ___ that she \nwas told was likely a virus and had two CXRs without \nabnormality, per her report. After this time, she had a \npersistent dry cough that never resolved. In ___ of this \nyear, she was seen in pulmonary clinic by Dr. ___ the \ncough with the following PFTs\n\nFVC 2.25 (70 % predicted)\nFEV1 1.83 (75 % predicted)\nFEV1/FVC 82 (106 % predicted)\nSpirograms and flow-volume loops demonstrate normal contours\n\nShe was also seen by ENT and had a fiberoptic endoscopic \nevaluation of swallowing (FEES) test, although she doesn't know \nthe result of this. \n\nIn ___, she again developed a bad cough and was given \nazithromycin, prednisone and an inhaler. She had a temperature \nas high ad 103 at this time. Her cough persisted. \n\nShe went to ___ ___. Initially was doing very well. She was \nsleeping flat and she walked for 8 hours at ___. On \n___, she felt shortness of breath. Over the next few \ndays, she could not lay flat at night, she became very short of \nbreath and she noticed her legs swelling. By ___, \nshe could not even walk 10 feet without becoming acutely short \nof breath. \n\nShe presented to ED at ___ and after a CTA develop acute \nshortness of breath and was transferred to the ICU for BiPAP.\n\nA TTE showed EF 34% with regional wall mortion abnormalities, \ndilated LV chamber, L atrial enlargement, ___ MR, 2+ TR and \npleural effusion. On ___ cardiac catheterization, EF 20% PCWP \nwas normal, dilated cardiomyopathy, severely depressed LV \nsystolic function. L heart cath with mid LAD 60% stenosis, mid \nCX 30% stenosis; mid RCA 50% stenosis; R PDA 90% stenosis. \n\nShe was diuresed with IV Lasix 40mg with good output, and O2 Sat \n98% on 3L nasal cannula off BiPAP. She was transferred to ___ \nout of concern that her symptoms were out of proportion to\ncardiac findings. \n\nWeights @ ___ \n___ 109.6kg (Net -3.2L, UOP 3.8L)\n___ 104.7kg (Net -3.3L, UOP 4.3L)\n___ 106.6kg (Net -85cc, UOP 875cc)\n___ 106.4kg (Net -180cc, UOP 800cc)\n\nAdmission Labs ___ @ ___ \n___ 11.6\nHgb 10.6\nHct 33.9\nPlt 394\nINR 1.01 \nNa 140\nK 3.4\nCl 101\nCO2 29\nBUN 20\nCr 1.18\nGlucose 139\nCa 9.3\nPhos 5.4\nMg 1.6\nBili 0.6\nAST 23\nALT 57\nAlk Phos 58\nCarboxyhemoglobin 1.8 (Ref 0.5-1.5) \nTroponin I 0.06 -> 0.06 -> 0.05 \nTSH 1.77\nFree T4 0.93 \nUA only with 1+ glucose \nUrine legionella = Negative\nUrine Strep Pneumo = Negative \n___ Blood Cultures = Negative\nFlu B and A = Negative\n\nMedications at ___\nAlbuterol/Ipratropium q4 PRN sob/wheeze\nASA 81 Daily\nAtorvastatin 20mg QPM\nDocusate Sodium 100mg BID PRN constipation\nHeparin 5000 units TID\nInsulin Detemir 25 units BID\nLisinopril 2.5mg daily\nMetop Tartrate 25mg PO q8hrs\nMultivitamin Daily\nProtonix 40mg IV Daily\nSenna 1 tab QHS PRN constipation\nSertraline 100mg PO daily\n\nLasix 40mg IV multiple times \n\n---\nEKG\n---\nSINUS RHYTHM\nPOSSIBLE LEFT ATRIAL ENLARGEMENT ___ P WAVE IN V1/V2]\nMODERATE LEFT AXIS DEVIATION [QRS AXIS < -20]\nNONSPECIFIC T WAVE ABNORMALITY\nABNORMAL ECG\n \n-------------------\nOn Arrival to ___\n-------------------\nShe reported feeling significantly better than the prior few \ndays. Her breathing was comfortable at rest, though she had not \ntried to walk at all. Her legs seemed much thinner. She still \nhad a persistent cough, though it felt improved.\n- Given IV Lasix 40mg \n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes Type II\n- Hypertension \n- Dyslipidemia \n\n2. CARDIAC HISTORY \nCORONARIES: mid LAD 60% stenosis, lesion on mid CX 30% stenosis; \nlesion on mid RCA 50% stenosis; lesion on R PDA 90% stenosis \nPUMP: LVEF 34% with RWMA on TTE, 20% on RHC, dilated LV chamber; \nLAE; 2 to 3+ MR; 2+ TR est SPAP 31 mmhg\nRHYTHM: Sinus \n\n3. OTHER PAST MEDICAL HISTORY \nChronic Kidney Disease\nTAH\nTotal Knee replacement RT\nRotator cuff R\nMiniscus tear R \n \nSocial History:\n___\nFamily History:\n- Mother: History of MI at age ___ remote colorectal cancer;\nvalve replacement\n- Father: Fatal MI age ___\n- Siblings: Sister with sinus issues, arthritis; \n- Sister with a mild arrhythmia (possibly atrial fibrillation)\n- Paternal grandmother with a valve replacement and an enlarged\nheart\n \nPhysical Exam:\n=======================\nADMISSION PHYSICAL EXAM\n=======================\nVS: BP 96/61, HR 95, RR 18, O2 93RA \n\nGENERAL: Comfortable appearing woman sitting in bed speaking to \nus in no apparent distress \nHEENT: Sclera anicteric. Pupils equal. Moist mucous membranes. \nNo xanthelasma. \nNECK: Supple. JVP mid-neck at 30 degrees. \nCARDIAC: S1/S2 regular with distant heart sounds and no obvious \nmurmurs or S3/S4. \nLUNGS: No use of accessory muscles, crackles at the bases \nbilaterally. \nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: No lower extremity edema. Feet cool, but shins \nwarm.\n\n=======================\nDISCHARGE PHYSICAL EXAM\n=======================\n24 HR Data (last updated ___ @ 1209)\nTemp: 97.6 (Tm 98.4), \nBP: 105/49 (96-110/47-73),\nHR: 82 (82-102), \nRR: 20 (___), \nO2 sat: 97% (95-99), O2 delivery: RA \n \nFluid Balance (last updated ___ @ 808) \n Last 8 hours Total cumulative -250ml\n IN: Total 0ml\n OUT: Total 250ml, Urine Amt 250ml\n Last 24 hours Total cumulative -680ml\n IN: Total 420ml, PO Amt 420ml\n OUT: Total 1100ml, Urine Amt 1100ml \n\nGENERAL: Well appearing woman sitting up in bed and reading. \nHEENT: Sclera anicteric. Pupils equal. Moist mucous membranes. \nNo xanthelasma. \nNECK: Supple. No jugular venous distension. \nCARDIAC: S1/S2 regular with distant heart sounds and no obvious \nmurmurs or S3/S4. \nLUNGS: No use of accessory muscles, lungs clear to auscultation \nbilaterally.\nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: No lower extremity edema. Feet cool, but shins \nwarm.\n \nPertinent Results:\n============================\nADMISSION LABORATORY RESULTS\n============================\n___ 05:00PM WBC-9.6 RBC-3.73* HGB-10.8* HCT-34.2 MCV-92 \nMCH-29.0 MCHC-31.6* RDW-13.7 RDWSD-46.0\n___ 05:00PM GLUCOSE-296* UREA N-24* CREAT-1.1 SODIUM-138 \nPOTASSIUM-5.3* CHLORIDE-100 TOTAL CO2-27 ANION GAP-11\n___ 05:00PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-2.0 \nCHOLEST-170\n___ 08:48PM %HbA1c-8.5* eAG-197*\n___ 05:00PM ___ PTT-26.0 ___\n\n==========================================\nDISCHARGE AND PERTINENT LABORATORY RESULTS\n==========================================\n___ 05:00PM TRIGLYCER-227* HDL CHOL-56 CHOL/HDL-3.0 \nLDL(CALC)-69\n\n___ 07:51AM BLOOD WBC-10.6* RBC-4.04 Hgb-11.8 Hct-36.7 \nMCV-91 MCH-29.2 MCHC-32.2 RDW-13.8 RDWSD-45.3 Plt ___\n___ 07:51AM BLOOD Glucose-143* UreaN-25* Creat-1.1 Na-139 \nK-4.4 Cl-97 HCO3-28 AnGap-14\n___ 07:51AM BLOOD Calcium-9.4 Phos-4.8* Mg-2.0\n___ 12:45PM BLOOD calTIBC-296 Ferritn-163* TRF-228\n___ 08:48PM BLOOD %HbA1c-8.5* eAG-197*\n___ 12:45PM BLOOD PEP-NO SPECIFI FreeKap-26.5* FreeLam-24.4 \nFr K/L-1.1\n\n===============\nIMAGING STUDIES\n===============\n___ CARDIAC MRI\nFINDINGS\n- Left Atrium ___ Veins (PV): Mildly increased ___ \n___. Moderately elongated.\n- Right Atrium (RA)/Coronary Sinus: Moderate RA dilation. Normal \ncoronary sinus diameter.\n- Left Ventricle (LV): Normal wall thickness. Normal mass. \nNormal mass index. Moderately increased ___. MIldly increased \n___ index. Mod increased EDV. Mildly increased EDVI. SEVERE \nglobal hypokinesis. SEVERELY depressed EF. Regional early GE. \nMidwall LGE.\n- Right Ventricle (RV): Normal cavity size. Normal \nregional/global free wall motion Low normal ejection fraction \n(EF).\n- Aorta: Normal origin of RCA and L main coronary arteries. \nNormal ascending aorta diameter. Normal aortic arch diameter. \nNormal descending aorta diameter. Normal abdominal aorta \ndiameter. \n- Pulmonary Artery: Mildly dilated. Normal BSA indexed PA \ndiameter.\n- Aortic Valve (AV): ?# leaflets. No stenosis. Mild \nregurgitation.\n- Mitral Valve (MV): Mod-severe regurgitation.\n- Pulmonic Valve (PV)/Tricuspid Valve (TV): Mild pulmonic \nregurgitation. Mod tricuspid regurgitation.\n- Pericardium/Pleura: Small effusion. Normal thickness. Small \nleft\npleural effusion. Small right pleural effusion.\n\nNon-cardiac Findings\nThere is a small right pleural effusion There is a small left \npleural effusion.\nThere is a small right pleural effusion.\n\nCONCLUSION/IMPRESSION\nThe left atrial AP dimension is mildly increased with moderate \nleft atrial elongation. The right atrium is moderately dilated. \nThere is normal left ventricular wall thickness with normal \nmass. and normal mass index. Moderately increased left \nventricular end-diastolic dimension with moderately increased \nleft ventricular end-diastolic volume. and mildly increased \nend-diastolic volume index. There is SEVERE global left \nventricular hypokinesis with SEVERELY depressed ejection \nfraction.\nEarly gadolinium enhancement images showed mid wall regional \nenhancement of the mid inferoseptal wall at the inferior RV \ninsertionpoint. There is mid-wall late gadolinium enhancement in \nthe mid inferoseptal wall at the inferior RV insertion point c/w \nnon-ischemic cardiomyopathy. Normal right ventricular cavity \nsize with normal regional/global free wall motion and low normal \nejection fraction. Normal origin of the right and left main \ncoronary arteries. Normal ascending\naorta diameter with normal aortic arch diameter and normal \ndescending thoracic aorta diameter. Normal abdominal aorta \ndiameter. Mildly increased pulmonary artery diameter. with \nnormal BSA indexed PA diameter. The # of aortic valve leaflets \ncould not be determined. There is no aortic valve stenosis. Mild \naortic regurgitation is seen. There is moderate to severe mitral \nregurgitation. There is moderate tricuspid regurgitation. There \nis a small pericardial effusion. Pericardial thickness is \nnormal. There is a small left pleural effusion. There is a small \nright pleural effusion.\n\nIMPRESSION: Mild to moderate dilatation of left ventricular \ncavity with severe global hypokinesis and akinesis of basal to \nmid septum. Normal right ventricular cavity size and free wall \nmotion. Early and late transmural gadolinium enhancement of the \nmid inferoseptum and inferior wall. Moderate to severe mitral \nregurgitation. Moderate tricuspid regurgitation. Overall \nfindings are most consistent with mixed ischemic and nonischemic \ncardiomyopathy. \n\n___ CT CHEST WITHOUT CONTRAST\n\nFINDINGS: \nTHORACIC INLET: Thyroid is unremarkable. There are no enlarged \nsupraclavicular lymph nodes\n \nBREAST AND AXILLA : There are no enlarged axillary lymph nodes\n \nMEDIASTINUM: There are no enlarged mediastinal hilar lymph \nnodes. There is mild coronary artery calcification. Heart size \nis top-normal. There is no pericardial effusion. The aorta and \npulmonary artery are normal in caliber. The airways are patent \nup to the subsegmental level\n \nThere is a small right pleural effusion.\n \nLUNG: Lungs are well expanded and clear. There is minimal \nbibasilar\natelectasis. No lung nodules are seen\n \nBONES AND CHEST WALL : Review of bones shows degenerative \nchanges involving the thoracic spine\n \nUPPER ABDOMEN: Limited sections through the upper abdomen are \nunremarkable\n \nIMPRESSION: \nNo evidence of sarcoidosis are infiltrative lung disease.\nCoronary artery calcification.\nSmall right pleural effusion\n\n___ TTE\nThe left atrial volume index is moderately increased. No atrial \nseptal defect is seen by 2D or color Doppler. The estimated \nright atrial pressure is ___ mmHg. Left ventricular wall \nthicknesses are normal. The left ventricular cavity is \nmoderately dilated. There is severe global left ventricular \nhypokinesis (LVEF = ___ %). The lateral wall is relatively \npreserved. Systolic function of apical segments is relatively \npreserved. Tissue Doppler imaging suggests an increased left \nventricular filling pressure (PCWP>18mmHg). There is no \nventricular septal defect. The right ventricular free wall \nthickness is normal. Right ventricular chamber size is normal \nTricuspid annular plane systolic excursion is depressed (1.4 cm) \nconsistent with right ventricular systolic dysfunction. The \ndiameters of aorta at the sinus, ascending and arch levels are \nnormal. The aortic valve leaflets (3) appear structurally normal \nwith good leaflet excursion and no aortic stenosis or aortic \nregurgitation. The mitral valve leaflets are mildly thickened. A \ncentrally directed jet of Moderate (2+) mitral regurgitation is \nseen. There is borderline pulmonary artery systolic \nhypertension. There is a trivial/physiologic pericardial \neffusion. \n\nIMPRESSION: Severe global left ventricular systolic dysfunction \nwith relative apical and lateral wall preservation suggestive of \nnon-ischemic cardiomyopathy. Depressed global right ventricular \nsystolic function. Moderate mitral regurgitation. \n\n============\nMICROBIOLOGY\n============\nNONE\n\n \nBrief Hospital Course:\n=================\nSUMMARY STATEMENT\n=================\n___ is a ___ year old woman with HTN, HLD, DM2, \nobesity who presents as a transfer from ___ \n___ for management of acute systolic heart failure. She was \nin her normal state of health as recently as one week prior to \nher ___ admission (walking multiple hours a day). On \n___ she developed shortness of breath, and within several days \nhad significant lower extremity edema and inability to walk even \na few feet. She was diuresed at ___ and at ___ with \nsignificant symptomatic improvement. Given that a coronary \nangiography did not demonstrate occlusive disease, we conducted \na thorough workup for heart failure etiology. \n\n====================\nACUTE MEDICAL ISSUES\n====================\n# CORONARIES: mid LAD 60% stenosis, lesion on mid CX 30% \nstenosis; lesion on mid RCA 50% stenosis; lesion on R PDA 90% \nstenosis \n# PUMP: LVEF 34% with RWMA, dilated LV chamber; LAE; 2 to 3+ MR; \n2+ TR est SPAP 31 mmhg\n# RHYTHM: Sinus \n\n#Acute Heart Failure with Reduced EF (20%)\nPatient presents with several months of cough and two weeks of \nlower extremity swelling with acute hypoxic respiratory failure \nafter CTA. Found to have LVEF 20% with LV dilation, ___, \n2+TR. No evidence of obstructive coronary disease, but did have \nregional wall motion abnormalities on ___ Echo. Repeat \nTTE again at ___ showed: Severe global left ventricular \nsystolic dysfunction with relative apical and lateral wall \npreservation suggestive of non-ischemic cardiomyopathy. \nDepressed global right ventricular systolic function. Moderate \nmitral regurgitation.\" Cardiac MRI: \"Overall findings are most \nconsistent with mixed ischemic and nonischemic cardiomyopathy.\" \nDoes have history of recent recurrent viral infections, so it is \npossible that a viral myocarditis was missed. Possible she's had \nprior MI with 90% PDA occlusion, though less likely that \ninflammatory of infiltrative cardiomyopathy. She also has a \nhistory of sinus tachycardia and was borderline tachycardia \nthroughout her admission, again raising concern for inflammatory \ncardiomyopathy. She was treated with IV Lasix at ___ and \ninitially at ___, then with torsemide 20mg and eventually \ntorsemide 10mg, on which she was mildly net negative to even. \n- Preload: Torsemide 10mg daily to be continued at discharge\n- Afterload: Valsartan 80mg daily to be continued at discharge \n(new)\n- NHB: Metop succinate 75mg (to help with tachycardia)\n\n#Hypertension\nHad recently been on lisinopril and atenolol as an outpatient, \nbut these had recently been held. She was treated with \nlisinopril and metoprolol at ___, but we stopped \nlisinopril out of concern it may be contributing to her chronic \ncough. Valsartan 80mg daily and metop succinate 75mg daily at \ndischarge \n\n#Chronic cough\nPersistent dry cough since her first viral illness in ___. Somewhat improved during her hospitalization. Seen by \npulmonology here with unremarkable PFTs. Stopped her ACEi and \nstarted on omeprazole for trial of PPI at this admission. \n\n#Hyperlipidemia\nAtorvastatin 20mg QHS was increased to 80mg. Continued on ASA \n81. \n\n#Type 2 DM\nOn lantus 25units BID and metformin 850mg TID. Held metformin in \nsetting of CTA at OSH and put on sliding scale. Metformin \nrestarted prior to discharge.\n\n======================\nCHRONIC MEDICAL ISSUES\n======================\nDepression: continued Sertraline 100mg PO daily\n\n====================\nTRANSITIONAL ISSUES:\n====================\n- New Meds: Torsemide 10mg daily; Valsartan 80mg daily; \nOmeprazole 20mg daily; Metop succinate 75mg daily; \n- Stopped/Held Meds: Losartan 25mg daily; \n- Changed Meds: Atorvastatin 80mg (previously 20mg) \n- Incidental Findings: none\n- Discharge weight: 101 kg (222.66 lb) \n\n- Post-Discharge Follow-up Labs Needed:\n\n[] please check Chem 10 (NA, K, Cl, HCO3, BUN, Cr, Ca, Mg, Phos) \nat patient f/u cardiology appointment with Dr. ___ / \n___ Cardiology to monitor renal function and \nelectrolytes\n\n# CODE: Full Code \n# CONTACT: ___, SISTER \n___ ___)\nOther Phone ___ \n\n[ ] Patient will need continued titration of her torsemide \ndosing. Was net negative even on torsemide 10mg, but likely \nlower PO intake than at home. \n\n[ ] Monitor chronic cough. Stopped ACEi and started on \nomeprazole, but unclear if this has benefitted her. please \nfollow up cough symptoms after ___ weeks of omeprazole and \nconsider discontinuing omeprazole if no significant improvement \nin cough\n\n[ ] Monitor sinus tachycardia that may be secondary to \ncardiomyopathy. Patient had been on atenolol until a few weeks \nbefore admission, and was started on metoprolol while inpatient \nwith rates 90-100. \n\n[ ] please assure that patient gets insurance approval to see \nDr. ___ (heart failure specialist) prior to her ___ \nvisit\n\n[ ] please continue to assess ability to uptitrate beta blocker \nas an outpatient\n\n[] please consider sending hepatitis B/C panel, HIV in order to \nfully work up patient's heart failure\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Glargine 25 Units Breakfast\nGlargine 25 Units Bedtime\n4. Losartan Potassium 25 mg PO DAILY \n5. MetFORMIN (Glucophage) 850 mg PO TID \n6. Multivitamins 1 TAB PO DAILY \n7. Sertraline 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Metoprolol Succinate XL 75 mg PO DAILY \nRX *metoprolol succinate 50 mg 1.5 tablet(s) by mouth daily Disp \n#*60 Tablet Refills:*0 \n2. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n3. Torsemide 10 mg PO DAILY \nRX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4. Valsartan 80 mg PO DAILY \nRX *valsartan 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n5. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n6. Aspirin 81 mg PO DAILY \n7. Glargine 25 Units Breakfast\nGlargine 25 Units Bedtime \n8. MetFORMIN (Glucophage) 850 mg PO TID \n9. Multivitamins 1 TAB PO DAILY \n10. Sertraline 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n=================\nPRIMARY DIAGNOSIS\n=================\nHFrEF, new diagnosis, acute\n\n===================\nSECONDARY DIAGNOSES\n===================\nDM2\nCAD\nHLD\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou came into the hospital because you were having shortness of \nbreath and swelling in your legs. \n\nAt ___, you were found to have blockages in your heart; \nit did not seem like these were new or causing a new heart \nattack, but they may have been there for a while and contributed \nto your shortness of breath.\n\nYou were found to have new heart failure, which means the heart \nis not pumping as well as it should be. This is what caused your \nbody to accumulate fluid. You were given IV diuretics. You were \ntransferred to ___ to be evaluated by our Heart Failure team.\n\nWe did a lot of tests, including an echocardiogram (heart \nultrasound), a heart MRI, and a stress test. We did all of this \nto find out what caused your heart failure.\n\nThese tests showed that it is probably blockages in the arteries \n(atherosclerosis/plaques or heart attacks) that caused your \nheart failure. The MRI that we did showed that there may be \npossibly another reason (such as inflammation from a virus in \nthe past) that also may have contributed to your heart failure.\n\nWHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL\n===========================================\nPlease take all of your medications as prescribed.\n\nPlease keep all follow-up appointments that we have made for \nyou.\n\nPlease weigh yourself every day, and call your doctor \nimmediately if your weight goes up by more than 3 pounds in 24 \nhours.\n\nWeight at discharge: 101 kg (222.66 lb) \n\n**Note: your insurance company is requiring that you get an \ninsurance referral to see Dr. ___ failure \nspecialist.) Please call them to discuss this before you go to \nsee Dr. ___. (His NPI number is ___. \n\nIt was a pleasure taking care of you at ___.\n\nSincerely,\nYour ___ Cardiology Team\n \nFollowup Instructions:\n___\n" ]

[ "I5021", "I428", "I081", "E119", "I2510", "E785", "I10", "R000", "E669", "Z794", "F329", "R05", "Z96651", "Z6838" ]

[ "I5021: Acute systolic (congestive) heart failure", "I428: Other cardiomyopathies", "I081: Rheumatic disorders of both mitral and tricuspid valves", "E119: Type 2 diabetes mellitus without complications", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "R000: Tachycardia, unspecified", "E669: Obesity, unspecified", "Z794: Long term (current) use of insulin", "F329: Major depressive disorder, single episode, unspecified", "R05: Cough", "Z96651: Presence of right artificial knee joint", "Z6838: Body mass index [BMI] 38.0-38.9, adult" ]

[ "E119", "I2510", "E785", "I10", "E669", "Z794", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \noxycodone / Omnipaque / adhesive tape\n \nAttending: ___.\n \nChief Complaint:\nCough\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with a history of mixed ischemic/non-ischemic HFrEF (EF\n___, type II diabetes mellitus, HTN, HLD, and CKD, who\npresented to the ED with dyspnea on exertion and cough.\n\nPatient reports she discontinued torsemide in ___ per\nthe recommendation of her outpatient cardiologist. Since then, \nhe\nhas developed progressive shortness of breath on exertion.\nCurrently she feels short of breath after climbing only four\nsteps, needing to stop to take a breath. Associated chronic dry\ncough, which has worsened over the past few weeks. Denies chest\npain, on exertion or at rest, palpitations, light-headedness,\ndizziness, orthopnea, or PND. However, she does report a\n\"gurgling\" sound in her chest when she lies down. With regards \nto\nher weight, she has gained ~20lbs since ___ (currently\n~240lbs from dry weight ~220lbs). Otherwise denies any other\nsymptoms. She tries to adhere to a low salt diet but\nunfortunately has not been compliant in recent weeks as her\nhusband passed away on ___ 10 in early ___ and was\nhospitalized for one month prior to this. She has understandably\nfelt very low since then. \n\nIn the ED, initial vital signs were notable for;\nTemp 97.4 HR 102 BP 163/90 RR 20 SaO2 99% RA\n\nExamination was notable for;\n2+ pitting edema, JVP elevated at 90 degrees, clear lungs\nbilaterally\n\nLabs were notable for;\nWBC 10.3 Hgb 12.8 Plt 279\nNa 139 K 5.1 Cl 102 HCO3 24 BUN 19 Cr 1.0 Plt 261\nALT 20 AST 15 ALP 79 LDH 268 Tbili 0.5 Alb 4.1\nTrop-T <0.01 NT-proBNP 1832\nLactate 1.4\n\nUrine studies notable for negative leuks, negative nitrites, 0\nWBC, and no bacteria.\n\nCXR demonstrated low lung volumes without focal consolidation or\npulmonar edema.\n\nEKG with rate of 103bpm, sinus rhythm, leftward axis, IVCD with\nleft bundaloid appearance, prolonged QTc, intra-atrial \nconduction\ndelay, poor R wave progression, Q wave in III, non-specific ST-T\nabnormalities, similar to prior.\n\nPatient was given;\n- IV furosemide 40mg \n\nVital signs on transfer notable for;\n\nUpon arrival to the floor, patient repeats the above story.\nReports significant urine output since she received IV \nfurosemide\nin the ED earlier today. Happy her weight is already 4lbs less\nsince she received furosemide. Currently denies chest pain,\nshortness of breath, palpitations, light-headedness, or\ndizziness.\n\n \nPast Medical History:\n- Mixed ischemic/non-ischemic cardiomyopathy/HFrEF (EF ___\n- CAD (60% mid LAD, 30% mid LCx, 50% mid RCA, 90% RPDA)\n- Mitral/Tricuspid regurgitation, likely functional\n- Type II diabetes mellitus\n- HTN\n- HLD\n- CKD\n- GERD\n- Right TKR\n- Right rotator cuff tear\n- Total abdominal hysterectomy\n \nSocial History:\n___\nFamily History:\nMother with history of MI at age ___, valve replacement and \nremote\ncolorectal cancer. Father died secondary to MI at age ___. Sister\nwith arrhythmia (possibly AF) and multiple stents. Paternal\ngrandmother with an \"enlarged heart\".\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: Temp 98.9 BP 163/72 HR 81 RR 18SaO2 96% RA\nGENERAL: sitting comfortably in bed, no distress\nHEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM\nNECK: supple, non-tender, JVP ~15cm at 90 degrees\nCV: RRR, S1 and S2 normal, no murmurs/rubs/gallops\nRESP: CTAB, no wheezes/crackles\n___: soft, non-tender, obese, BS normoactive\nEXTREMITIES: warm, well perfused, 2+ lower extremity edema\nNEURO: A/O x3, grossly intact\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: 24 HR Data (last updated ___ @ 541)\n Temp: 98.3 (Tm 100.0), BP: 93/58 (93-129/58-78), HR: 90\n(79-109), RR: 18 (___), O2 sat: 98% (95-98), O2 delivery: RA \nGENERAL: sitting comfortably in bed, no distress\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, JVP 8-9 cm\nCV: RRR, S1 and S2 normal, no murmurs/rubs/gallops\nRESP: CTAB\n___: soft, non-tender, obese\nEXTREMITIES: warm, well perfused, no ___ edema\nNEURO: alert, grossly intact\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:03PM BLOOD WBC-10.3* RBC-4.41 Hgb-12.8 Hct-39.2 \nMCV-89 MCH-29.0 MCHC-32.7 RDW-13.7 RDWSD-44.6 Plt ___\n___ 05:03PM BLOOD Neuts-58.7 ___ Monos-5.5 Eos-2.4 \nBaso-0.6 Im ___ AbsNeut-6.03 AbsLymp-3.31 AbsMono-0.57 \nAbsEos-0.25 AbsBaso-0.06\n___ 05:03PM BLOOD Glucose-261* UreaN-19 Creat-1.0 Na-139 \nK-5.1 Cl-102 HCO3-24 AnGap-13\n___ 05:03PM BLOOD ALT-20 AST-15 LD(LDH)-268* AlkPhos-79 \nTotBili-0.5\n___ 05:03PM BLOOD cTropnT-<0.01\n___ 05:03PM BLOOD proBNP-1832*\n___ 05:03PM BLOOD Albumin-4.1 Calcium-9.6 Phos-3.3 Mg-1.7\n___ 05:03PM BLOOD TSH-1.1\n___ 05:08PM BLOOD Lactate-1.4\n___ 05:43PM URINE Color-Yellow Appear-Clear Sp ___\n___ 05:43PM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 \nLeuks-NEG\n___ 05:43PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE \nEpi-<1\n\nINTERVAL LABS:\n==============\n___ 08:21AM BLOOD %HbA1c-9.2* eAG-217*\n___ 08:06AM BLOOD Triglyc-275* HDL-56 CHOL/HD-5.2 \nLDLcalc-181*\n\nDISCHARGE LABS:\n===============\n___ 07:42AM BLOOD WBC-10.0 RBC-4.26 Hgb-12.5 Hct-38.4 \nMCV-90 MCH-29.3 MCHC-32.6 RDW-14.0 RDWSD-46.0 Plt ___\n___ 07:42AM BLOOD Glucose-164* UreaN-41* Creat-1.5* Na-138 \nK-4.2 Cl-97 HCO3-28 AnGap-13\n___ 07:42AM BLOOD Calcium-9.5 Phos-5.4* Mg-1.8\n\nMICROBIOLOGY:\n=============\nNone\n\nIMAGING AND REPORTS:\n====================\nCHEST (PA & LAT) ___\nFINDINGS:\nThere are low lung volumes. No focal consolidation, pleural \neffusion, \nevidence of pneumothorax is seen. Cardiac silhouette size is \nlikely \naccentuated by low lung volumes and appears borderline to mildly \nenlarged. Mediastinal contours are unremarkable. No pulmonary \nedema is seen. \nIMPRESSION:\nLow lung volumes without focal consolidation.\n\nTRANSTHORACIC ECHO REPORT ___\nCONCLUSION:\nThe left atrial volume index is normal. The estimated right \natrial pressure is ___ mmHg. There is normal left ventricular \nwall thickness with a normal cavity size. There is SEVERE global \nleft ventricular hypokinesis and relative preservation of apical \nfunction. No thrombus or mass is seen in the left ventricle. \nQuantitative biplane left ventricular ejection fraction is 13 %. \nLeft ventricular cardiac index is depressed (less than 2.0 \nL/min/m2). There is no resting left ventricular outflow tract \ngradient.\nNo ventricular septal defect is seen. Tissue Doppler suggests an \nincreased left ventricular filling pressure (PCWP greater than \n18 mmHg). Normal right ventricular cavity size with normal free \nwall motion.\nTricuspid annular plane systolic excursion (TAPSE) is normal. \nThe aortic sinus diameter is normal for gender with normal \nascending aorta diameter for gender. The aortic arch diameter is \nnormal. There is no evidence for an aortic arch coarctation. The \naortic valve leaflets (3) appear structurally normal. There is \nno aortic valve stenosis. There is no aortic regurgitation. The \nmitral valve leaflets are mildly thickened.\nThere is an eccentric, inferolateral directed jet of mild to \nmoderate [___] mitral regurgitation. Due to the Coanda effect, \nthe severity of mitral regurgitation could be UNDERestimated. \nThe tricuspid valve\nleaflets appear structurally normal. There is trivial tricuspid \nregurgitation. The pulmonary artery systolic pressure could not \nbe estimated. There is a trivial pericardial effusion.\nIMPRESSION: Suboptimal image quality. Top normal left \nventricular cavity size with severe global hypokinesis in a \npattern most c/w a non-ischemic cardiomyopathy. Mild-moderate \nmitral regurgitation.\nCompared with the prior TTE (images reviewed) of ___ , \nthe left ventricular ejection fraction is further reduced.\n \nBrief Hospital Course:\n___ with a history of mixed ischemic/non-ischemic HFrEF (EF \n___, type II diabetes mellitus, HTN, HLD, and CKD, who \npresented to the ED with dyspnea on exertion and cough, in the \nsetting of decompensated heart failure. \n\n====================\nACUTE/ACTIVE ISSUES:\n====================\n#Acute on chronic HFrEF (EF 25%-30%). Patient presents with one \nmonth of weight gain, progressive dyspnea on exertion, and \nworsening chronic cough, in the setting of stopping\ntorsemide in ___. Prior to this date, the patient had \nexperienced a recovery in her EF to 45-50%. She has also \nreported stopping her ___ and ___ statin in the ___. \nVolume overload was felt to have occurred in the setting of \ndiuretic discontinuation as well as dietary indiscretion given \nthe recent passing of her husband earlier this month. BNP on \narrival was felt to be elevated at 1832. Repeat TTE on this \nadmission once again showed reduced EF, felt to be similar on \nimaging to her TTE from ___ (EF ___. She received IV Lasix \nwith improvement in her symptoms before being transitioned to \nTorsemide 40 mg daily on discharge. She has also been started on \nEntresto and restarted her on her home Metoprolol. \n\n#CAD\n#Hyperlipidemia. Patient reports discontinuation of atorvastatin \ndue to muscle cramps. She was continued on home ASA and started \non Rosuvastatin.\n\n#Type 2 diabetes mellitus. Patient with poorly controlled \nDiabetes found to have glucosuria on UA. A1c 9.2%. ___ was \nconsulted while she was hospitalized with optimization of her \ninsulin regimen and addition of Metformin. She also met with a \nheart failure nutritionist given recent dietary indiscretion as \ndescribed above. \n\n#Chronic cough. Patient has a history of chronic cough, likely \nworsened in the\nsetting of hypervolemia. She follows with pulmonology here. PFTs \nhave been unremarkable. \n\n======================\nCHRONIC/STABLE ISSUES:\n======================\n#Depression. Continued home sertraline. Her husband recently \npassed away but she declined social work consult. She was noted \nto have excellent family support.\n\n#GERD. Continued ranitidine.\n\n====================\nTRANSITIONAL ISSUES:\n====================\nDischarge weight: 105 kg (231.48 lb) \nDischarge creatinine: 1.5\n\nHeart Failure Medications\n- Torsemide 40 mg daily\n- Entresto ___ mg) 1 tab BID\n- Metoprolol Succcinate XL 75mg daily\n\n[] Follow-up with pulmonology as outpatient for chronic cough.\n[] Plan for patient to follow-up with ___ Endocrinology in the \nshort term given recent adjustments made to her insulin regimen \nand poorly controlled Diabetes\n[] Will need repeat electrolytes on ___ to be followed by her \ncardiologist Dr. ___. \n[] ___ CRT if no improvement in EF with medical therapy.\n[] Consider Vascepa if triglycerides continue to remain elevated \nin the future.\n\n#CODE STATUS: Full code\n#CONTACT: ___, sister, ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 75 mg PO DAILY \n2. Sertraline 100 mg PO DAILY \n3. Ranitidine 150 mg PO BID \n4. Glargine 25 Units Breakfast\nGlargine 25 Units Bedtime\n5. Aspirin 81 mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. MetFORMIN (Glucophage) 500 mg PO BID \nRX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*2 \n2. Rosuvastatin Calcium 20 mg PO QPM \nRX *rosuvastatin 20 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet \nRefills:*2 \n3. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID \nRX *sacubitril-valsartan [Entresto] 24 mg-26 mg 1 tablet(s) by \nmouth twice a day Disp #*60 Tablet Refills:*2 \n4. Torsemide 40 mg PO DAILY \nRX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet \nRefills:*2 \n5. Glargine 28 Units Breakfast\nGlargine 28 Units Bedtime\nHumalog 12 Units Breakfast\nHumalog 12 Units Lunch\nHumalog 12 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n6. Aspirin 81 mg PO DAILY \n7. Metoprolol Succinate XL 75 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Ranitidine 150 mg PO BID \n10. Sertraline 100 mg PO DAILY \n11.Outpatient Lab Work\nDx: Acute systolic (congestive) heart failure I50.21 \nPlease obtain chem-10 on ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n==================\nAcute on chronic heart failure with reduced ejection fraction\nCoronary artery disease\nHyperlipidemia\nType 2 diabetes mellitus\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital for shortness of breath and \nweight gain.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You were given medications (diuretics) to remove fluid from \nyour body.\n- Imaging of your heart showed decreased heart pumping function. \nYou were started on medications to help improve your heart \nfunction and reduce your cardiac risk.\n- You were found to have elevated blood sugars, so your diabetes \nregimen was adjusted and you were started on an additional \nmedication (metformin) to help control your blood sugar.\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- Weigh yourself every morning, call your doctor if your weight \ngoes 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- Your discharge weight: 105 kg (231.48 lb). You should use this \nas your baseline after you leave the hospital. \n\nWe wish you the best!\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5023", "N189", "E1122", "E785", "K219", "Z96651", "I428", "Z794", "I2510", "Z9111", "R05", "F329" ]

[ "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", "N189: Chronic kidney disease, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z96651: Presence of right artificial knee joint", "I428: Other cardiomyopathies", "Z794: Long term (current) use of insulin", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z9111: Patient's noncompliance with dietary regimen", "R05: Cough", "F329: Major depressive disorder, single episode, unspecified" ]

[ "I130", "N189", "E1122", "E785", "K219", "Z794", "I2510", "F329" ]

[]