Split (1)

train · 122k rows

text stringlengths 1.04k 60k
The icd codes present in this text will be G3183, F0280, R441, R296, E785, Z8546. The descriptions of icd codes G3183, F0280, R441, R296, E785, Z8546 are G3183: Dementia with Lewy bodies; F0280: Dementia in other diseases classified elsewhere without behavioral disturbance; R441: Visual hallucinations; R296: Repeated falls; E785: Hyperlipidemia, unspecified; Z8546: Personal history of malignant neoplasm of prostate. The common codes which frequently come are E785. The uncommon codes mentioned in this dataset are G3183, F0280, R441, R296, Z8546. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Visual hallucinations Major Surgical or Invasive Procedure N A History of Present Illness ___ male with ___ disease dyslipidemia and a history of prostate cancer s p prostatectomy who was referred to the ED by his neurologist for worsening gait falls and visual hallucinations. The following history is taken from chart review The patient was seen by his neurologist on ___ at which time he was noted to have visual hallucinations and worsening gait freezing. For his gait freezing his mirapex was increased by 0.125 mg every week to a goal dose of 0.75 mg t.i.d. He successfully up titrated the medicine to 0.75 0.625 0.625 but began to have visual hallucinations and confusion so on ___ his neurologist recommended decreasing the dose to 0.625 TID. Despite the changes to his Mirapex the patient s daughter has noted progressive gait stiffness and increased difficulty standing. This has resulted in difficulty with simply getting to the bathroom leading to episodes of incontinence. A UA performed on ___ was reassuring. On the day of presentation to the hospital the patient began to experience visual hallucinations of a motor cross race in his backyard. He subsequently had a fall while transferring from the couch to a chair. His wife was unable to get him off the floor. The fall was witnessed and there was no head strike. Per the patient s wife his gait has acutely worsened over the past 24 hours to the point where he has been unable to ambulate on his own. The patient s daughter called his neurologist who recommended presentation to the ED. In the ED the patient was afebrile HRs ___ normotensive and SpO2 100 RA. On exam he was noted to have cogwheeling of upper extremities and decrease ___ strength. Labs were remarkable for a negative urine and serum tox Na 132 K 5.8 hemolyzed and no EKG changes negative troponin normal LFTs unremarkable CBC. Chest Xray showed no acute process and CTH was reassuring. He was evaluated by neurology who recommended admission to medicine for failure to thrive to continue the patient s home medications and complete a toxo metabolic workup. The patient was given his home pramipexole and pravastatin before he was admitted. On arrival to the floor the patient is comfortable in bed. He is not accompanied by family on my interview. He knows that he is in the hospital and that it is ___. He is not sure why he is here and begins to tell me about a party in his house with a motor cross race in his backyard. When I asked him about his fall he mentions that he has not had a fall for ___ years. He denies any fevers chills cough chest pain abdominal pain nausea diarrhea or dysuria. REVIEW OF SYSTEMS Per HPI otherwise 10 point review of systems was within normal limits. Past Medical History ___ disease ___ Body Dementia dyslipidemia prostate cancer s p prostatectomy Social History ___ Family History His mother died at age ___ of old age. His father died of prostate cancer at ___. He has an older sister age ___ and a younger sister age ___. He has a younger brother age ___. As noted he has 2 daughters. There is no family history of neurologic illness or dementia. There is no family history of neurodevelopmental mental disorders such as learning disability or ADHD. There is no family history of psychiatric problems. Physical Exam ADMISSION PHYSICAL EXAM VITALS reviewed in OMR GENERAL Alert and interactive. In no acute distress. HEENT PERRL EOMI. Sclera anicteric and without injection. MMM. NECK No cervical lymphadenopathy. No JVD. CARDIAC Regular rhythm normal rate. Audible S1 and S2. No murmurs rubs gallops. LUNGS Clear to auscultation bilaterally. No wheezes rhonchi or rales. No increased work of breathing. BACK No CVA tenderness. ABDOMEN Normal bowels sounds non distended non tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES No clubbing cyanosis or edema. Pulses DP Radial 2 bilaterally. SKIN Warm. Cap refill 2s. No rashes. NEUROLOGIC AOx3. CN2 12 intact. cogwheel UE b l. Increased tone in LEs ___ strength b l ___. Normal sensation. DISCHARGE PHYSICAL EXAM 24 HR Data last updated ___ 2340 Temp 97.7 Tm 98.4 BP 130 80 130 153 80 90 HR 80 80 104 RR 18 ___ O2 sat 100 95 100 O2 delivery Ra GENERAL In no acute distress. Talking very quietly. CARDIAC Regular rhythm normal rate. Audible S1 and S2. No murmurs rubs gallops. LUNGS Clear to auscultation bilaterally. No wheezes rhonchi or rales. No increased work of breathing. ABDOMEN Normal bowels sounds non distended non tender to deep palpation in all four quadrants. EXTREMITIES No clubbing cyanosis or edema. Pulses DP Radial 2 bilaterally. SKIN Warm. NEUROLOGIC AOx3. CN2 12 intact. cogwheel UE b l. Increased tone in LEs ___ strength b l ___. Normal sensation. Pertinent Results ADMISSION LABS ___ 10 30PM BLOOD WBC 8.6 RBC 4.03 Hgb 12.8 Hct 38.2 MCV 95 MCH 31.8 MCHC 33.5 RDW 13.0 RDWSD 45.2 Plt ___ ___ 10 30PM BLOOD Neuts 48.1 ___ Monos 15.9 Eos 2.0 Baso 0.6 Im ___ AbsNeut 4.13 AbsLymp 2.86 AbsMono 1.36 AbsEos 0.17 AbsBaso 0.05 ___ 10 30PM BLOOD ___ PTT 23.4 ___ ___ 10 30PM BLOOD Glucose 100 UreaN 17 Creat 0.8 Na 132 K 5.8 Cl 98 HCO3 19 AnGap 15 ___ 10 30PM BLOOD ALT 18 AST 38 AlkPhos 39 TotBili 0.4 ___ 10 30PM BLOOD Lipase 47 ___ 10 30PM BLOOD cTropnT 0.01 ___ 10 30PM BLOOD Albumin 4.0 Calcium 9.9 Phos 3.7 Mg 2.0 ___ 10 30PM BLOOD VitB12 570 ___ 10 30PM BLOOD TSH 1.4 ___ 07 00AM BLOOD Trep Ab NEG ___ 10 30PM BLOOD ASA NEG Ethanol NEG Acetmnp NEG Tricycl NEG IMAGING ___ Imaging CT HEAD W O CONTRAST FINDINGS There is no evidence of infarction hemorrhage edema or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the remaining paranasal sinuses and middle ear cavities are clear. The visualized portion of the orbits are unremarkable apart from bilateral lens replacements. IMPRESSION 1. No acute intracranial abnormality. No hydrocephalus. ___ Imaging CHEST PA LAT IMPRESSION Mild atelectasis in the lung bases without focal consolidation. Age indeterminate moderate to severe compression deformity of a low thoracic vertebral body. DISCHARGE LABS ___ 06 21AM BLOOD WBC 7.0 RBC 4.02 Hgb 12.9 Hct 38.1 MCV 95 MCH 32.1 MCHC 33.9 RDW 12.8 RDWSD 44.4 Plt ___ ___ 06 21AM BLOOD Glucose 88 UreaN 10 Creat 0.7 Na 140 K 4.0 Cl 104 HCO3 24 AnGap 12 ___ 06 21AM BLOOD Calcium 9.5 Phos 3.2 Mg 1.___ male with ___ disease dyslipidemia and a history of prostate cancer s p prostatectomy who was referred to the ED by his neurologist for worsening gait falls and visual hallucinations concerning for progression of his neurologic disorder. ACUTE ACTIVE ISSUES ___ disease ___ Body Dementia Visual Hallucinations The patient appears to have acute on chronic progression of his ___ disease. Unclear if this is disease progression or underlying medical cause. Continued mirapex rasagiline and rivastigmine. Neurology recommended started Seroquel for his hallucinations. He was evaluated by physical therapy who recommended rehab. This recommendation was discussed with the family who opted for discharge to home with home physical therapy as this was in line with the patient s goals of care. TRANSITIONAL ISSUES f u visual hallucination symptoms on Seroquel f u physical therapy at home Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Rasagiline 1 mg PO DAILY 2. Pramipexole 0.625 mg PO TID 3. rivastigmine 9.5 mg 24 hr transdermal DAILY 4. Pravastatin 40 mg PO QPM 5. Cyanocobalamin Dose is Unknown PO DAILY 6. Loratadine 10 mg PO DAILY Discharge Medications 1. QUEtiapine Fumarate 25 mg PO QHS RX quetiapine 25 mg 1 tablet s by mouth AT NIGHT Disp 30 Tablet Refills 0 2. Loratadine 10 mg PO DAILY 3. Pramipexole 0.625 mg PO TID 4. Pravastatin 40 mg PO QPM 5. Rasagiline 1 mg PO DAILY 6. rivastigmine 9.5 mg 24 hr transdermal DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis ___ Dementia Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Discharge Instructions Dear Mr. ___ It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL You were sent to the emergency room by your neurologist who was concerned that you were having visual hallucinations. WHAT HAPPENED TO ME IN THE HOSPITAL You were started on a new medication to help treat your symptoms. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL Continue to take all your medicines and keep your appointments. We wish you the best Sincerely Your ___ Team Followup Instructions ___ The icd codes present in this text will be G3183, F0280, R441, R296, E785, Z8546. The descriptions of icd codes G3183, F0280, R441, R296, E785, Z8546 are G3183: Dementia with Lewy bodies; F0280: Dementia in other diseases classified elsewhere without behavioral disturbance; R441: Visual hallucinations; R296: Repeated falls; E785: Hyperlipidemia, unspecified; Z8546: Personal history of malignant neoplasm of prostate. The common codes which frequently come are E785. The uncommon codes mentioned in this dataset are G3183, F0280, R441, R296, Z8546.
The icd codes present in this text will be R1310, R0989, K31819, K219, K449, F419, I341, M810, Z87891. The descriptions of icd codes R1310, R0989, K31819, K219, K449, F419, I341, M810, Z87891 are R1310: Dysphagia, unspecified; R0989: Other specified symptoms and signs involving the circulatory and respiratory systems; K31819: Angiodysplasia of stomach and duodenum without bleeding; K219: Gastro-esophageal reflux disease without esophagitis; K449: Diaphragmatic hernia without obstruction or gangrene; F419: Anxiety disorder, unspecified; I341: Nonrheumatic mitral (valve) prolapse; M810: Age-related osteoporosis without current pathological fracture; Z87891: Personal history of nicotine dependence. The common codes which frequently come are K219, F419, Z87891. The uncommon codes mentioned in this dataset are R1310, R0989, K31819, K449, I341, M810. Allergies omeprazole Chief Complaint dysphagia Major Surgical or Invasive Procedure Upper endoscopy ___ History of Present Illness ___ w anxiety and several years of dysphagia who p w worsened foreign body sensation. She describes feeling as though food gets stuck in her neck when she eats. She put herself on a pureed diet to address this over the last 10 days. When she has food stuck in the throat she almost feels as though she cannot breath but she denies trouble breathing at any other time. She does not have any history of food allergies or skin rashes. In the ED initial vitals 97.6 81 148 83 16 100 RA Imaging showed CXR showed a prominent esophagus Consults GI was consulted. Pt underwent EGD which showed a normal appearing esophagus. Biopsies were taken. Currently she endorses anxiety about eating. She would like to try eating here prior to leaving the hospital. Past Medical History GERD Hypercholesterolemia Kidney stones Mitral valve prolapse Uterine fibroids Osteoporosis Migraine headaches Social History ___ Family History HTN father Dementia father Physical Exam ADMISSION DISCHARGE EXAM VS 97.9 PO 109 71 70 16 97 ra GEN Thin anxious woman lying in bed no acute distress HEENT Moist MM anicteric sclerae NCAT PERRL EOMI NECK Supple without LAD no JVD PULM CTABL no w c r COR RRR S1 S2 no m r g ABD Soft non tender non distended BS no HSM EXTREM Warm well perfused no ___ edema NEURO CN II XII grossly intact motor function grossly normal sensation grossly intact Pertinent Results ADMISSION LABS ___ 08 27AM BLOOD WBC 5.0 RBC 4.82 Hgb 14.9 Hct 44.4 MCV 92 MCH 30.9 MCHC 33.6 RDW 12.1 RDWSD 41.3 Plt ___ ___ 08 27AM BLOOD ___ PTT 28.6 ___ ___ 08 27AM BLOOD Glucose 85 UreaN 8 Creat 0.9 Na 142 K 3.6 Cl 104 HCO3 22 AnGap 20 ___ 08 27AM BLOOD ALT 11 AST 16 LD LDH 154 AlkPhos 63 TotBili 1.0 ___ 08 27AM BLOOD Albumin 4.8 IMAGING CXR ___ IMPRESSION Prominent esophagus on lateral view without air fluid level. Given the patient s history and radiographic appearance barium swallow is indicated either now or electively. NECK X ray ___ IMPRESSION Within the limitation of plain radiography no evidence of prevertebral soft tissue swelling or soft tissue mass in the neck. EGD ___ Impression Hiatal hernia Angioectasia in the stomach Angioectasia in the duodenum biopsy biopsy Otherwise normal EGD to third part of the duodenum Recommendations no obvious anatomic cause for the patient s symptoms follow up biopsy results to rule out eosinophilic esophagitis follow up with Dr. ___ if biopsies show eosinophilic esophagitis Brief Hospital Course Ms. ___ is a ___ with history of GERD who presents with subacute worsening of dysphagia and foreign body sensation. This had worsened to the point where she placed herself on a pureed diet for the last 10 days. She underwent CXR which showed a prominent esophagus but was otherwise normal. She was evaluated by Gastroenterology and underwent an upper endoscopy on ___. This showed a normal appearing esophagus. Biopsies were taken. TRANSITIONAL ISSUES f u biopsies from EGD if results show eosinophilic esophagitis follow up with Dr. ___. ___ for management pt should undergo barium swallow as an outpatient for further workup of her dysphagia f u with ENT as planned Code Full presumed Medications on Admission The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO BID Discharge Medications 1. Omeprazole 20 mg PO BID Discharge Disposition Home Discharge Diagnosis PRIMARY DIAGNOSIS dysphagia and foreign body sensation SECONDARY DIAGNOSIS GERD Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were hospitalized at ___. You came in due to difficulty swallowing. You had an endoscopy to look for any abnormalities in the esophagus. Thankfully this was normal. They took biopsies and you will be called with the results. You should have a test called a barium swallow as an outpatient. We wish you all the best Your ___ Team Followup Instructions ___ The icd codes present in this text will be R1310, R0989, K31819, K219, K449, F419, I341, M810, Z87891. The descriptions of icd codes R1310, R0989, K31819, K219, K449, F419, I341, M810, Z87891 are R1310: Dysphagia, unspecified; R0989: Other specified symptoms and signs involving the circulatory and respiratory systems; K31819: Angiodysplasia of stomach and duodenum without bleeding; K219: Gastro-esophageal reflux disease without esophagitis; K449: Diaphragmatic hernia without obstruction or gangrene; F419: Anxiety disorder, unspecified; I341: Nonrheumatic mitral (valve) prolapse; M810: Age-related osteoporosis without current pathological fracture; Z87891: Personal history of nicotine dependence. The common codes which frequently come are K219, F419, Z87891. The uncommon codes mentioned in this dataset are R1310, R0989, K31819, K449, I341, M810.
The icd codes present in this text will be S72012A, W010XXA, Y93K1, Y92480, K219, E7800, I341, G43909, Z87891, Z87442, F419, M810, Z7901. The descriptions of icd codes S72012A, W010XXA, Y93K1, Y92480, K219, E7800, I341, G43909, Z87891, Z87442, F419, M810, Z7901 are S72012A: Unspecified intracapsular fracture of left femur, initial encounter for closed fracture; W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter; Y93K1: Activity, walking an animal; Y92480: Sidewalk as the place of occurrence of the external cause; K219: Gastro-esophageal reflux disease without esophagitis; E7800: Pure hypercholesterolemia, unspecified; I341: Nonrheumatic mitral (valve) prolapse; G43909: Migraine, unspecified, not intractable, without status migrainosus; Z87891: Personal history of nicotine dependence; Z87442: Personal history of urinary calculi; F419: Anxiety disorder, unspecified; M810: Age-related osteoporosis without current pathological fracture; Z7901: Long term (current) use of anticoagulants. The common codes which frequently come are K219, Z87891, F419, Z7901. The uncommon codes mentioned in this dataset are S72012A, W010XXA, Y93K1, Y92480, E7800, I341, G43909, Z87442, M810. Allergies omeprazole Iodine and Iodide Containing Products hallucinogens Chief Complaint Left hip pain Major Surgical or Invasive Procedure Status post left CRPP ___ ___ History of Present Illness REASON FOR CONSULT Femur fracture HPI ___ female presents with the above fracture s p mechanical fall. This morning pt was walking ___ when dog pulled on leash. Pt fell on L hip. Immediate pain. ___ ___ with movement. Denies Head strike LOC or blood thinners. Denies numbness or weakness in the extremities. Past Medical History GERD Hypercholesterolemia Kidney stones Mitral valve prolapse Uterine fibroids Osteoporosis Migraine headaches Social History ___ Family History HTN father Dementia father Physical Exam General Well appearing female in no acute distress. Left Lower extremity Skin intact No deformity edema ecchymosis erythema induration Soft non tender thigh and leg Full painless ROM knee and ankle Fires ___ SILT S S SP DP T distributions 1 ___ pulses WWP Brief Hospital Course The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left valgus impacted femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left closed reduction and percutaneous pinning of hip which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications and progressed to a regular diet and oral medications by POD 1. The patient was given ___ antibiotics and anticoagulation per routine. The patient s home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient s pain was well controlled with oral medications incisions were clean dry intact and the patient was voiding moving bowels spontaneously. The patient is weightbearing as tolerated in the left lower extremity and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow up care. The patient expressed readiness for discharge. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lactaid lactase 3 000 unit oral DAILY PRN 2. Calcium Citrate D calcium citrate vitamin D3 315 200 mg unit oral DAILY Discharge Medications 1. Acetaminophen 1000 mg PO Q6H PRN Pain Mild Fever 2. Bisacodyl 10 mg PO PR DAILY PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS RX enoxaparin 40 mg 0.4 mL 40 mg Subcutaneously Nightly Disp 30 Syringe Refills 0 5. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth q4 PRN Disp 25 Tablet Refills 0 6. Senna 8.6 mg PO BID 7. Calcium Citrate D calcium citrate vitamin D3 315 200 mg unit oral DAILY 8. Lactaid lactase 3 000 unit oral DAILY PRN 9. Multivitamins 1 TAB PO DAILY 10. Vitamin D 400 UNIT PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Left valgus impacted femoral neck fracture Discharge Condition AVSS NAD A Ox3 LLE Incision well approximated. Dressing clean and dry. Fires FHL ___ TA GCS. SILT ___ n distributions. 1 DP pulse wwp distally. Discharge Instructions INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY You were in the hospital for orthopedic surgery. It is normal to feel tired or washed out after surgery and this feeling should improve over the first few days to week. Resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING Weightbearing as tolerated left lower extremity MEDICATIONS 1 Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2 Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down Take 1 tablet every 3 hours as needed x 1 day then 1 tablet every 4 hours as needed x 1 day then 1 tablet every 6 hours as needed x 1 day then 1 tablet every 8 hours as needed x 2 days then 1 tablet every 12 hours as needed x 1 day then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3 Do not stop the Tylenol until you are off of the narcotic medication. 4 Per state regulations we are limited in the amount of narcotics we can prescribe. If you require more you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5 Narcotic pain relievers can cause constipation so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds senna colace miralax are over the counter and may be obtained at any pharmacy. 6 Do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers. 7 Please take all medications as prescribed by your physicians at discharge. 8 Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION Please take Lovenox daily for 4 weeks Followup Instructions ___ The icd codes present in this text will be S72012A, W010XXA, Y93K1, Y92480, K219, E7800, I341, G43909, Z87891, Z87442, F419, M810, Z7901. The descriptions of icd codes S72012A, W010XXA, Y93K1, Y92480, K219, E7800, I341, G43909, Z87891, Z87442, F419, M810, Z7901 are S72012A: Unspecified intracapsular fracture of left femur, initial encounter for closed fracture; W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter; Y93K1: Activity, walking an animal; Y92480: Sidewalk as the place of occurrence of the external cause; K219: Gastro-esophageal reflux disease without esophagitis; E7800: Pure hypercholesterolemia, unspecified; I341: Nonrheumatic mitral (valve) prolapse; G43909: Migraine, unspecified, not intractable, without status migrainosus; Z87891: Personal history of nicotine dependence; Z87442: Personal history of urinary calculi; F419: Anxiety disorder, unspecified; M810: Age-related osteoporosis without current pathological fracture; Z7901: Long term (current) use of anticoagulants. The common codes which frequently come are K219, Z87891, F419, Z7901. The uncommon codes mentioned in this dataset are S72012A, W010XXA, Y93K1, Y92480, E7800, I341, G43909, Z87442, M810.
The icd codes present in this text will be I130, I5033, E872, N184, E1122, N2581, I2510, E11319, D6489, E785, Z955, Z86718, I252, Z2239, G4700, M1A9XX0, R0902, E1151, Z794, E669, Z6831. The descriptions of icd codes I130, I5033, E872, N184, E1122, N2581, I2510, E11319, D6489, E785, Z955, Z86718, I252, Z2239, G4700, M1A9XX0, R0902, E1151, Z794, E669, Z6831 are I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; I5033: Acute on chronic diastolic (congestive) heart failure; E872: Acidosis; N184: Chronic kidney disease, stage 4 (severe); E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; N2581: Secondary hyperparathyroidism of renal origin; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema; D6489: Other specified anemias; E785: Hyperlipidemia, unspecified; Z955: Presence of coronary angioplasty implant and graft; Z86718: Personal history of other venous thrombosis and embolism; I252: Old myocardial infarction; Z2239: Carrier of other specified bacterial diseases; G4700: Insomnia, unspecified; M1A9XX0: Chronic gout, unspecified, without tophus (tophi); R0902: Hypoxemia; E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene; Z794: Long term (current) use of insulin; E669: Obesity, unspecified; Z6831: Body mass index [BMI] 31.0-31.9, adult. The common codes which frequently come are I130, E872, E1122, I2510, E785, Z955, Z86718, I252, G4700, Z794, E669. The uncommon codes mentioned in this dataset are I5033, N184, N2581, E11319, D6489, Z2239, M1A9XX0, R0902, E1151, Z6831. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint shortness of breath Major Surgical or Invasive Procedure None History of Present Illness Patient is a ___ with history of coronary artery disease c b ischemic MR ___ DES to LCX ___ TTE ___ with mild regional LV systolic dysfunction heart failure with preserved ejection fraction LVEF 50 ___ peripheral vascular disease chronic kidney disease stage IV prior unprovoked DVT c b severe UGIB while on AC HTN dyslipidemia and T2DM who presents with several days of shortness of breath. Patients says that she first noticed rather acute onset dyspnea starting ___ when trying to walk up the stairs in her home. She had to sit down and catch her breath whereas just days prior she was able to mount ___ of stairs without difficulty. Patient denies any associated chest pain or palpitations. No dizziness or lightheadedness. Patient further denies any cough fevers chills or pleuritic chest discomfort. She has not experienced any symptoms consistent with orthopnea or PND. No increased ___ swelling patient notes that she has experienced this in the past. Patient takes her weight nearly every day 7lbs reported weight gain over the past week 154lbs 161lbs which she attributes to eating more over the ___. She is currently taking torsemide 40mg qd no missed doses. No issues with abdominal bloating or constipation. No recent travel. Patient s husband just recovered from a viral URI. In the ED initial VS were 97.2 90 186 87 22 100 RA Exam notable for Obvious bilateral wheezing. No overt volume overload. EKG NSR 92bpm normal axis normal PR QRS intervals QTc 479 q waves III aVF TWIs III aVF V3 V6 submm lateral STDs no STEs. Labs showed CBC 6.0 9.0 27.8 176 PMNs 75.2 MCV 97 BMP 142 4.8 105 ___ 2.4 189 Trop .01 proBNP 4512 VBG 7.33 40 UA 1.010 SG pH 6.0 urobilinogen NEG bilirubin NEG leuk NEG blood NEG nitrite NEG protein 100 glucose NEG ketones NEG RBC 1 WBC 1 few bacteria Imaging showed CXR ___ FINDINGS Lungs are moderately well expanded. There is an asymmetric right lower lung opacity new from ___. The heart appears mildly enlarged and there is mild pulmonary vascular congestion. No pleural effusion or pneumothorax. IMPRESSION Right lower lobe opacity could represent pneumonia in the right clinical setting although atelectasis or asymmetric pulmonary edema could account for this finding. Dedicated PA and lateral views could be helpful for further assessment. Consults NONE Patient received ___ 21 45 IH Albuterol 0.083 Neb Soln 1 NEB ___ 22 08 IH Albuterol 0.083 Neb Soln 1 NEB ___ 22 08 IH Ipratropium Bromide Neb 1 NEB ___ 22 47 IH Albuterol 0.083 Neb Soln 1 NEB ___ 22 47 IH Ipratropium Bromide Neb 1 NEB ___ 22 51 IV Azithromycin ___ 22 51 IV CefTRIAXone ___ 22 51 PO PredniSONE 60 mg ___ 22 51 IV Furosemide 80 mg ___ 23 01 IV CefTRIAXone 1 gm ___ 00 13 IV Azithromycin 500 mg ___ 00 23 PO NG Atorvastatin 80 mg ___ 00 23 PO NG Carvedilol 25 mg ___ 00 23 PO NIFEdipine Extended Release 60 mg ___ 00 23 IH Albuterol 0.083 Neb Soln 1 NEB ___ 00 23 IH Ipratropium Bromide Neb 1 NEB ___ 00 26 PO NG Gabapentin 100 mg ___ 00 44 SC Insulin 4 Units Transfer VS were 98.2 77 141 76 18 100 2L NC On arrival to the floor patient recounts the history as above. She says that she feels improved after treatment in the ED no ongoing SOB. 10 point ROS is otherwise NEGATIVE. Past Medical History Coronary artery disease Peripheral vascular disease Type II Diabetes Mellitus c b diabetic retinopathy Obesity Esophageal ring Hypertension Dyslipidemia Bilateral unprovoked posterior tibial DVTs ___ off AC given severe UGIB CKD Stage IV iso DM HTN secondary hyperparathyroidism Anemia Gout Social History ___ Family History Niece had some sort of cancer. Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam ADMISSION PHYSICAL EXAM VS 97.5 162 93 78 16 100RA GENERAL Pleasant female appearing younger than her stated age taking deep breaths while speaking HEENT EOMI PERRL anicteric sclera pink conjunctiva MMM. NECK JVD 10 CM. HEART RRR S1 S2 no murmurs gallops or rubs. LUNGS CTAB no wheezes. ABDOMEN Obese abdomen normoactive BS throughout nondistended nontender in all quadrants no rebound guarding no hepatosplenomegaly. EXTREMITIES No cyanosis clubbing or edema. PULSES 2 radial pulses bilaterally. NEURO A Ox3 moving all 4 extremities with purpose. SKIN Warm and well perfused no excoriations or lesions no rashes. DISCHARGE PHYSICAL EXAM VS Afeb 144 78 HR 57 97 RA RR 12 GEN Well appearing in NAD Neck No JVD appreciated CV RRR no m r g no carotid bruits appreciated PULM CTAB no wheezes rales or crackles. Symmetric expansion EXT warm well perfused no pitting edema Pertinent Results ADMISSION LABS ___ 09 37PM BLOOD WBC 6.0 RBC 2.88 Hgb 9.0 Hct 27.8 MCV 97 MCH 31.3 MCHC 32.4 RDW 15.1 RDWSD 52.0 Plt ___ ___ 09 37PM BLOOD Neuts 75.2 Lymphs 17.6 Monos 4.4 Eos 1.8 Baso 0.3 Im ___ AbsNeut 4.49 AbsLymp 1.05 AbsMono 0.26 AbsEos 0.11 AbsBaso 0.02 ___ 06 40AM BLOOD ___ PTT 25.9 ___ ___ 09 37PM BLOOD Glucose 189 UreaN 38 Creat 2.4 Na 142 K 4.8 Cl 105 HCO3 20 AnGap 17 ___ 09 37PM BLOOD proBNP 4512 ___ 09 37PM BLOOD cTropnT 0.01 ___ 06 40AM BLOOD CK MB 6 cTropnT 0.05 ___ 02 01PM BLOOD CK MB 5 cTropnT 0.04 ___ 09 37PM BLOOD Calcium 9.4 Phos 4.1 Mg 2.3 ___ 09 41PM BLOOD ___ pO2 30 pCO2 40 pH 7.33 calTCO2 22 Base XS 5 IMAGING TTE ___ The left atrial volume index is mildly increased. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal inferoseptal inferior inferolateral as well as mid inferior inferoseptal wall motion abnormalities. Doppler parameters are most consistent with Grade II moderate left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus ascending and arch levels are normal. The aortic valve leaflets 3 are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild 1 mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION 1 Mild regional LV systolic dysfunction c w prior myocardial infarction in the RCA territory. 2 Grade II LV diastolic dysfunction. Compared with the prior study images reviewed of ___ LV sytolic function appears mildly less vigorous. Regional wall motion abnormalities encompassess slightly greater territory. CXR PA LAT ___ No focal consolidation or pulmonary edema. BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND ___ 1. Nonocclusive thrombosis of one of the paired posterior tibial veins in the bilateral lower extremities which appears grossly unchanged compared to bilateral lower extremity ultrasound ___. No new deep venous thrombosis in either extremity. 2. Right ___ cyst measuring up to 1.8 cm across maximal diameter is unchanged in size compared to ___. MICROBIOLOGY URINE CULTURE ___ ENTEROCOCCUS SP.. 100 000 CFU mL. BLOOD CULTURE ___ Blood Culture PENDING BLOOD CULTURE ___ Blood Culture PENDING DISCHARGE LABS ___ 05 45AM BLOOD WBC 5.1 RBC 2.57 Hgb 7.9 Hct 24.5 MCV 95 MCH 30.7 MCHC 32.2 RDW 15.0 RDWSD 51.8 Plt ___ ___ 05 45AM BLOOD Glucose 144 UreaN 49 Creat 2.6 Na 147 K 4.0 Cl 105 HCO3 24 AnGap ___ yo F PMH CAD c b ischemic MR ___ DES to ___ ___ TTE ___ with mild regional LV systolic dysfunction HFpEF LVEF 50 ___ PAD CKD stage IV prior DVT c b severe UGIV on AC T2DM presents with subacute SOB weight gain c f acute heart failure exacerbation. She underwent diuresis with IV Lasix 80 mg 120mg IV x2 with rapid improvement in subjective dyspnea. ___ showed no acute DVT CXR without sign of consolidation. Given her improvement in dyspnea no supplemental O2 requirement the patient was discharged w o medication changes. Shortness of breath Hypoxia acute exacerbation of chronic diastolic heart failure with preserved LVEF 50 Dry weight per pt 154 lbs. Admission weight above baseline BNP elevated. Regarding trigger suspect dietary vs uncontrolled BP. No EKG changes for ACS trop negative repeat TTE showed mild regional LV systolic dysfunction c w prior myocardial infarction in the RCA territory as well as Grade II LV diastolic dysfunction and similar to prior ___ TTE. Doubt PNA given CXR and lack of cough fever doubt PE given low Wells score 1.5 and stable repeat ___. Underwent diuresis with IV Lasix 80 mg 120mg IV x2 with rapid improvement in subjective dyspnea. Resumed home torsemide 40mg nifedipine 60mg BID and carvedilol 25mg BID. Was stable on RA prior to discharge. Hypertension Patient missed her antiHTN medications earlier day of admission. Continued home carvedilol 25mg BID and nifedipine 60mg BID with holding parameters. Appears that a trial of ___ or spironolactone would be limited by hyperkalemia so this was deferred. Urinary frequency urge incontinence occurred in setting of diuresis however UCx ordered in ED did grow enterococci likely colonization. If symptoms persists would revaluate treat. CHRONIC STABLE ISSUES Normocytic anemia recent baseline Hb 9.4 ___ Hb was at baseline no signs of active bleeding. Likely multifactorial anemia of chronic disease as well as decreased erythropoiten production iso CKD. Non anion gap metabolic acidosis Patient has intermittently had a NAGMA in the past. No recent diarrhea. ___ suspect Type IV RTA given advanced age and history of T2DM both of which can cause hyporeninemia . Stage IV Chronic Kidney Disease baseline Cr 2.3 2.8 CKD iso HTN and T2DM Cr is currently at baseline. Low K Phos Na diet. Continued home calcitriol avoided nephrotoxins and renally dosed all medications. Coronary artery disease ___ DES to LCX ___ troponins were trended from 0.01 to 0.05 to 0.04 then stopped. CK MB was flat. Patient deneied any chest pain. A TTE showed mild regional LV systolic dysfunction c w prior myocardial infarction in the RCA territory and similar to prior ___ TTE. Continued home aspirin 81mg qd home carvedilol 25mg BID with holding parameters home atorvastatin 80mg qHS. Type II Diabetes Mellitus last HbA1C 6.4 ___ Under excellent control most recently in the pre diabetic range. Continue home 70 30 sliding scale t dinner if blood sugar over 130 10 units 90 130 none if blood sugar under 90 Dyslipidemia continued home atorvastatin Insomnia continued home gabapentin Gout continued home allopurinol TRANSITIONAL ISSUES Discharge weight 69.2kg Discharge creatinine 2.6 Discharge oral diuretic torsemide 40mg daily Transitional issue consider outpatient epo with renal Transitional issue BP goal of 140 90 per accord or even 130 80 per ACC AHA ___ guidelines however anticipate difficulty in adding additional agents iso CKD limits use of clonidine and baseline potassium would likely limit ___ or spironolactone TTE showed prior LV hypokinesis could consider MIBI or outpatient pharmacological stress test had some urinary retention incontinence while undergoing IV diuresis would assess for recurrent symptoms at routine outpatient visits CODE Full confirmed CONTACT ___ husband ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Atorvastatin 80 mg PO QPM 3. Calcitriol 0.5 mcg PO DAILY 4. Carvedilol 25 mg PO BID 5. Gabapentin 100 mg PO QHS 6. NIFEdipine Extended Release 60 mg PO BID 7. Torsemide 40 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 9. Acetaminophen 325 650 mg PO Q6H PRN Pain Mild 10. Aspirin 81 mg PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70 30 Insulin Discharge Medications 1. Acetaminophen 325 650 mg PO Q6H PRN Pain Mild 2. Allopurinol ___ mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Calcitriol 0.5 mcg PO DAILY 6. Carvedilol 25 mg PO BID 7. Gabapentin 100 mg PO QHS 8. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70 30 Insulin 9. NIFEdipine Extended Release 60 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 11. Torsemide 40 mg PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS Acute on chronic diastolic congestive heart failure SECONDARY DIAGNOSES Hypertension History of prior DVT Anemia NOS Chronic Kidney Disease stage IV Coronary Artery Disease ___ drug eluting stent Diabetes Mellitus Type 2 controlled Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear ___ You were admitted to the hospital with shortness of breath and weight gain. This was likely caused by an exacerbation of your heart failure possibly from salty foods over the holiday. While you were in the hospital we gave you IV diuretics to help remove extra fluid we checked for pneumonia with a chest x ray there was no sign of a pneumonia we checked for signs on new clots in your legs there was no new clot Now that you are going home continue to take all of your medications as prescribed monitor your salt intake this should be no more than 2 grams every day ask your doctors for help with this if you do not know how to keep track of your salt continue to weigh yourself every morning call your doctor if weight goes up more than 3 lbs. follow up with your primary care doctor regarding your blood pressure and blood sugar control It was a pleasure taking care of you Your ___ Inpatient Care Team Followup Instructions ___ The icd codes present in this text will be I130, I5033, E872, N184, E1122, N2581, I2510, E11319, D6489, E785, Z955, Z86718, I252, Z2239, G4700, M1A9XX0, R0902, E1151, Z794, E669, Z6831. The descriptions of icd codes I130, I5033, E872, N184, E1122, N2581, I2510, E11319, D6489, E785, Z955, Z86718, I252, Z2239, G4700, M1A9XX0, R0902, E1151, Z794, E669, Z6831 are I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; I5033: Acute on chronic diastolic (congestive) heart failure; E872: Acidosis; N184: Chronic kidney disease, stage 4 (severe); E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; N2581: Secondary hyperparathyroidism of renal origin; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema; D6489: Other specified anemias; E785: Hyperlipidemia, unspecified; Z955: Presence of coronary angioplasty implant and graft; Z86718: Personal history of other venous thrombosis and embolism; I252: Old myocardial infarction; Z2239: Carrier of other specified bacterial diseases; G4700: Insomnia, unspecified; M1A9XX0: Chronic gout, unspecified, without tophus (tophi); R0902: Hypoxemia; E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene; Z794: Long term (current) use of insulin; E669: Obesity, unspecified; Z6831: Body mass index [BMI] 31.0-31.9, adult. The common codes which frequently come are I130, E872, E1122, I2510, E785, Z955, Z86718, I252, G4700, Z794, E669. The uncommon codes mentioned in this dataset are I5033, N184, N2581, E11319, D6489, Z2239, M1A9XX0, R0902, E1151, Z6831.
The icd codes present in this text will be D500, I5023, N184, E118, K2970, Z23, K259, K5730, I2510, Z87891, I252, Z955, I129, Z794, Z8673, R0789, Z86718, R791, T45515A, I70218, K222, K219. The descriptions of icd codes D500, I5023, N184, E118, K2970, Z23, K259, K5730, I2510, Z87891, I252, Z955, I129, Z794, Z8673, R0789, Z86718, R791, T45515A, I70218, K222, K219 are D500: Iron deficiency anemia secondary to blood loss (chronic); I5023: Acute on chronic systolic (congestive) heart failure; N184: Chronic kidney disease, stage 4 (severe); E118: Type 2 diabetes mellitus with unspecified complications; K2970: Gastritis, unspecified, without bleeding; Z23: Encounter for immunization; K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation; K5730: Diverticulosis of large intestine without perforation or abscess without bleeding; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z87891: Personal history of nicotine dependence; I252: Old myocardial infarction; Z955: Presence of coronary angioplasty implant and graft; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z794: Long term (current) use of insulin; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; R0789: Other chest pain; Z86718: Personal history of other venous thrombosis and embolism; R791: Abnormal coagulation profile; T45515A: Adverse effect of anticoagulants, initial encounter; I70218: Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity; K222: Esophageal obstruction; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are I2510, Z87891, I252, Z955, I129, Z794, Z8673, Z86718, K219. The uncommon codes mentioned in this dataset are D500, I5023, N184, E118, K2970, Z23, K259, K5730, R0789, R791, T45515A, I70218, K222. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint fatigue anemia Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ year old woman with a past medical history of type 2 DM hypertension stage IV CKD CAD s p distant MI and bare metal stent stroke recent unprovoked DVTs on Coumadin and recent upper GI bleeding who was sent to ___ by her physician for anemia Hgb 6.5 . The patient was admitted to ___ in ___ with unprovoked bilateral lower extremity DVTs. She was started on heparin as an inpatient but anticoagulation was complicated by severely elevated PTT 150 and upper GI bleed. Endoscopy was notable for significant erythema superficial ulceration and gastritis without active bleeding. She was placed on BID PPI prophylaxis. She was eventually bridged to Coumadin for a planned 6 month course. Her INR is managed by her rehab facility and she is followed by Dr. ___ in ___ clinic. For the last two weeks she has noted increasing fatigue along with shortness of breath exertional sub sternal chest pain relieved with rest and symmetrical lower extremity swelling. During this period she reports that her appetite remained good and he bowel function was normal. She denies bloody stools or dark stool. On ___ she presented to her PCP office from rehab reporting increasing shortness of breath and fatigue. She was found to have a Hgb of 6.5 with an unconcerning CXR. She was sent to the ___ ED. In the ED her initial vitals were T 97.5 P 60 BP 156 76 RR 16 SPO2 100 RA. Exam was notable for guiac negative stool. Imaging was notable for 1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex ___ cyst. The patient was transfused with 2 units of pRBCs with appropriate increase in Hgb to 9.0. Following transfusion a repeat CXR was notable for pulmonary edema with bilateral pleural effusions. She was given 20mg PO Lasix and 40mg IV Lasix in the ED. The decision was made to admit the patient for anemia and flash pulmonary edema. On the floor vitals notable for T 97.9 BP 154 75 P 65 R 20 O2 99RA FSBG 76. She reports no acute complaints and that her shortness of breath has resolved. She denies chest pain dizziness lightheadedness. Past Medical History hypertension diabetes hx CVA cerebellar medullary stroke in ___ CAD hx of MI in ___ BMS to circumflex and POBA ___ peripheral arterial disease claudication followed by vascular managed conservatively stage IV CKD baseline 2.1 2.6 GERD esophageal rings Social History ___ Family History Niece had some sort of cancer. Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam ADMISSION PHYSICAL EXAM Vitals T 97.9 BP 154 75 P 65 R 20 O2 99RA FSBG ___ General Overweight woman alert oriented no acute distress HEENT Sclera anicteric MMM oropharynx clear Neck supple JVP not elevated Lungs Crackles to the mid lungs bilaterally CV Regular rate and rhythm normal S1 S2 no murmurs or gallops Abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly Ext Warm well perfused 2 pulses no clubbing or cyanosis. 2 pitting edema in dependent areas to the buttocks Skin no rashes noted Neuro ___ strength in deltoids biceps triceps wrist extensors finger extensors hip flexors hamstrings quadriceps gastrocs tibialis anterior bilaterally. Sensation intact bilaterally. PSYCH Alert and fully oriented normal mood and affect. sometimes slow to respond and responding with repetitive answers but otherwise appropriate DISCHARGE PHYSICAL EXAM VS T 97.6 BP 150s 160s 70s 80s P 60s 70s RR 18 SPO2 100RA General Overweight woman alert oriented no acute distress HEENT Sclera anicteric MMM oropharynx clear Neck supple JVP not elevated Lungs Clear to auscultation bilaterally CV Regular rate and rhythm normal S1 S2 no murmurs or gallops Abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly Ext Warm well perfused 2 pulses no clubbing or cyanosis. 1 pitting edema in shins bilaterally Skin no rashes noted Pertinent Results LABORATORY STUDIES ON ADMISSION ___ 12 30PM WBC 4.4 RBC 2.03 HGB 6.5 HCT 20.6 MCV 102 MCH 32.0 MCHC 31.6 RDW 16.3 RDWSD 59.6 ___ 12 30PM ___ ___ 12 30PM ALBUMIN 4.1 CALCIUM 9.2 PHOSPHATE 4.7 IRON 61 ___ 12 30PM calTIBC 303 FERRITIN 155 TRF 233 ___ 12 30PM UREA N 42 CREAT 2.3 SODIUM 142 POTASSIUM 4.7 CHLORIDE 109 TOTAL CO2 23 ANION GAP 15 ___ 04 50PM LD ___ 247 TOT BILI 0.2 ___ 04 50PM HAPTOGLOB 188 IMAGING LENIs ___ 1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex ___ cyst. CXR ___ 1. New mild pulmonary edema with persistent small bilateral pleural effusions. 2. Severe cardiomegaly is likely accentuated due to low lung volumes and patient positioning. CXR ___ As compared to ___ the lung volumes have slightly decreased. Signs of mild overinflation and moderate pleural effusions persist. Moderate cardiomegaly. Elongation of the descending aorta. No pneumonia. LABORAROTY STUDIES ON DISCHARGE ___ 05 45AM BLOOD WBC 3.4 RBC 2.93 Hgb 8.9 Hct 28.0 MCV 96 MCH 30.4 MCHC 31.8 RDW 17.5 RDWSD 59.7 Plt ___ ___ 05 45AM BLOOD ___ PTT 30.6 ___ ___ 05 45AM BLOOD Glucose 116 UreaN 41 Creat 2.1 Na 144 K 4.0 Cl 108 HCO3 25 AnGap 15 ___ 04 50PM BLOOD LD LDH 247 TotBili 0.2 ___ 05 45AM BLOOD Calcium 9.4 Phos 4.7 Mg 1.7 Brief Hospital Course Ms. ___ is a ___ year old woman with a past medical history of type 2 DM hypertension stage IV CKD CAD s p distant MI and bare metal stent stroke recent unprovoked DVTs on Coumadin and recent upper GI bleed who was sent to ___ by her physician for anemia. Anemia Patient presented with Hgb of 6.5 down from her recent baseline of 7.5 since her ___ hospitalization. Upon presentation she had a new macrocytic anemia. Hemolysis labs were negative. She received two units of packed red cells with an appropriate rise in her Hgb to 9.0. Stool was guiac negative with no reports of dark stool or blood in stool. Her hemoglobin remained stable at this level there was no overt bleeding and her stool was guiac negative. After transfusion the patient reported significant improvement in her shortness of breath and fatigue. Given her history of gastritis and diverticulosis a GI bleed was believed responsible for her anemia. Patient should receive an EGD colonoscopy as an outpatient. Acute exacerbation of heart failure with preserved ejection fraction The patient was also found to be slightly volume overloaded and was treated with 2x40mg IV Lasix with good urine output and symptomatic improvement. Her pulmonary edema and peripheral edema resolved with diuresis. CHRONIC ISSUES Gastic ulceration Continued on home pantoprazole BID Hypertension Continued on home nifedipine carvadilol lisinopril. Stage IV Chronic Kidney Disease Creatinine remained at baseline b l Cr 2.1 2.6 during admission. TRANSITIONAL ISSUES Patient s Anemia is thought to be due to slow GI bleed given history of gastritis and diverticulosis. Please schedule EGD colonoscopy within the next month Patient continued on Coumadin for bilateral DVTs please continue to weigh the risks and benefits of anticoagulation given history of bleed. Discharge weight 167.7 CONTACT ___ ___ CODE full confirmed Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. NIFEdipine CR 30 mg PO BID 8. Vitamin D ___ UNIT PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Gabapentin 100 mg PO QHS neuropathic pain 11. Pantoprazole 40 mg PO Q12H 12. Senna 8.6 mg PO BID constipation 13. Warfarin 4 mg PO 3X WEEK ___ 14. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 15. Furosemide 20 mg PO DAILY 16. Polyethylene Glycol 17 g PO DAILY 17. Acetaminophen 325 650 mg PO Q6H PRN pain or fever 18. Warfarin 3 mg PO 4X WEEK ___ 19. 70 30 30 Units Dinner Discharge Medications 1. Acetaminophen 325 650 mg PO Q6H PRN pain or fever RX acetaminophen 325 mg ___ tablet s by mouth Q6H PRN Disp 120 Tablet Refills 0 2. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 3. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet s by mouth QPM Disp 30 Tablet Refills 0 4. Carvedilol 12.5 mg PO BID RX carvedilol 12.5 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 5. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 0 6. Gabapentin 100 mg PO QHS neuropathic pain RX gabapentin 100 mg 1 capsule s by mouth at bedtime Disp 30 Capsule Refills 0 7. Lisinopril 40 mg PO DAILY RX lisinopril 40 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 8. Multivitamins 1 TAB PO DAILY RX multivitamin 1 capsule s by mouth daily Disp 30 Capsule Refills 0 9. NIFEdipine CR 30 mg PO BID RX nifedipine 30 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 10. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain RX nitroglycerin Nitrostat 0.3 mg 1 tablet s sublingually Q5MIN PRN Disp 10 Tablet Refills 0 11. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet s by mouth every twelve 12 hours Disp 60 Tablet Refills 0 12. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram dose 1 powder s by mouth daily Refills 0 13. Senna 8.6 mg PO BID constipation RX sennosides senna 8.6 mg 1 capsule by mouth twice a day Disp 60 Capsule Refills 0 14. Vitamin D ___ UNIT PO DAILY RX ergocalciferol vitamin D2 2 000 unit 1 tablet s by mouth daily Disp 30 Tablet Refills 0 15. Warfarin 4 mg PO 3X WEEK ___ RX warfarin 4 mg 1 tablet s by mouth 3X WEEK Disp 30 Tablet Refills 0 16. Warfarin 3 mg PO 4X WEEK ___ RX warfarin 3 mg 1 tablet s by mouth 4X WEEK Disp 30 Tablet Refills 0 17. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 18. Allopurinol ___ mg PO EVERY OTHER DAY RX allopurinol ___ mg 1 tablet s by mouth EVERY OTHER DAY Disp 30 Tablet Refills 0 19. 70 30 30 Units Dinner RX insulin NPH and regular human Humulin 70 30 KwikPen 100 unit mL 70 30 30 units SC Take 30 Units before DINER Disp 2 Package Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary diagnosis Anemia Congestive heart failure exacerbation Secondary diagnosis Hypertension DMII on insulin Coronary artery disease Stage IV chronic kidney disease Deep vein thrombosis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear ___ It was a pleasure caring for you. You were admitted to the hospital with fatigue chest pain and shortness of breath. You were found to have too few red blood cells anemia . We gave you blood and your symptoms improved. Additionally you were found to have too much fluid in your legs and lungs. We treated you with a diuretic which helped eliminate the fluid. Weigh yourself every morning call MD if weight goes up more than 3 lbs. Sincerely Your ___ Team Followup Instructions ___ The icd codes present in this text will be D500, I5023, N184, E118, K2970, Z23, K259, K5730, I2510, Z87891, I252, Z955, I129, Z794, Z8673, R0789, Z86718, R791, T45515A, I70218, K222, K219. The descriptions of icd codes D500, I5023, N184, E118, K2970, Z23, K259, K5730, I2510, Z87891, I252, Z955, I129, Z794, Z8673, R0789, Z86718, R791, T45515A, I70218, K222, K219 are D500: Iron deficiency anemia secondary to blood loss (chronic); I5023: Acute on chronic systolic (congestive) heart failure; N184: Chronic kidney disease, stage 4 (severe); E118: Type 2 diabetes mellitus with unspecified complications; K2970: Gastritis, unspecified, without bleeding; Z23: Encounter for immunization; K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation; K5730: Diverticulosis of large intestine without perforation or abscess without bleeding; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z87891: Personal history of nicotine dependence; I252: Old myocardial infarction; Z955: Presence of coronary angioplasty implant and graft; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z794: Long term (current) use of insulin; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; R0789: Other chest pain; Z86718: Personal history of other venous thrombosis and embolism; R791: Abnormal coagulation profile; T45515A: Adverse effect of anticoagulants, initial encounter; I70218: Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity; K222: Esophageal obstruction; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are I2510, Z87891, I252, Z955, I129, Z794, Z8673, Z86718, K219. The uncommon codes mentioned in this dataset are D500, I5023, N184, E118, K2970, Z23, K259, K5730, R0789, R791, T45515A, I70218, K222.
The icd codes present in this text will be I5023, N184, D631, E1121, Z86718, I129, Z955, I2510, Z7901, Z794, I340, I252, Z8673, Z87891, Z91128, E785. The descriptions of icd codes I5023, N184, D631, E1121, Z86718, I129, Z955, I2510, Z7901, Z794, I340, I252, Z8673, Z87891, Z91128, E785 are I5023: Acute on chronic systolic (congestive) heart failure; N184: Chronic kidney disease, stage 4 (severe); D631: Anemia in chronic kidney disease; E1121: Type 2 diabetes mellitus with diabetic nephropathy; Z86718: Personal history of other venous thrombosis and embolism; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z955: Presence of coronary angioplasty implant and graft; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z7901: Long term (current) use of anticoagulants; Z794: Long term (current) use of insulin; I340: Nonrheumatic mitral (valve) insufficiency; I252: Old myocardial infarction; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Z87891: Personal history of nicotine dependence; Z91128: Patient's intentional underdosing of medication regimen for other reason; E785: Hyperlipidemia, unspecified. The common codes which frequently come are Z86718, I129, Z955, I2510, Z7901, Z794, I252, Z8673, Z87891, E785. The uncommon codes mentioned in this dataset are I5023, N184, D631, E1121, I340, Z91128. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint dyspnea on exertion Major Surgical or Invasive Procedure None History of Present Illness ___ with a history of of HTN CAD s p DES with ischemic MR and systolic dysfunction ___ on torsemide hx of DVT who presents with 4 days of dyspnea on exertion leg swelling and 10 weight gain. Of note patient was seen in the Heart Failure Clinic with Dr. ___ on ___ where she noted that she has had persistent dyspnea on exertion and PND after a lengthy prior hospitalization for DVT GIB. At that time she was started on 40mg po torsemide which initially improved her symptoms. Over the holiday she indulged in a high salt diet and developed slow onset dyspnea on exertion. Denies any medication noncompliance chest pain palpitations palpitations. Describes PND worsening exercise tolerance unable to walk 50 feet and orthopnea. In the ED patient was found to have 1 bilateral lower extremity edema and have bibasilar crackles on exam. Patient underwent CXR BNP and was given one dose of IV 40mg Lasix. In the ED initial vitals were 97.8 73 199 100 18 95 RA. Prior to transfer vitals were 74 188 95 18 100 RA. Patient s labs were remarkable for sodium 146 Chloride 115 K 5.4 Bicarb 19 BUN 39 Creatinine 2.3. Patient had CK 229 with MB 6 Trop 0.01. Patient had BNP of 10 180. Patient also had Hgb 8.1 Hct 26.8 Platelet 168 WBC 5.4. Urinalysis still pending upon discharge. EKG notable for SR 76 with LAD TWI in the inferior leads which appears unchanged from prior on ___ On the floor she is symptomatically improved since coming to the ED. Past Medical History hypertension diabetes hx CVA cerebellar medullary stroke in ___ CAD hx of MI in ___ BMS to circumflex and POBA ___ peripheral arterial disease claudication followed by vascular managed conservatively stage IV CKD baseline 2.1 2.6 GERD esophageal rings Social History ___ Family History Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam ADMISSION PHYSICAL EXAMINATION VS T 98.0 BP 168 96 HR 67 RR 16 O2 sat 100 on 2L NC Admission weight 178lbs GENERAL WDWN obese sitting upright in bed in NAD. AOx3. Mood affect appropriate. HEENT NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva were pink no pallor or cyanosis of the oral mucosa. NECK Supple with JVP of 8cm. CARDIAC PMI located in ___ intercostal space midclavicular line. RR normal S1 S2 S3. No murmurs rubs gallops. No thrills lifts. LUNGS Resp were unlabored no accessory muscle use dyspneic at the end of a long sentence. Bibasilar crackles ___ up thorax diffuse wheezing. ABDOMEN Soft NTND. No HSM or tenderness. EXTREMITIES 2 edema to shins. No femoral bruits. PULSES Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAMINATION VS T 98.0 BP 135 72 HR 67 RR 16 O2 sat 100 on RA weight 74kg GENERAL WDWN obese sitting upright in bed in NAD. AOx3. Mood affect appropriate. HEENT NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva were pink no pallor or cyanosis of the oral mucosa. NECK Supple with JVP of 7cm. CARDIAC PMI located in ___ intercostal space midclavicular line. RR normal S1 S2 S3. No murmurs rubs gallops. No thrills lifts. LUNGS Resp were unlabored no accessory muscle use. Bibasilar crackles trace diffuse wheezing. ABDOMEN Soft NTND. No HSM or tenderness. EXTREMITIES dry. No femoral bruits. PULSES Distal pulses palpable and symmetric Pertinent Results ADMISSION LABS ___ 11 55AM BLOOD WBC 5.4 RBC 2.63 Hgb 8.1 Hct 26.8 MCV 102 MCH 30.8 MCHC 30.2 RDW 17.2 RDWSD 64.7 Plt ___ ___ 11 55AM BLOOD Neuts 80.6 Lymphs 11.2 Monos 5.0 Eos 2.4 Baso 0.2 Im ___ AbsNeut 4.38 AbsLymp 0.61 AbsMono 0.27 AbsEos 0.13 AbsBaso 0.01 ___ 12 45PM BLOOD ___ PTT 32.9 ___ ___ 07 30AM BLOOD Ret Aut 2.4 Abs Ret 0.06 ___ 11 55AM BLOOD Glucose 153 UreaN 39 Creat 2.3 Na 146 K 5.4 Cl 115 HCO3 19 AnGap 17 ___ 11 55AM BLOOD CK MB 6 cTropnT 0.01 ___ ___ 07 38PM BLOOD CK MB 6 cTropnT 0.01 ___ 11 55AM BLOOD Calcium 9.0 Phos 3.9 Mg 1.8 DISCHARGE LABS ___ 07 10AM BLOOD WBC 3.9 RBC 2.81 Hgb 8.6 Hct 26.7 MCV 95 MCH 30.6 MCHC 32.2 RDW 16.0 RDWSD 56.4 Plt ___ ___ 07 10AM BLOOD ___ ___ 07 10AM BLOOD Glucose 100 UreaN 37 Creat 1.9 Na 144 K 3.9 Cl 105 HCO3 29 AnGap 14 ___ 07 10AM BLOOD Calcium 9.5 Phos 4.4 Mg 1.8 IMAGING ___ CXR FINDINGS There is mild pulmonary edema with superimposed region of more confluent consolidation in the left upper lung. There are possible small bilateral pleural effusions. Moderate cardiomegaly is again seen as well as tortuosity of the descending thoracic aorta. No acute osseous abnormalities. IMPRESSION Mild pulmonary edema with superimposed left upper lung consolidation potentially more confluent edema versus superimposed infection. Brief Hospital Course ___ year old female with history of hypertension CAD s p DES with ischemic MR and systolic dysfunction ___ hx of DVT who admitted for CHF exacerbation. Acute on chronic decompensated heart failure presented in the setting of high salt diet with dyspnea on exertion decreased exercise tolerance ___ edema crackles on exam elevated BNP to 10K 8lbs above dry weight and pulmonary congestion on CXR. Later discovered on pharmacy review that patient had not filled torsemide after last outpatient Cardiology appointment where she was instructed to start taking it. Troponins cycled and negative. On admission she was placed on a salt and fluid restricted diet. She was diuresed with IV Lasix 80mg for 2 days and then transitioned to po torsemide 40mg with steady weight decline and net negative fluid balance of goal ___ and stable renal function. Electrolytes repleted for goal Mg 2 and K 4. She was continued on home carvedilol 12.5mg BID atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP 140. Discharged with close PCP and ___ to monitor weights and blood pressure control. Hypertension She was continued on home carvedilol 12.5mg BID atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP 140. Positive U A patient asymptomatic but with 32WBCs ___ bacteria although 3 epis . Asymptomatic with no fevers dysuria malaise. Urine culture negative. Left upper lung consolidation infiltrate per Radiology read on admission CXR. No cough fevers leukocytosis. Rereviewed with on call radiologist who favored pulmonary edema with no need for repeat imaging or PNA treatment unless clinically indicated. Monitored without any significant clinical findings. DVT anticoagulated on Coumadin goal 2.0 3.0 no signs of thrombus on exam. Daily INR trended and continued on home Coumadin 5mg daily. Anemia no signs of external loss specifically denying any melena. Chronically anemic with baseline ___ presented with Hgb 8. Likely ___ renal disease and ACD however elevated MCV indicates possible reticulocytosis. Altogether low suspicion for GIB so Coumadin was continued. Reticulocytes 2.4 which is inappropriate arguing against acute loss. Trended daily CBC with noted uprising by discharge. Chronic kidney disease stage IV baseline ___ likely ___ HTN and DM. Renally dosed medications and trended Cr with no significant change. HLD continued home atorvastatin DM held home 25U 70 30. Patient maintained on aspart ISS and glargine qHS with good glycemic control. TRANSITIONAL ISSUES CHF diuresed with IV lasix transitioned to po diuretics discharged home on 40mg po torsemide to take in the AM and take a banana. Pt complained of unilateral R sided incomplete hearing loss on day of discharge was not felt to be related to diuretics but would ___. HTN increased nifedipine CR to 60mg BID given elevated SBPs. Please f u at next appointments. Anemia multiple prior workups showing ACD. Hgb 8s during admission Prior DVT PE continued on warfarin will need continued monitoring DM stopped home 70 30 while in house and put on aspart glargine discharged on home regimen Discharge weight 74kg Discharge Cr 1.9 Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 650 mg PO Q6H PRN pain or fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 100 mg PO QHS neuropathic pain 7. Lisinopril 40 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. NIFEdipine CR 30 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 11. Pantoprazole 40 mg PO Q12H 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 8.6 mg PO BID constipation 14. Vitamin D ___ UNIT PO DAILY 15. Warfarin 5 mg PO DAILY16 16. Allopurinol ___ mg PO EVERY OTHER DAY 17. Torsemide 40 mg PO DAILY 18. HumuLIN 70 30 insulin NPH and regular human 100 unit mL 70 30 subcutaneous 25 units with dinner Discharge Medications 1. HumuLIN 70 30 insulin NPH and regular human 100 unit mL 70 30 subcutaneous 25 units with dinner 2. Warfarin 5 mg PO DAILY16 3. Vitamin D ___ UNIT PO DAILY 4. Acetaminophen 325 650 mg PO Q6H PRN pain or fever 5. Allopurinol ___ mg PO EVERY OTHER DAY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Docusate Sodium 100 mg PO BID 9. Gabapentin 100 mg PO QHS neuropathic pain 10. Lisinopril 40 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 13. Polyethylene Glycol 17 g PO DAILY 14. Senna 8.6 mg PO BID constipation 15. Torsemide 40 mg PO DAILY RX torsemide 20 mg 2 tablet s by mouth once daily Disp 60 Tablet Refills 0 16. Pantoprazole 20 mg PO Q12H 17. Carvedilol 25 mg PO BID 18. NIFEdipine CR 60 mg PO BID RX nifedipine 20 mg 3 capsule s by mouth twice daily Disp 180 Capsule Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary Diagnoses Acute on chronic decompensated congestive Heart Failure Hypertension Secondary Diagnoses Anemia Diabetes mellitus Prior deep vein thrombosis Chronic Kidney Disease Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Mrs. ___ ___ were admitted to ___ for treatment of your congestive heart failure and hypertension. ___ were given IV diuretics with improvement in your symptoms labs and exam. We increased one of your blood pressure medications and continued your other home medicines. It was a pleasure taking care of ___ during your stay we wish ___ all the best Your ___ Team Followup Instructions ___ The icd codes present in this text will be I5023, N184, D631, E1121, Z86718, I129, Z955, I2510, Z7901, Z794, I340, I252, Z8673, Z87891, Z91128, E785. The descriptions of icd codes I5023, N184, D631, E1121, Z86718, I129, Z955, I2510, Z7901, Z794, I340, I252, Z8673, Z87891, Z91128, E785 are I5023: Acute on chronic systolic (congestive) heart failure; N184: Chronic kidney disease, stage 4 (severe); D631: Anemia in chronic kidney disease; E1121: Type 2 diabetes mellitus with diabetic nephropathy; Z86718: Personal history of other venous thrombosis and embolism; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z955: Presence of coronary angioplasty implant and graft; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z7901: Long term (current) use of anticoagulants; Z794: Long term (current) use of insulin; I340: Nonrheumatic mitral (valve) insufficiency; I252: Old myocardial infarction; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Z87891: Personal history of nicotine dependence; Z91128: Patient's intentional underdosing of medication regimen for other reason; E785: Hyperlipidemia, unspecified. The common codes which frequently come are Z86718, I129, Z955, I2510, Z7901, Z794, I252, Z8673, Z87891, E785. The uncommon codes mentioned in this dataset are I5023, N184, D631, E1121, I340, Z91128.
The icd codes present in this text will be C675, I10, D259, Z87891, E785, E890. The descriptions of icd codes C675, I10, D259, Z87891, E785, E890 are C675: Malignant neoplasm of bladder neck; I10: Essential (primary) hypertension; D259: Leiomyoma of uterus, unspecified; Z87891: Personal history of nicotine dependence; E785: Hyperlipidemia, unspecified; E890: Postprocedural hypothyroidism. The common codes which frequently come are I10, Z87891, E785. The uncommon codes mentioned in this dataset are C675, D259, E890. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Bladder cancer Major Surgical or Invasive Procedure robotic anterior exenteration and open ileal conduit History of Present Illness ___ with invasive bladder cancer pelvic MRI concerning for invasion into anterior vaginal wall now s p robotic anterior exent Dr ___ and open ileal conduit Dr ___. Past Medical History Hypertension laparoscopic cholecystectomy six months ago left knee replacement six to ___ years ago laminectomy of L5 S1 at age ___ two vaginal deliveries. Social History ___ Family History Negative for bladder CA. Physical Exam A Ox3 Breathing comfortably on RA WWP Abd S ND appropriate postsurgical tenderness to palpation Urostomy pink viable Pertinent Results ___ 06 50AM BLOOD WBC 7.6 RBC 3.41 Hgb 10.6 Hct 32.5 MCV 95 MCH 31.1 MCHC 32.6 RDW 14.4 RDWSD 50.2 Plt ___ ___ 06 50AM BLOOD Plt ___ ___ 06 45AM BLOOD Glucose 117 UreaN 23 Creat 0.6 Na 136 K 4.4 Cl 104 HCO3 23 AnGap 13 ___ 06 45AM BLOOD Calcium 7.9 Phos 3.4 Mg 2.0 Brief Hospital Course Ms. ___ was admitted to the Urology service after undergoing robotic anterior exenteration with ileal conduit . No concerning intrao perative events occurred please see dictated operative note for details. Patient received ___ intravenous antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. The post operative course was notable for several episodes of emesis prompting NGT placement on ___. Pt self removed the NGT on ___ but nausea emesis resolved thereafter and pt was gradually advanced to a regular diet with passage of flatus without issue. With advacement of diet patient was transitioned from IV pain medication to oral pain medications. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema swelling or purulent drainage. Her drain was removed. The ostomy was perfused and patent and one ureteral stent had fallen out spontaneously. ___ was consulted and recommended disposition to rehab. Post operative follow up appointments were arranged discussed and the patient was discharged to rehab for further recovery. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Heparin 5000 UNIT SC ONCE Start in O.R. Holding Area 2. Losartan Potassium 50 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Levothyroxine Sodium 175 mcg PO DAILY Discharge Medications 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID take while taking narcotic pain meds RX docusate sodium Colace 100 mg 1 capsule s by mouth twice a day Disp 50 Capsule Refills 0 3. Enoxaparin Sodium 40 mg SC DAILY Start ___ First Dose Next Routine Administration Time RX enoxaparin 40 mg 0.4 mL 40 mg sc daily Disp 28 Syringe Refills 0 4. Nitrofurantoin Monohyd MacroBID 100 mg PO DAILY take while ureteral stents are in place RX nitrofurantoin monohyd m cryst Macrobid 100 mg 1 capsule s by mouth daily Disp 14 Capsule Refills 0 5. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth q4h prn Disp 30 Tablet Refills 0 6. Atorvastatin 10 mg PO QPM 7. Levothyroxine Sodium 175 mcg PO DAILY 8. Losartan Potassium 50 mg PO DAILY Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Bladder cancer Discharge Condition WdWn NAD AVSS Abdomen soft appropriately tender along incision Incision is c d I steris Stoma is well perfused Urine color is yellow Ureteral stent noted via stoma JP drain has been removed Bilateral lower extremities are warm dry well perfused. There is no reported calf pain to deep palpation. No edema or pitting Discharge Instructions Please also refer to the handout of instructions provided to you by your Urologist Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy You will be sent home with Visiting Nurse ___ services to facilitate your transition to home care of your urostomy Resume your pre admission home medications except as noted. Always call to inform review and discuss any medication changes and your post operative course with your primary care doctor ___ you have been prescribed IBUPROFEN please note that you may take this in addition to the prescribed NARCOTIC pain medications and or tylenol. FIRST alternate Tylenol acetaminophen and Ibuprofen for pain control. REPLACE the Tylenol with the prescribed narcotic if the narcotic is combined with Tylenol examples include brand names ___ Tylenol 3 w codeine and their generic equivalents . ALWAYS discuss your medications especially when using narcotics or new medications use with the pharmacist when you first retrieve your prescription if you have any questions. Use the narcotic pain medication for break through pain that is 4 on the pain scale. The MAXIMUM dose of Tylenol ACETAMINOPHEN is 4 grams from ALL sources PER DAY and remember that the prescribed narcotic pain medication may also contain Tylenol acetaminophen so this needs to be considered when monitoring your daily dose and maximum. If you are taking Ibuprofen Brand names include ___ this should always be taken with food. If you develop stomach pain or note black stool stop the Ibuprofen. Please do NOT drive operate dangerous machinery or consume alcohol while taking narcotic pain medications. Do NOT drive and until you are cleared to resume such activities by your PCP or urologist. You may be a passenger Colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener NOT a laxative. You may shower 2 days after surgery but do not tub bathe swim soak or scrub incision for 2 weeks If you had a drain or skin clips staples removed from your abdomen bandage strips called steristrips have been applied to close the wound OR the site was covered with a gauze dressing. Allow any steristrips bandage strips to fall off on their own ___ days . PLEASE REMOVE any gauze dressings within two days of discharge. Steristrips may get wet. No heavy lifting for 4 weeks no more than 10 pounds . Do not be sedentary. Walk frequently. Light household chores cooking folding laundry washing dishes are generally ok but AGAIN avoid straining pulling twisting do NOT vacuum . Followup Instructions ___ The icd codes present in this text will be C675, I10, D259, Z87891, E785, E890. The descriptions of icd codes C675, I10, D259, Z87891, E785, E890 are C675: Malignant neoplasm of bladder neck; I10: Essential (primary) hypertension; D259: Leiomyoma of uterus, unspecified; Z87891: Personal history of nicotine dependence; E785: Hyperlipidemia, unspecified; E890: Postprocedural hypothyroidism. The common codes which frequently come are I10, Z87891, E785. The uncommon codes mentioned in this dataset are C675, D259, E890.
The icd codes present in this text will be I2699, I82412, N390, I471, I10, I872, R918, B952, E039, E785, E876, E8342, G4700, K5900, Z66, N63, D509, D638, Z7901, Z8551, Z906, Z87891, Z96652. The descriptions of icd codes I2699, I82412, N390, I471, I10, I872, R918, B952, E039, E785, E876, E8342, G4700, K5900, Z66, N63, D509, D638, Z7901, Z8551, Z906, Z87891, Z96652 are I2699: Other pulmonary embolism without acute cor pulmonale; I82412: Acute embolism and thrombosis of left femoral vein; N390: Urinary tract infection, site not specified; I471: Supraventricular tachycardia; I10: Essential (primary) hypertension; I872: Venous insufficiency (chronic) (peripheral); R918: Other nonspecific abnormal finding of lung field; B952: Enterococcus as the cause of diseases classified elsewhere; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; E876: Hypokalemia; E8342: Hypomagnesemia; G4700: Insomnia, unspecified; K5900: Constipation, unspecified; Z66: Do not resuscitate; N63: Unspecified lump in breast; D509: Iron deficiency anemia, unspecified; D638: Anemia in other chronic diseases classified elsewhere; Z7901: Long term (current) use of anticoagulants; Z8551: Personal history of malignant neoplasm of bladder; Z906: Acquired absence of other parts of urinary tract; Z87891: Personal history of nicotine dependence; Z96652: Presence of left artificial knee joint. The common codes which frequently come are N390, I10, E039, E785, G4700, K5900, Z66, D509, Z7901, Z87891. The uncommon codes mentioned in this dataset are I2699, I82412, I471, I872, R918, B952, E876, E8342, N63, D638, Z8551, Z906, Z96652. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint dyspnea on exertion Major Surgical or Invasive Procedure None History of Present Illness Patient is a ___ year old woman s p robotic radical cystectomy ___ with ileal conduit creation with postop course complicated by bacteremia and abscess LLE DVT on prophylactic dosing lovenox who presents with dyspnea on exertion for past 3 days. Briefly patient was initially admitted to the Urology service from ___ for robotic anterior exenteration with ileal conduit. She was discharged to rehab on prophylactic dosing lovenox for 1 month. She was then readmitted from ___ for ileus requiring NGT decompression TPN. BCx grew Citrobacter for which CTX was started. CT showed intra abdominal interloop simple fluid collection and LLQ drain was placed by ___. Patient improved passing BMs and tolerating PO and was discharged on cipro flagyl. She was also discharged on PO Bactrim for presumed UTI though unclear if she actually took this. During this admission she was noted to have new bilateral ___ edema. LENIs at the time showed aute deep vein thrombosis of the duplicated mid and distal left femoral veins. She was discharged on Enoxaparin Sodium 40 mg SC daily. She reports that her PCP started PO ___ 20mg daily and since then there has been improvement of the swelling. Per her report a repeat ___ at the rehab facility ___ was negative for DVT. Patient reports that she recovered well post operatively and was doing well at her assisted living facility up until a week ago when she began experiencing dyspnea on exertion. She states that she typically is able to ambulate a block before stopping to catch her breath however in the past week she has been unable to take more than a few steps. She states that it has become increasingly more difficult to ambulate from her bedroom to the bathroom. When visited by the NP her ambulatory saturation was noted to be in the ___ with associated tachycardia to 110 pallor and diaphoresis. She endorses associated leg swelling left worse than right and she states that her thighs feel heavy . She denies any associated chest pain fever chills pain with deep inspiration abdominal pain rashes dizziness lightheadedness. In the ED initial VS were 97.7 72 136 93 20 100 Nasal Cannula ED physical exam was recorded as patient resting comfortably with NC pursed lip breathing unable to speak in full sentences before becoming short of breath urostomy pouch in RLQ stoma pink 2 edema to bilateral lower extremities L R. ED labs were notable for Hb 9 Hct 29 plt 479 UA large ___ 182 WBC many bact 0 epi. Trop neg x1 proBNP normal CTA chest showed 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper middle and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted as noted previously with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe suspicious for malignancy on the previous PET CT. 4. Re demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. EKG showed NSR with frequent PAC Patient was given ___ 20 26 PO NG Ciprofloxacin HCl 500 mg ___ 20 26 IV Heparin 6600 UNIT ___ 20 26 IV Heparin Transfer VS were 98.1 77 145 63 20 99 Nasal Cannula When seen on the floor she reports significant dyspnea with minimal exertion. Denies chest pain palpitations lightheadedness. A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History Hypertension laparoscopic cholecystectomy left knee replacement six to ___ years ago laminectomy of L5 S1 at age ___ two vaginal deliveries. s p ___ 1. Robot assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot assisted hysterectomy and bilateral oophorectomy for large uterus greater than 300 grams with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History ___ Family History Negative for bladder CA. Physical Exam ADMISSION EXAM Gen NAD speaking in 3 word sentences pursed lip breathing no accessory muscle use lying in bed Eyes EOMI sclerae anicteric ENT MMM OP clear Cardiovasc RRR no MRG full pulses 1 edema bilaterally with compression stockings in place no JVD Resp normal effort no accessory muscle use lungs CTA ___ to anterior auscultation. GI soft NT ND BS . Urostomy site does not appear infected MSK No significant kyphosis. No palpable synovitis. Skin No visible rash. No jaundice. Neuro AAOx3. No facial droop. Psych Full range of affect DISCHARGE EXAM vitals 98.3 140 42 90 24 96 1L Gen Lying in bed in no apparent distress HEENT Anicteric MMM Cardiovascular RRR normal S1 S2 no right sided heave ___ systolic murmur Pulmonary Lung fields clear to auscultation throughout. No crackles or wheezing. GI Soft distended nontender bowel sounds present urostomy in place. Extremities no edema though left leg appears larger than right leg warm well perfused with motor function intact. Her left lower leg is wrapped. Pertinent Results LABS Admission labs ___ 02 40PM GLUCOSE 101 UREA N 22 CREAT 0.7 SODIUM 136 POTASSIUM 4.1 CHLORIDE 98 TOTAL CO2 22 ANION GAP 20 ___ 02 40PM cTropnT 0.01 ___ 02 40PM proBNP 567 ___ 02 40PM WBC 7.7 RBC 3.07 HGB 9.0 HCT 29.1 MCV 95 MCH 29.3 MCHC 30.9 RDW 14.9 RDWSD 52.1 ___ 02 40PM PLT COUNT 479 ___ 02 40PM ___ PTT 33.4 ___ Discharge labs ___ 06 55AM BLOOD WBC 11.0 RBC 2.60 Hgb 7.5 Hct 24.5 MCV 94 MCH 28.8 MCHC 30.6 RDW 14.8 RDWSD 51.4 Plt ___ ___ 06 55AM BLOOD Glucose 99 UreaN 10 Creat 0.5 Na 141 K 4.3 Cl 105 HCO3 26 AnGap 14 ___ 06 55AM BLOOD Calcium 8.2 Phos 3.8 Mg 2.0 ___ 07 15AM BLOOD calTIBC 134 Ferritn 507 TRF 103 ___ 07 15AM BLOOD Iron 18 MICROBIOLOGY ___ 4 30 pm URINE FINAL REPORT ___ URINE CULTURE Final ___ MIXED BACTERIAL FLORA 3 COLONY TYPES CONSISTENT WITH SKIN AND OR GENITAL CONTAMINATION. ENTEROCOCCUS SP.. 100 000 CFU mL. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. SENSITIVITIES MIC expressed in MCG ML ___ ENTEROCOCCUS SP. AMPICILLIN 2 S NITROFURANTOIN 16 S TETRACYCLINE 1 S VANCOMYCIN 1 S IMAGING ___ CXR IMPRESSION Hilar congestion without frank edema. No convincing signs of pneumonia. ___ CTA chest showed 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper middle and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted as noted previously with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe suspicious for malignancy on the previous PET CT. 4. Re demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. ___ ___ IMPRESSION 1. Interval progression of deep vein thrombosis in the left lower extremity with occlusive thrombus involving the entire femoral vein previously only involving the mid and distal femoral vein. There is additional nonocclusive thrombus in the deep femoral vein. The left common femoral and popliteal veins are patent. 2. The bilateral calf veins were not visualized due to an overlying dressing. Otherwise no evidence of deep venous thrombosis in the right lower extremity. ___ TTE Conclusions The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness cavity size and global systolic function are normal LVEF 55 . Doppler parameters are most consistent with Grade I mild left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened . There is no aortic valve stenosis. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. ___ CXR IMPRESSION Compared to chest radiographs ___ through ___. Heart size top normal. Lungs grossly clear. No pleural abnormality or evidence of central lymph node enlargement. Brief Hospital Course Ms. ___ is a ___ woman s p robotic radical cystectomy omplicated by bacteremia and abscess LLE DVT currently on daily lovenox who presents with dyspnea on exertion and dyspnea on exertion and found to have large PE and progression of DVT. PE DVT Likely due to undertreatment of known LLE DVT with prophylactic dosing of lovenox. Given underdosing of lovenox this was not thought to be treatment failure and IVC filter was deferred. She had no signs of right heart strain on imaging EKG exam. TTE showed no evidence of right heart strain. She was treated with a heparin gtt then transitioned to treatment dose lovenox given malignancy associated thrombosis as noted in CLOT trial. She is quite symptomatic and requires oxygen supplementation though improved during hospitalization. Please wean oxygen as tolerated. Pulmonary nodules Known spiculated masses that were noted on CT in ___ concerning for primary lung malignancy vs mets. Current CT showed stable nodules still concerning for malignancy. She was evaluated by the thoracic team who recommended CT biopsy vs. surveillance. Given her current PE DVT the family and the patient decided for surveillance at this time. They will follow up with her primary care provider. Enterococcal UTI She was noted to have rising WBC in the setting of UCX from urostomy growing Enterococcus. Given her rising leukocytosis we proceeded with treatment. She was started on IV Ampicillin and transitioned to macrobid based on sensitivies. Leukocytosis improved on antibiotics. She should complete a 7 day course day 1 ___ day 7 ___. Normocytic Anemia No signs of bleeding or hemolysis. Hb dropped to nadir of 7.3 stable at discharge at 7.5. Iron studies consistent with likely combination iron deficiency anemia and anemia of chronic disease with low iron but elevated ferritin and low TIBC. Would recommend checking again as outpatient and work up as needed. ___ swelling Likley multifactorial including venous insufficiency as well as known LLE DVT. She responded quite well with compression stockings. Hx of bladder cancer s p ___ TURBT high grade TCC T1 no muscle identified . Then in ___ pelvic MRI showed bladder mass invasion perivesical soft tissue anterior vaginal wall on right C W T4 lesion . In ___ underwent robotic TAH BSO lap radical cystectomy and anterior vaginectomy with pathology showing pT2b node and margins negative. No plan for any further therapy at this time per Dr ___. The patient is safe to discharge today and 30min were spent on discharge day management services. Transitional issues She will need follow up chest CT for pulmonary nodules in 3 months ___ To complete 7 day course for UTI with macrobid day 7 ___ Continue oxygen therapy and wean as tolerated to maintain O2 sat 92 Please check CBC on ___ to ensure stability of h h and demonstrate resolution of leukocytosis HCP son Dr. ___ ___ Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Start ___ First Dose Next Routine Administration Time 4. Levothyroxine Sodium 175 mcg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Losartan Potassium 50 mg PO DAILY 7. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate 8. LORazepam 0.25 mg PO BID PRN anxiety 9. Senna 8.6 mg PO BID Discharge Medications 1. Nitrofurantoin Monohyd MacroBID 100 mg PO Q12H Last day ___. Enoxaparin Sodium 90 mg SC Q12H Start Today ___ First Dose Next Routine Administration Time 3. LORazepam 0.25 mg PO QHS PRN insomnia RX lorazepam 0.5 mg 0.5 One half tab by mouth QHS prn Disp 3 Tablet Refills 0 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Levothyroxine Sodium 175 mcg PO DAILY 8. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth Q8H prn Disp 3 Tablet Refills 0 9. Senna 8.6 mg PO BID Discharge Disposition Extended Care Facility ___ Discharge Diagnosis PE Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Out of Bed with assistance to chair or wheelchair. Discharge Instructions Ms. ___ it was a pleasure taking care you during your admission to ___. You were admitted for a clot in your lungs and leg. You were treated with a blood thinner. You will need to continue the blood thinner. You were also treated for a urinary tract infection. For your pulmonary nodules you should follow up with your primary care doctor. Followup Instructions ___ The icd codes present in this text will be I2699, I82412, N390, I471, I10, I872, R918, B952, E039, E785, E876, E8342, G4700, K5900, Z66, N63, D509, D638, Z7901, Z8551, Z906, Z87891, Z96652. The descriptions of icd codes I2699, I82412, N390, I471, I10, I872, R918, B952, E039, E785, E876, E8342, G4700, K5900, Z66, N63, D509, D638, Z7901, Z8551, Z906, Z87891, Z96652 are I2699: Other pulmonary embolism without acute cor pulmonale; I82412: Acute embolism and thrombosis of left femoral vein; N390: Urinary tract infection, site not specified; I471: Supraventricular tachycardia; I10: Essential (primary) hypertension; I872: Venous insufficiency (chronic) (peripheral); R918: Other nonspecific abnormal finding of lung field; B952: Enterococcus as the cause of diseases classified elsewhere; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; E876: Hypokalemia; E8342: Hypomagnesemia; G4700: Insomnia, unspecified; K5900: Constipation, unspecified; Z66: Do not resuscitate; N63: Unspecified lump in breast; D509: Iron deficiency anemia, unspecified; D638: Anemia in other chronic diseases classified elsewhere; Z7901: Long term (current) use of anticoagulants; Z8551: Personal history of malignant neoplasm of bladder; Z906: Acquired absence of other parts of urinary tract; Z87891: Personal history of nicotine dependence; Z96652: Presence of left artificial knee joint. The common codes which frequently come are N390, I10, E039, E785, G4700, K5900, Z66, D509, Z7901, Z87891. The uncommon codes mentioned in this dataset are I2699, I82412, I471, I872, R918, B952, E876, E8342, N63, D638, Z8551, Z906, Z96652.
The icd codes present in this text will be T814XXA, K651, N179, I82412, C679, I10, B966, R7881, Y838, Y9289, F17210, Z436, Z90710, D72829, Z96652. The descriptions of icd codes T814XXA, K651, N179, I82412, C679, I10, B966, R7881, Y838, Y9289, F17210, Z436, Z90710, D72829, Z96652 are T814XXA: Infection following a procedure; K651: Peritoneal abscess; N179: Acute kidney failure, unspecified; I82412: Acute embolism and thrombosis of left femoral vein; C679: Malignant neoplasm of bladder, unspecified; I10: Essential (primary) hypertension; B966: Bacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhere; R7881: Bacteremia; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y9289: Other specified places as the place of occurrence of the external cause; F17210: Nicotine dependence, cigarettes, uncomplicated; Z436: Encounter for attention to other artificial openings of urinary tract; Z90710: Acquired absence of both cervix and uterus; D72829: Elevated white blood cell count, unspecified; Z96652: Presence of left artificial knee joint. The common codes which frequently come are N179, I10, F17210. The uncommon codes mentioned in this dataset are T814XXA, K651, I82412, C679, B966, R7881, Y838, Y9289, Z436, Z90710, D72829, Z96652. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Abdominal pain distention nausea Major Surgical or Invasive Procedure Interventional radiology placement of abdominal abscess drain History of Present Illness ___ F with h o muscle invasive bladder cancer returning to the ED POD 15 with abdominal pain nausea and distension. She has been obstipated for nearly three days. KUB and CT scan notable for dilated loops air fluids and tapering small bowel without an obvious transition point. Labwork notable for ___ and leukocytosis. Concerned for small bowel obstruction or an ileus in presence ___ and leukocytosis she was re admitted for IVF bowel rest NGT decompression. Past Medical History Hypertension laparoscopic cholecystectomy left knee replacement six to ___ years ago laminectomy of L5 S1 at age ___ two vaginal deliveries. s p ___ 1. Robot assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot assisted hysterectomy and bilateral oophorectomy for large uterus greater than 300 grams with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History ___ Family History Negative for bladder CA. Physical Exam WdWn NAD AVSS Abdomen soft appropriately tender along incision Incision is c d I Stoma is well perfused Urine color is yellow Bilateral lower extremities are warm dry well perfused. There is no reported calf pain to deep palpation. Bilateral lower extremities have 2 pitting edema but no erythema callor pain. Pigtail drain has been removed dressing c d i Pertinent Results ___ 05 58AM BLOOD WBC 9.9 RBC 2.76 Hgb 8.2 Hct 26.2 MCV 95 MCH 29.7 MCHC 31.3 RDW 13.9 RDWSD 47.3 Plt ___ ___ 06 45AM BLOOD WBC 10.3 RBC 2.87 Hgb 8.7 Hct 27.7 MCV 97 MCH 30.3 MCHC 31.4 RDW 14.0 RDWSD 49.4 Plt ___ ___ 05 13AM BLOOD WBC 11.6 RBC 3.27 Hgb 9.8 Hct 31.0 MCV 95 MCH 30.0 MCHC 31.6 RDW 13.6 RDWSD 47.5 Plt ___ ___ 07 06PM BLOOD WBC 22.5 RBC 3.58 Hgb 10.9 Hct 34.0 MCV 95 MCH 30.4 MCHC 32.1 RDW 13.9 RDWSD 47.9 Plt ___ ___ 07 06PM BLOOD Neuts 89 Bands 1 Lymphs 5 Monos 3 Eos 0 Baso 0 ___ Metas 1 Myelos 0 Hyperse 1 AbsNeut 20.48 AbsLymp 1.13 AbsMono 0.68 AbsEos 0.00 AbsBaso 0.00 ___ 01 04PM BLOOD ___ PTT 30.9 ___ ___ 05 58AM BLOOD Glucose 106 UreaN 26 Creat 0.4 Na 136 K 4.6 Cl 107 HCO3 26 AnGap 8 ___ 06 45AM BLOOD Glucose 114 UreaN 32 Creat 0.4 Na 137 K 4.1 Cl 106 HCO3 25 AnGap 10 ___ 06 00AM BLOOD Glucose 121 UreaN 39 Creat 0.4 Na 140 K 3.6 Cl 107 HCO3 26 AnGap 11 ___ 07 06PM BLOOD Glucose 117 UreaN 60 Creat 1.7 Na 133 K 5.0 Cl 96 HCO3 21 AnGap 21 ___ 08 30AM BLOOD ALT 20 AST 19 AlkPhos 77 ___ 05 58AM BLOOD Calcium 7.6 Phos 2.8 Mg 2.2 ___ 06 45AM BLOOD Calcium 7.7 Phos 2.4 Mg 2.1 ___ 08 30AM BLOOD Albumin 1.8 Calcium 7.7 Phos 3.5 Mg 2.1 Iron 23 ___ 07 06PM BLOOD Calcium 8.0 Phos 5.5 Mg 2.2 ___ 08 30AM BLOOD calTIBC 116 Ferritn 789 TRF 89 ___ 05 09AM BLOOD Triglyc 106 ___ 08 30AM BLOOD Triglyc 89 ___ 07 06PM BLOOD Lactate 1.5 ___ 03 00PM ASCITES Creat 0.4 Amylase 18 Triglyc 29 Lipase 8 ___ 03 00PM OTHER BODY FLUID Creat 0.5 ___ 7 12 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ CITROBACTER KOSERI. FINAL SENSITIVITIES. SENSITIVITIES MIC expressed in MCG ML ___ CITROBACTER KOSERI CEFEPIME 1 S CEFTAZIDIME 1 S CEFTRIAXONE 1 S CIPROFLOXACIN 0.25 S GENTAMICIN 1 S MEROPENEM 0.25 S PIPERACILLIN TAZO 4 S TOBRAMYCIN 1 S TRIMETHOPRIM SULFA 1 S Aerobic Bottle Gram Stain Final ___ GRAM NEGATIVE ROD S . Reported to and read back by ___ ___ 14 35 ON ___. ___ 3 00 pm ABSCESS . PELVIC ASPIRATION. FINAL REPORT ___ GRAM STAIN Final ___ 4 10 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. 1 1 per 1000X FIELD GRAM NEGATIVE ROD S . WOUND CULTURE Final ___ NO GROWTH. ANAEROBIC CULTURE Final ___ BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. ___ 10 52 am STOOL CONSISTENCY NOT APPLICABLE Source Stool. FINAL REPORT ___ C. difficile DNA amplification assay Final ___ Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. Reference Range Negative . Brief Hospital Course Ms. ___ was admitted to Dr. ___ service for management of ileus. Upon admission a nasogastric tube was placed for decompression. On ___ PICC was placed and TPN started. Blood cultures grew gram negative rods and ceftriaxone was started. On ___ pt started to pass small amount of flatus. ___ CT scan demonstrated improving ileus but concern for possible urine leak and increased free fluid. On ___ a LLQ drain was placed by interventional radiology. on ___ pt passed clamp trial and NGT was removed. Pt continued to pass flatus and also started to have bowel movements. On ___ pt was advanced to a clear liquid diet. Repeat blood cultures were negative and positive blood culture from admission grew citrobacter. Diet was gradually advanced and ensure added. IV medications were gradually converted to PO and she was re evaluated by physical therapy for rehabilitative services. She was ambulating with walker assistance and prepared for discharge to her ___ facility ___ . TPN was continued up until day before discharge. At time of discharge she was tolerating regular diet passing flatus regularly and having bowel movements. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H 5. Docusate Sodium 100 mg PO BID 6. Enoxaparin Sodium 40 mg SC DAILY 7. Nitrofurantoin Monohyd MacroBID 100 mg PO DAILY 8. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate Discharge Medications 1. Ciprofloxacin HCl 500 mg PO Q12H Duration 7 Days Last dose ___ 2. MetroNIDAZOLE 500 mg PO Q6H Duration 7 Days Last dose ___ 3. Senna 8.6 mg PO BID 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Enoxaparin Sodium 40 mg SC DAILY Start ___ First Dose Next Routine Administration Time 8. Levothyroxine Sodium 175 mcg PO DAILY 9. LORazepam 0.25 mg PO BID PRN anxiety 10. Losartan Potassium 50 mg PO DAILY 11. Nitrofurantoin Monohyd MacroBID 100 mg PO DAILY 12. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate Discharge Disposition Extended Care Facility ___ Discharge Diagnosis bladder cancer post operative ileus bacteremia CITROBACTER KOSERI and abdominal pelvic abscess BACTEROIDES FRAGILIS GROUP requiring ___ drainage Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy Resume your pre admission home medications except as noted. Always call to inform review and discuss any medication changes and your post operative course with your primary care doctor ___ acetaminophen and Ibuprofen for pain control. Ciprofloxacin and Metronidazole are new ANTIBIOTIC medications to treat your infection. Continue for 7 days through ___. The MAXIMUM dose of Tylenol ACETAMINOPHEN is 3 grams from ALL sources PER DAY If you are taking Ibuprofen Brand names include ___ this should always be taken with food. If you develop stomach pain or note black stool stop the Ibuprofen. Please do NOT drive operate dangerous machinery or consume alcohol while taking narcotic pain medications. Do NOT drive and until you are cleared to resume such activities by your PCP or urologist. You may be a passenger Colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener NOT a laxative. No heavy lifting for 4 weeks no more than 10 pounds . Do not be sedentary. Walk frequently. Light household chores cooking folding laundry washing dishes are generally ok but AGAIN avoid straining pulling twisting do NOT vacuum . Followup Instructions ___ The icd codes present in this text will be T814XXA, K651, N179, I82412, C679, I10, B966, R7881, Y838, Y9289, F17210, Z436, Z90710, D72829, Z96652. The descriptions of icd codes T814XXA, K651, N179, I82412, C679, I10, B966, R7881, Y838, Y9289, F17210, Z436, Z90710, D72829, Z96652 are T814XXA: Infection following a procedure; K651: Peritoneal abscess; N179: Acute kidney failure, unspecified; I82412: Acute embolism and thrombosis of left femoral vein; C679: Malignant neoplasm of bladder, unspecified; I10: Essential (primary) hypertension; B966: Bacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhere; R7881: Bacteremia; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y9289: Other specified places as the place of occurrence of the external cause; F17210: Nicotine dependence, cigarettes, uncomplicated; Z436: Encounter for attention to other artificial openings of urinary tract; Z90710: Acquired absence of both cervix and uterus; D72829: Elevated white blood cell count, unspecified; Z96652: Presence of left artificial knee joint. The common codes which frequently come are N179, I10, F17210. The uncommon codes mentioned in this dataset are T814XXA, K651, I82412, C679, B966, R7881, Y838, Y9289, Z436, Z90710, D72829, Z96652.
The icd codes present in this text will be T8140XA, A4181, R6520, N179, N1330, N12, T8144XA, Z936, I10, E785, E039, Z87891, Z8551, Z86718, Y848, Y92239. The descriptions of icd codes T8140XA, A4181, R6520, N179, N1330, N12, T8144XA, Z936, I10, E785, E039, Z87891, Z8551, Z86718, Y848, Y92239 are T8140XA: Infection following a procedure, unspecified, initial encounter; A4181: Sepsis due to Enterococcus; R6520: Severe sepsis without septic shock; N179: Acute kidney failure, unspecified; N1330: Unspecified hydronephrosis; N12: Tubulo-interstitial nephritis, not specified as acute or chronic; T8144XA: Sepsis following a procedure, initial encounter; Z936: Other artificial openings of urinary tract status; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E039: Hypothyroidism, unspecified; Z87891: Personal history of nicotine dependence; Z8551: Personal history of malignant neoplasm of bladder; Z86718: Personal history of other venous thrombosis and embolism; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause. The common codes which frequently come are N179, I10, E785, E039, Z87891, Z86718. The uncommon codes mentioned in this dataset are T8140XA, A4181, R6520, N1330, N12, T8144XA, Z936, Z8551, Y848, Y92239. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Fevers and chills Major Surgical or Invasive Procedure ___ stent exchange History of Present Illness Ms. ___ is a ___ female with the past medical history notable for history of bladder cancer status post robotic TAH BSO lap radical cystectomy with ileal loop diversion and anterior vaginectomy in ___ complicated by abdominal fluid requiring placement of drainage catheters further complicated by a severe bilateral hydronephrosis requiring bilateral urostomy tube placement and then ultimately ureteral stent placements with improvement who presented to the hospital for routine stent exchange and cystoscopy. The patient underwent an uncomplicated procedure but then postoperatively in the PACU she developed a fever to 102.4 and was tachycardic 105 and as such was felt to need admission for treatment of sepsis. At that time she was given ampicillin and gentamicin given her history of drug resistant organisms. She reported at that time she was feeling feverish and chills with nausea and vomiting x1. She received IV fluids and her IV antibiotics and her symptoms improved. She was admitted to the medical service for further evaluation and management On the floor the patient reports that she continues to have persistent chills. She feels slightly nauseous. She denies any abdominal pain. She otherwise reports that she is feeling better than she did immediately postprocedural but is still significantly off of her baseline. She reports that she has a history of urinary tract infections and was most recently on ciprofloxacin and ___. She reports that she was on this medication for 7 day course. No ___ acute complaints. Past Medical History Hypertension s p lap chole s p left knee replacement s p laminectomy of L5 S1 at age ___ Bladder Cancer high grade TCC T1 diagnosed in ___ then ___ pelvic MRI w invasion into bladder wall perivesical soft tissue and anterior vaginal wall c w T4 staging s p hysterectomy and bilateral oophorectomy for large uterus w fibroid s p laparascopic b l pelvic lymph node resection s p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation ___ course complicated by bacteremia and development of intra abdominal fluid collection no s p drain placement by ___ ___ h o LLE DVT and PE no longer on anticoagulation. Social History ___ Family History Negative for bladder CA. Physical Exam ADMISSION EXAM VITALS ___ 2227 Temp 99.3 PO BP 119 54 HR 80 RR 16 O2 sat 98 O2 delivery RA Dyspnea 0 RASS 0 Pain Score ___ GENERAL Alert and in no apparent distress facial twitches EYES Anicteric pupils equally round ENT Ears and nose without visible erythema masses or trauma. Oropharynx without visible lesion erythema or exudate CV Heart regular no murmur no S3 no S4. No JVD. RESP Lungs clear to auscultation with good air movement bilaterally. Breathing is non labored GI Abdomen soft non distended non tender to palpation. Bowel sounds present. No HSM GU No suprapubic fullness or tenderness to palpation foley catheter in place MSK Neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs SKIN No rashes or ulcerations noted NEURO Alert oriented face symmetric gaze conjugate with EOMI speech fluent moves all limbs sensation to light touch grossly intact throughout PSYCH pleasant appropriate affect DISCHARGE EXAM AVSS ambulating comfortably at baseline. Urostomy bag in place with no surround erythema or pain. Pertinent Results LABORATORY RESULTS ___ 05 30AM BLOOD WBC 16.5 RBC 3.23 Hgb 9.8 Hct 31.8 MCV 99 MCH 30.3 MCHC 30.8 RDW 14.5 RDWSD 52.3 Plt ___ ___ 06 09AM BLOOD WBC 14.1 RBC 3.39 Hgb 10.2 Hct 33.2 MCV 98 MCH 30.1 MCHC 30.7 RDW 14.6 RDWSD 52.7 Plt ___ ___ 06 10AM BLOOD WBC 10.0 RBC 3.55 Hgb 10.5 Hct 33.6 MCV 95 MCH 29.6 MCHC 31.3 RDW 14.1 RDWSD 49.9 Plt ___ ___ 05 30AM BLOOD Glucose 115 UreaN 34 Creat 1.6 Na 142 K 4.2 Cl 106 HCO3 22 AnGap 14 ___ 06 10AM BLOOD Glucose 99 UreaN 29 Creat 1.3 Na 141 K 3.8 Cl 104 HCO3 23 AnGap 14 ___ 05 30AM BLOOD Calcium 8.1 Phos 3.4 Mg 1.8 MICROBIOLOGY ___ 3 00 pm URINE Site CYSTOSCOPY RIGHT KIDNEY WASH. FINAL REPORT ___ URINE CULTURE Final ___ ENTEROCOCCUS FAECIUM. 10 000 CFU ML. ___ ___ REQUESTS SUSCEPTIBILITY TESTING ___. STAPHYLOCOCCUS COAGULASE NEGATIVE. 1 000 10 000 CFU ML. CORYNEBACTERIUM SPECIES DIPHTHEROIDS . 1 000 10 000 CFU ML. SENSITIVITIES MIC expressed in MCG ML ___ ENTEROCOCCUS FAECIUM AMPICILLIN 8 S NITROFURANTOIN 16 S TETRACYCLINE 16 R VANCOMYCIN 2 S Blood cultures NGTD Brief Hospital Course Ms. ___ was admitted with sepsis from a urinary tract infection after her stent exchange. She was placed empirically on vancomycin and cefepime narrowed to vanc ceftriaxone on HD 1 because of her history of resistant organisms. She rapidly improved. Her urine grew E. faecium sensitive to ampicillin. Therefore a PICC line was placed and she will complete two weeks total of ampicillin for a complicated urinary tract infection additional day days . She will follow up with Dr. ___ as an outpatient. She will stop her prophylactic TMP while on ampicillin but then resume after finishing her course. ampicillin 500 mg TID x 9 additional days restart TMP 100 mg daily for ppx after antibiotic course follow up with Dr. ___ ___ problems addressed this hospitalization 1. ___. Ms. ___ initially had an ___ likely prerenal from her sepsis. She received IV fluids and antibiotics as above and her creatinine down trended. Losartan was initially held but restarted on discharge. 2. Hyperlipidemia continued atorvastatin 10 mg daily 3. Hypothyroidism continue levothyroxine 175 mcg daily 30 minutes spent on discharge activities. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 2. Atorvastatin 10 mg PO QPM 3. Cyanocobalamin 1000 mcg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Levothyroxine Sodium 175 mcg PO DAILY 6. LORazepam 0.5 mg PO Q12H PRN anxiety 7. Losartan Potassium 50 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 10. Trimethoprim 100 mg PO Q24H Discharge Medications 1. Ampicillin 500 mg IV Q8H RX ampicillin sodium 500 mg 500 mg IV Every eight hours Disp 15 Vial Refills 0 RX ampicillin sodium 500 mg 500 mg IV Every eight hours Disp 27 Vial Refills 0 2. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 3. Atorvastatin 10 mg PO QPM 4. Cyanocobalamin 1000 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Levothyroxine Sodium 175 mcg PO DAILY 7. LORazepam 0.5 mg PO Q12H PRN anxiety 8. Losartan Potassium 50 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 11. HELD Trimethoprim 100 mg PO Q24H This medication was held. Do not restart Trimethoprim until after you finish your ampicillin. Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Complicated E. faecium UTI Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You were admitted to the hospital after you developed fevers and chills after you developed fevers and chills from your stent exchange. Your urine grew the enterococcus species the source of your infection. Because it was enterococcus a PICC line was placed and you will finish a total 14 day course of IV ampicillin. You also had kidney injury likely from infection that resolved with antibiotics and fluids. It was a pleasure taking care of you Followup Instructions ___ The icd codes present in this text will be T8140XA, A4181, R6520, N179, N1330, N12, T8144XA, Z936, I10, E785, E039, Z87891, Z8551, Z86718, Y848, Y92239. The descriptions of icd codes T8140XA, A4181, R6520, N179, N1330, N12, T8144XA, Z936, I10, E785, E039, Z87891, Z8551, Z86718, Y848, Y92239 are T8140XA: Infection following a procedure, unspecified, initial encounter; A4181: Sepsis due to Enterococcus; R6520: Severe sepsis without septic shock; N179: Acute kidney failure, unspecified; N1330: Unspecified hydronephrosis; N12: Tubulo-interstitial nephritis, not specified as acute or chronic; T8144XA: Sepsis following a procedure, initial encounter; Z936: Other artificial openings of urinary tract status; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E039: Hypothyroidism, unspecified; Z87891: Personal history of nicotine dependence; Z8551: Personal history of malignant neoplasm of bladder; Z86718: Personal history of other venous thrombosis and embolism; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause. The common codes which frequently come are N179, I10, E785, E039, Z87891, Z86718. The uncommon codes mentioned in this dataset are T8140XA, A4181, R6520, N1330, N12, T8144XA, Z936, Z8551, Y848, Y92239.
The icd codes present in this text will be T814XXA, A419, K651, N179, N1330, D62, I2782, N138, C679, I10, E785, E039, K439, K435, E876, Y838, Y929, Z96652, Z86718, N63, Z7901, Z87891. The descriptions of icd codes T814XXA, A419, K651, N179, N1330, D62, I2782, N138, C679, I10, E785, E039, K439, K435, E876, Y838, Y929, Z96652, Z86718, N63, Z7901, Z87891 are T814XXA: Infection following a procedure; A419: Sepsis, unspecified organism; K651: Peritoneal abscess; N179: Acute kidney failure, unspecified; N1330: Unspecified hydronephrosis; D62: Acute posthemorrhagic anemia; I2782: Chronic pulmonary embolism; N138: Other obstructive and reflux uropathy; C679: Malignant neoplasm of bladder, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E039: Hypothyroidism, unspecified; K439: Ventral hernia without obstruction or gangrene; K435: Parastomal hernia without obstruction or gangrene; E876: Hypokalemia; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable; Z96652: Presence of left artificial knee joint; Z86718: Personal history of other venous thrombosis and embolism; N63: Unspecified lump in breast; Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, D62, I10, E785, E039, Y929, Z86718, Z7901, Z87891. The uncommon codes mentioned in this dataset are T814XXA, A419, K651, N1330, I2782, N138, C679, K439, K435, E876, Y838, Z96652, N63. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint subjective fevers lethargy and bloody drain output Major Surgical or Invasive Procedure ___ For the large pelvic fluid collections CT guided repositioning of existing drain and placement of an additional drain. ___ Removal of more recently placed drain History of Present Illness Ms. ___ is an ___ with PMH of hypertension and bladder cancer high grade invasive urothelial carcinoma pT2b s p TAH BSO radical cystectomy w ileal conduit c b intra abdominal infection and pelvic fluid collection s p ___ guided drain placement ___ who presents with 2 days of generalized malaise and 1 day of fevers. Patient underwent ___ guided JP drain placement for intra abdominal fluid collection and infection thought to be complicated of recent TAH BSO radical cystectomy and pelvic lymph node biopsy. This procedure was done on ___. Over the past 2 days she had noticed generalized malaise and 1 day of fever w rigors to Tmax 101.5 at home. She notes that the drainage from her intra abdominal drain is darker but her urostomy output has been unchanged. She notes some associated mild LLQ pain. She denies diarrhea BRBPR rash cough headache neck stiffness. She presented initially to OSH where she was evaluated with BCx and drain culture and was started on zosyn and vancomycin and given 650mg acetaminophen. She was transferred to ___ for further management. Past Medical History Hypertension s p lap chole s p left knee replacement s p laminectomy of L5 S1 at age ___ Bladder Cancer high grade TCC T1 diagnosed in ___ then ___ pelvic MRI w invasion into bladder wall perivesical soft tissue and anterior vaginal wall c w T4 staging s p hysterectomy and bilateral oophorectomy for large uterus w fibroid s p laparascopic b l pelvic lymph node resection s p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation ___ course complicated by bacteremia and development of intra abdominal fluid collection no s p drain placement by ___ ___ h o LLE DVT and PE on lovenox Social History ___ Family History Negative for bladder CA. Physical Exam ADMISSION EXAM Vital Signs 100.9 PO 130 54 L Lying 80 24 95 RA General Alert oriented no acute distress HEENT Sclerae anicteric MMM oropharynx clear CV RRR normal S1 S2 systolic murmur RUBS no rubs gallops Lungs Clear to auscultation bilaterally no wheezes rales rhonchi Abdomen Soft non tender non distended bowel sounds present ileal conduit drain in RLQ with pigtail drain in LLQ draining dark sang fluid GU No foley Ext Warm well perfused 1 nonpitting edema LLE Neuro CN2 12 grossly intact moving all extremities spontaneously DISCHARGE EXAM Vital signs 98.3 134 64 71 20 96 RA General AxO x3 HEENT Sclera anicteric Neck supple Lungs Clear to auscultation bilaterally no wheezes rales rhonchi on anterior auscultation CV Regular rate and rhythm normal S1 S2 III VI SEM Abdomen BS ileal conduit draining clear yellow urine. Has one LLQ drain in place draining serosanguinous fluid. Ext Warm well perfused 2 pulses no clubbing cyanosis or edema Pertinent Results ADMISSION LABS ___ 07 10PM BLOOD WBC 19.4 RBC 2.53 Hgb 6.9 Hct 22.9 MCV 91 MCH 27.3 MCHC 30.1 RDW 15.1 RDWSD 49.5 Plt ___ ___ 07 10PM BLOOD Neuts 81.4 Lymphs 9.4 Monos 7.4 Eos 0.0 Baso 0.1 Im ___ AbsNeut 15.77 AbsLymp 1.81 AbsMono 1.43 AbsEos 0.00 AbsBaso 0.02 ___ 07 10PM BLOOD ___ PTT 33.4 ___ ___ 07 10PM BLOOD Ret Aut 2.9 Abs Ret 0.07 ___ 07 10PM BLOOD Glucose 118 UreaN 25 Creat 1.1 Na 133 K 5.0 Cl 97 HCO3 23 AnGap 18 ___ 07 10PM BLOOD ALT 9 AST 9 AlkPhos 56 TotBili 0.3 ___ 07 10PM BLOOD Lipase 9 ___ 07 10PM BLOOD Albumin 2.5 Iron 6 ___ 07 10PM BLOOD calTIBC 170 Hapto 518 Ferritn 489 TRF 131 ___ 07 13PM BLOOD Lactate 1.0 DISCHARGE LABS ___ 06 00AM BLOOD WBC 6.9 RBC 2.92 Hgb 8.3 Hct 26.8 MCV 92 MCH 28.4 MCHC 31.0 RDW 15.4 RDWSD 52.4 Plt ___ ___ 06 00AM BLOOD ___ PTT 31.2 ___ ___ 06 00AM BLOOD Plt ___ ___ 06 00AM BLOOD Glucose 86 UreaN 8 Creat 0.8 Na 143 K 3.6 Cl 106 HCO3 25 AnGap 16 ___ 06 00AM BLOOD Calcium 7.5 Phos 3.7 Mg 2.3 MICROBIOLOGY Blood cultures x3 pending ___ 4 35 pm pelvic aspiration GRAM STAIN Final ___ 1 1 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE Final ___ NO GROWTH. ANAEROBIC CULTURE Preliminary NO GROWTH. PERTINENT IMAGING CT ABD PEL W CONTRAST ___ 1. Interval decrease in size of the right hemipelvis fluid collection 7.0 x 6.5 x 11.3 cm previously 10.0 x 12.7 x 14.8 cm with the anterior approach pigtail catheter unchanged in position. The pigtail is again located partly within the collection and partly outside its wall. 2. Interval increase in size of the left pelvic fluid collection now measuring 14.7 x 16.2 x 23.3 cm previously 13.6 x 13.9 x 23.0 cm . Increased peripheral enhancement may suggest superimposed infection. 3. No new fluid collection identified. CTA ABD PELVIS ___ 1. Decrease in size of right lower quadrant fluid collection that has percutaneous drain within it with areas of high attenuation on noncontrast exam consistent with blood products and associated hyperemia which is likely inflammatory but without evidence of contrast extravasation. 2. There is large stable fluid collection in the low left abdomen pelvis with mild linear peripheral enhancement infection cannot be excluded. 3. There is severe left and moderate to severe right hydroureteronephrosis with delayed left nephrogram stable from today. Mass effect about anastomosis between distal ureters and neobladder has resolved all since ___ and while hydronephrosis may be from residual edema if this does not resolve alternative etiologies including stenosis tumor infiltration should be excluded. 4. Tiny hepatic lesion segment ___ attention to this area on subsequent followups recommended. CT INTERVENTIONAL PROCEDURE ___ 1. Complete collapse the patient has recently drained left lower quadrant collection. The catheter from this collection was removed. 2. Near complete collapse of the patient is originally drained collection in the mid pelvis with pigtail catheter in place. 3. Left lower quadrant and deep pelvic collections as above. These findings were discussed with the team. Given the patient s improving clinical status the decision was made to pursue no further collection drainage at this time. 4. Severe bilateral hydronephrosis as on prior examinations. RECOMMENDATION Given persistence of severe hydronephrosis percutaneous nephrostomy tubes should be considered. Brief Hospital Course BRIEF SUMMARY ___ year old women with a history of bladder cancer s p cystectomy hysterectomy and BSO now with ileal conduit whose post operative course has been complicated by DVT PE ileus and pelvic fluid collections w one LLQ drain presented with subjective fevers lethargy and bloody drain output. She was found to have worsening anemia and was given 2 units of pRBC with appropriate increase in hemoglobin noted. She was also found on CT imaging to have an interval increase in size of a left abdominal fluid collection. Decision was made to place a drain per ID. Fluid was sent and revealed negative cultures negative malignant cells no evidence of lymphatic or urinary fluid. This new drain was subsequently removed per ___ as fluid collection was completely drained. The prior drain was still draining serosanguinous fluid and was kept in but repositioned. ID was consulted for the fevers leukocytosis and fluid collections and was deemed to need antibiotics and tranisitioned from broad spectrum to IV ertapenem at discharge. Will require multiple follow ups and imaging as specified in the transitional issues. ACUTE ISSUES Pelvic fluid collections patient arrived with one anterior drain putting out serosanguinous fluid. CT abdomen pelvis revealed enlarging left fluid collection and decision was made to place a drain per ___. The fluid was negative for malignant cells. The fluid had Cr 1 and triglycerides 9 suggesting that fluid collection is neither urine nor lymphatic fluid. Fluid culture was negative for bacteria. On interval imaging the new enlarging fluid collection had completely collapsed and the drain was removed. As for the other fluid collection that already had a drain putting out serosanguinous fluid it continued to drain serosanguinous fluid but at a lower rate than prior to admission. The drain was left in place as the fluid collection on imaging had not completely collapsed. BID N cultures for the aforementioned fluid collection came back positive for MSSA but per ID does not reflect rue intra abdominal infection. Given that patient had a fever at OSH and a leukocytosis she was placed on broad spectrum antibiotics with vanc ceftaz and flagyl. This was tapered per ID team to IV zosyn. On discharge ID recommended ertapenem for approximately 4 weeks with final length of treatment to be determined by fluid collection changes on repeat imaging on outpatient basis. Mrs. ___ remained afebrile and leukocytosis resolved. Pulmonary embolism Likely developed in the setting of being diagnosed with a post op DVT. She was placed on lovenox. She was transitioned to heparin ggt as she needed ___ procedures and was transitioned back to lovenox but at a lower dose per weight dosing to 70mg q12H upon discharge. Acute renal injury SCr has been steadily rising from a baseline of around 0.04 0.06 in ___ to 1.1 likely ___ obstructed uropathy ___ large pelbic fluid collections. ___ resolved over the course of her hospital stay with final Cr 0.8. Hydronephrosis bilateral and worsening on interval imaging from prior studies. Given patient s age adequate urinary output adequate creatinine clearance and no significant electrolyte abnormalities patient likely would not significantly benefit from intervention at this time. Per urology consult deemed stable for discharge and recommended outpatient urology followup. Anemia likely a combination of anemia of chronic inflammation and acute blood loss ___ to anterior abdominal drain showing serosanguinous fluid. Labs not consistent with hemolysis. Received 2 units of pRBC with appropriate response. Patient was discharged with Hgb of 8.3 per hem onc recommendation for threshold Hgb 8 as patient feels and functionally performs better with higher blood counts. Hypokalemia was hypokalemic and was repleted with oral KCl PRN. CHRONIC ISSUES Invasive high grade urothelial carcinoma involving the deep muscularis propria S p cystectomy hysterectomy and BSO now with ileal conduit whose post operative course has been complicated by DVT PE ileus and pelvic fluid collections. Patient stating that there is no plan for chemo and radiation her PET scan does show concerning foci of metastatic disease in the lung and peritoneum. Per patient s son Mrs. ___ has seen a doctor to work up the lung mass. Will need ongoing discussion with outpatient hem onc regarding how to best manage concerning lesions. Breast mass ___ mammogram showing BI RADS 5 Solid mass in the 3 o clock left breast with features of a highly suspicious for malignancy. Per patient s son she has seen a doctor for evaluating the new breast mass. Would recommend ongoing discussion with aforementioned doctor and outpatient hem onc about plan to manage. HLD continued atorvastatin without changes. Consider evaluation regarding stopping atorvastatin on outpatient basis Hypothyroidism continued levothyroxine without changes. HCP Dr. ___ son ___ physician ___ Code status full code confirmed with patient on ___ TRANSITIONAL ISSUES Will need infectious disease follow up. If ID has not contacted Mrs ___ by ___ she should call ___ to set up an appointment. The ID appointment needs to be AFTER her CT abdomen pelvis has already been done Assure that Mrs ___ has her CT abdomen pelvis with contrast in the week of ___ She should get weekly lab draws of the following CBC with differential BUN Cr AST ALT TB ALK PHOS. ALL LAB REQUESTS SHOULD BE ANNOTATED WITH ATTN ___ CLINIC FAX ___ If possible please give ertapenem at night time so it does not interfere with her daily activities. Tentatively she will be receiving ertapenem for ___ weeks but with final treatment length determined by the infectious disease team. Will need ongoing discussion with outpatient PCP and hem onc regarding how to manage new breast lesion and lung peritoneum lesions. Reevaluate need for atorvastatin Will need outpatient follow up with urology Dr. ___ his team regarding worsening hydronephrosis Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Atorvastatin 10 mg PO QPM 3. Enoxaparin Sodium 90 mg SC Q12H Start ___ First Dose Next Routine Administration Time 4. Levothyroxine Sodium 175 mcg PO DAILY 5. LORazepam 0.25 0.5 mg PO DAILY PRN anxiety Discharge Medications 1. Ertapenem Sodium 1 g IV 1X Duration 1 Dose please give ertapenem daily preferably at nighttime to not interfere with her daily activities 2. Milk of Magnesia 30 mL PO Q6H PRN constipation 3. Enoxaparin Sodium 70 mg SC Q12H Start Today ___ First Dose Next Routine Administration Time 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Levothyroxine Sodium 175 mcg PO DAILY 7. LORazepam 0.25 0.5 mg PO DAILY PRN anxiety Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Primary diagnosis Pelvic fluid collection infection ___ acute blood loss anemia Secondary diagnosis acute renal failure acute on chronic anemia recent pulmonary embolism invasive high grade urothelial carcinoma left breast mass BIRADS 5 hypothyroidism Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear ___ ___ did you come to the hospital You were feeling tired and your drain output was bloody. What happened at the hospital A CT scan showed very large fluid collections in your pelvis The radiologists placed another drain and removed it once it appeared that the large fluid collection was gone You were given a blood transfusion We placed a PICC a long IV so that you can receive antibiotics after you get discharged from the hospital What needs to happen when you leave the hospital Please continue seeing the doctors that are ___ your lung and breast lesions and follow their recommendations. Continue taking Lovenox every day to treat the blood clot in your lung. If the infectious disease doctor has not contacted you by ___ please call the following number to set up an appointment ___. Please make sure you have a repeat CT scan done BEFORE your appointment with the infectious disease doctor You will be getting IV antibiotics for several weeks. The infectious disease doctor ___ determine how long you will need to be on it. It was a pleasure taking care of you. Your ___ team Followup Instructions ___ The icd codes present in this text will be T814XXA, A419, K651, N179, N1330, D62, I2782, N138, C679, I10, E785, E039, K439, K435, E876, Y838, Y929, Z96652, Z86718, N63, Z7901, Z87891. The descriptions of icd codes T814XXA, A419, K651, N179, N1330, D62, I2782, N138, C679, I10, E785, E039, K439, K435, E876, Y838, Y929, Z96652, Z86718, N63, Z7901, Z87891 are T814XXA: Infection following a procedure; A419: Sepsis, unspecified organism; K651: Peritoneal abscess; N179: Acute kidney failure, unspecified; N1330: Unspecified hydronephrosis; D62: Acute posthemorrhagic anemia; I2782: Chronic pulmonary embolism; N138: Other obstructive and reflux uropathy; C679: Malignant neoplasm of bladder, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E039: Hypothyroidism, unspecified; K439: Ventral hernia without obstruction or gangrene; K435: Parastomal hernia without obstruction or gangrene; E876: Hypokalemia; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable; Z96652: Presence of left artificial knee joint; Z86718: Personal history of other venous thrombosis and embolism; N63: Unspecified lump in breast; Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, D62, I10, E785, E039, Y929, Z86718, Z7901, Z87891. The uncommon codes mentioned in this dataset are T814XXA, A419, K651, N1330, I2782, N138, C679, K439, K435, E876, Y838, Z96652, N63.
The icd codes present in this text will be N99820, E43, R310, N131, D62, R8271, E039, E785, N9989, I10, Z86718, Z936, Z7902, Z86711, Z87891, Z6822, Z8551, Z96652, Y848, Y833, Y929. The descriptions of icd codes N99820, E43, R310, N131, D62, R8271, E039, E785, N9989, I10, Z86718, Z936, Z7902, Z86711, Z87891, Z6822, Z8551, Z96652, Y848, Y833, Y929 are N99820: Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure; E43: Unspecified severe protein-calorie malnutrition; R310: Gross hematuria; N131: Hydronephrosis with ureteral stricture, not elsewhere classified; D62: Acute posthemorrhagic anemia; R8271: Bacteriuria; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; N9989: Other postprocedural complications and disorders of genitourinary system; I10: Essential (primary) hypertension; Z86718: Personal history of other venous thrombosis and embolism; Z936: Other artificial openings of urinary tract status; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z86711: Personal history of pulmonary embolism; Z87891: Personal history of nicotine dependence; Z6822: Body mass index [BMI] 22.0-22.9, adult; Z8551: Personal history of malignant neoplasm of bladder; Z96652: Presence of left artificial knee joint; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y833: Surgical operation with formation of external stoma as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable. The common codes which frequently come are D62, E039, E785, I10, Z86718, Z7902, Z87891, Y929. The uncommon codes mentioned in this dataset are N99820, E43, R310, N131, R8271, N9989, Z936, Z86711, Z6822, Z8551, Z96652, Y848, Y833. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Hematuria weakness Major Surgical or Invasive Procedure None History of Present Illness ___ y o female with h o PE on lovenox bladder cancer s p Robotic TAH BSO lap radical cystectomy with ileal loop diversion and anterior vaginectomy in ___ c b abdominal fluid requiring placement of drainage catheters. Recent abdominal imaging noted worsening of her bilateral severe hydronephrosis and her Cr was noted to have risen from 0.8 to 1.3 outside lab value . Patient recently underwent bilateral nephrostomy tube placement by ___ on ___. She first started feeling weak during ___ yesterday doing the exercises. Had palpitations with ambulation. Has tightness in chest with ambulating since yesterday. Felt light headed with ambulation. SNF noticed increased hematuria with R bag darker than L bag since yesterday. Her Urostomy placed in ___ also positive for hematuria. She was transferred to ___ ED for further management. In the ED initial vitals were Temp. 98.1 HR 72 BP 139 56 RR 16 99 RA Labs notable for WBC 5.9 Hg 8.1 platelets 374. Na 140 K 4.3 Cl 103 biacrb 22 BUN 29 Cr 1.0 UA from bilateral nephrostomy tubes with 100 WBC moderate leukocytes and large blood. Imaging was notable for CT abd pelvis w o contrast Interval placement of bilateral percutaneous nephroureterostomy tubes with resolved hydroureteronephrosis. No RP hematoma. Patient was given LR Upon arrival to the floor patient reports that she noticed shortness of breath today with walking in conjunction with bloody output from her ostomy tubes. She notes that the output from her nephrostomy tubes was pink tinged when she left the hospital 2 days ago. She also endorses associated chest tightness but no pain or pressure. She denies cough fever chills abdominal pain or diarrhea. She notes that she has an ostomy and nephroureterostomy without sensation of dysuria. Patient notes feeling dizzy and lightheaded previously though is currently asymptomatic. Past Medical History Hypertension s p lap chole s p left knee replacement s p laminectomy of L5 S1 at age ___ Bladder Cancer high grade TCC T1 diagnosed in ___ then ___ pelvic MRI w invasion into bladder wall perivesical soft tissue and anterior vaginal wall c w T4 staging s p hysterectomy and bilateral oophorectomy for large uterus w fibroid s p laparascopic b l pelvic lymph node resection s p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation ___ course complicated by bacteremia and development of intra abdominal fluid collection no s p drain placement by ___ ___ h o LLE DVT and PE on lovenox Social History ___ Family History Negative for bladder CA. Physical Exam ADMISSION PHYSICAL EXAM VITAL SIGNS Temp. 98.1 PO BP 158 66 HR 72 RR 18 Spo2 95 RA GENERAL well appearing elderly woman in no acute distress CARDIAC RRR no murmurs LUNGS clear to auscultation bilaterally ABDOMEN soft non tender to palpation normal bowel sounds. Ostomy draining brown stool. Nephroureterostomy draining dark red bloody urine. Bilateral nephrostomy tubes draining blood urine. EXTREMITIES No edema warm and well perfused. DISCHARGE PHYSICAL EXAM VS 98.3 PO 139 67 71 18 94 RA GENERAL well appearing elderly woman in no acute distress CARDIAC RRR no murmurs LUNGS clear to auscultation bilaterally ABDOMEN soft non tender to palpation normal bowel sounds. Nephroureterostomy draining dark red bloody urine. Bilateral nephrostomy tubes capped. EXTREMITIES No edema warm and well perfused Pertinent Results ADMISSION LABS ___ 05 20PM BLOOD WBC 5.9 RBC 2.90 Hgb 8.1 Hct 26.6 MCV 92 MCH 27.9 MCHC 30.5 RDW 15.4 RDWSD 51.2 Plt ___ ___ 05 48AM BLOOD WBC 4.6 RBC 2.46 Hgb 7.0 Hct 22.6 MCV 92 MCH 28.5 MCHC 31.0 RDW 15.3 RDWSD 51.7 Plt ___ ___ 05 20PM BLOOD Neuts 56.3 ___ Monos 12.6 Eos 1.5 Baso 0.3 Im ___ AbsNeut 3.29 AbsLymp 1.69 AbsMono 0.74 AbsEos 0.09 AbsBaso 0.02 ___ 05 20PM BLOOD Glucose 101 UreaN 29 Creat 1.0 Na 140 K 4.3 Cl 103 HCO3 22 AnGap 19 IMAGING STUDIES ___ CT Abd Pel w o Contrast IMPRESSION 1. Interval placement of bilateral percutaneous nephroureterostomy tubes with resolved hydroureteronephrosis. No RP hematoma. 2. Partially imaged nodular opacity in the right middle lobe which can be further assessed on a nonemergent dedicated CT chest. ___ CXR AP portable upright view of the chest. Right upper extremity access PICC line is seen with its tip in the upper SVC. Overlying EKG leads are present. Lungs are clear. Cardiomediastinal silhouette is stable. Bony structures are intact. MICROBIOLOGY ___ 6 35 pm URINE LEFT NEPHROSTOMY TUBE. FINAL REPORT ___ URINE CULTURE Final ___ NO GROWTH. DISCHARGE LABS ___ 05 08AM BLOOD WBC 5.4 RBC 2.86 Hgb 8.2 Hct 26.5 MCV 93 MCH 28.7 MCHC 30.9 RDW 15.3 RDWSD 51.8 Plt ___ ___ 05 08AM BLOOD Glucose 94 UreaN 29 Creat 0.9 Na 143 K 4.0 Cl 106 HCO3 26 AnGap 15 ___ 05 08AM BLOOD Calcium 8.8 Phos 5.2 Mg 2.1 Brief Hospital Course Ms. ___ is an ___ year old woman with history of provoked DVT PE on lovenox bladder cancer s p Robotic TAH BSO lap radical cystectomy with ileal loop diversion and anterior vaginectomy in ___ c b abdominal fluid requiring placement of drainage catheters and recent hydronephrosis requiring placement of bilateral PCN tubes on ___ presenting from rehab with hematuria and weakness. On arrival pt had evidence of frank hematuria in her urostomy bag and PCN tubes. Her hemoglobin was initially 8.1 which subsequently dropped to 7.0 Her lovenox was held and she was transfused with 1 U PRBC with an appropriate hemoglobin bump to 8.2. Hematuria was likely caused by recent instrumentation in the setting of anticoagulation. Her hematuria improved as did her dizziness weakness. ___ was consulted and recommending capping her PCN tubes. After discussion with the patient s hematologist it was decided to stop her lovenox treatment given that her DVT PE were provoked in the setting of her recovery from surgery and that she had received almost 6 months of treatment. Secondary Issues Asymptomatic bacteruria Patient with asymptomatic bacteruria in setting of recent procedural manipulation. She was afebrile and without leukocytosis so treatment with antibiotics was deferred. Hyperlipidemia continued atorvastatin 10 mg daily Hypothyroidism continue levothyroxine 175 mcg daily TRANSITIONAL ISSUES Medication Changes Lovenox stopped CT Abdomen Pelvis showed partially imaged nodular opacity in the right middle lobe which can be further assessed on a nonemergent dedicated CT chest. Pt s PCN tubes were capped per ___ recommendation during her hospitalization she was discharged with scheduled followup to decide on long term management If pt develops hematuria and or lightheadedness or other symptoms of anemia a CBC should be rechecked to assess for bleeding Hemoglobin Hematocrit on discharge 8.2 26.5 CODE presumed full CONTACT ___ MD ___ cell ___ home Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Enoxaparin Sodium 70 mg SC Q12H Start ___ First Dose Next Routine Administration Time 3. Levothyroxine Sodium 175 mcg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Probiotic Digestive Enzymes L. acidophilus dig ___ 5 ___ mg oral daily Discharge Medications 1. Atorvastatin 10 mg PO QPM 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Probiotic Digestive Enzymes L. acidophilus dig ___ 5 ___ mg oral daily Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Primary Diagnoses Hematuria anemia Secondary Diagnoses Bladder cancer hydronephrosis hypothyroidism DVT PE Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ It was a pleasure taking care of you at ___. WHY DID YOU COME TO THE HOSPITAL You noticed blood in your urine and you were feeling weak lightheaded. WHAT HAPPENED WHILE YOU WERE HERE We did not give you your blood thinner medication Lovenox and we gave you a unit of blood. The blood in your urine cleared up. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL Along with your oncologist Dr. ___ have decided that you no longer need to take any Lovenox. You should continue to follow up with your doctors and take all of your medications as prescribed. Your followup appointments are listed below. Again it was a pleasure taking care of you Sincerely Your ___ Team Followup Instructions ___ The icd codes present in this text will be N99820, E43, R310, N131, D62, R8271, E039, E785, N9989, I10, Z86718, Z936, Z7902, Z86711, Z87891, Z6822, Z8551, Z96652, Y848, Y833, Y929. The descriptions of icd codes N99820, E43, R310, N131, D62, R8271, E039, E785, N9989, I10, Z86718, Z936, Z7902, Z86711, Z87891, Z6822, Z8551, Z96652, Y848, Y833, Y929 are N99820: Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure; E43: Unspecified severe protein-calorie malnutrition; R310: Gross hematuria; N131: Hydronephrosis with ureteral stricture, not elsewhere classified; D62: Acute posthemorrhagic anemia; R8271: Bacteriuria; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; N9989: Other postprocedural complications and disorders of genitourinary system; I10: Essential (primary) hypertension; Z86718: Personal history of other venous thrombosis and embolism; Z936: Other artificial openings of urinary tract status; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z86711: Personal history of pulmonary embolism; Z87891: Personal history of nicotine dependence; Z6822: Body mass index [BMI] 22.0-22.9, adult; Z8551: Personal history of malignant neoplasm of bladder; Z96652: Presence of left artificial knee joint; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y833: Surgical operation with formation of external stoma as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable. The common codes which frequently come are D62, E039, E785, I10, Z86718, Z7902, Z87891, Y929. The uncommon codes mentioned in this dataset are N99820, E43, R310, N131, R8271, N9989, Z936, Z86711, Z6822, Z8551, Z96652, Y848, Y833.
The icd codes present in this text will be R471, I5030, E538, Z66, I4891, Z7902, I110, E7849, K5790, Z87891, R946, I455, R413. The descriptions of icd codes R471, I5030, E538, Z66, I4891, Z7902, I110, E7849, K5790, Z87891, R946, I455, R413 are R471: Dysarthria and anarthria; I5030: Unspecified diastolic (congestive) heart failure; E538: Deficiency of other specified B group vitamins; Z66: Do not resuscitate; I4891: Unspecified atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; I110: Hypertensive heart disease with heart failure; E7849: Other hyperlipidemia; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; Z87891: Personal history of nicotine dependence; R946: Abnormal results of thyroid function studies; I455: Other specified heart block; R413: Other amnesia. The common codes which frequently come are Z66, I4891, Z7902, I110, Z87891. The uncommon codes mentioned in this dataset are R471, I5030, E538, E7849, K5790, R946, I455, R413. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint slurred speech Major Surgical or Invasive Procedure None History of Present Illness ___ year old right handed woman with hx of Atrial fibrillation on Eliquis only once daily hypertension hyperlipidemia CHF presents as transfer from OSH after she had acute onset dysarthria and CTA showed possible partial thrombus or stenosis in superior division of L MCA. Transferred here for closer monitoring and possible thrombectomy if her exam acutely worsens. History obtained from patient and daughter at bedside. Patient is an excellent historian. On ___ she had dinner with friends and then returned to her apartment and was fooling around on her computer. Last known well was around 8 00 ___. Then she had an odd sensation and started throwing her arms around. She went to living room to sit down and tried to read but could not see the words very clearly. Then two family members were knocking at the door and she had a tough time standing up to open door. She was able to eventually stand up with great difficulty and walked with her walker. She usually walks with a walker because of knee replacement. Finally got up out of chair with walker and walked to the door to unlock. She noticed problems talking to family members. She had difficulty forming words and pronouncing words. Denies word finding difficulty. She could tell it was slurred like a person who had too much to drink. EMTs asked if she was intoxicated but she was not. She was very aware of her dysarthria and told her daughters that she thinks she s having a stroke. Then she said she had trouble sitting down but has no idea why she thought that. When she was standing she was able to walk with walker but she felt unsteady and almost fell. No visual changes. No numbness or tingling. Denies focal weakness she just had trouble standing up. She was able to unlock her door without issue but she felt shaky. She was brought by EMS to ___ where NIHSS was 1 for slurred speech. There she felt the same but her symptoms started to improve when she started to be transferred. Paramedics said her speech was improving rapidly en route. Last month started needing naps. Her hearing is poor at baseline and she normally uses hearing aids. For the past ___ months she has had ___ nocturia nightly. No dysuria. She has noticed more frequent headaches lately in the past ___ months. Last headache was yesterday. She takes tramadol and acetaminophen up to a couple times a night. She reports headaches at night which wake her up. She denies that the headache is positional it is the same sitting up or lying down. She has had some gradual weight loss over the past 12 months ___ year ago she was almost 140 lbs and now she is ___ lbs. Her appetite is still good and she enjoys eating but she is less hungry that she used to be. Daughter says that she has had marked decline in memory in past ___ weeks. Over past few years she has been forgetting plans times for pickpup and dinner plans which has become normal. Over the past ___ weeks family has noticed dramatic worsening. She doesn t remember which grandkids were coming to visit when she bought the plane tickets herself. She endorses 2 pillow orthopnea. Past Medical History Divertoculosis Atrial fibrillation on Eliquis CHF Hypercholesterolemia Hypertension Social History ___ Family History Father severe alcoholic schizophrenia Mother CHF Brother stroke carotid stenosis Physical Exam ADMISSION EXAM Vitals T 97.9 HR 79 BP 164 121 RR 19 SaO2 94 on RA General Awake cooperative elderly woman NAD. HEENT NC AT no scleral icterus noted MMM no lesions noted in oropharynx. Neck Supple. No nuchal rigidity. Pulmonary Normal work of breathing. Cardiac RRR warm well perfused. Abdomen Soft non distended. Extremities No ___ edema. Skin ecchymoses in L shin more extensive on R shin. Neurologic Mental Status Alert oriented ___. Able to relate history without difficulty. Attentive able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. Cranial Nerves II III IV VI PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V Facial sensation intact to light touch and pinprick. VII No facial droop facial musculature symmetric. VIII Hearing intact to finger snapping b l. Did not bring her hearing aids. IX X Palate elevates symmetrically. XI ___ strength in trapezii bilaterally. XII Tongue protrudes in midline with good excursions. Strength full with tongue in cheek testing. Motor Normal bulk and tone throughout. No pronator drift. No adventitious movements such as tremor or asterixis noted. ___ L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 Sensory No deficits to light touch pinprick temperature throughout. Decreased vibratory sense in b l feet up to ankles. Joint position sense intact in b l great toes. No extinction to DSS. Romberg absent. Reflexes Bic Tri ___ Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was flexor bilaterally. Coordination No intention tremor. No dysmetria on FNF bilaterally. HKS with L heel without dysmetria. Unable to bend R knee due to knee surgery. Gait unable to assess as patient needs a walker at baseline DISCHARGE EXAM 24 HR Data last updated ___ 419 Temp 97.4 Tm 98.6 BP 146 76 116 155 65 94 HR 53 53 86 RR 17 ___ O2 sat 96 92 97 O2 delivery Ra General Awake cooperative elderly woman NAD. HEENT NC AT no scleral icterus noted MMM no lesions noted in oropharynx. Neck Supple. No nuchal rigidity. Pulmonary Normal work of breathing. Cardiac NR RR warm well perfused. Abdomen Soft non distended. Extremities No ___ edema. Skin ecchymoses in L shin more extensive on R shin. Neurologic Mental Status Alert oriented to person and situation. Able to relate history without difficulty. Attentive to examiner. Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. Cranial Nerves II III IV VI PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. V Facial sensation intact to light touch. VII No facial droop facial musculature symmetric. VIII Hearing intact to conversation. IX X Palate elevates symmetrically. XI ___ strength in trapezii bilaterally. XII Tongue protrudes in midline with good excursions. Motor Normal bulk and tone throughout. No pronator drift. No adventitious movements such as tremor or asterixis noted. Delt Bic Tri ECR FEx IO IP Quad Ham TA Gas L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 Knee cannot bend after prior surgery Sensory No deficits to light touch throughout. Coordination No intention tremor. No dysmetria on FNF bilaterally. Gait needs a walker at baseline Pertinent Results ___ 01 50AM BLOOD WBC 7.2 RBC 4.75 Hgb 14.6 Hct 45.5 MCV 96 MCH 30.7 MCHC 32.1 RDW 13.2 RDWSD 46.5 Plt ___ ___ 01 50AM BLOOD Neuts 53.1 ___ Monos 8.2 Eos 1.5 Baso 0.3 Im ___ AbsNeut 3.81 AbsLymp 2.63 AbsMono 0.59 AbsEos 0.11 AbsBaso 0.02 ___ 01 50AM BLOOD ___ PTT 29.7 ___ ___ 01 50AM BLOOD Glucose 97 UreaN 18 Creat 0.7 Na 139 K 4.3 Cl 102 HCO3 26 AnGap 11 ___ 07 35AM BLOOD CK MB 4 cTropnT 0.01 ___ 07 35AM BLOOD Calcium 9.3 Phos 3.6 Mg 1.8 Cholest 207 ___ 07 35AM BLOOD Triglyc 62 HDL 69 CHOL HD 3.0 LDLcalc 126 ___ 10 57AM BLOOD HbA1c 5.5 eAG 111 ___ 05 22AM BLOOD VitB12 249 ___ 05 22AM BLOOD TSH 5.8 ___ 05 22AM BLOOD Trep Ab NEG ___ 03 12AM URINE Color Straw Appear Clear Sp ___ ___ 03 12AM URINE Blood NEG Nitrite NEG Protein NEG Glucose NEG Ketone NEG Bilirub NEG Urobiln NEG pH 6.5 Leuks NEG ___ OSH CTA head neck ___ opinion ___ IMPRESSION 1. Segmental left vertebral artery occlusion of indeterminate chronicity. No evidence of ischemia. 2. Somewhat small caliber attenuated left M2 inferior branch without evidence of focal occlusion. 3. No acute intracranial abnormality on noncontrast CT head. ___ MRI head w o contrast IMPRESSION 1. No acute intracranial abnormality. Specifically no large territory infarction or hemorrhage. 2. Scattered foci of T2 high signal intensity in the subcortical and periventricular white matter are nonspecific and may reflect changes due to chronic small vessel disease. ___ TTE IMPRESSION No structural source of thromboembolism identified underlying rhythm predisposes to thrombus formation . Preserved left ventricular systolic function in the setting of beat to beat variability due to arrhythmia. Mild to moderate mitral and tricuspid regurgitation. Normal pulmonary pressure. Very small pericardial effusion Brief Hospital Course Ms. ___ is a ___ year old female with AFib on Eliquis CHF HLD HTN who presented w sudden onset dysarthria abnormal arm movements and poor balance walker at baseline . NIHSS 1 for slurred speech at OSH. There a CTA head and neck was completed and there was concern for left M2 branch attenuation concerning for stenosis or occlusion and she was subsequently transferred for consideration of thrombectomy but NIHSS 0 on arrival so she was not deemed a candidate. She was admitted to the Neurology stroke service for further evaluation of possible TIA vs stroke. No further symptoms noted during admission. MRI head w o contrast were without evidence of stroke. Reports recent echocardiogram per outpatient PCP cardiologist reported as no acute findings and so this was not repeated. She mentioned concern about worsening memory but able to perform ADLs w meals cleaning provided by ALF moved 10 months ago it appears there has been no acute change. She was taking apixiban 2.5mg once daily unclear why as this is a BID medication and so her dose was increased to 2.5mg BID she was not a candidate for 5mg BID due to her age and weight . She was started on atorvastatin for her hyperlipidemia LDL 126 . EP cardiology was consulted for frequent sinus pauses noted on telemetry that persisted despite holding home atenolol recommending discontinuing home digoxin and close cardiology ___. Discharged to home w ___ ___ and close PCP ___. Transient slurred speech and instability c f TIA ___ consult cleared for home with home services Started on atorvastatin for HLD and increased home apixaban to therapeutic level ___ with stroke neurology after discharge Her stroke risk factors include the following 1 DM A1c 5.5 2 Likely chronic segmental left vertebral artery occlusion and somewhat small caliber attenuated left M2 inferior branch 3 Hyperlipidemia LDL 126 4 Obesity 5 No concern noted for sleep apnea she does not carry the diagnosis An echocardiogram did not show a PFO on bubble study. AHA ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake X Yes confirmed done Not confirmed No 2. DVT Prophylaxis administered X Yes No 3. Antithrombotic therapy administered by end of hospital day 2 X Yes No 4. LDL documented X Yes LDL 126 No 5. Intensive statin therapy administered simvastatin 80mg simvastatin 80mg ezetemibe 10mg atorvastatin 40mg or 80 mg rosuvastatin 20mg or 40mg for LDL 100 X Yes No if LDL if LDL 70 reason not given Statin medication allergy Other reasons documented by physician advanced practice nurse physician ___ physician APN PA or pharmacist LDL c less than 70 mg dL 6. Smoking cessation counseling given Yes X No reason X non smoker unable to participate 7. Stroke education personal modifiable risk factors how to activate EMS for stroke stroke warning signs and symptoms prescribed medications need for followup given verbally or written X Yes No 8. Assessment for rehabilitation or rehab services considered X Yes No 9. Discharged on statin therapy X Yes No if LDL 70 reason not given Statin medication allergy Other reasons documented by physician advanced practice nurse physician ___ physician APN PA or pharmacist LDL c less than 70 mg dL 10. Discharged on antithrombotic therapy X Yes Type Antiplatelet X Anticoagulation No 11. Discharged on oral anticoagulation for patients with atrial fibrillation flutter X Yes No N A Cognitive complaints B12 249 one time IM supplementation then start oral B12 supplementation Treponemal antibodies negative consider cognitive neurology referral as outpatient for memory difficulties not appreciated on our examination Afib frequent sinus pauses stopped digoxin will ___ closely w otpt cardiologist also PCP increased to appropriate therapeutic dosing at Eliquis 2.5 mg BID reduced dose given age and weight 60 kg HLD started atorvastatin HTN continue home antihypertensives elevated troponin RESOLVED Troponin elevated at OSH negative on admission elevated TSH should recheck as otpt w PCP ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. Apixaban 2.5 mg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Digoxin 0.125 mg PO DAILY 5. LevoFLOXacin 500 mg PO Q24H Discharge Medications 1. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet s by mouth once daily at bedtime Disp 30 Tablet Refills 5 2. Cyanocobalamin 500 mcg PO DAILY RX cyanocobalamin vitamin B 12 500 mcg 1 tablet s by mouth once daily Disp 30 Tablet Refills 5 3. Apixaban 2.5 mg PO BID 4. Atenolol 50 mg PO DAILY 5. LevoFLOXacin 500 mg PO Q24H 6. Losartan Potassium 50 mg PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis transient dysarthria not secondary to TIA or stroke Mild Vitamin B12 deficiency Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Ms. ___ You were hospitalized due to symptoms of slurred speech due to concern for an ACUTE ISCHEMIC STROKE a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. However the MRI of your brain did not show evidence of stroke or TIA. Your symptoms could have been related to blood pressure dehydration alcohol use or a combination of these factors. We are changing your medications as follows Increase apixaban to 2.5mg twice daily Start Vitamin B12 daily supplement Please take your other medications as prescribed. Please follow up with your primary care physician as listed below. You should also follow up with your cardiologist as you were noted to have occasional pauses on cardiac monitoring. If you experience any of the symptoms below please seek emergency medical attention by calling Emergency Medical Services dialing 911 . In particular please pay attention to the sudden onset and persistence of these symptoms Sudden partial or complete loss of vision Sudden loss of the ability to speak words from your mouth Sudden loss of the ability to understand others speaking to you Sudden weakness of one side of the body Sudden drooping of one side of the face Sudden loss of sensation of one side of the body Sincerely Your ___ Neurology Team Followup Instructions ___ The icd codes present in this text will be R471, I5030, E538, Z66, I4891, Z7902, I110, E7849, K5790, Z87891, R946, I455, R413. The descriptions of icd codes R471, I5030, E538, Z66, I4891, Z7902, I110, E7849, K5790, Z87891, R946, I455, R413 are R471: Dysarthria and anarthria; I5030: Unspecified diastolic (congestive) heart failure; E538: Deficiency of other specified B group vitamins; Z66: Do not resuscitate; I4891: Unspecified atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; I110: Hypertensive heart disease with heart failure; E7849: Other hyperlipidemia; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; Z87891: Personal history of nicotine dependence; R946: Abnormal results of thyroid function studies; I455: Other specified heart block; R413: Other amnesia. The common codes which frequently come are Z66, I4891, Z7902, I110, Z87891. The uncommon codes mentioned in this dataset are R471, I5030, E538, E7849, K5790, R946, I455, R413.
The icd codes present in this text will be J441, N179, Z9981, I4891, D649, I10, E785, G5622, I2510, M1990, Z96649, Z87891, J45909, F419, G4700, R040, I739. The descriptions of icd codes J441, N179, Z9981, I4891, D649, I10, E785, G5622, I2510, M1990, Z96649, Z87891, J45909, F419, G4700, R040, I739 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; N179: Acute kidney failure, unspecified; Z9981: Dependence on supplemental oxygen; I4891: Unspecified atrial fibrillation; D649: Anemia, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; G5622: Lesion of ulnar nerve, left upper limb; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; M1990: Unspecified osteoarthritis, unspecified site; Z96649: Presence of unspecified artificial hip joint; Z87891: Personal history of nicotine dependence; J45909: Unspecified asthma, uncomplicated; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; R040: Epistaxis; I739: Peripheral vascular disease, unspecified. The common codes which frequently come are N179, I4891, D649, I10, E785, I2510, Z87891, J45909, F419, G4700. The uncommon codes mentioned in this dataset are J441, Z9981, G5622, M1990, Z96649, R040, I739. Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint Shortness of breath Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ with hx COPD on home O2 atrial fibrillation on apixaban hypertension CAD and hyperlipidemia with recurrent hospitalizations for COPD exacerbations who presented with dyspnea. She has had multiple prior admissions for dyspnea. She was recently discharged on ___ after 3 day inpatient admission for COPD exacerbation. She was discharged on extended prednisone taper with plan for 5d 40mg Prednisone to finish ___ followed by 10mg taper every 5 days 35mg from ___ 30mg ___ etc... . On the evening prior to presentation patient experienced worsening shortness of breath nonproductive cough and wheezing c w prior COPD exacerbations. She reported taking inhalers as directed without relief. The patient reported that this is almost identical to her last presentation. She also felt that she was taking too many medications and does not wish to continue to take prednisone. The patient was also noted to have increased O2 requirement and she was referred to the ___ ED for further management. Of note please see prior admission note for details regarding prior admission. In the ED initial vital signs were 88 143 105 26 94 RA. Labs were notable for normal BNP and a creatinine of 1.2. Patient was given azithromycin and duoneb. Patient was scheduled to have methylpred but did not have it administered until arrival to the floor. Upon arrival to the floor she complained of wheezing and SOB. She otherwise felt well. She agreed to take the methyprednisone but does not wish to take prednisone any more. REVIEW OF SYSTEMS Per HPI. Denies headache visual changes pharyngitis fevers chills sweats weight loss chest pain abdominal pain nausea vomiting diarrhea constipation hematochezia dysuria rash paresthesias and weakness. Past Medical History COPD Asthma on home 2L O2 Atypical Chest Pain Hypertension Hyperlipidemia Osteroarthritis Atrial Fibrillation on Apixaban Anxiety Cervical Radiculitis Cervical Spondylosis Coronary Artery Disease Headache Herpes Zoster GI Bleeding Peripheral Vascular Disease s p bilateral iliac stents s p hip replacement Social History ___ Family History Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam PHYSICAL EXAMINATION ON ADMISSION VITALS 97.3 159 91 75 16 94 on 2L GENERAL Pleasant well appearing in no apparent distress. HEENT Normocephalic atraumatic no conjunctival pallor or scleral icterus PERRLA EOMI OP clear. NECK Supple no LAD no thyromegaly JVP flat. CARDIAC Normal S1 S2 no murmurs rubs or gallops. PULMONARY Mild expiratory wheezes in all lung fields ABDOMEN Normal bowel sounds soft non tender non distended no organomegaly. EXTREMITIES Warm well perfused no cyanosis clubbing or edema. SKIN Without rash. NEUROLOGIC A Ox3 CN II XII grossly normal normal sensation with strength ___ throughout. PHYSICAL EXAMINATION ON DISCHARGE VITALS 98.6 127 150 50 60 70 90 S 16 98 on 3L GENERAL Pleasant well appearing in no apparent distress. HEENT Normocephalic atraumatic no conjunctival pallor or scleral icterus PERRLA EOMI OP clear. NECK Supple no LAD no thyromegaly JVP flat. CARDIAC Normal S1 S2 no murmurs rubs or gallops. PULMONARY Minimally decreased bilateral air entry no wheezes in all lung fields ABDOMEN Normal bowel sounds soft non tender non distended no organomegaly. EXTREMITIES Warm well perfused no cyanosis clubbing or edema. SKIN Without rash. NEUROLOGIC A Ox3 CN II XII grossly normal normal sensation with strength ___ throughout. Pertinent Results LABS ON ADMISSION ___ 06 15PM BLOOD WBC 7.7 RBC 4.92 Hgb 13.5 Hct 42.4 MCV 86 MCH 27.4 MCHC 31.8 RDW 19.6 RDWSD 61.2 Plt ___ ___ 06 15PM BLOOD Neuts 87.4 Lymphs 5.7 Monos 6.1 Eos 0.0 Baso 0.1 Im ___ AbsNeut 6.72 AbsLymp 0.44 AbsMono 0.47 AbsEos 0.00 AbsBaso 0.01 ___ 06 15PM BLOOD ___ PTT 29.6 ___ ___ 06 15PM BLOOD Plt ___ ___ 06 15PM BLOOD Glucose 122 UreaN 21 Creat 1.2 Na 136 K 3.4 Cl 92 HCO3 31 AnGap 16 ___ 06 15PM BLOOD ALT 52 AST 34 AlkPhos 69 TotBili 0.3 ___ 06 15PM BLOOD Lipase 28 ___ 06 15PM BLOOD cTropnT 0.01 proBNP 325 ___ 06 15PM BLOOD Albumin 4.2 LABS ON DISHCHARGE ___ 06 40AM BLOOD WBC 10.3 RBC 4.20 Hgb 11.8 Hct 37.0 MCV 88 MCH 28.1 MCHC 31.9 RDW 19.9 RDWSD 65.1 Plt ___ ___ 06 40AM BLOOD Plt ___ ___ 06 40AM BLOOD Glucose 112 UreaN 18 Creat 0.9 Na 137 K 3.6 Cl 96 HCO3 28 AnGap 17 ___ 06 40AM BLOOD Calcium 9.5 Phos 2.6 Mg 2.1 IMAGING ___ CXR No acute cardiopulmonary process. Brief Hospital Course ___ yo F with history of COPD on home O2 atrial fibrillation on apixaban hypertension CAD hyperlipidemia and recurrent hospitalization for COPD exacerbation over the last 4 months who presented with dyspnea and increased wheezing secondary to severe COPD. Recurrent COPD exacerbation Patient presented with increased dyspnea and diffuse wheezing likely secondary to COPD exacerbation. She has a history of multiple recurrent COPD hospitalizations. According to Pulmonary patient has severe COPD based on her obstructive deficits on PFTs as well as her severe symptoms even at rest as well as her more frequent exacerbations and is likely approaching end stage disease. We continued Advair 500 50 BID Spiriva standing nebulizers and theophylline. Pulmonary recommended additional budesonide inhalers to allow reduction of PO prednisone dose. Prednisone dose was increased back to 40mg where patient was better with a plan for slow wean by 5mg every 2 weeks. Also patient was started on chronic azithromycin for chronic anti inflammation after discussion with Dr. ___ was agreed to stop azithromycin on discharge due to inability to monitor QT the week after discharge with plan to restart azithromycin once Dr. ___ is able to see the patient. Patient did not want to go to pulmonary rehab. She was seen by Palliative Care who recommended initiation of morphine liquid suspension as needed for shortness of breath. Acute kidney injury Creatinine was slightly elevated to 1.2 from a baseline of 1.0. She likely had poor PO intake. Creatinine on discharge was 0.9. CHRONIC ISSUES Anxiety Insomnia We continued home lorazepam. Atrial fibrillation We continued diltiazem for rate control and apixaban for anticoagulation. Hypertension We continued home imdur hydrochlorothiazide and diltiazem. CAD Cardiac catheterization in ___ showed no evidence of significant stenosis of coronaries. ECHO on ___ showed EF 55 and no regional or global wall motion abnormalities. We continued home aspirin and atorvastatin. Anemia We continued home iron supplements. TRANSITIONAL ISSUES Continue Advair 500 50 BID Spiriva and theophylline Make sure patient receives standing nebulizers Added additional budesonide inhalers to allow reduction of PO prednisone dose Start chronic azithromycin for chronic anti inflammation. Patient was started on azithromycin in the hospital and QTc on ___ was 472 ms. ___ discussion with Dr. ___ was agreed to stop azithromycin on discharge due to inability to monitor QT the week after discharge with the plan to restart azithromycin once Dr. ___ is able to see the patient. Would recommend audiology testing at some point while patient is on chronic azithromycin Continue supplemental oxygen for comfort Follow up with Dr. ___ discharge Continue Bactrim PPX 1 tab SS daily given extended courses of steroids Patient was discharged on prednisone 40 mg with plan for taper by 5mg every 2 weeks Prednisone 40 mg for two weeks Day 1 ___ end ___ Prednisone 35 mg for two weeks Day 1 ___ end ___ Prednisone 30 mg for two weeks Day 1 ___ end ___ etc... CONTACT ___ husband HCP ___ CODE STATUS Full confirmed Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. albuterol sulfate 90 mcg actuation inhalation Q4H 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended Release 240 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 11. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 12. Guaifenesin ___ mL PO Q4H PRN cough 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 15. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 16. Lorazepam 0.5 mg PO Q8H PRN Insomnia anxiety vertigo 17. Multivitamins 1 TAB PO DAILY 18. PredniSONE 30 mg PO DAILY Tapered dose DOWN 19. Ranitidine 300 mg PO DAILY 20. Theophylline SR 300 mg PO BID 21. Tiotropium Bromide 1 CAP IH DAILY 22. Levofloxacin 750 mg PO DAILY 23. Sulfameth Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use 24. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 25. cod liver oil 1 capsule oral BID 26. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing Discharge Medications 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 3. Tiotropium Bromide 1 CAP IH DAILY 4. Theophylline SR 300 mg PO BID 5. Sulfameth Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use 6. Ranitidine 300 mg PO DAILY 7. PredniSONE 40 mg PO DAILY 8. Lorazepam 0.5 mg PO Q8H PRN Insomnia anxiety vertigo 9. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 10. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 11. Ipratropium Bromide Neb 1 NEB IH Q6H Wheezing 12. Hydrochlorothiazide 50 mg PO DAILY 13. Guaifenesin ___ mL PO Q4H PRN cough 14. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 15. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 16. Ferrous Sulfate 325 mg PO DAILY 17. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 18. albuterol sulfate 90 mcg actuation inhalation Q4H 19. Apixaban 5 mg PO BID 20. Aspirin 81 mg PO DAILY 21. Atorvastatin 10 mg PO QPM 22. Diltiazem Extended Release 240 mg PO BID 23. Docusate Sodium 100 mg PO BID 24. Sodium Chloride Nasal ___ SPRY NU QID PRN nasal discomfort RX sodium chloride 0.65 ___ spray QID nasal congestion Disp 1 Spray Refills 0 25. Morphine Sulfate Oral Solution 2 mg mL 5 mg PO Q4H PRN shortness of breath RX morphine 10 mg 5 mL 2.5 mL by mouth every four 4 hours Disp ___ Milliliter Milliliter Refills 0 26. Budesonide Nasal Inhaler 180 mcg Other DAILY RX budesonide Pulmicort Flexhaler 180 mcg actuation 160 mcg delivered 1 puff INH DAILY Disp 1 Inhaler Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS Severe COPD SECONDARY DIAGNOSES CAD Hypertension Atrial fibrillation Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear ___ ___ was a great pleasure taking care of you at ___ ___. You came to the hospital because you were experiencing worsening shortness of breath. Pulmonary team saw you and reviewed your condition and your symptoms are thought to be related to severe COPD. We did some changes in your medications and increased the dose of prednisone. The Palliative Care team was consulted and started you on morphine liquid suspension to help with your breathing symptoms. Please take all your medications on time and follow up with your doctors as ___. Best regards Your ___ team Followup Instructions ___ The icd codes present in this text will be J441, N179, Z9981, I4891, D649, I10, E785, G5622, I2510, M1990, Z96649, Z87891, J45909, F419, G4700, R040, I739. The descriptions of icd codes J441, N179, Z9981, I4891, D649, I10, E785, G5622, I2510, M1990, Z96649, Z87891, J45909, F419, G4700, R040, I739 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; N179: Acute kidney failure, unspecified; Z9981: Dependence on supplemental oxygen; I4891: Unspecified atrial fibrillation; D649: Anemia, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; G5622: Lesion of ulnar nerve, left upper limb; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; M1990: Unspecified osteoarthritis, unspecified site; Z96649: Presence of unspecified artificial hip joint; Z87891: Personal history of nicotine dependence; J45909: Unspecified asthma, uncomplicated; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; R040: Epistaxis; I739: Peripheral vascular disease, unspecified. The common codes which frequently come are N179, I4891, D649, I10, E785, I2510, Z87891, J45909, F419, G4700. The uncommon codes mentioned in this dataset are J441, Z9981, G5622, M1990, Z96649, R040, I739.
The icd codes present in this text will be J441, Z9981, I4891, J45909, Z7901, I10, I2510, E785, M1990, F419, I739, G4700, D649, Z96649, Z87891. The descriptions of icd codes J441, Z9981, I4891, J45909, Z7901, I10, I2510, E785, M1990, F419, I739, G4700, D649, Z96649, Z87891 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; Z9981: Dependence on supplemental oxygen; I4891: Unspecified atrial fibrillation; J45909: Unspecified asthma, uncomplicated; Z7901: Long term (current) use of anticoagulants; I10: Essential (primary) hypertension; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; M1990: Unspecified osteoarthritis, unspecified site; F419: Anxiety disorder, unspecified; I739: Peripheral vascular disease, unspecified; G4700: Insomnia, unspecified; D649: Anemia, unspecified; Z96649: Presence of unspecified artificial hip joint; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I4891, J45909, Z7901, I10, I2510, E785, F419, G4700, D649, Z87891. The uncommon codes mentioned in this dataset are J441, Z9981, M1990, I739, Z96649. Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint Shortness of Breath Major Surgical or Invasive Procedure N A History of Present Illness Ms. ___ is a ___ female with history of COPD on home O2 atrial fibrillation on apixaban hypertension CAD and hyperlipidemia who presents with shortness of breath cough and wheezing for one day. The patient reports shortness of breath increased cough productive of ___ red flected sputum and wheezing since yesterday evening. She has been using albuterol IH more frequently ___ with ipratropium nebs every 4 hours with minimal relief. She had to increase her O2 flow up to 4L without significant improvement. She was currently taking 10mg of prednisone. She has also been taking tiotropium IH theophylline advair IH at home as prescribed. She denies sick contacts. She quit smoking approximately 1 month ago. She reports an episode of chest pain in waiting room while sitting down non exertional resolved after 2 minutes. She denies fever chills abdominal pain nausea vomiting palpitations and diaphoresis. She was recently admitted from ___ to ___ for dyspnea that was thought to be secondary to steroid taper for recent COPD exacerbation with a component of anxiety not an acute COPD exacerbation and was treated with steroids and duonebs but no antibiotics. She had a CT that showed emphysema but no evidence of infection such as ___. Pulmonary was consulted and recommended increasing her Advair dose to 500 50 which was done and switching from theophylline to roflumilast and initiation of long term azithromycin therapy which was deferred for outpatient follow up She was initiated on a steroid taper on ___ of prednisone 30 mg for 3 days then 20 mg for 3 days then 10 mg until outpatient follow up. In the ED initial vital signs were 97.6 67 132 82 22 97 4L. Exam was notable for limited air movement with wheezing bilaterally. Labs were notable for WBC 7.1 H H 12.8 41.1 Plt 233 Na 133 K 3.6 BUN Cr ___ trop 0.01 BNP 181 lactate 1.5 VBG 7.43 ___. Imaging with CXR showed mild basilar atelectasis without definite focal consolidation. The patient was given Duonebs and solumedrol 125mg IV. Vitals prior to transfer were Upon arrival to the floor she reports her breathing is improved. REVIEW OF SYSTEMS Per HPI. Denies headache visual changes pharyngitis rhinorrhea nasal congestion fevers chills sweats weight loss abdominal pain nausea vomiting diarrhea constipation hematochezia dysuria rash paresthesias and weakness. Past Medical History COPD Asthma on home 2L O2 Atypical Chest Pain Hypertension Hyperlipidemia Osteroarthritis Atrial Fibrillation on Apixaban Anxiety Cervical Radiculitis Cervical Spondylosis Coronary Artery Disease Headache Herpes Zoster GI Bleeding Peripheral Vascular Disease s p bilateral iliac stents s p hip replacement Social History ___ Family History Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam ADMISSION PHYSICAL EXAM VITALS Temp 97.3 HR 76 O2 sat 160 80 RR 20 O2 sat 94 4L GENERAL AOx3 speaking in full sentences NAD resting in bed comfortably. HEENT NCAT. PERRL. EOMI. Sclera anicteric and not injected. MMM. Oropharynx is clear. NECK Supple. No LAD. JVP not appreciated at 45 degrees. CARDIAC Irregularly irregular normal rate. ___ systolic murmur at the RUSB. No rubs or gallops. LUNGS Expiratory wheezes throughout with poor air movement. ABDOMEN BS soft nontender and nondistended. EXTREMITIES Warm and well perfused. No edema. 2 DP pulses bilaterally. NEUROLOGIC A Ox3 CNII XII intact strength and sensation grossly intact bilaterally. DISCHARGE PHYSICAL EXAM VITALS Tm 99.1 146 69 143 159 69 77 94 22 94 95 2L GENERAL speaking in full sentences NAD resting in bed comfortably. CARDIAC rrr normal rate. ___ systolic murmur at the RUSB LUNGS mild wheezes throughout ABDOMEN BS soft nontender and nondistended. EXTREMITIES Warm and well perfused. 1 b l ___ edema. NEUROLOGIC grossly nonfocal aaox3 Pertinent Results ADMISSION LABS ___ 05 54PM BLOOD WBC 7.1 RBC 4.74 Hgb 12.8 Hct 41.1 MCV 87 MCH 27.0 MCHC 31.1 RDW 22.6 RDWSD 69.0 Plt ___ ___ 05 54PM BLOOD Neuts 81.8 Lymphs 9.6 Monos 7.6 Eos 0.3 Baso 0.1 Im ___ AbsNeut 5.82 AbsLymp 0.68 AbsMono 0.54 AbsEos 0.02 AbsBaso 0.01 ___ 06 35AM BLOOD Calcium 9.9 Phos 4.1 Mg 2.0 ___ 05 54PM BLOOD ___ pO2 52 pCO2 49 pH 7.43 calTCO2 34 Base XS 6 ___ 05 54PM BLOOD Lactate 1.5 ___ 05 54PM BLOOD proBNP 181 ___ 05 54PM BLOOD cTropnT 0.01 STUDIES CXR ___ Mild basilar atelectasis without definite focal consolidation. EKG Sinus rhythm at 69 left bundle branch block no acute ST or T wave changes. DISCHARGE LABS ___ 06 38AM BLOOD WBC 14.4 RBC 4.34 Hgb 11.8 Hct 37.6 MCV 87 MCH 27.2 MCHC 31.4 RDW 22.5 RDWSD 69.4 Plt ___ ___ 06 38AM BLOOD Glucose 113 UreaN 18 Creat 0.8 Na 137 K 3.1 repleted Cl 94 HCO3 31 AnGap 15 Brief Hospital Course Ms. ___ is a ___ female with history of COPD on home O2 atrial fibrillation on apixaban hypertension CAD and hyperlipidemia who presents with shortness of breath cough and wheezing for one day. Pt recently DC d from hospital for dyspnea treated only w nebs and steroids as not thought ___ true COPD exacerbation c f anxiety component. Pt re admitted w similar Sx thought ___ COPD exacerbation received nebs steroids azithromycin. Pt s wheezing cough SOB improved shortly after admission O2 titrated down satting well on 2L in mid 90s which is baseline. Evaluated by ___ recommended DC to pulmonary rehab pt was agreeable. ACTIVE ISSUES Shortness of Breath Patient with history of COPD and recent admission for dyspnea in the setting of steroid taper. Her symptoms on presentation were consistent with severe COPD given diffuse wheezing and poor air movement. She likely had an exacerbation in the setting of a decrease in her steroids. There may also be a component of anxiety. She underwent CT last admission that was negative for infections such as ___. She was continued on home spiriva theophylline advair. She was started on standing duonebs q6h and albuterol q2h prn and prednisone was started at 40mg daily with slow taper. She was also given azithromycin to complete 5 day course. She had improvement in her wheezing and returned to baseline O2 requirement after 48 hours. She was seen by ___ who felt that she would benefit from discharge to inpatient pulmonary rehabilitation program. On DC to ___ rehab recommended continued Prendisone 40mg daily for 1x week with slow taper by 5mg every 5 days. ___ also consider starting bactrim ppx with extended duration of steroids if unable to wean less than 20mg qd. Will also f u as outpatient with pulm. CHRONIC ISSUES Anxiety Insomnia Continued home lorazepam. Consider starting SRRI as an outpatient. Atrial Fibrillation Continued dilt for rate control and apixaban for anticoagulation. Hypertension Continued home imdur hydrochlorothiazide and diltiazem. CAD Cardiac catheterization in ___ without evidence of significant stenosis of coronaries. ECHO on ___ with EF 55 and no regional or global wall motion abnormalities. Continued home aspirin and atorvastatin. Anemia Continued home iron supplements. TRANSITIONAL ISSUES For pt s continued COPD exacerbations recommend finishing 5d course of Azithromycin 250mg qd until ___ Recommend extended prednisone taper for pt 5d 40mg Prednisone to finish ___ followed by 10mg taper every 5 days 35mg from ___ 30mg ___ etc... . Would consider PCP prophylaxis with ___ if unable to wean prednisone to less than 20mg daily. Pt s SOB may have an anxiety component may benefit from starting SSRI in addition to home benzos already prescribed CONTACT Full Code CODE STATUS ___ husband HCP ___ ___ on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Diltiazem Extended Release 240 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 8. Ferrous Sulfate 325 mg PO DAILY 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 10. Hydrochlorothiazide 50 mg PO DAILY 11. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 12. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 13. Multivitamins 1 TAB PO DAILY 14. PredniSONE 10 mg PO DAILY 15. Ranitidine 300 mg PO DAILY 16. Theophylline SR 300 mg PO BID 17. Tiotropium Bromide 1 CAP IH DAILY 18. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing 19. cod liver oil 1 capsule oral BID 20. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 21. albuterol sulfate 90 mcg actuation inhalation Q4H 22. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 23. Lorazepam 0.5 mg PO Q8H PRN Anxiety 24. Guaifenesin ___ mL PO Q4H PRN cough Discharge Medications 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. albuterol sulfate 90 mcg actuation inhalation Q4H 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended Release 240 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 11. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 12. Guaifenesin ___ mL PO Q4H PRN cough 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 15. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 16. Lorazepam 0.5 mg PO Q8H PRN Anxiety 17. Multivitamins 1 TAB PO DAILY 18. Ranitidine 300 mg PO DAILY 19. Theophylline SR 300 mg PO BID 20. Tiotropium Bromide 1 CAP IH DAILY 21. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 22. cod liver oil 1 capsule oral BID 23. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing 24. Nicotine Patch 7 mg TD DAILY 25. Azithromycin 250 mg PO Q24H Duration 4 Doses please take until ___. PredniSONE 40 mg PO DAILY Duration 5 Days 40mg until ___ Tapered dose DOWN Discharge Disposition Extended Care Facility ___ ___ Diagnosis PRIMARY COPD Exacerbation SECONDARY Afib Anxiety HTN CAD Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Ms. ___ You were admitted to ___ after you developed shortness of breath and wheezing at home shortly after your last discharge. You were treated for a COPD exacerbation and your breathing quickly got better. Our physical therapists evaluated you and recommended that you have a short stay at Pulmonary ___ before going home to improve your breathing. We wish you all the best at rehab and send our condolences to your family on your recent loss. It was truly a pleasure taking care of you. Your ___ Team Followup Instructions ___ The icd codes present in this text will be J441, Z9981, I4891, J45909, Z7901, I10, I2510, E785, M1990, F419, I739, G4700, D649, Z96649, Z87891. The descriptions of icd codes J441, Z9981, I4891, J45909, Z7901, I10, I2510, E785, M1990, F419, I739, G4700, D649, Z96649, Z87891 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; Z9981: Dependence on supplemental oxygen; I4891: Unspecified atrial fibrillation; J45909: Unspecified asthma, uncomplicated; Z7901: Long term (current) use of anticoagulants; I10: Essential (primary) hypertension; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; M1990: Unspecified osteoarthritis, unspecified site; F419: Anxiety disorder, unspecified; I739: Peripheral vascular disease, unspecified; G4700: Insomnia, unspecified; D649: Anemia, unspecified; Z96649: Presence of unspecified artificial hip joint; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I4891, J45909, Z7901, I10, I2510, E785, F419, G4700, D649, Z87891. The uncommon codes mentioned in this dataset are J441, Z9981, M1990, I739, Z96649.
The icd codes present in this text will be J441, K7200, R579, J9602, J9601, I442, I82621, I4891, D696, I469, I10, E785, Z7901, M47892, I7389, I2510, Z87891, Z96641, J0190, F419, G4700, R609, D509, R509, M1990, Y92239, Z7952, Z825, Z781, Z515, Z66, Z9981, J45909, I447, M7981, T45515A. The descriptions of icd codes J441, K7200, R579, J9602, J9601, I442, I82621, I4891, D696, I469, I10, E785, Z7901, M47892, I7389, I2510, Z87891, Z96641, J0190, F419, G4700, R609, D509, R509, M1990, Y92239, Z7952, Z825, Z781, Z515, Z66, Z9981, J45909, I447, M7981, T45515A are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; K7200: Acute and subacute hepatic failure without coma; R579: Shock, unspecified; J9602: Acute respiratory failure with hypercapnia; J9601: Acute respiratory failure with hypoxia; I442: Atrioventricular block, complete; I82621: Acute embolism and thrombosis of deep veins of right upper extremity; I4891: Unspecified atrial fibrillation; D696: Thrombocytopenia, unspecified; I469: Cardiac arrest, cause unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z7901: Long term (current) use of anticoagulants; M47892: Other spondylosis, cervical region; I7389: Other specified peripheral vascular diseases; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z87891: Personal history of nicotine dependence; Z96641: Presence of right artificial hip joint; J0190: Acute sinusitis, unspecified; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; R609: Edema, unspecified; D509: Iron deficiency anemia, unspecified; R509: Fever, unspecified; M1990: Unspecified osteoarthritis, unspecified site; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; Z7952: Long term (current) use of systemic steroids; Z825: Family history of asthma and other chronic lower respiratory diseases; Z781: Physical restraint status; Z515: Encounter for palliative care; Z66: Do not resuscitate; Z9981: Dependence on supplemental oxygen; J45909: Unspecified asthma, uncomplicated; I447: Left bundle-branch block, unspecified; M7981: Nontraumatic hematoma of soft tissue; T45515A: Adverse effect of anticoagulants, initial encounter. The common codes which frequently come are J9601, I4891, D696, I10, E785, Z7901, I2510, Z87891, F419, G4700, D509, Z515, Z66, J45909. The uncommon codes mentioned in this dataset are J441, K7200, R579, J9602, I442, I82621, I469, M47892, I7389, Z96641, J0190, R609, R509, M1990, Y92239, Z7952, Z825, Z781, Z9981, I447, M7981, T45515A. Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint Shortness of breath Major Surgical or Invasive Procedure Intubation Mechanical Ventilation Extubated Temporary Pacer Placement CVL Insertion History of Present Illness ___ with COPD who has been admitted 9 times since ___ for dyspnea CAD atrial fibrillation on apixaban who presented with shortness of breath since being discharged on ___. She was discharged home with services. Mrs. ___ has significant COPD with recent PFTs on ___ showing severely reduced FEV1 and moderately reduced FEV1 FVC. She was generally feeling better since discharged on ___ continuing her prednisone at 40mg today until the day prior to presentation. She subsequently began to become short of breath especially with exertion and developed a cough productive of brown sputum. No fever chills nausea vomiting diarrhea. She sleeps with three pillows laying on her side which is stable. Her secondary concern is that she is having trouble walking due to pain in her R hip to R thigh with weight bearing. This was new. No falls or trauma. No loss of sensation numbness weakness urinary or fecal incontinence or difficulty urinating. In the ED initial vital signs were 99.0 80 116 66 24 98 Nasal Cannula Exam was notable for diffuse ronchi worst in the RLL tripoding Labs were notable for flu swab negative WBC 7.5 with left shift CBC otherwise WNL BNP 425 lactate 3.0 U A cloudy with 30 protein but otherwise negative BUN Cr ___ Imaging CXR with mild bibasilar atelectasis though ED physicians concerned for pneumonia on lateral view The patient was given 1g Vancomycin 2g cefepime 500 mg PO azithromycin 1 duoneb 20 mg prednisone total 60 mg that day Consults none Vitals prior to transfer were 98.2 87 148 76 18 92 RA Upon arrival to the floor Mrs. ___ stated her breathing was slightly better but she continued to have shortness of breath. She felt as though her ears are clogged up and this was her as well. She stated she has been taking all her medications as prescribed. Past Medical History COPD Asthma on home 2L O2 Atypical Chest Pain Hypertension Hyperlipidemia Osteroarthritis Atrial Fibrillation on Apixaban Anxiety Cervical Radiculitis Cervical Spondylosis Coronary Artery Disease Headache Herpes Zoster GI Bleeding Peripheral Vascular Disease s p bilateral iliac stents s p hip replacement Social History ___ Family History Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam PHYSICAL EXAMINATION ON ADMISSION VITALS 98.4 140 83 77 22 94 RA GENERAL breathing somewhat heavily with audible wheeze HEENT no pallor or icterus no oropharyngeal lesion no sinus tenderness NECK Supple JVP flat CARDIAC RRR unable to appreciate any m r g due to breathing PULMONARY diffuse wheezes and ronchi ABDOMEN NT ND BS EXTREMITIES 1 lower extremity edema up shins patient is sitting ___ style and I do not appreciate tenderness at the R hip SKIN Without rash. NEUROLOGIC A Ox3 moving all extremities with purpose PHYSICAL EXAMINATION ON DISCHARGE HR and RR went to zero on continuous telemetry. Patient did not respond to vocal or tactile stimuli. Pupils were non reactive to light. She had no heart or lung sounds for 1 minute on auscultation. She was pronounced dead at 0515. Family was notified they had previously declined an autopsy. Pertinent Results LABS ON ADMISSION ___ 04 38PM BLOOD WBC 7.5 RBC 4.39 Hgb 12.3 Hct 38.6 MCV 88 MCH 28.0 MCHC 31.9 RDW 18.0 RDWSD 56.9 Plt ___ ___ 04 38PM BLOOD Neuts 92.1 Lymphs 3.9 Monos 3.5 Eos 0.0 Baso 0.0 Im ___ AbsNeut 6.91 AbsLymp 0.29 AbsMono 0.26 AbsEos 0.00 AbsBaso 0.00 ___ 04 38PM BLOOD Plt ___ ___ 04 38PM BLOOD Glucose 143 UreaN 20 Creat 1.1 Na 135 K 3.5 Cl 91 HCO3 29 AnGap 19 ___ 04 38PM BLOOD ALT 50 AST 41 AlkPhos 73 TotBili 0.3 ___ 04 38PM BLOOD proBNP 425 ___ 04 38PM BLOOD Albumin 4.4 Calcium 10.3 Phos 3.6 Mg 2.0 ___ 10 40AM BLOOD ___ pO2 130 pCO2 41 pH 7.42 calTCO2 28 Base XS 2 Comment GREEN TOP ___ 04 44PM BLOOD Lactate 3.0 LABS ON DISCHARGE ___ 04 15AM BLOOD WBC 13.4 RBC 2.42 Hgb 7.0 Hct 22.9 MCV 95 MCH 28.9 MCHC 30.6 RDW 17.5 RDWSD 56.8 Plt ___ ___ 04 15AM BLOOD Glucose 94 UreaN 15 Creat 0.6 Na 138 K 4.2 Cl 97 HCO3 37 AnGap 8 ___ 04 15AM BLOOD Calcium 8.3 Phos 3.0 Mg 2.0 SELECT IMAGING ___ CXR COMPARISON ___ FINDINGS Heart size is mildly enlarged. There is mild unfolding of the thoracic aorta. Cardiomediastinal silhouette and hilar contours are otherwise unremarkable. There is mild bibasilar atelectasis. Lungs are otherwise clear. Pleural surfaces are clear without effusion or pneumothorax. Focus of air seen under the right hemidiaphragm likely represents colonic interposition. IMPRESSION No acute cardiopulmonary abnormality. ___ RUE U S IMPRESSION 4 cm acute deep vein thrombosis noted within the mid right brachial vein as detailed above. ___ CXR IMPRESSION The endotracheal tube tip is 6 cm above the carina. Nasogastric tube tip is beyond the GE junction and off the edge of the film. A left central line is present in the tip is in the mid SVC. A pacemaker is noted on the right in the lead projects over the right ventricle. There is probable scarring in both lung apices. There are no new areas of consolidation. There is upper zone redistribution and cardiomegaly suggesting pulmonary venous hypertension. There is no pneumothorax. Brief Hospital Course ___ hx severe COPD AFib CAD HTN HLD recent hospitalizations for recurrent COPD exacerbations over the last several months who presented with dyspnea and increased wheezing secondary to severe COPD. She was treated for her COPD with nebulizers and steroids but continued to decline eventually suffering a PEA arrest thought due to hypoxemia requiring endotracheal intubation and mechanical ventilation. A temporary pacemaker was placed for periods of bradycardia that may also have contributed to her PEA arrest versus being a manifestation of severe hypoxemia severe hypercarbia preceding her arrest . She made a cognitive recovery but was unable to be successfully weaned from her ventilator. She had capacity and was able to make it understand that she did not wish continued intubation mechanical ventilation re intubation and mechanical ventilation once extubated or positive non invasive pressure ventilation. After extensive discussions with her and her family she was transitioned to DNR DNI and comfort oriented care. She was extubated to spend quality time with her family before passing from respiratory failure on the morning of ___ at 0515. Autopsy was declined by family. She was incidentally found to have a RUE DVT that was treated with heparin gtt which was also used for anticoagulation for her atrial fibrillation she was temporarily transitioned to argatroban for concern of HIT but PF4 antibodies returned at very low OD making this diagnosis unlikely . She was also treated for an acute sinusitis with Augmentin during her hospital stay. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 3. Tiotropium Bromide 1 CAP IH DAILY 4. Theophylline SR 300 mg PO BID 5. Sulfameth Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use 6. Ranitidine 300 mg PO DAILY 7. PredniSONE 40 mg PO DAILY 8. Lorazepam 0.5 mg PO Q8H PRN Insomnia anxiety vertigo 9. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 10. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 11. Ipratropium Bromide Neb 1 NEB IH Q6H Wheezing 12. Hydrochlorothiazide 50 mg PO DAILY 13. Guaifenesin ___ mL PO Q4H PRN cough 14. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 15. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 16. Ferrous Sulfate 325 mg PO DAILY 17. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 18. albuterol sulfate 90 mcg actuation inhalation Q4H 19. Apixaban 5 mg PO BID 20. Aspirin 81 mg PO DAILY 21. Atorvastatin 10 mg PO QPM 22. Diltiazem Extended Release 240 mg PO BID 23. Docusate Sodium 100 mg PO BID 24. Sodium Chloride Nasal ___ SPRY NU QID PRN nasal discomfort 25. Morphine Sulfate Oral Solution 2 mg mL 5 mg PO Q4H PRN shortness of breath 26. Budesonide Nasal Inhaler 180 mcg Other DAILY Discharge Medications None. Discharge Disposition Expired Discharge Diagnosis PRIMARY DIAGNOSES s p PEA Arrest Respiratory Failure COPD Sinusitis RUE DVT SECONDARY DIAGNOSES Atrial fibrillation Hypertension CAD Discharge Condition Deceased. Discharge Instructions N A Followup Instructions ___ The icd codes present in this text will be J441, K7200, R579, J9602, J9601, I442, I82621, I4891, D696, I469, I10, E785, Z7901, M47892, I7389, I2510, Z87891, Z96641, J0190, F419, G4700, R609, D509, R509, M1990, Y92239, Z7952, Z825, Z781, Z515, Z66, Z9981, J45909, I447, M7981, T45515A. The descriptions of icd codes J441, K7200, R579, J9602, J9601, I442, I82621, I4891, D696, I469, I10, E785, Z7901, M47892, I7389, I2510, Z87891, Z96641, J0190, F419, G4700, R609, D509, R509, M1990, Y92239, Z7952, Z825, Z781, Z515, Z66, Z9981, J45909, I447, M7981, T45515A are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; K7200: Acute and subacute hepatic failure without coma; R579: Shock, unspecified; J9602: Acute respiratory failure with hypercapnia; J9601: Acute respiratory failure with hypoxia; I442: Atrioventricular block, complete; I82621: Acute embolism and thrombosis of deep veins of right upper extremity; I4891: Unspecified atrial fibrillation; D696: Thrombocytopenia, unspecified; I469: Cardiac arrest, cause unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z7901: Long term (current) use of anticoagulants; M47892: Other spondylosis, cervical region; I7389: Other specified peripheral vascular diseases; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z87891: Personal history of nicotine dependence; Z96641: Presence of right artificial hip joint; J0190: Acute sinusitis, unspecified; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; R609: Edema, unspecified; D509: Iron deficiency anemia, unspecified; R509: Fever, unspecified; M1990: Unspecified osteoarthritis, unspecified site; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; Z7952: Long term (current) use of systemic steroids; Z825: Family history of asthma and other chronic lower respiratory diseases; Z781: Physical restraint status; Z515: Encounter for palliative care; Z66: Do not resuscitate; Z9981: Dependence on supplemental oxygen; J45909: Unspecified asthma, uncomplicated; I447: Left bundle-branch block, unspecified; M7981: Nontraumatic hematoma of soft tissue; T45515A: Adverse effect of anticoagulants, initial encounter. The common codes which frequently come are J9601, I4891, D696, I10, E785, Z7901, I2510, Z87891, F419, G4700, D509, Z515, Z66, J45909. The uncommon codes mentioned in this dataset are J441, K7200, R579, J9602, I442, I82621, I469, M47892, I7389, Z96641, J0190, R609, R509, M1990, Y92239, Z7952, Z825, Z781, Z9981, I447, M7981, T45515A.
The icd codes present in this text will be K921, D62, I4891, J449, I10, F17210, D649, I2510, F419, E785, I739, M47892, R0602, G4700, H409, K449, K2970, Z7982, Z7901, Z96649. The descriptions of icd codes K921, D62, I4891, J449, I10, F17210, D649, I2510, F419, E785, I739, M47892, R0602, G4700, H409, K449, K2970, Z7982, Z7901, Z96649 are K921: Melena; D62: Acute posthemorrhagic anemia; I4891: Unspecified atrial fibrillation; J449: Chronic obstructive pulmonary disease, unspecified; I10: Essential (primary) hypertension; F17210: Nicotine dependence, cigarettes, uncomplicated; D649: Anemia, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; F419: Anxiety disorder, unspecified; E785: Hyperlipidemia, unspecified; I739: Peripheral vascular disease, unspecified; M47892: Other spondylosis, cervical region; R0602: Shortness of breath; G4700: Insomnia, unspecified; H409: Unspecified glaucoma; K449: Diaphragmatic hernia without obstruction or gangrene; K2970: Gastritis, unspecified, without bleeding; Z7982: Long term (current) use of aspirin; Z7901: Long term (current) use of anticoagulants; Z96649: Presence of unspecified artificial hip joint. The common codes which frequently come are D62, I4891, J449, I10, F17210, D649, I2510, F419, E785, G4700, Z7901. The uncommon codes mentioned in this dataset are K921, I739, M47892, R0602, H409, K449, K2970, Z7982, Z96649. Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint Anemia Melena SOB Major Surgical or Invasive Procedure Upper endoscopy ___ History of Present Illness ___ yo female with history of Afib on Xarelto COPD HTN PAD who presents for abnormal labs. She noted dark tarry stool on ___ and presented to PCP ___ ___ where H H was noted to be 8.8 28.6 from prior 11.___.6 baseline Hct about 38 . She has also been experiencing bright red blood with wiping she believes from her hemorrhoids. PCP called pt who agreed to come to ED. She had colonoscopy in ___ with showed a benign polyp internal hemorrhoids and diverticulosis. Her last BM was ___ was reportedly regular. She currently complains of increased exertional fatigue and has been feeling more SOB than her baseline. Over the last 6 months she has noticed she becomes increasingly out of breath walking or climbing stairs. She becomes SOB after 6 stairs or less than 1 block requiring her to stop and at times use albuterol inhaler. She used to use her only use her inhaler ___ times per day now she uses it over four times a day and nebulizers twice a day. She denies any fevers chills nausea vomit diarrhea dysuria rash unintentional weight loss. In the ED initial vitals 0 98 64 149 85 20 98 RA Labs significant for WBC 5.0 HGB 8.8 HCT 28.4 Last baseline of 11.___ 34.6 in ___ MCV PLT 240 ___ 16.7 INR 1.5 PTT 38.8 Chem 7 was normal She was given albuterol nebs and started on IV normal saline On transfer vitals were T 98.4 BP 152 60 P 68 R 18 18 O2 97 RA On arrival to the floor patient was stable and in good spirits. She notes that she had some blood per rectum on her underwear. Past Medical History ASTHMA COPD Tobacco use Peripheral Arterial disease s p recent common iliac stenting ATRIAL TACHYCARDIA ATYPICAL CHEST PAIN CERVICAL RADICULITIS CERVICAL SPONDYLOSIS CORONARY ARTERY DISEASE HEADACHE HIP REPLACEMENT HYPERLIPIDEMIA HYPERTENSION OSTEOARTHRITIS HERPES ZOSTER TOBACCO ABUSE ATRIAL FIBRILLATION ANXIETY GASTROINTESTINAL BLEEDING OSTEOARTHRITIS ATHEROSCLEROTIC CARDIOVASCULAR DISEASE PERIPHERAL VASCULAR DISEASE CATARACT SURGERY ___ Surgery BILATERAL COMMON ILIAC ARTERY STENTING ___ BUNIONECTOMY HIP REPLACEMENT PRIOR CESAREAN SECTION GANGLION CYST Social History ___ Family History Mother ___ HTN Father ___ CA Brother CA Brother ___ Physical ___ ADMISSION PHYSICAL EXAM Vitals T 98.4 BP 152 60 P 68 R 18 18 O2 97 RA GENERAL Well nourished well appearing AA female sitting up in bed Alert oriented no acute distress HEENT Sclera anicteric MMM oropharynx clear NECK supple JVP not elevated no LAD LUNGS Clear to auscultation bilaterally though decreased air movement. No no wheezes rales rhonchi CV Irregularly irregular rate and rhythm normal S1 S2 ___ systolic murmur heard best at RUSB no rubs or gallops ABD soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly Rectum No obvious hemorrhoids EXT Warm well perfused 2 pulses no clubbing cyanosis or edema SKIN clear NEURO No gross deficits. DISCHARGE PHYSICAL EXAM Vitals T 98.2 BP 146 152 67 78 P 57 60 ___ O2 97 RA GENERAL Well nourished well appearing sitting up in bed NAD HEENT Sclera anicteric MMM oropharynx clear NECK supple JVP not elevated no LAD LUNGS Scattered wheezes bilaterally but no resp distress CV Irregularly irregular rate and rhythm normal S1 S2 ___ systolic murmur heard best at RUSB no rubs or gallops ABD soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly EXT Warm well perfused 2 pulses no clubbing cyanosis or edema SKIN clear NEURO No gross deficits. Pertinent Results ADMISSION LABS ___ 12 28PM BLOOD WBC 5.0 RBC 3.28 Hgb 8.8 Hct 28.4 MCV 87 MCH 26.8 MCHC 31.0 RDW 16.1 RDWSD 50.4 Plt ___ ___ 02 28PM BLOOD ___ PTT 38.8 ___ ___ 12 28PM BLOOD Glucose 96 UreaN 18 Creat 1.0 Na 137 K 3.6 Cl 98 HCO3 28 AnGap 15 PERTINENT FINDINGS EGD negative for evidence of bleeding DISCHARGE LABS ___ 06 35AM BLOOD WBC 4.7 RBC 3.38 Hgb 9.1 Hct 29.1 MCV 86 MCH 26.9 MCHC 31.3 RDW 16.1 RDWSD 50.5 Plt ___ ___ 06 35AM BLOOD ___ PTT 37.1 ___ ___ 06 35AM BLOOD Glucose 99 UreaN 8 Creat 0.9 Na 137 K 3.2 Cl 98 HCO3 30 AnGap 12 ___ 06 35AM BLOOD Calcium 9.5 Phos 3.3 Mg 2.___ PMH of CAD PVD and COPD and history of recurrent chest pain present with drop in HCT and progressive SOB. ACTIVE PROBLEMS GI Bleed Presented to PCP with melena and wiping BRBPR. CBC was taken and Hgb found to drop from 11.3 8.8. Two large bore IVs were placed started on IV PPI and she was type and screened. Vitals remained stable so patient was continued on home rivaroxaban. She was evaluated by GI who recommended upper GI endoscopy which showed no evidence of bleeding. She remained hemodynamically stable throughout the admission. Hgb 9.1 on day of discharge. She was discharged home on both her Xarelto and ASA. SOB Long standing history of smoking and COPD. Progressive exertional dyspnea despite use of Spiriva advair fluticasone nasal spray theophylline and albuterol nebulizers. Has increased rescue inhaler use. Etiology unclear does not appear to be infectious given chronicity. Most likely is progression of underlying COPD. PFT s were obtained while in house. Smoking cessation was also discussed. Will need continued outpatient f u re her COPD. CHRONIC PROBLEMS Afib Continued home amiodarone and diltiazem. Continued rivaroxaban for anticoagulation as discussed above. HTN Stable continued on home diltiazem Imdur HCTZ Anxiety insomnia stable continued home lorazepam QHS PRN for insomnia anxiety. Dry eyes History of glaucoma. Continued home latanoprost ophthalmic drops. PAD Stable continued on home atorvastatin s p iliac stent. OK to continue aspirin as well. TRANSITIONAL ISSUES Should consider outpatient colonoscopy to potentially identify any source of lower GI Bleed. Given stable hemoglobin hematocrit while inpatient as well as no evidence of bleeding on EGD her Xarelto and Aspirin were continued on discharge Was treated with IV PPI while inpatient but given no evidence of active bleeding was discharged on home Ranitidine 300mg PO daily Continue to encourage smoking cessation Medications on Admission The Preadmission Medication list is accurate and complete. 1. Rivaroxaban 20 mg PO QPM 2. Acetaminophen 325 mg PO Q6H PRN pain 3. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN SOB 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended Release 180 mg PO BID 7. Fluticasone Propionate NASAL 2 SPRY NU BID nasal congestion 8. Fluticasone Salmeterol Diskus 250 50 1 INH IH BID 9. Hydrochlorothiazide 50 mg PO DAILY 10. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 11. Latanoprost 0.005 Ophth. Soln. 1 DROP LEFT EYE QHS 12. Lorazepam 0.5 mg PO QHS PRN insomnia 13. Multivitamins W minerals 1 TAB PO DAILY 14. Ranitidine 300 mg PO DAILY 15. Theophylline ER 300 mg PO BID 16. Tiotropium Bromide 1 CAP IH BID 17. TraMADOL Ultram 50 mg PO BID pain 18. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN irritation 19. Amiodarone 200 mg PO DAILY Discharge Medications 1. Acetaminophen 325 mg PO Q6H PRN pain 2. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN SOB 3. Amiodarone 200 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN irritation 6. Diltiazem Extended Release 180 mg PO BID 7. Fluticasone Propionate NASAL 2 SPRY NU BID nasal congestion 8. Fluticasone Salmeterol Diskus 250 50 1 INH IH BID 9. Hydrochlorothiazide 50 mg PO DAILY 10. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 11. Latanoprost 0.005 Ophth. Soln. 1 DROP LEFT EYE QHS 12. Lorazepam 0.5 mg PO QHS PRN insomnia 13. Rivaroxaban 20 mg PO QPM 14. Theophylline ER 300 mg PO BID 15. Ranitidine 300 mg PO DAILY 16. TraMADOL Ultram 50 mg PO BID pain 17. Tiotropium Bromide 1 CAP IH BID 18. Multivitamins W minerals 1 TAB PO DAILY 19. Aspirin 81 mg PO DAILY Discharge Disposition Home Discharge Diagnosis Primary Anemia Secondary Afib CAD HTN COPD Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Ms. ___ You were admitted to ___ due to a decrease in blood count on laboratory testing. Because we were concerned for a bleed in your GI tract you underwent an upper endoscopy. Fortunately this did not show any evidence of bleeding. Your blood counts remained stable while in the hospital. You were discharged with plan for outpatient follow up with GI for colonoscopy in the future. Pulmonary function testing was done as well while you were here. You will also follow up with Dr. ___ in his clinic. It was a pleasure taking care of your at ___. If you have any questions about the care you received please do not hesitate to ask. Sincerely Your Inpatient ___ Care Team Followup Instructions ___ The icd codes present in this text will be K921, D62, I4891, J449, I10, F17210, D649, I2510, F419, E785, I739, M47892, R0602, G4700, H409, K449, K2970, Z7982, Z7901, Z96649. The descriptions of icd codes K921, D62, I4891, J449, I10, F17210, D649, I2510, F419, E785, I739, M47892, R0602, G4700, H409, K449, K2970, Z7982, Z7901, Z96649 are K921: Melena; D62: Acute posthemorrhagic anemia; I4891: Unspecified atrial fibrillation; J449: Chronic obstructive pulmonary disease, unspecified; I10: Essential (primary) hypertension; F17210: Nicotine dependence, cigarettes, uncomplicated; D649: Anemia, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; F419: Anxiety disorder, unspecified; E785: Hyperlipidemia, unspecified; I739: Peripheral vascular disease, unspecified; M47892: Other spondylosis, cervical region; R0602: Shortness of breath; G4700: Insomnia, unspecified; H409: Unspecified glaucoma; K449: Diaphragmatic hernia without obstruction or gangrene; K2970: Gastritis, unspecified, without bleeding; Z7982: Long term (current) use of aspirin; Z7901: Long term (current) use of anticoagulants; Z96649: Presence of unspecified artificial hip joint. The common codes which frequently come are D62, I4891, J449, I10, F17210, D649, I2510, F419, E785, G4700, Z7901. The uncommon codes mentioned in this dataset are K921, I739, M47892, R0602, H409, K449, K2970, Z7982, Z96649.
The icd codes present in this text will be J441, J45909, H6991, F419, G4700, I4891, Z7901, I10, I2510, D649, E785, Z87891, Z006. The descriptions of icd codes J441, J45909, H6991, F419, G4700, I4891, Z7901, I10, I2510, D649, E785, Z87891, Z006 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; J45909: Unspecified asthma, uncomplicated; H6991: Unspecified Eustachian tube disorder, right ear; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; I4891: Unspecified atrial fibrillation; Z7901: Long term (current) use of anticoagulants; I10: Essential (primary) hypertension; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; D649: Anemia, unspecified; E785: Hyperlipidemia, unspecified; Z87891: Personal history of nicotine dependence; Z006: Encounter for examination for normal comparison and control in clinical research program. The common codes which frequently come are J45909, F419, G4700, I4891, Z7901, I10, I2510, D649, E785, Z87891. The uncommon codes mentioned in this dataset are J441, H6991, Z006. Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint Shortness of breath Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ with hx COPD on home O2 atrial fibrillation on apixaban hypertension CAD and hyperlipidemia who presented with dyspnea. She has had multiple prior admissions for dyspnea. She was recently discharged on ___ after 3 day inpatient admission for COPD exacerbation. She was discharged on extended prednisone taper with plan for 5d 40mg Prednisone to finish ___ followed by 10mg taper every 5 days 35mg from ___ 30mg ___ etc... . She initially went to rehab and subsequently went home 2 days prior to admission. Upon arrival at home she subsequently had recrudescence of fatigue wheezing dyspnea. She also had increased O2 requirements up to 3L using oxygen 24hr instead of during day only . Also with new cough non productive. Denies f c CP. No n v no myalgias. Decreased hearing in right ear with fullness for past 4 days. She was seen by PCP ___ noted to have inspiratory expiratory wheezes as well as decreased hearing and bulging TM right ear. She was referred to the ___ ED for further management. In the ED initial vital signs were 98.4 74 142 69 16 100 2L NC Labs were notable for 136 95 17 140 3.5 29 1.0 BNP 254 CBC within normal limits but with neutrophil predominance UA with 30 protein VBG pH 7.45 pCO2 43 pO2 59 HCO3 31 Flu PCR negative Imaging CXR notable for no acute cardiopulmonary process. The patient was given ___ 16 03 IH Albuterol 0.083 Neb Soln 1 NEB ___ 16 03 IH Ipratropium Bromide Neb 1 NEB ___ 17 12 IH Albuterol 0.083 Neb Soln 1 NEB ___ 17 12 IH Ipratropium Bromide Neb 1 NEB ___ 18 12 IH Albuterol 0.083 Neb Soln 1 NEB ___ 18 12 IH Ipratropium Bromide Neb 1 NEB ___ 21 05 IH Albuterol 0.083 Neb Soln 1 NEB ___ 21 05 PO PredniSONE 60 mg ___ 21 05 IV Magnesium Sulfate 2 gm ___ 21 33 IH Albuterol 0.083 Neb Soln 1 NEB Vitals prior to transfer were 98.8 87 131 83 16 97 2L Upon arrival to the floor she complained of wheezing and SOB and persistent decreased hearing with fullness in right ear. REVIEW OF SYSTEMS Per HPI. Denies headache visual changes pharyngitis rhinorrhea nasal congestion cough fevers chills sweats weight loss dyspnea chest pain abdominal pain nausea vomiting diarrhea constipation hematochezia dysuria rash paresthesias and weakness. Past Medical History COPD Asthma on home 2L O2 Atypical Chest Pain Hypertension Hyperlipidemia Osteroarthritis Atrial Fibrillation on Apixaban Anxiety Cervical Radiculitis Cervical Spondylosis Coronary Artery Disease Headache Herpes Zoster GI Bleeding Peripheral Vascular Disease s p bilateral iliac stents s p hip replacement Social History ___ Family History Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam PHYSICAL EXAMINATION ON ADMISSION VITALS 98.1 139 79 78 22 98RA GENERAL Pleasant well appearing in no apparent distress. HEENT normocephalic atraumatic no conjunctival pallor or scleral icterus PERRLA EOMI OP clear. NECK Supple no LAD no thyromegaly JVP flat. CARDIAC Normal S1 S2 no murmurs rubs or gallops. PULMONARY Inspiratory and expiratory wheezes in all lung fields ABDOMEN Normal bowel sounds soft non tender non distended no organomegaly. EXTREMITIES Warm well perfused no cyanosis clubbing or edema. SKIN Without rash. NEUROLOGIC A Ox3 CN II XII grossly normal normal sensation with strength ___ throughout. PHYSICAL EXAMINATION ON DISCHARGE VITALS 98.2 130 140 70 S 70 80 s 20 98RA GENERAL Pleasant well appearing in no apparent distress. HEENT normocephalic atraumatic no conjunctival pallor or scleral icterus PERRLA EOMI OP clear. NECK Supple no LAD no thyromegaly JVP flat. CARDIAC Normal S1 S2 no murmurs rubs or gallops. PULMONARY Decreased inspiratory and expiratory wheezes in all lung fields ABDOMEN Normal bowel sounds soft non tender non distended no organomegaly. EXTREMITIES Warm well perfused no cyanosis clubbing or edema. SKIN Without rash. NEUROLOGIC A Ox3 CN II XII grossly normal normal sensation with strength ___ throughout. Pertinent Results LABS ON ADMISSION ___ 04 00PM BLOOD Neuts 92.1 Lymphs 4.5 Monos 2.7 Eos 0.0 Baso 0.0 Im ___ AbsNeut 5.51 AbsLymp 0.27 AbsMono 0.16 AbsEos 0.00 AbsBaso 0.00 ___ 04 00PM BLOOD Plt ___ ___ 04 00PM BLOOD Glucose 140 UreaN 17 Creat 1.0 Na 136 K 3.5 Cl 95 HCO3 29 AnGap 16 ___ 04 00PM BLOOD proBNP 254 ___ 03 58PM BLOOD ___ pO2 59 pCO2 43 pH 7.45 calTCO2 31 Base XS 4 LABS ON DISCHARGE ___ 08 00AM BLOOD WBC 5.8 RBC 4.37 Hgb 11.9 Hct 38.2 MCV 87 MCH 27.2 MCHC 31.2 RDW 20.4 RDWSD 65.6 Plt ___ ___ 08 00AM BLOOD Plt ___ ___ 08 00AM BLOOD Glucose 156 UreaN 21 Creat 0.9 Na 134 K 3.4 Cl 92 HCO3 30 AnGap 15 ___ 08 00AM BLOOD Calcium 9.7 Phos 3.6 Mg 2.0 STUDIES CXR ___ No acute cardiopulmonary process EKG NSR rate 72 QTC 469 LBBB Brief Hospital Course ___ yo F with history of COPD on home O2 atrial fibrillation on apixaban hypertension CAD hyperlipidemia and recurrent hospitalization for COPD exacerbation over the last 4 months who presented with dyspnea consistent with COPD exacerbation possibly secondary to acute viral URI with concurrent sinusitis Eustachian tube dysfunction COPD exacerbation Patient has been experiencing recurrent COPD exacerbations over the last 4 months. She presented with dyspnea consistent with COPD exacerbation possibly secondary to acute viral URI with concurrent sinusitis Eustachian tube dysfunction. We continued home spiriva theophylline and advair. We continued her steroid therapy at 30mg prednisone daily with a slow taper 5mg every 2 weeks . We also treated her with levofloxacin Day ___ with plan for 5 day course given COPD exacerbation with concurrent concern for sinusitis bulging right tympanic membrane. CHRONIC ISSUES Anxiety Insomnia We continued home lorazepam. Atrial Fibrillation We continued diltiazem for rate control and apixaban for anticoagulation. Hypertension We continued home imdur hydrochlorothiazide and diltiazem. CAD Cardiac catheterization in ___ without evidence of significant stenosis of coronaries. ECHO on ___ with EF 55 and no regional or global wall motion abnormalities. We continued home aspirin and atorvastatin. Anemia We continued home iron supplements. TRANSITIONAL ISSUES Continue levofloxacin with plan for 5 day course Day ___ end ___ Patient was started Bactrim PPX 1 tab SS daily given extended courses of steroids stop after discontinuation of steroids Patient was discharged on prednisone 30 mg with plan for taper by 5mg every 2 weeks Prednisone 30 mg for two weeks Day 1 ___ end ___ Prednisone 25 mg for two weeks Day 1 ___ end ___ Prednisone 20 mg for two weeks Day 1 ___ end ___ etc... CONTACT ___ husband HCP ___ CODE STATUS Full confirmed Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. albuterol sulfate 90 mcg actuation inhalation Q4H 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended Release 240 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 11. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 12. Guaifenesin ___ mL PO Q4H PRN cough 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 15. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 16. Lorazepam 0.5 mg PO Q8H PRN Insomnia anxiety vertigo 17. Multivitamins 1 TAB PO DAILY 18. Ranitidine 300 mg PO DAILY 19. Theophylline SR 300 mg PO BID 20. Tiotropium Bromide 1 CAP IH DAILY 21. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 22. cod liver oil 1 capsule oral BID 23. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing 24. PredniSONE 30 mg PO DAILY Tapered dose DOWN Discharge Medications 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. albuterol sulfate 90 mcg actuation inhalation Q4H 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended Release 240 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 11. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 12. Guaifenesin ___ mL PO Q4H PRN cough 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 15. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 16. Lorazepam 0.5 mg PO Q8H PRN Insomnia anxiety vertigo 17. Multivitamins 1 TAB PO DAILY 18. PredniSONE 30 mg PO DAILY Please decrease dose by 5mg every 2 weeks Tapered dose DOWN RX prednisone 10 mg 3 tablets s by mouth once a day Disp 45 Dose Pack Refills 0 19. Ranitidine 300 mg PO DAILY 20. Theophylline SR 300 mg PO BID 21. Tiotropium Bromide 1 CAP IH DAILY 22. Levofloxacin 750 mg PO DAILY Duration 5 Days RX levofloxacin 750 mg 1 tablet s by mouth once a day Disp 4 Tablet Refills 0 23. Sulfameth Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use RX sulfamethoxazole trimethoprim 400 mg 80 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 24. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 25. cod liver oil 1 capsule oral BID 26. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS COPD exacerbation SECONDARY DIAGNOSES CAD Hypertension anxiety Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear ___ ___ was a great pleasure taking care of you at ___ ___. You came here because you were experiencing worsening shortness of breath as well as nasal congestion and decreased hearing. Your symptoms are likely related to an upper respiratory tract infection and exacerbation of your COPD. We started you on antibiotics and continued your prednisone. The dose of prednisone will be decreased by 5 mg every two weeks please take your prednisone as follows Prednisone 30 mg for two weeks Day 1 ___ end ___ Prednisone 25 mg for two weeks Day 1 ___ end ___ Prednisone 20 mg for two weeks Day 1 ___ end ___ Discuss with Dr. ___ further taper at f u Please take all your medications on time and follow up with your doctors as ___. Best regards Your ___ team Followup Instructions ___ The icd codes present in this text will be J441, J45909, H6991, F419, G4700, I4891, Z7901, I10, I2510, D649, E785, Z87891, Z006. The descriptions of icd codes J441, J45909, H6991, F419, G4700, I4891, Z7901, I10, I2510, D649, E785, Z87891, Z006 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; J45909: Unspecified asthma, uncomplicated; H6991: Unspecified Eustachian tube disorder, right ear; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; I4891: Unspecified atrial fibrillation; Z7901: Long term (current) use of anticoagulants; I10: Essential (primary) hypertension; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; D649: Anemia, unspecified; E785: Hyperlipidemia, unspecified; Z87891: Personal history of nicotine dependence; Z006: Encounter for examination for normal comparison and control in clinical research program. The common codes which frequently come are J45909, F419, G4700, I4891, Z7901, I10, I2510, D649, E785, Z87891. The uncommon codes mentioned in this dataset are J441, H6991, Z006.
The icd codes present in this text will be J441, I4892, Z9981, I480, J45998, Z87891, I2510, Z96649, I10, E785, D509, I739, F419, K5900, M1990, Z825, Z8249, Z7901. The descriptions of icd codes J441, I4892, Z9981, I480, J45998, Z87891, I2510, Z96649, I10, E785, D509, I739, F419, K5900, M1990, Z825, Z8249, Z7901 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; I4892: Unspecified atrial flutter; Z9981: Dependence on supplemental oxygen; I480: Paroxysmal atrial fibrillation; J45998: Other asthma; Z87891: Personal history of nicotine dependence; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z96649: Presence of unspecified artificial hip joint; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; D509: Iron deficiency anemia, unspecified; I739: Peripheral vascular disease, unspecified; F419: Anxiety disorder, unspecified; K5900: Constipation, unspecified; M1990: Unspecified osteoarthritis, unspecified site; Z825: Family history of asthma and other chronic lower respiratory diseases; Z8249: Family history of ischemic heart disease and other diseases of the circulatory system; Z7901: Long term (current) use of anticoagulants. The common codes which frequently come are I480, Z87891, I2510, I10, E785, D509, F419, K5900, Z7901. The uncommon codes mentioned in this dataset are J441, I4892, Z9981, J45998, Z96649, I739, M1990, Z825, Z8249. Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint cough dyspnea Major Surgical or Invasive Procedure None History of Present Illness HPI ___ year old female with history of COPD on home O2 HTN Afib admitted with dyspnea and cough. Pt states inc dyspnea since this am also one episode of retrosternal chest pressure lasting 2minuts on way to ED. No cp currently. on home O2. no fevers chills or abd sx. Patient was recently admitted from ___ with COPD flare and afib with RVR. She could not receive azithromycin due to concern for QTc prolongation and so was treated with ceftriaxone cefpodoxime. She was treated with 60mg PO prednisone and discharged with a prednisone taper of 10 mg decrease q3d until at 10 mg then stay at 10 mg until pulm follow up. She was also counseled to do pulmonary rehab and follow up with Dr. ___. She was discharged on 2L supplemental O2 to be worn at all times. He theophylline was decreased from 300 mg BID to ___ mg BID due to her afib with RVR. She was also seen in the ED on ___ and ___ due to dyspnea which was felt to be a continuation of her COPD flare in the setting of patient not taking her home medications. She was given nebulizers and improved. She was DCed home with ___ for assistance with medications. She declined pulmonary rehab facility disposition. In the ED initial vitals Exam notable for diffuse insp esp wheezing dry oropharynx Labs notable for nl WBC. Trop X1 neg. EKG in sinus. Imaging notable for CXR no acute process. Pt given duoneb X 3. methylpred 125mg. Aspirin 325mg 1L NS and azithromycin 500mg. Peak flow 150 baseline per pt. Symptoms overall improved after nebs. Vitals prior to transfer 98.2 76 138 72 20 97NC. On arrival to the floor pt reports feeling much improved and minimal wheezing. ROS No fevers chills night sweats or weight changes. No changes in vision or hearing no changes in balance. No cough no shortness of breath no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia no melena. No numbness or weakness no focal deficits. Past Medical History ASTHMA COPD ATYPICAL CHEST PAIN CERVICAL RADICULITIS CERVICAL SPONDYLOSIS CORONARY ARTERY DISEASE HEADACHE HIP REPLACEMENT HYPERLIPIDEMIA HYPERTENSION OSTEOARTHRITIS HERPES ZOSTER ATRIAL FIBRILLATION ANXIETY GASTROINTESTINAL BLEEDING OSTEOARTHRITIS ATHEROSCLEROTIC CARDIOVASCULAR DISEASE PERIPHERAL VASCULAR DISEASE Social History ___ Family History Mother ___ HTN Father ___ CA Brother CA Brother ___ Physical ___ Admission Vitals 99 142 80 77 20 95 2L General Alert oriented no acute distress appears very calm and can talk in full sentences HEENT Sclerae anicteric MMM oropharynx clear Neck supple JVP not elevated no LAD Lungs scattered wheezing CV II VI RUSB systolic murmur Nl S1 S2 No MRG Abdomen soft NT ND bowel sounds present no rebound tenderness or guarding no organomegaly GU no foley Ext warm well perfused 2 pulses no clubbing cyanosis 2 edema b l Neuro CN2 12 intact no focal deficits Vitals 98.5 122 69 130 150 76 70s 18 100 2L General Alert oriented no acute distress appears very calm and can talk in full sentences HEENT Sclerae anicteric MMM oropharynx clear Neck supple JVP not elevated no LAD Lungs scattered wheezing CV II VI RUSB systolic murmur Nl S1 S2 No MRG Abdomen soft NT ND bowel sounds present no rebound tenderness or guarding no organomegaly GU no foley Ext warm well perfused 2 pulses no clubbing cyanosis 2 edema b l Neuro CN2 12 intact no focal deficits Pertinent Results Admission ___ 01 46PM BLOOD WBC 8.3 RBC 4.52 Hgb 10.8 Hct 36.2 MCV 80 MCH 23.9 MCHC 29.8 RDW 21.6 RDWSD 52.4 Plt ___ ___ 01 46PM BLOOD Neuts 93.4 Lymphs 4.0 Monos 1.8 Eos 0.1 Baso 0.1 Im ___ AbsNeut 7.77 AbsLymp 0.33 AbsMono 0.15 AbsEos 0.01 AbsBaso 0.01 ___ 01 46PM BLOOD ___ PTT 31.9 ___ ___ 01 46PM BLOOD Glucose 121 UreaN 19 Creat 1.1 Na 134 K 3.7 Cl 91 HCO3 31 AnGap 16 ___ 01 46PM BLOOD cTropnT 0.01 ___ 01 46PM BLOOD Calcium 10.1 Phos 2.7 Mg 2.1 ___ 01 58PM BLOOD Lactate 1.6 DISCHARGE ___ 05 52AM BLOOD WBC 14.1 RBC 3.81 Hgb 9.4 Hct 30.8 MCV 81 MCH 24.7 MCHC 30.5 RDW 22.5 RDWSD 58.1 Plt ___ ___ 05 52AM BLOOD Glucose 107 UreaN 26 Creat 0.9 Na 136 K 3.5 Cl 94 HCO3 35 AnGap 11 CXR ___ IMPRESSION No acute cardiopulmonary process. Brief Hospital Course ___ year old female with history of COPD on home O2 HTN Afib admitted with dyspnea and cough. COPD exacerbation Presenting with cough significant wheezing and poor air movement initially consistent with COPD exacerbation. No PNA on CXR. No ischemic EKG changes. Symptoms improved with duonebs prednisone and doxycycline. Evaluated by ___ and discharged to rehab facility for physical strengthening and respiratory rehab. Discharged on home COPD meds and steroid taper and abx course. pAfib currently rate well controlled. on apixaban continued diltiazam continued apixaban continued amiodarone Anemia Fe def anemia on recent admission discharged on Fe continued iron supplement CAD continue aspirin atorvastatin Constipation continue home bowel reg Anxiety continued home meds TRANSITIONAL Discharged on steroid taper with maintenance dose of 10mg daily until she sees PCP Take ___ Doxycycline 100mg BID to ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN pain 2. Amiodarone 200 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Albuterol 0.083 Neb Soln 1 NEB IH Q2H PRN SOB 5. Artificial Tears ___ DROP BOTH EYES PRN irritation 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 10 mg PO QPM 8. Diltiazem Extended Release 180 mg PO BID 9. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 10. Fluticasone Propionate NASAL 1 SPRY NU BID 11. Fluticasone Salmeterol Diskus 250 50 1 INH IH BID 12. Hydrochlorothiazide 50 mg PO DAILY 13. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 14. Latanoprost 0.005 Ophth. Soln. 1 DROP LEFT EYE QHS 15. Lorazepam 0.5 mg PO QHS PRN insomnia 16. Multivitamins W minerals 1 TAB PO DAILY 17. Ranitidine 300 mg PO DAILY 18. Tiotropium Bromide 1 CAP IH DAILY 19. Theophylline SR 200 mg PO BID 20. Ferrous Sulfate 325 mg PO DAILY 21. Docusate Sodium 100 mg PO BID 22. Polyethylene Glycol 17 g PO DAILY 23. Ipratropium Bromide Neb 1 NEB IH Q6H PRN SOB 24. PredniSONE 30 mg PO DAILY Start ___ First Dose Next Routine Administration Time This is dose 1 of 2 tapered doses 25. PredniSONE 20 mg PO DAILY Start After 30 mg DAILY tapered dose This is dose 2 of 2 tapered doses 26. PredniSONE 10 mg PO DAILY Start After last tapered dose completes This is the maintenance dose to follow the last tapered dose Discharge Medications 1. Acetaminophen 650 mg PO Q6H PRN pain 2. Amiodarone 200 mg PO DAILY 3. Apixaban 5 mg PO BID 4. Artificial Tears ___ DROP BOTH EYES PRN irritation 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 10 mg PO QPM 7. Diltiazem Extended Release 180 mg PO BID 8. Docusate Sodium 100 mg PO BID 9. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 10. Ferrous Sulfate 325 mg PO DAILY 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. Fluticasone Salmeterol Diskus 250 50 1 INH IH BID 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 15. Latanoprost 0.005 Ophth. Soln. 1 DROP LEFT EYE QHS 16. Lorazepam 0.5 mg PO QHS PRN insomnia 17. Multivitamins W minerals 1 TAB PO DAILY 18. Polyethylene Glycol 17 g PO DAILY 19. Ranitidine 300 mg PO DAILY 20. Theophylline SR 200 mg PO BID 21. Tiotropium Bromide 1 CAP IH DAILY 22. Albuterol Inhaler ___ PUFF IH Q6H PRN SOB 23. Ipratropium Bromide Neb 1 NEB IH Q6H PRN SOB 24. Albuterol 0.083 Neb Soln 1 NEB IH Q2H PRN SOB 25. Doxycycline Hyclate 100 mg PO Q12H Duration 2 Days to end ___ 26. PredniSONE 10 mg PO ASDIR Take ___ Tapered dose DOWN Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Primary COPD exacerbation Secondary CORONARY ARTERY DISEASE HYPERLIPIDEMIA HYPERTENSION OSTEOARTHRITIS ATRIAL FIBRILLATION ANXIETY GASTROINTESTINAL BLEEDING OSTEOARTHRITIS Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear ___ ___ were admitted with exacerbation of your COPD. We gave ___ some treatments and ___ improved. ___ were evaluated by the physical therapy team who recommended a rehab stay for strengthening and improve your breathing. Please take your medications as prescribed and follow up with your providers. Sincerely ___ medical team Followup Instructions ___ The icd codes present in this text will be J441, I4892, Z9981, I480, J45998, Z87891, I2510, Z96649, I10, E785, D509, I739, F419, K5900, M1990, Z825, Z8249, Z7901. The descriptions of icd codes J441, I4892, Z9981, I480, J45998, Z87891, I2510, Z96649, I10, E785, D509, I739, F419, K5900, M1990, Z825, Z8249, Z7901 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; I4892: Unspecified atrial flutter; Z9981: Dependence on supplemental oxygen; I480: Paroxysmal atrial fibrillation; J45998: Other asthma; Z87891: Personal history of nicotine dependence; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z96649: Presence of unspecified artificial hip joint; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; D509: Iron deficiency anemia, unspecified; I739: Peripheral vascular disease, unspecified; F419: Anxiety disorder, unspecified; K5900: Constipation, unspecified; M1990: Unspecified osteoarthritis, unspecified site; Z825: Family history of asthma and other chronic lower respiratory diseases; Z8249: Family history of ischemic heart disease and other diseases of the circulatory system; Z7901: Long term (current) use of anticoagulants. The common codes which frequently come are I480, Z87891, I2510, I10, E785, D509, F419, K5900, Z7901. The uncommon codes mentioned in this dataset are J441, I4892, Z9981, J45998, Z96649, I739, M1990, Z825, Z8249.
The icd codes present in this text will be J441, I4892, I248, J45909, Z87891, I4891, F419, G4700, E780, I2510, E876, R312, I739, Z7952, Z9981. The descriptions of icd codes J441, I4892, I248, J45909, Z87891, I4891, F419, G4700, E780, I2510, E876, R312, I739, Z7952, Z9981 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; I4892: Unspecified atrial flutter; I248: Other forms of acute ischemic heart disease; J45909: Unspecified asthma, uncomplicated; Z87891: Personal history of nicotine dependence; I4891: Unspecified atrial fibrillation; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; E780: Pure hypercholesterolemia; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E876: Hypokalemia; R312: Other microscopic hematuria; I739: Peripheral vascular disease, unspecified; Z7952: Long term (current) use of systemic steroids; Z9981: Dependence on supplemental oxygen. The common codes which frequently come are J45909, Z87891, I4891, F419, G4700, I2510. The uncommon codes mentioned in this dataset are J441, I4892, I248, E780, E876, R312, I739, Z7952, Z9981. Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint Shortness of breath Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ yo woman with a PMH notable for COPD on home O2 hospitalized ___ multiple recent ED visits Afib on apixaban HTN CAD and HLD who presents with several days of worsening dyspnea. Patient has had several ED visits for dyspnea and a recent hospitalization for a COPD exacerbation in ___. She has been on steroid therapy with several attempts to taper over the last several months. After her most recent ED visit on ___ she was on placed on 60 mg PO prednisone with a taper down by 10 mg each day. Her SOB worsened with the taper and she was seen on ___ by her PCP who started her on a course of prednisone 30 mg PO to be tapered down by 5 mg every 3 days. With the taper she is currently on prednisone 25 mg QD. She reports that her SOB improved slightly after starting the steroids on ___. However last night it acutely worsened and she was unable to sleep. She usually uses 3 pillows to sleep but was only comfortable seated upright last night. This morning she increased her oxygen to 3L and felt better. She is usually on 2L NC at home. She reports that for the last several months she has been using two different albuterol inhalers each every ___ hours. She knows that this is more than they are prescribed for but it makes her comfortable. She mostly stays put on the second floor of her home. She states that she can walk to the bathroom without being short of breath but does not use the stairs unless she has to leave the house because it worsens her breathing. She endorses a cough occasionally productive of ___ sputum. This is consistent with her baseline. She endorses one episode of non exertional chest pain today that spontaneously resolved. She denies fever chills recent sick contacts and lower extremity edema. In the ED initial vital signs were T 98.5 P 80 BP 154 97 R 20 O2 sat 97 NC. Exam notable for Diffuse expiratory wheezing prolonged expiratory phase left inspiratory crackles irregularly irregular rhthym minimal pedal edema Labs were notable for CBC wnl proBNP 235 Trop 0.02 chem notable for bicarb 31 AG 13 UA notable for 40 RBCs Studies performed include CXR with stable mild moderate cardiomegaly atelectasis at bases otherwise clear lung fields Patient was given Albuterol neb x 1 ipratropium neb x 1 Azithromycin 500 mg PO Prednisone 25 mg PO Upon arrival to the floor the patient states that she is doing well. She says that her SOB has improved since this morning and is better than last night when she could not sleep. Review of Systems per HPI fever chills night sweats headache vision changes rhinorrhea congestion sore throat abdominal pain nausea vomiting diarrhea constipation BRBPR melena hematochezia dysuria hematuria. Past Medical History ASTHMA COPD ATYPICAL CHEST PAIN CERVICAL RADICULITIS CERVICAL SPONDYLOSIS CORONARY ARTERY DISEASE HEADACHE HIP REPLACEMENT HYPERLIPIDEMIA HYPERTENSION OSTEOARTHRITIS HERPES ZOSTER ATRIAL FIBRILLATION ANXIETY GASTROINTESTINAL BLEEDING OSTEOARTHRITIS PERIPHERAL VASCULAR DISEASE s p bilateral iliac stents Social History ___ Family History Mother ___ HTN Father ___ CA Brother CA Brother ___ Physical ___ ADMISSION EXAM Vitals T 98.0 BP 148 70 HR 70 RR 24 O2Sat 96 on 2L NC GENERAL AOx3 NAD sitting up in bed HEENT Normocephalic atraumatic. Pupils equal round and reactive bilaterally extraocular muscles intact. No conjunctival pallor or injection sclera anicteric and without injection. Moist mucous membranes good dentition. Oropharynx is clear. NECK Supple. JVD not visualized. CARDIAC Irregularly irregular ___ systolic murmur best at the LSB no rubs or gallops. LUNGS Poor air movement throughout. Mild diffuse inspiratory and expiratory wheezes. No use of accessory muscles of breathing. No rhonchi or rales. BACK No CVA tenderness ABDOMEN Normal bowels sounds non distended non tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES No clubbing or cyanosis. Bilateral pitting edema to the mid shin. Pulses DP Radial 2 bilaterally. SKIN No rash or ulcers NEUROLOGIC CN2 12 intact. Moves all extremities spontaneously. Normal sensation. DISCHARGE EXAM Vitals T 98.7 BP 154 85 HR 77 RR 18 O2Sat 99 on 3L NC GENERAL AOx3 NAD sitting up in bed HEENT NCAT. PERRL. EOMI. Sclera anicteric and not injected. MMM. Oropharynx is clear. NECK Supple. No LAD. JVP not appreciated at 45 degrees. CARDIAC Irregularly irregular normal rate. ___ systolic murmur at the RUSB. No rubs or gallops. LUNGS Poor air movement throughout all zones of the lungs. No wheezes. No prolonged expiratory phase. No rhonchi or rales. Does typically sit cross legged in the bed with forearms on her legs in a tripod position. BACK No CVA tenderness. ABDOMEN BS soft nontender nondistended EXTREMITIES Trace pitting edema to the mid shin. 2 DP pulses bilaterally. No TTP. SKIN No rash or ulcers. NEUROLOGIC CN2 12 intact. Moves all extremities spontaneously. Normal sensation. Pertinent Results ADMISSION LABS ___ 02 27PM BLOOD WBC 7.4 RBC 4.57 Hgb 12.3 Hct 39.3 MCV 86 MCH 26.9 MCHC 31.3 RDW 23.6 RDWSD 70.9 Plt ___ ___ 02 27PM BLOOD Neuts 86.5 Lymphs 6.1 Monos 6.6 Eos 0.0 Baso 0.0 Im ___ AbsNeut 6.38 AbsLymp 0.45 AbsMono 0.49 AbsEos 0.00 AbsBaso 0.00 ___ 02 27PM BLOOD Glucose 132 UreaN 17 Creat 1.0 Na 137 K 3.7 Cl 93 HCO3 31 AnGap 17 PERTINENT RESULTS LABS ___ 12 15AM BLOOD ___ pO2 103 pCO2 49 pH 7.42 calTCO2 33 Base XS 5 ___ 02 27PM BLOOD cTropnT 0.02 proBNP 235 ___ 09 05PM BLOOD CK MB 6 cTropnT 0.01 ___ 07 45AM BLOOD CK MB 6 cTropnT 0.02 ___ 07 45AM BLOOD THEOPHYLLINE 17.3 10.0 20.0 IMAGING CXR ___ PA and lateral views the chest provided. Biapical pleural parenchymal scarring noted. No focal consolidation concerning for pneumonia. No effusion or pneumothorax. No signs of congestion or edema. Cardiomediastinal silhouette is stable with an unfolded thoracic aorta and top normal heart size. Bony structures are intact. CT Chest ___ 1. Moderate upper lobe predominant centrilobular and paraseptal emphysema. 2. New left lower lobe nodule potentially measuring as large as 6 x 8 mm warrants close follow up. Stable to slightly smaller 4 mm right middle lobe nodule. 3. Severe coronary artery calcifications. Aortic valve calcifications. 4. Enlargement of the main and right pulmonary arteries is suggestive of chronic pulmonary arterial hypertension. 5. Fusiform aneurysmal dilatation of the abdominal aorta measuring up to 3.7 cm has progressed compared to prior examination. DISCHARGE LABS ___ 07 45AM BLOOD WBC 7.8 RBC 4.74 Hgb 12.7 Hct 41.0 MCV 87 MCH 26.8 MCHC 31.0 RDW 23.7 RDWSD 71.7 Plt ___ ___ 07 45AM BLOOD Glucose 94 UreaN 18 Creat 1.0 Na 135 K 3.3 Cl 93 HCO3 31 AnGap 14 ___ 07 45AM BLOOD Calcium 9.8 Phos 2.8 Mg 2.0 Brief Hospital Course Ms. ___ is a ___ y o woman with a PMH notable for COPD on home O2 hospitalized ___ multiple recent ED visits Afib on apixaban HTN CAD and HLD who presented with dyspnea and orthopnea in the setting of a steroid taper for recent COPD exacerbation. Her dyspnea was thought to be multifactorial due to her severe COPD and with a component of anxiety. The patient was not thought to be having an acute COPD exacerbation. ACTIVE ISSUES Dyspnea Patient was admitted after one night of worsened orthopnea and dyspnea in the setting of a steroid taper from 30 mg to 25 mg. Her dyspnea was thought to be multifactorial due to her severe COPD and with a component of anxiety. The patient was not thought to be having an acute COPD exacerbation. The patient was treated with occasional duonebs and lorazepam 0.5 mg PRN that helped relieve her dyspnea. Pulmonology was consulted. The patient underwent CT that showed emphysema but no evidence of infection such as ___. The patient was initiated on a steroid taper on ___ of prednisone 30 mg for 3 days then 20 mg for 3 days then 10 mg until outpatient follow up. Pulmonology recommended increasing her Advair dose to 500 50 which was done. They also recommended switching from theophylline to roflumilast and initiation of long term azithromycin therapy provided the patient s QTc was not prolonged this was deferred to the outpatient setting. Throughout her admission she had O2 sats greater than 95 on 2L NC. She did not desaturate on ambulation. Anxiety Insomnia Patient with a history of anxiety and insomnia thought to be contributing to her experience of dyspnea. The patient was discharged with lorazepam Q8H as needed for anxiety. The patient would likely benefit from therapy with an SSRI. Demand Ischemia Patient with troponin 0.02 0.01 then 0.02. ECG without acute ischemic changes. Microscopic hematuria On admission the patient had a UA with 40 RBCs. Occasional UAs over the last year in OMR with microscopic hematuria. Would recommend repeat UA as an outpatient or work up for microscopic hematuria. CHRONIC ISSUES Smoking Patient recently quit smoking one month ago. Patient was provided with a nicotine patch 7 mg while in house could consider continuing as an outpatient if patient endorses cravings. Atrial fibrillation Patient continued on diltiazem 240 mg PO BID and apixaban 5 mg BID. HTN Patient with a history of hypertension. Blood pressure well controlled. Continued on isosorbide mononitrate ER 240 mg PO daily and hydrochlorothiazide 50 mg PO daily. CAD Cardiac catheterization in ___ without evidence of significant stenosis of coronaries. ECHO on ___ with EF 55 and no regional or global wall motion abnormalities. The patient was continued on aspirin 81 mg daily and atorvastatin 10 mg QPM. TRANSITIONAL ISSUES New Medications Prednisone 30 mg PO QD through ___ then on ___ mg for 3 days then on ___ mg until outpatient follow up Increased Advair Fluticasone Salmeterol to 500 50 dose Lorazepam 0.5 mg PO Q8H PRN for anxiety Follow up Appointment arranged with PCP ___ ___ Appointment arranged with Pulmonologist Dr. ___ ___ COPD Patient was seen by pulmonology during admission who had the following recommendations to consider as an outpatient. Switch to roflumilast from theophylline Daily azithromycin for treatment of chronic inflammation provided QTc within normal limits. Patient may benefit from treatment of anxiety with an SSRI as her anxiety is likely contributing to her experience of dyspnea. In the future palliative care consult for consideration of opioid treatment of dyspnea Microscopic hematuria Patient had a UA with 40 RBCs on admission Recommend repeat UA as an outpatient or work up for microscopic hematuria Lung nodule New left lower lobe nodule potentially measuring as large as 6 x 8 mm warrants close follow up. Stable to slightly smaller 4 mm right middle lobe nodule. Follow up CT in ___ months as per ___ guidelines for evaluation of new left lower lobe pulmonary nodule. Code Status Full code Emergency Contact HCP ___ HUSBAND ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY Tapered dose DOWN 2. Acetaminophen 325 mg PO Q4H PRN Pain 3. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing 4. Tiotropium Bromide 1 CAP IH DAILY 5. Guaifenesin 1 teaspoon PO Q3H PRN cough 6. Lorazepam 0.5 mg PO QHS vertigo insomnia 7. Diltiazem Extended Release 240 mg PO BID 8. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 9. Docusate Sodium 100 mg PO BID 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 11. Apixaban 5 mg PO BID 12. Ranitidine 300 mg PO DAILY 13. Atorvastatin 10 mg PO QPM 14. Ferrous Sulfate 325 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 17. Fluticasone Salmeterol Diskus 250 50 1 INH IH BID 18. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 19. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 20. Theophylline SR 300 mg PO BID 21. Aspirin 81 mg PO DAILY 22. albuterol sulfate 90 mcg actuation inhalation Q4H 23. Hydrochlorothiazide 50 mg PO DAILY 24. cod liver oil 1 capsule oral BID Discharge Medications 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Diltiazem Extended Release 240 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 8. Ferrous Sulfate 325 mg PO DAILY 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 10. Hydrochlorothiazide 50 mg PO DAILY 11. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 12. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 13. Multivitamins 1 TAB PO DAILY 14. PredniSONE 30 mg PO DAILY RX prednisone 10 mg 3 tablet s by mouth Daily Disp 30 Tablet Refills 0 15. Ranitidine 300 mg PO DAILY 16. Theophylline SR 300 mg PO BID 17. Tiotropium Bromide 1 CAP IH DAILY 18. Guaifenesin 1 teaspoon PO Q3H PRN cough 19. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing 20. cod liver oil 1 capsule oral BID 21. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 22. albuterol sulfate 90 mcg actuation inhalation Q4H 23. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID RX fluticasone salmeterol Advair Diskus 500 mcg 50 mcg dose 1 dose Inhaled Twice a day Disp 1 Disk Refills 1 24. Lorazepam 0.5 mg PO Q8H PRN Anxiety RX lorazepam Ativan 0.5 mg 0.5 One half mg by mouth Every 8 hours Disp 30 Tablet Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary Diagnosis Chronic obstruction pulmonary disease exacerbation Secondary Diagnoses Tobacco use disorder Atrial fibrillation Hypertension Anxiety Coronary Artery Disease Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ It was a privilege taking care of you during your admission to ___. You were admitted to the hospital for shortness of breath and concern that you were having a flare of your COPD. While in the hospital we increased your dose of steroids to help your breathing. You also received several nebulizer treatments that helped your breathing. You were also expressing some anxiety that may have been contributing to your shortness of breath. You were given a medication called Ativan for your anxiety that also seemed to help your breathing. During your admission you were seen by the pulmonary specialists. They recommended a CT scan that showed that you have extensive COPD but did not show any infection. They also suggested increasing the dose of your Advair inhaler which we did. If you feel short of breath first please check your oxygen level. If it is less than 90 you can use oxygen and your inhaler. If not try to wait a few minutes take a few deep breaths and see if your shortness of breath improves. You can use the medication called Ativan lorazepam to help with the shortness of breath no more than three times a day . If still not improved you can use one of the inhalers oxygen. Please follow up with all your appointments as listed below and continue to take all of your medications as prescribed. If you experience any of the danger signs listed you should call your doctor immediately or go to the Emergency Room. We wish you the best Sincerely Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be J441, I4892, I248, J45909, Z87891, I4891, F419, G4700, E780, I2510, E876, R312, I739, Z7952, Z9981. The descriptions of icd codes J441, I4892, I248, J45909, Z87891, I4891, F419, G4700, E780, I2510, E876, R312, I739, Z7952, Z9981 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; I4892: Unspecified atrial flutter; I248: Other forms of acute ischemic heart disease; J45909: Unspecified asthma, uncomplicated; Z87891: Personal history of nicotine dependence; I4891: Unspecified atrial fibrillation; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; E780: Pure hypercholesterolemia; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E876: Hypokalemia; R312: Other microscopic hematuria; I739: Peripheral vascular disease, unspecified; Z7952: Long term (current) use of systemic steroids; Z9981: Dependence on supplemental oxygen. The common codes which frequently come are J45909, Z87891, I4891, F419, G4700, I2510. The uncommon codes mentioned in this dataset are J441, I4892, I248, E780, E876, R312, I739, Z7952, Z9981.
The icd codes present in this text will be I4891, J441, Z9981, Z7901, I10, E785, F419, I739, I2510, Z87891, D509, R079, G4700, H409. The descriptions of icd codes I4891, J441, Z9981, Z7901, I10, E785, F419, I739, I2510, Z87891, D509, R079, G4700, H409 are I4891: Unspecified atrial fibrillation; J441: Chronic obstructive pulmonary disease with (acute) exacerbation; Z9981: Dependence on supplemental oxygen; Z7901: Long term (current) use of anticoagulants; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F419: Anxiety disorder, unspecified; I739: Peripheral vascular disease, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z87891: Personal history of nicotine dependence; D509: Iron deficiency anemia, unspecified; R079: Chest pain, unspecified; G4700: Insomnia, unspecified; H409: Unspecified glaucoma. The common codes which frequently come are I4891, Z7901, I10, E785, F419, I2510, Z87891, D509, G4700. The uncommon codes mentioned in this dataset are J441, Z9981, I739, R079, H409. Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint Dyspnea Atrial Fibrillation Major Surgical or Invasive Procedure None History of Present Illness ___ F with pmhx of COPD nighttime O2 htn afib who presents with dyspnea currently being treated for COPD and admitted for Afib with RVR. The patient went to the ED on ___ and was diagnosed with a COPD flare. She was discharged with a prednisone taper currently on 60mg and azithromycin. This AM she initially felt well then developed dyspnea at rest worsening with exertion. Her inhalers improved her SOB. She felt that these symptoms were consistent with her COPD. She saw her PCP ___ today in clinic where she was found to be in Afib w RVR rate around 110 120. She has a history of afib. He referred her to the ED for persistent SOB and afib with RVR. She states she been compliant with nebs and steroid azithro regimen. She denies any ___ edema orthopnea. She denies recent travel surgeries. She had an episode of chest tightness this AM that felt like her COPD flares. Denies fevers or coughing or production of sputum hemomptysis. Past Medical History ASTHMA COPD ATYPICAL CHEST PAIN CERVICAL RADICULITIS CERVICAL SPONDYLOSIS CORONARY ARTERY DISEASE HEADACHE HIP REPLACEMENT HYPERLIPIDEMIA HYPERTENSION OSTEOARTHRITIS HERPES ZOSTER ATRIAL FIBRILLATION ANXIETY GASTROINTESTINAL BLEEDING OSTEOARTHRITIS ATHEROSCLEROTIC CARDIOVASCULAR DISEASE PERIPHERAL VASCULAR DISEASE Social History ___ Family History Mother ___ HTN Father ___ CA Brother CA Brother ___ Physical ___ ADMISSION PHYSICAL EXAM VS 98.14 154 74 71 24 98 2L GENERAL Well appearing NAD no accessory muscle use. HEENT NCAT. Sclera anicteric. PERRL EOMI. NECK No JVD CARDIAC Irregular rhythm normal rate. Normal S1 S2. No murmurs rubs gallops. LUNGS Moving air well bilaterally. Trace inspiratory wheezing and louder expiratory wheezing in all lung fields. No crackles rhonchi. ABDOMEN Soft NTND. No HSM or tenderness. EXTREMITIES No c c e. No femoral bruits. DISCHARGE PHYSICAL EXAM VS Tm 98.8 Tc 98.4 ___ RA GENERAL NAD HEENT NCAT. Sclera anicteric. Conjunctivae noninjected. OM clear. NECK No JVD CARDIAC RRR. Normal S1 S2. No murmurs rubs gallops. LUNGS Mildly reduced air movement significant wheezing bilaterally rhonchi no crackles ABDOMEN Soft NTND. No HSM or tenderness. EXTREMITIES No c c e. Pertinent Results ADMISSION LABS ___ 03 38PM BLOOD WBC 7.2 RBC 4.06 Hgb 9.4 Hct 31.4 MCV 77 MCH 23.2 MCHC 29.9 RDW 16.9 RDWSD 47.2 Plt ___ ___ 03 38PM BLOOD Neuts 93.8 Lymphs 4.2 Monos 1.3 Eos 0.0 Baso 0.0 Im ___ AbsNeut 6.74 AbsLymp 0.30 AbsMono 0.09 AbsEos 0.00 AbsBaso 0.00 ___ 03 38PM BLOOD ___ PTT 30.3 ___ ___ 03 38PM BLOOD Glucose 141 UreaN 20 Creat 1.0 Na 133 K 3.8 Cl 93 HCO3 30 AnGap 14 ___ 03 38PM BLOOD Calcium 9.9 Phos 2.8 Mg 2.1 PERTINENT LABS ___ 03 58PM BLOOD cTropnT 0.01 ___ 06 50AM BLOOD CK MB 4 cTropnT 0.01 ___ 06 50AM BLOOD calTIBC 398 Ferritn 16 TRF 306 ___ 06 50AM BLOOD TSH 4.5 ___ 09 31AM BLOOD ___ pO2 73 pCO2 58 pH 7.35 calTCO2 33 Base XS 3 ___ 07 15AM BLOOD T4 FREE DIRECT DIALYSIS Test DISCHARGE LABS ___ 05 30AM BLOOD WBC 13.2 RBC 3.97 Hgb 9.0 Hct 31.1 MCV 78 MCH 22.7 MCHC 28.9 RDW 17.4 RDWSD 48.7 Plt ___ ___ 05 30AM BLOOD Glucose 85 UreaN 23 Creat 0.9 Na 136 K 3.9 Cl 95 HCO3 30 AnGap 15 ___ 06 30AM BLOOD Calcium 9.7 Phos 3.0 Mg 2.0 IMAGING ___ Chest X ray Relative increase in opacity over the lung bases bilaterally felt due to overlying soft tissue rather than consolidation. Lateral view may be helpful for confirmation. ___ Chest X ray There is hyperinflation. There is no pneumothorax effusion consolidation or CHF. There is probable osteopenia. Brief Hospital Course ___ is a ___ with a history of CAD PVD and COPD and history of recurrent chest pain who presented with afib with RVR and COPD exacerbation. ACUTE PROBLEMS COPD exacerbation Ms. ___ had had two recent ED visits for COPD exacerbation most recently ___ when she was started on prednisone 60 mg. She presented to her PCP s office with worsening dyspnea despite this therapy and was also complaining of nasal congestion suggesting a viral URI trigger. In clinic she was also noted to be in afib with RVR so was referred to the ED where she was admitted after control of her heart rate see below . On admission to the floor she was noted to have wheezing increased work of breathing and poor air movement. She was treated with 125 mg solumedrol and maintained on 60 mg PO prednisone daily. Her home theophylline was decreased from 400 mg BID to ___ mg BID due to concerns it was contributing to her tachyarrhythmia. She was placed on ipratropium nebs q6h albuterol nebs q2h and fluticasone salmeterol. Pulmonary was consulted and recommended a trial of diuresis so she received 10 mg IV Lasix as well. Azithromycin was not given due to concerns for QT prolongation with theophylline and amiodarone QTc was 460 . She was started on a 5 day course of ceftriaxone instead and discharged to finish the course with cefpodoxime. She was discharged with a prednisone taper 10 mg decrease q3d until at 10 mg then stay at 10 mg until pulm follow up as well as follow up with pulmonary rehab and a pulmonologist she previously followed with Dr. ___. She was also discharged on 2L supplemental O2 to be worn at all times. Atrial fibrillation Ms. ___ has known atrial fibrillation for which she was on amiodarone and apixaban but was found to have HR in the 120s in her PCP s office prompting her referral to the ED. Her COPD exacerbation was the likely precipitant with medications also possibly contributing particularly theophylline. She was started on a diltiazem gtt in the ED to control her rates than transitioned to diltiazem 90 mg q6h. After arrival to the floor her rates remained controlled. Her amiodarone and apixaban were continued. Her theophylline was decreased to 200 mg BID from 400 mg BID. Iron deficiency anemia. Patient was found to have microcytic anemia with low iron and ferritin. She was started on IV iron 125 mg ferric gluconate x4 doses and wasdischarged on PO iron with a bowel regimen. Her H H was stable throughout the hospitalized there was no evidence of bleeding. Transitional issues patient discharged on prednisone taper decrease by 10 mg every 3 days until at 10 mg then keep at 10 mg until seen by pulmonology patient discharged with plan to follow up with pulmonology and pulmonary rehab. Can call ___ to schedule appointment with pulmonary rehab. patient discharged on with 2 days of cefpodoxime to complete 5 day course of antibiotics for severe COPD exacerbation patient discharged with O2 concentrator for continuous home O2 patient s theophylline decreased from 300 mg BID to ___ mg BID due to her afib with RVR may want to consider further theophylline wean and addition of azithromycin if QTc is decreased as patient also on amiodarone and or roflumilast therapy patient found to be iron deficient started on IV iron repletion discharged on PO iron patient found to have elevated TSH please follow up free T4 which was pending on discharge Code full Emergency Contact ___ Husband ___ Daughter ___ ___ ___ on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN pain 2. Apixaban 5 mg PO BID 3. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN shortness of breath 4. Amiodarone 200 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Artificial Tears ___ DROP BOTH EYES PRN irritation 7. Latanoprost 0.005 Ophth. Soln. 1 DROP LEFT EYE QHS 8. Diltiazem Extended Release 180 mg PO BID 9. Fluticasone Propionate NASAL 1 SPRY NU BID 10. Fluticasone Salmeterol Diskus 250 50 1 INH IH BID 11. Hydrochlorothiazide 50 mg PO DAILY 12. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 13. Lorazepam 0.5 mg PO QHS PRN insomnia 14. Theophylline ER 300 mg PO BID 15. Ranitidine 300 mg PO DAILY 16. Tiotropium Bromide 1 CAP IH DAILY 17. Multivitamins W minerals 1 TAB PO DAILY 18. Aspirin 81 mg PO DAILY 19. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID Discharge Medications 1. Home O2 2 Liters continuous nasal cannula with exertion Diagnosis chronic obstructive pulmonary disease J44.9 Length of Needs ongoing years 2. Acetaminophen 650 mg PO Q6H PRN pain 3. Amiodarone 200 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Albuterol 0.083 Neb Soln 1 NEB IH Q2H PRN shortness of breath 6. Artificial Tears ___ DROP BOTH EYES PRN irritation 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 10 mg PO QPM 9. Diltiazem Extended Release 180 mg PO BID 10. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 11. Fluticasone Propionate NASAL 1 SPRY NU BID 12. Fluticasone Salmeterol Diskus 250 50 1 INH IH BID 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 15. Latanoprost 0.005 Ophth. Soln. 1 DROP LEFT EYE QHS 16. Lorazepam 0.5 mg PO QHS PRN insomnia 17. Multivitamins W minerals 1 TAB PO DAILY 18. Ranitidine 300 mg PO DAILY 19. Tiotropium Bromide 1 CAP IH DAILY 20. Theophylline SR 200 mg PO BID RX theophylline 200 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 21. Cefpodoxime Proxetil 200 mg PO Q12H Duration 2 Days RX cefpodoxime 200 mg 1 tablet s by mouth twice a day Disp 4 Tablet Refills 0 22. Ferrous Sulfate 325 mg PO DAILY RX ferrous sulfate 325 mg 65 mg iron 1 tablet s by mouth daily Disp 30 Tablet Refills 0 23. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 0 24. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram dose 1 powder s by mouth daily Refills 0 25. Ipratropium Bromide Neb 1 NEB IH Q6H PRN dyspnea wheezing RX ipratropium bromide 0.2 mg mL 0.02 1 neb INH Every six hours Disp 30 Nebule Refills 0 26. PredniSONE 10 mg PO ASDIR 50 mg ___ then 40 mg ___ then 30 mg ___ then 20 mg ___ then 10 mg ongoing Tapered dose DOWN RX prednisone 10 mg 1 to 5 tablet s by mouth As directed Disp 50 Tablet Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary diagnoses Chronic obstructive pulmonary disease Atrial fibrillation with rapid ventricular response Secondary diagnoses Hypertension Coronary artery disease Peripheral vascular disease Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were hospitalized at ___ because you were having difficulty breathing and were found in clinic to have a fast heart rate. Your difficulty breathing was due to your COPD flaring. Your fast heart rate was due to your atrial fibrillation which is an irregular heart rate that can sometimes cause the heart to beat very quickly. Medications that you were taking such as theophylline were likely contributing. Your heart rate was lowered using the same medication that you take at home diltiazem given through your IV. Your COPD was likely worsened because of a cold. However your flare was very serious requiring IV steroids and many inhaled treatments. You should follow up with the lung doctors as ___ as with pulmonary rehab to make sure your lung disease is being treated as well as possible to prevent you from coming into the hospital as often. Please call ___ to schedule an appointment with them. It was a pleasure participating in your care. We wish you all the best in the future. Sincerely Your ___ team Followup Instructions ___ The icd codes present in this text will be I4891, J441, Z9981, Z7901, I10, E785, F419, I739, I2510, Z87891, D509, R079, G4700, H409. The descriptions of icd codes I4891, J441, Z9981, Z7901, I10, E785, F419, I739, I2510, Z87891, D509, R079, G4700, H409 are I4891: Unspecified atrial fibrillation; J441: Chronic obstructive pulmonary disease with (acute) exacerbation; Z9981: Dependence on supplemental oxygen; Z7901: Long term (current) use of anticoagulants; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F419: Anxiety disorder, unspecified; I739: Peripheral vascular disease, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z87891: Personal history of nicotine dependence; D509: Iron deficiency anemia, unspecified; R079: Chest pain, unspecified; G4700: Insomnia, unspecified; H409: Unspecified glaucoma. The common codes which frequently come are I4891, Z7901, I10, E785, F419, I2510, Z87891, D509, G4700. The uncommon codes mentioned in this dataset are J441, Z9981, I739, R079, H409.
The icd codes present in this text will be C169, C786, I82621, K9171, Y838, Y92234, N359, E039, K219, Z7901, Z8546. The descriptions of icd codes C169, C786, I82621, K9171, Y838, Y92234, N359, E039, K219, Z7901, Z8546 are C169: Malignant neoplasm of stomach, unspecified; C786: Secondary malignant neoplasm of retroperitoneum and peritoneum; I82621: Acute embolism and thrombosis of deep veins of right upper extremity; K9171: Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92234: Operating room of hospital as the place of occurrence of the external cause; N359: Urethral stricture, unspecified; E039: Hypothyroidism, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; Z7901: Long term (current) use of anticoagulants; Z8546: Personal history of malignant neoplasm of prostate. The common codes which frequently come are E039, K219, Z7901. The uncommon codes mentioned in this dataset are C169, C786, I82621, K9171, Y838, Y92234, N359, Z8546. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Locally advanced gastric carcinoma Major Surgical or Invasive Procedure Cystoscopy for foley catheter placement Laparoscopy with biopsy Gastroscopy History of Present Illness Mr. ___ is a ___ year old male with locally advanced gastric cancer stage II T3N2 who arrives to ___ for curative intent surgical resection after completion of induction chemotherapy. He was started on neoadjuvant chemotherapy with FLOT4 on ___. Overall he tolerated the chemotherapy well without any significant side effects. However last month he developed right upper extremity edema and was noted to have a thrombosis in the R SVC. He was started on Lovenox 1 mg kg BID which he is compliant with. Denies any fever nausea emesis chills weight loss melena hematochezia or hematuria. He comes after recent repeat staging ___ with torso CT scan demonstrating no evidence of disease. He is now now taken to the operating room for minimally invasive and possibly open radical distal gastrectomy with lymphadenectomy. The risks and benefits of surgery have been described with the patient in detail and are documented by Dr. ___ in a separate note. Past Medical History Past Medical History Prostate cancer Thyroid nodule Hypothyroid GERD mild Diverticulosis on colonoscopy ___ anemia iron def. anemia which resolved and no workup Past Surgical History Prostate cancer external beam ___ Achilles tendon repair ___ Shattered right tibia and fibula Tonsillectomy age ___. Social History ___ Family History Father died at ___ from Lymphoma. Mother died at ___ with type II DM Dementia. Physical Exam VS 24 HR Data last updated ___ 1118 Temp 98.1 Tm 98.9 BP 116 73 108 118 59 77 HR 79 77 86 RR 18 ___ O2 sat 99 97 99 O2 delivery Ra GEN A Ox3 NAD resting comfortably HEENT NCAT EOMI sclera anicteric CV RRR PULM no respiratory distress ABD soft NT ND no rebound or guarding EXT warm well perfused no edema PSYCH normal insight memory and mood WOUND S Incision c d i Brief Hospital Course Mr. ___ is a ___ year old Male who presented on ___ for a planned minimally invasive and possibly open radical distal gastrectomy with lymphadenectomy for locally advanced gastric carcinoma after chemotherapy. After placement of the Right upper quadrant port insufflation revealed the right upper quadrant port to be penetrating the omentum. It appeared to miss the transverse mesocolon as well as the colon itself. During the surgery there were visually obvious peritoneal deposits on all peritoneal surfaces in all four quadrants which demonstrated undetected carcinomatosis poorly differentiated adenocarcinoma involving the peritoneum. For this reason the procedure was then aborted. Post operatively the patient was taken to the PACU until stable and then transferred to the wards until stable to go home. NEURO The patient was alert and oriented throughout hospitalization pain was initially managed with dilaudid PCA which he was not using and then transitioned to tramadol which he got only one dose. Pain was very well controlled. CV The patient remained stable from a cardiovascular standpoint vital signs were routinely monitored. PULMONARY The patient remained stable from a pulmonary standpoint vital signs were routinely monitored. Good pulmonary toilet early ambulation and incentive spirometry were encouraged throughout hospitalization. GI GU FEN Before the procedure started OR nurse was unable to pass Foley after attempt with standard and coude type. PA ___ with usual sterile technique re attempted foley placement after 10cc urojet application with ___ and ___ coude type catheters but was also unable to get passed the prostate. Urology was consulted and they performed a flexible cystoscope demonstrating a normal urethra. Using a flexible guidewire cystoscope was advanced into the bladder. The scope was withdrawn and a ___ council was advanced over the wire passed the prostate and into the bladder. The patient was discharged with the Foley in place with instructions to follow up with urology as outpatient in 5 to 7 days for a voiding trial. No antibiotics were administered. The patient was tolerating a regular diet prior to discharge. ID The patient s fever curves were closely watched for signs of infection of which there were none. HEME Patient received BID SQH for DVT prophylaxis in addition to encouraging early ambulation and Venodyne compression devices. On POD1 the patient was restarted on his home enoxaparin before discharge. TRANSITIONAL ISSUES At the time of discharge the patient was doing well afebrile with stable vital signs. The patient was tolerating diet as above per oral ambulating and pain was well controlled. The patient was discharged home with the Foley catheter with appropriate teaching for care. The patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission Medications Prescription BIO THROID Bio Throid . 65 mg. once a day Prescribed by Other Provider ENOXAPARIN enoxaparin 120 mg 0.8 mL subcutaneous syringe. 120 mg SC daily OMEPRAZOLE omeprazole 20 mg capsule delayed release. 1 capsule s by mouth twice daily UBIQUINOL ubiquinol . 100 mg 2 tabs mouth twice a day Prescribed by Other Provider Medications OTC FERROUS SULFATE ferrous sulfate 325 mg 65 mg iron tablet. 1 tablet s by mouth twice a day Prescribed by Other Provider LACTOBACILLUS COMBINATION NO.4 PROBIOTIC Dosage uncertain Prescribed by Other Provider daily Discharge Medications 1. Acetaminophen 1000 mg PO TID 2. Docusate Sodium 100 mg PO BID 3. Senna 8.6 mg PO BID PRN Constipation First Line 4. TraMADol 50 mg PO Q6H PRN Pain Moderate This medication is a low dose narcotic and may cause constipation. RX tramadol 50 mg 1 One tablet s by mouth every six 6 hours Disp 20 Tablet Refills 0 5. Enoxaparin Sodium 120 mg SC DAILY Discharge Disposition Home Discharge Diagnosis Metastatic gastric cancer stage IV T3N2M1 Urethral stricture Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ It was a pleasure taking care of you here at ___ ___. You were admitted to our hospital for gastric cancer. You had an attempted Robot assisted laparoscopic partial gastrectomy and gastroscopy on ___ without complications. You tolerated the procedure well and are ambulating stooling tolerating a regular diet and your pain is controlled by pain medications by mouth. You are now ready to be discharged to home. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You should continue to walk several times a day. You may go outside but avoid traveling long distances until you see your surgeon at your next visit. You may start some light exercise when you feel comfortable. Slowly increase your activity back to your baseline as tolerated. Heavy exercise may be started after 6 weeks but use common sense and go slowly at first. No heavy lifting 10 pounds or more until cleared by your surgeon usually about 6 weeks. You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL You may feel weak or washed out for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during the surgery. YOUR BOWELS Constipation is a common side effect of narcotic pain medicine such as oxycodone. If needed you may take a stool softener such as Colace one capsule or gentle laxative such as milk of magnesia 1 tbs twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement or have pain moving the bowels call your surgeon. After some operations diarrhea can occur. If you get diarrhea don t take anti diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away or is severe and you feel ill please call your surgeon. PAIN MANAGEMENT You are being discharged with a prescription for oxycodone for pain control. You may take Tylenol as directed not to exceed 3500mg in 24 hours. Take regularly for a few days after surgery but you may skip a dose or increase time between doses if you are not having pain until you no longer need it. You may take the oxycodone for moderate and severe pain not controlled by the Tylenol. You may take a stool softener while on narcotics to help prevent the constipation that they may cause. Slowly wean off these medications as tolerated. Your pain should get better day by day. If you find the pain is getting worse instead of better please contact your surgeon. If you experience any of the following please contact your surgeon sharp pain or any severe pain that lasts several hours chest pain pressure squeezing or tightness cough shortness of breath wheezing pain that is getting worse over time or pain with fever shaking chills fever of more than 101 a drastic change in nature or quality of your pain nausea and vomiting inability to tolerate fluids food or your medications if you are getting dehydrated dry mouth rapid heart beat feeling dizzy or faint especially while standing any change in your symptoms or any symptoms that concern you Additional pain that is getting worse over time or going to your chest or back urinary burning or blood in your urine or the inability to urinate MEDICATIONS Take all the medicines you were on before the operation just as you did before unless you have been told differently. If you have any questions about what medicine to take or not to take please call your surgeon. WOUND CARE dressing removal You may remove your dressings tomorrow ___ and shower that same day with any bandage strips that may be covering your wound. Do not scrub and do not soak or swim and pat the incision dry. If you have steri strips they will fall off by themselves in ___ weeks. If any are still on in two weeks and the edges are curling up you may carefully peel them off. Do not take baths soak or swim for 6 weeks after surgery unless told otherwise by your surgical team. Notify your surgeon is you notice abnormal foul smelling bloody pus etc or increased drainage from your incision site opening of your incision or increased pain or bruising. Watch for signs of infection such as redness streaking of your skin swelling increased pain or increased drainage. Please call with any questions or concerns. Thank you for allowing us to participate in your care. We hope you have a quick return to your usual life and activities. Home with ___ You had a Foley catheter in your bladder placed by urology on the day of your surgery after difficulty trying to place it. You will keep the catheter until your appointment with Urology in 5 days please call the number below to schedule your appointment who will decide if you need it longer or attempt to remove it and see if you are able to void. Empty the bag as needed and as shown to you by nursing staff. You will be given a leg bag before your discharge that you may use for short trips. This is a smaller bag that straps to your leg to take home and wear if you are traveling outside your home. This holds a smaller amount than the bag you have now so it needs to be emptied more often. Some people find it easier to use the larger bad when they are at home or carry it with them. Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be C169, C786, I82621, K9171, Y838, Y92234, N359, E039, K219, Z7901, Z8546. The descriptions of icd codes C169, C786, I82621, K9171, Y838, Y92234, N359, E039, K219, Z7901, Z8546 are C169: Malignant neoplasm of stomach, unspecified; C786: Secondary malignant neoplasm of retroperitoneum and peritoneum; I82621: Acute embolism and thrombosis of deep veins of right upper extremity; K9171: Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92234: Operating room of hospital as the place of occurrence of the external cause; N359: Urethral stricture, unspecified; E039: Hypothyroidism, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; Z7901: Long term (current) use of anticoagulants; Z8546: Personal history of malignant neoplasm of prostate. The common codes which frequently come are E039, K219, Z7901. The uncommon codes mentioned in this dataset are C169, C786, I82621, K9171, Y838, Y92234, N359, Z8546.
The icd codes present in this text will be I25110, E1110, E1122, E11319, M869, I5032, I130, T82855A, E11621, E1142, E1165, E1169, L97529, N183, J449, B961, B951, F329, K219, G4733, Z87891, Z951, Z794, Z9114, G2581, Z955, Y840, Y929. The descriptions of icd codes I25110, E1110, E1122, E11319, M869, I5032, I130, T82855A, E11621, E1142, E1165, E1169, L97529, N183, J449, B961, B951, F329, K219, G4733, Z87891, Z951, Z794, Z9114, G2581, Z955, Y840, Y929 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; E1110: Type 2 diabetes mellitus with ketoacidosis without coma; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema; M869: Osteomyelitis, unspecified; I5032: Chronic diastolic (congestive) heart failure; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; T82855A: Stenosis of coronary artery stent, initial encounter; E11621: Type 2 diabetes mellitus with foot ulcer; E1142: Type 2 diabetes mellitus with diabetic polyneuropathy; E1165: Type 2 diabetes mellitus with hyperglycemia; E1169: Type 2 diabetes mellitus with other specified complication; L97529: Non-pressure chronic ulcer of other part of left foot with unspecified severity; N183: Chronic kidney disease, stage 3 (moderate); J449: Chronic obstructive pulmonary disease, unspecified; B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere; B951: Streptococcus, group B, as the cause of diseases classified elsewhere; F329: Major depressive disorder, single episode, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; G4733: Obstructive sleep apnea (adult) (pediatric); Z87891: Personal history of nicotine dependence; Z951: Presence of aortocoronary bypass graft; Z794: Long term (current) use of insulin; Z9114: Patient's other noncompliance with medication regimen; G2581: Restless legs syndrome; Z955: Presence of coronary angioplasty implant and graft; Y840: Cardiac catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable. The common codes which frequently come are E1122, I5032, I130, E1165, J449, F329, K219, G4733, Z87891, Z951, Z794, Z955, Y929. The uncommon codes mentioned in this dataset are I25110, E1110, E11319, M869, T82855A, E11621, E1142, E1169, L97529, N183, B961, B951, Z9114, G2581, Y840. Allergies lisinopril Chief Complaint Chest pain Major Surgical or Invasive Procedure Cardiac cath ___ Past Medical History COPD CAD s p BMS proximal LAD ___ DES to mid LAD ___ DES to edge ISR of mid LAD DES and stenosis distal to stent ___ DES to OM1 ___ s p 3 v CABG LIMA LAD SVG OM1 ___ HFpEF Depression DM GERD Hypertension Migraines Chronic shoulder pain on narcotics OSA Peripheral neuropathy Restless leg Social History ___ Family History Patient was ward of the state doesn t know full details of family history. Mother with possible alcohol abuse. Father deceased at ___ from Hodgkin s Disease per old records. Physical Exam ADMISSION EXAM GENERAL NAD AOx3 Pleasant woman. HEENT NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva pink no pallor or cyanosis of the oral mucosa NECK Supple with no JVD CARDIAC RRR normal S1 S2. No thrills lifts. LUNGS CTAB. No crackles wheezes or rhonchi. ABDOMEN Soft NTND. No HSM or tenderness. EXTREMITIES No ___ edema PULSES ___ and DP palpable on the right side. Did not take bandage down for exam as podiatry had just dressed. DISCHARGE EXAM VITALS ___ 0412 Temp 97.8 PO BP 105 67 R Lying HR 71 RR 18 O2 sat 97 O2 delivery Ra GENERAL NAD AOx3 Pleasant woman. HEENT NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva pink no pallor or cyanosis of the oral mucosa NECK Supple with no JVD CARDIAC RRR normal S1 S2. No thrills lifts. LUNGS CTAB. No crackles wheezes or rhonchi. ABDOMEN Soft NTND. EXTREMITIES No ___ edema PULSES ___ and DP palpable on the right side. Did not take bandage down for exam as podiatry had just dressed. Per podiatry exam ___ See attached picture on OMR ___ pulses palpable b l. CFT 3 sec to digits bilaterally. There is a L hallux wound present at the medial aspect of the toe at the level of the IPJ. Wound has eschar over top of the base w surrounding hyperkeratotic skin and surrounding erythema. There is no malodor or proximal streaking present. Once the wound was debrided and the eschar was deroofed there is fibrotic skin at the base of the wound. It does not probe deep to bone. 2cc of purulent drainage was expressed from wound. Wound is extremely TTP. Gross sensation is intact to b l lower extremities. MMT ___ to all ___ muscle groups crossing the ankle jt. No gross deformities noted. Pertinent Results ADMISSION LABS ___ 12 50AM BLOOD WBC 12.7 RBC 4.34 Hgb 14.4 Hct 41.7 MCV 96 MCH 33.2 MCHC 34.5 RDW 11.8 RDWSD 41.3 Plt ___ ___ 12 50AM BLOOD Glucose 318 UreaN 21 Creat 1.1 Na 134 K 4.2 Cl 92 HCO3 19 AnGap 23 ___ 12 50AM BLOOD cTropnT 0.01 ___ 06 00AM BLOOD cTropnT 0.01 ___ 11 40AM BLOOD cTropnT 0.01 ___ 05 20PM BLOOD CK MB 1 cTropnT 0.01 ___ 05 20PM BLOOD Albumin 3.5 Calcium 8.6 Phos 3.6 Mg 1.8 ___ 05 20PM BLOOD HbA1c 12.0 eAG 298 ___ 12 50AM BLOOD CRP 36.4 ___ 12 50AM BLOOD ASA NEG Acetmnp NEG Tricycl NEG STUDIES ___ Coronary Angiogram Coronary Anatomy Dominance Right Left Main Coronary Artery The LMCA is. Left Anterior Descending The LAD has diffuse 60 in stent restenosis with patent LIMA to distal vessel. The ___ Diagonal is small and diffusely diseased. Circumflex The Circumflex is occluded after a small OM1. There is a patent SVG to OM2. Right Coronary Artery The RCA has focal mid 50 stenosis. SVG to OM patent. LIMA to LAD patent. Intra procedural Complications None Impressions 1. three vessel CAD. 2. Patent SVG to OM and LIMA to LAD. Recommendations 1. Medical therapy. Pharmacological MIBI ___ IMPRESSION 1. Reversible medium sized moderate severity perfusion defect involving the LAD territory. 2. Normal left ventricular cavity size and systolic function. Compared to the prior study of ___ the perfusion defect is new. ECHO ___ LEFT ATRIUM Normal LA volume index. LEFT VENTRICLE Normal LV wall thickness cavity size and regional global systolic function biplane LVEF 55 . Doppler parameters are most consistent with normal LV diastolic function. RIGHT VENTRICLE Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with prior cardiac surgery. AORTA Normal diameter of aorta at the sinus ascending and arch levels. AORTIC VALVE Normal aortic valve leaflets 3 . No AS. No AR. MITRAL VALVE Normal mitral valve leaflets with trivial MR. ___ mitral valve supporting structures. No MS. ___ VALVE Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE PULMONARY ARTERY Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM No pericardial effusion. Conclusions The left atrial volume index is normal. Normal left ventricular wall thickness cavity size and regional global systolic function biplane LVEF 63 . Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus ascending and arch levels are normal. The aortic valve leaflets 3 appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION 1 Normal biventricular regional global systolic function. Compared with the prior study images reviewed of ___ no clinically significant change noted DISCHARGE LABS ___ 06 10AM BLOOD WBC 7.7 RBC 3.53 Hgb 11.6 Hct 33.8 MCV 96 MCH 32.9 MCHC 34.3 RDW 11.7 RDWSD 40.6 Plt ___ ___ 06 10AM BLOOD Glucose 245 UreaN 12 Creat 1.0 Na 140 K 4.3 Cl 101 HCO3 25 AnGap 14 ___ 02 45AM BLOOD ALT 14 AST 17 AlkPhos 50 TotBili 0.4 ___ 06 10AM BLOOD Calcium 8.0 Phos 2.6 Mg 1.___ year old female with CAD s p BMS proximal LAD ___ DES to mid LAD ___ DES to edge ISR of mid LAD DES and stenosis distal to stent ___ DES to ___ s p 3 v CABG LIMA LAD SVG OM1 SVG D1 occluded ___ HFpEF IDDM HTN who presented with several days atypical chest pain both with exertion and at rest with mild T wave deepening but no other EKG changes or troponin. She also presented with mild DKA and diabetic foot ulcer. She had a stress test with reversible ischemia in the LAD territory ___ and went to cardiac catheterization ___ which showed stable disease and no new obstructive lesions. Overall her chest pain was felt to have been either musculoskeletal or demand in the setting of DKA and diabetic foot ulcer. She was discharged on ASA 81 atorvastatin 80 Metoprolol XL 100mg daily. DKA IDDM Patient presented with anion gap metabolic acidosis and felt to be in mild DKA. She had insulin gtt in the ED but was rapidly switched to subcutaneous insulin. Her A1c returned at 12 which is the highest it has been recorded for her in our records. She had followed with ___ previously and was on canagliflozin and glipizide as well as SC insulin prior to admission. However she reported intermittent adherence to her medications and this was the likely reason for her DKA. While she was in house the ___ followed along and she met with a diabetes educator. Her canagliflozin was stopped at discharge due to increased risk of amputation. Diabetic foot ulcer Present for at least 3 weeks prior to admission. She underwent bedside debridement by Podiatry in ED. XR suggested presence of osteomyelitis . She was maintained on vanc cefepime flagyl in house and was switched to cipro clinda at discharge per podiatry recs with plans for close follow up. Her wound swab at time of discharge was polymicrobial but was growing Group B strep sensitivities pending and klebsiella pan sensitive . Med noncompliance She reported intermittent medication compliance related to difficulty remembering to take her medications as well as periods of depression and stress where taking her medication was not a priority. She has recently obtained a pillbox and her granddaughter is helping her with remembering to take her medications. HFpEF Metoprolol as above continued torsemide 20mg and she appeared euvolemic throughout admission. HL Continued atorvastatin HTN Metoprolol lowered to XL 100mg daily losartan kept at 25mg daily. Imdur stopped. COPD Duonebs q6h in house continued home inhalers on discharge. Restless legs continued ropinerole Transitional issues Please follow up her diabetic foot ulcer in ___ clinic. Plan at time of discharge was to take to OR for further surgical debridement patient was discharged with cipro clinda until Podiatry follow up Please review her blood sugars at home and continue to reinforce compliance with diabetes medications. Her Canagliflozin was stopped due to increased risk of amputation. Consider reintroducing metformin as this was stopped ___ years ago for diarrhea but may be a better option for her. Follow up blood pressures and heart rate on the current regimen. Suspect that due to noncompliance her medications were uptitrated to higher doses than she actually needs. We cut back her Metoprolol and stoped her imdur Can restart imdur if requiring for chest pain on outpatient basis Please continue to work with patient on med compliance and possible barriers. She denied depression with our social worker but does endorse that stress makes it hard to take her medications. f u final wound swab cultures Medications on Admission The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 25 mg PO DAILY 2. MetronidAZOLE Topical 1 Gel 1 Appl TP BID PRN Rosacea 3. Gabapentin 300 mg PO QHS PRN Headache 4. Metoprolol Succinate XL 250 mg PO DAILY 5. linaGLIPtin 5 mg oral DAILY 6. Atorvastatin 80 mg PO QPM 7. Furosemide 20 mg PO DAILY 8. Isosorbide Mononitrate 120 mg PO DAILY 9. Nitroglycerin SL 0.4 mg SL Q5MIN PRN angina 10. rOPINIRole 0.5 mg PO QHS restless leg syndrome 11. OxyCODONE Acetaminophen 5mg 325mg 1 TAB PO Q6H PRN Pain Severe 12. Fluticasone Propionate 110mcg 2 PUFF IH BID 13. Pantoprazole 40 mg PO BID 14. Aspirin 325 mg PO DAILY 15. TraZODone 50 mg PO QHS PRN insomnia 16. canagliflozin 100 mg oral DAILY 17. albuterol sulfate 90 mcg actuation inhalation Q8H PRN 18. Lidocaine 5 Patch 1 PTCH TD QPM Discharge Medications 1. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet s by mouth twice a day Disp 14 Tablet Refills 0 2. Clindamycin 300 mg PO Q6H RX clindamycin HCl 300 mg 1 capsule s by mouth four times per day Disp 28 Capsule Refills 0 3. Glargine 50 Units Bedtime Humalog 18 Units Breakfast Humalog 18 Units Lunch Humalog 18 Units Dinner Insulin SC Sliding Scale using HUM Insulin 4. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate 100 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 5. albuterol sulfate 90 mcg actuation inhalation Q8H PRN 6. Aspirin 325 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Furosemide 20 mg PO DAILY 10. Gabapentin 300 mg PO QHS PRN Headache 11. linaGLIPtin 5 mg oral DAILY 12. Losartan Potassium 25 mg PO DAILY 13. MetronidAZOLE Topical 1 Gel 1 Appl TP BID PRN Rosacea 14. Nitroglycerin SL 0.4 mg SL Q5MIN PRN angina 15. OxyCODONE Acetaminophen 5mg 325mg 1 TAB PO Q6H PRN Pain Severe RX oxycodone acetaminophen 5 mg 325 mg 1 tablet s by mouth three times daily Disp 15 Tablet Refills 0 16. Pantoprazole 40 mg PO BID 17. rOPINIRole 0.5 mg PO QHS restless leg syndrome 18. TraZODone 50 mg PO QHS PRN insomnia 19. HELD canagliflozin 100 mg oral DAILY This medication was held. Do not restart canagliflozin until you speak with your endocrinologist 20. HELD Lidocaine 5 Patch 1 PTCH TD QPM This medication was held. Do not restart Lidocaine 5 Patch until you speak with your PCP ___ Home With Service Facility ___ Discharge Diagnosis PRIMARY Diabetic foot ulcer Diabetic ketoacidosis Chest pain SECONDARY DIABETES MELLITUS INSULIN DEPENDENT COPD Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ It was a pleasure taking care of you at the ___ ___ WHY WAS I IN THE HOSPITAL You were admitted because you had chest pain. You also had a process called DKA from not taking enough insulin You also had a bad infection in your foot. WHAT HAPPENED IN THE HOSPITAL We did several tests to figure our if your chest pain was caused by a heart attack. The first was a stress test which had a positive results. We then did a procedure called a cardiac cath which showed that you did NOT have a heart attack. Our podiatrists did a debridement of your foot. We gave you antibiotics for your foot. We adjusted your insulin levels. WHAT SHOULD I DO WHEN I GO HOME Take all of your medications Ciproflocaxin and Clindamycin are antibiotics you need to take until the podiatrists tell you to stop. You are scheduled to see them ___ Your insulin regimen will be slightly different from your old regimen. You need to take aspirin and Atorvastatin every day to prevent blockages in your heart from forming. You will have many appointments in the next week. It is very important that you go to all of these to help get your health on track Your weight at discharge is 79.1 kg 174.38 lb . Please weigh yourself today at home and use this as your new baseline Please weigh yourself every day in the morning. Call your doctor if your weight goes up by more than 3 lbs. Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs abdominal distention or shortness of breath. If you have worsening pain or redness in your foot urinating frequently or very thirsty or if your blood sugar is consistently above 300 or below 70 please cal your doctor. It was a pleasure participating in your care. We wish you the ___ Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I25110, E1110, E1122, E11319, M869, I5032, I130, T82855A, E11621, E1142, E1165, E1169, L97529, N183, J449, B961, B951, F329, K219, G4733, Z87891, Z951, Z794, Z9114, G2581, Z955, Y840, Y929. The descriptions of icd codes I25110, E1110, E1122, E11319, M869, I5032, I130, T82855A, E11621, E1142, E1165, E1169, L97529, N183, J449, B961, B951, F329, K219, G4733, Z87891, Z951, Z794, Z9114, G2581, Z955, Y840, Y929 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; E1110: Type 2 diabetes mellitus with ketoacidosis without coma; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema; M869: Osteomyelitis, unspecified; I5032: Chronic diastolic (congestive) heart failure; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; T82855A: Stenosis of coronary artery stent, initial encounter; E11621: Type 2 diabetes mellitus with foot ulcer; E1142: Type 2 diabetes mellitus with diabetic polyneuropathy; E1165: Type 2 diabetes mellitus with hyperglycemia; E1169: Type 2 diabetes mellitus with other specified complication; L97529: Non-pressure chronic ulcer of other part of left foot with unspecified severity; N183: Chronic kidney disease, stage 3 (moderate); J449: Chronic obstructive pulmonary disease, unspecified; B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere; B951: Streptococcus, group B, as the cause of diseases classified elsewhere; F329: Major depressive disorder, single episode, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; G4733: Obstructive sleep apnea (adult) (pediatric); Z87891: Personal history of nicotine dependence; Z951: Presence of aortocoronary bypass graft; Z794: Long term (current) use of insulin; Z9114: Patient's other noncompliance with medication regimen; G2581: Restless legs syndrome; Z955: Presence of coronary angioplasty implant and graft; Y840: Cardiac catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable. The common codes which frequently come are E1122, I5032, I130, E1165, J449, F329, K219, G4733, Z87891, Z951, Z794, Z955, Y929. The uncommon codes mentioned in this dataset are I25110, E1110, E11319, M869, T82855A, E11621, E1142, E1169, L97529, N183, B961, B951, Z9114, G2581, Y840.
The icd codes present in this text will be A419, M86672, M86172, N179, L03116, J9811, I5032, I130, E1152, I96, E1169, L97524, E11621, B9561, J449, E11319, E1142, E1165, I2510, I252, G4733, K219, G2581, N189, E1122, Z794, Z951, Z955, Z87891. The descriptions of icd codes A419, M86672, M86172, N179, L03116, J9811, I5032, I130, E1152, I96, E1169, L97524, E11621, B9561, J449, E11319, E1142, E1165, I2510, I252, G4733, K219, G2581, N189, E1122, Z794, Z951, Z955, Z87891 are A419: Sepsis, unspecified organism; M86672: Other chronic osteomyelitis, left ankle and foot; M86172: Other acute osteomyelitis, left ankle and foot; N179: Acute kidney failure, unspecified; L03116: Cellulitis of left lower limb; J9811: Atelectasis; I5032: Chronic diastolic (congestive) heart failure; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; E1152: Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene; I96: Gangrene, not elsewhere classified; E1169: Type 2 diabetes mellitus with other specified complication; L97524: Non-pressure chronic ulcer of other part of left foot with necrosis of bone; E11621: Type 2 diabetes mellitus with foot ulcer; B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere; J449: Chronic obstructive pulmonary disease, unspecified; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema; E1142: Type 2 diabetes mellitus with diabetic polyneuropathy; E1165: Type 2 diabetes mellitus with hyperglycemia; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I252: Old myocardial infarction; G4733: Obstructive sleep apnea (adult) (pediatric); K219: Gastro-esophageal reflux disease without esophagitis; G2581: Restless legs syndrome; N189: Chronic kidney disease, unspecified; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; Z794: Long term (current) use of insulin; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, I5032, I130, J449, E1165, I2510, I252, G4733, K219, N189, E1122, Z794, Z951, Z955, Z87891. The uncommon codes mentioned in this dataset are A419, M86672, M86172, L03116, J9811, E1152, I96, E1169, L97524, E11621, B9561, E11319, E1142, G2581. Allergies lisinopril Chief Complaint Left diabetic foot ulcer Major Surgical or Invasive Procedure Left partial hallux amputation History of Present Illness ___ with poorly controlled diabetes complicated by retinopathy neuropathy PAD foot ulcer L hallux CAD with ___ s p CABG and narcotics agreement presenting with 3 days subjective fever chills increased pain in L great toe. Pt recently had ulcer debrided by podiatry on ___ ulcer had healed to the size of a pin but within the span of a week enlarged to size of a tennis ball. Presented to ___ urgent care in ___ found to be febrile to ___ given Tylenol sent to ER and was afebrile and normotensive upon arrival though sustained tachycardia to low 100s. Podiatry consulted in ER wound to left medial hallux probes to bone w high c f osteomyelitis. X rays show bony erosion but no subcutaneous gas. Plan for IV antibiotics and partial amputation of left great toe tomorrow ___ . ___ n v abd pain diarrhea excessive urination orthostasis dyspnea chest pain. In the ED Initial vital signs were notable for afebrile tachycardia to 118 normotensive Exam notable for PE warm slightly diaphoretic CV RRR S1 S2 Resp lungs clear b l MSK erythema involving L big toe tracking along inferior base. Tenderness tracking along path of great saphenous on L calf. Limited dorsiflexion and plantar flexion. Limited ROM of ankle and toe. Mental Status A ox4 Lines Drains 20g L hand Labs were notable for 136 98 26 AGap 20 266 4.2 18 1.6 Lactate elevated 2.4 Whites elevated 23.4 neut predominance Studies performed include Xray Foot Ap Lat Obl Left prelim read Re demonstration of ulceration along the medial distal aspect of the great toe and erosion along the medial base of the distal phalanx of the great toe perhaps slightly progressed in the interval. Findings again remain concerning for osteomyelitis and MRI with contrast could be obtained for further assessment. Patient was given Piperacillin Tazobactam Vancomycin Consults Podiatry Vitals on transfer T100.5 BP 154 80 HR117 RR18 99 Ra Upon arrival to the floor patient resting comfortably in bed complains of chills which resolve with blankets. Left foot wrapped in gauze dressing very tender up to midcalf. REVIEW OF SYSTEMS Complete ROS obtained and is otherwise negative Past Medical History COPD CAD s p BMS proximal LAD ___ DES to mid LAD ___ DES to edge ISR of mid LAD DES and stenosis distal to stent ___ DES to OM1 ___ s p 3 v CABG LIMA LAD SVG OM1 ___ HFpEF Depression DM GERD Hypertension Migraines Chronic shoulder pain on narcotics OSA Peripheral neuropathy Restless leg Social History ___ Family History Patient was ward of the ___ doesn t know full details of family history. Mother with possible alcohol abuse. Father deceased at ___ from Hodgkin s Disease per old records. Physical Exam ADMISSION EXAM VITALS T100.5 BP 154 80 HR117 RR18 99 Ra GENERAL Alert and interactive. In no acute distress. HEENT NCAT. MMM. CARDIAC RRR no MRG LUNGS Normal WOB CTA B L ABDOMEN Soft nontender to deep palpation nondistended normoactive bowel sounds. EXTREMITIES left foot wrapped in gauze dressing mildly erythematous and very tender up to lower calf RLE no edema thready DP pulses NEUROLOGIC Sensory and motor function grossly intact. DISCHARGE EXAM VS 98.5 134 75 75 18 97 RA General Appearance Well groomed in NAD. HEENT Atraumatic normocephalic. Sclera anicteric b l. MMM. No oropharyngeal lesions. No LAD. Lungs Equal chest rise. Good air movement. No increased work of breathing. Decreased breath sounds in LLL. Rales in left base. No wheezes or rhonchi. CV RRR. Normal S1 S2. No murmurs gallops or rubs. No carotid bruits b l. 2 carotid pulses b l 2 radial pulses b l 1 dorsalis pedis pulse on right unable to palpate on left due to surgical bandage. Abdomen Non distended. Bowel sounds present. Soft non tender to palpation throughout. Extremities No clubbing or cyanosis. Left foot dressing clean today. Erythema and edema around margin of surgical site is improved today. Suture site is clean with no pus. Skin No rashes or lesions besides surgical site. Neuro A O to person place and time. CN III XII grossly intact. Pertinent Results ADMISSION LABS ___ 05 50PM BLOOD WBC 23.4 RBC 4.01 Hgb 13.3 Hct 37.9 MCV 95 MCH 33.2 MCHC 35.1 RDW 12.0 RDWSD 42.1 Plt ___ ___ 05 50PM BLOOD Neuts 81.4 Lymphs 10.5 Monos 7.1 Eos 0.0 Baso 0.3 Im ___ AbsNeut 19.09 AbsLymp 2.47 AbsMono 1.66 AbsEos 0.00 AbsBaso 0.06 ___ 05 50PM BLOOD Glucose 266 UreaN 26 Creat 1.6 Na 136 K 4.2 Cl 98 HCO3 18 AnGap 20 ___ 05 50PM BLOOD CRP 180.1 ___ 07 45PM BLOOD ___ pO2 22 pCO2 44 pH 7.32 calTCO2 24 Base XS 4 ___ 05 50PM BLOOD Lactate 2.4 ___ 07 40PM URINE Color Straw Appear Clear Sp ___ ___ 07 40PM URINE Blood NEG Nitrite NEG Protein TR Glucose 1000 Ketone TR Bilirub NEG Urobiln NEG pH 6.0 Leuks SM ___ 07 40PM URINE RBC 4 WBC 7 Bacteri FEW Yeast NONE Epi 1 TransE 1 ___ 07 40PM URINE Mucous RARE PERTINENT INTERVAL LABS ___ 09 48AM BLOOD ALT 25 AST 29 LD LDH 210 AlkPhos 130 TotBili 0.8 DISCHARGE LABS ___ 07 17AM BLOOD WBC 9.9 RBC 3.07 Hgb 9.8 Hct 30.4 MCV 99 MCH 31.9 MCHC 32.2 RDW 12.3 RDWSD 44.2 Plt ___ ___ 07 29AM BLOOD Glucose 109 UreaN 18 Creat 1.2 Na 140 K 4.0 Cl 100 HCO3 25 AnGap 15 ___ 07 29AM BLOOD Calcium 8.8 Phos 4.3 Mg 1.8 ___ 07 29AM BLOOD CRP 44.6 IMAGING LEFT FOOT XRAY ___ IMPRESSION Re demonstration of ulceration along the medial distal aspect of the great toe and erosion along the medial base of the distal phalanx of the great toe the latter of which is perhaps slightly progressed in the interval. Findings again remain concerning for osteomyelitis and MRI with contrast could be obtained for further assessment. NIAS ___ FINDINGS On the right side triphasic Doppler waveforms are seen in the right femoral popliteal and dorsalis pedis arteries. Absent waveform in the posterior tibial artery. The right ABI was 1.6 artifactually elevated due to noncompressible vessels. On the left side triphasic Doppler waveforms are seen at the left femoral and popliteal arteries. Monophasic waveforms are seen in the posterior tibial and dorsalis pedis arteries. The left ABI could not be calculated Pulse volume recordings showed decreased amplitudes at the level the right calf ankle and metatarsal. IMPRESSION Significant bilateral tibial arterial insufficiency to the lower extremities at rest more significant on the right side. CXR ___ IMPRESSION Comparison to ___. No relevant change is noted. Alignment of the sternal wires is unremarkable. Mild elongation of the descending aorta. Borderline size of the heart. No pleural effusions. No pneumonia no pulmonary edema. MRI LEFT FOOT ___ IMPRESSION 1. Nonenhancing stump soft tissue and the plantar fat pad under the middle phalanges concerning for devitalized tissue. No evidence of drainable abscess. 2. 4 mm focus of low T1 signal with edema at the most distal cortex of the first metatarsal. This is nonspecific as there was no comparison study and focus of osteomyelitis cannot be excluded. 3. 2 sinus tracts medial to the head of the first metatarsal status post amputation at the first MTP with postsurgical changes. 4. Dorsal swelling and diffuse skin edema. CXR PICC PLACEMENT ___ IMPRESSION New right PICC with tip projecting over the junction of the superior vena cava and right atrium. No pneumothorax. Clear lungs. PATHOLOGY SURGICAL TISSUE ___ Bone with reparative changes consistent with chronic osteomyelitis. There is no evidence of acute osteomyelitis. SURGICAL TISSUE ___ 1. LEFT GREAT TOE EXCISION Acute osteomyelitis focal. Bone with reparative changes. Skin and subcutis with ulceration and acute inflammation. Atherosclerosis severe. 2. PROXIMAL PHALANX BASE MARGIN LEFT EXCISION Bone with reparative changes. There is no evidence of acute osteomyelitis. 3. PROXIMAL PHALANX LEFT EXCISION Bone with reparative changes. There is no evidence of acute osteomyelitis. MICROBIOLOGY ___ 10 00 am TISSUE PROXIMAL PHALYNX. GRAM STAIN Final ___ 2 ___ per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. 2 ___ per 1000X FIELD GRAM POSITIVE COCCI IN PAIRS. Reported to and read back by ___ ___ ON ___ AT 1 20PM. TISSUE Final ___ STAPH AUREUS COAG . SPARSE GROWTH. Susceptibility testing performed on culture ___ ___. ANAEROBIC CULTURE Final ___ NO ANAEROBES ISOLATED. ACID FAST SMEAR Final ___ NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE Preliminary ___ ___ 7 00 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. ___ ___ 5 38 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. ___ ___ 12 34 am BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. ___ ___ 11 00 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. ___ ___ 12 18 am BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. ___ ___ 10 53 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. Brief Hospital Course SUMMARY ___ yo F with hx of DMII HTN who presented with diabetic foot ulcer on her left hallux complicated by osteomyelitis. She underwent surgical debridement and partial tissue and bone removal on ___. However the infection persisted and she underwent left hallux amputation on ___. She was started on IV nafcillin for MSSA infection with plan to continue home infusions of nafcillin until at least ___ ACTIVE ISSUES Osteomyelitis of left hallux Due to diabetic ulcer of left hallux. Patient underwent partial left hallux amputation on ___ by podiatry. She was initially placed on IV Vancomycin Flagyl and cefepime. Initial surgical cultures came back positive for MSSA so was changed to IV nafcillin. Patient continued to be afebrile but her left foot continued to have erythema edema pain and the ulcer was not healing well. There was concern for poor arterial blood flow and therefore underwent noninvasive arterial studies on bilateral lower extremities. The studies showed mild atherosclerotic disease in her left leg and foot and severe atherosclerotic disease in her right leg and foot. Vascular surgery was consulted for potential intervention but they felt that no further vascular intervention was warranted prior to podiatric surgery. The patient was brought back to the OR by podiatry on ___ for total left hallux amputation given lack of clinical improvement. Her ___ blood cell count continued to down trend. The pathology report showed clean margins. However patient was continuing to have pain and there was increased erythema and swelling around surgical site. An MRI of the left foot was done which showed devitalization of the surgical flap some edema and a hyperintense focal spot at the site of the surgery. There were no signs of abscess or fluid collection. Podiatry team felt patient did not need any acute surgical intervention and will have close follow up on ___. A PICC line was placed in the right arm ___ with tentative plan to complete a two week course of IV nafcillin on ___. For the wound podiatry recommends daily dressing changes to left foot surgical site Betadine moistened gauze 4x4 gauze and kerlix. Cough During her stay the patient developed cough that was nonproductive. It was thought to be due to atelectasis after surgery especially since her rales on exam would clear with coughing. A repeat chest x ray was negative for any acute cardiopulmonary processes and on comparison to previous chest x ray during this hospital stay there were no changes. Will restart home Lasix at discharge. Hypertension Patient s antihypertensives were held upon admission given that her blood pressures were low with systolic blood pressures in the ___ likely due to sepsis in the setting of her osteomyelitis from her diabetic foot ulcer. After her first debridement patient s blood pressures increase to 160s 170s so we restarted her losartan and furosemide. However her blood pressure dipped back down again to the ___ systolic and her creatinine bumped up to 1.8 so we discontinued her losartan and furosemide. Her metoprolol was continued with holding parameters and it was held when her systolic blood pressure was less than 110. Her ___ resolved and she became hypertensive again so we restarted her losartan while in the hospital and instructed the patient to restart her Lasix upon discharge from the hospital. Acute Kidney Injury Her baseline creatinine is 1.0. It bumped up to 1.8 in the setting of sepsis restarting her losartan and furosemide and hypotension. We gave her IV fluids and stopped her losartan and furosemide. Her creatinine continued to improve with these measures and upon discharge it was 1.1 1.2 which is around her baseline. CHRONIC ISSUES Diabetes Mellitus Type 2 Upon admission patient was started on 80 of home insulin doses. Her Lantus inpatient dose was 32 units and her Humalog inpatient dose was 12 units 3 times daily. Patient s blood sugars were hard to control while she was inpatient. Working with the ___ diabetes consult team we adjusted her insulin doses as needed. ___ recommended discharging the patient on 48 units of Toujeo and 18 units of Novolog with meals as well as resuming her Trajenta and Jardiance. CODE STATUS Full presumed CONTACT ___ grandson s girlfriend ___ TRANSITIONAL ISSUES Patient is on oxycodone 5 mg Q8H for her foot pain from the surgery. She was given enough to get her to her PCP appointment which is ___. Please re assess pain management. Osteomyelitis infected diabetic foot ulcer Surgical margin from total left hallux amputation on ___ was negative for osteomyelitis. Patient to complete a 2 week course of nafcillin for ongoing soft tissue infection and will follow up with ID prior to completion of antibiotics to ensure resolution. Will be discharged on q4 hour nafcillin to be infused via a pump. Once finished an antibiotic should also have right arm PICC line removed. For the wound podiatry recommends daily dressing changes to left foot surgical site Betadine moistened gauze 4x4 gauze and kerlix Diabetes mellitus type 2 Patient s blood sugars were very labile. Given that she came in with a diabetic foot ulcer suggesting that her blood sugars are not well controlled at home she needs close follow up to optimize her diabetic medication regimen. She is being discharged on reduced dose Toujeo and regular home Novolog along with her usual Trajenta and Jardiance with close follow up with ___ provider on ___ ___ at 1 ___. Please reassess patient s need for Jardiance given history of recurrent AKIs Cough Patient developed non productive cough while in hospital but afebrile no leukocytosis CXR no signs of pleural effusion or consolidation. Suspect due to atelectasis in post op period after foot surgery. Will discharge on incentive spirometer and restarting home Lasix as outpatient. If not improved once back on outpatient Lasix would consider further workup. Hypertension Patient was discharged on her regular home medications. While she was an inpatient she became hypotensive when we restarted her on all of her antihypertensives. Please follow her blood pressure to ensure that she is on the right regimen. If too low might consider removing furosemide. ___ Discharge creatinine 1.2 on ___. Suspect patient will have a slight bump in creatinine after restarting losartan on ___. Patient had weekly labs checked with IV antibiotic infusions. If continues to rise may be due to nafcillin and would consider switching antibiotic to cefazolin. CODE STATUS Full presumed CONTACT ___ grandson s girlfriend ___ 30 minutes spent on complex discharge Medications on Admission The Preadmission Medication list is accurate and complete. 1. canagliflozin 100 mg oral DAILY 2. Nitroglycerin SL 0.4 mg SL Q5MIN PRN angina 3. rOPINIRole 0.5 mg PO QHS restless leg syndrome 4. TraZODone 50 mg PO QHS PRN insomnia 5. Pantoprazole 40 mg PO BID 6. Gabapentin 400 mg PO QHS PRN Neuropathic pain 7. Atorvastatin 80 mg PO QPM 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. linaGLIPtin 5 mg oral DAILY 10. Losartan Potassium 25 mg PO DAILY 11. OxyCODONE Acetaminophen 5mg 325mg 1 TAB PO TID PRN Pain Severe 12. Lidocaine 5 Patch 1 PTCH TD QPM 13. Furosemide 20 mg PO DAILY 14. Metoprolol Succinate XL 150 mg PO DAILY 15. albuterol sulfate 90 mcg actuation inhalation Q4H PRN 16. Aspirin EC 325 mg PO DAILY 17. MetronidAZOLE Topical 1 Gel 1 Appl TP DAILY Rosacea 18. nystatin 100 000 unit gram topical DAILY PRN Discharge Medications 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet s by mouth Every 8 hours for foot pain Disp 60 Tablet Refills 0 2. Bisacodyl 10 mg PO DAILY PRN Constipation Second Line RX bisacodyl 5 mg 2 tablet s by mouth Once a day as needed for constipation Disp 60 Tablet Refills 0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth Twice a day Disp 30 Capsule Refills 0 4. Nafcillin 2 g IV Q4H RX nafcillin in dextrose iso osm 2 gram 100 mL 2 g IV Every four hours Disp 84 Intravenous Bag Refills 0 5. OxyCODONE Immediate Release 5 mg PO Q8H PRN Pain Moderate RX oxycodone 5 mg 1 capsule s by mouth Once every 8 hours as needed for severe foot pain. Disp 15 Capsule Refills 0 6. Senna 8.6 mg PO BID PRN Constipation First Line RX sennosides senna 8.6 mg 1 tablet by mouth Twice a day as needed for constipation Disp 30 Tablet Refills 0 7. Novolog 18 Units Breakfast Novolog 18 Units Lunch Novolog 18 Units Dinner 8. albuterol sulfate 90 mcg actuation inhalation Q4H PRN 9. Aspirin EC 325 mg PO DAILY 10. Atorvastatin 80 mg PO QPM 11. canagliflozin 100 mg oral DAILY 12. Fluticasone Propionate 110mcg 2 PUFF IH BID 13. Furosemide 20 mg PO DAILY 14. Gabapentin 400 mg PO QHS PRN Neuropathic pain 15. Lidocaine 5 Patch 1 PTCH TD QPM 16. linaGLIPtin 5 mg oral DAILY 17. Losartan Potassium 25 mg PO DAILY 18. Metoprolol Succinate XL 150 mg PO DAILY 19. MetronidAZOLE Topical 1 Gel 1 Appl TP DAILY Rosacea 20. Nitroglycerin SL 0.4 mg SL Q5MIN PRN angina 21. nystatin 100 000 unit gram topical DAILY PRN 22. OxyCODONE Acetaminophen 5mg 325mg 1 TAB PO TID PRN Pain Severe 23. Pantoprazole 40 mg PO BID 24. rOPINIRole 0.5 mg PO QHS restless leg syndrome 25. ___ SoloStar U 300 Insulin insulin glargine 300 unit mL 1.5 mL subcutaneous QHS Inject 48U QHS 26. TraZODone 50 mg PO QHS PRN insomnia 27.Outpatient Lab Work ICD 10 E11.621 DATE weekly draw on ___ and ___ LAB TEST CBC with differential BUN Cr AST ALT Total Bili ALK PHOS ESR CRP PLEASE FAX RESULTS TO ATTN ___ CLINIC FAX ___ 28.Rolling Walker EQUIPMENT Rolling Walker DIAGNOSIS Left hallux amputation ICD 10 ___ PX Good ___ 13 months Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS Osteomyelitis of left hallux SECONDARY DIAGNOSES Hypertension Type 2 Diabetes Mellitus Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ It was a pleasure taking care of you. WHY WAS I ADMITTED TO THE HOSPITAL You had a diabetic foot ulcer on your left toe that was very infected and had caused an infection in your bone. WHAT WAS DONE WHILE I WAS HERE Your big left toe was removed because you had a bad bone infection. You were treated with antibiotics to fight the infection and will need to go home on IV antibiotics. WHAT DO I NEED TO DO WHEN I LEAVE Please continue to take your medications as directed. You will go home with an antibiotic infusion pump and will have a visiting nurse come to your house to teach you how to use it. You will need to administer antibiotics through the pump every 4 hours. We changed your diabetic medication regimen so please follow along as instructed below and keep close track of your sugars at home. Check your sugars 4 times a day and log the results. Bring the results in with you to your ___ appointment on ___ at 1 00 pm so that they can adjust your medication regimen appropriately. Please follow up with Dr. ___ team on ___ at 11 00 am. Please follow up with Dr. ___ your antibiotic regimen on ___ at 10 30 am. Please follow up with Dr. ___ in ___ ___ on ___ at 1 00 pm. Be well Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be A419, M86672, M86172, N179, L03116, J9811, I5032, I130, E1152, I96, E1169, L97524, E11621, B9561, J449, E11319, E1142, E1165, I2510, I252, G4733, K219, G2581, N189, E1122, Z794, Z951, Z955, Z87891. The descriptions of icd codes A419, M86672, M86172, N179, L03116, J9811, I5032, I130, E1152, I96, E1169, L97524, E11621, B9561, J449, E11319, E1142, E1165, I2510, I252, G4733, K219, G2581, N189, E1122, Z794, Z951, Z955, Z87891 are A419: Sepsis, unspecified organism; M86672: Other chronic osteomyelitis, left ankle and foot; M86172: Other acute osteomyelitis, left ankle and foot; N179: Acute kidney failure, unspecified; L03116: Cellulitis of left lower limb; J9811: Atelectasis; I5032: Chronic diastolic (congestive) heart failure; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; E1152: Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene; I96: Gangrene, not elsewhere classified; E1169: Type 2 diabetes mellitus with other specified complication; L97524: Non-pressure chronic ulcer of other part of left foot with necrosis of bone; E11621: Type 2 diabetes mellitus with foot ulcer; B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere; J449: Chronic obstructive pulmonary disease, unspecified; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema; E1142: Type 2 diabetes mellitus with diabetic polyneuropathy; E1165: Type 2 diabetes mellitus with hyperglycemia; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I252: Old myocardial infarction; G4733: Obstructive sleep apnea (adult) (pediatric); K219: Gastro-esophageal reflux disease without esophagitis; G2581: Restless legs syndrome; N189: Chronic kidney disease, unspecified; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; Z794: Long term (current) use of insulin; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, I5032, I130, J449, E1165, I2510, I252, G4733, K219, N189, E1122, Z794, Z951, Z955, Z87891. The uncommon codes mentioned in this dataset are A419, M86672, M86172, L03116, J9811, E1152, I96, E1169, L97524, E11621, B9561, E11319, E1142, G2581.
The icd codes present in this text will be R0789, E876, I25119, I25709, Z951, Z955, E1122, E1165, I129, N183, E785, J449, K219, E1140, F329, E669, Z6837, G8929, M25519, G4733, Z794, I252, Z87891. The descriptions of icd codes R0789, E876, I25119, I25709, Z951, Z955, E1122, E1165, I129, N183, E785, J449, K219, E1140, F329, E669, Z6837, G8929, M25519, G4733, Z794, I252, Z87891 are R0789: Other chest pain; E876: Hypokalemia; I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris; I25709: Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; E1165: Type 2 diabetes mellitus with hyperglycemia; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N183: Chronic kidney disease, stage 3 (moderate); E785: Hyperlipidemia, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified; F329: Major depressive disorder, single episode, unspecified; E669: Obesity, unspecified; Z6837: Body mass index [BMI] 37.0-37.9, adult; G8929: Other chronic pain; M25519: Pain in unspecified shoulder; G4733: Obstructive sleep apnea (adult) (pediatric); Z794: Long term (current) use of insulin; I252: Old myocardial infarction; Z87891: Personal history of nicotine dependence. The common codes which frequently come are Z951, Z955, E1122, E1165, I129, E785, J449, K219, F329, E669, G8929, G4733, Z794, I252, Z87891. The uncommon codes mentioned in this dataset are R0789, E876, I25119, I25709, N183, E1140, Z6837, M25519. Allergies lisinopril Chief Complaint Chest pain Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ year old woman with extensive cardiac history including multivessel vessel CAD S P stenting of the LAD with in stent restenosis and stenting of the CX S P CABG in ___ with known occluded SVG D1 with patent LIMA LAD and SVG OM in ___ poorly controlled type 2 diabetes mellitus hypertension COPD GERD now presenting with new chest pain. At 5 pm on the day of presentation she was resting at home when she had onset of severe stabbing pain left of the sternum. This pain radiated across her chest but not to the arm or jaw. She took 1 nitroglycerin which improved her pain slightly. She reports that the pain came in waves lasting 5 minutes. She also endorsed left chest wall tenderness. She did not remember when she last had chest pain prior to this. The pain was not clearly exertional. The sharp pains occurred when she was lying down. She says the area is very tender. Lying on the left side causes pain. She did have nausea the past 3 mornings which resolved. She denied vomiting diaphoresis fevers or chills. She had an episode of diarrhea yesterday but no abdominal pain. She already took a full dose aspirin on the day of presentation. In the ED initial vitals were T 98.0 HR 88 BP 127 65 RR 16 SaO2 100 on RA. FSBG 302 94. Labs notable for Troponin T 0.01 CK MB 1 D Dimer 268 Cr 1.2 Mg 1.4. Normal LFTs CBC Chem 7 coags WNL. CXR showed no acute cardiopulmonary abnormality. Bedside echocardiogram showed no substantial pericardial effusion or tamponade. Patient was given fluticasone propionate inhaled OxyCODONE Acetaminophen 5mg 325mg Magnesium Sulfate 2 gm IV. On arrival to the cardiology ward the patient reported that her pain was still there but it felt slow ___ but at its worse was ___. The area was tender. She had no breathing complaints. She felt a little congested this evening when the pain started. Past Medical History COPD CAD s p CABG and stenting as above Depression DM GERD Hypertension Migraines Chronic shoulder pain on narcotics OSA Peripheral neuropathy Restless leg Social History ___ Family History Patient was ward of the ___ doesn t know full details of family history. Mother with possible alcohol abuse. Father deceased at ___ from Hodgkin s Disease per old records. Physical Exam On admission General Obese middle aged ___ woman alert oriented in no acute distress Vital Signs T 98.7 BP 98 65 HR 79 RR 18 SaO2 95 on RA Weight 89 kg HEENT Sclera anicteric mucous membranes moist oropharynx clear NECK difficult to appreciate JVP CV Regular rate and rhythm normal S1 S2 no murmurs rubs gallops Chest Tenderness to palpation of the left anterior chest wall Lungs Clear to auscultation bilaterally no wheezes rales rhonchi Abdomen Soft non tender non distended obese GU No Foley Ext Warm well perfused no clubbing cyanosis or edema Exam unchanged at discharge left chest wall tender with palpation with pain after change in position Pertinent Results ___ 10 31PM BLOOD WBC 9.4 RBC 3.51 Hgb 12.0 Hct 34.3 MCV 98 MCH 34.2 MCHC 35.0 RDW 11.8 RDWSD 42.3 Plt ___ ___ 10 31PM BLOOD Glucose 105 UreaN 21 Creat 1.2 Na 137 K 3.4 Cl 97 HCO3 24 AnGap 19 ___ 10 31PM BLOOD ALT 15 AST 16 CK CPK 39 AlkPhos 53 TotBili 0.3 ___ 10 31PM BLOOD Albumin 3.9 Calcium 9.1 Phos 4.4 Mg 1.4 ___ 10 57PM BLOOD D Dimer 268 ___ 10 31PM BLOOD CK MB 1 cTropnT 0.01 ___ 06 00AM BLOOD CK MB 1 cTropnT 0.01 ___ 06 00AM BLOOD WBC 9.3 RBC 3.44 Hgb 11.8 Hct 33.1 MCV 96 MCH 34.3 MCHC 35.6 RDW 11.9 RDWSD 41.3 Plt ___ ___ 06 00AM BLOOD Glucose 147 UreaN 21 Creat 1.2 Na 139 K 3.0 Cl 99 HCO3 24 AnGap 19 ___ 06 00AM BLOOD Calcium 8.7 Phos 4.4 Mg 2.0 ECG ___ 8 33 29 ___ Baseline artifact. Sinus rhythm. Borderline P R interval prolongation. Prominent voltage in leads I and aVL but does not meet criteria for left ventricular hypertrophy. There are marked ST segment depressions and T wave inversions in leads I II aVL and apical lateral leads. Compared to the previous tracing of ___ the rate then was faster. ST T wave abnormalities were similar. Consider left ventricular hypertrophy as before. Clinical correlation is suggested. CXR ___ Patient is status post median sternotomy and CABG. Heart size is normal. Mediastinal and hilar contours are unchanged. Pulmonary vasculature is normal. No focal consolidation pleural effusion or pneumothorax is seen. No acute osseous abnormality is detected. IMPRESSION No acute cardiopulmonary abnormality. Dipyridamole MIBI Stress test ___ ___ yp woman with HL HTN DM PVD and diastolic CHF s p MI and multiple PCIs f b CABG x 3 in ___ with known SVG OM occlusion was referred to evaluate an atypical chest discomfort. The patient was administered 0.142 mg kg min of Persantine over 4 minutes. Prior to the procedure the patient reported an isolated left sided chest discomfort that had been present since admission and was tender to mild palpation ___. This discomfort did not change in intensity during the procedure. In the presence of diffuse ST T wave changes no additional ECG changes were noted during the procedure. The hemodynamic response to the Persantine infusion was appropriate. Post infusion the patient was administered 125 mg Aminophylline IV. IMPRESSION Non anginal type symptoms with no additional ST segment changes from baseline. Imaging Left ventricular cavity size is normal. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. The previously noted perfusion defect involving the inferolateral wall has resolved. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 64 . IMPRESSION Normal myocardial perfusion study. Interval normalization of prior LCx territory perfusion defect. Brief Hospital Course This is a ___ with type 2 diabetes mellitus on insulin CAD s p MI S P multiple PCIs and CABG ___ LIMA LAD SVG OM1 also SVG D1 known occluded ___ with chronic stable angina admitted with atypical stabbing focal chest pain. Chest pain Initially the patient was started on a heparin drip and other ACS protocol medications. Her home losartan and furosemide were held due to low blood pressures. Suspicion for cardiac etiology of chest pain was ultimately not high. She had an isolated ongoing ___ left sided chest discomfort exacerbated by changes in position and with chest wall tenderness to light palpation. Despite prolonged chest pain troponin T and CK MB negative x2 and EKGs mostly unchanged from prior. Given known H O CAD a vasodilator nuclear stress test was performed and was reassuring. Her discomfort did not change in intensity during the stress test drug infusion. In the presence of diffuse ST T wave changes no additional ECG changes were noted during the procedure. The hemodynamic response to the Persantine infusion was appropriate. Her perfusion study was normal with interval normalization of prior LCx territory perfusion defect. Given the stabbing quality and tenderness to palpation of the area of discomfort her symptoms were most likely related to costochondritis or other musculoskeletal causes. She was started on aspirin 650 mg q6h with plans to trial for 2 days and continue through the week if symptoms improve. Chronic medical problems Diabetes mellitus Continued levemir and was switched to a sliding scale of Humalog. Hypertension Losartan was held as above due to hypotension and once daily isosorbide mononitrate was switched temporarily to isosorbide dinitrate TID. For her hyperlipidemia COPD and GERD her home regimens were continued. TRANSITIONAL ISSUES Patient had low blood pressures initially 88 92 systolic . Would benefit from close monitoring and titration of blood pressure medications as an outpatient She was hypokalemic K 3.0 during admission with ___ and furosemide already held . Please recheck CHEM 10 at ___ ___ visit on ___ to determine whether she might benefit from K supplementation Cr elevated to 1.2 on discharge up from most recent 1.1.1 . Please recheck at ___ office on ___ Full code Medications on Admission The Preadmission Medication list is accurate and complete. 1. Oxycodone Acetaminophen 5mg 325mg 1 TAB PO Q8H PRN pain 2. Nitroglycerin SL 0.3 mg SL Q5MIN PRN pain 3. Metoprolol Succinate XL 250 mg PO DAILY 4. Levemir Flexpen insulin detemir 90 units subcutaneous in the evening 5. albuterol sulfate 90 mcg actuation inhalation q4hrs wheezing 6. Vitamin D 1000 UNIT PO DAILY 7. TraZODone 100 mg PO HS 8. Isosorbide Mononitrate Extended Release 120 mg PO DAILY 9. Aspirin 325 mg PO DAILY 10. Atorvastatin 80 mg PO HS 11. Fluticasone Propionate 110mcg 2 PUFF IH BID 12. Pantoprazole 40 mg PO Q12H 13. Ropinirole 0.5 mg PO QPM 14. HumaLOG KwikPen insulin lispro 0 SUBCUTANEOUS AS DIRECTED 15. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN wheeze 16. Methocarbamol 500 mg PO TID PRN muscle pain 17. Losartan Potassium 25 mg PO DAILY 18. Furosemide 20 mg PO DAILY 19. diclofenac sodium 1 topical TID PRN pain Discharge Medications 1. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN wheeze 2. Atorvastatin 80 mg PO HS 3. Fluticasone Propionate 110mcg 2 PUFF IH BID 4. Methocarbamol 500 mg PO TID PRN muscle pain 5. Nitroglycerin SL 0.3 mg SL Q5MIN PRN pain 6. Pantoprazole 40 mg PO Q12H 7. Ropinirole 0.5 mg PO QPM 8. TraZODone 100 mg PO HS 9. Vitamin D 1000 UNIT PO DAILY 10. albuterol sulfate 90 mcg actuation INHALATION Q4HRS wheezing 11. diclofenac sodium 1 topical TID PRN pain 12. Furosemide 20 mg PO DAILY 13. Isosorbide Mononitrate Extended Release 120 mg PO DAILY 14. Metoprolol Succinate XL 250 mg PO DAILY 15. HumaLOG KwikPen insulin lispro 0 SUBCUTANEOUS AS DIRECTED 16. Levemir Flexpen insulin detemir 90 units subcutaneous in the evening 17. Losartan Potassium 25 mg PO DAILY 18. Oxycodone Acetaminophen 5mg 325mg 1 TAB PO Q8H PRN pain 19. Aspirin 650 mg PO Q6H RX aspirin 650 mg 1 tablet s by mouth every six 6 hours Disp 28 Tablet Refills 0 Discharge Disposition Home Discharge Diagnosis Chest wall pain atypical for angina Musculoskeletal pain Known native coronary artery and bypass graft disease Type 2 Diabetes mellitus with Chronic kidney disease stage 3 Acute kidney injury Chronic obstructive pulmonary disease Hypertension Hypotension Hypokalemia Chronic shoulder pain on narcotics Obstructive sleep apnea Gastroseophageal reflux disease Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ It was our pleasure participating in your care here at ___. You were admitted with severe chest pain. You underwent a stress test that showed the pain is unlikely from a big blockage in the arteries that feed your heart. Your lab work also did not suggest injury to the heart. The pain you are experiencing is most likely musculoskeletal and should hopefully improve with supportive measures such as Tylenol maximum 3 grams per day and time. You will also be prescribed high dose aspirin 650mg . Please try this for two days and if there is improvement in your symptoms continue it for the week. If your symptoms worsen you develop shortness of breath or any other concerning symptom please let your doctor know right away. Again it was our pleasure participating in your care. We wish you the very ___ Your ___ Cardiology Team Followup Instructions ___ The icd codes present in this text will be R0789, E876, I25119, I25709, Z951, Z955, E1122, E1165, I129, N183, E785, J449, K219, E1140, F329, E669, Z6837, G8929, M25519, G4733, Z794, I252, Z87891. The descriptions of icd codes R0789, E876, I25119, I25709, Z951, Z955, E1122, E1165, I129, N183, E785, J449, K219, E1140, F329, E669, Z6837, G8929, M25519, G4733, Z794, I252, Z87891 are R0789: Other chest pain; E876: Hypokalemia; I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris; I25709: Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; E1165: Type 2 diabetes mellitus with hyperglycemia; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N183: Chronic kidney disease, stage 3 (moderate); E785: Hyperlipidemia, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified; F329: Major depressive disorder, single episode, unspecified; E669: Obesity, unspecified; Z6837: Body mass index [BMI] 37.0-37.9, adult; G8929: Other chronic pain; M25519: Pain in unspecified shoulder; G4733: Obstructive sleep apnea (adult) (pediatric); Z794: Long term (current) use of insulin; I252: Old myocardial infarction; Z87891: Personal history of nicotine dependence. The common codes which frequently come are Z951, Z955, E1122, E1165, I129, E785, J449, K219, F329, E669, G8929, G4733, Z794, I252, Z87891. The uncommon codes mentioned in this dataset are R0789, E876, I25119, I25709, N183, E1140, Z6837, M25519.
The icd codes present in this text will be I82412, I5033, E873, E46, I482, G309, I82432, F0280, I10, E876, M810, Z66, Z515, Z993, H9192, H409, M25551, K5900, Z6827, Z85828. The descriptions of icd codes I82412, I5033, E873, E46, I482, G309, I82432, F0280, I10, E876, M810, Z66, Z515, Z993, H9192, H409, M25551, K5900, Z6827, Z85828 are I82412: Acute embolism and thrombosis of left femoral vein; I5033: Acute on chronic diastolic (congestive) heart failure; E873: Alkalosis; E46: Unspecified protein-calorie malnutrition; I482: Chronic atrial fibrillation; G309: Alzheimer's disease, unspecified; I82432: Acute embolism and thrombosis of left popliteal vein; F0280: Dementia in other diseases classified elsewhere without behavioral disturbance; I10: Essential (primary) hypertension; E876: Hypokalemia; M810: Age-related osteoporosis without current pathological fracture; Z66: Do not resuscitate; Z515: Encounter for palliative care; Z993: Dependence on wheelchair; H9192: Unspecified hearing loss, left ear; H409: Unspecified glaucoma; M25551: Pain in right hip; K5900: Constipation, unspecified; Z6827: Body mass index [BMI] 27.0-27.9, adult; Z85828: Personal history of other malignant neoplasm of skin. The common codes which frequently come are I10, Z66, Z515, K5900. The uncommon codes mentioned in this dataset are I82412, I5033, E873, E46, I482, G309, I82432, F0280, E876, M810, Z993, H9192, H409, M25551, Z6827, Z85828. Allergies Penicillins Dilantin Kapseal Zofran as hydrochloride Chief Complaint Right hip pain Major Surgical or Invasive Procedure None History of Present Illness ___ is a ___ y o F with PMHx CHF Afib not on anticoagulation severe advanced Alzheimer s dementia osteoporosis HTN who presents from assisted living facility with R hip pain. The patient has severe dementia with short term memory loss so is unable to provide history. Much of the history is obtained from multiple family members in the room. She has multiple family members who live close by and are involved intimately in her care. They were called from the assisted living facility this morning when the patient was in ___ right hip pain. This occurred suddenly. No trauma. No reported falls. She was not complaining of other symptoms. She was brought to the ED. Discussing with the patient she moved into the Assisted living facility in ___ in ___ given worsening of her dementia. She was in her USOH bowling weekly and very social until ___ when she developed acute SOB with ambulation prompting admission to ___ where she was noted to be in Afib. She had a week long hospital stay complicated by an ICU course for an allergic reaction to a medication family thinks Zofran . Since returning from this hospitalization she has not been back to baseline and has deteriorated. She has spent much of her time wheelchair bound given deconditioning. She has worsening memory function now with severe short term memory loss. Decreased appetite and PO intake. She was recently seen in ___ clinic by Dr. ___ new diagnosis of CHF. She underwent an TTE at ___ yesterday ___ to evaluate her systolic function. In the ED initial vitals were 98.7 96 122 48 20 96 RA. Exam was significant for R hip TTP greater trochanter neg straight leg raise. ___ pulses 2 LLE 2 edema unknown duration Labs were significant for K 2.8 Cr 0.8 CBC 13.9 12.5 39.2 168 UA WBC 22 moderate leuks negative nitrites Studies Lower extremity ultrasound 1. Deep vein thrombosis of the left common femoral vein extending into at least the popliteal vein. Left calf veins were not clearly identified and possibly also occluded. 2. No DVT in the right lower extremity. CXR Bilateral pleural effusions large on the right and small on the left. No definite focal consolidation identified although evaluation is limited secondary to these effusions. She was given 80 mEq of K and 60mg Enoxaparin Sodium. Vitals on transfer were 97.9 79 125 53 18 100 Nasal Cannula. On the floor she is resting comfortably in bed. History is obtained as above with family members. She sleeps with 2 pillows at home and has DOE. She has not had a bowel movement in 2 days. Review of systems Per HPI Denies fever chills night sweats. denies headache sinus tenderness rhinorrhea or congestion. Denies cough. Denies nausea vomiting diarrhea constipation or abdominal pain. No dysuria. Denies arthralgias or myalgias. Past Medical History Hypertension Dementia Osteoporosis Irritable bowel syndrome Macrocytosis of unclear etiology Left ear hearing loss Status post hysterectomy Status post appendectomy Status post ovarian cyst removal Cataract surgery Glaucoma Social History ___ Family History Not relevant to the current admission. Physical Exam ADMISSION EXAM Vital Signs 98.3 107 43 72 16 99 2L NC General AOx1 pleasant smiling at baseline per family members at bedside ___ Sclera anicteric MMM oropharynx clear EOMI PERRL neck supple JVP not elevated no LAD CV Regular rate and rhythm normal S1 S2 soft ___ systolic murmur. Lungs Moderate inspiratory effort decreased breath sounds bilaterally at bases L R. No wheezes rales rhonchi Abdomen Soft non tender non distended bowel sounds present no organomegaly no rebound or guarding GU No foley Ext Warm well perfused 2 pulses L R lower extremity swelling with left leg erythematous and tender to palpation 2 pitting edema tender right lower extremity with e o chronic venous stasis changes 1 pitting edema non tender. Neuro AOx1 strength ___ upper and lower exteremities all facial movements in tact sensation grossly in tact gait deferred. DISCHARGE EXAM Vitals T 97.9 144 59 72 20 93 RA General AOx1 pleasant smiling at baseline per family members at bedside ___ Sclera anicteric MMM CV Irregularly irregular normal S1 S2 soft ___ systolic murmur. Lungs Moderate inspiratory effort decreased breath sounds bilateral bases Ext Warm well perfused 2 pulses L R lower extremity swelling with left leg erythematous and minimal tender to palpation 2 pitting edema tender right lower extremity with e o chronic venous stasis changes 1 pitting edema non tender. Neuro AOx1 Pertinent Results ADMISSION LABS ___ 11 35AM URINE RBC 2 WBC 22 BACTERIA NONE YEAST NONE EPI 1 TRANS EPI 1 ___ 11 35AM URINE BLOOD NEG NITRITE NEG PROTEIN NEG GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 5.5 LEUK MOD ___ 12 00PM PLT COUNT 168 ___ 12 00PM NEUTS 81.1 LYMPHS 10.8 MONOS 6.7 EOS 0.1 BASOS 0.2 IM ___ AbsNeut 11.29 AbsLymp 1.51 AbsMono 0.94 AbsEos 0.02 AbsBaso 0.03 ___ 12 00PM WBC 13.9 RBC 3.78 HGB 12.5 HCT 39.2 MCV 104 MCH 33.1 MCHC 31.9 RDW 13.6 RDWSD 51.9 ___ 12 00PM CALCIUM 7.8 PHOSPHATE 3.7 MAGNESIUM 1.6 ___ 12 00PM cTropnT 0.03 proBNP 8428 ___ 12 00PM GLUCOSE 118 UREA N 26 CREAT 0.8 SODIUM 144 POTASSIUM 2.8 CHLORIDE 95 TOTAL CO2 38 ANION GAP 14 STUDIES CXR Bilateral pleural effusions large on the right and small on the left. No definite focal consolidation identified although evaluation is limited secondary to these effusions. Pelvis Xray There is no acute fracture or dislocation. No focal lytic or sclerotic osseous lesion is seen. There is no radiopaque foreign body. Vascular calcifications are noted. The visualized bowel gas pattern is nonobstructive. IMPRESSION No acute fracture or dislocation. Lower extremity ultrasound 1. Deep vein thrombosis of the left common femoral vein extending into at least the popliteal vein. Left calf veins were not clearly identified possibly also occluded. 2. No right DVT. LAST LABS BEFORE DISCHARGE ___ 06 55AM BLOOD WBC 14.9 RBC 3.51 Hgb 11.5 Hct 36.8 MCV 105 MCH 32.8 MCHC 31.3 RDW 13.8 RDWSD 53.1 Plt ___ ___ 06 55AM BLOOD Glucose 109 UreaN 32 Creat 0.9 Na 144 K 3.7 Cl 96 HCO3 37 AnGap 15 ___ 06 55AM BLOOD Albumin 2.5 Calcium 8.0 Phos 3.2 Mg 1.5 Brief Hospital Course ___ is a ___ y o F with PMHx CHF Afib not on anticoagulation severe advanced Alzheimer s dementia osteoporosis HTN who presents from assisted living facility with R hip pain found to have DVT left common femoral vein with volume overload. During a meeting with patient and her family decision was made to transition care to comfort directed measures only and to pursue hospice services on discharge. ACTIVE ISSUES CMO. The team had a family meeting on ___ and decision was made to transition care to CMO and pursue 24 hour hospice services on discharge. Family did not want to pursue active treatments such as Lasix which would make her uncomfortable given incontinence or shots such as lovenox for treatment of DVT. Home medications metoprolol donepezil and Memantine were continued for comfort. She was discharged to an ___ ___ facility. OTHER HOSPITAL ISSUES DVT. Deep vein thrombosis of the left common femoral vein extending into at least the popliteal vein diagnosed on ultrasound on admission. This was likely acquired in the setting of immobility as the patient had been restricted to her wheelchair at her assisted living for greater than 1 month due to deconditioning. She was initially started on Lovenox for treatment but this was discontinued in the setting of transition to care to CMO as above. Acute CHF. Patient was volume overloaded on presentation with pleural effusions. She was diuresed with IV Lasix. Home metoprolol was continued at a decreased dose. In the setting of transition to care to CMO Lasix was discontinued. She was continued on metoprolol for comfort. She remained on room air without respiratory distress. Afib. She presented in sinus rhythm rate controlled on metoprolol. Metoprolol was continued at a decreased dose for comfort. Hip pain. The right hip pain that she presented with was resolved by the time of admission. Pelvic xray was without fracture. She was treated with Tylenol scheduled for pain control. Al Dementia. She was AOx1 at her baseline per family members. She was continued on Aricept Namenda. TRANSITIONAL ISSUES ___ facility to continue writing orders for pain anxiety secretions and other symptoms. Continued metoprolol succinate and Memantine and donepezil on discharge for comfort. Continuation of these medications can be further decided at inpatient hospice. MOLST form DNR DNI do not re hospitalize CODE DNR DNI CMO CONTACT HCP ___ daughter ___ Primary secondary ___ son ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 150 mg PO BID 2. Torsemide 40 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Donepezil 10 mg PO QHS 5. raloxifene 60 mg oral DAILY 6. Multivitamins 1 TAB PO DAILY 7. Namenda XR MEMAntine 21 mg oral DAILY 8. Ascorbic Acid ___ mg PO DAILY 9. Calcium Carbonate 1500 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Fish Oil Omega 3 1000 mg PO DAILY Discharge Medications 1. Donepezil 10 mg PO QHS 2. Metoprolol Succinate XL 200 mg PO DAILY 3. Namenda XR MEMAntine 21 mg oral DAILY 4. Acetaminophen 1000 mg PO TID 5. Glycopyrrolate 0.1 mg IV Q6H PRN excess secretions 6. Hyoscyamine 0.125 mg SL QID PRN excess secretions Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Primary Diagnosis Deep Vein Thrombosis Secondary Diagnosis Congestive heart failure Atrial fibrillation Constipation Malnutrition Hypertension Alzheimer s dementia Discharge Condition Mental Status Confused always. Level of Consciousness Alert and interactive. Activity Status Out of Bed with assistance to chair or wheelchair. Discharge Instructions Dear ___ It was a pleasure taking care of you during your hospitalization. Briefly you were hospitalized with right hip pain. We did Xrays of your hip which did not show any fractures. We also found a blood clot in your left leg and noticed that your heart wasn t pumping very efficiently. We talked with you and your family who shared with us many of your wishes about being hospitalized and the type of care you would like to receive. We decided to focus on your comfort. Because of this you are being discharged to ___ for hospice care. We wish you and your family the ___ Your ___ Treatment Team Followup Instructions ___ The icd codes present in this text will be I82412, I5033, E873, E46, I482, G309, I82432, F0280, I10, E876, M810, Z66, Z515, Z993, H9192, H409, M25551, K5900, Z6827, Z85828. The descriptions of icd codes I82412, I5033, E873, E46, I482, G309, I82432, F0280, I10, E876, M810, Z66, Z515, Z993, H9192, H409, M25551, K5900, Z6827, Z85828 are I82412: Acute embolism and thrombosis of left femoral vein; I5033: Acute on chronic diastolic (congestive) heart failure; E873: Alkalosis; E46: Unspecified protein-calorie malnutrition; I482: Chronic atrial fibrillation; G309: Alzheimer's disease, unspecified; I82432: Acute embolism and thrombosis of left popliteal vein; F0280: Dementia in other diseases classified elsewhere without behavioral disturbance; I10: Essential (primary) hypertension; E876: Hypokalemia; M810: Age-related osteoporosis without current pathological fracture; Z66: Do not resuscitate; Z515: Encounter for palliative care; Z993: Dependence on wheelchair; H9192: Unspecified hearing loss, left ear; H409: Unspecified glaucoma; M25551: Pain in right hip; K5900: Constipation, unspecified; Z6827: Body mass index [BMI] 27.0-27.9, adult; Z85828: Personal history of other malignant neoplasm of skin. The common codes which frequently come are I10, Z66, Z515, K5900. The uncommon codes mentioned in this dataset are I82412, I5033, E873, E46, I482, G309, I82432, F0280, E876, M810, Z993, H9192, H409, M25551, Z6827, Z85828.
The icd codes present in this text will be M1712, D6861, J449, G4733, F329, E119, M4696, E785, K219, E669, Z7901, Z87891, Z6837, Z86711. The descriptions of icd codes M1712, D6861, J449, G4733, F329, E119, M4696, E785, K219, E669, Z7901, Z87891, Z6837, Z86711 are M1712: Unilateral primary osteoarthritis, left knee; D6861: Antiphospholipid syndrome; J449: Chronic obstructive pulmonary disease, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); F329: Major depressive disorder, single episode, unspecified; E119: Type 2 diabetes mellitus without complications; M4696: Unspecified inflammatory spondylopathy, lumbar region; E785: Hyperlipidemia, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; E669: Obesity, unspecified; Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence; Z6837: Body mass index [BMI] 37.0-37.9, adult; Z86711: Personal history of pulmonary embolism. The common codes which frequently come are J449, G4733, F329, E119, E785, K219, E669, Z7901, Z87891. The uncommon codes mentioned in this dataset are M1712, D6861, M4696, Z6837, Z86711. Allergies Codeine Augmentin Topamax Chief Complaint left knee osteoarthritis pain Major Surgical or Invasive Procedure ___ left total knee arthroplasty History of Present Illness ___ year old female w left knee osteoarthritis pain who failed conservative measures now admitted for left total knee arthroplasty. Past Medical History Dyslipidemia varicose veins R L s p ligation COPD OSA CPap recent URI received course of Zithromax bilateral PEs ___ antiphospholipid antibody syndrome on lifelong anticoagulation T2DM last A1C 6.2 on ___ cerebral aneurysm followed by Dr. ___ unchanged GERD diverticulosis h o colon polyps depression s p right CMC joint arthroplasty b l rotator cuff repair excision right ___ digit mass CCY w stone pancreatic duct exploration ___ hysterectomy tonsillectomy Social History ___ Family History No family hx of DVT or PE two sisters have atrial fibrillation. Physical Exam Well appearing in no acute distress Afebrile with stable vital signs Pain well controlled Respiratory CTAB Cardiovascular RRR Gastrointestinal NT ND Genitourinary Voiding independently Neurologic Intact with no focal deficits Psychiatric Pleasant A O x3 Musculoskeletal Lower Extremity Aquacel dressing with scant serosanguinous drainage Thigh full but soft No calf tenderness ___ strength SILT NVI distally Toes warm Pertinent Results ___ 06 30AM BLOOD WBC 6.8 RBC 2.69 Hgb 8.3 Hct 25.3 MCV 94 MCH 30.9 MCHC 32.8 RDW 13.0 RDWSD 44.0 Plt ___ ___ 06 10AM BLOOD WBC 6.4 RBC 2.77 Hgb 8.6 Hct 26.0 MCV 94 MCH 31.0 MCHC 33.1 RDW 13.1 RDWSD 44.7 Plt ___ ___ 06 22AM BLOOD WBC 7.6 RBC 3.31 Hgb 10.2 Hct 30.5 MCV 92 MCH 30.8 MCHC 33.4 RDW 12.8 RDWSD 42.6 Plt ___ ___ 06 30AM BLOOD Plt ___ ___ 06 30AM BLOOD ___ ___ 06 10AM BLOOD Plt ___ ___ 06 10AM BLOOD ___ ___ 06 22AM BLOOD Plt ___ ___ 06 22AM BLOOD ___ ___ 10 55AM BLOOD ___ ___ 06 22AM BLOOD Glucose 136 UreaN 8 Creat 0.7 Na 138 K 3.7 Cl 96 HCO3 27 AnGap 15 ___ 06 22AM BLOOD Calcium 8.4 Phos 3.1 Mg 1.7 Brief Hospital Course The patient was admitted to the Orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following POD 1 patient was administered 500ml bolus of IV fluids for hypotension ___ which she responded to appropriately. She reported nausea on oxycodone and was switched to dilaudid with no reported adverse effects. POD 2 patient had INR of 1.8 and lovenox was discontinued. Patient will continue Coumadin 5mg daily. Next INR check day after discharge. Please direct results and all questions to PCP for INR monitoring Coumadin dosing. POD 3 INR 2.0 and patient will be due for 5mg Coumadin upon arrival to rehab facility. Otherwise pain was controlled with a combination of IV and oral pain medications. The patient received Coumadin starting on POD 0 with a Lovenox bridge starting on POD 1. Lovenox to be continued until INR 1.5 and discontinued on POD 2 with INR 1.8. Coumadin was dosed daily based on her INR levels. The surgical dressing will remain on until POD 7 after surgery. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient s hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the dressing was intact. The patient s weight bearing status is weight bearing as tolerated on the operative extremity. Please use walker or 2 crutches wean as able. Ms. ___ is discharged to rehab in stable condition. Patient will be in rehab facility for less than 30 days Medications on Admission 1. Albuterol 0.083 Neb Soln 2 NEB IH Q4H PRN wheezing cough 2. Atorvastatin 40 mg PO QPM 3. econazole 1 topical BID 4. Enoxaparin Sodium 110 mg SC Q12H Start Today ___ First Dose Next Routine Administration Time 5. Furosemide ___ mg PO DAILY PRN leg swelling 6. MetFORMIN Glucophage 500 mg PO QPM 7. Omeprazole 20 mg PO BID 8. Sertraline 100 mg PO DAILY 9. TraZODone 50 mg PO QHS PRN insomnia 10. Triamcinolone Acetonide 0.1 Ointment 1 Appl TP BID PRN rash itching 11. Warfarin ___ mg PO DAILY16 12. Aspirin 81 mg PO DAILY 13. Vitamin D ___ UNIT PO DAILY Discharge Medications 1. Docusate Sodium 100 mg PO BID 2. Gabapentin 100 mg PO TID 3. HYDROmorphone Dilaudid ___ mg PO Q4H PRN Pain Moderate do NOT drink alcohol or drive while taking med 4. Senna 8.6 mg PO BID 5. Acetaminophen 1000 mg PO Q8H 6. Warfarin 5 mg PO TO BE DOSED DAILY PER PCP DOSED DAILY PER PCP GOAL INR 1.8 2.2 7. Albuterol Inhaler ___ PUFF IH Q6H PRN shortness of breath 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. econazole 1 topical BID 11. Furosemide ___ mg PO DAILY PRN leg swelling 12. MetFORMIN XR Glucophage XR 500 mg PO DAILY 13. Omeprazole 20 mg PO BID 14. Sertraline 100 mg PO DAILY 15. TraZODone 50 mg PO QHS PRN insomnia 16. Triamcinolone Acetonide 0.1 Ointment 1 Appl TP BID PRN rash itching 17. Vitamin D ___ UNIT PO DAILY Discharge Disposition Extended Care Facility ___ Discharge Diagnosis left knee osteoarthritis pain Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions 1. Please return to the emergency department or notify your physician if you experience any of the following severe pain not relieved by medication increased swelling decreased sensation difficulty with movement fevers greater than 101.5 shaking chills increasing redness or drainage from the incision site chest pain shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive operate heavy machinery or drink alcohol while taking these medications. As your pain decreases take fewer tablets and increase the time between doses. This medication can cause constipation so you should drink plenty of water daily and take a stool softener such as Colace as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please call your surgeon s office to schedule or confirm your follow up appointment. 7. SWELLING Ice the operative joint 20 minutes at a time especially after activity or physical therapy. Do not place ice directly on the skin. You may wrap the knee with an ace bandage for added compression. Please DO NOT take any non steroidal anti inflammatory medications NSAIDs such as Celebrex ibuprofen Advil Aleve Motrin naproxen etc until cleared by your physician. 8. ANTICOAGULATION Lovenox discontinued on ___ due to INR 1.8. INR goal is 1.8 2.2. Please continue Coumadin 5mg daily. INR to be checked day after discharge. Please direct all INR results to patient s PCP. You may continue your dose of Aspirin 81mg daily. 9. WOUND CARE Please remove Aquacel dressing on POD 7 after surgery. It is okay to shower after surgery after 5 days but no tub baths swimming or submerging your incision until after your four 4 week checkup. Please place a dry sterile dressing on the wound after aqaucel is removed each day if there is drainage otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. 10. ___ once at home Home ___ dressing changes as instructed and wound checks. 11. ACTIVITY Weight bearing as tolerated on the operative extremity. Two crutches or walker. Wean assistive device as able. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy WBAT LLE No range of motion restrictions Wean assistive devices as able Mobilize frequently Treatments Frequency remove aquacel POD 7 after surgery apply dry sterile dressing daily if needed after aquacel dressing is removed wound checks daily after aquacel removed Followup Instructions ___ The icd codes present in this text will be M1712, D6861, J449, G4733, F329, E119, M4696, E785, K219, E669, Z7901, Z87891, Z6837, Z86711. The descriptions of icd codes M1712, D6861, J449, G4733, F329, E119, M4696, E785, K219, E669, Z7901, Z87891, Z6837, Z86711 are M1712: Unilateral primary osteoarthritis, left knee; D6861: Antiphospholipid syndrome; J449: Chronic obstructive pulmonary disease, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); F329: Major depressive disorder, single episode, unspecified; E119: Type 2 diabetes mellitus without complications; M4696: Unspecified inflammatory spondylopathy, lumbar region; E785: Hyperlipidemia, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; E669: Obesity, unspecified; Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence; Z6837: Body mass index [BMI] 37.0-37.9, adult; Z86711: Personal history of pulmonary embolism. The common codes which frequently come are J449, G4733, F329, E119, E785, K219, E669, Z7901, Z87891. The uncommon codes mentioned in this dataset are M1712, D6861, M4696, Z6837, Z86711.
The icd codes present in this text will be M7061, D6861, D509, E559, Z87891, Z86711, Z7901, C50912, G4733, E785, E119, K219, K5790, F329, J449, I83811. The descriptions of icd codes M7061, D6861, D509, E559, Z87891, Z86711, Z7901, C50912, G4733, E785, E119, K219, K5790, F329, J449, I83811 are M7061: Trochanteric bursitis, right hip; D6861: Antiphospholipid syndrome; D509: Iron deficiency anemia, unspecified; E559: Vitamin D deficiency, unspecified; Z87891: Personal history of nicotine dependence; Z86711: Personal history of pulmonary embolism; Z7901: Long term (current) use of anticoagulants; C50912: Malignant neoplasm of unspecified site of left female breast; G4733: Obstructive sleep apnea (adult) (pediatric); E785: Hyperlipidemia, unspecified; E119: Type 2 diabetes mellitus without complications; K219: Gastro-esophageal reflux disease without esophagitis; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; F329: Major depressive disorder, single episode, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; I83811: Varicose veins of right lower extremity with pain. The common codes which frequently come are D509, Z87891, Z7901, G4733, E785, E119, K219, F329, J449. The uncommon codes mentioned in this dataset are M7061, D6861, E559, Z86711, C50912, K5790, I83811. Allergies Codeine Augmentin Topamax Chief Complaint RLE pain and swelling Major Surgical or Invasive Procedure Ultrasound guided steroid injection of the right trochanteric bursa right hip History of Present Illness This is a ___ woman with a history of breast cancer with BRCA1 gene mutation COPD cerebral aneurysm sleep apnea depression hyperlipidemia antiphospholipid syndrome with hx DVT PE ___ ago on warfarin who presents for evaluation of severe right lower extremity pain. She was just admitted to the hospital for lumpectomy infiltrating ductal carcinoma of left breast and sentinel lymph node biopsy on ___ complicated by hematoma status post evacuation on ___. Prior to these procedures she had severe right lower extremity pain similar to today and underwent a DVT ultrasound on ___ which was negative. Her anticoagulation was held in the hospital due to the hematoma and she had DVT prophylaxis with pneumoboots. During her postoperative hematoma her anticoagulation was held. She did not have extremity pain during her time in the hospital. However upon returning home she developed severe pain which she describes as cramps in her mid calf on the right. She also has pain that intermittently occurs in the right thigh which she describes as spasms. She has not had numbness tingling or weakness on that side. She was seen in breast clinic today where she complained of this pain and was referred to the ED for further evaluation. She initially triggered as a pulseless extremity because of nonpalpable pulses in the right foot. She has been taking Tylenol as well as tramadol with minimal pain relief. Of note she resumed her warfarin without any enoxaparin bridge this past ___. She has been wearing compression stockings and elevating her leg in an attempt to relieve the pain. In the ED initial vitals T 98.7 HR 85 BP 175 77 RR 20 O2 Sat 98 RA Exam notable for Right lower extremity with dopplerable pulses palpable pulses in the left lower extremity. The right lower extremity is warm. There is tenderness to palpation of the right calf. Tenderness to palpation of the right thigh. Labs notable for Chem panel Unremarkable with Cr 0.8 CK 67 CBC WBC 5.6 Hgb 10.8 with MCV 93 Plt 264 Coags ___ 14.8 PTT 28.2 INR 1.4 Lactate 1.1 UA Mod Leuk few bacteria Imaging notable for RLE Ultrasound ___ Right calf veins not visualized. Otherwise no evidence of deep venous thrombosis in the right lower extremity veins. CT Lower Extremity Right ___ Unremarkable contrast enhanced CT of the right calf with a two vessel runoff to the foot. The veins of the lower extremity are not opacified therefore cannot be assessed for patency. Consider repeat ultrasound to more fully evaluate. No focal collection or obvious muscular abnormality identified by CT. Pt given IV Morphine 4mg IV APAP 1g IV NS IV Dilaudid 5 mg total 1mg x 5 Warfarin 7.5mg Atorvastatin 40mg Omeprazole 20mg Surgery was consulted Recommend vascular surgery consult for possible dvt with history of multiple vein stripping procedures and DVTs. Also recommend admission to medicine for pain control. Vascular surgery was consulted There is no clear vascular etiology for her pain. Vitals prior to transfer T 98.3 HR 83 BP 140 55 RR 20 O2 Sat 100 RA Upon arrival to the floor the patient reports the pain is ___. She reports again that this pain is similar to the pain she had on ___ but even then an ultrasound showed no DVT. She is able to move her toes but has pain with lifting her leg. She has never had this kind of pain before even with the vein stripping that she had in the past age ___. She has no chest pain or shortness of breath. She has had no recent travel or trauma to her leg. Past Medical History Dyslipidemia Varicose veins R L s p ligation COPD OSA CPap recent URI received course of Zithromax bilateral PEs ___ antiphospholipid antibody syndrome on lifelong anticoagulation T2DM last A1C 6.2 on ___ cerebral aneurysm followed by Dr. ___ unchanged GERD diverticulosis h o colon polyps depression s p right CMC joint arthroplasty b l rotator cuff repair excision right ___ digit mass CCY w stone pancreatic duct exploration ___ hysterectomy tonsillectomy Social History ___ Family History Mother ___ ___ OVARIAN CANCER dx age ___ Father ___ ___ BRAIN CANCER PGM OVARIAN CANCER Aunt OVARIAN CANCER paternal aunt in ___ MGM ENDOMETRIAL CANCER MGF PROSTATE CANCER Brother ___ ___ KIDNEY CANCER RENAL FAILURE CONGESTIVE HEART FAILURE DIABETES MELLITUS TOBACCO ABUSE ALCOHOL ABUSE Sister ___ ___ OVARIAN CANCER dx age ___ Brother ___ THROAT CANCER dx age ___ died in ___ Sister BRCA1 MUTATION BREAST CANCER Daughter Living ___ ABNORMAL PAP SMEAR ___ SUBSTANCE ABUSE Son Died ___ SUBSTANCE ABUSE ___ heroin overdose on ___. Physical Exam ADMISSION EXAM VITALS T 97.9 BP 125 80 HR 82 RR 16 O2 Sat 94 RA General Alert oriented no acute distress HEENT MMM oropharynx clear EOMI PERRL neck supple JVP not elevated Chest L breast incisions well healed. S p L axilla surgical drain removal. CV Regular rate and rhythm normal S1 S2 no murmurs Lungs Clear to auscultation bilaterally no wheezes or crackles Abdomen Soft non tender non distended bowel sounds present Ext Warm well perfused right lower extremity is tender to palpation and movement limited by pain. Swelling of RLE LLE. Palpable 2 ___ pulses bilaterally. Skin Warm dry varicose veins noted in lower extremities. Neuro CNII XII intact grossly normal strength and sensation and symmetric bilaterally DISCHARGE EXAM VITALS Temp 98.2 Tm 98.9 BP 133 74 127 147 72 83 HR 76 76 91 RR 18 O2 sat 99 90 99 O2 delivery Ra General Alert oriented no acute distress HEENT MMM oropharynx clear EOMI PERRL neck supple JVP not elevated Chest L breast incisions well healed. S p L axilla surgical drain removal. CV RRR no murmurs Lungs Clear Abdomen Soft non tender non distended bowel sounds present Ext Warm well perfused. No asymmetric swelling. Minimally tender to palpation along the right trochanteric bursa and minimally tender to palpation along the right tibia. Normal ROM though pain elicited with knee flexion improves with leg raise and extension. Palpable 2 ___ pulses bilaterally. Skin varicose veins noted in lower extremities. Neuro lower extremity sensation is equal on both sides to light touch. Normal bilateral lower extremity strength. Negative babinsky. Ambulating in hallway independently though it precipitates right tibial pain Pertinent Results ADMISSION LABS ___ 12 00PM BLOOD WBC 5.6 RBC 3.48 Hgb 10.8 Hct 32.3 MCV 93 MCH 31.0 MCHC 33.4 RDW 14.7 RDWSD 48.6 Plt ___ ___ 12 00PM BLOOD Neuts 73.6 ___ Monos 4.9 Eos 0.9 Baso 0.7 Im ___ AbsNeut 4.09 AbsLymp 1.08 AbsMono 0.27 AbsEos 0.05 AbsBaso 0.04 ___ 12 00PM BLOOD ___ PTT 28.2 ___ ___ 12 00PM BLOOD Glucose 107 UreaN 7 Creat 0.8 Na 139 K 4.0 Cl 100 HCO3 26 AnGap 13 ___ 05 40AM BLOOD Calcium 8.6 Phos 4.8 Mg 2.2 Iron 36 ___ 05 40AM BLOOD calTIBC 291 VitB12 331 Ferritn 50 TRF 224 ___ 07 15AM BLOOD 25VitD 45 ___ 12 25PM BLOOD Lactate 1.1 DISCHARGE LABS ___ 04 41AM BLOOD WBC 5.6 RBC 3.36 Hgb 10.1 Hct 31.1 MCV 93 MCH 30.1 MCHC 32.5 RDW 14.5 RDWSD 48.7 Plt ___ ___ 04 41AM BLOOD ___ ___ 04 41AM BLOOD Glucose 132 UreaN 15 Creat 0.7 Na 140 K 5.0 Cl 103 HCO3 26 AnGap 11 ___ 04 41AM BLOOD Calcium 9.2 Phos 4.0 Mg 2.4 IMAGING Unilat lower extremity vein R ___ Right calf veins not visualized. Otherwise no evidence of deep venous thrombosis in the right lower extremity veins. CT RLE ___ Unremarkable contrast enhanced CT of the right calf with a two vessel runoff to the foot. The veins of the lower extremity are not opacified therefore cannot be assessed for patency. Consider repeat ultrasound to more fully evaluate. No focal collection or obvious muscular abnormality identified by CT ___ 1.. Uneventful ultrasound guided injection of long acting anesthetic and steroid into theright greater trochanteric bursa. 2. Prior injection small amount of fluid in the right greater trochanteric bursa and dystrophic calcification within the bursal space. Findings raise suspicion for chronic trochanteric bursitis. Brief Hospital Course SUMMARY Ms. ___ is a ___ with a PMH significant for antiphospholipid syndrome with DVTs and PEs on Coumadin recent L sided breast cancer s p lumpectomy who presented to the ED with acute on chronic right lower extremity and right hip pain making it difficult to ambulate. Right lower extremity U S and CT did not reveal a DVT though calf veins were not well visualized. ACTIVE ISSUES Right trochanteric bursitis Right anterior lower leg pain Right sided varicose veins Pt endorsed 4mths of pain in RLE that became acutely worse over the last few wks. Her initial exam was most consistent with severe trochanteric bursitis on the right. She also has some focal pain along the right tibia which she felt was most consistent with pain from her varicose veins. The XRs of her tibia fibula and right hip were without obvious pathology. There are no concerning neurologic symptoms to suggest a radiculopathy no weakness or numbness though she may have some degree of chronic sciatica. Mildly decreased patellar reflex on the right as compared to left may have been in the setting of pain and guarding strength was normal bilaterally as was her sensation. She underwent U S guided steroid injection of her trochanteric bursa w significant improvement in symptoms ___ stated that there was some fluid near the bursa suggestive of acute on chronic trochanteric bursitis. Her anterior shin pain improved with initiation of gabapentin and lidocaine patch in addition to her home tylenol and an increase in the frequency of her home tramadol q8h PRN to q4h PRN . Pt was not given her home hydromorphone PRN though she did require one dose of 0.5 mg IV hydromorphone following her injection in the setting of an acute pain episode. She was discharged with Tramadol 50mg x15 tablets given increased requirement. By discharge she was able ambulate and was felt safe for discharge home with a cane per ___ evaluation. Pt was eager to leave and will reach out to her vascular surgeon for an appointment early in the new year for treatment of her painful varicose veins. Iron deficiency anemia Anemia is new since ___. Normocytic. Downtrended overnight to 8.9 from 10.8. No concern for active bleeding. Per iron studies she is iron deficient with a ferritin of 50. She endorses fatigue and restless leg syndrome. Etiology is unclear though it may be related to the recent left breast hematoma of her breast unlikely though the timing fits . Prior EGD with gastritis ___ for which she is on a BID PPI prior colonoscopy ___ with findings that may be suggestive of celiac disease though ttg at that time was normal with a normal IgA. She also had two polyps biopsied and were normal. On this admission a vitamin D level was obtained to assess for evidence of malabsorption iso daily supplementation level was 45. She was given ferric gluconate IV x1 on ___. TTG was repeated and pending at discharge. CHRONIC ISSUES History of DVT PE on warfarin Antiphospholipid antibody syndrome Subtherapeutic INR Lupus anticoagulant positive in ___. She has been taking her home dose of warfarin 5 mg ___ and 7.5 mg other days . Her warfarin was held last ___ iso hematoma and she was not bridged with Lovenox upon reinitiation. INR on this admission was subtherapeutic at 1.4. Bridged during this hospitalization with Lovenox for goal INR ___. She was given an increased dose of warfarin 7.5 mg daily while in house. INR at discharge was 1.9 with plan to continue home warfarin regimen. Patient will get repeat INR on ___. Vitamin D deficiency pt takes 2 000 U vitamin D daily. Repeat level IS 45 which suggests against malabsorption to account for her iron deficiency. TRANSITIONAL ISSUES Code status Full presumed HCP ___ granddaughter ___. Right trochanteric bursitis Consider repeat injection Consider physical therapy Right anterior leg pain discharged on gabapentin 600 mg three times daily discharged with tramadol 50mg home regimen is Q8hrs and required Q4hrs during hospitalization. Will give two day supply of increased dose. Plan to see PCP next week. Consider outpatient MRI of the lumbar spine for chronic pain Consider EMG Vascular surgery follow up as outpt for treatment of painful veins Iron deficiency anemia Consider repeat IV iron infusion F u pending TTG Consider further work up though may be related to left breast hematoma History of DVT PE antiphospholipid antibody syndrome subtherapeutic INR F u ___ clinic on ___. Patient can continue home Warfarin regimen Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Docusate Sodium 100 mg PO BID 3. Omeprazole 20 mg PO BID 4. Senna 8.6 mg PO HS 5. Sertraline 150 mg PO DAILY 6. TraZODone 50 mg PO QHS PRN sleep 7. TraMADol 50 mg PO Q8H PRN Pain Moderate Reason for PRN duplicate override Alternating agents for similar severity 8. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 9. ProAir HFA albuterol sulfate 90 mcg actuation inhalation Q4H PRN 10. Acetaminophen 1000 mg PO Q8H PRN Pain Mild Fever 11. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN cough wheeze 12. Vitamin D ___ UNIT PO DAILY 13. Erythromycin 0.5 Ophth Oint 0.5 in BOTH EYES QID 14. Furosemide 20 mg PO DAILY PRN Leg swelling 15. HYDROmorphone Dilaudid 2 mg PO Q4H PRN Pain Severe 16. Warfarin 7.5 mg PO 2X WEEK ___ 17. Warfarin 5 mg PO 5X WEEK ___ Discharge Medications 1. Gabapentin 600 mg PO TID RX gabapentin 600 mg 1 tablet s by mouth three times daily Disp 90 Tablet Refills 0 2. Lidocaine 5 Patch 1 PTCH TD QAM right hip RX lidocaine 5 Apply ___ patches daily Disp 12 Patch Refills 0 3. TraMADol 50 mg PO Q6H PRN Pain Moderate RX tramadol 50 mg 1 tablet s by mouth Every six hours as needed Disp 15 Tablet Refills 0 4. Acetaminophen 1000 mg PO Q8H PRN Pain Mild Fever 5. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN cough wheeze 6. Atorvastatin 40 mg PO QPM 7. Docusate Sodium 100 mg PO BID 8. Erythromycin 0.5 Ophth Oint 0.5 in BOTH EYES QID 9. Furosemide 20 mg PO DAILY PRN Leg swelling 10. Omeprazole 20 mg PO BID 11. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 12. ProAir HFA albuterol sulfate 90 mcg actuation inhalation Q4H PRN 13. Senna 8.6 mg PO HS 14. Sertraline 150 mg PO DAILY 15. TraZODone 50 mg PO QHS PRN sleep 16. Vitamin D ___ UNIT PO DAILY 17. Warfarin 5 mg PO 2X WEEK ___ 18. Warfarin 7.5 mg PO 5X WEEK ___ Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY Right trochanteric bursitis Right anterior leg pain Right sided varicose veins SECONDARY Iron deficiency anemia History of DVT PE on warfarin Antiphospholipid antibody syndrome Subtherapeutic INR Vitamin D deficiency Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear ___ You were admitted because you were having a lot of leg pain making it difficult to walk. In the hospital we gave you a steroid injection near your right thigh for a condition called Trochanteric Bursitis. We also gave you a medication called Gabapentin to help with your leg pain lower down. We also started you on a medication called Lovenox in order to bridge you back to your warfarin currently your warfarin dose is 7.5 mg daily and your INR was 1.9 at discharge goal ___. Finally you received 1 dose of intravenous iron because you are iron deficient which may be why you are more fatigued than usual. When you go home please take your medications as prescribed and make an appointment with your primary care doctor. We do not know what exactly is causing the lower leg pain so you may want to talk to your doctor about having an MRI of your spine. You can also ask your doctor about prescribing a medication called DICLOFENAC GEL also called VOLTAREN. This is essentially Motrin or Advil in a topical form and may help your pain. Additionally please talk to your doctor about why you may be iron deficient. It was a pleasure taking part in your care. We wish you all the best with your health. Sincerely The team at ___ Followup Instructions ___ The icd codes present in this text will be M7061, D6861, D509, E559, Z87891, Z86711, Z7901, C50912, G4733, E785, E119, K219, K5790, F329, J449, I83811. The descriptions of icd codes M7061, D6861, D509, E559, Z87891, Z86711, Z7901, C50912, G4733, E785, E119, K219, K5790, F329, J449, I83811 are M7061: Trochanteric bursitis, right hip; D6861: Antiphospholipid syndrome; D509: Iron deficiency anemia, unspecified; E559: Vitamin D deficiency, unspecified; Z87891: Personal history of nicotine dependence; Z86711: Personal history of pulmonary embolism; Z7901: Long term (current) use of anticoagulants; C50912: Malignant neoplasm of unspecified site of left female breast; G4733: Obstructive sleep apnea (adult) (pediatric); E785: Hyperlipidemia, unspecified; E119: Type 2 diabetes mellitus without complications; K219: Gastro-esophageal reflux disease without esophagitis; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; F329: Major depressive disorder, single episode, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; I83811: Varicose veins of right lower extremity with pain. The common codes which frequently come are D509, Z87891, Z7901, G4733, E785, E119, K219, F329, J449. The uncommon codes mentioned in this dataset are M7061, D6861, E559, Z86711, C50912, K5790, I83811.
The icd codes present in this text will be L7632, C50912, D6861, K760, K219, G4733, E785, I671, J449, E119, Y838, F329, Z7901, Z86711, Z87891, Z803, Z8041, Z9012. The descriptions of icd codes L7632, C50912, D6861, K760, K219, G4733, E785, I671, J449, E119, Y838, F329, Z7901, Z86711, Z87891, Z803, Z8041, Z9012 are L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure; C50912: Malignant neoplasm of unspecified site of left female breast; D6861: Antiphospholipid syndrome; K760: Fatty (change of) liver, not elsewhere classified; K219: Gastro-esophageal reflux disease without esophagitis; G4733: Obstructive sleep apnea (adult) (pediatric); E785: Hyperlipidemia, unspecified; I671: Cerebral aneurysm, nonruptured; J449: Chronic obstructive pulmonary disease, unspecified; E119: Type 2 diabetes mellitus without complications; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; F329: Major depressive disorder, single episode, unspecified; Z7901: Long term (current) use of anticoagulants; Z86711: Personal history of pulmonary embolism; Z87891: Personal history of nicotine dependence; Z803: Family history of malignant neoplasm of breast; Z8041: Family history of malignant neoplasm of ovary; Z9012: Acquired absence of left breast and nipple. The common codes which frequently come are K219, G4733, E785, J449, E119, F329, Z7901, Z87891. The uncommon codes mentioned in this dataset are L7632, C50912, D6861, K760, I671, Y838, Z86711, Z803, Z8041, Z9012. Allergies Codeine Augmentin Topamax ___ Complaint left breast swelling and pain Major Surgical or Invasive Procedure Evacuation of hematoma History of Present Illness ___ woman on anticoagulation with L breast IDC Grade 3 now s p L breast lumpectomy and SLNB with left breast swelling and pain concerning for a hematoma. Past Medical History Dyslipidemia varicose veins R L s p ligation COPD OSA CPap recent URI received course of Zithromax bilateral PEs ___ antiphospholipid antibody syndrome on lifelong anticoagulation T2DM last A1C 6.2 on ___ cerebral aneurysm followed by Dr. ___ unchanged GERD diverticulosis h o colon polyps depression s p right CMC joint arthroplasty b l rotator cuff repair excision right ___ digit mass CCY w stone pancreatic duct exploration ___ hysterectomy tonsillectomy Social History ___ Family History No family hx of DVT or PE two sisters have atrial fibrillation. Physical Exam Physical Exam VS ___ 0313 Temp 98.2 PO BP 98 62 HR 79 RR 18 O2 sat 95 O2 delivery RA GEN NAD pleasant conversant HEENT NCAT EOMI sclera anicteric CV RRR PULM no increased work of breathing comfortable on RA BREAST L breast with dependent ecchymosis mildly ttp inferior breast incision C D I. JP drain with serosanguineous output. ABD soft non tender non distended no masses or hernia EXT Warm well perfused no edema no tenderness NEURO A Ox3 no focal neurologic deficits PSYCH normal judgment insight normal memory normal mood affect Pertinent Results ___ 07 33AM BLOOD WBC 4.8 RBC 2.86 Hgb 8.6 Hct 27.2 MCV 95 MCH 30.1 MCHC 31.6 RDW 14.7 RDWSD 48.7 Plt ___ ___ 07 33AM BLOOD ___ PTT 26.2 ___ ___ 07 33AM BLOOD Glucose 130 UreaN 7 Creat 0.8 Na 141 K 4.2 Cl 101 HCO3 31 AnGap 9 ___ 07 33AM BLOOD Calcium 8.2 Phos 3.8 Mg 2.0 EXAMINATION CTA CHEST WITH CONTRAST COMPARISON Chest CT dated ___. FINDINGS HEART AND VASCULATURE There is no central pulmonary embolism. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. The heart pericardium and great vessels are within normal limits. No pericardial effusion is seen. AXILLA HILA AND MEDIASTINUM There is a 8.8 x 5.8 x 9.8 cm collection in the left breast with density measuring 39 Hounsfield units consistent with hematoma. There are few foci of air within the collection likely from prior aspiration as well as few punctate hyperdensities at the periphery. No axillary mediastinal or hilar lymphadenopathy is present. The right axilla is not included on the study. No mediastinal mass. PLEURAL SPACES No pleural effusion or pneumothorax. LUNGS AIRWAYS Partially visualized lungs are clear without masses or areas of parenchymal opacification. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK Visualized portions of the base of the neck show no abnormality. BONES No suspicious osseous abnormality is seen. There is no acute fracture. IMPRESSION 8.8 x 5.8 x 9.8 cm left breast hematoma with no evidence of active bleed. Please note timing was suboptimal as the patient needed to be re scanned due to incomplete field of view on initial images however the density of the collection was unchanged on all series. Brief Hospital Course Ms. ___ is a ___ woman who was admitted to the breast service following a left breast lumpectomy for invasive carcinoma performed on ___. She presented with a recurrent left breast hematoma after it was evacuated by needle aspiration in clinic on ___. She was admitted for observation and surgical evacuation of her hematoma. On ___ she was brought to the operating room for evacuation of the left ___ hematoma and placement of a surgical drain. Hospital course as detailed below Neuro pain was controlled with oral pain medication including acetaminophen and tramadol. ___ Vital signs were monitored per protocol. She was continued on her home medications. Resp she was continued on her home albuterol medications FEN GI she was continued on a regular diet throughout her admission. She was briefly made NPO for the operating room and hydrated with IV fluids in the perioperative period. GU She voided without issue throughout her hospital course Heme H H was closely monitored with daily labs and found to be stable. Her home anticoagulation was held during her hospital course. She was resumed on her home dose of warfarin on discharge without a lovenox bridge. She remained on compression boots during her hospital course to prevent DVTs. ID She was given ancef 2gm IV Q8hrs for prophylaxis she remained afebrile and did not develop a leukocytosis during her hospital course. Endo Due to a history of metabolic syndrome and pre diabetes she was kept on a constant carbohydrate diet. On the day of discharge she was tolerating a regular diet w o nausea or emesis. She was ambulating independently. Her pain was controlled with oral pain medications. She was afebrile and did not have a leukocytosis all antibiotics were discontinued. She was discharged home with ___ for drain management and close follow up with Dr. ___ in clinic for drain removal. She will also follow up with Dr. ___ in clinic in early ___ for routine follow up. Medications on Admission Active Medication list as of ___ Medications Prescription ALBUTEROL SULFATE albuterol sulfate 2.5 mg 3 mL 0.083 solution for nebulization. 3 ml inhalation four times a day as needed for cough wheeze ALBUTEROL SULFATE PROAIR HFA ProAir HFA 90 mcg actuation aerosol inhaler. 2 puffs inhalation q4 6 hours as needed for cough wheeze ATORVASTATIN atorvastatin 40 mg tablet. 1 One tablet s by mouth at bedtime Prescribed by Other Provider Dose adjustment no new Rx ENOXAPARIN enoxaparin 100 mg mL subcutaneous syringe. 100 mg SC twice daily approximately 12 hours apart will start ___ last dose ___ AM . Prescribed by Other Provider Dose adjustment no new Rx ERYTHROMYCIN erythromycin 5 mg gram 0.5 eye ointment. Apply ___ inch affected eye four times a day FUROSEMIDE furosemide 20 mg tablet. ___ tablet s by mouth once a day as needed for leg swelling HYDROMORPHONE hydromorphone 2 mg tablet. ___ tablet s by mouth every four 4 hours as needed for severe pain do not drink alcohol or drive while taking this medication NEBULIZER AND COMPRESSOR PORTABLE NEBULIZER SYSTEM Portable Nebulizer System. Use with albuterol nebulizer soln four times a day as needed for cough wheeze OMEPRAZOLE omeprazole 20 mg capsule delayed release. TAKE 1 CAPSULE TWICE DAILY FOR GASTROESOPHAGEAL REFLUXDISEASE SERTRALINE sertraline 100 mg tablet. 1.5 tablet s by mouth once a day TRAMADOL tramadol 50 mg tablet. one tablet s by mouth three times a day TRAZODONE trazodone 50 mg tablet. 1 tablet s by mouth at bedtime as needed for insomia WARFARIN warfarin 5 mg tablet. 1 One tablet s by mouth 2 times a ___ ___ tabs po 5 times a week last dose per ___ clinic ___ Prescribed by Other Provider Dose adjustment no new Rx Medications OTC ACETAMINOPHEN acetaminophen 500 mg tablet. 2 tablet s by mouth 3 times daily as needed for pain ___ DC med rec CHOLECALCIFEROL VITAMIN D3 cholecalciferol vitamin D3 2 000 unit tablet. 1 tablet s by mouth once a day OTC POLYETHYLENE GLYCOL 3350 MIRALAX Miralax 17 gram dose oral powder. 1 powder s by mouth once a day as needed for constipation Prescribed by Other Provider Dose adjustment no new Rx SENNOSIDES SENNA senna 8.6 mg tablet. 1 tablet s by mouth once a day as needed for constipation OTC Discharge Medications 1. TraMADol 50 mg PO Q4H PRN Pain Moderate Reason for PRN duplicate override Alternating agents for similar severity RX tramadol 50 mg 1 tablet s by mouth Q4hr prn Disp 7 Tablet Refills 0 2. Atorvastatin 40 mg PO QPM 3. Docusate Sodium 100 mg PO BID 4. Omeprazole 20 mg PO BID 5. Senna 17.2 mg PO HS 6. Sertraline 150 mg PO DAILY 7. TraZODone 50 mg PO QHS PRN sleep Discharge Disposition Home With Service Facility ___ Discharge Diagnosis breast hematoma Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Personal Care 1. You may keep your incisions open to air or covered with a clean sterile gauze that you change daily. 2. Clean around the drain site s where the tubing exits the skin with soap and water. 3. Strip drain tubing empty bulb s and record output s ___ times per day. 4. A written record of the daily output from each drain should be brought to every follow up appointment. Your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. You may wear a surgical bra or soft loose camisole for comfort. 6. Do not shower while your drain is in place. 7. The Dermabond skin glue will begin to flake off in about ___ days. Activity 1. You may resume your regular diet. 2. Walk several times a day. 3. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. Medications 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 3. Take prescription pain medications for pain not relieved by Tylenol. 4. Take Colace 100 mg by mouth 2 times per day while taking the prescription pain medication. You may use a different over the counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc. you should continue drinking fluids you may take stool softeners and should eat foods that are high in fiber. Call the office IMMEDIATELY if you have any of the following 1. Signs of infection fever with chills increased redness swelling warmth or tenderness at the surgical site or unusual drainage from the incision s . 2. A large amount of bleeding from the incision s or drain s . 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. Return to the ER if If you are vomiting and cannot keep in fluids or your medications. If you have shaking chills fever greater than 101.5 F degrees or 38 C degrees increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you. Any serious change in your symptoms or any new symptoms that concern you. ANTICOAGULATION You should begin taking your home warfarin dose this evening ___ and resume taking warfarin at your regular scheduled doses. You will not need a bridge therapy to begin warfarin. DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Please assist patient with drain care. A daily log of individual drain outputs should be maintained and brought with patient to follow up appointment with your surgeon. Followup Instructions ___ The icd codes present in this text will be L7632, C50912, D6861, K760, K219, G4733, E785, I671, J449, E119, Y838, F329, Z7901, Z86711, Z87891, Z803, Z8041, Z9012. The descriptions of icd codes L7632, C50912, D6861, K760, K219, G4733, E785, I671, J449, E119, Y838, F329, Z7901, Z86711, Z87891, Z803, Z8041, Z9012 are L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure; C50912: Malignant neoplasm of unspecified site of left female breast; D6861: Antiphospholipid syndrome; K760: Fatty (change of) liver, not elsewhere classified; K219: Gastro-esophageal reflux disease without esophagitis; G4733: Obstructive sleep apnea (adult) (pediatric); E785: Hyperlipidemia, unspecified; I671: Cerebral aneurysm, nonruptured; J449: Chronic obstructive pulmonary disease, unspecified; E119: Type 2 diabetes mellitus without complications; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; F329: Major depressive disorder, single episode, unspecified; Z7901: Long term (current) use of anticoagulants; Z86711: Personal history of pulmonary embolism; Z87891: Personal history of nicotine dependence; Z803: Family history of malignant neoplasm of breast; Z8041: Family history of malignant neoplasm of ovary; Z9012: Acquired absence of left breast and nipple. The common codes which frequently come are K219, G4733, E785, J449, E119, F329, Z7901, Z87891. The uncommon codes mentioned in this dataset are L7632, C50912, D6861, K760, I671, Y838, Z86711, Z803, Z8041, Z9012.
The icd codes present in this text will be M5116, D6861, N390, D62, I83811, D509, Z87891, Z86711, Z7901, E559, C50912, E785, G4733, E119, K219, K5790, F329, J449, I671, M48061, K5900, E876. The descriptions of icd codes M5116, D6861, N390, D62, I83811, D509, Z87891, Z86711, Z7901, E559, C50912, E785, G4733, E119, K219, K5790, F329, J449, I671, M48061, K5900, E876 are M5116: Intervertebral disc disorders with radiculopathy, lumbar region; D6861: Antiphospholipid syndrome; N390: Urinary tract infection, site not specified; D62: Acute posthemorrhagic anemia; I83811: Varicose veins of right lower extremity with pain; D509: Iron deficiency anemia, unspecified; Z87891: Personal history of nicotine dependence; Z86711: Personal history of pulmonary embolism; Z7901: Long term (current) use of anticoagulants; E559: Vitamin D deficiency, unspecified; C50912: Malignant neoplasm of unspecified site of left female breast; E785: Hyperlipidemia, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); E119: Type 2 diabetes mellitus without complications; K219: Gastro-esophageal reflux disease without esophagitis; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; F329: Major depressive disorder, single episode, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; I671: Cerebral aneurysm, nonruptured; M48061: Spinal stenosis, lumbar region without neurogenic claudication; K5900: Constipation, unspecified; E876: Hypokalemia. The common codes which frequently come are N390, D62, D509, Z87891, Z7901, E785, G4733, E119, K219, F329, J449, K5900. The uncommon codes mentioned in this dataset are M5116, D6861, I83811, Z86711, E559, C50912, K5790, I671, M48061, E876. Allergies Codeine Augmentin Topamax Chief Complaint Low back pain with radiation down the right leg Major Surgical or Invasive Procedure DECOMPRESSION L2 S1 FUSION L4 L5 DURAPLASTY on ___ History of Present Illness Ms. ___ is a ___ female with a past medical history significant for cerebral aneurysm abdominal aortic aneurysm antiphospholipid syndrome w multiple DVTs and one event of bilateral large PEs on warfarin BRCA1 mutation w L sided breast cancer s p lumpectomy who presents with over one month of right lower back pain with radicular pain down the right leg pain. She had recent admission ___ for acute worsening of RLE pain and swelling in background of about 4 months right leg pain. RLE US did not show evidence of DVT. Exam was most consistent with right trochanteric bursitis and pt received a steroid injection. Her right tibia pain was felt to be ___ to her varicose veins. On this admission Imaging notable for Normal CT A P with no e o nephrolithiasis MR ___ spine with disc bulge at L2 L3 and L3 4 cause severe narrowing of the spinal canal with crowding of the traversing cauda equina. Past Medical History Dyslipidemia Varicose veins R L s p ligation COPD OSA CPap recent URI received course of Zithromax bilateral PEs ___ antiphospholipid antibody syndrome on lifelong anticoagulation T2DM last A1C 6.2 on ___ cerebral aneurysm followed by Dr. ___ unchanged GERD diverticulosis h o colon polyps depression s p right CMC joint arthroplasty b l rotator cuff repair excision right ___ digit mass CCY w stone pancreatic duct exploration ___ hysterectomy tonsillectomy Social History ___ Family History Mother ___ ___ OVARIAN CANCER dx age ___ Father ___ ___ BRAIN CANCER PGM OVARIAN CANCER Aunt OVARIAN CANCER paternal aunt in ___ MGM ENDOMETRIAL CANCER MGF PROSTATE CANCER Brother ___ ___ KIDNEY CANCER RENAL FAILURE CONGESTIVE HEART FAILURE DIABETES MELLITUS TOBACCO ABUSE ALCOHOL ABUSE Sister ___ ___ OVARIAN CANCER dx age ___ Brother ___ THROAT CANCER dx age ___ died in ___ Sister BRCA1 MUTATION BREAST CANCER Daughter Living 40 ABNORMAL PAP SMEAR ___ SUBSTANCE ABUSE Son Died ___ SUBSTANCE ABUSE ___ heroin overdose on ___. Physical Exam Physical Exam On Admission VITALS ___ 1104 Temp 97.9 PO BP 129 79 R Lying HR 82 RR 16 O2 sat 96 O2 delivery Ra General Tearful expressing right back and leg pain with spasms Chest L breast incisions well healed. S p L axilla surgical drain removal. CV Regular rate and rhythm normal S1 S2 no murmurs Lungs Clear to auscultation bilaterally no wheezes or crackles Abdomen Soft non tender non distended bowel sounds present Ext Warm well perfused right lower extremity is tender to palpation and movement limited by pain. Swelling of RLE LLE. Palpable 2 ___ pulses bilaterally. Skin Warm dry varicose veins noted in lower extremities. Neuro Grossly oriented MSK exam Right SI Joint tenderness. Radicular pain worsened with back flexion and relieved with extension. ___ strength bilaterally w hip flexion and extension knee flexion and extension foot plantar and dorsiflexion sensation in tact bilaterally ___ Ortho Spine Exam PE VS ___ ___ Temp 98.7 PO BP 135 66 R Lying HR 99 RR 18 O2 sat 94 O2 delivery Ra ___ ___ Temp 98.7 PO BP 135 66 R Lying HR 99 RR 18 O2 sat 94 O2 delivery Ra NAD A Ox4 nl resp effort RRR Sensory UE C5 C6 C7 C8 T1 lat arm thumb mid fing sm finger med arm R SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT T2 L1 Trunk SILT ___ L2 L3 L4 L5 S1 S2 Groin Knee Med Calf Grt Toe Sm Toe Post Thigh R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor UE Dlt C5 Bic C6 WE C6 Tri C7 WF C7 FF C8 FinAbd T1 R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 ___ Flex L1 Add L2 Quad L3 TA L4 ___ ___ R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Reflexes Bic C4 5 BR C5 6 Tri C6 7 Pat L3 4 Ach L5 S1 R 2 2 2 2 2 L 2 2 2 2 2 ___ Negative Babinski Downgoing Clonus No beats Pertinent Results IMAGING MR THORACIC SPINE W O CONTRAST MR ___ SPINE W O CONTRAST ___ IMPRESSION 1. Severe central canal narrowing at L4 5 level from degenerative changes. 2. Large right paramedian superior disc extrusion L4 5 level extends into right L4 lateral recess mass effect on exiting right L4 traversing L5 nerves severe right L4 5 foraminal narrowing.. 3. Advanced degenerative changes lumbar spine. 4. Moderate central canal narrowing L2 L3 moderate to severe at L3 L4 levels. 5. Multilevel significant foraminal narrowing lumbar spine as above. 6. Degenerative changes thoracic spine mild to moderate central canal narrowing foraminal narrowing. CT ABD PELVIS WITH CONTRAST ___ IMPRESSION 1. No acute CT findings in the abdomen or pelvis to correlate with patient s reported symptoms. Specifically no evidence of obstructive renal stone or pyelonephritis. 2. Sigmoid diverticulosis without evidence of acute diverticulitis. Admission Labs ___ 12 49PM BLOOD WBC 6.3 RBC 3.97 Hgb 11.9 Hct 37.2 MCV 94 MCH 30.0 MCHC 32.0 RDW 14.3 RDWSD 49.1 Plt ___ ___ 12 49PM BLOOD ___ PTT 34.3 ___ ___ 12 49PM BLOOD Glucose 117 UreaN 11 Creat 0.8 Na 143 K 4.3 Cl 106 HCO3 26 AnGap 11 ___ 10 06AM BLOOD WBC 5.8 RBC 2.81 Hgb 8.5 Hct 26.1 MCV 93 MCH 30.2 MCHC 32.6 RDW 14.0 RDWSD 47.6 Plt ___ ___ 05 53AM BLOOD WBC 6.6 RBC 2.88 Hgb 8.9 Hct 27.6 MCV 96 MCH 30.9 MCHC 32.2 RDW 14.4 RDWSD 50.4 Plt ___ ___ 04 30AM BLOOD WBC 6.9 RBC 3.40 Hgb 10.2 Hct 32.6 MCV 96 MCH 30.0 MCHC 31.3 RDW 14.4 RDWSD 50.3 Plt ___ ___ 10 06AM BLOOD Plt ___ ___ 04 30AM BLOOD Glucose 107 UreaN 10 Creat 0.7 Na 142 K 4.8 Cl 105 HCO3 25 AnGap 12 ___ 04 30AM BLOOD Glucose 147 UreaN 12 Creat 0.9 Na 142 K 4.8 Cl 99 HCO3 28 AnGap 15 ___ 08 49AM BLOOD Glucose 128 UreaN 10 Creat 0.9 Na 141 K 4.3 Cl 102 HCO3 28 AnGap 11 ___ 04 30AM BLOOD Calcium 8.2 Phos 2.9 Mg 2.0 ___ 08 49AM BLOOD Calcium 9.5 Phos 4.3 Mg 2.1 ___ 04 30AM BLOOD Calcium 8.8 Phos 4.6 Mg 2.1 Brief Hospital Course Initial Admission ACTIVE ISSUES R Low Back pain and Leg Pain Radiculopathy Patient presents with severe right lower back pain with prominent lancinating component. CT A P with no evidence of visceral pathology or nephrolithiasis. MRI L spine with significant disc bulge at L2 L3 and L3 4 cause severe narrowing of the spinal canal and extrusion at L4 5 with significant L4 nerve root compression likely the cause of patient s pain. She was recently admitted with right leg pain with exam notable for trochanteric bursitis now s p injection of corticosteroid. Currently neruovascularly intact with no evidence of cord compression by history or on exam. Per ortho spine would benefit from decompression. She had a DECOMPRESSION L2 S1 FUSION L4 L5 DURAPLASTY on ___ w ortho spine once her INR was 1.2. She was started on a heparin bridge on ___ when her INR dropped below 2.0 and transitioned to lovenox bridge to coumadin on ___ Dysuria resolved UTI States she has been having burning pain with urination recently. She also feels that she needs to push on her abdomen to urinate. Most concerning for UTI. UA demonstrating large leukocytes and 8 WBC. However urine culture showing mixed bacterial flora consistent with contamination. Will treat given symptoms. Abdominal pain could also be from constipation in the setting of opioid use. Reports resolution of symptoms on ___. Was treated with bactrim DS BID for 3 days starting ___ and ending ___. CHRONIC ISSUES History of DVT PE Antiphospholipid antibody syndrome Lupus anticoagulant positive in ___. Had bilateral PE in ___. She has been taking her home dose of warfarin 7.5 mg ___ and 5 mg other days . Warfarin held on admission for procedure with heparin drip until procedure. AAA Has a reported history of AAA in chart but does not follow up with anyone for surveillance and CT abd pelvis did not show an abdominal aortic aneurysm. Vitamin D deficiency Continued Vitamin D ___ daily OSA Remained on CPAP Other Home Meds Continued omeprazole 20mg BID for GERD Continued sertraline 150mg PO daily for depression Continued Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN cough wheeze Held ProAir Held trazadone while getting opioids Held furosemide 20mg PO daily PRN takes rarely d c gabapentin not helping and not taking d c erythromycin no longer taking Admission to Ortho spine Ms. ___ is a ___ female with a past medical history significant for OSA cerebral aneurysm abdominal aortic aneurysm antiphospholipid syndrome w multiple DVTs and one event of bilateral large PEs on warfarin BRCA1 mutation w L sided breast cancer s p lumpectomy who presents with over one month of right lower back pain with radicular pain down the right leg pain found to have significant disc herniations at L2 L5. She is now s p L2 5 lami L4 5 discectomy and non instrumented fusion c b durotomy s p ___ ___ Post op course Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for the above procedure.Refer to the dictated operative note for further details.The surgery was without complication and the patient was transferred to the PACU in a stable condition. Postoperative DVT ___ drip post op with trasition back to lovenox bridge to coumadin on ___. Activity remained flat bedrest for dural tear precautions for 48 hours. Activity was advanced after 48 hours. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with oral and IV pain medication.Diet was advanced as tolerated.Foley was removed on POD 3. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL s. Post op course was notable for acute blood loss anemia constipation pain and hypokalemia. Acute blood loss anemia is stable and did not require intervention. She was treated with Immediate release morphine Valium and Tylenol for pain control. Oral Potassium was given for hypokalemia of 3.3 on ___. Vitals and labs are otherwise stable. Hospital course was otherwise unremarkable.On the day of discharge the patient was afebrile with stable vital signs comfortable on oral pain control and tolerating a regular diet. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H PRN Pain Mild Fever 2. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN cough wheeze 3. Atorvastatin 40 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. Omeprazole 20 mg PO BID 6. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 7. Senna 8.6 mg PO HS 8. Sertraline 150 mg PO DAILY 9. TraZODone 50 mg PO QHS PRN sleep 10. Vitamin D ___ UNIT PO DAILY 11. Warfarin 7.5 mg PO 2X WEEK ___ 12. Lidocaine 5 Patch 1 PTCH TD QAM right hip 13. Furosemide 20 mg PO DAILY PRN Leg swelling 14. ProAir HFA albuterol sulfate 90 mcg actuation inhalation Q4H PRN 15. Warfarin 5 mg PO 5X WEEK ___ 16. Gabapentin 600 mg PO TID 17. TraMADol 50 mg PO Q6H PRN Pain Moderate Discharge Medications 1. Diazepam 5 mg PO Q8H PRN pain spasm may cause drowsiness RX diazepam 5 mg 1 tablet by mouth every eight 8 hours Disp 25 Tablet Refills 0 2. Enoxaparin Sodium 110 mg SC Q12H Antiphospholipid Syndrome Treatment Bridge Dosing 3. Morphine Sulfate ___ 15 mg PO Q6H PRN Pain Severe please do not operate heavy machinery drink alcohol or drive RX morphine 15 mg 1 tablet s by mouth every six 6 hours Disp 30 Tablet Refills 0 4. Furosemide 10 mg PO DAILY PRN Leg swelling 5. Acetaminophen 1000 mg PO Q8H PRN Pain Mild Fever 6. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN cough wheeze 7. Atorvastatin 40 mg PO QPM 8. Docusate Sodium 100 mg PO BID 9. Lidocaine 5 Patch 1 PTCH TD QAM right hip 10. Omeprazole 20 mg PO BID 11. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 12. ProAir HFA albuterol sulfate 90 mcg actuation inhalation Q4H PRN 13. Senna 8.6 mg PO HS 14. Sertraline 150 mg PO DAILY 15. TraZODone 50 mg PO QHS PRN sleep 16. Vitamin D ___ UNIT PO DAILY 17. Warfarin 5 mg PO 5X WEEK ___ 18. Warfarin 7.5 mg PO 2X WEEK ___ Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Lumbar spinal stenosis. Spondylolisthesis L4 L5. UTI Constipation Secondary Diagnoses History of DVT PE Antiphospholipid antibody syndrome AAA OSA on CPAP Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions It was a pleasure to care for you at the ___ ___. Why did you come to the hospital You came to the hospital because you were having worsening back pain with pain radiating down your right leg. This pain started about a month ago and progressively got worse making it difficult to walk. You also had burning pain with urination. What did you receive in the hospital You had an MRI that showed significant disc herniation in your lower back which was the cause of your pain. The spine surgeons felt that you would benefit from surgery given that your pain was constant and worsening over the past month. We gave you pain medications and stopped your warfarin until it was safe for you to have surgery. You had a spinal decompression on ___. We also gave you antibiotics for your burning pain with urination which we believe was caused by a urinary tract infection. What should you do once you leave the hospital Lumbar Decompression With Fusion You have undergone the following operation Lumbar Decompression With Fusion Immediately after the operation Activity You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit or stand more than 45 minutes without getting up and walking around. Rehabilitation Physical ___ times a day you should go for a walk for ___ minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. Diet Eat a normal healthy diet.You may have some constipation after surgery.You have been given medication to help with this issue. Brace You may have been given a brace.If you have been given a brace this brace is to be worn when you are walking.You may take it off when sitting in a chair or while lying in bed. Wound Care Please keep the incision covered with a dry dressing on until your follow up appointment. Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery do not get the incision wet.Call the office at that time. You should resume taking your normal home medications. You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on ___.We are not allowed to call in or fax narcotic prescriptions oxycontin oxycodone percocet to your pharmacy.In addition we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. At the 2 week visit we will check your incision take baseline X rays and answer any questions.We may at that time start physical therapy We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever 101.5 degrees Fahrenheit and or drainage from your wound. Physical Therapy 1 Weight bearing as tolerated.2 Gait balance training.3 No lifting 10 lbs.4 No significant bending twisting. Treatments Frequency Please keep the incision covered with a dry dressing on until your follow up appointment. Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery do not get the incision wet.Call the office at that time. Followup Instructions ___ The icd codes present in this text will be M5116, D6861, N390, D62, I83811, D509, Z87891, Z86711, Z7901, E559, C50912, E785, G4733, E119, K219, K5790, F329, J449, I671, M48061, K5900, E876. The descriptions of icd codes M5116, D6861, N390, D62, I83811, D509, Z87891, Z86711, Z7901, E559, C50912, E785, G4733, E119, K219, K5790, F329, J449, I671, M48061, K5900, E876 are M5116: Intervertebral disc disorders with radiculopathy, lumbar region; D6861: Antiphospholipid syndrome; N390: Urinary tract infection, site not specified; D62: Acute posthemorrhagic anemia; I83811: Varicose veins of right lower extremity with pain; D509: Iron deficiency anemia, unspecified; Z87891: Personal history of nicotine dependence; Z86711: Personal history of pulmonary embolism; Z7901: Long term (current) use of anticoagulants; E559: Vitamin D deficiency, unspecified; C50912: Malignant neoplasm of unspecified site of left female breast; E785: Hyperlipidemia, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); E119: Type 2 diabetes mellitus without complications; K219: Gastro-esophageal reflux disease without esophagitis; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; F329: Major depressive disorder, single episode, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; I671: Cerebral aneurysm, nonruptured; M48061: Spinal stenosis, lumbar region without neurogenic claudication; K5900: Constipation, unspecified; E876: Hypokalemia. The common codes which frequently come are N390, D62, D509, Z87891, Z7901, E785, G4733, E119, K219, F329, J449, K5900. The uncommon codes mentioned in this dataset are M5116, D6861, I83811, Z86711, E559, C50912, K5790, I671, M48061, E876.
The icd codes present in this text will be C7931, G935, G936, G911, C3490, F05, I10, F17210, G510, M21372, E039, M810, Z781, R001, R739, T380X5A, Y92239, D72829, R3915. The descriptions of icd codes C7931, G935, G936, G911, C3490, F05, I10, F17210, G510, M21372, E039, M810, Z781, R001, R739, T380X5A, Y92239, D72829, R3915 are C7931: Secondary malignant neoplasm of brain; G935: Compression of brain; G936: Cerebral edema; G911: Obstructive hydrocephalus; C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung; F05: Delirium due to known physiological condition; I10: Essential (primary) hypertension; F17210: Nicotine dependence, cigarettes, uncomplicated; G510: Bell's palsy; M21372: Foot drop, left foot; E039: Hypothyroidism, unspecified; M810: Age-related osteoporosis without current pathological fracture; Z781: Physical restraint status; R001: Bradycardia, unspecified; R739: Hyperglycemia, unspecified; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; D72829: Elevated white blood cell count, unspecified; R3915: Urgency of urination. The common codes which frequently come are I10, F17210, E039. The uncommon codes mentioned in this dataset are C7931, G935, G936, G911, C3490, F05, G510, M21372, M810, Z781, R001, R739, T380X5A, Y92239, D72829, R3915. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Headaches Major Surgical or Invasive Procedure ___ Suboccipital craniotomy for resection of cerebellar lesion History of Present Illness ___ is a ___ female with hx cerebral aneurysm clipping in ___ who presents from OSH with left cerebellar hypodensity concerning for underlying lesion. Patient reports that three weeks ago she started having headaches which is abnormal for her. She describes the headaches to be global and resolve with Tylenol but at the worst was an ___. She also reports having difficulty walking which also started about three weeks ago. She describes her walking as staggering side to side. She denies any vision changes nausea vomiting confusion or word finding difficulty. She saw her eye doctor this morning for routine visit who referred her to the ED for evaluation of these symptoms. OSH CT showed an area of hypodensity in the left cerebellum concerning for underlying lesion. She was subsequently transferred to ___. Of note patient reports her aneurysm clip is not MRI compatible. Past Medical History ___ Hypertension S p aneurysm clipping ___ at ___ by Dr. ___ Social History ___ Family History No known history of stroke cancer aneurysm. Physical Exam ON ADMISSION O T 97.9 BP 130 62 HR 64 R 16 O2Sats 98 RA Gen WD WN comfortable NAD. HEENT Pupils L ___ R ___ EOMs full Neck Supple. Extrem Warm and well perfused. Neuro Mental status Awake and alert cooperative with exam normal affect. Orientation Oriented to person place and date. Language Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves I Not tested II Left pupil 5 4mm right 4 3mm both equally reactive to light. III IV VI Extraocular movements intact bilaterally without nystagmus. V VII Facial strength and sensation intact and symmetric. XI Sternocleidomastoid and trapezius normal bilaterally. XII Tongue midline without fasciculations. Motor Normal bulk and tone bilaterally. No abnormal movements tremors. Strength full power ___ throughout. Slight left upward drift Sensation Intact to light touch Coordination normal on finger nose finger and heel to shin ON DISCHARGE Exam Opens eyes x Spontaneous To voice To noxious Orientation x Person x Place x Time Follows commands Simple x Complex None Pupils Right 4 3mm Left 5 4mm chronic EOM Full x Restricted chronic most prominent left lateral Face Symmetric x Yes NoTongue Midline x Yes No Pronator Drift Yes x No Speech Fluent x Yes No Comprehension Intact x Yes No Motor TrapDeltoid BicepTricepGrip Right 5 5 5 5 5 Left 5 5 5 5 5 IPQuadHamATEHLGast Right5 5 5 5 5 5 Left5 5 5 5 5 5 x Sensation intact to light touch Pertinent Results Please see OMR for pertinent lab and imaging results. Brief Hospital Course Brain lesion Patient was found to have cerebellar hypodensity on NCHCT from OSH. CT w wo contrast was obtained while in the ED at ___ which was concerning for underlying mass lesion and hydrocephalus. Of note she was unable to get MRI due to reportedly having a non compatible aneurysm clip that was placed in ___ at ___. Patient was admitted to the ___ for close monitoring and surgical planning. She was started on dexamethasone 4mg Q6hr for mass effect. CT torso was obtained which showed two lung nodules see below for more information. Neuro and radiation oncology were consulted. Plan was made for surgical resection of the lesion. On ___ it was determined that her aneurysm clip was MRI compatible and she was able to have a MRI Brain for surgical planning. She went to the OR the evening of ___ for a suboccipital craniotomy for resection of her cerebellar lesion. Postoperatively she was monitored in Neuro ICU where she remained neurologically and hemodynamically stable. She was transferred to the ___ on POD 2 and made floor status. Her Dexamethasone was ordered to taper down to a maintenance dose of 2mg BID over the course of one week. Her pathology finalized as small cell lung carcinoma. Lung lesions CT torso was obtained which showed two lung nodules one in the left paramedian abutting the aortic arch and the other in the right upper lobe. Pulmonary was consulted and stated that no further intervention was indicated until final pathology was back. Heme Onc was also consulted and made recommendations that no further lung imaging or separate lung biopsy was needed. Both Pulmonary and Heme Onc stated that staging and treatment could be determined based on the tissue pathology from resection of the brain lesion. Her final pathology came back as small cell lung carcinoma. She will follow up with the thoracic oncologist on ___. Steroid induced hyperglycemia Throughout her admission the patient intermittently required sliding scale Insulin for elevated blood sugars while on Dexamethasone. She was evaluated by the ___ inpatient team on ___ who decided that she did not need to go home on Insulin. They recommended discharging her with a glucometer so that she could check her blood sugars daily with a goal blood sugar less than 200. She was advised to record her readings and follow up with her PCP and ___. Bradycardia She was due to transfer out to the ___ on POD1 however was kept in the ICU for asymptomatic bradycardia to the ___. She remained asymptomatic and her heartrate improved with fluids and administration of her levothyroxine. She intermittently dipped to the ___ however remained asymptomatic. Bell s palsy The patient was resumed on her home Valacyclovir and Prenisolone gtts. Urinary urgency On POD 2 the patient complained of urinary urgency and increased frequency. U A was negative and culture was negative. Her symptoms had resolved at the time of discharge. Dispo The patient was evaluated by ___ and OT who cleared her for home with services. She was discharged on ___ in stable condition. She will follow up in ___ on ___. Medications on Admission ASA 81mg Alendronate 70mg weekly Vitamin D3 ___ units daily Levothyroxine 88mcg daily Lisinopril 20mg daily Discharge Medications 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 2. Bisacodyl 10 mg PO PR DAILY 3. Dexamethasone 3 mg PO Q8H Duration 6 Doses start ___ 3tabsq8hrs x2 2tabsq8hrs x6 2tabsq12hrs maintenance dose. This is dose 2 of 3 tapered doses RX dexamethasone 1 mg 3 tablet s by mouth every eight 8 hours Disp 120 Tablet Refills 1 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg PO Q24H RX famotidine 20 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 1 6. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 7. Senna 17.2 mg PO HS 8. Levothyroxine Sodium 88 mcg PO DAILY 9. Lisinopril 20 mg PO DAILY 10. PrednisoLONE Acetate 1 Ophth. Susp. 1 DROP LEFT EYE QID 11. ValACYclovir 1000 mg PO Q8H 12. Vitamin D ___ UNIT PO DAILY 13. HELD Alendronate Sodium 70 mg PO 1X WEEK ___ This medication was held. Do not restart Alendronate Sodium until POD ___ ___ 14. HELD Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until POD 14 ___ ___ glucometer ___ Freestyle glucometer. Check blood sugars ___ hours after a starchy meal. Record numbers and show to your Oncologist. ___ test strips 50. Check blood sugars QD. 3 refills. ___ Lancets 50. Check blood sugars QD. 3 refills. Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Brain tumor Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid. Discharge Instructions Surgery You underwent surgery to remove a brain lesion from your brain. A sample of tissue from the lesion in your brain was sent to pathology for testing. Please keep your incision dry until your sutures are removed. You may shower at this time but keep your incision dry. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness fever or drainage. Activity We recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication Aspirin Ibuprofen Plavix Coumadin until cleared by the neurosurgeon. We held your Aspirin 81mg daily. You are cleared to resume this medication on POD 14 ___ . We held your home Alendronate during this admission. You are cleared to resume this medication on POD 14 ___ . You may use Acetaminophen Tylenol for minor discomfort if you are not otherwise restricted from taking this medication. You were started on Dexamethasone a steroid that treats intracranial swelling. This Dexamethasone is being tapered down to a maintenance dose of 2mg BID. Please take this medication as prescribed. While admitted you had elevated blood glucose levels that needed to be treated by Insulin. You should continue to check your blood sugars daily at home with the prescribed glucometer. You visiting nurse should teach you how to use this device at home. Please record your blood sugars and follow up with your PCP and ___ regarding the results. Your goal blood sugar is less than 200. What You ___ Experience You may experience headaches and incisional pain. You may also experience some post operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. Feeling more tired or restlessness is also common. Constipation is common. Be sure to drink plenty of fluids and eat a high fiber diet. If you are taking narcotics prescription pain medications try an over the counter stool softener. When to Call Your Doctor at ___ for Severe pain swelling redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face arms or leg Call ___ and go to the nearest Emergency Room if you experience any of the following Sudden numbness or weakness in the face arm or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking dizziness or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions ___ The icd codes present in this text will be C7931, G935, G936, G911, C3490, F05, I10, F17210, G510, M21372, E039, M810, Z781, R001, R739, T380X5A, Y92239, D72829, R3915. The descriptions of icd codes C7931, G935, G936, G911, C3490, F05, I10, F17210, G510, M21372, E039, M810, Z781, R001, R739, T380X5A, Y92239, D72829, R3915 are C7931: Secondary malignant neoplasm of brain; G935: Compression of brain; G936: Cerebral edema; G911: Obstructive hydrocephalus; C3490: Malignant neoplasm of unspecified part of unspecified bronchus or lung; F05: Delirium due to known physiological condition; I10: Essential (primary) hypertension; F17210: Nicotine dependence, cigarettes, uncomplicated; G510: Bell's palsy; M21372: Foot drop, left foot; E039: Hypothyroidism, unspecified; M810: Age-related osteoporosis without current pathological fracture; Z781: Physical restraint status; R001: Bradycardia, unspecified; R739: Hyperglycemia, unspecified; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; D72829: Elevated white blood cell count, unspecified; R3915: Urgency of urination. The common codes which frequently come are I10, F17210, E039. The uncommon codes mentioned in this dataset are C7931, G935, G936, G911, C3490, F05, G510, M21372, M810, Z781, R001, R739, T380X5A, Y92239, D72829, R3915.
The icd codes present in this text will be K922, E43, M8008XA, F0390, Z681, R000, I10, F329, E039, Z66, Z931, M3500, Z5309, I340. The descriptions of icd codes K922, E43, M8008XA, F0390, Z681, R000, I10, F329, E039, Z66, Z931, M3500, Z5309, I340 are K922: Gastrointestinal hemorrhage, unspecified; E43: Unspecified severe protein-calorie malnutrition; M8008XA: Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture; F0390: Unspecified dementia without behavioral disturbance; Z681: Body mass index [BMI] 19.9 or less, adult; R000: Tachycardia, unspecified; I10: Essential (primary) hypertension; F329: Major depressive disorder, single episode, unspecified; E039: Hypothyroidism, unspecified; Z66: Do not resuscitate; Z931: Gastrostomy status; M3500: Sicca syndrome, unspecified; Z5309: Procedure and treatment not carried out because of other contraindication; I340: Nonrheumatic mitral (valve) insufficiency. The common codes which frequently come are I10, F329, E039, Z66. The uncommon codes mentioned in this dataset are K922, E43, M8008XA, F0390, Z681, R000, Z931, M3500, Z5309, I340. Allergies meropenem Penicillins Chief Complaint BRBPR Major Surgical or Invasive Procedure aborted flexible sigmoidoscopy attempt due to stool in vault ___ Flexible sigmoidoscopy ___ History of Present Illness This is an ___ year old female with past medical history of sjogrens hypothyroidism recent diagnosis of L1 compression fracture prior cdiff infection presenting with bright red blood per rectum. Patient reports that on morning of presentation she awoke in her normal state of health. Her home health aid helped her to the commode and she suddenly had a large volume over blood per rectum. Over the next ___ minutes she then had 2 subsequent episodes. Home health aid consulted with family and then called ___. In the ED VS were 97.2 98 158 89 14 98 RA ___ 99. Labs were notable for WBC 10.1 Hgb 9.8 Plt 245 K 4.4 Cr 0.6 lactate 1.0 UA neg leuk nitr. Exam reported as tachycardia grossly blood rectum without large hemorrhoids. PEG lavage reported as negative for blood. GI note on the ED dashboard stated ___ with C.diff on flagyl presenting with maroon colored GIB. HDS. HCT 30.7 with normal Coag. Please continue with supportive care with fluids and transfusion as needed. If on going bleeding or hemodynamic changes please get CTA. If concern of upper GI bleeding can lavage via PEG. Please give PPI if positive. Patient was given 1L normal saline and was admitted to medicine. On arrival to the floor patient reported above. Reported recent diagnosis of L1 compression fracture and intermittent difficulty with flushing her PEG tube at home. Full 10 point review of systems positive where noted otherwise negative. Past Medical History Sjogrens Hypothyroidism h o severe Cdiff Protein calorie malnutrition s p PEG Osteoporosis s p L1 compression fracture Depression Hemorrhoids Normocytic anemia Bronchiectasis h o Shingles Dementia ___ ___ Mitral regurgitation Social History ___ Family History Has 2 children. Father had hemorrhoids. No history of cancer GI bleeding. Physical Exam ADMISSION VS 187 106 128 78 on recheck 112 16 96 RA Gen supine in bed comfortable pale Eyes EOMI ENT OP clear MMM Heart regularly tachycardic II VI systolic murmur loudest at axilla Lungs CTA bilaterally Abd soft nontender normoactive bowel sounds PEG in place Rectum dark maroon blood in vault no large hemorrhoids palpated Ext trace edema to mid shin Skin pale no rashes Vasc 2 DP radial pulses Neuro AOx2 3 full name ___ ___ moving all extremities Psych appropriate DISCHARGE VS 98.1 135 64 103 20 95 RA Gen supine in bed comfortable appearing Eyes EOMI ENT OP clear MMM Heart RRR II VI systolic murmur loudest at axilla Lungs CTA bilaterally unchanged from day prior Abd soft nontender normoactive bowel sounds PEG in place unchanged from yesterday Ext no edema Skin no rashes Vasc 2 DP radial pulses Neuro AOx3 full name ___ ___ moving all extremities Psych appropriate Pertinent Results ADMISSION ___ 10 37AM BLOOD WBC 10.1 RBC 3.15 Hgb 9.8 Hct 30.7 MCV 98 MCH 31.1 MCHC 31.9 RDW 13.6 RDWSD 48.4 Plt ___ ___ 10 37AM BLOOD Glucose 96 UreaN 27 Creat 0.6 Na 136 K 4.4 Cl 97 HCO3 30 AnGap 13 ___ 06 00AM BLOOD ALT 12 AST 19 AlkPhos 81 TotBili 0.3 DISCHARGE ___ 06 20AM BLOOD WBC 8.9 RBC 3.35 Hgb 10.5 Hct 32.7 MCV 98 MCH 31.3 MCHC 32.1 RDW 13.4 RDWSD 47.7 Plt ___ ___ 06 20AM BLOOD Glucose 106 UreaN 18 Creat 0.7 Na 137 K 3.8 Cl 100 HCO3 28 AnGap 13 Flexible Sigmoidoscopy ___ Mucosa Normal mucosa was noted in the rectum and sigmoid colon. Other No bleeding sources or blood identified though extent of sigmoid colon evaluated was limited by poor prep. Impression Normal mucosa in the rectum and sigmoid colon No bleeding sources or blood identified though extent of sigmoid colon evaluated was limited by poor prep. Otherwise normal sigmoidoscopy to sigmoid colon at 25 cm Recommendations If bleeding recurs would recommend full colonoscopy with prep. Brief Hospital Course This is an ___ year old female with past medical history of sjogrens hemorrhoids prior cdiff infection admitted ___ with bright red blood per rectum thought to be acute lower GI bleed subsequently stabilizing without intervention status post flexible sigmoidoscopy without identifiable source remaining stable x greater than 4 days able to be discharged to rehab facility. Acute GI Bleed NOS Patient presented with acute episode of BRBPR concerning for lower GI source. Patient subsequently monitored without new or worsening anemia. After discussion with family and patient regarding whether or not to further workup they opted for flexible sigmoidoscopy felt colonoscopy might be too invasive . Patient underwent aborted flexible sigmoidoscopy on ___ due to pressence of copious stool in rectal vault and then underwent successful flexible sigmoidoscopy on ___ without identifiable source for her bleeding. From admission Hgb 9.8 discharge hemoglobin was 10.5. Per GI could consider outpatient colonoscopy if consistent with patient s wishes. Osteoporosis chronic L1 compression fracture deconditioning patient with recent L1 compression fracture as outpatient prior to admission patient noted to be significantly deconditioned this admission requiring assistance with ADLs patient seen by ___ and recommended for rehab. Continued home Calcium 500 vitamin D calcitonin. Placed on Tylenol and tramadol for pain control with good effect Chronic Severe Protein Calorie Malnutrition per discussion with family and review of chart patient has lost weight despite PEG placement and bolus tube feeds has had difficulty maintaining PO intake due to her Sjogrens . At home patient has not be using full recommended 2 cans of Nutren 2.0 500 Cal 250ml BID. Here patient seen by nutrition continued on above 2 cans and was given oral supplementation with her PO meals as well. Depression continued home BuPROPion and mirtazapine Hypothryoidism continued levothyroxine Transitional Issues Code status DNR DNI Discharged to rehab No source for bleeding identified this admission can consider future colonoscopy to look for source of bleeding but would first discuss if consistent with patient s goals of care Would consider encouragement of PO intake and PEG tube supplementation given her malnutrition Medications on Admission The Preadmission Medication list is accurate and complete. 1. BuPROPion XL Once Daily 150 mg PO DAILY 2. Calcium 500 D calcium carbonate vitamin D3 500 mg 1 250mg 400 unit oral DAILY 3. Levothyroxine Sodium 75 mcg PO DAILY 4. Mirtazapine 30 mg PO QHS 5. TraMADol 50 mg PO BID PRN back pain 6. Acetaminophen 500 mg PO Q6H PRN back pain 7. Alendronate Sodium 70 mg PO QSUN 8. Calcitonin Salmon 200 UNIT NAS DAILY 9. Multivitamins 1 TAB PO DAILY 10. TraMADol 100 mg PO QHS PRN back pain 11. Artificial Tears ___ DROP BOTH EYES QID Discharge Medications 1. Acetaminophen 1000 mg PO Q8H PRN pain 2. BuPROPion XL Once Daily 150 mg PO DAILY 3. Calcitonin Salmon 200 UNIT NAS DAILY 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Mirtazapine 30 mg PO QHS 6. Multivitamins 1 TAB PO DAILY 7. TraMADol 50 mg PO BID PRN back pain 8. Alendronate Sodium 70 mg PO QSUN 9. Calcium 500 D calcium carbonate vitamin D3 500 mg 1 250mg 400 unit oral DAILY 10. TraMADol 100 mg PO QHS PRN back pain 11. Artificial Tears ___ DROP BOTH EYES QID Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Acute GI Bleed NOS Depression Osteoporosis chronic L1 compression fracture Hypothryoidism Chronic Severe Protein Calorie Malnutrition Dementia Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Ms. ___ It was a pleasure caring for you at ___. You were admitted with gastrointestinal bleeding. You were seen by GI specialists and underwent a flexible sigmoidiscopy without signs of a source of your bleeding. You were monitored and your blood levels were stable. You are now ready for discharge home. In the future you may wish to consider a colonoscopy to look for the source of your bleeding especially if it occurs again. You should discuss with your family and primary care doctor regarding if this is within your goals of care. Followup Instructions ___ The icd codes present in this text will be K922, E43, M8008XA, F0390, Z681, R000, I10, F329, E039, Z66, Z931, M3500, Z5309, I340. The descriptions of icd codes K922, E43, M8008XA, F0390, Z681, R000, I10, F329, E039, Z66, Z931, M3500, Z5309, I340 are K922: Gastrointestinal hemorrhage, unspecified; E43: Unspecified severe protein-calorie malnutrition; M8008XA: Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture; F0390: Unspecified dementia without behavioral disturbance; Z681: Body mass index [BMI] 19.9 or less, adult; R000: Tachycardia, unspecified; I10: Essential (primary) hypertension; F329: Major depressive disorder, single episode, unspecified; E039: Hypothyroidism, unspecified; Z66: Do not resuscitate; Z931: Gastrostomy status; M3500: Sicca syndrome, unspecified; Z5309: Procedure and treatment not carried out because of other contraindication; I340: Nonrheumatic mitral (valve) insufficiency. The common codes which frequently come are I10, F329, E039, Z66. The uncommon codes mentioned in this dataset are K922, E43, M8008XA, F0390, Z681, R000, Z931, M3500, Z5309, I340.
The icd codes present in this text will be I5033, I281, I272, I480, E871, J449, I2781, I2510, K219, I10, N400, E785, Z902, Z7982, Z9861, Z87891. The descriptions of icd codes I5033, I281, I272, I480, E871, J449, I2781, I2510, K219, I10, N400, E785, Z902, Z7982, Z9861, Z87891 are I5033: Acute on chronic diastolic (congestive) heart failure; I281: Aneurysm of pulmonary artery; I272: Other secondary pulmonary hypertension; I480: Paroxysmal atrial fibrillation; E871: Hypo-osmolality and hyponatremia; J449: Chronic obstructive pulmonary disease, unspecified; I2781: Cor pulmonale (chronic); I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; K219: Gastro-esophageal reflux disease without esophagitis; I10: Essential (primary) hypertension; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; E785: Hyperlipidemia, unspecified; Z902: Acquired absence of lung [part of]; Z7982: Long term (current) use of aspirin; Z9861: Coronary angioplasty status; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I480, E871, J449, I2510, K219, I10, N400, E785, Z87891. The uncommon codes mentioned in this dataset are I5033, I281, I272, I2781, Z902, Z7982, Z9861. Allergies Corgard Vasotec Chief Complaint leg edema Major Surgical or Invasive Procedure None History of Present Illness HISTORY OF PRESENTING ILLNESS Mr. ___ is an ___ year old gentleman with history of CAD s p 3V CABG ___ LM PCI ___ pulmonary HTN AFib on anticoagulation ___ EF 50 who presents with volume overload and new found RV dilation on office echocardiogram. Patient reports he has had 10 days of waking up feeling nervous and jittery. He also endorses weight gain and new onset lower extremity swelling. He has not had chest pain palpitations orthopnea or PND. He has not had any fevers cough recent travel medication non compliance increased salty food intake. He also has not had dyspnea on exertion and rides 4 miles per day on a stationary bike and does 6 minutes of weight lifting. He presented to Dr. ___ today for evaluation. There he had a TTE that showed new RV dilation and was referred to the ___ ED for further evaluation with concern for pulmonary embolism. In the ED initial vitals were T98. HR 70 BP 166 65 RR 16 100 RA. Exam in ED notable for bilateral pitting edema to knees. Labs notable for mild hyponatremia Cr 1.1. ALT AST mildly elevated at 81 64. WBC 4 Hgb 11.3 INR 1.3. DDimer 150. UA unremarkable. CXR with mild cardiomegaly but no evidence of consolidation or pulmonary edema. CTA was negative for PE showed severe emphysema and dilated pulmonary artery. Patient received 20 mg IV Lasix with significant urine output per patient. He was then admitted to the heart failure service for acute heart failure exacerbation and further workup of RV dilation. Vitals on transfer Afebrile HR 66 BP 129 54 RR 19 95 RA. On review of systems he denies any prior history of stroke TIA deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias joint pains cough hemoptysis black stools or red stools. He denies recent fevers chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain paroxysmal nocturnal dyspnea orthopnea palpitations syncope or presyncope. Past Medical History Past Medical History BILATERAL MODERATE CAROTID DISEASE CONGESTIVE HEART FAILURE CORONARY ARTERY DISEASE GASTROESOPHAGEAL REFLUX HYPERTENSION SEVERE EMPHYSEMA PULMONARY HYPERTENSION RIGHT BUNDLE BRANCH BLOCK BENIGN PROSTATIC HYPERTROPHY HYPERLIPIDEMIA PAROXYSMAL ATRIAL FIBRILLATION H O HISTIOPLASMOSIS Past Surgical History CARDIOVERSION ___ RIGHT LOWER LOBE LOBECTOMY ___ CORONARY BYPASS SURGERY ___ Social History ___ Family History Non contributory Physical Exam ADMISSION Vitals 98 159 62 16 98 on RA weight 143 lbs bed scale General very pleasant older gentleman lying in bed speaking in full sentences in NAD HEENT PERRL EOMI no scleral icterus oropharynx clear Neck supple JVP at 6cm no adenopathy CV regular rate and rhythm normal S1 physiologic split S2 ___ systolic murmur at LLSB. No rubs or gallops. Lungs CTAB no crackles wheezes or rhonchi Abdomen soft non distended non tender to deep palpation BS GU no CVA tenderness no foley Extr warm well perfused 2 pulses in radial and DP 2 edema in bilateral lower extremities to knees Neuro aoxo3 CN2 12 grossly intact moving all 4 extremities without deficit stable gait Skin warm well perfused dry no rashes or lesions DISCHARGE Vitals 98.3 100 121 49 59 54 62 18 96RA Tele no tele Last 8 hours I O ___ Last 24 hours I O 1200 3150 Weight on admission 64.3 Today s weight 63.1 General elderly NAD Neck JVP at base of clavicle when 90 degrees Lungs CTAB no crackles CV RRR split S2 Abdomen slightly obese soft NTND NABS Ext no edema Pertinent Results ADMISSION ___ 04 02PM BLOOD WBC 4.0 RBC 4.32 Hgb 11.3 Hct 35.1 MCV 81 MCH 26.2 MCHC 32.2 RDW 16.3 RDWSD 48.3 Plt ___ ___ 04 02PM BLOOD ___ PTT 35.8 ___ ___ 04 02PM BLOOD Glucose 93 UreaN 17 Creat 1.1 Na 131 K 3.8 Cl 93 HCO3 27 AnGap 15 ___ 04 02PM BLOOD ALT 81 AST 64 AlkPhos 89 TotBili 0.7 ___ 04 02PM BLOOD CK MB 3 cTropnT 0.01 proBNP 1284 ___ 04 02PM BLOOD Albumin 4.2 Calcium 9.7 Mg 2.2 ___ 04 34PM BLOOD D Dimer 150 ___ 04 02PM BLOOD TSH 3.0 DISCHARGE ___ 04 04AM BLOOD WBC 6.5 RBC 4.57 Hgb 12.2 Hct 36.8 MCV 81 MCH 26.7 MCHC 33.2 RDW 16.4 RDWSD 47.8 Plt ___ ___ 04 04AM BLOOD ___ PTT 34.1 ___ ___ 04 04AM BLOOD Glucose 113 UreaN 32 Creat 1.4 Na 133 K 3.9 Cl 94 HCO3 26 AnGap 17 ___ 04 04AM BLOOD ALT 79 AST 57 AlkPhos 83 TotBili 0.6 ___ 04 04AM BLOOD Calcium 10.0 Phos 4.4 Mg 2.0 ECHO ___ The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the mid anterior and mid distal inferior wall. The estimated cardiac index is normal 2.5L min m2 . Doppler parameters are indeterminate for left ventricular diastolic function. The right ventricular cavity is mildly dilated with depressed free wall contractility RV free wall is not well seen . The aortic valve leaflets 3 are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate 2 tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is no pericardial effusion. IMPRESSION Mild regional left ventricular dysfunction c w multivessel CAD with overall mildly depressed global systolic function. Mildly dilated right ventricle with depressed free wall systolic function. Moderate tricuspid regurgitation with moderate pulmonary hypertension. Brief Hospital Course Mr. ___ is an ___ year old gentleman with history of CAD s p CABG and PCI pAF PAH diastolic CHF who presents with weight gain leg swelling and new evidence of right ventricle dilation concerning for acute on chronic heart failure exacerbation. Acute on Chronic Diastolic Heart Failure Exacerbation with component of RV failure by report of OSH echo. Likely primary process is lung disease causing elevated RV pressures and subsequent poor filling of LV. He diuresed quite well with 20 IV Lasix which is consistent with RV failure. Started on torsemide 10 daily but this is likely too aggressive. We obtained an echo but read PND at time of discharge. We sent him home on a diuretic regimen on torsemide 5 mg daily and discontinued home triamterene HCTZ . Close follow up with Dr. ___ ensured. Elevated Transaminases Patient with mildly elevated AST and ALT. Most likely etiologies in this patient include amiodarone toxicity and congestive hepatopathy. Encouraged outpatient trending. Pulmonary disease patient with extensive emphysema on CTA though patient has no history of smoking. As this may be driving R heart failure Dr. ___ requested pulmonology consult prior to discharge but patient was insistent on leaving. Instead scheduled outpatient appointment. Atrial Fibrillation Continue home amiodarone 200mg daily Apixaban 5mg BID CAD Continue ASA 81mg rosuvastatin 40mg qHS HTN continue home losartan 25mg qD. TRANSITIONAL ISSUES New medication Torsemide 5 mg daily Discontinued triamterene HCTZ in favor of above LFTs mild elevated in house consider possible discontinuing changing amiodarone Please check LFT s and Creatinine at follow up appointment as these were elevated while hospitalized Follow up appointment with cardiology Dr. ___ Follow up appointment with pulmonology Follow up appointment with PCP Discharge weight 63.1 kg Medications on Admission The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Losartan Potassium 25 mg PO DAILY 6. Omeprazole 10 mg PO DAILY 7. Triamterene HCTZ 37.5 25 1 CAP PO DAILY 8. Senna 17.2 mg PO HS 9. Align bifidobacterium infantis 4 mg oral DAILY 10. coenzyme Q10 100 mg oral DAILY 11. Rosuvastatin Calcium 40 mg PO QPM 12. Vitamin D 1000 UNIT PO DAILY 13. Tamsulosin 0.4 mg PO QHS Discharge Medications 1. Amiodarone 200 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Losartan Potassium 25 mg PO DAILY 6. Rosuvastatin Calcium 40 mg PO QPM 7. Senna 17.2 mg PO HS RX sennosides senna 8.6 mg 1 capsule by mouth once a day Disp 30 Capsule Refills 0 8. Vitamin D 1000 UNIT PO DAILY 9. Torsemide 5 mg PO DAILY RX torsemide 5 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 10. Align bifidobacterium infantis 4 mg oral DAILY 11. coenzyme Q10 100 mg oral DAILY 12. Omeprazole 10 mg PO DAILY 13. Tamsulosin 0.4 mg PO QHS Discharge Disposition Home Discharge Diagnosis Primary Acute on chronic diastolic congestive heart failure Cor pulmonale Secondary Pulmonary hypertension Paroxysmal atrial fibrillation Hyponatremia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You were hospitalized for progressive leg swelling over the past week and a half. We started you on a new medication here that should help prevent this from happening. Of note Dr. ___ was concerned about a clot in your lungs but our scans showed NO clot. With this news you were discharged home with PCP and cardiology follow up. Please continue to take your torsemide in order to maintain your weight. Please weight yourself everyday and call your cardiologist if you weight changes by three pounds. You also have pulmonary hypertension which may be due to your underlying lung disease. Amiodarone can also cause lung changes and we recommend following up with the lung doctors as ___ outpatient to see if this may be contributing. It was a pleasure taking care of you Your ___ team Followup Instructions ___ The icd codes present in this text will be I5033, I281, I272, I480, E871, J449, I2781, I2510, K219, I10, N400, E785, Z902, Z7982, Z9861, Z87891. The descriptions of icd codes I5033, I281, I272, I480, E871, J449, I2781, I2510, K219, I10, N400, E785, Z902, Z7982, Z9861, Z87891 are I5033: Acute on chronic diastolic (congestive) heart failure; I281: Aneurysm of pulmonary artery; I272: Other secondary pulmonary hypertension; I480: Paroxysmal atrial fibrillation; E871: Hypo-osmolality and hyponatremia; J449: Chronic obstructive pulmonary disease, unspecified; I2781: Cor pulmonale (chronic); I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; K219: Gastro-esophageal reflux disease without esophagitis; I10: Essential (primary) hypertension; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; E785: Hyperlipidemia, unspecified; Z902: Acquired absence of lung [part of]; Z7982: Long term (current) use of aspirin; Z9861: Coronary angioplasty status; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I480, E871, J449, I2510, K219, I10, N400, E785, Z87891. The uncommon codes mentioned in this dataset are I5033, I281, I272, I2781, Z902, Z7982, Z9861.
The icd codes present in this text will be I130, I5023, N179, C799, N183, Z87891, J439, Z951, Z955, I071, I2720, I480, Z7902, Z8673, C439, I6523, K219, I4510, N400, E7849, Z902, R740, I255. The descriptions of icd codes I130, I5023, N179, C799, N183, Z87891, J439, Z951, Z955, I071, I2720, I480, Z7902, Z8673, C439, I6523, K219, I4510, N400, E7849, Z902, R740, I255 are I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; I5023: Acute on chronic systolic (congestive) heart failure; N179: Acute kidney failure, unspecified; C799: Secondary malignant neoplasm of unspecified site; N183: Chronic kidney disease, stage 3 (moderate); Z87891: Personal history of nicotine dependence; J439: Emphysema, unspecified; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; I071: Rheumatic tricuspid insufficiency; I2720: Pulmonary hypertension, unspecified; I480: Paroxysmal atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; C439: Malignant melanoma of skin, unspecified; I6523: Occlusion and stenosis of bilateral carotid arteries; K219: Gastro-esophageal reflux disease without esophagitis; I4510: Unspecified right bundle-branch block; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; E7849: Other hyperlipidemia; Z902: Acquired absence of lung [part of]; R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]; I255: Ischemic cardiomyopathy. The common codes which frequently come are I130, N179, Z87891, Z951, Z955, I480, Z7902, Z8673, K219, N400. The uncommon codes mentioned in this dataset are I5023, C799, N183, J439, I071, I2720, C439, I6523, I4510, E7849, Z902, R740, I255. Allergies Corgard Vasotec Chief Complaint Dyspnea on Exertion Major Surgical or Invasive Procedure None History of Present Illness ___ FAILURE ADMISSION NOTE OUTPATIENT CARDIOLOGIST ___. MD ___ cardiology ___ ___. MD CHF PCP ___. MD CHIEF COMPLAINT Dyspnea on Exertion HISTORY OF PRESENTING ILLNESS Mr. ___ is a ___ gentleman with a past medical history pertinent for HFrEF 35 ___ CAD s p CABG and subsequent PCI moderate tricuspid regurgitation right ventricular dysfunction moderate pulmonary hypertension and paroxysmal atrial fibrillation on apixaban stage III chronic kidney disease Baseline Cr 2.0 2.1 cerebrovascular disease and metastatic melanoma of unknown primary on checkpoint inhibitor pembrolizumab who was found volume overloaded with increased DOE admitted to ___ for IV diuresis. Per most recent outpatient CHF notes He was seen by his primary car primary Cardiologist Dr. ___ increased fatigue and exertional dyspnea. Dr. ___ a ___ and felt his LVEF was 30 and reduced from prior. He was started on low dose Entresto but couldn t tolerate it from a BP prospective. He was previously on losartan which was stopped due to this lightheadedness dizziness and worsening renal function. Dr. ___ concern about the possibility of myocarditis secondary to the checkpoint inhibitor. When he followed up with the Oncology team on ___ his symptoms were somewhat improved. Cardiac biomarkers were notable for a rising NTproBNP to 10K but normal CK MB and minimally elevated troponin T of 0.03 which is not unexpected in the setting of decompensated ___ failure and chronic kidney disease. He was planned to receive immunotherapy on ___ but treatment was held due to elevated Cr. Recheck showed improvement. The patient restarted pembrolizumab on ___. Pembrolizumab was again held in ___ for diarrhea and elevated LFTs In addition he also received intravenous hydration. Subsequently he was noted to be more volume overloaded at which time Torsemide from 20 mg daily to 30 mg daily then 40 mg daily. Troponin testing showed Trop T of 0.04 attributed to renal insufficiency. The patient was also noted to have mild hyperkalemia K 5.7 for which potassium supplementation was stopped and torsemide dose increased. He was also seen in the Emergency room in the ___ ___ due to a fall with resultant scalp laceration. CT head and neck was unremarkable. He presented this morning ___ for his scheduled visit at ___ clinic where he noted that his weight had been 126 lbs most recently on his home scale. He also reported decreased appetite that he attributes to eating a different diet. He currently has a ___ care taker that makes ___ food for him adhering to a low sodium diet that he does not like as much as his regular diet. He drinks ___ glasses of water or juice daily. He was taking torsemide 40 mg daily that he decreased to 30 mg daily several days ago as he felt he was urinating too frequently. He also ran out of tamsulosin several days ago so stopped taking this around the same time. He noted becoming short of breath after taking 20 steps or less. Due to his volume overloaded noted on exam he was recommended for admission to ___ for IV diuresis On the floor he endorses the above history. He noted that his SOB has progressive gotten worse. Mostly occurs with activity. None at rest. He noted that his weight has been slowly decreasing due lack of appetite and him being to lazy. He has a home health aid everyday from 11am 7pm who helps him with ADL. He endorses abdominal bloading. Cardiac review of systems is notable for absence of chest pain paroxysmal nocturnal dyspnea orthopnea palpitations syncope or presyncope. ROS otherwise negative unless otherwise noted above Past Medical History Past Medical History BILATERAL MODERATE CAROTID DISEASE CONGESTIVE ___ FAILURE CORONARY ARTERY DISEASE GASTROESOPHAGEAL REFLUX HYPERTENSION SEVERE EMPHYSEMA PULMONARY HYPERTENSION RIGHT BUNDLE BRANCH BLOCK BENIGN PROSTATIC HYPERTROPHY HYPERLIPIDEMIA PAROXYSMAL ATRIAL FIBRILLATION H O HISTIOPLASMOSIS Past Surgical History CARDIOVERSION ___ RIGHT LOWER LOBE LOBECTOMY ___ CORONARY BYPASS SURGERY ___ Social History ___ Family History Non contributory Physical Exam ADMISSION PHYSICAL EXAMINATION 24 HR Data last updated ___ 1335 Temp 97.4 Tm 97.4 BP 115 66 HR 61 RR 18 O2 sat 99 O2 delivery ra Wt 130.73 lb 59.3 kg GENERAL Well developed well nourished male in NAD. Oriented x3. Mood affect appropriate. HEENT Scalp laceration noted. Sclera slightly icteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK Supple. JVP 20 cm with positive hepatojugular reflex. CARDIAC Regular rate and rhythm. Normal S1 S2. ___ holosystolic murmur at the LLSB and the apex no rubs or gallops. No thrills or lifts. LUNGS No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. Bibasilar crackles ABDOMEN mildly distended normoactive bowel sounds soft and non tender to palpation there is no appreciable organomegaly or mass EXTREMITIES Cool 1 pitting edema to knee caps. bilateral status dermatitis. SKIN Eccymosis noted on left hand Multiple open biopsy excision sites on left shin and right calf PULSES Distal pulses palpable and symmetric. Discharge Physical exam 24 HR Data last updated ___ 751 Temp 98.2 Tm 98.6 BP 110 61 100 121 54 63 HR 72 60 99 RR 16 ___ O2 sat 91 91 95 O2 delivery Ra General elderly gentleman in NAD HEENT dressing in place on scalp from recent fall scalp laceration c d i. Sclera mildly icteric pupils equally round MMM NECK JVP 10cm with positive hepatojugular reflex CV irregularly irregular the precordium is quiet without RV heave normal S1 with fixed split S2 there is a soft ___ holosystolic murmur at the LLSB and the apex LUNGS Normal effort. Fine Bibasilar crackles Abd soft mildy distended no guarding rebound. EXT 1 pitting edema to the mid calf L leg R leg SKIN Multiple excision biopsy wounds on legs covered with dressing c d i NEURO Speech fluent strength grossly intact Pertinent Results ___ 01 00PM ___ PTT 34.4 ___ ___ 01 00PM PLT COUNT 169 ___ 01 00PM NEUTS 81.6 LYMPHS 6.6 MONOS 10.4 EOS 0.1 BASOS 0.1 IM ___ AbsNeut 6.00 AbsLymp 0.49 AbsMono 0.77 AbsEos 0.01 AbsBaso 0.01 ___ 01 00PM WBC 7.4 RBC 3.02 HGB 9.1 HCT 30.2 MCV 100 MCH 30.1 MCHC 30.1 RDW 16.4 RDWSD 59.2 ___ 01 00PM calTIBC 352 FERRITIN 111 TRF 271 ___ 01 00PM CALCIUM 9.2 PHOSPHATE 3.7 MAGNESIUM 2.8 IRON 88 ___ 01 00PM CK MB 4 cTropnT 0.01 ___ ___ 01 00PM ALT SGPT 56 AST SGOT 52 LD LDH 277 ALK PHOS 135 TOT BILI 0.7 ___ 01 00PM estGFR Using this ___ 01 00PM GLUCOSE 100 UREA N 52 CREAT 2.1 SODIUM 135 POTASSIUM 5.4 CHLORIDE 100 TOTAL CO2 24 ANION GAP 11 ___ 04 54PM URINE HYALINE 1 ___ 04 54PM URINE RBC 0 WBC 1 BACTERIA NONE YEAST NONE EPI 1 ___ 04 54PM URINE BLOOD NEG NITRITE NEG PROTEIN TR GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 7.0 LEUK NEG ___ 04 54PM URINE COLOR Straw APPEAR Clear SP ___ ___ 07 53AM BLOOD WBC 6.5 RBC 2.70 Hgb 8.2 Hct 26.5 MCV 98 MCH 30.4 MCHC 30.9 RDW 16.0 RDWSD 56.3 Plt ___ ___ 07 53AM BLOOD Plt ___ ___ 07 53AM BLOOD Glucose 105 UreaN 43 Creat 2.2 Na 140 K 4.2 Cl 102 HCO3 27 AnGap 11 ___ 04AM BLOOD ALT 45 AST 42 AlkPhos 113 TotBili 0.6 ___ 07 53AM BLOOD Calcium 8.6 Phos 3.5 Mg 2.4 ___ 01 00PM BLOOD calTIBC 352 Ferritn 111 TRF 271 Brief Hospital Course TRANSITIONAL ISSUES DISCHARGE WEIGHT 55.6 kg 122.57 lb DISCHARGE Cr BUN Cr 2.2 BUN 43 DISCHARGE DIURETIC 40 Torsemide daily MEDICATION CHANGES Decreased daily potassium to 40 mEq daily from 30 mEq twice dailye Please obtain repeat Chem10 within 2 weeks and after 4 weeks. Adjust electrolyte repletion accordingly. Please follow up weight and volume status and adjust torsemide accordingly. CODE STATUS Presumed full Health care proxy chosen Yes Name of health care proxy ___ ___ son Phone number ___ PATIENT SUMMARY Mr. ___ is a ___ gentleman with PMHx of CAD s p CABG and subsequent PCI HFrEF 35 ___ moderate tricuspid regurgitation right ventricular dysfunction moderate pulmonary hypertension and paroxysmal atrial fibrillation on apixaban stage III chronic kidney disease Baseline Cr 2.0 2.1 cerebrovascular disease and metastatic melanoma of unknown primary on checkpoint inhibitor pembrolizumab who was found volume overloaded with increased DOE admitted to acute ___ failure for IV diuresis now transitioned to oral duiretics. CORONARIES Left Main and two vessel coronary disease ___ . PUMP 35 ___ RHYTHM Ectopic rhythm PR prolongation left axis deviation RBBB ACTIVE ISSUES ___ Failure with reduced ejection fraction Right ventricular dysfunction TR pulm HTN Volume overload His ___ failure exacerbation is likely secondary to his recent administration of IV fluids in addition to his self down titration of his torsemide over the last week. In addition he does not follow a restricted fluid intake and drinks ___ glasses of water or juice daily. Furthermore he has not tolerated guideline directed medical therapy due to recurrent issues with acute kidney injury and elevated transaminitis while on pembrolizumab therapy. He was clinically volume overloaded with elevated BNP 16020. We initiated IV lasix 160 bolus and put him on a lasix gtt with good response however he his Cr increased from 2.1 2.7. His Cr. improved with transition to PO Torsemide 40 mg daily. We monitored and aggressively repleted his potassium. No afterload reduction or neural hormonal blockade was added. Chronic Kidney Disease Baseline 2.1 2.3 . Cr 2.1 on admission Stable Cr on discharge 2.2 Cr initially uptrended above baseline from 2.1 2.7. Felt likely due to increased diuretic usage as it improved with stopping diuretics. Less likely cardiorenal syndrome. In addition patient was recently seen in follow up by nephrology. They felt his CKD was less likely to be related to pembrolizumab and more likely related to age related decline in renal function. Creatinine 2.2 on discharge stable . Metastatic Melanoma He is followed by Dr. ___. He was previously on Pembrolizumab which was held due diarrhea elevated LFTs and worsening kidney function. Negative troponin and CK MB no concern for drug induced myocarditis at this point. Followup in ___ clinic in 2weeks after discharge Elevated transaminiatis Stable. Statin and ___ had previously been held. No changes made during admission. Urinary frequency Likely due to diuretic use. Afebrile and asx otherwise Continued home tamsulosin Coronary artery disease s p CABG and LAD PCI. Continued aspirin 81 mg daily Statin stopped prior to admission due to elevated LFTs. Continued holding. CHRONIC ISSUES Paroxysmal Atrial fibrillation Rythym Continue amiodarone 200mg for rhythm control strategy monitoring safety labs Continued anticoagulation with apixaban 2.5mg twice daily Hypertension Stable. Medications on Admission The Preadmission Medication list may be inaccurate and requires further investigation. 1. Amiodarone 200 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Senna 17.2 mg PO HS 5. Vitamin D 1000 UNIT PO DAILY 6. Align bifidobacterium infantis 4 mg oral DAILY 7. coenzyme Q10 100 mg oral DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Torsemide 40 mg PO DAILY 10. Ferrous Sulfate 325 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Potassium Chloride 30 mEq PO BID 13. Apixaban 2.5 mg PO BID 14. Cephalexin 500 mg PO Q6H Discharge Medications 1. Potassium Chloride 40 mEq PO DAILY RX potassium chloride 20 mEq 2 packet s by mouth once a day Disp 60 Tablet Refills 0 2. Align bifidobacterium infantis 4 mg oral DAILY 3. Amiodarone 200 mg PO DAILY 4. Apixaban 2.5 mg PO BID 5. Aspirin 81 mg PO DAILY 6. coenzyme Q10 100 mg oral DAILY 7. Docusate Sodium 100 mg PO BID 8. Ferrous Sulfate 325 mg PO DAILY 9. Senna 17.2 mg PO HS 10. Sertraline 50 mg PO DAILY 11. Tamsulosin 0.4 mg PO QHS RX tamsulosin 0.4 mg 1 capsule s by mouth nightly Disp 30 Capsule Refills 0 12. Torsemide 40 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary Diagnosis HFrEF excerterbation Secondary diagnosis Transaminitis Metastatic melanoma CKD Coronary artery disease s p CABG and LAD PCI Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions DISCHARGE INSTRUCTIONS Dear Mr. ___ It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL You were feeling short of breath because you had fluid in your lungs. This was caused by a condition called ___ failure where your ___ does not pump hard enough and fluid backs up into your lungs. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL You were given medications to help get the fluid out. Your breathing got better and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL Take all of your medications as prescribed listed below Follow up with your doctors as listed below Weigh yourself every morning. Your weight on discharge is 122.57 lbs. Call your doctor if your weight goes up more than 3 pounds. Call you doctor if you notice any of the danger signs below. We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I130, I5023, N179, C799, N183, Z87891, J439, Z951, Z955, I071, I2720, I480, Z7902, Z8673, C439, I6523, K219, I4510, N400, E7849, Z902, R740, I255. The descriptions of icd codes I130, I5023, N179, C799, N183, Z87891, J439, Z951, Z955, I071, I2720, I480, Z7902, Z8673, C439, I6523, K219, I4510, N400, E7849, Z902, R740, I255 are I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; I5023: Acute on chronic systolic (congestive) heart failure; N179: Acute kidney failure, unspecified; C799: Secondary malignant neoplasm of unspecified site; N183: Chronic kidney disease, stage 3 (moderate); Z87891: Personal history of nicotine dependence; J439: Emphysema, unspecified; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; I071: Rheumatic tricuspid insufficiency; I2720: Pulmonary hypertension, unspecified; I480: Paroxysmal atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; C439: Malignant melanoma of skin, unspecified; I6523: Occlusion and stenosis of bilateral carotid arteries; K219: Gastro-esophageal reflux disease without esophagitis; I4510: Unspecified right bundle-branch block; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; E7849: Other hyperlipidemia; Z902: Acquired absence of lung [part of]; R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]; I255: Ischemic cardiomyopathy. The common codes which frequently come are I130, N179, Z87891, Z951, Z955, I480, Z7902, Z8673, K219, N400. The uncommon codes mentioned in this dataset are I5023, C799, N183, J439, I071, I2720, C439, I6523, I4510, E7849, Z902, R740, I255.
The icd codes present in this text will be I5023, J189, J9691, C7951, J90, N179, I255, I480, Z7902, I2720, I079, I2510, Z951, N183, D638, D696, C439, Z87891. The descriptions of icd codes I5023, J189, J9691, C7951, J90, N179, I255, I480, Z7902, I2720, I079, I2510, Z951, N183, D638, D696, C439, Z87891 are I5023: Acute on chronic systolic (congestive) heart failure; J189: Pneumonia, unspecified organism; J9691: Respiratory failure, unspecified with hypoxia; C7951: Secondary malignant neoplasm of bone; J90: Pleural effusion, not elsewhere classified; N179: Acute kidney failure, unspecified; I255: Ischemic cardiomyopathy; I480: Paroxysmal atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; I2720: Pulmonary hypertension, unspecified; I079: Rheumatic tricuspid valve disease, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; N183: Chronic kidney disease, stage 3 (moderate); D638: Anemia in other chronic diseases classified elsewhere; D696: Thrombocytopenia, unspecified; C439: Malignant melanoma of skin, unspecified; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, I480, Z7902, I2510, Z951, D696, Z87891. The uncommon codes mentioned in this dataset are I5023, J189, J9691, C7951, J90, I255, I2720, I079, N183, D638, C439. Allergies Corgard ___ Major Surgical or Invasive Procedure None attach Pertinent Results ADMISSION LABS ___ 12 48AM BLOOD WBC 10.3 RBC 3.71 Hgb 10.6 Hct 36.6 MCV 99 MCH 28.6 MCHC 29.0 RDW 18.6 RDWSD 55.8 Plt ___ ___ 12 48AM BLOOD ___ PTT 82.4 ___ ___ 12 48AM BLOOD Glucose 128 UreaN 47 Creat 2.2 Na 144 K 3.8 Cl 105 HCO3 22 AnGap 17 ___ 12 48AM BLOOD ALT 75 AST 55 AlkPhos 150 TotBili 1.1 ___ 12 48AM BLOOD ___ ___ 12 48AM BLOOD Calcium 9.2 Phos 4.0 Mg 2.3 ___ 01 19AM BLOOD ___ pO2 59 pCO2 42 pH 7.34 calTCO2 24 Base XS 2 RELEVANT LABS ___ 12 48AM BLOOD ___ IMAGING CXR ___ No comparison. The lung volumes are low. Moderate cardiomegaly is present. Normal alignment of the sternal wires after CABG. Mild bilateral pleural effusions. Signs of moderate pulmonary edema. Retrocardiac atelectasis no evidence of pneumonia. CXR ___ There are stable postsurgical changes following wedge resection the right lower lobe. Small bilateral effusions right greater than left are unchanged. Cardiomediastinal silhouette is stable. There is moderate cardiomegaly. No pneumothorax. Mild pulmonary edema is unchanged. DISCARHGE LABS ___ 08 00AM BLOOD WBC 5.4 RBC 3.54 Hgb 10.3 Hct 34.1 MCV 96 MCH 29.1 MCHC 30.2 RDW 19.0 RDWSD 65.7 Plt ___ ___ 08 00AM BLOOD Glucose 94 UreaN 44 Creat 2.0 Na 140 K 3.6 Cl 99 HCO3 27 AnGap 14 ___ 08 00AM BLOOD ALT 38 AST 46 LD LDH 198 AlkPhos 108 TotBili 0.5 ___ 08 00AM BLOOD Calcium 9.0 Phos 3.5 Mg 2.3 Brief Hospital Course TRANSITIONAL ISSUES Consider discontinuing amiodarone given persistence of AF despite this medication Consider starting beta blocker if BP is able to tolerate. Patient previously did not tolerate this medication while on pembrolizumab dizziness and ___ but patient has been off of pembrolizumab since ___ Consider starting spironolactone and ___ pending blood pressures trialed losartan and spironolactone during this admission but ultimately held due to hypotension. His LFTs should be rechecked 2 weeks after discharge ___ . He has a history of transaminitis attributed in part to statin use in the past he was restarted on rosuvastatin this admission given history of CAD s p CABG and LFTs on day of admission were ALT 38 AST 46 Alk phos 108 Tbili 0.5. Follow up with Oncology regarding melanoma. Monitor for resolution of supplemental O2 requirement after discharge. He was requiring ___ of O2 by NC at time of discharge in the setting of recovering from pneumonia. DISCHARGE WT 116.18 lbs DISCHARTE Cr 2.0 DISCHARGE DIURETIC torsemide 60 mg PO BID SUMMARY Mr. ___ is a ___ man with PMH of HFrEF 35 ___ CAD s p 3v CABG ___ and subsequent PCI to the LAD ___ moderate tricuspid regurgitation right ventricular dysfunction moderate pulmonary hypertension and paroxysmal atrial fibrillation on apixaban stage III chronic kidney disease Baseline Cr 2.0 2.1 cerebrovascular disease and metastatic melanoma of unknown primary on Pembrolizumab on hold since ___ iso worsening transaminitis and concern for cardiotoxicity . He was admitted with volume overload from heart failure exacerbation and pneumonia with high oxygen requirements. He initially required CCU admission for high flow oxygen weaned to nasal cannula after aggressive IV diuresis and treatment of pneumonia with 5 day course of Zosyn after receiving vancomycin at OSH. He was transferred to cardiology floor where he continued to diurese well and his oxygen requirement was weaned to ___. He was transitioned to 60 mg torsemide PO BID which adequately maintained euvolemia. ACUTE ISSUES Acute on chronic systolic heart failure exacerbation Patient with history of heart failure with etiology likely ischemic cardiomyopathy given history of CAD s p CABG and PCI. Admitted with fluid overload and pleural effusion. Trigger for current exacerbation could be infectious given evidence of pneumonia in left lower lobe on admission. Patient with high oxygen requirements prior to admission but responded appropriately to diuresis with Lasix. After IV diuresis patient was transitioned PO torsemide and maintained at euvolemia. With effective diuresis the patient s oxygen requirement gradually lowered from 4L NC to ___ NC. He was discharged on torsemide 60 mg PO BID. He was unable to tolerate afterload reducing agents or neurohormonal blockade agents due to hypotension. Lower left lobe pneumonia Patient with evidence of pneumonia in the left lower lobe received vanc zosyn at outside hospital and continued on Zosyn here for a total of 5 day course with resolution of symptoms. We suspect that his lingering O2 requirement is at least in part due to slowly resorbing consolidation left over from his infection. He was requiring ___ of supplemental O2 by NC at time of discharge. Pleural effusion bilateral Patient with evidence of right pleural effusion. Etiology likely fluid overload given heart failure with reduced ejection fraction. Pleural effusion resolved improved with diuresis and his oxygen requirement trended down to ___ NC. Given this thoracentesis was deferred. Atrial fibrillation Patient with chronic history of atrial fibrillation. In afib throughout this admission. Continued amiodarone and apixaban. Rates appropriately controlled. CHRONIC ISSUES Coronary artery disease s p CABG Patient with history of 3 vessel CABG on ___ ___ and subsequent PCI to LAD ___ . Continued home aspirin. Patient was started on low dose rosuvastatin 5 mg daily. On review it appears he had been on this medication at this dose in the past but it was discontinued due to transamnitis however at the time it was unclear whether this was an effect of the statin or pembrolizumab. Given that the patient has not had his checkpoint inhibitor therapy since ___ the decision was to restart rosuvastatin. Chronic kidney disease Baseline Cr appears to be 2.1 2.2 over past year. Cr remained between 1.8 2.4 throughout admission. Anemia Chronic although worsening since ___. On admission hemoglobin 10.6 and remained stable. Thrombocytopenia Uncertain etiology appears subacute chronic. On admission platelets 130 down trended to 100s. No concern for bleeding throughout admission. Melanoma Patient with history of metastatic melanoma with unknown primary. On treatment with pembrolizumab but held since ___ iso toxicity. CODE DNR DNI CONTACT ___ ___ Relationship Son Phone number ___ ___ on Admission The Preadmission Medication list is accurate and complete. 1. Amiodarone 200 mg PO DAILY 2. Apixaban 2.5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Senna 17.2 mg PO HS 7. Sertraline 50 mg PO DAILY 8. Tamsulosin 0.4 mg PO QHS 9. Torsemide 40 mg PO DAILY 10. coenzyme Q10 100 mg oral DAILY 11. Align bifidobacterium infantis 4 mg oral DAILY 12. Potassium Chloride 40 mEq PO DAILY Discharge Medications 1. Rosuvastatin Calcium 5 mg PO QPM 2. Vitamin D 1000 UNIT PO DAILY 3. Torsemide 60 mg PO BID 4. Align bifidobacterium infantis 4 mg oral DAILY 5. Amiodarone 200 mg PO DAILY 6. Apixaban 2.5 mg PO BID 7. Aspirin 81 mg PO DAILY 8. coenzyme Q10 100 mg oral DAILY 9. Docusate Sodium 100 mg PO BID 10. Ferrous Sulfate 325 mg PO DAILY 11. Potassium Chloride 40 mEq PO DAILY 12. Senna 17.2 mg PO HS 13. Sertraline 50 mg PO DAILY 14. Tamsulosin 0.4 mg PO QHS ___ and mineralocorticoid receptor antagonist held in the setting of hypotension and CKD. Patient is intolerant of beta blockers due to dizziness hypotension previously. Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Primary diagnosis Acute on chronic systolic heart failure exacerbation Lower left lobe pneumonia Bilateral pleural effusion Atrial fibrillation Secondary diagnosis Coronary artery disease status post CABG Chronic kidney disease Anemia Thrombocytopenia Metastatic melanoma Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Mr. ___ It was a pleasure taking care of you at the ___ ___. WHY WAS I IN THE HOSPITAL You were admitted because of you were short of breath WHAT HAPPENED IN THE HOSPITAL You were found to have fluid on your lungs. This was because you have a medical condition called heart failure where your heart does not pump hard enough and fluid backs up into your lungs. You were given a diuretic medication to help get the fluid out. You improved considerably and are ready to leave the hospital. WHAT SHOULD I DO WHEN I GO HOME Be sure to take all your medications and attend all of your appointments listed below. Your weight at discharge is 116.18 lbs. Please weigh yourself today at home and use this as your new baseline Please weigh yourself every day in the morning. Call your doctor or the HeartLine at ___ if your weight goes up by more than 3 lbs or you experience significant chest pain and shortness of breath. Thank you for allowing us to be involved in your care we wish you all the best Sincerely Your ___ Team Followup Instructions ___ The icd codes present in this text will be I5023, J189, J9691, C7951, J90, N179, I255, I480, Z7902, I2720, I079, I2510, Z951, N183, D638, D696, C439, Z87891. The descriptions of icd codes I5023, J189, J9691, C7951, J90, N179, I255, I480, Z7902, I2720, I079, I2510, Z951, N183, D638, D696, C439, Z87891 are I5023: Acute on chronic systolic (congestive) heart failure; J189: Pneumonia, unspecified organism; J9691: Respiratory failure, unspecified with hypoxia; C7951: Secondary malignant neoplasm of bone; J90: Pleural effusion, not elsewhere classified; N179: Acute kidney failure, unspecified; I255: Ischemic cardiomyopathy; I480: Paroxysmal atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; I2720: Pulmonary hypertension, unspecified; I079: Rheumatic tricuspid valve disease, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; N183: Chronic kidney disease, stage 3 (moderate); D638: Anemia in other chronic diseases classified elsewhere; D696: Thrombocytopenia, unspecified; C439: Malignant melanoma of skin, unspecified; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, I480, Z7902, I2510, Z951, D696, Z87891. The uncommon codes mentioned in this dataset are I5023, J189, J9691, C7951, J90, I255, I2720, I079, N183, D638, C439.
The icd codes present in this text will be K4030, I480, I272, I509, I2510, I10, K219, N400, E785, J439, I4510, Z7982, Z951, Z87891. The descriptions of icd codes K4030, I480, I272, I509, I2510, I10, K219, N400, E785, J439, I4510, Z7982, Z951, Z87891 are K4030: Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent; I480: Paroxysmal atrial fibrillation; I272: Other secondary pulmonary hypertension; I509: Heart failure, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; E785: Hyperlipidemia, unspecified; J439: Emphysema, unspecified; I4510: Unspecified right bundle-branch block; Z7982: Long term (current) use of aspirin; Z951: Presence of aortocoronary bypass graft; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I480, I2510, I10, K219, N400, E785, Z951, Z87891. The uncommon codes mentioned in this dataset are K4030, I272, I509, J439, I4510, Z7982. Allergies Corgard Vasotec Chief Complaint incarcerated inguinal hernia Major Surgical or Invasive Procedure Left inguinal hernia repair History of Present Illness ___ with afib on apixiban CAD s p CABG b l carotid disease COPD emphysema with recent pneumonia presents for elective left inguinal hernia repair large with incarcerated sigmoid colon Past Medical History Past Medical History BILATERAL MODERATE CAROTID DISEASE CONGESTIVE HEART FAILURE CORONARY ARTERY DISEASE GASTROESOPHAGEAL REFLUX HYPERTENSION SEVERE EMPHYSEMA PULMONARY HYPERTENSION RIGHT BUNDLE BRANCH BLOCK BENIGN PROSTATIC HYPERTROPHY HYPERLIPIDEMIA PAROXYSMAL ATRIAL FIBRILLATION H O HISTIOPLASMOSIS Past Surgical History CARDIOVERSION ___ RIGHT LOWER LOBE LOBECTOMY ___ CORONARY BYPASS SURGERY ___ Social History ___ Family History Non contributory Physical Exam Gen Awake and alert CV Irregularly irregular rhythm normal rate Resp CTAB GI Soft appropriately tender near incision non distended Incision clean dry and intact with no erythema Ext Warm and well perfused Pertinent Results Brief Hospital Course Mr. ___ was admitted to ___ ___ on ___ after undergoing repair of a left incarcerated inguinal hernia. For details of the procedure please refer to the operative report. His postoperative course was uncomplicated. After a brief stay in the PACU he was transferred to the regular nursing floor. His pain was controlled with IV medication. On POD 1 he was started on a regular diet and his pain was controlled with PO pain medication. He voided without issue. He was ambulating independently in the halls. He was given a bowel regimen and passed flatus. On POD 2 he continued to tolerate his diet his pain was well controlled on oral medication and he continued to ambulate independently. He was discharged home in stable condition on POD 2 with plans to follow up with Dr. ___. Discharge Medications 1. Amiodarone 200 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Losartan Potassium 25 mg PO DAILY 6. Omeprazole 10 mg PO DAILY 7. Triamterene HCTZ 37.5 25 1 CAP PO DAILY 8. Acetaminophen 1000 mg PO Q6H PRN pain or fever Do not exceed 4 grams per day. RX acetaminophen 500 mg ___ tablet s by mouth every 6 hours Disp 60 Tablet Refills 0 9. OxycoDONE Immediate Release 5 mg PO Q4H PRN pain RX oxycodone 5 mg ___ tablet s by mouth every 4 hours Disp 40 Tablet Refills 0 10. Senna 17.2 mg PO HS Take this while you are taking oxycodone. RX sennosides Evac U Gen sennosides 8.6 mg 1 capsule by mouth daily Disp 30 Tablet Refills 0 11. Align bifidobacterium infantis 4 mg oral DAILY 12. coenzyme Q10 100 mg oral DAILY 13. Rosuvastatin Calcium 40 mg PO QPM 14. Vitamin D 1000 UNIT PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Inguinal hernia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ It was a pleasure taking care of you here at ___ ___. You were admitted to our hospital after undergoing repair of your inguinal hernia. You have recovered from surgery and are now ready to be discharged home. Please follow the recommendations below to ensure a speedy and uneventful recovery. ACTIVITY Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside but avoid traveling long distances until you see your surgeon at your next visit. Don t lift more than 10 lbs for 6 weeks. This is about the weight of a briefcase or a bag of groceries. This applies to lifting children but they may sit on your lap. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 6 weeks but use common sense and go slowly at first. You may resume sexual activity unless your doctor has told you otherwise. HOW YOU MAY FEEL You may feel weak or washed out for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not tell your surgeon. YOUR INCISION Your incision may be slightly red around the edges. This is normal. If you have steri strips do not remove them for 2 weeks. These are the thin paper strips that are on your incision. But if they fall off before that that s okay . You may gently wash away dried material around your incision. It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe please call your surgeon. You may shower. As noted above ask your doctor when you may resume tub baths or swimming. Over the next ___ months your incision will fade and become less prominent. YOUR BOWELS Constipation is a common side effect of medicine such as Percocet or codeine. If needed you may take a stool softener such as Colace one capsule or gentle laxative such as milk of magnesia 1 tbs twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement or have pain moving your bowels call your surgeon. After some operations diarrhea can occur. If you get diarrhea don t take anti diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away or is severe and you feel ill please call your surgeon. PAIN MANAGEMENT It is normal to feel some discomfort pain following abdominal surgery. This pain is often described as soreness . Your pain should get better day by day. If you find the pain is getting worse instead of better please contact your surgeon. You will receive a prescription from your surgeon for pain medicine to take by mouth. It is important to take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. If you are experiencing no pain it is okay to skip a dose of pain medicine. If you experience any of the folloiwng please contact your surgeon sharp pain or any severe pain that lasts several hours pain that is getting worse over time pain accompanied by fever of more than 101 a drastic change in nature or quality of your pain MEDICATIONS Take all the medicines you were on before the operation just as you did before unless you have been told differently. If you have any questions about what medicine to take or not to take please call your surgeon. Followup Instructions ___ The icd codes present in this text will be K4030, I480, I272, I509, I2510, I10, K219, N400, E785, J439, I4510, Z7982, Z951, Z87891. The descriptions of icd codes K4030, I480, I272, I509, I2510, I10, K219, N400, E785, J439, I4510, Z7982, Z951, Z87891 are K4030: Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent; I480: Paroxysmal atrial fibrillation; I272: Other secondary pulmonary hypertension; I509: Heart failure, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; E785: Hyperlipidemia, unspecified; J439: Emphysema, unspecified; I4510: Unspecified right bundle-branch block; Z7982: Long term (current) use of aspirin; Z951: Presence of aortocoronary bypass graft; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I480, I2510, I10, K219, N400, E785, Z951, Z87891. The uncommon codes mentioned in this dataset are K4030, I272, I509, J439, I4510, Z7982.
The icd codes present in this text will be I309, J9602, I314, I480, E119, Z66, I10, M069, E785, Z86718, Z87891. The descriptions of icd codes I309, J9602, I314, I480, E119, Z66, I10, M069, E785, Z86718, Z87891 are I309: Acute pericarditis, unspecified; J9602: Acute respiratory failure with hypercapnia; I314: Cardiac tamponade; I480: Paroxysmal atrial fibrillation; E119: Type 2 diabetes mellitus without complications; Z66: Do not resuscitate; I10: Essential (primary) hypertension; M069: Rheumatoid arthritis, unspecified; E785: Hyperlipidemia, unspecified; Z86718: Personal history of other venous thrombosis and embolism; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I480, E119, Z66, I10, E785, Z86718, Z87891. The uncommon codes mentioned in this dataset are I309, J9602, I314, M069. Allergies No Allergies ADRs on File Chief Complaint chest pain Major Surgical or Invasive Procedure ___ bedside pericardiocentesis at ___ History of Present Illness HISTORY OF PRESENTING ILLNESS Mr. ___ is a ___ male with rheumatoid arthritis DMARD holiday and recent brief hospitalization for presumptive pericarditis returned to outside hospital with probable cardiac tamponade now post bedside pericardiocentesis with drain placement prior to transfer. Importantly patient was hospitalized at ___ on ___ with acute pleuritic chest pain of two day duration in the context of constellation of fatigue malaise upper respiratory symptoms and non productive cough. While CTA exonerated pulmonary embolism thickened pericardium and small effusion were noted suggesting pericarditis. ECG revealed subtle diffuse ST elevations in keeping with pericarditis. Echocardiogram confirmed said effusion though no features of tamponade were appreciated. He was discharged the same day with ibuprofen 600 mg TID and colchicine 0.6 mg BID. He had persistence of minor residual chest pain which began to worsen two days later but was tolerable until yesterday evening when it evolved to severe unrelenting pain across his precordium likened to wearing shoulder pads bearing down on him. He notes a new concurrent substernal chest pain that goes straight to his back. He then became dyspneic prompting him to seek care. He arrived at ___ hypotensive with SBP in the 80 range. He was borderline tachycardic and in mild respiratory distress but oxygenation was acceptable. He rapidly received three liters of fluid for presumptive tamponade within the confines of poor windows on bedside echocardiogram. Pericardiocentesis yielded 400 cc or more of serous fluid and a pericardial drain was placed. Hemodynamics rapidly improved. On arrival to ___ ED patient was indeed hemodynamically stable but was then in moderate respiratory distress requiring non rebreather. He was given Lasix 20 mg IV. Bedside echocardiogram was limited but preliminarily suggestive of small residual effusion. In the CCU patient notes resurgence of said chest pain. His dyspnea is improving. An additional 250 cc was drained. Past Medical History PAST MEDICAL HISTORY Cardiac History Pericarditis as above. Hypertension. Dyslipidemia. Other PMH Rheumatoid arthritis. Remote traumatic DVT. Cholecystectomy. Appendectomy. Tonsillectomy. Left wrist reconstruction. Right rotator cuff reconstruction. Social History ___ Family History paternal history of ureothelial carcinoma. Maternal history of diabetes. Physical Exam ADMISSION PHYSICAL EXAMINATION VS T 96.7 HR 81 BP 136 81 O2 94 6L GENERAL obese male in mild to moderate respiratory distress. HEENT anicteric sclerae. Oropharynx clear. NECK JVP at mandibular angle. CARDIAC tachycardic regular with rare ectopy S1 S2 within the confines of body habitus. Subtle pericardial rub. Pericardial drain with serosanguinous fluid. Sternal tenderness. LUNGS Conversational dyspnea but tachypnea is slowing. Diffuse wheezing and crackles in bilateral lung fields. ABDOMEN obese soft non tender. EXTREMITIES Warm well perfused 2 pitting edema to knees. SKIN Chronic bilateral venous stasis dermatitis. PULSES Distal pulses palpable and symmetric. NEURO non focal. DISCHARGE PHYSICAL EXAMINATION GENERAL obese male in mild to moderate respiratory distress. HEENT anicteric sclerae. Oropharynx clear. NECK JVP not appreciated. CARDIAC normal rate and rhythm S1 S2 within the confines of body habitus. No pericardial rub appreciated. LUNGS Decreased respiratory effort compared to yesterday. Expiratory wheezing and bibasilar crackles. ABDOMEN obese soft non tender non distended. EXTREMITIES Warm well perfused 1 to 2 pitting edema to knees. SKIN Chronic venous stasis dermatitis. PULSES Distal pulses palpable and symmetric. NEURO non focal. Pertinent Results ADMISSION LABS ___ 10 57PM WBC 16.9 RBC 4.63 HGB 14.2 HCT 43.1 MCV 93 MCH 30.7 MCHC 32.9 RDW 13.1 RDWSD 44.1 ___ 10 57PM NEUTS 85.5 LYMPHS 4.3 MONOS 9.4 EOS 0.1 BASOS 0.2 IM ___ AbsNeut 14.43 AbsLymp 0.72 AbsMono 1.58 AbsEos 0.01 AbsBaso 0.04 ___ 10 57PM ___ PTT 27.2 ___ ___ 10 57PM GLUCOSE 269 UREA N 20 CREAT 0.9 SODIUM 135 POTASSIUM 5.3 CHLORIDE 106 TOTAL CO2 18 ANION GAP 11 ___ 10 57PM CALCIUM 7.4 PHOSPHATE 3.1 MAGNESIUM 1.6 ___ 10 57PM cTropnT 0.01 ___ 11 03PM LACTATE 2.0 ___ 01 05AM PLEURAL FLUID STUDIES ___ Polys 94 Lymphs 2 Monos 4 IMAGING ___ TTE The left atrium is normal in size. The inferior vena cava is dilated 2.5 cm . There is normal left ventricular wall thickness with a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 66 . Left ventricular cardiac index is normal 2.5 L min m2 . No ventricular septal defect is seen. Normal right ventricular cavity size with normal free wall motion. There is abnormal interventricular septal motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve is not well visualized. The tricuspid valve is not well seen. The pulmonary artery systolic pressure could not be estimated. There is no pericardial effusion. MICRO ___ 1 05 am FLUID OTHER PERICARDIAL FLUID. GRAM STAIN Final ___ 4 10 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE Preliminary Reported to and read back by ___ ___ 1 53PM. STAPHYLOCOCCUS COAGULASE NEGATIVE. 1 COLONY ON 1 PLATE. ANAEROBIC CULTURE Preliminary NO ANAEROBES ISOLATED. FUNGAL CULTURE Preliminary ACID FAST SMEAR Final ___ NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE Preliminary DISCHARGE LABS ___ 04 01AM BLOOD WBC 13.0 RBC 4.05 Hgb 12.3 Hct 37.3 MCV 92 MCH 30.4 MCHC 33.0 RDW 13.0 RDWSD 43.8 Plt ___ ___ 03 30PM BLOOD Glucose 115 UreaN 22 Creat 0.6 Na 138 K 4.1 Cl 100 HCO3 24 AnGap 14 ___ 04 01AM BLOOD ALT 43 AST 27 AlkPhos 99 TotBili 0.5 ___ 03 30PM BLOOD Calcium 8.2 Phos 2.9 Mg 1.9 ___ 10 57PM BLOOD proBNP 110 ___ 03 29AM BLOOD TSH 0.93 ___ 11 04AM BLOOD ___ pO2 82 pCO2 42 pH 7.34 calTCO2 24 Base XS 2 Brief Hospital Course SUMMARY ___ male with rheumatoid arthritis DMARD holiday and recent brief hospitalization for presumptive pericarditis returned to outside hospital with pericardial effusion with possible tamponade physiology now post bedside pericardiocentesis prior to transfer with persistent pericardial effusion now s p drain placement with course complicated by acute hypercapneic respiratory distress. CORONARIES unknown. PUMP normal biventricular structure and function. RHYTHM NSR. pAF ___ TRANSITIONAL ISSUES He was discharged on ibuprofen 600mg TID and colchicine 0.6mg BID for his inflammatory pericarditis. He should continue colchicine for 3 months. He should have his ibuprofen tapered weekly following resolution of his symptoms over 3 weeks to reduce the risk of recurrence. He was discharged on a PPI and should continue this while on ibuprofen. Strongly recommend that patient receive outpatient PFTs given high suspicion for baseline obstructive restrictive pulmonary disease Patient developed paroxysmal afib with RVR during this admission which is a new diagnosis. CHADSVASC 2 for hypertension and diabetes. Anticoagulation was not started during this admission given that he was felt to have relatively low risk for CVA however please make a note of this new diagnosis and reassess need for anticoagulation as medically appropriate. He was newly diagnosed with DM HbA1c 7.9 at ___ and will be discharged on metformin 500 BID. Will require outpatient follow up for this and can consider uptitration in the outpatient setting. Please reassess need for diuretic in the outpatient setting. He had no echocardiographic evidence of heart failure during this admission so was not discharged on diuretics. New medications Metformin 500mg BID Metoprolol XL 50mg QD Omeprazole 20mg QD Continued medications Atorvastatin 10mg QPM Colchicine 0.6mg BID Ibuprofen 600mg TID Folic acid 1mg PO QD Sertraline 100mg PO QD Stopped medications Methotrexate 20mg PO Famotidine 20mg QD ACUTE ISSUES Acute pericarditis Cardiac tamponade now s p pericardiocentesis and drain placement He presented with inflammatory pericarditis of probable viral nature in the context of viral like prodrome versus rheumatic pericarditis given serologic positive active disease in the absence of DMARD. Pericardial fluid cultures from ___ negative cultures here with 1 colony on 1 plate of coag negative staph felt to be contaminant negative acid fast smear. No biochemical evidence of myocardial injury on admission unlikely to have concurrent myocarditis or cardiac event sequelae. At ___ was initially noted to have SBPs in the ___ and received fluid resuscitation and pericardiocentesis given concern for tamponade physiology. Hemodynamics subsequently stabilized and remained so throughout the duration of his admission here. TTE on ___ showed no pericardial effusion. Pericardial drain was initially left to gravity due to continued output and was removed ___. He was treated with colchicine 0.6mg BID which he will continue for 3 months after discharge. He also received ibuprofen 600mg PO TID and will be discharged on a slow taper he received PPI while receiving NSAIDs. Acute hypercapnic respiratory failure resolving Probable flash pulmonary edema from rapid large volume fluid administration on tamponade as evidenced by radiographic pulmonary edema. Earlier echocardiogram otherwise not suggestive of ventricular dysfunction and BNP is within normal limits. TTE on ___ was without evidence of cardiac etiology for his pulmonary edema respiratory failure. Patient likely has unappreciated restrictive pulmonary physiology. Additionally no emphysematous changes noted on CT one week ago but background obstructive defect is conceivable given compelling smoking history. He had a negative CTA one week prior to admission. Patient had leukocytosis on admission without clear radiographic consolidation suggestive of pneumonia one dose of empiric azithromycin was given overnight and discontinued on ___. He received IV diuresis with significant improvement in his respiratory status. O2 weaned ___ morning. He was breathing comfortably on RA at the time of discharge with ambulatory saturations 90 . Paroxysmal AFib new diagnosis Patient went into Afib with RVR on ___ and subsequently received metoprolol. He subsequently flipped back into NSR. His CHADsVASC 2 DM HTN . Anticoagulation was discussed but ultimately deferred at the time of discharge given the patient s lower overall risk for CVA and concerns regarding medication adherence cost. He was discharged on metoprolol. He should have his need for anticoagulation reassessed as an outpatient as medically appropriate. Type II diabetes He was newly diagnosed with DM with a A1C of 7.9 during this admission. He was maintained on an insulin sliding scale during this admission and will be discharged on metformin 500mg BID. CHRONIC STABLE ISSUES Rheumatoid arthritis RF and anti CCP positive per outpatient rheumatology. Not currently endorsing sx suggestive of RA flare. Per discussion with OP rheumatologist deferred restarting MTX and or other DMARD until outpatient. HTN His home BP meds were held initially due to soft BPs and were stopped at the time of discharge as he remained normotensive. CORE MEASURES CODE DNR DNI. CONTACT HCP ___ ex wife ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Colchicine 0.6 mg PO BID 3. Ibuprofen 600 mg PO TID 4. Famotidine 20 mg PO DAILY 5. lisinopril hydrochlorothiazide ___ mg oral DAILY 6. Methotrexate 20 mg PO 1X WEEK ___ 7. Sertraline 100 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY Discharge Medications 1. Albuterol Inhaler 2 PUFF IH Q6H PRN wheezing shortness of breath RX albuterol sulfate ProAir HFA 90 mcg 2 puffs ih every 6 hours as needed Disp 1 Inhaler Refills 0 2. MetFORMIN Glucophage 500 mg PO BID RX metformin 500 mg 1 tablet s by mouth Twice a day Disp 60 Tablet Refills 2 3. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet s by mouth Daily Disp 30 Tablet Refills 2 4. Omeprazole 20 mg PO DAILY RX omeprazole 20 mg 1 capsule s by mouth Daily Disp 30 Capsule Refills 2 5. Atorvastatin 10 mg PO QPM 6. Colchicine 0.6 mg PO BID RX colchicine 0.6 mg 1 capsule s by mouth Twice a day Disp 60 Capsule Refills 2 7. FoLIC Acid 1 mg PO DAILY 8. Ibuprofen 600 mg PO TID 9. Sertraline 100 mg PO DAILY 10. HELD lisinopril hydrochlorothiazide ___ mg oral DAILY This medication was held. Do not restart lisinopril hydrochlorothiazide until instructed by your primary care doctor or cardiologist 11. HELD Methotrexate 20 mg PO 1X WEEK ___ This medication was held. Do not restart Methotrexate until a doctor tells you to Discharge Disposition Home Discharge Diagnosis Primary Diagnosis inflammatory pericarditis Secondary Diagnosis rheumatoid arthritis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ WHY WERE YOU ADMITTED TO THE HOSPITAL You were admitted to the hospital with chest pain. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL You were found to have inflammation and a build up of fluid in the lining of the heart. You had a procedure to remove the fluid from the lining of the heart and a temporary drain placed. This was removed before you left the hospital. You received medication to help you pee off the excess fluid in your body. You developed an abnormal heart rhythm afib while in the hospital. You were started on a new medication for this metoprolol . You were diagnosed with diabetes during this admission. You were started on a new medication for this metformin . WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL Take all of your medications as prescribed listed below Follow up with your doctors as listed below Weigh yourself every morning seek medical attention if your weight goes up more than 3 lbs. Seek medical attention if you have new or concerning symptoms or you develop swelling in your legs abdominal distention or shortness of breath at night. Please see below for more information on your hospitalization. It was a pleasure taking part in your care here at ___ We wish you all the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I309, J9602, I314, I480, E119, Z66, I10, M069, E785, Z86718, Z87891. The descriptions of icd codes I309, J9602, I314, I480, E119, Z66, I10, M069, E785, Z86718, Z87891 are I309: Acute pericarditis, unspecified; J9602: Acute respiratory failure with hypercapnia; I314: Cardiac tamponade; I480: Paroxysmal atrial fibrillation; E119: Type 2 diabetes mellitus without complications; Z66: Do not resuscitate; I10: Essential (primary) hypertension; M069: Rheumatoid arthritis, unspecified; E785: Hyperlipidemia, unspecified; Z86718: Personal history of other venous thrombosis and embolism; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I480, E119, Z66, I10, E785, Z86718, Z87891. The uncommon codes mentioned in this dataset are I309, J9602, I314, M069.
The icd codes present in this text will be I214, R570, I509, R578, A047, N179, S3730XA, I2510, E118, X58XXXA, Y92239, I10, E785, T45515A, Z86718, Z7901, R310, Z7902, I480, Z23, K2960, B9681, Z87891, I252, R410, K219. The descriptions of icd codes I214, R570, I509, R578, A047, N179, S3730XA, I2510, E118, X58XXXA, Y92239, I10, E785, T45515A, Z86718, Z7901, R310, Z7902, I480, Z23, K2960, B9681, Z87891, I252, R410, K219 are I214: Non-ST elevation (NSTEMI) myocardial infarction; R570: Cardiogenic shock; I509: Heart failure, unspecified; R578: Other shock; A047: Enterocolitis due to Clostridium difficile; N179: Acute kidney failure, unspecified; S3730XA: Unspecified injury of urethra, initial encounter; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E118: Type 2 diabetes mellitus with unspecified complications; X58XXXA: Exposure to other specified factors, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; T45515A: Adverse effect of anticoagulants, initial encounter; Z86718: Personal history of other venous thrombosis and embolism; Z7901: Long term (current) use of anticoagulants; R310: Gross hematuria; Z7902: Long term (current) use of antithrombotics/antiplatelets; I480: Paroxysmal atrial fibrillation; Z23: Encounter for immunization; K2960: Other gastritis without bleeding; B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere; Z87891: Personal history of nicotine dependence; I252: Old myocardial infarction; R410: Disorientation, unspecified; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are N179, I2510, I10, E785, Z86718, Z7901, Z7902, I480, Z87891, I252, K219. The uncommon codes mentioned in this dataset are I214, R570, I509, R578, A047, S3730XA, E118, X58XXXA, Y92239, T45515A, R310, Z23, K2960, B9681, R410. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint cardiogenic ___ NSTEMI Major Surgical or Invasive Procedure cardiac catheterization with DES to mid LAD occlusion via R radial access IABP placement and removal History of Present Illness Mr. ___ is a ___ M with HTN HLD DMII and prior MI with medical management w o cath presented to ___ with ___ transferred to ___ for catheterization for concern for STEMI. Patient has long standing angina pain w exertion. On ___ night had acute onset b l non radiating ___ CP not resolved with SL NTG that persisted on ___ morning. In addition had 3 episodes of diarrhea and weakness malaise so he went to ___. No orthopnea PND ___ edema palpitations or SOB. In the ED initial vitals were Exam Chest pain ___ nonradiating Labs Trop I 1.14 WBC 29.6 Hct 38.7 Plt 148 INR 1.25 Na 127 K 4.6 BUN 30 Cr1.86 Imaging EKG showed ST elevations in AVR 2mm borderline elevation in V1 and otherwise diffuse ST depressions. Bedside ECHO w septal wall motion abnormalities. CXR w o any acute abnormalities. Patient was given Heparin gtt Nitro gtt ASA 324mg Ticagrelor 180mg 1500 Vanco 125mg PO ___ Transferred to ___ for cardiac cath. Vitals on transfer were 106 64 86 100 on 2L afebrile Cath lab where he still had ___ pain on heparin and nitro gtt. Catheterization showed mid LAD septal occlusion diffuse disease throughout RCA complete occlusion of circumflex w collaterals and 20 stenosis of L main. DES to mid LAD occlusion via R radial access. Hypotensive throughout so given 750cc IVF. Coughing post procedure with LVEDP 25 so given Lasix 20mg IV. Was then hypertensive to 150 so given further Lasix 40mg IV. Admitted to CCU for hypotension throughout procedure WBC 30 and lack of ___ beds. In the CCU patient reports no chest pain but continues to have productive cough and diarrhea. Of note two weeks ago had endoscopy and diagnosed with H Pylori. Currently on clarithromycin and amoxicillin. On ___ night developed diarrhea. Also had 15lb weight loss in past 4 months. Past Medical History 1 HTN 2 HLD 3 DMII 4 CAD s p MI medically managed 5 H. Pylori 6 Spinal stenosis Social History ___ Family History Father possible dilated cardiomyopathy No family history of early MI arrhythmia or sudden cardiac death otherwise non contributory. Physical Exam On admission VS afebrile 160 80 114 94 on 15L Non rebreather Weight 69kg Tele NSR Gen Slightly tachypneic older man audibly wheezing but comfortably finishing sentences HEENT EOMI PERRLA NECK No JVD CV Tachycardic difficult to appreciate heart sounds due to significant rhonchi LUNGS b l rhonchi throughout w mild end expiratory wheezing and R base crackles ABD Soft Non tender non distended EXT 2 L radial pulses R arm w band in place and normal motor sensory function intact distally RLE non palpable DP but dopplerable 1 LLE DP. b l ___ slightly cold but normal sensation w full motor strength and ROM SKIN No rashes or chronic edematous changes NEURO Alert and attentive AOX3 Moving all extremities At discharge Weight 63.7kg 63.4 I O 980 800 T 98.4 BP 123 68 102 133 62 87 P 86 71 100 RR 20 O2 99 RA Gen awake alert oriented to self date hospital HEENT EOMI PERRLA NECK No JVD CV Tachycardic difficult to appreciate heart sounds LUNGS Bibasilar crackles ABD Soft Non tender non distended EXT 2 b l radial pulses R arm normal motor sensory function intact distally RLE non palpable DP but dopplerable trace edema b l. b l ___ slightly cold but normal sensation w full motor strength and ROM SKIN No rashes or chronic edematous changes NEURO Alert and attentive AOX3 Moving all extremities Pertinent Results Labs on Admission ___ 09 23PM WBC 36.8 RBC 4.40 HGB 14.0 HCT 40.6 MCV 92 MCH 31.8 MCHC 34.5 RDW 12.5 RDWSD 41.8 ___ 09 23PM PLT SMR NORMAL PLT COUNT 176 ___ 09 23PM NEUTS 81 BANDS 10 LYMPHS 3 MONOS 6 EOS 0 BASOS 0 ___ MYELOS 0 AbsNeut 33.49 AbsLymp 1.10 AbsMono 2.21 AbsEos 0.00 AbsBaso 0.00 ___ 09 23PM ___ PTT 49.6 ___ ___ 09 23PM GLUCOSE 264 UREA N 30 CREAT 1.4 SODIUM 129 POTASSIUM 4.1 CHLORIDE 96 TOTAL CO2 14 ANION GAP 23 ___ 09 23PM CALCIUM 8.2 PHOSPHATE 3.0 MAGNESIUM 1.7 CHOLEST 157 ___ 09 23PM HbA1c 5.9 eAG 123 ___ 09 23PM CK MB 44 cTropnT 0.69 ___ 09 23PM TRIGLYCER 90 HDL CHOL 42 CHOL HDL 3.7 LDL CALC 97 ___ 09 23PM HYPOCHROM NORMAL ANISOCYT NORMAL POIKILOCY 1 MACROCYT NORMAL MICROCYT NORMAL POLYCHROM NORMAL BURR 1 Labs at Discharge ___ 05 50AM BLOOD WBC 11.2 RBC 3.59 Hgb 11.2 Hct 34.7 MCV 97 MCH 31.2 MCHC 32.3 RDW 13.2 RDWSD 46.7 Plt ___ ___ 05 50AM BLOOD Neuts 76 Bands 0 Lymphs 16 Monos 5 Eos 2 Baso 0 ___ Metas 1 Myelos 0 AbsNeut 8.51 AbsLymp 1.79 AbsMono 0.56 AbsEos 0.22 AbsBaso 0.00 ___ 05 50AM BLOOD ___ PTT 27.3 ___ ___ 05 50AM BLOOD Glucose 165 UreaN 43 Creat 1.1 Na 136 K 4.3 Cl 103 HCO3 22 AnGap 15 ___ 05 50AM BLOOD ALT 38 AST 32 LD LDH 481 AlkPhos 99 TotBili 0.4 ___ 05 50AM BLOOD Albumin 3.3 Calcium 8.4 Phos 3.6 Mg 2.4 Relevant Imaging TTE ___ The left atrium is mildly dilated. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is moderately depressed LVEF 35 40 assessment limited by suboptimal image quality and significant beat to beat variability . There is hypokinesis of the mid distal LV segments and apex. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. There is mild aortic valve stenosis valve area 1.2 1.9cm2 . No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a trivial physiologic pericardial effusion. Compared with the prior focused study images reviewed of ___ left ventricular systolic function is probably similar although suboptimal image quality of both studies precludes definite comparison. ___ CXR IMPRESSION Generalized improvement in both lungs is probably due to decrease in pulmonary edema now mild and decrease in previous moderate right pleural effusion. There is still substantial consolidation in the right upper lobe probably pneumonia but the bilateral lower lobe components have improved. Heart size top normal. No pneumothorax. MICRO FINAL REPORT ___ C. difficile DNA amplification assay Final ___ CLOSTRIDIUM DIFFICILE. Positive for toxigenic C. difficile by the Illumigene DNA amplification. Reference Range Negative . ___ 12 53 pm SPUTUM Source Expectorated. GRAM STAIN Final ___ 10 PMNs and 10 epithelial cells 100X field. 2 ___ per 1000X FIELD GRAM NEGATIVE ROD S . 2 ___ per 1000X FIELD BUDDING YEAST. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE Preliminary Further incubation required to determine the presence or absence of commensal respiratory flora. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. GRAM NEGATIVE ROD 2. SPARSE GROWTH. SENSITIVITIES MIC expressed in MCG ML ___ KLEBSIELLA PNEUMONIAE AMPICILLIN SULBACTAM 4 S CEFAZOLIN 4 S CEFEPIME 1 S CEFTAZIDIME 1 S CEFTRIAXONE 1 S CIPROFLOXACIN 0.25 S GENTAMICIN 1 S MEROPENEM 0.25 S PIPERACILLIN TAZO 4 S TOBRAMYCIN 1 S TRIMETHOPRIM SULFA 1 S Brief Hospital Course Mr. ___ is a ___ M w HTN HLD DMII and old MI transferred from ___ w NSTEMI w diffuse 3 vessel disease s p DES to mid LAD occlusion found to have severe Cdiff. ACTIVE ISSUES NSTEMI NSTEMI based on STE aVR and V1 but o w ST depressions w significant multi vessel disease but significant stenosis in LAD s p DES that occluded diagnonal. Repeat cath unchanged. He was started on plavix atorvastatin ACE I and metoprolol. Echo showed LVEF 35 40 with hypokinesis of mid distal LV segments and apex. He was started on warfarin for his hypokinetic LV as well as his atrial fibrillation as discussed below. ___ Possibly mixed cardiogenic distributive given mixed venous O2 65 CI 2.1 PCWP 25. He initially required pressors and balloon pump and was then successfully weaned off both. He remained hemodynamically stable during rest of hospital course. Atrial Fibrillation Patient with a reported history of paroxysmal afib per his PCP for which he was maintained on digoxin as well as aspirin 325mg PO daily prior to admission. He was found to be in atrial fibrillation during admission and the decision was made to anticoagulate with Coumadin. He was continued on home dose digoxin. His home dose aspirin was decreased as discussed above with initiation of Coumadin. Hematuria Likely traumatic in setting of systemic anticoagulation as patient pulled at ___. Cytology was negative. He will followup outpatient with urology. Dyspnea Patient had acute episodes of dyspnea. This was mainly attributed to pulmonary edema and improved with diruesis. Additionally CXR showed possible consolidation of RUL concerning for aspiration pneumonia. However treatment was deferred as he had no other focal signs of infectious pna. He did have sputum cultures which grew Klebsiella pneumonia but on discussion with ID felt this did not warrant any treatment as he was asymptomatic. He was discharged on po lasix 20 mg daily with next electrolytes to be checked ___. C diff severe Had loose stool in setting of antibiotic tx for Hpylori initiated outpatient . Given WBC 15 ___ age ___ treated as severe. Patient was started on vancomycin 125mg PO qid for 14 day course day ___ last day ___. GASTROESOPHAGEAL REFLUX DISEASE GERD Endoscopy confirmed H Pylori treated with PPI clarithromycin amoxicillin since ___ for 14 days. Omeprazole was continued. Antibiotics held in setting of c.diff infection. Delirium Patient with frequent sundowning during hospitalization requiring Seroquel po. CHRONIC ISSUES Spinal Stenosis Continued gabapentin d ced naproxen. Did not complain of pain throughout hospital course. Explained he should not take any more NSAIDS in setting of recent ACS and now on Coumadin Plavix and asa. DM maintained on ISS during admission and discharged on home glipizide and metformin HTN Home dose metoprolol uptitrated. Home dose lisinopril decreased. Home dose imdur discontinued. HLD Transitioned home dose simvastatin to atorvastatin TRANSITIONAL ISSUES Discharge weight 63.7kg patient will require urology followup given hematuria during admission. Urine cytology negative. patient will need to be treated for hpylori once he completes a course of PO Vancomycin for Severe CDiff Please check electrolytes on ___ on lasix Coumadin initiated given atrial fibrillation ASA decreased from 325 mg to 81 mg daily Started on Plavix given recent stent placement atorvastatin 80 mg stopped simvastatin and Lasix 20 mg po daily Home metoprolol was increased from 25 mg XL to 50 mg XL daily lisinopril decreased to 2.5 mg po daily and home imdur was discontinued patient will need to continue a 14 day course of PO Vanc day ___ ___ last day ___ for cdiff infection Patient instructed to not take any NSAIDS SLP treatment at rehab for pharyngeal strengthening exercises Medications on Admission The Preadmission Medication list is accurate and complete. 1. Gabapentin 600 mg PO TID 2. Naproxen 500 mg PO DAILY 3. MetFORMIN Glucophage 500 mg PO BID 4. Metoprolol Succinate XL 25 mg PO DAILY 5. GlipiZIDE 2.5 mg PO BID 6. Simvastatin 40 mg PO QPM 7. Isosorbide Mononitrate Extended Release 60 mg PO DAILY 8. Lisinopril 10 mg PO DAILY 9. Digoxin 0.125 mg PO DAILY 10. Aspirin 325 mg PO DAILY Discharge Medications 1. Aspirin EC 81 mg PO DAILY 2. Digoxin 0.125 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Warfarin 4 mg PO DAILY16 6. GlipiZIDE 2.5 mg PO BID 7. Clopidogrel 75 mg PO DAILY 8. Omeprazole 20 mg PO BID 9. Vancomycin Oral Liquid ___ mg PO Q6H 10. MetFORMIN Glucophage 500 mg PO BID 11. Gabapentin 600 mg PO TID 12. Lisinopril 2.5 mg PO DAILY 13. Furosemide 20 mg PO DAILY Discharge Disposition Extended Care Facility ___ Discharge Diagnosis NSTEMI s p ___ likely mixed cardiogenic distributive Hematuria Dyspnea C. dif severe GERD Delirium Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Discharge Instructions Dear Mr. ___ You were admitted to ___ because you were experiencing chest pain due to a heart attack. In the cath lab you were found to have blockage of your arteries and a stent was placed. We also managed your low blood pressure infectious diarrhea and trauma from foley placement. You responded well. Please continue taking your medications as prescribed. You are being started on coumadin. Please do not take any non steroidal antiinflammatory drugs NSAIDS such as ibuprofen advil motrin aleve naproxen. Please also follow up with your cardiology and PCP appointments as scheduled It was a pleasure taking care of you Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I214, R570, I509, R578, A047, N179, S3730XA, I2510, E118, X58XXXA, Y92239, I10, E785, T45515A, Z86718, Z7901, R310, Z7902, I480, Z23, K2960, B9681, Z87891, I252, R410, K219. The descriptions of icd codes I214, R570, I509, R578, A047, N179, S3730XA, I2510, E118, X58XXXA, Y92239, I10, E785, T45515A, Z86718, Z7901, R310, Z7902, I480, Z23, K2960, B9681, Z87891, I252, R410, K219 are I214: Non-ST elevation (NSTEMI) myocardial infarction; R570: Cardiogenic shock; I509: Heart failure, unspecified; R578: Other shock; A047: Enterocolitis due to Clostridium difficile; N179: Acute kidney failure, unspecified; S3730XA: Unspecified injury of urethra, initial encounter; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E118: Type 2 diabetes mellitus with unspecified complications; X58XXXA: Exposure to other specified factors, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; T45515A: Adverse effect of anticoagulants, initial encounter; Z86718: Personal history of other venous thrombosis and embolism; Z7901: Long term (current) use of anticoagulants; R310: Gross hematuria; Z7902: Long term (current) use of antithrombotics/antiplatelets; I480: Paroxysmal atrial fibrillation; Z23: Encounter for immunization; K2960: Other gastritis without bleeding; B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere; Z87891: Personal history of nicotine dependence; I252: Old myocardial infarction; R410: Disorientation, unspecified; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are N179, I2510, I10, E785, Z86718, Z7901, Z7902, I480, Z87891, I252, K219. The uncommon codes mentioned in this dataset are I214, R570, I509, R578, A047, S3730XA, E118, X58XXXA, Y92239, T45515A, R310, Z23, K2960, B9681, R410.
The icd codes present in this text will be F4489, R29818, I7300, I951, R000, F410, E869, K219, D509, D519, F329. The descriptions of icd codes F4489, R29818, I7300, I951, R000, F410, E869, K219, D509, D519, F329 are F4489: Other dissociative and conversion disorders; R29818: Other symptoms and signs involving the nervous system; I7300: Raynaud's syndrome without gangrene; I951: Orthostatic hypotension; R000: Tachycardia, unspecified; F410: Panic disorder [episodic paroxysmal anxiety]; E869: Volume depletion, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; D509: Iron deficiency anemia, unspecified; D519: Vitamin B12 deficiency anemia, unspecified; F329: Major depressive disorder, single episode, unspecified. The common codes which frequently come are K219, D509, F329. The uncommon codes mentioned in this dataset are F4489, R29818, I7300, I951, R000, F410, E869, D519. Allergies amoxicillin Chief Complaint Weakness and lethargy Major Surgical or Invasive Procedure None History of Present Illness Patient is a ___ year old female with history of chronic abdominal pain and anemia w recent Fe sucrose infusion ___ complicated by infusion reaction mottling and discoloration of feet s p IV steroids who presents with increasing lethargy and headache. History per ___ records and per her Aunt as patient cannot provide much history. Per her aunt ___ has been doing well recently without any illness behavioral change. She had a cold she was getting over but otherwise doing well. She had an Fe transfusion on ___ around 3 30P at ___ and the aunt accompanied her to the visit. Towards the end of the infusion ___ developed mottle purple lower extremities and was having nausea heart racing. She was sent to ___ where she had SBP up to 144. Her exam per ___ records notable for shivering... doesn t open her eyes...mottled hands and feet . There was no concern for respiratory distress. She was given 50 mg IV Benadryl 100 mg IV hydrocortisone and observed for 5 hours and then discharged. At that time ___ was reportedly lethargic meaning sleeping frequently but able to sit up and walk without issue. They arrived home and ___ went to bed. Around 6 00 AM on ___ ___ aunt check on her and she was still sleeping. She was reporting a headache which the transfusion place said would happen but did not mention other characteristic. ___ aunt gave her acetaminophen and water and ___ went back to sleep. Over the next few hours she heard ___ awake several times and use the bathroom. Then as it got later and later into the day and ___ was not up and about yet her aunt became worried. She told ___ to call the ___ which she was able to do. She reportedly said she continued to have a headache and felt sleepy. She was instructed to go to the ED. She went to the ED at ___ for evaluation. At ___ she had T 99.5 P 58 RR 15 and sat 100 . BP 110 67. She was reportedly drowsy and arousing to voice alert oriented x3 consistent eye fluttering pupils reactive to light and extraocular eye movements full with reportedly non focal exam . Lab work notable for WBC 7.2 Hgb 13.2 Na 142 bicarb 26 Cr 0.9 Ca 9.4 normal LFTs Fe 360 Ferritin 438. VBG pH was 7.43 PCO2 was 45.She had a normal ___ and LP with WBC 2 100 monocytes glucose 57 protein 24 no xanthochromia. She ultimately had MRA and MRV which showed no thrombus or venoous thrombosis. She was transferred to ___ for further management. On my interview she cannot provide much history other than to say she is here because I m tired . She keeps her eyes closed during questioning. She reports headache but cannot describe where it is or features other than photophobia. She is unable to participate in other questioning often getting tearful and saying the questions are hard . Per her father and aunt she has no history of seizures or CNS infection. She did have a concussion at ___ years old. Past Medical History Anemia Social History ___ Family History Mother with a celiac disease and autoimmune hypothyroidism. Dad is healthy. She has a cousin with seizures. Physical Exam Admission exam 98.1 76 130 78 14 96 RA General appears to be sleeping occasional eye lid fluttering lip movements occasional slow movements of head from side to side HEENT no trauma no jaundice no lesions of oropharynx CV RRR wwp Pulm breathing comfortably on RA Ext clammy warm and no rash Neurologic Mental Status She frequently gets upset during exam and is tearful at times then abulic at other times. Eyes open only briefly to voice. She is oriented to ___ but not full date. Knows she is in a hospital but not the name. She says she is in the hospital because I m tired . She is unable to provide history. Speech is not dysarthric says ___ words when asked questions no spontaneous speech output. Follows simple commands like open eyes lift legs. She is able to name key and feather on stroke card but then stops naming and closes her eyes. She reads the first sentence on stroke card but then no more and closes her eyes. When asked to describe stroke card picture she says dishes . She does not participate in further exam. Cranial Nerves II III IV VI Pupils 8 mm 6 mm. EOMI without nystagmus. VFF to confrontation. Fundoscopic exam revealed no papilledema exudates or hemorrhages. VII No facial droop facial musculature symmetric with grimace. VIII Hearing intact to exam IX X Palate elevates symmetrically. XII Tongue protrudes in midline. Motor Normal bulk tone throughout. She says she cannot move her arms. When arms placed over her head her arms slowly miss her face and slowly drops to the bed in a controlled fashion. She does lift her arms to hold the side rails of the bed spontaneously. She lifts her legs antigravity and holds them without drift. Sensory slightly withdrawals in upper extremities and says ouch briskly withdrawals in lower extremities to noxious stimuli and says ouch DTRs ___ Tri ___ Pat Ach L 2 2 0 3 2 R 2 2 0 3 2 Plantar response was flexor bilaterally. Coordination patient could not participate Gait could not assess as patient would not get out of bed Discharge Exam General sitting up in her chair with eyes closed HEENT no trauma no jaundice no lesions of oropharynx CV sinus bradycardia no m r g Pulm Breathing comfortably on RA Ext Warm and well perfused no rash or mottling Neurologic Mental Status Answering questions with slow short sentence. More humor and complex sentences observed today. Eyes intermittently close while she is talking. Speech is not dysarthric no spontaneous speech output. Follows simple commands. Cranial Nerves II III IV VI Pupils 8 mm 4 mm. EOMI without nystagmus. V facial sensation intact throughout VII No facial droop facial musculature symmetric with grimace but limited facial movements. IX X XII palate elevates symmetrically tongue midline Motor Normal bulk tone throughout. Lifting arms and legs against gravity but not against resistance ___ Sensory Sensation intact to touch and temperature throughout DTRs 1 patellar biceps brachioradialis throughout Coordination No dysmetria or tremor. Gait Ambulated well with a ___. Pertinent Results Admission labs ___ 12 59PM GLUCOSE 77 UREA N 8 CREAT 0.7 SODIUM 142 POTASSIUM 3.8 CHLORIDE 104 TOTAL CO2 24 ANION GAP 14 ___ 12 59PM ALT SGPT 9 AST SGOT 13 ALK PHOS 39 TOT BILI 0.3 ___ 12 59PM CALCIUM 8.7 PHOSPHATE 4.0 MAGNESIUM 1.7 ___ 12 59PM tTG IgA 7 ___ 12 59PM WBC 5.0 RBC 3.89 HGB 11.5 HCT 34.4 MCV 88 MCH 29.6 MCHC 33.4 RDW 12.4 RDWSD 39.8 ___ 12 59PM PLT COUNT 235 ___ 05 11AM URINE HOURS RANDOM ___ 05 11AM URINE UCG NEGATIVE ___ 05 11AM URINE bnzodzpn NEG barbitrt NEG opiates NEG cocaine NEG amphetmn NEG oxycodn NEG mthdone NEG ___ 05 11AM URINE COLOR Straw APPEAR Clear SP ___ ___ 05 11AM URINE BLOOD LG NITRITE NEG PROTEIN NEG GLUCOSE NEG KETONE TR BILIRUBIN NEG UROBILNGN NEG PH 7.0 LEUK NEG ___ 05 11AM URINE RBC 5 WBC 1 BACTERIA FEW YEAST NONE EPI 0 ___ 05 11AM URINE MUCOUS RARE ___ 04 34AM ___ PTT 27.2 ___ ___ 04 28AM WBC 6.4 RBC 4.17 HGB 12.6 HCT 37.4 MCV 90 MCH 30.2 MCHC 33.7 RDW 12.4 RDWSD 40.8 ___ 04 28AM NEUTS 58.2 ___ MONOS 7.1 EOS 0.2 BASOS 0.6 IM ___ AbsNeut 3.70 AbsLymp 2.14 AbsMono 0.45 AbsEos 0.01 AbsBaso 0.04 ___ 04 28AM PLT COUNT 246 ___ 04 11AM ___ PO2 50 PCO2 34 PH 7.44 TOTAL CO2 24 BASE XS 0 COMMENTS GREEN TOP ___ 04 10AM GLUCOSE 84 UREA N 7 CREAT 0.8 SODIUM 143 POTASSIUM 3.6 CHLORIDE 106 TOTAL CO2 23 ANION GAP 14 ___ 04 10AM estGFR Using this ___ 04 10AM ALT SGPT 9 AST SGOT 14 CK CPK 67 ALK PHOS 41 TOT BILI 0.3 ___ 04 10AM CK MB 1 ___ 04 10AM ALBUMIN 3.9 CALCIUM 8.8 PHOSPHATE 2.9 MAGNESIUM 1.8 ___ 04 10AM VIT B12 227 ___ 04 10AM TSH 2.7 ___ 04 10AM TSH 2.6 ___ 04 10AM ___ TITER 1 1280 CRP 3.4 dsDNA NEGATIVE ___ 04 10AM C3 121 C4 27 ___ 04 10AM ASA NEG ETHANOL NEG ACETMNPHN NEG tricyclic NEG EEG ___ IMPRESSION This telemetry captured no pushbutton activations. The background showed normal waking and sleep patterns. There were no focal abnormalities epileptiform features or electrographic seizures. A bradycardia was noted. IMAGING MRI BRAIN WITH WITHOUT CONTRAST ___ FINDINGS A 5 mm FLAIR hypointense and T1 isointense lesion at midline between the anterior and posterior pituitary is noted. There is no evidence of hemorrhage edema mass effect midline shift or infarction. The ventricles and sulci are normal in caliber and configuration. There is no abnormal enhancement after contrast administration. IMPRESSION A 5 mm FLAIR hypointense and T1 isointense lesion at midline between the anterior and posterior pituitary likely represents a Rathke s cleft cyst. Further evaluation is needed dedicated pituitary MR may be obtained. Brief Hospital Course See worksheet Medications on Admission famotidine 40 mg daily birth control per her aunt ___ 1. ___ 250 mcg PO DAILY 2. Famotidine 40 mg PO DAILY 3. Metoprolol Tartrate 12.5 mg PO DAILY 4. Multivitamins W minerals 1 TAB PO DAILY 5. Nortriptyline 10 mg PO QHS 6. ___ 1 item miscellaneous ONCE Prognosis Good ___ 13 months RX ___ Once Disp 1 Each Refills 0 Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Functional neurological syndrome Discharge Condition Mental Status Clear and coherent. Level of Consciousness Lethargic but arousable. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ It was a pleasure taking care of you at ___ ___. You were in the hospital because of headache lethargy and weakness after an iron infusion. You had a number of tests performed in the hospital all of which were reassuring. An MRI of your brain showed no evidence of stroke or inflammation. An EEG to monitor your brain waves showed no evidence of seizure. Your weakness gradually improved over the course of your hospitalization and will continue to improve after you leave the hospital. After leaving the hospital you should continue to work on improving your strength. It will improve as long as you work hard We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be F4489, R29818, I7300, I951, R000, F410, E869, K219, D509, D519, F329. The descriptions of icd codes F4489, R29818, I7300, I951, R000, F410, E869, K219, D509, D519, F329 are F4489: Other dissociative and conversion disorders; R29818: Other symptoms and signs involving the nervous system; I7300: Raynaud's syndrome without gangrene; I951: Orthostatic hypotension; R000: Tachycardia, unspecified; F410: Panic disorder [episodic paroxysmal anxiety]; E869: Volume depletion, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; D509: Iron deficiency anemia, unspecified; D519: Vitamin B12 deficiency anemia, unspecified; F329: Major depressive disorder, single episode, unspecified. The common codes which frequently come are K219, D509, F329. The uncommon codes mentioned in this dataset are F4489, R29818, I7300, I951, R000, F410, E869, D519.
The icd codes present in this text will be R29818, F411, F329, F4310, F5082, Z6822, D649. The descriptions of icd codes R29818, F411, F329, F4310, F5082, Z6822, D649 are R29818: Other symptoms and signs involving the nervous system; F411: Generalized anxiety disorder; F329: Major depressive disorder, single episode, unspecified; F4310: Post-traumatic stress disorder, unspecified; F5082: Avoidant/restrictive food intake disorder; Z6822: Body mass index [BMI] 22.0-22.9, adult; D649: Anemia, unspecified. The common codes which frequently come are F329, D649. The uncommon codes mentioned in this dataset are R29818, F411, F4310, F5082, Z6822. Allergies amoxicillin iron Major Surgical or Invasive Procedure None attach Pertinent Results ADMISSION LABS ___ 10 45PM PLT COUNT 244 ___ 10 45PM NEUTS 55.7 ___ MONOS 10.8 EOS 0.7 BASOS 0.9 IM ___ AbsNeut 2.99 AbsLymp 1.70 AbsMono 0.58 AbsEos 0.04 AbsBaso 0.05 ___ 10 45PM WBC 5.4 RBC 4.19 HGB 13.4 HCT 41.2 MCV 98 MCH 32.0 MCHC 32.5 RDW 12.4 RDWSD 44.2 ___ 10 45PM ASA NEG ETHANOL NEG ACETMNPHN NEG tricyclic NEG ___ 10 45PM ALBUMIN 4.8 CALCIUM 9.6 PHOSPHATE 3.0 MAGNESIUM 2.1 ___ 10 45PM LIPASE 31 ___ 10 45PM ALT SGPT 20 AST SGOT 26 ALK PHOS 48 TOT BILI 0.4 ___ 10 45PM GLUCOSE 128 UREA N 15 CREAT 1.1 SODIUM 137 POTASSIUM 3.7 CHLORIDE 100 TOTAL CO2 23 ANION GAP 14 ___ 03 17AM URINE BLOOD NEG NITRITE NEG PROTEIN NEG GLUCOSE NEG KETONE 10 BILIRUBIN NEG UROBILNGN NORMAL PH 6.5 LEUK NEG ___ 03 17AM URINE COLOR Straw APPEAR CLEAR SP ___ ___ 03 17AM URINE bnzodzpn NEG barbitrt NEG opiates NEG cocaine NEG amphetmn NEG oxycodn NEG mthdone NEG ___ 03 17AM URINE UCG NEGATIVE ___ 03 17AM URINE HOURS RANDOM PERTINENT LABS ___ 05 45AM BLOOD VitB12 956 ___ 05 45AM BLOOD TSH 0.99 ___ 05 45AM BLOOD Free T4 1.3 ___ 05 45AM BLOOD VITAMIN B1 WHOLE BLOOD PND MICRO ___ 3 17 am URINE FINAL REPORT ___ URINE CULTURE Final ___ MIXED BACTERIAL FLORA 3 COLONY TYPES CONSISTENT WITH SKIN AND OR GENITAL CONTAMINATION. IMAGING none DISCHARGE LABS no labs on day of discharge DISCHARGE PHYSICAL EXAM VITALS ___ 1136 Temp 98.1 PO BP 107 68 R lying HR 68 RR 18 O2 sat 100 O2 delivery RA GENERAL NAD sitting up in chair smiling moving head around EYES Sclera anicteric and without injection. CARDIAC RRR. Audible S1 and S2. No murmurs rubs gallops. RESP Clear to auscultation bilaterally. No wheezes rhonchi or rales. No increased work of breathing. ABDOMEN Normal bowels sounds non distended non tender. EXTREMITIES Pulses DP Radial 2 bilaterally. SKIN Warm. Cap refill 2s. No rash. NEUROLOGIC Speech slow but markedly improved today and speaks in simple sentences. Sitting in a chair and able to move all extremities follow commands such as moving fingers toes on command and sticking thumb up. PSYCH Alert and awake pleasant smiling Brief Hospital Course BRIEF HOSPITAL SUMMARY ___ female with history of disordered eating PTSD GAD with panic disorder depression and functional neurological disorder presenting from a therapy session with weakness abnormal movement and aphasia concerning for an acute functional neurological episode. She was evaluated by neurology and psychology who felt this was consistent with functional neurological disorder similar to her prior presentation. She began working with ___ and OT and had made great improvement at time of discharge to acute rehab. TRANSITIONAL ISSUES For rehab Please continue aggressive ___ and OT for further improvement in functional status. On discharge please ensure patient has follow up with her PCP and her therapist. Patient was having some intermittent nausea as appetite improved. Please continue Zofran TID prn. QTc was 441 on EKG on ___. If continuing Zofran use for 1 week please recheck QTc on ___ and d c medication if prolonged. Patient has a history of disordered and restrictive eating. She does well eating with encouragement and did not show any evidence of eating disorder while inpatient. Please continue ensure supplements TID with meals. For PCP therapist Please refer patient to psychiatrist for further titration of psychiatric medications given report of previous sensitivity to medications and concern for possible bipolar disorder diagnosis. Please follow up pending thiamine level. ACUTE ISSUES GAD Panic disorder Depression PTSD Functional neurological disorder Patient presented from a therapy session where she had acute onset of weakness abnormal movement and aphasia in the setting of potential trigger of seeing shadows outside the door. Per her therapist over the past several weeks she has been increasingly more hypervigilant and stressed about going home for the holidays to see her mom which is a major trigger for her PTSD. Her therapist also reports a history of sexual physical verbal abuse but patient is very guarded about it and will not discuss it. On presentation to the ___ had significant and acute functional neurological symptoms including weakness abnormal movement and aphasia resulting in impaired functioning. There was concern for catatonia and she improved after 1 mg IV ativan in the ER. She endorsed significant anxiety but denied SI and per Psychiatry she did not meet ___ criteria. She had a similar episode in ___ after IV iron infusion and was admitted to the neurology service where she was diagnosed with functional neurological disorder and she improved with ___ and rehab. She was also started on nortriptyline 10 mg QHS at that time. Per her therapist she is sensitive to medications and when she was on SSRIs she became manic although she has not formally been diagnosed with bipolar disorder. Once admitted she was re evaluated by neuro and psychiatry who determined this was not consistent with catatonia and instead was likely functional neurological disorder. She was recommended for acute rehab to continue aggressive ___. She was continued on home nortriptyline 10mg qhs. Disordered eating Restrictive eating Over exercising She has a history of restrictive eating and over exercising and in the past she has had bradycardia and electrolyte abnormalities. Per her therapist her disordered eating has become much worse over the past few months in the setting of traveling a lot for work. She started an intensive outpatient program at ___ Eating ___ on ___. Per her therapist she restricts her calories to about 1 000 or less a day and over exercises and is good at hiding it from people. From review of OMR her BMI seems to be normal between ___ and she currently does not have any electrolyte abnormalities but she has been intermittently bradycardic with HR in the ___. Her appetite improved as her neurological symptoms began resolving. Per nutrition evaluation no need for eating disorder protocol while inpatient. She received Ensure supplements. Heart rates were stable bradycardic in ___. Electrolytes were monitored. TSH T4 and B12 levels were all normal. She received thiamine supplementation. She received Zofran PRN for nausea QTc 441 . CORE MEASURES CODE full code CONTACT Per patient s request do not contact her mother ___ Emergency Contacts ___ ___ ___ and ___ Uncle ___ Therapist ___ ___ ___ and coordinates all of her care and available for questions calls at anytime Medications on Admission The Preadmission Medication list is accurate and complete. 1. Nortriptyline 10 mg PO QHS Discharge Medications 1. Multivitamins W minerals 1 TAB PO DAILY 2. Ondansetron ODT 4 mg PO Q8H PRN Nausea Vomiting First Line 3. Thiamine 100 mg PO DAILY 4. Nortriptyline 10 mg PO QHS Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Functional neurological disorder GAD depression PTSD H o disordered eating Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Out of Bed with assistance to chair or wheelchair. Discharge Instructions Dear Ms. ___ It was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL You came to the hospital because you acutely had trouble moving and speaking. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL You were seen by the neurologists who diagnosed you with functional neurological disorder. You worked with physical and occupational therapists. Your symptoms began to improve. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL Please continue to take all your medications and follow up with your doctors at your ___ appointments. Please continue to work with your physical and occupational therapists. We wish you all the best Sincerely Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be R29818, F411, F329, F4310, F5082, Z6822, D649. The descriptions of icd codes R29818, F411, F329, F4310, F5082, Z6822, D649 are R29818: Other symptoms and signs involving the nervous system; F411: Generalized anxiety disorder; F329: Major depressive disorder, single episode, unspecified; F4310: Post-traumatic stress disorder, unspecified; F5082: Avoidant/restrictive food intake disorder; Z6822: Body mass index [BMI] 22.0-22.9, adult; D649: Anemia, unspecified. The common codes which frequently come are F329, D649. The uncommon codes mentioned in this dataset are R29818, F411, F4310, F5082, Z6822.
The icd codes present in this text will be O99613, K029, Z3A34, O99513, J45998, O9989, O99013, O99283, E890, Y836, M170, M479, Z853, Z85850, Z87891, K219. The descriptions of icd codes O99613, K029, Z3A34, O99513, J45998, O9989, O99013, O99283, E890, Y836, M170, M479, Z853, Z85850, Z87891, K219 are O99613: Diseases of the digestive system complicating pregnancy, third trimester; K029: Dental caries, unspecified; Z3A34: 34 weeks gestation of pregnancy; O99513: Diseases of the respiratory system complicating pregnancy, third trimester; J45998: Other asthma; O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium; O99013: Anemia complicating pregnancy, third trimester; O99283: Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester; E890: Postprocedural hypothyroidism; Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; M170: Bilateral primary osteoarthritis of knee; M479: Spondylosis, unspecified; Z853: Personal history of malignant neoplasm of breast; Z85850: Personal history of malignant neoplasm of thyroid; Z87891: Personal history of nicotine dependence; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are Z87891, K219. The uncommon codes mentioned in this dataset are O99613, K029, Z3A34, O99513, J45998, O9989, O99013, O99283, E890, Y836, M170, M479, Z853, Z85850. Allergies Percocet cucumber Tegaderm Chief Complaint cracked tooth s p fall Major Surgical or Invasive Procedure tooth extraction History of Present Illness Patient is a ___ year old G1P0 at ___ by U S w h o breast CA on DDAC chemotherapy in pregnancy and thyroid CA who presents after transfer from ED for tooth pain and for evaluation after a fall two days ago when she tripped on the ice and hit her shoulder. She reports progressive dental pain in the right lower molar. She has been unable to get dental treatment of her fractured molar in the outpatient setting due to concerns about pregnancy and medical complexity. She was therefore referred to the ED. OMFS was consulted while she was in the ED w plan for removal in the OR tomorrow. Findings included cracked tooth 29 w carriers extending to pulp. The patient was sent to OB triage given the mechanical fall. The patient denies any abdominal trauma or bruising. She has been having very irregular cramping no contractions. She also reports intermittent sharp shooting pain from the groin to her belly button. Not exacerbated by anything. Pain cannot be reproduced. She denies and VB or LOF. Past Medical History PNC ___ ___ by US Labs Rh ab neg RPRNR RI HBsAg neg HIV neg GBS unknown Genetics LR ERA FFS wnl GLT wnl US ___ 67 breech ___ nl fluid anterior placenta Issues breast cancer in pregnancy unilateral mastectomy w sentinel LN biopsy s p chemotherapy completed ___ plan for PP tamoxifen mild asthma History of papillary thyroid cancer x 2 on levothyroxine 175mcg daily labs ___ TSH 4.3 elevated but normal FT4 1.1 ROS per hpi GYNHx h o breast cancer OBHx G1 current PMH h o breast cancer mild asthma h o papillary PSH s p unilateral mastectomy w sentinel LN biopsy Social History ___ Family History Family history Aunt and mother with ALS. Mother aunt grandmother ___. Father prostate cancer age ___ Physical Exam On admission ___ 19 03Temp. 98.0 F ___ 19 03BP 121 65 76 ___ ___ 69 ___ ___ 67 GEN NAD Respiratory no increased WOB Abdomen no bruising non tender gravid SVE LCP TAUS vtx anterior placenta no sonographic evidence of abruption MVP 5.4 FHT 130 moderate accels no decels On discharge VS 98.0 114 71 73 16 O2 96 Gen x NAD Resp x No evidence of respiratory distress Abd x soft x non tender Ext x no edema x non tender Date ___ Time ___ FHT 120s mod var accels no decels reactive Toco occ ctx Pertinent Results n a Brief Hospital Course Patient is a ___ year old G1 with hx of breast CA on DDAC chemotherapy in pregnancy and thyroid CA admitted at 34w2d after a fall. On admission she had no evidence of abruption or preterm labor. She reported mild cramping and her cervix was LCP. Fetal testing was reassuring. She also had a painful cracked tooth and had been evaluated by OMFS in the emergency room. A plan was made for extraction in the OR. On HD 2 she underwent an uncomplicated tooth extraction under local anesthesia. Her pain resolved. She continued to have some intermittent cramping and pink discharge however she had no evidence of preterm labor. She was discharged to home in stable condition on HD 3 and will have close outpatient follow up. Medications on Admission albuterol levothyroxine Discharge Medications Acetaminophen 1000 mg PO Q6H PRN Pain Mild RX acetaminophen 500 mg ___ tablet s by mouth every 6 hours Disp 50 Tablet Refills 0 Levothyroxine Sodium 200 mcg PO DAILY Discharge Disposition Home Discharge Diagnosis Cracked tooth Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were admitted to the ___ service for monitoring after a fall and prior to your procedure with the oral surgeons for a tooth extraction. You procedure went well and your baby was monitored before and after the procedure. You are now stable to be discharged home. Please see instructions below. You should continue biting down on a piece of gauze for 30 minute interval. You may stop after ___ gauze changes. You should NOT have any hot solid foods for the time being. You may continue drinking cool liquids. You may transition to soft foods eggs pasta pancake tonight. For pain control you may take Tylenol as needed do not take more than 4000mg in 24 hours . Please call your primary dentist with any questions or concerns. Please call the office for Worsening painful or regular contractions Vaginal bleeding Leakage of water or concern that your water broke Abdominal pain Nausea vomiting Fever chills Decreased fetal movement Other concerns Followup Instructions ___ The icd codes present in this text will be O99613, K029, Z3A34, O99513, J45998, O9989, O99013, O99283, E890, Y836, M170, M479, Z853, Z85850, Z87891, K219. The descriptions of icd codes O99613, K029, Z3A34, O99513, J45998, O9989, O99013, O99283, E890, Y836, M170, M479, Z853, Z85850, Z87891, K219 are O99613: Diseases of the digestive system complicating pregnancy, third trimester; K029: Dental caries, unspecified; Z3A34: 34 weeks gestation of pregnancy; O99513: Diseases of the respiratory system complicating pregnancy, third trimester; J45998: Other asthma; O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium; O99013: Anemia complicating pregnancy, third trimester; O99283: Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester; E890: Postprocedural hypothyroidism; Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; M170: Bilateral primary osteoarthritis of knee; M479: Spondylosis, unspecified; Z853: Personal history of malignant neoplasm of breast; Z85850: Personal history of malignant neoplasm of thyroid; Z87891: Personal history of nicotine dependence; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are Z87891, K219. The uncommon codes mentioned in this dataset are O99613, K029, Z3A34, O99513, J45998, O9989, O99013, O99283, E890, Y836, M170, M479, Z853, Z85850.
The icd codes present in this text will be O9A112, C50412, O99512, Y836, E890, O99282, O26852, Z3A14, Z170, J45909, Z85850, Z87891. The descriptions of icd codes O9A112, C50412, O99512, Y836, E890, O99282, O26852, Z3A14, Z170, J45909, Z85850, Z87891 are O9A112: Malignant neoplasm complicating pregnancy, second trimester; C50412: Malignant neoplasm of upper-outer quadrant of left female breast; O99512: Diseases of the respiratory system complicating pregnancy, second trimester; Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; E890: Postprocedural hypothyroidism; O99282: Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester; O26852: Spotting complicating pregnancy, second trimester; Z3A14: 14 weeks gestation of pregnancy; Z170: Estrogen receptor positive status [ER+]; J45909: Unspecified asthma, uncomplicated; Z85850: Personal history of malignant neoplasm of thyroid; Z87891: Personal history of nicotine dependence. The common codes which frequently come are J45909, Z87891. The uncommon codes mentioned in this dataset are O9A112, C50412, O99512, Y836, E890, O99282, O26852, Z3A14, Z170, Z85850. Allergies Percocet cucumber Chief Complaint Left breast invasive ductal carcinoma Major Surgical or Invasive Procedure LEFT BREAST TOTAL MASTECTOMY W SENTINEL LYMPH NODE BIOPSY ___ History of Present Illness Ms ___ is a ___ year old pregnant female with breast cancer. She had a palpable left breast lump underwent ultrasound MRI and core biopsy that showed a grade 2 invasive ductal carcinoma ER positive PR positive HER2 negative. She later was found to be pregnant. She is currently feeling fine apart from tiredness. She reports that her levothyroxine dose was increased earlier this week. She also notes some left nipple crusting that there initially after the biopsy was some bloody output that has since declined and become mild and crusty. Otherwise no changes. Past Medical History PAST MEDICAL HISTORY thyroid CA postsurgical hypothyroidism IBS ovarian cysts PID spine arthritis asthma mononucleosisreported history of Lyme disease status post 3 weeks of antibiotic therapy. Hashimotos negative prior to surgery per her report Social History ___ Family History Family history Aunt and mother with ALS. Mother aunt grandmother ___. Father prostate cancer age ___. Physical Exam VS Refer to flowsheet GEN WD WN in NAD CV RRR PULM no respiratory distress BREAST L breast No evidence of hematoma seroma. Small amount of ecchymoses. Mildly tender to palpation. Incision healing well. ABD soft NT ND EXT WWP NEURO A Ox3 Brief Hospital Course The patient was admitted on ___ with left breast invasive ductal carcinoma for left total mastectomy and left axillary sentinel lymph node biopsy with Dr. ___. Please see operative note. The patient tolerated the procedure well. There were no immediate complications. She was awoken from general anesthesia in the operating room and transferred to the recovery room in stable condition. On post operative check she reported pain at the site of the incision and nausea and had an episode of emesis. The OB GYN team recommended pain control with Dilaudid. She was placed on subQ heparin and compression devices for prophylaxis. She tolerated a regular diet. On ___ the pain continued to have pain which was discussed with OB GYN and her dosage of Dilaudid was increased. She was given stool softener given the usage of narcotics. She reported some mild pink spotting which was discussed with OB and they performed an ultrasound which showed a strong fetal heart rate of 158. Per their report she has been spotting since earlier in the pregnancy as well. The dressing on the incision site continued to be clean dry and intact. There was no ecchymoses or hematoma on the chest wall. Drain output was serosanguineous. At the time of discharge on ___ vitals were stable pain well controlled and patient felt ready for discharge to home with ___ with follow up appointments in place. Medications on Admission Meds Allergies reviewed in OMR and medications listed here ALBUTEROL SULFATE PROAIR HFA Dosage uncertain Prescribed by Other Provider LEVOTHYROXINE levothyroxine 175 mcg tablet. 1 tablet s by mouth daily in the morning on empty stomach 90 minutes prior to any food or other meds PNV ___ FUMARATE FA PRENATAL Dosage uncertain Prescribed by Other Provider Discharge Medications 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. HYDROmorphone Dilaudid ___ mg PO Q3H PRN Pain Severe 4. Albuterol Inhaler ___ PUFF IH Q6H PRN wheezing dyspnea 5. Levothyroxine Sodium 175 mcg PO DAILY 6. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis left breast invasive ductal carcinoma Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were admitted to ___ for LEFT BREAST TOTAL MASTECTOMY W SENTINEL LYMPH NODE BIOPSY. You are now stable for discharge. Personal Care 1. You may keep your incisions open to air or covered with a clean sterile gauze that you change daily. 2. Clean around the drain site s where the tubing exits the skin with soap and water. 3. Strip drain tubing empty bulb s and record output s ___ times per day. 4. A written record of the daily output from each drain should be brought to every follow up appointment. Your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. You may wear a surgical bra or soft loose camisole for comfort. 6. You may shower daily with assistance as needed. Be sure to secure your drains so they don t hang down loosely and pull out. 7. The Dermabond skin glue will begin to flake off in about ___ days. Activity 1. You may resume your regular diet. 2. Walk several times a day. 3. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. Medications 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 3. Take prescription pain medications for pain not relieved by Tylenol. 4. Take Colace 100 mg by mouth 2 times per day while taking the prescription pain medication. You may use a different over the counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc. you should continue drinking fluids you may take stool softeners and should eat foods that are high in fiber. Call the office IMMEDIATELY if you have any of the following 1. Signs of infection fever with chills increased redness swelling warmth or tenderness at the surgical site or unusual drainage from the incision s . 2. A large amount of bleeding from the incision s or drain s . 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. Return to the ER if If you are vomiting and cannot keep in fluids or your medications. If you have shaking chills fever greater than 101.5 F degrees or 38 C degrees increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you. Any serious change in your symptoms or any new symptoms that concern you. DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Please assist patient with drain care. A daily log of individual drain outputs should be maintained and brought with patient to follow up appointment with your surgeon. Followup Instructions ___ The icd codes present in this text will be O9A112, C50412, O99512, Y836, E890, O99282, O26852, Z3A14, Z170, J45909, Z85850, Z87891. The descriptions of icd codes O9A112, C50412, O99512, Y836, E890, O99282, O26852, Z3A14, Z170, J45909, Z85850, Z87891 are O9A112: Malignant neoplasm complicating pregnancy, second trimester; C50412: Malignant neoplasm of upper-outer quadrant of left female breast; O99512: Diseases of the respiratory system complicating pregnancy, second trimester; Y836: Removal of other organ (partial) (total) as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; E890: Postprocedural hypothyroidism; O99282: Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester; O26852: Spotting complicating pregnancy, second trimester; Z3A14: 14 weeks gestation of pregnancy; Z170: Estrogen receptor positive status [ER+]; J45909: Unspecified asthma, uncomplicated; Z85850: Personal history of malignant neoplasm of thyroid; Z87891: Personal history of nicotine dependence. The common codes which frequently come are J45909, Z87891. The uncommon codes mentioned in this dataset are O9A112, C50412, O99512, Y836, E890, O99282, O26852, Z3A14, Z170, Z85850.
The icd codes present in this text will be Z421, Z4001, T85898A, Y834, Y92238, J4520, E890, F329, R509, Z9012, Z853, Z85850. The descriptions of icd codes Z421, Z4001, T85898A, Y834, Y92238, J4520, E890, F329, R509, Z9012, Z853, Z85850 are Z421: Encounter for breast reconstruction following mastectomy; Z4001: Encounter for prophylactic removal of breast; T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter; Y834: Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92238: Other place in hospital as the place of occurrence of the external cause; J4520: Mild intermittent asthma, uncomplicated; E890: Postprocedural hypothyroidism; F329: Major depressive disorder, single episode, unspecified; R509: Fever, unspecified; Z9012: Acquired absence of left breast and nipple; Z853: Personal history of malignant neoplasm of breast; Z85850: Personal history of malignant neoplasm of thyroid. The common codes which frequently come are F329. The uncommon codes mentioned in this dataset are Z421, Z4001, T85898A, Y834, Y92238, J4520, E890, R509, Z9012, Z853, Z85850. Allergies cucumber Tegaderm Chief Complaint Surgical absence of L breast Major Surgical or Invasive Procedure 1 ___ Right prophylactic mastectomy bilateral ___ reconstruction 2 ___ take back to OR for exploration of left flap vessels History of Present Illness ___ is a ___ year old female with history of L breast cancer Stage I IDC and Paget s and previous left sided mastectomy SLNB. She was admitted to the hospital after her prophylactic R mastectomy with ___ reconstruction on ___. She was taken back to the OR on ___ for flap exploration due to declining Vioptix recordings. Past Medical History PNC ___ ___ by US Labs Rh ab neg RPRNR RI HBsAg neg HIV neg GBS unknown Genetics LR ERA FFS wnl GLT wnl US ___ 67 breech ___ nl fluid anterior placenta Issues breast cancer in pregnancy unilateral mastectomy w sentinel LN biopsy s p chemotherapy completed ___ plan for PP tamoxifen mild asthma History of papillary thyroid cancer x 2 on levothyroxine 175mcg daily labs ___ TSH 4.3 elevated but normal FT4 1.1 ROS per hpi GYNHx h o breast cancer OBHx G1 current PMH h o breast cancer mild asthma h o papillary PSH s p unilateral mastectomy w sentinel LN biopsy Social History ___ Family History Family history Aunt and mother with ALS. Mother aunt grandmother ___. Father prostate cancer age ___ Physical Exam Gen Well appearing F in no acute distress. HEENT Normocephalic. Sclerae anicteric. CV RRR R Breathing comfortably on room air. No wheezing. Breasts Bilateral reconstructed breasts soft and without palpable fluid collection right mastectomy flap with lateral ecchymosis ___ skin paddles warm bilaterally with good capillary refill JP drains x 2 to bulb suction draining serosanguinous fluid Abdomen Soft non distended umbilicus viable lower abdominal incision without erythema or drainage JP drains x2 to bulb suction draining serosanguinous fluid Ext No cyanosis or edema Pertinent Results ___ 04 38AM BLOOD WBC 12.0 RBC 2.88 Hgb 8.8 Hct 26.3 MCV 91 MCH 30.6 MCHC 33.5 RDW 13.2 RDWSD 44.3 Plt ___ ___ 03 44AM BLOOD WBC 11.3 RBC 3.32 Hgb 10.2 Hct 29.5 MCV 89 MCH 30.7 MCHC 34.6 RDW 13.0 RDWSD 42.0 Plt ___ OR Right prophylactic mastectomy bilateral ___ reconstruction. Per protocol patient stayed in PACU overnight. ___ OR Patient was recovering well in PACU with morning plan of clear liquid diet out of bed to chair and transfer to floor. However Vioptix signal of Left breast with declining values so patient taken back to OR for exploration of L breast flap. Again stayed in PACU overnight per protocol ___ Recovering well. Febrile overnight to 103 but nurse removed BAIR hugger and re measured temperature at 99. clear liquid diet out of bed to chair transfer to floor She was admitted to the plastic surgery service where she was began the ___ postoperative pathway. She was given ASA 121.5 daily to be continued at discharge Ancef transitioned to Duricef at discharge and SCH during her stay. She will discharge home 4 with drains in place to be removed at office visit. She will daily bacitracin BID application to right mastectomy flap necrosis site. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 175 mcg PO DAILY 2. BuPROPion XL Once Daily 300 mg PO DAILY 3. albuterol sulfate 90 mcg actuation inhalation Q6H PRN Discharge Medications Resume taking your previous home prescriptions including 1. Levothyroxine Sodium 175 mcg PO DAILY 2. BuPROPion XL Once Daily 300 mg PO DAILY 3. albuterol sulfate 90 mcg actuation inhalation Q6H PRN 4. LIDOCAINE PRILOCAINE lidocaine prilocaine 2.5 2.5 topical cream. Apply thick layer to port a cath site at least 30 minutes prior to port access. C Not Taking as Prescribed 5. OMEPRAZOLE omeprazole 20 mg capsule delayed release. 1 capsule by mouth daily for heartburn symptoms Not Taking as Prescribed 6. TAMOXIFEN tamoxifen 20 mg tablet. 1 tablet s by mouth daily In addition patient discharged with these new medications 1. Aspirin 121.5 mg QD for 1 month 2. Duricef 500mg PO BID x7 days w 1 refill 2. Oxycodone ___ tablets q4 6 hours 50 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Surgical absence of left breast breast cancer Discharge Condition Awake alert oriented. Stable Discharge Instructions Personal Care 1. You may keep your incisions open to air or covered with a clean ___ ile gauze that you change daily. If any areas develop blistering you will need to apply Bactroban cream twice a day. 2. Clean around the drain site s where the tubing exits the skin w ith soap and water. 3. Strip drain tubing empty bulb s and record output s ___ times per day. 4. A written record of the daily output from each drain should be broug ht to every follow up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. DO NOT wear a normal bra for 3 weeks. You may wear a soft loose camisole for comfort. 6. You may shower daily with assistance as needed. Be sure to secure your upper drains to a lanyard that hangs down from your neck so they don t hang down and pull out. Y ___ may secure your lower drains to a fabric belt tied around your waist. 7. The Dermabond skin glue will begin to flake off in about ___ days. 8. No pressure on your chest or abdomen 9. Okay to shower but no baths until after directed by your doctor. . Activity 1. You may resume your regular diet. 2. Keep hips flexed at all times and then gradually stand upright as tolerated. 3. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity for 6 weeks following surgery. . Medications 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered . 2. You may take your prescribed pain medication for moderate to severe ___ n. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging 3. Take prescription pain medications for pain not relieved by tyleno l. 4. Take Colace 100 mg by mouth 2 times per day while taking the prescript ion pain medication. You may use a different over the counter stool softener if you wish. 5. Do not drive or operate heavy machinery while taking any narcotic pain m edication. You may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc. you should continue drinking fluids you may take stool soften ers and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following 1. Signs of infection fever with chills increased redness sw ___ warmth or tenderness at the surgical site or unusual drainage from the incision s . 2. A large amount of bleeding from the incision s or drain s . 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if If you are vomiting and cannot keep in fluids or your medications. If you have shaking chills fever greater than 101.5 F degrees or 38 C ___ es increased redness swelling or discharge from incision chest pain shortness of breath or anything else that is troubling you. Any serious change in your symptoms or any new symptoms that concern you. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a c lean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perfo rm drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of d rainage fluid on the record sheet. Reestablish drain suction. Followup Instructions ___ The icd codes present in this text will be Z421, Z4001, T85898A, Y834, Y92238, J4520, E890, F329, R509, Z9012, Z853, Z85850. The descriptions of icd codes Z421, Z4001, T85898A, Y834, Y92238, J4520, E890, F329, R509, Z9012, Z853, Z85850 are Z421: Encounter for breast reconstruction following mastectomy; Z4001: Encounter for prophylactic removal of breast; T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter; Y834: Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92238: Other place in hospital as the place of occurrence of the external cause; J4520: Mild intermittent asthma, uncomplicated; E890: Postprocedural hypothyroidism; F329: Major depressive disorder, single episode, unspecified; R509: Fever, unspecified; Z9012: Acquired absence of left breast and nipple; Z853: Personal history of malignant neoplasm of breast; Z85850: Personal history of malignant neoplasm of thyroid. The common codes which frequently come are F329. The uncommon codes mentioned in this dataset are Z421, Z4001, T85898A, Y834, Y92238, J4520, E890, R509, Z9012, Z853, Z85850.
The icd codes present in this text will be F1994, B20, F1490, F1099, F209, Z87820, B1920, Z87891. The descriptions of icd codes F1994, B20, F1490, F1099, F209, Z87820, B1920, Z87891 are F1994: Other psychoactive substance use, unspecified with psychoactive substance-induced mood disorder; B20: Human immunodeficiency virus [HIV] disease; F1490: Cocaine use, unspecified, uncomplicated; F1099: Alcohol use, unspecified with unspecified alcohol-induced disorder; F209: Schizophrenia, unspecified; Z87820: Personal history of traumatic brain injury; B1920: Unspecified viral hepatitis C without hepatic coma; Z87891: Personal history of nicotine dependence. The common codes which frequently come are Z87891. The uncommon codes mentioned in this dataset are F1994, B20, F1490, F1099, F209, Z87820, B1920. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint I m still hearing the voices Major Surgical or Invasive Procedure None History of Present Illness Please see psychiatry consult notes by Drs ___ and ___ dated ___ for details of HPI past psychiatric medical family and social histories. Additionally please refer to medicine discharge summary dated ___ for details of medicine ICU and floor course. Briefly this is a ___ y o homeless ___ F with PMH of TBI HIV not on HAART HCV not treated and past psychiatric hx of polysubstance abuse EtOH crack cocaine and heroin unspecified mood disorder MDD with psychotic features vs. ___ mood disorder and chronic AH who presented to the ED from ___ station with tangential thoughts and complaint of repeat head strikes after multiple falls. She was found to be exhibiting signs of severe EtOH withdrawal and was admitted to the ICU where she was initiated on the phenobarb protocol. She was transferred to the medical On arrival to Deac 4 Pt stated that she was continuing to hear voices and have suicidal thoughts. She declined to give details regarding her SI stating why would I tell you about it I would just do it. She also notes and obviously you guys are not gonna give me a razor to shave with or anything. She reported that the voices she hears are both male and female. They are not voices that she recognizes and she cannot make out what they are saying. They are frequently worse as she tries to fall asleep. She has a difficult time discerning whether they have been bothering her more frequently during the past several weeks because she has been drinking and maybe doing crack. She becomes fixated on a story about smoking a crack pipe and throwing it onto the ground where any kid could pick it up and light it and smoke it and she retells this multiple times. Past Medical History PAST PSYCHIATRIC HISTORY Per Dr. ___ note ___ confirmed with ___ and updated as relevant Diagnosis on discharge from ___ 4 on ___ MDD with psychotic features vs. ___ mood disorder Hospitalizations ___ reports many prior hospitalizations 10 including Arbour 20 detox admissions per OMR . Most recent hospitalization at ___ with discharge one day prior to ED presentation ___ . Suicide ___ stated she ODed on Amitriptyline ___ years ago per prior records stated she took ___ pills went to sleep on a park bench and then woke up and went to her shelter did not go to the hospital. In the past she has also reported ingestion of alcohol as a possible suicide attempt and a suicide attempt in ___ by overdose on unknown pills to ED staff. ___ 4 discharge summary dated ___ Per pt OD on Ultram probably to hurt her self ___ yrs ago Violence ___ Medication Trials Reports h o successful treatment with Zoloft denies knowledge of when . Also reports being txed with Haldol once and states she took too much and my jaw was locked for ___ hours. Past documentation from ___ 4 discharge summary dated ___ stated h o treatment with Elavil. BEST indicated previous reported treatment with Risperdal. OMR reveals past tx with Risperdal and Zoloft last filled ___. Stabilized on Deac 4 during most recent hospitalization with Amitriptyline and Seroquel. Treaters Denies past or present outpatient psychiatric treaters. Per records last had pending appointment at ___ for psychiatry Dr. ___ ___ at 9 AM . Currently states she doesn t remember last time she saw psych. Access to weapons Denies PAST MEDICAL HISTORY PCP ___ MD HIV not currently taking antiretrovirals today denies that she has HIV at all. Hepatitis C H o head injury Per ___ 4 ___ summary ___ pt reports she was assaulted and subsequently received 300 stitches was hospitalized x 2wks and underwent rehab at ___ she denies LOC or persistent deficits but receives SSDI for this injury HOME MEDICATIONS Not currently taking any medications. Per Deac 4 Discharge Summary dated ___ 1. Amitriptyline 50 mg PO QHS 2. QUEtiapine Fumarate 50 mg PO QHS Social History SUBSTANCE ABUSE HISTORY Per Dr. ___ note ___ confirmed with ___ and updated as relevant Alcohol ___ reports starting drinking age ___ due to conflict with parents. Reports numerous detox admissions 20 per OMR . States that she was sober from ___ and only involved with AA for 1 week of that time which she stopped because she did not like it . Most recent drink was 13 nips of vodka today. Currently states she drinks about 1x week. Denies history of complicated alcohol withdrawal but has required benzodiazepines during detox admissions. Benzodiazepines Denies lifetime illicit use. Reports only use in detox when prescribed. Marijuana Reports remote use in high school denies recent use. Crack cocaine Denies current use though say she has used in the past. Heroin Reports h o IVDU w heroin ___ years previously reported ending ___ yrs ago. Denies current use. Tobacco past smoker but denies currently. FORENSIC HISTORY Says not lately and can t remember last time. Per Dr. ___ note ___ Inconsistent history said she spent ___ yrs in jail for shoplifting drug related issues. Then states she was last in jail probably in early ___ Family History States she doesn t know. Physical Exam VS T 98.4 P 106 BP 137 90 RR 16 SpO2 100 RA General ___ in no apparent distress. Appears stated age. HEENT Normocephalic. PERRL EOMI. Oropharynx clear. Neck Supple trachea midline. No adenopathy or thyromegaly. Back No significant deformity no focal tenderness. Lungs Clear to auscultation no crackles or wheezes. CV Regular rate and rhythm no murmurs rubs gallops 2 pedal pulses. Abdomen Soft nontender nondistended no masses or organomegaly. Extremities No clubbing cyanosis or edema. Skin Warm and dry no rashes scars or lesions. Neurological Cranial Nerves I Not tested. II Pupils equally round and reactive to light bilaterally. Visual fields are full to confrontation. III IV VI Extraocular movements intact bilaterally significant horizontal nystagmus 7 beats bilaterally. V VII Facial strength and sensation intact and symmetric. VIII Hearing intact to voice. IX X Palatal elevation symmetrical. XI Sternocleidomastoid and trapezius normal bilaterally. XII Tongue midline without fasciculations. Motor Normal bulk and tone bilaterally. No abnormal movements no tremor. Strength full power ___ throughout. No gross focal motor or sensory deficits normal gait. Coordination Normal on ___. Deep tendon reflexes 2 and symmetrical toes downgoing. Sensation intact to light touch position sense intact. Gait steady no truncal ataxia normal stance and posture. Romberg negative. Pertinent Results ___ 06 05AM ___ ___ ___ 06 05AM ___ ___ IM ___ ___ ___ 06 05AM PLT ___ ___ 06 05AM ___ ___ ABS ___ ABS ___ ABS ___ ABS ___ Brief Hospital Course SAFETY ___ was placed on 15 minute checks on admission and remained here on that level of observation throughout. She was unit restricted. There were no acute safety issues during this hospitalization. LEGAL ___ PSYCHIATRIC ___ is a ___ year old ___ female with a history of TBI HIV not on HAART therapy HCV not treated polysubstance use EtOH crack cocaine and heroin unspecified mood disorder and chronic auditory hallucinations who presented to the emergency department on ___ with alcohol intoxication tangential thoughts and complaints of repeated head strikes now s p ICU medicine course for alcohol withdrawal with phenobarbital taper. On the unit ___ was started on quetiapine uptitrated to 300 mg BID and on sertraline 25 mg daily to good effect. ___ did well on the unit and attended groups regularly. She recognized effect illicit drugs and alcohol have had on her mental health social situation and interpersonal relationships. Although she has a history of multiple relapses failing to ___ and medication nonadherence she kept repeating that this admission was different and that she wants to maintain her sobriety. She showered daily and had no issues with sleep or appetite. On the day of discharge ___ endorsed exhibited good mood and euthymic affect. Denied SI HI and AVH. She expressed continued motivation to maintain her sobriety do 90 AA meetings in 90 days and desire to ___ at ___. A ___ application was submitted. Her PCP was updated on the plan and ___ appointments were coordinated. MEDICAL HIV ___ not currently taking HAART. Most recent CD4 count 42 on ___. Continued Bactrim DS 1 tab daily for PCP ppx ___ has appointment with Dr. ___ on ___ on ___ to discuss reinitiation of HAART Hepatitis C HCV Ab positive on ___. Not treated. ___ has appointment with Dr. ___ on ___ on ___ to discuss treatment PSYCHOSOCIAL GROUPS MILIEU ___ was encouraged to participate in unit s groups milieu and therapy opportunities. Usage of coping skills mindfulness and relaxation methods were encouraged. Therapy addressed family social work and housing issues. The ___ enjoyed groups and participated. She also participated in AA meetings on the unit. COLLATERAL CONTACTS Treaters PCP Dr. ___ Records Per OMR Family ___ refused family meetings FAMILY INVOLVEMENT Despite encouragement from the team throughout her admission ___ refused family meetings. INTERVENTIONS D Referral The team submitted a DMH application for the ___ to receive services and ___ support. Pharmacological treatment Quetiapine and sertraline as above. Individual group milieu therapy Coordinated aftercare with SW INFORMED CONSENT Quetiapine sertraline The Team discussed the indications for intended benefits of and possible side effects and risks of this medication and risks and benefits of possible alternatives including not taking the medication with this ___. We discussed the ___ right to decide whether to take this medication as well as the importance of the ___ actively participating in the treatment and discussing any questions about medications with the treatment team and I answered the ___ questions. The ___ appeared able to understand and consented to begin the medication. RISK ASSESSMENT Low imminent risk of harm violence to self others. Chronic Static Risk Factors Chronic mental illness chronic medical illness single ongoing homelessness. Modifiable Risk Factors Acute major mood episode with suicidal ideation Modified by medication adjustments and psychotherapeutic interventions as above. Active polysubstance misuse Modified by phenobarbital taper while on medical floor for alcohol withdrawal and detox attendance to AA meetings on the unit list of free substance use recovery resources in the community. Limited outpatient social support Modified by aftercare planning with SW outpatient appointments list of community resources. ___ Modified by counseling on the unit. ___ was adherent with medications on the unit. Protective Factors Protective factors include current outpatient providers treatment knowledge of community resources motivation to maintain sobriety ___ and ___ behaviors. PROGNOSIS Good ___ was engaged on the unit adherent with medications and attended groups regularly. She has outpatient appointments and community resources. Current risk is low for intentional ___ given that ___ denies suicidal ideation intent and plan is accepting of treatment is currently sober and is ___ with plans. Medications on Admission ___ was not taking medications prior to admission. Per Deac 4 Discharge Summary dated ___ 1. Amitriptyline 50 mg PO QHS 2. QUEtiapine Fumarate 50 mg PO QHS Discharge Medications 1. Sulfameth Trimethoprim DS 1 TAB PO DAILY RX ___ Bactrim DS 800 ___ mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 2. QUEtiapine Fumarate 300 mg PO BID RX quetiapine Seroquel 100 mg 3 tablet s by mouth twice a day Disp 180 Tablet Refills 0 3. Sertraline 25 mg PO DAILY RX sertraline Zoloft 25 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 Discharge Disposition Home Discharge Diagnosis Unspecified psychotic disorder ___ vs. schizophrenia spectrum EtOH use disorder Cocaine use disorder Heroin use disorder in full sustained remission Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Mental Status Examination Appearance Woman who appears older than stated age wearing jeans and a sweater tattoo on neck hair in a bun appropriate hygiene no acute distress. Behavior Good eye contact cooperative engaged. No psychomotor agitation retardation. Mood and Affect Good Mostly euthymic some smiling. Speech Normal rate volume rhythm prosody articulation. Fluent in ___. Thought process Linear and ___. No loosening of associations. Thought Content Denies SI HI and AVH. Focused on maintaining her sobriety. Judgment and Insight Fair Fair. ___ recognizes effect drug use has had on her mental health social situation and interpersonal relationships. She has a history of multiple relapses failing to ___ and medication nonadherence but keeps repeating that this admission is different and that she wants to maintain her sobriety. Cognition Awake alert attentive throughout interview. Memory intact to recent and remote history. Discharge Instructions You were hospitalized at ___ for alcohol detox depressed mood and suicidal ideation. We adjusted your medications and you are now ready for discharge and continued treatment on an outpatient basis. Please follow up with all outpatient appointments as listed take this discharge paperwork to your appointments. Please continue all medications as directed. Please avoid abusing alcohol and any drugs whether prescription drugs or illegal drugs as this can further worsen your medical and psychiatric illnesses. Please contact your outpatient psychiatrist or other providers if you have any concerns. Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you and we wish you the best of health. Followup Instructions ___ The icd codes present in this text will be F1994, B20, F1490, F1099, F209, Z87820, B1920, Z87891. The descriptions of icd codes F1994, B20, F1490, F1099, F209, Z87820, B1920, Z87891 are F1994: Other psychoactive substance use, unspecified with psychoactive substance-induced mood disorder; B20: Human immunodeficiency virus [HIV] disease; F1490: Cocaine use, unspecified, uncomplicated; F1099: Alcohol use, unspecified with unspecified alcohol-induced disorder; F209: Schizophrenia, unspecified; Z87820: Personal history of traumatic brain injury; B1920: Unspecified viral hepatitis C without hepatic coma; Z87891: Personal history of nicotine dependence. The common codes which frequently come are Z87891. The uncommon codes mentioned in this dataset are F1994, B20, F1490, F1099, F209, Z87820, B1920.
The icd codes present in this text will be F10239, F1110, R45851, Z87820, B1920, Z23, Z590, F1410, R509, F29, Z21, Z9114, D72819. The descriptions of icd codes F10239, F1110, R45851, Z87820, B1920, Z23, Z590, F1410, R509, F29, Z21, Z9114, D72819 are F10239: Alcohol dependence with withdrawal, unspecified; F1110: Opioid abuse, uncomplicated; R45851: Suicidal ideations; Z87820: Personal history of traumatic brain injury; B1920: Unspecified viral hepatitis C without hepatic coma; Z23: Encounter for immunization; Z590: Homelessness; F1410: Cocaine abuse, uncomplicated; R509: Fever, unspecified; F29: Unspecified psychosis not due to a substance or known physiological condition; Z21: Asymptomatic human immunodeficiency virus [HIV] infection status; Z9114: Patient's other noncompliance with medication regimen; D72819: Decreased white blood cell count, unspecified. The uncommon codes mentioned in this dataset are F10239, F1110, R45851, Z87820, B1920, Z23, Z590, F1410, R509, F29, Z21, Z9114, D72819. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint alcohol intoxication Major Surgical or Invasive Procedure none History of Present Illness ___ y o ___ homeless F with PMH of TBI HIV HCV polysubstance abuse alcohol crack cocaine and heroin unspecified mood disorder MDD with psychotic features vs. substance induced mood disorder and chronic AH who presented from ___ station via EMS with complaint of multiple head strikes found to have EtOH intoxication and SI admitted to MICU for EtOH withdrawal and CIWA monitoring. Patient is noted to be a poor historian however she reports she hit her head multiple times today ___ falling asleep. Of note she reports active EtOH use and states her last drink was at 1200 on ___. She is unsure if she used other drugs medications. In addition she reports concern that she is having auditory hallucinations with the voices increasing in frequency. In addition patient reports active SI although she does not have a plan. In the ED initial vitals 98.2 88 150 98 16 100 RA. During time in ED patient became febrile to 101 a urinalysis urine cx CXR and blood cultures were sent. Exam notable for pleasant patient with poor hygiene dress tangential and appearing to respond to internal stimuli neuro intact no clear HEENT trauma mild upper thoracic tenderness tongue fasiculation Labs were notable for 2.9 9.9 33.6 168 Na 140 K 3.5 Cl 103 HCO3 24 BUN 15 Cr 0.6 Gluc 111 AGap 17 ALT 77 AST 196 AP 98 Tbili 0.6 Alb 3.9 Serum EtOH 21 Serum ASA Acetmnphn ___ Tricyc Negative Lactate 1.0 U A with ketones 6 WBCs few bacteria negative leuks negative nitrites Imaging showed NCHCT ___ 1. No acute intracranial abnormality. 2. Stable left parietal encephalomalacia. CXR ___ No acute cardiopulmonary abnormality or fracture. Patient was given 40mg diazepam 100mg thiamine MVI 1mg folic acid 30mg ketorolac 2L NS 1gm Tylenol Psychiatry was consulted who felt patient was disorganized and endorsing AH and SI no plan . Per their recommendations patient was placed on a ___ with a 1 1 sitter with admission to medicine for EtOH withdrawal On arrival to the MICU she was sleeping comfortably. Would open eyes to voice and answer questions but was overall very sleepy. Denies pain. Cannot articulate when last drink was says yesterday. Denies taking anything else. Past Medical History Per Dr. ___ ___ confirmed with patient and updated as relevant HIV Hepatitis C H o head injury Per Deac 4 DC summary ___ pt reports she was assaulted and subsequently received 300 stitches was hospitalized x 2wks and underwent rehab at ___ she denies LOC or persistent deficits but receives SSDI for this injury Social History Per Dr. ___ ___ confirmed with patient and updated as relevant The patient reports that she was born and raised in ___ and that her parents were separated while she was growing up. She states that she lives with her grandmother her whole life until ___ years ago when her mother died and that she has been living in the ___ since. She states that she has 2 daughters age ___ and ___ named ___ and ___ who are both enrolled at ___ and that she also has 2 grandchildren. Denies contact with parents whom she reports are not supportive. On today s interview patient reports no contact with her family reports having 3 living children 2 daughters and 1 son and 1 dead son. She has no contact with her children. She did not wish to elaborate further. Confirms living at ___. Family History Unknown pt refused to answer in past Physical Exam ADMISSION PHYSICAL EXAM Vitals 98.2 103 138 77 22 99 ra GEN lying in bed somnolent but wakes to voice NAD HEENT no scleral icterus PERRL mmm nl OP NECK supple no JVD CV tachycardic regular rhythm II VI systolic murmur PULM nl wob on ra LCAB no wheezes or crackles ABD soft mild distension normal bs nontender EXT warm trace bilateral edema 2 DP pulses SKIN no rashes or visible track marks NEURO sleepy oriented to person didn t answer re place or time answering questions then falls asleep moving all 4 extremities ACCESS PIV DISCHARGE PHYSICAL EXAM stable vital signs lying comfortably in bed. bilateral knee ecchymosis. Pertinent Results ADMISSION LABS ___ 03 27PM BLOOD WBC 2.9 RBC 3.81 Hgb 9.9 Hct 33.6 MCV 88 MCH 26.0 MCHC 29.5 RDW 17.9 RDWSD 56.8 Plt ___ ___ 03 27PM BLOOD Neuts 74.0 ___ Monos 4.5 Eos 0.7 Baso 0.3 AbsNeut 2.16 AbsLymp 0.60 AbsMono 0.13 AbsEos 0.02 AbsBaso 0.01 ___ 03 27PM BLOOD Glucose 111 UreaN 15 Creat 0.6 Na 140 K 3.5 Cl 103 HCO3 24 AnGap 17 ___ 03 27PM BLOOD ALT 77 AST 196 AlkPhos 98 TotBili 0.6 ___ 03 27PM BLOOD Albumin 3.9 ___ 03 27PM BLOOD Osmolal 295 ___ 03 27PM BLOOD ASA NEG Ethanol 21 Acetmnp NEG Bnzodzp NEG Barbitr NEG Tricycl NEG MICRO Blood cx pending Urine cx pending IMAGING STUDIES NCHCT ___ 1. No acute intracranial abnormality. 2. Stable left parietal encephalomalacia. CXR ___ No acute cardiopulmonary abnormality or fracture. DISCHARGE LABS Brief Hospital Course ___ y o ___ homeless F with PMHx of TBI HIV HCV polysubstance abuse alcohol crack cocaine and heroin unspecified mood disorder MDD with psychotic features vs. substance induced mood disorder and chronic AH who presented from ___ station via EMS with complaint of multiple head strikes found to have EtOH intoxication and SI admitted to MICU for EtOH withdrawal and CIWA monitoring now stabilized and transferred to the floor now medically stable for discharge to psychiatric facility ACTIVE ISSUES EtOH intoxication withdrawal on phenobarbital withdrawal protocol. Last drink ___. Patient was loaded with phenobarbital which may continue if the accepting psychiatric facility is okay with administering however there is no contraindication to discontinuing. Phenobarb protocol while inpatient stopped at discharge Continued MVI thiamine folate Hydroxyzine PRN for additional agitation seen by psychiatry and social work appreciated. Suicidal ideation patient repeatedly stating I have suicidal thoughts and I m depressed though is unable to fully elaborate. Psychiatry saw the patient and had the following recommendations Patient meets ___ criteria for involuntary admission may not leave AMA should continue 1 1 observation. Would hold on any psychiatric medications given acute alcohol withdrawal. If chemical restraint necessary please call psychiatry for specific recs. Please be aware that patient has cited jaw locking with Haldol administration in the past thus would consider alternative antipsychotic. seen by psychiatry recommended inpatient psychiatric placement and transferred to deac 4. FEVER Patient febrile to 101 in the ED. No localizing signs of symptoms of infection. Suspect that this was likely related to acute ingestion however given her murmur which has not been documented previously obtained TTE which showed no evidence of vegetation or endocarditis. Psychosis suspect this is part of underlying psych disorder and not necessarily alcoholic hallucinosis. Will defer to psychiatry. Appreciate Psychiatry recs CHRONIC STABLE ISSUES HIV not on HAART started Bactrim for PCP prophylaxis given last CD4 count was 200 will send repeat CD4 count on ___ if still inpatient. Patient was previously not taking her HAART medications will defer to outpatient. HCV not on active treatment Monitor LFTs as above Transitioanl issues Should see PCP re HIV and HCV once psychiatrically stabilized. Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amitriptyline 25 mg PO QHS 2. Triamcinolone Acetonide 0.1 Cream 1 Appl TP BID 3. Sulfameth Trimethoprim DS 1 TAB PO DAILY not taking 4. Emtricitabine Tenofovir Truvada 1 TAB PO DAILY not taking 5. Darunavir 600 mg PO BID not taking 6. RiTONAvir 100 mg PO DAILY not taking Discharge Medications 1. Sulfameth Trimethoprim DS 1 TAB PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Thiamine 100 mg PO DAILY Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Polysubstance abuse Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were admitted to ___ for evaluation of numerous falls alcohol and substance abuse. While you were here you were briefly in the intensive care unit where you were started on phenobarbital to help you withdrawal from alcohol and prevent delirium tremens. You also disclosed that you were not taking any of your HIV medications. You were started on Bactrim as prophylaxis for opportunistic infections and should follow up with your outpatient providers regarding restarting your HIV medications and for evaluation of your hepatitis C. You were deemed medically stable for discharge to a psychiatric facility. Followup Instructions ___ The icd codes present in this text will be F10239, F1110, R45851, Z87820, B1920, Z23, Z590, F1410, R509, F29, Z21, Z9114, D72819. The descriptions of icd codes F10239, F1110, R45851, Z87820, B1920, Z23, Z590, F1410, R509, F29, Z21, Z9114, D72819 are F10239: Alcohol dependence with withdrawal, unspecified; F1110: Opioid abuse, uncomplicated; R45851: Suicidal ideations; Z87820: Personal history of traumatic brain injury; B1920: Unspecified viral hepatitis C without hepatic coma; Z23: Encounter for immunization; Z590: Homelessness; F1410: Cocaine abuse, uncomplicated; R509: Fever, unspecified; F29: Unspecified psychosis not due to a substance or known physiological condition; Z21: Asymptomatic human immunodeficiency virus [HIV] infection status; Z9114: Patient's other noncompliance with medication regimen; D72819: Decreased white blood cell count, unspecified. The uncommon codes mentioned in this dataset are F10239, F1110, R45851, Z87820, B1920, Z23, Z590, F1410, R509, F29, Z21, Z9114, D72819.
The icd codes present in this text will be I340, I5032, Z006, D8689, E785, J45909, K219, N400, Z8042, G4733, Z8572, Z87891, Z9621, H9190. The descriptions of icd codes I340, I5032, Z006, D8689, E785, J45909, K219, N400, Z8042, G4733, Z8572, Z87891, Z9621, H9190 are I340: Nonrheumatic mitral (valve) insufficiency; I5032: Chronic diastolic (congestive) heart failure; Z006: Encounter for examination for normal comparison and control in clinical research program; D8689: Sarcoidosis of other sites; E785: Hyperlipidemia, unspecified; J45909: Unspecified asthma, uncomplicated; K219: Gastro-esophageal reflux disease without esophagitis; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z8042: Family history of malignant neoplasm of prostate; G4733: Obstructive sleep apnea (adult) (pediatric); Z8572: Personal history of non-Hodgkin lymphomas; Z87891: Personal history of nicotine dependence; Z9621: Cochlear implant status; H9190: Unspecified hearing loss, unspecified ear. The common codes which frequently come are I5032, E785, J45909, K219, N400, G4733, Z87891. The uncommon codes mentioned in this dataset are I340, Z006, D8689, Z8042, Z8572, Z9621, H9190. Allergies Ragweed Chief Complaint shortness of breath Major Surgical or Invasive Procedure s p TRANSCATHETER MITRAL VALVE REPAIR on ___ History of Present Illness ___ year old male with a past medical history of hyperlipidemia congestive heart failure EF 61 mitral regurgitation lymphoma sarcoidosis and obstructive sleep apnea who has been experiencing progressive dyspnea on exertion over the last several months. His most recent echo showed moderate to severe mitral regurgitation. He presented for planned mitraclip. Past Medical History CHF Mitral regurgitation CKD Hyperlipidemia OSA Asthma Duodenal ulcer Lymphoma GERD Sarcoidosis with pulmonary and intestinal involvement BPH Inflammatory bowel disease Hard of hearing with cochlear implants PSH cochlear implants cataract surgery knee surgery splenectomy hernia repair tonsillectomy appendectomy rotator cuff repair brain biopsy vasectomy Social History ___ Family History Mother ___ cardiac disease. Father diverticulosis peptic ulcer disease died at age ___. Maternal grandfather ___ cancer. Two siblings living and healthy. Physical Exam Admission PE VS 103 51 HR 63 SR O2 sat 99 RA Gen alert not oriented but answers to name and asking appropriate questions. NAD. Neuro PERLA CN ___ intact. MAE strengths ___. speech clear. Neck no JVD lying flat. CV RRR ___ diastolic course murmur at ___. Chest clear ant ABD soft NT Extr no edema feet warm pulses palp Skin intact warm and dry Access sites right fem DSD with no hematoma or ecchymosis. GU condom cath with clear urine Weight EKG ___ SR LAD nl intervals Tele SR . DC Gen alert talkative mildly confused Neuro PERLA CN ___ intact. MAE strengths ___. speech clear. Neck supple CV RRR ___ diastolic course murmur at LUSB. Chest clear ant ABD soft NT Extr no edema feet warm pulses palp Skin intact warm and dry Access sites right fem DSD with no hematoma or ecchymosis. Pertinent Results Admission labs ___ 12 53PM BLOOD WBC 10.1 RBC 3.44 Hgb 10.6 Hct 32.0 MCV 93 MCH 30.8 MCHC 33.1 RDW 14.4 RDWSD 48.7 Plt ___ ___ 12 53PM BLOOD ___ PTT 150 ___ ___ 12 53PM BLOOD Glucose 94 UreaN 21 Creat 1.2 Na 142 K 4.3 Cl 106 HCO3 24 AnGap 12 ___ 09 15AM BLOOD GGT 41 ___ 12 53PM BLOOD Calcium 8.6 Phos 3.4 Mg 1.6 ___ 09 15AM BLOOD Albumin 3.5 TRANSCATHETER MITRAL VALVE REPAIR ___ Transfemoral Extreme Risk MITRAL REGURGITATION Procedures TransSEPTAL transcatheter MITRAL valve repair Catheter Placement Mitraclip sheath right femoral vein Percutaneous mitral Valve case complexity required a multidisciplinary approach with Cardiac Surgery and Interventional Cardiology. Vascular access was obtained in the right femoral veinusing vascular ultrasound techniques. RHC and LHC performed by transeptal approach and showed significant V waves Transeptal Puncture was done Using Lamp 45 and needle under fluoro and TEE guidance to ensure 4 cm clearance from annulus Unfractionated heparin was given to achieve an ACT 250 seconds. A 0.035 confida wire was advanced through sheath and used to advance the Pascal Guide system The Pascal was advanced through the guide and positioned across A2 and P2 under fluoro and TEE guidance. First Grab resulted in only modest reduction in MR therefore the leaflets were released and independently grabbed again with reduction in MR to ___ and great hemodynamics no V waves . An additional device was placed with resultant 1 MR and gradient of 2 mmHg The clip were released and sheath pulled to RA. No significant shunting seen therefore sheath removed after proglide in preclose fashion and applying skin suture There was no evidence of complications following the procedure. The patient was transported to PACU the in stable condition Transesophageal echocardiogram on ___ Ejection Fraction 55 100 nl M 52 72 F 54 74 FINDINGS ADDITIONAL FINDINGS No TEE related complications. PRE OPERATIVE STATE Pre bypass assessment. Left Atrium ___ Veins Dilated ___. No spontaneous echo contrast is seen in the ___. No ___ mass thrombus Right Atrium RA Interatrial Septum Inferior Vena Cava IVC DIlated RA. No spontaneous echo contrast is seen in the RA RA appendage. Lipomatous interatrial septum. No atrial septal defect by 2D color flow Doppler. Left Ventricle LV Normal cavity size. Normal regional global systolic function Normal ejection fraction. No resting LV outflow tract gradient. No mass thrombus. Right Ventricle RV Normal cavity size. Normal free wall motion. Aorta Normal sinus diameter. Normal ascending diameter. Normal descending aorta diameter. No dissection. Simple sinus atheroma. Siimple atheroma of ascending aorta. Simple arch atheroma. Aortic Valve Mildly thickened 3 leaflets. Minimal leaflet calcification. No stenosis. Trace regurgitation. Central jet. Mitral Valve Mildly thickened myxomatous leaflets. No stenosis. Mild annular calcification. SEVERE 4 regurgitation. Eccentric jet. Tricuspid Valve Mildly thickened leaflets. Trace regurgitation. Pericardium No effusion. POST OP STATE The post bypass TEE was performed at 13 18 00. Sinus rhythm. Post op Comments ___ guidance provided for trans septal puncture and positioning and deployment of the two PASCAL devices Support Vasopressor s none. Interatrial Septum Small residual secundum atrial septal defect on color Doppler. Left Ventricle Similar to preoperative findings. SImilar regional function. Global ejection fraction is normal. Right Ventricle No change in systolic function. Aorta Intact. No dissection. Aortic Valve No change in aortic valve morphology from preoperative state. Unchanged gradient. No change in aortic regurgitation. Mitral Valve MitraClip s . MitraClip s attached to both leaflets. Post bypass mean mitral valve gradient 1.75mmHg. Similar gradient to preoperative state. Mild 1 valvular regurgitation. Tricuspid Valve No change in tricuspid valve morphology vs. preoperative state. No change in regurgitation vs preoperative state. Pericardium No effusion. . DC ___ 08 13AM BLOOD WBC 10.1 RBC 3.48 Hgb 10.8 Hct 32.8 MCV 94 MCH 31.0 MCHC 32.9 RDW 14.6 RDWSD 49.9 Plt ___ ___ 08 13AM BLOOD Glucose 86 UreaN 19 Creat 1.2 Na 141 K 4.7 Cl 106 HCO3 24 AnGap 11 ___ 12 53PM BLOOD Calcium 8.6 Phos 3.4 Mg 1.___ yo M with PMH of severe MR HFpEF OSA sarcoid BPH s p Mitraclip using Pascal system. Severe mitral regurgitation s p Mitraclip with no complications. Full report above. MR now dec to ___. right groin site without sig ecchymosis or hematoma. Metoprolol restarted before discharge but lisinopril will be held because of soft blood pressures on day of discharge. Please consider restarting low dose lisinopril at follow up appointments. Anticoagulation is aspirin and Plavix for the mitral clip. He will return in 1 month for an echocardiogram to assess positioning of the mitral clips and will see Dr ___ in approximately 2 months Chronic diastolic heart failure looks euvolemic on exam. Pt s main symptom was SOB. holding BB and ACEI for lowish BP after anesthesia. As noted above restarted metoprolol before discharge but lisinopril was held. Started on Lasix 20 mg and low dose potassium which is standard post mitral clip. His weight at discharge is 154 pounds. sarcoidosis w pulmonary and intestinal involvement. Good O2 sats on RA. Unknown if he has cardiac involvement. cont prednisone 1mg hyperlipidemia LDL 130 TC 212 HDL 57. on simva 20. Patient could benefit from an increased dose of simvastatin if he has been tolerating at home. asthma no wheezes on exam and nl O2 sats. Continued Advair GERD change omeprazole to pantoprazole because of new Plavix. BPH currently on no meds no trouble with urinary retention after the procedure. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Fludrocortisone Acetate 0.1 mg PO 3X WEEK ___ 2. PredniSONE 1 mg PO DAILY 3. Lisinopril 2.5 mg PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Simvastatin 20 mg PO QPM 6. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 7. Omeprazole 20 mg PO DAILY 8. albuterol sulfate 90 mcg actuation inhalation Q4H PRN SOB 9. FLUoxetine 40 mg PO DAILY Discharge Medications 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Pantoprazole 40 mg PO Q24H 5. Potassium Chloride 20 mEq PO DAILY 6. albuterol sulfate 90 mcg actuation inhalation Q4H PRN SOB 7. Fludrocortisone Acetate 0.1 mg PO 3X WEEK ___ 8. FLUoxetine 40 mg PO DAILY 9. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 10. Metoprolol Succinate XL 25 mg PO DAILY 11. PredniSONE 1 mg PO DAILY 12. Simvastatin 20 mg PO QPM 13. HELD Lisinopril 2.5 mg PO DAILY This medication was held. Do not restart Lisinopril until after you see Dr ___ ___ Disposition Home Discharge Diagnosis Severe mitral regurgitation s p Mitraclip Hypertension Hyperlipidemia chronic diastolic heart failure Sleep apnea Sarcoid GERD Discharge Condition Mental Status Confused always. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You were admitted for your mitral valve clip procedure. By repairing the valve your heart can pump blood more easily and your shortness of breath should improve. It is very important to take all of your heart healthy medications. In particular you are now taking Aspirin and Clopidogrel Plavix . These medications help to prevent blood clots from forming in around the heart valve. If you stop these medications or miss ___ dose you risk causing a blood clot forming on your heart valve. This could cause it to malfunction and it may be life threatening. Please do not stop taking Aspirin or Plavix without taking to your heart doctor even if another doctor tells you to stop the medications. You will need prophylactic antibiotics prior to any dental procedure. Please obtain a prescription for a one time dose of antibiotics prior to procedures and inform your dentist about your recent cardiac procedure. Please weigh yourself every day in the morning after you go to the bathroom and before you get dressed. If your weight goes up by more than 3 lbs in 1 day or more than 5 lbs in 3 days please call your heart doctor or your primary care doctor and alert them to this change. Your weight at discharge is 154 pounds. We have made changes to your medication list so please make sure to take your medications as directed. You will also need to have close follow up with your heart doctor and your primary care doctor. If you were given any prescriptions on discharge any future refills will need to be authorized by your outpatient providers primary care or cardiologist. If you have any urgent questions that are related to your recovery from your procedure or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital please call the ___ Heart Line at ___ to speak to a cardiologist or cardiac nurse practitioner. It has been a pleasure to have participated in your care and we wish you the best with your health. Followup Instructions ___ The icd codes present in this text will be I340, I5032, Z006, D8689, E785, J45909, K219, N400, Z8042, G4733, Z8572, Z87891, Z9621, H9190. The descriptions of icd codes I340, I5032, Z006, D8689, E785, J45909, K219, N400, Z8042, G4733, Z8572, Z87891, Z9621, H9190 are I340: Nonrheumatic mitral (valve) insufficiency; I5032: Chronic diastolic (congestive) heart failure; Z006: Encounter for examination for normal comparison and control in clinical research program; D8689: Sarcoidosis of other sites; E785: Hyperlipidemia, unspecified; J45909: Unspecified asthma, uncomplicated; K219: Gastro-esophageal reflux disease without esophagitis; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z8042: Family history of malignant neoplasm of prostate; G4733: Obstructive sleep apnea (adult) (pediatric); Z8572: Personal history of non-Hodgkin lymphomas; Z87891: Personal history of nicotine dependence; Z9621: Cochlear implant status; H9190: Unspecified hearing loss, unspecified ear. The common codes which frequently come are I5032, E785, J45909, K219, N400, G4733, Z87891. The uncommon codes mentioned in this dataset are I340, Z006, D8689, Z8042, Z8572, Z9621, H9190.
The icd codes present in this text will be K208, E870, C342, E46, Y842, Y92009, D519, E876, R197, F17210, Z85038, E119, Z8673, E785, Z6822, R32, R1310. The descriptions of icd codes K208, E870, C342, E46, Y842, Y92009, D519, E876, R197, F17210, Z85038, E119, Z8673, E785, Z6822, R32, R1310 are K208: Other esophagitis; E870: Hyperosmolality and hypernatremia; C342: Malignant neoplasm of middle lobe, bronchus or lung; E46: Unspecified protein-calorie malnutrition; Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; D519: Vitamin B12 deficiency anemia, unspecified; E876: Hypokalemia; R197: Diarrhea, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; Z85038: Personal history of other malignant neoplasm of large intestine; E119: Type 2 diabetes mellitus without complications; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; E785: Hyperlipidemia, unspecified; Z6822: Body mass index [BMI] 22.0-22.9, adult; R32: Unspecified urinary incontinence; R1310: Dysphagia, unspecified. The common codes which frequently come are F17210, E119, Z8673, E785. The uncommon codes mentioned in this dataset are K208, E870, C342, E46, Y842, Y92009, D519, E876, R197, Z85038, Z6822, R32, R1310. Allergies Iodine Iodine Containing Chief Complaint difficulty with swallowing painful swallowing diarrhea Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ female with history of stage IIIA squamous cell carcinoma of lung undergoing chemoradiation completed at end of ___ multiple strokes hypertension hyperlipidemia DMII and prior colon cancer s p hemicolectomy who presents with throat pain and difficulty swallowing. She was recently seen in the ED on ___ after a fall with head strike. Imaging was negative and she was discharged home. K was noted to be 3.2 so she was called back to the ED. Her K was repleted and she was discharged home. Since then she has had significant odynophagia with difficulty swallowing leading to poor appetite weakness poor PO intake and continued weight loss. She has also been having diarrhea that is occasionally bloody. She also notes persistent dry cough. She called her Oncologist who recommended she present to the ED for further evaluation. On arrival to the ED initial vitals were 96.8 84 ___ 18 100 RA. Exam was notable for fatigued appearing woman. Labs were notable for WBC 2.9 H H 10.5 31.9 Plt 178 Na 145 K 3.0 BUN Cr ___ and lactate 1.1. Blood cultures were done. No imaging obtained. Patient was given 40mEq IV potassium. Prior to transfer vitals were 98.1 72 134 69 20 100 RA. On arrival to the floor patient endorses the above history. She has no acute issues or concerns. She denies fevers chills night sweats headache vision changes dizziness lightheadedness weakness numbnesss shortness of breath hemoptysis chest pain palpitations abdominal pain nausea vomiting hematemesis dysuria hematuria and new rashes. REVIEW OF SYSTEMS A complete 10 point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY Briefly patient initially presented to care in ___ with hemoptysis. She was subsequently admitted for workup of same and had a CT of the chest which showed a right infrahilar mass with complete occlusion of the right middle lobe bronchus and atelectasis of the right middle lobe with high suspicion for lung cancer there was evidence of bilateral intrathoracic adenopathy. During her hospital admission she was seen by the interventional pulmonary team and scheduled for outpatient bronchoscopy. She underwent bronchoscopy with EBUS under Dr. ___ care on ___. FNA of the right middle lobe mass showed findings consistent with squamous cell carcinoma there was biopsy proven involvement of the level 4L lymph node sampling of the 11 L lymph node showed no malignant cells. Patient underwent staging PET scan on ___. This showed an FDG avid 3.2 cm mass in the right infrahilar region with evidence of occlusion of the right middle lobe bronchus and atelectasis of the right middle lobe. FDG avid subcarinal adenopathy measuring up to 1.3 cm was noted additionally enlarged mediastinal and and hilar lymph nodes are also noted. A 2.2 cm left lower lobe subpleural FDG avid lesion was also noted. No other distant metastatic sites of disease were noted. ___ Weekly ___ and radiation started. Past Medical History prior paramedian pontine infarct ___ right sided lenticulostriate territory infarct ___ Hypertension as per prior medical records patient denies Dyslipidemia Colon cancer 2 p right colectomy in ___ with prolonged stuttering course of adjuvant chemotherapy diagnosed in setting of GI bleeding Cholecystectomy for chronic cholecystitis and gallstones in ___ Diverticulosis Hemorrhoids Social History ___ Family History Mother had stroke in her ___ or ___. Her paternal grandfather father and brother all had colon cancer. Sister had ovarian cancer and has prostate cancer in her family. Physical Exam ADMISSION PHYSICAL EXAM VS Temp 98.3 BP 110 62 HR 66 RR 18 O2 sat 100 RA. GENERAL Pleasant woman in no distress lying in bed comfortably. HEENT Anicteric PERLL OP clear. CARDIAC RRR normal s1 s2 no m r g. LUNG Appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi. ABD Soft non tender non distended normal bowel sounds. EXT Warm well perfused no lower extremity edema erythema or tenderness. NEURO A Ox3 good attention and linear thought CN II XII intact. Strength full throughout. Sensation to light touch intact. SKIN No significant rashes. ACCESS Right chest wall port without erythema. DISCHARGE PHYSICAL EXAM VS 24 HR Data last updated ___ 2327 Temp 98.3 Tm 98.4 BP 127 66 115 131 53 69 HR 66 58 73 RR 18 ___ O2 sat 97 97 99 O2 delivery Ra GENERAL Pleasant woman in no distress lying in bed comfortably. HEENT Anicteric PERLLA OP clear. CARDIAC RRR normal s1 s2 no m r g. LUNG CTAB no increased work of breathing ABD Soft non tender non distended normoactive BS EXT Warm well perfused no lower extremity edema erythema or tenderness. NEURO A Ox3 alert and interactive thought CN II XII intact. Strength full throughout. Sensation to light touch intact. SKIN No significant rashes. Pertinent Results ADMISSION LABS ___ 05 30PM BLOOD WBC 2.9 RBC 4.03 Hgb 10.5 Hct 31.9 MCV 79 MCH 26.1 MCHC 32.9 RDW 25.4 RDWSD 70.9 Plt ___ ___ 05 30PM BLOOD Neuts 54.0 ___ Monos 21.1 Eos 0.0 Baso 0.3 NRBC 1.0 Im ___ AbsNeut 1.56 AbsLymp 0.69 AbsMono 0.61 AbsEos 0.00 AbsBaso 0.01 ___ 05 30PM BLOOD Glucose 99 UreaN 7 Creat 0.6 Na 145 K 3.0 Cl 107 HCO3 27 AnGap 11 ___ 05 30PM BLOOD Calcium 9.7 Phos 2.8 Mg 1.8 DISCHARGE LABS ___ 05 33AM BLOOD WBC 6.0 RBC 3.75 Hgb 9.6 Hct 29.6 MCV 79 MCH 25.6 MCHC 32.4 RDW 25.7 RDWSD 71.3 Plt ___ ___ 05 33AM BLOOD Glucose 81 UreaN 4 Creat 0.7 Na 141 K 4.0 Cl 105 HCO3 26 AnGap 10 ___ 05 33AM BLOOD Calcium 9.3 Phos 2.2 Mg 1.9 MICROBIO ___ urine culture MIXED BACTERIAL FLORA 3 COLONY TYPES CONSISTENT WITH SKIN AND OR GENITAL CONTAMINATION. ___ blood culture final no growth C. difficile PCR Final ___ NEGATIVE. Reference Range Negative . ___ 12 20 pm STOOL CONSISTENCY NOT APPLICABLE Source Stool. FECAL CULTURE Final ___ NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE Final ___ NO CAMPYLOBACTER FOUND. OVA PARASITES Pending FECAL CULTURE R O VIBRIO Final ___ NO VIBRIO FOUND. FECAL CULTURE R O YERSINIA Final ___ NO YERSINIA FOUND. FECAL CULTURE R O E.COLI 0157 H7 Final ___ No E. coli O157 H7 found. Cryptosporidium Giardia DFA Final ___ NO CRYPTOSPORIDIUM OR GIARDIA SEEN. IMAGING AND STUDIES None Brief Hospital Course SUMMARY Ms. ___ is a ___ woman with stage IIIA squamous cell carcinoma of lung undergoing chemoradiation completed on ___ history of multiple strokes and prior colon cancer s p hemicolectomy who presents with odynophagia x several weeks attributed to radiation esophagitis. ACUTE ISSUES Odynophagia Dysphagia Radiation Esophagitis Managed with oral liquid lidocaine formulation which improved patient s ability to tolerate PO. Speech and language pathology consutled recommended soft ground diet and thin liquids which was advanced to regular solids. Nutrition consulted as well. If symptoms fail to improve with liquid lidocaine and with a time course consistent with radiation esophagitis will need further workup as outpatient such as barium swallow or EGD. Patient was started on lansoprazole for any contribution of GERD should continue to assess need for PPI as an outpatient. Hypernatremia Patient with rising Na this admission up to 149. Likely poor oral intake iso radiation esophagitis. Patient received 1L D5W with improvement of Na to 141 on day of discharge. She was encouraged to maintain liquids throughout the day. Severe Malnutrition Patient with poor PO intake and weight loss. Nutrition was consulted and per their recommendations she received Carnation supplements with soy milk with meals as well as Ensure Clear with meals and multivitamins. PO intake was encouraged. SW was consulted due to concern about her having adequate resources at home but she denies having issues with resources . ___ assessed her and recommended home where she already has a walker. OOB with assistance was encouraged during the admission. Vitamin B12 deficiency B12 was noted to be low this admission so the patient received cyanocobalamin 1000 mcg IM on ___ and was started on PO cyanocobalamin daily. MMA was obtained which was pending at time of discharge. CBC was obtained daily. Stage IIIA Squamous Cell Lung Carcinoma Undergoing concurrent chemoradiation. Will follow up with Dr. ___ as outpatient. CHRONIC ISSUES Hypokalemia chronic Hypokalemia has been chronic. Etiology unclear as patient is not on diuretics. Other etiologies include kidney dysfunction such as rental tubular acidosis. Reportedly does not take potassium as often as necessary at home d t difficulty swallowing pill. Urine electrolytes notable for 20 K which seems inappropriate in setting of hypokalemia. Potassium powder was trialed during the admission. Diarrhea stable Patient reports loose stool since radiation. On admission did report blood in stool that is streaky and superficial patient denied tarry stools or frank blood. The most concerning etiology would be recurrence of colorectal carcinoma s p hemicolectomy although more likely causes include diverticulosis flare or hemorrhoidal bleeding. Cdiff negative. Hb stable throughout this admission. Tobacco Abuse Managed inpatient with nicotine patch. TRANSITIONAL ISSUES Ensure that patient is eating and drinking without difficulty Continue to assess for presence of blood in stools Should repeat CBC and BMP at next PCP visit to ensure stable Hb and Na K Previously on potassium tablets but discharged on potassium powder given odynophagia will need to follow up with ability to tolerate this. Patient was started on lansoprazole for any contribution of GERD should continue to assess need for PPI as an outpatient. Found to have B12 deficiency anemia during this admission received cyanocobalamin 1000 mcg IM on ___ and was started on PO cyanocobalamin daily which she should continue. Follow up on lab tests that were pending at time of discharge campylobacter stool culture stool ova parasites fecal culture r o Yersinia methylmalonic acid. Patient was scheduled for outpatient CT chest ___ unable to complete as an inpatient will need to be rescheduled by her oncology team CODE Full Code confirmed EMERGENCY CONTACT HCP ___ daughter ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lidocaine Viscous 2 15 mL PO TID PRN throat pain 2. Ondansetron 8 mg PO Q8H PRN nausea vomiting 3. Prochlorperazine 10 mg PO Q6H PRN nausea vomiting 4. Potassium Chloride 20 mEq PO DAILY 5. Nicotine Patch 7 mg day TD DAILY Discharge Medications 1. Cyanocobalamin ___ mcg PO DAILY RX cyanocobalamin vitamin B 12 2 500 mcg 1 tablet s by mouth daily Disp 30 Tablet Refills 3 2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY RX lansoprazole 30 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 3 3. Maalox Diphenhydramine Lidocaine ___ mL PO QID PRN throat pain 4. Multivitamins W minerals 1 TAB PO DAILY RX multivitamin tx minerals 1 tablet s by mouth daily Disp 30 Tablet Refills 3 5. Potassium Chloride Powder 20 mEq PO DAILY RX potassium chloride 20 mEq 1 packet s by mouth daily Disp 30 Packet Refills 3 6. Lidocaine Viscous 2 15 mL PO TID PRN throat pain 7. Nicotine Patch 7 mg day TD DAILY 8. Ondansetron 8 mg PO Q8H PRN nausea vomiting 9. Prochlorperazine 10 mg PO Q6H PRN nausea vomiting Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary diagnoses Radiation Esophagitis stage IIIA squamous cell carcinoma of lung Severe Malnutrition Secondary diagnoses B12 deficiency Chronic hypokalemia Diarrhea Tobacco abuse Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Ms. ___ It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL You were having pain with swallowing and difficulty eating enough food. You were having diarrhea. WHAT HAPPENED TO ME IN THE HOSPITAL You received medication that decreased throat discomfort. You were seen by speech and swallow specialists who made recommendations for your diet. You received a soft liquid diet initially which was advanced to regular solid foods as tolerated. Studies were done on your stool to make sure that your diarrhea wasn t caused by an infection. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL Continue to take all your medicines and keep your appointments. We wish you the best Sincerely Your ___ Team Followup Instructions ___ The icd codes present in this text will be K208, E870, C342, E46, Y842, Y92009, D519, E876, R197, F17210, Z85038, E119, Z8673, E785, Z6822, R32, R1310. The descriptions of icd codes K208, E870, C342, E46, Y842, Y92009, D519, E876, R197, F17210, Z85038, E119, Z8673, E785, Z6822, R32, R1310 are K208: Other esophagitis; E870: Hyperosmolality and hypernatremia; C342: Malignant neoplasm of middle lobe, bronchus or lung; E46: Unspecified protein-calorie malnutrition; Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; D519: Vitamin B12 deficiency anemia, unspecified; E876: Hypokalemia; R197: Diarrhea, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; Z85038: Personal history of other malignant neoplasm of large intestine; E119: Type 2 diabetes mellitus without complications; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; E785: Hyperlipidemia, unspecified; Z6822: Body mass index [BMI] 22.0-22.9, adult; R32: Unspecified urinary incontinence; R1310: Dysphagia, unspecified. The common codes which frequently come are F17210, E119, Z8673, E785. The uncommon codes mentioned in this dataset are K208, E870, C342, E46, Y842, Y92009, D519, E876, R197, Z85038, Z6822, R32, R1310.
The icd codes present in this text will be R042, E210, R918, Z8673, E119, E785, F17210, I252, Z85038, J9819. The descriptions of icd codes R042, E210, R918, Z8673, E119, E785, F17210, I252, Z85038, J9819 are R042: Hemoptysis; E210: Primary hyperparathyroidism; R918: Other nonspecific abnormal finding of lung field; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; E119: Type 2 diabetes mellitus without complications; E785: Hyperlipidemia, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; I252: Old myocardial infarction; Z85038: Personal history of other malignant neoplasm of large intestine; J9819: Other pulmonary collapse. The common codes which frequently come are Z8673, E119, E785, F17210, I252. The uncommon codes mentioned in this dataset are R042, E210, R918, Z85038, J9819. Allergies Iodine Iodine Containing Chief Complaint hematemesis Major Surgical or Invasive Procedure None. History of Present Illness Ms. ___ is a ___ female with medical history notable for DM2 HTN HLD multiple strokes on Plavix and aspirin inferior MI tobacco use primary hyperparathyroidism and colon cancer s p colectomy and chemotherapy who presented with hemoptysis. Patient was initially seen for hemoptysis at ___ on ___ HPI reported She first noticed coughing and hemoptysis approximately ___ weeks ago and noticed very small blood clots at that time. She saw her PCP in clinic on ___ for this and CT with contrast was ordered but has not yet been scheduled note she has allergy to contrast . Over the past 3 days she has noticed worsening of her cough sputum production and hemoptysis with large clots on the order of teaspoons. No fevers or chills shortness of breath chest pain or lightheadedness. Has some weight loss. No night sweats homelessness or prison exposure. No recent travel surgery immobility ___ swelling pain. Notes some LUQ abdominal pain that began last night that is worsened by cough. It is not associated with food and she has no n v d constipation and has regular BMs with no hematochezia or melena. A CT chest was obtained which was notable for infrahilar mass with complete occlusion of the right middle lobe. She was not able to connect with her PCP to discuss the results. In the ED initial VS Pain 0 Temp 97.7 HR 78 BP 170 88 RR 16 POx 97 RA Exam O lung mild wheeze in the RLL. Work up Leukocytosis to 16 Elevated Ca ___ She received PO Oxybutynin 5 mg PO Azithromycin 500 mg IV CefTRIAXone 1 g ordered Consults IP Decision was made to admit for expedited oncology work up. On arrival to the floor the patient the endorsed the history per above. In addition she clarified that she has lost 3 pounds in the past month. She denies any decrease PO intake or abdominal pain. She denies SOB. She says she feels a lot better after receiving medications in the ED. Past Medical History prior paramedian pontine infarct ___ right sided lenticulostriate territory infarct ___ Hypertension as per prior medical records patient denies Dyslipidemia Colon cancer 2 p right colectomy in ___ with prolonged stuttering course of adjuvant chemotherapy diagnosed in setting of GI bleeding Cholecystectomy for chronic cholecystitis and gallstones in ___ Diverticulosis Hemorrhoids Social History ___ Family History Mother had stroke in her ___ or ___. Her paternal grandfather father and brother all had colon cancer. Sister had ovarian cancer and has prostate cancer in her family. Physical Exam Admission General Older woman who appears stated ago NAD lying flat on bed HEENT EOMI PERRLA MMM Neck No JVD no JVP elevation neck supple no cervical lymphadenopathy Lungs Decreased breath sounds on R side L side CTAB bases b l ronchi in b l upper lobes CV RRR distant heart sounds bradycardic no murmurs rubs or gallops Lymph 0.5 cm x 2 R enlarged supraclaviular node 0.5 cm x1 L enlarged supraclavicular node GI Soft nondistended nonrigid nontender to palpation Ext No lower extremity swelling distal pulses b l intact in UE and ___ ___ CNII XII intact L eyebrow lower than R eyebrow no lower facial droop ___ strength R grip strength RUE flexion and extension elbow RLE ___ strength on plantar flexion and dorsiflexion RUE antigravity L grip strength ___ LUE ___ flexion and extension elbow joint LLE antigravity LLE plantar and dorsiflexion ___ A O grossly Discharge No significant changes Pertinent Results Admission ___ 06 57AM PTH 106 ___ 06 57AM WBC 13.3 RBC 4.63 HGB 12.1 HCT 36.7 MCV 79 MCH 26.1 MCHC 33.0 RDW 14.5 RDWSD 41.5 ___ 06 57AM PLT COUNT 275 ___ 12 05AM ___ PTT 30.5 ___ ___ 10 18PM GLUCOSE 110 UREA N 12 CREAT 1.1 SODIUM 146 POTASSIUM 4.4 CHLORIDE 104 TOTAL CO2 28 ANION GAP 14 ___ 10 18PM estGFR Using this ___ 10 18PM ALT SGPT 7 AST SGOT 15 LD LDH 362 ALK PHOS 107 TOT BILI 0.2 ___ 10 18PM ALBUMIN 3.4 CALCIUM 10.5 PHOSPHATE 3.0 MAGNESIUM 2.3 URIC ACID 6.7 ___ 10 18PM WBC 16.9 RBC 4.99 HGB 13.3 HCT 39.5 MCV 79 MCH 26.7 MCHC 33.7 RDW 14.7 RDWSD 41.8 ___ 10 18PM NEUTS 75.3 LYMPHS 18.1 MONOS 5.8 EOS 0.2 BASOS 0.2 IM ___ AbsNeut 12.72 AbsLymp 3.05 AbsMono 0.98 AbsEos 0.04 AbsBaso 0.03 ___ 10 18PM PLT COUNT 348 Imaging CT Chest ___ IMPRESSION Right infrahilar mass with complete occlusion of the right middle lobe bronchus with complete atelectasis of the right middle lob concerning for bronchogenic carcinoma mediastinal bilateral hilar adenopathy. Diffuse enlargement the thyroid with multiple hypodense areas within it which most likely represent goiter. Brief Hospital Course Mrs. ___ is a ___ female with a medical history notable for DM2 HTN HLD multiple strokes inferior MI tobacco use and colon cancer who presented with 3 weeks of increasing hemoptysis i s o a R hilar lung mass found on CT. Hemoptysis R hilar mass Her hemoptysis and R hilar mass is concerning for bronchogenic carcinoma given her history of smoking colon cancer and weight loss. She was stable without hypoxia or respiratory distress. Her home Plavix and aspirin were held and her hemoptysis improved. IP consulted and planned for biopsy electrocautery cryo stent placement on ___ ___. She had a brain MRI on the evening of discharge that showed nothing acute though follow up on final read will be needed. She will also need a PET CT for complete staging. She has been told to hold home Plavix until further notice last dose ___ but continue her home aspirin. Hypercalcemia She has a history of primary hyperparathyroidism but an elevated calcium level can also be seen as paraneoplastic syndrome. Her Ca was 10.5 on admission in the same range as has been historically. She received her home Vitamin D but no specific treatment was started. CVA We held her home Plavix and aspirin per above. T2DM She was on SSI but did not require any. HLD We continued her home statin. Tobacco use She was given a Nicotine patch. TRANSITIONAL ISSUES MRI wet read negative for acute pathology will need to be followed up for final read PET CT scan to complete staging ___ ___ flex and rigid bronchoscopy EBUS TBNA and possible stenting Discuss restarting Plavix post procedurally Smoking cessation discussion CODE Full confirmed CONTACT ___ Daughter ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Oxybutynin 5 mg PO DAILY 5. Vitamin D ___ UNIT PO DAILY Discharge Medications 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Oxybutynin 5 mg PO DAILY 4. Vitamin D ___ UNIT PO DAILY 5. HELD Clopidogrel 75 mg PO DAILY This medication was held. Do not restart Clopidogrel until you have spoken with your doctors and it is safe to resume. Certainly not before ___ Discharge Disposition Home Discharge Diagnosis Primary Hemoptysis Secondary Hypercalcemia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear ___ was a pleasure taking part in your ___ here at ___ Why was I admitted to the hospital You were admitted because you were on blood thinners and were coughing up blood. What was done for me while I was in the hospital We were concerned about the blood that you were coughing up so we did a number of tests. We also stopped your Plavix a medicine that can make you bleed easier and that helped to reduce the amount of blood that you were coughing up. The lung doctors spoke with ___ about the results of your recent lung CT and explained that they will need to get a sample of tissue in order to find out what is in your lungs. You also got a head MRI to look for any changes in your brain. Since you were stable and did not need to be in the hospital for any other tests it was decided that you could go home safely. What should I do when I leave the hospital You have a bronchoscopy schedule for ___. Please DO NOT eat after 11 59PM on ___ and do not eat breakfast or lunch. You can take your morning medicines with water. Your appointments are as below Please DO NOT TAKE Plavix clopidogrel UNTIL after your procedure with the pulmonary doctors ___ call Health ___ Associates to make a follow up appointment with your primary ___ doctor about this hospitalization number below Sincerely Your ___ ___ Team Followup Instructions ___ The icd codes present in this text will be R042, E210, R918, Z8673, E119, E785, F17210, I252, Z85038, J9819. The descriptions of icd codes R042, E210, R918, Z8673, E119, E785, F17210, I252, Z85038, J9819 are R042: Hemoptysis; E210: Primary hyperparathyroidism; R918: Other nonspecific abnormal finding of lung field; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; E119: Type 2 diabetes mellitus without complications; E785: Hyperlipidemia, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; I252: Old myocardial infarction; Z85038: Personal history of other malignant neoplasm of large intestine; J9819: Other pulmonary collapse. The common codes which frequently come are Z8673, E119, E785, F17210, I252. The uncommon codes mentioned in this dataset are R042, E210, R918, Z85038, J9819.
The icd codes present in this text will be K208, E43, I82C11, C342, D6869, E512, I69354, R627, K2950, B9681, E860, K222, I10, K224, K449, K2980, F17210, Z66, Z6822, Y842, Y92009, Z9221, Z7901, Z85038, Z9049. The descriptions of icd codes K208, E43, I82C11, C342, D6869, E512, I69354, R627, K2950, B9681, E860, K222, I10, K224, K449, K2980, F17210, Z66, Z6822, Y842, Y92009, Z9221, Z7901, Z85038, Z9049 are K208: Other esophagitis; E43: Unspecified severe protein-calorie malnutrition; I82C11: Acute embolism and thrombosis of right internal jugular vein; C342: Malignant neoplasm of middle lobe, bronchus or lung; D6869: Other thrombophilia; E512: Wernicke's encephalopathy; I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; R627: Adult failure to thrive; K2950: Unspecified chronic gastritis without bleeding; B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere; E860: Dehydration; K222: Esophageal obstruction; I10: Essential (primary) hypertension; K224: Dyskinesia of esophagus; K449: Diaphragmatic hernia without obstruction or gangrene; K2980: Duodenitis without bleeding; F17210: Nicotine dependence, cigarettes, uncomplicated; Z66: Do not resuscitate; Z6822: Body mass index [BMI] 22.0-22.9, adult; Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; Z9221: Personal history of antineoplastic chemotherapy; Z7901: Long term (current) use of anticoagulants; Z85038: Personal history of other malignant neoplasm of large intestine; Z9049: Acquired absence of other specified parts of digestive tract. The common codes which frequently come are I10, F17210, Z66, Z7901. The uncommon codes mentioned in this dataset are K208, E43, I82C11, C342, D6869, E512, I69354, R627, K2950, B9681, E860, K222, K224, K449, K2980, Z6822, Y842, Y92009, Z9221, Z85038, Z9049. Allergies Iodine Iodine Containing Chief Complaint Throat Pain confusion worsening L hemiparesis Major Surgical or Invasive Procedure ___ and biopsy History of Present Illness Ms. ___ is a ___ w stage IIIA squamous cell carcinoma of lung s p completion of concurrent ___ ___ also w a h o multiple strokes w residual left hemiparesis HTN DL and prior colon cancer s p hemicolectomy who is transferred from ___ for continuity of care. Dr ___ the oncology service resident called me for signout. She presented there on ___ with subacute worsening of her chronic L sided hemiparesis and confusion. She was seen by neurology and her head CT and brain MRI did not reveal any new acute stroke or other acute process. The neurologic symptoms were therefore felt to be recrudescence of prior stroke symptoms in the setting of dehydration deconditioning malnutrition. She had a CXR that was concerning for pneumonia. She had a Chest CT which revealed no pneumonia but did reveal b l scapular mets. Her confusion resolved with some maintenance fluids and her lue weakness improved. Nutrition and ___ saw her as well. Her symptoms of poor po intake and esophagitis are known to her oncology team and they have been working closely together respecting her wishes to remain independent at home. She was even recently admitted ___ and her sx improved w oral liquid lidocaine formulation. She states this helps and is not taking it because she doesn t have it at home. I spoke w her daughter who is her HCP and she noted that her mom has been having increased confusion for weeks now at least. She thinks she may have dementia. She notes that she does have a new bottle of lidocaine at home. She notes worsening PO intake. REVIEW OF SYSTEMS A complete 10 point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History PAST ONCOLOGIC HISTORY Briefly patient initially presented to care in ___ with hemoptysis. She was subsequently admitted for workup of same and had a CT of the chest which showed a right infrahilar mass with complete occlusion of the right middle lobe bronchus and atelectasis of the right middle lobe with high suspicion for lung cancer there was evidence of bilateral intrathoracic adenopathy. During her hospital admission she was seen by the interventional pulmonary team and scheduled for outpatient bronchoscopy. She underwent bronchoscopy with EBUS under Dr. ___ care on ___. FNA of the right middle lobe mass showed findings consistent with squamous cell carcinoma there was biopsy proven involvement of the level 4L lymph node sampling of the 11 L lymph node showed no malignant cells. Patient underwent staging PET scan on ___. This showed an FDG avid 3.2 cm mass in the right infrahilar region with evidence of occlusion of the right middle lobe bronchus and atelectasis of the right middle lobe. FDG avid subcarinal adenopathy measuring up to 1.3 cm was noted additionally enlarged mediastinal and and hilar lymph nodes are also noted. A 2.2 cm left lower lobe subpleural FDG avid lesion was also noted. No other distant metastatic sites of disease were noted. ___ weekly ___ and radiation started ___ completed weekly ___ RT ___ ED visit for fall head scrape ___ ED visit for hypokalemia ___ Admission for esophagitis PAST MEDICAL HISTORY H o paramedian pontine infarct in ___ H o right sided lenticulostriate territory infarct in ___ Hypertension Dyslipidemia Colon cancer s p right hemicolectomy in ___ Cholecystectomy for chronic cholecystitis and gallstones in ___ Diverticulosis Hemorrhoids Tobacco Abuse Social History ___ Family History Mother had stroke in her ___ or ___. Her paternal grandfather father and brother all had colon cancer. Two brothers had gastric cancer. Sister had ovarian cancer. Physical Exam ADMISSION PHYSICAL EXAM VS Temp 98.3 74 140 64 100 on RA GENERAL Pleasant woman in no distress lying in bed omfortably. HEENT Anicteric PERLL OP clear. CARDIAC RRR normal s1 s2 no m r g. LUNG Appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi. ABD Soft non tender non distended normal bowel sounds. EXT Warm well perfused no lower extremity edema erythema or tenderness. NEURO A Ox3 L temporal field deficit CN XI weak ___ LUE good attention and linear thought CN III XII otherwise intact but she has a mild R facial drop but symmetric smile. Strength ___ RUE and RLE but 3 5 proximal LLE with ___ on plantar flexion and dorsiflexion. No nystagmus. gait not assessed SKIN xerosis on upper extremities ACCESS Right chest wall port without erythema accessed dressing c d i DISCHARGE PHYSICAL EXAM VS ___ 0740 Temp 99.0 PO BP 133 79 HR 96 RR 18 O2 sat 100 O2 delivery RA GENERAL Pleasant in no distress lying in bed comfortably HEENT Anicteric sclera EOMI CARDIAC RRR normal s1 s2 no m r g. LUNG Appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi. ABD Soft non tender non distended normal bowel sounds. EXT Warm well perfused no lower extremity edema erythema or tenderness. NEURO A Ox3 strength ___ RLE RUE ___ LLE LUE SKIN xerosis on upper extremities ACCESS Right chest wall port without erythema accessed dressing c d i Pertinent Results ADMISSION LABS ___ 05 39AM BLOOD WBC 21.5 RBC 3.78 Hgb 9.6 Hct 29.9 MCV 79 MCH 25.4 MCHC 32.1 RDW 23.9 RDWSD 69.0 Plt ___ ___ 05 39AM BLOOD Neuts 89.5 Lymphs 5.0 Monos 3.9 Eos 0.2 Baso 0.3 Im ___ AbsNeut 18.96 AbsLymp 1.07 AbsMono 0.83 AbsEos 0.04 AbsBaso 0.06 ___ 05 39AM BLOOD ___ PTT 30.1 ___ ___ 05 39AM BLOOD Glucose 174 UreaN 5 Creat 0.6 Na 145 K 3.6 Cl 107 HCO3 23 AnGap 15 ___ 05 39AM BLOOD ALT 21 AST 15 LD LDH 343 AlkPhos 240 TotBili 0.4 ___ 05 39AM BLOOD Albumin 2.5 Calcium 9.2 Phos 3.2 Mg 2.0 MICRO ___ c diff stool test negative IMAGING STUDIES ___ second opinion CT Torso 1. Within the confines of a motion limited unenhanced study the known approximately 1.8 cm right hilar mass appears stable. 2. Stable postobstructive collapse of the right middle lobe in the setting of right hilar mass. 3. Stable 3 mm left upper lobe pulmonary nodule. No definite new or growing pulmonary nodules. 4. Moderate paraseptal emphysema. ___ right upper extremity US 1. Nonocclusive thrombus is seen in the right internal jugular vein. 2. The remaining visualized veins of the right upper extremity are patent. ___ EGD erythema in middle third of esophagus consistent with non erosive esophagitis esophageal hiatal hernia erythema and erosion in gastric antrum and stomach body consistent with non erosive gastritis duodenitis ring in the distal esophagus ___ x rays of pelvis and femurs No evidence of lytic or sclerotic lesions within either femur or pelvis. DISCHARGE LABS ___ 05 21AM BLOOD WBC 22.4 RBC 3.44 Hgb 8.8 Hct 27.3 MCV 79 MCH 25.6 MCHC 32.2 RDW 23.0 RDWSD 65.7 Plt ___ ___ 05 21AM BLOOD Plt ___ ___ 05 21AM BLOOD Glucose 178 UreaN 8 Creat 0.6 Na 147 K 3.6 Cl 109 HCO3 25 AnGap 13 ___ 04 40AM BLOOD ALT 17 AST 13 AlkPhos 242 TotBili 0.4 ___ 05 21AM BLOOD Calcium 9.2 Phos 2.7 Mg 2.5 Brief Hospital Course SUMMARY ___ w stage IIIA squamous cell carcinoma of lung s p completion of concurrent ___ ___ also w a h o multiple strokes w residual left hemiparesis HTN DL and prior colon cancer s p hemicolectomy who is transferred from ___ for continuity of care after presenting there w confusion and worsening LUE weakness. ACTIVE ISSUES Odynophagia Dysphagia Most likely radiation esophagitis reflux esophagitis. ___ EGD with esophagitis gastritis duodenitis. Gastric biopsy showed H. pylori. She was given viscous lidocaine with meals BID PPI fluids as needed and a regular diet. We had long discussions about her goals of care with both her outpatient oncology team as well as her palliative care team detailed below and it was ultimately decided to not pursue full antibiotic therapy for H. pylori as her primary symptom of odynophagia is most likely primarily related to strictures and radiation esophagitis. Failure to thrive Seems like most likely etiology is poor po intake. Felt to be due to progressive esophagitis presumably radiation induced . She has odynophagia. TSH wnl. No e o pulmonary infection. UA neg at OSH. C diff negative this admission. Geriatrics was involved in the patient s care during this admission. Her throat and body pain was controlled with IV morphine and she received viscous lidocaine to help her eat drink more comfortably. She was supported with IVF as needed. ___ and OT evaluated her and recommended rehab placement however after long discussions of her GOC and it was decided that she would not want tube feeding and would like to go home on hospice. Nonocclusive thrombus in right IJ In the setting of being hypercoagulable from malignancy. HAS BLED score is 3 HTN stroke Hx age she is at high risk for major bleeding but is hypercogulable iso malignancy. The definitive treatment for her hypercoagulable state is treatment of her malignancy if within GOC. Her home ASA Plavix were continued and she was started on enoxaparin 80 mg SC daily with the plan to treat for 1 month. Stage IIIA Squamous Cell Lung Carcinoma Bilateral lytic scapular lesions Most recent imaging CT chest on ___ revealed substantial decrease in size of the pre existing right hilar mass which now measures 20 x 20 mm in diameter. However CT abd revealed new 1.3 cm hepatic segment VII lesion ... suspicious for metastasis. ___ elevated this admission consistent with liver involvement. Now CT from ___ revealed new bilateral lytic scapular lesions. Outpatient team arranging PET scan in ___ with future cancer treatment directed therapies to be determined. Her outpatient oncology team Drs ___ was contacted with updates. Hip femur x rays were obtained to eval for osseous lytic lesions because of delays with scheduling a bone scan . Encephalopathy She s been having episodes of confusion for some time now per daughter. She locked herself in the bathroom last week. Thetiles have me locked in the bathroom and I can t get out. But the bathroom was not locked. A few weeks ago she had left the stove on during a hot day and she stated she was heating food for her son who was murdered ___. Daughter is concerned about dementia. MRI brain did not reveal mets or new stroke. although pt is oriented x 3 she seems to have poor insight into reason for admission and her hospitalization. Confusion possibly also due to impaired sleep sleeps during day as lives with her son who works nights dehydration pain from malignancy. Geriatrics was consulted and assisted with her care. Her nutrition and hydration status were optimized and her pain was controlled with IV morphine. She received high dose thiamine for possible Wernicke s encephalopathy. She received folic acid repletion for severe protein calorie malnutrition. CHRONIC RESOLVED ISSUES Worsening LUE and LLE weakness stable History of CVA w residual hemiparesis Likely recrudescence from prior CVA and improved w hydration and nutrition. Her home aspirin Plavix and atorvastatin were continued. Her neurologic status was checked daily. She was started on Lovenox aily. Severe protein calorie malnutrition Nutrition was consulted. She received a regular diet high dose thiamine folic acid and MVI. Her electrolytes were monitored daily and repleted as needed. Tobacco Abuse Continued nicotine patch. TRANSITIONAL ISSUES Due to esophageal spasms seen during EGD outpatient esophageal mannometry should be considered to further work up her dysphagia odynophagia. Consider starting a bisphosphonate if osseous metastases are confirmed through bone scan bone biopsy. Code status DNR DNI EMERGENCY CONTACT HCP ___ daughter ___ This patient was prescribed or continued on an opioid pain medication at the time of discharge please see the attached medication list for details . As part of our safe opioid prescribing process all patients are provided with an opioid risks and treatment resource education sheet and encouraged to discuss this therapy with their outpatient providers to determine if opioid pain medication is still indicated. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Nicotine Patch 21 mg day TD DAILY 2. Cyanocobalamin ___ mcg PO DAILY 3. Multivitamins W minerals 1 TAB PO DAILY 4. Lidocaine Viscous 2 15 mL PO QID PRN throat pain 5. Potassium Chloride Powder 20 mEq PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Oxybutynin 5 mg PO DAILY 9. Clopidogrel 75 mg PO DAILY Discharge Medications 1. Enoxaparin Sodium 80 mg SC DAILY RX enoxaparin 80 mg 0.8 mL 80 mg SC daily Disp 30 Syringe Refills 3 2. Morphine Sulfate Concentrated Oral Solution 20 mg mL 10 mg PO Q4H PRN Pain Severe RX morphine concentrate 100 mg 5 mL 20 mg mL 10 mg by mouth q4hrs PRN Refills 0 3. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration 1 Dose RX naloxone Narcan 4 mg actuation 1 spray nasal once AS NEEDED Disp 1 Spray Refills 0 4. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule s by mouth daily Disp 30 Capsule Refills 3 5. Lidocaine Viscous 2 15 mL PO QID PRN throat pain 6. Nicotine Patch 21 mg day TD DAILY 7. Oxybutynin 5 mg PO DAILY 8. Potassium Chloride Powder 20 mEq PO DAILY Hold for K 4.0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary Diagnosis 1 Odynophagia Dysphagia 2 Failure to Thrive 3 H pylori gastritis 4 Stage IIA squamous cell carcinoma of the lung 5 Non occlusive thrombus of the right IJ 6 Severe protein calorie malnutrition Secondary Diagnosis 1 History of CVA 2 Tobacco Abuse Discharge Condition Level of Consciousness Alert and interactive. Mental Status Clear and coherent. Activity Status Bedbound. Discharge Instructions Dear Ms. ___ It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL You were having pain in your throat and body. You were not getting enough to eat and drink. Because of this you were weaker than usual which made your old stroke symptoms seem worse. Your children were concerned that you were more confused than usual. WHAT HAPPENED TO ME IN THE HOSPITAL You received scans to make sure that you did not have a new stroke. You were watched closely for signs of infection. You were supported with fluids and nutritious food. You underwent an endoscopy procedure which showed a lot of inflammation that is probably causing your swallowing pain. You were given liquid lidocaine for throat pain as well as an acid blocker medicine. Your body pain was treated with morphine. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL Continue to take all your medicines and keep your appointments. We wish you the best Sincerely Your ___ Team Followup Instructions ___ The icd codes present in this text will be K208, E43, I82C11, C342, D6869, E512, I69354, R627, K2950, B9681, E860, K222, I10, K224, K449, K2980, F17210, Z66, Z6822, Y842, Y92009, Z9221, Z7901, Z85038, Z9049. The descriptions of icd codes K208, E43, I82C11, C342, D6869, E512, I69354, R627, K2950, B9681, E860, K222, I10, K224, K449, K2980, F17210, Z66, Z6822, Y842, Y92009, Z9221, Z7901, Z85038, Z9049 are K208: Other esophagitis; E43: Unspecified severe protein-calorie malnutrition; I82C11: Acute embolism and thrombosis of right internal jugular vein; C342: Malignant neoplasm of middle lobe, bronchus or lung; D6869: Other thrombophilia; E512: Wernicke's encephalopathy; I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; R627: Adult failure to thrive; K2950: Unspecified chronic gastritis without bleeding; B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere; E860: Dehydration; K222: Esophageal obstruction; I10: Essential (primary) hypertension; K224: Dyskinesia of esophagus; K449: Diaphragmatic hernia without obstruction or gangrene; K2980: Duodenitis without bleeding; F17210: Nicotine dependence, cigarettes, uncomplicated; Z66: Do not resuscitate; Z6822: Body mass index [BMI] 22.0-22.9, adult; Y842: Radiological procedure and radiotherapy as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; Z9221: Personal history of antineoplastic chemotherapy; Z7901: Long term (current) use of anticoagulants; Z85038: Personal history of other malignant neoplasm of large intestine; Z9049: Acquired absence of other specified parts of digestive tract. The common codes which frequently come are I10, F17210, Z66, Z7901. The uncommon codes mentioned in this dataset are K208, E43, I82C11, C342, D6869, E512, I69354, R627, K2950, B9681, E860, K222, K224, K449, K2980, Z6822, Y842, Y92009, Z9221, Z85038, Z9049.
The icd codes present in this text will be I639, G8194, E119, I672, Z8673, I10, E785, I252, Z85038, E538, Z9181, F17210, I6529, I2510, R32, R159, M8580, Z7902. The descriptions of icd codes I639, G8194, E119, I672, Z8673, I10, E785, I252, Z85038, E538, Z9181, F17210, I6529, I2510, R32, R159, M8580, Z7902 are I639: Cerebral infarction, unspecified; G8194: Hemiplegia, unspecified affecting left nondominant side; E119: Type 2 diabetes mellitus without complications; I672: Cerebral atherosclerosis; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; I252: Old myocardial infarction; Z85038: Personal history of other malignant neoplasm of large intestine; E538: Deficiency of other specified B group vitamins; Z9181: History of falling; F17210: Nicotine dependence, cigarettes, uncomplicated; I6529: Occlusion and stenosis of unspecified carotid artery; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; R32: Unspecified urinary incontinence; R159: Full incontinence of feces; M8580: Other specified disorders of bone density and structure, unspecified site; Z7902: Long term (current) use of antithrombotics/antiplatelets. The common codes which frequently come are E119, Z8673, I10, E785, I252, F17210, I2510, Z7902. The uncommon codes mentioned in this dataset are I639, G8194, I672, Z85038, E538, Z9181, I6529, R32, R159, M8580. Allergies Iodine Iodine Containing Chief Complaint left leg weakness falls Major Surgical or Invasive Procedure None History of Present Illness ___ is a ___ RH female with a PMHx of paramedian pontine infarct ___ right sided lenticulostriate territory infarct ___ multiple strokes in the right posterior MCA PCA watershed region thought to be cardioembolic but no source identified ___ followed by Dr. ___ on Plavix and ASA hypertension hyperlipidemia prior MI colon cancer s p resection and chemotherapy in ___ extensive tobacco use recent DM diagnosis and recent diagnosis of B12 deficiency who presents with ___ weeks of frequent falls and 4 weeks of left leg weakness. The left leg weakness was gradual in onset and began about 4 weeks ago it has remained relatively stable. She now needs help getting off a toilet or up off of chairs. The falls occur when she is pivoting while using her cane and she has had 5 falls in the last week including once into her bathtub. Her legs feel like they get tangled up. She has only landed on her bottom no headstrikes or LOC. No prodrome prior to falls. She also has baseline LUE weakness that remains unchanged since her strokes in ___ she has trouble twisting caps and opening jars but she does not have trouble reaching up. Denies missing Plavix doses. Missed ___ doses of atorvastatin since starting it. She has also had urinary and fecal incontinence 3 months per prior notes since last stroke in ___ per patient per prior notes she loses control just after getting the urge to urinate or move her bowels today she says she sometimes does not get the urge to go. She sometimes does not have time to make it to the bathroom but this is not the chief reason for incontinence. Reports 2 days of lower back pain midline . Denies saddle anesthesia. She was seen by her PCP ___ she was noted to be dragging her left foot on the ground and she was noted to have left ankle dorsiflexion plantarflexion knee flexion extension and hip flexion extension weakness with more brisk reflexes on that side. Per ED she was noted to have ___ left hip flexion 4 hip extension 4 knee extension upgoing toes on left left arm. Of note she last saw Dr. ___ in ___ in clinic. At that time she was noted to have SCM weakness mild L pronation with upward drift and ___ left deltoid strength. She had brisk reflexes at left biceps and patella and her plantar response was mute bilaterally. She also had a broad based gait with small steps that was safe. She was continued on Plavix 75mg daily and a stronger statin was recommended but the patient preferred to stay on rosuvastatin Crestor . Left facial droop noticed during sleep by daughter one week which subsequently resolved date of resolution unknown per patient On neuro ROS the pt denies headache loss of vision blurred vision diplopia dysarthria dysphagia lightheadedness vertigo tinnitus and hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal numbness and parasthesiae. On general review of systems the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough shortness of breath. Denies chest pain or tightness palpitations. Denies nausea vomiting diarrhea constipation or abdominal pain. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History prior paramedian pontine infarct ___ right sided lenticulostriate territory infarct ___ Hypertension as per prior medical records patient denies Dyslipidemia Colon cancer 2 p right colectomy in ___ with prolonged stuttering course of adjuvant chemotherapy diagnosed in setting of GI bleeding Cholecystectomy for chronic cholecystitis and gallstones in ___ Diverticulosis Hemorrhoids Social History ___ Family History Mother had stroke in her ___ or ___. Her paternal grandfather father and brother all had colon cancer. Sister had ovarian cancer and has prostate cancer in her family. Physical Exam Admission Exam Vitals T 97.4 P 65 R 16 BP 153 70 SaO2 97 RA General Awake cooperative NAD. HEENT NC AT no scleral icterus noted MMM no lesions noted in oropharynx Neck Supple no carotid bruits appreciated. No nuchal rigidity Pulmonary Lungs CTA bilaterally without R R W Cardiac RRR nl. S1S2 no M R G noted Abdomen soft NT ND normoactive bowel sounds no masses or organomegaly noted. Extremities No C C E bilaterally 2 radial DP pulses bilaterally. Skin no rashes or lesions noted. Neurologic NIHSS as above. Mental Status Alert oriented x 3. Able to relate history without difficulty. Attentive able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes ___ with prompting . There was no evidence of apraxia or neglect. No cortical sensory loss. Cranial Nerves II III IV VI PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity ___ bilaterally. Fundoscopic exam revealed no papilledema exudates or hemorrhages. V Facial sensation intact to light touch. VII Mild L NLFF. VIII Hearing intact to finger rub bilaterally. IX X Palate elevates symmetrically. XI ___ strength in trapezii and SCM bilaterally. XII Tongue protrudes in midline. Motor Normal bulk and tone. Subtle LUE pronation without drift. RUE orbiting around left. No adventitious movements such as tremor noted. No asterixis noted. ___ C5 C5 C7 C6 C7 T1 L2 L3 L5 L4 S1 L5 L 5 5 5 5 5 5 4 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 Sensory No deficits to light touch pinprick cold sensation vibratory sense. ___ errors to proprioception in LLE. No extinction to DSS. No spinal sensory level. DTRs brisk diffusely L R. Left toe upgoing right downgoing. Coordination Missed target mildly with RUE on FNF. RAM slow bilaterally. FNF ok. HKS ok. Gait Dragging left leg when ambulating with some circumduction. Discharge exam Vitals T 97.4 P 65 R 16 BP 164 70 SaO2 97 RA General Awake cooperative NAD. HEENT NC AT no scleral icterus noted MMM no lesions noted in oropharynx Neck Supple no carotid bruits appreciated. No nuchal rigidity Pulmonary Lungs CTA bilaterally without R R W Cardiac RRR nl. S1S2 no M R G noted Abdomen soft NT ND normoactive bowel sounds no masses or organomegaly noted. Extremities No C C E bilaterally 2 radial DP pulses bilaterally. Skin no rashes or lesions noted. Neurologic NIHSS as above. Mental Status Alert oriented x 3. Able to relate history without difficulty. Attentive able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. Cranial Nerves II III IV VI PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. Visual acuity ___ bilaterally. V Facial sensation intact to light touch. VII symmetric VIII Hearing intact to finger rub bilaterally. IX X Palate elevates symmetrically. XI ___ strength in trapezii and SCM bilaterally. XII Tongue protrudes in midline. Motor Normal bulk and tone. Subtle LUE pronation without drift. RUE orbiting around left. No adventitious movements such as tremor noted. No asterixis noted. ___ C5 C5 C7 C6 C7 T1 L2 L3 L5 L4 S1 L5 L 5 5 5 5 4 5 5 5 5 ___ R 5 5 5 5 5 5 5 5 5 5 5 5 Sensory No deficits to light touch pinprick cold sensation vibratory sense. Intact proprioception b l. No extinction to DSS. No spinal sensory level. DTRs brisk diffusely L R. Left toe upgoing right downgoing. Coordination Missed target mildly with RUE on FNF. RAM slow bilaterally. FNF ok. HKS ok. Gait Dragging left leg but stable with cane Pertinent Results ___ 01 10PM GLUCOSE 125 UREA N 9 CREAT 0.9 SODIUM 144 POTASSIUM 4.2 CHLORIDE 105 TOTAL CO2 26 ANION GAP 17 ___ 01 10PM estGFR Using this ___ 01 10PM ALT SGPT 18 AST SGOT 30 ALK PHOS 97 TOT BILI 0.5 ___ 01 10PM ALBUMIN 3.7 CALCIUM 11.2 PHOSPHATE 3.4 MAGNESIUM 2.3 ___ 01 10PM ASA NEG ACETMNPHN NEG bnzodzpn NEG barbitrt NEG tricyclic NEG ___ 01 10PM WBC 9.4 RBC 4.87 HGB 13.4 HCT 41.0 MCV 84 MCH 27.5 MCHC 32.7 RDW 14.4 RDWSD 44.0 ___ 01 10PM NEUTS 64.6 ___ MONOS 5.8 EOS 0.5 BASOS 0.2 IM ___ AbsNeut 6.06 AbsLymp 2.68 AbsMono 0.54 AbsEos 0.05 AbsBaso 0.02 ___ 01 10PM PLT COUNT 276 CT head IMPRESSION 1. Small right caudate hypodensity lacunar infarct is new from ___ but otherwise appears chronic to possibly subacute lacunar infarct. Correlate with clinical symptoms. MRI is more sensitive in detecting acute ischemia. 2. Sequelae of prior right frontal lobe infarct and left pontine infarct. 3. Nonspecific bilateral white matter changes are similar the prior exam and consistent with sequelae of chronic small vessel ischemic disease. 4. No acute intracranial hemorrhage. 5. Cortical atrophy. CXR IMPRESSION No focal consolidation to suggest pneumonia. Possible minimal pulmonary vascular congestion. Stable mild cardiomegaly. MRI MRA brain and neck IMPRESSION 1. Substantially motion limited exam. 2. Punctate likely subacute infarcts of the right frontal periventricular white matter posterior limb of the right internal capsule or right thalamus and right periatrial white matter. 3. Chronic right frontal cortical infarct is again seen. Extensive supratentorial white matter signal abnormalities similar to prior nonspecific but likely sequela of chronic small vessel ischemic disease in this age group. 4. Nondominant left vertebral artery is diminutive and not adequately assessed on this motion limited exam. 0 5. Atherosclerosis of the proximal right internal carotid artery is again seen but could be exaggerated by artifact. Apparent irregularity of the left proximal internal carotid artery of the V2 and V3 segments of the right vertebral artery of the left greater than right carotid siphons and of the distal M1 and M2 segments of the left middle cerebral artery probably represents a combination of atherosclerosis and artifacts. Brief Hospital Course ___ RH female with a PMHx of paramedian pontine infarct ___ right sided lenticulostriate territory infarct ___ multiple strokes in the right posterior MCA PCA watershed region thought to be cardioembolic but no source identified ___ Plavix and ASA HTN HLD prior MI colon cancer s p resection and chemotherapy in ___ extensive tobacco use recent DM diagnosis and recent diagnosis of B12 deficiency presents with 4 week hx of progressively worsening left leg weakness and falls. On exam she had no signs of neuropathy intact sensation to light touch temperature and Pin Prick as well as intact proprioception. CT Head with right caudate hypodensity of indeterminate age but appears subacute chronic. MRI MRA brain and neck with punctate likely subacute infarcts of the right frontal periventricular white matter posterior limb of the right internal capsule or right thalamus and right periatrial white matter. Etiology most likely secondary to known intracranial athero seen on imaging vs. small vessel disease. Patient already on appropriate secondary stroke prophylaxis and thus no changes to her medications were made. She was evaluated by physical therapy who recommended home ___. Stroke risk factors LDL 48 A1C6.6 AHA ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake x Yes confirmed done Not confirmed No 2. DVT Prophylaxis administered x Yes No 3. Antithrombotic therapy administered by end of hospital day 2 x Yes No 4. LDL documented x Yes LDL 48 No 5. Intensive statin therapy administered simvastatin 80mg simvastatin 80mg ezetemibe 10mg atorvastatin 40mg or 80 mg rosuvastatin 20mg or 40mg for LDL 100 x Yes No if LDL 100 reason not given 6. Smoking cessation counseling given x Yes No reason non smoker unable to participate 7. Stroke education personal modifiable risk factors how to activate EMS for stroke stroke warning signs and symptoms prescribed medications need for followup given verbally or written x Yes No 8. Assessment for rehabilitation or rehab services considered x Yes No 9. Discharged on statin therapy x Yes No if LDL 100 reason not given 10. Discharged on antithrombotic therapy x Yes Type x Antiplatelet Anticoagulation No 11. Discharged on oral anticoagulation for patients with atrial fibrillation flutter Yes No x N A Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Oxybutynin 5 mg PO DAILY 3. MetFORMIN Glucophage 500 mg PO DAILY 4. Vitamin D 1000 UNIT PO DAILY 5. Clopidogrel 75 mg PO DAILY 6. Atorvastatin 80 mg PO QPM Discharge Medications 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. MetFORMIN Glucophage 500 mg PO DAILY 5. Oxybutynin 5 mg PO DAILY 6. Vitamin D 1000 UNIT PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Ischemic stroke Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear ___ were hospitalized due to symptoms of left leg weakness and falls resulting from an ACUTE ISCHEMIC STROKE a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes so we assessed ___ for medical conditions that might raise your risk of having stroke. In order to prevent future strokes we plan to modify those risk factors. Your risk factors are HTN atherosclerotic disease No changes to your medications were made since ___ are already on the appropriate secondary stroke prevention. Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If ___ experience any of the symptoms below please seek emergency medical attention by calling Emergency Medical Services dialing 911 . In particular since stroke can recur please pay attention to the sudden onset and persistence of these symptoms Sudden partial or complete loss of vision Sudden loss of the ability to speak words from your mouth Sudden loss of the ability to understand others speaking to ___ Sudden weakness of one side of the body Sudden drooping of one side of the face Sudden loss of sensation of one side of the body Sincerely Your ___ Neurology Team Followup Instructions ___ The icd codes present in this text will be I639, G8194, E119, I672, Z8673, I10, E785, I252, Z85038, E538, Z9181, F17210, I6529, I2510, R32, R159, M8580, Z7902. The descriptions of icd codes I639, G8194, E119, I672, Z8673, I10, E785, I252, Z85038, E538, Z9181, F17210, I6529, I2510, R32, R159, M8580, Z7902 are I639: Cerebral infarction, unspecified; G8194: Hemiplegia, unspecified affecting left nondominant side; E119: Type 2 diabetes mellitus without complications; I672: Cerebral atherosclerosis; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; I252: Old myocardial infarction; Z85038: Personal history of other malignant neoplasm of large intestine; E538: Deficiency of other specified B group vitamins; Z9181: History of falling; F17210: Nicotine dependence, cigarettes, uncomplicated; I6529: Occlusion and stenosis of unspecified carotid artery; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; R32: Unspecified urinary incontinence; R159: Full incontinence of feces; M8580: Other specified disorders of bone density and structure, unspecified site; Z7902: Long term (current) use of antithrombotics/antiplatelets. The common codes which frequently come are E119, Z8673, I10, E785, I252, F17210, I2510, Z7902. The uncommon codes mentioned in this dataset are I639, G8194, I672, Z85038, E538, Z9181, I6529, R32, R159, M8580.
The icd codes present in this text will be D497, K740, I10, K219, K660, Z87891. The descriptions of icd codes D497, K740, I10, K219, K660, Z87891 are D497: Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system; K740: Hepatic fibrosis; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; K660: Peritoneal adhesions (postprocedural) (postinfection); Z87891: Personal history of nicotine dependence. The common codes which frequently come are I10, K219, Z87891. The uncommon codes mentioned in this dataset are D497, K740, K660. Allergies Celexa Chief Complaint Adrenal Mass Major Surgical or Invasive Procedure 1. Laparoscopic right adrenalectomy with removal of large adrenal mass 12cm . 2. Percutaneous liver biopsy. History of Present Illness ___ yo F with right 10 cm nonfunctional adrenal mass. Past Medical History Past medical history of hypertension denies history of MI or stroke. 3 vaginal deliveries appendectomy Social History ___ Family History Family history is negative for adrenal issues Physical Exam WdWn NAD AVSS Interactive cooperative Abdomen soft appropriately tender along incisions Incisions otherwise c d i Extremities w out edema or pitting and there is no reported calf pain to deep palpation Pertinent Results ___ 12 50PM BLOOD WBC 6.4 RBC 2.72 Hgb 7.6 Hct 23.8 MCV 88 MCH 27.9 MCHC 31.9 RDW 15.8 RDWSD 50.2 Plt ___ ___ 12 50PM BLOOD Glucose 91 UreaN 7 Creat 0.6 Na 137 K 4.1 Cl 103 HCO3 23 AnGap 11 ___ 12 50PM BLOOD Calcium 7.7 Mg 1.7 Brief Hospital Course Ms. ___ was admitted to Urology with right adrenal mass and underwent laparoscopic right adrenalectomy with percutaneous liver biopsy. No concerning intraoperative events occurred please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0 pain was well controlled on PCA hydrated for urine output 30cc hour provided with pneumoboots and incentive spirometry for prophylaxis and ambulated once. On POD1 the patient was restarted on home medications basic metabolic panel and complete blood count were checked pain control was transitioned from PCA to oral analgesics diet was advanced to a clears toast and crackers diet. Urethral Foley catheter was removed without difficulty and on POD2 diet was advanced as tolerated. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition eating well ambulating independently voiding without difficulty and with pain control on oral analgesics. On exam incision was clean dry and intact with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow up in clinic in four weeks. Medications on Admission The Preadmission Medication list is accurate and complete. 1. lisinopril hydrochlorothiazide ___ mg oral DAILY 2. Omeprazole 20 mg PO DAILY 3. raloxifene 60 mg oral DAILY 4. Simvastatin 20 mg PO QPM 5. Citracal D3 calcium phos calcium phosphate vitamin D3 250 mg calcium 500 unit oral DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Centrum Silver Women multivit min iron FA lutein 8 mg iron 400 mcg 300 mcg oral DAILY Discharge Medications 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild 2. Ibuprofen 600 mg PO Q8H PRN Pain Mild RX ibuprofen 600 mg ONE tablet s by mouth Q8hrs Disp 25 Tablet Refills 0 3. OxyCODONE Immediate Release 2.5 5 mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg HALF to ONE FULL tablet by mouth Q4hrs Disp 30 Tablet Refills 0 4. Senna 8.6 mg PO BID Duration 4 Doses RX sennosides Senokot 8.6 mg ONE tab by mouth ___ x daily Disp 30 Tablet Refills 0 5. Centrum Silver Women multivit min iron FA lutein 8 mg iron 400 mcg 300 mcg oral DAILY 6. Citracal D3 calcium phos calcium phosphate vitamin D3 250 mg calcium 500 unit oral DAILY 7. lisinopril hydrochlorothiazide ___ mg oral DAILY 8. Omeprazole 20 mg PO DAILY 9. raloxifene 60 mg oral DAILY 10. Simvastatin 20 mg PO QPM 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition Home Discharge Diagnosis PREOPERATIVE DIAGNOSIS Right adrenal mass. POSTOPERATIVE DIAGNOSIS Right adrenal mass with possible liver fibrosis. Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Please also refer to the provided handout that details instructions and expectations for your post operative phase as made available by your urologist. Resume your pre admission home medications except as noted. ALWAYS call to inform review and discuss any medication changes and your post operative course with your primary care doctor. ___ reduce the strain pressure on your abdomen and incision sites remember to log roll onto your side and then use your hands to push yourself upright while taking advantage of the momentum of putting your legs feet to the ground. There may be bandage strips called steristrips which have been applied to reinforce wound closure. Allow these bandage strips to fall off on their own over time but PLEASE REMOVE ANY REMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may get the steristrips wet. UNLESS OTHERWISE NOTED AVOID aspirin or aspirin containing products and supplements that may have blood thinning effects like Fish Oil Vitamin E etc. . This will be noted in your medication reconciliation. IF PRESCRIBED see the MEDICATION RECONCILIATION IBUPROFEN the ingredient of Advil Motrin etc. may be taken even though you may also be taking Tylenol Acetaminophen. You may alternate these medications for pain control. For pain control try TYLENOL acetaminophen FIRST then ibuprofen and then take the narcotic pain medication as prescribed if additional pain relief is needed. Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool dark tarry stools Call your Urologist s office to schedule confirm your follow up appointment in 4 weeks AND if you have any questions. Do not eat constipating foods for ___ weeks drink plenty of fluids to keep hydrated No vigorous physical activity or sports for 4 weeks or until otherwise advised. Light household chores activity and leisurely walking activity is OK and should be continued. Do NOT be a couch potato Tylenol should be your first line pain medication. A narcotic pain medication has been prescribed for breakthrough pain ___. Max daily Tylenol acetaminophen dose is THREE to FOUR grams from ALL sources AVOID lifting pushing pulling items heavier than 10 pounds or 3 kilos about a gallon of milk or participate in high intensity physical activity which includes intercourse until you are cleared by your Urologist in follow up. No DRIVING for THREE WEEKS or until you are cleared by your Urologist You may shower normally but do NOT immerse your incisions or bathe Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery You may be given prescriptions for a stool softener and or a gentle laxative. These are over the counter medications that may be health care spending account reimbursable. Colace docusate sodium may have been prescribed to avoid post surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool softener NOT a laxative. Senokot or any gentle laxative may have been prescribed to further minimize your risk of constipation. If you have fevers 101.5 F vomiting or increased redness swelling or discharge from your incision call your doctor or go to the nearest emergency room. Followup Instructions ___ The icd codes present in this text will be D497, K740, I10, K219, K660, Z87891. The descriptions of icd codes D497, K740, I10, K219, K660, Z87891 are D497: Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system; K740: Hepatic fibrosis; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; K660: Peritoneal adhesions (postprocedural) (postinfection); Z87891: Personal history of nicotine dependence. The common codes which frequently come are I10, K219, Z87891. The uncommon codes mentioned in this dataset are D497, K740, K660.
The icd codes present in this text will be K629, L910, I10, D573, E669, Z6831, Z87891. The descriptions of icd codes K629, L910, I10, D573, E669, Z6831, Z87891 are K629: Disease of anus and rectum, unspecified; L910: Hypertrophic scar; I10: Essential (primary) hypertension; D573: Sickle-cell trait; E669: Obesity, unspecified; Z6831: Body mass index [BMI] 31.0-31.9, adult; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I10, E669, Z87891. The uncommon codes mentioned in this dataset are K629, L910, D573, Z6831. Allergies ___ ___ Chief Complaint perianal pain Major Surgical or Invasive Procedure None History of Present Illness Patient is a ___ man with history of hypertension who presents with perianal pain and purulent discharge. Patient states that he has had longstanding problems with hemorrhoids . He reports that for the past ___ years he has had intermittent sensation of swelling and rectal pain with defecation. This lasted for a few weeks followed by drainage of pus from the rectal areas followed by some asymptomatic months. However for the past month he has felt significant pain and irritation worse with sitting. He also see bloody drainage occasionally from the anal area. In the past he was seen at ___ ED in ___ for possibly possibly thrombosed painful internal hemmorhoid. He reports he has tried Anusol HC suppository without relief. He works using computers and therefore is quite sedentary at work. He was recently seen by his PCP ___ ___ due to worsening pain and purulent discharge. His doctor prescribed him augmentin and mupriocin as well as derm referral. HIV and RPR negative at that time. The patient states that the symptoms have not improved. He denies any history of receptive anal intercourse Crohn s disease ulcerative colitis fevers chills abdominal pain dysuria hematuria diarrhea. Patient denies any similar pustules in his inguinal region or armpits. No family history of Crohn s disease. Patient reports exquisite pain with defecation. In the ED initial VS were 99.9 96 148 102 16 100 RA ED physical exam was recorded as multiple pustules along the left buttock crease ED labs were notable for WBC 13.7 CT pelvis showed soft tissue thickening in the perianal region and extending along the left buttock without fluid collection. Patient was given 1g Tylenol and vancomycin 1gm Transfer VS were 98.0 67 141 91 18 100 RA REVIEW OF SYSTEMS A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History HYPERTENSION SICKLE CELL TRAIT ASTHMA HEMORRHOIDS OBESITY KELOID H O TOBACCO ABUSE H O ACL TEAR H O BACK PAIN Social History ___ Family History Mother ___ Grandmother Lung Cancer still alive Physical Exam ADMISSION DISCHARGE EXAM Gen NAD lying in bed Eyes EOMI sclerae anicteric ENT MMM OP clear Cardiovasc RRR no MRG full pulses no edema Resp normal effort no accessory muscle use lungs CTA ___. GI soft NT ND BS MSK No significant kyphosis. No palpable synovitis. Skin Multiple nodular pustular lesions on the left ___ region extending to the gluteal folds. Some of these are erythematous and draining pus. On the right perianal region at 6 o clock there is also an area of condylomatous lesions with no pus. No anal fissures observed. No external hemorrhoid observed. There are keloid lesions in the pubic area Neuro AAOx3. No facial droop. Pertinent Results ___ 12 10AM URINE HOURS RANDOM ___ 12 10AM URINE UHOLD HOLD ___ 12 10AM URINE COLOR Straw APPEAR Clear SP ___ ___ 12 10AM URINE BLOOD NEG NITRITE NEG PROTEIN TR GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 6.5 LEUK NEG ___ 12 10AM URINE RBC 0 WBC 0 BACTERIA NONE YEAST NONE EPI 0 ___ 12 10AM URINE MUCOUS RARE ___ 11 24PM estGFR Using this CT Soft tissue thickening in the perianal region and extending along the left buttock without fluid collection. Brief Hospital Course Mr. ___ is a ___ man with history of hypertension who presents with perianal pain and purulent discharge. He has had a history of multiple ___ lesions for ___ years pustules with some drainage and warts and discussed this with his PCP for the first time last week. He was prescribed a course of augmentin which he nearly completed and referred to Dermatology urgently for consideration of biopsy and further evaluation. Given the weather his outpatient appointment was canceled so presented to the ED and was admitted. He had no worsening symptoms from the ___ years of his chronic lesions with the exception of pain relieved with ibuprofen. He denied any fevers chills or sweats. His exam did not reveal s s cellulitis and CT was negative for an abscess. His dermatology appt was rescheduled for the following morning so he was discharged a few hours after admission in stable condition with instructions to keep his Dermatology appointment. No changes were made to his medications. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY Discharge Medications 1. Lisinopril 40 mg PO DAILY Discharge Disposition Home Discharge Diagnosis ___ lesions chronic HTN Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Mr. ___ You were admitted for ongoing pain due to the lesions in the ___ area. You have an appointment with Dermatology tomorrow AM it is very important you keep this appointment so these lesions can be evaluated. Please complete the antibiotics Dr. ___ for you last week. No other changes were made to your medications. We wish you the best ___ Team Followup Instructions ___ The icd codes present in this text will be K629, L910, I10, D573, E669, Z6831, Z87891. The descriptions of icd codes K629, L910, I10, D573, E669, Z6831, Z87891 are K629: Disease of anus and rectum, unspecified; L910: Hypertrophic scar; I10: Essential (primary) hypertension; D573: Sickle-cell trait; E669: Obesity, unspecified; Z6831: Body mass index [BMI] 31.0-31.9, adult; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I10, E669, Z87891. The uncommon codes mentioned in this dataset are K629, L910, D573, Z6831.
The icd codes present in this text will be T8131XA, R6521, J9601, N179, A419, G9340, C9000, J910, K5660, C786, C7889, C211, E46, Q620, T814XXA, T8359XA, N12, B3749, K311, I5032, D62, Z66, Z515, E8809, I482, Z7901, M179, I129, B9562, N183, Z433, R310, E669, Z6838, Y848, Y92239, B965, D696. The descriptions of icd codes T8131XA, R6521, J9601, N179, A419, G9340, C9000, J910, K5660, C786, C7889, C211, E46, Q620, T814XXA, T8359XA, N12, B3749, K311, I5032, D62, Z66, Z515, E8809, I482, Z7901, M179, I129, B9562, N183, Z433, R310, E669, Z6838, Y848, Y92239, B965, D696 are T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter; R6521: Severe sepsis with septic shock; J9601: Acute respiratory failure with hypoxia; N179: Acute kidney failure, unspecified; A419: Sepsis, unspecified organism; G9340: Encephalopathy, unspecified; C9000: Multiple myeloma not having achieved remission; J910: Malignant pleural effusion; K5660: Unspecified intestinal obstruction; C786: Secondary malignant neoplasm of retroperitoneum and peritoneum; C7889: Secondary malignant neoplasm of other digestive organs; C211: Malignant neoplasm of anal canal; E46: Unspecified protein-calorie malnutrition; Q620: Congenital hydronephrosis; T814XXA: Infection following a procedure; T8359XA: Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system; N12: Tubulo-interstitial nephritis, not specified as acute or chronic; B3749: Other urogenital candidiasis; K311: Adult hypertrophic pyloric stenosis; I5032: Chronic diastolic (congestive) heart failure; D62: Acute posthemorrhagic anemia; Z66: Do not resuscitate; Z515: Encounter for palliative care; E8809: Other disorders of plasma-protein metabolism, not elsewhere classified; I482: Chronic atrial fibrillation; Z7901: Long term (current) use of anticoagulants; M179: Osteoarthritis of knee, unspecified; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere; N183: Chronic kidney disease, stage 3 (moderate); Z433: Encounter for attention to colostomy; R310: Gross hematuria; E669: Obesity, unspecified; Z6838: Body mass index [BMI] 38.0-38.9, adult; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere; D696: Thrombocytopenia, unspecified. The common codes which frequently come are J9601, N179, I5032, D62, Z66, Z515, Z7901, I129, E669, D696. The uncommon codes mentioned in this dataset are T8131XA, R6521, A419, G9340, C9000, J910, K5660, C786, C7889, C211, E46, Q620, T814XXA, T8359XA, N12, B3749, K311, E8809, I482, M179, B9562, N183, Z433, R310, Z6838, Y848, Y92239, B965. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Sacral ulcer Major Surgical or Invasive Procedure Uretropelvic junction stent replacement Intubation PICC line placement Right Chest tube placement History of Present Illness Ms. ___ is a ___ year old woman a PMH significant for AFib on coumadin UPJ obstruction s p stent placement in ___ c b chronic Klebsiella bacturia IgG myeloma on lenolidamide and adenocarcinoma of the anal canal followed by Dr. ___ admitted to ___ for evaluation of anemia Hgb 8.6 with course complicated by atrial fibrillation with RVR requiring ICU admission for dilt gtt Acute of chronic kidney injury osteomyelitis from sacral decubitus ucler who was transferred to ___ for debridement of sacral ulcer. In the ED she developed afib with RVR with hypotension where she briefly required a dilt gtt. She was then transferred to the floor. Hospital course thus far has included an MRI without osteomyelitis abdominal distension w NGT placement draining bilious contents CBI and urology procedure for evaluation of hematuria. She underwent cystoscopy ___ to exchange ureteral stent and found purulence behind stent. There was no etiology of hematuria seen. She was started on vanc and zosyn and kept on fluconazole started pre procedure. Culture significant for ___ albicans and MDR pseudomonas SN to Gentamicin which was held ___ ___. Following cystoscopy were unable to extubate and couldn t get off pressors. Per report black colored liquid was coming out of NGT. Required FICU transfer FICU Course Significant for Extubation and starting on tube feeding. Was restabilized and discharged from the FICU where CT Torso revealed New retroperitoneal soft tissue mass encasing the aorta and common iliac vessels in comparison to the ___ examination. The mass abuts the second and third portion of the duodenum and pancreatic head. Suspected involvement of the pancreatic head and distal CBD with new intra and extrahepatic bile duct dilation. Encasement of both ureters with new left and worsened right moderate hydronephrosis in comparison to the ___ Transferred to ___ where course was complicated by hypotension and worsening of anemia in the setting of gross hematuria. Her VS were 85 Doppler and HR of high ___. She received one unit prbc at the time of initial assessment and 2nd unit being hung. Prior to transfer hung 2nd unit prbc first at about 3 . Obtained ABG. Guiac positive On arrival to the CCU pt in respiratory distress with shallow breathing. Intermittently responsive able to follow some commands. Felt ok but increasingly somnolent. Past Medical History PAST ONCOLOGIC HISTORY ANAL ADENOCA Per Dr. ___ Admitted to ___ ___ for BRBPR. Found to have anal adenocarcinoma T2N0 based on MRI and CT. Seen by Dr ___ in the hospital from surgery but has been noncompliant with f u with her despite multiple outreaches from her office. MM ___ woman who presented with anemia in ___. Further testing demonstrated an M spike of approximately 3.3 g dL IgG was 5800 mg dL. Eventually the patient was referred to Hematology IgG increased to 7100mg dL at the start of treatment. Initial Hematology consult was ___. Bone marrow biopsy revealed 60 of her bone marrow occupied by plasma cells cytogenetics demonstrated translocation of chromosomes 11 and 14 also monosomy 13. Skeletal survey was negative. Initial beta 2 microglobulin was 4.08 she started cycle 1 of Revlimid and dexamethasone on ___ Revlimid at 25 mg. She was admitted to ___ on ___ with pneumonia she was also coagulopathic and quite leukopenic. She was discharged on ___. On ___ she presented with severe back pain and she has sustained a compression fracture of L3 vertebra. Her white blood cell count was still low the Revlimid was held and restarted on ___ at a lower dose of 15 mg in combination with weekly dexamethasone at 20 mg. She was started on Zometa. The patient did well on this lower dose of Revlimid with a nice improvement in her IgG and M spike M spike going down to 1.0 g dL by ___ and her IgG going into the normal range at the same time she continued on Revlimid 15 mg every days ___ with weekly dexamethasone at 20 mg repeated every month with Zometa every 3 months for quite some time although by ___ the patient was becoming more leukopenic. At the start of cycle 19 of Revlimid and dexamethasone in ___ the M spike was down to 0.6 g dL and the Revlimid was reduced to 10 mg per day because of severe neutropenia. Unfortunately by ___ timeframe the M spike started to creep up to 0.8 g dL fairly consistently through the ___ and by ___ at her ___ cycle of Revlimid and dexamethasone the M spike increased to 0.9 g dL. She was increased to Rev 15 mg and her counts are holding. She reports she missed a month of Rev due to her hospitalization in ___ Cycle 27 Rev 15mg Dex ___ Clinic appt start Biaxin ___ Cycle 28 Rev Dex ___ Clinic appt reviewed labs M spike 0.8g dL ___ Cycle 29 Rev Dex ___ Admitted for hematuria elevated INR attributed to Ultram warfarin interaction ___ Clinic appt Zometa on cycle 29 ___ Cycle 30 Rev Dex ___ Cycle 31 decided to continue without a clinic appt she was having a great time visiting family in ___ ___ Cycle 31 day 19 ___ Cycle 32 ___ Cycle 33 and Zometa ___ Cycle 34 start on ___ end ___. ___ Cycle 35 start ___ end ___. M spike 0.9g dL ___ Cycle 36 start ___ or ___ Zometa end ___. M spike 0.8g dL ___ Cycle ___ M spike 0.9g dL. Now ___ years on Rev dex first cycle was ___ Cycle ___ M spike 0.9g dL IgG stable. Start Rev ___ ___ finish ___ See me in clinic before cycle 39 start ___ finish ___ See me in clinic Zometa cycle 40 will start ___ I am out of office ___ ___ Admitted ___ obstructive uropathy and enterococcal UTI discharged ___ to rehab ___ ___ discharged ___ Touched base by phone hold Revlimid until next follow up ___ Cycle 41 start ___ end ___ Stent change scheduled ___ Cycle 42 planned start ___ Zometa Previously followed in hem onc by Dr ___ today to establish care with me. ___ Cycle 44 ___ Cycle 45 zometa ___ Cycle 46 ___ Cycle 47 zometa ___ Cycle 48 Rev ___ Cycle 49 rev zometa ___ Cycle 50 rev ___ Cycle 51 rev ___ Anal cancer adeno diagnosed PAST MEDICAL HISTORY Hypertension Atrial fibrillation on coumadin Obesity Myeloma Osteoarthritis of right knee UPJ obstruction s p stent placement ___ c b persistent Klebsiella bacteruria Anal adenocarcinoma dx ___ Perirectal cyst drainage in 1980s PSH ___ EUA biopsy of ___ lesion ___ cystoscopy and R ureteral stent exchange ___ lap CCY Hysterectomy ___ unknown ___ procedure Social History ___ Family History Her parents died in their ___ or ___ of old age. Her parents and multiple siblings have hypertension. Sibling with Alzheimer s disease. No family history of significant arrhythmia or premature coronary disease. Physical Exam Admission Physical Exam Vitals 97.8 120 77 118 20 100RA GENERAL Elderly woman lying in bed NAD HEENT AT NC EOMI PERRL anicteric sclera pink conjunctiva MMM NECK nontender supple neck no LAD no JVD CARDIAC Irregularly irregular S1 S2 no murmurs gallops or rubs LUNG CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles ABDOMEN nondistended BS nontender in all quadrants no rebound guarding no hepatosplenomegaly. Anus with friable mucosa. Ostomy in place EXTREMITIES 2 piting edema up through shins bilaterally no cyanosis or clubbing PULSES 2 DP pulses bilaterally NEURO CN II XII and motor grossly intact intact SKIN warm and well perfused no excoriations or lesions no rashes Discharge Physical Exam deceased Pertinent Results Admission Labs ___ 04 38AM BLOOD WBC 4.3 RBC 2.88 Hgb 8.6 Hct 25.9 MCV 90 MCH 29.9 MCHC 33.2 RDW 15.9 RDWSD 52.1 Plt ___ ___ 04 38AM BLOOD Neuts 53 Bands 0 Lymphs 14 Monos 25 Eos 3 Baso 0 ___ Metas 2 Myelos 3 AbsNeut 2.28 AbsLymp 0.60 AbsMono 1.08 AbsEos 0.13 AbsBaso 0.00 ___ 04 38AM BLOOD Hypochr 2 Anisocy NORMAL Poiklo NORMAL Macrocy NORMAL Microcy NORMAL Polychr NORMAL ___ 04 38AM BLOOD ___ PTT 27.0 ___ ___ 04 38AM BLOOD Glucose 101 UreaN 35 Creat 2.0 Na 134 K 4.9 Cl 98 HCO3 27 AnGap 14 ___ 04 38AM BLOOD ALT 6 AST 18 LD LDH 182 AlkPhos 75 TotBili 0.4 ___ 04 38AM BLOOD Albumin 2.4 Calcium 8.1 Phos 3.6 Mg 2.1 ___ 04 38AM BLOOD Vanco 14.6 IMAGES ___ CXR Port A Cath catheter tip is at the level of the right ventricular outflow tract. The double tube has been removed. There is substantial distension of the stomach that might potentially benefit from the NG tube insertion. What appears to be a E ureteral stent is partially imaged. Bilateral pleural effusions right more than left are present. Vascular congestion is noted borderline with mild interstitial pulmonary edema. ___ KUB 1. A right double J stent projects over the expected location of the right renal pelvis and bladder. The stent is unchanged in position since ___. 2. The stomach is distended with air. ___ TTE The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal LVEF 50 55 . The estimated cardiac index is normal 2.5L min m2 . Tissue Doppler imaging suggests a normal left ventricular filling pressure PCWP 12mmHg . The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets 3 are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ___ mitral regurgitation is seen. There is mild to moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study images reviewed of ___ the findings are similar. ___ Renal US 1. Moderate hydronephrosis and cortical thinning on the right. Mild hydronephrosis on the left. These findings are unchanged from CT ___. 2. A large pleural effusion is unchanged from ___. ___ CXR As compared to the previous radiograph the right sided J stent is unchanged. The previously severe gastric over distension has further increased in severity and is now massive. ___ CXR As compared to ___ the patient has received a new nasogastric tube. The tube is located in the middle parts of the stomach. The previous overinflation of the stomach is no longer present. The lung volumes remain low. Moderate cardiomegaly. Moderate bilateral areas of atelectasis and mild to moderate right pleural effusion. ___ MRI Sacrum PND preliminary read is no osteomylelitis Discharge Labs N A Brief Hospital Course Ms. ___ is a ___ year old woman a PMH significant for AFib on coumadin UPJ obstruction s p stent placement in ___ c b chronic Klebsiella bacturia IgG myeloma on lenolidamide and adenocarcinoma of the anal canal followed by Dr. ___ admitted to ___ for evaluation of anemia Hgb 8.6 with course complicated by atrial fibrillation with RVR requiring ICU admission for dilt gtt Acute of chronic kidney injury osteomyelitis from sacral decubitus ulcer now transferred to ___ for debridement of sacral ulcer. Became hypotensive and quite anemic on the floor with H H of ___ and was transferred to the MICU ___. She peacefully passed away with her family and family pastor present in the room at ___ on ___. Hypercarbic respiratory failure The pt consistently required nasal cannula up to 6 L while on the floor. This was thought to be due to volume overload and increased work of breathing. While in the CCU pt became more lethargic and an ABG showed hypercarbic respiratory failure. She was intubated by anesthesia. CXR showed large bilateral pleural effusions and she was grossly anasarcic. IP placed a right chest tube to drain the effusion which showed that it was malignant with cytology showing adenocarcinoma. She was extubated successfully on ___ and was weaned down to room air thereafter. She was able to be comfortable on room air for the rest of her admission. Encephalopathy although the pt s mental status had noticed to be declining on the floor she was still able to answer appropriately. After extubation the pt was noted to be very lethargic and minimally responsive. EEG was done which showed triphasic waves consistent with an encephalopathy. The pt was trialed on Ativan and Keppra. Her mental status remained very poor in spite of continued Keppra. Neuro signed off after head imaging was unrevealing. Mental status continued to wax and wane through the rest of her time. Stage IV surgical dehiscence Patient had correction of abdominoperineal resection defect with a right vertical rectus abdominis muscular cutaneous flap in ___ following resection of anal cancer. She presented to the hospital with stage IV MRSA sacral ulcer with concern for osteomyelitis as wound probes to bone. CT scan with no mention of sacral osteomyelitis. GI deferred to plastics as they did flap surgery. Plastics does not recommend surgical intervention at this time. MRI shows no signs of osteomyelitis. This wound remained stable during her hospital course. ___ Baseline Creatinine 0.8. Creatinine on admission was 2.1 in setting of diuresis but also possible hypotension from afib with RVR. Pt is grossly volume overloaded with hypoalbumenemia. Concern for prerenal vs. intrinsic with possible multiple myeloma involvement vs obstructive. Creatinine remains above 2.0 today. Renal consulted and believed that her ___ was predominantly secondary to obstruction. After stent exchange by urology ___ renal function improved with a Cr to 1.5 with IV fluids and remained stable. Gastric Distension Patient developed nausea and 1 episode of vomiting ___ with increasing distention. And xray ___ showed significant gastric distension. NG tube was placed and 1L was drawn off. Patient s reported symptomatic improvement. Patient continued to have ostomy output throughout episode. No mass appreciated on exam though obese abdomen. Patient not on narcotic medication. On ___ NG tube was clamped without recurrence of distention patient denies nausea or distension. Unable to get CT abd due to poor kidney function but got OSH CT read by our radiologists. It was notable for new retroperitoneal mass encasing aorta throughout abdomen. It is touching and possibly invading ___ and ___ portion of duodenum potentially explaining gastric obstruction symptoms. Invades pancreatic head explaining ductal dilatation. Also surrounding common iliac vessels and both ureters hydronephrosis worse since ___. Speech and swallow was consulted who said the pt should be strict NPO. Tube feeds were started. Tube feeds On ___ Ms. ___ was no longer tolerating her tube feeds due to very high residuals. Tube feeds were stopped and she was given nutrition with D5NS at 75 hr. ___ attempted to place the Dobhoff tube post pyloric but they were unable to pass the tube through the pylorus and noted contrast barely trickles through ___ obstruction. In family meetings the family was informed that the feeding tube could not be advanced and that other options such as TPN would likely harm the pt more than help her because of her risk for bloodstream infection and metabolic derangements. Metastatic anal adenocarcinoma large retroperitoneal mass compressing the abdomen and constricting the aorta at the level of the iliacs noted on CT from OSH thought to be metastasis from her known anal adenocarcinoma. Per onc not a candidate for chemotherapy so likely not worth biopsying even though definitive diagnosis would not otherwise be reached. Recommend getting palliative care involved and having goals of care discussion with family. First family meeting was ___ and son ___ wanted us to do everything we could to help Ms. ___. This continued to be a theme during her hospital stay and several meetings were held with the family to discuss goals of care. On ___ it was decided to switch to focusing on her comfort only. Volume overload Likely from diastolic heart failure but will need to rule out hypoalbuminemic state and cirrhosis. Patient with gross volume overload with 2 ___ edema bilateral effusions and CT with anasarca on abdominal imaging. TTE unchanged from previous with EF 55 and no gross valvular dysfunction. TSH elevated T4 WNLs. Patient given albumin ___ with good response. However patient still significantly overloaded. On ___ she was anuric and hypotensive despite having significant lower extremity and abdominal edema. She was transferred to the MICU on this day. While in the MICU she was stabilized and pressors were downtitrated. Poor response to Lasix alone but given Lasix and Chlorothiazide with good UOP. Hematuria Unclear cause but patient was on anticoagulation. Concern would be primarily for tumor infiltration. Hematuria intermittent but seems to recur during transport. Potential mechanical irritation. Patient continues to pass dime sized clots. Stent exchange done ___ by urology with improvement in her hematuria. Hematuria with clots returned on ___. Urology recommended CBI which was started ___. She had CBI intermittently throughout her stay to relieve foley obstructions. Normocytic Anemia Hgb at ___ 8.6. No evidence of bleeding. She does have stage III CKD. MCV within normal range and iron studies not particularly suggestive of iron deficiency anemia with ferritin of 781. Folate level of 7.4 and B12 of 411. Concern could possibly be for chronic low grade bleed from gut or hematuria. transfused evening of ___. Hgb remained stable in the 7 s until ___ when H H dropped to ___. This same day she triggered for hypotension of 86 Doppler. As she was anuric at this time there was concern of intraabdominal bleeding and was one of the indications for MICU transfer. Pt had episode of gross hematuria requiring CBI and pRBC transfusion for BP control. Pt required Vasopressin and Phenylephrine while in the MICU but was able to be weaned off. She required intermittent pRBC transfusions during her time in the MICU. AFib on coumadin CHADS 2 of 3. Hemodynamically unstable with RVR upon arrival but controlled with diltiazem and metoprolol. She remained in AFib during her hospital stay. Due to her hematuria and dropping H H blood pressure medications and ultimately SQH were discontinued on ___. Pt put on an esmolol gtt as she had afib with RVR into the 130s on her first day in the ICU. She was taken off the esmolol drip and thereafter controlled with IV metoprolol and achieved good control on PO metoprolol with heart rates in the ___. Hypertension Currently normotensive. See above for issues with hypotension and reason for MICU transfer ___. IgG Myeloma Patient with longstanding IgG MM followed by ___ Oncology. Currently not on revlimid or dexamethasone. Kappa lamba increase but can be seen in kidney disease. Atrius oncology followed patient throughout hospital stay. TRANSITIONAL ISSUES Family Bereavement Counseling Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen Liquid 1000 mg PO TID 2. Diltiazem 30 mg PO QID 3. Heparin Flush 10 units ml 5 mL IV DAILY and PRN line flush 4. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes 5. Heparin Flush 100 units ml 5 mL IV PRN DE ACCESSING port 6. TraMADOL Ultram 25 mg PO Q6H PRN pain 7. Dexamethasone 4 mg PO 1X WEEK TH 8. Calcium Carbonate 500 mg PO BID PRN heart burn 9. Collagenase Ointment 1 Appl TP DAILY 10. Escitalopram Oxalate 5 mg PO DAILY 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Mirtazapine 7.5 mg PO QHS 13. Pantoprazole 40 mg PO Q24H 14. Furosemide 80 mg PO DAILY Discharge Medications N A Discharge Disposition Expired Discharge Diagnosis Patient Expired Discharge Condition Patient Expired Discharge Instructions Patient Expired Followup Instructions ___ The icd codes present in this text will be T8131XA, R6521, J9601, N179, A419, G9340, C9000, J910, K5660, C786, C7889, C211, E46, Q620, T814XXA, T8359XA, N12, B3749, K311, I5032, D62, Z66, Z515, E8809, I482, Z7901, M179, I129, B9562, N183, Z433, R310, E669, Z6838, Y848, Y92239, B965, D696. The descriptions of icd codes T8131XA, R6521, J9601, N179, A419, G9340, C9000, J910, K5660, C786, C7889, C211, E46, Q620, T814XXA, T8359XA, N12, B3749, K311, I5032, D62, Z66, Z515, E8809, I482, Z7901, M179, I129, B9562, N183, Z433, R310, E669, Z6838, Y848, Y92239, B965, D696 are T8131XA: Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter; R6521: Severe sepsis with septic shock; J9601: Acute respiratory failure with hypoxia; N179: Acute kidney failure, unspecified; A419: Sepsis, unspecified organism; G9340: Encephalopathy, unspecified; C9000: Multiple myeloma not having achieved remission; J910: Malignant pleural effusion; K5660: Unspecified intestinal obstruction; C786: Secondary malignant neoplasm of retroperitoneum and peritoneum; C7889: Secondary malignant neoplasm of other digestive organs; C211: Malignant neoplasm of anal canal; E46: Unspecified protein-calorie malnutrition; Q620: Congenital hydronephrosis; T814XXA: Infection following a procedure; T8359XA: Infection and inflammatory reaction due to prosthetic device, implant and graft in urinary system; N12: Tubulo-interstitial nephritis, not specified as acute or chronic; B3749: Other urogenital candidiasis; K311: Adult hypertrophic pyloric stenosis; I5032: Chronic diastolic (congestive) heart failure; D62: Acute posthemorrhagic anemia; Z66: Do not resuscitate; Z515: Encounter for palliative care; E8809: Other disorders of plasma-protein metabolism, not elsewhere classified; I482: Chronic atrial fibrillation; Z7901: Long term (current) use of anticoagulants; M179: Osteoarthritis of knee, unspecified; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere; N183: Chronic kidney disease, stage 3 (moderate); Z433: Encounter for attention to colostomy; R310: Gross hematuria; E669: Obesity, unspecified; Z6838: Body mass index [BMI] 38.0-38.9, adult; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere; D696: Thrombocytopenia, unspecified. The common codes which frequently come are J9601, N179, I5032, D62, Z66, Z515, Z7901, I129, E669, D696. The uncommon codes mentioned in this dataset are T8131XA, R6521, A419, G9340, C9000, J910, K5660, C786, C7889, C211, E46, Q620, T814XXA, T8359XA, N12, B3749, K311, E8809, I482, M179, B9562, N183, Z433, R310, Z6838, Y848, Y92239, B965.
The icd codes present in this text will be M4856XA, K913, T8489XA, M5136, Y831, Y92239, Y838, Y92009. The descriptions of icd codes M4856XA, K913, T8489XA, M5136, Y831, Y92239, Y838, Y92009 are M4856XA: Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture; K913: Postprocedural intestinal obstruction; T8489XA: Other specified complication of internal orthopedic prosthetic devices, implants and grafts, initial encounter; M5136: Other intervertebral disc degeneration, lumbar region; Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause. The uncommon codes mentioned in this dataset are M4856XA, K913, T8489XA, M5136, Y831, Y92239, Y838, Y92009. Allergies Chloroquine Chief Complaint L2 fracture back pain Major Surgical or Invasive Procedure ___ L2 corpectomy retroperitoneal approach and revision of posterior L1 L3 fusion History of Present Illness Mr. ___ is a ___ Ph.D. researcher at ___ who was in ___ for research projects in ___. He had to jump out of a second floor window secondary to a terrorist attack and broke his leg and fractured his L2 vertebrae. He initially received care for this in ___. The patient continued to have back pain and after exhausting medical treatment remained symptomatic. The decision was made to proceed with L2 corpectomy with a revision of posterior instrumentation and fusion. Past Medical History Mitral valve prolapse headaches GERD Past Surgical ___ L ankle ORIF ___ L1 L3 fusion Social History ___ Family History NC Physical Exam UPON DISCHARGE Afebrile Vital sigs stable No apparent distress Heart rate regular Respirations non labored Abdomen soft non tender non distended Back incision clean dry and intact with staples place ___ strength throughout Sensation intact throughout Pertinent Results ___ Portable abdomen xray IMPRESSION Diffuse dilatation of the large bowel in a pattern most consistent with ileus. No pneumoperitoneum or pneumatosis. ___ Ultrasound Bilateral ___ veins IMPRESSION No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ CTA Chest IMPRESSION 1. No evidence of pulmonary embolism or aortic abnormality. 2. Bilateral small nonhemorrhagic pleural effusions and adjacent bibasilar atelectasis. ___ Xray abdomen IMPRESSION 1. Interval improvement of colonic ileus. 2. Left loculated pleural effusion better assessed on CT chest from the same day. ___ Lumbosacral spine xray IMPRESSION Postsurgical changes. No acute fracture. ___ KUB Brief Hospital Course On ___ the patient was admitted for elective L2 corpectomy retroperitoneal approach and revision of posterior L1 L3 fusion. He underwent this procedure with Dr. ___ was subsequently transferred out of the OR to the PACU for post anesthesia care and monitoring. On ___ Patient was neurologically stable. He continued to complain of uncontrolled back pain so pain regimen was adjusted. On ___ the patient continued with back pain which he states was mildly improved. He complained of abdominal pain and distention and KUB showed large bowel ileus. His bowel regimen was increased and he received enema with no immediate BM but large amount of flatus. The patient underwent workup for tachycardia EKG showed sinus tach and Trops were negative. LENIs were negative for any DVTs and tachycardia improved to 110 after pain improved. On ___ overnight the patient s oxygen saturation dipped down to 80 while sleeping and he was therefore placed on 1L NC. In the morning his neurological and motor exam was stable. When working with ___ he had tachyacardia with a heart rate of 100 that increased to 140 when he rose from sitting to standin. He also had a correlating O2 drop to the ___. A CTA was ordered and was negative for PE though it revealed some atelectasis. A follow up KUB was ordered for investigation of resolution of ileus as he had a BM overnight. It showed interval improvement of colonic ileus. On ___ the patient remained neurologically stable. While trying to reposition himself in bed he reports he snapped his low back and has new posterior right sided lumbar pain. He denies numbness tingling in his lower extremities. He is full strength bilaterally. A repeat AP LAT xray are stable. Per CPS his diazepam was d c d and he was started on Tizanidine. Diet changed to full liquids. On ___ the patient remained neurologically stable and was awaiting a rehab bed. He continued to endorse right lower back pain although continued on pain medication as needed. On ___ the patient remained neurologically and hemodynamically stable. The patient was awaiting a rehab bed. On ___ the patient remained neurologically and hemodynamically stable. Patient complaining of diarrhea with intermittent abdominal pain. Ordered repeat KUB to evaluate previous ileus which showed resolving ileus. Diet was advanced as patient tolerates. At the time of discharge on ___ the patient s pain was well controlled with oral medications incisions were clean dry intact and the patient was voiding moving bowels spontaneously. The patient will follow up with Dr. ___ routine. The patient expressed readiness for discharge. Medications on Admission Gabapentin 300mg PO TID lansoprazole 15mg PO daily oxycodone prn tramadol prn Cialis 20mg q72 hours Discharge Medications 1. OxyCODONE Immediate Release ___ mg PO Q4H PRN pain RX oxycodone 5 mg ___ tablet s by mouth Every four 4 hours as needed Disp 60 Tablet Refills 0 2. Gabapentin 600 mg PO TID RX gabapentin 600 mg 1 tablet s by mouth three times a day Disp 42 Tablet Refills 0 3. Calcium Carbonate 1000 mg PO QID PRN indisgestion 4. Acetaminophen 650 mg PO Q6H 5. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet s by mouth Twice daily Disp 28 Tablet Refills 0 6. Tizanidine 2 mg PO TID PRN muscle spasm RX tizanidine 2 mg 1 tablet s by mouth Three times daily as needed Disp 42 Tablet Refills 0 7. Cyanocobalamin 1000 mcg PO DAILY 8. FoLIC Acid ___ mcg PO DAILY 9. lansoprazole 15 mg oral DAILY 10. Multivitamins 1 TAB PO DAILY 11. Vitamin D ___ UNIT PO DAILY Discharge Disposition Extended Care Facility ___ Discharge Diagnosis L2 fracture back pain Discharge Condition Stable Discharge Instructions Surgery Your dressing was removed on the second day after surgery. The wound may remain uncovered. Your incision is closed with staples. You will need to have staple removal. Do not apply any lotions or creams to the site. Please keep your incision dry until removal of your staples. Please avoid swimming for two weeks after staple removal. Call your surgeon if there are any signs of infection like redness fever or drainage. Activity You must wear your brace at all times when out of bed. You may apply your brace sitting at the edge of the bed. You do not need to sleep with it on. We recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment. You make take leisurely walks and slowly increase your activity at your own pace. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. No contact sports until cleared by your neurosurgeon. Do NOT smoke. Smoking can affect your healing and fusion. Medications Please do NOT take any blood thinning medication Aspirin Ibuprofen Plavix Coumadin until cleared by the neurosurgeon. Do not take any anti inflammatory medications such as Motrin Advil Aspirin and Ibuprofen etc until cleared by your neurosurgeon. You may use Acetaminophen Tylenol for minor discomfort if you are not otherwise restricted from taking this medication. It is important to increase fluid intake while taking pain medications. We also recommend a stool softener like Colace. Pain medications can cause constipation. When to Call Your Doctor at ___ for Severe pain swelling redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit New weakness or changes in sensation in your arms or legs. Followup Instructions ___ The icd codes present in this text will be M4856XA, K913, T8489XA, M5136, Y831, Y92239, Y838, Y92009. The descriptions of icd codes M4856XA, K913, T8489XA, M5136, Y831, Y92239, Y838, Y92009 are M4856XA: Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture; K913: Postprocedural intestinal obstruction; T8489XA: Other specified complication of internal orthopedic prosthetic devices, implants and grafts, initial encounter; M5136: Other intervertebral disc degeneration, lumbar region; Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause. The uncommon codes mentioned in this dataset are M4856XA, K913, T8489XA, M5136, Y831, Y92239, Y838, Y92009.
The icd codes present in this text will be R001, I5033, F0391, I2582, E871, Z9181, I2510, I252, I10, I350, I4891, Z7902, E785, Z66. The descriptions of icd codes R001, I5033, F0391, I2582, E871, Z9181, I2510, I252, I10, I350, I4891, Z7902, E785, Z66 are R001: Bradycardia, unspecified; I5033: Acute on chronic diastolic (congestive) heart failure; F0391: Unspecified dementia with behavioral disturbance; I2582: Chronic total occlusion of coronary artery; E871: Hypo-osmolality and hyponatremia; Z9181: History of falling; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I252: Old myocardial infarction; I10: Essential (primary) hypertension; I350: Nonrheumatic aortic (valve) stenosis; I4891: Unspecified atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; E785: Hyperlipidemia, unspecified; Z66: Do not resuscitate. The common codes which frequently come are E871, I2510, I252, I10, I4891, Z7902, E785, Z66. The uncommon codes mentioned in this dataset are R001, I5033, F0391, I2582, Z9181, I350. Allergies nifedipine Amitriptyline Prilosec OTC Terazosin Amlodipine Atenolol Oxybutynin Hydrochlorothiazide spironolactone furosemide Chief Complaint Fall bradycardia. Major Surgical or Invasive Procedure None. History of Present Illness ___ YO F w PMH significant for CAD mild AS afib flutter on dabigatran HFpEF HTN HLD chronic hyponatremia who presents after a fall at her nursing home. Pt unable to provide history but per nursing home and OSH notes in early AM on ___ pt fell and was discovered by nursing home RN. RN at that time noted that pt was confused and lethargic. HR at that time per report was in the ___. EMS was activated and pt brought to OSH ER. En route EMS report indicates that heart rates were labile but there are no EKG strips and unclear if pt received any cardiac medications. At OSH ER pt s EKG revealed bradycardia to 20 with ventricular escape and no signs of atrial activity. The pt was then given 1 mg of atropine with no effect and then transcutaneously paced for 1 hour. She was then noted to have HRs in the ___ and atrial activity. She was then transferred to ___ for possible PPM. Here at ___ noted to be intermittently lethargic and poorly responsive. CT head and neck negative. EP was consulted for possible PPM and initially recommended admission to ___ deferred PPM for the time being. She continued to be intermittently bradycardic to the ___ in the ED but given that she has a history of previous bradycardia and has been asymptomatic with her episodes she was felt to be stable for the floor. However after this she had increasing respiratory distress requiring a NRB. Due to this she was admitted to the CCU. Received Lasix 60mg IV x1. Of note pt s HCP reports that she had been more altered over the last week in the setting of higher doses of seroquel that the nursing home had started for increased agitation. In the ED initial vitals were 98.3 HR 90 142 73 18 93 RA EKG Labs studies notable for Na 140 K 4.6 Cl 98 HCO3 35 BUN 58 Cr 1.2 glu 125 WBC 7 Hct 34.8 AST 219 ALT 178 Trop 0.05 ___ 14.8 PTT 42.4 INR 1.4 AGap 12 BNP 2900 Lactate 1.5. ABG ___ On arrival to the CCU Awake but not answering questions. Pt does not speak ___ per report. On NRB. Past Medical History 1. CARDIAC RISK FACTORS Hypertension Dyslipidemia 2. CARDIAC HISTORY CAD 100 LAD occlusion . MI ___ year ago. Unclear history of PCI. Afib flutter on dabigatran Mild aortic stenosis 3. OTHER PAST MEDICAL HISTORY Chronic hyponatremia Dementia Social History ___ Family History Mother deceased at ___ yo from breast cancer. Father deceased at ___ yo. Son deceased at ___ yo from heart attack. Physical Exam ADMISSION PHYSICAL EXAM VS T 97.6 BP 132 103 HR 80 RR 21 O2 SAT 100 NRB GENERAL Ill appearing. Not answering questions. HEENT Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK Supple. JVP unable to assess due to restlessness. CARDIAC PMI located in ___ intercostal space midclavicular line. Irregularly irregular. Normal S1 S2. II VI systolic murmur at R sternal border. LUNGS No chest wall deformities or tenderness. Tachypneic but withoug increased work of breathing. Faint crackles. ABDOMEN Soft non tender non distended. No hepatomegaly. No splenomegaly. EXTREMITIES Warm well perfused. No clubbing cyanosis or peripheral edema. SKIN No significant skin lesions or rashes. PULSES Distal pulses palpable and symmetric. DISCHARGE PHYSICAL VS T 97.6 BP 144 75 HR 54 RR 22 O2 SAT 92 2 L NC GENERAL Skinny somewhat anxious. Oriented to self only. HEENT Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK Supple. JVP unable to assess due to restlessness. CARDIAC PMI located in ___ intercostal space midclavicular line. Irregularly irregular. Normal S1 S2. II VI systolic murmur at R sternal border. LUNGS No chest wall deformities or tenderness. Tachypneic no signs respiratory distress. Lungs clear to auscultation bilaterally. ABDOMEN Soft non tender non distended. No hepatomegaly. No splenomegaly. EXTREMITIES Warm well perfused. No clubbing cyanosis or peripheral edema. SKIN No significant skin lesions or rashes. PULSES Distal pulses palpable and symmetric. Pertinent Results ADMISSION LABS ___ 12 45PM BLOOD WBC 10.0 RBC 3.55 Hgb 10.5 Hct 34.8 MCV 98 MCH 29.6 MCHC 30.2 RDW 13.1 RDWSD 46.9 Plt ___ ___ 12 45PM BLOOD Neuts 87.3 Lymphs 5.0 Monos 7.0 Eos 0.0 Baso 0.2 Im ___ AbsNeut 8.76 AbsLymp 0.50 AbsMono 0.70 AbsEos 0.00 AbsBaso 0.02 ___ 12 45PM BLOOD ___ PTT 42.4 ___ ___ 12 45PM BLOOD Glucose 125 UreaN 58 Creat 1.2 Na 140 K 4.6 Cl 98 HCO3 35 AnGap 12 ___ 12 45PM BLOOD proBNP 2915 ___ 12 45PM BLOOD cTropnT 0.05 ___ 05 51AM BLOOD CK MB 9 cTropnT 0.13 ___ 05 51AM BLOOD Calcium 10.1 Phos 4.6 Mg 2.5 ___ 08 10PM BLOOD ___ pO2 23 pCO2 79 pH 7.29 calTCO2 40 Base XS 6 ___ 12 52PM BLOOD Lactate 1.5 PERTINENT RESULTS ___ 12 45PM BLOOD cTropnT 0.05 ___ 05 51AM BLOOD CK MB 9 cTropnT 0.13 ___ 12 52PM BLOOD Lactate 1.5 ___ 11 47PM BLOOD Lactate 1.0 ___ 06 04AM BLOOD Lactate 2.9 DISCHARGE LABS ___ 05 51AM BLOOD WBC 7.8 RBC 3.90 Hgb 11.3 Hct 37.7 MCV 97 MCH 29.0 MCHC 30.0 RDW 13.2 RDWSD 46.2 Plt ___ ___ 05 51AM BLOOD ___ PTT 36.7 ___ ___ 05 51AM BLOOD Glucose 89 UreaN 56 Creat 1.2 Na 141 K 4.1 Cl 97 HCO3 31 AnGap 17 ___ 05 51AM BLOOD CK MB 9 cTropnT 0.13 IMAGING CHEST XRAY ___ Large right and moderate left pleural effusions and severe bibasilar atelectasis are unchanged. Cardiac silhouette is obscured. No pneumothorax. Pulmonary edema is mild obscured radiographically by overlying abnormalities. MICROBIOLOGY None. Brief Hospital Course Ms. ___ is ___ year old female with a past medical history significant for CAD mild AS afib flutter on dabigatran HTN HLD chronic hyponatremia who presented to ___ on transfer from OSH after a fall and headstrike when subsequently found to be bradycardic to the ___. She was transferred here externally paced and was seen by our EP physicians. After discussion with patient s healthcare proxy it was decided not to purse pacemaker placement and to withdraw external pacemaker. She initially became profoundly bradycardic from ___ beats per minute but stabilized to the ___ overnight. She was made DNR DNI DNH and sent back to senior living facility hemodynamically stable. Of note CT head at outside facility was negative. TRANSITIONAL ISSUES Per discussion with patient s sister ___ patient was made DNH in addition to her DNR DNI. She will need a new MOLST signed by her sister and the doctors at ___ ___ She will also need a palliative care consult with possible escalation to hospice care as needed. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Artificial Tears ___ DROP BOTH EYES BID 2. Aspirin 81 mg PO DAILY 3. Dabigatran Etexilate 75 mg PO BID 4. Vitamin D ___ UNIT PO EVERY 3 WEEKS 5. Escitalopram Oxalate 15 mg PO DAILY 6. Losartan Potassium 37.5 mg PO DAILY 7. QUEtiapine Fumarate 12.5 mg PO QHS 8. Senna 17.2 mg PO QHS 9. Sodium Chloride Nasal ___ SPRY NU BID PRN congestion 10. Torsemide 60 mg PO DAILY 11. OxyCODONE Immediate Release 2.5 mg PO QAM 12. LORazepam 0.5 mg PO Q6H PRN anxiety 13. Acetaminophen 650 mg PO Q6H PRN Pain Mild Discharge Medications 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild 2. Artificial Tears ___ DROP BOTH EYES BID 3. Dabigatran Etexilate 75 mg PO BID 4. Escitalopram Oxalate 15 mg PO DAILY 5. LORazepam 0.5 mg PO Q6H PRN anxiety 6. Losartan Potassium 37.5 mg PO DAILY 7. OxyCODONE Immediate Release 2.5 mg PO QAM 8. QUEtiapine Fumarate 12.5 mg PO QHS 9. Senna 17.2 mg PO QHS 10. Sodium Chloride Nasal ___ SPRY NU BID PRN congestion 11. Torsemide 60 mg PO DAILY 12. Vitamin D ___ UNIT PO EVERY 3 WEEKS Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Bradycardia Discharge Condition Mental Status Confused always. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Ms. ___ It was a pleasure taking care of you at ___. Why was I here You originally went to another hospital because you fell and hit your head. You were found to have a very slow heart rate and transferred here to ___ for further management What was done while I was in the hospital A CT scan of your head and neck at the outside hospital was done and was normal. You were transferred here with an external pacemaker to bring your heart rate up but we eventually decided to withdraw this device. You were seen by our electrophysiologists who did not decided to put in a pacemaker at this time. What should I do when I get home Take your old medications as prescribed. All the best Your ___ team Followup Instructions ___ The icd codes present in this text will be R001, I5033, F0391, I2582, E871, Z9181, I2510, I252, I10, I350, I4891, Z7902, E785, Z66. The descriptions of icd codes R001, I5033, F0391, I2582, E871, Z9181, I2510, I252, I10, I350, I4891, Z7902, E785, Z66 are R001: Bradycardia, unspecified; I5033: Acute on chronic diastolic (congestive) heart failure; F0391: Unspecified dementia with behavioral disturbance; I2582: Chronic total occlusion of coronary artery; E871: Hypo-osmolality and hyponatremia; Z9181: History of falling; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I252: Old myocardial infarction; I10: Essential (primary) hypertension; I350: Nonrheumatic aortic (valve) stenosis; I4891: Unspecified atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; E785: Hyperlipidemia, unspecified; Z66: Do not resuscitate. The common codes which frequently come are E871, I2510, I252, I10, I4891, Z7902, E785, Z66. The uncommon codes mentioned in this dataset are R001, I5033, F0391, I2582, Z9181, I350.
The icd codes present in this text will be N179, I5022, I959, E8339, I2510, Z951, Z950, Z8673, D649, F17210, I10, E785, I255. The descriptions of icd codes N179, I5022, I959, E8339, I2510, Z951, Z950, Z8673, D649, F17210, I10, E785, I255 are N179: Acute kidney failure, unspecified; I5022: Chronic systolic (congestive) heart failure; I959: Hypotension, unspecified; E8339: Other disorders of phosphorus metabolism; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; Z950: Presence of cardiac pacemaker; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; D649: Anemia, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; I255: Ischemic cardiomyopathy. The common codes which frequently come are N179, I2510, Z951, Z8673, D649, F17210, I10, E785. The uncommon codes mentioned in this dataset are I5022, I959, E8339, Z950, I255. Allergies lisinopril Chief Complaint Hypotension Major Surgical or Invasive Procedure None History of Present Illness ___ hx of ischemic cardiomyopathy sent from ___ clinic when his BP was noted to be systolic ___. Patient reports that at 9am his vision was a little blurry and he felt diffusely weak and tired the subjective feelings completely resolved prior to admission. He states he had been taking his blood pressure medication regularly and drinking only about one small bottle of water daily. He reports over the last year his blood pressure has been regularly with systolic in the ___. He denies fevers or recent illness. Had perirectal abscess drained in ___ site looked well at evaluation today in clinic. No chest pain palpitations or cough. No abd pain n v d urinary symptoms. In the ED initial vitals were HR 82 BP79 42 RR16 SaO298 RA Exam notable for Labs notable for BNP 5890 Cr 2.8 WBC 13.4 Imaging notable for ___ CXR No acute cardiopulmonary abnormality. Patient was given 500 cc IVF Decision was made to admit for hypotension and ___ Vitals prior to transfer HR 73 BP101 57 RR20 SaO2 100 RA On the floor Patient was resting comfortably in bed and asymptomatic. ROS Per HPI Denies fever chills night sweats. Denies headache sinus tenderness rhinorrhea or congestion. Denies cough shortness of breath. Denies chest pain or tightness palpitations. Denies nausea vomiting diarrhea constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History Cards HTN HLD CAD c b MI s p PCI stent and CABG CHF with reduced EF LVEF 27 Single lead ICD pacemaker Neuro L MCA ischemic stroke GI Perirectal abscess s p I D ___ Anal fistula s p EUA ___ placement Social History ___ Family History Noncontributory Physical Exam ADMISSION EXAM Vital Signs T97.9 PO BP97 50 HR60 RR16 SaO2 100 RA General Alert oriented no acute distress HEENT Sclera anicteric MMM oropharynx clear EOMI PERRL neck supple JVP not elevated no LAD CV Regular rate and rhythm normal S1 S2 no murmurs rubs gallops Lungs Clear to auscultation bilaterally no wheezes rales rhonchi Abdomen Soft non tender non distended bowel sounds present no organomegaly no rebound or guarding GU No foley Ext Warm well perfused 2 pulses no clubbing cyanosis or edema Neuro CNII XII intact ___ strength upper lower extremities grossly normal sensation DISCHARGE EXAM Vital Signs Tmax 98.2 T97.4 BP 102 67 HR 71 RR 18 O2 100 RA General No acute distress HEENT Sclera anicteric conjunctiva without injection. PERRLA. Oropharynx clear with MMM. Neck supple no JVP elevation. Lungs Clear to auscultation bilaterally with no wheezes rales rhonchi CV Regular rate and rhythm normal S1 S2 no murmurs rubs gallops. Left sided AICD. Abdomen Soft non tender non distended. Bowel sounds present with no renal bruits. No rebound tenderness or guarding no organomegaly no pulsatile mass. Ext Warm well perfused with no cyanosis of the toes or fingers. No calf tenderness or edema. Skin Without rashes or lesions on gross exam. Tattoos over the forearm bilaterally. Neuro Alert and oriented. Face symmetric. Speech is fluent and logical with no evidence of dysarthria. Moves all extremities purposefully. Pertinent Results ADMISSION LABS ___ 02 05PM WBC 13.4 RBC 4.11 HGB 12.1 HCT 35.6 MCV 87 MCH 29.4 MCHC 34.0 RDW 14.0 RDWSD 43.9 ___ 02 05PM NEUTS 72.3 LYMPHS 13.0 MONOS 12.7 EOS 1.2 BASOS 0.4 IM ___ AbsNeut 9.68 AbsLymp 1.74 AbsMono 1.70 AbsEos 0.16 AbsBaso 0.05 ___ 02 05PM PLT COUNT 223 ___ 02 21PM ___ PTT 34.1 ___ ___ 02 05PM GLUCOSE 143 UREA N 78 CREAT 2.8 SODIUM 133 POTASSIUM 3.7 CHLORIDE 89 TOTAL CO2 23 ANION GAP 25 ___ 02 05PM CALCIUM 10.4 PHOSPHATE 4.6 MAGNESIUM 2.4 ___ 02 05PM CK CPK 59 ___ 02 05PM cTropnT 0.04 ___ 02 05PM CK MB 2 proBNP 5890 ___ 07 30PM URINE HOURS RANDOM ___ 07 30PM URINE COLOR Straw APPEAR Clear SP ___ ___ 07 30PM URINE BLOOD NEG NITRITE NEG PROTEIN 30 GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 5.5 LEUK NEG ___ 07 30PM URINE RBC 1 WBC 2 BACTERIA FEW YEAST NONE EPI 0 ___ 30PM URINE MUCOUS RARE ___ 07 30PM URINE HYALINE 13 DISCHARGE LABS ___ 07 35AM BLOOD WBC 7.7 RBC 3.84 Hgb 11.3 Hct 33.8 MCV 88 MCH 29.4 MCHC 33.4 RDW 14.1 RDWSD 44.8 Plt ___ ___ 07 35AM BLOOD Plt ___ ___ 07 35AM BLOOD ___ PTT 34.7 ___ ___ 07 35AM BLOOD Glucose 105 UreaN 91 Creat 2.6 Na 134 K 3.5 Cl 91 HCO3 25 AnGap 22 ___ 03 14PM BLOOD Glucose 96 UreaN 84 Creat 1.8 Na 134 K 3.4 Cl 95 HCO3 22 AnGap 20 ___ 07 35AM BLOOD CK MB 4 cTropnT 0.03 ___ 07 35AM BLOOD Calcium 9.6 Phos 5.1 Mg 2.6 ___ 03 14PM BLOOD Digoxin 0.2 DIAGNOSTICS ECHO CHA ___ CONCLUSIONS 1. LV ejection fraction is 27 . 2. The apical portion of the anterior wall and the LV apex are akinetic. 3. The left atrium is mildly dilated. 4. There is mild to moderate mitral regurgitation. 5. Estimated RV systolic pressure is moderately elevated at 55 mmHg. 6. Compared to the previous echo of ___ there is no significant change. CXR ___ FINDINGS Patient is status post median sternotomy and CABG. Left sided AICD is noted with single lead terminating in the right ventricle. Heart size is normal. Mediastinal and hilar contours are normal. Lungs are clear. No pleural effusion or pneumothorax. No acute osseous abnormalities are detected. IMPRESSION No acute cardiopulmonary abnormality. Brief Hospital Course ___ M with h o ischemic cardiomyopathy s p PCI stent CABG ICD pacemaker c b systolic CHF LVEF 27 L MCA stroke and perirectal abscess who presents with hypotension and new ___ in the setting fluid restriction while taking multiple diuretics and anti hypertensives. Hypotension Pt presented with a baseline SBP in ___ over past year was fluid restricting given history of pulmonary edema presented with SBP in 60 70s in ED. After 500cc fluid bolus SBP returned to baseline and pt was asymptomatic. Patient was not orthostatic. Bolused additional 1L NS. Hypotension seemed likely attributable to self fluid restriction in the setting of multiple diuretic and anti hypertensive medications. Losartan Spironolactone Carvedilol and Torsemide were held on discharge. Patient was instructed to schedule primary care to have follow up of his laboratory values. ___ Rise in pt s Cr to 2.8 from baseline of 1.1 with associated BUN Cr 20. UA was unremarkable. Pt was maintaining UOP w no history to suggest post renal obstruction. Elevated pro BNP suggestive of ventricular overload c w history of ischemic cardiomyopathy possible cardiorenal contribution to ___. Overall findings were pre renal ___ likely ___ decreased effective circulating volume in the setting of hypotension and fluid restriction in pt with underlying ischemic cardiomyopathy. He responded well to 1.5L IVFs with a creatinine of 1.8 at time of discharge. He was instructed to improve his PO intake to 1.5L per day has hx of CHF exacerbations . Antihypertensives were held at time of discharge. Hyperphosphatemia Phos to 5.1 on ___. Likely ___ renal insufficiency. He was given a low phosphate diet for one day. Normocytic Anemia H H down to 11.3 33.8 on ___ AM. Had low suspicion for hemolysis or acute blood loss. Was thought to be likely dilutional after fluids and was consistent with pt s normal range. RESOLVED ISSUES Leukocytosis Patient presented with transient leukocytosis which downtrended to wnl ___ AM likely ___ acute stress reaction. CXR UA was not concerning for infection. Further infectious workup was not pursued. CHRONIC ISSUES Ischemic Cardiomyopathy s p L ICD placement. No evidence of volume overload on exam ___. Losartan Spironolactone Torsemide Carvedilol in were held in the setting of hypotension and ___ and also held on discharge. Hypertension Losartan Spironolactone Torsemide Carvedilol were held as above. Hyperlipidemia atorvastatin was continued without issue. History of MCA stroke continued home warfarin without issue. TRANSITIONAL ISSUES patient was instructed to drink 1.5 L of fluid per day patient s home antihypertensives were held at time of discharge. patient was instructed to follow up with his PCP within one week patient may benefit from a repeat Na K Cl bicarb BUN Cr at time of follow up consideration of when to restart home antihypertensives can be considered at follow up. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Warfarin 4 mg PO DAILY16 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Digoxin 0.125 mg PO DAILY 6. Ferrous Sulfate uncertain mg PO DAILY 7. Losartan Potassium 25 mg PO DAILY 8. Spironolactone 25 mg PO DAILY 9. Torsemide 20 mg PO BID Discharge Medications 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Digoxin 0.125 mg PO DAILY 4. Ferrous Sulfate uncertain mg PO DAILY 5. Warfarin 4 mg PO DAILY16 6. HELD Carvedilol 12.5 mg PO BID This medication was held. Do not restart Carvedilol until following up with your primary care doctor 7. HELD Losartan Potassium 25 mg PO DAILY This medication was held. Do not restart Losartan Potassium until following up with your primary care doctor 8. HELD Spironolactone 25 mg PO DAILY This medication was held. Do not restart Spironolactone until following up with your primary care doctor 9. HELD Torsemide 20 mg PO BID This medication was held. Do not restart Torsemide until following up with your primary care doctor Discharge Disposition Home Discharge Diagnosis PRIMARY DIAGNOSIS Hypotension ___ Secondary Diagnosis Congestive Heart Failure Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You were admitted to the hospital when it was discovered that you had low blood pressures and evidence of kidney injury after having reduced fluid intake while still taking your antihypertensives. You were evaluated with bloodwork and imaging and given intravenous fluids. Your blood pressure medications were held and we have not restarted these on discharge from the hospital. Please follow up with your primary care doctor with ___ visit in the next week before resuming your home antihypertensives. Please continue to drink 1.5L of fluids per day. It was a pleasure to be involved with your care ___ Team Followup Instructions ___ The icd codes present in this text will be N179, I5022, I959, E8339, I2510, Z951, Z950, Z8673, D649, F17210, I10, E785, I255. The descriptions of icd codes N179, I5022, I959, E8339, I2510, Z951, Z950, Z8673, D649, F17210, I10, E785, I255 are N179: Acute kidney failure, unspecified; I5022: Chronic systolic (congestive) heart failure; I959: Hypotension, unspecified; E8339: Other disorders of phosphorus metabolism; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; Z950: Presence of cardiac pacemaker; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; D649: Anemia, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; I255: Ischemic cardiomyopathy. The common codes which frequently come are N179, I2510, Z951, Z8673, D649, F17210, I10, E785. The uncommon codes mentioned in this dataset are I5022, I959, E8339, Z950, I255.
The icd codes present in this text will be K611, I2582, I509, I2510, I252, Z950, Z951, Z8673, E785, I255, F17210. The descriptions of icd codes K611, I2582, I509, I2510, I252, Z950, Z951, Z8673, E785, I255, F17210 are K611: Rectal abscess; I2582: Chronic total occlusion of coronary artery; I509: Heart failure, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I252: Old myocardial infarction; Z950: Presence of cardiac pacemaker; Z951: Presence of aortocoronary bypass graft; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; E785: Hyperlipidemia, unspecified; I255: Ischemic cardiomyopathy; F17210: Nicotine dependence, cigarettes, uncomplicated. The common codes which frequently come are I2510, I252, Z951, Z8673, E785, F17210. The uncommon codes mentioned in this dataset are K611, I2582, I509, Z950, I255. Allergies lisinopril Chief Complaint perianal fistula and abscess Major Surgical or Invasive Procedure Examination under anesthesia incision and drainage of abscess placement of Malecot drain History of Present Illness ___ with PMH significant for fistula in ano with rectal abscess s p 3 OR drainages CAD CHF hx of stroke and ___ s p CABG pacemaker who presents with rectal pain. The patient states that he has been having worsening rectal pain for the past week. Patient first noticed pain on ___ and described as mild. He did his typical routine of warm shower which in the past has worked for rectal pain with mild abscess. On ___ he was admitted to ___ with cough c w pulmonary edema and was treated with lasix. He was discharged on ___ with continuing worsening rectal pain. On presentation he describes his pain as ___ with warm baths helping the pain. He had taken no medications to improve his pain. He felt a palpable mass on his inner right buttock and feels it has gotten larger. He had been bedridden with pain for several days. His last bowel movement was the morning of presentation. His last urine output was also that morning. He endorsed trouble passing stool and urine since this morning even if he were to try he is unable . He endorsed that all 3 times he has required OR intervention he has had these same set of symptoms. He denied fever chills abdominal pain nausea vomitting diarrhea constipation bloody bowel movements or blood from his rectal mass. In the ED his temp max was 99.5. Lactate is 2.1. WBC 15.8 and H H is 10.3 32.3. Past Medical History Illness HTN HLD CAD c b MI s p PCI stent ___ Hx perirectal abscess s p I D ___ ___ I D perirectal abscess ___ EUA ___ placement ___ Medications ASA 81 metoprolol succinate ER 25 Allergies NKDA Social History ___ Family History Noncontributory Physical Exam Discharge PE VS AVSS Gen well appearing male NAD HEENT no lymphadenopathy moist mucous membranes Lungs CTAB Heart rrr Abd soft nt nd Incisions cdi Extremities wwp Pertinent Results ___ 11 43PM ___ PTT 32.4 ___ ___ 05 30PM URINE HOURS RANDOM ___ 05 30PM URINE GR HOLD HOLD ___ 05 30PM URINE COLOR Straw APPEAR Clear SP ___ ___ 05 30PM URINE BLOOD NEG NITRITE NEG PROTEIN TR GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 6.0 LEUK NEG ___ 05 30PM URINE RBC 0 WBC 1 BACTERIA NONE YEAST NONE EPI 0 ___ 05 30PM URINE HYALINE 1 ___ 05 30PM URINE MUCOUS RARE ___ 01 02PM LACTATE 2.1 ___ 11 30AM GLUCOSE 103 UREA N 37 CREAT 1.6 SODIUM 135 POTASSIUM 4.1 CHLORIDE 96 TOTAL CO2 22 ANION GAP 21 ___ 11 30AM estGFR Using this ___ 11 30AM WBC 15.8 RBC 3.37 HGB 10.3 HCT 32.3 MCV 96 MCH 30.6 MCHC 31.9 RDW 14.7 RDWSD 52.4 ___ 11 30AM NEUTS 78.2 LYMPHS 9.6 MONOS 11.3 EOS 0.3 BASOS 0.2 IM ___ AbsNeut 12.33 AbsLymp 1.51 AbsMono 1.79 AbsEos 0.05 AbsBaso 0.03 ___ 11 30AM PLT COUNT 183 Brief Hospital Course Patient was taken to the OR on ___ for an examination under anesthesia drainage of abscess and placement of Malecot drain for perianal fistula and abscess. He tolerated the procedure well and was transferred to the floor with no issue. Neuro Pain was well controlled on oxycodone 5 mg q6 hours. CV Vital signs were routinely monitored during the patient s length of stay. Pulm The patient was encouraged to ambulate sit and get out of bed use the incentive spirometer and had oxygen saturation levels monitored as indicated. GI The patient was initially kept NPO after the procedure. The patient was later advanced to and tolerated a regular diet at time of discharge. GU Patient had a Foley catheter that was removed at time of discharge. Urine output was monitored as indicated. At time of discharge the patient was voiding without difficulty. ID The patient s vital signs were monitored for signs of infection and fever. The patient was started on continued on antibiotics as indicated. Heme The patient had blood levels checked post operatively during the hospital course to monitor for signs of bleeding. The patient had vital signs including heart rate and blood pressure monitored throughout the hospital stay. On ___ the patient was discharged to home. At discharge he was tolerating a regular diet passing flatus stooling voiding and ambulating independently. He will follow up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Medications on Admission ATORVASTATIN atorvastatin 80 mg tablet. 1 tablet s by mouth once a day CARVEDILOL carvedilol 12.5 mg tablet. 1 tablet s by mouth twice a day Prescribed by Other Provider DIGOXIN digoxin 125 mcg tablet. 1 tablet s by mouth daily Prescribed by Other Provider LOSARTAN losartan 25 mg tablet. 1 tablet s by mouth daily Prescribed by Other Provider SPIRONOLACTONE spironolactone 25 mg tablet. 1 tablet s by mouth daily Prescribed by Other Provider TORSEMIDE torsemide 20 mg tablet. 2 tablet s by mouth daily Prescribed by Other Provider WARFARIN COUMADIN Coumadin 5 mg tablet. 1 tablet s by mouth daily x 5 days per week 3mg on M and F Prescribed by Other Provider Medications OTC ASPIRIN ASPIR 81 Aspir 81 81 mg tablet delayed release. 1 tablet s by mouth once a day Prescribed by Other Provider IRON Dosage uncertain Prescribed by Other Provider Not Taking as Prescribed Discharge Medications 1. Aspirin 81 mg PO DAILY 2. sodium chloride 0.9 0.9 mallencot drain irrigation BID RX sodium chloride Saline Wound Wash 0.9 please irrigate rectal mallenot drain with 60cc of sterile normal saline twice a day Refills 3 3. Tamsulosin 0.4 mg PO QHS please take for 10 days RX tamsulosin 0.4 mg 1 capsule s by mouth at bedtime Disp 10 Capsule Refills 0 4. Atorvastatin 80 mg PO QPM 5. Carvedilol 12.5 mg PO BID 6. Digoxin 0.125 mg PO DAILY 7. Losartan Potassium 25 mg PO DAILY 8. Spironolactone 25 mg PO DAILY 9. Torsemide 20 mg PO DAILY 10. Warfarin 6 mg PO 1X WEEK FR 11. Warfarin 4 mg PO 6X WEEK ___ Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Perianal fistula and abscess Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You were admitted to the ___ on ___ for a perianal fistula with abscess. You underwent an examination under anesthesia with incision and drainage and placement of a drain. You have recovered from the procedure well and are ready to return home. You were seen by cardiology while you were here prior to your surgery. They recommended that you have close follow up with your cardiologist once you are discharged from the hospital. You required diuresis with Lasix several times during your hospital stay with good improvement in your shortness of breath. Please ensure that you make an appointment with both your PCP and your cardiologist once you are discharged for management of your diuretic regimen. The drain placed in your abscess site should remain until you follow up with Dr. ___ in his clinic. You will receive ___ to help you flush the drain twice daily. Followup Instructions ___ The icd codes present in this text will be K611, I2582, I509, I2510, I252, Z950, Z951, Z8673, E785, I255, F17210. The descriptions of icd codes K611, I2582, I509, I2510, I252, Z950, Z951, Z8673, E785, I255, F17210 are K611: Rectal abscess; I2582: Chronic total occlusion of coronary artery; I509: Heart failure, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I252: Old myocardial infarction; Z950: Presence of cardiac pacemaker; Z951: Presence of aortocoronary bypass graft; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; E785: Hyperlipidemia, unspecified; I255: Ischemic cardiomyopathy; F17210: Nicotine dependence, cigarettes, uncomplicated. The common codes which frequently come are I2510, I252, Z951, Z8673, E785, F17210. The uncommon codes mentioned in this dataset are K611, I2582, I509, Z950, I255.
The icd codes present in this text will be K603, I130, I5022, N179, N183, E785, I2510, I480, Z7682, I255, R590, I2722, I252, Z7901, Z8673, Z95810, Z951, Z955, Z87891. The descriptions of icd codes K603, I130, I5022, N179, N183, E785, I2510, I480, Z7682, I255, R590, I2722, I252, Z7901, Z8673, Z95810, Z951, Z955, Z87891 are K603: Anal fistula; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; I5022: Chronic systolic (congestive) heart failure; N179: Acute kidney failure, unspecified; N183: Chronic kidney disease, stage 3 (moderate); E785: Hyperlipidemia, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I480: Paroxysmal atrial fibrillation; Z7682: Awaiting organ transplant status; I255: Ischemic cardiomyopathy; R590: Localized enlarged lymph nodes; I2722: Pulmonary hypertension due to left heart disease; I252: Old myocardial infarction; Z7901: Long term (current) use of anticoagulants; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Z95810: Presence of automatic (implantable) cardiac defibrillator; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I130, N179, E785, I2510, I480, I252, Z7901, Z8673, Z951, Z955, Z87891. The uncommon codes mentioned in this dataset are K603, I5022, N183, Z7682, I255, R590, I2722, Z95810. Allergies lisinopril Major Surgical or Invasive Procedure ___ Right heart catheterization ___ Anal exam under anesthesia with anal fistuolotomy ___ Bronchoscopy with EBUS and lymph node biopsies attach Pertinent Results ADMISSION LABS ___ 05 49PM BLOOD WBC 9.0 RBC 3.71 Hgb 11.3 Hct 34.3 MCV 93 MCH 30.5 MCHC 32.9 RDW 16.9 RDWSD 56.8 Plt ___ ___ 05 49PM BLOOD Glucose 112 UreaN 69 Creat 1.9 Na 140 K 4.5 Cl 102 HCO3 24 AnGap 14 ___ 05 49PM BLOOD Calcium 10.1 Phos 3.3 Mg 2.3 Iron 65 PERTINENT INTERVAL LABS ___ 05 49PM BLOOD calTIBC 300 Ferritn 246 TRF 231 MICRO ___ 11 12 am BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE. GRAM STAIN Final ___ 1 1 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. 3 ___ per 1000X FIELD GRAM NEGATIVE ROD S . 1 1 per 1000X FIELD GRAM POSITIVE COCCI. ___ CLUSTERS. This is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count if applicable. SMEAR REVIEWED RESULTS CONFIRMED. RESPIRATORY CULTURE Final ___ 10 000 100 000 CFU mL Commensal Respiratory Flora. ACID FAST SMEAR Final ___ NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. FUNGAL CULTURE Preliminary NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION Final ___ Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our ___ studies. if pulmonary Histoplasmosis Coccidioidomycosis Blastomycosis Aspergillosis or Mucormycosis is strongly suspected contact the Microbiology Laboratory ___ . ACID FAST CULTURE Pending ___ 11 44 am TISSUE MEDIASTINAL LYMPH NODE. GRAM STAIN Final ___ 1 1 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE Preliminary RESULTS PENDING. ANAEROBIC CULTURE Preliminary ACID FAST SMEAR Final ___ NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE Preliminary FUNGAL CULTURE Preliminary NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION Preliminary STUDIES ___ CT chest w o contrast Mediastinal and hilar lymphadenopathy could be reactive ___ nature or sequela of the evident prior granulomatous infection however a lymphoproliferative disorder such as lymphoma cannot be excluded. A PET CT scan is recommended for further assessment. Moderate cardiomegaly with associated extensive coronary artery atherosclerotic disease and CABG postsurgical changes. Moderate pulmonary edema. ___ Right heart cath Normal right heart filling pressure. Mildly elevated left heart filling pressure. Mild pulmonary hypertension mPA 24mmHg with hemodynamic features consistent with predominant post capillary PH TPG 8 DPG 3 PVR 1.35 ___. Normal systemic blood pressure and SVR. Normal cardiac output index as estimated by both the indirect Fick method and by thermodilution. DISCHARGE LABS ___ 07 33AM BLOOD WBC 8.8 RBC 2.92 Hgb 9.0 Hct 28.1 MCV 96 MCH 30.8 MCHC 32.0 RDW 17.9 RDWSD 62.1 Plt ___ ___ 07 33AM BLOOD Glucose 102 UreaN 53 Creat 2.1 Na 139 K 4.4 Cl 101 HCO3 22 AnGap 16 ___ 07 33AM BLOOD Calcium 9.2 Phos 3.4 Mg 2.0 Brief Hospital Course PATIENT SUMMARY Mr. ___ is a ___ with CAD MI s p PCIs and CABG ___ HFrEF EF 28 s p ___ ICD ___ and cardiomems ___ pAF on apixaban HTN DLD prior L MCA CVA CKD and recurrent perirectal abscesses who presented as direct admit from home for heparin gtt bridge for planned procedures including RHC and anal fistulotomy. Chest CT was also performed which demonstrated enlarged lymph nodes now s p bronchoscopy with biopsies. He was actively diuresed for slight volume overload until euvolemic and then discharged on his home diuretic regimen. CORONARIES Unknown needs repeat stress ___ RHC RA 5 PA ___ 24 PCWP 16 CO 5.89 CI 2.92 SVR 1005 PUMP TTE ___ showed ___. IVS 1.0 PW 1.0. LVEDD 6.1 LVEF ___. RV normal size function. No AS AR. 1 MR. ___ TR. Mild pHTN. RHYTHM NSR w non specific intraventricular delay TRANSITIONAL ISSUES Discharge Weight 195.8 lbs Discharge Creatinine 2.1 Discharge diuretic Home torsemide 60mg BID Tooth extraction According to OMFS it is appropriate to continue apixaban prior to outpatient extraction. If his primary dentist has concerns he can be referred to our oral surgeons by calling ___. Recommend not holding apixaban for given his prior stroke. Stress testing Recommend another CPET cardiopulmonary stress test now that he is euvolemic and optimized. Interventional pulmonology Pt will follow up with IP ___ 2 weeks where he will review the results from his bronchoscopy biopsy. Cardiology Outpatient notes had said his spironolactone was increased from 25mg to 50mg PO daily but patient only reports taking 25mg per day. He was continued on 25mg daily of spironolactone while inpatient. ACTIVE ISSUES Chronic HFrEF s p ICD and cardiomems EF ___ History of dilated ischemic cardiomyopathy ___ Class II EDW previously documented as 185 187lbs but likely closer to 190 195lbs given relatively dry RHC at this weight. On presentation he was well compensated. RHC was performed while inpatient which had largely normal pressures and it was discovered that his cardiomems was not calibrated correctly and still is reporting falsely elevated numbers. He had a few days off diuretics due to NPO status for procedures and mild hypotension then restarted on his home dosing at discharge. He previously had a CPET that demonstrated poor function. This should be repeated now that he is optimized to reassess his need for LVAD transplant. PRELOAD Torsemide 60mg PO BID AFTERLOAD Entresto 97 103mg PO BID Carvedilol 12.5 18.75mg PO BID NHBK Spironolactone 25mg PO daily Carvedilol as above Ionotrope Digoxin 0.125mcg PO daily ICD s p ___ ICD placement ___ ___ Transplant VAD undergoing workup Transplant workup Evaluation for advanced therapies for VAD transplant started ___. Dental OMFS were consulted for teeth removal. He was found to have no acute dental infections requiring intervention. Therefore extractions were not performed during this admission. Dental OMFS recommended pursuing extraction of mobile tooth 9 as an outpatient with an outpatient dentist with no need to hold apixaban. If there are concerns from his primary dentist he can be referred to our outpatient ___ clinic for extraction. Underwent right heart catheterization on ___ which demonstrated only mildly elevated filling pressures including a mildly elevated PASP which is significantly improved from prior. Vasodilator study was not performed given low pulmonary pressures. CT chest was performed as part of workup found asymmetric pulmonary edema R L and enlarged mediastinal hilar lymph nodes. Given these findings IP was consulted and he underwent bronchoscopy w EBUS and lymph node biopsies on ___. Per pulmonology unclear etiology of the lymph nodes. Initially thought to be just pulmonary edema but RHC showed he was fairly euvolemic. Other possibilities include prior granulomatous disease or less likely lymphoma. Perianal fistula Initially presented ___ s p multiple exams under anesthesia I D most recently ___ abscess was drained and malecot catheter placed. Evaluated by ___ ___ ___ clinic after referral from cardiology for pre transplant evaluation. They noted no evidence of abscess but recommended exam under anesthesia with management of fistula ___ ano. He underwent anal fistulotomy with colorectal surgery on ___. The procedure was without complications and he had a cutting ___ placed that will remain until outpatient follow up. Outpatient CRS follow up on ___. At that visit they will schedule further follow up with Dr. ___. CHRONIC ISSUES CAD c b MI s p PCI and subsequent CABG Continued ASA 81mg Continued atorvastatin 80mg Paroxysmal atrial fibrillation Hx CVA Continued ASA 81 atorvastatin 80 Continued carvedilol digoxin per above Resumed home apixaban 5mg BID History of GI bleed Continued omeprazole ___ on CKD stage ___ B l 1.3 1.6. Cr 1.9 on admission had been up to 2.2 as outpatient. Fluctuated throughout admission 2.1 on discharge which may be new baseline. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Sacubitril Valsartan 97mg 103mg 1 TAB PO BID 2. Allopurinol ___ mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. CARVedilol 12.5 mg PO BID 5. CARVedilol 6.25 mg PO QPM 6. Digoxin 0.125 mg PO DAILY 7. Omeprazole 40 mg PO BID 8. Spironolactone 25 mg PO DAILY 9. Torsemide 60 mg PO BID 10. Apixaban 5 mg PO BID 11. Aspirin 81 mg PO DAILY Discharge Medications 1. Allopurinol ___ mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. CARVedilol 12.5 mg PO BID 6. CARVedilol 6.25 mg PO QPM 7. Digoxin 0.125 mg PO DAILY 8. Omeprazole 40 mg PO BID 9. Sacubitril Valsartan 97mg 103mg 1 TAB PO BID 10. Spironolactone 25 mg PO DAILY 11. Torsemide 60 mg PO BID Discharge Disposition Home Discharge Diagnosis Chronic heart failure with reduced ejection fraction Paroxysmal atrial fibrillation Perianal fistula Mediastinal hilar lymphadenopathy Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You were admitted to the hospital for heparin a blood thinner similar to the apixaban you take at home while getting multiple procedures done. Please see below for more information on your hospitalization. It was a pleasure participating ___ your care What happened while you were ___ the hospital We held your apixaban and started you on a heparin drip for continued anticoagulation for your atrial fibrillation You underwent multiple procedures while you were hospitalized this includes a right heart catheterization an anal fistulotomy and a bronchoscopy with lymph node biopsies We gave you a little extra diuretics while you were ___ the hospital to help keep fluid off you. What should you do after leaving the hospital Please take your medications as listed below and follow up at the listed appointments. We have made NO changes to your medications. You have an appointment with the lung doctors ___ ___. They will go over the results of your biopsy then. Your weight at discharge is 195.8 lbs. Please weigh yourself today at home and use this as your new baseline. Please weigh yourself every day ___ the morning. Call your doctor if your weight goes up or down by more than 3 lbs ___ one day or 5 lb ___ one week We wish you the best Your ___ Healthcare Team Followup Instructions ___ The icd codes present in this text will be K603, I130, I5022, N179, N183, E785, I2510, I480, Z7682, I255, R590, I2722, I252, Z7901, Z8673, Z95810, Z951, Z955, Z87891. The descriptions of icd codes K603, I130, I5022, N179, N183, E785, I2510, I480, Z7682, I255, R590, I2722, I252, Z7901, Z8673, Z95810, Z951, Z955, Z87891 are K603: Anal fistula; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; I5022: Chronic systolic (congestive) heart failure; N179: Acute kidney failure, unspecified; N183: Chronic kidney disease, stage 3 (moderate); E785: Hyperlipidemia, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I480: Paroxysmal atrial fibrillation; Z7682: Awaiting organ transplant status; I255: Ischemic cardiomyopathy; R590: Localized enlarged lymph nodes; I2722: Pulmonary hypertension due to left heart disease; I252: Old myocardial infarction; Z7901: Long term (current) use of anticoagulants; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Z95810: Presence of automatic (implantable) cardiac defibrillator; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I130, N179, E785, I2510, I480, I252, Z7901, Z8673, Z951, Z955, Z87891. The uncommon codes mentioned in this dataset are K603, I5022, N183, Z7682, I255, R590, I2722, Z95810.
The icd codes present in this text will be S066X0A, G92, N390, W050XXA, Y92009, I2510, I10, I739, J439, Z96641, B9620, F0390, I350, D649, D469, S0181XA, M4854XD, J8410, Z66, M8448XD, S7002XA, R402142, R402362, R402252. The descriptions of icd codes S066X0A, G92, N390, W050XXA, Y92009, I2510, I10, I739, J439, Z96641, B9620, F0390, I350, D649, D469, S0181XA, M4854XD, J8410, Z66, M8448XD, S7002XA, R402142, R402362, R402252 are S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter; G92: Toxic encephalopathy; N390: Urinary tract infection, site not specified; W050XXA: Fall from non-moving wheelchair, initial encounter; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; I739: Peripheral vascular disease, unspecified; J439: Emphysema, unspecified; Z96641: Presence of right artificial hip joint; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; F0390: Unspecified dementia without behavioral disturbance; I350: Nonrheumatic aortic (valve) stenosis; D649: Anemia, unspecified; D469: Myelodysplastic syndrome, unspecified; S0181XA: Laceration without foreign body of other part of head, initial encounter; M4854XD: Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with routine healing; J8410: Pulmonary fibrosis, unspecified; Z66: Do not resuscitate; M8448XD: Pathological fracture, other site, subsequent encounter for fracture with routine healing; S7002XA: Contusion of left hip, initial encounter; R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department; R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department; R402252: Coma scale, best verbal response, oriented, at arrival to emergency department. The common codes which frequently come are N390, I2510, I10, D649, Z66. The uncommon codes mentioned in this dataset are S066X0A, G92, W050XXA, Y92009, I739, J439, Z96641, B9620, F0390, I350, D469, S0181XA, M4854XD, J8410, M8448XD, S7002XA, R402142, R402362, R402252. Allergies Sulfa Sulfonamide Antibiotics nitrofurantoin Chief Complaint Fall from wheelchair Major Surgical or Invasive Procedure None History of Present Illness ___ female with a history of peripheral vascular disease hypertension coronary artery disease emphysema pelvic fracture s p hip replacement presents to the ED after a fall and a head CT from OSH showing ___ for neurosurgery evaluation. Patient was in her usual state of health until today when she fell from her wheelchair at home. Patient has a laceration to her forehead. Per report from outside hospital patient was getting up from her wheelchair when she tripped and fell forward hitting her head. Patient denies any chest pain and there is no nausea or vomiting Past Medical History Past medical history Peripheral vascular disease Hypertension Coronary artery disease Emphysema Pelvic fracture Past surgical history Right hip replacement Social History ___ Family History NC Physical Exam ADMISSION Vital signs reviewed General alert and oriented x3 cooperative speaks in full sentences HEENT EOMI PERLA left periorbital ecchymosis left forehead laceration sutured by ED team. Neck supple. Pulmonary clear to auscultation bilaterally Cardiovascular regular rate and rhythm no murmurs Abdomen soft nontedner nondistended. Extremities warm and well perfussed. Normal ___ 2 DISCHARGE Vitals 97.5 122 58R Lying 87 18 95 Ra Gen Calm alert NAD HEENT Ecchymosis surrounding the left eye improving no conjunctival hemorrhage CV RRR ___ harsh systolic murmur with radiation to the carotids Resp Lungs clear to auscultation bilaterally no w r r Abd Soft NTND Ext warm no edema L calf R calf MSK ecchymosis of L shoulder mild ttp and with movement large hematoma on lateral L hip buttock Neuro alert oriented to self and place not date Pertinent Results ADMISSION ___ 10 30PM BLOOD WBC 23.6 RBC 2.90 Hgb 9.4 Hct 29.5 MCV 102 MCH 32.4 MCHC 31.9 RDW 15.0 RDWSD 55.3 Plt ___ ___ 10 30PM BLOOD Neuts 79.6 Lymphs 8.2 Monos 10.3 Eos 0.6 Baso 0.5 Im ___ AbsNeut 18.76 AbsLymp 1.92 AbsMono 2.42 AbsEos 0.15 AbsBaso 0.12 ___ 10 30PM BLOOD ___ PTT 25.3 ___ ___ 10 30PM BLOOD Glucose 134 UreaN 16 Creat 0.5 Na 136 K 4.7 Cl 98 HCO3 26 AnGap 12 ___ 10 44AM BLOOD Calcium 8.0 Phos 3.4 Mg 1.6 DISCHARGE ___ 05 57AM BLOOD WBC 9.9 RBC 2.42 Hgb 7.7 Hct 24.8 MCV 103 MCH 31.8 MCHC 31.0 RDW 17.2 RDWSD 61.1 Plt ___ MICRO ___ BLOOD CULTURE Blood Culture Routine PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture Routine PENDING ___ 1 52 am URINE FINAL REPORT ___ URINE CULTURE Final ___ ESCHERICHIA COLI. 100 000 CFU mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES MIC expressed in MCG ML ___ ESCHERICHIA COLI AMPICILLIN 8 S AMPICILLIN SULBACTAM 4 S CEFAZOLIN 4 S CEFEPIME 1 S CEFTAZIDIME 1 S CEFTRIAXONE 1 S CIPROFLOXACIN 0.25 S GENTAMICIN 1 S MEROPENEM 0.25 S NITROFURANTOIN 16 S PIPERACILLIN TAZO 4 S TOBRAMYCIN 1 S TRIMETHOPRIM SULFA 1 S IMAGING ___ CT C A P 1. Severe T12 compression fracture with slight retropulsion of the superior T2 endplate indeterminate age. 2. Multiple fractures of posterior and lateral ___ ribs some of which demonstrate developing callus suggesting subacute chronicity. 3. Acute appearing right L1 transverse process fracture and probable T10 and T11 spinous process fractures. 4. Status post aortic bifemoral bypass with complete occlusion of right bypass graft. 5. 3.5 cm fluid collection encasing the left bypass graft in the left lower quadrant likely representing a seroma. 6. Apparent filling defect in the left common femoral vein likely mixing artifact. However ultrasound is recommended to evaluate for possible DVT. 7. UIP pattern of pulmonary fibrosis in the bilateral lung bases. 8. Diverticulosis without evidence of acute diverticulitis. 9. 4.2 cm abdominal aortic aneurysm at the level of the aortic hiatus. ___ L ___ IMPRESSION No evidence of deep venous thrombosis in the left lower extremity veins. ___ CT head 1. Mild left frontal subarachnoid hemorrhage. No prior studies available for comparison. 2. Presumed arachnoid cyst in the left middle cranial fossa. ___ TTE The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild non obstructive hypertrophy of the basal septum with a normal cavity size. There is normal regional left ventricular systolic function. Global left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 60 . Left ventricular cardiac index is normal 2.5L min m2 No ventricular septal defect is seen. There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal with normal ascending aorta diameter. The aortic arch diameter is normal. There are simple atheroma in the abdominal aorta. The aortic valve leaflets 3 are mildly thickened. There is moderate aortic valve stenosis valve area 1.0 1.5 cm2 . There is no aortic regurgitation. The mitral leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is no mitral valve stenosis. There is mild 1 mitral regurgitation. Due to acoustic shadowing the severity of mitral regurgitation could be UNDERestimated. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION Adequate image quality. Moderate low gradient aortic stenosis. Normal biventricular systolic function. ___ XR shoulder humerus 1. No fracture or dislocation. 2. Multiple focal lucencies in the left humeral shaft could reflect osteopenia but raise concern for multiple myeloma or diffuse metastatic disease which could be further evaluated with MRI SPEP and UPEP. 3. Moderate to severe degenerative changes of the acromioclavicular glenohumeral joints. Brief Hospital Course ___ is an ___ with history of dementia PAD HTN CAD COPD prior pelvic fracture s p hip replacement who presented to an OSH with an unwitnessed fall and was transferred to ___ due to CT head showing SAH. Transferred to the medicine service for encephalopathy. Encephalopathy toxic metabolic Patient was acutely altered on admission with waxing and waning mental status consistent with delirium on baseline of mild dementia. Found to have symptomatic UTI which was a like contributor as well as pain trauma from her fall. She was started on antibiotics and improved back to baseline. Small left frontal traumatic SAH Sustained in her fall. She had repeat head CT that showed stability. She was evaluated by neurosurgery who felt no surgical intervention was needed. Her home aspirin and prophylactic subcutaneous heparin were started on ___. Her goal blood pressure was under 160 and was maintained throughout her hospitalization. Per neurosurgery she did not need seizure prophylaxis and did not need neurosurgery follow up as an outpatient. Sutures were placed for her head laceration and can be removed on ___. T12 compression fracture L1 transverse fracture Per orthospine likely chronic and unrelated to recent fall. She worked with ___ who recommended rehab. She is weight bearing as tolerated and ROM as tolerated. She should follow up with spine clinic 2 weeks after discharge. Pain control was with lidocaine patch and Tylenol. Her home tramadol was restarted on discharge at reduced dose. Fall She suffered an unwitnessed fall and had poor memory of the event. She is on a number of medications that could pre dispose to falls including multiple antihypertensives and had positive orthostatics in house and sedating pain mediations. Symptomatic UTI likely contributer as well. A TTE revealed moderate AS. Telemetry revealed rare short runs of self terminating SVT. Low suspicion overall for cardiac cause of her fall. Her antihypertensives were held with acceptable blood pressures throughout SBPs 160 . Her tramadol and gabapentin which had been newly started uptitrated were also held. Tramadol was restarted at a lower dose on the day of discharge and well tolerated. Urinary tract infection patient with urinary frequency and pansensitive E coli in her urine culture. She was treated with ceftriaxone starting ___ and discharged with one day of cefpodoxime to complete a nemia She was found to be anemic on admission around 7s with a small drop to 6.4 for which she received 1U pRBC with appropriate increase. Her H H remained stable thereafter. Per her family she has chronic anemia. She may have element of MDS as she has borderline thrombocytopenia as well. She has a hip buttock hematoma that remained stable. Iron studies showed an elevated ferritin and normal Fe consistent with ACD. TRANSITIONAL ISSUES Patient discharged on cefpodoxime for 400 mg q12h for one day to complete a 5 day course of antibiotics for UTI Patient with sutures in place can be removed ___ Patient found to be anemic with unknown baseline if not previously evaluated could consider further work up Xray of the L humerus revealed Multiple focal lucencies in the left humeral shaft could reflect osteopenia but raise concern for multiple myeloma or diffuse metastatic disease which could be further evaluated with MRI SPEP and UPEP. Patients antihypertensives atenolol and lisinopril were stopped on admission due to fall and orthostatic hypotension. If she develops hypertension can consider restarting. Patient started on metoprolol succinate 25 mg daily for cardiac protection as atenolol was stopped Patient s tramadol was decreased to 50 mg TID PRN Patient s gabapentin was held on discharge The patient was seen and examined today and is stable for discharge. Greater than 30 minutes were spent on discharge coordination and counseling. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atenolol 25 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Calcium 500 D calcium carbonate vitamin D3 500 mg 1 250mg 200 unit oral DAILY 5. Docusate Sodium 100 mg PO BID 6. Donepezil 5 mg PO QHS 7. Bisacodyl AILY PRN constipation 8. DULoxetine 60 mg PO DAILY 9. Florastor Saccharomyces boulardii 250 mg oral BID 10. Gabapentin 100 mg PO QHS 11. Lisinopril 10 mg PO DAILY 12. Loratadine 10 mg PO DAILY 13. Milk of Magnesia 30 mL PO PRN constipation 14. Multivitamins 1 TAB PO DAILY 15. Nitroglycerin SL 0.4 mg SL Q5MIN PRN chest pain 16. Omeprazole 20 mg PO BID 17. Senna 17.2 mg PO BID 18. TraMADol 100 mg PO TID 19. Acetaminophen 1000 mg PO Q8H 20. Acetaminophen 650 mg PO Q6H PRN Pain Mild 21. Ondansetron 4 mg PO Q8H PRN nausea Discharge Medications 1. Cefpodoxime Proxetil 400 mg PO Q12H Duration 2 Doses Give on ___. Metoprolol Succinate XL 25 mg PO DAILY 3. TraMADol 50 mg PO TID PRN Pain Moderate 4. Acetaminophen 1000 mg PO Q8H 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Bisacodyl AILY PRN constipation 8. Calcium 500 D calcium carbonate vitamin D3 500 mg 1 250mg 200 unit oral DAILY 9. Docusate Sodium 100 mg PO BID 10. Donepezil 5 mg PO QHS 11. DULoxetine 60 mg PO DAILY 12. Florastor Saccharomyces boulardii 250 mg oral BID 13. Loratadine 10 mg PO DAILY 14. Milk of Magnesia 30 mL PO PRN constipation 15. Multivitamins 1 TAB PO DAILY 16. Nitroglycerin SL 0.4 mg SL Q5MIN PRN chest pain 17. Omeprazole 20 mg PO BID 18. Ondansetron 4 mg PO Q8H PRN nausea 19. Senna 17.2 mg PO BID 20. HELD Gabapentin 100 mg PO QHS This medication was held. Do not restart Gabapentin until talking with your PCP 21. HELD Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until talking with your PCP ___ Extended Care Facility ___ Discharge Diagnosis Small left frontal SAH T12 compression fracture Urinary tract infection Acute right L1 transverse process fracture and T10 T11 spinous process fractures. Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Ms. ___ You were admitted to the hospital after you fell and hit your head. You had a bleed in your brain but did not need surgery. You were found to have a small fracture in one of the small bones in your back but this was thought to have been present before you fell. You will follow up with spine doctors after ___ leave the hospital for this. You also hit your arm and hip but did not have any broken bones. You were found to have a urinary tract infection and treated with antibiotics. This may have contributed to your fall. You also were found to have low blood pressure when you stand up so your blood pressure medications stopped. You can discuss restarting them with your primary care doctor. You were found to be anemic to have low blood counts and got a blood transfusion. Your blood counts were stable after this. You may need further evaluation of your anemia by your primary care doctor unless this has already been done. It was a pleasure participating in your care. We wish you all the best in the future Sincerely Your ___ team Followup Instructions ___ The icd codes present in this text will be S066X0A, G92, N390, W050XXA, Y92009, I2510, I10, I739, J439, Z96641, B9620, F0390, I350, D649, D469, S0181XA, M4854XD, J8410, Z66, M8448XD, S7002XA, R402142, R402362, R402252. The descriptions of icd codes S066X0A, G92, N390, W050XXA, Y92009, I2510, I10, I739, J439, Z96641, B9620, F0390, I350, D649, D469, S0181XA, M4854XD, J8410, Z66, M8448XD, S7002XA, R402142, R402362, R402252 are S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter; G92: Toxic encephalopathy; N390: Urinary tract infection, site not specified; W050XXA: Fall from non-moving wheelchair, initial encounter; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; I739: Peripheral vascular disease, unspecified; J439: Emphysema, unspecified; Z96641: Presence of right artificial hip joint; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; F0390: Unspecified dementia without behavioral disturbance; I350: Nonrheumatic aortic (valve) stenosis; D649: Anemia, unspecified; D469: Myelodysplastic syndrome, unspecified; S0181XA: Laceration without foreign body of other part of head, initial encounter; M4854XD: Collapsed vertebra, not elsewhere classified, thoracic region, subsequent encounter for fracture with routine healing; J8410: Pulmonary fibrosis, unspecified; Z66: Do not resuscitate; M8448XD: Pathological fracture, other site, subsequent encounter for fracture with routine healing; S7002XA: Contusion of left hip, initial encounter; R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department; R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department; R402252: Coma scale, best verbal response, oriented, at arrival to emergency department. The common codes which frequently come are N390, I2510, I10, D649, Z66. The uncommon codes mentioned in this dataset are S066X0A, G92, W050XXA, Y92009, I739, J439, Z96641, B9620, F0390, I350, D469, S0181XA, M4854XD, J8410, M8448XD, S7002XA, R402142, R402362, R402252.
The icd codes present in this text will be D1802, I619, G40909. The descriptions of icd codes D1802, I619, G40909 are D1802: Hemangioma of intracranial structures; I619: Nontraumatic intracerebral hemorrhage, unspecified; G40909: Epilepsy, unspecified, not intractable, without status epilepticus. The uncommon codes mentioned in this dataset are D1802, I619, G40909. Allergies Penicillins Chief Complaint Seizures Headaches left frontal cavernous Malformation Major Surgical or Invasive Procedure ___ craniotomy for RSX of Cavernous malformation History of Present Illness Mr. ___ is a very pleasant ___ Caucasian male who was diagnosed with a left inferolateral frontal lobe cavernous malformation approximately ___ years ago in around ___. He has had an episode where he had twitching of the right side of his tongue some dysarthria and that resulted into more extensive simple partial seizures. Now this past ___ he again had a similar episode where he had twitching of the right side of his tongue and he had difficulty speaking. He is currently taking Keppra 1000 mg once a day at night. A recent CT shows some hyperdensity within the lesion that is indicative of recent hemorrhage. Given the fact that he has continuous seizures despite management of antiepileptic drugs and the vicinity of the small cavernoma to the brain surface we think it is reasonable to remove it surgically. We will set him up for surgical resection to a preresection Wand Brain Lab MRI prior. He reviewed the risks and benefits of this operation and he is okay with preceding. Past Medical History Left frontal cavernous malformation w seizures headaches Social History ___ Family History NC Physical Exam On Discharge alert oriented x3. PERRL. Face symmetric. Tongue midline. EOM intact. Strength ___ throughout. Sensation intact to light touch. No pronator drift. Incision c d I with staples no erythema. Mild L facial swelling Pertinent Results MR HEAD W CONTRAST Study Date of ___ 5 16 AM IMPRESSION 1. Unchanged appearance of a left temporal operculum 1.0 cm lesion compatible with a cavernoma with associated large developmental venous anomaly. 2. Unchanged appearance of a right posterior parasagittal 0.8 cm meningioma. Brief Hospital Course ___ Caucasian male who was diagnosed with a left inferolateral frontal lobe cavernous malformation approximately ___ years ago with recent recurrent seizure activity who presents for elective left craniotomy for Cav Mal resection. Inferolateral frontal lobe cavernous malformation The patient was taken to the OR on ___ for a left craniotomy for frontal lobe cavernous malformation resection with Dr. ___. The procedure was uncomplicated the patient was extubated and recovered in the PACU. He was closely monitored and then was transferred to the step down unit when stable. He remained neurologically intact. No postop imaging was indicated. Keppra was increased to 500 mg qAM and 1000 mg q ___. Foley was removed and he was urinating without retention. His diet was advanced and well tolerated he was ambulating and pain was well controlled with PO medications. He was discharged home on POD 2. Medications on Admission Keppra 1gm Daily lorazepam PRN seizures isotretinoin Discharge Medications 1. Acetaminophen Caff Butalbital ___ TAB PO Q6H PRN Headache no not take 4g acetaminophen in 24 hours from any source RX butalbital acetaminophen caff 50 mg 325 mg 40 mg ___ capsule s by mouth every 6 hours as needed Disp 30 Capsule Refills 0 2. Docusate Sodium 100 mg PO BID 3. LevETIRAcetam 500 mg PO QAM RX levetiracetam Keppra 500 mg 1 tablet s by mouth every morning Disp 30 Tablet Refills 0 4. LevETIRAcetam 1000 mg PO QHS 5. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth every 4 hours as needed Disp 30 Tablet Refills 0 6. Senna 8.6 mg PO BID PRN Constipation Discharge Disposition Home Discharge Diagnosis cavernous malformation Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Discharge Instructions Brain Tumor Surgery You underwent surgery to remove a Cavernous Malformation from your brain. Please keep your incision dry until your staples are removed. You may shower at this time but keep your incision dry. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness fever or drainage. Activity We recommend that you avoid heavy lifting running climbing or other strenuous exercise until your follow up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication Aspirin Ibuprofen Plavix Coumadin until cleared by the neurosurgeon. You have been discharged on Keppra Levetiracetam . This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You may use Acetaminophen Tylenol for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience You may experience headaches and incisional pain. You may also experience some post operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. Feeling more tired or restlessness is also common. Constipation is common. Be sure to drink plenty of fluids and eat a high fiber diet. If you are taking narcotics prescription pain medications try an over the counter stool softener. When to Call Your Doctor at ___ for Severe pain swelling redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face arms or leg Call ___ and go to the nearest Emergency Room if you experience any of the following Sudden numbness or weakness in the face arm or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking dizziness or loss of balance or coordination Sudden severe headaches with no known reason Followup Instructions ___ The icd codes present in this text will be D1802, I619, G40909. The descriptions of icd codes D1802, I619, G40909 are D1802: Hemangioma of intracranial structures; I619: Nontraumatic intracerebral hemorrhage, unspecified; G40909: Epilepsy, unspecified, not intractable, without status epilepticus. The uncommon codes mentioned in this dataset are D1802, I619, G40909.
The icd codes present in this text will be O133, O722, O8612, O639, L03311, L02211, O324XX0, O99334, O9952, R609, J45909, O860, Z3A37, Z370. The descriptions of icd codes O133, O722, O8612, O639, L03311, L02211, O324XX0, O99334, O9952, R609, J45909, O860, Z3A37, Z370 are O133: Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester; O722: Delayed and secondary postpartum hemorrhage; O8612: Endometritis following delivery; O639: Long labor, unspecified; L03311: Cellulitis of abdominal wall; L02211: Cutaneous abscess of abdominal wall; O324XX0: Maternal care for high head at term, not applicable or unspecified; O99334: Smoking (tobacco) complicating childbirth; O9952: Diseases of the respiratory system complicating childbirth; R609: Edema, unspecified; J45909: Unspecified asthma, uncomplicated; O860: Infection of obstetric surgical wound; Z3A37: 37 weeks gestation of pregnancy; Z370: Single live birth. The common codes which frequently come are J45909. The uncommon codes mentioned in this dataset are O133, O722, O8612, O639, L03311, L02211, O324XX0, O99334, O9952, R609, O860, Z3A37, Z370. Allergies Sulfamethoxazole Penicillins Chief Complaint arrest of descent gHTN incisional cellulitis with wound abscess Major Surgical or Invasive Procedure primary low transverse cesarean section History of Present Illness Patient is a ___ year old G3P0 with EDC ___ EGA 37w1d on ___ with elevated blood pressures in the office as high as 140 70 over the past week. Repeat BP in OB triage 142 70 141 72 139 85. PIH labs on ___ showed CBC 15.6 10.6 30.3 312 ALT 21 Cr 0.5 Uric Acid 5.0 UP C 0.1 She currently denies headache visual changes epigastric or RUQ pain. Denies ctx VB LOF. FM Past Medical History MEDICAL HISTORY Allergies Last Verified ___ by ___ Penicillins Sulfamethoxazole Active Medication list as of ___ Medications Prescription ALBUTEROL SULFATE PROAIR HFA ProAir HFA 90 mcg actuation aerosol inhaler. 2 puffs every four 4 hours PRN BUDESONIDE FORMOTEROL SYMBICORT Symbicort 160 mcg 4.5 mcg actuation HFA aerosol inhaler. 2 puffs inh twice a day PNV WITH CALCIUM ___ PRENATAL VITAMINS LOW IRON Dosage uncertain Prescribed by Other Provider Medications OTC DOCUSATE SODIUM docusate sodium 100 mg capsule. 1 capsule s by mouth once per day as needed for constipation Problems Last Verified ___ by ___ MD ASTHMA EXTRINSIC W ACUTE EXACERBATION 493.02 ECZEMATOUS DERMATITIS H O TOBACCO USE 305.1 Surgical History Last Verified ___ by ___ MD Surgical History updated no known surgical history. Family History Last Verified ___ by ___ MD Relative Status Age Problem Comments Other ASTHMA V17.5 F H GI MALIGNANCY V16.0 Social History ___ Family History NC Physical Exam VSS Gen NAD Lungs CTA CV RRR Abd 2cm opening on right side of incision with packing erythema improved from prior no pus Ext 1 pitting edema bilaterally with no calf tenderness Brief Hospital Course The patient is a ___ G3 P0 at 37 weeks 4 days admitted for induction of labor due to gestational hypertension. After a prolonged induction the patient progressed to fully dilated and 2 station. However after 5 hours fully dilated and ___ hours pushing there was no descent of the fetal head and significant caput was noted. The patient was recommended to undergo delivery via cesarean section. She experienced a PPH with EBL 1200cc from cervical extension but remained stable postpartum. In terms of her gestational hypertension she had normal labs. She was started on labetalol 200mg BID on ___ which was increased to 300mg BID on ___ for elevated pressures. During her postpartum course she developed an incisional cellulitis with wound abscess. She was noted to have erythema and induration on right side of incision and extending to mons. She was started on IV gent clinda PO clindamycin started ___ ___ 10d course. She incision was opened at bedside ___ and she underwent BID wet to dry dressing changes. She had a wound culture with mixed flora a negative urine culture and blood cultures with no growth. Patient also experienced bilateral lower extremity edema during her stay that she found very bothersome. She received Lasix 20mg PO x1 with improvement of symptoms. She was also maintained on Lovenox 40mg daily. She was discharged on ___ in stable condition with plan for outpatient ___ for BID dressing changes and blood pressure monitoring. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Prenatal Vitamins 1 TAB PO DAILY 2. Docusate Sodium 100 mg PO DAILY PRN constipation 3. Symbicort budesonide formoterol 160 4.5 mcg actuation inhalation 2 puffs bid 4. ProAir HFA albuterol sulfate 90 mcg actuation 2 puffs Q4H PRN wheezing Discharge Medications 1. Albuterol Inhaler 2 PUFF IH Q4H PRN asthma 2. Docusate Sodium 100 mg PO BID PRN Constipation RX docusate sodium Colace 100 mg 1 capsule s by mouth twice a day Disp 40 Capsule Refills 1 3. Ibuprofen 600 mg PO Q6H PRN Pain RX ibuprofen 600 mg 1 tablet s by mouth every 6 hours Disp 30 Tablet Refills 0 4. Symbicort budesonide formoterol 160 4.5 mcg actuation inhalation BID 5. Clindamycin 450 mg PO Q6H Duration 10 Days RX clindamycin HCl 150 mg 3 capsule s by mouth every 6 hrs Disp 108 Capsule Refills 0 6. Ferrous Sulfate 325 mg PO BID RX ferrous sulfate 140 mg 45 mg iron 1 tablet s by mouth twice a day Disp 60 Tablet Refills 1 7. HYDROmorphone Dilaudid ___ mg PO Q4H PRN pain RX hydromorphone Dilaudid 2 mg ___ tablet s by mouth q4hrs Disp 30 Tablet Refills 0 8. Labetalol 300 mg PO BID RX labetalol 300 mg 1 tablet s by mouth twice a day Disp 40 Tablet Refills 0 9. Prenatal Vitamins 1 TAB PO DAILY 10. ProAir HFA albuterol sulfate 90 mcg actuation 2 PUFFS Q4H PRN wheezing Discharge Disposition Home With Service Facility ___ Discharge Diagnosis primary low transverse cesarean section gestational hypertension asthma arrest of descent endometritis cellulitis wound infection Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions pelvic rest x 6 weeks until postpartum visit no heavy lifting or driving x 2 weeks keep incision clean and dry Followup Instructions ___ The icd codes present in this text will be O133, O722, O8612, O639, L03311, L02211, O324XX0, O99334, O9952, R609, J45909, O860, Z3A37, Z370. The descriptions of icd codes O133, O722, O8612, O639, L03311, L02211, O324XX0, O99334, O9952, R609, J45909, O860, Z3A37, Z370 are O133: Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester; O722: Delayed and secondary postpartum hemorrhage; O8612: Endometritis following delivery; O639: Long labor, unspecified; L03311: Cellulitis of abdominal wall; L02211: Cutaneous abscess of abdominal wall; O324XX0: Maternal care for high head at term, not applicable or unspecified; O99334: Smoking (tobacco) complicating childbirth; O9952: Diseases of the respiratory system complicating childbirth; R609: Edema, unspecified; J45909: Unspecified asthma, uncomplicated; O860: Infection of obstetric surgical wound; Z3A37: 37 weeks gestation of pregnancy; Z370: Single live birth. The common codes which frequently come are J45909. The uncommon codes mentioned in this dataset are O133, O722, O8612, O639, L03311, L02211, O324XX0, O99334, O9952, R609, O860, Z3A37, Z370.
The icd codes present in this text will be T83511A, G92, I10, B9620, J449, E119, F200, N390, Y846, Y929, Z87891, K210, I2510, E785, D649. The descriptions of icd codes T83511A, G92, I10, B9620, J449, E119, F200, N390, Y846, Y929, Z87891, K210, I2510, E785, D649 are T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter; G92: Toxic encephalopathy; I10: Essential (primary) hypertension; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; J449: Chronic obstructive pulmonary disease, unspecified; E119: Type 2 diabetes mellitus without complications; F200: Paranoid schizophrenia; N390: Urinary tract infection, site not specified; Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable; Z87891: Personal history of nicotine dependence; K210: Gastro-esophageal reflux disease with esophagitis; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; D649: Anemia, unspecified. The common codes which frequently come are I10, J449, E119, N390, Y929, Z87891, I2510, E785, D649. The uncommon codes mentioned in this dataset are T83511A, G92, B9620, F200, Y846, K210. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Altered Mental Status Major Surgical or Invasive Procedure None History of Present Illness ___ is a ___ year old male with history of schizophrenia with most recent ED visit ___ COPD DM mechanical falls most recently in ___ and s p negative syncope workup in ___ history of urinary retention s p indwelling foley in ___ admission in ___ for sepsis from pneumonia presenting with complaints of fever and altered mental status. ___ presented to the ED from his group home after reportedly being febrile yesterday. The group home care staff changed his foley yesterday and noted that he his mental status was altered this morning. Seen in ___ on ___ by Dr. ___ for evaluation of need for chronic foley which was placed in late ___ after ___ presented to the ED after a fall and was found to be in ___ prior to this he had no problems voiding and have obstructive uropathy. Noted to have a hypersensitive bladder with normal compliance terminal detrusor overactivity no obstruction and was able to empty bladder completely despite over activity. The plan was to leave the foley catheter out and monitor PVRs ___ times daily with foley re insertion if PVR 400 450cc and to continue tamsulosin. In the ED initial vital signs were T99.1 HR112 BP91 58 RR16 SaO2 95 on RA Exam notable for lethargy arousable only to pain oriented x1 Labs were notable for 1 Chem 10 134 94 28 159 4.2 20 1.5 2 CBC 27.3 10.5 32.5 376 Diff 85.6 4.5 Monos 8.7 3 LFTs ALP 167 ALT 5 AST 14 Tbili 0.5 Alb 3.8 4 U A hazy appearance with large leuks WBC 182 small amount of blood RBC 10 Few bacteria Negative Nitrites 30 Proteins 5 FluAPCR and FluBPCR negative 6 Lactate 1.6 7 Blood cx pnd 8 Urine cx pnd Studies performed include 1 CT C spine w o contrast No acute fracture or malalignment of the cervical spine. 2 NCHCT No acute intracranial process 3 CXR No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. Patient was given 1 IV NS 2 Ceftriaxone 2 gm Vitals on transfer ___ 99.2F HR111 106 113 BP135 67 91 135 55 67 RR25 ___ SaO2 100 on RA Upon arrival to the floor the patient was somnolent but arousable oriented to name only. History could not be completed as patient could not answer questions. REVIEW OF SYSTEMS per HPI chills night sweats headache vision changes rhinorrhea congestion sore throat cough shortness of breath chest pain abdominal pain nausea vomiting diarrhea constipation BRBPR melena hematochezia dysuria hematuria. Past Medical History 1. Paranoid schizophrenia well controlled on Clozaril Previous auditory and visual hallucinations none for awhile per patient 2. Mechanical falls with negative syncope workup ___ 3. T2DM last HbA1c 7.1 in ___ 4. COPD last FEV1 unknown 5. GERD Reflux Esophagitis 6. CAD 7. HTN 8. Hyperlipidemia Social History ___ Family History Unknown to patient Physical Exam ADMISSION PHYSICAL EXAM VS 98.9 109bpm BP129 66 RR18 SaO2 96 on RA GENERAL A Ox1 name only somnolent responsive to voice and gentle touch but quickly falls asleep unable to answer questions comprehensibly HEENT Normocephalic atraumatic. Pupils equal 3mm round and unreactive bilaterally. No conjunctival pallor or injection sclera anicteric and without injection. Moist mucous membranes good dentition. Oropharynx is clear. NECK Thyroid is normal in size and texture no nodules. No cervical lymphadenopathy. CARDIAC Regular rhythm normal rate no murmurs rubs gallops. No JVD. LUNGS Clear to auscultation bilaterally w appropriate breath sounds appreciated in all fields. No wheezes rhonchi or rales. BACK Skin. no spinous process tenderness. no CVA tenderness. ABDOMEN Normal bowels sounds non distended non tender to deep palpation in all four quadrants though difficult to assess given patient s altered sensorium. Tympanic to percussion. No organomegaly. well healed mid line incision measuring ___ inches EXTREMITIES No clubbing cyanosis or edema no sign of atrophy hypertrophy. Pulses DP Radial 2 bilaterally. SKIN No evidence of ulcers rash or lesions suspicious for malignancy NEUROLOGIC could not complete due to lack of patient cooperation DISCHARGE PHYSICAL EXAM VS 98.0PO Tmax 98.1 156 79 149 156 79 87 83 71 85 18 SaO2 95 on RA GENERAL A Ox2 name and place able to engage in conversation and keep eyes open HEENT Normocephalic atraumatic. Pupils equal 3mm round and unreactive bilaterally. No conjunctival pallor or injection sclera anicteric and without injection. Moist mucous membranes good dentition. Oropharynx is clear. NECK Thyroid is normal in size and texture no nodules. No cervical lymphadenopathy. CARDIAC Regular rhythm normal rate no murmurs rubs gallops. No JVD. LUNGS Clear to auscultation bilaterally w appropriate breath sounds appreciated in all fields. No wheezes rhonchi or rales. BACK Skin. no spinous process tenderness. no CVA tenderness. ABDOMEN Normal bowels sounds soft non tender non distended. Tympanic to percussion. No organomegaly. well healed mid line incision measuring ___ inches EXTREMITIES No clubbing cyanosis or edema no sign of atrophy hypertrophy. Pulses DP Radial 2 bilaterally. SKIN No evidence of ulcers rash or lesions suspicious for malignancy NEUROLOGIC could not complete due to lack of patient cooperation Pertinent Results ADMISSION LABS ___ 12 54PM PLT SMR NORMAL PLT COUNT 376 ___ 12 54PM HYPOCHROM NORMAL ANISOCYT NORMAL POIKILOCY OCCASIONAL MACROCYT NORMAL MICROCYT NORMAL POLYCHROM NORMAL OVALOCYT OCCASIONAL ___ 12 54PM NEUTS 85.6 LYMPHS 4.5 MONOS 8.7 EOS 0.0 BASOS 0.2 IM ___ AbsNeut 23.37 AbsLymp 1.23 AbsMono 2.36 AbsEos 0.00 AbsBaso 0.05 ___ 12 54PM WBC 27.3 RBC 3.75 HGB 10.5 HCT 32.5 MCV 87 MCH 28.0 MCHC 32.3 RDW 14.2 RDWSD 44.6 ___ 12 54PM ALBUMIN 3.8 ___ 12 54PM ALT SGPT 5 AST SGOT 14 ALK PHOS 167 TOT BILI 0.5 ___ 12 54PM estGFR Using this ___ 12 54PM GLUCOSE 159 UREA N 28 CREAT 1.5 SODIUM 134 POTASSIUM 4.2 CHLORIDE 94 TOTAL CO2 20 ANION GAP 24 ___ 01 19PM LACTATE 1.6 ___ 01 53PM OTHER BODY FLUID FluAPCR NEGATIVE FluBPCR NEGATIVE ___ 03 00PM URINE MUCOUS RARE ___ 03 00PM URINE HYALINE 4 ___ 03 00PM URINE RBC 10 WBC 182 BACTERIA FEW YEAST NONE EPI 1 ___ 03 00PM URINE BLOOD SM NITRITE NEG PROTEIN 30 GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 5.5 LEUK LG ___ 03 00PM URINE COLOR Yellow APPEAR Hazy SP ___ ___ 03 00PM URINE bnzodzpn NEG barbitrt NEG opiates NEG oxycodn NEG ___ 03 00PM URINE UHOLD HOLD ___ 03 00PM URINE HOURS RANDOM ___ 09 32PM PLT COUNT 334 ___ 09 32PM WBC 19.8 RBC 3.39 HGB 9.4 HCT 29.7 MCV 88 MCH 27.7 MCHC 31.6 RDW 14.5 RDWSD 46.8 ___ 09 32PM GLUCOSE 123 UREA N 24 CREAT 1.2 SODIUM 139 POTASSIUM 3.7 CHLORIDE 101 TOTAL CO2 21 ANION GAP 21 DISCHARGE PERTINENT LABS ___ 07 05AM BLOOD WBC 8.9 RBC 3.32 Hgb 9.2 Hct 27.7 MCV 83 MCH 27.7 MCHC 33.2 RDW 13.9 RDWSD 42.4 Plt ___ ___ 07 05AM BLOOD Glucose 118 UreaN 6 Creat 0.6 Na 140 K 3.5 Cl 101 HCO3 24 AnGap 19 ___ 07 00AM BLOOD ___ PTT 35.2 ___ ___ 07 00AM BLOOD ALT 6 AST 14 LD LDH 176 AlkPhos 127 TotBili 0.4 ___ 07 05AM BLOOD Calcium 8.5 Phos 2.5 Mg 1.7 MICROBIOLOGY ___ 3 00 pm URINE FINAL REPORT ___ URINE CULTURE Final ___ ESCHERICHIA COLI. 10 000 100 000 CFU mL. Fosfomycin Susceptibility testing requested by ___. ___ ___ ___ ON ___. FOSFOMYCIN 24MM SUSCEPTIBLE. FOSFOMYCIN sensitivity testing performed by ___ ___. SENSITIVITIES MIC expressed in MCG ML ___ ESCHERICHIA COLI AMIKACIN 8 S AMPICILLIN 32 R AMPICILLIN SULBACTAM 32 R CEFAZOLIN 64 R CEFTAZIDIME 1 S CEFTRIAXONE 64 R CIPROFLOXACIN 4 R GENTAMICIN 16 R MEROPENEM 0.25 S NITROFURANTOIN 16 S TOBRAMYCIN 16 R TRIMETHOPRIM SULFA 16 R IMAGING ___ Imaging ABDOMEN SUPINE ERECT Nonobstructive bowel gas pattern in the stomach small bowel and colon. No evidence of pneumoperitoneum. ___ Imaging CHEST SINGLE VIEW No acute cardiopulmonary process. No focal consolidation to suggest pneumonia. ___ SPINE W O CONTRAST No acute fracture or malalignment of the cervical spine. ___ Imaging CT HEAD W O CONTRAST No acute intracranial process. Brief Hospital Course Mr. ___ is a ___ man with history of paranoid schizophrenia COPD Type 2 DM urinary retention s p indwelling foley catheter placement in ___ who presented from his group home with report of 1 day of fever prior to admission and altered mental status on the day of presentation to the ED ___ . Altered mental status catheter associated urinary tract infection Patient hemodynamically stable on admission but drowsy and not oriented. Afebrile but WBC count of 27. Urinalysis consistent with infection in the setting of indwelling foley catheter. Head and neck imaging without acute abnormalities. He was without headaches photophobia or neck stiffness to suggest meningoencephalitis. Patient initially started on ceftriaxone however urine culture revealed ESBL E. coli resistant to ceftriaxone. Patient switched to meropenem which he received from ___ to ___. Patient was switched to fosfomycin 1 dose on discharge to complete a full antibiotic course. Foley catheter was replaced. Acute kidney injury Patient also noted to have acute kidney injury with Cr 1.5 likely prerenal in etiology that resolved with IV fluids. Cr on discharge 1.0. Paranoid schizophrenia Patient s clozapine was held on admission given altered mental status. He was seen by the psychiatry service for assistance with management. Clozapine was resumed at the suggestion of psychiatry at 100mg PO QHS with plan for outpatient uptitration by primary psychiatrist. Normocytic anemia He was found to have Hgb of 8.8 10.5 as compared to most recent baseline of 11.8. He was without signs of overt bleeding. There was low suspicion for hemolysis in the setting of normal TBili and lack of schistocytes on manual smear. Abdominal pain He experienced transient abdominal pain with benign abdomen possibly related to urinary tract infection though not specifically suprapubic. KUB was without signs of obstruction or perforation. Abdominal pain resolved prior to discharge. T2DM He received long acting insulin with sliding scale as needed. Home metformin was held throughout admission and resumed at discharge. COPD Home fluticasone and tiotropium inhaler were held throughout admission and resumed at discharge. GERD Reflux esophagitis He received omeprazole in place of home ranitidine in the inpatient setting. CAD Home ASA was continued. Hyperlipidemia Home gemfibrozil was held throughout admission and resumed at discharge. Orthostatic hypotension Home fludrocortisone was continued. TRANSITIONAL ISSUES Patient s clozapine was stopped on admission and restarted at 100mg PO QHS by recommendation from psychiatry. Patient should follow up with outpatient psychiatrist for uptitration. Patient was found to have anemia with Hgb of 9.2. He should have a follow up CBC with differential within 1 week and should be worked up for iron deficiency or other causes anemia if not improved downtrending monocyte count likely elevated on admission in the setting of infection also should be ensured. Follow up of coagulation studies to ensure downtrending INR elevated to 1.4 on this admission likely in the setting of infection and poor PO intake without overt signs of DIC also advised. Patient found to have 10 RBC on urinalysis on this admission likely in the setting of urinary tract infection please assess for resolution of hematuria following resolution of urinary tract infection though may be confounded if ongoing foley catheter needed. Patient should follow up with urology for foley catheter care and to assess whether ongoing foley catheter is needed. Appointment was made for ___. CODE Full CONTACT ___ ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension 2. Acetaminophen 650 mg PO Q6H PRN Pain Mild 3. Aspirin 81 mg PO DAILY 4. Clozapine 200 mg PO BID 5. Clozapine 75 mg PO QHS 6. Docusate Sodium 100 mg PO BID 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Gemfibrozil 600 mg PO BID 9. Levemir insulin detemir 32 units subcutaneous BREAKFAST 10. MetFORMIN Glucophage 1000 mg PO BID 11. Ranitidine 150 mg PO BID 12. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications 1. Clozapine 100 mg PO QHS 2. Acetaminophen 650 mg PO Q6H PRN Pain Mild 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension 6. Fluticasone Propionate 110mcg 2 PUFF IH BID 7. Gemfibrozil 600 mg PO BID 8. Levemir insulin detemir 32 units subcutaneous BREAKFAST 9. MetFORMIN Glucophage 1000 mg PO BID 10. Ranitidine 150 mg PO BID 11. Tiotropium Bromide 1 CAP IH DAILY 12. HELD Clozapine 200 mg PO BID This medication was held. Do not restart Clozapine until until you see your psychiatrist Discharge Disposition Extended Care Facility ___ Discharge Diagnosis PRIMARY DIAGNOSES Toxic Metabolic Encephalopathy Catheter associated UTI Acute Kidney Injury SECONDARY DIAGNOSES Paranoid Schizophrenia Type 2 Diabetes COPD Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ It was a pleasure taking care of you. You were admitted to the ___ because you were confused and had a fever. You were found to have a urinary tract infection and you were started on IV antibiotics and your mental status improved significantly. Your Clozaril was also stopped and restarted at a lower dose because of your confusion. You should follow up with your PCP and outpatient psychiatrist within ___ weeks of discharge. Wishing you a speedy recovery ___ Care Team Followup Instructions ___ The icd codes present in this text will be T83511A, G92, I10, B9620, J449, E119, F200, N390, Y846, Y929, Z87891, K210, I2510, E785, D649. The descriptions of icd codes T83511A, G92, I10, B9620, J449, E119, F200, N390, Y846, Y929, Z87891, K210, I2510, E785, D649 are T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter; G92: Toxic encephalopathy; I10: Essential (primary) hypertension; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; J449: Chronic obstructive pulmonary disease, unspecified; E119: Type 2 diabetes mellitus without complications; F200: Paranoid schizophrenia; N390: Urinary tract infection, site not specified; Y846: Urinary catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable; Z87891: Personal history of nicotine dependence; K210: Gastro-esophageal reflux disease with esophagitis; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; D649: Anemia, unspecified. The common codes which frequently come are I10, J449, E119, N390, Y929, Z87891, I2510, E785, D649. The uncommon codes mentioned in this dataset are T83511A, G92, B9620, F200, Y846, K210.
The icd codes present in this text will be J189, F200, N179, E1143, J449, Z794, Z87891, I951, K219, I2510, I10, E785, Z9181. The descriptions of icd codes J189, F200, N179, E1143, J449, Z794, Z87891, I951, K219, I2510, I10, E785, Z9181 are J189: Pneumonia, unspecified organism; F200: Paranoid schizophrenia; N179: Acute kidney failure, unspecified; E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy; J449: Chronic obstructive pulmonary disease, unspecified; Z794: Long term (current) use of insulin; Z87891: Personal history of nicotine dependence; I951: Orthostatic hypotension; K219: Gastro-esophageal reflux disease without esophagitis; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z9181: History of falling. The common codes which frequently come are N179, J449, Z794, Z87891, K219, I2510, I10, E785. The uncommon codes mentioned in this dataset are J189, F200, E1143, I951, Z9181. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint WEAKNESS Major Surgical or Invasive Procedure N A History of Present Illness ___ is a ___ year old M poor historian with a PMH of psychosis mechanical falls with negative syncope w u in ___ T2DM last HbA1c unknown on metformin and insulin and COPD last FEV1 unknown who presents with a 2 week history of weakness and cough with sputum production. He was in his usual state of health until 2 weeks ago when he began to feel weak and short of breath. Of note he has had similar episodes in the past that last for several days and said directly that this feels like pneumonia to me. This was associated with a frequent cough productive of yellow green sputum and anorexia with poor PO intake. He denies hemoptysis fevers chills and night sweats. He denies orthopnea and PND. He denies nausea vomiting diarrhea constipation hematochezia melena dysuria and hematuria. Yesterday he experienced worsening lightheadedness and he had frequent episodes of tripping. He denies falls LOC or head strike with these episodes. This morning he had an episode of chest pain that was midsternal sharp and pleuritic without radiation into the arm or neck or worsened SOB. Concurrently he was too weak to rise from his chair. Last FSG 138. Given his weakness and worsening respiratory status he presented to the ED. ___ ED Initial Vitals 97.5 91 126 81 17 100 RA Exam was notable for Dry MM R tonsillar fullness. No focality to pulmonary exam. Labs were significant for BUN 33 Cr 1.5 AGAP 21 WBC 13 Hgb 12.4 Plt 341 Trop 0.01 Imaging CT head showed no acute process. CXR showed streaky posteroinferior left lobe opacity may reflect atelectasis though infection cannot be entirely excluded. EKG showed NSR rate 90. Interventions 1L IVF azithromycin 500mg IV x1 CTX 1g x1. Vitals Prior to Transfer 97.9 84 132 78 17 99 RA Currently he continues to have a cough with intermittent sputum production. His appetite has returned and he was eating dinner at the time of the exam. He denies any other complaints. Past Medical History 1. Paranoid schizophrenia well controlled on Clozaril Previous auditory and visual hallucinations none for awhile per patient 2. Mechanical falls with negative syncope workup ___ 3. T2DM last HbA1c 7.1 in ___ 4. COPD last FEV1 unknown Social History ___ Family History Unknown to patient. Physical Exam ADMISSION PHYSICAL EXAM VS T 97.7 BP 137 80 HR 98 RR 20 SaO2 100 RA Wt 78.88kg GEN Man appearing older than stated age alert lying in bed watching TV no acute distress. HEENT Dry MM anicteric sclerae no conjunctival pallor. R tonsillar fullness. NECK Supple without LAD. PULM Globally decreased breath sounds with intermittent expiratory wheeze no rhonchi or rales symmetric air movement no increased work of breathing. COR RRR S1 S2 no m r g ABD Soft non tender non distended bowel sounds. EXTREM Warm well perfused no edema. 2 ___ pulses. NEURO A Ox3. CN II XII grossly intact motor function grossly normal. Diminished sensation in bilateral distal ___ although difficult to pinpoint given intermittent compliance with the exam . DISCHARGE PHYSICAL EXAM VS 97.2 141 86 83 18 97 RA Orthostatics ___ 154 77 82 lying 143 78 90 sitting 120 86 97 standing GEN Elderly gentleman lying in bed arousable but falls asleep quickly NAD. HEENT Chapped lips anicteric sclerae. Multiple missing teeth of front lower jaw. NECK Supple without LAD. PULM Breath sounds clearer than ___ bilaterally but general poor air movement decreased intermittent expiratory wheeze no increased work of breathing. No egophony. COR RRR S1 S2 no m r g heart sounds distant. ABD Soft non tender non distended bowel sounds. EXTREM Warm well perfused no edema. 2 ___ pulses. No e o diabetic foot ulcers. NEURO Refused to answer orientation Qs this AM. Gait deferred. Pertinent Results ADMISSION LABS ___ 12 30PM BLOOD WBC 13.0 RBC 4.26 Hgb 12.4 Hct 36.5 MCV 86 MCH 29.1 MCHC 34.0 RDW 13.8 RDWSD 42.5 Plt ___ ___ 12 30PM BLOOD Neuts 77.3 Lymphs 16.1 Monos 5.3 Eos 0.5 Baso 0.2 Im ___ AbsNeut 10.01 AbsLymp 2.08 AbsMono 0.69 AbsEos 0.06 AbsBaso 0.03 ___ 12 30PM BLOOD Glucose 139 UreaN 33 Creat 1.5 Na 136 K 4.2 Cl 97 HCO3 22 AnGap 21 OTHER LABS ___ 06 55AM BLOOD Cortsol 13.0 ___ 06 33AM BLOOD Triglyc 379 HDL 25 CHOL HD 8.8 LDLcalc 120 ___ 07 25AM BLOOD WBC 7.2 RBC 3.77 Hgb 10.9 Hct 32.7 MCV 87 MCH 28.9 MCHC 33.3 RDW 13.9 RDWSD 43.2 Plt ___ ___ 06 33AM BLOOD HbA1c 7.1 eAG 157 ___ 06 33AM BLOOD Triglyc 379 HDL 25 CHOL HD 8.8 LDLcalc 120 ___ 06 33AM BLOOD HBsAg Negative HBsAb Negative IgM HBc Negative ___ 06 33AM BLOOD HIV Ab Negative ___ 06 33AM BLOOD HCV Ab Negative ___ 10 07AM BLOOD ___ pO2 195 pCO2 33 pH 7.43 calTCO2 23 Base XS 0 ___ 12 30PM BLOOD cTropnT 0.01 DISCHARGE LABS ___ 06 13AM BLOOD WBC 9.3 RBC 4.19 Hgb 11.9 Hct 36.5 MCV 87 MCH 28.4 MCHC 32.6 RDW 13.7 RDWSD 43.2 Plt ___ ___ 06 13AM BLOOD Glucose 114 UreaN 16 Creat 1.1 Na 137 K 4.3 Cl 99 HCO3 21 AnGap 21 IMAGING CXR ___ Streaky left lobe opacity may reflect atelectasis though infection cannot be entirely excluded. CT Head ___ No acute intracranial abnormalities. Specifically no evidence of intra axial or extra axial hemorrhage. EKG ___ NSR rate 90 Brief Hospital Course ___ is a ___ year old M poor historian with a PMH of psychosis mechanical falls with negative syncope w u in ___ T2DM last HbA1c 7.1 in ___ on metformin and insulin and COPD last FEV1 unknown who presents with a 2 week history of weakness and cough with sputum production concerning for CAP as well as orthostatic hypotension. Cough Likely CAP given leukocytosis 13k malaise sputum production and LLL infiltrate on CXR. Never met SIRS criteria during hospitalization. He always saturated well on RA with no evidence of increased work of breathing. SputumCx indeterminate urine legionella negative. He received a 5 day course of antibiotics with ceftriaxone azithromycin ___ . On discharge he was feeling significantly better with no complaints of cough. Dizziness Weakness The patient presented with orthostatic hypotension thought secondary hypovolemia in the setting of poor PO intake given positive orthostatics and BUN Cr 20 1 suggestive of dehydration. Patient relies on cane at home. ECG NSR trops neg. CT Head with no acute process. Electrolytes WNL. Despite brisk fluid resuscitation and now likely euvolemic status orthostatics remain positive and he has a persistent unsteady gait. Underlying etiology unclear possibly autonomic dysfunction ___ DM versus medication on clozapine . Per outpatient psychiatrist Dr. ___ has been on the same dose of clozapine for ___ years. Adrenal insufficiency unlikely as ___ AM cortisol level 13.0. ___ evaluated him on ___ and recommended rehab. On discharge his orthostatic vital signs remained positive and he continued to require assistance with walking. He was initiated on fludrocortisone 0.1mg QD on ___ with some symptom relief. ___ Likely due to hypovolemia in the setting of poor PO intake given BUN Cr 20 1. Last baseline 0.95 in ___. We gave him IVF as above with resolution of his ___ to Cr 0.9. On discharge his BUN Cr were ___. Prior IVDU Patient reports prior history of heroin use and other drugs. He gave consent for HIV testing. HIV HepB HepC were all negative. CHRONIC ISSUES Psychosis Continued clozapine. Diabetes RISS held home metformin. Repeat HbA1c 7.2. FSGs 120s 180s here. No evidence of diabetic foot ulcers. COPD Continued home fluticasone and tiotropium inhaler. GERD Continued home ranitidine. CAD Continued home ASA. HTN Held home lisinopril given orthostatic hypotension. HL Continued home gemfibrozil. Total Chol 221 Triglycerides 379 elevated. HDL low at 25. Chol HD 8.8 LDL calc 120. TRANSITIONAL ISSUES Fludrocortisone The patient was initiated on Fluricil on ___ at 0.1mg daily. This can be uptitrated at a rate of 0.1mg per week to a maximum of 0.3mg daily. Transthoracic echo The patient was scheduled for an outpatient echo. ECHO office will call patient to make appointment. He should follow up with a cardiologist to review the results. Nutrition The patient arrived with evidence of dehydration. Please ensure that he is reminded to drink water and other fluids throughout the day especially if he is feeling ill. Former IVDU HIV HepC HepB found to be negative on this admission. No evidence of active IVDU. Diabetic neuropathy The patient intermittently reported reduced sensation and proprioception in bilateral distal extremities. His HbA1c was 7.2 on admission which is mildly elevated. His orthostatic hypotension may also be an effect of autonomic neuropathy. His primary care physician should reevaluate this at their next appointment. Orthostatic hypotension He will be scheduled for an outpatient follow up appointment with neurology to evaluate for potential causes of autonomic neuropathy. If negative his psychiatrist should consider redosing of his clozapine to minimize potential side effects. His primary care physician should continue to work closely with him to ensure his diabetes mellitus is being treated adequately. Blood cultures Negative since ___ final result pending at discharge. If any growth observed the patient will be notified. Lipid panel Total Chol 221 Triglycerides 379 elevated. HDL low at 25. Chol HD 8.8 LDL calc 120. He should have a repeat lipid panel performed with his primary care physician and consider alternative agents dosing to better manage his low HDL and high triglycerides. CODE STATUS Full unconfirmed CONTACT ___ ___ or ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN pain 2. Aspirin 81 mg PO DAILY 3. Clozapine 200 mg PO BID 4. Clozapine 75 mg PO HS 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate 110mcg 2 PUFF IH BID 7. Gemfibrozil 600 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Ranitidine 150 mg PO BID 10. Tiotropium Bromide 1 CAP IH DAILY 11. MetFORMIN Glucophage 1000 mg PO BID 12. Detemir 32 Units Breakfast The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN pain 2. Aspirin 81 mg PO DAILY 3. Clozapine 200 mg PO BID 4. Clozapine 75 mg PO HS 5. Docusate Sodium 100 mg PO BID 6. Fluticasone Propionate 110mcg 2 PUFF IH BID 7. Gemfibrozil 600 mg PO BID 8. Lisinopril 5 mg PO DAILY 9. Ranitidine 150 mg PO BID 10. Tiotropium Bromide 1 CAP IH DAILY 11. MetFORMIN Glucophage 1000 mg PO BID 12. Detemir 32 Units Breakfast Discharge Medications 1. Fludrocortisone Acetate 0.1 mg PO DAILY hypotension 2. Acetaminophen 650 mg PO Q6H PRN pain 3. Aspirin 81 mg PO DAILY 4. Clozapine 200 mg PO BID 5. Clozapine 75 mg PO HS 6. Docusate Sodium 100 mg PO BID 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. Gemfibrozil 600 mg PO BID 9. Detemir 32 Units Breakfast 10. MetFORMIN Glucophage 1000 mg PO BID 11. Ranitidine 150 mg PO BID 12. Tiotropium Bromide 1 CAP IH DAILY Discharge Disposition Extended Care Facility ___ Discharge Diagnosis PRIMARY DIAGNOSES COMMUNITY ACQUIRED PNEUMONIA DEHYDRATION ACUTE KIDNEY INJURY ORTHOSTATIC HYPOTENSION SECONDARY DIAGNOSES TYPE II DIABETES MELLITUS HYPERTENSION HYPERLIPIDEMIA CHRONIC OBSTRUCTIVE PULMONARY DISEASE PARANOID SCHIZOPHRENIA CORONARY ARTERY DISEASE GASTROESOPHAGEAL REFLUX DISORDER Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Mr. ___ You were admitted to the hospital for weakness and cough. We found that you had a pneumonia infection of the lungs and gave you antibiotics. We also found that you were very dehydrated and gave you IV fluids. Our physical therapists also evaluated you and decided you were strong enough to go home. You will need to continue your antibiotics until ___. It is very important not to stop your antibiotics early as this can lead to repeated or worse infections. Please make sure to drink enough water at least 8 cups a day and eat three meals a day. It was a pleasure taking care of you and we hope you continue to feel better. Sincerely Your Team at ___ Followup Instructions ___ The icd codes present in this text will be J189, F200, N179, E1143, J449, Z794, Z87891, I951, K219, I2510, I10, E785, Z9181. The descriptions of icd codes J189, F200, N179, E1143, J449, Z794, Z87891, I951, K219, I2510, I10, E785, Z9181 are J189: Pneumonia, unspecified organism; F200: Paranoid schizophrenia; N179: Acute kidney failure, unspecified; E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy; J449: Chronic obstructive pulmonary disease, unspecified; Z794: Long term (current) use of insulin; Z87891: Personal history of nicotine dependence; I951: Orthostatic hypotension; K219: Gastro-esophageal reflux disease without esophagitis; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z9181: History of falling. The common codes which frequently come are N179, J449, Z794, Z87891, K219, I2510, I10, E785. The uncommon codes mentioned in this dataset are J189, F200, E1143, I951, Z9181.
The icd codes present in this text will be I6521, I2510, Z955, Z8546, Z8571, E785, Z951, I081, Z952, G4733. The descriptions of icd codes I6521, I2510, Z955, Z8546, Z8571, E785, Z951, I081, Z952, G4733 are I6521: Occlusion and stenosis of right carotid artery; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z955: Presence of coronary angioplasty implant and graft; Z8546: Personal history of malignant neoplasm of prostate; Z8571: Personal history of Hodgkin lymphoma; E785: Hyperlipidemia, unspecified; Z951: Presence of aortocoronary bypass graft; I081: Rheumatic disorders of both mitral and tricuspid valves; Z952: Presence of prosthetic heart valve; G4733: Obstructive sleep apnea (adult) (pediatric). The common codes which frequently come are I2510, Z955, E785, Z951, G4733. The uncommon codes mentioned in this dataset are I6521, Z8546, Z8571, I081, Z952. Allergies Penicillins Tetracycline Analogues Amoxicillin IV Dye Iodine Containing Contrast Media Lactose Statins Hmg Coa Reductase Inhibitors metoprolol Chief Complaint Asymptomatic carotid stenosis Major Surgical or Invasive Procedure ___ RIGHT CAROTID ENDARTERECTOMY History of Present Illness The patient is a ___ male with progressive carotid stenosis now greater than 80 . In addition he is intolerant of statin so we discussed elective preventative repair. He understood the risks including stroke cranial nerve injury restenosis and bleeding. Past Medical History CAD s p DES to LAD in ___ Prostate cancer s p prostatectomy ___ Hodgkin s Lymphoma ___ s p splenectomy chemotherapy and radiation Gout Tonsillectomy Spontaneous subarachnoid hemorrhage ___ treated conservatively Hemorrhoids Herpes zoster and simplex Hyperlipidemia asthma peptic ulcer disease Social History ___ Family History Father had an MI at age ___ died at age ___. Physical Exam Physical Exam as of ___ 132 76 107 18 93 RA Gen NAD AOx3 HEENT PEERLA no neck masses right neck incision clean dry and intact flat his trachea is mobile PULM unlabored breathing normal chest excursion CV RRR no m r g Abd soft non distended non tender no masses Ext no edema Pertinent Results ___ 05 01AM BLOOD WBC 8.0 RBC 3.78 Hgb 12.2 Hct 37.8 MCV 100 MCH 32.3 MCHC 32.3 RDW 15.6 RDWSD 57.1 Plt ___ ___ 06 00AM BLOOD ___ PTT 25.3 ___ ___ 05 01AM BLOOD Plt ___ ___ 05 01AM BLOOD Glucose 98 UreaN 13 Creat 0.9 Na 141 K 4.3 Cl 105 HCO3 26 AnGap 10 ___ 05 01AM BLOOD Calcium 7.8 Phos 3.4 Mg 1.8 Brief Hospital Course Neuro Pain was well controlled on Tylenol and oxycodone CV Vital signs were routinely monitored during the patient s length of stay. Pulm The patient was encouraged to ambulate sit and get out of bed use the incentive spirometer and had oxygen saturation levels monitored as indicated. GI The patient was initially kept NPO after the procedure. The patient was later advanced to and tolerated a regular diet at time of discharge. GU Patient had a Foley catheter that was removed at time of discharge. Urine output was monitored as indicated. At time of discharge the patient was voiding without difficulty. ID The patient s vital signs were monitored for signs of infection and fever. The patient was started on continued on antibiotics as indicated. Heme The patient had blood levels checked post operatively during the hospital course to monitor for signs of bleeding. The patient had vital signs including heart rate and blood pressure monitored throughout the hospital stay. He was seen and evaluated by Physical Therapy The pt has a history of Tremor postural tremor and felt unsteady on his feet. ___ deemed him an appropriate rehab candidate. Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Testosterone Cypionate 300 mg sc Q3 WEEKS 2. Fish Oil Omega 3 1000 mg PO BID 3. Niacin 100 mg PO BID 4. Diltiazem Extended Release 120 mg PO DAILY 5. Budesonide Nasal Inhaler NF 90 mcg Other DAILY 6. lysine ___ mg oral TID 7. Vitamin E 400 UNIT PO DAILY 8. Vitamin D ___ UNIT PO TID 9. Aspirin 325 mg PO DAILY 10. Clindamycin 600 mg PO ONE HOUR BEFORE DENTAL CLEANING Discharge Medications 1. Acetaminophen 325 650 mg PO Q6H PRN Pain Mild Fever 2. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN wheeze 3. Docusate Sodium 100 mg PO BID 4. Levalbuterol Neb 0.63 mg NEB Q4H PRN sob 5. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate Reason for PRN duplicate override Alternating agents for similar severity RX oxycodone 5 mg 1 tablet s by mouth Q 4 HOURS Disp 10 Tablet Refills 0 6. Pulmicort Flexhaler budesonide 180 mcg actuation inhalation PRN 7. Senna 17.2 mg PO QHS 8. Aspirin 325 mg PO DAILY 9. Budesonide Nasal Inhaler NF 90 mcg Other DAILY 10. Clindamycin 600 mg PO ONE HOUR BEFORE DENTAL CLEANING 11. Diltiazem Extended Release 120 mg PO DAILY 12. Fish Oil Omega 3 1000 mg PO BID 13. lysine ___ mg oral TID 14. Niacin 100 mg PO BID 15. Testosterone Cypionate 300 mg sc Q3 WEEKS 16. Vitamin D ___ UNIT PO TID 17. Vitamin E 400 UNIT PO DAILY Discharge Disposition Extended Care Facility ___ ___ Diagnosis ASYMPTOMATIC CAROTID STENOSIS Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Carotid Endarterectomy Surgery Discharge Instructions WHAT TO EXPECT 1. Surgical Incision It is normal to have some swelling and feel a firm ridge along the incision Your incision may be slightly red and raised it may feel irritated from the staples 2. You may have a sore throat and or mild hoarseness Try warm tea throat lozenges or cool cold beverages 3. You may have a mild headache especially on the side of your surgery Try ibuprofen acetaminophen or your discharge pain medication If headache worsens is associated with visual changes or lasts longer than 2 hours call vascular surgeon s office 4. It is normal to feel tired this will last for ___ weeks You should get up out of bed every day and gradually increase your activity each day You may walk and you may go up and down stairs Increase your activities as you can tolerate do not do too much right away 5. It is normal to have a decreased appetite your appetite will return with time You will probably lose your taste for food and lose some weight Eat small frequent meals It is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing To avoid constipation eat a high fiber diet and use stool softener while taking pain medication MEDICATION Take all of your medications as prescribed in your discharge ACTIVITIES No driving until post op visit and you are no longer taking pain medications No excessive head turning lifting pushing or pulling greater than 5 lbs until your post op visit You may shower no direct spray on incision let the soapy water run over incision rinse and pat dry Your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing over the area CALL THE OFFICE FOR ___ Changes in vision loss of vision blurring double vision half vision Slurring of speech or difficulty finding correct words to use Severe headache or worsening headache not controlled by pain medication A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg Trouble swallowing breathing or talking Temperature greater than 101.5F for 24 hours Bleeding new or increased drainage from incision or white yellow or green drainage from incisions Followup Instructions ___ The icd codes present in this text will be I6521, I2510, Z955, Z8546, Z8571, E785, Z951, I081, Z952, G4733. The descriptions of icd codes I6521, I2510, Z955, Z8546, Z8571, E785, Z951, I081, Z952, G4733 are I6521: Occlusion and stenosis of right carotid artery; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z955: Presence of coronary angioplasty implant and graft; Z8546: Personal history of malignant neoplasm of prostate; Z8571: Personal history of Hodgkin lymphoma; E785: Hyperlipidemia, unspecified; Z951: Presence of aortocoronary bypass graft; I081: Rheumatic disorders of both mitral and tricuspid valves; Z952: Presence of prosthetic heart valve; G4733: Obstructive sleep apnea (adult) (pediatric). The common codes which frequently come are I2510, Z955, E785, Z951, G4733. The uncommon codes mentioned in this dataset are I6521, Z8546, Z8571, I081, Z952.
The icd codes present in this text will be N390, K2971, N179, F05, I701, G40409, I10, D500, I739, Z720, K219, B9620, K5903, T402X5A, Y92230, Z86718. The descriptions of icd codes N390, K2971, N179, F05, I701, G40409, I10, D500, I739, Z720, K219, B9620, K5903, T402X5A, Y92230, Z86718 are N390: Urinary tract infection, site not specified; K2971: Gastritis, unspecified, with bleeding; N179: Acute kidney failure, unspecified; F05: Delirium due to known physiological condition; I701: Atherosclerosis of renal artery; G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus; I10: Essential (primary) hypertension; D500: Iron deficiency anemia secondary to blood loss (chronic); I739: Peripheral vascular disease, unspecified; Z720: Tobacco use; K219: Gastro-esophageal reflux disease without esophagitis; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; K5903: Drug induced constipation; T402X5A: Adverse effect of other opioids, initial encounter; Y92230: Patient room in hospital as the place of occurrence of the external cause; Z86718: Personal history of other venous thrombosis and embolism. The common codes which frequently come are N390, N179, I10, K219, Y92230, Z86718. The uncommon codes mentioned in this dataset are K2971, F05, I701, G40409, D500, I739, Z720, B9620, K5903, T402X5A. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Weakness Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ female with past medical history notable for hypertension prior small intestinal bleed sounds like distal upper AVM recent hospitalization for seizures in the setting of gallstone pancreatitis status post cholecystectomy who was discharged on ___ who presents to the hospital with several days of weakness. She reports that initially following discharge she was feeling well. She reports that after several days at home she started to feel increasingly fatigued. She reports that she felt similar to when she was bleeding in ___ and required the upper GI which found a likely AVM. She reports the records from that hospitalization or at ___ in ___. She reports that at that time her bowel movements were normal. She reports that on the evening prior to admission she developed diarrhea with black stools. She reports that this is the exact same happened last time she had the upper GI bleed. She reports that she continue to feel further fatigue. She touch base with her primary care doctor who referred her into the emergency department for further evaluation. She also reports that while at home she had a decreased appetite. Per her daughter she started to look increasingly pale. She became lightheaded and dizzy in the shower on several occasions. She also reports that she had urinary symptoms from around the time she got home. She reports that over the last 6 days she has had increased lower abdominal pain burning on urination pressure. She reports that she feels like it got so bad she decreased her p.o. intake to reduce the amount that she would have to urinate. She also reports that she had some blood in the urine. In the emergency department she was seen and evaluated. Her initial vital signs were unremarkable. She was afebrile with a heart rate of 81 blood pressure 157 94 respiratory rate of 18. Her H H was notable for 11.3 35.3 which is up from her discharge hemoglobin and hematocrit of 8.7 26.8. She had a UA that was checked which unfortunately contained 9 epithelial cells. It did have positive nitrates large leukocyte esterase greater than 184 white blood cells as well as few bacteria. She received 1 g of IV ceftriaxone 2 L of normal saline and was admitted to the medical service for further evaluation and management. She was also evaluated by the surgery service while in the emergency department he felt like if she had anything was likely a slow GI bleed and would not require acute surgical intervention and would recommend admission to medicine for a GI workup. ROS Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History Gallstone pancreatitis status post cholecystectomy ___ Seizures in the setting of the above gallstone pancreatitis Hypertension due to renal artery stenosis difficult to control Prior history of upper GI bleed from a likely AVM Prior history of DVT no longer on anticoagulation Social History ___ Family History ___ and found to be not relevant to this illness reason for hospitalization. She specifically denies any family history of seizures or strokes. Physical Exam ADMISSION EXAM VITALS 98.4 PO 147 72 60 18 100 RA GENERAL Alert and in no apparent distress laying in bed EYES Anicteric pupils equally round ENT Ears and nose without visible erythema masses or trauma. Oropharynx without visible lesion erythema or exudate CV Heart regular no murmur. No JVD. RESP Lungs clear to auscultation with good air movement bilaterally. Breathing is non labored GI Abdomen soft non distended tender to palpation over the suprapubic region. Laparoscopic cholecystectomy incisions healing well. Bowel sounds present. No HSM. No CVA tenderness GU No suprapubic fullness but significant tenderness to palpation MSK Neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs SKIN No rashes or ulcerations noted NEURO Alert oriented face symmetric gaze conjugate with EOMI speech fluent moves all limbs sensation to light touch grossly intact throughout PSYCH pleasant appropriate affect DISCHARGE EXAM VS Reviewed GENERAL Alert and in no apparent distress laying in bed EYES Anicteric pupils equally round CV Heart regular no murmur. RESP Lungs clear to auscultation with good air movement bilaterally. Breathing is non labored GI Abdomen soft non distended tender to palpation over the suprapubic region. Laparoscopic cholecystectomy incisions healing well. Bowel sounds present. GU No suprapubic fullness but significant tenderness to palpation PSYCH pleasant appropriate affect Pertinent Results ADMISSION LABS ___ 03 46PM BLOOD WBC 10.6 RBC 3.78 Hgb 11.5 Hct 35.3 MCV 93 MCH 30.4 MCHC 32.6 RDW 14.0 RDWSD 47.6 Plt ___ ___ 03 46PM BLOOD Neuts 71.9 Lymphs 17.5 Monos 6.9 Eos 2.6 Baso 0.7 Im ___ AbsNeut 7.65 AbsLymp 1.86 AbsMono 0.73 AbsEos 0.28 AbsBaso 0.07 ___ 02 22PM BLOOD Glucose 108 UreaN 12 Creat 1.0 Na 145 K 4.8 Cl 104 HCO3 24 AnGap 17 ___ 02 22PM BLOOD ALT 18 AST 17 AlkPhos 121 TotBili 0.5 MICROBIOLOGY ___ 4 55 pm URINE FINAL REPORT ___ URINE CULTURE Final ___ MIXED BACTERIAL FLORA 3 COLONY TYPES CONSISTENT WITH SKIN AND OR GENITAL CONTAMINATION. ESCHERICHIA COLI. 100 000 CFU mL. PRESUMPTIVE IDENTIFICATION. PREDOMINATING ORGANISM. INTERPRET RESULTS WITH CAUTION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES MIC expressed in MCG ML ___ ESCHERICHIA COLI AMPICILLIN 2 S AMPICILLIN SULBACTAM 2 S CEFAZOLIN 4 S CEFEPIME 1 S CEFTAZIDIME 1 S CEFTRIAXONE 1 S CIPROFLOXACIN 0.25 S GENTAMICIN 1 S MEROPENEM 0.25 S NITROFURANTOIN 16 S PIPERACILLIN TAZO 4 S TOBRAMYCIN 1 S TRIMETHOPRIM SULFA 1 S DISCHARGE LABS ___ 08 10AM BLOOD WBC 5.6 RBC 2.92 Hgb 8.9 Hct 27.2 MCV 93 MCH 30.5 MCHC 32.7 RDW 13.3 RDWSD 45.4 Plt ___ ___ 08 10AM BLOOD Glucose 101 UreaN 11 Creat 1.0 Na 142 K 4.6 Cl 101 HCO3 30 AnGap 11 ___ 07 10AM BLOOD ALT 16 AST 17 AlkPhos 91 TotBili 0.4 ___ 07 45AM BLOOD Calcium 9.7 Phos 3.8 Mg 1.7 ___ 03 46PM BLOOD calTIBC 411 Ferritn ___ ___ ___ 02 35PM BLOOD Lactate 1.8 KUB IMPRESSION Normal bowel gas pattern. Brief Hospital Course ___ female with past medical history notable for hypertension prior small intestinal bleed sounds like distal upper AVM recent hospitalization for seizures in the setting of gallstone pancreatitis status post cholecystectomy who was discharged on ___ who presents to the hospital with several days of weakness. Possible upper GI bleed Gastritis Patient reported several episodes of black stools but none during admission. Hemoglobin downtrended over the course of admission. Awaiting records from ___ in ___. GI following patient but did not plan on EGD colonoscopy. H. pylori antigen was sent. She was placed on PO pantoprazole as well as home famotidine and simethicone given complaints of indigestion as well as antiemetics. Urinary tract infection Patient reported approximately five days of urinary tract symptoms with pain on urination burning on urination and suprapubic fullness. Pan sensitive E.coli on urine specimen placed on ceftriaxone and switched to ciprofloxacin for 7 day course. She was also placed on three day course of pyridium. Weakness suspect related to UTI and possible slow GI bleed see above. ___ consulted. She progressed and was able to be discharged home. Constipation Patient noted to constipated likely ___ to opioids and decreased mobility. KUB without obstruction. She received bowel regimen. She had a bowel movement prior to discharge. HTN due to RAS Patient has renal artery stenosis as documented on her prior admission. She has difficult to control blood pressures. She was stabilized on a regimen during her prior hospitalization. Continued home antihypertensive regimen of amlodipine labetalol lisinopril. Seizure Disorder Patient had generalized tonic clonic seizure during her prior hospitalization in the setting of her gallstone pancreatitis. She was seen by neurology during her prior hospitalization and is now on antiseizure medication with outpatient follow up. She was continued on her home Keppra. GERD continued on home famotidine and added PO pantoprazole. I updated her son and daughter with the plan of care. TRANSITIONS OF CARE Follow up patient will follow up with her PCP. Medications on Admission The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY hypertension 2. Atorvastatin 40 mg PO QPM 3. LevETIRAcetam 1500 mg PO Q12H 4. Acetaminophen 650 mg PO Q6H PRN Pain Mild 5. Lisinopril 40 mg PO DAILY 6. Famotidine 20 mg PO BID 7. Aspirin 81 mg PO DAILY 8. OxyCODONE Immediate Release 10 mg PO Q4H PRN Pain Severe 9. Labetalol 400 mg PO BID Hypertension Discharge Medications 1. Docusate Sodium 100 mg PO BID RX docusate sodium Colace 100 mg 1 capsule s by mouth twice a day Disp 30 Capsule Refills 0 2. Ondansetron 4 mg PO Q8H RX ondansetron 4 mg 1 tablet s by mouth every eight 8 hours Disp 30 Tablet Refills 0 3. OxyCODONE Immediate Release 10 mg PO Q4H PRN Pain Severe RX oxycodone 5 mg 1 capsule s by mouth every eight 8 hours Disp 6 Capsule Refills 0 4. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 5. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 Miralax 17 gram 1 powder s by mouth once a day Disp 30 Packet Refills 0 6. Acetaminophen 650 mg PO Q6H PRN Pain Mild 7. amLODIPine 10 mg PO DAILY hypertension 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. Famotidine 20 mg PO BID 11. Labetalol 400 mg PO BID Hypertension 12. LevETIRAcetam 1500 mg PO Q12H 13. Lisinopril 40 mg PO DAILY Discharge Disposition Home Discharge Diagnosis Urinary tract infection Gastritis peptic ulcer Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ It was a pleasure caring for you during your recent admission at ___. You came for further evaluation of weakness pain when urinating and black stools. It is important that you continue to take your medications as prescribed and follow up with the appointments listed below. Please follow up with your PCP ___. Please arrange to have you labs checked. Good luck Followup Instructions ___ The icd codes present in this text will be N390, K2971, N179, F05, I701, G40409, I10, D500, I739, Z720, K219, B9620, K5903, T402X5A, Y92230, Z86718. The descriptions of icd codes N390, K2971, N179, F05, I701, G40409, I10, D500, I739, Z720, K219, B9620, K5903, T402X5A, Y92230, Z86718 are N390: Urinary tract infection, site not specified; K2971: Gastritis, unspecified, with bleeding; N179: Acute kidney failure, unspecified; F05: Delirium due to known physiological condition; I701: Atherosclerosis of renal artery; G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus; I10: Essential (primary) hypertension; D500: Iron deficiency anemia secondary to blood loss (chronic); I739: Peripheral vascular disease, unspecified; Z720: Tobacco use; K219: Gastro-esophageal reflux disease without esophagitis; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; K5903: Drug induced constipation; T402X5A: Adverse effect of other opioids, initial encounter; Y92230: Patient room in hospital as the place of occurrence of the external cause; Z86718: Personal history of other venous thrombosis and embolism. The common codes which frequently come are N390, N179, I10, K219, Y92230, Z86718. The uncommon codes mentioned in this dataset are K2971, F05, I701, G40409, D500, I739, Z720, B9620, K5903, T402X5A.
The icd codes present in this text will be K31811, B1910, S0990XA, G629, D62, F1120, I452, I6523, G40909, I951, F319, Q2733, I10, W01198A, Y92008, I701, M5416, E039, E785, J449, K219, Z86718, Z87891, K2270, R110, T402X5A, Y929, I739, I69398, R531, R42, N3090, R079, I459, K5900. The descriptions of icd codes K31811, B1910, S0990XA, G629, D62, F1120, I452, I6523, G40909, I951, F319, Q2733, I10, W01198A, Y92008, I701, M5416, E039, E785, J449, K219, Z86718, Z87891, K2270, R110, T402X5A, Y929, I739, I69398, R531, R42, N3090, R079, I459, K5900 are K31811: Angiodysplasia of stomach and duodenum with bleeding; B1910: Unspecified viral hepatitis B without hepatic coma; S0990XA: Unspecified injury of head, initial encounter; G629: Polyneuropathy, unspecified; D62: Acute posthemorrhagic anemia; F1120: Opioid dependence, uncomplicated; I452: Bifascicular block; I6523: Occlusion and stenosis of bilateral carotid arteries; G40909: Epilepsy, unspecified, not intractable, without status epilepticus; I951: Orthostatic hypotension; F319: Bipolar disorder, unspecified; Q2733: Arteriovenous malformation of digestive system vessel; I10: Essential (primary) hypertension; W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter; Y92008: Other place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; I701: Atherosclerosis of renal artery; M5416: Radiculopathy, lumbar region; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; Z86718: Personal history of other venous thrombosis and embolism; Z87891: Personal history of nicotine dependence; K2270: Barrett's esophagus without dysplasia; R110: Nausea; T402X5A: Adverse effect of other opioids, initial encounter; Y929: Unspecified place or not applicable; I739: Peripheral vascular disease, unspecified; I69398: Other sequelae of cerebral infarction; R531: Weakness; R42: Dizziness and giddiness; N3090: Cystitis, unspecified without hematuria; R079: Chest pain, unspecified; I459: Conduction disorder, unspecified; K5900: Constipation, unspecified. The common codes which frequently come are D62, I10, E039, E785, J449, K219, Z86718, Z87891, Y929, K5900. The uncommon codes mentioned in this dataset are K31811, B1910, S0990XA, G629, F1120, I452, I6523, G40909, I951, F319, Q2733, W01198A, Y92008, I701, M5416, K2270, R110, T402X5A, I739, I69398, R531, R42, N3090, R079, I459. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Presyncope Fall Major Surgical or Invasive Procedure EGD ___ Capsule endoscopy ___ Colonoscopy ___ History of Present Illness ___ with history of CVA seizures upper GI AVM s with chronic anemia HTN presents after presyncopal fall. On ___ she was at home and went to linen closet to grab something. Then felt presyncopal dizzy warm feeling and fell backwards hitting her head first against a bedroom door which gave way and then against the floor. No LOC. Daughter came to her aid. She did not want to go to the hospital. The next day she went to ___. CT head and CT C spine negative for acute bleed or fracture. Today she went to her GI appointment and was referred to ___. Last ___ she reported a seizure episode where her arms were shaking and she was in a daze. This lasted for a few minutes. Consistent with prior seizures episodes. In the ___ initial VS were 98.3 77 147 45 19 100 RA Exam diffuse mild abd tenderness scant brown stool in rectal vault guaiac Labs Hgb 7.4 Creatinine 1.1 Lactate 1.3 urine WBC 35 lg leuk hazy few bac Imaging CXR clear. CT A P no acute process. On interview she reports acute on chronic soreness in neck back hips for which she takes oxycodone at home. Otherwise no acute complaints. REVIEW OF SYSTEMS tinnitus all other positives per HPI otherwise 10 point ROS reviewed and negative except as per HPI Past Medical History Hypertension Renal Artery Stenosis Seizures CVA Gallstone pancreatitis Iron deficiency anemia AVM s in stomach and duodenum Lumbar radiculopathy Chronic opioid use with pain contract Hypothyroidism Hyperlipidemia COPD Neuropathic pain GERD DVT Social History ___ Family History Mother had dementia. Father had asbestosis and mesothelioma. Physical Exam ADMISSION PHYSICAL VS 98.3 130 55 58 18 99 ra GENERAL NAD HEENT PERRL EOMI no nystagmus tongue moist NECK L carotid bruit HEART RRR S1 S2 no murmurs LUNGS LCAB ABDOMEN s lower abdominal tenderness GU suprapubic tenderness EXTREMITIES no edema NEURO A Ox3 moving all 4 extremities with purpose RLE weakness DISCHARGE PHYSICAL ___ ___ Temp 97.9 PO BP 162 62 HR 56 RR 18 O2 sat 97 O2 delivery Ra GENERAL NAD sitting in bed NECK bilateral carotid bruits HEART RRR S1 S2 no murmurs PULM CTABL ABDOMEN soft mildly distended without tenderness BS EXTREMITIES warm 1 ___ pulses bilaterally no edema NEURO A Ox3 no facial asymmetry moving all 4 extremities with purpose Pertinent Results ADMISSION LABS ___ 05 50PM BLOOD WBC 5.5 RBC 2.49 Hgb 7.4 Hct 22.3 MCV 90 MCH 29.7 MCHC 33.2 RDW 15.3 RDWSD 50.4 Plt ___ ___ 05 50PM BLOOD Neuts 47.5 ___ Monos 8.9 Eos 7.5 Baso 0.5 Im ___ AbsNeut 2.60 AbsLymp 1.94 AbsMono 0.49 AbsEos 0.41 AbsBaso 0.03 ___ 05 50PM BLOOD ___ PTT 34.2 ___ ___ 05 50PM BLOOD Glucose 101 UreaN 12 Creat 1.1 Na 138 K 4.2 Cl 99 HCO3 24 AnGap 15 ___ 05 50PM BLOOD ALT 14 AST 13 AlkPhos 43 TotBili 0.3 ___ 05 50PM BLOOD Lipase 22 ___ 05 50PM BLOOD proBNP 78 ___ 05 50PM BLOOD cTropnT 0.01 ___ 05 50PM BLOOD Albumin 4.8 Calcium 9.6 Phos 3.7 Mg 1.8 PERTINENT INTERVAL LABS ___ 09 10AM BLOOD Calcium 9.4 Phos 4.1 Mg 1.8 Iron 16 ___ 09 10AM BLOOD calTIBC 382 VitB12 318 Folate 14 Ferritn 14 TRF 294 ___ 06 48AM BLOOD TSH 3.6 ___ 06 48AM BLOOD Free T4 0.9 DISCHARGE LABS ___ 05 35AM BLOOD WBC 5.0 RBC 3.62 Hgb 10.7 Hct 34.0 MCV 94 MCH 29.6 MCHC 31.5 RDW 15.5 RDWSD 53.1 Plt ___ ___ 05 35AM BLOOD Glucose 91 UreaN 20 Creat 1.1 Na 144 K 4.5 Cl 104 HCO3 24 AnGap 16 ___ 05 35AM BLOOD Calcium 9.6 Phos 5.0 Mg 2.0 MICROBIOLOGY Urine Culture ___ MIXED BACTERIAL FLORA 3 COLONY TYPES CONSISTENT WITH SKIN AND OR GENITAL CONTAMINATION IMAGING AND STUDIES ___ CXR AP upright and lateral views of the chest provided. There is no focal consolidation effusion or pneumothorax. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. ___ CT ABD PEVLIS W CON 1. Colonic diverticulosis without evidence of diverticulitis. No signs of colitis or bowel obstruction. Normal appendix. 2. Status post cholecystectomy with stable mild prominence of the intrahepatic and extrahepatic biliary tree. 3. Extensive aortoiliac atherosclerotic calcification with stents in the bilateral external iliac arteries which appear patent. 4. Atrophic right kidney. 5. Trace free pelvic fluid nonspecific. ___ ECHO TTE The left atrial volume index is normal. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness cavity size and regional global systolic function are normal LVEF 55 . There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets 3 are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION Normal biventricular cavity size and global regional systolic function. No pathological valvular flow identified. No structural cause for syncope identified. ___ CAROTID ULTRASOUND Moderate to marked predominantly heterogeneous soft plaque within the bilateral carotid arteries most profound within the mid ICAs right greater than left resulting in hemodynamically significant stenosis estimated to be 80 99 bilaterally. ___ EGD Mucosa suggestive of ___ Esophagus Erosion in pylorus Angioectasias in stomach and second part of duodenum Thermal Therapy applied Capsule released in duodenum ___ COLONOSCOPY Aborted due to high residue material ___ pMIBI FINDINGS There was soft tissue attenuation. Left ventricular cavity size is within normal limits. Rest and stress perfusion images reveal uniform tracer uptake throughout the left ventricular myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 71 . IMPRESSION 1. No evidence of myocardial perfusion defect. 2. Normal left ventricular cavity size with normal systolic function. ___ KUB Endoscopy capsule in the proximal descending colon. ___ KUB Endoscopy pill capsule has migrated since ___ now possibly in the sigmoid colon. Brief Hospital Course ___ with history of CVA seizures upper GI AVM s with chronic anemia HTN peripheral vasculopathy who presented after presyncopal fall. ACUTE ISSUES Acute on Chronic Blood Loss Anemia Upper GI Bleed Presented with ongoing intermittent melena and known gastric and duodenal AVMs per prior EGD s s p single balloon enteroscopy with APC to small bowel AVMs. Stool guaiac positive in ___. Required 2u pRBCs during her hospitalization. EGD showed several duodenal gastric AVMs that were cauterized as well as likely ___ esophagus. Patient was iron deficient and was given 2 125mg IV infusions of ferric gluconate. Patient was continued on PPI prophylaxis. Seizures Patient reported that her last seizure 1 week prior to admission and involved extremity shaking and AMS that lasted several minutes consistent with previous episodes. Neurology was consulted for optimization of her AEDs. EEG was performed and the patient was continued on Keppra with plans for outpatient followup in neurology clinic. She had no seizures in house. Severe Bilateral Carotid Artery Stenosis Carotid US done as part of pre syncope work up revealed severe bilateral carotid artery stenosis 80 99 . She was seen by vascular surgery in house who recommended no urgent treatment. This could certainly contribute to pre syncope however vascular surgery will followup with patient for CEA consideration. Presyncope Presented 4 days after presyncopal episode at home with fall and head trauma. CT head and c spine were negative at OSH. Signs and symptoms not consistent with prior seizures. Initial ddx included CNS process TIA carotid stenosis cardiac had old RBBB on EKG and new LBBB on this admission orthostasis had previously documented orthostatic hypotension vasovagal event peripheral vertigo has tinnitus or symptomatic anemia. Concern for Cardiac Conduction Disease Noted patient has HRs usually in ___ even when standing and lightheaded. There was concern that she was not adequately augmenting her cardiac output with exertion due to conduction disease and this blunted response was contributing to her pre syncope. Also noted to initially have RBBB on EKG but then LBBB on EKG done later in the same day in ___ on presentation . Unusual and concerning for conduction disease so cardiology was consulted and beta blocker home med was held. pMIBI revealed no overt ischemia and ambulatory telemetry revealed that patients heart rates increased to ___. Cardiology felt that this was an appropriate response and the patient did not require further electrophysiologic evaluation during this hospitalization. Hypertension Patient has history of hypertension renal artery stenosis with orthostatic hypotension. Antihypertensives were held in the setting of GI bleed but were restarted once her GI bleed was addressed. She was continued on home doses of blood pressure medications and was also started on chlorthalidone 12.5mg daily for better control. Chronic Back and Neck Pain Has narcotics contract w PCP for oxycodone 5mg BID since ___. Review of MassPMP indicates pt also prescribed vicodin in OSH ___ three days prior to presentation. Likely that pain is exacerbated by recent fall so increased pain regimen while in house. CHRONIC ISSUES Neuropathic pain continued gabapentin 300mg TID. GERD continued PPI and famotidine. Chronic nausea continued ondansetron PRN. TRANSITIONAL ISSUES Ensure passage of capsule on discharge KUB ___ noted to be in sigmoid colon rectum. Consider repeat KUB to assess if concerned. Per GI very unlikely to cause obstruction once in colon. Labetalol Beta Blockade Recommend avoiding all beta blockade given heart rates in the ___. Patient s labetalol was discontinued to avoid negative chronotrope effect Chlorthalidone titrate dose as needed for adequate blood pressure control ASA 81 discharged on ASA 81 given stroke risk in the setting of severe carotid disease if GI bleed recurs risk benefit should be discussed with patient okay to hold per inpatient cardiology recommendations but neurology would recommend continuing Atorvastatin increased to 80mg although less data in secondary prevention due to severe vascular disease ___ esophagus Noted on EGD. Will have follow up endoscopy with plan for biopsy in ___ Labs Repeat CBC at clinic visit to ensure stability discharge Hgb 9.9 Vascular Followup Has appointment with Dr. ___ ___ for CEA evaluation Neurology Followup Has appointment for further management of anti seizure medications Contact HCP ___ daughter ___ Code status Full presumed Medications on Admission The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY hypertension 2. Atorvastatin 40 mg PO QPM 3. LevETIRAcetam 1500 mg PO Q12H 4. Lisinopril 40 mg PO DAILY 5. Simethicone 40 80 mg PO QID PRN abd pain 6. Famotidine 20 mg PO BID 7. Ondansetron 4 mg PO Q8H PRN nausea 8. Pantoprazole 40 mg PO Q12H 9. Aspirin 81 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID 11. Ascorbic Acid ___ mg PO BID 12. OxyCODONE Immediate Release 5 mg PO Q12H PRN BREAKTHROUGH PAIN 13. Labetalol 200 mg PO BID 14. Gabapentin 300 mg PO TID The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY hypertension 2. Atorvastatin 40 mg PO QPM 3. LevETIRAcetam 1500 mg PO Q12H 4. Lisinopril 40 mg PO DAILY 5. Simethicone 40 80 mg PO QID PRN abd pain 6. Famotidine 20 mg PO BID 7. Ondansetron 4 mg PO Q8H PRN nausea 8. Pantoprazole 40 mg PO Q12H 9. Aspirin 81 mg PO DAILY 10. Ferrous Sulfate 325 mg PO BID 11. Ascorbic Acid ___ mg PO BID 12. OxyCODONE Immediate Release 5 mg PO Q12H PRN BREAKTHROUGH PAIN 13. Labetalol 200 mg PO BID 14. Gabapentin 300 mg PO TID Discharge Medications 1. Bisacodyl 10 mg PO PR DAILY PRN constipation RX bisacodyl 5 mg 2 tablet s by mouth daily Disp 30 Tablet Refills 0 2. Chlorthalidone 12.5 mg PO DAILY RX chlorthalidone 25 mg 0.5 One half tablet s by mouth daily Disp 30 Tablet Refills 0 3. Docusate Sodium 100 mg PO BID constipation RX docusate sodium 100 mg 1 capsule s by mouth twice daily Disp 30 Capsule Refills 0 4. Multivitamins W minerals 1 TAB PO DAILY RX multivitamin tx minerals 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 5. Polyethylene Glycol 17 g PO DAILY constipation RX polyethylene glycol 3350 PEG 17 gram dose 17 g by mouth daily Refills 0 6. Senna 8.6 mg PO BID RX sennosides senna 8.6 mg 1 by mouth twice a day Disp 30 Tablet Refills 0 7. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet s by mouth at nightime Disp 30 Tablet Refills 0 8. amLODIPine 10 mg PO DAILY hypertension 9. Ascorbic Acid ___ mg PO BID 10. Aspirin 81 mg PO DAILY 11. Famotidine 20 mg PO BID 12. Ferrous Sulfate 325 mg PO BID 13. Gabapentin 300 mg PO TID 14. LevETIRAcetam 1500 mg PO Q12H 15. Lisinopril 40 mg PO DAILY 16. Ondansetron 4 mg PO Q8H PRN nausea 17. OxyCODONE Immediate Release 5 mg PO Q12H PRN BREAKTHROUGH PAIN 18. Pantoprazole 40 mg PO Q12H 19. Simethicone 40 80 mg PO QID PRN abd pain 20.Rolling Walker Please provide rolling walker. Dx Seizure Disorder ICD 9 780.39 Prognosis Good ___ 13 Months Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary Diagnoses Acute on chronic upper GI bleed Severe bilateral coronary artery stenosis Seizure disorder Orthostatic hypotension Secondary Diagnoses Bipolar Disorder Hepatitis B Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear ___ ___ was a pleasure taking care of you in the hospital. WHY DID YOU COME TO THE HOSPITAL You felt lightheaded and suffered a fall WHAT HAPPENED TO YOU DURING YOUR HOSPITAL STAY You were given blood to increase your blood counts Your bloody bowel movements were evaluated and treated by the gastroenterologists You were evaluated for seizures by the neurologists and was started on a medication to prevent seizures You were found to have severe blockages in both arteries supplying blood to brain and need to follow up with the vascular surgeons in vascular surgery clinic to discuss surgical correction of these blockages Your heart was evaluated by the cardiologists who do not recommend any further testing at this time WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL please take all of your medications as prescribed details below Please keep all of your appointments as scheduled Please keep track of whether you have passed the capsule in your bowel movement. If you have not passed the capsule in 2 days since discharge you should be seen in clinic by your PCP. Please call your PCP right away if you have any symptoms such as constipation vomiting anorexia and if you are not passing any gas. We wish you the very best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be K31811, B1910, S0990XA, G629, D62, F1120, I452, I6523, G40909, I951, F319, Q2733, I10, W01198A, Y92008, I701, M5416, E039, E785, J449, K219, Z86718, Z87891, K2270, R110, T402X5A, Y929, I739, I69398, R531, R42, N3090, R079, I459, K5900. The descriptions of icd codes K31811, B1910, S0990XA, G629, D62, F1120, I452, I6523, G40909, I951, F319, Q2733, I10, W01198A, Y92008, I701, M5416, E039, E785, J449, K219, Z86718, Z87891, K2270, R110, T402X5A, Y929, I739, I69398, R531, R42, N3090, R079, I459, K5900 are K31811: Angiodysplasia of stomach and duodenum with bleeding; B1910: Unspecified viral hepatitis B without hepatic coma; S0990XA: Unspecified injury of head, initial encounter; G629: Polyneuropathy, unspecified; D62: Acute posthemorrhagic anemia; F1120: Opioid dependence, uncomplicated; I452: Bifascicular block; I6523: Occlusion and stenosis of bilateral carotid arteries; G40909: Epilepsy, unspecified, not intractable, without status epilepticus; I951: Orthostatic hypotension; F319: Bipolar disorder, unspecified; Q2733: Arteriovenous malformation of digestive system vessel; I10: Essential (primary) hypertension; W01198A: Fall on same level from slipping, tripping and stumbling with subsequent striking against other object, initial encounter; Y92008: Other place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; I701: Atherosclerosis of renal artery; M5416: Radiculopathy, lumbar region; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; Z86718: Personal history of other venous thrombosis and embolism; Z87891: Personal history of nicotine dependence; K2270: Barrett's esophagus without dysplasia; R110: Nausea; T402X5A: Adverse effect of other opioids, initial encounter; Y929: Unspecified place or not applicable; I739: Peripheral vascular disease, unspecified; I69398: Other sequelae of cerebral infarction; R531: Weakness; R42: Dizziness and giddiness; N3090: Cystitis, unspecified without hematuria; R079: Chest pain, unspecified; I459: Conduction disorder, unspecified; K5900: Constipation, unspecified. The common codes which frequently come are D62, I10, E039, E785, J449, K219, Z86718, Z87891, Y929, K5900. The uncommon codes mentioned in this dataset are K31811, B1910, S0990XA, G629, F1120, I452, I6523, G40909, I951, F319, Q2733, W01198A, Y92008, I701, M5416, K2270, R110, T402X5A, I739, I69398, R531, R42, N3090, R079, I459.
The icd codes present in this text will be K31811, E440, R569, D62, I150, Z681, N390, E785, I739, I69398, R531, R2681, R51, R001, T448X5A, Y92230, R109, F1011, Z86718, Z87891. The descriptions of icd codes K31811, E440, R569, D62, I150, Z681, N390, E785, I739, I69398, R531, R2681, R51, R001, T448X5A, Y92230, R109, F1011, Z86718, Z87891 are K31811: Angiodysplasia of stomach and duodenum with bleeding; E440: Moderate protein-calorie malnutrition; R569: Unspecified convulsions; D62: Acute posthemorrhagic anemia; I150: Renovascular hypertension; Z681: Body mass index [BMI] 19.9 or less, adult; N390: Urinary tract infection, site not specified; E785: Hyperlipidemia, unspecified; I739: Peripheral vascular disease, unspecified; I69398: Other sequelae of cerebral infarction; R531: Weakness; R2681: Unsteadiness on feet; R51: Headache; R001: Bradycardia, unspecified; T448X5A: Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, initial encounter; Y92230: Patient room in hospital as the place of occurrence of the external cause; R109: Unspecified abdominal pain; F1011: Alcohol abuse, in remission; Z86718: Personal history of other venous thrombosis and embolism; Z87891: Personal history of nicotine dependence. The common codes which frequently come are D62, N390, E785, Y92230, Z86718, Z87891. The uncommon codes mentioned in this dataset are K31811, E440, R569, I150, Z681, I739, I69398, R531, R2681, R51, R001, T448X5A, R109, F1011. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint GI bleed Major Surgical or Invasive Procedure Endoscopy ___ Capsule Endoscopy ___ History of Present Illness ___ with history of GI bleed with unidentified etiology gallstone pancreatitis requiring lap CCY course c b seizures thought triggered by pancreatitis and possible prior stroke who presents from home with dark stools abd pain dysuria polyuria. In the ED initial VS were 98.5 76 179 62 18 100 RA Exam notable for TTP RLQ LLQ suprapubic region Labs showed Hgb 7.9 UA with few bacteria lg leuk 2 WBC Lactate 1.5 Imaging showed CTA ABD PELVIS 1. No evidence of active contrast extravasation into the bowel. 2. Colonic diverticulosis without diverticulitis. 3. Interval increased extrahepatic and central intrahepatic biliary dilation is likely due to post cholecystectomy status. Correlation with LFTs is Recommended and if there is continued concern for biliary obstruction consider MRCP for further assessment. Patient received ___ 15 00 IV Morphine Sulfate 4 mg ___ 16 39 IV Esomeprazole sodium 40 mg ___ 17 59 IV Morphine Sulfate 4 mg ___ 20 19 IV Morphine Sulfate 4 mg ___ 21 54 IV CefTRIAXone ___ 22 23 PO NG Atorvastatin 40 mg ___ 22 23 PO NG Labetalol 200 mg ___ 22 23 PO LevETIRAcetam 1500 mg ___ 23 30 IV Ondansetron 4 mg ___ 1 unit PRBCs ___ 1752 GI was consulted H H down from discharge at 7.9 24.5. Discharged on ___ at 8.9 27.2. Recommend 2 large bore IVs Trend CBC q12h IV PPI BID NPO at midnight Transfuse for hgb 7 Plan for EGD in AM Transfer VS were 98.3 67 164 70 16 100 RA On arrival to the floor patient reports that she simply does not feel well. She has been unable to sleep feeling weak upon standing melena x 2 days diffuse abdominal pain and dysuria. She typically knows when she has a UTI and these symptoms are consistent. She denies fevers weight change chest pain shortness of breath. Recently hospitalized ___ for weakness thought ___ UTI and possible slow GI bleed. UTI grew pan sensitive E coli treated with CTX ciprofloxacin. H H trended H pylori serology came back negative patient did not undergo endoscopy. Discharge Hgb 8.9. REVIEW OF SYSTEMS 10 point ROS reviewed and negative except as per HPI Past Medical History Gallstone pancreatitis status post cholecystectomy ___ Seizures in the setting of the above gallstone pancreatitis Hypertension due to renal artery stenosis difficult to control Prior history of upper GI bleed from a likely AVM Prior history of DVT no longer on anticoagulation Social History ___ Family History ___ and found to be not relevant to this illness reason for hospitalization. She specifically denies any family history of seizures or strokes. Physical Exam ADMISSION PHYSICAL EXAM VS 98.2 162 75 63 18 96 RA GENERAL NAD HEENT AT NC EOMI PERRL anicteric sclera pink conjunctiva MMM NECK supple no LAD no JVD HEART RRR S1 S2 no murmurs gallops or rubs LUNGS CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles ABDOMEN slightly TTP diffusely EXTREMITIES no cyanosis clubbing or edema PULSES 2 DP pulses bilaterally NEURO A Ox3 moving all 4 extremities with purpose SKIN warm and well perfused no excoriations or lesions no rashes DISCHARGE EXAM VS 98.4 ___ GENERAL NAD pale HEENT AT NC anicteric sclera pink conjunctiva MMM NECK supple HEART RRR S1 S2 no murmurs gallops or rubs LUNGS CTAB ABDOMEN Soft nondistended tender over umbilicus no rebound guarding. EXTREMITIES no cyanosis clubbing or edema. Warm NEURO A Ox3 moving all 4 extremities with purpose SKIN warm and well perfused no excoriations or lesions no rashes PSYCH Appropriate affect Pertinent Results ADMISSION LABS ___ 01 49PM BLOOD WBC 7.6 RBC 2.70 Hgb 7.9 Hct 24.5 MCV 91 MCH 29.3 MCHC 32.2 RDW 13.2 RDWSD 43.4 Plt ___ ___ 01 49PM BLOOD Neuts 58.9 ___ Monos 6.2 Eos 5.4 Baso 0.4 Im ___ AbsNeut 4.48 AbsLymp 2.19 AbsMono 0.47 AbsEos 0.41 AbsBaso 0.03 ___ 01 49PM BLOOD ___ PTT 30.9 ___ ___ 01 49PM BLOOD Glucose 106 UreaN 15 Creat 1.0 Na 143 K 4.3 Cl 103 HCO3 22 AnGap 18 ___ 01 49PM BLOOD ALT 15 AST 15 LD LDH 136 AlkPhos 62 TotBili 0.2 ___ 05 05AM BLOOD Calcium 9.4 Phos 4.1 Mg 1.9 ___ 02 09PM BLOOD Lactate 1.5 IMAGING KUB ___ 1. Enteric capsule in the small bowel of the left lower abdomen in similar position to the study 2 days ago. 2. Nonobstructive bowel gas pattern. KUB ___ Enteric capsule in the left lower abdomen. GI Endoscopy ___ Angioectasias in the body thermal therapy Otherwise normal EGD to third part of the duodenum CTA ABD PELVIS ___ 1. No evidence of active contrast extravasation into the bowel. 2. Colonic diverticulosis without diverticulitis. 3. Interval increased extrahepatic and central intrahepatic biliary dilation is likely due to post cholecystectomy status. Correlation with LFTs is Recommended and if there is continued concern for biliary obstruction consider MRCP for further assessment. DISCHARGE LABS ___ 05 15AM BLOOD WBC 4.8 RBC 2.66 Hgb 7.8 Hct 24.7 MCV 93 MCH 29.3 MCHC 31.6 RDW 13.2 RDWSD 44.8 Plt ___ ___ 05 00AM BLOOD Glucose 93 UreaN 9 Creat 1.0 Na 144 K 4.7 Cl 105 HCO3 26 AnGap 13 ___ 05 15AM BLOOD ___ PTT 31.1 ___ ___ 05 00AM BLOOD ALT 10 AST 9 AlkPhos 55 TotBili 0.3 ___ 05 00AM BLOOD Calcium 9.1 Phos 4.2 Mg 2.___ with history of recurrent GIB of unidentified source who presents with melena drop in H H and abdominal pain also with UTI and GPC bactermia. Acute blood loss anemia Melena Upper GI bleeding suspect recurrence of prior GIB. Has had reported extensive workup in past at hospital in ___ including capsule study. Required 3 transfusions in ___. No endoscopy in our system. Prior thought to be AVM in small bowel. EGD showed angiectasias in the body of the stomach. No further bleeding while inpatient. Capsule endoscopy ___ was complicated by poor transit time through the stomach and poor bowel prep. Capsule remained in colon by day of discharge will need visualization in stool or KUB ___ to ensure passage. Will need to be repeated as an outpatient. Staph bacteremia contaminant Coag negative staph and staph hemolyticus growing out of initial cultures. Unclear if contaminant however as affecting 2 out of 2 bottles. Patient without white count or systemic symptoms of infection and no further positive cultures. Treated with vancomycin until preantibiotic repeat cultures resulted negative. Overall thought to be contaminant. UTI Dysuria suprapubic pain in setting of recent E coli in urine dysuria and suprapubic tenderness concern for UTI despite equivocal urine. Initial urine culture was contaminated. Postvoid residual was 0. Pain was managed with Tylenol and oxycodone. S p ceftriaxone x 3 days for presumed UTI. Abdominal pain Patient had some gassy abdominal pain following MoviPrep. Treated with simethicone. She subsequently had abdominal pain following jerking with subcu heparin injection abdominal exam benign. History of seizure per neuro notes thought triggered by pancreatitis vs prior stroke. Continued Keppra HA Likely related to SBPs in 190s. Pain management with Tylenol oxycodone. Avoided NSAIDs given GIB. Trialed fioricet. Dizziness bradycardia Patient endorsed significant dizziness during hospitalization. Was bradycardic to the ___ on home labetalol. Labetalol was discontinued and patient was treated with IV fluids. HTN HTN to 190s inpatient. Restarted home amlodipine lisinopril. HLD atorvastatin. Restarted Asa on discharge. Chronic pain in bilateral legs no longer takes oxycodone at home. Not a complaint here. CTA findings of intrahepatic biliary dilation likely ___ post CCY state. LFTs negative. No RUQ pain. TRANSITIONAL ISSUES Outpatient follow up with Dr. ___ on ___ as already scheduled to determine whether EGD for capsule placement is needed Titrate antihypertensives Labetalol was held for bradycardia Needs KUB ___ to ensure passage of capsule CODE Full confirmed CONTACT ___ daughter ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY hypertension 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. LevETIRAcetam 1500 mg PO Q12H 5. Labetalol 400 mg PO BID Hypertension 6. Famotidine 20 mg PO BID 7. Ondansetron 4 mg PO Q8H PRN nausea 8. Pantoprazole 40 mg PO Q12H 9. Lisinopril 40 mg PO DAILY Discharge Medications 1. Simethicone 40 80 mg PO QID PRN abd pain RX simethicone 80 mg 1 tab by mouth four times a day Disp 80 Tablet Refills 0 2. amLODIPine 10 mg PO DAILY hypertension 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Famotidine 20 mg PO BID 6. LevETIRAcetam 1500 mg PO Q12H 7. Lisinopril 40 mg PO DAILY 8. Ondansetron 4 mg PO Q8H PRN nausea 9. Pantoprazole 40 mg PO Q12H Discharge Disposition Home Discharge Diagnosis Upper GI bleed UTI Bacteremia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were seen at ___ for gastrointestinal bleed. You underwent an endoscopic procedure that showed a small blood vessel abnormality in your stomach. We suspected that a similar abnormality in your small bowel could be the cause of your bleed. We tried to verify this with the capsule endoscopy however the images were of poor quality. You may need to have this capsule study repeated as an outpatient. You may require further transfusions in the future. You also had some burning pain in her lower abdomen that was likely due to a urinary tract infection. You were treated with antibiotics for this. Your initial blood cultures showed growth of some bacteria. Given that you did not have symptoms of a bloodstream infection it is likely that these were a contaminant. You were treated with antibiotics while we waited for these bacterial colonies to grow enough to be identified as contaminants from your skin. Please take all your medications as prescribed and follow up at your outpatient appointments. It was a pleasure taking care of you Your ___ team Followup Instructions ___ The icd codes present in this text will be K31811, E440, R569, D62, I150, Z681, N390, E785, I739, I69398, R531, R2681, R51, R001, T448X5A, Y92230, R109, F1011, Z86718, Z87891. The descriptions of icd codes K31811, E440, R569, D62, I150, Z681, N390, E785, I739, I69398, R531, R2681, R51, R001, T448X5A, Y92230, R109, F1011, Z86718, Z87891 are K31811: Angiodysplasia of stomach and duodenum with bleeding; E440: Moderate protein-calorie malnutrition; R569: Unspecified convulsions; D62: Acute posthemorrhagic anemia; I150: Renovascular hypertension; Z681: Body mass index [BMI] 19.9 or less, adult; N390: Urinary tract infection, site not specified; E785: Hyperlipidemia, unspecified; I739: Peripheral vascular disease, unspecified; I69398: Other sequelae of cerebral infarction; R531: Weakness; R2681: Unsteadiness on feet; R51: Headache; R001: Bradycardia, unspecified; T448X5A: Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, initial encounter; Y92230: Patient room in hospital as the place of occurrence of the external cause; R109: Unspecified abdominal pain; F1011: Alcohol abuse, in remission; Z86718: Personal history of other venous thrombosis and embolism; Z87891: Personal history of nicotine dependence. The common codes which frequently come are D62, N390, E785, Y92230, Z86718, Z87891. The uncommon codes mentioned in this dataset are K31811, E440, R569, I150, Z681, I739, I69398, R531, R2681, R51, R001, T448X5A, R109, F1011.
The icd codes present in this text will be G40409, K8510, G9340, K8064, E871, I701, I10, I160, K219, I739, E785, F17210, Z95820, Z86718, Z8673. The descriptions of icd codes G40409, K8510, G9340, K8064, E871, I701, I10, I160, K219, I739, E785, F17210, Z95820, Z86718, Z8673 are G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus; K8510: Biliary acute pancreatitis without necrosis or infection; G9340: Encephalopathy, unspecified; K8064: Calculus of gallbladder and bile duct with chronic cholecystitis without obstruction; E871: Hypo-osmolality and hyponatremia; I701: Atherosclerosis of renal artery; I10: Essential (primary) hypertension; I160: Hypertensive urgency; K219: Gastro-esophageal reflux disease without esophagitis; I739: Peripheral vascular disease, unspecified; E785: Hyperlipidemia, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; Z95820: Peripheral vascular angioplasty status with implants and grafts; Z86718: Personal history of other venous thrombosis and embolism; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. The common codes which frequently come are E871, I10, K219, E785, F17210, Z86718, Z8673. The uncommon codes mentioned in this dataset are G40409, K8510, G9340, K8064, I701, I160, I739, Z95820. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint seizures abdominal pain Major Surgical or Invasive Procedure mechanical intubation History of Present Illness Ms. ___ is a ___ woman with HTN who presents with seizure. Around ___ on ___ daughter received a text from her cousin that the patient was vomiting. The patien t daughter then got back from work in the morning of ___ when she found her mother sleeping on her R side facing opposite direction. She then did a full turn out of bed and fell on the floor face first. Per the daughter the patient had positive head strike on the night stand on her way down to the floor. Daughter turned her over and saw pt s bottom jaw retracted and top part of mouth sticking out eyes open arms straight out stiffly. Tongue was starting to come out and pt was banging up against the bed. After ___ min convulsions stopped and pt developed heavy breathing snoring. Her eyes kind of cracked open but she was not responsive to daughter. EMS came and brought her outside but head was flopping around as they were transporting her. When they got close to ___ pt started to come to and kept taking off the O2 mask. Seemed to go in and out of consciousness per daughter. She would get intermittently agitated pupils were dilated and she would have episodes of intermittent staring where she did not seem to be registering things. No further shaking. Reportedly got 2mg IV Ativan at ___ and transferred to ___. Once she arrived at ___ the patient was complaining of abdominal pain. CT abd pelvis showed acute pancreatitis. Patient was then intubated given her agitation and need for diagnostic procedures. LP was completed. Nicardipine gtt was initated at OSH for SBP 220. She is now admitted to the neuro ICU remains intubated on nicardipine gtt for further workup and management. Of note about 1mo ago pt was sitting with daughter s cousin. There was a yell so daughter went to go find her mother. At that time pt was sitting up with a deer caught in headlights look. Cousin who witnessed the episode said that she sat upright then started falling backwards and became stiff. Was shaking. Lasted a few seconds then came out of it. After the episode she said she was thirsty and did not remember the episode happening at all. Per son at bedside she did have a seizure ___ years ago without any clear cause. She was living in ___ alone at that time. She was taking a lot of Klonopin vicodin and Percocet along with antidepressants so unclear if this was a trigger. He does not know any further information about the seizure. Also unclear if she ever had strokes before. She had fallen ___ months ago in ___ but son does not think she had any brain hemorrhages from that. She came back to ___ about 5 months ago to live with her daughter. Since that time she has only been taking lisinopril. No other pain medications. Patient s daughter denies any further drug use over the past 5 months. Past Medical History HTN DVTs internal bleed from small intestine tubes tied plantar wart removed procedure in groin colonoscopies Social History ___ Family History no history of seizures or strokes Physical Exam ADMISSION EXAM General agitated refusing to participate in exam HEENT contusions on forehead with a few scrapes ___ tachycardic Pulmonary breathing comfortably on RA Abdomen Soft NT ND Extremities Warm no edema Neurologic Examination Mental status awake agitated oriented to ___ and ___. Able to name thumb and watch and green. Speech is clear and not dysarthric. No gibberish. Cranial Nerves PERRL 6 5mm brisk. BTT bilaterally. Face appears symmetric. Looks around the room fully. Unable to perform more dedicated CN exam ___ pt s agitation Motor moves all extremities spontaneously and equally Reflexes unable to obtain pt moving too much and is not relaxing Sensory withdraws to light touch in all extremities Coordination no ataxia when reaching for bed rails or trying to pull out foley catheter Gait unable to assess DISCHARGE EXAM VS 98.8 PO 100 56 53 18 97 RA GENERAL Pleasant elderly woman sitting up in bed appears comfortable in no acute distress. Persistent paranoid delusions. HEENT Sclerae anicteric EOMI moist mucous membranes LUNGS Clear to auscultation bilaterally no wheezes rales or rhonchi. Good inspiratory effort. HEART Regular rate and rhythm normal S1 and S2 no murmurs rubs gallops or thrills ABDOMEN Normal bowel sounds. Soft non distended. Mild improving tenderness and hyperesthesia around lap port incision sites. No organomegaly. No rebound tenderness or guarding. EXTREMITIES Warm and well perfused. No clubbing cyanosis or lower extremity edema. NEURO A Ox3 moving all 4 extremities with purpose Pertinent Results ADMISSION LABS ___ 12 00PM BLOOD WBC 15.7 RBC 5.35 Hgb 16.2 Hct 48.4 MCV 91 MCH 30.3 MCHC 33.5 RDW 13.6 RDWSD 45.3 Plt ___ ___ 12 00PM BLOOD Neuts 91.3 Lymphs 3.8 Monos 4.1 Eos 0.1 Baso 0.2 Im ___ AbsNeut 14.36 AbsLymp 0.59 AbsMono 0.65 AbsEos 0.01 AbsBaso 0.03 ___ 12 00PM BLOOD ___ PTT 29.7 ___ ___ 12 00PM BLOOD Glucose 228 UreaN 13 Creat 1.3 Na 132 K 8.4 Cl 93 HCO3 21 AnGap 18 ___ 06 30PM BLOOD ALT 523 AST 333 AlkPhos 252 TotBili 1.7 ___ 06 30PM BLOOD Lipase 1222 ___ 06 30PM BLOOD Calcium 9.6 Phos 2.7 Mg 1.7 ___ 12 00PM BLOOD Osmolal 287 ___ 12 00PM BLOOD TSH 3.5 ___ 12 00PM BLOOD ASA NEG Ethanol NEG Acetmnp NEG Bnzodzp NEG Barbitr NEG Tricycl NEG ___ 12 11PM BLOOD Lactate 3.4 K 4.5 PERTINENT LABS ___ 01 55PM BLOOD Lactate 1.1 ___ 01 45PM BLOOD WBC 10.5 RBC 3.25 Hgb 9.8 Hct 30.3 MCV 93 MCH 30.2 MCHC 32.3 RDW 14.4 RDWSD 49.2 Plt ___ ___ 05 25AM BLOOD WBC 7.0 RBC 3.04 Hgb 9.1 Hct 28.1 MCV 92 MCH 29.9 MCHC 32.4 RDW 14.3 RDWSD 48.3 Plt ___ ___ 04 45PM BLOOD Glucose 93 UreaN 5 Creat 0.7 Na 139 K 3.6 Cl 100 HCO3 24 AnGap 15 ___ 09 45AM BLOOD Glucose 144 UreaN 8 Creat 0.9 Na 138 K 3.7 Cl 100 HCO3 22 AnGap 16 ___ 01 36AM BLOOD ALT 177 AST 50 AlkPhos 110 Amylase 149 TotBili 0.6 ___ 02 32AM BLOOD ALT 139 AST 38 AlkPhos 131 Amylase 302 TotBili 0.9 ___ 03 58AM BLOOD Lipase 442 ___ 01 36AM BLOOD Lipase 67 ___ 02 32AM BLOOD Lipase 40 DISCHARGE LABS ___ 05 41AM BLOOD WBC 7.0 RBC 2.81 Hgb 8.7 Hct 26.8 MCV 95 MCH 31.0 MCHC 32.5 RDW 14.0 RDWSD 48.2 Plt ___ ___ 05 41AM BLOOD Glucose 98 UreaN 7 Creat 0.9 Na 140 K 4.4 Cl 101 HCO3 28 AnGap 11 IMAGING STUDIES CT A P ___ 1. Mild to moderate intra and extrahepatic biliary ductal dilatation with probable calculus in the distal common bile duct indicative of choledocholithiasis. If needed MRCP can provide further confirmation and assessment. 2. Edematous pancreas with peripancreatic fat stranding and fluid most suggestive of acute interstitial edematous pancreatitis. In the setting of probable choledocholithiasis constellation of findings likely indicate gallstone pancreatitis. Correlation with serum amylase and lipase levels are recommended. 3. Cholelithiasis. Pericholecystic fluid and stranding may be secondary to pancreatitis. 4. Extensive atherosclerotic disease with severe stenosis of the SMA and right renal artery with resultant atrophy of the right kidney. 5. Bilateral nodular adrenal glands which are incompletely characterized. 6. 0.5 cm pulmonary nodule in the right upper lobe. Please see recommendations section. MRI Brain w and w o ___ 1. Motion limited exam. 2. No evidence for acute infarction. 3. Nonmasslike FLAIR signal abnormality within the right posteriorperiventricular white matter with discontiguous foci of cystic encephalomalacia and no evidence for blood products. These may represent sequela of prior infarction demyelination infection or other insult. 4. Small chronic infarcts in the left cerebellar hemisphere. Punctate cortical FLAIR hyperintensity in the right frontal lobe may also represent a chronic infarct. 5. Small area of FLAIR hyperintensity and contrast enhancement in the right occipital cortex with associated chronic blood products and with questionable involvement of the adjacent sulci. This may represent a chronic infarct with hemorrhagic transformation or sequela of amyloid angiopathy. 6. Small chronic microhemorrhage in the right posterior internal capsule most likely hypertensive. 7. 6 mm round structure in the region of the left petroclival confluence with diagnostic considerations including a cholesterol granuloma another type of lesion or an aberrant blood vessel. Partial left mastoid air cell opacification. Brief Hospital Course PATIENT SUMMARY ___ year old woman who presented with generalized tonic clonic seizure in the setting of gallstone pancreatitis who was found to have right side renal artery stenosis. Seizures were controlled with keppra and patient underwent cholecystectomy and patients blood pressure was well controlled with medical management. ACUTE ISSUES Generalized tonic clonic seizures Patient presented after a witnessed generalized tonic clonic seizures. She presented to the emergency room and seizures were initially controlled with ativan in the emergency room. Neurology followed the patient during this hospitalization for workup of seizures. Patient was found to have gallstone induced pancreatitis which is believed to have caused seizures in a patient with underlying susceptibility given history of CVA. She underwent cholecystectomy. Infectious workup was negative. LP was preformed which was bland. MRI demonstrated existing infarcts but no evidence of acute infarction or intracranial process. The patient was maintained on Keppra 1500 BID and had no further seizures during hospitalization. Neurology recommends that the patient continue keppra 1500 BID indefinitely until potential modification by outpatient neurology in 6 months. If there is concern for mild encephalopathy and gait unsteadiness Keppra could be decreased to 1250 mg twice daily prior to follow up. She was started on atorvastatin and aspirin for primary prevention of CVA. Renal artery stenosis Patient was found to have right sided renal artery stenosis on CT during hospitalization. Systolic blood pressure were initially 170 systolic. Her blood pressure was controlled with nicardipine drip. Vascular surgery evaluated the patient and recommended no surgical intervention. She was medically managed with oral antihypertensive regime and blood pressure was successfully controlled to the 100 160s systolic. she should continue lisinopril amlodapine and labetalol as an outpatient. Gallstone pancreatitis Patient was found to have choledocolithiasis induced pancreatitis. She underwent cholecystectomy and had an uneventful postoperative course. Pain was well controlled with oral oxycodone in the postoperative period. The patient will follow with acute care surgery two weeks after discharge. CHRONIC ISSUES GERD Home famotidine was continued TRANSITIONAL ISSUES Please recheck patient blood pressure and adjust blood pressure medications accordingly as an outpatient Neurology recommends that the patient continue keppra 1500 BID indefinitely until potential modification by outpatient neurology in 6 months. If there is concern for mild encephalopathy and gait unsteadiness Keppra could be decreased to 1250 mg twice daily prior to follow up. She was started on atorvastatin and aspirin for primary prevention of CVA. Follow up with surgery for post operative check after cholecystectomy Follow up with new PCP to establish care and also for cardiology referral for her known peripheral vascular disease for which she was on aspirin and Plavix but were stopped for GI bleeding in ___. given recent seizure patient should not drive until cleared by her Neurologist FULL CODE HCP daughter ___ ___ ___ on Admission The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO BID 2. Famotidine 20 mg PO BID 3. Acetaminophen 500 mg PO Q12H PRN Pain Mild Discharge Medications 1. amLODIPine 10 mg PO DAILY hypertension RX amlodipine Norvasc 10 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 2. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 3. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 4. Labetalol 400 mg PO BID Hypertension RX labetalol 200 mg 2 tablet s by mouth twice a day Disp 60 Tablet Refills 0 5. LevETIRAcetam 1500 mg PO Q12H RX levetiracetam 1 000 mg 1.5 tablet s by mouth every twelve 12 hours Disp 90 Tablet Refills 0 6. OxyCODONE Immediate Release 10 mg PO Q4H PRN Pain Severe RX oxycodone 5 mg 1 tablet s by mouth every six 6 hours Disp 8 Tablet Refills 0 7. Acetaminophen 650 mg PO Q6H PRN Pain Mild 8. Lisinopril 40 mg PO DAILY RX lisinopril 40 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 9. Famotidine 20 mg PO BID Discharge Disposition Home Discharge Diagnosis Primary diagnosis Generalized tonic Clonic Seizures cholecystitis Secondary diagnosis Right Renal Artery Stenosis Hypertension Gallstone Pancreatitis Encephalopathy Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions DISCHARGE WORKSHEET INSTRUCTIONS Dear Ms. ___ It was a pleasure caring for you at ___ ___ WHY WERE YOU ADMITTED You were admitted to the hospital because you had seizures. WHAT HAPPENED IN THE HOSPITAL Your seizures were controlled with medication. You were found to have abdominal pain caused by inflammation in your gallbladder and pancreas. Your gallbladder was removed and this helped the inflammation. We think that your seizures were caused by the inflammation in your gallbladder and pancreas. You were also found to have hypertension caused by a partial blockage to the artery for your right kidney. You were started on new medications to treat your blood pressure and your blood pressure improved. WHAT SHOULD YOU DO AT HOME You should continue the new medications for your seizures and blood pressure and follow up with the surgeons and neurologist at your next scheduled appointment. You also have a primary care physician appointment scheduled for you to follow up and establish care. You will have to discuss with the new PCP about cardiologist referral for your peripheral vascular disease that was treated with aspirin Plavix and procedures in your lower extremity arteries in ___ last year. As you know your Plavix was stopped due to GI bleeding that occurred in ___ last year. You need a new cardiologist to continue to manage your antiplatelet agents. Because you had a seizure please do not drive a car until you are cleared by your Neurologist. Please work on switching your insurance to ___ so that you can continue to get care here. Thank you for allowing us be involved in your care we wish you all the best Your ___ Team Followup Instructions ___ The icd codes present in this text will be G40409, K8510, G9340, K8064, E871, I701, I10, I160, K219, I739, E785, F17210, Z95820, Z86718, Z8673. The descriptions of icd codes G40409, K8510, G9340, K8064, E871, I701, I10, I160, K219, I739, E785, F17210, Z95820, Z86718, Z8673 are G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus; K8510: Biliary acute pancreatitis without necrosis or infection; G9340: Encephalopathy, unspecified; K8064: Calculus of gallbladder and bile duct with chronic cholecystitis without obstruction; E871: Hypo-osmolality and hyponatremia; I701: Atherosclerosis of renal artery; I10: Essential (primary) hypertension; I160: Hypertensive urgency; K219: Gastro-esophageal reflux disease without esophagitis; I739: Peripheral vascular disease, unspecified; E785: Hyperlipidemia, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; Z95820: Peripheral vascular angioplasty status with implants and grafts; Z86718: Personal history of other venous thrombosis and embolism; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits. The common codes which frequently come are E871, I10, K219, E785, F17210, Z86718, Z8673. The uncommon codes mentioned in this dataset are G40409, K8510, G9340, K8064, I701, I160, I739, Z95820.
The icd codes present in this text will be T82868A, I82441, Y832, Y92009, I70411, Z86718, J45909. The descriptions of icd codes T82868A, I82441, Y832, Y92009, I70411, Z86718, J45909 are T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter; I82441: Acute embolism and thrombosis of right tibial vein; Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; I70411: Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, right leg; Z86718: Personal history of other venous thrombosis and embolism; J45909: Unspecified asthma, uncomplicated. The common codes which frequently come are Z86718, J45909. The uncommon codes mentioned in this dataset are T82868A, I82441, Y832, Y92009, I70411. Allergies Percocet Chief Complaint Right leg foot pain Major Surgical or Invasive Procedure ___ Right lower extremity angiogram angioJet mechanical thrombectomy of occluded bypass graft balloon angioplasty of outflow stenosis. ___ Right lower extremity angiogram angioJet mechanical thrombectomy of occluded bypass graft balloon angioplasty of outflow stenosis. History of Present Illness ___ w Rt AK pop to ___ bypass with NRGSV for a thrombosed popliteal aneurysm in ___ present with worsening new onset right foot claudication. Past Medical History PMH DVT R pop v ___ asthma Rt pop artery thrombus with negative hypercoagulable workup PSH Rt AK pop to ___ bypass with NRGSV ___ Physical Exam Physical Exam Alert and oriented x 3 VS BP 104 54 HR 72 RR 16 Resp Lungs clear Abd Soft non tender Ext Pulses palp throughout. Feet warm well perfused. No open areas Left groin puncture site Dressing clean dry and intact. Soft no hematoma or ecchymosis. Pertinent Results ___ 05 45AM BLOOD WBC 9.0 RBC 3.91 Hgb 11.5 Hct 34.2 MCV 88 MCH 29.4 MCHC 33.6 RDW 12.9 RDWSD 40.8 Plt ___ ___ 05 45AM BLOOD Plt ___ ___ 05 45AM BLOOD Glucose 108 UreaN 10 Creat 0.8 Na 141 K 3.7 Cl 107 HCO3 26 AnGap 12 ___ 05 45AM BLOOD Calcium 9.2 Phos 3.1 Mg 2.0 Arterial Duplex Findings. Doppler evaluation was performed of both lower extremity arterial systems at rest. On the right the tibial waveforms are monophasic and there is no audible Waveforms are flat. The left all waveforms are triphasic. The ankle brachial index is 1.3. Impression severe ischemia right lower extremity Brief Hospital Course ___ sp Rt AK pop to ___ bypass with NRGSV ___ for arterial thrombosis presents with worsening right leg pain that occurred over predictable distances and acute change over past 24 hours with fullness in her right leg. Her motor and sensation are intact with no signs of limb threat. A heparin infusion was started. Arterial duplex showed occluded right popliteal to posterior tibial artery bypass. She was taken to the OR for right lower extremity angiogram angioJet mechanical thrombectomy of occluded bypass graft balloon angioplasty of outflow stenosis. A tpa catheter was left in place overnight. She return the next day for right lower extremity angiogram angioJet mechanical thrombectomy of occluded bypass graft and balloon angioplasty of outflow stenosis. At that session we were able to remove residual thrombus in the native right popliteal artery and bypass with good outflow to the foot via the anterior tibial and peroneal arteries. At this point she was pain free with a palpable graft AT and DP pulse. The next morning we discontinued the heparin infusion and started xarelto. She was ambulatory ad lib voiding qs and tolerating a regular diet. She was discharged to home. We will see her again in followup in one month with surveillance duplex. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Clobetasol Propionate 0.05 Soln 1 Appl TP BID 2. Fluocinolone Acetonide 0.01 Solution 1 Appl TP Q24H PRN 3. metroNIDAZOLE 0.75 topical BID 4. ALPRAZolam 0.5 mg PO TID PRN anxiety 5. Lovastatin 10 mg ORAL DAILY 6. Montelukast 10 mg PO DAILY 7. Fluticasone Salmeterol Diskus 500 50 2 INH IH DAILY 8. Pantoprazole 40 mg PO Q24H 9. Aspirin 81 mg PO DAILY 10. Loratadine 10 mg PO BID Discharge Medications 1. Rivaroxaban 15 mg PO NG BID FOR THE NEXT 3 WEEKS ONLY. RX rivaroxaban ___ 15 mg 1 tablet s by mouth twice daily Disp 42 Tablet Refills 0 2. Clopidogrel 75 mg PO DAILY For the next ___ days. RX clopidogrel 75 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 3. metroNIDAZOLE 0.75 topical BID 4. Fluocinolone Acetonide 0.01 Solution 1 Appl TP Q24H PRN 5. Clobetasol Propionate 0.05 Soln 1 Appl TP BID 6. ALPRAZolam 0.5 mg PO TID PRN anxiety 7. Aspirin 81 mg PO DAILY 8. Fluticasone Salmeterol Diskus 500 50 2 INH IH DAILY 9. Loratadine 10 mg PO BID 10. Montelukast 10 mg PO DAILY 11. Pantoprazole 40 mg PO Q24H 12. Rivaroxaban 20 mg PO DAILY Start ___ after loading dose of 15 mg twice daily. RX rivaroxaban ___ 20 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 3 13. Lovastatin 10 mg ORAL DAILY Discharge Disposition Home Discharge Diagnosis Peripheral Arterial Disease Right Posterior Tibial Deep Vein Thrombosis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Ms. ___ It was a pleasure taking care of you at ___ ___. You were admitted to the hospital with right leg pain that we found was secondary to a blockage in your bypass graft. We also noted a clot in a vein in your calf. We did a peripheral angiogram to open up the graft with special catheter and balloons. To do the procedure a small puncture was made in one of your arteries. The puncture site heals on its own there are no stitches to remove. You tolerated the procedure well and are now ready to be discharged from the hospital. Please follow the recommendations below to ensure a speedy and uneventful recovery. Peripheral Angiography Puncture Site Care For one week Do not take a tub bath go swimming or use a Jacuzzi or hot tub. Use only mild soap and water to gently clean the area around the puncture site. Gently pat the puncture site dry after showering. Do not use powders lotions or ointments in the area of the puncture site. You may remove the bandage and shower the day after the procedure. You may leave the bandage off. You may have a small bruise around the puncture site. This is normal and will go away one two weeks. Activity For the first 48 hours Do not drive for 48 hours after the procedure For the first week Do not lift push pull or carry anything heavier than 10 pounds Do not do any exercises or activity that causes you to hold your breath or bear down with abdominal muscles. Take care not to put strain on your abdominal muscles when coughing sneezing or moving your bowels. After one week You may go back to all your regular activities including sexual activity. We suggest you begin your exercise program at half of your usual routine for the first few days. You may then gradually work back to your full routine. Medications Before you leave the hospital you will be given a list of all the medicine you should take at home. If a medication that you normally take is not on the list or a medication that you do not take is on the list please discuss it with the team Followup Instructions ___ The icd codes present in this text will be T82868A, I82441, Y832, Y92009, I70411, Z86718, J45909. The descriptions of icd codes T82868A, I82441, Y832, Y92009, I70411, Z86718, J45909 are T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter; I82441: Acute embolism and thrombosis of right tibial vein; Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; I70411: Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, right leg; Z86718: Personal history of other venous thrombosis and embolism; J45909: Unspecified asthma, uncomplicated. The common codes which frequently come are Z86718, J45909. The uncommon codes mentioned in this dataset are T82868A, I82441, Y832, Y92009, I70411.
The icd codes present in this text will be J690, G931, I82621, Z8674, J95811, I959, J9600, I10, D638, Y848, Y92238, Z66, Z515, Z781, F209, S42291D, W1830XD, Z9181, Z85828, H269, Z720, L409, M810, L570, M720, J309, F1021, Z7902, H6120. The descriptions of icd codes J690, G931, I82621, Z8674, J95811, I959, J9600, I10, D638, Y848, Y92238, Z66, Z515, Z781, F209, S42291D, W1830XD, Z9181, Z85828, H269, Z720, L409, M810, L570, M720, J309, F1021, Z7902, H6120 are J690: Pneumonitis due to inhalation of food and vomit; G931: Anoxic brain damage, not elsewhere classified; I82621: Acute embolism and thrombosis of deep veins of right upper extremity; Z8674: Personal history of sudden cardiac arrest; J95811: Postprocedural pneumothorax; I959: Hypotension, unspecified; J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia; I10: Essential (primary) hypertension; D638: Anemia in other chronic diseases classified elsewhere; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92238: Other place in hospital as the place of occurrence of the external cause; Z66: Do not resuscitate; Z515: Encounter for palliative care; Z781: Physical restraint status; F209: Schizophrenia, unspecified; S42291D: Other displaced fracture of upper end of right humerus, subsequent encounter for fracture with routine healing; W1830XD: Fall on same level, unspecified, subsequent encounter; Z9181: History of falling; Z85828: Personal history of other malignant neoplasm of skin; H269: Unspecified cataract; Z720: Tobacco use; L409: Psoriasis, unspecified; M810: Age-related osteoporosis without current pathological fracture; L570: Actinic keratosis; M720: Palmar fascial fibromatosis [Dupuytren]; J309: Allergic rhinitis, unspecified; F1021: Alcohol dependence, in remission; Z7902: Long term (current) use of antithrombotics/antiplatelets; H6120: Impacted cerumen, unspecified ear. The common codes which frequently come are I10, Z66, Z515, Z7902. The uncommon codes mentioned in this dataset are J690, G931, I82621, Z8674, J95811, I959, J9600, D638, Y848, Y92238, Z781, F209, S42291D, W1830XD, Z9181, Z85828, H269, Z720, L409, M810, L570, M720, J309, F1021, H6120. Allergies Penicillins Haldol ___ Complaint s p cardiac arrest Major Surgical or Invasive Procedure chest thoracostomy tube placement intubation central venous catheter placement History of Present Illness ___ with PMHx significant for schizophrenia hypertension and anemia who p w from nursing home with cardiac arrest. Per EMS he choked while sitting in his chair eating found slumped over in chair without e o trauma turned blue. Found cyanotic without pulses. Heimelich productive of large food bolus. ROSC ___ s p CPR and epi x2 and intubated w IO placed. In ___ became bradycardic transitioning to Asystole 1330. Given Epi further CPR obtained ROSC. His SBP of ___ started on levo. In ED initial VS T 34.9 HR 83 BP 111 63 RR 14 100 ra Exam Tube in place some secretions suctioned No e o trauma or prolonged down time Psoriatic plaques 2mm minimally responsive pupils Unresponsive No spontaneous limb movements Labs were notable for wbc 16.1 hgb 12.4 plt 635 Na 134 K 4.2 cr 0.3 TnT 0.47 AP 164 normal ALT AST INR 1.4 ABG ___ lactate 2.6 1.3 Imaging notable for NCCTH w o hemorrhage CXR w possible LLL PNA. EKG 88 NS NA No STTW changes concerning for ischemia Patient was given RIJ placed given rocuronium 80 mg norepinephrine gtt midazolam gtt fentanyl gtt Consults Post arrest response team recommended TTM at 35 degrees for 24 hours w EEG in ICU. TTM was initiated. He developed a CTX after the RIJ was placed that required chest tube placement. VS prior to transfer T 34.9 HR 87 BP 137 76 RR 20 99 RA On arrival to the MICU Patient is intubated and sedated chest tube in place. Past Medical History Basal cell carcinoma Schizophrenia Anemia Cataracts Constipation Hyponatremia Tobacco abuse Osteoporosis Psoriasis Actinic keratosis Dupuytrens Squamous cell carcinoma Hypertension Allergic rhinitis Social History ___ Family History Mother deceased old age Father prostate cancer Physical Exam ADMISSION PHYSICAL EXAM VITALS Reviewed in metavision. GENERAL Intubated and sedated HEENT Sclera anicteric PERRLA ETT in place NECK supple right CVL LUNGS Clear to auscultation bilaterally no wheezes rales rhonchi CV Regular rate and rhythm normal S1 S2 no murmurs rubs gallops ABD soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly EXT Cool well perfused 2 pulses no edema SKIN Artic sun in place Pertinent Results LABS ON ADMISSION ___ 06 38PM TYPE CENTRAL VE PO2 40 PCO2 31 PH 7.45 TOTAL CO2 22 BASE XS 0 ___ 06 38PM LACTATE 1.5 ___ 06 38PM O2 SAT 72 ___ 06 10PM GLUCOSE 182 UREA N 13 CREAT 0.3 SODIUM 134 POTASSIUM 4.2 CHLORIDE 97 TOTAL CO2 20 ANION GAP 17 ___ 06 10PM ALT SGPT 14 AST SGOT 31 CK CPK 279 ALK PHOS 164 TOT BILI 0.6 ___ 06 10PM ALBUMIN 3.0 CALCIUM 8.5 PHOSPHATE 2.8 ___ 06 10PM NEUTS 86.9 LYMPHS 5.1 MONOS 6.7 EOS 0.1 BASOS 0.2 IM ___ AbsNeut 14.01 AbsLymp 0.83 AbsMono 1.08 AbsEos 0.01 AbsBaso 0.04 ___ 06 10PM ___ PTT 29.3 ___ PERTIENT LABS Trops ___ 06 10PM BLOOD cTropnT 0.47 ___ 12 30AM BLOOD CK MB 41 MB Indx 13.4 cTropnT 0.41 ___ 07 32AM BLOOD CK MB 29 MB Indx 12.0 cTropnT 0.30 ___ 02 29PM BLOOD CK MB 27 MB Indx 13.6 cTropnT 0.22 MICRO BCx ___ pending GRAM STAIN Final ___ 25 PMNs and 10 epithelial cells 100X field. ___ MRSA SCREEN Final ___ No MRSA isolated. IMAGING ___ MRI Head Diffusion abnormalities along the cortex of both cerebral hemispheres predominantly in the parieto occipital lobes are suggestive of early ischemic brain injury. ___ LENIs 1. Limited examination but no evidence of deep vein thrombosis in the right upper extremity. 2. Probable hematoma in the upper inner arm as described. Correlate with physical examination for chronicity and advise clinical follow up to ensure resolution over time. ___ TTE The left atrial volume index is normal. Normal left ventricular wall thickness cavity size and regional global systolic function biplane LVEF 64 . Tissue Doppler imaging suggests a normal left ventricular filling pressure PCWP 12mmHg . Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus ascending and arch levels are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No valvular pathology or pathologic flow identified. No pericardial effusion. ___ EEG This is an abnormal ICU continuous video EEG monitoring study due to the presence of a burst suppression pattern indicative of a severe ecphalopathy. By the late afternoon overall amplitudes began to diminish and more prolonged background attenuation was seen with plentiful artifact. By the end of the recording definitive activity of cerebral origin was not clearly seen. These findings are indicative of worsening of the severe encephalopathy which could be related to medication effects toxic metabolic disturbances or progression of neurologic injury. There were no clear epileptiform discharges or electrographic seizures in this recording. ___ Shoulder ___ views Displaced humeral head fracture corresponding to given history with exact relation of fracture fragments difficult to identify given limited included two views. ___ CXR AP portable supine view of the chest. The endotracheal tube is positioned with its tip 3.8 cm above the carina. There is a vague opacity in the right lower lung which could reflect a focus of pneumonia though attention on followup advised. There is mild retrocardiac opacity likely atelectasis. No large effusion or pneumothorax is seen. The cardiomediastinal silhouette appears grossly unremarkable. There is a dextroscoliotic curvature of the thoracic spine. No acute bony abnormalities. Brief Hospital Course Mr ___ was admitted to the MICU at ___ for post cardiac arrest management. He received 5 rounds of CPR prior to ROSC. Unfortunately despite obtaining ROSC he suffered a devastating brain injury likely ___ anoxia. This was confirmed on MRI as well as with consult from the neurology team. After speaking with his HCP we agreed to progress to CMO. He was extubated and expired on ___. Medications on Admission The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Calcium Carbonate 500 mg PO BID 3. Citalopram 10 mg PO DAILY 4. Apixaban 5 mg PO BID 5. OLANZapine 20 mg PO DAILY 6. Divalproex DELayed Release 500 mg PO TID 7. Ketoconazole Shampoo 1 Appl TP ASDIR 8. Docusate Sodium 100 mg PO DAILY 9. Hydrocortisone Cream 2.5 1 Appl TP BID Discharge Medications Expired Discharge Disposition Expired Discharge Diagnosis Expired Discharge Condition Expired Discharge Instructions N A Followup Instructions ___ The icd codes present in this text will be J690, G931, I82621, Z8674, J95811, I959, J9600, I10, D638, Y848, Y92238, Z66, Z515, Z781, F209, S42291D, W1830XD, Z9181, Z85828, H269, Z720, L409, M810, L570, M720, J309, F1021, Z7902, H6120. The descriptions of icd codes J690, G931, I82621, Z8674, J95811, I959, J9600, I10, D638, Y848, Y92238, Z66, Z515, Z781, F209, S42291D, W1830XD, Z9181, Z85828, H269, Z720, L409, M810, L570, M720, J309, F1021, Z7902, H6120 are J690: Pneumonitis due to inhalation of food and vomit; G931: Anoxic brain damage, not elsewhere classified; I82621: Acute embolism and thrombosis of deep veins of right upper extremity; Z8674: Personal history of sudden cardiac arrest; J95811: Postprocedural pneumothorax; I959: Hypotension, unspecified; J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia; I10: Essential (primary) hypertension; D638: Anemia in other chronic diseases classified elsewhere; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92238: Other place in hospital as the place of occurrence of the external cause; Z66: Do not resuscitate; Z515: Encounter for palliative care; Z781: Physical restraint status; F209: Schizophrenia, unspecified; S42291D: Other displaced fracture of upper end of right humerus, subsequent encounter for fracture with routine healing; W1830XD: Fall on same level, unspecified, subsequent encounter; Z9181: History of falling; Z85828: Personal history of other malignant neoplasm of skin; H269: Unspecified cataract; Z720: Tobacco use; L409: Psoriasis, unspecified; M810: Age-related osteoporosis without current pathological fracture; L570: Actinic keratosis; M720: Palmar fascial fibromatosis [Dupuytren]; J309: Allergic rhinitis, unspecified; F1021: Alcohol dependence, in remission; Z7902: Long term (current) use of antithrombotics/antiplatelets; H6120: Impacted cerumen, unspecified ear. The common codes which frequently come are I10, Z66, Z515, Z7902. The uncommon codes mentioned in this dataset are J690, G931, I82621, Z8674, J95811, I959, J9600, D638, Y848, Y92238, Z781, F209, S42291D, W1830XD, Z9181, Z85828, H269, Z720, L409, M810, L570, M720, J309, F1021, H6120.
The icd codes present in this text will be I2510, I959, I4891, D649, I10, E7800, Z955, Z87891, R0902. The descriptions of icd codes I2510, I959, I4891, D649, I10, E7800, Z955, Z87891, R0902 are I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I959: Hypotension, unspecified; I4891: Unspecified atrial fibrillation; D649: Anemia, unspecified; I10: Essential (primary) hypertension; E7800: Pure hypercholesterolemia, unspecified; Z955: Presence of coronary angioplasty implant and graft; Z87891: Personal history of nicotine dependence; R0902: Hypoxemia. The common codes which frequently come are I2510, I4891, D649, I10, Z955, Z87891. The uncommon codes mentioned in this dataset are I959, E7800, R0902. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest pain Major Surgical or Invasive Procedure ___ Urgent coronary artery bypass graft x3 left internal mammary artery to left anterior descending artery saphenous vein graft to diagonal and distal right coronary arteries. 2. Endoscopic harvesting of long saphenous vein. History of Present Illness ___ old male hx of CAD underwent PCI ___ ago BMS to left circ and balloon angioplasty to diagonal branch. At that time was note to have RCA and LAD disease. He reports that over the past few months he has been having worsening chest discomfort described as burning sensation mid chest that radiates down both arms. He has pain with exertion relieved with rest. Yesterday he developed chest pain and took SL nitro pain reslved. He was seen by his PCP today who referred him to ___. His EKG was unremarkable troponin 0.22. He underwent cardiac cath today which revealed significant multivessel disease. He was transferred to ___ for CABG evaluation. Past Medical History Past Medical History CAD HTN Hypercholesterolemia Past Surgical History PCI ___ s p T A Social History ___ Family History unremarkable Physical Exam ___ Skin Dry x intact x HEENT PERRLA x EOMI x Neck Supple x Full ROM x Chest Lungs clear bilaterally x Heart RRR x Irregular Murmur grade ___ Abdomen Soft x non distended x non tender x bowel sounds x Extremities Warm x well perfused x Edema ___ Varicosities None x Neuro Grossly intact x Pulses Femoral Right 2 Left 2 DP Right 1 Left 1 ___ Right 1 Left 1 Radial Right cath site Left 2 Carotid Bruit Right no Left no Pertinent Results Cardiac Catheterization Date ___ Place ___ LM 90 stenosis LAD ___ 90 stenosis Circ 100 stenosis existing stent unknown instent stenosis no thrombosis RCA mid ___ 60 stenosis mid 70 Left heart cath revealed EF 65 grade 2 MR aortic valve Ok Cardiac Echocardiogram ___ ECHOCARDIOGRAPHY REPORT ___ ___ MRN ___ TEE Complete Done ___ at 9 24 37 AM FINAL Referring Physician ___ ___ of Cardiothoracic Surg ___ ___ ___ Status Inpatient DOB ___ Age years ___ M Hgt in 70 BP mm Hg 127 60 Wgt lb 143 HR bpm 68 BSA m2 1.81 m2 Indication Intraoperative TEE for CABG Diagnosis I25.9 I34.0 ___ Information Date Time ___ at 09 24 ___ MD ___ MD ___ Type TEE Complete Sonographer ___ MD Doppler Full Doppler and color Doppler ___ Location Anesthesia West OR cardiac Contrast None Tech Quality Adequate Machine Echocardiographic Measurements Results Measurements Normal Range Left Ventricle Septal Wall Thickness 1.2 cm 0.6 1.1 cm Left Ventricle Inferolateral Thickness 1.1 cm 0.6 1.1 cm Left Ventricle Ejection Fraction 60 to 65 55 Findings LEFT ATRIUM Dilated LA. RIGHT ATRIUM INTERATRIAL SEPTUM Dilated RA. LEFT VENTRICLE Normal LV wall thickness cavity size and global systolic function LVEF 55 . Normal regional LV systolic function. RIGHT VENTRICLE Normal RV chamber size and free wall motion. AORTA Normal ascending aorta diameter. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. Focal calcifications in descending aorta. AORTIC VALVE Normal aortic valve leaflets 3 . No AS. No AR. MITRAL VALVE Mildly thickened mitral valve leaflets. No MS. ___ 1 MR. ___ VALVE Normal tricuspid valve leaflets with trivial TR. No TS. PULMONIC VALVE PULMONARY ARTERY Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM Very small pericardial effusion. ___ COMMENTS Written informed consent was obtained from the ___. The ___ was under ___ anesthesia throughout the procedure. No TEE related complications. The ___ appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the ___. See Conclusions for post bypass data Conclusions PRE BYPASS The left atrium is dilated. The right atrium is dilated. Left ventricular wall thickness cavity size and global systolic function are normal LVEF 55 . Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets 3 appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is billowing of the anterior mitral leaflet. Mild 1 mitral regurgitation is seen. Trace tricuspid regurgitation is seen. There is a very small pericardial effusion. POST BYPASS The ___ is in sinus rhythm and receiving a phenylephrine infusion. Biventricular function remains preserved. There are no regional wall motion abnormalities. Valvular function is unchanged. The thoracic aorta is intact following decannulation. Brief Hospital Course Mr. ___ was transferred to ___ on ___. On ___ he underwent a coronary artery bypass grafting times three. Please see operative note for full details. He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. He was weaned from sedation awoke neurologically intact and was extubated on post operative day one. He weaned from inotropic and vasopressor support. Beta blocker was initiated and he was diuresed toward his preoperative weight. Mr. ___ remained hemodynamically stable and was transferred to the telemetry floor for further recovery. Chest tubes and epicardial wires were removed per protocol. He was evaluated by the physical therapy service for assistance with strength and mobility. On the evening of post operative day two he had about two hours of atrial fibrillation and therefore was placed on oral amiodarone. His beta blockade was up titrated as tolerated. By the time of discharge on post operative day four he was ambulating freely his wounds were healing well and his pain was controlled with oral analgesics. He was discharged to home in good condition with appropriate follow up instructions. Medications on Admission ASA 81mg daily atenolol 25mg daily atorvastatin 80mg daily Discharge Medications 1. Acetaminophen 1000 mg PO PR QID PRN pain or temperature 38.0 2. Amiodarone 200 mg PO BID take 200mg twice daily for one week then decrease to 200mg daily ongoing RX amiodarone 200 mg one tablet s by mouth twice daily Disp 120 Tablet Refills 2 3. Metoprolol Succinate XL 150 mg PO DAILY RX metoprolol succinate 50 mg three tablet s by mouth daily Disp 90 Tablet Refills 2 4. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain moderate severe RX oxycodone 5 mg ___ tablet s by mouth every four hours Disp 40 Tablet Refills 0 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Coronary Artery Disease Hypertension HTN Hypercholesterolemia Discharge Condition Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions Sternal healing well no erythema or drainage Leg Right Left healing well no erythema or drainage. Edema trace Discharge Instructions Please shower daily including washing incisions gently with mild soap no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions cream powder or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature these should be written down on the chart No driving for approximately one month and while taking narcotics will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Females Please wear bra to reduce pulling on incision avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours Followup Instructions ___ The icd codes present in this text will be I2510, I959, I4891, D649, I10, E7800, Z955, Z87891, R0902. The descriptions of icd codes I2510, I959, I4891, D649, I10, E7800, Z955, Z87891, R0902 are I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I959: Hypotension, unspecified; I4891: Unspecified atrial fibrillation; D649: Anemia, unspecified; I10: Essential (primary) hypertension; E7800: Pure hypercholesterolemia, unspecified; Z955: Presence of coronary angioplasty implant and graft; Z87891: Personal history of nicotine dependence; R0902: Hypoxemia. The common codes which frequently come are I2510, I4891, D649, I10, Z955, Z87891. The uncommon codes mentioned in this dataset are I959, E7800, R0902.
The icd codes present in this text will be C562, C786, C772, C787, E669, F419, F329, Z6836. The descriptions of icd codes C562, C786, C772, C787, E669, F419, F329, Z6836 are C562: Malignant neoplasm of left ovary; C786: Secondary malignant neoplasm of retroperitoneum and peritoneum; C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes; C787: Secondary malignant neoplasm of liver and intrahepatic bile duct; E669: Obesity, unspecified; F419: Anxiety disorder, unspecified; F329: Major depressive disorder, single episode, unspecified; Z6836: Body mass index [BMI] 36.0-36.9, adult. The common codes which frequently come are E669, F419, F329. The uncommon codes mentioned in this dataset are C562, C786, C772, C787, Z6836. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Malignant transformation of endometriosis final pathology report pending. Major Surgical or Invasive Procedure exploratory laparotomy total abdominal hysterectomy left salingo oophrectomy omentectomy para aortic lymph node biopsy liver resection cystoscopy History of Present Illness Ms. ___ is a ___ G0 with a history of fibroids and endometriosis who presents today for consultation regarding a large left adnexal mass identified on imaging. In ___ she underwent an abdominal myomectomy with left ovarian cystectomy for 27 fibroids and a 15 cm endometrioma. She reports recovering well until around ___ when she started to experience epigastric discomfort and occasional shortness of breath. She underwent CTA of the chest to evaluate for PE which was negative and there was no lymphadenopathy or suspicious nodule seen. In ___ she got the heaviest period she has had since her Mirena IUD was placed. She underwent endometrial biopsy on ___ which showed chronic endometritis. She was already taking doxycycline for a positive Lyme titer while awaiting confirmatory testing but continued to have vaginal bleeding. Her followup Lyme testing was negative. She continued to feel quite fatigued and noted abdominal pain epigastrically as well as in the LLQ back pain and decreased appetite and constipation which got progressively more bothersome during ___. She ultimately went to the ED on ___ where she underwent CT scan of the abdomen and pelvis which showed a large 10 cm left complex adnexal cystic mass with septations and irregular solid components. Additionally there were multiple subcapsular hepatic lesions and peritoneal implants as well as retroperitoneal lymphadenopathy. Findings were concerning for a metastatic primary ovarian neoplasm such as cystadenocarcinoma versus atypical distribution of endometriotic implants. On ___ patient underwent an MRI of the abdomen and pelvis lower thorax showed clear lung bases no focal consolidations no pleural or pericardial effusion. Liver showed multiple nonenhancing cystic subcapsular implants likely representing hemorrhage. The largest right arises from the right lobe of the liver and measured 4.1 x 2.8 cm. There was no associated enhancement likely represent adherent clot. There were no suspicious enhancing lesions intrinsic to the hepatic parenchyma. Again in regard to the pelvis there was a large cystic multiloculated left adnexal structure measuring up to 10.8 x 10.1 cm. The septations were thin without significant enhancement or nodular components. The loculations demonstrated fluid filled areas correction fluid filled levels also likely representing hemorrhage. Within one of the loculations there was a dark spot sign a finding that could be consistent with endometriosis. A smaller right adnexal cystic structure was seen measuring 3.5 x 3.0 cm. Uterus was enlarged with multiple small fibroids and IUD was seen within the endometrial cavity at. There was a trace free fluid within the pelvis multiple cystic anterior peritoneal implants were visualized with fluid filled levels likely representing hemorrhage. There was peripheral enhancement which may be reactive in nature. One of these peritoneal implants appeared to have significant surrounding fat stranding. A left periaortic retroperitoneal lesion had a similar appearance. Multiple subcentimeter periaortic lymph nodes were nonspecific. There was no inguinal or pelvic lymphadenopathy. She saw Dr. ___ in the office on ___ and received a 1 month dose of Lupron. She was referred to ___ Oncology for further evaluation given atypical imaging findings. Of note she had a CA125 checked on ___ which was 108 decreased from 209 in ___. CEA was 0.9 on ___. Today she reports abdominal bloating constipation decreased appetite and increased abdominal girth. She noted decreased vaginal spotting since her Lupron shot but it has been persistent. She also reports continued fatigue and occasional nausea. She denies chest pain shortness of breath diarrhea or dysuria. Past Medical History GYN HX G0 LMP ___ only minor spotting while IUD in place except when bleeding began in ___ Currently sexually active with female partner ___ history of abnormal Pap smears last Pap ___ Denies history of pelvic infections or sexually transmitted infections Known history of fibroids and ovarian cysts Known endometriosis PMH allergic rhinitis depression pseudocholinesterase deficiency Denies hypertension diabetes asthma thromboembolic disease PSH ___ knee surgery ___ abdominal myomectomy ___ RSO L ov cystectomy Path endometriotic cyst with focal metaplastic reactive changes ___ abdominal myomectomy LOA L ovarian cystectomy Path leiomyomata with degenerative changes endometriotic cyst Social History ___ Family History FHx Father living hx of bladder prostate skin and throat cancer non smoker Mother died age ___ of colon cancer also had DM and glaucoma Brother is healthy Niece with cystic fibrosis No known family history of breast uterine ovarian or cervical Physical Exam On day of discharge Afebrile vitals stable No acute distress CV regular rate and rhythm Pulm clear to auscultation bilaterally Abd soft appropriately tender nondistended incision clean dry intact no rebound guarding ___ nontender nonedematous Brief Hospital Course Ms. ___ was admitted to the gynecologic oncology service after undergoing exploratory laparaotomy total abdominal hysterectomy left salpingo oophorectomy omentectomy para aortic lymph node biopsy liver resection and cystoscopy for malignant transformation of endometriosis. Please see the operative report for full details. Her post operative course is detailed as follows. Immediately postoperatively her pain was controlled with an epidural and Dilaudid PCA with toradol. Her diet was gradually advanced without difficulty and she was transitioned to oral oxycodone Tylenol and ibuprofen. On post operative day 2 her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post operative day 5 she was tolerating a regular diet voiding spontaneously ambulating independently and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow up scheduled. Medications on Admission duloxetine 60mg daily Discharge Medications 1. Acetaminophen 1000 mg PO Q6H PRN Pain Mild do not exceed 4000mg in 24 hours RX acetaminophen 500 mg 2 tablet s by mouth every 6 hours Disp 60 Tablet Refills 2 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice daily Disp 60 Capsule Refills 2 3. Enoxaparin Sodium 30 mg SC Q12H Start ___ First Dose Next Routine Administration Time Take this medication for a total of 28 days after your surgery ending ___. RX enoxaparin 30 mg 0.3 mL 30 mg SC twice a day Disp 50 Syringe Refills 0 4. Ferrous GLUCONATE 324 mg PO DAILY RX ferrous gluconate 324 mg 36 mg iron 1 tablet s by mouth daily Disp 30 Tablet Refills 2 5. Ibuprofen 600 mg PO Q6H PRN Pain Moderate take with food RX ibuprofen 600 mg 1 tablet s by mouth every 6 hours Disp 60 Tablet Refills 1 6. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Severe do not drive or drink alcohol causes sedation RX oxycodone 5 mg ___ tablet s by mouth every 4 hours Disp 50 Tablet Refills 0 7. DULoxetine 60 mg PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis malignant transformation of endometriosis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ . You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation and the team feels that you are safe to be discharged home. Please follow these instructions . Abdominal instructions Take your medications as prescribed. We recommend you take non narcotics i.e. Tylenol ibuprofen regularly for the first few days post operatively and use the narcotic as needed. As you start to feel better and need less medication you should decrease stop the narcotic first. Do not drive while taking narcotics. Do not combine narcotic and sedative medications or alcohol. Do not take more than 4000mg acetaminophen tylenol in 24 hrs. No strenuous activity until your post op appointment. Nothing in the vagina no tampons no douching no sex for 12 weeks. No heavy lifting of objects 10 lbs for 6 weeks. You may eat a regular diet. It is safe to walk up stairs. . Incision care You may shower and allow soapy water to run over incision no scrubbing of incision. No bath tubs for 6 weeks. If you have staples they will be removed at your follow up visit. . To reach medical records to get the records from this hospitalization sent to your doctor at home call ___. . Call your doctor at ___ for fever 100.4 severe abdominal pain difficulty urinating vaginal bleeding requiring 1 pad hr abnormal vaginal discharge redness or drainage from incision nausea vomiting where you are unable to keep down fluids food or your medication chest pain or difficulty breathing onset of any concerning symptoms Followup Instructions ___ The icd codes present in this text will be C562, C786, C772, C787, E669, F419, F329, Z6836. The descriptions of icd codes C562, C786, C772, C787, E669, F419, F329, Z6836 are C562: Malignant neoplasm of left ovary; C786: Secondary malignant neoplasm of retroperitoneum and peritoneum; C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes; C787: Secondary malignant neoplasm of liver and intrahepatic bile duct; E669: Obesity, unspecified; F419: Anxiety disorder, unspecified; F329: Major depressive disorder, single episode, unspecified; Z6836: Body mass index [BMI] 36.0-36.9, adult. The common codes which frequently come are E669, F419, F329. The uncommon codes mentioned in this dataset are C562, C786, C772, C787, Z6836.
The icd codes present in this text will be D259, E8809, N3289, N8320, N736, Z90721, Z9079, N393, Z975, J309, F329, Z800, Z8042. The descriptions of icd codes D259, E8809, N3289, N8320, N736, Z90721, Z9079, N393, Z975, J309, F329, Z800, Z8042 are D259: Leiomyoma of uterus, unspecified; E8809: Other disorders of plasma-protein metabolism, not elsewhere classified; N3289: Other specified disorders of bladder; N8320: Unspecified ovarian cysts; N736: Female pelvic peritoneal adhesions (postinfective); Z90721: Acquired absence of ovaries, unilateral; Z9079: Acquired absence of other genital organ(s); N393: Stress incontinence (female) (male); Z975: Presence of (intrauterine) contraceptive device; J309: Allergic rhinitis, unspecified; F329: Major depressive disorder, single episode, unspecified; Z800: Family history of malignant neoplasm of digestive organs; Z8042: Family history of malignant neoplasm of prostate. The common codes which frequently come are F329. The uncommon codes mentioned in this dataset are D259, E8809, N3289, N8320, N736, Z90721, Z9079, N393, Z975, J309, Z800, Z8042. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint symptomatic fibroid uterus left ovarian cyst Major Surgical or Invasive Procedure exploratory laparotomy lysis of adhesions multiple myomectomy left ovarian cystectomy History of Present Illness Ms. ___ is a ___ gravida 0 with a long history of recurrent ovarian cyst and endometriosis who on ___ underwent a right salpingo oophorectomy left ovarian cystectomy for endometriomas. In ___ she had a multiple myomectomies for symptomatic fibroid uterus. The patient presents today for followup of unknown left adnexal cyst. The patient notes that she has no abdominal pain. She is simply experiencing increased bloatedness and pelvic pressure. New symptoms she has developed stress urinary incontinence with sneezing. We discussed that this certainly can be related to this large adnexal cyst in addition to her overweightedness. On ___ she had an ultrasound which showed an anteverted uterus that measured 14.3 x 6.7 x 9.2 cm slightly smaller than previous measurement on ___ where it measured 15.2 x 7.4 x 10.4 cm. Multiple masses were consistent with uterine fibroids. The dominant fibroid was seen at the fundus and measured 3.3 x 3.3 x 3.5 cm. The endometrium was distorted due to fibroids and not well evaluated. An IUD was demonstrated within the endometrial cavity. The patient is status post right oophorectomy previously seen 10.7 cm left adnexal cyst again visualized and now measuring slightly larger at 10.8 x 10 cm. It predominantly was thin walled however there was one area with the appearance of an incomplete septation. This either represented a hydrosalpinx or peritoneal inclusion cyst less likely a cystadenoma. There was no free pelvic fluid. These findings were discussed with the patient. Past Medical History Past OB GYN The patient has regular menses. She has never had a pregnancy. She does have a history of genital warts. The patient has a long history of uterine fibroids endometriosis endometriomas. She is in a monogamous relationship with a female partner. PMH ___ rhinitis Depression Uterine fibroids Endometriosis Endometriomas Pseudocholinesterase deficiency PSH Medial collateral ligament release ___ Abdominal MMY Social History ___ Family History Her mother had hypertension and died of colon cancer. Her father has hypertension and prostate cancer. Physical Exam Discharge Physical Exam AVSS Gen NAD CV RRR P CTAB Abd soft nondistended appropriately tender to palpation incision c d I Ext WWP Pertinent Results ___ 07 25AM WBC 5.9 RBC 4.30 HGB 13.4 HCT 40.5 MCV 94 MCH 31.2 MCHC 33.1 RDW 11.9 RDWSD 41.6 ___ 07 25AM PLT COUNT 268 Brief Hospital Course On ___ Ms. ___ was admitted to the gynecology service after undergoing an exploratory laparotomy lysis of adhesions left ovarian cystectomy abdominal myomectomy for symptomatic fibroid uterus and left ovarian cyst. Please see the operative report for full details. Her post operative course was uncomplicated. Immediately post op her pain was controlled with IV dilaudid and toradol. On post operative day 1 her urine output was adequate so her foley was removed and she voided spontaneously. Her diet was advanced without difficulty and she was transitioned to PO oxycodone Tylenol and ibuprofen pain meds . By post operative day 2 she was tolerating a regular diet voiding spontaneously ambulating independently and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow up scheduled. Medications on Admission Duloxetine 60mg QD Discharge Medications 1. DULoxetine 60 mg PO DAILY 2. Ibuprofen 600 mg PO Q6H PRN pain RX ibuprofen 600 mg 1 tablet s by mouth every six 6 hours Disp 50 Tablet Refills 0 3. OxyCODONE Immediate Release ___ mg PO Q4H PRN severe pain RX oxycodone 5 mg ___ tablet s by mouth every four 4 hours Disp 40 Tablet Refills 0 4. Docusate Sodium 100 mg PO BID RX docusate sodium Colace 100 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 3 Discharge Disposition Home Discharge Diagnosis fibroid uterus ovarian cyst Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office with any questions or concerns. Please follow the instructions below. General instructions Take your medications as prescribed. Do not drive while taking narcotics. Take a stool softener such as colace while taking narcotics to prevent constipation. Do not combine narcotic and sedative medications or alcohol. Do not take more than 4000mg acetaminophen APAP in 24 hrs. No strenuous activity until your post op appointment. No heavy lifting of objects 10 lbs for 6 weeks. You may eat a regular diet. You may walk up and down stairs. Incision care You may shower and allow soapy water to run over incision no scrubbing of incision. No tub baths for 6 weeks. If you have steri strips leave them on. They will fall off on their own or be removed during your followup visit. If you have staples they will be removed at your follow up visit. Call your doctor for fever 100.4F severe abdominal pain difficulty urinating vaginal bleeding requiring 1 pad hr abnormal vaginal discharge redness or drainage from incision nausea vomiting where you are unable to keep down fluids food or your medication To reach medical records to get the records from this hospitalization sent to your doctor at home call ___. Followup Instructions ___ The icd codes present in this text will be D259, E8809, N3289, N8320, N736, Z90721, Z9079, N393, Z975, J309, F329, Z800, Z8042. The descriptions of icd codes D259, E8809, N3289, N8320, N736, Z90721, Z9079, N393, Z975, J309, F329, Z800, Z8042 are D259: Leiomyoma of uterus, unspecified; E8809: Other disorders of plasma-protein metabolism, not elsewhere classified; N3289: Other specified disorders of bladder; N8320: Unspecified ovarian cysts; N736: Female pelvic peritoneal adhesions (postinfective); Z90721: Acquired absence of ovaries, unilateral; Z9079: Acquired absence of other genital organ(s); N393: Stress incontinence (female) (male); Z975: Presence of (intrauterine) contraceptive device; J309: Allergic rhinitis, unspecified; F329: Major depressive disorder, single episode, unspecified; Z800: Family history of malignant neoplasm of digestive organs; Z8042: Family history of malignant neoplasm of prostate. The common codes which frequently come are F329. The uncommon codes mentioned in this dataset are D259, E8809, N3289, N8320, N736, Z90721, Z9079, N393, Z975, J309, Z800, Z8042.
The icd codes present in this text will be J95821, I81, T82868A, K766, I8510, K740, I864, D6959, E785, Y838, K7460, Y92238. The descriptions of icd codes J95821, I81, T82868A, K766, I8510, K740, I864, D6959, E785, Y838, K7460, Y92238 are J95821: Acute postprocedural respiratory failure; I81: Portal vein thrombosis; T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter; K766: Portal hypertension; I8510: Secondary esophageal varices without bleeding; K740: Hepatic fibrosis; I864: Gastric varices; D6959: Other secondary thrombocytopenia; E785: Hyperlipidemia, unspecified; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; K7460: Unspecified cirrhosis of liver; Y92238: Other place in hospital as the place of occurrence of the external cause. The common codes which frequently come are E785. The uncommon codes mentioned in this dataset are J95821, I81, T82868A, K766, I8510, K740, I864, D6959, Y838, K7460, Y92238. Allergies No Known Allergies Adverse Drug Reactions ___ Surgical or Invasive Procedure ___ Redo TIPS ___ Redo TIPS attach Pertinent Results ADMISSION LABS ___ 07 30AM BLOOD WBC 4.2 RBC 4.29 Hgb 12.1 Hct 37.9 MCV 88 MCH 28.2 MCHC 31.9 RDW 14.7 RDWSD 47.1 Plt Ct 63 ___ 07 30AM BLOOD ___ ___ 07 30AM BLOOD Plt Ct 63 ___ 06 11PM BLOOD ___ ___ 07 30AM BLOOD UreaN 21 Creat 1.0 Na 142 K 4.6 Cl 109 HCO3 22 AnGap 11 ___ 07 30AM BLOOD ALT 75 AST 88 AlkPhos 487 TotBili 1.0 ___ 06 11PM BLOOD Albumin 4.0 Calcium 8.7 Phos 2.7 Mg 1.9 DISCHARGE LABS ___ 04 54AM BLOOD WBC 5.1 RBC 3.97 Hgb 11.2 Hct 35.4 MCV 89 MCH 28.2 MCHC 31.6 RDW 14.7 RDWSD 48.1 Plt Ct 71 ___ 12 07PM BLOOD PTT 83.3 ___ 04 54AM BLOOD Plt Ct 71 ___ 03 22PM BLOOD ___ 04 54AM BLOOD Glucose 95 UreaN 24 Creat 1.0 Na 140 K 4.4 Cl 109 HCO3 19 AnGap 12 ___ 04 54AM BLOOD ALT 501 AST 660 LD LDH 696 AlkPhos 428 TotBili 2.7 ___ 04 54AM BLOOD Albumin 3.6 Calcium 8.3 Phos 3.0 Mg 1.9 MICRO n a IMAGING ___ REDO TIPS Successful right internal jugular access with direct transjugular intrahepatic portosystemic shunt revision with extension of the TIPS cranially. New direct TIPS aspiration thrombectomy. Thrombolysis catheter placement through the right IJ sheath for overnight thrombolysis BD PELVIS W W O 1. Interval redo TIPS procedure with persistent thrombus in the TIPS shunt. The new TIPS shunt lies parallel to the superior most aspect of the pre existing stent with its upper portion approximately 1 cm below the cavoatrial junction. The tPA infusion catheter localizes in the lower right atrium with the lowest radiopaque marker overlying the lower cavoatrial junction. 2. There is increased burden of nonocclusive thrombus in the main portal vein. 3. Interval development of trace ascites. 4. Stable cirrhosis with secondary changes representing the sequela of portal hypertension including perisplenic perigastric and periesophageal varices and splenomegaly. ___ REDO TIPS Successful revision of occluded TIPS and thrombosed portal vein with a postprocedural portosystemic gradient of 11 mm Hg. Technically successful coronary variceal embolization and sclerotherapy. Brief Hospital Course ___ male with congenital hepatic fibrosis complicated by portal hypertension and variceal bleeding s p TIPS ___ who presented to the MICU s p TIPS revision with thrombolysis complicated by hypoxia. ACUTE ISSUES Hypoxic respiratory failure Patient developed new oxygen requirement after ___ TIPS revision. Unclear if VTE or atelectasis or just some orthodeoxia but responded to oxygen and remained on room air for the majority of his ICU course. Congenital Hepatic Fibrosis c b portal hypertension and variceal bleeding S p TIPS ___ and revision ___ Pt with congenital hepatic fibrosis c b portal HTN and variceal bleeding. TIPS revision complicated by hypoxia. He had a right IJ sheath with lysis catheter placed. He underwent CTV with persistent thrombus in TIPS shunt. Now s p revision of occuled TIPS and thrombosed portal vein with a postprocedural portosystemic gradient of 11 mm Hg. He also had successful coronary variceal embolization and sclerotherapy. He was placed on a heparin drip post TIPS and transitioned to lovenox on discharge. GIB VARICES EGD ___ which showed scarring at GE junction proximal grade 2 EVs s p esophageal band ligation x4 and large gastric varices. Pt also presented to an outside ED in ___ with acute UGIB variceal bleed. Not able to be banded embolized considered for future procedure. On nadolol at home which was continued while inpatient. ASCITES no history of ascites not on diuretics he was not overloaded on exam. Transminitis Likely due to liver disease and TIPS procedure Thrombocytopenia Likely ___ to liver disease and sequestration CHRONIC ISSUES Hyperlipidemia Continued Pravastatin 40 mg QHS TRANSITIONAL ISSUES please recheck LFTs in 1 week to ensure downtrending check CBC within 1 week as on anticoagulation and patient has bleeding history f u US of TIPS shunt in 1 week continue lovenox for one month follow up with ___ in 1 month CODE STATUS Presumed FULL CONTACT ___ wife ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Nadolol 40 mg PO DAILY 2. Pravastatin 40 mg PO QPM 3. Pantoprazole 40 mg PO Q24H Discharge Medications 1. Enoxaparin Sodium 90 mg SC Q12H 2. Nadolol 40 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Pravastatin 40 mg PO QPM Discharge Disposition Home Discharge Diagnosis PRIMARY DIANGOSIS Hypoxic respiratory failure Congenital Hepatic Fibrosis c b portal hypertension and variceal bleeding TIPS occlusion Portal vein thrombosis occlusion SECONDARY DIAGNOSIS Transaminitis Thrombocytopenia Hyperlipidemia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ WHY WAS I ADMITTED TO THE HOSPITAL You were admitted because you had a blood clot in your TIPS and your oxygen was low. WHAT WAS DONE WHILE I WAS HERE We opened up the vessels TIPS. We started you on a blood thinner. We watched your breathing closely. WHAT SHOULD I DO NOW You should take your medications as instructed. You should go to your doctor s appointments as below. We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be J95821, I81, T82868A, K766, I8510, K740, I864, D6959, E785, Y838, K7460, Y92238. The descriptions of icd codes J95821, I81, T82868A, K766, I8510, K740, I864, D6959, E785, Y838, K7460, Y92238 are J95821: Acute postprocedural respiratory failure; I81: Portal vein thrombosis; T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter; K766: Portal hypertension; I8510: Secondary esophageal varices without bleeding; K740: Hepatic fibrosis; I864: Gastric varices; D6959: Other secondary thrombocytopenia; E785: Hyperlipidemia, unspecified; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; K7460: Unspecified cirrhosis of liver; Y92238: Other place in hospital as the place of occurrence of the external cause. The common codes which frequently come are E785. The uncommon codes mentioned in this dataset are J95821, I81, T82868A, K766, I8510, K740, I864, D6959, Y838, K7460, Y92238.
The icd codes present in this text will be K7460, I81, N179, K766, I8510, K740, D6959, E785, I864. The descriptions of icd codes K7460, I81, N179, K766, I8510, K740, D6959, E785, I864 are K7460: Unspecified cirrhosis of liver; I81: Portal vein thrombosis; N179: Acute kidney failure, unspecified; K766: Portal hypertension; I8510: Secondary esophageal varices without bleeding; K740: Hepatic fibrosis; D6959: Other secondary thrombocytopenia; E785: Hyperlipidemia, unspecified; I864: Gastric varices. The common codes which frequently come are N179, E785. The uncommon codes mentioned in this dataset are K7460, I81, K766, I8510, K740, D6959, I864. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint post TIPS monitoring Major Surgical or Invasive Procedure TIPS ___ History of Present Illness Mr. ___ is a ___ male with congenital hepatic fibrosis complicated by portal hypertension and variceal bleeding who presents to the medicine floor s p TIPS procedure for TIPS monitoring. The patient recently presented to the ED on ___ with severe variceal bleeding requiring blood plasma transfusion as well as endoscopic banding of his esophageal gastric varices. He ultimately elected to undergo a TIPS placement by ___ on ___. Per sign out the TIPS procedure was quite complicated lasting a total of 6 hours. The HVPG was reduced to 10. His esophageal gastric were not embolized though he did receive tPA for his portal vein thrombosis. Past Medical History Congenital hepatic fibrosis Portal hypertension Gastric and esophageal varices s p band ligation Hyperlipidemia Social History ___ Family History non contributory to this admission Physical Exam VS 24 HR Data last updated ___ 1213 Temp 97.9 Tm 98.5 BP 133 78 129 146 75 78 HR 71 71 82 RR 16 ___ O2 sat 98 95 98 O2 delivery RA Wt 203.7 lb 92.4 kg GENERAL well appearing man in no acute distress HEENT anicteric sclera right neck access site bandaged clean. no active bleeding HEART RRR no murmurs rubs gallops LUNGS clear bilaterally ABDOMEN soft mildly distended non tender to palpation but subjective discomfort RUQ dressing c d I without surrounding erythema drainage bleeding EXTREMITIES wwp no edema NEURO A Ox3 moving all 4 extremities with purpose no asterixis. Able to say months of the year backwards. Pertinent Results ___ 06 47AM BLOOD WBC 4.2 RBC 3.93 Hgb 11.0 Hct 33.8 MCV 86 MCH 28.0 MCHC 32.5 RDW 15.2 RDWSD 47.3 Plt Ct 29 ___ 06 47AM BLOOD Glucose 109 UreaN 15 Creat 1.0 Na 141 K 3.8 Cl 104 HCO3 23 AnGap 14 ___ 06 47AM BLOOD ALT 824 AST 556 LD LDH 289 AlkPhos 360 TotBili 1.8 Brief Hospital Course Mr. ___ is a ___ male with congenital hepatic fibrosis complicated by portal hypertension and variceal bleeding who presents to the medicine floor for post TIPS monitoring. Mild ___ post op s p 25gm albumin otherwise uncomplicated course. Surgical wounds stable dressing clean and dry. Patient able to tolerate PO without issue. No evidence of hepatic encephalopathy prior to discharge. No further planned intervention by ___ this hospitalization they will see him in follow up in ___ weeks. TRANSITIONAL ISSUES please obtain repeat LFTs on ___ with results faxed to ___ f ___ consider repeat hepatitis A and B serologies to ensure immunization non immune as of ___ in ___ records consider repeat AFP as last AFP in BID system is from ___ please consider stopping lactulose that was continued on discharge depending on post op course regarding HE ACTIVE ISSUES Congenital Hepatic Fibrosis c b portal hypertension S p TIPS ___ As above patient presented in ___ with variceal bleeding requiring transfusions and banding of his esophageal gastric varices now s p elective TIPS placement on ___ with ___ 10 x 6 and 10 x 8 R TIPS placed . He has no history of HE or ascites. Per ___ team the TIPS procedure was complicated lasting 6 hours. His post TIPS HVPG is between ___ mmHg pre tips HVPG not documented . His varices were not embolized though he did receive tPA for his portal vein thrombosis. Tentatively may need another procedure in the near future. He was discharged on lactulose with instructions to titrate to two BMs daily. Consider stopping this at his follow up appointment. Post op his vitals have remained stable. His neck and abdominal access sites appear to be healing appropriately. His LFTs are up but expected post op changes downtrending by discharge. Telemetry and foley were dc d. Patient has been able to urinate and has had multiple bowel movements with lactulose. His MELD NA post op on ___ was 16. Pain control with acetaminophen hot cold packs. He post op course was uncomplicated except for a mild ___ discussed below which resolved with albumin. Discharge MELD NA 11 Discharge HgB 11 ___ SCR 1.1 1.4 1.0 Most likely related to NPO prior to procedure and prolonged operation. HRS very unlikely has patient has no ascites or hepatic hydrothorax on exam or history of . Urine lytes were unremarkable with UNa 20 which is an appropriate response to pre renal dehydration. UA and sediment unremarkable. Discharge Creatinine 1.0 Thrombocytopenia Plts in the ___ at baseline. Secondary to cirrhosis splenomegaly. SQH was held ___ thrombocytopenia. Patient had no e o bleeding or petichiae during his hospital course. Discharge platelets 29 CHRONIC ISSUES Hyperlipidemia Continued Pravastatin 40 mg QHS Medications on Admission The Preadmission Medication list is accurate and complete. 1. Nadolol 40 mg PO DAILY 2. Pravastatin 40 mg PO QPM Discharge Medications 1. Lactulose 30 mL PO DAILY RX lactulose 10 gram 15 mL 15 mL 30 ml by mouth once a day Disp 1 Bottle Refills 2 2. Nadolol 40 mg PO DAILY 3. Pravastatin 40 mg PO QPM 4.Outpatient Lab Work DX Elevated Liver Enzymes ICD 10 R94.5 Tests AST ALT ALP Total Bili Direct Bili Please fax results to ___ at ___. Discharge Disposition Home Discharge Diagnosis PRIMARY Congenital hepatic fibrosis Portal hypertension Cirrhosis SECONDARY History of esophageal and gastric varices Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ It was a pleasure taking care of you at the ___ ___ WHY WAS I IN THE HOSPITAL You were admitted because you had a TIPS procedure and needed routine monitoring afterwards WHAT HAPPENED IN THE HOSPITAL You had a TIPS procedure performed Post procedure your mental status liver kidney tests and blood counts were monitored You received a medicine to help you have regular bowel movements WHAT SHOULD I DO WHEN I GO HOME Be sure to take all your medications and attend all of your appointments listed below. Take your lactulose enough times daily to have two bowel movements every day. If you notice black or bloody stool or if you are vomiting blood please go to the ER right away Interventional Radiology will call you with an appointment in ___ weeks. Thank you for allowing us to be involved in your care we wish you all the best Your ___ Healthcare Team Followup Instructions ___ The icd codes present in this text will be K7460, I81, N179, K766, I8510, K740, D6959, E785, I864. The descriptions of icd codes K7460, I81, N179, K766, I8510, K740, D6959, E785, I864 are K7460: Unspecified cirrhosis of liver; I81: Portal vein thrombosis; N179: Acute kidney failure, unspecified; K766: Portal hypertension; I8510: Secondary esophageal varices without bleeding; K740: Hepatic fibrosis; D6959: Other secondary thrombocytopenia; E785: Hyperlipidemia, unspecified; I864: Gastric varices. The common codes which frequently come are N179, E785. The uncommon codes mentioned in this dataset are K7460, I81, K766, I8510, K740, D6959, I864.
The icd codes present in this text will be S72001A, E119, J449, I10, W1839XA, Y92009, Z87891, I70209, Z23. The descriptions of icd codes S72001A, E119, J449, I10, W1839XA, Y92009, Z87891, I70209, Z23 are S72001A: Fracture of unspecified part of neck of right femur, initial encounter for closed fracture; E119: Type 2 diabetes mellitus without complications; J449: Chronic obstructive pulmonary disease, unspecified; I10: Essential (primary) hypertension; W1839XA: Other fall on same level, initial encounter; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; Z87891: Personal history of nicotine dependence; I70209: Unspecified atherosclerosis of native arteries of extremities, unspecified extremity; Z23: Encounter for immunization. The common codes which frequently come are E119, J449, I10, Z87891. The uncommon codes mentioned in this dataset are S72001A, W1839XA, Y92009, I70209, Z23. Allergies morphine Demerol Chief Complaint Right femoral neck fracture Major Surgical or Invasive Procedure Closed reduction internal fixation with cannulated screws of Right femoral neck fracture History of Present Illness ___ M presents with right femoral neck fracture s p mechanical fall. He fell on his right side earlier this morning with immediate right hip pain and inability to ambulate. He denies pain elsewhere. He ambulates without assistance at baseline but reports he does not walk as much as he used to due to antecedent bilateral hip pain. He is fairly active and enjoys fishing regularly. Past Medical History PMH PSH DM HTN COPD Claudication Carotid stenosis S p L carotid endarterectomy ___ Social History ___ Family History Father CAD PVD Diabetes Type II Mother chf OTHER Sister ___ Physical ___ Right lower extremity Skin intact Fires ___ SILT S S SP DP T distributions 1 ___ pulses WWP Brief Hospital Course The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have right femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for closed reduction and cannulated screw fixation which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications and progressed to a regular diet and oral medications by POD 1. The patient was given ___ antibiotics and anticoagulation per routine. The patient s home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient s pain was well controlled with oral medications incisions were clean dry intact and the patient was voiding moving bowels spontaneously. The patient is NVI distally in the right extremity and will be discharged on lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow up care. The patient expressed readiness for discharge. Discharge Medications 1. Acetaminophen 650 mg PO Q6H 2. Calcium Carbonate 500 mg PO QID PRN indigestion 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QPM Duration 4 Weeks Start Today ___ First Dose Next Routine Administration Time RX enoxaparin 40 mg 0.4 mL 40 mg SC QPM Disp 28 Syringe Refills 0 5. Lisinopril 2.5 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. OxycoDONE Immediate Release 2.5 5 mg PO Q4H PRN pain RX oxycodone 5 mg ___ tablet s by mouth Q4H PRN Disp 60 Tablet Refills 0 8. Senna 8.6 mg PO BID Discharge Disposition Extended Care Facility ___ ___ Diagnosis Right femoral neck fracture Discharge Condition AOX3 OOB with assistance of ___ overall stable Discharge Instructions INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY You were in the hospital for orthopedic surgery. It is normal to feel tired or washed out after surgery and this feeling should improve over the first few days to week. Resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING Touchdown weight bearing RLE MEDICATIONS Please take all medications as prescribed by your physicians at discharge. Continue all home medications unless specifically instructed to stop by your surgeon. Do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers. Narcotic pain relievers can cause constipation so you should drink eight 8oz glasses of water daily and take a stool softener colace to prevent this side effect. ANTICOAGULATION Please take Lovenox 40mg daily for 4 weeks WOUND CARE You may shower. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed will be taken out at your 2 week follow up appointment. No dressing is needed if wound continues to be non draining. Physical Therapy Activity Activity Out of bed w assist Right lower extremity Touchdown weight bearing Left lower extremity Full weight bearing Encourage turning deep breathing and coughing qhour when awake. Treatments Frequency DSD as needed. Sutures staples removed at clinic. Elevation as tolerated. Followup Instructions ___ The icd codes present in this text will be S72001A, E119, J449, I10, W1839XA, Y92009, Z87891, I70209, Z23. The descriptions of icd codes S72001A, E119, J449, I10, W1839XA, Y92009, Z87891, I70209, Z23 are S72001A: Fracture of unspecified part of neck of right femur, initial encounter for closed fracture; E119: Type 2 diabetes mellitus without complications; J449: Chronic obstructive pulmonary disease, unspecified; I10: Essential (primary) hypertension; W1839XA: Other fall on same level, initial encounter; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; Z87891: Personal history of nicotine dependence; I70209: Unspecified atherosclerosis of native arteries of extremities, unspecified extremity; Z23: Encounter for immunization. The common codes which frequently come are E119, J449, I10, Z87891. The uncommon codes mentioned in this dataset are S72001A, W1839XA, Y92009, I70209, Z23.
The icd codes present in this text will be S82851A, W108XXA, Y92009. The descriptions of icd codes S82851A, W108XXA, Y92009 are S82851A: Displaced trimalleolar fracture of right lower leg, initial encounter for closed fracture; W108XXA: Fall (on) (from) other stairs and steps, initial encounter; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause. The uncommon codes mentioned in this dataset are S82851A, W108XXA, Y92009. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint right ankle fracture dislocation Major Surgical or Invasive Procedure right ankle surgical fixation History of Present Illness ___ healthy female who sustained a right ankle injury following a mechanical slip and fall down stairs. She states she was packing to fly home tomorrow morning when she was going to load up her suitcase down stairs slipped on the last step twisting and injuring her ankle. Denied head strike or loss of consciousness. She is not currently on anticoagulation. She denies any numbness or paresthesias in the right foot. She denies any previous injury to the right ankle. Notably she is currently in town visiting her son. She lives in ___ currently. She is here with her husband and son. Past Medical History none Social History ___ Family History noncontributory Physical Exam Right lower exam splint c d I grossly moves exposed toes silt in exposed toes toes WWP Brief Hospital Course The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right ankle fracture dislocation and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction internal fixation of right ankle fracture which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications and progressed to a regular diet and oral medications by POD 1. The patient was given ___ antibiotics and anticoagulation per routine. The patient s home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient s pain was well controlled with oral medications incisions were clean dry intact and the patient was voiding moving bowels spontaneously. The patient is nonweightbearing in the right lower extremity in a splint and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. Alternatively since she is from ___ she may choose to follow up with an orthopedic provider ___. She was instructed to follow up in 2 weeks. A thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow up care. The patient expressed readiness for discharge. Medications on Admission none Discharge Medications 1. Acetaminophen 1000 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC QHS RX enoxaparin 40 mg 0.4 mL t bedtime Disp 28 Syringe Refills 0 4. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain don t drink or drive while taking RX oxycodone 5 mg ___ tablet s by mouth every four 4 hours PRN Disp 30 Tablet Refills 0 5. Senna 8.6 mg PO BID Discharge Disposition Home Discharge Diagnosis right ankle fracture Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Discharge Instructions INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY You were in the hospital for orthopedic surgery. It is normal to feel tired or washed out after surgery and this feeling should improve over the first few days to week. Resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING Nonweightbearing right lower extremity in splint MEDICATIONS 1 Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2 Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down Take 1 tablet every 3 hours as needed x 1 day then 1 tablet every 4 hours as needed x 1 day then 1 tablet every 6 hours as needed x 1 day then 1 tablet every 8 hours as needed x 2 days then 1 tablet every 12 hours as needed x 1 day then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3 Do not stop the Tylenol until you are off of the narcotic medication. 4 Per state regulations we are limited in the amount of narcotics we can prescribe. If you require more you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5 Narcotic pain relievers can cause constipation so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds senna colace miralax are over the counter and may be obtained at any pharmacy. 6 Do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers. 7 Please take all medications as prescribed by your physicians at discharge. 8 Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION Please take Lovenox daily for 4 weeks WOUND CARE You may shower. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed will be taken out at your 2 week follow up appointment. Incision may be left open to air unless actively draining. If draining you may apply a gauze dressing secured with paper tape. If you have a splint in place splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. DANGER SIGNS Please call your PCP or surgeon s office and or return to the emergency department if you experience any of the following Increasing pain that is not controlled with pain medications Increasing redness swelling drainage or other concerning changes in your incision Persistent or increasing numbness tingling or loss of sensation Fever ___ 101.4 Shaking chills Chest pain Shortness of breath Nausea or vomiting with an inability to keep food liquid medications down Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Followup Instructions ___ The icd codes present in this text will be S82851A, W108XXA, Y92009. The descriptions of icd codes S82851A, W108XXA, Y92009 are S82851A: Displaced trimalleolar fracture of right lower leg, initial encounter for closed fracture; W108XXA: Fall (on) (from) other stairs and steps, initial encounter; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause. The uncommon codes mentioned in this dataset are S82851A, W108XXA, Y92009.
The icd codes present in this text will be K920, N179, F1010, I10, F17200, E8352, E876, E8342, K7030, D6959. The descriptions of icd codes K920, N179, F1010, I10, F17200, E8352, E876, E8342, K7030, D6959 are K920: Hematemesis; N179: Acute kidney failure, unspecified; F1010: Alcohol abuse, uncomplicated; I10: Essential (primary) hypertension; F17200: Nicotine dependence, unspecified, uncomplicated; E8352: Hypercalcemia; E876: Hypokalemia; E8342: Hypomagnesemia; K7030: Alcoholic cirrhosis of liver without ascites; D6959: Other secondary thrombocytopenia. The common codes which frequently come are N179, I10. The uncommon codes mentioned in this dataset are K920, F1010, F17200, E8352, E876, E8342, K7030, D6959. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Nausea Vomiting Major Surgical or Invasive Procedure None History of Present Illness ___ male history of cervical fusion in ___ ETOH abuse and HTN presenting with nausea hematemesis coffee ground emesis and melena. He was in his usual state of health consuming ___ shot glasses per night of ETOH last night however ___ shots and also using NSAIDS 1600 mg day and Tylenol ___ mg day for his neck pain after the surgery. On ___ he began having intermittent abdominal discomfort with food intake. He also had nausea and vomiting with hematemesis on day prior to presentation and 2 episodes of coffee ground emesis on day of presentation. He reports lightheadedness with standing. In the ED noted to have a dark tarry BM with subsequent dizziness. He reports no chest pain shortness of breath abdominal pain diarrhea. In ED vital signs were notable for tachycardia 110s 120s BP 130s 70s 80s satting well on RA. Labs are notable for Hgb 12.9 which is above his baseline of ___. He had elevated transaminases to 169 257 elevated from prior with normal AP Tbili and lipase. He has ___ with Cr of 1.2 from baseline of 0.5 and BUN of 29. Chemistry notable for K 5.0 Cl 82 and anion gap of 26. INR was 1.2. GI was consulted and recommended IV PPI NPO transfusion goal of ___ anti emetic and potential EGD. He was given NS pantoprazole ondansetron and morphine. On arrival to the floor patient reports severe pain in his neck at the site of his recent surgery. Otherwise feels well without complaints. REVIEW OF SYSTEMS 10 point ROS reviewed and negative except as per HPI Past Medical History ETOH abuse HTN S p posterior cervical decompression and fusion ___ C. diff Social History ___ Family History No family history of liver disease Physical Exam ADMISSION PHYSICAL VS 97.7 PO 177 92L Lying ___ Ra GENERAL NAD HEENT anicteric sclera pink conjunctiva MMM NECK supple no LAD no JVD HEART tachycardia S1 S2 no murmurs gallops or rubs LUNGS CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles ABDOMEN nondistended nontender in all quadrants no rebound guarding no hepatosplenomegaly on exam EXTREMITIES no cyanosis clubbing or edema PULSES 2 DP pulses bilaterally NEURO A Ox3 moving all 4 extremities with purpose SKIN warm and well perfused no excoriations or lesions no rashes DISCHARGE PHYSICAL ___ 0720 Temp 98.3 PO BP 107 56 R Lying HR 67 RR 16 O2 sat 97 O2 delivery Ra GENERAL NAD HEENT anicteric sclera pink conjunctiva MMM HEART normal S1 S2 no murmurs gallops or rubs LUNGS CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles ABDOMEN nondistended nontender in all quadrants no rebound guarding no hepatosplenomegaly on exam EXTREMITIES no cyanosis clubbing or edema PULSES 2 DP pulses bilaterally NEURO A Ox3 moving all 4 extremities with purpose SKIN warm and well perfused no excoriations or lesions no rashes Pertinent Results ADMISSION LABS ___ 04 00PM BLOOD WBC 8.4 RBC 4.51 Hgb 12.9 Hct 38.4 MCV 85 MCH 28.6 MCHC 33.6 RDW 16.7 RDWSD 48.5 Plt ___ ___ 04 00PM BLOOD Neuts 85.4 Lymphs 7.9 Monos 5.4 Eos 0.5 Baso 0.4 Im ___ AbsNeut 7.15 AbsLymp 0.66 AbsMono 0.45 AbsEos 0.04 AbsBaso 0.03 ___ 04 11PM BLOOD ___ PTT 27.5 ___ ___ 04 00PM BLOOD Glucose 109 UreaN 29 Creat 1.2 Na 138 K 5.0 Cl 82 HCO3 30 AnGap 26 ___ 04 00PM BLOOD ALT 169 AST 257 AlkPhos 112 TotBili 0.6 ___ 04 00PM BLOOD Lipase 30 ___ 04 00PM BLOOD Albumin 4.8 Calcium 11.2 Phos 4.1 Mg 1.6 ___ 09 48PM URINE Hours RANDOM Creat 200 Na 81 PERTINENT LABS ___ 08 57AM BLOOD HBsAg NEG HBsAb NEG HBcAb NEG ___ 08 57AM BLOOD HCV Ab NEG ___ 01 52PM STOOL HELICOBACTER ANTIGEN DETECTION STOOL PND MICRO None STUDIES US Liver ___. Echogenic liver consistent with steatosis. Mildly nodular suggests cirrhosis. 2. No cholelithiasis evidence of cholecystitis or biliary dilation. 3. Patent portal vein. DISCHARGE LABS ___ 04 47AM BLOOD WBC 3.7 RBC 2.81 Hgb 8.2 Hct 25.3 MCV 90 MCH 29.2 MCHC 32.4 RDW 15.6 RDWSD 51.0 Plt Ct 96 ___ 04 47AM BLOOD Glucose 82 UreaN 10 Creat 0.8 Na 141 K 3.7 Cl 99 HCO3 29 AnGap 13 ___ 04 47AM BLOOD Calcium 8.5 Phos 2.5 Mg 2.___ male history of cervical fusion in ___ ETOH abuse and HTN presenting with hematemesis and coffee ground emesis as well melena concerning for UGIB likely ___ alcoholic gastritis vs. esophagitis vs ___ tear. UGIB Patient presented after having two episodes of hematemesis coffee ground emesis and then proceeded to have large melena in ED. Hgb at presentation was 12.9 but subsequently dropped to 9.5 and then 8.9 in the setting of getting 2L IVF. Possible etiologies include ___ Tear esophagitis alcoholic gastritis and NSAID use. Patient was planned to undergo EGD on ___ but unfortunately given spinal fusion anesthesia felt that it would be safest to perform procedure in the OR. Patient was hemodynamically stable for 48 hours since admission and had no major changes in his hemoglobin. Multiple conversations were had with the patient and the inpatient GI team about our preference of having him stay and undergo EGD in the OR given possible evidence of cirrhotic changes on liver US. Patient preferred to leave due to multiple life stressors outside of the hospital including significant work issues with his boss and the patient s presentation was thought to be less concerning for acute variceal bleed. This plan was discussed with GI consultants. Patient was educated about danger signs that should prompt an immediate return to the ED and otherwise was encouraged to attend his scheduled follow up liver clinic where the EGD could be setup as an outpatient. ___ Cr was elevated to 1.2 at presentation from baseline 0.5. Likely pre renal in setting of ongoing nausea limiting PO intake and vomiting. Patient received 2L IVF and Cr downtrended. Cirrhosis Transaminitis Patient s liver enzymes were elevated on admission AST ALT 100s 200s. Baseline abnormal likely due to ongoing alcohol use vs. fatty liver disease. He was also found to be leukopenic and thrombocytopenic. No stigmata of chronic liver disease on exam. RUQ U S demonstrated stigmata of cirrhosis. Hepatitis serologies HBV HCV were obtained and were all negative. Patient was started on hepatitis B vaccination series and received the first immunization on ___. Alcohol abuse Patient formerly frank ten shots a night every night and drank continuously on weekends. He has since cut down and now drinks ___ shots ___ nights a week. No history of withdrawal seizures though did require phenobarb during prior admission. At his reduced level of drinking he did not have withdrawal on this admission. ___ w EtOH abuse admitted w hematemesis and melena. Imaging and labs c w a new diagnosis of cirrhosis. The patient was advised that even though he has cut down his drinking his liver is now much more fragile than before and even small amounts of alcohol can cause further damage. He was educated on the life threatening complications of cirrhosis and how he may not have any symptoms until it has become too late to undo the damage. He verbalized understanding of this but does not feel quite ready to quit drinking. He was educated about naltrexone and other resources and agrees to readdress sobriety at his follow up visit. H o cervical fusion in ___ Pain was controlled with Tylenol tizanadine gabapentin and oxycodone PRN. TRANSITIONAL ISSUES EGD Prompt outpatient EGD is recommended to clarify the cause of bleeding. Even if he has no further bleeding the patient still needs to complete an EGD to screen for esophageal varices. Pending Labs f u h pylori stool antigen Hepatology Close followup in liver clinic given new diagnosis of cirrhosis ___ Screening Patient will require q6 month ___ screening with abdominal ultrasound Hepatitis B non immune Patient was found to be hepatitis B non immune received first vaccine on ___ followup with course per recommended schedule PPI Discharged on PPI BID which should be continued until patient has GI follow up at ___ NO NSAIDS. Continue discussion regarding alcohol cessation. He is potentially interested in naltrexone. CODE Full presumed CONTACT ___ ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H 2. Gabapentin 300 mg PO Q8H 3. Tizanidine 4 mg PO TID PRN neck pain 4. Ibuprofen 400 mg PO Q6H Discharge Medications 1. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 2. Gabapentin 300 mg PO Q8H 3. Multivitamins W minerals 1 TAB PO DAILY RX multivitamin tx minerals Vitamins and Minerals 1 tablet s by mouth daily Disp 30 Tablet Refills 0 4. Omeprazole 40 mg PO BID RX omeprazole 40 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 0 5. Thiamine 200 mg PO DAILY RX thiamine HCl vitamin B1 100 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 6. Tizanidine 4 mg PO TID PRN neck pain 7. HELD Acetaminophen 1000 mg PO Q6H This medication was held. Do not restart Acetaminophen until you really need it and this should be no more than 2 grams per day Discharge Disposition Home Discharge Diagnosis Primary Diagnoses Upper GI bleed Alcoholic cirrhosis ___ Secondary Diagnoses Alcohol abuse Nicotine dependence Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ It was a pleasure taking care of you in the hospital. WHY WERE YOU ADMITTED You were having bloody vomit and dark stools which concerned us that you were having a bleed from somewhere in your esophagus stomach or intestines. WHAT HAPPENED IN THE HOSPITAL We gave you fluids We took lab tests to see if you were bleeding quickly We had the GI doctors ___ by and ___ you and they recommended that you get a procedure in which we look with a camera into your stomach. However because of your neck surgeries this would have to be done in the operating room. You decided that you did not want to wait and have this done so you were discharged with strict instructions to return if you start feeling ANY symptoms or experienced ANY bleeding You had imaging that suggested that you had cirrhosis in your liver. This needs follow up and further work up and it will be extremely important for you to follow up with a liver specialist. Importantly you should NOT take any further ibuprofen advil naproxen aleve. You should STOP drinking and consider a detoxification center. WHAT SHOULD I DO AFTER LEAVING Please take all of your medications as prescribed including a new medication 1. Pantoprazole 40mg twice daily Please follow up with your primary care doctor within the next ___ weeks to have a repeat blood draw. Please return to the hospital if you develop the following signs 1. More bloody or dark vomiting 2. More black tarry stools 3. New lightheadedness or shortness of breath Thank you for allowing us to participate in your care. Your ___ Team Followup Instructions ___ The icd codes present in this text will be K920, N179, F1010, I10, F17200, E8352, E876, E8342, K7030, D6959. The descriptions of icd codes K920, N179, F1010, I10, F17200, E8352, E876, E8342, K7030, D6959 are K920: Hematemesis; N179: Acute kidney failure, unspecified; F1010: Alcohol abuse, uncomplicated; I10: Essential (primary) hypertension; F17200: Nicotine dependence, unspecified, uncomplicated; E8352: Hypercalcemia; E876: Hypokalemia; E8342: Hypomagnesemia; K7030: Alcoholic cirrhosis of liver without ascites; D6959: Other secondary thrombocytopenia. The common codes which frequently come are N179, I10. The uncommon codes mentioned in this dataset are K920, F1010, F17200, E8352, E876, E8342, K7030, D6959.
The icd codes present in this text will be S12390A, J9690, S27321A, S14109A, S2220XA, F10121, A0472, G960, S22020A, S12490A, S12590A, S12690A, S93409A, W109XXA, Y9289, S0101XA, F17210, F1290, D649, M5382. The descriptions of icd codes S12390A, J9690, S27321A, S14109A, S2220XA, F10121, A0472, G960, S22020A, S12490A, S12590A, S12690A, S93409A, W109XXA, Y9289, S0101XA, F17210, F1290, D649, M5382 are S12390A: Other displaced fracture of fourth cervical vertebra, initial encounter for closed fracture; J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia; S27321A: Contusion of lung, unilateral, initial encounter; S14109A: Unspecified injury at unspecified level of cervical spinal cord, initial encounter; S2220XA: Unspecified fracture of sternum, initial encounter for closed fracture; F10121: Alcohol abuse with intoxication delirium; A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent; G960: Cerebrospinal fluid leak; S22020A: Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture; S12490A: Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture; S12590A: Other displaced fracture of sixth cervical vertebra, initial encounter for closed fracture; S12690A: Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture; S93409A: Sprain of unspecified ligament of unspecified ankle, initial encounter; W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter; Y9289: Other specified places as the place of occurrence of the external cause; S0101XA: Laceration without foreign body of scalp, initial encounter; F17210: Nicotine dependence, cigarettes, uncomplicated; F1290: Cannabis use, unspecified, uncomplicated; D649: Anemia, unspecified; M5382: Other specified dorsopathies, cervical region. The common codes which frequently come are F17210, D649. The uncommon codes mentioned in this dataset are S12390A, J9690, S27321A, S14109A, S2220XA, F10121, A0472, G960, S22020A, S12490A, S12590A, S12690A, S93409A, W109XXA, Y9289, S0101XA, F1290, M5382. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint neck fracture Major Surgical or Invasive Procedure ___ C5 6 corpectomy C4 C7 ACDF ___ C2 T2 posterior cervical fusion C4 6 cervical laminectomy History of Present Illness ___ year old male who presents s p intoxicated fall from ___ story balcony. He denies LOC but sustained a laceration to his face. He complaining of neck chest and right shoulder pain. CT of the cervical spine demonstrated comminuted C5 C7 fractures T2 superior endplate fracture. He also sustained a sternal fracture. He denies numbness tingling weakness or loss of bowel or bladder function. Past Medical History ETOH abuse Social History ___ Family History NC Physical Exam PHYSICAL EXAMINATION General laceration abrasions to face Alert and interacting but appears intoxicated nl resp effort RRR Sensory UE C5 C6 C7 C8 T1 lat arm thumb mid fing sm finger med arm R SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT T2 L1 Trunk SILT ___ L2 L3 L4 L5 S1 S2 Groin Knee Med Calf Grt Toe Sm Toe Post Thigh R SILT SILT SILT SILT SILT SILT L SILT SILT SILT SILT SILT SILT Motor UE Dlt C5 Bic C6 WE C6 Tri C7 WF C7 FF C8 FinAbd T1 R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 ___ Flex L1 Add L2 Quad L3 TA L4 ___ ___ R 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 Reflexes Bic C4 5 BR C5 6 Tri C6 7 Pat L3 4 Ach L5 S1 R 2 2 2 2 2 L 2 2 2 2 2 ___ Negative Babinski Downgoing Clonus No beats Postop gen awake pleasant Dressings with staining skin warm and dry incision are intact ___ normal breathing abd soft nt extr no c c e Neurologic Motor Strength Delt Bi Tri BR WF WE HI Right 5 5 5 5 5 5 Left 4 4 4 4 4 4 IP Quad Ham TA Gas ___ Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation dyesthesia bilateral C7 C8 distribution Pertinent Results Trauma Pelvis XR ___ IMPRESSION 1. No acute cardiopulmonary process. No obvious rib fractures. 2. No fracture or dislocation involving the ___ hips and partially imaged femurs. ___ C A P CT IMPRESSION 1. Comminuted and displaced sternal fracture with surrounding hematoma and underlying pulmonary contusion in the right middle lobe. 2. Subtle focal irregularity of the superior T12 vertebral body with subtle superior endplate depression suspicious for T12 compression fracture. 3. No additional acute fracture is identified. 4. Small amount of hyperdense material between the right kidney and psoas muscle most likely representing hematoma without active extravasation. Adjacent ureter appears patent but with short segment luminal narrowing. Close follow up is recommended. 5. No additional traumatic organ injury in the chest abdomen or pelvis. Ct c spine ___ 1. Multiple mildly displaced comminuted fractures through the C5 C6 and C7 vertebral bodies as described above with traumatic kyphotic angulation at C5 C6 and extension into the spinal canal with fractures involving the C4 C5 C6 spinous processes lamina and multiple levels and right C5 C6 facet joint and possibly right C6 C7 facet joint. Additional acute anterosuperior endplate fracture of T2 is also noted. 2. Extensive prevertebral edema from C2 C3 through T1 T2. CT head ___ 1. Large scalp hematoma over the vertex with skin laceration. No underlying calvarial fracture. No evidence of acute intracranial hemorrhage. CT Head angiogram ___ 1. Patent intracranial and cervical vasculature without high grade stenosis occlusion or dissection. 2. Numerous known comminuted fractures involving the mid to lower cervical spine are better delineated on the separately reported CT cervical spine examination. 3. For description of the intracranial parenchymal findings please see the separate CT head examination performed earlier on the same day. Cervical spine MRI ___ . Redemonstrated acute to subacute compression deformities of the C5 C6 and C7 vertebral bodies with associated unchanged traumatic kyphotic deformity at C5 C6. There is also evidence of acute to subacute compression deformities of the superior endplates of the T2 and T3 vertebral bodies with minimal loss of vertebral body height. 2. Redemonstrated multilevel mildly displaced cervical spine fractures extending from C4 through C7 better described on the recent CT cervical spine study. 3. Evidence of increased interspinous interval and ligamentum flavum disruption at C4 C5 with findings suspicious for CSF leak at this level. 4. Extensive edema of the posterior paraspinal musculature extending from C2 through T1. 5. Unchanged traumatic kyphotic angulation at C5 C6. 6. Moderate prevertebral edema is likely trauma related. 7. Degenerative changes of the cervical spine most significant at C5 C6 where superimposed traumatic kyphotic deformity results in mild spinal canal narrowing and flattening of the ventral cord without evidence of abnormal cord signal. pCXR ___ In comparison with the study of ___ the bilateral layering pleural effusions are no longer seen. However this appearance could merely reflect a more upright position of the patient. No pneumonia vascular congestion or other abnormality. Cervical fusion device is again seen. Brief Hospital Course Patient was admitted to Orthopedic Spine Service on ___ in the trauma ICU for further management. He underwent the above stated procedure on ___ and ___. Patient tolerated the procedures well without complication. Please review dictated operative report for details. Patient remained intubated postoperative for respiratory failure and delirium tremens. He was started on folate thiamine IV and phenobarb for agitation and DTs. His neuro exam was monitored closely. His ICU course is as follows ___ paresthesias in bilateral thumbs consented to remain intubated x2d for procedures if needed to OR for ACDF EBL 2.2L ___ 2u pRBC 4u FFP remained intubated easy with ___ lactate downtrending. plan for OR likely ___. started phenobarb load postop. BPs with MAPS in ___ UOP trending down gave albumin bolus expect Hct to continue slow downtrend for now but holding off on blood. ___ Neuro exam improved only mild numbness in left ___ digit. Hct stable 23.7 24. Sedation increased and phenobarb rescue dosed for agitation tremors. Hypercarbic on ASV with increased sedation. Switched to CMV but hypoxic with paO2 75 PEEP increased to 8. CXR without congestion or consolidation. TTE LVEF 74 . Grade I mild left ventricular diastolic dysfunction. ___ pt intermittently agitated will write midaz PRN pt to go to the OR today for posterior fusion EBL 3.5 L 6U PRBC 2U Plts 1U FFP post op Hct 28 pt HDS and has to be flat for CSF leak. Pt anemic preop got 1UPRBC. ankle XR showed ankle sprain can immobilize if uncomfortable consult ortho. ___ Og tube replaced. stays flat for 24h until ___ on ___. wean propofol add precedex. repeat CBC is 8.8 26.4. per spine SQH restarted. concern for CSF leak on the blanket ortho spine consulted discussed with ___. will monitor. does not think it is csf leak. ___ Pt extubated in the AM doing well from resp standpoint good O2 sat on RA. NGT out A line out gas BM Still agitated on precedex being weaned off. HLIV foley still in Neurochecks Q4H lactulose added to bowel regimen worked with ___ recommending rehab ___ pt continues on dex intermittently was interactive and appropriate with friend today. will continue to monitor for agitation ___ febrile with leukocytosis. plan is for fever workup with Cdiff UA Blood culture CXR. gabapentin TID. speech and swallow consult. plan to transfer to spine no longer has ICU needs. He was transferred to floor in stable condition on ___. During the patient s course ___ were used for postoperative DVT prophylaxis. Diet was advanced as tolerated. Foley was removed in routine fashion and patient voided without incident. Hemovac was removed in routine fashion once the output per 8 hours became minimal. He was complicated by diarrhea on ___ and CDIFF was sent. On ___ patient for CDIFF and was started on flagyl po for 10 days. His diarrhea improved as of ___. Neurologically he had dysesthesia and numbness. He had LUE weakness secondary to spinal cord injury and jumped facet. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL s. Now Day of Discharge patient is afebrile VSS and neuro stable s p SCI. He had LUE weakness and bilateral ulnar weaknessPatient tolerated a good oral diet and pain was controlled on oral pain medications. Patient ambulated without issues. Patient s wound is clean dry and intact. Patient is set for discharge to home in stable condition. Medications on Admission none Discharge Medications 1. Acetaminophen 1000 mg PO Q6H RX acetaminophen 650 mg ___ tablet s by mouth every eight 8 hours Disp 120 Tablet Refills 0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 0 3. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 4. Gabapentin 300 mg PO Q8H RX gabapentin 300 mg 1 capsule s by mouth every eight 8 hours Disp 90 Capsule Refills 1 5. MetroNIDAZOLE 500 mg PO Q8H Duration 7 Days RX metronidazole Flagyl 500 mg 1 tablet s by mouth three times a day Disp 21 Tablet Refills 0 6. OxycoDONE Liquid 5 mg PO Q3H PRN Pain Moderate RX oxycodone 5 mg 1 tab by mouth Q4 6h Disp 40 Tablet Refills 0 7. Thiamine 100 mg PO DAILY RX thiamine HCl vitamin B1 100 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 Discharge Disposition Home Discharge Diagnosis c5 fx C6 fx jumped facet fx CSF leak Delirium Tremens D diff colitis spinal cord injury respiratory failure alcohol abuse respiratory failure Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent with Hard collar on at all times Discharge Instructions ACDF You have undergone the following operation Anterior Cervical Decompression and Fusion. 1.When you are discharged from the hospital and settled at home rehab if you do not have an appointment please call to schedule two appointments 1.a wound check visit for 8 14 days after surgery 2.a post operative visit with your surgeon for ___ weeks after surgery. 1.You can reach the office at ___ and ask to speak with staff to schedule or confirm your appointments. Wound Care If not already done in the hospital remove the incision dressing on day 2 after surgery. Keep the incision dry for the first two days after surgery. There will often be small white strips of tape over the incision steri strips . These should be left alone and may get wet in the shower on day 3. Starting on the third day you should be washing your incision DAILY. While holding the head and neck still gently clean the incision and surrounding area with mild soap and water rinse and then pat dry. Do not put any lotion ointments alcohol or peroxide on the incision. If you have a multi level fusion and require a hard cervical collar this may be removed for showering and often sleeping and eating. The collar will typically be removed at the week 4 visit. You may remove the compression stockings when you leave the hospital Have someone look at the incision daily for 2 weeks. Call the surgeon s office if you notice any of the following ___ redness along the length of the incision ___ swelling of the area around your incision ___ from the incision ___ of your extremities greater than before surgery ___ of bowel or bladder control ___ of severe headache ___ swelling or calf tenderness ___ above 101.5 At your wound check visit the Nurse Practitioner or ___ ___ will check your wound and remove any sutures or staples or steri strips. Do not soak or immerse your incision in water for 1 month. For example no tub baths swimming pools or jacuzzi. Medications You will be given prescriptions for pain medications and stool softeners upon discharge from the hospital. Pain medications should be taken as prescribed by your surgeon or nurse practitioner physician ___. You are allowed to gradually reduce the number of pills you take when the pain begins to subside. If you are taking more than the recommended dose please contact the office to discuss this with a practitioner ___ medication may need to be increased or changed . Constipation Pain medications narcotics may cause constipation difficulty having a bowel movement . It is important to be aware of your bowel habits so you ___ develop severe constipation. Call the office if this occurs for more than 3 days or if you have stomach pain. Most prescription pain medications cannot be called into the pharmacy for renewal. The following are 2 options you may explore to obtain a renewal of your narcotic medications 1.Call the office ___ days before your prescription runs out and speak with our office staff about mailing a prescription to your home pharmacy. Prescriptions will not be sent by Fed Ex UPS 2.Call the office 24 hours in advance and speak with office staff about coming into the office to pick up a prescription. If you continue to require medications you may be referred to a pain management specialist or your medical doctor for ongoing management of your pain medications. Avoid NSAIDS for 12 weeks post operative. These medications include but are not limited to the following Non Steroidal Anti Inflammatory Agents Advil Aleve Cataflam Clinoril Diclofenac Dolobid Feldene Ibuprofen Indocin Medipren Motrin Nalfon Naprosyn Nuprin Relafen Rufen Tolectin Toradol Trilisate Voltarin Activity Guidelines If you have a multi level cervical fusion you will be asked to wear a hard cervical collar. This is typically removed at week 4 after surgery. You may not drive while wearing the collar. You may remove your cervical collar for eating sleeping and when showering. Avoid strenuous activity bending pushing or reaching overhead. For example you should not vacuum do large loads of laundry walk the dog wash the car etc. until your follow up visit with your surgeon. Avoid heavy lifting. Do not lift anything over ___ pounds for the first few weeks that you are home from the hospital. Increase your activities a little each day. Walking is a form of exercise. Exercise should not cause pain. Limit yourself to things that you can do comfortably and plan rest periods throughout the day. You are not unless you are not taking narcotic medication and are not required to wear a collar. You may ride in a car for short distances and avoid sitting in one position for too long. You may resume sexual activity ___ weeks after surgery avoiding stress on the neck and shoulders. Physical Therapy Outpatient Physical Therapy if appropriate will not begin until after your post operative visit with your surgeon. A prescription is needed for formal outpatient therapy. You may be given simple stretching exercises or a prescription for formal outpatient physical therapy based on what your needs are after surgery. Blood Clots in the Leg 1.It is not uncommon for patients who recently had surgery to develop blood clots in leg veins. Symptoms include low grade fever and or redness swelling tenderness and or an aching cramping pain in your calf. You should call your doctor immediately if you have these symptoms. To prevent blood clots in legs try walking and or pumping ankles several times during the day. If the blood clot breaks free from the leg vein it can travel to the lungs and cause severe breathing difficulty and or chest pain. If you experience this call ___ immediately. Questions Any questions may be directed to your surgeon or nurse practitioner physician ___. 1.During normal business hours 8 30am 5 00pm you can call our office directly at ___. If no one picks up please leave a message and someone will get back to you. If you are calling with an urgent medical issue please go to nearest emergency room i.e. pain unrelieved with medications wound breakdown infection or new neurological symptoms . Rigid Collar Instructions How to put collar on ___ collar is labeled front and back with arrows indicating top and bottom. ___ the back section on your neck first. Apply the front section placing your chin in the chin rest. ___ securing the Velcro make sure the front overlaps the back section. This allows more Velcro to be exposed giving the collar a more secure fit. ___ the collar as tight as you can while remaining comfortable. The tighter it is worn the more immobilization of your spine is obtained and the less likely you will move your neck. Care for during use ___ alert to pressures under your chin. Some pressure is necessary but do not allow a blister or pressure sore to develop. ___ provide comfort you should wear the collar liners provided between the brace and your chin to absorb perspiration and lessen irritation. We recommend that these liners be hand washed. ___ collar can be washed with mild soap and water then dried with a towel and or hair dryer on the lowest setting. Hand washing is recommended. Posterior Cervical Fusion You have undergone the following operation Posterior Cervical Decompression and Fusion Immediately after the operation Activity You should not lift anything greater than 10 lbs for 2 weeks.You will be more comfortable if you do not sit in a car or chair for more than 45 minutes without getting up and walking around. Rehabilitation Physical ___ times a day you should go for a walk for ___ minutes as part of your recovery.You can walk as much as you can tolerate.Limit any kind of lifting. Cervical Collar Neck Brace You need to wear the brace at all times until your follow up appointment which should be in 2 weeks.You may remove the collar to take a shower.Limit your motion of your neck while the collar is off.Place the collar back on your neck immediately after the shower. Wound Care Remove the dressing in 2 days.If the incision is draining cover it with a new sterile dressing.If it is dry then you can leave the incision open to the air.Once the incision is completely dry usually ___ days after the operation you may take a shower.Do not soak the incision in a bath or pool.If the incision starts draining at anytime after surgery do not get the incision wet.Call the office at that time.If you have an incision on your hip please follow the same instructions in terms of wound care. You should resume taking your normal home medications You have also been given Additional Medications to control your pain.Please allow 72 hours for refill of narcotic prescriptions so please plan ahead.You can either have them mailed to your home or pick them up at the clinic located on ___ 2.We are not allowed to call in narcotic prescriptions oxycontin oxycodone percocet to the pharmacy.In addition we are only allowed to write for pain medications for 90 days from the date of surgery. Follow up ___ Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. ___ At the 2 week visit we will check your incision take baseline x rays and answer any questions. Please call the office if you have a fever 101.5 degrees Fahrenheit drainage from your wound or have any questions. Followup Instructions ___ The icd codes present in this text will be S12390A, J9690, S27321A, S14109A, S2220XA, F10121, A0472, G960, S22020A, S12490A, S12590A, S12690A, S93409A, W109XXA, Y9289, S0101XA, F17210, F1290, D649, M5382. The descriptions of icd codes S12390A, J9690, S27321A, S14109A, S2220XA, F10121, A0472, G960, S22020A, S12490A, S12590A, S12690A, S93409A, W109XXA, Y9289, S0101XA, F17210, F1290, D649, M5382 are S12390A: Other displaced fracture of fourth cervical vertebra, initial encounter for closed fracture; J9690: Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia; S27321A: Contusion of lung, unilateral, initial encounter; S14109A: Unspecified injury at unspecified level of cervical spinal cord, initial encounter; S2220XA: Unspecified fracture of sternum, initial encounter for closed fracture; F10121: Alcohol abuse with intoxication delirium; A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent; G960: Cerebrospinal fluid leak; S22020A: Wedge compression fracture of second thoracic vertebra, initial encounter for closed fracture; S12490A: Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture; S12590A: Other displaced fracture of sixth cervical vertebra, initial encounter for closed fracture; S12690A: Other displaced fracture of seventh cervical vertebra, initial encounter for closed fracture; S93409A: Sprain of unspecified ligament of unspecified ankle, initial encounter; W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter; Y9289: Other specified places as the place of occurrence of the external cause; S0101XA: Laceration without foreign body of scalp, initial encounter; F17210: Nicotine dependence, cigarettes, uncomplicated; F1290: Cannabis use, unspecified, uncomplicated; D649: Anemia, unspecified; M5382: Other specified dorsopathies, cervical region. The common codes which frequently come are F17210, D649. The uncommon codes mentioned in this dataset are S12390A, J9690, S27321A, S14109A, S2220XA, F10121, A0472, G960, S22020A, S12490A, S12590A, S12690A, S93409A, W109XXA, Y9289, S0101XA, F1290, M5382.
The icd codes present in this text will be E1165, N179, E1122, I130, N189, I5022, N390, E871, E876, I482, F419, Z940, Z794, Z7901, E785. The descriptions of icd codes E1165, N179, E1122, I130, N189, I5022, N390, E871, E876, I482, F419, Z940, Z794, Z7901, E785 are E1165: Type 2 diabetes mellitus with hyperglycemia; N179: Acute kidney failure, unspecified; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N189: Chronic kidney disease, unspecified; I5022: Chronic systolic (congestive) heart failure; N390: Urinary tract infection, site not specified; E871: Hypo-osmolality and hyponatremia; E876: Hypokalemia; I482: Chronic atrial fibrillation; F419: Anxiety disorder, unspecified; Z940: Kidney transplant status; Z794: Long term (current) use of insulin; Z7901: Long term (current) use of anticoagulants; E785: Hyperlipidemia, unspecified. The common codes which frequently come are E1165, N179, E1122, I130, N189, N390, E871, F419, Z794, Z7901, E785. The uncommon codes mentioned in this dataset are I5022, E876, I482, Z940. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint High blood sugars labs showing acute on chronic kidney injury Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ with a h o renal transplant CHF AFib on Coumadin DM who presented to the ED on ___ with hyperglycemia 600s and worsening kidney function on routine tests at PCP. On ___ her blood glucose was 665 and her Hgb A1c was found to be 12.7. Her creatinine was 2.1 up from 1.4 in ___ most recent value . Had been taking her home Glipizide as prescribed. She had been urinating frequently and had a cold a few days prior to admission but otherwise had no symptomatic complaints. Past Medical History ATRIAL FIBRILLATION CHRONIC KIDNEY DISEASE DIABETES TYPE II HYPERLIPIDEMIA HYPERTENSION GALLSTONE PANCREATITIS S P SPHINCTEROTOMY S P RENAL TRANSPANT SYSTOLIC CONGESTIVE HEART FAILURE EF ___ SHINGLES FOREHEAD DIABETES MELLITUS MITRAL REGURGITATION URINARY TRACT INFECTION RENAL TRANSPLANT ___ BILATERAL NEPHRECTOMIES ___ SPHINCTEROTOMY BREAST AUGMENTATION Social History ___ Family History Sister RENAL TRANSPLANT Daughter POLYCYSTIC KIDNEYS Physical Exam PHYSICAL EXAM upon admission Vitals 97.4 PO 160 55 71 20 97 Ra Intake 480 outs not recorded General alert oriented no acute distress HEENT sclera anicteric slightly dry mucus membranes oropharynx clear Neck supple JVP not elevated no LAD Lungs clear to auscultation bilaterally no wheezes rales rhonchi CV Irregularly irregular rhythm normal S1 S2 no murmurs rubs gallops Abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly GU no foley Ext warm well perfused 2 pulses no clubbing cyanosis or edema Neuro CNs2 12 intact motor function grossly normal PHYSICAL EXAM upon discharge Vitals 97.4 PO 160 55 71 20 97 Ra Intake 480 outs not recorded General alert oriented no acute distress HEENT sclera anicteric slightly dry mucus membranes oropharynx clear Neck supple JVP not elevated no LAD Lungs clear to auscultation bilaterally no wheezes rales rhonchi CV Irregularly irregular rhythm normal S1 S2 no murmurs rubs gallops Abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly GU no foley Ext warm well perfused 2 pulses no clubbing cyanosis or edema Neuro CNs2 12 intact motor function grossly normal Pertinent Results LABS UPON ADMISSION ___ 05 42PM BLOOD UreaN 46 Creat 2.1 Na 127 K 4.0 Cl 86 HCO3 22 AnGap 23 ___ 05 42PM BLOOD Glucose 665 ___ 05 42PM BLOOD WBC 7.9 RBC 3.54 Hgb 9.8 Hct 29.1 MCV 82 MCH 27.7 MCHC 33.7 RDW 14.1 RDWSD 41.6 Plt ___ ___ 05 42PM BLOOD HbA1c 12.7 eAG 318 ___ 12 15PM BLOOD Glucose 548 UreaN 47 Creat 1.9 Na 122 K 3.8 Cl 85 HCO3 21 AnGap 20 ___ 12 15PM BLOOD WBC 11.2 RBC 3.64 Hgb 10.1 Hct 30.0 MCV 82 MCH 27.7 MCHC 33.7 RDW 14.1 RDWSD 41.8 Plt ___ ___ 12 15PM BLOOD Neuts 90.2 Lymphs 6.1 Monos 2.1 Eos 0.2 Baso 0.2 Im ___ AbsNeut 10.14 AbsLymp 0.68 AbsMono 0.24 AbsEos 0.02 AbsBaso 0.02 LABS UPON DISCHARGE ___ 11 19AM BLOOD Glucose 221 UreaN 42 Creat 1.8 Na 130 K 3.1 Cl 91 HCO3 22 AnGap 20 ___ 05 56PM BLOOD Glucose 356 UreaN 43 Creat 1.9 Na 126 K 4.0 Cl 89 HCO3 23 AnGap 18 ___ 11 19AM BLOOD WBC 11.4 RBC 3.64 Hgb 10.1 Hct 30.1 MCV 83 MCH 27.7 MCHC 33.6 RDW 14.1 RDWSD 41.7 Plt ___ ___ 11 19AM BLOOD ___ PTT 35.5 ___ IMAGING RENAL US ___ IMPRESSION 1. Patent renal transplant vasculature. 2. Borderline to minimally elevated intrarenal resistive indices measuring up to 0.79 in the interpolar region. CXR ___ IMPRESSION Persistent small left and trace right pleural effusions and cardiomegaly. No pulmonary edema. Brief Hospital Course ___ with a history of renal transplant CHF AFib on Coumadin DM who was admitted on ___ after she was found to have hyperglycemia 600s and worsening renal function on routine lab tests at PCP Cr 2.1 on ___ up from most recent 1.4 on ___. Hyperglycemia T2DM Pt presented with significant hyperglycemia with ___ and elevated serum osms but not meeting criteria for HHS . Treated with insulin in ED and developed low K. Given her significantly elevated glucose and HbA1c the patient requires insulin therapy for glucose control. ___ was consulted and recommended the following regimen NPH 10 Units fixed dose in the morning and Humalog sliding scale at meals see discharge paperwork for scale . Her electrolyte abnormalities resolved with repletion and intravenous fluids. Her home glipizide was held. Acute on chronic kidney disease s p renal transplant She presented with Cr 2.1 though her Cr has been baseline 1.2 1.3 for many years. Her acute presentation is likely due to hypovolemia in setting of hyperglycemia and gradual decline in kidney function. She was given intravenous fluids and her creatinine was followed closely. Her Lasix and Losartan were held during admission due to her dehydration and ___. Her home cyclosporine prednisone and MMF were continued. Cr was not back to baseline upon discharge. Losartan and Lasix held at discharge. UTI She was also found to have a urinalysis suggestive of UTI culture pending. This infection likely developed in setting of acute on chronic hyperglycemia. Endorsed urinary sx. She was treated with ceftriaxone 1g IV once daily and transitioned to cefpoxodime 500mg twice a day for a 7 day course last dose ___. Urine cultures were pending at the time of discharge. Extensive discussions were had with patient and husband regarding discharge plan. We requested that the patient stay overnight given the elevated Cr pending urine cultures electrolyte abnormalities and need for additional fluid repletion and patient education. Patient insisted on discharge and agreed to help ensure very close follow up. CHRONIC A fib Continued home warfarin at 0.5 and 1mg alternating note was just changed on ___ per ___ clinic because INR was high. Continued diltiazem metoprolol and digoxin. CHF ECHO ___ with normal regional global systolic function. Mild to moderate mitral regurgitation. Moderate pulmonary hypertension. EF 55 . Per hx and exam she was volume down. Lasix was held. Anxiety Continued home lorazepam HTN Losartan held in setting of ___. Furosemide held in setting of ___. HLD Continued home atorvastatin and zetia. TRANSITIONAL ISSUES NEW MEDICATIONS Insulin NPH 10 units at breakfast Insulin sliding scale Humalog see discharge medications Cefpodoxime 100 mg PO BID end date ___ STOPPED MEDICATIONS Glipizide Furosemide Lasix Losartan Pt needs close f u with PCP ___ and ___. PCP is ___. Discussed with patient and family Pt should have repeat labs on ___ chem 10 and INR. If her creatinine is improved and she does not appear hypovolemic please restart her losartan and furosemide. Medications on Admission The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. Losartan Potassium 25 mg PO DAILY 3. LORazepam 0.5 mg PO QHS PRN anxiety 4. Metoprolol Succinate XL 100 mg PO BID 5. Diltiazem Extended Release 120 mg PO DAILY 6. Ezetimibe 10 mg PO DAILY 7. Warfarin 1 mg PO EVERY OTHER DAY 8. Atorvastatin 10 mg PO QPM 9. CycloSPORINE Neoral MODIFIED 25 mg PO Q12H 10. Mycophenolate Mofetil 250 mg PO BID 11. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 12. Furosemide 60 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. GlipiZIDE XL 5 mg PO DAILY 15. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 16. Warfarin 0.5 mg PO EVERY OTHER DAY Discharge Medications 1. Cefpodoxime Proxetil 100 mg PO Q12H Duration 10 Days RX cefpodoxime 100 mg 1 tablet s by mouth twice per day Disp 18 Tablet Refills 0 2. NPH 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 3. Atorvastatin 10 mg PO QPM 4. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 5. CycloSPORINE Neoral MODIFIED 25 mg PO Q12H 6. Diltiazem Extended Release 120 mg PO DAILY 7. Ezetimibe 10 mg PO DAILY 8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY 9. LORazepam 0.5 mg PO QHS PRN anxiety 10. Metoprolol Succinate XL 100 mg PO BID 11. Multivitamins 1 TAB PO DAILY 12. Mycophenolate Mofetil 250 mg PO BID 13. PredniSONE 5 mg PO DAILY 14. Warfarin 1 mg PO EVERY OTHER DAY 15. Warfarin 0.5 mg PO EVERY OTHER DAY 16. HELD Furosemide 60 mg PO BID This medication was held. Do not restart Furosemide until you see your PCP or your kidney doctor 17. HELD Losartan Potassium 25 mg PO DAILY This medication was held. Do not restart Losartan Potassium until you see your PCP or kidney doctor 18.Outpatient Lab Work Chem 10 ___ fax to ___ MD ___ MD ___ Discharge Disposition Home Discharge Diagnosis PRIMARY DIAGNOSIS HYPERGLYCEMIA Acute kidney injury on chronic kidney injury Complicated urinary tract infection Hyponatremia Hypokalemia SECONDARY DIAGNOSIS Atrial fibrillation Renal transplant Congestive heart failure Anxiety Hypertension Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You came to the hospital because you had very high blood sugar and bloodwork showing that your kidneys were not working as well. While you were in the hospital you were given insulin and intravenous fluids. Your Lasix and Losartan medications were held because you were very dehydrated. Your electrolyte levels were abnormal which were repleted. You were also found to have a urinary tract infection which was treated with antibiotics. Since your blood sugars were so high it is very important that you take insulin every day as prescribed. When you leave the hospital you will also need to continue taking antibiotics cefpodoxime 100 mg PO twice per day for 10 days with last dose on ___. NEW MEDICATIONS Insulin NPH 10 units at breakfast Insulin sliding scale Humalog see discharge medications we have provided you with a chart that Cefpodoxime 100 mg PO twice a day through ___ STOPPED MEDICATIONS Glipizide Furosemide Lasix Losartan MAKE AN APPOINTMENT WITH YOUR NEPHROLOGIST FOR WITHIN ONE WEEK Dr. ___ AN APPOINTMENT WITH YOUR PRIMARY CARE DOCTOR Call ___ PLEASE ATTEND YOUR ___ APPOINTMENT Please get your labs checked next ___. It was a pleasure taking care of you. Your ___ Team Followup Instructions ___ The icd codes present in this text will be E1165, N179, E1122, I130, N189, I5022, N390, E871, E876, I482, F419, Z940, Z794, Z7901, E785. The descriptions of icd codes E1165, N179, E1122, I130, N189, I5022, N390, E871, E876, I482, F419, Z940, Z794, Z7901, E785 are E1165: Type 2 diabetes mellitus with hyperglycemia; N179: Acute kidney failure, unspecified; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N189: Chronic kidney disease, unspecified; I5022: Chronic systolic (congestive) heart failure; N390: Urinary tract infection, site not specified; E871: Hypo-osmolality and hyponatremia; E876: Hypokalemia; I482: Chronic atrial fibrillation; F419: Anxiety disorder, unspecified; Z940: Kidney transplant status; Z794: Long term (current) use of insulin; Z7901: Long term (current) use of anticoagulants; E785: Hyperlipidemia, unspecified. The common codes which frequently come are E1165, N179, E1122, I130, N189, N390, E871, F419, Z794, Z7901, E785. The uncommon codes mentioned in this dataset are I5022, E876, I482, Z940.
The icd codes present in this text will be J9621, J910, J189, N170, E883, I82412, C7B8, I5022, I871, C7A8, J449, I2510, F17210, Z951, Z955, E119, Z85048, F4310, I4891, Z515, I129, N189, R410, Z9981, Z7902. The descriptions of icd codes J9621, J910, J189, N170, E883, I82412, C7B8, I5022, I871, C7A8, J449, I2510, F17210, Z951, Z955, E119, Z85048, F4310, I4891, Z515, I129, N189, R410, Z9981, Z7902 are J9621: Acute and chronic respiratory failure with hypoxia; J910: Malignant pleural effusion; J189: Pneumonia, unspecified organism; N170: Acute kidney failure with tubular necrosis; E883: Tumor lysis syndrome; I82412: Acute embolism and thrombosis of left femoral vein; C7B8: Other secondary neuroendocrine tumors; I5022: Chronic systolic (congestive) heart failure; I871: Compression of vein; C7A8: Other malignant neuroendocrine tumors; J449: Chronic obstructive pulmonary disease, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; F17210: Nicotine dependence, cigarettes, uncomplicated; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; E119: Type 2 diabetes mellitus without complications; Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus; F4310: Post-traumatic stress disorder, unspecified; I4891: Unspecified atrial fibrillation; Z515: Encounter for palliative care; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N189: Chronic kidney disease, unspecified; R410: Disorientation, unspecified; Z9981: Dependence on supplemental oxygen; Z7902: Long term (current) use of antithrombotics/antiplatelets. The common codes which frequently come are J449, I2510, F17210, Z951, Z955, E119, I4891, Z515, I129, N189, Z7902. The uncommon codes mentioned in this dataset are J9621, J910, J189, N170, E883, I82412, C7B8, I5022, I871, C7A8, Z85048, F4310, R410, Z9981. Allergies Penicillins Chief Complaint weakness hypoxia secondary to superior vena cava syndrome Major Surgical or Invasive Procedure intubation ___ Left femoral line placement ___ R femoral line placement Left chest tube placement Radiation Therapy Left PICC placement History of Present Illness ___ h o COPD CAD s p CABG pAfib on xarelto CKD HTN HLD L supraclaviular mass dx as neuroendocrine tumor who presented to ___ on ___ for dehydration and failure to thrive. He did report scapular pain and dyspnea on exertion x 4 weeks starting about 2 months prior to presentation. Outpatient CT showed mediastinal lymphadenopathy and a supraclavicular mass. Biopsy on ___ showed poorly differentiated neuroendocrine tumor. Initial plan was to start chemotherapy of etoposide and carbaplantiunum x 3 days as well as additioning to PET scan to ___ however patient was unable to tolerate lying flat and PET scan was not performed. The patient was sent by his outpatient oncologist to ___ on ___ for failure to thrive and hypotension with SBPs in the ___. CT scan on ___ showed mediastinal adenopathy and SVC compromise and rec d radiation but this was not done due to clinical decompensation. However once the disease is staged if the patient has no sign of metastatic disease than chemotherapy would be curative. During his time at ___ his hospital course was notable for increased upper extremity swelling facial swelling and increased hypoxia. RUE ultrasound was negative for DVT. He had an increasing oxygen requirement from 2L to 7L. Given concern for airway compromise the patient was transferred to the ___ ICU on ___. Due to lack of surgical backup at ___ the patient was not intubated at ___ and subsequently transferred here for further airway evaluation. Of note the patient had a recent admission at ___ on ___ for pneumonia at which time he was treated with levaquin. Vital signs at the time of transfer were 97.6 80 160 76 19 96 on high flow NC 8L. Physical exam notable for facial flushing able to speak in full sentences RUE swelling. Labs prior to transfer notable for a WBC of 12.6 H H ___ platelets WNL. VBG 7.40 ___. Cr 1.7. Lactate 3.8 2.2. Procalcitonin 0.05 undetectable . On arrival to the MICU the patient was hemodynamically stable with pulse of 76 are blood pressure of 127 64. He had an increased work of breathing using his abdominal muscles. He was sitting upright unable to tolerate laying flat. Past Medical History Coronary artery disease w LAD stent now s p CABG x3 Left internal mammary artery to left anterior descending artery saphenous vein graft to diagonal and obtuse marginal arteries Chronic obstructive pulmonary disease hypertension Congestive heart failure EF 40 45 . Diabetes mellitus Rectal Cancer ___ treated w Chemo Rad followed by a surgical procedure to remove residual tumor via the rectum Post traumatic stress disorder pt is ___ veteran atrial fibrillation CKD Social History ___ Family History FAMILY HISTORY No premature coronary artery disease or neuroendocrine carcinomas Physical Exam MICU ADMISSION Vitals T 97.7 HR 76 BP 127 64 R 20 93 6L NC GENERAL fatigued no acute distress HEENT Sclera anicteric noted ___ swelling with rightsided facial fullness. Difficult to visualize posterior oropharynx ___ Regular without murmurs RESP Increased work of breathing with abnormal muscles. No stridor. RLL crackles ABD Non tender non distended EXT Warm no edema ___ Mild edema RUE NEURO CN II XII intact. Strength ___ UE and ___ b l DEATH EXAM ___ ___ Pupils non reactive to light No cardiac sounds auscultated No respiratory effort seen Telemetry without cardiac electrical activity Pertinent Results ADMISSION LABS ___ 10 30PM WBC 12.1 RBC 3.67 HGB 10.9 HCT 33.4 MCV 91 MCH 29.7 MCHC 32.6 RDW 14.0 RDWSD 46.3 ___ 10 30PM PLT COUNT 359 ___ 10 30PM GLUCOSE 190 UREA N 48 CREAT 1.6 SODIUM 138 POTASSIUM 4.5 CHLORIDE 101 TOTAL CO2 23 ANION GAP 19 ___ 10 51PM freeCa 1.11 ___ 10 30PM CALCIUM 9.0 PHOSPHATE 3.1 MAGNESIUM 2.4 URIC ACID 8.3 ___ 10 51PM LACTATE 2.3 DISCHARGE LABS ___ 01 02PM BLOOD WBC 9.8 RBC 3.06 Hgb 8.9 Hct 26.2 MCV 86 MCH 29.1 MCHC 34.0 RDW 14.6 RDWSD 44.7 Plt ___ ___ 05 00AM BLOOD ___ PTT 67.6 ___ ___ 11 14AM BLOOD Glucose 161 UreaN 102 Creat 2.7 Na 131 K 3.9 Cl 89 HCO3 28 AnGap 18 ___ 05 00AM BLOOD ALT 27 AST 55 LD LDH 925 AlkPhos 93 TotBili 0.4 ___ 11 14AM BLOOD Calcium 7.0 Phos 6.0 Mg 1.8 MICROBIOLOGY ___ FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture in Bottles PRELIMINARY INPATIENT ___ PLEURAL FLUID GRAM STAIN FINAL FLUID CULTURE FINAL ANAEROBIC CULTURE PRELIMINARY INPATIENT ___ URINE URINE CULTURE FINAL INPATIENT ___ BLOOD CULTURE Blood Culture Routine PENDING INPATIENT ___ SPUTUM GRAM STAIN FINAL RESPIRATORY CULTURE FINAL YEAST INPATIENT ___ URINE URINE CULTURE FINAL INPATIENT ___ BLOOD CULTURE Blood Culture Routine FINAL INPATIENT ___ STOOL C. difficile DNA amplification assay FINAL INPATIENT ___ BRONCHOALVEOLAR LAVAGE GRAM STAIN FINAL RESPIRATORY CULTURE FINAL YEAST POTASSIUM HYDROXIDE PREPARATION FINAL FUNGAL CULTURE PRELIMINARY YEAST INPATIENT ___ MRSA SCREEN MRSA SCREEN FINAL STAPH AUREUS COAG INPATIENT ___ PLEURAL FLUID GRAM STAIN FINAL FLUID CULTURE FINAL ANAEROBIC CULTURE FINAL PATHOLOGY PLEURAL FLUID LATERALITY NOT SPECIFIED POSITIVE FOR MALIGNANT CELLS. Consistent with metastatic poorly differentiated non small cell neuroendocrine carcinoma. A few small groups of and scattered single atypical epithelioid cells are seen on the cell block preparation. Immunohistochemical stains show the atypical cells to be focally weakly positive for synaptophysin and CK5 6. No immunoreactive cells for chromogranin are seen. The patient s prior slides of lymph node biopsy ___ were not available for comparison. Drs. ___ and ___ were informed of the diagnosis via e mail by Dr. ___ on ___ STUDIES TTE ___ The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal LVEF 65 . Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus ascending and arch levels are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course Mr. ___ is a ___ year old man with recently diagnosed metastatic poorly differentiated high grade neuroendocrine carcinoma likely of pulmonary origin with bulky retroperitoneal common iliac mediastinal lymphadenopathy concerning for metastatic disease who was admitted to ___ on ___ with progressive dyspnea and hypoxemia thought to be at least partially related to ___ syndrome from an enlarging chest neck mass which was treated with external radiotherapy. Hospital course was been complicated by hypoxemic respiratory failure requiring prolonged mechanical intubation sepsis ___ obstructive pneumonia acute kidney injury ___ acute tubular necrosis malignant pleural effusions requiring bilateral chest tube placement and hemodynamically unstable atrial fibrillation. Mr. ___ was followed closely by numerous consulting services Heme Onc Pulmonary Radiation Oncology Nephrology Infectious Disease . He developed progressive multi system organ failure despite aggressive supportive care. Given his progressive decline and based on family wishes his care was transitioned to a comfort focus and he was extubated with family at the bedside in accordance with his goals of care. He expired soon thereafter with official time of death being ___ 18 36. Autopsy was deferred. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Carvedilol 12.5 mg PO BID 3. Diltiazem Extended Release 240 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Fenofibrate 160 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Rivaroxaban 15 mg PO DAILY 9. SAXagliptin 2.5 mg oral DAILY 10. GlipiZIDE XL 10 mg PO QAM 11. GlipiZIDE XL 5 mg PO QPM 12. LamoTRIgine 100 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. HYDROcodone Acetaminophen 5mg 325mg 1 TAB PO Q6H PRN Pain Moderate 15. QUEtiapine Fumarate 25 mg PO QHS 16. Fentanyl Patch 75 mcg h TD Q72H 17. Midodrine 5 mg PO TID Discharge Medications patient expired Discharge Disposition Expired Discharge Diagnosis Superior Vena Cava Syndrome Poorly differentiated neuroendocrine tumor Acute Hypoxemic Respiratory failure Healthcare associated pneumonia Malignant Pleural Effusions Acute tubular necrosis Tumor lysis syndrome New onset atrial fibrillation flutter with rapid ventricular response. Discharge Condition Patient expired Discharge Instructions Patient expired Followup Instructions ___ The icd codes present in this text will be J9621, J910, J189, N170, E883, I82412, C7B8, I5022, I871, C7A8, J449, I2510, F17210, Z951, Z955, E119, Z85048, F4310, I4891, Z515, I129, N189, R410, Z9981, Z7902. The descriptions of icd codes J9621, J910, J189, N170, E883, I82412, C7B8, I5022, I871, C7A8, J449, I2510, F17210, Z951, Z955, E119, Z85048, F4310, I4891, Z515, I129, N189, R410, Z9981, Z7902 are J9621: Acute and chronic respiratory failure with hypoxia; J910: Malignant pleural effusion; J189: Pneumonia, unspecified organism; N170: Acute kidney failure with tubular necrosis; E883: Tumor lysis syndrome; I82412: Acute embolism and thrombosis of left femoral vein; C7B8: Other secondary neuroendocrine tumors; I5022: Chronic systolic (congestive) heart failure; I871: Compression of vein; C7A8: Other malignant neuroendocrine tumors; J449: Chronic obstructive pulmonary disease, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; F17210: Nicotine dependence, cigarettes, uncomplicated; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; E119: Type 2 diabetes mellitus without complications; Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus; F4310: Post-traumatic stress disorder, unspecified; I4891: Unspecified atrial fibrillation; Z515: Encounter for palliative care; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N189: Chronic kidney disease, unspecified; R410: Disorientation, unspecified; Z9981: Dependence on supplemental oxygen; Z7902: Long term (current) use of antithrombotics/antiplatelets. The common codes which frequently come are J449, I2510, F17210, Z951, Z955, E119, I4891, Z515, I129, N189, Z7902. The uncommon codes mentioned in this dataset are J9621, J910, J189, N170, E883, I82412, C7B8, I5022, I871, C7A8, Z85048, F4310, R410, Z9981.
The icd codes present in this text will be N62, N6082, N6081, E6601, Z6842, E039, E042, G8929, D869, I10, G4733, M4802, K589, M170, M545, F329, M25531, R7303, Z96653, Z8679, Z833, Z8249, Z803. The descriptions of icd codes N62, N6082, N6081, E6601, Z6842, E039, E042, G8929, D869, I10, G4733, M4802, K589, M170, M545, F329, M25531, R7303, Z96653, Z8679, Z833, Z8249, Z803 are N62: Hypertrophy of breast; N6082: Other benign mammary dysplasias of left breast; N6081: Other benign mammary dysplasias of right breast; E6601: Morbid (severe) obesity due to excess calories; Z6842: Body mass index [BMI] 45.0-49.9, adult; E039: Hypothyroidism, unspecified; E042: Nontoxic multinodular goiter; G8929: Other chronic pain; D869: Sarcoidosis, unspecified; I10: Essential (primary) hypertension; G4733: Obstructive sleep apnea (adult) (pediatric); M4802: Spinal stenosis, cervical region; K589: Irritable bowel syndrome without diarrhea; M170: Bilateral primary osteoarthritis of knee; M545: Low back pain; F329: Major depressive disorder, single episode, unspecified; M25531: Pain in right wrist; R7303: Prediabetes; Z96653: Presence of artificial knee joint, bilateral; Z8679: Personal history of other diseases of the circulatory system; Z833: Family history of diabetes mellitus; Z8249: Family history of ischemic heart disease and other diseases of the circulatory system; Z803: Family history of malignant neoplasm of breast. The common codes which frequently come are E039, G8929, I10, G4733, F329. The uncommon codes mentioned in this dataset are N62, N6082, N6081, E6601, Z6842, E042, D869, M4802, K589, M170, M545, M25531, R7303, Z96653, Z8679, Z833, Z8249, Z803. Allergies Aspirin Adhesive Tape Percocet Erythromycin Base Bee Sting Kit adhesive bandage Caffeine Chief Complaint Symptomatic macromastia Major Surgical or Invasive Procedure MAMMOPLASTY REDUCTION BILATERAL History of Present Illness ___ yo morbidly obese woman with multinodular goiter sarcoid HTN SPinal stenosis B TKAs lami and fusion with symptomatic macromastia. She is here today for bilateral breast reduction. Past Medical History ARTHRITIS BRAIN ANEURYSM HYPOTHYROIDISM MULTINODULAR GOITER LOW BACK PAIN HYPERSENSITIVITY RASH FRONTAL LOBE SYNDROME HEADACHE OBESITY ROTATOR CUFF INJURY LYMPHADENOPATHY PULMONARY NODULE SARCOID RIGHT WRIST PAIN Social History ___ Family History Positive for breast cancer in the patient s mother. Brother and father both status post CABG. Brother with type ___ diabetes. Physical Exam Physical exam per PRS post op check ___ 1516 Temp 97.7 PO BP 112 72 L Lying HR 66 RR 16 O2 sat 94 O2 delivery RA ___ 1520 Dyspnea 0 RASS 1 Pain Score ___ Pedal Pulses Left DPP Right DPP ___ 1521 IV Solution OR PACU IVF IV Amt Infused 1613ml ___ 1521 Urine Amt No Foley DTV 1600 General Sleepy NAD Mental psych A Ox3 chest bilateral breasts soft no evidence of hematoma. Bilateral IMF incisions intact with small amount of bleeding around xeroform strip. Nipples intact with xeroform dressings. Surgibra in place. Heart RRR Lungs CTAB Abd Large round and soft NT. BLE No ankle edema. Pneumoboots in place. Brief Hospital Course The patient was admitted to the plastic surgery service on ___ and had a bilateral breast reduction. The patient tolerated the procedure well. . Neuro Post operatively the patient was heavily sedated and difficult to arouse. She was given narcan with good effect in the PACU and then transferred to floor. Upon further assessment on the floor the patient again became difficult to arouse and was given a repeat dose of narcan with good result. She became much more alert and responsive. Patient was monitored with continuous oxygen monitoring overnight for safety. . CV The patient was stable from a cardiovascular standpoint vital signs were routinely monitored. . Pulmonary The patient was stable from a pulmonary standpoint vital signs were routinely monitored. . GI GU Post operatively the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate which was tolerated well. Intake and output were closely monitored. . Prophylaxis The patient was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD 1 the patient was doing well afebrile with stable vital signs tolerating a regular diet ambulating with cane and assistance voiding without assistance and pain was well controlled. Bilateral breasts soft without evidence of hematoma bilateral nipples warm pink and viable. ___ ecchymosis about IMF incisions bilaterally. Incisions intact. Surgibra in place. Patient discharged to rehab facility due to inability to safely go up and down stairs. She lives alone and needs to be able to go up and down stairs. She will continue work with ___ at rehab. Medications on Admission 1. Acetaminophen 650 mg PO Q6H pain 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Calcium Carbonate 1000 mg PO BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Minocycline 100 mg PO Q12H 6. Multivitamins 1 TAB PO DAILY 7. Pramipexole 0.25 mg PO TID 8. Topiramate Topamax 50 mg PO BID 9. trospium 60 mg oral DAILY 10. Venlafaxine 200 mg PO QHS Discharge Medications 1. Acetaminophen 650 mg PO Q6H pain 2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 3. Calcium Carbonate 1000 mg PO BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Minocycline 100 mg PO Q12H 6. Multivitamins 1 TAB PO DAILY 7. Pramipexole 0.25 mg PO TID 8. Topiramate Topamax 50 mg PO BID 9. trospium 60 mg oral DAILY 10. Venlafaxine 200 mg PO QHS Discharge Disposition Extended Care Facility ___ Discharge Diagnosis symptomatic macromastia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You were admitted on ___ for a bilateral breast reduction. Please follow these discharge instructions. . Personal Care 1. You may remove any dressings from your incision sites 48 hours after surgery. 2. You may shower 48 hours after surgery. 3. You should keep your surgibra in place. You may remove for laundering and showering. 4. You may expect some drainage from your incisions for up to 1 month. TIP You may pad your bras with clean ___ to absorb any drainage. This provides a clean and absorbent dressing . Activity 1. You may resume your regular diet. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity until instructed by Dr. ___. . Medications 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. 3. Take Colace 100 mg by mouth 2 times per day while taking the prescription pain medication. You may use a different over the counter stool softener if you wish. 4. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications oxycodone percocet vicodin hydrocodone dilaudid etc. you should continue drinking fluids you may take stool softeners and should eat foods that are high in fiber. 5. Do not take any medicines such as Motrin Aspirin Advil or Ibuprofen unless instructed to do so by Dr. ___. . Call the office IMMEDIATELY if you have any of the following 1. Signs of infection fever with chills increased redness swelling warmth or tenderness at the surgical site or unusual drainage from the incision s . 2. A large amount of bleeding from the incision s or drain s . 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if If you are vomiting and cannot keep in fluids or your medications. If you have shaking chills fever greater than 101.5 F degrees or 38 C degrees increased redness swelling or discharge from incisions chest pain shortness of breath or anything else that is troubling you. Any serious change in your symptoms or any new symptoms that concern you. Followup Instructions ___ The icd codes present in this text will be N62, N6082, N6081, E6601, Z6842, E039, E042, G8929, D869, I10, G4733, M4802, K589, M170, M545, F329, M25531, R7303, Z96653, Z8679, Z833, Z8249, Z803. The descriptions of icd codes N62, N6082, N6081, E6601, Z6842, E039, E042, G8929, D869, I10, G4733, M4802, K589, M170, M545, F329, M25531, R7303, Z96653, Z8679, Z833, Z8249, Z803 are N62: Hypertrophy of breast; N6082: Other benign mammary dysplasias of left breast; N6081: Other benign mammary dysplasias of right breast; E6601: Morbid (severe) obesity due to excess calories; Z6842: Body mass index [BMI] 45.0-49.9, adult; E039: Hypothyroidism, unspecified; E042: Nontoxic multinodular goiter; G8929: Other chronic pain; D869: Sarcoidosis, unspecified; I10: Essential (primary) hypertension; G4733: Obstructive sleep apnea (adult) (pediatric); M4802: Spinal stenosis, cervical region; K589: Irritable bowel syndrome without diarrhea; M170: Bilateral primary osteoarthritis of knee; M545: Low back pain; F329: Major depressive disorder, single episode, unspecified; M25531: Pain in right wrist; R7303: Prediabetes; Z96653: Presence of artificial knee joint, bilateral; Z8679: Personal history of other diseases of the circulatory system; Z833: Family history of diabetes mellitus; Z8249: Family history of ischemic heart disease and other diseases of the circulatory system; Z803: Family history of malignant neoplasm of breast. The common codes which frequently come are E039, G8929, I10, G4733, F329. The uncommon codes mentioned in this dataset are N62, N6082, N6081, E6601, Z6842, E042, D869, M4802, K589, M170, M545, M25531, R7303, Z96653, Z8679, Z833, Z8249, Z803.
The icd codes present in this text will be I5031, Z6843, R079, D649, E669, E039, R413, K219, G2581, G4700, H04129, R3915. The descriptions of icd codes I5031, Z6843, R079, D649, E669, E039, R413, K219, G2581, G4700, H04129, R3915 are I5031: Acute diastolic (congestive) heart failure; Z6843: Body mass index [BMI] 50.0-59.9, adult; R079: Chest pain, unspecified; D649: Anemia, unspecified; E669: Obesity, unspecified; E039: Hypothyroidism, unspecified; R413: Other amnesia; K219: Gastro-esophageal reflux disease without esophagitis; G2581: Restless legs syndrome; G4700: Insomnia, unspecified; H04129: Dry eye syndrome of unspecified lacrimal gland; R3915: Urgency of urination. The common codes which frequently come are D649, E669, E039, K219, G4700. The uncommon codes mentioned in this dataset are I5031, Z6843, R079, R413, G2581, H04129, R3915. Allergies Aspirin Adhesive Tape Percocet Erythromycin Base Bee Sting Kit adhesive bandage Caffeine Chief Complaint 20 lb weight gain DOE Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ year old F w history of hypertension obesity osteoarthritis hypothyroidism and sarcoidosis presenting for evaluation of a 20 lb weight gain in 1 week DOE and lower extremity edema. She was seen by Cognitive Neurology today who sent her in for evaluation. She reports that she woke up approximately 3 days before admission with new lower extremity swelling DOE bendopnea and orthopnea. She also endorses chest pain while walking that stops with slowing down. On ___ she was 265 pounds and today her weight is 293. She denies any chest pain. She also has had three weeks of rhinorrhea sore throat and a productive cough. In the ED initial vital signs were T 99 HR 87 BP 135 106 RR 22 SPO2 96 RA. Her exam was notable for volume overload with bilateral crackles and lower extremity edema. proBNP was only 221. TSH was normal. Hgb was newly decreased to 10.7. Urine alb Cr ratio was high at 109 and she had a low total protein of 5.8. ECG was unchanged from prior with sinus rhythm and borderline LVH. Bedside cardiac ultrasound reportedly performed but not documented anywhere. CXR in the ED showed pulmonary vascular congestion so she was given 40 mg IV Lasix. Upon arrival to the floor the patient reports the above story. She is currently chest pain free although notes dyspnea with walking to the bathroom. Her legs feel lighter than before since she received IV Lasix. This reminds her exactly of when she had strep induced nephritis at ___ years old. REVIEW OF SYSTEMS Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea palpitations syncope or presyncope. On further review of systems denies any prior history of stroke TIA deep venous thrombosis pulmonary embolism bleeding at the time of surgery myalgias hemoptysis black stools or red stools. Denies exertional buttock or calf pain. Denies recent fevers chills or rigors. All of the other review of systems were negative. Past Medical History 1. CARDIAC RISK FACTORS Hypertension Obesity 2. CARDIAC HISTORY CABG None PERCUTANEOUS CORONARY INTERVENTIONS None PACING ICD None Mitral valve prolapse 3. OTHER PAST MEDICAL HISTORY Hypothyroidism s p partial thyroidectomy for multinodular goiter Sarcoidosis Acute nephritis diagnosed at age ___ Urinary incontinence Spinal stenosis lumbar region with neurogenic claudication s p 3. Laminectomy lumbar L2 5 fusion I3 I5 instrumentation bone graft ___ S.viridans PJI of right knee ___ Chronic bilateral knee pain s p bilateral total knee replacement ___ Cerebral aneurysm s p clips Pulmonary nodule Irritable bowel syndrome Hx of CCY APPY TAH RSO S p remote CTS release Social History ___ Family History Mother breast cancer Brother type ___ DM CAD s p CABG Father CAD s p CABG iCM Physical Exam ADMISSION PHYSICAL EXAM VS 98.7 PO 154 84 74 20 92 ra GENERAL Obese elderly woman sitting up in bed in no acute distress HEENT PERRL EOMI anicteric sclera MMM no oropharyngeal erythema or exudates no rhinorrhea NECK supple no LAD JVP 12 cm CV RRR S1 S2 no murmurs gallops or rubs PULM CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles GI abdomen obese soft multiple surgical scar nontender in all quadrants no rebound guarding no hepatosplenomegaly EXTREMITIES no cyanosis or clubbing. 1 pitting ___ to knees. Bruising on knees PULSES 1 radial pulses bilaterally BACK Buffalo hump present NEURO Alert although sometimes forgetful when asked questions CN intact strength ___ x4 extremities sensation to LT intact DERM warm and well perfused no excoriations or lesions no rashes DISCHARGE PHYSICAL EXAM VS 24 HR Data last updated ___ 722 Temp 97.7 Tm 98.3 BP 124 63 117 142 63 75 HR 64 64 75 RR 16 ___ O2 sat 96 92 98 O2 delivery RA Wt 264.33 lb 119.9 kg GENERAL Obese elderly woman NAD HEENT anicteric sclera NECK supple JVP not appreciated CV RRR S1 S2 no murmurs gallops or rubs PULM CTAB no increased work of breathing GI abdomen obese soft nontender EXTREMITIES No ___ edema PULSES palpable distal pulses BACK Buffalo hump present NEURO alert moves all four extremities with purpose DERM warm and well perfused no excoriations or lesions no rashes Pertinent Results ADMISSION LABS ___ 03 00PM BLOOD WBC 9.6 RBC 4.07 Hgb 10.7 Hct 35.6 MCV 88 MCH 26.3 MCHC 30.1 RDW 16.4 RDWSD 52.0 Plt ___ ___ 03 00PM BLOOD Neuts 77.9 Lymphs 12.4 Monos 7.1 Eos 1.6 Baso 0.4 Im ___ AbsNeut 7.47 AbsLymp 1.19 AbsMono 0.68 AbsEos 0.15 AbsBaso 0.04 ___ 03 00PM BLOOD ___ PTT 28.2 ___ ___ 03 00PM BLOOD Glucose 97 UreaN 18 Creat 0.9 Na 147 K 4.6 Cl 110 HCO3 29 AnGap 8 ___ 03 00PM BLOOD ALT 13 AST 20 AlkPhos 97 TotBili 0.2 ___ 03 00PM BLOOD cTropnT 0.01 proBNP 221 ___ 03 00PM BLOOD Albumin 3.5 Calcium 9.1 Phos 3.4 Mg 2.0 Cholest 188 ___ 03 00PM BLOOD VitB12 713 ___ 03 00PM BLOOD Triglyc 114 HDL 71 CHOL HD 2.6 LDLcalc 94 ___ 03 00PM BLOOD TSH 0.84 MICROBIOLOGY ___ 3 00 pm SEROLOGY BLOOD FINAL REPORT ___ RAPID PLASMA REAGIN TEST Final ___ NONREACTIVE. Reference Range Non Reactive. INTERVAL LABS ___ C1 ESTERASE INHIBITOR PROTEIN Result 34 Ref ___ mg dL ___ COMPLEMENT TOTAL CH50 Result 60 H Ref ___ U mL ___ 06 18AM BLOOD cTropnT 0.01 ___ 01 18AM BLOOD HbA1c 5.3 eAG 105 ___ 03 10PM BLOOD C3 134 C4 28 IMAGING AND REPORTS CHEST PA LAT ___ Pulmonary vascular congestion without overt edema or focal consolidation. Transthoracic Echo Report ___ The left atrial volume index is mildly increased. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D color Doppler . The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 56 . There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Diastolic parameters are indeterminate. Normal right ventricular cavity size with mild global free wall hypokinesis. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender . The aortic arch diameter is normal. There is no evidence for an aortic arch coarctation. The aortic valve leaflets 3 are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is borderline elevated. There is a trivial pericardial effusion. IMPRESSION Biatrial enlargement. Mild symmetric left ventricular hypertrophy . Preserved biventricular systolic function. Borderline pulmonary hypertension. Compared with the prior TTE ___ the findings are similar . DISCHARGE LABS ___ 08 14AM BLOOD WBC 7.6 RBC 4.39 Hgb 11.6 Hct 38.5 MCV 88 MCH 26.4 MCHC 30.1 RDW 16.5 RDWSD 52.8 Plt ___ ___ 08 14AM BLOOD Glucose 98 UreaN 34 Creat 1.0 Na 143 K 4.3 Cl 100 HCO3 32 AnGap 11 ___ 08 14AM BLOOD Calcium 9.7 Phos 4.1 Mg 2.2 Brief Hospital Course Ms. ___ is a ___ year old F w history of hypertension obesity osteoarthritis hypothyroidism and sarcoidosis who presented for evaluation of a 20 lb weight gain in 1 week DOE and lower extremity edema which improved after diuresis. ACUTE PROBLEMS HFpEF Volume overload Patient with 20 lb weight gain in one week new ___ edema DOE orthopnea and bendopnea. TTE w LVEF 56 and biatrial enlargement. Diastolic parameters were indeterminate but clinical suspicion is for diastolic failure likely ___ obesity. Diastolic CHF likely given her symptoms. Renal disease or DI unlikely with unremarkable studies. Unlikely hypothyroidism given normal TSH or liver disease given normal LFTs and no stigmata on exam. Euvolemic and back to baseline weight s p Lasix diuresis. Transitioned to Lasix 20 mg PO. Admission Weight 133.6 kg 294.53 lb. Discharge Weight 119.9 kg 264.33 lb Chest pain Patient endorsed exertional chest pain. Unclear if this is similar to pain she has had in the past when she had stress tests. ECG unchanged and trops negative x1. ___ be stable angina vs. severe DOE vs. pulmonary HTN vs. MSK. No evidence of myocarditis or active ischemia. CP resolved. Should consider pMIBI. Acute normocytic anemia ___ be secondary to dilution from acute volume overload. No history of bleeding. Hgb increased with diuresis. CHRONIC PROBLEMS Hypothyroidism Continued levothyroxine. Hx of spinal hardware infection Continued home suppressive minocycline. Memory loss Seeing Cognitive Neurology for poor short term memory. B12 and TSH normal. RPR negative. Continued topiramate. GERD Continued omeprazole. Restless legs Continued Pramipexole. Insomnia Continued trazodone venlafaxine. Dry Eyes Held home restasis substituted for artificial tears. Urinary urgency Held home mirabegron and trospium given non formulary TRANSITIONAL ISSUES Consider pMIBI to further evaluate etiology of her chest pain. Started on Lasix 20 mg PO on discharge. Titrate as needed and please ensure the patient monitors her weight. Consider initiation of a statin. Please weigh yourself every day in the morning. Call your doctor at if your weight goes up by more than 3 lbs. PCP Dr. ___ ___. Discharge Weight 119.9 kg 264.33 lb Medications on Admission The Preadmission Medication list is accurate and complete. 1. Calcium Carbonate 1000 mg PO BID 2. L Lysine lysine 500 mg oral BID 3. Multivitamins 1 TAB PO DAILY 4. Restasis 0.05 ophthalmic eye BID 5. Minocycline 100 mg PO Q12H 6. Omeprazole 20 mg PO BID 7. Pramipexole 0.25 mg PO TID 8. Topiramate Topamax 50 mg PO BID 9. TraZODone 100 mg PO QHS 10. trospium 60 mg oral DAILY 11. Venlafaxine 200 mg PO QHS 12. mirabegron 25 mg oral DAILY 13. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications 1. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet s by mouth once a day Disp 90 Tablet Refills 2 2. Calcium Carbonate 1000 mg PO BID 3. L Lysine lysine 500 mg oral BID 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Minocycline 100 mg PO Q12H 6. mirabegron 25 mg oral DAILY 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 20 mg PO BID 9. Pramipexole 0.25 mg PO TID 10. Restasis 0.05 ophthalmic eye BID 11. Topiramate Topamax 50 mg PO BID 12. TraZODone 100 mg PO QHS 13. trospium 60 mg oral DAILY 14. Venlafaxine 200 mg PO QHS Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Heart failure with preserved ejection fraction Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Ms. ___ It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL You were admitted to the hospital for rapid weight gain and leg swelling. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL You were given medication to remove fluid from your body. You should continue to take this medication after you leave the hospital. You got imaging of your heart. The study showed normal pumping function but part of the results were indeterminate. You should follow up with your PCP and cardiologist to review these results. WHAT SHOULD I DO WHEN I GO HOME You should continue to take your medications as prescribed. You should attend the appointments listed below. Please weigh yourself every day in the morning. Call your doctor at ___ if your weight goes up by more than 3 lbs. We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I5031, Z6843, R079, D649, E669, E039, R413, K219, G2581, G4700, H04129, R3915. The descriptions of icd codes I5031, Z6843, R079, D649, E669, E039, R413, K219, G2581, G4700, H04129, R3915 are I5031: Acute diastolic (congestive) heart failure; Z6843: Body mass index [BMI] 50.0-59.9, adult; R079: Chest pain, unspecified; D649: Anemia, unspecified; E669: Obesity, unspecified; E039: Hypothyroidism, unspecified; R413: Other amnesia; K219: Gastro-esophageal reflux disease without esophagitis; G2581: Restless legs syndrome; G4700: Insomnia, unspecified; H04129: Dry eye syndrome of unspecified lacrimal gland; R3915: Urgency of urination. The common codes which frequently come are D649, E669, E039, K219, G4700. The uncommon codes mentioned in this dataset are I5031, Z6843, R079, R413, G2581, H04129, R3915.
The icd codes present in this text will be K265, E43, J811, D688, K766, D6959, D62, I471, I959, K255, I4891, K209, B182, K7031, F1011, K660, K3189, Z5309, G8929, I8510, Z66, Z515, R0902, D638, Z590, Z6824, K449, Z720. The descriptions of icd codes K265, E43, J811, D688, K766, D6959, D62, I471, I959, K255, I4891, K209, B182, K7031, F1011, K660, K3189, Z5309, G8929, I8510, Z66, Z515, R0902, D638, Z590, Z6824, K449, Z720 are K265: Chronic or unspecified duodenal ulcer with perforation; E43: Unspecified severe protein-calorie malnutrition; J811: Chronic pulmonary edema; D688: Other specified coagulation defects; K766: Portal hypertension; D6959: Other secondary thrombocytopenia; D62: Acute posthemorrhagic anemia; I471: Supraventricular tachycardia; I959: Hypotension, unspecified; K255: Chronic or unspecified gastric ulcer with perforation; I4891: Unspecified atrial fibrillation; K209: Esophagitis, unspecified; B182: Chronic viral hepatitis C; K7031: Alcoholic cirrhosis of liver with ascites; F1011: Alcohol abuse, in remission; K660: Peritoneal adhesions (postprocedural) (postinfection); K3189: Other diseases of stomach and duodenum; Z5309: Procedure and treatment not carried out because of other contraindication; G8929: Other chronic pain; I8510: Secondary esophageal varices without bleeding; Z66: Do not resuscitate; Z515: Encounter for palliative care; R0902: Hypoxemia; D638: Anemia in other chronic diseases classified elsewhere; Z590: Homelessness; Z6824: Body mass index [BMI] 24.0-24.9, adult; K449: Diaphragmatic hernia without obstruction or gangrene; Z720: Tobacco use. The common codes which frequently come are D62, I4891, G8929, Z66, Z515. The uncommon codes mentioned in this dataset are K265, E43, J811, D688, K766, D6959, I471, I959, K255, K209, B182, K7031, F1011, K660, K3189, Z5309, I8510, R0902, D638, Z590, Z6824, K449, Z720. Allergies Neurontin Chief Complaint Abdominal pain Major Surgical or Invasive Procedure ___ Exploratory laparotomy ___ EGD ___ EGD nasojejeunal placed and bridled removed ___ CT guided placement of an ___ pigtail catheter into the lesser sac collection. removed ___ PICC placement. History of Present Illness ___ man with multiple recent admissions for waxing and waning abdominal pain history of EtOH hep C cirrhosis now presents with 24 hours of acutely worsening epigastric pain associated with multiple episodes of emesis and dark stools. Patient states that his abdominal pain was at its baseline yesterday at which point he noticed an acute worsening of his pain that he describes as sharp and in his upper abdomen. He also had several episodes of emesis reporting his vomit as being dark brown in character. Decided to re present to ED for reevaluation of abdominal pain given acute worsening status. Most recently presented to the ED over the weekend where he got a CT abdomen pelvis that did not show any acute interval changes compared to prior scans. Was discharged home with expectant management transplant surgery was not consulted at that time. Now underwent repeat CT scan showing free air and fluid in the lesser sac concerning for gastric perforation. Transplant surgery is consulted for surgical management of this disease. ROS per HPI Past Medical History Hepatitis C genotype 3 Cirrhosis Child s Class C due EtOH and HCV d b hepatic encephalopathy portal hypertension with ascites and esophageal varices portal hypertensive gastropathy Gastric Duodenal ulcers Insomnia Umbilical hernia Sacral osteoarthritis Past Surgical History Umbilical hernia repair ___ SBO requiring Ex lap repair of ruptured umbilical hernia with lysis of adhesions ___ Abdominal Hematoma evacuation ___ Abdominal incision opened wound vac placed ___ Social History ___ Family History Sister and brother both with collapsed lungs. No family history of liver disease. Physical Exam Admission Physical Exam Vitals T 97.8 HR 96 BP 145 79 RR 20 100 RA GEN A O uncomfortable appearing HEENT No scleral icterus mucus membranes moist CV RRR PULM No respiratory distress ABD Firm tender to percussion in the epigastric region guarding present moderately distended no fluid wave DRE Deferred Neuro CSM grossly intact x 4 Ext No ___ edema UE and ___ warm and well perfused bilat Discharge Physical Exam VS 97.5 95 56 65 18 99 Ra GENERAL cachectic appearing older male sitting up in bed more conversant and interactive today. HEENT anicteric sclera temporal muscle wasting Neck supple HEART irregular rhythm no m r g LUNGS CTAB on anterior exam ABDOMEN protuberant but soft BS tenderness to palpation in right upper quadrant midline surgical incision with staples removed well healed dressing over RLQ with drain place draining dark brown serosanguineous fluid EXTREMITIES no lower extremity edema no clubbing or cyanosis SKIN no jaundice warm and dry NEURO alert oriented no asterixis moving all extremities Pertinent Results Admission Labs ___ 02 35AM WBC 15.9 RBC 3.39 Hgb 11.7 Hct 35.5 MCV 105 MCH 34.5 MCHC 33.0 RDW 14.7 RDWSD 56.3 Plt ___ PTT 29.5 ___ Glucose 122 UreaN 15 Creat 0.5 Na 134 K 4.3 Cl 97 HCO3 22 AnGap 15 ALT 24 AST 63 AlkPhos 92 TotBili 2.5 Lipase 24 Calcium 6.8 Phos 3.7 Mg 1.7 Triglyc 36 Microbiology Blood Culture Routine Final ___ NO GROWTH. HELICOBACTER PYLORI ANTIBODY TEST Final ___ NEGATIVE BY EIA. Reference Range Negative . ___ 7 44 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN Final ___ NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE Final ___ NO GROWTH. ANAEROBIC CULTURE Preliminary NO GROWTH. Imaging CT Abdomen Pelvis ___ IMPRESSION 1. Free air and increased fluid within the lesser sac concerning for perforated viscus which could be from the stomach based on location. 2. Mildly dilated small bowel bowel a transition point. This could represent ileus versus partial small bowel obstruction. No initial in of the bowel or pneumatosis. 3. Cirrhotic liver with findings of portal hypertension including varices and ascites. Upper GI Contrast Study ___ IMPRESSION Leak of contrast from the posterior antrum of the stomach. CXR ___ COMPARISON ___ IMPRESSION Pulmonary edema has slightly worsened. Cardiomediastinal silhouette is stable. Left sided PICC line is unchanged the NG tube projects below the left hemidiaphragm. Small bilateral effusions left greater than right are unchanged. No pneumothorax is seen CT Abdomen Pelvis ___ IMPRESSION 1. A 8.5 x 5.9 cm loculated fluid collection with rim enhancement in the lesser sac is identified. Compared to ___ the fluid collection demonstrates thicker and more discrete wall. 2. Small ascites and peritonitis is similar to before. 3. Liver cirrhosis with mild splenomegaly and portosystemic shunt. 4. Small bilateral pleural effusions. CT Abdomen for Interventional Procedure ___ IMPRESSION Successful CT guided placement of an ___ pigtail catheter into the lesser sac collection. Samples were sent for microbiology evaluation. Abdominal Ultrasound ___ IMPRESSION No fluid pocket amenable to percutaneous sampling. A diagnostic paracentesis was not performed. Transfer Labs ___ 06 32AM WBC 5.0 RBC 2.99 Hgb 9.7 Hct 31.0 MCV 104 MCH 32.4 MCHC 31.3 RDW 17.1 RDWSD 64.6 Plt ___ PTT 28.8 ___ Glucose 108 UreaN 15 Creat 0.5 Na 137 K 4.5 Cl 106 HCO3 24 AnGap 7 ALT 18 AST 58 AlkPhos 194 TotBili 1.2 Albumin 2.2 Calcium 7.3 Phos 2.6 Mg 1.8 Discharge Labs ___ 05 55AM WBC 4.2 RBC 2.72 Hgb 9.0 Hct 28.7 MCV 106 MCH 33.1 MCHC 31.4 RDW 16.6 RDWSD 65.1 Plt ___ Glucose 97 UreaN 14 Creat 0.5 Na 136 K 4.8 Cl 105 HCO3 21 AnGap 10 ALT 19 AST 59 AlkPhos 198 TotBili 1.2 Albumin 2.1 Calcium 7.3 Phos 2.6 Mg 1.8 Brief Hospital Course Summary Mr ___ is a ___ man with alcoholic and hepatitis C cirrhosis who presented with abdominal pain and was found to have a perforated inoperable duodenal and stomach ulcer. Active Issues DUODENAL AND GASTRIC ULCERS with ___ GUIDED DRAINAGE OF LESSER SAC COLLECTION The patient presented to the ___ Emergency Department with abdominal pain. There was evidence of perforated ulcer on both CT abdomen and upper GI series posterior antral leak to lesser sac . Initially he was kept NPO with IV hydration and placed on broad spectrum antibiotics with pip tazo and fluconazole from ___. He underwent EGD on ___ with the following finding large ulcer measuring approximately 5 6cm was seen in the first part of the duodenum. There was likely perforation around the edge of the ulcer measuring 2 3cm This appeared contained. The perforation was too large for endoscopic intervention. There was also moderate to severe esophagitis in the distal esophagus with portal hypertensive gastropathy seen. H. pylori was negative. He was put on the maximum dose of PPI. A NG was in place. He underwent exploratory laparotomy by Dr. ___ but was found to have a frozen abdomen thus unable to see perforated stomach. Postop he was transferred to the SICU for management as he was hypotensive and hematocrit had decreased. He was given albumin and 4 units of PRBC. Hct stabilized but on ___ he had brief episode of SVT with rate of 160 without blood pressure drop afib with intermittent RVR that was treated with metoprolol IV x 2 with decrease in BP. The patient required pressors and amiodarone was started please see Afib below . He transferred out of the SICU and was started on TPN. Afib was managed with metoprolol. Metoprolol dose was increased and he was given intermittent doses of Lasix for volume control and pulmonary edema seen on CXR. His diet was initially advanced to clears then full liquids. However he did not tolerate advancement to a regular diet. He experienced a lot of abdominal pain. Diet was changed to just sips of clears and pain was managed with a Dilaudid PCA. His diet was eventually changed to tube feeds and then regular diet as per an initial goals of care discussion. An abdominal CT ___ an 8cm loculated fluid collection in lesser sac. He then underwent ___ placement of a drain in the fluid collection. Microbiology evaluation of the fluid collection did not grow any organisms so antibiotics were discontinued on ___. ___ continued to follow the drain until output was 5cc for 2 consecutive days at which point the drain was pulled. Diet was advanced slowly for comfort with supplemental nutrition from nasogastric tube feeds. After a goals of care meeting on ___ Pt endorsed a desire to transition towards measures that would improve his comfort. In light of this his NGT was pulled ___ and he was permitted a regular PO diet which he tolerated well. Patient was continued on sucralfate for continued gastric coating and comfort. PPI and other unnecessary medicines were held. GOALS OF CARE DISCUSSION Pt with poor prognosis due to his perforated viscus surgically frozen abdomen and non transplant candidacy. A goals of care meeting was held on ___ with the patient and his friend as well as newly chosen HCP ___. At this meeting Pt acknowledged the severity of his illness and endorsed a willingness to transition his course more towards comfort focused care. Medicines that would not contribute to his comfort were discontinued. Unnecessary tubes and lines including his NGT and PICC line were removed prior to discharge. Patient was discharged to a ___ facility for housing and further titration of his care. ETOH HCV CIRRHOSIS with ASCITES and NEED FOR SBP PPX Previously complicated by hepatic encephalopathy ascites grade I esophageal varices. Pt without significant hepatic encephalopathy or large ascites during his hospital stay he was initially put on oral diuretics to minimize the ascites and risk of wound dehiscence but these were held in the setting of significant weight loss while on tube feeds and overall hypo to euvolemic appearance on exam. Patient was continued on Bactrim for SBP prophylaxis. He was continued on lactulose to keep his mental status clear. Given goals of care discussion as above vitamins such as thiamine and multivitamin were discontinued. ATRIAL FIBRILLATION Had one episode of Afib on ___ for which he was amiodarone loaded and started on amio gtt. He was stable on PO metoprolol in house though sometimes limited due to soft blood pressures. He had a CHADS VASC of 0. Given his goals of care discussion at discharge PO metoprolol was discontinued. Anticoagulation was deferred given recent surgery as well as goals of care discussion as above. NUTRITION Initially requiring TPN then tube feeds by ___. He continued to lose muscle mass despite optimal nutrition on TF s. After goals of care discussion ___ patient was provided with a regular diet which he tolerated well. TRANSITIONAL ISSUES CODE STATUS DNR DNI CMO Do not Hospitalize CONTACT Friend HCP ___ ___ GOALS OF CARE Pt transitioned to DNR DNI and comfort measures only given his poor prognosis and lack of surgical alternatives for his medical conditions. PAIN MANAGEMENT If patient is requiring more than 3 daily doses of oxycodone for breakthrough pain consider uptitrating his TID oxyconTIN for further long lasting pain relief. MEDICATION CHANGES Added Oxycodone 10mg PO q2h PRN breakthrough pain acetaminophen 500mg Q6H Bactrim DS 1 tab daily lidocaine patch oxyconTIN 20mg PO TID sucralfate 1gm PO QID polyethylene glycol 17g daily Changed Lactulose QID TID Bactrim 1 SS tab 1 DS tab for SBP Ppx Stopped Metoprolol Vitamins furosemide lansoprazole Medications on Admission The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Spironolactone 50 mg PO DAILY 5. Sulfameth Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis 6. Polyethylene Glycol 17 g PO DAILY 7. Bisacodyl AILY PRN constipation 8. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 9. Multivitamins 1 TAB PO DAILY 10. Potassium Chloride 20 mEq PO DAILY 11. Simethicone 40 80 mg PO TID PRN gas pain 12. Thiamine 100 mg PO DAILY 13. OxyCODONE Immediate Release 10 mg PO Q4H PRN Pain Moderate Discharge Medications 1. Acetaminophen 500 mg NG Q6H 2. Lidocaine 5 Patch 1 PTCH TD QAM apply to abdomen remove in pm 3. OxyCODONE SR OxyconTIN 20 mg PO TID abdominal pain RX oxycodone 5 mg 5 mL 20 mL by mouth three times a day Refills 0 4. Simethicone 40 80 mg PO TID PRN gas pain 5. Sucralfate 1 gm PO QID 6. Sulfameth Trimethoprim DS 1 TAB PO NG DAILY 7. OxyCODONE Immediate Release 10 mg PO Q2H PRN BREAKTHROUGH PAIN RX oxycodone 5 mg 5 mL 10 mL by mouth every 2 hours Refills 0 8. Bisacodyl AILY PRN constipation 9. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 10. Lactulose 30 mL PO TID 11. Multivitamins 1 TAB PO DAILY 12. Polyethylene Glycol 17 g PO DAILY 13. Thiamine 100 mg PO DAILY Discharge Disposition Extended Care Facility ___ Discharge Diagnosis PRIMARY DIAGNOSES Gastric perforation frozen abdomen. Duodenal ulcer Esophagitis SECONDARY DIAGNOSES portal hypertensive gastropathy anemia malnutrition Cirrhosis Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Mr. ___ WHY WAS I ADMITTED TO THE HOSPITAL You were having pain in your abdomen. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL You were found to have a hole in your intestine perforated ulcer that could not be repaired due to scarred down tissue in your abdomen frozen abdomen You were given antibiotics to prevent infection You had a temporary drain placed in your abdomen to drain an infection and this was removed. You initially were given a feeding tube to bypass the hole but as it healed from the inside you were able to eat regular food. Because you were so sick and there was no cure for your advance liver disease and holes in your stomach and intestines you chose hospice care. WHAT SHOULD I DO WHEN I GO HOME Take medications to help your pain Eat for comfort Thank you for letting us be a part of your care Your ___ Team Followup Instructions ___ The icd codes present in this text will be K265, E43, J811, D688, K766, D6959, D62, I471, I959, K255, I4891, K209, B182, K7031, F1011, K660, K3189, Z5309, G8929, I8510, Z66, Z515, R0902, D638, Z590, Z6824, K449, Z720. The descriptions of icd codes K265, E43, J811, D688, K766, D6959, D62, I471, I959, K255, I4891, K209, B182, K7031, F1011, K660, K3189, Z5309, G8929, I8510, Z66, Z515, R0902, D638, Z590, Z6824, K449, Z720 are K265: Chronic or unspecified duodenal ulcer with perforation; E43: Unspecified severe protein-calorie malnutrition; J811: Chronic pulmonary edema; D688: Other specified coagulation defects; K766: Portal hypertension; D6959: Other secondary thrombocytopenia; D62: Acute posthemorrhagic anemia; I471: Supraventricular tachycardia; I959: Hypotension, unspecified; K255: Chronic or unspecified gastric ulcer with perforation; I4891: Unspecified atrial fibrillation; K209: Esophagitis, unspecified; B182: Chronic viral hepatitis C; K7031: Alcoholic cirrhosis of liver with ascites; F1011: Alcohol abuse, in remission; K660: Peritoneal adhesions (postprocedural) (postinfection); K3189: Other diseases of stomach and duodenum; Z5309: Procedure and treatment not carried out because of other contraindication; G8929: Other chronic pain; I8510: Secondary esophageal varices without bleeding; Z66: Do not resuscitate; Z515: Encounter for palliative care; R0902: Hypoxemia; D638: Anemia in other chronic diseases classified elsewhere; Z590: Homelessness; Z6824: Body mass index [BMI] 24.0-24.9, adult; K449: Diaphragmatic hernia without obstruction or gangrene; Z720: Tobacco use. The common codes which frequently come are D62, I4891, G8929, Z66, Z515. The uncommon codes mentioned in this dataset are K265, E43, J811, D688, K766, D6959, I471, I959, K255, K209, B182, K7031, F1011, K660, K3189, Z5309, I8510, R0902, D638, Z590, Z6824, K449, Z720.
The icd codes present in this text will be K660, E43, K766, Z720, K7031, Z6820, R1084. The descriptions of icd codes K660, E43, K766, Z720, K7031, Z6820, R1084 are K660: Peritoneal adhesions (postprocedural) (postinfection); E43: Unspecified severe protein-calorie malnutrition; K766: Portal hypertension; Z720: Tobacco use; K7031: Alcoholic cirrhosis of liver with ascites; Z6820: Body mass index [BMI] 20.0-20.9, adult; R1084: Generalized abdominal pain. The uncommon codes mentioned in this dataset are K660, E43, K766, Z720, K7031, Z6820, R1084. Allergies Tylenol Neurontin Chief Complaint Abdominal pain Major Surgical or Invasive Procedure None History of Present Illness ___ man presents for evaluation of abdominal pain. Patient recently hospitalized for acute exacerbation of his chronic abdominal pain likely partial bowel obstruction. Discharged yesterday after undergoing conservative management of likely partial bowel obstruction of note at the time of discharge he was pain free and tolerating a regular diet as well as having bowel function. Also had repeat ultrasound of liver which showed resolution of prior portal vein partially occlusive thrombus. Patient reports arriving to his daughter s home having a cup of tea and dinner without issue. However overnight his abdominal pain recurred and he decided to come back in for evaluation. He denies any nausea or vomiting has not had a bowel movement since leaving the hospital yesterday. Denies any fevers chills dysuria chest pain shortness of breath numbness tingling. Transplant surgery is consulted to evaluate for surgical causes of recurrent abdominal pain. ROS per HPI Past Medical History Hepatitis C genotype 3 Cirrhosis Child s Class C due EtOH and HCV d b hepatic encephalopathy portal hypertension with ascites and esophageal varices portal hypertensive gastropathy Gastric Duodenal ulcers Insomnia Umbilical hernia Sacral osteoarthritis Past Surgical History Umbilical hernia repair ___ SBO requiring Ex lap repair of ruptured umbilical hernia with lysis of adhesions ___ Abdominal Hematoma evacuation ___ Abdominal incision opened wound vac placed ___ Social History ___ Family History Sister and brother both with collapsed lungs. No family history of liver disease. Physical Exam Admission Exam VITAL SIGNS 97.9 65 165 75 16 99 RA GENERAL AAOx3 NAD HEENT NCAT EOMI PERRLA No scleral icterus mucosa moist no LAD CARDIOVASCULAR R R R PULMONARY CTA ___ No crackles or rhonchi GASTROINTESTINAL protuberant soft more distended than usual tender to palpation in right hemi abdomen left hemi abdomen mildly tender No guarding rebound or peritoneal signs. EXT MS SKIN No C C E Feet warm. Good perfusion. NEUROLOGICAL Reflexes strength and sensation grossly intact . Discharge Exam VS 97.8 123 72 70 18 98 RA GENERAL NAD patient appears chronically ill sunken temples A Ox3 HEENT AT NC EOMI PERRL anicteric sclera pink conjunctiva adentulous NECK supple no JVD HEART RRR S1 S2 no murmurs gallops or rubs LUNGS CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles ABDOMEN protuberant abdomen not tense decreased bowel sounds. Tender to moderate palpation mostly on R side. Multiple surgical scars appearing c d i. EXTREMITIES no cyanosis clubbing or edema moving all 4 extremities with purpose PULSES 2 DP pulses bilaterally NEURO CN II XII intact SKIN warm and well perfused no excoriations or lesions no rashes Pertinent Results Labs on admission ___ 07 00AM BLOOD WBC 5.7 RBC 3.43 Hgb 11.5 Hct 35.6 MCV 104 MCH 33.5 MCHC 32.3 RDW 14.9 RDWSD 57.2 Plt ___ ___ 07 45AM BLOOD WBC 5.9 RBC 3.49 Hgb 11.7 Hct 36.4 MCV 104 MCH 33.5 MCHC 32.1 RDW 14.7 RDWSD 57.0 Plt ___ ___ 07 00AM BLOOD ___ PTT 35.6 ___ ___ 07 45AM BLOOD ___ ___ 04 42AM BLOOD Glucose 90 UreaN 4 Creat 0.7 Na 136 K 4.6 Cl 102 HCO3 26 AnGap 8 ___ 04 42AM BLOOD ALT 17 AST 50 AlkPhos 110 TotBili 2.4 . Microbiology ___ 7 31 am PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN Final ___ NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE Final ___ NO GROWTH. ANAEROBIC CULTURE Preliminary NO GROWTH. . ___ 07 31AM ASCITES TNC 37 RBC 92 Polys 1 Lymphs 30 Monos 8 Basos 1 Macroph 60 ___ 07 31AM ASCITES TotPro 0.4 Glucose 101 . . Reports imaging RUQ ultrasound IMPRESSION 1. Cirrhotic liver without evidence of focal lesion. 2. Mild to moderate ascites and a right pleural effusion. 3. Patent main and right portal vein with appropriate direction of flow. . Abdominal XR IMPRESSION Borderline diameter of a single loop of small bowel with a few small nonspecific small bowel air fluid levels and air seen in the colon. Findings are nonspecific but a very early very mild partial small bowel obstruction is not entirely excluded in the appropriate clinical setting. . CT abd and pelvis with contrast IMPRESSION 1. Redemonstration cirrhotic liver with sequela of portal hypertension. New branching hypoattenuation in segments VIII and ___ may be due to periportal edema or inflammation along intrahepatic biliary ducts the latter possibly related to cholangitis. The main portal vasculature is patent. 2. Moderate amount of ascites as on prior. Mild peritoneal enhancement without free air or drainable fluid collections could represent peritonitis or secondary to recent paracentesis. . Labs on discharge ___ 06 32AM BLOOD WBC 6.6 RBC 2.84 Hgb 9.8 Hct 29.5 MCV 104 MCH 34.5 MCHC 33.2 RDW 14.2 RDWSD 54.1 Plt ___ ___ 06 32AM BLOOD Glucose 109 UreaN 7 Creat 0.7 Na 133 K 4.3 Cl 100 HCO3 24 AnGap 9 ___ 06 32AM BLOOD ALT 17 AST 50 AlkPhos 104 Amylase 110 TotBili 1.7 ___ 07 00AM BLOOD Lipase 42 ___ 06 32AM BLOOD Lipase 32 ___ 06 32AM BLOOD Calcium 7.6 Phos 2.8 Mg 1.___ with Cirrhosis Child s Class C due EtOH and HCV d b hepatic encephalopathy portal hypertension with ascites and esophageal varices portal hypertensive gastropathy hx numerous abdominal surgeries with suspected frozen abdomen chronic abdominal pain with subacute worsening. Patient had recent admission with small bowel obstruction that was treated conservatively with NG tube and bowel rest and resolved who went home with decreased pain med regimen and who is now returning with worsening abdominal pain. . Abdominal pain CT abd pain pelvis showed no obstruction or extravasation of contrast. Patient was first placed on home pain regiment oxy 10mg q6hr with improvement of pain but given increased pain at 4hours after oxy dose chronic pain service recommended a regimen of 7.5mg oxy every 4 hours which better controlled pain. Lidocaine patch attempted for back pain but without noticeable change. Patient was eating regular diet and with ongoing ___ pain but appearing comfortable walking eating and passing soft stool. . Cirrhosis With regards to cirrhosis Child s Class C due EtOH and HCV with past hepatic encephalopathy portal hypertension with ascites and esophageal varices portal hypertensive gastropathy. No evidence of decompensation during this hospitalization. Para was done that did not show SBP. . TRANSITIONAL ISSUES CHANGED oxycodone 10mg q6hr to 7.5mg q4hr with improvement in pain control STARTED miralax thiamine Please consider outpatient pain consult if worsening pain CONTACT ___ HCP sister ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Furosemide 20 mg PO DAILY 3. OxyCODONE Immediate Release 10 mg PO Q6H PRN pain 4. Spironolactone 50 mg PO DAILY 5. Sulfameth Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis 6. Simethicone 40 80 mg PO TID PRN gas pain 7. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 8. Lactulose 30 mL PO QID 9. Multivitamins 1 TAB PO DAILY 10. Potassium Chloride 20 mEq PO DAILY 11. Bisacodyl AILY PRN constipation Discharge Medications 1. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 ClearLax 17 gram dose 1 scoop powder s by mouth daily Disp 1 Package Refills 0 2. Simethicone 40 80 mg PO TID PRN gas pain 3. Thiamine 100 mg PO DAILY RX thiamine HCl vitamin B1 100 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 4. OxyCODONE Immediate Release 7.5 mg PO Q4H PRN Pain Moderate RX oxycodone Oxaydo 7.5 mg 1 tablet s by mouth every 4 hours Disp 42 Tablet Refills 0 5. Bisacodyl AILY PRN constipation 6. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 7. Famotidine 20 mg PO BID 8. Furosemide 20 mg PO DAILY 9. Lactulose 30 mL PO QID Titrate to ___ bowel movements daily 10. Multivitamins 1 TAB PO DAILY 11. Potassium Chloride 20 mEq PO DAILY 12. Spironolactone 50 mg PO DAILY 13. Sulfameth Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis Discharge Disposition Home Discharge Diagnosis Primary Cirrhosis Intermittent abdominal pain of unknown origin Intraabdominal bowel adhesions . Secondary History of multiple abdominal surgeries Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear. Mr. ___ . It was a pleasure taking part in your care at ___ ___. You were seen for increasing abdominal pain. A number of tests including laboratory and a CT scan were reassuring. You were initially on the surgical service but the surgical team did not feel there was any problem requiring surgery. You were seen by the chronic pain service that made an adjustment to the dose and timing of your pain medication. Please take this new dose as prescribed. Please take the new medications as prescribed. . Please call the surgery doctor ___ office at ___ if you are having increasing abdominal pain inability to tolerate diet not passing gas or having bowel movements nausea vomiting or any other concerning GI complaints. . You are likely to be having intermittent abdominal pain. Please work with your primary care physician regarding your pain management strategies. . No driving if taking narcotic pain medication. . Try to eat small frequent meals using no additional salt stay hydrated. . We wish you the best Your ___ care team Followup Instructions ___ The icd codes present in this text will be K660, E43, K766, Z720, K7031, Z6820, R1084. The descriptions of icd codes K660, E43, K766, Z720, K7031, Z6820, R1084 are K660: Peritoneal adhesions (postprocedural) (postinfection); E43: Unspecified severe protein-calorie malnutrition; K766: Portal hypertension; Z720: Tobacco use; K7031: Alcoholic cirrhosis of liver with ascites; Z6820: Body mass index [BMI] 20.0-20.9, adult; R1084: Generalized abdominal pain. The uncommon codes mentioned in this dataset are K660, E43, K766, Z720, K7031, Z6820, R1084.
The icd codes present in this text will be A084, I81, R188, E872, K766, E871, K7469, K7290, Z720. The descriptions of icd codes A084, I81, R188, E872, K766, E871, K7469, K7290, Z720 are A084: Viral intestinal infection, unspecified; I81: Portal vein thrombosis; R188: Other ascites; E872: Acidosis; K766: Portal hypertension; E871: Hypo-osmolality and hyponatremia; K7469: Other cirrhosis of liver; K7290: Hepatic failure, unspecified without coma; Z720: Tobacco use. The common codes which frequently come are E872, E871. The uncommon codes mentioned in this dataset are A084, I81, R188, K766, K7469, K7290, Z720. Allergies Tylenol Neurontin Chief Complaint RUQ abdominal pain vomiting diarrhea Major Surgical or Invasive Procedure diagnostic para ___ History of Present Illness Mr ___ is a ___ year old man with cirrhosis EtOH HCV untreated genotype 3 Child Class C complicated by esophageal varices ascites and encephalopathy chronic abdominal pain and multiple prior abdominal surgeries presenting with 3 days of more severe RUQ pain vomiting and diarrhea. After a several month stay in rehab in ___ following his last ___ hospitalization in ___ the patient has been doing well at home. In his usual state of health he has chronic RUQ abdominal pain and is followed by his PCP and hepatologist patient states that his pain has been attributed to possibly scar tissue from his several abdominal surgeries. He was previously on fentanyl patch for this but is now on oxycodone 10mg QID. ___ checked ___. Last filled oxycodone 10mg 30 day supply 120 pills ___. He has Child s class C cirrhosis but overall his ascites and hepatic encephalopathy are well controlled with Lasix spironolactone and lactulose. Prior paracentesis was Several years ago. He developed his present symptoms 3 days ago with the subacute onset of worsening RUQ pain stabbing constant with waves of more severe pain worse with vomiting no change with eating position movement . For the past 3 days he has also had ___ episodes per day of vomiting clear yellow fluid no blood or coffee ground emesis and has been unable to tolerate food or fluids and thinks he has also vomited pills although has been trying to stay compliant with his regimen . He has also been having multiple episodes per day of watery yellow fluid diarrhea no blood or melena . His ROS is positive for chills sweats and fatigue. His abdominal distention is moderate but stable. But he denies fevers myalgia arthralgias HA URI symptoms visual complaint chest pain pressure dyspnea cough rash bruising lower extremity edema. No recent travel sick contacts or recent raw uncooked spoiled food. He presented to the ED for further evaluation. In the ED initial vitals were Temp. 98.0 HR 82 BP 157 82 RR 22 100 RA Exam notable for RUQ tenderness to palpitation abdomen distended but soft Bedside abdominal ultrasound showed small volume of ascites without a pocket amenable to paracentesis. Labs notable for WBC 5.4 Hgb 14.0 plt 181 Na 130 K 4.8 HCO3 15 creatinine 0.8 glucose 144 BUN 9 ALT 32 AST 127 alk phos 145 Tbili 4.7 albumin 2.8 lactate 2.6 repeat lactate 1.7 INR 1.4 PTT 38.7 Imaging was notable for CT abdomen ___ 1. Cirrhosis with evidence of portal hypertension with moderate volume ascites partially loculated in the right upper quadrant extensive portosystemic varices. Partially occlusive thrombus in the main portal vein. 2. Small bowel distention without obstruction may reflect ileus. Mild thickening of the proximal colon may reflect portal colopathy. 3. Trace right pleural effusion with chronic appearing atelectasis in the right lower lung. 4. Extensive atherosclerotic disease of the aorta. Liver US ___ 1. There is a new nonocclusive thrombus within the main portal vein with extension into the left and right portal vein branches. There is normal hepatopetal flow within the main portable vein and evidence of sluggish flow within the left and right portal vein branches. 2. Large volume ascites. 3. Worsening splenomegaly measuring 13.7 cm today previously measuring 12 cm ___. 4. New 1.6 cm focus within the right hepatic lobe is incompletely characterized. Follow up MR for further evaluation is recommended. Patient was given morphine 4mg IV x2 ondansetron 4mg IV 1L normal saline started on heparin drip Upon arrival to the floor patient reports continued abdominal pain in the RUQ and being very thirsty and a little hungry. REVIEW OF SYSTEMS Per HPI 10 point ROS reviewed and negative unless stated above in HPI Past Medical History Hepatitis C genotype 3 Cirrhosis Child s Class C due EtOH and HCV d b hepatic encephalopathy portal hypertension with ascites and esophageal varices portal hypertensive gastropathy Gastric Duodenal ulcers Insomnia Umbilical hernia Sacral osteoarthritis Past Surgical History Umbilical hernia repair ___ SBO requiring Ex lap repair of ruptured umbilical hernia with lysis of adhesions ___ Abdominal Hematoma evacuation ___ Abdominal incision opened wound vac placed ___ Social History ___ Family History Sister and brother both with collapsed lungs. No family history of liver disease. Physical Exam ADMISSION PHYSICAL EXAM VITAL SIGNS BP 115 77 hr 64 RR18 SPO2 98 Ra GENERAL chronically ill appearing man resting in bed in moderate discomfort. Able to move around in bed without obvious increase in pain. Alert fully conversant very pleasant. HEENT NCAT. Dry oral mucosa. No scleral icterus. Conjunctivae white. No JVD. NECK full ROM no masses CARDIAC RRR no murmurs no lower extremity edema LUNGS CTAB unlabored breathing on ambient air ABDOMEN moderately distended but soft. Moderately tender in RUQ. Umbilical hernia site intact non tender. Dull to percussion no fluid wave. Normal bowel sounds. Collateral vessels faintly visible in abdominal wall EXTREMITIES warm no edema. No asterixis NEUROLOGIC alert fully oriented. CN exam normal. Strength sensation intact. Gait not tested. No asterixis or tremor. SKIN no rashes no jaundice DISCHARGE PHYSICAL EXAM VS 98.1 PO 106 68 R Lying 68 18 96 Ra GENERAL chronically ill appearing man resting in bed in moderate discomfort. HEENT NCAT. MMM. No scleral icterus CARDIAC RRR no murmurs no lower extremity edema LUNGS CTAB unlabored breathing on ambient air ABDOMEN moderately distended but soft. Moderately tender in RUQ. Umbilical hernia site intact non tender. Normal bowel sounds. Collateral vessels faintly visible in abdominal wall EXTREMITIES warm no edema. No asterixis NEUROLOGIC alert fully oriented. CN exam normal. Strength sensation intact. Gait not tested. No asterixis or tremor. SKIN no rashes no jaundice Pertinent Results ADMISSION LABS ___ 09 36AM BLOOD WBC 5.4 RBC 3.97 Hgb 14.0 Hct 42.2 MCV 106 MCH 35.3 MCHC 33.2 RDW 14.2 RDWSD 56.4 Plt ___ ___ 09 36AM BLOOD Neuts 65.3 ___ Monos 10.4 Eos 1.9 Baso 1.7 Im ___ AbsNeut 3.51 AbsLymp 1.08 AbsMono 0.56 AbsEos 0.10 AbsBaso 0.09 ___ 11 21AM BLOOD ___ PTT 38.7 ___ ___ 09 36AM BLOOD Glucose 144 UreaN 9 Creat 0.8 Na 130 K 4.8 Cl 101 HCO3 15 AnGap 19 ___ 09 36AM BLOOD ALT 32 AST 127 AlkPhos 145 TotBili 4.7 ___ 09 36AM BLOOD Albumin 2.8 ___ 05 00AM BLOOD Calcium 7.7 Phos 2.9 Mg 1.4 ___ 09 44AM BLOOD Lactate 2.6 DISCHARGE LABS ___ 04 46AM BLOOD WBC 5.1 RBC 3.46 Hgb 12.3 Hct 37.0 MCV 107 MCH 35.5 MCHC 33.2 RDW 14.2 RDWSD 55.5 Plt ___ ___ 04 46AM BLOOD ___ PTT 36.8 ___ ___ 04 46AM BLOOD Glucose 93 UreaN 9 Creat 0.9 Na 133 K 4.2 Cl 99 HCO3 26 AnGap 12 ___ 04 46AM BLOOD ALT 21 AST 63 AlkPhos 159 TotBili 2.3 ___ 04 46AM BLOOD Albumin 2.4 Calcium 8.0 Phos 3.6 Mg 1.6 PERTINENT RESULTS ___ 01 55PM ASCITES TNC 64 RBC 650 Polys 1 Lymphs 48 Monos 6 Mesothe 2 Macroph 43 Other 0 ___ 01 55PM ASCITES TotPro 1.7 Glucose 103 LD LDH 104 Albumin 0.7 Cholest 19 ___ 08 58PM STOOL NoroGI NEGATIVE NoroGII NEGATIVE MICROBIOLOGY ___ 1 55 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. Fluid Culture in Bottles Preliminary NO GROWTH. ___ 1 48 pm PERITONEAL FLUID PERITONEAL FLUID. FINAL REPORT ___ GRAM STAIN Final ___ 1 1 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method please refer to hematology for a quantitative white blood cell count. IMAGING ___ IMPRESSION 1. Cirrhosis with new partially occlusive thrombus within the main portal vein. 2. Large volume ascites. 3. Worsening splenomegaly measuring 13.7 cm today previously measuring 12 cm ___. 4. New 1.6 cm focus within the right hepatic lobe is incompletely characterized. Follow up MR for further evaluation is recommended. ___ IMPRESSION Tiny right pleural effusion otherwise unremarkable exam. ___ IMPRESSION 1. Cirrhosis with evidence of portal hypertension with moderate volume ascites partially loculated in the right upper quadrant extensive portosystemic varices. Partially occlusive thrombus in the main portal vein. 2. Small bowel distention without obstruction may reflect ileus. Mild thickening of the proximal colon may reflect portal colopathy. 3. Trace right pleural effusion with chronic appearing atelectasis in the right lower lung. 4. Extensive atherosclerotic disease of the aorta. Brief Hospital Course ___ year old man with cirrhosis EtOH HCV untreated genotype 3 Child Class C complicated by esophageal varices ascites and encephalopathy chronic abdominal pain and multiple prior abdominal surgeries presenting with 3 days of acute on chronic RUQ pain vomiting and diarrhea likely ___ viral gastroenteritis. C.diff negative norovorius negative. Diagnostic para w no e o SBP. Stool Cx pending at time of discharge. Patient was given IV fluids with spontaneous resolution though persistent chronic RUQ pain . Hospital course complicated by new non occlusive PVT lactate slightly elevated on initial presentation normalized with IVF less c f ischemia. Outpatient hepatologist Dr. ___ was contacted who recommended against anticoagulation given non occlusive and concerns with patient compliance. Otherwise no changes to home medications. ACUTE ISSUES Abdominal pain vomiting diarrhea presented with 3 days of acute on chronic RUQ pain vomiting and diarrhea likely ___ viral gastroenteritis. C.diff negative norovorius negative. Diagnostic para w no e o SBP. Stool Cx pending at time of discharge. Patient was given IV fluids with spontaneous resolution though persistent chronic RUQ pain . Of note RUQ U S and CT A P w e o non occlusive PVT though unlikely explanation for presentation as non occlusive w down trending lactate. Partially occlusive portal vein thrombosis iso decompensated cirrhosis RUQ ultrasound and CT abdomen with contrast demonstrated partially occlusive portal vein thrombus new since ___ ultrasound. Lactate slightly elevated on initial presentation normalized with IVF less c f ischemia. Outpatient hepatologist Dr. ___ was contacted who recommended against anticoagulation given non occlusive and concerns with patient compliance. Hyponatremia Admitted w serum sodium 130. Per history multiple days of low fluid intake diarrhea vomiting while continuing to take diuretics suggested he was intravascularly depleted. Resolved s p 1L IVF and resolution of gastroenteritis w improved PO intake. Home diuretics restarted upon discharge. Cirrhosis Child s Class C complicated by ascites hepatic encephalopathy prior SBP esophageal varices. volume home Lasix spironolactone initially held iso n v d resumed upon discharge. hepatic encephalopathy cont home lactulose after resolution of diarrhea SBP ppx cont home Bactrim esophageal varices last EGD in ___ no evidence of bleeding on this presentation Transitional Issues On RUQ U S There is a 1.6 cm echogenic focus within the mid right hepatic lobe peripherally for which follow up MR for further evaluation is recommended. Patient w new non occlusive PVT. Would recommend f u CT in 3 months to eval for progression of PVT thrombus. Stool cultures pending at time of discharge please follow up CODE full CONTACT sister HCP ___ ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. Lactulose 30 mL PO TID 3. Spironolactone 50 mg PO DAILY 4. Famotidine 20 mg PO Q12H 5. OxycoDONE Immediate Release 10 mg PO Q6H PRN Pain Moderate 6. Multivitamins 1 TAB PO DAILY 7. Potassium Chloride 10 mEq PO DAILY 8. Sulfameth Trimethoprim SS 1 TAB PO DAILY 9. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 10. Polyethylene Glycol 17 g PO DAILY PRN constipation Discharge Medications 1. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 2. Famotidine 20 mg PO Q12H 3. Furosemide 20 mg PO DAILY 4. Lactulose 30 mL PO TID 5. Multivitamins 1 TAB PO DAILY 6. OxycoDONE Immediate Release 10 mg PO Q6H PRN Pain Moderate RX oxycodone 10 mg 1 tablet s by mouth every six 6 hours Disp 8 Tablet Refills 0 7. Polyethylene Glycol 17 g PO DAILY PRN constipation 8. Potassium Chloride 10 mEq PO DAILY Hold for K 9. Spironolactone 50 mg PO DAILY 10. Sulfameth Trimethoprim SS 1 TAB PO DAILY Discharge Disposition Home Discharge Diagnosis Primary Diagnosis viral gastroenteritis Secondary Diagnosis ETOH HCV Cirrhosis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr ___ It was a pleasure being involved in your care. Why you were here You came in for nausea vomiting diarrhea. What we did while you were here We gave you some fluids through your IV because you were dehydrated. We believe that you had a viral illness which cleared on its own. We also took some fluid out of your abdomen to make sure you were not having an infection and this was negative for any infection. Your next steps please take all your medications as indicated below please keep all of your appointments We wish you well Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be A084, I81, R188, E872, K766, E871, K7469, K7290, Z720. The descriptions of icd codes A084, I81, R188, E872, K766, E871, K7469, K7290, Z720 are A084: Viral intestinal infection, unspecified; I81: Portal vein thrombosis; R188: Other ascites; E872: Acidosis; K766: Portal hypertension; E871: Hypo-osmolality and hyponatremia; K7469: Other cirrhosis of liver; K7290: Hepatic failure, unspecified without coma; Z720: Tobacco use. The common codes which frequently come are E872, E871. The uncommon codes mentioned in this dataset are A084, I81, R188, K766, K7469, K7290, Z720.
The icd codes present in this text will be K565, K7031, I8510, K766, F17210, Z6823, B1920, I81, E43. The descriptions of icd codes K565, K7031, I8510, K766, F17210, Z6823, B1920, I81, E43 are K565: Intestinal adhesions [bands] with obstruction (postinfection); K7031: Alcoholic cirrhosis of liver with ascites; I8510: Secondary esophageal varices without bleeding; K766: Portal hypertension; F17210: Nicotine dependence, cigarettes, uncomplicated; Z6823: Body mass index [BMI] 23.0-23.9, adult; B1920: Unspecified viral hepatitis C without hepatic coma; I81: Portal vein thrombosis; E43: Unspecified severe protein-calorie malnutrition. The common codes which frequently come are F17210. The uncommon codes mentioned in this dataset are K565, K7031, I8510, K766, Z6823, B1920, I81, E43. Allergies Tylenol Neurontin Chief Complaint Acute Abdominal pain Major Surgical or Invasive Procedure None History of Present Illness This patient is a ___ year old male with ETOH and Hep C cirrhosis child s class B MELD 16 presenting to the ED with acute abdominal pain concerning for recurrent bowel obstruction. Patient is now being seen by Transplant surgery in consultation. As above the patient has a history of cirrhosis secondary to both ethanol and Hep C. Currently compensated. Last paracentesis performed ___ years ago. His surgical history is pertinent for a prior umbilical repair and an exploratory laparotomy for a closed loop obstruction requiring lysis of an internal hernia. The patient was in his usual state of health until last night when he developed an acute abdominal pain. He describes the pain as stabbing in nature and constant. The pain is located in his right flank. He has had around 10 episodes of bilious emesis. Denies hematemesis. Last episode of vomiting was this morning at 10 00. He has not felt better after the emesis triggering this ED visit. He describes this pain similar in nature as prior one last year when he required exploration. The patient endorses chills but denies any fever chest pain SOB dysuria or urinary urgency or frequency. He last passed gas this morning and has not had a bowel movement in the last two days. In the ED VSS. Patient with persistent nausea. No NG in place. Abdomen soft but tender to right flank. No peritoneal. Labs w o leukocytosis or acidosis. Imaging studies c w distal ileum bowel obstruction. No signs of bowel ischemia. Moderate ascites. ROS per HPI Denies pain fevers chills night sweats unexplained weight loss fatigue malaise lethargy changes in appetite trouble with sleep pruritis jaundice rashes bleeding easy bruising headache dizziness vertigo syncope weakness paresthesias nausea vomiting hematemesis bloating cramping melena BRBPR dysphagia chest pain shortness of breath cough edema urinary frequency urgency Past Medical History Hepatitis C genotype 3 Cirrhosis Child s Class C due EtOH and HCV d b hepatic encephalopathy portal hypertension with ascites and esophageal varices portal hypertensive gastropathy Gastric Duodenal ulcers Insomnia Umbilical hernia Sacral osteoarthritis Past Surgical History Umbilical hernia repair ___ SBO requiring Ex lap repair of ruptured umbilical hernia with lysis of adhesions ___ Abdominal Hematoma evacuation ___ Abdominal incision opened wound vac placed ___ Social History ___ Family History Sister and brother both with collapsed lungs. No family history of liver disease. Physical Exam Vitals 98.1 121 70 57 18 98 RA GEN A O NAD HEENT No scleral icterus mucus membranes moist CV RRR No M G R PULM Clear to auscultation b l No W R R ABD Soft tender to deep palpation to right flank. No rebound. Ascites. Dull to percussion. Ext No ___ edema ___ warm and well perfused . Weight at discharge 64.5 kg Pertinent Results Labs on Admission ___ WBC 6.1 RBC 4.29 Hgb 14.8 Hct 44.0 MCV 103 MCH 34.5 MCHC 33.6 RDW 15.7 RDWSD 56.9 Plt ___ PTT 38.3 ___ Glucose 121 UreaN 9 Creat 0.7 Na 138 K 4.4 Cl 100 HCO3 24 AnGap 14 ALT 27 AST 102 AlkPhos 135 TotBili 4.1 Albumin 3.1 Calcium 8.5 Phos 4.2 Mg 1.6 . Labs at Discharge ___ WBC 5.8 RBC 3.88 Hgb 13.3 Hct 39.9 MCV 103 MCH 34.3 MCHC 33.3 RDW 15.7 RDWSD 58.6 Plt ___ Glucose 145 UreaN 6 Creat 0.8 Na 136 K 5.3 Cl 105 HCO3 23 AnGap 8 ALT 18 AST 54 AlkPhos 94 TotBili 3.8 Calcium 7.6 Phos 3.7 Mg 1.___ y o male with HCV ETOH cirrhosis with prior ex lap who now presents with acute abdominal pain. On admission the patient had a CT done with findings suspicious for partial small bowel obstruction with adhesive disease in the right lower quadrant involving loops of ileum with alternating areas of luminal narrowing and dilatation. Overall the appearance of the small bowel is similar to the previous CT from ___. Of note there is liver cirrhosis with small to moderate ascites mild splenomegaly and portosystemic varices. There is also a nonocclusive small thrombus in the main portal vein which is slightly smaller compared to ___. An NG tube was placed and he was having bilious output from the NG tube. He reported passing some flatus and the abdominal pain was present but stable on exam. On hospital day two he was reporting an increase in abdominal pain. A KUB was done showing that there was no evidence of free air. The abdominal exam still showed him to be soft and serial exams over the next ___ hours showed him to be less tender. A suppository was given resulting in a loose bowel movement and he was reporting passing some flatus still. The NG tube output was lightening in colr and less volume. Prior to the NG tube being discontinued another KUB was obtained with no evidence of obstruction. The NG tube was removed and he was kept NPO for the next ___ hours. He had no nausea with tube removed and so he was started on a clear diet which he tolerated without nausea or vomiting. The abdominal exam was significantly improved so he was deemed safe for discharge with plan for clears for three days. Liver function tests were slightly improved at discharge. Additionally the patient has a follow up appointment with his hepatologist this week which the patient was advised to keep. Home medications including diuretics were resumed at discharge. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Fentanyl Patch 50 mcg h TD Q72H 3. Furosemide 20 mg PO DAILY 4. Lactulose 30 mL PO QID 5. Lidocaine 5 Patch 1 PTCH TD QAM 6. OxyCODONE Immediate Release 10 mg PO Q6H PRN Pain Moderate 7. Potassium Chloride 20 mEq PO DAILY 8. Spironolactone 50 mg PO DAILY 9. Sulfameth Trimethoprim SS 1 TAB PO DAILY 10. Bisacodyl 10 mg PR QHS PRN constipation 11. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 12. Polyethylene Glycol 17 g PO DAILY Discharge Medications 1. Bisacodyl 10 mg PR QHS PRN constipation 2. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 3. Famotidine 20 mg PO BID 4. Fentanyl Patch 50 mcg h TD Q72H 5. Furosemide 20 mg PO DAILY 6. Lactulose 30 mL PO QID 7. Lidocaine 5 Patch 1 PTCH TD QAM 8. OxyCODONE Immediate Release 10 mg PO Q6H PRN Pain Moderate 9. Polyethylene Glycol 17 g PO DAILY 10. Potassium Chloride 20 mEq PO DAILY 11. Spironolactone 50 mg PO DAILY 12. Sulfameth Trimethoprim SS 1 TAB PO DAILY Discharge Disposition Home Discharge Diagnosis Small bowel obstruction Resolved Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Please call Dr. ___ office at ___ if you have fever greater than 101 chills nausea vomiting constipation you are not passing gas you have a lot of hiccupping or burping your abdomen is becoming more distended you have pain in your abdomen or any other concerning symptoms. Continue all your home medications as they have been prescribed to you. Follow up with your primary providers if you have questions about those medications. To help your bowel heal and not become obstructed again you should continue a clear diet through ___. This means liquids you can see through clear sodas water clear juices jello and broth. Followup Instructions ___ The icd codes present in this text will be K565, K7031, I8510, K766, F17210, Z6823, B1920, I81, E43. The descriptions of icd codes K565, K7031, I8510, K766, F17210, Z6823, B1920, I81, E43 are K565: Intestinal adhesions [bands] with obstruction (postinfection); K7031: Alcoholic cirrhosis of liver with ascites; I8510: Secondary esophageal varices without bleeding; K766: Portal hypertension; F17210: Nicotine dependence, cigarettes, uncomplicated; Z6823: Body mass index [BMI] 23.0-23.9, adult; B1920: Unspecified viral hepatitis C without hepatic coma; I81: Portal vein thrombosis; E43: Unspecified severe protein-calorie malnutrition. The common codes which frequently come are F17210. The uncommon codes mentioned in this dataset are K565, K7031, I8510, K766, Z6823, B1920, I81, E43.
The icd codes present in this text will be K56600, K766, I8510, K7031, F17210, M47818. The descriptions of icd codes K56600, K766, I8510, K7031, F17210, M47818 are K56600: Partial intestinal obstruction, unspecified as to cause; K766: Portal hypertension; I8510: Secondary esophageal varices without bleeding; K7031: Alcoholic cirrhosis of liver with ascites; F17210: Nicotine dependence, cigarettes, uncomplicated; M47818: Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region. The common codes which frequently come are F17210. The uncommon codes mentioned in this dataset are K56600, K766, I8510, K7031, M47818. Allergies Tylenol Neurontin Chief Complaint Abdominal pain nausea vomiting Major Surgical or Invasive Procedure Paracentesis ___ History of Present Illness ___ year old male with ETOH and Hep C cirrhosis child s class B MELD 16 presenting to the ED with acute abdominal pain concerning for recurrent bowel obstruction. His surgical history is pertinent for a prior umbilical repair and an exploratory laparotomy for a closed loop obstruction requiring lysis of an internal hernia. The patient was in his usual state of health until 5 days ago when he started having mild diffuse abdominal pain associated with nausea and multiple episodes of emesis. Denies bilious or bloody emesis. Last episode of emesis was 2 days ago but still complains of nausea and abdominal pain. He also mentions that his last bowel movement was 2 days ago same time when he last passed flatus. He also mentions some subjective fevers but denies taking his temperature. Off note on ___ this year he presented to the ED with similar symptoms which required hospitalization for SBO that was managed conservatively. Other than that he denies shortness of breath palpitations night sweats unexplained weight loss fatigue malaise lethargy changes in appetite trouble with sleep dysuria. In the ED VSS. Patient with persistent nausea and abdominal pain. No NG tube in place. Abdomen soft but tender to palpation in right hemi abdomen. No peritoneal. Labs w o leukocytosis or acidosis. Imaging studies suggestive of SBO with transition in right hemi abdomen. No signs of bowel ischemia. Moderate ascites. Past Medical History Hepatitis C genotype 3 Cirrhosis Child s Class C due EtOH and HCV d b hepatic encephalopathy portal hypertension with ascites and esophageal varices portal hypertensive gastropathy Gastric Duodenal ulcers Insomnia Umbilical hernia Sacral osteoarthritis Past Surgical History Umbilical hernia repair ___ SBO requiring Ex lap repair of ruptured umbilical hernia with lysis of adhesions ___ Abdominal Hematoma evacuation ___ Abdominal incision opened wound vac placed ___ Social History ___ Family History Sister and brother both with collapsed lungs. No family history of liver disease. Physical Exam VITAL SIGNS T97.7 BP 156 76 HR 58 RR 18 SpO2 97 RA GENERAL AAOx3 NAD HEENT NCAT no scleral icterus CARDIOVASCULAR rrr S1S2 PULMONARY CTABL non labored respirations GASTROINTESTINAL soft minimally distended per baseline mildly TTP over R abdomen much improved from admission and consistent with baseline. No guarding rebound or peritoneal signs. EXT MS SKIN No cyanosis clubbing or edema NEUROLOGICAL Strength and sensation grossly intact Pertinent Results Admission labs ___ 06 10PM BLOOD WBC 7.8 RBC 3.46 Hgb 12.0 Hct 35.9 MCV 104 MCH 34.7 MCHC 33.4 RDW 15.6 RDWSD 58.6 Plt ___ ___ 06 10PM BLOOD Glucose 99 UreaN 5 Creat 0.6 Na 134 K 3.6 Cl 98 HCO3 25 AnGap 11 ___ 06 10PM BLOOD ALT 16 AST 44 AlkPhos 122 TotBili 2.7 ___ 06 10PM BLOOD Albumin 2.7 Calcium 8.1 Phos 2.9 Mg 1.4 ___ 06 10PM BLOOD Lipase ___ year old male with ETOH and Hep C cirrhosis child s class B presented to the ED with acute abdominal pain nausea and vomiting concerning for recurrent bowel obstruction. His initial CT abdomen showed slightly dilated loops of jejunum with relative transition point right hemiabdomen followed by decompressed bowel distal small bowel loops were normal in caliber with air and stool present. No pneumatosis bowel wall thickening or pneumoperitoneum were seen. He was admitted to Transplant surgery and kept NPO with IV fluid. Serial abdominal exams were done noting increased distension and tenderness. No free air was seen on KUB. A nasogastric tube was placed to decompress the stomach and a Foley catheter was placed to closely monitor urine output. He was given a dulcolax suppository with passage of a BM. Lactate increased the next day to 2.1 then 3.1. A CT was done that showed colonic thickening but no obstruction. He continued to require IV fluid bolus for low u o.Lactate decrease to 1.9. By hospital day 4 exam was improved and lactate had decreased. The foley was removed. On ___ he tolerated NG clamp trials and the NG was removed. On ___ a clear diet was tolerated and this advanced to regular diet that he also tolerated. However over night he c o sudden right hemi abdominal pain and gas pain. Simethicone was administered with relief. He was moving his bowels without difficulty. Hepatology was consulted and recommended a paracentesis. This done on ___ with 0.4 liter removed. Cell count was notable for WBC TNC and zero polys. Culture of ascites was negative. On ___ he felt ready for discharge to home. His home Nadolol was held as his heart rates were in the ___. SBP ranged between 104 160s. On ___ t.bili increased from 2.0 to 2.4. A liver duplex was done to evaluate his portal vein given h o portal vein thrombus. U S demonstrated patent main and right portal vein small ascites and small right pleural effusion. He was discharged to home in stable condition. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Famotidine 20 mg PO BID 2. Furosemide 20 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Lidocaine 5 Patch 1 PTCH TD QAM 5. OxyCODONE Immediate Release 5 mg PO Q6H PRN pain 6. Potassium Chloride 20 mEq PO DAILY 7. Spironolactone 50 mg PO DAILY 8. Sulfameth Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis 9. Bisacodyl AILY PRN constipation 10. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 11. Multivitamins 1 TAB PO DAILY Discharge Medications 1. Simethicone 40 80 mg PO TID PRN gas pain 2. Bisacodyl AILY PRN constipation 3. Calcium 600 D 3 calcium carbonate vitamin D3 600 mg 1 500mg 400 unit oral DAILY 4. Famotidine 20 mg PO BID 5. Furosemide 20 mg PO DAILY 6. Lactulose 30 mL PO QID 7. Multivitamins 1 TAB PO DAILY 8. OxyCODONE Immediate Release 5 mg PO Q6H PRN pain continue to follow up with your outpatient provider for management 9. Potassium Chloride 20 mEq PO DAILY Hold for K 5.0 10. Spironolactone 50 mg PO DAILY 11. Sulfameth Trimethoprim SS 1 TAB PO DAILY SBP prophylaxis Discharge Disposition Home Discharge Diagnosis Cirrhosis Abdominal pain Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Please call Dr. ___ office at ___ for fever 101 chills nausea vomiting diarrhea constipation increased abdominal pain pain not controlled by your pain medication swelling of the abdomen or ankles yellowing of the skin or eyes inability to tolerate food fluids or medications or any other concerning symptoms. You may return to your usual healthy diet. If your abdomen becomes distended you stop passing gas or you begin burping go back to having only sips of clear liquids. If your symptoms worsen or do not resolve call the clinic number above or come to the ED. No driving if taking narcotic pain medications. You did not have surgery on this admission and do not need a surgical follow up visit. However please keep the appointment we have made for you with your usual hepatologist Dr. ___ to monitor your liver function. Followup Instructions ___ The icd codes present in this text will be K56600, K766, I8510, K7031, F17210, M47818. The descriptions of icd codes K56600, K766, I8510, K7031, F17210, M47818 are K56600: Partial intestinal obstruction, unspecified as to cause; K766: Portal hypertension; I8510: Secondary esophageal varices without bleeding; K7031: Alcoholic cirrhosis of liver with ascites; F17210: Nicotine dependence, cigarettes, uncomplicated; M47818: Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region. The common codes which frequently come are F17210. The uncommon codes mentioned in this dataset are K56600, K766, I8510, K7031, M47818.
The icd codes present in this text will be K565, E43, J189, J952, K766, M96831, D62, T814XXA, L03311, K7031, M47817, Z6823, F17210, D696, Y838, Y92239, T17990A, R339. The descriptions of icd codes K565, E43, J189, J952, K766, M96831, D62, T814XXA, L03311, K7031, M47817, Z6823, F17210, D696, Y838, Y92239, T17990A, R339 are K565: Intestinal adhesions [bands] with obstruction (postinfection); E43: Unspecified severe protein-calorie malnutrition; J189: Pneumonia, unspecified organism; J952: Acute pulmonary insufficiency following nonthoracic surgery; K766: Portal hypertension; M96831: Postprocedural hemorrhage of a musculoskeletal structure following other procedure; D62: Acute posthemorrhagic anemia; T814XXA: Infection following a procedure; L03311: Cellulitis of abdominal wall; K7031: Alcoholic cirrhosis of liver with ascites; M47817: Spondylosis without myelopathy or radiculopathy, lumbosacral region; Z6823: Body mass index [BMI] 23.0-23.9, adult; F17210: Nicotine dependence, cigarettes, uncomplicated; D696: Thrombocytopenia, unspecified; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; T17990A: Other foreign object in respiratory tract, part unspecified in causing asphyxiation, initial encounter; R339: Retention of urine, unspecified. The common codes which frequently come are D62, F17210, D696. The uncommon codes mentioned in this dataset are K565, E43, J189, J952, K766, M96831, T814XXA, L03311, K7031, M47817, Z6823, Y838, Y92239, T17990A, R339. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Abd pain Major Surgical or Invasive Procedure ___ ex lap and LOA ___ hematoma evacuation ___ Incision opened and VAC placed History of Present Illness ___ with HCV ETOH cirrhosis MELD 13 MELD Na 18 p w 5 days of nausea vomiting abdominal pain and melena. His symptoms started 5 days ago and he has not been able to maintain adequate PO intake since. His pain was initially diffuse but is now localized to the RLQ. Denies fevers or chills. No prior similar episodes in the past. The patient is followed by Dr. ___ at ___. Per patient report his liver disease has been stable in the past ___ years and his ascites has been well controlled with medical therapy last paracenthesis over one year ago per pt report . Last EGD on file done in ___ significant for 2 bleeding gastric ulcers and one duodenal ulcer. Past Medical History HCV cirrhosis lumbar and sacral osteoarthritis FTT gastric and duodenal ulcers Social History ___ Family History Non Contributory Physical Exam Temp 98.5 P 89 BP 109 69 RR 18 O2 100 RA General alert OrientedX3 in no acute distress HEENT atraumatic normocephalic oral mucosa moist Resp clear breath sounds bilaterally CV RRR no murmurs rubs or gallops Abd soft protuberant mid line vac intact Vac measurement 5cm long x2cm wide x1cm deep low suction 75mm Hg Extr atraumatic skin intact Pertinent Results ___ 05 00AM BLOOD WBC 7.2 RBC 2.11 Hgb 7.2 Hct 22.2 MCV 105 MCH 34.1 MCHC 32.4 RDW 19.5 RDWSD 73.1 Plt ___ ___ 07 30AM BLOOD WBC 7.3 RBC 3.44 Hgb 11.9 Hct 35.3 MCV 103 MCH 34.6 MCHC 33.7 RDW 14.8 RDWSD 55.3 Plt ___ ___ 05 20AM BLOOD ___ PTT 41.5 ___ ___ 05 00AM BLOOD Glucose 86 UreaN 10 Creat 0.5 Na 131 K 3.8 Cl 103 HCO3 22 AnGap 10 ___ 04 40AM BLOOD ALT 14 AST 38 AlkPhos 83 TotBili 3.4 ___ 07 30AM BLOOD Lipase 126 ___ 05 00AM BLOOD Albumin 2.2 Calcium 7.2 Phos 2.4 Mg 1.7 ___ CT ABD PELVIS WITH CO IMPRESSION 1. Large right rectus sheath hematoma measuring 9 x 5.9 x 8.5 cm with evidence of active extravasation. Given patient s history of cirrhosis and portal hypertension and venous collaterals it is unclear whether the source of this hematoma is arterial or venous. 2. Moderate right sided pleural effusion. 3. Cirrhotic appearing liver extensive esophageal perigastric and perisplenic varices and large volume ascites. ___ PARACENTESIS DIAG THERA IMPRESSION Technically successful ultrasound guided diagnostic and therapeutic paracentesis removing 0.8 L of serosanguineous ascitic fluid. Brief Hospital Course Mr. ___ is a ___ year old male with a history of HCV cirrhosis who presented to ___ on ___ with the chief complaint of abdominal pain evaluation in the ED by surgery revealed localized abdominal pain with clinical and radiological signs of an acute abdomen with concern for an internal hernia. The patient was taken to the OR for a lysis of adhesions and relief of obstruction due to multiple adhesions into the pelvis causing an internal loop obstruction. The patient tolerated the procedure well please refer to the operative report for further details. Post procedure the patient was extubated in PACU due to prolonged sedation which went unremarkably. He did receive 24 hours of cefazolin after surgery in addition to 5 albumin for a total of 500cc for volume support. On POD1 The patient was kept NPO with a NG tube in place. He electrolytes were closely monitored and repleted as necessary. His pain was further managed with IV and PO pain medications. POD2 a NGT clamp trial was performed and the patient was started on glutamine supplementation. His electrolytes were continued to be closely monitored and repleted. There was a concern for a RUE DVT due to difficult CVL placement in the OR however a repeat RUE neck US showed no evidence of a DVT. POD3 the patient underwent a KUB which did not show signs of obstruction or ileus. NGT was dc d and the patient was kept NPO. He electrolytes were repleted as per protocol. His foley catheter was removed at mid night and the patient voided spontaneously. POD4 the patient complained of a cough with intermittent sputum production he was given a PRN nebulizer therapy and a PA LAT cxr was consistent with clearing of a prior mucous plug. The patient was started on a clear liquid diet and his IVF were stopped once he was taking in a good amount PO. His home Lasix dose was continued as well. The patient s expected post operative pain and transient electrolyte abnormalities were followed and corrected. POD5 overnight the patient complained of ___ erythema along with fluctuance and increased pain tenderness. An Abd Pelv CT scan without contrast revealed a large right rectus sheath hematoma measuring 9 x 5.9 x 8.5 cm with evidence of active extravasation given those findings several wound staples were removed at bed side with the plan to take to OR as soon as possible. The patient received a ___ in the interim due to continuous oozing from his abdominal wound. A foley was placed due to urinary retention. The patient was taken to the OR and a rectus sheath hematoma was evacuated and any active bleeders were treated with argon beam laser. A wound vac was placed in the OR for wound management. Post op the patient s medications were resumed and he was started on a clear liquid diet. POD6 the patient tolerated his clear diet well and was advanced to a regular diet while his IVF were dc d. His diuretics were restarted and he was given 1U of FFP due to a high INR and anticipation of a paracentesis. The patient s levaquin for presumed pneumonia was changed to vanc cefepime for broader coverage in addition he underwent a nasal MRSA screen which was negative along with sputum cx which grew commensal flora. The patient under paracentesis due to abdominal distention where 0.8L were removed and cell count was not consistent with SBP. The patient received 12.5 grams of albumin for repletion. POD7 the patient was restarted on his lactulose his foley dc d and a vac placed. POD8 the patient was managed for his routine pain control electrolyte repletion along with ambulation. POD9 a physical therapy consult was placed and the patient resumed his PO levaquin to complete a 7 day course. POD10 11 an occupation therapy consult was placed and the patient was discharged to rehab. The patient s vac was changed on ___ its measurements are 5cmX2cmX1cm deep and the vac is set on min suction at 75 mmHg At the time of discharge the patient was comfortable with the discharge plan and recommendations. Medications on Admission Spironolactone 50 mg daily Furosemide 20 mg daily Lactulose 20 GM 30 ML solution 30 mLs by mouth 3 three times daily. Lidocaine 5 patch MVI Potassium chloride ___ MEQ tablet1 tablet by mouth daily. Discharge Medications 1. Furosemide 20 mg PO DAILY 2. Lactulose 30 mL PO TID Titrate to ___ bowel movements daily 3. Spironolactone 50 mg PO DAILY 4. Famotidine 20 mg PO Q12H 5. OxycoDONE Immediate Release ___ mg PO Q4H PRN pain 6. Lidocaine 5 Patch 1 PTCH TD QAM 7. Multivitamins 1 TAB PO DAILY 8. Potassium Chloride 10 mEq PO DAILY Hold for K 5 Discharge Disposition Extended Care Facility ___ ___ Diagnosis ETOH Cirrhosis Small bowel obstruction Rectus sheath hematoma Pneumonia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Please contact Dr. ___ office at ___ if the patient develops fever 101 chills bleeding from the wound nausea vomiting diarrhea constipation inability to tolerate food fluids or medications increased abdominal pain jaundice yellowing of the skin or eyes VAC fails to hold suction or any other concerns No lifting more than 10 pounds VAC dressing change to abdominal wound q 3 days using black foam and 75 mmHG continuous suction. If VAC fails wound may be temporarily dressed with a NS damp to dry dressing. Followup Instructions ___ The icd codes present in this text will be K565, E43, J189, J952, K766, M96831, D62, T814XXA, L03311, K7031, M47817, Z6823, F17210, D696, Y838, Y92239, T17990A, R339. The descriptions of icd codes K565, E43, J189, J952, K766, M96831, D62, T814XXA, L03311, K7031, M47817, Z6823, F17210, D696, Y838, Y92239, T17990A, R339 are K565: Intestinal adhesions [bands] with obstruction (postinfection); E43: Unspecified severe protein-calorie malnutrition; J189: Pneumonia, unspecified organism; J952: Acute pulmonary insufficiency following nonthoracic surgery; K766: Portal hypertension; M96831: Postprocedural hemorrhage of a musculoskeletal structure following other procedure; D62: Acute posthemorrhagic anemia; T814XXA: Infection following a procedure; L03311: Cellulitis of abdominal wall; K7031: Alcoholic cirrhosis of liver with ascites; M47817: Spondylosis without myelopathy or radiculopathy, lumbosacral region; Z6823: Body mass index [BMI] 23.0-23.9, adult; F17210: Nicotine dependence, cigarettes, uncomplicated; D696: Thrombocytopenia, unspecified; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; T17990A: Other foreign object in respiratory tract, part unspecified in causing asphyxiation, initial encounter; R339: Retention of urine, unspecified. The common codes which frequently come are D62, F17210, D696. The uncommon codes mentioned in this dataset are K565, E43, J189, J952, K766, M96831, T814XXA, L03311, K7031, M47817, Z6823, Y838, Y92239, T17990A, R339.
The icd codes present in this text will be I82422, I871, I9751, Y838, Y92234. The descriptions of icd codes I82422, I871, I9751, Y838, Y92234 are I82422: Acute embolism and thrombosis of left iliac vein; I871: Compression of vein; I9751: Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92234: Operating room of hospital as the place of occurrence of the external cause. The uncommon codes mentioned in this dataset are I82422, I871, I9751, Y838, Y92234. Allergies amoxicillin Chief Complaint ___ Syndrome Major Surgical or Invasive Procedure ___ Thrombolysis mechanical thrombectomy ___ IVC filter placement Repeat mechanical thrombectomy angiojet Common iliac wall stent x2 History of Present Illness Ms. ___ is a ___ with hx of hypothyroidism presenting with left leg swelling and pain. She was in her usual state of health until last night when she noted progressive left leg swelling and pain. Over the night she developed worsening pain in her left groin pain radiating down her leg which prompted her to present to ___ for further evaluation in the morning. On venous duplex she was found to extensive left leg DVT. She was started on a heparin gtt with a loading bolus and transferred to ___ for further management. She denies recent long periods of immobility travel history or history of DVT. No recent surgery or leg trauma. Denies shortness or breath or leg weakness parasthesias or loss of sensation. No known hypercoaguability disorder. Her mother notes a possible GSV aneurysm which was resected after a pregnancy many years ago. Her father had a DVT after a prolonged ICU course. Vascular surgery was consulted for further management. Past Medical History Hypothyroidism depression Social History ___ Family History No family history of hypercoagulability disorders. Father had history of DVT while hospitalized in the ICU. Physical Exam Physical Exam on Discharge Vitals 99 100 122 74 24 100 RA GEN AOx3 NAD HEENT No scleral icterus mucus membranes moist CV RRR No M G R PULM Clear to auscultation b l No W R R ABD Soft nondistended nontender no rebound or guarding normoactive bowel sounds no palpable masses Ext LLE mildly swollen wrapped with ace wrap no RLE swelling no evidence of phlegmasia strength and sensation equal Pulses R p p p p L p p p p Pertinent Results ___ 07 14AM BLOOD WBC 13.1 RBC 2.88 Hgb 8.5 Hct 26.6 MCV 92 MCH 29.5 MCHC 32.0 RDW 13.5 RDWSD 45.2 Plt ___ ___ 07 14AM BLOOD Plt ___ ___ 07 14AM BLOOD ___ PTT 84.5 ___ ___ 07 14AM BLOOD Glucose 92 UreaN 6 Creat 0.6 Na 140 K 3.3 Cl 104 HCO3 25 AnGap 14 ___ 07 14AM BLOOD Calcium 8.2 Phos 2.6 Mg 1.9 ___ 07 14AM BLOOD Brief Hospital Course The patient was admitted on ___ for left lower extremity swelling. CTA demonstrated right iliac artery compression of the left iliac vein and the patient was started on heparin. The patient was brought to the operating room on ___ and underwent IVC filter placement and catheter directed thrombolysis which was the patient had no evidence of hematoma and was transferred to the PACU for recovery where she remained hemodynamically stable. Hematocrit q6hrs remained stable and the patient complained of mild back pain which improved with pain management. The patient was closely monitored in the ICU and remained stable. She was brought back to the OR on ___ for mechanical thrombectomy and placement of left CIV wall stent. The procedure was without complications. The patient did well intraoperatively and was transferred back to the ICU where she continued to recover. On ___ her diet was advanced and foley was d c ed. She was discharged to home on POD 2 in stable condition with rivaroxaban 15mg BID for first 3 weeks followed by 20mg daily. Follow up has been arranged with Dr. ___ in clinic with surveillance with LLE duplex in 3 wks. At the time of discharge the patient s pain was well controlled with oral medications thrombectomy incisions were clean dry intact and the patient was voiding moving bowels spontaneously. The patient will follow up with a LLE duplex and Dr. ___ in three weeks. She will be discharged on xarelto. A thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow up care. The patient expressed readiness for discharge. Medications on Admission The Preadmission Medication list is accurate and complete. 1. DULoxetine 120 mg PO DAILY 2. Levothyroxine Sodium 75 mcg PO DAILY 3. ClonazePAM 0.5 mg PO BID Discharge Medications 1. Docusate Sodium 100 mg PO BID 2. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth every four hours Disp 30 Tablet Refills 0 3. Rivaroxaban 15 mg PO BID for first three weeks only RX rivaroxaban ___ 15 mg 1 tablet s by mouth twice a day Disp 42 Tablet Refills 0 4. Rivaroxaban 20 mg PO DAILY after first 3 weeks RX rivaroxaban ___ 20 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 2 5. ClonazePAM 0.5 mg PO BID 6. DULoxetine 120 mg PO DAILY 7. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition Home Discharge Diagnosis ___ syndrome DVT in LLE Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Lower Extremity Angioplasty Stent Discharge Instructions MEDICATION Take Aspirin 325mg enteric coated once daily If instructed take Plavix Clopidogrel 75mg once daily Continue all other medications you were taking before surgery unless otherwise directed You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT It is normal to have slight swelling of the legs Elevate your leg above the level of your heart with pillows every ___ hours throughout the day and night Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite your appetite will return with time Drink plenty of fluids and eat small frequent meals It is important to eat nutritious food options high fiber lean meats vegetables fruits low fat low cholesterol to maintain your strength and assist in wound healing To avoid constipation eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES When you go home you may walk and use stairs You may shower let the soapy water run over groin incision rinse and pat dry Your incision may be left uncovered unless you have small amounts of drainage from the wound then place a dry dressing or band aid over the area No heavy lifting pushing or pulling greater than 5 lbs for 1 week to allow groin puncture to heal After 1 week you may resume sexual activity After 1 week gradually increase your activities and distance walked as you can tolerate No driving until you are no longer taking pain medications CALL THE OFFICE FOR ___ Numbness coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white yellow or green drainage from incisions Bleeding from groin puncture site SUDDEN SEVERE BLEEDING OR SWELLING Groin puncture site Lie down keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops call vascular office ___. If bleeding does not stop call ___ for transfer to closest Emergency Room. Followup Instructions ___ The icd codes present in this text will be I82422, I871, I9751, Y838, Y92234. The descriptions of icd codes I82422, I871, I9751, Y838, Y92234 are I82422: Acute embolism and thrombosis of left iliac vein; I871: Compression of vein; I9751: Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92234: Operating room of hospital as the place of occurrence of the external cause. The uncommon codes mentioned in this dataset are I82422, I871, I9751, Y838, Y92234.
The icd codes present in this text will be N179, C221, C259, C7802, C7801, I10, E785, F419, N400, I129, E1122, N189, Z7984, Z87891, T464X5A, Y929, D6481, T451X5A, E039, Z794, Z905, I959, E860, Z7901. The descriptions of icd codes N179, C221, C259, C7802, C7801, I10, E785, F419, N400, I129, E1122, N189, Z7984, Z87891, T464X5A, Y929, D6481, T451X5A, E039, Z794, Z905, I959, E860, Z7901 are N179: Acute kidney failure, unspecified; C221: Intrahepatic bile duct carcinoma; C259: Malignant neoplasm of pancreas, unspecified; C7802: Secondary malignant neoplasm of left lung; C7801: Secondary malignant neoplasm of right lung; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F419: Anxiety disorder, unspecified; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; N189: Chronic kidney disease, unspecified; Z7984: Long term (current) use of oral hypoglycemic drugs; Z87891: Personal history of nicotine dependence; T464X5A: Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounter; Y929: Unspecified place or not applicable; D6481: Anemia due to antineoplastic chemotherapy; T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter; E039: Hypothyroidism, unspecified; Z794: Long term (current) use of insulin; Z905: Acquired absence of kidney; I959: Hypotension, unspecified; E860: Dehydration; Z7901: Long term (current) use of anticoagulants. The common codes which frequently come are N179, I10, E785, F419, N400, I129, E1122, N189, Z87891, Y929, E039, Z794, Z7901. The uncommon codes mentioned in this dataset are C221, C259, C7802, C7801, Z7984, T464X5A, D6481, T451X5A, Z905, I959, E860. Allergies ___ Chief Complaint Hypotension ___ on CKD Major Surgical or Invasive Procedure none History of Present Illness Mr. ___ is a ___ male with history metastatic RCC locally advanced cholangiocarcinoma s p six months of gemcitabine and cisplatin and recent diagnosis of pancreatic acinar cell carcinoma receiving liposomal irinotecan and ___ who presents with hypotension and acute on chronic renal failure. He reports that he checks his blood pressure using a machine at home every morning. His BP this morning was 79 44 about 15 minutes after taking amlodipine atenolol and lisinopril. This was associated with dizziness. Later in the morning repeat check was 110 70. He notes decreased appetite. He had one loose small bowel movement yesterday but otherwise no diarrhea. He presented to clinic for follow up His vitals were Temp 97.3 BP 125 58 HR 72 RR 16 and O2 sat 100 RA. Labs were notable for Cr 2.7 from baseline Cr 1.7 1.8. He was given 2L NS and referred for direct admission to 11 ___. On arrival to the floor patient reports shortness of breath with exertion mild nausea without vomiting and tingling in his hands. He denies fevers chills night sweats headache vision changes weakness cough hemoptysis chest pain palpitations abdominal pain nausea vomiting hematemesis hematochezia melena dysuria hematuria and new rashes. REVIEW OF SYSTEMS A complete 10 point review of systems was performed and was negative unless otherwise noted in the HPI. PAST ONCOLOGIC HISTORY ___ Presented with acute onset of gross hematuria accompanied with some mild flank pain. During his workup he was found to have a 4.8 cm mass on a CAT scan dated ___ specifically the scan describes a left renal mass with internal enhancement measuring 4.1 x 4.8 cm in size in the mid and upper pole of the left kidney. Also described was the fat containing left inguinal hernia and left perinephric stranding. There was no adenopathy or other suspicious lesions. There is also an old sclerotic right ilial lesion and left sacral lesion. ___ Underwent a laparoscopic hand assisted radical right nephrectomy by Dr. ___ pathology showed a renal cell carcinoma clear cell type ___ grade II IV measuring 4 cm extending but not invading through the renal capsule or Gerota s fascia margins were questionably positive at the renal vein and otherwise negative. On review of pathology here at ___ the margins are described as negative including the renal vein margin. A background of global glomerulosclerosis is described. Overall this was a T3bNxMx lesion. Postoperative imaging on ___ which was a CT torso showed no evidence of recurrent or metastatic disease. ___ CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b l pulmonary nodules concerning for progression ___ Fine needle aspirate of 11R and 11L lymph nodes which was consistent with metastatic RCC ___ CT Torso mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra abdominal sites of disease ___ C1D1 ___ randomized to sunitinib ___ Multiple grade ___ adverse events including thrombocytopenia grade 2 platelet 52 000 leukopenia grade 2 WBC 2.9 elevated lipase grade 1 elevated amylase grade 1 elevated at baseline elevated ALT grade 1 and hypothyroidism grade 1 . Mild symptoms with treatment. Continued sunitinib at 50mg daily per protocol. ___ CT Torso Response of mediastinal lymphadenopathy bilateral hilar lymphadenopathy and numerous parenchymal metastases. Stable disease by RECIST decrease 19.1 from baseline . ___ Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. ___ CT Torso Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 decrease 22.5 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 39.8 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 46.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 40.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 42.6 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 47.7 from baseline . ___ CT torso Ongoing partial response comments No significant change compared to prior scan. No new lesions. ___ CT Torso PR by RECIST 1.1 ___ CT Torso PR by RECIST 1.1 54.22 change from baseline and 10.29 change from last scan. ___ CT Torso Partial response 57.79 from baseline 7.79 from nadir ___ CT Torso shows continued partial response no significant change compared to prior ___ C25D1 held admitted for biliary stricture ___ Resumed cycle 25 day 1 ___ Admitted for biliary stricture and cholangitis diagnosed with pancreatobiliary adenocarcinoma and taken off study. ERCP x2 with placement of plastic then metal biliary stent. EUS biopsy of CBD mass showed new pancreatobiliary adenocardinoma. ___ C1D1 Gemcitabine 1000mg m2 Cisplatin 25 mg m2 D1 ___ C2D1 Gemcitabine 1000mg m2 Cisplatin 25 mg m2 D1 ___ C3D1 Gemcitabine 1000mg m2 Cisplatin 25 mg m2 D1 ___ CT torso showed stable disease ___ C4D1 Gemcitabine 1000mg m2 Cisplatin 25 mg m2 D1 ___ C5D1 Gemcitabine 1000mg m2 Cisplatin 25 mg m2 D1 ___ MR liver showed ongoing inoperable disease but stable ___ C6D1 Gemcitabine 1000mg m2 Cisplatin 25 mg m2 D1 15 dose modified for low counts ___ CT torso showed stable disease ___ C7D1 Gemcitabine 1000mg m2 Cisplatin 25 mg m2 D1 15 ___ C8D1 Gemcitabine 1000mg m2 Cisplatin 18.75 mg m2 D1 15 reduced for CKD ___ CT torso showed possible liver lesion and pancreatic lesion. Biopsy of liver lesion suggests poorly differentiated carcinoma. Biopsy of pancreas lesion suggests acinar cell carcinoma. ___ C1D1 nanoliposomal irinotecan ___ leucovorin ___ I Past Medical History PAST ONCOLOGIC HISTORY per OMR ___ presented with acute onset of gross hematuria accompanied with some mild flank pain. During his workup he was found to have a 4.8 cm mass on a CAT scan dated ___ specifically the scan describes a left renal mass with internal enhancement measuring 4.1 x 4.8 cm in size in the mid and upper pole of the left kidney. Also described was the fat containing left inguinal hernia and left perinephric stranding. There was no adenopathy or other suspicious lesions. There is also an old sclerotic right ilial lesion and left sacral lesion. ___ underwent a laparoscopic hand assisted radical right nephrectomy by Dr. ___ pathology showed a renal cell carcinoma clear cell type ___ grade II IV measuring 4 cm extending but not invading through the renal capsule or Gerota s fascia margins were questionably positive at the renal vein and otherwise negative. On review of pathology here at ___ the margins are described as negative including the renal vein margin. A background of global glomerulosclerosis is described. Overall this was a T3bNxMx lesion. Postoperative imaging on ___ which was a CT torso showed no evidence of recurrent or metastatic disease. ___ CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b l pulmonary nodules concerning for progression ___ Fine needle aspirate of 11R and 11L lymph nodes which was consistent with metastatic RCC ___ CT Torso mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra abdominal sites of disease ___ C1D1 ___ randomized to sunitinib ___ Multiple grade ___ adverse events including thrombocytopenia grade 2 platelet 52 000 leukopenia grade 2 WBC 2.9 elevated lipase grade 1 elevated amylase grade 1 elevated at baseline elevated ALT grade 1 and hypothyroidism grade 1 . Mild symptoms with treatment. Continued sunitinib at 50mg daily per protocol. ___ CT Torso Response of mediastinal lymphadenopathy bilateral hilar lymphadenopathy and numerous parenchymal metastases. Stable disease by RECIST decrease 19.1 from baseline . ___ Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. ___ CT Torso Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 decrease 22.5 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 39.8 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 46.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 40.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 42.6 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 47.7 from baseline . ___ CT torso Ongoing partial response comments No significant change compared to prior scan. No new lesions. ___ CT Torso PR by RECIST 1.1 ___ CT Torso PR by RECIST 1.1 54.22 change from baseline and 10.29 change from last scan. ___ CT Torso partial response 57.79 from baseline 7.79 from nadir ___ CT Torso shows continued partial response no significant change compared to prior PAST MEDICAL HISTORY per OMR 1. Clear cell kidney cancer as above. 2. Benign prostatic hypertrophy. 3. Diabetes mellitus. 4. Hypertension. 5. Hyperlipidemia. 6. History of anxiety. Social History ___ Family History Colorectal cancer mother ___ cancer sister dx at age ___ Liver cancer brother ___ cell leukemia brother ___ father Physical ___ ADMISSION PHYSICAL EXAM VS Temp 97.9 BP 150 74 HR 71 RR 20 O2 sat 100 RA. GENERAL Pleasant man in no distress lying in bed comfortably. HEENT Anicteric PERLL OP clear. CARDIAC RRR normal s1 s2 no m r g. LUNG Appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi. ABD Soft non tender non distended normal bowel sounds. EXT Warm well perfused no lower extremity edema. NEURO A Ox3 good attention and linear thought CN II XII intact. Gross strength and sensation intact. SKIN No significant rashes. ACCESS Right chest wall port without erythema. DISCHARGE PHYSICAL EXAM VS ___ 1623 Temp 98.1 PO BP 148 78 HR 76 RR 18 O2 sat 97 O2 delivery RA GENERAL Pleasant man in no distress lying in bed comfortably. HEENT Anicteric PERLL OP clear. CARDIAC RRR normal s1 s2 no m r g. LUNG Appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi. ABD Soft non tender non distended normal bowel sounds. EXT Warm well perfused no lower extremity edema. NEURO A Ox3 good attention and linear thought CN II XII intact. Gross strength and sensation intact. SKIN No significant rashes. ACCESS Right chest wall port without erythema. Pertinent Results ADMISSION LABS ___ 12 45PM BLOOD WBC 5.6 RBC 3.04 Hgb 9.1 Hct 28.6 MCV 94 MCH 29.9 MCHC 31.8 RDW 14.6 RDWSD 49.4 Plt ___ ___ 12 45PM BLOOD Neuts 72.3 Lymphs 17.0 Monos 8.0 Eos 2.0 Baso 0.2 Im ___ AbsNeut 4.05 AbsLymp 0.95 AbsMono 0.45 AbsEos 0.11 AbsBaso 0.01 ___ 12 45PM BLOOD Plt ___ ___ 12 45PM BLOOD UreaN 48 Creat 2.7 Na 135 K 4.7 Cl 102 HCO3 18 AnGap 15 ___ 12 45PM BLOOD ALT 24 AST 31 LD LDH 667 AlkPhos 173 TotBili 0.4 ___ 12 45PM BLOOD Albumin 3.9 Calcium 9.4 Phos 3.1 Mg 2.1 ___ 05 54AM BLOOD Hapto 271 ___ 10 41PM URINE Color Straw Appear Clear Sp ___ ___ 10 41PM URINE Blood NEG Nitrite NEG Protein NEG Glucose NEG Ketone NEG Bilirub NEG Urobiln NEG pH 6.0 Leuks NEG ___ 10 41PM URINE Hours RANDOM Creat 78 Na 34 DISCHARGE LABS ___ 05 47AM BLOOD WBC 5.2 RBC 2.74 Hgb 8.3 Hct 26.1 MCV 95 MCH 30.3 MCHC 31.8 RDW 14.6 RDWSD 49.2 Plt ___ ___ 05 47AM BLOOD Plt ___ ___ 05 47AM BLOOD Glucose 120 UreaN 26 Creat 1.7 Na 141 K 4.9 Cl 106 HCO3 23 AnGap 12 ___ 05 47AM BLOOD Calcium 9.0 Phos 3.9 Mg 2.0 PERTINENT STUDIES Radiology Report RENAL U.S. Study Date of ___ 8 18 AM COMPARISON CT abdomen and pelvis ___ FINDINGS The left kidney is surgically absent. A cortical defect is re demonstrated in the interpolar region of the right kidney. There is a 1.3 cm exophytic simple cyst arising from the lower pole of the right kidney stable from the prior CT. There is no hydronephrosis or stones bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. Right kidney 11.5 cm The bladder is moderately well distended and normal in appearance. IMPRESSION No hydronephrosis. Normal cortical echogenicity and corticomedullary differentiation within the remaining right kidney. Radiology Report CHEST PORTABLE AP Study Date of ___ 7 22 ___ COMPARISON CT is available from ___. FINDINGS Port terminates in the mid superior vena cava. Cardiac mediastinal and hilar contours appear stable. There is no pleural effusion or pneumothorax. Lungs appear clear. IMPRESSION No evidence of acute cardiopulmonary process. MICROBIOLOGY ___ 10 41 pm URINE Source ___. FINAL REPORT ___ URINE CULTURE Final ___ NO GROWTH. Brief Hospital Course Brief hospital summary Mr. ___ is a ___ male with history metastatic RCC locally advanced cholangiocarcinoma s p six months of gemcitabine and cisplatin and recent diagnosis of pancreatic acinar cell carcinoma receiving liposomal irinotecan and ___ who presents with hypotension and acute on chronic renal failure. Hypotension and ___ resolved with IVFs and holding BP medications. He was discharged in stable condition. Transitional issues Hgb on discharge 8.3. Held home lisinopril atenolol and amlodipine given concern for dehydration and hypotension. BPs improved during course of hospital stay. Please titrate BP medications on outpatient basis as clinically indicated Cr on discharge 1.7 baseline appears to be 1.4 1.7 . Please recheck BMP within one week of discharge to trend Cr. Glipizide held on discharge due to increase risk of hypoglycemia. Would consider d c vs restart based on renal function Acute issues Hypotension Likely combination of poor PO intake and dehydration in setting of poor appetite and nausea from new chemotherapy regimen while continuing multiple home BP medications. Given IVF and held BP medications with resolution of hypotension. Orthostatics prior to discharge unremarkable. ___ on CKD Likely prerenal in setting of poor PO intake. FeNa 1 consistent with diagnosis. Held lisinopril which we will continue to hold upon discharge. Renal ultrasound without evidence of hydronephrosis. Anemia Likely secondary to chemotherapy and malignancy. Hemolysis labs reassuring. No clinical evidence of bleeding. Hgb on discharge 8.3. Chronic issues Fatigue Likely from anemia and chemotherapy side effect. Stable during course of hospitalization Pancreatic Acinar Cell Carcinoma Cholangiocarcinoma Secondary Neoplasm of Liver Currently on palliative liposomal ___. Follow up with Dr. ___ Metastatic Renal Cell Carcinoma Secondary Neoplasm of Lung He is on a treatment hold due to the management of his cholangiocarcinoma and now pancreatic cancer. Portal Vein Thrombus continued home rivaroxaban BPH continued home Flomax Hypothyroidism continued home levothyroxine Diabetes continued home lantus started humalog ISS and held home glipizide while in house and on discharge. Anxiety continued home citalopram Medications on Admission The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Ascorbic Acid ___ mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO DAILY 5. LORazepam 0.5 mg PO DAILY PRN anxiety insomnia 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Ondansetron 8 mg PO Q8H PRN nausea vomiting 9. Prochlorperazine 5 mg PO Q8H PRN nausea vomiting 10. Tamsulosin 0.4 mg PO QHS 11. Vitamin D 5000 UNIT PO DAILY 12. GlipiZIDE 2.5 mg PO BID 13. Lisinopril 10 mg PO DAILY 14. Fenofibrate 48 mg PO DAILY 15. Amoxicillin ___ mg PO PREOP 16. Citalopram 20 mg PO DAILY 17. Glargine 16 Units Bedtime 18. Rivaroxaban 10 mg PO DAILY 19. Acetaminophen ___ mg PO Q8H PRN Pain Mild Fever 20. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications 1. Acetaminophen ___ mg PO Q8H PRN Pain Mild Fever 2. Ascorbic Acid ___ mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. Fenofibrate 48 mg PO DAILY 6. Glargine 16 Units Bedtime 7. Levothyroxine Sodium 100 mcg PO DAILY 8. LORazepam 0.5 mg PO DAILY PRN anxiety insomnia 9. Multivitamins 1 TAB PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Ondansetron 8 mg PO Q8H PRN nausea vomiting 12. Prochlorperazine 5 mg PO Q8H PRN nausea vomiting 13. Rivaroxaban 10 mg PO DAILY 14. Tamsulosin 0.4 mg PO QHS 15. Vitamin D 5000 UNIT PO DAILY 16. HELD amLODIPine 10 mg PO DAILY This medication was held. Do not restart amLODIPine until you discuss with your primary care doctor. 17. HELD Atenolol 50 mg PO DAILY This medication was held. Do not restart Atenolol until you discuss with your primary care doctor. 18. HELD GlipiZIDE 2.5 mg PO BID This medication was held. Do not restart GlipiZIDE until you follow up with your PCP. 19. HELD Lisinopril 10 mg PO DAILY This medication was held. Do not restart Lisinopril until you discuss with your primary care doctor. Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Acute Issues Hypotension Acute on chronic CKD Secondary Issues Hypertension CKD Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions DISCHARGE INSTRUCTIONS Dear Mr. ___ It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL You were admitted for low blood pressures WHAT HAPPENED TO ME IN THE HOSPITAL We gave you fluids through an IV and we held your blood pressure medications. Your blood pressures eventually improved to normal range. We monitored your kidney function which improved with fluids and holding your blood pressure medications. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL Continue to take all your medicines and keep your appointments. Do not take any of your blood pressure medications until you discuss with your primary care doctor. We wish you the best Sincerely Your ___ Team Followup Instructions ___ The icd codes present in this text will be N179, C221, C259, C7802, C7801, I10, E785, F419, N400, I129, E1122, N189, Z7984, Z87891, T464X5A, Y929, D6481, T451X5A, E039, Z794, Z905, I959, E860, Z7901. The descriptions of icd codes N179, C221, C259, C7802, C7801, I10, E785, F419, N400, I129, E1122, N189, Z7984, Z87891, T464X5A, Y929, D6481, T451X5A, E039, Z794, Z905, I959, E860, Z7901 are N179: Acute kidney failure, unspecified; C221: Intrahepatic bile duct carcinoma; C259: Malignant neoplasm of pancreas, unspecified; C7802: Secondary malignant neoplasm of left lung; C7801: Secondary malignant neoplasm of right lung; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F419: Anxiety disorder, unspecified; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; N189: Chronic kidney disease, unspecified; Z7984: Long term (current) use of oral hypoglycemic drugs; Z87891: Personal history of nicotine dependence; T464X5A: Adverse effect of angiotensin-converting-enzyme inhibitors, initial encounter; Y929: Unspecified place or not applicable; D6481: Anemia due to antineoplastic chemotherapy; T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter; E039: Hypothyroidism, unspecified; Z794: Long term (current) use of insulin; Z905: Acquired absence of kidney; I959: Hypotension, unspecified; E860: Dehydration; Z7901: Long term (current) use of anticoagulants. The common codes which frequently come are N179, I10, E785, F419, N400, I129, E1122, N189, Z87891, Y929, E039, Z794, Z7901. The uncommon codes mentioned in this dataset are C221, C259, C7802, C7801, Z7984, T464X5A, D6481, T451X5A, Z905, I959, E860.
The icd codes present in this text will be C786, E43, C250, C787, C781, C771, N179, E871, G893, K8681, Z85528, Z8589, Z905, Z66, Z515, E1122, I129, N189, Z794, E7849, N400, K529, Z87891, K117, D630, E860, Z6826, Z7902, B001, F419, G4700, R739, T380X5A, Y92230, K5900. The descriptions of icd codes C786, E43, C250, C787, C781, C771, N179, E871, G893, K8681, Z85528, Z8589, Z905, Z66, Z515, E1122, I129, N189, Z794, E7849, N400, K529, Z87891, K117, D630, E860, Z6826, Z7902, B001, F419, G4700, R739, T380X5A, Y92230, K5900 are C786: Secondary malignant neoplasm of retroperitoneum and peritoneum; E43: Unspecified severe protein-calorie malnutrition; C250: Malignant neoplasm of head of pancreas; C787: Secondary malignant neoplasm of liver and intrahepatic bile duct; C781: Secondary malignant neoplasm of mediastinum; C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes; N179: Acute kidney failure, unspecified; E871: Hypo-osmolality and hyponatremia; G893: Neoplasm related pain (acute) (chronic); K8681: Exocrine pancreatic insufficiency; Z85528: Personal history of other malignant neoplasm of kidney; Z8589: Personal history of malignant neoplasm of other organs and systems; Z905: Acquired absence of kidney; Z66: Do not resuscitate; Z515: Encounter for palliative care; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N189: Chronic kidney disease, unspecified; Z794: Long term (current) use of insulin; E7849: Other hyperlipidemia; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; K529: Noninfective gastroenteritis and colitis, unspecified; Z87891: Personal history of nicotine dependence; K117: Disturbances of salivary secretion; D630: Anemia in neoplastic disease; E860: Dehydration; Z6826: Body mass index [BMI] 26.0-26.9, adult; Z7902: Long term (current) use of antithrombotics/antiplatelets; B001: Herpesviral vesicular dermatitis; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; R739: Hyperglycemia, unspecified; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; Y92230: Patient room in hospital as the place of occurrence of the external cause; K5900: Constipation, unspecified. The common codes which frequently come are N179, E871, Z66, Z515, E1122, I129, N189, Z794, N400, Z87891, Z7902, F419, G4700, Y92230, K5900. The uncommon codes mentioned in this dataset are C786, E43, C250, C787, C781, C771, G893, K8681, Z85528, Z8589, Z905, E7849, K529, K117, D630, E860, Z6826, B001, R739, T380X5A. Allergies mirtazapine Chief Complaint Nausea and vomiting Major Surgical or Invasive Procedure None History of Present Illness Mr. ___ is a pleasant ___ w ID T2DM HTN DL BPH and three concurrent cancers 1 metastatic clear cell RCC s p radical L nephrectomy in ___ found to have pulmonary mediastinal and hilar mets ___ now off sunitinib w o disease progression 2 metastatic cholangiocarcinoma s p 6 months gem cisplatin who subsequently had new 3 acinar cell carcinoma of the pancreas now on ___ I regimen of liposomal irinotecan and ___ last dose ___ p w nausea vomiting that started last evening. Patient was interviewed with his daughter at bedside and she helped provide collateral. They note that he has had n v the past few weeks especially with chemo. He had poor appetite as well since chemo. The vomiting seemed to be intermittent sometimes able to tolerate PO. Last night he developed abdominal pain and vomiting. He had regular bowel movements last night. This morning he had diarrhea but no further episodes of vomiting and his abdominal pain improved and nausea improved. He had special K cereal with skim milk today and tolerated it well. He called into his ___ clinic where he was seen this am. There he had 2L NS and obtained a KUB which suggested SBO. He is only a little tender in the epigastrium on exam. He was then admitted to 12R to the oncology service. Past Medical History PAST ONCOLOGIC HISTORY per OMR ___ presented with acute onset of gross hematuria accompanied with some mild flank pain. During his workup he was found to have a 4.8 cm mass on a CAT scan dated ___ specifically the scan describes a left renal mass with internal enhancement measuring 4.1 x 4.8 cm in size in the mid and upper pole of the left kidney. Also described was the fat containing left inguinal hernia and left perinephric stranding. There was no adenopathy or other suspicious lesions. There is also an old sclerotic right ilial lesion and left sacral lesion. ___ underwent a laparoscopic hand assisted radical right nephrectomy by Dr. ___ pathology showed a renal cell carcinoma clear cell type ___ grade II IV measuring 4 cm extending but not invading through the renal capsule or Gerota s fascia margins were questionably positive at the renal vein and otherwise negative. On review of pathology here at ___ the margins are described as negative including the renal vein margin. A background of global glomerulosclerosis is described. Overall this was a T3bNxMx lesion. Postoperative imaging on ___ which was a CT torso showed no evidence of recurrent or metastatic disease. ___ CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b l pulmonary nodules concerning for progression ___ Fine needle aspirate of 11R and 11L lymph nodes which was consistent with metastatic RCC ___ CT Torso mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra abdominal sites of disease ___ C1D1 ___ randomized to sunitinib ___ Multiple grade ___ adverse events including thrombocytopenia grade 2 platelet 52 000 leukopenia grade 2 WBC 2.9 elevated lipase grade 1 elevated amylase grade 1 elevated at baseline elevated ALT grade 1 and hypothyroidism grade 1 . Mild symptoms with treatment. Continued sunitinib at 50mg daily per protocol. ___ CT Torso Response of mediastinal lymphadenopathy bilateral hilar lymphadenopathy and numerous parenchymal metastases. Stable disease by RECIST decrease 19.1 from baseline . ___ Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. ___ CT Torso Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 decrease 22.5 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 39.8 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 46.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 40.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 42.6 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 47.7 from baseline . ___ CT torso Ongoing partial response comments No significant change compared to prior scan. No new lesions. ___ CT Torso PR by RECIST 1.1 ___ CT Torso PR by RECIST 1.1 54.22 change from baseline and 10.29 change from last scan. ___ CT Torso partial response 57.79 from baseline 7.79 from nadir ___ CT Torso shows continued partial response no significant change compared to prior PAST MEDICAL HISTORY per OMR 1. Clear cell kidney cancer as above. 2. Benign prostatic hypertrophy. 3. Diabetes mellitus. 4. Hypertension. 5. Hyperlipidemia. 6. History of anxiety. Social History ___ Family History Colorectal cancer mother ___ cancer sister dx at age ___ Liver cancer brother ___ cell leukemia brother ___ father Physical ___ ADMISSION EXAM VITAL SIGNS 98.4 PO 112 71 89 18 97 Ra General NAD Resting in bed comfortably with daughter at bedside ___ xerostomia healing dried cold sore the L lower lip CV RR NL S1S2 no S3S4 No MRG PULM CTAB No C W R No respiratory distress ABD scant bowel sounds mostly tympanic soft minimally tender in epigastrium no peritoneal signs no significant distention LIMBS WWP no ___ no tremors SKIN No notable rashes on trunk nor extremities NEURO Face symmetric speech clear and fluent strength b l ___ intact PSYCH Thought process logical linear future oriented ACCESS R Chest port site intact w o overlying erythema accessed and dressing C D I DISCHARGE EXAM ___ 0910 Temp 97.4 PO BP 136 89 HR 102 RR 18 O2 sat 95 O2 delivery RA FSBG 269 ___ 0918 Pain Score ___ GENERAL appears uncomfortable weaker and pale. EYES Anicteric ENT MMM no lesions noted CV RRR no murmur. Right chest port. RESP anterior exam quiet lungs normal respiratory effort. GI Abdomen soft mild distention G tube in place. MSK no edema or swelling NEURO sleepy but awakens with gentle touch face symmetric speech fluent moves all limbs answers all questions fully oriented. PSYCH Pleasant appropriate affect Pertinent Results ADMISSION LABS ___ 01 15PM BLOOD WBC 3.5 RBC 2.83 Hgb 8.4 Hct 26.9 MCV 95 MCH 29.7 MCHC 31.2 RDW 17.2 RDWSD 58.1 Plt ___ ___ 01 15PM BLOOD Neuts 74 Lymphs 12 Monos 13 Eos 0 ___ Metas 1 AbsNeut 2.59 AbsLymp 0.42 AbsMono 0.46 AbsEos 0.00 AbsBaso 0.00 ___ 05 41AM BLOOD ___ PTT 25.9 ___ ___ 01 15PM BLOOD UreaN 26 Creat 1.8 Na 132 K 4.4 Cl 95 HCO3 22 AnGap 15 ___ 01 15PM BLOOD ALT 20 AST 28 LD ___ 861 AlkPhos 150 TotBili 0.4 ___ 01 15PM BLOOD Albumin 3.3 Calcium 9.1 Phos 3.9 Mg 2.2 DISCHARGE LABS ___ 06 25AM BLOOD WBC 19.0 RBC 3.27 Hgb 9.4 Hct 31.4 MCV 96 MCH 28.7 MCHC 29.9 RDW 17.6 RDWSD 59.2 Plt ___ ___ 06 25AM BLOOD Glucose 176 UreaN 35 Creat 1.5 Na 141 K 4.8 Cl 100 HCO3 22 AnGap 19 ___ 06 25AM BLOOD ALT 24 AST 79 LD LDH 1713 AlkPhos 184 TotBili 0.8 ___ 06 25AM BLOOD Calcium 9.0 Phos 4.0 Mg 2.1 MICROBIOLOGY ___ 3 07 am STOOL CONSISTENCY LOOSE Source Stool. FINAL REPORT ___ C. difficile PCR Final ___ NEGATIVE. ___ 3 07 am STOOL CONSISTENCY LOOSE Source Stool. FECAL CULTURE R O E.COLI 0157 H7 Pending ABDOMINAL X RAY ___ FINDINGS There are multiple centrally located distended loops of small bowel concerning for small bowel obstruction. There is no free intraperitoneal air. Osseous structures are unremarkable. Re demonstrated is a common bile duct extent in grossly unchanged position compared to the prior study given differences in techniques. Two small linear hyperdensities noted over the midline adjacent to the biliary stent likely surgical clips. IMPRESSION Imaging findings concerning for small bowel obstruction. Further evaluation with CT abdomen and pelvis with iv contrast is recommended. CT ABDOMEN PELVIS WITH ORAL CONTRAST ___ 1. Interval increase in size of pancreatic head mass now measuring up to 8.0 cm previously 6.0 cm. 2. Numerous metastatic lesions throughout the liver increased in size and number. 3. Interval worsening of retroperitoneal lymphadenopathy. 4. Wall thickening of an approximately 20 cm segment of distal and terminal ileum with adjacent fat stranding compatible with infectious or inflammatory ileitis. No small bowel obstruction. Oral contrast is seen to the rectum. 5. New 3 mm pulmonary nodule in the left lower lobe. Brief Hospital Course Mr. ___ is a ___ year old male with type 2 diabetes hypertension hyperlipidemia BPH and three concurrent cancers 1 metastatic clear cell renal cell carcinoma s p radical L nephrectomy in ___ found to have pulmonary mediastinal and hilar metastases ___ now off sunitinib without disease progression 2 metastatic cholangiocarcinoma s p 6 months gem cisplatin who subsequently had new 3 acinar cell carcinoma of the pancreas now on ___ I regimen of liposomal irinotecan and ___ last dose ___ who went to ___ clinic with nausea vomiting abdominal pain and was found to have possible SBO on KUB. This led to direct admission for workup. CT abdomen pelvis with oral contrast showed no evidence of bowel obstruction but showed findings of ileitis as well as increasing pancreatic mass size and new hepatic lesions all concerning for progression of his cancer. While hospitalized he developed recurrent symptoms of nausea vomiting after an initial improvement and then developed signs and symptoms of frank obstruction likely related to his pancreatic mass or peritoneal carcinomatosis. No further imaging was pursued. An NG tube was placed for decompression and he had significant improved symptoms. He subsequently underwent palliative venting G tube is a transition to hospice. ACUTE ACTIVE PROBLEMS Abdominal pain Nausea and vomiting with malignant obstruction in setting of progressive acinar cell cancer and large pancreatic mass Acinar cell pancreatic cancer He has been off sutinib as his other cancers are being managed and his pulm hepatic mets have been stable. He is not yet due for restaging imaging. He is due for ___ LV liposomal irinotecan. His oncologists are Dr ___ ___ Dr ___ seen on ___. CT abdomen pelvis showed increased size of pancreatic head mass from 6.0 to 8.0 cm numerous metastatic liver lesions increased in size and number interval worsening of retroperitoneal lymphadenopathy and new 3 mm pulmonary nodule in the left lower lobe. He had been having nausea and vomiting likely related to chemo for several weeks but then developed diarrhea vomiting and abdominal pain the night prior to presentation. His symptoms have resolved. He had 2 watery bowel movements after admission. KUB had showed multiple centrally located distended loops of small bowel concerning for small bowel obstruction. He has not had prior bowel obstruction. Since he has only 1 kidney with a Cr of 1.6 initial CT was done without IV contrast. CT abdomen pelvis with oral contrast showed no evidence of bowel obstruction but showed wall thickening of distal and terminal ileum with adjacent fat stranding compatible with infectious or inflammatory ileitis. Since he was afebrile with improved symptoms empiric antibiotics were not started. C. difficile was negative as was ecoli. He was initially treated with bowel rest and IV fluids then diet was advanced. The CT scan also showed increasing size of pancreatic mass enlarging and new hepatic lesions new left lung nodule worsening retroperitoneal lymphadenopathy all concerning for progression of disease. Given this new complication of his pancreatic cancer family meeting was held on ___ with a decision to pursue hospice care at home given no other therapeutic options. His prognosis was given as weeks. He was transitioned to liquid concentrated morphine for pain as well as lorazepam for anxiety and dexamethasone for nausea. Oral medications were given after his PEG was placed with clear instructions on how to take them. This included dexamethasone concentrated morphine and olanzapine. Other home medications were continued at this time with decisions to stop these medications going forward to occur with hospice services and Dr. ___ patient s oncologist. MOLST form was completed. Acute on chronic anemia Baseline hemoglobin is ___. Hemoglobin was low at 6.7 on ___ so he was transfused 1 unit PRBCs with improvement to 8.3. He had no obvious signs of acute blood loss anemia and stool has not appeared grossly bloody or signs of melena evident. His blood count remained stable. Labs were not checked after goals of care were changed. CHRONIC STABLE PROBLEMS Chronic kidney disease Creatinine is 1.4 1.6 at baseline. He had recent ___ with Cr of 2.2 on ___ and 1.8 on admission likely due to dehydration. Renal function returned to baseline after getting IV fluids then rose after he likely developed recurrent dehydration. As stated above labs were not rechecked after goals of care change. History of Portal Vein Thrombus He was continued on home Rivaroxaban 10mg daily except for initially being held while NPO. This was continued for now but should be stopped if decided not consistent with comfort going forward. Severe protein calorie malnutrition He has low albumin and reported low oral intake due to nausea vomiting and abdominal pain which has been ongoing off on for weeks likely due to chemo and his known cancers. Consulted nutrition who recommended low fiber diet with Ensure Clear early in hospitalization but given transition to hospice he was recommended to have diet as tolerated. Type 2 diabetes His glargine was initially decreased while NPO on IV D5LR then stopped and treated with sliding scale insulin only and Glipizide was held. On discharge glipizide was continued. TRANSITIONS OF CARE Follow up patient is being discharged to hospice. Dr. ___ ___ be the physician responsible for decisions going forward. Code status DNR DNI comfort focused care Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO Q8H PRN Pain Mild Fever 2. Citalopram 20 mg PO DAILY 3. Levothyroxine Sodium 100 mcg PO DAILY 4. LORazepam 0.5 mg PO DAILY PRN anxiety insomnia 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Prochlorperazine 5 mg PO Q8H PRN nausea vomiting 8. Rivaroxaban 10 mg PO DAILY 9. Tamsulosin 0.4 mg PO QHS 10. Vitamin D 5000 UNIT PO DAILY 11. Ascorbic Acid ___ mg PO DAILY 12. Cyanocobalamin 1000 mcg PO DAILY 13. Fenofibrate 48 mg PO DAILY 14. Ondansetron 8 mg PO Q8H PRN nausea vomiting 15. GlipiZIDE 2.5 mg PO BID 16. Abreva docosanol 10 topical ___ times daily prn cold sore Discharge Medications 1. Dexamethasone 4 mg PO DAILY RX dexamethasone 4 mg 1 tablet s by mouth once a day Disp 5 Tablet Refills 0 2. Morphine Sulfate Concentrated Oral Solution 20 mg mL ___ mg PO Q2H PRN Breakthrough pain RX morphine concentrate 100 mg 5 mL 20 mg mL 0.25 0.75 ml by mouth q2h Refills 0 3. OLANZapine Disintegrating Tablet 5 mg PO BID PRN nausea not addressed by ondansetron RX olanzapine 5 mg 1 tablet s by mouth twice a day Disp 10 Tablet Refills 0 4. Abreva docosanol 10 topical ___ times daily prn cold sore 5. Acetaminophen ___ mg PO Q8H PRN Pain Mild Fever 6. Ascorbic Acid ___ mg PO DAILY 7. Citalopram 20 mg PO DAILY 8. Cyanocobalamin 1000 mcg PO DAILY 9. Fenofibrate 48 mg PO DAILY 10. Levothyroxine Sodium 100 mcg PO DAILY 11. LORazepam 0.5 mg PO DAILY PRN anxiety insomnia 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Ondansetron 8 mg PO Q8H PRN nausea vomiting 15. Prochlorperazine 5 mg PO Q8H PRN nausea vomiting 16. Rivaroxaban 10 mg PO DAILY 17. Tamsulosin 0.4 mg PO QHS 18. HELD GlipiZIDE 2.5 mg PO BID This medication was held. Do not restart GlipiZIDE until someone tells you to Discharge Disposition Home With Service Facility ___ ___ Diagnosis Abdominal pain Nausea with vomiting Diarrhea Ileitis Metastatic cholangiocarcinoma Acinar cell pancreatic cancer Metastatic renal cell carcinoma Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You were hospitalized with abdominal pain. Despite the fact that you initially improved you subsequently worsened and the symptoms were all related to progressive cancer. We talked about the meaning of this with you and your family and you are opting to go home with hospice care. We put a gastric tube in to help alleviate any symptoms of obstruction. You should keep the gastric tube hooked up to low suction overnight and when you are not doing anything during the day. When you are active and for ___ minutes after taking oral medications you should clamp the tube. You were continued on most of your oral medications that you take at home. Over time you may decide to discontinue these medications if they are not necessary for your comfort for instance your vitamin supplements and can discuss this with your hospice team. The hospice team will help you manage your symptoms at home. We wish you the best of luck going forward. Thanks Your ___ Team Followup Instructions ___ The icd codes present in this text will be C786, E43, C250, C787, C781, C771, N179, E871, G893, K8681, Z85528, Z8589, Z905, Z66, Z515, E1122, I129, N189, Z794, E7849, N400, K529, Z87891, K117, D630, E860, Z6826, Z7902, B001, F419, G4700, R739, T380X5A, Y92230, K5900. The descriptions of icd codes C786, E43, C250, C787, C781, C771, N179, E871, G893, K8681, Z85528, Z8589, Z905, Z66, Z515, E1122, I129, N189, Z794, E7849, N400, K529, Z87891, K117, D630, E860, Z6826, Z7902, B001, F419, G4700, R739, T380X5A, Y92230, K5900 are C786: Secondary malignant neoplasm of retroperitoneum and peritoneum; E43: Unspecified severe protein-calorie malnutrition; C250: Malignant neoplasm of head of pancreas; C787: Secondary malignant neoplasm of liver and intrahepatic bile duct; C781: Secondary malignant neoplasm of mediastinum; C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes; N179: Acute kidney failure, unspecified; E871: Hypo-osmolality and hyponatremia; G893: Neoplasm related pain (acute) (chronic); K8681: Exocrine pancreatic insufficiency; Z85528: Personal history of other malignant neoplasm of kidney; Z8589: Personal history of malignant neoplasm of other organs and systems; Z905: Acquired absence of kidney; Z66: Do not resuscitate; Z515: Encounter for palliative care; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N189: Chronic kidney disease, unspecified; Z794: Long term (current) use of insulin; E7849: Other hyperlipidemia; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; K529: Noninfective gastroenteritis and colitis, unspecified; Z87891: Personal history of nicotine dependence; K117: Disturbances of salivary secretion; D630: Anemia in neoplastic disease; E860: Dehydration; Z6826: Body mass index [BMI] 26.0-26.9, adult; Z7902: Long term (current) use of antithrombotics/antiplatelets; B001: Herpesviral vesicular dermatitis; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; R739: Hyperglycemia, unspecified; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; Y92230: Patient room in hospital as the place of occurrence of the external cause; K5900: Constipation, unspecified. The common codes which frequently come are N179, E871, Z66, Z515, E1122, I129, N189, Z794, N400, Z87891, Z7902, F419, G4700, Y92230, K5900. The uncommon codes mentioned in this dataset are C786, E43, C250, C787, C781, C771, G893, K8681, Z85528, Z8589, Z905, E7849, K529, K117, D630, E860, Z6826, B001, R739, T380X5A.
The icd codes present in this text will be A408, K831, I81, J189, K830, C7802, C7801, C771, N179, C249, R6520, F419, N400, Z85528, E785, Z87891, D539, F329, E039, E1122, I129, N189, Z794. The descriptions of icd codes A408, K831, I81, J189, K830, C7802, C7801, C771, N179, C249, R6520, F419, N400, Z85528, E785, Z87891, D539, F329, E039, E1122, I129, N189, Z794 are A408: Other streptococcal sepsis; K831: Obstruction of bile duct; I81: Portal vein thrombosis; J189: Pneumonia, unspecified organism; K830: Cholangitis; C7802: Secondary malignant neoplasm of left lung; C7801: Secondary malignant neoplasm of right lung; C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes; N179: Acute kidney failure, unspecified; C249: Malignant neoplasm of biliary tract, unspecified; R6520: Severe sepsis without septic shock; F419: Anxiety disorder, unspecified; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z85528: Personal history of other malignant neoplasm of kidney; E785: Hyperlipidemia, unspecified; Z87891: Personal history of nicotine dependence; D539: Nutritional anemia, unspecified; F329: Major depressive disorder, single episode, unspecified; E039: Hypothyroidism, unspecified; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N189: Chronic kidney disease, unspecified; Z794: Long term (current) use of insulin. The common codes which frequently come are N179, F419, N400, E785, Z87891, F329, E039, E1122, I129, N189, Z794. The uncommon codes mentioned in this dataset are A408, K831, I81, J189, K830, C7802, C7801, C771, C249, R6520, Z85528, D539. Allergies ___ Chief Complaint Fatigue Major Surgical or Invasive Procedure ___ ERCP and EUS History of Present Illness Mr. ___ is a ___ male with IDDM HTN BPH and clear cell RCC s p radical L nephrectomy ___ metastatic to the lungs mediastinum and hilum currently on chemotherapy experimental trial on sunitinib with recent admission ___ for biliary stricture s p ERCP with plastic stent placement CBD brushing cytology non diagnostic and non occlusive portal vein thrombus started on enoxaparin who presented to the ED with fever jaundice and confusion. The CBD brushing cytology from his prior admission was non diagnostic. His imaging was reviewed at multidisciplinary pancreas conference and no mass lesion was visualized in the head of the pancreas but there was some peripancreatic stranding around the head of the pancreas noted. There was some concern for a potential primary pancreatobiliary tumor rather than rare RCC metastasis to pancreas so he was planned for a repeat ERCP and EUS in ___ weeks planned for the week of ___ off sunatinib . He last followed up in ___ clinic with Dr. ___ on ___. He was complaining of a week of increased fatigue nausea and poor PO intake. His sunatinib was held due to concern for side effects. Over the past week since then he has had worsening jaundice and fatigue. Last night he developed chills restlessness mild confusion and fevers to 101 which prompted his wife to bring him to ___. He was transferred from there to the ___ ED. Right now he feels ok just a little tired. He feels like his thinking is foggy. No fevers chills since he presented to the hospital. No nausea vomiting abdominal pain. He has had loose stools which he associates with the sunatinib. No bloody black or ___ stools. His urine has been tea colored. He has had poor appetite. No chest pain shortness of breath or palpitations. ED COURSE VS Tmax 98.6 HR ___ BP 100s 110s 60s RR 16 SpO2 98 100 on RA Labs WBC 3.4 AST ALT 71 97 AP 214 Tbili 7.6 lipase 148 lactate 1.4 Exam jaundiced abdomen benign guaiac negative brown stool Imaging RUQ US persistent left intrahepatic biliary dilation persistent GB sludge Interventions None ROS Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History PAST ONCOLOGIC HISTORY per OMR ___ presented with acute onset of gross hematuria accompanied with some mild flank pain. During his workup he was found to have a 4.8 cm mass on a CAT scan dated ___ specifically the scan describes a left renal mass with internal enhancement measuring 4.1 x 4.8 cm in size in the mid and upper pole of the left kidney. Also described was the fat containing left inguinal hernia and left perinephric stranding. There was no adenopathy or other suspicious lesions. There is also an old sclerotic right ilial lesion and left sacral lesion. ___ underwent a laparoscopic hand assisted radical right nephrectomy by Dr. ___ pathology showed a renal cell carcinoma clear cell type ___ grade II IV measuring 4 cm extending but not invading through the renal capsule or Gerota s fascia margins were questionably positive at the renal vein and otherwise negative. On review of pathology here at ___ the margins are described as negative including the renal vein margin. A background of global glomerulosclerosis is described. Overall this was a T3bNxMx lesion. Postoperative imaging on ___ which was a CT torso showed no evidence of recurrent or metastatic disease. ___ CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b l pulmonary nodules concerning for progression ___ Fine needle aspirate of 11R and 11L lymph nodes which was consistent with metastatic RCC ___ CT Torso mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra abdominal sites of disease ___ C1D1 ___ randomized to sunitinib ___ Multiple grade ___ adverse events including thrombocytopenia grade 2 platelet 52 000 leukopenia grade 2 WBC 2.9 elevated lipase grade 1 elevated amylase grade 1 elevated at baseline elevated ALT grade 1 and hypothyroidism grade 1 . Mild symptoms with treatment. Continued sunitinib at 50mg daily per protocol. ___ CT Torso Response of mediastinal lymphadenopathy bilateral hilar lymphadenopathy and numerous parenchymal metastases. Stable disease by RECIST decrease 19.1 from baseline . ___ Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. ___ CT Torso Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 decrease 22.5 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 39.8 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 46.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 40.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 42.6 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 47.7 from baseline . ___ CT torso Ongoing partial response comments No significant change compared to prior scan. No new lesions. ___ CT Torso PR by RECIST 1.1 ___ CT Torso PR by RECIST 1.1 54.22 change from baseline and 10.29 change from last scan. ___ CT Torso partial response 57.79 from baseline 7.79 from nadir ___ CT Torso shows continued partial response no significant change compared to prior PAST MEDICAL HISTORY per OMR 1. Clear cell kidney cancer as above. 2. Benign prostatic hypertrophy. 3. Diabetes mellitus. 4. Hypertension. 5. Hyperlipidemia. 6. History of anxiety. Social History ___ Family History Colorectal cancer mother ___ cancer sister dx at age ___ Liver cancer brother ___ cell leukemia brother ___ father Physical ___ ADMISSION EXAM VITALS T 97.6 HR 68 BP 115 76 RR 16 SpO2 98 on RA ___ Alert NAD breathing room air comfortably EYES Icteric sclera PERRL ENT MMM sublingual jaundice OP clear CV NR RR no m r g RESP CTAB no wheezes crackles or rhonchi GI Abdomen soft non distended non tender to palpation. Bowel sounds present. No HSM. MSK Neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs SKIN Jaundiced NEURO Alert oriented to hospital city date able to recite the days of the week backwards face symmetric gaze conjugate with EOMI speech fluent moves all limbs PSYCH pleasant appropriate affect DISCHARGE EXAM T 97.9 HR 70 BP 143 79 RR 18 SpO2 97 on RA ___ Alert NAD breathing room air comfortably EYES Icteric sclera ENT MMM OP clear CV NR RR no m r g RESP CTAB no wheezes crackles or rhonchi GI Abdomen soft non distended non tender to palpation. Bowel sounds present. MSK Neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs SKIN Jaundiced but improved NEURO Alert oriented face symmetric gaze conjugate with EOMI speech fluent moves all limbs PSYCH pleasant appropriate affect Pertinent Results ADMISSION LABS ___ 05 43AM BLOOD WBC 3.4 RBC 2.48 Hgb 8.4 Hct 24.9 MCV 100 MCH 33.9 MCHC 33.7 RDW 16.8 RDWSD 61.6 Plt ___ ___ 05 43AM BLOOD Glucose 95 UreaN 24 Creat 1.5 Na 138 K 4.4 Cl 106 HCO3 18 AnGap 14 ___ 05 55AM BLOOD Albumin 2.5 Calcium 8.1 Phos 3.5 Mg 1.9 Iron 18 ___ 05 43AM BLOOD Albumin 2.8 ___ 05 55AM BLOOD calTIBC 160 Hapto 230 Ferritn 990 TRF 123 ___ 05 43AM BLOOD ALT 97 AST 71 AlkPhos 214 TotBili 7.6 DirBili 5.6 IndBili 2.0 MICRO BCx ___ NGTD Blood culture ___ STREPTOCOCCUS ANGINOSUS ___ GROUP CEFTRIAXONE 0.5 S CLINDAMYCIN 0.25 S ERYTHROMYCIN 0.12 S PENICILLIN G 0.06 S VANCOMYCIN 0.5 S PATHOLOGY CYTOLOGY Biliary mass biopsy ___ Minute fragment of highly atypical cells with sclerotic stroma consistent with adenocarcinoma Common bile duct stricture brushings ___ POSITIVE FOR MALIGNANT CELLS. Adenocarcinoma. IMAGING RUQ US ___ IMPRESSION 1. Persistent mild left intrahepatic biliary dilation in presence of a partially visualized CBD stent raises concern for stent malfunction. Compared to the prior ultrasound the degree of intrahepatic biliary dilation has not changed significantly. 2. Persistent gallbladder sludge. ERCP ___ removal of the old stent and placement of a new stent over a 2cm malignant appearing stricture of the distal CBD. Cytology brushings were sampled. EUS ___ 1.8 x 1.1 cm ill defined hypoechoic area around the distal CBD. FNB was performed x3 CT torso ___ IMPRESSION Non obstructive pneumonia left upper lobe. Minimal residual pulmonary edema and pleural effusions attributable to heart failure. Atherosclerotic coronary calcification. Left PICC line ends just above the superior cavoatrial junction. IMPRESSION 1. No evidence of local recurrence or metastatic disease in the abdomen and pelvis. 2. Mild intrahepatic and extrahepatic biliary ductal dilatation with CBD stent in place. 3. Known nonocclusive main portal vein thrombus appears increased in size though difficult to directly compare to MR due to differences in imaging technique. ERCP ___ Biliary plastic stent removed with a snare. A metal stent was placed over 2cm long malignant appearing stricture in the distal CBD. TTE ___ IMPRESSION Adequate image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and regional global left ventricular systolic function. No 2D echocardiographic evidence for endocarditis. If clinically suggested the absence of a discrete vegetation on echocardiography does not exclude the diagnosis of endocarditis. Brief Hospital Course SUMMARY ASSESSMENT Mr. ___ is a ___ male with IDDM HTN BPH and metastatic clear cell RCC s p radical L nephrectomy ___ on chemotherapy sunitinib with recent admission ___ for biliary stricture s p ERCP with plastic stent placement CBD brushing cytology non diagnostic and non occlusive portal vein thrombus started on enoxaparin who presented to the ED with fever jaundice and confusion found to have persistent intrahepatic biliary dilation and gallbladder sludge on ___ US s p ERCP x2 with placement of plastic then metal biliary stent and EUS with pathology from FNB of CBD mass consistent with new pancreatobiliary adenocardinoma. ACUTE ACTIVE PROBLEMS Cholangitis Strep spp. likely Enterococcus bacteremia Adenocarcinoma pancreaticobiliary origin He presented with fever jaundice and mental status changes. RUQ US also showed persistent left intrahepatic biliary dilation and gallbladder sludge despite the presence of CBD stent suggesting that the stent was non functioning occluded or there was some other source of obstruction. The CBD brushing cytology from his prior ERCP was non diagnostic. He had no apparent mass in the head of the pancreas on imaging but there remained some concern for a primary pancreatobiliary tumor so he was planned to have a repeat ERCP and EUS the week he was admitted. Blood culture at ___ is growing Strep spp. He was treated with Unasyn for cholangitis as well as Strep bacteremia. BCx here grew Strep anginosus. He had an ERCP on ___ with removal of the old stent and placement of a new stent over a 2cm malignant appearing stricture of the distal CBD. Cytology brushings were sampled. EUS was completed on which they visualized a 1.8 x 1.1 cm ill defined hypoechoic area around the distal CBD. FNB was performed x3. Pathology was consistent with adenocarcinoma. After the plastic stent placement his LFTs did not improve and bilirubin continued to rise. A repeat ERCP was done on ___ with removal of the plastic stent and placement of a metal stent. After this his LFTs started to improve. His Unasyn was changed to ceftriaxone and metronidazole for ease of dosing to complete a 2 week course ___ ___. A PICC was placed prior to discharge. TTE did not show evidence of endocarditis. ___ on CKD Cr peaked at 1.8 from baseline 1.2. Most likely this was prerenal in the setting of cholangitis. It improved after ERCP antibiotics and fluid resuscitation. PVT He was found to have a non occlusive portal vein thrombus on MRCP during his recent hospital admission and was started on enoxaparin. HIs home enoxaparin was initially held for ERCP then resumed. Macrocytic anemia Macrocytic anemia is chronic. Baseline H H appears to be ___ so he is lower than baseline. He had no signs of bleeding. Recent TSH folate B12 ferritin and TIBC were wnl. Bilirubin is predominantly direct so less likely hemolysis. Other hemolysis labs were not consistent with hemolysis. Acute on chronic anemia is perhaps ___ bone marrow suppression from sepsis. He was given 1 unit pRBCs for Hgb 7.6. Metastatic clear cell RCC on chemotherapy He is followed at ___ by Dr. ___. He was diagnosed in ___ in workup of gross hematuria and flank pain. He underwent a laparoscopic radical right nephrectomy in ___. He was found to have metastases to the lungs mediastinal lymph nodes and hilar lymph nodes in ___. In ___ he was enrolled in an experimental trial and started on sunatinib. His most recent CT showed clinical response. He is currently in his regularly scheduled two weeks off on sunatinib. He had a surveillance CT on ___ which showed no evidence of local recurrence of metastatic disease in the abdomen pelvis. LUL pneumonia He was found to have LUL opacity on CT chest ordered for surveillance. He was also complaining of cough. He was on Unasyn while inpatient then transitioned to ceftriaxone and metronidazole for 2 weeks total which should cover him for pneumonia. HTN Initially his home atenolol dose was halved due to concern for cholangitis impending sepsis. His home amlodipine 10 mg and lisinopril 40 mg daily were also initially held. These were resumed prior to or at discharge. Insulin dependent DM type II At home he takes glargine 16 units qhs if his FSBG is 170 and he takes 18 units qhs if his FBSG is 170. While inpatient he was given glaring 8 units qhs as he was not taking much PO as well as lispro SSI. CHRONIC STABLE PROBLEMS Hypothyroidism continued home levothyroxine Depression and anxiety continued home fluoxetine held home cariprazine as it is non formulary Mr. ___ is clinically stable for discharge. The total time spent today on discharge planning counseling and coordination of care was greater than 30 minutes. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Enoxaparin Sodium 120 mg SC DAILY Start ___ First Dose Next Routine Administration Time 2. amLODIPine 10 mg PO DAILY 3. Ascorbic Acid ___ mg PO DAILY 4. Atenolol 100 mg PO DAILY 5. cariprazine 1.5 mg oral DAILY 6. FLUoxetine 20 mg PO DAILY 7. Gabapentin 100 mg PO BID 8. GlipiZIDE 2.5 mg PO BID 9. Glargine 16 Units Bedtime 10. Levothyroxine Sodium 100 mcg PO DAILY 11. Lisinopril 40 mg PO DAILY 12. LORazepam 0.5 mg PO DAILY PRN anxiety 13. Omeprazole 20 mg PO DAILY 14. Ondansetron 4 mg PO Q8H PRN nausea 15. Prochlorperazine 5 mg PO Q8H PRN nausea 16. Tamsulosin 0.4 mg PO QHS 17. Vitamin D 5000 UNIT PO DAILY 18. Multivitamins 1 TAB PO DAILY 19. Fenofibrate 48 mg PO DAILY Discharge Medications 1. CefTRIAXone 2 gm IV Q24H RX ceftriaxone in dextrose iso os 2 gram 50 mL 2 gm IV once a day Disp 9 Intravenous Bag Refills 0 2. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 tablet s by mouth every eight 8 hours Disp 27 Tablet Refills 0 3. Glargine 16 Units Bedtime 4. amLODIPine 10 mg PO DAILY 5. Ascorbic Acid ___ mg PO DAILY 6. Atenolol 100 mg PO DAILY 7. cariprazine 1.5 mg oral DAILY 8. Enoxaparin Sodium 120 mg SC DAILY Start ___ First Dose Next Routine Administration Time 9. Fenofibrate 48 mg PO DAILY 10. FLUoxetine 20 mg PO DAILY 11. Gabapentin 100 mg PO BID 12. GlipiZIDE 2.5 mg PO BID 13. Levothyroxine Sodium 100 mcg PO DAILY 14. Lisinopril 40 mg PO DAILY 15. LORazepam 0.5 mg PO DAILY PRN anxiety 16. Multivitamins 1 TAB PO DAILY 17. Omeprazole 20 mg PO DAILY 18. Ondansetron 4 mg PO Q8H PRN nausea 19. Prochlorperazine 5 mg PO Q8H PRN nausea 20. Tamsulosin 0.4 mg PO QHS 21. Vitamin D 5000 UNIT PO DAILY Discharge Disposition Home With Service Facility ___ ___ Diagnosis Cholangitis Bacteremia Adenocarcinoma Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You were admitted to the hospital after you were found to have a blockage of your bile ducts causing a serious infection called cholangitis. You were also found to have bacteria in your blood stream. You underwent an ERCP with a plastic stent placed. After the procedure your bilirubin continued to rise and you underwent a second ERCP to place a metal stent. For your serious infection you were started on IV antibiotics and will need to continue this for two weeks. This blockage in the bile duct was caused by a stricture. Samples of the stricture were taken and found to be cancer adenocarcinoma . You were seen by the oncology team and have follow up with them in a few days to talk about treatment options. It was a pleasure caring for you Your ___ Team Followup Instructions ___ The icd codes present in this text will be A408, K831, I81, J189, K830, C7802, C7801, C771, N179, C249, R6520, F419, N400, Z85528, E785, Z87891, D539, F329, E039, E1122, I129, N189, Z794. The descriptions of icd codes A408, K831, I81, J189, K830, C7802, C7801, C771, N179, C249, R6520, F419, N400, Z85528, E785, Z87891, D539, F329, E039, E1122, I129, N189, Z794 are A408: Other streptococcal sepsis; K831: Obstruction of bile duct; I81: Portal vein thrombosis; J189: Pneumonia, unspecified organism; K830: Cholangitis; C7802: Secondary malignant neoplasm of left lung; C7801: Secondary malignant neoplasm of right lung; C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes; N179: Acute kidney failure, unspecified; C249: Malignant neoplasm of biliary tract, unspecified; R6520: Severe sepsis without septic shock; F419: Anxiety disorder, unspecified; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z85528: Personal history of other malignant neoplasm of kidney; E785: Hyperlipidemia, unspecified; Z87891: Personal history of nicotine dependence; D539: Nutritional anemia, unspecified; F329: Major depressive disorder, single episode, unspecified; E039: Hypothyroidism, unspecified; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N189: Chronic kidney disease, unspecified; Z794: Long term (current) use of insulin. The common codes which frequently come are N179, F419, N400, E785, Z87891, F329, E039, E1122, I129, N189, Z794. The uncommon codes mentioned in this dataset are A408, K831, I81, J189, K830, C7802, C7801, C771, C249, R6520, Z85528, D539.
The icd codes present in this text will be K831, I81, C7800, K862, C771, E785, I129, E1122, N189, F419, N400, D539, F329, E039, Z85528, Z905, Z87891, Z800, Z807, Z8041. The descriptions of icd codes K831, I81, C7800, K862, C771, E785, I129, E1122, N189, F419, N400, D539, F329, E039, Z85528, Z905, Z87891, Z800, Z807, Z8041 are K831: Obstruction of bile duct; I81: Portal vein thrombosis; C7800: Secondary malignant neoplasm of unspecified lung; K862: Cyst of pancreas; C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes; E785: Hyperlipidemia, unspecified; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; N189: Chronic kidney disease, unspecified; F419: Anxiety disorder, unspecified; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; D539: Nutritional anemia, unspecified; F329: Major depressive disorder, single episode, unspecified; E039: Hypothyroidism, unspecified; Z85528: Personal history of other malignant neoplasm of kidney; Z905: Acquired absence of kidney; Z87891: Personal history of nicotine dependence; Z800: Family history of malignant neoplasm of digestive organs; Z807: Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues; Z8041: Family history of malignant neoplasm of ovary. The common codes which frequently come are E785, I129, E1122, N189, F419, N400, F329, E039, Z87891. The uncommon codes mentioned in this dataset are K831, I81, C7800, K862, C771, D539, Z85528, Z905, Z800, Z807, Z8041. Allergies ___ Chief Complaint anbormal lfts Major Surgical or Invasive Procedure ERCP ___ History of Present Illness PRIMARY ONCOLOGIST Dr ___ ___ Metastatic clear cell renal cell carcinoma TREATMENT ___ randomized to sunitinib 50 mg PO daily x 4 weeks followed by 2 weeks off. Dose reduced sunitinib to 37.5 mg daily. Cycle 25 Week 1. CHIEF COMPLAINT Abnormal LFTs HISTORY OF PRESENT ILLNESS Mr. ___ is a pleasant ___ w ID T2DM HTN DL BPH and metastatic clear cell RCC s p radical L nephrectomy in ___ found to have pulmonary mediastinal and hilar mets ___ now on ___ randomized to sunitinib dose reduced currently 2 weeks off sunitinib per protocol who is directly admitted from clinic for abnormal LFTs found on routine lab screening. He feels tired but has no localizing symptoms. He did not have any F C no abd pain no N V. Appeared mildly lethargic today after he took his Ativan today for anxiety related coming into ___. His family reported ___ episodes of confusion since his last clinic visit. He states he s had greasy foods lately without any n v no abd pain. He drinks a couple beers a week during his weeks off sunitinib. No new meds. No apap nsaids. No recent travel. No camping. REVIEW OF SYSTEMS 10 point ROS reviewed in detail and negative except for what is mentioned above in HPI Past Medical History PAST ONCOLOGIC HISTORY per OMR ___ presented with acute onset of gross hematuria accompanied with some mild flank pain. During his workup he was found to have a 4.8 cm mass on a CAT scan dated ___ specifically the scan describes a left renal mass with internal enhancement measuring 4.1 x 4.8 cm in size in the mid and upper pole of the left kidney. Also described was the fat containing left inguinal hernia and left perinephric stranding. There was no adenopathy or other suspicious lesions. There is also an old sclerotic right ilial lesion and left sacral lesion. ___ underwent a laparoscopic hand assisted radical right nephrectomy by Dr. ___ pathology showed a renal cell carcinoma clear cell type ___ grade II IV measuring 4 cm extending but not invading through the renal capsule or Gerota s fascia margins were questionably positive at the renal vein and otherwise negative. On review of pathology here at ___ the margins are described as negative including the renal vein margin. A background of global glomerulosclerosis is described. Overall this was a T3bNxMx lesion. Postoperative imaging on ___ which was a CT torso showed no evidence of recurrent or metastatic disease. ___ CT chest showed interval increase in prominence of mediastinal lymph nodes and minimal interval increase in multiple b l pulmonary nodules concerning for progression ___ Fine needle aspirate of 11R and 11L lymph nodes which was consistent with metastatic RCC ___ CT Torso mediastinal and hilar nodes and pulmonary lesions increased in size. No definite intra abdominal sites of disease ___ C1D1 ___ randomized to sunitinib ___ Multiple grade ___ adverse events including thrombocytopenia grade 2 platelet 52 000 leukopenia grade 2 WBC 2.9 elevated lipase grade 1 elevated amylase grade 1 elevated at baseline elevated ALT grade 1 and hypothyroidism grade 1 . Mild symptoms with treatment. Continued sunitinib at 50mg daily per protocol. ___ CT Torso Response of mediastinal lymphadenopathy bilateral hilar lymphadenopathy and numerous parenchymal metastases. Stable disease by RECIST decrease 19.1 from baseline . ___ Sunitinib reduced to 37.5 mg daily due to erythematous rash and blistering on palms and sole of right foot. ___ CT Torso Decrease in pulmonary and mediastinal lesions. Stable disease by RECIST 1.1 decrease 22.5 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 39.8 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 46.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 40.3 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 42.6 from baseline . ___ CT Torso Partial response by RECIST 1.1 decrease 47.7 from baseline . ___ CT torso Ongoing partial response comments No significant change compared to prior scan. No new lesions. ___ CT Torso PR by RECIST 1.1 ___ CT Torso PR by RECIST 1.1 54.22 change from baseline and 10.29 change from last scan. ___ CT Torso partial response 57.79 from baseline 7.79 from nadir ___ CT Torso shows continued partial response no significant change compared to prior PAST MEDICAL HISTORY per OMR 1. Clear cell kidney cancer as above. 2. Benign prostatic hypertrophy. 3. Diabetes mellitus. 4. Hypertension. 5. Hyperlipidemia. 6. History of anxiety. Social History ___ Family History Mother Died of rectal colon cancer. Father No cancers history of diabetes. Other He has a sister with ovarian cancer diagnosed at age ___ and a brother with liver cancer at age ___ and another brother with hairy cell leukemia which is in remission. Physical Exam VITAL SIGNS 97.5 PO 160 89 R Sitting 71 18 99 ra General NAD Resting in bed comfortably with daughter at bedside ___ MMM no OP lesions no cervical supraclavicular adenopathy no icterus CV RR NL S1S2 no S3S4 No MRG PULM CTAB No C W R No respiratory distress ABD BS soft NTND no palpable masses or HSM LIMBS WWP trace b l pitting edema at the distal ___ no tremors SKIN No rashes on the extremities NEURO Grossly normal speech clear AOx3 ACCESS No port Pertinent Results ___ 06 55AM BLOOD WBC 3.9 RBC 3.12 Hgb 10.5 Hct 33.5 MCV 107 MCH 33.7 MCHC 31.3 RDW 16.8 RDWSD 65.9 Plt ___ ___ 07 25AM BLOOD WBC 3.0 RBC 3.03 Hgb 10.2 Hct 32.2 MCV 106 MCH 33.7 MCHC 31.7 RDW 16.9 RDWSD 66.0 Plt ___ ___ 11 30AM BLOOD WBC 3.6 RBC 3.21 Hgb 10.8 Hct 34.9 MCV 109 MCH 33.6 MCHC 30.9 RDW 17.0 RDWSD 68.3 Plt ___ ___ 06 55AM BLOOD Glucose 121 UreaN 14 Creat 1.2 Na 147 K 4.5 Cl 106 HCO3 27 AnGap 14 ___ 07 25AM BLOOD Glucose 204 UreaN 18 Creat 1.3 Na 140 K 4.3 Cl 103 HCO3 25 AnGap 12 ___ 11 30AM BLOOD UreaN 19 Creat 1.4 Na 139 K 5.3 Cl 101 ___ 06 55AM BLOOD ALT 101 AST 47 LD ___ 239 AlkPhos 188 TotBili 1.5 DirBili 0.7 IndBili 0.8 ___ 09 45PM BLOOD ALT 123 AST 57 LD LDH 274 CK CPK 106 AlkPhos 241 TotBili 2.3 ___ 11 30AM BLOOD ALT 133 AST 71 LD ___ 289 AlkPhos 259 Amylase 210 TotBili 3.0 DirBili 1.8 IndBili 1.2 ___ 09 45PM BLOOD cTropnT 0.01 ___ 11 30AM BLOOD Lipase 252 ___ 06 55AM BLOOD Lipase 63 ___ 06 55AM BLOOD Albumin 3.7 Calcium 9.3 Phos 3.7 Mg 2.0 ___ 09 45PM BLOOD calTIBC 306 VitB12 356 Folate 20 ___ Ferritn 597 TRF 235 ___ 09 45PM BLOOD Triglyc 207 HDL 30 CHOL HD 4.7 LDLcalc 70 ___ 11 30AM BLOOD Free T4 1.2 ___ 09 45PM BLOOD HBsAg NEG HBsAb NEG HBcAb NEG ___ 09 45PM BLOOD Smooth NEGATIVE ___ 09 45PM BLOOD ___ ___ 09 45PM BLOOD IgG 666 IgA 165 IgM 120 ___ 09 45PM BLOOD HCV Ab NEG ___ 09 46PM BLOOD Lactate 0.7 ___ 11 30AM BLOOD FREE T3 Test ___ 11 30AM BLOOD Free T4 1.2 Brief Hospital Course IMAGING RUQ US ___ 1. Biliary sludge without evidence of gallbladder wall thickening or intrahepatic biliary dilatation. 2. No evidence of focal liver lesions MRCP ___ 1. Moderate intra and extrahepatic biliary ductal dilatation with duct penetrating sign suggestive of inflammatory rather than neoplastic stricture. Correlation with ERCP may be considered. No evidence of choledocholithiasis or definite obstructing mass. 2. Short segment 11 mm eccentric filling defect within the main portal vein suspicious for nonocclusive thrombus. 3. Sludge within the gallbladder lumen. 4. Status post left nephrectomy with stable soft tissue within the left nephrectomy bed. 5. Multiple pancreatic cystic lesions likely small side branch IPMNs measuring up to 10 mm. ASSESSMENT AND PLAN ___ w ID T2DM HTN DL BPH and metastatic clear cell RCC s p radical L nephrectomy in ___ found to have pulmonary mediastinal and hilar mets ___ now on ___ randomized to sunitinib dose reduced currently 2 weeks off sunitinib per protocol who is directly admitted from clinic for abnormal LFTs found on routine lab screening. Elevated LFTs Non specific elevations. US did not reveal any focal lesions nor any biliary dilatation nor stones. Lipase elevated at 252 but in absence of any abd pain unlikely pancreatitis. Unlikely sunitinib effect per oncology. Pt did appear to be lethargic per oncologist but is AOx3 and no asterixis but cannot rule out some element of encephalopathy. Found on MRCP to have moderate intra extrahepatic biliary ductal dilatation suggestive of stricture. Hepto wnl and anemia stable so unlikely hemolysis. SPEP largely wnl. ERCP on ___ revealed stricture in bile duct and had plastic biliary stent placed. He tolerated procedure well. Had no infectious symptoms nor any signs of post ercp pancreatitis. He was advanced to full diet and instructed to f u with oncology for the results of the brushings done during ERCP. Their team will coordinate a repeat ERCP in 4 wks. Portal Vein THrombus MRCP revealed a small non occlusive filling defect within the main portal vein suspicious for thrombus. Due to risk of progression patient was started on once daily dosing lovenox at 1.5 mg kg. Due to sphincterotomy during the ERCP patient was instructed to wait 5 days after ercp to start the lovenox. He was provided teaching on how to inject and warning signs while he was here. Pancreatic cysts Found on MRCP per radiology felt to be to be small side branch Intraductal papillary mucinous neoplasm. f u in ___ year ___ CT scans from ___ revealed partial response to sunitinib. sunitinib is currently on hold will f u w Dr ___ Macrocytic Anemia Chronic and at baseline. TSH WNL as well as VIt B12 Folate spep and ferritin TIBC. Depressed mood anxiety hold cariprazine ___ lfts cont fluoxetine T2DM cont home insulin glipizide HTN cont amlodipine atenolol lisinopril DL hold statin fibrate CKD cr baseline Hypothyroidism cont levothyroxine TSH WNL BPH cont flomax FEN Regular low fat diabetic diet DVT PROPHYLAXIS HSQ ACCESS PIV CODE STATUS Full code presumed PCP ___ MD DISPO Home w o services BILLING 45 min spent coordinating care for discharge ___ ___ D.O. Heme Onc Hospitalist p ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Atenolol 100 mg PO DAILY 3. cariprazine 1.5 mg oral DAILY 4. Fenofibrate 48 mg PO DAILY 5. FLUoxetine 20 mg PO DAILY 6. Gabapentin 100 mg PO DAILY 7. GlipiZIDE 2.5 mg PO BID 8. Lantus Solostar U 100 Insulin insulin glargine ___ units subcutaneous QPM 9. Levothyroxine Sodium 100 mcg PO DAILY 10. LORazepam 0.5 mg PO DAILY PRN anxiety 11. Ondansetron 4 mg PO Q8H PRN nausea 12. Prochlorperazine 5 mg PO Q8H PRN nausea 13. Simvastatin 40 mg PO QPM 14. Tamsulosin 0.4 mg PO QHS 15. Ascorbic Acid ___ mg PO DAILY 16. Vitamin D 5000 UNIT PO DAILY 17. Omeprazole 20 mg PO DAILY 18. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 19. Lisinopril 40 mg PO DAILY Discharge Medications 1. Enoxaparin Sodium 120 mg SC DAILY Start Future Date ___ First Dose First Routine Administration Time RX enoxaparin 120 mg 0.8 mL 120 mg sc daily Disp 30 Syringe Refills 0 2. amLODIPine 10 mg PO DAILY 3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry eyes 4. Ascorbic Acid ___ mg PO DAILY 5. Atenolol 100 mg PO DAILY 6. cariprazine 1.5 mg oral DAILY 7. FLUoxetine 20 mg PO DAILY 8. Gabapentin 100 mg PO DAILY 9. GlipiZIDE 2.5 mg PO BID 10. Lantus Solostar U 100 Insulin insulin glargine ___ units subcutaneous QPM 11. Levothyroxine Sodium 100 mcg PO DAILY 12. Lisinopril 40 mg PO DAILY 13. LORazepam 0.5 mg PO DAILY PRN anxiety 14. Omeprazole 20 mg PO DAILY 15. Ondansetron 4 mg PO Q8H PRN nausea 16. Prochlorperazine 5 mg PO Q8H PRN nausea 17. Tamsulosin 0.4 mg PO QHS 18. Vitamin D 5000 UNIT PO DAILY 19. HELD Fenofibrate 48 mg PO DAILY This medication was held. Do not restart Fenofibrate until discussed with your oncologist 20. HELD Simvastatin 40 mg PO QPM This medication was held. Do not restart Simvastatin until discussed with your oncologist Discharge Disposition Home Discharge Diagnosis Biliary Stricture Portal Vein Thrombus Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear ___ ___ were admitted to the hospital because ___ had abnormal liver enzymes. MRI of your liver MRCP revealed a narrowing in your bile duct also known as a stricture. ___ had an ERCP endoscopy and a camera into your bile duct which confirmed a stricture. These improved after ___ had an ERCP. ___ had a plastic stent placed in your bile duct and ___ tolerated this well. Your liver enzymes are already improving. ERCP team will call ___ to schedule another ERCP in 4 weeks or so to possibly remove the stent. ___ will follow up on the biopsy results with your oncology team. ___ were also found to have a clot in one of your veins portal vein which will need to be treated with a blood thinner. ___ will start this ___. Call your oncology team if there are any issues or questions. Regards Your ___ team Followup Instructions ___ The icd codes present in this text will be K831, I81, C7800, K862, C771, E785, I129, E1122, N189, F419, N400, D539, F329, E039, Z85528, Z905, Z87891, Z800, Z807, Z8041. The descriptions of icd codes K831, I81, C7800, K862, C771, E785, I129, E1122, N189, F419, N400, D539, F329, E039, Z85528, Z905, Z87891, Z800, Z807, Z8041 are K831: Obstruction of bile duct; I81: Portal vein thrombosis; C7800: Secondary malignant neoplasm of unspecified lung; K862: Cyst of pancreas; C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes; E785: Hyperlipidemia, unspecified; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; N189: Chronic kidney disease, unspecified; F419: Anxiety disorder, unspecified; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; D539: Nutritional anemia, unspecified; F329: Major depressive disorder, single episode, unspecified; E039: Hypothyroidism, unspecified; Z85528: Personal history of other malignant neoplasm of kidney; Z905: Acquired absence of kidney; Z87891: Personal history of nicotine dependence; Z800: Family history of malignant neoplasm of digestive organs; Z807: Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues; Z8041: Family history of malignant neoplasm of ovary. The common codes which frequently come are E785, I129, E1122, N189, F419, N400, F329, E039, Z87891. The uncommon codes mentioned in this dataset are K831, I81, C7800, K862, C771, D539, Z85528, Z905, Z800, Z807, Z8041.
The icd codes present in this text will be B003, C20, K626, K2960, K2980, I10, F329, D508. The descriptions of icd codes B003, C20, K626, K2960, K2980, I10, F329, D508 are B003: Herpesviral meningitis; C20: Malignant neoplasm of rectum; K626: Ulcer of anus and rectum; K2960: Other gastritis without bleeding; K2980: Duodenitis without bleeding; I10: Essential (primary) hypertension; F329: Major depressive disorder, single episode, unspecified; D508: Other iron deficiency anemias. The common codes which frequently come are I10, F329. The uncommon codes mentioned in this dataset are B003, C20, K626, K2960, K2980, D508. Allergies No Known Allergies Adverse Drug Reactions Major Surgical or Invasive Procedure EGD Colonoscopy Biopsy during colonoscopy Lumbar puncture attach Pertinent Results ADMISSION LABS ___ 11 00AM WBC 10.0 RBC 4.66 HGB 8.4 HCT 30.9 MCV 66 MCH 18.0 MCHC 27.2 RDW 20.1 RDWSD 45.3 ___ 11 00AM NEUTS 85.1 LYMPHS 6.6 MONOS 7.7 EOS 0.0 BASOS 0.2 IM ___ AbsNeut 8.47 AbsLymp 0.66 AbsMono 0.77 AbsEos 0.00 AbsBaso 0.02 ___ 11 00AM PLT COUNT 225 ___ 11 00AM GLUCOSE 111 UREA N 15 CREAT 1.0 SODIUM 128 POTASSIUM 4.6 CHLORIDE 95 TOTAL CO2 18 ANION GAP 15 ___ 11 00AM ALT SGPT 13 AST SGOT 20 ALK PHOS 80 TOT BILI 1.0 ___ 11 00AM ALBUMIN 4.9 ___ 07 20AM BLOOD Hypochr 1 Anisocy 1 Macrocy 1 Microcy 1 Polychr 1 Tear Dr 1 RBC Mor SLIDE REVI ___ 11 42AM BLOOD Ret Aut 3.1 Abs Ret 0.13 ___ 07 20AM BLOOD calTIBC 371 VitB12 293 Folate 8 Ferritn 5.6 TRF 285 ___ 11 42AM BLOOD Hapto 208 ___ 07 20AM BLOOD TSH 1.1 ___ 07 20AM BLOOD 25VitD 17 ___ 03 30AM BLOOD IgA 162 ___ 03 40PM CEREBROSPINAL FLUID CSF TNC 146 RBC 7 POLYS 1 ___ MONOS 12 BASOS 1 OTHER 0 ___ 03 40PM CEREBROSPINAL FLUID CSF TNC 141 RBC 2 POLYS 1 ___ MONOS 3 OTHER 0 ___ 03 40PM CEREBROSPINAL FLUID CSF PROTEIN 100 GLUCOSE 57 ___ 11 00AM Lyme Ab NEG ___ 04 45PM BLOOD Trep Ab NEG ___ 07 20AM BLOOD HIV Ab NEG ___ 03 05PM BLOOD Parst S NEGATIVE MICRO ___ 3 40 pm CSF SPINAL FLUID Site LUMBAR PUNCTURE TUBE 3. GRAM STAIN Final ___ NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE Final ___ NO GROWTH. HSV CSF HSV2 low positive IMAGING CT head w o acute intracranial process Discharge Labs ___ 06 00AM BLOOD WBC 5.6 RBC 3.79 Hgb 7.2 Hct 27.1 MCV 72 MCH 19.0 MCHC 26.6 RDW 22.1 RDWSD 56.4 Plt ___ ___ 06 00AM BLOOD Glucose 80 UreaN 12 Creat 0.8 Na 143 K 3.9 Cl 111 HCO3 21 AnGap 11 ___ 06 00AM BLOOD Calcium 8.2 Phos 4.5 Mg 1.7 ___ 05 45AM BLOOD Hapto 126 ___ 07 20AM BLOOD TSH 1.1 ___ 05 50AM BLOOD CEA 1.9 ___ 03 30AM BLOOD IgA 162 Colonoscopy Circumferential mass of malignant appearance was found in the distal rectum completely encircling the rectal verge. There were local ulcerations in the 12 o clock position. Multiple cold forceps biopsies were performed for histology in the rectal mass. EGD Normal erythema in the whole esophagus. Erythema in the antrum with gastritis. Erythema in the duodenum compatible with duodenitis. Brief Hospital Course Hospital Medicine Attending Progress Note Time patient seen and examined today HPI on Admission Mr. ___ is a ___ male with a PMHX of partial aortic dissection HTN who presents w HA fever x2d concerning for meningitis. Patient reports that 3 days ago he developed malaise and terrible headache constant dull diffuse. The following day headache was relenting ___ pain. Also had fever of 102 and took tylenol ibuprofen without relief of symptoms. He reports nausea and decreased PO intake. Denies vision changes sensitivity to light syncope URI sx chest pain shortness of breath abd pain diarrhea constipation sick contacts. Has mild neck stiffness as well. He lives in ___ does a lot of yardwork. Has had exposure to ticks mosquitoes but none he memorably recalls recently. No recent travel hx. No rash. He was feeling entirely well prior to onset of these symptoms. Given terrible headache and fever he presented to the ED. Hospital Course to Date The pt was admitted for acute onset headache and fever. LP showed a cell count of 141 with lymphocytic predominance and elevated protein to 100. He was initially started on bacterial meningitis coverage then narrowed to acyclovir based on negative CSF stain and cultures. Doxycycline was added to cover potential lyme meningitis. The pt s CSF came back positive for HSV PCR. Per ID recommendations from ___ Would recommend continuing on Acyclovir for now but when safe for discharge can change to Valtrex 1 gram po three times per day to complete 14 day course. In setting of only low positive HSV 2 PCR and extensive outdoor activity would also complete 14 day course of doxycycline even though lyme is less likely. The pt improved dramatically. His headache resolved. Throughout his hospitalization he had no confusion or neurologic deficits. He was transitioned to oral acyclovir the day before discharge and discharged on PO acyclovir PO doxycycline for a total 14 day course. Of note the pt was incidentally found to have an abnormally low Hb on admission. He required 1u PRBC transfusion ___. He denies any known bleeding. GI was consulted and recommended EGD colonoscopy performed ___. EGD showed diffuse erythema of the mucosa with no bleeding noted in the antrum consistent with gastritis. Colonoscopy showed a circumferential mass of malignant appearance in the distal rectum completely encircling the rectal verge. There were local ulcerations in the 12 00 position. Colorectal surgery was consulted. They recommended follow up at the colorectal cancer clinic. Follow up was arranged prior to discharge and the pt was aware of the diagnosis and need for follow up. The clinic and colorectal surgery asked for a baseline CEA which was normal. They asked for a staging MRI pelvis which did not show any spread of the presumed cancer. Pathology was sent by GI. Initial pathology showed superficial fragments of tubulovillous adenoma. This was pending at the time of discharge though initial reports had shown the same diagnosis so the pt was instructed to follow up with GI. The GI phone number was shared with the patient and he was instructed to call them directly if he did not hear from the clinic within 24 hours. The pt received a total of 2u PRBCs this hospitalization. Hb was 7.2 on the morning of discharge and the pt received 1u PRBCs the second unit this stay on the day of discharge after the Hb of 7.2 in order to ensure that his Hb did not drop below 7.0 at home. Close follow up was arranged prior to discharge. The pt had no active bleeding at the time of discharge. Return to ER precautions such as dizziness and increased bleeding were reviewed with the patient. The pt s BP meds were held on admission but restarted prior to discharge. Medications on Admission The Preadmission Medication list is accurate and complete. 1. TraZODone 50 mg PO QHS PRN insomnia 2. Citalopram 20 mg PO DAILY 3. Lisinopril 20 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications 1. Acetaminophen 1000 mg PO Q6H PRN Pain Mild Fever 2. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 capsule s by mouth twice a day Disp 12 Capsule Refills 0 3. Pantoprazole 40 mg PO DAILY RX pantoprazole 40 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 4. ValACYclovir 1000 mg PO TID RX valacyclovir Valtrex 1 000 mg 1 tablet s by mouth three times a day Disp 18 Tablet Refills 0 5. Citalopram 20 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. TraZODone 50 mg PO QHS PRN insomnia Discharge Disposition Home Discharge Diagnosis Viral meningitis ___ HSV Iron deficiency anemia Rectal cancer Discharge Condition Stable for outpatient follow up Discharge Instructions Dear ___ You came to the hospital with severe headache and fevers. You were found to have a viral meningitis with testing showing herpes simplex virus to be the cause. Please continue taking Valtrex and doxycycline until ___ to treat this infection. When you were in the hospital you were found to have iron deficiency anemia. You were seen by the Gastroenterologists. You underwent an EGD and a colonoscopy. The EGD showed a little stomach irritation. Avoid ibuprofen higher dose aspirin and naproxen. Take pantoprazole to help with the irritation. There was no cancer found in the stomach. The colonoscopy showed a rectal cancer. Please follow up as instructed with gastroenterology for a better pathology sample and with the multi disciplinary colorectal cancer team as instructed. Your appointment with the multi disciplinary team has already been set up. Call the ___ clinic to set up an appointment with them in order for them to get a better sample of the tumor. This is needed for the pathologists and oncologists. If you do not hear from the office within 48 hours call them at ___. We wish you the best in your recovery. Your medical team Followup Instructions ___ The icd codes present in this text will be B003, C20, K626, K2960, K2980, I10, F329, D508. The descriptions of icd codes B003, C20, K626, K2960, K2980, I10, F329, D508 are B003: Herpesviral meningitis; C20: Malignant neoplasm of rectum; K626: Ulcer of anus and rectum; K2960: Other gastritis without bleeding; K2980: Duodenitis without bleeding; I10: Essential (primary) hypertension; F329: Major depressive disorder, single episode, unspecified; D508: Other iron deficiency anemias. The common codes which frequently come are I10, F329. The uncommon codes mentioned in this dataset are B003, C20, K626, K2960, K2980, D508.
The icd codes present in this text will be G893, Z66, K8580, E43, C250, C787, C7900, I959, K219, Z681, I10, E049, E7800, K5900. The descriptions of icd codes G893, Z66, K8580, E43, C250, C787, C7900, I959, K219, Z681, I10, E049, E7800, K5900 are G893: Neoplasm related pain (acute) (chronic); Z66: Do not resuscitate; K8580: Other acute pancreatitis without necrosis or infection; E43: Unspecified severe protein-calorie malnutrition; C250: Malignant neoplasm of head of pancreas; C787: Secondary malignant neoplasm of liver and intrahepatic bile duct; C7900: Secondary malignant neoplasm of unspecified kidney and renal pelvis; I959: Hypotension, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; Z681: Body mass index [BMI] 19.9 or less, adult; I10: Essential (primary) hypertension; E049: Nontoxic goiter, unspecified; E7800: Pure hypercholesterolemia, unspecified; K5900: Constipation, unspecified. The common codes which frequently come are Z66, K219, I10, K5900. The uncommon codes mentioned in this dataset are G893, K8580, E43, C250, C787, C7900, I959, Z681, E049, E7800. Allergies latex Chief Complaint abd pain Major Surgical or Invasive Procedure ___ EUS was performed using a linear echoendoscope at ___ MHz frequency. Celiac Plexus Neurolysis was performed. The take off of the celiac artery was identified. A 22 gauge EUS needle was primed with saline and advanced adjacent to the Aorta just superior to the celiac artery take off. The celiac plexus was visualized. This was aspirated to assess for vascular injection. No blood was noted. Bupivacaine 0.25 x 10 cc was injected bilaterally. Dehydrated 98 alcohol x 10 cc was injected. The needle was then withdrawn. History of Present Illness ONCOLOGY HOSPITALIST ADMISSION NOTE ___ PRIMARY ONCOLOGIST ___ PRIMARY DIAGNOSIS Metastatic pancreatic cancer TREATMENT REGIMEN C7D1 Gemcitabine ___ CC ___ pain HISTORY OF PRESENTING ILLNESS ___ is a ___ year old woman with metastatic pancreatic cancer on palliative gemcitabine who is admitted with one week of progressive epigastric abdominal pain. Patient is deaf and uses ASL interview conducted with the aid of her son translating. Patient developed insidious onset of progressive epigastric abdominal pain after chemotherapy on ___. Her pain progressed and was associated with nausea dry heaves and poor po intake. Olanzapine was prescribed for her worsening nausea on ___ which made her very sleepy. By ___ she was not tolerating po intake with emesis x2 and her pain was up to ___. She discusse with her oncologist and presented to the ___ ED. There her lipase was 2800. CT a p reportedly showed large infiltrative pancreatic head tumor along with tumor infiltrate and or pancreatitis in the lesser sac and about the celiac axis . She was transferred to ___ ED. In the ED initial VS were pain 10 T 99.6 HR 94 BP 115 75 RR 16 O2 97 RA. Initial labs notable for Na 137 K 4.4 HCO3 24 Cr 0.5 Ca 9.6 Mg 2.0 P 2.9 ALT 14 AST 14 ALP 138 TBili 0.6 Alb 3.3 Lipase 508 INR 1.2 lactate 1.2. Patient was given IV lR along with IV Zofran and IV morphine. VS prior to transfer were T 98.4 HR 80 BP 121 57 RR 16 O2 98 RA. On arrival to the floor patient reports progressive epigastric pain up to ___ with occaisional radiation into RUQ and LUQ. It is worse with any po intake. Minimal relief with home oxycodone and tramadol. She has mild intermittent abdominal pain but nothing like this. She has associated poor appetite and nausea. No fevers or chills. No dysphagia or odynophagia. No UTRI symptoms. No SOB cough or chest pian. No dysuria although has had low UOP. No BM in last two days and no diarrhea. No new joint pains rashes or leg swelling. REVIEW OF SYSTEMS A complete 10 point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History PAST ONCOLOGIC HISTORY ___ has a history of hypertension congenital deafness and GERD and presented in ___ to ___ with painless jaundice. At the time she also noted several weeks of nausea vomiting postprandial abdominal pain and a 20 pound weight loss. She was referred to ___ where she underwent ERCP. This study identified a stricture in the common bile duct due to external compression. Brushings were atypical. Her CA ___ was elevated at 180 U mL. She underwent endoscopic ultrasound ___ which identified a 1.8 x 1.6 cm pancreatic head mass without vascular involvement. Biopsy by ___ showed adenocarcinoma. CT angiogram also showed a 1.6 x 1.4 x 1.4 cm pancreatic head mass with stranding but no definite involvement at the SMA and SMV. There was no evidence of distant metastases. Ms. ___ was diagnosed with borderline resectable PDA and initiated chemotherapy with neoadjuvant FOLFIRINOX ___. C1D15 was dose reduced for N V D. She was hospitalized ___ with diarrhea nausea anorexia and neutropenia. Her C2D15 treatment was held. With cycle 3 she transitioned to mFOLFOX. She completed five infusion and was taken to the OR ___. Liver metastases were identified intraoperatively and plans for resection were aborted. She initiated palliative chemotherapy with gemcitabine ___. The dose was reduced to 750mg m2 on C1D8 due to neutropenia. With cycle 2 she transitioned to day 1 and 15 schedule. Following six cycles there was further progression and she was referred for combination gemcitabine nab paclitaxel. PAST MEDICAL HISTORY 1. Hypertension. 2. Congenital deafness. 3. GERD. 4. Goiter. 5. History of nephrolithiasis. 6. Hypercholesterolemia. 7. Status post C section x 2. Social History ___ Family History The patient s father died of an MI at ___ years. Her mother died with type 2 diabetes mellitus. A sister died with colon cancer at ___ years. Another sister died of ___ disease. She has two sons without health concerns. Physical Exam VITAL SIGNS 97.9 PO 108 66 Lying 70 18 95 RA ___ NAD HEENT MMM CV RR NL S1S2 no S3S4 no MRG PULM CTAB respirations unlabored ABD BS S less TTP epigastric area LIMBS No ___ SKIN No rashes on extremities NEURO Grossly WNL Pertinent Results ___ 05 19AM BLOOD WBC 12.0 RBC 3.41 Hgb 9.6 Hct 30.0 MCV 88 MCH 28.2 MCHC 32.0 RDW 14.7 RDWSD 46.3 Plt ___ ___ 05 19AM BLOOD Glucose 69 UreaN 4 Creat 0.4 Na 135 K 3.6 Cl 98 HCO3 25 AnGap 12 ___ 05 19AM BLOOD ALT 9 AST 14 LD LDH 127 AlkPhos 109 TotBili 0.5 ___ 04 46AM BLOOD Lipase 293 ___ 05 19AM BLOOD Albumin 2.7 Calcium 8.5 Phos 2.1 Mg 1.7 ___ 04 46AM BLOOD Triglyc 73 Brief Hospital Course IMAGING BDOMEN ___ Image loaded into PACS. Read in chart Large infiltrative pancreatic head tumor. There is tumor infiltrate and or pancreatitis in the lesser sac and about the celiac axis SMA. Attenuation of the portal vein and splenic vein due to tumor. Multiple liver metastases. Large amount stool in the right colon ASSESSMENT AND PLAN ___ w metastatic pancreatic cancer on palliative gemcitabine who is admitted with one week of progressive epigastric abdominal pain Pancreatitis Abdominal pain Patient with one week of progressive worsening of epigastric abdominal pain nausea. Found to have elevated lipase and OSH imaging suggestive of acute inflammation c w pancreatitis flare although difficult to interpret given her pancreatic cancer . No elevation in LFT s to suggest acute obstruction. Pain has been largely insidious since diagnosis of pancreatic ca so possibly acute pancreatitis but largely pain is due to the tumor hence celiac plexus block ___. Symptoms cont to improve slowly. low fat diet appreciate Pal care c l for sx control started on oxycontin 10 mg bid w modicum of improvement of her sx cont oxycodone prn uses rarely Metastatic pancreatic cancer Initially thought locally advanced and went to OR for Whipple after neoadjuvant chemotherapy unfortunately found to have metastatic liver disease intraoperatively. Recently progressive after 6C palliative gemcitabine. Plan has been to initiate nab paclitaxel for C7D15 however she noted several times she is not interested in receiving any more chemo until she regains her strength. chemo on hold for this week f u Onc arranged f u w palliative care being arranged Hypertension now hypotensive hence dc d home acei w SBP ___ GERD cont PPI CODE DNR DNI COMMUNICATION Patient EMERGENCY CONTACT HCP Health care proxy chosen Yes Name of health care proxy ___ Cell phone ___ phone DISPO Home w ___ BILLING 30 min spent coordinating care for discharge ___ ___ D.O. Heme Onc Hospitalist ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. OLANZapine 5 mg PO BID PRN nausea 3. Omeprazole 20 mg PO DAILY 4. Ondansetron 8 mg PO Q8H PRN nausea 5. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate 6. Prochlorperazine 10 mg PO Q6H PRN nausea 7. TraMADol 50 100 mg PO Q6H PRN Pain Moderate 8. Acetaminophen 1000 mg PO Q6H PRN Pain Mild Discharge Medications 1. Lidocaine 5 Patch ___ PTCH TD QAM to LUQ area RX lidocaine 5 ___ patches daily to LUQ daily 12 hrs on 12 hrs off Disp 30 Patch Refills 0 2. Magnesium Citrate 300 mL PO ONCE Duration 1 Dose RX magnesium citrate 300 ml by mouth q3 days Refills 0 3. Milk of Magnesia 30 mL PO Q6H PRN constipation RX magnesium hydroxide Milk of Magnesia 400 mg 5 mL 30 ml by mouth q6h prn Refills 0 4. Multivitamins W minerals 1 TAB PO DAILY 5. OxyCODONE SR OxyconTIN 10 mg PO Q12H RX oxycodone 10 mg 1 tablet s by mouth q12 Disp 60 Tablet Refills 0 6. Polyethylene Glycol 17 g PO DAILY constipation RX polyethylene glycol 3350 17 gram 1 powder s by mouth daily Disp 30 Packet Refills 0 7. Senna 17.2 mg PO BID constipation RX sennosides senna 8.6 mg 17.2 mg by mouth twice a day Disp 120 Tablet Refills 0 8. Ondansetron ODT ___ mg PO Q8H PRN nausea RX ondansetron 4 mg ___ tablet s by mouth every eight 8 hours Disp 60 Tablet Refills 0 9. Acetaminophen 1000 mg PO Q6H PRN Pain Mild 10. OLANZapine 5 mg PO BID PRN nausea 11. Omeprazole 20 mg PO DAILY 12. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate Discharge Disposition Home With Service Facility ___ ___ Diagnosis Acute Pancreatitis Pancreatic Cancer Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear ___ ___ was a pleasure caring for ___ in the hospital. ___ were admitted because of worsening abdominal pain. ___ had a celiac plexus block and were started on oxycontin with improvement of your pain. ___ will need to continue a low fat diet. ___ were seen by the nutritionist who recommended eating small frequent meals. Please eat high protein nutrient dense diets that include fruits vegetables whole grains low fat dairy and other lean protein sources. Abstinence from alcohol and greasy or fried foods is important in helping to prevent malnutrition and pain. Best Your ___ Team Followup Instructions ___ The icd codes present in this text will be G893, Z66, K8580, E43, C250, C787, C7900, I959, K219, Z681, I10, E049, E7800, K5900. The descriptions of icd codes G893, Z66, K8580, E43, C250, C787, C7900, I959, K219, Z681, I10, E049, E7800, K5900 are G893: Neoplasm related pain (acute) (chronic); Z66: Do not resuscitate; K8580: Other acute pancreatitis without necrosis or infection; E43: Unspecified severe protein-calorie malnutrition; C250: Malignant neoplasm of head of pancreas; C787: Secondary malignant neoplasm of liver and intrahepatic bile duct; C7900: Secondary malignant neoplasm of unspecified kidney and renal pelvis; I959: Hypotension, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; Z681: Body mass index [BMI] 19.9 or less, adult; I10: Essential (primary) hypertension; E049: Nontoxic goiter, unspecified; E7800: Pure hypercholesterolemia, unspecified; K5900: Constipation, unspecified. The common codes which frequently come are Z66, K219, I10, K5900. The uncommon codes mentioned in this dataset are G893, K8580, E43, C250, C787, C7900, I959, Z681, E049, E7800.
The icd codes present in this text will be C250, C787, E860, H903, K219, I10, D473, D72829, E861, R112, Z66, G893, Z800, R634, Z6821. The descriptions of icd codes C250, C787, E860, H903, K219, I10, D473, D72829, E861, R112, Z66, G893, Z800, R634, Z6821 are C250: Malignant neoplasm of head of pancreas; C787: Secondary malignant neoplasm of liver and intrahepatic bile duct; E860: Dehydration; H903: Sensorineural hearing loss, bilateral; K219: Gastro-esophageal reflux disease without esophagitis; I10: Essential (primary) hypertension; D473: Essential (hemorrhagic) thrombocythemia; D72829: Elevated white blood cell count, unspecified; E861: Hypovolemia; R112: Nausea with vomiting, unspecified; Z66: Do not resuscitate; G893: Neoplasm related pain (acute) (chronic); Z800: Family history of malignant neoplasm of digestive organs; R634: Abnormal weight loss; Z6821: Body mass index [BMI] 21.0-21.9, adult. The common codes which frequently come are K219, I10, Z66. The uncommon codes mentioned in this dataset are C250, C787, E860, H903, D473, D72829, E861, R112, G893, Z800, R634, Z6821. Allergies latex Chief Complaint Nausea anorexia abdominal pain Major Surgical or Invasive Procedure None History of Present Illness ___ PMH of Deafness uses ASL GERD HTN Metastatic Pancreatic Cancer mets to liver recently on palliative gemcitabine CBD obstruction s p sphincerotomy and metal stent placement who recently was admitted for pain control and possible pancreatitis s p celiac plexus block and increased pain regimen now returns with nausea vomiting abdominal pain and decreased PO intake Pt was last discharged on ___ after being admitted for possible pancreatitis vs pain ___ progression of malignancy. She had celiac nerve plexus block and had oxycontin initiated. As a result pain was improved and patient was discharged with outpatient oncology followup OF note patient is deaf and uses ASL to communicate for complex decision making but was able to communicate by writing and with lip reading for purposes of this interview. Pt noted that since discharge she has had intermittent abdominal pain which is epigastric and radiating to the back which comes on in spasms with sharp stabbing sensation. She noted that her pain may be slightly improved compared to prior though. However she is more concerned with nausea vomiting at home with yellow colored vomitus and lack of po intake ___ decreased appetite. Denied fever chills sore throat dysuria rash significant diarrhea. In the ED initial vitals 98.1 107 122 87 18 99 RA. Labs revealed WBC of 23 recent baseline was 12 Hgb 11.9 baseline 9.5 plt 585 baseline 268 . Chem wnl LFTs unchanged since last admission. Lipase 123 down from 500 on last admit. Lactate normal. She was given IVF Zofran and dilaudid. She noted that she felt unsafe going home as did not feel remarkably improved so was admitted to oncology for further care. REVIEW OF SYSTEMS A complete 10 point review of systems was performed and was negative unless otherwise noted in the HPI. Past Medical History PAST ONCOLOGIC HISTORY As per OMR presented in ___ to ___ with painless jaundice. At the time she also noted several weeks of nausea vomiting postprandial abdominal pain and a 20 pound weight loss. She was referred to ___ where she underwent ERCP. This study identified a stricture in the common bile duct due to external compression. Brushings were atypical. Her CA ___ was elevated at 180 U mL. She underwent endoscopic ultrasound ___ which identified a 1.8 x 1.6 cm pancreatic head mass without vascular involvement. Biopsy by ___ showed adenocarcinoma. CT angiogram also showed a 1.6 x 1.4 x 1.4 cm pancreatic head mass with stranding but no definite involvement at the ___ and ___. There was no evidence of distant metastases. Ms. ___ was diagnosed with borderline resectable PDA and initiated chemotherapy with neoadjuvant FOLFIRINOX ___. C1D15 was dose reduced for N V D. She was hospitalized ___ with diarrhea nausea anorexia and neutropenia. Her C2D15 treatment was held. With cycle 3 she transitioned to mFOLFOX. She completed five infusion and was taken to the OR ___. Liver metastases were identified intraoperatively and plans for resection were aborted. She initiated palliative chemotherapy with gemcitabine ___. The dose was reduced to 750mg m2 on C1D8 due to neutropenia. With cycle 2 she transitioned to day 1 and 15 schedule. Following six cycles there was further progression and she was referred for combination gemcitabine nab paclitaxel PAST MEDICAL HISTORY 1. Hypertension. 2. Congenital deafness. 3. GERD. 4. Goiter. 5. History of nephrolithiasis. 6. Hypercholesterolemia. 7. Status post C section x 2. 8. CBD obstruction s p sphincerotomy and metal stent placement via ERCP Social History ___ Family History The patient s father died of an MI at ___ years. Her mother died with type 2 diabetes mellitus. A sister died with colon cancer at ___ years. Another sister died of ___ disease. She has two sons without health concerns. Physical Exam Vitals 98.3 134 84 104 18 98RA ___ Sitting in bed appears comfortable no acute distress EYES PERRLA HEENT Moist mucous membranes oropharynx clear NECK Supple LUNGS Clear to auscultation bilaterally no wheezes rales or rhonchi normal respiratory rate CV Regular rate and rhythm without any murmurs rubs or gallops ABD Slight epigastric tenderness to moderate palpation nondistended normoactive bowel sounds no ascites EXT Normal bulk tone no deformity SKIN Warm dry no rash NEURO Alert and oriented 3 fluent speech but has difficulty with correct pronunciation as is deaf but reads lips and writes to communicate ACCESS chest port with dressing c d i Pertinent Results ___ 02 10PM WBC 23.0 RBC 4.30 HGB 11.9 HCT 37.1 MCV 86 MCH 27.7 MCHC 32.1 RDW 16.1 RDWSD 48.4 ___ 02 10PM PLT COUNT 585 ___ 02 10PM cTropnT 0.05 ___ 02 10PM ALT SGPT 10 AST SGOT 18 ALK PHOS 153 TOT BILI 0.5 ___ 02 10PM LIPASE 123 ___ 02 10PM GLUCOSE 132 UREA N 10 CREAT 0.4 SODIUM 138 POTASSIUM 4.3 CHLORIDE 97 TOTAL CO2 23 ANION GAP 18 ___ 02 53PM LACTATE 1.7 Brief Hospital Course Ms ___ is a pleasant ___ year old female with deafness admitted with recurrent abdominal pain nausea and poor appetite attributed to her pancreatic cancer. Her anti nausea and pain medications were adjusted to achieve better symptom control including increase of her oxycontin dose from bid to tid and adding baclofen to address some element of back spasm. Her appetite remained minimal but she was able to tolerate fluids throughout her stay. She met with Dr ___ our ___ Care service and discussed options for home hospice though at the time of discharge she remains uncertain whether she may pursue palliative chemotherapy instead. Her ___ agency has the ability to deliver hospice care and will continue to offer information on this option after she arrives home. Throughout her admission she was seen at least daily with the assistance of our ASL interpreter. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H PRN Pain Mild 2. Ondansetron ODT ___ mg PO Q8H PRN nausea 3. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate 4. Omeprazole 20 mg PO DAILY 5. Lidocaine 5 Patch ___ PTCH TD QAM to LUQ area 6. Milk of Magnesia 30 mL PO Q6H PRN constipation 7. OxyCODONE SR OxyconTIN 10 mg PO Q12H 8. Polyethylene Glycol 17 g PO DAILY constipation 9. Senna 17.2 mg PO BID constipation 10. OLANZapine 5 mg PO BID PRN nausea 11. Magnesium Citrate 300 mL PO ONCE 12. Multivitamins W minerals 1 TAB PO DAILY Discharge Medications 1. Baclofen 5 mg PO Q8H PRN Back Pain RX baclofen 10 mg 0.5 One half tablet s by mouth every eight 8 hours Disp 90 Tablet Refills 2 2. lidocaine 5 topical QAM RX lidocaine Lidoderm 5 apply to left upper abdomen qam Disp 30 Patch Refills 3 RX lidocaine 5 apply to left upper abdomen qam Disp 30 Patch Refills 2 3. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg ___ tablet s by mouth every four 4 hours Disp 60 Tablet Refills 0 4. OxyCODONE SR OxyconTIN 10 mg PO Q8H abdominal pain 5. Lidocaine 5 Patch ___ PTCH TD QAM to LUQ area 6. Magnesium Citrate 300 mL PO ONCE 7. Milk of Magnesia 30 mL PO Q6H PRN constipation 8. Multivitamins W minerals 1 TAB PO DAILY 9. OLANZapine 5 mg PO BID PRN nausea 10. Omeprazole 20 mg PO DAILY 11. Ondansetron ODT ___ mg PO Q8H PRN nausea 12. Polyethylene Glycol 17 g PO DAILY constipation 13. Senna 17.2 mg PO BID constipation Discharge Disposition Home With Service Facility ___ ___ Diagnosis Metastatic pancreatic cancer Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Please take your medications as prescribed. Followup Instructions ___ The icd codes present in this text will be C250, C787, E860, H903, K219, I10, D473, D72829, E861, R112, Z66, G893, Z800, R634, Z6821. The descriptions of icd codes C250, C787, E860, H903, K219, I10, D473, D72829, E861, R112, Z66, G893, Z800, R634, Z6821 are C250: Malignant neoplasm of head of pancreas; C787: Secondary malignant neoplasm of liver and intrahepatic bile duct; E860: Dehydration; H903: Sensorineural hearing loss, bilateral; K219: Gastro-esophageal reflux disease without esophagitis; I10: Essential (primary) hypertension; D473: Essential (hemorrhagic) thrombocythemia; D72829: Elevated white blood cell count, unspecified; E861: Hypovolemia; R112: Nausea with vomiting, unspecified; Z66: Do not resuscitate; G893: Neoplasm related pain (acute) (chronic); Z800: Family history of malignant neoplasm of digestive organs; R634: Abnormal weight loss; Z6821: Body mass index [BMI] 21.0-21.9, adult. The common codes which frequently come are K219, I10, Z66. The uncommon codes mentioned in this dataset are C250, C787, E860, H903, D473, D72829, E861, R112, G893, Z800, R634, Z6821.
The icd codes present in this text will be C250, H905, I10, E042, K838, L298, K219, D509, G4700, Z800. The descriptions of icd codes C250, H905, I10, E042, K838, L298, K219, D509, G4700, Z800 are C250: Malignant neoplasm of head of pancreas; H905: Unspecified sensorineural hearing loss; I10: Essential (primary) hypertension; E042: Nontoxic multinodular goiter; K838: Other specified diseases of biliary tract; L298: Other pruritus; K219: Gastro-esophageal reflux disease without esophagitis; D509: Iron deficiency anemia, unspecified; G4700: Insomnia, unspecified; Z800: Family history of malignant neoplasm of digestive organs. The common codes which frequently come are I10, K219, D509, G4700. The uncommon codes mentioned in this dataset are C250, H905, E042, K838, L298, Z800. Allergies latex Chief Complaint Painless jaundice nausea Major Surgical or Invasive Procedure EUS History of Present Illness Ms. ___ is a ___ PMHx HTN and congenital deafness who was initially admitted to ___ on ___ for painless jaundice biliary obstruction associated with n v post prandial abdominal pain and unintentional weight loss over the past month. History is obtained with assistance of her son who is fluent in ___ sign language. She had an MRCP as an outpatient which showed concern for possible lesion at uncinated process. She was then sent to ___ on ___ for ERCP evaluation ERCP showed stricture with post obstructive dilation with severely dilated proximal CBD. These findings were compatible with extrinsic compression of malignant pancreatic lesion at the head uncinate process of the pancreas. She underwent sphincterotomy with stent placement brushings showed atypical cells on cytology. She was transferred back to ___ ___. Post ERCP the patient has had ongoing obstructive symptoms of n v abdominal pain and very limited PO tolerance barely tolerating a liquid diet . EUS was performed on ___ which was wnl but her CA ___ level was elevated to 180. She has been afebrile and labs have shown improvement of her LFTs with AST46 ALT 86 alkphos 376 at admission to 303 today. Tbili 18 at admission to 10.1 today. WBC nml. Transfer is requested for repeat ERCP evaluation and further work up for malignancy. Upon arrival to the floor the patient feels overall well and endorses just some mild epigastric and RUQ abdominal soreness. She has been only on liquids for the past 2 weeks without any significant PO intake. ROS Per HPI Denies fever chills night sweats. Denies headache sinus tenderness rhinorrhea or congestion. Denies cough shortness of breath. Denies chest pain or tightness palpitations. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History HTN congenital deafness GERD Goiter Social History ___ Family History Father passed away from complications of gangrenous colitis. Mother with T2DM. Sister with colon CA. Sister deceased ___. Physical Exam Vital Signs 98.3 158 92 71 18 99 on RA ___ Well appearing elderly jaundiced female oriented no acute distress HEENT Sclera icteric MMM oropharynx clear EOMI PERRL neck supple JVP not elevated no LAD CV Regular rate and rhythm normal S1 S2 no murmurs rubs gallops Lungs Clear to auscultation bilaterally no wheezes rales rhonchi Abdomen Soft obese nondistended mild TTP of epigastrium and RUQ normal bowel sounds GU No foley Ext Warm well perfused 2 pulses trace pitting edema of BLE Neuro AOX3 moving all extremities spontaneously nml gait. Can read lips responding to all commands On discharge GEN Lying in bed in NAD jaundiced HEENT EOMI sclerae anicteric MMM OP clear NECK No LAD no JVD CARDIAC RRR no M R G PULM normal effort no accessory muscle use LCAB GI soft NT ND NABS MSK No visible joint effusions or deformities. DERM No visible rash. No jaundice. NEURO AAOx3. No facial droop moving all extremities. PSYCH Full range of affect EXTREMITIES WWP trace edema Pertinent Results ___ OSH labs WBC 7.6 Hgb 11.1 down from 14.8 at admission on ___ Plt 260 MCV 77 Na 142 K 4.1 Cl 107 CO2 28 Cr 0.672 Tbili 10.1 AST 46 ALT 86 AP 303 CEA 112 CA ___ 180.6 On Admission ___ 06 50AM BLOOD WBC 8.2 RBC 3.78 Hgb 10.2 Hct 29.4 MCV 78 MCH 27.0 MCHC 34.7 RDW 18.1 RDWSD 48.0 Plt ___ ___ 06 50AM BLOOD ___ PTT 26.9 ___ ___ 06 50AM BLOOD Glucose 110 UreaN 6 Creat 0.7 Na 142 K 4.1 Cl 106 HCO3 31 AnGap 9 ___ 06 50AM BLOOD ALT 69 AST 56 AlkPhos 277 TotBili 8.8 ___ 06 50AM BLOOD calTIBC 177 Ferritn 755 TRF 136 On Discharge ___ 06 44AM BLOOD WBC 9.1 RBC 3.81 Hgb 10.1 Hct 30.4 MCV 80 MCH 26.5 MCHC 33.2 RDW 18.6 RDWSD 50.7 Plt ___ ___ 06 44AM BLOOD Glucose 144 UreaN 6 Creat 0.5 Na 141 K 3.3 Cl 104 HCO3 29 AnGap 11 ___ 06 44AM BLOOD ALT 61 AST 51 AlkPhos 257 TotBili 6.1 ___ 06 44AM BLOOD Calcium 9.1 Phos 2.6 Mg 1.9 ___ 06 15AM BLOOD IGG SUBCLASSES 1 2 3 4 Test IMAGING STUDIES ___ ERCP Findings Esophagus Limited exam of the esophagus was normal Stomach Limited exam of the stomach was normal Duodenum Limited exam of the duodenum was normal Major Papilla Normal major papilla was noted. Cannulation Cannulation of the biliary duct was successful and deep with a sphincterotome using a free hand technique. Contrast medium was injected resulting in complete opacification. The procedure was not difficult. Biliary Tree Fluoroscopy Interpretation The scout film was normal. A single 1.5 cm stricture was seen at the lower third of the common bile duct. There was post obstructive dilation with severely dilated proximal CBD. with both CBD. These findings are compatible with extrinsic compression of malignant pancreatic lesion at the head uncinate process of pancreas. A sphincterotomy was performed in the 12 o clock position using a sphincterotome over an existing guidewire. No evidence of post sphincterotomy bleeding was noted. Cytology samples were obtained for histology using a brush in the lower third of the common bile duct for final diagnosis. Due to obstructive pattern a ___ biliary plastic stent was placed into the distal common bile duct. Post stent deployment a good contrast and bile drainage was noted both endoscopically and fluoroscopically. I supervised the acquisition and interpretation of the fluoroscopy images. The quality of the images was good. Impression The scout film was normal. Normal major papilla was noted. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free hand technique. Contrast medium was injected resulting in complete opacification. A single 1.5 cm stricture was seen at the lower third of the common bile duct. There was post obstructive dilation with severely dilated proximal CBD. These findings are compatible with extrinsic compression of malignant pancreatic lesion at the head uncinate process of pancreas. A sphincterotomy was performed in the 12 o clock position using a sphincterotome over an existing guidewire. No evidence of post sphincterotomy bleeding was noted. Cytology samples were obtained for histology using a brush in the lower third of the common bile duct for final diagnosis. Due to obstructive pattern a ___ biliary plastic stent was placed into the distal common bile duct. Post stent deployment a good contrast and bile drainage was noted both endoscopically and fluoroscopically. Otherwise normal ercp to third part of the duodenum ___ Tissue biopsy pancreas Adenocarcinoma ___ CT Chest IMPRESSION No evidence of metastasis. Large goiter substantially narrows the trachea at the thoracic inlet and could contribute to malacia though not assessed by this study. Ultrasound recommended to exclude concurrent thyroid nodules. Small bilateral pleural effusions. Severe bibasilar relaxation atelectasis. ___ CT A P Pancreas Protocol 1. Patient is now status post biliary stenting with the stent extending from the common hepatic duct to the duodenum. There is associated pneumobilia the but interval reduction in the intra and extrahepatic biliary dilatation. 2. A approximately 1.6 cm x 1.4 cm x 1.4 cm poorly defined hypoenhancing lesion is seen at the head of the pancreas. 3. Peripancreatic fluid and fat stranding particularly surrounding the head of the pancreas SMA and SMV. This may represent pancreatitis in the appropriate clinical setting. 4. Subcentimeter hypodensity in segment 4B of the liver likely represents a biliary hamartoma versus simple cyst. 5. Multiple bilateral subcentimeter renal hypodensities are too small to characterize but likely represent simple renal cysts. 6. 1.7 cm homogeneously enhancing lesion in the uterus likely a fibroid. 7. Please see separate report of CT chest performed on the same date. ___ Thyroid US Multinodular goiter. Dominant solid nodules arising from the isthmus and right lower pole measuring 3.2 cm and at least 4.9 cm respectively are recommended for biopsy. RECOMMENDATION S Thyroid biopsy of the dominant isthmic and right lower pole nodules as above. Brief Hospital Course Ms. ___ is a ___ PMHx HTN and congenital deafness who was initially admitted to ___ on ___ for painless jaundice biliary obstruction associated with n v post prandial abdominal pain and unintentional weight loss s p ERCP with sphincterotomy and stent placement for CBD dilation transferred for repeat ERCP evaluation for likely ongoing obstruction. Pancreatic adenocarcinoma Resulting in painless jaundice and nausea. She underwent ERCP with sphincterotomy on ___ with plastic stent placement to relieve the obstruction. Her LFTs subsequently downtrended and her nausea improved. CT pancreas notable for 1.6 cm x 1.4 cm x 1.4 cm poorly defined hypoenhancing lesion is seen at the head of the pancreas. Staging CT of the chest was negative for metastases. She was seen by the surgery team and is scheduled for follow up in the surgery clinic on ___ to discuss the next steps in surgical management. Goiter Patient has known goiter and reportedly has an outpatient endocrinologist. Staging CT of the chest noted this large goiter and advised for further evaluation with ultrasound. Ultrasound revealed multinodular goiter. Dominant solid nodules arising from the isthmus and right lower pole measuring 3.2 cm and at least 4.9 cm respectively are recommended for biopsy. On discussion of these findings with the patient she revealed that she has in fact recently undergone biopsy of her thyroid and has follow up with her endocrinologist in the near future. Pruritis Likely secondary to elevated bilirubin. She found most symptomatic relief with sarna lotion rather than cholestyramine and was discharged with a prescription. HTN Continued home lisinopril Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Omeprazole 40 mg PO DAILY 3. Aspirin 81 mg PO DAILY Discharge Medications 1. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice a day Disp 30 Capsule Refills 0 2. Polyethylene Glycol 17 g PO DAILY Do not take if you are having loose stools RX polyethylene glycol 3350 Miralax 17 gram 1 powder s by mouth daily Disp 15 Packet Refills 0 3. Sarna Lotion 1 Appl TP QID PRN pruritus RX camphor menthol Sarna Anti Itch 0.5 0.5 Apply to affected area Four times daily Refills 0 4. Senna 8.6 mg PO BID Please do not take this if you are having loose stools RX sennosides senna 8.6 mg 1 tablet by mouth twice daily Disp 30 Tablet Refills 0 5. Aspirin 81 mg PO DAILY 6. Cholestyramine 4 gm PO DAILY 7. Lisinopril 20 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Ondansetron 4 mg PO Q4H PRN nausea 10. zaleplon 5 mg oral QHS PRN Discharge Disposition Home Discharge Diagnosis Primary Pancreatic adenocarcinoma Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were admitted to the hospital because of an inability to tolerate food. This is likely from compression of part of your GI tract by a mass. Fortunately your symptoms improved during your hospitalization. You underwent imaging to help further characterize what may be going on in your GI tract to cause these symptoms. You are scheduled for follow up with the surgery team to discuss the next steps in your diagnosis and treatment plan. Of note your CT scan revealed a large goiter. The recommendation was to obtain an ultrasound to determine the presence of nodules. The ultrasound did reveal some nodules that were recommended for biopsy. However it appears that you have recently undergone a thyroid nodule biopsy. Please continue to follow up with your thyroid specialist as previously scheduled. Please follow up with your primary care doctor as previously scheduled. It was a pleasure to be a part of your care Your ___ treatment team Followup Instructions ___ The icd codes present in this text will be C250, H905, I10, E042, K838, L298, K219, D509, G4700, Z800. The descriptions of icd codes C250, H905, I10, E042, K838, L298, K219, D509, G4700, Z800 are C250: Malignant neoplasm of head of pancreas; H905: Unspecified sensorineural hearing loss; I10: Essential (primary) hypertension; E042: Nontoxic multinodular goiter; K838: Other specified diseases of biliary tract; L298: Other pruritus; K219: Gastro-esophageal reflux disease without esophagitis; D509: Iron deficiency anemia, unspecified; G4700: Insomnia, unspecified; Z800: Family history of malignant neoplasm of digestive organs. The common codes which frequently come are I10, K219, D509, G4700. The uncommon codes mentioned in this dataset are C250, H905, E042, K838, L298, Z800.
The icd codes present in this text will be K521, K831, C250, D6959, E860, I10, K219, R110, T451X5A, Y929. The descriptions of icd codes K521, K831, C250, D6959, E860, I10, K219, R110, T451X5A, Y929 are K521: Toxic gastroenteritis and colitis; K831: Obstruction of bile duct; C250: Malignant neoplasm of head of pancreas; D6959: Other secondary thrombocytopenia; E860: Dehydration; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; R110: Nausea; T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter; Y929: Unspecified place or not applicable. The common codes which frequently come are I10, K219, Y929. The uncommon codes mentioned in this dataset are K521, K831, C250, D6959, E860, R110, T451X5A. Allergies latex Chief Complaint diarrhea Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a pleasant ___ w HTN DL congenital deafness and recently diagnosed borderline resectable pancreatic head adenocarcinoma on neoadjuvant C1D21 Folfirinox who presents for diarrhea for two days. She had ERCP with stent placement done yesterday. No complications with that. She reports multiple episodes of watery brown non bloody diarrhea for the past two days. She reports not eating or drinking as much over the past several months. Also some nausea on and off over the same time period. She reports mild gas pain but denies abdominal pain and vomiting. In ED initial vitals were Temp 97.7 HR 91 BP 102 65 RR 15 O2 sat 98 RA. She received 1L NS. CXR was negative for infection. Vitals prior to transfer were Temp 98.1 HR 77 BP 106 66 RR 16 O2 sat 100 RA. On arrival to the floor she reports that she is feeling well. She denies fevers chills headache dizziness lightheadedness shortness of breath cough chest pain palpitations abdominal pain vomiting constipation dysuria and rashes. Past Medical History HTN congenital deafness GERD Goiter Social History ___ Family History Father passed away from complications of gangrenous colitis. Mother with T2DM. Sister with colon CA. Sister deceased ___. Physical Exam ADMISSION PHYSICAL EXAM VS Temp 97.3 BP 125 89 HR 69 RR 18 O2 sat 100 RA. GENERAL Pleasant woman in no distress lying in bed comfortably. HEENT Anicteric PERLL OP clear. CARDIAC RRR normal s1 s2 no m r g. LUNG Appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi. ABD Normal bowel sounds soft nontender nondistended no hepatomegaly no splenomegaly. EXT Warm well perfused no lower extremity edema erythema or tenderness. NEURO Alert oriented good attention and linear thought CN II XII intact. Strength full throughout. SKIN No significant rashes. Brief Hospital Course ___ is a pleasant ___ w HTN DL congenital deafness and recently diagnosed borderline resectable pancreatic head adenocarcinoma on neoadjuvant C1D21 Folfirinox who presents for diarrhea for two days. Diarrhea She has 2 loose watery diarrhea everyday mostly at AM. Her stool c diff was negative. She was started on Imodium and the dose was titrated up to 4mg TID but she still continued to have loose watery diarrhea. Her diarrhea is most likely from Irinotecan. She was also started on peptobismol to help her diarrhea Elevated Lipase She had a mild elevation of lipase levels but this is likely from her having a ERCP on the day prior to admission. She does not have any epigastric abdominal pain or lipase levels high enough to suspect pancreatitis. Her blood and urine cultures were negative during this admission. She was discharged home in a stable condition. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lisinopril 20 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Ondansetron 8 mg PO Q8H PRN nausea vomiting 4. LORazepam 0.5 mg PO BID PRN anxiety nausea 5. Prochlorperazine 10 mg PO Q6H PRN nausea vomiting 6. TraMADol 50 100 mg PO Q6H PRN Pain Moderate 7. Dexamethasone 4 mg PO BID Discharge Medications 1. Bismuth Subsalicylate 30 mL PO TID ___ cause black discoloration of stool RX bismuth subsalicylate Bismatrol 525 mg 15 mL 15 ml by mouth three times daily Refills 0 2. LOPERamide 4 mg PO Q8H RX loperamide 2 mg 2 tablets by mouth three times daily Disp 50 Capsule Refills 1 3. Dexamethasone 4 mg PO BID take for 2 days after chemotherapy 4. Lisinopril 20 mg PO DAILY 5. LORazepam 0.5 mg PO BID PRN anxiety nausea RX lorazepam 0.5 mg 1 tablet by mouth twice daily Disp 30 Tablet Refills 1 6. Omeprazole 20 mg PO DAILY 7. Ondansetron 8 mg PO Q8H PRN nausea vomiting 8. Prochlorperazine 10 mg PO Q6H PRN nausea vomiting 9. TraMADol 50 100 mg PO Q6H PRN Pain Moderate Discharge Disposition Home Discharge Diagnosis Diarrhea likely from Irinotecan. Pancreatic cancer Discharge Condition stable alert and oriented to time place and person independent ambulation Discharge Instructions Dear ___ It was a pleasure taking care of you. You were admitted since you developed loose stools. We found out that you had no infections causing the diarrhea. It is likely a adverse reaction from chemotherapy agent. Please take Imodium and Peptobismol as directed until your diarrhea is controlled. Please follow up for your appointment with ___ on ___. Sincerely ___ MD Followup Instructions ___ The icd codes present in this text will be K521, K831, C250, D6959, E860, I10, K219, R110, T451X5A, Y929. The descriptions of icd codes K521, K831, C250, D6959, E860, I10, K219, R110, T451X5A, Y929 are K521: Toxic gastroenteritis and colitis; K831: Obstruction of bile duct; C250: Malignant neoplasm of head of pancreas; D6959: Other secondary thrombocytopenia; E860: Dehydration; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; R110: Nausea; T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter; Y929: Unspecified place or not applicable. The common codes which frequently come are I10, K219, Y929. The uncommon codes mentioned in this dataset are K521, K831, C250, D6959, E860, R110, T451X5A.
The icd codes present in this text will be E860, C250, K521, D701, H905, I10, K219, R112, T451X5A, Z6823, R630, E7800, F419, Y929. The descriptions of icd codes E860, C250, K521, D701, H905, I10, K219, R112, T451X5A, Z6823, R630, E7800, F419, Y929 are E860: Dehydration; C250: Malignant neoplasm of head of pancreas; K521: Toxic gastroenteritis and colitis; D701: Agranulocytosis secondary to cancer chemotherapy; H905: Unspecified sensorineural hearing loss; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; R112: Nausea with vomiting, unspecified; T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter; Z6823: Body mass index [BMI] 23.0-23.9, adult; R630: Anorexia; E7800: Pure hypercholesterolemia, unspecified; F419: Anxiety disorder, unspecified; Y929: Unspecified place or not applicable. The common codes which frequently come are I10, K219, F419, Y929. The uncommon codes mentioned in this dataset are E860, C250, K521, D701, H905, R112, T451X5A, Z6823, R630, E7800. Allergies latex Chief Complaint Nausea vomting diarrhea Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ female with with HTN DL congenital deafness and borderline resectable pancreatic head adenocarcinoma on neoadjuvant C2D12 Folfirinox who presents with nausea vomiting diarrhea and inability to tolerate POs. Patient reports continued diarrhea as well as nausea vomiting that has not been controlled with home medications. She was seen in clinic on ___ where she noted diarrhea for one week and was given immodium Zofran and 1L NS. She had been taking Pepto Bismal. Stool studies were ordered however patient unable to give a sample and attempted to be done at outside facility but not processed. She continued to have diarrhea and poor PO intake due to nausea and poor appetite. She tried immodium without significant improvement. She wants to stop chemo due to the side effects. Of note she was recently admitted ___ to ___ with diarrhea. Stool studies were negative. She was started on immodium and pepto bismal. On arrival to the ED initial vitals were 97.9 80 118 71 16 100 RA. Labs were notable for WBC 3.0 H H 13.0 39.8 Plt 248 Na 134 K 3.5 BUN Cr ___ LFTs wnl INR 1.2 and UA bland. CT abdomen was negative for acute process. Patient was given Zofran 4mg IV x 2 and 1L Ns at 100 cc hr. Vitals prior to transfer were 98.0 99 117 90 18 99 RA. On arrival to the floor patient reports that she is feeling better. She is able to drink without nausea. She denies fevers chills headache dizziness lightheadedness vision changes weakness numbness shortness of breath cough chest pain palpitations and dysuria. Past Medical History PAST ONCOLOGIC HISTORY ___ has a history of hypertension congenital deafness and GERD and presented in early ___ to ___ with painless jaundice. At the time she also noted several weeks of nausea vomiting postprandial abdominal pain and a 20 pound weight loss. She was referred to ___ where she underwent ERCP. This study identified a stricture in the common bile duct due to external compression. Brushings were atypical. Her CA ___ was elevated at 180 U mL. She underwent endoscopic ultrasound ___. This study identified a 1.8 x 1.6 cm pancreatic head mass without vascular involvement. Biopsy by ___ showed adenocarcinoma. CT angiogram also showed a 1.6 x 1.4 x 1.4 cm pancreatic head mass with stranding but no definite involvement at the SMA and SMV. There was no evidence of distant metastases. Ms. ___ was diagnosed with borderline resectable PDA and initiated chemotherapy with neoadjuvant FOLFIRINOX ___. C1D15 dose reduced for N V D. She underwent biliary stent change and was then hospitalized ___ with persistent diarrhea and leukocytosis. PAST MEDICAL HISTORY 1. Hypertension 2. Congenital deafness 3. GERD 4. Goiter 5. History of nephrolithiasis 6. Hypercholesterolemia 7. Status post C section x 2 Social History ___ Family History The patient s father died of an MI at ___ years. Her mother died with type 2 diabetes mellitus. A sister died with colon cancer at ___ years. Another sister died of ___ disease. She has two sons without health concerns. Physical Exam ADMISSION PHYSICAL EXAM VS Temp 97.2 BP 154 84 HR 99 RR 18 O2 sat 98 RA. ___ Pleasant woman in no distress lying in bed comfortably. HEENT Anicteric PERLL OP clear. CARDIAC RRR normal s1 s2 no m r g. LUNG Appears in no respiratory distress clear to auscultation bilaterally no crackles wheezes or rhonchi. ABD Normal bowel sounds soft nontender nondistended no hepatomegaly no splenomegaly. EXT Warm well perfused no lower extremity edema erythema or tenderness. NEURO Alert oriented good attention and linear thought CN II XII intact. Strength full throughout. SKIN No significant rashes. Discharge PE 97.7 142 80 82 18 97 RA ___ Well appearing lying in bed in NAD Eyes PERLL EOMI sclera anicteric ENT MMM oropharynx clear without exudate or lesions Respiratory CTAB without crackles wheeze rhonchi though breath sounds reduced at bases. Cardiovascular RRR normal S1 and S2 no murmurs rubs or gallops Gastrointestinal Soft nontender nondistended BS no masses or HSM Extremities Warm and well perfused no peripheral edema Skin warm no rashes no jaundice no skin ulcerations noted Neurological Alert and oriented x3 Pertinent Results ADMISSION LABS ___ 10 35AM URINE COLOR Straw APPEAR Clear SP ___ ___ 10 35AM URINE BLOOD NEG NITRITE NEG PROTEIN 30 GLUCOSE NEG KETONE 40 BILIRUBIN NEG UROBILNGN NEG PH 6.5 LEUK NEG ___ 10 35AM URINE RBC 0 WBC 0 BACTERIA NONE YEAST NONE EPI 1 ___ 04 29AM GLUCOSE 103 UREA N 10 CREAT 0.5 SODIUM 134 POTASSIUM 3.5 CHLORIDE 99 TOTAL CO2 20 ANION GAP 19 ___ 04 29AM ALT SGPT 29 AST SGOT 22 ALK PHOS 60 TOT BILI 0.4 ___ 04 29AM LIPASE 33 ___ 04 29AM ALBUMIN 3.0 CALCIUM 8.1 PHOSPHATE 2.3 MAGNESIUM 1.6 ___ 04 29AM WBC 3.0 RBC 4.66 HGB 13.0 HCT 39.8 MCV 85 MCH 27.9 MCHC 32.7 RDW 15.0 RDWSD 45.9 ___ 04 29AM NEUTS 41 BANDS 3 ___ MONOS 21 EOS 2 BASOS 0 ATYPS 1 ___ MYELOS 0 AbsNeut 1.32 AbsLymp 0.99 AbsMono 0.63 AbsEos 0.06 AbsBaso 0.00 ___ 04 29AM HYPOCHROM NORMAL ANISOCYT 2 POIKILOCY 3 MACROCYT NORMAL MICROCYT 2 POLYCHROM NORMAL OVALOCYT 1 SCHISTOCY OCCASIONAL BURR 3 TEARDROP OCCASIONAL ___ 04 29AM ___ PTT 22.7 ___ DISCHARGE LABS ___ 06 17AM BLOOD WBC 7.6 RBC 4.35 Hgb 12.0 Hct 36.5 MCV 84 MCH 27.6 MCHC 32.9 RDW 15.4 RDWSD 46.3 Plt ___ ___ 06 17AM BLOOD Glucose 94 UreaN 8 Creat 0.4 Na 137 K 4.0 Cl 99 HCO3 29 AnGap 13 ___ 06 17AM BLOOD Calcium 8.9 Phos 3.4 Mg 1.7 MICRO URINE CULTURE Final ___ MIXED BACTERIAL FLORA 3 COLONY TYPES CONSISTENT WITH SKIN AND OR GENITAL CONTAMINATION. ___ C diff stool studies negative IMAGING ___ CXR IMPRESSION In comparison with the study of ___ there is little interval change. The cardiac silhouette remains within normal limits with no evidence of vascular congestion or acute focal pneumonia. There is blunting of the left costophrenic angle on the lateral view suggesting small interval pleural effusion. The right Port A Cath again extends to the lower SVC. ___ CT A P IMPRESSION 1. No evidence of acute intra abdominal process. 2. Pancreatic head hypodensity is unchanged and associated peripancreatic soft tissue density is less conspicuous potentially due to interval improvement or differences in technique. 3. Left pelvic vein engorgement and left gonadal vein enlargement are nonspecific findings but may be seen in the setting of pelvic congestion syndrome. Brief Hospital Course ___ female with with HTN congenital deafness and borderline resectable pancreatic head adenocarcinoma on neoadjuvant C2D12 Folfirinox who presents with nausea vomiting diarrhea and inability to tolerate POs. Diarrhea Nausea Vomiting Most likely due to side effects of FOLFIRINOX. Abdominal CT without acute process and exam benign. Similar symptoms in past after chemotherapy. Less likely infection especially given negative stool studies. C. diff negative so after consultation with outpatient oncologist treated with typical antidiarrheal regimen of loperamide and lomotil with resolution of diarrhea. Beginning to improve mildly increased PO intake but solid foods still limited. Diarrhea largely resolved. After discussion with patient and outpatient oncologist was started on Decadron 2 mg PO daily to help improve appetite reduce nausea in order to allow adequate PO intake for safe discharge. Continue 2mg dexamethasone daily likely will stop after 7 day course if continued improvement Continue anti emetic regimen Continue PPI Cough Having cough intermittently productive of yellow sputum. Lung exam reassuring CXR shows no evidence of pneumonia afebrile without leukocytosis. Monitor off antibiotics if symptoms worsening consider repeat chest imaging Cont IS Encourage ambulation Pancreatic Cancer neutropenia s p FOLFIRINOX cycle 2 on ___. GI sx likely ___ further plans for administration of this drug. Neutropenic with ANC ___ likely ___ recent chemotx no fevers to date WBC now improved with ANC 2800. Will follow with Dr. ___. Continue tramadol for pain HTN Lisinopril was held initially restarted on discharge Anxiety She reports having anxiety about leaving the hospital as after multiple recent discharges she quickly went to a local ED. She was counseled extensively that she had made gradual improvement and there was no further treatment recommended in the hospital at this time. Consider outpatient social work or palliative care referral to help with anxiety and symptom management. Medications on Admission The Preadmission Medication list is accurate and complete. 1. LORazepam 0.5 mg PO BID PRN anxiety nausea 2. Omeprazole 20 mg PO DAILY 3. Ondansetron 8 mg PO Q8H PRN nausea vomiting 4. TraMADol 50 100 mg PO Q6H PRN Pain Moderate 5. Bismuth Subsalicylate 30 mL PO TID PRN diarrhea nausea abdominal pain 6. LOPERamide 4 mg PO TID PRN diarrhea 7. Dexamethasone 4 mg PO BID 8. Lisinopril 20 mg PO DAILY 9. Prochlorperazine 10 mg PO Q6H PRN nausea vomiting 10. ___ ___ UNIT PO QID Discharge Medications 1. Docusate Sodium 100 mg PO BID PRN constipation RX docusate sodium 100 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 2. Senna 8.6 mg PO BID PRN constipation RX sennosides senna 8.6 mg 1 tablet by mouth twice a day Disp 60 Tablet Refills 0 3. Dexamethasone 2 mg PO DAILY Duration 7 Days RX dexamethasone 2 mg 1 tablet s by mouth once a day Disp 7 Tablet Refills 0 4. Bismuth Subsalicylate 30 mL PO TID PRN diarrhea nausea abdominal pain 5. Lisinopril 20 mg PO DAILY 6. LOPERamide 4 mg PO TID PRN diarrhea 7. LORazepam 0.5 mg PO BID PRN anxiety nausea 8. ___ ___ UNIT PO QID 9. Omeprazole 20 mg PO DAILY 10. Ondansetron 8 mg PO Q8H PRN nausea vomiting 11. Prochlorperazine 10 mg PO Q6H PRN nausea vomiting 12. TraMADol 50 100 mg PO Q6H PRN Pain Moderate Discharge Disposition Home With Service Facility ___ ___ Diagnosis Primary Chemotherapy related nausea Secondary Pancreatic adenocarcinoma Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were admitted to ___ for nausea vomiting diarrhea and inability to tolerate food after your recent chemotherapy. You were given medicine which resolved your diarrhea and helped with nausea. Since you continued to have difficulty eating you were started on a course of steroids. Please follow up with your oncologist to determine your ongoing chemotherapy plans. It was a pleasure caring for you Your ___ Healthcare Team Followup Instructions ___ The icd codes present in this text will be E860, C250, K521, D701, H905, I10, K219, R112, T451X5A, Z6823, R630, E7800, F419, Y929. The descriptions of icd codes E860, C250, K521, D701, H905, I10, K219, R112, T451X5A, Z6823, R630, E7800, F419, Y929 are E860: Dehydration; C250: Malignant neoplasm of head of pancreas; K521: Toxic gastroenteritis and colitis; D701: Agranulocytosis secondary to cancer chemotherapy; H905: Unspecified sensorineural hearing loss; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; R112: Nausea with vomiting, unspecified; T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter; Z6823: Body mass index [BMI] 23.0-23.9, adult; R630: Anorexia; E7800: Pure hypercholesterolemia, unspecified; F419: Anxiety disorder, unspecified; Y929: Unspecified place or not applicable. The common codes which frequently come are I10, K219, F419, Y929. The uncommon codes mentioned in this dataset are E860, C250, K521, D701, H905, R112, T451X5A, Z6823, R630, E7800.

Subsets and Splits

No community queries yet

The top public SQL queries from the community will appear here once available.