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[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms\n \nAttending: ___.\n \nChief Complaint:\nT1 compression fracture, T6 burst fracture \n\n \nMajor Surgical or Invasive Procedure:\n___ - T4-T8 fusion\n\n \nHistory of Present Illness:\n___. is a ___ year old male status post liver \ntransplant who presented to the Emergency Department on ___ \nas a transfer from an outside facility status post mechanical \nfall. Imaging at the outside facility showed a T1 compression \nfracture and T6 burst fracture. Patient was transferred to ___ \n___ for further evaluation and \nmanagement. The Neurosurgery Service was consulted for \nevaluation and management recommendations related to the T1 \ncompression fracture and T6 burst fracture.\n\n \nPast Medical History:\n- attention deficit hyperactivity disorder\n- bipolar disorder\n- hemorrhoids\n- history of alcohol abuse\n- history of deep vein thrombosis in ___\n- history of hemorrhagic pericarditis complicated by cardiac \ntamponade status post pericardial window in ___, recurrent \npericarditis in ___\n- history of neutropenia complicated by neutropenic fever\n- history of positive tuberculin skin test status post INH \n- hyperlipidemia \n- osteoporosis \n- primary biliary cirrhosis status post orthotopic liver \ntransplant\n \nSocial History:\n___\nFamily History:\nNoncontributory\n\n \nPhysical Exam:\nOn Admission:\n-------------\nVital Signs: T 97.8F, HR 90, BP 127/91, RR 20, O2Sat 96% room \nair\n\nGeneral: Well dressed, well nourished, comfortable, no acute \ndistress.\nExtremities: Warm and well perfused.\n\nNeurologic:\nMental status: Awake and alert, cooperative with exam, normal \naffect.\n\nMotor:\n\n Deltoid Biceps Triceps Wrist Flexion Wrist \nExtension \nRight 5 5 5 5 5\nLeft 5 5 5 5 5\n\n IP Quadriceps Hamstring AT ___ Gastrocnemius\nRight 5 5 5 5 5 5\nLeft 5 5 5 5 5 5 \n\nSensation: Intact to light touch.\n\nReflexes: \n\n Biceps Triceps Brachial\nRight 2+ 2+ 2+\nLeft 2+ 2+ 2+\n\nPropioception intact.\n\nRectal tone within normal limits per Acute Care Surgery \nresident, patient refused rectal tone when attempted by us. \n\nNo ___, no clonus.\n\nOn Discharge:\n-------------\nVS: 98.4, 102, 121/88, 18, 95% RA\nAlert and Orient x 3, conversant, pain managed\nHEENT: Anicteric, no JVD\nCard: Sl tachy, regular\nLungs: No respiratory distress\nAbd: Sl obese, well healed incision, non-distended, non-tender\nExtr: No edema,\n.\nWeight at discharge: 71.2 kg\n \nPertinent Results:\nPlease see OMR for relevant laboratory and imaging results.\n\nCTA ABDOMEN AND PELVIS ___\nIMPRESSION: \n1. Mild distension of the small bowel up to a maximum caliber of \n3.8 cm with air-fluid levels coming to a single transition point \nat the distal ileum compatible with small-bowel obstruction. \n2. Unremarkable appearance of the orthotopic liver transplant. \n3. Splenomegaly to a maximum dimension of 17 cm. \n4. Small bilateral pleural effusions with adjacent compressive \natelectasis. \n.\nLabs on Admission: ___\nWBC-4.7 RBC-4.37* Hgb-12.8* Hct-38.7* MCV-89 MCH-29.3 MCHC-33.1 \nRDW-17.7* RDWSD-52.9* Plt ___ PTT-27.7 ___\nGlucose-85 UreaN-11 Creat-1.2 Na-141 K-4.7 Cl-107 HCO3-23 \nAnGap-11\nALT-14 AST-19 AlkPhos-244* TotBili-0.7\nLipase-23\nCalcium-8.2* Phos-3.2 Mg-1.7\nAlbumin-3.4*\ntacroFK-2.4*\n.\nLabs at Discharge ___\nWBC-2.8* RBC-3.36* Hgb-9.7* Hct-30.2* MCV-90 MCH-28.9 MCHC-32.1 \nRDW-20.0* RDWSD-60.2* Plt ___ PTT-30.5 ___\nGlucose-79 UreaN-3* Creat-0.9 Na-147 K-3.9 Cl-108 HCO3-20* \nAnGap-19*\nALT-9 AST-15 AlkPhos-179* TotBili-0.8\nCalcium-8.2* Phos-3.0 Mg-1.8\ntacroFK-5.___ year old male who was admitted on ___ status post fall \nwith findings of a T1 compression fracture and T6 burst fracture \non MRI. \n.\n#T1 Compression Fracture and T6 Burst Fracture\nThe Neurosurgery Spine Service was consulted on ___ for \nevaluation and management recommendations related to the \npatient's T1 compression fracture and T6 burst fracture. \nInitially, we recommended that the patient be placed in a \n___ brace at all times when out of bed or when head of bed \ngreater than 30 degrees. Physical Therapy and Occupational \nTherapy were consulted and recommended discharge to \nrehabilitation. While pending bed availability at \nrehabilitation, patient complained of persistent back pain \ndespite narcotic administration. The Neurosurgery Spine Service \nwas reconsulted on ___ given the patient's persistent back \npain. It was decided that the patient would undergo operative \nintervention. Patient went to the operating room on ___ for \na T4-T8 fusion. The procedure was uncomplicated. Please see \nseparately dictated operative report by Dr. ___ \nfurther details. The patient was extubated in the operating room \nand recovered in the PACU. He was transferred to the floor \npostoperatively for close neurologic monitoring. Patient was \nneurologically stable after surgery. \n.\n#Primary Biliary Cirrhosis\nPatient with primary biliary cirrhosis status post liver \ntransplant. Patient was followed by Transplant Hepatology while \ninpatient. They recommended continuing the patient's home \nregimen of prednisone and tacrolimus. Creatinine and tacrolimus \nlevels were checked daily. Per Transplant Hepatology, the \npatient's liver appears to be functioning well and Tacro and \nprednisone should be continued.\n.\n#Chest Pressure, Tachycardia, and Oxygen Desaturations\nMedicine was consulted as the patient complained of chest \npressure and was tachycardic with low oxygen saturations. An ECG \nwas done, which showed some nonspecific ST depressions. Cardiac \nbiomarkers were negative. Repeat cardiac biomarkers were also \nnegative. CTA of the chest was obtained and was negative for \npulmonary embolism, but revealed bibasilar atelectasis and \nbaseline emphysema. Per Medicine, these signs and symptoms are \nmost likely related to pain, atelectasis, and baseline \nemphysema. They recommended a Chronic Pain consult, which was \nordered. They also stated that there is no need to for \nadditional repeat ECGs and cardiac biomarkers. They also \nrecommended standing DuoNebs every six hours and instruction to \nkeep the head of bed greater than 30 degrees when eating to \navoid aspiration. Patient was encouraged to do aggressive \nincentive spirometry and mobilization. ___ patient had no \nfurther complaint of chest pain and tachycardia was improving. \nPatient was triggered for sustained tachycardia, worsening \noxygen requirement and fever on ___. Repeat infectious workup \nwas started and patient was started on empiric antibiotics. \n.\n#Abdominal distention \nPatient began to complain of abdominal distension on ___ and \nnausea/1 episode of emesis . KUB showed multiple dilated small \nbowel loops as well as nondistended, air-filled colon are most \nsuggestive of ileus. Bowel regimen was increased. Patient was \nable to move his bowels later that day on ___. Repeat KUB on \n___ showed improvement and patient denied any further nausea or \nvomiting. Patient was having bowel movements and tolerating a \nregular diet for several days prior to his discharge. He has a \nhistory of ? IBS that has been evaluated and continues to be \nfollowed by GI.\n.\n#Thrombocytopenia, Elevated ___ and INR, and Hematuria\nAfter starting prophylactic subcutaneous heparin on ___, \nthe patient's platelet count decreased and ___ and INR slightly \nincreased. Per the nurse, the patient also had some hematuria. \nThe prophylactic subcutaneous heparin was held on ___ given \nthese findings. It was discussed with ___ \nwhether or not these findings were related to the patient's \nliver. Transplant Hepatology stated that the patient's liver is \nfunctioning well and that these findings are likely not related \nto his liver. Platelet count and ___ and INR were trended daily. \nSQH was restarted given normal PTT on ___ and platelet count is \n120 on discharge.\n.\n#Acute on Chronic Pain\nPatient was continued on his home gabapentin and tramadol. \nPatient complained of significant postoperative pain not \nrelieved by the typical postoperative pain regimen of \nacetaminophen and narcotics. Patient was initially started on a \nPCA however this did not provide good pain control. He was \nstarted on standing oxycodone, flexeril, and acetaminophen with \nbetter results. \n.\n**MEDICINE FLOOR COURSE: ___ - ___\nOn ___, Mr. ___ was transferred to medicine due to \npersistent tachycardia, worse in the setting of a fever on the \nmorning of ___ prior to transfer. On transfer, he was \nknown to have ileus that seemed to be improving, with several \nsmall-volume loose stools on the day prior to transfer. Patient \nhad bilateral LENIs on ___ that were negative for DVT, which \nwere ordered due to persistent concern for PE despite negative \nCTA on ___. He was also started on Ceftazidime/Vancomycin on the \nmorning of transfer given fever to 101.8F (course dates \n___. These antibiotics were continued during his time on \nthe Medicine service due to concern for hospital-acquired PNA \ndespite the lack of a clear consolidation on CXR. He had no \nfurther hypoxia on the medicine service but persistent rhonchi, \nlikely ___ COPD and for which he was continued on \nduonebs/albuterol PRN. On ___ into ___ in the AM, the patient \ntolerated sips/liquids but abdominal exam was quiet. On ___ in \nthe afternoon, he then developed ___ pain without any change \nin his Cr or lactate. He had a KUB followed by a CT scan that \nwere consistent with SBO. NGT was placed. Given increased \ntenderness on exam and concern for SBO, he was transferred to \nthe Transplant Surgery service for further management.\nThe patient was having return of bowel function with passing \nflatus, having bowel movement and improvement in abdominal exam.\nHe was started on clears and then transitioned to a regular diet \nwith good tolerance. Other notations are recent treatment for \nodonophagia with 3 weeks of acyclovir which was completed on \n___, and he will need follow up with the ___ clinic which \nwill be scheduled.\n.\nPatient will be transferred to Care ___ where he is \nplanned for a Less than 30 day stay.\n\n \nMedications on Admission:\n- acetaminophen 650mg PO Q6H\n- acyclovir 800mg PO Q8H\n- atorvastatin 10mg PO QPM\n- bupropion extended length 150mg PO daily\n- colchicine 0.6mg PO BID\n- dicyclomine 20mg PO QID\n- gabapentin 600mg PO BID\n- ondansetron 4mg PO Q8H PRN nausea\n- pantoprazole 40mg PO BID\n- prednisone 5mg PO daily\n- ranitidine 150mg PO BID\n- sucralfate 1g PO QID\n- tacrolimus 1mg PO Q12H\n- tramadol 25mg PO BID PRN moderate pain \n- ursodiol 300mg PO TID\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H \nMaximum 2 grams Tylenol for Liver transplant recipients \n2. Cyclobenzaprine 5 mg PO Q8H:PRN muscle spasm \n___ discontinue use if not using \n3. Docusate Sodium 100 mg NG BID \n4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nTaper as tolerated \n5. Lidocaine 5% Patch 1 PTCH TD QPM \nHas been using near incision \n6. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n7. Senna 8.6 mg PO BID:PRN Constipation - First Line \n8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing \n9. Aspirin 325 mg PO DAILY \n10. Atorvastatin 10 mg PO QPM \n11. BuPROPion XL (Once Daily) 150 mg PO DAILY \n12. Colchicine 0.6 mg PO BID \n13. DICYCLOMine 10 mg PO QID \n14. Gabapentin 600 mg PO BID \n15. Ondansetron 4 mg PO Q8H:PRN nausea \n16. Pantoprazole 40 mg PO Q12H \n17. PredniSONE 5 mg PO DAILY \n18. Ranitidine 150 mg PO DAILY \n19. Tacrolimus 1 mg PO Q12H \n20. TraMADol 50 mg PO BID \nTransition to tramadol off narcotics as indicated \n21. Ursodiol 300 mg PO TID \n22. Vitamin D ___ UNIT PO 1X/WEEK (FR) \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n- Manubrium fracture\n- Right L1 transverse process fracture\n- T1 compression fracture\n- T6 burst fracture\n- Tachycardia \n- Ileus \n- History of liver transplant ___\n- History of ? IBS\n- Recent Odophaghia treated with 3 weeks Acyclovir. Completed \n___\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory, must wear ___ brace at all \ntimes when out of bed or when head of bed is greater than 30 \ndegrees.\nPlease see ___ notes\n\n \nDischarge Instructions:\nDischarge Facility: ___\n Address: ___\n Telephone: ___\n.\nPlan is Less than 30 days stay\n.\nPatient must wear your ___ brace at all times when out of \nbed. Patient may apply your brace sitting at the edge of the \nbed. Patient does not need to sleep with brace on. \n.\nSurgery:\n- Your incision is closed with staples. You will need staple \nremoval. \n- Do not apply any lotions or creams to the site. \n- Please keep your incision dry until removal of your staples.\n- Please avoid swimming for two weeks after staple removal.\n- Call your surgeon if there are any signs of infection like \nfever, redness, or drainage.\n\nActivity:\n- You must wear your ___ brace at all times when out of bed. \nYou may apply your brace sitting at the edge of the bed. You do \nnot need to sleep with it on. \n- You may shower briefly without your brace if you are sitting \nin a shower chair. If not, you must wear your brace while \nshowering. \n- We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n- You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n- No driving while taking any narcotic or sedating medication. \n- No contact sports until cleared by your neurosurgeon. \n- Do NOT smoke. Smoking can affect your healing and fusion.\n\nMedications:\n- ***Please do NOT take any blood thinning medication (aspirin, \nCoumadin, ibuprofen, Plavix) until cleared by the neurosurgeon. \n- Do not take any anti-inflammatory medications, such as Advil, \naspirin, ibuprofen, or Motrin, until cleared by the \nneurosurgeon. \n- You may use acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication. Do \nnot take more than 2000mg in 24 hours.\n- It is important to increase fluid intake while taking pain \nmedications. We also recommend a stool softener like Colace. \nPain medications can cause constipation.\n\nWhen to Call Your Doctor at ___:\n- Severe pain, redness, swelling, or drainage from the incision \nsite \n- Fever greater than 101.5 degrees Fahrenheit\n- New weakness or changes in sensation in your arms or legs.\n.\nPlease assure patient receives all transplant related \nmedications are given to patient as prescribed. \n.\nFor liver transplant recipients, Please call the transplant \nclinic at ___ for fever of 101 or greater, chills, \nnausea, vomiting, diarrhea, constipation, inability to tolerate \nfood, fluids or medications, yellowing of skin or eyes, \nincreased abdominal pain, incisional redness, drainage or \nbleeding, dizziness or weakness, decreased urine output or dark, \ncloudy urine, swelling of abdomen or ankles, weight gain of 3 \npounds in a day or any other concerning symptoms.\n.\nYou will have labwork drawn as arranged by the transplant \nclinic, with results to the transplant clinic (Fax ___ \n. CBC, Chem 10, AST, ALT, Alk Phos, T Bili, Trough Tacro level, \n.\n*** On the days you have your labs drawn, do not take your \nTacrolimus until your labs are drawn. Bring your Tacrolimus with \nyou so you may take your medication as soon as your labwork has \nbeen drawn.\n\n \nFollowup Instructions:\n___\n" ]

[ "S22052A", "J9601", "S2221XA", "S32018A", "Z944", "J9811", "J441", "K9131", "D6832", "S22018A", "W001XXA", "Y9289", "E785", "F319", "Z87891", "Z86718", "R000", "E8342", "R5082", "R197", "D649", "D696", "M810", "F909", "F1021", "R319", "T45515A", "Y92230", "G8929", "G8918" ]

[ "S22052A: Unstable burst fracture of T5-T6 vertebra, initial encounter for closed fracture", "J9601: Acute respiratory failure with hypoxia", "S2221XA: Fracture of manubrium, initial encounter for closed fracture", "S32018A: Other fracture of first lumbar vertebra, initial encounter for closed fracture", "Z944: Liver transplant status", "J9811: Atelectasis", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "K9131: Postprocedural partial intestinal obstruction", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "S22018A: Other fracture of first thoracic vertebra, initial encounter for closed fracture", "W001XXA: Fall from stairs and steps due to ice and snow, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified", "Z87891: Personal history of nicotine dependence", "Z86718: Personal history of other venous thrombosis and embolism", "R000: Tachycardia, unspecified", "E8342: Hypomagnesemia", "R5082: Postprocedural fever", "R197: Diarrhea, unspecified", "D649: Anemia, unspecified", "D696: Thrombocytopenia, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F1021: Alcohol dependence, in remission", "R319: Hematuria, unspecified", "T45515A: Adverse effect of anticoagulants, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "G8929: Other chronic pain", "G8918: Other acute postprocedural pain" ]

[ "J9601", "E785", "Z87891", "Z86718", "D649", "D696", "Y92230", "G8929" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, diarrhea\n \nMajor Surgical or Invasive Procedure:\nSigmoidoscopy (___)\n \nHistory of Present Illness:\nMr ___ is a ___ w/hx of Mr. ___ is a ___ with a history of \nPBC s/p OLT in ___, Pericarditis, Bipolar, COPD who p/w abd \npain, diarrhea. \n Pt states he has been having 4d of worsening abd pain, nausea, \nand diarrhea. Denies GIB though states stools are khaki colored. \nFeels similar to when previously had CMV infection. No recent \nAbx. Endorsing chills but no fever/NS. No emesis, dysuria, \ncough, confusion, ___ swelling. Endorsing SOB, orthopnea though \nthese are baseline Sx for him. Hasn't been taking his COPD \ninhalers. \n Of note, pt states he developed severe chest pain x2d, \nsqueezing/non-radiating, upper chest, worse with exertion. \nStates this is similar to his pericarditis pain and not to his \nprior CAD pain. Hasn't had pain like this in last 6 mo. No \nLH/dizziness, palp, vision changes. \n -In the ED, initial vitals: T99.0 85 113/99 18 99% RA \n -On exam, sig for Abd with diffuse TTP worse over epigastrum \nand LLQ; nondistended \n -Labs sig for: neg UA, INR 1.2, WBC 4.0, Plt 97, AlkP 140, \nAST/ALT wnl, Cr 1.4, Trop neg, Lac 0.9 \n -Studies sig for: \n EKG with Diffuse ST segment depression V2-V5/V6, I, II, ?ST \nelevation in aVR, with TWI in V2-V5/V6 as compared to ___. \nPericarditis vs demand ischemia? \n CT A/P w/possible early colitis vs underdistention \n CXR wnl \n -Pt was given: 2L NS, 2mg IV Morphine x2, 4mg IV Zofran x2, \n0.6mg colchicine, 600mg gabapentin, 40mg omeprazole, 150mg \nranitdine, 1mg tacro \n -Transplant hepatology was consulted, recommended admit to ET \nfor infectious w/u, trend trops \n -Vitals before transfer: 64 121/87 18 97% RA \n On the floor, pt's abdominal pain was improved s/p Morphine. \n ROS: per HPI, denies fever, chills, night sweats, headache, \nvision \n changes, rhinorrhea, congestion, sore throat, cough, shortness \nof breath, chest pain, abdominal pain, nausea, vomiting, \ndiarrhea, constipation, BRBPR, melena, hematochezia, dysuria, \nhematuria. \n \nPast Medical History:\nPAST MEDICAL HISTORY: \n PBC s/p deceased liver donor tx ___ \n Neutropenia \n DVT ___ \n Prior alcohol abuse now abstinent \n Hemorrhagic pericarditis c/b tamponade with pericardial window \n\n ___ \n Positive PPD s/p INH \n HLD \n Osteoporosis \n Bipolar disorder \n Hemorrhoids \n ADHD \n PTSD \n\n \nSocial History:\n___\nFamily History:\n Father (living): coronary artery disease, diabetes, \nhypercholesterolemia, and depression. Prostate and head and neck \ncancer \n Mother (deceased): brain aneurysm and hyperthyroidism \n \nPhysical Exam:\nADMISSION EXAM:\nVital Signs: 97.6 127/84 48 16 100 ra \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops. No pulsus on exam. \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, +diffuse abdominal tenderness, bowel sounds \npresent, no organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, gait deferred. \n \n\nDISCHARGE EXAM:\nVS Tc 98.0 BP 110/81 HR 89 RR 16 O2 100% RA\nI/Os: 3260/925 B+2335\nGeneral: Alert, oriented, mild distress due to pain\nHEENT: MMM, oropharynx clear, EOMI, \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops. \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, +diffuse mild abdominal tenderness, bowel sounds \npresent, no organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNII-XII intact, no focal deficits. \n \nPertinent Results:\nADMISSION LABS:\n___ 06:01PM LACTATE-0.9\n___ 05:54PM GLUCOSE-91 UREA N-17 CREAT-1.4* SODIUM-136 \nPOTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17\n___ 05:54PM ALT(SGPT)-28 AST(SGOT)-31 ALK PHOS-140* TOT \nBILI-0.8\n___ 05:54PM LIPASE-20\n___ 05:54PM cTropnT-<0.01\n___ 05:54PM ALBUMIN-4.6\n___ 05:54PM WBC-4.0 RBC-5.80 HGB-17.3 HCT-48.7 MCV-84 \nMCH-29.8 MCHC-35.5 RDW-16.0* RDWSD-47.3*\n___ 05:54PM NEUTS-45.2 ___ MONOS-11.6 EOS-0.8* \nBASOS-1.5* IM ___ AbsNeut-1.79 AbsLymp-1.60 AbsMono-0.46 \nAbsEos-0.03* AbsBaso-0.06\n___ 05:54PM ___ PTT-29.5 ___\n___ 04:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 04:41PM URINE RBC-3* WBC-1 BACTERIA-FEW YEAST-NONE \nEPI-<1\n\nINTERIM LABS:\n___ 05:54PM BLOOD cTropnT-<0.01\n___ 05:21AM BLOOD cTropnT-<0.01\n___ 05:21AM BLOOD tacroFK-11.2\n___ 05:43AM BLOOD tacroFK-7.8\n___ 04:58AM BLOOD tacroFK-7.7\n\nDISCHARGE LABS:\n___ 04:58AM BLOOD tacroFK-7.7\n___ 04:58AM BLOOD WBC-2.6* RBC-4.70 Hgb-14.0 Hct-41.0 \nMCV-87 MCH-29.8 MCHC-34.1 RDW-16.2* RDWSD-51.4* Plt Ct-68*\n___ 04:58AM BLOOD Glucose-127* UreaN-7 Creat-1.4* Na-138 \nK-4.5 Cl-102 HCO3-27 AnGap-1\n\nMICROBIOLOGY:\nURINE CULTURE (Final ___: < 10,000 CFU/mL. \nBlood Culture, Routine (Final ___: NO GROWTH. \nCMV Viral Load (Final ___: \n CMV DNA not detected. \n Performed by Cobas Ampliprep / Cobas Taqman CMV Test. \n Linear range of quantification: 137 IU/mL - 9,100,000 \nIU/mL. \n Limit of detection 91 IU/mL. \n This test has been verified for use in the ___ patient \npopulation. \nC. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Illumigene DNA\n amplification assay. \n (Reference Range-Negative). \n\n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\nVIRAL CULTURE (Final ___: NO VIRUS ISOLATED. \n\nIMAGING/STUDIES:\nEKG ___:\nSinus rhythm. Prominent early R wave progression. Anterior ST-T \nwave\nabnormalities. Cannot rule out underlying myocardial ischemia. \nCompared to the previous tracing of ___ wave \nabnormalities are new. Clinical correlation is suggested.\n\nEKG ___: \nSinus bradycardia. Compared to tracing #2 there is no \nsignificant diagnostic change.\n\nCXR ___ FINDINGS: \nThe cardiomediastinal silhouette and pulmonary vasculature are \nunchanged. The\nlungs are clear. There is no pleural effusion or pneumothorax. \nNo acute\nosseous injury.\nIMPRESSION: \nNo acute intrathoracic abnormality.\n\nCT Abd/Pelvis w/ CONTRAST ___:\nIMPRESSION:\n1. Equivocal mucosal hyper enhancement of the sigmoid and \nproximal transverse colon are likely related to underdistention, \ncorrelate for possibility of an early colitis.\n2. Status post liver transplant with expected postsurgical \nchanges. Patent main portal vein.\n3. Stable mild splenomegaly.\n4. 0.9 cm right lower pole renal hypodensity is better \ncharacterized on prior MRCP as benign.\n\nECHO ___:\nThe left atrium is normal in size. Left ventricular wall \nthicknesses and cavity size are normal. Regional left \nventricular wall motion is normal. Overall left ventricular \nsystolic function is low normal (LVEF 50-55%). There is no \nventricular septal defect. Right ventricular chamber size and \nfree wall motion are normal. The diameters of aorta at the \nsinus, ascending and arch levels are normal. The aortic valve \nleaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosis. Trace aortic regurgitation is \nseen.There is also a small turbulent diastolic color doppler \nsignal seen at the margin between the left and non-coronary \naortic valve cusps ( clips #9, 14, 30, 37) in the aortic root \nthat likely reflects brisk coronary artery flow. The mitral \nvalve appears structurally normal with trivial mitral \nregurgitation. The estimated pulmonary artery systolic pressure \nis normal. There is no pericardial effusion. \n\nColonoscopy ___ Biopsies pending at discharge:\nPrelim results positive for colitis in multiple locations.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ male with a PMH of PBC s/p OLT in \n___, pericarditis, bipolar disorder, COPD who p/w abd pain, \ndiarrhea, and chest pain. Patient was ruled out for acute \ncoronary syndrome with EKG, CXR, and troponins negative. CT for \nthe abdomen found new colitis. It was felt this was most likely \ndue to an infectious etiology. Highest concern was for CMV, \ngiven previous infections and patient's immunosuppressed state. \nCMV serology was negative for active infection. Colonoscopy \nshowed colitis but otherwise no other abnormalities. Patient \nsymptoms were improved with addition of dicyclomine. No other \ninfectious source for his colitis was found. Since symptoms were \nimproving, it was felt his symptoms represented resolving viral \ngastroenteritis with on-going post-infectiuos IBS. \n\n#Abdominal pain and diarrhea:\nPatient presented with four days of worsening abdominal pain and \ndiarrhea. He had CT imaging concerning for colitis. An \ninfectious workup was initiated, but CMV and C diff were \nnegative. Fecal cultures and other stool studies (camoylobacter, \nviral/fecal cultures) have thus far been negative. Final viral \nstool culture was pending at discharge. Patient had a \nsigmoidoscopy on ___ to evaluate CT imaging findings of colitis \nthat was unrevealing. Pain was controlled with oxycodone 5 mg \nq6h prn pain and dicyclomine 20mg QID. Discharged on dicyclomine \nonly. Since no infectious etiology was determined, it was felt \nthe patient had a viral gastroenteritis that lead to \npost-infectious IBS causing on-going abdominal pain, diarrhea. \nIt was recommended to try ___ as an over the counter \nmedication for further symptom control and follow up with \noutpatient providers. \n\n#Chest pain: Pt presented with severe upper chest pain x2d that \nwas squeezing and non-radiating, and worse with exertion. His \nEKG showed new T wave inversions in lateral leads but his \ntroponins were negative. ECHO was without wall motion \nabnormalities or pericardial effusion. Chest pain seemed to be \nrelated to his abdominal pain which was greatest in his \nepigastric region. Patient was continued on his home \nanti-inflammatory meds (ASA 650 BID, colchicine, oxycodone) \nduring this hospitalization for chronic pericarditis. Chest pain \nwas improved by time of discharge. Follow up appointment with \ncardiology was made prior to discharge. \n\n#COPD:\nPatient reports dyspnea and orthopnea greater than baseline on\nadmission. He was not taking his home meds (albuterol, \nsalmeterol), but these were restarted during this \nhospitalization. CXR was negative for acute intrathoracic \nabnormalities. SOB resolved and no further work up was \nperformed. \n\n==============\nCHRONIC ISSUES\n==============\n#PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, HEMORRHAGIC \nPERICARDITIS, RECURRENT PERICARDITIS: LFTs remained normal \nthroughout the admission. Patient reported compliance with his \ntacrolimus, prednisone. Tacrolimus levels were monitored daily. \nHis dosing was decreased to tacrolimus 1mg Q12hrs from 1.5mg \nQ12hrs. He was discharged to follow up with his hepatologist and \nre-check tacrolimus levels as an outpatient.\n\n#THROMBOCYTOPENIA: Chronic thrombocytopenia likely due to liver \ndisease or immunosuppression. Stable in comparison to prior \nlabs. CBC was trended daily.\n\n#BIPOLAR DISORDER: Patient was recently off of Abilify, Symptoms \nwere monitored as inpatient and patient mental status remained \nstable. \n\n#GERD: Known GERD possibly contributing to epigastric abdominal \npain. Continued on home omeprazole 40mg BID and home ranitidine \n150mg qHS. \n\n#CHRONIC NEUROPATHIC PAIN: Patient noted that he has been having \nincreased neuropathy in hands bilaterally. Continued on home \ngabapentin 600mg BID without exacerbation or changes in \nneuropathic sx. \n\n=======================\nTRANSITIONAL ISSUES:\n=======================\n-Tacrolimus changed to 1 mg BID; check levels at next \nappointment\n-Follow-up final viral stool studies.\n-Follow-up biopsies from colonoscopy\n-Follow-up cardiology appointment as scheduled above\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Colchicine 0.6 mg PO BID \n2. Gabapentin 600 mg PO BID \n3. Omeprazole 40 mg PO BID \n4. Ondansetron 4 mg PO Q8H:PRN nausea \n5. PredniSONE 5 mg PO DAILY \n6. Ranitidine 150 mg PO QHS \n7. Tacrolimus 1.5 mg PO QAM \n8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n9. Aspirin 650 mg PO BID \n10. Tacrolimus 1 mg PO QPM \n\n \nDischarge Medications:\n1. DICYCLOMine 20 mg PO TID abdominal pain \nRX *dicyclomine 20 mg 1 tablet(s) by mouth TID PRN Disp #*30 \nTablet Refills:*0 \n2. IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain \nRX *peppermint oil [___] 90 mg 1 capsule(s) by mouth TID PRN \nDisp #*48 Capsule Refills:*0 \n3. Aspirin 650 mg PO BID \n4. Colchicine 0.6 mg PO BID \n5. Gabapentin 600 mg PO BID \n6. Omeprazole 40 mg PO BID \n7. Ondansetron 4 mg PO Q8H:PRN nausea \n8. PredniSONE 5 mg PO DAILY \n9. Ranitidine 150 mg PO QHS \n10. Tacrolimus 1 mg PO QPM \nRX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*0 \n11. Tacrolimus 1 mg PO QAM \n12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal pain concerning for colitis\nDiarrhea \nChest pain\nCOPD \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted because you had abdominal pain. We got images \nof your abdomen that showed you had some mild inflammation in \nyour colon. This was likely due to a viral infection. We \ncontrolled your pain with medications. It is important for your \nto follow-up with your PCP and Dr. ___. There are biopsy \nresults pending from the colonoscopy that you will discuss with \nDr. ___. \n\nWe have given you a prescription for dicyclomine to help your \nabdominal pain. There is also a form of peppermint oil called \n\"IBgard\" that you can buy over the counter to help with your \npain. Your pain should improve with time. Avoid dairy products \nand eat a bland diet. \n\nLastly, we decreased the dose of your tacrolimus to 1 mg twice \ndaily. \n\nIt was a pleasure taking care of you. \n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "K529", "N179", "Z944", "D696", "J449", "F319", "I2510", "Z86718", "Z87891", "Z8249", "K219", "R079" ]

[ "K529: Noninfective gastroenteritis and colitis, unspecified", "N179: Acute kidney failure, unspecified", "Z944: Liver transplant status", "D696: Thrombocytopenia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "F319: Bipolar disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z86718: Personal history of other venous thrombosis and embolism", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "K219: Gastro-esophageal reflux disease without esophagitis", "R079: Chest pain, unspecified" ]

[ "N179", "D696", "J449", "I2510", "Z86718", "Z87891", "K219" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms / propofol\n \nAttending: ___.\n \nChief Complaint:\nWeakness\n \nMajor Surgical or Invasive Procedure:\nEndoscopy ___\ncolonoscopy ___\n\n \nHistory of Present Illness:\nPatient is a ___ male with a past medical history\nsignificant for liver transplant in ___ for PBC, hemorrhagic\npericarditis in ___ status post pericardial window, MI x2 in\n___, IBS versus Crohn's, osteoporosis with multiple \npathological\nfractures presenting to the emergency department with \ngeneralized\nweakness and found to have an ___.\n\nPatient had a colonoscopy performed approximately 2 weeks ago. \nAt\nthis time the patient did receive propofol. Per review of\nrecords, it seems that the patient became hypoxic and the\ncolonoscopy was not performed. Upon awakening, the patient noted\nsome chest pain and shortness of breath. For this the patient \nwas\ntaken to ___. He was observed for 1 day from the \nfifth\nto the sixth of this month. At that time, the patient's\ncreatinine was noted to be 1.6. The patient was discharged in\nstable condition.\n\nPatient states that today he developed generalized weakness. He\ndoes not note any focal weakness. The patient describes \ndizziness\nupon standing up quickly. This dizziness is not related to rapid\nmovements of the head. The patient does not have dizziness here\nin the emergency department. The patient notes that he has not\nbeen eating or drinking well for the past 2 weeks and that he \nhas\nhad some diarrhea over the past two weeks. The patient does not\nnote any new cough or any urinary changes. He does have some\nnausea but no vomiting. The patient has some chills but no \nfever.\nPatient does not have any chest pain. He does describe some\nshortness of breath.\n\nPatient presented to an outside hospital where he was noted to\nhave an increase in his creatinine to 2.0. Patient was\ntransferred here for further workup given this was where he had\nhis liver transplant.\n\nPatient presents to us in no acute distress. He states that he\nhas been compliant with all of his medications. He is on\nimmunosuppression at this time consisting of tacrolimus and\nprednisone.\n\n \nPast Medical History:\n- attention deficit hyperactivity disorder\n- bipolar disorder\n- hemorrhoids\n- history of alcohol abuse\n- history of deep vein thrombosis in ___\n- history of hemorrhagic pericarditis complicated by cardiac \ntamponade status post pericardial window in ___, recurrent \npericarditis in ___\n- history of neutropenia complicated by neutropenic fever\n- history of positive tuberculin skin test status post INH \n- hyperlipidemia \n- osteoporosis \n- primary biliary cirrhosis status post orthotopic liver \ntransplant \n- PULMONARY NODULE \n\n\n- CHRONIC OBSTRUCTIVE PULMONARY DISEASE \n\n\n- ALTERNATING CONSTIPATION/DIARRHEA, ?IBS vs chrons \n\n\n- HISTORY OF CAD W/ MI x2 in ___\n- T1 COMPRESSION FRACTURE, T6 BURST FRACTURE \n\n\n \nSocial History:\n___\nFamily History:\nNoncontributory to the patients current admission,\nFather passed away from head and neck cancer \n \nPhysical Exam:\nAdmission Exam:\n==================\nVITALS: Reviewed in OMR \n___: Weight: 172.2\n\nGEN: Alert, cooperative, no distress, appears stated age\nHENT: NC/AT, MMM. Nares patent, no drainage or sinus\ntenderness. no teeth, and normal gums normal.\nEYES: PERRL, EOM intact, conjunctivae clear, no scleral\nicterus.\nNECK: No cervical lymphadenopathy. No JVD, Neck supple,\nsymmetrical, trachea midline.\nLUNG: CTA ___, good air movement, no accessory muscle use \nHEART: RRR, Normal S1/S2, No M/R/G\nBACK: Symmetric, no curvature. ROM normal. No CVA tenderness.\nABD: Soft, non-tender, non-distended; nl bowel sounds; midline\nwell healed scar, no rebound or guarding, no organomegaly\nGU: Not examined\nEXTRM: Extremities warm, no edema, tender to palpation over the\nleft shin, no cyanosis, positive ___ pulses bilaterally\nSKIN: Skin color and temperature, appropriate. No rashes or\nlesions\nNEUR: CN II-XII intact grossly. Moving all extremities,\nstrength, sensation equal and intact throughout.\nPSYC: Mood and affect appropriate \n\nDischarge Exam:\n================\nGen: NAD\nHENT: NC/AT, sclerae anicteric, normal conjunctivae, oropharynx\nclear, MMM\nLUNG: CTAB, no increased work of breathing\nHEART: RRR, normal S1/S2, no m/r/g\nABD: Soft, non-tender, non-distended\nEXTRM: Warm, DP pulses 2+ bilaterally, no edema\nSKIN: Well-healed scar along upper spine, well-healed scar over\nRUQ of abdomen\nNEUR: AOx3\n\n \nPertinent Results:\nAdmission labs:\n==================\n\n___ 11:15PM BLOOD WBC-2.8* RBC-4.67 Hgb-10.8* Hct-36.8* \nMCV-79* MCH-23.1* MCHC-29.3* RDW-17.4* RDWSD-49.3* Plt ___\n___ 11:15PM BLOOD Neuts-36.2 ___ Monos-15.2* \nEos-5.1 Baso-2.2* Im ___ AbsNeut-1.00* AbsLymp-1.11* \nAbsMono-0.42 AbsEos-0.14 AbsBaso-0.06\n___ 11:15PM BLOOD Plt ___\n___ 11:15PM BLOOD Glucose-87 UreaN-15 Creat-1.7* Na-142 \nK-4.3 Cl-109* HCO3-24 AnGap-9*\n___ 11:15PM BLOOD ALT-20 AST-24 CK(CPK)-33* AlkPhos-131* \nTotBili-0.3\n___ 11:15PM BLOOD Lipase-19\n___ 11:15PM BLOOD cTropnT-<0.01\n___ 06:15PM BLOOD cTropnT-<0.01\n___ 11:15PM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.5 Mg-1.8\n___ 04:27AM BLOOD calTIBC-283 VitB12-440 Folate-8 Hapto-47 \nFerritn-23* TRF-218\n___ 11:15PM BLOOD Osmolal-283\n___ 06:13AM BLOOD TSH-2.6\n___ 06:13AM BLOOD Cortsol-<0.3*\n___ 05:20PM BLOOD Cortsol-0.5*\n___ 07:45PM BLOOD Cortsol-0.8*\n___ 09:38AM BLOOD tacroFK-2.9*\n\nKey labs:\n===================\n\n___ 04:27AM BLOOD Ret Aut-2.2* Abs Ret-0.09\n___ 05:20PM BLOOD Cortsol-0.5*\n___ 07:45PM BLOOD Cortsol-0.8*\n___ 04:36AM BLOOD tacroFK-3.3*\n___ 11:23AM BLOOD CMV VL-DETECTED, \n___ 05:31AM BLOOD CMV VL-DETECTED, \n___ 07:45PM BLOOD ALDOSTERONE-Test \n___ 05:20PM BLOOD ALDOSTERONE-Test \n___ 05:20PM BLOOD ACTH - FROZEN-Test \n\nDischarge labs:\n======================\n \n___ 04:36AM BLOOD WBC-3.6* RBC-4.32* Hgb-9.8* Hct-33.0* \nMCV-76* MCH-22.7* MCHC-29.7* RDW-17.8* RDWSD-48.1* Plt Ct-95*\n___ 05:31AM BLOOD Neuts-44.3 ___ Monos-12.9 Eos-1.2 \nBaso-1.6* Im ___ AbsNeut-1.13* AbsLymp-1.00* AbsMono-0.33 \nAbsEos-0.03* AbsBaso-0.04\n___ 04:36AM BLOOD Plt Ct-95*\n___ 04:36AM BLOOD Glucose-106* UreaN-13 Creat-1.4* Na-138 \nK-4.4 Cl-107 HCO3-21* AnGap-10\n___ 05:09AM BLOOD ALT-18 AST-21 AlkPhos-109 TotBili-0.4\n___ 04:36AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9\n\nImaging:\n====================\n___ Dupplex abdominal Doppler\n1. Patent hepatic vasculature with appropriate waveforms. \nPlease note that the left hepatic artery was not able to be \nvisualized secondary to poor acoustic windows and patient \nbreathing. \n2. Splenomegaly. \n\n___ TTE\nProminent epicardial fat without clear pericardial effusion. \nMild global right ventricular hypokinesis. Low normal global \nleft ventricular systolic function.\n\n___ EGD\nRing in the distal esophagus\nNormal mucosa in the whole stomach\nnormal mucosa in the duodenum \n\n___ Colonoscopy\nHigh residue material and unable to visualize adequately\nNormal as far as visualized. Not adequate for screening \npurposes. Terminal ileum was not intubated due to patient \ndiscomfort\n\nPath:\n=====================\n___ GI mucosal biopsy\n1. Terminal ileum:\nTerminal ileal mucosa, within normal limits.\n2. Colon:\nColonic mucosa with patchy moderately active colitis (multiple \nneutrophilic crypt abscesses), focal\nbasal crypt regeneration, and scattered prominent basal \napoptotic debris; no definitive evidence of\nchronic colitis, granulomas, or viral inclusions/cytopathic \neffect are identified.\nImmunostain for cytomegalovirus is in progress and the results \nwill be reported in a revised report.\nNote: The colonic mucosal biopsy findings are favored to \nrepresent an acute infectious colitis versus\na drug-induced change. Correlation with clinical and laboratory \nfindings is needed.\n\n___ GI biopsy \n1. Esophagus, biopsy:\n- Squamous mucosa with active erosive esophagitis.\n- Numerous Herpes simplex virus viral cytopathic changes \n(confirmed by HSV I/II immunostain) .\n2. Stomach, biopsy:\n- Antral and corpus mucosa within normal limits.\n\n___ GI Biopsy \n1. Duodenum, biopsy:\n-Duodenal mucosa with crypt regeneration (non-specific), \notherwise within normal limits.\n-CMV immunostain highlights rare positive cells in the lamina \npropria (see note).\nNote: The clinical significance of this finding is uncertain, \nsince no significant duodenitis is identified.\n2. Random colon, biopsy:\n-Colonic mucosa within normal limits.\n-Immunohistochemical stain for CMV is negative with adequate \ncontrols.\n\n \nBrief Hospital Course:\nPATIENT SUMMARY\n=================\nPatient is a ___ male with a past medical history\nsignificant for liver transplant in ___ for PBC, hemorrhagic\npericarditis in ___ status post pericardial window, MI x2 in\n___, IBS versus Crohn's, osteoporosis with multiple \npathological\nfractures who presented to the emergency department with \ngeneralized\nweakness and was found to have an ___. Diagnosed with secondary \nadrenal insufficiency and CMV. Treated for both. Colonoscopy and \nEGD unrevealing.\n\nTransitional Issues\n===================\n[] Prednisone course:\n7.5mg for three days (___) then 5mg daily \n[] Will need f/u CMV viral titers until negative\n[] discharge tacro dosing of 1 mg BID discharge tacro level of \n3.3\n[] Patient ASA reduced to 325mg daily from BID dosing and \ncontinue colchicine 0.6 bid due to his history of pericarditis. \nWill need follow up arranged with Dr. ___ likely \ndiscontinuation or downtitration of medications. Unable to reach \nvia E-mail\n\n==============\nActive Issues\n==============\n#Weakness\n#Anemia\n#Orthostasis\n#Exertional dyspnea\nPatient presented with recent weakness, exertional dyspnea, with \ninitial differential including worsening anemia, dehydration, \ninfectious process, cardiac etiology, and adrenal insufficiency. \nPatient has baseline\npancytopenia (see below) but with an acute drop in Hgb shortly \nafter admission from 11 to 9.5, and from recent baseline ~13 in \n___.\nRemained hemodynamically stable. No overt bleeding, melena, or\nhematochezia. EGD and colonoscopy on ___, revealing no \ninflammation or source of bleeding. Alternating diarrhea and \nconstipation chronic (\"since forever\") per patient, with no \nacute change.. CXR and abdominal US unremarkable (aside from \nsplenomegaly on US). AM cortisol <0.3, with further testing \nconsistent with adrenal insufficiency that may be have \ncontributed to overall weakness. \n\n#CMV Viremia\n#CMV Duodenal infection\nPatient presents with the symptoms, discussed below, raising \nconcern for CMV infection. CMV titer returned as detectable, but \nbelow 1.7 on two separate titers which does not meet criteria \nfor induction therapy. Endoscopic biopsy of the duodenum \nrevealed positive staining for CMV without evidence of \ninflammation, which is of unclear significance. Given the \noverall clinical picture discussed below, in addition to the CMV \nviral load and biopsy findings, valganciclovir treatment was \ninitiated with 450mg bid (dose reduced for renal function) for \n28 days as is recommended for treatment. \n\n#Secondary Adrenal insufficiency\nLow morning cortisol, low ACTH and cosyntropin stimulation test\nresults obtained when he received corticosteroids on the day of\nthe stim test, and values were also obtained 2 hours after\nadminisration of cosyntropin, making these less reliable. \nHowever\nit seems very likely that he is adrenally insufficient. We \nultimately increased his prednisone dosing to 10mg daily while \ntreating for CMV with slower taper to 7.5mg x3 days and back to \n5mg daily given worsening nausea with quick taper. \n\n___\nPatient admitted with ___, pre-renal in setting of poor PO \nintake and diarrhea. Peaked at 2.0, subsequently downtrended to \n1.4. Baseline appeared to range 0.6 to 0.9. No major electrolyte \nabnormalities. Per Dr. ___ for discharge with current Cr \nelevation with follow up outpatient. \n\n#PBC s/p DDLT\n#immunosuppression\n#Leukopenia/pancytopenia \nPatient reported he has had pancytopenia since his liver \ntransplant ___ years ago. This is likely immunosuppressive effect \nfrom his Tacrolimus resulting in chronic iatrogenic \nmyelosuppression. He had a workup for this including BM-biopsy \nin ___ iso CMV viremia, which was non-revealing. CMV viral load \nthis admission was Detected, discussed above. Acute on chronic \nanemia was further evaluated as above. \n\n#Hx pericarditis with loculated pericardial effusion \nPatient has a history of hemorrhagic pericarditis c/b tamponade\ns/p pericardial window ___ and recurrent pericarditis \n___\nand moderate pericardial effusion seen on TTE on ___. The\npatient has no new chest pain or pressure symptoms and does not\nendorse any tachycardia or palpitations. Repeat TTE showed no \neffusion. Patient was continued on colchicine and ASA though \ndose of ASA reduced to 325mg daily for GI protection as unclear \nwhy such high dose has been maintained and unable to reach \noutpatient providers. \n\n==============\nChronic Issues\n==============\n#Osteoporosis\nPer OMR review, has had since before his liver transplant so\nlikely not related to prednisone.\n\n#Bipolar\nContinued home bupropion.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 325 mg PO BID \n2. Atorvastatin 10 mg PO QPM \n3. BuPROPion (Sustained Release) 300 mg PO QAM \n4. Colchicine 0.6 mg PO BID \n5. DICYCLOMine 20 mg PO TID:PRN diarrhea \n6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n7. Gabapentin 800 mg PO BID \n8. Pantoprazole 40 mg PO Q12H \n9. PredniSONE 5 mg PO DAILY \n10. Ranitidine 150 mg PO DAILY \n11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n13. Tacrolimus 0.5 mg PO QPM \n14. Tacrolimus 1 mg PO QAM \n15. Naloxone Nasal Spray 4 mg IH ONCE MR1 \n\n \nDischarge Medications:\n1. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n2. ValGANCIclovir 450 mg PO Q12H Duration: 28 Days \nRX *valganciclovir 450 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Aspirin 325 mg PO DAILY \n4. Pantoprazole 40 mg PO Q24H \n5. PredniSONE 7.5 mg PO DAILY \nRX *prednisone 5 mg 1.5 tablet(s) by mouth once a day for 3 days \nthen one tablet daily thereafter Disp #*30 Tablet Refills:*0 \n6. Tacrolimus 1 mg PO QAM \nRX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*0 \n7. Tacrolimus 1 mg PO QPM \n8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n9. Atorvastatin 10 mg PO QPM \n10. BuPROPion (Sustained Release) 300 mg PO QAM \n11. Colchicine 0.6 mg PO BID \n12. DICYCLOMine 20 mg PO TID:PRN diarrhea \n13. Naloxone Nasal Spray 4 mg IH ONCE MR1 \n14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n15. Ranitidine 150 mg PO DAILY \n16. HELD- Gabapentin 800 mg PO BID This medication was held. Do \nnot restart Gabapentin until seen by PCP\n\n \n___:\nHome\n \nDischarge Diagnosis:\n#Adrenal Insufficiency\n#Anemia\n#CMV viremia\n#CMV duodenitis\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 weakness \n \nWhat was done for me while I was in the hospital? \nWe found that your adrenal glands were not working very well and \nwe gave you steroid medication\nWe performed an endoscopy and colonoscopy to look for evidence \nof inflammation in you GI tract\nWe found that you are infected by a virus that can cause GI \nsymptoms and started you on the appropriate treatment\n\nWhat should I do when I leave the hospital? \n-Please take all of your medications and keep all of your \nappointments \n- Dr. ___ will contact you with an appointment \n- The Endocrinology department is working on scheduling an \nearlier appointment for you as well. \n\n*****Prednisone course****\n7.5mg for three days (___) then 5mg daily \n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "N179", "D61811", "B258", "Z944", "E273", "K625", "M810", "I252", "I2510", "E785", "F319", "E860", "R197", "J449", "T451X5A", "T380X5A", "Z87891", "Z981", "Z86718", "Z79899" ]

[ "N179: Acute kidney failure, unspecified", "D61811: Other drug-induced pancytopenia", "B258: Other cytomegaloviral diseases", "Z944: Liver transplant status", "E273: Drug-induced adrenocortical insufficiency", "K625: Hemorrhage of anus and rectum", "M810: Age-related osteoporosis without current pathological fracture", "I252: Old myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified", "E860: Dehydration", "R197: Diarrhea, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Z87891: Personal history of nicotine dependence", "Z981: Arthrodesis status", "Z86718: Personal history of other venous thrombosis and embolism", "Z79899: Other long term (current) drug therapy" ]

[ "N179", "I252", "I2510", "E785", "J449", "Z87891", "Z86718" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms\n \nAttending: ___\n \nChief Complaint:\nRib pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ h/o idiopathic hemorrhagic pericarditis (___) requiring\npericardial window, osteoporosis c/b multiple pathologic\nfractures, PBC s/p liver transplant (___) on tacro/pred c/b HSV\nesophagitis (___), presenting now with ongoing\npositional/inspiratory CP in the setting of sustaining rib\nfractures 2 weeks ago during a workout. \n\nHe is a military veteran and 2 weeks ago was doing some physical\nexercises with a bunch of infantry friends, when during a\nmaneuver where he was pulling himself up by his arms, he felt a\npop in his sternum and thereafter experienced severe pain in his\nchest with movement or deep breaths, but little/none at rest. He\nwent to ___ ED, where he was assured that this was\nrib fractures and not his heart, and sent home. \n\n___ he re-presented to ___ because his chest pain\nand associated SOB (again, clarifies that this was exertional \nbut\nlargely because it hurt him to breathe) if anything had gotten a\nbit worse in the few preceding days. At ___ he was reported\nto have an ANC of 600 and therefore transferred here to ___ \nfor\nfurther workup. \n \nPatient denies any fevers or chills, rash, headache, abdominal\npain, changes in bowel movement or changes in urination. Normal\np.o. intake with no weight loss or night sweats. \n\n \nPast Medical History:\n- attention deficit hyperactivity disorder\n- bipolar disorder\n- hemorrhoids\n- history of alcohol abuse\n- history of deep vein thrombosis in ___\n- history of hemorrhagic pericarditis complicated by cardiac \ntamponade status post pericardial window in ___, recurrent \npericarditis in ___\n- history of neutropenia complicated by neutropenic fever\n- history of positive tuberculin skin test status post INH \n- hyperlipidemia \n- osteoporosis \n- primary biliary cirrhosis status post orthotopic liver \ntransplant\n \nSocial History:\n___\nFamily History:\nNoncontributory\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nT 97.4 BP 164 / 114 HR 67 RR 18 SpO2 99% RA \nYoung man resting comfortably in bed, alert/conversing\nappropriately. Heart regular without murmurs, lungs CTAB, \nAbdomen\nsoft/ND, legs without edema. MSK: moderate/severe TTP in \nsternum,\nL lateral ribcage, one of the cervical vertebra. His sensation\nand strength is normal and symmetric in upper extremities. \n\nDISCHARGE PHYSICAL EXAM:\n=======================\nVS: ___ 0722 Temp: 97.5 PO BP: 150/84 HR: 80 RR: 18 O2 sat:\n96% O2 delivery: Ra \nGENERAL: Pleasant, conversant. \nHEENT: Normocephalic, atraumatic. PEERL. MMM. Extraocular\nmovements grossly intact. Tender over c4-c7 posteriorly. Tender\ndiffusely to palpation over sternum. \nCARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops. \n\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi. \nABD: Normal bowel sounds, soft, no hepatomegaly, no \nsplenomegaly.\nSlightly distended. TTP in epigastrum primarily, and LUQ/RUQ. \nEXT: Warm, well perfused, no lower extremity edema. \nPULSES: 1+ ___ & DP pulses \nNEURO: Alert, oriented, motor and sensory function grossly\nintact. \nSKIN: No significant rashes. \n \n\n \nPertinent Results:\nAdmission labs:\n===============\n___ 09:20PM GLUCOSE-86 UREA N-13 CREAT-1.3* SODIUM-140 \nPOTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-14\n___ 09:20PM estGFR-Using this\n___ 09:20PM ALT(SGPT)-18 AST(SGOT)-27 ALK PHOS-133* TOT \nBILI-0.5\n___ 09:20PM LIPASE-12\n___ 09:20PM cTropnT-<0.01\n___ 09:20PM ALBUMIN-3.9 IRON-41*\n___ 09:20PM calTIBC-333 VIT B12-440 FOLATE-14 \nFERRITIN-27* TRF-256\n___ 09:20PM WBC-2.1* RBC-4.81 HGB-12.6* HCT-39.1* MCV-81* \nMCH-26.2 MCHC-32.2 RDW-16.3* RDWSD-47.5*\n___ 09:20PM NEUTS-48.6 ___ MONOS-7.9 EOS-1.4 \nBASOS-1.9* IM ___ AbsNeut-1.04* AbsLymp-0.85* AbsMono-0.17* \nAbsEos-0.03* AbsBaso-0.04\n___ 09:20PM HOS-AVAILABLE \n___ 09:20PM HYPOCHROM-2+* ANISOCYT-1+* POIKILOCY-1+* \nMACROCYT-NORMAL MICROCYT-1+* POLYCHROM-1+* SPHEROCYT-OCCASIONAL \nOVALOCYT-1+* SCHISTOCY-OCCASIONAL BURR-1+* TEARDROP-OCCASIONAL\n___ 09:20PM PLT COUNT-68*\n___ 09:20PM ___ PTT-27.0 ___\n___ 09:20PM RET AUT-2.1* ABS RET-0.10\n\nDischarge Labs:\n===============\n___:23AM BLOOD WBC-3.1* RBC-5.10 Hgb-13.6* Hct-40.9 \nMCV-80* MCH-26.7 MCHC-33.3 RDW-16.5* RDWSD-47.5* Plt Ct-84*\n___ 07:23AM BLOOD Plt Ct-84*\n___ 07:23AM BLOOD Glucose-87 UreaN-11 Creat-1.1 Na-141 \nK-4.2 Cl-104 HCO3-23 AnGap-14\n___ 07:23AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9\n___ 07:23AM BLOOD tacroFK-4.2*\n\nImaging:\n___\nFinal Report\nEXAMINATION: RIB BILAT, W/AP CHEST\n \nINDICATION: ___ year old man with chest pain w previous fracture \nand\nmechanical cause of pain// eval rib frx\n \nTECHNIQUE: Frontal and oblique views of the chest\n \nCOMPARISON: Chest radiographs between ___ and ___\n \nFINDINGS: \n \nThe lungs are well expanded. Linear atelectasis in the lower \nleft lung is\nimproved. No focal consolidation. No pleural effusion or \npneumothorax. \nHeart size is normal. The mediastinal silhouette is \nunremarkable. There are\nminimally displaced anterolateral right probably fifth through \nseventh rib\nfractures. Thoracic spine fusion hardware is noted.\n \nIMPRESSION: \n \nMinimally displaced anterolateral right probably fifth through \nseventh rib\nfractures.\n\nCT C-Spine without contrast\n\nFinal Report\nEXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE\n \nINDICATION: ___ year old man with history of previously status \npost liver\ntransplant ___ years ago, leukopenia, with osteoporosis \ncomplicated by several\nfractures, now presenting with ongoing chest pain in the setting \nof recent rib\nfractures from exercising, found to have C-spine tenderness on \nexam. Please\nevaluate for cervical spine fractures.\n \nTECHNIQUE: Non-contrast helical multidetector CT was performed. \nSoft tissue\nand bone algorithm images were generated. Coronal and sagittal \nreformations\nwere then constructed.\n \nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 5.8 s, 22.7 cm; CTDIvol = 25.1 mGy \n(Body) DLP = 568.8\nmGy-cm.\n Total DLP (Body) = 569 mGy-cm.\n \nCOMPARISON: C-spine CT from ___.\n \nFINDINGS: \n \nAlignment is normal. There is diffuse osseous demineralization. \n Compression\ndeformities with loss of vertebral body height are noted at C4, \nC5, C6, and\nT1, largely unchanged compared to previous study. No acute \nfractures are\nidentified. There is no evidence of spinal canal or neural \nforaminal stenosis.\nThere is no prevertebral soft tissue swelling. There is no \nevidence of\ninfection or neoplasm.\nEmphysematous changes are noted at the lung apices bilaterally.\n \nIMPRESSION:\n \n \n1. Diffuse bone demineralization with compression deformities at \nC4, C5, C6\nand T1, similar to the previous study.\n2. No evidence of acute fractures or traumatic malalignment.\n\n___\nFinal Report\nEXAMINATION: CT CHEST W/O CONTRAST\n \nINDICATION: ___ year old man with PBC s/p liver transplant ___ yrs \nago \nosteoporosis c/b multiple fractures now p/w chest cervical \nvertebral pain\ns/p injury 2 weeks ago probable ___ rib fxs on CXR. \nEvaluate rib\nfractures.\n \nTECHNIQUE: Multi-detector helical scanning of the chest was \nperformed\nwithout intravenous iodinated contrast agent and reconstructed \nas 5 and 1.25\nmm thick axial, 2.5 mm thick coronal and sagittal, and 8 mm MIP \naxial images.\n \nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 2.6 s, 41.7 cm; CTDIvol = 13.2 mGy \n(Body) DLP = 550.9\nmGy-cm.\n Total DLP (Body) = 551 mGy-cm.\n \nCOMPARISON: Rib x-rays ___. Chest CTA ___. CT abdomen\nand pelvis ___.\n \nFINDINGS: \n \nNECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is \nunremarkable.\nThere is no supraclavicular or axillary lymphadenopathy. The \nesophagus is\npatulous.\n \nUPPER ABDOMEN: The transplant liver demonstrates homogeneous \nattenuation. \nNonobstructing right renal stones measure up to 3 mm, near a \nfocal area of\ncortical thinning. Moderate pancreatic atrophy.\n \nMEDIASTINUM: There is no mediastinal mass or lymphadenopathy.\n \nHILA: There is no hilar mass or lymphadenopathy.\n \nHEART and PERICARDIUM: Heart size is normal. The thoracic aorta \nis normal in\ncaliber. There is no pericardial effusion.\n \nPLEURA: No pleural effusion or pneumothorax.\n \nLUNG:\n \n1. PARENCHYMA: Probable bilateral lower lobe scarring and \natelectasis, less\nlikely interstitial disease. Mild, apical predominant \nparaseptal emphysema. \nA sub 3 mm right lower lobe pulmonary nodule is not definitively \nidentified on\nthe prior study (302:139), possibly due to differences in \ntechnique. No other\npulmonary nodules identified.\n2. AIRWAYS: The airways are patent to the level of the \nsegmental bronchi\nbilaterally.\n3. VESSELS: Main pulmonary artery diameter is within normal \nlimits.\nCHEST CAGE: Thoracic spinal fusion hardware is in place. The \nbones are\ndiffusely osteopenic. A chronic appearing deformity of the \nright scapula\n(302:125) appears new since ___. Chronic deformities of \nthe right\nanterior second through seventh ribs, similar to multiple priors \ndating back\nto ___. A compression deformity of the T6 vertebral \nbody is\nredemonstrated. Redemonstrated manubrial fracture. There is no \nacute\nfracture.\n \nIMPRESSION:\n \n \n1. Multiple, chronic right-sided rib fractures, similar in \nappearance to at\nleast ___. No acute rib fractures identified.\n2. Chronic appearing right scapular deformity, new since ___.\n3. Stable T6 compression fracture and manubrial fracture.\n4. Sub 3 mm right lower lobe pulmonary nodule, not definitively \nidentified on\nthe prior study from ___, possibly due to differences in \nstudy\ntechnique. No other pulmonary nodules identified.\n5. Nonobstructing right renal stones, measuring up to 3 mm.\n\n___\nCONCLUSION:\nThe left atrial volume index is normal. There is mild symmetric \nleft ventricular hypertrophy with a\nnormal cavity size. There is normal regional left ventricular \nsystolic function. Overall left ventricular\nsystolic function is normal.\nQuantitative biplane left ventricular ejection fraction is 53 %.\nNormal right ventricular cavity size with normal free wall \nmotion. The aortic sinus diameter is normal for\ngender. The aortic valve leaflets (3) appear structurally \nnormal. There is no aortic valve stenosis. There is no aortic \nregur\ngitation. The mitral valve leaflets appear structurally normal \nwith no mitral valve prolapse. There is trivial mitral regur\ngitation. The tricuspid valve leaflets appear structurally \nnormal.\nThere is trivial tricuspid regurgitation. There is a moderate \npericardial effusion. There is increased respiratory variation \nin transmitral/transtricuspid inflow but no right atrial/right \nventricular diastolic collapse.\nIMPRESSION: 1) Moderate pericardial effusion largely anterior to \nthe right atrium. It appears to be serous and loculated. There \nappears to be an epicardial fat pat in addition to the \npericardial effusion. The pericardial effusion is difficult to \nbe reached by either percutaneous approaches. 2)\nThere is respiratory variation in mitral inflow reaching \nthreshold of hemodynamically significant pericardial pressure \nelevation. However, there is no RA/RV collapse. RA pressure \ncould not be estimated on this study. There is a septal bounce \non this echocardiogram however no clear signs of\npericaridal constriction are note\n\n \nBrief Hospital Course:\nASSESSMENT & PLAN:\n___ h/o idiopathic hemorrhagic pericarditis (___) requiring \npericardial window, osteoporosis c/b multiple pathologic \nfractures, PBC s/p liver transplant (___) on tacro/pred c/b HSV\nesophagitis (___), admitted for neutropenia, acute kidney \ninjury, and pain management of right rib fractures.\n\nACUTE ISSUES:\n==============\n#Acute kidney injury\nAdmitted with a creatinine of 1.4. Likely a combination of \npre-renal in the setting of decreased PO intake due to rib \nfractures as well as a possible component of tacrolimus \ntoxicity. He initially responded to maintence fluids but then \nhis creatinine returned to 1.4. We then decreased his tacrolimus \nto 0.5 mg at night and 1 mg in the morning, his creatinine was \n1.1 on discharge.\n\n#Pancytopenia\n#Neutropenia\nPatient reports he has had pancytopenia since his liver \ntransplant ___ years ago. This is likely immunosuppressive effect \nfrom his Tacrolimus resulting in chronic iatrogenic \nmyelosuppression. He had a workup for this including BM-biopsy \nin ___ iso CMV viremia, which was non-revealing. This is most \nlikely a chronic issue however given his history we need to rule \nout acute infectious causes of myelosuppression such as CMV, his \nviral load was negative. His EBV viral load was pending on \ndischarge. Another contributor is possibly his colchicine as \nwell. Per chart review, he appears to be at his baseline.\n\n#R-sided rib Fractures\n#Dyspnea\n#Pericardial effusion\nPt reports continued sternal/chest pain from over-exertion \nduring workout 2 weeks ago. CXR w/ bilat rib imaging ___ \ndemonstrated minimally displaced anterolateral R-sided ___ \nribs. Pain and hx most c/w rib fractures. He also has RF for \nfracture with known osteoporosis. Acute coronary syndrome is \nless likely given normal EKG & troponin. He also has a history \nof pericarditis requiring pericardial window. We were concerned \nWe checked an echocardiogram which showed a loculated \npericardial effusion, he had no evidence of tamponade physiology \nand had a pulsus of 6mmhg. He was never hypotensive. We \nconsulted cardiology who saw the patient and advised follow up \nwith his primary provider, Dr. ___, in ___ weeks. At the time \nof discharge, the note was not signed by the supervising \nprovider. I reached out the cardiology fellow who was on call on \n___ and they were unable to assist in the finalization of \nthe recommendations. However, I was able to speak with \ncardiology fellow on the day of consult (___) who said that \nthe recommendations would likely be follow up in ___ weeks. I \nalso discussed the cause ___ with the consulting resident \nwho had reportedly staffed the case with the attending per the \nnote at that time. \n\n#C-spine tenderness\nPatient had C4, 5, or 6 tenderness on physical exam, which he \nsaid was new. Given his h/o pathologic fractures and recent \nmechanical trauma, we checked a CT of the C spine which showed \nno evidence of acute fracture. At this time we feel that the c \nspine tenderness is likely caused by muscle spasm.\n\n#Iron Deficiency Anemia\nOn admission, low ferritin, serum iron, transferrin saturation, \nmicrocytic anemia and hypochromic cells on smear c/w iron \ndeficiency anemia. Pt reports this is baseline since his liver \ntransplant ___ years ago, currently on Tacrolimus. Also a chronic \nissue iso pancytopenia which underwent work-up in ___ (Above). \nPPI regimen and/or nutrition iso rib fractures may also be \ncontributing factors. He is currently at his baseline so no \nacute\nconcerns. Hgb 13.7 today.\n\n#HTN\nSBP in the 160s on admission, likely I/s/o pain from rib \nfractures. Not on antihypertensives at home. Improved throughout \nthe admission.\n\nCHRONIC ISSUES:\n===============\n#PBC s/p liver transplant\n-Continued home tacrolimus at 1 mg PO BID and prednisone 5 mg PO \ndaily for immunosuppression. Tacro level was 6.1\n\n#Osteoporosis\nPer OMR review, has had since before his liver transplant so \nlikely not caused by prednisone but if definitely exacerbated by \nit. Has not seen his ___ endocrinologist since ___ several \nno-shows since that time. Does not appear that he has been on \nany bisphosphonate treatmentsalthough at one point was taking \nhigh-dose vitamin D.\n\n#Pericarditis:\n-We Continued home colchicine and ASA 325 mg\n\nTransitional Issues:\n====================\n[]CT scan in 6 months to evaluate right lower lobe pulmonary \nnodule\n[]Hypertension to 160s in setting of acute pain, will need a BP \nrecheck at ___ ___\n[]Evaluate for treatment of osteoporosis\n[]F/u with Endocrinology\n[]F/u with cardiology in ___ weeks\n[]F/u with hepatology in 2 months\n[]Recheck CBC in one week\n[]Check chem 7 in one week to ensure normalization of kidney \nfunction\n[]Decreased tacro dosing to 1 mg qam and 0.5 qpm\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. Atorvastatin 10 mg PO QPM \n2. BuPROPion (Sustained Release) 300 mg PO QAM \n3. Colchicine 0.6 mg PO BID \n4. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm \n5. DICYCLOMine 20 mg PO TID:PRN diarrhea \n6. Gabapentin 600 mg PO BID \n7. Pantoprazole 40 mg PO Q12H \n8. PredniSONE 5 mg PO DAILY \n9. Ranitidine 150 mg PO DAILY \n10. Tacrolimus 1 mg PO Q12H \n11. Aspirin 325 mg PO BID \n12. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n13. LidoPatch (lidocaine-menthol) ___ % topical DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth q8hrs Disp #*60 \nTablet Refills:*0 \n2. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose \nUse if very tired after oxycodone \nRX *naloxone [Narcan] 4 mg/actuation 1 spray IN once, MR1 Disp \n#*1 Spray Refills:*2 \n3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth q6hrs PRN Disp #*10 \nTablet Refills:*0 \n4. Tacrolimus 0.5 mg PO QPM \nRX *tacrolimus 0.5 mg 1 capsule(s) by mouth qPM Disp #*30 \nCapsule Refills:*1 \n5. Tacrolimus 1 mg PO QAM \nRX *tacrolimus 1 mg 1 capsule(s) by mouth qAM Disp #*30 Capsule \nRefills:*1 \n6. Aspirin 325 mg PO BID \n7. Atorvastatin 10 mg PO QPM \n8. BuPROPion (Sustained Release) 300 mg PO QAM \n9. Colchicine 0.6 mg PO BID \n10. DICYCLOMine 20 mg PO TID:PRN diarrhea \n11. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n \n12. Gabapentin 600 mg PO BID \n13. LidoPatch (lidocaine-menthol) ___ % topical DAILY \n14. Pantoprazole 40 mg PO Q12H \n15. PredniSONE 5 mg PO DAILY \n16. Ranitidine 150 mg PO DAILY \n17. HELD- Cyclobenzaprine 5 mg PO TID:PRN muscle spasm This \nmedication was held. Do not restart Cyclobenzaprine until you \nsee your PCP\n\n \n___:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis\n=================\n1) Right ___ rib fractures \n2) Liver transplant \n3) Osteoporosis \n4) Acute kidney injury \n\nSecondary Diagnosis \n===================\n1)Pericarditis \n2)Iron decifiency anemia\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 low white blood cell counts and rib pain\n \nWhat was done for me while I was in the hospital? \n-We controlled your pain with medication\n-We decreased your tacrolimus dose \n-We did an echocardiogram which was mostly normal\n\nWhat should I do when I leave the hospital? \n-Please take all of your medications as prescribed, especially \nyour tacrolimus and prednisone \n-Please follow up with your endocrinologist\n-Please follow up with your cardiologist\n-Please follow up with your hepatologist in 2 months \n-Please follow up with you PCP \n \n___, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "M8000XA", "N179", "I319", "Z944", "I313", "D509", "I10", "Z87891", "D702" ]

[ "M8000XA: Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture", "N179: Acute kidney failure, unspecified", "I319: Disease of pericardium, unspecified", "Z944: Liver transplant status", "I313: Pericardial effusion (noninflammatory)", "D509: Iron deficiency anemia, unspecified", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "D702: Other drug-induced agranulocytosis" ]

[ "N179", "D509", "I10", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms\n \nAttending: ___.\n \nChief Complaint:\ncolonoscopy\n \nMajor Surgical or Invasive Procedure:\nColonoscopy ___\n\n \nHistory of Present Illness:\nPatient is a ___ year old man with PBC s/p liver transplantation \nin ___ (on tacrolimus/ prednisone), pericarditis complicated by \ntamponade with pericardial window, bipolar disorder, & recurrent \nC Difficile, who presents for colonoscopy prep.\n\nPt reports that for the past 6 months he has had intermittent \ndiarrhea, watery, ___ episodes daily, ongoing for periods of ___ \ndays before being constipated with no BMs for a ___ days. Also \nreports chronic abdominal pain, nausea, dyspepsia, chills. No \nblood in stools, no hematemesis, fever. He has been hospitalized \nmultiple times, most recently in ___, for diarrhea, stool \nstudies and C diff PCR was negative. A flexible sigmoidoscopy \nshowed inflammation in the rectum, biopsy results showed active \ncolitis that was consistent with ischemic type. Special stains \nfor cytomegalovirus at that time were negative. He also has had \na tissue transglutaminase IgA antibody, which has been low only \nfor pretty much excluding celiac disease. Per pathology, changes \nseen on his biopsies seemed most consistent with \nmedication-induced injury, infectious injury and less likely \nischemia. They have not favored idiopathic inflammatory bowel \ndisease and there has been no evidence of the same. Per GI \"need \nto consider diarrhea of a multifactorial origin, possibly\nmedication, irritable bowel syndrome of the alternating type \nversus other etiologies. Recommended reassessment with \ncolonoscopy and multiple biopsies\nof the ileum and of the colon. I see no need to repeat stool \nsamples.\"\n\nOn arrival to floor (direct admit from home), he denies any \ncurrent sxs, VSS.\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n PBC s/p deceased liver donor tx ___ \n Neutropenia \n DVT ___ \n Prior alcohol abuse now abstinent \n Hemorrhagic pericarditis c/b tamponade with pericardial window \n\n ___ \n Positive PPD s/p INH \n HLD \n Osteoporosis \n Bipolar disorder \n Hemorrhoids \n ADHD \n PTSD \n\n \nSocial History:\n___\nFamily History:\n Father (living): coronary artery disease, diabetes, \nhypercholesterolemia, and depression. Prostate and head and neck \ncancer \n Mother (deceased): brain aneurysm and hyperthyroidism \n \nPhysical Exam:\nAdmission Exam:\n==================\n Gen: NAD, lying in bed\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n Cardiovasc: RRR, no MRG, full pulses, no edema \n Resp: normal effort, no accessory muscle use, lungs CTA ___.\n GI: soft, temder to palpation of epigastrium, well healed \nincisional scars from prior surgeries, non distended, 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=================\n97.3 PO 114 / 78 67 16 98 Ra \nGen: NAD, lying in bed\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n Cardiovasc: RRR, no MRG, full pulses, no edema \n Resp: normal effort, no accessory muscle use, lungs CTA ___.\n GI: soft, mild ttp in epigastrium, well healed incisional scars \nfrom prior liver transplant, non distended, BS+\n MSK: No edema\n Skin: No visible rash. No jaundice.\n Neuro: AAOx3. Moving all extremities\n Psych: Full range of affect\n \nPertinent Results:\n___ 10:16PM BLOOD WBC-4.2 RBC-5.97 Hgb-17.0 Hct-50.4 MCV-84 \nMCH-28.5 MCHC-33.7 RDW-15.4 RDWSD-47.6* Plt Ct-95*\n___ 10:16PM BLOOD ___ PTT-32.5 ___\n___ 09:57AM BLOOD Glucose-78 UreaN-9 Creat-1.4* Na-141 \nK-3.8 Cl-107 HCO3-22 AnGap-16\n___ 10:16PM BLOOD Glucose-78 UreaN-7 Creat-1.4* Na-142 \nK-5.0 Cl-105 HCO3-26 AnGap-16\n___ 09:57AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.4\n\nImaging:\n=========\nColonoscopy ___: Those portions of the mucosa that were well \nvisualized appeared to be normal. The mucosa of the terminal \nileum also appeared normal. Many areas were not well prepped. \nCold forceps biopsies were performed for histology at the \nterminal ileum. \n \nOther procedures: Cold forceps biopsies were performed for \nhistology at the whole colon at random. \n \n\nImpression: Those portions of the mucosa that were well \nvisualized appeared to be normal. The mucosa of the terminal \nileum also appeared normal. Many areas were not well prepped. \n(biopsy)\n (biopsy)\nOtherwise normal colonoscopy to cecum and terminal ileum \n\nRecommendations: ___ biopsy results\n___ with Dr. ___ as needed\n___ with endoscopist within 6 weeks \n\n \nBrief Hospital Course:\nA/P: Patient is a ___ year old man with PBC s/p liver \ntransplantation in ___ (on tacrolimus/ prednisone), \npericarditis complicated by tamponade with pericardial window, \nbipolar disorder, & recurrent C Difficile, who presents for \ncolonoscopy prep.\n\n# Chronic diarrhea\n# Colonoscopy prep\nMr. ___ presented with 6 months of alternating constipation \nand severe diarrhea. He has had C diff infections in the past \nbut none recently, and no evidence of an infectious process \ngiven chronicity. Per GI note, changes seen on his colonic \nbiopsies seem most consistent with medication-induced injury, \ninfectious injury and less likely ischemia. They have not \nfavored idiopathic inflammatory bowel disease and there has been \nno evidence of the same. Etiology is thought to be \nmultifactorial, possibly medication, irritable bowel syndrome of \nthe alternating type versus other etiologies. He was admitted \nfor inpatient colonoscopy prep in the setting of severe \ndehydration from GI losses with prior preps. He was prepped with \nmoviprep overnight and given IV fluids with stable electrolytes \non morning of colonoscopy. He underwent colonoscopy on ___ \nsuccessfully with biopsies taken. He recovered on the floor and \nwas discharged that evening. \n\n# PBC s/p OLT: Chronic abdominal pain, nausea likely ___ PBC. \nMost recent LFTs and abdominal imaging have been normal. He was \ncontinued on his prednisone, tacrolimus, Zofran and gabapentin. \n\n# Hx of pericardial effusion/pericarditis complicated by \ntampondade: No further recurrence, followed by Dr ___. \nContinued on prednisone, aspirin and colchicine. \n\nTransitional Issues:\n========================\n[]f/u with Colonic biopsies from ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 650 mg PO BID \n2. Colchicine 0.6 mg PO BID \n3. Gabapentin 600 mg PO BID \n4. Ondansetron 4 mg PO Q8H:PRN nausea \n5. PredniSONE 5 mg PO DAILY \n6. Ranitidine 150 mg PO QHS \n7. Tacrolimus 1 mg PO QPM \n8. Tacrolimus 1 mg PO QAM \n9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n10. Sulfameth/Trimethoprim DS 1 TAB PO BID \n11. Docusate Sodium 100 mg PO BID \n12. Senna 8.6 mg PO BID \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID:PRN constipation \n2. Senna 8.6 mg PO BID:PRN constipation \n3. Aspirin 650 mg PO BID \n4. Colchicine 0.6 mg PO BID \n5. Gabapentin 600 mg PO BID \n6. Ondansetron 4 mg PO Q8H:PRN nausea \n7. PredniSONE 5 mg PO DAILY \n8. Ranitidine 150 mg PO QHS \n9. Tacrolimus 1 mg PO QPM \n10. Tacrolimus 1 mg PO QAM \n11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nDiarrhea\nColonoscopy preparation\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 for inpatient colonoscopy \npreparation. You tolerated the procedure well and your \ncolonoscopy was unremarkable. Biopsies were taken and you will \nbe called with the results of these biopsies. \n\nYou are ready for discharge. Please continue to take all of your \nmedications as prescribed. \n\nIt was a pleasure taking care of you,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K529", "K830", "R109", "G8929", "J449", "R634", "Z6823", "R110", "Z87891", "F319", "F909", "F4310", "Z944", "Z86718" ]

[ "K529: Noninfective gastroenteritis and colitis, unspecified", "K830: Cholangitis", "R109: Unspecified abdominal pain", "G8929: Other chronic pain", "J449: Chronic obstructive pulmonary disease, unspecified", "R634: Abnormal weight loss", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "R110: Nausea", "Z87891: Personal history of nicotine dependence", "F319: Bipolar disorder, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F4310: Post-traumatic stress disorder, unspecified", "Z944: Liver transplant status", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "G8929", "J449", "Z87891", "Z86718" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms\n \nAttending: ___.\n \nChief Complaint:\nDiarrhea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo man with PBC s/p liver transplantation in \n___ (on tacrolimus/ prednisone), pericarditis complicated by \ntamponade with pericardial window, bipolar disorder, & recurrent \nC \nDifficile with recent hospitalization, who presents with \ndiarrhea, nausea, vomiting, and abdominal pain. \n\nHe reports that his diarrhea had improved by the time of his \nlast discharge from the hospital. However, it started to \nincrease in frequency once he got home. He reports that he did \nnot change his diet at all. No sick contacts. Has not consumed \nany raw or undercooked shellfish or other food. His bowel \ndiarrhea is watery and non-bloody. He reports he has anywhere \nfrom ___ bowel movements per day. He reports his vomit is \nnon-bloody and non-bilious. Denies fever, chills, chest pain, \nshortness of breath. \n \nPast Medical History:\nPAST MEDICAL HISTORY: \n PBC s/p deceased liver donor tx ___ \n Neutropenia \n DVT ___ \n Prior alcohol abuse now abstinent \n Hemorrhagic pericarditis c/b tamponade with pericardial window \n\n ___ \n Positive PPD s/p INH \n HLD \n Osteoporosis \n Bipolar disorder \n Hemorrhoids \n ADHD \n PTSD \n\n \nSocial History:\n___\nFamily History:\n Father (living): coronary artery disease, diabetes, \nhypercholesterolemia, and depression. Prostate and head and neck \ncancer \n Mother (deceased): brain aneurysm and hyperthyroidism \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=====================\nVITAL SIGNS - 97.7 PO 104 / 69 L Lying 60 18 98 RA \nGENERAL - Appears stated age in NAD\nHEENT - neck supple, PERRLA, EOMI, no appreciable cervical or \nsupravlavicular LAD. mucous membranes dry.\nCARDIAC - S1/S2, bradycardic, regular rhythm\nPULMONARY - CTAB\nABDOMEN - one large surgical scar on L side of abdomen. Well \nhealed. Tender to palpation in the epigastric area and the LUQ \nEXTREMITIES - No edema, well-perfused\nSKIN - no bruising or notable rashes.\nNEUROLOGIC - A&O x 3, normal gait, ___ strength in upper and \nlower extremities\n\nDISCHARGE PHYSICAL EXAM\n======================\nVITAL SIGNS - 97.5 PO 121 / 85 56 18 97 ra \nGENERAL - lying in bed, sleeping\nHEENT - neck supple, PERRLA, EOMI, no appreciable cervical or \nsupravlavicular LAD. Area of mild erythema periortibally on \nlateral left eye has resolved. Mild tenderness to palpation over \nerythema and also posterior auricular lymph nodes have resolved.\nCARDIAC - S1/S2, bradycardic, regular rhythm\nPULMONARY - CTAB\nABDOMEN - one large surgical scar on L side of abdomen. Well \nhealed. Tender to palpation in the epigastric area and the LUQ \nEXTREMITIES - No edema, well-perfused\nSKIN - no bruising or notable rashes.\nNEUROLOGIC - A&O x 3, normal gait, ___ strength in upper and \nlower extremities\n \nPertinent Results:\nADMISSION LAB RESULTS\n===================\n___ 09:00AM BLOOD WBC-3.1* RBC-4.93 Hgb-15.0 Hct-43.7 \nMCV-89 MCH-30.4 MCHC-34.3 RDW-15.2 RDWSD-48.1* Plt ___\n___ 09:00AM BLOOD Neuts-49.3 ___ Monos-10.3 Eos-1.6 \nBaso-2.3* Im ___ AbsNeut-1.53* AbsLymp-1.10* AbsMono-0.32 \nAbsEos-0.05 AbsBaso-0.07\n___ 09:00AM BLOOD ___ PTT-25.7 ___\n___ 09:00AM BLOOD Glucose-77 UreaN-11 Creat-1.2 Na-136 \nK-4.4 Cl-103 HCO3-16* AnGap-21*\n___ 09:00AM BLOOD ALT-25 AST-34 AlkPhos-98 TotBili-0.8\n___ 09:00AM BLOOD Albumin-4.0 Calcium-8.9 Mg-1.9\n___ 09:12AM BLOOD Lactate-1.0\n\nDISCHARGE LAB RESULTS\n====================\n___ 04:52AM BLOOD WBC-3.3* RBC-4.65 Hgb-13.9 Hct-40.1 \nMCV-86 MCH-29.9 MCHC-34.7 RDW-14.5 RDWSD-45.1 Plt Ct-96*\n___ 04:52AM BLOOD ___ PTT-32.1 ___\n___ 04:52AM BLOOD Glucose-77 UreaN-10 Creat-1.3* Na-137 \nK-4.6 Cl-101 HCO3-25 AnGap-16\n___ 04:52AM BLOOD ALT-18 AST-18 AlkPhos-98 TotBili-0.6\n___ 04:52AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1\n\nMICROBIOLOGY\n============\n___ Stool Culture\nFECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n\n___ C diff: Negative\n\n___ Urine culture: Negative\n\n___ Blood culture: Pending\n\nIMAGING\n=======\n___ Chest X-Ray: \nFaint linear densities in the lower lungs likely reflect \nplatelike atelectasis. The lungs are otherwise clear. There is \nstable prominence of the mediastinal silhouette, which has\nbeen previously assessed by CT chest from ___. The \nheart size is\nnormal. Bony structures are intact. No free air below the \nright hemidiaphragm.\n\n___ Abdominal X-Ray:\nSupine and upright views of the abdomen pelvis were provided. \nBowel gas pattern is unremarkable without signs of ileus or \nobstruction. No free air is seen below the right hemidiaphragm. \nNo worrisome calcifications. The imaged osseous structures \nappear intact. There is a mild dextroscoliosis of the \nthoracolumbar spine, apex at L1. A clip again noted in the \nright upper quadrant.\n\n___ RUQ Ultrasound with Doppler:\nThe main hepatic arterial waveform is within normal limits, with \nprompt systolic upstrokes and continuous antegrade diastolic \nflow. Peak systolic velocity in the main hepatic artery is 24. \nAppropriate arterial waveforms are seen in the right hepatic \nartery and the left hepatic artery with resistive indices of \n0.74, and 0.79, respectively. The main portal vein and the \nright and left portal veins are patent with hepatopetal flow and \nnormal waveform. Appropriate flow is seen in the hepatic veins \nand the IVC. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ man with PBC s/p liver transplantation in \n___ (on tacrolimus/prednisone), pericarditis complicated by \ntamponade with pericardial window, bipolar disorder, & recurrent \nC Difficile with recent hospitalization, who presents with \nworsening diarrhea, n/v, and abdominal pain.\n\n# Diarrhea, Nausea, Vomiting: The patient initially presented \nwith abdominal pain, vomiting x3 the night prior to admission, \nand reports of increase in diarrhea. There was initial concern \nfor toxic megacolon or SBO. However, ___ ruled out those \netiologies. It was thought that this may either be viral \ngastroenteritis or relapsed C. Diff infection. Flex \nsigmoidoscopy on previous hospitalization showed active colitis \nwith focal superficial features suggestive of a component of \nischemic type injury. Stool studies were sent including \nnorovirus NAAT, and C. Diff which were negative. The patient's \nlast bowel movement was in the emergency department. He did not \nhave one for three days after that. The patient had still not \nhad a bowel movement on the day of discharge, so he was given \nsenna, colace, and miralax. \n\n#Cellulitis: The patient had some erythema and swelling without \nwarmth over the lateral left ___ area. He remained \nafebrile. ID was consulted for questionable cellulitis since the \npatient was at a higher risk for infection given \nimmunosuppression. A diagnosis of pre-septal cellulitis was \nmade, and the patient was started on Bactrim. He was sent home \non Bactrim 1 DS tab BID x 7 days to finish the course for facial \ncellulitis.\n\n# PBC s/p orthotopic liver transplant with CMV+ donor \ncomplicated by cellular rejection: The patient was continued on \nhis home tacrolimus/prednisone and tacrolimus troughs were \nchecked daily; they ranged from ___. \n\n# Normocytic Anemia: The patient's hemoglobin dropped from 15 to \n12.8 the day after admission. This was likely dilutional given \nthat the patient received IV fluids in the ED. Hemolysis labs \nwere negative. Iron deficiency labs ___ ferritin, but \notherwise normal.\n \n# Thrombocytopenia: Patient has known chronic thrombocytopenia \nlikely due to liver disease, immunosuppression and \nhypersplenism.\n\n# Bipolar Disorder: The patient was recently taken off Abilify. \nHe was monitored during his hospitalization, and there were no \nacute issues.\n \n# GERD: Stable. Possibly contributing to abdominal pain as \ndescribed above. He was continued on his home ranitidine 150mg \nqHS, maalox PRN. \n \n# Chronic neuropathic pain: He was continued on his home \nGabapentin 600mg BID.\n \n# COPD: There was no SOB throughout the admission. He was \ncontinued on home albuterol PRN\n\nTRANSITIONAL ISSUES\n====================\n-Patient will follow up with Dr. ___ as outpatient to monitor \nalternating diarrhea and constipation. \n-Consider follow up colonoscopy in several months to monitor for \nresolution of active colitis.\n-Patient will be discharged on Bactrim 1 DS tab BID for total \ncourse of 7 days (end date ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 650 mg PO BID \n2. Colchicine 0.6 mg PO BID \n3. Gabapentin 600 mg PO BID \n4. PredniSONE 5 mg PO DAILY \n5. Ranitidine 150 mg PO QHS \n6. Tacrolimus 1 mg PO QPM \n7. Tacrolimus 1 mg PO QAM \n8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n9. Ondansetron 4 mg PO Q8H:PRN nausea \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*45 Capsule Refills:*0 \n2. Senna 8.6 mg PO BID \nRX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*45 \nTablet Refills:*0 \n3. Sulfameth/Trimethoprim DS 1 TAB PO BID \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by \nmouth twice a day Disp #*11 Tablet Refills:*0 \n4. Aspirin 650 mg PO BID \n5. Colchicine 0.6 mg PO BID \n6. Gabapentin 600 mg PO BID \n7. Ondansetron 4 mg PO Q8H:PRN nausea \n8. PredniSONE 5 mg PO DAILY \n9. Ranitidine 150 mg PO QHS \n10. Tacrolimus 1 mg PO QPM \n11. Tacrolimus 1 mg PO QAM \n12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nDiarrhea\n\nSECONDARY DIAGNOSIS\n====================\nChronic pain\nPrimary Biliary Cirrohsis S/P Liver Transplant\nCellular Rejection\nAnemia\nBipolar Disorder\nGastroesophageal Reflux Disease\nCellulitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nMr. ___,\nYou were admitted to ___.\n\nWhy were you admitted?\n======================\nYou had abdominal pain, diarrhea, nausea and vomiting\n\nWhat did we do for you?\n=======================\n-We gave you fluids because of dehydration from diarrhea and \nvomiting.\n-We sent off tests of your stool to ensure you do not have \nanother infection. The tests that did come back were negative. \nSome of the other cultures were still pending at time of \ndischarge. \n\nWhat should you do when you get home?\n=====================================\n-Continue to take your anti-nausea medication before meals when \nyou are feeling nauseous. \n-We suggest that you follow the \"BRAT\" diet until you feel \nbetter. This consists of bananas, rice, applesauce and toast. \nYou can advance your diet when you feel you are able\n-Expect to have loose stools, up to 1 or 2 per day, for the \nnext few months. Your colon is still recovering from your \nClostridium \ndifficile infection in ___.\n- Call the doctor if you have 6 or more loose stools per day.\n- Attend a follow-up appointment with your primary care doctor.\n- Attend a follow-up appointment with your liver transplant \ndoctor. \n- Consider seeing a pain specialist to help treat your multiple \ncauses of pain.\n\nIt was a pleasure taking part in your care.\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K529", "T8641", "D6959", "G629", "E860", "L03213", "F319", "Z590", "R0789", "K219", "D731", "J449", "D649", "K5900", "F909", "F4310", "G8929", "Z86718", "Z87891", "Y830", "Y929" ]

[ "K529: Noninfective gastroenteritis and colitis, unspecified", "T8641: Liver transplant rejection", "D6959: Other secondary thrombocytopenia", "G629: Polyneuropathy, unspecified", "E860: Dehydration", "L03213: Periorbital cellulitis", "F319: Bipolar disorder, unspecified", "Z590: Homelessness", "R0789: Other chest pain", "K219: Gastro-esophageal reflux disease without esophagitis", "D731: Hypersplenism", "J449: Chronic obstructive pulmonary disease, unspecified", "D649: Anemia, unspecified", "K5900: Constipation, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F4310: Post-traumatic stress disorder, unspecified", "G8929: Other chronic pain", "Z86718: Personal history of other venous thrombosis and embolism", "Z87891: Personal history of nicotine dependence", "Y830: Surgical operation with transplant of whole organ as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]

[ "K219", "J449", "D649", "K5900", "G8929", "Z86718", "Z87891", "Y929" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone\n \nAttending: ___\n \nChief Complaint:\nBRBPR\n \nMajor Surgical or Invasive Procedure:\nSigmoidoscopy ___\n\n \nHistory of Present Illness:\n___ with hx of COPD, PBC s/p DDLTx (SCD ___ c/b CMV viremia \nand acute rejection, and pericarditis (on ASA 975mg TID) and hx \nof hemmorhoids who presents with BRBPR. Patient noted blood in \nthe toilet bowel water and on the toilet paper and on his stool. \nStool brown in appearance and formed. Had 2x episodes of blood \nwith BM starting at noon today. No further BMs or blood. Patient \nalso endorses periumbilical abdominal pain since first ___ where \nhe noted blood. Pain is located in LLQ and comes and goes in \nwaves. Occasional nausea but no vomiting. Patient has been \ntolerating PO without issues or associated pain/nausea. No \nrecent illness, sick contacts, diarrhea. \n\n Patient initially presented to ___ who directed \nhim to ___ given his transplant status. Most recent labs from \n___ demonstrate an H/H of 13.9/40.9, INR of 0.9, and plt ct \nof 67K. Mr ___ denies any symptoms of orthostasis including \ndizziness, lightheadedness, or weakness. \n\n In the ED, initial VS were pain ___. T 96.6, HR 80, BP 137/92, \nRR 18 satting 100% on RA. Initial labs notable for Cr of 1.3, \nAlt 49, AST 33, TBili 0.5, WBC 3.8, Hgb 14, Plt 69. INR 1. \nPatient given 500cc NS and 5mg Morphine x3. Blood Cx, Urine Cx \nobtained. CT abdomen/Pelvis without evidence of acute pathology. \n \n\n On arrival to the floor, patient states that he continues to \nhave mild LLQ pain, but this has improved with IV morphine. He \nhas not other complaints. \n\n REVIEW OF SYSTEMS: \n Denies fever, night sweats, headache, vision changes, \nrhinorrhea, congestion, sore throat, cough, shortness of breath, \nchest pain, abdominal pain, nausea, vomiting, diarrhea, \nconstipation, melena, dysuria, hematuria. \n\n All other 10-system review negative in detail. \n \nPast Medical History:\n PBC s/p deceased liver donor tx ___ \n Neutropenia \n DVT ___ \n Alcohol abuse now abstinent \n Hemorrhagic pericarditis c/b tamponade with pericardial window \n___ \n Positive PPD \n HLD \n Osteoporosis \n Bipolar disorder \n Hemorrhoids \n ADHD\n PTSD\n \nSocial History:\n___\nFamily History:\n Father (living): coronary artery disease, diabetes, \nhypercholesterolemia, and depression. Prostate and head and neck \ncancer \n Mother (deceased): brain aneurysm and hyperthyroidism \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n======================== \n VS - 96.8; 131/87; 77; 18; 77; 18; 99RA; Pain ___ \n GENERAL: NAD \n HEENT: AT/NC, EOMI, PER, anicteric sclera, pink conjunctiva, \nMMM, good dentition \n NECK: nontender supple neck \n CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs \n LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \n ABDOMEN: nondistended, +BS, mild TTP in LLQ, no \nrebound/guarding, no hepatosplenomegaly appreciated. No CVA \nTenderness \n Rectal: large anal skin tag, no visible external hemmorhoids \n EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose \n PULSES: 2+ DP pulses bilaterally \n NEURO: A&Ox3. No gross deficits \n SKIN: warm and well perfused, no excoriations or lesions, no \nrashes\n\nDISCHARGE PHYSICAL EXAM \n=======================\nVitals: T:98.3 BP:113/77 P:69 R:22 O2:99 RA \nGENERAL: Appears chronically ill, mild jaundice \nHEENT: AT/NC, EOMI, PER, anicteric sclera, pink conjunctiva, \nMMM, good dentition \nCARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: well healed abdominal scar, +BS, mild TTP in RUQ and \nRLQ, no rebound/guarding, no hepatosplenomegaly appreciated. No \nCVA Tenderness \nRectal: Per admission exam: large anal skin tag, no visible \nexternal hemmorhoids \nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3. No gross deficits \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes\n\n \nPertinent Results:\n==============\nADMISSION LABS\n==============\n\n___ 04:00PM BLOOD WBC-3.8* RBC-4.58* Hgb-14.0 Hct-40.1 \nMCV-88 MCH-30.6 MCHC-34.9 RDW-14.5 RDWSD-46.1 Plt Ct-69*\n___ 04:00PM BLOOD Neuts-75.4* Lymphs-15.2* Monos-6.6 \nEos-0.5* Baso-0.5 Im ___ AbsNeut-2.87# AbsLymp-0.58* \nAbsMono-0.25 AbsEos-0.02* AbsBaso-0.02\n___ 04:00PM BLOOD Plt Ct-69*\n___ 04:00PM BLOOD Glucose-95 UreaN-17 Creat-1.3* Na-140 \nK-4.1 Cl-105 HCO3-26 AnGap-13\n___ 04:00PM BLOOD ALT-49* AST-33 AlkPhos-76 TotBili-0.5\n\n==============\nPERTINENT LABS\n==============\n\n___ 07:10AM BLOOD CRP-0.7\n___ 07:10AM BLOOD tacroFK-4.8*\n___ 10:00AM BLOOD tacroFK-8.0\n___ 09:35AM BLOOD tacroFK-6.6\n\n=============\nMICROBIOLOGY\n=============\n\n___ 7:15 am STOOL CONSISTENCY: LOOSE Source: \nStool. \n\n **FINAL REPORT ___\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___ 10:00 am Immunology (CMV)\n\n **FINAL REPORT ___\n\n CMV Viral Load (Final ___: \n CMV DNA not detected. \n Performed by Cobas Ampliprep / Cobas Taqman CMV Test. \n Linear range of quantification: 137 IU/mL - 9,100,000 \nIU/mL. \n Limit of detection 91 IU/mL. \n This test has been verified for use in the ___ patient \npopulation. \n__________________________________________________________\n___ 8:26 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n C. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Illumigene DNA\n amplification assay. \n (Reference Range-Negative). \n\n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n NO E.COLI 0157:H7 FOUND. \n__________________________________________________________\n___ 5:05 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 4:55 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 4:55 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: <10,000 organisms/ml.\n\n=======\nIMAGING\n=======\n\nCT Abdomen and Pelvis w/ Contrast \n\n1. No evidence of diverticulosis or diverticulitis. \n2. Status post liver transplant with normal appearance of the \ntransplanted \nliver. \n3. Stable splenomegaly. \n\nFlexible Sigmoidoscopy Biopsy: Results Pending\n\n==============\nDISCHARGE LABS\n==============\n\n___ 07:33AM BLOOD WBC-2.4* RBC-4.48* Hgb-13.5* Hct-40.6 \nMCV-91 MCH-30.1 MCHC-33.3 RDW-14.8 RDWSD-49.0* Plt Ct-58*\n___ 07:33AM BLOOD Plt Ct-58*\n___ 07:33AM BLOOD Glucose-79 UreaN-6 Creat-1.2 Na-142 K-4.1 \nCl-107 HCO3-28 AnGap-11\n___ 07:33AM BLOOD ALT-45* AST-32 AlkPhos-76 TotBili-0.7\n___ 07:33AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.4\n___ 09:35AM BLOOD tacroFK-6.___ with hx of COPD, PBC s/p DDLTx (SCD ___ and pericarditis \n(on ASA 975mg TID) and hx of hemmorhoids who presents with BRBPR \nand abdominal pain. \n\n=============\nACTIVE ISSUES\n============= \n\n#BRBPR/Abdominal Pain. He presented with BRBPR at home but did \nnot exhibit further episodes of bleeding upon hospitalization. \nCT Abdomen and pelvis did not show any diverticulosis or \ndiverticulitis. Hemoglobin/Hematocrit was trended and stable. C. \ndiff was negative and stool studies were negative. CMV viral \nload was not detected. He underwent flexible sigmoidoscopy which \nshowed rectal erythema and perianal skin tag/condyloma. Biopsies \nwere taken and were pending at the time of discharge. Home \nAspirin (for treatment of pericarditis) was held and outpatient \ncardiologist was notified who was in agreement with this plan. \nThe patient will have follow up with colorectal surgery as an \noutpatient for evaluation of perianal skin tissues. On the day \nof discharge the patient was having normal bowel movements \nwithout blood and denies nausea and vomiting. His baseline \nadnominal pain was mild and stable. \n\n#H/o idiopathic hemorrhagic pericarditis/Recurrent chest pain: \nHe did not exhibit chest pain during admission. Home Aspirin was \nheld and outpatient cardiologist was notified who was in \nagreement with this plan. Colchicine and tramadol were \ncontinued. He will contact his outpatient cardiologist for \nrecurrence of chest pain and advice on when/how to restart \naspirin. \n\n#S/P PBC s/p liver tx ___ from CMV+ donor; cellular rejection \nin ___ ___s a hemorrhagic pericarditis with \nrecurrent pericarditis. He was continued on home Prednisone and \nTacrolimus with daily tacrolmius levels. LFTs were trended and \ndemonstrated a mild ALT elevation ongoing and stable since \n___. His last liver biopsy from ___ did not show \nany e/o rejection. \n\n============== \nCHRONIC ISSUES\n==============\n \n#Bipolar disorder: Continued home ARIPiprazole \n\n#COPD - Continued home albuterol, salmeterol. \n \n#GERD - Continued home omeprazole 40mg BID, ranitidine 150mg qHS \n \n\n#Chronic Neuropathic Pain - Continued Gabapentin 600mg BID \n\n#Nutritional Deficiency- Continued home Vit D 800U qD, calcium \ncarbonate 500mg qD\n \n#Lymphopenia: This was trended and thought secondary to his \nimmunosuppression. C diff was negative. \n\n#Thrombocytopenia: This was trended and thought secondary to his \nimmunosuppression/liver disease. \n\n===================\nTransitional Issues\n===================\n\nLiver Transplant \n- Tacrolimus level on discharge: 6.6, dose 1mg BID \n\nCardiology \n- Aspirin held in the setting of presenting GIB. Recommend \ndiscussion with Dr. ___ as an outpatient on appropriate \ntiming of restarting ASA if chest pain reoccurs \n\nMild Leukopenia: Patient found to have mild leukopenia in the \nsetting of immunosuppression from transplant, please f/u and \ntrend as outpatient.\n\nGastroenterology \n- Please follow up biopsies from sigmoidoscopy.\n- Patient to follow up with colorectal surgery (to be scheduled) \nfor evaluation of perianal skin \n\n# CODE: Full (confirmed) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea \n2. Calcium Carbonate 500 mg PO DAILY \n3. Colchicine 0.6 mg PO BID \n4. Docusate Sodium 100 mg PO BID:PRN constipation \n5. Gabapentin 600 mg PO BID \n6. Omeprazole 40 mg PO BID \n7. Ondansetron 4 mg PO Q8H:PRN nausea \n8. PredniSONE 5 mg PO DAILY \n9. Ranitidine 150 mg PO QHS \n10. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H \n11. Tacrolimus 1 mg PO Q12H \n12. TraMADOL (Ultram) 50 mg PO TID:PRN pain \n13. Vitamin D 800 UNIT PO DAILY \n14. Aspirin EC 975 mg PO TID \n15. ARIPiprazole 20 mg PO QHS \n16. HydrOXYzine 25 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea \n2. ARIPiprazole 20 mg PO QHS \n3. Calcium Carbonate 500 mg PO DAILY \n4. Colchicine 0.6 mg PO BID \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Gabapentin 600 mg PO BID \n7. HydrOXYzine 25 mg PO QHS:PRN insomnia \n8. Omeprazole 40 mg PO BID \n9. Ondansetron 4 mg PO Q8H:PRN nausea \n10. Ranitidine 150 mg PO QHS \n11. TraMADOL (Ultram) 50 mg PO TID:PRN pain \n12. Vitamin D 800 UNIT PO DAILY \n13. PredniSONE 5 mg PO DAILY \n14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H \n15. Tacrolimus 1 mg PO Q12H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n-------------------\nHEMATOCHEZIA\n\nSECONDARY DIAGNOSIS \n-------------------\nH/o Pericarditis\nH/o Liver Transplant \nBipolar\nCOPD\nGERD\nChronic neuropathic pain \nLymphopenia\nThrombocytopenia \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were evaluated in the hospital for having bloody stools. You \nunderwent a flexible sigmoidoscopy which did not show any \nevidence of bleeding. Several biopsies were taken which will be \nreviewed in the outpatient setting. \n\nYour home aspirin was held in the setting of bleeding. You will \nbe following up with Dr. ___ on ___ to further determine \nyour pericarditis treatment. \n\nPlease follow up with you liver doctor for further evaluation on \n___. You will also be set up to see a colorectal surgeon to \nevaluate a possible skin tag. \n\nWe wish you the best, \n\nYour ___ Treatment Team \n \nFollowup Instructions:\n___\n" ]

[ "K625", "Z944", "D6959", "R161", "G629", "J449", "Z86718", "E785", "F319", "M818", "Z87891", "A630", "I2510", "F909", "Z7982", "Z7952", "Z8249", "K219", "G8929", "D72810", "D72819", "K644", "L538" ]

[ "K625: Hemorrhage of anus and rectum", "Z944: Liver transplant status", "D6959: Other secondary thrombocytopenia", "R161: Splenomegaly, not elsewhere classified", "G629: Polyneuropathy, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified", "M818: Other osteoporosis without current pathological fracture", "Z87891: Personal history of nicotine dependence", "A630: Anogenital (venereal) warts", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F909: Attention-deficit hyperactivity disorder, unspecified type", "Z7982: Long term (current) use of aspirin", "Z7952: Long term (current) use of systemic steroids", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "K219: Gastro-esophageal reflux disease without esophagitis", "G8929: Other chronic pain", "D72810: Lymphocytopenia", "D72819: Decreased white blood cell count, unspecified", "K644: Residual hemorrhoidal skin tags", "L538: Other specified erythematous conditions" ]

[ "J449", "Z86718", "E785", "Z87891", "I2510", "K219", "G8929" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms\n \nAttending: ___\n \nChief Complaint:\nDiarrhea\n \nMajor Surgical or Invasive Procedure:\nFlexible sigmoidoscopy (___)\n\n \nHistory of Present Illness:\n Mr. ___ is a ___ man with PBC s/p liver transplantation in \n___ (on tacrolimus/prednisone), pericarditis c/b tamponade with \npericardial window, bipolar disorder, & recurrent C Difficile \nwith recent hospitalization, who presents with diarrhea & \nabdominal pain. \n Patient was discharged on ___ with a course of oral Vancomycin \nfor C diff colitis, which he completed on ___. He had minor \nimprovement in his watery stools, experiencing ___ days of \nformed stool at the end of his antibiotic treatment course. \nAfter completing his Vancomycin course, he continued to have \nintermittent diarrhea. Three days ago, he developed acutely \nworsening diarrhea with ___ episodes of loose, water, brown \nstool. Diarrhea has been getting worse. It is associated with \nabdominal pain, subjective fevers, nausea, & limited PO intake. \nNo vomiting. Abdominal pain is diffuse, and a ___ at worse. He \nhas been on a stable dose of Prednisone/Tacrolimus for years, \nwith no recent changes in dose. \n In the ED, initial vitals were: 98.3 114 127/99 18 100% RA \n Exam notable for diffuse ttp, no r/g \n Labs notable for WBC 2.6, plts 88 (baseline) \n Imaging notable for KUB without evidence of obstruction or \nperforation \n GI was consulted and recommended: PO Vancomycin \n Patient was given: 1L NS, 4mg IV Morphine, & 4mg IV Zofran. \n Decision was made to admit for likely C diff colitis. \n Vitals prior to transfer: 110 154/84 18 100% RA \n On the floor, he feels okay. He has diffuse, ___ abdominal \npain, slightly better than when he first came to the ED. He \nhasn't had diarrhea since coming to the ED. No pain anywhere \nelse. He says this feels similar to when he has been admitted \nfor C dif in the past, but this time his abdominal pain is \nworse. \n \n \nPast Medical History:\nPAST MEDICAL HISTORY: \n PBC s/p deceased liver donor tx ___ \n Neutropenia \n DVT ___ \n Prior alcohol abuse now abstinent \n Hemorrhagic pericarditis c/b tamponade with pericardial window \n\n ___ \n Positive PPD s/p INH \n HLD \n Osteoporosis \n Bipolar disorder \n Hemorrhoids \n ADHD \n PTSD \n\n \nSocial History:\n___\nFamily History:\n Father (living): coronary artery disease, diabetes, \nhypercholesterolemia, and depression. Prostate and head and neck \ncancer \n Mother (deceased): brain aneurysm and hyperthyroidism \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVital Signs: 97.9 PO 133 / 97 63 18 98 RA \nGen: well appearing man, NAD, nontoxic \nHEENT: no scleral icterus, dry mm \nCV: Tachycardic, no m/r/g \nPULM: lungs clear bilaterally \nABD: soft, mildly tender to palpation diffusely no r/g, normal \nbowel sounds \nGU: no foley \nEXT: warm, no edema \nNEURO: CN II-XII intact, moving all 4 extremities, mentating \nwell \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS: 97.4 ___ 16 97 ra\nGeneral: Alert, oriented, no acute distress\nHEENT: Round face with puffy cheeks and jaw, sclera anicteric, \nMMM, oropharynx clear\nNeck: supple, no LAD\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nAbdomen: Soft, non-distended with scar in RUQ. Diffusely tender \nto deep palpation. No rebound. No psoas or heel tap sign.\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema. Tender to palpation throughout.\nSkin: Skin is thin, no rashes noted. Multiple tattoos.\nNeuro: CNII-XII intact. Sensation intact to light touch in all \nfour extremities. \n \nPertinent Results:\nADMISSION LAB VALUES:\n=====================\n___ 05:50PM BLOOD WBC-2.6* RBC-5.27 Hgb-15.8 Hct-45.1 \nMCV-86 MCH-30.0 MCHC-35.0 RDW-14.8 RDWSD-46.4* Plt Ct-88*\n___ 05:50PM BLOOD Neuts-62.0 ___ Monos-7.8 Eos-0.4* \nBaso-1.2* Im ___ AbsNeut-1.58*# AbsLymp-0.71* AbsMono-0.20 \nAbsEos-0.01* AbsBaso-0.03\n___ 05:50PM BLOOD ___ PTT-28.9 ___\n___ 05:50PM BLOOD Glucose-94 UreaN-10 Creat-1.0 Na-139 \nK-4.2 Cl-105 HCO3-22 AnGap-16\n___ 05:50PM BLOOD ALT-23 AST-26 AlkPhos-102 TotBili-0.8\n___ 05:50PM BLOOD Lipase-23\n___ 05:50PM BLOOD Albumin-4.7 Calcium-9.1 Phos-3.1 Mg-1.9\n___ 06:20PM BLOOD Lactate-1.2\n___ 05:50PM URINE Color-Straw Appear-Clear Sp ___\n___ 05:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n \n \nOTHER PERTINENT LABS:\n=====================\n___ 06:31AM BLOOD WBC-2.8* RBC-4.68 Hgb-14.3 Hct-41.2 \nMCV-88 MCH-30.6 MCHC-34.7 RDW-15.2 RDWSD-49.1* Plt Ct-67*\n___ 07:48AM BLOOD WBC-3.9* RBC-5.13 Hgb-15.7 Hct-44.3 \nMCV-86 MCH-30.6 MCHC-35.4 RDW-15.1 RDWSD-48.3* Plt Ct-99*\n___ 06:31AM BLOOD Glucose-77 UreaN-9 Creat-1.1 Na-139 K-3.7 \nCl-105 HCO3-26 AnGap-12\n___ 07:48AM BLOOD Glucose-87 UreaN-12 Creat-1.3* Na-139 \nK-4.3 Cl-102 HCO3-23 AnGap-18\n___ 06:31AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9\n___ 10:30AM BLOOD tacroFK-5.9\n___ 07:48AM BLOOD tacroFK-6.4\n \n \nMICROBIOLOGY:\n=============\n___ 5:50 URINE CULTURE (Final ___: NO GROWTH. \n___ 5:50 pm BLOOD CULTURE:Routine (Pending)\n___ 6:08 pm BLOOD CULTURE:Routine (Pending)\n___ 7:44 pm CMV Viral Load (Pending): \n \n \nIMAGING/OTHER STUDIES:\n======================\n___ 7:28 ___ ABDOMEN (SUPINE & ERECT): \nIMPRESSION: No evidence for small bowel obstruction, ileus or \ntoxic megacolon. Air-fluid levels in the right abdomen likely \nreflect fluid within the colon, compatible with the history of \ndiarrhea.\n \n \nDISCHARGE LABS:\n===============\n___ 06:45AM BLOOD WBC-2.7* RBC-4.42* Hgb-13.2* Hct-39.1* \nMCV-89 MCH-29.9 MCHC-33.8 RDW-14.8 RDWSD-47.9* Plt Ct-73*\n___ 06:45AM BLOOD Plt Ct-73*\n___ 06:45AM BLOOD Glucose-84 UreaN-12 Creat-1.2 Na-139 \nK-4.0 Cl-104 HCO3-24 AnGap-15\n___ 06:45AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8\n___ 06:45AM BLOOD tacroFK-4.9*\n \nBrief Hospital Course:\nMr. ___ is a ___ man with PBC s/p liver transplantation in \n___ (on tacrolimus/ prednisone), pericarditis c/b tamponade \nwith pericardial window, bipolar disorder, & recurrent C \nDifficile with recent hospitalization, who presents with \ndiarrhea & abdominal pain, concerning for relapsed C diff \ndiarrhea.\n\nACUTE ISSUES:\n=============\n# DIARRHEA & # ABDOMINAL PAIN: Initial presentation with \ndiffusely tender abdomen concerning for toxic megacolon or SBO, \nhowever, ___ ruled out those etiologies. Patient continued to \npass gas, but had no bowel movements for his first 72 hours in \nthe hospital. This was felt to be a C diff relapse based on his \nhistory and reports of frequent loose stools at home. The team \nadded IV metronidazole to his usual oral vancomycin regimen. ID \nwas consulted. Stool studies were obtained. On hospital day 4 a \nflexible sigmoidoscopy was completed. It showed erythema \nconsistent with prior tap water enema. On discharge the patient \nwas informed of the usual course of recovery from C diff \ninfections, including to expect intermittent loose stools for \nthe next few months. He was hemodynamically stable, tolerating \nPO, and not having diarrhea.\n\n# ORTHOSTATIC HYPOTENSION: Patient had reported subjective \nlightheadedness that did not resolve with initial PO intake on \nhospital days 1 and 2. On hospital day 3, he was confirmed to \nhave orthostatic vital signs. He was treated with a 1L bolus of \nNS. On subsequent days he improved.\n\nCHRONIC ISSUES:\n===============\n# PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, \nHEMORRHAGIC PERICARDITIS, RECURRENT PERICARDITIS: Had one \nepisode of chest pain on ___ in the AM. EKG and trops were \nobtained, ruled out ACS. Pulsus was 5mmHg. This was most likely \ncostochondritis, for which he received ASA 650mg x1 and \nhydromorphone 1mg PO x1. Patient continued on home \ntacrolimus/prednisone doses and daily tacro levels were \nappropriate. Daily LFTs were also WNL. \n \n# THROMBOCYTOPENIA. Stable throughout admission. Patient has \nknown chronic thrombocytopenia likely due to liver disease, \nimmunosuppression and hypersplenism. \n\n# BIPOLAR DISORDER. No acute issues. Recently off of Abilify. \nMonitored without need to restart therapy.\n \n# GERD: Stable. Possibly contributing to abdominal pain as \ndescribed above with C diff infection. Continued home ranitidine \n150mg qHS, maalox PRN. \n \n# CHRONIC NEUROPATHIC PAIN: Stable. Continued on home Gabapentin \n600mg BID \n \n# COPD: No SOB throughout admission. Continued home albuterol \nprn \n\nTRANSITIONAL ISSUES:\n--------------------\n# LOOSE STOOLS: Patient informed that C diff recovery includes \nloose stools for months and he should expect this.\n# PAIN: Consider referral to pain specialist. Would benefit from \nweaning opiates and possibly starting duloxetine or \nnortriptyline. Patient discharged with 15 tramadol 50mg, as he \nhas a follow-up appointment in 6 days.\n# BLOOD COUNTS: Chronic leukopenia and thrombocytopenia, stable \nthis hospitalization.\n# PENDING STUDIES: Some stool and STI studies are pending at the \ntime of discharge. The patient will be contacted if results are \npositive.\n------------------\nImportant numbers\nWBC: 2.7 (___)\nPLT: 73 (___)\nTacro: 5.4 (___)\n------------------\n# CODE: Full (presumed)\n# CONTACT: father/HCP ___ ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 650 mg PO BID \n2. Colchicine 0.6 mg PO BID \n3. Gabapentin 600 mg PO BID \n4. Ondansetron 4 mg PO Q8H:PRN nausea \n5. PredniSONE 5 mg PO DAILY \n6. Ranitidine 150 mg PO QHS \n7. Tacrolimus 1 mg PO QPM \n8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n9. Tacrolimus 1 mg PO QAM \n\n \nDischarge Medications:\n1. Aspirin 650 mg PO BID \n2. Colchicine 0.6 mg PO BID \n3. Gabapentin 600 mg PO BID \n4. Ondansetron 4 mg PO Q8H:PRN nausea \n5. PredniSONE 5 mg PO DAILY \n6. Ranitidine 150 mg PO QHS \n7. Tacrolimus 1 mg PO QPM \n8. Tacrolimus 1 mg PO QAM \n9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n==================\nDiarrhea, unspecified\nGeneralized abdominal pain\nOrthostatic Hypotension\n\nSECONDARY DIAGNOSES:\n====================\nPrimary biliary cirrhosis status-post orthotopic liver \ntransplant with cytomegalovirus-positive donor, complicated by \ncellular rejection, hemorrhagic pericarditis and recurrent \npericarditis\nThrombocytopenia\nChronic immunosuppression\nGastroesophageal reflux disease\nChronic neuropathic 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 Mr. ___,\n\nYou came to ___ because you had \nabdominal pain and diarrhea.\n\nWhat was done for me while I was in the hospital?\n- You received fluids because you had become dehydrated\n- We did studies of your blood and stool to look for a cause of \nyour infection. There was no infection.\n- The gastroenterologists did a flexible sigmoidoscopy to \nexamine your sigmoid colon for evidence of infection. They did \nnot see any evidence of infection.\n- You were visited by our Infectious Diseases doctors for \n___ and treatment of your diarrhea. They recommended some \nadditional studies. They agreed with the decision to stop your \nantibiotics.\n- You received a new antibiotic for your diarrhea in case it was \nrecurrent Clostridium difficile diarrhea. Fortunately, you did \nnot have recurrent diarrhea, so we stopped your antibiotics.\n\nWhat should I do now that I am leaving the hospital?\n- Continue to take your medications as prescribed. You do not \nneed to take any more antibiotics.\n- Expect to have loose stools, up to 1 or 2 per day, for the \nnext few months. Your colon is recovering from your Clostridium \ndifficile infection in ___.\n- Call the doctor if you have 6 or more loose stools per day.\n- Attend a follow-up appointment with your primary care doctor.\n- Attend a follow-up appointment with your liver transplant \ndoctor.\n- Consider seeing a pain specialist to help treat your multiple \ncauses of pain.\n\nIt was a pleasure taking care of you. Wishing you all the best!\n\n- Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R197", "D6959", "Z944", "G629", "R1084", "I951", "K219", "F319", "D72818", "Z87891", "F901", "F4310", "M940", "J449", "K6289", "K5289", "Z86718" ]

[ "R197: Diarrhea, unspecified", "D6959: Other secondary thrombocytopenia", "Z944: Liver transplant status", "G629: Polyneuropathy, unspecified", "R1084: Generalized abdominal pain", "I951: Orthostatic hypotension", "K219: Gastro-esophageal reflux disease without esophagitis", "F319: Bipolar disorder, unspecified", "D72818: Other decreased white blood cell count", "Z87891: Personal history of nicotine dependence", "F901: Attention-deficit hyperactivity disorder, predominantly hyperactive type", "F4310: Post-traumatic stress disorder, unspecified", "M940: Chondrocostal junction syndrome [Tietze]", "J449: Chronic obstructive pulmonary disease, unspecified", "K6289: Other specified diseases of anus and rectum", "K5289: Other specified noninfective gastroenteritis and colitis", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "K219", "Z87891", "J449", "Z86718" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone / \nmushrooms\n \nAttending: ___\n \nChief Complaint:\nAbdominal pain, diarrhea\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n ___ yo M w/ PMH PBC s/p liver transplant ___, pericarditis, \nbipolar disorder, COPD, with recent admission at ___ for \ndiarrhea who re-presents with ongoing diarrhea and muscle aches. \n \n He reports that he is having watery diarrhea ___ per day. He \nhas aches all over his body and feels weak. He also endorses \ntinnitus. He says this feels similar to when he had CMV \ninfection in the past. He did not hear the results of his \ncolonoscopy yet. \n Of note, his colonoscopy biopsies showed active colitis \nthroughout the colon. CMV testing was pending. \n In the ED, initial vitals were: T97.0 HR67 BP115/96 RR18 \nO2Sat100% RA. \n \n Labs notable for WBC 2.9, ANC 1260, Plt 93, Cr 1.1, HCO3 21. \n Patient was given 4 mg IV morphine and 4 mg Zofran. \n Decision was made to admit for continued diarrhea. \n Vitals prior to transfer: T98.4 HR50 BP112/82 RR16 O2Sat100% \nRA. \n On the floor, he reported that he had ongoing abdominal pain, \nnausea, and body aches. He reports that he has not started any \nnew medications except for 1 dose of Adderall last week. \n ROS: per HPI, denies fever, chills, night sweats, headache, \nvision changes, rhinorrhea, congestion, sore throat, cough, \nshortness of breath, chest pain, abdominal pain, nausea, \nvomiting, diarrhea, constipation, BRBPR, melena, hematochezia, \ndysuria, hematuria. \n \nPast Medical History:\nPAST MEDICAL HISTORY: \n PBC s/p deceased liver donor tx ___ \n Neutropenia \n DVT ___ \n Prior alcohol abuse now abstinent \n Hemorrhagic pericarditis c/b tamponade with pericardial window \n\n ___ \n Positive PPD s/p INH \n HLD \n Osteoporosis \n Bipolar disorder \n Hemorrhoids \n ADHD \n PTSD \n\n \nSocial History:\n___\nFamily History:\n Father (living): coronary artery disease, diabetes, \nhypercholesterolemia, and depression. Prostate and head and neck \ncancer \n Mother (deceased): brain aneurysm and hyperthyroidism \n \nPhysical Exam:\n================\nADMISSION EXAM:\n================\nVital Signs: 97.6 115/77 53 18 100% on RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, most tender over epigastric area and LLQ with \nvoluntary guarding, but diffusely mildly tender to palpation, \nnon-distended, bowel sounds present, no organomegaly, no rebound \nor guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \n\n================\nDISCHARGE EXAM:\n================\nVS - T 97.9 HR 67 BP 110/78 RR 18 02 99% sat on RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \n Neck: supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: +BS Soft, mild diffuse tenderness to palpation most in \nepigastric region, minimal distension, no organomegaly, no \nrebound or guarding . Large RUQ scar. \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Neuro: CNII-XII intact, No focal deficits. \n\n \nPertinent Results:\n================\nADMISSION LABS:\n================\n___ 08:05PM WBC-2.9* RBC-5.05 HGB-15.0 HCT-42.9 MCV-85 \nMCH-29.7 MCHC-35.0 RDW-15.7* RDWSD-47.9*\n___ 08:05PM NEUTS-43.1 ___ MONOS-10.3 EOS-1.7 \nBASOS-1.4* IM ___ AbsNeut-1.26*# AbsLymp-1.25 AbsMono-0.30 \nAbsEos-0.05 AbsBaso-0.04\n___ 08:05PM ___ PTT-28.2 ___\n___ 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 08:05PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 08:05PM ALT(SGPT)-37 AST(SGOT)-27 ALK PHOS-120 TOT \nBILI-0.4\n___ 08:05PM LIPASE-24\n___ 08:05PM ALBUMIN-4.3\n___ 08:05PM GLUCOSE-88 UREA N-15 CREAT-1.1 SODIUM-137 \nPOTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15\n\n================\nDISCHARGE LABS:\n================\n___ 04:40AM BLOOD WBC-3.2* RBC-4.71 Hgb-13.9 Hct-40.7 \nMCV-86 MCH-29.5 MCHC-34.2 RDW-15.4 RDWSD-48.0* Plt Ct-78*\n___ 04:40AM BLOOD Glucose-96 UreaN-14 Creat-1.0 Na-139 \nK-3.9 Cl-102 HCO3-25 AnGap-16\n___ 04:17AM BLOOD ALT-34 AST-32 LD(LDH)-192 AlkPhos-110 \nAmylase-23 TotBili-0.4\n___ 04:40AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9\n___ 04:40AM BLOOD tacroFK-6.3\n\n==============\nMICROBIOLOGY:\n==============\n___ 5:05 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM \nSEEN. \n\n CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. \n\n C. difficile DNA amplification assay (Final ___: \n Reported to and read back by ___ ___ ___ 10AM. \n CLOSTRIDIUM DIFFICILE. \n Positive for toxigenic C. difficile by the Illumigene \nDNA\n amplification. (Reference Range-Negative). \n\n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n ___ CRYSTALS PRESENT. \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n NO E.COLI 0157:H7 FOUND. \n\n Cryptosporidium/Giardia (DFA) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n\n O&P MACROSCOPIC EXAM - WORM (Final ___: NO WORM \nSEEN. \n\n___ 8:25 pm BLOOD CULTURES x2\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n=================\nIMAGING/STUDIES:\n=================\nEKG ___: Sinus rhythm with non-specific T wave flattening \nin leads aVL and V2. There is early R wave progression in the \nprecordium. Compared to the previous tracing of ___ the \npreviously seen T wave inversions are no longer present. \n\nKUB ___ FINDINGS: \nThere is gas distending the colon. The colon does not exceed \n4.5-5 cm in \ncaliber. There is gas in scattered nondilated small bowel \nloops. Supine assessment limits detection for free air; there \nis no gross pneumoperitoneum. A surgical clip is seen in the \nright upper quadrant. \nThere are degenerative changes in the femoroacetabular joints. \nThere are no unexplained soft tissue calcifications or \nradiopaque foreign bodies. \n\nIMPRESSION: No radiographic evidence of toxic megacolon. \n\n \nBrief Hospital Course:\n___ y/o M with ___ PBC s/p liver transplant in ___, bipolar \ndisorder, pericarditis p/w worsening abdominal pain, chest pain, \ndiarrhea. Patient was recently admitted and discharged from \n___ for the same complaint on ___. Colonoscopy was \nperformed on ___ and showed colitis. Stool studies were positive \nof C diff on this admission (previously negative on prior \nadmission). Therefore, patient was started on vancomycin PO on \n___ for treatment of C diff colitis with plans to complete a \n14-day total course. Abdominal pain and diarrhea gradually \nimproved during the admission. Patient maintained good PO intake \nthroughout admission. \n\n# Diarrhea ___ to C diff Colitis: Patient presented again to the \nED on ___ for worsening abdominal pain, nausea, diarrhea (7 \nwatery BMs daily). He was recently discharged on ___ for the \nsame complaint. Repeat stool studies were obtained that returned \npositive for C diff on ___. CMV stains of colonoscopy specimens \nwere negative. Antibiotic therapy was started with PO vancomycin \nsince patient had no elevated WBC count or ___. Nausea was \nmanaged with PRN Zofran with good effect. During admission, \npatient had gradual improvement in abdominal pain/diarrhea. KUB \nwas ordered to r/o toxic megacolon and showed only distended \nbowel loops with gas. Gradually pain improved with PRN \nacetaminophen, simethicone, dicyclomine, tramadol. On discharge, \npatient was tolerating regular diet with good PO intake and \ndiarrhea/abdominal pain were improving. He was discharged with a \nscript to complete a full 14-day course of PO vancomycin at \nhome. \n\n================\n Chronic Issues \n================ \n #PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION, \nHEMORRHAGIC \n PERICARDITIS, RECURRENT PERICARDITIS: No active issues while \ninpatient. Patient continued on home tacrolimus/prednisone doses \nand daily tacro levels were appropriate. Daily LFTs were also \nWNL. \n \n #THROMBOCYTOPENIA. Stable throughout admission. Patient has \nknown chronic thrombocytopenia likely due to liver disease vs \nimmunosuppression. \n\n #BIPOLAR DISORDER. No acute issues. Recently off of Abilify. \nMonitored without need to restart therapy.\n \n #GERD: Stable. Possibly contributing to abdominal pain as \ndescribed above with C diff infection. Continued on home \nomeprazole 40mg BID, ranitidine 150mg qHS. \n \n #CHRONIC NEUROPATHIC PAIN: Stable. Continued on home Gabapentin \n600mg BID \n \n #COPD: No SOB throughout admission. Continued home albuterol \nprn \n\nTRANSITIONAL ISSUES:\n[ ] Complete Vancomycin 125 mg PO Q6H x 14 days \n(___)\n[ ] Follow up with PCP, ___.\n[ ] Full Code (confirmed)\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Aspirin 650 mg PO BID \n2. Colchicine 0.6 mg PO BID \n3. Gabapentin 600 mg PO BID \n4. Omeprazole 40 mg PO BID \n5. Ondansetron 4 mg PO Q8H:PRN nausea \n6. PredniSONE 5 mg PO DAILY \n7. Ranitidine 150 mg PO QHS \n8. Tacrolimus 1 mg PO QPM \n9. Tacrolimus 1 mg PO QAM \n10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n11. DICYCLOMine 20 mg PO TID abdominal pain \n12. IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain \n\n \nDischarge Medications:\n1. Simethicone 80 mg PO QID pain \nRX *simethicone 80 mg 1 tablet by mouth QID PRN Disp #*60 Tablet \nRefills:*0 \n2. Vancomycin Oral Liquid ___ mg PO Q6H \nRX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours \nDisp #*40 Capsule Refills:*0 \n3. DICYCLOMine 20 mg PO TID abdominal pain \nYou may continue to take this medication as needed for abdominal \npain. \nRX *dicyclomine [Bentyl] 20 mg 1 tablet(s) by mouth TID PRN Disp \n#*30 Tablet Refills:*0 \n4. Aspirin 650 mg PO BID \n5. Colchicine 0.6 mg PO BID \n6. Gabapentin 600 mg PO BID \n7. Omeprazole 40 mg PO BID \n8. Ondansetron 4 mg PO Q8H:PRN nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*30 Tablet Refills:*0 \n9. PredniSONE 5 mg PO DAILY \n10. Ranitidine 150 mg PO QHS \n11. Tacrolimus 1 mg PO QAM \n12. Tacrolimus 1 mg PO QPM \n13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \nRX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*15 Tablet Refills:*0 \n14. HELD- IBgard (peppermint oil) 90 mg oral TID:PRN abdominal \npain This medication was held. Do not restart IBgard until you \ndiscuss this with your transplant doctor. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES: C. diff Colitis\n\nSECONDARY DIAGNOSES: PBC s/p liver transplant ___, \nNeutropenia, DVT ___, HLD, HLD, Osteoporosis, Bipolar \ndisorder, Hemorrhoids, ADHD, PTSD\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 ___.\n\nWhy you were in the hospital:\n- You were having abdominal pain and diarrhea and your \ncolonoscopy results showed inflammation in your colon. This was \ndue to an infection in your colon with C. Diff. \n\nWhat was done while you were in the hospital:\n- You were started on an antibiotic called vancomycin and were \ngiven medications for your nausea and pain. \n\nWhat you need to do when you go home:\n- You will continue taking antibiotics for your C. diff \ninfection through ___ (10 more days). \n- Please follow up with your primary ___ doctor's office on \n___.\n- Please also follow up with your liver transplant doctor, ___. \n___ on ___. \n\nIt was a pleasure taking ___ of you at ___ Deaconess.\n\n___,\nYour ___ ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "A047", "I319", "D696", "Z944", "I509", "G629", "R110", "M810", "I252", "F319", "J449", "F4310", "K219", "G8929" ]

[ "A047: Enterocolitis due to Clostridium difficile", "I319: Disease of pericardium, unspecified", "D696: Thrombocytopenia, unspecified", "Z944: Liver transplant status", "I509: Heart failure, unspecified", "G629: Polyneuropathy, unspecified", "R110: Nausea", "M810: Age-related osteoporosis without current pathological fracture", "I252: Old myocardial infarction", "F319: Bipolar disorder, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "F4310: Post-traumatic stress disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G8929: Other chronic pain" ]

[ "D696", "I252", "J449", "K219", "G8929" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / rifampin / Lamictal / lorazepam / risperidone\n \nAttending: ___.\n \nChief Complaint:\nBright red blood per rectum with abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ gentleman with a history of PBC s/p \nOLT in ___ and recent admission for BRBPR/abdominal pain found \nto have an anal skin tag/condyloma on sigmoidoscopy now s/p \nexcision on ___ who presents with one episode of BRBPR. He \nhas not had any recent bleeding. This episode occurred this \nafternoon and was approximately one cup of bright red blood per \nrectum not mixed with stool. He then developed lower abdominal \ncramping. No further BMs or bleeding subsequently. Mild nausea \nbut no vomiting, no fevers. He was seen at ___ and was \nreferred here for further work up as patient is liver transplant \nrecipient. \n He is followed by Dr. ___ saw him today in clinic for \nfollow up of chest pain. This is thought to be due to \nchondrochondritis. He is on tramadol, high dose aspirin, and \ncolchicine for this. \n In the ED, initial vitals were: T 96.6, HR 72, BP 133/88, RR \n18, SaO2 \n 100% RA. \n - Labs were notable for: WBC 3.1 (stable), H/H 13.9/40.8, plts \n84 (stable), Cr 1.3 (stable); RUQ with Dopplers showed normal \ntransplanted liver, splenomegaly. \n - Rectal exam notable for intact suture, no masses or \nhemorrhoids, dark stool guaiac positive \n - Patient was given: tacrolimus 1 mg, morphine 4 mg, and \nZofran. \n - Consults: Transplant surgery, who recommended inpatient \ncolorectal surgery consult; GI, who recommended hepatology \nconsult \n On the floor, patient continued to report mild lower abdominal \npain and chest pain. No nausea currently. He does have an \nappetite but has not eaten today. \n Review of systems: \n (+) Per HPI. Chronic chills, chronic shortness of breath. \n (-) Denies fever, night sweats, recent weight loss or gain. \nDenies headache, cough, vomiting, diarrhea, constipation. No \nrecent change in bowel or bladder habits. No dysuria. \n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n PBC s/p deceased liver donor tx ___ \n Neutropenia \n DVT ___ \n Prior alcohol abuse now abstinent \n Hemorrhagic pericarditis c/b tamponade with pericardial window \n\n ___ \n Positive PPD s/p INH \n HLD \n Osteoporosis \n Bipolar disorder \n Hemorrhoids \n ADHD \n PTSD \n\n \nSocial History:\n___\nFamily History:\n Father (living): coronary artery disease, diabetes, \nhypercholesterolemia, and depression. Prostate and head and neck \ncancer \n Mother (deceased): brain aneurysm and hyperthyroidism \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n Vitals: T 97.3, HR 57, BP 114/81, RR 18, SaO2 99% RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n Neck: Supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops, severe pain to palpation of right costochondral \njunctions \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Scar present, soft, bowel sounds present, \nnondistended, tender to palpation diffusely though no rebound or \nguarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Rectal: skin tag removal site intact without bleeding or signs \nof infection, external hemorrhoids appreciated, old blood in \nrectal vault without masses.\n\nDISCHARGE PHYSICAL EXAM:\nVitals: T 97.5/97.4, 105-117/59-70, HR 62-80, RR 18, O2 Sat \n>97% RA\nGeneral: Well-appearing, NAD.\nHEENT: MMM, PERRL, EOMI w/o nystagmus.\nLungs: CTAB\nCV: RRR, normal S1 and S2 appreciated. No murmurs, rubs, \ngallops.\nAbdomen: Soft, non-distended, mild tenderness to deep palpation \nof the bilateral LLQ and suprapubic region. Normal bowel sounds.\nExt: Warm, well-perfused. No edema. Bilateral pulses +2\n\n \nPertinent Results:\nADMISSION LABS:\n___ 08:25PM BLOOD WBC-3.1* RBC-4.66 Hgb-13.9 Hct-40.8 \nMCV-88 MCH-29.8 MCHC-34.1 RDW-14.7 RDWSD-46.9* Plt Ct-84*\n___ 08:25PM BLOOD Neuts-48.9 ___ Monos-9.7 Eos-3.9 \nBaso-1.9* Im ___ AbsNeut-1.51* AbsLymp-1.09* AbsMono-0.30 \nAbsEos-0.12 AbsBaso-0.06\n___ 08:00AM BLOOD ___ PTT-28.9 ___\n___ 08:25PM BLOOD Glucose-91 UreaN-19 Creat-1.3* Na-141 \nK-4.1 Cl-108 HCO3-22 AnGap-15\n___ 08:00AM BLOOD ALT-37 AST-33 LD(LDH)-189 AlkPhos-77 \nTotBili-0.5\n___ 08:00AM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.8 Mg-1.8\n___ 08:00AM BLOOD tacroFK-6.0\n\nIMAGING / STUDIES:\n\nRUQ US ___\nIMPRESSION: \n1. Unremarkable liver transplant with patent hepatic vasculature \nand normal waveforms. \n2. Splenomegaly. \n\nGU Ultrasound ___\nFINDINGS: \nThe right kidney measures 9.3 cm and contains a simple appearing \n1.1 cm lower pole cyst. The left kidney measures 9.7 cm. There \nis no hydronephrosis, stones, or masses bilaterally. Normal \ncortical echogenicity and corticomedullary differentiation are \nseen bilaterally. \nThe bladder is normal in appearance. Postvoid images of the \nbladder were not obtained secondary to the patient's inability \nto void. Calculated prostate volume is 22 cc. \nIMPRESSION: \nNormal appearance of the bilateral kidneys. \n\nDISCHARGE LABS:\n___ 08:00AM BLOOD WBC-1.9* RBC-4.43* Hgb-13.3* Hct-40.0 \nMCV-90 MCH-30.0 MCHC-33.3 RDW-14.6 RDWSD-48.4* Plt Ct-64*\n___ 08:00AM BLOOD ___ PTT-27.9 ___\n___ 08:00AM BLOOD Glucose-102* UreaN-20 Creat-1.0 Na-142 \nK-3.6 Cl-109* HCO3-24 AnGap-13\n___ 08:00AM BLOOD ALT-37 AST-29 AlkPhos-82 TotBili-0.4\n___ 08:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7\n___ 08:00AM BLOOD tacroFK-6.0\n \nBrief Hospital Course:\nMr. ___ is a ___ gentleman with a history of PBC s/p \nOLT in ___ and recent admission for BRBPR/abdominal pain found \nto have an anal skin tag/condyloma on sigmoidoscopy now s/p \nexcision on ___ who presents with one episode of BRBPR. \n\n # BRBPR: Patient with single episode of BRBPR, possibly related \nto recent excision of anal skin tag/condyloma. Examination of \nthe area showed intact excision site without active bleed. He \nalso had associated lower abdominal pain of unclear etiology. No \nrecent fevers or diarrhea to suggest infectious or inflammatory \netiology. After his anal tag excision he reports regular soft \nstools without straining. H&H on admission at baseline. \nPotentially diverticular bleed vs. vascular malformation. Rectal \nexam with old blood in rectal vault without active bleeding or \nmass. He did not have any further bleeding during admission and \nhis lower abdominal pain was controlled with home tramadol Q6H. \nRecommend outpatient colonoscopy and continued Metamucil use. \nHis high dose ASA was stopped in the setting of recurrent GI \nbleeds. \n\n # Abdominal pain: Continued despite resolution of BRBPR. \nPatient with similar presentation in ___ with work-up (CT \nA/P, stool studies) unrevealing aside from sigmoidoscopy showing \nrectal erythema and perianal skin tag/condyloma. RUQ ultrasound \nwith Dopplers in the ED was normal. Patient complained of \nurinary hesitancy on ROS but was voiding without difficulty. GU \nultrasound showed normal kidneys bilaterally and bladder with \nnormal prostate mass of 22cc. Post-void bladder was not \nvisualized as patient did not void. Low suspicion for bladder \nobstruction as cause of supra-pubic pain. He was instructed to \nseek urology referral should his urinary symptoms persist or \nworsen.\n\n # Acute kidney injury: Patient noted to have mild ___ on \nadmission labs. Likely from hypovolemia in the setting of high \ndose NSAIDs. Serum Cr normalized to 1.1 on discharge; no \nevidence of renal pathology on GU U/S (___). He was \ndischarged off aspirin as above.\n \n # PBC s/p liver transplant in ___ from CMV+ donor, cellular \nrejection in ___ ___s a hemorrhagic pericardial \neffusion with recurrent pericarditis: RUQ ultrasound with \nDopplers in the ED was normal. LFTs normal. Continued home \ntacrolimus 1 mg PO Q12H. Tacro level 6.0 on admission. Continued \nprednisone 5 mg daily. \n\n # Costochondritis: Followed by Dr. ___ in cardiology. On \nhigh dose ASA, prednisone, and tramadol, recently increased from \nTID to QID. Pain is at baseline on admission. His high dose ASA \nwas held and tramadol continued. He was discharged off of \naspirin as above.\n\n # Pericarditis: Followed by Dr. ___ in cardiology. On high \ndose ASA and colchicine. Pain at baseline on admission and his \ncolchicine was continued but ASA stopped as above. \n\n # Thrombocytopenia: Patient presented with chronic low platelet \ncount around baseline. Chronic thrombocytopenia likely due to \nliver disease and immunosuppression. His platelets were \nmonitored without acute event. Of note high dose ASA in setting \nof thrombocytopenia likely contributing to recurrent GIB. \n\n # Bipolar disorder: Continued home ARIPiprazole \n\n # COPD: Continued home albuterol, salmeterol. \n \n # GERD: Continued home omeprazole 40mg BID, ranitidine 150mg \nqHS \n \n # Chronic Neuropathic Pain: Continued Gabapentin 600mg BID \n\nTRANSITIONAL ISSUES:\n- Patient discharged off of aspirin given GIB. Please address \nrestating or alternative therapy at next cardiology appointment.\n- Recommend outpatient colonoscopy for evaluation of likely \ndistal GIB. Follow up scheduled with GI. \n- Patient continued on tramadol QID for pain control.\n- Recommend urology follow up for lower urinary tract symptoms \nif persistent. \n- H&H stable throughout admission. Please re-check at GI follow \nup appointment if continued GI bleeding. \n- Patient continued on tacrolimus during admission with random \nlevel of 6.0. LFTs normal.\nCODE: Full (confirmed) \nCONTACT: ___ (father) ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea \n2. ARIPiprazole 20 mg PO QHS \n3. Calcium Carbonate 500 mg PO DAILY \n4. Colchicine 0.6 mg PO BID \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Gabapentin 600 mg PO BID \n7. HydrOXYzine 25 mg PO QHS:PRN insomnia \n8. Omeprazole 40 mg PO BID \n9. Ondansetron 4 mg PO Q8H:PRN nausea \n10. Ranitidine 150 mg PO QHS \n11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n12. Vitamin D 800 UNIT PO DAILY \n13. PredniSONE 5 mg PO DAILY \n14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H \n15. Tacrolimus 1 mg PO Q12H \n16. Aspirin 975 mg PO TID \n17. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram \noral DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea \n2. ARIPiprazole 20 mg PO QHS \n3. Colchicine 0.6 mg PO BID \n4. Docusate Sodium 100 mg PO BID:PRN constipation \n5. Gabapentin 600 mg PO BID \n6. HydrOXYzine 25 mg PO QHS:PRN insomnia \n7. Omeprazole 40 mg PO BID \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. PredniSONE 5 mg PO DAILY \n10. Ranitidine 150 mg PO QHS \n11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H \n12. Tacrolimus 1 mg PO Q12H \n13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \n14. Vitamin D 800 UNIT PO DAILY \n15. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram \noral DAILY \n16. Calcium Carbonate 500 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\nGastrointestinal Bleed\nAbdominal Pain\n\nSECONDARY:\nH/O Primary biliary cirrhosis s/p liver transplant\nUrinary hesitancy\nChronic pericarditis\nCostochondritis\nBipolar disorder\nCOPD\nGERD\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n It was a pleasure participating in your care here at ___ \n___. \n\nYou were admitted with rectal bleeding and abdominal pain. We \nchecked you blood counts and everything was stable. Your recent \nskin tag removal site looked good and was not actively bleeding. \nYou did not have another episode of bleeding and recovered \nwithout incident. An ultrasound of your liver was normal and you \nwere kept on your home tramadol for pain.\n\nYou also were noted to have some difficulty initiating \nurination. You had an ultrasound done of your kidneys and \nbladder which was also normal. You prostate on ultrasound was a \nnormal size. If you continue to have urinary symptoms please see \nyour PCP about referral to urology. ___ clinic number: \n___.\n\nYou were discharged with the follow up appointments scheduled \nbelow,. Please make sure to attend these appointments because \nyou will likely need a colonoscopy aks an outpatient. If you \nhave another single episode of bleeding please call your \ngastroenterologist.\n\nPlease continue taking your medications as prescribed but stop \ntaking your aspirin until you see your cardiologist. You can \ncontinue taking your tramadol every 6 hours as needed.\n\nThank you for choosing ___ for your healthcare needs.\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K922", "Z944", "N179", "I319", "D6959", "G629", "J449", "K219", "R3911", "Z7982", "Z7952", "Z86718", "E785", "Z87891", "F909", "F319", "M940", "G8929" ]

[ "K922: Gastrointestinal hemorrhage, unspecified", "Z944: Liver transplant status", "N179: Acute kidney failure, unspecified", "I319: Disease of pericardium, unspecified", "D6959: Other secondary thrombocytopenia", "G629: Polyneuropathy, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R3911: Hesitancy of micturition", "Z7982: Long term (current) use of aspirin", "Z7952: Long term (current) use of systemic steroids", "Z86718: Personal history of other venous thrombosis and embolism", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "F909: Attention-deficit hyperactivity disorder, unspecified type", "F319: Bipolar disorder, unspecified", "M940: Chondrocostal junction syndrome [Tietze]", "G8929: Other chronic pain" ]

[ "N179", "J449", "K219", "Z86718", "E785", "Z87891", "G8929" ]

[]

[ " \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:\nright hip pain\n \nMajor Surgical or Invasive Procedure:\n___: Intramedullary nail (short trochanteric fixation \nnail), right hip\n \nHistory of Present Illness:\nMrs. ___ is a ___ year old female with dementia who was \nbrought\nto ___ after being found down on he floor in \nher\nbedroom. According to notes, the patient did not pick up the\nphone when family called in the evening. The family found her\nseated on he floor in her bedroom with her back to the wall. She\nwas complaining of right hip pain. She does not remember how she\nfell, and when questioned says she did not fall. She reports no\nhead or neck pain, no chest pain, abdominal pain or back pain.\nReview of systems is otherwise limited due to patient's \ndementia.\n \nPast Medical History:\n- Hypothyroidism \n- Hypertension \n- dementia\n- bladder cancer\n\nPSH: \n- cholecystectomy\n \nSocial History:\n___\nFamily History:\nn/c\n \nPhysical Exam:\nAdmission Physical Exam: \n====================\nVS: T 97.3, HR 72, BP 111/68, RR 18, SaO2 97% RA \nGEN: Resting comfortably, alert, oriented to person and place\nHEENT: C-collar in place, nontender\nCV: regular rate and rhythm\nPULM: Clear to auscultation\nABD: Soft, nontender, nondistended, no guarding or rebound\ntenderness\nMSK: Right hip tender to palpation. No ecchymosis, no midline\nback tenderness. \nNEURO: CII-XII intact\nPSYCH: Pleasant\n\nDischarge Physical Exam: \n====================\nT 99.5 BP 139/69 75 18 96%RA \nGeneral: Comfortable, AAOX3 \nHEENT: sclera anicteric\nCV: systolic ejection murmur heard best at RUSB, regular rate \nand rhythm\nNeck: JVP at clavicle \nPULM: CTAB \nABD: Soft, Soft, nontender, nondistended, no guarding or rebound\ntenderness\nMSK: R hip mild TTP. Dressing in place with blood overlying. No \nfrank echymosses. R thigh > L thigh but soft, no TTP. Moving RLE \ntoes. +DP pulse. \nNEURO: CN2-12 grossly intact. ___ upper extremity strength \ngrossly intact. ___ strength LLE, unable to test RLE strength \nsecondary to discomfort. \n\n \nPertinent Results:\nAdmission Labs:\n=============\n___ 02:00AM BLOOD WBC-16.9* RBC-3.16* Hgb-10.1* Hct-31.0* \nMCV-98 MCH-32.0 MCHC-32.6 RDW-14.4 RDWSD-51.5* Plt ___\n___ 02:00AM BLOOD Neuts-82* Bands-0 Lymphs-8* Monos-9 Eos-0 \nBaso-1 ___ Myelos-0 AbsNeut-13.86* AbsLymp-1.35 \nAbsMono-1.52* AbsEos-0.00* AbsBaso-0.17*\n___ 02:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL\n___ 02:00AM BLOOD ___ PTT-31.0 ___\n___ 02:00AM BLOOD Plt Smr-NORMAL Plt ___\n___ 02:00AM BLOOD Glucose-131* UreaN-19 Creat-0.8 Na-140 \nK-3.7 Cl-101 HCO3-28 AnGap-15\n___ 02:00AM BLOOD CK(CPK)-1517*\n___ 08:45AM BLOOD CK(CPK)-1231*\n___ 02:00AM BLOOD cTropnT-0.04*\n___ 08:45AM BLOOD cTropnT-0.03*\n___ 04:30AM BLOOD Iron-26*\n___ 04:30AM BLOOD calTIBC-260 VitB12-621 Ferritn-249* \nTRF-200\n___ 04:30AM BLOOD TSH-1.3\n___ 02:18AM BLOOD Lactate-2.2*\n\nMicrobiology:\n==========\n___ 2:00 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n___ 4:51 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: <10,000 organisms/ml. \n\nUrine:\n=====\n___ 04:50AM URINE Color-Yellow Appear-Clear Sp ___\n___ 04:50AM URINE Blood-MOD Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG\n___ 04:50AM URINE RBC-11* WBC-2 Bacteri-FEW Yeast-NONE \nEpi-<1\n___ 04:51AM URINE CastHy-3*\n\nEKG: \n====\nECGStudy Date of ___ 1:52:25 AM\nClinical indication for EKG: W19.XXXA - Unspecified fall, \ninitial encounter\n \nAtrial fibrillation with mean ventricular rate of 73. Possible \nleft\nventricular hypertrophy with secondary repolarization \nabnormalities. No\nprevious tracing available for comparison.\nRate 73 PR 124 QRS 80 QT399 QTC421/440\n\nImaging:\n=======\nFEMUR (AP & LAT) RIGHTStudy Date of ___ 2:09 AM\nIMPRESSION: \nNo distal femoral fracture is seen. There is comminuted right\nintertrochanteric proximal femoral fracture.\n\nHIP NAILING IN OR W/FILMS & FLUORO RIGHT IN O.R.Study Date of \n___ 4:18 ___\nIMPRESSION: \nFluoroscopic images show placement of a fixation device about \nfracture of the\nproximal femur. Further information can be gathered from the \noperative\nreport.\n\nCHEST (PA & LAT)Study Date of ___ 7:12 ___\nIMPRESSION: \nCardiomegaly is substantial. Large hiatal hernia is projecting \nover the\ncardiac silhouette. Lungs assessment demonstrate vascular \ncongestion but no\nfocal consolidations to suggest pneumonia. Bilateral pleural \neffusion is\nmoderate, increased as compared to ___.\n\nPortable TTE (Complete) Done ___ at 3:15:49 ___ FINAL\n\n___ ___ MRN: ___ Portable TTE \n(Complete) Done ___ at 3:15:49 ___ FINAL\nGENERAL COMMENTS: The patient appears to be in sinus rhythm. \nEchocardiographic results were reviewed by telephone with the \nhouseofficer caring for the patient.\nConclusions\nThe left atrium is elongated. No atrial septal defect is seen by \n2D or color Doppler. The estimated right atrial pressure is ___ \nmmHg. Mild symmetric left ventricular hypertrophy with normal \ncavity size, and regional/global systolic function (biplane LVEF \n= 61 %). There is no ventricular septal defect. Right \nventricular chamber size and free wall motion are normal. The \naortic valve leaflets are moderately thickened. There is severe \naortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. Moderate (2+) mitral regurgitation is seen. The \ntricuspid valve leaflets are mildly thickened. There is moderate \npulmonary artery systolic hypertension. There is a small \ncircumferential pericardial effusion without evidence for \nhemodynamic compromise. \n\nIMPRESSION: Severe aortic valve stenosis. Mild symmetric left \nventricular hypertrophy with preserved regional and global \nbiventricular systolic function. Moderate mitral regurgitation. \nModerate pulmonary artery systolic hypertension. Small \ncircumferential pericardial effusion. \n\nCLINICAL IMPLICATIONS: \nThe patient has severe aortic valve stenosis. Based on ___ \nACC/AHA Valvular Heart Disease Guidelines, if the patient is \nasymptomatic, it is reasonable to consider an exercise stress \ntest to confirm symptom status. In addition, a follow-up study \nis suggested in ___ months. If they are symptomatic (angina, \nsyncope, CHF) and a surgical or TAVI candidate, a mechanical \nintervention is recommended. \n\nCAROTID SERIES COMPLETEStudy Date of ___ 10:50 AM\nIMPRESSION:\nNo evidence of atherosclerotic disease in the bilateral carotid \nvasculature. \nTortuous bilateral ICAs are incidentally noted.\n\nDischarge Labs: \n============\n___ 04:15AM BLOOD WBC-13.0* RBC-3.06* Hgb-9.6* Hct-29.5* \nMCV-96 MCH-31.4 MCHC-32.5 RDW-15.3 RDWSD-52.3* Plt ___\n___ 04:15AM BLOOD Plt ___\n___ 04:15AM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-141 \nK-4.1 Cl-104 HCO3-25 AnGap-16\n___ 04:15AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.9\n \nBrief Hospital Course:\nSummary:\n========\n___ yo F with PMH of HTN, hypothyroidism, and dementia who was \ntransferred from OSH after unwitnessed fall with imaging \nconcerning for C6-C7 anterior osteophyte fracture and right \nsubtrochanteric fractures, now s/p ORIF ___ and transferred to \nmedicine for syncope workup found to have new paroxysmal atrial \nfibrillation and aortic stenosis. \n\n# Presumed syncope w/ fall: \nCircumstances surrounding fall unclear given patient's dementia. \nFound down by son . ___ for fall included mechanical \nfall, however was also found to have new paroxysmal atrial \nfibrillation and new aortic stenosis noted on TTE, thus raising \nconcern for potential cardiac etiology. Orthostatics negative. \nBlood pressures tolerated restarting home losartan. Pulmonary \nembolus was lower on differential given absence of tachycardia, \nchest pain, or new O2 requirement. EKG was without acute \nischemic changes and no q waves noted. No prior seizure history. \nPatient was initially monitored on telemetry which captured \nintermittent atrial fibrillation. \n\n# Anemia: \nDowntrend during hospital stay with concern for acute on chronic \netiology. Patient noted to be iron deficient and with normal \nB12. Exam notable for enlargement of right thigh compared to \nleft, concerning for accumulating hematoma in prior operative \nsite. No evidence of compartment syndrome on exam. Received 2 \nunits pRBC transfusion with appropriate h/h bump. Orthopedic \nsurgery aware and recommended continuing enoxaparin 30mg QHS. \n\n# Aortic stenosis: \nModerate to severe aortic stenosis noted on echo ___ with \npreserved EF. Moderate pulmonary effusions noted on CXR but \npatient was satting well on room air and thus no active diuresis \nwas performed. Home losartan was restarted. Seen by CT surgery. \nCarotid US normal. Pat not deemed candidate for open AV \nreplacement. Should be referred for Trans-aortic valve \nreplacement to TABR team who saw her while in hospital Since \npatient was not particularly otherwise symptomatic and had low \nAV gradients, plan was for a 3 month follow-up with Dr ___. \nThe rehab or PCP can call the Call center to set that up \n___. (This information was relayed to the rehab center \nby resident Dr. ___ discharge).\n\n# Paroxysmal atrial fibrillation: \nCHADs2 score 2 (age, HTN); CHADSs2Vasc 3 (age, HTN, sex) \nNew onset per conversation with PCP and review of last office \nEKG by PCP ___ ___. Spontaneously rhythm controlled and on \npost operative enoxaparin per orthopedic surgery. Given CHADs \nscore, decision regarding anticoagulation deferred to outpatient \nsetting. TSH normal. No evidence of infection on UA, UCx. Blood \ncultures NGTD but final read pending at time of discharge. \n\n# Intertrochanteric fracture: \ns/p ORIF ___. Concern for hematoma per above with no evidence of \ncompartment syndrome on exam. Pain control with acetaminophen \nand oxycodone. Anticoagulation with enoxaparin 30mg QHS x 4 \nweeks per ortho (Day ___= ___. Follow up 2 weeks post op with \northo. Per ortho, WBAT. Patient worked with physical therapy who \nrecommended d/c to rehab. \n\n# Concern for C6-C7 anterior osteophyte fracture: \nConcern given imaging findings at OSH. Examined by neurosurgery \nin ___ who noted no deficits on neuro exam, no neck pain and \ndetermined no neurosurgical intervention required. Per \nneurosurgery, no c-collar, follow up imaging, or neurosurgery \nfollow up required. \n\n# Leukocytosis: \nStress response from fall, surgery, hematoma noted above. \nAfebrile and VSS with stable to downtrending leukocytosis. No \ninfectious source identified at this time with negative UA, \nfinal neg UCx, and BCx NGTD. CXR without PNA. \n\n# Thrombocytopenia: \nResolved at time of discharge. Attributed to post surgical \nstress response. On enoxaparin but 4T score was 2 (40% drop; plt \nfall <4d without prior exposure, other probable cause, no \nthrombosislow probability). \n \n# Rhabdomyolysis: \n1517 on admission, likely secondary to being found down. \nDowntrending with no evidence of renal compromise. \n \n# Hypothyroidism: \nTSH wnl. Continued on Levothyroxine Sodium 125 mcg PO/NG DAILY \n\n# Osteoporosis: \nGiven age and hip fracture, osteoporosis is likely. Started on \nCalcium Carbonate 1000 mg PO/NG DAILY and Vitamin D 800 UNIT \nPO/NG DAILY. Consider outpatient bisphosphonate therapy. \n \n# DVT prophylaxis: \nHigh risk of VTE ___. Started lovenox QHS per ortho \nfor 4 weeks. \n\nTransitional Issues: \n====================\n- started calcium and vitamin D for likely osteoporosis given \nhip fracture. Consider bisphosphonate therapy.\n- 4 weeks lovenox 30mg QHS from operation date (___) \n- s/p ORIF ___ of R hip c/b hematoma. Please monitor \nhematoma. \n- orthopedic surgery follow up 2 weeks post op. \n- aortic stenosis newly noted on echo. TAVR workup started. \nPlease follow up for further consideration of TAVR surgery. Seen \nby CT surgery. Carotid US normal. Pat not deemed candidate for \nopen AV replacement. Should be referred for Trans-aortic valve \nreplacement to TABR team who saw her while in hospital Since \npatient was not particularly otherwise symptomatic and had low \nAV\ngradients, plan was for a 3 month follow-up with Dr ___. The \nrehab or PCP can call the Call center to set that up \n___. (This information was relayed to the rehab center \nby resident Dr. ___ discharge).\n- new paroxysmal atrial fibrillation noted. No rate control \nrequired. Started on ASA 81 mg daily. Consideration of further \nanticoagulation deferred to outpatient setting. \n- per conversation with PCP and son, concern for ability to care \nfor self at home. Please consider discharge from rehab with home \nservices. \n\n#Full Code \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 100 mg PO DAILY \n2. Levothyroxine Sodium 125 mcg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Vitamin D Dose is Unknown PO DAILY \n\n \nDischarge Medications:\n1. Levothyroxine Sodium 125 mcg PO DAILY \n2. Losartan Potassium 100 mg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Vitamin D 800 UNIT PO DAILY \n5. Acetaminophen 650 mg PO TID \n6. Calcium Carbonate 1000 mg PO DAILY \nplease take 4 hours after your levothyroxine \n7. Enoxaparin Sodium 30 mg SC Q12H \nStart: Tomorrow - ___, First Dose: First Routine \nAdministration Time \n8. Aspirin 81 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: \n-Right intertrochanteric hip fracture \n-Aortic stenosis \n-Paroxysmal atrial fibrillation \n-Acute blood loss anemia \n\nSecondary: \n-Hypothyroidism \n-Hypertension \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was our pleasure caring for you during your admission to \n___. You were transferred to our hospital after you \nexperienced a fall. You were initially felt to have a fracture \nof your neck, but after evaluation by our neurosurgeons, this \nwas felt to be unlikely. This fall did however result in a \nfracture of your hip that required orthopedic surgery. After \nyour surgery, you experienced some bleeding into your thigh and \nrequired a blood transfusion. This can occasionally occur after \nhip surgery. Please see below for specific instructions from our \northopedic surgeons. \n\nWhile you were in the hospital, we noted that your heart was \noccasionally going into an abnormal rhythm called \"atrial \nfibrillation.\" We also performed a image of your heart called an \n\"echocardiogram\" that showed that one of your heart valves had \nnarrowed (\"aortic stenosis\"). One or both of these cardiac \nissues may have contributed to the fall that you experienced. \nYou should follow up with your primary care physician to decide \nif you need to start any new medications for the atrial \nfibrillation. You should also follow up with our cardiac surgery \nteam to find out if you might benefit from surgery for your \naortic stenosis. \n\nOur physical therapists felt that you would benefit from going \nto rehab after this hospital stay. Please follow up with your \nprimary care physician, ___, and our cardiac \nsurgery team. \n\nWe wish you the best! \nYour ___ Care Team \n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- You are encouraged to bear weight as tolerated on your right \nlower 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 Lovenox 40 MG daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- No dressing is needed if wound continues to be non-draining.\n \nFollowup Instructions:\n___\n" ]

[ "S72141A", "T796XXA", "D696", "F0390", "I080", "I272", "M96830", "D62", "W1830XA", "Y92013", "D509", "E039", "I10", "M810", "I4891", "M25512", "Z8551", "Z87891" ]

[ "S72141A: Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture", "T796XXA: Traumatic ischemia of muscle, initial encounter", "D696: Thrombocytopenia, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "I080: Rheumatic disorders of both mitral and aortic valves", "I272: Other secondary pulmonary hypertension", "M96830: Postprocedural hemorrhage of a musculoskeletal structure following a musculoskeletal system procedure", "D62: Acute posthemorrhagic anemia", "W1830XA: Fall on same level, unspecified, initial encounter", "Y92013: Bedroom of single-family (private) house as the place of occurrence of the external cause", "D509: Iron deficiency anemia, unspecified", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "M810: Age-related osteoporosis without current pathological fracture", "I4891: Unspecified atrial fibrillation", "M25512: Pain in left shoulder", "Z8551: Personal history of malignant neoplasm of bladder", "Z87891: Personal history of nicotine dependence" ]

[ "D696", "D62", "D509", "E039", "I10", "I4891", "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:\nLeft arm and jaw pain with GI upset\n \nMajor Surgical or Invasive Procedure:\nCardiac catheterization\nLeft Ventriculography: The ejection fraction was visually \nestimated to be 30%.\nThe left ventricle was of normal size.\nAnterobasal: Normal\nAnterolateral: Dyskinesis\nApical: Dyskinesis\nDiaphragmatic: Dyskinesis\nPosterobasal: Normal\nCoronary Anatomy\nLM: Normal\nLAD: Mild lumenal irregularities\nLCx: Mild lumenal irregularities\nRCA: Mild lumenal irregularites.\nImpressions:\nThere is no significant CAD. There is an area of apical \ndyskinesis and \"ballooning\" with moderately\nreduced LV systolic function. Overall this picture is consistent \nwith Takotsubo cardiomyopathy.\n \nHistory of Present Illness:\n___ without significant PMHx presented to ___ with 1 day of \nleft arm pain, now transferred to ___ for further evaluation. \n\n Patient was in her USOH until last evening when she had left \narm pain at rest. Lasted fromo ___-0400 with some residual pain \nleft in the morning. Also noted to have belching and some chest \ndiscomfort. ROS negative for nausea/vomiting, sob, dizziness. \nShe presented to her PCP with EKG showing new TWI in lateral \nleads and inferior TW changes concerning for ischemia. She was \nreferred into the ED at ___. At ___ initial vitals were \nstable. Labs were notable for: \n \n Labs at ___: \n - CBC 8.54/13.9/40.6/248 \n - INR 0.9 \n - CMP: ___, AST 26, ALT 23 \n - Trp T 0.232, CK-MB 9, CPK 169 \n She was given ASA and started on a heparin gtt prior to \ntransfer. \n In the ED initial vitals were: 95, 109/71, 18, 95% RA \n Pt arrives awake and alert. Denies CP at this time. Heparin \ninfusing on arrival \n EKG: Sinus rhythm, rate 79, QTc 470/502, TWI V3-V6, qwaves in \nII, no clear STE or STD \n Labs/studies notable for: Trp 0.17->0.12 \n Patient was given: IV Heparin \n Vitals on transfer: 98.5, 75, 113/68, 16, 98% RA \n \n On the floor patient was resting comfortably without chest \npain. Denies any other symptoms. Inquisitive about possible \ninterventions tomorrow. \n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death.\n \nPhysical Exam:\nPHYSICAL EXAMINATION ON ADMISSION: \nTele: HR ___, TWI throughout \nVS: T 98.2 BP ___ HR ___ RR 15 O2 sat 94% on RA\nWeight: 90.2\nGENERAL: Resting comfortably. Oriented x3. Mood, affect \nappropriate. \nHEENT: Sclera anicteric. EOMI. Conjunctiva were pink, no pallor \nor cyanosis of the oral mucosa. \nNECK: Supple with JVP 1 cm above clavicle at 30 degrees. \nCARDIAC: Slightly distant heart sounds, RR, normal S1, S2. No \nm/r/g. No thrills, lifts. No S3 or S4. \nLUNGS: Diffuse crackles right lower ___, clear on left. Resp \nwere unlabored, no accessory muscle use. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: Warm, 2+ radial and ___ pulses \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \n\nPHYSICAL EXAMINATION ON DISCHARGE: \nVitals: T= 97.9 HR=60-70s BP=100-110s/40-50s RR=18 O2= 95% on RA \n \nTelemetry: HR ___, persisting TWI, no alarms\nGeneral: Resting comfortably\nHEENT: JVP not visible at 45 degrees.\nLungs: CTAB, no wheezes\nCV: RRR, normal S1, S2, no murmurs\nAbdomen: NT, ND, no masses\nExt: warm, 2+ radial and ___ pulses\nNeuro: right pupil 7-8 mm, left pupil 3-4 mm, both respond to \nlight. Visual fields full to confrontation. EOMI, smile and \ntongue symmetric, SCM strength symmetric, hearing grossly intact \nbilaterally.\n \nPertinent Results:\nLABS ON ADMISSION:\n___ 11:10PM BLOOD WBC-8.0 RBC-4.48 Hgb-14.0 Hct-41.7 MCV-93 \nMCH-31.3 MCHC-33.6 RDW-13.2 RDWSD-44.6 Plt ___\n___ 11:10PM BLOOD ___ PTT-61.2* ___\n___ 11:10PM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-138 \nK-5.4* Cl-104 HCO3-21* AnGap-18\n___ 08:30PM BLOOD cTropnT-0.17*\n___ 11:10PM BLOOD cTropnT-0.12*\n___ 06:15AM BLOOD CK-MB-7 cTropnT-0.08*\n\nLABS ON DISCHARGE:\n___ 07:05AM BLOOD WBC-6.6 RBC-4.52 Hgb-14.5 Hct-42.4 MCV-94 \nMCH-32.1* MCHC-34.2 RDW-13.3 RDWSD-45.4 Plt ___\n___ 07:05AM BLOOD ___ PTT-32.2 ___\n___ 07:05AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-141 \nK-4.1 Cl-104 HCO3-25 AnGap-16\n___ 07:05AM BLOOD cTropnT-0.03*\n\nOTHER FINDINGS:\nEKGs ___: TWI V2-V6, QRS 100 mm, left axis \n\nCardiac catheterization ___ PRELIMINARY REPORT: There is no \nsignificant CAD. There is an area of apical dyskinesis and \n\"ballooning\" with moderately reduced LV systolic function. \nOverall this picture is consistent with Takotsubo \ncardiomyopathy.\n\nTEE ___ FINAL: The left atrium is normal in size. No atrial \nseptal defect is seen by 2D or color Doppler. The estimated \nright atrial pressure is ___ mmHg. Left ventricular wall \nthicknesses are normal. There is moderate regional left \nventricular systolic dysfunction with akinesis of the \nmid-anterior and anteroseptal segments and the distal ___ of the \nleft ventricle. The remaining segments contract normally (LVEF = \n30%). No masses or thrombi are seen in the left ventricle. There \nis no ventricular septal defect. Right ventricular chamber size \nand free wall motion are normal. The aortic valve leaflets (3) \nappear structurally normal with good leaflet excursion and no \naortic stenosis. No aortic regurgitation is seen. Mild (1+) \nmitral regurgitation is seen. There is no pericardial effusion. \nIMPRESSION: Moderate regional left ventricular systolic \ndysfunction. Mild mitral regurgitation. Findings are most c/w \ntakotsubo cardiomyopathy. LAD-territory infarction cannot be \nreliably excluded, however. \n \nBrief Hospital Course:\nMrs. ___, ___ without significant past medical history, \npresented with 1 day of left arm and jaw pain and belching and \nwas found to have new T wave inversions on EKG and troponin \nelevated to 0.232. We were concerned for NSTEMI and initiated \ntreatment with ASA, heparin gtt, atorvastatin 80 mg, and \nmetroprolol. Subsequently, TTE revealed apical akinesis with \nLVEF 30% and apical ballooning, and cardiac catheterization \nrevealed non-obstructive disease and confirmed with left \nventriculogram apical ballooning and akinesis, overall \nconsistent with Takotsubo's cardiomyopathy. The patient did \nendorse losing two close friends in the last 6 months. In light \nof echo markedly reduced EF (30%), we initiated treatment for \nheart failure intended to be short-term. We transitioned from \nheparin to apixiban for anticoagulation (given apical akinesis \nand risk for LV thrombus), initiated treatment with ACE \ninhibitor and continued metoprolol. We continued a low dose of \natorvastatin at 20 mg daily as well as aspirin 81 daily. We \nrecommend revisiting the need for these medications at the \npatient's next cardiology appointment.\n\n#Transitional issues:\n- NEW MEDICATIONS: apixiban, metoprolol, atorvastatin, ASA, and \nlisinopril until EF improves\n- recommend consideration for outpatient cardiac rehab\n- recommend discussing need for continued ASA and atorvastatin \ngiven limited utility in heart failure, but mild CAD (mild \nluminal irregularities on catheterization)\n- can consider uptitrating lisinopril from 2.5 to 5 mg daily as \nblood pressure tolerates\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. Apixaban 5 mg PO/NG BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*1 \n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*1 \n3. Atorvastatin 20 mg PO QPM \nRX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*1 \n4. Lisinopril 2.5 mg PO DAILY \nRX *lisinopril 2.5 mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*1 \n5. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp \n#*30 Tablet Refills:*1 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nStress cardiomyopathy (aka Takotsubo cardiomyopathy)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nYou were hospitalized due to arm and jaw pain with stomach \nupset, and found to have stress cardiomyopathy, also called \nTakotsubo cardiomyopathy. This condition is a temporary \nreduction in heart function that is sometimes, but not always, \nassociated with a recent physical or emotion stress. \nFortunately, this is not a permanent condition and we expect \nyour heart to return to normal in the next ___ months.\n\nBecause your heart function is currently decreased, it is \nimportant that you take several new medications listed below \nuntil your cardiologist tells you to stop taking these \nmedications. \n\nYour follow-up appointments are listed below. \n\nIt was a pleasure taking care of you.\n\nSincerely,\nYour ___ Cardiology Team\n \nFollowup Instructions:\n___\n" ]

[ "I5181", "R9431", "Z7902", "Z23" ]

[ "I5181: Takotsubo syndrome", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z23: Encounter for immunization" ]

[ "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \namiodarone / ceftriaxone / Bactrim / Cipro\n \nAttending: ___\n \nChief Complaint:\nnausea, vomiting\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female patient with recent mechanical\nTAVR, Afib, VT arrest, PPM who presented early ___ with an\nincarcerated left femoral hernia. She was taken promptly to the\noperating room on ___. She underwent femoral hernia repair and\npostoperatively was in the cardiac ICU for close monitoring,\nlater on transferred to the surgical floor, she tolerated a\nregular diet and was discharged home with ___. She now returns\ncomplaining of nausea, 1 episode of emesis and constipation. She\nreports that since her discharge she has only had 3 bowel\nmovements, last one being over 5 days ago, she has been eating\nsmall amounts of food daily and her appetite has not returned\nfully yet. She reports that this morning due to discomfort\nbecause of constipation she drank milk of magnesia which made \nher\nnauseus and had 1 episode of half a cup of bilious emesis. She\nreports also using a small fleet enema this morning with a very\nsmall bowel movement after this. She denies any other complaint.\nReports passing flatus multiple times a day, last one being\nminutes before arriving to ___. Of note patient reports that\nshe has started treatment for a UTI 2 days ago with Bactrim. \n\nDue to these symptoms patient presented to ___ and\nwas transferred here for further management. \n\n \nPast Medical History:\nPMH: \n - HFrEF ___\n - HTN\n - HLD\n - Known severe AS\n - Esophageal rupture s/p endoscopic clipping\n - OA\n - Endometrial polyps\n - Cholecystectomy\n\nPSH:\n - CCY\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY:\n- no family history of cancer, heart disease\n- Father: died of alcohol use\n- Mother: died in ___\n- Grandmother: died at 99 of unknown cause\n\n \nPhysical Exam:\nAdmission Physical Exam:\nTemp 97.7 HR 89 BP 121/61 RR 17 02Sat: 98% RA\n___: resting comfortably in NAD, generalized scaly rash \nHEENT: EOMI, PERRL, anicteric\nNeck: supple, no LAD\nChest: CTAB, no respiratory distress\nHeart: RRR, normal S1&S2\nAbdomen: soft, non tender, non distended, no rebound or \nguarding.\nL 9cm induration around left groin incision. Suprapubic \nbruising.\n\nDischarge Physical Exam:\nVS: 98.1, 96/52, 84, 18, 97 Ra\nGen: A&O x3. Sitting up in chair, talkative, appears comfortable\nPulm: LS ctab\nAbd: soft, NT/ND. Left groin with hernia repair incision, \nmoderate sized firm hematoma present. \nExt: chronic discoloration of vascular disease, trace edema\n \nPertinent Results:\n___ 06:16AM BLOOD WBC-5.9 RBC-2.42* Hgb-7.8* Hct-25.0* \nMCV-103* MCH-32.2* MCHC-31.2* RDW-14.2 RDWSD-53.9* Plt ___\n___ 11:02AM BLOOD WBC-10.3* RBC-3.09* Hgb-10.1* Hct-31.7* \nMCV-103* MCH-32.7* MCHC-31.9* RDW-14.4 RDWSD-54.0* Plt ___\n___ 09:40AM BLOOD WBC-7.9 RBC-2.90* Hgb-9.5* Hct-29.7* \nMCV-102* MCH-32.8* MCHC-32.0 RDW-14.3 RDWSD-53.8* Plt ___\n___ 06:39AM BLOOD WBC-4.8 RBC-2.22* Hgb-7.2* Hct-22.6* \nMCV-102* MCH-32.4* MCHC-31.9* RDW-14.1 RDWSD-52.9* Plt ___\n___ 06:16AM BLOOD Glucose-85 UreaN-9 Creat-1.0 Na-138 K-4.4 \nCl-103 HCO3-21* AnGap-14\n___ 06:39AM BLOOD Glucose-87 UreaN-12 Creat-0.9 Na-137 \nK-4.5 Cl-105 HCO3-22 AnGap-10\n___ 06:00AM BLOOD Glucose-79 UreaN-15 Creat-1.0 Na-139 \nK-4.4 Cl-107 HCO3-22 AnGap-10\n\nImaging:\n\nCT scan of abdomen and pelvis from OSH showed a 9cm\nhematoma around prior hernia site with no distended loops of\nbowel and no evidence of small bowel obstruction.\n\n___ KUB:\nMildly dilated loops of small bowel in the abdomen with \nair-fluid levels on the upright view, concerning for small bowel \nobstruction. \n\n \nBrief Hospital Course:\nThe patient was admitted to the ___ Surgical Service on \n___ for evaluation and treatment of abdominal pain. Admission \nabdominal/pelvic CT revealed a 9cm hematoma at the site of her \nleft femoral hernia repair. The patient was hemodynamically \nstable. She was admitted for bowel rest, IV fluids, bowel \nregimen, and monitoring of H&H. \n\nOnce nausea subsided, diet was progressively advanced as \ntolerated to a regular diet with good tolerability. The patient \nvoided without problem. During this hospitalization, the patient \nambulated early and frequently, was adherent with respiratory \ntoilet and incentive spirometry, and actively participated in \nthe plan of care. The patient received home eliquis and venodyne \nboots were used during this stay. Hematocrit remained stable. \n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home with ___ services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n\n \nMedications on Admission:\nMedications - Prescription\nAPIXABAN [ELIQUIS] - Eliquis 5 mg tablet. 1 tablet(s) by mouth\ntwice a day\nLISINOPRIL - lisinopril 2.5 mg tablet. 1 tablet(s) by mouth once\na day\nMETOPROLOL SUCCINATE - metoprolol succinate ER 25 mg\ntablet,extended release 24 hr. 0.5 (One half) tablet(s) by mouth\nonce a day\nSPIRONOLACTONE - spironolactone 25 mg tablet. 0.5 (One half)\ntablet(s) by mouth once a day\nTRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.1 % topical\ncream. Apply to instructed area as needed three times a day as\nneeded for prn\n \nMedications - OTC\nASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by\nmouth once a day\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n2. Apixaban 5 mg PO BID \n3. Lansoprazole Oral Disintegrating Tab 30 mg PO BID \n4. Polyethylene Glycol 17 g PO DAILY \n5. Senna 8.6 mg PO BID \n6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 9 Doses \n7. aspirin 81 mg tablet one tablet PO daily\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft femoral hernia repair site post-op hematoma\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 ___ with nausea and vomiting after your \nleft femoral hernia repair. CT scan was done which showed a \nhematoma beneath your hernia repair incision but it was not \ncausing any obstruction. Your diet was slowly advanced and you \nare now tolerating food without any issues. \n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n\n \nFollowup Instructions:\n___\n" ]

[ "L7632", "K567", "D6832", "N390", "I5020", "Y839", "Y92009", "I4891", "Z952", "Z950", "Z7902", "I10", "E785", "I110" ]

[ "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "K567: Ileus, unspecified", "D6832: Hemorrhagic disorder due to extrinsic circulating anticoagulants", "N390: Urinary tract infection, site not specified", "I5020: Unspecified systolic (congestive) heart failure", "Y839: Surgical procedure, unspecified as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "I4891: Unspecified atrial fibrillation", "Z952: Presence of prosthetic heart valve", "Z950: Presence of cardiac pacemaker", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I110: Hypertensive heart disease with heart failure" ]

[ "N390", "I4891", "Z7902", "I10", "E785", "I110" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \namiodarone / ceftriaxone / Bactrim / Cipro\n \nAttending: ___.\n \nChief Complaint:\nAbdominal Pain\n \nMajor Surgical or Invasive Procedure:\n___: Mesh repair of incarcerated left femoral hernia.\n\n \nHistory of Present Illness:\nMs. ___ is an ___ year old woman with recent TAVR c/b CHB, VT \narrest requiring PPM placement who presents as a transfer from \nOSH with incarcerated left femoral hernia. She was admitted in \n___ with afib with RVR and a type two NSTEMI and found to \nhave critical aortic stenosis. She subsequently underwent TAVR \nas above with PPM. In the setting of this, her apixaban was held \nand she has not resumed it. \n\nShe began to have lower abdominal pain yesterday afternoon which \nhas progressively worsened and been associated with emesis. She \ngave herself an enema and had a small loose bowel movement, but \nher symptoms persisted. She presented to OSH where CT scan \ndemonstrated a left femoral hernia and she was transferred to \n___ for further care. Prior to her arrival here she was given\ncefoxitin and unasyn as well as 2L crystalloid. At this time \nshe reports ongoing moderate to severe abdominal pain. \n\nOf note, she has not taken her medications including aspirin and \nPlavix since ___ as she was told she had borderline low \nblood pressure and should hold all her medications. \n \nPast Medical History:\nPMH: \n - HFrEF ___\n - HTN\n - HLD\n - Known severe AS\n - Esophageal rupture s/p endoscopic clipping\n - OA\n - Endometrial polyps\n - Cholecystectomy\n\nPSH:\n - CCY\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY:\n- no family history of cancer, heart disease\n- Father: died of alcohol use\n- Mother: died in ___\n- Grandmother: died at ___ of unknown cause\n\n \nPhysical Exam:\nPhysical Exam on Admission:\nVitals: 97.8 85 101/51 18 96RA\nGEN: A&O, NAD\nCV: RRR, No M/G/R\nPULM: Clear to auscultation\nABD: moderate distension. Soft. TTP suprapubic and LLQ. There is \na left femoral hernia which is not reducible\nExt: No ___ edema, ___ warm and well perfused\n\nPHYSICAL EXAM ON DISCHARGE:\nVS: 97.6, 108/69, 84, 18, 97 RA\nGen: A&O x3. Sitting up in bed in NAD. \nCV: Normal rate, regular rhythm. No murmurs, rubs, or gallops. \nLUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. No adventitious breath \nsounds. \nAbd: soft, NT/ND\nSkin: Left groin hernia repair site with some swelling / \nhematoma. Scant serosanguinous drainage oozing from incision. \nBruising tracking down into suprapubic area. \nExt: WWP. BLE discoloration of chronic PVD. skin dry/flaky. \n \n \nPertinent Results:\nTransthoracic Echocardiogram Report: ___\nWell-seated, normally functioning Lotus Edge aortic \nbioprosthesis with mild\nparavalvular leak. Severe regional left ventricular systolic \ndysfunction c/w multivessel CAD. Mildly hypokinetic right \nventricle. Mild mitral and tricuspid regurgitation. Normal \npulmonary pressure.\n\nPORTABLE ABDOMEN Study Date of ___ \nBorderline dilatation of air-filled small bowel loops throughout \nthe \nmid-abdomen, which may represent a postoperative ileus in this \nsetting or, \nsmall bowel obstruction not excluded in the appropriate clinical \nsetting. \n\nLAB DATA:\n\n___ 08:08AM BLOOD WBC-8.0 RBC-2.94* Hgb-9.8* Hct-30.5* \nMCV-104* MCH-33.3* MCHC-32.1 RDW-13.0 RDWSD-48.7* Plt ___\n___ 04:20AM BLOOD WBC-7.9 RBC-3.10* Hgb-10.2* Hct-31.6* \nMCV-102* MCH-32.9* MCHC-32.3 RDW-13.2 RDWSD-49.1* Plt ___\n___ 05:05PM BLOOD Glucose-99 UreaN-15 Creat-0.9 Na-143 \nK-4.0 Cl-105 HCO3-20* AnGap-18\n___ 08:08AM BLOOD Glucose-118* UreaN-17 Creat-0.9 Na-140 \nK-5.0 Cl-101 HCO3-23 AnGap-16\n___ 05:05PM BLOOD Calcium-8.9 Phos-2.5* Mg-1.8\n___ 08:08AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.___ with PMHx of non-ischemic HFrEF (EF 26%), severe AS s/p \nTAVR, pAF (CHADS2VASc 5) , HTN, HLD, and esophageal dissection \ns/p clipping. On previous admission patient had TAVR complicated \nby CHB for which she received temporary pacing c/b RV puncture \nfrom pacing wire and polymorphic VT arrest s/p ROSC. The patient \nhad a dual-chamber PPM placed ___. On this occasion \npresented with abdominal pain and was found to have incarcerated \nleft femoral hernia. The patient was taken to the operating room \nfor repair. See operative note for details.In the ___ \nprocedural interval patient was hypotensive and required pressor \nsupport. She was transferred to the CCU postoperatively. On \nbedside echo no evidence of pericardial effusion concerning for \ncardiac tamponade but signs of hypovolemia. Phenylephrine \nweaned, given IVF. \n\nPatient also noted to have evidence of erythematous pruritic \nrash in bilateral\nupper extremities. She states it is similar to the one she got \nwith the amiodarone during her last admission. Bactrim (started \noutpatient for UTI) was stopped. \n\nOnce the patient had weaned from pressures and was \nhemodynamically stable, she was transferred back to the ___ \nservice for furether post-op care on POD2. An NGT was placed on \nPOD1 for ileus, nausea and vomiting. The patient was maintained \non bowel rest with supportive care and gentle IV fluids. On \nPOD4, the NGT output had diminished and the patient was passing \ngas. the NGT was removed and she was given sips. POD5, diet was \nadvanced as tolerated to regular. The Foley catheter was removed \nat midnight and the patient voided. ___ worked with the patient \nand she was cleared for discharge home with home ___ and ___ \nservices. On the day of discharge, apixaban was restarted per \nCardiology recs, and home meds were slowly re-introduced. \n\nDuring this hospitalization, the patient ambulated early and \nfrequently, was adherent with respiratory toilet and incentive \nspirometry, and actively participated in the plan of care. The \npatient received subcutaneous heparin and venodyne boots were \nused during this stay.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home with ___ services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan. She was going to call to schedule Cardiology \nfollow-up within a week of discharge and also would schedule ___ \nclinic follow-up. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Lisinopril 2.5 mg PO DAILY \n3. Spironolactone 12.5 mg PO DAILY \n4. Clopidogrel 75 mg PO/NG DAILY \n5. Metoprolol Succinate XL 12.5 mg PO DAILY \n6. Apixaban 5 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Polyethylene Glycol 17 g PO DAILY \n3. Apixaban 5 mg PO BID \n4. Aspirin 81 mg PO DAILY \n5. Lisinopril 2.5 mg PO DAILY \n6. Metoprolol Succinate XL 12.5 mg PO DAILY \n7. Spironolactone 12.5 mg PO DAILY \n8. HELD- Clopidogrel 75 mg PO/NG DAILY This medication was \nheld. Do not restart Clopidogrel until seen by cardiology\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nIncarcerated left femoral hernia.\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 ___ for \nabdominal pain and were found to have an acute obstruction from \nan incarcerated left femoral hernia. You were taken urgently to \nthe operating room and underwent mesh repair of incarcerated \nleft femoral hernia. After surgery, you had low blood pressure \nand were managed by the Cardiology service. Once you were stable \nfrom a cardiology standpoint, you were transferred back to the \nSurgery service. You are recovering well and are now ready for \ndischarge. Please follow the instructions below to continue your \nrecovery:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n \nFollowup Instructions:\n___\n" ]

[ "K4130", "I5022", "I442", "I429", "K567", "I130", "D696", "I480", "E785", "I252", "E861", "N189", "Z23", "I959", "L270", "T368X5A", "T361X5A", "M1990", "R339", "Y92230", "Z7901", "Z950", "Z952", "Z8674" ]

[ "K4130: Unilateral femoral hernia, with obstruction, without gangrene, not specified as recurrent", "I5022: Chronic systolic (congestive) heart failure", "I442: Atrioventricular block, complete", "I429: Cardiomyopathy, unspecified", "K567: Ileus, 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", "D696: Thrombocytopenia, unspecified", "I480: Paroxysmal atrial fibrillation", "E785: Hyperlipidemia, unspecified", "I252: Old myocardial infarction", "E861: Hypovolemia", "N189: Chronic kidney disease, unspecified", "Z23: Encounter for immunization", "I959: Hypotension, unspecified", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "T361X5A: Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter", "M1990: Unspecified osteoarthritis, unspecified site", "R339: Retention of urine, unspecified", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z7901: Long term (current) use of anticoagulants", "Z950: Presence of cardiac pacemaker", "Z952: Presence of prosthetic heart valve", "Z8674: Personal history of sudden cardiac arrest" ]

[ "I130", "D696", "I480", "E785", "I252", "N189", "Y92230", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \namiodarone / ceftriaxone / Bactrim / Cipro\n \nAttending: ___\n \nChief Complaint:\nShortness of breath, lethargy \n \nMajor Surgical or Invasive Procedure:\n___: TAVR\n___: Temporary pacing wire placement\n___: Permanent pacemaker placement\n \nHistory of Present Illness:\n___ with H/O severe aortic stenosis, hypertension, \nhyperlipidemia, esophageal dissection s/p clipping, and recent \nadmission to ___ ___ for atrial fibrillation with a \nrapid ventricular rate, new diagnosis of HFrEF (LVEF<20%) and \nType II NSTEMI, who initially presented to ___ on \nthe day of admission with shortness of breath and lethargy. She \nwas found to be in an acute heart failure exacerbation, now \ntransferred to ___ for further management. \n\nShe initially presented to ___ on the day of \nadmission with shortness of breath and increased \nlethargy/generalized weakness for 1 week, which was worse on the \nday of presentation. Labs there were notable for BNP>35,000, \ntroponin I 0.56. She was felt to be in HFrEF exacerbation and \nreceived diuresis with furosemide 40 mg IV x2. \n\nShe additionally reports that since discharge, she developed a \nworsening pruritic rash which was present during her recent \nhospitalization but has since spread to her torso, arms, and \nlegs. She called the Heartline and it was felt that this was \npossibly a reaction to amiodarone. She was subsequently \ninstructed to discontinue amiodarone by her outpatient \ncardiologist, and the rash resolved. Additionally she was \nrecently started on furosemide 20 mg a couple of days prior to \npresentation.\n \nUpon arrival to the cardiology ward, she endorsed the above \nhistory. She denies any shortness of breath or pain anywhere \nincluding chest pain currently, though she reported that if she \nwere to move around, she would develop palpitations and \nweakness. She denied fevers, chills, lightheadedness, dizziness, \nnausea, vomiting, cough, abdominal pain, black or bloody stool, \npain with urinating. \n \nREVIEW OF SYSTEMS: Pertinent positives per HPI. All of the other \nreview of systems were negative.\n \nPast Medical History:\n- Hypertension\n- Hyperlipidemia\n- Severe aortic stenosis\n- Atrial fibrillation with rapid ventricular rate\n- Esophageal rupture s/p endoscopic clipping\n- OA\n- Endometrial polyps\n- Cholecystectomy\n \nSocial History:\n___\nFamily History:\n- no family history of cancer, heart disease\n- Father: died of alcohol use\n- Mother: died in ___\n- Grandmother: died at ___ of unknown cause\n \nPhysical Exam:\nOn admission\n___: Well-developed, well-nourished elderly white woman in \nNAD. Mood, affect\nappropriate.\nVITALS: 24 HR Data (last updated ___ @ 2358) Temp: 97.8 (Tm \n97.8), BP: 96/66 (96-104/66-69), HR: 85 (85-91), RR: 17, O2 sat: \n93% (93-95), O2 delivery: Ra, Wt: 180.11 lb/81.7 kg\nHEENT: NCAT. Sclera anicteric. EOMI.\nNECK: Supple with JVP elevated to midneck at 45 degrees\nCARDIAC: RRR, normal S1, S2. ___ systolic ejection murmur at \nRUSB\nLUNGS: Resp were unlabored, no accessory muscle use. No \ncrackles, wheezes or rhonchi.\nABDOMEN: Soft, non-tender, not distended. No HSM or tenderness.\nEXTREMITIES: Warm and well perfused, trace edema bilaterally\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES: Distal pulses palpable and symmetric\n\nAt discharge\n___: Well developed, well nourished, in NAD. Oriented x3. \nMood, affect appropriate.\n___ 1117 Temp: 98.2 PO BP: 92/50 L Sitting HR: 85 RR: 17 O2 \nsat: 94% O2 delivery: RA\nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.\nNECK: Supple. JVP non-elevated at 45 degrees\nCARDIAC: Normal rate, regular rhythm. Faint systolic murmur at \nRUSB. Distant heart sounds.\nLUNGS: CTAB--no rales/crackles. \nABDOMEN: Soft, non-tender, not distended. No palpable \nhepatomegaly or splenomegaly.\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Left \narm slightly edematous vs. Right. No pedal edema.\nSKIN: erythema of trunk and extremities, no edema \nPULSES: Distal pulses palpable and symmetric.\n \nPertinent Results:\n___ 09:50PM BLOOD WBC-8.6 RBC-3.29* Hgb-11.4 Hct-35.1 \nMCV-107* MCH-34.7* MCHC-32.5 RDW-12.8 RDWSD-50.0* Plt ___\n___ 09:50PM BLOOD ___ PTT-46.7* ___\n\n___ 09:50PM BLOOD Glucose-115* UreaN-13 Creat-1.2* Na-140 \nK-3.3* Cl-100 HCO3-23 AnGap-17\n___ 09:50PM BLOOD Calcium-9.0 Phos-3.5 Mg-1.6\n___ 09:50PM BLOOD ALT-16 AST-34 CK(CPK)-53 AlkPhos-56 \nTotBili-0.9\n___ 09:50PM BLOOD CK-MB-3 cTropnT-0.03* ___\n\nECG ___ 21:22:02\nSinus rhythm with 1st degree AV delay. Left axis deviation. Left \nbundle branch block. Abnormal EC. GWhen compared with ECG of \n___ 08:40,PR interval has increased. Left bundle branch \nblock is now present.\n\nECG ___ 09:14:03\nProbable A sensing V pacing. When compared with ECG of \n___ 17:35, (Unconfirmed), Sinus rhythm has replaced \nElectronic atrial pacemaker. T wave amplitude has decreased in \nLateral leads\n\nCXR ___\n In comparison with the prior study a right lower lobe \nparahilar consolidation has developed in the interval. Left \nhemidiaphragm obscuration with retrocardiac opacification is \nstable in appearance, a superimposed consolidation cannot be \nruled out.\n Hilar congestion with engorged pulmonary vasculature although \nresolved in the ___ study has developed again, however, \nthis could also be merely due to reduced lungs volume in the \npresent study. Stable cardiomediastinal silhouette. The \nleft-sided central line has been removed in the interval.\nIMPRESSION:\n Right lower lobe parahilar developing consolidation could \npotentially represent an infectious process, however, given the \nlimitations of the chest radiograph, pulmonary embolism cannot \nbe ruled out and if clinically suspected, assessment with a \nseparate CT angiography is recommended.\n Left lower lung volume loss with associated pleural effusion \nis stable in appearance, superimposed consolidation cannot be \nruled out.\n Hilar congestion and engorged pulmonary vasculature could \nreflect underlying pulmonary edema, however, this could be \nmerely representation of the reduced lung volumes. \n\nTAVR ___\nLotus Edge 27mm TAVR using Sentinel cerebral protection, \ncomplicated by complete heart block with junctional escape \nrhythm in the ___ but with AV dissociation, treated with \ntemporary transvenous pacing.\n\nEchocardiogram ___\nThere is normal left ventricular wall thickness with a normal \ncavity size. There is suboptimal image quality to assess \nregional left ventricular function. Overall left ventricular \nsystolic function is depressed. Quantitative biplane left \nventricular ejection fraction is 33 % (normal 54-73%).The right \nventricle has depressed free wall motion. There is abnormal \nseptal motion c/w conduction abnormality/paced rhythm. There is \na small to moderate, echodense, circumferential pericardial \neffusion generally measuring no more than 0.6 cm in greatest \ndimension. In one subcostal clip up to 1.6 cm of fluid is seen \nanterior to the free wall of the proximal right ventricle. No \nRA/RV invagination or collapse to suggest tamponade physiology. \nThere is no right atrial systolic or right ventricular diastolic \ncollapse, suggesting absence of tamponade physiology.\nIMPRESSION: Small-moderate echodense, circumferential \npericardial effusion (although generally very small to small) \nwithout echocardiographic evidence of tamponade. Depressed \nbiventricular systolic function. Compared with the prior TTE, \nthere is no obvious change seen, but the suboptimal image \nquality/limited views of the studies precludes definitive \ncomparison\n\nTEE ___\nPre-TAVR: Overall left ventricular systolic function is moderate \nto severely depressed. The right ventricle has depressed free \nwall motion. Aortic valve stenosis is present (not quantified). \nThere is mild [1+] aortic regurgitation. There is mitral \nregurgitation (cannot be qualified). There is mild [1+] \ntricuspid regurgitation. Due to acoustic shadowing, the severity \nof tricuspid regurgitation may be UNDERestimated. There is a \nvery small pericardial effusion. Bilateral pleural effusions are \npresent.\nPOST-PROCEDURE: The Lotus Edge TAVR with leaflets not well seen \nbut normal gradient. There is a paravalvular jet of trace aortic \nregurgitation is seen. The effusion may be slightly larger \nalthough many more images with alternative angles used post \nimplant so cannot be directly compared. Compared with the prior \nTTE(images reviewed) of ___, the pericardial effusion is \nslightly larger. TAVR now present\n\nEchocardiogram ___\nOverall left ventricular systolic function is depressed. The \nright ventricle has depressed free wall motion. A Lotus Edge \naortic valve bioprosthesis is present. Due to acoustic \nshadowing, the severity of tricuspid regurgitation may be \nUNDERestimated. There is a small circumferential pericardial \neffusion. There are no 2Dor Doppler echocardiographic evidence \nof tamponade. Bilateral pleural effusions are present. Ascites \nis seen.\nIMPRESSION: Small circumferential pericardial effusion without \ntamponade. Pacing wire placed in the RV free wall and is seated \ndeeply in the myocardium ? through it. Compared with the prior \nTTE(images reviewed) of ___, looking back across echos \nfrom the Pre-TAVR to now, it is hard to say that there has been \na significant change in the size of the effusion. The pre-TAVR \necho had limited images. The post TAVR echo suggests there could \nbe slightly more fluid, but many more images taken highlighting \nthe effusion. The current study is similar to the post TAVR \nstudy and looking back the temporary pacing wire placement was \nseen int he RV free wall on the post TAVR echo (not noted in the \nreport).\n\nCXR ___\nThe size of the cardiac silhouette is enlarged but unchanged. A \nnew a temporary pacing wire is seen overlying the medial left \nlower hemithorax, possibly in the region of the tricuspid valve \nor upper right ventricle. There is no pneumothorax identified. \nPulmonary edema is increased since prior as well as retrocardiac \nopacification and bilateral pleural effusions, left greater than \nright. A TAVR is present.\n\nEchocardiogram ___\nThe estimated right atrial pressure is ___ mmHg. Quantitative \nbiplane left ventricular ejection fraction is 27 % (normal \n54-73%).Due to acoustic shadowing, the severity of tricuspid \nregurgitation may be UNDERestimated. There is a small-moderate, \nechodense circumferential pericardial effusion, measuring up to \n1.4 cm anterior to the proximal free wall of the right ventricle \nin the subcostal view, but generally up to only 0.6 cm of \npericardial fluid is seen at end diastole. There is no right \natrial systolic or right ventricular diastolic collapse, \nsuggesting absence of tamponade physiology.\nIMPRESSION: Small-moderate (although generally very small to \nsmall), circumferential, echodense pericardial effusion without \nechocardiographic evidence of tamponade physiology. Compared \nwith the prior ___, there is no obvious change, but \nthe suboptimal image quality of the studies precludes definitive \ncomparison\n\nEchocardiogram ___\nThere is suboptimal image quality to assess regional left \nventricular function. Overall left ventricular systolic function \nis moderate to severely depressed. The visually estimated left \nventricular ejection fraction is 30%.Due to acoustic shadowing, \nthe severity of tricuspid regurgitation may be UNDERestimated. \nThere is a small to moderate circumferential pericardial \neffusion. There is no right atrial systolic or right ventricular \ndiastolic collapse, suggesting absence of tamponade physiology.\nIMPRESSION: Small to moderate pericardial effusion \n(predominantly very small to small (0.6cm) with up to 1.3 cm \nanterolateral to the left ventricle in the apical 4-chamber \nview) without echocardiographic signs of tamponade physiology. \nDepressed left ventricular systolic function. Compared with the \nprior ___, a catheter/pacing wire is no longer \nappreciated in the right ventricle. The pericardial effusion \nsize/distribution is similar.\n\nCXR ___\nComparison to ___. The patient has received the \nnew left pectoral pacemaker. The position of the generator is \nunremarkable. 1 lead projects over the right atrium and 1 over \nthe right ventricle. The temporary previously-seen pacemaker has \nbeen removed. Pre-existing pulmonary edema is completely \nresolved. Moderate cardiomegaly persists. Also persistent is a \nrelatively extensive left lower lobe atelectasis. No pneumonia.\n\nEchocardiogram ___\nThe left atrial volume index is normal. There is no evidence for \nan atrial septal defect by 2D/color Doppler. The estimated right \natrial pressure is >15mmHg. There is mild symmetric left \nventricular hypertrophy with a borderline increased/dilated \ncavity. There are moderate to extensive areas of severe regional \nleft ventricular systolic dysfunction with hypokinesis to \nakinesis of the mid to distal ventricle (see schematic) and \npreserved/normal contractility of the remaining segments. No \nthrombus or mass is seen in the left ventricle. Overall left \nventricular systolic function is moderate to severely depressed. \nQuantitative 3D volumetric left ventricular ejection fraction is \n33 % (normal 54-73%). Left ventricular cardiac index is normal \n(>2.5 L/min/m2). Global longitudinal strain is depressed (-7%; \nnormal less than -20%) There is no resting left ventricular \noutflow tract gradient. Normal right ventricular cavity size \nwith mild global free wall hypokinesis. Tricuspid annular plane \nsystolic excursion(TAPSE) is depressed. The aortic sinus \ndiameter is normal for gender with mildly dilated ascending \naorta. The aortic arch is mildly dilated with a normal \ndescending aorta diameter. A Lotus Edge aortic valve \nbioprosthesis is present. The prosthesis is well seated with \nnormal leaflet motion and gradient. There is a paravalvular jet \nof mild [1+] aortic regurgitation. The mitral valve leaflets are \nmildly thickened with no mitral valve prolapse. There is mild \n[1+] mitral regurgitation. The pulmonic valve leaflets are \nnormal. The tricuspid valve leaflets appear structurally normal. \nThere is mild [1+] tricuspid regurgitation. Due to acoustic \nshadowing, the severity of tricuspid regurgitation may be \nUNDERestimated. The estimated pulmonary artery systolic pressure \nis normal. There is a small circumferential pericardial \neffusion. The effusion is echo dense, c/w blood, inflammation or \nother cellular elements. There are no 2D or Doppler \nechocardiographic evidence of tamponade. Bilateral pleural \neffusions are present.\nIMPRESSION: Well seated, normal functioning TAVR with normal \ngradient and mild paravalvular aortic regurgitation. Mild \nsymmetric left ventricular hypertrophy with mildly dilated LV \ncavity and regional systolic dysfunction most consistent with \nmultivessel coronary artery disease, with moderately reduced \nejection fraction and depressed global longitudinal strain. \nMildly dilated thoracic aorta. Mild mitral and tricuspid \nregurgitation. Small pericardial effusion and bilateral pleural \neffusions.\nCompared with the prior TTE(images reviewed) of ___, the \nfindings are similar.\n\nEchocardiogram ___\nThe left atrium is elongated. The right atrium is mildly \nenlarged. The estimated right atrial pressure is10-15 mmHg. \nThere is moderate symmetric left ventricular hypertrophy with a \nnormal cavity size. There is moderate global left ventricular \nhypokinesis. The apex is aneurysmal. Quantitative biplane left \nventricular ejection fraction is 26 % (normal 54-73%).Normal \nright ventricular cavity size with focal hypokinesis of the \napical free wall. There is a normal descending aorta diameter. A \nLotus Edge aortic valve bioprosthesis is present. The prosthesis \nis well seated with normal gradient. The effective orifice area \nindex is normal (>=0.85 cm2/m2). There is a paravalvular jet of \nmild [1+] aortic regurgitation. The mitral valve leaflets are \nmildly thickened. There is moderate mitral annular \ncalcification. There is mild [1+] mitral regurgitation. Due to \nacoustic shadowing, the severity of mitral regurgitation could \nbe UNDERestimated. The tricuspid valve leaflets appear \nstructurally normal. There is mild [1+] tricuspid regurgitation. \nDue to acoustic shadowing, the severity of tricuspid \nregurgitation may be UNDERestimated. The estimated pulmonary \nartery systolic pressure is normal. There is a small to moderate \npericardial effusion most prominent anterior to the RA/RV \njunction. There are no 2D or Doppler echocardiographic evidence \nof tamponade. A left pleural effusion is present.\nIMPRESSION: Suboptimal image quality. Symmetric left ventricular \nhypertrophy with normal cavity size and apical \naneurysm/dysfunction with moderate hypokinesis of other \nsegments. The basal anterior and anterolateral walls contract \nbest. Small-moderate circumferential pericardial effusion \nwithout echocardiographic evidence for tamponade physiology. \nWell seated, normal functioning Lotus Edge TAVR with normal \ngradient and mild paravalvular aortic regurgitation. Compared \nwith the prior TTE (images reviewed) of ___, the left \nventricular systolic function is now more reduced. The \npericardial effusion and other findings are similar.\n\nDISCHARGE LABS\n___ 06:19AM BLOOD WBC-4.9 RBC-2.81* Hgb-9.6* Hct-29.8* \nMCV-106* MCH-34.2* MCHC-32.2 RDW-12.8 RDWSD-50.1* Plt ___\n___ 06:19AM BLOOD Glucose-87 UreaN-8 Creat-0.9 Na-141 K-4.2 \nCl-104 HCO3-24 AnGap-13\n___ 06:19AM BLOOD Calcium-9.3 Phos-3.2 Mg-1.___ with H/O non-ischemic cardiomyopathy HFrEF (LVEF 31%; no CAD \non coronary angiogram ___, severe aortic stenosis, \nparoxysmal atrial fibrillation on apixiban (CHADS2VASc 5), \nhypertension, hyperlipidemia, and esophageal dissection s/p \nclipping who presented with acute decompensated heart failure. \nFollowing diuresis, she underwent Lotus TAVR placement \ncomplicated by complete heart block. She had a transvenous \npacing electrode placed complicated by RV puncture and \npolymorphic VT arrest with ROSC. The patient had a dual-chamber \nPPM placed ___.\n\nACUTE ISSUES: \n# Severe AS (peak velocity 4.8, peak gradient 92, mean gradient \n53, valve area 0.9): Patient with severe aortic stenosis and \npossible resultant systolic dysfunction. She had a Lotus Edge \n27mm LIS TAVR placed ___ with improved gradients and no \nconcern for paravalvular leak with mild aortic regurgitation \n(peak velocity 4.3->1.5, peak gradient 74->9, mean gradient \n49->6). Procedure was complicated by complete heart block \ntreated with venous pacing (see below). She was continued on ASA \n+ clopidogrel and will discontinue clopidogrel after two weeks \nand start apixaban with continued aspirin thereafter (assuming \nstable pericardial effusion).\n \n# CHB s/p dual-chamber PPM placement in setting of prior LBBB \nand AV delay: Patient developed CHB after Lotus TAVR deployment \nafter TAVR (in setting of underlying conduction disease with \nLBBB and PR prolongation). She had a temporary transvenous \npacing electrode placed, complicated by right ventricular \npuncture. She then had polymorphic VT arrest with ROSC. \nDual-chamber permanent pacemaker placed ___. Post procedure \nechocardiogram revealed small-moderate pericardial effusion (0.6 \ncm) on ___. Echo on ___ showed effusion was unchanged and \nrepeat echocardiogram on ___ showed small-moderate effusion \nwithout evidence of tamponade physiology. She remained stable \nwithout evidence of tamponade. Apixiban resumption was deferred \nfor at least 2 weeks as above. \n\n# Polymorphic VT arrest iso long QT: Patient with long-QT in \nsetting of relative bradycardia with pacer rate set at 60, and \nsignificant ectopy with PVCs/bigeminy. SHe had R on T phenomenon \nand resultant polymorphic VT. She required one round of CPR, one \nshock at 200 J, and one dose of epinepherine before achieving \nROSC. After pacer rate increased to 100, had 100% ventricular \npacing again. Dual-chamber PPM placed ___.\n\n# Non-ischemic HFrEF (LVEF 33%): Patient initially volume \noverloaded on admission, now s/p successful IV diuresis. \nPost-TAVR echocardiogram on ___ showed LVEF of 33% (vs 31% \nbefore), moderate to extensive areas of severe regional LV \nsystolic dysfunction with hypokinesis to akinesis of mid to \ndistal left ventricle. She was transitioned to PO furosemide, \nhowever, furosemide was discontinued ___ due to seeming \neuvolemic status and started on spirolactone 12.5 mg for \ncardioprotective effects. This was continued upon discharge. \n\n# New Erythematous Rash: After pacemaker placement on ___, \npatient developed truncal rash, which expanded to all four \ndistal extremities with edema, not associated with pain, \nitching, or fever that was present during the amiodarone \nreaction during previous admission. Suspected reaction to \n___ antibiotics (Vancomycin and cefazolin). These \nimproved with sarna and diphenhydramine. \n\nCHRONIC ISSUES: \n# CKD: Baseline Cr around 1.1-1.3, stable. \n\n# Paroxsymal atrial fibrillation (CHADS2VASc 5): During last \nadmission, patient developed atrial fibrillation with rapid \nventricular rates to 130-140, subsequently converted to sinus \nafter adenosine, amiodarone, diltiazem, and digoxin. She was \ndischarged on amiodarone, however this was subsequently \ndiscontinued as an outpatient due to rash. She presented in NSR. \nApixaban was held for two weeks in setting of pericardial \neffusion.\n\nTRANSITIONAL ISSUES\nDischarge Wt: 177.25 lb\nDischarge Cr: 0.9\nDischarge diuretic: Spironolactone 12.5 mg PO DAILY \n\n[] TTE in two weeks to monitor pericardial effusion. At that \ntime, can start apixaban if no worsening of pericardial effusion \nand discontinue clopidogrel (per structural cardiology team)\n[] lab check (BMP w Cr, K+) on ___\n[] Patient should be referred to outpatient cardiac \nrehabilitation \n[] Continue incentive spirometry\n[] Please monitor volume status and adjust diuretic accordingly\n[] Please check CBC within 1 week to follow up hemoglobin \n[] Please weigh patient and perform vital signs check at nursing \nvisits\n[] Patient developed full body rash while taking amiodarone. \nThis drug should be avoided in the future. \n\n# CODE: Full code\n# CONTACT/HCP: \n___ ___ (cell) \n___ ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Apixaban 5 mg PO BID \n2. Furosemide 20 mg PO DAILY \n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Clopidogrel 75 mg PO/NG DAILY \n3. Lisinopril 2.5 mg PO DAILY \n4. Metoprolol Succinate XL 12.5 mg PO DAILY \n5. Spironolactone 12.5 mg PO DAILY \n6. HELD- Apixaban 5 mg PO BID This medication was held. Do not \nrestart Apixaban until 2 weeks (due to fluid around heart)\n7.Outpatient Lab Work\nI35.0\n\nPlease obtain creatinine, potassium and fax results to Dr. \n___ at ___\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n-Aortic stenosis, severe\n-Transcatheter aortic valve replacement complicated by\n-Complete heart block, complicated by\n-Polymorphic ventricular tachycardia cardiac arrest\n-Prolonged QT interval\n-Pericardial effusion\n-Permanent dual chamber pacemaker implantation\n-Paroxysmal atrial fibrillation\n-Acute on chronic left ventricular systolic and diastolic heart \nfailure with reduced ejection fraction\n-Rash attributed to vancomycin and/or cefazolin\n-Prior rash attributed to amiodarone\n-Chronic Kidney Disease stage 3\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 the ___ \n___! \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n- You were admitted because of shortness of breath \n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- You were admitted to the hospital because you had been \nfeeling short of breath and you were found to have fluid in your \nlungs. This was felt to be due to a condition called heart \nfailure, where your heart does not pump hard enough and fluid \nbacks up into your lungs. You were given a diuretic medication \nthrough the IV to help get the fluid out. You were also found to \nhave a valve in your heart that was narrow (Aortic valve). You \nunderwent a procedure to repair the valve\n- You were also found to have an abnormal rhythm and fluid \naround your heart. A pacemaker was placed to help your heart \nbeat normally and the fluid around your heart was monitored with \nserial ultrasounds. \n- Your medication furosemide (or lasix) was discontinued and you \nwere started on a different diuretic (spironolactone)\n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Be sure to take all your medications and attend all of your \nappointments listed below. \n- Your weight at discharge is 177.25 lb. Please weigh yourself \ntoday at home and use this as your new baseline \n- Please weigh yourself every day in the morning. Call your \ndoctor if your weight goes up or down by more than 3 pounds in a \nday or 5 pounds in a week. \n-Do not stop taking your aspirin or clopidogrel (also known as \nPlavix) unless told to do so by your cardiologist\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I468", "I5043", "I21A1", "I442", "I313", "I9751", "T85628A", "I97790", "I083", "I447", "Y838", "Y92234", "L270", "T361X5A", "T368X5A", "I4581", "Z7901", "Z006", "I480", "Y738", "N183", "Y711" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I468: Cardiac arrest due to other underlying condition", "I5043: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure", "I21A1: Myocardial infarction type 2", "I442: Atrioventricular block, complete", "I313: Pericardial effusion (noninflammatory)", "I9751: Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure", "T85628A: Displacement of other specified internal prosthetic devices, implants and grafts, initial encounter", "I97790: Other intraoperative cardiac functional disturbances during cardiac surgery", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I447: Left bundle-branch block, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "T361X5A: Adverse effect of cephalosporins and other beta-lactam antibiotics, initial encounter", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "I4581: Long QT syndrome", "Z7901: Long term (current) use of anticoagulants", "Z006: Encounter for examination for normal comparison and control in clinical research program", "I480: Paroxysmal atrial fibrillation", "Y738: Miscellaneous gastroenterology and urology devices associated with adverse incidents, not elsewhere classified", "N183: Chronic kidney disease, stage 3 (moderate)", "Y711: Therapeutic (nonsurgical) and rehabilitative cardiovascular devices associated with adverse incidents" ]

[ "I130", "Z7901", "I480" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest pain & SOB\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ Hx HTN, HLD, esophageal dissection s/p clipping, aortic\nstenosis(followed by outside cardiology, ___ with\nplanned cardiac cath in ___ and referral for TAVR, who\npresented to OSH ED with 1 week hx of increasing substernal \nchest\npain and SOB, found to be in Afib with RVR, transferred here for\nmanagement of acute systolic HF and ACS. \n\nIn the OSH, she reported intermittent chest pain that worsens on\nexertion and lying down and was associated with weakness,\nfatigue, & diaphoresis. She denies palpitations, SOB, n/v, ___\nedema. She was found to be in Afib with RVR 140s-150s, SBP\n80-100s. EKG showed + ischemic changes, and she received given\nASA 325mg, Adenosisine 6mg and 12mg, Digoxin 500mcg, Diltiazem\ngtt 10mg/hr, and calcium gluconate 1mg. She was then transferred\nto the ICU and given Verapamil 5mg, another dose of Digoxin 250,\nIV amiodarone bolus 150mg followed by 1mg/min gtt. She then\nconverted to sinus rhythm with LVH and ST depressions laterally\non EKG. She was given morphine 2mg x2 for pain and was started \non\nIV heparin gtt. A bedside TTE showed LVEF <20%, akinetic \nanterior\nwall and global hypokinesis. Troponins were 5.07->6.240. She\ncontinues to have persistent chest pain.\n\nOn transfer, \n - Initial vitals were: T 98.0 HR 88 BP 94/65 RR 34 99% ___ NC\n - Exam notable for: tachycardic, irregularly irregular rate,\nnormal S1, S2; access: left subclavian TLC\n - Labs notable for: \n - BMP: BUN 17 Cr 1.09 \n - CBC: WBC 9.2 Hgb 13.3 Plt 176\n - coags: PTT 43.8 (pre heparin), INR 1.18\n - LFTs: AST 90 ALT 36 tbili 1.9\n - troponins: 5.07->6.240\n - Studies notable for: \n - CXR: bilateral lung opacities. interstitial and patchy\nopacities consistent with CHF and pulmonary edema\n - EKG: NSR with LVH, STD in lateral leads, prelim\ncritical AS\n - TTE: LVEF <20%, mild concentric LVH, akinetic \nanterior\nwall and global hypokinesis, severe AS, mild MR with mod ___, dilated IVC, mild pulm HTN, trace TR, normal RV\n - AS grading: LVOT peak velocity 75.5cm/s, mean \nvelocity\n52.8cm/s, peak gradient 2mmHg, mean gradient 1mmHg\n - Patient was given: 2 mg morphine IV x 2, IV heparin at 15 \nunits/kg/hr (awaiting first PTT), ASA 325mg x 1, Amiodarone gtt\n(bolus150mg x 1 now 1mg/hr up at 1500), Dilt 10mg/hr IV stopped\n1600, 250mcg IV digoxin x1 at 1400, 5mg IV Verapamil x 1 at \n1400,\n0.5mg IV Ativan plus and 1mg IV Ativanat 1530, IN ED 1gram\ncalcium gluconate, 500mcg IV digoxin, Adenosine x 2 (6mg and\n12mg)\n\n On arrival to the CCU, she confirms the above history. She\nreports she is still in ___ chest pain but denies SOB,\npalpitations, cough, ___ edema. She is also complaining of her\nchronic low back pain. Additionally, she denies recent falls,\nsyncope, or lightheadedness. She sustained a fall ___ ago when \nshe\n\"got up too quickly\" and syncopized. \n\n \nPast Medical History:\n - HTN\n - HLD\n - Known severe AS\n - Esophageal rupture s/p endoscopic clipping\n - OA\n - Endometrial polyps\n - Cholecystectomy\n \nSocial History:\n___\nFamily History:\n- no family history of cancer, heart disease\n- Father: died of alcohol use\n- Mother: died in ___\n- Grandmother: died at ___ of unknown cause\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\n VS: T98.3 HR 75 BP 100/66 RR 21 SpO2 99%\n GENERAL: Well developed, well nourished in NAD. Oriented x3.\nMood, affect appropriate. \n HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. \nEOMI.\n NECK: Supple. JVP elevated to mid neck at 45 degrees. \n CARDIAC: Normal rate, regular rhythm. LUSB ___ systolic \nejection\nmurmur. No gallop or rub.\n LUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. Crackles present\nbilaterally to mid lung fields. No wheezes or ronchi.\n ABDOMEN: Soft, non-tender, non-distended. No palpable\nhepatomegaly or splenomegaly. \n EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. \n SKIN: No significant lesions or rashes. \n PULSES: Distal pulses palpable and symmetric. Radial pulses 2+. \n\n NEURO: AOx3 \n\nDISCHARGE PHYSICAL EXAM:\n========================\n VS: Reviewed in OMR\n GENERAL: Well developed, well nourished in NAD. Oriented x3.\nMood, affect appropriate. \n HEENT: Normocephalic, atraumatic. Sclera anicteric. EOMI.\n NECK: Supple. JVP at level of clavicle. \n CARDIAC: Normal rate, regular rhythm. LUSB ___ systolic \nejection\nmurmur. No gallop or rub.\n LUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. Crackles present at \nbases\nbilaterally to mid lung fields. No wheezes or ronchi.\n ABDOMEN: Soft, non-tender, non-distended. No palpable\nhepatomegaly or splenomegaly. \n EXTREMITIES: Warm, well perfused. 1+ peripheral edema. \n SKIN: No significant lesions or rashes. \n PULSES: Distal pulses palpable and symmetric. Radial pulses 2+. \n\n NEURO: AOx3\n \nPertinent Results:\nADMISSION LABS:\n___ 09:08PM LACTATE-0.8\n___ 09:01PM GLUCOSE-146* UREA N-17 CREAT-0.9 SODIUM-136 \nPOTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-19* ANION GAP-13\n___ 09:01PM estGFR-Using this\n___ 09:01PM ALT(SGPT)-24 AST(SGOT)-71* LD(LDH)-362* \nCK(CPK)-237* ALK PHOS-50 TOT BILI-1.2\n___ 09:01PM CK-MB-19* MB INDX-8.0* cTropnT-0.85*\n___ 09:01PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.1 \nMAGNESIUM-1.8\n___ 09:01PM WBC-9.0 RBC-3.22* HGB-11.7 HCT-34.9 MCV-108* \nMCH-36.3* MCHC-33.5 RDW-12.4 RDWSD-49.3*\n___ 09:01PM NEUTS-76.5* LYMPHS-11.7* MONOS-11.2 EOS-0.0* \nBASOS-0.3 IM ___ AbsNeut-6.90* AbsLymp-1.06* AbsMono-1.01* \nAbsEos-0.00* AbsBaso-0.03\n___ 09:01PM PLT COUNT-132*\n___ 09:01PM ___ PTT-150* ___\n\nKEY INTERVAL LABS:\n___ 03:41AM BLOOD ALT-22 AST-65* AlkPhos-47 TotBili-1.5\n___ 05:42AM BLOOD ALT-17 AST-36 AlkPhos-54 TotBili-1.1\n___ 09:01PM BLOOD CK-MB-19* MB Indx-8.0* cTropnT-0.85*\n___ 03:41AM BLOOD CK-MB-17* cTropnT-1.12*\n___ 10:43AM BLOOD CK-MB-13* cTropnT-1.00*\n___ 03:41AM BLOOD ___ PTT-105.2* ___\n___ 06:30PM BLOOD TSH-5.8*\n___ 06:30PM BLOOD Free T4-1.4\n\nKEY REPORTS:\n___: CXR Portable AP\nLeft subclavian central venous catheter terminates in the \nsuperior vena cava. Lung volumes are low. Heart appears mildly \nenlarged. Azygos vein is perhaps distended. Each hilum shows \nperihilar opacification in the context of a more generalized \nmild interstitial abnormality. This is consistent with \ncongestive heart failure. Left basilar opacification is a \ntypical site for atelectasis and may also involve a small \npleural effusion. Small pleural effusion is not excluded on the \nright. No visible pneumothorax. \n\n___: Coronary angiogram\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. The Diagonal, arising from the \nproximal segment, is a medium caliber vessel.\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel. The ___ Obtuse Marginal, arising from the \nproximal segment, is a medium caliber vessel. The ___ Obtuse \nMarginal, arising from the mid segment, is a medium caliber \nvessel.\nRCA: The Right Coronary Artery, arising from the right cusp, is \na large caliber vessel. The Right Posterior Descending Artery, \narising from the distal segment, is a medium caliber vessel.\n\n___: CXR Portable AP\nComparison to ___. Pre-existing signs of centralized \npulmonary \nedema have resolved. There is now a small left pleural effusion \nwith \nsubsequent left retrocardiac atelectasis. Moderate cardiomegaly \npersists. Correct position of the left central venous access \nline. No pneumonia, no pneumothorax. \n\n___: Transthoracic Echo\nThe left atrial volume index is moderately increased. There is \nno evidence for an atrial septal defect by 2D/color Doppler. The \nestimated right atrial pressure is ___ mmHg. There is focal \nnon-obstructive hypertrophy\nof the basal septum with a SEVERELY increased/dilated cavity. \nThere are moderate to extensive areas of severe regional left \nventricular systolic dysfunction with akinesis of the distal ___ \nof the ventricle (see\nschematic) and preserved/normal contractility of the remaining \nsegments. No thrombus or mass is seen in the left ventricle. \nQuantitative biplane left ventricular ejection fraction is 31 % \n(normal 54-73%). There\nis no resting left ventricular outflow tract gradient. No \nventricular 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. The aortic sinus is mildly dilated with mildly \ndilated ascending aorta. There is a normal descending aorta \ndiameter. The abdominal aorta diameter is normal. There is no \nevidence for an aortic arch coarctation. The aortic valve \nleaflets are severely thickened. There is SEVERE aortic valve \nstenosis (valve area 1.0 cm2 or less). There is trace aortic \nregurgitation. The mitral valve leaflets appear structurally \nnormal with no mitral valve prolapse. There is mild to moderate \n[___] mitral regurgitation. The pulmonic valve leaflets are \nnormal. The tricuspid valve leaflets appear structurally normal. \nThere is mild to moderate [___] tricuspid regurgitation. There \nis moderate pulmonary artery systolic hypertension. There is a \ntrivial pericardial effusion. A left pleural effusion is \npresent.\nIMPRESSION: Mild basal septal hypertrophy with severe cavity \ndilation and severe regional systolic dysfunction most c/w \n___'s cardiomyopathy though an LAD lesion cannot be fully \nexcluded. Increased PCWP. Normal right ventricular cavity size \nand systolic function. Severe trileaflet calcific aortic \nstenosis. Mild to moderatoe mitral regurgitation. Mild to \nmoderate tricuspid regurgitation. Moderate pulmonary artery \nsystolic hypertension.\n\nMICROBIOLOGY: None\n\nDISCHARGE LABS: \n___ 03:15AM BLOOD WBC-5.2 RBC-2.79* Hgb-10.0* Hct-29.6* \nMCV-106* MCH-35.8* MCHC-33.8 RDW-12.3 RDWSD-48.3* Plt ___\n___ 04:47AM BLOOD PTT-84.5*\n___ 04:47AM BLOOD Glucose-107* UreaN-11 Creat-1.0 Na-139 \nK-4.3 Cl-99 HCO3-23 AnGap-17\n___ 04:47AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.___RIEF HOSPITAL COURSE:\n___ Hx HTN, HLD, esophageal dissection s/p clipping, aortic \nstenosis(followed by cardiology, ___ with planned \ncardiac cath in ___ and referral for TAVR, who presented \nto OSH ED with 1 week hx of increasing intermittent substernal \nchest pain and SOB, found to be in Afib with RVR with new \nHFrEF<20%, transferred here for management of NSTEMI c/b acute \nHFrEF & afib w/ RVR in the context of severe AS. She was started \non rhythm control therapy and anticoagulation for her afib and \ndiuresed until euvolemic. She also received a CT scan for her \nupcoming TAVR. \n\n ACUTE ISSUES: \n ============= \n#NSTEMI c/b acute HFrEF (<20%)\n#Hypotension\nTropI at OSH 6.240, tropT 0.85 here. ECG with diffuse ST\ndepressions. No ST elevations. S/p ASA 325mg at OSH, transferred \non hep gtt.\nUnknown prior baseline EF, OSH TTE EF<20% w/ akinetic anterior \nwall and global hypokinesis. Hypervolemic on exam w/ pulm edema \non CXR. Plavix not given. Diuresed with Lasix with good response \nand became euvolemic over the next 2 days. Did not tolerate \nmetoprolol d/t asymptomatic hypotension. Given HFrEF with clean \ncoronaries, ASA/Atorvastatin not indicated. \nTx:\n- F/u with outpatient cardiologist about starting HF meds (BB, \nACE-I, etc)\n-Initially given statin and Aspirin, though no longer indicated. \n\n\n# Afib with RVR\nOn presentation HR 130-140, now converted to sinus s/p \nadenosine, amio, dilt, and digoxin. Maintained in sinus rhythm \nwith HR ___ on amio gtt, now transitioned to PO. \nTx:\n- Amiodarone 200mg TID, amiodarone 200 QD starting ___\n- Transition to apixaban 5mg BID\n\n# Severe AS\nPreviously identified. Was planning on TAVR eval in ___ with\noutpatient cardiologist Dr. ___. Not a SAVR candidate due to \nhigh risk per c-surg. Structural team to arrange TAVR. Spoke to \nstructural cardiology, OK to d/c on DOAC with plan for \noutpatient TAVR. TAVR CT performed on day of discharge prior to \nsurgery, result pending on DC. \nTx:\n- f/u as outpatient structural heart team for TVAR \n- workup: dental clearance\n\n#Rash\nNoted to have rash on back, possibly ___ contact dermatitis. \nPrevious rashes in past responded to Triamcinolone, which was \nstarted prior to DC to continue going forward. \n\n CHRONIC/STABLE ISSUES:\n =====================\n# HTN\n- D/c home losartan 100mg/HCTZ 12.5mg d/t hypotension\n\n TRANSITIONAL ISSUES:\n ====================\n[ ] Follow up with structural cardiology for scheduling of TAVR\n[ ] Needs dental clearance prior to TAVR \n[ ] To continue Amiodarone 200mg TID through ___. Transition to \nAmiodarone 200mg daily on ___\n[ ] Noted to have rash on back/trunk. Treated with \nTriamcinolone. Ensure resolution as outpatient \n[ ] f/u TAVR CT \n[ ] Stopped HCTZ-Losartan given relative hypotension.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY \n\n \nDischarge Medications:\n1. Amiodarone 200 mg PO TID \n2. Apixaban 5 mg PO BID \n\nSTOP:\n3. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nAtrial Fibrillation\nHeart failure with reduced ejection fraction (HFrEF)\nAortic Stenosis\n\n \nDischarge Condition:\nAlert and oriented x3\nAmbulatory, d/c to home with ___\n\n \nDischarge Instructions:\nDISCHARGE INSTRUCTIONS \n ====================== \n Dear ___, \n WHY WERE YOU ADMITTED TO THE HOSPITAL? \n - Abnormal, fast heart rhythm (atrial fibrillation)\n - Heart failure exacerbation\n - Aortic stenosis\n \n WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n You were admitted to the hospital for a fast, irregular \nheart rhythm called atrial fibrillation as well as heart \nfailure. We found that your heart wasn't beating as well as it \nshould be, which caused you to accumulate some fluid in your \nlegs and lungs. We helped you get rid of this extra fluid with \npills that help you pee it out. We also started you on a \nmedication to help your heart rate stay normal and regular. On \nyour last day, we performed a CAT scan of your torso for your \nworkup for TAVR. After monitoring you for several days in the \nhospital and treating your problems, we felt it was safe to \ndischarge you home with continued follow up with your primary \ncare doctor and the structural cardiology team for your upcoming \nTAVR. \n \n WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n - Take all of your medications as prescribed (listed below):\n - Amiodarone 200mg three times daily\n - Apixaban 5mg twice daily \n - Follow up with your doctors as listed below \n - Weigh yourself every morning, seek medical attention if your \nweight goes up more than 3 lbs. \n - Seek medical attention if you have new or concerning symptoms \nor you develop swelling in your legs, abdominal distention, or \nshortness of breath at night. \n Please see below for more information on your hospitalization. \nIt was a pleasure taking part in your care here at ___! \n We wish you all the best! \n - Your ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I110", "I5021", "I214", "E785", "I350", "I482", "Z7901", "I952", "T447X5A", "L259", "M1990", "K219" ]

[ "I110: Hypertensive heart disease with heart failure", "I5021: Acute systolic (congestive) heart failure", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "E785: Hyperlipidemia, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "I482: Chronic atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "I952: Hypotension due to drugs", "T447X5A: Adverse effect of beta-adrenoreceptor antagonists, initial encounter", "L259: Unspecified contact dermatitis, unspecified cause", "M1990: Unspecified osteoarthritis, unspecified site", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "I110", "E785", "Z7901", "K219" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with hx Hep C, polysubstance abuse and ? withdrawal \nseizures vs. PNES presenting after overdose and seizure. EMS was \ncalled after a bystander found him in a car. He was unresponsive \nat that time reportedly. Patient is unable to provide any \nhistory at all history is taken from EMS and outside hospital \nrecords. Reportedly patient received 4 mg of intranasal Narcan \non scene at which time he became alert and responsive. Not long \nafter he became unresponsive again and another 2 mg of IV Narcan \nfailed to change his mental status. At ___ he was \nfound to have a GCS of 7 and there was concern for bilateral \nupper extremity shaking movements with concern for seizure \nactivity. He reportedly arrived with a small bag of pills as \nwell as a white powder with Klonopin and Suboxone tablets in a \nbag. Blood glucose on arrival was 74. Utox + opiates, fentanyl, \ncocaine. He was loaded with a gram of Keppra and intubated for \nairway protection with etomidate and succinylcholine. He also \nreceived 2 doses of rocuronium in the outside hospital ER. \nReported neg NCHCT, cervical spine CT. \n\nOf note, was hospitalized from ___ with concern for \nseizure activity after getting admitted to OSH for w/u of \nabdominal pain. Was treated with a benzo taper for detox, and \nwas transferred to ___ on ___ after had activity concerning \nfor seizure. Per prior neurology notes, has a history of these \nepisodes in the past with many EEGs that have been unrevealing. \nEEG was unrevealing. Felt seizure episodes were nonepileptiform \nin nature. Had planned to discharge to a detox bed, but eloped. \nReturned to the ED later that day with opiate overdose requiring \nnarcan. Was discharged w/ detox placement at ___ \n___. \n \nIn ED initial VS: 97.5 61 148/94 18 100% RA\nExam: Moves all 4 ext vigorously\n\nPatient was given: nothing \n\nImaging notable for: CXR neg, OSH Head CT neg\n\nConsults: neurology\n\nVS prior to transfer: 97.5 61 148/94 18 100% RA \n \nOn arrival to the MICU, patient was intubated and sedated and \nunable to give any history. Attempted to reach patient's mother \nbut listed number is a fax number. \n \nPast Medical History:\n-bipolar disorder h/o suicide attempt\n-hepatitis C (s/p successful treatment with\nHarvoni)\n-Self-reported history of seizure disorder (previously on\nvalproate 500mg BID prescribed by neurologist in CA; has not\ntaken for \"years)\n-Polysubstance abuse - He used to be a heroin addict but he \nstopped \"awhile ago\". In the past has been on methadone and \nsuboxone, unclear if taking currently. Also abuse of cocaine, \nbenzos and etoh in the past. \n \nSocial History:\n___\nFamily History:\nunknown\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVITALS:97.9 72 131/91 22 on CMV, FiO2 50%, Vt 600, PEEP 5 \nGENERAL: sedated, intubated\nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: no rashes noted \nNEURO: sedated, not following commands, however noted to be \nmoving all 4 extremities following commands with nursing on \narrival \n\nDISCHARGE PHYSICAL EXAM:\nVITALS: 97.8 140/85 95 18 98% Ra \nGENERAL: sitting upright in bed, in NAD, \nNECK: supple \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops. no chest tenderness to palpation \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, no clubbing, cyanosis or edema. + \nbilateral fine tremor on outstretched hands bilaterally \nSKIN: no rashes noted \nNEURO: moving all extremities, CN II-XII grossly intact \nbilaterally\n \nPertinent Results:\nADMISSION LABS\n___ 03:48AM BLOOD WBC-7.7 RBC-4.60 Hgb-13.5* Hct-40.5 \nMCV-88 MCH-29.3 MCHC-33.3 RDW-14.4 RDWSD-46.0 Plt ___\n___ 11:10PM BLOOD Neuts-66.6 ___ Monos-7.4 Eos-1.6 \nBaso-0.5 Im ___ AbsNeut-6.35* AbsLymp-2.25 AbsMono-0.71 \nAbsEos-0.15 AbsBaso-0.05\n___ 03:48AM BLOOD Glucose-78 UreaN-13 Creat-1.0 Na-144 \nK-3.7 Cl-110* HCO3-25 AnGap-13\n___ 11:10PM BLOOD ALT-11 AST-16 AlkPhos-56 TotBili-0.5\n___ 03:48AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.1\n___ 11:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 11:37PM BLOOD ___ Rates-18/ PEEP-5 FiO2-50 \npO2-117* pCO2-42 pH-7.38 calTCO2-26 Base XS-0 Intubat-INTUBATED \nVent-CONTROLLED\n___ 11:37PM BLOOD Lactate-1.0\n___ 11:37PM BLOOD O2 Sat-95\n\nPERTINENT/DISCHARGE LABS\n___ 05:55AM BLOOD WBC-9.2 RBC-4.69 Hgb-13.6* Hct-40.8 \nMCV-87 MCH-29.0 MCHC-33.3 RDW-14.5 RDWSD-46.2 Plt ___\n___ 05:55AM BLOOD Glucose-94 UreaN-14 Creat-0.9 Na-141 \nK-3.8 Cl-105 HCO3-23 AnGap-17\n___ 11:10PM BLOOD ALT-11 AST-16 AlkPhos-56 TotBili-0.5\n___ 05:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.9\n___ 09:20AM BLOOD Valproa-38*\n___ 11:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 11:10PM URINE bnzodzp-POS* barbitr-NEG opiates-POS* \ncocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG\n\nMICROBIOLOGY \nUrine culture: No growth\n \nBrief Hospital Course:\nThis is a ___ with HCV and polysubstance abuse who presented \nwith altered mental status and possible seizure activiy \nrequiring intubation in the setting of polysubstance abuse, \noverall most concerning for opiate overdose.\n\n==============\nACTIVE ISSUES \n==============\n#Altered mental status:\n#Polysubstance abuse\nUtox positive for opiates, benzos, cocaine at OSH. Patient \nreports use of heroin/cocaine \"one last time\" before he \npresented to ___ facility which likely explains his \nrespiratory failure. Initiated on ___ protocol while \ninpatient, and had moderate opiate withdrawal symptoms, but did \nnot require benzodiazepines for alcohol withdrawal. Social work \nand substance abuse RN were consulted during his inpatient stay. \nUltimately, decision was made to discharge patient to ___ \n___ facility in ___. \n\n#Respiratory failure: Patient admits to using heroin/fentanyl \nprior to being hospitalized. Intubated at OSH for airway \nprotection. Extubated without issue within 12 hours of admission \nto ICU at ___. Respiratory rate remained stable while he was \non the floor. \n\n#Question of seizure: per report had episode of bilateral upper \nextremity shaking movements at OSH after intubation with concern \nfor seizure. Was given Keppra load at OSH. Patient states that \nhis seizures have been in the setting of withdrawal. However, \nprior history of seizure like episodes thought to be likely \npsychogenic in nature given multiple negative EEGs. Neurology \nservice here recommended restarting home Depakote which patient \nhad been prescribed in past but not taking for the last month. \n(Dual indication with bipolar disorder history.)\n\n#Hepatitis C: per review of chart h/o treatment w. ___ in \nthe past, LFTs normal now\n\n#Bipolar disorder: He reported history of bipolar disorder; on \nbuproprion as an outpatient. Continued BuPROPion (Sustained \nRelease) 150 mg PO BID at this admission.\n\nTRANSITIONAL ISSUES:\n-Pt will be discharged home and will present immediately to ___ \n___ Detox program in ___.\n-Pt provided with Rx for Clonazepam 1mg TID. He reported taking \nhigher doses as an outpatient but we were unable to verify this. \nConsider titration of Clonazepam as indicated.\n-Pt provided with Rx for Narcan nasal spray.\n\nBilling: \n>30 minutes spent coordinating discharge to home\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 1200 mg PO TID \n2. ClonazePAM 2 mg PO BID \n3. ClonazePAM 1 mg PO QHS \n4. Divalproex (EXTended Release) 500 mg PO BID \n5. BuPROPion (Sustained Release) 150 mg PO BID \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. Multivitamins 1 TAB PO DAILY \nRX *multivitamin 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Narcan (naloxone) 4 mg/actuation nasal ONCE:PRN \nFor overdose \nRX *naloxone [Narcan] 4 mg/actuation 1 spray NU ONCE Disp #*1 \nCanister Refills:*0 \n4. 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 \n5. ClonazePAM 1 mg PO TID \nRX *clonazepam 1 mg 1 tablet(s) by mouth three times a day Disp \n#*90 Tablet Refills:*0 \n6. BuPROPion (Sustained Release) 150 mg PO BID \nRX *bupropion HCl [Wellbutrin XL] 150 mg 1 tablet(s) by mouth \ntwice a day Disp #*60 Tablet Refills:*0 \n7. Divalproex (EXTended Release) 500 mg PO BID \nRX *divalproex ___ mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n8. Gabapentin 1200 mg PO TID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY\n=======\nAcute hypoxic respiratory failure\nPolysubstance abuse\nOverdose\nSeizure\nBipolar disorder\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr ___,\n\nIt was a pleasure taking care of you at ___ \n___.\n\nYou were in the hospital after overdosing. You briefly had a \ntube inserted in your throat to breath for you. Once this was \nremoved, we monitored you for withdrawal, but you did not \nrequire medicine for withdrawal.\n\nWhen you leave the hospital, we encourage you to maintain \nsobriety. You may benefit from a Suboxone or Methadone program, \nbut this decision is up to you. You should continue to take your \nsame medications as prescribed. \n\nWe will give you a prescription for Narcan nasal spray. This can \nbe used in case of overdose. \n\nBest wishes,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "T401X1A", "J9601", "T424X1A", "T405X1A", "T404X1A", "R4182", "Y92810", "F1123", "F17210", "F319", "S0990XS", "G629", "F54", "R569", "B1920", "T426X6A", "Y92038", "Z915" ]

[ "T401X1A: Poisoning by heroin, accidental (unintentional), initial encounter", "J9601: Acute respiratory failure with hypoxia", "T424X1A: Poisoning by benzodiazepines, accidental (unintentional), initial encounter", "T405X1A: Poisoning by cocaine, accidental (unintentional), initial encounter", "T404X1A: Poisoning by, adverse effect of and underdosing of other synthetic narcotics", "R4182: Altered mental status, unspecified", "Y92810: Car as the place of occurrence of the external cause", "F1123: Opioid dependence with withdrawal", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F319: Bipolar disorder, unspecified", "S0990XS: Unspecified injury of head, sequela", "G629: Polyneuropathy, unspecified", "F54: Psychological and behavioral factors associated with disorders or diseases classified elsewhere", "R569: Unspecified convulsions", "B1920: Unspecified viral hepatitis C without hepatic coma", "T426X6A: Underdosing of other antiepileptic and sedative-hypnotic drugs, initial encounter", "Y92038: Other place in apartment as the place of occurrence of the external cause", "Z915: Personal history of self-harm" ]

[ "J9601", "F17210" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nseizure like activity\n \nMajor Surgical or Invasive Procedure:\nn/a\n\n \nHistory of Present Illness:\nThe patient is a ___ yo man with history of polysubstance abuse\nand ? withdrawal seizures vs. ___ transferred from an OSH for\nmanagement of bilateral dysynchronous movements of alternating\nlimbs which were aborted with sternal rub. Neurology consulted \nto\nassess for seizure vs. PNES. \n\nHe initially presented to the OSH ED on ___ for evaluation of\nabdominal pain, was found to have biliary sludge and discharged\nhome. He later represented on the same day after falling forward\nand hitting his head at his ___ facility (___), with\nsubsequent shaking episodes concerning for seizure. At the time\nhe was treated with a total of 5 mg of Ativan, as well as a\nKeppra dose of 1000 mg. CT C-spine was unremarkable. Basic \nlabs\nwere unremarkable. Tox screen was ordered, which was positive\nfor benzos and barbiturates. Shaking activity was decreased,\nhowever later on patient developed agitation and behavior that\nwas threatening towards staff he was placed in 4. restraints and\ntransferred immediately to ___.\n\nOn arrival to the ED he had at least 2 witnessed episodes of\nalternating asynchronous bilateral upper and lower extremity\nshaking. These episodes were aborted with sternal rub. He was\ngiven Ativan total of 2 mg. As he became progressively agitated\nhe was also given Zyprexa 10 mg.\n\nLast drink 3 days ago. Also states he is prescribed benzos and\nstates he ran out of this 3 days ago. Per PMP prescribed 1mg\nalprazolam ___ last for 7 day course. States he also buys\nbenzos off the street. \n \nUnable to obtain general or neurologic review of systems due to\ndrowsiness and perseveration. \n\n \nPast Medical History:\nPolysubstance abuse - He used to be a heroin addict but he \nstopped \"awhile ago\". He goes to a ___ clinic. He \ncurrently uses cocaine and buys benzos on the street. \nHe denies other medical problems.\n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nPHYSICAL EXAMINATION\nVitals: \n74 \n116/82 \n20 \n96% RA \n\nGeneral: NAD\nHEENT: NCAT, dried blood in his mouth\n___: RRR, no M/R/G\nPulmonary: CTAB, no crackles or wheezes\nAbdomen: Soft, NT, ND, +BS, no guarding\nExtremities: Warm, no edema\n\nNeurologic Examination:\nMS: Drowsy but arousable to voice oriented to person and \nhospital\nbut thinks he is at ___ and unsure of date. Able to state \nbasic\nhistory with repeated questioning. Able to relate history\nwithout difficulty. Inattentive, perseverating on restraint\nremoval, which is not possible at this time. Following commands\nwith repetitive stimulation.\n\nCranial Nerves: PERRL 2.5->2mm brisk. BTT bilaterally in all\nfields. V1-V3 with grimace to pinprick symmetrically. No facial\nmovement asymmetry. Palate elevation symmetric. Tongue midline.\n\nMotor: Examination limited by the need of restraints but can \nmove\nall extremites antigravity on command and briskly withdraws to\nnoxious. \n \nSensory: Withdraws to noxious symmetrically.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 2\nR 2 2 2 2 2\nPlantar response flexor bilaterally.\n\nLAB DATA:\nAs per OMR \nDISCHARGE PHYSICAL EXAMINATION: \nTemp 97.4, BP 104-165/65-82, HR 60, RR 18, 96% RA\nGeneral: NAD\nHEENT: NCAT, dried blood in his mouth\n___: RRR, no M/R/G\nPulmonary: CTAB, no crackles or wheezes\nAbdomen: Soft, NT, ND, +BS, no guarding\nExtremities: Warm, no edema\n\nNeurologic Examination:\nMS: Patient alert, oriented x3. Able to follow all commands. \nLanguage intact, no paraphasic errors, repetition intact. naming \nhigh and low frequency items intact. \n\nCranial Nerves: PERRL 2.5->2mm brisk. BTT bilaterally in all \nfields. V1-V3 with grimace to pinprick symmetrically. No facial \nmovement asymmetry. Palate elevation symmetric. Tongue midline.\n\nMotor: Moves all extremities antigravity. ___ in all muscle \ngroups to confrontation testing. \n \nSensory: Withdraws to noxious symmetrically.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 2\nR 2 2 2 2 2\nPlantar response flexor bilaterally.\n\n \nPertinent Results:\nCOMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt \nCt \n___ 07:55AM 6.6 5.08 14.7 43.8 86 28.9 33.6 15.0 \n47.1* 181 Import Result \n\n \n___ 08:33AM 5.7 5.09 14.1 43.3 85 27.7 32.6 14.8 45.8 \n150 Import Result \n\n \n DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im \n___ AbsLymp AbsMono AbsEos AbsBaso \n___ 08:33AM 52.3 33.7 10.5 2.8 0.5 0.2 2.99 \n1.93 0.60 0.16 0.03 Import Result \n\n \n BASIC COAGULATION ___, PTT, PLT, INR) Plt Smr Plt Ct \n___ 07:55AM 181 Import Result \n\n \n___ 08:33AM LOW 150 Import Result \n\n \n \n\nChemistry \n RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap \n___ 07:55AM 106* 14 0.9 142 4.3 ___ Import \nResult \n\n \n___ 08:33AM ___ 145 4.3 108 21* 20 Import \nResult \n\n \n ESTIMATED GFR (MDRD CALCULATION) estGFR \n___ 08:33AM Using this Import Result \n\n \n ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase \nTotBili DirBili \n___ 08:33AM 23 29 68 0.3 Import Result \n\n \n CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron \n___ 07:55AM 9.0 4.2 2.3 Import Result \n\n \n___ 08:33AM 3.8 9.0 2.7 2.4 Import Result \n\n \n TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Carbamz Acetmnp \nBnzodzp Barbitr Tricycl \n___ 09:52PM NEG NEG NEG POS* NEG NEG Import Result \n\n \n___ 07:55AM 1.1* Import Result \n\n \n___ 08:33AM NEG NEG NEG POS* NEG NEG Import Result \n \n \n\nIMAGES: \n\nCXR ___: \nThere is no focal consolidation, pleural effusion or \npneumothorax identified. The size the cardiomediastinal \nsilhouette is within normal limits. \n\n \nBrief Hospital Course:\n___ is a ___ yo man with history of polysubstance abuse \ntransferred from detox to an OSH and ultimately to ___ for \nmanagement of bilateral asynchronous movements of alternating \nlimbs. Patient endorses a history of having these episodes in \nthe past with many EEGs and work up. \n\nHospital course was complicated by patient's conflicting history \nabout his home medications, current substance use, outpatient \nproviders, and social history. He had multiple non epileptic \nepisodes during hospitalization after which patient immediately \nreturned to his baseline mental status. His vital signs remained \nstable during all of these events. He endorsed abusing benzos \nheavily prior to checking himself into detox (which he entered \nfor detoxification from alcohol), and he continued to take his \nown personal stash of benzodiazepenes's (primarily klonopin and \nXanax) secretly while in detox. The patient presented to an OSH \nwith abdominal pain initially from detox and had a non epileptic \nevent which prompted transfer to ___ in ___. At this point, \nthe patient had finished his complete alcohol detox taper and \nwas staying at the detox program for after-care. \nWhen the patient was admitted to ___, he was placed on Ativan \n1mg BID which was later changed to klonopin 1mg BID. The plan \nwas to arrange for a safe discharge back to detox with the \nintent for him to undergo a detox program for benzodiazepenes. \nOn the day that the patient left, he was found to have opiates \npositive in his urine. He endorsed sniffing heroin during detox \nprior to coming to the hospital. Neurologically, the patient \nremained intact and his seizure episodes were non epileptiform \nin nature, which the patient endorsed are triggered by anxiety. \n\nPrior to the team organizing a safe discharge plan, the patient \nleft AMA/eloped prior to us confirming that the patient had a \ndetox bed. He left prior to us providing prescriptions for his \nhome medications. \n\n1. Transitions of care issues: Patient stated he will call detox \nto find a bed for benzo withdrawal \n \nMedications on Admission:\nMEDICATIONS: (Unconfirmed as he has multiple prescribers and\nmultiple pharmacies)\nalprazolam 2 mg tid\nwellbutrin 150 mg tid\ngabapentin 1200 mg tid\nsuboxone 16 daily\n \nDischarge Medications:\nNone as patient left AMA\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nProbable Non-Epileptic Event\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 You were hospitalized at ___ following events concerning \nfor seizure. On discussion with you, you have had similar \nevents in the past and are triggered by stress and anxiety. \nYou were monitored on video EEG that measures when you have \nseizures to correlate it with brain activity. We were unable to \ncapture any seizures on EEG. You left prior to us able to \ndischarge you safely with prescriptions or a bed in detox. \n \nFollowup Instructions:\n___\n" ]

[ "R569", "F329", "B1920", "F1910", "F1010", "Z590", "Z87820", "F17210" ]

[ "R569: Unspecified convulsions", "F329: Major depressive disorder, single episode, unspecified", "B1920: Unspecified viral hepatitis C without hepatic coma", "F1910: Other psychoactive substance abuse, uncomplicated", "F1010: Alcohol abuse, uncomplicated", "Z590: Homelessness", "Z87820: Personal history of traumatic brain injury", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "F329", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: ERCP with sphincterotomy and stent with removal of \nstones and pus.\n\n___: Laparoscopic cholecystectomy\n\n \nHistory of Present Illness:\nPatient is a ___ y/o male with Diabetes who was in his usual \nstate of health until morning of ___ he went to ___ \n___ and a few hours later had abrupt \"attack\" of severe lower \nabdominal pain. Accompanied by some mild shortness of breath. \nWent to ___ where labs showed lipase greater than \n12K and imaging showed choledocholithiasis; he was transferred \nto ___ for ERCP and surgical evaluation.\n\nPatient reports good relief of pain at ___ with IV \ndilaudid. At present, no n/v/ha/cp/sob. Is briefly lightheaded \nwhen he stands up. \n \nPast Medical History:\n1. Diabetes Mellitus\n2. Gout\n3. Hyperlipidemia\n4. Prostate cancer\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nAdmission Physical Exam:\nVitals: 103 60 121/69 18 95 RA\nGEN: A&Ox3, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR\nPULM: Clear to auscultation b/l\nABD: Soft, nondistended, tender over epigastrum, no rebound or\nguarding, large nonreducible left inguinal hernia, nontender, no\nskin changes\nExt: No ___ edema, ___ warm and well perfused\n\nDischarge Physical Exam:\nVS: 98.5, 78, 130/70, 18, 99%ra\nGEN: AA&O x 3, NAD, calm, cooperative.\nHEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI, \nPERRL.\nCHEST: Clear to auscultation bilaterally, (-) cyanosis.\nABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation \nincisionally, non-distended. Incisions: clean, dry and intact, \ndressed and closed with steristrips.\nEXTREMITIES: Warm, well perfused, pulses palpable, (-) edema\n\n \nPertinent Results:\n___ 10:48PM BLOOD WBC-13.3* RBC-4.07* Hgb-12.3* Hct-36.8* \nMCV-90 MCH-30.2 MCHC-33.4 RDW-14.3 RDWSD-46.8* Plt ___\n___ 10:48PM BLOOD Glucose-212* UreaN-19 Creat-0.9 Na-133 \nK-4.8 Cl-98 HCO3-26 AnGap-14\n___ 10:48PM BLOOD ALT-191* AST-196* AlkPhos-70 TotBili-3.1*\n___ 10:48PM BLOOD Lipase-722*\n___ 10:48PM BLOOD Albumin-3.8\n___ 10:45PM BLOOD Lactate-2.4*\n\n___: ___ ___\n\nCT scan ___:\nSeveral biliary stones in CBD, largest measuring 7.5 mm\nLeft inguinal hernia containing a significant portion of the \nsigmoid colon\nBrachytherapy seeds throughout prostate glands\nProminent bibasilar atelectasis\n\nu/s: CBD measures 9.5 mm\n\n \nBrief Hospital Course:\n___ y/o male with DM, gout, history of prostate cancer admitted \nwith one day of abdominal pain, found to have lipase greater \nthan 12K and choledocholitiasis, consistent with gallstone \npancreatitis. The patient was made NPO with IV fluids. By \nmorning of HD2 the lipase had fallen to 700s. The patient \nunderwent ERCP on HD2 with sphincterotomy and removal of pus, \nsludge, and stones. The patient tolerated the procedure well and \nremained hemodynamically stable. \n\nOn HD3 the patient was transferred to the Acute Care Surgery \nservice. He was consented and taken to the operating room for a \nlaparoscopic cholecystectomy, which went well without \ncomplications (reader referred to the Operative Note for \ndetails). After a brief, uneventful stay in the PACU, the \npatient arrived on the floor tolerating sips, on IV fluids, and \nIV analgesia for pain control. The patient was hemodynamically \nstable.\n.\nWhen tolerating a diet, the patient was converted to oral pain \nmedication with continued good effect. Diet was progressively \nadvanced as tolerated to a regular diet with good tolerability. \nThe patient voided without problem. During this hospitalization, \nthe patient ambulated early and frequently, was adherent with \nrespiratory toilet and incentive spirometry, and actively \nparticipated in the plan of care. The patient received \nsubcutaneous heparin and venodyne boots were used during this \nstay.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home without services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Pravastatin 40 mg PO QPM \n4. glimepiride 2 mg oral DAILY \n5. MetFORMIN (Glucophage) 500 mg PO DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. glimepiride 2 mg oral DAILY \n3. MetFORMIN (Glucophage) 500 mg PO DAILY \n4. Pravastatin 40 mg PO QPM \n5. Acetaminophen 650 mg PO Q6H pain \nRX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*30 Tablet Refills:*0\n6. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*20 Capsule Refills:*0\n7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*25 Tablet Refills:*0\n8. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nGallstone pancreatitis, choledocholithiasis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital with gallstone pancreatitis \nand choledocholithiasis. You underwent an ERCP in the GI suite. \nLater, you were taken to the operating room and had your \ngallbladder removed laparoscopically. You tolerated the \nprocedure well and are now being discharged home to continue \nyour recovery with the following instructions:\n \nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below.\n\nPlease hold your Aspirin for 5 days from the ERCP, until ___. \n \nACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You may have a sore throat because of a tube that was in your \nthroat during surgery.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow you may shower and remove the gauzes over your \nincisions. Under these dressing you have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay).\no Your incisions may be slightly red around the stitches. This \nis normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K851", "K8033", "K8063", "E119", "K269", "K4030", "M109", "Z794", "E785", "I10", "Z8546", "E806" ]

[ "K851: Biliary acute pancreatitis", "K8033: Calculus of bile duct with acute cholangitis with obstruction", "K8063: Calculus of gallbladder and bile duct with acute cholecystitis with obstruction", "E119: Type 2 diabetes mellitus without complications", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "K4030: Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent", "M109: Gout, unspecified", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "Z8546: Personal history of malignant neoplasm of prostate", "E806: Other disorders of bilirubin metabolism" ]

[ "E119", "M109", "Z794", "E785", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLipitor / Atenolol\n \nAttending: ___.\n \nChief Complaint:\nFatigue\n \nMajor Surgical or Invasive Procedure:\n___ EPS with Biventricular pacemaker implant \n \nHistory of Present Illness:\nCC: fatigue \n \n___ yo gentleman with Amyloid cardiomyopathy (EF 30%) identified \nby endomyocardial biopsy in ___ at which time he presented with \nacute systolic ___ failure. He went to ___ urgent care with \nsymptoms of 2 days increased fatigue. He reports stable 5-pillow \northopnea and LEs edema. He denies any PND, CP, palpitations, \ndizziness, lightheadedness, fevers, or chills. Of note, since \n___ admission he has been seen in diuresis with torsemide \ndosing titrated as needed. Upon arrival to the ED, he was noted \nto be bradycardic in the ___. With concern for 2:1 AV block, EP \nwas consulted for the management of bradycardia. He was admitted \nfor planned EPS and pacemaker placement. \n\n \nPast Medical History:\nCoronary artery disease \ns/p DES x1 to LAD (___)\nChronic systolic ___ failure EF 30% \nTTR amyloid \nHypertension\nHyperlipidemia\nAtrial fibrillation\nLumbar spinal stenosis\nDiabetes mellitus 2\nChronic kidney disease stage III\n \n \n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\nPHYSICAL EXAM: \n Vital Signs: 96.2 ___ 18 96%RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic \nmurmur \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: trace edema, 2+ pulses, no clubbing/cyanosis \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \n\nPHYSICAL EXAM ON DAY OF DISCHARGE ___:\n\nAfebrile, tele SR with biv pacing with rates 60's to 80's \n Tele: A-V paced and BiV paced 60-80's \n ___: 111, 108, 138, 128\n Wt: 78.2 kg (75.2 kg) - determined yesterday's wt. close to \naccurate\n 24 HR I&O 2380 (2400)\n\n **Pertinent exam findings: \n VS: T 98 HR 60-80's RR 16 BP 90/50 to 86/50's 95% RA\n Gen: No acute distress, denies pain \n Neck/JVD: no elevation appreciated\n CV:RRR, II/VI holosystolic best heard LUSB\n Chest:Lungs clear bilaterally\n ABD:Abdomen soft, bowel sounds present, last BM 1 week ago\n Extr: trace to 1+ lower extremity edema L>R\n Access sites: PIV\n Skin: Feet cool, skin dry and intact. \n Left chest wall pacer sites, soft, diffuse ecchymosis noted, \nimproved over ___, mildly tender to palpation, hematoma appears \nto be resolving, no active drainage, shadowing of old drainage \nnoted on dressing approx. 2 cm\n Neuro:A+Ox3, no focal deficts\n\n \nPertinent Results:\n___ 07:35AM BLOOD Glucose-63* UreaN-49* Creat-1.9* Na-137 \nK-3.7 Cl-97 HCO3-20* AnGap-24*\n___ 07:10AM BLOOD UreaN-43* Creat-1.6* K-3.3\n___ 07:20AM BLOOD Glucose-98 UreaN-32* Creat-1.4* Na-137 \nK-3.4 Cl-99 HCO3-27 AnGap-14\n___ 07:00AM BLOOD UreaN-33* Creat-1.3* K-4.0\n___ 09:30AM BLOOD UreaN-38* Creat-1.5* Na-130* K-4.2\n___ 02:47PM BLOOD ALT-13 AST-24 AlkPhos-114 TotBili-2.4*\n___ 09:30AM BLOOD Albumin-4.1\n___ 07:35AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.8\n___ 02:47PM BLOOD VitB12-317 Folate-12.2\n___ 02:47PM BLOOD TSH-2.8\n___ 02:47PM GLUCOSE-98 UREA N-49* CREAT-2.0* SODIUM-131* \nPOTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-21* ANION GAP-19\n___ 02:47PM ALT(SGPT)-13 AST(SGOT)-24 ALK PHOS-114 TOT \nBILI-2.4*\n___ 02:47PM proBNP-6774*\n___ 02:47PM VIT B12-317 FOLATE-12.2\n___ 02:47PM TSH-2.8\n___ 02:47PM WBC-5.3 RBC-3.48* HGB-11.6*# HCT-35.0* \nMCV-101*# MCH-33.3*# MCHC-33.1 RDW-18.4* RDWSD-67.4*\n___ 02:47PM NEUTS-62.1 ___ MONOS-9.7 EOS-5.1 \nBASOS-1.0 IM ___ AbsNeut-3.27 AbsLymp-1.14* AbsMono-0.51 \nAbsEos-0.27 AbsBaso-0.05\n___ 02:47PM PLT COUNT-127*\n___ 07:35AM BLOOD WBC-4.6 RBC-3.50* Hgb-11.5* Hct-36.4* \nMCV-104* MCH-32.9* MCHC-31.6* RDW-18.5* RDWSD-70.0* Plt ___\n___ 07:10AM BLOOD WBC-6.3 RBC-2.71* Hgb-9.0* Hct-28.2* \nMCV-104* MCH-33.2* MCHC-31.9* RDW-18.2* RDWSD-68.9* Plt ___\n___ 12:50PM BLOOD Hct-27.8*\n___ 07:20AM BLOOD WBC-4.9 RBC-2.30* Hgb-7.7* Hct-23.7* \nMCV-103* MCH-33.5* MCHC-32.5 RDW-18.1* RDWSD-67.4* Plt ___\n___ 10:45AM BLOOD Hct-24.8*\n___ 07:00AM BLOOD Hct-25.1*\n___ 03:20PM BLOOD WBC-5.5 RBC-2.51* Hgb-8.3* Hct-26.3* \nMCV-105* MCH-33.1* MCHC-31.6* RDW-17.9* RDWSD-68.9* Plt ___\n\n \nBrief Hospital Course:\nThe patient had a course postoperatively that was marked by some \natrial tachycardia requiring pacer modifications which resolved \nwithout issue, with a burden of afib of approximately 20 to no \nmore than 30%. He had low blood pressures and on clinical exam \nwas noted to be hydrating inadequately with concentrated urine \nand well below his 2 liter daily restriction. He was given two \nfluid boluses and received one liter of normal saline to good \neffect. His blood pressure returned to baseline mid 80's to \n90's with a peak of 100's. He continued on his adjusted \nTorsemide dose once this resolved. He has underlying anemia of \nchronic disease which requires further management by his \nRheumatologist and his PCP given his underlying amyloid \ndiagnosis. He reported not having a bowel movement for a week \nand was given a suppository with no results. He should increase \nhis laxative use on discharge to home, we recommend Miralax x 3 \ndoses 20 minutes apart, or his laxative of choice, including Mag \nCitrate, all available over the counter.\n\n# AV ___ BLOCK with bradycardia: s/p BiV pacer implant on \n___\n - EP interrogated device and feels AT requiring pacer setting \nmodifications, no addition of beta blocker necessary, continue \nto monitor on telemetry\n - Vanco in house postop, followed by Keflex in house for \ntotal 3 days\n - Follow up in device clinic in a week\n - EP f/u with Dr. ___: requested through Care Connections \n \n \n # ATRIAL FIBRILLATION\n - A-V and BiV pacing and having runs of atrial tachycardia vs\n atrial flutter\n - Atrial arrhythmia reviewed with EP, pacemaker settings \nadjusted ___, improved\n - Continue Apixaban \n\n # CHRONIC SYSTOLIC ___ FALURE: \n - Euvolemic on exam, still with sporadic hypotension. Review \nof ___ reveals he rec'd 40 mg Torsemide last evening and has \nsince had low pressures now to the 70's systolic, rec'd 60 mg \n___ ___ and had lows yesterday as well. Improved fluid \nstatus with IV boluses and PO intake. No further fluids needed, \npatient remains asymptomatic with MAP > 60.\n - Hct improving gradually, baseline ___ but admitted here \nw/Hct 35. Last admit ___ shows baseline 32, currently 26.2 \nand dilute from fluids. Follow with both PCP and ___ \nfor ongoing care\n - Torsemide 60 mg AM and 40 mg ___ continues - no dose \nadjustment since he had increased his intake to his fluid \nrestriction, urine clearing\n - Daily weights - inaccurate weights vs. I&O's - see above\n - No ___ in setting of CKD stage III\n - Cardiology f/u Dr ___ ___ clinic (pt goes to \nthe \n ___ clinic every ___ \n\n # ___: \n - Now resolving. CKD stage 3. Cr stable at 1.3\n - Torsemide resumed and re-evaluated on day of discharge. \nGiven appropriate hydration and improved clinical status, \ndischarge on the 60 mg and 40 mg divided day dosing as \ndetermined during recent ___ clinic visit\n - Continue Keflex for 2 days\n - Avoid nephrotoxins \n \n # Macrocytic anemia: \n - patient with baseline anemia, MCV 101. Overall, Hct 27 \nwhich is\n baseline ___. Denies heavy EtOH use\n - Hct stable at 26.2, no active bleeding seen, hematoma at \npacer site improved, seen by Fellow. No active drainage noted \nand currently appears stable\n - suspect low Hct in setting of overdiuresis, procedure loss \nand resolving hematoma with no active drainage\n - Pt denies knowledge of anemia and has not been transfused\n - Further follow up ___ MD who is following for Amyloid\n\n # HLD: \n - Continue rosuvastatin 10mg daily \n\n # T2DM: FBS 156, sugars 86-161\n - Humalog sliding scale while in-house \n - Resume Metformin at discharge\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Apixaban 5 mg PO BID \n2. Aspirin 81 mg PO DAILY \n3. Ferrous Sulfate 325 mg PO BID \n4. MetFORMIN (Glucophage) 500 mg PO BID \n5. Rosuvastatin Calcium 10 mg PO ___ \n6. Torsemide 80 mg PO DAILY (per instructions by diuresis \nclininc was due to decrease to 60 mg QQM and ___ ___ on ___ \n\n7. Potassium Chloride 60 mEq PO BID \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Rosuvastatin Calcium 10 mg PO ___ \n3. Ferrous Sulfate 325 mg PO BID \n4. Apixaban 5 mg PO BID \nrestart on ___ \n5. MetFORMIN (Glucophage) 500 mg PO BID \nrestart on ___ morning \n6. Cephalexin 500 mg PO Q6H \nx 2 days \n7. Potassium Chloride 60 mEq PO BID \n8. Torsemide 60 mg PO QAM \n9. Torsemide 40 mg PO ___ \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCAD remote MI\nCardiac Amyloidosis ___ ___ block\nAtrial fibrillation\nChronic systolic ___ failure\nHyperlipidemia\nDM2\nCKD stage III\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\n You were admitted after evaluation for symptoms of fatigue \nshowed a slow heartbeat. A pacemaker was placed by Dr. ___. \nThis pacemaker is set to help prevent your ___ from beating to \nslowing and also to coordinate the beating of the 2 bottom ___ \nchambers so that symptoms of ___ failure may be improved.\n Activity restrictions and care of the incision as per written \nnursing discharge instructions.\n Please continue all your usual medicines. Your Apixaban was \nresumed ___. In addition you will need to take an \nantibiotic for 2 days to prevent infection at the pacemaker site \nand were started on this while in the hospital. You should \nresume your Metformin on arrival to home. While hospitalized, \nyour blood glucose remained stable and you were maintained on a \nsliding scale insulin regimen.\n Your hemoglobin did drop post procedure but has been trending \nup steadily since then. You did not receive any blood \ntransfusions and your last hemoglobin/hematocrit was 8.3 and \n26.3 respectively.\n Please continue to weigh yourself daily and report any weight \ngain to your ___ failure Nurse Practitioner. ___ your weight \ngoes up ___ lbs in ___ hours, contact your ___ NP. \nYou should continue a 2 gram ___ healthy low sodium diet and \nlimit free fluids, including those that melt at room temperature \nto 2 liters daily. Post procedure you were noted to be \ndehydrated and drinking inadequate amounts of fluid, even with a \n2 liter fluid restriction. Your blood pressure dropped to a low \nof 70/50's and has improved to baseline 80-90's systolic. \nContinue measuring and tracking your fluids and your sodium \nintake.\n Keep all of your follow up appointments as noted below.\n \n \nFollowup Instructions:\n___\n" ]

[ "I441", "E854", "N179", "I43", "I5022", "E1122", "I447", "I2510", "Z955", "I129", "N183", "Z794", "E785", "I4891", "D638", "I9581", "I252", "Z7982", "Z7902" ]

[ "I441: Atrioventricular block, second degree", "E854: Organ-limited amyloidosis", "N179: Acute kidney failure, unspecified", "I43: Cardiomyopathy in diseases classified elsewhere", "I5022: Chronic systolic (congestive) heart failure", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I447: Left bundle-branch block, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "I4891: Unspecified atrial fibrillation", "D638: Anemia in other chronic diseases classified elsewhere", "I9581: Postprocedural hypotension", "I252: Old myocardial infarction", "Z7982: Long term (current) use of aspirin", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "N179", "E1122", "I2510", "Z955", "I129", "Z794", "E785", "I4891", "I252", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLipitor / Atenolol\n \nAttending: ___.\n \nChief Complaint:\ndyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\nPICC Line placement. \n\n \nHistory of Present Illness:\n___ yo male with PMH significant for mixed ischemic/senile \namyloid cardiomyopathy, HFrEF (EF 22%), coronary artery disease \ns/p PCI to LAD, atrial fibrillation, and history of high degree \nAV block s/p biventricular pacemaker, recent hospitalization \nwith decompensated ___ presenting with increased \ndyspnea and fatigue. Patient was admitted with fatigue and \ndyspnea, decompensated possibly in the setting of increased Afib \nburden vs excessive fluid intake vs progression of advanced CHF. \nIt was also thought that some of his symptoms were actually \nrelated to his pacer since after his BiV pacer setting was \nincreased to 95, he had significant symptom resolution. \nDischarge weight was 72.6kg.\n\nPer report, since discharge, pt has had dyspnea and overall \nfatigue that has been worsening. He has not noted any weight \ngain or edema. He has some orthopnea but is primarily dyspnea on \nexertion. He denies any chest pain. Denies any fever chills or \ncough. He does endorse some heaviness in his legs. He was seen \nin clinic on ___ and was found to be volume overloaded, and \nrecommended admission, but he declined. Was discharged from \nclinic on increased dose of 60mg QAM and 40mg QPM. However, he \npresented to ED today due to worsening symptoms.\n\nIn the ED initial vitals were: 84/62 95 afebrile 96RA.\nEKG: Afib, V-paced\nLabs/studies notable for: CKMB 13/trop .12, repeat trop .1. Na \n131. Cr 2.2(2 on ___, on discharge on ___ BNP ___ \n13000s), lactate 2.6.\nPatient was given: asp 325\nVitals on transfer: ___\n\nOn the floor, pt appears comfortable. Denies any \nSOB/CP/abdominal pain while sitting. \n\n \nPast Medical History:\nCoronary artery disease \ns/p DES x1 to LAD (___)\nsystolic heart failure EF 30% \nTTR amyloid \nHypertension\nHyperlipidemia\nAtrial fibrillation\nLumbar spinal stenosis\nDiabetes mellitus 2\nChronic kidney disease stage III\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n====================\nVS: afebrile 97/62 96 18 96RA Wt 73kg, dry weight 72.6kg \nGENERAL: Appears comfortable and can have a full conversation. \nOriented x3. Mood, affect appropriate.\nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \nNo xanthelasma.\nNECK: Supple. JVP 15cm, above angle of jaw.\nCARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs, \nor gallops. \nLUNGS: clear to auscultation bilaterally \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly.\nEXTREMITIES: cool to touch upper and lower extremities\nSKIN: No significant skin lesions or rashes.\nPULSES: Distal pulses palpable and symmetric.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: 98, 90-100/61-66, 95, ___, 100% on RA. \nI/O= ___ on ___. 1624/2200 on ___. 2284/3050 on ___. \n1864/6150 on ___, 1560/4630 on ___, 2150/4150 ___, ___ ___ from 12a-8a\nWeight: 69.4 < 70.3 < 71.1 < 70.7 < 75.8 < 75.4 < 73.3 < 74.0 < \n73.2 < 71.8 kg on ___ (73.0 kg on admission)\nGENERAL: Alert and oriented x 3, pleasant, comfortable \nHEENT: Normocephalic atraumatic. Sclera anicteric.\nNECK: Supple. JVP 11 cm, +HJR\nCARDIAC: regular rate and rhythm, Normal S1, S2. No murmurs, \nrubs, or gallops. \nLUNGS: CTAB \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly.\nEXTREMITIES: warm, wp, no ___ edema\nSKIN: No significant skin lesions or rashes.\nPULSES: Distal pulses palpable and symmetric.\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 01:22PM BLOOD WBC-4.1 RBC-3.89* Hgb-13.4* Hct-41.6 \nMCV-107* MCH-34.4* MCHC-32.2 RDW-15.7* RDWSD-61.7* Plt ___\n___ 01:22PM BLOOD Neuts-58.1 ___ Monos-10.9 Eos-2.4 \nBaso-1.5* Im ___ AbsNeut-2.40 AbsLymp-1.11* AbsMono-0.45 \nAbsEos-0.10 AbsBaso-0.06\n___ 01:22PM BLOOD Glucose-73 UreaN-58* Creat-2.2* Na-131* \nK-4.6 Cl-92* HCO3-22 AnGap-22*\n___ 01:22PM BLOOD CK(CPK)-260\n___ 01:22PM BLOOD CK-MB-13* MB Indx-5.0 ___\n___ 03:42PM BLOOD ALT-23 AST-35 LD(LDH)-360* AlkPhos-138* \nTotBili-2.4*\n___ 01:45PM BLOOD ___ Comment-GREEN TOP\n___ 01:45PM BLOOD Lactate-2.6*\n___ 02:06PM BLOOD Lactate-2.1*\n\nOTHER RELEVANT LABS:\n==================\n___ 04:50AM BLOOD WBC-3.4* RBC-3.44* Hgb-11.6* Hct-36.8* \nMCV-107* MCH-33.7* MCHC-31.5* RDW-15.4 RDWSD-60.5* Plt ___\n___ 05:42AM BLOOD WBC-4.5 RBC-3.28* Hgb-11.2* Hct-35.4* \nMCV-108* MCH-34.1* MCHC-31.6* RDW-15.2 RDWSD-60.9* Plt ___\n___ 01:00PM BLOOD Glucose-101* UreaN-51* Creat-1.7* Na-137 \nK-3.9 Cl-97 HCO3-26 AnGap-18\n___ 03:00PM BLOOD Glucose-165* UreaN-44* Creat-1.5* Na-137 \nK-3.7 Cl-98 HCO3-27 AnGap-16\n___ 04:50AM BLOOD ALT-21 AST-30 LD(LDH)-325* AlkPhos-137* \nTotBili-2.1*\n___ 05:42AM BLOOD ALT-19 AST-28 LD(LDH)-277* AlkPhos-133* \nTotBili-1.9*\n___ 01:22PM BLOOD cTropnT-0.12*\n___ 03:42PM BLOOD cTropnT-0.10*\n___ 02:06PM BLOOD Lactate-2.1*\n___ 06:26AM BLOOD Lactate-1.0\n___ 05:00AM BLOOD Glucose-78 UreaN-40* Creat-1.7* Na-140 \nK-3.7 Cl-100 HCO3-25 AnGap-19\n___ 04:47AM BLOOD Glucose-130* UreaN-50* Creat-1.5* Na-137 \nK-3.4 Cl-99 HCO3-26 AnGap-15\n___ 09:46PM BLOOD Glucose-143* UreaN-69* Creat-1.6* Na-135 \nK-3.9 Cl-93* HCO3-30 AnGap-16\n___ 09:30AM BLOOD Lactate-1.2\n___ 06:38AM BLOOD O2 Sat-67\n___ 09:30AM BLOOD O2 Sat-50\n\nDISCHARGE LABS:\n=================\n___ 05:24AM BLOOD Glucose-94 UreaN-68* Creat-1.5* Na-137 \nK-3.3 Cl-93* HCO3-29 AnGap-18\n___ 05:24AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0\n___ 05:24AM BLOOD WBC-5.5 RBC-3.18* Hgb-10.8* Hct-33.8* \nMCV-106* MCH-34.0* MCHC-32.0 RDW-14.9 RDWSD-58.0* Plt ___\n\nCXR (___): IMPRESSION: Moderate cardiomegaly without \ncongestive heart failure.\n \nBrief Hospital Course:\n___ yo male with PMH significant for mixed ischemic/senile \namyloid cardiomyopathy, HFrEF (EF 22%), coronary artery disease \ns/p PCI to LAD, atrial fibrillation, and history of high degree \nAV block s/p biventricular pacemaker, recent hospitalization \nwith decompensated ___ who presented with with \nincreased dyspnea.\n\n# I50.42 Chronic combined systolic and diastolic heart failure\n# Acute on Chronic Heart Failure with Reduced Ejection Fraction\n# Mixed Ischemic and Amyloid Cardiomyopathy\nPt re-presented with dyspnea/fatigue, elevated BNP (higher than \nprevious admissions), thought to be in a low output state. He \nwas given inotrope support with dobutamine 2.5 mcg/kg/min (dosed \nat a weight of 73 kg) to augment output to result in lower JVP \nand his symptoms improved. His was initially given 40 Lasix IV, \nthen transitioned to PO toresemide 100 daily BID at discharge. \nAlso required additional doses of metolazone for diuresis. \nResponded very briskly to 2.5 mg so was decided that he should \ntake 1.25 mg of metolazone every second or third day. Prescribed \ndaily KCl repletion with 40 mEq BID on days in which he only \nreceived torsemide 100 mg BID and 40 TID on days in which he \nreceives torsemide + metolazone days. Also started on \nspironolactone 12.5 daily.\n\n#Home Support\nThe patient was accepted by ___ service. \nHe will be assigned ___ home ___ and ___ worker. The patient \nwill be confined to his home for the next ___ weeks and will \nhave Meals on Wheels Delivered.\n\n# Acute on chronic renal failure: thought to be a result of low \ncardiac output. Cr remained stable around 1.4-1.6 with \ndobutamine and diuresis\n\nCHRONIC ISSUES:\n===============\n# Coronary artery disease: s/p DES x1 to LAD (___)- aspirin was \ncontinued, and the pt was started on rosuvastatin 10 QPM. \n \n# Hyperlipidemia: Rosuvastatin was restarted during this \nhospitalization, as above. \n\n# Atrial fibrillation: Home apixiban 5 mg BID was continued. \n\n# Diabetes Mellitus type II: Patient was started on ISS and \nmetformin was on hold. Can resume metformin at discharge. \n\nTRANSITIONAL ISSUES:\n==================\n-Medications added:\n1. dobutamine 2.5 mcg/kg/min infusion, based on weight of 73 kg\n2. rosuvastatin 10 mg nightly\n3. metolazone 1.25 mg every second or third day depending on \npatient's weight, to be coordinated by ___ service and \nCardiologist. \n4. spironolactone 12.5 mg daily\n-Medications stopped: none\n-Medications changed:\n1. torsemide 60 mg QAM, 40 mg QPM -> torsemide 100 BID\n2. Potassium Chloride 60 mEq PO DAILY -> Potassium Chloride 40 \nmEq PO BID on torsemide days, and 40 mEq PO TID on \ntorsemide+metolazone days.\n-Discharge weight: 69.4 kg- 153 pounds (PLEASE NOTE THAT THE \nDOSE OF THE DOBUTAMINE SHOULD BE DOSED FOR A WEIGHT OF 73 \nKILOGRAMS AS DESCRIBED ABOVE).\n-Creatinine at the time of discharge 1.5. \n\n[ ] follow up LFT's, CBC, chemistry as outpatient\n[ ] if patient remains anemic as outpatient, please perform \nanemia workup. \n[ ] coordinate set up with Care ___ service \nfor dobutamine drip education and monitoring\n[ ] f/u with ___ (Heart failure) on ___\n[ ] f/u with Dr. ___ within 2 weeks for heart \nfailure\n[ ] Patient cannot drive while on dobutamine due to arrhythmia \nrisk with inotropes\n[ ] discuss a schedule for metolazone. If taking metolazone, \ndiscuss a potassium supplementation regimen patient should be \non. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Apixaban 5 mg PO BID \n2. Aspirin 81 mg PO DAILY \n3. Ferrous Sulfate 325 mg PO BID \n4. Torsemide 60 mg PO QAM \n5. MetFORMIN (Glucophage) 500 mg PO BID \n6. Torsemide 40 mg PO QPM \n7. Potassium Chloride 60 mEq PO BID \n\n \nDischarge Medications:\n1. DOBUTamine 2.5 mcg/kg/min IV DRIP INFUSION \nRX *dobutamine 250 mg/20 mL (12.5 mg/mL) 2.5 mcg/kg/min \nintravenous continuous infusion Disp #*30 Vial Refills:*50 \n2. Metolazone 1.25 mg PO AS DIRECTED BY YOUR CARDIOLOGIST \nRX *metolazone 2.5 mg 0.5 (One half) tablet(s) by mouth as \ndirected by your cardiologist Disp #*5 Tablet Refills:*0 \n3. Potassium Chloride 40 mEq PO TID WHEN YOU TAKE A DOSE OF \nMETOLAZONE \nHold for K > 4.5 \nRX *potassium chloride 20 mEq 2 tablet(s) by mouth three times a \nday Disp #*56 Tablet Refills:*0 \n4. Rosuvastatin Calcium 10 mg PO QPM \nRX *rosuvastatin 10 mg 1 tablet(s) by mouth every night Disp \n#*28 Tablet Refills:*0 \n5. Spironolactone 12.5 mg PO DAILY \nRX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily \nDisp #*14 Tablet Refills:*0 \n6. Potassium Chloride 40 mEq PO BID \nRX *potassium chloride 20 mEq 2 tablet(s) by mouth twice a day. \nDisp #*112 Tablet Refills:*0 \n7. Torsemide 100 mg PO BID \nRX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*56 \nTablet Refills:*0 \n8. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*56 Tablet Refills:*0 \n9. Aspirin 81 mg PO DAILY \n10. Ferrous Sulfate 325 mg PO BID \n11. MetFORMIN (Glucophage) 500 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY\n=======\nAcute on Chronic Systolic and Diastolic Heart Failure\nMixed Ischemic and Amyloid Cardiomyopathy\n\nSECONDARY\n=========\nCoronary Artery Disease\nAtrial Fibrillation\nChronic Kidney Disease\nHypertension\nHyperlipidemia\nDiabetes Mellitus type II\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ \nbecause you had a heart failure exacerbation. You were treated \nwith water pills to get rid of the extra fluid in your lungs, \nand you were put on a continuous (\"drip\") medication called \ndobutamine that helps your heart pump blood to your organs more \neffectively.\n\nIt is very important to take all of your heart healthy \nmedications, including aspirin, rosuvastatin, torsemide and \ndobutamine. Please do not stop any of these medications without \ntalking to your Cardiologist first. You will also need to have \nclose follow up with your heart doctor and your primary care \ndoctor.\n\nFor your water pill medication, you will require torsemide EVERY \nDAY. Please take torsemide 100 milligrams EVERY 12 HOURS. You \nwill require potassium supplementation with potassium chloride \n40 milliequivalents TWICE on those days. \n\nOn certain days you will require a medication called metolazone \n(this will be given in addition to the standing torsemide dose \nyou take). You may require the metolazone once every three days, \nhowever this will need to be discussed at your next Cardiology \nappointment. Please do not take the metolazone until you have \nyour follow up appointment in the heart failure clinic. The dose \nof the metolazone and the schedule of the metolazone will be \ndiscussed at your next visit.\n\nIf they recommend that you take the metolazone in addition to \nthe torsemide (as described above) on certain days, the amount \nof potassium supplementation will be 40 milliequivalents of \npotassium chloride THREE TIMES on the days you take the \nmetolazone. \n\nSince you are on dobutamine, you CANNOT DRIVE, as there are \nrisks associated with developing arrhythmias which can lead to \nmotor vehicle accidents.\n\nPlease weigh yourself every day in the morning after you go to \nthe bathroom and before you get dressed. If your weight goes up \nby more than 3 lbs in 1 day or more than 5 lbs in 3 days, please \ncall your heart doctor or your primary care doctor and alert \nthem to this change. Your weight at the time of discharge was \n153 pounds. \n\nIt was a pleasure to take care of you. We wish you the best with \nyour health!\n\nYour ___ Cardiac Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5043", "N179", "E854", "I255", "I43", "I081", "I2510", "E785", "E119", "I4891", "I129", "Z950", "Z955", "N183", "Z7902", "Z66" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5043: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "E854: Organ-limited amyloidosis", "I255: Ischemic cardiomyopathy", "I43: Cardiomyopathy in diseases classified elsewhere", "I081: Rheumatic disorders of both mitral and tricuspid valves", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "I4891: Unspecified atrial fibrillation", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z950: Presence of cardiac pacemaker", "Z955: Presence of coronary angioplasty implant and graft", "N183: Chronic kidney disease, stage 3 (moderate)", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z66: Do not resuscitate" ]

[ "I130", "N179", "I2510", "E785", "E119", "I4891", "I129", "Z955", "Z7902", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLipitor / Atenolol\n \nAttending: ___.\n \nChief Complaint:\nEdema, Dyspnea on Exertion\n \nMajor Surgical or Invasive Procedure:\n- cardiac catheterization with endomyocardial biopsy (___)\n\n \nHistory of Present Illness:\nMr. ___ is a ___ y/o man with a PMH of atrial fibrillation (on \ndabigatran), CHF/cardiomyopathy (LVEF 24%), HTN, CAD, who \npresented with 1 week of progressive dyspnea on exertion, \nfatigue, and cough. He reports worsening fatigue and dyspnea \nassociated with climbing stairs, hills or walking. He now notes \nthat he has to use a walker, which he says he has not used in a \nlong time. Reports increased dry cough during this period and 4 \npillow orthopnea (he says that he has been having this for ___ \nmonths), without PND. He denies any history of dietary \nindiscretion, any medication changes, chest pain, or signs and \nsymptoms of infection. He was seen in clinic today, where he \nwas found to have a BP 90/70 mmHg, HR in the ___, with edema, \ncool extremities. EKG showed known atrial fibrillation with low \nvoltage, and he was referred to the ED for concern for acute \ndecompensated heart failure and low output state. \n\nED COURSE\nIn the ED intial vitals were: T 97.9F BP 147/97 P 60 RR 26 O2 \n98% RA\nLabs/studies notable for: Na 131, K 4.3, Cl 101, HCO3 15, BUN \n31, Cr 1.4, Gluc 73. CK 286, MB 21, MBI 7.3. Ca 8.6, Mg 2.0, P \n3.5, ALT 18, AST 30, Alk phos 106, Tbili 1.8, Alb 3.9. proBNP of \n54___. UA was negative. Lactate 2.3. Trop-T 0.07. \n\nExam notable for JVD, irregularly irregular cardiac exam without \nmurmurs, mildly distended abdomen with no tenderness to \npalpation, 3+ lower extremity edema, and cool extremities. \n\nPatient was given: \n___ 14:10 IV Furosemide 20 mg \n___ 17:00 IV Furosemide 40 mg \n\nVitals on transfer: P 81 BP 116/73 mmHg RR 18 O2 97% RA\n\nPOC ultrasound demonstrated: Bilateral pleural effusions, \nintraperitoneal fluid. No pericardial effusion. CXR notable for \ncardiomegaly. \n\n \nPast Medical History:\nHypertension\nHyperlipidemia\nAtrial fibrillation\nLumbar spinal stenosis\nDiabetes mellitus\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\n===============\nADMISSION EXAM:\n===============\nWeight: 212 lbs (ED)\nVS: BP 122/86 mmHg P 40 RR 18 O2 100% RA\nGeneral: Well appearing man, in NAD. Mood, affected appropriate.\nHEENT: Sclerae anicteric. EOMs intact. OP clear.\nNeck: Supple. JVP elevated above clavicle while seated upright. \nEJ prominent.\nCV: Bradycardic, regular, normal S1/S2. No MRGs.\nPulm: CTA b/l; no wheezes, rhonchi, or rales. \nAbd: Soft, non-tender, non-distended. NABS. \nExt: 2+ pitting edema up to mid thigh. Cool to touch. 2+ pulses.\nNeuro: A&Ox3. CNs II-XII grossly intact. Full strength in upper \nand lower extremities b/l. \n.\n===============\nDISCHARGE EXAM:\n===============\nWeight: 78.1 <-- 77.3 kg \nVS: 97.8 60 100/64 16 100% RA\nGeneral: Well appearing man, in NAD. Mood, affect appropriate.\nHEENT: Sclerae anicteric. EOMs intact. OP clear.\nNeck: Supple. JVP elevated to jaw at 45 degrees but disappears \nupright.\nCV: Irregular, normal S1/S2. No MRGs.\nPulm: CTA b/l; no wheezes, rhonchi, or rales. \nAbd: Soft, non-tender, non-distended. NABS. \nExt: 1+ edema in feet b/l. Extremities warm. Distal pulses \ndifficult to assess given edema.\nNeuro: A&Ox3. CNs II-XII grossly intact. Full strength in upper \nand lower extremities b/l. \n\n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n___ 12:00PM ___ PTT-55.0* ___\n___ 12:00PM PLT COUNT-203\n___ 12:00PM NEUTS-59.9 ___ MONOS-12.2 EOS-1.3 \nBASOS-1.3* NUC RBCS-0.4* IM ___ AbsNeut-2.68 AbsLymp-1.12* \nAbsMono-0.55 AbsEos-0.06 AbsBaso-0.06\n___ 12:00PM WBC-4.5 RBC-3.38* HGB-9.8* HCT-32.1* MCV-95# \nMCH-29.0# MCHC-30.5* RDW-16.7* RDWSD-57.6*\n___ 12:00PM ALBUMIN-3.9 CALCIUM-8.6 PHOSPHATE-3.5 \nMAGNESIUM-2.0\n___ 12:00PM CK-MB-21* MB INDX-7.3* proBNP-5469*\n___ 12:00PM cTropnT-0.07*\n___ 12:00PM ALT(SGPT)-18 AST(SGOT)-30 CK(CPK)-286 ALK \nPHOS-106 TOT BILI-1.8*\n___ 12:00PM estGFR-Using this\n___ 12:00PM GLUCOSE-73 UREA N-31* CREAT-1.4* SODIUM-131* \nPOTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-15* ANION GAP-19\n___ 12:59PM LACTATE-2.3*\n___ 01:40PM URINE MUCOUS-RARE\n___ 01:40PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 01:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 \nLEUK-NEG\n___ 01:40PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 01:40PM URINE GR HOLD-HOLD\n___ 01:40PM URINE UHOLD-HOLD\n___ 01:40PM URINE HOURS-RANDOM\n___ 01:40PM URINE HOURS-RANDOM\n___ 03:42PM cTropnT-0.08*\n___ 09:10PM PLT COUNT-214\n___ 09:10PM WBC-3.9* RBC-3.67* HGB-10.7* HCT-35.0* MCV-95 \nMCH-29.2 MCHC-30.6* RDW-16.7* RDWSD-57.9*\n___ 09:10PM TSH-2.3\n___ 09:10PM calTIBC-451 FERRITIN-32 TRF-347\n___ 09:10PM TOT PROT-6.9 CALCIUM-9.1 MAGNESIUM-2.1 \nIRON-26*\n___ 09:10PM GLUCOSE-114* UREA N-32* CREAT-1.5* SODIUM-134 \nPOTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-17* ANION GAP-21*\n___ 09:20PM LACTATE-2.1*\n___ 10:46PM URINE HOURS-RANDOM TOT PROT-<6\n.\n=============\nINTERIM LABS:\n=============\n___ 05:25AM BLOOD WBC-4.4 RBC-3.36* Hgb-9.4* Hct-31.0* \nMCV-92 MCH-28.0 MCHC-30.3* RDW-16.5* RDWSD-55.7* Plt ___\n___ 05:25AM BLOOD WBC-5.2 RBC-3.21* Hgb-9.0* Hct-29.6* \nMCV-92 MCH-28.0 MCHC-30.4* RDW-16.7* RDWSD-55.0* Plt ___\n___ 07:50PM BLOOD PTT-30.0\n___ 10:06PM BLOOD PTT-69.3*\n___ 05:25AM BLOOD ___ PTT-48.9* ___\n___ 03:25PM BLOOD Glucose-114* UreaN-34* Creat-1.5* Na-136 \nK-4.0 Cl-102 HCO3-19* AnGap-19\n___ 03:20PM BLOOD Glucose-88 UreaN-42* Creat-1.4* Na-138 \nK-3.8 Cl-100 HCO3-24 AnGap-18\n___ 05:25AM BLOOD Glucose-100 UreaN-55* Creat-1.7* Na-134 \nK-4.5 Cl-95* HCO3-30 AnGap-14\n___ 08:45AM BLOOD LD(___)-307* DirBili-1.0*\n___ 05:25AM BLOOD ALT-15 AST-27 LD(LDH)-288* AlkPhos-105 \nTotBili-1.3\n___ 12:00PM BLOOD cTropnT-0.07*\n___ 03:42PM BLOOD cTropnT-0.08*\n___ 05:25AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9\n___ 05:25PM BLOOD Calcium-9.3 Phos-5.2* Mg-2.2\n___ 09:10PM BLOOD %HbA1c-5.5 eAG-111\n___ 08:45AM BLOOD FreeKap-39.3* FreeLam-27.8* Fr K/L-1.42\n___ 09:20AM BLOOD Lactate-1.9\n___ 06:07AM BLOOD Lactate-1.8\n___ 05:52AM BLOOD Lactate-1.3\n.\n===============\nDISCHARGE LABS:\n===============\n___ 05:35AM BLOOD WBC-5.3 RBC-3.09* Hgb-8.8* Hct-28.7* \nMCV-93 MCH-28.5 MCHC-30.7* RDW-17.0* RDWSD-55.8* Plt ___\n___ 05:35AM BLOOD Plt ___\n___ 05:35AM BLOOD Glucose-101* UreaN-40* Creat-1.5* Na-133 \nK-4.7 Cl-95* HCO3-27 AnGap-16\n___ 05:35AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3\n.\n===============\nIMAGING/STUDIES\n===============\nCHEST (PA & LAT) (___):\nFINDINGS: \nPA and lateral views of the chest provided. \n \nMild cardiomegaly is grossly unchanged from comparison study. \nThere is no \npneumothorax, effusion, or focal consolidation. There is no \npulmonary \ninterstitial edema or congestion. Imaged osseous structures are \nunremarkable. \nNo free air below the right hemidiaphragm is seen. \n \nIMPRESSION: \nCardiomegaly without pulmonary edema or other acute \nintrathoracic abnormality. \n\nECHO (___):\nFindings \nThis study was compared to the prior study of ___. \nLEFT ATRIUM: Moderate ___. \n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. Normal \ninteratrial septum. IVC dilated (>2.1cm) with <50% decrease with \nsniff (estimated RA pressure (>=15 mmHg). \n\nLEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size. \n[Intrinsic LV systolic function likely depressed given the \nseverity of valvular regurgitation.] Estimated cardiac index is \ndepressed (<2.0L/min/m2). No LV mass/thrombus. TDI E/e' >13, \nsuggesting PCWP>18mmHg. No resting LVOT gradient. \n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free \nwall hypokinesis. [Intrinsic RV systolic function likely more \ndepressed given the severity of TR]. Abnormal septal \nmotion/position consistent with RV pressure/volume overload. \nProminent moderator band/trabeculations are noted in the RV \napex. \n\nAORTA: Mildy dilated aortic root. Mildly dilated ascending \naorta. Mildly dilated aortic arch. \n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. AR vena \ncontracta is <0.3cm. Mild (1+) AR. \n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate \n(2+) MR. \n\n___ VALVE: Normal tricuspid valve leaflets. Moderate to \nsevere [3+] TR. Given severity of TR, PASP may be underestimated \ndue to elevated RA pressure. \n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. \nNo PS. Mild PR. \n\nPERICARDIUM: Very small pericardial effusion. \n\nGENERAL COMMENTS: Ascites. \nConclusions \n The left atrium is moderately dilated. The right atrium is \nmarkedly dilated. The estimated right atrial pressure is at \nleast 15 mmHg. There is severe symmetric left ventricular \nhypertrophy. The left ventricular cavity size is normal. \n[Intrinsic left ventricular systolic function is likely more \ndepressed given the severity of valvular regurgitation.] LVEF = \n50 %. The estimated cardiac index is depressed (<2.0L/min/m2). \nNo masses or thrombi are seen in the left ventricle. Tissue \nDoppler imaging suggests an increased left ventricular filling \npressure (PCWP>18mmHg). The right ventricular cavity is mildly \ndilated with mild global free wall hypokinesis. [Intrinsic right \nventricular systolic function is likely more depressed given the \nseverity of tricuspid regurgitation.] There is abnormal septal \nmotion/position consistent with right ventricular \npressure/volume overload. The aortic root is mildly dilated at \nthe sinus level. The ascending aorta is mildly dilated. The \naortic arch is mildly dilated. The aortic valve leaflets (3) \nappear structurally normal with good leaflet excursion. There is \nno aortic valve stenosis. Mild (1+) aortic regurgitation is \nseen. The mitral valve leaflets are structurally normal. There \nis no mitral valve prolapse. Moderate (2+) mitral regurgitation \nis seen. Moderate to severe [3+] tricuspid regurgitation is \nseen. [In the setting of at least moderate to severe tricuspid \nregurgitation, the estimated pulmonary artery systolic pressure \nmay be underestimated due to a very high right atrial pressure.] \nThere is a very small pericardial effusion. \n\n IMPRESSION: Marked symmetric left ventricular hypertrophy with \nnormal cavity size and global hypokinesis. Mild right \nventricular dilation and systolic dysfunction. Moderate to \nsevere tricuspid regurgitation. Moderate mitral regurgitation. \nIncreased PCWP and reduced cardiac index. Findings are \nsuggestive of an infiltrative cardiomyopathy, such as \namyloidosis. \n\n Compared with the prior study (images reviewed) of ___, \nthe severity of mitral and tricuspid regurgitation has \nincreased. Ascites is now present. \n\nCARDIAC CATHETERIZATION (___):\nCoronary Anatomy\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is normal\n* Left Anterior Descending\nThe LAD has a widely patent proximal stent. There is otherwise \nminimal disease.\nThe ___ Diagonal is a small vessel with 50% proximal disease\n* Circumflex\nThe Circumflex is normal.\n* Right Coronary Artery\nThe RCA has 90% stenosis just after the origin of a large normal \nacute marginal brsanch. Bejons this\nthere is a long segment of severe disease with total occlusion \nin the proximal PDA branch. The PDA fills\nvia left coronary collaterals\n\nImpressions:\nUpper normal PCW and PA pressures\nOccluded RCA ___ distal vessel filling via left coronary \narteries. Patent LAD stent\nSuccessful RV endomyocardial biopsy - specimens to be reporeted \nby Pathology\nRecommendations\nContinued medical therapy\n\nPATHOLOGY: MYOCARDIUM, BIOPSY (___):\nRight ventricular endomyocardial biopsy:\n- AMYLOID HEART DISEASE.\n- ___ Red and Trichrome stains highlight the interstitial \namyloid deposits.\n- Mild interstitial fibrosis (also highlighted by a Trichrome \nstain).\n- Specimen adequacy: Two fragments of myocardium and one \nfragment of fibrous tissue/blood clot.\n\n \nBrief Hospital Course:\n___ y/o man with a PMH of T2DM, CAD s/p DESx1 to LAD in ___, \npersistent atrial fibrillation (on dabigatran), hypertension, \nand hyperlipidemia, who presented with acute decompensated heart \nfailure (massive peripheral edema, 4 pillow orthopnea, cool \nextremities marked JVD, proBNP ___, lactate 2.3). \n.\n# Acute decompensated heart failure. Initially diuresed with IV \nfurosemide 5 mg gtt to dry weight of 75.6 kg. EKG demonstrated \ncoarse atrial fibrillation, rate of 62, Q waves in II, III, aVF, \npoor R wave progression, TTE demonstrated LVEF 50%, marked \nsymmetric left ventricular hypertrophy with normal cavity size \nand global hypokinesis, with moderate to severe TR and moderate \nMR suggestive of infiltrative cardiomyopathy. Underwent cardiac \ncatheterization which demonstrated occluded RCA with distal \nvessel filling via left coronary arteries and patient LAD stent. \nRight heart catheterization demonstrated pressures of RA: 6 \nmmHg, PA ___ mmHg, PCWP 13 mmHg, cardiac index 1.9. Underwent \nendomyocardial biopsy, which showed amyloid heart disease by \n___ Red and Trichome stains. Etiology of his acute heart \nfailure was therefore thought to be a mixed picture of ischemic \nand infiltrative. He was not treated with a beta blocker given \nheart rates in ___. He was subsequently transitioned to \nmaintenance diuresis with 20 mg torsemide daily. No ACE \ninhibitors were started given that the etiology of his heart \nfailure was likely amyloidosis. \n.\n# Atrial fibrillation. CHA2DS2-Vasc score of 6. He was switched \nfrom dabigatran to apixaban for anticoagulation. \n.\n# HLD. Switched from simvastatin to rosuvastatin 10 mg daily.\n.\n# T2DM. Home metformin was held, and he was placed on an insulin \nsliding scale. \n\n===================\nTRANSITIONAL ISSUES\n===================\n# Discharge weight: 78.1 kg\n# Discharge creatinine: 1.5\n# Patient to have labs drawn on ___ with results forwarded to \nDr. ___ at ___ service Ms. ___ and Dr. ___ \n___, intern and attending on ___ service\n# Patient has follow up with PCP on following week; please have \nweight rechecked on this visit. If significant weight ___ \nconsider titrating torsemide dose and contacting Dr. ___ \n___ CHF attending on week of ___ and Dr. ___\n# Medication changes: Aspirin reduced from full-dose to 81 mg \ndaily. Started apixaban 5 mg daily. Started iron \nsupplementation. Home lisinopril and spironolactone were \nstopped. Maintenance diuresis was started with 20 mg torsemide \ndaily. \n-The patient's simvastatin was switched to rosuvastatin 10 mg \ndaily\n# CODE: FULL\n# CONTACT: ___ (friend), ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Dabigatran Etexilate 150 mg PO BID \n2. Furosemide 20 mg PO DAILY \n3. Lisinopril 5 mg PO DAILY \n4. MetFORMIN (Glucophage) 500 mg PO BID \n5. Simvastatin 40 mg PO QPM \n6. Spironolactone 12.5 mg PO DAILY \n7. Aspirin 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0\n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 (one) tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n3. Ferrous Sulfate 325 mg PO BID \nRX *ferrous sulfate 325 mg (65 mg iron) 1 (one) tablet(s) by \nmouth daily Disp #*30 Tablet Refills:*0\n4. MetFORMIN (Glucophage) 500 mg PO BID \n5. Rosuvastatin Calcium 10 mg PO QPM \nRX *rosuvastatin [Crestor] 10 mg 1 (one) tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n6. Torsemide 20 mg PO DAILY \nRX *torsemide 20 mg 1 (one) tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n=================\nPRIMARY DIAGNOSES\n=================\n- acute decompensated systolic heart failure\n- amyloidosis\n- atrial fibrillation\n\n===================\nSECONDARY DIAGNOSES\n===================\n- type 2 diabetes mellitus\n- hypertension\n- hyperlipidemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure caring for you at ___ \n___. \n\nYou were admitted with worsening heart failure. While you were \nhere, we gave you diuretics, which are medications to help you \nurinate. First, we did this through your IV and then we switched \nyou to an oral regimen. \n\nAt discharge, you weighed 172 pounds. It is very important that \nyou weigh yourself every morning before getting dressed and \nafter going to the bathroom. Call your doctors if your ___ \ngoes up by more than 3 lbs in 1 day or more than 5 lbs in 3 \ndays.\n\nWe wish you all the best! \n\nWarmly,\nYour ___ Cardiology team\n\n \nFollowup Instructions:\n___\n" ]

[ "I5021", "E873", "E854", "I43", "I481", "I081", "Z7901", "I10", "I2510", "E785", "E119", "Z955" ]

[ "I5021: Acute systolic (congestive) heart failure", "E873: Alkalosis", "E854: Organ-limited amyloidosis", "I43: Cardiomyopathy in diseases classified elsewhere", "I481: Persistent atrial fibrillation", "I081: Rheumatic disorders of both mitral and tricuspid valves", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z955: Presence of coronary angioplasty implant and graft" ]

[ "Z7901", "I10", "I2510", "E785", "E119", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLipitor / Atenolol\n \nAttending: ___.\n \nChief Complaint:\nFall with trauma and ___ \n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ w/ systolic heart failure on dobutamine gtt, \nischemic/amyloid cardiomyopathy, Afib on apixaban, and s/p BiV \nPPM for multilevel disease, coronary artery disease s/p DES x1 \nto LAD (___), DM2, CKD3, HTN, presenting after a fall. Patient \nstates Was getting out of his car when he fell today. It is \nunclear if fall was mechanical or syncopal, he believes he was \nreaching for his cane but does not recall the events exactly. He \nfell forward and hit his face on the curb but denies LOC. No \nassociated CP, SOB, palpitations. He has had oral bleeding since \nthe injury. \n\nIn the ED, initial vitals: T 97.5F, 94, 91/60, 18, 100%RA\n - Exam notable for: 3cm laceration to bridge of nose with \nhematoma, scattered abrasions to face, small stellate interior \nupper lip laceration not containing tooth. He is missing tooth \n10. Tooth 8 and 9 are chipped. No C-spine tenderness or pain \nwith ROM neck No chest wall tenderness. Ranging hips w/o \ndiscomfort.\n - Labs notable for: WBC 4.8, Hgb 11.4, Plt 126, Na 127, BUN/Cr \n73/2.8\n - Imaging notable for: CT Head w/o acute process, CXR w/ , CT \nSinus/Mandible/Maxillofacial w/ ___ tooth 10 is not visualized. \nSuspected fractures seen through the tips of the roots ___ \ntooth numbers 24 and 25. No facial fracture.\nSoft tissue swelling overlying the nasal bridge and overlying \nthe chin on the left without underlying fracture.\n - Patient given: KCl 40meQ, Torsemide 100mg qd, Metformin \n500mg, Rosuvastatin 10mg, TDaP\n- His lip was sutured. \n - Vitals prior to transfer: 97.7F, 95, 96/68, 16, 100% RA\n\nHe was admitted to cardiology for ___ (Cr 2.8 from 1.6) and for \nmonitoring of oropharyngeal bleeding on eliquis which has been \nstable/resolved. \n \nPast Medical History:\nCoronary artery disease s/p DES x1 to LAD (___)\nCombined systolic and diastolic HF (EF 22%) on dobutamine gtt\nMixed ischemic/senile amyloid cardiomyopathy\nTTR amyloid \nHypertension\nHyperlipidemia\nAtrial fibrillation on apixaban\nInfranodal AV disease with multilevel conduction disease s/p \nBi-V pacemaker ___ Valitude ___\nLumbar spinal stenosis\nDiabetes mellitus 2\nChronic kidney disease stage III (Baseline Cr 1.4-1.6) - suspect \ndue to low CO\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: 97.7F, 95, 96/68, 16, 100% RA\nGeneral: Alert, oriented, no acute distress \nHEENT: abrasion of forehead and lips with dried blood around \nmouth \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 \nSkin: Without rashes or lesions \nNeuro: A&Ox3. Grossly intact.\n\nDISCHARGE PHYSICAL EXAM:\nVitals: 98.0 ___ 80s-90s/___-70s 100%RA\nI/O= 2701/2925\nWeight: 69.4 <-- 68.5 <-- 70.1 <-- 71.0<--72.2<--71.2<--70.5 \n<--71.9 <-- 70.2\nWeight on admission: 69.0 \nTelemetry: V-paced\n\nGeneral: Alert, oriented, no acute distress \nHEENT: abrasion of forehead and lips with dried blood around \nmouth \nNeck: JVP to mid-neck at 90 degrees\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 lower extremities from shin down, no clubbing or \nedema. \nSkin: Without rashes or lesions\nNeuro: A&Ox3. Grossly intact.\n \nPertinent Results:\n======================================\nADMISSION/IMPORTANT LABS\n======================================\n___ 10:15PM BLOOD WBC-4.8 RBC-3.38* Hgb-11.4* Hct-35.0* \nMCV-104* MCH-33.7* MCHC-32.6 RDW-16.0* RDWSD-61.0* Plt ___\n___ 10:15PM BLOOD Neuts-69.5 Lymphs-18.2* Monos-9.0 Eos-1.7 \nBaso-1.0 NRBC-0.6* Im ___ AbsNeut-3.33 AbsLymp-0.87* \nAbsMono-0.43 AbsEos-0.08 AbsBaso-0.05\n___ 10:15PM BLOOD ___ PTT-34.7 ___\n___ 10:15PM BLOOD Glucose-103* UreaN-73* Creat-2.8* Na-127* \nK-4.2 Cl-86* HCO3-22 AnGap-23*\n___ 06:40AM BLOOD ALT-17 AST-33 LD(LDH)-358* AlkPhos-117 \nTotBili-2.6*\n___ 06:40AM BLOOD CK-MB-20* cTropnT-0.15* ___\n___ 11:54AM BLOOD CK-MB-17* MB Indx-3.9\n___ 06:40AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8\n___ 06:47PM BLOOD Type-MIX pH-7.43\n___ 06:40AM BLOOD Lactate-3.0*\n___ 08:26AM BLOOD Lactate-3.0*\n___ 07:50AM BLOOD Lactate-1.6\n___ 06:47PM BLOOD Lactate-2.3*\n___ 10:39AM BLOOD Lactate-1.9\n___ 09:12AM BLOOD Lactate-1.3\n___ 09:30AM BLOOD Lactate-2.2*\n___ 03:34PM BLOOD Lactate-2.1*\n___ 05:08PM BLOOD O2 Sat-47\n___ 05:46AM BLOOD O2 Sat-55\n___ 05:06AM BLOOD O2 Sat-88\n___ 06:47PM BLOOD O2 Sat-60\n___ 10:39AM BLOOD O2 Sat-49\n___ 05:06AM BLOOD O2 Sat-79\n___ 09:12AM BLOOD O2 Sat-56\n\n=======================================\nMICROBIOLOGY\n=======================================\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n=======================================\nIMAGING/STUDIES\n=======================================\nCXR ___: Cardiomegaly without superimposed acute \ncardiopulmonary process.\n\nCT SINUS MANDIBLE/MAXILLARY:\n___ tooth 10 is not visualized. Suspected fractures seen \nthrough the tips of \nthe roots ___ tooth numbers 24 and 25. No facial fracture. \n \nSoft tissue swelling overlying the nasal bridge and overlying \nthe chin on the \nleft without underlying fracture. \n\nCT HEAD ___:\nNo acute intracranial process.\n\nCHEST XR ___:\nIn comparison to ___ radiograph, a right PICC is \npresent, \nterminating in the expected location of the cavoatrial junction. \n Persistent \nmarked cardiomegaly without evidence of pulmonary edema. \n\n=======================================\nDISCHARGE LABS\n=======================================\n___ 05:58AM BLOOD WBC-4.7 RBC-3.04* Hgb-10.4* Hct-32.5* \nMCV-107* MCH-34.2* MCHC-32.0 RDW-17.2* RDWSD-67.0* Plt ___\n___ 05:58AM BLOOD Glucose-93 UreaN-79* Creat-1.9* Na-131* \nK-3.4 Cl-87* HCO3-27 AnGap-20\n___ 04:41AM BLOOD ALT-19 AST-32 LD(LDH)-330* AlkPhos-149* \nTotBili-2.5*\n___ 03:42AM BLOOD ALT-19 AST-33 LD(LDH)-353* AlkPhos-143* \nTotBili-2.6* DirBili-1.4* IndBili-1.2\n___ 05:58AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.7*\n___ 03:34PM BLOOD Lactate-2.1*\n \nBrief Hospital Course:\nMr. ___ is a ___ year old gentleman with advanced heart \nfailure on dobutamine gtt, ischemic/amyloid cardiomyopathy, Afib \non apixaban, and s/p BiV PPM for multilevel disease, coronary \nartery disease s/p DES x1 to LAD (___), DM2, CKD3, HTN, \npresenting after a fall with s/s HF exacerbation (elev JVP, \nhyponatremia, ___ on CKD). \n\n# Acute on chronic systolic heart failure exacerbation: \nPt has ischemic/amyloid cardiomyopathy on dobutamine gtt at home \nwith EF 22%. On admission, Cr 2.8 from 1.6, elevated JVP, and \nhyponatremia to 127, suggestive of AoC CHF exacerbation. \nPrecipitating factor unclear given he is adherent to \nmedications, though there may be a component of dietary \nindiscretion. No chest pain. Story of fall was not suggestive of \nsyncope given that there was no loss of consciousness. Lactate \n3.0, but there was no evidence of shock on exam, and this \ndowntrended. Pro-BNP elevated at ___ with prior ___ in \nclinic with mild exacerbation in ___. CK-MB index was flat. \nPacer function normal with acceptable lead measurements and \nbattery status. SvO2 was low at 47 on ___ and improved to 55 on \n___. Lactate improved to 1.3. He was diuresed with lasix gtt at \n25, IV lasix boluses of 160mg and metolazone 1.25mg as needed. \n___ and hyponatremia improved with diuresis. Diuresis course was \nprolonged by the fact that the patient was drinking water from \nthe sink. Evenutally approached euvolemia and was transitioned \nto PO torsemide 100mg BID (home dose). Dobutamine drip was \nincreased to 5 from 2.5 because of low lactate, poor diuresis, \nand mildly cool extremities on exam. He felt symptomatic \nimprovement with increase in dobutamine. Spironolactone was \ninitially held for ___, but re-started as ___ resolved (with \ndiuresis). Of note, the patient admitted to driving, and was \ncounseled on the dangers of driving given his advanced heart \nfailure requiring dobutamine gtt.\n [ ] Medication change: dobutamine gtt increased to 5 from \n2.5. \n [ ] Continue to counsel patient on the dangers of driving \ngiven his condition.\n\n#Facial trauma: \nHad open wound on front of forehead, as well as several tooth \ninjuries and bleeding from the mouth. OMFS was consulted and \nrecommended no surgery at this time. Sutures were placed in the \nED for the forehead lesion, and removed after 5 days. Panorex \nscan revealed fractured central incisors, upper left lateral \nincisor appears to have been lost. Dental was consulted and \nrecommended full dental evaluation and restoration as an \noutpatient. Patient experienced occaisional oozing, which \nresolved with pressure and biting down on gauze. Bleeding, \nswelling and erythma were markedly improved at discharge.\n [ ] Full dental evaluation and restoration as outpatient\n\n#Atrial fibrillation:\nApixiban was initially held given his mouth wounds and bleeding. \nIt was re-started at lower dose of 2.5mg for the ___ and ___ \nincreased to 5mg once ___ improved.\n\n#CHRONIC\n-HLD: continued rosuvstatin\n-CAD: continued ASA and rosuvastatin\n-DMII: held metformin, started ISS\n\n=============================\nTRANSITIONAL ISSUES\n=============================\n [ ] Medication change: dobutamine gtt increased to 5 from \n2.5. \n [ ] Continue to counsel patient on the dangers of driving \ngiven his condition.\n [ ] Full dental evaluation and restoration as outpatient.\n [ ] Home ___.\n\nDischarge weight: 69.4 kg\nDischarge Cr: 1.9\nDischarge Hgb: 10.4\n\n# CODE STATUS: DNR/DNI \n# CONTACT/HCP: ___ (landlady): ___. Preferred HCP \nis brother Dr. ___, but patient does not have \nnumber. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Apixaban 5 mg PO BID \n2. DOBUTamine 2.5 mcg/kg/min IV DRIP INFUSION \n3. MetFORMIN (Glucophage) 500 mg PO BID \n4. Metolazone 1.25 mg PO ONLY AS DIRECTED BY CARDIOLOGY \n5. Potassium Chloride 40 mEq PO BID \n6. Rosuvastatin Calcium 10 mg PO QPM \n7. Spironolactone 12.5 mg PO DAILY \n8. Torsemide 100 mg PO BID \n9. Aspirin 81 mg PO DAILY \n10. Ferrous Sulfate 325 mg PO BID \n\n \nDischarge Medications:\n1. DOBUTamine 5 mcg/kg/min IV DRIP INFUSION \nRX *dobutamine 250 mg/20 mL (12.5 mg/mL) 5 mcg/kg/min IV \ncontinuous infusion Disp #*52 Vial Refills:*0 \n2. Apixaban 5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Ferrous Sulfate 325 mg PO BID \n5. MetFORMIN (Glucophage) 500 mg PO BID \n6. Metolazone 1.25 mg PO ONLY AS DIRECTED BY CARDIOLOGY \n7. Potassium Chloride 40 mEq PO BID \nHold for K > \n8. Rosuvastatin Calcium 10 mg PO QPM \n9. Spironolactone 12.5 mg PO DAILY \n10. Torsemide 100 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\n - Acute on chronic systolic heart failure exacerbation.\n - Facial trauma.\n - Dental fractures.\n\nSecondary:\n - Atrial fibrillation.\n - Diabetes.\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 ___ because you had a fall and \nwere found to have a heart failure exacerbation.\n\nWhile you were here, the oral surgeons saw you and you did not \nneed any surgery. The dentists saw you and recommended you see a \ndentist after the hospitalization to repair your teeth. You were \nhaving a heart failure exacerbation, with too much fluid backing \nup from your heart. We gave you lasix and metolazone to help \nremove some of the fluid. Eventually, you were able to go back \nonto your home torsemide. We increased your dobutamine drip to 5 \nfrom 2.5, and you felt better.\n\nWhen you go home, it is very important that you DO NOT DRIVE. \nDriving can be very dangerous because your heart could go into \nan abnormal heart rhythm and you could pass out behind the \nwheel. Please weigh yourself every morning and call your doctor \nif weight goes up more than 3 lbs. Your medications and \nappointments are below.\n\nIt was a pleasure taking care of you!\n\nSincerely,\nYour ___ Cardiology Team\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5023", "N179", "E854", "E1122", "I43", "E871", "I4891", "N183", "I2510", "Z66", "Z955", "E785", "Z7902", "S025XXA", "W101XXA", "S0181XA", "Y929", "I255", "E669", "Z6823", "S01511A", "S0121XA", "Z45018", "V484XXA" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "E854: Organ-limited amyloidosis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I43: Cardiomyopathy in diseases classified elsewhere", "E871: Hypo-osmolality and hyponatremia", "I4891: Unspecified atrial fibrillation", "N183: Chronic kidney disease, stage 3 (moderate)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z66: Do not resuscitate", "Z955: Presence of coronary angioplasty implant and graft", "E785: Hyperlipidemia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "S025XXA: Fracture of tooth (traumatic), initial encounter for closed fracture", "W101XXA: Fall (on)(from) sidewalk curb, initial encounter", "S0181XA: Laceration without foreign body of other part of head, initial encounter", "Y929: Unspecified place or not applicable", "I255: Ischemic cardiomyopathy", "E669: Obesity, unspecified", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "S01511A: Laceration without foreign body of lip, initial encounter", "S0121XA: Laceration without foreign body of nose, initial encounter", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "V484XXA: Person boarding or alighting a car injured in noncollision transport accident, initial encounter" ]

[ "I130", "N179", "E1122", "E871", "I4891", "I2510", "Z66", "Z955", "E785", "Z7902", "Y929", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLipitor / Atenolol\n \nAttending: ___.\n \nChief Complaint:\nDyspnea, Fatigue \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo male with PMH significant for mixed \nischemic/senile amyloid cardiomyopathy, chronic systolic heart \nfailure (EF 50%), severe tricuspid regurgitation, moderate \nmitral regurgitation, mild pulmonary hypertension, coronary \nartery disease s/p PCI to LAD, atrial fibrillation, and history \nof high degree AV block s/p biventricular pacemaker presenting \nwith increased dyspnea and fatigue. The patient was last seen in \n___ clinic on ___ during which time he stated that his \nbreathing became more labored and he felt more fatigued. He \nstated that by noontime his legs feel tired and it is difficult \nto catch his breath. The patient states that he can walk about \n50 feet before feeling short of breath. He denies CP, \npalpitations, nausea, dizziness, lightheadedness, presyncope, or \nsyncope. Of note, the patient states that he has noticed greater \northopnea and has had a poor appetite. \n\nThe was last hospitalized at ___ from ___ for \nnewly diagnosed AV block necessitating biventricular pacemaker \nimplantation ___ Valitude ___. He has \nsubsequently followed up in the heart failure clinic several \ntimes, most recently with the nurse practitioner on ___. At \nhis last visit, Mr. ___ complained of mildly increased \ndyspnea and fatigue. His weight at the time was 154 lbs and he \nappeared euvolemic on exam. His device was interrogated and he \nwas noted to be Bi-V paced only 92% of the time. Therefore, \nseveral programming changes were made as well as his rate \nincreased to 80 bpm (for potential symptomatic benefit). No \nmedication changes were made. \n\nOn the floor, the patient's vital signs were T 97.7F, BP 91/63, \nHR 80, RR 18, PO2 99% RA. He denied shortness of breath, CP, \nlightheadedness, dizziness, nausea, or vomiting. \n\n \nPast Medical History:\nCoronary artery disease \ns/p DES x1 to LAD (___)\nChronic systolic heart failure EF 30% \nTTR amyloid \nHypertension\nHyperlipidemia\nAtrial fibrillation\nLumbar spinal stenosis\nDiabetes mellitus 2\nChronic kidney disease stage III\n \n \n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \nPhysical Exam:\nON ADMISSION:\nT 97.7F, BP: 91/63, HR: 80, RR 18, PO2 99% RA\nWeight: 73.2 kg \nGeneral: ___ male, no acute distress \nHEENT: NC/AT, PERRL, EOMI, MMM, neck supple; +elevated JVP to \nbase of jaw at 90 degrees (~15 cm H2O) with dilated EJ \nLungs: CTA bilaterally, no crackles/rhonchi/wheezes\nCV: Irregularly irregular, no audible murmurs; no edema\nAbd: Soft, NT/ND, +BS\nExt: Slightly cool thighs with 2+ ___ pulses bilaterally; no\nclubbing, cyanosis, or edema \nNeuro: A&O x 4, no focal neurologic deficits\n\nON DISCHARGE:\nVS: T 97.6, BP: 88/53, HR: 95, RR: 18, PO2: 100 RA\nI/O: 24h ___ (-725cc), 8h ___ (-900cc)\nWeight: 73.2 kg > 70.9 > 71.5 > 70.4 > 71.8 > 71.1 > 72.6\nGeneral: ___ male, no acute distress \nHEENT: NC/AT, PERRL, EOMI, MMM, neck supple; JVP ~8 cm H2O\nLungs: CTA bilaterally, no crackles/rhonchi/wheezes\nCV: Irregularly irregular, no m/r/g\nAbd: Soft, NT/ND, +BS\nExt: WWP with 2+ DP pulses bilaterally; no clubbing, cyanosis, \nor edema \nNeuro: AAOx3, no focal neurologic deficits\n \nPertinent Results:\nADMISSION LABS:\n___ 04:56PM BLOOD ___ PTT-36.5 ___\n___ 04:56PM BLOOD Glucose-70 UreaN-43* Creat-1.9* Na-132* \nK-4.0 Cl-95* HCO3-20* AnGap-21*\n___ 04:56PM BLOOD ALT-18 AST-32 LD(LDH)-373* AlkPhos-118 \nTotBili-2.3*\n___ 04:56PM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.0 Mg-1.6\n\nINTERVAL LABS:\n___ 06:20AM BLOOD WBC-3.3* RBC-3.51* Hgb-11.8* Hct-37.3* \nMCV-106* MCH-33.6* MCHC-31.6* RDW-15.2 RDWSD-59.7* Plt ___\n___ 06:40AM BLOOD WBC-4.1 RBC-3.67* Hgb-12.4* Hct-39.6* \nMCV-108* MCH-33.8* MCHC-31.3* RDW-15.2 RDWSD-59.8* Plt ___\n___ 06:40AM BLOOD WBC-4.6 RBC-3.46* Hgb-11.7* Hct-37.5* \nMCV-108* MCH-33.8* MCHC-31.2* RDW-15.6* RDWSD-62.0* Plt ___\n___ 06:20AM BLOOD Neuts-49.8 ___ Monos-13.0 Eos-3.9 \nBaso-1.5* Im ___ AbsNeut-1.64 AbsLymp-1.04* AbsMono-0.43 \nAbsEos-0.13 AbsBaso-0.05\n___ 04:56PM BLOOD Plt ___\n___ 06:20AM BLOOD ___ PTT-36.5 ___\n___ 05:29AM BLOOD ___ PTT-34.9 ___\n___ 05:29AM BLOOD Plt ___\n___ 06:20AM BLOOD Glucose-57* UreaN-42* Creat-1.8* Na-137 \nK-3.4 Cl-98 HCO3-24 AnGap-18\n___ 05:29AM BLOOD Glucose-95 UreaN-44* Creat-1.8* Na-138 \nK-4.3 Cl-99 HCO3-26 AnGap-17\n___ 08:45PM BLOOD Glucose-124* UreaN-49* Creat-1.6* Na-137 \nK-3.6 Cl-98 HCO3-27 AnGap-16\n___ 04:16PM BLOOD Glucose-113* UreaN-46* Creat-1.5* Na-140 \nK-3.8 Cl-98 HCO3-29 AnGap-17\n___ 11:54PM BLOOD Glucose-96 UreaN-52* Creat-1.5* Na-135 \nK-3.3 Cl-97 HCO3-27 AnGap-14\n___ 12:32AM BLOOD Glucose-113* UreaN-61* Creat-1.5* Na-137 \nK-3.9 Cl-98 HCO3-24 AnGap-19\n___ 06:20AM BLOOD ALT-17 AST-29 LD(LDH)-351* AlkPhos-117 \nTotBili-2.2*\n___ 06:40AM BLOOD ALT-16 AST-25 LD(LDH)-306* AlkPhos-127 \nTotBili-2.1*\n___ 02:55PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.3\n___ 06:17AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2\n___:32AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.3\n\nDISCHARGE LABS:\n___ 06:14AM BLOOD WBC-4.2 RBC-3.47* Hgb-11.8* Hct-37.2* \nMCV-107* MCH-34.0* MCHC-31.7* RDW-15.3 RDWSD-60.0* Plt ___\n___ 06:14AM BLOOD Plt ___\n___ 06:14AM BLOOD Glucose-91 UreaN-59* Creat-1.4* Na-140 \nK-3.6 Cl-99 HCO3-24 AnGap-21*\n___ 06:14AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.3\n\nIMAGING:\n\nCHEST (PORTABLE AP) ___:\n \nIMPRESSION: \nComparison to ___. No relevant change. Moderate \ncardiomegaly with elongation of the descending aorta. No \npulmonary edema. No pleural \neffusions. No pneumonia. Left pectoral pacemaker in situ. \n\nECG (___):\nProbable underlying atrial fibrillation with biventricular \npacing. Low QRS\nvoltage throughout, most consistent with a dilated \ncardiomyopathy.\nTRACING #2\n\nECHO (___):\nThe left atrium is moderately dilated. No atrial septal defect \nis seen by 2D or color Doppler. The estimated right atrial \npressure is ___ mmHg. There is moderate symmetric left \nventricular hypertrophy with normal cavity size. There is severe \nglobal left ventricular hypokinesis. Systolic function of apical \nsegments is relatively preserved. Quantitative (biplane) LVEF = \n22 %. The right ventricular cavity is mildly dilated with \nmoderate global free wall hypokinesis. The aortic arch and \ndescending thoracic aorta are mildly dilated. The aortic valve \nleaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosisn. Mild (1+) aortic \nregurgitation is seen. The mitral valve leaflets are \nstructurally normal. There is no mitral valve prolapse. Mild \n(1+) mitral regurgitation is seen. There is mild pulmonary \nartery systolic hypertension. Significant pulmonic regurgitation \nis seen. The end-diastolic pulmonic regurgitation velocity is \nincreased suggesting pulmonary artery diastolic hypertension. \n\nIMPRESSION: Symmetric left ventricular hypertrophy with severe \nglobal biventricular hypokinesis in a pattern most suggestive of \nan infiltrative process (e.g., amyloid). Mild mitral \nregurgitation. Mild aortic regurgitation. PA hypertension.\n\nCompared with the prior study (images reviewed) of ___, \nglobal left ventricular systolic function is slightly worse. \n\nCLINICAL IMPLICATIONS: \nThe left ventricular ejection fraction is <40%, a threshold for \nwhich the patient may benefit from a beta blocker and an ACE \ninhibitor or ___. \n\nMICROBIOLOGY:\nNone\n\n \nBrief Hospital Course:\n#Acute on Chronic Systolic heart failure: Mixed ischemic and \nnon-ischemic cardiomyopathy (cardiac amyloid). Patient was \nadmitted with fatigue and dyspnea, decompensated possibly in the \nsetting of increased Afib burden vs excessive fluid intake vs \nprogression of advanced CHF. Patient diuresed with Lasix 120 mg \nIV on admission on ___, 80 mg IV on ___. Patient's volume \nexam was not very convincing for hypervolemia apart from \nmarkedly elevated JVD. Transitioned from IV diuretics to \ntorsemide PO. Patient markedly improved since admission despite \nhis current weight being roughly his weight on admission. It \nseems likely that setting his BiV pacer to 95 helped to resolve \nhis dyspnea on exertion in combination with diuresis as this \nchange occurred just prior to him beginning to feel subjectively \nbetter. He will be discharged with close cardiology follow up.\n\n#Atrial fibrillation: Patient with BiV pacer implant on ___. \nPrevious EKGs showed e/o atrial tachycardia vs. atrial flutter.\n- Continued apixiban 5 mg PO BID \n\n#CKD: Patient with stage 3 CKD, baseline Cr around 1.5, elevated \nat 1.9 on admission. Improved to 1.4 at time of discharge.\n-continue to monitor \n-renally dose medications \n- Avoid nephrotoxins \n\n# HLD: Patient noted to have muscle aches on atorvastatin. \nStatin held at time of discharge but can be can possibly be \nrestarted as an outpatient.\n\n# T2DM: ISS while in hospital.\n\nTRANSITIONAL ISSUES:\nDischarge weight: 72.6kg\nDischarge diuretics: Torsemide 80 mg PO/NG DAILY \nDischarge afterload: None\n- Follow up with PCP and cardiologist for potential changes to \nheart failure regimen\n- Consider re-starting rosuvastatin. Stopped during \nhospitalization due to reported muscle cramps.\n- Changed potassium 60 mEq BID to 60 mEq daily. Please follow up \nwith electrolyte check at next PCP ___.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Potassium Chloride 60 mEq PO BID \n2. Aspirin 81 mg PO DAILY \n3. Ferrous Sulfate 325 mg PO BID \n4. Apixaban 5 mg PO BID \n5. Torsemide 80 mg PO DAILY \n\n \nDischarge Medications:\n1. Potassium Chloride 60 mEq PO DAILY \nRX *potassium chloride 20 mEq 3 tablet(s) by mouth daily Disp \n#*90 Tablet Refills:*0 \n2. Apixaban 5 mg PO BID \n3. Aspirin 81 mg PO DAILY \n4. Ferrous Sulfate 325 mg PO BID \n5. MetFORMIN (Glucophage) 500 mg PO BID \n6. Torsemide 80 mg PO DAILY \nRX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet \nRefills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnoses:\n- Acute on chronic systolic heart failure\n- Atrial fibrillation\n- Chronic kidney disease stage 3\n\nSecondary diagnoses:\n- Hyperlipidemia\n- Type 2 diabetes mellitus\n- Severe malnutrition\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___,\n\nIt was a pleasure taking care of you. You were admitted to the \nhospital because you were having shortness of breath when \nexerting yourself. We believe this was because your heart was \nhaving a difficult time managing the fluid in your body. You \nwere given diuretics to help take fluid off.\n\nWhen you leave the hospital, it is very important that you take \nyour medications as directed. Weigh yourself every morning, call \nMD if weight goes up more than 3 lbs. You will follow up with \nyour PCP, ___ your cardiologist, Dr. ___.\n\nAll our best,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I5023", "E43", "N179", "E854", "I4891", "I428", "I361", "I340", "I43", "I130", "Z6825", "E785", "I2510", "N183", "M4806", "I4430", "Z955", "Z950", "Z7901" ]

[ "I5023: Acute on chronic systolic (congestive) heart failure", "E43: Unspecified severe protein-calorie malnutrition", "N179: Acute kidney failure, unspecified", "E854: Organ-limited amyloidosis", "I4891: Unspecified atrial fibrillation", "I428: Other cardiomyopathies", "I361: Nonrheumatic tricuspid (valve) insufficiency", "I340: Nonrheumatic mitral (valve) insufficiency", "I43: Cardiomyopathy in diseases classified elsewhere", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N183: Chronic kidney disease, stage 3 (moderate)", "M4806: Spinal stenosis, lumbar region", "I4430: Unspecified atrioventricular block", "Z955: Presence of coronary angioplasty implant and graft", "Z950: Presence of cardiac pacemaker", "Z7901: Long term (current) use of anticoagulants" ]

[ "N179", "I4891", "I130", "E785", "I2510", "Z955", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / oxycodone\n \nAttending: ___.\n \nChief Complaint:\nSyncope\n \nMajor Surgical or Invasive Procedure:\nPacemaker and ICD placement \n\n \nHistory of Present Illness:\n___ yo M with atrial fibrillation on rivaroxaban, CAD s/p stent\nplacement (unknown vessel), HFrEF (EF ___, mitral valve\nprolapse, HTN, HLD, depression, multiple spine surgeries,\ncholecystectomy who presents from heart failure clinic for acute\nHF management. \n\nOn arrival, patient was alert and oriented with no distress with\nO2 at\n3L 89% sats. At 3pm, he had a sip of water, and then started\ncoughing\nand vomiting during phlebotomy. Per PCT, he passed out briefly\nwith his eyes rolling back in his head and he was unconscious \nfor\na few minutes. He responded to calling his name and shaking. He\nthen started coughing and was disoriented. He vomited brown\nbilous mucous/clear. His systolic blood pressure was in the low\n___ and he was then put on 4L of O2 and his coughing and \nvomiting\nstopped. He remembers drinking water but not precipitating\nevents. There were no reported shaking episodes or stool/urine\nincontinence. \n\nOf note, patient recently discharged from ___ on ___. He\nwas found to have acute heart failure exacerbation likely due to\nmissed diuretic doses at rehab. He was treating with Lasix drip\nin the MICU as well as anitbiotics (vancomycin, ceftazidime, and\nazithromycin) for HCAP. While here, he developed ___ on CKD with\na discharge creatinine of 1.7 (baseline of 1.1-1.2) thought to \nbe\nin setting of possible diuresis and initiation of spironolactone\nand ace-I and also elevated vancomycin level (66) several days\nprior to d/c.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n=======================\n1. CARDIAC RISK FACTORS \n- Hypertension \n- Dyslipidemia \n\n2. CARDIAC HISTORY \n- CAD s/p stent placement\n- CHF with EF ___\n- Afib on warfarin\n- mitral valve prolapse\n\n3. OTHER PAST MEDICAL HISTORY \ndepression\nchronic neck pain secondary to cervical disc disease\nmultiple spine surgeries including fusion of L-S1 laminectomy \ncholecystectomy\nTotal knee replacement\nB/l shoulder surgery\nc diff infection ___\n \nSocial History:\n___\nFamily History:\nMother: alive, age ___. Macular degeneration\nFather: deceased in mid ___. ?brain tumor and heart issues\n\n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nGENERAL: Well developed, pleasant, lying in bed in NAD. Oriented\nx3. Mood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva\npink. No pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple. JVP to earlobe at 30 degrees. \nCARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs, \nor gallops. No thrills or\nlifts. \nLUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. Clear to auscultation \nbilaterally. No wheezes, rales, or rhonchi.\nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No\nsplenomegaly. \nEXTREMITIES: Patient with warm distal extremities and warm\nproximal extremities. 1+-2+ peripheral edema to the mid-shin. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nDischarge Physical Exam:\n========================\n\n24 HR Data (last updated ___ @ 917)\n Temp: 97.4 (Tm 99.1), BP: 92/56 (88-116/44-73), HR: 80\n(75-96), RR: 20 (___), O2 sat: 92% (92-95), O2 delivery: RA,\nWt: 183.2 lb/83.1 kg \n\nI: 660 O: ___ B: -___ \n\nWt: 83.1 kg <- 84 kg <- 84.2 kg <- 83.7 kg <- 82.6 kg <- 82.9 \nkg\n<- 83.2<-83.0 kg <- 82.6 kg <- 84.7 kg <- 87.1 kg <- 87 kg <-\n87.09 <- 86.96 <- 90.22\n\nTele: AFib with no paced beats\n\nGENERAL: Well developed, pleasant, lying in bed in NAD. Oriented\nx3. Mood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva\npink. \nNECK: Supple. JVP 10 cm\nCARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs,\nor gallops. No thrills or lifts. \nLUNGS: No chest wall deformities or tenderness. Respiration is\ncomfortable, particularly when laying flat. trace bibasilar\ncrackles R side > L. very diminished on R \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No\nsplenomegaly. \nEXTREMITIES: Patient with warm distal extremities and warm\nproximal extremities. no peripheral edema . \nPULSES: Distal pulses palpable and symmetric. \n\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 12:34PM BLOOD WBC-6.1 RBC-2.40* Hgb-7.6* Hct-25.1* \nMCV-105* MCH-31.7 MCHC-30.3* RDW-16.1* RDWSD-62.5* Plt ___\n___ 09:30PM BLOOD Glucose-120* UreaN-57* Creat-1.8* Na-135 \nK-4.7 Cl-92* HCO3-26 AnGap-17\n___ 12:34PM BLOOD ALT-22 AST-38 LD(LDH)-259* AlkPhos-264* \nTotBili-1.1\n___ 04:52AM BLOOD ALT-292* AST-467* AlkPhos-357* \nTotBili-1.4\n___ 12:34PM BLOOD CK-MB-2 cTropnT-0.02* ___\n___ 12:34PM BLOOD TSH-4.6*\n___ 03:18PM BLOOD Lactate-3.3*\n\nImaging:\n========\nCXR ___:\nNo appreciable change since the prior chest radiograph including \nright lower\nlobe collapse and loculated right pleural fluid.\nCT Chest w/out contrast ___\nRenal U/S ___: No hydronephrosis. Trace perihepatic ascites\n\nCT CHEST W/O CONTRAST\nIMPRESSION:\n1. Unchanged volume of a moderate right pleural effusion with \ndecreased locule\nof gas likely from prior chest tube with persistent diffuse \npleural thickening\nand areas of dependent pleural nodularity. Correlation with \npleural fluid\nanalysis is advised.\n2. Previously seen extensive ground-glass opacities throughout \nthe left lung\nhave nearly completely resolved as has the left-sided pleural \neffusion.\n3. Stable 2 mm left lower lobe pulmonary nodules.\n4. Dilated main pulmonary artery to 4 cm suggesting pulmonary \narterial\nhypertension.\n5. Posterior gastric diverticulum.\n \nDischarge Labs:\n===============\n___ 06:20AM BLOOD WBC-5.9 RBC-2.65* Hgb-8.6* Hct-27.0* \nMCV-102* MCH-32.5* MCHC-31.9* RDW-16.4* RDWSD-61.2* Plt ___\n___ 07:25AM BLOOD Glucose-97 UreaN-39* Creat-1.3* Na-140 \nK-3.8 Cl-96 HCO3-31 AnGap-13\n___ 06:20AM BLOOD ALT-9 AST-14 AlkPhos-154* TotBili-0.7\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old man with a history of atrial \nfibrillation on rivaroxaban, CAD s/p stent placement (unknown \nvessel), HFrEF (EF ___, mitral valve prolapse, HTN, HLD, \ndepression, multiple spine surgeries, and cholecystectomy, who \ninitially presented from heart failure clinic for acute\nHF management. Subsequently, was noted to have sinus arrest and \nsyncope requiring placement of single-chamber ICD implant. His \nheart failure regimen was optimized but somewhat limited by \nhypotension.\n\nACUTE ISSUES: \n=============\n# SYNCOPE\n# SINUS PAUSES \n# SINUS ARREST \nThe patient experienced a 9-second pause with associated \nunresponsiveness. Subsequently was noted to have ventricular \nescape beats. The patient spontaneously recovered. He had an \nuncomplicated single-chamber ICD implant via L cephalic on \n___ without any further pauses or syncope. \n\n# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE \n# HYPOXEMIA \nThe patient has an EF of 34% ___, and presented with weight \ngain, elevated JVP, hypoxemia, evidence of pulmonary edema on \nCXR, all suggestive of acute decompensation, likely secondary to \ndecreased regimen at rehab due to a rise in creatinine. He \ninitially responded well to IV diuresis and was transitioned to \nPO diuretics, but again developed an oxygen requirement. He was \nplaced back on IV diuretics including a furosemide drip and once \neuvolemic was transitioned to PO torsemide 100 mg BID. He \nrequired intermittent metolozone. He required signifincant \nrepletion of low potassium levels prior to starting \nspironolactone. His metoprolol was increased and he did not \ntolerate afterload reduction given low blood pressures. His \nweight on discharge was 83.1 kg (183.2 lb).\n\n# RIGHT PLEURAL EFFUSION / TRAPPED LUNG \n# HYPOXEMIA \nThe patient has known right lower lobe collapse and loculated \nright pleural fluid, which appears similar to prior CXR. Given \nhistory of having been weaned off O2, and then having an \nincrease requirement with holding of diuresis, acute CHF \nexacerbation is most likely explanation for hypoxemia. He was \ndiuresed with improvement his oxygenation. Pulmonology was \nconsulted given hypoxia on exertion and believes that the \npatient may have some underlying COPD in addition to his CHF \ncontributing to hypoxia. He will benefit from having outpatient \npulmonary function testing and follow up with ___ clinic (IP \n+ thoracic surgery). \n\n# ATRIAL FIBRILLATION \nHe was transitioned to apixaban given high INRs on rivaroxaban \nand concern for GI bleed. Metoprolol was continued at a slightly \nreduced dose based on patient's tolerance. \n\n# MACROCYTIC ANEMIA\nThe patient has a hemoglobin baseline of ___, presenting with \nHgb 7.6. Methylmalonic acid was WNL during recent admission and \nferritin 500 suggesting anemia of chronic inflammation. Patient \ndoes have history of GI bleed requiring 2 pRBCs during last \nadmission. Denies melena, hematochezia. He received 1 U of blood \nthis admission and his hemoglobin was stable on discharge at \n8.6.\n\n# ___ on CKD\nBaseline ~1.2, however up to 1.7 on last discharge and on this \nadmission. Improved to near baseline with diuresis. Discharged \nwith Cr of 1.3.\n\nCHRONIC ISSUES:\n===============\n# CHRONIC PAIN\nThe patient has history of multiple prior spinal surgeries with \nardware in place. Etiology of pain is unclear but likely \nmultifactorial from degenerative disc disease and frequent \nsurgeries. He continued on prn lidocaine patches, gabapentin, \nand tramadol. \n\n# GOUT\nHe continued allopurinol.\n\n# DEPRESSION\nHe continued sertraline. \n\nTransitional Issues:\n====================\n[ ] DISCHARGE WEIGHT: 83.1 kg (183.2 lb) \n[ ] DISCHARGE DIURETIC: 100 torsemide BID\n[ ] DISCHARGE Cr/BUN: 1.___\n\n[ ] GOAL BLOOD PRESSURE: MAP ___\n\n[ ] MEDICATIONS STOPPED: \n- Ferrous Sulfate 325 mg PO DAILY \n- Rivaroxaban 20 mg PO QHS \n[ ] MEDICATIONS CHANGED: \n- Torsemide 40 mg PO DAILY increased to Torsemide 100 mg PO/NG \nBID \n- Metoprolol Succinate XL 50 mg PO BID decreased to Metoprolol \nSuccinate XL 37.5 mg PO BID \n[ ] MEDICATIONS STARTED: \n- Apixaban 5 mg PO/NG BID \n- Spironolactone 12.5 mg PO/NG DAILY \n\n[ ] The patient has a known trapped lung and imaging suggestive \nof COPD. He will benefit from outpatient PFTs and an appointment \nwith interventional ___ clinic. \n[ ] Weigh the patient daily. If his weight increases by 3 lbs in \none day or 5 lbs in two days, please call his cardiologist at \n___ for further directions and possible dosing of \nmetolazone.\n[ ] If planning to adjust torsemide dose based on Cr increase or \nother parameter, please discuss with heart failure team @ \n___. His CHF doctor will be Dr. ___\n[ ] The patient required significant repletion of potassium \nwhile diuresing as an inpatient. He was started on \nspironolactone prior to discharge. Please continue to check BMP \non ___ and then every other day until creatinine and potassium \nhave stabilized. He was discharged on 40mEq of potassium daily. \nPlease adjust potassium supplementation as indicated. \n[ ] The patient will benefit from a right and left heart \ncatheterization once his ICD has been in place for ___ months \n___ or ___. He would benefit from vasodilator study \nand full evaluation for pulmonary hypertension. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 1000 mg PO TID \n2. Allopurinol ___ mg PO DAILY \n3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN upset \nstomach \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. Calcium Carbonate 500 mg PO QID:PRN heartburn \n7. Docusate Sodium 100 mg PO TID:PRN constipation \n8. Gabapentin 300 mg PO BID \n9. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing \n10. Lidocaine 5% Patch 1 PTCH TD QPM \n11. Metoprolol Succinate XL 50 mg PO BID \n12. Pantoprazole 40 mg PO Q24H \n13. Rivaroxaban 20 mg PO QHS \n14. Senna 17.2 mg PO QHS:PRN constipation \n15. Sertraline 50 mg PO DAILY \n16. TraMADol 75 mg PO BID:PRN Pain - Moderate \n17. Torsemide 40 mg PO DAILY \n18. Bisacodyl ___AILY:PRN constipation \n19. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat \n20. Cholestyramine 2 mg gm PO BID \n21. Ferrous Sulfate 325 mg PO DAILY \n22. Hydrocerin 1 Appl TP DAILY dry skin \n23. Magnesium Oxide 400 mg PO DAILY \n24. melatonin 3 mg oral QHS:PRN \n25. Milk of Magnesia 30 mL PO QHS:PRN constipation \n26. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \n2. Potassium Chloride 40 mEq PO DAILY \nHold for K > \n3. Spironolactone 12.5 mg PO DAILY \n4. Metoprolol Succinate XL 37.5 mg PO BID \n5. Torsemide 100 mg PO BID \n6. TraMADol 50 mg PO Q6H:PRN Pain - Severe \n7. Acetaminophen 1000 mg PO TID \n8. Allopurinol ___ mg PO DAILY \n9. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN \nupset stomach \n10. Aspirin 81 mg PO DAILY \n11. Atorvastatin 40 mg PO QPM \n12. Bisacodyl ___AILY:PRN constipation \n13. Calcium Carbonate 500 mg PO QID:PRN heartburn \n14. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat \n\n15. Cholestyramine 2 mg gm PO BID \n16. Docusate Sodium 100 mg PO TID:PRN constipation \n17. Gabapentin 300 mg PO BID \n18. Hydrocerin 1 Appl TP DAILY dry skin \n19. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing \n20. Lidocaine 5% Patch 1 PTCH TD QPM \n21. Magnesium Oxide 400 mg PO DAILY \n22. melatonin 3 mg oral QHS:PRN \n23. Milk of Magnesia 30 mL PO QHS:PRN constipation \n24. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting \n25. Pantoprazole 40 mg PO Q24H \n26. Senna 17.2 mg PO QHS:PRN constipation \n27. Sertraline 50 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n#Syncope\n#Sinus arrest\n#Heart failure with reduced ejection fraction, acute on chronic\n#Right pleural effusion/Trapped lung\n#Hypoxemia\n\nSecondary Diagnosis:\n# Atrial fibrillation\n# Macrocytic Anemia\n# ___ on CKD\n# Chronic back pain\n# Gout\n# Depression\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n \nIt was a pleasure taking part in your care here at ___! \n \nWhy was I admitted to the hospital? \n- You had too much fluid backed up and were short of breath, a \ncondition known as heart failure.\n- You passed out while you were having your blood drawn.\n- You were found to have a dangerous heart rhythm.\n- This rhythm was causing your heart to have pauses which were \ncausing you to pass out.\n \nWhat was done for me in the hospital? \n- You were transferred to the ICU and received a device near \nyour heart to prevent you from passing out.\n- You received medications through your IV to help you urinate \noff the extra fluid.\n- Your breathing improved with this medication, and you were \nswitched to an oral version. \n- When you no longer had extra fluid, you were discharged to \nrehab.\n \nWhat should I do when I leave the hospital? \n- Please take all of your medicines and attend all of your \nfollow-up appointments.\n- Weigh yourself every morning, call your doctor if your weight \ngoes up by more than three pounds in one day or five pounds in \ntwo days. You weighed 183 lbs at discharge. If your weight \nincreases, please call our heart failure specialists for \ndirections on what to do. \n- Call your doctors ___ develop worsening shortness of \nbreath, chest pressure, or any other symptoms that concern you\n- You will need to make appointment with the lung doctors ___ \n___ to follow up on the best course of action for your \ntrapped lung. \n \nWe wish you the best of luck in your health! \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I130", "N179", "D689", "D62", "I959", "E872", "I482", "I495", "I5023", "L7632", "J9811", "D539", "R55", "E785", "I255", "I455", "F329", "I2510", "G8929", "I341", "I340", "N189", "J449", "M109", "M5080", "R740", "R0902", "Z4502", "Z87891", "Z7902", "Z96659", "Z955", "Y838", "Y92230" ]

[ "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", "D689: Coagulation defect, unspecified", "D62: Acute posthemorrhagic anemia", "I959: Hypotension, unspecified", "E872: Acidosis", "I482: Chronic atrial fibrillation", "I495: Sick sinus syndrome", "I5023: Acute on chronic systolic (congestive) heart failure", "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "J9811: Atelectasis", "D539: Nutritional anemia, unspecified", "R55: Syncope and collapse", "E785: Hyperlipidemia, unspecified", "I255: Ischemic cardiomyopathy", "I455: Other specified heart block", "F329: Major depressive disorder, single episode, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "G8929: Other chronic pain", "I341: Nonrheumatic mitral (valve) prolapse", "I340: Nonrheumatic mitral (valve) insufficiency", "N189: Chronic kidney disease, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "M109: Gout, unspecified", "M5080: Other cervical disc disorders, unspecified cervical region", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "R0902: Hypoxemia", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator", "Z87891: Personal history of nicotine dependence", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z96659: Presence of unspecified artificial knee joint", "Z955: Presence of coronary angioplasty implant and graft", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "I130", "N179", "D62", "E872", "E785", "F329", "I2510", "G8929", "N189", "J449", "M109", "Z87891", "Z7902", "Z955", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / oxycodone\n \nAttending: ___.\n \nChief Complaint:\nBack pain\n \nMajor Surgical or Invasive Procedure:\n___: Thoracentesis w chest tube insertion \n___: Thoracentesis w chest tube insertion\n\n \nHistory of Present Illness:\n___ male history of afib, ___, previous lumbar and \ncervical spine surgeries by Dr. ___ osteomyelitis \n___, and HFrEF who presents now with one half weeks of \nworsening back pain. He was seen prior to arrival at ___ \n___ emergency room where he was found to have had a \nCT of\nlumbar spine concerning for discitis at L1-L2 with epidural \nabscess and probable to level as well as the pathologic \nfractures involving the L1-L2 vertebral bodies. Patient \ntransferred to ___ for further \nmanagement. Workup prior to arrival notable for white blood cell \ncount 7.96, hemoglobin 11.6, hematocrit 34.6, MCV 107, platelet \ncount 178,\nneutrophils 81%, ESR 17, normal range ___, GFR 38, BUN 49, \nglucose 110, creatinine 1.76, calcium 8.9, sodium 142, potassium \n4.1, chloride 105, bicarb 25, bilirubin 0.6, alk phos 168, AST \n11, ALT 15, CRP 36.6. He was transferred from OSH after CT \nL-spine showed L1-2 discitis, osteomyelitis and pathologic\nfracture. \nHe presents today with low back and hip pain for the past \nseveral months which has worsened over the past 4 days. He \nreports intermittent weakness of the left lower extremity when \nchanging from seated to standing which resolves with ambulation. \nDenies paresthesias or other weakness, intermittent bowel \nincontinence at baseline and no other bowel/bladder symptoms. \nDenies fevers/chills. He has recent falls due to losing his \nbalance while walking and carrying large items but is unable to \nelaborate on this. Patient states he has a long history of \nchronic hip/back pain. His typical pain is bilateral hip, front \nthink and buttock \"shock like pain\" without radiation that is \ndaily, intensifies with movement (worst in AM when getting out \nof bed and out of a\nchair) and when laying flat. He typically takes ___ advil in the \nmorning before he gets out of bed but this doesn't help very \nmuch. He reports he has never tried typical neuropathic pain \nagents. He describes worsening of the pain for the last ___ \nmonths without a clear provoking etiology. For the last ___ \ndays,\nhe has noted working shock like pain especially in hips and a \nmild ache in his mid back. He does report he fell up the stairs \n3 weeks ago while carrying packages (the weight carried him \nforward) and he landed on his chest but did not note worsening \nin his chronic pain at that time. He specifically denies chest \npain, dyspnea, jaw/arm pain, diaphoresis, nausea recently or \ntoday. He\ndenies recent fevers, chills, night sweats, weight loss. He \nreports he has had two episodes of spinal infection and was \nunsure of his symptoms at that point. Patient denied any saddle \nanesthesia, urinary retention, bowel or bladder incontinence, or \nfevers. Patient did describe intermittent weakness of left lower \nextremity and numbness of the whole leg that occurs with \nposition but none now. \n \nPast Medical History:\nAfib on warfarin\nCAD s/p stent placement\nCHF with EF ___\nmitral valve prolapse\nHTN\nHLD\ndepression\nchronic neck pain secondary to cervical disc disease\nmultiple spine surgeries including fusion of L-S1 laminectomy \ncholecystectomy\nTotal knee replacement\nB/l shoulder surgery\n\n \nSocial History:\n___\nFamily History:\nMother: alive, age ___. Macular degeneration\nFather: deceased in ___. ?brain tumor and heart issues\n\n \nPhysical Exam:\nADMISSON PHYSICAL EXAM\n=====================\nVITALS: 98.1 110 / 61 87 20 97 2LNc \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: Normocephalic, atraumatic. Pupils equal, round\nbilaterally, extraocular muscles intact. Sclera anicteric and\nwithout injection. Moist mucous membranes, good dentition.\nOropharynx is clear. \nNECK: No JVD. \nCARDIAC: Irreg irreg rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. \nLUNGS: Clear to auscultation bilaterally w/appropriate breath\nsounds appreciated in all fields. No wheezes, rhonchi or rales.\nNo increased work of breathing.\nBACK: No spinous process tenderness. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly. \nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally. \nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: CN2-12 intact. ___ strength throughout, patient\ngrimacing when checking hip flexion. Normal sensation. AOx3.\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVITALS: 97.7 PO 99/61 L Lying 80 18 92 2L \nGENERAL: Laying in bed, NAD\nHEENT: EOMI grossly, anicteric sclera, MMM\nHEART: Irregular rhythm, normal S1/S2, no murmurs, gallops, or\nrubs. \nLUNGS: Diffusely decreased breath sounds\nABDOMEN: Normoactive bowel sounds. Soft, distended, tympanic,\nnontender in all quadrants, no rebound/guarding.\nEXTREMITIES: no cyanosis, clubbing, or edema, moving all 4\nextremities with purpose, warm w good cap refill\nNEURO: A/O X3 (person, place, time)\n \nPertinent Results:\n___\n=====================\n___ 11:30PM BLOOD WBC-7.3 RBC-3.18* Hgb-11.5* Hct-34.1* \nMCV-107*# MCH-36.2*# MCHC-33.7 RDW-16.2* RDWSD-62.9* Plt ___\n___ 11:30PM BLOOD Neuts-77.1* Lymphs-10.3* Monos-10.0 \nEos-1.4 Baso-0.8 Im ___ AbsNeut-5.63 AbsLymp-0.75* \nAbsMono-0.73 AbsEos-0.10 AbsBaso-0.06\n___ 11:30PM BLOOD ___ PTT-28.8 ___\n___ 11:30PM BLOOD Glucose-102* UreaN-44* Creat-1.5* Na-144 \nK-3.5 Cl-103 HCO3-24 AnGap-17\n___ 01:35PM BLOOD Calcium-8.5 Phos-4.2 Mg-1.2*\n___ 01:35PM BLOOD VitB12-321\n___ 07:12AM BLOOD TSH-1.6\n___ 11:30PM BLOOD CRP-50.0*\n\n___ 05:30PM BLOOD Cortsol-19.6\n___ 07:56PM BLOOD CK-MB-3 cTropnT-0.46* ___\n___ 06:27AM BLOOD ALT-30 AST-27 AlkPhos-191* TotBili-0.5\n___ 03:00PM BLOOD calTIBC-251* Ferritn-829* TRF-193*\n___ 01:35PM BLOOD SED RATE- 46\n\nMICROBIOLOGY\n=====================\n___ 2:00 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n___ 2:33 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\n___ STOOL C. difficile DNA amplification assay- POSITIVE\n\n___ 2:35 pm PLEURAL FLUID PLEURAL FLUID. \n **FINAL REPORT ___\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n___ MRSA SCREEN- NEGATIVE\n___ Blood Culture x2: NO GROWTH \n___ 10:35 am PLEURAL FLUID PLEURAL FLUID. \n **FINAL REPORT ___\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n___ Blood Culture x2: NO GROWTH, Routine-FINAL INPATIENT \n___ URINE CULTURE- NO GROWTH\n___ Blood Culture x2 NO GROWTH \n\nPLEURAL FLUID ANALYSIS:\n=======================\n___ 10:35AM PLEURAL TotProt-2.4 Glucose-90 Creat-3.5 \nLD(___)-104 Albumin-1.2 ___ Misc-BODY FLUID\n___ 10:35AM PLEURAL TNC-62* RBC-___* Polys-4* Lymphs-75* \nMonos-8* Atyps-8* Macro-5* Other-0\n\n___ 02:35PM PLEURAL TotProt-1.7 Glucose-89 Creat-1.6 \nLD(___)-103 Albumin-1.1 Cholest-20\n___ 02:35PM PLEURAL TNC-49* ___ Polys-23* Lymphs-74* \nMonos-2* Macro-1*\n\n___ CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS.\n___ CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS.\n\nDISCHARGE LABS:\n================\n___ 04:35AM BLOOD WBC-7.1 RBC-2.53* Hgb-8.8* Hct-27.3* \nMCV-108* MCH-34.8* MCHC-32.2 RDW-16.7* RDWSD-66.0* Plt ___\n___ 04:35AM BLOOD Glucose-88 UreaN-20 Creat-1.2 Na-140 \nK-4.1 Cl-100 HCO3-26 AnGap-14\n___ 04:35AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1\n\nIMAGING\n======================\nMRI spine ___ IMPRESSION:\n1. Study is degraded by motion and by lumbar spinal fusion \nhardware artifact.\n2. Cervical degenerative disc disease as detailed above, without \nhigh-grade\nspinal canal narrowing or cord signal abnormality. There is \nsevere neural\nforaminal narrowing at multiple levels.\n3. Mild thoracic degenerative disc disease, without high-grade \nspinal canal or neural foraminal narrowing.\n4. Loculated right pleural effusion basilar right lower lobe \ncould reflect\natelectasis, however pneumonia cannot be excluded. Chest CT is \nsuggested.\n5. Instrumented lumbar fusion at L4-S1, interbody fusion graft \nat L3-4 with\npartial osseous fusion, and solid osseous fusion of the L2-3 \nlevel as detailed above.\n6. L1-2 disc extrusion with superior migration results in severe \nspinal canal narrowing. There is probable impingement of the \ntraversing L2 and possibly other nerve roots. Allowing for \ndifference technique, finding may be slightly progressed \ncompared to ___ prior exam.\n7. Within limits of study, no definite evidence of \ndiscitis-osteomyelitis, or epidural abscess.\n8. Probable subacute to chronic oblique fracture of the superior \nendplate of L2 with lateral extension through the lateral \nvertebral body.\n9. Right L1-2 and bilateral L2-3 Severe neural foraminal \nnarrowing.\n\nCXR ___ IMPRESSION: \nThere is a mild to moderate layering right pleural effusion.\nThere is dilation of colon at the splenic fracture.\n\nCT A/P ___ IMPRESSION:\n1. Volume loss in the right lower lobe may represent atelectasis \nor infection.\nPlease correlate with clinical status.\n2. No retroperitoneal hematoma or free intra-abdominal fluid.\n3. Intermediate density fluid in the bladder may represent \ndelayed excretion\nof iodinated contrast from prior CT study or hemorrhage \nproducts. Please\ncorrelate with visual inspection of the urine or urinalysis.\n4. Moderate right pleural effusion.\n\nTTE ___ IMPRESSION: \nNormal left ventricular cavity size with regional systolic \ndysfunction most c/w CAD (mid-LAD distribution vs. Takotsubo \nCM). Moderate mitral regurgitation. Mild pulmonary artery \nsystolic hypertension. Mild-mderate tricuspid regurgitation. \n\nAbdominal x-ray ___ IMPRESSION: \nGaseous distension of the colon, appearing unchanged compared to \nthe recent CT scan\n\nDX PELVIS & FEMUR ___: No fracture of the bilateral femurs. \n\nCT CHEST ___: \n1. Mild to moderate right pleural collection containing \nloculated fluid and air with a chest tube in situ. \nMild-to-moderate free-flowing left pleural effusion. \n2. Bilateral patchy peripheral ground-glass opacities are \nconcerning for an atypical infection. Presence of interlobular \nseptal thickening may be \nsecondary to pulmonary edema. Clinical correlation is \nrecommended. \n3. Mild mediastinal and hilar lymphadenopathy is nonspecific and \ncould be \nrelated to infections. \n\nPORTABLE ABDOMEN ___\nInterval improvement of dilation of large bowel, however large \nbowel dilation has not resolved. \nThere is no evidence of intraperitoneal free air. \n \nBrief Hospital Course:\nPATIENT SUMMARY:\n================\nMr. ___ is a ___ year old man with w/ HFrEF, CAD s/p stent, \natrial fibrillation on Xarelto, ___ syndrome, CKD, chronic \nneck pain ___ cervical disc disease and multiple spine surgeries \nincluding fusion of L-S1 laminectomy who presented to OSH with \n___ weeks of worsening back pain and left hip pain, transferred \nfor spine eval, with MRI negative for infection, admitted for \npain management. Hospital course was complicated by oliguric \nrenal failure in setting of contrast load on ___ and NSAID \nuse, and hypotension in setting of receiving entresto and \ndiuresis, requiring transfer to the MICU for worsening hypoxia \nand persistent hypotension. He was found to have R side pleural \neffusion with improvement after chest tube placement x2 ___, \nremoved, replaced ___. Further hospital course complicated by \nC difficile. \n\nACUTE ISSUES:\n=============\n#Hypoxemia \n#Right pleural effusion\n#Concern for RLL PNA\n#Trapped lung\nOn arrive to ED at ___, pt noted to be developing progressive \nhypoxemia requiring nasal cannula in setting of developing \noliguric renal failure. Suspected multifactorial due to PNA, \npleural effusion, & pulmonary edema from volume overload. \nEffusion likely chronic per review of imaging, and potentially \nhas formed fibrosis causing trapped lung. s/p R side chest tube \n___, which was removed same day after minimal draining, \nreplaced ___ for reaccumulation and quickly removed again. CT \nchest ___ also indicated possible atypical PNA, completed 7 day \ncourse of cefepime for HAP (___), transitioned briefly to \nceftriaxone/azithro (___). He was also found to have e/o \nvolume overload in setting of diuretic held and receiving IVF \nfor hypotension. Hypoxia improved somewhat with gentle diuresis, \nand home Lasix was restarted three days prior to discharge with \nstable volume status and oxygen requirement. At time of \ndischarge, he is still requiring oxygen although has decreased \nfrom 4L to 1.5-2L. Likely will remain dependent on oxygen until \ndecortication after rehab. Eventual plan is to likely \ndecortication per IP, who will follow outpt with patient in 4 \nweeks, when he will also receive a chest CT. \n\n#Hypotension \n#History of Hypertension\nInitially suspected PNA & Entresto use I/s/o sepsis. Entresto \nand diuretics were held. Per nephrology, sacubitril's inhibition \nof neprilysin leads to increase in several vasoactive substances \nincluding BNP and bradykinin which are vasodilators, and likely \nculprits for what appears to be his prior distributive \nhypotension. Metoprolol succinate home dose is 225 mg; he was \nswitched to metoprolol succinate 50mg daily with good blood \npressure and HR control. BP remained stable 99-103/62-70 since \n___. Discussed ___ meds with outpatient cardiologist \nDr. ___ requested that patient remain on BB and at least \na low-dose ACEi if tolerated. Started lisinopril 2.5mg daily on \n___, patient tolerating well on discharge. Holding home \nentresto on discharge. \n\n#C difficile infection\nPt w frequent loose stools that developed during \nhospitalization, found to be cdiff+ on ___ and started on PO \nvanc ___. Switched to PO flagyl (___) as infection not \nconsidered to be complicated, for 10d course ending ___. \n\n___ \n#?CKD\nLikely multifactorial from CIN (given contrast on ___ at OSH), \nNSAID-use, valsartan in Entrosto +/- ATN. Cr 1.5 on admission \n___ and peaked to 3.4. Creatinine stable around 1.2-1.4 for \nthe week prior to discharge, baseline unknown but likely has \nsome underlying mild CKD. \n\n#Acute on chronic back pain \n#Hip/leg pain\nPatient with hx of multiple prior spinal surgeries with hardware \nin place and spinal osteomyelitis/discitis/epidural abscess in \n___. He presented with 4 days of worsening back pain. CRP 50, \nconcerning for infectious process, however MRI showed no e/o \ninfection. Spine surgery consulted and no acute intervention \nneeded. XR b/l femur showed generalized degenerative changes \nthroughout b/l SI joints, hip joints, and pubic symphysis. No \nfracture. Etiology of pain unclear but likely multifactorial \nfrom DJD and frequent surgeries. Managed with lidocaine patches, \nacetaminophen standing, and tramadol PRN.\n\nCHRONIC ISSUES: \n=============== \n#HFrEF, CAD \n#Troponinemia \nPt with hx of CAD and HFrEF 35%, likely iCMP. Troponins mildly \nelevated in setting ___ to 0.46 without CK-MB elevation or \nischemic changes on EKG. Continued home ASA 81mg and \natorvastatin 10mg PO QD. For preload, held home metolazone given \nhypotension, diuresis as above. Home metop dosing was changed as \nabove. Held home entresto given ___ and hypotension as above, \nstarted 2.5mg lisinopril for afterload mgmt per outpatient \ncardiologist. Will have outpatient followup.\n\n#Afib (CHADS2VASC = 3)\nAnticoagulation was briefly held for chest tube placement, after \nwhich home Xarelto was held. Home metoprolol changed as above, \ndischarged on 50 mg succinate daily with good rate control. \n\n___ syndrome\nPt dx during an admission in ___. Was monitored during \nhospitalization, especially in setting of receiving narcotics, \nwith some abdominal distension noted. KUB obtained ___ showed \ninterval improvement in colonic distention from prior imaging.\n\n#Gout: Continued home allopurinol ___ mg QD \n\n#Depression: Continued home sertraline 50 mg PO QD \n\n#GERD: Continued home omeprazole 20 mg PO QD \n\n#Acute on chronic macrocytic anemia MCV elevated from last \nadmission: Continued Ferrous Sulfate 65 mg PO DAILY \n\nTRANSITIONAL ISSUES: \n====================== \nNEW MEDICATIONS\n-Acetaminophen 1g TID (for pain)\n-Calcium carbonate 500mg QID PRN (heartburn)\n-Ipratropium-Albuterol Neb Q4H PRN (SOB, wheezing) \n-Lidocaine 5% patch QPM (for pain)\n-Lisinopril 2.5mg PO daily (for CHF, HTN)\n-Flagyl 500mg PO Q8H (cdiff, abx course ___\n-Ondansetron ODT 8mg PO Q8H PRN (nausea, vomiting) \n-Tramadol 50mg PO Q4H PRN (moderate pain)\n-Tramadol 50mg PO BID PRN (severe pain)\n-Oxygen support (usually on ___ NC)\n\nCHANGED MEDICATIONS\n-Metoprolol succinate XL 50mg PO daily (changed from 125 QAM and \n100 QPM given hypotension)\n\nSTOPPED/HELD MEDICATIONS\n-Metolazone 2.5mg PO every other day (held for hypotension, ___\n-Sacubitril-Valsartan 24mg-26mg BID (held for hypotension, ___\n\nOTHER:\n[ ]Will follow-up with interventional pulm and Thoracics in 4 \nweeks for chest CT and to discuss need for decortication of \nfibrotic trapped lung\n[ ]S/P R side chest tube ___\n[ ]Please discuss mgmt. of patient's HTN and CHF, his BPs \nremained soft (100s/50s) throughout hospitalization despite \n___ agents had been held for a week. \n[ ___ appt w PCP/cardiology Dr. ___ on ___\n[ ___ appt with IP to be scheduled, likely ___ as pt has chest \nCT scheduled that day\n[ ]Pt being discharged to rehab on oxygen ___ NC). If unable \nto wean at rehab, will need home O2 as well.\n[ ___ need further titration of pain medication with increased \nactivity at rehab. \n\n#code status: full\n#contact: ___ ___ (daughter)\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 10 mg PO QPM \n4. Sertraline 50 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Metolazone 2.5 mg PO EVERY OTHER DAY \n7. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID \n8. Metoprolol Succinate XL 125 mg PO DAILY \n9. Metoprolol Succinate XL 100 mg PO QHS \n10. Ferrous Sulfate 65 mg PO DAILY \n11. magnesium chloride 1250 oral DAILY \n12. Rivaroxaban 20 mg PO DAILY \n13. Furosemide 80 mg PO QAM \n14. Furosemide 40 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO TID \n2. Calcium Carbonate 500 mg PO QID:PRN heartburn \n3. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing \n4. Lidocaine 5% Patch 1 PTCH TD QPM \n5. Lisinopril 2.5 mg PO DAILY \n6. MetroNIDAZOLE 500 mg PO Q8H \n___ - ___ \n7. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting \n8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nhold for somnolence or RR<12 \nRX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours as needed \nDisp #*18 Tablet Refills:*0 \n9. Metoprolol Succinate XL 50 mg PO DAILY \n10. Allopurinol ___ mg PO DAILY \n11. Aspirin 81 mg PO DAILY \n12. Atorvastatin 10 mg PO QPM \n13. Ferrous Sulfate 65 mg PO DAILY \n14. Furosemide 80 mg PO QAM \n15. Furosemide 40 mg PO QPM \n16. magnesium chloride 1250 oral DAILY \n17. Omeprazole 20 mg PO DAILY \n18. Rivaroxaban 20 mg PO DAILY \n19. Sertraline 50 mg PO DAILY \n20. HELD- Metolazone 2.5 mg PO EVERY OTHER DAY This medication \nwas held. Do not restart Metolazone until until you talk to your \ncardiologist\n21. HELD- Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID This \nmedication was held. Do not restart Sacubitril-Valsartan \n(24mg-26mg) until you talk to you cardiologist\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary\n-Acute hypoxemic respiratory failure\n-Chronic pleural effusions\n-Trapped lung, R side \n-Hypotension\n-Acute kidney injury\n-Cdiff infection\n-Acute on chronic back, hip pain\n\nSECONDARY\n-Heart failure with reduced ejection fraction\n-Coronary artery disease\n-Atrial fibrillation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou came to the hospital because you were having terrible back \npain and the doctors at the ___ hospital were concerned you \nmight have an infection in your back. \n\nWhile you were here, we did not see any evidence of infection in \nyour back, but we did notice you had fluid behind your lungs \n(pleural effusions). We drained these, treated you for \npneumonia, and gave you oxygen to support your breathing. \n\nWe also noticed that your blood pressure was very low. We \nstopped your blood pressure medications for a little while, and \nrestarted some of them at lower doses. Your cardiologist should \ntalk to you about these at your follow-up appointment next week. \n\n\nWhen you leave, you will go to rehab to work on your strength \nand mobility. You will continue to use your oxygen until you \nfeel more comfortable off of it. \n\nIt was a pleasure to care for you. We wish you the best in your \nrecovery. \n___ Medicine Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I130", "J9601", "N170", "R578", "J189", "A0472", "I4891", "J918", "I5022", "J9811", "E8342", "J984", "I2510", "N189", "Z7902", "K598", "Z955", "I341", "E785", "F329", "Z96659", "Z87891", "T39395A", "T508X5A", "Y92239", "T502X5A", "T465X5A", "Z9981", "M159", "T8189XA", "Y838", "I255", "M109", "K219", "D539", "M5126", "M48061", "N141", "R112" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "J9601: Acute respiratory failure with hypoxia", "N170: Acute kidney failure with tubular necrosis", "R578: Other shock", "J189: Pneumonia, unspecified organism", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "I4891: Unspecified atrial fibrillation", "J918: Pleural effusion in other conditions classified elsewhere", "I5022: Chronic systolic (congestive) heart failure", "J9811: Atelectasis", "E8342: Hypomagnesemia", "J984: Other disorders of lung", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N189: Chronic kidney disease, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "K598: Other specified functional intestinal disorders", "Z955: Presence of coronary angioplasty implant and graft", "I341: Nonrheumatic mitral (valve) prolapse", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z96659: Presence of unspecified artificial knee joint", "Z87891: Personal history of nicotine dependence", "T39395A: Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial encounter", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "T502X5A: Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter", "T465X5A: Adverse effect of other antihypertensive drugs, initial encounter", "Z9981: Dependence on supplemental oxygen", "M159: Polyosteoarthritis, unspecified", "T8189XA: Other complications of procedures, not elsewhere classified, initial encounter", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "I255: Ischemic cardiomyopathy", "M109: Gout, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "D539: Nutritional anemia, unspecified", "M5126: Other intervertebral disc displacement, lumbar region", "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "R112: Nausea with vomiting, unspecified" ]

[ "I130", "J9601", "I4891", "I2510", "N189", "Z7902", "Z955", "E785", "F329", "Z87891", "M109", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / oxycodone\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ YO M with afib on rovarozaban, CAD s/p stent placement, HFrEF\n(EF ___, mitral valve prolapse, HTN, HLD, depression,\nmultiple spine surgeries, cholecystectomy who presents from \nrehab\nwith dyspnea, felt to be in acute heart failure exacerbation ___\nholding of diuretic regimen at rehab in setting of hypotension. \nHe brought in from rehab with concern of shortness of breath and\nincreased pleural effusion on CXR at rehab. \n\nPer ED notes: \nHe's had recent hospitalization for hypoxemia, pneumonia and\nright sided pleural effusion. He had a chest tube placed x2 by \nIP\nwith fluid consistent with HF and concern for trapped lung as\nwell. Patient treated with abx for presumed pneumonia and\ndischarged to rehab on 1.5-2L NC. While in rehab weaned off O2 \nby\n___ but started to have new O2 requrimenet yesterday that\nincreased to 2L NC again today. SOB worse with movement. No \nchest\npain, fever/chills/ night sweates or new cough. Notes increase \nin\nabdominal distension though diarrhea has improved now while he\nremains on antibiotics for c.diff. Notes weight gain of ~15 lbs\nwith dry weight of 205 and 220 this am at rehab\n\nIn the ED initial vitals were: \n97.9 86 107/57 22 99% 2L NC \n \n \nED exam notable for: \nGen:NAD, breathing comfortably on 2L O2, AOx3\nCV: irregularly irregular, no murmurs, JVD to jawline\nPulm: Decreased right sided lower breath sounds, no crakcles\nAbd: soft, significantly distended, no peritoneal signs,\nnon-tender, \n___: 3+ edema bilaterally up to the low thigh\n\n \nLabs/studies notable for: \n \n6.7 > 8.___.7 < ___ \n------------<116 AGap=14 \n5.4 23 1.1 \n\nTrop-T: <0.01 \nproBNP: ___\nLactate:2.6\n\nCXR notable for:\nFINDINGS: \n \n AP portable upright view of the chest. No significant change\nfrom recent prior exam with loculated right pleural effusion\ntracking circumferentially with a similar overall pattern.\nOpacities within the right lung again noted. \n Left lung is grossly clear. The heart appears mildly enlarged.\nMediastinal contour stable. Imaged bony structures are intact.\nMultiple surgical anchors are noted at bilateral humeral heads. \n\n \nIMPRESSION: \nNo significant interval change. \n\n \n\nPatient was given: \n___ 16:28 IV Furosemide 80 mg \n\nPatient was seen by cardiology:\nPer Cards ED evaluation: \n\"Patient presenting with likely primarily CHF exacerbation.\nPatient unclear if he has been taking diuretics appropriately,\nwhich could be precipitant. Given this is the primary reason for\nadmission, his reduced EF, and some concern that diuresis was\nbeing held at rehab due to hypotension.\"\nRecommended admission to Cardiology.\n\nPer ED assessment:\n\"Likely HFrEF exacerbation with weight gain and increase in\nshortness of breath and ___ edema. AM Lasix held for a few days\nwhile in rehab given soft BP that may have caused volume\noverload. Will touch base wit IP re worsening shortness of \nbreath\nand history of concern for trapped lung and placement of chest\ntube. CXR without evidence of new consolidation or significantly\nworsening pulm edema though has right sided pleural effusion\ntracking circumferentially. Clinically without fever, new cough,\nor sputum production concerning for pneumonia. No evidence of\npericardial effusion on bedside echo. No ascites on bedside echo\neither. Abdominal distenstion without n/v and with regular bowel\nmovement unlikely caused by obstruction though has history of\n___ syndrome.\"\n\nOf note, patient is s/p discharge on ___ after presenting to\nOSH with ___ weeks of worsening back pain and left hip pain,\ntransferred \nfor spine eval, with MRI negative for infection, admitted for \npain management. Hospital course was complicated by oliguric \nrenal failure in setting of contrast load on ___ and NSAID \nuse, and hypotension in setting of receiving entresto and \ndiuresis, requiring transfer to the MICU for worsening hypoxia \nand persistent hypotension. He was found to have R side pleural \neffusion with improvement after chest tube placement x2 ___, \nremoved, replaced ___. Further hospital course complicated by \n\nC difficile. \n\nVitals on transfer: \n\n97.6 109 100/76 22 94% 3L NC \n\nOn the floor... \n\nHe reports he was at rehab and things were going fairly well. He\nreported they took him off O2 on ___ through the weekend until\n___ (back on O2). He reports that he didn't have much \nactivity\nover the weekend, but this Am he reported that he felt more SOB\nand was sent back. \n\nHe reports he feels \"bloated\" but denies weight gain; he reports\nhis weight at rehab was 223-224; he doesn't remember what his\nweight was when he got to rehab (?220). He reports his dry \nweight\nis about 205 lbs. \n\nHe reports his SOB has been going on \"for a long time\"; he first\nnoticed it a few months. He reports some improvement after his\nchest tubes; he reported once he was active at rehab his\nrespiratory symptoms had improved. Denies CP, but does report\noccasional \"palpitations\" but he denies attributing this to his\nafib (and reports it has seemed to have gotten better.)\nRpeorts some lightheadedness this AM. Denies LOC. Reports\nsignificant leg swelling. \n\nDenies recent infections, cough or cold symptoms. \nDenies abd pain, n/v but reports some nausea with c diff\nmedication but none in the past two days. Reports + diarrhea at\nadmission today x2. He reports this seems like his C. diff\nsymptoms. Denies dysuria. Denies blood in stool or urine. \n \nPast Medical History:\nPAST MEDICAL HISTORY: \n=======================\n1. CARDIAC RISK FACTORS \n- Hypertension \n- Dyslipidemia \n\n2. CARDIAC HISTORY \n- CAD s/p stent placement\n- CHF with EF ___\n- Afib on warfarin\n- mitral valve prolapse\n\n3. OTHER PAST MEDICAL HISTORY \ndepression\nchronic neck pain secondary to cervical disc disease\nmultiple spine surgeries including fusion of L-S1 laminectomy \ncholecystectomy\nTotal knee replacement\nB/l shoulder surgery\nc diff infection ___\n \nSocial History:\n___\nFamily History:\nMother: alive, age ___. Macular degeneration\nFather: deceased in mid ___. ?brain tumor and heart issues\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n=================================\nVS: Temp: 98.4 (Tm 98.4), BP: 103/74 (90-134/49-87), HR: 111\n(111-148), RR: 26 (___), O2 sat: 93% (86-97), O2 delivery: \n2LNC\n(2LNC-3L), Wt: 218 lb/98.88 kg \nGENERAL: Well developed, well nourished M, sitting at bedside in\nNAD. Oriented x3. Mood, affect appropriate. \nHEENT: Normocephalic atraumatic. Sclera anicteric. EOMI grossly.\nConjunctiva were pink. No pallor or cyanosis of the oral mucosa.\nNo xanthelasma. \nNECK: Supple. JVP to angle of mandible at 90 degrees \nCARDIAC: PMI located in ___ intercostal space, midclavicular\nline. irregularly irregular rate, Tachycardic. \nLUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. diminished lung sounds R\nlung extending up to mid lung fields. no crackles appreciated\nbilaterally; no wheezes. \nABDOMEN: Soft, non-tender, mildly distended\nEXTREMITIES: extremities slightly cool perfused. 3+ pitting \nedema\nto knees bilaterally \n\nDISCHARGE PHYSICAL EXAMINATION: \n=================================\nPHYSICAL EXAM: \nVS: 98.3 90/52 89 18 94% Ra \nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric\nNECK: supple, JVP to 10 cm \nLUNGS: Decreased BS in RLL, no wheezing \nCV: Irrregular, tachycardic, ___ pansystolic murmur at apex and\nLLSB\nABD: mild distention, non-tender, and soft, normoactive BS\nEXT: Warm, non-edematous bilaterally, non-tender \nNEURO: No gross motor or coordination abnormalities\n\n \nPertinent Results:\nADMISSION LABS\n========================\n___ 12:50PM BLOOD WBC-6.7 RBC-2.63* Hgb-8.9* Hct-27.7* \nMCV-105* MCH-33.8* MCHC-32.1 RDW-16.2* RDWSD-62.4* Plt ___\n___ 12:50PM BLOOD Neuts-76.2* Lymphs-7.2* Monos-13.8* \nEos-1.4 Baso-0.9 Im ___ AbsNeut-5.08 AbsLymp-0.48* \nAbsMono-0.92* AbsEos-0.09 AbsBaso-0.06\n___ 12:50PM BLOOD Glucose-116* UreaN-18 Creat-1.1 Na-135 \nK-5.4* Cl-98 HCO3-23 AnGap-14\n___ 12:50PM BLOOD CK(CPK)-42*\n___ 06:20AM BLOOD ALT-<5 AST-9 LD(LDH)-180 AlkPhos-94 \nTotBili-0.7\n___ 12:50PM BLOOD CK-MB-2 proBNP-6666*\n___ 12:50PM BLOOD cTropnT-<0.01\n___ 09:35PM BLOOD Calcium-8.9 Phos-2.6* Mg-1.2*\n___ 01:11PM BLOOD Lactate-2.6* K-5.1\n___ 01:34PM BLOOD Lactate-1.8\n\nPERTIENT LABS\n========================\n___ 06:20AM BLOOD calTIBC-212* VitB12-498 Folate-3 \nFerritn-500* TRF-163*\n___ 06:50AM BLOOD Vanco-66.0*\n\nDISCHARGE LABS\n========================\n___ 08:10AM BLOOD WBC-7.2 RBC-2.55* Hgb-8.2* Hct-26.0* \nMCV-102* MCH-32.2* MCHC-31.5* RDW-17.0* RDWSD-63.9* Plt ___\n___ 08:10AM BLOOD Plt ___\n___ 08:10AM BLOOD ___ PTT-35.1 ___\n___ 08:10AM BLOOD Glucose-93 UreaN-31* Creat-1.7* Na-136 \nK-3.9 Cl-93* HCO3-30 AnGap-13\n___ 02:11AM BLOOD ALT-<5 AST-11 LD(LDH)-217 AlkPhos-79 \nTotBili-1.0 DirBili-0.4* IndBili-0.6\n___ 08:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.7\n\nIMAGING\n========================\nCXR ___\nAP portable upright view of the chest. No significant change \nfrom recent \nprior exam with loculated right pleural effusion tracking \ncircumferentially with a similar overall pattern. Opacities \nwithin the right lung again noted. Left lung is grossly clear. \nThe heart appears mildly enlarged. Mediastinal contour stable. \nImaged bony structures are intact. Multiple surgical anchors \nare noted at bilateral humeral heads. \n\nCT CHEST ___\nPersistent large and probably loculated right hydropneumothorax, \nprobably \nreflecting chronic restrictive right pleural thickening, in \ncombination with severe lower lobe atelectasis. No contributory \nbronchial obstruction. Severe coronary atherosclerosis. Mild \ncardiomegaly. Substantially improved bilateral airspace \npulmonary abnormality, nature \nindeterminate, could be post infectious or slow to resolve \nhemorrhage. \n\nKUB ___\nColonic obstruction, worse than on prior examination. There is \nan abrupt\ncutoff of the colonic dilatation in the proximal descending \ncolon, as on prior\nCT. The possibility of a stricture at this level is suggested. \nNo free air\non supine.\n\nCT A/P ___. Colonic distension is minimally increased since the prior \nstudy measures\napproximately 8.1 cm, previously measured 7 cm with smooth \ntapering in the\nproximal descending colon is suggestive ___ syndrome. No \ngross\nstricture identified.\n2. Small bowel is normal caliber. No evidence of bowel \nobstruction.\n3. Air-fluid levels within the colon suggests a diarrheal state.\n4. Partially visualized known right hydropneumothorax.\n5. Ground-glass opacifications in the visualized central left \nlower and\nanterior left upper lobe are nonspecific and may reflect an \ninfectious or\ninflammatory process.\n\nCT CHEST ___. Extensive progression of more confluent areas of ground-glass \nopacification\nin a peribronchovascular distribution involving the entire left \nlung since the\nprior study of ___, raises concern for infection. \nAsymmetric\npulmonary edema could also be considered..\n2. Overall stable appearance moderate right hydropneumothorax \nand associated\ncollapse of the left lower lobe.\n3. Slightly increased size of small left pleural effusion.\n\nCXR ___\nFINDINGS:\nThe heart size is enlarged, stable in appearance as compared to \n___. Re-demonstrated are bilateral parenchymal opacities, \nunchanged with\nassociated air bronchograms, more prominent on the right. There \nis a\nloculated right pleural effusion, no left pleural effusion. \nThere is near\ncomplete atelectasis with the right lower lobe. There is \nunchanged over\ndistention of the stomach. There is no pneumothorax.\nIMPRESSION: \nIn comparison to the prior radiograph dated ___, \nthere is stable\nappearance of near complete right lower lobe atelectasis with a \nnow larger\nloculated right pleural effusion. Persistent bibasilar \nopacities.\n\nMICROBIOLOGY\n========================\nBlood Cx ___: No growth \nBlood Cx ___: No growth \nBlood Cx ___: No growth \nUrine Cx ___: No growth \nMRSA Screen ___: Negative \nC. Difficile ___: Negative \n\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE\n===================================\n___ yo M with atrial fibrillation on rivaroxaban, CAD s/p stent \nplacement, HFrEF\n(EF ___, mitral valve prolapse, HTN, HLD, depression, \nmultiple spine surgeries, cholecystectomy who presents from \nrehab with dyspnea and weight gain consistent with acute heart \nfailure exacerbation likely secondary to missed diuretic doses \nat rehab (held for SBP < 100), treated with a Lasix drip to \neuvolemia. Once euvolemic, he still required 2L O2 and thoracic \nsurgery was consulted for possible intervention for trapped \nlung. While awaiting intervention, patient had a vagal episode \nfollowed by hypotension and bradycardia requiring ICU admission. \nThere was suspicion of GI bleed and he was transfused 2u pRBCs. \nHe was briefly on pressors but was able to be quickly weaned. On \ntransfer back to the floor, he continued diuresis but repeat \nchest CT showed increased ground glass opacities of the left \nlung concerning for infection versus pulmonary edema, so he was \ntreated for HAP with vancomycin, ceftazidime and azithromycin. \nWith antibiotics and diuresis, his dyspnea, hypoxia improved. \n\n___ Course:\nMr. ___ is a ___ man with A fib on rivaroxaban, CAD s/p \nPCI/stent, chronic systolic congestive heart failure (LV EF \n___, mitral valve prolapse, hypertension, hyperlipidemia, \nand other issues admitted with acute pulmonary edema attributed \nto acute on chronic systolic congestive failure, with his \nhospital course complicated by GI bleeding and vasovagal event \nresulting in bradycardia to ___ when using the commode on ___. \nHe recovered spontaneously without atropine. He subsequently \nbecame progressively hypotensive to ___, lactate 6.9, hgb \ndrop 6.1 from 7.4. Dark brown, guaiac + stool. GI and ACS were \nconsulted who did not recommend immediate intervention. KUB w/o \nfree air. On arrival to the MICU, patient was awake and \nmentating well. Complaining mostly of back pain. Cdiff was \nordered given for significant abdominal distention. \nNorepinephrine max 0.15 mcg/kg/hr, nurse was able to quickly \nwean to .04 prior to receiving blood. He was transfused with \n2uPRBC and 1U FFP, chased with 100 mg Lasix. He was weaned off \nLevophed prior to transfer.) \n\n===============\nACTIVE ISSUES: \n===============\n#Heart failure with reduced ejection fraction, acute \ndecompensation:\nPatient with history of heart failure with reduced ejection \nfraction secondary to ischemic cardiomyopathy. Patient presented \nwith >20lbs weight gain from dry weight and increased SOB, \nconsistent with heart failure exacerbation likely secondary to \nmissed diuretic doses at rehab (held for SBP < 100). He was \ntreated with a lasix drip 20 mg/hr and lasix boluses of 160 mg \nIV to euvolemia. He was unable to tolerate a Persantine MIBI due \nto back pain, despite pre-medication. He was changed to \nTorsemide 60mg daily and remained euvolemic, however this dose \nwas changed to 40mg daily given creatinine up to 1.7 (from \nbaseline 1.2). He was discharged on diuretic regimen torsemide \n40 mg daily. \n\nHis metoprolol was uptitrated and he was discharged on \nmetoprolol succinate XL 50 mg BID. Lisinopril 2.5 mg daily was \nHELD due to ___ on CKD (see below). Spironolactone could not be \nadded on to regimen due to low blood pressure and increase in \ncreatinine after two doses.\n\n#Hypoxemia: \n#Right pleural effusion/Trapped lung:\n#Pneumonia:\nPatient developed trapped lung as complication of anterior \napproach to L2-L3 fusion. Patient was hypoxic during last \nadmission due in part to trapped lung and right sided pleural \neffusion, and he had chest tube placed x 2. Thoracic surgery was \nconsulted, and deferred intervention urgently given poor \nclinical status. ___ benefit from VATS vs possible open \nthoracotomy decortication of entrapped right lung. Toward end of \nhospital course, patient developed more SOB and hypoxia \nrequiring up to 4L NC. Repeat CT chest suggested increased \nground glass opacities of left lung concerning for infection vs \npulmonary edema, stable hydropneumothorax. Completed a course of \nvancomycin/ceftazidime/azithromycin (___). MRSA \nscreen was negative. After management with antibiotics and \ndiuresis, patient's oxygen requirement decreased to 96% RA. \nHowever, patient did occasionally require ___ with exertion \n(desat to 87%). Thoracic surgery and IP will follow up as \noutpatient. \n\n#Atrial fibrillation:\nPatient's rates were well controlled after up-titrating \nmetoprolol to succinate XL 50 mg BID (HR ___, peaked in 130s \nwith significant exertion). Patient was on metoprolol XL 225mg \ndaily prior to last admission, which was decreased to 50mg daily \nat discharge ___. This had been further reduced to 12.5mg at \nrehab prior to this admission. He was continued on Rivaroxaban \n20 mg PO QHS and Metop XL 50mg BID. \n\n#C diff infection: \nPatient was diagnosed with C. difficile during last admission, \nand planned to complete PO flagyl 10 day course on ___. Per \nrehab records, it was unclear whether he completed this course. \nGiven he reported ongoing diarrhea on admission, he was treated \nwith a second 10 day course of PO vancomycin to ensure complete \ntreatment, with course from ___. C. diff negative on \n___. \n\n#Abdominal distention with Ogilvies:\nPt with known history of ___ syndrome. He was noted to \nhave prominent abdominal distention without pain, constipation, \nor other concerning signs. Had CT abdomen consistent with \nOgilvies. A bowel regimen was continued. Abdominal distention \nimproved. \n\n___ on CKD:\nBaseline 1.2, initially uptrended in the setting of diuresis \ndespite appearing overloaded on exam, possibly related to ATN in \nsetting of transient hypotension from valsalva, bradycardic \nepisode. Cr improved later with continued diuresis but increased \nagain on ___ possibly in the setting of starting \nspironolactone, which was discontinued. On ___, a vancomycin \nlevel was checked which was elevated at 66. Creatinine started \nto increase 48 hours after this, and additionally patient was \ngiven Spirinolactone x 2 days. Likely both of these insults \nexplain the worsening ___. His lisinopril was stopped and \nTorsemide was decreased to 40mg daily. On discharge, Cr 1.7 \n(baseline 1.2). Patient euvolemic and I/Os and weight stable, \nhowever Torsemide was decreased due Cr 1.7. It is expected that \npatient's creatinine will start to improve ___ weeks after \nVancomycin, Spirinolactone, Lisinopril were stopped, and \nTorsemide decreased. A post void residual was 21. Patient should \navoid all NSAIDs going forward. \n\n#Macrocytic Anemia: \nNoted to have macrocytic anemia with hemoglobin ___ during \nadmission. Prior to transfer to ICU, he was noted to have guaiac \npositive stool with hemoglobin drop and was transfused 2u pRBCs. \nIron studies showed an Fe/TIBC 22%, consistent with mild iron \ndeficiency. B12 and folate were normal. Methylmalonic acid was \nWNL. His Ferrous Sulfate 325 mg PO DAILY was continued at \ndischarge. Please re-check iron studies to ensure no iron \ntoxicity on supplemental iron and discontinue supplemental iron \nwhen iron replete. If within goals, pt may be further evaluated \nfor MDS.\n\n# Shock, hypotension, lactic acidosis (resolved): \nPatient developed hypotension and bradycardia in setting of \nvalsalva c/w vagal event. However, had persistent hypotension \nafter event with elevated lactate to 6.9 and hgb drop to from \n7.4 to 6.1, guaiac positive stools, cool extermities, and volume \noverload with elevated JVP. Initially, concern for hemorrhagic \nshock (Hgb drop and guaiac positive stools) vs abdominal \nischemia (distended abdomen, lactate) vs cardiogenic shock \n(cool, elevated JVP, increased BNP). Levophed was maxed, but \nrapidly weaned off prior to any other treatments. Lactate also \nresolved prior to any other treatments. ACS and GI were \nconsulted for concern for abdominal compartment syndrome vs \nischemia, but felt that exam was not concerning. He received 2U \npRBC and 1U FFP chased with 100mg IV lasix with good Hgb \nresponse. No further signs of bleeding. Weaned off of pressors \nand was warm on exam.\n\n================\nCHRONIC ISSUES:\n================\n#Chronic back pain: \n#Hip/leg pain:\nPer last discharge summary, patient has history of multiple \nprior spinal surgeries with hardware in place. No evidence of \ninfection during last admission. Etiology of pain is unclear but \nlikely multifactorial from degenerative disc disease and \nfrequent surgeries. He was continued on lidocaine patches, \nacetaminophen standing, gabapentin, and tramadol prn. His \nneurologic exam was intact. Consider chronic pain clinic \noutpatient for possible injection/nerve block. \n\n#Gout:\nContinued allopurinol ___ mg daily\n\n#Depression:\nContinued Sertraline 50 mg PO DAILY \n\nTRANSITIONAL ISSUES:\n=============================\n [ ] DISCHARGE WEIGHT: 89.3 kg (196.87 lb) \n [ ] DISCHARGE DIURETIC: Torsemide 40 mg daily \n [ ] DISCHARGE ANTICOAGULATION: Rivaroxaban 20 mg PO QHS\n [ ] DISCHARGE BUN/CR: ___\n [ ] FOLLOW UP LABORATORY TESTING: Recheck Chem 10, monitor \nlytes and creatinine ON ___. \n\n[ ] If Cr continues to uptrend, >2, would refer to Nephrology.\n[ ] Please continue to monitor weights and volume overload. Call \nCardiology office with > 3 lb weight change.\n[ ] Please ensure follow-up with thoracic surgery and \ninterventional pulmonology (appointments scheduled) for trapped \nlung. \n[ ] Please continue to monitor heart rates and atrial \nfibrillation. Metoprolol was uptitrated with improvement in \nrates (final dose Metop XL 50mg BID).\n[ ] Torsemide reduced to 40 mg daily due to uptrending Cr\n[ ] Rivaroxaban dosing continued given GFR > 50, but may need to \nreduce dose if Cr continues to uptrend >1.7.\n[ ] Holding lisinopril due to ___ on CKD. Please restart \nlisinopril 2.5mg daily if Cr normalizes. \n[ ] Please re-check iron studies to ensure no iron toxicity on \nsupplemental iron and discontinue supplemental iron when iron \nreplete. \n[ ] Follow up on macrocytic anemia with further work up (?MDS).\n[ ] Please continue to counsel patients to avoid NSAIDs given \nhis heart failure diagnosis and history of NSAID implicated \nacute tubular necrosis during last admission.\n[ ] Consider adding spironolactone as tolerated by creatinine to \noptimize HF regimen.\n[ ] Please note that Tramadol and Gabapentin were decreased \ngiven delirium earlier in hospitalization; pain was \nappropriately controlled at these smaller doses.\n[ ] Atorvastatin was increased to 40mg QPM this hospitalization.\n\n# CODE STATUS: FULL CODE\n# CONTACT: \nName of health care proxy: ___ \nRelationship: daughter \nPhone number: ___ \nCell phone: ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 10 mg PO QPM \n4. Furosemide 80 mg PO QAM \n5. Furosemide 40 mg PO QPM \n6. Metoprolol Succinate XL 12.5 mg PO DAILY \n7. Rivaroxaban 20 mg PO QHS \n8. Sertraline 50 mg PO DAILY \n9. Acetaminophen 1000 mg PO TID \n10. Calcium Carbonate 500 mg PO QID:PRN heartburn \n11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing \n12. Lidocaine 5% Patch 1 PTCH TD QPM \n13. Lisinopril 2.5 mg PO DAILY \n14. MetroNIDAZOLE 500 mg PO Q8H \n15. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting \n16. TraMADol 100 mg PO Q4H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\n17. Ferrous Sulfate 325 mg PO DAILY \n18. Pantoprazole 40 mg PO Q24H \n19. Hydrocerin 1 Appl TP DAILY dry skin \n20. Cholestyramine 2 mg gm PO BID \n21. Gabapentin 300 mg PO TID \n22. Milk of Magnesia 30 mL PO QHS:PRN constipation \n23. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN \nupset stomach \n24. Bisacodyl ___AILY:PRN constipation \n25. Docusate Sodium 100 mg PO TID:PRN constipation \n26. Senna 17.2 mg PO QHS:PRN constipation \n27. melatonin 3 mg oral QHS:PRN \n28. Vancomycin Oral Liquid ___ mg PO Q6H \n29. Magnesium Oxide 400 mg PO DAILY \n30. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat \n\n \nDischarge Medications:\n1. Torsemide 40 mg PO DAILY \n2. Allopurinol ___ mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Gabapentin 300 mg PO BID \n5. Metoprolol Succinate XL 50 mg PO BID \n6. TraMADol 75 mg PO BID:PRN Pain - Moderate \n7. Acetaminophen 1000 mg PO TID \n8. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN \nupset stomach \n9. Aspirin 81 mg PO DAILY \n10. Bisacodyl ___AILY:PRN constipation \n11. Calcium Carbonate 500 mg PO QID:PRN heartburn \n12. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat \n\n13. Cholestyramine 2 mg gm PO BID \n14. Docusate Sodium 100 mg PO TID:PRN constipation \n15. Ferrous Sulfate 325 mg PO DAILY \n16. Hydrocerin 1 Appl TP DAILY dry skin \n17. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing \n18. Lidocaine 5% Patch 1 PTCH TD QPM \n19. Magnesium Oxide 400 mg PO DAILY \n20. melatonin 3 mg oral QHS:PRN \n21. Milk of Magnesia 30 mL PO QHS:PRN constipation \n22. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting \n23. Pantoprazole 40 mg PO Q24H \n24. Rivaroxaban 20 mg PO QHS \n25. Senna 17.2 mg PO QHS:PRN constipation \n26. Sertraline 50 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: \n=============\n- Heart failure with reduced ejection fraction, acute on chronic \n\n- Atrial fibrillation\n- Trapped lung, right pleural effusion\n- Pneumonia \n- Anemia \n- ___ syndrome \n- Acute on chronic kidney disease \n\nSecondary: \n==================\n- C. difficile colitis \n- Chronic back pain \n- Gout \n- Depression\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to the hospital because you were short of \nbreath. \n\nWhat happened while I was in the hospital? \n- You were found to have a lot of extra fluid in your body, so \nyou were started on Lasix (a water pill). The fluid built up in \nyour body because of your heart failure. \n- The thoracic surgery team evaluated your lung, and you should \nfollow-up with them to discuss possible surgery for your lung. \n- You were treated with an antibiotic for a c. diff infection in \nyour bowel. \n- You were briefly treated in the intensive care unit for low \nblood pressure and low heart rates. \n- You developed a pneumonia in the hospital, which was treated \nwith antibiotics. \n\nWhat should I do when I go home? \n- Please take all your medicines as described in this discharge \npaperwork. \n- Please keep all your appointments with your doctors, as listed \nbelow. \n- You should not take any Advil, ibuprofen, Aleve or other pain \nrelievers in the medication family called NSAIDS (non-steroidal \nanti-inflammatory drugs). \n- Please weigh yourself every morning, and call MD if weight \ngoes up more than 3 lbs in 1 day or is steadily increasing. Your \nweight at discharge was 89.3 kg (196.9 lb). \n\nIt was a pleasure to participate in your care, and we wish you \nall the best.\n\nSincerely, \nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "I130", "J189", "N170", "R578", "E872", "A0472", "F05", "J948", "I5023", "K921", "I482", "I255", "D539", "I2510", "M5030", "J984", "I081", "K9289", "R001", "I341", "N189", "R0902", "M109", "Z96659", "G8929", "F329", "Z955", "Z7901", "Z87891" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "J189: Pneumonia, unspecified organism", "N170: Acute kidney failure with tubular necrosis", "R578: Other shock", "E872: Acidosis", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "F05: Delirium due to known physiological condition", "J948: Other specified pleural conditions", "I5023: Acute on chronic systolic (congestive) heart failure", "K921: Melena", "I482: Chronic atrial fibrillation", "I255: Ischemic cardiomyopathy", "D539: Nutritional anemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M5030: Other cervical disc degeneration, unspecified cervical region", "J984: Other disorders of lung", "I081: Rheumatic disorders of both mitral and tricuspid valves", "K9289: Other specified diseases of the digestive system", "R001: Bradycardia, unspecified", "I341: Nonrheumatic mitral (valve) prolapse", "N189: Chronic kidney disease, unspecified", "R0902: Hypoxemia", "M109: Gout, unspecified", "Z96659: Presence of unspecified artificial knee joint", "G8929: Other chronic pain", "F329: Major depressive disorder, single episode, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence" ]

[ "I130", "E872", "I2510", "N189", "M109", "G8929", "F329", "Z955", "Z7901", "Z87891" ]

[]

[ " \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:\naltered mental status\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with a past medical history\nof bipolar disorder, OSA, GERD, and anemia; presenting with\nconfusion for 3 days. History is difficult to obtain due to\npatient confusion, language barrier with family (despite\ntranslator), and records scattered across multiple providers\n___, new PCP and new psychiatrist). \n\nShe was brought to the ED by her family for 3 days of confusion. \n\nHer husband says that she has been walking around the house \n\"like\na zombie\", \"not making any sense\" when she speaks, not eating,\nbathing, or sleeping. Family also notes intermittent outbursts\nof arm raising and shaking that is nonsynchronized, nonrhythmic,\nand resembles a protracted startle response (which they\ndemonstrated). \n\nHer husband believes her symptoms are the result of recent\nmedication changes by a new psychiatrist she is seeing. At a\nrecent PCP ___ visit on ___ she was noted to be alert\nand oriented with an essentially normal exam. She complained of\n15 days of headache at that time. She was referred to a new\npsychiatrist, who the husband says she saw on ___ and \nwho\nreportedly changed her medications. The husband believes her\naltered mental status is result of the medication changes but he\ndoes not know specifically what these are. He believes she may\nbe taking too many of some of her medications. The OMR note on\n___ noted she was taking lithium 600mg BID, but apparently this\nhas been stopped at present (-- her husband did not bring the\nmedication and her serum level is low.)\n\nIn the ED a CT head revealed a left posterior fossa mass\nconsistent with a meningioma, exerting mass-effect on the left\ncerebellum causing edema and minor distortion of the fourth\nventricle. Neurosurgery was consulted and they did not think\nthat this mass was related to her alterations in mental status,\nso neurology was consulted. \n\n \nPast Medical History:\n-Bipolar disorder\n-OSA\n-GERD\n-Anemia\n-Hyperlipidemia\n-Hepatic steatosis\n \nSocial History:\n___\nFamily History:\nMother with hypertension. Maternal grandfather with CAD. Aunt \nwith colon cancer. \n \nPhysical Exam:\nAdmission Physical Exam: \nVitals: T:98.8 P:99 BP:143/72 r:20 SaO2:100%\nGeneral: Awake, frequently moving in bed. Inattentive and not\ncooperative with exam.\nHEENT: NC/AT, no scleral icterus noted.\nNeck: Supple.\nPulmonary: Lungs CTA bilaterally without R/R/W\nCardiac: RRR\nAbdomen: Obese, soft, NT/ND.\n\nNeurologic:\n-Mental Status: Alert, not oriented no self, place, situation;\nsaid \"I don't know\" in ___ these questions but replied yes \nto\nwhether her name was ___. Profoundly inattentive,\ncontinuously moving in bed and unable to cooperate with exam. \n\n-Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally. \n-Motor: Moved all extremities equally. \n-Sensory: Reacted to light touch in all extremities. \n-Coordination: Appeared able to grab bed rails with both hands\nwithout apparent ataxia. \n-Gait: Able to stand unassisted. Stable gait, short steps. \n\nDischarge Physical Exam: \nVitals: Tm 37.2, HR 65-87, BP 75-175/46-155, RR ___, >97% RA\nGeneral: Awake, lying in bed quietly, NAD\nHEENT: NC/AT, no scleral icterus noted.\nNeck: Supple.\nPulmonary: Lungs CTA bilaterally \nCardiac: RRR\nAbdomen: Obese, soft, NT/ND.\n\nNeurologic:\n-Mental Status: Awake, alert, refuses to participate with exam;\nlooks away to avoid eye contact\n-Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally. \n-Motor: Moved all extremities equally antigravity \n-Sensory: Withdraws to light touch in all extremities. \n-Coordination: No truncal ataxia, no dysmetria reaching for\nobjects\n\n \nPertinent Results:\n___ 05:15AM BLOOD WBC-8.8 RBC-4.44 Hgb-11.3 Hct-36.6 MCV-82 \nMCH-25.5* MCHC-30.9* RDW-18.8* RDWSD-56.3* Plt ___\n___ 05:48PM BLOOD Neuts-63.2 ___ Monos-9.9 Eos-0.8* \nBaso-0.5 Im ___ AbsNeut-8.24* AbsLymp-3.28 AbsMono-1.29* \nAbsEos-0.11 AbsBaso-0.07\n___ 08:23PM BLOOD ___ PTT-29.6 ___\n___ 05:15AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-142 \nK-3.3 Cl-107 HCO3-23 AnGap-15\n___ 06:35AM BLOOD ALT-19 AST-21 CK(CPK)-404* AlkPhos-67 \nTotBili-0.4\n___ 05:15AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1\n___ 06:35AM BLOOD TSH-1.2\n___ 08:00PM BLOOD Lithium-0.2*\n___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 12:08AM BLOOD Lactate-1.1\n\nCXR:\nFINDINGS: \nThere are low lung volumes.No definite focal consolidation is \nseen. There is \nno large pleural effusion or pneumothorax. The cardiac \nsilhouette is mildly \nenlarged, likely accentuated by low lung volumes and AP \ntechnique. \nMediastinal contours unremarkable. No pulmonary edema is seen. \n \nIMPRESSION: \nLow lung volumes without focal consolidation or pleural effusion \nseen. \n\nCT Head ___:\nFINDINGS: \nAbutting the superolateral left cerebellar hemisphere and the \ntentorium, there \nis a 3.2 x 2.6 x 2.8 cm dense lesion with adjacent vasogenic \nedema with \nresultant mass effect on the quadrigeminal plate cistern and \nfourth ventricle. \nNo evidence of herniation currently. \nThere is no evidence of acute fracture. The visualized portion \nof the \nparanasal sinuses, mastoid air cells, and middle ear cavities \nare clear. The \nvisualized portion of the orbits are unremarkable. \n \nIMPRESSION: \nA dense mass abutting the tentorium and left cerebellar \nhemisphere with \nadjacent vasogenic edema and mass effect effacing the fourth \nventricle and \nquadrigeminal plate cistern, most likely represents meningioma. \nNo current \nherniation. Recommend MRI with intravenous contrast for further \nevaluation, \nif no contraindication. \n\nMRI Brain ___:\n \nFINDINGS: \nIn the left posterior fossa, there is a round 3.2 x 2.9 x 3.0 cm \ndural-based \nmass inseparable from the left tentorium, abutting the \nsuperolateral aspect of \nthe left cerebellar hemisphere, presumably meningioma. It is \nisointense to \ngray matter on T1 and T2 weighted imaging with homogeneous avid \nenhancement. \nThere is regional T2 prolongation within the left cerebellar \nhemisphere \nconsistent with vasogenic edema with and mild effacement of the \nfourth \nventricle. No hydrocephalus. No evidence of hemorrhage or \ninfarction. \n \nThe left transverse sinus is hypoplastic. The left distal \ntransverse sinus \nand sigmoid sinus do not enhance and may be compressed or \noccluded by the \npresumed meningioma. The left internal jugular vein traits \npostcontrast \nenhancement. The remainder of the dural venous sinuses are \npatent. \n \nIMPRESSION: \nDural-based mass in the left posterior fossa, consistent with a \nmeningioma. \nThere is regional vasogenic edema with mild effacement of the \nfourth ventricle \nbut no obstructing hydrocephalus. No definite enhancement of \nthe distal left \ntransverse sinus and sigmoid sinus which may be severely \ncompressed with \nocclusion a possibility. There is reconstitution of contrast \nenhancement of \nthe left internal jugular vein. \n \n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with a history of bipolar \ndisorder who presented with headache and increasing psychosis in \nthe setting of medication non-compliance. Her exam was notable \nfor limited speech output, paranoia and paratonia without clear \nfocal neurologic deficits. CT demonstrated a left posterior \nfossa mass adjacent to the cerebellum with MRI confirming the \ndiagnosis of meningioma (3.1 x2.6cm enhancing extra-axial mass \nabutting tentorium and left cerebellum), which per Neurosurgery \nrequired no acute surgical intervention and will be followed \nover time as an outpatient. \n\nShe remained in a state of decompensated psychosis and \nPsychiatry recommended restarting her home Invega (paliperidone) \n9mg daily, as she was likely non-compliant with this medication. \nShe had notably last had this medication filled on ___ in \nquantity of 30 and there were still 20 pills left in bottle she \nbrought with her to the hospital. EKG with QTc 473msec. She \nremained afebrile with stable vital signs throughout her \nadmission and she is medically cleared for discharge. She will \nbe discharged to ___ \naccepting MD ___. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. paliperidone 9 mg oral DAILY \n2. Omeprazole 20 mg PO DAILY \n3. Ferrous Sulfate 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Ferrous Sulfate 325 mg PO DAILY \n2. Omeprazole 20 mg PO DAILY \n3. paliperidone 9 mg oral DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nmeningioma, psychosis\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\nYou were admitted due to concern for a mass in the brain \n(cerebellum) that was found to be a meningioma. No surgical \nintervention was required and you will be followed as an \noutpatient by Neurosurgery. You were seen by Psychiatry who \nrecommended restarting your home paliparidone (Invega) and your \nmedications will continued to be titrated at ___ \n___. \nBest,\nYour ___ Neurology Team\n \nFollowup Instructions:\n___\n" ]

[ "F29", "G936", "D320", "F319", "G4733", "K219", "D649", "E669", "T43596A", "Y929", "R278" ]

[ "F29: Unspecified psychosis not due to a substance or known physiological condition", "G936: Cerebral edema", "D320: Benign neoplasm of cerebral meninges", "F319: Bipolar disorder, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K219: Gastro-esophageal reflux disease without esophagitis", "D649: Anemia, unspecified", "E669: Obesity, unspecified", "T43596A: Underdosing of other antipsychotics and neuroleptics, initial encounter", "Y929: Unspecified place or not applicable", "R278: Other lack of coordination" ]

[ "G4733", "K219", "D649", "E669", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"I am feeling sick\"\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPer Dr. ___ initial psychiatry note: \n\"___ ___, homeless, unemployed, ___ client, w/PPHx\nof schizoaffective disorder (bipolar type), multiple psychiatric\nhospitalizations, prior suicide attempts, but no substance use,\nw/PMHx of meningioma s/p resection now on anti-epileptics, was\nBIBA after she was found on the street agitated and walking into\nthe traffic. \n\nPer RN notes, in triage, patient was agitated and yelling in\n___, providing little information and getting even more\nagitated when a ___ interpreter tried helping. After she was\nbrought inside the ___, patient calmed down and answered some\nquestions with the help of a ___ security guard. \nShe\nsaid she had a long Hx of depression with thoughts of SI and\nreported that she has not taken her medications \"in a very long\ntime.\"\n\nPsychiatry attempted interviewing patient twice, first in\n___, then with the help of a ___ interpreter. Overall,\npatient was minimally cooperative with both interviews, turning\nher back to the interviewers early in the interview, answering\nmost questions with \"I don't know, I don't know, I don't know\"\n(\"no se, no se, no se\"), others with \"I don't want to talk about\nit\" (specifically regarding her breakup with her former \npartner),\nand ended up the interview with stating, \"You cannot force me to\ntalk about anything\". Patient did say that she was not feeling\nwell and didn't want to live. She refused to elaborate on what\nexactly she meant by not feeling well (whether physically or\npsychologically). She denied any intent or plan to commit \nsuicide\nherself, stating that she wanted to be killed by someone else.\nShe was able to give her name and knew she was at ___\" but couldn't state a year even after being given\nseveral choices (\"no se, no se, no se\"). She couldn't state why\nshe was at the hospital and how she ended up here, but seemed to\nremember walking in the traffic after she was reminded about it;\nshe refused to answer whether it was a suicide attempt. When\nasked about her current living situation, she said she was \nliving\non the street since she and her partner in whose apartment she\nused to live broke up, and she emphatically refused to talk \nabout\nit any further. Patient denied any drug use. She refused to talk\nabout her medications or psychiatric providers. Patient refused\nto answer questions on psychiatric or general medical ROS. \n\nCOLLATERAL from BEST: \n- per BEST records, patient had 18 psychiatric hospitalizations\nsince ___ \n- her psychiatric hospitalizations between now and ___ \nwhen\nshe was last seen at ___ ___ are: \n--- ___: BIB police to ___ ___ for erratic behavior on\nthe street, was very agitated and had to be physically and\nchemically restrained, was then hospitalized at ___ for\npsychosis; \n--- ___: was BIB police to ___ ___ for agitation and\npsychosis on the street (patient was found lying on the street\nw/o shoes and yelling insults at passerby's), evaluators\nstruggled to interview her, was hospitalized at ___; \n--- ___: patient self-presented to ___ reporting \nbeing\ndepressed and a recent suicide attempt (details unavailable),\nreported being on lithium and Risperdal, denied substance use,\nhospitalized at ___\"\n\nReviewed and selected pertinent information from Dr. ___\n___ Collateral information from patient's significant other\n(___):\n-psychiatrically admitted from ___ to ___ at ___.\n-Stayed in a shelter for one night then returned to live with\n___, then left home ___ and was on streets. \n-Saw her on streets on ___, offered her food and asked her\nto return home which she declined.\n-Saying only \"God help me.\" \n-\"patient seemed like a zombie\"\n-___ unable to provide medication list\n-Trauma history, family difficulties, \n\nReviewed and selected pertinent information from Dr. ___ physician ___ evaluation on ___\n-Review of discharge summary from Deaconess 4 ___ - ___,\npatient also exhibited signs of catatonia and had responded to\nlorazepam 2 mg Q8H with significant improvement. \n___ Catatonia Rating Scale (___) score = 27\nExcitement 1\nImmobility/stupor 1 \nMutism 0\nStaring 2\nPosturing/catalepsy 0\nGrimacing 0\nEchopraxia/echolalia 1\nStereotypy 0\nMannerisms 0\nVerbigeration 1\nRigidity 1\nNegativism 1\nWaxy Flexibility 3\nWithdrawal 2\nImpulsivity 0\nAutomatic obedience ___\nMitgehen 3\nGegenhalten 3\nAmbitendency 3\nGrasp reflex 0\nPerseveration 3\nCombativeness 0\nAutonomic abnormality 1\n\nIn the ___, Ms. ___ had a leukocytosis of 14 without \nevidence\nof fever or tachycardia and thus medically cleared by ___\nphysician, ___, MD ___ borderline at times). \nOn review by this examiner, TSH normal, no hypo/hyperkalemia,\nhypo/hypernatremia. Serum tox negative. \n___ ECG HR 100 QRS 90 QTc 496 ms. \n\n___ arrival to the inpatient psychiatry unit, interview was\nconducted and legal paperwork reviewed with a trained ___ \nstaff\n___ interpreter. \nMs. ___ reports she came to the hospital because \"she was\nfeeling sick.\" On attempted clarification of \"sick\" patient\nreplied via direct translation, \"sick, not very sick, like a bit\nsick.\" Spontaneous speech is not present. The following obtained\nfrom direct questioning only. The police brought her in while \nshe\nwas on the streets. They stopped her when she was trying to go\ninto a store and wanted to ask her questions. They then asked \nher\nto get into the car and was brought to the ___. She feels\nconfused, has some trouble remembering things, but not \"as bad \nas\nbefore.\" She reports feeling happy and denies suicidal thoughts.\nShe denies difficulty with sleep, auditory or visual\nhallucinations. She reports she is religious, does not have a\nfavorite passage of scripture at this time. She reports diarrhea\ntwo days ago, has mild right anterior knee pain but denies \nrecent\nor current shortness of breath, palpitations, rapid heart beat,\nchest pain, dysuria, frequency. Interview is terminated early \ndue\nto patient report of distress associated with repeated\nquestioning. \n\nREVIEW OF SYSTEMS:\n -Psychiatric: \ncurrently denies thoughts of death/SI, sleep disturbance\nincluding insomnia or hypersomnia, worry, rumination, flight of\nideas, increased\nactivity, decreased need for sleep, or talkativeness/pressured\nspeech, auditory or visual hallucinations, or delusions of\nreference, paranoia, thought insertion/broadcasting.\n\n -General: Denies fatigue, fever, chills, polyuria, cough, SOB,\nCP, palpitations, abdominal pain, nausea, vomiting, \nconstipation,\ndysuria, increased urinary frequency or odor. \n+edema on lower extremities, left knee pain, +diarrhea two days\npreviously.\n\n \nPast Medical History:\nPer ___ ___ neuro-oncology note:\n1. Left-sided posterior fossa meningioma \n2. Dyslipidemia\n3. Bipolar disorder, psychosis\n4. Cardiomegaly\n5. Kidney stones\n6. Prediabetes\n7. Sleep apnea, not on CPAP\n8. Steatosis\n9. Left sided thoracic pain\n10. Catatonia after medication non-compliance\n\n11. Chronic R knee pain (per Dr. ___ ___ \n\n \nSocial History:\n___\nFamily History:\nMother with hypertension. Maternal grandfather with CAD. Aunt \nwith colon cancer.\nPatient denies any family psychiatric history, though prior OMR \nnotes have suggested a mother with possible ___. \n \nPhysical Exam:\nPhysical Exam on admission:\n\nGeneral:\n -HEENT: Normocephalic, atraumatic. Moist mucous membranes,\noropharynx clear. No scleral icterus, \n -Cardiovascular: +tachycardia, hyperdynamic, no rubs or murmurs\n -Pulmonary: No increased work of breathing. Lungs clear to\nauscultation bilaterally. No rhonchi/rales. +exp. wheezes\n -Abdominal: Non-distended, bowel sounds normoactive. No\ntenderness to palpation in all quadrants. No guarding, no\n rebound tenderness.\n -Extremities: Warm and well-perfused. chronic ___ non-pitting\nedema\n -Skin: No rashes or lesions noted.\n\nNeurological:\n -Cranial Nerves:\n ---I: Olfaction not tested.\n ---II: pupils 2mm, equal, round\n ---III, IV, VI: EOMI without nystagmus\n ---V: Masseter ___ bilaterally\n ---VII: nasolabial folds symmetric bilaterally\n ---VIII: deferred\n ---IX, X: Palate elevates symmetrically\n ---XI: trapezii ___ symmetric bilaterally\n ---XII: Tongue protrudes midline\n -Motor: Normal bulk and tone bilaterally. Strength ___ in\ndeltoids, biceps, triceps, quadriceps, hamstrings,\n -Sensory: deferred\n -DTRs: 2+ patellar, biceps, \n Coordination: Normal on finger to nose test, no intention \ntremor\nnoted\n -Gait: deferred \nAbsence of resting tremor, absence of action tremor\n+rigidity\nCognition: EXAM limited by limited participation with the\nfollowing:\n -Wakefulness/alertness: Awake and alert\n -Orientation: ___, ___\n -Executive function: absence of ideomotor apraxia: able to \nbrush\nteeth, comb hair\n -Visuospatial: Left thumb to right ear\n -Memory: unable to recall ___, blue\"...\"apple, \nflower,\nI don't remember\"\n -Fund of knowledge: unable to assess\n -Calculations: unable to assess\n -Abstraction: unable to assess\n -Attention: unable to assess\n -Language: non-fluent with ___ interpreter, ___ \nspeaking\n\nMental Status:\n -Appearance/Behavior: overweight female, sitting in chair, deep\nsighs at times, fair eye contact, mild psychomotor retardation\n -Attitude: engaged\n -Mood: \"Happy\"\n -Affect: mood incongruent, dysphoric, blunted, non reactive,\nmostly appropriate\n -Speech: decreased spontaneity of speech, no latency, normal\nrate, decreased prosody\n -Thought process: linear, vague, mildly disorganized\n -Thought Content:\n ---Safety: Denies SI/HI\n ---Delusions: No evidence of paranoia, etc. \n ---Obsessions/Compulsions: No evidence based on current\nencounter\n ---Hallucinations: Denies AVH, not appearing to be attending to\ninternal stimuli\n -Insight: limited\n -Judgment: poor\n\n___\n1+ Mutism\n1+ posturing\n2+ rigidity\n2+ negativism\n3+ Waxy Flexibility\n3+Ambitendency \n3+Gegenhalten\n\nDischarge MSE: \nAppearance: Obese, age-appearing woman, slightly frizzy hair, \ndressed casually, fair hygiene\nBehavior: Cooperative with interview, albeit a bit irritable\nSpeech: Slightly rapid rate, otherwise normal \nrhythm/tone/prosody\nMood: 'Good' \nAffect: Slightly irritable, constricted-range\nThought process: Slightly tangential, but goal-directed\nThought content: Denies SI/HI/AVH, perseverative on leaving with \nher husband instead of her ___ case worker\nInsight/judgment: Improved/improved \n \nPertinent Results:\n___ 04:00PM BLOOD WBC-9.9 RBC-4.33 Hgb-10.9* Hct-37.0 \nMCV-86 MCH-25.2* MCHC-29.5* RDW-20.0* RDWSD-61.5* Plt ___\n\n___ 12:25PM BLOOD Glucose-135* UreaN-10 Creat-0.7 Na-141 \nK-3.7 Cl-105 HCO3-23 AnGap-13\n\n___ 04:00PM BLOOD Phos-3.2\n\n___ 12:25PM BLOOD calTIBC-329 Ferritn-24 TRF-253\n\n___ 06:30AM BLOOD %HbA1c-5.9 eAG-123\n\n___ 06:30AM BLOOD Triglyc-202* HDL-29* CHOL/HD-6.1 \nLDLcalc-108\n\n___ 12:25PM BLOOD TSH-3.8\n\n___ 06:30AM BLOOD 25VitD-28*\n\n___ 12:25PM BLOOD Trep Ab-NEG\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n Culture workup discontinued. Further incubation showed \ncontamination\n with mixed skin/genital flora. Clinical significance of \nisolate(s)\n uncertain. Interpret with caution. \n PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n PROTEUS MIRABILIS\n | \nAMPICILLIN------------ <=2 S\nAMPICILLIN/SULBACTAM-- <=2 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---- =>16 R\n\n SMEAR FOR BACTERIAL VAGINOSIS (Final ___: \n GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS. \n \nBrief Hospital Course:\n1. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout her admission. She was also placed on 15 minute \nchecks status on admission and remained on that level of \nobservation throughout while being unit restricted. Ms. ___ \nalso signed a 3-day notice on ___ as she felt she was ready \nfor discharge at the time. This 3-day notice expired on \n___, on the day of discharge. \n\n2. PSYCHIATRIC:\n#) Schizoaffective disorder/Catatonia\n\nDuring initial presentation to the ___, patient demonstrated \nsigns and symptoms suggestive of catatonia. After receiving \nseveral doses of ativan in ___, patient did not demonstrate any \novert signs of catatonia on the inpatient unit, though appeared \nthought disordered, disorganized, and paranoid. She was \ncontinued on ativan 1 mg TID throughout hospital course. She was \nirritable, with blunted affect. She was started on olanzapine \nfor psychotic symptoms which was titrated to 5 mg QHS. She \ntolerated this medication well and responded well to this, \nbecoming more organized, linear, and brighter in affect. \nDiagnostically, presentation is consistent with decompensated \nschizoaffective disorder in the setting of medication \nnon-adherence.\n\nHer outpatient psychiatrist suggested that she be restarted on \ninjectable antipsychotics due to her history of medication \nnon-compliance; however, the patient declined to do so multiple \ntimes. Given repetitive inpatient psychiatric medications due to \nmedication non-compliance, this ___ be something that can be \nimplemented in the future. \n\nOn day of discharge, ___ denied having any thoughts of \nwanting to hurt herself, others, and did not appear to be \nresponding to internal stimuli. She voiced a preference to leave \nthe hospital; though she was irritable, she did appear overtly \npsychotic. She was told the importance of medication-adherence, \nthe importance of going to her outpatient providers, and that \nshe should report back to the ___ or reach out to her ___ team \nshould she begin to feel more paranoid. \n\n3. SUBSTANCE USE DISORDERS:\n#) Patient does not have a history of substance use disorder.\n\n4. MEDICAL\n#Seizure prophylaxis: Ongoing, chronic\n-The patient was continued on her home regimen of Oxcarbazepine \n300mg BID. No seizures were observed during hospitalization. \n\n#QTc prolongation: Ongoing, chronic\nPatient was noted have a slightly prolonged qtc at 448 ms; her \nhome haldol was held and she was started on olanzapine. ECG \nobtained prior to discharge was: \n\n#UTI: Resolved\nThe patient was found to have an uncomplicated UTI and was \nappropriately treated with nitrofurantoin. \n\n#?Bacterial vaginosis: Resolved \nStaff noted she and her room had a persistent, malodorous fishy \nsmell concerning for BV. OB-GYN was consulted and obtained smear \nwhich was negative for bacterial vaginosis and \ngonorrhea/chlamydia. \n\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. Despite \ngentle encouragment, the patient declined to participate in \ngroups. In the milieu, ___ was a bit isolative, seen \nspending most time by herself watching television or walking \naround in the unit. \n\n#) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT\nFamily meeting was held with her spouse, ___, ___ workers, \nand inpatient clinicians present. \n\nClinical team spoke with the patient's outpatient psychiatrist \nto provide clinical updates, schedule aftercare appointments, \nand gather additional collateral. \n\n___ therapist also visited her while she was on the \ninpatient unit. \n\n#) INTERVENTIONS\n- Medications: Olanzapine\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: Clinical team was in correspondence \nwith her ___ outpatient treatment team as mentioned above. \n- Behavioral Interventions: Increased coping skills and distress \ntolerance\n\nINFORMED CONSENT: \nClinical team attempted to discuss the indications for, intended \nbenefits of, and possible side effects and risks of Zyprexa, and \nrisks and benefits of possible alternatives, including not \ntaking the medication, with this patient. We discussed the \npatient's right to decide whether to take this medication as \nwell as the importance of the patient's actively participating \nin the treatment and discussing any questions about medications \nwith the treatment team. The patient appeared able to understand \nand consented to continue and to adjust the medication to \nclinical response. Overall, her participation was decreased.\n\nRISK ASSESSMENT & PROGNOSIS\nOn initial presentation, the patient was evaluated and felt to \nbe at increased risk of harm to self due to her chronic mental \nillness, history of inpatient psychiatric hospitalizations, \nhistory of suicide attempts; she was at acutely elevated risk of \nharm to self due to medication non-compliance, ongoing \npsychosis, and lack of community supports. Protective factors \ninclude her long-term relationship with her husband, her good \nrelationship with her outpatient providers, and lack of suicidal \nideation. \n\nInpatient psychiatric hospitalization was able to address her \nmodifiable risk factors of psychosis and medication \nnon-compliance with the initiation of antipsychotic medications. \nOverall, the patient is no longer at acutely elevated risk of \nself-harm. \n\nOverall prognosis is guarded, as patient's longstanding history \nof psychosis with periods of medication non-compliance. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lithium Carbonate 300 mg PO BID \n2. OXcarbazepine 300 mg PO BID \n3. Pantoprazole 20 mg PO Q24H \n4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \n\n \nDischarge Medications:\n1. LORazepam 1 mg PO TID \nRX *lorazepam 1 mg 1 tablet(s) by mouth three times a day Disp \n#*42 Tablet Refills:*0 \n2. OLANZapine 7.5 mg PO QHS mood dos \nRX *olanzapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*14 \nTablet Refills:*0 \n3. Lithium Carbonate 600 mg PO QHS \nRX *lithium carbonate 600 mg 1 capsule(s) by mouth at bedtime \nDisp #*14 Capsule Refills:*0 \n4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \nRX *docusate sodium 100 mg 1 capsule(s) by mouth at bedtime Disp \n#*28 Capsule Refills:*0 \n5. OXcarbazepine 300 mg PO BID \nRX *oxcarbazepine 300 mg 1 tablet(s) by mouth twice a day Disp \n#*28 Tablet Refills:*0 \n6. Pantoprazole 20 mg PO Q24H \nRX *pantoprazole 20 mg 1 tablet(s) by mouth once a day Disp #*14 \nTablet Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSchizoaffective disorder\n\n \nDischarge Condition:\nOn day of discharge, ___ denied having any thoughts of \nwanting to hurt herself, others, and did not appear to be \nresponding to internal stimuli. She voiced a preference to leave \nthe hospital; though she was irritable, she did appear overtly \npsychotic. She was told the importance of medication-adherence, \nthe importance of going to her outpatient providers, and that \nshe should report back to the ___ or reach out to her ___ team \nshould she begin to feel more paranoid. \n\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\nMental Status:\nAppearance: Obese, age-appearing woman, slightly frizzy hair, \ndressed casually, fair hygiene\nBehavior: Cooperative with interview, albeit a bit irritable\nSpeech: Slightly rapid rate, otherwise normal \nrhythm/tone/prosody\nMood: 'Good' \nAffect: Slightly irritable, constricted-range\nThought process: Slightly tangential, but goal-directed\nThought content: Denies SI/HI/AVH, perseverative on leaving with \nher husband instead of her ___ case worker\nInsight/judgment: Improved/improved \n\n \nDischarge Instructions:\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n-Unless a limited duration is specified in the prescription, \nplease continue all medications as directed until your \nprescriber tells you to stop or change.\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F250", "N390", "R45851", "B964", "I4581", "M25561", "Z590", "Z560", "Z9114", "E663", "Z6835" ]

[ "F250: Schizoaffective disorder, bipolar type", "N390: Urinary tract infection, site not specified", "R45851: Suicidal ideations", "B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere", "I4581: Long QT syndrome", "M25561: Pain in right knee", "Z590: Homelessness", "Z560: Unemployment, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "E663: Overweight", "Z6835: Body mass index [BMI] 35.0-35.9, adult" ]

[ "N390" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n\"...\"\n \nMajor Surgical or Invasive Procedure:\nNinguno\n\n============================================================\n\nNone\n\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS:\nMrs ___ is a ___ year old ___ female with a\nhistory of bipolar disorder, psychosis, and meningioma who\npresents with altered mental status, sent here overnight from\n___ where she had walked in for unknown\nreason.\n\nMinimal communication on initial attempts to interview, even \nwith\n___ interpreter, saying nothing or- per report- repeatedly\nmumbling either ___ or \"muerto\" (dead). Nursing staff\nreport patient has been minimally interactive but has followed\ninstructions to robe/disrobe, and patient has also asked for the\nbathroom. Poor PO intake.\n\nOn repeat interview with interpreter patient was somewhat more\ninteractive. When asked why she is here does not respond. States\nher name and location (\"deaconess\" \"emergency\"). Asked if she\ntakes lithium says she takes it, asked who helps her says \"I \ntake\nit.\" Successfully identifies a pen and its colors \"black and\nwhite.\" When asked to write her name and date of birth writes\n\"blac and whit.\"\n\nPer collateral from BEST, patient last seen ___ with\nconfusion and psychosis and was admitted to ___.\n\nPatient's psych meds are prescribed by ___ at ___. Dr ___ is currently away. Left message with covering\nphysician Dr ___ (___).\n\nOn chart review, patient had somewhat similar episode ___ in\nthe setting of non-adherence to lithium: \"She was brought to the\nED by her family for 3 days of confusion. Her husband says that\nshe has been walking around the house \"like a zombie\", \"not\nmaking any sense\" when she speaks, not eating, bathing, or\nsleeping. Family also notes intermittent outbursts of arm\nraising and shaking that is nonsynchronized, nonrhythmic, and\nresembles a protracted startle response (which they\ndemonstrated).\"\n\n___ Rating scale: 16\nExcitement: 0\nImmobility/stupor: ___\nMutism: 1\nStaring: 2\nPosturing/catalepsy: 0\nGrimacing: 1\nEchopraxia/echolalia: 1\nStereotypy: 1\nMannerisms: 0\nVerbigeration: 1\nRigidity: 1\nNegativism: 2\nWaxy flexibility: 0\nWithdrawal: 2\nImpulsivity: 0\nAutomatic obedience: ___\nMitgehen: 0\nGegenhalten: 0\nAmbitendency: 0\nGrasp reflex: -\nPerseveration: 3\nCombativeness: 0\nAutonomic abnormality: 0\n\nOn re-examination the following day: \nPatient much more interactive this morning and able to give some\nhistory. Says she got out of Arbour 3 days ago. Went home.\nContinued taking her meds. On day of presentation was only able\nto say that she ate and then came here. Does not know why. Asked\nabout the large amount of money she was found to be carrying,\nsays she went to the bank to move her money to her house. Denies\nany triggers, denies fighting with her husband.\n\nThis morning patient says she is \"good\" and her mood is \"good.\"\nHowever she also endorses feeling tired and \"heavy\" and says she\n\"felt more alive yesterday\". Denies SI/HI and AH/VH. \n\n___ Scale: 5\nScoring only for...\nImmobility/stupor: 1\nStaring: 1\nRigidity: 1\nNegativism: 1\nWithdrawal: 1\n\nOn arrival to the inpatient unit: \nBriefly, ___ is a ___ year old female with a history of\nbipolar disorder type 1, meningioma, HLD and OSA who was sent to\nthe ___ ED from ___ where she had gone\nfor no apparent reason. In the ED, the patient appeared\ncatatonic and received Ativan which resulted in some \nimprovement.\nPer chart review, patient was seen at ___ in ___ for \nAMS\nand was found to have a meningioma on head CT. However, per\nneurological evaluation at that time was not felt to be the \ncause\nof her AMS and agitation. Psychiatry was consulted and patient\nwas found to be psychotic and likely not taking her lithium. A\nlithium level from ___ was <0.1 which is concerning for\nmedication non-compliance for this admission as well. Neurology\nexamined the patient in the ED during this admission for \nconcerns\nof seizures and did an EEG but her AMS was felt to be more \nlikely\ndue to psychosis rather than infection or seizure. \nOn admission to deaconess 4, the patient was not cooperative \nwith\ninterview and lay down face first on the floor and wouldn't\nanswer questions. Patient was brought to her room and she lay\ndown on the bed. Attempted to interview her with ___\ninterpreter but she asked interviewer to leave and stated she\nwanted to sleep. She denied SI. She then stopped answering\nquestions. \n \nPast Medical History:\nPast Psychiatric History: \nDx: Bipolar disorder\nHospitalizations: \nTreaters: \n- Psychiatrist: Dr. ___ (___)\n- Therapist: ___, ___ (___)\n- PCP: Dr. ___ (___)\nMedication and ECT Trials: Invega, Lithium, Zyprexa, (has never \ntried Depakote)\nSelf-Injury/Self harm: ___ past suicide attempts \n\nPast Medical History\n-OSA (per patient, does not use CPAP at home)\n-GERD\n-Anemia\n-Hyperlipidemia\n-Hepatic steatosis\n-left posterior fossa benign meningioma\n \nSocial History:\n___\nFamily History:\nMother with hypertension. Maternal grandfather with CAD. Aunt \nwith colon cancer. \n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION: \n\nVS: 98.5, 94 / 61, 73, 16, 95% \n\nGEN:NAD, obese, Hispanic female lying in bed with her eyes\nclosed and covers pulled up. Refusing to answer further\nquestions. Moving limbs spontaneously, speaking fluent ___. \n\nHEENT: Normocephalic, atraumatic. Moist mucous membranes.\nCardio: Regular Rate and Rhythm, no murmurs/rubs/gallops\nPulm: Normal work of breathing, clear to auscultation\nbilaterally.\nAbd: Non-distended, non-tender to palpation, positive bowel\nsounds\nExt: Warm and well perfused, capillary refill < 2 seconds\n\nNeuro: CN: PERRLA, EOM full, facial sensation to touch equal in\nall 3 divisions bilaterally, face symmetric on eye closure and\nsmile, hearing normal bilaterally to rubbing fingers, phonation\nnormal, head turning and shoulder shrug intact, tongue midline.\nStrength: ___ throughout. Sensation: within normal limits to\nlight touch. Gait and station: Normal gait, no ataxia noted.\nAbnormal movements: No tremor or abnormal movements \nappreciated.\n\nMSE on discharge: \nAppearance: well groomed\nfacial expression: friendly \nbuild: overweight\nBehavior: Engaging, cooperative\npsychomotor: no abnormal involuntary movements, no agitation\nSpeech: slightly pressured today, normal tone and volume\nmood/affect: stable, no angry outbursts \nthought process/content: reality oriented, goal directed, denied\nSI/HI, denied AH/VH/ paranoid delusions\nIntellectual Functioning: Decreased concentration\nOriented: ×4 \nmemory: Grossly intact \ninsight: fair\nJudgment: fair\n\n \nPertinent Results:\nCBC: \n___ 07:35AM WBC-7.5 RBC-4.32 HGB-12.0 HCT-37.9 MCV-88 \nMCH-27.8 MCHC-31.7* RDW-20.5* RDWSD-65.9*\n___ 07:35AM NEUTS-54.9 ___ MONOS-8.8 EOS-2.1 \nBASOS-0.3 IM ___ AbsNeut-4.12 AbsLymp-2.52 AbsMono-0.66 \nAbsEos-0.16 AbsBaso-0.02\n___ 07:35AM PLT COUNT-265\n\nBMP: \n___ 04:35AM GLUCOSE-95 UREA N-8 CREAT-0.6 SODIUM-138 \nPOTASSIUM-4.1 CHLORID ___ TOTAL CO2-24 ANION GAP-15\n___ 07:35AM GLUCOSE-111* UREA N-12 CREAT-0.6 SODIUM-138 \nPOTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-16\n\nUA: \n___ 02:00PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 02:00PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 02:00PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE \nEPI-1\n___ 02:00PM URINE MUCOUS-RARE*\n\nUTox: \n___ 02:00PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n\nSerum Tox: \n___ 07:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n\nLithium:\n___: LITHIUM <0.1\n___: LITHIUM 0.7\n___: LITHIUM 0.7\n\nTSH: \n___: 52.5\n___: 7.6,, free T4 0.9\n___: 5.4\n___: 4.5\n\nB-HCG: \n___: <___. LEGAL & SAFETY: \nOn admission, Ms. ___ was unwilling to cooperate with \ninterview and thus, was admitted on a ___ which expired \non ___. She signed a conditional voluntary agreement (Section \n10 & 11) on ___ which was accepted. Ms. ___ was also \nplaced on q15 minute checks status on admission and remained on \nthat level of observation throughout while being unit \nrestricted.\n\nEvaluation for fresh air access: Ms. ___ was deemed to not \nbe eligible for access to the outdoors based on danger to self \nand inability to ensure safety in an open environment even with \nsupervision as evidenced by depression, catatonia, poor \ncooperativeness with initial interview, psychotic\n \n2. PSYCHIATRIC:\n#) Catatonia\nMs. ___ presented to the ED with symptoms concerning for \nnon-malignant, retarded catatonia on presentation to the ED with \n___ of 16. Neurology was consulted to rule out \nseizures and other neurologic processes as a potential \ncontributor. EEG did not show any epileptiform activity and CT \nHead was stable. Ms. ___ level was sub \ntherapeutic (<0.1) suggesting medication non-compliance as a \nlikely etiology (and per her outpatient psychiatrist's \ncollateral, Ms. ___ has a history of recurring \nhospitalization in the setting of medication non-compliance. She \nwas started on standing ativan (2mg q8h) with dramatic \nimprovement in her symptoms, scoring ___ of 5 \non re-evaluation. She was re-started on her Lithium at a lower \ndose (300mg BID) and Olanzapine 5mg PO BID for management of \npsychosis. Per ___'s recent discharge summary, she \nhad been recently discharged on Lithium ER 600mg PO BID and \nZyprexa 15mg PO bedtime. Ms. ___ tolerated an ___ taper \nwith continued improvement of her symptoms. Her lithium was \ngradually up-titrated to 600mg BID (dose on discharge). Her \nolanzapine was tapered given her daytime sleepiness, however, \nMs. ___ began exhibiting some symptoms concerning for mania \nincluding irritability, rapid and pressured speech, and \ndisorganization (with reoccurring concern that insurance won't \ncover her outpatient ___ providers despite reassurance). She \nwas re-started on Paliperidone (Invega) which she had previously \ntaken as an outpatient and had been stable-on as an injectable \nwhich was up-titrated to 9mg. The team discussed switching from \nPO to IM administration on discharge with the patient, however, \nMs. ___ refused stating the the injectable form had \npreviously affected her ability to walk. She continued to \nimprove, however, on routine labs, Ms. ___ had an increase \nin her TSH to 7.6 with a free T4 of 0.7 concerning for Lithium \ninduced hypothyroidism given that her TSH had been within normal \nlimits on admission (and per collateral had been previously \nunremarkable). Her lithium was decreased to 300mg BID with \nsubsequent decrease in TSH to 5.4, however, patient began \ndemonstrating some worsening of her symptoms (more irritability, \ndisorganization, constricted affect) and her Lithium was \nincreased to 300mg qAM and 600mg qhs, with reduction of TSH on \ndischarge to 4.5 and a Lithium level of 0.7. Ms. ___ was \neager to return home and continue care with her outpatient \nproviders on discharge no longer demonstrating symptoms of \ncatatonia or mania. She denied suicidal and homicidal ideation \nthroughout her hospitalization and denied any auditory or visual \nhallucinations. \n\n3. SUBSTANCE USE DISORDERS:\nMs. ___ does not have any substance use disorders, and \ntherefore did not require any counseling or treatment in this \nregard.\n\n4. MEDICAL\nMs. ___ was evaluated by the Neurology Consult service on \ninitial presentation to the ED to evaluate for seizures as a \npossible etiology of her presenting symptoms. Per their \nassessment: \"There are no clear toxic, metabolic or infectious \ntriggers to explain her presentation. Her presentation is likely \n___ noncompliance given subtherapeutic lithium level on arrival \n(though patient endorses compliance with lithium). As improved \nparticipation in exam and no focal deficits, no further workup \nneeded at this time. I would defer LP at this time, as patient \nis afebrile, without leukocytosis and given location of \nmeningioma. \nImportant Diagnostic Tests: \n- EEG: negative\n- CT brain\n--- 1. No acute hemorrhage or territorial infarction. \n--- 2. Stable appearance of left extra-axial mass abutting the \ntentorium and left cerebellar hemisphere, most consistent with a \nmeningioma. Stable associated vasogenic edema and mass effect \non the fourth ventricle and quadrigeminal cistern. \n\nShe was ultimately medically cleared in the ED and no acute \nmedical issues prevented admission to Deac \n\n#) Benign Meningioma: \n- Ms. ___ was supposed to follow-up with Dr. ___ \n___ (neurosurgeon) but missed her follow-up appointment. Dr. \n___ was contacted by inpatient psychiatry team, they \nwill contact patient following discharge to arrange follow-up. \nNeurosurgeon: Dr ___: ___\nOffice will call Ms. ___ following discharge to arrange for \nfollow-up appointment. Will also provide Ms. ___ with \nnumber to assist in arranging appointment. \n\n#) GERD\n- Ms. ___ was continued on her home omeprazole\n\n#)Anemia\n- Ms. ___ was continued on her home iron supplementation\n\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nMs. ___ was encouraged to participate in the various \ngroups and milieu therapy opportunities offered by the unit. The \noccupational therapy and social work groups that focus on \nteaching patients various coping skills. Ms. ___ \ninfrequently attended these groups, occasionally attending \nprojects group, though notably participation may have been \nlimited by language barrier. Patient was often visible on the \nunit, occasionally smiling at staff though had limited \ninteraction with staff and peers.\n\n#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT:\nMs. ___ gave verbal permission for the team to contact her \noutpatient psychiatrist, Dr. ___, and outpatient \ntherapist, ___. Both were contacted upon Ms. ___ \npresentation to the ___ ED/Deac 4 and an update of her \nprogress since admission on Deac 4, and they provided collateral \ninformation and treatment recommendations.\n\n6. INFORMED CONSENT: \nMs. ___ was not started on any new medications during this \nhospitalization and was in agreement to re-starting Lithium and \nInvega as she had been previously taking. \n\n7. RISK ASSESSMENT\nOn presentation, Ms. ___ evaluated and felt to be at an \nincreased risk of harm to herself given her symptoms of \ncatatonia. Ms. ___ static risk factors noted at that \ntime include Static risk factors include history of suicide \nattempts (per collateral ___ previous attempts), chronic mental \nillness with lack of insight, recent discharge from an inpatient \npsychiatric unit, unemployment, chronic medical illness. \nModifiable risk factors include psychosis, disorganized and \nunpredictable behavior, medication noncompliance, poorly \ncontrolled mental illness, intermittent engagement with \noutpatient treatment, and poor reality testing which were \nmitigated on the inpatient setting with re-starting outpatient \nmedications, treating her catatonia which has since resolved, \ncontacting outpatient providers to arrange follow-up and \ncoordinating ___ services post discharge. These modifiable risk \nfactors were also addressed with acute stabilization in a safe \nenvironment on a locked inpatient unit, psychopharmacologic \nadjustments, psychotherapeutic interventions (OT groups, SW \ngroups, individual therapy meetings with psychiatrists), and \npresence on a social milieu environment. Ms. ___ is being \ndischarged with many protective factors, including female \ngender, age, children (though not in the home), sense of \nresponsibility to family, long-term relationship, some strong \nsocial supports, lack of suicidal ideation, positive therapeutic \nrelationship with outpatient providers, no chronic substance \nuse. Overall, based on the totality of our assessment at this \ntime, Ms. ___ is not at an acutely elevated risk of harm to \nself nor danger to others. \n\nOur prognosis of this patient is limited to fair as patient has \nlong-term outpatient treaters and has done well when medication \ncompliant. However, patient has a history of decompensation with \nmedication non-compliance and is not amenable to injectable \nformulations at this time. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO DAILY \n2. OLANZapine 15 mg PO QHS \n3. Lithium Carbonate 600 mg PO BID \n4. Ferrous Sulfate 325 mg PO DAILY \n5. PALIperidone ER 12 mg PO DAILY \n\n \nDischarge Medications:\n1. Lithium Carbonate 300 mg PO QAM \nRX *lithium carbonate 300 mg 1 tablet(s) by mouth every morning \nDisp #*30 Tablet Refills:*0 \n2. Lithium Carbonate 600 mg PO QHS \nRX *lithium carbonate 300 mg 2 tablet(s) by mouth nightly Disp \n#*30 Tablet Refills:*0 \n3. PALIperidone ER 9 mg PO QHS \nRX *paliperidone [Invega] 9 mg 1 tablet(s) by mouth nightly Disp \n#*30 Tablet Refills:*0 \n4. Ferrous Sulfate 325 mg PO DAILY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n5. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCatatonia\nBipolar disorder with psychotic features\n\n \nDischarge Condition:\nalert and oriented, ambulating well. Linear thought process, \neuthymic and bright affect. \n\n \nDischarge Instructions:\n-Por favor, siga con todas las citas para pacientes ambulatorios \nindicados -- tomar este papeleo de descarga a sus citas. \n-Una duración limitada ___ se ___, por \nfavor continúe todos ___ según las instrucciones \nhasta ___ dice para detener o cambiar. \n-Evitar abusar ___ alcohol y ___ droga, ___ sea medicamentos o \ndrogas ilegales, como ___ más empeoran sus enfermedades \nmédicas y psiquiátricas. \n-Póngase en contacto con el ___ ambulatorio u otros \nproveedores si tiene ___. \n-Por favor, llame al 911 o ___ de emergencias más \ncercana si se siente inseguro de ___ y no \ninmediatamente llegar a sus proveedores de atención médica. \n\nFue un placer ___ con ___ \nde ___. \n\n===========================================================\n\n-Please follow up with all outpatient appointments as listed -- \ntake this discharge paperwork to your appointments.\n-Unless a limited duration is specified in the prescription, \nplease continue all medications as directed until your \nprescriber tells you to stop or change.\n-Please avoid abusing alcohol and any drugs -- whether \nprescription drugs or illegal drugs -- as this can further \nworsen your medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\n\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F315", "G936", "D320", "Z9114", "D649", "K219", "G4733", "E7800", "E785", "F4310" ]

[ "F315: Bipolar disorder, current episode depressed, severe, with psychotic features", "G936: Cerebral edema", "D320: Benign neoplasm of cerebral meninges", "Z9114: Patient's other noncompliance with medication regimen", "D649: Anemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E7800: Pure hypercholesterolemia, unspecified", "E785: Hyperlipidemia, unspecified", "F4310: Post-traumatic stress disorder, unspecified" ]

[ "D649", "K219", "G4733", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nNausea and vomiting\n \nMajor Surgical or Invasive Procedure:\nSub-occipital craniectomy for cerebellar meningioma resection, \n___\n\n \nHistory of Present Illness:\n___ y/o female with known left cerebellar lesion, believed to\nbe a meningioma returns to the ED with complaints of a headache\nwhich started last week and three days of nausea and vomiting\nseveral days ago. The patient has been taking Aleve and\nAcetaminophen without improvement to her symptoms. She presents\nto the ED with these concerning symptoms. She describes the\nheadache as located globally and denies nausea and vomiting\ntoday. She experienced nausea and vomiting for three days \nearlier\nthis week on ___, and ___ but has not\nsuffered from these symptoms since that time. She denies\ndiplopia, blurred vision, chest pain, shortness of breath,\nconfusion, difficulties with speech and language, and extremity\npain, numbness or weakness. \n\n \nPast Medical History:\nPast Psychiatric History: \nDx: Bipolar disorder\nHospitalizations: \nTreaters: \n- Psychiatrist: Dr. ___ (___)\n- Therapist: ___ (___)\n- PCP: Dr. ___ (___)\nMedication and ECT Trials: Invega, Lithium, Zyprexa, (has never \ntried Depakote)\nSelf-Injury/Self harm: ___ past suicide attempts \n\nPast Medical History\n-OSA (per patient, does not use CPAP at home)\n-GERD\n-Anemia\n-Hyperlipidemia\n-Hepatic steatosis\n-left posterior fossa benign meningioma\n \nSocial History:\n___\nFamily History:\nMother with hypertension. Maternal grandfather with CAD. Aunt \nwith colon cancer. \n \nPhysical Exam:\nUpon Admission:\n===============\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: 4-3mm bilaterally. EOMs intact throughout. \nExtrem: Warm and well-perfused.\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, 4mm to\n3mm bilaterally. \nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift.\n\nSensation: Intact to light touch bilaterally.\n\nUpon Discharge:\n===============\nVS: Temp:98.5PO BP: 113/80 HR:84 RR:18 Sat:96% RA\n\nBowel Regimen: [x]Yes [ ]No \n\nExam: Primarily ___ speaking\nOpens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious\nOrientation: [x]Person [x]Place [x]Time\nFollows Commands: [ ]Simple [x]Complex [ ]None\nPupils: PERRLA\nEOM: [x]Full [ ]Restricted\nFace Symmetric: [x]Yes [ ]No\nTongue Midline: [x]Yes [ ]No\nPronator Drift: [ ]Yes [x]No \nSpeech Fluent: [x]Yes [ ]No\nComprehension Intact: [x]Yes [ ]No\n\nMotor:\nTrap Deltoid Bicep Tricep Grip\nRight5 5 5 5 5\nLeft5 5 5 5 5\n\nIP Quad Ham AT ___ ___\n___ 5 55\nLeft5 5 5 5 5 5\n\n[x]Sensation intact to light touch\n\nWound: \n[x]Clean, dry, intact \n[x]Sutures [x]Staples\n \nPertinent Results:\nPlease see OMR for relevant findings.\n \nBrief Hospital Course:\n___ is a ___ year old female with known left \ncerebellar lesion who presents with three days of nausea and \nvomiting that has resolved.\n\n#Cerebellar lesion\nMs. ___ underwent MRI brain, which showed slight increase \nin lesion with increased surrounding edema and mass effect. She \nwas started on Dexamethasone. She underwent CTA/V for \npre-operative planning. She was intermittently uncooperative \nwith care. After Ativan challenge on ___ (see below), she was \nneurologically intact. Surgery was scheduled for ___. However \ngiven the psychiatric issue described below, there was concern \nthat patient did not understand her current and planned \ntreatments and need for invoking health care proxy with the \nlegal team was discussed, and surgery was delayed until consent \nfrom a health care proxy could be obtained. Consent was obtained \non ___ and patient was rescheduled to go to the OR on ___ \n___. While in the OR, A-line access was unattainable, and the \nsurgery was aborted. Once the patient had both A-line and PICC \nplaced, she underwent suboccipital craniotomy for tumor \nresection. On ___, subgaleal drain was removed without \ndifficulty. She was transferred to the floor. Physical therapy \nand occupational therapy were consulted for disposition planning \nand recommended that she be discharge.\n\n#Catatonia \nDuring her stay she has had an odd affect, with occasional \nincreases in agitation, uncooperativeness with exam, and refusal \nof all PO intake including meds. She is prescribed 300/600mg \nlithium qam/qpm. On admission, a lithium level was ordered, \nwhich was sub-therapeutic. On ___, psychiatry was consulted, \nand she was diagnosed with catatonia. Recommended Ativan \nchallenge, which showed a large improvement in cooperativeness \nwith exam. Psychiatry recommended continued Ativan 2mg TID, \nwhich was tapered over time and discontinued prior to discharge. \n The patient's lithium level was therapeutic and stable x2 prior \nto discharge. \n\n#UTI\nInitial pre-operative urinalysis was suspicious for a UTI and \nthe patient was started on a three day course of Ciprofloxacin. \nCulture grew out mixed flora and Cipro was discontinued. \n\n#Leukocytosis \nThe patient's WBC uptrended, and on ___ a chest x-ray was \nperformed and negative for pneumonia. A repeat urinalysis was \nsent, and negative for UTI. She underwent LENIs, which were \nnegative for DVT. WBC downtrended from 22 to 16. Leukocytosis \nlikely ___ dexamethasone given negative infectious work-up but \nshould be followed up with PCP\n\n___ patient had a mild insulin requirement (FSBGs consistently \nin the mid- to high-100s, requiring 2u insulin qmeal). Her \nhyperglycemia is likely secondary to dexamethasone but should be \nfollowed as an outpatient. \n \nMedications on Admission:\nFerrous sulfate 325mg PO daily; Levothyroxine 25mcg PO daily; \nLithium carbonate ER 300mg 1 tab PO QAM & 2 tabs PO QPM; \nOmeprazole 20mg PO daily; Paliperidone ER 9mg PO daily\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCerebellar meningioma\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nSurgery\n•You underwent surgery to remove a brain lesion from your \nbrain. \n•You may shower at this time but keep your incision dry.\n•It is best to keep your incision open to air but it is ok to \ncover it when outside. \n•Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n•We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n•You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n•No driving while taking any narcotic or sedating medication. \n•If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n•No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n•You may use Acetaminophen (Tylenol) for minor discomfort\n•Continue medications as indicated on your discharge paperwork\n\nWhat You ___ Experience:\n•You may experience headaches and incisional pain. \n•You may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n•You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n•Feeling more tired or restlessness is also common.\n•Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite. \n•Fever greater than 101.5 degrees Fahrenheit\n•Nausea and/or vomiting\n•Extreme sleepiness and not being able to stay awake\n•Severe headaches not relieved by pain relievers\n•Seizures\n•Any new problems with your vision or ability to speak\n•Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n•Sudden numbness or weakness in the face, arm, or leg\n•Sudden confusion or trouble speaking or understanding\n•Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n•Sudden severe headaches with no known reason\n\n \nFollowup Instructions:\n___\n" ]

[ "D320", "G936", "F202", "E785", "F319", "G4733", "K219", "D649", "K760", "D72829", "R739" ]

[ "D320: Benign neoplasm of cerebral meninges", "G936: Cerebral edema", "F202: Catatonic schizophrenia", "E785: Hyperlipidemia, unspecified", "F319: Bipolar disorder, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K219: Gastro-esophageal reflux disease without esophagitis", "D649: Anemia, unspecified", "K760: Fatty (change of) liver, not elsewhere classified", "D72829: Elevated white blood cell count, unspecified", "R739: Hyperglycemia, unspecified" ]

[ "E785", "G4733", "K219", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nprimidone\n \nAttending: ___\n \nChief Complaint:\nFall\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man s/p fall from standing. His wife \nwas in the same room and heard him fall, but does not know if \nthere was a associated syncope or seizure activity. OSH CT \nshowed a small SAH and R clavulcular frx. He was transferred to \n___ for further care.\n \nPast Medical History:\nPMH: hypercholesterolemia, HTN, afib, arthritis, adenocarcinoma \nlung, squamous cell face, left knee surgery, DM ___, CVA, \nSick sinus syndrome, essential tremor, recurrent falls.\n\nPSH: Cholecystectomy, lung tumor removal\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nAdmission Physical Exam:\nTemp: 98.1 HR: 94 BP: 142/89 Resp: 16 O(2)Sat: 95 Normal \nConstitutional: Comfortable\nHEENT: small skin abrasion lateral to right eyebrow, no\nactive bleeding, Extraocular muscles intact\nNo C-spine tenderness\nChest: Clear to auscultation, no chest wall tenderness\nCardiovascular: Regular Rate and Rhythm\nAbdominal: Nontender, Soft\nGU/Flank: No costovertebral angle tenderness\nExtr/Back: Right clavicle swelling and tenderness, pain with\nROM.\nSkin: Warm and dry\nNeuro: Speech fluent, moves all extremities except for right\narm, answering questions and following commands\nappropriately, no focal neurological deficits\nPsych: Normal mentation, Normal mood\n___: No petechiae\n\nDischarge Physical Exam:\nVS: 97.4 PO 138 / 82 102 18 96 Ra \nGENERAL: Elderly gentleman in NAD, daughter and wife at bedside\nHEENT: dried scabs on R side of forehead, EOMI, PERRL, anicteric \nsclera, pink conjunctiva, MMM, poor dentition \nNECK: nontender supple neck, no LAD, no JVD \nHEART: irregularly irregular, S1/S2, no murmurs, gallops, or \nrubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose; lower legs both cool to touch \nPULSES: 2+ DP pulses bilaterally \nNEURO: CN ___ intact, strength ___ x ___xam \nlimited by clavicle fracture\nSKIN: forehead lesions as above, cool ___ as above \n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:28AM BLOOD WBC-5.2 RBC-3.95* Hgb-13.6* Hct-38.7* \nMCV-98 MCH-34.4* MCHC-35.1 RDW-12.2 RDWSD-44.3 Plt ___\n___ 04:29AM BLOOD WBC-7.0 RBC-4.06* Hgb-13.9 Hct-39.4* \nMCV-97 MCH-34.2* MCHC-35.3 RDW-12.3 RDWSD-43.9 Plt ___\n___ 04:29AM BLOOD ___ PTT-28.4 ___\n___ 05:28AM BLOOD Glucose-152* UreaN-20 Creat-0.8 Na-136 \nK-4.0 Cl-98 HCO3-30 AnGap-12\n___ 04:29AM BLOOD Glucose-111* UreaN-21* Creat-0.9 Na-139 \nK-3.5 Cl-100 HCO3-29 AnGap-14\n___ 04:29AM BLOOD cTropnT-<0.01\n___ 04:29AM BLOOD Calcium-8.7 Phos-3.4\n\nDISCHARGE LABS:\n==============\n___ 05:04AM BLOOD WBC-6.2 RBC-3.88* Hgb-13.3* Hct-37.1* \nMCV-96 MCH-34.3* MCHC-35.8 RDW-12.1 RDWSD-42.1 Plt ___\n___ 05:04AM BLOOD Glucose-171* UreaN-13 Creat-0.8 Na-135 \nK-4.0 Cl-97 HCO3-28 AnGap-14\n___ 05:04AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9\n___ 05:28AM BLOOD VitB12-552\n\nMICRO:\n=====\n\nUrine Culture: No Growth\n\nIMAGING/STUDIES:\n================\n\n___ CXR: \nIMPRESSION: \nIncreased heart size, mild pulmonary vascular congestion. \nSuggestion of pleural effusion. Basilar opacity, likely \natelectasis, repeat lateral radiograph suggested. Acute or \nsubacute fracture distal right clavicle.\n\nNCHCT ___:\nAcute subarachnoid hemorrhage involving the right hemisphere, \nthe\nmagnitude of which is mild. No midlines shift. Age-related\natrophy and chronic white matter ischemic changes, no evidence \nof\nadditional acute intracranial abnormality. \n\nCT C-spine ___:\nMarked degenerative disease, no definite fracture, soft tissues\nunremarkable. \n\nXR R shoulder ___:\nDistal right clavicular fracture. No dislocation or shoulder or\nhumerus fracture. \n\n \nBrief Hospital Course:\n___ HTN, DM, Afib (not on AC), hx ___ presenting s/p \nfall c/b SAH and clavicular fracture, initially admitted to ___ \nand subsequently transferred to medicine for fall/?syncope \nworkup. \n\nACUTE ISSUES\n============\n\n# SAH/R clavicular fracture: Pt initially presented to ___ \nwhere CT imaging showed small right new acute subdural \nhemorrhage. Xray imaging showed new acute right clavicle \nfracture. He was transferred to ___ for neurosurgical \nevaluation. Neurosurgery was consulted and recommended no \nintervention, frequent neurologic monitoring, and maintain \nsystolic blood pressure less than 160. Initially admitted to \nsurgery service. No neurosurgical intervention needed as SAH \nsmall and stable. R clavicular fracture nonoperative. Sling \nprovided as needed for comfort. No need for keppra prophylaxis \nper neurosurgery. Pt was on q4h neuro checks. He exhibited no \nneurologic deficits, and did not require additional medication \nfor blood pressure control. ___ was consulted and recommended \ndischarge to rehab.\n\n# Fall/syncope workup: Patient transferred to medicine service \nfor further workup of recent falls. Orthostatics positive. Pt \nmaintained on telemetry without arrhythmias noted (besides his \nbaseline Afib). TTE was ordered, but patient and family wished \nto be discharged to rehab prior to the completion of this study. \nThis can be completed as an outpatient. No further \nfalls/syncope. B12 normal and infectious workup negative \n(negative blood/urine cultures, CXR). Continued home florinef \n(which was started for orthostatic hypotension). \n\n# Afib: Pt not anticoagulated in setting of recent falls (was \npreviously on Eliquis, stopped in ___ due to falls). \nMaintained good rate control on home meds and did not require \nany further intervention.\n\n# Urinary retention: Patient retained urine during \nhospitalization, requiring foley catheter. Tamsulosin started. \nUA with neg nit/leuks, 3 RBCs, 1 WBC. Foley catheter able to be \nremoved and patient voided without issue before discharge.\n\nCHRONIC ISSUES\n==============\n# Hx ___: Continued home AED. According to outpatient \nneurologist and family, pt's possible seizures are typically \ncharacterized by aphasia and confusion. No concerning neuro \nchanges while in-house. \n\n#Afib: Pt was previously on eliquis, but this was stopped I/s/o \nfrequent falls. Continued home propranolol (this is prescribed \nfor essential tremor but may be contributing to rate control). \nHR was well controlled.\n\n#HTN, HLD: continue home propranolol and simvastatin\n\n#DM: ISS while in house\n\n# Goals of care: Palliative care consulted per patient's family \nrequest for more information about hospice. We confirmed pt's \nDNR/DNI status, and filled out a MOLST with him before \ndischarge.\n\nTRANSITIONAL ISSUES:\n[] Consider obtaining TTE as an outpatient for further workup of \nfalls.\n[] Pt noted to have incidental thrombocytopenia while admitted. \nPlatelets 121 on discharge. HCV negative. He had no evidence of \nactive bleeding other than provoked SAH as above. Consider \nongoing monitoring of platelets as an outpatient.\n[] Clavicle fracture: pt should avoid lifting with R arm, but \nROM exercises as tolerated are fine\n#Code Status: DNR/DNI (confirmed with patient and family)\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Simvastatin 20 mg PO QPM \n2. Propranolol 10 mg PO DAILY \n3. Valproic Acid ___ mg PO Q8H \n4. Fludrocortisone Acetate 0.1 mg PO DAILY \n5. Nexium 40 mg Other DAILY \n6. 70/30 20 Units Breakfast\n70/30 10 Units Bedtime\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol \n4. Docusate Sodium 100 mg PO BID \n5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol \n6. Glucose Gel 15 g PO PRN hypoglycemia protocol \n7. Heparin 5000 UNIT SC BID \n8. Lidocaine 5% Patch 1 PTCH TD QAM \n9. Senna 8.6 mg PO BID:PRN constipation \n10. Tamsulosin 0.4 mg PO QHS \n11. TraMADol 25 mg PO Q6H:PRN pain \nRX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 hours \nDisp #*16 Tablet Refills:*0 \n12. 70/30 20 Units Breakfast\n70/30 10 Units Bedtime \n13. Fludrocortisone Acetate 0.1 mg PO DAILY \n14. Nexium 40 mg Other DAILY \n15. Propranolol 10 mg PO DAILY \n16. Simvastatin 20 mg PO QPM \n17. Valproic Acid ___ mg PO Q12H \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnoses:\nSubarachnoid hemorrhage\nR Clavicular fracture \nFall\n\nSecondary diagnoses:\nHypertension\nDiabetes\nAtrial fibrillation \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:\nDr. ___,\n\nYou were admitted to the Acute Care Trauma Surgery Service at \n___ after a fall that caused a small bleed in your head \nand a right clavicle fracture. You were seen and evaluated by \nthe neurosurgery team for your head bleed and no intervention \nwas needed. Your clavicle fracture is stable and will continue \nto heal without surgical intervention. Please continue to avoid \nusing your right arm for activity but range of motion exercises \nas tolerated are okay. Wear your sling for comfort as needed. \n\nThe medical team was contacted to further evaluate for \nunderlying causes of your falls. You chose not to stay for an \nechocardiogram of your heart. This can be done as an outpatient. \n\n\nThank you for allowing us to participate in your care.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "S066X0A", "D696", "E119", "I4891", "G40909", "I10", "E785", "I6521", "W010XXA", "Z9181", "S42031A", "Z66", "R339", "Z794", "Z8673", "Z85118", "Y92009" ]

[ "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "D696: Thrombocytopenia, unspecified", "E119: Type 2 diabetes mellitus without complications", "I4891: Unspecified atrial fibrillation", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I6521: Occlusion and stenosis of right carotid artery", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Z9181: History of falling", "S42031A: Displaced fracture of lateral end of right clavicle, initial encounter for closed fracture", "Z66: Do not resuscitate", "R339: Retention of urine, unspecified", "Z794: Long term (current) use of insulin", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[ "D696", "E119", "I4891", "I10", "E785", "Z66", "Z794", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAce Inhibitors / Penicillins / Percocet / metformin\n \nAttending: ___\n \nChief Complaint:\nSOB\n \nMajor Surgical or Invasive Procedure:\nDiagnostic coronary angiogram\nCoronary Anatomy\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is.free of significant disease.\n* Left Anterior Descending\nThe LAD has mid 40% stenosis.\n* Circumflex\nThe Circumflex has origin 40% stenosis.\nThe ___ Marginal has origin 50% stenosis.\n* Right Coronary Artery\nThe RCA is very difficult to engage. Non-selective angiography \nshows mid ___ stenosis.\nThe Right PDA is a small vessel and the distal RCA is possibly \noccluded before a small RPL branch.\nImpressions:\n1. Moderate 3 vessel CAD with possible branch occlusion of \ndistal RCA. There are no good targets for PCI or surgery.\nRecommendations\n1. Medical therapy,\n\n \nHistory of Present Illness:\nThis patient is a ___ year old female who complains of headache \nfollowing a fall at a casino three days ago, injuring the left \nside of her face. She has poor recall of the circumstances and \nsince has had left sided headaches and facial pain. She reports \nthree weeks of dyspnea and non-productive cough for which she \nsaw her PCP one week ago. \n \nPast Medical History:\ndiabetes \nhypothyroidism \nhypertension \nobesity \narthritis, chronic pain \n-s/p: \nbilateral TKRs \nhernia repair x5 \ncholecystectomy \n\n \nSocial History:\n___\nFamily History:\nFamily history of arthritis \n \nPhysical Exam:\nOn Admission:\nPHYSICAL EXAMINATION\n \nTemp: 98.9 HR: 72 BP: 153/69 Resp: 16 O(2)Sat: 99 Normal\n \nConstitutional: Comfortable\nHEENT: abrasion over her left zygoma, Pupils equal, round\nand reactive to light, Extraocular muscles intact\ndiffuse C-spine tenderness\nChest: Clear to auscultation\nCardiovascular: Regular Rate and Rhythm\nAbdominal: Soft, Nontender\nExtr/Back: No cyanosis, clubbing or edema\nSkin: Warm and dry\nNeuro: Speech fluent\nPsych: Normal mentation\n___: No petechiae\n \nECG\n \n Heart Rate: 70\n Rhythm: Sinus\n Ischemia: None\n ECG Axis: Normal\n Intervals: Normal\n Comparison to prior results: Same\n\nAt Discharge:\nVS: T 98 HR 70 RR 18 BP 138/78 97% RA\ntele: SR 70-90's\nGeneral: no c/o discomfort currently, asking why her BP was so \nhigh post procedure and her severe headache cause\nHEENT: no JVP appreciated. supple, thick neck, no masses\nCHEST: CTAB\nCV: RRR no m/r/g\nABD: Soft, obese, NT, +BS\nSkin: Warm and dry, R radial access site with gauze and Tegaderm \nc/d/I, no erythema or excess warmth\nNeuro: Grossly N/V/I, moving all 4 extremities, thoughts linear, \ncrosses hemispheres, answering questions appropriately\n \nPertinent Results:\nLABS ON ADMISSION:\n\n___ 09:30AM BLOOD WBC-6.3 RBC-3.96 Hgb-11.9 Hct-36.9 MCV-93 \nMCH-30.1 MCHC-32.2 RDW-13.2 RDWSD-45.1 Plt ___\n___ 09:30AM BLOOD Neuts-59.3 ___ Monos-8.1 Eos-2.2 \nBaso-1.0 Im ___ AbsNeut-3.71 AbsLymp-1.79 AbsMono-0.51 \nAbsEos-0.14 AbsBaso-0.06\n___ 09:30AM BLOOD ___ PTT-34.3 ___\n___ 09:30AM BLOOD Glucose-169* UreaN-10 Creat-0.7 Na-139 \nK-3.6 Cl-100 HCO3-23 AnGap-20\n___ 09:30AM BLOOD cTropnT-<0.01\n___ 04:30PM BLOOD cTropnT-<0.01\n___ 09:30AM BLOOD proBNP-111\n___ 09:30AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.6\n\nLABS AT DISCHARGE:\n\n___ 06:00AM BLOOD WBC-10.6* RBC-3.78* Hgb-11.9 Hct-35.1 \nMCV-93 MCH-31.5 MCHC-33.9 RDW-13.5 RDWSD-46.5* Plt ___\n___ 06:00AM BLOOD ___ PTT-33.3 ___\n___ 06:00AM BLOOD Glucose-209* UreaN-12 Creat-0.8 Na-136 \nK-4.4 Cl-98 HCO3-19* AnGap-23*\n___ 06:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.7\n\nCATHETERIZATIN REPORT ___:\nCoronary Anatomy\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is.free of significant disease.\n* Left Anterior Descending\nThe LAD has mid 40% stenosis.\n* Circumflex\nThe Circumflex has orign 40% stenosis.\nThe ___ Marginal has oirigin 50% stenosis.\n* Right Coronary Artery\nThe RCA is very difficult to engage. Non-selective angiography \nshows mid ___ stenosis.\nThe Right PDA is a small vessel and the distal RCA is possibly \noccluded before a small RPL branch.\nImpressions:\n1. Moderate 3 vessel CAD with possible branch occlusion of \ndistal RCA. There are no good targets for PCI or surgery.\nRecommendations\n1. Medical therapy,\n\nCARDIAC PERFUSION STUDY ___:\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 injected. She had no anginal symptoms or \nischemic ECG changes. \n \nTECHNIQUE: \nISOTOPE DATA: (___) 31.9 mCi Tc-99m Sestamibi Stress; DRUG \nDATA: (Non-NM admin) Dipyridamole; Following intravenous \ninfusion of the pharmacologic agent, Tc-99m sestamibi was \nadministered intravenously. Stress images were obtained \napproximately 30 minutes following tracer injection. \n \nResting perfusion images were obtained on a subsequent day with \nTc-99m \nsestamibi. Tracer was injected approximately 45 minutes prior to \nobtaining the resting images. \n \nImaging protocol: Gated SPECT. \n \nThis study was interpreted using the 17-segment myocardial \nperfusion model. \n \nFINDINGS: \n \nThe image quality is adequate but limited due to soft tissue and \nbreast \nattenuation. \n \nLeft ventricular cavity size is normal. \n \nRest and stress perfusion images reveal a reversible, mild \nreduction in photon \ncounts involving the entire inferior wall. \n \nGated images reveal normal wall motion. \n \nThe calculated left ventricular ejection fraction is 57% with an \nEDV of 77 ml. \n \n \nIMPRESSION: \n \n1. Reversible, medium sized, mild perfusion defect involving the \nRCA territory. \n \n2. Normal left ventricular cavity size and systolic function. \n \nCT HEAD w/o CONTRAST ___:\nCOMPARISON: CT head without contrast ___ \n \nFINDINGS: \n \nThere is no evidence of infarction, hemorrhage, edema, or mass. \nThere is \nprominence of the ventricles and sulci suggestive of \ninvolutional changes. \n \nThere is no evidence of fracture. Small mucous retention cyst \nis noted in the right anterior ethmoid sinus. The visualized \nportion of the orbits are unremarkable. \n \nIMPRESSION: \n \n1. No acute intracranial process. \n \nCT C-SPINE w/o CONTRAST ___:\nFINDINGS: \n \nAlignment is normal. No fractures are identified. There is no \nprevertebral \nsoft tissue swelling. Degenerative changes notable for disc \nbulges and \nthickening of the ligamentum flavum. Disc protrusion at C2-3 \nand C3-4 effaces the ventral CSF and may contact the ventral \naspect of the cord. \n \nThyroid is small but grossly unremarkable. Lung apices are \nnotable for a 3 mm right apical nodule (3:70), unchanged from \nprior. \n \nIMPRESSION: \n \nNo acute fracture or malalignment of the cervical spine. \nA 3 mm right apical pulmonary nodule unchanged since prior ___. \n \nRECOMMENDATION(S): If patient has risk factors such as smoking \nor malignancy, ___ year followup suggested for followup of a 3 mm \nright apical pulmonary nodule. Otherwise no additional imaging \nnecessary. \n\nCT SINUS ___:\nFINDINGS: \n \nThere is no facial bone fracture. Pterygoid plates are intact. \nThere is no mandibular fracture and the temporomandibular joints \nare anatomically aligned. The orbits are intact. The globes and \nextra-ocular muscles are unremarkable. \nThere is no orbital hematoma. \n \nIncluded paranasal sinuses are clear besides a mucous retention \ncyst in the right maxillary sinus. Included extracranial soft \ntissues are unremarkable. \n \nIMPRESSION: \n \nNo fracture. \n\nCXR PA & LATERAL ___:\nFINDINGS: \n \nSlightly lower lung volumes on the current exam. Lungs remain \nclear without consolidation, effusion, or edema. \nCardiomediastinal silhouette is stable. Atherosclerotic \ncalcifications seen at the aortic arch. No acute osseous \nabnormalities, hypertrophic changes again noted in the spine. \n \nIMPRESSION: \n \nNo acute cardiopulmonary process. \n\n \nBrief Hospital Course:\nThe patient presented to the ED complaining of a headache, SOB \nand facial pain following a fall at a casino several days \nearlier. She reports no significant headaches in the past and \nwhen quizzed regarding her blood pressure control states she \nchecks her pressure at home and it typically runs in the 120's \nsystolic. She was subsequently transferred to the ___ for \nfurther observation until she underwent numerous studies include \na pharmacological stress test indicating a mild perfusion \ndefect. It was suspected given her history that she could have \ncoronary artery disease. She underwent catheterization on \n___ and had three vessel moderate disease not obstructive or \namenable to PCI or surgery and to continue/enhance medical \nmanagement, particularly in light of her other co-morbidities \nincluding obesity and diabetes. She was expected to discharge \nhome following the catheterization but reported a severe \nheadache and had a high blood pressure running to 230/97. She \nwas subsequently triggered and had vomiting. She was given \nZofran, Hydralazine and persistently hypertensive. A nitro drip \nwas started and she was given Ativan to help with her anxiety \nand her nausea, which subsequently resolved. She was started on \nAtorvastatin and Metoprolol. Her blood pressure normalized by \nthe early morning hours on ___ and her nitro drip was \ndiscontinued. At the time of discharge, her blood pressure was \nranging in the 130's systolic. She had no further headache, was \ntolerating her diet and voiding without difficulty. She was \ncounseled regarding lifestyle changes, management of blood \npressure and close follow up with her physicians. Her headache \nwas felt to be multi-factorial, including her NPO status until \nher late day catheterization, and her high blood pressures, \nwhich likely exist at home.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 100 mg PO DAILY \n2. Sucralfate 1 gm PO QID \n3. Levothyroxine Sodium 125 mcg PO DAILY \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. GlipiZIDE 5 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Metoprolol Tartrate 25 mg PO BID \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. GlipiZIDE 5 mg PO DAILY \n6. Levothyroxine Sodium 125 mcg PO DAILY \n7. Losartan Potassium 100 mg PO DAILY \n8. Sucralfate 1 gm PO QID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNEW:\nAbnormal stress test:\nCardiac Cath: multivessel moderate disease, no obstructive CAD \nw/o good targets for PCI or surgery - manage medically\nPRIOR:\nDM Type 2\nHypertension\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).\nVS: T 98 HR 70 RR 18 BP 134/65 97% RA\ntele: SR 70-90's\nLABS: Na2+ 136; K+ 4.4; Cl- 98; HCO3 19; BUN 12; Cr 0.8; Ca2+ \n9.1; P 3.8; Mg2+ 1.7\n\nPHYSICAL EXAM:\nGen: ___ yr old woman in NAD. Seen post-procedure. She is alert \nand oriented and resting comfortably with no CP, SOB, \npalpitations or dizziness\nNeck: No JVD appreciated\nLungs: CTAB, no wheezing or rhonchi\nHeart: S1S2 regular, no MRG\nAbd: soft, obese, non-tender, BS +\nPV: right radial site is soft with no bleeding or hematoma. \ngauze and Tegaderm c/d/I. Good CSM to wrist. Pedal pulses \npalpable. No clubbing, cyanosis or edema\nNeuro: Alert and oriented x 3. No focal deficits or asymmetries \nnoted. \n\nA/P: ___ from ED after + pharm stress showing a 'reversible, \nmedium sized, mild perfusion defect involving the RCA \nterritory'. Initially presented with left sided headache s/p \nfall at a casino on ___ with ongoing sharp left-sided \nheadaches and facial pain. Her head CT was negative. At that \ntime, she complained of dyspnea with exertion, prompting cardiac \nworkup. EKG: NSR @ 70, NA/NI, no ischemia or ectopy, Trop- \nnegative x2. She underwent a coronary angiogram, which showed \nmoderate 3 vessel CAD\n\n#. CAD\n-start ASA 81\n-start Atorvastatin (escripted to her pharmacy)\n-start Metoprolol 25 mg bid (escripted to her pharmacy)\n-follow up with Dr. ___ in ___ wks\n#. DM A1C 7.3%\n-cont Glipizide\n-heart healthy carb consistent diet\n#. Hypertension\n-cont Losartan\n-Added Metoprolol\n#. Disp\n-DC home\n\n \n\n \nDischarge Instructions:\nYou were admitted overnight to our cardiac direct access unit \nfor monitoring due to your symptoms of shortness of breath and \nabnormal stress test. You had an elevated blood pressures that \nrequired some additional medication. We also imaged your head \nwhich was negative for any bleeding or stroke.\n\nYou had a cardiac catheterization which showed that you had some \nblockages in 3 of your heart arteries. Because of these \nblockages, you were started on a low dose Aspirin, Atorvastatin \nand Metoprolol. You will follow up with Dr. ___ in ___ weeks.\n\nActivity restrictions and care of our wrist site will be \nincluded in your discharge instructions.\n\nPlease follow up with your PCP within the next ___ weeks for \ncontinued outpatient management.\n\n \nFollowup Instructions:\n___\n" ]

[ "I25110", "E119", "E785", "E669", "Z6841", "E7800", "G4733", "I169", "R112", "E876", "G44309", "Z9181" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E7800: Pure hypercholesterolemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I169: Hypertensive crisis, unspecified", "R112: Nausea with vomiting, unspecified", "E876: Hypokalemia", "G44309: Post-traumatic headache, unspecified, not intractable", "Z9181: History of falling" ]

[ "E119", "E785", "E669", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nAce Inhibitors / Penicillins / Percocet / metformin\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___ incisional hernia repair with underlay mesh, lipoma \nexcision\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with history of NIDDM, CAD \n(cath ___ and PDA occlusion not amenable to \nrevascularization), hyperlipidemia\npresents with abdominal pain and acute onset diarrhea starting \nat 7pm last evening. She denies nausea or vomiting. She has \nnever experienced similar episodes; however, she continues to \npass flatus and have bowel movements. She continues to have pain \nbut has been alleviated with medication. The pain is constant in \nher abdomen and has not remitted.\n \nPast Medical History:\ndiabetes \nhypothyroidism \nhypertension \nobesity \narthritis, chronic pain \n-s/p: \nbilateral TKRs \nhernia repair x5 \ncholecystectomy \n\n \nSocial History:\n___\nFamily History:\nFamily history of arthritis \n \nPhysical Exam:\nAdmission Physical Exam:\n\nVitals: 97.8 63 179/78 18 100%RA\nGEN: AOx3, NAD, obese\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, tender over paramedian incision +guarding, no \nrebound,\nunable to reduce as the exam is limited by pain, 2 separate\nhernias appreciated on exam. \nExt: No ___ edema, ___ warm and well perfused\n\nDischarge Physical Exam:\nVS: 97.6, 147/73, 60, 20, 95% RA \nGen: A&O x3\nCV: HRR\nPulm: CTAB\nAbd: soft, NT/ND. Midline incision w/ staples, OTA\nExt: No edema\n \nPertinent Results:\n___ 12:25AM BLOOD WBC-11.1* RBC-3.88* Hgb-11.3 Hct-35.4 \nMCV-91 MCH-29.1 MCHC-31.9* RDW-13.1 RDWSD-43.2 Plt ___\n___ 10:46AM BLOOD WBC-9.6 RBC-3.64* Hgb-10.7* Hct-33.6* \nMCV-92 MCH-29.4 MCHC-31.8* RDW-13.1 RDWSD-44.3 Plt ___\n___ 10:00PM BLOOD WBC-12.8* RBC-3.71* Hgb-11.1* Hct-34.2 \nMCV-92 MCH-29.9 MCHC-32.5 RDW-13.2 RDWSD-44.6 Plt ___\n___ 05:16AM BLOOD WBC-13.3* RBC-3.60* Hgb-10.8* Hct-33.5* \nMCV-93 MCH-30.0 MCHC-32.2 RDW-13.4 RDWSD-45.4 Plt ___\n___ 05:40AM BLOOD WBC-9.6 RBC-3.21* Hgb-9.5* Hct-30.0* \nMCV-94 MCH-29.6 MCHC-31.7* RDW-13.2 RDWSD-45.5 Plt ___\n___ 06:15AM BLOOD WBC-8.7 RBC-2.97* Hgb-8.9* Hct-27.9* \nMCV-94 MCH-30.0 MCHC-31.9* RDW-13.2 RDWSD-45.9 Plt ___\n___ 05:30AM BLOOD WBC-7.6 RBC-2.99* Hgb-8.9* Hct-27.9* \nMCV-93 MCH-29.8 MCHC-31.9* RDW-13.1 RDWSD-44.5 Plt ___\n___ 05:30AM BLOOD Glucose-147* UreaN-7 Creat-0.7 Na-139 \nK-3.7 Cl-102 HCO3-27 AnGap-14\n___ 06:15AM BLOOD Glucose-140* UreaN-6 Creat-0.7 Na-140 \nK-3.4 Cl-102 HCO3-24 AnGap-17\n___ 05:40AM BLOOD Glucose-143* UreaN-7 Creat-0.8 Na-138 \nK-3.3 Cl-100 HCO3-25 AnGap-16\n___ 05:16AM BLOOD Glucose-155* UreaN-12 Creat-1.0 Na-144 \nK-4.0 Cl-106 HCO3-24 AnGap-18\n___ 10:00PM BLOOD Glucose-214* UreaN-15 Creat-1.0 Na-139 \nK-3.2* Cl-103 HCO3-21* AnGap-18\n___ 05:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7\n___ 06:15AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.8\n___ 05:40AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.4*\n\nCT A/P:\n1. Re-demonstrated are 2 midline, ventral abdominal wall \nhernias-the hernia located more cranially contains a small \nsegment of the nonobstructed transverse colon, while the hernia \nlocated caudally contains a small portion of a small bowel loop. \n There is trace fluid within the hernial sac containing the \nsmall bowel however no transition point or other evidence to \nsuggest bowel obstruction noted. There has been prior mesh \nrepair of the ventral abdominal wall and the mesh is located \ninferior to the latter hernial sac. \n2. Mild hepatic steatosis, extensive sigmoid diverticulosis, \nsevere \natherosclerotic calcification of the abdominal aorta and its \nbranches with \nfocal narrowing (up to 50%) at the origin of the celiac artery \nare additional incidental findings. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old female who presented to the \nEmergency Department on ___ with abdominal pain. The \npatient was evaluated by the Acute Care Surgery Service and a CT \nscan of abdomen and pelvis was obtained. These images revealed \nan incarcerated hernia. Given these findings, the patient was \ntaken to the operating room for repair. There were no adverse \nevents in the operating room; please see the operative note for \ndetails. She was extubated, taken to the PACU until stable, then \ntransferred to the surgical floor for observation. \n\nThe patient was alert and oriented throughout hospitalization; \npain was initially managed with IV Tylenol and Dilaudid and then \ntransitioned to oral Tylenol and Tramadol once tolerating a \ndiet. \nThe patient remained stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\nShe remained stable from a pulmonary standpoint; vital signs \nwere routinely monitored. Good pulmonary toileting, early \nambulation and incentive spirometry were encouraged throughout \nhospitalization.\nThe patient was initially kept NPO. On POD1 diet was advanced to \nclears with good tolerability. On POD2 the patient tolerated a \nregular diet. Patient's intake and output were closely monitored \nShe has a midline incision to her abdomen with staples that are \nclean, dry and intact (will be removed at follow up appointment \nwith Dr. ___. Her bowel function returned and began to \npass gas and have bowel movements. \nThe patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nThe patient's blood counts were closely watched for signs of \nbleeding, of which there were none.\nThe patient received subcutaneous heparin and ___ dyne boots \nwere used during this stay and was encouraged to get up and \nambulate as early as possible.\n\nThe patient was seen and evaluated by physical therapy who \nrecommended discharge to home with continued home physical \ntherapy. \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:\nAMMONIUM LACTATE - ammonium lactate 12 % topical cream. apply to\ndry skin on feet but not between toes twice a day\nATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth\nonce a day\nERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000\nunit capsule. 1 capsule(s) by mouth 1 week for 40 weeks get\nrepeat level when this is completed - (Not Taking as \nPrescribed)\nFLUTICASONE - fluticasone 50 mcg/actuation nasal\nspray,suspension. 2 sprays(s) each nostril daily as needed for\ncongestion or post nasal drip for 2 weeks\nGLIPIZIDE - glipizide 5 mg tablet. One tablet(s) by mouth daily\nHYDROCORTISONE - hydrocortisone 2.5 % topical ointment. apply \npea\nsize to affected area every day after bathing for 14 days, then\nas needed for itching\nISOSORBIDE MONONITRATE - isosorbide mononitrate ER 30 mg\ntablet,extended release 24 hr. 1 tablet(s) by mouth daily\nLEVOTHYROXINE - levothyroxine 150 mcg tablet. 1 tablet(s) by\nmouth daily This is an INCREASED dose\nLOSARTAN - losartan 100 mg tablet. 1 tablet(s) by mouth once a\nday\nMETOPROLOL TARTRATE - metoprolol tartrate 25 mg tablet. 1\ntablet(s) by mouth twice a day\nPENCICLOVIR [DENAVIR] - Denavir 1 % topical cream. apply to lips\nevery 2 hours until cold sores resolve - (Not Taking as\nPrescribed: discontinued)\nSUCRALFATE - sucralfate 1 gram tablet. 1 tablet(s) by mouth tid\nbefore meals and hs tell her to take about 30min before meals.\nSTOP THE PANTAPROZOLE\n \nMedications - OTC\nASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by\nmouth once a day - (Not Taking as Prescribed)\nBLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra\nTest strips. Use as directed for blood sugar monitoring twice a\nday and as needed. Dx Code: 250.00 - (Not Taking as Prescribed:\ndiscontinued)\nBLOOD-GLUCOSE METER [ONETOUCH ULTRA2] - OneTouch Ultra2 kit. Use\nas directed for blood sugar monitoring twice a day and as needed\nDx Code: 250.00 - (Not Taking as Prescribed: discontinued)\nCAMPHOR-MENTHOL [ANTI-ITCH (MENTHOL/CAMPHOR)] - Anti-Itch\n(menthol/camphor) 0.5 %-0.5 % lotion. apply to affected areas as\nneeded as needed for itch disp qs for 30 days - (Pt denies\ntaking) (Not Taking as Prescribed: discontinued)\nCYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000\nmcg tablet. 1 tablet(s) by mouth daily\nLANCETS [ONETOUCH ULTRASOFT LANCETS] - OneTouch UltraSoft\nLancets. Use as directed for blood sugar monitoring twice a day\nand as needed Dx Code: 250.00 - (Not Taking as Prescribed:\ndiscontinued)\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \nRX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*20 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*20 Capsule Refills:*0 \n3. Polyethylene Glycol 17 g PO DAILY \n4. TraMADol ___ mg PO Q6H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours \nDisp #*15 Tablet Refills:*0 \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Fluticasone Propionate NASAL 2 SPRY NU BID \n8. GlipiZIDE 5 mg PO DAILY \n9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n10. Levothyroxine Sodium 150 mcg PO DAILY \n11. Losartan Potassium 100 mg PO DAILY \n12. Metoprolol Tartrate 25 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nVentral hernia, lipoma of the abdominal wall\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 ___ on \n___ with abdominal pain. You were evaluated by the Acute \nCare Surgery Service and after a CT scan was done, we found a \npiece of your bowel was entrapped in your stomach lining. We \ntook you to the operating room and repaired this. You tolerated \nthe procedure well and are now being discharged home to continue \nyour 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.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n\nIt was a pleasure being part of your care!\n \nFollowup Instructions:\n___\n" ]

[ "K430", "Z6841", "E1121", "D1779", "E1140", "E11319", "I2510", "E785", "E039", "E669", "M1990", "G8929", "Z96653", "E876" ]

[ "K430: Incisional hernia with obstruction, without gangrene", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "D1779: Benign lipomatous neoplasm of other sites", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "E669: Obesity, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "G8929: Other chronic pain", "Z96653: Presence of artificial knee joint, bilateral", "E876: Hypokalemia" ]

[ "I2510", "E785", "E039", "E669", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAce Inhibitors / Penicillins / Percocet / metformin\n \nAttending: ___.\n \nChief Complaint:\nmuscle cramps, lightheadedness\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nPatient is a ___ year old woman with DM, CAD, recent incarcerated \nhernia s/p ventral hernia repair (___) who presents at the \nrecommendation of her PCP for hypomagnesemia.\n\nShe recently underwent ventral hernia repair (___) which was \nuncomplicated. DUring that admission, she was noted to be \nhypomagenesemic on ___ and ___ requiring repletion. On ___, she \nwent to see her surgeon for staple removal from her surgery and \nhad blood work checked. Mg was 0.9. PCP was notified of the \nresult, and called the patient to come in for Mg repletion. She \nreports for the past few days she has been having left sided \nmuscle cramping/spasms, lightheadedness/dizziness and fatigue. \nDenies nausea, vomiting, diarrhea but has had ~2 loose BMs/day. \nPt is not on diuretics. No new meds recently. Reports mediocre \nPO intake.\n\n In the ED, initial VS were: 98.1 76 180/78 17 97% RA \n ED physical exam was recorded as abdomen non-distended, soft, \nlarge midline surgical incision with steristrips over wound, no \ndrainage or surrounding erythema/induration. TTP around \nincision, otherwise non-tender. \n\nED labs were notable for: \nH/H 10.8/32.7\nCa 6.8, Mg 0.8\nK 3.8\nEKG showed NSR with QTC 520\n Patient was given:\n ___ 11:56 PO/NG Azithromycin 500 mg\n ___ 11:56 IV CefePIME 2 g \n ___ 13:31 PO/NG Aspirin 324 mg \nLater, Mg 2.1\nfreeCa 0.94\npH on VBG 7.42\nTransfer VS were: 98.1 64 154/73 16 99% RA \n When seen on the floor a ten point ROS was conducted and was \nnegative except as above in the HPI.\n\n \nPast Medical History:\n-CAD: Cath on ___ with moderate 3VD and PDA occlusion not\namenable to revascularization. \ndiabetes \nhypothyroidism \nhypertension \nobesity \narthritis, chronic pain \n-s/p: \nbilateral TKRs \nhernia repair x5 \ncholecystectomy \n\n \nSocial History:\n___\nFamily History:\nFamily history of arthritis \n \nPhysical Exam:\nAdmission PE \nGen: NAD, lying in bed\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n Cardiovasc: RRR, no MRG, full pulses, no edema \n Resp: normal effort, no accessory muscle use, lungs CTA ___.\n GI: soft, NT, ND, BS+\n MSK: No significant kyphosis. No palpable synovitis.\n Skin: No visible rash. No jaundice.\n Neuro: AAOx3. No facial droop.\n Psych: Full range of affect\n\nDischarge PE\n97.9 151 / 84 63 20 98 RA\nGen: NAD, lying in bed\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n Cardiovasc: RRR, no MRG, full pulses, no edema \n Resp: normal effort, no accessory muscle use, lungs CTA ___.\n GI: soft, NT, ND, BS+\n MSK: No significant kyphosis. No palpable synovitis.\n Skin: No visible rash. No jaundice.\n Neuro: AAOx3. No facial droop.\n Psych: Full range of affect\n \nPertinent Results:\n___ 10:31PM CALCIUM-7.7* MAGNESIUM-1.6\n___ 07:20PM URINE HOURS-RANDOM\n___ 07:20PM URINE UHOLD-HOLD\n___ 07:20PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 07:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-MOD\n___ 07:20PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE \nEPI-2\n___ 07:20PM URINE MUCOUS-RARE\n___ 04:38PM PH-7.42\n___ 04:38PM freeCa-0.94*\n___ 04:31PM CALCIUM-7.5* MAGNESIUM-2.1\n___ 12:17PM GLUCOSE-130* UREA N-14 CREAT-0.9 SODIUM-140 \nPOTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-25 ANION GAP-22*\n___ 12:17PM ALBUMIN-4.1 CALCIUM-6.8* PHOSPHATE-3.6 \nMAGNESIUM-0.8*\n___ 12:17PM PTH-67*\n___ 12:17PM WBC-7.4 RBC-3.56* HGB-10.8* HCT-32.7* MCV-92 \nMCH-30.3 MCHC-33.0 RDW-13.4 RDWSD-45.1\n___ 12:17PM NEUTS-62.8 ___ MONOS-10.5 EOS-2.4 \nBASOS-0.9 IM ___ AbsNeut-4.64 AbsLymp-1.70 AbsMono-0.78 \nAbsEos-0.18 AbsBaso-0.07\n___ 12:17PM PLT COUNT-328\n___ 02:00PM GLUCOSE-157*\n___ 02:00PM UREA N-16 CREAT-0.9 SODIUM-143 POTASSIUM-3.9 \nCHLORIDE-100 TOTAL CO2-26 ANION GAP-21*\n___ 02:00PM estGFR-Using this\n___ 02:00PM CALCIUM-7.1* PHOSPHATE-4.4 MAGNESIUM-0.9*\n___ 02:00PM TSH-3.7\n\nDischarge labs:\n\n___ 08:10AM BLOOD WBC-6.7 RBC-3.54* Hgb-10.5* Hct-32.0* \nMCV-90 MCH-29.7 MCHC-32.8 RDW-13.4 RDWSD-44.3 Plt ___\n___ 08:10AM BLOOD Glucose-194* UreaN-12 Creat-0.7 Na-140 \nK-3.3 Cl-101 HCO3-24 AnGap-18\n___ 08:10AM BLOOD Calcium-8.0* Phos-3.9 Mg-2.___/P: Patient is a ___ year old woman with DM, CAD, recent \nincarcerated hernia s/p ventral hernia repair (___) who \npresents at the recommendation of her PCP for hypomagnesemia.\n\n# hypomagnesemia and hypocalcemia\nShe appears to have periodic hypomagnesemia as ___ as ___, per \nchart review without clear etiology. Most recently she presented \nwith sxs of muscle cramps most likely due to above electrolyte \nabnormalities. Unclear etiology, she reports chronic loose \nstools and intermittent diarrhea which may cause her \nhypomagnesemia. Mild hypocalcemia, PTH appropriately elevated at \n67, possibly due to vitamin D deficiency. She was repleted with \nIV magnesium and calcium. \n- Started on PO magnesium and calcium carbonate-vitamin D on \ndischarge\n- Follow-up 25-hydoxy vitamin D level (pending on discharge)\n- Recommend repeat chem 10 as outpatient\n\n# Fatigue: \n# Lightheadedness:\nChronic, multifactorial including poor sleep, deconditioning and \nknown OSA with noncompliance with CPAP. She also has had prior \nneurological workup suggestive of small fiber neuropathy or \ngeneralized dysfunction of sudomotor function which may have \ncaused autonomic dysfunction. \n- Encourage follow up with sleep clinic for CPAP after discharge\n\n# CAD: Cath on ___ with moderate 3VD and PDA occlusion not \namenable to revascularization. Exertional sxs have improved \nsince adding imdur, although per cards, she does not have \nclearly anginal sxs.\n- continue ASA\n- continue atorvastatin 80mg\n- continue isosorbide mononitrate 30mg\n- continue Metoprolol Tartrate 25 mg PO BID \n\n# Hypothyroidism: TSH 3.7.\n- continue home Levothyroxine Sodium 150 mcg PO DAILY \n\n# HTN\n- continue Losartan Potassium 100 mg PO DAILY \n\n# DM2: A1C 7% in ___\n- continue GlipiZIDE 5 mg PO DAILY \n- diabetic diet\n\nFull code\nSQH\nPIV\nRegular diet\nDispo home with resumed home services\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H \n2. Atorvastatin 80 mg PO QPM \n3. Fluticasone Propionate NASAL 2 SPRY NU BID \n4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n5. Levothyroxine Sodium 150 mcg PO DAILY \n6. Losartan Potassium 100 mg PO DAILY \n7. TraMADol ___ mg PO Q6H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\n8. Metoprolol Tartrate 25 mg PO BID \n9. GlipiZIDE 5 mg PO DAILY \n10. Docusate Sodium 100 mg PO BID \n11. Polyethylene Glycol 17 g PO DAILY \n12. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. calcium carbonate-vitamin D3 600 mg (1,500 mg)-800 unit oral \nDAILY \nRX *calcium carbonate-vitamin D3 600 mg calcium (1,500 mg)-800 \nunit 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 \n\n2. Docusate Sodium 100 mg PO BID \n3. Magnesium Oxide 400 mg PO BID \nRX *magnesium oxide 400 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n4. Polyethylene Glycol 17 g PO DAILY \n5. TraMADol ___ mg PO Q6H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. Fluticasone Propionate NASAL 2 SPRY NU BID \n10. GlipiZIDE 5 mg PO DAILY \n11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n12. Levothyroxine Sodium 150 mcg PO DAILY \n13. Losartan Potassium 100 mg PO DAILY \n14. Metoprolol Tartrate 25 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nHypomagnesemia\nHypocalcemia\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted with lightheadedness, low magnesium and low \ncalcium levels. You were given IV magnesium and calcium and \nyour lightheadedness improved. Please follow-up with your \nprimary care physician ___ 1 week.\n \nFollowup Instructions:\n___\n" ]

[ "E8342", "E119", "Z6841", "E8351", "R42", "R5383", "I2510", "E039", "I10", "E669", "M1990", "G8929", "Z96653", "G4733", "Z9119" ]

[ "E8342: Hypomagnesemia", "E119: Type 2 diabetes mellitus without complications", "Z6841: Body mass index [BMI]40.0-44.9, adult", "E8351: Hypocalcemia", "R42: Dizziness and giddiness", "R5383: Other fatigue", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E039: Hypothyroidism, unspecified", "I10: Essential (primary) hypertension", "E669: Obesity, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "G8929: Other chronic pain", "Z96653: Presence of artificial knee joint, bilateral", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z9119: Patient's noncompliance with other medical treatment and regimen" ]

[ "E119", "I2510", "E039", "I10", "E669", "G8929", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nanastrozole / Augmentin / barocat / Latex, Natural Rubber\n \nAttending: ___.\n \nChief Complaint:\ncomplicated diverticulitis \n \nMajor Surgical or Invasive Procedure:\n___: exploratory laparotomy, complicated sigmoid colectomy, \nileocecectomy, and total abdominal hysterectomy and bilateral \nsalpingo-oopherectomy with diverting loop ileostomy\n\n \nHistory of Present Illness:\n___ hx of sigmoid diverticulitis in ___, breast ca presents \nwith\nover 1wk of LLQ abdominal pain, N/V and imaging consistent with\nlarge bowel obstruction and a focal thickening of sigmoid colon\nconcerning for a diverticular stricture vs malignant \nobstruction.\nColorectal surgery is consulted for a surgical evaluation.\n\nPatient reports she has had an uncomplicated sigmoid\ndiverticulitis ___ where she was admitted to ___ medicine\nservice for about 2 days and resolved with antibiotics. She\nsubsequently underwent a colonoscopy at the time that showed\ndiverticulosis and no other abnormalities. She has been feeling\nwell until about 4 weeks ago, had a similar LLQ abdominal pain\nand was seen by her PCP and underwent ___ CT ___ scan which \nshowed\na focal thickening in the sigmoid colon and a proximal\nobstruction. She was sent home with 5 days of Cipro/Flagyl and\nfeeling better however started having recurrent crampy LLQ\nabdominal pain, nausea, vomiting and ostipation. She presented \nto\n___ ED where she underwent a CT A/P w/IV contrast which\nshowed a worsened large bowel obstruction at a focal thickening\nof the sigmoid colon. She was transferred to ___ ED for \nfurther\nmanagement. Upon transfer, patient had normal vitals, labs only\nnotable for elevated lipase at 587. She currently endorses \nstable\nLLQ pain, no nausea, last passed flatus yesterday, last BM 2 \ndays\nago. She denies any fevers, chills, night sweats, weight loss \nor\nbloody stools\n\n \nPast Medical History:\nsigmoid diverticulitis ___\nHTN, HL\nMitral valve prolapse.\nAutoimmune disorder of unclear etiology, manifesting as\nneutrophilic dermatosis, diagnosed in ___ for which she is \nunder\nthe care of Dr. ___ and ___ recently Dr.\n___.\n \nSocial History:\n___\nFamily History:\nThe patient's mother developed breast cancer at\nage ___. Her father had lymphoma at age ___. She underwent\nBRCA1-2 testing drawn on ___ at ___, which was\nnegative. She is of ___ ethnic background.\n\n \nPhysical Exam:\nafebrile, vital signs stable \nGeneral: well appearing, NAD \n HEENT: normocephalic, atraumatic, no scleral icterus \n Resp: breathing comfortably on room air \n CV: regular rate and rhythm on monitor \n Abdomen: soft, NT, ND, incision clean, dry, intact\n \nBrief Hospital Course:\nMrs. ___ presented to the emergency department with \nabdominal pain and imaging consistent with complicated \ndiverticulitis with a malignant vs inflammatory stricture on \n___. She underwent a sigmoidosocopy on ___ which \nshowed a 3 cm stricture that decompressed with rectal tube in \nthe proximal sigmoid colon. NGT was placed and the patient was \nkept NPO. The decision was made to take her to the operating \nroom on ___ for Sigmoid colectomy, ileocecectomy, \nTAH/BSO, and diverting loop ileostomy. The procedure was \ncomplicated by intraoperative blood loss of 1.2L. She remained \nhemodynamically unstable with pressor requirement in the \nimmediate post operative period, thus she was transferred to the \nsurgical ICU for further management. \n Neuro: Pain was initially controlled with dilaudid PCA until \nthe patient had return of bowel function. At this point the \npatient was transitioned to PO pain meds. \n CV: The patient was hemodynamically unstable after the OR with \npersistent tachycardia and hypotension requiring pressors, \nlikely secondary to post operative systemic inflammatory \nresponse. She was resuscitated with chrystalloid and colloid, \nand her lactate normalized by the end of post op day 1. She no \nlonger required pressors to maintain her pressure by the end of \npost operative day one, and her tachycardia resolved by post \noperative day 2. \n Pulm: She was extubated in the PACU after her operation. She \nhad a persistent oxygen requirement until post operative day 3 \nwhen she was able to be weaned off of oxygen. She was \ntransferred to the floor on post operative day 3. \n GI: Diet was advanced in a stepwise fashion until the patient \nwas tolerating a regular diet without difficulty. \n GU: foley was removed on POD 2, patient voided appropriately \nwithout issue. \n ID: Due to presumed intra-abdominal contamination from the \nvisualized abscesses, she was started on a 7 day course of \nantibiotics. When she was tolerating a regular diet, she was \ntransitioned to PO antibiotics. Previna vac was used over her \nwound until post operative day 5. It was removed on the day of \ndischarge. \n Heme: No major issues. \n On POD 5, the patient was discharged to home. At discharge, the \npatient was tolerating a regular diet, passing flatus, stooling, \nvoiding, and ambulating independently. The patient will \nfollow-up in the clinic in ___ weeks. This information was \ncommunicated to the patient directly prior to discharge. \n\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\n [ ] Acute Urinary Retention requiring discharge with Foley \n Catheter \n [ ] DVT \n [ ] Pneumonia \n [x] Abscess \n [ ] None \n Social Issues Causing a Delay in Discharge: \n [ ] Delay in organization of ___ services \n [ ] Difficulty finding appropriate rehabilitation hospital \n disposition. \n [ ] Lack of insurance coverage for ___ services \n [ ] Lack of insurance coverage for prescribed medications. \n [ ] Family not agreeable to discharge plan. \n [ ] Patient knowledge deficit related to ileostomy delaying \n discharge. \n [x] No social factors contributing in delay of discharge. \n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1 \nStart: ___, First Dose: Next Routine Administration Time \n2. Lisinopril 10 mg PO DAILY \n3. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n\n \nDischarge Medications:\n1. Lisinopril 10 mg PO DAILY \n2. Acetaminophen 1000 mg PO Q6H \nRX *acetaminophen 80 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*100 Tablet Refills:*0\n3. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*4 Tablet Refills:*0\n4. Enoxaparin Sodium 40 mg SC DAILY \nStart: Today - ___, First Dose: Next Routine Administration \nTime \nRX *enoxaparin 40 mg/0.4 mL ___aily Disp #*25 Syringe \nRefills:*0\n5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H \nRX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every \neight (8) hours Disp #*6 Tablet Refills:*0\n6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*45 \nTablet Refills:*0\n7. Psyllium Wafer ___ WAF PO BID \nRX *psyllium [Metamucil] 1.7 g ___ wafer(s) by mouth twice a day \nDisp #*100 Wafer Refills:*0\n8. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n9. Medical Assist Device: Commode\nplease provide patient with commode upon discharge \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nrecurrent diverticulitis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n___ were admitted to the hospital after an exploratory \nlaparotomy, complicated sigmoid colectomy, ileocecectomy, and \ntotal abdominal hysterectomy and bilateral salpingo-oopherectomy \nwith diverting loop ileostomy. ___ have recovered from this \nprocedure well and ___ are now ready to return home. Samples \nfrom your colon were taken and this tissue has been sent to the \npathology department for analysis. ___ will receive these \npathology results at your follow-up appointment. If there is an \nurgent need for the surgeon to contact ___ regarding these \nresults they will contact ___ before this time. ___ have \ntolerated a regular diet, passing gas and your pain is \ncontrolled with pain medications by mouth. ___ may return home \nto finish your recovery. \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 ___ have an ileostomy. The most common complication from a new \nileostomy placement is dehydration. The output from the stoma is \nstool from the small intestine and the water content is very \nhigh. The stool is no longer passing through the large intestine \nwhich is where the water from the stool is reabsorbed into the \nbody and the stool becomes formed. ___ must measure your \nileostomy output for the next few weeks. The output from the \nstoma should not be more than 1200cc or less than 500cc. If ___ \nfind that your output has become too much or too little, please \ncall 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. \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___ have a long vertical incision on your abdomen that is closed \nwith staples. This incision can be left open to air or covered \nwith a dry sterile gauze dressing if the staples become \nirritated from clothing. The staples will stay in place until \nyour first post-operative visit at which time they can be \nremoved in the clinic, most likely by the office nurse. Please \nmonitor the incision for signs and symptoms of infection \nincluding: increasing redness at the incision, opening of the \nincision, increased pain at the incision line, draining of \nwhite/green/yellow/foul smelling drainage, or if ___ develop a \nfever. Please call the office if ___ develop these symptoms or \ngo to the emergency room if the symptoms are severe. ___ may \nshower, let the warm water run over the incision line and pat \nthe area dry with a towel, do not rub. \nNo heavy lifting for at least 6 weeks after surgery unless \ninstructed otherwise by your surgical team. ___ may gradually \nincrease your activity as tolerated but clear heavy exercise \nwith your surgical team. \n___ will be prescribed a small amount of the pain medication \noxycodone. Please take this medication exactly as prescribed. \n___ may take Tylenol as recommended for pain. Please do not take \nmore than 4000mg of Tylenol daily. Do not drink alcohol while \ntaking narcotic pain medication or Tylenol. Please do not drive \na car while taking narcotic pain medication. \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 \nFollowup Instructions:\n___\n" ]

[ "K5732", "K651", "K5669", "R6510", "M9689", "K9161", "K9181", "T814XXA", "Z853", "Z923", "N736", "I10", "E785", "I341", "R000", "I9581", "Y92239", "Y836", "M359" ]

[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "K651: Peritoneal abscess", "K5669: Other intestinal obstruction", "R6510: Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction", "M9689: Other intraoperative and postprocedural complications and disorders of the musculoskeletal system", "K9161: Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure", "K9181: Other intraoperative complications of digestive system", "T814XXA: Infection following a procedure", "Z853: Personal history of malignant neoplasm of breast", "Z923: Personal history of irradiation", "N736: Female pelvic peritoneal adhesions (postinfective)", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I341: Nonrheumatic mitral (valve) prolapse", "R000: Tachycardia, unspecified", "I9581: Postprocedural hypotension", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "M359: Systemic involvement of connective tissue, unspecified" ]

[ "I10", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nanastrozole / Augmentin / barocat / Latex, Natural Rubber\n \nAttending: ___.\n \nChief Complaint:\nS/p ileostomy takedown\n \nMajor Surgical or Invasive Procedure:\nIleostomy Takedown\n\n \nHistory of Present Illness:\n___ s/p sigmoid colectomy, loop ileostomy, TAH and BSO for \nsevere diverticulitis, now s/p ileostomy takedown\n \nPast Medical History:\nsigmoid diverticulitis ___\nHTN, HL\nMitral valve prolapse.\nAutoimmune disorder of unclear etiology, manifesting as\nneutrophilic dermatosis, diagnosed in ___ for which she is \nunder\nthe care of Dr. ___ and ___ recently Dr.\n___.\n \nSocial History:\n___\nFamily History:\nThe patient's mother developed breast cancer at\nage ___. Her father had lymphoma at age ___. She underwent\nBRCA1-2 testing drawn on ___ at ___, which was\nnegative. She is of ___ ethnic background.\n\n \nPhysical Exam:\nGeneral: Awake and alert in no apparent distress\nCardiac: Regular rate and rhythm\nPulm: Breathing comfortably on room air\nGI: Soft, non-distended, minimal incisional tenderness. \nIncisions c/d/i\n \nPertinent Results:\n___ 06:30AM BLOOD WBC-10.7* RBC-3.41* Hgb-10.2* Hct-31.0* \nMCV-91 MCH-29.9 MCHC-32.9 RDW-16.1* RDWSD-52.8* Plt ___\n___ 06:30AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-138 \nK-3.9 Cl-106 HCO3-19* AnGap-17\n___ 06:30AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0\n \nBrief Hospital Course:\nMrs ___ was admitted to the inpatient Colorectal Surgery \nService after ileostomy takedown. She recovered without issue in \nthe PACU. She was transferred to the inpatient unit without \nissue. On ___ the patient tolerated a clear liquid diet. The \nFoley catheter was removed and the patient did void however, on \n___ the patient did not void and was straight cathed for \n525 on blader scan and the catheter was left in place. When the \npatient passed gas, her diet was advanced. The ileostomy \ntakedown site was cared for appropriately and was intact. The \npatient was discharged home when tolerating a regular diet. Her \npain was controlled. \n\n \nMedications on Admission:\niron 325 mg daily\n CaCO3/VitD daily \n MVI daily \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN pain \ndo not take more than 3000mg of Tylenol in 24hr or drink alcohol \nwhile taking \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8) \nhours Disp #*50 Tablet Refills:*0\n2. Docusate Sodium 100 mg PO BID \n3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nso 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 #*40 Tablet Refills:*0\n4. Ferrous Sulfate 325 mg PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. home vitamin\nok to take home calcium and vitamin D\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUnneeded Ileostomy\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital after an ileostomy takedown. \nYou have recovered from this procedure well and you are now \nready to return home. You have tolerated a regular diet, passing \n \ngas and your pain is controlled with pain medications by mouth. \nYou may return home to finish your recovery. \n \nPlease monitor your bowel function closely. You may or may not \nhave had a bowel movement prior to your discharge which is \nacceptable, however it is important that you have a bowel \nmovement in the next ___ days. After anesthesia it is not \nuncommon for patient’s to have some decrease in bowel function \nbut your should not have prolonged constipation. Some loose \nstool and passing of small amounts of dark, old appearing blood \nare expected however, if you notice that you are passing bright \nred blood with bowel your please seek medical attention. If you \nare passing loose stool without improvement please call the \noffice or go to the emergency room if the symptoms are severe. \nIf you are taking narcotic pain medications there is a risk that \nyou will have some constipation. Please take an over the counter \nstool softener such as Colace, and if the symptoms does not \nimprove call the office. It is also not uncommon after an \nileostomy takedown to have frequent loose stools until you are \ntaking more regular food however this should improve. \n\nThe muscles of the sphincters have not been used in quite some \ntime and you may experience urgency or small amounts of \nincontinence however this should improve. If you do not show \nimprovement in these symptoms within ___ days please call the \noffice for advice. Occasionally, patients will need to take a \nmedication to slow their bowel movements as their bodies adjust \nto the new normal without an ileostomy, you should consult with \nour office for advice. If you have any of the following symptoms \nplease call the office for advice or go to the emergency room if \nsevere: increasing abdominal distension, increasing abdominal \npain, nausea, vomiting, inability to tolerate food or liquids, \nprolonged loose stool, or constipation. \n \nYou have an incision where the old ileostomy once was. This \nshould be covered with a dry sterile gauze dressing. The wound \nno longer requires packing with gauze packing strip. Please \nmonitor the incision for signs and symptoms of infection \nincluding: increasing redness at the incision, opening of the \nincision, increased pain at the incision line, draining of \nwhite/green/yellow/foul smelling drainage, or if you develop a \nfever. Please call the office if you develop these symptoms or \ngo to the emergency room if the symptoms are severe. You may \nshower, let the warm water run over the wound line and pat the \narea dry with a towel, do not rub. Please apply a new gauze \ndressing after showering. \n \nNo heavy lifting for at least 6 weeks after surgery unless \ninstructed otherwise by your surgical team. You may gradually \nincrease your activity as tolerated but clear heavy exercise \nwith your surgical team.\n \nYou will be prescribed a small amount of the pain medication \nOxycodone. Please take this medication exactly as prescribed. \nYou may take Tylenol as recommended for pain. Please do not take \nmore than 3000mg of Tylenol daily. Do not drink alcohol while \ntaking narcotic pain medication or Tylenol. Please do not drive \na car while taking narcotic pain medication. \n \nThank you for allowing us to participate in your care! Our hope \nis that you will have a quick return to your life and usual \nactivities. Good luck! \n\n \nFollowup Instructions:\n___\n" ]

[ "Z432", "I10", "E785", "L989", "M359", "K660", "K5790", "Z85828" ]

[ "Z432: Encounter for attention to ileostomy", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "L989: Disorder of the skin and subcutaneous tissue, unspecified", "M359: Systemic involvement of connective tissue, unspecified", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "Z85828: Personal history of other malignant neoplasm of skin" ]

[ "I10", "E785" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nPneumococcal Vaccine\n \nAttending: ___.\n \nChief Complaint:\ns/p MVC with intrusion into driver's side\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ s/p MVC restr driver with intrusion, L comminuted clavicle \nFx, small R abdominal hematoma extending to L iliacus with ? \nbone fragment vs small extrav by R iliac crest, L5 R TP Fx\n \nPast Medical History:\nPMH: chron MRSA, A fib, ?CKD, pulmonary infection\nPSH: hx RLL resection\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nExam at discharge:\nVitals: 98.0F, HR 60, RR 18, SpO2 97% RA, BP 148/74\nGen app: sitting upright in bedside chair, appears comfortable, \nNAD\nHEENT: EOMI, PERRL. There is erythema of the left eye but no \ndrainage or pain. Vision grossly intact. Oral mucosa pink and \nmoist.\nNeck: trachea midline\nCV: RRR, no m/r/g\nLungs: CTA\nAbd: bowel sounds present. Soft, NT.\nExtrem: warm, well-perfused\nNeuro: CN II-XII intact. Sensation intact and symmetric \nthroughout. Strength ___ in all muscle groups, except for LUE, \nwhich was unable to be tested ___ presence of sling. Gait \nintact.\nSkin: large ecchymosis at left upper chest and over the left \nshoulder. \n \nPertinent Results:\nOn admission:\n\n___ 10:44AM BLOOD WBC-9.0 RBC-4.32* Hgb-13.8 Hct-42.9 \nMCV-99* MCH-31.9 MCHC-32.2 RDW-12.6 RDWSD-46.0 Plt ___\n___ 10:44AM BLOOD ___ PTT-37.3* ___\n___ 10:44AM BLOOD UreaN-19\n___ 05:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.1\n\nOn day of discharge:\n___ 03:20PM BLOOD Hct-37.6*\n___ 05:00AM BLOOD WBC-8.9 RBC-3.69* Hgb-11.9* Hct-36.8* \nMCV-100* MCH-32.2* MCHC-32.3 RDW-12.7 RDWSD-46.6* Plt ___\n \nBrief Hospital Course:\nPt brought to ___ via EMS after ___ where pt was the driver of \na car that was T-boned with intrusion into the driver's side. \nFound to have L comminuted and displaced clavicular fx, L5 right \ntransverse process fx, and R abdominal wall hematoma. On CT \nabdomen/pelvis, there was a small hyperdense area in the R low \nabdomen that was felt to represent either a bone fragment or \npossible extravasation of IV contrast. Given that pt was on \nEliquis, the pt was admitted for observation. His hematocrits \nwere trended and initially dropped from 42.9 on arrival to 36.8. \n Subsequent labs demonstrated stable hemocrit with last value \nprior to discharge 37.6. He was seen and evaluated by the \northopedic service for his clavicle fracture. They recommended \nsling for the L arm and follow up in their clinic in 2 weeks. \nHis pain was well controlled with Tylenol alone. He was doing \nwell and was discharged to home. He was instructed to stop his \nEliquis until he sees his cardiologist. \n \nMedications on Admission:\nEliquis\nBactrim \n \nDischarge Medications:\nBactrim\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n1. s/p motor vehicle collision\n2. Displaced comminuted left clavicle fx\n3. Right abdominal wall hematoma\n4. L5 right transverse process fx\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou came to the hospital after a car accident. You were found \nto have a broken left collarbone, a broken piece of bone in your \nlow back, and a blood collection in your right abdomen. You \nwere monitored overnight to ensure there was no evidence of \ncontinued bleeding. Your blood counts decreased initially but \nwere stable on repeat lab work. You were discharged to home in \nstable condition. You should not restart your Eliquis unless \ntold to do so by your cardiologist. You should keep your left \narm in the sling until told otherwise by the orthopedic surgeons \nat your follow up appointment. You may take Tylenol for the \npain. You should take no more than 3,000mg of Tylenol per day.\n \nFollowup Instructions:\n___\n" ]

[ "S42022A", "S301XXA", "S32058A", "V4352XA", "Y9289", "M549", "R001", "Z85828", "Z85038", "E785", "I10", "N289", "M109", "Z87891", "I4891", "Z7902", "Z8614" ]

[ "S42022A: Displaced fracture of shaft of left clavicle, initial encounter for closed fracture", "S301XXA: Contusion of abdominal wall, initial encounter", "S32058A: Other fracture of fifth lumbar vertebra, initial encounter for closed fracture", "V4352XA: Car driver injured in collision with other type car in traffic accident, initial encounter", "Y9289: Other specified places as the place of occurrence of the external cause", "M549: Dorsalgia, unspecified", "R001: Bradycardia, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "Z85038: Personal history of other malignant neoplasm of large intestine", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "N289: Disorder of kidney and ureter, unspecified", "M109: Gout, unspecified", "Z87891: Personal history of nicotine dependence", "I4891: Unspecified atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z8614: Personal history of Methicillin resistant Staphylococcus aureus infection" ]

[ "E785", "I10", "M109", "Z87891", "I4891", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nheparin\n \nAttending: ___.\n \nChief Complaint:\nAbdominal aortic aneurysm rupture with hemodynamic instability \n \nMajor Surgical or Invasive Procedure:\n___ INFRARENAL PROXIMAL AORTIC CUFF X 4, OPEN ABDOMEN FOR \nWASHOUT OF HEMATOMA\n\n___ ABDOMINAL WASHOUT, LOA, ABTHERA PLACEMENT \n\n___ ABDOMINAL WASHOUT, CLOSURE OF ABDOMEN\n\n \nHistory of Present Illness:\nHPI:\nMr. ___ is a ___, former smoker, with PVD s/p \naortobifemoral bypass (___ ___ vs ___ per wife), who presented \nto the OSH with sudden onset abdominal pain this morning. He \nunderwent a CTA which showed a disrupted proximal anastomosis of \nthe aorto-femoral graft with rupture. Additionally he has a \nright groin pseudoaneurysm between the right limb of the \naort-bifemoral\ngraft with the native artery which appears contained. He was \ntherefore transferred to ___ for further management. On \nMedflight, he became hypotensive with worsening abdominal \ndistention and was given a total of 4u pRBC and ___ FFP. He was \ntaken directly to the OR for definitive treatment.\n\n \nPast Medical History:\nPMH: \nafib, stroke (no neuro deficits ___, PVD, HTN\n \nPSH: \n- aortobifemoral bypass ___ vs ___\n- >___nd endovascular procedures\nincluding left iliac artery stent, fem-fem bypass, ultimately\nresulting in R BKA\n\n \nSocial History:\n___\nFamily History:\nFH:\nunknown\n\n \nPhysical Exam:\nPhysical Exam: ON ARRIVAL \nVitals: HR 112 BP 135/110 \nGEN: in acute distress, conversant \nCV: tachycardic\nPULM: no respiratory distreess\nABD: tense, distended abdomen, tender to palpation\nExt: No ___ edema, ___ warm and well perfused\nPulses: R: p/d/BKA L: p/d/d/d\n\nON DISCHARGE\n\n***************\n \nPertinent Results:\n___ 05:37AM BLOOD WBC-8.7 RBC-3.49* Hgb-9.7* Hct-33.4* \nMCV-96 MCH-27.8 MCHC-29.0* RDW-21.0* RDWSD-74.2* Plt ___\n___ 05:37AM BLOOD ___ PTT-33.4 ___\n___ 05:37AM BLOOD Glucose-96 UreaN-41* Creat-0.8 Na-138 \nK-5.0 Cl-97 HCO3-27 AnGap-14\n___ 05:37AM BLOOD Calcium-8.8 Phos-5.6* Mg-2.2\n___ 06:41AM BLOOD calTIBC-332 Ferritn-277 TRF-255\n \nBrief Hospital Course:\nMr. ___ is a ___ PVD s/p aortobifemoral bypass (___) who \npresented to the OSH with sudden onset of abdominal pain with \nCTA confirming p/w ruptured ___ anastomosis. He was transfused \n4u rPBC 2uFFP in medflight with worsening hypotension. He was \ntaken immediately to the OR where he underwent infrarenal ___ \naortic cuff x4 w open abdomen (see op note for further \ndetails). He was transferred to the ICU in critical condition. \nHe was started on fondaparinux prophylaxis due to his history of \nHIT. His respiratory status was tenuous and he frequently \ndesatted and required increasing FiO2 while he remained \nintubated. Pulmonology was consulted and he was started on \nLasix. During this initial post-op period his antibiotic \ncoverage was adjusted as appropriate and he was started on tube \nfeeds. He had a TTE that showed a PFO, but cardiology did not \nfeel that any intervention was necessary at this time. He \nreturned to the OR on POD4 for an abdominal washout, lysis of \nadhesions, and abthera placement. Following his second trip to \nthe OR he had continued PRN Lasix requirements in the ICU. Two \ndays following this he became febrile and his R IJ line had \nevidence of pus when it was removed, so a L IJ was placed. His \nfevers continued and he was taken back to the OR again for \nanother washout and at this time his abdomen was closed. After \nthis third trip to the OR he was persistently hypertensive and \nrequired nicardipine for BP control. In the following days the \nICU team attempted to wean him from the vent but it was not well \ntolerated. He also went into Afib and was started on metoprolol. \nHe continued to be febrile so a CTA of his torso was obtained, \nbut it showed no obvious source of infection that would explain \nhis fevers. On POD12 from his original operation he was \nextubated, but developed respiratory distress and needed to be \nreintubated. The following day he continued to be febrile so ID \nwas consulted. The following day he went into Afib with RVR \nagain and was started on a dilt drip. He had an echo for \nunexplained hypotension which didn't show a cardiac cause, but \nrevealed a thrombus in his IJ. At this time he was also \ntransitioned to bivalirudin for a short period before being \nrestarted on fondaparinux. On POD16 from his original operation \nhe was successfully extubated and his oxygen requirements were \nsubsequently weaned down. His mental status then became one of \nhis chief issues, as he would only occasionally follow commands \nand would not communicate in any meaningful manner. His fevers \nsubsided and on POD18 he was transferred to the VICU.\nWhile on the floor in the VICU his blood pressure and mental \nstatus were his main issues. Vascular medicine provided \nassistance with his anti-hypertensive regimen, which needed to \nbe adjusted multiple times for adequate control. Neurology was \nconsulted for his altered mental status, which they attributed \nto delirium secondary to an extended ICU stay. Additionally, ACS \nwas consulted for placement of a PEG tube as he would likely \nneed long term feeding access due to his mental status. \nUltimately, his family opted not to go through with the PEG so \nthat they could avoid reintubation, so his feedings were \ncontinued with the Dobhoff. Neurology attributed his mental \nstatus to delirium related to his prolonged ICU stay, so \ndelirium precautions were put in place. His mental status began \nto improve and he became more conversant and oriented as time \nprogressed. Vascular medicine continued to be involved in his \ncare and he was diuresed as necessary. On hospital day ___ he had \na brief run of afib that was seen on telemetry, but had no \nfurther issues with afib afterwards. On hospital day ___ he was \nhemodynamically stable and his mental status continued to \nimprove so he was determined to be fit for discharge. His \ndischarge was ultimately delayed due to difficulties with \nfinding rehab placement, but by hospital day 27 case management \nhad found a rehab facility and he was transferred there with \nplans to follow up with vascular surgery clinic for re-imaging \nof his abdomen.\n \nMedications on Admission:\nLisinopril\nLovastatin\nGabapentin\nPrilosec\nWarfarin\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n2. amLODIPine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN \ndry eyes \n4. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n6. Captopril 37.5 mg PO TID \nRX *captopril 25 mg 1.5 tablet(s) by mouth three times a day \nDisp #*135 Tablet Refills:*0 \n7. CARVedilol 12.5 mg PO BID \nRX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n8. Chlorthalidone 25 mg PO DAILY \nRX *chlorthalidone 25 mg 1 tablet(s) by mouth once a day Disp \n#*30 Tablet Refills:*0 \n9. Docusate Sodium (Liquid) 100 mg PO BID \n10. Fondaparinux 7.5 mg SC DAILY \nRX *fondaparinux 7.5 mg/0.6 mL 1 once a day Disp #*30 Syringe \nRefills:*0 \n11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H \n12. Metoclopramide 10 mg PO Q6H \n13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n14. QUEtiapine Fumarate 12.5 mg PO QHS agitation \n15. Senna 8.6 mg PO BID \n16. Divalproex (DELayed Release) 500 mg PO BID \n17. Gabapentin 800 mg PO TID \n18. Lovastatin 40 mg oral DAILY \n19. Memantine 10 mg PO DAILY ___ \n20. Memantine 5 mg PO DAILY AM \n21. Omeprazole 20 mg PO DAILY \n22. Warfarin 2 mg PO 5X/WEEK (___) \n23. Warfarin 4 mg PO 2X/WEEK (___) \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAbdominal Aortic Aneurysm Rupture\nPeripheral Vascular Disease\nAnemia secondary to rupture requiring transfusion\nOliguria\nPleural effusions with pulmonary edema requiring diuresis\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nMr. ___-\n\nIt was a pleasure taking care of you at ___ \n___. You were admitted to the hospital after \ntransfer from an outside institution for ruptured abdominal \naortic aneurysm. You underwent emergent repair which required \nplacement of a graft in you aorta. You also required an \nincision made into your abdomen to release the blood that \ncollected after the rupture. \n\nPlease follow the recommendations below to ensure a speedy and \nuneventful recovery.\n\nDivision of Vascular and Endovascular Surgery\nEndovascular Abdominal Aortic Aneurysm Repair Discharge \nInstructions\n\nPLEASE NOTE: After endovascular aortic repair (EVAR), it is very \nimportant to have regular appointments (every ___ months) for \nthe rest of your life. These appointments will include a CT \n(“CAT”) scan and/or ultrasound of your graft. If you miss an \nappointment, please call to reschedule. \nWHAT TO EXPECT:\n•Bruising, tenderness, and a sensation of fullness at the groin \npuncture sites (or incisions) is normal and will go away in \none-two weeks\nCARE OF THE GROIN PUNCTURE SITES:\n•It is normal to have mild swelling, a small bruise, or small \namounts of drainage at the groin puncture sites. In two weeks, \nyou may feel a small, painless, pea sized knot at the puncture \nsites. This too is normal. Male patients may notice some \nswelling in the scrotum. The swelling will get better over \none-two weeks.\n•Look at the area daily to see if there are any changes. Be \nsure to report signs of infection. These include: increasing \nredness; worsening pain; new or increasing drainage, or drainage \nthat is white, yellow, or green; or fever of 101.5 or more. (If \nyou have taken aspirin, Tylenol, or other fever reducing \nmedicine, wait at least ___ hours after taking it before you \ncheck your temperature in order to get an accurate reading.)\nFOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or \nincision)\n•If you have sudden, severe bleeding or swelling at either of \nthe groin puncture sites: \n-Lie down, keep leg straight and apply (or have someone apply) \nfirm pressure to area for ___ minutes with a gauze pad or \nclean cloth. \n-Once bleeding has stopped, call your surgeon to report what \nhappened. \n-If bleeding does not stop, call ___ for transfer to closest \nEmergency Room. \n•You may shower 48 hours after surgery. Let the soapy water \nrun over the puncture sites, then rinse and pat dry. Do not rub \nthese sites and do not apply cream, lotion, ointment or powder. \n•Wear loose-fitting pants and clothing as this will be less \nirritating to the groin puncture sites. \nMEDICATIONS\n•Take aspirin daily. Aspirin helps prevent blood clots that \ncould form in your repaired artery. \n•It is very important that you never stop taking aspirin or \nother blood thinning medicines-even for a short while- unless \nthe surgeon who repaired your aneurysm tells you it is okay to \nstop. Do not stop taking them, even if another doctor or nurse \ntells you to, without getting an okay from the surgeon who first \nprescribed them. \n•You will be given prescriptions for any new medication started \nduring your hospital stay.\n•Before you go home, your nurse ___ give you information about \nnew medication and will review all the medications you should \ntake at home. Be sure to ask any questions you may have. If \nsomething you normally take or may take is not on the list you \nreceive from the nurse, please ask if it is okay to take it. \nPAIN MANAGEMENT\n•Most patients do not have much pain following placement of the \nstent alone. You had an abdominal incision in addition to this, \nso recovery may take longer. Your puncture sites may be a \nlittle sore. This will improve daily. If it is getting worse, \nplease let us know.\n•You will be given instructions about taking pain medicine if \nyou need it.\nACTIVITY\n•You must limit activity to protect the puncture sites in your \ngroin. For ONE WEEK:\n-Do not drive\n-Do not swim, take a tub bath or go in a Jacuzzi or hot tub\n-Do not lift, push, pull or carry anything heavier than five \npounds\n-Do not do any exercise or activity that causes you to hold your \nbreath or bear down with your abdominal muscles.\n-Do not resume sexual activity\n•Discuss with your surgeon when you may return to other regular \nactivities, including work. If needed, we will give you a \nletter for your workplace. \n•It is normal to feel weak and tired. This can last six-eight \nweeks, but should get better day by day. You may want to have \nhelp around the house during this time.\n___ push yourself too hard during your recovery. Rest when \nyou feel tired. Gradually return to normal activities over the \nnext month.\n•We encourage you to walk regularly. Walking, especially \noutdoors in good weather is the best exercise for circulation. \nWalk short distances at first, even in the house, then do a \nlittle more each day.\n•It is okay to climb stairs. You may need to climb them slowly \nand pause after every few steps. \n\nBOWEL AND BLADDER FUNCTION\n•You should be able to pass urine without difficulty. Call you \ndoctor if you have any problems urinating, such as burning, \npain, bleeding, going too often, or having trouble urinating or \nstarting the flow of urine. Call if you have a decrease in the \namount of urine. \n•You may experience some constipation after surgery because of \npain medicine and changes in activity. Increasing fluids and \nfiber in your diet and staying active can help. To relief \nconstipation, you may talk a mild laxative. Please take to \nyour pharmacist for advice about what to take. \nSMOKING\n•If you smoke, it is very important that you STOP. Research \nshows smoking makes vascular disease worse. This could increase \nthe chance of a blockage in your new graft. Talk to your \nprimary care physician about ways to quit smoking. \n\n \nFollowup Instructions:\n___\n" ]

[ "T82898A", "I713", "T80211A", "J9601", "R578", "D62", "J90", "Q211", "F05", "J811", "T17890A", "J9811", "D6861", "J95851", "N179", "E873", "E870", "Y832", "Y92009", "I724", "I10", "Z8673", "Z87891", "I739", "I4891", "R680", "Z89511", "G40909", "X58XXXA", "Y929", "K660", "B9689", "Y848", "Y92230", "R34", "E806", "T82868A" ]

[ "T82898A: Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter", "I713: Abdominal aortic aneurysm, ruptured", "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "J9601: Acute respiratory failure with hypoxia", "R578: Other shock", "D62: Acute posthemorrhagic anemia", "J90: Pleural effusion, not elsewhere classified", "Q211: Atrial septal defect", "F05: Delirium due to known physiological condition", "J811: Chronic pulmonary edema", "T17890A: Other foreign object in other parts of respiratory tract causing asphyxiation, initial encounter", "J9811: Atelectasis", "D6861: Antiphospholipid syndrome", "J95851: Ventilator associated pneumonia", "N179: Acute kidney failure, unspecified", "E873: Alkalosis", "E870: Hyperosmolality and hypernatremia", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "I724: Aneurysm of artery of lower extremity", "I10: Essential (primary) hypertension", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "I739: Peripheral vascular disease, unspecified", "I4891: Unspecified atrial fibrillation", "R680: Hypothermia, not associated with low environmental temperature", "Z89511: Acquired absence of right leg below knee", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "X58XXXA: Exposure to other specified factors, initial encounter", "Y929: Unspecified place or not applicable", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "B9689: Other specified bacterial agents 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", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R34: Anuria and oliguria", "E806: Other disorders of bilirubin metabolism", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter" ]

[ "J9601", "D62", "N179", "I10", "Z8673", "Z87891", "I4891", "Y929", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___\n \nChief Complaint:\nsustained VT \n \nMajor Surgical or Invasive Procedure:\ncardiac cath: ___\n- No angiographically apparent coronary artery disease\n\n \nHistory of Present Illness:\n___ y/o M with history of bladder cancer, lymphoma, BPH who\npresented initially to ___ for palpitations, found\nto have sustained VT, transferred for further care.\n\nHe endorses 1 week of palpitations for which he was advised by\nhis PCP to stop drinking EtOH and caffeine and was planned for \nan\noutpatient TTE. Palpitations last usually about a couple of\nseconds. On the night of admission, he was at home watching TV\nwhen he started having palpitations again. This episode was\nlonger lasting, caused some lightheadedness and shortness of\nbreath, and lead to them calling the ED. While at ___, his\nlab work was unremarkable, including negative troponin. While\nthere, he had multiple episodes of ventricular tachycardia for\nwhich he was given amiodarone bolus and started on gtt and\nintubated for mental status. In total, he received heparin \nbolus,\n150 IV amiodarone x 3 and started on gtt, 2 gm Mg, 3 mg\nlorazepam, 10 mg metoprolol. He was then transferred to the\n___.\n\nEn route to ___, he had 10 episodes of sustained ventricular\ntachycardia requiring cardioversion and 2 episodes of \nventricular\nfibrillation requiring defibrillation. These were mostly\nMonomorphic VT per report. In review there is one strip \navailable\nwhich shows possible polymorphic VT as well. \n\nOn arrival to the ED, he was intubated and sedated with fentanyl\nand propofol, which was transitioned to midazolam. He was\ncontinued on amiodarone gtt, lidocaine 100 mg x 1, 1 L NS at 200\nml/hr. \n \nIn the ED, initial vials with HR 51, BP 91/65, O2 99% intubated.\nWBC 5.8, Hgb 10.1, Hct 30.6, Plt 128, pro BNP 229. Trop negative\nx 1. When examined off sedation, he was able to follow commands,\npupils equal and reactive with non-purposeful movements. Bedside\nTTE without pericardial effusion.\n\nOn arrival to the CCU, the patient was intubated and sedated,\nthough was responsive.\n\n \nPast Medical History:\n- \"Blood cancer\" s/p chemotherapy, none for past ___ years as \nwas\ntold counts looked better\n\nCardiac History: \n- \"bad valve\" scheduled for TTE\n- Recent palpitations, started on Metoprolol succinate 25mg PO\ndaily\n\n \nSocial History:\n___\nFamily History:\n- Father died of old age (no cardiac history)\n- Mother died from lung cancer (smoker)\n- No sudden cardiac death in family, no unexplained deaths \n(MVCs,\ndrownings)\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS: HR 74, O2 99, 140/85 \nGENERAL: Intubated, sedated. Comfortable and responding to \nquestions this morning. Following commands.\nHEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI. \n\nNECK: Supple. JVP at 8-9 cm \nCARDIAC: Normal rate, regular rhythm. ___ holosystolic murmur \nheard best at the apex.\nLUNGS: No chest wall deformities or tenderness. No adventitious \nbreath sounds. \nABDOMEN: Soft, non-tender, non-distended. No palpable \nhepatomegaly or splenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or \nperipheral edema. \nSKIN: No significant lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE PHYSICAL EXAMINATION: \nVS: tmax 98.9, BP ___, HR 90's\nTele: SR 90, had some ST overnight for 5 minutes, no VT\nWeight: 206.5 lbs (214.9 lbs on admit)\n\nGen: Pleasant, calm \nHEENT: NC/AT. \nNECK: Supple. No JVD\nCV: RRR. normal S1,S2. No murmurs heard.\nLUNGS: CTAB. No wheezes, rales, or rhonchi. \nABD: Soft, NT, ND. +BS\nLower EXT: No edema, no erythema. \n \nPertinent Results:\nADMISSION LABS\n___ 10:07PM BLOOD WBC-5.8 RBC-3.38* Hgb-10.1* Hct-30.6* \nMCV-91 MCH-29.9 MCHC-33.0 RDW-14.2 RDWSD-46.8* Plt ___\n___ 10:07PM BLOOD Neuts-60.3 ___ Monos-3.9* \nEos-0.0* Baso-0.2 Im ___ AbsNeut-3.52 AbsLymp-2.05 \nAbsMono-0.23 AbsEos-0.00* AbsBaso-0.01\n___ 10:07PM BLOOD ___ PTT-45.9* ___\n___ 10:07PM BLOOD Glucose-183* UreaN-21* Creat-1.1 Na-138 \nK-4.2 Cl-109* HCO3-23 AnGap-6*\n___ 10:07PM BLOOD Calcium-8.1* Phos-3.5 Mg-2.4\n___ 10:07PM BLOOD proBNP-229*\n___ 10:07PM BLOOD cTropnT-<0.01\n___ 05:17AM BLOOD Triglyc-65 HDL-26* CHOL/HD-3.8 LDLcalc-59\n___ 05:17AM BLOOD %HbA1c-5.4 eAG-108\n\nINTERVAL LABS:\n___ 06:00AM BLOOD WBC-4.9 RBC-3.59* Hgb-10.7* Hct-32.2* \nMCV-90 MCH-29.8 MCHC-33.2 RDW-14.1 RDWSD-45.7 Plt ___\n___ 05:53AM BLOOD WBC-4.9 RBC-3.68* Hgb-11.0* Hct-33.2* \nMCV-90 MCH-29.9 MCHC-33.1 RDW-13.8 RDWSD-45.7 Plt ___\n___ 05:32AM BLOOD WBC-4.5 RBC-3.57* Hgb-10.7* Hct-33.0* \nMCV-92 MCH-30.0 MCHC-32.4 RDW-14.2 RDWSD-48.0* Plt ___\n___ 05:17AM BLOOD WBC-5.2 RBC-3.21* Hgb-9.6* Hct-29.0* \nMCV-90 MCH-29.9 MCHC-33.1 RDW-14.3 RDWSD-47.1* Plt ___\n___ 05:17AM BLOOD Neuts-59.3 ___ Monos-3.9* \nEos-0.0* Baso-0.2 Im ___ AbsNeut-3.06 AbsLymp-1.88 \nAbsMono-0.20 AbsEos-0.00* AbsBaso-0.01\n___ 06:00AM BLOOD ___ PTT-27.6 ___\n___ 05:53AM BLOOD ___ PTT-27.9 ___\n___ 05:32AM BLOOD ___ PTT-27.0 ___\n___ 05:17AM BLOOD ___ PTT-27.6 ___\n___ 06:48AM BLOOD Glucose-133* UreaN-17 Creat-1.1 Na-138 \nK-4.1 Cl-102 HCO3-24 AnGap-12\n___ 06:00AM BLOOD Glucose-118* UreaN-18 Creat-1.0 Na-137 \nK-4.0 Cl-104 HCO3-25 AnGap-8*\n___ 05:53AM BLOOD Glucose-116* UreaN-12 Creat-0.9 Na-136 \nK-4.1 Cl-104 HCO3-23 AnGap-9*\n___ 11:00PM BLOOD Glucose-230* UreaN-13 Creat-1.0 Na-135 \nK-3.6 Cl-100 HCO3-26 AnGap-9*\n___ 05:32AM BLOOD Glucose-110* UreaN-13 Creat-1.0 Na-138 \nK-4.2 Cl-105 HCO3-24 AnGap-9*\n___ 05:17AM BLOOD Glucose-131* UreaN-20 Creat-0.9 Na-140 \nK-4.0 Cl-108 HCO3-24 AnGap-8*\n___ 06:48AM BLOOD Mg-1.8\n___ 06:00AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0\n___ 05:53AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.3\n___ 11:00PM BLOOD Mg-1.6\n___ 05:32AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8\n___ 05:17AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.2 Cholest-98\n___ 05:17AM BLOOD %HbA1c-5.4 eAG-108\n___ 05:17AM BLOOD Triglyc-65 HDL-26* CHOL/HD-3.8 LDLcalc-59\n\nDISCHARGE LABS:\n___ 06:48AM BLOOD Hct-33.0* Plt ___\n___ 06:18AM BLOOD Na-137 K-4.2\n___ 06:18AM BLOOD Mg-1.9\n\nMICRODATA: none\n\n==============\nREPORTS\n==============\n___ CARDIAC CATH: Right dominant system; The left main, \nleft anterior descending, circumflex and right coronary artery \nhave no angiographically significant coronary abnormalities.\n\n___ Cardiac MR\nFINDINGS\nLeft Atrium (LA)/Pumonary Veins (PV): Normal LA volume index.\nRight Atrium (RA)/Coronary Sinus: Normal RA length. Normal\ncoronary sinus diameter.\nLeft Ventricle (LV): Normal wall thickness. Mildly increased \nmass\nindex. Normal ___. Mod increased EDV. Mildly increased EDVI.\nNormal regional/global systolic function. Normal EF. Midwall \nLGE.\nRight Ventricle (RV): No free wall fat. Normal cavity size. Mild\nincrease end-diastolic volume (EDV) index. Normal \nregional/global\nfree wall motion Low normal ejection fraction (EF).\n\nAorta: Normal origin of the L main; RCA origin not seen. Normal\nsinus diameter. Normal ascending aorta diameter. Mildly dilated \naortic\narch. Normal BSA indexed aortic arch. Mild dilation descending \naorta.\nNormal descending aorta indexed diameter. MIld dilation \nabdominal\naorta. Normal BSA indexed abdominal aorta. No coactation.\nPulmonary Artery: Normal diameter.\nAortic Valve (AV): 3 leaflets. Mildly thickened leaflets. No \nstenosis.\nTrace regurgitation.\nMitral Valve (MV): Bileaflet prolapse. MIld-moderate \nregurgitation.\nPulmonic Valve (PV)/Tricuspid Valve (TV): Trivial pulmonic\nregurgitation. Mild tricuspid regurgitation.\nPericardium/Pleura: Small effusion. Normal thickness. No pleural\neffusions.\n\nNon-cardiac Findings\nThere is a 2.2 cm nodule at the right lung base, which appears\nhypointense on fat suppressed sequences suggesting a possible\npulmonary hamartoma (___). Multiple smaller areas of \nsubpleural\nnodularity are seen in the region of the right middle and upper \nlobe\n(___). These findings should be further assessed with a\ndedicated chest CT. Spleen is mildly enlarged, measuring up to \n16.9\ncm. There is a 2.4 cm T2 hyperintense lesion in the interpolar \nregion of\nthe right kidney, which may represent a cyst (___).\n\nCONCLUSION/IMPRESSION:\nNormal left atrial volume index. Right atrial size is normal. \nThere is\nnormal left ventricular wall thickness with mildly increased \nmass\nindex. The left ventricular end-diastolic dimension was normal \nwith\nmoderately increased left ventricular end-diastolic volume and \nmildly\nincreased end-diastolic volume index. There is normal regional \nand\nglobal left ventricular systolic function with normal ejection \nfraction.\nThere is left ventricular mid-wall late gadolinium enhancement \nin the\nbasal lateral wall (see schematic) consistent with non-ischemic\ncardiomyopathy. There is no fatty infiltration of the right \nventricular\nfree wall. Mildly dilated right ventricle with low normal \nejection\nfraction. Normal origin of the left main coronary artery; right \ncoronary\nIMPRESSION:\n1. Mildly dilated left ventricle with normal global and regional \nLV systolic function.\n2. Small amount of mid-myocardial fibrosis in the basal lateral \nLV wall.\n3. Mildly dilated right ventricle with low-normal RV systolic \nfunction.\n4. Bileaflet mitral valve prolapse with mild to moderate mitral\nregurgitation.\n5. Mild tricuspid regurgitation.\n6. Small pericardial effusion.\n7. Multiple non-cardiac findings, as described above, which \nshould be further assessed with a dedicated chest CT scan.\n\n___ EP report\nFindings\nSpontaneous PVCs at baseline. Trabeculated RV. Earlierst \nseptum/apical RV in trabeculations. 30 ms pre QRS with QS \nunipolar. Ablation caused VT and supressed. Multiple lesions in \nthe area. After ablation no more spontaneous/catheter stimulated \nclinical VT, but other likely catheter related VTs with \nmanipulation of trabeculations. Run of VT induced Vflutter - \nDCCV. Very irritable with cathter manipulation. Plan for ICD\n\n___ Stress Test \nINTERPRETATION: This ___ year old man was referred to the lab \nfrom \nthe EP service for evaluation of VT, s/p recent ablation and ICD \n\nplacement now on flecainide therapy for the past 24 hours. The \npatient \nexercised for 6.0 minutes of a Gervino protocol and was stopped \nfor \nachieving the target sub-max HR. The patient perceived the work \nas hard \nto very hard. No arm, neck, back or chest discomfort was \nreported by \nthe patient throughout the study. The baseline EKG showed RBBB \nwith \nsecondary inverted T waves. There were no significant ST segment \n\nchanges throughout. The rhythm was sinus with rare isolated vpbs \nvs \nabps with aberrant conduction. The QRS duration at rest, peak \nexercise \nand 10 minutes of recovery was 160, 156 and 154 msec, \nrespectively. \nAppropriate heart rate and blood pressure response to exercise \nand \nrecovery. \n \nIMPRESSION: No significant ectopy, ST segment changes or \nsymptoms \nto achieved workload. Normal hemodynamnic response to exercise. \n\n \nBrief Hospital Course:\n___ y/o M with history of bladder cancer, lymphoma, BPH who \npresented initially to ___ for palpitations x1 \nweek, found to have sustained VT, and subsequently transferred \nto ___ for further management of VT.\n\nACUTE ISSUES: \n============= \n#Monomorphic wide complex ventricular tachycardia\nReported a history of 1 week of palpitations prior to \npresentation. On the day of presentation to ___, \nreported persistent palpitations, dyspnea, and lightheadedness. \nAt ___, patient had multiple episodes of Vtach for \nwhich he was given amiodarone 150mg boluses x3 + gtt, 2gm Mg, \n3mg Ativan, 10mg metoprolol and intubated for altered mental \nstatus. On his way to ___, patient had ~10 episodes of \nsustained monomorphic and polymorphic VT requiring \ncardioversion, along with 2 episodes of ventricular fibrillation \nrequiring defibrillation. He received lidocaine 100 mg x 1 upon \narrival to ___ ED, another dose of 100 mg IV lidocaine in the \nCCU followed by drip at 1 mg/hr. Amiodarone gtt was discontinued \non ___ in favor of lidocaine. ___ TTE showed LVEF >/=55%, \nbiatrial enlargement, mild symmetric LVH with normal systolic \nfunction; no valvular pathology identified. Per EP, he underwent \ncardiac MRI on ___ which showed CMR mildly dilated left \nventricle with normal global and regional LV systolic function, \nsmall amount of mid-myocardial fibrosis in the basal lateral LV \nwall, mildly dilated right ventricle with low-normal RV systolic \nfunction, bileaflet mitral valve prolapse with mild to moderate \nmitral regurgitation, mild tricuspid regurgitation, small \npericardial effusion and multiple non-cardiac findings, as \ndescribed above, which should be further assessed with a \ndedicated chest CT scan. He underwent cardiac catheterization on \n___ which showed no angiographically apparent coronary artery \ndisease. He underwent EP study on ___ with ablation (inducible \nVT); found to have flutter circuit and irritable myocardium. \nAfter the study, he continued to have multiple runs of \nmonomorphic VT lasting ___ sec for which he was started on \nlidocaine gtt. Started verapamil 120mg on ___, increased to \n120mg bid on ___. Dual chamber ___ ICD was implanted on \n___ and the site and interrogation are all within normal \nlimits. Verapamil was stopped on ___ and flecinaine 100mg BID \nstarted. No VT noted since initially of flecainide, had brief \nepisode of NSVT 6 beats between ___. He underwent a stress \ntest (no imaging) and QRS complex remained stable as well his \nvital signs. He will be discharged on flecainide 100mg and will \nfollow up on ___ in the device clinic and Dr. ___ \nwill see him during that appointment. He will decide at that \ntime whether another stress test is needed.\n\n#Encephalopathy - resolved\n#Mechanical ventilation\nHe was intubated at ___ for altered mental status \ni/s/o V-tach. Encephalopathy resolved and he was subsequently \nextubated on ___ in the CCU.\n\n#Anemia\n#Thrombocytopenia:\nUnknown baseline, though wife reports a history of a \"blood \ncancer.\" Outpatient oncologist is at ___. Discharge hemocrit \n33.0, Discharge plt: 150\n- ___ with PCP \n\n#BPH:\n- Continued home Doxazosin\n\n#HTN:\n- continue Metoprolol and lisinopril\n\nTRANSITIONAL ISSUES\n===================\n[ ] MR ___ showed findings c/f pulmonary nodules that may be \nc/w hamartoma. Needs chest CT.\n- discharge summary to be sent to PCP, cardiologist and \noncologist\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO QAM \n2. Lisinopril 30 mg PO QPM \n3. Doxazosin 6 mg PO HS \n4. Viagra (sildenafil) 50 mg oral DAILY:PRN \n\n \nDischarge Medications:\n1. Flecainide Acetate 100 mg PO Q12H \n2. Doxazosin 6 mg PO HS \n3. Lisinopril 30 mg PO QPM \n4. Metoprolol Succinate XL 25 mg PO QAM \n5. HELD- Viagra (sildenafil) 50 mg oral DAILY:PRN This \nmedication was held. Do not restart Viagra until you talk to Dr. \n___\n\n \n___ Disposition:\nHome\n \nDischarge Diagnosis:\nventricular tachycardia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You were transferred from ___ to ___ \n___ for \"ventricular tachycardia.\" This is \nan abnormal fast heart rate.\n \nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL? \n- We started you on IV medications to help control your heart \nrate.\n- The doctors at ___ placed a breathing to in your \nlungs to help you breathe, because you were confused due to this \nrapid heart rate.\n- Our electrophysiology doctors saw ___ and several different \nmedications were trailed and decision was to keep you on \nflecainide 100mg twice a day since it was most effective in \nkeeping you out of the arrhythmia. You had a stress test to \nfurther assess this new medication. You tolerated the procedure \nwell and we feel comfortable sending you on this new medication. \nWritten drug information has been provided to you.\n \nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Resume your lisinopril tomorrow night\n- take a one time dose of short acting Metoprolol (which we gave \nyou) and take that tonight around 8pm. Resume your long acting \nMetoprolol tomorrow morning\n- Do not drive until you see and speak with Dr. ___ week \nand from that appointment Dr. ___ will decide when you can \nresume.\n- Follow up with your primary care doctor about the need for \nchest CT to further assess the pulmonary nodules found on the \nCardiac MR that was done while you were here.\n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below .\n- Please see below for more information on your hospitalization. \nIt was a pleasure taking part in your care here at ___! \n \n We wish you all the best! \n - Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I472", "G9340", "I081", "R0689", "D696", "I10", "D649", "N400", "R918", "Z8579", "Z8551", "Z4502" ]

[ "I472: Ventricular tachycardia", "G9340: Encephalopathy, unspecified", "I081: Rheumatic disorders of both mitral and tricuspid valves", "R0689: Other abnormalities of breathing", "D696: Thrombocytopenia, unspecified", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "R918: Other nonspecific abnormal finding of lung field", "Z8579: Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues", "Z8551: Personal history of malignant neoplasm of bladder", "Z4502: Encounter for adjustment and management of automatic implantable cardiac defibrillator" ]

[ "D696", "I10", "D649", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nIodinated Contrast Media / methylprednisolone / Nubain / Biaxin \n/ Caltrate / Avelox / shellfish derived\n \nAttending: ___.\n \nChief Complaint:\nACA aneurysm\n \nMajor Surgical or Invasive Procedure:\n___ Pipeline embolization of A2 aneurysm\n\n \nHistory of Present Illness:\n___ is a ___ female with PMH of subclavian \nsteal syndrome and COPD who was found to have a 6mm ACA aneurysm \non workup of dizziness. Diagnostic angiogram ___ confirmed \nleft A2 bifurcation aneurysm and left PCOM aneurysm. Plan was \nmade for elective pipeline embolization of A2 aneurysm. \n \nPast Medical History:\nsubclavian steal syndrome\nCOPD\n \nSocial History:\n___\nFamily History:\nShe had a mother who died of an abdominal aortic aneurysm, but \nno brain aneurysm history in the family. \n \nPhysical Exam:\nON DISCHARGE: \nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\n\nOrientation: [x]Person [x]Place [x]Time\n\nFollows commands: [ ]Simple [x]Complex [ ]None\n\nPupils: PERRL\n\nEOM: [x]Full [ ]Restricted\n\nFace Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No\n\nPronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No\n\nComprehension intact [x]Yes [ ]No\n\nMotor:\nTrapDeltoidBicepTricepGrip\nRight 5 5 5 5 5\nLeft 5 5 5 5 5\n\nIPQuadHamATEHLGast\nRight5 5 5 5 5 5\nLeft5 5 5 5 5 5\n\n[x]Sensation intact to light touch\n\nAngio Groin Site: \n[x]Palpable pulses\n[x]soft, no hematoma, extensive ecchymosis over lower right\nabdomen and thigh with extension across midline\n\n \nPertinent Results:\nPlease refer to ___ for pertinent lab and imaging results. \n \nBrief Hospital Course:\n#pipeline embolization A2 aneurysm \nPatient presented to ___ on ___ for elective cerebral \nangiogram for pipeline embolization of A2 aneurysm. Please see \ndedicate report for further detail. Case was uncomplicated and \nthe patient recovered from anesthesia in the PACU. Patient's \ngroin site was noted to have small palpable hematoma at the \naccess site therefore HOB was kept flat for a total of 3 hours \npostop and then activity was advanced to as tolerated. Patient \nwas started on aspirin 325mg and Brillinta 90mg BID \npostoperatively. Patient's blood pressure goal was 120-190 \npostoperatively; she received IVF initially and then was \nrequiring vasopressors in the PACU to maintain SBP goal. POD1 \nshe was liberalized to SBP > 100.but still did not maintain goal \nand so midodrine was started at 5mg PO TID. She was liberalized \nto SBP > 90 but still did not maintain goal and so midodrine was \nuptitrated to 10mg TID. Hematocrit was stable. She transferred \nto the ___. Foley and Aline were removed.\n\nOn POD 2, the patient was maintaining her SBP and remained \nneurologically intact. She was transferred home with the plan \nfor Daily blood pressure monitoring while on midodrine. Prior \nto discharge her prescriptions were faxed to her pharmacy in \n___ for her family to obtain prior to the pharmacy \nclosing. She was sent with 3 tabs of Midodrine from ___ pharmacy \nbecause ___ would not have it in stock until tomorrow.\n\nAt the time of discharge she was tolerating a regular diet, \nambulating without difficulty, afebrile with stable vital signs.\n \nMedications on Admission:\nalbuterol; HFA 90 mcg 2 puffs q 4, alendronate 70 mg qweek, \nXanax 0.5 mg, atorvastatin 10 mg qday,azelastine ? dose, \nPrednisone 50 mg pre contrat, zanta 150 mg BID, Stiolto \nRespimat 2.5mcg-2.5mcg 2 ___ 81 qd, Brilinta 90 bId, \nVit D3 2000u qd, Claritin 10 mg QD, \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain \n2. Aspirin 325 mg PO DAILY \nRX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*3 \n3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n4. Docusate Sodium 100 mg PO BID \n5. Midodrine 10 mg PO TID \nRX *midodrine 10 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*90 Tablet Refills:*1 \n6. Senna 17.2 mg PO QHS \n7. TiCAGRELOR 90 mg PO BID \nRX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*3 \n8. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze \n9. Atorvastatin 10 mg PO QPM \n10. Loratadine 10 mg PO DAILY \n11. Stiolto Respimat (tiotropium-olodaterol) 2.5-2.5 \nmcg/actuation inhalation DAILY \n12. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ncerebral ACA aneurysm \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDischarge Instructions\nDr. ___ & Dr. ___ \n\nActivity\n- You will need to check your Blood pressure every day while you \nare on Midodrine. If your systolic blood pressure is above ___ \nyou should call the Neurosurgery Office at ___.\n•You may gradually return to your normal activities, but we \nrecommend you take it easy for the next ___ hours to avoid \nbleeding from your groin.\n•Heavy lifting, running, climbing, or other strenuous exercise \nshould be avoided for ten (10) days. This is to prevent bleeding \nfrom your groin.\n•You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n•Do not go swimming or submerge yourself in water for five (5) \ndays after your procedure.\n•You make take a shower.\nMedications\n•Resume your normal medications and begin new medications as \ndirected.\n•You have been instructed by your doctor to take Aspirin 325mg \ndaily and Brilinta 90mg twice daily. Do not take any other \nproducts that have aspirin in them. If you are unsure of what \nproducts contain Aspirin, as your pharmacist or call our office.\n•You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n•If you take Metformin (Glucophage) you may start it again \nthree (3) days after your procedure.\nCare of the Puncture Site\n•You will have a small bandage over the site.\n•Remove the bandage in 24 hours by soaking it with water and \ngently peeling it off.\n•Keep the site clean with soap and water and dry it carefully.\n•You may use a band-aid if you wish.\n\nWhat You ___ Experience:\n•Mild tenderness and bruising at the puncture site (groin).\n•Soreness in your arms from the intravenous lines.\n•Mild to moderate headaches that last several days to a few \nweeks.\n•Fatigue is very normal\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.\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the puncture \nsite. \n•Fever greater than 101.5 degrees Fahrenheit\n•Constipation\n•Blood in your stool or urine\n•Nausea and/or vomiting\n•Extreme sleepiness and not being able to stay awake\n•Severe headaches not relieved by pain relievers\n•Seizures\n•Any new problems with your vision or ability to speak\n•Weakness or changes in sensation in your face, arms, or leg\n \nFollowup Instructions:\n___\n" ]

[ "I671", "J449", "Z87891", "E785", "F419" ]

[ "I671: Cerebral aneurysm, nonruptured", "J449: Chronic obstructive pulmonary disease, unspecified", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "J449", "Z87891", "E785", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlisinopril\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with the past medical\nhistory of morbid obesity, T2DM, HTN, HLD, CKD3, anemia,\nneuropathy, venous ulcer, and and venous insufficiency who\ninitially presented to ___ from his PCP for new hypoxemia (SpO2\n88% on RA), fatigue, and dyspnea on exertion. He was transferred\nto ___ for CTA to rule out PE (___ does not have equipment \nthat\ncan fit the patient). \n\nPer the ER MD, \"In the ED, he has been on ___ with SpO2 > 94%,\nbreathing comfortably. He tells me that his dyspnea has been at\nhis recent baseline and typically is related to exertion. I \nspoke\nwith his PCP regarding his symptoms, and he strongly feels that\nthe patient should be admitted for further evaluation. Even\nthough the patient reports little change from his baseline, his\nPCP who has known him for years, reports that his mobility and\nfunctional status has declined relatively acutely and that he \nhas\nnot had a low SpO2 in clinic prior to the day of presentation. \nHe\nhas been referred to sleep medicine in the past out of suspicion\nfor OSA but has not had a formal sleep study or PFTs. Of note,\nthe patient has had similar presentations in the past.\nSpecifically, a hospitalization at ___ ___ for dyspnea. At\nthat time his SpO2 was 89% RA. He had negative trops, negative\nd-dimer, negative infxs workup, neg cardiac w/u.\" \n\nHe states that the dyspnea is acute on chronic, worse with\nexertion where he can only walk ___ feet, moderate to severe,\nnot associated with chest pain, improved with rest. He denies\nany wheezing. He does report orthopnea and states that he \nsleeps\non 4 pillows. He has not had PND. He used to walk his dog using\na wheelchair as his walker, but now he has to sit in the\nwheelchair to walk these distances. \n\nVitals in the ER: 98.8 97 142/78 16 94% 4L NC \n\nThere, the patient received: \n___ 08:15 PO/NG Gabapentin 600 mg ___ \n___ 15:08 PO/NG Gabapentin 600 mg ___ \n___ 15:08 PO/NG MetFORMIN (Glucophage) 1000 mg \n___ 21:05 NEB Ipratropium-Albuterol Neb 1 NEB \n___ 21:32 PO/NG Gabapentin 600 mg ___ \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\nPAST MEDICAL/SURGICAL HISTORY: morbid obesity, T2DM, HTN, HLD,\nCKD3, anemia, neuropathy, venous ulcer, and and venous\ninsufficiency. S/p puncutured lung and other injuries from\nmotorcycle accident ___ years ago\n\n \nSocial History:\n___\nFamily History:\nFather had MI, no known lung disease \n\n \nPhysical Exam:\nEXAM:\nVITALS: (see eFlowsheet)\nGENERAL: Alert and in no apparent distress, malodorous \nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular rate; normal perfusion, no appreciable JVD but\ndifficult to assess with neck habitus \nRESP: Symmetric breathing pattern with no stridor. Breathing is\nnon-labored\nGI: Abdomen soft, non-distended, no hepatosplenomegaly\nappreciated. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, normal muscle bulk and tone \nSKIN: RLE anterior leg ulcer noted and is dressed, edema is\npresent\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, impaired mobility \nPSYCH: normal thought content, logical thought process,\nappropriate affect\n \nPertinent Results:\n___:00AM BLOOD WBC-9.9 RBC-5.64 Hgb-13.2* Hct-45.0 \nMCV-80* MCH-23.4* MCHC-29.3* RDW-18.6* RDWSD-49.1* Plt ___\n___ 01:00AM BLOOD Glucose-129* UreaN-14 Creat-0.9 Na-142 \nK-4.8 Cl-99 HCO3-32 AnGap-11\n___ 03:00PM BLOOD cTropnT-<0.01\n___ 05:24PM BLOOD Type-ART pO2-58* pCO2-65* pH-7.38 \ncalTCO2-40* Base XS-9\n\nCTPA ___. Limited study due to poor penetration and suboptimal bolus\ntiming. Within this limitation, no evidence of pulmonary \nembolism or aortic\nabnormality. \n2. Enlarged main pulmonary artery suggests pulmonary arterial\nhypertension. \n\nTTE: EF 55%, poor windows, limited views, patient refused ECHO \ncontrast\n \nBrief Hospital Course:\nMr. ___ is a ___ male with the past medical history of \nmorbid obesity, T2DM, HTN, HLD, CKD3, anemia, neuropathy, venous \nulcer, and and venous insufficiency who initially presented to \n___ from his PCP for hyperemic respiratory failure \n\n# Hypoxemic respiratory failure\nAcute on Chronic, patient evaluated by pulmonary service who \nsuspects large component of obesity hypoventilation syndrome. \nCTPE (poor quality) did not show PE: unable to get VQ scan due \nto habitus. ECHO was also poor quality due to habitus, reveals \nnormal EF. Pulmonary service also recommended daily lasix to \noptimize right heart function, and inpatient trial of BiPAP. \nWith bipap his ABGs significantly improved and was discharged \nhome with bipap for obesity hypoventilation syndrome. We will \nhave close pulmonology follow up. Also discussed the role for \nweight loss and gave him the number to the weight clinic \nassociated with his PCP.\n\n#DM2 causing CKD and neuropathy - Home medications continued on \ndischarge\n\n#Right leg venous ulcer - cont dressing daily, evaluated by \nwound RN, did not find any evidence of superinfection. Will \nhave ___ for dressing changes\n\n# Depression: Patient without SI/HI, engaged with ease with our \nsocial worker, noted closeness to his dog and finance, attempts \nto expand social connections and desire for volunteer \nopportunities. Dysthymia appears secondary to loss of mobility, \nindependence from his morbid obesity. \n\n# Obesity: PCP can consider referral to outpatient ___ \nclinic, but patient would have to demonstrate significant \nlifestyle changes to be a candidate for bariatric surgery. He \nendorses poor dietary habits\n\n#Obesity - outpatient exercise program \n\n#HTN - losartan\n\n>30 minutes spent on complex discharge \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 1000 mg PO BID \n2. glimepiride 4 mg oral DAILY \n3. Pioglitazone 30 mg PO DAILY \n4. Losartan Potassium 50 mg PO DAILY \n5. Gabapentin 600 mg PO TID \n6. Vitamin D ___ UNIT PO DAILY \n7. Ferrous Sulfate 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line \n\nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*0 \n2. Furosemide 40 mg PO DAILY \nRX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Miconazole Powder 2% 1 Appl TP TID \nRX *miconazole nitrate [Micro-Guard] 2 % apply to groin three \ntimes a day Refills:*0 \n4. Polyethylene Glycol 17 g PO BID \nRX *polyethylene glycol 3350 [Gavilax] 17 gram/dose 1 powder(s) \nby mouth once a day Refills:*0 \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Gabapentin 600 mg PO TID \n7. glimepiride 4 mg oral DAILY \n8. Losartan Potassium 50 mg PO DAILY \n9. MetFORMIN (Glucophage) 1000 mg PO BID \n10. Pioglitazone 30 mg PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Shortness of breath and hypoxia due to obesity \nhypoventilation and presumed pulmonary hypertension\n2. Diabetes Mellitus\n3. Venous stasis ulcer\n4. Tinea corporis\n5. OSA \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital for evaluation of your \nshortness of breath and wheezing. You were evaluated by the \npulmonary team, social worker and wound care nurse. The \npulmonary team recommends that you take lasix 40 mg a day to \nhelp reduce the fluid in your lungs. You were found to have low \noxygen levels likely from the stress on your lungs from extra \nweight. This is called obesity hypoventilation syndrome. For \nthis you were started on continuous oxygen. \n\nYou were also found to have severe sleep apnea. You were started \non bipap. With Bipap you improved. You will have a bipap \ndelivered to your home tonight. It is important you wear this \nevery night. \n\nAs we discussed losing weight is extremely important. This would \nhelp alleviate many of your illnesses including diabetes, sleep \napnea, and your need for oxygen. After discharge please call the \nmedical weight management center at ___. Our nutritionist met with you and as we discussed it is \nimportant to eat ___ calories or less a day. It is also \nimportant to avoid concentrated sweets like soda. It is also \nimportant that you find a therapist to help you with your weight \nloss journey. \n\nIt was a pleasure caring for you, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "E662", "J9601", "Z6844", "L97811", "E872", "I2723", "G4733", "E1122", "E1140", "I129", "N183", "B354", "E785", "D649", "I872", "Z993" ]

[ "E662: Morbid (severe) obesity with alveolar hypoventilation", "J9601: Acute respiratory failure with hypoxia", "Z6844: Body mass index [BMI] 60.0-69.9, adult", "L97811: Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin", "E872: Acidosis", "I2723: Pulmonary hypertension due to lung diseases and hypoxia", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "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)", "B354: Tinea corporis", "E785: Hyperlipidemia, unspecified", "D649: Anemia, unspecified", "I872: Venous insufficiency (chronic) (peripheral)", "Z993: Dependence on wheelchair" ]

[ "J9601", "E872", "G4733", "E1122", "I129", "E785", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest Pain, SOB\n \nMajor Surgical or Invasive Procedure:\nEGD with duodenal stenting ___\n\n \nHistory of Present Illness:\nMr. ___ is an ___ year-old gentleman with hypertension,\nhyperlipidemia, T2DM and recently diagnosed pancreatic ductal\nadenonocarcinoma with biliary/duodenal involvement who presents\nwith nausea, vomiting, chest pain and shortness of breath. \n\nPer ED report he presented to ED complaining of shortness of\nbreath and chest discomfort since the morning of ___ via son as\ninterpreter. He also had intermittent diarrhea and nausea. \n\nED initial vitals were 97.1 106 114/63 18 99% RA\nPrior to transfer vitals were 97.7 103 113/56 16 100% RA \n\nExam in the ED showed : \"Gen: Comfortable, appears chronically\nill but in no acute distress. HEENT: NC/AT. EOMI. Neck: No\nswelling. Cor: RRR. No m/r/g. Pulm: CTAB, Nonlabored\nrespirations. Abd: Soft, NT, ND. Ext: No edema, cyanosis, or\nclubbing. Skin: No rash, skin pale Neuro: AAOx3. Gross \nsensorimotor intact. Psych: Normal mentation. \"\n \nED work-up significant for:\n-CBC: WBC: 5.2. HGB: 8.3*. Plt Count: 206. Neuts%: 90*. \n-Chemistry: Na: 125*. K: 4.0 . Cl: 86*. CO2: 13* . BUN: 21*.\nCreat: 1.0. Ca: 8.0*. Mg: 1.2*. PO4: 3.3. \n-Lactate:4.4-> 1.9\n-Coags: INR: 2.1*. PTT: 31.6. \n-UA: WBC 4, Gluc 300, Ket 40, UA \n-EKG read as \"sinus, ischemia:non-specific\"\n-TnT: 0.02\n-CT Torso: \"1. Small, subsegmental right lower lobe pulmonary\nembolus. No evidence of right heart strain or definite pulmonary\ninfarction. 2. ___ and ground-glass opacities most\nconspicuous at left lung base and lingula, appear similar to ___ and are likely infectious or inflammatory. 3. No\nsignificant interval change in the large hypoenhancing mass\narising from the head of the pancreas. Peripancreatic adenopathy\nis overall minimally increased. The mass invades the second and\nthird portion of the duodenum resulting in upstream obstruction\nwhich appears progressed in comparison to the prior examination.\nThere has been interval CBD stent placement with decompression \nof\nthe intrahepatic biliary tree and expected pneumobilia, however\nthere is extensive soft tissue at the inferior ostium of the\nstent and partial or pending obstruction can't be excluded. The\nmass again obliterates the main portal vein, but the aorta and\nencases the SMA. 4. 8 mm right middle lobe pulmonary nodule,\nunchanged from ___. 5. Multiple bilateral old rib\nfractures are noted.\"\n-CT head: No acute intracranial hemorrhage\n-___: negative\n\nED management significant for:\n-Medications: MgSO4 2g iv, CTX 1g, Levofloxacin 750mg iv,\nenoxaparin 60mg sc x1\n\nPatient had bed assignment 15:56, accepted by HMED. First\ndocumented vital signs at 1823. Patient transferred from HMED to\nthis writer at 20:00, signout out as stable.\n\nWhen asked about his symptoms patient reports having had an\nepisode of nausea, diarrhea and malaise on ___ that\nsubsided. On the morning of ___ he woke up with nausea, chest\npain and shortness of breath. He tried to eat but could not as \nhe\nvomited. He also reports having 2 episodes of loose stool. He\nfelt unwell and had prominent malaise and was brought in to ED \nby\nson. Here he continues to feel unwell, no longer has shortness \nof\nbreath or chest discomfort. He feels much better than in the\nmorning. \n\nPatient denies fevers/chills, night sweats, headache, vision\nchanges, dizziness/lightheadedness, weakness/numbnesss, cough,\nhemoptysis, chest pain, abdominal pain, nausea/vomiting,\ndiarrhea, hematemesis, hematochezia/melena, dysuria, hematuria,\nand new rashes. \n\nREVIEW OF SYSTEMS: A complete 10-point review of systems was\nperformed and was negative unless otherwise noted in the HPI. \n \nPast Medical History:\n1. Cardiac Risk Factors \n-Hypertension\n-Hyperlipidemia \n-DM2\n\n2. Cardiac History \n-None \n\n3. Other PMH\n-Stage III/IV pancreatic adenocarcinoma \n-Pituitary macroadenoma complicated by ___\n \nSocial History:\n___\nFamily History:\nNo known family history of malignancy. His mother lived to ___ \nyears. His father died at a young age of unknown causes. He \nhad 4 brothers and 3 sisters most of whom lived to their ___. \nHe has 2 sons without health concerns. \n \nPhysical Exam:\nADMISSION PHYSICAL\n=================\nVS: T:97.9, BP: 109/58, HR: 97, RR: 17, O2: 100% RA \nGENERAL: Chronically ill appearing, NAD \nHEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM \nNECK: Supple. No appreciable JVD. \nCARDIAC: RRR, +S1/2, no murmurs, rubs, gallops \nLUNGS: CTAB \nABDOMEN: Soft, NTND, +BS \nEXTREMITIES: Warm, 1+ symmetric pitting edema upto knees \nSKIN: no rashes \nPULSES: symmetric distal pulses\n\nDISCHARGE PHYSICAL\n=================\nVS: ___ 0511 Temp: 97.8 PO BP: 90/54 R Lying HR: 114 RR: 16 \n\nGENERAL: Chronically ill appearing, cachectic, NAD\nHEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM\nNECK: Supple. No appreciable JVD \nCARDIAC: sinus tachycardia, +S1/2, no murmurs, rubs, gallops \nLUNGS: CTAB \nABDOMEN: Distended. Epigastric TTP throughout. No rebound or\nguarding\nEXTREMITIES: Warm, 1+ symmetric pitting edema upto knees \nSKIN: no rashes \nPULSES: symmetric distal pulses \n\n \nPertinent Results:\nADMISSION LABS\n=============\n___ 05:25AM BLOOD WBC-5.2 RBC-3.26* Hgb-8.3* Hct-25.3* \nMCV-78* MCH-25.5* MCHC-32.8 RDW-15.3 RDWSD-42.7 Plt ___\n___ 05:25AM BLOOD Neuts-90* Bands-3 Lymphs-7* Monos-0 Eos-0 \nBaso-0 ___ Myelos-0 AbsNeut-4.84 AbsLymp-0.36* \nAbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*\n___ 05:25AM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-1+* \nMacrocy-NORMAL Microcy-3+* Polychr-NORMAL Burr-1+*\n___ 05:25AM BLOOD ___ PTT-31.6 ___\n___ 05:25AM BLOOD Glucose-297* UreaN-21* Creat-1.0 Na-125* \nK-4.0 Cl-86* HCO3-13* AnGap-26*\n___ 05:25AM BLOOD CK(CPK)-58\n___ 05:25AM BLOOD CK-MB-5\n___ 05:25AM BLOOD cTropnT-0.02*\n___ 09:56PM BLOOD CK-MB-40* MB Indx-13.6* cTropnT-1.37*\n___ 05:25AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.2*\n___ 05:31AM BLOOD Lactate-4.4* Na-122* K-3.8\n___ 08:09AM URINE Color-Yellow Appear-Clear Sp ___\n___ 08:09AM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-300* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 08:09AM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE \nEpi-<1\n___ 08:09AM URINE CastHy-35*\n___ 08:09AM URINE Mucous-RARE*\n___ 08:09AM URINE Hours-RANDOM Na-80\n___ 08:09AM URINE Osmolal-405\n\nPERTINENT RESULTS\n================\n___ 05:28AM BLOOD ___\n___ 04:46AM BLOOD ___ 05:28AM BLOOD Ret Aut-0.4 Abs Ret-0.01*\n___ 03:56AM BLOOD CK-MB-24* MB Indx-11.8* cTropnT-1.92*\n___ 05:28AM BLOOD calTIBC-101* VitB12-324 Hapto-347* \nFerritn-695* TRF-78*\n___ 11:30AM BLOOD ___ pO2-165* pCO2-20* pH-7.34* \ncalTCO2-11* Base XS--12 Comment-GREEN TOP \n___ 08:52AM BLOOD Lactate-1.9\n___ 11:30AM BLOOD Lactate-7.6*\n___ 07:30PM BLOOD Lactate-1.8\n___ 12:18PM BLOOD Lactate-2.3*\n___ 09:12PM BLOOD Lactate-1.4\n___ 12:04PM BLOOD Lactate-2.2*\n\nMICRO\n=====\n___ 11:18 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 11:13 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 8:45 am BLOOD CULTURE #2. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. \n Isolated from only one set in the previous five days. \n SENSITIVITIES PERFORMED ON REQUEST.. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN CLUSTERS. \n Reported to and read back by ___ (___) @12:26 \n(___). \n__________________________________________________________\n___ 5:25 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\nSTUDIES\n=======\nCXR PA and LAT ___\nAn infrahilar opacity best seen on lateral view is unchanged \nfrom ___. In the appropriate clinical setting this may \nrepresent pneumonia, although this could represent atelectasis \ngiven low volumes.\n\nCTA Chest, CT Abdomen ___. Small, subsegmental right lower lobe pulmonary embolus. No \nevidence of right heart strain or definite pulmonary infarction.\n2. ___ and ground-glass opacities most conspicuous at \nleft lung base and lingula, appear similar to ___ and are \nlikely infectious or inflammatory.\n3. No significant interval change in the large hypoenhancing \nmass arising from the head of the pancreas. Peripancreatic \nadenopathy is overall minimally increased. The mass invades the \nsecond and third portion of the duodenum resulting in upstream \nobstruction which appears progressed in comparison to the prior \nexamination. There has been interval CBD stent placement with \ndecompression of the intrahepatic biliary tree and expected \npneumobilia, however there is extensive soft tissue at the \ninferior ostium of the stent and partial or impending \nobstruction can't be excluded. The mass again obliterates the \nmain portal vein, abuts the aorta and encases the SMA.\n4. 8 mm right middle lobe pulmonary nodule, unchanged from ___.\n5. Multiple bilateral old rib fractures are noted.\n\nCT Head w/o Contrast ___. No acute intracranial process.\n2. Paranasal sinus retention cysts, similar to previous study.\n\n___ ___\nNo evidence of deep venous thrombosis in the lower extremities.\n\nTTE ___\nThe left atrial volume index is normal. There is normal left \nventricular wall thickness with a normal cavity size. There is \nmild regional left ventricular systolic dysfunction with \nnear-akinesis of the distal ___ of the left ventricle (distal \nLAD territory; see schematic) and preserved/normal contractility \nof the remaining segments. The visually estimated left \nventricular ejection fraction is 40%. No thrombus or mass is \nseen in the left ventricle. Normal right ventricular cavity size \nwith normal free wall motion. The aortic sinus diameter is \nnormal for gender with normal ascending aorta diameter for \ngender. The aortic arch diameter is normal. There is no evidence \nfor an aortic arch coarctation. The aortic valve leaflets (3) \nare mildly thickened. There is no aortic valve stenosis. There \nis no aortic regurgitation. The mitral leaflets are mildly \nthickened with no mitral valve prolapse. There is mild [1+] \nmitral regurgitation. The tricuspid valve leaflets appear \nstructurally normal. There is trivial tricuspid regurgitation. \nThe estimated pulmonary artery systolic pressure is normal. \nThere is no pericardial effusion.\n\nIMPRESSION: Adequate image quality. Mild regional left \nventricular systolic dysfunction most consistent with coronary \nartery disease (LAD distribution). Mild mitral regurgitation.\n\nCXR ___\nPatchy retrocardiac opacity, potentially atelectasis with \ninfection or aspiration not excluded in the correct clinical \nsetting. Marked distension of the stomach.\n\nAbdomen Xray ___\nMassive distention of the stomach for which nasogastric tube \ndecompression is recommended. No evidence for small or large \nbowel obstruction.\n\nAbdomen Xray ___\nNG tube in the stomach loops back into the still esophagus. \nImprovement of the gastric distension.\n\nAbdomen Xray ___\nMassive distention of the stomach similar in appearance to study \nof ___ with duodenal air-fluid levels compatible with \ngastric outlet obstruction.\n\nCXR ___\nExtensive dilatation of the stomach is re-demonstrated with the \nstomach bubble approaching 27 x 19 cm. NG tube tip is \nprojecting over the stomach bubble left basal consolidation is \nmost likely representing atelectasis. Right PICC line tip is at \nthe cavoatrial junction no appreciable pleural effusion\ndemonstrated.\n\nCXR ___ (NG Placement)\nExtensive dilatation of the stomach is re-demonstrated with the \nstomach bubble approaching 27 x 19 cm. NG tube tip is \nprojecting over the stomach bubble left basal consolidation is \nmost likely representing atelectasis. Right PICC line tip is at \nthe cavoatrial junction no appreciable pleural effusion\ndemonstrated.\n\nEGD ___\nLarge gastric ulcer. Malignant duodenal sweep ulcer. Duodenal \nstricture s/p placement of uncovered duodenal stent.\n\nDISCHARGE LABS\n=============\n___ 06:26AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.7* Hct-32.5* \nMCV-89 MCH-29.2 MCHC-32.9 RDW-21.2* RDWSD-59.5* Plt ___\n___ 06:26AM BLOOD Glucose-186* UreaN-32* Creat-1.6* Na-137 \nK-5.1 Cl-107 HCO3-17* AnGap-13\n___ 06:26AM BLOOD Calcium-7.8* Phos-4.4 Mg-2.0\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with PMHx of stage III/IV \npancreatic adenocarcinoma, DM2, Hyponatremia, SIADH who \npresented with a 1-day history of chest pain and shortness of \nbreath found to have anterior missed STEMI s/p medical \nmanagement (high risk for PCI, missed window, no symptoms), \nhospital course complicated by GI bleed in the setting of \nanticoagulation with heparin and known active malignancy with \ngastric and duodenal ulcerations, now s/p 5U PRBC with improved \nhemodynamics, evidence of gastric obstruction likely ___ \nmalignancy s/p palliative duodenal stent discharged to hospice \ncare. \n\nACUTE ISSUES: \n============ \n#GOC \nMr. ___ presented with known advanced pancreatic cancer on \npalliative chemotherapy, complicated by symptomatic gastric \noutlet obstruction. Patient was also noted to have a GI bleed in \nthe setting of anticoagulation for STEMI and small subsegmental \nPE. Several goals of care discussions were held with the \npatient's son and the patient was made DNR/DNI based on these \nconversations. Goals of care discussions included patient's \nprimary oncologist as well as the inpatient palliative care \nteam. He was screened for hospice eligibility and is now being \ndischarged to hospice care.\n\n#Melena\n#Acute Blood Loss Anemia \nHospital course complicated by GI bleed requiring 5U PRBC total. \nThe patient had a GI bleed was secondary to known necrotic \ngastric and duodenal malignant ulcerations. Patient's \nanticoagulation as well as antiplatelet therapy (started for \nmedical management of STEMI) were held in the setting of an \nactive GI bleed. Gastroenterology was consulted and placed a \npalliative uncovered duodenal stent via EGD for symptomatic \nrelief of gastric outlet obstruction.\n\n#Bilious emesis\n#Gastric outlet obstruction \nThe ___ hospital course was complicated by gastric \nobstruction in setting of known pancreatic malignancy invading \nduodenum and KUB revealed severely distended stomach without \nevidence of small or large bowel obstruction. Patient underwent \nEGD with palliative duodenal stenting with marked improvement in \nsymptoms. An NG tube was also placed prior to stenting and was \nremoved once stent was placed.\n\n___ \nPatient was noted to have ___ on presentation. This was \nthought to be likely in the setting of hypotension and decreased \nPO intake secondary to gastric obstruction. He was managed \nsupportively. His creatinine initially improved with fluids \nhowever had a repeat ___ likely in the setting of hypotension \nwith Cr 1.6 at discharge. \n\n#STEMI \nThe patient presented with 1 day history of chest pain and was \ninitially admitted to oncology service but was transferred to \nCCU after EKG showing STE in V2-V3 and troponin elevation at \n1.02. Onset of symptoms occurred ___ hours prior to \npresentation and given complex comorbidities and complete \nresolution of symptoms, cardiac cath was deferred and medical \nmanagement was pursued. A TTE showing mild regional LV systolic \ndysfunction in LAD distribution with EF 40%. The patient was \ninitially started on heparin drip and on dual anti platelet \ntherapy but these were deferred in the setting of GI bleed. \nMetoprolol and lisinopril were not started due to hypotension \nand significant GI bleed per above.\n\n# Small Subsegmental Pulmonary Embolus \nOn admission, there was evidence of small sub-subsegmental PE on \nCTA chest. He was started on anticoagulation for STEMI that \nwould also cover small segmental PE, however given active GI \nbleed, continuation of anticoagulation was deferred.\n\n# Hyponatremia\n# ___ \nPatient presented with known history of hyponatremia thought to \nbe SIADH in the setting of a macroadenoma in the pituitary. \nSodium was trended daily and improved with IVF and PO intake\n\n# Possible LLL Pneumonia, CAP \nPatient was initially started on a 5 day course of ceftriaxone \nand briefly broadened to vancomycin and cefepime. However given \nlack of fevers, leukocytosis, clinical signs of pneumonia, the \npatient's antibiotics were stopped and he was closely monitored.\n\n# H. pylori Infection\nThe patient was continued on metronidazole QID, tetracycline \nQID, omeprazole,\nbismuth x 2 weeks (___)\n\n# Pancreatic Adenocarcinoma, Stage III-IV\n# Functional Gastric Outlet Obstruction\nRecently diagnosed with stage III-IV pancreatic adenocarcinoma \n(7.5cm) obliterating SMV and encasing SMA on cycle 1 of \npalliative gemcitabine (first/last dose ___. CT torso ___ \nagain with large hypodense mass in pancreatic head invading \nsecond and third portions of the duodenum. Possible or impending \nobstruction of CBD stent also noted. Patient underwent \npalliative duodenal stenting.\n\nCHRONIC ISSUES: \n=============== \n# Type 2 Diabetes Mellitus\nPatient had known history of type 2 diabetes. He was on a \nregimen of metformin and glimepiride at home. These oral \nhypoglycemics were held in the inpatient setting and the patient \nwas started on insulin sliding scale.\n\n# Pituitary Macroadenoma\n14mm non-enhancing lesion in anterior right pituitary noted on\nMRI ___. Thought to possibly be cystic. Further management \nnot within goals of care. \n\nTRANSITIONAL ISSUES \n=================== \n[]Pain control: Recommend titration of pain control to make \npatient comfortable\n[]Nausea/Vomiting: Recommend use of anti-emetics/benzodiazepines \nto aggressively control symptoms\n\n# CODE: DNR/DNI, MOLST in chart\n# CONTACT/HCP: ___ (son, lives with him) ___ ___ \n(son) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 4 mg PO Q8H:PRN nausea \n2. Bismuth Subsalicylate 15 mL PO QID \n3. Simethicone 120 mg PO QID:PRN gas \n4. MetroNIDAZOLE 250 mg PO QID \n5. Omeprazole 20 mg PO DAILY \n6. glimepiride 4 mg oral DAILY \n7. Tetracycline 500 mg PO QID \n8. Nephrocaps 1 CAP PO DAILY \n\n \nDischarge Medications:\n1. GlipiZIDE XL 2.5 mg PO DAILY \n2. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN Pain - Moderate \n \n3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild \n4. Sucralfate 1 gm PO QID \n5. Bismuth Subsalicylate 15 mL PO QID \n6. Ondansetron 4 mg PO Q8H:PRN nausea \n7. Simethicone 120 mg PO QID:PRN gas \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses\n=================\nAcute blood loss anemia\nUpper GI bleed\nGastric outlet obstruction\nThrombocytopenia\nLeukocytosis\nAcute Kidney Injury\nSTEMI\nPulmonary embolus, small sub-submental\nHyponatremia\nSIADH\nLeft lower lobe pneumonia, community-acquired\n\nSecondary Diagnoses\n===================\nPancreatic adenocarcinoma, stage III–IV\nH pylori infection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you in the hospital!\n\nWhy was I admitted?\nYou were admitted to the hospital because had a heart attack\n\nWhat happened while I was admitted?\n-You had a heart attack and were given blood thinning \nmedications\n-You had a stent placed in your stomach to help with nausea and \nvomiting\n-You were given blood back because you were bleeding\n\nWhat should I do after I leave the hospital?\n-Spend time with your family and loved ones\n\nWe wish you the very best!\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I2109", "J189", "E43", "K254", "K264", "I2699", "E222", "N179", "K311", "E872", "K56609", "C170", "C259", "I2510", "E785", "I10", "E861", "I959", "Z66", "D696", "D649", "Z7401", "E8809", "B9681" ]

[ "I2109: ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall", "J189: Pneumonia, unspecified organism", "E43: Unspecified severe protein-calorie malnutrition", "K254: Chronic or unspecified gastric ulcer with hemorrhage", "K264: Chronic or unspecified duodenal ulcer with hemorrhage", "I2699: Other pulmonary embolism without acute cor pulmonale", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "N179: Acute kidney failure, unspecified", "K311: Adult hypertrophic pyloric stenosis", "E872: Acidosis", "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "C170: Malignant neoplasm of duodenum", "C259: Malignant neoplasm of pancreas, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "E861: Hypovolemia", "I959: Hypotension, unspecified", "Z66: Do not resuscitate", "D696: Thrombocytopenia, unspecified", "D649: Anemia, unspecified", "Z7401: Bed confinement status", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere" ]

[ "N179", "E872", "I2510", "E785", "I10", "Z66", "D696", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nnausea, abdominal discomfort\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ y/o M with PMhx of HTN, NIDDM, pituitary macroadenoma and\nrecently diagnosed pancreatic mass causing biliary obstruction\ns/p recent ERCP with stent who returns after discharge with\nnausea, abd discomfort and inability to tolerate much po. Pt\nreports feeling much better after ERCP with stent and felt \nreturn\nof appetite. He went home and ate well initially. However, he\nsoon developed abd discomfort and intractable nausea. He tried\nsimethicone without any relief and was unable to sleep because \nof\nsymptoms. He returned to the ED and was found to have mild\ndehydration, acute on chronic hyponatremia and persistent LFT\nabnormalities. He was able to have a BM in the ED which\nprovided some relief. He has not eaten much all day and feels\nsome improvement in symptoms. Denies any nausea currently and\nabd discomfort has improved. He is concerned about how to\nmanage symptoms at home and feels his stomach may be blocked up. \n\nDenies any CP, SOB, cough, LH, HA, congestion, dysuria,\nhematuria, rash or abd pain currently. He has not noticed and\nworsening in ___ edema and is wearing TEDs currently. \n\n \nPast Medical History:\nNIDDM\nHTN\nRecently Dx with large pancreatic mass causing biliary\nobstruction now s/p ERCP with stent, final path pending though\nprelim + adenocarcinoma\n \nSocial History:\n___\nFamily History:\nnone relevant to current presentation \n \nPhysical Exam:\nPE: ___ Temp: 98.3 PO BP: 133/75 L Lying HR: 91 RR: 18\nO2 sat: 100% O2 delivery: Ra \nGEN: pleasant elderly Asian male in NAD\nHEENT: MMM\nCV: RRR \nRESP: CTAB no w/r\nABD: distended, mild TTP over RUQ but no rebound, BS present\nGU: no foley \nEXTR: thin, trace ankle edema bilaterally, TEDS in place\nNEURO: alert, appropriate, oriented x 3\n\n \nPertinent Results:\n___ 07:20AM BLOOD WBC-9.1 RBC-3.19* Hgb-8.3* Hct-26.0* \nMCV-82 MCH-26.0 MCHC-31.9* RDW-16.1* RDWSD-47.8* Plt ___\n___ 07:15AM BLOOD WBC-9.6 RBC-3.04* Hgb-8.0* Hct-23.8* \nMCV-78* MCH-26.3 MCHC-33.6 RDW-15.7* RDWSD-43.9 Plt ___\n___ 08:55AM BLOOD WBC-9.6 RBC-3.59* Hgb-9.5* Hct-28.0* \nMCV-78* MCH-26.5 MCHC-33.9 RDW-15.7* RDWSD-43.5 Plt ___\n___ 06:47AM BLOOD WBC-9.8 RBC-3.13* Hgb-8.2* Hct-24.5* \nMCV-78* MCH-26.2 MCHC-33.5 RDW-15.5 RDWSD-42.9 Plt ___\n___ 08:55AM BLOOD Neuts-84.4* Lymphs-7.4* Monos-6.4 \nEos-0.8* Baso-0.2 Im ___ AbsNeut-8.11* AbsLymp-0.71* \nAbsMono-0.62 AbsEos-0.08 AbsBaso-0.02\n___ 07:20AM BLOOD Glucose-129* UreaN-13 Creat-0.7 Na-130* \nK-3.8 Cl-91* HCO3-24 AnGap-15\n___ 07:15AM BLOOD Glucose-158* UreaN-13 Creat-0.6 Na-131* \nK-3.7 Cl-95* HCO3-24 AnGap-12\n___ 10:25PM BLOOD Glucose-260* UreaN-15 Creat-0.8 Na-129* \nK-3.8 Cl-92* HCO3-24 AnGap-13\n___ 10:20AM BLOOD Glucose-208* UreaN-17 Creat-0.9 Na-126* \nK-5.0 Cl-92* HCO3-20* AnGap-14\n___ 06:47AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-131* \nK-3.9 Cl-93* HCO3-21* AnGap-17\n___ 07:20AM BLOOD ALT-43* AST-29 AlkPhos-217* TotBili-2.0*\n___ 07:15AM BLOOD ALT-47* AST-31 AlkPhos-235* TotBili-2.1*\n___ 10:20AM BLOOD ALT-59* AST-57* AlkPhos-286* TotBili-2.5*\n___ 06:47AM BLOOD ALT-59* AST-44* LD(LDH)-218 AlkPhos-291* \nTotBili-3.0*\n___ 10:20AM BLOOD Lipase-61*\n\nKUB:\nIMPRESSION: \nNonspecific bowel gas pattern. Stomach is mildly dilated. No \nevidence of \nsmall-bowel obstruction. Gas and stool filling the large bowel \nloops \n\n \nBrief Hospital Course:\n___ y/o M with NIDDM, HTN and recently diagnosed pancreatic \ncancer\ncausing biliary obstruction s/p ERCP with stent who returns with\nnausea and decreased ability to tolerate po.\n\n#possible functional duodenal/gastric outlet obstruction\n#Pancreatic adenocarcinoma\n#Nausea/abd discomfort: mass invasion of duodenum may be\ncausing functional gastric outlet obstruction. Pt's symptoms\nimproved with decreased PO intake, after ERCP, and after BM, gas\nmay be contributing. Pt tolerated better PO during admission. \nD/w Pt importance of\nnutrition and taking what he is able to tolerate and to\nsupplement with ensure or boost if needed. Nutrition consulted. \nDiscussed attempting a liquid diet if he is unable to tolerate \nsolid food. Discussed symptom control with ___, simethicone, \nbowel regimen. Discussed case with oncology and ERCP teams. Plan \nfor outpt onc f/u (as already arranged ___ and per ERCP team, \nno significant intestinal stricture noted on ERCP to intervene \nupon at this time.\n\n#Hyponatremia/SIADH: clinically euvolemic now and Na improved on\nrepeat labs likely because pt was taking decreased PO. Na stable \nduring admission without IVF or fluid restriction.\n\n#anemia-no clear evidence of bleeding. Trend/monitor. Outpt f/u. \n\n\n#NIDDM: Restarted home oral agents on DC. If PO intake over the \nlong run becomes an issue, he may need to DC some of these \nagents. \n\n#Pituitary Macroadenoma: outpt f/u\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line \n2. Polyethylene Glycol 17 g PO BID \n3. Senna 17.2 mg PO BID \n4. Simethicone 40-80 mg PO QID:PRN stomach upset \n5. Simvastatin 10 mg PO QPM \n6. glimepiride 4 mg oral DAILY \n7. MetFORMIN (Glucophage) 1000 mg PO BID \n8. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 \ngram-1.8 kcal/mL oral TID W/MEALS \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nyou may purchase over the counter \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n2. Ondansetron 4 mg PO Q8H:PRN nausea \nRX *ondansetron HCl 4 mg 1 tablet(s) by mouth daily Disp #*20 \nTablet Refills:*0 \n3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line \nRX *bisacodyl [Dulcolax (bisacodyl)] 5 mg ___ tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n4. glimepiride 4 mg oral DAILY \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 \ngram-1.8 kcal/mL oral TID W/MEALS \n7. Polyethylene Glycol 17 g PO BID \nRX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17gm \npowder(s) by mouth daily Refills:*0 \n8. Senna 17.2 mg PO BID \nRX *sennosides [Senna-Gen] 8.6 mg 1 tab by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n9. Simethicone 40-80 mg PO QID:PRN stomach upset \n10. Simvastatin 10 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\npancreatic cancer\nnausea\nconstipation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nYou were admitted for evaluation and treatment of abdominal \npain/bloating and nausea and decreased ability to eat and drink \nlikely secondary to your pancreatic cancer and also some \nconstipation. For this, you were evaluated by the nutritionist \nand we discussed using supplements such as boost or ensure if \nyou are unable to eat and drink well. Please try to eat and \ndrink as you are able. You may need to have a liquid or a softer \ndiet if you feel unable to eat and drink well. You will meet \nwith the cancer doctors this week to discuss the next steps in \nyour treatment. \n \nFollowup Instructions:\n___\n" ]

[ "C259", "E222", "K315", "K311", "R110", "K5900", "E119", "I10", "D649", "E860" ]

[ "C259: Malignant neoplasm of pancreas, unspecified", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "K315: Obstruction of duodenum", "K311: Adult hypertrophic pyloric stenosis", "R110: Nausea", "K5900: Constipation, unspecified", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "D649: Anemia, unspecified", "E860: Dehydration" ]

[ "K5900", "E119", "I10", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nlower extremity weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is an ___ year old ___ and ___ speaking man \nwith PMH of HTN, non-insulin dependent DM2, HLD, referred by his \nPCP at ___ (Dr. ___, who presented to the ED \nwith BLE weakness of 2 weeks' duration. He also had a fall on \n___. He is a very good historian. Patient reports he was \nusing a walker, felt weak, and fell to the floor gently on his \nknees (able to support himself on walker). No LOC, no head \nstrike, no presyncopal symptoms, no dizziness, lightheadedness, \nor palpitations. He did not have the strength to get back up \nafter he fell, so he was on the floor for 2 hours until his son \ncame and helped him. \n\nPatient states he also has increasing difficulty with urinary \nretention and incontinence. Denies change in urinary frequency. \nAlso reports constipation and increased urgency but no diarrhea \nor uncontrolled bowel movements. \n\nHe checks his blood glucose daily in the morning. They are \nnormally high 100's-200. \n\nNo recent fever, chills, sweats, headache, problems with \nspeaking, gait problems, chest pain, cough, shortness of breath, \nabdominal pain, trauma to back. No ___ services. Usually just \ncared for by family.\n\nIn the ED, initial VS were 97.6, HR 100, BP 146/64, RR 16, 100% \nRA.\n\nLabs showed Na 110, K 5.6, glucose 223, WBC 10.5, Hgb 10.6, \nlactate 1.4, VBG 7.35/33. UA showed SGr 1.012, 14 RBCs, few \nbacteria, 400 glucose, 10 ketones. Urine Na 67, osm 460.\n\nHe has no recent labs prior to presentation, per ED report. \n\nHe was given 1L NS, and another L was running prior to transfer \nto MICU. UOP>50cc/h, increased with fluids. \n\nGuaiac negative. He had normal rectal tone, no saddle \nanesthesia. EKG showed sinus tachycardia. CXR showed bibasilar \npatchy opacities, may reflect atelectasis with pneumonia or \naspiration not excluded. \n\nVitals on transfer 98.1, HR 101, BP 147/60; RR 18, 100% RA. \n\nOn arrival to the MICU, patient reports history as above. Since \nthe ___ year 2 weeks ago, has had worsening ___ weakness, \nnow requiring a walker to walk. Onlychange at that time was that \nhe may have eaten more sugar than normal. Reports low appetite \nover this time as well, eating only oatmeal and rice. He usually \nhas low sodium diet, now just eating less of it. Denies \nincreased thirst/excessive water intake. Currently has some \nabdominal discomfort but no pain, nausuea, vomiting. Urinating \nok today, but as above has been having incontinence/retention \nissue. Constipated over last few days, passing flatus. No chest \npain, SOB, cough, dizziness. \n\n \nPast Medical History:\nType II Diabetes\nHTN\nHLD\n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: Reviewed in metavision\nHEENT: PERRL, EOMI. NC/AT. \nOropharynx: moist mucous membranes\nCV: Regular rate and rhythm, normal S1/S2\nResp: Normal work of breathing, bibasilar crackles. Chest with \nsome discomfort on deep palpation diffusely\nAbd: Soft, nontender, distended at baseline. Tympanic.\nRectal: good tone, hemoccult negative\nMSK: Able to move all extremities, no saddle anesthesia\nExtremities: Intact to sensation bilaterally in upper and lower \nextremities, ___ strength in upper and lower extremities \nproximally and distally. No lower extremity edema.\nNeuro: Alert, oriented, normal speech, able to respond to \ncommands and follow directions. ___ strength diffusely, CN \nII-XII intact.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nOropharynx: moist mucous membranes\nCV: Regular rate and rhythm, normal S1/S2\nResp: Normal work of breathing, clear bilaterally. \nAbd: Soft, nontender, distended at baseline. \nMSK: Able to move all extremities\nExtremities: Intact to sensation bilaterally in upper and lower\nextremities, ___ strength in upper and lower extremities\nproximally and distally. No lower extremity edema.\nNeuro: Alert, oriented, normal speech, able to respond to\ncommands and follow directions. ___ strength diffusely, CN \nII-XII\nintact.\n\n \nPertinent Results:\n===============\nADMISSION LABS \n===============\n___ 05:04PM BLOOD WBC-10.5* RBC-3.97* Hgb-10.6* Hct-30.7* \nMCV-77* MCH-26.7 MCHC-34.5 RDW-11.8 RDWSD-32.8* Plt ___\n___ 05:04PM BLOOD Neuts-82.1* Lymphs-9.2* Monos-7.0 \nEos-0.7* Baso-0.4 Im ___ AbsNeut-8.62* AbsLymp-0.97* \nAbsMono-0.73 AbsEos-0.07 AbsBaso-0.04\n___ 05:04PM BLOOD Glucose-223* UreaN-23* Creat-0.9 Na-110* \nK-5.6* Cl-78* HCO3-16* AnGap-16\n___ 06:08PM BLOOD ALT-10 AST-17 LD(LDH)-200 AlkPhos-68 \nTotBili-0.4\n___ 05:04PM BLOOD Calcium-8.7 Phos-3.1 Mg-1.5*\n___ 10:00PM BLOOD calTIBC-218* Ferritn-288 TRF-168*\n___ 06:08PM BLOOD TSH-1.4\n___ 06:19PM BLOOD pO2-38* pCO2-32* pH-7.34* calTCO2-18* \nBase XS--7\n\n===============\nDISCHARGE LABS\n===============\n___ 05:06AM BLOOD WBC-7.9 RBC-2.85* Hgb-7.7* Hct-23.1* \nMCV-81* MCH-27.0 MCHC-33.3 RDW-12.6 RDWSD-36.6 Plt ___\n___ 05:04PM BLOOD Neuts-82.1* Lymphs-9.2* Monos-7.0 \nEos-0.7* Baso-0.4 Im ___ AbsNeut-8.62* AbsLymp-0.97* \nAbsMono-0.73 AbsEos-0.07 AbsBaso-0.04\n___ 05:06AM BLOOD Plt ___\n___ 05:06AM BLOOD Glucose-200* UreaN-17 Creat-0.9 Na-133* \nK-4.5 Cl-97 HCO3-22 AnGap-14\n___ 05:06AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.8\n___ 05:17AM BLOOD calTIBC-215* Ferritn-289 TRF-165*\n\n==================\nSTUDIES/PATHOLOGY\n==================\nMRI pituitary (___): FINDINGS:  \n1\n4\n \nx\n \n1\n0\n \nx\n \n9\n \nm\nm\n \n(\nA\nP\n \nb\ny\n \nT\nV\n \nb\ny\n \nS\nI\n)\n \nn\no\nn\ne\nn\nh\na\nn\nc\ni\nn\ng\n \ns\nl\ni\ng\nh\nt\nl\ny\n \nT\n1\n \nh\ny\np\ne\nr\ni\nn\nt\ne\nn\ns\ne\n \nl\ne\ns\ni\nn\ni\ns\n \ni\nd\ne\nn\nt\ni\nf\ni\ne\nd\n \ni\nn\n \nt\nh\ne\n \nr\ni\ng\nh\nt\n \np\ni\nt\nu\ni\nt\na\nr\ny\n.\n \n \nI\nn\nf\nu\nn\nd\ni\nb\nu\nl\nu\nm\n \ni\ns\n \nm\ni\nl\nd\nl\ny\n \nd\ne\nv\ni\na\nt\ne\nd\n \nt\no\n \nt\nh\ne\nl\ne\nf\nt\n.\n \nT\nh\ne\n \ns\nu\np\nr\na\ns\ne\nl\nl\na\nr\n \nc\ni\ns\nt\ne\nr\nn\n \na\nn\nd\n \nc\na\nv\ne\nr\nn\no\nu\ns\n \ns\ni\nn\nu\ns\ne\ns\na\np\np\ne\na\nr\n \nu\nn\nr\ne\nm\na\nr\nk\na\nb\nl\ne\n.\n \n \nT\nh\ne\nl\ni\nm\ni\nt\ne\nd\n \np\no\nr\nt\ni\no\nn\n \no\nf\n \nt\nh\ne\n \nb\nr\na\ni\nn\n \ni\nn\nc\nl\nu\nd\ne\nd\n \no\nn\n \ni\ns\n \nn\no\nt\na\nb\nl\ne\n \nf\no\nr\n \np\ne\nr\ni\nv\ne\nn\nt\nr\ni\nc\nu\nl\na\nr\n \na\nn\nd\ns\nu\nb\nc\no\nr\nt\ni\nc\na\nl\n \nw\nh\ni\nt\ne\n \nm\na\nt\nt\ne\nr\n \nT\n2\n \nh\ny\np\ne\nr\ni\nn\nt\ne\nn\ns\ni\nt\ni\ne\ns\n \nc\no\nn\ns\ni\ns\nt\ne\nn\nt\n \nw\ni\nt\nh\n \nc\nh\nr\no\nn\ni\nc\n \ns\nm\na\nl\nl\nv\ne\ns\ns\ne\nl\n \nd\ni\ns\ne\na\ns\ne\n.\n \n \nSmall mucous retention cyst is noted in the right sphenoidsinus.\n\nCT head w/o contrast (___):  \nIMPRESSION:\n1\n.\n \nN\no intracranial hemorrhage.  No acute intracranial abnormality on\nnoncontrast head CT.\n2. Probable sequelae of chronic small vessel ischemic disease.\n3. Cortical atrophy.\n4. Paranasal sinus disease.\n\nCXR (___): IMPRESSION: \nCompared to chest radiographs ___.\nU\np\np\ne\nr\n \nl\no\nb\ne\ns are clear and pulmonary vasculature is not engorged.  Previous\nv\no\nl\nume loss in the left lower lobe has improved, but there is still\ns\nu\nb\ns\nt\na\nn\nt\ni\na\nl peribronchial opacification.  This could be atelectasis due to\nr\ne\nt\na\ni\nn\ned secretions.  Pleural effusion is small on the right, if any. \nModerate cardiomegaly stable.\n\nCXR (___): IMPRESSION: \nB\ni\nb\na\nsilar patchy opacities may reflect atelectasis with pneumonia or\naspiration not excluded in the correct clinical setting.\n\n============\nMICROBIOLOGY\n============\nUrine culture (___): negative\n \nBrief Hospital Course:\n====================\nPATIENT SUMMARY:\n====================\nMr. ___ is an ___ year old ___ speaking man with PMH of \nHTN, non-insulin dependent DM2, HLD, referred by his PCP at \n___ (Dr. ___, who presented to the ED with \nBLE weakness of 2 weeks' duration, found to be profoundly \nhyponatremic to 110, likely secondary to hypovolemia and SIADH \nperhaps due to an underlying pituitary mass.\n\n====================\nACUTE ISSUES:\n====================\n#Hyponatremia: The patient was profoundly hyponatremic on \nadmission with Na of 110. There was almost certainly some \ncomponent of hypovolemic hyponatremia initially given the robust \ninitial response to IVF. However, given sustained elevated urine \nOsms and lack of continued response to volume resuscitation \nalone, the continued hyponatremia was likely driven by SIADH. \nThe etiology for SIADH is also unclear, though possibly related \nto pituitary mass (discussed below). There was also likely some \ncomponent of Type IV RTA secondary to Lisinopril use, and \nLisinopril was held which we continued to hold on discharge. The \npatient continued treatment for SIADH with 1L free water \nrestriction and TID ensure shakes with a high salt diet as well \nas 20mg PO Lasix. The patient was refusing ensure shakes while \nin the hospital, however we discharged him with TID shakes and \nrecommended that he continue to take these with every meal. His \nTSH and AM cortisol (x2) were normal. He was discharged with \nprimary care follow up and should have his sodium checked at his \nfirst follow up.\n\n#Pituitary lesion: MRI showed 14mm lesion in the anterior \npituitary with ddx including cystic macroadenoma with possible \nsubacute hemorrhage vs Rathke's cleft cyst (less likely based on \nlocation of lesion). Macroadenoma may be non-functioning or \nfunctioning (with excess secretion of LH/FSH vs ___ vs prolactin; \nTSH or ACTH-secreting microadenoma is less likely given normal \nTSH and AM free cortisol on this admission). Unclear if this \nlesion is responsible for hyponatremia leading to excess ADH \nsecretion but so far there is no other possible explanation for \nSIADH. Visual field testing normal by ICU team and ophtho.\nNeurosurgery consulted and given no optic chiasm compression no \nneed for intervention at this time. Will need f/u MRI as \noutpatient in 6 months and neurosurgery follow up.\n\n___ Weakness/fall, resolved\nNeuro exam intact. Good rectal tone. No spinal tenderness. Most \nlikely Hyponatremia related as improved with treatment. Of note, \nhe was found to have some orthostatic hypotension though was \nasymptomatic and was ambulating well with physical therapy. \n\n#Metabolic Acidosis, resolved\n#Ketonuria, resolved\nPatient with bicarb 16, gap 16, pH 7.34, 10 ketones urine, \nnormal lactate. Given poor diet most likely some element of \nstarvation ketosis. His blood sugar was 400 on initial check, \nbut has been low 200s on repeat checks, and type II diabetic not \non SGL-2 inhibitor, less concern for DKA/HONK. \n\n#Abdominal distension\n#Constipation\nAbdominal exam benign. Likely due to constipation. TSH normal. \nGiven bowel regimen.\n\n#Urinary retention/incontinence\nNormal rectal exam, less concern for neurological process. \nSugars have been more elevated lately, so could be symptomatic \nfrom glucosuria/osmotic diuresis. Improved. \n\n====================\nCHRONIC ISSUES:\n====================\n#HTN: Held Lisinopril i/s/o hyperkalemia on admission. Blood \npressure was normal during admission. If needs better BP control \nas outpatient, would recommend starting on a non-Ace inhibitor \nregimen.\n\n#DM: Held home oral medications and gave sliding scale insulin \nduring hospitalization. Restarted home meds on discharge.\n\n#Microcytic anemia: Unknown baseline. Iron studies consistent \nwith anemia of chronic disease. Consider colonoscopy as \noutpatient \n\n====================\nTRANSITIONAL ISSUES:\n====================\n[ ] 14 mm pituitary mass: Will need f/u MRI as outpatient in 6 \nmonths and neurosurgery follow up. \n[ ] Lisinopril held with stable blood pressure due to \nhyperkalemia on admission as well as possible contribution to \nType IV RTA, can consider starting different antihypertensive if \nneeds better BP control as outpatient\n[ ] Found to have mild asymptomatic orthostatic hypotension. Can \nconsider midodrine if develops issues with pre-syncope/syncope\n[ ] Found to have stable microcytic anemia. Ensure he is up to \ndate on colonoscopies. \n- New Meds: lasix\n- Stopped/Held Meds: lisinopril \n- Changed Meds: none \n- Follow-up appointments: PCP, ___, neurosurgery\n- Post-Discharge Follow-up Labs Needed: chem 10\n- Incidental Findings: pituitary mass\n- Discharge weight: 194 lb. \n- Discharge creatinine: 0.9\n\n# Communication: ___ (son, lives with him) ___ \n___ (son) ___ \n# Code: Full confirmed \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 5 mg PO DAILY \n2. Simvastatin 10 mg PO QPM \n3. MetFORMIN (Glucophage) 500 mg PO BID \n4. glimepiride 4 mg oral DAILY \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line \nRX *bisacodyl 5 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet \nRefills:*0 \n2. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 \ngram-1.8 kcal/mL oral TID W/MEALS \nRX *nut.tx.imp.renal fxn,lac-reduc [Nepro Carb Steady] 0.08 \ngram-1.8 kcal/mL 8 ounces by mouth TID with meals Refills:*0 \n3. Polyethylene Glycol 17 g PO BID \nRX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth \nTwice daily Refills:*0 \n4. Senna 17.2 mg PO BID \nRX *sennosides [senna] 8.8 mg/5 mL 10 mL by mouth Twice daily \nRefills:*0 \n5. Simethicone 40-80 mg PO QID:PRN stomach upset \nRX *simethicone 125 mg 1 tablet by mouth Four times per day Disp \n#*60 Capsule Refills:*0 \n6. MetFORMIN (Glucophage) 1000 mg PO BID \nRX *metformin 1,000 mg 1 tablet(s) by mouth Twice daily Disp \n#*60 Tablet Refills:*0 \n7. glimepiride 4 mg oral DAILY \n8. Simvastatin 10 mg PO QPM \n9. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do \nnot restart Lisinopril until you are told to do so by your \nprimary care doctor\n10.Outpatient Lab Work\nPlease draw a basic metabolic panel: ICD-9 code 253.6\n\nPlease fax results to ___. at ___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n====================\nSIADH\nPituitary mass\n\nSECONDARY DIAGNOSIS\n====================\nT2DM\nHTN\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n \nYou came to ___ because you had a fall. You were found to have \nvery low sodium. Please see more details listed below about what \nhappened while you were in the hospital and your instructions \nfor what to do after leaving the hospital. \n\nIt was a pleasure participating in your care. We wish you the \nbest! \n\nSincerely, \nYour ___ Care Team \n\nWHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:\n- You underwent work up which revealed a mass in your brain \nwhich is thought to be benign, but you should follow up with the \nNeurosurgery team as below \n- You were treated with a low fluid and high salt diet to \nimprove the low sodium\n- You were started on a water pill called lasix\n- You improved considerably and were ready to leave the hospital \n \n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL: \n- Please continue the low fluid diet and restrict fluids to 1 \nliter per day\n- Please drink one glucerna shake with EACH meal (three times \nper day)\n- Please follow up with your primary care doctor and other \nhealth care providers (see below) \n- Please take all of your medications as prescribed (see below). \n \n- Seek medical attention if you have light-headedness, falls, \nweakness or other symptoms of concern. \n\n \nFollowup Instructions:\n___\n" ]

[ "E222", "E872", "E1165", "E875", "E861", "E236", "I10", "Z7984", "E785", "Z9181", "R338", "R32", "K5900", "T464X5A", "Y92018", "I951", "R824", "D638", "H547", "H353131", "R531" ]

[ "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E872: Acidosis", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E875: Hyperkalemia", "E861: Hypovolemia", "E236: Other disorders of pituitary gland", "I10: Essential (primary) hypertension", "Z7984: Long term (current) use of oral hypoglycemic drugs", "E785: Hyperlipidemia, unspecified", "Z9181: History of falling", "R338: Other retention of urine", "R32: Unspecified urinary incontinence", "K5900: Constipation, unspecified", "T464X5A: Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounter", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "I951: Orthostatic hypotension", "R824: Acetonuria", "D638: Anemia in other chronic diseases classified elsewhere", "H547: Unspecified visual loss", "H353131: Nonexudative age-related macular degeneration, bilateral, early dry stage", "R531: Weakness" ]

[ "E872", "E1165", "I10", "E785", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nabdominal bloating\n \nMajor Surgical or Invasive Procedure:\nERCP with biopsy \n\n \nHistory of Present Illness:\n___ old gentleman with HTN, NIDDM. He was admitted last month\nfor ___ weakness and noted to have severe hyponatremia of 110. It\npartially corrected with IVF and was thought to be combination \nof\nhypovolemia and SIADH. Pituitary mass was found on imaging and \nit\nwas unclear if this macroadenoma was functional. Outpatient\nfollow up was advised after inpatient consultation by\nendocrine/neurosurgery and ophthalmology.\n\nHe reports being in usual ___ till about 2 weeks ago. He\nstarted having abdominal discomfort, more in upper abdomen, \nalong\nwith nausea and poor intake. Pain is worse on eating. also\nabdomen in bloated. no constipation with his new laxative\nregimen. c/o generalized weakness but no other complaints.\nHe has been adherent to 1L fluid restriction. Unable to take\nprotein shakes because they are 'too sweet'.\n\nReview of Systems:\n==================\nComplete ROS obtained and is otherwise negative. no \ndyspnea/chest\npain. no urinary complaints. no fever/chills. no vomiting\n \nPast Medical History:\npituitary macroadenoma\nSIADH\nType II Diabetes\nHTN\nHLD\n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nVITALS: 97.4PO 153 / 76R Lying 85 18 100 Ra \nOrthostatic vital: SBP 149-->115 on standing\nHEENT: has icterus. dry mucosa\nCV: Regular rate and rhythm, normal S1/S2\nResp: Normal work of breathing, clear bilaterally. \nAbd: Soft, distended, tympanic, mild generalized tenderness, BS\npresent\nMSK: Able to move all extremities\nExtremities: trace ___ edema\nNeuro: Alert, oriented, normal speech, able to respond to\ncommands and follow directions\n \nPertinent Results:\n___ 06:47AM BLOOD WBC-9.8 RBC-3.13* Hgb-8.2* Hct-24.5* \nMCV-78* MCH-26.2 MCHC-33.5 RDW-15.5 RDWSD-42.9 Plt ___\n___ 07:45AM BLOOD WBC-10.7* RBC-3.32* Hgb-8.8* Hct-25.8* \nMCV-78* MCH-26.5 MCHC-34.1 RDW-15.1 RDWSD-41.9 Plt ___\n___ 09:45PM BLOOD WBC-10.8* RBC-3.78* Hgb-10.1* Hct-29.5* \nMCV-78* MCH-26.7 MCHC-34.2 RDW-15.2 RDWSD-42.6 Plt ___\n___ 09:45PM BLOOD Neuts-84.6* Lymphs-7.7* Monos-5.4 Eos-1.4 \nBaso-0.3 Im ___ AbsNeut-9.17* AbsLymp-0.84* AbsMono-0.59 \nAbsEos-0.15 AbsBaso-0.03\n___ 06:47AM BLOOD ___ PTT-29.7 ___\n___ 06:47AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-131* \nK-3.9 Cl-93* HCO3-21* AnGap-17\n___ 05:23PM BLOOD Na-127*\n___ 07:45AM BLOOD Glucose-145* UreaN-12 Creat-0.7 Na-129* \nK-4.1 Cl-92* HCO3-22 AnGap-15\n___ 10:10PM BLOOD Glucose-185* UreaN-17 Creat-1.1 Na-123* \nK-6.6* Cl-91* HCO3-17* AnGap-15\n___ 06:47AM BLOOD ALT-59* AST-44* LD(LDH)-218 AlkPhos-291* \nTotBili-3.0*\n___ 07:45AM BLOOD ALT-77* AST-59* AlkPhos-378* TotBili-5.8*\n___ 10:10PM BLOOD ALT-87* AST-102* AlkPhos-386* \nTotBili-5.9*\n___ 10:10PM BLOOD Lipase-108*\n___ 06:47AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8\n___ 07:45AM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.8\n___ 10:10PM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.1 \nMg-1.4*\n\nLiver u/s:\nIMPRESSION: \n1. Diffuse severe intra- and extrahepatic biliary ductal \ndilation, with the CBD measuring up to 19 mm. No obstructing \nstone or mass is seen, however the distal CBD is not well seen \nby ultrasound due to bowel gas. This could be further evaluated \nwith CT or MRCP. \n2. Gallbladder is distended but there is no pericholecystic \nfluid, wall edema, or gallstones to suggest acute cholecystitis. \n\n \nRECOMMENDATION(S): Consider CT or MRCP for further evaluation \nof diffuse \nsevere intra and extrahepatic biliary ductal dilation \n\nCT:IMPRESSION: \n1. Large at least 7.5 cm heterogeneously hypoenhancing mass \ncentered in the head of the pancreas with mild upstream \npancreatic ductal dilation, concerning for pancreatic neoplasm, \nspecifically pancreatic ductal adenocarcinoma. \n2. The mass obliterates the SMV, encases the SMA, and abuts the \nportal splenic confluence and the anterior aspect of the \ninfrarenal abdominal aorta, also with wide abutment of the \nduodenum, as detailed above. \n3. Enlarged and heterogeneously hypoenhancing metastatic \nmesenteric lymph \nnodes. No definite omental or peritoneal disease identified. \nNo ascites. \n4. Marked, severe upstream intra- and extrahepatic biliary \nductal dilation \nupstream from the mass, including a distended gallbladder and \ncystic duct. Gallbladder does not appear inflamed by CT. \n5. Chronic rib fractures of right posterior ribs ___. Other \nincidental \nfindings, as above \n\nCXR:\nIMPRESSION: \nDifficult to say whether left basilar peribronchial \nopacification is due to atelectasis or early pneumonia. Suggest \nrepeat chest radiographs at full inspiration. \nRECOMMENDATION(S): Repeat chest radiographs at full \ninspiration. \n\n___:\nIMPRESSION: \nNo evidence of left deep venous thrombosis in the left lower \nextremity veins. \n\nERCP ___: biliary stricture, metal stent placed. Biospy taken. \n\nPathology: though path pending in computer per email by ERCP \nteam, +adenocarcinoma \n\n \nBrief Hospital Course:\nPt is a ___ y.o male with h.o HTN, DM, hyponatremia, ?recent\npituitary macroadenoma who presented with jaundice and bloating\nand was found to have a pancreatic mass with biliary \nobstruction,\nnow s/p ERCP. \n\n#pancreatic mass- adenocarcinoma\n#biliary obstruction with jaundice \nImaging concerning for pancreatic adenocarcinoma with concern \nfor\nmetastasis. S/p ERCP with metal stent placement, biopsy taken, \npathology per email pertinent for adenocarcinoma. Pt aware. Will \nneed to ___ with oncology after discharge to discuss next steps \nin treatment and options. Diet successfully advanced prior to \nDC. Outpt ___ for repeat labs. \n\n#hyponatremia-has been felt to be combination of hypovolemic and\nSIADH. Improved after IVF. Na 131 on DC. Outpt ___ for repeat \nlabs. \n\n___ edema-neg for DVT\n\n#?pituitary ___ with repeat MRI in 6 months and\noutpt neurosurg per prior dc summary. \n\n#DM-HISS, Fs qid, resume home regimen on DC, metformin to be \nresumed ___. \n#HTN-not on any home meds\n#anemia-no clear signs of bleeding. Outpt ___. Trend HCT. \n\nTransitional care\n1. outpt oncology referral (referral made, office supposed to \ncall pt with ___.\n2.outpt PCP ___ for repeat labs-Na and LFTs \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 1000 mg PO BID \n2. Simvastatin 10 mg PO QPM \n3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line \n4. Polyethylene Glycol 17 g PO BID \n5. Senna 17.2 mg PO BID \n6. Simethicone 40-80 mg PO QID:PRN stomach upset \n7. glimepiride 4 mg oral DAILY \n8. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 \ngram-1.8 kcal/mL oral TID W/MEALS \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line \n2. glimepiride 4 mg oral DAILY \n3. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08 \ngram-1.8 kcal/mL oral TID W/MEALS \n4. Polyethylene Glycol 17 g PO BID \n5. Senna 17.2 mg PO BID \n6. Simethicone 40-80 mg PO QID:PRN stomach upset \n7. Simvastatin 10 mg PO QPM \n8. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication \nwas held. Do not restart MetFORMIN (Glucophage) until ___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nbile duct obstruction and jaundice due to pancreatic cancer \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nYou were admitted for jaundice. You had a CT scan that showed a \npancreatic mass. You then had an ERCP where a stent was placed \nand a biopsy was taken. The biopsy results show pancreatic \ncancer and you will need to follow up with an oncologist for \nongoing care and to discuss your options. \nYour diet was advanced during admission and you tolerated this \nwell. \n \nFollowup Instructions:\n___\n" ]

[ "C250", "K831", "E222", "K311", "K315", "D352", "E119", "I10", "E785", "K259", "K269", "R600", "D649", "I951", "R110", "K5900", "E860" ]

[ "C250: Malignant neoplasm of head of pancreas", "K831: Obstruction of bile duct", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "K311: Adult hypertrophic pyloric stenosis", "K315: Obstruction of duodenum", "D352: Benign neoplasm of pituitary gland", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "R600: Localized edema", "D649: Anemia, unspecified", "I951: Orthostatic hypotension", "R110: Nausea", "K5900: Constipation, unspecified", "E860: Dehydration" ]

[ "E119", "I10", "E785", "D649", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nRemicade\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___ ERCP with sphincterotomy and sludge and stone removal\n\n \nHistory of Present Illness:\n___ year old male with history of ulcerative colitis complicated \nby primary sclerosing cholangitis (followed by Dr. ___, \npresenting as a transfer from ___, with concern for \ncholangitis. Last week, the patient had a four hour episode of \nnausea, PO intolerance and RUQ/epigastric pain which completely \nresolved. He now has had 2 days of recurrence of symptoms with \nRUQ/epigastric pain, nausea and vomiting. He reports no \nfever/chills, diarrhea/constipation. At the OSH, CAST 140, ALT \n136, AP 771, TBili 5.8 WBC 9.6, H&H 15.3/44.8, plt 327K. CT A/P \nat the OSH showed asymmetric L>R central intrahepatic biliary \ndilatation, with CBD also mildly dilated with suggestion of \nmultisegmental mild narrowing. No discrete mass was identified. \nAreas of mural thickening involving portions of the descending \ncolon and mild to distal sigmoid and rectum were suggestive of \ncolitis or sequlae of colitis, may be inflammatory or \ninfectious. He received piperacillin/tazobactam at the OSH.\n\nIn the ED, initial vitals were 98.0 77 123/80 19 98% RA. Labs \nshowed ALT 136, AST 155, AP 741, Tbili 7.1, WBC 10.2K, lacate \n1.2. Blood cultures x 2 were sent, as well as urine culture. \nUA was unremarkable. Patient received 1 liter NS as well as 1 \nmg IV hydromorphone.\n\nCurrently, the patient notes ___ pain, located periumbilically \nat this time. There is no current nausea, fevers or chills.\n \nReview of systems: \n10 pt ROS negative other than noted\n \nPast Medical History:\nUlcerative colitis\nPrimary sclerosing cholangitis\nRetinal detachment\n \nSocial History:\n___\nFamily History:\nNo history of UC or Crohns. No colon, liver, pancreas, or GB \ncancer.\n \nPhysical Exam:\nADMISSION EXAM:\nVitals: 98.3PO 142/75 86 18 98% on RA \nGEN: Alert, oriented to name, place and situation. Fatigued \nappearing but comfortable, no acute signs of distress. Thin.\nHEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP \nclear, MMM. \nNeck: Supple, no JVD\nLymph nodes: No cervical, supraclavicular LAD. \nCV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. \nRESP: Good air movement bilaterally, no rhonchi or wheezing. \nABD: Soft, mildly tender in the periumbilical area, \nnon-distended, + bowel sounds. \nEXTR: No lower leg edema, no clubbing or cyanosis \nDERM: No active rash. \nNeuro: non-focal. \nPSYCH: Appropriate and calm. \n\nDischarge Exam\n\n \nPertinent Results:\nADMISSION LABS\n--------------\n___ 05:30PM BLOOD WBC-10.2*# RBC-4.66 Hgb-14.1 Hct-42.3 \nMCV-91 MCH-30.3 MCHC-33.3 RDW-14.1 RDWSD-47.5* Plt ___\n___ 05:30PM BLOOD Neuts-76.1* Lymphs-13.3* Monos-8.8 \nEos-1.0 Baso-0.4 Im ___ AbsNeut-7.73* AbsLymp-1.35 \nAbsMono-0.89* AbsEos-0.10 AbsBaso-0.04\n___ 05:30PM BLOOD ___ PTT-32.4 ___\n___ 05:30PM BLOOD Glucose-94 UreaN-7 Creat-0.7 Na-137 K-3.8 \nCl-97 HCO3-26 AnGap-18\n___ 05:30PM BLOOD ALT-136* AST-155* AlkPhos-741* \nTotBili-7.1*\n___ 05:30PM BLOOD Albumin-4.2 Calcium-9.8 Phos-2.8 Mg-1.9\n___ 05:50PM BLOOD Lactate-1.2\n\nIMAGING\n-------\nCT A/P (OSH):\nAsymmetric L>R central intrahepatic biliary dilatation. CBD is \nalso mildly dilated with suggestion of multisegmental mild \nnarrowing. Findings may be related to patient's known PSC. No \ndiscrete mass is identified. Areas of mural thickening involving \nportions of the descending colon and mild to distal sigmoid and \nrectum suggestive of colitis or sequlae of colitis, may be \ninflammatory or infectious. Patient has a hx of UC which \ntypically does not demonstrate skip areas. \n\nCXR (OSH):\nIncreased lung volumes consistent with COPD. Cardiomediastinal \nsilhouette and hilar shadows without significant change from \nprior study. There are no pleural effusions. There is no acute \nconsolidating lung infiltrate.\n\n___ ERCP -- Findings: \nEsophagus: Limited exam of the esophagus was normal \nStomach: Limited exam of the stomach was normal \nDuodenum: Limited exam of the duodenum was normal \nMajor Papilla: Evidence of a previous sphincterotomy was noted \nin\nthe major papilla. \nCannulation: Cannulation of the biliary duct was successful and\ndeep with a sphincterotome using a free-hand technique. Contrast\nmedium was injected resulting in complete opacification. \nBiliary Tree: The scout film was normal. The bile duct was \ndeeply\ncannulated with the sphincterotome. Contrast was injected and\nthere was brisk flow through the ducts. Contrast extended to the\nentire biliary tree. Multiple intrahepatic bile duct strictures\nand beading was found in keeping with patints knonw diagnosis of\nprimary sclerosing cholangiditis. No dominant stricture was\nidentified. The left intrahepatic duct was more dilated than the\nright intrahepatic duct. The biliary tree was swept with a \n9-12mm\nballoon starting in the left intrahepatic duct. Multiple stone\nfragments, debris and sludge was. The left intrahepatic, CBD and\nCHD were swept repeatedly until no further stones were seen.\nExcellent bile and contrast drainage was seen endoscopically and\nfluoroscopically.I supervised the acquisition and interpretation\nof the fluoroscopic images. The quality of the fluoroscopic\nimages was good. \nImpression: (cannulation)\nOtherwise normal ercp to third part of the duodenum \nRecommendations: Continue antibiotics to complete atleast 7 days\nReturn to ward ongoing care.\nFollow for response and complications. If any abdominal pain,\nfever, jaundice, gastrointestinal bleeding please call ERCP\nfellow on call ___ \n\nMICRO\n-----------\n___ Blood Culture, Routine-PENDING EMERGENCY WARD \n___ Blood Culture, Routine-PENDING EMERGENCY WARD \n___ URINE CULTURE-PENDING EMERGENCY WARD \n\nDischarge Day labs\n------------------\n\n \nBrief Hospital Course:\n___ man w/PMHx UC c/b PSC now txf from ___ with \nconcern for cholangitis based on sx, labs and imaging\n\nUC c/b PSC txf from OSH for cholangitis, s/p ERCP on ___ - \nRUQ pain, N/V w/obstructive LFTs at OSH w/CT A/P showing L>R \nintrahepatic biliary dilation w/CBD dil w/a suggestion of \nmultisegmental narrowing, no mass, also with descd colon and\nmid-distal sigmoid + rectum with mural thickening c/w colitis\n- f/u BCx\n- was initially placed on pip/tazo, and was then transitioned to \ncipro with a plan for 7d total, D1 ___ day of \"source \ncontrol\")\n- takes mesalamine at home -- continued this -- has allergy to \ninfliximab (convulsions)\n- follow up arranged with Dr. ___\n- he did have some pain with advancing diet and was given a \nshort prescription for oxycodone with instructions not to drive \nwhile taking this medication. \n\nSignificant EtOH use\n- ___ wines daily for several months now - knows he should cut \ndown\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ___ (mesalamine) 4.8 grams oral DAILY \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth q12 Disp #*14 \nTablet Refills:*0 \n2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth q4h prn Disp #*6 Tablet \nRefills:*0 \n3. ___ (mesalamine) 4.8 grams oral DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCholangitis\nPrimary sclerosing cholangitis (PSC)\nUlcerative colitis (UC)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted with cholangitis (infection of the bile ducts \nin the liver) which was likely caused by your primary sclerosing \ncholangitis (PSC), which is associated with your ulcerative \ncolitis. You underwent ERCP on ___ at which time sludge and \nstones were removed. You were treated with antibiotics and \nimproved.\n\nYou are being given a short supply of pain medications for your \nabdominal pain. Do not drive while taking this medication \n(oxycodone). \n \nFollowup Instructions:\n___\n" ]

[ "K8036", "K5150", "K743", "H3320", "F1020", "K838", "R1011", "K5289" ]

[ "K8036: Calculus of bile duct with acute and chronic cholangitis without obstruction", "K5150: Left sided colitis without complications", "K743: Primary biliary cirrhosis", "H3320: Serous retinal detachment, unspecified eye", "F1020: Alcohol dependence, uncomplicated", "K838: Other specified diseases of biliary tract", "R1011: Right upper quadrant pain", "K5289: Other specified noninfective gastroenteritis and colitis" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nRemicade / erythromycin base\n \nAttending: ___.\n \nChief Complaint:\nUlcerative colitis with multifocal high-grade dysplasia\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic proctocolectomy with end ileostomy and parastomal \nmesh\n\n \nHistory of Present Illness:\nPt is a ___ male with a history of ulcerative colitis \nand primary sclerosing cholangitis. He was diagnosed with UC ___ \nyears ago when he was in his ___. In the early days, he was \ntaking Azocol. He was taking that for many years on and off. \nIn___, he started taking Azocol again for few years. He has \nbeen on and off ___ for a while. He is currently taking \n___ for the last ___ years and ursodiol for PSC (taking this on \nand off for ___ years). Currently, he has no significant active \nsymptoms. He has some mild pain in the lower abdomen. He has BM \nabout 5 times per week. He has not had a flare \"in a while\" but \nunable to say when his last major flare was. He had a \ncolonoscopy in ___, which showed low grade dysplasia \non random biopsies in the right colon. He underwent another \ncolonoscopy in ___, which showed high grade dysplasia. He \ndenies any fevers, chills, no weight loss. He denies any \nsymptoms from his PSC, but occasionally does have RUQ pain. He \nhas no other complaints at this time.\n\n \nPast Medical History:\nUlcerative colitis\nPrimary sclerosing cholangitis\nRetinal detachment\nOSTEOPOROSIS \nCCY ___ years ago \n \nSocial History:\n___\nFamily History:\nFamily History: no history of colon cancer/IBD in the family. \nDenies family history of stomach, colon, or pancreatic cancer. \n \nPhysical Exam:\nObjective\n___ ___ Temp: 97.7 PO BP: 114/70 HR: 90 RR: 18 O2 sat: 98% \nO2 delivery: Ra \n\nGENERAL: NAD, A/O x 3\nCV: RRR \nPULM: no respiratory distress \nABD: soft, minimally distended, minimally tender, no\nrebound/guarding, ostomy mucosa pink, with bilious liquid output \nand gas \nWOUND: Incisions and dressings c/d/i\n \nPertinent Results:\n___ 07:02AM BLOOD WBC-12.4* RBC-3.83* Hgb-11.9* Hct-36.6* \nMCV-96 MCH-31.1 MCHC-32.5 RDW-13.8 RDWSD-48.2* Plt ___\n___ 06:46AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-137 \nK-4.1 Cl-101 HCO3-28 AnGap-8*\n___ 06:46AM BLOOD ALT-55* AST-59* AlkPhos-412* TotBili-3.1* \nDirBili-2.2* IndBili-0.9\n___ 06:46AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.6\n___ 07:02AM BLOOD CRP-73.7*\n \nBrief Hospital Course:\nMr. ___ presented to ___ holding at ___ on ___ \nfor laparoscopic proctocolectomy with end ileostomy and \nparastomal mesh. He tolerated the procedure well without \ncomplications (Please see operative note for further details). \nAfter a brief and uneventful stay in the PACU, the patient was \ntransferred to the floor for further post-operative management.\n\nNeuro: Pain was well controlled on Tylenol and tramadol for \nbreakthrough pain.\n\nCV: Vital signs were routinely monitored. He was noted to be \northostatic on postop day 1 and received IV fluid boluses with \ngood response. On the day prior to discharge, ___, he was \nmildly dizzy while working with physical therapy. He improved \nwith another fluid bolus. He was encouraged to increase his \np.o. fluid intake. On the day of discharge, he was ambulating \nindependently with without lightheadedness. He was cleared by \nphysical therapy for discharge home without additional ___. \n\nPulm: The patient remained stable from a pulmonary standpoint; \noxygen saturation was routinely monitored. He had good pulmonary \ntoileting, as early ambulation and incentive spirometry were \nencouraged throughout hospitalization.\n\nGI: The patient was briefly kept NPO after the procedure. The \npatient was advanced to and tolerated a regular diet starting on \npostoperative day 2. Patient's intake and output were closely \nmonitored. He was kept on peritoneal precautions after his \noperation. He received teaching from the ostomy nurse and \ndemonstrated good understanding of the function and use of the \nostomy. He will continue to have ostomy teaching through ___ at \nhome. The patient was advised to follow-up as soon as possible \nwith his primary care provider and hepatologist once discharged.\n\nGU: The patient had a Foley catheter that was removed prior to \ndischarge. At time of discharge, the patient was voiding without \ndifficulty. Urine output was monitored as indicated.\n\nID: The patient was closely monitored for signs and symptoms of \ninfection and fever, of which there was none.\n\nHeme: The patient received subcutaneous heparin and ___ dyne \nboots during this stay. He was encouraged to get up and ambulate \nas early as possible. The patient is being discharged on \nprophylactic Lovenox. \n\nOn ___, the patient was discharged to home. At discharge, \nhe was tolerating a regular diet, passing flatus, voiding, and \nambulating independently. He will follow-up in the clinic in ___ \nweeks. This information was communicated to the patient directly \nprior to discharge.\n\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 rehab hospital disposition.\n[ ] Lack of insurance coverage for ___ services\n[ ] Lack of insurance coverage for prescribed medications.\n[ ] Family not agreeable to discharge plan.\n[ ] Patient knowledge deficit related to ileostomy delaying \ndispo\n[x] No social factors contributing in delay of discharge.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ursodiol 300 mg PO TID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Bacitracin Ointment 1 Appl TP BID perineum \n3. Enoxaparin Sodium 40 mg SC DAILY \nStart: Today - ___, First Dose: Next Routine Administration \nTime \nRX *enoxaparin 40 mg/0.4 mL 40 SC once a day Disp #*24 Syringe \nRefills:*0 \n4. TraMADol 50-100 mg PO Q4H:PRN Pain - Moderate \nRX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours \nDisp #*16 Tablet Refills:*0 \n5. Ursodiol 300 mg PO TID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n___ with history of ulcerative colitis for ___ years & current \nmultifocal dysplasia s/p laparoscopic proctocolectomy with end \nileostomy and parastomal mesh.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital after a laparoscopic \nproctocolectomy w/end ileostomy and parastomal mesh placement \nfor surgical management of your ulcerative colitis with \nmultifocal high-grade dysplasia. You have recovered from this \nprocedure and you are now ready to return home. \n\nYou have a new ileostomy and stool no longer passes through the \ncolon (part of the body where water and electrolytes are \nreabsorbed back into the body), so your output will be liquid. \nThe most common complication from an ileostomy is dehydration. \nYou must measure your ileostomy output for the next few weeks- \nplease bring your I&O sheet to your post-op appointment. The \noutput should be no less than 500cc or greater than 1200cc per \nday. If you find that your output has become too much or too \nlittle, please call the office. Please monitor for signs and \nsymptoms of dehydration. If you notice these symptoms, please \ncall the office or go to the emergency room. You will need to \nkeep yourself well hydrated, if you notice your ileostomy output \nincreasing, drink liquids with electrolytes such as Gatorade.\n\nPlease monitor the appearance of your stoma and care for it as \ninstructed by the ostomy nurses. ___ you notice that the stoma is \nturning darker blue or purple please call the office or go to \nthe emergency room. The stoma may ooze small amounts of blood at \ntimes when touched which will improve over time. Monitor the \nskin around the stoma for any bulging or signs of infection. You \nwill follow up with the ostomy nurses in the clinic ___ weeks \nafter surgery. You will also have a visiting nurse at home for \nthe next few weeks to help to monitor your ostomy (until you are \ncomfortable caring for it on your own).\n\nYou have ___ laparoscopic surgical incisions on your abdomen \nwhich are closed with internal sutures. It is important that \nyou monitor these areas for signs and symptoms of infection \nincluding: increasing redness of the incision lines, \nwhite/green/yellow/foul smelling drainage, increased pain at the \nincision, increased warmth of the skin at the incision, or \nswelling of the area. You may shower; pat the incisions dry with \na towel, do not rub. If you have steri-strips (the small white \nstrips), they will fall off over time, please do not remove \nthem. Please do not take a bath or swim until cleared by the \nsurgical team.\n\nPain is expected after surgery. This will gradually improve over \nthe first week or so you are home. You should continue to take \n2 Extra Strength Tylenol (___) for pain every 8 hours around \nthe clock. Please do not take more than 3000mg of Tylenol in 24 \nhours or any other medications that contain Tylenol such as cold \nmedication. Do not drink alcohol while taking Tylenol. You may \nalso take Advil (Ibuprofen) 600mg every 8 hours for 7 days. \nPlease take Advil with food. If these medications are not \ncontrolling your pain to a point where you can ambulate and \nperform minor tasks, you should take a dose of the narcotic pain \nmedication tramadol. Please do not take sedating medications, \ndrink alcohol, or drive while taking the narcotic pain \nmedication. \n\nYou will be going home with your JP (surgical) drain, which will \nbe removed at your post-op visit. Please look at the site every \nday for signs of infection (increased redness or pain, swelling, \nodor, yellow or bloody discharge, warm to touch, fever). \nMaintain suction of the bulb. Note color, consistency, and \namount of fluid in the drain. Call the doctor, nurse \npractitioner, or ___ nurse if the amount increases significantly \nor changes in character. Be sure to empty the drain as needed \nand record output. You may shower; wash the area gently with \nwarm, soapy water. Keep the insertion site clean and dry \notherwise. Avoid swimming, baths, hot tubs; do not submerge \nyourself in water. Make sure to keep the drain attached securely \nto your body to prevent pulling or dislocation.\n\nYou may feel weak or \"washed out\" for up to 6 weeks after \nsurgery. Do not lift greater than a gallon of milk for 3 weeks. \nAt your post op appointment, your surgical team will clear you \nfor heavier exercise. In the meantime, you may climb stairs and \ngo outside and walk. Please avoid traveling long distances \nuntil you speak with your surgical team at your post-op visit. \n\n\nThank you for allowing us to participate in your care, we wish \nyou all the best! \n\nSincerely,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "K5100", "K8301", "I951", "D122" ]

[ "K5100: Ulcerative (chronic) pancolitis without complications", "K8301: Primary sclerosing cholangitis", "I951: Orthostatic hypotension", "D122: Benign neoplasm of ascending colon" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nAmpicillin / Wellbutrin / Penicillins\n \nAttending: ___\n \nChief Complaint:\ncolonscopy prep\n \nMajor Surgical or Invasive Procedure:\ncolonoscopy\n\n \nHistory of Present Illness:\n___ hospitalized for elective colonoscopy for colon cancer \nscreening. She is hospitalized in the setting of aortic \nstenosis with aortic valve area below 1.0 cm2. She has not had \nany worsening cardio-pulmonary symptoms or syncope. The patient \nhas had chronic SOB with walking up stairs. She also has \nchronic dizziness when she stands up or bends down quickly. She \nsaw GI earlier this month who arranged colonoscopy. The patient \nhas not had palpitations.\n\nShe and I commented on fast pulse approx. 110. She does feel \nanxious currently.\n\nROS negative for leg swelling, PND, cough, fevers, chills, \ndiarrhea\n \nPast Medical History:\nanxiety\nexcezma\naortic stenosis\nglucose intolerance\n\nphotosensitivity\n \nSocial History:\n___\nFamily History:\nnot pertinent to management of current hospital diagnosis\n \nPhysical Exam:\n98.4 136/72 109 99RA\nslightly anxious female, attentive and cooperative\nasymmetry of her eyes due to \"lazy eye\" chronic\nmoist oral mucosa\nclear breath sounds\nregular s1 and s2 with loud mid systolic murmur, loudest near R \nclavicle\nsoft abdomen\nobese\nno peripheral edema\n\nDISCHARGE EXAM\nafebrile, HR 95, BP and respiratory status wnl\nanxious, NAD\nL sided ptosis (baseline per pt)\nMMM\nCTAB\nmildly tachycardic, III/VI SEM heard throughout precordium and \ninto back but best at RUSB\nsntnd\nwwp, neg edema\n \nPertinent Results:\nColonoscopy:\nImpression:\nNormal mucosa in the colon from the rectum to the cecum\nRecommendations:\nRepeat colonoscopy in ___ years.\n \nBrief Hospital Course:\n___ with anxiety, aortic stenosis w ___ <1.0cm2 hospitalized to \ncomplete colonoscopy prep for screening colonoscopy. She \ntolerated colonoscopy well. She had tachycardia on admission \nwith negative orthostatics, but after the procedure when she was \nless anxious HR returned to high ___, which is baseline HR based \non review of records. EKG also noted new RBBB and RVH; suggest \nTTE which had previously been scheduled for several months from \nnow be performed sooner to assess R sided structures, but defer \nto cardiology and primary care. Continued home clonazepam, \ndoxepin, venlafaxine for anxiety.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clindamycin 1% Solution 1 Appl TP BID \n2. ClonazePAM 0.5 mg PO DAILY \n3. Venlafaxine XR 225 mg PO DAILY \n4. Doxepin HCl 10 mg PO HS \n\n \nDischarge Medications:\n1. Clindamycin 1% Solution 1 Appl TP BID \n2. ClonazePAM 0.5 mg PO DAILY \n3. Doxepin HCl 10 mg PO HS \n4. Venlafaxine XR 225 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ncolonoscopy prep\naortic stenosis\n\n \nDischarge Condition:\nAlert, ambulatory\n\n \nDischarge Instructions:\nMs. ___,\nYou were admitted for colonoscopy preparation. You tolerated the \nprep and the procedure well. Your colonoscopy was normal. You \nhad a few minor changes on your EKG. Please follow up with your \nprimary care doctor and your cardiologist. \n \nFollowup Instructions:\n___\n" ]

[ "Z1211", "Q231", "R000", "F419" ]

[ "Z1211: Encounter for screening for malignant neoplasm of colon", "Q231: Congenital insufficiency of aortic valve", "R000: Tachycardia, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "F419" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nAmpicillin / Wellbutrin / Penicillins\n \nAttending: ___.\n \nChief Complaint:\nchest pain \n \nMajor Surgical or Invasive Procedure:\n1. Aortic root enlargement with bovine pericardial patch.\n2. Aortic valve replacement with a 21 ___ Ease\n pericardial tissue valve, model ___. Serial number\n is ___.\n\n \nHistory of Present Illness:\n ___ year old male presented in\n___ with palpitations and shortness of breath found to be \nin\natrial fibrillation and ruled in for NSTEMI. He underwent TEE\nthat revealed left atrial thrombus, cardioversion was deferred\nand he was anticoagulated with Eliquis. In ___ he noticed\nchest pain and dyspnea with minimal exertion that resolved with\n1 nitroglycerin and rest. He had palpitations that he was taking\nadditional Lopressor for approximately 4 times during ___ month.\nHe underwent cardiac catheterization which revealed\ncoronary artery disease and cardiac surgery was consulted. He\nunderwent TEE that revealed no clot and was cardioverted. ___ discussed with Dr ___ the surgery for a least 30\ndays from cardioversion unless his symptoms worsened and he\nrequired surgery sooner. He presents today for preop work up for\nCABG in AM with ___. \n\n \nPast Medical History:\n- Bicuspid aortic valve stenosis.\n- Moderate mitral annular calcification, mild mitral valve\nprolapse with no significant MR.\n- Anxiety\n- Cognitive Delay\n- Eczema\n- Glucose intolerance\n- Recent colonoscopy was normal\n\n \nSocial History:\n___\nFamily History:\nDenies premature coronary artery disease\n \nPhysical Exam:\nVitals: 98.5, 18 RR, 94% RA, 91bpm, 95/68\n\nGeneral: No acute distress\nSkin: Dry [X] intact [X] Eczema present\nHEENT: PERRLA [X] EOMI [X]\nNeck: Supple [X] Full ROM [X]\nChest: Lungs clear bilaterally [X]\nHeart: RRR [X] Irregular [] Murmur [X] grade ___ systolic \nAbdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds \n+\n[]\nExtremities: Warm [X], well-perfused [X] Edema [] _trace pedal\nedema____\nVaricosities: None [X]\nNeuro: Grossly intact [X]\nPulses:\nFemoral Right: 1+ Left: 1+\nDP Right: 1+ Left: 1+\n___ Right: 1+ Left: 1+\nRadial Right: 1+ Left: 1+\n\nCarotid Bruit Right: - Left: -\n\n \nPertinent Results:\n___ Intra-op TEE\nConclusions \nPre Bypass: No thrombus is seen in the left atrial appendage. \nColor-flow imaging of the interatrial septum raises the \nsuspicion of an atrial septal defect, but this could not be \nconfirmed on the basis of this study. Regional left ventricular \nwall motion is normal. 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 aortic arch. There are simple atheroma in the descending \nthoracic aorta. The aortic valve is bicuspid. There is severe \naortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. Trivial mitral regurgitation is seen. \n\n Post Bypass: Patient is AV paced on phenylepherine infusion. \nThere is a tissue prosthesis in the aortic position without AI \nor perivalvular leaks. Peak gradient 30, mean 15 mm Hg. Aortic \ncontours intact. Preserved biventricular function. Mitral \nregurgitation unchanged. Remaining exam is unchanged. All \nfindings discussed with surgeons at the time of the exam. \n\nCXR: ___ \nIMPRESSION: \nComparison to ___. Stable moderate to severe \ncardiomegaly with \nextensive pleural effusions and signs of moderate pulmonary \nedema. Stable \nalignment of the sternal wires. Stable position of the right \ncentral venous \naccess line. \n.\n\n___ 04:08AM BLOOD WBC-7.3 RBC-3.24* Hgb-9.5* Hct-30.0* \nMCV-93 MCH-29.3 MCHC-31.7* RDW-14.5 RDWSD-48.2* Plt ___\n___ 03:43AM BLOOD WBC-12.2* RBC-3.63*# Hgb-10.6*# \nHct-32.9*# MCV-91 MCH-29.2 MCHC-32.2 RDW-13.9 RDWSD-45.4 Plt \n___\n___ 02:12AM BLOOD ___ PTT-24.4* ___\n___ 04:08AM BLOOD Glucose-124* UreaN-22* Creat-0.5 Na-140 \nK-3.9 Cl-97 HCO3-31 AnGap-16\n___ 02:12AM BLOOD Glucose-125* UreaN-25* Creat-0.5 Na-143 \nK-3.3 Cl-100 HCO3-30 AnGap-16\n___ 04:08AM BLOOD Mg-2.3\n \nBrief Hospital Course:\nThe patient was brought to the Operating Room on ___ where \nthe patient underwent Aortic root enlargement with bovine \npericardial patch and Aortic valve replacement with a 21 mm \n___ Ease pericardial tissue valve. Overall the patient \ntolerated the procedure well and post-operatively was \ntransferred to the CVICU in stable condition for recovery and \ninvasive monitoring. \n POD 1 found the patient extubated, alert and oriented and \nbreathing comfortably. The patient was neurologically intact \nand hemodynamically stable. Beta blocker was initiated. The \npatient was transferred to the telemetry floor for further \nrecovery. Chest tubes and pacing wires were discontinued \nwithout complication. The patient was transfused with 2 units of \nRBCs for acute blood loss anemia. There was no concern for \nhemorrhage and the patient's hematocrit responded appropriately. \nShe was started on iron supplementation.\n\nOn POD 4 the patient developed acute respiratory distress and \nwas transferred to the ICU. She was placed on BiPAP with \nimprovement of her dyspnea. A CXR showed volume overload and she \nwas placed on IV Lasix. She developed atrial fibrillation and \nwas started on amiodarone. With diuresis her SOB resolved and \nshe was transferred back to the floor. Her discharge CXR shows \nsmall bilateral pleural effusions and she will be discharged on \na 14 day course of Lasix.\n\nThe patient was evaluated by the speech pathology team due to \nconcern for aspiration. She was deemed to be deconditioned and \nshe will be discharged tolerating a nectar thick liquid and \nregular solid diet. The patient was evaluated by the physical \ntherapy service for assistance with strength and mobility and \nwas deemed appropriate for rehab. By the time of discharge on \nPOD 7 the patient was ambulating freely, the wound was healing \nand pain was controlled with oral analgesics. The patient was \ndischarged to ___ Rehab in ___, ___ in good condition \nwith appropriate follow up instructions.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ClonazePAM 0.5-1 mg PO DAILY \n2. Doxepin HCl 10 mg PO HS \n3. Venlafaxine 225 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO/PR Q6H:PRN pain or temperature \n>38.0 \n2. Amiodarone 200 mg PO BID \n___ bid x 7 days, then 200mg daily \n3. Ascorbic Acid ___ mg PO BID \n4. Aspirin EC 81 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \nhold for loose stool \n6. Ferrous Sulfate 325 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. Furosemide 40 mg PO BID Duration: 14 Days \n9. Metoprolol Tartrate 50 mg PO TID \n10. Multivitamins 1 TAB PO DAILY \n11. Potassium Chloride 20 mEq PO BID Duration: 14 Days \n12. Ranitidine 150 mg PO BID \n13. ClonazePAM 0.25 mg PO BID \nRX *clonazepam 0.5 mg 0.5 (One half) tablet(s) by mouth twice a \nday Disp #*30 Tablet Refills:*0 \n14. Doxepin HCl 10 mg PO HS \n15. Venlafaxine XR 225 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n- Bicuspid aortic valve stenosis.\n- Moderate mitral annular calcification, mild mitral valve\nprolapse with no significant MR.\n- Anxiety\n- Cognitive Delay\n- Eczema\n- Glucose intolerance\n- Recent colonoscopy was normal\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal\n Ambulating, gait steady\n Sternal pain managed with oral analgesics\n Sternal Incision - healing well, no erythema or drainage\n\nEdema- 1+\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\n Please - NO lotion, cream, powder or ointment to incisions\n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n No driving for approximately one month and while taking \nnarcotics\n\nClearance to drive will be discussed at follow up appointment \nwith surgeon\n No lifting more than 10 pounds for 10 weeks\n **Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n Females: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "Q231", "J9601", "I5030", "I959", "D62", "F410", "I4891", "I252", "I2510", "I341", "E785" ]

[ "Q231: Congenital insufficiency of aortic valve", "J9601: Acute respiratory failure with hypoxia", "I5030: Unspecified diastolic (congestive) heart failure", "I959: Hypotension, unspecified", "D62: Acute posthemorrhagic anemia", "F410: Panic disorder [episodic paroxysmal anxiety]", "I4891: Unspecified atrial fibrillation", "I252: Old myocardial infarction", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I341: Nonrheumatic mitral (valve) prolapse", "E785: Hyperlipidemia, unspecified" ]

[ "J9601", "D62", "I4891", "I252", "I2510", "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:\ndyspnea\n \nMajor Surgical or Invasive Procedure:\nCardiac Catheterization ___\n=====================================\nR femoral artery approach\nL dominance\nLMCA - calcified and 99% stenosed at its ostium\nLAD - long calcified 95% stenosis\nLCx - serial 70% stenosis in its midcourse\n___ marginal is subtotally occluded\nRCA - small, diffusely diseased and non dominant with a 90% mid \nstenosis\nImpression: critical L main and 3v disease in an elderly woman \nwith an EF of 18%\n\nCardiac Catheterization, Impella placement, Percutaneous \nCoronary Intervention ___\n======================================\nR femoral artery approach\nCo-dominant \nLMCA - 80% stenosis in LMCA. TIMI flow 2 and has moderate \ncalcification noted. This lesion is further described as focal. \nAn intervention was performed on the LMCA with a final stenosis \nof 0%. No lesion complications.\nLAD - 90% stenosis of proximal LAD. TIMI flow 2 and severe \ncalcification noted. Diffusely diseased. An intervention was \nperformed on the proximal LAD with final stenosis of 0%. There \nwere no lesion complications. There is diffuse mid and distal \ndisease without focal stenosis.\nLCx - diffuse distal 60% stenosis. ___ marginal is occluded in \nmid portion. \nRCA - not injected\nImpressions:\n1. Severe left main and 3v CAD\n2. Cardiogenic shock (CI 1.6, cardiorenal syndrome)\n3. Successful ___ main and LAD\n4. Successful impella placement\n\n \nHistory of Present Illness:\nThis is a ___ year old female with no known PMH though patient \nhas not seen PCP ___ ___ years presents with a chief complaint of \ndyspnea on exertion for the past 5 days. DOE acutely worse over \nthe past 2 days. \nPatient reports she felt unwell with nonspecific malaise and \nnausea 5 days ago while the family was on ___; she normally \nenjoys walks with her family but stayed inside due to her \nsymptoms. She has had progressively worsening shortness of \nbreath with minimal exertion since then. Denies active chest \npain, current nausea or vomiting. No SOB at rest. Patient \ntypically uses 2 pillows to sleep at night and this has not \nchanged. No recent fever/chills, nausea, vomiting. or diarrhea \nthough with mild decreased appetite. Patient also without \nworsening lower extremity edema. Daughter brought patient into \nthe ___ where EKG showed possible ST \nchanges in anterior leads - V1, V2, V3 with no old EKG for \ncomparison. She was referred into ED for further evaluation. CXR \nwas concerning for pulmonary edema. U/A with evidence of UTI and \nCreatinine elevated at 1.6. Vitals on transfer to ED were ___, \nP94, R20, 125/82, 97%RA \n \nIn the ED initial vitals were: 22:23 ___ 98.1 90 126/78 16 96% \nRA \nEKG: STE V1-V3 and Q wave in III \nLabs/studies notable for: h/h 9.4/29.7 (no baseline), creat 1.6, \nu/a with neg nitrite, >50wbc, many bacteria, sm leuk. \nCXR with cardiomegaly with small bilateral pleural effusions and \npulmonary vascular congestion. \nPatient was given: 325mg aspirin, 20mg IV Lasix, 500mg \nciprofloxacin. \nVitals on transfer: Today 01:10 0 98.1 96 149/93 21 99% RA \nOn the floor, patient states that she does not want to be here. \nShe denies any chest pain or shortness of breath. She did have \nsome decreased appetite over the last week. She is typically \nable to ambulate around the ___ without difficulty \nand believes she would still be able to do at this time. \nROS: \nOn review of systems, denies any prior history of stroke, TIA, \ndeep venous thrombosis, pulmonary embolism, bleeding at the time \nof surgery, myalgias, joint pains, cough, hemoptysis, black \nstools or red stools. Denies recent fevers, chills or rigors. \nDenies exertional buttock or calf pain. All of the other review \nof systems were negative. Cardiac review of systems is notable \nfor absence of chest pain, dyspnea on exertion, paroxysmal \nnocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope \nor presyncope. \n \nPast Medical History:\ns/p appendectomy unknown year\n \nSocial History:\n___\nFamily History:\nFather died when she was very young due to a bowel issue. Mother \ndied at ___ due to an unknown cause. No early CAD or sudden \ncardiac death. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM \nVS: T97.5 BP143/83 HR102 RR18 95%RA 64.5kg \nGENERAL: NAD. Oriented x3. Mood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. \nNECK: Supple with JVP to level of jaw. \nCARDIAC: ___ systolic murmur \nLUNGS: Crackles in b/l bases \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\nDISCHARGE PHYSICAL EXAM:\nVS: 98.5 91-117/46-69 ___ 20 94%RA\nDISCHARGE WEIGHT: 58.4 kg\nGENERAL: no respiratory distress \nHEENT: conjunctiva pale, NCAT, sclera anicteric, PERRL, OP clear\nNECK: no JVD\nCARDIAC: RRR, nl S1 S2, ___ systolic murmur RUSB/LUSB\nLUNGS: poor air movement at bases, no wheezes or crackles \nappreciated\nABDOMEN: soft, NT, ND, NABS \nEXTREMITIES: WWP, no ___ edema\n\n \nPertinent Results:\nADMISSION LABS:\n==========================\n___ 08:20PM BLOOD WBC-8.9 RBC-3.64* Hgb-9.4* Hct-29.7* \nMCV-82 MCH-25.8* MCHC-31.6* RDW-14.8 RDWSD-43.9 Plt ___\n___ 08:20PM BLOOD Neuts-64.2 ___ Monos-11.0 Eos-1.4 \nBaso-0.7 Im ___ AbsNeut-5.69 AbsLymp-1.98 AbsMono-0.97* \nAbsEos-0.12 AbsBaso-0.06\n___ 08:20PM BLOOD Plt ___\n___ 08:20PM BLOOD Glucose-189* UreaN-46* Creat-1.6* Na-134 \nK-4.0 Cl-98 HCO3-21* AnGap-19\n___ 08:20PM BLOOD ALT-52* AST-58* CK(CPK)-151 AlkPhos-179* \nTotBili-0.6\n___ 08:20PM BLOOD CK-MB-6 cTropnT-2.35* ___\n___ 08:20PM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0 Iron-11* \nCholest-210*\n___ 08:20PM BLOOD calTIBC-360 Ferritn-25 TRF-277\n___ 02:19AM BLOOD %HbA1c-6.5* eAG-140*\n___ 08:20PM BLOOD Triglyc-139 HDL-45 CHOL/HD-4.7 \nLDLcalc-137* LDLmeas-140*\n\nPERTINENT INTERVAL LABS:\n==========================\n___ 09:30AM BLOOD ALT-67* AST-90* AlkPhos-258* TotBili-0.6\n___ 06:40PM BLOOD CK-MB-39* cTropnT-3.24*\n___ 05:26PM BLOOD ___ pO2-59* pCO2-39 pH-7.34* \ncalTCO2-22 Base XS--4 Comment-GREEN-TOP\n___ 03:24PM BLOOD Lactate-3.1*\n___ 05:26PM BLOOD Lactate-3.3*\n___ 10:57PM BLOOD Lactate-1.8\n\n___ 02:07PM BLOOD Glucose-163* UreaN-96* Creat-4.2* Na-131* \nK-4.6 Cl-97 HCO3-19* AnGap-20\n___ 03:57AM BLOOD Glucose-124* UreaN-101* Creat-4.1* \nNa-132* K-4.0 Cl-98 HCO3-21* AnGap-17\n___ 06:00AM BLOOD Glucose-107* UreaN-93* Creat-3.4* Na-130* \nK-3.9 Cl-95* HCO3-22 AnGap-17\n___ 04:45AM BLOOD Glucose-105* UreaN-84* Creat-2.5* Na-133 \nK-3.7 Cl-95* HCO3-27 AnGap-15\n___ 05:08AM BLOOD ALT-124* AST-171* LD(LDH)-671* \nAlkPhos-766* TotBili-1.4\n___ 03:35PM BLOOD ALT-109* AST-162* LD(LDH)-602* \nAlkPhos-651* TotBili-1.4\n___ 06:00AM BLOOD ALT-79* AST-134* LD(LDH)-462* \nAlkPhos-267* TotBili-0.8\n___ 08:20PM BLOOD CK-MB-6 cTropnT-2.35* ___\n___ 07:50AM BLOOD CK-MB-7 cTropnT-2.28*\n___ 03:15AM BLOOD CK-MB-9\n___ 07:02AM BLOOD CK-MB-20* cTropnT-2.11*\n___ 07:10AM BLOOD CK-MB-52* cTropnT-3.04*\n___ 06:40PM BLOOD CK-MB-39* cTropnT-3.24*\n___ 10:50PM BLOOD CK-MB-30* MB Indx-7.2* cTropnT-3.12*\n___ 04:56AM BLOOD CK-MB-24* MB Indx-6.5* cTropnT-3.08*\n___ 08:06PM BLOOD cTropnT-4.87*\n___ 06:16AM BLOOD cTropnT-5.33*\n___ 08:20PM BLOOD TSH-2.4\n\nTEST RESULT REFERENCE RANGE \n UNITS\n____________________ ______ _______________ \n _____\nPF4 Heparin Antibody 0.47 0.00 -0.39 \n OD\n \n\n___ 08:40PM URINE Type-RANDOM Color-Yellow Appear-Cloudy Sp \n___\n___ 08:40PM URINE Blood-MOD Nitrite-NEG Protein-100 \nGlucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.5 Leuks-SM\n___ 08:40PM URINE ___ WBC->50 Bacteri-MANY Yeast-NONE \n___ 08:40PM URINE Mucous-FEW\n___ 11:00AM URINE Color-Yellow Appear-Hazy Sp ___\n___ 11:00AM URINE Blood-TR Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 11:00AM URINE RBC-2 WBC-9* Bacteri-FEW Yeast-NONE Epi-0\n___ 11:00AM URINE Mucous-RARE\n___ 03:14AM URINE Hours-RANDOM Creat-46 Na-91 K-27 Cl-107\n___ 08:05PM URINE Hours-RANDOM UreaN-791 Creat-52 Na-23 \nK-21 Cl-13\n___ 08:05PM URINE Osmolal-479\n___ 10:59AM URINE Hours-RANDOM UreaN-303 Creat-34 Na-60 \nK-30 Cl-76\n\nMICROBIOLOGY:\n==========================\n MRSA SCREEN (Final ___: No MRSA isolated. \n Staph aureus Screen (Final ___: \n NO STAPHYLOCOCCUS AUREUS ISOLATED. \n Blood Culture, Routine (Final ___: NO GROWTH. \n Blood Culture, Routine (Final ___: NO GROWTH. \n URINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING/STUDIES:\n========================== \nECG Study Date of ___ 8:44:30 ___ \nSinus rhythm. Delayed R wave progression across the precordium. \nPossible \nold anterior myocardial infarction. No previous tracing \navailable for \ncomparison. \n\nCHEST (PA & LAT) Study Date of ___ \nCardiomegaly with small bilateral pleural effusions and \npulmonary vascular \ncongestion. \n \nRENAL U.S. Study Date of ___ \nNo hydronephrosis. Numerous cysts are seen bilaterally in the \nkidneys. Mild caliectasis is noted in the right kidney and the \nleft renal pelvis is \nectatic.\n\nTTE ___\nThe left atrium is mildly dilated. The estimated right atrial \npressure is at least 15 mmHg. There is mild symmetric left \nventricular hypertrophy with normal cavity size. Overall left \nventricular systolic function is severely depressed \n(Quantitative (biplane) LVEF = 18%) secondary to akinesis of the \nmid-distal LV. The basal LV segments are normo to hypokinetic. \nDoppler parameters are indeterminate for left ventricular \ndiastolic function. Right ventricular chamber size is normal \nwith focal hypokinesis of the apical free wall. The aortic valve \nleaflets are moderately thickened. There is no aortic valve \nstenosis. No aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. There is no mitral valve \nprolapse. The mitral valve leaflets do not fully coapt. Moderate \n(2+) mitral regurgitation is seen. Moderate [2+] tricuspid \nregurgitation is seen. There is moderate pulmonary artery \nsystolic hypertension. [In the setting of at least moderate to \nsevere tricuspid regurgitation, the estimated pulmonary artery \nsystolic pressure may be underestimated due to a very high right \natrial pressure.] There is no pericardial effusion. \n\nIMPRESSION: Severe regional and global systolic dysfunction \nsuggestive of CAD. Moderate functional mitral regurgitation. \nFocal right ventricular systolic dysfunction with moderate \ntricuspid regurgitation and moderate pulmonary artery systolic \nhypertension. \n\nTTE ___\nOverall left ventricular systolic function is severely depressed \n(LVEF<= 20 %). An Impella catheter is seen in the left \nventricualr apex. The inlet area appears to be advanced slightly \ntoo far into the LV (~5.4cm), but the color doppler signal is \nconsistent with appropriate outflow location when interrogated \nfrom the apical 5-chamber view (standard would be form the \nparasternal view). Right ventricular chamber size is normal with \nfocal hypokinesis of the apical free wall. Mild (1+) aortic \nregurgitation is seen. [Due to acoustic shadowing, the severity \nof aortic regurgitation may be significantly UNDERestimated.] \nThe mitral valve leaflets are mildly thickened. Moderate [2+] \ntricuspid regurgitation is seen. \n\nTTE ___\nOverall left ventricular systolic function is severely \ndepressed. No masses or thrombi are seen in the left ventricle. \nThe IMPELLA appears imrpoerply positioned with inflow about 3.0 \ncm below the aortic valve from an apical view. The outflow \nappears above the aortic valve but not well seen. RV with \ndepressed free wall contractility. There is no pericardial \neffusion. Mild AR and MR are suggested.\n\nCompared with the prior study (images reviewed) of ___, \nthe inflow may have migrated closer to the aortic valve. MR and \nAR are similar. Basal lateral LV systolic function appears more \nvigorous. \n\nDISCHARGE LABS:\n=============================\n___ 06:30AM BLOOD WBC-8.3 RBC-3.77* Hgb-10.0* Hct-32.6* \nMCV-87 MCH-26.5 MCHC-30.7* RDW-16.6* RDWSD-52.3* Plt ___\n___ 06:30AM BLOOD Plt ___\n___ 06:30AM BLOOD Glucose-99 UreaN-47* Creat-1.5* Na-139 \nK-4.0 Cl-96 HCO3-33* AnGap-14\n___ 06:30AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.___ year old female with no known PMH though patient has not seen \nPCP ___ ___ years presents with a chief complaint of dyspnea on \nexertion found to have acute systolic heart failure. \n\n# ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE: \nThe patient presented with progressive dyspnea, found to have \nelevated BNP and CXR with pulmonary edema. TTE showed severe \nsystolic dysfunction with EF of 18%. CHF was thought to be \nprecipitated by ischemia as the patient presented with elevated \ntroponin. The patient was started on metoprolol and aspirin (see \nbelow). ACEi was not started given ___ and soft pressures and \nunknown baseline (see below). She was treated with repeated \ndoses of 20mg IV furosemide, but ultimately was transferred to \nthe CCU for further management due to concern for cardiogenic \nshock. In the CCU she underwent RHC and LHC notable for \ncardiogenic shock and an impella was placed and removed as \nfurther described below. She also had a swan placed for \nmonitoring in the CCU which was removed prior to transfer to the \nfloor. She diuresed well with IV Lasix, and was euvolemic upon \ntransfer to the floor. She continued to autodiurese on the floor \nthought secondary to post ATN diuresis. She had an episode of \nshortness of breath prior to discharge that was thought to be \ndue to volume overload, and was restarted on IV lasix with good \neffect. This was transitioned to 80 mg torsemide on discharge. \nAs an outpatient will need consideration of ICD/lifevest. \n\n# CAD s/p NSTEMI: \nThe patient presented with vague symptoms of chest pain and \ndyspnea. ECG as outside facility showed old anterior infarct. \nUpon CCU transfer, patient had uptrending MB and Troponins, \nconcerning for ongoing NSTEMI. ECG showed stable anterior Q \nwaves with poor R wave progression. Trops peaked at 5.33 on \n___. Pt had cath on ___, which showed severe 3 vessel \ndisease: LMCA 99% at ostium, LAD 95%, LCX mid 70%, RCA mid 90%. \nCABG recommended, but CT surgery evaluated her on ___, and \ndetermined she was not a surgical candidate. Underwent PCI and \nImpella placement ___ c/b displacement of Impella on ___ and \n___ with bedside repositioning as well as ongoing bleeding \nfrom femoral access sites requiring 3 U pRBCs. The impella was \nremoved on ___. She was started on Aspirin 81mg daily, \nmetoprolol, Atorvastatin 80mg daily, and Plavix 75mg daily which \nwere continued on discharge.\n\n# ___ on CKD: On admission, patient had ___ on CKD with \nuptrending BUN/Cr > 20 consistent with pre-renal picture and \nconcerning for cardiogenic shock. Also had received contrast, so \nthe ___ was thought to be possibly multifactorial with \ncontribution from post-contrast nephropathy as well. She had \nmultiple loads of contrast with a second catheterization/PCI \n___. The patient was evaluated with renal US which showed no \nobstruction but some evidence of ectatic cortex of left kidney. \nThe patient's creatinine ultimately peaked at 4.2 on ___. The \ncreatinine subsequently downtrended and on discharge the \npatient's creatinine was 1.5. \n\n# UTI: \nThe patient was found to have positive UA. Though she did not \nreport symptoms of dysuria, she was treated with ciprofloxacin \nx3 days given additional comorbidities. \n\n# THROMBOCYTOPENIA:\nPatient had decreasing platelets since admission. She had never \nhad heparin before, with score of 5 for HIT. Discontinued \nheparin on ___. Differential also included shearing from \nimpella device. HIT antibody was 0.47. The patient's heparin \nproducts were discontinued and platelets uptrended to within \nnormal limits. The Serotonin Release Assay was sent and was \npending at discharge. Platelets at discharge were 351.\n\n# ANEMIA: Unknown baseline. Patient found to have iron studies \nconsistent with iron deficiency anemia. Patient has never had hx \ncolonoscopy. Patient without hx of melena/hematochezia or \nhemoptysis. There was also thought to be a contribution from \nbleeding during her CCU course as described above. The patient \nwas started on iron supplementation and should f/u as outpatient \nfor colonoscopy. Hgb 10 on discharge. \n\n# TRANSAMINITIS: The patient was found to have a transaminitis \nduring the admission that was thought to be due to congestion \nvs. poor perfusion in the setting of cardiogenic shock. This \nimproved with treatment of the cardiogenic shock. \n\n# FATIGUE: The patient was noted to profoundly fatigued during \nthe end of her admission. course including acute systolic heart \nfailure/cardiogenic shock requiring PCI and impella assist as \nabove, renal failure, and iron deficiency anemia. Patient's mood \nappeared down overall, and SW was consulted.\n\n# DIABETES: Patient was found to have HbA1c of 6.5% on \nadmission. She will need follow up as an outpatient for \nmanagement. \n\nTransitional Issues\n=====================\n# Anemia: Please follow up her CBC at next follow up, Hgb 10 \nlikely from chronic disease. \n# Acute on Chronic Systolic Heart Failure: Please continue to \ntrend Cr and trend weights. Patient was tolerating torsemide \nprior to discharge. \n# Diabetes Mellitus Type II: HgbA1c 6.5% - not started on any \nmedications for diabetes while inpatient. Please monitor sugars. \n\n# Acute Decompensated Heart Failure: Please re-evaluate and when \nblood pressure can tolerate, start low dose lisinopril. Consider \naddition of spironolactone and consider placement of ICD pending \npossible improvement in cardiac function and resolution ___\n# Anemia: Consider EGD/colonoscopy as outpatient for further \nwork-up of iron deficiency anemia \n\nDISCHARGE WEIGHT: 58.4 kg\nDISCHARGE Cr: 1.5\n\n# CODE: Full \n# CONTACT: ___, daughter ___ \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. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Clopidogrel 75 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Multivitamins W/minerals 1 TAB PO DAILY \n7. Senna 17.2 mg PO QHS:PRN CONSTIPATION \n8. TraZODone ___ mg PO QHS:PRN insomnia \n9. Metoprolol Succinate XL 37.5 mg PO DAILY \n10. Torsemide 80 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses\n====================\nacute systolic heart failure\ncoronary artery disease s/p percutaneous coronary intervention \nwith drug eluting stent to LAD and LCMA\ntype 2 diabetes\niron deficiency anemia\nthrombocytopenia\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 at ___. \nYou were admitted to the hospital with shortness of breath. You \nwere found to have heart failure. This was likely caused by \ncoronary artery disease. You were evaluated with an ultrasound \nof your heart which showed poor heart function. You had to be \ntreated briefly with a device called an Impella to help pump \nblood in your body. You were evaluated with a cardiac \ncatheterization which showed coronary artery disease. You were \nevaluated by the cardiac surgeons who did not believe you were a \ncandidate for cardiac surgery, so you were treated with stents \nto help keep the arteries in your heart open. \n\nYou were started on several medications to help protect your \nheart and help your heart function. Your medications are and \nappointments are listed below. \n\nAfter discharge, please weight yourself daily and call your \ndoctor if your weight goes up more than 3 pounds. \n\nWe wish you the best! \nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I214", "R570", "I5023", "N179", "N390", "D62", "I97610", "T82528A", "D696", "I083", "I2584", "I2510", "I252", "E119", "D509", "R740", "Z87891", "T508X5A", "Y840", "R5383", "N189", "D72829", "M549", "N141", "Y848", "Y92230" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "R570: Cardiogenic shock", "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "D62: Acute posthemorrhagic anemia", "I97610: Postprocedural hemorrhage of a circulatory system organ or structure following a cardiac catheterization", "T82528A: Displacement of other cardiac and vascular devices and implants, initial encounter", "D696: Thrombocytopenia, unspecified", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I2584: Coronary atherosclerosis due to calcified coronary lesion", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "E119: Type 2 diabetes mellitus without complications", "D509: Iron deficiency anemia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z87891: Personal history of nicotine dependence", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "Y840: Cardiac catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "R5383: Other fatigue", "N189: Chronic kidney disease, unspecified", "D72829: Elevated white blood cell count, unspecified", "M549: Dorsalgia, unspecified", "N141: Nephropathy induced by other drugs, medicaments and biological substances", "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", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "N179", "N390", "D62", "D696", "I2510", "I252", "E119", "D509", "Z87891", "N189", "Y92230" ]

[]

[ " \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:\nrectal cancer\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic Low Anterior Resection\nIleostomy takedown \n\n \nHistory of Present Illness:\nThe patient is a ___ man with previously\nidentified malignant polyp that was removed. He had multiple\ndiscussions. He chose to proceed with observation, which was\ndone. However, on the recent colonoscopy, a polyp was noted\nto be regrowing, although the biopsies were negative. We had\nadditional number of discussions whether to proceed with\ntransanal excision versus LAR, and he chose to proceed with\nradical excision. Risks and benefits including but not\nlimited to infection, bleeding, leak, injury to surrounding\norgans, conversion to open, need for more procedures were\ndiscussed, urinary, sexual dysfunction. The patient\nunderstood and agreed.\n \nPast Medical History:\nHypertension, essential \n Hypertriglyceridemia \n Fatty liver \n Pulmonary nodule/lesion, solitary \n Alcohol abuse \n Obesity \n Proliferative diabetic retinopathy(362.02) \n Amblyopia \n Uncontrolled type 2 diabetes mellitus with proteinuric diabetic \nnephropathy \n Hyperlipidemia associated with type 2 diabetes mellitus \n Spondylosis of cervical joint \n Proteinuria \n B12 deficiency \n Cancer of rectum \n PROGRAM - Clinical Pharmacy Medication Management (not Dx, for \nprob list only) \n Chronic right-sided low back pain without sciatica \n Coronary artery calcification seen on CT scan \n Liver nodule \n \nSocial History:\n___\nFamily History:\nnon-contributory \n \nPhysical Exam:\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended, incisions well approximated \nExt: WWP.\nNEURO: A&Ox3, no focal neurologic deficits\nPSYCH: normal judgment/insight, normal memory, normal \nmood/affect\n \nPertinent Results:\n___ 10:25PM POTASSIUM-4.7\n___ 10:25PM MAGNESIUM-1.4*\n___ 10:25PM HCT-32.5*\n \nBrief Hospital Course:\nMr. ___ presented to ___ holding at ___ on ___ for a \nlaparoscopic low anterior resection. During the procedure, his \nureter was severed and required a ureteral stent to be placed \nintraoperatively. He tolerated the procedure well despite the \ncomplication (Please see operative note for further details). \nAfter a brief and uneventful stay in the PACU, the patient was \ntransferred to the floor for further post-operative management. \nWhen he arrived on the floor, he failed his foley void trial and \na foley catheter was replaced in his bladder. Over the next \nseveral days, his post-operative course was further complicated \nby high ileostomy output. He was trialed on a variety of \nmedications to decrease his ostomy output but he continued to \nlose large amounts of fluid through his stoma. He became \nhyponatremic and was treated with a high sodium diet, free water \nrestriction, and IV normal saline boluses. His electrolyte \nabnormalities slowly resolved but he continued to have high \nostomy output and he was taken back to the operating room on \n___ for an ileostomy reversal. He was initially kept NPO \nafter the procedure but was slowly advanced to a regular diet, \nwhich he tolerated well. He underwent a third foley-catheter \nvoid trial, but again failed and a foley catheter was placed in \nhis bladder. During his hospitalization, he remained stable from \na cardiovascular standpoint and his vital signs were routinely \nmonitored. He also had good pulmonary toileting, as early \nambulation and incentive spirometry were encouraged throughout \nhospitalization. He was found to have a urinary tract infection \nand was started on a prescription for ciprofloxacin. \nAdditionally, he developed a minor soft-tissue infection on his \nabdomen which resolved after a short course of Keflex. During \nhis hospitalization, his blood levels were checked daily to \nmonitor for signs of bleeding. The patient received subcutaneous \nheparin and ___ dyne boots were used during this stay. He was \nencouraged to get up and ambulate as early as possible. The \npatient is being discharged on a prophylactic dose of Lovenox. \n\nOn ___, the patient was discharged to home. At discharge, he \nwas tolerating a regular diet and ambulating independently. He \nhad a foley catheter in place and an appointment was scheduled \nat the outpatient ___ clinic for a void trial. He will \nfollow-up in the colorectal surgery clinic in ___ weeks. This \ninformation was communicated to the patient directly prior to \ndischarge.\n\nPost-Surgical Complications During Inpatient Admission:\n[ ] Post-Operative Ileus resolving w/o NGT\n[x] Post-Operative Ileus requiring management with NGT\n[x] 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] Intraoperative ureteral injury resulting in post-operative \nfoley catheter placememt and JP drain placement. \n\nSocial Issues Causing a Delay in Discharge:\n[ ] Delay in organization of ___ services\n[ ] Difficulty finding appropriate rehab hospital disposition.\n[ ] Lack of insurance coverage for ___ services\n[ ] Lack of insurance coverage for prescribed medications.\n[ ] Family not agreeable to discharge plan.\n[ ] Patient knowledge deficit related to ileostomy delaying \ndispo\n[x] No social factors contributing in delay of discharge.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Hydrochlorothiazide 25 mg PO DAILY \n2. MetFORMIN (Glucophage) 1000 mg PO BID \n3. amLODIPine 5 mg PO DAILY \n4. GlipiZIDE 10 mg PO BID \n5. Lisinopril 40 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Glargine 22 Units Bedtime\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*13 Tablet Refills:*0 \n3. Enoxaparin Sodium 40 mg SC DAILY \nRX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous once a day \nDisp #*8 Syringe Refills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0 \n5. Tamsulosin 0.4 mg PO QHS \n6. Glargine 20 Units Bedtime \n7. amLODIPine 5 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. GlipiZIDE 10 mg PO BID \n10. Hydrochlorothiazide 25 mg PO DAILY \n11. Lisinopril 40 mg PO DAILY \n12. MetFORMIN (Glucophage) 1000 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRectal Cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital after a laparoscopic low \nanterior resection to treat your rectal cancer. Samples of \ntissue were taken and the pathology results were reviewed with \nyou during your hospitilization. Due to the high volume output \nof your new ileostomy, you were trialed on new medications. \nAfter several weeks, you were taken back to the OR to have an \nileostomy reversal. \n\nYou have recovered from this procedure well and you are now \nready to return home. You are tolerating a regular diet, passing \ngas and your pain is controlled with pain medications by mouth. \n\nPlease monitor your bowel function closely. You may or may not \nhave had a bowel movement prior to discharge which is \nacceptable; however it is important that you have a bowel \nmovement in the next ___ days. After anesthesia it is not \nuncommon for patients to have some decrease in bowel function \nbut you should not have prolonged constipation. Some loose stool \nand passing of small amounts of dark, old appearing blood are \nexpected. However, if you notice that you are passing bright red \nblood with bowel movements or having large amounts of loose \nstool without improvement please call the office or go to the \nemergency room. While taking narcotic pain medications you are \nat risk for constipation. Please take an over the counter stool \nsoftener such as Colace, and if the symptoms do not improve call \nthe office. If you are passing loose stool without improvement \nplease call the office or go to the emergency room if you are \nhaving symptoms of dehydration: headache, lightheadedness, \ndizziness, dark urine, or dry mouth. \n\nWhile taking narcotic pain medications there is a risk that you \nwill have some constipation. Please take an over the counter \nstool softener such as Colace, and if the symptoms does not \nimprove call the office. It is also not uncommon after an \nileostomy takedown to have frequent loose stools until you are \ntaking more regular food however this should improve.\n\nThe muscles of the sphincters have not been used in quite some \ntime and you may experience urgency or small amounts of \nincontinence, however, this should improve. If you do not see \nimprovement in these symptoms within ___ days please call the \noffice. If you experience any of the following symptoms please \ncall the office or go to the emergency room: increasing \nabdominal distension, increasing abdominal pain, nausea, \nvomiting, inability to tolerate food or liquids, prolonged loose \nstool, or constipation.\n\nYou have a small wound where the old ileostomy once was. This \nshould be covered with a dry sterile gauze dressing. Please \nmonitor the incision for signs and symptoms of infection \nincluding: increasing redness and pain at the incision site, \ndraining of white/green/yellow/foul smelling drainage, or if you \ndevelop a fever. If you develop these symptoms please call the \noffice or go to the emergency room. You may shower, let the warm \nwater run over the wound line and pat the area dry with a towel, \ndo not rub. Please apply a new gauze dressing after showering.\n\nPain\nIt is expected that you will have pain after surgery, this will \ngradually improve over the first week or so you are home. You \nshould continue to take 2 Extra Strength Tylenol (___) for \npain every 8 hours around the clock. Please do not take more \nthan 3000mg of Tylenol in 24 hours or any other medications that \ncontain Tylenol such as cold medication. Do not drink alcohol \nwhile taking Tylenol. You may also take Advil (Ibuprofen) 600mg \nevery 8 hours for 7 days, please take Advil with food. If these \nmedications are not controlling your pain to a point where you \ncan ambulate and perform minor tasks, you should take a dose of \nthe narcotic pain medication oxycodone. Please do not take \nsedating medications or drink alcohol while taking the narcotic \npain medication. Do not drive while taking narcotic medications.\n\nActivity\nYou may feel weak or \"washed out\" for up to 6 weeks after \nsurgery. Do not lift greater than a gallon of milk for 3 weeks. \nAt your post op appointment, your surgical team will clear you \nfor heavier exercise. In the meantime, you may climb stairs, \nand go outside and walk. Please avoid traveling long distances \nuntil you speak with your surgical team at your post-op visit. \nAgain, please do not drive while taking narcotic pain \nmedications. \n\nYou will be discharged home on Lovenox injections to prevent \nblood clots after surgery. You will take this for 30 days after \nyour surgery date, please finish the entire prescription. This \nwill be given once daily. Please follow all nursing teaching \ninstruction given by the nursing staff. Please monitor for any \nsigns of bleeding: fast heart rate, bloody bowel movements, \nabdominal pain, bruising, feeling faint or weak. If you have any \nof these symptoms please call our office or seek medical \nattention. Avoid any contact activity while taking Lovenox. \nPlease take extra caution to avoid falling.\n\nFoley catheter instructions:\n\nReturn to the emergency department if:\n•Your catheter comes out.\n•You suddenly have material that looks like sand in the tubing \nor drainage bag.\n•No urine is draining into the bag and you have checked the \nsystem.\n•You have pain in your hip, back, pelvis, or lower abdomen.\n•You are confused or cannot think clearly.\n\nContact your healthcare provider ___:\n•You have a fever.\n•You have bladder spasms for more than 1 day after the catheter \nis placed.\n•You see blood in the tubing or drainage bag.\n•You have a rash or itching where the catheter tube is secured \nto your skin.\n•Urine leaks from or around the catheter, tubing, or drainage \nbag.\n•The closed drainage system has accidently come open or apart.\n•You see a layer of crystals inside the tubing.\n•You have questions or concerns about your condition or care.\n\nCare for your Foley catheter:\n•Clean your genital area 2 times every day. Clean your catheter \nand the area around where it was inserted. Use soap and water. \nClean your anal opening and catheter area after every bowel \nmovement.\n•Secure the catheter tube so you do not pull or move the \ncatheter. This helps prevent pain and bladder spasms. Healthcare \nproviders ___ show you how to use medical tape or a strap to \nsecure the catheter tube to your body.\n•Keep a closed drainage system. Your Foley catheter should \nalways be attached to the drainage bag to form a closed system. \nDo not disconnect any part of the closed system unless you need \nto change the bag.\n\nCare for your drainage bag:\n•Ask if a leg bag is right for you. A leg bag can be worn under \nyour clothes. Ask your healthcare provider for more information \nabout a leg bag.\n•Keep the drainage bag below the level of your waist. This helps \nstop urine from moving back up the tubing and into your bladder. \nDo not loop or kink the tubing. This can cause urine to back up \nand collect in your bladder. Do not let the drainage bag touch \nor lie on the floor.\n•Empty the drainage bag when needed. The weight of a full \ndrainage bag can be painful. Empty the drainage bag every 3 to 6 \nhours or when it is 75% full.\n•Clean and change the drainage bag as directed. Ask your \nhealthcare provider how often you should change the drainage bag \nand what cleaning solution to use. Wear disposable gloves when \nyou change the bag. Do not allow the end of the catheter or \ntubing to touch anything. Clean the ends with an alcohol pad \nbefore you reconnect them.\n\nWhat to do if problems develop:\n•No urine is draining into the bag: ___ for kinks in \nthe tubing and straighten them out. Check the tape or strap used \nto secure the catheter tube to your skin. Make sure it is not \nblocking the tube. Make sure you are not sitting or lying on the \ntubing.Make sure the urine bag is hanging below the level of \nyour waist.\n\n•Urine leaks from or around the catheter, tubing, or drainage \nbag: Check if the closed drainage system has accidently come \nopen or apart. Clean the catheter and tubing ends with a new \nalcohol pad and reconnect them.\n\nPrevent an infection:\n•Wash your hands often. Wash before and after you touch your \ncatheter, tubing, or drainage bag. Use soap and water. Wear \nclean disposable gloves when you care for your catheter or \ndisconnect the drainage bag. Wash your hands before you prepare \nor eat food. \n•Drink liquids as directed. Ask your healthcare provider how \nmuch liquid to drink each day and which liquids are best for \nyou. Liquids will help flush your kidneys and bladder to help \nprevent infection.\n\nThank you for allowing us to participate in your care, we wish \nyou all the best! \n \nFollowup Instructions:\n___\n" ]

[ "C20", "C7989", "T83511A", "N390", "N9972", "T814XXA", "E871", "K567", "B965", "R339", "E113599", "E11649", "E1142", "E1121", "K760", "E784", "M47892", "I10", "Y846", "Y832", "Y92234", "Z794", "Z87891", "Y92230", "B9689" ]

[ "C20: Malignant neoplasm of rectum", "C7989: Secondary malignant neoplasm of other specified sites", "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "N390: Urinary tract infection, site not specified", "N9972: Accidental puncture and laceration of a genitourinary system organ or structure during other procedure", "T814XXA: Infection following a procedure", "E871: Hypo-osmolality and hyponatremia", "K567: Ileus, unspecified", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "R339: Retention of urine, unspecified", "E113599: Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eye", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "K760: Fatty (change of) liver, not elsewhere classified", "E784: Other hyperlipidemia", "M47892: Other spondylosis, cervical region", "I10: Essential (primary) hypertension", "Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "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", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere" ]

[ "N390", "E871", "I10", "Z794", "Z87891", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, nausea, vomiting \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPer admission note: ___ Hx rectal CA s/p robotic LAR, diverting \nloop ileostomy\n(reversed), repair L ureteral injury in ___ now presenting\nwith abdominal pain and N/V.\n\nSudden onset crampy, intermittent LLQ abdominal pain at 11 AM\ntoday that worsened during the day. Emesis x 3, bilious. \n+chills,\nno fevers. Denies nausea now. +flatus, multiple BMs last night\n\nHe completed FOLFOX about 3 weeks ago. Denies history of prior\nbowel obstructions.\n\nIn the ED, NGT was placed with 300 cc of light-colored output.\nPatient received 8 mg of IV morphine and 2 mg IV dilaudid.\n\n \nPast Medical History:\nPMH: rectal CA, HTN, DM\n\nPSH:\n___: Reversal of ileostomy and placement of left internal\njugular Port-A-Cath\n___: Robotic low anterior resection, diverting loop\nileostomy, repair of left ureteral injury.\n\n \nSocial History:\n___\nFamily History:\nnon-contributory \n \nPhysical Exam:\nAdmission Physical Exam:\n\nVS: 98.5, 104, 134/71, 18, 95% RA\nGen - NAD\nHeart - borderline tachycardic, regular rhythm\nLungs - CTAB\nAbdomen - soft, mildly distended, tender to deep palpation on \nthe\nleft, no rebound or guarding, well-healed abdominal incisions\nExtrem - warm, no edema\n\n========================\n\nDischarge Physical Exam:\n\n98.1, 132/86, 104, 18, 100%/RA\nGEN: NAD, A&Ox3\nHEENT: NCAT, EOMI\nCV: RRR, No JVD\nPULM: normal excursion, no respiratory distress\nABD: soft, mild distension, non tender, no rebound, no guarding \nEXT: WWP, no CCE, 2+ B/L radial\nNEURO: A&Ox3, no focal neurologic deficits\nPSYCH: normal judgment/insight, normal memory, normal \nmood/affect \n \nPertinent Results:\n___ 06:59AM BLOOD WBC-6.3 RBC-3.14* Hgb-9.4* Hct-29.1* \nMCV-93 MCH-29.9 MCHC-32.3 RDW-13.4 RDWSD-45.4 Plt ___\n___ 06:40AM BLOOD WBC-6.6 RBC-3.25* Hgb-9.8* Hct-30.5* \nMCV-94 MCH-30.2 MCHC-32.1 RDW-13.3 RDWSD-45.9 Plt ___\n___ 07:00AM BLOOD WBC-7.1 RBC-3.29* Hgb-10.1* Hct-30.9* \nMCV-94 MCH-30.7 MCHC-32.7 RDW-13.7 RDWSD-46.5* Plt ___\n___ 05:22AM BLOOD WBC-8.9 RBC-3.32* Hgb-10.1* Hct-30.9* \nMCV-93 MCH-30.4 MCHC-32.7 RDW-14.1 RDWSD-47.7* Plt ___\n___ 02:45PM BLOOD WBC-12.8* RBC-3.69* Hgb-11.1* Hct-33.8* \nMCV-92 MCH-30.1 MCHC-32.8 RDW-13.7 RDWSD-45.9 Plt ___\n___ 02:45PM BLOOD Neuts-87.1* Lymphs-6.7* Monos-4.1* \nEos-1.1 Baso-0.5 Im ___ AbsNeut-11.16* AbsLymp-0.86* \nAbsMono-0.53 AbsEos-0.14 AbsBaso-0.06\n___ 06:59AM BLOOD Glucose-165* UreaN-10 Creat-0.9 Na-143 \nK-4.3 Cl-102 HCO3-29 AnGap-12\n___ 06:40AM BLOOD Glucose-178* UreaN-15 Creat-1.0 Na-147 \nK-4.3 Cl-105 HCO3-30 AnGap-14\n___ 07:00AM BLOOD Glucose-121* UreaN-21* Creat-0.9 Na-147 \nK-4.3 Cl-105 HCO3-33* AnGap-9*\n___ 05:22AM BLOOD Glucose-146* UreaN-32* Creat-1.2 Na-142 \nK-4.7 Cl-105 HCO3-24 AnGap-13\n___ 02:45PM BLOOD Glucose-195* UreaN-24* Creat-1.0 Na-140 \nK-5.4 Cl-109* HCO3-16* AnGap-15\n___ 02:45PM BLOOD ALT-21 AST-24 AlkPhos-138* TotBili-0.7\n___ 02:45PM BLOOD Lipase-155*\n___ 06:59AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.7\n___ 06:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.6\n___ 07:00AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.5*\n___ 05:22AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.4*\n___ 02:45PM BLOOD Albumin-4.4\n___ 02:53PM BLOOD Lactate-1.7\n \nBrief Hospital Course:\nMr. ___ presented to the emergency department at ___ \n___ on ___ with complaints of abdominal \npain, nausea, and vomiting. The patient underwent a CT scan that \nshowed High-grade small-bowel obstruction with abrupt transition \npoint in the right lower quadrant and possible internal hernia, \nas\ndescribed above. The patient was examined by and admitted to the \ncolorectal surgery service for further management. The patient \nhad a nasogastric tube for bowel decompression, was given bowel \nrest, intravenous fluids, and symptom management. His abdominal \nexam was monitored closely which improved daily. The output from \nthe nasogastric tube was very high with greater than 2500cc \noutput daily and the patient required intermittent IV fluid \nboluses. On ___, the patient had a bowel movement. On ___, the \nnasogastric tube output decreased significantly. He was given a \nclamping trial with residual gastric output of 100cc, the tube \nwas sequentially removed. The patient was later advanced to and \ntolerated a regular diet. On ___, the patient was discharged \nto home. At discharge, he was tolerating a regular diet, passing \nflatus, voiding, and ambulating independently. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Lisinopril 40 mg PO DAILY \n2. Gabapentin 300 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. amLODIPine 5 mg PO DAILY \n5. GlipiZIDE 10 mg PO BID \n6. MetFORMIN (Glucophage) 1000 mg PO BID \n7. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Gabapentin 300 mg PO DAILY \n4. GlipiZIDE 10 mg PO BID \n5. Lisinopril 40 mg PO DAILY \n6. MetFORMIN (Glucophage) 1000 mg PO BID \n7. Tamsulosin 0.4 mg PO QHS \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 Mr. ___, \n\nYou were admitted to the hospital for a small bowel obstruction. \nYou were given bowel rest, intravenous fluids, and a nasogastric \ntube was placed in your stomach to decompress your bowels. Your \nobstruction has subsequently resolved after conservative \nmanagement. You are tolerating a regular diet, passing gas and \nyour pain is controlled with pain medications by mouth. \n \nIf you have any of the following symptoms please call the office \nor go to the emergency room if severe: increasing abdominal \ndistension, increasing abdominal pain, nausea, vomiting, \ninability to tolerate food or liquids, prolonged loose stool, or \nextended constipation.\n \nThank you for allowing us to participate in your care, we wish \nyou all the best! \n \nFollowup Instructions:\n___\n" ]

[ "K56609", "K458", "Z85038", "I10", "E119" ]

[ "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "K458: Other specified abdominal hernia without obstruction or gangrene", "Z85038: Personal history of other malignant neoplasm of large intestine", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications" ]

[ "I10", "E119" ]

[]

[ " \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 \nMajor Surgical or Invasive Procedure:\nNone\nattach\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 08:32AM BLOOD WBC-7.5 RBC-3.28* Hgb-13.7 Hct-40.7 \nMCV-124* MCH-41.8* MCHC-33.7 RDW-12.1 RDWSD-55.6* Plt ___\n___ 08:32AM BLOOD ___ PTT-66.7* ___\n___ 08:32AM BLOOD Plt ___\n___ 09:10PM BLOOD LD(___)-297*\n___ 08:32AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 08:32AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.4\n\nPERTINENT LABS:\n================\n___ 07:00PM BLOOD cTropnT-<0.01 proBNP-2117*\n___ 09:10PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-829*\n___ 09:10PM BLOOD LD(___)-297*\n\nIMAGING:\n=========\nCTA ___ (___): \nIMPRESSION: \n1. Multiple scattered pulmonary emboli involving lobar and \nsegmental branches bilaterally, largest within the right main \npulmonary artery and bifurcation of the left main pulmonary \nartery. Evidence of right heart strain.\n2. Multiple pulmonary nodules in the right upper lobe and right \nlower lobe measuring up to 3 mm. Several are stable although a \nfew may be new. \nIn a low risk patient, no follow-up suggested. In high risk \npatient, follow-up chest CT in ___ year can be performed.\n3. No discrete infarct or infiltrate. Mild mosaic attenuation \nthe lungs likely sequela of vascular occlusive disease, in the \nsetting of pulmonary emboli.\n4. Asymmetric focal soft tissue opacities in the right breast \nand mild sub areolar thickening. Suggest correlation with \nmammogram\n5. Heterogeneous right lobe of the thyroid gland, suboptimally \nvisualized. Consider correlation with thyroid ultrasound\n6. Small hiatal hernia. Possible hepatic steatosis.\n\nLLE US ___ (___):\nIMPRESSION: \nIn the left leg, there is occlusive thrombus within the \npopliteal vein and occlusive thrombus within the posterior \ntibial vein of the calf. \nPrior ___ left lower extremity venous ultrasound showed \nno DVT.\n\nCXR ___:\nIMPRESSION: \nThere are patchy opacities in the left lung base which may \nrepresent pulmonary infarcts or infection. There is no pulmonary \nedema, pleural effusion or pneumothorax. The cardiomediastinal \nsilhouette is stable in appearance. There is prominence of the \ncentral pulmonary arteries. No acute osseous abnormalities are \nidentified.\n\nTTE ___:\nQuantitative biplane left ventricular ejection fraction is 71 % \n(normal 54-73%). IMPRESSION: Mildly dilated right ventricle with \nmild free wall hypokinesis. Mild tricuspid regurgitation with \nmoderate pulmonary arterial systolic hypertension. Normal left \nventricular wall thickness, cavity size and regional/global \nsystolic function.\n\nDISCHARGE LABS:\n=================\n___ 06:35AM BLOOD WBC-5.9 RBC-2.88* Hgb-12.0 Hct-36.3 \nMCV-126* MCH-41.7* MCHC-33.1 RDW-11.9 RDWSD-55.8* Plt ___\n___ 06:35AM BLOOD ___ PTT-73.0* ___\n___ 06:35AM BLOOD Plt ___\n___ 06:35AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-142 \nK-4.7 Cl-104 HCO3-25 AnGap-13\n___ 06:35AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.3\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVITALS: ___ 0744 Temp: 97.6 PO BP: 138/83 R Lying HR: 83 \nRR:\n18 O2 sat: 94% O2 delivery: Ra \nGENERAL: Well-appearing elderly female in no acute distress. \nNECK: Supple.\nHEART: Regular rate and rhythm, normal S1, S2, no murmurs, rubs \nor gallops\nLUNGS: Clear to auscultation bilaterally; expiratory wheezes \ndiffusely\nABDOMEN: Soft, nontender, nondistended with normoactive bowel \nsounds throughout.\nEXTREMITIES: Warm, well-perfused, slight edema on left ankle but \nimproved skin slightly red\n \nBrief Hospital Course:\nSUMMARY:\n===========\nMs. ___ is a ___ Female with a past medical history of \nmyeloproliferative disorder stable on hydroxyurea, remote DVT \nnot on AC, HTN, seizures, and thyroid disease who presented with \ntwo weeks of shortness of breath and leg swelling, found to have \nPE on outpatient work up, admitted for further management. She \nwas started on anticoagulation with a heparin gtt and ultimately \ndischarged on ___ bridge to warfarin as an outpatient.\n\nTRANSITIONAL ISSUE:\n===================\n[ ] Discharged on lovenox bridge to warfarin\n[ ] Follow up with PCP and need for ___ clinic\n[ ] Lisinopril held in the setting of normal BP/PE. Consider \nrestarting as an outpatient\n[ ] Will need follow-up with vascular medicine and heme/onc in \n___ months\n[ ] if she ever comes off phenytoin, she will be a candidate for \nDOAC\n\nACUTE ISSUES:\n=============\n#Submassive PE\nPatient with a history of DVT in ___ in the setting of Jak-2 + \nmyeloproliferative disease, no other identified provoking \nfactors, which was treated with lovenox/coumadin until her \ncounts normalized with hydroxyurea in ___. Presented with two \nweeks of LLE swelling and dyspnea. Outpatient work up included \nLLE DVT ultrasound which was positive for DVT and CT showed \n\"multiple scattered pulmonary emboli involving lobar and \nsegmental branches bilaterally, largest within the right main \npulmonary artery and bifurcation of the left main pulmonary \nartery along with evidence of right heart strain.\" Labs were \nnotable for elevated trop-T to 0.021 and proBNP to 2168 and TTE \nhad mildly dilated right ventricle with mild free wall \nhypokinesis with PASP 38, concerning for submassive PE. MASCOT \nwas consulted and recommended heparin without thrombolysis given \nclinical stability. She was started on heparin gtt and improved \nclinically. She was transitioned to lovenox bridge to warfarin. \nShe should follow up with her PCP and heme/onc provider for \nfurther management. Etiology felt ___ her myeloproliferative \ndisorder; she will likely need lifelong anticoagulation given \nrecurrent thromboembolic events.\n\nCHRONIC/STABLE ISSUES:\n========================\n#Hypothyroidism:\n- Continued home levothyroxine\n\n#Seizure:\n- Continued home Levetiracetam 500 BID\n- Continued home Phenytonin 100 mg BID except 200 mg QPM on \n___ and ___\n\n#Hypertention:\n-Held home Lisinopril given hypotension, restarted upon \ndischarge when became hypertensive\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 40 mg PO DAILY \n2. LevETIRAcetam 500 mg PO BID \n3. Hydroxyurea 500 mg PO DAILY \n4. Phenytoin Sodium Extended 100 mg PO QAM \n5. Phenytoin Sodium Extended 200 mg PO 2X/WEEK (MO,TH) \n6. Aspirin 81 mg PO DAILY \n7. Levothyroxine Sodium 100 mcg PO DAILY \n8. Phenytoin (Suspension) 100 mg PO 5X/WEEK (___) \n\n \nDischarge Medications:\n1. Enoxaparin Sodium 60 mg SC Q12H \n2. Warfarin 5 mg PO DAILY16 \nRX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once a day \nDisp #*10 Tablet Refills:*0 \n3. Aspirin 81 mg PO DAILY \n4. Hydroxyurea 500 mg PO DAILY \n5. LevETIRAcetam 500 mg PO BID \n6. Levothyroxine Sodium 100 mcg PO DAILY \n7. Phenytoin Sodium Extended 100 mg PO QAM \n8. Phenytoin Sodium Extended 200 mg PO 2X/WEEK (MO,TH) \n9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do \nnot restart Lisinopril until instructed by your primary care \nprovider\n\n \n___:\nHome\n \nDischarge Diagnosis:\n#Primary\nSubmassive PE\nDVT\nAcute hypoxic respiratory failure\n\n#Secondary \nHypothyroidism\nSeizure\nHypertension \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n===================================\n- Your primary care doctor was worried about your left leg \nswelling and shortness of breath \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n- You were found to have a blood clot in your lungs, and were \nstarted on blood thinners to treat the clot. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n============================================ \n- Please continue to take all your medications and follow up \nwith your doctors at your ___ appointments. \n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I2694", "I82492", "Z86718", "I10", "Z7901", "Z87891", "D473", "Z85828", "G40909" ]

[ "I2694: Multiple subsegmental pulmonary emboli without acute cor pulmonale", "I82492: Acute embolism and thrombosis of other specified deep vein of left lower extremity", "Z86718: Personal history of other venous thrombosis and embolism", "I10: Essential (primary) hypertension", "Z7901: Long term (current) use of anticoagulants", "Z87891: Personal history of nicotine dependence", "D473: Essential (hemorrhagic) thrombocythemia", "Z85828: Personal history of other malignant neoplasm of skin", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus" ]

[ "Z86718", "I10", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\nStatus post aortic valve replacement with a 21 ___ \n___\n\n \nHistory of Present Illness:\n___ with known h/o of aortic stenosis, initially admitted to \n___ on ___ for worsening DOE, now transferred to \n___ for evaluation for TAVR. DOE onset was over about ___ \nweeks prior to admission. Of note, patient reports that she has \nlost about 20 lbs over the past year. Was 175 lbs (79.4 kg) on a \nstanding scale at home a few days prior to presenting to \n___. \n Per ___ discharge summary, the patient has a \nhistory of known aortic stenosis for which she saw Dr. ___ \n___ 2 months prior to admission. She had been having \npalpitations at that time and had a Holter monitor in ___ \nwhich showed PVCs and PACs. TTE in ___ had showed \nmoderate-severe AS with mild MR and stage I diastolic \ndysfunction with EF 60-65%. \n At ___, CXR was within normal limits on ___. TTE, LHC \nand RHC were performed. It does not appear that any diuretics \nwere given. \n Labs at ___: \n Cr 0.9 w/ eGFR of 67 (___) \n Trop-I negative x1 (___) \n CK-MB 2.1 (___) \n EKG at ___ on ___ showed SR at 68bpm, ___, RBBB, first \ndegree AV block (PR 213ms). \n TTE on ___: normal EF (60-65%) and LV cavity size, moderately \nincreased LV wall thickness. Normal RV size, thickness and \nfunction. Severe thickening of AV and severe aortic stenosis. \nPeak gradient 65mmHg. Mean gradient 40mmHg. AV area 0.44 cm2. \nTrace/trivial AR. All other valves normal functioning. Mild PA \nsystolic hypertension (TR gradient 30mmHg). No effusion. \n RHC ___: \n - RA ___ (mean 7) \n - RV ___ (mean 8) \n - PCW ___ (mean 7) \n - PA ___ (mean 16) \n - Ao 130/63 (mean 90) \n - Fick: 4.77 / 2.49 (CO/CI) \n - Thermodilution: 3.8 / 1.98 (CO/CI) \n - AV gradient 60mmHg \n - AV area 0.55 cm2 \n LHC (___): \n - LM: No CAD \n - LAD: No CAD \n - LCx: No CAD \n - RCA: Non-dominant, No CAD \n On arrival to ___, patient has no complaints. She reports \nthat no diuretics were administered at ___. No \nchest pain at rest or with exertion. No SOB at present (and \nnever had it at rest, even on day of admission to ___. \nStill has SOB with exertion to the point where she can't climb 2 \nflights of stairs. \n\n \nPast Medical History:\n - Severe aortic stenosis \n - Hypertension \n - H/o coarctation of aorta (s/p repair at ___ years of age) \n - H/o patent foramen ovale (s/p closure at ___ years of age) \n - H/o rheumatic fever 3x \n - H/o breast reduction surgery \n - H/o bladder suspension \n\n \nSocial History:\n___\nFamily History:\nMother: s/p ___ MIs and AAA.\n \nPhysical Exam:\nADMISSION EXAM\n===================\nVital Signs: T 98.0, 158/71, 73, 18, 98%RA \n Weight: 80.0 kg on admission standing \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n NECK: No JVD \n CV: Regular rate and rhythm, ___ systolic murmur appreciated at \nbase \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, trace bilateral pitting \nedema \n Neuro: CNII-XII intact, ___ strength upper/lower extremities \n Access: PIV\n\nDischarge exam:\nNeuro: alert, oriented and intact\nCV: SR-ST, S1S2 no m/r/g\nResp: bibasilar rales\nGI: soft, flat, non tender, + BS\nGU: voids\nSkin: midline incision c/d/I well appreoximated\n \nPertinent Results:\nADMISSION LABS\n======================\n___ 06:35AM BLOOD WBC-6.2 RBC-4.44 Hgb-12.7 Hct-39.1 MCV-88 \nMCH-28.6 MCHC-32.5 RDW-13.3 RDWSD-43.1 Plt ___\n___ 06:35AM BLOOD Neuts-59.1 ___ Monos-8.4 Eos-2.9 \nBaso-0.5 Im ___ AbsNeut-3.67 AbsLymp-1.79 AbsMono-0.52 \nAbsEos-0.18 AbsBaso-0.03\n___ 06:35AM BLOOD ___ PTT-31.2 ___\n___ 06:35AM BLOOD Glucose-87 UreaN-19 Creat-0.9 Na-141 \nK-4.0 Cl-104 HCO3-26 AnGap-15\n___ 06:35AM BLOOD ALT-45* AST-42* LD(LDH)-227 AlkPhos-76 \nTotBili-0.4\n___ 07:25AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 06:35AM BLOOD Albumin-3.8 Calcium-9.4 Phos-4.4 Mg-2.1\n___ 06:35AM BLOOD TSH-5.5*\n___ 06:35AM BLOOD %HbA1c-5.0 eAG-97\n\nIMAGING/STUDIES\n======================\nCXR ___:\nIMPRESSION: \nThere are no prior chest radiographs available for review. \n \nOr lingula projecting over the region of the aortic valve on the \nlateral view obscures heavy calcifications. \n\nECHO: ___\nThe left atrium is normal in size. Left ventricular wall \nthicknesses and cavity size are normal. Left ventricular \nsystolic function is hyperdynamic (EF>75%). There is a mild \nresting left ventricular outflow tract obstruction (less than \napical gradient). An apical intracavitary gradient is identified \nwith peak gradient 30mmHg. Right ventricular chamber size and \nfree wall motion are normal. The aortic root is mildly dilated \nat the sinus level. The ascending aorta is mildly dilated. A \nbioprosthetic aortic valve prosthesis is present. The aortic \nvalve prosthesis appears well seated, with normal leaflet/disc \nmotion and transvalvular gradients. The effective orifice \narea/m2 is normal (1.0; nl >0.9 cm2/m2). No aortic regurgitation \nis seen. The mitral valve leaflets are structurally normal. Mild \n(1+) mitral regurgitation is seen. There is moderate pulmonary \nartery systolic hypertension. There is a small pericardial \neffusion. There are no echocardiographic signs of tamponade. \n\n IMPRESSION: Well seated aortic valve bioprosthesis with \nhyperdynamic systolic function and normal transvalvular \ngradients. Small posterior pericardial effusion without \ntamponade. Dilated thoracic aorta. Moderate pulmonary \nhypertension.\n \nLungs fully expanded and clear. Cardiomediastinal and hilar \nsilhouettes and pleural surfaces are normal. \n\nCT CHEST ___:\nIMPRESSION: \n1. Heavily calcified aortic valve, in keeping with history of \nsevere aortic stenosis. Non dilated thoracic aorta, with only \nminimal atheromatous calcifications. These images are available \nfor review for preoperative planning. \n2. 3 incidentally detected small pulmonary nodules are \nstatistically very likely benign though require no definite \nfurther imaging followup in the absence of risk factors for lung \ncancer such as cigarette smoking history. If the patient has \nrisk factors for lung cancer, a ___ year followup CT would be \nrecommended. \n \nBrief Hospital Course:\n___ y/o F w/ PMH aortic stenosis, HTN, childhood history of \naortic coarctation repair transferred from OSH w/ 2 wk hx \nprogressive DOE, found to have severe aortic stenosis on echo. \nAdmitted to ___ on ___ and evaluated by cardiac surgery \nand after pre-op work up completed she was taken to the \noperating room on ___ where she underwent an AVR(#21mm \n___ tissue). See operative notes for details.\n\nOverall the patient tolerated the procedure well and \npost-operatively was transferred to the CVICU in stable \ncondition for recovery and invasive monitoring. POD 1 found \nthe patient extubated, alert and oriented and breathing \ncomfortably. The patient was neurologically intact and \nhemodynamically stable on no inotropic or vasopressor support. \nPost-operatively she developed CHB and wenchbach requiring \ntemporary epicardial pacing to maintain hemodynamic stability. \nShe also developed acute kidney injury and responded to volume \nresuscitation with albumin and PRBC for acute blood loss anemia. \nShe remained in the ICU until her native sinus rhythm returned \nand her ___ resolved. Once hemodynamically stable in sinus \nrhythm with a normal creat, low dose betablocker was started and \nuptitrated to oprimize HR and BP. She was gently diuresed toward \nthe preoperative weight. The patient was transferred to the \ntelemetry floor for further recovery. Chest tubes and pacing \nwires were discontinued without complication. The patient was \nevaluated by the physical therapy service for assistance with \nstrength and mobility. By the time of discharge on POD #8 the \npatient was deconditioned and ambulating with asssit, the wound \nwas healing and pain was controlled with oral analgesics. The \npatient was discharged to ___ TCU in good condition with \nappropriate follow up instructions.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. calcium carb-vitamin D3-vit K2 500 mg calcium- 200 unit-90 \nmcg oral DAILY \n2. Vitamin D 1000 UNIT PO DAILY \n3. irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY \n4. Multivitamins 1 TAB PO DAILY \n5. Omeprazole 40 mg PO BID \n6. Phenylephrine 0.5% Nasal Spray 2 SPRY NU BID:PRN congestion \n7. Ranitidine 150 mg PO QHS \n8. Semprex-D (acrivastine-pseudoephedrine) ___ mg oral BID:PRN \ncongestion \n9. Simvastatin 20 mg PO QPM \n\n \nDischarge Medications:\n1. Aspirin EC 81 mg PO DAILY \n2. azelastine 137 mcg (0.1 %) nasal BID \n3. Docusate Sodium 100 mg PO BID \n4. Furosemide 40 mg PO BID Duration: 7 Days \n5. Metoprolol Tartrate 25 mg PO TID \n6. Potassium Chloride 20 mEq PO BID Duration: 7 Days \n7. Senna 8.6 mg PO BID:PRN constipation \n8. TraMADol ___ mg PO Q6H:PRN Pain - Moderate \nRX *tramadol 50 mg ___ tablet(s) by mouth every 6 hours Disp \n#*45 Tablet Refills:*0 \n9. calcium carb-vitamin D3-vit K2 500 mg calcium- 200 unit-90 \nmcg oral DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 40 mg PO BID \n12. Ranitidine 150 mg PO QHS \n13. Simvastatin 20 mg PO QPM \n14. Vitamin D 1000 UNIT PO DAILY \n15. HELD- irbesartan-hydrochlorothiazide 300-12.5 mg oral DAILY \nThis medication was held. Do not restart \nirbesartan-hydrochlorothiazide until you see your cardiologist\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nStatus post aortic valve replacement with a 21 ___ \n___ \n\nSecondary:\nSevere aortic stenosis \nHypertension \nCoarctation of aorta s/p repair \nPatent foramen ovale s/p closure \nRheumatic fever 3x \nHyperlipidemia \nGastroesophageal reflux disease \nSquamous Cell carcinoma s/p excision \nStress incontinence s/p bladder suspension \nStage 1 diastolic dysfunction based on echo \n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\n \nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\nEdema: trace ___\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\n \nPlease NO lotions, cream, powder, or ointments to incisions\n \nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n \nNo driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\n \nNo lifting more than 10 pounds for 10 weeks\n \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 \nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "I080", "I442", "N179", "I110", "I5030", "I452", "D62", "I440", "E785", "K219", "Z006", "Z8774", "Z8589" ]

[ "I080: Rheumatic disorders of both mitral and aortic valves", "I442: Atrioventricular block, complete", "N179: Acute kidney failure, unspecified", "I110: Hypertensive heart disease with heart failure", "I5030: Unspecified diastolic (congestive) heart failure", "I452: Bifascicular block", "D62: Acute posthemorrhagic anemia", "I440: Atrioventricular block, first degree", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z006: Encounter for examination for normal comparison and control in clinical research program", "Z8774: Personal history of (corrected) congenital malformations of heart and circulatory system", "Z8589: Personal history of malignant neoplasm of other organs and systems" ]

[ "N179", "I110", "D62", "E785", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nagitation\n \nMajor Surgical or Invasive Procedure:\nIntubation ___\nExtubation ___\n \nHistory of Present Illness:\nMr. ___ is a ___ ___ year old M w/ hx of EtOH \nuse disorder presenting from ___ Center detoxification \npresenting with acute agitation. At around 8 ___, patient became \nacutely agitated at detox, swinging at staff members. He \nreportedly was new to the program in the last day or so. Police \nwere called who patient was placed in handcuffs and brought here \nwithout medication. In the ED, he was unable to give a coherent \nhistory. He denies other drug use except for taking a cup of an \nunknown drink while at detox. \n\nIn the ED, initial vitals were notable for tachycardia, \ntachypnea, and hypertension. He was noted to be diaphoretic, \ntachycardic, hypertensive, and tremulous. Serum and urine tox \nscreens were negative. Given agitation and being a danger to \nhimself, he was given 4 mg IV Ativan then Ketamine 300 mg IM \nwith no response. He began to be a danger to himself and the \ndecision was made to intubate. He was induced with etomidate \nand rocuronium and started on propofol and fentanyl drips \nafterwards. Toxicology was consulted who recommended adding on a \nmidazolam gtt for concern for severe EtOH withdrawal. Given \nconcern for\npossible pneumonia on chest x-ray, he was started on ceftriaxone \nand azithromycin initially. He was also given a liter of IV \nfluids and Tylenol for fever. Given altered mental status upon \nadmission, a head CT was ordered and the lumbar puncture was \nperformed. He was given vanc and ceftriaxone. Vital signs after \nintubation still notable for tachycardia, hypertension, and \nfever to 102.8. \n \nPast Medical History:\nEtOH use disorder\nSuspected EtOH cirrhosis \n \nSocial History:\n___\nFamily History:\nNo family history of liver disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================== \nVS: T 98.7 HR 86 BP 94/63 RR 35 SPO2 99% FIO2\nGEN: Chronically ill appearing male laying in bed, intubated and\nsedated \nHEENT: Pupils pinpoint, minimally reactive. No facial droop. ETT\nand OGT in place. Dried blood in oropharynx. R posterior\nhematoma. \nNECK: Elevated JVP\nCV: RRR. Nl s1/s2. Grade ___ systolic murmur heard throughout\nprecordium\nRESP: CTAB anteriorly. No wheezes, rales, or rhonchi. \nGI: Abd soft, non-tender, mildly distended. Hepatomegaly \npresent.\nNo fluid wave. No caput medusae.\nEXT: No ___. Diffuse ecchymoses on lower extremities. \nSKIN: Jaundiced. Spider angiomas on chest. \nNEURO: Intubated and sedated. Moving upper extremities when\nagitated. \n\nDISCHARGE PHYSICAL EXAM: \n======================== \nVITALS: T: 98.2 PO BP: 112 / 73 R Sitting HR: 84 RR: 17 SO2: 96 \nRA \nGEN: Well appearing\nHEENT: No scleral icterus. MMM.\nCV: RRR, ___ systolic murmur throughout.\nRESP: CTAB\nABD: soft, NDNT\nEXT: No c/c/e. Diffuse ecchymoses on lower extremities. \nSKIN: No jaundice. No spider angiomata.\nNEURO: Alert, oriented x3, intact attention. CN ___ intact.\nStrength ___ throughout. Gait normal.\n\n \nPertinent Results:\n===============\nAdmission labs\n===============\n___ 09:40PM BLOOD WBC-12.4* RBC-4.49* Hgb-14.8 Hct-46.1 \nMCV-103* MCH-33.0* MCHC-32.1 RDW-13.3 RDWSD-50.4* Plt ___\n___ 09:40PM BLOOD Neuts-57.2 ___ Monos-12.8 \nEos-0.4* Baso-0.4 Im ___ AbsNeut-7.07* AbsLymp-3.55 \nAbsMono-1.58* AbsEos-0.05 AbsBaso-0.05\n___ 09:40PM BLOOD ___ PTT-30.3 ___\n___ 09:40PM BLOOD Glucose-164* UreaN-11 Creat-1.1 Na-138 \nK-3.2* Cl-100 HCO3-10* AnGap-28*\n___ 09:40PM BLOOD ALT-107* AST-345* CK(CPK)-8309* \nAlkPhos-241* TotBili-4.5* DirBili-2.5* IndBili-2.0\n___ 09:40PM BLOOD Albumin-4.2 Calcium-9.4 Phos-3.3 Mg-2.1\n___ 12:00AM BLOOD Type-ART PEEP-5 pO2-128* pCO2-49* \npH-7.29* calTCO2-25 Base XS--3 Intubat-INTUBATED\n___ 10:31PM BLOOD Lactate-9.6*\n\n===============\nPertinent labs\n===============\n___ 03:01AM BLOOD VitB12-356\n___ 09:40PM BLOOD TSH-4.9*\n___ 03:01AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* HAV \nAb-POS*\n___ 09:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 03:01AM BLOOD HCV Ab-NEG\n\n===============\nDischarge labs\n===============\n___ 07:55AM BLOOD WBC-5.9 RBC-3.89* Hgb-13.0* Hct-40.3 \nMCV-104* MCH-33.4* MCHC-32.3 RDW-14.5 RDWSD-54.5* Plt ___\n___ 07:55AM BLOOD ___\n___ 07:55AM BLOOD Glucose-97 UreaN-6 Creat-0.6 Na-140 K-3.7 \nCl-106 HCO3-25 AnGap-9*\n___ 07:55AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.0\n___ 07:55AM BLOOD ALT-84* AST-117* AlkPhos-234* \nTotBili-2.6*\n\n===============\nStudies\n===============\nCXR ___: IMPRESSION: Status post intubation with appropriate \npositioning of the endotracheal tube in the lower trachea. \nPatchy bibasilar opacities which likely represent mild \natelectasis. Infection versus aspiration at the right lung base \nwould be possible. \n\nCT head w/o contrast ___: IMPRESSION: 1. No acute \nintracranial abnormality on noncontrast CT head. Specifically, \nno acute large territory infarct or intracranial hemorrhage. 2. \n1.8 cm subcutaneous soft tissue density about the right parietal \nscalp could represent a scalp hematoma in the posttraumatic \nsetting. Direct inspection recommended. 3. Extensive paranasal \nsinus disease. 4. Nasal cavity opacification is likely related \nto intubation. 5. Increased prominence of intracranial vessels \nwithout definitive evidence for inflammatory stranding of \nuncertain clinical significance. The superior ophthalmic veins \ndo not appear significantly enlarged nor do the extraocular eye \nmuscles to suggest cavernous sinus thrombosis or fistula. \n\nCT abd/pelvis ___: IMPRESSION: 1. Bibasilar pulmonary \nconsolidations worrisome for aspiration/pneumonia. 2. No \nevidence of acute cholecystitis. 3. Hepatomegaly with diffuse \ndecrease in parenchymal attenuation could suggest steatosis or \nacute hepatitis. \n\nECG ___: Normal sinus rhythm. Prolonged QTc\n\nCXR ___: IMPRESSION: Low bilateral lung volumes. Increased \nbibasilar opacities, left greater than right could reflect \natelectasis however pneumonia, particularly in the left lower \nlobe should be considered. New pulmonary vascular congestion and \nsmall bilateral pleural effusions. \n\n===============\nMicrobiology \n===============\n___ 1:50 am CSF;SPINAL FLUID # 3.\nGRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES \nSEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO \nGROWTH. \n\nURINE CULTURE ___: NEGATIVE\n\nBLOOD CULTURES ___: NEGATIVE\n\n \nBrief Hospital Course:\nSUMMARY: \n___ y/o ___ immigrant with h/o alcohol use disorder, no \nprior medical care, admitted from ___ detox for alcohol \nwithdrawal seizure requiring intubation and phenobarb load. \nCourse c/b aspiration pneumonia, alcoholic hepatitis, possible \ncirrhosis, and paranoid delusions. Discharge delayed by lack of \ninsurance.\n\n# Complex Alcohol Withdrawal with Seizures (resolved): Patient \npresented with agitation, tachycardia, hypertension, and fevers, \nmost likely due to alcohol withdrawal, resolved with phenobarb \nload. Workup for alternate cause has been negative including tox \nscreen, CT head, LP, and EEG. \n\n# Alcohol Use Disorder:\n# Suicide Attempt: He reports he was drinking ___ bottles of \nvodka daily with the\nintention to harm himself after being accused by friends of \ncrimes that he reports he did not commit. He denies any prior \nproblems with alcohol use. He endorsed ongoing passive SI to \nMICU team but no longer endorses this to floor team and does not \nappear to be an acute threat to himself or others. He is \nmotivated to quit drinking through religion (interested in AA) \nand amenable to medication assisted treatment. Addiction \nPsychiatry was consulted, started on oral naltrexone. \n\n# Resources: Does not have health insurance or PCP though should \nbe eligible for limited ___. High risk for alcohol \nrelapse and recurrent seizures, hepatitis, and psychiatric \ndecompensation unless has ongoing follow-up. He is scheduled for \nfollow-up at ___. \n\n# Paranoid delusions:\n# ?Traumatic brain injury: Patient's mental status has improved \nbut he continues to have\nfixed paranoid delusions regarding medical staff preventing \nfriends from visiting. Family confirms that patient has had \nthese symptoms for at least several weeks prior to \nhospitalization. His mental status appeared to worsen after he \nwas hit by a car several weeks ago. He did not seek medical \nattention due to lack of insurance and instead turned to alcohol \nfor analgesia. They also report he has struggled with \nsignificant significant psychosocial stress (wife imprisoned in \n___, leaving his two teenage daughters without an adult \ncaretaker; no stable employment or insurance). Workup for an \norganic cause for his symptoms has been negative including CT \nhead, LP, EEG, and thiamine load. He does not appear to be an \nacute threat to himself but would benefit from close mental \nhealth f/u for further assessment.\n\n# Acute Alcoholic Hepatitis\n# Possible Cirrhosis\n# Positive HBV core antibody with negative viral load: LFT \nabnormalities concerning for alcoholic hepatitis and RUQUS \nconcerning for underlying cirrhosis. HAV/HCV negative, HBV core \nantibody positive but viral load undetectable. His exam, labs, \nand imaging are concerning for underlying alcoholic cirrhosis \nand he should have further eval as outpatient. Fibroscan as \noutpatient, if cirrhosis confirmed, would benefit from HCC and \nvariceal screening. Offered HBV and PPSV-23 vaccines he is \ndeclining ___ will need both as outpatient. \n\nRESOLVED:\n# Aspiration PNA (resolved): Imaging consistent with aspiration \nPNA. Afebrile now on Augmenting, no worsening respiratory \nsymptoms. No evidence for hepatobiliary source on RUQUS. \nCultures thus far negative.\nFinished 7-day total course of antibiotics with \namoxicillin/clavulanate.\n\n# Thrombocytopenia (resolved):\n# Mild Coagulopathy: Plt nadired in ___ but now have normalized. \nOngoing mild ___ derangement not improved with Vitamin K. \nLikely underlying cirrhosis (see above). No e/o bleeding.\n\n# Rhabdomyolysis (resolved): Likely due to seizures and/or \nalcohol use. No known downtime or other trauma. Drug-induced \nrhabdo possible but tox screen negative. Renal function \nfortunately has remained stable. CK downtrended appropriately.\n\n# Tongue Swelling (resolved): Likely in setting of tongue biting \nduring seizure. s/p dexamethasone 10 mg x 3 doses but no \nevidence of anaphylaxis or angioedema.\n\n# Epigastric Pain: Suspect alcohol-related esophagitis/gastritis \nvs alcoholic hepatitis. ECG non-ischemic. Resolved while \ninpatient could consider ongoing omeprezaole, evaluation for H/ \nPylori if needed. \n\n# TSH Elevation: TSH elevated to 4.9 but unreliable iso critical \nillness. Would repeat in ___ weeks. \n\n \nTRANSITIONAL ISSUES:\n- repeat TSH in ___ weeks (elevated to 4.9 iso acute illness)\n- would continue nalexone (prvodied with one month prescription \nat discharge)\n - would consider IM naltrexone\n- would ensure routine healthcare screening including HIV is up \nto date \n- will need to complete HBV series (s/p HBV and pneumonia \nvaccines on ___\n- fibroscan as outpatient \n - If cirrhosis confirmed, would benefit from ___ and variceal \nscreening\n - was ordered for Hep B series, he declined \n- if recurrent epigastric pain while not drinking EtOH would \nconsider mgmt./evaluation for GERD vs peptic ulcer disease\n- #CONTACTS: ___ (Son) ___ ___ (friend who is \nstaying with) ___ \n- #CODE STATUS: Full, presumed\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ___ Original (aspirin-sod bicarb-citric acid) \n325-1,916-1,000 mg oral DAILY:PRN indigestion \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n# Complex Alcohol Withdrawal with Seizures\n# Alcohol Use Disorder\n# Acute Alcoholic Hepatitis\n# Possible Cirrhosis\n# Aspiration Pneumonia \n# Thrombocytopenia\n# Coagulopathy\n# Rhabdomyolysis \n# Lack of health insurance\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n___,\n\nFue un placer atenderlo en ___ Médico ___ \nDeaconess.\n\n¿POR QUÉ ESTABA ___ ___ HOSPITAL?\n- Tuvo una convulsión\n- Tuvo daño en ___ hígado.\n- Tuvo una infección en ___ (neumonía).\n\n¿QUÉ ME PASÓ ___ ___ HOSPITAL?\n- ___ y se mejoró.\n\n¿QUÉ ___ DESPUÉS DE ___ HOSPITAL?\n- ___ de tomar alcohol.\n- Vaya a Alcohólicos Anónimos y tome ___ para reducir \n___.\n- ___ una cita con ___ doctor ___.\n\n___ deseamos lo mejor!\n\nSinceramente,\n___ de ___\n\n=========================\nDear Mr. ___, \n\nIt was a pleasure caring for you at ___ \n___.\n\nWHY WAS I IN THE HOSPITAL? \n- You had a seizure\n- You had damage to your liver\n- You had an infection in your lungs (pneumonia)\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- We gave you medications and you got better\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n- Stop drinking alcohol.\n- Go to Alcoholics Anonymous and take your medicine to reduce \ncravings.\n- Make an appointment with your new doctor.\n\nWe wish you the best!\n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "F10231", "J690", "G92", "G4089", "M6282", "E872", "K7030", "K7010", "T510X2A", "F22", "D696", "S069X0A", "R1013", "R946", "Z597", "E876", "I4581", "S0093XA", "F209", "F39", "F6089", "R791", "D531", "R61", "I10", "G252", "S098XXA" ]

[ "F10231: Alcohol dependence with withdrawal delirium", "J690: Pneumonitis due to inhalation of food and vomit", "G92: Toxic encephalopathy", "G4089: Other seizures", "M6282: Rhabdomyolysis", "E872: Acidosis", "K7030: Alcoholic cirrhosis of liver without ascites", "K7010: Alcoholic hepatitis without ascites", "T510X2A: Toxic effect of ethanol, intentional self-harm, initial encounter", "F22: Delusional disorders", "D696: Thrombocytopenia, unspecified", "S069X0A: Unspecified intracranial injury without loss of consciousness, initial encounter", "R1013: Epigastric pain", "R946: Abnormal results of thyroid function studies", "Z597: Insufficient social insurance and welfare support", "E876: Hypokalemia", "I4581: Long QT syndrome", "S0093XA: Contusion of unspecified part of head, initial encounter", "F209: Schizophrenia, unspecified", "F39: Unspecified mood [affective] disorder", "F6089: Other specific personality disorders", "R791: Abnormal coagulation profile", "D531: Other megaloblastic anemias, not elsewhere classified", "R61: Generalized hyperhidrosis", "I10: Essential (primary) hypertension", "G252: Other specified forms of tremor", "S098XXA: Other specified injuries of head, initial encounter" ]

[ "E872", "D696", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nAll allergies / adverse drug reactions previously recorded have \nbeen deleted\n \nAttending: ___\n \nChief Complaint:\nabdominal distension \n \nMajor Surgical or Invasive Procedure:\nDiagnostic and therapeutic paracentesis bedside ___\nDiagnostic and therapeutic paracentesis bedside ___\n___ TIPS ___\nCentral venous line insertion ___\nDiagnostic paracentesis ___\n\n \nHistory of Present Illness:\n___ year old man with PBC c/b esophageal varices and ascites and \nschizoaffective disorder who presented to clinic yesterday with \nworsening abdominal distention in the setting of not taking his \ndiuretics. He has lost a tremendous\namount of weight and he has not been able to eat. \n\nPer OMR on ___, his PCP spoke to him because she had\nreceived an email from his psychiatrist that he reported that he\nis no longer taking his Lasix due to concerns that it is an\namphetamine and concerns about dizziness. At that point he \nagreed\nto restart his Lasix and spironolactone but his PCP did not feel\nconfident in him following through with this. On ___\nthere is a note from his psychiatrist that he had been seen in\nthe ___ ED 3 days prior with dizziness causing him to be unable\nto ambulate. He was seen by ___, labs were checked, and he was\ndischarged home. He had self decreased his Seroquel from 300 to\n200 mg qHS and his psychiatrist recommended decreasing his\nlamotrigine from 200 to 100 due to the concern that dizziness \nmay\nhave been related to this medication. A serum level of the\nmedication was checked while he was on 200 mg which was within\nnormal limits and thus it was felt that the lamotrigine was less\nlikely to be causing his dizziness.\n\nOn ___ he was seen by psychiatry at which point he had\nbeen doing \"all right\" on the reduced doses of his psychiatric\nmedications. \n\nIn the ED initial vitals: Temperature 97.4, heart rate 97, blood\npressure 143/91, respiratory rate 18, 98% on room air\n\n- Exam notable for: Tense, distended abdomen, non-tender. \nBreathing comfortable on room air with crackles at bilateral\nbases\n\n- Labs notable for:\nCBC: Hemoglobin 12.9, otherwise unremarkable\nChem7: Unremarkable\nLFTs: Unremarkable, except for albumin of 3.1\nCoags: Not obtained\nAscites: TNC of 685, 6% polys\nUrinalysis: 9 WBCs, 0 epis, 10 ketones, few bacteria, negative\nnitrite\n\n- Imaging notable for:\nRUQUS with Doppler: \n1. Cirrhosis with large ascites.\n2. Patent portal vein.\n\nCXR: Low lung volumes without focal consolidation or pulmonary\nedema.\n\n- Patient was given: Nothing\n\n- ED Course: Patient underwent diagnostic and therapeutic\nparacentesis for 2 L with improvement in symptoms.\n\nOn arrival to the floor he says he feels better after \ntherapeutic\nparacentesis. He says that last ___ he started to feel \ntired\nand fatigued and had some shortness of breath which has been\nworsening over the last 6 months or so. He can only walk about \n7\nblocks before feeling tired and short of breath at this time. \nHe\ndoes state that he feels that the diuretics are making him dizzy\nand so he has been only taking them about twice a week. He\ndenies dysuria, urinary frequency, hematuria, hematochezia,\nmelena. He endorses swelling around his ankles. He endorses\nchills but no fevers. He says that over the last ___ weeks he\nonly ate ___ boosts per day in addition to some juice and coffee\nand water. He says that he has been doing this in order to make\nhis stool softer and is afraid to eat regular food because it\nwill make him constipated. He says he did have a soft bowel\nmovement over the weekend but still feels constipated. He does\nsay that people have told him that he looks much thinner than\npreviously.\n\n \nPast Medical History:\nBPH\nDepression \nSchizoaffective disorder\nColon polyps\nPortal hypertensive gastropathy\nPrimary biliary cirrhosis complicated by ascites s/p banding and\nascites\nChronic cough, improved \n \nSocial History:\n___\nFamily History:\nFather died from complications from polio. His\nmother died at the age of ___ and she had a tumor removed at some\npoint (he thinks from her abdomen). Brother with stage IV rectal\ncancer who recently underwent surgery. He was diagnosed with\ncolon cancer in his late ___. \n\n \nPhysical Exam:\nADMISSION EXAM:\n===============\nVS: 98.1F, 129/84, HR 77, RR 18, on room air \nGENERAL: NAD, appears markedly cachectic with muscle wasting and\ntemporal wasting \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM\nNECK: supple, no LAD, no JVD\nHEART: RRR, S1/S2, no murmurs, gallops, or rubs\nLUNGS: Breathing comfortable on room air, crackles at the bases\nof his lungs bilaterally \nABDOMEN: distended but soft, nontender in all quadrants, no\nrebound/guarding, normoactive bowel sounds, right sided para \nsite\nwith bloody bandage in place \nEXTREMITIES: 2+ pitting edema to the knees bilaterally \nPULSES: 2+ DP pulses bilaterally\nNEURO: A&Ox3, moving all 4 extremities with purpose, no \nasterixis\n\nDISCHARGE EXAM:\n===============\nVS: 24 HR Data (last updated ___ @ 2340)\n Temp: 98.3 (Tm 100.3), BP: 127/72 (112-127/68-72), HR: 105\n(82-105), RR: 20 (___), O2 sat: 91% (89-100), O2 delivery: 2 L\nNc \nFluid Balance (last updated ___ @ 530) \n Last 8 hours Total cumulative 873ml\n IN: Total 873ml, TF/Flush Amt 447ml, IV Amt Infused 426ml\n OUT: Total 0ml, Urine Amt 0ml\n Last 24 hours Total cumulative 2001ml\n IN: Total 4061ml, PO Amt 120ml, TF/Flush Amt 748ml, IV Amt\nInfused 3193ml\n OUT: Total 2060ml, Urine Amt 2060ml, Flexiseal 0ml \nGEN: Elderly, frail man, lying in bed, appears uncomfortable\nHEENT: Anicteric sclerae. NG tube in place, dried blood in \nnares.\nCV: Normal rate and rhythm. Grade ___ systolic murmur.\nLungs: Clear to auscultation bilaterally without wheezes,\nrhonchi, or rales in anterior fields.\nAbdomen: Hyperactive bowel sounds throughout. Soft. \nSignificantly\ndistended, tympanitic to percussion. Mildly tender to deep\npalpation diffusely, no rebound or guarding.\nExtremities: Warm. No pitting edema.\nNeuro: Alert. Oriented to self, place ___ building\"). Not\noriented to year. Does not answer all questions or follow\ncommands appropriately. Dysarthric. No asterixis appreciated.\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:53PM WBC-7.4 RBC-4.41* HGB-12.9* HCT-41.4 MCV-94 \nMCH-29.3 MCHC-31.2* RDW-17.3* RDWSD-60.1*\n___ 05:53PM PLT COUNT-183\n___ 05:53PM NEUTS-72.6* LYMPHS-15.0* MONOS-11.2 EOS-0.8* \nBASOS-0.3 IM ___ AbsNeut-5.36 AbsLymp-1.11* AbsMono-0.83* \nAbsEos-0.06 AbsBaso-0.02\n___ 05:53PM GLUCOSE-76 UREA N-14 CREAT-0.8 SODIUM-139 \nPOTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-10\n___ 05:53PM ALT(SGPT)-32 AST(SGOT)-38 ALK PHOS-109 TOT \nBILI-1.5\n___ 05:53PM proBNP-560*\n___ 05:53PM LIPASE-15\n___ 05:53PM ALBUMIN-3.1* CALCIUM-9.1 PHOSPHATE-2.7 \nMAGNESIUM-2.2\n\nPERTINENT LABS:\n===============\n___ 07:05PM BLOOD 25VitD-49\n___ 04:41AM BLOOD CRP-52.0*\n___ 02:12PM ASCITES TNC-1131* RBC-120* Polys-48* Lymphs-2* \nMonos-10* Mesothe-5* Macroph-32* Other-3*\n___ 03:40PM URINE RBC-65* WBC-83* Bacteri-FEW* Yeast-NONE \nEpi-<1\n\nDISCHARGE LABS:\n===============\n___ 03:51AM BLOOD WBC-15.5* RBC-2.80* Hgb-8.4* Hct-27.1* \nMCV-97 MCH-30.0 MCHC-31.0* RDW-21.0* RDWSD-73.1* Plt ___\n___ 03:51AM BLOOD ___ PTT-46.5* ___\n___ 07:58AM BLOOD Glucose-150* UreaN-28* Creat-0.7 Na-150* \nK-4.1 Cl-114* HCO3-23 AnGap-13\n___ 03:51AM BLOOD ALT-27 AST-42* AlkPhos-109 TotBili-3.0* \nDirBili-0.9* IndBili-2.1\n___ 07:58AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.1\n___ 06:18AM BLOOD ___ pO2-206* pCO2-38 pH-7.42 \ncalTCO2-25 Base XS-0 Comment-GREEN TOP \n___ 10:32AM BLOOD Lactate-2.1*\n\nPERTINENT MICROBIOLOGY:\n=======================\n__________________________________________________________\n___ 10:52 pm STOOL CONSISTENCY: LOOSE Source: \nStool. \n\n C. difficile PCR (Pending): \n__________________________________________________________\n___ 9:45 pm BLOOD CULTURE 2 OF 2. \n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 9:30 pm BLOOD CULTURE Source: Line-CVL. \n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 3:40 pm URINE Source: Catheter. \n\n URINE CULTURE (Pending): \n__________________________________________________________\n___ 5:13 pm MRSA SCREEN Source: Nasal swab. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: No MRSA isolated. \n__________________________________________________________\n___ 2:12 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES\n PERITONEAL FLUID. \n\n Fluid Culture in Bottles (Pending): No growth to date. \n__________________________________________________________\n___ 2:12 pm PERITONEAL FLUID PERITONEAL FLUID. \n\n GRAM STAIN (Final ___: \n 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count, if \napplicable. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n__________________________________________________________\nTime Taken Not Noted Log-In Date/Time: ___ 11:44 am\n STOOL CONSISTENCY: FORMED Source: Stool. \n\n **FINAL REPORT ___\n\n C. difficile PCR (Final ___: \n NEGATIVE. \n (Reference Range-Negative). \n The C. difficile PCR is highly sensitive for toxigenic \nstrains of C.\n difficile and detects both C. difficile infection (CDI) \nand\n asymptomatic carriage. \n A negative C. diff PCR test indicates a low likelihood of \nCDI or\n carriage. \n__________________________________________________________\nTime Taken Not Noted Log-In Date/Time: ___ 11:03 am\n URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n__________________________________________________________\n___ 9:13 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 4:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES\n PERITONEAL FLUID. \n\n **FINAL REPORT ___\n\n Fluid Culture in Bottles (Final ___: NO GROWTH. \n__________________________________________________________\n\nPERTINENT IMAGING:\n===================\nLIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ \n\nIMPRESSION: \n1. Limited evaluation of the left hepatic lobe due to poor \nsonographic \nwindows. \n2. Cirrhosis with large volume ascites. \n3. Patent portal vein. \n\nTransthoracic Echocardiogram Report ___\nIMPRESSION: Normal biventricular cavity sizes and \nregional/global biventricular systolic function. Mild mitral \nregurgitation. Dilated thoracic aorta.\n\nCT CHEST W/CONTRAST Study Date of ___ \nIMPRESSION: \nMild-to-moderate diffuse interstitial lung disease may explain \nchronic cough. \nNS IP is the most likely diagnosis alternatively severe \nelevation of the \ndiaphragm due to ascites may be triggering coughing. \nFusiform aneurysm noncalcified ascending thoracic aorta, 50 mm \ndiameter. \n\nCT ABD & PELVIS WITH CONTRAST Study Date of ___ \nIMPRESSION: \n1. Cirrhotic liver without focal liver lesions. Evaluation for \nHCC is limited \non this portal venous phase contrast-enhanced study. Recommend \nfurther \nevaluation a dedicated liver CT which includes the noncontrast, \narterial, and 3 minutes delayed phases. The portal venous phase \ndoes not need to be \nrepeated. \n2. Large volume ascites, splenomegaly, and portosystemic varices \ncompatible with sequela of portal hypertension. \n3. Multiple pancreatic cystic lesions better evaluated on MR, \nlikely represent side branch IPMNs. Recommend attention on \nfollow-up imaging. \n4. Please refer to separate report of CT chest performed on the \nsame day for description of the thoracic findings. \n\nTIPS Study Date of ___ \nFINDINGS: \n1. Pre-TIPS right atrial pressure of 11 mm Hg and \nballoon-occluded portal \npressure measurement of 31 mm Hg resulting in portosystemic \ngradient of 20 \nmmHg. \n2. CO2 portal venogram predominantly shunted into alternative \nhepatic veins with minimal opacification of the portal vein. \n3. Contrast enhanced portal venogram showing patent portal \nvenous system and hepatopetal flow. \n4. Post-TIPS portal venogram showing predominant flow of \ncontrast through the TIPS. \n5. Post-TIPS right atrial pressure of 14 mm Hg and portal \npressure of 20 mmHg resulting in portosystemic gradient of 6 \nmmHg. \n6. Right upper quadrant ultrasound demonstrated trace ascites, \ntoo small \nvolume for paracentesis \nIMPRESSION: \nSuccessful transjugular intrahepatic portosystemic shunt \nplacement with \ndecrease in porto-systemic pressure gradient from 20 to 6 mmHg. \n\nDUPLEX DOPP ABD/PEL Study Date of ___ \nIMPRESSION: \nPatent TIPS in this baseline ultrasound. Velocities as \nreported. \n\nCT ABD & PELVIS WITH CONTRAST Study Date of ___ \nIMPRESSION: \n1. No evidence of perforation. Air and fluid filled mildly \ndilated colon. \n2. Patent TIPS \n3. Cirrhosis and findings compatible with portal hypertension. \nInterval \ndecrease in extent of abdominopelvic ascites. \n4. Unchanged pancreatic hypodensities, presumably reflecting \nIPMNs. \n\nPORTABLE ABDOMEN Study Date of ___ \nIMPRESSION: \nDilated colonic bowel loops measuring up to 10 cm. Evaluation \nfor small bowel dilatation is limited. \n\nCHEST (PORTABLE AP) Study Date of ___ \nIMPRESSION: \n1. Unchanged bibasilar opacities may represent atelectasis or \npneumonia/aspiration. \n2. Mild interstitial pulmonary edema. \n3. Multiple dilated colonic loops. \n\nMR HEAD W & W/O CONTRAST Study Date of ___ \nIMPRESSION: \nModerately motion limited exam. No evidence for an acute \ninfarction or other acute intracranial abnormalities. \n\n \nBrief Hospital Course:\nBRIEF DISCHARGE SUMMARY\n=========================\nMr. ___ is a ___ man with PBC c/b cirrhosis (c/b \nesophageal varices and ascites) and schizoaffective disorder who \npresented from clinic with worsening abdominal distension in the \nsetting of not taking his diuretics due to dizziness. We found \nthat he had lost a tremendous amount of weight and was fearful \nof eating because of chronic constipation. Given his anorexia \nand significant weight loss, there was concern for malignancy. A \nCT torso showed no evidence of cancer. We placed a feeding tube \nand had it advanced post-pyloric and initiated tube feeds for \nnutrition. We did a TTE that showed no significant cardiac \nabnormalities and did two bedside paracenteses for comfort. We \nrecommended a TIPS procedure, which was done on ___ after Mr. \n___ son was able to visit from ___. His post-TIPS \ncourse was complicated by ongoing fluid overload, and septic \nshock secondary to spontaneous bacterial peritonitis. After \ndiscussion with his family, patient was transitioned to comfort \ncare and was discharged to hospice.\n\nTRANSITIONAL ISSUES\n===================\n[ ] NG tube to suction kept in place at discharge for symptom \nrelief of colonic and intestinal distension.\n\nACTIVE ISSUES\n=============\n#Primary biliary cholangitis\n#Acute decompensated cirrhosis \n#Refractory ascites s/p TIPS\nMELD 12 and CHILDS B on admission. Presented with large volume \nascites in the setting of not taking diuretics due to persistent \ndizziness. RUQUS showed no evidence of PVT, infectious workup \nwas negative, and he had no signs of bleeding. He had a \nparacentesis in the ED to remove 2L fluid which resulted in \nsignificant improvement in symptoms. He was actively diuresed \nwith IV furosemide, which removed significant volume clinically \nbut caused low blood pressures (systolics ___, asymptomatic). \nAdditional large volume paracenteses were performed for ongoing \nreaccumulation of ascites. Patient underwent a TIPS procedure on \n___. His post-TIPS course was complicated by volume overload \nrequiring additional diuresis, hepatic encephalopathy requiring \nlactulose and rifaximin, and septic shock secondary to SBP (see \nbelow). Given his poor prognosis, a discussion was held with his \nsister and son, and the decision was made to transition the \npatient to comfort care and discharge to hospice.\n\n#Septic shock\n#Spontaneous bacterial peritonitis\n#Hospital acquired pneumonia\nPatient developed fever, hypotension, and tachycardia, \nconcerning for infection. Infectious workup was significant for \nascites fluid with PMN>250. Patient was transferred to the ICU \nand maintained on pressors. Patient was started on antibiotics \nfor SBP. Chest imaging was also concerning for a pulmonary \nconsolidation, so he was maintained on broad spectrum \nVancomycin, cefepime, and metronidazole. He was stabilized and \ntransferred back to the general medical floor. Antibiotics were \ndiscontinued after patient was transitioned to comfort care.\n\n#Acute colonic pseudoobstruction\nPatient developed worsening abdominal distension and tenderness. \nImaging revealed dilated colonic bowel loops measuring up to \n10cm. Patient was evaluated by the surgical service, who \nrecommended strict NPO and maintaining NG tube to suction for \ndecompression.\n\n#Severe malnutrition \n#Weight loss\nReported purposeful food restriction because of concern for \nconstipation and that he was mostly drinking Ensures. His \nsignificant weight loss raised concern for malignancy and he had \na CT torso, which showed no evidence of cancer. A colonoscopy \nwas deferred given his significant improvement with treatment of \nhis liver disease. Nutrition was consulted and a dobhoff was \nplaced (and advanced post-pyloric) to initiate tube feeds. Tube \nfeeds were subsequently held after development of acute colonic \npseudoobstruction.\n\n#Dyspnea\n#Lower extremity edema\nAppeared significantly volume overloaded on exam with crackles \nin bilateral bases, subjective shortness of breath, and 2+ \npitting edema to his knees bilaterally. Likely in the setting of \nnot taking his diuretics due to persistent dizziness. His \nsymptoms improved with diuresis and therapeutic paracentesis. \nBNP and TTE on admission were unremarkable so there was less \nconcern for a cardiogenic cause of his volume overload. Given \ndiuretic intolerance, a TIPS procedure was performed. He had \nongoing peripheral edema after his TIPS that required diuresis.\n\n#Asymptomatic bacteriuria\nUA showed pyuria and bacteriuria but patient had no symptoms. \nTreatment was therefore deferred.\n\nCHRONIC ISSUES\n=============== \n#Depression\n#Schizoaffective disorder\nContinued home seroquel 100mg QHS. Psychiatry initially \nrecommended continuing the seroquel and then follow up after \ndischarge to consider cross downtitration with another \nmedication as seroquel can be constipating. However, after \ndiscussion with the family, patient was transitioned to comfort \ncare, and this plan was not undertaken. Of note, we discontinued \nhis home lamotrigine per recommendation from his outpatient \npsychiatrist Dr. ___ due to conflicting reports about whether \nhe was taking/stopping/restarting this medication. Per Dr. \n___, patient is not a good candidate for lamotrigine with \nrisk of abrupt start/stop and risk for SJS.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Furosemide 20 mg PO DAILY \n2. LamoTRIgine 100 mg PO DAILY \n3. QUEtiapine Fumarate 100 mg PO DAILY \n4. Spironolactone 50 mg PO DAILY \n5. Ursodiol 500 mg PO BID \n6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n7. Calcium Carbonate 500 mg PO DAILY \n8. Vitamin D 400 UNIT PO DAILY \n9. Polyethylene Glycol 17 g PO BID \n10. Vitamin A ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. rifAXIMin 550 mg PO BID \n2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n4. QUEtiapine Fumarate 100 mg PO DAILY \n\n \nDischarge Disposition:\nExpired\n \nFacility:\n___ \n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nACUTE DECOMPENSATED CIRRHOSIS\n\nSECONDARY DIAGNOSES\n===================\nPRIMARY BILIARY CHOLANGITIS\nLIVER CIRRHOSIS\nASCITES\nSPONTANEOUS BACTERIAL PERITONITIS\nACUTE COLONIC PSEUDOOBSTRUCTION\nSEPTIC SHOCK\nSEVERE MALNUTRITION\nWEIGHT LOSS\nANOREXIA\nSHORTNESS OF BREATH\nLOWER EXTREMITY EDEMA\nASYMPTOMATIC BACTERIURIA\nCONSTIPATION\nDEPRESSION\nSCHIZOAFFECTIVE DISORDER\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr ___,\n\nIt was our pleasure to take care of you at ___. You came to \nthe hospital because your abdomen was getting very big.\n\nWHAT HAPPENED IN THE HOSPITAL?\n- We removed extra fluid from your belly through a procedure \nknown as a paracentesis\n- You had a TIPS procedure, which was done to help reduce the \namount of fluid that built up in your belly \n- We treated you for an infection in the fluid in your belly. \nYou were briefly in the intensive care unit because the \ninfection made you very sick.\n- We placed a tube through your nose into your stomach to remove \nthe gas and help make you feel more comfortable\n- We discussed with you and your family and decided to no longer \nperform any invasive procedures, and rather to focus on symptom \nmanagement and helping you feel comfortable.\n- You were discharged to hospice.\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE?\n- You should enjoy spending time with your family\n\nWe wish you the best,\n\nSincerely,\nYour care team at ___\n \nFollowup Instructions:\n___\n" ]

[ "K7460", "E43", "K652", "A419", "J189", "R6521", "K7200", "R188", "K766", "K56699", "T8140XA", "N400", "F329", "F259", "K3189", "K5900", "K743", "Z515", "E8770", "R8271", "Z66", "Z6821" ]

[ "K7460: Unspecified cirrhosis of liver", "E43: Unspecified severe protein-calorie malnutrition", "K652: Spontaneous bacterial peritonitis", "A419: Sepsis, unspecified organism", "J189: Pneumonia, unspecified organism", "R6521: Severe sepsis with septic shock", "K7200: Acute and subacute hepatic failure without coma", "R188: Other ascites", "K766: Portal hypertension", "K56699: Other intestinal obstruction unspecified as to partial versus complete obstruction", "T8140XA: Infection following a procedure, unspecified, initial encounter", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "F329: Major depressive disorder, single episode, unspecified", "F259: Schizoaffective disorder, unspecified", "K3189: Other diseases of stomach and duodenum", "K5900: Constipation, unspecified", "K743: Primary biliary cirrhosis", "Z515: Encounter for palliative care", "E8770: Fluid overload, unspecified", "R8271: Bacteriuria", "Z66: Do not resuscitate", "Z6821: Body mass index [BMI] 21.0-21.9, adult" ]

[ "N400", "F329", "K5900", "Z515", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nDilaudid\n \nAttending: ___.\n \nChief Complaint:\nright knee OA\n \nMajor Surgical or Invasive Procedure:\nright knee replacement ___, ___\n\n \nHistory of Present Illness:\n___ year old female with right knee OA s/p right TKR.\n \nPast Medical History:\nPMH: Obesity, anxiety, depression, GERD, asthma. BP at PAT \n160/87\nPShx: L knee athroscopy, C-section\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\n Well appearing in no acute distress \n Afebrile with stable vital signs \n Pain well-controlled \n Respiratory: CTAB \n Cardiovascular: RRR \n Gastrointestinal: NT/ND \n Genitourinary: Voiding independently \n Neurologic: Intact with no focal deficits \n Psychiatric: Pleasant, A&O x3 \n Musculoskeletal Lower Extremity: \n * Aquacel dressing with scant serosanguinous drainage \n * Thigh full but soft \n * No calf tenderness \n * ___ strength \n * SILT, NVI distally \n * Toes warm\n \nPertinent Results:\n___ 06:55AM BLOOD Hgb-11.6 Hct-35.5\n___ 06:55AM BLOOD Creat-0.7\n \nBrief Hospital Course:\nThe patient was admitted to the Orthopaedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nPOD#0, the patient was unable to void post-operatively and a \nfoley catheter was placed. This was discontinued at midnight \nand the patient was able to void independently thereafter.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 81 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 with no range of motion \nrestrictions. Please use walker or 2 crutches, wean as able. \n \nMs. ___ is discharged to home with services in stable \ncondition.\n\n \nMedications on Admission:\n1. GuaiFENesin-CODEINE Phosphate ___ mL PO BID:PRN cough \n2. Metoprolol Succinate XL 25 mg PO DAILY \n3. Fluticasone Propionate NASAL 1 SPRY NU BID \n4. fluticasone propion-salmeterol 115-21 mcg/actuation \ninhalation BID \n5. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n6. Omeprazole 40 mg PO DAILY \n7. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN cough \n\n \nDischarge Medications:\n1. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN Pain - Moderate \n2. Aspirin EC 81 mg PO BID \n3. Docusate Sodium 100 mg PO BID \n4. Gabapentin 100 mg PO TID \n5. Senna 8.6 mg PO BID \n6. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN cough \n\n7. fluticasone propion-salmeterol 115-21 mcg/actuation \ninhalation BID \n8. Fluticasone Propionate NASAL 1 SPRY NU BID \n9. GuaiFENesin-CODEINE Phosphate ___ mL PO BID:PRN cough \n10. Metoprolol Succinate XL 25 mg PO DAILY \n11. Omeprazole 40 mg PO DAILY \nTake daily while on Aspirin \n12. HELD- Ibuprofen 800 mg PO Q8H:PRN Pain - Mild This \nmedication was held. Do not restart Ibuprofen until you've been \ncleared by your surgeon\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nright knee OA\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n \n8. ANTICOAGULATION: Please continue your Aspirin 81 twice daily \nwith food for four (4) weeks to help prevent deep vein \nthrombosis (blood clots). Continue Omeprazole daily while on \nAspirin to prevent GI upset (x 4 weeks). If you were taking \nAspirin prior to your surgery, take it at 81 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 2 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. Two crutches or walker. Wean assistive device as \nable. Mobilize. ROM as tolerated. No strenuous exercise or \nheavy lifting until follow up appointment. \n\nPhysical Therapy:\nWBAT RLE\nNo range of motion restrictions\nMobilize frequently\nWean assistive devices as able (i.e., 2 crutches, walker)\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 \nFollowup Instructions:\n___\n" ]

[ "M1711", "F329", "F419", "K219", "J45909", "Z87891", "R339", "E669", "Z6833", "Z006" ]

[ "M1711: Unilateral primary osteoarthritis, right knee", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "R339: Retention of urine, unspecified", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[ "F329", "F419", "K219", "J45909", "Z87891", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLeft knee pain\n \nMajor Surgical or Invasive Procedure:\n___ - Total Knee Arthroplasty, Left Knee\n\n \nHistory of Present Illness:\n___ year old female with left knee osteoarthritis, unresponsive \nto conservative management, who has elected to proceed with a \nleft total knee replacement on ___.\n\n \nPast Medical History:\nPMH: Obesity, anxiety, depression, GERD, asthma. BP at PAT \n160/87\n\nPShx: L knee athroscopy, C-section\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Incision healing well with staples \n* Scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n\n \nPertinent Results:\n___ 07:55AM BLOOD WBC-11.4* RBC-3.28* Hgb-10.2* Hct-31.1* \nMCV-95 MCH-31.1 MCHC-32.8 RDW-12.3 RDWSD-42.7 Plt ___\n___ 03:00PM BLOOD WBC-13.5* RBC-3.29* Hgb-10.4* Hct-30.8* \nMCV-94 MCH-31.6 MCHC-33.8 RDW-12.1 RDWSD-41.7 Plt ___\n___ 07:50AM BLOOD WBC-15.9*# RBC-3.59* Hgb-11.3 Hct-33.5* \nMCV-93 MCH-31.5 MCHC-33.7 RDW-12.0 RDWSD-41.3 Plt ___\n___ 07:55AM BLOOD Plt ___\n___ 03:00PM BLOOD Plt ___\n___ 07:50AM BLOOD Plt ___\n___ 07:55AM BLOOD Glucose-115* UreaN-16 Creat-0.7 Na-141 \nK-3.9 Cl-103 HCO3-29 AnGap-13\n___ 07:50AM BLOOD Glucose-168* UreaN-15 Creat-0.6 Na-132* \nK-3.9 Cl-98 HCO3-23 AnGap-15\n___ 07:50AM BLOOD estGFR-Using this\n___ 07:55AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.2\n___ 07:50AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8\n \nBrief Hospital Course:\nThe patient was admitted to the orthopedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\n\nOn POD#1 Ms. ___ was afebrile with a WBC of 15.9. Urinalysis \nand urine cultures were sent. Urinalysis was negative for UTI. \nUrine cultures were pending at time of discharge. Also, the \npatient's sodium was 132. She was placed on a fluid \nrestriction. The following day, her sodium improved to 141.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Lovenox for DVT \nprophylaxis starting on the morning of POD#1. The foley was \nremoved and the patient was voiding independently thereafter. \nThe surgical dressing was changed on POD#2 and the surgical \nincision was found to be clean and intact without erythema or \nabnormal drainage. The patient was seen daily by physical \ntherapy. Labs were checked throughout the hospital course and \nrepleted accordingly. At the time of discharge the patient was \ntolerating a regular diet and feeling well. The patient was \nafebrile with stable vital signs. The patient's hematocrit was \nacceptable and pain was adequately controlled on an oral \nregimen. The operative extremity was neurovascularly intact and \nthe wound was benign. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity.\n \nMs. ___ is discharged to home with services in stable \ncondition.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQID:PRN cough \n2. Citalopram 20 mg PO DAILY \n3. codeine-guaifenesin ___ mg/5 mL oral BID:PRN \n4. fluticasone 50 mcg/actuation nasal DAILY:PRN \n5. Ibuprofen 800 mg PO Q8H:PRN pain \n6. Omeprazole 40 mg PO DAILY:PRN heartburn \n\n \nDischarge Medications:\n1. fluticasone 50 mcg/actuation nasal DAILY:PRN \n2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQID:PRN cough \n3. Acetaminophen 1000 mg PO Q8H \n4. Docusate Sodium 100 mg PO BID \n5. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days \nStart: ___, First Dose: Next Routine Administration Time \n6. Gabapentin 300 mg PO TID \n7. Senna 8.6 mg PO BID \n8. codeine-guaifenesin ___ mg/5 mL oral BID:PRN \n9. Omeprazole 40 mg PO DAILY:PRN heartburn \n10. TraMADol 50 mg PO Q4H:PRN pain \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nOsteoarthritis, Left Knee\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc).\n \n8. ANTICOAGULATION: Please continue your Lovenox for four (4) \nweeks to help prevent deep vein thrombosis (blood clots). If \nyou were taking aspirin prior to your surgery, it is OK to \ncontinue at your previous dose while taking this medication. \n \n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed at your follow-up \nappointment in two weeks.\n \n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Mobilize. ROM as tolerated. No strenuous exercise or \nheavy lifting until follow up appointment.\n\nPhysical Therapy:\nWBAT LLE\nNo range of motion restrictions\nUse of assistive ambulatory device, wean as able\nTreatments Frequency:\ndry sterile dressing changes daily\nmonitor incision for drainage\nelevate and ice the operative extremity\nstaples to be removed at first ___ clinic visit\n \nFollowup Instructions:\n___\n" ]

[ "M170", "F329", "E669", "Z6832", "F419", "K219", "J45909", "Z87891", "D72829", "G8918", "R110", "I9581" ]

[ "M170: Bilateral primary osteoarthritis of knee", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "Z6832: Body mass index [BMI] 32.0-32.9, adult", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "Z87891: Personal history of nicotine dependence", "D72829: Elevated white blood cell count, unspecified", "G8918: Other acute postprocedural pain", "R110: Nausea", "I9581: Postprocedural hypotension" ]

[ "F329", "E669", "F419", "K219", "J45909", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Codeine\n \nAttending: ___.\n \nChief Complaint:\nnausea, epigastric pain, & coffee ground emesis\n \nMajor Surgical or Invasive Procedure:\nEndoscopic gastroduodenoscopy (___)\n \nHistory of Present Illness:\n___ y.o woman with h/o cardiomyopathy, HTN, HLD, \nGERD/gastritis/hiatal hernia, and recent indirect inguinal \nhernia repair (___) who presented to the ED with one day of \nepigastric pain and coffee ground emesis iso several years of \nintermittent epigastric pain with self-induced emesis.\n\nA day prior to admission (___), the patient developed epigastric \npain after consuming eggplant salad and crabmeat for lunch, \nwhich her husband also ate with no illness. She describes the \npain as ___ \"pressure,\" which she has had intermittently for \nthe past few years, occasionally accompanied by diaphoresis, \nsubsternal burning pain, and left shoulder pain. The pain does \nnot occur with exertion or worsen with activity. She usually \ninduces vomiting (with resultant coffee ground emesis) with her \nfinger, which typically relieves the pain. However, after \ninducing vomiting the afternoon of ___, she continued to have \n>10 emesis throughout the evening with persistent pain \nunresponsive to omeprazole. Due to her continued emesis, she \npresented to the ED.\n\nShe reported passing gas and denied constipation (last BM ___, \ndiarrhea, black stools, or bloody stools. She denied She denied \nfever, chills. sick contacts, recent travel, or recent NSAID, \ncorticosteroid, EtOH, or tobacco use. She denied chest pain, \npalpitations, or shortness of breath.\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n-Angina Pectoris\n-Osteoarthritis of the knees and spine.\n-Temporal arteritis/polymyalgia rheumatica.\n-Osteoporosis.\n-Hyperlipidemia.\n-Hypertension.\n-LBBB.\n-Multiple bowel movements. When she's constipated she will take\nMiraLAX and then have about six bowel movements a day \n-Erosive gastritis, GERD, hiatal hernia\n-Recurrent rectal prolapse\n\nPSH: \n-B/L knee replacement ___\n-Vaginal hysterectomy, ___.\n-Excision of lipoma-upper back\n-Surgeries multiple for rectal prolapse\n-Colonoscopies ___ last polyps \n\n \nSocial History:\n___\nFamily History:\nMother ___ MURDERED ___ \n\nFather ___ MURDERED ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVitals: 97.9 165/85 77 18 99%2L\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, bilateral surgical defects in ___ (L \n> R), MMM, oropharynx clear \nNeck: supple, no LAD or thyromegaly \nLungs: CTAB, no wheezes, rales, rhonchi \nCV: NRRR, Nl S1, S2, ___ holosystolic murmur loudest at left \nlower sternal border \nAbdomen: soft, mild tenderness with palpation of LUQ, 3 cm \nincision over RLQ with mild tenderness to palpation but no \nerythema non-distended, bowel sounds present, no rebound \ntenderness or guarding, no organomegaly \nGU: no foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis, \ntrace edema bilaterally in lower extremities \nNeuro: CN3-12 intact, no focal deficits \n\nDISCHARGE PHYSICAL EXAM\nPHYSICAL EXAM: \nVitals: T 98 141/54 96 2L ___\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, bilateral surgical defects in ___ (L \n> R), oropharynx clear, mucous membranes dry \nNeck: supple, no LAD or thyromegaly \nLungs: CTAB, no wheezes, rales, rhonchi \nCV: NRRR, Nl S1, S2, ___ holosystolic murmur loudest at left \nlower sternal border \nAbdomen: soft, nondistended, nontender in upper quadrants, 3 cm \nincision over RLQ with mild tenderness to palpation but no \nerythema, drainage, or induration, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nGU: no foley \nExt: warm, well perfused, 2+ pulses, no clubbing, cyanosis, \ntrace edema bilaterally in lower extremities \nNeuro: CN3-12 intact, no focal deficits\n \nPertinent Results:\nADMISSION LABS\n___ 02:30AM BLOOD WBC-9.3 RBC-3.45* Hgb-9.3* Hct-29.2* \nMCV-85 MCH-27.0 MCHC-31.8* RDW-16.0* RDWSD-48.9* Plt ___\n___ 02:30AM BLOOD Neuts-90.7* Lymphs-5.7* Monos-2.8* \nEos-0.1* Baso-0.2 Im ___ AbsNeut-8.43* AbsLymp-0.53* \nAbsMono-0.26 AbsEos-0.01* AbsBaso-0.02\n___ 02:30AM BLOOD ___ PTT-21.5* ___\n___ 02:30AM BLOOD Glucose-172* UreaN-37* Creat-1.3* Na-146* \nK-3.6 Cl-95* HCO3-38* AnGap-17\n___ 02:30AM BLOOD ALT-12 AST-17 LD(LDH)-207 AlkPhos-76 \nTotBili-0.3\n___ 02:30AM BLOOD Lipase-26\n___ 02:30AM BLOOD cTropnT-<0.01\nNegative stool guaiac\n\nIMAGING\nUpper GI series (___): Mild tertiary contractions and \ngastroesophageal reflux. Brief holdup of 13-mm barium tablet at \nthe gastroesophageal junction.\n\nENDOSOCOPY\nEGD (___):\nDiffuse erythema and patulous esophagus. The erythema seemed \nmost likely secondary to her recent vomiting.\nOver 1 liter of fluid was suctioned out of the stomach upon \nentrance into the stomach. There was a very large hiatal hernia \nand the stomach anatomy was all distorted. over an hour was \nspent attempting to find and intubate the pylorus but this could \nnot be located. \nOtherwise normal EGD to stomach\n\nDISCHARGE LABS \n___ 6.8RBC 2.91 Hgb 8.0 Hct26.3 MCV 90MCH \n27.5MCHC 30.4RDW 15.8RDWSD 52.0Plt Ct ___\n\n ___ Glucose 891 UreaN 38Creat 1.3 Na 142K \n4.2Cl 99HCO3 34 AnGap ___ y.o woman with h/o cardiomyopathy, HTN/HLD, \nGERD/gastritis/hiatal hernia, and recent indirect inguinal \nhernia repair (___) presented with one day of epigastric pain \nand coffee ground emesis, concerning for upper GI bleed, likely \nd/t erosive esophagitis found on EGD. \n\nBRIEF HOSPTIAL COURSE\n=======================\nACTIVE ISSUES\n-------------\n#Upper GI bleed secondary to erosive esophagitis: The patient \npresented with epigastric pain and coffee ground emesis iso \nyears of epigastric pain with self-induced vomiting. She was \nfound to be afebrile and hemodynamically stable with exam \nnotable for mild tenderness with palpation of the epigastric \narea. Initial labs revealed a drop in H/H from her baseline \nchronic normocytic anemia with a normal WBC count, LFTs, \namylase, and troponin. She was made NPO and started on IV \npantoprazole. with her home aspirin and antihypertensives \ndiscontinued. An EGD revealed erosive esophagitis and gastric \noutlet obstruction. The patient was advanced to water with the \nhead of the bed raised with no ensuing emesis. However, due to a \n___ H/H (Hgb 9.3 to 7), she was transfused 1uRBC with \nstable post-transfusion H/H (Hgb 7.6 and 8.9). An upper GI \nseries showed only slight gastric outlet obstruction with no \nfocal lesions. Her presentation was thought to be consistent \nwith an upper GI bleed due to erosive esophagitis. Her \nepigastric pain, nausea, and vomiting resolved, and her H/H \nremained stable at discharge.\n\n#Metabolic alkalosis with prerenal ___: At presentation, the \npatient had an elevated bicarbonate with decreased chloride, \nreflecting metabolic alkalosis from emesis. Her Cr was also \nelevated from baseline (1.3 from 1) with BUN/Cre >20, consistent \nwith prerenal ___ from volume depletion. Given her history of \ncardiomyopathy, she was given gentle resuscitation when NPO. At \ntime of discharge, her metabolic alkalosis had improved with Cr \n___. \n\n#Hypoxic respiratory failure of unclear etiology: The patient \nhad a new oxygen requirement (~97% on 2L) while hospitalized, \nwith desaturations in the ___ with walking. As the patient was \nafebrile with clear pulmonary exam and essentially normal WBC \n(peak of 10.2), her hypoxia was thought to reflect atelectasis \nrather than aspiration pneumonia. \n\nCHRONIC ISSUES\n---------------\n#Anemia: Patient's H/H returned to her baseline normocytic \nanemia by discharge.\n \n#CKD-Stable, with superimposed ___ and ___ Cr at \ndischarge. \n\n#HTN- Patient discontinued amlodipine and ACEi due to risk of \nhypotension. She will resume these medications on discharge. \n\n#HL-Patient was continued on her home statin, which she will \ncontinue at discharge.\n\n#Insomnia-Patient's mirtazapine was held while NPO. She will \nresume this medication on discharge.\n\nTRANSITIONAL ISSUES\n=====================\n[ ] Esophagitis: Patient with stabilized hematocrit, discharge \nHgb 8. Please consider rechecking as outpatient. \n[ ] PPI: Patient to continue PPI, and f/u with outpatient GI\n\n# CODE STATUS: DNR/DNI \n# CONTACT: daughter ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amlodipine 5 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Mirtazapine 7.5 mg PO QHS \n4. Omeprazole 20 mg PO DAILY \n5. Align (bifidobacterium infantis) 4 mg oral DAILY \n6. Atorvastatin 20 mg PO QPM \n7. Lisinopril 20 mg PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n9. Calcium Carbonate 750 mg PO QID:PRN gastric upset \n\n \nDischarge Medications:\n1. Amlodipine 5 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. Calcium Carbonate 750 mg PO QID:PRN gastric upset \n5. Mirtazapine 7.5 mg PO QHS \n6. Vitamin D 1000 UNIT PO DAILY \n7. Omeprazole 40 mg PO DAILY \nRX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0\n8. Lisinopril 20 mg PO DAILY \n9. Align (bifidobacterium infantis) 4 mg oral DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nUpper gastrointestinal bleeding\nErosive esophagiitis\n\nSECONDARY DIAGNOSES\n=====================\nHiatal hernia\nGastroesophageal reflux disease\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___,\n\n___ were admitted to ___ due to stomach pain, nausea, and \nvomiting blood, which was concerning for bleeding from your GI \ntract. ___ were started on a medication to block acid production \nin your stomach, and some of your home medications were \ntemporarily discontinued while hospitalized, such as aspirin, \ndue to the risk of bleeding. Your labs showed a drop in red \nblood cells in your blood, and ___ needed a blood transfusion to \nreplace some of the lost blood. In order to identify the source \nof bleeding, ___ underwent an endoscopy looking at your \nesophagus and stomach. We were not able to look at your small \nintestine. This endoscopy showed irritation to your esophagus, \nwhich we think was caused by your hiatal hernia and causing \nyourself to vomit. ___ also underwent an upper GI series, which \ndid not show ulcers in your small intestine and only showed very \nmild blockage of small intestine. Based on these results, we \nthink that your bleeding was ultimately caused by the irritation \nin your esophagus. At discharge, your lab tests showed that \nyour red blood cells had remained stable, suggesting that the \nbleeding had stopped. At home, ___ will be on a higher dose of \nomeprazole, which can help prevent bleeding from the GI tract \nand prevent pain in your stomach and esophagus. ___ will \nfollow-up with your PCP. If ___ start to throw up blood again or \nfeel lightheaded and weak, ___ should return to the ED. \n\nIt was a pleasure taking care of ___.\n\nBest regards,\nYour ___ medicine team\n\n \nFollowup Instructions:\n___\n" ]

[ "K311", "K2211", "N179", "E873", "K920", "I429", "M316", "N183", "D62", "J9811", "K210", "K449", "E860", "M353", "K5790", "I25119", "M479", "M810", "E785", "Z96653", "I447", "K2970", "K623", "Z86010", "Z87891", "R0902", "I129", "G4700", "Z66" ]

[ "K311: Adult hypertrophic pyloric stenosis", "K2211: Ulcer of esophagus with bleeding", "N179: Acute kidney failure, unspecified", "E873: Alkalosis", "K920: Hematemesis", "I429: Cardiomyopathy, unspecified", "M316: Other giant cell arteritis", "N183: Chronic kidney disease, stage 3 (moderate)", "D62: Acute posthemorrhagic anemia", "J9811: Atelectasis", "K210: Gastro-esophageal reflux disease with esophagitis", "K449: Diaphragmatic hernia without obstruction or gangrene", "E860: Dehydration", "M353: Polymyalgia rheumatica", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "M479: Spondylosis, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "E785: Hyperlipidemia, unspecified", "Z96653: Presence of artificial knee joint, bilateral", "I447: Left bundle-branch block, unspecified", "K2970: Gastritis, unspecified, without bleeding", "K623: Rectal prolapse", "Z86010: Personal history of colonic polyps", "Z87891: Personal history of nicotine dependence", "R0902: Hypoxemia", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "G4700: Insomnia, unspecified", "Z66: Do not resuscitate" ]

[ "N179", "D62", "E785", "Z87891", "I129", "G4700", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Codeine\n \nAttending: ___\n \n___ Complaint:\nasymptomatic hyponatremia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with PMH of HTN, backpain, GERD who pw\nhyponatremia. Patient originally presented to emergency\ndepartment 2 days ago for a mechanical fall (CT head and neck\nnegative) at which time she was noted to have hyponatremia with\nsodium of 125. Patient was given IV fluids but repeat ___ was\nstill low at 126. She then left the ED against medical advice \ndue\nto long wait. For the last 2 days since that prior ED visit, she\nhas been drinking ___ glasses of water per day. Of note, she was\nstarted on HCTZ for HTN on ___, which was stopped 2 days ago\ndue to low ___. She also recently had her mirtazapine increased\nfrom 15 to 30 mg per day in ___. In clinic today with her\nPCP, her ___ was 122 and pt was somewhat confused with slower\nspeech than usual so she was sent to ED today for eval. Today \nshe\ndenies fevers, chills, HA, lightheadedness, nausea, vomiting,\nchest pain, shortness of breath, focal neurologic deficits.\n\n \nPast Medical History:\n(per chart, confirmed with pt and updated):\n-Osteoarthritis of the knees and spine.\n-Temporal arteritis/polymyalgia rheumatica.\n-Osteoporosis.\n-Hyperlipidemia.\n-Hypertension.\n-LBBB.\n-Multiple bowel movements. When she's constipated she will take\nMiraLAX and then have about six bowel movements a day \n-Erosive gastritis, GERD, hiatal hernia\n\nPSH: \n-B/L knee replacement ___\n-Vaginal hysterectomy, ___.\n-Excision of lipoma-upper back\n-Surgeries multiple for rectal prolapse\n-Colonoscopies ___ last polyps \n\n-Recurrent rectal prolapse\n\n \nSocial History:\n___\nFamily History:\nMother and father died in the ___. No known medical \nproblems.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: T 97.8, BP 183/63, HR 53, RR 18, O2 Sat: 95% RA\n\nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Soft, non distended, non-tender to deep palpation in \nall\nfour quadrants. No organomegaly.\nEXTREMITIES: No clubbing, cyanosis, or edema. Radial pulses 3+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rashes.\nNEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.\n\nDISCHARGE PHYSICAL EXAM:\nVITALS: 24 HR Data (last updated ___ @ 2201)\n Temp: 98.1 (Tm 98.1), BP: 147/62 (103-147/47-80), HR: 54\n(43-71), RR: 18, O2 sat: 93%, O2 delivery: Ra \nGENERAL: pleasant lady lying in bed, NAD. Alert and interactive.\nIn no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: Supple, normal range of motion, JVP @ 6cm.\nCARDIAC: RRR, normal S1/S2, II/VI systolic murmur best heard at\nRUSB, no other r/g\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Soft, non distended, non-tender to deep palpation in \nall\nfour quadrants. No organomegaly.\nEXTREMITIES: No clubbing, cyanosis, or edema. Radial pulses 2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rashes.\nNEUROLOGIC: AOx3. Moving all 4 limbs spontaneously.\n \nPertinent Results:\nADMISSION LABS:\n___ 02:00PM BLOOD WBC-9.1 RBC-3.52* Hgb-10.7* Hct-32.1* \nMCV-91 MCH-30.4 MCHC-33.3 RDW-13.4 RDWSD-45.1 Plt Ct-UNABLE TO \n___ 02:00PM BLOOD Neuts-84.1* Lymphs-9.2* Monos-4.9* \nEos-0.8* Baso-0.1 Im ___ AbsNeut-7.63* AbsLymp-0.83* \nAbsMono-0.44 AbsEos-0.07 AbsBaso-0.01\n___ 02:00PM BLOOD ___ PTT-28.8 ___\n___ 09:45AM BLOOD UreaN-20 Creat-0.9 ___ K-4.0 Cl-86* \nHCO3-26 AnGap-13\n___ 02:00PM BLOOD ALT-18 AST-24 AlkPhos-67 TotBili-0.5\n___ 02:00PM BLOOD Lipase-57\n___ 02:00PM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.1 Mg-1.7\n___ 02:00PM BLOOD Osmolal-253*\n___ 07:20PM BLOOD ___\n\nDISCHARGE LABS:\n___ 05:25AM BLOOD WBC-9.3 RBC-3.52* Hgb-11.0* Hct-33.5* \nMCV-95 MCH-31.3 MCHC-32.8 RDW-13.9 RDWSD-48.7* Plt Ct-UNABLE TO \n___ 05:25AM BLOOD Glucose-106* UreaN-36* Creat-1.0 ___ \nK-4.7 Cl-97 HCO3-25 AnGap-13\n___ 05:25AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.8\n___ 06:00AM BLOOD TSH-2.5\n___ 06:00AM BLOOD Cortsol-16.0\n___ 05:41PM BLOOD ___\n___ 09:43PM BLOOD ___\n___ 01:22AM BLOOD ___\n___ 05:45AM BLOOD ___\n\nIMAGING:\n\nMICRO:\n___ 2:44 pm URINE\n\n URINE CULTURE (Pending): \n\n \nBrief Hospital Course:\nMs. ___ is a ___ with PMH of HTN, backpain, GERD who pw\nasymptomatic hyponatremia to 122 in setting of recent HCTZ use\nand increased PO free water intake, now off diuretic and on \nfluid\nrestriction c/b rapid ___ correction but now at a safer level,\nmost recently ___.\n\nTRANSITIONAL ISSUES\n===================\n[] Please draw chem-10 on ___ to check sodium (DC sodium 132 \non ___\n\nACUTE/ACTIVE ISSUES:\n====================\n# SIADH ___ mirtazapine\nPt found to have serum ___ of 122 two days prior to admission. Pt \nhad recently been started on HCTZ, which was stopped. She had \nalso increased her free water PO intake (6 glasses per day). Her \nserum and urine studies were consistent with SIADH. Her SIADH \nwas thought to be secondary to her Mirtazapine so this was held \nas well. There was some concern for overcorrection so she got \none dose of DDAVP. Her sodiums were then trended carefully and \nshe was discharged with the plan for repeat labs on ___, and \nPCP follow up on ___.\n\n# HTN\nPt was started on ___ in ___ for HTN as above. HCTZ \nstopped\n\nCHRONIC/STABLE ISSUES:\n======================\n# GERD\nContinue 20mg omeprazole BID. \n\n# back pain\nReceived Tylenol ___ TID PRN.\n\n# CODE: DNR/DNI confirmed with patient and HCP\n# ___ (HCP, daughter, ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 30 mg PO DAILY \n2. Calcium Carbonate 750 mg PO BID \n3. Mirtazapine 30 mg PO QHS \n4. amLODIPine 5 mg PO HS \n5. Atorvastatin 20 mg PO QPM \n6. Ferrous Sulfate 325 mg PO 2X/WEEK (MO,FR) \n7. Omeprazole 20 mg PO BID \n8. Aspirin 81 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO HS \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. Calcium Carbonate 750 mg PO BID \n5. Ferrous Sulfate 325 mg PO 2X/WEEK (MO,FR) \n6. Lisinopril 30 mg PO DAILY \n7. Omeprazole 20 mg PO BID \n8. Vitamin D 1000 UNIT PO DAILY \n9.Outpatient Lab Work\nPlease draw Chem-10 on ___\nE22.2\nPCP: ___., MD\nNP: ___\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: syndrome of inappropriate antiduretic hormone \nsecondary to mirtazapine\n\nSecondary diagnosis: hypertension\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___. \n\nWHY WERE YOU IN THE HOSPITAL? \n- You were admitted to the hospital for very low sodium levels \nin your blood.\n\nWHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?\n- The amount of liquids you were able to receive and drink was \nlowered\n- You received a medication to help control the amount of water \nin your blood\n- You received frequent blood draws to test the amount of sodium \nin your blood\n\nWHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? \n- Continue to take all your medicines as prescribed below. \n- Show up to your appointments as listed below.\n- Do not drink more than one (1) liter of fluids per day\n- It is important to keep track of the amount of liquids you are \ndrinking at home to make sure that your sodium doesn't drop too \nlow.\n- Salty soups, milk, protein shakes, and eating foods such as \neggs are good to keep the amount of sodium in your blood safe\n- You will have your labs checked on ___ and you will have \nfollow up with your primary care doctor after that\n\nWe wish you the best! \n\nSincerely, \n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "E222", "I5022", "I110", "T43025A", "K219", "Z96653", "M549", "Z66", "M810", "E7800", "F4320", "F329", "Y92531", "Z9181" ]

[ "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "I5022: Chronic systolic (congestive) heart failure", "I110: Hypertensive heart disease with heart failure", "T43025A: Adverse effect of tetracyclic antidepressants, initial encounter", "K219: Gastro-esophageal reflux disease without esophagitis", "Z96653: Presence of artificial knee joint, bilateral", "M549: Dorsalgia, unspecified", "Z66: Do not resuscitate", "M810: Age-related osteoporosis without current pathological fracture", "E7800: Pure hypercholesterolemia, unspecified", "F4320: Adjustment disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Y92531: Health care provider office as the place of occurrence of the external cause", "Z9181: History of falling" ]

[ "I110", "K219", "Z66", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillins / Codeine\n \nAttending: ___.\n \nChief Complaint:\nCoffee ground emesis\n \nMajor Surgical or Invasive Procedure:\n___ Laparascopic gastropexy, percutaneous gastrostomy (PEG) \ntube placement (Dr ___\n\n \nHistory of Present Illness:\nMs ___ is a pleasant ___ with hx cardiomyopathy, HTN, HLD, \nGERD/gastritis recent hx erosive esophagitis GIB (___) \npresenting with worsening abd pain and coffee ground emesis. \nWhen she presented in ___, she underwent EGD which showed \nesophagitis and was treated with PPI. On this occasion, pt \nstates she had LUQ pain, nausea and coffee ground emesis x6. \nHer LUQ pain is chronic ___ yrs however had been getting worse \nrecently, states improves with simethecone. She also endorses \ndiaphoresis and weakness. No CP/SOB/dizziness. Of note, pt has \nbeen inducing vomiting previously as she feels that this makes \nher belly pain better. Prior to this admission she vomited \nspontaneously due to the pain.\n\nIn the ED, initial vitals were: 97 80 152/62 16 96% RA. Exam \nwas notable for LUQ tenderness. Labs were notable for sodium of \n147, creatinine of 1.4, BUN 45, crit 32.5 (near ___ Guiac was \nnegative. Pt was given dilaudid, Zofran, pantoprazole and IVF. \nGI was notified and agreed with admission.\n\nOn the floor, she c/o ongoing ___ LUQ pain which is preventing \nher from sleeping. She has not had any further vomiting since \narrival in the ED. Denies CP/SOB. + wt loss.\n\nReview of systems:\n(+) Per HPI\n(-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies cough, shortness of breath. Denies chest pain \nor tightness, palpitations. Denies diarrhea, constipation. No \nrecent change in bowel or bladder habits. No dysuria. Denies \narthralgias or myalgias. 10 pt ros otherwise negative.\n\n \nPast Medical History:\n(per chart, confirmed with pt and updated):\n-Osteoarthritis of the knees and spine.\n-Temporal arteritis/polymyalgia rheumatica.\n-Osteoporosis.\n-Hyperlipidemia.\n-Hypertension.\n-LBBB.\n-Multiple bowel movements. When she's constipated she will take\nMiraLAX and then have about six bowel movements a day \n-Erosive gastritis, GERD, hiatal hernia\n\nPSH: \n-B/L knee replacement ___\n-Vaginal hysterectomy, ___.\n-Excision of lipoma-upper back\n-Surgeries multiple for rectal prolapse\n-Colonoscopies ___ last polyps \n\n-Recurrent rectal prolapse\n\n \nSocial History:\n___\nFamily History:\nMother and father died in the holocaust. No known medical \nproblems.\n\n \nPhysical Exam:\nADMISSION EXAM:\nVitals: 97.5 130/60 69 18 97% RA\nConstitutional: Alert, oriented, no acute distress\nHEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL\nNeck: Supple\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nRespiratory: Clear to auscultation bilaterally, no wheezes, \nrales, rhonchi\nGI: Soft, ttp diffusely, worse in LUQ, non-distended, bowel \nsounds present, no organomegaly, no rebound or guarding\nGU: No foley\nExt: Warm, well perfused, no CCE\nNeuro: aaox3 CNII-XII and strength grossly intact \nSkin: no rashes or lesions\n\nDISCHARGE PHYSICAL EXAM:\nGen: NAD, A&Ox3\nHEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL\nNeck: Supple\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nRespiratory: Clear to auscultation bilaterally, no wheezes, \nrales, rhonchi\nGI: soft, incisionally tender, nondistended; incisions c/d/I; \nPEG in the left upper quadrant is capped.\nExt: Warm, well perfused, no CCE\n\n \nPertinent Results:\nLABS:\nSee below, prior labs reviewed in ___\nPrior records and imaging reviewed by me\n\nMICRO: none\n\nSTUDIES:\n \nEGD ___\nImpression: Diffuse erythema and patulous esophagus. The \nerythema seemed most likely secondary to her recent vomiting.\nOver 1 liter of fluid was suctioned out of the stomach upon \nentrance into the stomach. There were a few streaks of hematin \nin the fluid but it was unclear if this was secondary to scope \ntrauma from suctioning or prior bleeding. There were a few areas \nof mild erythema but again this could have been from the scope. \nThere was a very large hiatal hernia and the stomach anatomy was \nall distorted. over an hour was spent attempting to find and \nintubate the pylorus but this could not be located. A regular \nscope was used and then a therapeutic scope was used for the \nincreased stiffness but again the pylorus could not be \nidentified and the scope kept looping. The procedure was then \naborted.\nOtherwise normal EGD to stomach \n\nEKG: LBBB, unchanged from prior\n\n___ 11:35PM PLT SMR-NORMAL PLT COUNT-235#\n___ 10:02PM LACTATE-1.6\n___ 09:41PM GLUCOSE-153* UREA N-45* CREAT-1.4* \nSODIUM-147* POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-33* ANION \nGAP-18\n___ 09:41PM estGFR-Using this\n___ 09:41PM ALT(SGPT)-13 AST(SGOT)-23 ALK PHOS-65 TOT \nBILI-0.3\n___ 09:41PM LIPASE-47\n___ 09:41PM ALBUMIN-4.5\n___ 09:41PM WBC-10.0# RBC-3.77* HGB-10.3* HCT-32.5* \nMCV-86 MCH-27.3 MCHC-31.7* RDW-16.6* RDWSD-51.2*\n___ 09:41PM NEUTS-86.9* LYMPHS-8.1* MONOS-4.1* EOS-0.2* \nBASOS-0.1 IM ___ AbsNeut-8.71* AbsLymp-0.81* AbsMono-0.41 \nAbsEos-0.02* AbsBaso-0.01\n___ 09:41PM PLT SMR-UNABLE TO PLT COUNT-UNABLE TO \n___ 09:41PM ___ PTT-27.8 ___ year old female with history of cardiomyopathy, HTN, HLD, \nGERD/gastritis recent history of erosive esophagitis GIB (___) presenting with worsening abdominal pain and coffee ground \nemesis concerning for recurrent upper GI bleed. CT abdomen \nshowed organoaxial gastric volvulus. NGT was placed, and she was \ntaken to the operating room on ___ for gastropexy and PEG \nplacement. She tolerated the procedure well, was tolerating a \nregular diet, and her pain was well controlled on oral regimen. \nShe was discharged to rehab on ___ with plan to follow up \nwith Dr. ___ in 3 weeks.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amlodipine 5 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Calcium Carbonate 750 mg PO QID:PRN gastric upset \n4. Mirtazapine 7.5 mg PO QHS \n5. Vitamin D 1000 UNIT PO DAILY \n6. Omeprazole 40 mg PO DAILY \n7. Align (bifidobacterium infantis) 4 mg oral DAILY \n8. Valsartan 80 mg PO DAILY \n\n \nDischarge Medications:\n1. Align (bifidobacterium infantis) 4 mg oral DAILY \n2. Amlodipine 5 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. Calcium Carbonate 750 mg PO QID:PRN gastric upset \n5. Mirtazapine 7.5 mg PO QHS \n6. Omeprazole 40 mg PO DAILY \n7. Valsartan 80 mg PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n9. TraMADol 50 mg PO Q4H:PRN Severe pain \nTake as prescribed. Do not drive or drink alcohol. \nRX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*42 Tablet Refills:*0\n10. Docusate Sodium 100 mg PO BID \nTake with plenty of fluids for constipation. \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*20 Capsule Refills:*0\n11. Acetaminophen 650 mg PO Q6H:PRN Pain \nDO not exceed 4000 mg in 24 hours \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nGastric volvulus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMrs. ___, \n\n___ were admitted to the hospital for treatment of gastric \nvolvulus, which required a surgery called laparascopic \ngastropexy and percutaneous gastrostomy (PEG) tube placement. \n___ tolerated the procedure well, and are now ready to be \ndischarged home to complete your recovery. Please follow these \ninstructions to ensure timely recovery.\n\nDIET:\n___ may resume regular diet without restrictions. Eat small \nfrequent meals. Sit in chair for all meals. Remain sitting up \nfor ___ minutes after all meals, do not lie down or eat prior \nto bedtime. If ___ develop symptoms of obstruction (nausea, \nvomiting), ___ may vent your PEG tube to release the pressure. \nOtherwise keep the tube clamped. \n\nACTIVITY:\nAvoid heavy lifting for ___ weeks after surgery to ensure the \nintegrity of your incisions, otherwise ___ may resume regular \nactivity as before. ___ may drive and walk without restrictions. \n\n___ may shower. Your incisions are covered with thin strips of \ntape called Sterristrips. They will fall off on their own, do \nnot attempt to remove them as this may rip your stitches. Your \nstitches are dissolvable, they will disappear on their own and \nwill not need to be removed. \n\nMEDICATIONS:\n___ may resume your other regular medications as before. \n\nFOLLOW-UP:\n___ will need to follow up with Dr. ___ in ___ weeks. Our \noffice will call ___ to schedule an appointment.\n\nThank ___ for letting us participate in your care!\n\nGood luck!\n \nFollowup Instructions:\n___\n" ]

[ "K3189", "I429", "N179", "E870", "D62", "K922", "K449", "K219", "E785", "M810", "I447", "M1710", "M479", "I129", "N189", "G4700", "Z96653", "Z66", "Z86010", "Z87440", "M353" ]

[ "K3189: Other diseases of stomach and duodenum", "I429: Cardiomyopathy, unspecified", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "D62: Acute posthemorrhagic anemia", "K922: Gastrointestinal hemorrhage, unspecified", "K449: Diaphragmatic hernia without obstruction or gangrene", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "I447: Left bundle-branch block, unspecified", "M1710: Unilateral primary osteoarthritis, unspecified knee", "M479: Spondylosis, 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", "G4700: Insomnia, unspecified", "Z96653: Presence of artificial knee joint, bilateral", "Z66: Do not resuscitate", "Z86010: Personal history of colonic polyps", "Z87440: Personal history of urinary (tract) infections", "M353: Polymyalgia rheumatica" ]

[ "N179", "D62", "K219", "E785", "I129", "N189", "G4700", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ntransfer for preeclampsia\n \nMajor Surgical or Invasive Procedure:\nprimary high transverse cesarean section\n \nHistory of Present Illness:\n___ is a ___ G1 at 28 weeks and 2 days transferred \nfrom ___ with ___ w/o SF. She wad diagnosed with gestational \nhypertension at 27 weeks. She was seen for routine care on \n___ and had a BP at 146/79 and labs were sent. Serum \nlabs were wnl, although uric acid was 5.3, urine protein was \n678. First dose of betamethasone administered at 1015 (___). \nToday she feels well. Denies HA, visual changes, RUQ pain and \nSOB. She reports that her swelling has gotten progressively \nworse, but denies calf tenderness or pain. \n\nShe denies ctx, VB, LOF. Endorses active fetal movement.\n\nROS: Denies fevers/chills or recent illness. Denies HA, vision \nchanges. Denies chest pain/shortness of breath/palpitations. \nDenies abdominal pain. Denies recent falls or abdominal trauma. \nDenies any unusual foods/undercooked foods, nausea, vomiting, \ndiarrhea.\n \nPast Medical History:\nPNC: \n - ___ ___ by LMP, c/w ___ trimester u/s\n - B+/Abs-/RPRNR/RI/HBsAg-/HIV-/GC-/CT-/GBS+ (urine)\n - Screening: FFS wnl, CF/FXS/SMA-\n - GLT 95\n - Issues\n#Hypothyroidism: 75mcg levothyroxine; ___ trimester TSH: 2.8\n#Mumps/Rubeola NI: [ ] postpartum vaccine\n#Vaginal bleeding ___ necrotic cervical polyp, resolved\n \nOBHx:\n- G1\n \nGynHx:\n- denies abnormal Pap or cervical procedures\n- denies fibroids/endometriosis/cysts\n- denies STIs, including HSV\n \nPMH: obesity, anxiety, depression, ADD\n\nSurgical Hx: wisdom teeth extraction\n \nSocial History:\n___\nFamily History:\ndenies family history of gynecologic cancers\n \nPhysical Exam:\nOn admission:\nGen: A&O, comfortable\nCV: RRR\nPULM: CTAB\nAbd: soft, gravid, nontender\nExt: no calf tenderness, +2 DTR bilateral patellar reflexes\nSVE: deferred\n\nToco\nFHT 130/moderate variability/+accels/-decels\n\n \nPertinent Results:\n___ WBC-11.0 RBC-4.28 Hgb-11.8 Hct-35.7 MCV-83 Plt-216\n___ WBC-10.3 RBC-4.33 Hgb-12.3 Hct-36.3 MCV-84 Plt-238\n___ WBC-12.4 RBC-4.11 Hgb-11.5 Hct-33.9 MCV-83 Plt-148\n___ WBC-11.2 RBC-4.39 Hgb-12.1 Hct-35.8 MCV-82 Plt-151\n___ WBC-11.7 RBC-4.13 Hgb-11.5 Hct-34.2 MCV-83 Plt-110\n___ WBC-11.9 RBC-4.33 Hgb-12.1 Hct-35.3 MCV-82 Plt-108\n___ WBC-13.9 RBC-4.24 Hgb-12.1 Hct-35.0 MCV-83 Plt-113\n___ WBC-12.3 RBC-4.34 Hgb-12.3 Hct-37.0 MCV-85 Plt-96\n___ WBC-12.5 RBC-4.22 Hgb-11.8 Hct-34.6 MCV-82 Plt-92\n___ WBC-12.8 RBC-3.84 Hgb-10.9 Hct-32.2 MCV-84 Plt-99\n___ ___ PTT-26.0 ___ ___ ___ PTT-27.1 ___ ___ ___ PTT-25.4 ___ ___ ___ PTT-24.2 ___ ___ Glucose-151* UreaN-11 Creat-0.7\n___ Creat-0.6\n___ Glucose-97 UreaN-12 Creat-0.7 Na-134* K-5.0 Cl-105 \nHCO3-17* AnGap-12\n___ UreaN-11 Creat-0.6\n___ UreaN-12 Creat-0.6\n___ UreaN-14 Creat-0.6\n___ Creat-0.6\n___ UreaN-11 Creat-0.6\n\n___ 07:58PM BLOOD ALT-15 AST-11 LD(LDH)-159 TotBili-<0.2\n___ 04:56AM BLOOD ALT-16 AST-22\n___ 12:55AM BLOOD ALT-73* AST-71*\n___ 05:54AM BLOOD ALT-87* AST-92* LD(___)-516* TotBili-0.3\n___ 04:27PM BLOOD ALT-89* AST-63* LD(___)-275* TotBili-0.3\n___ 05:17AM BLOOD ALT-79* AST-44* LD(___)-289* TotBili-0.2\n___ 11:15AM BLOOD ALT-74* AST-36 LD(___)-273* TotBili-0.2\n___ 09:52PM BLOOD ALT-64* AST-30 TotBili-0.3\n___ 05:22AM BLOOD ALT-59* AST-25 LD(LDH)-251*\n___ 10:40AM BLOOD ALT-57* AST-30 LD(LDH)-325*\n___ 09:12PM BLOOD ALT-53* AST-30\n___ 07:58PM BLOOD Hapto-136\n___ 05:54AM BLOOD Hapto-78\n___ 04:27PM BLOOD Hapto-69\n___ 11:10PM BLOOD Hapto-55\n___ 11:15AM BLOOD Hapto-57\n___ 05:22AM BLOOD Hapto-77\n\n___ 12:09PM BLOOD ___ pO2-18* pCO2-44 pH-7.26* \ncalTCO2-21 Base XS--8 Comment-CORD VEIN\n \nBrief Hospital Course:\n___ G1 transferred from ___ at 28w2d with preeclampsia. On \nadmission, she had mild range blood pressures and normal labs. \nFetal testing was reassuring. By HD#2, she was started on po \nNifedipine for severe range blood pressures, which was \nuptitrated to Nifedipine 60mg daily on HD#2. Her 24 hour urine \nwas positive with 678mg of protein. She was made betamethasone \ncomplete on ___. She remained stable until 29w0d when she \nagain developed severe range blood pressures, epigastric pain, \nand a transaminitis. She was transferred to labor and delivery \nfor induction due to preeclampsia with severe features. She was \nstarted on Magnesium for seizure prophylaxis and her induction \nwas begun with cytotec followed by Pitocin. She progressed to \n4cm, however, developed a Category 2 tracing remove from \ndelivery. Delivery by cesarean section was recommended. She \nunderwent a primary high transverse cesarean section and \ndelivered (at 29w2d) a liveborn female weighing 1050 grams with \nApgars of 5 and 9. NICU staff was present for delivery. Please \nsee operative report for delivery.\n\nHer postoperative course was uncomplicated. Her pain was \nwell-controlled with an epidural for 24 hours after her \nprocedure and she was transitioned to oral medications without \nissue. She received magnesium for 24 hours post delivery. She \nwas continued on nifedipine 60mg qAM/30mg qPM and her blood \npressures remained within goal. By postoperative day 4, she was \nmeeting all milestones and her blood pressures were well \ncontrolled. She was discharged in stable condition with \noutpatient follow up scheduled. \n\n \nMedications on Admission:\nPNV, levothyroxine 75mcg \n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \nRX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) \nhours Disp #*30 Tablet Refills:*3 \n2. Citalopram 10 mg PO DAILY \nRX *citalopram [Celexa] 10 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*3 \n3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*30 Capsule Refills:*3 \n4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate \nRX *ibuprofen [IBU] 600 mg 1 tablet(s) by mouth every six (6) \nhours Disp #*30 Tablet Refills:*3 \n5. NIFEdipine (Extended Release) 60 mg PO QAM \nRX *nifedipine 60 mg 1 tablet(s) by mouth daily in the morning \nDisp #*30 Tablet Refills:*0 \n6. NIFEdipine (Extended Release) 30 mg PO QPM \nRX *nifedipine 30 mg 1 tablet(s) by mouth daily at night Disp \n#*30 Tablet Refills:*0 \n7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*25 Capsule Refills:*0 \n8. Levothyroxine Sodium 75 mcg PO DAILY\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ncesarean delivery\nsevere pre-eclampsia\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nNothing in the vagina for 6 weeks (No sex, douching, tampons)\nNo heavy lifting for 6 weeks\nDo not drive while taking narcotics (i.e. Dilaudid, Percocet)\nDo not take more than 4000mg acetaminophen (tylenol) in 24 hrs\nDo not take more than 2400mg ibuprofen in 24 hrs\nPlease call the on-call doctor at ___ if you develop \nshortness of breath, dizziness, palpitations, fever of 100.4 or \nabove, abdominal pain, increased redness or drainage from your \nincision, nausea/vomiting, heavy vaginal bleeding, or any other \nconcerns.\n\nYou should continue to monitor your blood pressure at home and \ntake medications as prescribed. If the systolic blood pressure \n(top number) is more than 150 or the diastolic blood pressure \n(bottom number) is more than 100, please call your doctor. If \nthe systolic blood pressure is less than 110 or the diastolic \nblood pressure is less than 60, please don't take the medication \nand call your doctor.\n \nFollowup Instructions:\n___\n" ]

[ "O1424", "O76", "O99824", "O99214", "O99284", "E039", "O99344", "F419", "Z370", "Z3A28" ]

[ "O1424: HELLP syndrome, complicating childbirth", "O76: Abnormality in fetal heart rate and rhythm complicating labor and delivery", "O99824: Streptococcus B carrier state complicating childbirth", "O99214: Obesity complicating childbirth", "O99284: Endocrine, nutritional and metabolic diseases complicating childbirth", "E039: Hypothyroidism, unspecified", "O99344: Other mental disorders complicating childbirth", "F419: Anxiety disorder, unspecified", "Z370: Single live birth", "Z3A28: 28 weeks gestation of pregnancy" ]

[ "E039", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nincomplete abortion\n \nMajor Surgical or Invasive Procedure:\nnone\n \nPhysical Exam:\nDischarge physical exam\nVitals: VSS\nGen: NAD, A&O x 3\nCV: RRR\nResp: no acute respiratory distress\nAbd: soft, appropriately tender, no rebound/guarding\nExt: no TTP\n \nPertinent Results:\n___ 06:02PM WBC-7.9 RBC-4.39 HGB-13.0 HCT-37.3 MCV-85 \nMCH-29.6 MCHC-34.9 RDW-11.9 RDWSD-36.4\n___ 06:02PM PLT COUNT-273\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service for \nan incomplete abortion at 6 weeks gestation. She was given \nmisoprostol and monitored overnight. Her vital signs and CBC \nwere normal. She was given Doxycycline for infection \nprophylaxis. She was placed on a regular diet, and was kept NPO \nafter midnight on ___ for possible ultrasound-guided D&C in \nthe operative room. She was given oral acetaminophen and \noxycodone for pain. She passed some blood and tissue vaginally \novernight, which was sent to pathology for further analysis.\n\nOn hospital day 1, her HCG was 4394. Ultrasound showed: \"The \nuterus is anteverted and measures 7 x 3 x 4.5 cm cm. The \nendometrial cavity demonstrates heterogeneity and debris with \ninternal color Doppler vascularity seen at the corpus, \nparticularly at the fundus. The cervical canal is open and \ndemonstrates heterogeneous contents without internal \nvascularity. The findings are compatible with expulsion of \nretained products of conception, vascularized at the corpus and \neither blood products or devascularized retained products of \nconception in the endocervical canal. The ovaries are normal. \nThere is no free fluid. IMPRESSION: Prolapsing retained products \nof conception with vascularity seen within the corpus and either \nblood clots or devascularized products of conception in the \ncervical canal.\"\n\nShe continued to improve clinically with mild vaginal bleeding \nand normal vital signs. She was then discharged to home in \nstable condition with outpatient follow-up as scheduled, and \nplan to repeat HCG in 4 days, and trend weekly until value is \nzero. \n \nMedications on Admission:\ncitalopram 40mg, levothyroxine 25mcg, zolpidem 10mg\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nDo not exceed 4,000mg in 24 hours \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*30 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily \nDisp #*30 Capsule Refills:*2 \n3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild \nTake with food or milk \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*30 Tablet Refills:*0 \n4. Citalopram 40 mg PO DAILY \n5. Levothyroxine Sodium 25 mcg PO DAILY \n6. LORazepam 1 mg PO BID \n7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nincomplete abortion\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service. You have recovered \nwell and the team believes you are ready to be discharged home. \nPlease call Dr. ___ office with any questions or concerns. \nPlease follow the instructions below.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Do not drive while taking narcotics.\n* Take a stool softener such as colace while taking narcotics to \nprevent constipation.\n* Do not combine narcotic and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* No heavy lifting of objects >10 lbs for 6 weeks.\n* You may eat a regular diet.\n* You may walk up and down stairs.\n\nCall your doctor for:\n* fever > 100.4F\n* severe abdominal pain\n* difficulty urinating\n* vaginal bleeding requiring >1 pad/hr\n* abnormal vaginal discharge\n* redness or drainage from incision\n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n\n \nFollowup Instructions:\n___\n" ]

[ "O031", "O99281", "E039", "O99341", "F418", "O09811" ]

[ "O031: Delayed or excessive hemorrhage following incomplete spontaneous abortion", "O99281: Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester", "E039: Hypothyroidism, unspecified", "O99341: Other mental disorders complicating pregnancy, first trimester", "F418: Other specified anxiety disorders", "O09811: Supervision of pregnancy resulting from assisted reproductive technology, first trimester" ]

[ "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nacute situational anxiety related to pregnancy\n \nMajor Surgical or Invasive Procedure:\nDilation and evacuation\n\n \nPhysical Exam:\nDischarge physical exam\nVitals: VSS\nGen: NAD, A&O x 3\nCV: RRR\nResp: no acute respiratory distress\nAbd: soft, appropriately tender, no rebound/guarding, incision \nc/d/i\nExt: no TTP\n \nPertinent Results:\n___ 09:45AM WBC-31.2* RBC-2.82* HGB-8.8* HCT-24.7* MCV-88 \nMCH-31.2 MCHC-35.6 RDW-13.6 RDWSD-43.3\n___ 09:45AM PLT COUNT-159\n___ 09:45AM ___ PTT-26.2 ___\n___ 09:45AM ___ 09:02AM HGB-8.1* calcHCT-24\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service \nafter undergoing dilation and evacuation, which was complicated \nby a 2L blood loss due to prolonged surgical time and twin \ngestation. Please see the operative report for full details.\n\nImmediately post-op, her pain was controlled with IV \ndilaudid/toradol. She had symptoms of dizziness and fatigue, and \nfound to have a hematocrit nadir at 20.2. She was given a total \nof 4 units of packed red blood cells during her hospital \nadmission, with symptomatic improvement. \n\nOn post-operative day 1, her diet was advanced without \ndifficulty and she was transitioned to \nacetaminophen/ibuprofen/oxycodone (pain meds). She was \ntolerating a regular diet, voiding spontaneously, ambulating \nindependently, and pain was controlled with oral medications. \nShe was then discharged home in stable condition with outpatient \nfollow-up scheduled.\n\n \nMedications on Admission:\nlevothyroxine, aspirin 81mg, PNV\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \nDo not take more than 4000mg in 24 hours. \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*50 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily \nDisp #*60 Capsule Refills:*1 \n3. Ibuprofen 600 mg PO Q6H \ntake with food. \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*50 Tablet Refills:*1 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nDo not drink alcohol or drive while taking this medication. \nRX *oxycodone 5 mg ___ capsule(s) by mouth every 4 hours Disp \n#*15 Capsule Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute situational anxiety related to pregnancy\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your \nprocedure. You have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ office with \nany questions or concerns. Please follow the instructions below.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Do not drive while taking narcotics.\n* Take a stool softener such as colace while taking narcotics to \nprevent constipation.\n* Do not combine narcotic and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* No heavy lifting of objects >10 lbs for 6 weeks.\n* You may eat a regular diet.\n* You may walk up and down stairs.\n\nCall your doctor for:\n* fever > 100.4F\n* severe abdominal pain\n* difficulty urinating\n* vaginal bleeding requiring >1 pad/hr\n* abnormal vaginal discharge\n* redness or drainage from incision\n* nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n\n \nFollowup Instructions:\n___\n" ]

[ "O0489", "D62", "I959", "N9961", "O30042", "O09522", "R000", "O09812", "Z3A20", "O359XX2", "Y92234" ]

[ "O0489: (Induced) termination of pregnancy with other complications", "D62: Acute posthemorrhagic anemia", "I959: Hypotension, unspecified", "N9961: Intraoperative hemorrhage and hematoma of a genitourinary system organ or structure complicating a genitourinary system procedure", "O30042: Twin pregnancy, dichorionic/diamniotic, second trimester", "O09522: Supervision of elderly multigravida, second trimester", "R000: Tachycardia, unspecified", "O09812: Supervision of pregnancy resulting from assisted reproductive technology, second trimester", "Z3A20: 20 weeks gestation of pregnancy", "O359XX2: Maternal care for (suspected) fetal abnormality and damage, unspecified, fetus 2", "Y92234: Operating room of hospital as the place of occurrence of the external cause" ]

[ "D62" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nvaginal bleeding\n \nMajor Surgical or Invasive Procedure:\ndilation and curettage\n\n \nHistory of Present Illness:\n___ yo ___ s/p D&E ___ presents with heavy vaginal\nbleeding x1 day. The patient reports daily bleeding since her\nprocedure on ___, requiring ___ pads, with new heavy vaginal\nbleeding and passage of clots since this morning. She reports\nmultiple large gushes soaking her clothes and covering the floor\nbeneath her, then subsequently going through \"at least 10\" pads.\nReports multiple grapefruit sized clots. She endorses some \ncrampy\nabdominal discomfort. Denies nausea or vomiting. Denies abnormal\nbowel movements, no blood in the stool. Denies urinary symptoms.\nShe has not been sexually active. \n\nOf note, the D&E on ___ was performed at 21 weeks for anomalous\nfetuses, complicated by a large intraoperative blood loss of 2L\nrequiring transfusion and admission for observation overnight.\nShe has done well since then, aside from daily bleeding and this\nrecent new onset heavy bleeding.\n \nPast Medical History:\nOBHx: G3P0\nG1: TAB at the age of ___, no complications\nG2: IVF with SAB -> D&C\nG3: IVF conceived dichorionic twins, one with an ONTD and one\nwith the abnormal microarray (same abnormality that her partner\ncarries); had D&E at 21 week complicated by hemorrhage requiring\nblood transfusion\n\nGYNHx: Denies hx of abnormal Pap testing or STIs\nPMHx:\n- hypothyroidism\n- depression/anxiety\n- infertility\n\nPSHx: \n- lsc right salpingectomy (hydrosalpinx discovered on HSG for\ninfertility workup)\n- D&C x2\n- D&E\n- tonsillectomy\n- knee arthroscopy\n \nSocial History:\n___\nFamily History:\nNon contributory\n \nPhysical Exam:\nVitals: VSS\nGen: NAD, A&O x 3\nCV: RRR\nResp: no acute respiratory distress\nAbd: soft, appropriately tender, no rebound/guarding\nGU: scant spotting on pad\nExt: no TTP\n \nPertinent Results:\n___ 01:15AM BLOOD WBC-10.3* RBC-3.79* Hgb-10.9* Hct-33.9* \nMCV-89 MCH-28.8 MCHC-32.2 RDW-11.9 RDWSD-38.1 Plt ___\n___ 05:30PM BLOOD WBC-7.4 RBC-4.07 Hgb-11.7 Hct-36.2 MCV-89 \nMCH-28.7 MCHC-32.3 RDW-11.9 RDWSD-38.8 Plt ___\n___ 11:50AM BLOOD WBC-8.0# RBC-4.41# Hgb-12.6# Hct-39.0# \nMCV-88 MCH-28.6 MCHC-32.3 RDW-12.0 RDWSD-38.7 Plt ___\n___ 11:50AM BLOOD Neuts-68.7 ___ Monos-6.7 Eos-1.0 \nBaso-0.4 Im ___ AbsNeut-5.50 AbsLymp-1.83 AbsMono-0.54 \nAbsEos-0.08 AbsBaso-0.03\n___ 11:50AM BLOOD ___ PTT-34.6 ___\n___ 11:50AM BLOOD Glucose-88 UreaN-12 Creat-0.6 Na-140 \nK-4.0 Cl-100 HCO3-26 AnGap-18\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service after \nundergoing attempted dilation and curettage for retained \nproducts of conception. Please see the operative report for full \ndetails.\nProducts of conception were not able to be completely evacuated \nbecause of hemorrhage during the case. An intrauterine foley \nballoon was placed. Ms. ___ bleeding was stable after the \ncase, and her hematocrit was also stable. She underwent \nultrasound imaging on postoperative day 1 to better \ncharacterized the retained products of conception. Ultrasound \nwas concerning for an arteriovenous malformation as well as \nfurther retained products. AVM was better characterized on MRI \nimaging. The decision was made, after discussion with the \ninterventional radiology team, to proceed with ___ embolization, \nwhich occurred on ___. On ___, the intrauterine foley was \nremoved without complication. Ms. ___ spiked a fever during \nthe intrauterine foley removal; this was thought to be most \nlikely in the setting of the uterine artery embolization, and \nshe was kept on gentamicin/clindamycin until she had been \nafebrile for 24 hours (___).\nPatient requested HIV and hepatitis B and C testing in the \nsetting of recent blood transfusion. Testing was negative \nduring this admission (though HCV viral load pending at time of \ndischarge).\nBy ___, she was tolerating a regular diet, voiding \nspontaneously, ambulating independently, and pain was controlled \nwith oral medications. She had only minor spotting from the \nvagina. She was then discharged home in stable condition with \noutpatient follow-up scheduled.\n \nMedications on Admission:\nActive Medication list as of ___:\n \nMedications - Prescription\nCITALOPRAM - citalopram 20 mg tablet. 1 tablet(s) by mouth once \na\nday\nLEVOTHYROXINE - Dosage uncertain - (Prescribed by Other\nProvider; daily)\nZOLPIDEM [AMBIEN] - Dosage uncertain - (Prescribed by Other\nProvider; bedtime)\n \nMedications - OTC\nFOLIC ACID - folic acid ___ mcg tablet. 2 tablet(s) by mouth \nonce\na day - (Prescribed by Other Provider)\nIBUPROFEN [ADVIL] - Dosage uncertain - (Prescribed by Other\nProvider; as needed)\nIRON - Dosage uncertain - (Prescribed by Other Provider; daily)\nPRENATAL - Prenatal 27 mg-0.8 mg tablet. 1 tablet(s) by mouth\nonce a day - (Prescribed by Other Provider)\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRetained products of conception s/p D&E\nArteriovenous malformation, now s/p embolization\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \n ___ MD ___\n \nCompleted by: ___\n" ]

[ "O046", "F329", "E039", "F419", "N979", "O021", "Q2732" ]

[ "O046: Delayed or excessive hemorrhage following (induced) termination of pregnancy", "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "F419: Anxiety disorder, unspecified", "N979: Female infertility, unspecified", "O021: Missed abortion", "Q2732: Arteriovenous malformation of vessel of lower limb" ]

[ "F329", "E039", "F419" ]

[]

[ " \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:\nAbdominal distention, umbilical hernia fluid leakage\n \nMajor Surgical or Invasive Procedure:\nDiagnostic Paracentesis ___\nTherapeutic Paracentesis ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ history of HCV cirrhosis c/b HCC s/p TACE\n(___) at ___, HTN, EtOH abuse, OA on chronic\ndisability, initially presenting to ___ with worsening\nabdominal distention and ___ ascitic fluid leakage\ntransferred here for further management. \n\nPatient has had fluid leakage from umbilical hernia since ___,\ninitially yellow straw color, however now has become more bloody\nsince starting earlier today. His periumbilical fluid leakage \nhas\nbeen quite intermittent, states it worsens when he bends over or\nlifts heavy materials at work where he does ___. \nPatient\nreports fluid drainage has been a recurring issue and he has \nbeen\nevaluated at both ___ and ___ and surgical intervention has so\nfar been deferred. \n\nHe recently underwent a therapeutic paracentesis on ___ \nwith\n4.8L serosanguinous fluid removed. He was referred to surgery at\n___ with Dr. ___ prior to admission who\napplied silver nitrate to umbilical hernia with temporary\nimprovement in leaking. This morning he had some worsening\nleakage again in additional to abdominal distention and \npresented\nto ___. Denies any fever, chills, nausea, vomiting, no\nchanges in bowel movements. Given medical complexity was\ntransferred here for further management. \n\nIn the ED, initial VS were: T 98.1 HR 66 Bp 145/85 RR 16 O2\n100%RA\n\nExam notable for: \nGeneral- NAD\nHEENT- PERRL, EOMI\nLungs- Non-labored breathing, CTAB\nCV- RRR, no murmurs, normal S1, S2, no S3/S4\nAbd-very distended, soft, large umbilical hernia with\nserosanguineous drainage, nontender\nMsk- No spine tenderness\nNeuro-A&O x3, CN ___ intact, normal strength and sensation in\nall extremities, normal coordination and gait.\nExt- No edema, cyanosis, or clubbing\n\nLabs notable for: \n- WBC 10.0, Hb 11.7, HCT 34.5, PLT 149\n- Na 132, K 4.3, BUN 10, Cr 0.9, Glc 82\n- ___ 14.2, PTT 32.9, INR 1.3\n- ALT 33, AST 65, ALP 156, T. bili 1.4, Albumin ___\n- S/p diagnostic para: TNC 476, RBP ___ with 26% polys and \n41%\nlymphs\n\nImaging: \nRUQUS with duplex/Doppler ___: \n1. Patent hepatic vasculature. Eccentric filling defect in the\nright portal vein may represent nonocclusive thrombus.\n2. Cirrhotic liver with 5.4 cm hypoechoic partially cystic\nhepatic mass, likely HCC, if clinically indicated further\nevaluation can be performed with a liver MRI or multiphase CT.\n3. Moderate intrahepatic biliary dilatation.\n4. Moderate to large volume ascites.\n5. Cholelithiasis.\n\nConsults: \n- Hepatology consulted: Recommending completing infectious\nwork-up, holding diuretics pending rule out of infection, if\nsignificant leakage albumin 25% x1 \n\nAdministered: \n___ 15:02 PO OxyCODONE (Immediate Release) 5 mg \n___ 16:30 PO/NG Lactulose 15 mL \n\nSubjective: On arrival to the floor, patient confirms the above\nhistory. At present, states that his periumbilical hernia is not\nleaking any ascitic fluid. Describes some abdominal distention,\nhowever denies any abdominal pain at this time. No nausea or\nvomiting. Denies any recent fevers, chills, cough, hematemesis,\nno bloody stools, no changes in bowel habits recently.\n\n \nPast Medical History:\n- HCV cirrhosis c/b HCC s/p TACE (___) at ___\n- COPD\n- HTN\n- EtOH abuse\n- OA on chronic disability, \n \nSocial History:\n___\nFamily History:\nNo family history of cirrhosis or ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: T 97.9 BP 155/79 HR 68 RR 18 O2 99%RA\nGENERAL: Comfortable, NAD\nHEENT: NC/AT, PERRL, EOMI\nLungs: Clear to auscultation bilaterally, no wheezes, rales, or\nrhonchi\nCV: Regular rate and rhythm. No murmurs, rubs, or gallops\nAbd: Distended. Periumbilical hernia no drainage observed, mild\noverlying erythema although non-tender to palpation. Reducible.\nAbdomen otherwise nontender throughout, no peritoneal signs.\nExt: 2+ peripheral pulses. 1+ pitting edema to hips bilaterally. \n\nNeuro: CN II-XII intact. No focal neurological deficits. Motor\nstrength intact throughout. \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVitals: Afebrile, BP: 139/79, HR: 77, RR: 18, O2: 98% RA \nGENERAL: Comfortable, NAD\nHEENT: NC/AT, PERRL, EOMI\nLungs: Clear to auscultation bilaterally, no wheezes, rales, or\nrhonchi\nCV: Regular rate and rhythm. No murmurs, rubs, or gallops\nAbd: Mildly distended, NABS. Periumbilical hernia no drainage\nobserved, mild overlying erythema although non-tender to\npalpation. Reducible. Abdomen otherwise nontender throughout, \nno\nperitoneal signs.\nExt: 2+ peripheral pulses. 1+ pitting edema to hips bilaterally. \n\nNeuro: CN II-XII intact. No focal neurological deficits. Motor\nstrength intact throughout. \n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 02:50PM BLOOD WBC-10.0 RBC-3.95* Hgb-11.7* Hct-34.5* \nMCV-87 MCH-29.6 MCHC-33.9 RDW-15.9* RDWSD-50.8* Plt ___\n___ 02:50PM BLOOD ___ PTT-32.9 ___\n___ 02:50PM BLOOD Glucose-82 UreaN-10 Creat-0.9 Na-132* \nK-4.3 Cl-94* HCO3-29 AnGap-9*\n___ 02:50PM BLOOD ALT-33 AST-65* AlkPhos-156* TotBili-1.4\n___ 06:14AM BLOOD Albumin-2.2* Calcium-8.1* Phos-3.3 Mg-1.6\n___ 06:14AM BLOOD HBsAg-NEG HBsAb-Borderline HBcAb-POS*\n___ 06:10AM BLOOD AFP-44.8*\n___ 06:14AM BLOOD HCV Ab-POS*\n___ 06:10AM BLOOD HCV VL-3.5*\n___ 07:05AM BLOOD HBV VL-NOT DETECT\n___ 06:21AM URINE Color-Yellow Appear-Clear Sp ___\n___ 06:21AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG\n\nASCITIC FLUID ANALYSIS:\n=======================\nDiagnostic para ___ 03:30PM ASCITES TNC-476* ___ Polys-26* \nLymphs-41* Monos-0 Plasma-1* Mesothe-10* Macroph-22*\n___ 03:30PM ASCITES TotPro-1.6 LD(LDH)-89 Albumin-0.6\n\nTherapeutic para ___ 03:30PM ASCITES TNC-453* ___ Polys-9* \nLymphs-51* ___ Mesothe-3* Macroph-37*\n___ 03:30PM ASCITES TotPro-1.3 Albumin-0.4\n\nDISCHARGE LABS:\n===============\n___ 06:15AM BLOOD WBC-11.7* RBC-3.56* Hgb-10.8* Hct-32.1* \nMCV-90 MCH-30.3 MCHC-33.6 RDW-15.9* RDWSD-52.6* Plt ___\n___ 06:15AM BLOOD Glucose-90 UreaN-17 Creat-1.2 Na-130* \nK-4.6 Cl-90* HCO3-29 AnGap-11\n___ 06:15AM BLOOD ALT-41* AST-68* AlkPhos-122 TotBili-1.0\n___ 06:15AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.8\n\nIMAGING STUDIES:\n================\nRUQ U/S (___):\n1. Patent main portal vein. Apparent eccentric filling defect in \nthe right \nportal vein may represent nonocclusive thrombus. \n2. Cirrhotic liver with 5.4 cm hypoechoic partially cystic \nhepatic mass, \nconcerning for HCC. Multiphasic liver MRI is suggested to \nfurther \ncharacterize. Evaluation of the right portal vein can be \nperformed at this \ntime as well. \n3. Moderate focal intrahepatic biliary dilatation. \n4. Moderate to large volume ascites. \n5. Cholelithiasis. \n\nCXR (___): \nSlightly limited study with exclusion of bilateral costophrenic \nangles \nrevealing no acute radiographic cardiopulmonary abnormality. \n \nCT ABD/PELVIS (___):\n1. Cirrhotic liver morphology with findings of portal \nhypertension. Moderate ascites. \n2. Dominant, heterogeneously enhancing mass in segment 6 is \nlikely HCC, \npresumably previously treated. There is residual nodular \nenhancement \nsuggesting active tumor. \n3. Ill-defined arterial enhancement in segment 8 associated with \nlocalized \nbiliary dilation, incompletely characterized but concerning for \nHCC. \n4. Numerous arterially enhancing nodular foci throughout the \nliver, a few of which demonstrate mild portal venous washout but \nno definite capsular \nenhancement. \n5. MRI could be considered for further evaluation of the above \nabnormalities, \nif there is not a recent outside MRI study for review. \n \nCT CHEST (___):\n1. No evidence of metastasis to the chest. \n2. Evidence of cirrhosis with hypodense lesion in the right lobe \nof liver which could represent patient's treated HCC. \n3. Ascites. \n4. Lack of intravenous contrast limits evaluation of the liver. \n\nMRI LIVER (___):\n1. Multifocal HCC as described above with 2 lesions meeting OPTN \n5B criteria and 2 lesions meeting OPTN 5A criteria. \n2. The largest HCC extends exophytically through the liver \ncapsule. A smaller HCC in segment ___ causes upstream biliary \nobstruction. \n3. Post treatment changes in segment II related to prior \nablation without \ndefinite local recurrence. \n4. Cirrhotic liver with sequelae of portal hypertension \nincluding moderate \nascites and variceal formation. \n\nTTE (___):\nCONCLUSION:\nThe left atrial volume index is mildly increased. The right \natrium is mildly enlarged. The right atrial pressure could not \nbe estimated. There is normal left ventricular wall thickness \nwith a normal cavity size. There is normal regional and global \nleft ventricular systolic function. Quantitative biplane left \nventricular ejection fraction is 66 %. Left ventricular cardiac \nindex is high (>4.0 L/min/m2). There is no resting left \nventricular outflow tract gradient. No ventricular septal defect \nis seen. Normal right ventricular cavity size with normal free \nwall motion. The aortic sinus diameter is normal for gender with \nmildly dilated ascending aorta. The aortic arch diameter is \nnormal with a normal descending aorta diameter. The aortic valve \nleaflets (3) appear structurally normal. There is no aortic \nvalve stenosis. There is no aortic regurgitation. The mitral \nvalve leaflets appear structurally normal with no mitral valve \nprolapse. There is mild [1+] mitral regurgitation. The tricuspid \nvalve leaflets appear structurally normal. There is physiologic \ntricuspid regurgitation. The estimated pulmonary artery systolic \npressure is normal. There is no pericardial effusion. Ascites is \nseen.\n\nIMPRESSION: Normal regional and global biventricular systolic \nfunction. Mild mitral regurgitation. Normal pulmonary artery \nsystolic pressure. Mildly dilated ascending aorta.\n\nBONE SCAN (___):\nIMPRESSION: No areas of focally increased uptake. As such, no \nevidence of metastatic disease. \n\nMICROBIOLOGY:\n=============\n__________________________________________________________\n___ 3:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES\n PERITONEAL FLUID. \n\n **FINAL REPORT ___\n\n Fluid Culture in Bottles (Final ___: NO GROWTH. \n__________________________________________________________\n___ 4:03 pm PERITONEAL FLUID PERITONEAL FLUID. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n__________________________________________________________\n___ 6:14 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 11:55 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 3:30 pm PERITONEAL FLUID PERITONEAL FLUID. \n\n **FINAL REPORT ___\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 (Final ___: NO GROWTH. \n\nCYTOLOGY:\n=========\nPeritoneal fluid (___):\nNEGATIVE FOR MALIGNANT CELLS.\n- Mesothelial cells, histiocytes, and lymphocytes.\n \nBrief Hospital Course:\nSUMMARY:\n========\nMr. ___ is a ___ history of HCV cirrhosis c/b HCC s/p TACE \n(most recently ___ at ___, HTN, EtOH abuse, OA on \nchronic disability, initially presenting to ___ with abdominal \ndistention and ascitic fluid leakage from umbilical hernia, \ntransferred to ___ for further management. \n\nACUTE ISSUES:\n=============\n#HCV/ETOH Cirrhosis\n#Umbilical Hernia\n#Hepatocellular carcinoma\nHistory of HCV cirrhosis with HCC s/p TACE (___) at ___, c/b \nrecurrent, large volume ascites (last LVP for 4.8 L on ___, \nand periumbilical hernia. He was transferred to ___ with \nworsening abdominal distention and ascetic fluid leakage from \numbilical hernia. He underwent diagnostic paracentesis here on \nadmission, without evidence of SBP, followed by therapeutic \nparacentesis on ___ for 3.8L. Leaking from hernia has since \nresolved after silver nitrate application at ___. CT on \nadmission was notable for multiple concerning lesions for HCC, \nalthough we do not have prior imaging for comparison. Hepatology \nwas consulted, and patient underwent re-staging of ___ to \ndetermine next steps in treatment. MRI was notable for \nmulti-focal HCC with 2 lesions meeting OPTN 5B criteria and 2 \nlesions meeting OPTN 5A criteria, with the largest HCC extending \nthrough the liver capsule. CT chest and bone scan otherwise \nnegative for metastasis. Multi-disciplinary liver tumor \nconference was held to discuss next steps moving forward. Per \nhepatology recommendations, will first optimize ascites, with \nup-titration of diuretics as an outpatient +/- therapeutic \nparacentesis PRN. If ascites is refractory, will consider TIPS \nprocedure at that point. There is still an option to treat his \nHCC with locoreginal therapy, however will need to optimize \nascites and consider elective hernia repair as an outpatient \nbefore ___ intervention. He will be discharged on Lasix \n40mg/spironolactone 100mg BID, with liver tumor clinic and \ntransplant surgery follow up on ___. Will also continue \nlactulose 30ml daily. \n\n#Hepatitis C\nHCV viral load 3.5, untreated. Per hepatology, unlikely to be a \ncandidate for HCV treatment at this time given poor prognosis. \nWill follow up in liver clinic as above.\n\n#Hyponatremia \nHyponatremic to 132, improving, likely in setting of cirrhosis. \nContinue low Na+ diet and diuresis as above.\n\n#Anemia \nHb 11.7, unknown baseline. No obvious signs of bleeding. \nPossibly ___ splenomegaly, alcohol use, and anemia of chronic \ndisease. Consider sending iron studies as an outpatient. \n\n#Malnutrition\nNutrition consulted on admission. Recommending Ensure Enlive TID \nwith meals and multi-vitamin with minerals. \n\nCHRONIC ISSUES:\n===============\n#HTN \nContinue home norvasc and metoprolol.\n\n#EtOH abuse\nDrinks several cans of beers daily. Currently no signs of \nwithdrawal, continue to encourage abstinence as an outpatient. \n\n#OA on chronic disability \nOn narcotics agreement at ___. Takes oxycodone at home for hip, \nback, and abdominal pain. Given stable on current home regimen, \nwill continue oxycodone 10mg PO Q6H:PRN.\n\nTRANSITIONAL ISSUES:\n====================\n[] Started on Lasix 40mg BID and spironolactone 100mg BID for \nascites\n[] Please repeat chemistry panel, LFTs, albumin, INR at PCP \nfollow up and fax results to Dr. ___: ___, \nphone: ___\n[] Please continue to monitor abdominal exam for re-accumulation \nof ascites, as patient may need interval therapeutic \nparacentesis vs. up-titration of diuretics as an outpatient\n[] If ascites becomes refractory to medical management, patient \nwill likely need TIPs procedure \n[] Please ensure outpatient Liver Tumor MDC follow up as well as \nfollow up with Dr. ___ in transplant surgery clinic \nfor elective hernia repair (scheduled for ___\n[] Patient has undergone re-staging of HCC during this \nadmission. MRI was notable for multi-focal HCC with 2 lesions \nmeeting OPTN 5B criteria and 2 lesions meeting OPTN 5A criteria. \nNo metastasis on bone scan/CT chest. Per hepatology, there is \nstill an option to treat his HCC with locoreginal therapy, \nhowever, will need to optimize ascites control and consider \nrepairing hernia before ___ intervention. Please ensure follow \nup with liver clinic as above to discuss next steps in \ntreatment.\n\n#CODE: Full (presumed)\n#CONTACT:\nName of health care proxy: ___ \nPhone number: ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Spironolactone 50 mg PO DAILY \n2. Furosemide 20 mg PO DAILY \n3. Metoprolol Succinate XL 50 mg PO DAILY \n4. amLODIPine 10 mg PO DAILY \n5. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - \nModerate \n6. LORazepam 1 mg PO QHS:PRN insomnia \n7. Lactulose 15 mL PO QID \n8. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Multivitamins 1 TAB PO DAILY \n2. Furosemide 40 mg PO BID \nRX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n3. Lactulose 30 mL PO DAILY \nRX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth once a day \nDisp #*60 Package Refills:*0 \n4. Spironolactone 100 mg PO BID \nRX *spironolactone 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n5. amLODIPine 10 mg PO DAILY \n6. LORazepam 1 mg PO QHS:PRN insomnia \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - \nModerate \n9. Vitamin D 1000 UNIT PO DAILY \n10.Outpatient Lab Work\nLabs: Chem 10, LFTs, INR, albumin \nDate: ___\nICD10: ___\nPlease fax results to Dr. ___\n11.Nutrition\nEnsure Enlive Supplements TID with meals\nDispense: 90 shakes\nRefills: 0\nICD 10: E44.0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n#Hepatocellular carcinoma\n#ETOH/HCV cirrhosis\n#Large volume ascites\n#Leakage of ascites fluid via periumbilical hernia\n#Anemia\n#Hyponatremia\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 abdominal swelling. You also \nneeded repeat staging tests for your liver cancer.\n\nWhat happened while I was in the hospital? \n- You had a paracentesis to drain the fluid in your abdomen. You \nare likely accumulating this fluid because of your cirrhosis and \nliver cancer.\n- You were started on diuretics (Lasix, spironolactone) to help \nprevent this abdominal fluid from re-accumulating.\n- You underwent multiple CT scans and a bone scan to evaluate \nyour liver cancer. You were seen by our liver team who are \nrecommending follow up as an outpatient for further treatment of \nyour cancer.\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\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nSincerely,\n\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "C220", "E871", "E440", "K766", "K7031", "B1920", "I10", "F1010", "D6489", "J449", "F17210", "M1990", "K429", "Z6828" ]

[ "C220: Liver cell carcinoma", "E871: Hypo-osmolality and hyponatremia", "E440: Moderate protein-calorie malnutrition", "K766: Portal hypertension", "K7031: Alcoholic cirrhosis of liver with ascites", "B1920: Unspecified viral hepatitis C without hepatic coma", "I10: Essential (primary) hypertension", "F1010: Alcohol abuse, uncomplicated", "D6489: Other specified anemias", "J449: Chronic obstructive pulmonary disease, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M1990: Unspecified osteoarthritis, unspecified site", "K429: Umbilical hernia without obstruction or gangrene", "Z6828: Body mass index [BMI] 28.0-28.9, adult" ]

[ "E871", "I10", "J449", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Asacol / Dipentum / \nMercaptopurine\n \nAttending: ___.\n \nChief Complaint:\nBloody didarrhea\n \nMajor Surgical or Invasive Procedure:\nVedolizumab infusion (___)\n\n \nHistory of Present Illness:\n___ is a ___ yo woman with PMH of ulcerative colitis, \nincomplete pancreas divisum, pancreatitis, lactose intolerance \nwho presents with headache and persistent diarrhea.\n\nPatient follows with Dr. ___ pan-UC. Colitis first \ndiagnosed on colonoscopy in early ___. She has had a number \nof subsequent colonoscopies over the years, with biopsies \nshowing active disease. Her most recent scope was done in ___, \nwhich showed rectal scarring and no signs of active disease. A \nbiopsy of colonic and rectal tissue showed normal mucosa.\n\nPatient states that the last time she felt well was ___. \nSince then, she has had persistent diarrhea. It has increased in \nfrequency, is almost always bloody, and often associated with \nabdominal pain, bloating and cramping. During this time, she was \non treatment with Humira. \nShe saw Dr. ___ in ___, at which time she was started \non daily prednisone 30 mg, with plan to start vedolizumab \n(anti-integrin monoclonal antibody inhibits T cell migration). \nShe recalls some improvement in diarrhea while on steroid, but \nshe felt fatigued/generally unwell. She was instructed to start \ntapering, but she thinks she may have tapered too quickly. She \nfinished her steroid taper in early ___.\nShe received her first vedolizumab treatment on ___. She \ncontinues to have bloody bowel movements about 10x/day, and she \nreports being unable to keep hydrated due to constant fluid \nloss. \nShe also developed a headache around ___, for which \nshe took Aleve and tylenol and did not feel relief. She \ndescribes the headache as constant, localized to the occiput and \nforehead bilaterally. She denies photophobia, phonophobia, \nnausea, or vomiting. She does not typically have headache like \nthis. \n\nIn the ED:\n- Initial vital signs were notable for: Afebrile, HR 85, BP \n114/69\n- Exam notable for: abdomen soft, nontender \n- Labs were notable for: Hb 11.8\n- Studies performed include: none\n- Patient was given: Tylenol, prochlorperazine, Benadryl \n- Consults: GI \n\nGI evaluated the patient in the ED and recommended stool \nstudies, inflammatory markers, and prep for flex sig in the \nmorning. \n\nVitals on transfer: Temp 98.0, BP 110 / 73, HR 78, RR 18, 97 Ra\n \nUpon arrival to the floor, patient describes history as above. \nShe continues to have headache. She denies abdominal pain, \nnausea. She is worried about dehydration. \n\n \nPast Medical History:\nPancreas divisum w/ pancreatitis, s/p sphincterotomy ___\nLactose intolerance\nUlcerative colitis\nSeasonal allergies\nVitamin D deficiency\n \nSocial History:\n___\nFamily History:\nMother: constipation\nFather: coronary artery disease, pancreatitis \n\nPer OMR review:\nFather had a myocardial infarction at age ___. No family history \nof colon cancer or inflammatory bowel disease. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS:\nGENERAL: Alert and interactive. Occasionally touches her head in \ndiscomfort.\nHEENT: mucous membranes moist. No oral lesions. Sclera \nanicteric. Pupils equal and reactive to light. EOMI.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No \nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or \nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep \npalpation in all four quadrants. \nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+ bilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal \nsensation.\n\nDISCHARGE PHYSICAL EXAM:\nVITALS: \n___ 1325 Temp: 98.3 PO BP: 117/76 HR: 97 RR: 18 O2 sat: 96%\nO2 delivery: RA \nGENERAL: Alert and interactive. Pleasant, alert and \nappropriate.\n\nHEENT: Mucous membranes moist. Sclerae anicteric.\nCARDIAC: RRR, normal S1 and S2. No murmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds. Abdomen is soft, non distended,\nnontender to palpation without rebound or guarding. \nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal\nsensation.\n \nPertinent Results:\nADMISSION LABS:\n___ 06:56PM LACTATE-0.8\n___ 06:52PM URINE HOURS-RANDOM\n___ 06:52PM URINE UHOLD-HOLD\n___ 06:52PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 06:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-SM*\n___ 06:52PM URINE RBC-0 WBC-2 BACTERIA-FEW* YEAST-NONE \nEPI-2 TRANS EPI-<1\n___ 06:52PM URINE MUCOUS-OCC*\n___ 06:44PM GLUCOSE-79 UREA N-13 CREAT-0.6 SODIUM-143 \nPOTASSIUM-4.2 CHLORIDE-111* TOTAL CO2-22 ANION GAP-10\n___ 06:44PM estGFR-Using this\n___ 06:44PM ALT(SGPT)-19 AST(SGOT)-21 ALK PHOS-91 TOT \nBILI-0.3\n___ 06:44PM LIPASE-17\n___ 06:44PM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-3.2 \nMAGNESIUM-1.9\n___ 06:44PM CRP-1.7\n___ 06:44PM WBC-6.6 RBC-4.27 HGB-11.8 HCT-38.2 MCV-90 \nMCH-27.6 MCHC-30.9* RDW-13.2 RDWSD-43.1\n___ 06:44PM NEUTS-58.6 ___ MONOS-9.1 EOS-4.4 \nBASOS-0.6 IM ___ AbsNeut-3.88 AbsLymp-1.79 AbsMono-0.60 \nAbsEos-0.29 AbsBaso-0.04\n___ 06:44PM PLT COUNT-280\n\nPERTINENT IMAGING:\nFLEXIBLE SIGMOIDOSCOPY (___):\n-Erythema, congestion and friability in the rectum and sigmoid \ncolon to 30cm (biopsy).\n-Normal mucosa in the sigmoid colon and descending colon \nstarting at 30-50cm (biopsy).\n\nPERTINENT MICROBIOLOGY:\nStool C. diff (___): Negative\nStool culture (___): Pending, negative to date\nStool O&P (___): Pending, negative to date\nBlood cultures (___): Pending, NGTD\nUrine culture (___): No growth, final\n\nDISCHARGE LABS:\n___ 06:31AM BLOOD WBC-8.8 RBC-4.05 Hgb-11.4 Hct-35.1 MCV-87 \nMCH-28.1 MCHC-32.5 RDW-13.1 RDWSD-40.9 Plt ___\n___ 06:31AM BLOOD Glucose-134* UreaN-9 Creat-0.6 Na-144 \nK-4.4 Cl-107 HCO3-27 AnGap-10\n___ 06:31AM BLOOD Calcium-9.3 Phos-4.0 Mg-1.8\n___ 06:31AM BLOOD CRP-1.___ with PMHx ulcerative colitis, incomplete pancreas divisum, \nand lactose intolerance who presented with headaches and bloody \ndiarrhea concerning for ulcerative colitis flare.\n\nACTIVE ISSUES:\n# MODERATE-TO-SEVERE PANULCERATIVE COLITIS with\n# ACUTE FLARE OF ULCERATIVE COLITIS:\nHad been having diarrhea since ___ that briefly improved \nwith a steroid burst. It started to worse, to greater than 10 \nbloody bowel movements per day. Her arrival lab work was notable \nfor CRP within normal limits (1.7), with subsequent CRP's also \nwithin normal. Stool culture and C. diff PCR negative; O&P \npending at time of discharge.\n\nShe was given IV methylprednisolone for 3d, and received her \nscheduled dose of vedolizumab (300mg) on ___ without \ndifficulty. Her bowel movements decreased in frequency, from \ngreater than 10 per day, to less than 4. She felt markedly \nimproved at discharge and was sent home with a course of 40mg \nprednisone for at least 2 weeks (or until such time as she \nfollows up with her gastroenterologist, ___, on \n___. \n\n# HEADACHES:\nPt with constant frontal headache since ___, for which she \ntook Aleve + Tylenol without relief. No other neurologic \nsymptoms associated with it. Initially improved with fioricet, \nbut also improved with hydration in the ED and standing PO \nTylenol. She was without headaches at time of discharge. \n\nTRANSITIONAL ISSUES:\n#CODE: Full, presumed\n#CONTACT: ___, spouse, ___\n\n[ ] MEDICATION CHANGES:\n-Added: Prednisone 40mg daily (D1 ___ - D14 ___, or until \nsuch time as seen by Dr. ___, pantoprazole 40mg daily (for \nGI prophylaxis while on prolonged taper).\n\n[ ] PROLONGED STEROID COURSE:\n-Written for a 14d course of 40mg prednisone daily. Depending on \nthe length of the patient's taper, consider Bactrim for PJP \nprophylaxis if her course exceeds the equivalent of 20mg \nprednisone x 30d.\n\n[ ] HEADACHES:\n-If recurrent or persistent headaches, consider referral to \nNeurology Headache Clinic. Her headaches here did not seem \ntypical for migraines.\n\n============\n> 30 minutes in patient care and coordination of discharge\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal \ncongestion \n2. Nasonex (*NF*) 50 mcg Other BID:PRN \n3. Cetirizine 10 mg PO DAILY:PRN allergies \n4. Vitamin D Dose is Unknown PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. vedolizumab 300 mg injection unknown \n\n \nDischarge Medications:\n1. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30 \nTablet Refills:*0 \n2. PredniSONE 40 mg PO DAILY Duration: 14 Doses \nRX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*28 Tablet \nRefills:*0 \n3. Cetirizine 10 mg PO DAILY:PRN allergies \n4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal \ncongestion \n5. Multivitamins 1 TAB PO DAILY \n6. Nasonex (*NF*) 50 mcg Other BID:PRN \n7. vedolizumab 300 mg injection unknown \n8. Vitamin D 400 UNIT PO DAILY \nTake whatever dosage you were previously taking. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nFlare of ulcerative colitis\nHeadaches\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 the ___ \n___.\n\nWHY WAS I SEEN IN THE HOSPITAL?\n-You were having headaches and bad diarrhea.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n-The stomach doctors looked at your bowels (\"sigmoidoscopy\"), \nwhere they saw that you have a likely ulcerative colitis flare. \n\n-You got steroids through the IV to help with your flare.\n-You received your usually-scheduled medicine (\"entyvio,\" or \n\"vedolizumab\") to help with your ulcerative colitis.\n\nWHAT SHOULD I DO WHEN I AM AT HOME?\n-Take your medications, including your steroids, as listed \nbelow.\n-Please follow up with the specialists as listed below.\n\nWe wish you the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K51011", "Q453", "R51", "R197", "E559" ]

[ "K51011: Ulcerative (chronic) pancolitis with rectal bleeding", "Q453: Other congenital malformations of pancreas and pancreatic duct", "R51: Headache", "R197: Diarrhea, unspecified", "E559: Vitamin D deficiency, unspecified" ]

[]

[]

[ " \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:\nScheduled Chemotherapy and Port Placement\n \nMajor Surgical or Invasive Procedure:\n___ - Port Placement\n \nHistory of Present Illness:\n___ yo male with a history of recently diagnosed \nneurolymphomatosis who is admitted for port placement and cycle \n1 methotrexate. The patient states he has been feeling well and \ndenies any recent fevers, headaches, shortness of breath, \nnausea, diarrhea, dysuria, or rashes. He occasionally has some \npain or tiredness feeling in his legs. Of note he was recently \nadmitted from ___ - ___ with a CSF leak so his \nchemotherapy was delayed. He received rituxan on ___.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n- Neurolymphomatosis\n(1) swallowing study on ___ showed oropharyngeal and \nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___ \nshowed T12-L1 enhancement that is located in the anterior spinal \ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114 \nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal \n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology \nfor malignant cells, \n(5) bone marrow aspiration on ___ showed lambda restricted \nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again \nshowed T12-L1 enhancement that is located in the anterior spinal \ncord with an exophytic component eccentric to the left side, and \n this enhancement appears slightly more prominent,\n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146 \nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin cytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range \n0.36-2.56) and presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by \nDr. ___ and the pathology showed \nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET showed uptake in the lower spinal cord but no \nsystemic uptake, \n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non ___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___\n(19) Rituxan ___.\n \nSocial History:\n___\nFamily History:\nFather had prostate cancer. Denies otherwise history of blood or \noncologic history.\n \nPhysical Exam:\n========================\nAdmission Physical Exam:\n========================\nGeneral: NAD.\nVITAL SIGNS: T 97.5 BP 127/74 HR 97 RR 18 O2 100% RA.\nHEENT: MMM, no OP lesions.\nCV: RR, NL S1S2.\nPULM: CTAB.\nABD: Soft, NTND, no masses or hepatosplenomegaly.\nLIMBS: No edema, clubbing, tremors, or asterixis.\nSKIN: No rashes or skin breakdown, Lumbar surgical incision well \nhealing without drainage or opening.\nNEURO: Alert and oriented, Cranial nerves II-XII are within \nnormal limits excluding visual acuity which was not assessed, no \nnystagmus; strength is ___ of the proximal and distal upper and \nlower extremities; no focal deficits.\n\n========================\nDischarge Physical Exam:\n========================\nVS: 97.7, BP 141/80, HR 79, RR 18, O2 sat 99% RA.\nRight chest wall port. Exam otherwise unchanged.\n \nPertinent Results:\n===============\nAdmission Labs:\n===============\n___ 01:28PM BLOOD WBC-4.4 RBC-3.83* Hgb-10.3* Hct-31.9* \nMCV-83 MCH-26.9 MCHC-32.3 RDW-14.0 RDWSD-42.6 Plt ___\n___ 01:28PM BLOOD Neuts-66.5 ___ Monos-7.8 Eos-1.8 \nBaso-0.5 Im ___ AbsNeut-2.90 AbsLymp-1.01* AbsMono-0.34 \nAbsEos-0.08 AbsBaso-0.02\n___ 01:28PM BLOOD ___ PTT-28.7 ___\n___ 01:28PM BLOOD Glucose-82 UreaN-10 Creat-0.7 Na-140 \nK-4.1 Cl-102 HCO3-26 AnGap-12\n___ 01:28PM BLOOD ALT-15 AST-12 AlkPhos-75 TotBili-0.3\n___ 01:28PM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1\n\n===============\nDischarge Labs:\n===============\n___ 02:00AM BLOOD WBC-4.5 RBC-3.52* Hgb-9.7* Hct-29.1* \nMCV-83 MCH-27.6 MCHC-33.3 RDW-14.1 RDWSD-42.3 Plt ___\n___ 02:00AM BLOOD Glucose-97 UreaN-7 Creat-0.9 Na-142 K-3.5 \nCl-98 HCO3-34* AnGap-10\n___ 02:00AM BLOOD ALT-59* AST-31 AlkPhos-68 TotBili-0.3\n___ 02:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4\n___ 01:53PM BLOOD mthotrx-0.14\n\n========\nImaging:\n========\nCXR ___\nImpression: In comparison with the study of ___, the \ncardiac silhouette remains within normal limits without evidence \nof vascular congestion, pleural effusion, or acute focal \npneumonia. The right subclavian PICC line remains at the \nmidportion of the SVC.\n \nBrief Hospital Course:\nMr. ___ is a ___ male with history of recently \ndiagnosed neurolymphomatosis who is admitted for port placement \nand cycle 1 methotrexate. \n\n# Neurolymphomatosis: Port placed on ___. Received cycle 1 \nmethotrexate per protocol with leucovorin and sodium bicarb and \npremedications which he tolerated well. His methotrexate level \nat discharge was 0.14. As he had not completely cleared he was \ndischarged with 3 days of PO leucovorin and instructions to \ndrink lots of fluids. He will return to clinic on ___ \n___ for rituxan. He will return for admission for next cycle \nof methotrexate on ___.\n\n# Elevated Aminotransferases: Mild elevation likely secondary to \nmethotrexate. Improving at time of discharge.\n\n# Severe Protein-Calorie Malnutrition: Meets criteria based on \nweight loss and decreased intake.\n\n# Anemia: Likely secondary to malignancy and inflammatory state. \nNo evidence of bleeding.\n\n# MGUS: Needs outpatient Hematology follow-up.\n\n# BILLING: 45 minutes were spent in preparation of discharge \npaperwork and coordination with outpatient providers.\n\n====================\nTransitional Issues:\n====================\n- Plan for admission to ___ for next cycle of \nmethotrexate on ___. Patient provided with prescription for \nsodium bicarbonate to take prior to scheduled admissions.\n- Patient discharged with leucovorin tablets and hydration \ninstructions for 3 days as methotrexate level at discharge was \nslightly higher than goal at 0.14.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n2. Docusate Sodium 100 mg PO BID \n3. Senna 8.6 mg PO BID:PRN constipation \n4. Multivitamins 1 TAB PO DAILY \n5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild\n \nDischarge Medications:\n1. Leucovorin Calcium 40 mg PO Q6H \nRX *leucovorin calcium 10 mg Take 4 tablets by mouth every 6 \nhours. Disp #*48 Tablet Refills:*0 \n2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \nRX *ondansetron HCl 8 mg Take 1 tablet by mouth every 8 hours \nDisp #*30 Tablet Refills:*0 \n3. Sodium Bicarbonate 1300 mg PO Q6H \nRX *sodium bicarbonate 650 mg Take 2 tablets by mouth every 6 \nhours. Disp #*64 Tablet Refills:*2 \n4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n6. Docusate Sodium 100 mg PO BID \n7. Multivitamins 1 TAB PO DAILY \n8. Senna 8.6 mg PO BID:PRN constipation\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n- Neurolymphomatosis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at the ___ \n___. You were admitted for your first cycle \nof methotrexate which you tolerated well. You also had a port \nplaced.\n\nYou methotrexate levels were monitored and were slightly high \nprior to discharge. Please take the leucovorin four times per \nday for the next 3 days for a total of 12 doses. Please also \nstay hydrated and drink lots of water over the next 3 days.\n\nAfter discussion with Dr. ___ your radiation oncologist Dr. \n___, it was decided to hold off on radiation for \nright now so you do not have to keep your radiation mapping \nappointment on ___.\n\nYou have an appointment on ___ for your next dose of \nRituxan as below.\n\nYou will return to ___ for your next cycle of \nmethotrexate on ___. Please start taking the sodium \nbicarbonate pills two days prior to your methotrexate \nadmissions.\n\nAll the best,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "E43", "C8339", "Z87891", "D630", "D472", "Z6821", "R740", "T451X5A", "Y92239" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "E43: Unspecified severe protein-calorie malnutrition", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "Z87891: Personal history of nicotine dependence", "D630: Anemia in neoplastic disease", "D472: Monoclonal gammopathy", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nNeurolymphomatosis \n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___\nPRIMARY ONCOLOGIST: ___, MD\nPRIMARY CARE PHYSICIAN: ___, MD\nPRIMARY DIAGNOSIS: Neurolymphomatosis, MGUS\nTREATMENT REGIMEN: HD-MTX C4D1 ___, rituximab C4D1 ___\n\nCC: ___ chemotherapy, neurolymphomatosis\n\nHISTORY OF PRESENTING ILLNESS: \n\nMr. ___ is a ___ year-old gentlema with a history of MGUS and\nneurolymphomatosis on rituximab/HD-MTX presenting for his fifth\ncycle of induction HD-MTX. \n\nHe has felt well since his previous discharge. He reports that\nthe swelling in his left foot is improved as well as the \nstrength\non flexion of his left foot. He continues to have\nhyperpigmentation in both of his forearms which are, in his\nopinion, unchanged from past discharge. He asks to start his\nchemotherapy as soon as possible. \n\nPatient denies fevers/chills, night sweats, headache, vision\nchanges, dizziness/lightheadedness, weakness/numbnesss, \nshortness\nof breath, cough, hemoptysis, chest pain, palpitations, \nabdominal\npain, nausea/vomiting, diarrhea, hematemesis,\nhematochezia/melena, dysuria, 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, reviewed): \n(1) swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells, \n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and \n\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake, \n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___, and\n(29) received C4 high-dose methotrexate at 8 grams/m2 on ___\n \nSocial History:\n___\nFamily History:\nHis father died at age ___ and he had dementia and prostate\ncancer. His mother is alive with osteoarthritis, knee\nreplacement, asthma and tuberculosis. He has 3 siblings and \nthey\nare all healthy. He does not have children.\n \nPhysical Exam:\n98.5 PO 167 / 91 65 16 98 Ra\nGENERAL: Well- appearing gentleman, in no distress lying in bed\ncomfortably.\nHEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx\nclear.\nCARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Non-distended, normal bowel sounds, soft, non-tender, no\nguarding.\nEXT: Warm, well perfused. No lower extremity edema. No erythema\nor tenderness.\nNEURO: Alert and oriented, good attention, linear thought\nprocess. CN II-XII intact. Strength full throughout except for\n___ in left foot flexion. Sensation to light touch intact.\nSKIN: Well-demarkated hyperpigmentation of bilateral forearms\nboth in anterior/posterior surfaces. Right chest port without\nerythema, secretion, tenderness.\n\n \nPertinent Results:\n___ 04:39AM BLOOD WBC-2.0* RBC-3.49* Hgb-9.4* Hct-29.4* \nMCV-84 MCH-26.9 MCHC-32.0 RDW-15.6* RDWSD-47.5* Plt ___\n___ 04:39AM BLOOD Glucose-95 UreaN-3* Creat-0.8 Na-141 \nK-3.4* Cl-95* HCO3-39* AnGap-7*\n___ 04:39AM BLOOD ALT-50* AST-29 LD(LDH)-130 AlkPhos-83 \nTotBili-0.3\n___ 04:39AM BLOOD Albumin-3.3* Calcium-8.9 Phos-3.6 Mg-1.7\n___ 04:39AM BLOOD mthotrx-0.14\n___ 03:31PM BLOOD mthotrx-0.44*\n___ 04:47AM BLOOD mthotrx-0.25*\n___ 08:30PM BLOOD mthotrx-0.93*\n___ 08:33PM BLOOD mthotrx-1.6*\n___ 08:20PM BLOOD mthotrx-5.3*\n \nBrief Hospital Course:\n___ w/ MGUS and neurolymphomatosis on HD MTX/Rituxan who \npresents\nfor admission for C5 q 2 week induction HD MTX. \n\n# Neurolymphomatosis (on HD MTX/Rituximab)\nHis CSF leak has resolved and continues to improve\nneurologically. No evidence of systemic lymphoma and is off\ndexamethasone and not on antiepileptics. His post laminectomy at\nL2-5 for nerve resection on ___ resulted in LLE weakness\nwhich is improving. He tolerated his cycle well with HD MTX \nexcept\nfor some nausea which resolved with substituting bicarb tabs \nwith\ncalcium carbonate \n\n- C5 HD MTX per Dr ___ on a q 2 week cycle\n- MRI/PET/LP to be done within next week which will determine \nnext cycle\n- Urine alkalinization w/ tums as sodium bicarb tabs causing N/V\n- per Dr ___ patient was clearing slowly and he was \nrequesting to go home asap, and his level was between 0.10 and \n0.30 (level was 0.14 on discharge), he will take leucovorin and \nbicarbonate tabs q6h \n- he tolerated Bicarb IV continuous @ 200 mL/hr, will go up to \n250 ml/hr next cycle to help expedite clearance\n- Emend with the next cycle of MTX\n\n# MGUS: With rising IgG level. Will recheck IgG in 2 months\n\n# Elevated BP: Multiple SBPs >150, likely from IVF. He will \nobtain BP monitor for home use\n\n# HBcAb+: HbSag/ab-. HBV viral load UL. Dr ___ will discuss w/ \npatient whether he wants antiviral\n\n# Hypokalemia: expected from bicarb fluid and repleted\n\nFEN: Regular diet\nDVT PROPHYLAXIS: Lovenox 40 sc q24hr (he declined) while \ninpatient \nACCESS: PORT\nCODE STATUS: Full code, presumed\nHCP: Health Care Proxy: ___ \nPCP: ___, MD\nDISPO: Home\nBILLING: >30 min spent coordinating care for discharge\n________________\n___, D.___.\nHeme/___ Hospitalist\np: ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Senna 8.6 mg PO BID:PRN constipation \n5. Sodium Bicarbonate 1300 mg PO Q6H \n6. Multivitamins 1 TAB PO DAILY \n7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n\n \nDischarge Medications:\n1. Leucovorin Calcium 100 mg PO Q6H Duration: 3 Days \nRX *leucovorin calcium 25 mg 4 tablet(s) by mouth q6 Disp #*48 \nTablet Refills:*1 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n4. Docusate Sodium 100 mg PO BID:PRN constipation \n5. Multivitamins 1 TAB PO DAILY \n6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n7. Senna 8.6 mg PO BID:PRN constipation \n8. Sodium Bicarbonate 1300 mg PO Q6H Duration: 3 Days \nstart taking 1 day before your next admission for methotrexate \nRX *sodium bicarbonate 650 mg 2 tablet(s) by mouth q6 Disp #*32 \nTablet Refills:*6 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNeurolymphomatosis \n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr ___\n\n___ tolerated your chemotherapy well. Please take your \nmedications as instructed and follow up with Dr ___. \nDo not take any aspirin or any other medications in the class of \nNSAIDs such as ibuprofen, motrin, aleve in preparation for your \nlumbar puncture with Dr. ___. Please see the attached reference \nfor the PET CT scan preparation. ___ need to follow a strict \ndiet for this PET scan to be successful. \n\nBecause your methotrexate level was still elevated, ___ were \ndischarged on a 3 day course of Leucovorin and Sodium \nBicarbonate. Please drink at least ___ liters of fluid a day to \nkeep your urine clear. \n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8599", "D472", "E876", "T451X5A", "Y92230", "R030", "F17210" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "E876: Hypokalemia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "R030: Elevated blood-pressure reading, without diagnosis of hypertension", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "Y92230", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nchlorhexidine\n \nAttending: ___.\n \nChief Complaint:\nElective admission for chemotherapy\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented \n\nfor C11 maintenance HD-MTX. \n\nThis is patient's ___ q2 month HD-MTX. He was last admitted for\nC10 on ___, which he tolerated well. He also received his\nrituximab in clinic on ___.\n\nHe notes a single episode about a month ago of having transient\nnumbness throughout his right leg - this was after he was \nsitting\nwith his legs crossed and only lasted a few minutes. His only\nremaining neurologic complaint is weakness in dorsiflexion of \nhis\nleft foot which is improving. He was fitted for AFO to left foot\na few months ago. No longer uses a cane to ambulate. \n\nOtherwise no headaches or visual complaints. No FC. No CP, SOB \nor\ncough. No N/V/D. Nl BM this am. No dysuria. No recent URTI.\n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n(1) swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells, \n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and \n\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake, \n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___,\n(29) received C3 rituximab 375 mg/m2/week on ___,\n(30) received C4 high-dose methotrexate at 8 grams/m2 on\n___,\n(30) received C4 rituximab 375 mg/m2/week on ___, \n(31) received C5 high-dose methotrexate at 8 grams/m2 on\n___, \n(32) gadolinium-enhanced total spine MRI on ___ showed\nresponse,\n(33) gadolinium-enhanced head MRI on ___ showed no evidence\nof disease,\n(34) FDG-PET on ___ showed improved FDG-Avid disease at\nT12-L2,\n(35) CSF cytology showed atypical cells,\n(36) received C5 monthly maintenance rituximab 375 mg/m2/week on\n___,\n(37) received C6 first monthly maintenance high-dose \nmethotrexate\nat 8 grams/m2 on ___,\n(38) gadolinium-enhanced MRI of the lumbosacral spine performed\non ___ showed no evidence of disease,\n(39) received C6 second monthly maintenance rituximab 375\nmg/m2/week on ___,\n(40) received C7 second monthly maintenance high-dose\nmethotrexate at 8 grams/m2 on ___,\n(41) received C7 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(42) received C8 maintenance rituximab 375 mg/m2/week on\n___ \n(43) received C8 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(44) received C9 first 2-month interval rituximab 375 mg/m2/week\non ___, and\n(45) received C9 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___\n(46) received C10 interval maintenance rituximab 375\nmg/m2/week on ___.\n(47) received C10 ___ 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___.\n(48)received C11 interval maintenance rituximab 375\nmg/m2/week on ___.\n\n \nPAST MEDICAL HISTORY: \n- MGUS\n- Laminectomy L2-5 for nerve resection on ___ c/b CSF leak\non ___ s/p subsequent repair \n- Left foot drop\n- Elbow Bursitis\n- HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior\ninfection. Discussed w/ Dr ___ by previous providers with\ndecision to hold off on antiviral for reactivation\n\n \nSocial History:\n___\nFamily History:\nHis father died at age ___ and he had dementia and prostate\ncancer. His mother is alive with osteoarthritis, knee\nreplacement, asthma and tuberculosis. He has 3 siblings and they\nare all healthy. He does not have children.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: T 97.7 HR 80 BP 137/87 RR 16 SAT 100% O2 on RA\nGENERAL: Pleasant, lying in bed comfortably\nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: Oropharynx clear without lesion, JVD not elevated \nCARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or\ngallops; 2+ radial pulses\nRESPIRATORY: Appears in no respiratory distress, clear to\nauscultation bilaterally, no crackles, wheezes, or rhonchi\nGASTROINTESTINAL: Normal bowel sounds; nondistended; soft,\nnontender without rebound or guarding; no hepatomegaly, no\nsplenomegaly\nMUSKULOSKELATAL: Warm, well perfused extremities without lower\nextremity edema; Normal bulk \nNEURO: Alert, oriented, CN III-XII intact, motor and sensory\nfunction grossly intact aside from maybe ___ left dorsiflexion\nSKIN: No significant rashes\nLYMPHATIC: No cervical, supraclavicular, submandibular\nlymphadenopathy. No significant ecchymoses\n\nDISCHARGE EXAM:\n___ 0748 Temp: 97.9 PO BP: 144/91 L Lying HR: 53 RR: 16 O2\nsat: 100% O2 delivery: RA \nGENERAL: Pleasant, sitting up in bed\nEYES: Anicteric sclerae, PERLL, EOMI; \nENT: Oropharynx clear without lesion, JVD not elevated \nCARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or\ngallops\nRESPIRATORY: Appears in no respiratory distress, clear to\nauscultation bilaterally\nGASTROINTESTINAL: Normal bowel sounds; nondistended; soft,\nnontender without rebound or guarding\nMUSKULOSKELATAL: Warm, well perfused extremities without lower\nextremity edema; Normal bulk \nNEURO: Alert, oriented, motor and sensory function grossly \nintact\nSKIN: No significant rashes\n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 10:25AM BLOOD WBC-3.4* RBC-4.30* Hgb-11.8* Hct-36.4* \nMCV-85 MCH-27.4 MCHC-32.4 RDW-14.6 RDWSD-44.6 Plt ___\n___ 10:25AM BLOOD Glucose-94 UreaN-14 Creat-1.0 Na-142 \nK-3.9 Cl-102 HCO3-30 AnGap-10\n___ 10:25AM BLOOD ALT-16 AST-18 TotBili-0.2\n___ 10:25AM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.4 Mg-2.2\n\nDISCHARGE LABS:\n===============\n___ 05:46AM BLOOD WBC-2.6* RBC-4.13* Hgb-11.2* Hct-34.8* \nMCV-84 MCH-27.1 MCHC-32.2 RDW-13.2 RDWSD-41.0 Plt ___\n___ 03:57PM BLOOD K-3.4*\n___ 05:46AM BLOOD Glucose-92 UreaN-3* Creat-0.9 Na-141 \nK-3.4* Cl-98 HCO3-35* AnGap-8*\n___ 05:46AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8\n___ 03:57PM BLOOD mthotrx-0.31*\n\nIMAGING: \n========\n___ Imaging MR ___ & W/O CONT \n1. No significant change since the previous MRI study. \n2. No abnormal enhancement or signal within the distal spinal\ncord or abnormal intraspinal enhancement. \n3. Mild degenerative changes and lumbar laminectomy as before. \n4. Dumping of the nerve roots in the lower lumbar region\nindicating arachnoiditis. \n \nBrief Hospital Course:\nPRINCIPLE REASON FOR ADMISSION:\n___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented \n for C11 maintenance HD-MTX. He received 8g/m2 infusion on \n___. As his typical course has been, he had delayed clearance, \nbut otherwise tolerated infusion well. With prior admissions, we \nallowed discharge when MTX<0.3 with strict instructions to \ncontinue po leucovorin and bicarb tabs x3 days. His level ___ \nreturned at 0.31, this was discussed with ___ who felt that \nit was safe to discharge him. He will follow up in ___ with \nPET-CT. His next HD MTX treatment is planned in three months on \n___.\n\n# Encounter for HD-MTX chemotherapy: Patient presented for C11 \nmaintenance HD-MTX. Urine was alkalanized per protocol po NaHCO3 \nand 150mEq NaHCO3/D5w at 250 cc/hr (as he tends to clear \nslowly). Underwent 8g/m2 HD-MTX infusion on ___ per OMS order \nset. Leucovorin rescue 24 hours post infusion. Monitored MTX \nlevels q24 hours. As is his pattern, he had delayed MTX \nclearance. There was no evidence of extravascular fluid \ncollection. As per Dr ___ admits, patient ok to \ndischarge when level less than 0.3, with NaHCO3 1300mg q6 hours \nand leucovorin 40mg q6 hours for three days after admission. His \nlevel ___ returned at 0.31, this was discussed with ___ \nwho felt that it was safe to discharge him. Maintained on MTX \nDiet (No carbonated beverages, no citric acid, no Vit C) and \navoided PPI, bactrim, PCNs and cephalosporins w/ HD MTX.\n\n# Neurolymphomatosis: \n# SP laminectomy at L2-5 for nerve resection (___)\n# Left foot drop\nPatient will have yearly PET-CT in ___. Next HD-MTX \ntreatment scheduled in 3 months, on ___. Left foot drop \ncontinues to improve. He has AFO to left foot prn.\n\n# Normocytic anemia\n# Leukopenia: Stable and at recent baseline. ___ with Dr. ___ \n___ him for MGUS).\n\n#Hypokalemia: Expected effect of chemotherapy treatment. PRN \nsliding scale for repletion.\n\n#MGUS: Followed by Dr ___ as outpatient as previously \nscheduled\n\n#Hypertension: Not currently on meds. BP's typically 150's \nduring admissions. Should follow up with PCP\n\n# ___: HbSag/ab-. HBV viral load negative ___. \nIndicative of prior infection. No plans for antiviral treatment\n\nTRANSITIONAL ISSUES:\n- Cont leucovorin 40mg q6 hours x3 days\n- Con't NaHCO3 1300mg q6 hours x3 days\n- ___ with PET_CT in ___\n- Next HD-MTX with rituximab in 3 months (HD MTX scheduled for \n___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n3. Sodium Bicarbonate 1300 mg PO QID \n4. Leucovorin Calcium 40 mg PO Q6H \n5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate \n\n6. Diazepam 5 mg PO Q8H:PRN muscle spasm \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Diazepam 5 mg PO Q8H:PRN muscle spasm \n3. Leucovorin Calcium 40 mg PO Q6H Duration: 3 Days \nRX *leucovorin calcium 10 mg 4 tablet(s) by mouth four times a \nday Disp #*48 Tablet Refills:*3 \n4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \n6. Sodium Bicarbonate 1300 mg PO QID Duration: 3 Days \nTake for three days before and after chemotherapy \nRX *sodium bicarbonate 650 mg 2 tablet(s) by mouth four times a \nday Disp #*24 Tablet Refills:*6 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Admission for chemotherapy\n# Neurolymphomatosis\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___. You were admitted for your scheduled \nchemotherapy, which you tolerated well. You have a PET scan \nscheduled in ___, with follow up in Dr. ___ \nafterward. Your next planned HD-MTX treatment will be in three \nmonths on ___. Dr. ___ will arrange for rituximab before \nthat admission. Please be sure to take your leucovorin and \nbicarb tabs for the next three days. \n\nYour methotrexate level prior to discharge was 0.31. We \ndiscussed this with Dr ___ works with Dr. ___. He felt \nthat it was safe for you to leave the hospital, but it is very \nimportant to take your leucovorin and bicarbonate for the next 3 \ndays.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8589", "D472", "M21372", "Z87891", "Z8042", "D649", "D72819", "E876", "T451X5A", "Y92230", "I10" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "M21372: Foot drop, left foot", "Z87891: Personal history of nicotine dependence", "Z8042: Family history of malignant neoplasm of prostate", "D649: Anemia, unspecified", "D72819: Decreased white blood cell count, unspecified", "E876: Hypokalemia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "I10: Essential (primary) hypertension" ]

[ "Z87891", "D649", "Y92230", "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:\nScheduled Chemotherapy\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), \npresents\nfor scheduled HD MTX Cycle 3\n\nOn last admission patient left while his MTX level was slightly\ngreater than 0.1, so was discharged on leucovorin. He noted that\nhe was tried of being in the hospital and just wanted to be home\nat the time. He noted that he took the leucovorin as directed\n\nPatient noted that since then he has been afebrile, without any\ninfectious symptoms. He noted that he was without cough,\nshortness of breath, rhinorrhea, abdominal pain, headache. He\nnoted that his left leg strength continues to improve, but noted\nthat he has persistent pedal edema in the dorsum of left foot\n(which is stable and thought to be ___ foot drop/inactivity).\n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \nAs per Dr. ___ clinic note:\n\"His neurologic problem began in late ___ when he noted\ndysphagia and dysphonia. His voice became hoarse and he\ndeveloped difficulty swallowing solids and liquids. Solid foods\ngot stuck in his throat. He had decreased PO intake and he lost\nabout ___ lbs. He saw his primary care physician and ___ \nvideo\nswallowing study on ___ showed oropharyngeal and esophageal\ndysphagia on the right-sided. He was subsequently referred to\nthe ___ clinic. On the day of his evaluation ___, he was\nfound to have left lower extremity weakness. He was sent to the\nemergency department for evaluation and was admitted to the\ngeneral neurology service for work up. He underwent a\ngadolinium-enhanced thoracic and lumbar MRI that showed T12-L1\nenhancement that is located in the anterior spinal cord with an\nexophytic component eccentric to the left side. His first \nlumbar\npuncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63\nglucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), \nCA\n___ <6, VDRL non-reactive, and negative cytology for malignant\ncells. He also had a bone marrow aspiration on ___ that\nshowed lambda restricted plasma cells. His repeat\ngadolinium-enhanced lumbar MRI performed on ___ again \nshowed\nT12-L1 enhancement that is located in the anterior spinal cord\nwith an exophytic component eccentric to the left side, and this\nenhancement appears slightly more prominent. A second lumbar\npuncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57\nglucose, 23 LDH, and atypical large lymphoid cells in cytology.\nA third lumbar puncture on ___ showed 27 WBC, 0 RBC, 88\nprotein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range\n0.36-2.56) and presence of oligoclonal bands. Because the\ndiagnosis could not be established via non-invasive measn, he\neventually underwent a laminectomy at L2-5 for nerve resection \non\n___ by Dr. ___. During the immediate\npostoperative period, he had C1W1 rituximab 375 mg/m2 and\nlamivudine 100 mg QD on ___. He experienced CSF leak on\n___, and therefore lamuvidine and dexamethasone were\ndiscontinued on ___. He underwent a repair of CSF leak on\n___ by Dr. ___. He re-started rituximab on\n___ and high-dose methotrexate on ___\n\nC2 MEthotrexate ___\nC2 Rituxan ___ \n \nPAST MEDICAL HISTORY: \n-MGUS\n-Laminectomy L2-5 for nerve resection on ___ c/b CSF leak \non\n___ s/p subsequent repair \n-Left foot drop\n\n \nSocial History:\n___\nFamily History:\nFather had prostate cancer. Denies otherwise history of blood or \n\noncologic history.\n\n \nPhysical Exam:\nPHYSICAL EXAM: \nVitals: 24 HR Data (last updated ___ @ 1023)\n Temp: 98.0 (Tm 98.0), BP: 145/85, HR: 81, RR: 16, O2 sat:\n100%, O2 delivery: RA, Wt: 140.2 lb/63.59 kg (140.2-142.2) \nGENERAL: sitting upright in bed, appears well, smiling, NAD\nEYES: PERRLA, EOMI\nHEENT: OP clear, MMM\nNECK: supple\nLUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR\nCV: RRR normal distal perfusion no edema\nABD: soft NT, ND, normoactive BS\nGENITOURINARY: no foley\nEXT: gross sensation unchanged in all extremities, but has ___\nstrength in all muscles of the left lower extremity, RLE/RUE/LUE\n___. (maybe slightly stronger than baseline)\nSKIN: warm, dry, no rash \nNEURO: AOx3, fluent speech, CNII-XII intact without deficits,\nstrength ___ in LLE, otherwise other extremities normal strength\nACCESS: port in right chest, accessed, dressing c/d/i\n\nDISCHARGE PHYSICAL EXAM: \n___ ___ Temp: 98.3 PO BP: 130/67 HR: 74 RR: 18 O2 sat: 99% \nO2 delivery: ra \n\nGENERAL: Pleasant and well appearing man, ambulating room\ncomfortably\nEYES: PERRLA, EOMI\nHEENT: OP clear, MMM\nNECK: supple, JVD not elevated\nLUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR\nCV: RRR normal distal perfusion no edema\nABD: soft NT, ND, normoactive BS\nEXT: Trace edema left foot with TEDS in place. Normal bulk\nSKIN: warm, dry, no rash \nNEURO: AOx3, fluent speech, strength ___ in left hip flexor and\nknee extensor, 3+/5 dorsiflexion, ___ strength in RLE and BUE.\nACCESS: port in right chest, accessed, dressing c/d/i\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 11:42AM BLOOD WBC-3.8* RBC-3.48* Hgb-9.5* Hct-29.4* \nMCV-85 MCH-27.3 MCHC-32.3 RDW-15.6* RDWSD-47.8* Plt ___\n___ 11:42AM BLOOD ___ PTT-29.5 ___\n___ 11:42AM BLOOD Glucose-99 UreaN-6 Creat-0.8 Na-142 K-3.8 \nCl-102 HCO3-27 AnGap-13\n___ 11:42AM BLOOD ALT-39 AST-24 LD(___)-149 AlkPhos-85 \nTotBili-0.2\n___ 11:42AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0 UricAcd-4.9\n\nDISCHARGE LABS:\n===============\n\n___ 05:05AM BLOOD WBC-3.2* RBC-3.20* Hgb-8.6* Hct-26.7* \nMCV-83 MCH-26.9 MCHC-32.2 RDW-14.6 RDWSD-44.4 Plt ___\n___ 05:05AM BLOOD Plt ___\n___ 05:05AM BLOOD Glucose-89 UreaN-4* Creat-0.7 Na-141 \nK-3.2* Cl-95* HCO3-37* AnGap-9*\n___ 05:05AM BLOOD ALT-36 AST-23 LD(___)-132 AlkPhos-70 \nAmylase-80 TotBili-0.3\n___ 05:05AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.1 Mg-1.9 \nIron-39*\n___ 05:05AM BLOOD calTIBC-199* Ferritn-245 TRF-153*\n___ 05:05AM BLOOD mthotrx-0.11\n\nIMAGING:\n========\n___ Imaging VENOUS DUP EXT UNI (MAP \nNo evidence of deep venous thrombosis in the left lower \nextremity veins.\n \nBrief Hospital Course:\nPRINCIPLE REASON FOR ADMISSION:\n___ PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), \npresented\nfor scheduled HD MTX Cycle 3. \n\n# Neurolymphatosis (on HD MTX/Rituximab)\nUrine was alkalinized per protocol with IV and po NaHCO3. \nReceived infusion on ___. He tolerated infusion well despite \nsome nausea. Leucovorin rescue initiated per protocol. We \nmonitored MTX levels q24 hours. He will continue q2 week HD MTX \ninduction after discharge, but will start to space rituximab to \nq2 weeks (next will be the ___, prior to his next \nHD-MTX admission on ___.\n\n#Constipation history: Continued home bowel regimen\n\n#Left Foot drop c/b left foot edema\nPatient with slight edema in left foot but not leg, which is \nlikely ___ venous pooling from inactivity due to foot drop. TEDS \nto help with limited pedal edema. Duplex left leg for DVT \nnegative. Consider outpatient ___.\n\n# Transaminitis\n# Drug induced liver injury: Occurs as expected with HD MTX: \nNormalized prior to discharge.\n\n#Anemia/Leukopenia\nIndices near baseline, likely combination of Neurolymphatosis \nand antineoplastic therapy causing BM suppression.\n\n# Hypokalemia: Repleted per scales\n\n# Billing: >30 minutes spent coordinating and executing this \ndischarge plan\n\nTRANSITIONAL ISSUES:\n====================\n- Start sodium bicarb tabs three days prior to next admission\n- Next rituximab ___\n- Next HD-MTX ___\n- Consider higher rate of HCO3 next admission to facilitate \nquicker clearance\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID \n4. Multivitamins 1 TAB PO DAILY \n5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n6. Senna 8.6 mg PO BID:PRN constipation \n7. Sodium Bicarbonate 1300 mg PO Q6H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID \n4. Multivitamins 1 TAB PO DAILY \n5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n6. Senna 8.6 mg PO BID:PRN constipation \n7. Sodium Bicarbonate 1300 mg PO Q6H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Encounter for chemotherapy\n# Neurolymphomatosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___. You were admitted for your planned high dose \nmethotrexate chemotherapy, which you tolerated well. You will \nneed to get your next rituximab on ___ and your \nnext HD-MTX admission is planned for ___. You can \nstart taking the sodium bicarbonate tabs 3 days before your next \nadmission.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8599", "D701", "D472", "Z87891", "K5900", "R740", "D6481", "E876", "T451X5A", "M21372", "R600" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D701: Agranulocytosis secondary to cancer chemotherapy", "D472: Monoclonal gammopathy", "Z87891: Personal history of nicotine dependence", "K5900: Constipation, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "D6481: Anemia due to antineoplastic chemotherapy", "E876: Hypokalemia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "M21372: Foot drop, left foot", "R600: Localized edema" ]

[ "Z87891", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nintramedullary spinal cord lesion at the conus medullaris\n \nMajor Surgical or Invasive Procedure:\n___: L4-L5 lumbar laminectomy and nerve root biopsy\n___: Repair of Lumbar CSF Leak \n\n \nHistory of Present Illness:\n___ yo male with no previous medical\nhistory who presented to the ED on ___ with new-onset LLE\nweakness, dysphagia, and dysphonia. He was admitted ___ to \n___ to work up new left leg weakness, dysphagia, and \ndysphonia. MRI showed 1.5 x 0.6 x 0.5 \ncm T12-L1 intramedullary enhancing lesion. He was subsequently \nfound to have monoclonal gammopathy and concern for plasma cell\ndyscrasia on bone marrow biopsy. CSF cytology was non-diagnostic\nat the time, and he was deemed high risk for biopsy of the\nlesion. He was discharged with outpatient follow up. He had\nrepeat LP on ___ and repeat MRI on ___. There was concern\nfor large lymphocytic proliferation on CSF and seemed to have\nexpansion of lesion on MRI. After evaluation in the spine \nclinic, the patient ultimately decided to proceed with lumbar \nlaminectomy and biopsy.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n___ is a ___ right-handed man, without \n___\nmedical history, who has subacute onset of dysphagia, dysphonia\nand left lower extremity weakness over one month.\n\nTreatment History:\n(1) swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells, and \n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n\n \nPAST MEDICAL HISTORY: \nNone\n \nSocial History:\n___\nFamily History:\nFather had prostate cancer. Denies otherwise history of blood \nor\noncologic history.\n \nPhysical Exam:\n-------------\nOn admission:\n-------------\nGENERAL: Pleasant, well appearing man, lying in bed comfortably\nEYES: Anicteric sclerea, PERLL, EOMI \nENT: Oropharynx with MMM\nCARDIOVASCULAR: Regular rate and rhythm, 2+ radial pulses\nRESPIRATORY: Appears in no respiratory distress\nGASTROINTESTINAL: nondistended, soft,\nnontender without rebound or guarding\nMUSKULOSKELATAL: Warm, well perfused extremities without lower\nextremity edema\nSKIN: No significant rashes\nLYMPHATIC: No cervical, supraclavicular, submandibular LAD\n\nNEURO:\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\nOrientation: [x]Person [x]Place [x]Time\nFollows commands: [ ]Simple [x]Complex [ ]None\nPupils: PERRL ___\nEOM: [x]Full [ ]Restricted\nFace Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No\nPronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No\nComprehension intact [x]Yes [ ]No\n\nMotor:\nTrapDeltoidBicepTricepGrip\nRight5 5 5 5 5\nLeft5 5 5 5 5 \n\nIPQuadHamATEHLGast\nRight5 4 5 4 5 5\nLeft5 3 5 3 0 5\n\n[x]Clonus - negative\n[x]Sensation decreased in BLE L>R\n\n-------------\nOn discharge:\n-------------\n\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\nOrientation: [x]Person [x]Place [x]Time\nFollows commands: [ ]Simple [x]Complex [ ]None\nSpeech Fluent: [x]Yes [ ]No\nComprehension intact [x]Yes [ ]No\n\nMotor:\nBilateral upper extremity ___ \n IP Quad Ham AT ___ ___\nRight 5 5 5 5 5 5\nLeft 4 4 5 2 0 5\n\n[x]Numbness and tingling to bilateral lower extremity from knees\ndown stable from preop. \n\nWound: \nLumbar incision: c/d/I, staples open to air\n\n \nPertinent Results:\nPlease see OMR for pertinent results.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ without significant medical history, who \npresented with ___ weakness, with known intramedullary spinal \ncord lesion and monoclonal gammopathy diagnosed on previous \nadmission in ___. Repeat imaging was concerning for \nexpanding mass.\n\n#Intramedullary lesion at the conus meddularis:\n#CNS lymphoma vs neurolymphomatosis\nThe patient was taken to the operating room on ___ and \nunderwent L4-L5 lumbar laminectomy with nerve root biopsy. He \ntolerated the procedure well and had an uneventful recovery in \nthe PACU. He was transferred to the ward for continued care and \nmonitoring of his neurologic status. \nBiopsy resulted as diffuse large B cell lymphoma (primary CNS \nlymphoms/neurolymphomatosis). He was transferred to ___ to \ninitiate Chemotherapy on ___. PET scan was without \nadditional lesions. Ophthomology was consulted for slit lamp \ngiven risk of ophtho lymphoma involvement, which was negative \nfor no eye involvement.\nHe was started on 4mg dexamethasone PO daily on arrival given \nsignificant neurological deficits. HbcAb positive, surface ag/ab \nnegative so was started on entecavir for HBV prophylaix in the \nsetting of starting rituximab ___. Planned to initiate \nMethotrexate ___, but he subsequently developed CSF leak (see \nbelow), and chemo was put on hold as he had to return to OR for \nCSF leak repair. He is cleared to resume steroids in 1 week \nafter surgery (___), and chemo/radiation after 3 weeks \n(___). \n\n#CSF leak s/p durotomy: \nAfter biopsy, the patient was placed on strict flat bedrest for \n48hr post-operatively. His activity out of bed and HOB status \nwas liberalized the evening of POD2. However the morning of \nPOD3, he was noted to have positional headaches and drainage of \nclear fluid to his dressings c/f CSF Leak. He was again placed \non bed rest precautions with HOB flat x 24hr. On the morning of \nPOD4 Mr. ___ denied positional headaches but his dressings \nwere CDI without any drainage noted. His HOB status was \nliberalized, and later that day he was permitted OOB, which was \nwell tolerated until ___ when he was noted to have positional \nheadaches, fluid collection with clear fluid leaking from \nincision concerning for CSF leak. Incision was oversewn with \nsuture ___, however continued with clear drainage. Given \npersistent leak, he retuned to the OR on ___ and he underwent \nrepair of CSF leak with Dr. ___. Procedure was \nuncomplicated. He was maintained on strict flat bed rest \npostoperatively until POD#3. The HOB was elevated by 10 degrees \nper hour to maximum flexion of bed, which he tolerated well, and \nthen was permitted to get OOB to chair, which he again tolerated \nwell. His activity was advanced to as tolerated the same day. ___ \ncleared for home with services. The patient remained \nneurologically stable and was discharged home ___.\n\n#Plasma cell dyscresia\nMonoclonal spike of 730mg/dL found on prior admissions. Prior BM \nbiopsy concerning for plasma cell dyscresia. Likely MGUS. \n\nTransitional Issues\n===================\n[]ENT follow up for vocal cord paralysis (patient is a ___)\n\n# CODE: Presumed Full\n# EMERGENCY CONTACT: \nName of ___ care proxy: ___ \n___: partner \nPhone number: ___ \nBrother ___: ___\n\n \n\n \n___ on Admission:\n1. Multivitamins W/minerals 1 TAB PO DAILY \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n \nDischarge Medications:\n1. Bisacodyl 10 mg PO/PR DAILY constipation \nRX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth \nDaily Disp #*30 Tablet Refills:*0 \n2. Diazepam ___ mg PO Q8H:PRN muscle spasm or agitation \nRX *diazepam 2 mg ___ tablets by mouth Q8H PRN Disp #*30 \nTablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*30 Capsule Refills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n___ request partial fill. \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*60 \nTablet Refills:*0 \n5. Polyethylene Glycol 17 g PO DAILY Constipation - Third Line \n\n6. Senna 17.2 mg PO QHS \nRX *sennosides [senna] 8.6 mg 2 tablets by mouth Daily Disp #*30 \nTablet Refills:*0 \n7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n Reason for PRN duplicate override: Patient is NPO or unable to \ntolerate PO \n8. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nintramedullary spinal cord lesion at the conus medullaris\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 intramedullary spinal cord lesion and \nunderwent L4-L5 laminectomy and nerve root biopsy on ___ \nand repair of CSF leak ___.\n\nSurgery\n•Your dressing may come off. \n•Your incision is closed with staples. You will need staple \nremoval. Please keep your incision dry until staple removal.\n•Do not apply any lotions or creams to the site. \n•Please avoid swimming for two weeks after suture/staple \nremoval.\n•Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n•We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n•You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n•No driving while taking any narcotic or sedating medication. \n•No contact sports until cleared by your neurosurgeon. \n\nMedications\n•Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by your neurosurgeon. \n\n•You may take Ibuprofen/ Motrin for pain.\n•You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n•It is important to increase fluid intake while taking pain \nmedications. We also recommend a stool softener like Colace. \nPain medications can cause constipation. \n\nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite. \n•Fever greater than 101.5 degrees Fahrenheit\n•New weakness or changes in sensation in your arms or legs.\n \nFollowup Instructions:\n___\n" ]

[ "C8339", "E43", "G9782", "G960", "T8132XA", "D472", "Z720", "Y92239", "Y838", "Z6822" ]

[ "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "E43: Unspecified severe protein-calorie malnutrition", "G9782: Other postprocedural complications and disorders of nervous system", "G960: Cerebrospinal fluid leak", "T8132XA: Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter", "D472: Monoclonal gammopathy", "Z720: Tobacco use", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Z6822: Body mass index [BMI] 22.0-22.9, adult" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nchlorhexidine\n \nAttending: ___.\n \nChief Complaint:\nMTX administration\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ yo man with neurolymphomatosis on HD-MTX \nand\nrituximab maintenance, who presents for scheduled chemotherapy.\n\nHe saw Dr ___ in clinic ___ and received C15 of maintenance\nrituximab. His last PET scan was ___ which showed no \nevidence\nof systemic lymphoma. MRI L spine ___ was stable without \nany\nnew findings. \n\nHe returns for HD-MTX at q3 month maintenance interval. He is in\nhis USOH. No headache, nausea, vomiting, abd pain, chest pain,\nSOB, fevers, chills, fatigue, appetite changes, dysuria. \n\nHe started his sodium bicarb on ___ morning (>48 hrs prior\nto admission).\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n(1) swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells, \n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and \n\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake, \n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___,\n(29) received C3 rituximab 375 mg/m2/week on ___,\n(30) received C4 high-dose methotrexate at 8 grams/m2 on\n___,\n(30) received C4 rituximab 375 mg/m2/week on ___, \n(31) received C5 high-dose methotrexate at 8 grams/m2 on\n___, \n(32) gadolinium-enhanced total spine MRI on ___ showed\nresponse,\n(33) gadolinium-enhanced head MRI on ___ showed no evidence\nof disease,\n(34) FDG-PET on ___ showed improved FDG-Avid disease at\nT12-L2,\n(35) CSF cytology showed atypical cells,\n(36) received C5 monthly maintenance rituximab 375 mg/m2/week on\n___,\n(37) received C6 first monthly maintenance high-dose \nmethotrexate\nat 8 grams/m2 on ___,\n(38) gadolinium-enhanced MRI of the lumbosacral spine performed\non ___ showed no evidence of disease,\n(39) received C6 second monthly maintenance rituximab 375\nmg/m2/week on ___,\n(40) received C7 second monthly maintenance high-dose\nmethotrexate at 8 grams/m2 on ___,\n(41) received C7 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(42) received C8 maintenance rituximab 375 mg/m2/week on\n___ \n(43) received C8 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(44) received C9 first 2-month interval rituximab 375 mg/m2/week\non ___, and\n(45) received C9 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___\n(___) received C10 interval maintenance rituximab 375\nmg/m2/week on ___.\n(47) received C10 ___ 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___.\n(___)received C11 interval maintenance rituximab 375\nmg/m2/week on ___.\n(49) Received C11 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___: stable MRI L-spine and no definite abnormal area of\nuptake on FDG PET. \n \nPAST MEDICAL HISTORY: \n- MGUS\n- Laminectomy L2-5 for nerve resection on ___ c/b CSF leak\non ___ s/p subsequent repair \n- Left foot drop\n- Elbow Bursitis\n- HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior\ninfection. Discussed w/ Dr ___ by previous providers with\ndecision to hold off on antiviral for reactivation\n \nSocial History:\n___\nFamily History:\nHis father died at age ___ and he had dementia and prostate\ncancer. His mother is alive with osteoarthritis, knee\nreplacement, asthma and tuberculosis. He has 3 siblings and they\nare all healthy. He does not have children.\n \nPhysical Exam:\nVitals: ___ 0727 Temp: 97.5 PO BP: 156/97 HR: 62 RR: 16 O2\nsat: 100% O2 delivery: RA\nGENERAL: NAD, pleasant and cooperative\nEYES: no scleral icterus\nHEENT: moist mucous membranes\nNECK: supple\nLUNGS: CTAB, no wheezing or rales\nCV: RRR, S1, S2, no murmurs\nABD: BS+; soft, non-tender, no hepatosplenomegaly\nGENITOURINARY: no foley\nEXT: moves all 4 extremeties w/ purpose\nSKIN: intact\nNEURO: AOx3; gross CNII-XII intact\n \nPertinent Results:\n___ 05:30AM BLOOD WBC-3.0* RBC-4.41* Hgb-12.0* Hct-37.5* \nMCV-85 MCH-27.2 MCHC-32.0 RDW-12.9 RDWSD-40.2 Plt ___\n___ 05:30AM BLOOD Neuts-62.2 ___ Monos-4.7* Eos-4.7 \nBaso-0.3 Im ___ AbsNeut-1.83 AbsLymp-0.82* AbsMono-0.14* \nAbsEos-0.14 AbsBaso-0.01\n___ 06:00AM BLOOD Poiklo-1+* Ovalocy-1+* RBC Mor-SLIDE REVI\n___ 05:30AM BLOOD Glucose-99 UreaN-4* Creat-0.8 Na-139 \nK-3.5 Cl-97 HCO3-32 AnGap-10\n___ 05:30AM BLOOD ALT-28 AST-21\n___ 05:30AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.1 Mg-2.2\n___ 05:30AM BLOOD mthotrx-0.05\n \nBrief Hospital Course:\nMr. ___ was admitted for C15 HD-MTX. He tolerated the regimen \nwithout major complaints or complications. His levels were \nmonitored frequently while on supportive leucovorin rescue. His \nlevel on day of discharge is 0.05.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Diazepam 5 mg PO Q8H:PRN muscle spasm \n3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate \n\n5. Sodium Bicarbonate 1300 mg PO QID \n6. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN allergies \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Diazepam 5 mg PO Q8H:PRN muscle spasm \n3. Fluticasone Propionate NASAL 2 SPRY NU BID:PRN allergies \n4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \n6. Sodium Bicarbonate 1300 mg PO QID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nEncounter for antineoplastic therapy\nNeurolymphomatosis\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 for MTX administration and tolerated it \nwell. Please confirm with your ___ clinic your next \nadmission date (tentatively scheduled for ___.\n\nBest,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8580", "E876", "D472", "F17210" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8580: Other specified types of non-Hodgkin lymphoma, unspecified site", "E876: Hypokalemia", "D472: Monoclonal gammopathy", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "F17210" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nweakness\n \nMajor Surgical or Invasive Procedure:\nLP on ___\n \nHistory of Present Illness:\nMr. ___ is a ___ without significant medical history, but\nrecent diagnosis of new intramedullary spinal cord lesion and\nmonoclonal gammopathy in the setting of left leg weakness,\ndysphagia, and dysphonia.\n\nHe was admitted ___ to ___ to work up new left leg\nweakness, dysphagia, and dysphonia. MRI showed 1.5 x 0.6 x 0.5 \ncm\nT12-L1 intramedullary enhancing lesion. He was subsequently \nfound\nto have monoclonal gammopathy and concern for plasma cell\ndyscrasia on bone marrow biopsy. CSF cytology was non-diagnostic\nat the time, and he was deemed high risk for biopsy of the\nlesion. He was discharged with outpatient follow up. He had\nrepeat LP on ___ and repeat MRI on ___. There was concern\nfor large lymphocytic proliferation on CSF and seemed to have\nexpansion of lesion on MRI. Due to these findings he was asked \nto\ncome back to the hospital for expediated workup.\n\nIn the ED, initial VS were pain 5, T 98.0, HR 91, BP 148/90, RR\n16, O2 99%RA. Initial labs notable for Na 141, K 4.4, HCO3 27, \nCr\n0.7, WBC 4.8, HCT 38.3, PLT 257, INR 1.0. Patient was given 1g\nAPAP. VS prior to transfer were pain 5, T 97.9, HR 82, BP \n141/76,\nR R18, O2 99%RA. \n\nOn arrival to the floor, patient only notes some back pain he \nhas\nbeen having since his first LP. Gets up to ___, well controlled\nwith Tylenol, and has some radicular symptoms down left leg.\nOtherwise notes his left leg weakness is a bit worse, but he is\nstill ambulatory and active without assistance despite limp. He\ndenies fevers or chills. Mild recent nasal congestion. No ST.\nDysphagia seems improved, tolerates regular food with head turn.\nNo chest pain, SOB, or cough. No N/V/D. No dysuria. No urinary\nretention or bowel incontinence. No new leg pain or swelling. No\nrashes.\n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n___ is a ___ right-handed man, without \n___\nmedical history, who has subacute onset of dysphagia, dysphonia\nand left lower extremity weakness over one month.\n\nTreatment History:\n(1) swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells, and \n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n\n \nPAST MEDICAL HISTORY: \nNone\n \nSocial History:\n___\nFamily History:\nFather had prostate cancer. Denies otherwise history of blood \nor\noncologic history.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n========================\nVS: T 98.0 HR 70 BP 140/68 RR 18 SAT 99% O2 on RA\nGENERAL: Pleasant, well appearing man, lying in bed comfortably\nwith excellent bed mobility\nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: Oropharynx clear without lesion, JVD not elevated \nCARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or\ngallops; 2+ radial pulses\nRESPIRATORY: Appears in no respiratory distress, clear to\nauscultation bilaterally, no crackles, wheezes, or rhonchi\nGASTROINTESTINAL: Normal bowel sounds; nondistended; soft,\nnontender without rebound or guarding; no hepatomegaly, no\nsplenomegaly\nMUSKULOSKELATAL: Warm, well perfused extremities without lower\nextremity edema; Normal bulk \nNEURO: Alert, oriented, CN III-XII intact, motor strength ___\nthroughout except 4+/5 left hip flexion, ___nd ___ left dorsiflexion\nSKIN: No significant rashes\nLYMPHATIC: No cervical, supraclavicular, submandibular\nlymphadenopathy. No significant ecchymoses\n\nDISCHARGE PHYSICAL EXAM: \n========================\nVS: ___ 0003 Temp: 98.4 PO BP: 130/84 HR: 67 RR: 18 O2 sat:\n100% O2 delivery: RA \nGENERAL: Pleasant, well appearing man, lying in bed comfortably \nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: Oropharynx clear without lesion, JVD not elevated \nCARDIOVASCULAR: RRR, no m/r/g\nRESPIRATORY: On room air, no increased work of breathing, no\nwheezes, rales or rhonchi\nGASTROINTESTINAL: NABS, soft, NT, ND\nMUSKULOSKELATAL: wwp, no edema\nNEURO: Alert, oriented, CN II-XII intact, motor strength ___\nthroughout except 3+/5 left hip flexion, ___nd ___ left dorsiflexion\nSKIN: No significant rashes\n \nPertinent Results:\nADMISSION LABS: \n===============\n\n___ 07:25PM BLOOD WBC-4.8 RBC-4.56* Hgb-12.6* Hct-38.3* \nMCV-84 MCH-27.6 MCHC-32.9 RDW-14.4 RDWSD-44.0 Plt ___\n___ 07:25PM BLOOD Neuts-60.5 ___ Monos-8.3 Eos-1.5 \nBaso-0.2 Im ___ AbsNeut-2.91 AbsLymp-1.41 AbsMono-0.40 \nAbsEos-0.07 AbsBaso-0.01\n___ 07:25PM BLOOD ___ PTT-26.0 ___\n___ 07:25PM BLOOD Plt ___\n___ 07:25PM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-141 \nK-4.4 Cl-102 HCO3-27 AnGap-12\n___ 06:38AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.2 UricAcd-4.4\n___ 06:38AM BLOOD ALT-31 AST-20 LD(LDH)-105 AlkPhos-73 \nTotBili-0.4\n\nRELEVANT LABS/IMAGING: \n======================\n\n___ 12:30PM CEREBROSPINAL FLUID (CSF) TNC-27* RBC-0 Polys-0 \n___ Macroph-4\n___ 12:30PM CEREBROSPINAL FLUID (CSF) TotProt-88* \nGlucose-55 LD(___)-33\n___ 12:30PM CEREBROSPINAL FLUID (CSF) CSF-PEP-OLIGOCLONA\n\nPATHOLOGY ___: \n===================\n\nCSF Flow Cytometry: Diagnostic immunophenotypic features of \ninvolvement by a plasma cell dyscrasia or B cell lymphoma are \nnot identified.\n\nCSF Protein Electropheresis: OLIGOCLONAL BANDS ARE SEEN IN CSF\nHOWEVER, THE SAME PATTERN IS SEEN MORE STRONGLY IN PAIRED SERUM \nSAMPLE PATTERN SUGGESTS LEAK OF OLIGOCLONAL IMMUNOGLOBULINS FROM \nSERUM AND IS NOT SPECIFIC FOR INTRATHECAL OLIGOCLONAL BANDING \nAND NOT SPECIFIC FOR INTRATHECAL MONOCLONAL PROCESS\n\nMICRO: \n======\nNONE\n\nDISCHARGE LABS: \n===============\n___ 06:42AM BLOOD WBC-4.3 RBC-4.67 Hgb-12.7* Hct-39.0* \nMCV-84 MCH-27.2 MCHC-32.6 RDW-14.3 RDWSD-42.9 Plt ___\n___ 06:42AM BLOOD Plt ___\n___ 06:42AM BLOOD ___ PTT-26.7 ___\n___ 06:42AM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-142 \nK-4.5 Cl-101 HCO3-27 AnGap-14\n___ 06:42AM BLOOD Calcium-10.0 Phos-4.0 Mg-2.4\n \nBrief Hospital Course:\nMr. ___ is a ___ without significant medical history, but\nrecent diagnosis of new intramedullary spinal cord lesion and\nmonoclonal gammopathy in the setting of left leg weakness,\ndysphagia, and dysphonia.\n\n# Intramedullary spinal mass\n# Plasma cell dyscrasia\n# Lymphocytic proliferation: Solitary spinal mass in setting of\nconfirmed plasma cell dyscrasia is concering for solitary\nextramedullary plasmacytoma. There could also be concern of a\nlymphomatous lesion given the abnormal proliferation of\nlymphocytes. CSF PEP showed ogliclonal bands which likely from \nserum, no clear significance on the read. Diagnostic \nimmunophenotypic features of involvement by a plasma cell \ndyscrasia or B cell lymphoma were not identified on flow \ncytometry. Given this, a biopsy of the mass would be the next \nstep. Neurosurgery was contacted regarding this and the patient \nelected to follow-up as an outpatient. \n\n# Leg weakness\n# Back pain\n# Vocal cord paralysis: Symptoms likely due to mass effect from\nknown spinal mass. Weakness slightly worsening on exam. \nDysphonia and back pain have been stable. Steroids were held due \nto no signs of cord compression. \n\nTransitional Issues: \n[ ] f/u with neurosurgery (ideally ___ if possible) \n[ ] f/u with speech and swallow\n[ ] f/u with Dr. ___ ___ if possible) \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Multivitamins W/minerals 1 TAB PO DAILY \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Multivitamins W/minerals 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis: \nIntramedullary Spinal Mass\nPlasma Cell Dyscrasia\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 for an expedited work-up of your spinal mass. \nWhile you were here Dr. ___ a lumbar puncture which \nwe sent for testing. The testing did not show any specific \ndiagnosis which could tell us what this spinal mass is. \n\nAs you requested, here are results of these tests in medical \nlanguage: \n\nCSF Flow Cytometry: \"Diagnostic immunophenotypic features of \ninvolvement by a plasma cell dyscrasia or B cell lymphoma are \nnot identified.\"\n\nCSF Protein Electropheresis: \"OLIGOCLONAL BANDS ARE SEEN IN CSF\nHOWEVER, THE SAME PATTERN IS SEEN MORE STRONGLY IN PAIRED SERUM \nSAMPLE PATTERN SUGGESTS LEAK OF OLIGOCLONAL IMMUNOGLOBULINS FROM \nSERUM AND IS NOT SPECIFIC FOR INTRATHECAL OLIGOCLONAL BANDING \nAND NOT SPECIFIC FOR INTRATHECAL MONOCLONAL PROCESS\"\n\nPlease call neurosurgery, Dr. ___ and speech and \nswallow about appointments (number list below). If you have any \nworsening weakness, please call Dr. ___.\n\nIt was a pleasure taking care of you, \n\n-Your ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "D472", "G9589", "R531", "R1319", "R490", "R836", "F17210", "M5416", "J3801" ]

[ "D472: Monoclonal gammopathy", "G9589: Other specified diseases of spinal cord", "R531: Weakness", "R1319: Other dysphagia", "R490: Dysphonia", "R836: Abnormal cytological findings in cerebrospinal fluid", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M5416: Radiculopathy, lumbar region", "J3801: Paralysis of vocal cords and larynx, unilateral" ]

[ "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:\nNeurolymphomatosis\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with history of MGUS and\nneurolymphomatosis on rituximab/HD-MTX presenting for C6 HD-MTX. \n\n\nHe has felt well since his previous discharge. He received\nRituximab with Dr. ___ on ___ which went fine. He notes\nsome improvement in his arm discoloration and thinks he needs to\nsee a Dermatologist. He has gained some weight back. He noticed \na\nrash around his port which has improved with steroid cream. He\nstarted taking his bicab tabs on ___ prior to admission.\n\nHe denies fevers/chills, night sweats, headache, vision changes,\ndizziness/lightheadedness, weakness/numbnesss, shortness of\nbreath, cough, hemoptysis, chest pain, palpitations, abdominal\npain, nausea/vomiting, diarrhea, hematemesis,\nhematochezia/melena, 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:\n(1) Swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells,\n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake,\n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___,\n(29) received C3 rituximab 375 mg/m2/week on ___,\n(30) received C4 high-dose methotrexate at 8 grams/m2 on\n___,\n(30) received C4 rituximab 375 mg/m2/week on ___, \n(31) received C5 high-dose methotrexate at 8 grams/m2 on\n___, \n(32) gadolinium-enhanced total spine MRI on ___ showed\nresponse,\n(33) gadolinium-enhanced head MRI on ___ showed no evidence\nof disease,\n(34) FDG-PET on ___ showed improved FDG-Avid disease at\nT12-L2, and\n(35) CSF cytology showed atypical cells.\n(36) received C5 monthly maintenance rituximab 375 mg/m2/week on\n___,\n(37) received C6 first monthly maintenance high-dose \nmethotrexate\nat 8 grams/m2 on ___, and\n(38) gadolinium-enhanced MRI of the lumbosacral spine performed\non ___ showed no evidence of disease.\n\nPAST MEDICAL HISTORY: \n-Hypertension\n-Forearm hyperpigmentation\n \nSocial History:\n___\nFamily History:\nHis father died at age ___ and he had dementia and prostate\ncancer. His mother is alive with osteoarthritis, knee\nreplacement, asthma and tuberculosis. He has 3 siblings and \nthey\nare all healthy. He does not have children.\n \nPhysical Exam:\nON ADMISSION\n=============\n\nVS: Temp 98.3, BP 158/92, HR 84, RR 18, O2 sat 99% RA.\nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN III-XII\nintact. Strength full throughout with 3+/5 LLE on \nplantarflexion.\nSensation to light touch intact. gait intact without using cane\nACCESS: Right chest wall port site intact.\n\nON DISCHARGE\n============\n\nVS: 98.4 ___ 16 99%RA\nENERAL: Well-appearing young man, in no distress, lying in bed\ncomfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\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 except for mild L foot drop. \nSensation to light touch intact.\nACCESS: Right chest wall port.\n \nPertinent Results:\n___ 06:19PM BLOOD mthotrx-3.2*\n___ 08:27PM BLOOD mthotrx-2.9*\n___ 05:44PM BLOOD mthotrx-0.85*\n___ 05:24AM BLOOD mthotrx-0.64*\n___ 06:00PM BLOOD mthotrx-0.63*\n___ 05:15AM BLOOD mthotrx-0.37*\n___ 04:17AM BLOOD mthotrx-0.17\n___ 11:51AM BLOOD mthotrx-0.___ w/ MGUS and neurolymphomatosis now in ___ ___ for C7\nHD MTX/Rituxan \n\n# Neurolymphomatosis: His CSF leak resolved and is now \nneurologically intact except for drop foot. No evidence of \nsystemic lymphoma. Receiving high-dose methotrexate which is a \nhighly toxic therapy with risk of transient or permanent \nneurological toxicity needing close monitoring of levels to \nbeable to provide adequate support. Received MTX 8g/m2 without \ncomplications. He had supportive hydration, alkalinization, \nanti-emesis and leucovorin rescue based on drug levels. \nTolerated this cycle well. \n\n# MGUS: Obtained SPEP on this admission and IgG level is steady \nat 2k. Labs reviewed with the oncology fellow on call. Patient \nwas made an appointment w/ Dr ___ in ___ clinic in \n___ to establish care and review his findings. \n\n#Forearm hyperpigmentation: Given improvement with time, this is \n\nlikely a superficial form of hyperpigmentation (epidermal) which \n\ncan improved with epidermal turnover and moisturization. \nContinued lactic acid 12% lotion TID.\n\n# Hypertension: Multiple SBPs >150 in house during prior \nadmissions. Likely a component of IVF. Usually asx. Have been \n<140 here. Pt agreed to schedule a f/u w/ PCP to follow up on \nthis. \n\n# HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior\ninfection. Discussed w/ Dr ___. \n\nTRANSITIONAL ISSUES:\n====================\n#MGUS: Stable IgG. To be followed by Dr. ___\n#Next steps: ___ Rituximab, ___ re-admission for HD-MTX\n\nOver 50 minutes spent formulating and coordinating this \npatient's discharge plan. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Senna 8.6 mg PO BID:PRN constipation \n4. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission \n5. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin \n6. Docusate Sodium 100 mg PO BID:PRN constipation \n7. Multivitamins 1 TAB PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n9. Leucovorin Calcium 40 mg PO Q6H \n10. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin \n5. Leucovorin Calcium 40 mg PO Q6H \nRX *leucovorin calcium 10 mg 4 tablet(s) by mouth every six (6) \nhours Disp #*48 Tablet Refills:*0 \n6. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety \n7. Multivitamins 1 TAB PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n9. Senna 8.6 mg PO BID:PRN constipation \n10. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission \n\nRX *sodium bicarbonate 650 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*48 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNeurolymphomatosis\nMGUS\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 your seventh cycle of high dose \nmethotrexate. \nYou tolerated chemo well. Please return to clinic on ___ \nfor your third monthly maintenance rituximab and on ___ for \nC8 or your third monthly maintenance high-dose methotrexate. \n\nPlease follow up with your new hematologist, Dr ___ \nyour blood condition called MGUS. \n\nHave a wonderful ___ weekend.\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8589", "D472", "I10", "L814", "M21372", "Z8619", "Z87891" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "I10: Essential (primary) hypertension", "L814: Other melanin hyperpigmentation", "M21372: Foot drop, left foot", "Z8619: Personal history of other infectious and parasitic diseases", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nDrainage from lumbar incision\n \nMajor Surgical or Invasive Procedure:\nPrevious recent admission:\n___: L4-L5 lumbar laminectomy and nerve root biopsy\n___: Repair of Lumbar CSF Leak \n\nCurrent admission:\nNone\n\n \nHistory of Present Illness:\n___ y/o male s/p L4-5 lumbar laminectomy and nerve root\nbiopsy on ___ and s/p repair of lumbar CSF leak on \n___.\nHe was discharged to home on ___. He returned to the ED ___\nwith complaints of wound drainage that started overnight. He\ndenies positional headache and describes the fluid that is\ndraining as blood tinged. He reported of a small bump, likely\nfluid collection, that went away when his wound again drained. \nHe\ndenies any new numbness or tingling within his bilateral lower\nextremities. He denies any new weakness of the BLEs. \n\n \nPast Medical History:\n___ is a ___ right-handed man, with a recent\ndiagnosis of neurolymphomatosis, who has left lower extremity\nweakness and CSF fluid leak after his diagnostic laminectomy.\n\nTreatment History:\n(1) swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells, \n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and \n\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET showed uptake in the lower spinal cord but no\nsystemic uptake, \n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\nand\n(18) repair of CSF leak on ___ by Dr. ___.\n\n \nSocial History:\n___\nFamily History:\nFather had prostate cancer. Denies otherwise history of blood \nor\noncologic history.\n \nPhysical Exam:\nExam at discharge:\n___ 0807 Temp: 98.5 PO BP: 154/108 HR: 115 RR: 18 O2 sat:\n100% O2 delivery: RA \n\nExam:\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\nOrientation: [x]Person [x]Place [x]Time\nFollows commands: [ ]Simple [x]Complex [ ]None\nMotor:\nTrapDeltoidBicepTricepGrip\nRight5 5 5 5 5\nLeft5 5 5 5 5\nIPQuadHamATEHLGast\nRight5 5 55 5 5\nLeft4- 4 5 2 0 5\n\n[ ] No Clonus \n[ ] Neg ___\n\nWound: \n [x]Clean, dry, intact, dressing dry\n [x]Suture [x]Staples [x] Dermabond with loose gauze, dry \n\n \nPertinent Results:\nplease see OMR for pertinent results \n \nBrief Hospital Course:\nMr. ___ was admitted to the Neurosurgery floor for continued \nmonitoring of his wound drainage.\n\n#CSF leak \nCT L spine in the ED showed near resolution of previously seen \nfluid collection in surgical bed and stable 3 cm x 3.5 cm x 1.6 \ncm collection along the right margin of L3 spinous process. A \nsingle figure-of-8 suture was oversown the area of drainage. Mr. \n___ was placed on strict flat bedrest. He was noted to be \nnoncompliant with this activity order, and was found OOB to the \nbathroom and OOB changing his clothes, or sitting up in bed. \nFrequent encouragement and reminders of his strict flat bed rest \nstatus were provided to the patient, and he proved more \ncompliant with strict flat bedrest by ___.\nFrom ___ - ___ he continued to have intermittent episodes \nof drainage from the inferior portion of his lumbar incision \nwith small quantity serosanguinous fluid that was expressible \nfrom the incision upon firm palpation. At no time did his \nincision display signs of fluctuance, nor signs of \nlocal/systemic infection. An MRI of the lumbar spine was \nobtained on ___ and was revealing of a fluid collection in \nthe soft tissues immediately posterior to the thecal sac, with \ncommunication to an opening in the skin via a small fistulous \ntract; c/w possible recurrent CSF leak and sinus. Two layers of \ndermabond were applied to the incision on ___. On ___ his \nincision remained clean, dry, and intact without drainage, and \ncontinued to remain dry through ___ when the head of his bed \nwas incrementally raised 20 degrees per hour. He tolerated this \nand mobilized out of bed without incisional drainage or \npositional headaches. He was discharged on ___ to home under \nself care to resume home ___ services.\n\n# neurolymphomatosis\nAll steroid, chemotherapeutic, and radiation therapies continued \nto be held during his hospitalization. It was conveyed to his \noncology and radiation team that he may resume steroid, \nchemotherapeutic, and radiation therapies on ___.\n-Mr. ___ was scheduled to follow up with radiation oncology \non ___ at 2:00pm.\n- He was provided the clinic phone numbers to follow up with Dr. \n___ and Hematology Oncology (for review of \nbone marrow biopsy results, concerning for plasma cell \ndyscrasia/MGUS), to schedule outpatient follow-up.\n\n#vocal cord paralysis, patient is a singer\n-Mr. ___ was provided the clinic phone number for the ___ \n___ clinic, and directed to schedule an outpatient appointment \nfor follow-up.\n\nMr. ___ was discharged on ___.\n\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan. \n \nMedications on Admission:\nAcetaminophen 650mg PO Q6H PRN pain; Bisacodyl 10mg PO Daily PRN \nconstipation; Diazepam 2mg PO Q6H PRN muscle spasm; Docusate \nSodium 100mg PO PO BID; Oxycodone ___ PO Q4H PRN pain; Senna \n17.2mg PO QHS\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID \n4. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n5. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nIncisional drainage\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 monitoring of your wound with concern for \nrecurrent CSF leak. You underwent L4-L5 laminectomy and nerve \nroot biopsy on ___ and repair of CSF leak ___. You were \ndischarged last on ___. Your discharge instructions are \nlargely unchanged, please see below.\n\nRecent Surgery\n• Your incision is closed with staples and a small portion of \nsuture with overlying dermabond (surgical skin glue). You will \nneed staple/suture removal in about a week. Please keep your \nincision dry until your staples/sutures are removed.\n• Do not apply any lotions or creams to the site. \n• Please avoid swimming for two weeks after suture/staple \nremoval.\n• Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n• We recommend that you lay flat as much as possible while at \nhome to support wound healing and minimize risk of CSF leak.\n• We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n• You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n• No driving while taking any narcotic or sedating medication. \n• No contact sports until cleared by your neurosurgeon. \n\nMedications\n• Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by your neurosurgeon. \n\n• You may take Ibuprofen/ Motrin for pain.\n• You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n• It is important to increase fluid intake while taking pain \nmedications. We also recommend a stool softener like Colace. \nPain medications can cause constipation. \n\nWhen to Call Your Doctor at ___ for:\n• Severe pain, swelling, redness or drainage from the incision \nsite. \n• Fever greater than 101.5 degrees Fahrenheit\n• New weakness or changes in sensation in your arms or legs.\n \nFollowup Instructions:\n___\n" ]

[ "G9782", "G960", "C8599", "J3800", "Y838", "Y92234", "Z9119" ]

[ "G9782: Other postprocedural complications and disorders of nervous system", "G960: Cerebrospinal fluid leak", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "J3800: Paralysis of vocal cords and larynx, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92234: Operating room of hospital as the place of occurrence of the external cause", "Z9119: Patient's noncompliance with other medical treatment and regimen" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nLLE weakness, dysphagia\n \nMajor Surgical or Invasive Procedure:\nLumbar puncture\nBone marrow biopsy \n\n \nHistory of Present Illness:\n___ is a ___ year-old right-handed male without \n___\nmedical history who presents to the ED for evaluation of LLE\nweakness. \n\nHe was seen in ___ outpatient clinic this morning for evaluation\nof new dysphasia and dysphonia (began ___. He reports\nthat he had gone to bed the previous day feeling normal but woke\nup with new difficulty swallowing as well as a change in his\nvoice (more raspy, hoarse). With regards to his dysphagia, he\ndescribes feeling that solids \"won't go down...the food gets\nstuck\" but he has not had any difficulties with liquids. He was\nseen by a community physician who told him that he likely had\nsinus disease and recommended a few days of Sudafed. When the\nsymptoms persisted and he had lost 15 pounds due to difficulty\neating, he had a video swallow test performed ___, see below)\nwhich revealed \"significant oropharyngeal and esophageal\ndysphagia most notable for diffuse right-sided weakness.\" This \nprompted referral to ___ clinic, where he was seen today and\ndiagnosed with right vocal fold paralysis. He was noted to have\nLLE weakness, so was prompted to come to the ED for further\nevaluation. \n\nHe reports that the LLE weakness began gradually, probably over\nthe ___. This did not impair him in any way until the last\nweek of ___ when he was unable to stand up from a squatting\nposition without the use of his hands. Overall, his weakness has\nbeen progessively worsening since that time. In particular, he\nnotices difficulty with lifting his left leg up in order to \ncross\nit over the right leg, difficulty going upstairs > downstairs --\nand needs to hold onto the railing for both. He is able to stand\nup out of a chair without difficulty but cannot stand from the\nfloor. He has not had any foot drop or toe stubbing. He has not\nhad any difficulty with the right leg or either arm. \n\nOn neuro ROS, Mr. ___ denies headache, loss of vision, \nblurred\nvision, diplopia, dysarthria, dysphagia, lightheadedness,\nvertigo, tinnitus or hearing difficulty. Denies difficulties\nproducing or comprehending speech. Denies focal numbness or\nparasthesiae. No bowel or bladder incontinence or retention. \n\nOn general review of systems, this is notable for + \nunintentional\nweight loss over the past 2 weeks (15 pounds), which he\nattributes to his dysphagia. He has also noticed saliva pooling\nin his mouth which he sometimes has difficulty swallowing. He \nhas\nbeen coughing more, but he attributes this to the irritation in\nhis throat, as he has not had any nasal congestion or \"deep\ncough.\"\n\nHe denies recent fever or chills. No night sweats. Denies\nshortness 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\n \nPast Medical History:\nTobacco use disorder\n\n \nSocial History:\n___\nFamily History:\n- Great nephew ___ years) with recently diagnosed epilepsy\n- Father (now deceased) had prostate cancer. \n \n \nPhysical Exam:\nADMISSION Physical Exam:\n============================\nVitals ___, time: 14:23): \nT: 98.6\nHR: 80\nRR: 18 \nBP: 161/100\nSaO2: 100% on RA\n\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, full ROM\nPulmonary: breathing comfortably on RA\nCardiac: warm and well-perfused with brisk capillary refill\nAbdomen: ND\nExtremities: + signficant atrophy of the left thigh. No C/C/E\nbilaterally.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive, able to name ___ backward without\ndifficulty. Language is fluent with intact comprehension. Normal\nprosody. There were no paraphasic errors. Pt was able to name\nboth high and low frequency objects. Able to read without\ndifficulty. Speech was not dysarthric. Able to follow both\nmidline and appendicular commands. The pt had good knowledge of\ncurrent events. There was no evidence of apraxia or neglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic\nexam revealed no disc blurring, exudates, or hemorrhages.\nIII, IV, VI: EOMI without nystagmus. Normal saccades.\nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric at rest and\nupon activation.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically. + gag on the left,\nequivocal on the right\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline; + fasciculations.\n\n-Motor: Normal tone throughout. Significantly decreased bulk in\nthe L thigh. No pronator drift bilaterally. No adventitious\nmovements, such as tremor, noted. No asterixis noted. ___\nstrength throughout with the following exceptions: \n- Bilateral abductor pollicis brevis: 4+/5 \n- Left IP: 2+/5 \n- Left Quad: 2+/5\n- Left Hamstring: 4+/5\n- Left ___: 4+/5 \n\nReflexes: \n Bi ___ Pat Ach\nL 3 3 tr* 1\nR 3 3 2* 1\n\n*: with reinforcement\nOf note: + spread (finger flexion) in the bilateral UE reflexes\nPlantar response was upgoing in the left, mute on the right. \n___: negative \n\n-Sensory: No deficits to light touch, pinprick, cold sensation,\nvibratory sense, proprioception throughout. \n\n-Coordination: No intention tremor, no dysdiadochokinesia noted.\nNo dysmetria on FNF bilaterally.\n\n-Gait: Good initiation. Narrow-based, normal stride and arm\nswing. Romberg absent.\n\nDISCHARGE Physical Exam: \n========================\n Vitals: T: 98.6 BP: 113/79 HR: 98 RR: 18 SpO2: 99% RA\n General: awake, cooperative, NAD\n HEENT: NC/AT, no scleral icterus noted, MMM\n Pulmonary: breathing comfortably, no tachypnea or increased WOB\n Cardiac: skin warm, well-perfused\n Abdomen: soft, ND\n Extremities: symmetric, no edema\n\nNeurologic:\n\n-Mental Status: Alert, cooperative. Language is fluent with \nintact comprehension. Able to follow both midline and \nappendicular commands. \n\n-Cranial Nerves: PERRL (3 to 2 mm ___. EOMI without nystagmus. \nFace symmetric at rest and with activation. Hearing intact to \nconversation. Palatal elevation symmetric. Tongue protrudes in \nmidline.\n\n-Motor: No pronator drift bilaterally. No adventitious \nmovements,\nsuch as tremor, noted.\n Delt Bic Tri WrE FE IP Quad Ham TA Gastroc\n L 5 ___ 5 4+ 3 5 5 5 \n R 5 ___ ___ 5 5 5 \n\n-Sensory: Intact to LT throughout. No extinction to DSS.\n\n-DTRs: \n Bi ___ Pat Ach\n L 2 2 1 1\n R 2 2 1 1\n\n-Coordination: No intention tremor or dysmetria on FNF \nbilaterally.\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 04:30PM URINE HOURS-RANDOM\n___ 04:30PM URINE HOURS-RANDOM\n___ 04:30PM URINE HOURS-RANDOM\n___ 04:30PM URINE UHOLD-HOLD\n___ 04:30PM URINE GR HOLD-HOLD\n___ 04:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 04:10PM GLUCOSE-89 UREA N-13 CREAT-1.0 SODIUM-143 \nPOTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15\n___ 04:10PM estGFR-Using this\n___ 04:10PM CALCIUM-10.1 PHOSPHATE-3.7 MAGNESIUM-2.2\n___ 04:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 04:10PM WBC-3.3* RBC-5.41 HGB-14.8 HCT-44.9 MCV-83 \nMCH-27.4 MCHC-33.0 RDW-13.4 RDWSD-40.1\n___ 04:10PM NEUTS-53.8 ___ MONOS-6.9 EOS-0.6* \nBASOS-0.6 IM ___ AbsNeut-1.78 AbsLymp-1.25 AbsMono-0.23 \nAbsEos-0.02* AbsBaso-0.02\n___ 04:10PM PLT COUNT-241\n\nINTERVAL LABS: \n==============\n___ 05:40AM BLOOD calTIBC-251* VitB12-722 Ferritn-172 \nTRF-193*\n___ 01:14PM BLOOD ANCA-NEGATIVE\n___ 10:34AM BLOOD CEA-3.4\n___ 01:14PM BLOOD RheuFac-<10 ___\n___ 02:40PM BLOOD CRP-1.5\n___ 05:25AM BLOOD ___ Fr K/L-1.1\n___ 10:34AM BLOOD PEP-ABNORMAL B IgG-2326* IgA-204 IgM-44 \nIFE-MONOCLONAL\n___ 01:14PM BLOOD C3-114 C4-20\n___ 02:40PM BLOOD HIV Ab-NEG\n___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 10:34AM BLOOD QUANTIFERON-TB GOLD-Test \n___ 10:34AM BLOOD TOXOCARA (T. CANIS & T. CATI) \nANTIBODY-Test \n___ 10:34AM BLOOD CA ___ -Test \n___ 01:14PM BLOOD RO & ___ \n___ 01:14PM BLOOD HTLV I AND II, WITH REFLEX TO WESTERN \nBLOT-Test \n___ 01:14PM BLOOD ANGIOTENSIN 1 - CONVERTING ___ \n___ 02:40PM BLOOD SED RATE-Test \n___ 02:40PM BLOOD PARANEOPLASTIC AUTOANTIBODY \nEVALUATION-CANCELLED\n___ 02:40PM BLOOD ENCEPHALOPATHY, AUTOIMMUNE EVALUATION, \nSERUM-PND\n___ 10:00AM URINE U-PEP-NO PROTEIN IFE-NEGATIVE F\n___ 10:00AM URINE Hours-RANDOM Creat-153 TotProt-12 \nProt/Cr-0.1\n___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-1 Polys-2 \n___ Monos-9 Promyel-0 Plasma-3 Other-0\n___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-18* RBC-4 Polys-4 \n___ Monos-6 Eos-1 Plasma-2 Other-0\n___ 04:55PM CEREBROSPINAL FLUID (CSF) TotProt-114* \nGlucose-63 ___ Misc-BODY FLUID\n___ 04:55PM CEREBROSPINAL FLUID (CSF) BETA 2 \nMICROGLOBULIN-Test \n___ 04:55PM CEREBROSPINAL FLUID (CSF) CA ___ \n___ 04:55PM CEREBROSPINAL FLUID (CSF) VDRL-Test \n___ 04:55PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY \nPCR-Test \n___ 04:55PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS \nPCR-Test Name \n___ 04:55PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS DNA, \nQUALITATIVE, PCR-Test \n___ 04:55PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1 \nCONVERTING ENZYME-Test \n___ 04:55PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI \nANTIBODY INDEX FOR CNS INFECTION-CANCELLED\n\nIMAGING: \n========\n+ MRI of L-spine notable for mild expansion in T2/STIR\nhyperintensity of the distal lumbar spinal cord with \ndifferential\nincluding infectious, inflammatory etiologies, or intramedullary\nneoplasm. On the contrast-enhanced study, this is described as\n1.5 x 0.6 x 0.5 cm with associated cord expansion and extensive\nleptomeningeal involvement extending superiorly and inferiorly\nbeyond the margins of the intramedullary lesion with possible\ninvolvement of the adjacent nerve roots. Abnormal bone marrow\nsignal diffusely is also noted.\n\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE\n\nMr. ___ was admitted to the Neurology service for evaluation \nof subacute progressive LLE weakness as well as dysphagia and \ndysphonia, found on ENT evaluation to be due to right-sided \nvocal cord paralysis. Despite initial concern for motor neuron \ndisease, his EMG instead revealed a moderate to severe, chronic \nand ongoing left L4-L5 radiculopathy, without electrophysiologic \nevidence for a more generalized disorder of motor neurons or \ntheir axons. \n\nFollow-up MR imaging of the neuraxis was notable for:\n1. Multilevel patchy cervical vertebral body T1 hypointensities \nwith possible minimal postcontrast enhancement concerning for a \npotential marrow infiltrative process;\n2. A 1.5 x 0.6 x 0.5 cm T12-L1 intramedullary enhancing focus \nwith surrounding\nSTIR/T2 signal abnormality and associated cord expansion, along \nwith extensive leptomeningeal involvement and possible \ninvolvement of the adjacent nerve roots.\n\nThese findings were concerning for infectious, inflammatory, or \nneoplastic processes. Inflammatory evaluation revealed \nunremarkable CSF ACE, ESR, CRP, and SS-A and SS-B Ab. Infectious \nevaluation revealed negative Lyme serologies, CSF culture, \nRPR/VDRL, Toxoplasma serologies and CSF PCR, HSV/CMV PCR, \nQuantiFERON Gold, and HTLV I/II Ab.\n\nNeoplastic evaluation revealed negative ___ and CSF cytology \nand flow cytometry. CT chest/abdomen/pelvis was also negative \nfor additional malignancy. SPEP, however, revealed a monoclonal \ngammopathy, though with negative skeletal survey and absence of \nrenal findings to suggest multiple myeloma; in consultation with \nthe Hematology/Oncology service, a bone marrow-biopsy was \nobtained that preliminarily revealed plasma cells as well as \nabnormal proliferation of lymphocytes concerning for lymphoma. \nAs it remained unclear whether the bone marrow findings could \nalso be implicated in the intramedullary spinal cord lesion and \nleptomeningeal/radicular enhancement seen on imaging, the \nHematology/Oncology and Neuro-oncology teams deferred inpatient \ntreatment in lieu of close outpatient follow-up for repeat \nimaging, repeat lumbar puncture, and follow up of molecular \ntesting.\n\nWith respect to Mr. ___ leg and vocal cord symptoms, these \nmay be related to the leptomeningeal/nerve root infiltrative \nprocess noted on imaging. During admission he also developed \nmild hyperreflexia and spasticity in the RLE (without weakness), \nindicating myelopathy, in line with cord signal abnormalities \nseen on imaging. Accordingly, Mr. ___ was evaluated by ___ and \nSLP as an inpatient, with plans for outpatient follow-up. Mr. \n___ was cleared for a regular diet and advised to turn his \nhead to the right to facilitate swallowing.\n\nTRANSITIONAL ISSUES:\n===================\n[] Follow-up outpatient MRI.\n[] Follow up with Neuro-oncology and Hematology/Oncology as \nnoted above.\n[] Follow up final report from bone marrow biopsy as well as \nserum autoimmune encephalopathy panel.\n[] Outpatient ___ and SLP follow up as noted above.\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals [Vitamins and Minerals] 1 (One) \ntablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 \n2.Outpatient Physical Therapy\nDiagnosis: Left leg weakness, L4/L5 radiculopathy\n3.Outpatient Speech/Swallowing Therapy\nDiagnosis: right vocal cord paralysis, dysphonia \nPlease continue to evaluate and treat dysphagia and dysphonia\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLumbar Radiculopathy\nLumbar myelopathy\nIntramedullary intradural spinal cord lesion\nVocal cord paralysis\nMonoclonal gammopathy\nSuspected lymphoma\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 \nevaluation of difficulty swallowing and speaking, as well as \nleft leg weakness. Imaging of your spine showed an area of \nswelling and inflammation affecting your spinal cord and \nsurrounding coverings; blood and cerebrospinal fluid tests did \nnot show signs of an infection or inflammation, so there is \nconcern that the spine findings may be due to cancer. Although \nimaging of your chest, abdomen, and pelvis did not show signs of \nadditional cancer, your bone marrow did have abnormal blood \ncells (lymphocytes) that could reflect lymphoma.\n\nIn order to further direct treatment of your spinal cord lesion, \na follow-up appointment has been scheduled for you with Dr. ___ \nin Neruo-oncology; you are also scheduled for a repeat MRI the \nday prior. A follow-up appointment was also requested with \nHematology/Oncology regarding your bone marrow biopsy findings; \nyou may call ___ to follow up on this appointment with \nDrs. ___.\n\nPlease also follow-up with a speech and swallow specialist for \nyour voice as well as swallowing function and for speech \ntherapy. We have written a prescription for outpatient speech \ntherapy. Your follow-up is being coordinated by ___. \nPlease call the number below (under recommended follow-up \nsection) to follow-up regarding your appointment. \n\nIt was a pleasure taking care of you at ___.\n\nSincerely,\nNeurology at ___\n\n \nFollowup Instructions:\n___\n" ]

[ "C8599", "G959", "J3801", "E440", "F17210", "M5416", "D472", "D649", "D72819", "Z6823" ]

[ "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "G959: Disease of spinal cord, unspecified", "J3801: Paralysis of vocal cords and larynx, unilateral", "E440: Moderate protein-calorie malnutrition", "F17210: Nicotine dependence, cigarettes, uncomplicated", "M5416: Radiculopathy, lumbar region", "D472: Monoclonal gammopathy", "D649: Anemia, unspecified", "D72819: Decreased white blood cell count, unspecified", "Z6823: Body mass index [BMI] 23.0-23.9, adult" ]

[ "F17210", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nchlorhexidine\n \nAttending: ___.\n \nChief Complaint:\nScheduled Chemotherapy\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX \npresenting\nfor C8 HD-MTX. He received cycle 7 rituximab in clinic on\n___.\n\nHe states he is feeling well with stability of his foot drop. No\nnew neurologic symptoms. foot drop. No new c/o. Last MRI L-spine\n___ revealed no evidence of disease\n\nREVIEW OF SYSTEMS: A complete 10-point review of systems was\nperformed and was negative unless otherwise noted in the HPI.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n(1) Swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells,\n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake,\n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___,\n(29) received C3 rituximab 375 mg/m2/week on ___,\n(30) received C4 high-dose methotrexate at 8 grams/m2 on\n___,\n(30) received C4 rituximab 375 mg/m2/week on ___, \n(31) received C5 high-dose methotrexate at 8 grams/m2 on\n___, \n(32) gadolinium-enhanced total spine MRI on ___ showed\nresponse,\n(33) gadolinium-enhanced head MRI on ___ showed no evidence\nof disease,\n(34) FDG-PET on ___ showed improved FDG-Avid disease at\nT12-L2, and\n(35) CSF cytology showed atypical cells.\n(36) received C5 monthly maintenance rituximab 375 mg/m2/week on\n___,\n(37) received C6 first monthly maintenance high-dose \nmethotrexate\nat 8 grams/m2 on ___, and\n(38) gadolinium-enhanced MRI of the lumbosacral spine performed\non ___ showed no evidence of disease.\n(39) received C6 second monthly maintenance rituximab 375\nmg/m2/week on ___, and\n(40) received C7 second monthly maintenance high-dose\nmethotrexate at 8 grams/m2 on ___.\n(41) received C7 maintenance ritixumab on ___\n(42) admitted to oncology for C8 maintenance HD-MTX on ___\n\nPAST MEDICAL HISTORY: None prior.\n\n \nSocial History:\n___\nFamily History:\n His father died at age ___ and he had dementia and\nprostate cancer. His mother is alive with osteoarthritis, knee\nreplacement, asthma and tuberculosis. He has 3 siblings and they\nare all healthy. He does not have children.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: ___ 1039 Temp: 98.3 PO BP: 136/87 L Sitting HR: 84 RR:\n16 O2 sat: 97% O2 delivery: RA \nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN III-XII\nintact. Strength full throughout with 3+/5 LLE on \nplantarflexion.\nSensation to light touch intact. gait intact without using cane\nACCESS: Right chest wall port site intact.\n\nDISCHARGE EXAM:\nTemp: 97.8 PO BP: 157/81 HR: 62 RR: 18 O2 sat: 100% O2 delivery:\nRa \n\nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN III-XII\nintact. Strength full throughout with ___ LLE on plantar \nflexion.\nSensation to light touch intact. gait intact\nACCESS: Right chest wall port site intact.\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 11:00AM BLOOD WBC-2.8* RBC-4.04* Hgb-11.0* Hct-33.8* \nMCV-84 MCH-27.2 MCHC-32.5 RDW-15.8* RDWSD-47.9* Plt ___\n___ 11:00AM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-139 \nK-4.3 Cl-100 HCO3-27 AnGap-12\n___ 11:00AM BLOOD ALT-21 AST-17 LD(LDH)-120 AlkPhos-83 \nTotBili-0.2\n___ 11:00AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.9 Mg-2.0\n\nDISCHARGE LABS:\n===============\n\n___ 05:23AM BLOOD WBC-2.9* RBC-3.98* Hgb-10.8* Hct-32.9* \nMCV-83 MCH-27.1 MCHC-32.8 RDW-14.1 RDWSD-42.4 Plt ___\n___ 06:54AM BLOOD Neuts-55.3 ___ Monos-4.3* Eos-3.9 \nBaso-0.0 Im ___ AbsNeut-1.41* AbsLymp-0.92* AbsMono-0.11* \nAbsEos-0.10 AbsBaso-0.00*\n___ 05:23AM BLOOD Glucose-100 UreaN-5* Creat-0.9 Na-141 \nK-3.7 Cl-97 HCO3-36* AnGap-8*\n___ 05:23AM BLOOD ALT-34 AST-23 LD(LDH)-128 AlkPhos-78 \nTotBili-0.6\n___ 05:23AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX \npresenting for C8 HD-MTX. He received cycle 7 rituximab in \nclinic on ___.\n\n# Neurolymphomatosis: Urine was alkalinized with HCO3 per \nprotocol and he underwent 8g/m2 infusion on ___. Leucovorin \nrescue 24 hours after infusion per protocol. He tolerated \ntreatment well without significant side effects. He was somewhat \nslow to clear MTX and HCO3 was kept at 200/hour. Day of \ndischarge level was 0.2 and downtrending. He requested DC home. \nWe provided him with three days of leucovorin and NaHCO3 tabs to \ntake at home. He will need follow up for C8 monthly rituximab , \nC9 monthly rituximab, and C9 HD MTX ___ 2-month dose).\n\n# MGUS:\n- He has follow up with Dr. ___ on ___.\n\n# Hypertension: Multiple SBPs >150 in house during prior \nadmissions. Likely a component of IVF. Asymptomatic. \n\n# HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior \ninfection.\n\n# Billing: >30 minutes spent coordinating and executing this \ndischarge plan\n\nTRANSITIONAL ISSUES:\n- Leucovorin 100mg qid through ___\n- NaHCO3 1300mg qid through ___\n- Tentatively scheduled for Rituximab on ___ and ___ Next HD \nMTX on ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin \n5. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety \n6. Multivitamins 1 TAB PO DAILY \n7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n8. Senna 8.6 mg PO BID:PRN constipation \n9. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission \n10. Leucovorin Calcium 40 mg PO Q6H \n\n \nDischarge Medications:\n1. Leucovorin Calcium 40 mg PO Q6H \nRX *leucovorin calcium 10 mg 4 tablet(s) by mouth four times a \nday Disp #*48 Tablet Refills:*0 \n2. Sodium Bicarbonate 1300 mg PO QID \nRX *sodium bicarbonate 650 mg 2 tablet(s) by mouth four times a \nday Disp #*48 Tablet Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin \n7. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety \n8. Multivitamins 1 TAB PO DAILY \n9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n10. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n# Admission for chemotherapy\n# Neurolymphomatosis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___. You were admitted for your scheduled high-dose \nmethotrexate. You tolerated your treatment well. Please continue \nto take leucovorin and sodium bicarbonate tabs four times daily \nfor the next three days to help clear the remaining \nmethotrexate. You will continue monthly rituximab and space out \nyour HD-MTX to every two months. \n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8599", "D472", "Z8619", "Z87891" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "Z8619: Personal history of other infectious and parasitic diseases", "Z87891: Personal history of nicotine dependence" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nchlorhexidine\n \nAttending: ___.\n \nChief Complaint:\nScheduled Chemotherapy\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nAs per admitting MD:\nMr. ___ is a pleasant ___ w/ MGUS and neurolymphomatosis on\nrituximab/HD-MTX presenting for C9 maintenance HD-MTX. He states\nhe is feeling well with continued improvement of his foot drop.\nGadolinium-enhanced MRI of the lumbosacral spine performed on\n___ showed no evidence of disease. Took 3 bicarb tabs q6h x\n2 days. urine PH on admission 8. \n\n \nPast Medical History:\nAs per admitting MD:\nPAST ONCOLOGIC HISTORY:\n(1) Swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells,\n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake,\n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___,\n(29) received C3 rituximab 375 mg/m2/week on ___,\n(30) received C4 high-dose methotrexate at 8 grams/m2 on\n___,\n(30) received C4 rituximab 375 mg/m2/week on ___, \n(31) received C5 high-dose methotrexate at 8 grams/m2 on\n___, \n(32) gadolinium-enhanced total spine MRI on ___ showed\nresponse,\n(33) gadolinium-enhanced head MRI on ___ showed no evidence\nof disease,\n(34) FDG-PET on ___ showed improved FDG-Avid disease at\nT12-L2, and\n(35) CSF cytology showed atypical cells.\n(36) received C5 monthly maintenance rituximab 375 mg/m2/week on\n___,\n(37) received C6 first monthly maintenance high-dose \nmethotrexate\nat 8 grams/m2 on ___, and\n(38) gadolinium-enhanced MRI of the lumbosacral spine performed\non ___ showed no evidence of disease.\n(38) gadolinium-enhanced MRI of the lumbosacral spine performed\non ___ showed no evidence of disease,\n(39) received C6 second monthly maintenance rituximab 375\nmg/m2/week on ___,\n(40) received C7 second monthly maintenance high-dose\nmethotrexate at 8 grams/m2 on ___,\n(41) received C8 third monthly maintenance rituximab 375\nmg/m2/week on ___, and\n(42) received C9 third maintenance rituximab 375 mg/m2/week on\n___ given at every 2-month interval.\n\nPAST MEDICAL HISTORY: None prior\n \nSocial History:\n___\nFamily History:\nAs per admitting MD:\nHis father died at age ___ and he had dementia and\nprostate cancer. His mother is alive with osteoarthritis, knee\nreplacement, asthma and tuberculosis. He has 3 siblings and they\nare all healthy. He does not have children.\n \nPhysical Exam:\nAdmission:\nVS: Temp 98.3, BP 158/92, HR 84, RR 18, O2 sat 99% RA.\nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN III-XII\nintact. Strength full throughout with ___ LLE on dorsiflexion.\nSensation to light touch intact. \nACCESS: Right chest wall port site intact, dressing c/d/I\n\nDischarge:\nGENERAL: Pleasant man, in no distress, sitting on bed \ncomfortably, calm, talkative\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. normal RR\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness. normal sensation to light touch. upper extremities\nwith normal strength and ROM. Has non tender, non erythematous\nbursitis of left elbow, not warm to touch (unchanged)\nNEURO: A&Ox3, good attention and linear thought, Strength full\nthroughout except for ___ LLE. Sensation to light touch intact. \nACCESS: Right chest wall port site intact, dressing c/d/i\n \nPertinent Results:\nAdmit:\n\n___ 02:20PM BLOOD WBC-4.1 RBC-4.16* Hgb-11.0* Hct-33.8* \nMCV-81* MCH-26.4 MCHC-32.5 RDW-15.3 RDWSD-45.1 Plt ___\n___ 02:20PM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-138 \nK-4.4 Cl-98 HCO3-27 AnGap-13\n___ 02:20PM BLOOD ALT-12 AST-14 LD(LDH)-104 AlkPhos-91 \nTotBili-0.3\n___ 02:20PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1\n\nDischarge:\n\n___ 05:04AM BLOOD WBC-2.3* RBC-3.86* Hgb-10.3* Hct-32.0* \nMCV-83 MCH-26.7 MCHC-32.2 RDW-14.4 RDWSD-43.2 Plt ___\n___ 05:04AM BLOOD Glucose-89 UreaN-4* Creat-0.8 Na-140 \nK-3.4* Cl-96 HCO3-33* AnGap-11\n___ 05:04AM BLOOD ALT-20 AST-17 AlkPhos-92 TotBili-0.5\n___ 05:04AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8\n___ 05:04AM BLOOD mthotrx-0.14\n\nMicro/Imaging:\nNone\n \nBrief Hospital Course:\n___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented \nfor C9 maintenance HD-MTX which he tolerated well with hospital \ncourse c/b bursitis\n\n#Left elbow bursitis\nNontraumatic, unclear etiology. No tenderness, warmth, erythema \nto suggest infection or crystalline disease so was not \naspirated. Patient was instructed that he can not take naproxen \nuntil he completely clears MTX. In order to ensure he is \ncleared, he should not start naproxen until ___\n\n#Neurolymphomatosis: \nHis CSF leak has previously resolved and patient continues to \nimprove neurologically. Last PET w/ low-level FDG uptake \ncentered in the spinal canal at T12-L2, which is significantly \nimproved in comparison to the prior examination and may be \nwithin normal limits. Pt is off dexamethasone and not on \nantiepileptics. His post laminectomy at L2-5 for nerve resection \non ___ resulted in LLE weakness which is improving. He \ntolerated prior cycles well with HD MTX except for delayed \nclearance and nausea. On this cycle patient was asymptomatic but \nagain had delayed clearance. \n\n#MTX Discharge Level\nAs per Dr ___, on future admits, patient can leave when level \nis <0.3. Dr ___ that given his age, and reliability in \ntaking leucovorin tablets at home, could be safely discharged at \nthat level so long as there are no other complicating factors. \nPatient is to be scheduled for an MRI of L/S Spine in ___ weeks, \nthen f/u with Dr ___, and be re-admitted for next \ncycle in 2 months ___\n\n#Leukopenia\nPatient known to develop leukopenia during previous \nadministrations likely ___ BM suppression from MTX, which \nspontaneously resolves with time. Patient is to have leukopenia \nre-evaluated at next outpatient f/u appt. \n\nTransitional Issues:\n1. Bursitis to be followed up in outpatient setting\n2. Patient is to be scheduled for an MRI of L/S Spine in ___ \nweeks, then f/u with Dr ___, and be re-admitted for \nnext cycle in 2 months ___\n3. Patient is to have leukopenia re-evaluated at next outpatient \nf/u appt. \n\nI personally spent 43 minutes coordinating care with outpatient \nproviders, preparing discharge paperwork, educating patient and \nanswering questions. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin \n5. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety \n6. Multivitamins 1 TAB PO DAILY \n7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n8. Senna 8.6 mg PO BID:PRN constipation \n9. Sodium Bicarbonate 1300 mg PO QID \n10. Leucovorin Calcium 40 mg PO Q6H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Lactic Acid 12% Lotion 1 Appl TP TID:PRN dry skin \n5. Leucovorin Calcium 40 mg PO Q6H \nRX *leucovorin calcium 10 mg 4 tablet(s) by mouth every six (6) \nhours Disp #*100 Tablet Refills:*0 \n6. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety \n7. Multivitamins 1 TAB PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n9. Senna 8.6 mg PO BID:PRN constipation \n10. Sodium Bicarbonate 1300 mg PO QID \nRX *sodium bicarbonate 650 mg 2 tablet(s) by mouth four times a \nday Disp #*100 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n#Left elbow bursitis\n#Neurolymphomatosis\n#Hypokalemia\n#Hypertension\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\n___ was a pleasure taking care of you while you received your \nchemo. \n\nDr ___ that although your level was not ___ you were ok \nto go home as long as you continued to take leucovorin. Please \ntake your bicarb for 1 more day, and your leucovorin for 2 more \ndays (ending ___\n\nDr ___ will call you for a follow up appointment in \n___ weeks when you will get a L/S spine MRI beforehand. You will \nbe re-admitted for next cycle in 2 months (___)\n\nAs you know, you were found to have a condition called bursitis, \nwhich will improve with time. Remember, you are not to start \nAleve to help its resolution until ___\n\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8331", "R1312", "D472", "Z87891", "I10", "E876", "M7032", "M6281" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8331: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck", "R1312: Dysphagia, oropharyngeal phase", "D472: Monoclonal gammopathy", "Z87891: Personal history of nicotine dependence", "I10: Essential (primary) hypertension", "E876: Hypokalemia", "M7032: Other bursitis of elbow, left elbow", "M6281: Muscle weakness (generalized)" ]

[ "Z87891", "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:\nScheduled Chemotherapy\n\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), \npresents\nfor scheduled HD MTX Cycle 2\n\nPatient noted that prior to this admission was feeling in his \nUSOH. He denied fever, chills, sore throat, cough, shortness of \nbreath, nausea, vomiting, diarrhea, abdominal pain, dysuria, \nrash. \n\nHe noted that he was without headache, vision/hearing changes. \nHe noted that his left leg is weak, but feels that it has \nimproved slightly s/p recent chemotherapy.\n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \nAs per Dr. ___ clinic note:\n\"His neurologic problem began in late ___ when he noted\ndysphagia and dysphonia. His voice became hoarse and he\ndeveloped difficulty swallowing solids and liquids. Solid foods\ngot stuck in his throat. He had decreased PO intake and he lost\nabout ___ lbs. He saw his primary care physician and ___ \nvideo\nswallowing study on ___ showed oropharyngeal and esophageal\ndysphagia on the right-sided. He was subsequently referred to\nthe ___ clinic. On the day of his evaluation ___, he was\nfound to have left lower extremity weakness. He was sent to the\nemergency department for evaluation and was admitted to the\ngeneral neurology service for work up. He underwent a\ngadolinium-enhanced thoracic and lumbar MRI that showed T12-L1\nenhancement that is located in the anterior spinal cord with an\nexophytic component eccentric to the left side. His first \nlumbar\npuncture on ___ showed ___ WBC, ___ RBC, 114 protein, 63\nglucose, 19 LDH, beta-2-microglobulin 1.87 (normal 0.36-2.56), \nCA\n___ <6, VDRL non-reactive, and negative cytology for malignant\ncells. He also had a bone marrow aspiration on ___ that\nshowed lambda restricted plasma cells. His repeat\ngadolinium-enhanced lumbar MRI performed on ___ again \nshowed\nT12-L1 enhancement that is located in the anterior spinal cord\nwith an exophytic component eccentric to the left side, and this\nenhancement appears slightly more prominent. A second lumbar\npuncture on ___ showed 26 WBC, 4 RBC, 146 protein, 57\nglucose, 23 LDH, and atypical large lymphoid cells in cytology.\nA third lumbar puncture on ___ showed 27 WBC, 0 RBC, 88\nprotein, 55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range\n0.36-2.56) and presence of oligoclonal bands. Because the\ndiagnosis could not be established via non-invasive measn, he\neventually underwent a laminectomy at L2-5 for nerve resection \non\n___ by Dr. ___. During the immediate\npostoperative period, he had C1W1 rituximab 375 mg/m2 and\nlamivudine 100 mg QD on ___. He experienced CSF leak on\n___, and therefore lamuvidine and dexamethasone were\ndiscontinued on ___. He underwent a repair of CSF leak on\n___ by Dr. ___. He re-started rituximab on\n___ and high-dose methotrexate on ___ \n \nPAST MEDICAL HISTORY: \nMGUS\nLaminectomy L2-5 for nerve resection on ___ c/b CSF leak on\n___ s/p subsequent repair \n\n \nSocial History:\n___\nFamily History:\nFather had prostate cancer. Denies otherwise history of blood or \n\noncologic history.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: ___ 1025 Temp: 98.0 PO BP: 160/89 HR: 100 RR: 18 \nO2\nsat: 100% O2 delivery: RA \nGENERAL: sitting upright in bed, appears well, smiling, NAD\nEYES: PERRLA, EOMI\nHEENT: OP clear, MMM\nNECK: supple\nLUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR\nCV: RRR normal distal perfusion no edema\nABD: soft NT, ND, normoactive BS\nGENITOURINARY: no foley\nEXT: gross sensation unchanged in all extremities, but has ___\nstrength in all muscles of the left lower extremity, RLE/RUE/LUE\n___. PAtient noted that this is his baseline\nSKIN: warm, dry, no rash \nNEURO: AOx3, fluent speech, CNII-XII intact without deficits,\nstrength ___ in LLE, otherwise other extremities normal strength\nACCESS: port in right chest, no yet accessed\n\nDISCHARGE PHYSICAL EXAM: \n___ ___ Temp: 98.7 PO BP: 151/87 HR: 67 RR: 18 O2 sat: \n100%\nO2 delivery: Ra \n\nGENERAL: Pleasant and well appearing man sitting up in bed in \nNAD\nEYES: PERRLA, EOMI, sclerae are anicteric\nHEENT: OP clear, MMM\nNECK: supple\nLUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR\nCV: RRR normal distal perfusion no edema\nABD: soft NT, ND, normoactive BS, nontender, no HSM\nGENITOURINARY: no foley\nEXT: No edema, normal bulk\nSKIN: warm, dry, no rash \nNEURO: AOx3, fluent speech, CNIII-XII intact without deficits,\nstrength ___ in LLE with foot drop, otherwise other extremities\nnormal strength\nACCESS: port in right chest\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 11:20AM BLOOD WBC-4.6 RBC-3.54* Hgb-9.6* Hct-29.4* \nMCV-83 MCH-27.1 MCHC-32.7 RDW-14.8 RDWSD-45.1 Plt ___\n___ 11:20AM BLOOD ___ PTT-28.9 ___\n___ 11:20AM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-140 \nK-4.1 Cl-101 HCO3-30 AnGap-9*\n___ 11:20AM BLOOD ALT-36 AST-18 LD(___)-122 AlkPhos-85 \nTotBili-0.2\n___ 11:20AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.0 UricAcd-4.5\n\nDISCHARGE LABS:\n===============\n\n___ 05:34AM BLOOD WBC-3.0* RBC-3.48* Hgb-9.3* Hct-29.2* \nMCV-84 MCH-26.7 MCHC-31.8* RDW-14.5 RDWSD-43.8 Plt ___\n___ 05:34AM BLOOD Glucose-85 UreaN-5* Creat-0.8 Na-141 \nK-3.7 Cl-96 HCO3-38* AnGap-7*\n___ 05:34AM BLOOD ALT-86* AST-39 LD(LDH)-133 AlkPhos-86 \nTotBili-0.6\n___ 05:34AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9\n\nMTX:\n====\n\n___ 08:15PM BLOOD mthotrx-10.6*\n___ 06:04PM BLOOD mthotrx-0.69*\n___ 06:19PM BLOOD mthotrx-0.20\n___ 05:34AM BLOOD mthotrx-0.14\n___ 05:10PM BLOOD mthotrx-0.14\n \nBrief Hospital Course:\nPRINCIPLE REASON FOR ADMISSION:\n===============================\n___ PMH of MGUS, Neurolymphatosis (on HD MTX/Rituximab), \npresents\nfor scheduled HD MTX Cycle 2. \n\n#Neurolymphatosis (on HD MTX/Rituximab): Urine was alkalnized \nwith sodium bicarb per protocol. He received 8g/m2 per OMS order \nset on ___ without incident. Leucovorin rescue was initiated 24 \nhours after infusion per protocol. MTX levels were monitored q24 \nhours. MTX on discharge was 0.14. After discussion with patient \nhe elected to be discharged despite MTX >0.1. He was provided \nwith rx for leucovorin 40mg q6 hours x3 days and sodium bicarb \n1300mg q6 hours x3 days. He will follow up in clinic on ___ for \nrituximab. He will be readmitted on ___ for his next HD-MTX.\n\n#Transaminitis: Due to MTX infusion. Down trending prior to \ndischarge.\n\n# Weakness\n# Foot drop: Much improved, overall. Will continue home ___ with \nplans for PFO.\n\n#Nausea: Stable/improving. Due to methotrexate/leucovorin\n\n#Constipation history: Continued home bowel regimen\n\n#Billing: >30 minutes spent coordinating and executing this \ndischarge plan.\n\nTRANSITIONAL ISSUES:\n====================\n- Con't leucovorin and sodium bicarb tabs for three days \n(through ___, or as otherwise directed)\n- ___ in clinic on ___ for rituximab\n- Next cycle of HD MTX on ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n2. Docusate Sodium 100 mg PO BID \n3. Multivitamins 1 TAB PO DAILY \n4. Senna 8.6 mg PO BID:PRN constipation \n5. Sodium Bicarbonate 1300 mg PO Q6H \n6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n\n \nDischarge Medications:\n1. Leucovorin Calcium 40 mg PO Q6H \nTake through ___ \nRX *leucovorin calcium 10 mg 4 tablet(s) by mouth q6 hours Disp \n#*48 Tablet Refills:*0 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n4. Docusate Sodium 100 mg PO BID \n5. Multivitamins 1 TAB PO DAILY \n6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n7. Senna 8.6 mg PO BID:PRN constipation \n8. Sodium Bicarbonate 1300 mg PO Q6H \nTake for three days (through ___ \nRX *sodium bicarbonate 650 mg 2 tablet(s) by mouth q6 hours Disp \n#*24 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nNeurolymphomatosis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at ___ \n___. You were admitted for your planned HD-MTX \nchemotherapy, which you tolerated well. You will need to follow \nup in clinic on ___ for rituximab and then return for your next \nHD-MTX on ___ for your next HD-MTX. Because your MTX level \nis still a little high you should take Sodium Bicarb and \nLeucovorin tabs for the next three days.\n\nSincerely,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8599", "D472", "Z87891", "M21379", "R748", "R110", "T451X5A", "Y92239" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D472: Monoclonal gammopathy", "Z87891: Personal history of nicotine dependence", "M21379: Foot drop, unspecified foot", "R748: Abnormal levels of other serum enzymes", "R110: Nausea", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nneurolymphomatosis, scheduled chemotherapy\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with history of MGUS and\nneurolymphomatosis on rituximab/HD-MTX presenting for C6 HD-MTX. \n\n\nHe has felt well since his previous discharge. He received\nRituximab with Dr. ___ on ___ which went fine. He notes\nsome improvement in his arm discoloration and thinks he needs to\nsee a Dermatologist. He has gained some weight back. He noticed \na\nrash around his port which has improved with steroid cream. He\nstarted taking his bicab tabs on ___ prior to admission.\n\nHe denies fevers/chills, night sweats, headache, vision changes,\ndizziness/lightheadedness, weakness/numbnesss, shortness of\nbreath, cough, hemoptysis, chest pain, palpitations, abdominal\npain, nausea/vomiting, diarrhea, hematemesis,\nhematochezia/melena, 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:\n(1) Swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells,\n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake,\n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___,\n(29) received C3 rituximab 375 mg/m2/week on ___,\n(30) received C4 high-dose methotrexate at 8 grams/m2 on\n___,\n(30) received C4 rituximab 375 mg/m2/week on ___, \n(31) received C5 high-dose methotrexate at 8 grams/m2 on\n___, \n(32) gadolinium-enhanced total spine MRI on ___ showed\nresponse,\n(33) gadolinium-enhanced head MRI on ___ showed no evidence\nof disease,\n(34) FDG-PET on ___ showed improved FDG-Avid disease at\nT12-L2, and\n(35) CSF cytology showed atypical cells.\n(36) C6 HD-MTX (8g/m2) ___\n\nPAST MEDICAL HISTORY: \n-Hypertension\n-Forearm hyperpigmentation\n \nSocial History:\n___\nFamily History:\nHis father died at age ___ and he had dementia and prostate\ncancer. His mother is alive with osteoarthritis, knee\nreplacement, asthma and tuberculosis. He has 3 siblings and \nthey\nare all healthy. He does not have children.\n \nPhysical Exam:\nON ADMISSSION\n==============\nVS: Temp 98.3, BP 158/92, HR 84, RR 18, O2 sat 99% RA.\nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\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.\nACCESS: Right chest wall port.\n\nON DISCHARGE\n============\nVS: 98.0 ___ 20 100%RA\nGENERAL: Pleasant, well-appearing, in no distress, lying in bed\ncomfortably. 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: Non-distended, normal bowel sounds, soft, non-tendedr.\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.L-foot-drop.\nSKIN: Hyperpigmentation in both fore-arms decreasing in\nextension.\nACCESS: Right chest wall port\n \nPertinent Results:\n___ 10:23AM BLOOD WBC-3.4* RBC-4.07* Hgb-11.1* Hct-34.4* \nMCV-85 MCH-27.3 MCHC-32.3 RDW-16.5* RDWSD-51.4* Plt ___\n___ 05:52AM BLOOD WBC-2.7* RBC-4.05* Hgb-11.0* Hct-33.9* \nMCV-84 MCH-27.2 MCHC-32.4 RDW-15.6* RDWSD-47.3* Plt ___\n___ 10:23AM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-140 \nK-3.9 Cl-101 HCO3-29 AnGap-10\n___ 05:52AM BLOOD Glucose-94 UreaN-4* Creat-0.8 Na-139 \nK-3.4* Cl-94* HCO3-36* AnGap-9*\n\n___ 08:24PM BLOOD mthotrx-3.7*\n___ 08:26PM BLOOD mthotrx-1.6*\n___ 08:28PM BLOOD mthotrx-0.43*\n___ 01:15PM BLOOD mthotrx-0.43*\n___ 06:08AM BLOOD mthotrx-0.13\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old gentleman with history of MGUS and \nneurolymphomatosis on rituximab/HD-MTX admitted his for C6 \nHD-MTX which he tolerated well.\n\n# Neurolymphomatosis: His CSF leak has resolved and he continues \nto improve neurologically. No evidence of systemic lymphoma and \nis off dexamethasone and not on antiepileptics. Received \nhigh-dose methotrexate which is a highly toxic therapy with\nrisk of transient or permanent neurological toxicity needing \nclose monitoring of levels to be able to provide adequate \nsupport. Required IV NaHCO3 250cc/h. He tolerated this cycle \nwith only mild intermittent headache and nausea which responded \nto supportive antiemesis and analgesia.\n\n#Forearm hyperpigmentation: Given improvement with time, this is \nlikely a superficial form of hyperpigmentation (epidermal) which \ncan improved with epidermal turnover and moisturization. Started \non lactic acid 12% lotion TID.\n\n# MGUS: With rising IgG level. No intervention\n\n# Hypertension: Multiple SBPs >150 in house during prior \nadmissions. \n\nTRANSITIONAL ISSUES\n====================\n1. HYPERTENSION: Patient is hypertensive up to 160s during all \nhis admissions. It is unclear whether he is not hypertensive \nwhile not receiving IVF. \n2. Next admission for HD MTX to be in ~1 month\n3. Discharged on po leucovorin x3d and MTX diet given tendency \nto have rising levels after apparent clearance\n\n40 minutes were spent formulating and coordinating this \npatient's discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Multivitamins 1 TAB PO DAILY \n4. Senna 8.6 mg PO BID:PRN constipation \n5. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission \n6. Docusate Sodium 100 mg PO BID:PRN constipation \n7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n\n \nDischarge Medications:\n1. Lactic Acid 12% Lotion 1 Appl TP TID \nRX *ammonium lactate [AmLactin] 12 % apply to both forearms \nthree times a day Refills:*0 \n2. Leucovorin Calcium 40 mg PO Q6H Duration: 3 Days \nRX *leucovorin calcium 10 mg 4 tablet(s) by mouth every six (6) \nhours Disp #*48 Tablet Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Multivitamins 1 TAB PO DAILY \n7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n8. Senna 8.6 mg PO BID:PRN constipation \n9. Sodium Bicarbonate 1300 mg PO Q6H 3 days prior to admission \n\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nEncounter for antineoplastic chemotherapy\nNeurolymphomatosis\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 Mr. ___,\n\nYou were admitted for another cycle of your high dose \nmethotrexate chemotherapy which you tolerated well. \n\nIt was a pleasure to take care of you,\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8589", "Z87891", "D472", "I10", "R51", "R112", "L818" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "Z87891: Personal history of nicotine dependence", "D472: Monoclonal gammopathy", "I10: Essential (primary) hypertension", "R51: Headache", "R112: Nausea with vomiting, unspecified", "L818: Other specified disorders of pigmentation" ]

[ "Z87891", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nchlorhexidine\n \nAttending: ___\n \nChief Complaint:\nScheduled Chemotherapy\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n================================================================ \n\n\nOncology Hospitalist Admission \nDate: ___ \n================================================================ \n\n\nPRIMARY ONCOLOGIST: ___\nPRIMARY DIAGNOSIS: neurolymphomatosis\nTREATMENT REGIMEN: HD MTX\nCHIEF COMPLAINT: Scheduled Chemotherapy\n\nHISTORY OF PRESENT ILLNESS: \n___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented \n\nfor C10 maintenance HD-MTX \n\nAs per review of notes, last MRI of L spine was in ___\nrevealed that the hyperintensities, cord expansion and\nenhancement in the distal spinal cord seen on the MRI of ___ had resolved with subtle T2 hyperintensities\nremaining in the region, without new areas of enhancement or new\nT2 abnormalities within the distal spinal cord. Patient is\ntherefore continuing on 2 month maintenance HD MTX for which he\npresents today for cycle 10.\n\nPt reports that he was recently fitted for left foot orthotic \nand\nfeels that his left leg strength is robust, and only has\nlingering weakness in dorsiflexion of left foot. Reported that\ngait was normal. Otherwise was eating, drinking, voiding,\nstooling without difficulty. Reported he was in good spirits.\nDenied fever or chills. Reported that weight is stable. He\nreported receiving rituximab in clinic several days ago. \n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \nAs per Dr ___:\n\"(1) swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells, \n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and \n\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake, \n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___,\n(29) received C3 rituximab 375 mg/m2/week on ___,\n(30) received C4 high-dose methotrexate at 8 grams/m2 on\n___,\n(30) received C4 rituximab 375 mg/m2/week on ___, \n(31) received C5 high-dose methotrexate at 8 grams/m2 on\n___, \n(32) gadolinium-enhanced total spine MRI on ___ showed\nresponse,\n(33) gadolinium-enhanced head MRI on ___ showed no evidence\nof disease,\n(34) FDG-PET on ___ showed improved FDG-Avid disease at\nT12-L2,\n(35) CSF cytology showed atypical cells,\n(36) received C5 monthly maintenance rituximab 375 mg/m2/week on\n___,\n(37) received C6 first monthly maintenance high-dose \nmethotrexate\nat 8 grams/m2 on ___,\n(38) gadolinium-enhanced MRI of the lumbosacral spine performed\non ___ showed no evidence of disease,\n(39) received C6 second monthly maintenance rituximab 375\nmg/m2/week on ___,\n(40) received C7 second monthly maintenance high-dose\nmethotrexate at 8 grams/m2 on ___,\n(41) received C7 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(42) received C8 third maintenance rituximab 375 mg/m2/week on\n___ given at every 2-month interval\n(43) received C8 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(___) received C9 first 2-month interval rituximab 375 mg/m2/week\non ___, and\n(45) received C9 first 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___ \n \nPAST MEDICAL HISTORY: \n-MGUS\n-Laminectomy L2-5 for nerve resection on ___ c/b CSF leak \non ___ s/p subsequent repair \n-Left foot drop\n-Elbow Bursitis\n-HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior\ninfection. Discussed w/ Dr ___ by previous providers with\ndecision to hold off on antiviral for reactivation\n \nSocial History:\n___\nFamily History:\nHis father died at age ___ and he had dementia and prostate\ncancer. His mother is alive with osteoarthritis, knee\nreplacement, asthma and tuberculosis. He has 3 siblings and they\nare all healthy. He does not have children.\n \nPhysical Exam:\nVitals: Temp: 97.8 PO BP: 143/85 HR: 61 RR: 18 O2\nsat: 98% O2 delivery: Ra Dyspnea: 0 RASS: 0 Pain Score: ___ \nGENERAL: Pleasant man, in no distress, sitting in bed, calm,\ntalkative\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. normal RR\nABD: Soft, non-tender, non-distended, normal bowel sounds\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness. normal sensation to light touch. upper extremities\nwith normal strength and ROM. \nNEURO: A&Ox3, good attention and linear thought, Strength full\nthroughout except for ___ dorsiflexion of left foot. Sensation \nto\nlight touch intact. \nACCESS: Right chest wall port site intact, dressing c/d/I\n \nPertinent Results:\n___ 06:30PM BLOOD mthotrx-3.1*\n___ 06:25PM BLOOD mthotrx-1.6*\n___ 06:25PM BLOOD mthotrx-1.6*\n___ 06:00AM BLOOD mthotrx-1.1*\n___ 06:11PM BLOOD mthotrx-1.4*\n___ 06:30AM BLOOD mthotrx-0.45*\n___ 02:25PM BLOOD mthotrx-0.32*\n___ 05:04AM BLOOD mthotrx-0.___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX \npresenting\nfor C10 maintenance HD-MTX\n\n# Neurolymphomatosis: \nHe is post laminectomy at L2-5 for nerve resection on ___\nwhich resulted in LLE weakness which is improving gradually over\ntime. He tolerated prior cycles well with HD MTX except for\ndelayed clearance and nausea. Last MRI of L spine was in ___\nrevealed that the hyperintensities, cord expansion and\nenhancement in the distal spinal cord seen on the MRI of ___ had resolved with subtle T2 hyperintensities\nremaining in the region, without new areas of enhancement or new\nT2 abnormalities within the distal spinal cord. Patient is\ntherefore continuing on 2 month maintenance HD MTX for which he\npresented for cycle 10. He tolerated the chemo well.\n[] benefits from Emend premed significantly, cont on next admit\n[] despite IVF 250 ml/hr entire course, cleared slowly (4.5 \ndays)\n[] level 0.15 on d/c, will go home on PO LV and Bicarb \n[] MRI ___, then will see Dr ___ to determine next chemo\n\n# Hypokalemia: expected, repleted PO\n# MGUS: Followed by Dr ___ \n# Hypertension: SBP 130s-150s\n# HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior\ninfection. Discussed w/ Dr ___. Holding off on antiviral \n\nPPX: Lovenox 40mg QD ordered but he refused, ambulated \nfrequently\nACCESS: POC\nCODE: Full Code (confirmed on admission)\nEMERGENCY CONTACT HCP: ___ (partner) ___\nDISPO: Home \nBILLING: >30 min spent coordinating care for discharge\n______________\n___, D.O.\nHeme/Onc Hospitalist\n___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety \n5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n6. Senna 8.6 mg PO BID:PRN constipation \n7. Sodium Bicarbonate 1300 mg PO QID \n8. Leucovorin Calcium 40 mg PO Q6H \n9. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Lidocaine-Prilocaine 1 Appl TP DAILY:PRN port access \nRX *lidocaine-prilocaine 2.5 %-2.5 % apply to port site daily \nprn prior to getting port accessed Refills:*0 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n4. Docusate Sodium 100 mg PO BID:PRN constipation \n5. Leucovorin Calcium 40 mg PO Q6H Duration: 2 Days \n6. LORazepam 0.5 mg PO Q8H:PRN nausea, insomnia, anxiety \n7. Multivitamins 1 TAB PO DAILY \n8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n9. Senna 8.6 mg PO BID:PRN constipation \n10. Sodium Bicarbonate 1300 mg PO QID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNeurolymphomatosis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nYou tolerated your chemotherapy well. Please take your bicarb \nfor 1 more day, and your leucovorin for 2 more days. Please \nfollow up with Dr ___ in clinic. \n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8331", "D472", "E876", "I10", "Z87891" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8331: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck", "D472: Monoclonal gammopathy", "E876: Hypokalemia", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nScheduled Chemotherapy\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nAs per admitting MD:\nMr. ___ is a pleasant ___ w/ MGUS and neurolymphomatosis on \nHD\nMTX/Rituxan who presents for admission for C4 q 2 week induction\nHD MTX. He has been doing well after his last cycle. His left\nfoot drop which occured due to a laminectomy at L2-5 for nerve\nresection on ___ continues to improve. He took his sodium\nbicarb tabs q6hrs x 3 days and surprised on arrival pH still 6. \n\n \nPast Medical History:\nAs per admitting MD:\n \nSocial History:\n___\nFamily History:\nAs per admitting MD:\nFather had prostate cancer. Denies otherwise history of blood or \n\noncologic history.\n \nPhysical Exam:\nAdmission:\nVITAL SIGNS: ___ 1041 Temp: 97.9 PO BP: 160/84 L Lying HR:\n84 RR: 18 O2 sat: 100% O2 delivery: RA \nGeneral: NAD, Resting in bed comfortably\nHEENT: MMM, no OP lesions, no cervical/supraclavicular\nadenopathy\nCV: RR, NL S1S2 no S3S4 No MRG\nPULM: CTAB, No C/W/R, No respiratory distress\nABD: BS+, soft, NTND, no palpable masses or HSM\nLIMBS: WWP, no ___, no tremors\nSKIN: No rashes on the extremities, R chest port site intact\nNEURO: Grossly normal with exception of ___ strength in all\nmuscles of LLE ___ dorsiflexion, 4+/5 plantarflexion), \notherwise\nRLE/RUE/LUE ___. \n\nDischarge:\nGeneral: NAD, sitting in bed comfortably, pleasant, talkative\nEYES: PERRLA, anicteric\nHEENT: MMM, no OP lesions\nCV: RRR, No murmurs, normal distal perfusion without edema\nPULM: CTAB, no w/r/r, no accessory muscle use. \nABD: BS+, soft, NTND, no ascites\nLIMBS: WWP, no ___, no tremors, normal muscle bulk, has ___ \nstrength on LLE which is unchanged from prior admissions\nSKIN: hyperpigmentation and xerosis on b/l forearm extending \nslightly above the elbow which was flat without \nerythema/warmth/tenderness, R chest port site intact without e/o \ninfection\nNEURO: Grossly normal with exception of ___ strength in all\nmuscles of LLE \nPSYCH: Normal mood, insight, judgment, affect\nACCESS: Right chest port with c/d/I dressing\n \nPertinent Results:\nAdmission:\n\n___ 11:54AM BLOOD WBC-4.0 RBC-3.46* Hgb-9.3* Hct-29.5* \nMCV-85 MCH-26.9 MCHC-31.5* RDW-16.0* RDWSD-49.2* Plt ___\n___ 11:54AM BLOOD ___ PTT-31.3 ___\n___ 11:54AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-142 K-4.1 \nCl-103 HCO3-26 AnGap-13\n___ 11:54AM BLOOD ALT-34 AST-23 LD(LDH)-157 AlkPhos-79 \nTotBili-0.2\n___ 11:54AM BLOOD Albumin-3.7 Calcium-9.1 Phos-4.1 Mg-2.1\n___ 09:06PM BLOOD mthotrx-7.1*\n\nDischarge:\n\n___ 05:45AM BLOOD WBC-2.4* RBC-3.43* Hgb-9.2* Hct-28.6* \nMCV-83 MCH-26.8 MCHC-32.2 RDW-14.9 RDWSD-45.1 Plt ___\n___ 05:45AM BLOOD ___ PTT-27.1 ___\n___ 05:45AM BLOOD Neuts-41.5 ___ Monos-9.5 \nEos-10.0* Baso-0.8 Im ___ AbsNeut-1.00* AbsLymp-0.91* \nAbsMono-0.23 AbsEos-0.24 AbsBaso-0.02\n___ 05:45AM BLOOD Glucose-94 UreaN-3* Creat-0.8 Na-142 \nK-3.7 Cl-97 HCO3-35* AnGap-10\n___ 05:45AM BLOOD ALT-46* AST-26 LD(LDH)-153 AlkPhos-80 \nTotBili-0.3\n___ 05:45AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.8 UricAcd-4.1\n___ 05:45AM BLOOD mthotrx-0.10\n\nCXR ___:\n \nLungs are clear. Right-sided Port-A-Cath tip projects over the \nSVC. \nCardiomediastinal silhouette is stable. There is no pleural \neffusion. No \npneumothorax is seen \n\n \nBrief Hospital Course:\n___ PMH MGUS and neurolymphomatosis on HD MTX/Rituxan who \npresented for admission for C4 q 2 week induction HD MTX, who \nhas tolerated regimen well with exception of slight \ntransaminitis, and fluctuating MTX levels, who eventually \ncleared with higher rate of IVF, and was discharged with \noutpatient neuro-oncology followup\n\n# Neurolymphomatosis (on HD MTX/Rituximab)\nNo evidence of systemic lymphoma and is off dexamethasone and \nnot on antiepileptics. His post laminectomy at L2-5 for nerve \nresection on ___ resulted in LLE weakness which is \nimproving. Methotrexate clearance stalled with levels \nfluctuating without clear trend, difficult to say what was \ncausing it. Pathology attending/resident reviewed quality \ncontrol measures and machine was apparently functioning well, \npatient without third spacing on exam, and weight decreased \nsince admission so unclear cause. Pt eventually discharged once \nvalue 0.1. As per Dr ___ have patient on IV Bicarb fluids \nat 200cc/hr on future admits to hopefully prevent such issue \nfrom recurring. Patient should also likely be started on 100 \nLeucovorin given his delay in clearing MTX.\n\nPatient is to have repeat LP, MRI and PET scan in ___ per Dr \n___, with radmission ___ (email sent to neuro-onc \ndischarge clinic). Lastly, pt is to receive rituxan in clinic q2 \nweeks, next on ___ (while apt not in system, patient is \naware of date/time).\n\n#Neutropenia/Leukopenia\nOn prior admits patient had leukopenia that was mild by end of \nstay likely ___ MTX. On this admission MTX clearance was delayed \nso patient had more severe leukopenia/neutropenia with ANC of \n984 on discharge. I expect that value will increase in the \ncoming days now that methotrexate now excreted. Patient was \ninstructed to return if he has fever/chills or infectious \nsymptoms given risk of rapid progression while neutropenic. He \nwas informed to have his CBC re-checked at next outpatient \nneuro-oncology appointment next week. \n\n#Hyperpigmentation of both forearms\nOn day of discharge patient had hyperpigmentation and xerosis \nwith sharp demarcations of both forearms extending slightly \nabove elbow which were not raised, warm, erythematous, tender so \nunlikely infectious/allergic/inflammatory. He noted that they \nwere asymptomatic. As per Dr ___, reaction to ___ (MTX) \nseemed less likely. Given xerosis and distribution, contact \nirritation was considered (possibly new sweater that patient was \nwearing), so he was informed to moisturize BID and to followup \nwith dermatology if progressed. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Multivitamins 1 TAB PO DAILY \n5. Senna 8.6 mg PO BID:PRN constipation \n6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n7. Sodium Bicarbonate 1300 mg PO Q6H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Multivitamins 1 TAB PO DAILY \n5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n6. Senna 8.6 mg PO BID:PRN constipation \n7. Sodium Bicarbonate 1300 mg PO Q6H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNeurolymphomatosis\nLeukopenia/Neutropenia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr ___,\n\nIt was a pleasure taking care of you in the hospital. You were \nadmitted for chemotherapy and you did well. Please take your \nmedications as instructed and follow up as noted below. \n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8599", "D701", "D472", "M21372", "Z87891", "G8314", "T451X5A", "Y92239", "L259" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "D701: Agranulocytosis secondary to cancer chemotherapy", "D472: Monoclonal gammopathy", "M21372: Foot drop, left foot", "Z87891: Personal history of nicotine dependence", "G8314: Monoplegia of lower limb affecting left nondominant side", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "L259: Unspecified contact dermatitis, unspecified cause" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nchlorhexidine\n \nAttending: ___.\n \nChief Complaint:\nElective admission for chemotherapy\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w/ MGUS and neurolymphomatosis on rituximab/HD-MTX presented \n\nfor C12 maintenance HD-MTX. \n\nHe was last admitted for C11 on ___, which he tolerated\nwell. As was the case on prior admits, he was discharged when \nMTX\nlevel roughly 0.3 with plan to continue bicarb and leucovorin\ntabs at home. Cycle 12 of Rituxan was given on ___. \n\nPatient noted that he was without complaint, was at his baseline\nhealth without any new neurologic deficits/abnormalities.\nreported that he is tolerating a normal diet, voiding/stooling\nwithout difficulty. Denied any fever or chills.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n(1) swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells, \n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and \n\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake, \n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___,\n(29) received C3 rituximab 375 mg/m2/week on ___,\n(30) received C4 high-dose methotrexate at 8 grams/m2 on\n___,\n(30) received C4 rituximab 375 mg/m2/week on ___, \n(31) received C5 high-dose methotrexate at 8 grams/m2 on\n___, \n(32) gadolinium-enhanced total spine MRI on ___ showed\nresponse,\n(33) gadolinium-enhanced head MRI on ___ showed no evidence\nof disease,\n(34) FDG-PET on ___ showed improved FDG-Avid disease at\nT12-L2,\n(35) CSF cytology showed atypical cells,\n(36) received C5 monthly maintenance rituximab 375 mg/m2/week on\n___,\n(37) received C6 first monthly maintenance high-dose \nmethotrexate\nat 8 grams/m2 on ___,\n(38) gadolinium-enhanced MRI of the lumbosacral spine performed\non ___ showed no evidence of disease,\n(39) received C6 second monthly maintenance rituximab 375\nmg/m2/week on ___,\n(40) received C7 second monthly maintenance high-dose\nmethotrexate at 8 grams/m2 on ___,\n(41) received C7 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(42) received C8 maintenance rituximab 375 mg/m2/week on\n___ \n(43) received C8 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(44) received C9 first 2-month interval rituximab 375 mg/m2/week\non ___, and\n(45) received C9 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___\n(___) received C10 interval maintenance rituximab 375\nmg/m2/week on ___.\n(47) received C10 ___ 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___.\n(48)received C11 interval maintenance rituximab 375\nmg/m2/week on ___.\n(49) Received C11 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___: stable MRI L-spine and no definite abnormal area of\nuptake on FDG PET. \n \nPAST MEDICAL HISTORY: \n- MGUS\n- Laminectomy L2-5 for nerve resection on ___ c/b CSF leak\non ___ s/p subsequent repair \n- Left foot drop\n- Elbow Bursitis\n- HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior\ninfection. Discussed w/ Dr ___ by previous providers with\ndecision to hold off on antiviral for reactivation\n \nPhysical Exam:\nGeneral: Well appearing pleasant ___ man \nambulating around room, packing up his belongings\nHEENT: No lesions in the oropharynx, MMM. Small erosions over \nthe lower lip from yesterday have healed\nCV: RRR, no murmurs\nPULM: CTAB\nABD: Soft nontender nondistended, normoactive bowel sounds\nLIMBS: WWP no edema\nSKIN: No rashes\nNEURO: Alert, answers questions appropriately, PERRL, palate \nelevates symmetrically, ambulating around room without \ndifficulty\nACCESS: POC c/d/i\n \nPertinent Results:\nDISCHARGE LABS\n___ 06:43AM BLOOD WBC-2.9* RBC-4.02* Hgb-11.1* Hct-33.9* \nMCV-84 MCH-27.6 MCHC-32.7 RDW-13.2 RDWSD-40.9 Plt ___\n___ 06:43AM BLOOD UreaN-5* Creat-0.8 Na-143 K-3.5 Cl-100 \nHCO3-35* AnGap-8*\n___ 06:43AM BLOOD ALT-26 AST-19 AlkPhos-73 TotBili-0.7\n___ 06:43AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8\n\nMETHOTREXATE LEVELS:\n___ 05:59PM BLOOD mthotrx-3.2*\n___ 06:30PM BLOOD mthotrx-1.9*\n___ 06:16PM BLOOD mthotrx-1.5*\n___ 05:48PM BLOOD mthotrx-0.33*\n___ 09:15AM BLOOD mthotrx-0.17\n___ 04:08PM BLOOD mthotrx-0.15\n___ 06:43AM BLOOD mthotrx-0.09\n \nBrief Hospital Course:\n___ is a ___ year old man with MGUS and \nneurolymphomatosis on rituximab/HD-MTX presented for C12 \nmaintenance HD-MTX.\n\nHe tolerated HD-MTX well apart from some nausea and mild \ntransaminitis. He cleared methotrexate on day 6.\n\n#Neurolymphomatosis: \nPt is off dexamethasone and not on antiepileptics. No \nnew/worsening neurologic changes. Recent MRI spine and PET \nwithout e/o disease recurrence. Received Rituximab prior to \nadmission.\n\nHe tolerated C12 HD-MTX well apart from some mild nausea, \nhypokalemia, and transaminitis (AST/ALT peaked at 79/57 on \n___. He will return for follow up PET ___ followed by MRI \nL spine ___ prior to appointment with Dr ___. \n\nHe should return in 3 months for his next cycle of HD-MTX. For \nnext cycle:\n\n- Alkainization w/ 150mEq NaHCO3/D5w at 250 cc/hr as he tends to \nclear slowly\n- Per Dr ___ need to wait until level is less than 0.1, \ncan no longer leave at 0.3. \n\n#Bleeding at Urethra: He had one episode on ___ where he \nnoticed blood at the tip of the penis. He was not \nthrombocytopenic and had not had any trauma. There were no \nrecurrent episodes. He can consider outpatient GU follow up if \nrecurrent. \n\n- consider outpatient GU f/u \n\n#MGUS: Follow up scheduled with Dr ___ ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Sodium Bicarbonate 1300 mg PO QID \n3. Diazepam 5 mg PO Q8H:PRN muscle spasm \n4. Leucovorin Calcium 40 mg PO ASDIR \n5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n6. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate \n\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Diazepam 5 mg PO Q8H:PRN muscle spasm \n3. Leucovorin Calcium 40 mg PO ASDIR \n4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \n6. Sodium Bicarbonate 1300 mg PO QID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nEncounter for chemotherapy\nNeurolymphomatosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \n ___ MD ___\n \nCompleted by: ___\n" ]

[ "Z5111", "C8599", "B1910", "D472", "Z87891", "F1290", "E876", "I10", "R109", "R112", "N368" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8599: Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites", "B1910: Unspecified viral hepatitis B without hepatic coma", "D472: Monoclonal gammopathy", "Z87891: Personal history of nicotine dependence", "F1290: Cannabis use, unspecified, uncomplicated", "E876: Hypokalemia", "I10: Essential (primary) hypertension", "R109: Unspecified abdominal pain", "R112: Nausea with vomiting, unspecified", "N368: Other specified disorders of urethra" ]

[ "Z87891", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nchlorhexidine\n \nAttending: ___\n \nChief Complaint:\nadmission for chemo\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nDATE: ___\nPRIMARY ONCOLOGIST: ___., MD\nPRIMARY DIAGNOSIS: neurolymphomatosis \nTREATMENT REGIMEN: HD-MTX and rituximab maintenance\n\n=== HPI ===\nChief Complaint: Scheduled chemotherapy\n\n___ is a ___ yo man with neurolymphomatosis on HD-MTX \nand\nrituximab maintenance, who presents for scheduled chemotherapy.\n\nHe saw Dr ___ in clinic ___ and received C14 of maintenance\nrituximab. His last PET scan was ___ which showed no \nevidence\nof systemic lymphoma. MRI L spine ___ was stable without any\nnew findings. \n\nHe returns for HD-MTX at q3 month maintenance interval. He is in\nhis USOH. No headache, nausea, vomiting, abd pain, chest pain,\nSOB, fevers, chills, fatigue, appetite changes, dysuria. \n\nHe started his sodium bicarb on ___ morning (>48 hrs prior\nto admission). \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n(1) swallowing study on ___ showed oropharyngeal and\nesophageal dysphagia on the right-sided,\n(2) gadolinium-enhanced thoracic and lumbar MRI on ___\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side,\n(3) CT of the torso on ___ showed no malignancy,\n(4) lumbar puncture on ___ showed ___ WBC, ___ RBC, 114\nprotein, 63 glucose, 19 LDH, beta-2-microglobulin 1.87 (normal\n0.36-2.56), CA ___ <6, VDRL non-reactive, and negative cytology\nfor malignant cells, \n(5) bone marrow aspiration on ___ showed lambda restricted\nplasma cells,\n(6) gadolinium-enhanced lumbar MRI performed on ___ again\nshowed T12-L1 enhancement that is located in the anterior spinal\ncord with an exophytic component eccentric to the left side, and \n\nthis enhancement appears slightly more prominent, and \n(7) lumbar puncture on ___ showed 26 WBC, 4 RBC, 146\nprotein, 57 glucose, 23 LDH, and atypical large lymphoid cells \nin\ncytology,\n(8) lumbar puncture on ___ showed 27 WBC, 0 RBC, 88 \nprotein,\n55 glucose, 33 LDH, beta-2-microglobulion 2.50 (range 0.36-2.56)\nand presence of oligoclonal bands,\n(9) laminectomy L2-5 for right L5 nerve resection on ___ by\nDr. ___ and the pathology showed\nneurolymphomatosis,\n(10) HBV core antibody positive on ___ and ___,\n(11) HIV negative on ___,\n(12) echocardiogram showed LVEF >55%,\n(13) FDG-PET from ___ showed uptake in the lower spinal \ncord\nbut no systemic uptake, \n(14) PICC line insertion on ___,\n(15) started C1W1 rituximab 375 mg/m2 and lamivudine 100 mg QD \non\n___,\n(16) CSF leak on ___,\n(17) discontinuation of lamuvidine and dexamethasone on \n___,\n(18) repair of CSF leak on ___ by Dr. ___,\n(19) received C1W1 rituximab 375 mg/m2/week on ___,\n(20) Portacath placement on ___,\n(21) received C1 high-dose methotrexate at 6 grams/m2 on\n___,\n(22) received C1W1 rituximab 375 mg/m2/week on ___,\n(23) received C1W2 rituximab 375 mg/m2/week on ___,\n(24) received C1W3 rituximab 375 mg/m2/week on ___,\n(25) received C2 high-dose methotrexate at 8 grams/m2 on\n___,\n(26) received C1W4 rituximab 375 mg/m2/week on ___,\n(27) received C2 rituximab 375 mg/m2/week on ___,\n(28) received C3 high-dose methotrexate at 8 grams/m2 on\n___,\n(29) received C3 rituximab 375 mg/m2/week on ___,\n(30) received C4 high-dose methotrexate at 8 grams/m2 on\n___,\n(30) received C4 rituximab 375 mg/m2/week on ___, \n(31) received C5 high-dose methotrexate at 8 grams/m2 on\n___, \n(32) gadolinium-enhanced total spine MRI on ___ showed\nresponse,\n(33) gadolinium-enhanced head MRI on ___ showed no evidence\nof disease,\n(34) FDG-PET on ___ showed improved FDG-Avid disease at\nT12-L2,\n(35) CSF cytology showed atypical cells,\n(36) received C5 monthly maintenance rituximab 375 mg/m2/week on\n___,\n(37) received C6 first monthly maintenance high-dose \nmethotrexate\nat 8 grams/m2 on ___,\n(38) gadolinium-enhanced MRI of the lumbosacral spine performed\non ___ showed no evidence of disease,\n(39) received C6 second monthly maintenance rituximab 375\nmg/m2/week on ___,\n(40) received C7 second monthly maintenance high-dose\nmethotrexate at 8 grams/m2 on ___,\n(41) received C7 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(42) received C8 maintenance rituximab 375 mg/m2/week on\n___ \n(43) received C8 third monthly maintenance rituximab 375\nmg/m2/week on ___, \n(44) received C9 first 2-month interval rituximab 375 mg/m2/week\non ___, and\n(45) received C9 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___\n(46) received C10 interval maintenance rituximab 375\nmg/m2/week on ___.\n(47) received C10 ___ 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___.\n(___)received C11 interval maintenance rituximab 375\nmg/m2/week on ___.\n(___) Received C11 2-month interval maintenance high-dose\nmethotrexate at 8 grams/m2 on ___: stable MRI L-spine and no definite abnormal area of\nuptake on FDG PET. \n \nPAST MEDICAL HISTORY: \n- MGUS\n- Laminectomy L2-5 for nerve resection on ___ c/b CSF leak\non ___ s/p subsequent repair \n- Left foot drop\n- Elbow Bursitis\n- HBcAb+: HbSag/ab-. HBV viral load UL. Indicative of prior\ninfection. Discussed w/ Dr ___ by previous providers with\ndecision to hold off on antiviral for reactivation\n \nSocial History:\n___\nFamily History:\nHis father died at age ___ and he had dementia and prostate\ncancer. His mother is alive with osteoarthritis, knee\nreplacement, asthma and tuberculosis. He has 3 siblings and they\nare all healthy. He does not have children.\n \nPhysical Exam:\n0716 Temp: 98.2 PO BP: 143/83 R Sitting HR: 55 RR: 18 O2\nsat: 98% O2 delivery: RA \nGeneral: Well appearing pleasant man resting in bed in no acute \ndistress\nHEENT: Oropharynx clear, MMM, no lesions\nCV: RRR no murmurs\nPULM: CTAB\nABD: Soft, nontender, nondistended. Bowel sounds present\nLIMBS: WWP, no peripheral edema\nSKIN: No obvious acute rashes\nNEURO: Alert, oriented, PERRL, palate elevate symmetrically\nACCESS: R POC\n \nPertinent Results:\n___ 05:52PM BLOOD WBC-3.4* RBC-4.20* Hgb-11.6* Hct-35.2* \nMCV-84 MCH-27.6 MCHC-33.0 RDW-13.1 RDWSD-40.1 Plt ___\n___ 05:52PM BLOOD Neuts-60.9 ___ Monos-2.6* Eos-2.6 \nBaso-0.3 Im ___ AbsNeut-2.08 AbsLymp-1.14* AbsMono-0.09* \nAbsEos-0.09 AbsBaso-0.01\n___ 05:03AM BLOOD Glucose-98 UreaN-4* Creat-0.9 Na-140 \nK-3.5 Cl-97 HCO3-34* AnGap-9*\n___ 05:52PM BLOOD ALT-33 AST-24 AlkPhos-82 TotBili-0.7\n___ 05:03AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9\n___ 05:03AM BLOOD mthotrx-0.14\n___ 05:52PM BLOOD mthotrx-0.46*\n___ 06:00PM BLOOD mthotrx-1.4*\n___ 05:35PM BLOOD mthotrx-1.5*\n___ 05:38PM BLOOD mthotrx-3.2*\n \nBrief Hospital Course:\n___ with neurolymphomatosis on HD-MTX and rituximab maintenance, \nwho presents for C14 HD-MTX. MRI spine and PET ___ without \ne/o disease recurrence. Received C14 rituximab ___ and now here \nfor C14 HD-MTX. Tolerated it well with IVF running at 250 ml/hr \n(w/ condom cath per his request). ___ clinic will contact \npt when able to schedule repeat admission in 3 mo. His level was \n0.14 and he requested to be discharged and agreed to take \nLV/bicarb at home for the next 3 days. \n\n# Hypokalemia: repleted \n# HBcAb+: HbSag/ab-. HBV viral load negative ___. \nIndicative of prior infection. No plans for antiviral treatment \nas per Dr ___\n \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Diazepam 5 mg PO Q8H:PRN muscle spasm \n3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate \n\n4. Sodium Bicarbonate 1300 mg PO QID \n5. Leucovorin Calcium 40 mg PO ASDIR \n6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n\n \nDischarge Medications:\n1. Leucovorin Calcium 40 mg PO Q6H Duration: 3 Days \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n3. Diazepam 5 mg PO Q8H:PRN muscle spasm \n4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \n6. Sodium Bicarbonate 1300 mg PO QID \ntake for 3 days following discharge and again 2 days PRIOR to \nyour next MTX admission \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNeurolymphomatosis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___\n\n___ tolerated your MTX well. ___ didn't fully clear it at time \nof discharge so please continue taking your leucovorin and \nbicarbonate for the next 3 days. Please confirm with your \n___ clinic your next admission date. \n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8589", "E876", "Z87891", "Z8619" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "E876: Hypokalemia", "Z87891: Personal history of nicotine dependence", "Z8619: Personal history of other infectious and parasitic diseases" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nLamictal / hydrochlorothiazide\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\n___ Debridement of intra-abdominal fluid collection\n\nattach\n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n\n___ 09:54AM BLOOD WBC-26.0* RBC-5.36* Hgb-12.3 Hct-39.2 \nMCV-73* MCH-22.9* MCHC-31.4* RDW-17.1* RDWSD-43.2 Plt ___\n___ 09:54AM BLOOD Neuts-81.7* Lymphs-8.2* Monos-8.9 \nEos-0.0* Baso-0.3 Im ___ AbsNeut-21.26* AbsLymp-2.12 \nAbsMono-2.31* AbsEos-0.00* AbsBaso-0.07\n___ 09:54AM BLOOD Glucose-356* UreaN-22* Creat-0.8 Na-130* \nK-3.6 Cl-99 HCO3-14* AnGap-17\n___ 09:54AM BLOOD ALT-15 AST-12 AlkPhos-120* TotBili-0.4\n___ 09:54AM BLOOD Albumin-3.2* Calcium-9.6 Phos-1.9* Mg-1.9\n___ 10:03AM BLOOD Lactate-2.1*\n___ 01:17PM BLOOD Glucose-318* Na-131* K-2.7* Cl-104 \ncalHCO3-18*\n\n=====================\nOTHER PERTINENT LABS:\n=====================\n\n___ 09:54AM BLOOD WBC-26.0* RBC-5.36* Hgb-12.3 Hct-39.2 \nMCV-73* MCH-22.9* MCHC-31.4* RDW-17.1* RDWSD-43.2 Plt ___\n___ 03:13AM BLOOD WBC-13.1* RBC-4.96 Hgb-11.5 Hct-36.8 \nMCV-74* MCH-23.2* MCHC-31.3* RDW-17.3* RDWSD-45.1 Plt ___\n___ 09:54AM BLOOD Glucose-356* UreaN-22* Creat-0.8 Na-130* \nK-3.6 Cl-99 HCO3-14* AnGap-17\n___ 11:00PM BLOOD Glucose-195* UreaN-15 Creat-0.7 Na-137 \nK-4.1 Cl-107 HCO3-16* AnGap-14\n___ 05:58AM BLOOD Glucose-154* UreaN-7 Creat-0.6 Na-137 \nK-3.7 Cl-106 HCO3-20* AnGap-11\n___ 03:40PM BLOOD %HbA1c-13.8* eAG-349*\n___ 10:03AM BLOOD Lactate-2.1*\n___ 08:04PM BLOOD Lactate-1.5\n___ 05:58AM BLOOD C-PEPTIDE-1.41\n___ 05:37AM BLOOD INSULIN ANTIBODIES-<0.4\n___ 05:37AM BLOOD GLUTAMIC ACID DECARBOXYLASE (GAD65) \nANTIBODY ASSAY, SERUM-0.00\n___ 06:45AM BLOOD PREALBUMIN-9 \n___ 06:45AM BLOOD ZINC (SPIN NVY/EDTA)-58\n\n================\nIMAGING/STUDIES:\n================\n\n___ US DOPPLER LOWER EXTREMITY\nNo evidence of deep venous thrombosis in the right lower \nextremity veins. \n\n___ CXR\nInterval removal of right-sided PICC line. Cardiomediastinal \nsilhouette is within normal limits. There are no focal \nconsolidations, pleural effusion, or pulmonary edema. Mild \nprominence of for rounded structure within the right infrahilar \nregion, may represent the vessel. There are no pneumothoraces. \n\n___BDOMEN/PELVIS\nInterval increase in size of an anterior abdominal wound, \nfollowing ventral hernia repair, with a peripherally enhancing \nfluid collection along the left margin of the wound, which \nmeasures approximately 2.0 x 1.0 x 10.0 cm. \n\n___ CT ABDOMEN/PELVIS WITH CONTRAST\nPostsurgical changes from ventral hernia repair with a large \nanterior \nabdominal wall defect. Interval placement of surgical drains \nalong the superior margin of the abdominal wall defect with near \ncomplete resolution of the fluid collection along the left \nlateral margin. Multiple loops of small bowel and transverse \ncolon abuts the anterior abdominal wall defect. A focal \nirregularity of the anterior abdominal wall adjacent to the mid \ntransverse colon may represent a small colocutaneous fistula. \n4. New bowel wall thickening and submucosal edema involving the \nileum, which may represent developing enteritis. New fluid \nwithin the colon most likely represents diarrhea. \n \n___ US LOWER EXTREMITY \nNo evidence of deep venous thrombosis in the right lower \nextremity veins.\n\n===============\nDISCHARGE LABS:\n===============\n\n___ 05:32AM BLOOD WBC-9.9 RBC-3.73* Hgb-8.6* Hct-29.2* \nMCV-78* MCH-23.1* MCHC-29.5* RDW-17.6* RDWSD-49.9* Plt ___\n___ 05:32AM BLOOD Glucose-139* UreaN-10 Creat-0.6 Na-142 \nK-4.6 Cl-101 HCO3-28 AnGap-13\n___ 05:32AM BLOOD Calcium-9.3 Phos-5.0* Mg-1.___ year old female with past medical history of type 2 diabetes, \natrial fibrillation, diverticulosis status post ___ \nProcedure with subsequent colostomy take down complicated by \nventral hernia, subsequently requiring several attempted ventral \nhernia repairs, most recently status post split thickness skin\ngraft over exposed mesh and closure of enterocutaneous fistula \n___ admitted ___ with DKA, abdominal wall fluid \ncollection and recurrence of enterocutaneous fistula, status \npost resolution of DKA with insulin drip, treated with \nantibiotics and basal bolus insulin regimen, clinically \nimproving and able to be discharged home\n\n# Abdominal wall abscess\n# Enterocutaneous fistula\nPresented with three days of weakness, abdominal pain, and \nincreased drainage from chronic abdominal wound, with CT showing \nevidence of fluid collection at site of ventral hernia repair. \nUnderwent debridement and ___ drain x2 placement with \ngeneral surgery in the ED. Repeat CT abdomen/pelvis with near \nresolution of fluid collection and findings consistent with \nenterocutaneous fistula. Initially started on vancomycin/Zosyn \nwhile culture data was pending, per ID. Cultures returned \npositive for S. anginosus and polymicrobial infection. Per ID \nservice, patient was transitioned to Augmentin 875mg BID on \n___ with continued clinical improvement in pain. Based on \nimaging and exam, unclear if known abdominal mesh could be \ninfected. Per ID, reasonable plan to continue Augmentin for ___ \nweeks for soft tissue infection pending repeat surgical \nassessment and decision regarding potential operative \nintervention. Patient will follow-up with ACS as an outpatient. \nWound care nursing evaluated patient during admission and \ncounseled patient regarding management of her enterocutaneous \nfistula.\n\n# Type II diabetes mellitus with DKA \nPatient with poorly controlled DM as an outpatient requiring \nrecent initiation of insulin, with which patient has not been \ncompliant, who presented to ___ with blood glucose \n>700 and anion gap of 17. Initially admitted to MICU for insulin \ndrip, before transitioning to subcutaneous insulin per ___ \nrecs. C-peptide 1.4 with associated glucose of 156. Anti-insulin \nand anti-GAD antibodies negative. Subcutaneous insulin regimen \nwas titrated to achieve better glucose control. Patient was \nevaluated by the diabetic educator and given teaching regarding \ninsulin administration and diabetes management. Patient will be \nfollowed closely by ___ following discharge to assess ongoing \nmanagement. Discharge insulin regimen: insulin glargine 28 units \nQAM and 34 units QPM, and insulin Humalog 18 units with meals. \nInsulin sliding scale was discontinued at discharge as patient \nwas not able to demonstrate safe use of same with the diabetic \neducator. Home glipizide and sitagliptin held at the time of \ndischarge. Can be considered for additional agents at ___ \nfollow-up. Continued home atorvastatin 20mg QHS for primary \nprevention. \n\n# Diarrhea\nPatient reported multiple episodes of liquid stools upon \nadmission to ___, however this resolved over the course of \nhospitalization. Baseline frequency of bowel movements is one \nevery three days. CT abdomen/pelvis with bowel wall thickening \nand submucosa edema was concerning for developing enteritis, \nwith evidence of diarrhea in the GI tract, however given \nimprovement in symptoms, no further intervention was required. \nCan consider repeat CT scan in ___ week to look for resolution. \n\n# Zinc deficiency\nZinc level returned marginally low at 58. Patient was started on \nzinc 220mg daily for 14 days. Will need repeat level checked \nfollowing completion of course. \n\n# Paroxysmal Atrial fibrillation\nContinued home diltiazem, fractionated to 30mg Q6H, which was \nconsolidated at the time of discharge. Aspirin 81mg daily was \ncontinued. Notably patient not on anticoagulation. Would \nconsider outpatient risk/benefit discussion regarding \nanticoagulation, given elevated CHADS2VASc. \n\n# Hypertension\nContinued home diltiazem as above.\n\n# Anxiety\nContinued clonidine 0.2mg TID:PRN.\n\n====================\nTRANSITIONAL ISSUES:\n====================\n\n[] ENTEROCUTANEOUS FISTULA: follow-up with ACS to determine \nfinalized plan for management of same\n[] ANTIBIOTICS: Augmentin is to continue until finalized \nsurgical plan is put in place\n[] DM: follow-up with ___ on ___\n[] ZINC DEFICIENCY: patient needs repeat zinc level check upon \ncompletion of zinc therapy\n[] AF: elevated CHADS2VASC; discussion should be had re: \ninitiation of anticoagulation as an outpatient \n\n===============================================\n# CODE: Full\n# CONTACT: ___, mother, ___\n\n> 30 minutes spent on discharge\n\n \nMedications on Admission:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Atorvastatin 20 mg PO QPM \n3. CloNIDine 0.2 mg PO TID:PRN Anxiety \n4. Diltiazem Extended-Release 120 mg PO DAILY \n5. GlipiZIDE 10 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. SITagliptin 100 mg oral DAILY \n8. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheeze \n9. Aspirin 81 mg PO DAILY \n10. Cyclobenzaprine 10 mg PO TID:PRN Back pain \n11. Glargine 30 Units Bedtime\n12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \n2 puffs once daily \n13. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \n2. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days \n3. Glargine 28 Units Breakfast\nGlargine 34 Units Bedtime\nHumalog 18 Units Breakfast\nHumalog 18 Units Lunch\nHumalog 18 Units Dinner \n4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n5. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheeze \n6. Aspirin 81 mg PO DAILY \n7. Atorvastatin 20 mg PO QPM \n8. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID \n9. CloNIDine 0.2 mg PO TID:PRN Anxiety \n10. Cyclobenzaprine 10 mg PO TID:PRN Back pain \n11. Diltiazem Extended-Release 120 mg PO DAILY \n12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation \ninhalation 2 puffs once daily \n13. Omeprazole 20 mg PO DAILY \n14. HELD- GlipiZIDE 10 mg PO DAILY This medication was held. Do \nnot restart GlipiZIDE until informed by ___\n15. HELD- SITagliptin 100 mg oral DAILY This medication was \nheld. Do not restart SITagliptin until informed by ___\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n# Intra-abdominal infection/abscess\n# Enterocutaneous fistula\n# Possible mesh infection\n# Possible diabetic ketoacidosis\n# Type II diabetes mellitus \n# Atrial fibrillation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nWHY YOU CAME TO THE HOSPITAL?\nYou were transferred to ___ for management of your elevated \nblood sugars and abdominal wound\n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?\n- Your blood sugars were initially managed with an insulin drip, \nbefore transitioning to insulin injections as they improved\n- Our surgeons drained the fluid collection in your abdomen and \nplaced two drains to help prevent the fluid from re-accumulating \n\n- Repeat imaging showed resolution of the collection\n- Our infectious disease doctors helped decide the antibiotics \nyou required\n- You will follow-up with the surgeons as an outpatient\n- Our diabetes doctors helped change the dose of your insulin to \ngain better control of your blood sugars\n\nWHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?\n- Please follow-up with your outpatient doctors as arranged\n- ___ is important you take all of your medications as prescribed\n\nIt was a pleasure taking care of you!\n\nYour ___ Healthcare Team\n \nFollowup Instructions:\n___\n" ]

[ "T8141XA", "E1110", "K632", "D682", "L02211", "T83728A", "Y838", "Y929", "I10", "J449", "Z794", "Z87891", "Z9114", "I480", "F419", "E876", "B954", "E60", "R197" ]

[ "T8141XA: Infection following a procedure, superficial incisional surgical site, initial encounter", "E1110: Type 2 diabetes mellitus with ketoacidosis without coma", "K632: Fistula of intestine", "D682: Hereditary deficiency of other clotting factors", "L02211: Cutaneous abscess of abdominal wall", "T83728A: Exposure of other implanted mesh into organ or tissue, initial encounter", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "I10: Essential (primary) hypertension", "J449: Chronic obstructive pulmonary disease, unspecified", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence", "Z9114: Patient's other noncompliance with medication regimen", "I480: Paroxysmal atrial fibrillation", "F419: Anxiety disorder, unspecified", "E876: Hypokalemia", "B954: Other streptococcus as the cause of diseases classified elsewhere", "E60: Dietary zinc deficiency", "R197: Diarrhea, unspecified" ]

[ "Y929", "I10", "J449", "Z794", "Z87891", "I480", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nLamictal / hydrochlorothiazide\n \nAttending: ___.\n \nChief Complaint:\nEnterocutaneous/enteroatmospheric fistula\n \nMajor Surgical or Invasive Procedure:\n___:\n\n1. Split-thickness skin graft, left and right thigh to \nabdominal bowel site and closure of intestinal fistula.\n2. VAC sponge 20 x 15 cm.\n\n \nHistory of Present Illness:\nMs. ___ is a ___ F w/hx of Afib on diltizaem, Factor V not \non anticoagulation, diverticulosis, HTN, COPD and DMII who \npresents with abdominal pain and an abdominal wound site with \nexposed mesh. She reports a complex surgical history including \nlaparoscopic cholecystectomy in ___ followed by ___ \nProcedure for diverticulitis ___ with colostomy take down \n___. After this procedure she states she developed a large \nventral hernia and underwent open VHR with cadaveric underlay \nmesh and prolene overlay mesh ___ c/b skin dehiscence \nbeginning in ___ and progressing until today, despite \nmultiple debridements at ___ and the use of a \nwound vac, which was last used 2 mo ago.\n\nShe presents to the ED for follow up of her ventral hernia since \nthe wound continues to expand and has become more painful. 3 \nweeks ago, Ms. ___ developed pain at the RUQ of the wound \nthat has since progressed and intermittent nausea without \nvomiting. This morning at 7 am she changed her dressings and \nnoticed brown, foul-smelling staining in the middle of the mesh\nand a \"nipple-like\" protrusion that resolved. At 8pm in the ED, \nher 12x17 cm open wound with visible mesh currently had more \nbrown staining than this morning. When she pressed on the edges \nof her wound, which is tender and erythematous \ncircumferentially, pus drained out at the 10 o'clock position. \nShe was given dilute barium contrast PO for a CT +IV +oral \ncontrast; CTAP was not read as showing enterocutaneous fistula. \nHowever, after drinking the contrast the patient began to leak \nfeculent material that appeared to be succus mixed with \ncontrast.\n.\nShe smokes recreational marijuana which help curb the nausea, \nwhich allows her to eat. She is passing flatus and has regular \nBM, though she notes her stools are hard and she has felt \nconstipated since her last hernia repair (___). She is \nafraid to strain while going to the bathroom because of the \npressure it puts on her hernia. She has not had any fevers, \nchills, diarrhea, constipation different from baseline, SOB, \nchest pain, or urinary symptoms.\n.\n \nPast Medical History:\nPMH\na fib on diltiazem\nFactor V Leiden deficiency\ndiverticulosis (with diverticulitis episodes)\nSBO (___)\ngallstones\nHTN\nCOPD\nanxiety\nsciatica\nscoliosis\nvaricose veins\nDMII\n\nPSH\ncholecystectomy ___, ___\numbilical hernia repair ___, ___\nLeft ventral hernia c/b SBO s/p colostomy (___)\ncolostomy reversal ___, ___\nventral hernia repair w/ mesh ___, ___\nventral hernia repair, debridement ___, ___)\n\n \nSocial History:\n___\nFamily History:\n- both parents and multiple siblings have DVTs ___ Factor V \nLeiden deficiency\n\n \nPhysical Exam:\nDischarge Physical Exam:\nVS: T: 98.1 PO BP: 110/74 R Sitting HR: 81 RR: 18 O2: 96% Ra \nGEN: A+Ox3, NAD\nHEENT: normocephalic, atraumatic\nCV: RRR\nPULM: CTA b/l\nABD: soft, non-distended. Area of wound with skin graft about \n14x16 cm, skin graft approximately 90% taken, left and right \nedges still not taken up skin graft, but edges beginning to scar \ndown. \nEXT: wwp, no edema b/l. B/l thigh donor sites OTA, healing w/ \nno s/s infection \n\n \nPertinent Results:\nADMISSION LABS:\n\n___ 06:04PM BLOOD WBC-9.5 RBC-4.08 Hgb-9.9* Hct-32.3* \nMCV-79* MCH-24.3* MCHC-30.7* RDW-15.8* RDWSD-45.4 Plt ___\n___ 06:04PM BLOOD Neuts-46.9 ___ Monos-14.4* \nEos-2.5 Baso-0.6 Im ___ AbsNeut-4.47 AbsLymp-3.35 \nAbsMono-1.37* AbsEos-0.24 AbsBaso-0.06\n___ 06:04PM BLOOD ___ PTT-28.4 ___\n___ 06:04PM BLOOD Glucose-152* UreaN-11 Creat-0.7 Na-136 \nK-4.7 Cl-98 HCO3-24 AnGap-14\n\nIMAGING:\n\n___: CT Abdomen/Pelvis:\n\n1. No enterocutaneous fistula or small-bowel obstruction \nidentified. \n2. Open anterior abdominal wall wound measuring up to 14.5 x \n16.1 cm with \nmoderate soft tissue thickening along the lateral borders. \nSmall focus of \nsubcutaneous air tracking along the right superior border \nsuggests increasing wound extension. \n\n___: Abdominal x-ray:\nNo enterocutaneous fistula demonstrated radiographically. \nConsider a \nfistulogram for this purpose. \n\n___: Dx Portable PICC:\nRight PICC in the mid SVC. No acute cardiopulmonary process.\n\n___: Abdominal x-ray:\nNo acute abnormality with nonobstructive bowel gas pattern. \nInterval \nplacement of wound VAC which projects over the mid abdomen. \n\n___: CXR:\nNo acute cardiopulmonary process.\n\n___ 10:16 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\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:\nMs. ___ is a ___ year old female with a history of multiple \nprior abdominal surgeries most recently a ventral hernia repair \nat ___ (___) who presented to ___ \n___ on ___ with an open abdominal wound, \nexposed mesh, and a low output entero-atmospheric fistula. She \nwas admitted to the Acute Care Surgery Service for further \nmanagement. \n\nThe patient was kept NPO and initiated on TPN. She was started \non octreotide for a short time period to help reduce fistula \noutput. Plastic surgery was consulted to evaluate the patient in \npreparation for eventual abdominal wall reconstruction and \noffered to be available to assist with surgery when needed. \nWound care nursing was also asked to assist with optimizing the \npatient's abdominal dressing, and a large wound manager was \napplied and placed to wall suction with good result. \n\nOn ___, the patient was taken to the operating room and \nunderwent an abdominal skin graft with anterior bilateral thigh \ndonor sites. For details of the procedure, please see the \nsurgeon's operative note. The patient tolerated the procedure \nwell without complication and was taken to the post anesthesia \ncare unit in stable condition. \n\nThe patient was placed on bedrest precautions and then activity \nrestrictions were liberalized and the patient ambulated. ___ \nwas d/c'd and she voided appropriately. She was started on a \nregular diet which she tolerated and TPN was d/c'd. WBC was \nelevated on POD #3 and so PICC was d/c'd a fever work-up was \nsent and urine culture was positive for e.coli (sensitive to \ncipro). She was started on a 7 day course of cipro and WBC \nnormalized. \n\nThe patient's skin graft took approximately 90%. Non-adherent \ndressing were placed over the wound while ambulating and left \nopen to the air for periods of time while in bed to let the \ngraft dry. \n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home with ___ services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n \nMedications on Admission:\nacetaminophen PRN\nalbuterol (proair)\naspirin 81\natorvastatin 20\nsuboxone\nClonidine 0.2 TID\nDiltiazem 120mg 24 hour capsule\nColace\nFlonase\nGlipizide\nIbuprofen\nMetformin 500mg daily\nomeprazole 20mg daily\ntrazodone 50mg daily\numeclidinium 62.6 mcg/actuation\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Ciprofloxacin HCl 250 mg PO Q12H \nClosely monitor your blood sugars to assess for low blood sugar \nwhile taking this medication \nRX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*9 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nHold for loose stool \n4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate \n Reason for PRN duplicate override: d/c oxycodone\nTake lowest effective dose. Patient may request partial fill. \nRX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) \nhours Disp #*20 Tablet Refills:*0 \n5. Atorvastatin 20 mg PO QPM \n6. CloNIDine 0.2 mg PO TID \n7. Diltiazem Extended-Release 120 mg PO DAILY \n8. Fluticasone Propionate NASAL 1 SPRY NU DAILY PRN \n9. GlipiZIDE 5 mg PO DAILY \n10. MetFORMIN (Glucophage) 500 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Topiramate (Topamax) 50 mg PO BID \n13. TraZODone 50 mg PO QHS:PRN PRN \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nGiant abdominal hernia with exposed bowel and intestinal \nfistula.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ with a \nlarge abdominal hernia after multiple prior surgeries. You had \na fistula (an abnormal connection between the bowel and the \nskin) from the wound. You were initially placed on TPN to \nreceive nutrition. You were later taken to the operating room \nand you underwent skin grafting from your thighs to your \nabdominal wound to protect the exposed bowel to prevent another \nfistula and also to close\nthe current fistula. You tolerated this procedure well and your \ngraft has mostly taken. You are now tolerating a regular diet, \nlow residue diet. You were found to have a urinary tract \ninfection and were started on a 1 (one) week course of an \nantibiotic, called ciprofloxacin. You will have a nurse visit \nyou at home to check up on you to evaluate your wound and also \nhelp with your dressing changes. You are ready to be discharged \nhome 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\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 \n \nFollowup Instructions:\n___\n" ]

[ "T8131XA", "T8183XA", "K632", "D6851", "N390", "Y838", "Y92018", "I480", "I10", "J449", "E119", "Z7984", "F1290", "F419", "M5430", "M419", "I8390", "Z9049", "Z87891", "B9620", "Z1611", "I9581" ]

[ "T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter", "T8183XA: Persistent postprocedural fistula, initial encounter", "K632: Fistula of intestine", "D6851: Activated protein C resistance", "N390: Urinary tract infection, site not specified", "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", "I480: Paroxysmal atrial fibrillation", "I10: Essential (primary) hypertension", "J449: Chronic obstructive pulmonary disease, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z7984: Long term (current) use of oral hypoglycemic drugs", "F1290: Cannabis use, unspecified, uncomplicated", "F419: Anxiety disorder, unspecified", "M5430: Sciatica, unspecified side", "M419: Scoliosis, unspecified", "I8390: Asymptomatic varicose veins of unspecified lower extremity", "Z9049: Acquired absence of other specified parts of digestive tract", "Z87891: Personal history of nicotine dependence", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z1611: Resistance to penicillins", "I9581: Postprocedural hypotension" ]

[ "N390", "I480", "I10", "J449", "E119", "F419", "Z87891" ]

[]