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The icd codes present in this text will be A4151, R6521, N179, C250, K831, N009, A4181, I10, E785, I350, T85898A, Y838, Y92230, I4891. The descriptions of icd codes A4151, R6521, N179, C250, K831, N009, A4181, I10, E785, I350, T85898A, Y838, Y92230, I4891 are A4151: Sepsis due to Escherichia coli [E. coli]; R6521: Severe sepsis with septic shock; N179: Acute kidney failure, unspecified; C250: Malignant neoplasm of head of pancreas; K831: Obstruction of bile duct; N009: Acute nephritic syndrome with unspecified morphologic changes; A4181: Sepsis due to Enterococcus; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; I350: Nonrheumatic aortic (valve) stenosis; T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92230: Patient room in hospital as the place of occurrence of the external cause; I4891: Unspecified atrial fibrillation. The common codes which frequently come are N179, I10, E785, Y92230, I4891. The uncommon codes mentioned in this dataset are A4151, R6521, C250, K831, N009, A4181, I350, T85898A, Y838. Allergies tramadol lisinopril Chief Complaint Fever abdominal pain loose stools Major Surgical or Invasive Procedure None History of Present Illness ___ w locally advanced pancreatic CA biliary obstruction s p PTBD ___ admitted to the FICU with septic shock in the setting of E coli and enterococcus bacteremia of presumed biliary source. The patient presented on ___ with fever to 100.9 worsening abdominal pain and loose stools. She was noted to have soft BP and lactate of 3.0. Tbili was lower than prior and URQ US showed no acute ductal dilitation with drain appropriately placed ___ was consulted and the drain was uncapped for external drainage. Blood culture x1 was collected she was given vanc zosyn IVF and was admitted to the FICU. In the FICU she was continued on Vanc Zosyn and IVF but intermittently required phenylephrine during the first hospital day. Blood cultures grew enterococcus and E coli. When stable off pressors for over 24 hours she was transferred to the floor. ROS as above otherwise negative in remaining systems. Past Medical History Locally advanced pancreatic adenocarcinoma diagnosed ___ Malignant CBD obstruction s p PTBD HTN HLD Moderate AS Remote carotid endarterectomy Gastric outlet obstruction s p gastrojejunostomy ___ Social History ___ Family History No known cancer is first degree relatives. Physical Exam ADMISSION PHYSICAL EXAM VITALS T 98.8 HR 114 BP 111 52 RR 19 O2 98 2L NC GENERAL Mild jaundice NAD HEENT PERRL MMM NECK JVP not elevated CARDIAC RRR S1 S2 systolic murmur at base LUNG Bibasilar crackles ABDOMEN R PTBD in place covered with clean bandage ecchymosis around edge of bandage. Non tender to palpation. Abdomen soft nt nd. EXTREMITIES WWP no ___ edema PULSES 2 DP pulses bilaterally NEURO No gross deficits appreciated Discharge exam Vitals stable. No jaundice or scleral icterus PTBD in place capped abdomen non tender. Ext without edema. Pertinent Results ADMISSION LABS ___ 09 30PM BLOOD WBC 9.6 RBC 3.11 Hgb 9.7 Hct 29.8 MCV 96 MCH 31.2 MCHC 32.6 RDW 14.8 RDWSD 51.9 Plt ___ ___ 09 30PM BLOOD Neuts 83.5 Lymphs 8.2 Monos 7.2 Eos 0.5 Baso 0.2 Im ___ AbsNeut 8.03 AbsLymp 0.79 AbsMono 0.69 AbsEos 0.05 AbsBaso 0.02 ___ 09 30PM BLOOD ___ PTT 34.6 ___ ___ 09 30PM BLOOD Glucose 129 UreaN 20 Creat 0.5 Na 131 K 3.8 Cl 92 HCO3 26 AnGap 17 ___ 09 30PM BLOOD ALT 93 AST 90 AlkPhos 472 TotBili 3.4 ___ 09 30PM BLOOD Lipase 41 ___ 09 30PM BLOOD Albumin 3.7 ___ 04 17AM BLOOD Calcium 8.2 Phos 3.1 Mg 1.7 ___ 09 40PM BLOOD Lactate 1.8 Blood culture ___ ESCHERICHIA COLI ENTEROCOCCUS FAECALIS AMPICILLIN 32 R 2 S AMPICILLIN SULBACTAM 32 R CEFAZOLIN 8 R CEFEPIME 1 S CEFTAZIDIME 1 S CEFTRIAXONE 1 S CIPROFLOXACIN 0.25 S DAPTOMYCIN S GENTAMICIN 1 S MEROPENEM 0.25 S PENICILLIN G 2 S PIPERACILLIN TAZO 8 S TOBRAMYCIN 1 S TRIMETHOPRIM SULFA 1 S VANCOMYCIN 2 S RUQ US ___. Heterogeneous hepatic parenchyma likely due to areas of prior Gel Foam embolization biloma seen on recent CT. 2. Percutaneous transhepatic biliary drain in the right posterior biliary system extending to the region of the common bile duct. No intrahepatic biliary dilation. 3. Sludge filled gallbladder. ECHO ___ The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness cavity size and regional global systolic function are normal LVEF 55 . There is no ventricular septal defect. 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. There is mild to moderate aortic valve stenosis valve area 1.2 cm2 . Trace aortic regurgitation is seen. The mitral valve leaflets are mildly 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. ___ Renal ultrasound FINDINGS The right kidney measures 10.7 cm. The left kidney measures 10.3 cm. There is no hydronephrosis stones or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is moderately well distended and normal in appearance. IMPRESSION No hydronephrosis. Normal cortical echogenicity and corticomedullary differentiation. discharge labs ___ 06 07AM BLOOD WBC 6.7 RBC 2.58 Hgb 8.0 Hct 25.1 MCV 97 MCH 31.0 MCHC 31.9 RDW 15.2 RDWSD 54.6 Plt ___ ___ 06 07AM BLOOD Glucose 105 UreaN 30 Creat 2.0 Na 138 K 3.9 Cl 100 HCO3 25 AnGap 17 ___ 06 07AM BLOOD ALT 45 AST 36 AlkPhos 284 TotBili 2.0 Brief Hospital Course ___ w locally advanced pancreatic CA biliary obstruction s p PTBD ___ admitted to the FICU with septic shock in the setting of E coli and enterococcus bacteremia of presumed biliary source. ENTEROCOCCUS AND E COLI BACTEREMIA OF PRESUMED BILIARY SOURCE SEPTIC SHOCK On arrival patient was hypotensive and a lactate of 3.0 despite fluids. The patient intermittently required a small dose of phenylephrine. Blood cultures grew E coli resistant to early generation beta lactams and enterococcus not VRE . She was on empiric vanc Zosyn since ___ which has now been narrowed to vanc CTX based on sensitivities. Her urine culture was negative and her CT showed no obvious biliary pathology. The perc biliary drain has been uncapped for external drainage in the setting of possible cholangitis and the patient improved. On transfer to the medical floor the patient s antibiotics were narrowed to Cipro Ampicllin. She subsequently developed renal failure thought to be due to betalactams so Vancomycin was restarted. Unfortunately she developed recurrent lft and bilirubin elevation and underwent repeat PTBD placed on ___ with subsequent improvement. She was discharged to complete a 2 week course of ciprofloxacin and ampicillin ampicillin was restarted as likelihood of AIN was quite low per nephrology with ATN more likely . PANCREATIC ADENOCARCINOMA Malignant biliary obstruction. Diagnosed ___ by EUS FNA. It is locally advanced and unresectable encases vasculature . Pt will f u with Dr. ___ to discuss palliative chemo if functional status allows and she wants to pursue treatment. She was followed by interventional radiology and had placement of metal stent on ___ with removal of external PTBD and then replacement after she developed recurrent obstruction as described above. She will have ___ follow up next week for repeat stent evaluation to try to clarify reason for rapid failure of stent. ACUTE RENAL FAILURE The patient developed acute renal failure. She was seen by nephrology who felt her renal failure was likely due to either AIN in the setting of antibiotics or ATN from sepsis. Her renal function slowly improved but plateaued at approximately 2. She will have nephrology follow up for further evaluation. HTN Resumed metoprolol given recent hypotension VASCULAR DISEASE Remote history of carotid endarterectomy. Continue ASA 81 mg AS Would not arrange cardiology follow up given that the valve will not progress to critical stenosis within her duration of expected survival. HCP ___ daughter. ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Omeprazole 40 mg PO DAILY 2. calcium carbonate vitamin D3 600 mg 1 500mg 800 unit oral DAILY 3. Aspirin 81 mg PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. Fish Oil Omega 3 1000 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Vitamin D 1000 UNIT PO DAILY 8. OxyCODONE Immediate Release 5 mg PO Q4H PRN BREAKTHROUGH PAIN Discharge Medications 1. Ampicillin 2 g IV Q6H RX ampicillin sodium 2 gram 2 g IV q 6 hours Disp 20 Vial Refills 0 2. Ciprofloxacin HCl 500 mg PO Q24H RX ciprofloxacin HCl Cipro 500 mg 1 tablet s by mouth daily Disp 5 Tablet Refills 0 3. Aspirin 81 mg PO DAILY 4. calcium carbonate vitamin D3 600 mg 1 500mg 800 unit oral DAILY 5. Cyanocobalamin 1000 mcg PO DAILY 6. Fish Oil Omega 3 1000 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. OxyCODONE Immediate Release 5 mg PO Q4H PRN BREAKTHROUGH PAIN 10. Vitamin D 1000 UNIT PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Sepsis Bacteremia Malignant biliary obstruction Acute renal failure Pancreatic cancer Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Ms. ___ You were admitted with a bloodstream infection from your bile duct blockage. You were treated with antibiotics with improvement in your infection. You were seen by the radiologists and had the external drain removed and a metal stent placed into your bile ducts but this did not work and you needed another drain put in. While you were hospitalized you developed kidney failure which is likely because you were dehydrated. You need to take another 5 days of antibiotics the ciprofloxacin pills once a day as well as the ampicillin IV 4 times per day. After you go home you need to see a number of doctors The kidney doctor they will call you with an appointment. Dr. ___ cancer doctor they will call you with an appointment. Dr. ___ a new primary care doctor whom you are scheduled to see on ___ Dr. ___ an interventional radiologist who will reschedule you to have another interventional procedure to evaluate your drain and your stent. If you develop fever or right sided abdominal pain you should reattach the drain to a bag. Followup Instructions ___ The icd codes present in this text will be A4151, R6521, N179, C250, K831, N009, A4181, I10, E785, I350, T85898A, Y838, Y92230, I4891. The descriptions of icd codes A4151, R6521, N179, C250, K831, N009, A4181, I10, E785, I350, T85898A, Y838, Y92230, I4891 are A4151: Sepsis due to Escherichia coli [E. coli]; R6521: Severe sepsis with septic shock; N179: Acute kidney failure, unspecified; C250: Malignant neoplasm of head of pancreas; K831: Obstruction of bile duct; N009: Acute nephritic syndrome with unspecified morphologic changes; A4181: Sepsis due to Enterococcus; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; I350: Nonrheumatic aortic (valve) stenosis; T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92230: Patient room in hospital as the place of occurrence of the external cause; I4891: Unspecified atrial fibrillation. The common codes which frequently come are N179, I10, E785, Y92230, I4891. The uncommon codes mentioned in this dataset are A4151, R6521, C250, K831, N009, A4181, I350, T85898A, Y838.
The icd codes present in this text will be A4151, R6521, N179, C250, K831, N009, A4181, K315, K838, I10, E785, I350, T85898A, Y838, Y838, Y92230, Z934. The descriptions of icd codes A4151, R6521, N179, C250, K831, N009, A4181, K315, K838, I10, E785, I350, T85898A, Y838, Y838, Y92230, Z934 are A4151: Sepsis due to Escherichia coli [E. coli]; R6521: Severe sepsis with septic shock; N179: Acute kidney failure, unspecified; C250: Malignant neoplasm of head of pancreas; K831: Obstruction of bile duct; N009: Acute nephritic syndrome with unspecified morphologic changes; A4181: Sepsis due to Enterococcus; K315: Obstruction of duodenum; K838: Other specified diseases of biliary tract; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; I350: Nonrheumatic aortic (valve) stenosis; T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92230: Patient room in hospital as the place of occurrence of the external cause; Z934: Other artificial openings of gastrointestinal tract status. The common codes which frequently come are N179, I10, E785, Y92230. The uncommon codes mentioned in this dataset are A4151, R6521, C250, K831, N009, A4181, K315, K838, I350, T85898A, Y838, Y838, Z934. Allergies tramadol lisinopril Chief Complaint OSH transfer s p ERCP here for obstructive jaundice pancreatic head mass Major Surgical or Invasive Procedure EUS with fine needle biopies of pancreatic mass ___ Percutaneous transhepatic biliary drain placement ___ History of Present Illness ___ hx AS HTN HLD remote carotid endarterectomy s p gastrojejunostomy ___ for gastric outlet obstruction EGD with duodenal apex stricture benign pathology MRCP ___ with dilated pancreatic duct normal CBD and no mass repeat EGD ___ with persistent duodenal stricture transfer from OSH with painless jaundice hyperbilirubinemia and found to have pancreatic head mass s p EGD EUS now admitted to ___ for further w u. History taken from patient her two daughters and available ___ records. The surgery above did relieve her feelings of nausea and vomiting but she continued to have LUQ pain intermittently that was attributed to post operative pain. Despite being able to eat and drink and having a near normal appetite her weight dropped about 10lbs. She noticed that her stools were getting lighter and more recently that her urine was darker. On ___ her daughter visiting her noticed that she was jaundiced she lives with another daughter but that daughter had been away for hip surgery on ___ the patient was itching but did not have a rash. She was taken to ___ were labs were notable for Bilirubin 7.7 AST 155 ALT 176 AP 742. CA ___ was elevated at 282. An MRI MRCP showed Impression 2.9x2.0cm mass in the pancreatic head causing obstruction of the CBD with moderate biliary ductal dilatation. HMED and ERCP were contacted for transfer with patient going to the ERCP suite prior to admission. EGD EUS was with the following findings EUS was performed using a linear echoendoscope at ___ MHz frequency The head and uncinate pancreas were imaged from the duodenal bulb and the second third duodenum. The body and tail partially were imaged from the gastric body and fundus. Mass A 3.4 cm X 2.9 cm ill defined mass was noted in the head of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. FNB was performed. Color doppler was used to determine an avascular path for needle biopsy. A 22 gauge needle with a slow pull technique was used to perform biopsy. Five needle passes were made into the mass. biopsy was sent for pathology. Impression as below. When seen on the floor patient contributes to the history as above and below. She is currently feeling okay. She denies current abdominal pain HA n v fevers chills. She denies vision change dizziness lightheadedness cough congestion chest pain sob urinary frequency or pain with urination diarrhea or constipation focal weakness. Her daughters note she s been stooling x3 per day not loose but pt again confirms the light color. Past Medical History HTN HLD AS remote carotid endarterectomy s p gastrojejunostomy ___ for gastric outlet obstruction Social History ___ Family History Mother died at ___ unclear reasons did have a stroke before death Father died in old age of stroke Physical Exam ADMISSION PHYSICAL EXAM Vitals 96.1 100 62 83 16 96 RA Gen Pleasant elder female sitting in chair NAD HEENT NCAT EOMI PERRLA icteric sclera clear OP MMM CV II VI SEM best heard RUSB RRR Chest CTAB no w r r GI soft NT ND BS MSK Mild kyphosis. No synovitis. Skin Jaundice. Varicose veins b l ___. Neuro AAOx3. No facial droop. Full strength all extremities. Psych Full range of affect Pertinent Results ADMISSION LABS ___ 10 24PM BLOOD WBC 4.4 RBC 2.95 Hgb 9.3 Hct 27.5 MCV 93 MCH 31.5 MCHC 33.8 RDW 18.4 RDWSD 62.6 Plt ___ ___ 10 24PM BLOOD Glucose 103 UreaN 13 Creat 0.7 Na 138 K 3.3 Cl 100 HCO3 25 AnGap 16 ___ 10 24PM BLOOD ALT 154 AST 168 AlkPhos 648 TotBili 7.9 DirBili 6.3 IndBili 1.6 ___ 10 24PM BLOOD Calcium 9.2 Phos 3.2 Mg 1.7 DISCHARGE LABS IMAGING OSH MRI MRCP showed Impression 2.9x2.0cm mass in the pancreatic head causing obstruction of the CBD with moderate biliary ductal dilatation CT chest with Contrast ___ IMPRESSION 1. No specific CT evidence of active intrathoracic infection or metastasis. 2. Sub 2 mm right upper lobe subpleural pulmonary nodule. CT abdomen pelvis ___ 1. There are several hypoattenuating lesions within the right hepatic lobe some of which demonstrate internal foci of air and the largest demonstrates rim enhancement. After discussion with the interventional radiology team in light of the somewhat difficult recent PTBD placement with gelfoam embolization these are likely sequela of this procedure hmeatoma bilioma . 2. Ill defined hypoenhancing 3.0 x 2.5 cm pancreatic head mass is concerning for pancreatic adenocarcinoma. Arterial and venous invasion as well as invasion of adjacent structures is described in detail above. Specifically the main portal vein SMV gastroduodenal artery proper hepatic artery and duodenum are affected by this lesion. 3. There is no calcified gallstone or pericholecystic fluid however the gallbladder wall is thickened. This could be further evaluated with ultrasound if indicated. PROCEDURES ___ ___ EGD EUS Impression Normal mucosa in the esophagus Previous Gastro Jejunal bypass of the stomach body A malignant intrinsic stricture was found in the first part of the duodenum. The scope did not traverse the lesion. EUS was performed using a linear echoendoscope at ___ MHz frequency The head and uncinate pancreas were imaged from the duodenal bulb and the second third duodenum. The body and tail partially were imaged from the gastric body and fundus. Mass A 3.4 cm X 2.9 cm ill defined mass was noted in the head of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. FNB was performed. Color doppler was used to determine an avascular path for needle biopsy. A 22 gauge needle with a slow pull technique was used to perform biopsy. Five needle passes were made into the mass. biopsy was sent for pathology. Otherwise normal upper eus to third part of the duodenum ___ Percutaneous Transhepatic Biliary Drain placement FINDINGS 1. Dilated biliary system. While many left sided biliary ducts were dilated the left sided system was inaccessible due to what appeared to be an overlying bowel on ultrasound.. 2. High grade severe CBD obstruction with intrahepatic ductal dilatation. 3. 10 ___ internal external drain through the right posterior ducts. 4. Initial placement complicated by peribiliary sheath placement and wire traversion into hepatic parenchyma. This track was gelfoam embolized and a second access was obtained in uncomplicated fashion. IMPRESSION Successful placement of the right ___ internal external biliary drain. High grade distal CBD obstruction. ___ 07 10AM BLOOD WBC 6.9 RBC 3.07 Hgb 9.7 Hct 29.8 MCV 97 MCH 31.6 MCHC 32.6 RDW 16.7 RDWSD 59.4 Plt ___ ___ 07 30AM BLOOD WBC 6.7 RBC 3.02 Hgb 9.5 Hct 28.5 MCV 94 MCH 31.5 MCHC 33.3 RDW 17.6 RDWSD 61.5 Plt ___ ___ 07 10AM BLOOD Glucose 92 UreaN 14 Creat 0.6 Na 133 K 3.8 Cl 93 HCO3 28 AnGap 16 ___ 07 10AM BLOOD ALT 121 AST 89 AlkPhos 488 TotBili 3.8 ___ 07 30AM BLOOD ALT 156 AST 151 AlkPhos 552 TotBili 4.5 ___ 06 30AM BLOOD ALT 156 AST 176 AlkPhos 654 TotBili 10.3 ___ 06 35AM BLOOD ALT 156 AST 172 LD LDH 168 TotBili 10.1 DirBili 7.9 IndBili 2.2 ___ 06 30AM BLOOD CEA 6.2 Result Reference Range Units CA ___ 83 H 34 U mL CT chest IMPRESSION 1. No specific CT evidence of active intrathoracic infection or metastasis. 2. Sub 2 mm right upper lobe subpleural pulmonary nodule. CT abd pelvis IMPRESSION 1. There are several hypoattenuating lesions within the right hepatic lobe some of which demonstrate internal foci of air and the largest demonstrates rim enhancement. After discussion with the interventional radiology team in light of the somewhat difficult recent PTBD placement with gelfoam embolization these are likely sequela of this procedure hmeatoma bilioma . 2. Ill defined hypoenhancing 3.0 x 2.5 cm pancreatic head mass is concerning for pancreatic adenocarcinoma. Arterial and venous invasion as well as invasion of adjacent structures is described in detail above. Specifically the main portal vein SMV gastroduodenal artery proper hepatic artery and duodenum are affected by this lesion. 3. There is no calcified gallstone or pericholecystic fluid however the gallbladder wall is thickened. This could be further evaluated with ultrasound if indicated. Impression Normal mucosa in the esophagus Previous Gastro Jejunal bypass of the stomach body A malignant intrinsic stricture was found in the first part of the duodenum. The scope did not traverse the lesion. EUS was performed using a linear echoendoscope at ___ MHz frequency The head and uncinate pancreas were imaged from the duodenal bulb and the second third duodenum. The body and tail partially were imaged from the gastric body and fundus. Mass A 3.4 cm X 2.9 cm ill defined mass was noted in the head of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. FNB was performed. Color doppler was used to determine an avascular path for needle biopsy. A 22 gauge needle with a slow pull technique was used to perform biopsy. Five needle passes were made into the mass. biopsy was sent for pathology. Otherwise normal upper eus to third part of the duodenum Recommendations Clear liquid diet when awake then advance diet as tolerated. Follow up with Dr. ___ as previously scheduled. If any fever worsening abdominal pain or post procedure symptoms please call the advanced endoscopy fellow on call ___ pager ___. Follow up will depend on pathology results. Patient will be contacted to discuss when results become available. Follow up with pathology reports. Please call Dr. ___ office ___ in 7 days for the pathology results. Please obtain chest CT and CTA abdomen and pelvis Please contact ___ service Dr. ___ contact ___ for PTBD evaluation PATHOLOGIC DIAGNOSIS Pancreas mass core needle biopsy Adenocarcinoma. Brief Hospital Course ___ hx HTN HLD remote carotid endarterectomy s p gastrojejunostomy ___ for gastric outlet obstruction recent presentation to OSH with painless jaundice and hyperbilirubinemia found to have pancreatic head mass transferred for ERCP EUS and ___ evaluation. Jaundice Hyperbilirubinemia Pancreatic Head Mass Pt transferred from ___ for painless jaundice newly diagnosed pancreatic head mass c f adenocarcinoma rapidly progressive as per report as not seen on imaging ___ during evaluation for gastric outlet obstruction which did not have another obvious cause . She underwent EUS with fine needle biopsy on ___ which she tolerated well. Pathology returned c w adenocarcinoma. However as endoscopy was unable to traverse duodenal stricture ___ mass pt underwent PTBD placement on ___ which she tolerated well. Post procedure bilis downtrended. Drain was capped on ___ without issue and pt will be discharged with drain pending ___ surgery s decision regarding potential surgical options. CTA pancreatic protocol obtained prior to pt s discharge. Per ___ if surgery is not an option will plan to replace drain with stent. Pt will be seen in ___ clinic on ___. HTN Continued home metoprolol HLD Held home statin given elevated LFT s held on discharge. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lovastatin 40 mg oral DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Fish Oil Omega 3 1000 mg PO DAILY 4. calcium carbonate vitamin D3 600 mg 1 500mg 800 unit oral DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Cyanocobalamin 1000 mcg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Omeprazole 40 mg PO DAILY Discharge Medications 1. OxyCODONE Immediate Release 5 mg PO Q4H PRN BREAKTHROUGH PAIN RX oxycodone 5 mg 1 tablet s by mouth every ___ hours as needed Disp 20 Tablet Refills 0 2. Aspirin 81 mg PO DAILY 3. calcium carbonate vitamin D3 600 mg 1 500mg 800 unit oral DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. Fish Oil Omega 3 1000 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Pancreatic head mass Duodenal stricture Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You were transferred from ___ due to a newly diagnosed pancreatic mass which was causing an obstruction in drainage of your bile ducts. You underwent placement of an external biliary drain which is currently working well and has a cap on it. You will meet with the surgeons and oncologists in clinic to decided how to proceed with further work up and treatment of your pancreatic mass. You were prescribed a medication for pain called oxycodone. This medication can be addictive and can cause difficulty breathing and even death. Please only use this medication as prescribed and do not drive when taking this medication. Do not take with other sedating medications. You may have a partial fill. It was a pleasure taking care of you at ___ ___. Followup Instructions ___ The icd codes present in this text will be A4151, R6521, N179, C250, K831, N009, A4181, K315, K838, I10, E785, I350, T85898A, Y838, Y838, Y92230, Z934. The descriptions of icd codes A4151, R6521, N179, C250, K831, N009, A4181, K315, K838, I10, E785, I350, T85898A, Y838, Y838, Y92230, Z934 are A4151: Sepsis due to Escherichia coli [E. coli]; R6521: Severe sepsis with septic shock; N179: Acute kidney failure, unspecified; C250: Malignant neoplasm of head of pancreas; K831: Obstruction of bile duct; N009: Acute nephritic syndrome with unspecified morphologic changes; A4181: Sepsis due to Enterococcus; K315: Obstruction of duodenum; K838: Other specified diseases of biliary tract; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; I350: Nonrheumatic aortic (valve) stenosis; T85898A: Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92230: Patient room in hospital as the place of occurrence of the external cause; Z934: Other artificial openings of gastrointestinal tract status. The common codes which frequently come are N179, I10, E785, Y92230. The uncommon codes mentioned in this dataset are A4151, R6521, C250, K831, N009, A4181, K315, K838, I350, T85898A, Y838, Y838, Z934.
The icd codes present in this text will be I636, I608, I2699, I82421, Q211, K8000, D6859, G8101, R29704, F1410, F1210, F1910, F1110, R61, B1920, F17210, F1010, Z818, Z814, Z7901, R509. The descriptions of icd codes I636, I608, I2699, I82421, Q211, K8000, D6859, G8101, R29704, F1410, F1210, F1910, F1110, R61, B1920, F17210, F1010, Z818, Z814, Z7901, R509 are I636: Cerebral infarction due to cerebral venous thrombosis, nonpyogenic; I608: Other nontraumatic subarachnoid hemorrhage; I2699: Other pulmonary embolism without acute cor pulmonale; I82421: Acute embolism and thrombosis of right iliac vein; Q211: Atrial septal defect; K8000: Calculus of gallbladder with acute cholecystitis without obstruction; D6859: Other primary thrombophilia; G8101: Flaccid hemiplegia affecting right dominant side; R29704: NIHSS score 4; F1410: Cocaine abuse, uncomplicated; F1210: Cannabis abuse, uncomplicated; F1910: Other psychoactive substance abuse, uncomplicated; F1110: Opioid abuse, uncomplicated; R61: Generalized hyperhidrosis; B1920: Unspecified viral hepatitis C without hepatic coma; F17210: Nicotine dependence, cigarettes, uncomplicated; F1010: Alcohol abuse, uncomplicated; Z818: Family history of other mental and behavioral disorders; Z814: Family history of other substance abuse and dependence; Z7901: Long term (current) use of anticoagulants; R509: Fever, unspecified. The common codes which frequently come are F17210, Z7901. The uncommon codes mentioned in this dataset are I636, I608, I2699, I82421, Q211, K8000, D6859, G8101, R29704, F1410, F1210, F1910, F1110, R61, B1920, F1010, Z818, Z814, R509. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint R arm paralysis Major Surgical or Invasive Procedure None History of Present Illness ___ RHD M w PMH HepC IVDU presents with R arm weakness. Patient was in his usual state of health until ___ when he woke up he noticed R arm felt numb thought he slept on it funny went to sleep and woke up and it was still the same. He also noticed he couldn t move it. When he woke up around lunch time that day he stated he couldn t use it to do anything. States it seems like it affects the whole arm up to the shoulder. sensation intact in shoulder. He states he has sensation and has been able to feel people examine him. He is not sure exactly how the sensation is different than normal. Was normal on ___ night no preceding symptoms. No headache. No tingling. Denies fever or chills. Gets night sweats periodically states it drenches the sheets. He is not sure how frequently. No palpitations chest pain. He states he was arrested ___ and has been in jail since then. No head trauma. After initial evaluation he later states he developed mild headache of gradual onset thatstarted while he was in the emergency room. that he states was due to the beeping noise from teh infusion pump. On neuro ROS the pt denies headache loss of vision blurred vision diplopia dysarthria dysphagia lightheadedness vertigo tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. 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 recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History HepC has not taken any medications for it diagnosed ___ year ago lyme disease had general fatigue dx by blood test took 1 month of antibiotics for that about ___ year ago back and knee problems Social History ___ Family History Father overdose Brother suicide Physical Exam Admission Physical Exam Vitals T98.5 HR 76 BP 108 76 RR18 Spo2 99 RA General Awake cooperative NAD thin HEENT NC AT no scleral icterus noted MMM no lesions noted in oropharynx Neck Supple no carotid bruits appreciated. No nuchal rigidity Pulmonary Normal work of breathing Cardiac RRR warm well perfused Abdomen soft non distended Extremities No ___ edema. Skin no rashes or lesions noted. many tattoos Neurologic Mental Status Alert oriented to ___ ___. Able to relate history without difficulty. name ___ backward gets to ___. DOWB gets to ___. Does DOWF easily. 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. 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. Fundoscopic exam revealed no papilledema exudates ___ spots V Facial sensation intact to light touch. VII No facial droop facial musculature symmetric. VIII Hearing intact to finger rub bilaterally. IX X Palate elevates symmetrically. XI ___ strength in trapezius on R no movement noted on L XII Tongue protrudes in midline with good excursions. Strength full with tongue in cheek testing. Motor Normal bulk tone throughout. No pronator drift bilaterally. No adventitious movements such as tremor noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ L 5 ___ ___ 5 5 5 5 R 2 ___ 0 5 5 5 5 5 5 Sensory No deficits to light touch cold sensation vibratory sense proprioception throughout. No extinction to DSS. decreased sensation to pinprick in R arm to shoulder level DTRs Bi Tri ___ Pat Ach L 2 2 2 2 1 R 1 0 0 2 1 Plantar response was flexor bilaterally. Coordination No intention tremor. Normal finger tap . No dysmetria on FNF or HKS on L. Gait deferred patient handcuffed to bed Discharge Physical Exam Tmax 36.8 C 98.2 F Tcurrent 36.6 C 97.8 F HR 81 52 91 bpm BP 109 80 90 94 60 71 120 87 97 mmHg RR 19 18 26 insp min SpO2 97 Heart rhythm SR Sinus Rhythm General young man lying in bed NAD HEENT NC AT Pulmonary breathing comfortably on room air Cardiac warm well perfused Abdomen soft NT ND Extremities wwp no C C E bilaterally Skin no rashes or lesions noted. Neurologic MS Awake alert. Oriented to self hospital date. Able to relay history clearly. Language is fluent. No paraphasic errors. No dysarthria. Follows midline and appendicular commands. CN PERRL 7 5mm b l. VFF to confrontation. EOMI no nystagmus. Sensation intact and equal b l. No facial asymmetry. Tongue protrudes to midline. Symmetric palate elevation. Motor Intermittent tremor in R thumb some fingers. RUE unable to move at all except R deltoid is 2. LUE with full ROM and ___. Both ___. Bilateral IP TA ___. Sensory Equal and symmetric sensation to pinprick. Reflexes Deferred. Coordination deferred Gait deferred. Pertinent Results ___ 06 05AM BLOOD WBC 7.9 RBC 4.34 Hgb 13.9 Hct 40.2 MCV 93 MCH 32.0 MCHC 34.6 RDW 14.4 RDWSD 48.4 Plt ___ ___ 06 05AM BLOOD Neuts 33.7 Lymphs 53.5 Monos 10.1 Eos 1.2 Baso 0.9 Im ___ AbsNeut 2.76 AbsLymp 4.39 AbsMono 0.83 AbsEos 0.10 AbsBaso 0.07 ___ 02 30PM BLOOD Hypochr NORMAL Anisocy OCCASIONAL Poiklo NORMAL Macrocy OCCASIONAL Microcy NORMAL Polychr NORMAL ___ 06 05AM BLOOD ___ PTT 83.7 ___ ___ 06 05AM BLOOD Glucose 98 UreaN 6 Creat 0.6 Na 143 K 4.3 Cl 108 HCO3 24 AnGap 11 ___ 09 22AM BLOOD ALT 27 AST 27 LD LDH 386 AlkPhos 75 TotBili 0.3 ___ 06 05AM BLOOD Calcium 8.4 Phos 4.2 Mg 2.0 ___ 06 10AM BLOOD HbA1c 5.3 eAG 105 ___ 06 10AM BLOOD Cryoglb NO CRYOGLO ___ 06 10AM BLOOD Triglyc 149 HDL 21 CHOL HD 8.2 LDLcalc 122 ___ 06 10AM BLOOD TSH 2.6 ___ 06 10AM BLOOD CRP 50.8 ___ 06 15AM BLOOD PEP ABNORMAL B IgG 1099 IgA 268 IgM 263 IFE MONOCLONAL ___ 02 06AM BLOOD PEP ABNORMAL B IgG 1268 IgA 295 IgM 315 IFE MONOCLONAL ___ 02 36PM BLOOD Lactate 0.9 MRI ___ IMPRESSION 1. Study is mildly degraded by motion. 2. Dural venous sinus thrombosis involving the superior sagittal sinus left transverse sinus left sigmoid sinus proximal left internal jugular vein and multiple bilateral cerebral veins at the vertex. 3. Left frontoparietal acute to subacute infarct with adjacent subarachnoid hemorrhage as described. 4. Right frontal thrombosed vessel versus small subarachnoid hemorrhage as described. 5. Additional chronic left frontal infarcts. 6. Partial opacification of the left mastoid air cells is nonspecific and appears increased compared with outside CT head performed earlier on same day suggesting it is possibly due to patient s left sided dural venous sinus thrombosis however mastoiditis as a source of the dural sinus venous thrombosis cannot be excluded. TEE ___ IMPRESSION Small PFO by color flow corroborated by crossing of saline contrast into the left atrium. Unable to quantify with confidence the volume of bubbles crossing due to echo reverberations right above the interatrial septum. There is no interartial septal aneurym however the interatrial septum appears dynamic. The anatomy lends itself to interatrial septal occluder device placement. No ___ thrombus or spontaneous echo contrast Scrotal US ___ IMPRESSION Normal scrotal ultrasound. No testicular mass is identified. CTA Chest ___ IMPRESSION 1. Bilateral lobar and subsegmental pulmonary embolisms without signs of right heart strain or pulmonary infarcts most likely acute. Bilateral subsegmental atelectasis in both bases without clear pulmonary infarcts. CT A P with cont ___ IMPRESSION 1. Distended gallbladder with surrounding fat stranding and stone in the gallbladder neck consistent with acute cholecystitis. 2. Nonocclusive thrombus in the distal right common iliac vein. 3. Age indeterminate compression deformity of T12 although chronic appearing. 4. No evidence of intra abdominal intrapelvic malignancy. RUQ US ___ IMPRESSION 1. Cholelithiasis with findings concerning for acute cholecystitis as seen on same day CT abdomen and pelvis. 2. No biliary dilatation. Brief Hospital Course Brief Hospital Course ___ is a ___ yo M with a past medical history of HepC IVDU currently incarcerated who presented with R arm weakness since ___. He was brought to the ER where acute imaging was obtained. A Non contrast head ct was obtained and showed a hypodensity in L corona radiata some of the L precentral gyrus CTA showed concern for transverse sinus thrombosis. CTA also shows 8 mm L ICA aneurysm. His exam on admission was notable for R arm weakness decreased sensation to pinprick. He was admitted to the stroke team for further management and work up Acute R arm weakness secondary to venous sinus thrombosis The patient was admitted to the stroke service where MRI was completed. MRI showed a subacute L frontoparietal infarction likely due to compression from cortical vein thrombosis. CTA and MRI showed L transverse venous thrombosis and sagittal venous sinus thrombosis. No clear explanation for a venous sinus thrombosis. The patient had an extensive hypercoaguable work up and was initiated on a heparin drip gtt no bolus stroke protocol goal PTT 50 70 . Hematology oncology was also consulted The patient was treated with heparin gtt. Bridging to Coumadin. His INR on discharge was 1.9 Fever Patient febrile to ___ F on ___. Blood cultures and urine culture negative. TEE was complete and negative for any source of vegetation. CT abdomen showed possible evidence of acute cholecystitis Treated empirically with ceftriaxone flagyl vancomycin for 7 day course to complete after last doses on ___. no further fevers or symptoms Pulmonary embolism bilateral PEs seen on CTA. No R heart strain on TTE. treated with heparin gtt bridged to Coumadin will need Coumadin indefinitely and to be discussed with hematology oncology Hypercoagulable state still uncertain etiology CT Torso did not show obvious mass concerning for malignancy Beta 2 glycoprotein negative. Anti cardiolipin pending. Acute cholecystitis seen on CT abdomen CT obtained when patient was febrile. Acute cholecystitis on CT abd and abd US patient afebrile and not symptomatic. General surgery was consulted however given that the patient was asymptomatic they did not think the cholecsytitis was acute nor did it need intervention. Patient tolerating PO diet well without symptoms Chronic issues Multi substance abuse patient with history of active IVDU with heroin. Also uses cocaine fentanyl marijuana Xanax illegally No withdrawal symptoms seen except for frequent night sweats. was written for Ativan prn 0.5mg Q8hours for anxiety. Transitional Issues check INR daily to adjust Coumadin dose please overlap heparin and Coumadin for 48 hours once Coumadin is therapeutic. Will need Coumadin indefinitely. INR goal 2.0 3.0. complete IV antibiotics last day ___ Follow up with hematology appointment to be scheduled by calling ___. Follow up anti cardiolipin ab still pending Follow up with neurology scheduled ___ at 8 AM ___ need resources for substance abuse vs possible rehab referral 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. If no reason why 2. DVT Prophylaxis administered x Yes No. If no why not I.e. bleeding risk hemorrhage etc. 3. Antithrombotic therapy administered by end of hospital day 2 Yes x No. If not why not Therapeutic anticoagulated. I.e. bleeding risk hemorrhage etc. 4. LDL documented x Yes LDL 122 No 5. Intensive statin therapy administered simvastatin 80mg simvastatin 80mg ezetemibe 10mg atorvastatin 40mg or 80 mg rosuvastatin 20mg or 40mg for LDL 70 Yes x No if LDL 70 reason not given Stroke caused by compression from venous thrombosis 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 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 Yes No. If no why not I.e. patient at baseline functional status 9. Discharged on statin therapy Yes x No if LDL 70 reason not given Stroke caused by compression from venous thrombosis 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 Yes No If no why not I.e. bleeding risk etc. x N A Medications on Admission None He states that he was taking Xanax 1mg TID which he obtained from illicit sources for anxiety. He states he last took this prior to being arrested around ___ Discharge Medications 1. Acetaminophen 650 mg PO Q4H PRN pain or temp ___ 2. CefTRIAXone 2 gm IV Q24H 3. Docusate Sodium 100 mg PO BID 4. Heparin IV per Weight Based Dosing Protocol Indication Anticoagulation in Patient with Acute Stroke Continue existing infusion at 850 units hr Therapeutic Target PTT Range 50 70.9 seconds Start Today ___ First Dose 1300 hrs Stop Instructions When Coumadin is consistently therapuetic between ___ for 3 days 5. LORazepam 0.5 mg PO Q8H PRN Anxiety 6. MetroNIDAZOLE 500 mg PO TID Continue until ___ 7. TraMADol 50 100 mg PO Q6H PRN Pain Moderate 8. Vancomycin 1500 mg IV Q 8H Continue until ___ 9. Warfarin 5 mg PO DAILY16 Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Venous sinus thrombosis DVT Pulmonary Embolism 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 because you had paralysis of your right arm along with right arm numbness. You were found to have multiple blood clots in the vein around your brain. These also caused compression and caused a small stroke with a small amount of bleeding around it. More scans showed you also have blood clots in both your lungs and a vein in your abdomen. You were started on blood thinners to prevent further clots from forming. We are not sure why you seem predisposed to developing clots right now. Please follow up with neurology. An appointment has been made for you on ___ at 8 00 AM. Please follow up with hematology within ___ weeks of discharge please call ___ to schedule if you do not hear from them this week. Please follow up with your primary care physician ___ ___ weeks of discharge. Followup Instructions ___ The icd codes present in this text will be I636, I608, I2699, I82421, Q211, K8000, D6859, G8101, R29704, F1410, F1210, F1910, F1110, R61, B1920, F17210, F1010, Z818, Z814, Z7901, R509. The descriptions of icd codes I636, I608, I2699, I82421, Q211, K8000, D6859, G8101, R29704, F1410, F1210, F1910, F1110, R61, B1920, F17210, F1010, Z818, Z814, Z7901, R509 are I636: Cerebral infarction due to cerebral venous thrombosis, nonpyogenic; I608: Other nontraumatic subarachnoid hemorrhage; I2699: Other pulmonary embolism without acute cor pulmonale; I82421: Acute embolism and thrombosis of right iliac vein; Q211: Atrial septal defect; K8000: Calculus of gallbladder with acute cholecystitis without obstruction; D6859: Other primary thrombophilia; G8101: Flaccid hemiplegia affecting right dominant side; R29704: NIHSS score 4; F1410: Cocaine abuse, uncomplicated; F1210: Cannabis abuse, uncomplicated; F1910: Other psychoactive substance abuse, uncomplicated; F1110: Opioid abuse, uncomplicated; R61: Generalized hyperhidrosis; B1920: Unspecified viral hepatitis C without hepatic coma; F17210: Nicotine dependence, cigarettes, uncomplicated; F1010: Alcohol abuse, uncomplicated; Z818: Family history of other mental and behavioral disorders; Z814: Family history of other substance abuse and dependence; Z7901: Long term (current) use of anticoagulants; R509: Fever, unspecified. The common codes which frequently come are F17210, Z7901. The uncommon codes mentioned in this dataset are I636, I608, I2699, I82421, Q211, K8000, D6859, G8101, R29704, F1410, F1210, F1910, F1110, R61, B1920, F1010, Z818, Z814, R509.
The icd codes present in this text will be J208, Z9484, C9000, D6959, E8339, R197, E876, D630, M109, Z87891, E860, F329. The descriptions of icd codes J208, Z9484, C9000, D6959, E8339, R197, E876, D630, M109, Z87891, E860, F329 are J208: Acute bronchitis due to other specified organisms; Z9484: Stem cells transplant status; C9000: Multiple myeloma not having achieved remission; D6959: Other secondary thrombocytopenia; E8339: Other disorders of phosphorus metabolism; R197: Diarrhea, unspecified; E876: Hypokalemia; D630: Anemia in neoplastic disease; M109: Gout, unspecified; Z87891: Personal history of nicotine dependence; E860: Dehydration; F329: Major depressive disorder, single episode, unspecified. The common codes which frequently come are M109, Z87891, F329. The uncommon codes mentioned in this dataset are J208, Z9484, C9000, D6959, E8339, R197, E876, D630, E860. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Weakness malaise cough congestion diarrhea Major Surgical or Invasive Procedure None History of Present Illness Mr. ___ is a ___ gentleman with a PMH significant for multiple myeloma s p autologous transplant in ___ who presents with weakness malaise cough congestion and diarrhea. The patient was feeling well up until last ___. On ___ he started feeling unwell with weakness myalgias and throughout his body especially in his shoulders. He then progressed to have cough congestion and rhinorrhea. On ___ ___ he started having diarrhea which improved the day of presentation. He has had no sick contacts. The day prior to presentation he felt so weak that he fell while in the bathroom with unsteadiness on his feet. He had no loss of consciousness or head strike. In the ED initial VS were T 98.1 HR 94 BP 107 50 RR 22 SAT 100 on RA. Labs were notable for K 2.6 that trended to 3.1 then 2.9. Lactate 1.4. WBC 6.7 H H 12.6 35.4 PLT 99. BUN Cr ___. TBILI 1.8 DBILI 0.8. Imaging included chest x ray. Treatments received cefepime 2 gm IV x1 500 mL NS 1L NS with 40 mEq KCl KCl 40 mEq PO x1 Mg 2 gm IV x1 oxycodone 5 mg PO x1 and home medications of venlafaxine acyclovir allopurinol aspirin clonazepam gabapentin omeprazole and sertraline 100 mg. On arrival to the floor the patient reports feeling unwell but slightly improved. He has had no more diarrhea since reaching the ED. He still has whole body weakness. He reports no shortness of breath or chest pain. He has some mild abdominal pain. He makes mention of a red slightly painful lesion at his right lateral malleolus that has been there for 2 weeks. Of note he has been feeling more depressed recently with the divorce having to live with his mother financial stresses and coping with his cancer. He denies any suicidal ideation or prior suicide attempts. He does have access to a gun due to his work as a ___ and he keeps it locked. Past Medical History PAST ONCOLOGIC HISTORY ___ Diagnosed with stage III multiple myeloma treated with Velcade Revlimid and dexamethasone ___ Autologous stem cell transplant ___ Restarted on Revlimid and dexamethasone ___ Completed protocol ___ including pomalidomide dexamethasone and Velcade ___ Represented after being lost to follow up restarted on pomalidomide at 4 mg daily but decreased dose due to cytopenia. Eventually had to complete 4 cycles of Velcade pomalidomide and dexamethasone with good disease control. On pomalidomide maintenance therapy 21 days on 7 days off . PAST MEDICAL HISTORY Multiple myeloma Anxiety Depression Gout History of opioid abuse History of benzodiazepine abuse Social History ___ Family History Son has a history of opioid dependence. Multiple family members with depression and substance abuse. Physical Exam ADMISSION PHYSICAL EXAM VS T 98.0 HR 86 BP 126 80 RR 20 SAT 96 O2 on RA GENERAL Middle aged gentleman lying in bed no acute distress but appears lethargic and ill HEENT PERRL MMM sclerae anicteric no JVD CARDIAC Regular rate and rhythm no murmurs rubs or gallops LUNG Appears in no respiratory distress diffuse wheezing throughout ABD Normal bowel sounds soft nontender nondistended no hepatomegaly no splenomegaly EXT Warm well perfused no lower extremity edema PULSES 2 radial pulses 2 ___ pulses 2 DP pulses NEURO Alert oriented CN II XII intact motor and sensory function grossly intact SKIN Has a 3x3 cm area of erythema on the right lateral malleolus that is mildly painful DISCHARGE PHYSICAL EXAM VS 98.2 132 82 78 18 95 on RA 1200cc UOP GENERAL Middle aged gentleman lying in bed no acute distress HEENT PERRLA MMM sclerae anicteric no JVD CARDIAC RRR no murmurs rubs or gallops LUNG faint bibasilar rhonchi otherwise CTAB normal work of breathing on RA ABD Normal bowel sounds soft nontender nondistended no hepatomegaly no splenomegaly EXT Warm well perfused no lower extremity edema PULSES 2 radial pulses 2 ___ pulses 2 DP pulses NEURO Alert oriented CN II XII intact motor and sensory function grossly intact Pertinent Results ADMISSION LABS ___ 08 22PM ___ PTT 26.9 ___ ___ 08 22PM PLT SMR LOW PLT COUNT 99 ___ 08 22PM NEUTS 66 BANDS 0 ___ MONOS 11 EOS 2 BASOS 1 ___ MYELOS 0 AbsNeut 4.42 AbsLymp 1.34 AbsMono 0.74 AbsEos 0.13 AbsBaso 0.07 ___ 08 22PM WBC 6.7 RBC 3.97 HGB 12.6 HCT 35.4 MCV 89 MCH 31.7 MCHC 35.6 RDW 13.2 RDWSD 43.2 ___ 08 22PM ALBUMIN 3.8 CALCIUM 8.5 PHOSPHATE 2.5 MAGNESIUM 1.7 ___ 08 22PM LIPASE 13 ___ 08 22PM ALT SGPT 18 AST SGOT 20 LD LDH 161 ALK PHOS 72 TOT BILI 1.8 DIR BILI 0.8 INDIR BIL 1.0 ___ 08 22PM estGFR Using this ___ 08 22PM GLUCOSE 112 UREA N 12 CREAT 1.0 SODIUM 136 POTASSIUM 2.6 CHLORIDE 100 TOTAL CO2 22 ANION GAP 17 ___ 08 43PM LACTATE 1.4 ___ 09 40PM OTHER BODY FLUID FluAPCR NEGATIVE FluBPCR NEGATIVE ___ 11 47PM URINE RBC 3 WBC 0 BACTERIA FEW YEAST NONE EPI 1 ___ 11 47PM URINE BLOOD NEG NITRITE NEG PROTEIN TR GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 6.5 LEUK NEG ___ 11 47PM URINE COLOR Yellow APPEAR Clear SP ___ ___ 11 47PM URINE bnzodzpn NEG barbitrt NEG opiates NEG cocaine NEG amphetmn NEG oxycodn NEG mthdone NEG ___ 11 47PM URINE UHOLD HOLD ___ 11 47PM URINE HOURS RANDOM ___ 06 48AM CALCIUM 8.1 PHOSPHATE 2.5 MAGNESIUM 2.3 ___ 06 48AM GLUCOSE 93 UREA N 9 CREAT 0.9 SODIUM 141 POTASSIUM 3.1 CHLORIDE 108 TOTAL CO2 24 ANION GAP 12 ___ 10 25AM CALCIUM 8.6 PHOSPHATE 1.5 MAGNESIUM 2.1 ___ 10 25AM GLUCOSE 152 UREA N 10 CREAT 0.9 SODIUM 140 POTASSIUM 2.9 CHLORIDE 106 TOTAL CO2 25 ANION GAP 12 ___ 11 03AM OTHER BODY FLUID FluAPCR NEGATIVE FluBPCR NEGATIVE ___ 06 45PM PHOSPHATE 2.7 MAGNESIUM 1.9 ___ 06 45PM SODIUM 136 POTASSIUM 3.4 CHLORIDE 104 IMAGING STUDIES ___ 10 09 ___ CHEST PA AND LAT FINDINGS PA and lateral views of the chest provided. A retrocardiac opacity contains a small air bubble likely a small hiatal hernia. Lungs are clear. 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. IMPRESSION No acute intrathoracic process. Small hiatal hernia. ___ CT Chest FINDINGS The thyroid is normal. Supraclavicular axillary mediastinal and hilar lymph nodes are not enlarged though are more prominent than on prior examination measuring up to 1 cm in short axis likely reactive particularly in the peritracheal region. Aorta and pulmonary arteries are normal size. Cardiac configuration is normal. Again seen are aortic valvular and annular calcifications as well as mitral annular calcifications. Coronary calcifications and or stenting is noted. In comparison to the prior examination scattered ___ opacities are seen involving primarily the right middle and lower lobes. There is diffuse bronchial wall thickening with scattered secretions particularly involving the bilateral lower lobes. No large focal consolidation is identified. Limited evaluation of the upper abdomen shows no significant abnormalities. The esophagus is patulous. Bony changes are similar to the prior examination. IMPRESSION 1. Diffuse airways thickening with scattered secretions and ___ opacities primarily involving the right middle and lower lobes are suspicious for bronchopneumia or possibly aspiration in the appropriate clinical context. 2. Otherwise stable examination since priors. DISCHARGE LABS ___ 07 18AM BLOOD WBC 3.7 RBC 3.71 Hgb 11.8 Hct 33.9 MCV 91 MCH 31.8 MCHC 34.8 RDW 12.5 RDWSD 41.1 Plt ___ ___ 07 18AM BLOOD Glucose 85 UreaN 6 Creat 1.0 Na 137 K 4.2 Cl 103 HCO3 25 AnGap 13 ___ 07 18AM BLOOD Calcium 8.7 Phos 3.2 Mg 1.9 MICROBIOLOGY ___ 8 22 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. Time Taken Not Noted Log In Date Time ___ 11 05 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. ___ 11 47 pm URINE FINAL REPORT ___ URINE CULTURE Final ___ NO GROWTH. ___ 6 20 am Rapid Respiratory Viral Screen Culture Source Nasopharyngeal swab. FINAL REPORT ___ Respiratory Viral Culture Final ___ No respiratory viruses isolated. Culture screened for Adenovirus Influenza A B Parainfluenza type 1 2 3 and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen Final ___ Negative for Respiratory Viral Antigen. Specimen screened for Adeno Parainfluenza 1 2 3 Influenza A B and RSV by immunofluorescence. Refer to respiratory viral culture and or Influenza PCR results listed under OTHER tab for further information.. ___ 7 42 pm URINE Source ___. FINAL REPORT ___ Legionella Urinary Antigen Final ___ NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. Reference Range Negative . Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore in infected patients the excretion of antigen in urine may vary. Brief Hospital Course Mr. ___ is a ___ year old gentleman with a past medical history significant for multiple myeloma s p autologous transplant in ___ who presents with weakness malaise cough congestion and diarrhea. Bronchitis patient presented with cough congestion diarrhea and myalgia initially attributed to a viral syndrome. Respiratory viral screen and culture negative x2. Legionella urinary antigen urine culture blood cultures x2 negative. He had no further loose stools to send C. difficile PCR. No oxygen requirement or hypoxia. Placed on nebulizers treatments but given persistence of wheezing and paroxysmal coughing underwent CT chest which showed diffuse airways thickening with scattered secretions and ___ opacities primarily involving the right middle and lower lobes suspicious for bronchopneumonia or possibly aspiration. Started on levofloxacin for a planned 5 day course with daily improvement in symptoms. Remained afebrile throughout admission. Electrolyte disturbances noted hypokalemia 2.6 and hypophosphatemia 3.0 are likely consequences of diarrhea. Improved with aggressive IV and PO potassium and phosphate repletion. Fall prior to arrival mechanical in nature with no prodrome and likely occurred in the setting of dehydration and acute illness. No further episodes following hydration and electrolyte repletion. Physical therapy consulted and recommended continued work with outpatient ___ on discharge. Multiple Myeloma on pomalidomide which was held during acute illness. Chronic anemia and thrombocytopenia were at baseline likely secondary to his multiple myeloma. Continued prophylaxis with Acyclovir 400 mg PO Q8H. He will follow up with Dr. ___ as an outpatient. Depression Anxiety Patient had been feeling more depressed recently due to multiple stressors including financial issues recent divorce losing his house and having to live with his mother and coping with cancer. Denied SI or recent substance abuse. Urine toxicology screen negative. Continued on home Sertraline 200 mg PO DAILY Doxepin HCl 150 mg PO QHS and ClonazePAM 0.5 mg PO TID. Social Work consulted for adjustment for illness. Gout continued on home Allopurinol ___ daily TRANSITIONAL ISSUES f u with PCP and primary oncologist Needed 1 more day of levofloxacin for 5 days total on discharge course ___ to ___ Patient needed home ___ on discharge Medications on Admission The Preadmission Medication list is accurate and complete. 1. Sertraline 200 mg PO DAILY 2. Doxepin HCl 150 mg PO QHS 3. ClonazePAM 0.5 mg PO TID 4. pomalidomide 3 mg oral DAILY 5. Allopurinol ___ mg PO DAILY 6. Acyclovir 400 mg PO Q8H 7. Aspirin 81 mg PO DAILY Discharge Medications 1. Acyclovir 400 mg PO Q8H 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. ClonazePAM 0.5 mg PO TID 5. Doxepin HCl 150 mg PO QHS 6. Sertraline 200 mg PO DAILY 7. Guaifenesin ___ mL PO Q6H PRN cough RX guaifenesin 100 mg 5 mL ___ mL by mouth every six 6 hours Refills 1 8. Acetaminophen 650 mg PO Q6H PRN pain 9. Levofloxacin 750 mg PO DAILY RX levofloxacin 750 mg 1 tablet s by mouth daily Disp 1 Tablet Refills 0 Discharge Disposition Home Discharge Diagnosis Bronchitis bacterial vs. viral Multiple myeloma 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 ___ for evaluation and treatment of your malaise cough and diarrhea. We carefully monitored your hydration and electrolytes and gave you IV fluids and extra potassium and phosphorus to help you maintain your blood levels. We ran several tests and believe your symptoms are most likely related to a viral syndrome. However in the event that there could a bacteria contributing to your symptoms we treated you with an antibiotics levofloxacin for 5 days. It was a pleasure taking care of you during your stay we wish you all the best Your ___ Oncology Team Followup Instructions ___ The icd codes present in this text will be J208, Z9484, C9000, D6959, E8339, R197, E876, D630, M109, Z87891, E860, F329. The descriptions of icd codes J208, Z9484, C9000, D6959, E8339, R197, E876, D630, M109, Z87891, E860, F329 are J208: Acute bronchitis due to other specified organisms; Z9484: Stem cells transplant status; C9000: Multiple myeloma not having achieved remission; D6959: Other secondary thrombocytopenia; E8339: Other disorders of phosphorus metabolism; R197: Diarrhea, unspecified; E876: Hypokalemia; D630: Anemia in neoplastic disease; M109: Gout, unspecified; Z87891: Personal history of nicotine dependence; E860: Dehydration; F329: Major depressive disorder, single episode, unspecified. The common codes which frequently come are M109, Z87891, F329. The uncommon codes mentioned in this dataset are J208, Z9484, C9000, D6959, E8339, R197, E876, D630, E860.
The icd codes present in this text will be C9002, Z9484, R110, F329, M109, J45909, M5414. The descriptions of icd codes C9002, Z9484, R110, F329, M109, J45909, M5414 are C9002: Multiple myeloma in relapse; Z9484: Stem cells transplant status; R110: Nausea; F329: Major depressive disorder, single episode, unspecified; M109: Gout, unspecified; J45909: Unspecified asthma, uncomplicated; M5414: Radiculopathy, thoracic region. The common codes which frequently come are F329, M109, J45909. The uncommon codes mentioned in this dataset are C9002, Z9484, R110, M5414. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Rib back pain Major Surgical or Invasive Procedure None History of Present Illness Mr. ___ is a ___ yo man with a history of substance abuse disorder opioids and benzodiazepines and multiple myeloma Dx ___ s p multiple lines of treatment as described below s p auto SCT ___ currently being treated with Daratumumab and Dexamethasone who is now presenting with pain crisis. The patient was found to have a T7 T8 mass in ___ which is compressing the neural foramen but with no evidence of cord compression. He is receiving T6 T9 radiation therapy for this 2 more sessions last ___. He presented to clinic today with ongoing pain that starts in L ribs and radiates posteriorly and superiorly to his left scapula. He describes this as a sharp stabbing pain. It started ___ but became more severe when he stopped his dexamethasone yesterday ___ . XR T spine on ___ showed no new findings. In clinic he received IV decadron 10 mg IV Zofran 8 mg Tylenol ___ mg and Tramadol 25 mg po with some effect. Pain rated ___ before medications ___ after. He was sent to MRI to evaluate for possible pathologic fracture. Patient notes nausea and early satiety which began around the same time as his pain. He notes 10lbs weight loss over the past week. He denies recent episodes of vomiting. He also notes diaphoresis today but denies subjective fevers or chills. He denies bowel bladder incontinence weakness numbness parasthesias. Past Medical History S P AUTOLOGOUS STEM CELL TRANSPLANT ACUTE RENAL FAILURE AUTO HPC APHERESIS INFUSION GOUT MULTIPLE MYELOMA STEM CELL COLLECTION STUDY ___ THERAPUTIC PLASMAPHERESIS MULTIPLE MYELOMA DEPRESSION ADVANCE CARE PLANNING BACK PAIN Denies h o head injuries or seizure Social History ___ Family History paternal grandmother was institutionalized. Physical Exam ADMISSION Vitals 24 HR Data last updated ___ 1837 Temp 98.3 Tm 98.3 BP 125 84 HR 101 RR 18 O2 sat 98 O2 delivery Ra Wt 169.1 lb 76.7 kg Gen Pleasant calm HEENT No conjunctival pallor. No icterus. MMM. OP clear. NECK JVP not appreciable. Normal carotid upstroke without bruits. BACK Tenderness to palpation T8. Full ROM without pain. LYMPH No cervical or supraclav LAD CV Normocardic regular. Normal S1 S2. No MRG. LUNGS No increased WOB. CTAB. No wheezes crackles or rhonchi. ABD NABS. Tenderness to palpation in LUQ underlying incisions. Soft ND. EXT WWP. No ___ edema. SKIN Well healing incisions over LUQ of abdomen. No rashes lesions petechiae purpura ecchymoses. NEURO A Ox3. Strength LUE ___. RUE 4 5 RLE ___ LLE ___. Sensation intact to light touch. Reflexes 2 and symmetric throughout. Plantar reflex neutral bilaterally. LINES PIV DISCHARGE Gen Pleasant calm HEENT No conjunctival pallor. No icterus. MMM. OP clear. NECK JVP not appreciable. Normal carotid upstroke without bruits. BACK No tenderness to palpation. Full ROM without pain. LYMPH No cervical or supraclav LAD CV Normocardic regular. Normal S1 S2. No MRG. LUNGS No increased WOB. CTAB. No wheezes crackles or rhonchi. ABD NABS. Tenderness to palpation in LUQ underlying well healing incisions. Soft ND. EXT WWP. No ___ edema. SKIN Well healing incisions over LUQ of abdomen. No rashes lesions petechiae purpura ecchymoses. NEURO A Ox3. Strength LUE ___. RUE 4 5 RLE ___ LLE ___. Sensation intact to light touch. Reflexes 2 and symmetric throughout. Plantar reflex neutral bilaterally. LINES PIV Pertinent Results ADMISSION ___ 09 19AM BLOOD WBC 7.2 RBC 4.91 Hgb 16.1 Hct 45.7 MCV 93 MCH 32.8 MCHC 35.2 RDW 13.1 RDWSD 44.8 Plt Ct 80 ___ 09 19AM BLOOD Neuts 83.6 Lymphs 8.4 Monos 6.8 Eos 0.3 Baso 0.1 Im ___ AbsNeut 6.04 AbsLymp 0.61 AbsMono 0.49 AbsEos 0.02 AbsBaso 0.01 ___ 09 19AM BLOOD Plt Ct 80 ___ 05 30AM BLOOD ___ PTT 27.0 ___ ___ 09 19AM BLOOD UreaN 19 Creat 1.2 Na 141 K 4.2 Cl 100 HCO3 28 AnGap 13 ___ 09 19AM BLOOD ALT 18 AST 12 LD LDH 125 AlkPhos 90 TotBili 0.6 ___ 09 19AM BLOOD TotProt 6.4 Calcium 9.2 ___ 05 30AM BLOOD Albumin 4.1 Calcium 9.0 Phos 3.4 Mg 2.0 DISCHARGE ___ 05 30AM BLOOD WBC 5.1 RBC 4.16 Hgb 13.7 Hct 39.6 MCV 95 MCH 32.9 MCHC 34.6 RDW 12.9 RDWSD 44.7 Plt Ct 90 ___ 05 30AM BLOOD Neuts 78.4 Lymphs 13.5 Monos 7.1 Eos 0.0 Baso 0.2 Im ___ AbsNeut 3.96 AbsLymp 0.68 AbsMono 0.36 AbsEos 0.00 AbsBaso 0.01 ___ 05 30AM BLOOD Plt Ct 90 ___ 05 30AM BLOOD ___ PTT 27.0 ___ ___ 05 30AM BLOOD Glucose 122 UreaN 20 Creat 0.9 Na 139 K 4.7 Cl 100 HCO3 29 AnGap 10 ___ 05 30AM BLOOD ALT 26 AST 18 LD LDH 117 AlkPhos 84 TotBili 0.4 Brief Hospital Course Mr. ___ is a ___ yo man with a history of substance abuse disorder opioids and benzodiazepines and multiple myeloma Dx ___ s p multiple lines of treatment as described below s p auto SCT ___ currently being treated with Daratumumab and Dexamethasone who is now presenting with acute pain crisis. Pain Crisis This pain is most likely related to his underlying T7 T8 lesion. He has a history of acute worsening of his pain upon cessation of steroids with this most recent episode of pain worsening after his dexamethasone was tapered. MRI ___ showed stable lesion at T2 T7 T8 and L1 similar to ___ with known T7 lesion ocludes left neural foramina similar to before. No indication for kyphoplasty or other procedures at this point. He was given Dexamethasone 10mg for 2 days with plan to taper for 4mg BID x4 days then 4mg daily x4 days then 2mg daily x4 days then 2mg every other day x4 day. He was also give tramadol 50mg PO q4h PRN and scheduled Tylenol ___ q8h with good pain control. Was seen by chronic pain service who recommended increasing home gabapentin to 400mg TID. Ultimately he was discharged home with good pain control. Nausea Patient s nausea suspected to be ___ to pain. KUB negative for obstruction or ileus. improved with pain control and Zofran. Multiple Myeloma Relapsed IgG Lambda previously treated on pomalidomide maintenance. Switched to Daratumumab Pomalyst and Dexamethasone due to disease progression with good response. Pomalidomide stopped due to possible pulmonary fibrosis. ___ his PET scan continued to show improvement in his disease burden. He received daratumumab Dexamethasone Cycle 6 Day 1 ___. Dose every 4 weeks . His counts remained stable while in house. Depression Substance Use Disorder Patient recently discharged on risperidone however he is no longer taking this. We attempted to obtain records from his outpatient psychiatrist however were not able to while in house. Patient should follow up as outpatient for further management of psychiatric medication management. Pain management as above. TRANSITIONAL ISSUES Patient should taper dexamethasone for 4mg BID for 4 days then 4mg for 4 days then 2mg daily for 4 days then 2mg every other day for 4 days. Continue with gabapentin to 400 mg TID. Per chronic pain service you may increase the dose by 100 mg each dose every 3 to 7 days to a max of 800mg TID. If the patient reports drowsiness or unsteady gait please titrate down the dose by 100 mg each time. Patient was discharged on scheduled Tylenol q8h. Would stop this after acute pain issues to avoid liver toxicity Patient was previously discharged from ___ on risperidone QHS and 0.5mg BID PRN anxiety though has not been taking it at home. Will follow up with psychiatrist ___ to discuss restarting psych med regimen. CODE Presumed Full EMERGENCY CONTACT ___ sister ___ ___ ___ on Admission The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Allopurinol ___ mg PO DAILY 3. Sulfameth Trimethoprim SS 1 TAB PO DAILY 4. Gabapentin 300 mg PO TID 5. Aspirin 81 mg PO DAILY 6. ClonazePAM 0.5 mg PO TID PRN anxiety 7. Qvar RediHaler beclomethasone dipropionate 40 mcg actuation inhalation BID Discharge Medications 1. Dexamethasone 4 mg PO BID Duration 4 Days then 4mg daily x4 days then 2mg daily x4 days then 2mg EOD for 4 days RX dexamethasone 2 mg 2 tablet s by mouth twice daily Disp 30 Tablet Refills 0 2. Famotidine 20 mg PO Q12H gi ppx RX famotidine 20 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 3. Lidocaine 5 Patch 1 PTCH TD DAILY pain RX lidocaine Lidoderm 5 Place 1 patch on back QAM Disp 30 Patch Refills 0 4. Gabapentin 400 mg PO TID back pain RX gabapentin 400 mg 1 capsule s by mouth three times a day Disp 90 Capsule Refills 0 5. Acyclovir 400 mg PO Q12H 6. Allopurinol ___ mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. ClonazePAM 0.5 mg PO TID PRN anxiety 9. Qvar RediHaler beclomethasone dipropionate 40 mcg actuation inhalation BID 10. Sulfameth Trimethoprim SS 1 TAB PO DAILY Discharge Disposition Home Discharge Diagnosis PRIMARY Pain Crisis SECONDARY Multiple Myeloma Narcotic use disorder stable 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 ___ You were here because you were having significant back pain. While you were here you were seen by the pain service who recommended to increase your gabapentin for pain. You also underwent your scheduled radiation therapy. We started you on steroids to help with your pain. When you leave it is important to take your medications as prescribed. It is also important you follow up at the appointments as listed below. If you have any fevers chills arm or leg numbness or tingling bowel or bladder dysfunction or significant worsening of your back pain come back to the ER immediately. We wish you the best of luck Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be C9002, Z9484, R110, F329, M109, J45909, M5414. The descriptions of icd codes C9002, Z9484, R110, F329, M109, J45909, M5414 are C9002: Multiple myeloma in relapse; Z9484: Stem cells transplant status; R110: Nausea; F329: Major depressive disorder, single episode, unspecified; M109: Gout, unspecified; J45909: Unspecified asthma, uncomplicated; M5414: Radiculopathy, thoracic region. The common codes which frequently come are F329, M109, J45909. The uncommon codes mentioned in this dataset are C9002, Z9484, R110, M5414.
The icd codes present in this text will be R4182, J690, J9601, D61818, Z9481, C9002, E222, A09, E873, N179, I951, I4891, Z006, F329, M109, I959, E876, F419, G4700, Y929, T451X1A. The descriptions of icd codes R4182, J690, J9601, D61818, Z9481, C9002, E222, A09, E873, N179, I951, I4891, Z006, F329, M109, I959, E876, F419, G4700, Y929, T451X1A are R4182: Altered mental status, unspecified; J690: Pneumonitis due to inhalation of food and vomit; J9601: Acute respiratory failure with hypoxia; D61818: Other pancytopenia; Z9481: Bone marrow transplant status; C9002: Multiple myeloma in relapse; E222: Syndrome of inappropriate secretion of antidiuretic hormone; A09: Infectious gastroenteritis and colitis, unspecified; E873: Alkalosis; N179: Acute kidney failure, unspecified; I951: Orthostatic hypotension; I4891: Unspecified atrial fibrillation; Z006: Encounter for examination for normal comparison and control in clinical research program; F329: Major depressive disorder, single episode, unspecified; M109: Gout, unspecified; I959: Hypotension, unspecified; E876: Hypokalemia; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; Y929: Unspecified place or not applicable; T451X1A: Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional), initial encounter. The common codes which frequently come are J9601, N179, I4891, F329, M109, F419, G4700, Y929. The uncommon codes mentioned in this dataset are R4182, J690, D61818, Z9481, C9002, E222, A09, E873, I951, Z006, I959, E876, T451X1A. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint nausea vomiting diarrhea Major Surgical or Invasive Procedure Intubated ___ Extubated ___ ___ LP ___ LP ___ Bone marrow biopsy ___ History of Present Illness ___ with h o multiple myeloma c b recent spinal lesions s p radiation with recent initiation of clinical trial drug regimen on ___ ___ ___ and history of opiate withdrawal with recent decrease in outpatient pain medication regimen who presented to the ED on ___ with c o nausea vomiting and diarrhea. Shortly after receiving clinical trial medications patient developed profuse non bloody non bilious vomiting and non bloody diarrhea. Patient called EMS given concern for symptoms when EMS arrived they had difficulty obtaining an SpO2 with the highest recorded level in the ___ with poor waveform. En route to the emergency department patient developed a sharp periumbilical abdominal pain. He otherwise noted subjective chills and dysuria but denied any fever chest pain SOB melena or BRBPR. In the ED Initial Vitals T 98.0 HR 108 BP 96 53 RR 18 SpO2 76 4L NC Exam Mottled skin appears chronically ill RRR no murmur no JVD Decreased breath sounds in LLL no wheezing or crackles Abdomen soft no focal tenderness no rebound or guarding Skin warm and dry Labs WBC 6.4 Hg 13.3 Plt 67 D dimer 1718 Fibrinogen 546 INR 1.4 LDH 656 Uric Acid 10.0 K 3.1 Cr 1.5 baseline 0.9 HCO3 21 AG 20 VBG ___ 7.42 42 Lactate 4.0 VBG 0000 7.58 26 Lactate 1.4 Trop 0.01 AST 50 ALT 79 ALP 100 Tbili 1.5 Imaging CTA CHEST 1. No evidence of pulmonary embolism. 2. Fluid throughout all visualized bowel loops with diffuse bowel wall hyperemia likely reflecting diffuse enteritis likely infectious or inflammatory. No bowel wall thickening. 3. New ground glass opacities within the lower lobes bilaterally compatible with infection. 4. Mild bladder wall thickening anteriorly which should be correlated with urinalysis for evidence of cystitis. 5. Known osseous myeloma lesions are better visualized on prior examinations. Soft tissue within the spinal canal at the level of L3 is re demonstrated but better evaluated on the MR ___ dated ___. 6. Large hiatal hernia. ___ IMAGING PRELIM READS CT ___ WITHOUT CONTRAST No acute intracranial abnormality. CTA ___ The vessels of the circle of ___ and their principal intracranial branches appear normal without stenosis occlusion or aneurysm formation. The dural venous sinuses are patent. CTA NECK There are atherosclerotic calcifications of the bilateral carotid bifurcations without evidence of internal carotid stenosis by NASCET criteria. The vertebral arteries and their major branches appear normal with no evidence of stenosis or occlusion. PERFUSION No evidence of abnormal perfusion. Consults Code Stroke low suspicion for stroke given no evidence large territory infarct bleed on CT and non localizing exam. Recommended MRI Brain w and ___ contrast LP for CSF gram stain culture cell count protein glucose HSV PCR Cryptococcus antigen flow cytometry cytology and CSF Hold.Recommend empiric treatment with meningitic dosing of vanc CTX and acyclovir. Neurology Consult service will follow along. Interventions ___ 22 05 IVF LR 1000 mL ordered ___ 23 49 IV CefePIME 2 g ___ 00 33 IVF LR 1000 mL ordered ___ 00 33 IV Vancomycin 1500 mg ordered Central venous line placed in ED. LP deferred iso thrombocytopenia and agitation. In the unit patient was agitated and attempting to remove clothing screaming at staff for help. He was unable to communicate when asked ROS questions and did not fully participate in examination. Received 5 mg IV Haldol placed on CIWA reinitiated on opiates to minimize risk of withdrawal initiated on IVF administered morphine IV x2 in s o likely withdrawal and ordered for stat TLS labs. Past Medical History Multiple myeloma s p autologous stem cell transplant radiation Orthostatic hypotension Opiate withdrawal w substance use disorder Depression Gout Social History ___ Family History paternal grandmother was institutionalized. Physical Exam ADMISSION PHYSICAL EXAM VS T 99.7 HR 63 BP 134 53 RR 23 SPO2 100 GEN ___ yo M sitting up in bed repeatedly screaming out god help please and trying to get out of bed. EYES Pupils equal round reactive and dilated at 5 mm HENNT Poor dentition CV RRR no M R G RESP No increased work of breathing. Decreased basilar breath sounds. No crackles rhonchi. GI Non distended. Voluntary guarding. Soft with patient unable to communicate if pain to palpation. MSK No peripheral edema. SKIN Petechiae over bilateral legs. NEURO Unable to follow commands. AAOx0 PSYCH Agitated. DISCHARGE PHYSICAL EXAM Vitals 24 HR Data last updated ___ 651 Temp 98.0 Tm 98.3 BP 130 80 102 177 67 102 HR 104 79 113 RR 18 O2 sat 97 96 99 O2 delivery Ra Wt 137.2 lb 62.23 kg Gen sitting up in bed alert and interactive in no acute distress CV regular rhythm tachycardic no m g r LUNGS CTAB breathing comfortably on room air ABD soft nontender nondistended EXT warm and well perfused no ___ edema. NEURO alert grossly oriented ___ strength on ankle dorsiflexion and plantarflexion bilaterally Pertinent Results ADMISSION LABS ___ 09 31PM BLOOD WBC 6.4 RBC 4.23 Hgb 13.3 Hct 38.6 MCV 91 MCH 31.4 MCHC 34.5 RDW 13.2 RDWSD 41.1 Plt Ct 67 ___ 09 31PM BLOOD Neuts 81.9 Lymphs 10.9 Monos 4.1 Eos 0.2 Baso 0.2 Im ___ AbsNeut 5.25 AbsLymp 0.70 AbsMono 0.26 AbsEos 0.01 AbsBaso 0.01 ___ 09 31PM BLOOD ___ PTT 29.0 ___ ___ 09 31PM BLOOD ___ D Dimer 1718 ___ 09 31PM BLOOD Glucose 114 UreaN 19 Creat 1.5 Na 142 K 3.1 Cl 101 HCO3 21 AnGap 20 ___ 09 31PM BLOOD Albumin 4.2 Calcium 9.7 Phos 2.4 Mg 1.9 UricAcd 10.0 ___ 09 31PM BLOOD ALT 50 AST 79 LD LDH 656 AlkPhos 100 TotBili 1.5 ___ 09 31PM BLOOD Lipase 22 ___ 09 31PM BLOOD cTropnT 0.01 ___ 09 31PM BLOOD ASA NEG Acetmnp NEG Tricycl NEG ___ 09 42PM BLOOD ___ pO2 19 pCO2 42 pH 7.42 calTCO2 28 Base XS 1 ___ 09 42PM BLOOD Lactate 4.0 Na 140 K 3.1 PERTINENT LABS MICRO IMAGING ___ 11 19AM BLOOD Osmolal 272 ___ 06 43AM URINE Osmolal 522 ___ 06 43AM URINE Hours RANDOM Na 127 ___ 06 14AM BLOOD Osmolal 269 ___ 03 16PM URINE Osmolal 415 ___ 03 16PM URINE Hours RANDOM Na 146 ___ 12 00PM BLOOD TSH 3.8 ___ 06 35AM BLOOD Cortsol 17.4 ___ 07 07AM BLOOD Cortsol 25.5 ___ 07 44AM BLOOD Cortsol 29.5 ___ 06 35 ACTH FROZEN Test Result Reference Range Units ACTH PLASMA 21 ___ pg mL ___ 12 40PM BLOOD CK MB 3 cTropnT 0.01 ___ 02 49AM BLOOD cTropnT 0.02 ___ 01 57AM BLOOD cTropnT 0.01 ___ 12 00AM BLOOD PEP NO MONOCLO FreeKap 1.0 FreeLam 0.9 Fr K L 1.1 IgG 394 IgA 18 IgM 22 IFE NO MONOCLO ___ 00 00 VitB12 155 Folate 4 ___ 12 07 Osmolal 281 MICRO ___ 10 20 am URINE Source Catheter. URINE CULTURE Final ___ NO GROWTH. ___ 2 41 am BLOOD CULTURE Source Venipuncture. Blood Culture Routine Final ___ NO GROWTH. ___ 2 42 am BLOOD CULTURE Source Venipuncture. Blood Culture Routine Final ___ STAPHYLOCOCCUS COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain Final ___ Reported to and read back by ___. ___ ON ___ AT 0115. GRAM POSITIVE COCCI IN CLUSTERS. ___ 9 29 pm STOOL CONSISTENCY NOT APPLICABLE Source Stool. CDT ADDED ON ___ AT 0035. FECAL CULTURE Final ___ NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE Final ___ NO CAMPYLOBACTER FOUND. OVA PARASITES Final ___ NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O P the Giardia antigen test may enhance detection when organisms are rare. Cryptosporidium Giardia DFA Final ___ NO CRYPTOSPORIDIUM OR GIARDIA SEEN. C. difficile PCR Final ___ NEGATIVE. Reference Range Negative . ___ 12 45 pm BLOOD CULTURE Blood Culture Routine Final ___ NO GROWTH. ___ 11 20 pm BLOOD CULTURE Source Line cvl. Blood Culture Routine Final ___ NO GROWTH. ___ 2 22 pm URINE Source ___. URINE CULTURE Final ___ NO GROWTH. ___ 4 02 pm CATHETER TIP IV Source central line. WOUND CULTURE Final ___ No significant growth. ___ 12 34 am BLOOD CULTURE Source Line right IJ. Blood Culture Routine Final ___ NO GROWTH. ___ 12 34 am BLOOD CULTURE Source Venipuncture. Blood Culture Routine Final ___ NO GROWTH. ___ 9 31 am URINE Source Catheter. URINE CULTURE Final ___ NO GROWTH. ___ 05 14PM CEREBROSPINAL FLUID CSF TNC 99 ___ Polys 73 ___ ___ 05 14PM CEREBROSPINAL FLUID CSF TotProt ___ Glucose 78 ___ 5 14 pm CSF SPINAL FLUID SOURCE LP. GRAM STAIN Final ___ NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE Final ___ NO GROWTH. ___ 04 20PM CEREBROSPINAL FLUID CSF TNC 11 ___ Polys 9 ___ ___ 04 20PM CEREBROSPINAL FLUID CSF TotProt 255 Glucose 108 ___ 4 18 pm CSF SPINAL FLUID Source LP TUBE 3. GRAM STAIN Final ___ NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE Final ___ NO GROWTH. IMAGING CXR ___ No acute cardiopulmonary abnormality. Moderate sized hiatal hernia. CTA ___ AND NECK ___ 1. No acute intracranial abnormality by unenhanced ___ CT. No hemorrhage. 2. No large vessel occlusion. Minimal narrowing left cavernous ICA. Otherwise unremarkable circle of ___. 3. 55 mL volume of elevated MTT primarily left temporal lobe. No evidence of abnormal cerebral blood flow or cerebral blood volume. No evidence of infarct core. 4. Calcified atherosclerotic plaque causes 18 proximal right ICA luminal narrowing by NASCET criteria. Mild narrowing bilateral ECA origins. Otherwise widely patent cervical vertebral and carotid arteries. No left ICA narrowing. 5. Lytic lesions in the right clavicle and humerus unchanged in size previously FDG avid on PET CT from ___ better evaluated on that study. 6. Ground glass opacity in the superior segment left lower lobe better evaluated on same day CTA chest. CTA CHEST AND CT ABDOMEN ___ 1. No evidence of pulmonary embolism. 2. Fluid throughout all visualized bowel loops with diffuse bowel wall hyperemia likely reflecting diffuse enteritis likely infectious or inflammatory. No bowel wall thickening. 3. New ground glass opacities within the lower lobes bilaterally compatible with infection. 4. Mild bladder wall thickening anteriorly which should be correlated with urinalysis for evidence of cystitis. 5. Known osseous myeloma lesions are better visualized on prior examinations. Soft tissue within the spinal canal at the level of L3 is re demonstrated but better evaluated on the MR ___ dated ___. ___. Large hiatal hernia. EEG ___ This continuous ICU monitoring study was abnormal due to 1 attenuation and continuous focal slowing in the left hemisphere indicative of focal cerebral dysfunction. 2 Generalized background slowing suggestive of a mild encephalopathy non specific in etiology however toxic metabolic disturbances infection or medication effect are possible causes. There were no push button events. There were no electrographic seizures or epileptiform discharges. CT ___ WITHOUT CONTRAST ___ 1. No acute intracranial abnormality. 2. Bilateral periventricular and subcortical hypodensities that are most likely related to chronic small vessel ischemia. MR ___ WITHOUT CONTRAST ___ 1. No acute intracranial abnormality. 2. Chronic findings include global parenchymal volume loss and mild changes of chronic white matter microangiopathy. EEG ___ This continuous ICU monitoring study was abnormal due to Near continuous focal slowing in the left temporal and parasagittal regions suggestive of focal cerebral dysfunction. There were no push button events. There were no electrographic seizures or epileptiform discharges. Compared to the previous day there was no significant change. CHEST X RAY ___ Probable mild bronchitis lung bases again noted. Hazy opacity left lung base appears slightly improved. CXR ___ No evidence of pneumonia or pleural effusion. TTE ___ The left atrial volume index is mildly increased. The inferior vena cava diateter is normal. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 57 . There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure PCWP greater than 18mmHg . Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. The aortic arch is mildly dilated. The aortic valve leaflets are mildly thickened. There is mild aortic valve stenosis valve area 1.5 1.9 cm2 . There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION Normal biventricular function. Mildly thickened aortic valve leaflets with mild AS. Mildly thickened mitral valve leaflets with moderate MAC. Trivial MR. ___ ___ 1. No acute intracranial abnormality. Please note MRI of the brain is more sensitive for the detection of acute infarct. 2. Atrophy probable small vessel ischemic changes and atherosclerotic vascular disease as described. EEG ___ This is an abnormal ICU EEG study because of diffuse slowing of background with periods of diffuse voltage attenuation indicative of moderate severe encephalopathy which is nonspecific as to etiology. Frontal rhythmic delta activity is a nonspecific finding that can be seen with diffuse encephalopathies as well as structural disorders involving deep midline structure or increased intracranial pressure. There are no epileptiform discharges or electrographic changes. CTA ___ ___ 1. No evidence of mass hemorrhage or infarction. 2. The major arteries the ___ and neck are patent. 3. Partially imaged left lower lobe collapse. Difficult to exclude pneumonia in the appropriate clinical setting. Please see report for subsequent chest radiograph dated ___. EEG ___ This is an abnormal ICU EEG study because of diffuse slowing of the background indicative of mild moderate encephalopathy which is nonspecific as to etiology. Frontal rhythmic delta activity is a nonspecific finding that can be seen with diffuse encephalopathies as well as structural disorders involving deep midline structure or increased intracranial pressure. There are no epileptiform discharges or electrographic changes. Compared to the prior day s recording there is improvement in background. MR ___ contrast ___ No acute infarction or evidence of other acute intracranial abnormalities. EEG ___ This is an abnormal ICU EEG study because of diffuse slowing of background indicative of mild moderate encephalopathy which is nonspecific as to etiology. Frontal rhythmic delta activity is a nonspecific finding that can be seen with diffuse encephalopathies as well as structural disorders involving deep midline structure or increased intracranial pressure. There are no epileptiform discharges or electrographic changes. Compared to the prior day s recording there is no significant change. MR ___ and ___ contrast ___ 1. Multiple T2 hyperintense T1 hypointense enhancing lesions throughout the thoracic and lumbar ___ are consistent with clinical history of multiple myeloma. Dominant lesion in the L3 vertebral body has slightly decreased in size compared to prior exam with resolution of the soft tissue component. 2. Subtle enhancement of the cauda equina nerve roots on the left at the level of L2 are new compared to prior exam concerning for leptomeningeal metastatic infiltration. 3. Multilevel degenerative disc disease in the cervical ___ most pronounced at C4 C5 with moderate spinal canal narrowing. 4. Multilevel degenerative disc disease in the lumbar ___ most pronounced at L3 L4 with moderate spinal canal narrowing and moderate right spinal canal narrowing. 5. Small bilateral pleural effusions with consolidations in the dependent portions of the lungs are consistent with worsening pleural parenchymal disease. CXR ___ Comparison to ___. Resolution of a pre existing left pleural effusion. Stable normal size of the cardiac silhouette. No pulmonary edema no pneumonia no pleural effusions. Stable correct position of a right internal jugular vein catheter. A previous left lower lobe consolidation is still visualized. The consolidation shows air inclusion and could correspond to the hiatal hernia documented on the CT examination from ___. No pleural effusions. No pulmonary edema. MRI ___ w and ___ contrast ___ 1. Multiple T2 hyperintense T1 hypointense enhancing lesions throughout the lumbar ___ are consistent with clinical history of multiple myeloma similar compared to prior exam. 2. Increasing subtle enhancement of the cauda equina nerve roots are concerning for worsening leptomeningeal metastatic infiltration. 3. Moderate to severe spinal canal narrowing at L3 L4 appears minimally progressed. DISCHARGE LABS ___ CBC 2.4 10.3 30.4 93 ANC 1.26 ___ Coags ___ 11.0 PTT 31.2 INR 1.0 ___ BMP 136 3.9 ___ ___ 109 Ca 9.0 Phos 4.1 Mg 2.0 ___ LFTs ALT 15 AST 10 AlkP 82 tBili 0.6 Brief Hospital Course PATIENT SUMMARY ___ with history of multiple myeloma c b recent spinal lesions s p radiation with recent initiation of Ninlaro ___ held on admission also with history of opiate benzo use and withdrawal who presented to the ED on ___ with c o nausea vomiting diarrhea AMS with aphasia in the setting of taking an extra dose of Ninlaro. Stroke workup and EEG negative treated empirically for meningoencephalitis and mental status back to baseline within 24 hours though also in setting of holding sedating meds . Course c b persistent thrombocytopenia refractory to transfusion persistent pain requiring narcotics orthostatic hypotension on midodrine and hyponatremia. Patient had unresponsive hypoxic hypotensive episode on ___ required intubation and transfer to the ICU with ICU course c b intermittent hypotensive unresponsive episodes Afib with RVR and agitation. Stabilized and transferred back to the floor with ongoing severe orthostasis and pain now under better control. Also found to have possible leptomeningeal involvement on MRI ___ discharged on dexamethasone. ACUTE ISSUES AMS Aphasia Per daughter patient had been intermittently confused since ___. Patient then developed acute change in mental status in ED with inability to follow commands and word finding difficulties word salad. Given concern for stroke code stroke called. NIHSS 4. No evidence of hemorrhage or large territory infarct on ___. No new abnormalities noted on MRI and CTA ___ without significant stenosis. Neuro with low suspicion for stroke as exam did not localize to a particular vascular territory. EEG showed no epileptiform activity. He was started on empiric treatment for meningoencephalitis with vanc ceftriaxone acyclovir ampicillin while awaiting LP. Unfortunately LP could not initially be done due to thrombocytopenia that did not improve with transfusions. Antibiotics were discontinued on ___ after about 5 days of treatment given low suspicion for infection. Unclear what caused the acute change in mental status word finding difficulties. Potentially related to the Ninlaro as patient reports taking two pills instead of one however nothing like this has been reported in the literature. He was monitored off antibiotics. LP was able to be done later in hospital course which was negative for infection. He did have further episodes of AMS unresponsiveness during hospitalization see below which subsequently improved. Unresponsive episodes Hypotension Fever Starting on ___ patient had numerous unresponsive episodes. During these he did not respond to voice or sternal rub SBP was low in 60 80s and HRs were high normal. Basic labs were checked and no clear etiology was found. There was no evidence of infection. Differential diagnosis included primary neurologic process such as autonomic dysreflexia secondary to spinal radiation vs. multiple myeloma meningeal involvement vs. metastasis to the ___. These episodes were felt to be less likely due to drug overdose as narcan did not help though could have still been benzo OD given he was found to have pill bottle in his room earlier in his course. During the first episode the patient was intubated due to agonal breathing and transferred to the ICU. He was then extubated and continued to have unresponsive episodes. EEG showed no seizures. MRI showed no acute infarcts or evidence of prior. Infectious workup was unremarkable. LP done by ___ on ___ was traumatic but unrevealing. He was then transferred back to the floors. Repeat LP by Dr. ___ ___ showed no evidence of myeloma though repeat MRI ___ showed increasing enhancement around the cauda equina concerning for leptomeningeal involvement and he was started on dexamethasone. Overall etiology of these episodes is still unclear at this point though the thought is that there is an element of autonomic dysfunction secondary to prior myeloma treatment and now possibly and element of leptomeningeal involvement. Orthostatic hypotension On ___ patient noted to be hypotensive to SBP 99 from SBP 140s a few hours earlier and on manual repeat SBP 80. HR ___ no hypoxia asymptomatic. Positive orthostatic vitals. Orthostasis did not improve with IVF so unlikely due to hypovolemia. Sepsis workup negative. No medications on list that lead to hypotension. ___ stim negative for adrenal insufficiency. Likely due to autonomic dysfunction in the setting of Velcade Ninlaro treatment. Started on midodrine 5mg TID which was downtitrated to 2.5mg BID given supine hypertension. Multiple myeloma Pancytopenia Pt with relapsed multiple myeloma diagnosed in ___ c b ___ lesions s p radiation. Recent ___ PET CT c f disease progression with decision to move forward with triple therapy with ninlaro dexamethasone and revlimid as part of a clinical trial at ___ in the s o multiple failed prior treatments. Received first dose of Ninlaro at 8mg initial starting dose usually 4 mg on ___ with plan to initiate revlimid if well tolerated at a later date. He reported taking an extra dose of Ninlaro prior to admission. He was noted to have worsening pancytopenia especially thrombocytopenia which was though to be due to the Ninlaro. Thrombocytopenia was minimally responsive to transfusions and IVIG hydrocortisone also had minimal effect. Counts uptrended and plateaued. Bone marrow biopsy done ___ which showed no disease. LP was also done on ___ due to c f leptomeningeal involvement on MRI ___ and this also showed no evidence of myeloma on cytology specimen inadequate for flow . However MRI ___ did show enhancement of cauda equina which was thought to more likely represent leptomeningeal involvement though could be arachnoiditis due to radiation. He was started on dexamethasone and will follow up with Dr. ___ Dr. ___ for further workup. He was seen by radiation oncology and they did not feel that he was a candidate for further radiation should this represent disease. DOE improved Patient complaining of increased SOB on exertion since hospitalization. Lungs clear no peripheral edema. TTE done earlier in the hospitalization without any e o heart failure. Consider deconditioning vs. symptomatic anemia vs. cardiopulm etiology. Improved after pRBC transfusion. Continued to work with ___ while inpatient. Afib with RVR resolved Symptomatic AFib with RVR in the ICU without a known history although prior EKGs have shown frequent ectopy with PVCs and PACs. Unclear trigger without obvious signs of infection or ACS. There was concern for autonomic dysfunction and any adrenergic stimuli could be responsible. Reverted to sinus on diltiazem. Remained in NSR off nodal agents. Hyponatremia resolved Na noted to be 130 had downtrended daily asymptomatic. Serum osm 269 with urine osm and urine Na elevated which would be consistent with SIADH picture. Had been on IVF and received boluses so less likely hypovolemic hyponatremia. No renal failure diuretic use peripheral edema or ascites. ___ stim and TSH wnl. Placed on fluid restriction 1200cc. After he returned to the floor from the ICU fluid restriction lifted and Na remained within normal range. Diarrhea resolved Enteritis Hypokalemia CT scan with diffuse bowel wall hyperemia. Likely infectious vs. inflammatory in the setting of recent medication introduction. C.Diff negative and stool cultures negative. Symptomatic treatment with loperamide. Also may be element of opioid withdrawal. Resolved about a week into hospitalization. CHRONIC ISSUES Chronic pain Opiate use Benzodiazepine use Patient on significant opiate regimen oxycodone morphine as outpatient with recent decrease in opiate dosing oxycodone 10 mg TID to 5 mg TID on ___ and history of withdrawal in the past per daughter. On initial exam patient with pupillary dilation and recent complaints of diarrhea concerning for possible withdrawal. Patient also on significant benzodiazepine regimen as outpatient with patient completing medications prior to end of prescription in recent past per family members. During this hospitalization found to have empty Klonapin bottle and bottle with 2 pills of ambien. Reports he last took pills 2 days prior to being found. He continued to report severe pain while on oxycodone 10mg TID so his regimen was changed to oxycodone 15mg q4h prn which he was taking consistently. Klonapin was decreased from 1mg TID to BID. Pain management intermittently followed and then palliative care came on board to help optimize pain regimen. He was ultimately discharged on oxycontin 20mg q12h oxycodone 5 mg PO q4h prn BTP gabapentin 800mg 800mg 1200mg cymbalta 40mg. He was also discharged on dexamethasone for presumed cord irritation symptoms. Insomnia Anxiety Agitation Patient with hx of anxiety and insomnia multiple prior psych admissions most recently ___ who is now complaining of worsening insomnia and anxiety. Normally takes Ambien and Klonapin 1mg TID at home. Tried on various regimens inpatient including ramelteon zyprexa and trazodone. Tried ambien however patient had episode of sleepwalking where he felt like he was in a dream. Required Haldol for agitation in the ICU. Was placed on Olanzapine standing and PRN with some improvement in mood and agitation which was d c ed when the above changes were made to regimen. Psychiatry was briefly involved in medication management. TRANSITIONAL ISSUES Discharged on dexamethasone 4mg PO q8h. Up or down titrate as appropriate. Will require follow up with Dr. ___ further workup treatment of possible leptomeningeal involvement on MRI. Follow up orthostatic hypotension autonomic dysfunction. Can consider up titrating midodrine currently on 2.5mg BID however be mindful of supine hypertension. Can also consider addition of fludrocort. Would likely benefit from ___ clinic follow up. Given frequent PVCs PACs and episode of Afib in the ICU may consider outpatient Holter monitor. Would benefit from follow up with palliative care for help with analgesic management given history of opioid use disorder and chronic pain. The ___ care team ___ MD is currently working on scheduling this appointment. Patient qualifies for home ___ and OT per inpatient team recs. CODE Full 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. OxyCODONE Immediate Release 5 mg PO TID 2. Doxepin HCl 100 mg PO HS 3. ClonazePAM 1 mg PO TID 4. Morphine SR MS ___ 60 mg PO Q12H 5. Zolpidem Tartrate 12.5 mg PO QHS 6. Promethazine 25 mg PO Q6H PRN Discharge Medications 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet s by mouth every eight 8 hours Disp 84 Tablet Refills 0 2. Acyclovir 400 mg PO Q12H RX acyclovir 400 mg 1 tablet s by mouth every twelve 12 hours Disp 60 Tablet Refills 0 3. Atovaquone Suspension 1500 mg PO DAILY RX atovaquone 750 mg 5 mL 1500 mg by mouth daily Refills 0 4. Bengay Cream 1 Appl TP BID PRN knee pain RX menthol Bengay Cold Therapy 5 Apply to painful areas twice a day Refills 0 5. Cyanocobalamin 1000 mcg PO DAILY RX cyanocobalamin vitamin B 12 1 000 mcg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 6. Dexamethasone 4 mg PO Q8H RX dexamethasone 4 mg 1 tablet s by mouth every eight hours Disp 90 Tablet Refills 0 7. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 8. DULoxetine 40 mg PO DAILY RX duloxetine 40 mg 1 capsule s by mouth daily Disp 30 Capsule Refills 0 9. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 10. Gabapentin ___ mg PO TID Please take 800mg at 8am 800mg at 3pm and 1200mg at 11pm. RX gabapentin 800 mg ___ tablet s by mouth three times a day Disp 105 Tablet Refills 0 11. Midodrine 2.5 mg PO BID Please check BP in AM. If SBP 150 please hold both daily doses and recheck the next morning. RX midodrine 2.5 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 12. OxyCODONE SR OxyconTIN 20 mg PO Q12H RX oxycodone 20 mg 1 tablet s by mouth every twelve 12 hours Disp 14 Tablet Refills 0 13. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line RX polyethylene glycol 3350 17 gram 1 powder s by mouth daily Disp 30 Packet Refills 0 14. Senna 8.6 mg PO BID RX sennosides senna 8.6 mg 1 tablet by mouth twice a day Disp 60 Tablet Refills 0 15. ClonazePAM 1 mg PO BID RX clonazepam 1 mg 1 tablet s by mouth twice a day Disp 14 Tablet Refills 0 16. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth every four hours Disp 20 Tablet Refills 0 17. Promethazine 25 mg PO Q6H PRN RX promethazine 25 mg 1 tablet by mouth every six 6 hours Disp 20 Tablet Refills 0 18. HELD Doxepin HCl 100 mg PO HS This medication was held. Do not restart Doxepin HCl until you speak with your doctor. 19. HELD Morphine SR MS ___ 60 mg PO Q12H This medication was held. Do not restart Morphine SR MS ___ until you speak with your doctor. 20. HELD Zolpidem Tartrate 12.5 mg PO QHS This medication was held. Do not restart Zolpidem Tartrate until you speak with your doctor. Discharge Disposition Home Discharge Diagnosis PRIMARY Altered mental status aphasia Unresponsive episodes Orthostatic hypotension SECONDARY Multiple myeloma Pancytopenia Chronic pain neuropathic pain Atrial fibrillation Agitation Hyponatremia Diarrhea 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 ___. WHY WAS I ADMITTED TO THE HOSPITAL You were admitted to the hospital because you were vomiting and having diarrhea and you were feeling more confused. You were initially admitted to the ICU then transferred to the floor once you were feeling better. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL In the emergency room you were unable to speak normally. Imaging of your ___ was done which did not show any stroke. You also had an EEG which did not show any seizures. You were given antibiotics to treat a possible infection. No infectious cause of your diarrhea was found. It was probably due to the extra chemotherapy medication that you took. Your diarrhea improved. Your platelets became low so you were given a few platelet transfusions as well as some medications to try to increase your platelets. You were seen by the psychiatry team to help manage medications for your insomnia. You were also seen by the pain management team to help manage your pain and you were started on gabapentin. You were later seen by palliative care who optimized your pain regimen. You had frequent episodes of low blood pressure mostly upon sitting or standing so you were started on a medication midodrine to help with this. You had an episode where you became unresponsive and your oxygenation level was low so you were intubated and transferred back to the ICU. In the ICU you continued to have a few episodes where your blood pressure dropped. You also were noted to have an irregular and fast heart rhythm which resolved with medications. You had a lumbar puncture and bone marrow biopsy which did not show myeloma in the spinal fluid or bone marrow. However you had an MRI of your ___ which showed findings that could be consistent with myeloma of the ___. You were then started on steroids and you will need to follow up with Dr. ___ Dr. ___ for further workup. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL Continue to take all of your medications as prescribed. Have your sister check your BP every morning. If the systolic BP is greater than 150 hold your midodrine doses for that day. Please attend all ___ clinic appointments. The inpatient physical and occupational therapy teams evaluated you and you qualify for home physical therapy ___ and occupational therapy OT which can be set up. If you develop sudden weakness in your legs worsening numbness tingling or you feel you cannot control your urination or defecation please immediately go to the ED. We wish you all the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be R4182, J690, J9601, D61818, Z9481, C9002, E222, A09, E873, N179, I951, I4891, Z006, F329, M109, I959, E876, F419, G4700, Y929, T451X1A. The descriptions of icd codes R4182, J690, J9601, D61818, Z9481, C9002, E222, A09, E873, N179, I951, I4891, Z006, F329, M109, I959, E876, F419, G4700, Y929, T451X1A are R4182: Altered mental status, unspecified; J690: Pneumonitis due to inhalation of food and vomit; J9601: Acute respiratory failure with hypoxia; D61818: Other pancytopenia; Z9481: Bone marrow transplant status; C9002: Multiple myeloma in relapse; E222: Syndrome of inappropriate secretion of antidiuretic hormone; A09: Infectious gastroenteritis and colitis, unspecified; E873: Alkalosis; N179: Acute kidney failure, unspecified; I951: Orthostatic hypotension; I4891: Unspecified atrial fibrillation; Z006: Encounter for examination for normal comparison and control in clinical research program; F329: Major depressive disorder, single episode, unspecified; M109: Gout, unspecified; I959: Hypotension, unspecified; E876: Hypokalemia; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; Y929: Unspecified place or not applicable; T451X1A: Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional), initial encounter. The common codes which frequently come are J9601, N179, I4891, F329, M109, F419, G4700, Y929. The uncommon codes mentioned in this dataset are R4182, J690, D61818, Z9481, C9002, E222, A09, E873, I951, Z006, I959, E876, T451X1A.
The icd codes present in this text will be J189, C9000, Z9484, J45909, I4891, F419, E876, F329, Z87891, F1511, R0602, I951, C44529. The descriptions of icd codes J189, C9000, Z9484, J45909, I4891, F419, E876, F329, Z87891, F1511, R0602, I951, C44529 are J189: Pneumonia, unspecified organism; C9000: Multiple myeloma not having achieved remission; Z9484: Stem cells transplant status; J45909: Unspecified asthma, uncomplicated; I4891: Unspecified atrial fibrillation; F419: Anxiety disorder, unspecified; E876: Hypokalemia; F329: Major depressive disorder, single episode, unspecified; Z87891: Personal history of nicotine dependence; F1511: Other stimulant abuse, in remission; R0602: Shortness of breath; I951: Orthostatic hypotension; C44529: Squamous cell carcinoma of skin of other part of trunk. The common codes which frequently come are J45909, I4891, F419, F329, Z87891. The uncommon codes mentioned in this dataset are J189, C9000, Z9484, E876, F1511, R0602, I951, C44529. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Shortness of breath Major Surgical or Invasive Procedure None History of Present Illness Pt reports that he has had episodic shortness of breath x several months which has worsened significantly over the last week. He noted that it occurs both at rest and with exertion. Noted that it causes him to breathe deeply quickly and improves with rest. For example he noted that he gets SOB after the third step in a staircase but is able to make it to the top with great difficulty and will need to rest for 15 at the top of the stairs before trying to walk again. This week he felt so SOB in ___ he had to have ___ employee bring a chair for him to sit on. He noted that episodes wake him up at night but ___ does not awake gasping for air. Pt reports that he has more episodes of shortness of breath than asymptomatic periods. He noted that symptoms became persistent in the 2 days prior to admission so he presented here. Noted that symptoms have improved since being in the ED. He denies any new allergens at home. Noted that he is without recent travel. Denied fevers cough sore throat rhinorrhea rash sick contacts. Denied chest pain palpitations lightheadedness In the ED initial vitals 97.9 ___ 16 96 RA. However he was noted to desaturate with ambulation. Coags wnl WBC 2.7 Hgb 10.5 plt 80 BNP ___ Uric Acid 7.4 LFTs wnl CHEM w Cr of 1.1 K 3.0 HCO3 20 lactate 3.2 decreased to 1.8 on repeat Trop 0.01 Flu negative. CXR There has been interval development of a right small pleural effusion and patchy opacity at the right base since the prior study. There is no overt pulmonary edema or pneumothoraces. Heart size is within normal limits. Initial EKG AFib w RVR prolonged QT interval 517 no STEMI. Repeat EKG Sinus prolonged QTC 487 no STEMI Patient was given NS CTX Azithromycin Metoprolol and admitted for further care. Past Medical History ONCOLOGIC TREATMENT HISTORY Per primary hemoncologist Dr. ___ Diagnosed with multiple myeloma in acute renal failure in ___. He was found to be anemic with a hemoglobin of 7 to 9.9 with splenomegaly seen on CT of the abdomen. Bone marrow biopsy and aspirate on ___ showed that CD138 positive cells replaced 90 of his marrow with abnormal plasma cells seen. Cytogenetics showed a normal male karyotype and skeletal survey done on ___ showed degenerative disease in the cervical and lumbar spine and a question of a ___ versus a lytic lesion in the frontal skull. He had an elevated serum free lambda of 1140 mg L beta 2 of 10 IgG of 2.3 g dL calcium of 10.1 creatinine of 1.18 and albumin of 3.6. However over the span of ___ weeks he developed renal failure and ultimately was admitted for plasmapheresis and Velcade. TREATMENT HISTORY ___ Cycle 1 Plasmapheresis Velcade Cycle 2 Velcade Dexamethasone severe neuropathy Cycle 3 5 Revlimid Dexamethasone ___ High Dose Cytoxan for Mobilization ___ Autologous Stem cell Transplant Treated on Protocol ___ vaccination with DC Tumor fusion vaccine in patients with multiple myeloma ___ Completed ___ fusion vaccines ___ Found modest rise in paraprotein. Started on Revlimid but tolerated poorly due to nausea and loose stools and ultimately stopped in ___. Slow rising paraprotien over the following year ___ Started on Protocol ___ A Phase I multicenter open label dose escalation to determine the maximum tolerated dose for the combination of Pomalidamide Velcade and low dose dexamethasone in subject with relapsed or refractory multiple myeloma. Lost to follow up for one year re presented in ___ with a rising light chain. M protein was found to be 780 with a max of 1110 and a free light chain of 270. His free lambda did rise to as high as 447 in ___ prior to initiating treatment. ___ Placed back on pomalidomide at 4 mg daily decreased to 2mg due to cytopenias. ___ Found to have a small rise in his light chain and SPEP revealed a monoclonal protein of 910 and a free light chain of 293. Reinitiated treatment with Velcade and dexamethasone and increased the pomalidomide to 3 mg daily. Received four cycles of Velcade pomalidomide and dexamethasone with great disease control then placed on pomalidomide maintenance for close to ___ years. Dose was decreased from 3mg to 2mg ___ due to fatigue and nausea. ___ Presented with right sacral pain unrelieved by Tylenol. Pelvic and lumbar sacral MRI obtained. Clear progression of disease including L3 and L5 lesions. ___ Daratumumab added to current pomalidomide treatment. Treatment plan Daratumumab 16 mg kg weekly for 8 weeks Pomalidomide 2 mg p.o. daily for 21 out of 28 days will increase to 3 mg next cycle Dexamethasone 20 mg p.o. day of and day following Daratumumab ___ Week 2 ___ ___ Week 3 ___ ___ Week 4 ___ ___ Week 5 ___ ___ Week 6 ___ ___ Week 7 ___ ___ Week 8 ___ Dexamethasone decreased to 10 mg on day of ___ and ___ 4 mg on following 2 days ___ Treatment held and admitted for respiratory work up ___ Started Daratumumab Dexamethasone alone ___ T7 T8 lesions. RT therapy started ___ Retuned to Daratumumab Monthly ___ Pet shows progression of disease. RT to L spine and femur ___ started Ninlaro Dex but accidently took two Ninlaro pills in two subsequent days. Admitted for MS changes. ___ PET CT shows interval resolution uptake in the bones now demonstrating background uptake. No new suspicious uptake. ___ 2. Mild uptake along the thoracic esophagus likely representing mild esophagitis secondary to hiatal hernia. Problems Last Verified ___ by ___ S P AUTOLOGOUS STEM CELL TRANSPLANT ACUTE RENAL FAILURE AUTO HPC APHERESIS INFUSION GOUT MULTIPLE MYELOMA STEM CELL COLLECTION STUDY ___ THERAPUTIC PLASMAPHERESIS MULTIPLE MYELOMA DEPRESSION ADVANCE CARE PLANNING BACK PAIN ASTHMA NARCOTICS AGREEMENT DYSPNEA Social History ___ Family History paternal grandmother was institutionalized. Physical Exam ADMISSION PHYSICAL Vitals ___ Temp 97.5 PO BP 166 87 R Lying HR 71 RR 18 O2 sat 98 O2 delivery RA GENERAL laying in bed smiling comfortable NAD EYES PERRLA anicteric HEENT OP clear MMM NECK supple normal ROM LUNGS CTA b l no wheezes rales rhonchi normal RR no increased WOB at rest but became dyspneic while ambulating in hallway recovered within 5 minutes auscultation unchanged at that point CV RRR no murmur normal distal perfusion no peripheral edema ABD soft NT ND normoactive BS GENITOURINARY no foley or suprapubic tenderness EXT warm no deformity normal muscle bulk no peripheral edema SKIN warm dry no rash NEURO AOx3 fluent speech ACCESS PIV DISCHARGE PHYSICAL see flow sheet of vitals GEN A Ox3 resting in bed in no acute distress cooperative with exam. HEENT MMM no OP lesions no cervical supraclavicular or axillary lymphadenopathy. CV RR S1 S2 appreciated no S3 S4 no MRG PULM Lungs CTAB. No adventitious LS. Respirations are even non labored. ABD BS x4 quadrants soft NT ND no masses or hepatosplenomegaly MUSC No edema BLE are equal in size no erythema or tenderness on palpation of RLE. Negative ___ sign. SKIN No rashes or lesions skin warm and dry. ACCESS Dressing CDI. Pertinent Results ADMISSION LABS Reviewed ___ 11 40AM BLOOD WBC 2.7 RBC 3.21 Hgb 10.5 Hct 31.7 MCV 99 MCH 32.7 MCHC 33.1 RDW 15.5 RDWSD 54.8 Plt Ct 80 ___ 11 40AM BLOOD Glucose 190 UreaN 14 Creat 1.1 Na 145 K 3.0 Cl 106 HCO3 20 AnGap 19 ___ 11 40AM BLOOD ALT 8 AST 16 LD LDH 216 AlkPhos 74 TotBili 0.8 ___ 11 40AM BLOOD TotProt 6.2 Albumin 4.2 Globuln 2.0 Calcium 8.6 Phos 3.4 Mg 1.7 UricAcd 7.4 Iron Pending MICROBIOLOGY Reviewed Blood Cx pending STUDIES Reviewed CXR There has been interval development of a right small pleural effusion and patchy opacity at the right base since the prior study. There is no overt pulmonary edema or pneumothoraces. Heart size is within normal limits. Initial EKG AFib w RVR prolonged QT interval 517 no STEMI. Repeat EKG Sinus prolonged QTC 487 no STEMI echo ___ IMPRESSION Normal left ventricular wall thickness and biventricular cavity sizes and regional global biventricular systolic function. No right to left intracardiac shunt at rest. Mild pulmonary artery systolic hypertension. Compared with the prior TTE images reviewed of ___ the severity of tricuspid regurgitation is now decreased. ___ CT chest IMPRESSION Stable bilateral pleural effusions right greater than left. Bibasilar atelectasis. Subsegmental atelectasis in the right lower lobe. No new consolidations concerning for pneumonia. ___ CTA 1. No evidence of pulmonary embolism or acute aortic abnormality. 2. Interval increase in size of a moderate sized right pleural effusion and a new small left pleural effusion with adjacent compressive atelectasis. 3. No focal consolidation to suggest pneumonia. 4. Similar diffuse moderate bronchial wall thickening consistent with small airway inflammation. 5. Stable moderate sized hiatal hernia and patulous esophagus. 6. Subtle sclerotic region at the left humeral head in keeping with known history of multiple myeloma better assessed on prior FDG PET CT from ___. ___ 06 10AM BLOOD WBC 2.5 RBC 2.78 Hgb 8.9 Hct 27.0 MCV 97 MCH 32.0 MCHC 33.0 RDW 14.8 RDWSD 51.8 Plt Ct 72 ___ 06 10AM BLOOD Neuts 55.3 ___ Monos 13.7 Eos 2.0 Baso 0.4 Im ___ AbsNeut 1.37 AbsLymp 0.69 AbsMono 0.34 AbsEos 0.05 AbsBaso 0.01 ___ 06 10AM BLOOD Glucose 92 UreaN 8 Creat 0.8 Na 147 K 3.6 Cl 108 HCO3 24 AnGap 15 ___ 06 10AM BLOOD ALT 6 AST 13 LD LDH 215 AlkPhos 58 TotBili 0.6 ___ 06 10AM BLOOD Calcium 8.8 Phos 4.0 Mg 1. SSESSMENT PLAN ___ PMh of AFib MM in partial response not currently on treatment Prior substance abuse Anxiety Depression presented to ED with shortness of breath Shortness of breath Symptoms have been ongoing for months but are now worse. Etiology remains unclear despite extensive workup in past which included PFTs decreased DLCO suggestive perfusion deficit but CTA normal at the time STRESS ECHO no ischemia though was suboptimal study Repeat TTE mod TR borderline pHTN . AFib was considered as cause but patient has been dyspneic while in sinus rhythm. Exaggerated response to allergen considered but patient denied new exposures. RAD does not appear to be cause as no wheezing with ambulation and no improvement with albuterol inhaler. On this admission patient with question of pneumonia which is a possible cause of worsening dyspnea but does not explain his baseline dysfunction. That said is worthwhile to treat. BNP was also elevated but patient is without JVP or lower extremity pulm edema. CTA without PE. No PNA on CT. Echo with Initially started CTX Doxycycline for empiric pneumonia treatment Azithro contraindicated with his prolonged QTC . No PNA on CT and deescalated to just doxycycline. RVP pending. Duonebs q6h prn Continuous O2 monitoring Repeat TEE improved EF 57 improved severity of MVR encouraged to follow up with pulmonary and cardiology as outpatient. Prolonged QTC Avoid QTC proloning meds MM In partial response not currently on treatment F u light chains Continue pred acyclovir Care per outpatient team. AFib RVR in ED now in sinus Continue metoprolol Off A C given ongoing thrombocytopenia will order for ppx dosing lovenox and trend platelets daily hold for count 50K PLts now 77 can resume epixaban upon discharge. Hypokalemia Replete PO as needed Anxiety Depression Euthymic but noted that his living situation stresses him out and likely potentiates his SOB Continue home escitalopram gabapentin klonopin Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Escitalopram Oxalate 20 mg PO DAILY 3. Albuterol Inhaler 2 PUFF IH Q6H PRN SOB 4. Vitamin D3 cholecalciferol vitamin D3 2 000 unit oral DAILY 5. ClonazePAM 1 mg PO QID anxiety 6. Fludrocortisone Acetate 0.2 mg PO DAILY 7. Gabapentin 900 mg PO QHS 8. Gabapentin 600 mg PO BID 9. Cyanocobalamin 1000 mcg PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY 11. Midodrine 2.5 mg PO BID orthostasis 12. Midodrine 5 mg PO DAILY 13. Acetaminophen 325 650 mg PO Q4H PRN Pain Mild 14. Omeprazole 40 mg PO DAILY 15. PredniSONE 7.5 mg PO DAILY 16. FoLIC Acid 1 mg PO DAILY 17. Multivitamins W minerals 1 TAB PO DAILY 18. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose 19. Zolpidem Tartrate 12.5 mg PO QHS Discharge Medications 1. Acetaminophen 325 650 mg PO Q4H PRN Pain Mild 2. Acyclovir 400 mg PO Q12H 3. Albuterol Inhaler 2 PUFF IH Q6H PRN SOB 4. ClonazePAM 1 mg PO QID anxiety 5. Cyanocobalamin 1000 mcg PO DAILY 6. Escitalopram Oxalate 20 mg PO DAILY 7. Fludrocortisone Acetate 0.2 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Gabapentin 900 mg PO QHS 10. Gabapentin 600 mg PO BID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Midodrine 5 mg PO DAILY as needed. 13. Multivitamins W minerals 1 TAB PO DAILY 14. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose 15. Omeprazole 40 mg PO DAILY 16. PredniSONE 7.5 mg PO DAILY 17. Vitamin D3 cholecalciferol vitamin D3 2 000 unit oral DAILY 18. Zolpidem Tartrate 12.5 mg PO QHS Discharge Disposition Home Discharge Diagnosis Primary Diagnoses Rule out pneumonia Dyspnea without Hypoxia Hypertension Secondary Diagnoses Multiple Myeloma 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. ___ You were admitted due to worsening shortness of breath. You underwent a workup including imaging blood work and an echocardiogram. We did not find any infection in your blood. You received antibiotics for a possible pneumonia. The rest of your work up was reassuring however we recommend you follow up with your outpatient pulmonologist. Please continue to take all of your medications as prescribed. Your appointment with Dr. ___ is as listed below. It was an absolute pleasure taking care of you. Sincerely Your ___ TEAM Followup Instructions ___ The icd codes present in this text will be J189, C9000, Z9484, J45909, I4891, F419, E876, F329, Z87891, F1511, R0602, I951, C44529. The descriptions of icd codes J189, C9000, Z9484, J45909, I4891, F419, E876, F329, Z87891, F1511, R0602, I951, C44529 are J189: Pneumonia, unspecified organism; C9000: Multiple myeloma not having achieved remission; Z9484: Stem cells transplant status; J45909: Unspecified asthma, uncomplicated; I4891: Unspecified atrial fibrillation; F419: Anxiety disorder, unspecified; E876: Hypokalemia; F329: Major depressive disorder, single episode, unspecified; Z87891: Personal history of nicotine dependence; F1511: Other stimulant abuse, in remission; R0602: Shortness of breath; I951: Orthostatic hypotension; C44529: Squamous cell carcinoma of skin of other part of trunk. The common codes which frequently come are J45909, I4891, F419, F329, Z87891. The uncommon codes mentioned in this dataset are J189, C9000, Z9484, E876, F1511, R0602, I951, C44529.
The icd codes present in this text will be D61818, C9000, T80211A, N179, N390, R7881, Z9484, E872, E440, B961, I4891, J45909, F329, I951, M109, B965, Z85828, L988, F1290, F1111, F1511, E8339, Z7901, K219, Y848, Y92239, E876, Z87891, I350, G4730, Z6823. The descriptions of icd codes D61818, C9000, T80211A, N179, N390, R7881, Z9484, E872, E440, B961, I4891, J45909, F329, I951, M109, B965, Z85828, L988, F1290, F1111, F1511, E8339, Z7901, K219, Y848, Y92239, E876, Z87891, I350, G4730, Z6823 are D61818: Other pancytopenia; C9000: Multiple myeloma not having achieved remission; T80211A: Bloodstream infection due to central venous catheter, initial encounter; N179: Acute kidney failure, unspecified; N390: Urinary tract infection, site not specified; R7881: Bacteremia; Z9484: Stem cells transplant status; E872: Acidosis; E440: Moderate protein-calorie malnutrition; B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere; I4891: Unspecified atrial fibrillation; J45909: Unspecified asthma, uncomplicated; F329: Major depressive disorder, single episode, unspecified; I951: Orthostatic hypotension; M109: Gout, unspecified; B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere; Z85828: Personal history of other malignant neoplasm of skin; L988: Other specified disorders of the skin and subcutaneous tissue; F1290: Cannabis use, unspecified, uncomplicated; F1111: Opioid abuse, in remission; F1511: Other stimulant abuse, in remission; E8339: Other disorders of phosphorus metabolism; Z7901: Long term (current) use of anticoagulants; K219: Gastro-esophageal reflux disease without esophagitis; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; E876: Hypokalemia; Z87891: Personal history of nicotine dependence; I350: Nonrheumatic aortic (valve) stenosis; G4730: Sleep apnea, unspecified; Z6823: Body mass index [BMI] 23.0-23.9, adult. The common codes which frequently come are N179, N390, E872, I4891, J45909, F329, M109, Z7901, K219, Z87891. The uncommon codes mentioned in this dataset are D61818, C9000, T80211A, R7881, Z9484, E440, B961, I951, B965, Z85828, L988, F1290, F1111, F1511, E8339, Y848, Y92239, E876, I350, G4730, Z6823. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint nausea vomiting diarrhea and subacute SOB Major Surgical or Invasive Procedure none History of Present Illness HISTORY OF PRESENTING ILLNESS Mr. ___ is a ___ year old M admitted for dyspnea n v and abdominal pain found to have ___ pancytopenia and klebsiella bacteremia. His PMH is significant for multiple myeloma s p auto SCT in ___ afib asthma depression substance abuse in remission orthostatic hypotension and other co morbidities. He was in his usual state of health until approximately two weeks prior to admission when he began to feel more SOB. This was on exertion and began to become more prominent. No CP leg swelling fevers or chills. Notably he has been having exertional dyspnea episodically since approximately ___. He has seen Pulmonology and Cardiology as well as Hem Onc. Studies have included PFTs TTE EKG and routine imaging with no definitive cause found. Per Pulm suspicion for deconditioning. Infectious workup on admission showed pan sensitive klebsiella bacteremia and pseudomonas aeruginosa UTI. Past Medical History ONCOLOGIC TREATMENT HISTORY Per primary hemoncologist Dr. ___ Diagnosed with multiple myeloma in acute renal failure in ___. He was found to be anemic with a hemoglobin of 7 to 9.9 with splenomegaly seen on CT of the abdomen. Bone marrow biopsy and aspirate on ___ showed that CD138 positive cells replaced 90 of his marrow with abnormal plasma cells seen. Cytogenetics showed a normal male karyotype and skeletal survey done on ___ showed degenerative disease in the cervical and lumbar spine and a question of a ___ versus a lytic lesion in the frontal skull. He had an elevated serum free lambda of 1140 mg L beta 2 of 10 IgG of 2.3 g dL calcium of 10.1 creatinine of 1.18 and albumin of 3.6. However over the span of ___ weeks he developed renal failure and ultimately was admitted for plasmapheresis and Velcade. TREATMENT HISTORY ___ Cycle 1 Plasmapheresis Velcade Cycle 2 Velcade Dexamethasone severe neuropathy Cycle 3 5 Revlimid Dexamethasone ___ High Dose Cytoxan for Mobilization ___ Autologous Stem cell Transplant Treated on Protocol ___ vaccination with DC Tumor fusion vaccine in patients with multiple myeloma ___ Completed ___ fusion vaccines ___ Found modest rise in paraprotein. Started on Revlimid but tolerated poorly due to nausea and loose stools and ultimately stopped in ___. Slow rising paraprotien over the following year ___ Started on Protocol ___ A Phase I multicenter open label dose escalation to determine the maximum tolerated dose for the combination of Pomalidamide Velcade and low dose dexamethasone in subject with relapsed or refractory multiple myeloma. Lost to follow up for one year re presented in ___ with a rising light chain. M protein was found to be 780 with a max of 1110 and a free light chain of 270. His free lambda did rise to as high as 447 in ___ prior to initiating treatment. ___ Placed back on pomalidomide at 4 mg daily decreased to 2mg due to cytopenias. ___ Found to have a small rise in his light chain and SPEP revealed a monoclonal protein of 910 and a free light chain of 293. Reinitiated treatment with Velcade and dexamethasone and increased the pomalidomide to 3 mg daily. Received four cycles of Velcade pomalidomide and dexamethasone with great disease control then placed on pomalidomide maintenance for close to ___ years. Dose was decreased from 3mg to 2mg ___ due to fatigue and nausea. ___ Presented with right sacral pain unrelieved by Tylenol. Pelvic and lumbar sacral MRI obtained. Clear progression of disease including L3 and L5 lesions. ___ Daratumumab added to current pomalidomide treatment. Treatment plan Daratumumab 16 mg kg weekly for 8 weeks Pomalidomide 2 mg p.o. daily for 21 out of 28 days will increase to 3 mg next cycle Dexamethasone 20 mg p.o. day of and day following Daratumumab ___ Week 2 ___ ___ Week 3 ___ ___ Week 4 ___ ___ Week 5 ___ ___ Week 6 ___ ___ Week 7 ___ ___ Week 8 ___ Dexamethasone decreased to 10 mg on day of ___ and ___ 4 mg on following 2 days ___ Treatment held and admitted for respiratory work up ___ Started Daratumumab Dexamethasone alone ___ T7 T8 lesions. RT therapy started ___ Retuned to Daratumumab Monthly ___ Pet shows progression of disease. RT to L spine and femur ___ started Ninlaro Dex but accidently took two Ninlaro pills in two subsequent days. Admitted for MS changes. ___ PET CT shows interval resolution uptake in the bones now demonstrating background uptake. No new suspicious uptake. ___ 2. Mild uptake along the thoracic esophagus likely representing mild esophagitis secondary to hiatal hernia. Problems Last Verified ___ by ___ S P AUTOLOGOUS STEM CELL TRANSPLANT ACUTE RENAL FAILURE AUTO HPC APHERESIS INFUSION GOUT MULTIPLE MYELOMA STEM CELL COLLECTION STUDY ___ THERAPUTIC PLASMAPHERESIS MULTIPLE MYELOMA DEPRESSION ADVANCE CARE PLANNING BACK PAIN ASTHMA NARCOTICS AGREEMENT DYSPNEA Social History ___ Family History paternal grandmother was institutionalized. Physical Exam ADMISSION PHYSICAL EXAMINATION General Sitting upright in no acute distress Skin No obvious rashes lesions pale HENT Normocephalic atraumatic. Oropharynx clear with moist mucous membranes no lesions Eyes Extraocular movements intact non injected no scleral icterus. Lymph No palpable cervical submandibular or supraclavicular lymphadenopathy. CV Regular rate and rhythm S1 S2 systolic murmur noted no audible rubs ___ Resp CTAB with diminishment in bases no inc WOB Abd Bowel sounds present soft nondistended. Tender in RUQ and LUQ to deep palpation. No palpable hepatosplenomegaly Extremities Warm without edema Neuro Grossly normal moving all limbs Psych Alert oriented to conversation euthymic appropriately conversant ECOG performance status 2 DISCHARGE PHYSICAL EXAMINATION 24 HR Data last updated ___ 1114 Temp 97.8 Tm 98.4 BP 144 81 134 175 69 91 HR 60 55 73 RR 20 ___ O2 sat 98 97 98 O2 delivery RA Wt 161.4 lb 73.21 kg GEN A Ox3 NAD HEENT MMM no OP lesions no cervical supraclavicular lymphadenopathy. CV Irregularly irregular sometimes but currently in sinus bradycardia. No murmurs rubs or gallops PULM non labored fine crackles at bases. No rhonchi or wheezing ABD BS soft NT ND no masses or hepatosplenomegaly. No rebound or guarding. MUSC No edema or tremors SKIN Dry. Pink papules with concave yellow center noted on right chest. No other lesions ACCESS PIV C D I Pertinent Results ADMISSION LABS ___ 08 54PM URINE HOURS RANDOM TOT PROT 9 ___ 08 54PM URINE U PEP ALBUMIN IS ___ 08 54PM URINE COLOR Yellow APPEAR Clear SP ___ ___ 08 54PM URINE BLOOD SM NITRITE NEG PROTEIN NEG GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 5.5 LEUK LG ___ 08 54PM URINE RBC 1 WBC 33 BACTERIA FEW YEAST NONE EPI 1 TRANS EPI 1 ___ 07 11PM LIPASE 31 ___ 07 11PM TOT PROT 6.3 ___ 07 11PM PEP ABNORMAL B Free K 19.4 Free L 76.7 Fr K L 0.25 b2micro 6.5 ___ 10 58AM cTropnT 0.01 ___ 07 55AM OTHER BODY FLUID FluAPCR NEG FluBPCR NEG ___ 07 52AM ___ PTT 34.2 ___ ___ 07 52AM D DIMER 871 ___ 07 29AM GLUCOSE 83 UREA N 24 CREAT 1.8 SODIUM 136 POTASSIUM 3.4 CHLORIDE 101 TOTAL CO2 20 ANION GAP 15 ___ 07 29AM estGFR Using this ___ 07 29AM ALT SGPT 14 AST SGOT 29 ALK PHOS 70 TOT BILI 0.5 ___ 07 29AM LIPASE 17 ___ 07 29AM proBNP 670 ___ 07 29AM cTropnT 0.01 ___ 07 29AM ALBUMIN 3.8 CALCIUM 8.0 PHOSPHATE 3.4 MAGNESIUM 1.8 ___ 07 29AM WBC 1.4 RBC 3.12 HGB 10.0 HCT 29.8 MCV 96 MCH 32.1 MCHC 33.6 RDW 14.2 RDWSD 49.2 ___ 07 29AM NEUTS 32.4 ___ MONOS 33.1 EOS 0.0 BASOS 0.0 IM ___ AbsNeut 0.45 AbsLymp 0.47 AbsMono 0.46 AbsEos 0.00 AbsBaso 0.00 ___ 07 29AM PLT COUNT 58 IMAGING STUDIES ___ CT abd pelv IMPRESSION No acute intra abdominal pathology to account for patient s symptoms within the limitations of this unenhanced scan. ___ RUQ U S IMPRESSION No cholelithiasis or evidence of acute cholecystitis. No biliary ductal dilatation. Laboratory pulmonary function tests from ___ show total lung capacity 7.4 107 predicted and residual volume 3.5 138 predicted with an RV TLC of 130 predicted. Slow vital capacity is 88 predicted and forced vital capacity is 3.96 91 predicted . FEV1 to vital capacity ratio is 74 99 predicted . Diffusing capacity is 16.8 66 predicted DL divided by alveolar volume is 2.9 77 predicted . DISCHARGE LABS ___ 07 10AM BLOOD WBC 2.9 RBC 2.76 Hgb 8.6 Hct 27.1 MCV 98 MCH 31.2 MCHC 31.7 RDW 15.3 RDWSD 49.2 Plt Ct 57 ___ 07 10AM BLOOD Neuts 48.9 Lymphs ___ Monos 16.0 Eos 0.7 Baso 0.7 Im ___ 3.1 AbsNeut 1.44 AbsLymp 0.90 AbsMono 0.47 AbsEos 0.02 AbsBaso 0.02 ___ 07 10AM BLOOD Glucose 88 UreaN 13 Creat 0.8 Na 145 K 4.2 Cl 106 HCO3 29 AnGap 10 ___ 07 10AM BLOOD ALT 8 AST 12 LD LDH 204 AlkPhos 53 TotBili 0.5 ___ 07 10AM BLOOD Calcium 8.6 Phos 3.7 Mg 1.9 ___ 9 00 BLOOD CULTURE KLEBSIELLA PNEUMONIAE. 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 CTA ___ 1. No evidence of pulmonary embolism centrally through the segmental pulmonary arteries. Evaluation of the subsegmental pulmonary arteries is limited due to timing of the contrast bolus. 2. Trace right nonhemorrhagic pleural effusion is new from prior. 3. Stable to slightly improved diffuse bronchial wall thickening. 4. Stable right upper lobe 4 mm pulmonary nodule. 5. Severe coronary artery and mitral annular calcifications. 6. Moderate hiatal hernia and patulous esophagus which may predispose to aspiration. bil LENIs ___ No evidence of deep venous thrombosis in the right or left lower extremity veins. CT chest ___ No evidence of pneumonia in the present examination. Stable right upper lobe 4 mm nodule 5 34 . Moderate bronchial wall thickening reflecting chronic bronchitis. Severe coronary artery atherosclerotic disease. Severe mitral annulus calcification. ___ CT abd pelvis 1. No acute intra abdominal pathology to account for patient s symptoms within the limitations of this unenhanced scan. Brief Hospital Course ASSESSMENT AND PLAN Mr. ___ is a ___ year old male admitted with dyspnea N V D and abdominal pain found to have ___ pancytopenia as well as klebsiella bacteremia and pseudomonas UTI. His PMH is significant for MM s p auto SC in ___ afib asthma depression substance abuse in remission orthostatic hypotension and other comorbidities. Acute Conditions Bacteremia Klebsiella Pneumoniae UTI Pseudomonas Aeruginosa initial culture 100K Presented with SOB N V D and abdominal discomfort. CT Torso and CXR ___ without evidence of infection. Blood culture ___ grew GNR. Started on cefepime while awaiting culture data which showed klebsiella. Additionally UA showed 33 WBC with culture growing pseudomonas A. Of note patient left ___ with PIV which may have been likely source of bacteremia but source of UTI is unclear imaging did not show enlarged prostate recent PSA ___ 0.6 . He did have urinary symptoms urgency and dysuria on presentation but since these have resolved. PIV Culture No growth Repeat UA improved and Ucx without growth Cefepime ___ x7 days then transitioned to Ciprofloxacin x7 days ___ ___ with plan for a 14 day course per ID Surveillance cultures NGTD ID signed off Multiple Myeloma Pancytopenia Improving Diagnosed in ___ with anemia ___ showing CD138 cells in 90 of marrow with abnormal plasma cells. He is status post plasmapharesis velcade auto transplant ___ and other therapies with his last treatment being in ___. His counts the day of admission showed pancytopenia with neutropenia and a Cr of 1.8. His recent numbers over the past few months when trended see above showed a worsening free kappa lambda since ___ with rising IgG. His ___ SPEP was deemed monoclonal. Given this change plan was to obtain PET scan to further evaluate whether he has evidence of disease progression. Unclear if his pancytopenia is related to progression of disease or infection counts improving now so presume likely infection related . Received x1 dose of GSCF on ___. Has mild LDH elevation which may be due to counts recovery recent GSCF. Free Lamdba trending up modestly. Bone marrow biopsy done ___ results pending . Continue infectious prophylaxis acyclovir Transfuse if plts 10 and or hgb 7 B12 folate normal F U zinc copper Plan for PET scan ___ outpatient. follow up bone marrow bx results. Asthma AS DOE SOB Improving overall since admission but persists. His SOB is subacute has been ongoing episodically with exertion since approximately ___. He has had workup with cardiology pulmonary and hem Onc with PFTs TTE EKG and myeloma restaging. Overall he has known asthma and AS however his other studies do not point to a clear cause. Per Pulmonary concern raised for deconditioning. As suspicion for myeloma recurrence looms his SOB may be a constitutional symptom reflecting brewing underlying disease. EKG and troponins are appropriate. CXR x2 without evidence of infection. No evidence of clot on CTA or LENIs. Of note patient has been recently on apixaban 2 weeks as part of afib management but this has been on hold in s o TCP. Consider restarting apixaban if plts remains 50K. Continue supportive care Epigastric Chest Pain Largely resolved but occasionally reports symptoms. Chest pain is sharp in intensity but does not refer elsewhere. No worsening of SOB or hypoxia. No exacerbating factors. Suspect GERD related. Current cardiac workup negative no new arrhythmias cardiac enzymes flat and repeat chest imaging without acute pulmonary infection . Improved with H2 blocker and continues on home PPI. Remains on telemetry Trend examination ___ Resolved Abdominal Pain Resolved N V D Largely resolved Resolved since admission but with recrudescence of diarrhea on ___ due to IV ABX . On admission BUN Cr ___ was above his usual of 0.9 significantly. His bicarb is low reflecting metabolic acidosis. Previous values from ___ show a rising trend Cr 0.9 on ___ and Cr 1.2 on ___. Thus this has been a protracted process again consistent with multiple myeloma. Contribution may also be from vomiting and diarrhea Notably RUQ U S and CT A P did not reveal abnormality so fundamental reason for his GI symptoms is unclear. ___ resolved with IVF. Overall stool studies have been unrevealing. Repeat stool studies if persists Loperamide prn IVF prn Lipase normal Atrial Fibrillation with RVR History of a fib on metoprolol ER 25mg . Held apixaban in setting of low plts. On telemetry and had been in NSR until ___ when he was in afib with rvr rates in 170s no recurrence since then . He was asymptomatic and maintaining BPs. Continue metoprolol Continue telemetry Holding apixaban as above Hypertension Improved. SBPs ranging between 150 170s since admission asymptomatic. Besides BB metoprolol for rate control in s o known afib patient is not on anti HTNs. Unclear exacerbating factor at this point but will hold off on initiating new regimen. Monitor and trend BPs Hypophosphatemia Suspect ___ decreased PO intake repleting prn Chronic Stable Resolved Conditions Substance Use Disorder Depression Has had issues in the past with improper use of benzodiazepines and opiates. Follows OSH Psychiatry and states he has been in remission for months. Continue clonazepam as 1mg QID Continue home escitalopram Takes cannabinoid at home but holding inpatient B12 folate normal as above Lesion on Chest History of Basal Cell Patient has lesion on chest which should be biopsied. However given low counts we will hold but will likely pursue dermatology follow up could be done as an outpatient . Orthostatic Hypotension Continues florinef. Hold off on daily orthostatic VS as stable Held midodrine as he only takes it PRN. Transitional Issues Bone marrow biopsy results pending Stable right upper lobe 4 mm nodule follow up with cardiology consider restarting anticoagulation depending on platelet count. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. Acyclovir 400 mg PO Q12H 3. ClonazePAM 1 mg PO BID 4. Cyanocobalamin 1000 mcg PO DAILY 5. Escitalopram Oxalate 20 mg PO DAILY 6. Fludrocortisone Acetate 0.2 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Gabapentin 900 mg PO QHS 9. Gabapentin 600 mg PO BID 10. Multivitamins W minerals 1 TAB PO DAILY 11. Omeprazole 40 mg PO DAILY 12. PredniSONE 10 mg PO DAILY 13. Zolpidem Tartrate ___ mg PO QHS PRN sleep 14. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose 15. Vitamin D3 cholecalciferol vitamin D3 2 000 unit oral DAILY 16. Midodrine 2.5 mg PO TID Discharge Medications 1. Ciprofloxacin HCl 500 mg PO Q12H Continue as ordered until ___ 2. Acetaminophen 325 650 mg PO Q4H PRN Pain Mild 3. ClonazePAM 1 mg PO QID PRN anxiety 4. Acyclovir 400 mg PO Q12H 5. Cyanocobalamin 1000 mcg PO DAILY 6. Escitalopram Oxalate 20 mg PO DAILY 7. Fludrocortisone Acetate 0.2 mg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Gabapentin 900 mg PO QHS 10. Gabapentin 600 mg PO BID 11. Midodrine 2.5 mg PO TID PRN orthostasis 12. Multivitamins W minerals 1 TAB PO DAILY 13. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose 14. Omeprazole 40 mg PO DAILY 15. PredniSONE 7.5 mg PO DAILY 16. Vitamin D3 cholecalciferol vitamin D3 2 000 unit oral DAILY 17. Zolpidem Tartrate ___ mg PO QHS PRN sleep 18. HELD Apixaban 5 mg PO BID This medication was held. Do not restart Apixaban until instructed to restart by your healthcare provider due to low platelet count . Discharge Disposition Home Discharge Diagnosis Primary Diagnoses Klebsiella Bacteremia Pseudomonas UTI Dyspnea without Hypoxia Hypertension Secondary Diagnoses Multiple Myeloma 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. ___ You were admitted due to worsening shortness of breath nausea vomiting and diarrhea. Extensive workup showed infection in your blood and urine which were treated with IV antibiotics. You will complete treatment for your infections with oral antibiotics ciprofloxacin. Please continue to take all of your medications as prescribed. Your appointment with Dr. ___ is as listed below. It was an absolute pleasure taking care of you. Sincerely Your ___ TEAM Followup Instructions ___ The icd codes present in this text will be D61818, C9000, T80211A, N179, N390, R7881, Z9484, E872, E440, B961, I4891, J45909, F329, I951, M109, B965, Z85828, L988, F1290, F1111, F1511, E8339, Z7901, K219, Y848, Y92239, E876, Z87891, I350, G4730, Z6823. The descriptions of icd codes D61818, C9000, T80211A, N179, N390, R7881, Z9484, E872, E440, B961, I4891, J45909, F329, I951, M109, B965, Z85828, L988, F1290, F1111, F1511, E8339, Z7901, K219, Y848, Y92239, E876, Z87891, I350, G4730, Z6823 are D61818: Other pancytopenia; C9000: Multiple myeloma not having achieved remission; T80211A: Bloodstream infection due to central venous catheter, initial encounter; N179: Acute kidney failure, unspecified; N390: Urinary tract infection, site not specified; R7881: Bacteremia; Z9484: Stem cells transplant status; E872: Acidosis; E440: Moderate protein-calorie malnutrition; B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere; I4891: Unspecified atrial fibrillation; J45909: Unspecified asthma, uncomplicated; F329: Major depressive disorder, single episode, unspecified; I951: Orthostatic hypotension; M109: Gout, unspecified; B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere; Z85828: Personal history of other malignant neoplasm of skin; L988: Other specified disorders of the skin and subcutaneous tissue; F1290: Cannabis use, unspecified, uncomplicated; F1111: Opioid abuse, in remission; F1511: Other stimulant abuse, in remission; E8339: Other disorders of phosphorus metabolism; Z7901: Long term (current) use of anticoagulants; K219: Gastro-esophageal reflux disease without esophagitis; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; E876: Hypokalemia; Z87891: Personal history of nicotine dependence; I350: Nonrheumatic aortic (valve) stenosis; G4730: Sleep apnea, unspecified; Z6823: Body mass index [BMI] 23.0-23.9, adult. The common codes which frequently come are N179, N390, E872, I4891, J45909, F329, M109, Z7901, K219, Z87891. The uncommon codes mentioned in this dataset are D61818, C9000, T80211A, R7881, Z9484, E440, B961, I951, B965, Z85828, L988, F1290, F1111, F1511, E8339, Y848, Y92239, E876, I350, G4730, Z6823.
The icd codes present in this text will be I951, E43, Z9484, Z681, B370, D61818, C9000, F329, G629, Z9221, G893, Z87891, D696, R296, W19XXXA, S92412A, S92512A, Y92009, D472, F1190, I4581, K2970, T402X5A, T424X5A, T43215A, Z9119. The descriptions of icd codes I951, E43, Z9484, Z681, B370, D61818, C9000, F329, G629, Z9221, G893, Z87891, D696, R296, W19XXXA, S92412A, S92512A, Y92009, D472, F1190, I4581, K2970, T402X5A, T424X5A, T43215A, Z9119 are I951: Orthostatic hypotension; E43: Unspecified severe protein-calorie malnutrition; Z9484: Stem cells transplant status; Z681: Body mass index [BMI] 19.9 or less, adult; B370: Candidal stomatitis; D61818: Other pancytopenia; C9000: Multiple myeloma not having achieved remission; F329: Major depressive disorder, single episode, unspecified; G629: Polyneuropathy, unspecified; Z9221: Personal history of antineoplastic chemotherapy; G893: Neoplasm related pain (acute) (chronic); Z87891: Personal history of nicotine dependence; D696: Thrombocytopenia, unspecified; R296: Repeated falls; W19XXXA: Unspecified fall, initial encounter; S92412A: Displaced fracture of proximal phalanx of left great toe, initial encounter for closed fracture; S92512A: Displaced fracture of proximal phalanx of left lesser toe(s), initial encounter for closed fracture; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; D472: Monoclonal gammopathy; F1190: Opioid use, unspecified, uncomplicated; I4581: Long QT syndrome; K2970: Gastritis, unspecified, without bleeding; T402X5A: Adverse effect of other opioids, initial encounter; T424X5A: Adverse effect of benzodiazepines, initial encounter; T43215A: Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounter; Z9119: Patient's noncompliance with other medical treatment and regimen. The common codes which frequently come are F329, Z87891, D696. The uncommon codes mentioned in this dataset are I951, E43, Z9484, Z681, B370, D61818, C9000, G629, Z9221, G893, R296, W19XXXA, S92412A, S92512A, Y92009, D472, F1190, I4581, K2970, T402X5A, T424X5A, T43215A, Z9119. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint dizziness Major Surgical or Invasive Procedure None History of Present Illness Mr. ___ is a ___ year old male with multiple myeloma and orthostatic hypotension who presents with dizziness and poor PO intake after a mechanical fall. Of note the patient was admitted at ___ from ___ with nausea vomiting and diarrhea. This was complicated by intermittent confusion and aphasia. Stroke and seizure work up was negative. He was treated empirically for meningoencephalitis but abx were d c d after 5 days due to low concern for infection. LP negative for infection but noted that this was delayed due to thrombocytopenia. The patient continued to have intermittent episodes of unresponsiveness of unclear etiology with associated hypotension to the ___. This required intubation nand ICU transfer with again negative stroke and seizure work up. This was thought to possibly be due to leptomeningeal involvement of the patient s myeloma due to enhancement found around the cauda equina on MRI L spine for which the patient was started on dexamethasone. Furthermore the patient s hospitalization was further complicated by orthostatic hypotension. Negative infectious and endocrinologic work up. Patient was started on midodrine with underlying etiology thought to be due to treatment with velcade ninlaro. Initially after discharge the patient had been feeling well. He was seen by Dr. ___ on ___ in follow up where further treatment plans were held until more work up could be completed for the patient s symptoms. In addition the patient underwent EGD on ___ for progressive weight loss that demonstrated mild gastritis. Biopsy was negative for malignant invasion. Over the last ___ days the patient has complained of progressive dizziness. He describes this as feeling as if he is about to pass out with tunnel vision upon changes in position. This is occasionally associated with dyspnea but no chest pain or palpitations. He has noted occasional fevers chills but no recorded temperatures. No cough. No abdominal pain. 1 episode of nausea and vomiting the day prior to admission. He notes no diarrhea or constipation. No blood in his stool and occasional dysuria. Initial vitals in the ED T 97.2 HR 108 BP 117 82 R 16 SpO2 98 RA Labs notable for Normal Chem7 WBC 10.1 Hgb 13.3 plt 72 Lactate 1.4 INR 1.3 Imaging was notable for ___ 21 12 CT C Spine W O Contrast 1. No acute fracture or traumatic malalignment. 2. Moderate to severe cervical spondylosis. ___ 21 11 CT Head W O Contrast No acute intracranial abnormality. No fracture. ___ 21 39 Chest Pa Lat IMPRESSION 1. No acute osseous abnormality. 2. No acute cardiopulmonary process. ECG Sinus tachycardia rate 106 with occasional PACs. No ST T wave changes. Normal intervals. Patient received ___ 20 56 IVF NS 1000 mL ordered Upon arrival to ___ the patient endorses the above history and feels improved but fatigued. He notes stable pain in his back and is requesting his breakthrough oxycodone. ROS 10 point review of systems discussed with patient and negative unless noted above Past Medical History Multiple myeloma s p autologous stem cell transplant ___ radiation Orthostatic hypotension Opiate withdrawal w substance use disorder Depression Gout Social History ___ Family History paternal grandmother was institutionalized. Physical Exam ADMISSION PHYSICAL EXAM VITALS T 98.2 BP 174 83 HR 99 R 16 SpO2 100 Ra GENERAL Tired NAD HEENT Multiple scattered white plaques. No erythema. Noted temporal wasting EYES PERRL anicteric NECK supple RESP No increased WOB CTAB ___ no MRG RRR GI Soft NTND no HSM EXT warm noted sarcopenia. No edema SKIN dry NEURO CN II XII intact. Strength ___ ___ b l ACCESS PIV DISCHARGE PHYSICAL EXAM VITALS 24 HR Data last updated ___ 604 Temp 97.6 Tm 98.4 BP 166 100 84 166 57 100 HR 91 85 122 RR 18 ___ O2 sat 96 96 99 O2 delivery Ra Wt 132.7 lb 60.19 kg GENERAL alert an interactive in no acute distress HEENT NC AT sclera anicteric and without injection RESP breathing comfortably on room air CTAB CARDIAC normal rate regular rhythm normal S1 and S2 no m r g GI soft non distended non tender EXT WWP no ___ edema Pertinent Results ADMISSION LABS ___ 06 48PM ___ PTT 25.7 ___ ___ 06 48PM PLT COUNT 72 ___ 06 48PM NEUTS 88.4 LYMPHS 5.8 MONOS 5.0 EOS 0.1 BASOS 0.1 IM ___ AbsNeut 8.92 AbsLymp 0.59 AbsMono 0.51 AbsEos 0.01 AbsBaso 0.01 ___ 06 48PM WBC 10.1 RBC 4.03 HGB 13.3 HCT 39.2 MCV 97 MCH 33.0 MCHC 33.9 RDW 15.4 RDWSD 54.6 ___ 06 48PM cTropnT 0.01 ___ 06 48PM estGFR Using this ___ 06 48PM GLUCOSE 177 UREA N 22 CREAT 1.0 SODIUM 141 POTASSIUM 3.7 CHLORIDE 103 TOTAL CO2 25 ANION GAP 13 ___ 06 52PM LACTATE 1.4 ___ 06 52PM ___ COMMENTS GREEN TOP PERTINENT STUDIES NCHCT ___ FINDINGS There is no evidence of infarction hemorrhage edema or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. Mild periventricular and subcorticalwhite matter hypodensities are nonspecific but likely reflect the sequela of chronic microvascular infarction. There is no evidence of fracture. The visualized portion of the paranasal sinuses mastoid air cells and middle ear cavities are clear. The visualized portion of the orbits are unremarkable. IMPRESSION No acute intracranial abnormality. No fracture. CT C spine w o contrast ___ FINDINGS Alignment is unchanged with minimal retrolisthesis of C4 on C5.No fractures are identified.Moderate to severe multilevel degenerative changes with intervertebral disc space narrowing endplate sclerosis and cystic change and anterior and posterior osteophyte formation most pronounced from C4 C5 through C6 C7. Multilevel mild to moderate central canal stenosis is most severe at C3 C4 and C4 C5 due to combination of a disc bulge and posterior osteophyte. Bilateral mild to moderate neural foraminal narrowing due to uncovertebral spurring and facet hypertrophy is most pronounced C4 5. There is no prevertebral soft tissue swelling. There is no evidence of infection or neoplasm. The esophagus is patulous. Visualized lung apices are clear. The thyroid gland is unremarkable. Partially imaged is a periapical lucency within the left mandibular molar tooth. IMPRESSION 1. No acute fracture or traumatic malalignment. 2. Moderate to severe cervical spondylosis. Carotid U S ___ 1. Mild partially calcified atheromatous plaque involving the proximal left common carotid artery and the bilateral carotid bulbs. 2. No significant stenosis of the extracranial portions of the carotid arteries and vertebral arteries. MRI brain w and w o contrast ___ Small area of dural thickening enhancement left vertex nonspecific differential considerations include posttraumatic change recent lumbar puncture inflammatory neoplastic etiology. Follow up brain MRI without and with gadolinium recommended. TTE ___ The left atrium is mildly dilated. The right atrial pressure could not be estimated. 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 hyperdynamic. The visually estimated left ventricular ejection fraction is 75 . Left ventricular cardiac index is high 4.0 L min m2 . There is no left ventricular outflow tract gradient at rest or with Valsalva. Tissue Doppler suggests an increased left ventricular filling pressure PCWP greater than 18 mmHg . Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender. The aortic valve leaflets are mildly thickened. There is minimal aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is trivial mitral regurgitation. Due to acoustic shadowing the severity of mitral regurgitation could be UNDERestimated. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior TTE images reviewed of ___ left ventricular function is hyperdynamic and the resting heart rate is significantly faster. MRI thoracic and lumbar spine ___ 1. No evidence of fracture. 2. Scattered myelomatous lesions are unchanged. No new or enlarging lesions. 3. Unchanged mild enhancement of the cauda equina nerve roots. 4. Mild thoracic and lumbar spondylosis. MICROBIOLOGY ___ ___ 7 35 am SEROLOGY BLOOD RAPID PLASMA REAGIN TEST Pending ___ ___ 4 45 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. ___ ___ 4 50 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. ___ ___ 8 38 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. ___ ___ 6 48 pm BLOOD CULTURE 1. FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. DISCHARGE LABS ___ 07 35AM BLOOD WBC 3.3 RBC 3.22 Hgb 10.7 Hct 31.6 MCV 98 MCH 33.2 MCHC 33.9 RDW 15.0 RDWSD 53.1 Plt Ct 57 ___ 07 35AM BLOOD Glucose 84 UreaN 21 Creat 0.6 Na 139 K 4.0 Cl 103 HCO3 27 AnGap 9 ___ 07 35AM BLOOD Calcium 8.6 Phos 3.2 Mg 1.___ with multiple myeloma presents with failure to thrive dizziness and mechanical falls after recent prolonged hospitalization for altered mental status. recurrent falls Patient presented s p fall complicated by two toe fractures. This is a recurrent issue. Also had two falls while in house. Etiology of falls likely multifactorial orthostatic hypotension polypharmacy including opioids non compliance with walker and possible large fiber sensory neuropathy positive Romberg test . See below for expanded discussion of these separate issues. orthostatic hypotension Patient with profound orthostatic hypotension. Etiology of orthostasis unclear but most likely related to autonomic failure. Good PO intake and supine hypertension so hypovolemia unlikely. Low AM cortisol in setting of dexamethasone use but ___ stim test during prior admission negative so adrenal insufficiency unlikely. No signs symptoms of Parkinsonism. HgbA1C wnl. B12 repleted. VEGF level POEMS syndrome anti nicotinic acetylcholine receptor antibody pending. Started midodrine salt tabs and compression stockings with improvement symptoms though remains orthostatic. Will follow up in ___ clinic with Dr. ___. subacute comminuted fracture of the L first proximal phalanx subacute fracture of the shaft of the L fifth proximal phalanx without intra articular extension Secondary to trauma. Seen by ortho who recommended a walking boot for LLE when ambulating. Will follow up in ___ clinic. multiple myeloma Patient was most recently treated with Ninlaro Dex on ___. Unclear status of disease in some ways appears well controlled PET on ___ showed resolution of previously identified bony lesions he has low paraprotein levels and bone marrow biopsy on ___ showed no involvement by MM. MRI lumbar spine on ___ showed enhancement of the cauda equina nerve roots concerning for worsening leptomeningeal metastatic infiltration vs. post radiation changes. Reassuringly MRI ___ showed stable enhancement of cauda equina nerve roots arguing against metastatic infiltration. His dexamethasone was tapered discharged on 2mg PO daily . He was continued on acyclovir and atovaquone for prophylaxis. pancytopenia Unclear etiology. BM biopsy on ___ did not show replacement of marrow by MM cells. B12 folate copper and zinc levels all normal. Viral labs HIV EBV CMV have been negative in the past. Parvovirus Ab and PCR pending at time of discharge. acute on chronic pain opioid use disorder Patient with acute pain from toe fractures and trauma to thoracic spine in setting of recent fall. However also with history of misusing opioids with concern that opioids may have contributed to his fall and to his AMS during his prior admission. We weaned his pain regimen while he was here should be further tapered off as an outpatient. malnutrition Noted progressive weight loss over the past year. Recent EGD with mild gastritis. No signs of malignant invasion on biopsy. Followed by nutrition in house who recommended ___ nutritional supplements per day. Weight increased from 128 lbs to 135 lbs during this admission. He was continued on his home B12 and folate. prolonged QTc QTc was prolonged at 496 on ___ this improved to 467 on ___. thrush White plaques were noted on exam. No dysphagia odynophagia to suggest esophagitis. The patient was started on Nystatin swish and swallow. depression The patient was continued on his home clonazepam and duloxetine. TRANSITIONAL ISSUES discharge weight 134.7 lbs discharge QTc 467 NEW MEDICATIONS sodium chloride 2 g PO TID with meals omeprazole 40 mg PO daily nystatin swish and swallow 10 mL PO QID PRN thrush ondansetron 4 mg q8H PRN PO nausea CHANGED MEDICATIONS dexamethasone 4 mg PO q8H changed to 2 mg PO daily gabapentin ___ mg changed to ___ mg oxycodone SR 20 mg PO BID changed to 10 mg PO BID oxycodone ___ 5 mg q4H PRN breakthrough pain changed to q8H PRN breakthrough pain STOPPED MEDICATIONS promethazine Please check orthostatics at next outpatient appointment. Please follow up pending labs for orthostatic hypotension workup VEGF level anti nicotinic acetylcholine receptor antibody RPR. Patient will need to follow up in ___ clinic with Dr. ___ ___. Please ensure patient compliant with compression stockings and walker. He should be taking his midodrine first thing in the morning and then staying upright throughout the day. He should not take his third dose of midodrine past 6 pm want it to be out of his system before going to bed to prevent supine hypertension. He should be taking his salt tabs with meals. Patient will need to follow up in orthopedics clinic for his toe fractures. Dr. ___ ___. Should be ambulating with a walking boot on his LLE. dexamethasone was tapered to 2mg PO daily in house please continue to taper as appropriate for management of multiple myeloma Please follow up pending parvovirus studies for pancytopenia workup. Please wean opioids and gabapentin as tolerated to reduce falls Please check weight at next outpatient appointment. At high risk for malnutrition. Please check QTc at next outpatient appointment. Was prolonged during hospital course. Please examine oropharynx for resolution of thrush. Omeprazole started given dyspepsia and gastritis seen on recent EGD as well as steroid use. Promethazine stopped because it can cause hypotension. Patient was treated with ondansetron for nausea in house so he was discharged on this medication. Please re evaluate need for anti emetics and titrate as needed. HCP CONTACT Name of health care proxy ___ Relationship daughter Phone number ___ Alternate HCP ___ son ___ CODE STATUS Full confirmed Medications on Admission The Preadmission Medication list is accurate and complete. 1. Promethazine 25 mg PO Q6H PRN 2. Senna 8.6 mg PO BID 3. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 4. Docusate Sodium 100 mg PO BID 5. Bengay Cream 1 Appl TP BID PRN knee pain 6. Atovaquone Suspension 1500 mg PO DAILY 7. Acyclovir 400 mg PO Q12H 8. ClonazePAM 1 mg PO BID 9. Acetaminophen 1000 mg PO Q8H 10. Cyanocobalamin 1000 mcg PO DAILY 11. Dexamethasone 4 mg PO Q8H 12. DULoxetine 40 mg PO DAILY 13. FoLIC Acid 1 mg PO DAILY 14. OxyCODONE SR OxyconTIN 20 mg PO Q12H 15. Gabapentin ___ mg PO TID 16. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate 17. Midodrine 2.5 mg PO BID Discharge Medications 1. Nystatin Oral Suspension 10 mL PO QID PRN thrush RX nystatin 100 000 unit mL 10 mL by mouth four times per day Disp 480 Milliliter Milliliter Refills 0 2. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule s by mouth every day Disp 30 Capsule Refills 0 3. Ondansetron 4 mg PO Q8H PRN Nausea Vomiting First Line RX ondansetron 4 mg 1 tablet s by mouth every eight hours Disp 90 Tablet Refills 0 4. Sodium Chloride 2 gm PO TID W MEALS RX sodium chloride 1 gram 2 tablet s by mouth three times per day with meals Disp 180 Tablet Refills 0 5. Dexamethasone 2 mg PO DAILY RX dexamethasone 2 mg 1 tablet s by mouth every day Disp 10 Tablet Refills 0 6. Gabapentin 600 mg PO BID RX gabapentin 300 mg 2 capsule s by mouth every morning and afternoon Disp 120 Capsule Refills 0 7. Gabapentin 900 mg PO QHS RX gabapentin 300 mg 3 capsule s by mouth every night before bed Disp 90 Capsule Refills 0 8. Midodrine 5 mg PO TID RX midodrine 5 mg 1 tablet s by mouth Three times per day at 6AM 12PM and 6PM Disp 90 Tablet Refills 0 9. OxyCODONE Immediate Release 5 mg PO Q8H PRN Pain Moderate RX oxycodone 5 mg 1 capsule s by mouth every eight hours Disp 21 Capsule Refills 0 10. OxyCODONE SR OxyconTIN 10 mg PO Q12H RX oxycodone 10 mg 1 tablet s by mouth every twelve hours Disp 14 Tablet Refills 0 11. Acetaminophen 1000 mg PO Q8H 12. Acyclovir 400 mg PO Q12H 13. Atovaquone Suspension 1500 mg PO DAILY 14. Bengay Cream 1 Appl TP BID PRN knee pain 15. ClonazePAM 1 mg PO BID 16. Cyanocobalamin 1000 mcg PO DAILY 17. Docusate Sodium 100 mg PO BID 18. DULoxetine 40 mg PO DAILY 19. FoLIC Acid 1 mg PO DAILY 20. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 21. Senna 8.6 mg PO BID Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS recurrent falls orthostatic hypotension subacute comminuted fracture of the L first proximal phalanx subacute fracture of the shaft of the L fifth proximal phalanx multiple myeloma pancytopenia acute on chronic pain opioid use disorder malnutrition SECONDARY DIAGNOSIS thrush depression 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 ___. You were here because of a fall and you were found to have fractures in two of the toes of your left foot. For the two fractures you were given a boot to help you walk while your fractures heal. You will need to follow up in orthopedics clinic for this issue. We believe there are several factors contributing to your falls. One factor is the drop in blood pressure that you get when you stand up from a seated position called orthostatic hypotension . We are not entirely sure what is causing this problem but we feel it is most likely related to your multiple myeloma. For this issue we increased your midodrine dose gave you compression stockings to wear and started you on salt tabs. We also believe the pain and anxiety medications you are taking are contributing to your falls. We reduced the amount of pain medications you are getting. You will need to follow up in neurology clinic for this issue. To prevent falls in the future please get up slowly from a seated position wear your compression stockings and use your walker. Please take you midodrine first thing in the morning. This medicine raises your blood pressure so you should stay in an upright position throughout the day and not take your afternoon and evening doses too late we want it to be out of your system before you go to sleep at night. Please continue to take your salt tabs if you take them with meals they should be less nauseating. Finally you should only take pain medication when you ABSOLUTELY need it and should try your best to taper off of the pain medications over the next few days. After you leave the hospital please take all of your medications as prescribed and attend all of your scheduled appointments. We wish you the best in the future Sincerely Your ___ care team. Followup Instructions ___ The icd codes present in this text will be I951, E43, Z9484, Z681, B370, D61818, C9000, F329, G629, Z9221, G893, Z87891, D696, R296, W19XXXA, S92412A, S92512A, Y92009, D472, F1190, I4581, K2970, T402X5A, T424X5A, T43215A, Z9119. The descriptions of icd codes I951, E43, Z9484, Z681, B370, D61818, C9000, F329, G629, Z9221, G893, Z87891, D696, R296, W19XXXA, S92412A, S92512A, Y92009, D472, F1190, I4581, K2970, T402X5A, T424X5A, T43215A, Z9119 are I951: Orthostatic hypotension; E43: Unspecified severe protein-calorie malnutrition; Z9484: Stem cells transplant status; Z681: Body mass index [BMI] 19.9 or less, adult; B370: Candidal stomatitis; D61818: Other pancytopenia; C9000: Multiple myeloma not having achieved remission; F329: Major depressive disorder, single episode, unspecified; G629: Polyneuropathy, unspecified; Z9221: Personal history of antineoplastic chemotherapy; G893: Neoplasm related pain (acute) (chronic); Z87891: Personal history of nicotine dependence; D696: Thrombocytopenia, unspecified; R296: Repeated falls; W19XXXA: Unspecified fall, initial encounter; S92412A: Displaced fracture of proximal phalanx of left great toe, initial encounter for closed fracture; S92512A: Displaced fracture of proximal phalanx of left lesser toe(s), initial encounter for closed fracture; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; D472: Monoclonal gammopathy; F1190: Opioid use, unspecified, uncomplicated; I4581: Long QT syndrome; K2970: Gastritis, unspecified, without bleeding; T402X5A: Adverse effect of other opioids, initial encounter; T424X5A: Adverse effect of benzodiazepines, initial encounter; T43215A: Adverse effect of selective serotonin and norepinephrine reuptake inhibitors, initial encounter; Z9119: Patient's noncompliance with other medical treatment and regimen. The common codes which frequently come are F329, Z87891, D696. The uncommon codes mentioned in this dataset are I951, E43, Z9484, Z681, B370, D61818, C9000, G629, Z9221, G893, R296, W19XXXA, S92412A, S92512A, Y92009, D472, F1190, I4581, K2970, T402X5A, T424X5A, T43215A, Z9119.
The icd codes present in this text will be B3781, R17, N179, E871, C9002, R0600, F418, D649, D696, R109, M109, G8929, E43, Z87891, Z6826. The descriptions of icd codes B3781, R17, N179, E871, C9002, R0600, F418, D649, D696, R109, M109, G8929, E43, Z87891, Z6826 are B3781: Candidal esophagitis; R17: Unspecified jaundice; N179: Acute kidney failure, unspecified; E871: Hypo-osmolality and hyponatremia; C9002: Multiple myeloma in relapse; R0600: Dyspnea, unspecified; F418: Other specified anxiety disorders; D649: Anemia, unspecified; D696: Thrombocytopenia, unspecified; R109: Unspecified abdominal pain; M109: Gout, unspecified; G8929: Other chronic pain; E43: Unspecified severe protein-calorie malnutrition; Z87891: Personal history of nicotine dependence; Z6826: Body mass index [BMI] 26.0-26.9, adult. The common codes which frequently come are N179, E871, D649, D696, M109, G8929, Z87891. The uncommon codes mentioned in this dataset are B3781, R17, C9002, R0600, F418, R109, E43, Z6826. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Dyspnea Abdominal Pain Elevated Bilirubin Major Surgical or Invasive Procedure None this hospitalization. History of Present Illness Mr. ___ is a ___ male with history of multiple myeloma on Daratumumab Pomalidomide Dex who presents from clinic with dyspnea abdominal pain and elevated bilirubin. Patient reports that two days ago he was prescribed doxepin for sleep by his Psychiatrist. Prior to this he was taking abmien and has continued to take klonopin. He took the doxepin for the past two nights. During this time he has been feeling sick. He has been dizzy. Two nights ago he got out of bed to use the bathroom and lost his balance falling on his right side. He denies head stroke loss of consciousness and chest pain. He was unable to get up due to weakness and slept on the floor. His daughter helped him up in the morning. He also notes shortness of breath with exertion for the past two days. He has been more nervous and shaky. He also developed a sharp pain across his mid abdomen and burning sensation in his throat when drinking Gatorade and soda that feels like reflux. He notes decreased appetite and 20 pound weight loss in 3 weeks. He notes multiple family issues at home. He presented to clinic for Daratumumab. Vitals were Temp 98.5 BP 146 97 HR 66 RR 16 O2 sat 100 RA. Ambulatory O2 sat was 95 on RA. EKG showed sinus tachycardia without other abnormalities. His chemotherapy was held. He had a CTA chest which was negative for PE. His labs were notable for elevated bilirubin. He got 1L IVF. On arrival to the floor patient reports cough with deep breaths. His abdominal pain has resolved. He denies fevers chills night sweats headache vision changes weakness numbness hemoptysis chest pain palpitations nausea vomiting diarrhea hematemesis hematochezia melena dysuria hematuria and new rashes. Past Medical History Mr. ___ was diagnosed with multiple myeloma in acute renal failure in ___. He was found to be anemic with a hemoglobin of 7 to 9.9 with splenomegaly seen on CT of the abdomen and he underwent a bone marrow biopsy and aspirate on ___ which showed that CD138 positive cells replaced 90 of his marrow. There were abnormal plasma cells seen. Cytogenetics showed a normal male karyotype and skeletal survey done on ___ shows degenerative disease in the cervical and lumbar spine and a question of a ___ versus a lytic lesion in the frontal skull. He had an elevated serum free lambda of 1140 mg L beta 2 of 10 IgG of 2.3 g dL calcium of 10.1 creatinine of 1.18 and albumin of 3.6 however over the span of only ___ weeks he developed renal failure and ultimately was admitted for plasmapheresis and Velcade. TREATMENT HISTORY ___ Cycle 1 Plasmapheresis Velcade Cycle 2 Velcade Dexamethasone severe neuropathy Cycle 3 5 Revlimid Dexamethasone ___ High Dose Cytoxan for Mobilization ___ Autologous Stem cell Transplant Treated on Protocol ___ vaccination with DC Tumor fusion vaccine in patients with multiple myeloma ___ Completed ___ fusion vaccines ___ Found modest rise in paraprotein. Started on Revlimid but tolerated poorly due to nausea and loose stools and ultimately stopped in ___. Slow rising paraprotien over the following year ___ Started on Protocol ___ A Phase I multicenter open label dose escalation to determine the maximum tolerated dose for the combination of Pomalidamide Velcade and low dose dexamethasone in subject with relapsed or refractory multiple myeloma. He was lost to follow up for one year re presented in ___ with a rising light chain. ___ His M protein was found to be 780 with a max of 1110 and a free light chain of 270. His free lambda did rise to as high as 447 in ___ prior to initiating treatment. ___ He was placed back on pomalidomide at 4 mg daily however was decreased to 2mg due to cytopenias. ___ Found to have a small rise in his light chain and SPEP revealed a monoclonal protein of 910 and a free light chain of 293. This did seem to be after a period of dose decrease and therefore we reinitiated treatment with Velcade and dexamethasone and increased the pomalidomide to 3 mg daily. He completed four cycles of Velcade pomalidomide and dexamethasone with great disease control and he has now been on pomalidomide maintenance for close to ___ years. This dose was decreased from 3mg to 2mg ___ due to fatigue and nausea. ___ Presented with right sacral pain unrelieved by Tylenol. Pelvic and lumbar sacral MRI obtained. Clear progression of disease including L3 and L5 lesions. ___ At Daratumumab addition to current pomalidomide treatment. Treatment plan Daratumumab 16 mg kg weekly 8 weeks Pomalidomide 2 mg p.o. daily for 21 out of 28 days will increase to 3 mg next cycle Dexamethasone 20 mg p.o. day of and day following Daratumumab ___ Week 2 ___ ___ Week 3 ___ ___ Week 4 ___ ___ Week 5 ___ ___ Week 6 ___ ___ Week 7 ___ ___ Week 8 ___ PAST MEDICAL HISTORY Multiple myeloma Anxiety Depression Gout History of opioid abuse History of benzodiazepine abuse Social History ___ Family History Son has a history of opioid dependence. Multiple family members with depression and substance abuse. Physical Exam Admission Physical Exam VS Temp 97.9 BP 124 75 HR 92 RR 18 O2 sat 100 RA. GENERAL Pleasant man very anxious appearing lying in bed comfortably. Ambulating independently around the hallways without difficulty. 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. Speaking in full sentences. ABD Soft mild lower abdominal tenderness to deep palpation without rebound or guarding 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. Discharge Physical Exam VS Temp 98.5 BP 118 73 HR 91 RR 18 O2 sat 95 RA. Exam otherwise unchanged. Pertinent Results Admission Labs ___ 09 50AM BLOOD WBC 4.5 RBC 3.62 Hgb 11.9 Hct 33.8 MCV 93 MCH 32.9 MCHC 35.2 RDW 14.0 RDWSD 46.8 Plt Ct 99 ___ 09 50AM BLOOD Neuts 71 Bands 1 Lymphs 11 Monos 17 Eos 0 Baso 0 ___ Myelos 0 AbsNeut 3.24 AbsLymp 0.50 AbsMono 0.77 AbsEos 0.00 AbsBaso 0.00 ___ 09 50AM BLOOD UreaN 18 Creat 1.3 Na 133 K 4.2 Cl 94 HCO3 22 AnGap 17 ___ 09 50AM BLOOD ALT 68 AST 24 LD ___ 263 AlkPhos 92 TotBili 2.7 DirBili 1.1 IndBili 1.6 ___ 09 50AM BLOOD Calcium 8.4 Discharge Labs ___ 07 02AM BLOOD WBC 2.6 RBC 2.74 Hgb 8.9 Hct 25.6 MCV 93 MCH 32.5 MCHC 34.8 RDW 14.0 RDWSD 47.8 Plt Ct 67 ___ 01 00PM BLOOD WBC 2.7 RBC 2.77 Hgb 9.0 Hct 25.7 MCV 93 MCH 32.5 MCHC 35.0 RDW 14.0 RDWSD 47.1 Plt Ct 73 ___ 07 02AM BLOOD Glucose 105 UreaN 10 Creat 0.9 Na 139 K 3.8 Cl 102 HCO3 26 AnGap 11 ___ 07 02AM BLOOD ALT 41 AST 13 LD ___ 201 AlkPhos 70 TotBili 1.5 ___ 07 02AM BLOOD Calcium 7.7 Phos 2.1 Mg 1.9 ___ 07 02AM BLOOD Hapto 73 Imaging CTA Chest ___ Impression Mild bibasilar fibrotic changes. No evidence of pulmonary embolism. RUQ Ultrasound ___ Impression Splenomegaly. Otherwise unremarkable abdominal ultrasound. Brief Hospital Course Mr. ___ is a ___ male with history of multiple myeloma on Daratumumab Pomalidomide Dex who presents from clinic with dyspnea abdominal pain and elevated bilirubin. Elevated Bilirubin Unclear etiology. ___ medication related possibly doxepin or pomalidomide. Abdominal pain has resolved. RUQ US negative for biliary process. LFTs improving at time of discharge. Possibly intermittent hemolysis as indirect was elevated. Please continue to monitor. ___ Patient found to have evidence of ___ esophagitis given oral thrush on exam and odynophagia. He was prescribed a 14 day course of fluconazole for total duration to be determined by outpatient providers. Also checked baseline QTc which was 400. Please continue to monitor. Dyspnea Normal O2 sats at rest and ambulation. Does not appear in respiratory distress. CTA chest unremarkable. Resolved at time of discharge. Acute Kidney Injury Cr 1.3 on admission baseline 0.9 1.1. Likely due to poor PO intake. Improved with IVF. Hyponatremia Mild. Likely hypovolemic due to poor PO intake. Improved with IVF. Multiple Myeloma Relapsed refractory IgG Lambda multiple myeloma currently on Daratumumab Pomalidomide Dex. Continued Bactrim and acyclovir for prophylaxis. Follow up with outpatient Oncologist Depression Anxiety Multiple stressors in life. Follows with Psychiatrist Dr. ___. Severe anxiety and insomnia. Held home doxepin. Continued Lexapro and clonazepam. Anemia Thrombocytopenia Counts at baseline. All lines down on ___ likely ___ IVF and stable on recheck. Abdominal Pain Unclear cause. Currently resolved. Gout Continued home allopurinol. Chronic Pain Continue gabapentin and Tylenol. Severe Protein Calorie Malnutrition Patient with weight loss and poor PO intake. He was seen by Nutrition. Transitional Issues Patient found to have evidence of ___ esophagitis given oral thrush on exam and odynophagia. He was prescribed a 14 day course of fluconazole for total duration to be determined by outpatient providers. Patient had baseline EKG with QTc of 400 given interaction between fluconazole and escitalopram. Please continue to monitor QTc. Patient with mildly elevated bilirubin on admission which normalized without intervention. Please consider intermittent hemolysis and continue to monitor LFTs. Please note CTA chest with mild bibasilar fibrotic changes. Please note abdominal ultrasound with splenomegaly of 15.5cm. Patient s doxepin held at time of discharge. Please ensure follow up with Psychiatry. Patient was seen by Nutrition given evidence of malnutrition. Please ensure follow up with Oncology. BILLING 45 minutes spent completing discharge paperwork counseling patient and coordinating with outpatient providers. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO TID 2. Allopurinol ___ mg PO DAILY 3. ClonazePAM 1 mg PO QHS 4. ClonazePAM 1 mg PO QID 5. Dexamethasone 4 mg PO AS DIRECTED WITH CHEMOTHERAPY 6. Doxepin HCl 100 mg PO HS 7. Gabapentin 300 mg PO TID 8. Ondansetron 4 mg PO Q8H PRN nausea vomiting 9. pomalidomide 2 mg oral DAILY AS DIRECTED 10. Prochlorperazine 5 mg PO Q6H PRN nausea vomiting 11. Sulfameth Trimethoprim SS 1 TAB PO DAILY 12. Aspirin 81 mg PO DAILY 13. Acetaminophen 650 mg PO Q6H PRN Pain Mild 14. Escitalopram Oxalate 20 mg PO DAILY Discharge Medications 1. Fluconazole 200 mg PO Q24H RX fluconazole 200 mg Take 1 tablet by mouth daily. Disp 14 Tablet Refills 0 2. Acetaminophen 650 mg PO Q6H PRN Pain Mild 3. Acyclovir 400 mg PO TID 4. Allopurinol ___ mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. ClonazePAM 1 mg PO QHS 7. ClonazePAM 1 mg PO QID 8. Dexamethasone 4 mg PO AS DIRECTED WITH CHEMOTHERAPY 9. Escitalopram Oxalate 20 mg PO DAILY 10. Gabapentin 300 mg PO TID 11. Ondansetron 4 mg PO Q8H PRN nausea vomiting 12. pomalidomide 2 mg oral DAILY AS DIRECTED 13. Prochlorperazine 5 mg PO Q6H PRN nausea vomiting 14. Sulfameth Trimethoprim SS 1 TAB PO DAILY Discharge Disposition Home Discharge Diagnosis Primary Diagnosis ___ Elevated Bilirubin Acute Kidney Injury Hyponatremia Multiple Myeloma 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 ___ ___. You were admitted to the hospital for shortness of breath abdominal pain and elevated liver numbers. For your shortness of breath you had a chest CT scan which did not show any blood clots in your lungs. It did not show any cause for your difficulty breathing. Most importantly your breathing improved while in the hospital and were having no symptoms when being discharged. Your abdominal pain also resolved. You had an ultrasound of your liver that did not show any cause of your elevated liver numbers. This improved the following day and your Oncologist will continue to monitor. You also reported throat discomfort with swallowing. You had signs of ___ infection in your mouth. This throat pain is likely due to a ___ infection in your esophagus. You were started on a medication called fluconazole which you have been on in the past. This should help your symptoms improve. Please discuss how long you should continue this medication with your Oncologist. We did stop your doxepin which may have been causing some of your side effects. Please continue the remainder of your home medications. Please follow up with your Oncologist as below. Please call your doctors ___ have any fevers. All the best Your ___ Team Followup Instructions ___ The icd codes present in this text will be B3781, R17, N179, E871, C9002, R0600, F418, D649, D696, R109, M109, G8929, E43, Z87891, Z6826. The descriptions of icd codes B3781, R17, N179, E871, C9002, R0600, F418, D649, D696, R109, M109, G8929, E43, Z87891, Z6826 are B3781: Candidal esophagitis; R17: Unspecified jaundice; N179: Acute kidney failure, unspecified; E871: Hypo-osmolality and hyponatremia; C9002: Multiple myeloma in relapse; R0600: Dyspnea, unspecified; F418: Other specified anxiety disorders; D649: Anemia, unspecified; D696: Thrombocytopenia, unspecified; R109: Unspecified abdominal pain; M109: Gout, unspecified; G8929: Other chronic pain; E43: Unspecified severe protein-calorie malnutrition; Z87891: Personal history of nicotine dependence; Z6826: Body mass index [BMI] 26.0-26.9, adult. The common codes which frequently come are N179, E871, D649, D696, M109, G8929, Z87891. The uncommon codes mentioned in this dataset are B3781, R17, C9002, R0600, F418, R109, E43, Z6826.
The icd codes present in this text will be F332, C9000, Z9484, R45851, F411, Z818, F1990, F1190, M109, R0789, D696, Z9181. The descriptions of icd codes F332, C9000, Z9484, R45851, F411, Z818, F1990, F1190, M109, R0789, D696, Z9181 are F332: Major depressive disorder, recurrent severe without psychotic features; C9000: Multiple myeloma not having achieved remission; Z9484: Stem cells transplant status; R45851: Suicidal ideations; F411: Generalized anxiety disorder; Z818: Family history of other mental and behavioral disorders; F1990: Other psychoactive substance use, unspecified, uncomplicated; F1190: Opioid use, unspecified, uncomplicated; M109: Gout, unspecified; R0789: Other chest pain; D696: Thrombocytopenia, unspecified; Z9181: History of falling. The common codes which frequently come are M109, D696. The uncommon codes mentioned in this dataset are F332, C9000, Z9484, R45851, F411, Z818, F1990, F1190, R0789, Z9181. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint I m sick and tired of being sick and tired. Major Surgical or Invasive Procedure None History of Present Illness Briefly Mr. ___ is a ___ year old man with prior psychiatric history of depression opiate and benzo use disorders as well as medical history of multiple myeloma currently on daratumumab and dexamethasone. Patient presented to his outpatient oncologist s office at ___ without an appointment with complaint of worsening symptoms of confusion and mood. Per Dr. ___ ___ consultation note Patient presented to his outpatient oncologist s office at ___ without an appointment with complaint of worsening symptoms of confusion and mood. Patient was referred to the ED for further evaluation and psychiatry is now asked to assess patient for safety and treatment planning. Patient has been calm and cooperative in the ED overnight. This morning he is awake alert listening to music. He reports that over the past months he has been having a lot of difficulties with his thinking and hallucinating. He gives an example of going to look for a new apartment and believing that his sister is with him. He reports he parked his car to go get paperwork and thought she stayed behind when he returned to the car she was not there and he began to look for her. Eventually he called her to ask where she went and she was surprised by his phone call as she was not with him for any part of that day. ___ family gives other examples of such odd behaviors and confusion refer to Dr. ___ note in ___. Patient and his family noted that in the past few months he has started psychiatric treatment with a new psychiatrist in ___ and ___ been started on a number of medications. Patient also reports that when stressed or anxious he reaches for pills and is using significantly more than prescribed. Patient reports fairly steady mood but with significant stressors. He continues to go through process of divorced and cope with his grandson s special needs. He continues to live in his home with his wife separated daughter and grandchildren. During our interview he has a bright and reactive affect notes that his ___ year old granddaughter is the light of his life asks friendly questions of myself. Patient denies any current ownership or access to firearms. Does report that he continues to have a permit but does not own any weapons. Patient completed MOCA exam this morning. Total score ___. He lost points in all domains. Copy in paper chart. On admission interview patient describes how it has been difficult for him since being diagnosed with multiple myeloma in ___. He discusses his ongoing treatment and states that after being diagnosed he went doctor shopping. He states that yesterday he felt a pain in his shoulder and worried that it was connected to his multiple myeloma and so he decided to go to his oncologist s office. From his oncologist office he was referred to the ED for additional help. The patient states that he has been previously treated for substance abuse and continue to misuse Klonopin and Ativan. He states I can t live like this anymore. He goes into detail about how his wife filed for divorce a couple of years ago. He went to live with his mother initially but then had difficultly living with her and so his wife allowed him to move back into the house. He currently has a difficult relationship with his wife. He reports multiple verbal altercations and states that his wife has called the police on him but denies that any of the arguments have been physical. He reports that his family has been concerned over he past few days due to his confusion. He states that yesterday he thought that it was Christmas. He states that he told the doctor this pointing to Dr. ___ in the room. Of note the patient had not told this story previously to Dr. ___. He states that his daughter was worried about him watching his grandson alone due to his confusion. Regarding his Klonopin and Ativan use the patient reports that he generally will use around 4 mg per day or Klonopin or Ativan but may use up to 10 mg per day. He states that he will alternate which medication he takes. He states that he has learned what to say to doctors in order to obtain prescriptions. He has also been taking Seroquel around 4x day although is unsure of the dose. He reports recent thoughts of wanting to let his cancer kill him but denies current SI. Reports that he currently feels safe on the unit. States that he would not want to hurt himself because of his children. PAST PSYCHIATRIC HISTORY Per Dr. ___ ___ consultation note confirmed and updated with patient Diagnoses Depression Hospitalizations ___ prior hospitalizations at ___ on a special unit for police and firemen Current treaters and treatment Dr. ___ in ___ with ___ Psychiatry sees a therapist before his medication appointment Medication and ECT trials He is currently unsure per review of ___ looks like he has been on Zoloft Quetiapine Lorazepam Clonazepam Doxepin Self injury Unknown Harm to others Denies Access to weapons Denies Past Medical History S P AUTOLOGOUS STEM CELL TRANSPLANT ACUTE RENAL FAILURE AUTO HPC APHERESIS INFUSION GOUT MULTIPLE MYELOMA STEM CELL COLLECTION STUDY ___ THERAPUTIC PLASMAPHERESIS MULTIPLE MYELOMA DEPRESSION ADVANCE CARE PLANNING BACK PAIN Denies h o head injuries or seizure Social History ___ Family History paternal grandmother was institutionalized. Physical Exam PHYSICAL EXAMINATION VS T 97.7 BP 158 88 HR 82 R 20 O2 sat 99 on RA General elderly male in NAD. Well nourished well developed. Appears stated age. HEENT Normocephalic atraumatic. PERRL EOMI. Oropharynx clear. Neck Supple. Back No significant deformity. Lungs CTA ___. No crackles wheezes or rhonchi. CV RRR no murmurs rubs gallops. Abdomen BS soft nontender nondistended. No palpable masses or organomegaly. Extremities No clubbing cyanosis or edema. Skin No rashes abrasions scars or lesions. Neurological Cranial Nerves Pupils symmetry and responsiveness to light and accommodation PERRLA EOM full Facial sensation to light touch in all 3 divisions equal Facial symmetry on smile symmetric Hearing bilaterally normal Phonation normal Tongue midline Motor Normal bulk and tone bilaterally. No abnormal movements no tremor. Gait Steady. Normal stance and posture. No truncal ataxia. In initial personal interview pt reported I am sick and tired of being sick and tired . He admitted experiencing several major losses within last couple years loss of health ___ Multiple Myeloma loss of job ___ health issues marriage falling apart and wife divorcing him ___ ___ ago feeling that kids are ashamed of him. He admitted dealing with depression in the context of multiple losses. Denied S H I. Reported that children are important protective factors for him. He admitted to have problem controlling intake of Benzodiazepines and opiates. Pt reported that Seroquel has been contributing to his confusion. Per ___ pt s daughter expressed concern about pt s decline in the context of starting Ambien. Pt also reported being confused e.g. he started to talk about Christmas in the middle of the ___ per daughter pt has been frequently confused about time of the day. Pt described episode of confusion visual hallucinosis when he thought his sister was sitting with him in the car. Pt exhibited some confabulation during the interview he believed that he already spoke with writer and told his story . Re. medical sx s he complained of pain in L shoulder blade ___ acceptable level of pain ___. VS 158 88 82 Pt s initial clinical exam could be summarized as delirious syndrome he appeared to be somewhat confused in the sequency of events. However he was able to state date ___ . NAD no facial asymmetry unremarkable gait. His face appeared to be flushed. He was friendly cooperative with interview. Spontaneous fluent speech in normal rate and prosody. Somewhat vague TP vague about time sequence of the events. Described depression severe anxiety ___ . Described episode of confusion with VH seeing sister in his car . Clearly denied S H I. Stating that his cares about his children. Pt s insight and judgment were decreased ___ neuro cognitive issues. He was quite inattentive. He was unable to register ___ even after 3 attempts registered ___ recalled ___ after 3 min delay. Identified third item from the list. Decreased digit span 5df and 3 db. He was unable to answer question If the flag waves towards the Southeast where is the wind coming from He responded Southeast...Northeast IMP While there was concern for mood disorder in the context of multiple psycho social and medical stressors delirium better described pt s initial clinical presentation. As for possible contributors benzodiazepines benzodiazepine withdrawal exposure to meds with anticholinergic side effects e.g. seroquel Doxepin have been considered on top of diff diagnosis. Pertinent Results ___ 07 55PM BLOOD WBC 4.1 RBC 4.49 Hgb 14.7 Hct 40.8 MCV 91 MCH 32.7 MCHC 36.0 RDW 13.4 RDWSD 42.9 Plt Ct 83 ___ 06 30PM BLOOD Glucose 108 UreaN 10 Creat 1.2 Na 141 K 4.7 Cl 102 HCO3 19 AnGap 20 ___ 06 30PM BLOOD ASA NEG Ethanol NEG Acetmnp NEG Tricycl POS ___ 07 30PM URINE bnzodzp POS barbitr NEG opiates NEG cocaine NEG amphetm NEG oxycodn NEG mthdone NEG Brief Hospital Course 1. LEGAL SAFETY On admission the patient signed a conditional voluntary agreement Section 10 11 and remained on that level throughout their admission. On ___ the patient signed a 3 day notice and was discharged prior to the 3 day notice expiring. He was placed on 15 minute checks status on admission. The patient was briefly switched to q5 minute checks per patients request as patient felt unsafe with other patients knowing that he was a police officer. However he was quickly changed back to q15 minute checks which remained the rest of hospitalization while being unit restricted. There were no behavioral concerns requiring restraint or seclusion. 2. PSYCHIATRIC On admission patient reported worsening depression in the context of psychosocial stressors and medical issues. Given the ___ confusion the ___ Seroquel and Doxepin were held on admission. The patient consistently denied SI. The patient had initially reported to his oncology providers that he had a gun at home however he consistently denied this during hospitalization. The patient was started on Risperdal 0.5 mg QHS with 0.5 mg BID PRN which he tolerated well. The patient was initially irritable and was focused on being discharged to a program at ___ that he had previously attended. Social work discussed the patient with this program however patient was declined due to acuity. During hospitalization the patient reported improvement in his depressive symptoms and became more engaged in sessions with the treatment team. He was motivated to engage in further treatment and was agreeable attending PHP at ___ after discharge. 3. SUBSTANCE USE DISORDERS Benzodiazepine use disorder The patient reported misusing benzodiazepines. On admission he reported using around 4 mg per day or Klonopin or Ativan but may use up to 10 mg per day. Per ___ the patient was prescribed Klonopin 1 mg QID. On admission the patient was placed on standing Klonopin 1 mg TID and placed on CIWA with 0.5 mg q4h PRN CIWA 10. During the first couple of days of admission the patient intermittently required PRN Klonopin per ___ protocol. During admission CIWA was discontinued and ___ standing Klonopin was decreased to 1 mg qAM 0.5 mg in the afternoon and 1 mg qPM which he tolerated well. The team discussed with the patient extensively the risks of ongoing use of benzodiazepines. The patient was instructed to not drive once discharged. He was encouraged to follow up in outpatient to continue to decrease his use of benzodiazepines and patient reported motivation to do this. 4. MEDICAL Delirium On presentation patient reported confusion and MSE was notable for tangential and circumstantial thought process. This coincided with initiation of multiple psychotropic medications many of which have sedating and anticholinergic properties Seroquel Doxepin coupled with ongoing misuse and over use of benzodiazepines. A MOCA was completed in the ED and the patient scored a ___ losing points in all domains. ___ daughter reported that in the past few months the patient has seemed disoriented and did odd behaviors such as not remembering how to turn on a car and putting things in the microwave that should not be microwaved. On admission the ___ Seroquel and Doxepin were held. He was given ramelteon QHS to help with sleep. Extensively discussed with the patient how his misuse of benzodiazepines is contributing to his cognitive issues. His Klonopin was down titrated to 1 mg qAM 0.5 mg at 3 ___ and 1 mg QHS. During admission the patient reported improvement in his confusion. He was able to attend to his ADLs and participated in interview although continued to be tangential. His completed another MOCA on ___ and scored a ___. At discharge the patient was engaged with his treatment team with a linear thought process and was able to discuss outpatient treatment options as above. He reported motivation to continue to reduce his benzodiazepine use. 5. PSYCHOSOCIAL GROUPS MILIEU The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient initially refused to attend groups however was later able to engage in some groups. He was social in the milieu. There were no behavioral concerns requiring restraint or seclusion. COLLATERAL CONTACTS FAMILY INVOLVEMENT The team communicated with Dr. ___ outpatient psychiatrist with ___ permission. Dr. ___ that he was not aware of the patient misusing his medication. Confirmed that the patient has been hospitalized at ___ previously. He stated that the patient was often anxious but no history of SI. INTERVENTIONS Medications started Risperdal 0.5 mg QHS Risperdal 0.5 mg daily PRN discontinued Seroquel and Doxepin down titrated to Klonopin 1 mg BID Psychotherapeutic Interventions Individual group and milieu therapy. Coordination of aftercare Patient to follow up with his outpatient psychiatrist Dr. ___ as well as ___ ___ Guardianships N A On the discharge day Mr. ___ was adamant that he would like to be discharged. He said that he will continue with outpatient treatment. He claimed that he will follow up with recommendation to attend partial hospital program. He clearly and repeatedly denied any intend to hurt himself or anybody else. While inpt team recommended pt to continue with inpt level of care there were no legal grounds to impose inpt level of treatment. INFORMED CONSENT The team discussed the indications for intended benefits of and possible side effects and risks of starting this medication Risperdal and risks and benefits of possible alternatives including not taking the medication with this patient. 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. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT PROGNOSIS On presentation the patient was evaluated and felt to be at an increased risk of harm to himself based upon inability to care for self. His static factors noted at that time include age Caucasian race previous psychiatric hospitalization chronic medical illness and divorced. His modifiable risk factors included active substance use disorder poor coping skills and depression. During hospitalization the patient reported improvement in his depressive symptoms. He was encouraged to attend groups to develop coping skills. He reported motivation to continue to engage in outpatient treatment for his benzodiazepine use. The patient is being discharged with many protective risk factors including no SI no major mood episode no psychosis help seeking and outpatient follow up. Based on the totality of our assessment at this time the patient is not at an acutely elevated risk of self harm nor danger to others. Our Prognosis of this patient is guarded. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Acyclovir 400 mg PO Q12H 3. ClonazePAM 1 mg PO QID Discharge Medications 1. RisperiDONE 0.5 mg PO QHS RX risperidone Risperdal 0.5 mg 1 tablet s by mouth at bedtime Disp 14 Tablet Refills 0 2. RisperiDONE 0.5 mg PO BID PRN anxiety agitation RX risperidone Risperdal 0.5 mg 1 tablet s by mouth daily PRN Disp 14 Tablet Refills 0 3. ClonazePAM 1 mg PO BID anxiety withdrawal RX clonazepam 1 mg 1 tablet s by mouth twice a day Disp 10 Tablet Refills 0 4. Acyclovir 400 mg PO Q12H 5. Allopurinol ___ mg PO DAILY Discharge Disposition Home Discharge Diagnosis Benzodiazepine use disorder Delirium resolved. Depression not otherwise specified. Discharge Condition Vitals T 97.7 BP 136 92 HR 81 RR 16 O2 95 Mental Status Appearance No apparent distress appears stated age fair grooming appropriately dressed Behavior calm cooperative appropriate eye contact no psychomotor agitation or retardation Mood and Affect good euthymic appropriate to situation Thought Process logical linear Thought Content denies SI HI does not report AVH no evidence of delusions or paranoia Judgment and Insight fair fair Discharge Instructions Please follow up with all outpatient appointments as listed take this discharge paperwork to your appointments. Unless a limited duration is specified in the prescription please continue all medications as directed until your prescriber tells you to stop or change. 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 F332, C9000, Z9484, R45851, F411, Z818, F1990, F1190, M109, R0789, D696, Z9181. The descriptions of icd codes F332, C9000, Z9484, R45851, F411, Z818, F1990, F1190, M109, R0789, D696, Z9181 are F332: Major depressive disorder, recurrent severe without psychotic features; C9000: Multiple myeloma not having achieved remission; Z9484: Stem cells transplant status; R45851: Suicidal ideations; F411: Generalized anxiety disorder; Z818: Family history of other mental and behavioral disorders; F1990: Other psychoactive substance use, unspecified, uncomplicated; F1190: Opioid use, unspecified, uncomplicated; M109: Gout, unspecified; R0789: Other chest pain; D696: Thrombocytopenia, unspecified; Z9181: History of falling. The common codes which frequently come are M109, D696. The uncommon codes mentioned in this dataset are F332, C9000, Z9484, R45851, F411, Z818, F1990, F1190, R0789, Z9181.
The icd codes present in this text will be I951, E43, C9001, D61818, Z681, F1120, Z9484, Z923, M109, F329, R627, R7989, R531, K449, K2970, Z7902, Z7952, Z9181, G8929, G629, R339. The descriptions of icd codes I951, E43, C9001, D61818, Z681, F1120, Z9484, Z923, M109, F329, R627, R7989, R531, K449, K2970, Z7902, Z7952, Z9181, G8929, G629, R339 are I951: Orthostatic hypotension; E43: Unspecified severe protein-calorie malnutrition; C9001: Multiple myeloma in remission; D61818: Other pancytopenia; Z681: Body mass index [BMI] 19.9 or less, adult; F1120: Opioid dependence, uncomplicated; Z9484: Stem cells transplant status; Z923: Personal history of irradiation; M109: Gout, unspecified; F329: Major depressive disorder, single episode, unspecified; R627: Adult failure to thrive; R7989: Other specified abnormal findings of blood chemistry; R531: Weakness; K449: Diaphragmatic hernia without obstruction or gangrene; K2970: Gastritis, unspecified, without bleeding; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z7952: Long term (current) use of systemic steroids; Z9181: History of falling; G8929: Other chronic pain; G629: Polyneuropathy, unspecified; R339: Retention of urine, unspecified. The common codes which frequently come are M109, F329, Z7902, G8929. The uncommon codes mentioned in this dataset are I951, E43, C9001, D61818, Z681, F1120, Z9484, Z923, R627, R7989, R531, K449, K2970, Z7952, Z9181, G629, R339. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint SOB weight loss Major Surgical or Invasive Procedure Bone marrow biopsy ___ EGD ___ Colonoscopy ___ History of Present Illness ___ is a ___ year old man with multiple myeloma orthostatic hypotension anxiety who presents with worsening dyspnea and weakness since he was discharged 3 days ago. The patient was just admitted ___ for similar symptoms of weakness lightheadedness shortness of breath and failure to thrive. Overall his symptoms were felt to be from a combination of polypharmacy orthostatic hypotension psychosocial stress and severe malnutrition. Work up for his dyspnea was negative for PE pneumonia and severe weakness. He did have an mild obstructive pattern on PFTs with a reduced negative inspiratory force normal sniff test. TTE on ___ revealed normal EF of 60 65 . He was discharged home with services with a plan to follow up with palliative care outpatient as well as ___ clinic. His symptoms now continue with marked dyspnea and weakness though he is satting well on room air in the ED. As was the case when he was discharged he is only able to walk a few steps before needing to catch his breath. He has a poor appetite and still has not been eating much. In the ED work up was performed to ensure no new causes of his symptoms. ECG reassuring trop negative CXR clear and his vitals are normal satting 99 on room air. Upon arrival to the floor the patient confirms that he has not had any new symptoms since discharge just increasing concern that he is not feeling better. While his appetite was good during the end of his last admission it has worsened significantly again. REVIEW OF SYSTEMS A 10 point ROS was taken and is negative except otherwise stated in the HPI. Past Medical History Multiple myeloma s p autologous stem cell transplant ___ radiation Orthostatic hypotension Opiate withdrawal w substance use disorder Depression Gout Social History ___ Family History paternal grandmother was institutionalized. Physical Exam ADMISSION PHYSICAL EXAM VITALS T 98.3 BP 158 100 HR 90 RR 16 O2 98 RA General Alert oriented no acute distress HEENT Sclerae 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 foley Ext Warm well perfused no clubbing cyanosis or edema compression stockings in place Skin Warm dry no rashes or notable lesions. Neuro CNII XII intact ___ strength upper lower extremities grossly normal sensation Psych Flat affect DISCHARGE PHYSICAL EXAM ___ 1202 Temp 97.5 PO BP 152 78 L Sitting HR 95 RR 18 O2 sat 99 O2 delivery RA General thin no acute distress. Lungs clear bilaterally Heart s1 s2 normal nl rate regular rhythm Abd soft non tender. Lower extremities no edema Skin no rash Pertinent Results ADMISSION LABS ___ 06 25PM URINE HOURS RANDOM ___ 06 25PM URINE UHOLD HOLD ___ 06 25PM URINE COLOR Straw APPEAR Clear SP ___ ___ 06 25PM URINE BLOOD SM NITRITE NEG PROTEIN NEG GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 6.5 LEUK NEG ___ 06 25PM URINE RBC 1 WBC 2 BACTERIA NONE YEAST NONE EPI 0 ___ 06 25PM URINE MUCOUS RARE ___ 05 30PM GLUCOSE 126 UREA N 15 CREAT 0.9 SODIUM 140 POTASSIUM 3.7 CHLORIDE 105 TOTAL CO2 23 ANION GAP 12 ___ 05 30PM ALT SGPT 12 AST SGOT 13 CK CPK 16 ALK PHOS 52 TOT BILI 1.0 ___ 05 30PM LIPASE 9 ___ 05 30PM cTropnT 0.01 ___ 05 30PM CK MB 1 proBNP 400 ___ 05 30PM ALBUMIN 4.5 CALCIUM 9.1 PHOSPHATE 3.2 MAGNESIUM 1.9 ___ 05 30PM WBC 4.6 RBC 3.16 HGB 10.7 HCT 31.3 MCV 99 MCH 33.9 MCHC 34.2 RDW 14.0 RDWSD 49.5 ___ 05 30PM NEUTS 86.7 LYMPHS 7.4 MONOS 4.8 EOS 0.0 BASOS 0.4 IM ___ AbsNeut 3.98 AbsLymp 0.34 AbsMono 0.22 AbsEos 0.00 AbsBaso 0.02 ___ 05 30PM PLT COUNT 77 INTERVAL LABS Test Result Reference Range Units CALPROTECTIN STOOL 178.0 H mcg g ___ 07 00AM BLOOD TSH 1.0 ___ 06 26AM BLOOD T4 5.8 T3 61 ___ 06 14AM BLOOD HIV Ab NEG DISCHARGE LABS IMAGING CXR ___ IMPRESSION No evidence of a cute cardiopulmonary process. Colonoscopy ___ Impressions high residue material was noted throughout. Multiple attempts were made to irrigate the colon but the mucosa could not be visualized adequately. Normal mucosa in the whole colon with biopsy. Recommendations Follow up pending biopsy results. No evidence of colitis or abnormal mucosa. Given inadequate prep colonoscopy is in adequate for screening. EGD ___ Impressions Normal mucosa in the whole esophagus esophageal hiatal hernia. Erythema in the stomach compatible with gastritis biopsy done. Erosions in the antrum. Normal mucosa in the whole examined duodenum biopsy done. Recommendations Follow up pending biopsies continue daily PPI proceed with colonoscopy. PATHOLOGIC DIAGNOSIS 1. Stomach biopsy Antral and fundic mucosa within normal limits. 2. Duodenum biopsy Duodenal mucosa within normal limits. 3. Right colon biopsy Colonic mucosa within normal limits. 4. Transverse colon biopsy Colonic mucosa within normal limits. 5. Left colon biopsy Colonic mucosa within normal limits. All tested for ___ RED and Negative MICROBIOLOGY Urine culture negative Brief Hospital Course ___ who presents after a recent discharge just a few days prior to admission with continued failure to thrive at home with continued dyspnea weakness and malnutrition. At discharge etiology was unclear however given substantial weight gain while inpatient determined discharge with close follow up would be sufficient. TRANSITIONAL ISSUES Noted to have low T3 with normal T4 and TSH Recommend rechecking thyroid function tests in outpatient setting and consideration of levothyroxine initiation Fecal calprotectin level pending at discharge please follow up. Recommend GI referral for further evaluation if this remains abnormal. A script was provided for outpatient physical therapy. Patient states he goes to his local YMCA which has a physical therapy outpatient program. At discharge following appointments were pending scheduling Urology Dr. ___ to coordinate follow up for urinary retention and bladder training ___ Request placed for Dr. ___ Palliative Care Dr. ___ ACTIVE ISSUES Failure to thrive and weakness Unclear etiology likely multifactorial. He was placed on fall precautions and instructed to ambulate with a walking. We discontinued salt tabs as pt was drinking enough fluid and sodium was increasing. Continue home MV B12 folate supplements vit D. Nutrition and ___ evaluate the patient and recommended SAR. Palliative care clinician and SW continued to participate care and with their help we were able to discontinue tramadol. He continued to eat and drink well while in house. All testing returned reassuring specifically EGD Colon with biopsies MR ___. Repeat bone marrow biopsy without any evidence of myeloma activity. elevated calprotectin To evaluate the elevated calprotectin an EGD and Colonoscopy w biopsies were done on ___ mucosa generally normal some known gastritis biopsies normal and amyloid negative. MRE was done to eval the small bowel which was normal. As testing was normal a repeat calprotectin was done and pending at discharge. Chronic Pancytopenia Unclear etiology of chronic pancytopenia. Pt has not been on recent tx of MM since ___. Also does not clearly correlate with known dates of treatment. MULTIPLE MYELOMA Most recently he was treated with a dose of ixazomib but has been off therapy now for a months due to significant deconditioning and incorrectly taking the medication which required a prolonged hospital admission including ICU in ___. Most recent PET in ___ negative for MM. Continued home prednisone 10mg plan to continue taper as outpatient. Continued atovaquone and acyclovir ppx. Bone marrow biopsy did not show any myeloma activity. ORTHOSTATIC HYPOTENSION DAILY orthostatic blood pressure measurements were done which redemonstrated significant orthostatic hypotension however pt denies symtoms. Increased fludrocortisone from 0.1 to 0.2mg PO daily. Continued thigh high compression stockings. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose 2. Nystatin Oral Suspension 10 mL PO QID PRN thrush 3. Fludrocortisone Acetate 0.1 mg PO DAILY 4. PredniSONE 10 mg PO DAILY 5. Acetaminophen 1000 mg PO Q8H 6. Acyclovir 400 mg PO Q12H 7. Atovaquone Suspension 1500 mg PO DAILY 8. Bengay Cream 1 Appl TP BID PRN knee pain 9. ClonazePAM 1 mg PO BID 10. Cyanocobalamin 1000 mcg PO DAILY 11. Escitalopram Oxalate 20 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Gabapentin 900 mg PO QHS 14. Ondansetron 4 mg PO Q8H PRN Nausea Vomiting First Line 15. OxyCODONE Immediate Release 5 mg PO Q8H PRN Pain Moderate 16. OxyCODONE SR OxyconTIN 10 mg PO Q12H 17. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 18. Senna 8.6 mg PO BID 19. TraMADol 50 mg PO QHS 20. Zolpidem Tartrate 12.5 mg PO QHS 21. Multivitamins W minerals 1 TAB PO DAILY 22. Mirtazapine 15 mg PO QHS 23. Docusate Sodium 100 mg PO BID 24. Omeprazole 40 mg PO DAILY 25. Gabapentin 600 mg PO BID 26. Sodium Chloride 2 gm PO TID W MEALS 27. Vitamin D3 cholecalciferol vitamin D3 2 000 unit oral DAILY Discharge Medications 1. Fludrocortisone Acetate 0.2 mg PO DAILY 2. Zolpidem Tartrate ___ mg PO QHS PRN sleep 3. Acetaminophen 1000 mg PO Q8H 4. Acyclovir 400 mg PO Q12H 5. Atovaquone Suspension 1500 mg PO DAILY 6. Bengay Cream 1 Appl TP BID PRN knee pain 7. ClonazePAM 1 mg PO BID 8. Cyanocobalamin 1000 mcg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Escitalopram Oxalate 20 mg PO DAILY 11. FoLIC Acid 1 mg PO DAILY 12. Gabapentin 900 mg PO QHS 13. Gabapentin 600 mg PO BID 14. Mirtazapine 15 mg PO QHS 15. Multivitamins W minerals 1 TAB PO DAILY 16. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose 17. Nystatin Oral Suspension 10 mL PO QID PRN thrush 18. Omeprazole 40 mg PO DAILY 19. Ondansetron 4 mg PO Q8H PRN Nausea Vomiting First Line 20. OxyCODONE Immediate Release 5 mg PO Q8H PRN Pain Moderate 21. OxyCODONE SR OxyconTIN 10 mg PO Q12H 22. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 23. PredniSONE 10 mg PO DAILY 24. Senna 8.6 mg PO BID 25. Vitamin D3 cholecalciferol vitamin D3 2 000 unit oral DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS Orthostatic hypotension SECONDARY DIAGNOSIS Failure to thrive malnutrition urinary retention dyspnea without hypoxia Discharge Condition Mental Status Clear and coherent. Activity Status Ambulatory requires assistance or aid walker or cane . Level of Consciousness Alert and interactive. Discharge Instructions Dear Mr. ___ It was a privilege caring for you at ___. Please see below for more information on your hospitalization. WHY WERE YOU ADMITTED TO THE HOSPITAL For shortness of breath and unsteadiness on your feet. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL We looked at your entire gut system with upper endoscopy colonoscopy and imaged your small intestine. We took biopsies of your gut which were normal All of this testing was normal. We increased a medication to help with your orthostatic hypotension We did a bone marrow biopsy that showed no myeloma activity in your bone marrow. 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 Seek medical attention if you have new or concerning symptoms or you develop shortness of breath chest pain falls or weight loss. 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 I951, E43, C9001, D61818, Z681, F1120, Z9484, Z923, M109, F329, R627, R7989, R531, K449, K2970, Z7902, Z7952, Z9181, G8929, G629, R339. The descriptions of icd codes I951, E43, C9001, D61818, Z681, F1120, Z9484, Z923, M109, F329, R627, R7989, R531, K449, K2970, Z7902, Z7952, Z9181, G8929, G629, R339 are I951: Orthostatic hypotension; E43: Unspecified severe protein-calorie malnutrition; C9001: Multiple myeloma in remission; D61818: Other pancytopenia; Z681: Body mass index [BMI] 19.9 or less, adult; F1120: Opioid dependence, uncomplicated; Z9484: Stem cells transplant status; Z923: Personal history of irradiation; M109: Gout, unspecified; F329: Major depressive disorder, single episode, unspecified; R627: Adult failure to thrive; R7989: Other specified abnormal findings of blood chemistry; R531: Weakness; K449: Diaphragmatic hernia without obstruction or gangrene; K2970: Gastritis, unspecified, without bleeding; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z7952: Long term (current) use of systemic steroids; Z9181: History of falling; G8929: Other chronic pain; G629: Polyneuropathy, unspecified; R339: Retention of urine, unspecified. The common codes which frequently come are M109, F329, Z7902, G8929. The uncommon codes mentioned in this dataset are I951, E43, C9001, D61818, Z681, F1120, Z9484, Z923, R627, R7989, R531, K449, K2970, Z7952, Z9181, G629, R339.
The icd codes present in this text will be I951, E43, Z681, N179, C9001, F339, Z9484, D61818, E872, G990, R339, R0609, G909, F419, Z923, M109, F1110, N50812, N50811, G893, E8339, G4700, E861, Z9181. The descriptions of icd codes I951, E43, Z681, N179, C9001, F339, Z9484, D61818, E872, G990, R339, R0609, G909, F419, Z923, M109, F1110, N50812, N50811, G893, E8339, G4700, E861, Z9181 are I951: Orthostatic hypotension; E43: Unspecified severe protein-calorie malnutrition; Z681: Body mass index [BMI] 19.9 or less, adult; N179: Acute kidney failure, unspecified; C9001: Multiple myeloma in remission; F339: Major depressive disorder, recurrent, unspecified; Z9484: Stem cells transplant status; D61818: Other pancytopenia; E872: Acidosis; G990: Autonomic neuropathy in diseases classified elsewhere; R339: Retention of urine, unspecified; R0609: Other forms of dyspnea; G909: Disorder of the autonomic nervous system, unspecified; F419: Anxiety disorder, unspecified; Z923: Personal history of irradiation; M109: Gout, unspecified; F1110: Opioid abuse, uncomplicated; N50812: Left testicular pain; N50811: Right testicular pain; G893: Neoplasm related pain (acute) (chronic); E8339: Other disorders of phosphorus metabolism; G4700: Insomnia, unspecified; E861: Hypovolemia; Z9181: History of falling. The common codes which frequently come are N179, E872, F419, M109, G4700. The uncommon codes mentioned in this dataset are I951, E43, Z681, C9001, F339, Z9484, D61818, G990, R339, R0609, G909, Z923, F1110, N50812, N50811, G893, E8339, E861, Z9181. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Fall Major Surgical or Invasive Procedure None History of Present Illness ___ yo M with history of multiple myeloma anxiety and orthostatic hypotension presenting with weakness lightheadedness shortness of breath decreased intake by mouth and weight loss. He had 2 falls today ___ when getting up from the bed and walking to the bathroom. He reports feeling dizzy with SOB denies palpitations CP. He fell on his back denies headstrike. He then tried to get back up and fell again. He denies LOC. Over the past 2 wks he had has progressive SOB. He reports that 4 wks ago he was able to walk over a block but now is unable to walk more than a few steps before feeling SOB. Denies any cough sputum production hemoptysis congestion. He reports that SOB was not present during his last admission. Pt reports he sleeps with 4 pillows but is able to lay flat w o dyspnea denies PND. He also mentions that for the past 3 days he has had minimal oral intake due to lack of appetite. He reports 6lbs unintentional wt loss since discharge. Denies n v diarrhea. Mentioned that his appetite has been low since about ___. Of note was recently admitted at ___ ___ with similar symptoms of dizziness poor oral intake and fall. It was that that his falls were due to orthostatic hypotension which was treated with midodrine compression stockings and salt tabs. It was also thought that the medications could also be contributing and a taper was started. He was also instructed to f u with ___ clinic w Dr ___ reports that his appointment was scheduled for today ___ but he presented to the ED for the fall. Last saw Dr. ___ on ___ after discharge pt reported worsening neuropathy in setting of decreased gabapentin. At that time it seemed that his MM did not require immediate therapy as recent evaluation w o clear evidence of disease. In the ED Initial vital signs were notable for afeb 110 116 73 18 95 RA lowest BP 81 55 Exam notable for oral thrush tachycardic. Labs were notable for 142 106 16 11.1 124 5.5 111 3.9 22 1.2 31.5 Ca 9 Mg 2 Phos 2.4 ___ 12 PTT 23.1 INR 1.1 Lactate 3.2 Blood cultures pending Studies performed include CXR CT Head Patient was given 1L IVF Consults None Vitals on transfer 98.4 91 118 69 18 99 RA Upon arrival to the floor pt reports that he is hungry and would like a diet so that he can order food. He reports that his symptoms are similar to his last admission but the SOB is new again he emphasized that he is unable to ambulate more than a few steps before feeling SOB. Again denies fever chills n v diarrhea dysuria cough palpitations CP orthopnea PND leg swelling. Also mentioned that his sister who he lives with had a cold last week. Past Medical History Multiple myeloma s p autologous stem cell transplant ___ radiation Orthostatic hypotension Opiate withdrawal w substance use disorder Depression Gout Social History ___ Family History paternal grandmother was institutionalized. Physical Exam ADMISSION PHYSICAL EXAM Vitals 24 HR Data last updated ___ 1731 Temp 98.1 Tm 98.1 BP 115 77 HR 94 RR 20 O2 sat 100 O2 delivery Ra Wt 129 lb 58.51 kg Gen Cachectic Lying in bed. NAD HEENT PERRLA EOMI pupils 4mm. No conjunctival pallor. No icterus. Dry MM. No visible thrush. NECK JVP wnl no hepatojugular reflux LYMPH No cervical or supraclav LAD CV Tachycardic irregular rhythm. No MRG. LUNGS No incr WOB. reduced air movement B L. No wheezes rales or rhonchi. When standing pt becomes dyspneic ABD ND nl bowel sounds NT no HSM. EXT WWP. No ___ edema. SKIN No rashes lesions petechiae purpura ecchymoses. NEURO AOx3. CN ___ intact. Full strength in upper and lower extremities DISCHARGE PHYSICAL EXAM Gen Cachectic Lying in bed. NAD HEENT PERRLA EOMI No conjunctival pallor. No icterus. Dry MM. No visible thrush. NECK JVP present about mid neck LYMPH No cervical or supraclav LAD CV regular rhythm . No MRG. LUNGS No incr WOB. CTAB. No wheezes rales or rhonchi. ABD thin ND nl bowel sounds NT no HSM. EXT WWP. No ___ edema. SKIN No rashes lesions petechiae purpura ecchymoses. NEURO AOx3. CN ___ intact. Full strength in upper and lower extremities GU normal appearing genitalia. Testes w o edema or erythema. L testicle tender no palpable masses. Unable to appreciate inguinal hernia. R testicle normal Pertinent Results ADMISSION LABS ___ 07 35PM ALT SGPT 6 AST SGOT 7 LD LDH 160 ALK PHOS 47 TOT BILI 1.3 ___ 07 35PM TOT PROT 5.1 ALBUMIN 3.9 GLOBULIN 1.2 ___ 07 35PM PEP HYPOGAMMAG Free K 1.5 Free ___ Fr K L 0.25 IgG 292 IgA 16 IgM 12 ___ 07 35PM D DIMER 824 ___ 03 06PM ___ COMMENTS GREEN TOP ___ 03 06PM LACTATE 1.4 ___ 10 39AM ___ COMMENTS GREEN TOP ___ 10 39AM LACTATE 3.2 ___ 10 32AM GLUCOSE 124 UREA N 16 CREAT 1.2 SODIUM 142 POTASSIUM 3.9 CHLORIDE 106 TOTAL CO2 22 ANION GAP 14 ___ 10 32AM estGFR Using this ___ 10 32AM CALCIUM 9.0 PHOSPHATE 2.4 MAGNESIUM 2.0 ___ 10 32AM ASA NEG ACETMNPHN NEG tricyclic NEG ___ 10 32AM WBC 5.5 RBC 3.30 HGB 11.1 HCT 31.5 MCV 96 MCH 33.6 MCHC 35.2 RDW 14.3 RDWSD 48.4 ___ 10 32AM NEUTS 56.5 ___ MONOS 11.7 EOS 0.2 BASOS 0.6 IM ___ AbsNeut 3.08 AbsLymp 1.65 AbsMono 0.64 AbsEos 0.01 AbsBaso 0.03 ___ 10 32AM ___ PTT 23.1 ___ ___ 10 32AM PLT COUNT 111 DISCHARGE LABS ___ 06 40AM BLOOD WBC 2.8 RBC 2.58 Hgb 8.7 Hct 26.3 MCV 102 MCH 33.7 MCHC 33.1 RDW 14.3 RDWSD 51.5 Plt Ct 63 ___ 06 00AM BLOOD Neuts 49.3 ___ Monos 13.0 Eos 0.5 Baso 0.5 Im ___ AbsNeut 1.02 AbsLymp 0.74 AbsMono 0.27 AbsEos 0.01 AbsBaso 0.01 ___ 06 40AM BLOOD Plt Ct 63 ___ 06 35AM BLOOD ___ PTT UNABLE TO ___ ___ 07 35PM BLOOD D Dimer 824 ___ 06 40AM BLOOD Glucose 86 UreaN 17 Creat 0.7 Na 142 K 4.6 Cl 104 HCO3 30 AnGap 8 ___ 06 40AM BLOOD ALT 7 AST 9 LD LDH 156 AlkPhos 52 TotBili 0.5 ___ 06 40AM BLOOD Albumin 3.5 Calcium 8.6 Phos 4.3 Mg 2.0 ___ 06 15AM BLOOD VitB12 450 Folate 13 Hapto 10 ___ 03 20PM BLOOD calTIBC 222 Ferritn 370 TRF 171 ___ 03 40PM BLOOD HbA1c 4.4 eAG 80 ___ 06 00AM BLOOD 25VitD 21 ___ 06 00AM BLOOD Cortsol 1.6 ___ 07 35PM BLOOD PEP HYPOGAMMAG FreeKap 1.5 FreeLam 5.9 Fr K L 0.25 IgG 292 IgA 16 IgM 12 ___ 10 32AM BLOOD ASA NEG Acetmnp NEG Tricycl NEG ___ 03 40PM BLOOD tTG IgA 0 ___ 10 39AM BLOOD Lactate 3.2 ___ 03 06PM BLOOD Lactate 1.4 ___ 03 40PM BLOOD HVY MTL WHLE BLD NVY EDTA Test IMAGING CXR ___ IMPRESSION No acute intrathoracic process. CT Head ___ IMPRESSION 1. No acute intracranial process. No fracture. TTE ___ EF 60 65 suboptimal study no change obvious change from prior MRI spine ___ IMPRESSION 1. Study is moderately degraded by motion. 2. No definite evidence of fracture. 3. Scattered myelomatous lesions are unchanged. 4. Within limits of study no definite new or enlarging myomatous lesions identified. 5. Previously seen enhancement of the cauda equina nerve roots is less conspicuous. 6. Grossly stable multilevel thoracic and lumbar spondylosis compared to 3 weeks prior thoracic and lumbar spine contrast MRI as described again most pronounced at L3 4 where there is mild to moderate vertebral canal moderate left and severe right neural foraminal narrowing. 7. Limited imaging of the lungs suggests bilateral scarring and probable dependent atelectasis. If concern for lung opacities consider dedicated chest imaging for further evaluation. Sniff test ___ IMPRESSION No evidence of diaphragmatic paralysis. PFTS ___ FEV1 FVC 62 DsbHb 83 MIP 44 MEP 33 Scrotal U S ___ IMPRESSION 1. Heterogeneous echotexture of the right testis without evidence of focal mass or abnormal vascularity. Findings may reflect sequelae of prior injury. 2. Otherwise normal scrotal ultrasound. MICROBIOLOGY ___ 3 40 pm Blood LYME Lyme IgG Pending Lyme IgM Pending ___ ___ 5 42 am URINE Source Catheter. FINAL REPORT ___ URINE CULTURE Final ___ NO GROWTH. ___ ___ 10 32 am BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ NO GROWTH. Brief Hospital Course ___ with multiple myeloma presents with progressive dyspnea failure to thrive dizziness and mechanical falls after recent hospitalization for similar symptoms. TRANSITIONAL ISSUES New Meds Fludrocortisone 0.1mg PO Daily for orthostatic hypotension Naloxone Inhaler for opioid overdose Prednisone 10mg PO daily WILL NEED TAPER ONLY GIVEN 7DAY Rx Multivitamins with minerals daily Vitamin D3 2000U daily Stopped Held Meds Dexamethasone Midodrine Discharge weight 62 kg Consider ADDRESSING POLYPHARMACY to help reduce the risk of falls patient on multiple psych sedating medications as well as opioid pain medications f u orthostatic blood pressure and symptoms consider uptitrating Fludrocortisone to 0.2mg daily Continue to wear thigh high compression stockings F u weights for adequate oral intake encourage fluid intake ___ daily Discharge Creatinine 0.7 Continue BM regimen as on chronic opioids Only new medication Rx s were provided no opioid psych sleep prescriptions were provided as pt should have enough at home after reviewing fill history and time in hospital FOLLOW UP APPOINTMENTS F u with urology Dr. ___ will coordinate f u for urinary retention and bladder training f u with ___ clinic Request placed for Dr. ___ ___ will f u on HBA1c B1 B6 ___ Ro La ACE heavy metals tTG IgA lyme HIV urine PBG BNP f u with palliative care Dr. ___ ___ 9am f u PCP Dr. ___ ___ 10AM ACTIVE ISSUES POLYPHARMACY Pt is on many medications that may be contributing to his recurrent falls which include Clonazepam gabapentin oxycodone oxycontin tramadol zolpidem and mirtazepapine. We would highly suggest that his polypharmacy burden be reduced given recurrent admissions. dyspnea Pt with 4wk hx of dyspnea that has been progressively worsening now he can only take a couple steps. Modified Wells score 2.5 unlikely. CXR clear. Denies hemoptysis. On exam Tachy with reduced air movement. Dyspnea upon standing. CTA negative for PE. Monitored on Tele which was NSR. PFTs were done showing obstructive pattern with reduced MIP. Sniff test nl diaphragm movement. Pulmonology was consulted. Dyspnea improved with IVF and nutrition thus it was thought to be secondary to underlying orthostatic hypotension. This improved prior to discharge Falls Orthostatic hypotension Pt has long hx of falls which are likely multifactorial orthostatic hypotension polypharmacy including opioids non compliance with walker and possible large fiber sensory neuropathy. Pt with hx of orthostatic hypotension. Recently has also had poor PO intake which may further exacerbate orthostatic hypotension. Other possibilities include adrenal insufficiency POEMS syndrome autonomic dysfunction ___ Parkinsonism no signs symptoms . Was instructed to f u with Dr ___ ___ clinic. Neurology was consulted and suggested a panel of labs for small fiber polyneuropathy most of which are pending we have requested f u with Dr. ___ will f u on the labs. We continued compression stockings. Stopped home midodrine and started Fludrocortisone 0.1 mg po daily for orthostatic hypotension in the hopes of better home compliance. urinary retention testicular pain During admission pt had intermittent urinary retention requiring straight catheterization. Urology was consulted they recommended foley placement and will f u with him as an outpatient for straight cath education and urodynamic testing. MRI was done to evaluate his thoracic and lumbar spine which revealed no change in known lesions. Pt then complained of testicular pain testicular U S was reassuring and it was likely due to tension on foley this resolved when foley was addressed. Multiple Myeloma MM studies were stable. He was admitted on dexamethasone 2mg po daily and was transitioned to prednisone 10mg PO daily. He continued home acyclovir atovaquone and omeprazole. FFT severe MALNUTRITION Likely multifactorial given multiple chronic issues outlined above. As well as psychosocial stressors at home. Psych was consulted and helped to clarify medications. Palliative was consulted as they followed him during the last admission. Nutrition was consulted. We continued B12 folate and MVI. GI was consulted and suggested stool elastase and calprotectin both remain pending. SW was consulted to help with resources. ___ resolved Creatine on admission was 1.2 with rehydration decreased to 0.5 suggesting it was likely pre renal in setting of poor PO intake. Urine culture was negative. PO intake was encouraged. Creatinine upon discharge was CHRONIC MALIGNANCY ASSOCIATED PAIN Opiate use Per OMR Management previously complicated by history of opiate misuse. Recently transitioned from morphine to oxycodone. Stable pain in knees and back. Has narcotic contract with ___ however this was discontinued due to violation on ___. Has been Rx OxyCONTIN and Oxycodone by Dr. ___ filled ___ with one month supply. Serum and urine tox screen were as expected. No prescriptions for controlled substances were provided on discharge. Home oxyCONTIN oxycodone lorazepam were continued as inpatient. Please consider reducing opioid medications as may contribute to fall risk. Also on discharge was given inhaled naloxone as a precaution for opioid overdose. pancytopenia thrombocytopenia anemia On arrival counts were low normal however with IVF counts decreased and remained low. Unclear etiology but counts were stable. MM may be contributing however MM labs do not suggest active disease. There was was appears to be a spurious low platelet count to 15 upon repeat was back up to 57 HIT abs were checked and were negative. Smear was also done no schistocytes were seen. hypophos was repleted per scale Thrush Pt reports 2 wks of stomach pain denies odynophagia. On exam no oral thrush. Pt may continue home nystatin as needed. lactic acidosis Resolved Likely secondary to hypovolemia as improved with IVF CHRONIC ISSUES DEPRESSION Continued home clonazepam BID pt reports he takes it TID home gabapentin home Escitalopram and mirtaz insomnia continued home tramadol home zolpidem CODE Presumed Full EMERGENCY CONTACT Name of health care proxy ___ Relationship daughter Phone number ___ Alternate HCP ___ son ___ 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. Acetaminophen 1000 mg PO Q8H 2. Acyclovir 400 mg PO Q12H 3. Atovaquone Suspension 1500 mg PO DAILY 4. Bengay Cream 1 Appl TP BID PRN knee pain 5. ClonazePAM 1 mg PO BID 6. Cyanocobalamin 1000 mcg PO DAILY 7. Dexamethasone 2 mg PO DAILY 8. Docusate Sodium 100 mg PO BID 9. FoLIC Acid 1 mg PO DAILY 10. Gabapentin 600 mg PO BID 11. Gabapentin 900 mg PO QHS 12. Midodrine 5 mg PO TID 13. OxyCODONE Immediate Release 5 mg PO Q8H PRN Pain Moderate 14. OxyCODONE SR OxyconTIN 10 mg PO Q12H 15. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 16. Senna 8.6 mg PO BID 17. Nystatin Oral Suspension 10 mL PO QID PRN thrush 18. Omeprazole 40 mg PO DAILY 19. Sodium Chloride 2 gm PO TID W MEALS 20. Ondansetron 4 mg PO Q8H PRN Nausea Vomiting First Line 21. TraMADol 50 mg PO QHS 22. Escitalopram Oxalate 20 mg PO DAILY 23. Mirtazapine 15 mg PO QHS 24. Zolpidem Tartrate 12.5 mg PO QHS Discharge Medications 1. Fludrocortisone Acetate 0.1 mg PO DAILY RX fludrocortisone 0.1 mg 1 tablet s by mouth daily in the morning Disp 30 Tablet Refills 0 2. 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 3. Naloxone Nasal Spray 4 mg IH ONCE MR1 opioid overdose Duration 1 Dose RX naloxone Narcan 4 mg actuation 1 spray nasal spray once Disp 1 Spray Refills 0 4. PredniSONE 10 mg PO DAILY RX prednisone 5 mg 2 tablet s by mouth daily Disp 20 Tablet Refills 0 5. Vitamin D3 cholecalciferol vitamin D3 2 000 unit oral DAILY RX cholecalciferol vitamin D3 2 000 unit 1 capsule s by mouth daily Disp 30 Capsule Refills 0 6. Acetaminophen 1000 mg PO Q8H 7. Acyclovir 400 mg PO Q12H 8. Atovaquone Suspension 1500 mg PO DAILY 9. Bengay Cream 1 Appl TP BID PRN knee pain 10. ClonazePAM 1 mg PO BID 11. Cyanocobalamin 1000 mcg PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Escitalopram Oxalate 20 mg PO DAILY 14. FoLIC Acid 1 mg PO DAILY 15. Gabapentin 900 mg PO QHS 16. Gabapentin 600 mg PO BID 17. Mirtazapine 15 mg PO QHS 18. Nystatin Oral Suspension 10 mL PO QID PRN thrush 19. Omeprazole 40 mg PO DAILY 20. Ondansetron 4 mg PO Q8H PRN Nausea Vomiting First Line 21. OxyCODONE Immediate Release 5 mg PO Q8H PRN Pain Moderate 22. OxyCODONE SR OxyconTIN 10 mg PO Q12H 23. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 24. Senna 8.6 mg PO BID 25. Sodium Chloride 2 gm PO TID W MEALS 26. TraMADol 50 mg PO QHS 27. Zolpidem Tartrate 12.5 mg PO QHS Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS Orthostatic hypotension SECONDARY DIAGNOSIS Failure to thrive malnutrition acute kidney injury urinary retention dyspnea without hypoxia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr ___ It was a privilege caring for you at ___. Please see below for more information on your hospitalization. WHY WERE YOU ADMITTED TO THE HOSPITAL You fell lost weight had low blood pressure and was short of breath WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL We gave you fluid through your IV for hydration We made sure you were eating 3 meals a day We had neurology see you they recommended some lab testing and the results are pending you will follow up with Dr. ___ in the ___ clinic to follow up on those results. We had urology see you because you were having difficulty urinating we placed a foley to drain your bladder. You will follow up with urology as an outpatient they will come up with a plan regarding the foley We had our pulmonology lung doctors ___ for your shortness of breath we did imaging and testing which came back reassuring. We monitored your orthostatic blood pressures and your symptoms. Similar to prior hospital admissions your blood pressure dropped when you stood up when you first arrived you would become dizzy and short of breath. This improved but you were still orthostatic after you were hydrated and well fed. You complained of testicular pain we did an ultrasound which was normal We had psychiatry see you to help us with your medications. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL Take all of your medications as prescribed listed below We ARE VERY CONCERNED ABOUT YOUR MEDICATION LIST. There are multiple medications that you take that may be contributing you your recurrent falls. It would be beneficial to reduce the amount of sedating medications that you take. Follow up with your doctors as listed below Seek medical attention if you have new or concerning symptoms of falls dizziness or shortness of breath. 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 I951, E43, Z681, N179, C9001, F339, Z9484, D61818, E872, G990, R339, R0609, G909, F419, Z923, M109, F1110, N50812, N50811, G893, E8339, G4700, E861, Z9181. The descriptions of icd codes I951, E43, Z681, N179, C9001, F339, Z9484, D61818, E872, G990, R339, R0609, G909, F419, Z923, M109, F1110, N50812, N50811, G893, E8339, G4700, E861, Z9181 are I951: Orthostatic hypotension; E43: Unspecified severe protein-calorie malnutrition; Z681: Body mass index [BMI] 19.9 or less, adult; N179: Acute kidney failure, unspecified; C9001: Multiple myeloma in remission; F339: Major depressive disorder, recurrent, unspecified; Z9484: Stem cells transplant status; D61818: Other pancytopenia; E872: Acidosis; G990: Autonomic neuropathy in diseases classified elsewhere; R339: Retention of urine, unspecified; R0609: Other forms of dyspnea; G909: Disorder of the autonomic nervous system, unspecified; F419: Anxiety disorder, unspecified; Z923: Personal history of irradiation; M109: Gout, unspecified; F1110: Opioid abuse, uncomplicated; N50812: Left testicular pain; N50811: Right testicular pain; G893: Neoplasm related pain (acute) (chronic); E8339: Other disorders of phosphorus metabolism; G4700: Insomnia, unspecified; E861: Hypovolemia; Z9181: History of falling. The common codes which frequently come are N179, E872, F419, M109, G4700. The uncommon codes mentioned in this dataset are I951, E43, Z681, C9001, F339, Z9484, D61818, G990, R339, R0609, G909, Z923, F1110, N50812, N50811, G893, E8339, E861, Z9181.
The icd codes present in this text will be K208, B3781, C9000, I82611, B0089, T801XXA, F329, E860, M109, D72819, R509, D696, I6521, R911, E8339, R1310, Z923, Z7982, J45909, Z87891, R451, Z7952, K449. The descriptions of icd codes K208, B3781, C9000, I82611, B0089, T801XXA, F329, E860, M109, D72819, R509, D696, I6521, R911, E8339, R1310, Z923, Z7982, J45909, Z87891, R451, Z7952, K449 are K208: Other esophagitis; B3781: Candidal esophagitis; C9000: Multiple myeloma not having achieved remission; I82611: Acute embolism and thrombosis of superficial veins of right upper extremity; B0089: Other herpesviral infection; T801XXA: Vascular complications following infusion, transfusion and therapeutic injection, initial encounter; F329: Major depressive disorder, single episode, unspecified; E860: Dehydration; M109: Gout, unspecified; D72819: Decreased white blood cell count, unspecified; R509: Fever, unspecified; D696: Thrombocytopenia, unspecified; I6521: Occlusion and stenosis of right carotid artery; R911: Solitary pulmonary nodule; E8339: Other disorders of phosphorus metabolism; R1310: Dysphagia, unspecified; Z923: Personal history of irradiation; Z7982: Long term (current) use of aspirin; J45909: Unspecified asthma, uncomplicated; Z87891: Personal history of nicotine dependence; R451: Restlessness and agitation; Z7952: Long term (current) use of systemic steroids; K449: Diaphragmatic hernia without obstruction or gangrene. The common codes which frequently come are F329, M109, D696, J45909, Z87891. The uncommon codes mentioned in this dataset are K208, B3781, C9000, I82611, B0089, T801XXA, E860, D72819, R509, I6521, R911, E8339, R1310, Z923, Z7982, R451, Z7952, K449. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint severe throat esophageal pain Major Surgical or Invasive Procedure EGD with biopsies ___ iliac bone bx ___ History of Present Illness Mr. ___ is a pleasant ___ w benzo opiate disorder and MM s p auto HSCT ___ now on Daratumumab dex XRT for T7 T8 who p w severe burning sensation radiating down his throat. 10 day course of radiation therapy ended 10 days ago. Since has developed a burning sensation that travels down his throat to his stomach that worsens significantly to meals but not exertion. Feels at times that the food is stuck in his throat. Has had decreased PO for several days now as a result. No f c SOB CP In ED VSS w SBP 99 70 HR 86. 98 RA. REceived maalox donnatal viscous lidocaine 10 ml Pronix and gabapentin 400. GI consulted and recommended bid PPI and judicious pain management. On arrival to ___ pt notes hat this back pain for which he s had XRT is now essentially gone. Had effective relief. But he notes that he s been having stabbing pain in the epigastric area radiating to both sides that is constant and worse w eating. It is always there. Then on swallowing food he has a burning painful sensation throughout the entire esophagus. Denied CP SOB admits to cough. States he s been able to tolerate pancakes the best. 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 Mr ___ was diagnosed with multiple myeloma in acute renal failure in ___. He was found to be anemic with a hemoglobin of 7 to 9.9 with splenomegaly seen on CT of the abdomen. Bone marrow biopsy and aspirate on ___ showed that CD138 positive cells replaced 90 of his marrow with abnormal plasma cells seen. Cytogenetics showed a normal male karyotype and skeletal survey done on ___ showed degenerative disease in the cervical and lumbar spine and a question of a ___ versus a lytic lesion in the frontal skull. He had an elevated serum free lambda of 1140 mg L beta 2 of 10 IgG of 2.3 g dL calcium of 10.1 creatinine of 1.18 and albumin of 3.6. However over the span of ___ weeks he developed renal failure and ultimately was admitted for plasmapheresis and Velcade. ___ Cycle 1 Plasmapheresis Velcade Cycle 2 Velcade Dexamethasone severe europathy Cycle 3 5 Revlimid Dexamethasone ___ High Dose Cytoxan for Mobilization ___ Autologous Stem cell Transplant Treated on Protocol ___ vaccination with DC Tumor fusion vaccine in patients with multiple myeloma ___ Completed ___ fusion vaccines ___ Found modest rise in paraprotein. Started on Revlimid but tolerated poorly due to nausea and loose stools and ultimately stopped in ___. Slow rising paraprotien over the following year ___ Started on Protocol ___ A Phase I multicenter open label dose escalation to determine the maximum tolerated dose for the combination of Pomalidamide Velcade and low dose dexamethasone in subject with relapsed or refractory multiple myeloma. Lost to follow up for one year re presented in ___ with a rising light chain. M protein was found to be 780 with a max of 1110 and a free light chain of 270. His free lambda did rise to as high as 447 in ___ prior to initiating treatment. ___ Placed back on pomalidomide at 4 mg daily decreased to 2mg due to cytopenias. ___ Found to have a small rise in his light chain and SPEP revealed a monoclonal protein of 910 and a free light chain of 293. Reinitiated treatment with Velcade and dexamethasone and increased the pomalidomide to 3 mg daily. Received four cycles of Velcade pomalidomide and dexamethasone with great disease control then placed on pomalidomide maintenance for close to ___ years. Dose was decreased from 3mg to 2mg ___ due to fatigue and nausea. ___ Presented with right sacral pain unrelieved by Tylenol. Pelvic and lumbar sacral MRI obtained. Clear progression of disease including L3 and L5 lesions. ___ Daratumumab added to current pomalidomide treatment. Treatment plan Daratumumab 16 mg kg weekly for 8 weeks Pomalidomide 2 mg p.o. daily for 21 out of 28 days will increase to 3 mg next cycle Dexamethasone 20 mg p.o. day of and day following Daratumumab ___ Week 2 ___ ___ Week 3 ___ ___ Week 4 ___ ___ Week 5 ___ ___ Week 6 ___ ___ Week 7 ___ ___ Week 8 ___ Dexamethasone decreased to 10 mg on day of ___ and ___ 4 mg on following 2 days ___ Treatment held and admitted for respiratory work up ___ Started Daratumumab Dexamethasone alone ___ T7 T8 lesions. RT therapy started PAST MEDICAL SURGICAL HISTORY Substance use disorder Depression Multiple Myeloma Gout Back pain Social History ___ Family History paternal grandmother was institutionalized. Physical Exam ADMISSION PHYSICAL EXAM VITAL SIGNS 97.6 PO 100 65 67 18 96 Ra General NAD Resting in bed comfortably HEENT MMM no OP lesions no thrush no ulcerations noted CV RR NL S1S2 no S3S4 No MRG PULM CTAB No C W R No respiratory distress ABD BS soft mostly TTP in epigastric area but also diffusely TTP no peritoneal signs LIMBS WWP no ___ no tremors SKIN No notable rashes on trunk nor extremities NEURO CN III XII intact strength b l ___ intact PSYCH Thought process logical linear future oriented ACCESS PIV DISCHARGE PHYSICAL EXAM VSS GEN NAD Resting in bed comfortably HEENT MMM. No visible OP lesions thrush ulcerations noted CV RR NL S1 S2 no S3 S4 No MRG PULM CTA. No increased WOB. ABD BS soft non tender LIMBS mild pain and swelling RUE no ___ or tremors SKIN palpable mass to L rib. Multiple healed scars on abdomen with scattered old bruising. No notable new rashes on trunk nor extremities NEURO CN III XII intact strength b l ___ intact PSYCH Thought process logical linear future oriented ACCESS PIV C D I Pertinent Results ADMISSION LABS ___ 10 33AM PLT COUNT 55 ___ 10 33AM NEUTS 68.8 ___ MONOS 9.4 EOS 0.5 BASOS 0.0 IM ___ AbsNeut 2.93 AbsLymp 0.87 AbsMono 0.40 AbsEos 0.02 AbsBaso 0.00 ___ 10 33AM WBC 4.3 RBC 4.20 HGB 13.8 HCT 39.3 MCV 94 MCH 32.9 MCHC 35.1 RDW 12.9 RDWSD 43.9 ___ 10 33AM ALBUMIN 3.6 ___ 10 33AM LIPASE 26 ___ 10 33AM ALT SGPT 20 AST SGOT 17 ALK PHOS 78 TOT BILI 0.8 ___ 10 33AM GLUCOSE 107 UREA N 14 CREAT 1.0 SODIUM 135 POTASSIUM 5.0 CHLORIDE 101 TOTAL CO2 23 ANION GAP 11 DISCHARGE LABS ___ 07 10AM BLOOD WBC 3.1 RBC 3.62 Hgb 11.8 Hct 33.9 MCV 94 MCH 32.6 MCHC 34.8 RDW 13.7 RDWSD 43.8 Plt Ct 93 ___ 07 10AM BLOOD Neuts 50.0 ___ Monos 8.3 Eos 0.3 Baso 1.0 Im ___ AbsNeut 1.56 AbsLymp 1.23 AbsMono 0.26 AbsEos 0.01 AbsBaso 0.03 ___ 07 10AM BLOOD Glucose 112 UreaN 8 Creat 0.9 Na 145 K 4.0 Cl 102 HCO3 27 AnGap 16 ___ 07 10AM BLOOD ALT 15 AST 19 LD LDH 258 AlkPhos 94 TotBili 0.7 ___ 07 10AM BLOOD Albumin 4.1 Calcium 9.2 Phos 3.7 Mg 1.9 UricAcd 4.___ w benzo opiate disorder and MM s p auto HSCT ___ now on Daratumumab dex XRT for T7 T8 who p w 5 day progressively worsening constant epigastric band like pain w worsening whole esophagus pain w eating. ACUTE ISSUES Epigastric pain Esophageal pain In discussion with radiation oncology his symptoms are felt most consistent with esophageal candidiasis particularly given history of chronic steroids albeit there may have been some component of radiation esophagitis. He was started empirically outpatient on fluconazole day 1 ___ completed over two week course. ENT evaluated ___ and their exam was consistent w OP candidiasis. GI was consulted ___ for additional workup. Obtained CT neck ___ which showed no abnormal enhancement in the neck but did note severe atherosclerotic plaque at the origin of the right ICA as well as 2 mm lung nodule at the right lung apex. Upon discussion with GI team felt it was prudent to obtain further imaging with CT abdomen and chest to evaluate for other abnormalities that may be contributing to his esophageal pain. CT abd pelvis benign underwent EGD with biopsies ___. radiation esophagitis most likely cause as bx stains negative with slow improvement over the last two weeks EGD results fungi neg CMV EBV HSV stains neg CMV EBV vL neg ENT GI signed off ADAT per GI on regular diet speech swallow also cleared patient Judicious pain control consulted CPS and followed throughout admission. originally added Oxycodone ___ Q6hr prn ___ and increased gabapentin from 400mg TID to ___ TID ___ weaned gaba back to home dosing in setting of no improvement in pain and increased lethargy lower RR. trying to wean off oxycodone alternating between 5mg and Tylenol with no relief started low dose methadone per CRS ___ with significant relief overnight will go home with 5mg methadone BID prn x14days only 28 tabs only expect resolution in XRT esophagitis over the next two weeks CPS recs requested follow up with Dr. ___ pain service outpatient end of ___ request placed in OMR pain receptionist said they would book Continues with supportive care including PPI sucralfate tums Multiple Myeloma Relapsed after AutoSCT IgG Lambda previously treated on pomalidomide maintenance. Switched to Daratumumab Pomalyst and Dexamethasone due to disease progression with good response. Pomalidomide stopped due to possible pulmonary fibrosis. He mostly received daratumumab Dexamethasone Cycle 6 Day 1 ___. Dose every 4 weeks . His counts seem to be stable on admission though does have evidence of leukopenia and thrombocytopenia as below. Bone marrow on ___ showed no morphologic evidence of his myeloma. He does report new pain to his left rib. Most recent PET CT showed multiple small areas of lytic lesions which seem to show progression from prior imaging studies. Consulted ___ about biopsy underwent iliac bone bx ___ results consistent with no malignancy likely repeat PET outpatient to compare results Holding ASA due to TCP instructed to hold until outpatient team tells him to restart Continue ACV increased to 400mg TID from BID to cover for herpes esophagitis back to BID dosing on discharge Continue allopurinol and gabapentin holding Bactrim due to TCP F U Spep M protein continued response ratio 0.17 RUE swelling pain mild pain and swelling associated with PIV infiltration. u s neg for DVT but noted sup R cephalic thrombosis supportive care for now Leukopenia Thrombocytopenia Most likely secondary to recent radiotherapy in combination with recent chemotherapy and underlying malignancy r o viral cause. Not requiring transfusion support at this time. holding Bactrim for now due to TCP with improvement in counts Transfuse if platelets 10K and hgb 7 Monitor and Trend CBC Active T S High risk for Malnutrition In the context of nutritional decline in setting of limited PO intake with esophageal pain. Appreciate nutrition recommendations Daily MVI Trend weights daily CHRONIC CONDITIONS Depression Substance Use Disorder Patient recently discharged on risperidone however he is no longer taking this. Judicious use of benzos narcotics Continues on clonazepam 1mg TID Appreciate CPS recommendations SW going home on 14d of methadone for acute esophagitis pain will f u pain service end of ___ CORE MEASURES FEN ADAT mIVF DVT PROPH None due to TCP ACCESS PIV CODE STATUS Full code presumed EMERGENCY CONTACT ___ sister ___ ___ DISPO home Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. ClonazePAM 1 mg PO TID anxiety 5. Sulfameth Trimethoprim SS 1 TAB PO DAILY 6. Gabapentin 400 mg PO TID back pain 7. Famotidine 20 mg PO Q12H gi ppx 8. Qvar RediHaler beclomethasone dipropionate 40 mcg actuation inhalation DAILY 9. Zolpidem Tartrate 5 mg PO QHS Discharge Medications 1. Calcium Carbonate 500 mg PO QID RX calcium carbonate 500 mg calcium 1 250 mg 1 tablet s by mouth four times a day Disp 56 Tablet Refills 0 2. Methadone 5 mg PO BID PRN pain RX methadone 5 mg 1 tab by mouth BID prn Disp 28 Tablet Refills 0 3. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 3 4. Sucralfate 1 gm PO QID RX sucralfate 1 gram 10 mL 10 suspension s by mouth four times a day Disp 1 Bottle Refills 0 5. Acyclovir 400 mg PO Q12H 6. Allopurinol ___ mg PO DAILY 7. ClonazePAM 1 mg PO TID anxiety 8. Gabapentin 400 mg PO TID back pain 9. Qvar RediHaler beclomethasone dipropionate 40 mcg actuation inhalation DAILY 10. Zolpidem Tartrate 5 mg PO QHS 11. HELD Aspirin 81 mg PO DAILY This medication was held. Do not restart Aspirin until outpatient team tells you to do so 12. HELD Sulfameth Trimethoprim SS 1 TAB PO DAILY This medication was held. Do not restart Sulfameth Trimethoprim SS until outpatient team tells you to restart Discharge Disposition Home Discharge Diagnosis myeloma esophagitis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Mr. ___ You were admitted due to throat pain associated with radiation. This improved with methadone and time. You will follow up with Dr. ___ as stated below. It was a pleasure taking care of you. Followup Instructions ___ The icd codes present in this text will be K208, B3781, C9000, I82611, B0089, T801XXA, F329, E860, M109, D72819, R509, D696, I6521, R911, E8339, R1310, Z923, Z7982, J45909, Z87891, R451, Z7952, K449. The descriptions of icd codes K208, B3781, C9000, I82611, B0089, T801XXA, F329, E860, M109, D72819, R509, D696, I6521, R911, E8339, R1310, Z923, Z7982, J45909, Z87891, R451, Z7952, K449 are K208: Other esophagitis; B3781: Candidal esophagitis; C9000: Multiple myeloma not having achieved remission; I82611: Acute embolism and thrombosis of superficial veins of right upper extremity; B0089: Other herpesviral infection; T801XXA: Vascular complications following infusion, transfusion and therapeutic injection, initial encounter; F329: Major depressive disorder, single episode, unspecified; E860: Dehydration; M109: Gout, unspecified; D72819: Decreased white blood cell count, unspecified; R509: Fever, unspecified; D696: Thrombocytopenia, unspecified; I6521: Occlusion and stenosis of right carotid artery; R911: Solitary pulmonary nodule; E8339: Other disorders of phosphorus metabolism; R1310: Dysphagia, unspecified; Z923: Personal history of irradiation; Z7982: Long term (current) use of aspirin; J45909: Unspecified asthma, uncomplicated; Z87891: Personal history of nicotine dependence; R451: Restlessness and agitation; Z7952: Long term (current) use of systemic steroids; K449: Diaphragmatic hernia without obstruction or gangrene. The common codes which frequently come are F329, M109, D696, J45909, Z87891. The uncommon codes mentioned in this dataset are K208, B3781, C9000, I82611, B0089, T801XXA, E860, D72819, R509, I6521, R911, E8339, R1310, Z923, Z7982, R451, Z7952, K449.
The icd codes present in this text will be I951, E861, R0989, R232, I471, K7581, I10, K219, K2270, M549. The descriptions of icd codes I951, E861, R0989, R232, I471, K7581, I10, K219, K2270, M549 are I951: Orthostatic hypotension; E861: Hypovolemia; R0989: Other specified symptoms and signs involving the circulatory and respiratory systems; R232: Flushing; I471: Supraventricular tachycardia; K7581: Nonalcoholic steatohepatitis (NASH); I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; K2270: Barrett's esophagus without dysplasia; M549: Dorsalgia, unspecified. The common codes which frequently come are I10, K219. The uncommon codes mentioned in this dataset are I951, E861, R0989, R232, I471, K7581, K2270, M549. Allergies Codeine Latex Chief Complaint presyncope Major Surgical or Invasive Procedure None History of Present Illness The patient is a ___ year old woman with PMH of ___ esophagus and HTN who presents with acute onset nausea lightheadedness and pallor. She describes that in the afternoon on ___ she suddently felt nauseated and her granddaughter who was present said she looked white as a ghost. She felt lightheaded and her vision went black. She then had the immediate urge to have a bowel movement and proceeded to have a watery bowel movement after which her symptoms improved. Of note the patient has a longstanding history of HTN. She was recently seen in the ED for hypertensive urgency with BP 200 90s with flushing and palpitations and was discharged after BP normalized without intervention. During this visit she described having ___ swelling which never happens to her at home. She was then evaluated by ___ cardiology on ___ for follow up. At this visit she also reported episodes of palpitations and facial flushing. At this visit her atenolol was increased to 25mg daily. Labs from this visit ESR 49 CRP 6.2 TSH 2.81. Urinary metanephrines were ordered but not yet sent. CTA chest was also ordered but not performed since the patient had a reaction to IV contrast in the past. She describes occasional episodes of palpitations and flushing associated with elevated BP around 200 90 in the past. The episodes always resolve on their own. She has also had nausea and worsening back pain after eating the last few months that she thinks is possibly due to her ___ esophagus. She says during these episode she does not have abdominal pain. In the ED initial VS were 97.7 75 117 69 18 98 RA. Right arm BP 154 68 and left arm BP 125 96. CBC and chem 7 were WNL. CXR showed no acute process. CTA chest was ordered but not performed. On the floor the patient endorses the above history and does not currently feel any SOB CP palpitations flushing sweating or abdominal pain. Past Medical History HTN ___ esophagus Social History ___ Family History Family history of leukemia daughter with breast cancer aunts with stomach cancer. No family history of adrenal tumors episodic hypertension flushing or palpitations. Physical Exam ADMISSION VS 98.3 102 60 59 20 95 RA General Well appearing speaking calmly NAD HEENT OP clear symmetric palate elevation Neck Supple no LAD CV RRR no m r g Pulm CTAB without wheezes or rales Abd Soft NT ND NABS Ext No ___ edema WWP Neuro CNII XII intact UE and ___ strength ___ sensation grossly intact DISCHARGE EXAM VITALS 97.7 BP 110 125 60 70s 50 60s 18 95 RA GENERAL NAD skin dry comfortable appearing HEENT Face erythematous but no diaphoresis. MMM. NECK supple HEART normal S1 S2 no murmurs gallops or rubs LUNGS CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles ABDOMEN BS soft nontender nondistended no masses palpated EXTREMITIES warm no edema NEURO alert and interactive. Face grossly symmetric moving both limbs with purpose against gravity. Pertinent Results ADMISSION ___ 09 29PM BLOOD WBC 7.1 RBC 4.37 Hgb 12.9 Hct 37.8 MCV 87 MCH 29.5 MCHC 34.1 RDW 12.3 RDWSD 38.9 Plt ___ ___ 09 29PM BLOOD Neuts 66.4 ___ Monos 5.9 Eos 0.3 Baso 0.1 Im ___ AbsNeut 4.70 AbsLymp 1.91 AbsMono 0.42 AbsEos 0.02 AbsBaso 0.01 ___ 09 29PM BLOOD Glucose 89 UreaN 19 Creat 0.7 Na 142 K 4.3 Cl 103 HCO3 24 AnGap 15 ___ 07 32AM BLOOD Albumin 4.0 Calcium 9.1 Phos 3.0 Mg 2.1 ___ 09 29PM BLOOD ALT 85 AST 71 LD LDH 240 AlkPhos 84 TotBili 0.7 ___ 09 29PM BLOOD cTropnT 0.01 ___ 09 29PM BLOOD D Dimer 521 IMAGING ___ CT head 1. No acute intracranial abnormalities 2. Paranasal sinus disease as above. ___ CTA torso 1. No acute pulmonary embolism. 2. No acute intra abdominal findings. 3. Mild hepatic steatosis. 4. No evidence of dissection in the thoracic or abdominal aorta. ___ CXR IMPRESSION No acute intrathoracic process. DISCHARGE ___ 05 35AM BLOOD WBC 8.3 RBC 4.15 Hgb 11.9 Hct 36.7 MCV 88 MCH 28.7 MCHC 32.4 RDW 12.6 RDWSD 40.6 Plt ___ ___ 05 35AM BLOOD Glucose 87 UreaN 21 Creat 0.6 Na 143 K 3.7 Cl 106 HCO3 25 AnGap ___ with history of ___ esophagus hypertension palpitations and recent episode of uncontrolled hypertension and flushing who presents with back pain and episode of presyncope associated with nausea and vomiting. Presyncopal episode She had symptoms of vision going black and felt better with sitting suggesting orthostasis versus vasovagal. Hyaline casts in urine support dehydration and uptitration of antihypertensives in outpatient setting may have contributed. Stroke ruled out with negative head CT head was unremarkable. Already had Holter monitor which has not been read yet. Tachycardia She had episodes of sinus tachycardia to the 150s while in the hospital that were thought to be due to hypovolemia. She did not have any for 24h prior to discharge. Hypertension with labile blood pressures Episode of flushing with elevated BP Concern for pheochromoyctoma given flushing episodic palpitations and hypertension although CT was negative for adrenal mass. Patient appears to be medication adherent and denies substance abuse. No history to suggest panic disorder. Imaging and history not consistent with vasculopath to suggest renal artery or other stenosis. Of note did not have hypertension recorded during inpatient portion of this present hospitalization. Back pain concern for dissection especially with labile BP but CTA negative was for dissection. TRANSITIONAL ISSUES NEW MEDS carvedilol 6.25mg BID hctz 12.5 mg daily STOPPED MEDS Atenolol 25 mg PO DAILY valsartan hydrochlorothiazide 160 25 mg oral DAILY Follow up blood pressures and adjust as needed Follow up Holter Monitor Follow up urine metanephrines Consider outpatient renal artery ultrasound given report of hypertension Hepatitis B surface antibody negative consider vaccination CT abdomen showed hepatic steatosis consider lifestyle modification counseling diet counseling trending LFTs starting statin Incidental finding A mucous retention cyst is noted in the right maxillary sinus. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atenolol 25 mg PO DAILY 2. Omeprazole 20 mg PO DAILY 3. valsartan hydrochlorothiazide 160 25 mg oral DAILY Discharge Medications 1. Carvedilol 6.25 mg PO BID RX carvedilol 6.25 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 2. Hydrochlorothiazide 25 mg PO DAILY RX hydrochlorothiazide 25 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 3. Omeprazole 20 mg PO DAILY Discharge Disposition Home Discharge Diagnosis PRIMARY DIAGNOSIS ORTHOSTATIC HYPOTENSION d t HYPOVOLEMIA LABILE BLOOD PRESSURES w FLUSHING ATRIAL TACHYCARDIA SECONDARY DIAGNOSIS HEPATIC STEATTHOSIS Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ WHY WASI IN THE HOSPITAL You had an episode of feeling like you were going to lose consciousness associated with vomiting and diarrhea. This was likely due to low blood pressure. WHAT HAPPEENED IN THE HOSPITAL You were admitted to the hospital to work up your episodes of very high blood pressure and periods of fast heart rate. You had a CT scan which did not show an obvious cause of your symptmos. We started doing an extended workup. WHAT SHOULD I DO WHEN I GO HOME Follow up with your cardiologist regarding changes to your blood pressure medicines Follow up with your doctors regarding the results of your urine tests Take all medicines as prescribed It was a pleasure participating in your care. We wish you all the best Sincerely Your ___ team Followup Instructions ___ The icd codes present in this text will be I951, E861, R0989, R232, I471, K7581, I10, K219, K2270, M549. The descriptions of icd codes I951, E861, R0989, R232, I471, K7581, I10, K219, K2270, M549 are I951: Orthostatic hypotension; E861: Hypovolemia; R0989: Other specified symptoms and signs involving the circulatory and respiratory systems; R232: Flushing; I471: Supraventricular tachycardia; K7581: Nonalcoholic steatohepatitis (NASH); I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; K2270: Barrett's esophagus without dysplasia; M549: Dorsalgia, unspecified. The common codes which frequently come are I10, K219. The uncommon codes mentioned in this dataset are I951, E861, R0989, R232, I471, K7581, K2270, M549.
The icd codes present in this text will be I480, I313, I314, N390, I9589, I9788, Z7901, Y838, Y92238, I10, E785, F419, I471, Z87891. The descriptions of icd codes I480, I313, I314, N390, I9589, I9788, Z7901, Y838, Y92238, I10, E785, F419, I471, Z87891 are I480: Paroxysmal atrial fibrillation; I313: Pericardial effusion (noninflammatory); I314: Cardiac tamponade; N390: Urinary tract infection, site not specified; I9589: Other hypotension; I9788: Other intraoperative complications of the circulatory system, not elsewhere classified; Z7901: Long term (current) use of anticoagulants; 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; Y92238: Other place in hospital as the place of occurrence of the external cause; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F419: Anxiety disorder, unspecified; I471: Supraventricular tachycardia; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I480, N390, Z7901, I10, E785, F419, Z87891. The uncommon codes mentioned in this dataset are I313, I314, I9589, I9788, Y838, Y92238, I471. Allergies Penicillins Bactrim DS Fosamax Scallops atorvastatin Chief Complaint Paroxysmal Afib Major Surgical or Invasive Procedure PVI AP Ablation ___ Percardiocentesis and Pericardial Drain Placement ___ History of Present Illness ___ hx. paroxysmal Afib s p PVI x2 cardioversion and multiple AADs with symptomatic Afib AT admitted for redo PVI AT ablation. The patient was intubated and sedated for procedure. During EP procedure the patient became hypotensive and was found to be in cardiac tamponade. The patient was started on dopamine for hypotension and subsequently had pericardiocentesis with 550 cc removed. TTE and ICE showed no further effusion 1 hour post . Pericardial drain was sutured in. On arrival to the CCU the patient continued to be intubated and sedated. She was hemodynamically stable and did not appear to be in cardiac tamponade. Pericardial drain continued to have hemorrhagic output. The patient was continued on dopamine and fentanyl for pain and sedation. Past Medical History 1. Hypertension 2. Long standing paroxysmal atrial fibrillation with initial reasonable control for over ___ years on Norpace which became ineffective in ___. Followed by a trial of quinidine procainamide and amiodarone. She continued symptomatic atrial fibrillation despite theseefforts and so she underwent pulmonary vein isolation in ___. Recurrent AF following the pulmonary vein isolation and underwent DC cardioversion x 2 later in ___ at which point Norpace was restarted. Recurrent symptomatic AF in ___ with increasing frequency over time. Holter monitoring revealed atrial fibrillation. Due to ongoing symptomatic episodes and that she had failed multiple antiarrhythmic medications in the past a decision was made to proceed with repeat PVI which was performed on ___. Following PVI she had recurrence of AT AF her Norpace was discontinued and amiodarone was resumed at a dose of 400 mg daily x 30 days she is now on 200 mg daily. Ongoing symptomatic palpitations almost daily for the past 3 weeks for ___ hours which give her a feeling of anxiety. Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory. Physical Exam ON ADMISSION VS HR 57 BP 146 59 RR 10 SpO2 100 on vent settings Gen Intubated and sedated but appears comfortable. HEENT Sclera clear. NECK No JVD or cervical lymphadenopathy CV RRR no m r g. LUNGS Pericardial drain in place with bloody output but appears clean dry and intact. CTAB in anterior lung fields. ABD L groin sheath appears clean dry and intact. EXT Warm well perfused no ___ edema SKIN No petechiae or ecchymoses. NEURO Moving all extremities with purpose. Biting on breathing tube. ON DISCHARGE VS Tc 97.9 HR 80 120 BP 120s 50s RR ___ SpO2 97 RA Wt 69.4 kg I O 24h ___ 8h NPO Gen alert and appears comfortable but anxious HEENT Sclera clear. NECK No JVD or cervical lymphadenopathy CV fast rate irregular rhythm no m r g. PPM in place left upper chest wall mildly ttp but no surrounding warmth or erythema or drainage LUNGS CTAB in anteriolateral lung fields. ABD soft nt nd EXT Warm well perfused no ___ edema SKIN No petechiae or ecchymoses. NEURO Moving all extremities with purpose. Pertinent Results LABS ADMISSION LABS ___ 07 15AM BLOOD WBC 7.0 RBC 4.51 Hgb 13.6 Hct 42.0 MCV 93 MCH 30.2 MCHC 32.4 RDW 13.1 RDWSD 44.4 Plt ___ ___ 07 15AM BLOOD Neuts 58.1 ___ Monos 8.7 Eos 1.3 Baso 0.4 Im ___ AbsNeut 4.09 AbsLymp 2.19 AbsMono 0.61 AbsEos 0.09 AbsBaso 0.03 ___ 07 15AM BLOOD ___ ___ 07 15AM BLOOD Plt ___ ___ 07 15AM BLOOD Glucose 72 UreaN 31 Creat 1.1 Na 141 K 4.1 Cl 104 HCO3 27 AnGap 14 ___ 10 55AM BLOOD ___ pO2 35 pCO2 39 pH 7.33 calTCO2 21 Base XS 4 Intubat NOT INTUBA ___ 11 47AM BLOOD Hgb 10.6 calcHCT 32 ___ 02 21PM BLOOD Glucose 170 Lactate 1.0 DISCHARGE LABS ___ 05 50AM BLOOD WBC 8.4 RBC 3.84 Hgb 11.9 Hct 36.5 MCV 95 MCH 31.0 MCHC 32.6 RDW 13.5 RDWSD 45.6 Plt ___ ___ 10 05AM BLOOD ___ PTT 31.0 ___ ___ 05 50AM BLOOD Glucose 102 UreaN 18 Creat 0.8 Na 138 K 4.0 Cl 103 HCO3 26 AnGap 13 ___ 05 50AM BLOOD Calcium 8.5 Phos 3.6 Mg 2.0 INR TREND ___ 07 15AM BLOOD ___ ___ 10 40AM BLOOD ___ PTT 45.0 ___ ___ 11 45AM BLOOD ___ PTT 31.9 ___ ___ 02 00PM BLOOD ___ PTT 34.6 ___ ___ 03 51AM BLOOD ___ PTT 34.6 ___ ___ 04 23AM BLOOD ___ PTT 43.0 ___ ___ 06 55AM BLOOD ___ PTT 37.8 ___ ___ 08 00AM BLOOD ___ PTT 27.8 ___ ___ 07 25AM BLOOD ___ PTT 27.5 ___ ___ 09 55AM BLOOD ___ PTT 28.1 ___ ___ 10 05AM BLOOD ___ PTT 31.0 ___ IMAGING TRANSTHORACIC ECHOCARDIOGRAM ___ Conclusions Overall left ventricular systolic function is normal LVEF 55 . Right ventricular chamber size and free wall motion are normal. There is a trivial physiologic pericardial effusion. There are no echocardiographic signs of tamponade. TRANSTHORACIC ECHOCARDIOGRAM ___ Conclusions FOCUSED STUDY LIMITED VIEWS. Overall left ventricular systolic function is normal LVEF 55 . Right ventricular chamber size and free wall motion are normal. There is a very small pericardial effusion best seen on subcostal images anterior to the right ventricle. There is an anterior space which most likely represents a prominent fat pad. There are no echocardiographic signs of tamponade. Compared with the prior study images reviewed of ___ the pericardial effusion is minimally larger. CXR ___ IMPRESSION Heart size and mediastinum are stable. Central venous line of unclear origin potentially pulmonary is present projecting over the heart please correlate with patient history. Lungs are clear. There is no pleural effusion or pneumothorax. MICRO ___ 8 53 pm MRSA SCREEN Source Nasal swab. FINAL REPORT ___ MRSA SCREEN Final ___ No MRSA isolated. Brief Hospital Course ___ y.o. woman with paroxysmal Afib Atach s p PVI x2 cardioversion and multiple AADs with symptomatic Afib AT admitted for redo PVI AT ablation complicated by pericardial tamponade during ablation s p pericardiocentesis and drain placement. Tamponade On ___ she underwent PVI AT ablation. During the procedure on ___ she was found to be in cardiac tamponade requiring pericardiocentesis. Pericardial drain was removed ___ and she remained hemodynamically stable Echo showed no reaccumulation of pericardial fluid. Atrial fibrilliation She went back into afib with rates in the 130s despite third PVI. Metoprolol was uptitrated but given recurrent medication failure and now 3 failed PV ablations decision was made for AVJ ablation and pacemaker. On ___ underwent dual chamber pacemaker placement. Patient was briefly on Dronedarone but discontinued after AVJ ablation. Her home norpace was discontinued as well. On ___ underwent successful AV nodal ablation. These procedures were uncomplicated. Urinary Tract Infection She was started on macrodantin for a urinary tract infection on ___ as an outpatient with a plan for nd macrodantin was continued until full 5 day course was complete. She had no urinary tract symptoms while inaptient. TRANSITIONAL ISSUES She will follow up in device clinic and with her primary cardiologist. Her norpace was stopped during this admission Patient discharged on Metoprolol Succinate 100 mg PO QDaily INR 2.2 at discharge. She was discharged on her home Coumadin regimen please recheck an INR within next few days and adjust Coumadin dosing as needed. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Disopyramide Phosphate 300 mg PO Q12H 3. Metoprolol Tartrate 75 mg PO BID 4. Warfarin 5 mg PO DAILY16 5. Simvastatin 20 mg PO QPM 6. lutein 10 mg oral BID 7. Vitamin D 1000 UNIT PO DAILY 8. Nitrofurantoin Macrodantin 100 mg PO BID Discharge Medications 1. Lisinopril 10 mg PO DAILY 2. Vitamin D 1000 UNIT PO DAILY 3. biotin 1000 mcg oral DAILY 4. cranberry conc ascorbic acid unknown ORAL DAILY 5. lutein 10 mg oral BID 6. Simvastatin 20 mg PO QPM 7. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate 100 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 1 8. Warfarin 7.5 mg PO 2X WEEK ___ 9. Warfarin 5 mg PO 5X WEEK ___ Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSES atrial fibrillation cardiac tamponade SECONDARY DIAGNOSES anxiety 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 your during your hospitalization at the ___. As you know you were admitted for a procedure to address your atrial fibrillation but developed bleeding around your heart covering called pericardial effusion cardiac tamponade leading to low blood pressures. You had a procedure to drain the bleeding and temporarily had a drain in place which was removed. You had a pacemaker placed and had a procedure called atrioventricular junction AVJ ablation. Please take your medication as instructed. Please followup with your cardiologists and primary care doctors. Sincerely ___ Care Team Followup Instructions ___ The icd codes present in this text will be I480, I313, I314, N390, I9589, I9788, Z7901, Y838, Y92238, I10, E785, F419, I471, Z87891. The descriptions of icd codes I480, I313, I314, N390, I9589, I9788, Z7901, Y838, Y92238, I10, E785, F419, I471, Z87891 are I480: Paroxysmal atrial fibrillation; I313: Pericardial effusion (noninflammatory); I314: Cardiac tamponade; N390: Urinary tract infection, site not specified; I9589: Other hypotension; I9788: Other intraoperative complications of the circulatory system, not elsewhere classified; Z7901: Long term (current) use of anticoagulants; 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; Y92238: Other place in hospital as the place of occurrence of the external cause; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F419: Anxiety disorder, unspecified; I471: Supraventricular tachycardia; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I480, N390, Z7901, I10, E785, F419, Z87891. The uncommon codes mentioned in this dataset are I313, I314, I9589, I9788, Y838, Y92238, I471.
The icd codes present in this text will be K5732, K521, Z23, R300, K5900, T368X5A, Y92239, L271, T3695XA, H538, R400, T450X5A. The descriptions of icd codes K5732, K521, Z23, R300, K5900, T368X5A, Y92239, L271, T3695XA, H538, R400, T450X5A are K5732: Diverticulitis of large intestine without perforation or abscess without bleeding; K521: Toxic gastroenteritis and colitis; Z23: Encounter for immunization; R300: Dysuria; K5900: Constipation, unspecified; T368X5A: Adverse effect of other systemic antibiotics, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; L271: Localized skin eruption due to drugs and medicaments taken internally; T3695XA: Adverse effect of unspecified systemic antibiotic, initial encounter; H538: Other visual disturbances; R400: Somnolence; T450X5A: Adverse effect of antiallergic and antiemetic drugs, initial encounter. The common codes which frequently come are K5900. The uncommon codes mentioned in this dataset are K5732, K521, Z23, R300, T368X5A, Y92239, L271, T3695XA, H538, R400, T450X5A. Allergies codeine ciprofloxacin diphenhydramine Chief Complaint RLQ abdominal pain Major Surgical or Invasive Procedure None History of Present Illness This is a ___ female with a past medical history of ___ s thyroiditis diagnosed 1 month ago diverticulosis who presents to the ED with 2 days of sharp right lower quadrant abdominal pain. The patient notes that she had constipation for the past week and took MiraLAX which allowed her to have a bowel movement yesterday. The pain was initially crampy and then became more acute and sharp. She continues to pass flatus. She also noted 2 episodes of blood in the tissue status post bowel movements however she did not notice any blood in her stool. She had fevers and some chills on ___. She denies any nausea or vomiting. Of note she traveled to ___ 1 month ago but she felt fine upon return. She denies any fevers or diarrhea while traveling. In the ED initial VS were 96.6 90 131 98 19 100 RA Labs showed Normal CBC lactate 1.1 normal chemistry panel UA without evidence of infection LFTs normal Imaging showed CT Abd Pelvis w contrast impression 1. Ascending colonic diverticulitis. No fluid collection or perforation. Follow up colonoscopy or cross sectional imaging is recommended in ___ weeks after treatment to ensure absence of an underlying mass lesion. 2. Focus of gas within the bladder lumen. Correlation with any history of recent instrumentation is recommended and if no such history is present correlation with urinalysis is recommended as infectious cystitis may be present. ACS was consulted after diverticulitis was seen on CT scan. They recommended n.p.o. IV fluids IV antibiotics and admission to medicine. Patient received IV Dilaudid IV Tylenol 2 L IV fluid IV ciprofloxacin IV metronidazole IV Zofran On evaluation in the ED the patient verifies the above history. She reports nausea but no vomiting. She reports some burning with urination. She is not sure how long she has been having this dysuria. She reports a fever to 102 for 1 day the day prior to admission. She was hoping that her abdominal pain would get better but when it got worse she presented to the ED. Further she states she developed right leg pain on the morning of admission. She says is in her groin and upper thigh. It so severe that is causing weakness in her leg. The patient states that at baseline she has a bowel movement every ___ days. Prior to this admission she had not had a bowel movement for approximately 1 week. Of note she was recently diagnosed with ___ s thyroiditis and took ibuprofen for approximately 2 days. It was giving her stomach cramps so she stopped 2 days ago. REVIEW OF SYSTEMS 10 point ROS reviewed and negative except as per HPI Past Medical History PAST MEDICAL AND SURGICAL HISTORY ___ s Thyroiditis Diverticulosis Osteopenia PSH lap cholecystectomy ___ appendectomy 30 years ago Social History ___ Family History No family history of colon cancer. Physical Exam ADMISSION PHYSICAL EXAM VS 98.4PO 117 68 74 20 97 GENERAL Uncomfortable appearing lying in bed HEENT AT NC anicteric sclera MMM NECK supple no LAD CV RRR S1 S2 no murmurs gallops or rubs PULM CTAB GI Severe tenderness to palpation in the right lower quadrant. Also severely tender in the right groin. Hypoactive bowel sounds EXTREMITIES no cyanosis clubbing or edema PULSES 2 radial pulses bilaterally NEURO Alert sensation intact in bilateral lower cavities. Patient unable to flex right lower extremity at the hip secondary to pain. 5 out of 5 strength in the left lower extremity. DERM warm and well perfused no excoriations or lesions no rashes DISCHARGE PHYSICAL EXAM VS Reviewed in POE. GENERAL Comfortable appearing sitting in bed watching movie on laptop HEENT AT NC anicteric sclera MMM NECK supple no LAD CV RRR S1 S2 no murmurs gallops or rubs PULM CTAB GI mild TTP in RLQ no guarding rebound BS EXTREMITIES no cyanosis clubbing or edema NEURO Alert sensation intact in bilateral lower extremities. Patient now able to flex right lower extremity at the hip without pain. ___ strength b l ___. DERM warm and well perfused no excoriations or lesions no rashes Pertinent Results ADMISSION LABS ___ 09 20PM BLOOD WBC 6.1 RBC 3.88 Hgb 11.3 Hct 34.4 MCV 89 MCH 29.1 MCHC 32.8 RDW 12.4 RDWSD 40.0 Plt ___ ___ 09 20PM BLOOD Neuts 59.7 ___ Monos 11.8 Eos 2.1 Baso 0.7 Im ___ AbsNeut 3.65 AbsLymp 1.56 AbsMono 0.72 AbsEos 0.13 AbsBaso 0.04 ___ 12 50PM BLOOD Glucose 109 UreaN 12 Creat 0.7 Na 141 K 4.7 Cl 98 HCO3 29 AnGap 14 ___ 12 50PM BLOOD ALT 19 AST 20 AlkPhos 89 TotBili 0.6 ___ 12 50PM BLOOD Lipase 36 ___ 12 50PM BLOOD Albumin 4.6 ___ 07 25AM BLOOD Calcium 9.1 Phos 3.7 Mg 2.0 ___ 12 57PM BLOOD Lactate 1.3 ___ 09 25PM BLOOD Lactate 1.1 PERTINENT INTERVAL AND DISCHARGE LABS ___ 07 45AM BLOOD WBC 4.3 RBC 3.92 Hgb 11.4 Hct 34.5 MCV 88 MCH 29.1 MCHC 33.0 RDW 12.0 RDWSD 38.6 Plt ___ ___ 07 45AM BLOOD Glucose 115 UreaN 8 Creat 0.7 Na 142 K 4.0 Cl 105 HCO3 23 AnGap 14 ___ 07 45AM BLOOD Calcium 8.9 Phos 3.9 Mg 1.9 MICRO ___ 4 09 pm STOOL CONSISTENCY NOT APPLICABLE Source Stool. FECAL CULTURE Final ___ NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE Final ___ NO CAMPYLOBACTER FOUND. OVA PARASITES Preliminary 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. IMAGING ___ CT A P 1. Ascending colonic diverticulitis. No fluid collection or perforation. Follow up colonoscopy or cross sectional imaging is recommended in ___ weeks after treatment to ensure absence of an underlying mass lesion. 2. Focus of gas within the bladder lumen. Correlation with any history of recent instrumentation is recommended and if no such history is present correlation with urinalysis is recommended as infectious cystitis may be present. RECOMMENDATION S Follow up colonoscopy or cross sectional imaging is recommended in ___ weeks after treatment to ensure absence of an underlying mass lesion. Brief Hospital Course Pt presented to the ED with severe sharp RLQ pain and right upper leg and groin pain with movement as well as urinary frequency and fever found to have diverticulitis treated conservatively with 14 day course Levofloxacin and Flagyl. Active Issues Diverticulitis CT A P showed diverticulitis of the ascending colon corresponding to the pts reported pain and TTP. This was treated with IV fluids bowel rest and ciprofloxacin and metronidazole. However cipro was discontinued given c f allergic reaction as below. Her regimen of ciprofloxacin and metronidazole was switched to amoxicillin clavulanic acid for 1 dose but out of concern for E.coli resistance and due to low rate of cross reactivity between ciprofloxacin and levofloxacin per pharmacy recommendation we switched to levofloxacin and metronidazole. She tolerated levofloxacin without apparent allergic reaction. Pt was monitored until she was pain free and could tolerate adequate PO intake. Nausea had almost completely resolved at the time of discharge. Provided with a prescription for prn Zofran QTc 399ms on discharge . Ciprofloxacin reaction After three doses of ciprofloxacin the pt had a reaction in which she had an itchy rash extend proximally from the site of infusion and experienced lightheadedness. Subsequently switched to Levofloxacin as above without recurrent reaction. Dysuria UA showed blood and few bacteria but otherwise was fairly bland. CT scan showed gas in the bladder lumen. Her symptoms resolved on their own without intervention. Diarrhea Pt had one episode of watery diarrhea up to every 20 mins for ___ days. Diarrhea resolved on its own. Likely antibiotic related. Given spontaneous resolution low suspicion for C diff. Sensitivity to anti cholinergic medications In the setting of the above noted allergic reaction to ciprofloxacin patient received diphenhydramine Benadryl and became acutely confused. This medication was added to her adverse drug reaction ADR list. On ___ she was given a scopolamine patch for nausea and developed abrupt onset of moderate severe blurry vision that was very concerning to the patient as well as dry mouth and drowsiness. These anticholinergic symptoms resolved shortly after removing the scopolamine patch. We would advise extreme caution in utilizing any medications with anti cholinergic effects going forward. Transitional issues Completing 14 day antibiotic course with levofloxacin and Flagyl for diverticulitis last dose ___. Please refer to GI for colonoscopy in ___ weeks. Had allergic reaction to cipro but tolerated levofloxacin Seems to be very sensitive to anti cholinergic medications Core issues Code Full presumed Contact ___ friend ___ . . . . Time in care greater than 30 minutes in discharge related activities on the day of discharge. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Calcium 500 calcium carbonate 500 mg calcium 1 250 mg oral DAILY Discharge Medications 1. Levofloxacin 750 mg PO Q24H Duration 8 Doses RX levofloxacin Levaquin 750 mg 1 tablet s by mouth daily Disp 8 Tablet Refills 0 2. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole Flagyl 500 mg 1 tablet s by mouth every 8 hours Disp 24 Tablet Refills 0 3. Ondansetron 4 mg PO Q8H PRN Nausea Vomiting First Line Duration 3 Days RX ondansetron 4 mg 1 tablet s by mouth three times daily as needed Disp 9 Tablet Refills 0 4. Calcium 500 calcium carbonate 500 mg calcium 1 250 mg oral DAILY Discharge Disposition Home Discharge Diagnosis Diverticulitis of the ascending colon. Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear ___ It was a pleasure taking care of you at ___. Why you were in the hospital You had severe pain in your right lower abdomen pain in your right upper leg and urinary frequency. What was done for you in the hospital We did a CT scan of your abdomen and pelvis to evaluate your pain and found diverticulitis which is inflammation in diverticula of the colon. These are small out pouchings that can become inflamed and cause pain. We gave you antibiotics to treat diverticulitis and when you reacted to one of the antibiotics ciproflaxacin we switched you to another levofloxacin . We gave you IV fluids and encouraged rest of your bowels followed by light intake of clear liquids then soft foods. We gave you a medication to help with nausea with eating We did an analysis of your urine and did not see clear evidence of an infection. We did not intervene because the symptoms resolved on their own. What you should do after you leave the hospital Please take your medications as detailed in the discharge papers. If you have questions about which medications to take please contact your regular doctor to discuss. Please go to see your primary care doctor as detailed in discharge papers. Please also visit a gastroenterologist for a colonoscopy ___ weeks after discharge. Please monitor for worsening symptoms. If you do not feel like you are getting better or have any other concerns please call your doctor to discuss or return to the emergency room. We wish you the best Sincerely Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be K5732, K521, Z23, R300, K5900, T368X5A, Y92239, L271, T3695XA, H538, R400, T450X5A. The descriptions of icd codes K5732, K521, Z23, R300, K5900, T368X5A, Y92239, L271, T3695XA, H538, R400, T450X5A are K5732: Diverticulitis of large intestine without perforation or abscess without bleeding; K521: Toxic gastroenteritis and colitis; Z23: Encounter for immunization; R300: Dysuria; K5900: Constipation, unspecified; T368X5A: Adverse effect of other systemic antibiotics, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; L271: Localized skin eruption due to drugs and medicaments taken internally; T3695XA: Adverse effect of unspecified systemic antibiotic, initial encounter; H538: Other visual disturbances; R400: Somnolence; T450X5A: Adverse effect of antiallergic and antiemetic drugs, initial encounter. The common codes which frequently come are K5900. The uncommon codes mentioned in this dataset are K5732, K521, Z23, R300, T368X5A, Y92239, L271, T3695XA, H538, R400, T450X5A.
The icd codes present in this text will be K661, K831, K754, I10, K589, F329, E119, Z794, I776, I9581. The descriptions of icd codes K661, K831, K754, I10, K589, F329, E119, Z794, I776, I9581 are K661: Hemoperitoneum; K831: Obstruction of bile duct; K754: Autoimmune hepatitis; I10: Essential (primary) hypertension; K589: Irritable bowel syndrome without diarrhea; F329: Major depressive disorder, single episode, unspecified; E119: Type 2 diabetes mellitus without complications; Z794: Long term (current) use of insulin; I776: Arteritis, unspecified; I9581: Postprocedural hypotension. The common codes which frequently come are I10, F329, E119, Z794. The uncommon codes mentioned in this dataset are K661, K831, K754, K589, I776, I9581. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint LUQ pain Major Surgical or Invasive Procedure ___ Gel Foam embolization of the left gastric artery. ___ Upper endoscopy History of Present Illness ___ PMHx for alcoholism DM vasculitis and a remote hx of a rupture splenic artery pseudoaneurysm that was embolized ___ who was admitted from OSH with concerns for hemoperitoneum. Of significance patient was seen by the surgical service in ___ for an acute onset of UGI bleed with subsequent findings significant for ruptured pseudoaneurysm into the lesser sac of the stomach. CT scan back in ___ characterized two splenic proximal distal aneurysms. The proximal pseudoaneurysm that was ruptured was coiled. Patient did have a prolonged hospital course but was eventually discharged in stable condition. Patient now states that she has been complaining of significant bilateral rib pain since ___ that have progressed. She now complains of colicky sharp left upper quadrant abdominal pain as well as difficulty with PO intake. She states that she hasn t passed gas for ___ days. Denies fevers BRBPR or UGB. She went to OSH where she was scanned and was found to have a three pockets of hemoperitoneum perihepatic pelvic and near the stomach. Past Medical History PAST MEDICAL HISTORY Autoimmune hepatitis Vasculitis HTN IBS Depression DM Alcoholism Migraines . PAST PSYCHITATRIC HISTORY Pt sees a psychiatrist and a therapist for likely depression with possibility of mania per patient report. This is to be confirmed with her Psychiatrist Dr ___ and therapist Dr ___. She denies ever being hospitalized for such depressions. She states that she has contemplated suicide but has bot been really serious about it. She has poor sleep treated with sleeping medicines and feels guilty about not feeling good and letting her family down by not taking care of herself. Her mother s death ___ years ago remains a source of her depression. Social History SOCIAL HISTORY Pt is older of two children describes happy childhood. Denies abuse. One year of college. Works as a ___ for the fourth grade. Married with ___ old twins and is happy that she has coinciding holidays with them. SUBSTANCE USE Denies tobacco. History of ETOH abuse though claims sobriety from ETOH for past ___ years. Used to drink 1 qt whisky qday x years denies ___. blackouts no seizures no severe withdrawal. History of 2 detoxes at least including ___ in ___. History of fairly heavy marijuana use x years between ages ___ History of heavy daily cocaine use x years between ages ___ Denies IVDU Family History FAMILY PSYCHIATRIC HISTORY Sister and Grandmother diagnosed with depression. Her grandmother had been hospitalized for this. Physical Exam Admission Physical exam Vitals Stable General AAOx3 Cardiac Normal S1 S2 Respiratory Breathing comfortably on room air Abdomen Soft distended tenderness in LUQ mid tenderness RUQ. No rebound or guarding. No signs of peritonitis. Skin No lesions Discharge Physical Exam VS 98.2 99 171 87 18 98 GEN AA O x 3 NAD calm cooperative. HEENT LAD mucous membranes moist trachea midline EOMI PERRL. CHEST Clear to auscultation bilaterally cyanosis. ABDOMEN BS x 4 quadrants soft mildly tender to palpation EXTREMITIES Warm well perfused pulses palpable edema Pertinent Results ___ 03 15PM BLOOD Hct 29.9 ___ 03 11AM BLOOD WBC 11.2 RBC 2.88 Hgb 9.0 Hct 28.1 MCV 98 MCH 31.3 MCHC 32.0 RDW 12.9 RDWSD 45.1 Plt ___ ___ 07 22PM BLOOD WBC 11.5 RBC 2.76 Hgb 8.9 Hct 26.9 MCV 98 MCH 32.2 MCHC 33.1 RDW 12.9 RDWSD 45.0 Plt ___ ___ 05 10PM BLOOD WBC 11.7 RBC 2.72 Hgb 8.8 Hct 26.5 MCV 97 MCH 32.4 MCHC 33.2 RDW 12.9 RDWSD 45.2 Plt ___ ___ 12 50PM BLOOD WBC 12.7 RBC 2.80 Hgb 8.8 Hct 27.2 MCV 97 MCH 31.4 MCHC 32.4 RDW 12.9 RDWSD 45.2 Plt ___ ___ 11 06PM BLOOD WBC 10.3 RBC 2.55 Hgb 8.1 Hct 25.2 MCV 99 MCH 31.8 MCHC 32.1 RDW 13.0 RDWSD 46.2 Plt ___ ___ 07 44PM BLOOD WBC 11.0 RBC 2.36 Hgb 7.6 Hct 23.3 MCV 99 MCH 32.2 MCHC 32.6 RDW 12.9 RDWSD 45.1 Plt ___ ___ 02 27PM BLOOD WBC 13.3 RBC 2.66 Hgb 8.4 Hct 26.2 MCV 99 MCH 31.6 MCHC 32.1 RDW 12.8 RDWSD 45.3 Plt ___ ___ 05 26AM BLOOD WBC 9.9 RBC 2.97 Hgb 9.4 Hct 29.0 MCV 98 MCH 31.6 MCHC 32.4 RDW 12.8 RDWSD 45.2 Plt ___ Imaging ___ CT A P 1. No evidence of aneurysm pseudoaneurysm or active extravasation. 2. Small volume hemoperitoneum in the upper abdomen and pelvis little changed from the outside hospital CT performed several hours earlier. 3. More localized fluid with surrounding stranding along the greater curvature of the stomach raising the possibility that the source of bleeding is from the gastroepiploic territory. However an underlying lesion cannot be excluded and an MRI is recommended for further evaluation when clinically appropriate. ___ MESENTERIC ARTERIOGRAM Abnormal appearance of the left gastric artery treated with Gel Foam embolization. Otherwise normal arteriograms of the celiac gastroduodenal artery gastroepiploic artery and superior mesenteric artery without active extravasation. ___ MRI Abdomen 1. Limited exam due to the artifact from splenic artery embolization coils. Diffusion and pre and post contrast sequences cannot be used to assess for tumor given this artifact. However no obvious signal abnormality or other finding is seen in the gastric wall on other T1 or T2 weighted sequences. 2. Similar appearance of hematoma along the greater curvature of the stomach intimately associated with the gastric wall again raising the possibility of a gastroepiploic artery or gastric wall vascular abnormality as the etiology of this finding. 3. Main pancreatic ductal dilation to 6 mm without extrahepatic or intrahepatic biliary dilation. A ___ at the ampulla or ampullary stenosis is not excluded. 4. Bibasilar atelectasis right greater than left. 5. 4 mm gallbladder polyp. No specific follow up is needed for this finding. Brief Hospital Course Ms. ___ was admitted to spontaneous hemoperitoneum with unknown etiology. CTA did not reveal any extravasation. ___ was consulted and an angiogram was performed. They did not see any extravasation but noted the left gastric to be abnormal in appearance. The left gastric was then gel foam embolized given it s abnormal appearance. An MRI was obtained to rule out any gastric masses. It revealed a possibly abnormal gastric wall and a possibly stenotic ampulla. Given these findings GI was consulted. During this time she was admitted to the ICU with the following course. Neuro Her pain was controlled with IV and then subsequently PO pain medication. CV hemodynamics were monitored closely. She was intermittently tachycardic upon arrival which shortly resolved. Resp She remained stable on room air GI Please see above imaging and intervention course. Her diet was advanced once her Hcts were stable. GU UOP was adequate with a foley in place Heme Serial hematocrits were obtained without need for transfusions. ID no acute issues She was stable for transfer to the floor on ___. Hematocrit was stable and subcutaneous heparin was restarted for DVT prophylaxis. On HD5 the patient was triggered for hypotension hypoxia and downtrending hematocrit. Repeat CT of abdomen pelvis showed mild interval decrease in the amount of small volume hemoperitoneum. Chest xray and cardiac enzymes were normal. The following day the hematocrit came up on its own. GI was consulted for endoscopic evaluation to rule out a gastric malignancy that may have led to her bleed. on HD7 the patient underwent an EGD which was normal and showed no findings to explain the bleeding. Pain was well controlled. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization the patient ambulated early and frequently was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. . At the time of discharge the patient was doing well afebrile with stable vital signs. The patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. TraZODone 200 mg PO QHS PRN insomnia 2. Verapamil 360 mg PO Q12H 3. Venlafaxine XR 150 mg PO DAILY 4. PredniSONE 7 mg PO DAILY 5. Metoclopramide 10 mg PO DAILY 6. Pramipexole 1 mg PO QHS 7. Omeprazole 20 mg PO BID 8. MethylPHENIDATE Ritalin 20 mg PO TID 9. NovoLIN 70 30 insulin NPH and regular human 8 units subcutaneous DAILY 10. Gabapentin 1200 mg PO BID 11. Fluticasone Propionate NASAL 2 SPRY NU DAILY 12. Fluoxetine 20 mg PO DAILY 13. Celebrex ___ mg oral BID 14. Atenolol 25 mg PO DAILY Discharge Medications 1. OxycoDONE Immediate Release ___ mg PO Q4H PRN pain RX oxycodone 5 mg 1 tablet s by mouth every six 6 hours Disp 20 Tablet Refills 0 2. NovoLIN 70 30 insulin NPH and regular human 8 units subcutaneous DAILY 3. Celebrex ___ mg oral BID 4. Senna 8.6 mg PO BID 5. Atenolol 25 mg PO DAILY 6. Fluoxetine 20 mg PO DAILY 7. Fluticasone Propionate NASAL 2 SPRY NU DAILY 8. Gabapentin 1200 mg PO BID 9. MethylPHENIDATE Ritalin 20 mg PO TID 10. Metoclopramide 10 mg PO DAILY 11. Omeprazole 20 mg PO BID 12. Pramipexole 1 mg PO QHS 13. PredniSONE 7 mg PO DAILY 14. TraZODone 200 mg PO QHS PRN insomnia 15. Venlafaxine XR 150 mg PO DAILY 16. Verapamil 360 mg PO Q12H 17. Bisacodyl 10 mg PO PR DAILY PRN constipation 18. Docusate Sodium 100 mg PO BID Discharge Disposition Home Discharge Diagnosis Hemoperitoneum Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You were transferred to ___ with complaints of abdominal pain and CT imaging concerning for blood in your peritoneum but did not show any active bleeding. You were admitted for close monitoring for any sign of continued bleeding. Your hematocrit and vital signs have been stable and you did not require any blood transfusions or interventional procedure to stop the bleeding. The Gastroenterology doctors were ___ and they performed an endoscopic exam of your stomach which showed no findings on EGD to explain the bleeding. You are now tolerating a regular diet and your pain is improved. You are ready to be discharged home to continue your recovery. Please note the following discharge instructions Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following You experience new chest pain pressure squeezing or tightness. New or worsening cough shortness of breath or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting diarrhea or other reasons. Signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing. You see blood or dark black material when you vomit or have a bowel movement. You experience burning when you urinate have blood in your urine or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms or any new symptoms that concern you. Please resume all regular home medications unless specifically advised not to take a particular medication. Also please take any new medications as prescribed. Please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids. Followup Instructions ___ The icd codes present in this text will be K661, K831, K754, I10, K589, F329, E119, Z794, I776, I9581. The descriptions of icd codes K661, K831, K754, I10, K589, F329, E119, Z794, I776, I9581 are K661: Hemoperitoneum; K831: Obstruction of bile duct; K754: Autoimmune hepatitis; I10: Essential (primary) hypertension; K589: Irritable bowel syndrome without diarrhea; F329: Major depressive disorder, single episode, unspecified; E119: Type 2 diabetes mellitus without complications; Z794: Long term (current) use of insulin; I776: Arteritis, unspecified; I9581: Postprocedural hypotension. The common codes which frequently come are I10, F329, E119, Z794. The uncommon codes mentioned in this dataset are K661, K831, K754, K589, I776, I9581.
The icd codes present in this text will be S7222XA, D62, W010XXA, G4731, S82842A, M810, I498. The descriptions of icd codes S7222XA, D62, W010XXA, G4731, S82842A, M810, I498 are S7222XA: Displaced subtrochanteric fracture of left femur, initial encounter for closed fracture; D62: Acute posthemorrhagic anemia; W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter; G4731: Primary central sleep apnea; S82842A: Displaced bimalleolar fracture of left lower leg, initial encounter for closed fracture; M810: Age-related osteoporosis without current pathological fracture; I498: Other specified cardiac arrhythmias. The common codes which frequently come are D62. The uncommon codes mentioned in this dataset are S7222XA, W010XXA, G4731, S82842A, M810, I498. Allergies Diflucan Chief Complaint Left ankle and foot pain Major Surgical or Invasive Procedure Left cephalo medullary nail air cast boot for ankle History of Present Illness ___ female with a history of Ehlers Danlos syndrome pots disease and dysautonomia presents with left hip and left ankle pain for 1 days duration. Today the patient was sitting on the couch watching TV for prolonged period of time. She stood up and her foot was asleep and she attempted to ambulate into her kitchen. She stumbled on her sleeping foot landing onto her left side. She denies head strike or loss of consciousness. She denies presyncopal symptoms. She complains of isolated left hip and left ankle pain. She denies numbness and tingling in the extremity. She denies headache neck pain back pain chest pain shortness of breath abdominal pain nausea and other medical complaints Past Medical History POTs ALLERGIC RHINITIS ATTENTION DEFICIT DISORDER WITHOUT HYPERACTIVITY GASTRITIS HAYFEVER L5 DISC MACROSCOPIC HEMATURIA OSTEOPOROSIS RAYNAUD S PHENOMENON PLANTAR FASCIITIS IRRITABLE BOWEL SYNDROME LACTOSE INTOLERANCE EHLERS DANLOS SYNDROME SLEEP APNEA CENTRAL SLEEP APNEA Social History She lives locally. She is a former ___ of astro . She works mostly from home. She drinks a small amount of alcohol on very rare occasions. Denies tobacco marijuana and illicit drug use. She is a community ambulator that completes all her activities of daily living. Marital status Married Name ___ ___ Children No Lives with ___ Work ___ Domestic violence Denies Contraception N A Tobacco use Never smoker Tobacco Use no tobacco products ever Comments Alcohol use Present Alcohol use 4 year comments Recreational drugs Denies marijuana heroin crack pills or other Depression Based on a PHQ 2 evaluation the patient does not report symptoms of depression Exercise Activities ___ walks daily. limited by plantar fascitis ___ Exercise comments Footnote treadmill Diet coffee 2 day Seat belt vehicle Always Family History NC Physical Exam Gen NAD Res No resp distress LLE Knee effusion Fires ___ ___ Pulses WWP Dressing C D I SILT Sural saphenous tibial peroneal distributions 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 subtrochanteric femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for a cephalo medullary nail 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 patient also has a left ankle fracture which will be managed non operatively in an air cast boot. 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 weight bearing as tolerated in the left lower extremity 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 1. ACETAZOLAMIDE acetazolamide 125 mg tablet. 1 tablet s by mouth once As needed for sleep study 2. ESTROGEN TESTOSTERON PROGESTERONE Dosage uncertain Prescribed by Other Provider 3. IODORAL Iodoral . 6.25 mg by mouth three times a week Prescribed by Other Provider 4. QUERCETIN DIHYDRATE BULK Dosage uncertain Prescribed by Other Provider 5. ACTIVATED CHARCOAL activated charcoal 200 mg capsule. capsule s by mouth as needed OTC 6. CHOLECALCIFEROL VITAMIN D3 cholecalciferol vitamin D3 2 000 unit capsule. 1 Capsule s by mouth once a day Prescribed by Other Provider 7. COENZYME Q10 CO Q 10 Dosage uncertain OTC 8. DIGESTIVE ENZYMES digestive enzymes capsule. capsule s by mouth daily OTC 9. FERROUS SULFATE IRON iron 325 mg 65 mg iron tablet. tablet s by mouth three times a week Prescribed by Other Provider Dose adjustment no new Rx 10. LORATADINE CLARITIN Claritin 10 mg tablet. tablet s by mouth Prescribed by Other Provider Dose adjustment no new Rx 11. MAGNESIUM magnesium 200 mg tablet. 2 tablet s by mouth Prescribed by Other Provider Dose adjustment no new Rx 12. MULTIVITAMIN multivitamin tablet. tablet s by mouth OTC Dose adjustment no new Rx 13. PHYTONADIONE VITAMIN K1 phytonadione vitamin K1 100 mcg tablet. tablet s by mouth OTC 14. WODENZYME wodenzyme . ___ tablets daily OTC Discharge Medications 1. Acetaminophen 1000 mg PO Q8H 2. Cyclobenzaprine 5 mg PO TID PRN Spasm 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC DAILY RX enoxaparin 40 mg 0.4 mL 1 syringe subcutaneous daily Disp 28 Syringe Refills 0 5. HYDROmorphone Dilaudid ___ mg PO Q4H PRN Pain Moderate Reason for PRN duplicate override Alternating agents for similar severity Partial fill ok RX hydromorphone Dilaudid 2 mg ___ tablet s by mouth every 4 hours Disp 30 Tablet Refills 0 6. Loratadine 10 mg PO DAILY 7. Senna 8.6 mg PO BID Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Left subtrochanteric femur fracture Left bimalleolar ankle fracture Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. 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 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. 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 Physical Therapy Activity Activity Out of bed w assist Left lower extremity Full weight bearing Encourage turn cough and deep breathe q2h when awake Treatments Frequency Any staples or superficial sutures you have are to remain in place for at least 2 weeks postoperatively. Incision may be left open to air unless actively draining. If draining you may apply a gauze dressing secured with paper tape. You may shower and allow water to run over the wound but please refrain from bathing for at least 4 weeks postoperatively. Followup Instructions ___ The icd codes present in this text will be S7222XA, D62, W010XXA, G4731, S82842A, M810, I498. The descriptions of icd codes S7222XA, D62, W010XXA, G4731, S82842A, M810, I498 are S7222XA: Displaced subtrochanteric fracture of left femur, initial encounter for closed fracture; D62: Acute posthemorrhagic anemia; W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter; G4731: Primary central sleep apnea; S82842A: Displaced bimalleolar fracture of left lower leg, initial encounter for closed fracture; M810: Age-related osteoporosis without current pathological fracture; I498: Other specified cardiac arrhythmias. The common codes which frequently come are D62. The uncommon codes mentioned in this dataset are S7222XA, W010XXA, G4731, S82842A, M810, I498.
The icd codes present in this text will be E1065, C8590, T380X5A, I10, E785, Z9641. The descriptions of icd codes E1065, C8590, T380X5A, I10, E785, Z9641 are E1065: Type 1 diabetes mellitus with hyperglycemia; C8590: Non-Hodgkin lymphoma, unspecified, unspecified site; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z9641: Presence of insulin pump (external) (internal). The common codes which frequently come are I10, E785. The uncommon codes mentioned in this dataset are E1065, C8590, T380X5A, Z9641. Allergies Codeine pseudoephedrine Chief Complaint hyperglycemia Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ woman with a history of type 1 diabetes on insulin pump as well as non Hodgkin lymphoma who presents with concern for hyperglycemia after starting prednisone for chemotherapy. She reports that she just received chemotherapy including prednisone on day of presentation to the ED and that her blood sugars have been elevated above 300 since. She is due to receive 4 more days of 100 mg prednisone. She is finished with the rest of the chemotherapeutic agents. She did receive Neulasta. She spoke to her endocrinologist at ___ and ___ recommended that she come in to be evaluated. She recently was inpatient for hyperglycemia in the setting of steroids for a prior chemotherapy regimen as well. She is currently completely asymptomatic. Per phone call note in OMR patient stated her NHL returned aggressively and that she is currently on 100mg of steroids daily. She was last admitted in ___ also for hyperglycemia in the setting of dexamethasone. In the ED Initial vital signs were notable for T 96.5 HR 84 BP 150 72 RR 18 O2 sat 99 on RA FSBG 378 Exam notable for no concerning findings Labs were notable for CBC WBC 8.5 Hb 10.3 Hct 29.5 Plt 239 VBG pH 7.46 pCO2 30 pO2 110 HCO3 22 BMP Na 136 K 4.3 Cl 102 Bicarb 18 BUN 35 Cr 0.9 Glu 319 AG 16 Studies performed include U A neg leuk est blood nitr ketones 1000 gluc 1 RBC 1 WBC No imaging Patient was given none Consults ___ Vitals on transfer T 98.2 HR 68 BP 122 70 RR 16 O2 sat 99 on RA Upon arrival to the floor patient is very anxious regarding her hospitalization specifically being in a shared room because she is afraid of catching infection given chemotherapy. Patient started R CHOP therapy on ___ and is due for prednisone 100mg daily for 5 days ___ . She reports her blood glucose was increased to 450 last night prompting decision to come to the ED because she lives alone and was afraid that she would not be okay by herself. On interview she denies any infectious symptoms including cough dysuria fever chills. She also denies chest pain dyspnea change in bowel habits nausea vomiting headache numbness or dizziness. She got neulasta yesterday as part of her chemotherapy regimen. She had previously gotten dexamethasone and rituximab over the ___ for NHL but notes her disease is more aggressive now and so she will be getting R CHOP chemo q3 weeks until ___. REVIEW OF SYSTEMS See above as per HPI. Past Medical History Type I DM on insulin pump Non Hodgkin s Lymphoma diagnosed ___ and never treated Hyperlipidemia Hypertension Social History ___ Family History Non contributory to this hospitalization Physical Exam ADMISSION PHYSICAL EXAM VITALS ___ 1756 Temp 98.4 PO BP 130 65 R Lying HR 79 RR 18 O2 sat 98 O2 delivery Ra GENERAL Alert and interactive. Anxious appearing. Wearing latex gloves and surgical mask. HEENT NCAT. PERRL EOMI. Sclera anicteric and without injection. MMM. 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 on RA. ABDOMEN BS soft ND NT to palpation. No organomegaly. Insulin pump on RLQ site without erythema or tenderness. EXTREMITIES No clubbing cyanosis or edema. SKIN Warm. No rash. NEUROLOGIC AOx3. No focal neurologic deficits. CN2 12 grossly intact. DISCHARGE PHYSICAL EXAM VITALS 24 HR Data last updated ___ 1144 Temp 98.7 Tm 98.9 BP 157 72 109 157 63 72 HR 83 62 89 RR 18 O2 sat 96 95 98 O2 delivery Ra GENERAL Alert and interactive. Anxious appearing. HEENT NCAT. PERRL EOMI. Sclera anicteric and without injection. MMM. 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 on RA. ABDOMEN BS soft ND NT to palpation. No organomegaly. Insulin pump on RLQ site without erythema or tenderness. EXTREMITIES No clubbing cyanosis. Non pitting edema is present bilaterally SKIN Warm. No rash. NEUROLOGIC AOx3. No focal neurologic deficits. CN2 12 grossly intact. Pertinent Results ADMISSION LABS ___ 01 25AM BLOOD WBC 8.5 RBC 3.58 Hgb 10.3 Hct 29.5 MCV 82 MCH 28.8 MCHC 34.9 RDW 13.5 RDWSD 40.9 Plt ___ ___ 01 25AM BLOOD Neuts 83.5 Lymphs 8.9 Monos 6.9 Eos 0.0 Baso 0.2 Im ___ AbsNeut 7.12 AbsLymp 0.76 AbsMono 0.59 AbsEos 0.00 AbsBaso 0.02 ___ 06 38AM BLOOD Glucose 319 UreaN 35 Creat 0.9 Na 136 K 4.3 Cl 102 HCO3 18 AnGap 16 ___ 08 25AM BLOOD Calcium 10.0 Phos 1.7 Mg 2.0 ___ 01 28AM BLOOD ___ pO2 110 pCO2 30 pH 7.46 calTCO2 22 Base XS 0 Comment GREEN TOP IMAGING None MICROBIOLOGY ___ 1 25 am URINE FINAL REPORT ___ URINE CULTURE Final ___ 10 000 CFU mL. DISCHARGE INTERVAL LABS ___ 07 35AM BLOOD WBC 19.5 RBC 3.55 Hgb 10.1 Hct 31.0 MCV 87 MCH 28.5 MCHC 32.6 RDW 13.6 RDWSD 43.7 Plt ___ ___ 07 35AM BLOOD Glucose 110 UreaN 28 Creat 0.8 Na 139 K 3.6 Cl 102 HCO3 25 AnGap 12 ___ 07 35AM BLOOD Calcium 9.9 Phos 2.4 Mg 2.0 Brief Hospital Course Ms. ___ is a ___ female with past medical history notable for Type 1 DM with insulin pump and Non Hodgkin s Lymphoma started on R CHOP ___ who presented with hyperglycemia in the setting of taking prednisone without evidence of inciting infection or DKA. ACUTE ISSUES Hyperglycemia Type 1 DM with insulin pump. Patient with Type I DM and presenting with elevated sugars in the setting of taking prednisone for treatment of Non Hodgkin s Lymphoma. Patient has an insulin pump for management and is followed by Dr. ___ at ___. Blood glucose elevated to 300s on admission. No evidence of DKA as normal anion gap 16 and no ketonuria. No evidence of infection and patient not reporting any localizing symptoms. Patient also denies chest pain or cardiac symptoms. Of note patient is able to manage her insulin pump quite well as documented in previous notes. Patient will need prednisone until ___ and will continue to require increased insulin during this period of time as well as with future chemotherapy cycles. Patient evaluated by ___ with recommendations to add 10 U NPH in AM and 5 U NPH at 1300. On the first day patient agreed to 5 U NPH in AM and in afternoon with improvement in FSBGs. On the day of discharge patient took 10 U NPH in AM but refused to take additional NPH in ___. She was evaluated by ___ who felt that she was safe to discharge and can manage her FSBGs on her own with the assistance of the on call ___ physician. Leukocytosis. No localizing symptoms concerning for infection. U A without pyuria nitrites leuk esterase or bacteria. Most likely due to recent Neulasta injection which patient received on ___ with chemotherapy. Non Hodgkins lymphoma. Diagnosed in ___. Previously treated with rituximab now more aggressive per patient. Her primary oncologist is Dr. ___ at ___. She initiated R CHOP on ___ with plan for chemotherapy q3 weeks until ___. She will continue prednisone 100mg x5d as part of the chemotherapy protocol ___. CHRONIC ISSUES Hyperlipidemia. Continue atorvastatin 20mg qPM TRANSITIONAL ISSUES Insulin plan while on Prednisone per ___ 10 units NPH at time of steroid dose administration in am. Then give another 5 units NPH at 1pm She should be continued on a similar regimen at her next steroid cycle to avoid hospital readmissions Will need to reschedule her eye appointment with ___ Continue to engage with ___ team about obtaining assistance for anxiety coping . . . . . . . Attending addendum Greater than 30 minutes were spent providing and coordinating care for this patient on day of discharge. ___ MD Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Probiotic B.breve L.acid L.rham S.thermo br L. acidophilus L. rhamnosus br L.rhamn A ___ ___ 40 Bifido 3 S.thermop br Lactobacillus acidophilus br lactobacillus comb no.10 br lactobacillus combination no.4 br lactobacillus combo no.11 10 billion cell oral DAILY 3. PredniSONE 100 mg PO DAILY 4. Atorvastatin 20 mg PO QPM 5. Insulin Pump SC Self Administering Medication Insulin Lispro Humalog Target glucose 80 180 Discharge Medications 1. Insulin Pump SC Self Administering Medication Insulin Lispro Humalog Basal Rates Midnight 0430 .7 Units Hr 0430 0900 .85 Units Hr 0900 1200 .9 Units Hr 1200 1500 .88 Units Hr 1500 2200 .88 Units Hr 2200 0000 .7 Units Hr Meal Bolus Rates Breakfast 1 7 Lunch 1 7 Dinner 1 6 MD has ordered ___ consult Use of ___ medical equipment Insulin pump Reason for use medically necessary and justified as ___ cannot provide this type of equipment or suitable alternative not appropriate. Provider acknowledges patient competent 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. PredniSONE 100 mg PO DAILY 5. Probiotic B.breve L.acid L.rham S.thermo br L. acidophilus L. rhamnosus br L.rhamn A ___ ___ 40 Bifido 3 S.thermop br Lactobacillus acidophilus br lactobacillus comb no.10 br lactobacillus combination no.4 br lactobacillus combo no.11 10 billion cell oral DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSES HYPERGLYCEMIA TYPE I DIABETES MELLITUS LEUKOCYTOSIS SECONDARY DIAGNOSES NON HODGKIN S LYMPHOMA HYPERLIPIDEMIA 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 ___ for hyperglycemia that was exacerbated by your recent Prednisione use associated with your chemotherapy. ___ saw you while hospitalized and recommended that you take NPH twice a day while you are on Prednisone. Your blood sugars were better controlled while taking NPH. You will need close follow up with ___ after discharge. It is really important that you take your medications and attend your follow up appointments listed below. If you have difficulty with managing your blood sugars over the weekend please call ___ and ask for pager ___. It was a pleasure taking care of you We wish you the best Your ___ Team Followup Instructions ___ The icd codes present in this text will be E1065, C8590, T380X5A, I10, E785, Z9641. The descriptions of icd codes E1065, C8590, T380X5A, I10, E785, Z9641 are E1065: Type 1 diabetes mellitus with hyperglycemia; C8590: Non-Hodgkin lymphoma, unspecified, unspecified site; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z9641: Presence of insulin pump (external) (internal). The common codes which frequently come are I10, E785. The uncommon codes mentioned in this dataset are E1065, C8590, T380X5A, Z9641.
The icd codes present in this text will be E1065, C8590, E871, E8352, T380X5A, Y92019, Z794, Z9641, E785, Z87891, D72829. The descriptions of icd codes E1065, C8590, E871, E8352, T380X5A, Y92019, Z794, Z9641, E785, Z87891, D72829 are E1065: Type 1 diabetes mellitus with hyperglycemia; C8590: Non-Hodgkin lymphoma, unspecified, unspecified site; E871: Hypo-osmolality and hyponatremia; E8352: Hypercalcemia; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause; Z794: Long term (current) use of insulin; Z9641: Presence of insulin pump (external) (internal); E785: Hyperlipidemia, unspecified; Z87891: Personal history of nicotine dependence; D72829: Elevated white blood cell count, unspecified. The common codes which frequently come are E871, Z794, E785, Z87891. The uncommon codes mentioned in this dataset are E1065, C8590, E8352, T380X5A, Y92019, Z9641, D72829. Allergies Codeine pseudoephedrine Chief Complaint Hyperglycemia Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ female with past medical history notable for Type 1 DM and NHL who presented with hyperglycemia in the setting of taking steroids. Patient states it all began 2 weeks prior to admission where she noticed LLE RLE. She was sent to ___ where significant workup was done to rule out PE with CTA and LENIs . It was concluded she had no clot however she was found to have worsening of her Non Hodgkin s lymphoma. Her oncologist prescribed dexamethasone for 4 days which she started taking 2 days prior to admission with plan for initiation of rituximab in 1 week ___. Both patient and providers were aware of hyperglycemia and thus she was closely monitoring her sugars. Of note patient is very knowledgeable about her sugars and diabetes management. She uses an insulin pump with Humalog and noticed elevated sugars as expected. However when sugars started being uncontrolled and instructions by phone from ___ did not resolve them with basal insulin adjustment she presented to the emergency room. She denies any symptoms except a cough for the past month. She denies dizziness increased urinary frequency chest pain N v Diarrhea In the ED Initial vitals 96.6 74 110 66 16 100 on RA Labs WBC 13.4 Hgb 10.8 Plt 267 Na 123 K 6.5 hemolyzed creatinine 1.2 Imaging Cxray with no findings Patient was given ceftriaxone for a question of UTI and regular insulin 10units followed by 8 units humalog Transfer vitals HR 77 BP 126 93 RR 16 98 on RA. Patient s ___ on arrival to the floor is 180 Past Medical History Type I DM on insulin pump Non Hodgkin s Lymphoma diagnosed ___ and never treated Hyperlipidemia Hypertension Social History ___ Family History Reviewed and found to be not relevant to this illness reason for hospitalization. Physical Exam Admission physical exam VITALS Afebrile and vital signs stable see eFlowsheet GENERAL Alert and in no apparent distress EYES Anicteric pupils equally round ENT Ears and nose without visible erythema masses or trauma. Oropharynx without visible lesion erythema or exudate oral mucosa is dry 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. Insulin pump attached to RLQ area is clean with no erythema GU No suprapubic fullness or tenderness to palpation MSK Neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs 2 BLE with LLE RLE 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 physical exam ___ 0818 Temp 98.5 PO BP 107 58 HR 93 RR 18 O2 sat 99 O2 delivery Ra GENERAL Alert and in no apparent distress EYES Anicteric pupils equally round ENT Ears and nose without visible erythema masses or trauma. Oropharynx without visible lesion erythema or exudate oral mucosa is dry 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. Insulin pump attached to RLQ area is clean with no erythema GU No suprapubic fullness or tenderness to palpation MSK Neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs 3 BLE with LLE RLE 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 Pertinent Results Admission labs ___ 04 17AM BLOOD WBC 13.4 RBC 4.03 Hgb 10.8 Hct 32.6 MCV 81 MCH 26.8 MCHC 33.1 RDW 13.8 RDWSD 40.4 Plt ___ ___ 04 17AM BLOOD Glucose 441 UreaN 45 Creat 1.2 Na 123 K 6.5 Cl 87 HCO3 19 AnGap 17 ___ 04 17AM BLOOD Calcium 12.2 Phos 4.6 Mg 1.6 ___ 05 55AM BLOOD 25VitD 10 ___ 06 42AM BLOOD PTH 20 ___ 05 55AM BLOOD PEP NO MONOCLO IgG 628 IgA 90 IgM 31 IFE NO MONOCLO Discharge labs ___ 05 55AM BLOOD WBC 6.6 RBC 3.93 Hgb 10.6 Hct 31.8 MCV 81 MCH 27.0 MCHC 33.3 RDW 14.2 RDWSD 41.3 Plt ___ ___ 05 55AM BLOOD Glucose 60 UreaN 37 Creat 1.0 Na 140 K 4.0 Cl 103 HCO3 23 AnGap 14 ___ 05 55AM BLOOD TotProt 4.8 Albumin 2.9 Globuln 1.9 Calcium 12.4 Phos 4.3 Mg 1.8 ___ 04 31AM BLOOD Lactate 2.1 K 4.2 Brief Hospital Course Ms. ___ is a ___ female with past medical history notable for Type 1 DM and NHL who presented with hyperglycemia in the setting of taking steroids. ACUTE ACTIVE PROBLEMS Hyperglycemia Type 1 DM Patient with Type I DM and presenting with elevated sugars in the setting of taking dexamethasone for treatment of advancing NHL. No evidence of DKA currently. Patient uses an insulin pump and very experienced with its use and given ability to manage her own sugars with well controlled numbers we continued to use the pump with her direction and ___ support. No evidence of infection. No chest pain cardiac symptoms. Hyponatremia Resolved likely in the setting of high sugars. Na was 123 on admission but corrected for sugars was 130. Discharge Na was 140 Hypercalcemia Currently asymptomatic and stable. We reviewed ___ records where her last calcium in ___ was 10.1. This is likely new in the setting of malignancy. In order not to anchor on that work up done to rule out other etiologies workup pending at the time of discharge PTH Vitamin D SPEP and UPEP given trace anemia. Patient educated to avoid factors that can aggravate hypercalcemia including thiazide diuretics volume depletion to drink ___ glasses of water daily given risk of dehydration in the setting of diabetes avoid high calcium diet 1000 mg day . Leukocytosis Resolved. No evidence of infection despite intermittent cough for 1 month patient states was treated for Pneumonia 1 month ago . Leukocytosis likely due to steroids. NHL Significantly advanced per patient report and CT image records patient presented. LLE RLE worked up and DVT ruled out at ___ 2 weeks earlier with suspicion for malignancy as etiology. TRANSITIONAL ISSUES F u on workup sent for hypercalcemia Continue to monitor calcium as outpatient and ensure it is mild or moderate 30 minutes spent on discharge planning and coordination Medications on Admission The Preadmission Medication list is accurate and complete. 1. Dexamethasone 4 mg PO DAILY 2. Probiotic B. coagulans Bacillus coagulans 10 billion cell oral DAILY 3. Insulin Pump SC Self Administering Medication Insulin Lispro Humalog Target glucose 80 180 4. Simvastatin 20 mg PO QPM 5. Aspirin EC 81 mg PO DAILY Discharge Medications 1. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 2. Aspirin EC 81 mg PO DAILY 3. Probiotic B. coagulans Bacillus coagulans 10 billion cell oral DAILY 4. Simvastatin 20 mg PO QPM Discharge Disposition Home Discharge Diagnosis Hyperglycemia Hypercalcemia Hyponatremia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Miss ___ ___ were admitted due to uncontrolled sugar in the setting of taking steroids. ___ improved significantly managing your sugars with your insulin pump. Please DO NOT take anymore steroids and follow up with your doctor. Your calcium levels were also found to be moderately elevated. ___ had no symptoms and ___ were also hydrated significantly in the hospital. We sent labs to understand what caused this which were pending by discharge though we also suspect the Lymphoma could be the cause. Please follow up with your doctor to ensure your calcium levels are rechecked. It was a pleasure being part of your team Your ___ team Followup Instructions ___ The icd codes present in this text will be E1065, C8590, E871, E8352, T380X5A, Y92019, Z794, Z9641, E785, Z87891, D72829. The descriptions of icd codes E1065, C8590, E871, E8352, T380X5A, Y92019, Z794, Z9641, E785, Z87891, D72829 are E1065: Type 1 diabetes mellitus with hyperglycemia; C8590: Non-Hodgkin lymphoma, unspecified, unspecified site; E871: Hypo-osmolality and hyponatremia; E8352: Hypercalcemia; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause; Z794: Long term (current) use of insulin; Z9641: Presence of insulin pump (external) (internal); E785: Hyperlipidemia, unspecified; Z87891: Personal history of nicotine dependence; D72829: Elevated white blood cell count, unspecified. The common codes which frequently come are E871, Z794, E785, Z87891. The uncommon codes mentioned in this dataset are E1065, C8590, E8352, T380X5A, Y92019, Z9641, D72829.
The icd codes present in this text will be A4159, J439, I10, N136, N390, Z6841, B964, F17210, E559, E669. The descriptions of icd codes A4159, J439, I10, N136, N390, Z6841, B964, F17210, E559, E669 are A4159: Other Gram-negative sepsis; J439: Emphysema, unspecified; I10: Essential (primary) hypertension; N136: Pyonephrosis; N390: Urinary tract infection, site not specified; Z6841: Body mass index [BMI]40.0-44.9, adult; B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere; F17210: Nicotine dependence, cigarettes, uncomplicated; E559: Vitamin D deficiency, unspecified; E669: Obesity, unspecified. The common codes which frequently come are I10, N390, F17210, E669. The uncommon codes mentioned in this dataset are A4159, J439, N136, Z6841, B964, E559. Allergies Oxycodone Naprosyn Chief Complaint L flank pain Major Surgical or Invasive Procedure cystoscopy L ureteral stent History of Present Illness This is a ___ year old female who presents with right lower quadrant pain. She reports sudden onset of RLQ pain starting 2 days ago that radiated to her right flank. This was associated with nausea emesis x1 and chills. Denies dysuria hematuria fevers. She denies history of nephrolithiasis. Past Medical History PGynHx No abl paps regular menses until ___ no STIs PObHx G5P4 1 TAB PMH Reported no current medical issues though in reports found notes re. ___ right breast granular cell tumor found on bx but no f u from pt. Also h o back pain. PSH ___ laparoscopically assisted vaginal hysterectomy with cystoscopy ___ Operative hysteroscopy with myomectomy and endometrial ablation with rollerball ___ R breast bx Social History ___ Family History FamHx no breast gyn colon malignancy. fam history of fibroids. Physical Exam On discharge NAD No cardiopulmonary distress Abd soft nt nd Pertinent Results ___ 06 15AM BLOOD WBC 7.4 RBC 4.35 Hgb 11.8 Hct 37.8 MCV 87 MCH 27.1 MCHC 31.2 RDW 15.6 RDWSD 49.5 Plt Ct 94 ___ 06 15AM BLOOD Glucose 110 UreaN 11 Creat 1.1 Na 142 K 3.8 Cl 108 HCO3 21 AnGap 13 Brief Hospital Course This is a ___ yF who presented with obstructive uropathy and SIRS fevers leukocytosis due to a L ureteral calculus. She underwent a cystoscopy R ureteral stent placement by Dr. ___ on ___. Post operatively the patient s hospitalization stay involved treating septicemia Proteus pan sensitive that grew in her blood on presentation. She stayed until ___ when she de effervesced. Her Foley was removed prior to discharge. When it was demonstrated that she was afebrile x 24 hours on oral therapy and voiding without issues she was discharged on ___. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY Discharge Medications 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever Reason for PRN duplicate override Alternating agents for similar severity 2. Ibuprofen 600 mg PO Q8H PRN pain fever 3. Polyethylene Glycol 17 g PO DAILY PRN constipation 4. Sulfameth Trimethoprim DS 1 TAB PO BID RX sulfamethoxazole trimethoprim 800 mg 160 mg 1 tablet s by mouth twice a day Disp 22 Tablet Refills 0 5. Tamsulosin 0.4 mg PO DAILY RX tamsulosin 0.4 mg 1 capsule s by mouth daily Disp 30 Capsule Refills 1 6. TraMADol 50 100 mg PO Q4H PRN BREAKTHROUGH PAIN RX tramadol 50 mg 1 tablet s by mouth every six 6 hours Disp 15 Tablet Refills 0 7. Lisinopril 10 mg PO DAILY Discharge Disposition Home Discharge Diagnosis Urosepsis secondary to obstructed ureteral stone Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Take antibiotic as prescribed for 11 days. Drink 8 or more glasses of water daily. Go to emergency room if you develop any of the following fevers nausea vomiting leading to inability to tolerate fluids worsening pain persistent shakes and chills The urology office phone number is ___. Call office on ___ to confirm your surgery date. Followup Instructions ___ The icd codes present in this text will be A4159, J439, I10, N136, N390, Z6841, B964, F17210, E559, E669. The descriptions of icd codes A4159, J439, I10, N136, N390, Z6841, B964, F17210, E559, E669 are A4159: Other Gram-negative sepsis; J439: Emphysema, unspecified; I10: Essential (primary) hypertension; N136: Pyonephrosis; N390: Urinary tract infection, site not specified; Z6841: Body mass index [BMI]40.0-44.9, adult; B964: Proteus (mirabilis) (morganii) as the cause of diseases classified elsewhere; F17210: Nicotine dependence, cigarettes, uncomplicated; E559: Vitamin D deficiency, unspecified; E669: Obesity, unspecified. The common codes which frequently come are I10, N390, F17210, E669. The uncommon codes mentioned in this dataset are A4159, J439, N136, Z6841, B964, E559.
The icd codes present in this text will be N10, C3432, J9611, B9620, N200, Z87442, Z902, J449, E559, Z87891, Z803, Z808, Z833, R5081, K029. The descriptions of icd codes N10, C3432, J9611, B9620, N200, Z87442, Z902, J449, E559, Z87891, Z803, Z808, Z833, R5081, K029 are N10: Acute pyelonephritis; C3432: Malignant neoplasm of lower lobe, left bronchus or lung; J9611: Chronic respiratory failure with hypoxia; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; N200: Calculus of kidney; Z87442: Personal history of urinary calculi; Z902: Acquired absence of lung [part of]; J449: Chronic obstructive pulmonary disease, unspecified; E559: Vitamin D deficiency, unspecified; Z87891: Personal history of nicotine dependence; Z803: Family history of malignant neoplasm of breast; Z808: Family history of malignant neoplasm of other organs or systems; Z833: Family history of diabetes mellitus; R5081: Fever presenting with conditions classified elsewhere; K029: Dental caries, unspecified. The common codes which frequently come are J449, Z87891. The uncommon codes mentioned in this dataset are N10, C3432, J9611, B9620, N200, Z87442, Z902, E559, Z803, Z808, Z833, R5081, K029. Allergies Oxycodone Naprosyn Chief Complaint back pain fever Major Surgical or Invasive Procedure None History of Present Illness ___ w NSCLC s p VATS wedge resection LUL and LLL ___ w path showing positive margins COPD hypoxic respiratory failure on O2 w exertion chronic nephrolithiasis presenting with midline low back pain fevers and malaise. Pt presents now with reports of feeling generally unwell x1 week. She now works the 11 pm 7 am shift at a homeless shelter at about 8 am on ___ she returned home from work and noted chills. Temp at home was 99.7 and she notes that she typically runs between 97 and 98. She took theraflu and slept all day until 11 pm that evening. On ___ morning she noted low back pain. At that point temp was increasing to 100.2 with drenching sweats. She central low back pain as shooting worse with movement rated as ___ without associated nausea. She took tylenol extra strength without relief for pain she takes tylenol every day for arthritis. Associated symptoms included decreased appetite and malaise. Denies dysuria but did notice increased urinary frequency over the past week without sensation of incomplete voiding. She noted dark cloudy urine but no hematuria. She went to church on ___ morning and noted increasing back pain with onset of lightheadedness. EMTs were called. Apparently her O2 dipped down to 85 on 2L SBP 160 some members of church are RNs and did a brief assessment before EMTs arrived . She denies chest pain but did notice a sensation of dyspnea transiently at church resolved within minutes. She denies headaches had ___ epistaxis overnight earlier in the week which resolved with pressure after approx 5 minutes. She denies urinary retention fecal incontinence or saddle anesthesia. In the ___ ED VS 98.5 101.5 99.3 140 70 100 2L UA markedly positive with WBCs too numerous to count. CXR and CT abdomen were fairly unremarkable for acute pathologies. Flu negative. Received CTX 1g symptomatic treatments On arrival to the floor pt feels rested. She endorses ___ R low back pain dull crampy feeling without nausea. With additional probing pt notes that she has two separate kinds of back pain. One pain is R flank ___ aching like you exercised after not exercising for a while intermittent has been present on and off ___ years without associated nausea. The pain that prompted presentation to the ED is not R flank pain but rather low midline back pain in the region of the coccyx. This low midline pain reached ___ stabbing worse with movement. It is the low midline back pain that is reminiscent of prior episodes of obstructing nephrolithiasis. Past Medical History Stress urinary incontinence COPD Vitamin D deficiency Vaginal hysterectomy Nephrolithiasis status post right ureteral stent placement lithotripsy and basket extraction of stone and stent removal L VATS wedge resection x 2 mediastinal lymph node dissection Social History ___ Family History Mother with history of breast cancer died aged ___. Family history also notable for HTN and diabetes mellitus. Son died from GBM. Physical Exam ADMISSION EXAM VS ___ 2244 Temp 99.0 PO BP 113 74 HR 91 RR 18 O2 sat 96 O2 delivery 2L GEN obese female delightful alert and interactive comfortable no acute distress HEENT PERRL anicteric conjunctiva pink oropharynx without lesion or exudate moist mucus membranes ears without lesions or apparent trauma LYMPH no anterior posterior cervical supraclavicular adenopathy CARDIOVASCULAR Regular rate and rhythm without murmurs rubs or gallops LUNGS clear to auscultation bilaterally without rhonchi wheezes or crackles diminished breath sounds at L base GI soft obese TTP at RUQ and epigastrium without rebounding or guarding nondistended with normal active bowel sounds no hepatomegaly appreciated EXTREMITIES no clubbing cyanosis or edema GU no foley SKIN no rashes petechia lesions or echymoses warm to palpation NEURO Alert and interactive cranial nerves II XII grossly intact strength is ___ in bilateral ___ normal mood and affect DISCHARGE EXAM VITALS Afebrile 24 hours. No O2 requirement at rest. CONSTITUTIONAL obese woman in NAD EYE sclerae anicteric EOMI ENT audition grossly intact MMM OP clear LYMPHATIC No LAD CARDIAC RRR no M R G JVP not elevated no edema PULM normal effort of breathing while on NC O2 LCAB GI soft ND NABS. Minimal residual TTP in the mid abdomen and the RLQ GU no CVA tenderness suprapubic region soft and nontender MSK no visible joint effusions or acute deformities. Minimal residual TTP over sacrum point tenderness on bilateral flanks but no pain when striking the flank with a dull impact . DERM no visible rash. No jaundice. NEURO AAOx3. No facial droop moving all extremities. PSYCH Full range of affect Pertinent Results ADMISSION LABS ___ 01 43PM BLOOD WBC 4.0 RBC 5.21 Hgb 13.6 Hct 44.4 MCV 85 MCH 26.1 MCHC 30.6 RDW 14.4 RDWSD 44.___ ___ 01 43PM BLOOD Neuts 67.1 Lymphs ___ Monos 11.4 Eos 0.0 Baso 0.3 Im ___ 0.5 AbsNeut 2.66 AbsLymp 0.82 AbsMono 0.45 AbsEos 0.00 AbsBaso 0.01 ___ 01 43PM BLOOD Glucose 121 UreaN 14 Creat 0.9 Na 140 K 4.0 Cl 104 HCO3 22 AnGap 14 ___ 01 43PM BLOOD Calcium 8.6 Phos 4.1 Mg 1.8 ___ 01 49PM BLOOD Lactate 1.3 ___ 03 00PM URINE Color Yellow Appear Hazy Sp ___ 1.027 ___ 03 00PM URINE Blood SM Nitrite POS Protein 30 Glucose NEG Ketone NEG Bilirub NEG Urobiln NEG pH 6.0 Leuks LG ___ 03 07PM OTHER BODY FLUID FluAPCR NEGATIVE FluBPCR NEGATIVE DISCHARGE LABS ___ 07 15AM BLOOD WBC 3.8 RBC 5.12 Hgb 13.2 Hct 42.0 MCV 82 MCH 25.8 MCHC 31.4 RDW 13.9 RDWSD 41.4 Plt ___ ___ 07 15AM BLOOD Glucose 123 UreaN 10 Creat 0.9 Na 139 K 3.5 Cl 97 HCO3 26 AnGap 16 CT ABD AND PELVIS WITH CONTRAST 1. No hydronephrosis. Stable right lower pole staghorn calculus. 2. Symmetric enhancement of the kidneys with stable scarring of the interpolar region of the right kidney. 3. New small left pleural effusion. Evidence of interval left lower lobe resection given surgical chain sutures. CXR ___ Left lower lobe consolidation is improving. Subtle opacity in the right lower lobe may be related to low lung volumes. There is no definite pleural effusion or pneumothorax. Volume loss in the left hemithorax is compatible with multiple left sided resections. The heart size is mildly enlarged not significantly changed from prior exam. The pulmonary vasculature is mildly engorged without overt edema. Brief Hospital Course ___ w NSCLC s p VATS wedge resection LUL and LLL ___ w path showing positive margins COPD hypoxic respiratory failure on O2 w exertion chronic nephrolithiasis admitted w UTI. UTI cystitis vs pyelonephritis Fever Pt presented with fevers urinary frequency and positive UA consistent with UTI. Urine culture grew pan sensitive E coli. Her pains and her fevers were a bit slow to improve but she has been afebrile for over 24 hours and has only minimal residual pain on day of discharge. She received four doses of CTX which is appropriate for this pathogen then was transitioned to Cipro at discharge to complete a seven day course for complicated UTI. Although she has no typical flank pain and CT showed no perinephric stranding she is still suspected to have an upper tract infection. This would better explain her high fevers and her disparate atypical pains around her pelvis abdomen and flanks. Given some incongruity between her symptoms and what might be expected with a UTI and because she had a transient leukopenia instead of the expected leukocytosis the possibility of some other concurrent infection causing the fevers was seriously considered. However she has no other localizing symptoms or signs and no exposure history whatsoever to suggest a tick borne illness or systemic viral illness if necessary please see note from ___ for details of all the various infectious exposures that she has denied . Midline low back pain overlying coccyx This correlates poorly with the expected location of pain from a UTI. She has a nonspecific soft tissue abnormality on CT deep to the coccyx but on review of serial imaging by me it is entirely stable over at least a year and was not PET avid on her recent staging PET CT probably incidental and unrelated. Pain has resolved so no further imaging w u was pursued. LUL and LLL lung carcinomas Two different NSCLCs in the left lung now s p wedge resections. LLL lesion resected with positive margins. Due to her tenuous respiratory function risks of re operation for lobectomy probably outweigh benefits so plan is referral to rad onc. booked her an appointment with Dr. ___ rad onc in late ___ patient was made aware of results HCP ___ ___ her friend and a local ___ same last name no relation Code Status presumed Full TRANSITIONAL ISSUES 1 Ensure follow up with radiation oncology scheduled regarding management of her positive surgical margins after wedge resection of NSCLC. Consider also a medical oncology referral deferred . 2 Ensure f u with urology scheduled regarding management of her chronic nephrolithiasis. 3 All her molars on the upper right are completely rotten and need extraction. Please ensure this occurs before she suffers an infectious complication of her poor dentition. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H 2. Vitamin D ___ UNIT PO 1X WEEK MO Discharge Medications 1. Ciprofloxacin HCl 500 mg PO BID Duration 3 Days RX ciprofloxacin HCl 500 mg 1 tablet s by mouth twice a day Disp 6 Tablet Refills 0 2. Acetaminophen 1000 mg PO Q6H 3. Vitamin D ___ UNIT PO 1X WEEK MO Discharge Disposition Home With Service Facility ___ Discharge Diagnosis UTI presumed pyelonephritis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You were admitted for fevers and also pains in your abdomen back flanks. These were probably both caused by a urinary tract infection. You were treated with IV antibiotics ceftriaxone and have improved greatly. Please take antibiotic pills twice daily for three more days ___ through ___ to complete your treatment. You also had residual cancer cells after your surgery positive margins . You will probably need radiation therapy to the surgical site to mop up the final cancer cells. We have booked you with a radiation oncologist Dr. ___ month. Please also get your three rotten teeth taken care of before they cause some more serious problem. Followup Instructions ___ The icd codes present in this text will be N10, C3432, J9611, B9620, N200, Z87442, Z902, J449, E559, Z87891, Z803, Z808, Z833, R5081, K029. The descriptions of icd codes N10, C3432, J9611, B9620, N200, Z87442, Z902, J449, E559, Z87891, Z803, Z808, Z833, R5081, K029 are N10: Acute pyelonephritis; C3432: Malignant neoplasm of lower lobe, left bronchus or lung; J9611: Chronic respiratory failure with hypoxia; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; N200: Calculus of kidney; Z87442: Personal history of urinary calculi; Z902: Acquired absence of lung [part of]; J449: Chronic obstructive pulmonary disease, unspecified; E559: Vitamin D deficiency, unspecified; Z87891: Personal history of nicotine dependence; Z803: Family history of malignant neoplasm of breast; Z808: Family history of malignant neoplasm of other organs or systems; Z833: Family history of diabetes mellitus; R5081: Fever presenting with conditions classified elsewhere; K029: Dental caries, unspecified. The common codes which frequently come are J449, Z87891. The uncommon codes mentioned in this dataset are N10, C3432, J9611, B9620, N200, Z87442, Z902, E559, Z803, Z808, Z833, R5081, K029.
The icd codes present in this text will be C3412, J90, C3432, F17210, I10, N393, E559, J439. The descriptions of icd codes C3412, J90, C3432, F17210, I10, N393, E559, J439 are C3412: Malignant neoplasm of upper lobe, left bronchus or lung; J90: Pleural effusion, not elsewhere classified; C3432: Malignant neoplasm of lower lobe, left bronchus or lung; F17210: Nicotine dependence, cigarettes, uncomplicated; I10: Essential (primary) hypertension; N393: Stress incontinence (female) (male); E559: Vitamin D deficiency, unspecified; J439: Emphysema, unspecified. The common codes which frequently come are F17210, I10. The uncommon codes mentioned in this dataset are C3412, J90, C3432, N393, E559, J439. Allergies Oxycodone Naprosyn Chief Complaint DOE Major Surgical or Invasive Procedure ___ VATS left upper lobe wedge resection left lower lobe wedge resection and mediastinal lymph node dissection. History of Present Illness ___ with LUL lung cancer hilar FDG avid lymphadenopathy and LLL FDG avid lesion. Discussed findings with patient who was also seen by Dr. ___ today. Marginal lung function and continues to smoke though she is trying to stop. Higher risk pulmonary resection but would be helpful to be able to excise LLL lesion and hilar lymphadenopathy to more fully stage at the same time of sublobar resection of the LUL. Overall patient continues to smoke and feels as though her breathing is labored at baseline. Occasional cough not worsened recently. No fevers chills sweats. No weight gain or loss no lightheadedness headaches bony pains. Past Medical History Hypertension Stress urinary incontinence Emphysema Vitamin D deficiency Vaginal hysterectomy Nephrolithiasis status post right ureteral stent placement lithotripsy and basket extraction of stone and stent removal Social History ___ Family History Mother with history of breast cancer died aged ___. Family history also notable for HTN and diabetes mellitus. Physical Exam BP 160 87. Heart Rate 83. O2 Saturation 98. Weight 273.5 With Clothes . Height 66.750. BMI 43.2. Temperature 98.0.GENERAL x WN WD x NAD x AAO abnormal findings HEENT x NC AT EOMI x PERRL A x Anicteric x OP NP mucosa normal x Tongue midline x Palate symmetric x Neck supple NT without mass x Trachea midline Thyroid nl size contour Abnormal findings RESPIRATORY x CTA bilat Excursion normal No fremitus No egophony No spine CVAT Abnormal findings CARDIOVASCULAR x RRR No m r g No JVD PMI nl x No edema Peripheral pulses nl No abd carotid bruit Abnormal findings GI x Soft x NT x ND No mass HSM No hernia Abnormal findings GU x Deferred Nl genitalia Nl pelvic testicular exam Nl DRE Abnormal findings NEURO Strength intact symmetric Sensation intact symmetric Reflexes nl x No facial asymmetry x Cognition intact Cranial nerves intact Abnormal findings MS No clubbing x No cyanosis x No edema uses a cane Gait nl No tenderness Tone align ROM nl Palpation nl Nails nl Abnormal findings LYMPH NODES x Cervical nl x Supraclavicular nl Axillary nl Inguinal nl Abnormal findings SKIN x No rashes lesions ulcers on visible skin No induration nodules tightening Abnormal findings PSYCHIATRIC x Nl judgment insight x Nl memory x Nl mood affect Abnormal findings Pertinent Results WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 05 20 8.4 4.10 11.0 36.2 88 26.8 30.4 15.0 48.5 162 ___ 05 06 10.2 4.48 12.4 39.7 89 27.7 31.2 15.1 48.9 175 Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 05 20 ___ 141 4.0 ___ ___ CXR In comparison with the study of ___ the left chest tube remains in place and there is no evidence of appreciable pneumothorax. Postsurgical changes are again seen in the left lung. Continued enlargement of the cardiac silhouette with elevated pulmonary venous pressure and small bilateral pleural effusions with compressive atelectatic changes at the bases. ___ CXR Interval improvement of left midlung consolidation. Unchanged moderate left pleural effusion with overlying volume loss. No evidence of focal consolidation or pneumothorax. Brief Hospital Course Ms. ___ was admitted to the hospital and taken to the Operating Room where she underwent a VATS left upper lobe wedge resection left lower lobe wedge resection and mediastinal lymph node dissection. She tolerated the procedure well and returned to the PACU in stable condition. She maintained stable hemodynamics and her pain was controlled with IV Tylenol. Her ___ drain put out a modest amount of serosanguious fluid and had no air leak. Following transfer to the Surgical floor she continued to have adequate pain control with scheduled Tylenol. Her port sites were healing well and her ___ drain was removed on post op day 1 as the drainage was minimal. Her post pull chest xray showed no pneumothorax and bibasilar atelectasis. She was encouraged to use her incentive spirometer frequently and she was also encouraged to increase her ambulation. She noticed that she had more dyspnea than pre op. She was placed on Mucinex to thin out her secretions and also tried some nebulizer treatments. Attempts were made to wean her oxygen but she was unable to maintain room air saturations 90 with ambulation. She continued to use her incentive spirometer effectively and a repeat chest xray showed some accumulation of a left pleural effusion. As her ambulatory saturations were in the 82 88 range home oxygen was arranged so that she could use it with all activity. The ___ was set up to help assess her O2 needs and attempt to wean the oxygen off. She was discharged to home on ___ on oxygen at 2 LPM and will follow up with Dr. ___ in 2 weeks with a chest xray prior to the appointment. Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 1000 mg PO Q6H PRN Pain Mild Fever 2. ibuprofen diphenhydramine cit 200 38 mg oral QHS 3. Vitamin D ___ UNIT PO 1X WEEK MO Discharge Medications 1. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 2 2. GuaiFENesin ER 600 mg PO Q12H RX guaifenesin 1 200 mg 1 tablet s by mouth twice a day Disp 28 Tablet Refills 0 3. Acetaminophen 1000 mg PO Q6H RX acetaminophen 500 mg 2 tablet s by mouth every six 6 hours Disp 100 Tablet Refills 0 4. ibuprofen diphenhydramine cit 200 38 mg oral QHS 5. Vitamin D ___ UNIT PO 1X WEEK MO Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Left upper lobe lung cancer. Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent w O2 at 2 LPM Discharge Instructions You were admitted to the hospital for lung surgery and you ve recovered well. You are now ready for discharge but will need to go home on oxygen until your lungs heal and your oxygenation improves. Use oxygen at 2 LPM via nasal cannula to maintain saturations 90 at rest and with activity. Continue to use your incentive spirometer 10 times an hour while awake. Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. Your chest tube dressing may be removed in 48 hours. If it starts to drain cover it with a clean dry dressing and change it as needed to keep site clean and dry. You may need pain medication once you are home but you can wean it over the next week as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. No driving while taking narcotic pain medication. Take Tylenol on a standing basis to avoid more opiod use. Continue to stay well hydrated and eat well to heal your incisions No heavy lifting 10 lbs for 4 weeks. Shower daily. Wash incision with mild soap water rinse pat dry No tub bathing swimming or hot tubs until incision healed No lotions or creams to incision site Walk ___ times a day and gradually increase your activity as you can tolerate. Call Dr. ___ ___ if you experience Fevers 101 or chills Increased shortness of breath chest pain or any other symptoms that concern you. If pathology specimens were sent at the time of surgery the reports will be reviewed with you in detail at your follow up appointment. This will give both you and your doctor time to understand the pathology its implications and discuss options going forward. Followup Instructions ___ The icd codes present in this text will be C3412, J90, C3432, F17210, I10, N393, E559, J439. The descriptions of icd codes C3412, J90, C3432, F17210, I10, N393, E559, J439 are C3412: Malignant neoplasm of upper lobe, left bronchus or lung; J90: Pleural effusion, not elsewhere classified; C3432: Malignant neoplasm of lower lobe, left bronchus or lung; F17210: Nicotine dependence, cigarettes, uncomplicated; I10: Essential (primary) hypertension; N393: Stress incontinence (female) (male); E559: Vitamin D deficiency, unspecified; J439: Emphysema, unspecified. The common codes which frequently come are F17210, I10. The uncommon codes mentioned in this dataset are C3412, J90, C3432, N393, E559, J439.
The icd codes present in this text will be J101, N390, I10, J439, F17210, R918, R590, B9620, E559. The descriptions of icd codes J101, N390, I10, J439, F17210, R918, R590, B9620, E559 are J101: Influenza due to other identified influenza virus with other respiratory manifestations; N390: Urinary tract infection, site not specified; I10: Essential (primary) hypertension; J439: Emphysema, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; R918: Other nonspecific abnormal finding of lung field; R590: Localized enlarged lymph nodes; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; E559: Vitamin D deficiency, unspecified. The common codes which frequently come are N390, I10, F17210. The uncommon codes mentioned in this dataset are J101, J439, R918, R590, B9620, E559. Allergies Oxycodone Naprosyn Chief Complaint Cough RLQ pain Urinary frequency Major Surgical or Invasive Procedure None History of Present Illness HISTORY OF PRESENTING ILLNESS ___ with history of HTN emphysema and vitamin D deficiency who presented to the ED with cough right lower quadrant suprapubic pain and urinary frequency. Patient was in her usual state of health until ___. At that time she developed cough and mild sore throat. Of note her partner and coworkers had been sick with a similar respiratory illness over the past week. Cough has progressively worsened becoming productive in nature over the weekend and she would cough up large quantities of clear mucous. Yesterday she had 1 episode of hemoptysis where she coughed up dark red sputum with mucous about the size of a quarter. She reports associated muscular pain when coughing SOB and DOE when walking to the bathroom. She has had fatigue myalgias and poor oral intake endorses nausea without vomiting and denies unintentional weight loss. Patient noted subjective fever and took her temperature which was 100 but was febrile to 102.7F at one point in the ED.. Also reported some loose stools non bloody diarrhea. Receives yearly influenza vaccines and PPD tests as part of her occupation. Over the same time period patient also reported right lower quadrant pain radiating to her back similar feeling to previous UTIs. Pain had been present for about one week during which time she also had urinary frequency and increased leakage of urine with coughing. Of note she does carry a history of stress urinary incontinence. Denied dysuria urgency hematuria or foul smelling urine. Patient also has a history of shortness of breath on exertion. For several years she has noticed becoming progressively short of breath after walking only a few steps and needing to stop to catch her breath. She breathes comfortably at rest but notices labored breathing after approximately 10 steps. Patient denies additional pain chills nausea or vomiting. In the ED initial VS were notable for Temp 99.4 HR 103 BP 150 86 RR 16 SaO2 93 RA. Exam notable for Comfortable appearing woman distant lung sounds but overall clear bilaterally normal S1 and S2 without murmurs soft non tender no lower extremity edema. Labs were notable for WBC 5.1 Hgb 13.7 Plt 137 ___ 13.3 PTT 26.2 INR 1.2 Na 137 K 3.8 Cl 100 HCO3 25 BUN 11 Cr 0.9 Gluc 112 ALT 19 AST 31 ALP 138 Lipase 25 Tbili 0.2 Alb 4.1 Ca 8.8 Mg 1.8 Phos 2.8 Lactate 1.2 Urine studies notable for large leuk positive nitrites 182 WBC with 36 RBCs moderate bacteria and 8 epithelial cells. Influenza A PCR positive. ECG with sinus tachycardia normal intervals and axis no significant territorial ST segment deviation or T wave inversion to suggest ischemia non specific ST T changes throughout and intra atrial conduction delay. CXR demonstrated a 2.8 x 2.0cm oval round opacity projecting over the left mid lung field new from prior may represent malignancy or infection. CT torso with contrast with new 3cm left upper lobe mass and a smaller 1cm left lower lobe mass concerning for primary left upper lobe lung malignancy with metastasis to the left lower lobe mediastinal lymphadenopathy measuring up to 1 cm in the prevascular region n non obstructing 1.5 x 1.1 cm calcified stone outlining the calyx of the right lower pole no evidence of abdominopelvic metastases no suspicious osseous lesions 1.7 cm hypoattenuating nodule within the isthmus of the partially imaged enlarged thyroid gland and mild nonspecific focal thickening of the left common iliac artery wall. Patient was given IV acetaminophen 1000mg x2 1L D5LR IV ceftriaxone 1g PO trazodone 25mg Vital signs on transfer notable for Temp 101.0 HR 105 BP 137 84 RR 18 SaO2 100 RA SUBJECTIVE HISTORY morning of ___ Patient describes feeling better this morning. Weakness and mylagias are improved but still with DOE when walking to bathroom. Describes no chills or fever overnight. Notes coughing less since her admission last night and experiencing less abdominal pain. Reports SOB characteristic of her baseline comfortable at rest but labored after walking approximately 10 steps. Denies other pain fever chills nausea or vomiting. Past Medical History Hypertension Stress urinary incontinence Emphysema Vitamin D deficiency Vaginal hysterectomy Nephrolithiasis status post right ureteral stent placement lithotripsy and basket extraction of stone and stent removal Social History ___ Family History Mother with history of breast cancer died aged ___. Family history also notable for HTN and diabetes mellitus. Physical Exam ADMISSION PHYSICAL EXAMINATION VS 24 HR Data last updated ___ 1142 Temp 99.1 Tm 99.5 BP 126 82 126 134 79 82 HR 82 79 88 RR 18 ___ O2 sat 94 92 94 O2 delivery Ra Wt 275.35 lb 124.9 kg GENERAL lying comfortably in bed no distress HEENT AT NC no conjunctival pallor anicteric sclera MMM NECK supple non tender no JVP elevation CV RRR S1 and S2 normal no murmurs rubs gallops RESP Diminished lung sounds throughout but weakest in left upper lobe mild wheezing in lower lobes bilaterally no crackles ___ Tender to deep palpation in RLQ and suprapubic region no tenderness to superficial palpation throughout soft ND BS EXTREMITIES WWP no lower extremity edema NEURO A O x3 otherwise grossly intact DISCHARGE PHYSICAL EXAM VS 98.4 115 72 77 18 O2 93 Ra GENERAL lying comfortably in bed no distress HEENT AT NC no conjunctival pallor anicteric sclera oropharynx clear without erythema or exudates MMM NECK supple non tender CV RRR S1 and S2 normal no murmurs rubs gallops RESP Diminished lung sounds throughout no wheezing crackles or rhonchi ___ Soft NTND BS EXTREMITIES WWP no lower extremity edema NEURO A O x3 otherwise grossly intact Pertinent Results ___ 05 14PM BLOOD WBC 5.1 RBC 5.06 Hgb 13.7 Hct 43.9 MCV 87 MCH 27.1 MCHC 31.2 RDW 14.7 RDWSD 46.5 Plt ___ ___ 05 40AM BLOOD WBC 5.0 RBC 4.69 Hgb 12.9 Hct 40.4 MCV 86 MCH 27.5 MCHC 31.9 RDW 14.6 RDWSD 45.5 Plt ___ ___ 05 45AM BLOOD WBC 4.8 RBC 4.66 Hgb 12.6 Hct 40.8 MCV 88 MCH 27.0 MCHC 30.9 RDW 14.6 RDWSD 46.9 Plt ___ ___ 06 15AM BLOOD WBC 4.4 RBC 4.63 Hgb 12.5 Hct 40.5 MCV 88 MCH 27.0 MCHC 30.9 RDW 14.4 RDWSD 45.5 Plt ___ ___ 05 14PM BLOOD Neuts 62.4 ___ Monos 15.5 Eos 0.2 Baso 0.2 Im ___ AbsNeut 3.19 AbsLymp 1.10 AbsMono 0.79 AbsEos 0.01 AbsBaso 0.01 ___ 07 00PM BLOOD ___ PTT 26.2 ___ ___ 05 45AM BLOOD ___ PTT 30.5 ___ ___ 05 14PM BLOOD Glucose 112 UreaN 11 Creat 0.9 Na 137 K 3.8 Cl 100 HCO3 25 AnGap 12 ___ 05 40AM BLOOD Glucose 137 UreaN 12 Creat 0.9 Na 141 K 3.8 Cl 103 HCO3 21 AnGap 17 ___ 05 45AM BLOOD Glucose 135 UreaN 12 Creat 0.7 Na 141 K 3.5 Cl 104 HCO3 24 AnGap 13 ___ 06 15AM BLOOD Glucose 119 UreaN 12 Creat 0.8 Na 144 K 3.4 Cl 105 HCO3 25 AnGap 14 ___ 05 14PM BLOOD ALT 19 AST 31 AlkPhos 138 TotBili 0.2 ___ 05 45AM BLOOD ALT 25 AST 38 AlkPhos 113 TotBili 0.2 ___ 05 14PM BLOOD Albumin 4.1 Calcium 8.8 Phos 2.8 Mg 1.8 ___ 05 45AM BLOOD Calcium 8.2 Phos 3.4 Mg 1.8 ___ 06 15AM BLOOD Calcium 8.6 Phos 3.8 Mg 1.9 ___ 09 03PM BLOOD Lactate 1.2 IMAGING CXR ___ FINDINGS The lungs are well aerated. There is a linear opacity in the right lung base which may represent chronic atelectasis. There is an oval 2.8 x 2.2 cm mass projecting over the left midlung field which is new from prior the differential for which includes malignancy versus infection. No pleural effusion or pneumothorax. The heart appears normal in size. No evidence of pulmonary edema IMPRESSION 2.8 x 2.0 cm oval round nodular opacity projecting over the left mid lung field is new from prior this may represent malignancy or infection. Chest CT is recommended for further evaluation. CT Torso ___ 1. New 3 cm left upper lobe mass and a smaller 1 cm left lower lobe mass are concerning for primary left upper lobe lung malignancy. 2. Borderline enlarged mediastinal lymph nodes measuring up to 1 cm in the prevascular region. 3. Nonobstructing 1.5 x 1.1 cm calcified stone outlining the calyx of the right lower pole is smaller in size when compared to ___ CT abdomen and pelvis. 4. No evidence of abdominopelvic metastases. No suspicious osseous lesions. 5. 1.7 cm hypoattenuating nodule within the isthmus of the partially imaged enlarged thyroid gland. This can be further evaluated with outpatient thyroid ultrasound if not previously worked up. 6. Mild nonspecific focal thickening of the left common iliac artery wall is new from ___ CT query vasculitis. MICRO ___ 1 57 pm SPUTUM Source Induced. ACID FAST SMEAR Final ___ NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE Pending MTB Direct Amplification Preliminary M. TUBERCULOSIS DNA NOT DETECTED BY NAAT A negative NAAT cannot rule out TB or other mycobacterial infection. . NAAT results will be followed by confirmatory testing with conventional culture and DST methods. This TB NAAT method has not been approved by FDA for clinical diagnostic purposes. However this laboratory has established assay performance by in house validation in accordance with ___ standards. . Test done at ___ Mycobacteriology Laboratory.. ___ 11 26 pm SPUTUM Source Induced. ACID FAST SMEAR Final ___ NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE Pending ___ 10 51 am SPUTUM Source Induced. ACID FAST SMEAR Final ___ NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE Pending MTB Direct Amplification Final ___ CANCELLED. PATIENT CREDITED. Specimen received less than 7 days from previous testing. ___ 7 00 pm URINE FINAL REPORT ___ URINE CULTURE Final ___ ESCHERICHIA COLI. 100 000 CFU mL. PRESUMPTIVE IDENTIFICATION. 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 32 S PIPERACILLIN TAZO 4 S TOBRAMYCIN 1 S TRIMETHOPRIM SULFA 1 S Brief Hospital Course ___ with h o HTN emphysema and vitamin D deficiency who presented to the ED with cough RLQ pain and urinary frequency treated for influenza A UTI pending outpatient workup of lung nodules and mediastinal LAD. ACUTE ACTIVE ISSUES Multiple lung nodules Mediastinal LAD CXR with new opacity in left mid lung. Subsequent CT with new 3cm left upper love mass and smaller 1cm left lower lobe mass with mediastinal lymphadenopathy in the prevascular region most concerning for new lung cancer diagnosis given extensive smoking history. Also considering history of homelessness and current occupation as ___ of ___ need to r o mycobacterial infection. IP consulted planned outpatient PETCT bronch biopsy. SW consulted given possible cancer diagnosis. Induced sputum x 3 with NAAT were sent 3 AFB smears finalized as negative with MTB and AFB culture pending at time of discharge. Influenza A Presented with three days of productive cough sore throat muscle aches and shortness of breath fatigue on exertion in the setting of multiple sick contacts. Febrile to 102.7 in the ED. Influenza A positive. Started oseltamivir 75mg BID given possible underlying lung disease. Possible UTI One week of RLQ pain and urinary frequency similar to previous episodes of UTI. Urine studies notable for large leuks positive nitrites 182 WBC and moderate bacteria although 8 epithelial cells were present indicating contaminated sample. History of nephrolithiasis CT abdomen pelvis did show 1.5 x 1.1cm calcified stone in lower pole of right kidney but no evidence of pyelonephritis. Repeat UA with WBC 182 and large leuks UCx growing E Coli sensitive to CTX. Completed 3d course CTX 1g daily for uncomplicated UTI. CHRONIC STABLE ISSUES Vitamin D deficiency continued vitamin D2 50 000 units weekly Transitional Issues CODE STATUS Full HCP ___ ___ ___ Acid fast MTB pending at time of discharge with two smears finalized as negative 1.7cm hypoattenuating nodule in isthmus of thyroid gland recommend thyroid US as outpatient Outpatient bronchoscopy tentatively scheduled for ___ PET CT scheduled for ___ depending on results of pathology will need follow up with heme onc in clinic Recommend further conversation about smoking cessation. Patient provided with nicotine lozenges prior to discharge. Would continue to encourage healthy lifestyle change. Recommend checking vitamin D level and evaluate continued need for vitamin D supplementation especially in setting of possible lung CA Medications on Admission The Preadmission Medication list is accurate and complete. 1. Vitamin D ___ UNIT PO 1X WEEK ___ 2. Acetaminophen 1000 mg PO Q8H PRN Pain Mild Fever Discharge Medications 1. GuaiFENesin ___ mL PO Q6H PRN cough RX guaifenesin 100 mg 5 mL 5 mL by mouth every 6 hours Disp 473 Milliliter Milliliter Refills 0 2. Nicotine Lozenge 2 mg PO Q2H PRN nicotine craving RX nicotine polacrilex 2 mg take 1 lozenge every 2 to 4 hours Disp 81 Lozenge Refills 0 3. OSELTAMivir 75 mg PO BID RX oseltamivir 75 mg 1 capsule s by mouth twice a day Disp 5 Capsule Refills 0 4. Acetaminophen 1000 mg PO Q8H PRN Pain Mild Fever 5. Vitamin D ___ UNIT PO 1X WEEK ___ Discharge Disposition Home Discharge Diagnosis Primary diagnosis Influenza A Lung nodules Mediastinal LAD Urinary Tract Infection Secondary diagnoses Vitamin D Deficiency 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 You had a fever cough and shortness of breath During your stay You were found to be positive for the flu and received Tamiflu A new lung nodule was noted on chest x ray. Therefore you underwent a chest CT which showed a lung mass and enlarged lymph nodes. You will have further workup as an outpatient. After you leave Please finish your course of Tamiflu last day ___ You have a PET CT scan scheduled on ___. You will also undergo a bronchoscopy tentatively scheduled on ___. The interventional pulmonology team office will be in touch with you after discharge to finalize the timing of the bronchoscopy. Please attend any other outpatient appointments you have upcoming. You have a PCP appointment scheduled on ___ with Dr. ___. Please continue taking vitamin D for 6 more weeks 1 per week starting on ___ It was a pleasure participating in your care We wish you the very best Your ___ Healthcare Team Followup Instructions ___ The icd codes present in this text will be J101, N390, I10, J439, F17210, R918, R590, B9620, E559. The descriptions of icd codes J101, N390, I10, J439, F17210, R918, R590, B9620, E559 are J101: Influenza due to other identified influenza virus with other respiratory manifestations; N390: Urinary tract infection, site not specified; I10: Essential (primary) hypertension; J439: Emphysema, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; R918: Other nonspecific abnormal finding of lung field; R590: Localized enlarged lymph nodes; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; E559: Vitamin D deficiency, unspecified. The common codes which frequently come are N390, I10, F17210. The uncommon codes mentioned in this dataset are J101, J439, R918, R590, B9620, E559.
The icd codes present in this text will be I609, G8194, R200, R51, E119, E785, I10, E039, Z85118, Z87891. The descriptions of icd codes I609, G8194, R200, R51, E119, E785, I10, E039, Z85118, Z87891 are I609: Nontraumatic subarachnoid hemorrhage, unspecified; G8194: Hemiplegia, unspecified affecting left nondominant side; R200: Anesthesia of skin; R51: Headache; E119: Type 2 diabetes mellitus without complications; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; E039: Hypothyroidism, unspecified; Z85118: Personal history of other malignant neoplasm of bronchus and lung; Z87891: Personal history of nicotine dependence. The common codes which frequently come are E119, E785, I10, E039, Z87891. The uncommon codes mentioned in this dataset are I609, G8194, R200, R51, Z85118. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Left sided weakness and tingling Major Surgical or Invasive Procedure None History of Present Illness ___ is an ___ yo right handed man with a history of metastatic SCLC with solitary left cerebellar brain met s p gamma knife radiosurgery in ___ gets care at ___ who presents with transient left arm weakness as well as abnormal sensation in his face. The day of presentation he tried to pick up a glass of juice with his left hand at around 6 30 pm but found he was unable. He could reach to the glass and wrap his fingers around it but couldn t bring it to his mouth. He denies having shaking in his arm. At the same time his left face began to feel funny like a swollen numb feeling. The arm was weak for ___ minutes. The left face was numb for 7 minutes. Then the sensation he had on his left face moved to his right face. He walked to the kitchen and told his daughter about his symptoms who called an ambulance. He was taken to ___ where ___ was read as having a SAH vs. laminar necrosis with edema in the right parietal cortex. He was transferred to ___ for neurology evaluation. He denied trouble talking or walking. He doesn t know if his face was drooping. This morning he feels back to normal apart from a mild headache though this is similar to his chronic headaches which are a pressure like sensation in his forehead bilaterally. He gets care at ___ for brain cancer and lung cancer . He s had radiation treatment for the brain cancer. He doesn t know what type of cancer it is but denies it being a metastasis from his lung cancer. He says he was treated for his cancer ___ years ago and he s been told he is currently cancer free. Review of Systems for recent cough w SOB chronic dizziness chronic memory problems and headache The pt denies loss of vision blurred vision diplopia dysarthria dysphagia lightheadedness tinnitus or new hearing difficulty. Denies difficulties producing or comprehending speech. No bowel or bladder incontinence or retention. Denies new difficulty with gait. The pt denies recent fever or chills. Denies chest pain or palpitations. Denies nausea vomiting diarrhea constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies rash. Past Medical History metastatic small cell lung cancer diagnosed ___ s p chemo and radiation ___ metastatic to L1 adrenal gland and brain solitary brain met to left cerebellum s p gamma knife radiosurgery ___ diabetes HLD hypothyroidism HTN Social History ___ Family History history of cancer in family Physical Exam Admission Exam Vitals 97.1 69 136 77 15 96 RA General Awake cooperative NAD. HEENT NC AT Neck Supple. Pulmonary breathing comfortably on RA CV RRR Abdomen soft nondistended Extremities no edema warm Skin no rashes or lesions noted. Neuro Mental Status Awake not oriented to ___ but knows he s in a hospital. Has difficulty relating details of his medical history. 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. Speech was not dysarthric. Able to follow both midline and appendicular commands. Inattentive unable to name ___ backward stuck at ___. There was no evidence of neglect. Cranial Nerves I Olfaction not tested. II in light left pupil 3.5 2.5 right 2.5 1.5mm pupillary asymmetry is more pronounced in the dark. VFF to confrontation with finger counting. III IV VI EOMI without nystagmus. slightly smaller palpebral fissure on right V Facial sensation intact to light touch and pin in all distributions VII Subtle decreased activation of left lower face with flattening of the NLF. VIII hard of hearing. IX X Palate elevates symmetrically. XI full strength in trapezii bilaterally. XII Tongue protrudes in midline Motor Normal bulk throughout. No pronator drift bilaterally. No tremor noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 5 R ___ ___ ___ 5 5 5 5 5 DTRs ___ Tri ___ Pat Ach L 1 tr tr 1 0 R 1 tr tr 1 0 Toes were downgoing bilaterally. Sensory left arm and leg with 50 pinprick sensation compared to right. Decreased temperature sensation in left arm. Temperature gradient in the legs. Vibration absent in the feet. Coordination subtle dysmetria on FNF bilaterally. Rapid alternating movements are slower on the left. Gait Good initiation. Narrow based normal stride appears mildly unsteady. Romberg absent but with subjective unsteadiness. Discharge Exam Vitals 97.9 155 95 66 17 98 RA General Awake cooperative NAD. HEENT NC AT Neck Supple. Pulmonary breathing comfortably on RA CV RRR Abdomen soft nondistended Extremities no edema warm Skin no rashes or lesions noted. Neuro Mental Status Awake initially not oriented to date but recalled that it was ___ and ___ is fluent with intact repetition and comprehension. Normal prosody. Pt. was able to name high but not low frequency objects pen but not tip glasses but not lens . Speech was not dysarthric. Able to follow both midline and appendicular commands. Inattentive unable to name ___ backward stuck at ___. There was no evidence of neglect. Cranial Nerves I Olfaction not tested. II in light left pupil 3 2 right 2 1mm pupillary asymmetry is more pronounced in the dark. VFF to confrontation with finger counting. III IV VI EOMI without nystagmus. slightly smaller palpebral fissure on right pseudoptosis R eye inverse ptosis V Facial sensation intact to light touch and pin in all distributions VII face symmetrical with mild flattening of NLF on left VIII hard of hearing. IX X Palate elevates symmetrically. XI full strength in trapezii bilaterally. XII Tongue protrudes in midline Motor Normal bulk throughout. No pronator drift bilaterally. No tremor noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ ___ ___ 5 5 5 5 5 R ___ ___ ___ 5 5 5 5 5 DTRs ___ Tri ___ Pat Ach L 1 tr tr 1 0 R 1 tr tr 1 0 Toes were downgoing bilaterally. Sensory intact to light touch throughout Coordination subtle dysmetria on FNF bilaterally with pass pointing. Pertinent Results OSH Labs Na 143 K 4.6 Cl 103 Glu 90 bicarb 28 Cr 1.2 BUN 18 ALT 10 AST 17 trop 0.01 WBC 4.6 Hb 13.1 ___ 12.8 INR 1.15 PTT 31.6 Admission Labs ___ 12 15am WBC 3.3 RBC 3.84 Hgb 12.9 Hct 38.5 MCV 100 MCH 33.6 MCHC 33.5 RDW 12.7 RDWSD 46.8 Plt Ct 72 Neuts 47.3 ___ Monos 10.1 Eos 1.8 Baso 0.6 Im ___ AbsNeut 1.55 AbsLymp 1.31 AbsMono 0.33 AbsEos 0.06 AbsBaso 0.02 ___ PTT 30.4 ___ Glucose 92 UreaN 18 Creat 1.0 Na 139 K 4.1 Cl 103 HCO3 24 AnGap 16 Discharge Labs ___ 07 45am WBC 3.9 RBC 3.96 Hgb 13.2 Hct 39.6 MCV 100 MCH 33.3 MCHC 33.3 RDW 12.4 RDWSD 46.4 Plt ___ Glucose 80 UreaN 15 Creat 0.9 Na 141 K 3.7 Cl 105 HCO3 25 AnGap 15 Calcium 9.1 Phos 2.7 Mg 1.6 Images NCHCT ___ ___ PRIMARY READ ribbon like high density in the right parietal lobe superiorly with surrounding mild intra axial edema. Finding is nonspecific may be secondary to small subarachnoid hemorrhage or possibly laminar necrosis secondary to recent infarct in this area. ___ SECOND READ 1. Right frontal subarachnoid hemorrhage. 2. Reported brain tumor not visualized on this non contrast enhanced study and review of prior imaging is recommended. CTA HEAD CTA NECK WET READ ___ Non con head Stable to perhaps minimal increase in right frontal subarachnoid hemorrhage. Otherwise no significant change from prior. CTA Final read pending 3D recons. The carotid and vertebral arteries and their major intracranial branches are patent with no aneurysm greater than 3mm high grade stenosis or other vascular abnormality. Numerous pulmonary nodules bilaterally. Comparison with prior imaging would be helpful to evaluate stability. MR HEAD W W OUT CONTRAST ___ 1. Sulcal FLAIR hyperintensity and leptomeningeal enhancement involving the right central precentral and superior frontal sulci. Additional focus of leptomeningeal enhancement at the left frontal superior gyrus. Findings may represent reactive changes secondary to subarachnoid hemorrhage versus leptomeningeal carcinomatosis given clinical history of lung cancer. Consider correlation with CSF cytology and or follow up imaging to characterize the evolution of these findings. 2. Extensive bilateral cortical siderosis consistent with prior subarachnoid hemorrhages. 3. No discrete parenchymal lesion. CXR PA LAT ___ The lungs are mildly hyperinflated. The cardiomediastinal contour is within normal limits. The heart is not enlarged. There is a slightly prominent epicardial fat pad along the right heart border. No consolidation pneumothorax or pleural effusion seen. There are moderately severe multilevel degenerative changes in the thoracic spine. Brief Hospital Course ___ is an ___ yo R handed man with a history of metastatic SCLC with a single cerebellar met s p knife radiosurgery who presented to OSH with transient left arm weakness as well as left followed by right face numbness. A ___ at ___ demonstrated a right frontal convexal subarachnoid hemorrhage which may have prompted a seizure leading to his transient symptoms. The etiology of his SAH is unclear the differential includes metastatic lesion from his known expanding primary lung cancer no current evidence of MRI amyloidosis no evidence on MRI AVM no evidence on CTA traumatic no history but patient poor historian aneurysm not seen on CTA or RCVS. Upon admission to ___ all of his labs were within normal limits he was given Keppra 1000mg PO for seizure prophylaxis. A CTA of the head and neck showed no aneurysms with patent carotid and vertebral arteries. An MRI did not show any discrete masses or evidence of amyloid. It did show sulcal FLAIR hyperintensity and leptomeningeal enhancement involving the right central precentral and superior frontal sulci. Additional focus of leptomeningeal enhancement at the left frontal superior gyrus. This could be consistent with reactive changes secondary to SAH versus leptomeningeal carinomatosis. The MRI also showed evidence of extensive bilateral sidersosis from prior SAHs. He improved over the course of his admission and his neurological exam was unremarkable the day after admission. He was discharged home on 1g Keppra BID with plans to follow up with his oncologist at ___ for further workup regarding the etiology of his SAH including outpatient LP once SAH resorbs and plans to have his PCP refer him to a neurologist for outpatient titration of Keppra. Transitional Issues Spoke with outpatient ___ on call oncologist Dr. ___ agreed to pursue further work up for etiology of ___ as outpatient Will need to follow up with oncologist Dr. ___ evidence of mass or amyloid on MRI Will need outpatient referral by PCP to neurologist in home network for titration of Keppra currently on 1g Keppra BID due to concern for seizure Will need outpatient monitoring of blood pressure goal BP 140 90 CTA final read pending wet read only Numerous pulmonary nodules on CTA Medications on Admission The Preadmission Medication list is accurate and complete. 1. MetFORMIN Glucophage 750 mg PO TID 2. Pioglitazone 15 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. Levothyroxine Sodium 25 mcg PO DAILY 5. Lisinopril 10 mg PO DAILY Discharge Medications 1. Atorvastatin 20 mg PO QPM 2. Levothyroxine Sodium 25 mcg PO DAILY 3. Lisinopril 10 mg PO DAILY 4. Pioglitazone 15 mg PO DAILY 5. LeVETiracetam 1000 mg PO BID RX levetiracetam 1 000 mg 1 tablet s by mouth twice daily Disp 30 Tablet Refills 2 6. MetFORMIN Glucophage 750 mg PO TID Discharge Disposition Home Discharge Diagnosis Subarachnoid hemorrhage Discharge Condition Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Mental Status Confused sometimes. Discharge Instructions Dear Mr. ___ You were admitted with a brain bleed subarachnoid hemorrhage . There was no evidence of a new mass on your MRI. It will be important for you to buy a blood pressure cuff and measure your blood pressure once daily at home and keep a diary of blood pressures. Bring this diary to your primary care doctor. Your goal blood pressure should be less than 140 for the top number and less than 90 for the bottom number. We are concerned that your symptoms may have been due to a seizure due to irritation of your brain by the blood. We have started you on a seizure medication Keppra you will need to take 1 gram twice a day. We spoke with the on call oncologist at the office at ___ that follows you for your cancer. It will be very important that you call them to make a follow up appointment due to the growing cancer in your lungs and for further work up to make sure you do not have a new mass in your brain. It was a pleasure meeting you Your ___ Neurology Team Followup Instructions ___ The icd codes present in this text will be I609, G8194, R200, R51, E119, E785, I10, E039, Z85118, Z87891. The descriptions of icd codes I609, G8194, R200, R51, E119, E785, I10, E039, Z85118, Z87891 are I609: Nontraumatic subarachnoid hemorrhage, unspecified; G8194: Hemiplegia, unspecified affecting left nondominant side; R200: Anesthesia of skin; R51: Headache; E119: Type 2 diabetes mellitus without complications; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; E039: Hypothyroidism, unspecified; Z85118: Personal history of other malignant neoplasm of bronchus and lung; Z87891: Personal history of nicotine dependence. The common codes which frequently come are E119, E785, I10, E039, Z87891. The uncommon codes mentioned in this dataset are I609, G8194, R200, R51, Z85118.
The icd codes present in this text will be I313, I5033, D62, I2510, I110, Z951, Z952, F1010, E785, E119, M109, I480, Z87891, R410, T402X5A, Y92239. The descriptions of icd codes I313, I5033, D62, I2510, I110, Z951, Z952, F1010, E785, E119, M109, I480, Z87891, R410, T402X5A, Y92239 are I313: Pericardial effusion (noninflammatory); I5033: Acute on chronic diastolic (congestive) heart failure; D62: Acute posthemorrhagic anemia; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I110: Hypertensive heart disease with heart failure; Z951: Presence of aortocoronary bypass graft; Z952: Presence of prosthetic heart valve; F1010: Alcohol abuse, uncomplicated; E785: Hyperlipidemia, unspecified; E119: Type 2 diabetes mellitus without complications; M109: Gout, unspecified; I480: Paroxysmal atrial fibrillation; Z87891: Personal history of nicotine dependence; R410: Disorientation, unspecified; T402X5A: Adverse effect of other opioids, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause. The common codes which frequently come are D62, I2510, I110, Z951, E785, E119, M109, I480, Z87891. The uncommon codes mentioned in this dataset are I313, I5033, Z952, F1010, R410, T402X5A, Y92239. Allergies hydromorphone Chief Complaint Recurrent pleural effusion Major Surgical or Invasive Procedure ___ Left anterior mini thoracotomy pericardial window. History of Present Illness Mr. ___ is a ___ year old man with a history of aortic stenosis and coronary artery disease status post aortic valve replacement and coronary artery bypass grafting x 2 in ___. His medical history is also notable alcohol abuse disorder atrial fibrillation diabetes mellitus goat hyperlipidemia and hypertension. He was admitted to the cardiology service after being redirected by outpatient cardiologist for evaluation of worsening pericardial effusion. He was recently admitted to ___ ___ for pericardial tamponade Dressler syndrome that required emergent pericardiocentesis subxiphoid approach removed over 800cc of fluid and subsequent CCU level of care. A pericardial drain was left in situ at the time and then removed on ___ prior to home discharge on ___. Today he was following up with his cardiologist Dr. ___ ___ and he was describing progressive shortness of breath and some orthopnea over the last two days along with increase in his weights from 178 lb baseline to 185 today . Still frames from the echo performed in the office two days ago show an increased amount of fluid around the right ventricle. After reviewing the images during Today s visit inpatient cardiologist at ___ Dr. ___ was contacted. He recommended redirecting patient to the ED for further evaluation and potential pericardial window given failure of recent percutaneous pericardial drainage . During office visit this morning patient s vital signs remained stable. His clinical condition was considered appropriate for direct admission to the general cardiology floor. Past Medical History Alcohol Abuse Aortic Stenosis Diabetes Mellitus Type II Gout Hyperlipidemia Hypertension Social History ___ Family History No family history of heart disease Physical Exam ADMISSION PHYSICAL EXAM VS T 97.8 F BP 130 74 mmHg HR 89 x min RR 18 x min O2 SAT 95 RA. Pulsus paradoxus SBP expiration 110 mmHg SBP inspiration 102 104 mmHg Bedside TTE performed by ___ Cardiology Fellow . No signs of tamponade. Large posterior pericardial effusion. GENERAL Well developed well nourished in NAD. Oriented x3. Mood affect appropriate. HEENT Sclera anicteric. PERRL. EOMI. NECK JVP 10 cmH2O sitting upright. CARDIAC RRR normal intensity of S1 S2 ___ holo systolic murmur best appreciated over the apex. no g r. Negative pulsus paradoxus. CHEST Healed sternotomy scar hypoventilation on B l bases clear to auscultation otherwise no crackles or no wheezes. ABDOMEN NTND bowel sounds present EXTREMITIES WWP no pitting edema noted over lower extremities SKIN No significant lesions or rashes. PULSES Distal pulses palpable and symmetric Discharge Exam Physical Examination General c o chest wall pain at CT insertion site. x Neurological A O x3 x non focal HEENT PEERL Cardiovascular RRR x Irregular Murmur Rub Respiratory Decreased at the bases left right No resp distress x GI Abdomen Bowel sounds present x Soft x ND x NT x Extremities Right Upper extremity Warm x Edema none Left Upper extremity Warm x Edema none Right Lower extremity Warm x Edema none Left Lower extremity Warm x Edema none Pulses DP Right Left ___ Right Left Radial Right Left Skin Wounds Dry x intact x Thoracotomy site CDI x no erythema or drainage x Sternum stable well healed x Pertinent Results LABS ___ 04 58AM BLOOD WBC 6.0 RBC 4.81 Hgb 9.5 Hct 31.9 MCV 66 MCH 19.8 MCHC 29.8 RDW 16.0 RDWSD 37.1 Plt Ct 91 ___ 04 58AM BLOOD ___ PTT 30.5 ___ ___ 04 58AM BLOOD Glucose 149 UreaN 12 Creat 0.8 Na 139 K 4.2 Cl 101 HCO3 26 AnGap 12 ___ 04 23AM BLOOD WBC 5.1 RBC 4.49 Hgb 9.0 Hct 30.1 MCV 67 MCH 20.0 MCHC 29.9 RDW 16.3 RDWSD 38.2 Plt Ct 80 ___ 04 20AM BLOOD WBC 8.4 RBC 5.10 Hgb 10.1 Hct 34.1 MCV 67 MCH 19.8 MCHC 29.6 RDW 16.3 RDWSD 37.7 Plt Ct 86 ___ 04 23AM BLOOD ___ ___ 04 20AM BLOOD ___ PTT 26.7 ___ ___ 04 23AM BLOOD Glucose 229 UreaN 12 Creat 0.9 Na 136 K 4.1 Cl 100 HCO3 26 AnGap 10 ___ 04 20AM BLOOD Glucose 178 UreaN 11 Creat 0.9 Na 136 K 4.2 Cl 99 HCO3 24 AnGap 13 ___ 06 07AM BLOOD Glucose 237 UreaN 13 Creat 1.0 Na 139 K 4.5 Cl 98 HCO3 22 AnGap 19 ___ 07 05AM BLOOD Glucose 204 UreaN 12 Creat 0.8 Na 138 K 3.9 Cl 100 HCO3 24 AnGap 14 ___ 05 00PM BLOOD WBC 7.1 RBC 5.35 Hgb 10.6 Hct 35.3 MCV 66 MCH 19.8 MCHC 30.0 RDW 16.0 RDWSD 36.3 Plt ___ ___ 05 00PM BLOOD ___ PTT 28.8 ___ ___ 05 00PM BLOOD Glucose 144 UreaN 15 Creat 0.8 Na 139 K 4.1 Cl 99 HCO3 24 AnGap 16 ___ 07 05AM BLOOD ALT 30 AST 25 LD LDH 168 AlkPhos 66 Amylase 53 TotBili 0.3 ___ 07 05AM BLOOD Lipase 34 ___ 05 00PM BLOOD cTropnT 0.01 proBNP 399 ___ 05 00PM BLOOD Calcium 9.9 Phos 4.7 Mg 1.7 ___ 05 00PM BLOOD CRP 1.4 IMAGING Transthoracic Echocardiogram ___ The left atrial volume index is SEVERELY increased. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 58 normal 54 73 . There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with depressed free wall motion. Tricuspid annular plane systolic excursion TAPSE is depressed. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. An aortic valve bioprosthesis is present. The prosthesis is well seated with normal gradient. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with mild bileaflet systolic prolapse. There is moderate mitral annular calcification. There is trivial mitral regurgitation. Due to acoustic shadowing the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets are mildly thickened. There is no tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a large circumferential pericardial effusion. There are no 2D or Doppler echocardiographic evidence of tamponade. Compared with the prior TTE images reviewed of ___ pericardial effusion is significantly larger but without evidence of frank cardiac tamponade. Chest CT ___ Large nonhemorrhagic pericardial effusion. Correlate clinically for tamponade. CXR ___ IMPRESSION Comparison with the study of ___ the cardiac silhouette appears slightly less prominent than the left hemidiaphragmatic contour is sharply seen. However there is opacification along the lateral chest wall with a configuration raising the possibility of a loculated collection. The pulmonary vascular congestion has essentially cleared. No evidence of acute pneumonia. ___ Pericardial tissue pathology Organizing fibrinous pericarditis. No malignancy identified specimen entirely submitted for histologic examination. Brief Hospital Course ___ year old male patient of PCP ___ and Dr s . ___ with H O CAD S P CABG ___ ___ LIMA LAD SVG D for LAD and diagonal CAD and AVR 23 mm pericardial for aortic stenosis type 2 diabetes mellitus hypertension hyperlipidemia paroxysmal atrial fibrillation previously on apixiban EtOH use disorder gout S P pericardiocentesis ___ 865 mL amber serosanguinous fluid negative for malignancy or bacterial growth with subsequent colchicine therapy presenting with worsening pericardial effusion progressive shortness of breath exertional fatigue and ___ transferred to ___ for pericardial window. He was treated for acute on chronic diastolic heart failure with intermittent Lasix 40 mg. An echocardiogram demonstrated pericardial effusion was significantly larger but without evidence of frank cardiac tamponade. A chest CT revealed a large hemorrhagic pericardial effusion. He was taken to the operating room on ___ and underwent pericardial window via anterior mini thoracotomy. Per OR note 1.5L drained of serous pericardial effusion. He tolerated the procedure well and post operatively returned to the floor. Chest tube discontinued without complication. Pain was controlled with ATC Tylenol Toradol changed to Ibuprofen for discharge oxycodone and Dilaudid cause confusion . Follow up chest XRay stable with opacification along the lateral chest wall with a configuration raising the possibility of a loculated collection. The pulmonary vascular congestion had essentially cleared. No evidence of acute pneumonia. The patient was discharged home on POD 3 with ___ services. He is to follow up with Dr ___ in 2 weeks with CXR prior to clinic visit. He was discharged home in stable condition with follow up appointments arranged. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. Thiamine 100 mg PO DAILY 5. Colchicine 0.6 mg PO BID 6. Rosuvastatin Calcium 20 mg PO QPM 7. Amaryl glimepiride 4 mg oral BID 8. Furosemide 40 mg PO DAILY 9. Januvia SITagliptin 100 mg oral DAILY 10. MetFORMIN Glucophage 500 mg PO BID 11. Ranitidine 150 mg PO DAILY 12. Metoprolol Succinate XL 100 mg PO DAILY 13. GuaiFENesin ER 1200 mg PO Q12H 14. GuaiFENesin Dextromethorphan ___ mL PO Q6H Cough 15. Pantoprazole 40 mg PO Q24H Discharge Medications 1. Acetaminophen 1000 mg PO Q6H 2. Apixaban 5 mg PO BID 3. Ibuprofen 800 mg PO Q8H PRN Pain Mild Take with food 4. Senna 17.2 mg PO QHS 5. GuaiFENesin ER 1200 mg PO Q12H PRN cough 6. Metoprolol Tartrate 25 mg PO BID RX metoprolol tartrate 25 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 1 7. Amaryl glimepiride 4 mg oral BID 8. Aspirin 81 mg PO DAILY 9. Colchicine 0.6 mg PO BID 10. FoLIC Acid 1 mg PO DAILY 11. Losartan Potassium 25 mg PO DAILY 12. MetFORMIN Glucophage 500 mg PO BID 13. Pantoprazole 40 mg PO Q24H 14. Ranitidine 150 mg PO DAILY 15. Rosuvastatin Calcium 20 mg PO QPM 16. Thiamine 100 mg PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Recurrent Pericardial Effusion Acute on Chronic Congestive Heart Failure Alcohol Abuse Aortic Stenosis Congestive Heart Failure chronic Diabetes Mellitus Type II Gout Hyperlipidemia Hypertension Discharge Condition Alert and oriented x3 non focal Ambulating gait steady Thoracotomy pain managed with oral analgesics Thoracotomy Incision healing well no erythema or drainage No edema Discharge Instructions Please shower daily wash incisions gently with mild soap no baths or swimming look at your incisions daily Please NO lotion cream powder or ointment 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 while taking narcotics Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 2 weeks Encourage full shoulder range of motion unless otherwise specified 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 I313, I5033, D62, I2510, I110, Z951, Z952, F1010, E785, E119, M109, I480, Z87891, R410, T402X5A, Y92239. The descriptions of icd codes I313, I5033, D62, I2510, I110, Z951, Z952, F1010, E785, E119, M109, I480, Z87891, R410, T402X5A, Y92239 are I313: Pericardial effusion (noninflammatory); I5033: Acute on chronic diastolic (congestive) heart failure; D62: Acute posthemorrhagic anemia; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I110: Hypertensive heart disease with heart failure; Z951: Presence of aortocoronary bypass graft; Z952: Presence of prosthetic heart valve; F1010: Alcohol abuse, uncomplicated; E785: Hyperlipidemia, unspecified; E119: Type 2 diabetes mellitus without complications; M109: Gout, unspecified; I480: Paroxysmal atrial fibrillation; Z87891: Personal history of nicotine dependence; R410: Disorientation, unspecified; T402X5A: Adverse effect of other opioids, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause. The common codes which frequently come are D62, I2510, I110, Z951, E785, E119, M109, I480, Z87891. The uncommon codes mentioned in this dataset are I313, I5033, Z952, F1010, R410, T402X5A, Y92239.
The icd codes present in this text will be I313, R571, E872, N179, I314, Z952, I2510, Z951, E785, I10, M109, F1010, E119, Z7901, Z87891, Z7984, I480, R05, R740. The descriptions of icd codes I313, R571, E872, N179, I314, Z952, I2510, Z951, E785, I10, M109, F1010, E119, Z7901, Z87891, Z7984, I480, R05, R740 are I313: Pericardial effusion (noninflammatory); R571: Hypovolemic shock; E872: Acidosis; N179: Acute kidney failure, unspecified; I314: Cardiac tamponade; Z952: Presence of prosthetic heart valve; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; M109: Gout, unspecified; F1010: Alcohol abuse, uncomplicated; E119: Type 2 diabetes mellitus without complications; Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence; Z7984: Long term (current) use of oral hypoglycemic drugs; I480: Paroxysmal atrial fibrillation; R05: Cough; R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]. The common codes which frequently come are E872, N179, I2510, Z951, E785, I10, M109, E119, Z7901, Z87891, I480. The uncommon codes mentioned in this dataset are I313, R571, I314, Z952, F1010, Z7984, R05, R740. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Shortness of breath Major Surgical or Invasive Procedure Pericardiocentesis History of Present Illness ___ with PMHx aortic stenosis s p AVR 23MM Magna Ease and coronary artery disease s p coronary artery bypass graft x 2 LIMA LAD SVG D ___ alcohol use disorder T2DM gout HLD HTN a fib on apixiban admitted to the CCU for management of pericardial tamponade and cardiogenic shock. He presented with 1 day of significant shortness of breath inability to lay flat and extreme weakness. The patient denies any chest pain or abdominal pain. He also has hyperglycemia and metabolic acidosis concerning for DKA. Bedside ultrasound showed a large pericardial effusion with significant right ventricular collapse consistent with pericardial tamponade. The patient received K Centra. In the ED Initial vitals were 96.0 100 ___ 95 2L NC Labs notable for H H 12.1 41.8 WBC 15.0 plt 239 Na 128 BUN 22 Cr 1.7 glucose 390 ___ 19.9 PTT 27.1 INR 1.8 Trop T 0.01 VBG 7.18 42 Studies notable for CXR Low lung volumes with mild retrocardiac atelectasis and trace left pleural effusion. Possible mild pulmonary vascular congestion without frank pulmonary edema. Patient was given IV Kcentra 1L NS Bedside ECHO performed by cardiology fellow notable for large pericardial effusion. Patient subsequently taken to the cath lab for emergent pericardiocentesis. Per procedural report The pericardial space was accessed from the subxiphoid approach with echocardiographic and fluoroscopic guidance. The initial mean pericardial pressure was 35 mm Hg with an amber fluid dripping back. After removal of 865 mL of dark amber slightly reddish brown fluid 60 60 20 mL in syringes 725 in vacuum bottle the pericardial effusion was minimal on echocardiogram with marked symptomatic improvement and closing pericardial pressure of 3 mm Hg. The pericardial drainage catheter was secured in place. On arrival to the CCU the patient feels much improved and was sitting comfortably in bed. He denied any dizziness LH CP SOB abdominal pain n v d or urinary symptoms. ROS Positive per HPI. Remaining 10 point ROS reviewed and negative. Past Medical History Alcohol Abuse Aortic Stenosis Diabetes Mellitus Type II Gout Hyperlipidemia Hypertension Social History ___ Family History No family history of heart disease Physical Exam ADMISSION EXAM VS Reviewed in MetaVision GENERAL Well developed well nourished in NAD. Oriented x3. Mood affect appropriate. HEENT Sclera anicteric. PERRL. EOMI. NECK Supple. JVP 10 at 60 degrees. CARDIAC rrr ___ holo systolic murmur no g r CHEST Healing sternotomy scar mild moderate bibasilar crackles no wheeze. ABDOMEN NTND bowel sounds present EXTREMITIES WWP no pitting edema SKIN No significant lesions or rashes. PULSES Distal pulses palpable and symmetric. NEURO CNII XII intact DISCHARGE LABS 24 HR Data last updated ___ 316 Temp 98.0 Tm 98.8 BP 147 83 123 147 62 88 HR 97 75 97 RR 18 O2 sat 96 96 99 O2 delivery Ra GENERAL Well developed well nourished in NAD. Oriented x3. Mood affect appropriate. HEENT Sclera anicteric. PERRL. EOMI. NECK Supple. JVP 8 at 60 degrees. CARDIAC rrr ___ holo systolic murmur no g r CHEST Healing sternotomy scar mild moderate bibasilar crackles no wheeze. ABDOMEN NTND bowel sounds present EXTREMITIES WWP no pitting edema SKIN No significant lesions or rashes. PULSES Distal pulses palpable and symmetric. NEURO CNII XII intact Pertinent Results ADMISSION LABS ___ 06 55PM BLOOD WBC 15.0 RBC 5.92 Hgb 12.1 Hct 41.8 MCV 71 MCH 20.4 MCHC 28.9 RDW 18.6 RDWSD 42.3 Plt ___ ___ 06 55PM BLOOD Neuts 72.0 ___ Monos 4.6 Eos 0.2 Baso 0.9 NRBC 0.2 Im ___ AbsNeut 10.78 AbsLymp 3.18 AbsMono 0.69 AbsEos 0.03 AbsBaso 0.13 ___ 06 55PM BLOOD ___ PTT 27.1 ___ ___ 06 55PM BLOOD Glucose 390 UreaN 22 Creat 1.7 Na 128 K 7.5 Cl 95 HCO3 11 AnGap 22 ___ 01 52AM BLOOD ALT 261 AST 186 AlkPhos 76 TotBili 0.5 ___ 06 55PM BLOOD cTropnT 0.01 ___ 10 01PM BLOOD Calcium 8.6 Phos 5.8 Mg 1.7 ___ 07 05PM BLOOD Lactate 9.2 DISCHARGE LABS ___ 07 27AM BLOOD WBC 7.7 RBC 5.92 Hgb 12.0 Hct 40.5 MCV 68 MCH 20.3 MCHC 29.6 RDW 17.3 RDWSD 38.7 Plt ___ ___ 07 27AM BLOOD Glucose 239 UreaN 19 Creat 0.9 Na 136 K 4.6 Cl 100 HCO3 22 AnGap 14 ___ 06 55AM BLOOD ALT 182 AST 25 AlkPhos 102 TotBili 0.5 ___ 07 27AM BLOOD Calcium 9.8 Phos 4.1 Mg 1.9 PERTINENT LABS ___ 05 06AM BLOOD CK MB 2 cTropnT 0.05 ___ 06 55PM BLOOD Beta OH 0.2 ___ 05 06AM BLOOD HBsAg NEG HBsAb POS HBcAb POS HAV Ab POS ___ 06 27AM BLOOD CRP 18.7 ___ 05 06AM BLOOD HCV Ab NEG ___ 10 19PM BLOOD Lactate 5.8 ___ 02 14AM BLOOD Lactate 2.8 ___ 12 19PM BLOOD Lactate 1.3 ___ 05 06AM BLOOD HBsAg NEG HBsAb POS HBcAb POS HAV Ab POS ___ 02 56PM BLOOD IgM HAV NEG ___ 06 27AM BLOOD HBV VL NOT DETECT HCV VL NOT DETECT ___ 05 06AM BLOOD HCV Ab NEG IMAGING CXR ___ Low lung volumes with mild retrocardiac atelectasis and trace left pleural effusion. Possible mild pulmonary vascular congestion without frank pulmonary edema. TTE ___ EF 60 . Well seated normal functioning bioprosthetic AVR with normal gradient and no aortic regurgitation. Normal left ventricular wall thickness and biventricular cavity sizes and regional global systolic function. Small circumferential pericardial effusion without echocardiographic evidence for tamponade physiology. Compared with the prior TTE images reviewed of ___ the pericardial effusion is now slightly larger but remains small and without echo evidence of hemodynamic compromise. CXR ___ In comparison with the study of ___ following pericardiocentesis the cardiac silhouette is now essentially within normal limits. Pericardial drain is in place. Blunting of the left costophrenic angle is consistent with pleural fluid. No evidence of appreciable vascular congestion or acute focal pneumonia. RUQUS ___ 1. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis cirrhosis cannot be excluded on this study. 2. Mild splenomegaly. 3. Cholelithiasis. Focused TTE ___ The estimated right atrial pressure is ___ mmHg. There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is normal. The visually estimated left ventricular ejection fraction is 60 . Normal right ventricular cavity size with depressed free wall motion. The mitral valve leaflets are mildly thickened. There is moderate mitral annular calcification. Due to acoustic shadowing the severity of mitral regurgitation could be UNDERestimated. There is a small posterior pericardial effusion. The effusion is echo dense c w blood inflammation or other cellular elements. There are no 2D or Doppler echocardiographic evidence of tamponade. Compared with the prior TTE images reviewed of ___ there is no obvious change but the suboptimal image quality of the studies precludes definitive comparison. CT abdomen pelvis without contrast ___ 1. Punctate subpleural nodules in the right lower lobe are nonspecific but likely infectious versus inflammatory in etiology. 2. Trace residual pericardial effusion with a pericardial drain in situ. 3. Incidentally noted are multiple healing right sided rib fractures. TTE ___ Small posterior loculated pericardial effusion without tampoande. Compared with the prior TTE ___ small posterior effusion not echolucent. Appears slightly larger see apical 4 and apical long axis views . MICRO PERICARDIAL FUID. FINAL REPORT ___ 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 if applicable. FLUID CULTURE Final ___ NO GROWTH. ANAEROBIC CULTURE Final ___ NO GROWTH. URINE CULTURE Final ___ NO GROWTH. Blood Culture Routine Final ___ NO GROWTH. PATH Pericardial fluid ___ NEGATIVE FOR MALIGNANT CELLS. Predominantly lymphocytes with scattered admixed reactive mesothelial cells. Brief Hospital Course ___ with PMHx aortic stenosis s p AVR 23MM Magna Ease and coronary artery disease s p coronary artery bypass graft x 2 LIMA LAD SVG D ___ alcohol use disorder T2DM gout HLD HTN a fib on apixiban admitted to the CCU for management of pericardial tamponade and cardiogenic shock. ACUTE ISSUES Pericardial effusion w effusoconstrictive physiology Patient presented to ED on ___ with 1 month cough and 2 day worsening dyspnea on exertion. Bedside TTE in the ED showed large effusion with normal global LV function and signs of RV collapse. Had an emergent pericardiocentesis with mean pericardial opening pressures of 35 mmHg and closing pressures of 3 mm Hg. 875 mL of dark amber fluid was removed and a pericardial drainage catheter was secured in place. He was transferred to the CCU where he continued to be monitored. The drainage catheter was removed on ___ after 24 hour collection was 50cc. Pericardial fluid fluid cell count chemistry cytology culture was c w post surgical inflammatory pericardial effusion. CRP was 18.7. Patient was started on colchicine 0.6mg BID for 3 months End date ___. The patient s apixaban was held at discharge. Would consider restarting after repeating TTE in 1 week. Post surgical cough Dysphonia Patient has noticed a chronic cough after his CABG. Despite being euvolemic the patient continues to have a cough. CT Chest was done without evidence of cause. The patient was started on cough suppressants and had a SNIFF test given L diaphragm was slightly elevated on CXR. This showed no evidence diaphragmatic weakness. He was started on pantoprazole for empiric treatment of GERD. Planned for ENT referral as an outpatient. Lactic acidosis Hypotensive shock Pt presented with lactic acidosis to 9.2 which down trended to 2.8 pH of 7.18 and PCO2 42 Bicarbonate of 16. Labs were initially concerning for DKA given FBG of 390 so pt was placed on insulin gtt which was weaned to SSI after urine ketones and serum beta hydroxybutyrate resulted negative. Lactic acidosis likely in the setting of poor cadiac perfusion d t tamponade physiology which responded to therapeutic pericardiocentesis. ___ Cr baseline 0.9 1.2 peak 1.7 down trended to 0.9. Likely pre renal given hypoperfusion iso tamponade. Cr on discharge 0.9 Paroxysmal AF Metoprolol succinate was held initially iso temponade and hypotension. Patient had one episode of afib with RVR and was started on metoprolol tartrate that was consolidated to metoprolol succinate 100mg daily. Apixaban was held initially due to concerns that the pericardial effusion was hemorrhagic. Patient was discharged on metop succinate 100mg daily and held apixaban 5mg BID. Transaminitits improving on ___ ALT was 542 and AST of 187 with normal total Bilirubin. No clear etiology however this coincidenced with starting colchicine. RUQUS showed hepatic steatosis without obstruction. Hep. B serology showed immunity due to previous infection. Hep B viral load was pending. Hep A antibodies were negative and Hep C antibodies were negative. Atorvastatin was switched to Crestor 20mg. LFTs came down. On discharge ALT was 182 and AST was 25. Gout Flare Pt had gout flare in R second PIP joint on ___ was given three days of PO prednisone 20 mg. CHRONIC ISSUES NIDDM The patient was placed on insulin sliding scale while inpatient. His home oral regimen was continued on discharged. Would consider switching to SGLT2 for cardiovascular benefit. home Amaryl glimepiride pt not taking home Januvia SITagliptin 100 mg oral daily home MetFORMIN Glucophage 500 mg PO BID Aortic Stenosis s p Aortic valve replacement Coronary Artery Disease s p coronary artery bypass graft x 2 Cont ASA 81. Cont Atorvastatin 40mg qHS TRANSITIONAL ISSUES repeat CRP after treatment. CRP was 18.7 while inpatient Will need repeat echo in ___ weeks to ensure no reaccumulation. Would consider restarting apixaban if stable. Consider switching from glimepiride to SGLT2 given cardiovascular benefit Ensure ENT follow up for chronic cough f u HBV and HCV VL CODE Full code confirmed CONTACT HCP ___ wife ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. GuaiFENesin ER 1200 mg PO Q12H 4. Ranitidine 150 mg PO DAILY 5. Senna 17.2 mg PO QHS 6. TraMADol 50 mg PO Q6H PRN Pain Moderate 7. Apixaban 5 mg PO BID 8. Amaryl glimepiride 4 mg oral BID 9. Januvia SITagliptin 100 mg oral DAILY 10. Losartan Potassium 25 mg PO DAILY 11. MetFORMIN Glucophage 500 mg PO BID 12. FoLIC Acid 1 mg PO DAILY 13. Thiamine 100 mg PO DAILY 14. TraZODone 25 mg PO QHS PRN insomnia 15. Furosemide 40 mg PO DAILY 16. Metoprolol Succinate XL 100 mg PO DAILY Discharge Medications 1. Colchicine 0.6 mg PO BID RX colchicine 0.6 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 2 2. GuaiFENesin Dextromethorphan ___ mL PO Q6H Cough 3. Pantoprazole 40 mg PO Q24H 4. Rosuvastatin Calcium 20 mg PO QPM RX rosuvastatin 20 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 3 5. Amaryl glimepiride 4 mg oral BID 6. Aspirin 81 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. GuaiFENesin ER 1200 mg PO Q12H 9. Januvia SITagliptin 100 mg oral DAILY 10. Losartan Potassium 25 mg PO DAILY 11. MetFORMIN Glucophage 500 mg PO BID 12. Metoprolol Succinate XL 100 mg PO DAILY 13. Ranitidine 150 mg PO DAILY 14. Senna 17.2 mg PO QHS 15. Thiamine 100 mg PO DAILY 16. TraMADol 50 mg PO Q6H PRN Pain Moderate 17. TraZODone 25 mg PO QHS PRN insomnia 18. HELD Apixaban 5 mg PO BID This medication was held. Do not restart Apixaban until you see your cardiologist 19. HELD Furosemide 40 mg PO DAILY Duration 7 Days This medication was held. Do not restart Furosemide until you are told to by your heart doctor Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS Pericardial Effusion with tamponade physiology SECONDARY DIAGNOSES Atrial fibrillation Chronic cough transaminitis Gout Type 2 diabetes mellitus Acute kidney injury 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 ___. WHY WAS I IN THE HOSPITAL You were admitted to the hospital because you were having trouble breathing. WHAT WAS DONE IN THE HOSPITAL You had an ultrasound of your heart. This showed that there was a collection of fluid surrounding your heart. You had a procedure called a pericardiocentesis to remove the extra fluid surrounding your heart. WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL Continue to take all your medications as prescribed. Make sure to follow up with your heart doctor and primary care doctor. We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I313, R571, E872, N179, I314, Z952, I2510, Z951, E785, I10, M109, F1010, E119, Z7901, Z87891, Z7984, I480, R05, R740. The descriptions of icd codes I313, R571, E872, N179, I314, Z952, I2510, Z951, E785, I10, M109, F1010, E119, Z7901, Z87891, Z7984, I480, R05, R740 are I313: Pericardial effusion (noninflammatory); R571: Hypovolemic shock; E872: Acidosis; N179: Acute kidney failure, unspecified; I314: Cardiac tamponade; Z952: Presence of prosthetic heart valve; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; M109: Gout, unspecified; F1010: Alcohol abuse, uncomplicated; E119: Type 2 diabetes mellitus without complications; Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence; Z7984: Long term (current) use of oral hypoglycemic drugs; I480: Paroxysmal atrial fibrillation; R05: Cough; R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]. The common codes which frequently come are E872, N179, I2510, Z951, E785, I10, M109, E119, Z7901, Z87891, I480. The uncommon codes mentioned in this dataset are I313, R571, I314, Z952, F1010, Z7984, R05, R740.
The icd codes present in this text will be E8770, I4892, J90, E785, E871, Z952, Z87891, Z7901, I4891, Z7984, I129, E1122, N189, I2510, Z951. The descriptions of icd codes E8770, I4892, J90, E785, E871, Z952, Z87891, Z7901, I4891, Z7984, I129, E1122, N189, I2510, Z951 are E8770: Fluid overload, unspecified; I4892: Unspecified atrial flutter; J90: Pleural effusion, not elsewhere classified; E785: Hyperlipidemia, unspecified; E871: Hypo-osmolality and hyponatremia; Z952: Presence of prosthetic heart valve; Z87891: Personal history of nicotine dependence; Z7901: Long term (current) use of anticoagulants; I4891: Unspecified atrial fibrillation; Z7984: Long term (current) use of oral hypoglycemic drugs; 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; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft. The common codes which frequently come are E785, E871, Z87891, Z7901, I4891, I129, E1122, N189, I2510, Z951. The uncommon codes mentioned in this dataset are E8770, I4892, J90, Z952, Z7984. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Dyspnea and cough with thick sputum Major Surgical or Invasive Procedure None History of Present Illness ___ year old man with a history of alcohol abuse aortic stenosis hyperlipidemia and hypertension. On ___ he underwent coronary artery bypass grafting x 2 and aortic valve replacement tissue . His post operative course was complicated by gout and hyperglycemia. In addition he returned to the ICU due to cough and possible pneumonia with thick secretions and leukocytosis. He remained hemodynamically stable and was transferred back to the floor on POD 9 and discharged home on ___. During his time at home he complains of worsening dyspnea and productive cough. He denies fever chills or chest pain. His ___ was concerned and sent him to the ER for further evaluation. Upon presentation to the ER he was HD stable and O2 sat 98 on 2L NC. CXR concerning for fluid overload pleural effusion bilaterally. Otherwise he appears deconditioned and complains of in ability to sleep due to his persistent coughing. He is unable to lie flat. Past Medical History Alcohol Abuse Aortic Stenosis Diabetes Mellitus Type II Gout Hyperlipidemia Hypertension Social History ___ Family History No family history of heart disease Physical Exam Pulse Resp 62 O2 sat 99 on 2L NC 95 on RA B P Right 132 80 Left Height Weight General Skin Dry X intact X HEENT PERRLA X EOMI X Neck Supple Full ROM X Chest Coarse breath sounds and crackles at lung bases bilaterally. Healing sternotomy incision. No erythema drainage. Heart RRR X Irregular Murmur grade ___ Abdomen Soft X non distended non tender bowel sounds Extremities Warm well perfused Edema X 1 pitting edema in B L ___ Varicosities None Neuro Grossly intact Pulses Femoral Right Left DP Right Left ___ Right Left Radial Right Left Carotid Bruit Right None Left None Discharge Exam Pertinent Results ___ CXR Mild to moderate pulmonary edema with grown small bilateral pleural effusions and bibasilar opacities which may reflect atelectasis adjacent to the pleural effusions although superinfection cannot be excluded. Cardiomegaly. ___ Abdominal xray No radiographic evidence of ileus or bowel obstruction. Brief Hospital Course Mr. ___ was readmitted to the ___ on ___ for further management of his cough and bilateral pleural effusions. He was diuresed aggressively with good results. Shortness of breath resolved. His rhythm was alternating between atrial fibrillation flutter and NSR. He is anticoagulated with Eiquis. EP was consulted regarding his rhythm and concern for using Amiodarone with his recent eval done by Hepatology. Amiodarone was discontinued per their recommendation. On ___ Mr. ___ was successfully electrically cardioverted to sinus rhythm. He remained so during the rest of his hospitalization. By the time of hospital day six he was ambulating independently his wound was healing and his pain was well controlled. He was cleared for discharge to home with ___ services. All follow up appointments were advised. Medications on Admission 1. Apixaban 5 mg PO BID RX apixaban Eliquis 5 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 1 2. Atorvastatin 20 mg PO QPM will need to increase to 40mg daily once off amiodarone RX atorvastatin 20 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 1 3. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 4. Furosemide 40 mg PO DAILY Duration 10 Days RX furosemide Lasix 40 mg 1 tablet s by mouth once a day Disp 10 Tablet Refills 0 5. GuaiFENesin ER 1200 mg PO Q12H RX guaifenesin 1 200 mg 1 tablet s by mouth twice a day Disp 20 Tablet Refills 0 6. Lactulose 30 mL PO DAILY RX lactulose 20 gram 30 mL 1 ml by mouth once a day Disp 1 Bottle Refills 0 7. Lisinopril 2.5 mg PO DAILY RX lisinopril 2.5 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 8. Metoprolol Tartrate 37.5 mg PO TID RX metoprolol tartrate 37.5 mg 1 tablet s by mouth three times a day Disp 90 Tablet Refills 1 9. Ranitidine 150 mg PO DAILY Duration 1 Month RX ranitidine HCl Zantac Maximum Strength 150 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 10. Senna 17.2 mg PO QHS RX sennosides senna 8.6 mg 2 tablet s by mouth at bedtime Disp 30 Tablet Refills 0 11. Thiamine 100 mg PO DAILY RX thiamine HCl vitamin B1 100 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 12. TraMADol 50 mg PO Q4H PRN Pain Moderate RX tramadol Ultram 50 mg 1 tablet s by mouth four times a day Disp 60 Tablet Refills 0 13. Aspirin 81 mg PO DAILY 14. glimepiride 4 mg oral BID 15. Januvia SITagliptin 100 mg oral DAILY 16. MetFORMIN Glucophage 500 mg PO BID Discharge Medications 1. Apixaban 5 mg PO BID RX apixaban Eliquis 5 mg one tablet s by mouth twice a day Disp 60 Tablet Refills 2 2. Aspirin 81 mg PO DAILY 3. Furosemide 40 mg PO DAILY Duration 7 Days RX furosemide 40 mg one tablet s by mouth once a day Disp 7 Tablet Refills 0 4. Losartan Potassium 25 mg PO DAILY RX losartan 25 mg one tablet s by mouth once a day Disp 30 Tablet Refills 2 5. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate 100 mg one tablet s by mouth once a day Disp 30 Tablet Refills 2 6. Amaryl glimepiride 4 mg oral DAILY 7. Atorvastatin 40 mg PO QPM 8. FoLIC Acid 1 mg PO DAILY 9. GuaiFENesin ER 1200 mg PO Q12H 10. Januvia SITagliptin 100 mg oral DAILY 11. MetFORMIN Glucophage 500 mg PO BID 12. Ranitidine 150 mg PO DAILY 13. Senna 17.2 mg PO QHS 14. Thiamine 100 mg PO DAILY 15. TraMADol 50 mg PO Q4H PRN Pain Moderate 16. TraZODone 25 mg PO QHS PRN insomnia Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Aortic Stenosis s p Aortic valve replacement Coronary Artery Disease s p coronary artery bypass graft x 2 Secondary Diagnosis Alcohol Abuse Diabetes Mellitus Type II Gout Hyperlipidemia Hypertension Discharge Condition Alert and oriented x3 nonfocal Ambulating gait steady Sternal pain managed with oral analgesics Sternal Incision healing well no erythema or drainage Edema trace R L Discharge Instructions Please shower daily wash incisions gently with mild soap no baths or swimming look at your incisions daily Please NO lotion cream powder or ointment 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 Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion unless otherwise specified 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 E8770, I4892, J90, E785, E871, Z952, Z87891, Z7901, I4891, Z7984, I129, E1122, N189, I2510, Z951. The descriptions of icd codes E8770, I4892, J90, E785, E871, Z952, Z87891, Z7901, I4891, Z7984, I129, E1122, N189, I2510, Z951 are E8770: Fluid overload, unspecified; I4892: Unspecified atrial flutter; J90: Pleural effusion, not elsewhere classified; E785: Hyperlipidemia, unspecified; E871: Hypo-osmolality and hyponatremia; Z952: Presence of prosthetic heart valve; Z87891: Personal history of nicotine dependence; Z7901: Long term (current) use of anticoagulants; I4891: Unspecified atrial fibrillation; Z7984: Long term (current) use of oral hypoglycemic drugs; 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; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft. The common codes which frequently come are E785, E871, Z87891, Z7901, I4891, I129, E1122, N189, I2510, Z951. The uncommon codes mentioned in this dataset are E8770, I4892, J90, Z952, Z7984.
The icd codes present in this text will be R0789, I5030, I313, R0609, I480, I110, I4430, R008, I2510, E119, Z951, Z952, E785, M1A9XX0, Z7901, Z87891, Z7289, K219. The descriptions of icd codes R0789, I5030, I313, R0609, I480, I110, I4430, R008, I2510, E119, Z951, Z952, E785, M1A9XX0, Z7901, Z87891, Z7289, K219 are R0789: Other chest pain; I5030: Unspecified diastolic (congestive) heart failure; I313: Pericardial effusion (noninflammatory); R0609: Other forms of dyspnea; I480: Paroxysmal atrial fibrillation; I110: Hypertensive heart disease with heart failure; I4430: Unspecified atrioventricular block; R008: Other abnormalities of heart beat; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E119: Type 2 diabetes mellitus without complications; Z951: Presence of aortocoronary bypass graft; Z952: Presence of prosthetic heart valve; E785: Hyperlipidemia, unspecified; M1A9XX0: Chronic gout, unspecified, without tophus (tophi); Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence; Z7289: Other problems related to lifestyle; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are I480, I110, I2510, E119, Z951, E785, Z7901, Z87891, K219. The uncommon codes mentioned in this dataset are R0789, I5030, I313, R0609, I4430, R008, Z952, M1A9XX0, Z7289. Allergies hydromorphone Chief Complaint Dyspnea on exertion Major Surgical or Invasive Procedure Coronary Angiography History of Present Illness Mr. ___ is a ___ male with paroxysmal Atrial fibrillation on apixaban CHFpEF CAD s p CABG ___ AS s p AVR recurrent pericardial effusions s p pericardiocentesis ___ f b pericardial window ___ and diabetes mellitus who presents with chest discomofort dyspnea and dizziness. The patient developed progressive dyspnea on exertion and chest pressure approximately one week ago. The chest pressure occurs with exertion. It is located substernally and radiates to the neck with a choking sensation. The chest pressure is associated with dyspnea occasional palpitations and most recently dizziness. The dyspnea has progressed to the point where he can only walk a few steps before feeling symptomatic and has to stop and rest. These symptoms prompted the patient to present to the ED. In the ED the patient was afebrile HR ___ BPs normal 100s 120s 60s SpO2 100 RA. Exam showed ___ systolic murmur pulsus of 6 lungs clear benign abd no edema or elevated JVP. Bedside echo with pericardial effusion. EKG w first degree AV block TWI V4 6. Labs notable for Hgb 12 MCV 64 Plt 138 BNP 277 normal LFTs and electrolytes with tropT assay. CXR with small left effusion vs pleural thickening. Cardiac surgery was consulted and did not feel that his symptoms were secondary to the pericardial effusion. On arrival to the floor the patient appears well and is comfortable. He is concerned that the above symptoms are related to electricity abnormalities in his heart. He reports that he is beginning to feel short of breath just speaking with me. He has no fevers chills or cough. No positional chest pain. Denies PND or orthopnea. No ___ swelling. Past Medical History Alcohol Abuse Aortic Stenosis Diabetes Mellitus Type II Gout Hyperlipidemia Hypertension CAD s p CABG ___ recurrent pericardial effusions s p pericardiocentesis ___ f b pericardial window ___ paroxysmal a fib CHFpEF Social History ___ Family History No family history of heart disease Physical Exam ADMISSION PHYSICAL EXAM 24 HR Data last updated ___ 431 Temp 97.6 Tm 97.7 BP 150 79 148 150 79 89 HR 82 82 85 RR 20 ___ O2 sat 97 O2 delivery RA 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. systolic ejection murmur best at RUSB. 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. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. Discharge Physical Exam 24 HR Data last updated ___ 728 Temp 98.2 Tm 98.2 BP 152 88 120 154 66 88 HR 95 80 95 RR 20 O2 sat 96 94 98 O2 delivery Ra Wt 185.85 lb 84.3 kg Fluid Balance last updated ___ 659 Last 8 hours Total cumulative 1454.8ml IN Total 70.2ml IV Amt Infused 70.2ml OUT Total 1525ml Urine Amt 1525ml Last 24 hours Total cumulative ___ IN Total 970.2ml PO Amt 900ml IV Amt Infused 70.2ml OUT Total 2995ml Urine Amt 2995ml GENERAL Alert and interactive. In no acute distress. NECK No JVD. CARDIAC Regular rhythm normal rate. Audible S1 and S2. systolic ejection murmur best at RUSB. 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 Moving all four extremities spontaneously alert and interactive. Pertinent Results Admission Labs ___ 07 50PM BLOOD WBC 7.1 RBC 5.94 Hgb 11.7 Hct 37.9 MCV 64 MCH 19.7 MCHC 30.9 RDW 17.6 RDWSD 36.9 Plt ___ ___ 07 50PM BLOOD Neuts 44.6 ___ Monos 8.4 Eos 4.8 Baso 1.1 Im ___ AbsNeut 3.18 AbsLymp 2.91 AbsMono 0.60 AbsEos 0.34 AbsBaso 0.08 ___ 05 58PM BLOOD ___ PTT 32.1 ___ ___ 07 50PM BLOOD Glucose 130 UreaN 21 Creat 0.8 Na 137 K 4.2 Cl 102 HCO3 23 AnGap 12 ___ 07 50PM BLOOD ALT 30 AST 23 AlkPhos 85 TotBili 0.3 ___ 07 50PM BLOOD Albumin 4.6 Calcium 9.7 Phos 4.5 Mg 1.9 Discharge Labs ___ 01 40AM BLOOD WBC 6.4 RBC 5.64 Hgb 11.0 Hct 36.2 MCV 64 MCH 19.5 MCHC 30.4 RDW 16.7 RDWSD 37.0 Plt ___ ___ 09 15AM BLOOD ___ PTT 65.6 ___ ___ 01 40AM BLOOD Glucose 286 UreaN 20 Creat 0.9 Na 137 K 4.1 Cl 99 HCO3 23 AnGap 15 ___ 01 40AM BLOOD Calcium 9.3 Phos 4.9 Mg 2.0 Reports TTE LEFT ATRIUM LA PULMONARY VEINS SEVERELY increased LA volume index. RIGHT ATRIUM RA INTERATRIAL SEPTUM INFERIOR VENA CAVA IVC Moderately dilated RA. No atrial septal defect by 2D color Doppler. LEFT VENTRICLE LV Normal cavity size. Focal non obstructive basal septal hypertrophy. Normal regional global systolic function. The visually estimated left ventricular ejection fraction is 55 . No ventricular septal defect. No resting outflow tract gradient. RIGHT VENTRICLE RV Normal cavity size. Mild global free wall hypokinesis. Depressed tricuspid annular plane systolic excursion TAPSE . AORTA Normal sinus diameter for gender. Normal ascending diameter for gender. Normal descending aorta. AORTIC VALVE AV Bioprosthesis. Well seated prosthesis. Normal prosthesis leaflet motion and gradient. No stenosis. Trace regurgitation. Paravalvular regurgitant jet. MITRAL VALVE MV Mildly thickened leaflets. No systolic prolapse. Mild MAC. Mild chordal thickening. Trivial regurgitation. PULMONIC VALVE PV Normal leaflets. Physiologic regurgitation. TRICUSPID VALVE TV Normal leaflets. Trivial regurgitation. Normal pulmonary artery systolic pressure. PERICARDIUM Small moderate effusion. Circumferential effusion. Echo dense The left atrial volume index is SEVERELY increased. The right atrium is moderately enlarged. There is no evidence for an atrial septal defect by 2D color Doppler. The left ventricle has a normal cavity size. There is mild non obstructive focal basal septal hypertrophy. There is normal regional and global left ventricular systolic function. The visually estimated left ventricular ejection fraction is 55 . There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Normal right ventricular cavity size with mild global free wall hypokinesis. Tricuspid annular plane systolic excursion TAPSE is depressed. The aortic sinus diameter is normal for gender with normal ascending aorta diameter for gender. There is a normal descending aorta diameter. An aortic valve bioprosthesis is present. The prosthesis is well seated with normal leaflet motion and gradient. There is no aortic valve stenosis. There is a paravalvular jet of trace aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is trivial tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a small circumferential pericardial effusion measuring up to 1.3 cm anterior to the right atrium 1.2 cm inferolateral to the left ventricle and 0.8 cm anterior to the right ventricle. The effusion is echo dense c w blood inflammation or other cellular elements. There are no 2D or Doppler echocardiographic evidence of tamponade. IMPRESSION Small to moderate circumferential pericardial effusion without echocardiographic evidence of tamponade. Biatrial enlargement. Mild right ventricular hypokinesis. Preserved left ventricular systolic function. Cardiac Catheterization Coronary Description The coronary circulation is right dominant. LM The Left Main arising from the left cusp is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD The Left Anterior Descending artery which arises from the LM is a large caliber vessel. There is severe calcification in the proximal segment. There is a 99 stenosis in the proximal segment. The ___ Diagonal arising from the proximal segment is a very small caliber vessel. There is a 100 stenosis in the proximal segment. The ___ Diagonal arising from the proximal segment is a medium caliber vessel. Cx The Circumflex artery which arises from the LM is a large caliber vessel. The ___ Obtuse Marginal arising from the proximal segment is a medium caliber vessel. The ___ Obtuse Marginal arising from the mid segment is a medium caliber vessel. RCA The Right Coronary Artery arising from the right cusp is a large caliber vessel. The Right Posterior Descending Artery arising from the distal segment is a medium caliber vessel. The Right Posterolateral Artery arising from the distal segment is a medium caliber vessel. Bypass Grafts LIMA A medium caliber arterial LIMA graft connects to the proximal segment of the LAD. This graft is patent. 11 23 35 p. ___ SVG A medium caliber saphenous vein graft connects to the proximal segment of the ___ Diag. This graft is patent. Interventional Details Complications There were no clinically significant complications. Findings Elevated left heart filling pressure. Single vessel coronary artery disease. Patent LIMA LAD and SVG D1. Brief Hospital Course Mr. ___ is a ___ male with paroxysmal Atrial fibrillation on apixaban CHFpEF CAD s p CABG ___ AS s p AVR recurrent pericardial effusions s p pericardiocentesis ___ f b pericardial window ___ and diabetes mellitus who presents with chest discomofort dyspnea and dizziness. ACUTE ACTIVE ISSUES Chest Pain CAD s p CABG ___ Underwent cardiac catheterization as he is about 3 months out from CABG with chest pain. Catheterization showed patent grafts. Low suspicion for PE as he was not tachycardic and on apixaban. TTE was performed which revealed moderate pericardial effusion without tamponade and pt is status post window on recent admission. Patient ambulated about the floor without return of symptoms. Rosuvastatin was increased from 20 mg to 40 mg. He will continue on aspirin and metoprolol. CHFpEF. No e o decompensation on exam. No need for active diuresis. Not on maintenance diuretic dose at home. Recurrent pericardial effusion s p pericardial window. TTE with moderate pericardial effusion without evidence of tamponade. He is continuing a 3 month course of colchicine which will stop in early ___. Chronic Problems Aortic Stenosis s p AVR continue metoprolol Paroxysmal Afib continue metoprolol and apixaban Transitional Issues Please ensure resolution of chest pain consider further workup for non cardiac chest pain Medications on Admission The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Ranitidine 150 mg PO DAILY 3. Rosuvastatin Calcium 20 mg PO QPM 4. Pantoprazole 40 mg PO Q24H 5. Amaryl glimepiride 4 mg oral BID 6. Aspirin 81 mg PO DAILY 7. Colchicine 0.6 mg PO BID 8. GuaiFENesin ER 1200 mg PO Q12H PRN cough 9. Losartan Potassium 25 mg PO DAILY 10. MetFORMIN Glucophage 500 mg PO BID 11. Thiamine 100 mg PO DAILY 12. Acetaminophen 1000 mg PO Q6H 13. Apixaban 5 mg PO BID 14. Ibuprofen 800 mg PO Q8H PRN Pain Mild 15. Senna 17.2 mg PO QHS 16. Metoprolol Tartrate 25 mg PO BID Discharge Medications 1. Rosuvastatin Calcium 40 mg PO QPM RX rosuvastatin 40 mg 1 tablet s by mouth at bedtime Disp 30 Tablet Refills 0 2. Acetaminophen 1000 mg PO Q6H 3. Amaryl glimepiride 4 mg oral BID 4. Apixaban 5 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Colchicine 0.6 mg PO BID 7. FoLIC Acid 1 mg PO DAILY 8. GuaiFENesin ER 1200 mg PO Q12H PRN cough 9. Ibuprofen 800 mg PO Q8H PRN Pain Mild 10. Losartan Potassium 25 mg PO DAILY 11. MetFORMIN Glucophage 500 mg PO BID 12. Metoprolol Tartrate 25 mg PO BID 13. Pantoprazole 40 mg PO Q24H 14. Ranitidine 150 mg PO DAILY 15. Senna 17.2 mg PO QHS 16. Thiamine 100 mg PO DAILY Discharge Disposition Home Discharge Diagnosis Non Cardiac Chest Pain Secondary Diagnoses Coronary Artery Disease post Coronary Artery Bypass Graft Pericardial Effusion Hypertension Diabetes Mellitus II 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 while you were admitted at ___. Why were you admitted to the hospital You were having chest pain. What happened while you were in the hospital We performed several tests to evaluate the cause of your symptoms including a catheterization. The catheterization was negative for blockages in the blood vessels around your heart. What should you do when you go home Continue taking all of your medications as prescribed. Keep all of your appointments with you clinicians. Sincerely Your ___ Team. Followup Instructions ___ The icd codes present in this text will be R0789, I5030, I313, R0609, I480, I110, I4430, R008, I2510, E119, Z951, Z952, E785, M1A9XX0, Z7901, Z87891, Z7289, K219. The descriptions of icd codes R0789, I5030, I313, R0609, I480, I110, I4430, R008, I2510, E119, Z951, Z952, E785, M1A9XX0, Z7901, Z87891, Z7289, K219 are R0789: Other chest pain; I5030: Unspecified diastolic (congestive) heart failure; I313: Pericardial effusion (noninflammatory); R0609: Other forms of dyspnea; I480: Paroxysmal atrial fibrillation; I110: Hypertensive heart disease with heart failure; I4430: Unspecified atrioventricular block; R008: Other abnormalities of heart beat; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E119: Type 2 diabetes mellitus without complications; Z951: Presence of aortocoronary bypass graft; Z952: Presence of prosthetic heart valve; E785: Hyperlipidemia, unspecified; M1A9XX0: Chronic gout, unspecified, without tophus (tophi); Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence; Z7289: Other problems related to lifestyle; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are I480, I110, I2510, E119, Z951, E785, Z7901, Z87891, K219. The uncommon codes mentioned in this dataset are R0789, I5030, I313, R0609, I4430, R008, Z952, M1A9XX0, Z7289.
The icd codes present in this text will be I214, N179, D62, E871, E872, J9811, I309, I2510, M109, D696, F1010, K700, E785, I10, I083, I672, I4891, E1165, D72829, Z87891. The descriptions of icd codes I214, N179, D62, E871, E872, J9811, I309, I2510, M109, D696, F1010, K700, E785, I10, I083, I672, I4891, E1165, D72829, Z87891 are I214: Non-ST elevation (NSTEMI) myocardial infarction; N179: Acute kidney failure, unspecified; D62: Acute posthemorrhagic anemia; E871: Hypo-osmolality and hyponatremia; E872: Acidosis; J9811: Atelectasis; I309: Acute pericarditis, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; M109: Gout, unspecified; D696: Thrombocytopenia, unspecified; F1010: Alcohol abuse, uncomplicated; K700: Alcoholic fatty liver; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves; I672: Cerebral atherosclerosis; I4891: Unspecified atrial fibrillation; E1165: Type 2 diabetes mellitus with hyperglycemia; D72829: Elevated white blood cell count, unspecified; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, D62, E871, E872, I2510, M109, D696, E785, I10, I4891, E1165, Z87891. The uncommon codes mentioned in this dataset are I214, J9811, I309, F1010, K700, I083, I672, D72829. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Shortness of breath Major Surgical or Invasive Procedure ___ Coronary artery bypass grafting x2 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to diagonal artery. Aortic valve replacement with a 23 ___ Ease pericardial tissue valve. History of Present Illness Mr. ___ is a ___ year old man with a history of alcohol abuse aortic stenosis hyperlipidemia and hypertension. He presented to ___ with worsening shortness of breath on exertion. He ruled in for non ST elevation myocardial infarction. An echocardiogram demonstrated moderate aortic stenosis with normal ejection fraction. He underwent a coronary angiogram which revealed two vessel coronary artery disease. He was transferred to ___ for surgical evaluation. Past Medical History Alcohol Abuse Aortic Stenosis Diabetes Mellitus Type II Gout Hyperlipidemia Hypertension Social History ___ Family History No family history of heart disease Physical Exam BP 183 94 HR 90 RR 18 O2 Sat 96 RA General A O NAD Skin Dry intact HEENT PERRLA EOMI x Neck Supple x Full ROM Chest Lungs B scattered rhonchi Heart RRR x Irregular Murmur x grade ___ Abdomen Soft x non distended x non tender x bowel sounds x umbilicus bruits noted Extremities Warm x well perfused Edema none Varicosities None x Neuro Grossly intact x Pulses Femoral Right Left DP Right Left ___ Right Left Radial Right 2 Left 2 Carotid Bruit B Right Left Umbilicus bruit appreciated Discharge Exam Temp 98.0 Tm 98.0 BP 136 78 122 165 55 86 HR 66 54 67 RR 18 ___ O2 sat 95 95 99 O2 delivery Ra wgt 92kg General NAD x Neurological A O x3 x non focal x HEENT PEERL Cardiovascular RRR x Irregular Murmur Rub Respiratory B rhonchi noted No resp distress x mostly NPC noted GI Abdomen Bowel sounds present x Soft x ND x NT x Extremities Right Upper extremity Warm Edema Left Upper extremity Warm Edema Right Lower extremity Warm x Edema trace Left Lower extremity Warm x Edema trace Pulses DP Right Left ___ Right Left Radial Right Left Skin Wounds Dry intact Sternal CDI x no erythema or drainage x Sternum stable x Prevena Lower extremity Right Left CDI Upper extremity Right Left CDI Other Pertinent Results ADMISSION LABS ___ 09 29PM BLOOD WBC 7.4 RBC 5.10 Hgb 10.7 Hct 34.2 MCV 67 MCH 21.0 MCHC 31.3 RDW 15.5 RDWSD 36.1 Plt ___ ___ 09 29PM BLOOD ___ PTT 40.3 ___ ___ 09 29PM BLOOD Glucose 169 UreaN 12 Creat 0.7 Na 140 K 4.0 Cl 103 HCO3 23 AnGap 14 ___ 09 29PM BLOOD ALT 31 AST 27 LD LDH 180 AlkPhos 57 Amylase 55 TotBili 0.6 ___ 09 29PM BLOOD Albumin 4.4 Mg 1.8 ___ 09 29PM BLOOD HbA1c 6.9 eAG 151 . Transthoracic Echocardiogram ___ The left atrial volume index is SEVERELY increased. The right atrium is mildly enlarged. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional left ventricular systolic function. Overall left ventricular systolic function is low normal. The visually estimated left ventricular ejection fraction is 50 55 . There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure PCWP greater than 18 mmHg . Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch diameter is normal. The aortic valve leaflets are severely thickened. There is SEVERE aortic valve stenosis valve area 1.0 cm2 or less . There is mild 1 aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate mitral annular calcification. There is mild 1 mitral regurgitation. Due to acoustic shadowing the severity of mitral regurgitation could be UNDERestimated. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild 1 tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial pericardial effusion. IMPRESSION Severe calcific aortic stenosis. Symmetric LVH with low normal left ventricular systolic function. Mild pulmonary hypertension. . Carotid Ultrasound ___ Significant atherosclerotic calcified plaque bilaterally. 40 stenosis of the right internal carotid artery. 40 stenosis of the left internal carotid artery. . Transesophageal Echocardiogram ___ PRE OPERATIVE STATE Pre bypass assessment. Sinus rhythm. Left Atrium LA Pulmonary Veins Normal LA size. Right Atrium RA Interatrial Septum Inferior Vena Cava IVC Normal interatrial septum. Left Ventricle LV Normal cavity size. Normal regional global systolic function Normal ejection fraction. Right Ventricle RV Normal cavity size. Normal free wall motion. Aorta Normal sinus diameter. Normal ascending diameter. Normal arch diameter. Normal descending aorta diameter. Simple descending atheroma. Aortic Valve Severely thickened leaflets. SEVERE less than or equal 1.0cm2 stenosis. Trace regurgitation. Mitral Valve Normal leaflets. Mild leaflet calcification. No stenosis. Mild annular calcification. No regurgitation. Tricuspid Valve Trace regurgitation. Pericardium No effusion. Normal pericardial thickness. Miscellaneous No pleural effusions. POST OP STATE The post bypass TEE was performed at. Atrial paced rhythm. Left Ventricle Similar to preoperative findings. Similar regional function. Aorta No change from pre op state. Aortic Valve Bioprosthetic valve. Normal gradient for prosthesis. Normal gradient for prosthesis. No regurgitation. Mitral Valve No change in mitral valve morphology from preoperative state. Similar gradient to preoperative state. No change in valvular regurgitation from preoperative state. Pericardium No effusion. ___ Abd US 1. Echogenic liver may be due to steatosis however apparent slight nodular contour of the liver raises concern for more advanced liver disease. 2. Mild splenomegaly small amount of ascites and right pleural effusion. 3. Cholelithiasis and nonspecific gallbladder wall edema may be due to hepatic dysfunction third spacing however acute cholecystitis cannot be excluded. Nuclear medicine hepatobiliary scan is recommended for further evaluation. RECOMMENDATION S 1. Nuclear medicine hepatobiliary scan. 2. Radiological evidence of fatty liver does not exclude cirrhosis or significant liver fibrosis which could be further evaluated by ___. This can be requested via the ___ FibroScan or the Radiology Department with either MR ___ or US ___ in conjunction with a GI Hepatology consultation ___ et al. The diagnosis and management of nonalcoholic fatty liver disease Practice guidance from the ___ Association for the Study of Liver Diseases. Hepatology ___ 67 1 328 357 ___ PA lat Slightly increased aeration of left lower lung. Improved left lower lobe atelectasis and small left pleural effusion. Slightly improved trace right pleural effusion. Resolved mild pulmonary edema. Residual mild pulmonary vascular congestion. ___ 05 41AM BLOOD WBC 8.9 RBC 3.90 Hgb 8.5 Hct 28.3 MCV 73 MCH 21.8 MCHC 30.0 RDW 20.8 RDWSD 49.8 Plt ___ ___ 05 41AM BLOOD ___ ___ 05 41AM BLOOD Glucose 73 UreaN 25 Creat 1.0 Na 136 K 4.6 Cl 97 HCO3 24 AnGap 15 Brief Hospital Course He was admitted on ___ and underwent routine preoperative testing and evaluation. A transthoracic echocardiogram demonstrated severe aortic stenosis. A carotid ultrasound revealed moderate bilateral plaque but stenosis of 40 stenosis. He remained stable and was taken to the operating room on ___. He underwent coronary artery bypass grafting x 2 and aortic valve replacement. 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 weaned from sedation awoke neurologically intact and was extubated on POD 1. He was weaned from inotropic and vasopressor support. Beta blocker was initiated and he was diuresed toward his preoperative weight. He was noted to have diffuse ST elevation and mild gout and was started on colchicine. Patient transferred to the floor. While recovering on the floor he was weak and deconditioned slow to progress. He developed rate control afib. On POD 4 he had significant hyperglycemia with lactate 4.8 and peak creatinine 1.7 and returned to the CVICU for insulin gtt and medical management. He transitioned to lantus and Humalog sliding scale. Oral diabetic agents and colchicine were held due to mild ___. During his ICU stay he also developed leukocytosis and culture data was negative. Patient had a persistent cough with thick secretions that eventually resolved into a dry persistent cough. CXR was not concerning for pneumonia. Patient also has a known significant alcohol intake. As part of his fever work up he underwent RUQ US and this was significant for fatty liver concerns for cirrhosis or significant liver fibrosis. He was seen by hepatology and medications were adjusted amiodarone for afib was discontinued. LFTs were initially elevated but are currently downtrending. He will need to follow up with hepatology as an outpatient Dr. ___. Lopressor was optimized and he was in and out of afib and apixaban was initiated for anticoagulation. He remained hemodynamically stable and was transferred back to the floor on POD 9. All surgical tubes and wires were remove without incident. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 11. He was ambulating freely his wounds were healing and pain was controlled with oral analgesics. He continued to have a mild dry cough with stable sternum. He was discharged to home in good condition with appropriate follow up instructions. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. MetFORMIN Glucophage 500 mg PO BID 3. glimepiride 4 mg oral BID 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Januvia SITagliptin 100 mg oral DAILY Discharge Medications 1. Apixaban 5 mg PO BID RX apixaban Eliquis 5 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 1 2. Atorvastatin 20 mg PO QPM will need to increase to 40mg daily once off amiodarone RX atorvastatin 20 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 1 3. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 4. Furosemide 40 mg PO DAILY Duration 10 Days RX furosemide Lasix 40 mg 1 tablet s by mouth once a day Disp 10 Tablet Refills 0 5. GuaiFENesin ER 1200 mg PO Q12H RX guaifenesin 1 200 mg 1 tablet s by mouth twice a day Disp 20 Tablet Refills 0 6. Lactulose 30 mL PO DAILY RX lactulose 20 gram 30 mL 1 ml by mouth once a day Disp 1 Bottle Refills 0 7. Lisinopril 2.5 mg PO DAILY RX lisinopril 2.5 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 8. Metoprolol Tartrate 37.5 mg PO TID RX metoprolol tartrate 37.5 mg 1 tablet s by mouth three times a day Disp 90 Tablet Refills 1 9. Ranitidine 150 mg PO DAILY Duration 1 Month RX ranitidine HCl Zantac Maximum Strength 150 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 10. Senna 17.2 mg PO QHS RX sennosides senna 8.6 mg 2 tablet s by mouth at bedtime Disp 30 Tablet Refills 0 11. Thiamine 100 mg PO DAILY RX thiamine HCl vitamin B1 100 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 12. TraMADol 50 mg PO Q4H PRN Pain Moderate RX tramadol Ultram 50 mg 1 tablet s by mouth four times a day Disp 60 Tablet Refills 0 13. Aspirin 81 mg PO DAILY 14. glimepiride 4 mg oral BID 15. Januvia SITagliptin 100 mg oral DAILY 16. MetFORMIN Glucophage 500 mg PO BID Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Aortic Stenosis s p Aortic valve replacement Coronary Artery Disease s p coronary artery bypass graft x 2 Secondary Diagnosis Alcohol Abuse Diabetes Mellitus Type II Gout Hyperlipidemia Hypertension Discharge Condition Alert and oriented x3 nonfocal Ambulating gait steady Sternal pain managed with oral analgesics Sternal Incision healing well no erythema or drainage Edema trace Discharge Instructions Please shower daily wash incisions gently with mild soap no baths or swimming look at your incisions daily Please NO lotion cream powder or ointment 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 Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion unless otherwise specified 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 I214, N179, D62, E871, E872, J9811, I309, I2510, M109, D696, F1010, K700, E785, I10, I083, I672, I4891, E1165, D72829, Z87891. The descriptions of icd codes I214, N179, D62, E871, E872, J9811, I309, I2510, M109, D696, F1010, K700, E785, I10, I083, I672, I4891, E1165, D72829, Z87891 are I214: Non-ST elevation (NSTEMI) myocardial infarction; N179: Acute kidney failure, unspecified; D62: Acute posthemorrhagic anemia; E871: Hypo-osmolality and hyponatremia; E872: Acidosis; J9811: Atelectasis; I309: Acute pericarditis, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; M109: Gout, unspecified; D696: Thrombocytopenia, unspecified; F1010: Alcohol abuse, uncomplicated; K700: Alcoholic fatty liver; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves; I672: Cerebral atherosclerosis; I4891: Unspecified atrial fibrillation; E1165: Type 2 diabetes mellitus with hyperglycemia; D72829: Elevated white blood cell count, unspecified; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, D62, E871, E872, I2510, M109, D696, E785, I10, I4891, E1165, Z87891. The uncommon codes mentioned in this dataset are I214, J9811, I309, F1010, K700, I083, I672, D72829.
The icd codes present in this text will be I25110, Z955, I10, F419, E785, E119, Z993, M170, K5900, Z7902, Z794, Z951. The descriptions of icd codes I25110, Z955, I10, F419, E785, E119, Z993, M170, K5900, Z7902, Z794, Z951 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; Z955: Presence of coronary angioplasty implant and graft; I10: Essential (primary) hypertension; F419: Anxiety disorder, unspecified; E785: Hyperlipidemia, unspecified; E119: Type 2 diabetes mellitus without complications; Z993: Dependence on wheelchair; M170: Bilateral primary osteoarthritis of knee; K5900: Constipation, unspecified; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z794: Long term (current) use of insulin; Z951: Presence of aortocoronary bypass graft. The common codes which frequently come are Z955, I10, F419, E785, E119, K5900, Z7902, Z794, Z951. The uncommon codes mentioned in this dataset are I25110, Z993, M170. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest Pain Major Surgical or Invasive Procedure None History of Present Illness ___ year old man with PMH notable for CAD s p CABG BMS and DES as well as DM and HTN. ___ has had four admissions since ___ with complaints of chest pain. He underwent a PCI to OM1 with DES in ___. He underwent angiography again on ___ which showed stable nonobstructive CAD with evidence of diffuse microvascular disease. At discharge ___ added amlodipine increased isosorbide from 15mg to 30mg and added protonix. He again presents with c o CP. Per EMS report was distraught and crying in the ambulance. He was admitted through the ED to rule out for MI. Past Medical History 1. CARDIAC RISK FACTORS Diabetes Hypertension Dyslipidemia 2. CARDIAC HISTORY CABG ___ PERCUTANEOUS CORONARY INTERVENTIONS ___ BMS to proximal anomalous RCA ___ PACING ICD None 3. OTHER PAST MEDICAL HISTORY Osteoarthritis Constipation Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death. Physical Exam Admission exam Physical Examination General chronically ill appearing man looking older than stated age sitting up in bed in NAD Neuro alert and oriented w o focal deficit speech clear and coherent Cardiac RRR no M R G Lungs diminished bilat breathing regular and unlabored Abd BS soft NT ND Extremities Warm and dry w o edema 2 palpable peripheral pulses. Bilateral knees with long scars because of BKA. No obvious swelling or tenderness to palpation. Admission weight 109.2 kg Discharge exam VS 97.9 112 73 118 73 HR 64 98 RR 16 02 sat 96 RA WEIGHT 108.9 kg I O 120 1000cc TELEMETRY SR 70 s no alarms per telemetry review Physical Examination Gen Patient is comfortable in no acute distress. HEENT Face symmetrical trachea midline. Neuro A Ox3. Speaking in complete coherent sentences. No face arm or leg weakness. Pulm Breathing unlabored. Breath sounds clear bilaterally. Cardiac No JVD. No thrills or bruits heard on carotids bilaterally. S1 S2 RRR. No splitting of heart sounds murmurs S3 S4 or friction rubs heard. Vasc No edema noted in bilateral upper or lower extremities. No pigmentation changes noted in bilateral upper or lower extremities. Skin dry warm. Bilateral radial ___ pulses palpable 2 . Abd Rounded soft non tender. Diagnostic studies CXR ___ No focal consolidations. No pneumothorax. Pertinent Results ___ 07 27PM cTropnT 0.01 ___ 11 11AM cTropnT 0.01 ___ 05 00AM cTropnT 0.01 ___ 04 45AM cTropnT 0.01 proBNP 47 ___ 11 11AM GLUCOSE 165 UREA N 10 CREAT 0.8 SODIUM 141 POTASSIUM 3.9 CHLORIDE 100 TOTAL CO2 28 ANION GAP 13 Brief Hospital Course Mr. ___ is an ___ gentleman with a history of coronary artery disease status post CABG and multiple PCI s hypertension hyperlipidemia type 2 diabetes who has had multiple admissions for chest pain in recent months. He resides at the ___ in ___ ___ due to chronic disability and being wheelchair bound at this time. His last cardiac catheterization was in ___ showing stable CAD and chest pain thought to be secondary to micro vascular disease. On ___ he was residing at the rehab when he was anxious and upset and reports a delay in response to complaints of chest pain. He then called ___ himself and was brought to the emergency department by EMS. His troponins were negative x5 with no new EKG changes. We increased his metoprolol succinate to 50 mg daily as his heart rate was initially in the ___ which he has tolerated well. On day of discharge his heart rate was 60 80. We did not increase isosorbide mononitrate due to blood pressure he has been running SBP 112 118. That might be a consideration in the future if his blood pressure is higher and he tolerates the increased dose of beta blocker. We also considered introducing Ranexa but felt he may benefit from maximizing beta blockade goal HR 60 bpm as BP tolerates and having his anxiety managed first and see if that helps decrease chest pain. He had a few transient episodes of chest pain in the setting of anxiety and in the absence of EKG changes while admitted. He was given Ativan 0.5 mg on 2 separate occasions which was very effective and chest pain resolved without any further intervention. He admits to high anxiety and stress being a trigger for his multiple episodes of chest pain requiring hospital admission. He is anxious about his disability being wheelchair bound and needing knee surgery which he reportedly has not been cleared to undergo. He is willing to follow up with his PCP and willing to trial medication in attempt to better manage his anxiety which seems to be consistently a trigger for these chest pain episodes. For now we will prescribe Ativan 0.5 mg up to twice daily for anxiety. He was instructed not to drive while taking this medication. He is currently wheelchair bound and in a long term care facility so this should not impact him at this time. We requested that the rehab make a hospital follow up appointment with his PCP ___ 1 week of discharge to address ongoing anxiety and stress. We are hopeful that managing this will decrease his episodes of chest pain. He may also benefit from additional support services such as social work. For cardiac medications he will continue atorvastatin Plavix aspirin isosorbide metoprolol succinate amlodipine and as needed nitro. He may benefit from an ACE given prior NSTEMI with hypertension and diabetes though we will not start it now given recent reported orthostasis prior to this hospitalization and soft BP. He has a follow up appointment with Dr. ___ who is his primary cardiologist in ___ and continues to be followed by orthopedics for his ongoing knee issue. Also to note there was some report of pyuria prior to admission and reportedly was ordered for Cipro at the rehab but never took it. A urine culture done here this admission was negative for growth . He was afebrile and had no urinary complaints and did not get any antibiotics during this admission. He is voiding without difficulty. We will discharge him back to rehab today via chair car. 30 minutes spent on discharge planning coordination of care. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 2. Gabapentin 300 mg PO TID 3. Metoprolol Succinate XL 25 mg PO DAILY 4. MetFORMIN Glucophage 1000 mg PO BID 5. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 6. Docusate Sodium 100 mg PO BID 7. Polyethylene Glycol 17 g PO BID PRN Constipation Third Line 8. amLODIPine 5 mg PO DAILY 9. Atorvastatin 80 mg PO QPM 10. exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 11. Glargine 18 Units Bedtime 12. Senna 17.2 mg PO QHS PRN Constipation First Line 13. Multivitamins 1 TAB PO DAILY 14. Isosorbide Mononitrate Extended Release 30 mg PO DAILY 15. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 16. TraMADol 75 mg PO Q6H PRN Pain Moderate 17. melatonin 3 mg oral HS 18. Clopidogrel 75 mg PO DAILY 19. Pantoprazole 40 mg PO Q24H 20. Aspirin 81 mg PO DAILY 21. Tamsulosin 0.4 mg PO QHS 22. GlipiZIDE 10 mg PO BID Discharge Medications 1. LORazepam 0.5 mg PO Q12H PRN anxiety RX lorazepam 0.5 mg 1 tablet by mouth every twelve 12 hours Disp 30 Tablet Refills 0 2. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 3. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 4. amLODIPine 5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 8. Clopidogrel 75 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 11. Gabapentin 300 mg PO TID 12. GlipiZIDE 10 mg PO BID 13. Glargine 18 Units Bedtime 14. Isosorbide Mononitrate Extended Release 30 mg PO DAILY 15. melatonin 3 mg oral HS 16. MetFORMIN Glucophage 1000 mg PO BID 17. Multivitamins 1 TAB PO DAILY 18. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 19. Pantoprazole 40 mg PO Q24H 20. Polyethylene Glycol 17 g PO BID PRN Constipation Third Line 21. Senna 17.2 mg PO QHS PRN Constipation First Line 22. Tamsulosin 0.4 mg PO QHS 23. TraMADol 75 mg PO Q6H PRN Pain Moderate Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Chest pain coronary microvascular disease Discharge Condition See discharge summary Discharge Instructions You were admitted to ___ with chest pain. You EKG and blood work showed that you did not have a heart attack. You had a recent cardiac catheterization in ___ during prior admission which showed stable coronary arteries. It is felt that you have microvascular disease which involves the very small branches off the main coronary arteries. We have optimized your medical management to treat this and attempt to prevent chest pain. There also appears to be a component of stress anxiety which precipitates the chest pain episodes. You were given a dose of Ativan during one of your episodes here at the hospital which worked well to decrease the stress and the chest pain resolved at that time without further intervention. We request that you see your PCP within one week of discharge in order to discuss medication options and perhaps start on something daily to help decrease your baseline anxiety. If your stress anxiety was better managed it may decrease your episodes of chest pain. Meanwhile we have prescribed Ativan Lorazepam 0.5mg by mouth to take up to twice daily as needed for anxiety. PLEASE ONLY TAKE WHEN NEEDED TO MANAGE ACUTE ANXIETY. YOU CAN NOT DRIVE WHILE TAKING THIS MEDICATION. You should continue your current medications with the following changes 1. Increase Metoprolol Succinate to 50mg daily 2. Start Ativan Lorazepam 0.5mg every 12 hours AS NEEDED for anxiety. If you have any urgent questions that are related to your recovery from your hospitalization or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital please call the ___ HeartLine at ___ to speak to a cardiologist or cardiac nurse practitioner. You will follow up with PCP within one week of hospital discharge. We have asked the rehab to scheduled this appointment and necessary transportation to and from. You will follow up with your cardiologist as scheduled below. It has been a pleasure to have participated in your care and we wish you the best with your health Your ___ Cardiac Care Team Followup Instructions ___ The icd codes present in this text will be I25110, Z955, I10, F419, E785, E119, Z993, M170, K5900, Z7902, Z794, Z951. The descriptions of icd codes I25110, Z955, I10, F419, E785, E119, Z993, M170, K5900, Z7902, Z794, Z951 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; Z955: Presence of coronary angioplasty implant and graft; I10: Essential (primary) hypertension; F419: Anxiety disorder, unspecified; E785: Hyperlipidemia, unspecified; E119: Type 2 diabetes mellitus without complications; Z993: Dependence on wheelchair; M170: Bilateral primary osteoarthritis of knee; K5900: Constipation, unspecified; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z794: Long term (current) use of insulin; Z951: Presence of aortocoronary bypass graft. The common codes which frequently come are Z955, I10, F419, E785, E119, K5900, Z7902, Z794, Z951. The uncommon codes mentioned in this dataset are I25110, Z993, M170.
The icd codes present in this text will be R0789, I25118, Z951, Z955, Z7902, M170, G8929, F419, N390, E119, Z794, I10, E785, K5900, K219, N400, Z993. The descriptions of icd codes R0789, I25118, Z951, Z955, Z7902, M170, G8929, F419, N390, E119, Z794, I10, E785, K5900, K219, N400, Z993 are R0789: Other chest pain; I25118: Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z7902: Long term (current) use of antithrombotics/antiplatelets; M170: Bilateral primary osteoarthritis of knee; G8929: Other chronic pain; F419: Anxiety disorder, unspecified; N390: Urinary tract infection, site not specified; E119: Type 2 diabetes mellitus without complications; Z794: Long term (current) use of insulin; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; K5900: Constipation, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z993: Dependence on wheelchair. The common codes which frequently come are Z951, Z955, Z7902, G8929, F419, N390, E119, Z794, I10, E785, K5900, K219, N400. The uncommon codes mentioned in this dataset are R0789, I25118, M170, Z993. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint chest pain Major Surgical or Invasive Procedure none History of Present Illness Mr. ___ is a ___ male with history of CAD s p CABG Type II diabetes hypertension and chronic knee pain who presents from rehab with chest pain. Patient states at rehab he had to use the bathroom and called for assistance but nobody would come to help him. He then called ___. EMS helped him to the restroom. During this interaction he developed sudden onset moderate chest pain which he describes as a left sided heaviness that then radiated to the right side. This is in the setting of coronary artery disease and is typical for his episodes of angina. He was therefore brought to the ED. Denies any associated shortness of breath cough fever diaphoresis nausea vomiting. Denies abdominal pain. Denies dizziness or lightheadedness. Patient states that his typical chest pain will start on the left side. He will often try SL nitro at this point which most often relieves the pain. However at times it does not and radiates to the right side and will become squeezing. He states that this happened a lot in ___ and ___ but has been doing better. He feels that it is triggered by stress. Regarding his UTI he notes that had he has had two urinary tract infections this past month. The one he is being treated for now he did not have any symptoms but it was found on testing. Regarding his knee pain he notes that he both knees hurt especially the left which will buckle sometimes causing him to fall. This was worse after knee replacements ___ years ago. Uses a wheelchair. He has discussed an operation to help repair his knees but states that his cardiologist doesn t feel that a surgery would be safe until can go a year without a cardiac event. He states that being in rehab has been very difficult. He notes that he is there with many people who are much older than him and this has taken a mental toll. He has seen many things that have made him uncomfortable and feel that the care he gets is often very poor. He also struggles with the idea of being stuck in a wheelchair at a rehab at such a young age. He also reports that he used to see Dr ___ who is now at ___. Would like to see her again previously limited by insurance. On review of records patient has had around five admissions since ___ with chest pain and several additional ED visits. He underwent a PCI to OM1 with DES in ___. He underwent angiography again on ___ which showed stable nonobstructive CAD with evidence of diffuse microvascular disease. He most recently underwent a nuclear stress on ___ which was normal. In the ED Initial vital signs were notable for T 97 HR 95 BP 133 86 RR 20 97 RA Exam notable for well appearing on exam. He has tenderness to palpation of the anterior chest wall. He is breathing comfortably on room air and lungs are clear to auscultation. Radial pulses intact. Abdomen soft and nontender. Labs were notable for CBC WBC 4.8 hgb 12.9 plt 354 Lytes 139 103 11 AGap 12 242 4.4 24 0.8 trop 0.01 x2 Studies performed include CXR with no acute intrathoracic process. Patient was given ___ 06 40 IV Ketorolac 15 mg ___ 08 02 PO NG amLODIPine 5 mg ___ 08 02 PO NG Clopidogrel 75 mg ___ 08 02 PO NG Gabapentin 300 mg ___ 08 02 PO Isosorbide Mononitrate Extended Release 30 mg ___ 08 02 PO Metoprolol Succinate XL 25 mg ___ 08 02 PO Pantoprazole 40 mg ___ 08 03 SC Insulin 2 Units ___ 08 04 PO NG Aspirin 81 mg ___ 08 04 PO TraMADol 75 mg ___ 15 19 PO NG Gabapentin 300 mg ___ 17 08 SC Insulin 6 Units ___ 18 10 PO TraMADol 75 mg Plan was initially for patient to return to rehab. However he declined to go with plan to go to Motel. After multiple discussions with ___ CM SW plan to admit patient to medicine for further physical therapy and discuss returning to rehab. Patient amenable with this plan. Vitals on transfer T 98.3 HR 81 BP 134 70 RR 18 95 RA Upon arrival to the floor patient recounts history as above. He has no chest pain now. ROS Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History 1. CARDIAC RISK FACTORS Diabetes Hypertension Dyslipidemia 2. CARDIAC HISTORY CABG ___ PERCUTANEOUS CORONARY INTERVENTIONS ___ BMS to proximal anomalous RCA ___ PACING ICD None 3. OTHER PAST MEDICAL HISTORY Osteoarthritis Constipation Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death. Physical Exam ADMISSION EXAM VITALS T 98.2 HR 79 BP 120 70 RR 18 99 RA GENERAL Alert and in no apparent distress 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 MSK Neck supple moves all extremities. Lower extremities with knee pain to flexion and extension 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 GENERAL Alert and in no apparent distress sitting up in CHAIR EYES Anicteric pupils equally round CV RRR no m r g LUNGS CTAB ABD obese normal bowel sounds. NEURO Alert oriented face symmetric speech fluent PSYCH Calm Pertinent Results ADMISSION LABS ___ 12 14AM BLOOD WBC 4.8 RBC 4.50 Hgb 12.9 Hct 40.8 MCV 91 MCH 28.7 MCHC 31.6 RDW 12.4 RDWSD 41.1 Plt ___ ___ 12 14AM BLOOD Neuts 53.8 ___ Monos 7.6 Eos 3.1 Baso 1.0 Im ___ AbsNeut 2.60 AbsLymp 1.66 AbsMono 0.37 AbsEos 0.15 AbsBaso 0.05 ___ 12 14AM BLOOD Glucose 242 UreaN 11 Creat 0.8 Na 139 K 4.4 Cl 103 HCO3 24 AnGap 12 ___ 12 14AM BLOOD cTropnT 0.01 ___ 03 24AM BLOOD cTropnT 0.01 ___ 03 24AM BLOOD cTropnT 0.01 EXAMINATION CHEST PA AND LAT INDICATION History ___ with chest pain eval pna COMPARISON Chest radiograph ___ FINDINGS AP and lateral views of the chest. Mid sternotomy wires are again seen and appear similarly positioned. Low lung volumes bilaterally particularly on the right where there is unstable right hemidiaphragm elevation. No areas of focal consolidation pulmonary edema pneumothorax or pericardial effusion. Cardiac size is normal. IMPRESSION No acute intrathoracic process. Brief Hospital Course Mr. ___ is a ___ male with history of CAD s p CABG type II diabetes hypertension and chronic knee pain who presents from rehab with recurrent chest pain with negative workup for acute cardiac cause admitted as declined to return to nursing facility. Patient was ultimately discharged to a hotel as patient refused to return to prior SAR. Coronary artery disease Microvascular coronary disease Chest Pain Chronic stable angina Patient with significant history of CAD and what is felt to be angina from microvascular disease. Multiple troponins negative and EKG without ischemic changes. No chest pain since arrival and extensive recent workup including nuclear stress last month. This was thought to be exacerbated by anxiety. patient also complained of pleuritic chest pain and lightheadedness and underwent a CT chest that was negative. Osteoarthritis Knee pain Patient is unable to ambulate as knees buckle which has currently left him wheelchair bound and previously in rehab. This is reportedly due to prior failed knee surgery. Plan for eventual surgery though first would need to be improved from a cardiac standpoint. Discharged with wheelchair and bedside commode. UTI previously treated with cefpodoxime for a Klebsiella UTI patient unaware if he received the antibiotics as he was in rehab. UA suggestive of infection. Culture pending at discharge. Given Cipro for 10day course. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lidocaine 5 Patch 1 PTCH TD QAM 2. LORazepam 0.5 mg PO BID PRN anxiety 3. Clopidogrel 75 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Isosorbide Mononitrate Extended Release 30 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. amLODIPine 5 mg PO DAILY 8. Pantoprazole 40 mg PO Q24H 9. melatonin 3 mg oral QHS 10. Tamsulosin 0.4 mg PO QHS 11. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 13. Polyethylene Glycol 17 g PO BID PRN Constipation Third Line 14. Gabapentin 300 mg PO TID 15. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 16. GlipiZIDE 10 mg PO BID 17. TraMADol 75 mg PO Q6H PRN Pain Moderate 18. Milk of Magnesia 30 mL PO Q12H PRN Constipation Second Line 19. Cefpodoxime Proxetil 100 mg PO Q12H 20. MetFORMIN Glucophage 1000 mg PO BID 21. Acetaminophen 975 mg PO Q6H PRN Pain Mild Fever 22. Aspirin 81 mg PO DAILY 23. Multivitamins 1 TAB PO DAILY 24. Senna 17.2 mg PO QHS 25. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 26. Mylanta 30 ml oral Q4H PRN dyspepsia Discharge Medications 1. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection RX ciprofloxacin HCl 750 mg 1 tablet s by mouth every twelve 12 hours Disp 20 Tablet Refills 0 2. Acetaminophen 650 mg PO Q8H PRN Pain Mild Fever RX acetaminophen 8HR Muscle Aches Pain 650 mg 1 tablet s by mouth q8 Disp 30 Tablet Refills 0 3. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin RX blood sugar diagnostic Blood Glucose Test use for blood sugar monioring 4x dialy Disp 200 Strip Refills 0 RX insulin glargine Lantus Solostar U 100 Insulin 100 unit mL 3 mL ___ Units before BED Disp 3 Syringe Refills 0 RX blood glucose meter Blood Glucose Monitoring blood sugar monitoring 4X day Disp 1 Kit Refills 0 RX lancets BD Microtainer Lancet 30 gauge use for glucose monitoring Disp 200 Each Refills 0 4. Aspirin 81 mg PO DAILY RX aspirin 81 mg 81 tablet s by mouth once a day Disp 30 Tablet Refills 0 5. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet s by mouth qpm Disp 30 Tablet Refills 0 6. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 7. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID RX exenatide Byetta 10 mcg 0.04 mL per dose 250 mcg mL 2.4 mL 10 mcg twice a day Disp 1 Syringe Refills 0 8. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 9. Gabapentin 300 mg PO TID RX gabapentin 300 mg 1 capsule s by mouth three times a day Disp 90 Capsule Refills 0 10. GlipiZIDE 10 mg PO BID diabetes RX glipizide 10 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 11. Isosorbide Mononitrate Extended Release 30 mg PO DAILY RX isosorbide mononitrate 30 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 12. Lidocaine 5 Patch 1 PTCH TD QAM 13. LORazepam 0.5 mg PO BID PRN anxiety RX lorazepam Ativan 0.5 mg 1 tablet s by mouth twice a day Disp 10 Tablet Refills 0 14. melatonin 3 mg oral QHS 15. MetFORMIN Glucophage 1000 mg PO BID RX metformin Fortamet 1 000 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 16. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate Kapspargo Sprinkle 50 mg 1 capsule s by mouth once a day Disp 30 Capsule Refills 0 17. Milk of Magnesia 30 mL PO Q12H PRN Constipation Second Line 18. Multivitamins 1 TAB PO DAILY 19. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain RX nitroglycerin 0.4 mg 1 tablet s sublingually q5min Disp 15 Tablet Refills 0 20. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet s by mouth q24h Disp 30 Tablet Refills 0 21. Tamsulosin 0.4 mg PO QHS RX tamsulosin Flomax 0.4 mg 1 capsule s by mouth at bedtime Disp 30 Capsule Refills 0 22. TraMADol 75 mg PO Q6H PRN Pain Moderate RX tramadol Ultram 50 mg 1.5 tablet s by mouth every six 6 hours Disp 30 Tablet Refills 0 23.bedside Commode Drop arm no diagnosis ambulatory dysfunction physical function good length of need 13 months 24.Standard Manual Wheelchair Standard Manual Wheelchair Seat and back cushion Elevating leg rests Anti tip and brake extensions Dx Ambulatory dysfunction Px good ___ 13 months Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Diabetes type II Coronary artery disease Anxiety Knee osteoarthritis 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 Mr. ___ You were admitted to the hospital for chest discomfort and anxiety while at rehab. We made adjustments in your blood pressure regimen to help in case the chest pain was due to heart disease. We also adjusted your insulin regimen since you had elevated blood sugars. You should continue your home regimen at discharge. Your urine studies revealed elevation in WBC concerning for a urinary tract infection. You are prescribed 10 days of Ciprofloxacin antibiotics. Followup Instructions ___ The icd codes present in this text will be R0789, I25118, Z951, Z955, Z7902, M170, G8929, F419, N390, E119, Z794, I10, E785, K5900, K219, N400, Z993. The descriptions of icd codes R0789, I25118, Z951, Z955, Z7902, M170, G8929, F419, N390, E119, Z794, I10, E785, K5900, K219, N400, Z993 are R0789: Other chest pain; I25118: Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z7902: Long term (current) use of antithrombotics/antiplatelets; M170: Bilateral primary osteoarthritis of knee; G8929: Other chronic pain; F419: Anxiety disorder, unspecified; N390: Urinary tract infection, site not specified; E119: Type 2 diabetes mellitus without complications; Z794: Long term (current) use of insulin; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; K5900: Constipation, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z993: Dependence on wheelchair. The common codes which frequently come are Z951, Z955, Z7902, G8929, F419, N390, E119, Z794, I10, E785, K5900, K219, N400. The uncommon codes mentioned in this dataset are R0789, I25118, M170, Z993.
The icd codes present in this text will be R0789, R51, R29818, I2510, Z951, Z955, E119, F419, M1710, G8929, Z993, N400, Z794, Z7902, K219, I252, I10, E785. The descriptions of icd codes R0789, R51, R29818, I2510, Z951, Z955, E119, F419, M1710, G8929, Z993, N400, Z794, Z7902, K219, I252, I10, E785 are R0789: Other chest pain; R51: Headache; R29818: Other symptoms and signs involving the nervous system; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; E119: Type 2 diabetes mellitus without complications; F419: Anxiety disorder, unspecified; M1710: Unilateral primary osteoarthritis, unspecified knee; G8929: Other chronic pain; Z993: Dependence on wheelchair; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z794: Long term (current) use of insulin; Z7902: Long term (current) use of antithrombotics/antiplatelets; K219: Gastro-esophageal reflux disease without esophagitis; I252: Old myocardial infarction; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified. The common codes which frequently come are I2510, Z951, Z955, E119, F419, G8929, N400, Z794, Z7902, K219, I252, I10, E785. The uncommon codes mentioned in this dataset are R0789, R51, R29818, M1710, Z993. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint chest pain Major Surgical or Invasive Procedure none History of Present Illness Mr. ___ is a ___ year old M w hx of CAD s p CABG x1 SVG dRCA DES to OM and BMS to RCA HTN DM and anxiety who was recently discharged from the hospital who presents from rehab with chest pain. He was at ___ but left ___ after a dispute over a TV. He was supposed to be picked up by a family member but they did not come. He then started to complain of chest pain and was brought to ___. He was given aspirin in the ambulance. In the ED initial vitals were notable for tachycardia to 104 with BP 148 90. A code stroke was called as the patient was non verbal in the ED with lack of movement in his RUE. He was evaluated by Neurology who felt his exam had many functional features and he was noted to intermittently able to speak in full sentences and move LUE and LLE antigravity. CTA head neck and NCHCT were unremarkable. Further history was limited by minimal patient participation regarding his chest pain. Troponin negative x1 and EKG showed sinus tachycardia. He was not given any medications. Of note on his last admission he also had a code stroke which showed no evidence of TIA or stroke and were more consistent with a functional disorder. He also had chest pain felt to be secondary to microvascular disease vs. anxiety. He has had multiple admissions with complex care involved as he is unable to care for himself at home. On arrival to the floor the patient complains of right sided headache that he describes as similar to someone sticking needles in his head. He denies nausea vomiting lightheadedness dizziness blurry vision. He also complains of chest pain which he said has been ongoing since his fight at rehab on day prior to admission. He describes it as a squeezing pulling pain. He also notes that he intermittently can hear but can t respond or move as directed . He notes that when this happens he cannot move his RUE. Past Medical History Diabetes HTN HLD CABGx1 SVG dRCA ___ BMS to anomalous RCA ___ DES to OM ___ Chronic knee pain Anxiety Wheelchair bound Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death. Physical Exam ADMISSION PHYSICAL EXAM VITALS 24 HR Data last updated ___ 721 Temp 98.3 Tm 98.3 BP 118 77 HR 90 RR 18 O2 sat 98 O2 delivery Ra Wt 253.31 lb 114.9 kg 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. mild TTP on left chest wall. 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. did not participate in CN exam. Strength ___ in ___ upper extremities ___ in LLE and ___ in RLE at the time of my exam. Normal sensation. DISCHARGE PHYSICAL EXAM 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. mild TTP on left chest wall. 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. did not participate in CN exam. Strength ___ in ___ upper extremities ___ in LLE and ___ in RLE at the time of my exam. Normal sensation. Pertinent Results ADMISSION LABS ___ 03 07AM BLOOD WBC 6.7 RBC 4.71 Hgb 13.4 Hct 42.5 MCV 90 MCH 28.5 MCHC 31.5 RDW 14.0 RDWSD 45.4 Plt ___ ___ 03 07AM BLOOD Neuts 58.8 ___ Monos 5.6 Eos 3.2 Baso 0.8 Im ___ AbsNeut 3.93 AbsLymp 2.07 AbsMono 0.37 AbsEos 0.21 AbsBaso 0.05 ___ 03 25AM BLOOD ___ PTT 22.5 ___ ___ 03 07AM BLOOD Glucose 161 UreaN 10 Creat 0.8 Na 138 K 4.5 Cl 101 HCO3 22 AnGap 15 ___ 03 07AM BLOOD ALT 21 AST 23 AlkPhos 96 TotBili 0.4 ___ 07AM BLOOD cTropnT 0.01 ___ 03 07AM BLOOD ASA NEG Ethanol NEG Acetmnp NEG ___ 03 25AM BLOOD Glucose 160 Creat 0.7 Na 140 K 4.7 Cl 105 calHCO3 34 STUDIES ___ ___ No evidence of intracranial hemorrhage acute large territorial infarction edema or mass. CTA HEAD AND NECK ___ No evidence of dissection occlusion high grade stenosis or aneurysm greater than 3 mm within the great vessels of the head or neck. The vessels of the circle of ___ and their principal intracranial branches appear patent. Brief Hospital Course Mr. ___ is a ___ year old M w hx of CAD s p CABG x1 SVG dRCA DES to OM and BMS to RCA HTN DM and anxiety who was recently discharged from the hospital who presents from rehab with chest pain and a code stroke in the ED with concern for functional neurological disorder. TRANSITIONAL ISSUES Will need psychiatry outpatient follow up and consideration of initiation of SSRI for anxiety Patient will need ongoing management with social work and case management as he has had numerous recent hospitalizations He would benefit from ongoing outpatient workup for etiology of headache Please consider referral to Dr. ___ at ___ for suspect functional neurological disorder ACUTE ACTIVE ISSUES Chest pain While patient certainly has a history of CAD and risk factors trop negative x1 and EKG shows no signs of ischemia although could be microvascular disease . In addition constant pain for 24hrs with TTP on exam is not consistent with cardiac etiology. Most likely Ddx at this point includes malingering given no place to reside vs. anxiety. Patient was continued on home aspirin Plavix atorvastatin metoprolol and nitroglycerin prn chest pain. Unresponsiveness Functional neurological deficit Patient had a code stroke in the ED with inconsistent neurologic exam more consistent with functional neurological deficit. All head imaging including NCHCT and CTA were negative for intracranial etiology. In addition exam changed between ED exam and admission exam. Neurology was consulted and agree with diagnosis of likely functional neurological deficit. He was continued on home tramadol gabapentin and lorazepam. Recommend followup with Dr. ___ at ___ for further evaluation. Headache All imaging was negative for intracranial etiology. He was seen by neurology in the ED who felt that this was less likely a complex migraine. More likely ___ medication overuse given ongoing headache and numerous recent hospitalizations and rehab stay. Tylenol was discontinued. He should be considered for bridge therapy with NSAIDS vs steroids vs DHE if he continued to experience severe headaches despite holding likely culprit. Possibly also a component of left sided occipital neuralgia. Recommend warm compresses to back of head followup with neurology if headache fails to improve. CHRONIC STABLE ISSUES Anxiety Social work was consulted. He was continued on home lorazepam. He should have outpatient f u with psychiatry and should consider initiation of an SSRI. Type II DM Held home exanetide placed on ISS while inpatient. Knee osteoarthritis Continued home lidocaine patch gabapentin and tramadol. Held home Tylenol. BPH Continued home Tamsulosin GERD Continued home pantoprazole Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q8H PRN Pain Mild Fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 5. Clopidogrel 75 mg PO DAILY 6. Gabapentin 300 mg PO TID 7. Isosorbide Mononitrate Extended Release 30 mg PO QHS 8. Lidocaine 5 Patch 1 PTCH TD QAM 9. LORazepam 0.5 mg PO BID PRN anxiety 10. Metoprolol Succinate XL 50 mg PO DAILY 11. Milk of Magnesia 30 mL PO Q12H PRN Constipation Second Line 12. Multivitamins 1 TAB PO DAILY 13. Pantoprazole 40 mg PO Q24H 14. Tamsulosin 0.4 mg PO QHS 15. TraMADol 75 mg PO Q6H PRN Pain Moderate 16. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 17. GlipiZIDE 10 mg PO BID diabetes 18. melatonin 3 mg oral QHS 19. MetFORMIN Glucophage 1000 mg PO BID 20. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 21. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications 1. Glargine 18 Units Bedtime 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 5. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 6. Clopidogrel 75 mg PO DAILY 7. Gabapentin 300 mg PO TID 8. GlipiZIDE 10 mg PO BID diabetes 9. Isosorbide Mononitrate Extended Release 30 mg PO QHS 10. Lidocaine 5 Patch 1 PTCH TD QAM 11. LORazepam 0.5 mg PO BID PRN anxiety 12. melatonin 3 mg oral QHS 13. MetFORMIN Glucophage 1000 mg PO BID 14. Metoprolol Succinate XL 50 mg PO DAILY 15. Milk of Magnesia 30 mL PO Q12H PRN Constipation Second Line 16. Multivitamins 1 TAB PO DAILY 17. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 18. Pantoprazole 40 mg PO Q24H 19. Tamsulosin 0.4 mg PO QHS 20. TraMADol 75 mg PO Q6H PRN Pain Moderate Discharge Disposition Extended Care Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS Functional neurological deficit SECONDARY DIAGNOSIS Chest pain non cardiac Headache Anxiety 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 part in your care here at ___ Why was I admitted to the hospital You were admitted for chest pain and a headache. What was done for me while I was in the hospital We did tests of your heart and your chest pain was determined to not be coming from your heart You had trouble moving your arm and leg but we took images and determined you did not have a stroke You complained of a headache which we think may be because you take so many medications or an irritated nerve What should I do when I leave the hospital Take all of your medications as prescribed Go to all of your appointments Sincerely Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be R0789, R51, R29818, I2510, Z951, Z955, E119, F419, M1710, G8929, Z993, N400, Z794, Z7902, K219, I252, I10, E785. The descriptions of icd codes R0789, R51, R29818, I2510, Z951, Z955, E119, F419, M1710, G8929, Z993, N400, Z794, Z7902, K219, I252, I10, E785 are R0789: Other chest pain; R51: Headache; R29818: Other symptoms and signs involving the nervous system; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; E119: Type 2 diabetes mellitus without complications; F419: Anxiety disorder, unspecified; M1710: Unilateral primary osteoarthritis, unspecified knee; G8929: Other chronic pain; Z993: Dependence on wheelchair; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z794: Long term (current) use of insulin; Z7902: Long term (current) use of antithrombotics/antiplatelets; K219: Gastro-esophageal reflux disease without esophagitis; I252: Old myocardial infarction; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified. The common codes which frequently come are I2510, Z951, Z955, E119, F419, G8929, N400, Z794, Z7902, K219, I252, I10, E785. The uncommon codes mentioned in this dataset are R0789, R51, R29818, M1710, Z993.
The icd codes present in this text will be I25119, R42, I10, E119, K5909, M170, F419, E785, Z794, Z993, Z951, Z955, I252. The descriptions of icd codes I25119, R42, I10, E119, K5909, M170, F419, E785, Z794, Z993, Z951, Z955, I252 are I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris; R42: Dizziness and giddiness; I10: Essential (primary) hypertension; E119: Type 2 diabetes mellitus without complications; K5909: Other constipation; M170: Bilateral primary osteoarthritis of knee; F419: Anxiety disorder, unspecified; E785: Hyperlipidemia, unspecified; Z794: Long term (current) use of insulin; Z993: Dependence on wheelchair; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; I252: Old myocardial infarction. The common codes which frequently come are I10, E119, F419, E785, Z794, Z951, Z955, I252. The uncommon codes mentioned in this dataset are I25119, R42, K5909, M170, Z993. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest pain Major Surgical or Invasive Procedure None History of Present Illness ___ man with history of CAD s p CABG SVG to RCA ___ as well as BMS to RCA DES to distal OM1 HTN HLD and diabetes presenting for recurrent chest pain. Reports symptoms of left sided and sub sternal squeezing chest pain that began yesterday around 4 ___ while at ___ rehab. Occurs intermitently throughout the day ___ minutes per episode. Non radiating no improvement with nitro SL that he received. No dyspnea. Describes symptoms as similar to his prior ACS events but worse in severity this time. Because of this was brought to the ED from ___ rehab where he has been since discharge approximately two weeks ago. He was at rest when pain began denies any exertional component to his symptoms. Of note he was recently admitted in ___ for recurrent chest pain for which he underwent coronary angiography with no evidence of new progressive disease all grafts and vessels similarly patent to prior study in ___. Attempted to maximize medical therapy with anti anginals however this has been limited by orthostatic hypotension and dizziness. Of note his Imdur appears to have been decreased from 30 to 15 mg daily while at rehab. Otherwise denies any fever chills weight gain loss back pain dyspnea cough abdominal pain nausea vomiting or diarrhea. In the ED initial vitals were 96 160 80 16 99 Exam notable for No increased work of breathing. CTAB. RRR. Normal S1 S2. 2 radial pulse bilaterally. Labs notable for troponin 0.01 x2. Imaging was notable for CXR with no acute process. Notable medications received nitroglycerin SL 0.4 mg x2 Imdur 30 aspirin 81 243 metoprolol succinate 25 started on heparin gtt. Reports currently being chest pain free on arrival. Past Medical History 1. CARDIAC RISK FACTORS Diabetes Hypertension Dyslipidemia 2. CARDIAC HISTORY CABG ___ PERCUTANEOUS CORONARY INTERVENTIONS ___ BMS to proximal anomalous RCA ___ PACING ICD None 3. OTHER PAST MEDICAL HISTORY Osteoarthritis Constipation Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death. Physical Exam ADMISSION PE VITALS 98.1 149 88 80 18 100 Ra GENERAL Older appearing man in no acute distress. Comfortable. AAOx3. NEURO AAOx3. CNII XII grossly intact. Moving all four extremities with purpose. HEENT NCAT. EOMI. MMM. CARDIAC Regular rate rhythm. Normal S1 S2. No murmurs rubs or gallops. CHEST Well healed midline sternotomy scar. PULMONARY Clear to auscultation bilaterally. Breathing comfortably on room air. ABDOMEN Soft non tender non distended. EXTREMITIES Warm well perfused non edematous. SKIN No significant rashes. DISCHARGE PE VS 97.5 121 70 70 16 100 RA GENERAL Older appearing man in no acute distress. Comfortable. AAOx3. NEURO AAOx3. CNII XII grossly intact. Moving all four extremities with purpose. HEENT NCAT. EOMI. MMM. CARDIAC Regular rate rhythm. Normal S1 S2. No murmurs rubs gallops clicks. CHEST Well healed midline sternotomy scar. PULMONARY Clear to auscultation bilaterally. Breathing comfortably on room air. No wheezes rubs rhonchi or accessory use. ABDOMEN Soft non tender non distended normoactive BS throughout no HSM. EXTREMITIES Warm well perfused non edematous. SKIN No significant rashes or varicosities WT ADMIT 112.31 kg DISCHARGE 109.5 kg Pertinent Results ___ 06 26AM BLOOD WBC 3.9 RBC 4.45 Hgb 13.5 Hct 41.5 MCV 93 MCH 30.3 MCHC 32.5 RDW 12.9 RDWSD 43.8 Plt ___ ___ 06 14AM BLOOD WBC 5.0 RBC 4.60 Hgb 13.9 Hct 44.3 MCV 96 MCH 30.2 MCHC 31.4 RDW 12.9 RDWSD 45.7 Plt ___ ___ 12 44AM BLOOD WBC 5.3 RBC 4.04 Hgb 12.3 Hct 37.1 MCV 92 MCH 30.4 MCHC 33.2 RDW 12.7 RDWSD 42.9 Plt ___ ___ 12 44AM BLOOD Neuts 51.0 ___ Monos 8.6 Eos 4.2 Baso 0.8 Im ___ AbsNeut 2.69 AbsLymp 1.85 AbsMono 0.45 AbsEos 0.22 AbsBaso 0.04 ___ 06 26AM BLOOD Plt ___ ___ 08 41AM BLOOD PTT 54.6 ___ 06 14AM BLOOD Plt ___ ___ 06 26AM BLOOD UreaN 10 Creat 0.7 Na 139 K 4.7 ___ 10 42AM BLOOD Glucose 199 UreaN 8 Creat 0.7 Na 141 K 4.3 Cl 103 HCO3 25 AnGap 13 ___ 06 14AM BLOOD Glucose 185 UreaN 9 Creat 0.9 Na 132 K GREATER TH Cl 95 HCO3 14 AnGap 23 ___ 12 44AM BLOOD Glucose 214 UreaN 9 Creat 0.7 Na 135 K 5.1 Cl 99 HCO3 24 AnGap 12 ___ 08 15PM BLOOD CK MB 2 cTropnT 0.01 ___ 05 10AM BLOOD cTropnT 0.01 ___ 12 44AM BLOOD cTropnT 0.01 ___ 06 26AM BLOOD Mg 2.0 ___ 10 42AM BLOOD Calcium 9.3 Mg 1.8 ___ 06 14AM BLOOD Calcium LESS THAN Phos 4.0 Mg LESS THAN ___ 12 44AM BLOOD HbA1c 8.8 eAG 206 Brief Hospital Course Assessment ___ man with history of CAD s p CABG SVG to RCA ___ well as BMS to RCA DES to distal OM1 HTN HLD and diabetes presenting for recurrent chest pain most likely due to chronic stable angina in the setting of microvascular disease. Plan CAD Microvascular disease Chest Pain Ongoing intermittent symptoms 24h similar in character to prior angina though without dynamic EKG changes or troponin elevation. Given recent stable cor angio this is more likely reflective of known microvascular disease instead of acute thrombosis. Has been CP free for greater than 24 hours. Continue Aspirin 81 mg PO NG DAILY Continue Atorvastatin 80 mg PO NG QPM Continue Clopidogrel 75 mg PO NG DAILY Changed Metop Tartrate and Isosorbide dinatrate back to home Imdur and Metop succinate as pt not orthostatic. Amlodipine added yesterday increase to 5mg once daily today and monitor orthostatics post no signs of orthostasis Consider increasing Imdur if continued symptoms and if BP tolerates Would benefit from ACE given prior NSTEMI with concurrent hypertension diabetes though may be limited given recent orthostasis and need for uptitrtation of antianginals ___ consulted to assess for activity tolerance and assess if any CP with activity CHRONIC STABLE ISSUES Osteoarthritis Needs bilat knee replacement work up in progress. Has been largely wheel chair bound for about 3 months. Return to rehab ___ consult while inpatient encourage up OOB to recliner DIABETES Hgb 8.8 down from 10.1 in ___. Continue close management as likely exacerbating microvascular disease Monitor blood glucose QACHS Diabetic diet Continue Glargine 18 QHS with sliding scale Holding outpatient PO medications while inpatient resume on discharge HYPERTENSION BP 110 130 50 70 s. Increasing Amlodipine to 5mg daily for microvascular disease Metoprolol succinate Imdur as above Monitor orthostatic vital signs no evidence while in hospital CHRONIC CONSTIPATION Continue home regimen PROPHYLAXIS DVT prophylaxis with Heparin SC Pain management with Tylenol gabapentin and Tramadol Bowel regimen with Senna QD and Milk of Mag miralax and Ducolax as PRN Emergency contact ___ sister ___ Family HCP updated No. Patient updated Dispo Continued medication management today discharge to rehab. Discharge time 35 min Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 5. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 6. Gabapentin 300 mg PO TID 7. Lidocaine 5 Patch 1 PTCH TD QAM 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 11. Senna 17.2 mg PO DAILY 12. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 13. GlipiZIDE 10 mg PO BID 14. melatonin 3 mg oral QHS 15. MetFORMIN Glucophage 1000 mg PO BID 16. Milk of Magnesia 30 mL PO QHS PRN Constipation First Line 17. Docusate Sodium 100 mg PO BID 18. Polyethylene Glycol 17 g PO BID PRN Constipation First Line 19. TraMADol 75 mg PO Q6H PRN Pain Moderate 20. Mylanta 30 ml oral Q4H PRN 21. Isosorbide Mononitrate Extended Release 15 mg PO DAILY 22. Glargine 18 Units Bedtime Discharge Medications 1. amLODIPine 5 mg PO DAILY 2. Pantoprazole 40 mg PO Q24H 3. Glargine 18 Units Bedtime 4. Isosorbide Mononitrate Extended Release 30 mg PO DAILY 5. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 9. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 10. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 11. Docusate Sodium 100 mg PO BID 12. Gabapentin 300 mg PO TID 13. GlipiZIDE 10 mg PO BID 14. Lidocaine 5 Patch 1 PTCH TD QAM 15. melatonin 3 mg oral QHS 16. MetFORMIN Glucophage 1000 mg PO BID 17. Metoprolol Succinate XL 25 mg PO DAILY 18. Milk of Magnesia 30 mL PO QHS PRN Constipation First Line 19. Multivitamins 1 TAB PO DAILY 20. Mylanta 30 ml oral Q4H PRN 21. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 22. Polyethylene Glycol 17 g PO BID PRN Constipation First Line 23. Senna 17.2 mg PO DAILY 24. TraMADol 75 mg PO Q6H PRN Pain Moderate Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Chest pain CAD 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 You were admitted to the hospital with chest pain and ongoing issues with dizziness. Your heart enzymes were negative and you did not have any changes on your EKGs while admitted to the hospital. Given that you recently had cardiac catheterization in ___ with stent placement and again in ___ and known microvascular disease you did not undergo additional imaging. We increased some of your medications while you were in the hospital to help with your ongoing issues with chest pain. We continued to monitor your blood pressure and heart rate throughout your hospital course. We completed orthostatic blood pressures daily and they were normal. Please continue ALL of your current medications with the following changes Isosorbide Mononitrate INCREASED from 15 mg daily back to 30 mg daily Amlodipine 5 mg daily NEW Protonix 40 mg daily NEW It is very important to take all of your heart healthy medications. In particular aspirin and clopidogrel Plavix keep the stents in the vessels of the heart open from stent placed in ___ and help reduce your risk of having a future heart attack. If you stop these medications or miss ___ dose you risk causing a blood clot forming in your heart stents and you may die from a massive heart attack. Please do not stop taking either medication without taking to your heart doctor even if another doctor tells you to stop the medications. If you have any urgent questions that are related to your recovery from your hospitalization or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital please call the ___ HeartLine 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 Your ___ Cardiac Care Team Followup Instructions ___ The icd codes present in this text will be I25119, R42, I10, E119, K5909, M170, F419, E785, Z794, Z993, Z951, Z955, I252. The descriptions of icd codes I25119, R42, I10, E119, K5909, M170, F419, E785, Z794, Z993, Z951, Z955, I252 are I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris; R42: Dizziness and giddiness; I10: Essential (primary) hypertension; E119: Type 2 diabetes mellitus without complications; K5909: Other constipation; M170: Bilateral primary osteoarthritis of knee; F419: Anxiety disorder, unspecified; E785: Hyperlipidemia, unspecified; Z794: Long term (current) use of insulin; Z993: Dependence on wheelchair; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; I252: Old myocardial infarction. The common codes which frequently come are I10, E119, F419, E785, Z794, Z951, Z955, I252. The uncommon codes mentioned in this dataset are I25119, R42, K5909, M170, Z993.
The icd codes present in this text will be R0789, I2510, I10, E119, F419, K219, N400, M1710, E785, Z993, Z794, Z951, Z955, Z8249. The descriptions of icd codes R0789, I2510, I10, E119, F419, K219, N400, M1710, E785, Z993, Z794, Z951, Z955, Z8249 are R0789: Other chest pain; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; E119: Type 2 diabetes mellitus without complications; F419: Anxiety disorder, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; M1710: Unilateral primary osteoarthritis, unspecified knee; E785: Hyperlipidemia, unspecified; Z993: Dependence on wheelchair; Z794: Long term (current) use of insulin; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z8249: Family history of ischemic heart disease and other diseases of the circulatory system. The common codes which frequently come are I2510, I10, E119, F419, K219, N400, E785, Z794, Z951, Z955. The uncommon codes mentioned in this dataset are R0789, M1710, Z993, Z8249. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest pain Major Surgical or Invasive Procedure None History of Present Illness Mr. ___ is a ___ man with past medical history notable for CAD with anomalous RCA s p S P BMS to mid RCA in ___ S P 1 vesel CABG SVG dRCA in ___ S P DES to ___ type 2 diabetes mellitus hypertension hyperlipidemia severe anxiety and chronic debilitating knee pain rendering him wheelchair bound presenting with chief complaint of chest discomfort. Patient noted he had substernal chest pain that he described as a pressure starting at 2 00 pm the afternoon of presentation while he was sitting down watching TV. He received sublingual nitroglycerin x3 with relief. The pain returned when he got up to use the bathroom. It was not associated with any lightheadedness nausea diaphoresis or abdominal pain. He has not had this pain before. It was worse with deep breathing. He denied any fevers cough trauma or lower extremity swelling. In the ED initial vitals T 98.1 HR 94 BP 121 74 RR 20 SaO2 97 on RA. Benign physical examination. Labs studies notable for WBC 5.3 Hgb 13 Hct 39.7 Pl5 307 INR 1.2 PTT 28 Na 138 K 7.5 3.9 on repeat BUN 11 Cr 0.8 glc 76 D Dimer 1837. CTA showed no evidence of pulmonary embolism or aortic abnormality. Patient was given nitroglycerin SL 0.4 mg X 2 morphine sulfate IV. Vitals on transfer T 97.7 PO BP 155 73 HR 91 RR 17 SaO2 98 on RA. After arrival to the cardiology ward the patient confirmed the history as above. He has a history of chest pain but felt the pain he had ambulating to the bathroom was much more severe than he has had in the past. Past Medical History 1. CAD RISK FACTORS Diabetes mellitus Hypertension Dyslipidemia 2. CARDIAC HISTORY CAD S P CABGx1 SVG dRCA ___ BMS to anomalous RCA ___ DES to OM ___ PACING ICD None 3. OTHER PAST MEDICAL HISTORY chronic knee pain from OA wheelchair bound anxiety Social History ___ Family History Both his mother and father had cardiac issues. His mother died in her ___ or ___ due to some issue with her pacemaker. His father died in his ___ he thinks from a massive stroke. Physical Exam On admission GENERAL Well developed well nourished middle aged black man in NAD. Mood affect appropriate. VITALS T 97.7 PO BP 155 73 HR 91 RR 17 SaO2 98 on RA HEENT Sclera anicteric. EOMI. Conjunctiva pink no pallor or cyanosis of the oral mucosa. NECK No appreciable JVD CARDIAC PMI located in ___ intercostal space midclavicular line. RRR normal S1 S2. No murmurs rubs gallops. LUNGS No chest wall deformities scoliosis or kyphosis. Resp were unlabored no accessory muscle use. No crackles wheezes or rhonchi. ABDOMEN Soft non tender not distended. EXTREMITIES No clubbing cyanosis or edema. No femoral bruits. SKIN No stasis dermatitis ulcers scars or xanthomas. At discharge General in NAD sitting comfortably in bed 24 HR Data last updated ___ 1512 Temp 98.4 Tm 98.6 BP 121 75 101 143 55 81 HR 80 68 80 RR 20 ___ O2 sat 98 96 99 O2 delivery RA Wt 257.5 lb 116.8 kg HEENT NCAT PERRL mucous membranes moist. Neck Supple trachea midline Heart RRR no murmurs rubs or gallops. No peripheral edema. Lungs CTAB No wheezes rales or rhonchi. Abd Soft non tender not distended. MSK No obvious limb deformities. Derm Skin warm and dry Neuro Awake alert moves all extremities. Pertinent Results ___ 04 21PM WBC 5.3 RBC 4.49 HGB 13.0 HCT 39.7 MCV 88 MCH 29.0 MCHC 32.7 RDW 14.0 RDWSD 45.1 ___ 04 21PM NEUTS 55.9 ___ MONOS 6.9 EOS 2.9 BASOS 0.6 IM ___ AbsNeut 2.94 AbsLymp 1.75 AbsMono 0.36 AbsEos 0.15 AbsBaso 0.03 ___ 04 21PM PLT COUNT 307 ___ 04 21PM ___ PTT 28.0 ___ ___ 04 21PM GLUCOSE 76 UREA N 11 CREAT 0.8 SODIUM 138 POTASSIUM 7.5 CHLORIDE 101 TOTAL CO2 23 ANION GAP 14 ___ 05 36PM K 3.9 ___ 04 21PM cTropnT 0.01 ___ 04 21PM CK MB 3 ___ 09 45PM cTropnT 0.01 ___ 09 45PM CK MB 3 ___ 06 35AM CK MB 3 cTropnT 0.01 ___ 05 30PM D DIMER ___ ECG ___ 16 01 59 Sinus rhythm. Normal ECG CXR ___ Median sternotomy wires are intact and unchanged from prior. Surgical clips project over the right border of the mediastinum. Stable elevation of the right hemidiaphragm. No areas of focal consolidation pleural effusion or pneumothorax. Cardiomediastinal contours are normal. IMPRESSION No acute cardiopulmonary findings. CTA Chest ___ HEART AND VASCULATURE Pulmonary vasculature is well opacified to the segmental level without filling defect to indicate a pulmonary embolus. Subsegmental branches are not particularly well assessed due to timing of the contrast bolus. Main pulmonary artery is top normal in size which may suggest pulmonary arterial hypertension. Mild atherosclerotic calcifications of the thoracic aorta. The thoracic aorta is normal in caliber without evidence of dissection or intramural hematoma. Patient is status post CABG. Otherwise the heart pericardium and great vessels are within normal limits. No pericardial effusion is seen. AXILLA HILA AND MEDIASTINUM No axillary mediastinal or hilar lymphadenopathy is present. No mediastinal mass. PLEURAL SPACES No pleural effusion or pneumothorax. LUNGS AIRWAYS Linear atelectasis within the right lower lobe is unchanged. No new focal consolidations. No suspicious pulmonary nodules. Small amount of secretions within the trachea at the carina. Otherwise 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. ABDOMEN Simple cyst partially imaged within the upper pole of the right kidney. BONES Sternotomy wires appear intact and appropriately aligned. Well circumscribed sclerotic lesion within the manubrium is likely a bone island. Lucent lesions in the anterolateral right fourth rib and the posterolateral right seventh rib are unchanged dating back to ___ and of doubtful clinical significance. No suspicious osseous abnormality is seen. There is no acute fracture. IMPRESSION No evidence of pulmonary embolism or aortic abnormality. Vasodilator nuclear stress test ___ This ___ year old IDDM man with a h o CAD HTN HLD anomalous RCA s p CABG x1 SVG dRCA in ___ BMS x1 to the mid RCA in ___ and DES x1 to the OM1 in ___ was referred to the lab for evaluation of chest discomfort. The patient is wheelchair bound and arm ergometer was unable to be performed therefore the patient was administered 0.4 mg of regadenoson IV bolus over 20 seconds. At 1 minute post infusion the patient reported a diffuse chest discomfort which he was unable to characterize further but different from the discomfort he was referred for. This discomfort improved during recovery and was absent by 4.25 minutes of recovery. There were no significant ST segment changes seen during the infusion or in recovery. The rhythm was sinus with occasional isolated APBs and question of a two sinus pauses one at 6 minutes and 7 minutes of recovery. Apppropriate blood pressure and heart rate responses to the infusion and in recovery. Post MIBI the regadenoson was reversed with 60 mg IV caffeine. IMPRESSION Atypical type symptoms in the absence of significant ST segment changes. Appropriate hemodynamic response to vasodilator stress. IMAGING Left ventricular cavity size is normal. 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 55 . IMPRESSION Normal myocardial perfusion. Left ventricular ejection fraction of 55 . DISCHARGE LABS ___ 06 35AM BLOOD WBC 4.7 RBC 4.44 Hgb 12.6 Hct 39.3 MCV 89 MCH 28.4 MCHC 32.1 RDW 14.3 RDWSD 45.9 Plt ___ ___ 05 35AM BLOOD Glucose 184 UreaN 13 Creat 0.8 Na 139 K 4.5 Cl 102 HCO3 25 AnGap 12 ___ 05 35AM BLOOD Calcium 9.0 Phos 3.9 Mg 1.8 Brief Hospital Course Mr. ___ is a ___ man with past medical history notable for CAD with BMS to anomalous mid RCA in ___ s p 1 vessel CABG SVG dRCA in ___ DES to ___ type 2 diabetes mellitus hypertension hyperlipidemia severe anxiety and chronic debilitating knee pain rendering him wheelchair bound presenting with acute on chronic chest discomfort. ACTIVE ISSUES Chest pain. CAD with anomalous RCA arising next to the ___ s p BMS to mid RCA in ___ for NSTEMI 1 vessel CABG SVG dRCA in ___ DES to ___ He has had multiple admissions for chest pain atypical for ischemia with extensive negative work up including 2 coronary angiograms nuclear stress testing transthoracic echocardiograms and multiple evaluations for unstable angina with serial troponins and normal EKGs. His work up this admission again was reassuring with no evidence of acute cardiac pathology. ECG was normal serial troponin T normal. CTPA for elevated D dimer showed no evidence of pulmonary embolus or aortic pathology. Patient was medically managed with aspirin clopidogrel atorvastatin metoprolol isorbide mononitrate and sublingual nitroglycerin prn all his home medications . As patient moves his wheelchair using his arms to spin the rims on the wheels of his chair the possibility of ischemia or musculoskeletal pain from exertion using upper chest arm musculature was entertained. Unfortunately we were unable to obtain arm ergometry stress testing. Vasodilator nuclear stress test on ___ showed uniform myocardial perfusion with left ventricular ejection fraction of 55 . He was started on scheduled acetaminophen for musculoskeletal chest pain. CHRONIC STABLE ISSUES Anxiety Continued home lorazepam. It was hypothesized that the patient s chest discomfort may be related to his underlying anxiety given that cardiac ischemia was exonerated. Please strongly consider referral for CBT and or initiation of an SSRI versus buspirone. Type 2 diabetes mellitus Patient did have glucose of 60 while in ED therefore his Lantus was dose reduced from 25 to 20 units. He was also placed on insulin sliding scale. Held home liraglutide and glipizide while patient in hospital but they were restarted on discharge. Knee osteoarthritis Continued home acetaminophen lidocaine patch gabapentin and tramadol BPH Continued home tamsulosin GERD Continued home pantoprazole TRANSITIONAL ISSUES New meds none Held discontinued meds Changed medication regimen scheduled acetaminophen for presumed musculoskeletal chest pain It was hypothesized that the patient s chest discomfort may be related to his underlying anxiety given that cardiac ischemia was exonerated. Please strongly consider referral for CBT and or initiation of an SSRI versus buspirone. CODE Full per MOLST CONTACT Name of health care proxy ___ Sister ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 2. Gabapentin 300 mg PO TID 3. Metoprolol Succinate XL 50 mg PO DAILY 4. MetFORMIN Glucophage 1000 mg PO BID 5. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 6. Atorvastatin 80 mg PO QPM 7. liraglutide 0.6 mg 0.1 mL 18 mg 3 mL subcutaneous DAILY 8. Glargine 25 Units Dinner Insulin SC Sliding Scale using HUM Insulin 9. Multivitamins 1 TAB PO DAILY 10. Isosorbide Mononitrate 120 mg PO DAILY 11. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 12. TraMADol 75 mg PO Q6H PRN Pain Moderate 13. Melatin melatonin 3 mg oral QHS 14. Clopidogrel 75 mg PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Aspirin 81 mg PO DAILY 17. Tamsulosin 0.4 mg PO QHS 18. GlipiZIDE 10 mg PO BID 19. LORazepam 0.5 mg PO BID PRN anxiety 20. Milk of Magnesia 30 mL PO Q12H PRN Constipation Second Line Discharge Medications 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 5. Clopidogrel 75 mg PO DAILY 6. Gabapentin 300 mg PO TID 7. GlipiZIDE 10 mg PO BID 8. Glargine 25 Units Dinner Insulin SC Sliding Scale using HUM Insulin 9. Isosorbide Mononitrate 120 mg PO DAILY 10. liraglutide 0.6 mg 0.1 mL 18 mg 3 mL subcutaneous DAILY 11. LORazepam 0.5 mg PO BID PRN anxiety 12. Melatin melatonin 3 mg oral QHS 13. MetFORMIN Glucophage 1000 mg PO BID 14. Metoprolol Succinate XL 50 mg PO DAILY 15. Milk of Magnesia 30 mL PO Q12H PRN Constipation Second Line 16. Multivitamins 1 TAB PO DAILY 17. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 18. Pantoprazole 40 mg PO Q24H 19. Tamsulosin 0.4 mg PO QHS 20. TraMADol 75 mg PO Q6H PRN Pain Moderate RX tramadol 50 mg 1.5 tablet s by mouth every six 6 hours Disp 18 Tablet Refills 0 Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Chest pain without objective evidence of myonecrosis or ischemia Coronary artery disease with prior bypass surgery for congenitally anomalous coronary arteries and prior stenting Anxiety Chronic knee osteoarthritis with pain Gastroesophageal reflux disease Diabetes mellitus type 2 with Hypoglycemia Benign prostatic hypertrophy 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 Mr. ___ It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL You were admitted to the hospital because you were having chest discomfort WHAT HAPPENED TO ME IN THE HOSPITAL In the hospital we tracked your blood levels of certain enzymes which indicate whether someone has had a heart attack. We also performed a stress test to see if your heart was getting reduced blood flow. All of the cardiac testing came back normal. The pain you were feeling is not due to a heart attack. 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 R0789, I2510, I10, E119, F419, K219, N400, M1710, E785, Z993, Z794, Z951, Z955, Z8249. The descriptions of icd codes R0789, I2510, I10, E119, F419, K219, N400, M1710, E785, Z993, Z794, Z951, Z955, Z8249 are R0789: Other chest pain; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; E119: Type 2 diabetes mellitus without complications; F419: Anxiety disorder, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; M1710: Unilateral primary osteoarthritis, unspecified knee; E785: Hyperlipidemia, unspecified; Z993: Dependence on wheelchair; Z794: Long term (current) use of insulin; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z8249: Family history of ischemic heart disease and other diseases of the circulatory system. The common codes which frequently come are I2510, I10, E119, F419, K219, N400, E785, Z794, Z951, Z955. The uncommon codes mentioned in this dataset are R0789, M1710, Z993, Z8249.
The icd codes present in this text will be R079, N390, R4701, R531, R51, F419, I2510, I10, E785, E119, G8929, M25562, M25561, Z96653, B961, N400, Z951, Z955, Z993, Z7902. The descriptions of icd codes R079, N390, R4701, R531, R51, F419, I2510, I10, E785, E119, G8929, M25562, M25561, Z96653, B961, N400, Z951, Z955, Z993, Z7902 are R079: Chest pain, unspecified; N390: Urinary tract infection, site not specified; R4701: Aphasia; R531: Weakness; R51: Headache; F419: Anxiety disorder, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E119: Type 2 diabetes mellitus without complications; G8929: Other chronic pain; M25562: Pain in left knee; M25561: Pain in right knee; Z96653: Presence of artificial knee joint, bilateral; B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z993: Dependence on wheelchair; Z7902: Long term (current) use of antithrombotics/antiplatelets. The common codes which frequently come are N390, F419, I2510, I10, E785, E119, G8929, N400, Z951, Z955, Z7902. The uncommon codes mentioned in this dataset are R079, R4701, R531, R51, M25562, M25561, Z96653, B961, Z993. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint chest pain Major Surgical or Invasive Procedure None History of Present Illness From admitting H P ___ male with history of CAD s p CABGx1 SVG dRCA ___ BMS to anomalous RCA ___ DES to OM ___ T2DM HTN and chronic knee pain from OA wheelchair bound multiple recent admissions for chest pain who presents with chest pain. On day of admission he reports waking up with ___ chest pain from sleep at 7 am no shortness of breath nausea or vomiting. He says the pain has been persistent over the day and has not improved with sublingual nitro. He does not notice any change with inspiration position or with exertion. Of note he s had 6 admissions over the last 6 months for chest pain and several additional ED visits. In ___ he presented with unstable angina and underwent DES to OM ___. On the subsequent admissions chest pain was thought to be related to either anxiety or microvascular disease as he s had negative troponins and no ischemic changes on EKG. He underwent angiography again on ___ which showed stable nonobstructive CAD with evidence of diffuse microvascular disease. He most recently underwent a nuclear stress on ___ which was normal. His recent admission was ___ to ___ with chest pain thought to be related to anxiety. After his last admission he was discharged to a hotel rather than to a skilled nursing facility. Per the note He states that being in rehab has been very difficult. He notes that he is there with many people who are much older than him and this has taken a mental toll. He has seen many things that have made him uncomfortable and feel that the care he gets is often very poor. He also struggles with the idea of being stuck in a wheelchair at a rehab at such a young age. He reports that he s very anxious regarding his ability to care for himself. He feels he made a mistake by requesting discharge to hotel and he has trouble getting in and out of bed and getting to the bathroom. He has not been taking Ativan recently but he reports that the Ativan appears to help his chest pain. In the ED while he was getting an EKG he suddenly became confused and complained of sudden onset headache. Then had weakness and inattentiveness. A code stroke called. CTA head showed no hemorrhage or large vessel occlusion. Neurology evaluated him and found no neurologic deficits exam notable for anxiety and treated his headache with IVF and migraine cocktail. He reports he s never had these types of symptoms before. In the ED initial vitals were 97.8 90 135 71 18 96 RA Exam was notable for Confused in pain unable to state name location date inattentive on the right. Weakness RUE LUE weakness RLE LLE inattentive on right not able to follow exam commands for CN able to wiggle toes. Labs were notable for trop negative x2 negative serum tox urine tox normal CBC Cr lytes LFTs. Studies were notable for 4 EKG s obtained showing NSR normal intervals no ischemic changes The patient was given SL nitro x 3 ASA 325 Tylenol prochlorperazine 1L LR plavix atorvastatin 80 mg tramadol 50 mg insulin 4 U cardiology was consulted recommended admission for medication titration given his recurrent presentations to the ED for chest pain. On arrival to the cardiology service he endorses history above. He reports constant chest pain which is ___ and unchanged from prior. He does appear comfortable and has been mostly concerned with anxiety surrounding inability to complete ADLs. Past Medical History 1. CARDIAC RISK FACTORS Diabetes Hypertension Dyslipidemia 2. CARDIAC HISTORY CABGx1 SVG dRCA ___ BMS to anomalous RCA ___ DES to OM ___ PACING ICD None 3. OTHER PAST MEDICAL HISTORY chronic knee pain from OA wheelchair bound anxiety Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death. Physical Exam On day of discharge Vitals 24 HR Data last updated ___ 800 Temp 98.3 Tm 98.4 BP 119 73 108 143 64 89 HR 74 70 78 RR 18 ___ O2 sat 96 96 99 O2 delivery Ra Weight 113kg Weight on admission 110.3 kg Telemetry sinus rhythm General Well appearing no apparent distress HEENT Normocephalic atraumatic. EOMI. Neck Supple trachea midline. Lungs Decreased breath sounds throughout but otherwise clear to auscultation bilaterally in all lung fields. CV RRR. Normal S1 S2. No murmurs rubs or gallops. Abdomen Bowel sounds present throughout. Nontender to palpation in 4 quadrants. Ext Warm well perfused. No cyanosis Neuro CN II XII intact. UE strength ___ bilaterally. ___ strength ___ bilaterally. Sensation intact and symmetric throughout. Tone normal. Pertinent Results At admission ___ 01 10PM BLOOD WBC 5.9 RBC 4.43 Hgb 12.8 Hct 39.4 MCV 89 MCH 28.9 MCHC 32.5 RDW 13.1 RDWSD 42.7 Plt ___ ___ 01 10PM BLOOD ___ PTT 28.0 ___ ___ 05 28AM BLOOD Glucose 153 UreaN 11 Creat 0.6 Na 141 K 3.9 Cl 101 HCO3 28 AnGap 12 ___ 01 10PM BLOOD ALT 22 AST 19 AlkPhos 104 TotBili 0.3 ___ 01 10PM BLOOD Lipase 18 ___ 01 10PM BLOOD cTropnT 0.01 ___ 05 05PM BLOOD cTropnT 0.01 ___ 01 10PM BLOOD Albumin 3.7 Interim labs At discharge CTA head neck 1. No evidence of acute territorial infarction or intracranial hemorrhage. 2. CT perfusion is nondiagnostic due to poor bolus timing. 3. No evidence of large vessel occlusion stenosis aneurysm or dissection. MRI brain 1. There is no evidence of hemorrhage edema mass or infarction. The ventricles and sulci are age appropriate. There is no mass effect or midline shift. 2. Scattered T2 and FLAIR hyperintense foci in the periventricular and subcortical white matter are nonspecific but likely reflect chronic small vessel ischemic changes. 3. There is mild mucosal thickening of the paranasal sinuses. There is mild fluid signal in the left mastoid air cells. The intraorbital contents are unremarkable. Brief Hospital Course Chest Pain The patient presented with chest pain similar to previous multiple admissions over the last 6 months. Patient has known CAD and microvascular disease. Workup in the ED for ischemia was negative. No pleurisy. Chest pain not responsive to sublingual nitroglycerin and the pain persisted through 2 sets of negative biomarkers and repeated EKGs. During his most recent admission ___ his chest pain was thought to be related to anxiety. He was given small dose Ativan to see if the chest pain would improve on anxiolytics and although the pain improved it did not go away. The cause of the chest pain remains unclear with anxiety vs microvasular disease both possible. Low suspicion for ACS. Given his known CAD he was continued on Imdur but the timing of the dose was changed to nightly for improved antianginal effect in the morning. CAD Patient is s p CABGx1 SVG dRCA ___ BMS to anomalous RCA ___ and DES to OM ___ . Additionally coronary angiography on ___ showed stable nonobstructive CAD with evidence of diffuse microvascular disease. Nuclear stress on ___ was normal. Troponin negative x 2 this admission. EKG without ischemic changes x4. Initially it was thought that the chest pain could be due to microvascular disease but the pain did not improve after nitroglycerin administration making this unlikely. He was continued on his aspirin and Plavix as well as Toprol XL. His Imdur was changed to nightly as stated above. Anxiety Patient has a hx of anxiety however he is not followed by a therapist or a psychiatrist as an outpatient and is not on an SSRI. His stress is worsened by his inability to perform his ADLs. Pt denies anxiety specifically but endorses significant worry and stress. He was trialed on Ativan 0.5mg prn on prior admission and currently with some relief and discharged with limited course. Recommend trial of longer acting anxiolytic SSRI or a TCA for anxiety symptoms. Social work was consulted for assistance with discharge planning and coping. It was felt that discharging the patient back to a hotel was unsafe given failure of this strategy requiring rehospitalization. He was set up with a complex case manager and discharged to a SNF. Code stroke in ED While in the ED the patient had an episode where he felt unable to speak. A code stroke was called. NIHSS 0. The episode was brief and the symptoms resolved by time the patient was evaluated by neurology. CT head and CTA head neck showed no evidence of hemorrhage. The patient had no residual deficits or recurrence of his symptoms. He was monitored on telemetry for the duration of his hospital stay and no arrhythmias were recorded. MRI brain was obtained with no evidence of bleed or acute ischemia. The transient speech difficulty was felt highly unlikely to represent TIA and was not due to stroke given lack of findings on imaging. His symptoms given his underlying psychiatric symptoms are more consistent with a functional neurologic symptom disorder. Neurology recommended 1 month of outpatient heart monitoring but this was deferred given lack of MRI findings and no recorded arrhythmias on telemetry suggesting a low likelihood of arrhythmia leading to an embolic event. This should be readdressed by the PCP. T2DM Home ___ held while hospitalized but restarted at discharge. Patient covered with sliding scale insulin while in hospital. Osteoarthritis Patient reports history of work injury and is s p bilateral knee replacement complicated by chronic knee pain. Patient is unable to bear weight and is wheelchair bound. Patient is reportedly planning for surgery however needs to be stable from cardiac perspective. He was continued on his home analgesic regimen without changes. Prior UTI Patient was found to have Klebsiella UTI at last admission ___. He remained on ___ with plan to finish course ___. 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. Acetaminophen 650 mg PO Q8H PRN Pain Mild Fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 5. Clopidogrel 75 mg PO DAILY 6. Gabapentin 300 mg PO TID 7. GlipiZIDE 10 mg PO BID diabetes 8. Isosorbide Mononitrate Extended Release 30 mg PO DAILY 9. Lidocaine 5 Patch 1 PTCH TD QAM 10. LORazepam 0.5 mg PO BID PRN anxiety 11. MetFORMIN Glucophage 1000 mg PO BID 12. Metoprolol Succinate XL 50 mg PO DAILY 13. Multivitamins 1 TAB PO DAILY 14. Pantoprazole 40 mg PO Q24H 15. TraMADol 75 mg PO Q6H PRN Pain Moderate 16. Tamsulosin 0.4 mg PO QHS 17. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 18. melatonin 3 mg oral QHS 19. Milk of Magnesia 30 mL PO Q12H PRN Constipation Second Line 20. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 21. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection Discharge Medications 1. Isosorbide Mononitrate Extended Release 30 mg PO QHS 2. Acetaminophen 650 mg PO Q8H PRN Pain Mild Fever 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 6. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 7. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection Duration 2 Doses 8. Clopidogrel 75 mg PO DAILY 9. Gabapentin 300 mg PO TID 10. GlipiZIDE 10 mg PO BID diabetes 11. Glargine 18 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 12. Lidocaine 5 Patch 1 PTCH TD QAM 13. LORazepam 0.5 mg PO BID PRN anxiety 14. melatonin 3 mg oral QHS 15. MetFORMIN Glucophage 1000 mg PO BID 16. Metoprolol Succinate XL 50 mg PO DAILY 17. Milk of Magnesia 30 mL PO Q12H PRN Constipation Second Line 18. Multivitamins 1 TAB PO DAILY 19. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 20. Pantoprazole 40 mg PO Q24H 21. Tamsulosin 0.4 mg PO QHS 22. TraMADol 75 mg PO Q6H PRN Pain Moderate Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Chest pain Coronary artery disease Transient aphasia Urinary tract infection 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 Mr. ___ It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL You were admitted to the hospital because of chest pain WHAT HAPPENED WHILE I WAS IN THE HOSPITAL In the emergency room you had an episode where you were unable to speak so you were evaluated by the neurology team Your chest pain was evaluated with EKGs and lab work all of which was reassuring and not indicative of a cardiac cause of your chest pain. Your pain was felt to be most likely related to anxiety You were evaluated by the physical therapists who felt you would benefit from a rehab facility. We agreed so you were discharged to a skilled nursing facility to help you with self care and medication administration WHAT SHOULD I DO WHEN I GO HOME You should continue to take your medications as prescribed. You should attend the appointments listed below. 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. We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be R079, N390, R4701, R531, R51, F419, I2510, I10, E785, E119, G8929, M25562, M25561, Z96653, B961, N400, Z951, Z955, Z993, Z7902. The descriptions of icd codes R079, N390, R4701, R531, R51, F419, I2510, I10, E785, E119, G8929, M25562, M25561, Z96653, B961, N400, Z951, Z955, Z993, Z7902 are R079: Chest pain, unspecified; N390: Urinary tract infection, site not specified; R4701: Aphasia; R531: Weakness; R51: Headache; F419: Anxiety disorder, unspecified; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E119: Type 2 diabetes mellitus without complications; G8929: Other chronic pain; M25562: Pain in left knee; M25561: Pain in right knee; Z96653: Presence of artificial knee joint, bilateral; B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z993: Dependence on wheelchair; Z7902: Long term (current) use of antithrombotics/antiplatelets. The common codes which frequently come are N390, F419, I2510, I10, E785, E119, G8929, N400, Z951, Z955, Z7902. The uncommon codes mentioned in this dataset are R079, R4701, R531, R51, M25562, M25561, Z96653, B961, Z993.
The icd codes present in this text will be I25110, R0789, I252, Z951, E119, I10, E785, Z7984, M170, Z96653. The descriptions of icd codes I25110, R0789, I252, Z951, E119, I10, E785, Z7984, M170, Z96653 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; R0789: Other chest pain; I252: Old myocardial infarction; Z951: Presence of aortocoronary bypass graft; E119: Type 2 diabetes mellitus without complications; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z7984: Long term (current) use of oral hypoglycemic drugs; M170: Bilateral primary osteoarthritis of knee; Z96653: Presence of artificial knee joint, bilateral. The common codes which frequently come are I252, Z951, E119, I10, E785. The uncommon codes mentioned in this dataset are I25110, R0789, Z7984, M170, Z96653. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest Pain Major Surgical or Invasive Procedure Percutaneous Coronary Intervention PCI ___ History of Present Illness ___ y.o. M w h o CAD w anomalous RCA prior NSTEMI w BMS to anomalous RC and CABG w SVG to anomalous ___ ___ DM2 HTN and HLD who presents w worsened chest pain. He states that his chest pain began around 4 pm this afternoon while watching TV and was at its worst in the right side of his chest. It is associated with tingling that spreads down his right arm. He took SLNTG with some relief which improved to discomfort. Patient was last seen in the ED on ___ at that time he underwent stress test which revealed mild fixed defect and hypokinesis of septum c w patient s prior CABG no perfusion defects or other wall motion abnormalities EF 61 CTA chest w o PE. He was subsequently discharged. Since ___ discharge patient has noted more frequent episodes of chest pain he states he never used to take SLNTG but now has been taking SLNTG ___ times day. Symptoms are relieved briefly by SLTNG but recur. Chest pain can occur at rest minimally active often in wheelchair . He describes it as a sensation of chest heaviness tightness with some arm radiation similar to prior MI. Given more frequent SLNTG use and chest pain he presented to ED again today. He denies vomiting diarrhea lightheadedness palpitations fevers cough sore throat abdominal pain bleeding or black stools Past Medical History 1. CARDIAC RISK FACTORS Diabetes Hypertension Dyslipidemia 2. CARDIAC HISTORY CABG ___ PERCUTANEOUS CORONARY INTERVENTIONS ___ BMS to proximal anomalous RCA ___ PACING ICD None 3. OTHER PAST MEDICAL HISTORY Osteoarthritis Constipation Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death. Physical Exam Admission VS 97.9PO ___ GENERAL NAD AAOx3 HEENT AT NC anicteric sclera MMM NECK supple CV RRR S1 S2 no murmurs gallops or rubs PULM CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles GI abdomen soft nondistended nontender in all quadrants no rebound guarding no hepatosplenomegaly EXTREMITIES no cyanosis clubbing or edema PULSES 2 radial pulses bilaterally NEURO Alert moving all 4 extremities with purpose face symmetric DERM warm and well perfused no excoriations or lesions no rashes Discharge Gen in NAD ambulating in halls Neuro alert and oriented x4 no focal deficits or asymmetries. Ambulation is very slow with difficulty standing up due to knee pain. No obvious focal weaknesses. Neck JVP neg JVD neg carotid bruits bilaterally CV RRR S1 S2 no m r g or clicks Chest CTA throughout no wheezes rubs or accessory use ABD soft nt nd with BS throughout no rebound tenderness or guarding and no hepatosplenomegaly Extr peripheral pulses no clubbing cyanosis or edema Skin warm dry and well perfused Access sites RRA with no hematoma or ecchymosis. Pertinent Results Admission Labs ___ 08 00PM BLOOD WBC 5.2 RBC 4.47 Hgb 13.5 Hct 41.4 MCV 93 MCH 30.2 MCHC 32.6 RDW 12.4 RDWSD 42.4 Plt ___ ___ 08 00PM BLOOD Glucose 150 UreaN 10 Creat 0.6 Na 138 K 4.3 Cl 100 HCO3 25 AnGap 13 ___ 08 00PM BLOOD cTropnT 0.01 ___ 01 57AM BLOOD CK MB 2 cTropnT 0.01 ___ 05 56AM BLOOD CK MB 2 cTropnT 0.01 ___ 05 56AM BLOOD Triglyc 69 HDL 35 CHOL HD 2.7 LDLcalc 45 Cath Report ___ Coronary Description The coronary circulation is right dominant. LM The Left Main arising from the left cusp is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD The Left Anterior Descending artery which arises from the LM is a large caliber vessel. There is a 30 stenosis in the proximal segment. There is a 30 stenosis in the proximal and mid segments. The Septal Perforator arising from the proximal segment is a small caliber vessel. The Diagonal arising from the proximal segment is a medium caliber vessel. Cx The Circumflex artery which arises from the LM is a large caliber vessel. The ___ Obtuse Marginal arising from the proximal segment is a medium caliber vessel. There is an 80 stenosis in the mid segments. The ___ Obtuse Marginal arising from the mid segment is a medium caliber vessel. RCA The Right Coronary Artery arising from the mid cusp is a large caliber vessel. There is a 50 in stent restenosis in the mid segment. There is a stent in the mid segment. The Acute Marginal arising from the proximal segment is a small caliber vessel. The Right Posterior Descending Artery arising from the distal segment is a medium caliber vessel. The Right Posterolateral Artery arising from the distal segment is a medium caliber vessel. Bypass Grafts SVG A medium caliber saphenous vein graft connects to the distal segment of the RCA. This graft is patent. Interventional Details Percutaneous Coronary Intervention Percutaneous coronary intervention PCI was performed on an ad hoc basis based on the coronary angiographic findings from the diagnostic portion of this procedure. A 6 ___ AL2 guide provided adequate support. Crossed with the IFR wire into the distal OM1 Predilated with a 2.0 mm balloon and then deployed a 2.5mm x 12mm Onyx DES at 14 atms for 15 seconds. THe stent delivery system was removed. Final angiography revealed excellent results. There was no evidence of perforation distal embolization or dissection and 0 residual stenosis. Complications There were no clinically significant complications. Recommendations ASA 81mg per day Plavix 75mg day . Discharge labs ___ 08 20AM BLOOD WBC 4.0 RBC 4.53 Hgb 13.8 Hct 41.7 MCV 92 MCH 30.5 MCHC 33.1 RDW 12.6 RDWSD 42.5 Plt ___ ___ 08 20AM BLOOD ___ PTT 25.4 ___ ___ 08 35AM BLOOD UreaN 8 Creat 0.7 Na 140 K 4.5 Cl 102 HCO3 22 AnGap 16 ___ 05 56AM BLOOD CK MB 2 cTropnT 0.01 ___ 01 57AM BLOOD CK MB 2 cTropnT 0.01 ___ 05 56AM BLOOD Triglyc 69 HDL 35 CHOL HD 2.7 LDLcalc ___ y.o. M w h o CAD w anomalous RCA prior NSTEMI w BMS to anomalous RC and CABG w SVG to anomalous dRCA ___ DM2 HTN and HLD who presents w worsened chest pain requiring more SLNTG than before concerning for unstable angina. . CAD USA Presents with increased chest pain episodes requiring increasing use of SLNTG. Ruled out. PCI as above with DES to distal OM1. Chest pain overall is better today than yesterday though had a minor fleeting episode during ambulation. Appears to be tolerating isosorbide well with mild headache. Heart rate slightly slower today with increased metoprolol. continue ASA 81 mg daily isosorbide 30 start clopidogrel inc atorvastatin 80 mg QHS inc metoprolol to 75mg Restart lisinopril ___ with Dr. ___ in 1 month PCP ___ deferred as patient is going to rehab. . Type 2 diabetes Fingersticks in the mid ___. On metformin byetta and glipizide as an outpatient glipizide restarted but continue to hold metformin and Byetta. . Severe osteoarthritis of bilateral knee status post replacement in ___ with recent fall and severe pain with ambulation. Continue lidocaine ointment Change APAP to around the clock Start gabapentin 3 times daily ___ recommends continued rehab ___ with previous orthopedist here Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 3. GlipiZIDE 10 mg PO BID 4. Lisinopril 5 mg PO DAILY 5. MetFORMIN Glucophage 1000 mg PO BID 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 10. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 11. Lidocaine 5 Patch 1 PTCH TD QAM 12. Milk of Magnesia 30 mL PO QHS PRN Constipation First Line 13. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain Discharge Medications 1. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 2. Gabapentin 300 mg PO TID 3. Isosorbide Mononitrate Extended Release 30 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Metoprolol Succinate XL 75 mg PO DAILY 6. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 7. Aspirin 81 mg PO DAILY 8. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 9. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 10. GlipiZIDE 10 mg PO BID 11. Lidocaine 5 Patch 1 PTCH TD QAM 12. Lisinopril 5 mg PO DAILY 13. MetFORMIN Glucophage 1000 mg PO BID 14. Milk of Magnesia 30 mL PO QHS PRN Constipation First Line 15. Multivitamins 1 TAB PO DAILY 16. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Coronary Artery Disease Diabetes Hypertension Hyperlipidemia CAD Severe bilateral knee osteoarthritis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You were admitted because of your symptoms of chest pain. You underwent a cardiac catheterization in which a drug coated stent was placed to open a blockage in your Left Cirucmflex OM1 coronary artery. Instructions regarding care of the right wrist access site are included with your discharge information. Please continue your current medications with the following changes Continue Aspirin 81mg daily lifelong. Start Plavix 75mg daily you should take this for a minimum of one year and ONLY stop when told by a cardiologist specifically. Hold Metformin for 48 hours after the procedure. start isosorbide to prevent chest pain start Tylenol and gabapentin to help with your knee pain It is very important to take all of your heart healthy medications. In particular aspirin and clopidogrel Plavix keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. If you stop these medications or miss ___ dose you risk causing a blood clot forming in your heart stents and you may die from a massive heart attack. Please do not stop taking either medication without taking to your heart doctor even if another doctor tells you to stop the medications. It is strongly recommended that you attend a cardiac rehab program in the near future. A referral form was provided to you that lists the locations of these programs. Please bring this with you to your follow up visit with your cardiologist and they will inform you when it is safe to begin a program. If you have any urgent questions that are related to your recovery from your hospitalization or are experiencing any symptoms that are concerning to you and you think you may need to return to the hospital please call the ___ HeartLine 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 Your ___ Cardiac Care Team Followup Instructions ___ The icd codes present in this text will be I25110, R0789, I252, Z951, E119, I10, E785, Z7984, M170, Z96653. The descriptions of icd codes I25110, R0789, I252, Z951, E119, I10, E785, Z7984, M170, Z96653 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; R0789: Other chest pain; I252: Old myocardial infarction; Z951: Presence of aortocoronary bypass graft; E119: Type 2 diabetes mellitus without complications; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z7984: Long term (current) use of oral hypoglycemic drugs; M170: Bilateral primary osteoarthritis of knee; Z96653: Presence of artificial knee joint, bilateral. The common codes which frequently come are I252, Z951, E119, I10, E785. The uncommon codes mentioned in this dataset are I25110, R0789, Z7984, M170, Z96653.
The icd codes present in this text will be I25110, I951, E119, I10, E785, K5900, M170, E7800, Z951, Z955, Z993. The descriptions of icd codes I25110, I951, E119, I10, E785, K5900, M170, E7800, Z951, Z955, Z993 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; I951: Orthostatic hypotension; E119: Type 2 diabetes mellitus without complications; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; K5900: Constipation, unspecified; M170: Bilateral primary osteoarthritis of knee; E7800: Pure hypercholesterolemia, unspecified; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z993: Dependence on wheelchair. The common codes which frequently come are E119, I10, E785, K5900, Z951, Z955. The uncommon codes mentioned in this dataset are I25110, I951, M170, E7800, Z993. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest Pain Major Surgical or Invasive Procedure ___ Cardiac Cath History of Present Illness ___ y.o. male w h o CAD w anomalous RCA prior NSTEMI w BMS to anomalous RC and CABG w SVG to anomalous dRCA ___ and s p PCI ___ with DES to distal OM1 on ASA and plavix DM2 HTN and HLD presenting with chest pain. He says he has been having chest pain intermittently since discharge that he describes as sharp stabbing pains. He has been taking SL nitro which improved his pain except for today. This morning the patient developed substernal CP at rest that lasted 10 secs. At 4 ___ he developed L sided chest pressure ___ at rest that was non radiating and worsened with talking and got better with resting. The pain was also associated with lightheadness and he said it felt like pressure squeezing. He tried NTG x3 and full dose ASA with slight improvement. Denies nausea vomiting diaphoresis abdominal pain SOB. Initial reports from EMS was that the patient had ST depressions on EKG. He was discharged to rehab ___ after undergoing PCI. He saw his cardiologist on ___ as an outpatient at which point he reported frequent presyncopal episodes with standing and reported that his blood pressure has been low. His lisinopril was stopped by the rehab but his symptoms continued. Dr. ___ his metoprolol and Imdur dosing. In the ED... Initial vitals 96.9F BP 120 80 RR 16 100 on RA EKG Slight horizontal flattening of inferior leads otherwise not significantly changed from prior Labs studies notable for Trop neg x1 Patient was given SL nitro x2 Vitals on transfer HR 81 BP 98 59 RR 25 95 on RA On the floor he reports that his chest pain improved from ___ to ___ since receiving 2 SL nitro in the ED. He said the pain never went away completely. He received a ___ SL nitro during the interview with ultimate resolution of chest pain. He reports that he was feeling lightheaded at his rehab when getting up to be washed and reports that his SBP was as low as 74 during these episodes. He says that once his Imdur and metoprolol doses were reduced he noticed improvement in those symptoms. Past Medical History 1. CARDIAC RISK FACTORS Diabetes Hypertension Dyslipidemia 2. CARDIAC HISTORY CABG ___ PERCUTANEOUS CORONARY INTERVENTIONS ___ BMS to proximal anomalous RCA ___ PACING ICD None 3. OTHER PAST MEDICAL HISTORY Osteoarthritis Constipation Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death. Physical Exam ADMISSION PHYSICAL EXAMINATION VS 97.4F 122 78 HR 81 RR 18 96 on RA GENERAL Sitting on the edge of the bed in no acute distress HEENT AT NC anicteric sclera MMM NECK supple no LAD CV RRR S1 S2 no murmurs gallops or rubs CHEST pain not reproducible to palpation PULM CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles GI abdomen soft nondistended nontender in all quadrants no rebound guarding no hepatosplenomegaly EXTREMITIES no cyanosis clubbing or edema PULSES 2 radial pulses bilaterally NEURO Alert moving all 4 extremities with purpose face symmetric DISCHARGE PHYSICAL EXAM VS 24 HR Data last updated ___ 828 Temp 98.6 Tm 98.7 BP 106 62 103 128 62 80 HR 84 79 94 RR 17 ___ O2 sat 96 94 100 GENERAL Sitting on the edge of the bed in some pain. HEENT AT NC anicteric sclera MMM NECK supple no LAD CV NR RR. Nl S1 S2. No m r g. CHEST Pain not reproducible to palpation PULM CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles GI abdomen soft nondistended nontender in all quadrants no rebound guarding no hepatosplenomegaly EXTREMITIES no cyanosis clubbing or edema PULSES 2 radial pulses bilaterally NEURO Alert moving all 4 extremities with purpose face symmetric Pertinent Results ADMISSION PERTINENT LABS ___ 06 43PM BLOOD WBC 5.0 RBC 4.38 Hgb 13.4 Hct 40.5 MCV 93 MCH 30.6 MCHC 33.1 RDW 12.8 RDWSD 43.8 Plt ___ ___ 06 35AM BLOOD WBC 3.9 RBC 4.28 Hgb 12.9 Hct 39.7 MCV 93 MCH 30.1 MCHC 32.5 RDW 13.0 RDWSD 44.2 Plt ___ ___ 06 43PM BLOOD Neuts 56.3 ___ Monos 8.5 Eos 3.0 Baso 0.6 Im ___ AbsNeut 2.83 AbsLymp 1.57 AbsMono 0.43 AbsEos 0.15 AbsBaso 0.03 ___ 06 43PM BLOOD ___ PTT 26.8 ___ ___ 06 35AM BLOOD Glucose 173 UreaN 14 Creat 0.7 Na 140 K 4.4 Cl 103 HCO3 25 AnGap 12 ___ 06 43PM BLOOD cTropnT 0.01 ___ 12 58AM BLOOD CK MB 2 cTropnT 0.01 ___ 08 31AM BLOOD CK MB 2 cTropnT 0.01 ___ 06 35AM BLOOD Calcium 9.3 Phos 4.0 Mg 2.0 STUDIES Cath ___ LM The left main coronary artery had mild plaquing. LAD The left anterior descending coronary artery had an ostial 30 stenosis. The mid LAD had a slightly hazy 30 stenosis unchanged from prior angiogram. The distal LAD wrapped well around the apex. Flow in the LAD was delayed and pulsatile consistent with microvascular dysfunction. Circ The circumflex coronary artery had a near ostial 20 plaque. The retroflexed OM1 had an origin 40 stenosis. The mid OM1 was angulated with some dynamic bending during systole. The angulated OM2 had mild proximal plaquing. The AV groove CX was retroflexed after OM2 with mild plaquing before supplying 2 LPLs. Flow in OMs and LPLs was delayed consistent with microvascular dysfunction. RCA The right coronary artery arose anomalously adjacent to the LMCA and had mild luminal irregularities. The proximal stent had mild in stent restenosis. There was competitive flow in the mid RCA from the SVG. SVG RCA The saphenous vein graft to the distal RCA had luminal irregularities. There was antegrade perfusion into the RPDA and retrograde perfusion into the native mid RCA. Complications There were no clinically significant complications. Findings 1. Stable native coronary atherosclerosis with patent recent OM1 stent and mild restenosis of the prior stent in the anomalous RCA arising adjacent to the LMCA. 2. Patent SVG distal RCA. 3. Diffuse slow pulsatile flow consistent with microvascular dysfunction. Brief Hospital Course Mr. ___ is a ___ year old man w h o CAD w anomalous RCA prior NSTEMI w BMS to anomalous RC and CABG w SVG to anomalous dRCA ___ and s p PCI ___ with DES to distal OM1 on ASA and plavix DM2 HTN and HLD presenting with chest pain. CORONARIES Patent SVG distal RCA patent recent OM1 stent and mild restenosis of prior stent in anomalous RCA arising adjacent to LMCA diffuse slow pulsatile flow consistent with microvascular dysfunction PUMP EF 55 RHYTHM NSR ACTIVE ISSUES Unstable Angina CAD H o DES to OM1 last month with remainder of vessels relatively patent. Had decreased Imdur and Metoprolol I s o presyncope at last visit with Dr. ___. Presented with multiple intermittent episodes of CP initially atypical and mostly stabbing then progressive to more of a pressure sensation which responded to NTG. Trops negative x3. EKGs unchanged. Started on NTG drip due to persistent pain. Underwent cath via RRA with no evidence of new progressive disease and all grafts and vessels similarly patent to prior study in ___. Increased imdur to 30mg. Continued on ASA Plavix Metoprolol Atorvastatin. Pre syncope Reports several episodes at rehab of orthostasis and pre syncope and reports low systolic blood pressures. His lisinopril was discontinued but symptoms persisted. Imdur and metroprolol doses were reduced at recent outpatient cardiology visit as above and since then symptoms have resolved. Orthostatics here negative. Increased imdur without recurrence in symptoms. CHRONIC ISSUES Type 2 diabetes On lantus metformin byetta and glipizide as an outpatient. A1c 10.1 in ___ and since then has been started on insulin. Continued on Lantus and ISS. Severe osteoarthritis of bilateral knee status post replacement Wheelchair bound. Continued lidocaine patches APAP tramadol gabapentin. TRANSITIONAL ISSUES Increased Imdur due to persistent CP though most likely small vessel I s o no intervenable lesions on cath. Monitor for presyncope syncopal symptoms. ___ likely continue with some CP can take SL nitroglycerin for pain that lasts more than a few seconds. If pain persists despite SL nitro should come to ED for evaluation. Patient brought up desire for surgery for OA of knees. Discussed that orthopedics can communicate with Dr. ___ ___ regarding ___ risk evaluation. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 5. GlipiZIDE 10 mg PO BID 6. Lidocaine 5 Patch 1 PTCH TD QAM 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 9. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 10. Isosorbide Mononitrate Extended Release 15 mg PO DAILY 11. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 12. MetFORMIN Glucophage 1000 mg PO BID 13. Milk of Magnesia 30 mL PO QHS PRN Constipation First Line 14. Multivitamins 1 TAB PO DAILY 15. Gabapentin 300 mg PO TID 16. melatonin 3 mg oral QHS 17. Glargine 18 Units Bedtime 18. TraMADol 75 mg PO Q6H PRN Pain Moderate 19. Senna 17.2 mg PO DAILY Discharge Medications 1. Glargine 18 Units Bedtime 2. Isosorbide Mononitrate Extended Release 30 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Bisacodyl 10 mg PR QHS PRN Constipation Second Line 7. Byetta exenatide 10 mcg dose 250 mcg mL 2.4 mL subcutaneous BID 8. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis 9. Gabapentin 300 mg PO TID 10. GlipiZIDE 10 mg PO BID 11. Lidocaine 5 Patch 1 PTCH TD QAM 12. melatonin 3 mg oral QHS 13. MetFORMIN Glucophage 1000 mg PO BID 14. Metoprolol Succinate XL 25 mg PO DAILY 15. Milk of Magnesia 30 mL PO QHS PRN Constipation First Line 16. Multivitamins 1 TAB PO DAILY 17. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 18. Senna 17.2 mg PO DAILY 19. TraMADol 75 mg PO Q6H PRN Pain Moderate RX tramadol 50 mg 1.5 tablet s by mouth every six 6 hours Disp 30 Tablet Refills 0 Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Unstable Angina 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 Mr. ___ It was a pleasure taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL You were admitted to the hospital because you were having chest pain. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL We gave you medicine to treat your chest pain. We did a cardiac catheterization to look at the stents and the blood vessels in your heart which showed no new disease. We changed your medications to try and reduce the frequency of your chest pain. WHAT SHOULD I DO WHEN I GO HOME You should continue to take your medications as prescribed. You should attend the appointments listed below. We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I25110, I951, E119, I10, E785, K5900, M170, E7800, Z951, Z955, Z993. The descriptions of icd codes I25110, I951, E119, I10, E785, K5900, M170, E7800, Z951, Z955, Z993 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; I951: Orthostatic hypotension; E119: Type 2 diabetes mellitus without complications; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; K5900: Constipation, unspecified; M170: Bilateral primary osteoarthritis of knee; E7800: Pure hypercholesterolemia, unspecified; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z993: Dependence on wheelchair. The common codes which frequently come are E119, I10, E785, K5900, Z951, Z955. The uncommon codes mentioned in this dataset are I25110, I951, M170, E7800, Z993.
The icd codes present in this text will be G7001, Z9114, M8580, R7303, E559. The descriptions of icd codes G7001, Z9114, M8580, R7303, E559 are G7001: Myasthenia gravis with (acute) exacerbation; Z9114: Patient's other noncompliance with medication regimen; M8580: Other specified disorders of bone density and structure, unspecified site; R7303: Prediabetes; E559: Vitamin D deficiency, unspecified. The uncommon codes mentioned in this dataset are G7001, Z9114, M8580, R7303, E559. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Fatigue decreased voice globus sensation drooling diplopia Myasthenia ___ Flare Major Surgical or Invasive Procedure None History of Present Illness The patient is a ___ woman with medical history of MuSK positive myasthenia ___ with predominantly bulbar symptoms MGFA classification II B followed in neurology clinic by Dr. ___ presents to the ED for evaluation of worsening bulbar symptoms in the setting of a cold and medication noncompliance. She reports was in her usual state of health which includes independence in all activities of daily living until ___. Of note she stopped taking her prednisone around ___ for the space of 2 weeks and felt well so she discontinued the use of her azathioprine last filled in ___ as well . She then developed an upper respiratory tract infection in ___ and has not been feeling like herself. Subsequently she has been complaining of progressive fatigue which is especially worse at the end of the day or when climbing up stairs. She has also noted her voice has a different quality as she is somewhat hypophonic and describes that her tongue is very slow. She has to repeat what she wants to say several times as people have trouble comprehending her. Additionally she has been complaining of upper back pain like she is carrying camping bag. She reports a sensation like something is caught in her throat however denies choking. She does complain that her throat is dry but has persistent drooling. She is concerned that the sweating palms have returned. Her eyes are also tearing excessively which is unusual for her and 2 days ago she developed horizontal diplopia which resolves when covering either eye. She denies any breathing difficulties nausea vomiting or diarrhea but reports poor appetite which has been a problem in the past. She initially presented in ___ with acute respiratory failure requiring intubation and was found to have Musk antibody positive myasthenia ___ with predominantly bulbar features. Her initial symptoms were fluctuating diplopia left eyelid ptosis dysphagia dysarthria lightheadedness and generalized weakness. She was treated with 5 days of plasma exchange and subsequently prednisone. She had also been prescribed a BiPAP machine upon discharge for overnight respiratory support. She has been managed in neurology clinic by Dr. ___ has slowly tapered her prednisone from 5060 mg p.o. daily down to 5 mg p.o. daily and continued her on azathioprine 50 mg every morning and 100 mg every afternoon. Neurologic review of systems notable for the above mentioned symptoms otherwise unremarkable. On general review of systems the patient reports recent upper respiratory tract infection. Otherwise denies fevers rigors night sweats or noticeable weight loss. Denies chest pain palpitations dyspnea or cough. Denies nausea vomiting diarrhea constipation or abdominal pain. No recent change in bowel or bladder habits. Denies dysuria or hematuria. Denies myalgias arthralgias or rash. ALLERGIES Allergies Last Verified ___ by ___ Patient recorded as having no known allergies to drugs Past Medical History PMH PSH Problems Last Verified ___ by ___ MD MYASTHENIA ___ OSTEOPENIA PREDIABETES VITAMIN D DEFICIENCY HEADACHE Social History ___ Family History FAMILY HISTORY Reports no family history of neurologic conditions Physical Exam ADMISSION EXAMINATION Vitals 98.0 81 128 67 16 100 RA NIF 60 FVC 2.5L General NAD HEENT NCAT LT proptosis without scleral irritation no oropharyngeal lesions ___ RRR no M R G Pulmonary CTAB no crackles or wheezes Abdomen Soft NT ND BS no guarding Extremities Warm no edema Neurologic Examination MS Awake alert oriented x 3. Able to relate history without difficulty. Attentive. Speech is fluent with full sentences but mildly hypophonic. Normal prosody. No evidence of hemineglect. No left right confusion. Able to follow both midline and appendicular commands. Cranial Nerves PERRL 4 2 brisk. VF full to confrontation. EOMI but notable for saccadic pursuit. Horizontal diplopia worse on LT gaze. Outer image disappears when covering her right eye. V1 V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM Trapezius strength ___ bilaterally. Tongue midline. There is mild upgaze fatigability with frontalis activation left greater than right orbicularis oculi weakness on forced eye closure full strength in her orbicularis oris jaw and tongue. Does exhibit some weakness when trying to keep her cheeks puffed. Neck flexion and extension full strength. Motor Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 4 5 5 5 5 5 R 5 ___ ___ 4 5 5 5 5 5 Sensory No deficits to light touch bilaterally. No extinction to DSS. DTRs Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. Coordination No dysmetria with finger to nose testing bilaterally. Good speed and intact cadence with rapid alternating movements. Gait Normal initiation. Narrow base. Normal stride length and arm swing. Stable without sway. Negative Romberg. DISCHARGE EXAMINATION Vitals T 98.6 BP 111 75 HR 71 RR 16 spO2 100 RA General thin ___ female appears well in no acute distress HEENT NCAT LT proptosis without scleral irritation no oropharyngeal lesions mild soft tissue swelling in anterior neck on left no LAD ___ RRR no M R G Pulmonary CTAB no crackles or wheezes breathing comfortably without use of accessory respiratory muscles counts to 30 in one breath Abdomen soft NT ND BS no guarding Extremities warm no edema Neurologic Examination MS Awake alert oriented x 3. Able to relate history without difficulty. Attentive. Speech is fluent with full sentences but mildly hypophonic. Normal prosody. Able to follow both midline and appendicular commands. Cranial Nerves PERRL 6 4 brisk. VF full to confrontation. EOMI but notable for saccadic pursuit. There is subtle hyper and exotropia on the left and exotropia on the right on cover uncover tests. Lower lid retraction bilaterally. No reported diplopia on resting gaze and left gaze. Horizontal diplopia on far right gaze with outside image disappearing with covering right eye. Upgaze intact with fatigability after 10 seconds. Mild bifacial weakness left slightly greater than right with decreased forehead wrinkling and orbicularis oris strength orbicularis oculi is ___ bilaterally. Hearing intact to finger rub bilaterally. Palate elevation symmetric. SCM Trapezius strength ___ bilaterally. Tongue midline. Motor Normal bulk and tone. No drift. No tremor or asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 Neck flexion and extension ___. There is fatigability to 4 on the right deltoid. Sensory No deficits to light touch bilaterally. No extinction to DSS. DTRs Bi Tri ___ Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. Coordination No dysmetria with finger to nose testing bilaterally. Gait Good initiation narrow based gait with normal arm swing. Can ascend 2 flights of stairs with minimal dyspnea. Pertinent Results IMAGING Noncontrast head CT with look at the orbits with No acute intracranial process. CXR without acute intrathoracic process ___ 07 10AM BLOOD WBC 4.9 RBC 3.89 Hgb 11.5 Hct 35.5 MCV 91 MCH 29.6 MCHC 32.4 RDW 12.4 RDWSD 41.1 Plt ___ ___ 07 00PM BLOOD WBC 4.7 RBC 4.29 Hgb 12.7 Hct 39.6 MCV 92 MCH 29.6 MCHC 32.1 RDW 12.7 RDWSD 42.7 Plt ___ ___ 07 10AM BLOOD Glucose 93 UreaN 13 Creat 0.7 Na 140 K 4.1 Cl 100 HCO3 23 AnGap 17 ___ 07 00PM BLOOD Glucose 89 UreaN 15 Creat 0.6 Na 140 K 4.9 Cl 100 HCO3 26 AnGap 14 ___ 07 00PM BLOOD ALT 11 AST 21 AlkPhos 68 TotBili 0.2 ___ 07 00PM BLOOD Lipase 19 ___ 07 00PM BLOOD TSH 2.2 ___ 07 00PM BLOOD T4 7.8 ___ 07 00PM BLOOD antiTPO LESS THAN Brief Hospital Course The patient is a ___ year old woman with history of MUSK ab positive myasthenia ___ who presents with a few weeks of fatigue blurred vision and hypophonia in the setting of a recent respiratory viral illness and after self tapering her antimyasthenic medications several months ago. Her respiratory status was stable and inspiratory force vital capacity in the normal ranges. She had mild anterior neck swelling that was Her neurologic examination was notable for bilateral proptosis diplopia in horizontal endgaze and upgaze mild bifacial weakness and full motor power in skeletal muscles including neck flexors extensors though with mild fatigability. An active infection was excluded with negative CXR and UA. She was started on prednisone 10mg daily and azathioprine 50mg BID and mestinon 30 mg TID. Her fatigue and neurologic examination improved with these interventions and her respiratory status remained stable with consistent ability to count to 30 in one breath and daily respiratory mechanics Nif 60 and VC 2.75. For neck swelling TSH was negative anti TPO antibodies were also negative she will be ordered for outpatient thyroid ultrasound. Given her good social supports with family to monitor her she was deemed safe to discharge with follow up in the ___ clinic with her provider ___. Transitional issues Consider uptitrating her prednisone to 20mg this week patient will contact Dr. ___ to discuss this. Follow up with Dr. ___ on ___. Follow up thyroid ultrasound to be performed outpatient. Medications on Admission MEDICATIONS See the prescribed medication list below however she reports has not been taking any medications since ___ ___. As per pharmacy records she last filled her as a therapy and prednisone in ___. Active Medication list as of ___ Medications Prescription AZATHIOPRINE azathioprine 50 mg tablet. 1 tablet s by mouth twice daily ERGOCALCIFEROL VITAMIN D2 ergocalciferol vitamin D2 50 000 unit capsule. 1 One capsule s by mouth weekly for 12 weeks FOLIC ACID folic acid 1 mg tablet. 1 tablet s by mouth once a day Medications OTC ACETAMINOPHEN TYLENOL Dosage uncertain OTC as needed CALCIUM CITRATE VITAMIN D3 calcium citrate vitamin D3 315 mg 250 unit tablet. 2 Two tablet s by mouth once a day CHOLECALCIFEROL VITAMIN D3 cholecalciferol vitamin D3 2 000 unit capsule. 2 Two capsule s by mouth once a day TOLNAFTATE TINACTIN Tinactin 1 topical spray. Apply to affected areas twice a day Discharge Medications 1. AzaTHIOprine 50 mg PO BID RX azathioprine 50 mg 1 tablet s by mouth twice daily Disp 60 Tablet Refills 1 2. PredniSONE 10 mg PO DAILY RX prednisone 10 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 1 3. Pyridostigmine Bromide 30 mg PO TID RX pyridostigmine bromide Mestinon 60 mg 5 mL 2.5 mL by mouth three times daily Refills 1 4. Vitamin D 1000 UNIT PO DAILY Discharge Disposition Home Discharge Diagnosis MUSK myasthenia ___ flare Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were admitted because of recent fatigue blurred vision and voice changes which we felt was likely symptoms of a myasthenia flare which probably resulted from a recent viral infection. Because this is now your second presentation of myasthenia we restarted you on your medications including Azathioprine at 50mg twice daily and prednisone at a low dose of 10mg daily. You will need to remain on these medications for a prolonged length of time in order to prevent another myasthenia flare. For symptomatic relief we also started on you a medication called Mestinon pyridostigmine at a dose of 30mg which you may take three times a day. Fortunately you responded well to the above treatments. Your respiratory status was monitored and you showed no sign of any weakness in your breathing muscles. Your neurologic examination was also improved. Therefore we will discharge you home as long as you remain well monitored by your family members and come back to the Emergency Department for any signs of worsening or development of difficulty breathing. You should call Dr. ___ and keep your follow up appointment with her on ___ in order to address next steps. It was a pleasure taking care of you. We wish you the best Sincerely Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be G7001, Z9114, M8580, R7303, E559. The descriptions of icd codes G7001, Z9114, M8580, R7303, E559 are G7001: Myasthenia gravis with (acute) exacerbation; Z9114: Patient's other noncompliance with medication regimen; M8580: Other specified disorders of bone density and structure, unspecified site; R7303: Prediabetes; E559: Vitamin D deficiency, unspecified. The uncommon codes mentioned in this dataset are G7001, Z9114, M8580, R7303, E559.
The icd codes present in this text will be G7000, E663, Z6829, E559. The descriptions of icd codes G7000, E663, Z6829, E559 are G7000: Myasthenia gravis without (acute) exacerbation; E663: Overweight; Z6829: Body mass index [BMI] 29.0-29.9, adult; E559: Vitamin D deficiency, unspecified. The uncommon codes mentioned in this dataset are G7000, E663, Z6829, E559. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Myasthenia ___ subacute worsening Major Surgical or Invasive Procedure tunneled plasmapheresis catheter Brief Hospital Course Ms. ___ is a ___ y o female w myasthenia ___ MUSK who presented to the ED for b l leg pain. Pain improved w analgesics. She has also had subacute worsening of her myasthenic symptoms. Exam only significant for diplopia on L lateral gaze. No respiratory signs symptoms. It was decided to have her admitted. Case was discussed w Dr. ___ neurologist who felt that pt needs pheresis catheter placed for recurrent outpt plasmapheresis. It was arranged for ___ to place pheresis catheter. After catheter placement pt reported chest pain at site of line placement. Likely pleuritic pain CXR negative. Pain improved by AM. Discharged in stable condition to continue outpt care. She will undergo plasmapheresis as outpt starting ___ and f up w Dr. ___ in clinic. Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Myasthenia ___ subacute worsening Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Ms. ___ You were diagnosed with a worsening of your myasthenia ___ that will require plasmapheresis. For this you had a plasmapheresis catheter placed. You will receive plasma exchange on ___ and ___. You should also follow up with Dr. ___ in clinic. Followup Instructions ___ The icd codes present in this text will be G7000, E663, Z6829, E559. The descriptions of icd codes G7000, E663, Z6829, E559 are G7000: Myasthenia gravis without (acute) exacerbation; E663: Overweight; Z6829: Body mass index [BMI] 29.0-29.9, adult; E559: Vitamin D deficiency, unspecified. The uncommon codes mentioned in this dataset are G7000, E663, Z6829, E559.
The icd codes present in this text will be S12600A, G9340, T83511A, N390, J90, J9811, W19XXXA, Y92129, R296, Z9181, S42109D, S2231XD, Z8673, Z87440, F419, I951, R1310, R0902, M810, I10, R41841, F0390, B952, Y846, Y92230, R339, K5900, E8770. The descriptions of icd codes S12600A, G9340, T83511A, N390, J90, J9811, W19XXXA, Y92129, R296, Z9181, S42109D, S2231XD, Z8673, Z87440, F419, I951, R1310, R0902, M810, I10, R41841, F0390, B952, Y846, Y92230, R339, K5900, E8770 are S12600A: Unspecified displaced fracture of seventh cervical vertebra, initial encounter for closed fracture; G9340: Encephalopathy, unspecified; T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter; N390: Urinary tract infection, site not specified; J90: Pleural effusion, not elsewhere classified; J9811: Atelectasis; W19XXXA: Unspecified fall, initial encounter; Y92129: Unspecified place in nursing home as the place of occurrence of the external cause; R296: Repeated falls; Z9181: History of falling; S42109D: Fracture of unspecified part of scapula, unspecified shoulder, subsequent encounter for fracture with routine healing; S2231XD: Fracture of one rib, right side, subsequent encounter for fracture with routine healing; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Z87440: Personal history of urinary (tract) infections; F419: Anxiety disorder, unspecified; I951: Orthostatic hypotension; R1310: Dysphagia, unspecified; R0902: Hypoxemia; M810: Age-related osteoporosis without current pathological fracture; I10: Essential (primary) hypertension; R41841: Cognitive communication deficit; F0390: Unspecified dementia without behavioral disturbance; B952: Enterococcus as the cause of diseases classified elsewhere; 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; Y92230: Patient room in hospital as the place of occurrence of the external cause; R339: Retention of urine, unspecified; K5900: Constipation, unspecified; E8770: Fluid overload, unspecified. The common codes which frequently come are N390, Z8673, F419, I10, Y92230, K5900. The uncommon codes mentioned in this dataset are S12600A, G9340, T83511A, J90, J9811, W19XXXA, Y92129, R296, Z9181, S42109D, S2231XD, Z87440, I951, R1310, R0902, M810, R41841, F0390, B952, Y846, R339, E8770. Allergies Celebrex codeine Sulfa Sulfonamide Antibiotics Chief Complaint unwitnessed fall with headstrike Major Surgical or Invasive Procedure None History of Present Illness In brief this is a ___ year old woman with a history of R thalamic stroke recent scapula and R 2nd rib fx h o syncope and orthostatic hypotension who initially presented s p unwitnessed fall at ___. She was brought to ___ ED on ___ early morning. Vitals 145 78 68 22 96.4 90 RA 96 2L O2. Troponin T 0.01. CT head negative for bleed. CT C spine with minimally displaced fracture of C7 facet and transverse process. There was no neurosurgeon on call so she was transferred to ___ on ___ for neurosurgery evaluation. At ___ Neurosurgery evaluated and recommend conservative management with outpatient follow up and imaging in 1 month. She was admitted to ___ service for monitoring. Overnight ___ she triggered for tachypnea to 32 34 and increasing hypoxia with new 4L O2 requirement. She was also noted to be febrile to Tmax 101.0. CXR re demonstrated L pleural effusion seen on OSH film. Given her new O2 requirement and isolated fever the patient was transferred to medicine for further management. On arrival to the floor the patient states that she feels very tired but does not have any specific complaints. Does not think she has had fevers and chills. Does not report chest pain shortness of breath nausea vomiting abdominal pain and changes in bowel or bladder habits. For complete medication past medical social and family histories please see the admission note. ROS Full 10 point ROS otherwise negative except as described above Past Medical History PMH Falls thalamic stroke dysphagia cognitive communication deficit anxiety osteoporosis scapular fracture compression fractures 2nd rib fracture constipation hypertension UTIs bronchitis left pleural effusion PSH THR Social History ___ Family History Unable to obtain given poor historian Physical Exam Admission Physical Exam Vitals T 95.5 HR 57 BP 132 55 RR 22 SatO2 98 2L NC General NAD Alert oriented to person and place Neck no signs of trauma to the head C collar in place No tenderness to palpation of the spine from cervical to sacral Lungs CTA bil Chest No tenderness to palpation of the chest Abdomen soft non tender non distended Pelvis stable Motor and sensory intact in 4 extremities no deformity No edema Discharge Physical Exam Vitals 99.1 HR 71 BP 136 77 RR 18 93 2L Gen sitting up in chair c collar in place awake and alert HEENT EOMI MMM oropharynx clear Neck Aspen C collar in place PULM CTAB in anterior lung fields no wheezes rales or rhonchi CV RRR nl S1 S2 no m r g t Abd softly distended minimally periumbilical tenderness no rebound or guarding Ext no clubbing or cyanosis warm and well perfused Neuro difficult neuro exam due to mental status pt able to lift right leg with strength ___ left leg ___. Good dorsiflexion and plantarflexion. Good hand grips bilaterally. Follows simple commands squeeze fingers lift arms legs Mental Status inattentive lethargic generally hypoactive Pertinent Results ADMISSION LABS ___ GLUCOSE 88 UREA N 21 CREAT 0.8 SODIUM 140 POTASSIUM 4.2 CHLORIDE 101 TOTAL CO2 27 ANION GAP 12 CALCIUM 8.3 PHOSPHATE 3.4 MAGNESIUM 1.9 WBC 9.3 HGB 12.3 HCT 38.3 MCV 95 PLT COUNT 155 ___ PTT 22.6 ___ ProBNP 362 SIGNIFICANT LABS OSH troponin 0.01 DISCHARGE LABS ___ 05 20AM BLOOD WBC 8.7 RBC 3.73 Hgb 11.4 Hct 34.8 MCV 93 MCH 30.6 MCHC 32.8 RDW 13.9 RDWSD 47.4 Plt ___ ___ 05 20AM BLOOD Glucose 84 UreaN 18 Creat 0.8 Na 142 K 4.1 Cl 104 HCO3 30 AnGap 8 ___ 05 20AM BLOOD Calcium 8.6 Phos 3.6 Mg 1.8 IMAGING ___ OSH CT Head No intracranial injury ___ OSH CR Chest Minimally displaced fracture of R C7 facet and right transverse process. Fracture extends through the transverse foramen and could be associated with vertebral artery injury ___ CXR No definite focal consolidation. Improved pulmonary vascular congestion. Probable small left pleural effusion. ___ CXR Lungs are low volume with bibasilar atelectasis. Cardiomediastinal silhouette is stable. Small left small bilateral pleural effusions are unchanged. No pneumothorax is seen MICROBIOLOGY ___ URINE Color Yellow Appear Clear Sp ___ Blood NEG Nitrite NEG Protein NEG Glucose NEG Ketone NEG Bilirub NEG Urobiln NEG pH 6.0 Leuks NEG ___ URINE Color Yellow Appear Clear Sp ___ Blood NEG Nitrite NEG Protein TR Glucose NEG Ketone NEG Bilirub NEG Urobiln NEG pH 6.0 Leuks MOD RBC 7 WBC 28 Bacteri FEW Yeast NONE Epi 1 ___ 12 06 am URINE Source Catheter. FINAL REPORT ___ URINE CULTURE Final ___ ENTEROCOCCUS SP 10 000 100 000 CFU mL. AMPICILLIN 2 S NITROFURANTOIN 16 S TETRACYCLINE 1 S VANCOMYCIN 1 S Brief Hospital Course SUMMARY ___ with history of right thalamic stroke recent scapula and R 2nd rib fx h o syncope and orthostatic hypotension presents s p unwitnessed fall at ___. Course complicated by hypoxia and hypoactive delirium. ACTIVE ISSUES Fall unwitnessed Minimally displaced fracture of C7 facet and transverse process Arrived to ___ ED on ___ s p unwitnessed fall head strike. Vitals notable for new 2L O2 requirement. Troponin T 0.01. EKG with sinus bradycardia 57. CT head negative for bleed. CT C spine with minimally displaced fracture of C7 facet and transverse process. Transferred to ___ for neurosurgery evaluation. Recommended conservative management c collar with outpatient follow up and imaging in 1 month. Pt s daughter reports pt has frequent dizzy spells at ___. Given bradycardia on admission home metoprolol 100mg once daily was decreased to 50mg once daily. Hypoxia Left pleural effusion Aspiration risk Triggered overnight ___ for hypoxia 4L O2 requirement associated with low grade fever and mild leukocytosis. CXR notable for a left small to moderate pleural effusion of unknown chronicity. Fevers and leukocytosis resolved within 24 hours. She was on room air 1L O2 during the day and ___ at bedtime. Her acute episode was attributed to an aspiration event and we did not think that the small pleural effusion was contributing significantly to her hypoxia or mental status. Speech and swallow recommended ground nectar thickened food meds whole in puree and 1 1 supervision with feeds. Plan for surveillance CXR at rehab next week. Hypoactive delirium Pt alert and oriented x1 throughout the admission. She was inattentive emotionally labile crying spells and would fall asleep during conversations. Etiology multifactorial underlying cognitive impairment hospitalization fracture pain c collar hypoxia constipation and a likely urinary tract infection. Pain was addressed the Acetaminophen and lidocaine patches. She required suppositories and an enema to relieve her constipation. Lines and tubes were limited. Deliriogenic medications held e.g. home benzodiazepine . She was treated for a CAUTI see below . Mental status slowly improving. Catheter associated urinary tract infection ampicillin sensitive enterococcus Urinary retention Prior to admission the patient was treated for a UTI with ciprofloxacin. Admission UA unremarkable w negative culture. s p catheter placement ___. Pancultured on ___ for fever and repeat UA showed moderate leuks trace protein 28 WBC hpf and few bacteria with no squamous cells. Culture grew enterococcus 10 000 100 000 CFU. Given the delirium low grade fever and mild leukocytosis and recent catheterization the patient was treated for a catheter associated UTI. Pending sensitivities she received vancomycin ___ and was transitioned to amoxicillin on ___ for completion of a uring this time the patient was intermittently retaining urine and requiring straight caths thought to be secondary to trauma from the foley in addition to constipation. This resolved by discharge. Pt is incontinent at baseline. Constipation resolved with aggressive bowel regimen. Likely contributed to delirium and urinary retention. CHRONIC ISSUES Hypertension HCTZ held during hospitalization Scapula and R 2nd rib fx recent pain management with acetaminophen and lidocaine patch. Home tramadol was held due to concern altered mental status History of right thalamic stroke continued home aspirin 325mg consider decreasing to 81mg if indicated Anxiety intermittent episodes of acute anxiety. However given delirium home clonazapam was held. Per ___ records she had not received it in 5 days therefore there was no concern for withdrawal. TRANSITIONAL ISSUES Code status Full presumed Contact Daughter ___ ___ Fall unwitnessed Metoprolol succinate decreased from 100mg to 50mg assess heart rates and whether this has helped with episodes of dizziness Hypoxia 1L intermittent O2 requirement at discharge Please obtain surveillance chest x ray PA and lateral after completion of antibiotics ___ to determine interval change of left pleural effusion. Modified diet see below to help prevent aspiration Hypoactive delirium Continue to reorient avoid delirogenic medications and monitor for infections. If new focal neurologic findings are discovered none at discharge could consider head CT CAUTI Amoxicillin 500mg PO TID final day ___ Hypertension Restart HCTZ if medically indicated History of stroke Consider decreasing home ASA 325mg to ASA 81mg if indicated Anxiety Would consider discontinuing all BZDs especially given risk of delirium and frequent falls Medications on Admission acetaminophen 325 mg every ___ hrs Acidophilus BID Aspirin 325 mg daily Atorvastatin 40 mg daily Diazepam 5 mg BID Docusate sodium 100 mg BID Allergy Relief fluticasone 50 mcg actuation nasal Hydrochlorothiazide 25 mg daily Melatonin 3 mg daily Toprol XL 100 mg daily Tramadol 50 mg every ___ hours Discharge Medications 1. Amoxicillin 500 mg PO TID Duration 5 Days 2. Bisacodyl AILY PRN constipation 3. Lidocaine 5 Patch 1 PTCH TD QAM PRN pain 4. Polyethylene Glycol 17 g PO DAILY Please hold for loose stools 5. Senna 8.6 mg PO BID 6. Acetaminophen 650 mg PO Q6H PRN Pain Mild 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Acidophilus Lactobacillus acidophilus 1 quantity oral DAILY 9. Aspirin 325 mg PO DAILY 10. Atorvastatin 40 mg PO QPM 11. Docusate Sodium 100 mg PO BID 12. Fluticasone Propionate NASAL 1 SPRY NU DAILY 13. melatonin 3 mg oral QHS 14. HELD Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until your doctor says it is safe to do so 15. HELD TraMADol 50 mg PO Q6H PRN Pain Moderate This medication was held. Do not restart TraMADol until your doctor says it is safe to do so Discharge Disposition Extended Care Facility ___ Discharge Diagnosis PRIMARY Fall unwitnessed Minimally displaced fracture of C7 facet and transverse process SECONDARY Hypoxia left pleural effusion aspiration risk Hypoactive delirium Catheter associated urinary tract infection ampicillin sensitive enterococcus Urinary retention Constipation Hypertension Scapula and R 2nd rib fx recent Right thalamic stroke history of Anxiety Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid Discharge Instructions Dear Ms. ___ You were admitted to ___ after a fall. You have a small fracture in your spine and it is important that you wear a cervical collar until you follow up with the neurosurgeon in clinic. While you were in the hospital you needed oxygen to help you breathe but this got better. You were also treated for a urinary tract infection and will need to keep taking your antibiotics when you leave. It was a pleasure taking part in your care. We wish you all the best with your future health Sincerely The team at ___ Followup Instructions ___ The icd codes present in this text will be S12600A, G9340, T83511A, N390, J90, J9811, W19XXXA, Y92129, R296, Z9181, S42109D, S2231XD, Z8673, Z87440, F419, I951, R1310, R0902, M810, I10, R41841, F0390, B952, Y846, Y92230, R339, K5900, E8770. The descriptions of icd codes S12600A, G9340, T83511A, N390, J90, J9811, W19XXXA, Y92129, R296, Z9181, S42109D, S2231XD, Z8673, Z87440, F419, I951, R1310, R0902, M810, I10, R41841, F0390, B952, Y846, Y92230, R339, K5900, E8770 are S12600A: Unspecified displaced fracture of seventh cervical vertebra, initial encounter for closed fracture; G9340: Encephalopathy, unspecified; T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter; N390: Urinary tract infection, site not specified; J90: Pleural effusion, not elsewhere classified; J9811: Atelectasis; W19XXXA: Unspecified fall, initial encounter; Y92129: Unspecified place in nursing home as the place of occurrence of the external cause; R296: Repeated falls; Z9181: History of falling; S42109D: Fracture of unspecified part of scapula, unspecified shoulder, subsequent encounter for fracture with routine healing; S2231XD: Fracture of one rib, right side, subsequent encounter for fracture with routine healing; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Z87440: Personal history of urinary (tract) infections; F419: Anxiety disorder, unspecified; I951: Orthostatic hypotension; R1310: Dysphagia, unspecified; R0902: Hypoxemia; M810: Age-related osteoporosis without current pathological fracture; I10: Essential (primary) hypertension; R41841: Cognitive communication deficit; F0390: Unspecified dementia without behavioral disturbance; B952: Enterococcus as the cause of diseases classified elsewhere; 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; Y92230: Patient room in hospital as the place of occurrence of the external cause; R339: Retention of urine, unspecified; K5900: Constipation, unspecified; E8770: Fluid overload, unspecified. The common codes which frequently come are N390, Z8673, F419, I10, Y92230, K5900. The uncommon codes mentioned in this dataset are S12600A, G9340, T83511A, J90, J9811, W19XXXA, Y92129, R296, Z9181, S42109D, S2231XD, Z87440, I951, R1310, R0902, M810, R41841, F0390, B952, Y846, R339, E8770.
The icd codes present in this text will be R109, E43, K5190, Z932, F329, F419, R339, Z87891, Z6825, G8929. The descriptions of icd codes R109, E43, K5190, Z932, F329, F419, R339, Z87891, Z6825, G8929 are R109: Unspecified abdominal pain; E43: Unspecified severe protein-calorie malnutrition; K5190: Ulcerative colitis, unspecified, without complications; Z932: Ileostomy status; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified; R339: Retention of urine, unspecified; Z87891: Personal history of nicotine dependence; Z6825: Body mass index [BMI] 25.0-25.9, adult; G8929: Other chronic pain. The common codes which frequently come are F329, F419, Z87891, G8929. The uncommon codes mentioned in this dataset are R109, E43, K5190, Z932, R339, Z6825. Allergies Erythromycin Base medline brand surgical film NOT tegederm brand Iodinated Contrast Media IV Dye thimerosal Neomycin fentanyl Chief Complaint Abd pain second opinion Major Surgical or Invasive Procedure Ileoscopy History of Present Illness ___ with h o ulcerative colitis s p ileoanal pouch ___ resection for closed loop bowel stricture s p loop ileostomy ___ for anastomotic leak s p permanent ileostomy ___ at ___ s o LOA ___ chronic abdominal pain with multiple hospitalizations depression chronic opiate use anxiety disorder is transferred from ___ for second opinion of abdominal pain. Admitted ___ to ___ surgical service with abdominal pain bloating nausea. Fluoroscopic small bowel series ___ was without obstruction.CT abd pelvis ___ showed no obstruction though showed portion of small bowel adhered to the wall 6 x 4 cm presacral fluid collection with question ovarian cyest versus postop seroma. Was seen also by GI service and thought was possible ileus. Was on up to 15mg Oxycodone q4hr and still requesting breakthrough IV dilaudid for breakthrough. Surgical GI and pain service saw her and determined no clear role for IV narcotics and concurrent opiate risks for hyperalgesia and decreased intestinal motility. Re admitted ___ ___ clinic with pain aftger toast and inability to keep down PO. Continued symtoms of bloating intermittent absence of ostomy output followed by immediate large volume release. She was on oral oxycodone with intermittent IV dilaudid administrations and had heightened anxiety. OSH notes reflect multiple conversations with GI surgery psychiatry medical team patient and husband around opiate use. There was questionable suicidal ideation on ___ which prompted the psychiatric evaluation. She was difficult to arouse upon meeting her though when awake she was able to give a history. She would intermittently c o abdominal pain when we approached a discussion of setting general expectations with respect to pain management and her expectation that the ___ team missed the diagnosis. She believes she has a problem behind the stoma and has read about stomal stenosis. ROS fevers vomiting weight loss paresthesias bloody stool bloating intermittent cramping thicker ostomy output Other 10pt ROS negative Past Medical History PMH Ulcerative colitis s p J pouch reversed now with end ileostomy Chronic abdominal pain OPiate use Panic attacks anxiety Depression Alcohol use PSH ___ total colectomy w diverting ileostomy ___ j pouch creation ___ ileostomy takedown ___ admitted with closed loop obstruction and had small bowel resection all surgeries done by Dr. ___ at ___ ___ C Section x2 R Inguinal Hernia repair at ___ years old. Social History ___ ___ History Mother had IBS. Physical Exam AVSS Difficult to arouse initially otherwise able to engage thereafter intermittently tearful. Pupils dilated OP clear neck supple no JVD Lungs CTA bilat COR RRR ABD mild distention stoma bag with scant liquid brown stool per GI fellow digital exam at bedside there are no obvious stomal strictures EXT no edema SKIN no rashes NEURO CN2 12 intact bilat pupils 5 6mm bilat EOMI fluent speech normal strength gait not tested PSYCH flat tearful fluent speech perseverates on need for IV dilaudid Exam on discharge 97.6 BP 95 59 lying HR 72 Standing 96 67 HR 76 O2 95 RA Well appearing female laying in bed intermittently tearful HEENT MMM Lungs Clear B L on auscultation ___ RRR S1 S2 present no M R G Abdomen Soft stoma in right lower quadrant tender on palpation of LLQ no rebound or guarding Ext No edema neuro CN II XII grossly intact AAOx3 Psych intermittently tearful flat affect mood depressed denies SI Pertinent Results ADMISSION LABS ___ 07 20PM BLOOD WBC 5.6 RBC 4.19 Hgb 12.8 Hct 38.1 MCV 91 MCH 30.5 MCHC 33.6 RDW 11.9 RDWSD 39.6 Plt ___ ___ 07 20PM BLOOD ___ PTT 35.6 ___ ___ 07 20PM BLOOD Glucose 89 UreaN 6 Creat 0.8 Na 138 K 4.1 Cl 100 HCO3 24 AnGap 18 ___ 07 20PM BLOOD ALT 28 AST 34 AlkPhos 42 Amylase 42 TotBili 0.2 ___ 07 20PM BLOOD Lipase 13 ___ 07 20PM BLOOD Albumin 3.9 Iron 127 ___ 07 20PM BLOOD calTIBC 304 Ferritn 82 TRF 234 ___ 05 00AM URINE Color Straw Appear Clear Sp ___ ___ 05 00AM URINE Blood NEG Nitrite NEG Protein TR Glucose NEG Ketone NEG Bilirub NEG Urobiln NEG pH 6.0 Leuks TR ___ 05 00AM URINE RBC 1 WBC 1 Bacteri NONE Yeast NONE Epi 9 TransE 1 ___ 06 38AM URINE Porphob NEGATIVE ___ 06 38AM URINE UCG NEGATIVE MRE IMPRESSION 1. Evaluation of the upper abdomen is markedly limited due to respiratory motion. No findings of small bowel inflammation active disease or bowel obstruction. 2. Mild interval increase of presacral fluid collection as described. 3. Status post hysterectomy. 4.7 cm fluid collection at the apex of the vaginal cuff without surrounding inflammation possibly postoperative although nonspecific. Ileoscopy At 25 cm from the stoma there is an area of stenosis of benign appearance. A diverticulum was seen as well. The endoscope could not be advanced passed the area of stenosis. Second Ileoscopy Evidence of a previous side to side anastomosis was seen at 25cm. There was acute angulation at this point but no intrinsic stricture and the scope passed easily. The scope was then advanced to 35cm. Impression Previous intervention of the small bowel Otherwise normal ercp to ileum to 35cm Recommendations previously described narrowing likely represents blind limb of previous side to side anastomosis there was acute angulation of the lumen at that point but no intrinsic stricture Barium Enema IMPRESSION High grade narrowing within the ileum at approximately 25 cm from the ileostomy with mild proximal dilation. No evidence of leak. CT 1. Ileostomy present in the right lower abdomen. The ileum is suboptimally opacified with contrast. No extravasation of contrast. No complete obstruction. 2. Presacral collection measuring 48 x 42 mm in the axial plane is increased in size compared to prior appears to displace the ileum to the left and it may correlate to the area of acute ileal angulation that was seen on the loopogram. 3. Multiple air fluid levels at the same level in nondilated small bowel suggests ileus. Brief Hospital Course ___ y o F with h o ulcerative colitis s p ileoanal pouch ___ ___ resection for closed loop bowel stricture s p loop ileostomy ___ for anastomotic leak s p permanent ileostomy ___ at ___ s o LOA ___ chronic abdominal pain with multiple hospitalizations depression anxiety chronic opiate use transferred from ___ for second opinion of abdominal pain. Acute on Chronic Abdominal Pain GI and CRS were consulted. Initially used PO narcotics for pain given lack of clear etiology for pain work up at OSH was largely negative . She underwent MRE here which showed no evidence of obstruction or other acute pathology. Around the time of the MRE decision was made to try bowel rest initial read of MRE was concerning for possible early partial SBO ultimately felt to not be the case . So she was transitioned to IV narcotics and all oral meds were held. Pain largely unchanged with bowel rest and IV pain medications. The patient ultimately underwent ileoscopy and f u barium enema which showed high grade narrowing of the bowel 25 cm from the ileostomy. She then underwent a second ileoscopy that showed acute angulation at site of side to side anastomosis in ileum but scope was passed beyond this to 35 cm. The feeling is that the area noted in the initial illeoscopy was blind limb of previous side to side anastomosis and not an obstructing stricture. GI here spoke with her colorectal surgeon at ___ ___ per patient request. Integrating all the available imaging and endoscopy data the consulting gastroenterology and colorectal teams did not think the findings above were clinically significant and that the risks of surgery would outweigh any benefits of which there were felt to be few if any. No clear cause was found for the patient s pain. It is likely functional with possible component of hyperalgesia from ongoing opiate use. The patient was frustrated with her plan of care while hospitalized. She felt that surgery was the only way that her pain would improve. She expressed concern that this was being withheld despite numerous conversations with the patient her husband regarding lack of surgical option her ability to tolerate a regular diet and no objective evidence of dehydration. In terms of pain management the patient was managed actively with the pain service and the patient s PCP. Given minimal improvement with IV narcotics and bowel rest and the concern that part of the patient s presentation may be due to opiate hyperalgesia the patient was weaned off of IV opioids.. She was provided a script for oral oxycodone until her PCP follow up at which time PCP ___ begin wean of oxycodone. The need to taper oxycodone was discussed with the patient. She was also counseled on the risks of narcotic and benzodiazepines and barbiturates together. She was continued on a number of antiemetics Zofran phenergan ativan donnatol these were continued on discharge. Concern for dehydration The patient had concerns that she was dehydrated. She had labs checked which had no abnormalities. Orthostatic vital signs were checked daily after IV fluids were discontinued and the patient had no evidence of orthostatic hypotension. She was tolerating a regular diet prior to discharge. Depression Anxiety With reported SI and psych evaluation at OSH. While patient denies active SI she did continue to endorse some passive SI suggestive that she doesn t know what she will do in the future if her pain doesn t get better . Psych saw her and did not feel that there was any contraindication to d c when she is medically stable. Severe protein calorie Malnutrition The patient during her hospitalization was unable to eat due to reports of nausea. TPN was recommended several times which she declined. The patient was ultimately able to advance her diet. She was tolerating a regular diet prior to discharge and her weight remained stable throughout her hospitalization. Transitional issues Please continue to wean narcotics as an outpatient Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild 2. LORazepam 0.5 mg PO Q8H PRN anxiety 3. diphenhydrAMINE HCl 25 mg oral Q6H PRN 4. FLUoxetine 40 mg oral DAILY 5. gabapentin 875 mg oral TID 6. Hyoscyamine 0.125 mg SL TID PRN abd pain 7. Ondansetron ODT 8 mg PO Q8H PRN nausea 8. OxycoDONE Liquid 15 mg PO Q4H PRN Pain Moderate 9. phenobarb hyoscy atropine scop 16.2 0.1037 0.0194 mg oral TID 10. Promethazine 12.5 mg PO Q8H PRN nausea Discharge Medications 1. Multivitamins W minerals Liquid 15 mL PO DAILY 2. OxycoDONE Liquid 10 mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 5 mL 10 ml by mouth Q4hs as needed for pain Disp 240 Milliliter Refills 0 3. Tizanidine 2 mg PO QHS RX tizanidine 2 mg 2 capsule s by mouth at bedtime Disp 7 Capsule Refills 0 4. Acetaminophen 1000 mg PO Q8H 5. Gabapentin 900 mg PO TID 6. Promethazine 25 mg PO Q6H PRN nausea 7. diphenhydrAMINE HCl 25 mg oral Q6H PRN 8. FLUoxetine 40 mg oral DAILY 9. Hyoscyamine 0.125 mg SL TID PRN abd pain 10. LORazepam 0.5 mg PO Q8H PRN anxiety 11. Ondansetron ODT 8 mg PO Q8H PRN nausea 12. phenobarb hyoscy atropine scop 16.2 0.1037 0.0194 mg oral TID Discharge Disposition Home Discharge Diagnosis Acute on Chronic Abdominal Pain Ulcerative Colitis Depression Anxiety Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Ms. ___ You were transferred here for a second opinion of your ongoing abdominal pain. You had an MRI which did not show any clear cause for your pain. You also had an endoscopy and a barium enema which did not show any clinically significant disease. After several consultations with gastroenterology and colorectal surgery they felt that surgery would not be helpful and could cause more harm. It is very important that you take the minimal amount of pain and nausea medications to treat your symptoms. These medications when used together can cause respiratory depression reduced breathing rate constipation and even death. It is very important that you follow up with your PCP for ongoing care and to slowly reduce your dose of narcotic pain medications. We wish you the best Your ___ Care team Followup Instructions ___ The icd codes present in this text will be R109, E43, K5190, Z932, F329, F419, R339, Z87891, Z6825, G8929. The descriptions of icd codes R109, E43, K5190, Z932, F329, F419, R339, Z87891, Z6825, G8929 are R109: Unspecified abdominal pain; E43: Unspecified severe protein-calorie malnutrition; K5190: Ulcerative colitis, unspecified, without complications; Z932: Ileostomy status; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified; R339: Retention of urine, unspecified; Z87891: Personal history of nicotine dependence; Z6825: Body mass index [BMI] 25.0-25.9, adult; G8929: Other chronic pain. The common codes which frequently come are F329, F419, Z87891, G8929. The uncommon codes mentioned in this dataset are R109, E43, K5190, Z932, R339, Z6825.
The icd codes present in this text will be M1712, F05, J45909, K219, I10, E785, F329, E669, Z6834, T426X5A, Y92239, R0902, E8342. The descriptions of icd codes M1712, F05, J45909, K219, I10, E785, F329, E669, Z6834, T426X5A, Y92239, R0902, E8342 are M1712: Unilateral primary osteoarthritis, left knee; F05: Delirium due to known physiological condition; J45909: Unspecified asthma, uncomplicated; K219: Gastro-esophageal reflux disease without esophagitis; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F329: Major depressive disorder, single episode, unspecified; E669: Obesity, unspecified; Z6834: Body mass index [BMI] 34.0-34.9, adult; T426X5A: Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; R0902: Hypoxemia; E8342: Hypomagnesemia. The common codes which frequently come are J45909, K219, I10, E785, F329, E669. The uncommon codes mentioned in this dataset are M1712, F05, Z6834, T426X5A, Y92239, R0902, E8342. Allergies Bactrim DS nadolol Motrin NSAIDS Non Steroidal Anti Inflammatory Drug Chief Complaint left knee OA Major Surgical or Invasive Procedure left knee replacement ___ ___ History of Present Illness ___ year old female with left knee OA s p left TKR. Past Medical History asthma GERD migraine headaches obesity seasonal allergies with sinusitis hypertension hyperlipidemia and depression Social History ___ Family History Non contributory 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 Incision healing well with staples Thigh full but soft No calf tenderness ___ strength SILT NVI distally Toes warm Pertinent Results ___ 07 15AM BLOOD Hct 30.0 ___ 08 07AM BLOOD Hgb 10.4 Hct 32.3 ___ 08 40PM BLOOD WBC 11.2 RBC 3.41 Hgb 10.1 Hct 31.4 MCV 92 MCH 29.6 MCHC 32.2 RDW 13.3 RDWSD 44.7 Plt ___ ___ 07 55AM BLOOD Hgb 10.7 Hct 33.8 ___ 08 40PM BLOOD Neuts 77.9 Lymphs 12.4 Monos 8.3 Eos 0.7 Baso 0.2 Im ___ AbsNeut 8.69 AbsLymp 1.38 AbsMono 0.93 AbsEos 0.08 AbsBaso 0.02 ___ 09 55PM BLOOD ___ PTT 29.8 ___ ___ 08 40PM BLOOD Plt ___ ___ 08 40PM BLOOD Glucose 121 UreaN 14 Creat 0.8 Na 136 K 3.9 Cl 97 HCO3 25 AnGap 14 ___ 07 55AM BLOOD Creat 0.9 ___ 07 15AM BLOOD Mg 2.1 ___ 08 40PM BLOOD Calcium 8.6 Phos 3.7 Mg 1.5 ___ 08 57PM BLOOD Type ART pO2 184 pCO2 43 pH 7.43 calTCO2 29 Base XS 4 Intubat NOT INTUBA Brief Hospital Course The patient was admitted to the orthopedic 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 drain discontinued. Patient had ongoing nausea despite IV Zofran and was given a scopolamine patch and Phenergan was ordered. Patient noted to be acutely confused overnight and was triggered. CXR EKG and arterial gases were obtained all within normal limits. Patient was given Narcan x 1 and Gabapentin was discontinued. Oxycodone was switched to Tramadol PRN. POD 2 Tramadol was switched back to low dose Oxycodone due to inadequate pain control. Patient cleared ___ without further issues. Otherwise pain was controlled with a combination of IV and oral pain medications. The patient received Eliquis 2.5 mg twice daily for DVT prophylaxis starting on the morning of POD 1. The surgical dressing was changed on POD 2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. 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 wound was benign. The patient s weight bearing status is weight bearing as tolerated on the operative extremity with no range of motion restrictions. Ms. ___ is discharged to home with services in stable condition. Medications on Admission 1. ALPRAZolam 0.5 mg PO ASDIR 2. Docusate Sodium 100 mg PO BID 3. Tizanidine ___ mg PO BID PRN ASDIR 4. Pravastatin 20 mg PO QPM 5. HYDROcodone Acetaminophen 5mg 325mg 1 TAB PO BID PRN Pain Moderate 6. diclofenac sodium 1 topical ASDIR 7. Chlorpheniramine Maleate 4 mg PO ASDIR 8. Pantoprazole 40 mg PO Q24H 9. Fexofenadine 60 mg PO DAILY 10. albuterol sulfate 90 mcg actuation inhalation Q4H PRN SOB 11. FLUoxetine 10 mg PO TID Discharge Medications 1. Acetaminophen 1000 mg PO Q8H 2. Apixaban 2.5 mg PO BID 3. OxyCODONE Immediate Release 2.5 5 mg PO Q4H PRN Pain Moderate 4. Senna 8.6 mg PO BID 5. albuterol sulfate 90 mcg actuation inhalation Q4H PRN SOB 6. ALPRAZolam 0.5 mg PO ASDIR 7. Chlorpheniramine Maleate 4 mg PO ASDIR 8. Docusate Sodium 100 mg PO BID 9. Fexofenadine 60 mg PO DAILY 10. FLUoxetine 10 mg PO TID 11. Pantoprazole 40 mg PO Q24H 12. Pravastatin 20 mg PO QPM 13. Tizanidine ___ mg PO BID PRN ASDIR Discharge Disposition Home With Service Facility ___ Discharge Diagnosis left knee OA 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 Please continue your Eliquis 2.5 mg twice daily for four 4 weeks to help prevent deep vein thrombosis blood clots . 9. WOUND CARE Please keep your incision clean and dry. It is okay to shower five days after surgery 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 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. Staples will be removed at your follow up appointment in two weeks. 10. ___ once at home Home ___ dressing changes as instructed wound checks. 11. ACTIVITY Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy WBAT LLE ROMAT Wean assistive device as able i.e. 2 crutches or walker Mobilize frequently Treatments Frequency daily dressing changes as needed for drainage wound checks daily ice staple removal and replace with steri strips at follow up visit in clinic Followup Instructions ___ The icd codes present in this text will be M1712, F05, J45909, K219, I10, E785, F329, E669, Z6834, T426X5A, Y92239, R0902, E8342. The descriptions of icd codes M1712, F05, J45909, K219, I10, E785, F329, E669, Z6834, T426X5A, Y92239, R0902, E8342 are M1712: Unilateral primary osteoarthritis, left knee; F05: Delirium due to known physiological condition; J45909: Unspecified asthma, uncomplicated; K219: Gastro-esophageal reflux disease without esophagitis; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F329: Major depressive disorder, single episode, unspecified; E669: Obesity, unspecified; Z6834: Body mass index [BMI] 34.0-34.9, adult; T426X5A: Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; R0902: Hypoxemia; E8342: Hypomagnesemia. The common codes which frequently come are J45909, K219, I10, E785, F329, E669. The uncommon codes mentioned in this dataset are M1712, F05, Z6834, T426X5A, Y92239, R0902, E8342.
The icd codes present in this text will be Q514, Q51818, N857. The descriptions of icd codes Q514, Q51818, N857 are Q514: Unicornate uterus; Q51818: Other congenital malformations of uterus; N857: Hematometra. The uncommon codes mentioned in this dataset are Q514, Q51818, N857. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint prolonged menses fever Major Surgical or Invasive Procedure none Physical Exam Discharge physical exam Vitals stable and within normal limits Gen no acute distress alert and oriented to person place and date CV regular rate and rhythm no murmurs rubs or gallops Resp no acute respiratory distress clear to auscultation bilaterally Abd soft appropriately tender no rebound guarding Ext no tenderness to palpation Pertinent Results Labs on Admission ___ 05 45PM BLOOD WBC 13.7 RBC 3.78 Hgb 8.9 Hct 29.8 MCV 79 MCH 23.5 MCHC 29.9 RDW 15.3 RDWSD 43.8 Plt ___ ___ 05 45PM BLOOD Neuts 77.7 Lymphs 15.1 Monos 6.1 Eos 0.2 Baso 0.4 Im ___ AbsNeut 10.61 AbsLymp 2.06 AbsMono 0.83 AbsEos 0.03 AbsBaso 0.05 ___ 05 45PM BLOOD Glucose 103 UreaN 10 Creat 0.8 Na 140 K 4.1 Cl 97 HCO3 23 AnGap 20 ___ 05 45PM BLOOD ALT 6 AST 14 AlkPhos 62 TotBili 0.5 ___ 05 45PM BLOOD Lipase 16 ___ 05 45PM BLOOD Albumin 4.3 ___ 05 45PM BLOOD HCG 5 ___ 11 04PM BLOOD Lactate 1.6 ___ 10 41PM URINE Color Yellow Appear Hazy Sp ___ ___ 10 41PM URINE Blood SM Nitrite NEG Protein 30 Glucose NEG Ketone 150 Bilirub NEG Urobiln NEG pH 6.5 Leuks NEG ___ 10 41PM URINE RBC 1 WBC 3 Bacteri FEW Yeast NONE Epi 3 Relevant Labs ___ 06 48AM BLOOD WBC 15.5 RBC 3.26 Hgb 7.7 Hct 25.7 MCV 79 MCH 23.6 MCHC 30.0 RDW 15.2 RDWSD 43.7 Plt ___ ___ 12 53PM BLOOD WBC 13.4 RBC 3.25 Hgb 7.8 Hct 25.4 MCV 78 MCH 24.0 MCHC 30.7 RDW 15.3 RDWSD 42.9 Plt ___ ___ 08 06PM BLOOD WBC 11.9 RBC 3.44 Hgb 8.2 Hct 27.0 MCV 79 MCH 23.8 MCHC 30.4 RDW 15.5 RDWSD 43.8 Plt ___ ___ 04 54AM BLOOD WBC 10.4 RBC 3.36 Hgb 8.0 Hct 26.4 MCV 79 MCH 23.8 MCHC 30.3 RDW 15.3 RDWSD 43.7 Plt ___ ___ 04 54AM BLOOD Neuts 61.4 ___ Monos 8.5 Eos 1.3 Baso 0.3 Im ___ AbsNeut 6.38 AbsLymp 2.93 AbsMono 0.88 AbsEos 0.14 AbsBaso 0.03 ___ 04 49AM BLOOD WBC 8.5 RBC 2.98 Hgb 7.0 Hct 23.4 MCV 79 MCH 23.5 MCHC 29.9 RDW 15.2 RDWSD 43.3 Plt ___ ___ 04 49AM BLOOD Neuts 57.0 ___ Monos 6.2 Eos 2.2 Baso 0.4 Im ___ AbsNeut 4.85 AbsLymp 2.87 AbsMono 0.53 AbsEos 0.19 AbsBaso 0.03 Brief Hospital Course On ___ Ms. ___ was admitted to the gynecology service with prolonged menses and pelvic pain. Transabdominal US showed didelphys uterus dilated tubular structure concerning for hydrosalpinx and possibly blood within the endometrial cavity of left horn. Patient spiked a fever to a Tmax of 102.9. CXR showed no evidence of acute processes. WBC was 13.7. U A was negative. Flu swab was negative. She was given 1 dose of IV flagyl and ciprofloxacin. Her fever resolved and further antibiotics were deferred given no clear etiology of infection. She then had an MRI pelvis that showed unicornuate uterus with left rudimentary non communicating horn containing blood products pelvic endometriosus with a large hematosalpinx and non visualized left kidney. On ___ patient underwent diagnostic laparoscopy under ultrasound guidance. Please see operative report for full details. Her post operative course was uncomplicated. Immediately post operatively her pain was controlled with PO acetaminophen and ibuprofen. Her diet was advanced without difficulty. By hospital day 3 she was tolerating a regular diet ambulating independently and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow up scheduled and prescription for continuous combined oral contraceptives. Medications on Admission none Discharge Medications 1. Apri desogestrel ethinyl estradiol 0.15 0.03 mg oral daily RX desogestrel ethinyl estradiol 0.15 mg 0.03 mg 1 tablet s by mouth daily Disp 90 Tablet Refills 3 Discharge Disposition Home Discharge Diagnosis unicornate uterus with left rudimentary non communicating horn containing blood products left hematosalpinx 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 with prolonged menses and fever. You were given IV antibiotics to treat a possible pelvic infection. You had a pelvic ultrasound that showed your previously diagnosed uterine abnormality. You then had an MRI that showed that the left side of your uterus was a separate entity that is closed off and does not connect with the right side of your uterus or your vagina. Accordingly there was blood visualized within the left side of uterus that was found to be spilling back through your fallopian tube on that side into your pelvis. We recommended that you start continuous oral contraceptive pills to prevent further menstrual blood from collecting in the left side of your uterus. We also recommended that you have surgery to remove the left side of your uterus. The team believes you are now ready to be discharged home. Please call our Ob Gyn office at ___ with any questions or concerns. Please follow the instructions below. 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 Q514, Q51818, N857. The descriptions of icd codes Q514, Q51818, N857 are Q514: Unicornate uterus; Q51818: Other congenital malformations of uterus; N857: Hematometra. The uncommon codes mentioned in this dataset are Q514, Q51818, N857.
The icd codes present in this text will be S066X0A, G92, I6340, I421, F05, N390, Z515, F0391, E870, N179, E039, M1990, G4733, K224, R32, I10, I959, E876, E785, F319, R001, R0902, R569, R402142, R402242, R402362, B9620, Z9183, Z66, Z781, Z91130, X58XXXA, Y929. The descriptions of icd codes S066X0A, G92, I6340, I421, F05, N390, Z515, F0391, E870, N179, E039, M1990, G4733, K224, R32, I10, I959, E876, E785, F319, R001, R0902, R569, R402142, R402242, R402362, B9620, Z9183, Z66, Z781, Z91130, X58XXXA, Y929 are S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter; G92: Toxic encephalopathy; I6340: Cerebral infarction due to embolism of unspecified cerebral artery; I421: Obstructive hypertrophic cardiomyopathy; F05: Delirium due to known physiological condition; N390: Urinary tract infection, site not specified; Z515: Encounter for palliative care; F0391: Unspecified dementia with behavioral disturbance; E870: Hyperosmolality and hypernatremia; N179: Acute kidney failure, unspecified; E039: Hypothyroidism, unspecified; M1990: Unspecified osteoarthritis, unspecified site; G4733: Obstructive sleep apnea (adult) (pediatric); K224: Dyskinesia of esophagus; R32: Unspecified urinary incontinence; I10: Essential (primary) hypertension; I959: Hypotension, unspecified; E876: Hypokalemia; E785: Hyperlipidemia, unspecified; F319: Bipolar disorder, unspecified; R001: Bradycardia, unspecified; R0902: Hypoxemia; R569: Unspecified convulsions; R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department; R402242: Coma scale, best verbal response, confused conversation, at arrival to emergency department; R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; Z9183: Wandering in diseases classified elsewhere; Z66: Do not resuscitate; Z781: Physical restraint status; Z91130: Patient's unintentional underdosing of medication regimen due to age-related debility; X58XXXA: Exposure to other specified factors, initial encounter; Y929: Unspecified place or not applicable. The common codes which frequently come are N390, Z515, N179, E039, G4733, I10, E785, Z66, Y929. The uncommon codes mentioned in this dataset are S066X0A, G92, I6340, I421, F05, F0391, E870, M1990, K224, R32, I959, E876, F319, R001, R0902, R569, R402142, R402242, R402362, B9620, Z9183, Z781, Z91130, X58XXXA. Allergies No Allergies ADRs on File Chief Complaint Altered mental status Major Surgical or Invasive Procedure Foley catheter placed ___ History of Present Illness As per HPI by admitting MD Ms. ___ is an ___ female w PMH hypothyroidism depression HLD OA esophageal spasm OSA urinary incontinence HTN HOCM who presents with altered mental status. The patient is not able to answer questions on my interview on arrival to the floor. Per ED notes she was found wandering the streets and the water was left on in her house. She was found to have a subarachnoid hemorrhage in the right parietal lobe at an OSH and was transferred here. VS significant for T101 HR 102. She had a normal neurologic exam ___ cardiac murmur. Neurosurgery was consulted and said Patient examined and imaging reviewed with attending neurosurgeon. The right parietal SAH is not the cause of her altered mental status. She is not on anticoagulation. There is no indication for urgent or emergent neurosurgical intervention. Recommended toxic metabolic work up. Psych consulted and said Impression most likely delirium superimposed on dementia. Recommended to hold lithium and risperidone for now and to use Haldol for agitation. Neurology consulted and said Rads confirms that subarachnoid blood present in R parietal lobe potentially d t underlying amyloid angiopathy or unwitnessed trauma. Exam shows pt to be disoriented and poorly interactive although intermittently regards and follows simple commands. At this time pt s clinical condition is more likely related to a systemic issue with resulting delirium. Do not clearly see complication from newfound SAH. Will consider MRI in future to assist with determining etiology of SAH pending improvement in pt s mentation She was given IV Olanzapine and IV Ativan multiple doses in the ED for agitation. She was also given IV Zosyn for possible UTI based on UA results and IVF. ROS Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History Hypothyroidism Depression HLD OA Esophageal spasm OSA HTN Hypertrophic obstructive cardiomyopathy Social History ___ Family History 1 grandchild with bipolar disorder 1 grandchild with anxiety Physical Exam ADMISSION EXAM GENERAL sleeping not opening eyes to voice 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 ___ systolic murmur heard best at axilla 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 appears tender to palpation in lower abdomen suprapubic area. Bowel sounds present. No HSM GU No suprapubic fullness tender to palpation. MSK Neck supple moves all extremities SKIN No rashes or ulcerations noted NEURO not opening eyes to voice not responding does respond to touching all limbs by withdrawing moves all limbs sensation to light touch grossly intact throughout PSYCH pleasant appropriate affect DISCHARGE EXAM T98.0 BP 170 90 HR 83 RR 18 O2 96 RA General awake appears a bit uncomfortable HEENT slightly dry oral mucosa ___ rrr s1 2 no murmurs Lungs diminished but CTA from anterior aspect no w r r GI soft NT ND BS Ext no edema or cyanosis Skin warm dry no rash Psych awake but not fully alert able to make eye contact and state doctor but none further. Unable to follow commands GU foley Pertinent Results ADMISSION LABS ___ 02 25PM WBC 12.0 RBC 4.28 HGB 13.2 HCT 41.3 MCV 97 MCH 30.8 MCHC 32.0 RDW 13.3 RDWSD 46.7 ___ 02 25PM NEUTS 67.2 ___ MONOS 9.1 EOS 0.1 BASOS 0.3 IM ___ AbsNeut 8.04 AbsLymp 2.71 AbsMono 1.09 AbsEos 0.01 AbsBaso 0.03 ___ 02 25PM PLT COUNT 281 ___ 02 25PM GLUCOSE 118 UREA N 10 CREAT 0.6 SODIUM 143 POTASSIUM 3.7 CHLORIDE 103 TOTAL CO2 23 ANION GAP 17 ___ 02 25PM ASA NEG ETHANOL NEG ACETMNPHN NEG tricyclic NEG ___ 02 25PM LITHIUM 0.4 ___ 08 09PM URINE RBC 1 WBC 182 BACTERIA MOD YEAST NONE EPI 1 ___ 08 09PM URINE BLOOD MOD NITRITE POS PROTEIN 30 GLUCOSE NEG KETONE 40 BILIRUBIN NEG UROBILNGN NEG PH 6.0 LEUK LG ___ 08 30PM OTHER BODY FLUID FluAPCR NEGATIVE FluBPCR NEGATIVE ___ 06 30AM BLOOD VitB12 396 Folate 5 ___ 10 43AM BLOOD HbA1c 5.4 eAG 108 ___ 10 31AM BLOOD Triglyc 169 HDL 52 CHOL HD 3.2 LDLcalc 78 ___ 06 26AM BLOOD TSH 0.16 ___ 06 30AM BLOOD Free T4 1.6 ___ 06 30AM BLOOD Trep Ab NEG IMAGING ___ CTA Head Neck IMPRESSION 1. Study graded by dental and overlying surgical hardware streak artifact and motion. 2. Right parietal ill defined hyperdensity concerning for intraparenchymal or subarachnoid hemorrhage grossly stable compared to prior. Please note that underlying mass is not excluded on the basis examination. If concern for intracranial mass consider contrast brain MRI for further evaluation. Recommend follow up imaging to resolution. 3. Nonocclusive probable atherosclerotic narrowing of circle of ___ as described. 4. Otherwise patent circle of ___ without definite evidence of stenosis occlusion or aneurysm. 5. Grossly patent bilateral cervical carotid and vertebral arteries without definite evidence of stenosis occlusion or dissection. 6. Limited imaging of lungs suggest biapical patchy opacities versus artifact and central airway thickening. If clinically indicated consider correlation with dedicated chest imaging. 7. Calcified bilateral thyroid nodules measuring up to 0.8 cm. 8. Nonspecific subcentimeter cervical lymph nodes as described which may be reactive. 9. Left maxillary molar tooth dental disease as described. RECOMMENDATION S Right parietal ill defined hyperdensity concerning for intraparenchymal or subarachnoid hemorrhage grossly stable compared to prior. Please note that underlying mass is not excluded on the basis examination. If concern for intracranial mass consider contrast brain MRI for further evaluation. Recommend follow up imaging to resolution. MRI Head w o contrast IMPRESSION 1. The study was terminated prematurely due to patient s inability to cooperate and is moderately limited by motion. Only sagittal and axial T1 precontrast imaging was performed. 2. Within the above limitations no definite large hemorrhage or intracranial mass identified. Please see the subsequent complete MRI that was obtained on the same date. ___ MRI Head w and w o contrast IMPRESSION 1. Trace right parietal subarachnoid hemorrhage corresponding to the hyperdensity seen on prior CT. No new or worsening hemorrhage. 2. Punctate right putaminal right frontal and bilateral occipital subacute infarcts. 3. Pontine periventricular and deep white matter FLAIR hyperintensities are nonspecific but likely represent sequela of chronic microangiopathy. ___ TTE IMPRESSION Moderate symmetric left ventricular hypertrophy with normal cavity size and regional global biventricular systolic function. Moderate aortic valve stenosis with moderately thickened leaflets. Moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. No definite structural cardiac source of embolism identified. CLINICAL IMPLICATIONS The patient has moderate aortic valve stenosis. Based on ___ ACC AHA Valvular Heart Disease Guidelines if the patient is asymptomatic a follow up echocardiogram is suggested in ___ years. EEG ___ IMPRESSION This is an abnormal continuous video EEG monitoring study due to 1 Occasional to frequent bursts of generalized rhythmic delta activity with embedded multifocal sharps GRDA S . The finding indicates diffuse cortical hyperexcitability with potential for seizure. 2 Persistent mild attenuation of voltages especially of the faster rhythms present broadly in the right hemisphere indicating a focal region of cortical dysfunction that is nonspecific in etiology. 3 Diffuse slowing and disorganization present in the background indicating moderate superimposed diffuse cerebral dysfunction that is nonspecific in etiology. Common causes include medications sedation toxic metabolic disturbances and infections. EEG ___ IMPRESSION This is an abnormal continuous video EEG monitoring study due to 1 Occasional to frequent bursts of generalized rhythmic delta activity with embedded multifocal sharps GRDA S . The finding indicates diffuse cortical hyperexcitability with potential for seizure. 2 Persistent mild attenuation of voltages especially of the faster rhythms present broadly in the right hemisphere indicating a focal region of cortical dysfunction that is nonspecific in etiology. 3 Diffuse slowing and disorganization present in the background indicating moderate superimposed diffuse cerebral dysfunction that is nonspecific in etiology. Common causes include medications sedation toxic metabolic disturbances and infections. There are no pushbutton events. Compared to the prior day s study the degree of encephalopathy has improved and the rhythmic periodic patterns are less abundant. EEG ___ IMPRESSION This is an abnormal continuous video EEG monitoring study due to 1 Abundant generalized periodic discharges with associated rhythmic delta GPD R and a shifting lateral predominance. The finding indicates diffuse cortical hyperexcitability lies on the ictal end of the ictal interictal continuum and is at times concerning for electrographic status epilepticus. 2 Persistent mild attenuation of voltages especially of the faster rhythms present broadly in the right hemisphere indicating a focal region of cortical dysfunction that is nonspecific in etiology. 3 Diffuse slowing and disorganization present in the background indicating moderate superimposed diffuse cerebral dysfunction that is nonspecific in etiology. Common causes include medications sedation toxic metabolic disturbances and infections. CT head ___ IMPRESSION No acute intracranial abnormality since prior. Evolving subarachnoid hemorrhage in the right parietal lobe. Micro Urine culture ___ URINE CULTURE Final ___ Culture workup discontinued. Further incubation showed contamination with mixed skin genital flora. Clinical significance of isolate s uncertain. Interpret with caution. ESCHERICHIA COLI. 100 000 CFU mL. PRESUMPTIVE IDENTIFICATION. 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 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 Blood culture ___ negative Urine culture ___ 9 31 pm URINE Source ___. FINAL REPORT ___ URINE CULTURE Final ___ 10 000 CFU mL. Brief Hospital Course ___ yo F w PMHx HOCM hypothyroidism HLD OA OSA HTN depression with SI new diagnosis of bipolar and subacute neurocognitive decline who presents with encephalopathy knocking on neighbors doors roaming around apartment building found to have UTI and CT head with small non aneurysmal R parietal SAH. Her hospital course was prolonged and involved many different diagnostic tests to better understand her encephalopathy. Briefly she was treated with Depakote for seizures and aspirin for subacute ischemic stroke. Concern for autoimmune process or infectious process remained in the differential diagnosis and LP was recommended however ultimately this was declined would have needed intubation sedation and her goals of care were shifted to hospice. Her overall encephalopathy persists but etiology remains unclear. Clinically she continues to be confused and not significantly awake or alert but after discussions with her family transition to hospice was felt appropriate and she will be admitted to an ___ facility. Agitation Acute encephalopathy Seizures Suspect multifactorial ___ new SAH subacute seizures subacute cerebral infarct and UTI. These insults occurred in the setting of underlying mood disorder with sub acute cognitive decline and possibly early dementia although never formally diagnosed. cvEEG initially showed bilateral multifocal discharges suggestive of diffuse cortical irritability as well as diffuse slowing suggestive of delirium. She was started on Depakote with improvement in noted EEG findings. Valproate levels were monitored while she was in the hospital and were appropriate. MRI showed punctate bilateral ischemic infarcts as below. Work up for underlying dementia including B12 TSH syphilis Ab were all within normal limits. Neurology and Psychiatry were consulted. Hospital course was complicated by behavioral challenges and agitation with patient combative and requiring many doses of IM Haldol. She was initiated on standing Haldol with improvement in combativeness however still difficult to redirect and for some time required 1 1 sitter to maintain safety. She was treated with five days of empiric steroids 1000mg IV solumedrol daily to treat for a possible underlying autoimmune encephalitis. Neurology was particularly concerned about ___ s encephalopathy given positive anti TPO antibodies. Serum encephalopathy panel was also sent results pending at the time of discharge. Given lack of improvement of symptoms with further decompensation GOC initiated. It was ultimately decided to change code status to CMO and pursue hospice. She was continued on Depakote for comfort to prevent seizures but all other non essential medications were discontinued including aspirin statin . Hypernatremia Na up to 154 the day before discharge had been trending up. Her fluids were changed to D5W from LR to help with sodium management but given her transition to hospice no further labs were checked. Fluids were discontinued before discharge from the hospital. Her son inquired if fluids would be used at ___ facility advised him not unless needed for comfort but generally not felt necessary within ___. Sodium was not rechecked before discharge most recent ___ 154 . Unresponsive episodes patient began to develop episodes of unresponsiveness with accompanying hypotension 60s 70s systolic and bradycardia. EEG was negative for seizure activity during this time. Episodes were suspected to be due to autonomic dysfunction secondary to her underlying CNS process. Her last episode was ___. SAH Suspected traumatic given bruising on exam. CTA and MRI without signs of vascular abnormality. Neurosurgery was consulted but did not recommend any surgical intervention. Punctate bilateral ischemic infarcts MRI brain with punctate subacute R putaminal and punctate bilateral infarcts. DDx cardioembolic or hypercoagulable state. TTE did not show any thrombus. Telemetry monitoring x 48 hours did not show any atrial fibrillation. Lipids and A1c were within acceptable range. She was started on a statin. Ultimately given her transition of care to hospice aspirin and statin were discontinued. UTI Ucx with pansensitive E coli early in hospitalization. She completed a course of ceftriaxone. Patient endorsed UTI symptoms on ___ and less lucid so started on Bactrim given prior sensitivities which she completed. A foley catheter was placed ___ due to the need for a urinalysis she had had a low grade temp the UA was negative and because of her transition to hospice the Foley was left in place. HTN Poorly controlled at admission. She was continued on home metoprolol. Given intermitent episodes of hypotension newly started on amlodipine was discontinued. Ultimately given GOC her anti hypertensives were discontinued. CHRONIC STABLE PROBLEMS Hypothyroidism discontinued levothyroxine HOCM discontinued metoprolol Psychiatric disorders Lithium was held per psychiatry recs. As above she was started on Depakote for EEG findings. Overall GOC MOLST form filled while in the hospital Bowel regimen and narcotics continued for comfort she has only required ___ doses of IV morphine in the 24 hours before discharge Has not required any benzos but has been on Haldol which will be continued on med rec Discontinued all non essential meds Discontinued IV fluids Contact son ___ ___ updated via phone regarding discharge plan and plans to discontinue non essential meds. 55 minutes spent in discharge planning. PCP notified of hospital discharge. Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Lithium Carbonate 150 mg PO BID 2. RisperiDONE 2 mg PO QHS 3. TraZODone 25 mg PO QHS 4. Fluticasone Propionate NASAL 2 SPRY NU DAILY 5. Levothyroxine Sodium 75 mcg PO 6X WEEK ___ 6. Levothyroxine Sodium 150 mcg PO 1X WEEK ___ 7. Oxybutynin 5 mg PO BID 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Pregabalin 50 mg PO DAILY 10. Brimonidine Tartrate 0.15 Ophth. 1 DROP BOTH EYES Q8H 11. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 12. Dorzolamide 2 Timolol 0.5 Ophth. 1 DROP BOTH EYES BID 13. Acetaminophen 650 mg PO BID PRN Pain Mild Fever Discharge Medications 1. Depakote Sprinkles divalproex 375 mg oral BID 2. Docusate Sodium 100 mg PO BID 3. Haloperidol 4 mg PO QHS 4. Haloperidol 1 mg PO DAILY 5. Mirtazapine 15 mg PO QHS 6. Morphine Sulfate 0.5 mg IV Q4H PRN pain 7. Ramelteon 8 mg PO QHS Should be given 30 minutes before bedtime 8. Acetaminophen 650 mg PO BID PRN Pain Mild Fever Discharge Disposition Extended Care Discharge Diagnosis Encephalopathy toxic metabolic Seizure Ischemic stroke Hemorrhagic stroke Hypernatremia Hypotension ___ Discharge Condition Mental Status Confused always. Level of Consciousness Lethargic but arousable. Activity Status Bedbound. Discharge Instructions Dear Ms. ___ You will be discharged to a ___ facility to focus on your comfort and symptoms related to well being. We have discontinued many of your medications that are not felt to be essential to your care. We wish you and your family the very best during this time. Sincerely Your care team at ___ Followup Instructions ___ The icd codes present in this text will be S066X0A, G92, I6340, I421, F05, N390, Z515, F0391, E870, N179, E039, M1990, G4733, K224, R32, I10, I959, E876, E785, F319, R001, R0902, R569, R402142, R402242, R402362, B9620, Z9183, Z66, Z781, Z91130, X58XXXA, Y929. The descriptions of icd codes S066X0A, G92, I6340, I421, F05, N390, Z515, F0391, E870, N179, E039, M1990, G4733, K224, R32, I10, I959, E876, E785, F319, R001, R0902, R569, R402142, R402242, R402362, B9620, Z9183, Z66, Z781, Z91130, X58XXXA, Y929 are S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter; G92: Toxic encephalopathy; I6340: Cerebral infarction due to embolism of unspecified cerebral artery; I421: Obstructive hypertrophic cardiomyopathy; F05: Delirium due to known physiological condition; N390: Urinary tract infection, site not specified; Z515: Encounter for palliative care; F0391: Unspecified dementia with behavioral disturbance; E870: Hyperosmolality and hypernatremia; N179: Acute kidney failure, unspecified; E039: Hypothyroidism, unspecified; M1990: Unspecified osteoarthritis, unspecified site; G4733: Obstructive sleep apnea (adult) (pediatric); K224: Dyskinesia of esophagus; R32: Unspecified urinary incontinence; I10: Essential (primary) hypertension; I959: Hypotension, unspecified; E876: Hypokalemia; E785: Hyperlipidemia, unspecified; F319: Bipolar disorder, unspecified; R001: Bradycardia, unspecified; R0902: Hypoxemia; R569: Unspecified convulsions; R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department; R402242: Coma scale, best verbal response, confused conversation, at arrival to emergency department; R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department; B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere; Z9183: Wandering in diseases classified elsewhere; Z66: Do not resuscitate; Z781: Physical restraint status; Z91130: Patient's unintentional underdosing of medication regimen due to age-related debility; X58XXXA: Exposure to other specified factors, initial encounter; Y929: Unspecified place or not applicable. The common codes which frequently come are N390, Z515, N179, E039, G4733, I10, E785, Z66, Y929. The uncommon codes mentioned in this dataset are S066X0A, G92, I6340, I421, F05, F0391, E870, M1990, K224, R32, I959, E876, F319, R001, R0902, R569, R402142, R402242, R402362, B9620, Z9183, Z781, Z91130, X58XXXA.
The icd codes present in this text will be R4182, R0600, F0390, I4891, Z781, R451, R9431, I69320, I10, I2510, E785, J45909, E041, Z7902, E119, K753, R10819, E806, F419, Z9114. The descriptions of icd codes R4182, R0600, F0390, I4891, Z781, R451, R9431, I69320, I10, I2510, E785, J45909, E041, Z7902, E119, K753, R10819, E806, F419, Z9114 are R4182: Altered mental status, unspecified; R0600: Dyspnea, unspecified; F0390: Unspecified dementia without behavioral disturbance; I4891: Unspecified atrial fibrillation; Z781: Physical restraint status; R451: Restlessness and agitation; R9431: Abnormal electrocardiogram [ECG] [EKG]; I69320: Aphasia following cerebral infarction; I10: Essential (primary) hypertension; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; J45909: Unspecified asthma, uncomplicated; E041: Nontoxic single thyroid nodule; Z7902: Long term (current) use of antithrombotics/antiplatelets; E119: Type 2 diabetes mellitus without complications; K753: Granulomatous hepatitis, not elsewhere classified; R10819: Abdominal tenderness, unspecified site; E806: Other disorders of bilirubin metabolism; F419: Anxiety disorder, unspecified; Z9114: Patient's other noncompliance with medication regimen. The common codes which frequently come are I4891, I10, I2510, E785, J45909, Z7902, E119, F419. The uncommon codes mentioned in this dataset are R4182, R0600, F0390, Z781, R451, R9431, I69320, E041, K753, R10819, E806, Z9114. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint altered mental status Major Surgical or Invasive Procedure None. History of Present Illness Ms. ___ ___ female with unknown medical history who presents to the ED for unknown reasons with TWIs on EKG. As per EMS the patient did not know why she called an ambulance and was rambling when they arrived. Patient denies any particular complaints or pain. At one point she did apparently state I m not right in the head. Patient frequently made references to events that have happened in the past and was unable to answer questions. She was unable to give any names or contact information for family. She declined labs and imaging. In the ED initial vitals were HR76 BP114 60 RR18 Exam notable for Moving all extremities no dysarthria smile symmetric atraumatic exam Labs notable for Tbili 1.6 Trop T 0.01 Leuk Sm Nitr neg WBC Bact few INR 1.5 Imaging was notable for Unable to obtain a CT Head secondary to agitation Patient was given ___ 17 55 injection OLANZapine NF 5 mg ___ 17 55 PO Aspirin 324 mg ___ 18 53 IM OLANZapine 10 mg ___ 19 30 IV Lorazepam .5 mg ___ 20 10 IV Lorazepam .5 mg Vitals prior to transfer T97.5 HR81 BP122 70 RR18 SaO2 95 RA Upon arrival to the floor patient reports she has no complaints. She is interviewed by a ___ interpreter and was unable to articulate why she came in. REVIEW OF SYSTEMS Per HPI 10 point ROS reviewed and negative unless stated above in HPI Past Medical History CVA ___ cardioembolic inferior cerebellar occipital and parietal stroke has residual aphasia Atrial fibrillation Hypertension Hyperlipidemia Reactive Airway disease Thyroid Nodule Social History ___ Family History Unknown. Physical Exam ADMISSION PHYSICAL EXAM Vital Signs BP 125 76 HR81 O2 saturation 91 RA General Alert oriented to person no acute distress HEENT Sclerae 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 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 gait deferred. Patient unwilling to participate in pronator drift test. DISCHARGE PHYSICAL EXAM Vital Signs 97.9 104 64 93 136 55 80 79 74 88 ___ 92 95 RA General Alert oriented to person no acute distress. HEENT Sclerae 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 tender to deep palpation diffusely difficult to localize given patient s attentional deficits non distended bowel sounds present no rebound or guarding GU No foley Ext Warm well perfused 2 pulses no clubbing cyanosis or edema Neuro CNII XII intact. ___ strength throughout. Normal sensation to light palpation. Gait deferred. FNF intact. Patient unable to sustain attention to answer questions. Patient s thought process is not goal directed or linear. Pertinent Results ADMISSION LABS ___ 07 33PM URINE HOURS RANDOM ___ 07 33PM URINE UHOLD HOLD ___ 07 33PM URINE COLOR Straw APPEAR Clear SP ___ ___ 07 33PM URINE BLOOD NEG NITRITE NEG PROTEIN NEG GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 6.5 LEUK SM ___ 07 33PM URINE RBC 2 WBC 2 BACTERIA FEW YEAST NONE EPI 1 TRANS EPI 1 ___ 07 33PM URINE AMORPH RARE ___ 07 33PM URINE MUCOUS RARE ___ 06 45PM WBC 6.4 RBC 4.63 HGB 13.8 HCT 41.5 MCV 90 MCH 29.8 MCHC 33.3 RDW 13.0 RDWSD 42.6 ___ 06 45PM NEUTS 56.7 ___ MONOS 9.2 EOS 1.4 BASOS 0.3 IM ___ AbsNeut 3.62 AbsLymp 2.03 AbsMono 0.59 AbsEos 0.09 AbsBaso 0.02 ___ 06 45PM PLT COUNT 237 ___ 05 39PM ___ PTT 30.6 ___ ___ 04 00PM GLUCOSE 126 UREA N 13 CREAT 0.8 SODIUM 140 POTASSIUM 4.8 CHLORIDE 105 TOTAL CO2 20 ANION GAP 20 ___ 04 00PM estGFR Using this ___ 04 00PM ALT SGPT 13 AST SGOT 30 ALK PHOS 124 TOT BILI 1.6 ___ 04 00PM cTropnT 0.01 ___ 04 00PM ALBUMIN 3.5 MICROBIOLOGY URINE CULTURE Final ___ MIXED BACTERIAL FLORA 3 COLONY TYPES CONSISTENT WITH SKIN AND OR GENITAL CONTAMINATION. Blood culture x2 ___ No growth to date Blood culture ___ No growth to date Blood culture ___ No growth to date IMAGING Portable CXR ___ Findings Slightly low lung volumes noted. There are regions of parenchymal opacity at the left lung base. Elsewhere lungs are clear. Cardiac silhouette is slightly enlarged but likely accentuated by portable technique. No acute osseous abnormalities. IMPRESSION Patchy left basilar opacities which could represent pneumonia. Non contrast head CT ___ FINDINGS There is hypoattenuation and encephalomalacia in the left parietal lobe compatible with chronic infarct. There is no intra axial or extra axial hemorrhage edema shift of normally midline structures or evidence of acute major vascular territorial infarction. Prominent ventricles sulci compatible with age related involutional changes. Periventricular and subcortical confluent hypoattenuation is nonspecific but likely represent sequelae of small vessel ischemic disease in this age group. There are moderate atherosclerotic calcifications in the carotid siphons and intracranial portions of the vertebral arteries bilaterally. Imaged paranasal sinuses are clear. Mastoid air cells and middle ear cavities are well aerated. The bony calvarium is intact. IMPRESSION 1. Hypoattenuation and encephalomalacia in the left parietal lobe likely represents a chronic infarct. 2. No acute intracranial abnormality. 3. Age related involutional changes and chronic small vessel ischemic disease. Abdominal U S ___ FINDINGS LIVER The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There are multiple echogenic foci consistent with granulomas. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS There is no intrahepatic biliary dilation. The CHD measures 9 mm. GALLBLADDER The patient is status post cholecystectomy. PANCREAS The imaged portion of the pancreas appears within normal limits without masses or pancreatic ductal dilation with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN Normal echogenicity measuring 8.1 cm. KIDNEYS The right kidney measures 10.4 cm. The left kidney measures 10.1 cm. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses stones or hydronephrosis in the kidneys. RETROPERITONEUM The visualized portions of aorta and IVC are within normal limits. IMPRESSION 1. Status post cholecystectomy. Hepatobiliary system is within normal limits. 2. Hepatic granulomata. CXR PA LAT ___ FINDINGS Increased left lower lobe and right basal parenchymal opacities which may reflect atelectasis and or consolidation. No pleural effusion or pneumothorax identified. The size of the cardiac silhouette is unchanged. IMPRESSION Slight interval increase in left lower lobe and right basilar opacities which may reflect atelectasis and or consolidation. DISCHARGE AND PERTINENT LABS ___ 07 20AM BLOOD WBC 6.6 RBC 4.59 Hgb 13.9 Hct 42.0 MCV 92 MCH 30.3 MCHC 33.1 RDW 12.8 RDWSD 42.7 Plt ___ ___ 07 20AM BLOOD Plt ___ ___ 07 20AM BLOOD Ret Aut 2.1 Abs Ret 0.09 ___ 07 20AM BLOOD Glucose 169 UreaN 15 Creat 0.9 Na 139 K 3.7 Cl 103 HCO3 25 AnGap 15 ___ 05 15PM BLOOD ALT 12 AST 16 LD ___ 200 AlkPhos 126 TotBili 1.8 ___ 07 30AM BLOOD ALT 12 AST 15 LD ___ 198 AlkPhos 126 TotBili 1.8 ___ 08 15AM BLOOD ALT 11 AST 15 LD ___ 228 AlkPhos 129 TotBili 2.4 DirBili 0.3 IndBili 2.1 ___ 07 20AM BLOOD ALT 10 AST 14 LD ___ 255 AlkPhos 114 TotBili 2.5 DirBili 0.3 IndBili 2.2 ___ 07 20AM BLOOD GGT PND ___ 04 00PM BLOOD cTropnT 0.01 ___ 02 50AM BLOOD CK MB 3 cTropnT 0.01 ___ 07 20AM BLOOD Calcium 8.9 Phos 3.8 Mg 2.1 ___ 07 20AM BLOOD Hapto PND ___ 02 50AM BLOOD TSH 1.9 ___ 08 15AM BLOOD ___ ___ 08 15AM BLOOD AMA NEGATIVE ___ 02 50AM BLOOD Digoxin 0.2 ___ 08 15AM BLOOD Digoxin 0.3 ___ 07 20AM BLOOD Digoxin 0.4 ___ 02 50AM BLOOD ASA NEG Ethanol NEG Acetmnp NEG Bnzodzp NEG Barbitr NEG Tricycl NEG ___ 05 30PM BLOOD ___ pO2 25 pCO2 38 pH 7.45 calTCO2 27 Base XS 1 Brief Hospital Course Ms. ___ ___ woman w hx of Afib on Apixaban inferior cerebellar occipital and parietal cardioembolic stroke HLD HTN DMII hyperactive airway disease of unknown etiology who presents to the ED for AMS with TWIs on EKG. Dyspnea Patient has known history of reactive airway disease of unknown etiology. She was admitted at ___ for bronchitis and was discharged with 5 day course of azithromycin and prednisone which she feels did not help. She denies smoking history. She desatted to 86 on RA while walking stopped and took deep breaths with O2 increasing back to 93 95 in a few seconds. Etiology was considered to be cardiac vs chronic pulmonary etiology e.g. indolent infection vs reactive airway disease vs COPD vs interstitial lung disease . On admission portable CXR showed patchy left basilar opacities and repeat CXR PA LAT on ___ demonstrated interval increase in LLL and R basilar opacities which may be atelectasis vs consolidation. Given concern for hepatic granulomas on abdominal CT imaging see below some concern also for sarcoid vs TB although no hilar lymphadenopathy or cavitary lesions on CXR and Ca wnl. Patient was started on empiric albuterol inhaler 2 puffs q6h resulting in her ability to ambulate without desatting O2Sat in ___ on RA and without dyspnea or other symptoms suggesting obstructive picture consistent with reactive airway disease. Patient may benefit from outpatient PFTs. Altered mental status History of cardioembolic stroke The patient has known inferior cerebellar occipital and parietal cardioembolic strokes ___ and she has a residual aphasia Wernicke type worsened by anxiety. Per daughter and ___ she does not take her medications as prescribed and has likely missed doses of her anti hypertensive medications and apixaban. Patient has been more aphasic and confused in the week of ___ since her discharge from ___. Her neurology exam was non focal and strength sensation cerebellar function were intact although patient demonstrated difficulty with attention which her daughter felt was worse than her baseline. There was photophobia or meningeal signs. Urine toxicology screen was negative. TSH 1.9. Portable chest x ray on admission showed patchy left basilar opacities consistent with atelectasis versus less likely pneumonia although patient was afebrile had no other signs of infection had no leukocytosis and urine and blood cultures were negative. Antibiotics were therefore deferred. Patient was agitated initially requiring wrist restraints and then IV Haldol although became much calmer within 24hrs of admission allowing for discontinuation of both restraints and haldol. Her change in mental status given her history of atrial fibrillation and prior cardioembolic strokes was concerning for a new CVA especially in the setting of possible medication noncompliance. Non contrast head CT on ___ showed chronic parietal lobe infarct but no new acute intracranial abnormality. Abdominal tenderness Indirect bilirubinemia Patient endorsed mild tenderness to deep abdominal palpation although were unable to localize quadrant in the setting of her attention deficits but had no jaundice and was afebrile. She had an Alk phos of 126 and indirect bilirubinemia with Tbili of 1.8 w normal transaminases. Tbili continued to uptrend during hospitalization and was 2.5 at time of discharge. This was in the setting of a stable H H retic 2.1 and abs retic count within normal limits. Haptoglobin is pending at time of discharge. GGT is also pending at time of discharge. Patient had abdominal U S which demonstrated that she is status post cholecystectomy but had multiple echogeneic foci suspicious for hepatic granulomas. Overall picture is suspicious for biliary conjugation defect e.g. ___ syndrome. Of note however patient did not have bilirubinemia duing prior hospitalization in ___ ___. Patient should have outpatient hepatology follow up and should have repeat LFTs within ___ days of discharge. Diffuse TWI on EKG Coronary artery disease Patient s admission EKG was notable for diffuse TWI. CKMB and trop flat x2. Patient denied chest pain but did endorse dyspnea and feeling as if she was gasping for air as above. Per records from ___ patient had a p mibi scan in ___ showing ischemia and infarct in the LAD territory and her prior EKGs on ___ and ___ showed diffuse TWI similar to that seen on admission EKG here. She was monitored on telemetry and for anginal equivalents throughout her hospitalization. Atrial fibrillation CHADSVASC2 8. Patient is rate controlled at home on atenolol 50mg BID and digoxin 0.125mg daily. Digoxin was initially held until home dose was clarified and was restarted on ___. Digoxin level at time of discharge on ___ was 0.4. Patient was also continued on her home apixaban 5mg BID. Type 2 Diabetes mellitus Patient takes glimepiride 2 mg daily at home. This was held and patient was maintained on house insulin sliding scale while inpatient. Home glimepiride was resumed for discharge. Hypertension Patient was continued on her home hydrochlorothiazide 12.5mg daily amlodipine 5mg daily atenololl 50mg daily and valsartan 160mg daily. Her BP at time of discharge was 104 64. Hyperlipidemia Patient was continued on her home atorvastatin 40mg QPM. Anxiety Patient s home clonazepam 1mg qhs was held initially in the setting of altered mental status as above but was restarted for discharge. TRANSITIONAL Patient was started on albuterol INH 2 puffs q6hr. Patient may benefit from outpatient pulmonary function testing. Patient should have repeat LFTs within ___ days of discharge. At time of discharge haptoglobin and GGT labs are pending. The ___ clinic will contact patient to schedule outpatient hepatology follow up. If the patient does not hear from them within 48hrs of discharge she should call ___ to schedule an appointment. CODE full confirmed CONTACT Daughter ___ ___ Home care extended in ___ ___ ___ ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Atenolol 50 mg PO BID 3. Atorvastatin 40 mg PO QPM 4. ClonazePAM 1 mg PO DAILY 5. Digoxin 0.125 mg PO DAILY 6. Apixaban 5 mg PO BID 7. glimepiride 2 mg oral Other 8. Hydrochlorothiazide 12.5 mg PO DAILY 9. Valsartan 160 mg PO DAILY 10. Aspirin EC 81 mg PO DAILY 11. Vitamin D ___ UNIT PO DAILY 12. Bisacodyl 5 mg PO DAILY PRN constipation Discharge Medications 1. Albuterol Inhaler 2 PUFF IH Q6H 2. glimepiride 2 mg oral DAILY 3. amLODIPine 5 mg PO DAILY 4. Apixaban 5 mg PO BID 5. Aspirin EC 81 mg PO DAILY 6. Atenolol 50 mg PO BID 7. Atorvastatin 40 mg PO QPM 8. Bisacodyl 5 mg PO DAILY PRN constipation 9. ClonazePAM 1 mg PO DAILY 10. Digoxin 0.125 mg PO DAILY 11. Hydrochlorothiazide 12.5 mg PO DAILY 12. Valsartan 160 mg PO DAILY 13. Vitamin D ___ UNIT PO DAILY Discharge Disposition Extended Care Facility ___ Discharge Diagnosis PRIMARY DIAGNOSES Dyspnea Altered mental status Indirect bilirubinemia Coronary artery disease SECONDARY DIAGNOSES Atrial fibrillation Hypertension Hyperlipidemia Type 2 Diabetes mellitus Anxiety Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ It was a pleasure taking care of you Why you were admitted You were admitted with shortness of breath. What we did for you We started you on an albuterol inhaler which helped improve your breathing. We obtained laboratory studies which showed that you have a high bilirubin level which is particular type of liver function test. What you should do when you go home Please continue to use your albuterol inhaler as directed. Please take your other medications as directed. The ___ clinic will contact you to schedule outpatient hepatology follow up. If you do not hear from them within 48hrs of discharge she should call ___ to schedule an appointment. We wish you all the best Your ___ Medicine Team Followup Instructions ___ The icd codes present in this text will be R4182, R0600, F0390, I4891, Z781, R451, R9431, I69320, I10, I2510, E785, J45909, E041, Z7902, E119, K753, R10819, E806, F419, Z9114. The descriptions of icd codes R4182, R0600, F0390, I4891, Z781, R451, R9431, I69320, I10, I2510, E785, J45909, E041, Z7902, E119, K753, R10819, E806, F419, Z9114 are R4182: Altered mental status, unspecified; R0600: Dyspnea, unspecified; F0390: Unspecified dementia without behavioral disturbance; I4891: Unspecified atrial fibrillation; Z781: Physical restraint status; R451: Restlessness and agitation; R9431: Abnormal electrocardiogram [ECG] [EKG]; I69320: Aphasia following cerebral infarction; I10: Essential (primary) hypertension; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; J45909: Unspecified asthma, uncomplicated; E041: Nontoxic single thyroid nodule; Z7902: Long term (current) use of antithrombotics/antiplatelets; E119: Type 2 diabetes mellitus without complications; K753: Granulomatous hepatitis, not elsewhere classified; R10819: Abdominal tenderness, unspecified site; E806: Other disorders of bilirubin metabolism; F419: Anxiety disorder, unspecified; Z9114: Patient's other noncompliance with medication regimen. The common codes which frequently come are I4891, I10, I2510, E785, J45909, Z7902, E119, F419. The uncommon codes mentioned in this dataset are R4182, R0600, F0390, Z781, R451, R9431, I69320, E041, K753, R10819, E806, Z9114.
The icd codes present in this text will be K8020, E785, Z87891, I10, J45909, Z8501, F329, F419. The descriptions of icd codes K8020, E785, Z87891, I10, J45909, Z8501, F329, F419 are K8020: Calculus of gallbladder without cholecystitis without obstruction; E785: Hyperlipidemia, unspecified; Z87891: Personal history of nicotine dependence; I10: Essential (primary) hypertension; J45909: Unspecified asthma, uncomplicated; Z8501: Personal history of malignant neoplasm of esophagus; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified. The common codes which frequently come are E785, Z87891, I10, J45909, F329, F419. The uncommon codes mentioned in this dataset are K8020, Z8501. Allergies ibuprofen NSAIDS Non Steroidal Anti Inflammatory Drug Chief Complaint Symptomatic choledocolithiasis Major Surgical or Invasive Procedure ___ Open cholecystectomy History of Present Illness Mr. ___ is a ___ male with history of symptomatic choledocolithiasis. Patient had ERCP with stent placement on ___. Stent was removed on ___. Patient was followed by Dr. ___ today he is present for elective interval cholecystectomy. Past Medical History Multifocal Parieto occipital CVA ___ left parieto occipital area most affected some left MCA involvement HTN HLD Carotid stenosis s p bilateral CEA AAA without rupture 2.6 cm Aortic dissection not otherwise specified Esophageal adenocarcinoma GERD ___ Esophagus s p ___ fundoplication revision Diverticulitis Adrenal Adenoma Asthma COPD Former smoker 40 pack yrs Asbestos exposure Pneumonia recurrent Chronic pain pain agreement potentially broken ___ Low back pain Urinary frequency Inguinal hernia ventral hernias Prior alcohol abuse Surgical or Invasive Procedure Bilateral carotid endarterectomies Inguinal and ventral hernia repair x4 Endoscopic mucosal resection of mass at ___ junction ___ Revision of ___ Fundoplication Upper EUS ___ ERCP and biliary stent placement ___ Social History ___ Family History Mother CAD PVD Father Liver ca Other Uncles CVA ___ cancer Physical Exam Vitals 98.2 PO 141 75 76 18 93 Ra Gen well appearing AAOX3 HEENT EOMI PERRLA MMM oropharynx clear CV RRR no m r g Lungs CTAB breathing comfortably on RA Abd soft mild ___ tenderness and edema but no erythema or drainage Incision healing well c d I Ext WWP no edema Neuro CN ___ grossly intact motor and sensory ___ bilaterally in upper and lower extremities sensation grossly intact Pertinent Results RECENT LABS ___ 06 40AM BLOOD WBC 9.3 RBC 4.23 Hgb 12.5 Hct 38.1 MCV 90 MCH 29.6 MCHC 32.8 RDW 13.0 RDWSD 43.0 Plt ___ ___ 06 40AM BLOOD Glucose 98 UreaN 9 Creat 0.7 Na 140 K 4.3 Cl 98 HCO3 31 AnGap 11 ___ 03 42AM BLOOD ALT 29 AST 31 AlkPhos 87 TotBili 1.0 ___ 06 40AM BLOOD Calcium 8.8 Phos 3.3 Mg 2.0 Brief Hospital Course The patient was admitted to the General Surgical Service for elective open cholecystectomy. On ___ the patient underwent open cholecystectomy which went well without complication reader referred to the Operative Note for details . After a brief uneventful stay in the PACU the patient arrived on the floor NPO on IV fluids and antibiotics with a foley catheter and Dilaudid PCA for pain control. The patient was hemodynamically stable. Post operative pain was initially well controlled with Dilaudid PCA which was converted to oral pain medication when tolerating clear liquids. The patient was started on sips of clears on POD 1. Diet was progressively advanced as tolerated to a regular diet by POD 2. Patient failed to void post operative and Foley was placed on POD 0. The foley catheter was discontinued at midnight of POD 1. The patient subsequently voided without problem. On POD 1 patient was hypotensive and received fluid boluses. Blood pressure improved on POD 2 and remained stable prior discharge. During this hospitalization the patient ambulated early and frequently was adherent with respiratory toilet and incentive spirrometry and actively participated in the plan of care. Patient anticoagulation was restarted on POD 2 his INR on discharge was 1.1 he will be doing a lovenox bridge and following up with his PCP. At the time of discharge the patient was doing well afebrile with stable vital signs. The patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled. The patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission Albuterol sulfate ProAir HFA 90 mcg HFA inhaler 2 puffs inh prn Atorvastatin 80 Lovenox 80 mg 0.8 mL syringe SQH Levetiracetam 1 000 Lorazepam 1 Metoprolol XL 100 Zofran 4 q8h Pantoprazole 40 Sertraline 100 ohs Trazodone 50 Coumadin Zolpidem 10 when not taking Trazadone Discharge Medications 1. Acetaminophen 1000 mg PO Q8H Do not exceed 4000mg in 24 hours. 2. Docusate Sodium 100 mg PO BID Please use while taking narcotics RX docusate sodium 100 mg 1 capsule s by mouth twice a day as needed Disp 100 Capsule Refills 0 3. Ondansetron ODT 4 mg PO Q8H PRN nausea RX ondansetron 4 mg 1 tablet s by mouth every eight 8 hours Disp 15 Tablet Refills 0 4. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Moderate Do not drive or drink alcohol on this med. RX oxycodone 5 mg 1 tablet s by mouth every ___ hours as needed for pain Disp 30 Tablet Refills 0 5. Senna 8.6 mg PO BID RX sennosides senna 8.6 mg 1 tab by mouth twice a day Disp 60 Tablet Refills 0 6. Atorvastatin 80 mg PO QPM 7. Enoxaparin Sodium 80 mg SC BID lovenox bridge RX enoxaparin 80 mg 0.8 mL 80 mg every twelve 12 hours Disp 30 Syringe Refills 1 8. LevETIRAcetam 1000 mg PO BID 9. LORazepam 1 mg PO TID Do not take this while you take narcotic pain medications like oxycodone. 10. Metoprolol Succinate XL 100 mg PO DAILY 11. ProAir HFA albuterol sulfate 90 mcg actuation inhalation DAILY PRN 12. Sertraline 100 mg PO DAILY 13. TraZODone 50 mg PO QHS PRN sleep 14. Warfarin 5 mg PO DAILY16 Discharge Disposition Home Discharge Diagnosis Choledocolithiasis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Mr. ___ You were admitted to the surgery service at ___ for elective cholecystectomy. You have done well in the post operative period and are now safe to return home to complete your recovery with the following instructions . Please call Dr. ___ office at ___ or Office RNs at ___ if you have any questions or concerns. . Please resume all regular home medications unless specifically advised not to take a particular medication. Also please take any new medications as prescribed. Please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow up with your surgeon who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow up with your surgeon and Primary Care Provider PCP as advised. Incision Care Please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site. Avoid swimming and baths until your follow up appointment. You may shower and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have steri strips they will fall off on their own. Please remove any remaining strips ___ days after surgery. Followup Instructions ___ The icd codes present in this text will be K8020, E785, Z87891, I10, J45909, Z8501, F329, F419. The descriptions of icd codes K8020, E785, Z87891, I10, J45909, Z8501, F329, F419 are K8020: Calculus of gallbladder without cholecystitis without obstruction; E785: Hyperlipidemia, unspecified; Z87891: Personal history of nicotine dependence; I10: Essential (primary) hypertension; J45909: Unspecified asthma, uncomplicated; Z8501: Personal history of malignant neoplasm of esophagus; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified. The common codes which frequently come are E785, Z87891, I10, J45909, F329, F419. The uncommon codes mentioned in this dataset are K8020, Z8501.
The icd codes present in this text will be I63412, J9600, I619, N179, D6869, I959, C160, G8191, J9811, R569, H53462, I10, Z87891, D72829, R109, I714, E785, M545, K219, J449, F329, F419, Z9119. The descriptions of icd codes I63412, J9600, I619, N179, D6869, I959, C160, G8191, J9811, R569, H53462, I10, Z87891, D72829, R109, I714, E785, M545, K219, J449, F329, F419, Z9119 are I63412: Cerebral infarction due to embolism of left middle cerebral artery; J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia; I619: Nontraumatic intracerebral hemorrhage, unspecified; N179: Acute kidney failure, unspecified; D6869: Other thrombophilia; I959: Hypotension, unspecified; C160: Malignant neoplasm of cardia; G8191: Hemiplegia, unspecified affecting right dominant side; J9811: Atelectasis; R569: Unspecified convulsions; H53462: Homonymous bilateral field defects, left side; I10: Essential (primary) hypertension; Z87891: Personal history of nicotine dependence; D72829: Elevated white blood cell count, unspecified; R109: Unspecified abdominal pain; I714: Abdominal aortic aneurysm, without rupture; E785: Hyperlipidemia, unspecified; M545: Low back pain; K219: Gastro-esophageal reflux disease without esophagitis; J449: Chronic obstructive pulmonary disease, unspecified; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified; Z9119: Patient's noncompliance with other medical treatment and regimen. The common codes which frequently come are N179, I10, Z87891, E785, K219, J449, F329, F419. The uncommon codes mentioned in this dataset are I63412, J9600, I619, D6869, I959, C160, G8191, J9811, R569, H53462, D72829, R109, I714, M545, Z9119. Allergies ibuprofen Chief Complaint R sided weakness Major Surgical or Invasive Procedure endoscopic mucosal resection with GI ___ History of Present Illness Mr. ___ is a ___ year old gentleman who awoke this morning at 7am with right sided arm and leg weakness with decreased sensation to light touch. He was last known well last night at 11pm. CT at OSH showed wedge shaped hypodensity in parieto occipital lobe. CTA showed no flow limiting stenosis. Past Medical History PAST MEDICAL HISTORY Post op from ___ fundoplication revision. Pneumonia recurrent Low back pain GERD ___ Esophagus HLD Urinary frequency Inguinal hernia ventral hernias HTN Diverticulitis Asthma Chronic pain pain agreement potentially broken ___ Carotid stenosis AAA without rupture 2.6 cm Aortic dissection not otherwise specified COPD Adrenal Adenoma Esophageal adenocarcinoma Prior alcohol abuse Prior tobacco use Social History ___ Family History Mother CAD PVD Father Liver ca Other Uncles CVA ___ cancer Physical Exam ADMISSION PHYSICAL EXAMINATION Vitals T 98.6 HR 78 BP 110 81 RR 20 SaO2 95 on RA. General Appeared uncomfortable and slightly distressed at rest lying in stretcher bed. HEENT NCAT no oropharyngeal lesions neck supple Pulmonary Breathing comfortably on room air. Extremities Warm no edema Neurologic Examination Mental status Awake alert oriented x 2 said ___ instead of ___. Able to relate history without difficulty. Attentive. Speech is fluent with full sentences intact repetition and intact verbal comprehension. Naming with a few errors with low frequency objects. No paraphasias. No dysarthria. Normal prosody. Able to follow both midline and appendicular commands. Cranial Nerves PERRL 3 2 brisk. Right homonymous hemianopia. EOMI no nystagmus. V1 V3 without deficits to light touch bilaterally. No facial movement asymmetry but slight right facial droop at rest. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Tongue midline. Motor Normal bulk and tone. No drift. No tremor or asterixis. ___ L 5 5 5 5 ___ 5 5 5 5 5 R 4 3 3 3 ___ 3 3 3 3 3 Reflexes Bic Tri ___ Quad Gastroc L 2 UN 2 2 0 R 2 UN 2 2 0 Plantar response flexor bilaterally Sensory Unable to sense pinprick or any touch in right upper extremity. Pinprick felt dull in right lower extremity. No deficits on left upper and lower extremities. Coordination dysmetria with finger to nose testing on left unable to complete FNF on right. Gait Unable to assess. DISCHARGE PHYSICAL EXAM Vitals T 98 BP 115 130 68 96 HR 53 68 RR ___ SpO2 95 98 General Appeared comfortable at rest lying in bed HEENT NCAT no oropharyngeal lesions neck supple Pulmonary Breathing comfortably on room air. Extremities Warm no edema Neurologic Examination Mental status AAOX3 person place full date . Fluent speech with intact repetition and comprehension. Follows multistep axial and appendicular commands without difficulty. Naming intact. No dysarthria. Cranial Nerves PERRL 3 2. EOMI without nystagmus. V1 V3 intact bilaterally. V1 V3 intact to light touchbilaterally. Hearing intact to finger rub bilaterally. Face symmetric with full facial strength. Symmetric palate elevation. Midline tongue with protrusion. No visual field deficits to confrontational testing. Motor Normal bulk and tone throughout. Slight R sided pronator drift No tremor. ___ L 5 5 5 5 ___ 5 5 5 5 5 R 5 5 5 5 ___ 5 5 5 5 5 Sensory Grossly intact to light touch throughout. Coordination Deferred. Gait Deferred. Pertinent Results Admission ___ 02 10PM BLOOD WBC 8.9 RBC 3.87 Hgb 11.6 Hct 35.5 MCV 92 MCH 30.0 MCHC 32.7 RDW 12.7 RDWSD 42.3 Plt ___ ___ 02 10PM BLOOD Neuts 74.1 Lymphs 13.1 Monos 11.8 Eos 0.0 Baso 0.2 Im ___ AbsNeut 6.57 AbsLymp 1.16 AbsMono 1.05 AbsEos 0.00 AbsBaso 0.02 ___ 02 10PM BLOOD ___ PTT 30.8 ___ ___ 02 10PM BLOOD Glucose 86 UreaN 19 Creat 1.4 Na 140 K 4.5 Cl 99 HCO3 27 AnGap 14 ___ 02 10PM BLOOD ALT 36 AST 53 CK CPK 1339 AlkPhos 80 TotBili 0.2 ___ 02 10PM BLOOD CK MB 32 MB Indx 2.4 Discharge ___ 05 10AM BLOOD WBC 10.4 RBC 4.39 Hgb 13.4 Hct 39.6 MCV 90 MCH 30.5 MCHC 33.8 RDW 13.2 RDWSD 43.0 Plt ___ ___ 05 10AM BLOOD ___ PTT 30.2 ___ ___ 05 10AM BLOOD Glucose 84 UreaN 9 Creat 0.9 Na 140 K 3.8 Cl 100 HCO3 27 AnGap 13 ___ 05 10AM BLOOD Calcium 8.6 Phos 4.2 Mg 1.9 ___ 02 03AM BLOOD D Dimer 1655 IMAGING MRI MRA ___ MRI brain Several foci of slow diffusion are demonstrated in the left parieto occipital cortex deep white matter as well as the left frontal lobe see 07 13 15 24 . There is corresponding T2 and FLAIR hyperintensity in these regions. Additionally in the parieto occipital region there is susceptibility suggestive of hemorrhage 11 13 . This is most consistent with multifocal infarcts with hemorrhagic transformation in the parieto occipital portion. Addendum ___ Partially visualized right supra auricular scalp soft tissue enhancement is noted see 105 35 4 15 8 105 64 . Finding is nonspecific however dermal lesion is not excluded on the basis of this examination. Recommend correlation with direct examination. MRA Vessels of the circle of ___ and their major branches are patent without evidence of stenosis occlusion or dissection. There is a right sided dominant vertebrobasilar system. ECHO ___ No definite cardiac source of embolism identified in the setting of suboptimal agitated saline injection. Mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function. Normal right ventricular cavity size and systolic function. Mild to moderate mitral regurgitation. Mild tricuspid regurgitation. CTA HEAD AND CTA NECK 1. Known subacute infarcts within left parietal and occipital lobes. The extent of these are better characterized on the patient s recent MRI examination. 2. Hyperdensity within the dominant left occipital lobe infarct is compatible with hemorrhagic conversion correlating with findings on gradient echo sequences on recent MRI examination. 3. Luminal irregularity involving the left greater than right proximal internal carotid arteries demonstrating a mildly beaded appearance on the left with up to approximately 50 stenosis by NASCET criteria. Findings may reflect noncalcified atherosclerotic disease versus fibromuscular dysplasia. 4. Multifocal calcified atherosclerotic disease within the bilateral V4 segments and cavernous internal carotid arteries. No high grade stenosis occlusion dissection or aneurysm greater than 3 mm. 5. ETT terminating in the lower thoracic trachea near the level of the carina and directed into the proximal right mainstem bronchus. 6. Moderate right pleural effusion and small left pleural effusion with bilateral emphysematous changes and dependent atelectasis. If clinically indicated consider correlation with dedicated chest imaging. BTCPS SPECTRO AND PERF TUMOR CLINIC PROTOCOL ___ MR HEAD 1. Interval evolution of a dominant left parieto occipital infarction with increasing internal hemorrhagic products with surrounding edema and enhancement. 2. Multiple additional areas of known subacute infarction as above several of which also demonstrate increasing internal hemorrhagic components. 3. MR contrast perfusion of the dominant infarct demonstrates increased mean transit time and areas of decreased cerebral blood volume compatible with infarction. 4. ASL perfusion demonstrates several areas curvilinear and focal increased perfusion generally involving the smaller more superior areas of infarction and correlating with areas of enhancement. These findings may represent reactive changes in the setting of recent ischemia. 5. MR spectroscopy of the dominant left parieto occipital infarct is limited secondary to extensive hemorrhagic products within the lesion. Allowing for this there are increased choline and creatinine levels although the choline NAA ratio remains at 1 or below. Associated areas of increased MI creatinine ratio are suggestive of a non neoplastic etiology such as infarction including the possibility of a cortical hemorrhagic venous infarct. Increased lipids and lactate likely correlate with areas of necrosis following infarction. 6. These findings taken together are suggestive of areas of evolving ischemia infarction some of which contain internal hemorrhagic components a venous hemorrhagic cortical infarction is a consideration recommend attention at follow up imaging to further exclude any underlying mass. CT abdomen 1. No retroperitoneal hematoma or active extravasation of contrast in the abdomen or pelvis. 2. Soft tissue stranding in the omentum and gastroesophageal junction presumably related to recent revision of ___ fundoplication. 3. 2 cm right adrenal adenoma mildly increased compared to ___. Brief Hospital Course stroke Mr. ___ is a ___ year old man with history of adrenal adenoma recent esophageal adenocarcinoma AAA without rupture s p bilateral carotid endarterectomies HLD HTN who presented with acute onset right arm and leg weakness with left homonymous hemianopia. Found to have multifocal infarcts with the left parieto occipital area. He was started on heparin drip as it felt that his strokes were likely due to hypercoaguability of malignancy D dimer was 1600 or embolic. TTE showed enlarged left atrial size. MR spect of his brain was performed to assess for underlying malignancy but was unremarkable. He underwent endoscopic mucosal resection of a mass at the GE junction on ___. This procedure had already been planned for prior to admission. Pathology was pending at the time of discharge. He was transitioned from heparin to aspirin 325 mg daily and warfarin. Warfarin was chosen instead of lovenox because of cost considerations and it was felt that self administration of lovenox would not be ideal for him. He was discharged to rehab. An order for an outpatient ___ of hearts event monitor was placed as well. He should be on tele at rehab for post stroke monitoring for afib. He is on high intensity statin atorvastatin 80 mg qhs as well. seizure He had an episode of apnea unwitnessed shaking activity was intubated for airway protection and transferred to NeuroICU for further care and stabilization while on the floor. cvEEG with was with no epileptiform discharges and was discontinued. CTA head and neck negative for acute process. Event felt to be related to seizure in the setting of acute stroke or perhaps may be related to chronic benzodiazepine use as well. He was continued on Keppra 1000 mg BID and transferred to the floor and did not have further seizure activity. He was on IV keppra while vomiting this can be switched to PO at rehab as long as he is tolerating PO. abdominal pain nausea vomiting he was given PRN Zofran and reglan. CT A P was unremarkable. Improved after resection of esophageal mass. Given PRN tramadol. Occasionally received low doses of morphine. He was on IV fluids due to his vomiting. This can be discontinued once his PO intake is more consistent. esophageal mass resected by GI on ___. He should be on an IV PPI for 7 days post procedure until ___ to prevent bleeding per GI recs. He is on esomeprazole 40 mg q12h. Afterwards he should be on oral PPI pantoprazole 40 mg BID. Chronic issues held home hypertensives due to hypotension these can be resumed as tolerated. He is on metoprolol succinate 100 mg daily at home. Transitional issues Stroke titrate warfarin until therapeutic goal INR ___ discontinue aspirin 325 mg daily once therapeutic on warfarin for 24 hours ___ of hearts monitor ordered as an outpatient follow up results should be referred to neurology by his PCP as he is an Atrius patient seizure keppra 1 gm BID until seen by neurology should be referred to neurology by his PCP as he is an Atrius patient esophageal resection follow up with GI as an outpatient should continue on IV PPI until ___ per GI he is on esomeprazole 40 mg q12h then should be oral PPI pantoprazole 40 mg BID. follow up pathology from biopsy 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 113 No 5. Intensive statin therapy administered simvastatin 80mg simvastatin 80mg ezetemibe 10mg atorvastatin 40mg or 80 mg rosuvastatin 20mg or 40mg for LDL 70 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 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 x Antiplatelet x 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. Atorvastatin 80 mg PO DAILY 2. LORazepam 0.5 mg PO BID PRN anxiety sleep 3. Albuterol Sulfate Extended Release Dose is Unknown PO DAILY PRN asthma 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Sertraline 25 mg PO DAILY 6. TraZODone 50 mg PO QHS 7. Zolpidem Tartrate 10 mg PO QHS 8. Nicotine Patch 14 mg TD DAILY 9. Pantoprazole 40 mg PO BID 10. Sucralfate 1 gm PO QIDACHS 11. Aspirin 81 mg PO DAILY Discharge Medications 1. Albuterol Inhaler 2 PUFF IH Q4H PRN wheezing 2. Docusate Sodium 100 mg PO BID PRN constipation 3. Esomeprazole sodium 40 mg IV Q12H 4. LevETIRAcetam 1000 mg PO BID 5. Metoclopramide 10 mg IV Q6H PRN Nausea 6. Ondansetron 4 mg IV Q8H PRN nausea 7. Senna 8.6 mg PO BID PRN Constipation 8. TraMADol 50 mg PO Q6H PRN Pain Moderate 9. Warfarin 5 mg PO DAILY16 10. Aspirin 325 mg PO DAILY 11. Atorvastatin 80 mg PO QPM 12. Sertraline 50 mg PO DAILY 13. TraZODone 50 mg PO QHS PRN insomnia 14. LORazepam 0.5 mg PO BID PRN anxiety sleep 15. Metoprolol Succinate XL 100 mg PO DAILY 16. Nicotine Patch 14 mg TD DAILY 17. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Mutlifocal parieto occipital strokes Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Neuro exam nonfocal Discharge Instructions Dear Mr. ___ You were hospitalized here after your were presented with acute onset right arm and leg weakness with visual problems 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. The etiology may be due to increased chance of clotting due to cancer but an abnormal heart rhythm causing clots traveling to your brain also remain as a possibility. You were temporarily on a blood thinner on IV heparin we changed this to aspirin 325 mg daily and started a blood thinner called warfarin for anticoagulation to decrease your risk of strokes. The aspirin is temporary until the warfarin has completely taken effect. You should continue taking these medications as indicated. New medications Aspirin 325 mg daily this should be discontinued once your warfarin has completely kicked in in other words once your INR is ___. warfarin 5 mg daily your dose will be adjusted at rehab to reach the goal INR Please follow up with Neurology and your primary care physician as listed below. If you 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 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 I63412, J9600, I619, N179, D6869, I959, C160, G8191, J9811, R569, H53462, I10, Z87891, D72829, R109, I714, E785, M545, K219, J449, F329, F419, Z9119. The descriptions of icd codes I63412, J9600, I619, N179, D6869, I959, C160, G8191, J9811, R569, H53462, I10, Z87891, D72829, R109, I714, E785, M545, K219, J449, F329, F419, Z9119 are I63412: Cerebral infarction due to embolism of left middle cerebral artery; J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia; I619: Nontraumatic intracerebral hemorrhage, unspecified; N179: Acute kidney failure, unspecified; D6869: Other thrombophilia; I959: Hypotension, unspecified; C160: Malignant neoplasm of cardia; G8191: Hemiplegia, unspecified affecting right dominant side; J9811: Atelectasis; R569: Unspecified convulsions; H53462: Homonymous bilateral field defects, left side; I10: Essential (primary) hypertension; Z87891: Personal history of nicotine dependence; D72829: Elevated white blood cell count, unspecified; R109: Unspecified abdominal pain; I714: Abdominal aortic aneurysm, without rupture; E785: Hyperlipidemia, unspecified; M545: Low back pain; K219: Gastro-esophageal reflux disease without esophagitis; J449: Chronic obstructive pulmonary disease, unspecified; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified; Z9119: Patient's noncompliance with other medical treatment and regimen. The common codes which frequently come are N179, I10, Z87891, E785, K219, J449, F329, F419. The uncommon codes mentioned in this dataset are I63412, J9600, I619, D6869, I959, C160, G8191, J9811, R569, H53462, D72829, R109, I714, M545, Z9119.
The icd codes present in this text will be T814XXA, L02211, Y838, Y929, E860, R110, Z8673, I10, E785, Z8501, K219, J45909, Z87891, G8929. The descriptions of icd codes T814XXA, L02211, Y838, Y929, E860, R110, Z8673, I10, E785, Z8501, K219, J45909, Z87891, G8929 are T814XXA: Infection following a procedure; L02211: Cutaneous abscess of abdominal wall; 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; E860: Dehydration; R110: Nausea; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z8501: Personal history of malignant neoplasm of esophagus; K219: Gastro-esophageal reflux disease without esophagitis; J45909: Unspecified asthma, uncomplicated; Z87891: Personal history of nicotine dependence; G8929: Other chronic pain. The common codes which frequently come are Y929, Z8673, I10, E785, K219, J45909, Z87891, G8929. The uncommon codes mentioned in this dataset are T814XXA, L02211, Y838, E860, R110, Z8501. Allergies ibuprofen NSAIDS Non Steroidal Anti Inflammatory Drug Chief Complaint Abdominal wall abscess Major Surgical or Invasive Procedure ___ Ultrasound guided drainage of superficial right abdominal collection History of Present Illness We have been consulted on this patient known to Dr. ___ who is status post open cholecystectomy for choledocolothiasis who presents to the ED with dehydration leukocytosis and clinical radiological findings concerning for abdominal wall abscess He s a ___ year old very frail male with medical history pertinent for multifocal parieto occipital CVA carotid stenosis s p bilateral CEA COPD HTN HLD history of a Nissen fundoplication and a subsequent takedown ___ esophagus that progressed to esophageal carcinoma. As above he is status post open cholecystectomy performed for choledocholithiasis on ___ with uncomplicated postoperative course and discharged home on POD 3. Since discharge he endorses area of swelling pain and ecchymosis at his incision. He was given Rx for Oxycodone post op used these but still in pain. He presented to PCP to follow on these symptoms on ___. At that time he was found with area of ecchymosis and distention at incision site as well as tender to palpation. A CT abdomen was performed which demonstrated postsurgical changes as well as a postoperative seroma along the right rectus musculature measuring approximately 2.2 cm. He presents to the ED today with progression of symptoms more specifically he feels a lump at his incision. Denies any fever nausea chills chest pain shortness of breath change in bowel habits GI bleeding. Of note he endorses lack of appetite but this seems usual after each of the prior operations he has had as well as intermittent dysuria. Upon arrival to the ED VS 98.8 66 108 66 16 97 RA. He is no in acute distress but oral mucosa is dry. Abdominal exam notable for area of swelling to subcostal incision with two ecchymotic areas at the mid portion of the incision. I could not express any purulent material of the incision. Slight tenderness to palpation. Otherwise abdomen is soft. Outside hospital labs remarkable for leukocytosis to 15 and hypokalemia. Liver function test unrevealing. Outside hospital CT abdomen performed today demonstrating a 7cm walled off collection with some fat stranding at the right upper quadrant abdominal wall. This collection seems not to communicate with the abdominal wall cavity. I could not appreciate any intraabdominal process. 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 Per HPI. Multifocal Parieto occipital CVA ___ left parieto occipital area most affected some left MCA involvement HTN HLD carotid stenosis s p bilateral CEA AAA without rupture 2.6 cm Aortic dissection not otherwise specified Esophageal adenocarcinoma GERD ___ Esophagus s p Nissen fundoplication revision Diverticulitis Adrenal Adenoma Asthma COPD Former smoker 40 pack yrs Asbestos exposure Pneumonia recurrent Chronic pain pain agreement potentially broken ___ Low back pain Urinary frequency Inguinal hernia ventral hernias Prior alcohol abuse Past Surgical History Per HPI. Bilateral carotid endarterectomies Inguinal and ventral hernia repair x4 Endoscopic mucosal resection of mass at ___ junction ___ ___ and revision of ___ Fundoplication Upper EUS ___ ERCP and biliary stent placement ___ Social History ___ Family History Mother CAD PVD Father Liver ca Other Uncles CVA ___ cancer Physical Exam Physical Exam on arrival Vitals 98.8 66 108 66 16 97 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 nondistended nontender no rebound or guarding normoactive bowel sounds no palpable masses DRE normal tone no gross or occult blood Ext No ___ edema ___ warm and well perfused Physical Exam on arrival Vitals Stable 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 nondistended nontender no rebound or guarding normoactive bowel sounds no palpable masses upper quadrant wound packed with wick healing appropriately Ext No ___ edema ___ warm and well perfused Pertinent Results Lab Results ___ 05 22AM BLOOD WBC 8.1 RBC 3.63 Hgb 10.7 Hct 31.7 MCV 87 MCH 29.5 MCHC 33.8 RDW 12.0 RDWSD 39.1 Plt ___ ___ 06 00AM BLOOD WBC 9.2 RBC 3.68 Hgb 11.0 Hct 32.1 MCV 87 MCH 29.9 MCHC 34.3 RDW 12.3 RDWSD 39.5 Plt ___ ___ 05 42AM BLOOD WBC 9.7 RBC 3.70 Hgb 10.6 Hct 32.9 MCV 89 MCH 28.6 MCHC 32.2 RDW 12.4 RDWSD 40.2 Plt ___ ___ 06 45AM BLOOD WBC 12.0 RBC 3.83 Hgb 10.9 Hct 33.3 MCV 87 MCH 28.5 MCHC 32.7 RDW 12.5 RDWSD 40.0 Plt ___ ___ 08 18AM BLOOD WBC 11.6 RBC 3.65 Hgb 10.8 Hct 32.5 MCV 89 MCH 29.6 MCHC 33.2 RDW 12.5 RDWSD 40.6 Plt ___ ___ 04 35AM BLOOD WBC 14.5 RBC 3.84 Hgb 11.1 Hct 33.4 MCV 87 MCH 28.9 MCHC 33.2 RDW 12.5 RDWSD 39.7 Plt ___ ___ 05 22AM BLOOD Neuts 60.2 ___ Monos 12.5 Eos 5.2 Baso 0.5 Im ___ AbsNeut 4.88 AbsLymp 1.69 AbsMono 1.01 AbsEos 0.42 AbsBaso 0.04 ___ 08 18AM BLOOD Neuts 68.6 Lymphs 17.3 Monos 12.8 Eos 0.2 Baso 0.3 Im ___ AbsNeut 7.98 AbsLymp 2.01 AbsMono 1.49 AbsEos 0.02 AbsBaso 0.04 ___ 04 35AM BLOOD Neuts 74.2 Lymphs 11.5 Monos 13.0 Eos 0.0 Baso 0.4 Im ___ AbsNeut 10.76 AbsLymp 1.67 AbsMono 1.88 AbsEos 0.00 AbsBaso 0.06 ___ 05 22AM BLOOD Glucose 80 UreaN 6 Creat 1.2 Na 140 K 3.5 Cl 97 HCO3 31 AnGap 12 ___ 06 00AM BLOOD Glucose 100 UreaN 5 Creat 1.1 Na 141 K 3.4 Cl 99 HCO3 29 AnGap 13 ___ 05 42AM BLOOD Glucose 90 UreaN 9 Creat 1.3 Na 143 K 3.9 Cl 99 HCO3 29 AnGap 15 ___ 06 45AM BLOOD Glucose 87 UreaN 6 Creat 0.8 Na 136 K 3.3 Cl 93 HCO3 29 AnGap 14 ___ 08 18AM BLOOD Glucose 89 UreaN 14 Creat 0.8 Na 142 K 3.6 Cl 106 HCO3 26 AnGap 10 ___ 04 35AM BLOOD Glucose 106 UreaN 17 Creat 0.9 Na 140 K 3.9 Cl 103 HCO3 25 AnGap 12 ___ 05 22AM BLOOD Plt ___ ___ 05 22AM BLOOD ___ PTT 37.7 ___ ___ 09 50PM BLOOD PTT 36.3 ___ 01 20PM BLOOD PTT 49.3 Imaging PERC IMAGE GUID FLUID COLLECT DRAIN W CATH ___ IMPRESSION Successful US guided placement of ___ pigtail catheter into the right abdominal wall collection. Sample was sent for microbiology evaluation. Microbiology results from drain GRAM STAIN Final ___ 4 10 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. 2 ___ per 1000X FIELD GRAM NEGATIVE ROD S . FLUID CULTURE Final ___ NO GROWTH. ANAEROBIC CULTURE Preliminary ANAEROBIC GRAM NEGATIVE ROD S . SPARSE GROWTH Brief Hospital Course The patient presented to Emergency Department on ___. Patient was found to have an abdominal wall abscess. For this reason he was admitted to the ___ Surgery for further management. On admission the patient s INR was 4.3 and for this reason it was not possible to have the abscess drained on presentation. For this reason he was admitted for further management. His Coumadin was held and he was also given fresh frozen plasma and vitamin K. The following day the patient went to ___ and got the fluid drained and a drainage was placed. The fluid collected from the peritoneal fluid collected it grew sparse anaerobic gram negative rods for full results please see results section of discharge summary . The patient s creatinine was elevated to 1.3 during the admission and for this reason he was started on IV normal saline. Following the ___ procedure the patient was restarted on a heparin drip. The heparin drip was then stopped and the patient was placed on warfarin with lovenox bridging. His creatinine function was downtrending. On discharge his INR was therapeutic and his lovenox was discontinued. Furthermore in summary during this hospital course review of systems had as follow Neuro The patient was alert and oriented throughout hospitalization pain was well controlled with acetaminophen and oxycodone. CV The patient remained stable from a cardiovascular standpoint vital signs were routinely monitored. He had two episodes of asymptomatic high blood pressure that responded to IV hydrazine. 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 The patient was on a regular diet which was well tolerated. Patient s intake and output were closely monitored. He had two episodes of emesis during the hospital course that did not require further work up at the time. ID The patient s fever curves were closely watched for signs of infection of which there were none. When the patient s admission the ___ was 14 that was within normal limits on discharge. The patient was placed on IV antibiotics Vancomycin and zosyn that was transitioned to oral augmentin on discharge. The patient needs to complete a two weeks course of augmentin upon discharge. HEME The patient s blood counts were closely watched for signs of bleeding of which there were none. The patient was bridged back to Coumadin with lovenox. The INR level was appropriate at the time of discharge. Prophylaxis ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. Social work During this hospital course the patient expressed feelings of having difficulty coping. For this reason a social work consult was obtained and coping strategies and resources were put in place. At the time of discharge the patient was doing well afebrile and hemodynamically stable. The patient was tolerating a diet ambulating voiding without assistance and pain was well controlled. The patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler 2 PUFF IH Q6H PRN wheezing 2. Atorvastatin 80 mg PO QPM 3. Zolpidem Tartrate 10 mg PO QHS ___ MD to order daily dose PO DAILY16 5. TraZODone 50 mg PO QHS PRN insomnia 6. Sertraline 100 mg PO DAILY 7. Pantoprazole 40 mg PO Q12H 8. Ondansetron 4 mg PO Q8H PRN nausea 9. Metoprolol Succinate XL 100 mg PO DAILY 10. LORazepam 1 mg PO Q8H PRN anxiety 11. LevETIRAcetam 1000 mg PO BID 12. Enoxaparin Sodium 70 mg SC Q12H Start ___ First Dose Next Routine Administration Time Discharge Medications 1. Acetaminophen ___ mg PO Q8H PRN Pain Mild Reason for PRN duplicate override Patient is NPO or unable to tolerate PO RX acetaminophen 500 mg 2 tablet s by mouth every 8 hours Disp 30 Tablet Refills 0 2. Amoxicillin Clavulanic Acid ___ mg PO Q12H RX amoxicillin pot clavulanate 875 mg 125 mg 1 tab by mouth twice a day Disp 17 Tablet Refills 0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet s by mouth twice a day Disp 30 Tablet Refills 0 4. OxyCODONE Immediate Release 5 mg PO Q8H PRN Pain Mild RX oxycodone 5 mg 1 tablet s by mouth every eight 8 hours Disp 9 Tablet Refills 0 RX oxycodone 5 mg ___ tablet s by mouth every 8 hours Disp 25 Tablet Refills 0 5. Senna 8.6 mg PO BID 6. Albuterol Inhaler 2 PUFF IH Q6H PRN wheezing 7. Atorvastatin 80 mg PO QPM 8. Enoxaparin Sodium 70 mg SC Q12H If your INR is between ___ you can stop taking this medication. RX enoxaparin 80 mg 0.8 mL 70 mg SC every twelve 12 hours Disp 10 Syringe Refills 0 9. LevETIRAcetam 1000 mg PO BID 10. LORazepam 1 mg PO Q8H PRN anxiety 11. Metoprolol Succinate XL 100 mg PO DAILY 12. Ondansetron 4 mg PO Q8H PRN nausea 13. Pantoprazole 40 mg PO Q12H 14. Sertraline 100 mg PO DAILY 15. TraZODone 50 mg PO QHS PRN insomnia 16. ___ MD to order daily dose PO DAILY16 17. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition Home Discharge Diagnosis Abdominal wall 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 ___ Surgery because you were found to have an abdominal wall abscess. You were placed on antibiotics and your anticoagulation was reversed. Then you had the abdominal wall abscess drained and have recovered well. You are now ready for discharge. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following You experience new chest pain pressure squeezing or tightness. New or worsening cough shortness of breath or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting diarrhea or other reasons. Signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing. You see blood or dark black material when you vomit or have a bowel movement. You experience burning when you urinate have blood in your urine or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms or any new symptoms that concern you. Please resume all regular home medications unless specifically advised not to take a particular medication. Also please take any new medications as prescribed. Please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Coumadin Please follow up with your PCP ___ ___ for an INR check and instructions on dosing your warfarin. Antibiotics Please complete the full 9 day course finish all the pills that you were prescribed at discharge. Incision Care Your dressing was changed on the day of discharge. Please continue to change it daily with clean dry gauze until it heals or scabs over. Then you should keep it covered only as needed. Please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site. Avoid swimming and baths until your follow up appointment. You may shower and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples they will be removed at your follow up appointment. If you have steri strips they will fall off on their own. Please remove any remaining strips ___ days after surgery. It has been a pleasure looking after you and we wish you a speedy recovery. ___ Surgery Followup Instructions ___ The icd codes present in this text will be T814XXA, L02211, Y838, Y929, E860, R110, Z8673, I10, E785, Z8501, K219, J45909, Z87891, G8929. The descriptions of icd codes T814XXA, L02211, Y838, Y929, E860, R110, Z8673, I10, E785, Z8501, K219, J45909, Z87891, G8929 are T814XXA: Infection following a procedure; L02211: Cutaneous abscess of abdominal wall; 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; E860: Dehydration; R110: Nausea; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z8501: Personal history of malignant neoplasm of esophagus; K219: Gastro-esophageal reflux disease without esophagitis; J45909: Unspecified asthma, uncomplicated; Z87891: Personal history of nicotine dependence; G8929: Other chronic pain. The common codes which frequently come are Y929, Z8673, I10, E785, K219, J45909, Z87891, G8929. The uncommon codes mentioned in this dataset are T814XXA, L02211, Y838, E860, R110, Z8501.
The icd codes present in this text will be K8050, E785, I10, Z8501, Z87891, I69398, K219, J45909, F329, F419. The descriptions of icd codes K8050, E785, I10, Z8501, Z87891, I69398, K219, J45909, F329, F419 are K8050: Calculus of bile duct without cholangitis or cholecystitis without obstruction; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; Z8501: Personal history of malignant neoplasm of esophagus; Z87891: Personal history of nicotine dependence; I69398: Other sequelae of cerebral infarction; K219: Gastro-esophageal reflux disease without esophagitis; J45909: Unspecified asthma, uncomplicated; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified. The common codes which frequently come are E785, I10, Z87891, K219, J45909, F329, F419. The uncommon codes mentioned in this dataset are K8050, Z8501, I69398. Allergies ibuprofen Chief Complaint post ERCP Major Surgical or Invasive Procedure ERCP with sphincterotomy and CBD stent placement History of Present Illness Mr. ___ is a ___ male with history of HTN HL PAD former alcohol abuse recent multifocal CVA started on Coumadin post CVA course complicated by seizure now on AEDs GERD ___ s p Nissen fundoplication with recent revision and newly diagnosed Esophageal adenocarcinoma who p w biliary obstruction and underwent ERCP for CBD stone with biliary stent placement earlier today now admitted for post ERCP care. He initially presented with w elevated LFT s found to have a CBD stone on EUS ___. Today ___ he underwent ERCP with biliary sphincterotomy after PD stent to assist cannulation balloon sweeps performed but no clear stones removed. There was question of retroperitoneal contrast extravasation during procedure concerning for possible small perforation in the distal CBD for which fully covered biliary metal stent was placed treatment of choice . He is expected to have some pain given above. Per ERCP fellow plan to keep NPO today with IVF abx advance to clears in AM and resume lovenox on ___. Patient was started on Coumadin in ___ of this year after presenting with acute multifocal CVA with left parieto occipital area most affected but also with left MCA involvement. This was thought to be related to hypercoagulability of malignancy and decision made to start patient on Coumadin for secondary stroke prevention. At the time Coumadin was thought to be preferable over Lovenox due to concern that he would not be able to self administer Lovenox. More recently in the setting of planned endoscopic procedures his Coumadin has been held since ___ and he has been on Lovenox instead with plan to continue through both his endoscopic procedures EUS on ___ ERCP ___. Per instructions his ___ dose of Lovenox the night before each procedure has been held. Per ERCP recs will continue to hold Lovenox until ___ at least. On arrival to the floor patient stated that his pain and nausea improved after Zofran and dilaudid. He reports poor po intake since ___ with persistent N V and RUQ abdominal pain. He denies fevers chills SOB cough chest pain dysuria. He does note mild hematochezia with his BM s this morning. He states he has not taken his keppra since discharge from rehab 3 weeks ago because he didn t have refills but denies any episodes of seizure like activity. He ambulates with cane and has been continuing with outpatient ___ and speech therapy since discharge from rehab. ROS Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History Multifocal Parieto occipital CVA ___ left parieto occipital area most affected some left MCA involvement HTN HLD Carotid stenosis s p bilateral CEA AAA without rupture 2.6 cm Aortic dissection not otherwise specified Esophageal adenocarcinoma GERD ___ Esophagus s p Nissen fundoplication revision Diverticulitis Adrenal Adenoma Asthma COPD Former smoker 40 pack yrs Asbestos exposure Pneumonia recurrent Chronic pain pain agreement potentially broken ___ Low back pain Urinary frequency Inguinal hernia ventral hernias Prior alcohol abuse Surgical or Invasive Procedure Bilateral carotid endarterectomies Inguinal and ventral hernia repair x4 Endoscopic mucosal resection of mass at GE junction ___ Revision of ___ Fundoplication Upper EUS ___ ERCP and biliary stent placement ___ Social History ___ Family History Mother CAD PVD Father Liver ca Other Uncles CVA ___ cancer Physical Exam ADMISSION EXAM VITALS 97.8 P 68 BP 164 97 RR 17 93 on RA GENERAL Alert and in no apparent distress EYES Anicteric pupils equally round ENT Ears and nose without visible erythema masses or trauma. Oropharynx without visible lesion erythema or exudate. Dry MM. 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. Old surgical scars across abdomen. Marks from Lovenox injection sites on left side of abdomen. GU No suprapubic fullness or tenderness to palpation MSK Neck supple moves all extremities 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 VITALS 97.9PO 153 89 59 18 93 RA GENERAL Alert and in no apparent distress EYES Anicteric pupils equally round ENT Ears and nose without visible erythema masses or trauma. Oropharynx without visible lesion erythema or exudate. Dry MM. 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. Old surgical scars across abdomen. Marks from Lovenox injection sites on left side of abdomen. GU No suprapubic fullness or tenderness to palpation MSK Neck supple moves all extremities 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 Pertinent Results ADMISSION LABS ___ 12 50PM BLOOD WBC 6.0 RBC 4.12 Hgb 12.5 Hct 36.6 MCV 89 MCH 30.3 MCHC 34.2 RDW 13.2 RDWSD 43.3 Plt ___ ___ 12 50PM BLOOD ___ PTT 33.1 ___ ___ 12 50PM BLOOD UreaN 13 Creat 0.9 Na 141 K 3.3 Cl 97 HCO3 33 AnGap 11 ___ 12 50PM BLOOD ALT 22 AST 20 AlkPhos 77 Amylase 51 TotBili 0.5 DISCHARGE LABS ___ 07 13AM BLOOD WBC 6.4 RBC 4.00 Hgb 11.9 Hct 35.6 MCV 89 MCH 29.8 MCHC 33.4 RDW 13.2 RDWSD 43.3 Plt ___ ___ 07 13AM BLOOD Glucose 87 UreaN 6 Creat 0.8 Na 142 K 3.6 Cl 98 HCO3 35 AnGap 9 ___ 07 13AM BLOOD ALT 15 AST 14 AlkPhos 80 TotBili 0.5 ___ 07 13AM BLOOD Albumin 3.6 Calcium 8.7 Mg 1.8 ___ ERCP Report Impression The scout film was normal. During difficult biliary cannulation the pancreatic duct was partially filled with contrast and visualized proximally. The course and caliber of the duct was normal with no evidence of filling defects masses chronic pancreatitis or other abnormalities. To aid in difficult biliary cannulation a ___ x 5 cm single pigtail plastic pancreatic duct stent was placed. The bile duct was deeply cannulated with the sphincterotome. Contrast was injected and there was brisk flow through the ducts. Contrast extended to the entire biliary tree. The CBD was 6 mm in diameter. There was no clear evidence of a filling defect. Opacification of the gallbladder was incomplete. The left and right hepatic ducts and all intrahepatic branches were normal. Given CBD stone seen on EUS a biliary sphincterotomy was made with a sphincterotome. There was no post sphincterotomy bleeding. The biliary tree was swept with a 9 12mm balloon starting at the bifurcation. Scant sludge was removed successfully. Given evidence of a small amount of contrast extravasation near the distal CBD compatible with possible small perforation a 10mm x 60 mm ___ ___ REF ___ LOT ___ fully covered metal biliary stent was placed. The final occlusion cholangiogram showed no evidence of filling defects in the CBD. Excellent bile and contrast drainage was seen endoscopically and fluoroscopically. Otherwise normal ercp to third part of the duodenum Recommendations Admit to hospital for monitoring NPO overnight with aggressive IV hydration with LR at 200 cc hr If no abdominal pain in the morning advance diet to clear liquids and then advance as tolerated Recommend surgical evaluation for possible cholecystectomy in the future once fully covered metal stent is removed Resume lovenox on ___ Continue with antibiotics Ciprofloxacin 500mg BID x 5 days. Repeat ERCP in 4 weeks for PD and CBD stent pull and re evaluation. Follow for response and complications. If any abdominal pain fever jaundice gastrointestinal bleeding please call Advanced Endoscopy Fellow on call ___ Brief Hospital Course Mr. ___ is a ___ male with history of HTN HL PAD former alcohol abuse recent multifocal CVA started on Coumadin post CVA course complicated by seizure now on AEDs GERD ___ s p ___ fundoplication with recent revision and newly diagnosed Esophageal adenocarcinoma who p w biliary obstruction and underwent ERCP for CBD stone with biliary stent placement now admitted for post ERCP care. CBD Stone s p ERCP He initially presented with w elevated LFT s found on EUS ___ to have a CBD stone. He underwent ERCP with biliary sphincterotomy after PD stent to assist cannulation balloon sweeps no clear stones removed. There was question of retroperitoneal contrast extravasation during procedure concerning for possible small perforation in the distal CBD for which fully covered biliary metal stent placed which is treatment of choice . Can have some expected pain due to this. He was monitored post procedure and was noted to have stable labs vitals and exam. He was tolerating a regular diet on discharge. Sent home with a few days of oxycodone for post procedural pain. He will also complete 5 days of Ciprofloxacin. Pt will be called to return for repeat ERCP in 4 weeks for stent pull and evaluation. He was also provided with number for Surgery clinic to discuss optimal timing of ccy. Chronic anticoagulation Coumadin held since ___. Anticoagulation Indication Stroke TIA INR goal 2.0 3.0 last outpatient INR 2.2 on ___ Plan ___ Hold ___ Hold ___ Hold ___ Hold ___ Hold ___ 6 mg ___ 6 mg ___ 6 mg. Next INR check ___. Resumed ___ on ___ per ERCP team CHRONIC STABLE PROBLEMS Recently diagnosed Esophageal Adenocarcinoma mass at ___ junction s p endoscopic mucosal resection in ___ c w low grade Adenocarcinoma. Per outpatient notes from ___ found to have positive resection margins but Surgery recommended against esophagectomy given recent CVA. He will f u with OP providers ___ CVA c b seizure A C plan as above restarted keppra HTN continued home antihypertensives HL continued home statin GERD continued home PPI Asthma COPD prn inhalers Hx depression anxiety insomnia continude home SSRI prn ativan Billing greater than 30 minutes spent on discharge counseling and coordination of care. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Zolpidem Tartrate 10 mg PO QHS 2. Atorvastatin 80 mg PO QPM 3. Pantoprazole Granules for ___ ___ 20 mg PO DAILY 4. Sertraline 100 mg PO QHS 5. TraZODone 100 mg PO QHS PRN sleep if not taking ambien 6. LORazepam 1 mg PO Q8H PRN anxiety 7. Albuterol Inhaler 2 PUFF IH Q4H PRN wheezing 8. Docusate Sodium 100 mg PO BID PRN constipation 9. LevETIRAcetam 1000 mg PO BID 10. Senna 8.6 mg PO BID PRN Constipation 11. Warfarin 6 mg PO DAILY16 12. Metoprolol Succinate XL 100 mg PO DAILY 13. Nicotine Patch 14 mg TD DAILY 14. Enoxaparin Sodium 80 mg SC Q12H 15. Ondansetron 4 mg PO Q8H PRN nausea Discharge Medications 1. Ciprofloxacin HCl 500 mg PO Q12H Duration 5 Days RX ciprofloxacin HCl 500 mg 1 tablet s by mouth every 12 hours Disp 6 Tablet Refills 0 2. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg ___ tablet s by mouth every ___ hours Disp 20 Tablet Refills 0 3. Albuterol Inhaler 2 PUFF IH Q4H PRN wheezing 4. Atorvastatin 80 mg PO QPM 5. Docusate Sodium 100 mg PO BID PRN constipation 6. Enoxaparin Sodium 80 mg SC Q12H 7. LevETIRAcetam 1000 mg PO BID 8. LORazepam 1 mg PO Q8H PRN anxiety 9. Metoprolol Succinate XL 100 mg PO DAILY 10. Nicotine Patch 14 mg TD DAILY 11. Ondansetron 4 mg PO Q8H PRN nausea 12. Pantoprazole Granules for ___ ___ 20 mg PO DAILY 13. Senna 8.6 mg PO BID PRN Constipation 14. Sertraline 100 mg PO QHS 15. TraZODone 100 mg PO QHS PRN sleep if not taking ambien 16. Warfarin 6 mg PO DAILY16 17. Zolpidem Tartrate 10 mg PO QHS Discharge Disposition Home Discharge Diagnosis Choledocholithiasis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You came in with abdominal pain and abnormal liver tests. We did a procedure called an ERCP which showed you had a gallstone obstructing your bile duct. They cleared the stone and placed a stent to assist drainage of the duct. You tolerated this procedure well. You will need a repeat ERCP in 4 weeks for reevaluation and stent removal. You will get called by the Endoscopy Department for this appointment. Please call ___ and make an appointment in the Surgery Department to discuss timing of gallbladder removal. It was a pleasure taking care of you at ___ ___ ___. Followup Instructions ___ The icd codes present in this text will be K8050, E785, I10, Z8501, Z87891, I69398, K219, J45909, F329, F419. The descriptions of icd codes K8050, E785, I10, Z8501, Z87891, I69398, K219, J45909, F329, F419 are K8050: Calculus of bile duct without cholangitis or cholecystitis without obstruction; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; Z8501: Personal history of malignant neoplasm of esophagus; Z87891: Personal history of nicotine dependence; I69398: Other sequelae of cerebral infarction; K219: Gastro-esophageal reflux disease without esophagitis; J45909: Unspecified asthma, uncomplicated; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified. The common codes which frequently come are E785, I10, Z87891, K219, J45909, F329, F419. The uncommon codes mentioned in this dataset are K8050, Z8501, I69398.
The icd codes present in this text will be K219, C159, Z9049, K660, Z87891, J449, E785, I10, I739, Z7901, I69398, R569, F329, F419. The descriptions of icd codes K219, C159, Z9049, K660, Z87891, J449, E785, I10, I739, Z7901, I69398, R569, F329, F419 are K219: Gastro-esophageal reflux disease without esophagitis; C159: Malignant neoplasm of esophagus, unspecified; Z9049: Acquired absence of other specified parts of digestive tract; K660: Peritoneal adhesions (postprocedural) (postinfection); Z87891: Personal history of nicotine dependence; J449: Chronic obstructive pulmonary disease, unspecified; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; I739: Peripheral vascular disease, unspecified; Z7901: Long term (current) use of anticoagulants; I69398: Other sequelae of cerebral infarction; R569: Unspecified convulsions; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified. The common codes which frequently come are K219, Z87891, J449, E785, I10, Z7901, F329, F419. The uncommon codes mentioned in this dataset are C159, Z9049, K660, I739, I69398, R569. Allergies ibuprofen NSAIDS Non Steroidal Anti Inflammatory Drug Chief Complaint GERD Major Surgical or Invasive Procedure ___ Laparoscopic lysis of adhesions. History of Present Illness ___ is a ___ former ___ py smoker with hx of prior ___ repair s p ___ EGD lap lysis of adhesions takedown of prior fundoplication closure of diaphragm for treatment by EMR of recently diagnosed T1 esophageal cancer. Unfortunately following discharge from hospital he had a parieto occipital stroke and had undergone intense rehabilitation. He continues to be followed closely by GI for his esophageal ca with EGD q 6 months with last on ___ showed no malignancy. He presents for discussion of consideration of redo fundo. He reports worsening of his GERD symptoms even though he is on protonix 40 mg twice a day. He notes increase acid reflux sour taste in mouth bubble lots of belching gurling sound in stomach bloating early satiety regurgitation vomiting. Otherwise denies dysphagia or food stuck in mid epigastric area but finds himself at times needing to stand up mostly at restaurant to make the food go down. Denies abdominal pain diarrhea constipation melena hematochezia. He reports some difficulty concentrating or words finding but no dysphasia per se mostly when he feels anxious and overwhelmed. He is careful with walking at times notes some imbalance no falls otherwise no new or worsening neurologic concerns. Past Medical History Per HPI. Multifocal Parieto occipital CVA ___ left parieto occipital area most affected some left MCA involvement HTN HLD carotid stenosis s p bilateral CEA AAA without rupture 2.6 cm Aortic dissection not otherwise specified Esophageal adenocarcinoma GERD ___ Esophagus s p ___ fundoplication revision Diverticulitis Adrenal Adenoma Asthma COPD Former smoker 40 pack yrs Asbestos exposure Pneumonia recurrent Chronic pain pain agreement potentially broken ___ Low back pain Urinary frequency Inguinal hernia ventral hernias Prior alcohol abuse Past Surgical History Per HPI. Bilateral carotid endarterectomies Inguinal and ventral hernia repair x4 Endoscopic mucosal resection of mass at ___ junction ___ Nissen and revision of ___ Fundoplication Upper EUS ___ ERCP and biliary stent placement ___ Social History ___ Family History Mother CAD PVD Father Liver ca Other Uncles CVA ___ cancer Physical Exam BP 158 87. Heart Rate 64. O2 Saturation 99. Weight 170 With Clothes With Shoes . BMI 26.6. Temperature 97.8. Resp. Rate 16. Pain Score 0. Distress Score 0. Gen AxOx3. NAD. Conversing in full sentences. No dysarthria Neck WNL Chest CTAB Abd Soft NT ND. Well healed abd incisions. Multiple ecchymotic areas from old injections sites Extrem Warm and well perfused. Gait guarded but stable. Pertinent Results ___ Ba swallow Evaluation demonstrates GE junction just below the diaphragm Brief Hospital Course Mr. ___ was admitted to the hospital and taken to the Operating Room where he underwent laparoscopic lysis of adhesions. The planned Linx procedure was aborted to dense adhesions. Please see formal op note for details. He recovered well in the PACU and returned to the Surgical floor for further monitoring. His diet was gradually advanced to regular and his port sites were healing well. His pre op Lovenox and Coumadin were resumed on ___ with an INR of 1.0. His pain was controlled with Oxycodone and Tylenol and he was up and ambulating independently. He will follow up with Dr. ___ in a few weeks and discuss his further surgical options at that time. He was discharged on ___. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q6H PRN Pain Mild Fever 2. LevETIRAcetam 1000 mg PO BID 3. Zolpidem Tartrate 10 mg PO QHS PRN insomnia 4. LORazepam 1 mg PO TID 5. amLODIPine 5 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Pantoprazole 40 mg PO Q12H 8. Aspirin 81 mg PO DAILY 9. TraZODone 50 mg PO QHS PRN insomnia 10. Warfarin 3 mg PO DAILY16 11. Enoxaparin Sodium 70 mg SC BID Start ___ First Dose Next Routine Administration Time Discharge Medications 1. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 0 2. Lidocaine 5 Patch 1 PTCH TD ONCE prev patch fell off Duration 1 Dose RX lidocaine 5 1 patch once a day Disp 15 Patch Refills 0 3. Milk of Magnesia 30 mL PO Q12H PRN Constipation First Line 4. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg ___ tablet s by mouth Q ___ hrs Disp 20 Tablet Refills 0 5. Acetaminophen 1000 mg PO Q8H RX acetaminophen 500 mg 2 tablet s by mouth every eight 8 hours Disp 100 Tablet Refills 0 6. amLODIPine 5 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 80 mg PO QPM 9. Enoxaparin Sodium 70 mg SC BID Start ___ First Dose Next Routine Administration Time 10. LevETIRAcetam 1000 mg PO BID 11. LORazepam 1 mg PO TID 12. Pantoprazole 40 mg PO Q12H 13. TraZODone 50 mg PO QHS PRN insomnia 14. Warfarin 3 mg PO DAILY16 15. Zolpidem Tartrate 10 mg PO QHS PRN insomnia Discharge Disposition Home Discharge Diagnosis Gastroesophageal reflux disease. Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Call Dr. ___ ___ if you experience Fevers 101 or chills Difficult or painful swallowing Increased shortness of breath Pain control You may need pain medication once you are home but you can wean it over the next few days as the discomfort resolves. Make sure that you have regular bowel movements while on narcotic pain medications as they are constipating which can cause more problems. Use a stool softener or gentle laxative to stay regular. No driving while taking narcotic pain medication. Take Tylenol on a standing basis to avoid more opiod use. Activity Shower daily. Wash incision with mild soap and water rinse pat dry No tub bathing swimming or hot tubs until incision healed No lotions or creams to incision Walk ___ times a day for ___ minutes increase to a Goal of 30 minutes daily Diet Regular diet Anticoagulation Continue your Lovenox shots twice a day. Take your Coumadin 3 mg daily You will need an INR drawn on ___ at ___ and the ___ clinic will follow up the result and adjust your Coumadin as needed. They will also decide when you will stop the Lovenox. Followup Instructions ___ The icd codes present in this text will be K219, C159, Z9049, K660, Z87891, J449, E785, I10, I739, Z7901, I69398, R569, F329, F419. The descriptions of icd codes K219, C159, Z9049, K660, Z87891, J449, E785, I10, I739, Z7901, I69398, R569, F329, F419 are K219: Gastro-esophageal reflux disease without esophagitis; C159: Malignant neoplasm of esophagus, unspecified; Z9049: Acquired absence of other specified parts of digestive tract; K660: Peritoneal adhesions (postprocedural) (postinfection); Z87891: Personal history of nicotine dependence; J449: Chronic obstructive pulmonary disease, unspecified; E785: Hyperlipidemia, unspecified; I10: Essential (primary) hypertension; I739: Peripheral vascular disease, unspecified; Z7901: Long term (current) use of anticoagulants; I69398: Other sequelae of cerebral infarction; R569: Unspecified convulsions; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified. The common codes which frequently come are K219, Z87891, J449, E785, I10, Z7901, F329, F419. The uncommon codes mentioned in this dataset are C159, Z9049, K660, I739, I69398, R569.
The icd codes present in this text will be C651, E039, E785, F329. The descriptions of icd codes C651, E039, E785, F329 are C651: Malignant neoplasm of right renal pelvis; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; F329: Major depressive disorder, single episode, unspecified. The common codes which frequently come are E039, E785, F329. The uncommon codes mentioned in this dataset are C651. Allergies lamotrigine codeine Chief Complaint right renal pelvis tumor Major Surgical or Invasive Procedure Right robotic assisted laparoscopic nephroureterectomy History of Present Illness ___ is a ___ female with history of gross hematuria. She has been having blood in the urine on and off for about the past ___ months. She was seen in the ___ about 9 months ago and was found to have very small right sided kidney stones on CT scan. She had a ultrasound in ___ that again showed some small stones. She was evaluation by Dr. ___ month. A CT Urogram was obtained and cystoscopy was performed revealing right sided hematuria. She underwent right ureteroscopy 4 days ago that revealed a papillary tumor arising out of the lower pole calyx within the right kidney suspicious for transitional cell carcinoma. Urinary cytologies were obtained from the renal pelvis and returned positive for high grade urothelial carcinoma. The stent was left in place. She complains of some mild right sided upper back and abdominal pain similar to gallbladder pain she previously had. No dysuria urgency or frequency. Past Medical History ABNL LFT S CHOLECYSTECTOMY COLONIC POLYPS GYNECOLOGIC HYPOTHYROIDISM MENOPAUSE ROSACEA SEIZURE DISORDER HYPERCHOLESTEROLEMIA PYELONEPHRITIS NEPHROLITHIASIS Social History Country of Origin US Marital status Divorced Children Yes dtr ___ grandson ___ . ___ Lives with Alone Lives in Apartment Work ___ Sexual activity Past Sexual orientation Male Sexual Abuse Denies Domestic violence Denies Contraception N A None Tobacco use Never smoker Alcohol use Present drinks per week 4 Alcohol use Footnote few glasses of WINE QO NIGHT comments Recreational drugs Denies marijuana heroin crack pills or other Depression Patient already being treated for depression Exercise Activities walks ___ x week Exercise comments Footnote WALKS climbs stairs. WTS less recently Diet low sugar Seat belt vehicle Always restraint use Bike helmet use N A Family History Nephrolithiasis Malignant Hyperthermia Renal Cell CA Testisa CA Prostate CA Bladder CA Physical Exam WdWn NAD AVSS Interactive cooperative Abdomen soft appropriately tender along incisions Incisions otherwise c d I Foley catheter in place draining clear yellow urine Extremities w out edema or pitting and there is no reported calf pain to deep palpation Pertinent Results ___ 06 21AM BLOOD WBC 7.4 RBC 3.01 Hgb 8.5 Hct 27.5 MCV 91 MCH 28.2 MCHC 30.9 RDW 13.7 RDWSD 45.1 Plt ___ ___ 06 50AM BLOOD Hct 30.6 ___ 06 50AM BLOOD Glucose 92 UreaN 12 Creat 0.9 Na 141 K 4.7 Cl 103 HCO3 28 AnGap 10 ___ 10 14AM ASCITES Creat 1.0 Brief Hospital Course Patient was admitted to Urology after undergoing laparoscopic RIGHT radical nephroureterectomy. 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. On POD2 JP was checked for creatinine found to be consistent with serum and was removed without difficulty and 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 catheter draining clear yellow urine 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 1 week for a cystogram with an antibiotic to take beforehand. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Phenazopyridine 100 mg PO TID PRN bladder pain spasms 2. Docusate Sodium 100 mg PO BID 3. Simvastatin 10 mg PO QPM 4. OxyCODONE Immediate Release 5 mg PO Q6H PRN Pain Severe 5. Aspirin 81 mg PO DAILY 6. Citalopram 20 mg PO DAILY 7. Levothyroxine Sodium 88 mcg PO DAILY 8. Liothyronine Sodium 50 mcg PO DAILY 9. Vitamin D Dose is Unknown PO Frequency is Unknown Discharge Medications 1. Acetaminophen 650 mg PO Q6H 2. Sulfameth Trimethoprim DS 1 TAB PO ONCE Duration 1 Dose Take tablet 1 hour prior to cystogram RX sulfamethoxazole trimethoprim 800 mg 160 mg 1 tablet s by mouth once Disp 1 Tablet Refills 0 3. Vitamin D 1000 UNIT PO DAILY 4. Aspirin 81 mg PO DAILY 5. Citalopram 20 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Levothyroxine Sodium 88 mcg PO DAILY 8. Liothyronine Sodium 50 mcg PO DAILY 9. OxyCODONE Immediate Release 5 mg PO Q6H PRN Pain Severe 10. Simvastatin 10 mg PO QPM Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Right renal pelvic tumor Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions 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 C651, E039, E785, F329. The descriptions of icd codes C651, E039, E785, F329 are C651: Malignant neoplasm of right renal pelvis; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; F329: Major depressive disorder, single episode, unspecified. The common codes which frequently come are E039, E785, F329. The uncommon codes mentioned in this dataset are C651.
The icd codes present in this text will be K5732. The descriptions of icd codes K5732 are K5732: Diverticulitis of large intestine without perforation or abscess without bleeding. The uncommon codes mentioned in this dataset are K5732. Allergies Penicillins Chief Complaint LLQ Abdominal Pain Major Surgical or Invasive Procedure None History of Present Illness ___ w PMHx appendicitis s p appendectomy presents with LLQ pain. Patient reports being in his USOH other than a mild URI about a week ago until this morning when he developed sudden onset LLQ pain. Patient was at work when he first noticed this pain around noon. Reports that it began as squeezing and became progressively more severe as the day went continued. Said it was initially intermittent but had periods where it got to about an ___. He also developed nausea but no episodes of vomiting. No diarrhea or constipation but notes stools have been dark. Denied urinary symptoms. Reports some subjective fevers at home. He said he was unable to take in much after breakfast as he was too nauseous and uncomfortable. His pain increased in intensity up to a reported ___ to the point where he decided to come in for further evaluation. In the ED initial vitals Labs notable for WBC 19.4 lactate 2.2 otherwise unremarkable Imaging notable for CT A P Acute uncomplicated diverticulitis involving the distal descending colon. Pt given ___ 20 21 IV Morphine Sulfate 4 mg ___ 20 21 IV Ondansetron 4 mg ___ 21 15 IVF NS 1000 mL ___ 21 47 IV Ondansetron 4 mg ___ 22 34 IV Morphine Sulfate 4 mg ___ 22 43 IV CefTRIAXone 1 gm ___ 22 43 IV Acetaminophen IV 1000 mg ___ 23 50 IVF NS 1000 mL Vitals prior to transfer 99.7 91 115 79 17 99 RA On the floor the patient reports his pain is tolerable after recently having a dose of IV morphine. Past Medical History Sciatica B l tonsillectomy in ___ Social History ___ Family History Noncontributory Physical Exam ADMISSION PHYSICAL EXAM VITALS 98.1 128 84 100 20 96 Ra General Pleasant M in NAD HEENT NCAT MMM CV RRR no m r g Lungs CTAB Abdomen Soft TTP in LLQ no rebound guarding BS Ext Warm well perfused 2 pulses no clubbing cyanosis or edema Skin Warm dry no rashes or notable lesions. Neuro AAOx3 grossly intact DISCHARGE PHYSICAL EXAM VS 24 HR Data last updated ___ 1305 Temp 99.5 Tm 99.5 BP 123 74 123 131 74 84 HR 93 85 100 RR 18 ___ O2 sat 97 96 97 O2 delivery RA GENERAL Pleasant lying in bed comfortably HEENT NT AC MMM CARDIAC Regular rate and rhythm no murmurs rubs or gallops LUNG Breathing comfortably clear to auscultation bilaterally no crackles wheezes or rhonchi ABD Normal bowel sounds soft diffusely tender worst in LLQ to deep palpation nondistended no hepatomegaly no splenomegaly EXT Warm well perfused no lower extremity edema PULSES 2 radial pulses 2 ___ pulses 2 DP pulses NEURO Alert oriented CN II XII intact motor and sensory function grossly intact SKIN No significant rashes Pertinent Results ADMISSION LABS ___ 06 45PM BLOOD WBC 19.4 RBC 4.92 Hgb 14.7 Hct 44.9 MCV 91 MCH 29.9 MCHC 32.7 RDW 12.5 RDWSD 41.1 Plt ___ ___ 06 45PM BLOOD Neuts 70.0 ___ Monos 6.9 Eos 0.2 Baso 0.4 Im ___ AbsNeut 13.62 AbsLymp 4.27 AbsMono 1.34 AbsEos 0.03 AbsBaso 0.08 ___ 07 56PM BLOOD Glucose 126 UreaN 13 Creat 0.9 Na 138 K 3.7 Cl 99 HCO3 22 AnGap 17 ___ 07 59PM BLOOD Lactate 2.2 DISCHARGE LABS ___ 06 34AM BLOOD WBC 12.3 RBC 4.46 Hgb 13.3 Hct 40.8 MCV 92 MCH 29.8 MCHC 32.6 RDW 12.8 RDWSD 42.5 Plt ___ ___ 06 34AM BLOOD Glucose 83 UreaN 11 Creat 0.9 Na 140 K 4.0 Cl 100 HCO3 24 AnGap 16 MICROBIOLOGY ___ 6 45 pm BLOOD CULTURE Blood Culture Routine Pending No growth to date. ___ 10 40 pm BLOOD CULTURE Blood Culture Routine Pending No growth to date. IMAGING CT ABD PELVIS WITH CONTRAST Study Date of ___ 9 50 ___ Acute uncomplicated diverticulitis involving the distal descending colon. Brief Hospital Course PATIENT SUMMARY ___ w PMHx appendicitis s p appendectomy presents with LLQ pain found on imaging to have acute diverticulitis. ACUTE ISSUES Uncomplicated Diverticulitis Noted to have leukocytosis of 19.4 and Tmax 100.4. Started on CTX flagyl and transitioned to cipro flagyl. Following day WBC down to 12.3. Patient reported feeling much better. Pain was then well controlled with Tylenol. Over the first 24 hours diet was slowly progressed which patient tolerated. He was discharged when he showed that he consistently tolerated PO intake. Due to the holiday patient was unable to pick up antibiotics on day of discharge. He was given doses of medications to take home and instructed to take them at appropriate times 10pm for ciprofloxacin and midnight for flagyl. Patient then was instructed to fill out prescription as soon as the pharmacy opened the next day. TRANSITIONAL ISSUES New Meds Ciprofloxacin 500mg BID flagyl 500mg TID Stopped Held Meds None Changed Meds None CODE Full CONTACT None provided Medications on Admission None Discharge Medications 1. Acetaminophen 650 mg PO Q6H 2. Ciprofloxacin HCl 500 mg PO Q12H RX ciprofloxacin HCl 500 mg 1 tablet s by mouth twice a day Disp 12 Tablet Refills 0 3. MetroNIDAZOLE 500 mg PO Q8H RX metronidazole 500 mg 1 tablet s by mouth three times a day Disp 18 Tablet Refills 0 Discharge Disposition Home Discharge Diagnosis Primary Diagnosis Uncomplicated Diverticulitis 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 here at ___ Why was I admitted to the hospital You were admitted for abdominal pain and found to have diverticulitis What was done for me while I was in the hospital You were started on antibiotics ciprofloxacin and metronidazole Your pain was monitored and treated as needed with standing Tylenol ___ every 6 hours What should I do when I leave the hospital Please follow up with your PCP office call ___ to schedule with ___ MD Complete your antibiotic course of ciprofloxacin twice a day and metronidazole three times a day. Your last doses will be on ___ Please continue with Tylenol ___ every 4 to 6 hours as needed Start with liquids and clear solids i.e. jello then slowly advance diet over the next day or two to foods that are not heavy like rice and toasts. Do not drink alcohol while you are taking metronidazole. Combining the two will cause severe nausea and or vomiting Sincerely Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be K5732. The descriptions of icd codes K5732 are K5732: Diverticulitis of large intestine without perforation or abscess without bleeding. The uncommon codes mentioned in this dataset are K5732.
The icd codes present in this text will be K3580, K388, H578, Z006, M549, G8929. The descriptions of icd codes K3580, K388, H578, Z006, M549, G8929 are K3580: Unspecified acute appendicitis; K388: Other specified diseases of appendix; H578: Other specified disorders of eye and adnexa; Z006: Encounter for examination for normal comparison and control in clinical research program; M549: Dorsalgia, unspecified; G8929: Other chronic pain. The common codes which frequently come are G8929. The uncommon codes mentioned in this dataset are K3580, K388, H578, Z006, M549. Allergies Penicillins Chief Complaint Abdominal pain Major Surgical or Invasive Procedure ___ lap appy History of Present Illness ___ PMH significant for sciatica ___ remote MVC who was transferred from ___ for concern of appendicitis. Patient relays that last night he was awoken at 2am due to acute onset of RLQ pain and vomited shortly thereafter. He then went to his usual day of IT work went home at 4pm and then presented to ___ at 5pm. He endorses the following symptoms nausea constipation last bowel movement ___ at 4 30AM . Workup there includes WBC of ___ with CT scan c w acute uncomplicated appendicitis. He was given cipro flagyl and transferred to ___. At ___ he continues to be HDS and was given morphine for pain control. Resuscitation efforts continued. His pain has come down some however character and location remains unchanged. Subjective fevers chills nausea and po intolerance are all endorsed. No chest pain shortness of breath other GI or GU symptoms. Past Medical History Sciatica B l tonsillectomy in ___ Social History ___ Family History Noncontributory Physical Exam ADMISSION PHYSICAL EXAM Vitals 96.6 98 130 76 16 99 RA GEN A O NAD CV RRR No M G R PULM Clear to auscultation b l No W R R ABD Soft mildly distended tender to deep palpation in RLQ positive rebound. No guarding. normoactive bowel sounds no palpable masses negative psoas and obturator signs DISCHARGE PHYSICAL EXAM Vitals 98.8 125 78 97 18 99 RA GEN A O NAD CV RRR No M G R PULM CTAB ABD soft nondistended appropriately TTP surgical incisions c d I without erythema Pertinent Results ADMISSION LABS ___ 01 10AM BLOOD WBC 13.0 RBC 4.34 Hgb 13.2 Hct 39.1 MCV 90 MCH 30.4 MCHC 33.8 RDW 12.8 RDWSD 42.4 Plt ___ ___ 01 10AM BLOOD Neuts 68.8 ___ Monos 6.9 Eos 1.2 Baso 0.3 Im ___ AbsNeut 8.94 AbsLymp 2.91 AbsMono 0.89 AbsEos 0.15 AbsBaso 0.04 ___ 01 10AM BLOOD Glucose 93 UreaN 8 Creat 0.7 Na 135 K 4.9 Cl 98 HCO3 24 AnGap 18 ___ 01 10AM BLOOD ALT 27 AST 31 AlkPhos 67 TotBili 0.5 ___ 01 10AM BLOOD Albumin 3.8 ___ 01 13AM BLOOD Lactate 1.2 Brief Hospital Course The patient was transferred from ___ and admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain. OSH abdominal pelvic CT revealed thickened appendix with stranding and fecalith. WBC was elevated at 13.0. The patient underwent laparoscopic appendectomy which went well without complication reader referred to the Operative Note for details . After a brief uneventful stay in the PACU the patient arrived on the floor tolerating PO intake on IV fluids and on PO Tylenol and oxycodone for pain control. The patient was hemodynamically stable. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization the patient ambulated early and frequently was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge the patient was doing well afebrile with stable vital signs. The patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission None Discharge Medications 1. Acetaminophen 1000 mg PO Q8H RX acetaminophen Acetaminophen Pain Relief 500 mg 2 tablet s by mouth every eight 8 hours Disp 90 Tablet Refills 0 2. Artificial Tear Ointment 1 Appl RIGHT EYE PRN Right Eye Discomfort RX dextran 70 hypromellose Artificial Tears PF ___ drops in the right eye PRN Disp 1 Bottle Refills 0 3. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Moderate Reason for PRN duplicate override Alternating agents for similar severity RX oxycodone 5 mg ___ tablet s by mouth q4h PRN Disp 20 Tablet Refills 0 Discharge Disposition Home Discharge Diagnosis Appendicitis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You were recently admitted to ___ ___ abdominal pain. You were found to have appendicitis an inflamed appendix and had an operation to remove your appendix. The surgery went well and was uncomplicated. Please follow the below instructions to ensure a smooth recovery Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following You experience new chest pain pressure squeezing or tightness. New or worsening cough shortness of breath or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting diarrhea or other reasons. Signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing. You see blood or dark black material when you vomit or have a bowel movement. You experience burning when you urinate have blood in your urine or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms or any new symptoms that concern you. Please resume all regular home medications unless specifically advised not to take a particular medication. Also please take any new medications as prescribed. Please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care Please call your doctor or nurse practitioner if you have increased pain swelling redness or drainage from the incision site. Avoid swimming and baths until your follow up appointment. You may shower and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. Followup Instructions ___ The icd codes present in this text will be K3580, K388, H578, Z006, M549, G8929. The descriptions of icd codes K3580, K388, H578, Z006, M549, G8929 are K3580: Unspecified acute appendicitis; K388: Other specified diseases of appendix; H578: Other specified disorders of eye and adnexa; Z006: Encounter for examination for normal comparison and control in clinical research program; M549: Dorsalgia, unspecified; G8929: Other chronic pain. The common codes which frequently come are G8929. The uncommon codes mentioned in this dataset are K3580, K388, H578, Z006, M549.
The icd codes present in this text will be C50912, C773, Z006, Z803, I10, K219. The descriptions of icd codes C50912, C773, Z006, Z803, I10, K219 are C50912: Malignant neoplasm of unspecified site of left female breast; C773: Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes; Z006: Encounter for examination for normal comparison and control in clinical research program; Z803: Family history of malignant neoplasm of breast; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are I10, K219. The uncommon codes mentioned in this dataset are C50912, C773, Z006, Z803. Allergies shellfish derived Chief Complaint Breast cancer Major Surgical or Invasive Procedure Bilateral Total Mastectomies and Left Axillary Lymph Node Dissection and Right Sentinel Lymph Node Biopsy and Left Lymphaticovenous axillary bypass History of Present Illness ___ is a ___ year old woman who presented with left inflammatory breast cancer. Her staging was negative for distant disease ipsilateral axillary node uptake on PET . She has underwent neoadjuvant chemotherapy but had persistent nodal involvement. She elected to undergo bilateral mastectomy due to her wish to have contralateral prophylactic mastectomy. She is not interested in breast reconstruction and has met with Plastics. She will undergo left axillary lymph node dissection given the persistent nodal involvement. She will also undergo right axillary sentinel lymph node biopsy in the event that an occult invasive disease is identified in the right breast following the mastectomy. At the same time she will undergo lymphatic bypass performed by Dr. ___. Past Medical History Glaucoma hypertension and asthma. Social History ___ Family History There is a positive family history for breast cancer. The patient has a maternal aunt who had breast cancer at age ___ and a maternal cousin who had breast cancer in her ___. Three daughters of that first cousin have breast cancer in their late ___ or early ___. Physical Exam VS 24 HR Data last updated ___ 526 Temp 98.2 Tm 99.1 BP 130 81 130 137 81 84 HR 79 79 82 RR 18 O2 sat 95 95 98 O2 delivery Ra Wt 198.0 lb 89.81 kg GEN NAD A O HEENT NCAT EOMI anicteric CV RRR No JVD PULM normal excursion no respiratory distress ABD soft nontender ND EXT WWP no CCE 2 B L radial NEURO A Ox3 no focal neurologic deficits PSYCH normal judgment insight normal memory normal mood affect WOUND Wounds c d i. Serosanguinous output in both JP drains. Axillae soft. Pertinent Results Please see OMR Brief Hospital Course Ms. ___ presented to pre op holding at ___ on ___ for Bilateral Total Mastectomies and Left Axillary Lymph Node Dissection and Right Sentinel Lymph Node Biopsy and left Lymphaticovenous axillary bypass. She tolerated the procedure well without complications Please see operative note for further details . After a brief and uneventful stay in the PACU the patient was transferred to the floor for further post operative management. Neuro Pain was well controlled on tylenol and oxycodone. CV The patient remained stable from a cardiovascular standpoint vital signs were routinely monitored. Pulm The patient remained stable from a pulmonary standpoint oxygen saturation was routinely monitored. Had good pulmonary toileting as early ambulation and incentive spirometry were encouraged throughout hospitalization. GI The patient was advanced to and tolerated a regular diet after the procedure and at time of discharge. Patient s intake and output were closely monitored. GU Urine output was monitored as indicated. At time of discharge the patient was voiding without difficulty. Foley catheter was not placed during patient s admission. ID The patient was closely monitored for signs and symptoms of infection and fever of which there were none. She received ___ antibiotics per routine. Heme The patient had blood levels checked on POD1 to monitor for signs of bleeding. The patient received ___ dyne boots and was encouraged to get up and ambulate as early as possible. On ___ POD1 the patient was discharged to home with ___ services. At discharge she was tolerating a regular diet passing flatus voiding and ambulating independently. She will follow up in the clinic in ___ weeks. This information was communicated to the patient directly prior to discharge. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 2. Lisinopril 5 mg PO DAILY 3. Omeprazole 20 mg PO DAILY 4. Ondansetron ODT 8 mg PO Q8H PRN Nausea Vomiting First Line 5. Prochlorperazine 10 mg PO Q12H PRN Nausea Vomiting Second Line 6. Calcium Carbonate 500 mg PO TID 7. Hydrocortisone Cream 0.5 1 Appl TP BID PRN Dermatitis Discharge Medications 1. Acetaminophen 650 mg PO Q5H PRN Pain Mild Fever RX acetaminophen 650 mg 1 tablet s by mouth every five 5 hours Disp 35 Tablet Refills 0 2. Diazepam 2 mg PO Q6H PRN chest wall spasms RX diazepam 2 mg 1 tablet s by mouth every six 6 hours Disp 4 Tablet Refills 0 3. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice a day Disp 20 Capsule Refills 0 4. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth every six 6 hours Disp 12 Tablet Refills 0 5. Senna 17.2 mg PO HS RX sennosides senna 8.6 mg 1 tablet s by mouth at bedtime Disp 10 Tablet Refills 0 6. Calcium Carbonate 500 mg PO TID 7. Hydrocortisone Cream 0.5 1 Appl TP BID PRN Dermatitis 8. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 9. Lisinopril 5 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Ondansetron ODT 8 mg PO Q8H PRN Nausea Vomiting First Line 12. Prochlorperazine 10 mg PO Q12H PRN Nausea Vomiting Second Line Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Breast cancer 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. 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 C50912, C773, Z006, Z803, I10, K219. The descriptions of icd codes C50912, C773, Z006, Z803, I10, K219 are C50912: Malignant neoplasm of unspecified site of left female breast; C773: Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes; Z006: Encounter for examination for normal comparison and control in clinical research program; Z803: Family history of malignant neoplasm of breast; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are I10, K219. The uncommon codes mentioned in this dataset are C50912, C773, Z006, Z803.
The icd codes present in this text will be S62304B, S62511B, S62306B, X93XXXA, Y9229, F17210, F1010. The descriptions of icd codes S62304B, S62511B, S62306B, X93XXXA, Y9229, F17210, F1010 are S62304B: Unspecified fracture of fourth metacarpal bone, right hand, initial encounter for open fracture; S62511B: Displaced fracture of proximal phalanx of right thumb, initial encounter for open fracture; S62306B: Unspecified fracture of fifth metacarpal bone, right hand, initial encounter for open fracture; X93XXXA: Assault by handgun discharge, initial encounter; Y9229: Other specified public building as the place of occurrence of the external cause; F17210: Nicotine dependence, cigarettes, uncomplicated; F1010: Alcohol abuse, uncomplicated. The common codes which frequently come are F17210. The uncommon codes mentioned in this dataset are S62304B, S62511B, S62306B, X93XXXA, Y9229, F1010. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint ___ to R hand Major Surgical or Invasive Procedure I D x2 Bone graft to thumb MC and ring MC from iliac crest History of Present Illness CC ___ to right hand HPI Mr. ___ is a ___ year old RHD man with PMH of smoking and heavy EtOH use who presents with ___ to right hand. At baseline the patient smokes 1PPD and drinks 1 liter of hard EtOH per day and is currently unemployed. The patient was drinking EtOH overnight when he was shot in the hand just a few feet away at approximately 1 30am the morning of presentation. He initially presented to an OSH who transferred him to ___ for evaluation and treatment. He notes pain of his hand and swelling and decreased sensation of his third webspace. He has two wounds one at the site of his right dorsal radial thumb and the other between his ___ and ___ distal metacarpals on the dorsal aspect of his hand. He does not recall his last tetanus shot. He last ate around 6pm the prior evening and last drank EtOH at approximately the time of the gun shot at 1 30am. ROS per HPI Denies fevers chills headache dizziness nausea vomiting chest pain shortness of breath Past Medical History ___ to left thigh Past Surgical History L thigh surgery for ___ Medications None Allergies NKDA Social History Drinks 1 bottle hard liquor daily tequila . Smokes 1PPD ___ years . Smokes occasional marijuana. Denies other illicit drugs and IVDU. Not currently employed. Lives with sister. Physical ___ T 98.6 HR 69 BP 103 58 RR 16 SpO2 100 RA GEN A O NAD HEENT mucus membranes moist CV RRR PULM Breathing comfortably on room air Ext ___ on right hand dorsal radial base of thumb and ___ right hand dorsal between ring and little finger distal metacarpals. Doppler signal intact all digital arteries and palmar arch. Radial pulse 2 palpable. Decreased sensation ulnar aspect middle finger and radial aspect of ring finger. Motor and tendon exam limited due to pain. Deficiency in right middle and index finger extension from MCP but exam difficult due to limitation of pain. Some extension and flexion of right thumb IP joint however limited due to pain. Able to extend and flex wrist but limited due to pain. Right hand with volar and dorsal swelling but forearm and hand compartments currently soft. Laboratory pending Imaging R hand x ray Severely comminuted and intraarticular fracture right base of thumb metacarpal. Comminuted extraarticular fractures of distal ___ and ___ metacarpals. Assessment Plan Mr. ___ is a ___ year old RHD man with PMH of smoking and heavy EtOH use who presents with ___ to right hand. He is vascularly intact without current signs of compartment syndrome. He has extremely comminuted right proximal thumb metacarpal intraarticular fractures and right distal ring and little finger distal metacarpal extraarticular fractures right ulnar middle finger and radial ring finger decreased sensation suggesting nerve injury and inability to extend right middle and ring fingers suggestive of possible tendon injury although exam limited due to pain. Plan for tetanus shot IV antibiotics and likely OR today for right hand I D ORIF of right thumb ring and little finger fractures possible neurovascular repair possible tendon repair and possible ex fix. Given history of heavy EtOH use will need to be monitored closely for withdrawal signs and symptoms. Past Medical History Asthma Social History ___ Family History Noncontributory Physical Exam No acute distress Unlabored breathing Abdomen soft non tender non distended. ICBG site c d i. RUE Incision clean dry intact with no erythema or discharge minimal ecchymosis. Splint in place clean dry and intact Pertinent Results ___ 06 15AM GLUCOSE 127 UREA N 17 CREAT 1.0 SODIUM 140 POTASSIUM 4.0 CHLORIDE 102 TOTAL CO2 21 ANION GAP 21 ___ 06 15AM estGFR Using this ___ 06 15AM WBC 13.7 RBC 4.50 HGB 14.8 HCT 41.5 MCV 92 MCH 32.9 MCHC 35.7 RDW 12.2 RDWSD 41.1 ___ 06 15AM NEUTS 85.9 LYMPHS 7.2 MONOS 6.2 EOS 0.0 BASOS 0.2 IM ___ AbsNeut 11.73 AbsLymp 0.98 AbsMono 0.84 AbsEos 0.00 AbsBaso 0.03 ___ 06 15AM PLT COUNT 240 ___ 06 15AM ___ PTT 27.6 ___ 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 gunshot wound to the right hand and was admitted to the orthopedic surgery service. The patient was taken to the operating room on for I D x2 and bone graft to thumb MC and ring MC from iliac crest 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. He will be discharged on oral antibiotics for 7 days. 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 NWB in the RUE and will be discharged on Keflex for antibiotics 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 N a Discharge Medications 1. Cephalexin 500 mg PO Q6H Duration 7 Days RX cephalexin 500 mg 1 tablet s by mouth every six 6 hours Disp 28 Tablet Refills 0 2. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet s by mouth twice a day Disp 30 Tablet Refills 0 3. Gabapentin 300 mg PO TID RX gabapentin 300 mg 1 capsule s by mouth three times a day Disp 30 Capsule Refills 0 4. HYDROmorphone Dilaudid ___ mg PO Q4H PRN Pain Moderate RX hydromorphone 2 mg ___ tablet s by mouth Q3H PRN Disp 72 Tablet Refills 0 5. Acetaminophen 1000 mg PO Q8H Discharge Disposition Home Discharge Diagnosis ___ to R hand. Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. 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 NWB 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. 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. Please remain in your dressing and do not change unless it is visibly soaked or falling off. 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 FOLLOW UP Please follow up with your surgeon Dr. ___ in 2 weeks. Please call ___ to make an appointment. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications refills. Followup Instructions ___ The icd codes present in this text will be S62304B, S62511B, S62306B, X93XXXA, Y9229, F17210, F1010. The descriptions of icd codes S62304B, S62511B, S62306B, X93XXXA, Y9229, F17210, F1010 are S62304B: Unspecified fracture of fourth metacarpal bone, right hand, initial encounter for open fracture; S62511B: Displaced fracture of proximal phalanx of right thumb, initial encounter for open fracture; S62306B: Unspecified fracture of fifth metacarpal bone, right hand, initial encounter for open fracture; X93XXXA: Assault by handgun discharge, initial encounter; Y9229: Other specified public building as the place of occurrence of the external cause; F17210: Nicotine dependence, cigarettes, uncomplicated; F1010: Alcohol abuse, uncomplicated. The common codes which frequently come are F17210. The uncommon codes mentioned in this dataset are S62304B, S62511B, S62306B, X93XXXA, Y9229, F1010.
The icd codes present in this text will be I25110, T82218A, I10, Z951, Z955, Z23, Z794, Z7984, Z9641, E785, I255, E109, Y832. The descriptions of icd codes I25110, T82218A, I10, Z951, Z955, Z23, Z794, Z7984, Z9641, E785, I255, E109, Y832 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; T82218A: Other mechanical complication of coronary artery bypass graft, initial encounter; I10: Essential (primary) hypertension; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z23: Encounter for immunization; Z794: Long term (current) use of insulin; Z7984: Long term (current) use of oral hypoglycemic drugs; Z9641: Presence of insulin pump (external) (internal); E785: Hyperlipidemia, unspecified; I255: Ischemic cardiomyopathy; E109: Type 1 diabetes mellitus without complications; 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. The common codes which frequently come are I10, Z951, Z955, Z794, E785. The uncommon codes mentioned in this dataset are I25110, T82218A, Z23, Z7984, Z9641, I255, E109, Y832. Allergies Epinephrine Novocain Major Surgical or Invasive Procedure Percutaneous coronary intervention with drug eluting stent placement attach Pertinent Results ADMISSION LABS ___ 10 27AM BLOOD WBC 6.6 RBC 3.89 Hgb 12.5 Hct 37.1 MCV 95 MCH 32.1 MCHC 33.7 RDW 12.4 RDWSD 42.9 Plt ___ ___ 10 27AM BLOOD ___ PTT 29.3 ___ ___ 10 27AM BLOOD Glucose 381 UreaN 20 Creat 1.2 Na 129 K 5.2 Cl 92 HCO3 23 AnGap 14 ___ 10 27AM BLOOD cTropnT 0.01 ___ 01 55PM BLOOD cTropnT 0.01 ___ 07 40PM BLOOD cTropnT 0.01 ___ 10 27AM BLOOD Calcium 9.2 Phos 3.1 Mg 1.8 ___ 10 57AM BLOOD pO2 60 pCO2 37 pH 7.43 calTCO2 25 Base XS 0 Comment GREEN TOP ___ 11 04AM BLOOD ___ pO2 76 pCO2 40 pH 7.40 calTCO2 26 Base XS 0 DISCHARGE LABS ___ 08 56AM BLOOD WBC 6.8 RBC 4.29 Hgb 13.8 Hct 40.8 MCV 95 MCH 32.2 MCHC 33.8 RDW 12.7 RDWSD 43.8 Plt ___ ___ 08 56AM BLOOD Glucose 255 UreaN 17 Creat 1.0 Na 135 K 4.9 Cl 100 HCO3 21 AnGap 14 ___ 08 56AM BLOOD Calcium 9.4 Phos 3.3 Mg 2.0 IMAGING TTE ___ The left atrial volume index is normal. The right atrial pressure could not be estimated. There is normal left ventricular wall thickness with a normal cavity size. There is a small to moderate area of regional left ventricular systolic dysfunction with hypo to akinesis of the basal inferior and basal inferolateral walls mid to apical anterior wall and interventricualr septum see schematic . The visually estimated left ventricular ejection fraction is 35 40 . There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with uninterpretable free wall motion assessment. The aortic sinus diameter is normal for gender with a normal ascending aorta diameter for gender. There is a normal descending aorta diameter. The aortic valve leaflets appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve is not well seen. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION Suboptimal image quality. Mild to moderate regional dysfunction c w multiveselCAD infarction. Cannot assess right ventricular function due to poor image quality. No overt valvular abnormalities. Compared with the prior TTE images not available for review of ___ the findings are new. CARDIAC CATHETERIZATION ___ Coronary Description LM The left main coronary artery is with eccentric 30 distal. Circ The circumflex coronary artery is with widely patent stent and 90 hazy stenosis distal prior to bifurcation. L L and L R collaterals are present. RCA The right coronary artery is with multiple prior stents and mid occlusion. A moderate branching AM is now with origin occlusion and fills slowly via R R collaterals. LIMA LAD A left internal mammary artery to the LAD is widely patent. There is retrograde filling of a diagonal branch. L L and L R collaterals are present. SVGs Known occluded and not engaged. RI The ramus intermedius is small caliber with diffuse 70 80 proximal. Complications There were no clinically significant complications. Findings Three vessel coronary artery disease. Successful PCI with drug eluting stent of the circumflex coronary artery. Recommendations ASA 81mg per day. Plavix 75mg day Secondary prevention of CAD Maximize medical therapy Brief Hospital Course Mr. ___ is a ___ year old man with PMH of CAD s p 4v CABG as well as numerous PCIs HTN HLD T1DM on insulin pump who presented with recurrent MI equivalent pain of jaw L arm pain with EKG negative for ischemia and troponins negative x2 most concerning for unstable angina. The patient was admitted with initial plan for nuclear stress test. Following admission the patient had significant chest pain not relieved with sublingual nitro with no troponin elevation or EKG changes. He was started on a nitro gtt and underwent PCI with coronary angiography with placement of one DES for 90 hazy stenosis distal prior to bifurcation in the circumflex artery. The patient remained free from chest pain following PCI and was discharged home in stable condition with continuation of dual antiplatelet therapy. CORONARIES CABG ___ with LIMA to LAD SVG to OM Diagonal PDA ___ . Multiple PCI s on SVG s the last in ___ PTCA to ramus PCI of mid LCX ___. PUMP LVEF 45 50 echo from ___ RHYTHM NSR CODE Full Code Presumed CONTACT No healthcare proxy selected TRANSITIONAL ISSUES Discharge weight 182.98 lb 83 kg Discharge creatinine 1.0 Discharge Hgb Hct 13.8 40.8 Please check Chem 7 at discharge to monitor electrolytes on lisinopril Consider increasing dose of lisinopril from 5mg to 10mg daily Continue dual antiplatelet therapy with ASA 81mg and Plavix 75mg daily indefinitely for coronary artery disease Consider increasing atorvastatin from 40mg to 80mg daily if patient tolerates. Recommend repeating TTE within 5 weeks of discharge to evaluate LVEF and regional wall motion abnormalities. Pre cath TTE revealed suboptimal image quality mild to moderate regional dysfunction c w multiveselCAD infarction and no overt valvular abnormalities with LVEF 35 40 reduced from prior 45 50 in ___. ACTIVE ISSUES Unstable Angina The patient presented with intermittent return of MI equivalent pain represented as jaw L arm pain at rest. Symptoms started several weeks prior to admission and recurred most recently experiencing these symptoms a few days prior to admission while at rest. He had been using SL nitro with relief of his symptoms as well as restarted Imdur per the advice of his RN sister. He was free from chest pain upon arrival. EKG re demonstrated LBBB. Troponins were negative x2. His presentation is concerning for UA. After discussion with patient decision was originally to go for cardiac nuclear stress test. However due to several episodes of chest pain overnight ___ requiring nitro gtt the patient underwent PCI for unstable angina on ___. Pre cath TTE revealed suboptimal image quality mild to moderate regional dysfunction c w multivesel CAD infarction and no overt valvular abnormalities with LVEF 35 40 . Coronary angiography revealed 3 vessel CAD with 90 hazy stenosis distal prior to bifurcation in the circumflex artery for which 1 DES was placed without complications. Continued optimal medical management for CAD with aspirin clopidogrel atorvastatin lisinopril and metoprolol succinate HTN Continued home Lisinopril 5mg daily and home metoprolol succinate 100mg daily. Consider increasing lisinopril from 5mg to 10mg daily if tolerated. CHRONIC ISSUES T1DM on insulin pump ___ Diabetes was consulted for in patient diabetes management who determined that the patient was fully capable of operating his insulin pump. The patient managed his insulin independently throughout the admission without complications. CAD s p 4v CABG and numerous PCIs Ischemic cardiomyopathy without evidence of HF EF 45 50 ___ Continued Atorvastatin ASA clopidogrel and metoprolol Consider increasing atorvastatin from 40mg to 80mg daily if patient tolerates. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Lisinopril 5 mg PO QHS 4. Atorvastatin 40 mg PO QPM 5. Brimonidine Tartrate 0.15 Ophth. 1 DROP BOTH EYES BID 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Nitroglycerin SL 0.3 mg SL Q5MIN PRN Neck L arm pain 8. Terazosin 5 mg PO QHS 9. Timolol Maleate 0.25 1 DROP BOTH EYES BID 10. Vitamin D 1000 UNIT PO DAILY 11. Insulin Pump SC Self Administering Medication Insulin Lispro Humalog Target glucose ___ Fingersticks QAC and HS Discharge Medications 1. Insulin Pump SC Self Administering Medication Insulin Lispro Humalog Target glucose ___ Fingersticks QAC and HS 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Brimonidine Tartrate 0.15 Ophth. 1 DROP BOTH EYES BID 5. Clopidogrel 75 mg PO DAILY 6. Lisinopril 5 mg PO QHS 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN PRN Neck L arm pain 9. Terazosin 5 mg PO QHS 10. Timolol Maleate 0.25 1 DROP BOTH EYES BID 11. Vitamin D 1000 UNIT PO DAILY Discharge Disposition Home Discharge Diagnosis PRIMARY DIAGNOSIS Unstable angina Coronary artery disease SECONDARY DIAGNOSIS Type 1 diabetes mellitus 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 ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL You were having chest pain and there was concern for a blockage in one of the arteries that supplies your heart. WHAT WAS DONE IN THE HOSPITAL The function of your heart and lungs was monitored. You were given medications to treat your chest pain. You had a procedure called a cardiac catheterization and a stent was placed to open a blockage in one of your coronary arteries. WHAT SHOULD I DO WHEN I GET HOME FROM THE HOSPITAL Continue to take all of your medications as prescribed. Follow up with your Cardiologist and your other doctors. If you experience chest pain shortness of breath or generally feel unwell call your doctor or go to the nearest emergency room. Sincerely Your ___ Treatment Team Followup Instructions ___ The icd codes present in this text will be I25110, T82218A, I10, Z951, Z955, Z23, Z794, Z7984, Z9641, E785, I255, E109, Y832. The descriptions of icd codes I25110, T82218A, I10, Z951, Z955, Z23, Z794, Z7984, Z9641, E785, I255, E109, Y832 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; T82218A: Other mechanical complication of coronary artery bypass graft, initial encounter; I10: Essential (primary) hypertension; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z23: Encounter for immunization; Z794: Long term (current) use of insulin; Z7984: Long term (current) use of oral hypoglycemic drugs; Z9641: Presence of insulin pump (external) (internal); E785: Hyperlipidemia, unspecified; I255: Ischemic cardiomyopathy; E109: Type 1 diabetes mellitus without complications; 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. The common codes which frequently come are I10, Z951, Z955, Z794, E785. The uncommon codes mentioned in this dataset are I25110, T82218A, Z23, Z7984, Z9641, I255, E109, Y832.
The icd codes present in this text will be I214, I2510, Z7902. The descriptions of icd codes I214, I2510, Z7902 are I214: Non-ST elevation (NSTEMI) myocardial infarction; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z7902: Long term (current) use of antithrombotics/antiplatelets. The common codes which frequently come are I2510, Z7902. The uncommon codes mentioned in this dataset are I214. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest pain Major Surgical or Invasive Procedure ___ Coronary angiogram with POBA History of Present Illness ___ year old male with no known PMH presents as a transfer from ___ with NSTEMI and ongoing CP at rest concerning for ACS. Patient developed severe chest pressure pain around 9PM last night. He tried to go to sleep but was unable to get comfortable. HE denied any associated shortness of breath N V diaphoresis radiation or lightheadedness. He denied any pleuritic or positional component to the pain. Has not had recent infection. He has no cardiac history but does get occasional chest pain lasting a few minutes relieved by drinking water. No exertional chest pain. In the ED initial vitals were 98.4 60 144 80 20 96 RA EKG NSR LVH diffuse J point elevation Not particularly ischemic. Labs studies notable for CKmb 94 troponin 1.38 Patient was given IV heparin. full dose ASA 500 cc IV fluids. Vitals on transfer 50 127 69 12 95 RA On the floor He was complaining of ___ typical chest pain refractory to SL nitro glycerine. Past Medical History No known medical history. Denied HTN HLD DM. Social History ___ Family History Mother with cardiac disease in early ___. Divorced. Works in ___ Physical Exam ADMISSION PHYSICAL EXAM 24 HR Data last updated ___ 1701 Temp 98.3 Tm 98.3 BP 109 57 109 152 57 83 HR 63 51 63 RR 18 O2 sat 97 97 98 O2 delivery RA Wt 159.83 lb 72.5 kg 159.83 161.82 GENERAL Well developed well nourished male in NAD. Oriented x3. Mood affect appropriate. HEENT Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis of the oral mucosa. No xanthelasma. NECK Supple. JVP not elevated CARDIAC Regular rate and rhythm. Soft heart sounds but nl S1 S2. No murmurs rubs or gallops. no thrills or lifts. LUNGS No chest wall deformities or tenderness. Respiration is unlabored with no accessory muscle use. No crackles wheezes or rhonchi. ABDOMEN Soft non tender non distended. No hepatomegaly. No splenomegaly. EXTREMITIES clammy but 2 DP s and radial pulses. SKIN clammy PULSES Distal pulses palpable and symmetric. DISCHARGE PHYSICAL EXAM 24 HR Data last updated ___ 1205 Temp 98.8 Tm 98.8 BP 104 64 91 152 50 83 HR 57 47 67 RR 16 ___ O2 sat 95 94 98 O2 delivery RA Wt 159.83 lb 72.5 kg 159.83 161.82 Fluid Balance last updated ___ 601 Last 8 hours Total cumulative 470ml IN Total 130ml IV Amt Infused 130ml OUT Total 600ml Urine Amt 600ml Last 24 hours Total cumulative 408ml IN Total 992ml PO Amt 50ml IV Amt Infused 942ml OUT Total 1400ml Urine Amt 1400ml GENERAL Well developed well nourished male in NAD. Oriented x3. Mood affect appropriate. HEENT PERRLA. MMM. NECK Supple. JVP not elevated CARDIAC Regular rate and rhythm. Normal S1 S2. No murmurs rubs or gallops. no thrills or lifts. LUNGS Normal work of breathing on RA. No crackles wheezes or rhonchi. Pertinent Results ADMISSION LAB RESULTS ___ 02 29PM BLOOD WBC 6.7 RBC 4.21 Hgb 13.3 Hct 39.0 MCV 93 MCH 31.6 MCHC 34.1 RDW 11.5 RDWSD 38.8 Plt ___ ___ 02 29PM BLOOD Glucose 112 UreaN 11 Creat 1.2 Na 139 K 4.4 Cl 100 HCO3 25 AnGap 14 ___ 02 29PM BLOOD cTropnT 1.38 ___ 07 00AM BLOOD Calcium 8.8 Phos 2.9 Mg 2.2 Cholest 157 PERTINENT LAB RESULTS ___ 02 29PM BLOOD cTropnT 1.38 ___ 07 36PM BLOOD CK MB 96 cTropnT 1.68 ___ 03 00AM BLOOD CK MB 64 cTropnT 2.22 ___ 07 00AM BLOOD CK MB 45 cTropnT 1.96 DISCHARGE LAB RESULTS ___ 07 00AM BLOOD WBC 7.2 RBC 3.64 Hgb 11.7 Hct 34.2 MCV 94 MCH 32.1 MCHC 34.2 RDW 11.9 RDWSD 41.0 Plt ___ ___ 07 00AM BLOOD Glucose 107 UreaN 11 Creat 1.2 Na 140 K 4.2 Cl 105 HCO3 21 AnGap 14 IMAGING ___ CXR No evidence of pulmonary edema. Mildly enlarged cardiac silhouette when compared to prior. ___ Coronary angiogram A 6 ___ EBU3.5 guide provided adequate support. Crossed with a Prowater wire into the distal LAD.Dilated with a 2.0 mm balloon. Final angiography revealed normal flow no dissection and 40 residual stenosis. Findings Two vessel and branch coronary artery disease. Successful POBA of the diagonal coronary artery. Possible culprits tiny OM not amenable to PCI or diseased diagonal branch. Brief Hospital Course TRANSITIONAL ISSUES New medications on discharge metoprolol XL 25 mg daily atorvastatin 80 mg daily clopidogrel 75 mg daily for one year imdur 30 mg and aspirin 81 mg daily. SUMMARY STATEMENT ___ year old male with no known past medical history transferred from ___ with ongoing chest pain and troponin elevations concerning for NSTEMI. Patient was placed on a heparin and nitro drip and noted to have troponins 1.38 1.68 2.22. Cardiac cath showed 90 stenosis of the first diagonal branch of the LAD. PCTA was performed at the site. Patient was Plavix loaded and discharged on statin aspirin metoprolol and Plavix for one year. HOSPITAL COURSE NSTEMI Patient presented with typical cardiac chest pain at rest without known cardiac risk factors except for family history of heart disease. EKG non ischemic with likely LVH. Patient was aspirin loaded placed on a heparin drip and nitro drip. Hb A1c 4.9 and lipids were within normal limits. Chest pain resolved as of ___ AM after being on nitro drip. Troponin elevations were noted 1.38 1.68 2.22 along with lactate elevations to 2.3. He was taken to cath which showed 90 stenosis of the ___ diagonal branch of the LAD. PCTA was performed at this site. Patient was Plavix loaded and discharged on Plavix for one year asa 81 metoprolol xl 25 imdur 30 mg and atorvastatin 80. TTE and ___ eval were performed prior to discharge. Medications on Admission None Discharge Medications 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet s by mouth Daily Disp 30 Tablet Refills 0 2. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet s by mouth Daily Disp 30 Tablet Refills 0 3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis RX clopidogrel 75 mg 1 tablet s by mouth Daily Disp 30 Tablet Refills 0 4. Isosorbide Mononitrate Extended Release 30 mg PO DAILY RX isosorbide mononitrate 30 mg 1 tablet s by mouth Daily Disp 30 Tablet Refills 0 5. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet s by mouth Daily Disp 30 Tablet Refills 0 6. Nitroglycerin SL 0.3 mg SL Q5MIN PRN Chest pain RX nitroglycerin 0.3 mg 1 tablet s sublingually Q5MIN PRN Disp 30 Tablet Refills 0 Discharge Disposition Home Discharge Diagnosis Non ST elevation myocardial infarction 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 ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL You were admitted to the hospital because of chest pain WHAT HAPPENED WHILE I WAS IN THE HOSPITAL You were found to have a heart attack. You were started on blood thinning medication and medication to help increase blood flow in the heart. Your chest pain went away on this medication. A procedure was done to see the vessels around the heart. It showed a significant blockage of one of the vessels. A procedure was performed to open the blockage up with a balloon through the vessel. When your chest pain improved you were discharged home. 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 return to the emergency room if you have severe chest pain worsening shortness of breath or loss of consciousness. We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I214, I2510, Z7902. The descriptions of icd codes I214, I2510, Z7902 are I214: Non-ST elevation (NSTEMI) myocardial infarction; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z7902: Long term (current) use of antithrombotics/antiplatelets. The common codes which frequently come are I2510, Z7902. The uncommon codes mentioned in this dataset are I214.
The icd codes present in this text will be I200, E871, E785, J449, N183, I129, Z87891, K219. The descriptions of icd codes I200, E871, E785, J449, N183, I129, Z87891, K219 are I200: Unstable angina; E871: Hypo-osmolality and hyponatremia; E785: Hyperlipidemia, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; N183: Chronic kidney disease, stage 3 (moderate); I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z87891: Personal history of nicotine dependence; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are E871, E785, J449, I129, Z87891, K219. The uncommon codes mentioned in this dataset are I200, N183. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest pain shortness of breath Major Surgical or Invasive Procedure Cardiac catheterization History of Present Illness Ms. ___ is an ___ year old female with PMH of HTN HLD LVH COPD and CKD III who was transferred from ___ with non exertional chest pain. Patient reports that she has been having chest pain for several months. Of note she had an outpatient stress test performed last week which she reports was abnormal. She was scheduled to see cardiology tomorrow but this morning developed worsening of her chest pain. She describes it as a midsternal chest pressure with no radiation. She reports that she took 4 chewable aspirin at home and this resulted in resolution of her symptoms. Her symptoms then returned several hours later and her pain has been constant since this afternoon. Her EKG at ___ was reportedly concerning for ischemia and she was transferred to ___ for urgent cardiology consult and likely cath. Report of the EKG at ___ ECG Impression Sinus rhythm ECG Impression Short PR interval ECG Impression Borderline ST depression lateral leads ECG Impression Minimal ST elevation inferior leads Troponin T at ___ was 0.010 at 18 35 Of note was only able to access the report of the EKG and images of the EKG were not sent with the patient. EKG done at ___ was negative for ischemic changes. Patient was given SL nitro with no relief of her pain and started on a heparin gtt prior to transfer to ___. Past Medical History Wegener s granulomatosis OSTEOARTHRITIS MULT JOINTS Kidney horseshoe Esophageal reflux Hyperlipidemia Basal cell carcinoma Diverticulosis Impaired fasting glucose Microalbuminuria Mitral regurgitation LVH left ventricular hypertrophy Pulmonary hypertension Kidney disease chronic stage III ___ ___ ml min Raynaud disease COPD chronic obstructive pulmonary disease Gastritis Gastroparesis Non rheumatic tricuspid valve insufficiency Lung nodule multiple Lung mass lung biopsy giant cell vasculitis Social History ___ Family History Brother CAD PVD Daughter Cancer ___ Father CAD PVD Mother Cancer ___ Physical Exam ADMISSION EXAM VITALS 24 HR Data last updated ___ 213 Temp 97.8 Tm 97.8 BP 117 56 84 117 46 61 HR 53 RR 16 O2 sat 93 O2 delivery RA Wt 167.99 lb 76.2 kg GENERAL Alert and interactive. In no acute distress. HEENT PERRL EOMI. MMM. CARDIAC RRR no m r g appreciated LUNGS CTAB no r r w ABDOMEN Soft NT ND BS EXTREMITIES No clubbing cyanosis or edema. SKIN Warm. No rashes. NEUROLOGIC AOx3. Grossly intact. DISCHARGE EXAM 24 HR Data last updated ___ 1154 Temp 97.7 Tm 97.8 BP 127 66 84 127 46 74 HR 69 53 69 RR 16 O2 sat 95 93 96 O2 delivery Ra Wt 167.99 lb 76.2 kg Fluid Balance last updated ___ 839 Last 8 hours Total cumulative 374.2ml IN Total 75.8ml IV Amt Infused 75.8ml OUT Total 450ml Urine Amt 450ml Emesis 0ml Last 24 hours Total cumulative 125.8ml IN Total 575.8ml IV Amt Infused 575.8ml OUT Total 450ml Urine Amt 450ml Emesis 0ml Weight 76.2kg Weight on admission unknown Telemetry NSR General Ill appearing tremulous pale HEENT JVD up to 8cm no masses or thyromegaly. Lungs bibasilar crackles no wheezes CV RRR no m r g. 2 radial and dp pulses Abdomen Soft NTND. Normoactive BS Ext Trace edema b l. Pertinent Results ADMISSION LABS ___ 09 36PM BLOOD WBC 5.4 RBC 3.15 Hgb 10.0 Hct 29.4 MCV 93 MCH 31.7 MCHC 34.0 RDW 12.8 RDWSD 43.6 Plt ___ ___ 09 36PM BLOOD Neuts 64.6 ___ Monos 11.7 Eos 0.9 Baso 0.6 Im ___ AbsNeut 3.47 AbsLymp 1.18 AbsMono 0.63 AbsEos 0.05 AbsBaso 0.03 ___ 09 36PM BLOOD Glucose 120 UreaN 21 Creat 0.9 Na 131 K 5.7 Cl 92 HCO3 23 AnGap 16 ___ 09 36PM BLOOD Calcium 9.3 Phos 4.0 Mg 1.8 DISCHARGE LABS ___ 07 07AM BLOOD WBC 6.4 RBC 3.05 Hgb 9.7 Hct 29.1 MCV 95 MCH 31.8 MCHC 33.3 RDW 12.8 RDWSD 43.9 Plt ___ ___ 07 07AM BLOOD Glucose 128 UreaN 16 Creat 0.7 Na 131 K 3.9 Cl 95 HCO3 25 AnGap 11 CARDIAC CATH ___ Mild coronary coronary artery mild 30 stenosis in the LAD Brief Hospital Course HOSPITAL COURSE Ms. ___ is an ___ year old female with PMH of HTN HLD LVH COPD and CKD III who was transferred from ___ with non exertional chest pain. Patient reports that she has been having chest pain for several months. Of note she had an outpatient stress test performed last week which she reports was abnormal. She was scheduled to see cardiology tomorrow but on the morning of presentation developed worsening of her chest pain. She describes it as a midsternal chest pressure with no radiation. She reports that she took 4 chewable aspirin at home and this resulted in resolution of her symptoms. Her symptoms then returned several hours later and her pain has been constant since this afternoon. Her EKG at ___ was reportedly concerning for ischemia and she was transferred to ___ for urgent cardiology consult and likely cath. Report of the EKG at ___ ECG Impression Sinus rhythm ECG Impression Short PR interval ECG Impression Borderline ST depression lateral leads ECG Impression Minimal ST elevation inferior leads Troponin T at ___ was 0.010 at 18 35 Of note was only able to access the report of the EKG and images of the EKG were not sent with the patient. EKG done at ___ was negative for ischemic changes. Patient was given SL nitro with no relief of her pain and started on a heparin gtt prior to transfer to ___. TRANSITIONAL ISSUES Ongoing management of CAD risk factors Further treatment of noncardiac chest pain Further work up of her hyponatremia ACUTE ACTIVE ISSUES Chest Pain Unstable Angina Stress test from At last week showed mild to moderate ischemia at ___. Unable to review EKG from OSH but no ST elevations seen on EKG done in the ED. Troponin negative at OSH and repeat negative here as well. Cardiac cath performed today showed only non obstructive disease with ___ in LAD nothing on RCA or LCx as previously suspected. We increased the dose of her atorvastatin to 80mg daily. Hyponatremia Given not volume overloaded and not in acute heart failure euvolemic causes including SIADH are high on the differential given her medications. Her Na 131 is unchanged from OSH records last week so it is possible this is her baseline. Did not replete prior to discharge CHRONIC STABLE ISSUES HTN Continue home antihypertensive regimen HLD Increased atorvastatin to 80mg GERD Continued pantoprazole Ativan for nausea COPD Albuterol nebulizer PRN Pts inhalers not formulary did not stay inpatient long enough for family to bring them in Medications on Admission The Preadmission Medication list may be inaccurate and requires further investigation. 1. Atorvastatin 40 mg PO QPM 2. Atenolol 25 mg PO DAILY 3. Losartan Potassium 25 mg PO DAILY 4. Pantoprazole 40 mg PO Q12H 5. LORazepam 0.5 mg PO Q8H PRN anxiety 6. Hydrochlorothiazide 25 mg PO DAILY 7. Incruse Ellipta umeclidinium 62.5 mcg actuation inhalation DAILY 8. Symbicort budesonide formoterol 160 4.5 mcg actuation inhalation BID 9. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN SOB Discharge Medications 1. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet s by mouth at bedtime Disp 30 Tablet Refills 0 2. Atenolol 25 mg PO DAILY 3. Hydrochlorothiazide 25 mg PO DAILY 4. Incruse Ellipta umeclidinium 62.5 mcg actuation inhalation DAILY 5. LORazepam 0.5 mg PO Q8H PRN anxiety 6. Losartan Potassium 25 mg PO DAILY 7. Symbicort budesonide formoterol 160 4.5 mcg actuation inhalation BID Discharge Disposition Home Discharge Diagnosis Unstable angina 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 worsening chest pain and an abnormal stress test result. WHAT HAPPENED IN THE HOSPITAL In the hospital we obtained further tests to look for performed a cardiac cath to assess for possible blockage in the vessels of your heart that could explain the cause of your chest pain which was negative. We increased the dose of your statin to 80 mg. WHAT SHOULD I DO WHEN I GO HOME Please continue to take your medications as prescribed Please follow up with your cardiologist in ___ weeks for further management. 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 I200, E871, E785, J449, N183, I129, Z87891, K219. The descriptions of icd codes I200, E871, E785, J449, N183, I129, Z87891, K219 are I200: Unstable angina; E871: Hypo-osmolality and hyponatremia; E785: Hyperlipidemia, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; N183: Chronic kidney disease, stage 3 (moderate); I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z87891: Personal history of nicotine dependence; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are E871, E785, J449, I129, Z87891, K219. The uncommon codes mentioned in this dataset are I200, N183.
The icd codes present in this text will be I615, I675, R45851, F329, F419, D649. The descriptions of icd codes I615, I675, R45851, F329, F419, D649 are I615: Nontraumatic intracerebral hemorrhage, intraventricular; I675: Moyamoya disease; R45851: Suicidal ideations; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified; D649: Anemia, unspecified. The common codes which frequently come are F329, F419, D649. The uncommon codes mentioned in this dataset are I615, I675, R45851. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint ___ Major Surgical or Invasive Procedure ___ Diagnostic angiogram History of Present Illness ___ yo female with known ___ s p right EDAS. She had previous admission her since then in ___ with ___ that required bilateral EVDs and TPA. She returns with 1 week of HA and nausea. Head CT at the OSH shows left occipital IPH with ___. She c o continued HA and Nausea. Past Medical History ___ Thalamic bleed admitted to ___ Stroke angio showed ___ and 2 small aneurysms near the ventricles. Patient was seen at ___ and underwent bypass surgery with Dr ___. Depression was on medication but discontinued secondary to side effects. Social History ___ Family History Unknown hx of vascular anomalies Physical Exam ON ADMISSION 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 Pupils equally round and reactive to light to mm bilaterally. Visual fields are full to confrontation. III IV VI Extraocular movements intact bilaterally without nystagmus. 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 tremors. Strength full power ___ throughout. No pronator drift Sensation Intact to light touch propioception pinprick and vibration bilaterally. Coordination normal on finger nose finger rapid alternating movements heel to shin ON DISCHARGE Opens eyes x spontaneous to voice to noxious Orientation x Person x Place x Time Follows commands Simple x Complex None Pupils 2.5 2mm b l PERRL EOM x Full Restricted 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 TrapDeltoidBicepTricepGrip ___ IPQuadHamATEHLGast ___ Left5 5 5 5 5 5 x Sensation intact to light touch throughout Pertinent Results Please see OMR for pertinent imaging labs Brief Hospital Course ___ On ___ Ms. ___ was admitted to the Neuro ICU. Arterial line was placed for BP control with SBP goal 160. Diagnostic angio on ___ re demonstrated bilateral ___. U S of right groin was obtained on ___ for palpable nodule and was negative for pseudoaneurysm. Medications were adjusted for headache management. On ___ she was called out of the ICU to ___ where she remained neurologically stable. She was mobilized and encouraged POs. She was transferred to the neuro floor. NCHCT on ___ was stable to improved. Moyamoya Neurology was consulted to assist with management of her Moyamoya. It was recommended to avoid significant hypotension. Patient was cleared to start ASA 81mg on ___. She should follow up with Dr. ___ discharge. Depression anxiety Psych was consulted for the patient stating I want to die. It was felt the patient did not require a 1 1 sitter. The valium was discontinued and the patient was started on Seroquel per Psych recommendation. The Seroquel was discontinued and low dose Ativan was ordered BID PRN. Patient was started on mirtazepime 7.5mg qHS to help with sleep mood appetite and nausea. Social work was consulted to assist with setting up outpatient psych for follow up after discharge. Medications on Admission None Discharge Medications 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY RX aspirin Aspir 81 81 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 2 3. Docusate Sodium 100 mg PO BID 4. LORazepam 0.25 mg PO BID PRN anxiety RX lorazepam 0.5 mg 0.5 One half tab by mouth BID PRN Disp 7 Tablet Refills 0 5. Mirtazapine 7.5 mg PO QHS RX mirtazapine 7.5 mg 1 tablet s by mouth at bedtime Disp 30 Tablet Refills 0 6. Multivitamins W minerals 1 TAB PO DAILY 7. OxyCODONE Immediate Release 2.5 mg PO Q4H PRN Pain Severe RX oxycodone 5 mg 0.5 One half tablet s by mouth Q4H PRN Disp 24 Tablet Refills 0 8. Senna 17.2 mg PO QHS Discharge Disposition Home Discharge Diagnosis ___ Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Brain Hemorrhage without Surgery 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 Ibuprofen Plavix Coumadin until cleared by the neurosurgeon. Your neurosurgeon is recommending starting aspirin 81mg daily starting on ___. You may use Acetaminophen Tylenol for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience You may have difficulty paying attention concentrating and remembering new information. Emotional and or behavioral difficulties are common. Feeling more tired restlessness irritability and mood swings are 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. Headaches Headache is one of the most common symptom after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse develop arm or leg weakness increased sleepiness and or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches avoid caffeine get enough sleep daily exercise relaxation meditation massage acupuncture heat or ice packs. 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 I615, I675, R45851, F329, F419, D649. The descriptions of icd codes I615, I675, R45851, F329, F419, D649 are I615: Nontraumatic intracerebral hemorrhage, intraventricular; I675: Moyamoya disease; R45851: Suicidal ideations; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified; D649: Anemia, unspecified. The common codes which frequently come are F329, F419, D649. The uncommon codes mentioned in this dataset are I615, I675, R45851.
The icd codes present in this text will be I25119, G92, E10319, I959, F200, Z794, G4700, I259, E861. The descriptions of icd codes I25119, G92, E10319, I959, F200, Z794, G4700, I259, E861 are I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris; G92: Toxic encephalopathy; E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema; I959: Hypotension, unspecified; F200: Paranoid schizophrenia; Z794: Long term (current) use of insulin; G4700: Insomnia, unspecified; I259: Chronic ischemic heart disease, unspecified; E861: Hypovolemia. The common codes which frequently come are Z794, G4700. The uncommon codes mentioned in this dataset are I25119, G92, E10319, I959, F200, I259, E861. Allergies Dulcolax Balance Chief Complaint Insomnia Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ year old female with a PMHx of T1DM since age ___ and paranoid schizophrenia who presents to the ED on ___ w insomnia x3 days. Pt states that she has not slept a wink for the past three nights and has hysteria. Patient cannot pinpoint any specific triggers but mentions she is a light sleeper and everything can interrupt her sleep. She has not followed with a psychiatrist in ___ months as she states her psychiatrist told her she needed to find a new prescriber because of her schedule. She states that she has not missed any doses of her psychiatric medications. She also reports good control of her diabetes. She did not take her insulin prior to coming to hospital because when she woke her blood sugar was 90. In the ED initial vitals were 97.3 115 141 69 20 100 RA FSBG 302 Exam notable for delirium Labs notable for 9.3 14.0 40.9 290 130 5.1 ___ 412 Gap 10 Correct Na 135 U A large leuks trace prot 1000 gluc 80 ket blood WBCs HbA1C pending Studies ECG ___ NSR normal axis 0.5mm depression in V4 1mm depression in V5 0.5mm depression II no STE Patient was given ___ 18 21 SC Insulin 4 Units ___ 23 32 SC Insulin 6 Units ___ 23 45 PO Chlorpheniramine Maleate 4 mg ___ 05 44 IVF 1000 mL NS 1000 mL ___ 05 44 PO Sulfameth Trimethoprim DS 1 TAB Patient was seen by Psychiatry who evaluated the patient and stated Pt appears delirious initially appeared oriented attentive and organized now disoriented inattentive short term memory deficits though also unclear her baseline functioning but definitely a change in later several days in setting of hyperglycemia unclear adherence at home UTI. Recommended restarting Trifluoperazine 10 mg PO daily Benztropine 0.5 mg PO daily. Patient was kept overnight in the ED for monitoring. Decision was made to admit for management of hyperglycemia UTI. On the floor patient is upset because someone poisoned her water. Her step father was present in the room and patient reported she wanted him to stay away and wasn t sure what he was going to do to her if they left. She reports palpitations which she attributed to not sleeping. She denies f c lightheadedness dizziness CP SOB abd pain N V dysuria. She is unsure when she had her last BM. Per review of OMR patient was recently seen by GI for hemoccult test. Noted to have difficulty with constipation and will often go ___ w o bowel movement. Patient attributes her constipation to her psychiatric medications. She was started on Linzess she reports she has not started this medication. Review of systems Per HPI Denies fever chills night sweats recent weight loss or gain. Denies headache sinus tenderness rhinorrhea or congestion. Denies cough shortness of breath. Denies chest pain or tightness. Denies nausea vomiting diarrhea constipation or abdominal pain. No recent change bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History Paranoid schizophrenia on trifluoperazine benztropine IDDM dx age ___ c b retinopathy Constipation Stress test ___ IMPRESSION Borderline EKG evidence of myocardial ischemia in the absence of anginal symptoms at the achieved level of work. Social History ___ Family History Mother is alive and well. Father is deceased had lung cancer. She has two sisters and two brothers all of whom are relatively healthy. Physical Exam ADMISSION PHYSICAL EXAM ___ VS T 97.9 BP 145 63 HR 118 RR 16 O2 sat 100 RA fs 162 Gen Well appearing NAD sitting up in bed HEENT Sclera anicteric dry mucous membranes oropharynx clear Neck supple JVP not elevated no LAD normal thyroid exam Lungs Clear to auscultation bilaterally no wheezes rales rhonchi CV RRR S1 S2 no m r g Abdomen soft ND NT no rebound guarding bowel sounds present Back no CVAT b l Ext Warm well perfused 2 pulses no clubbing cyanosis or edema Skin improving non tender non pruritic papules on erythematous base on cheeks and upper chest Neuro PERRL EOMI Psych Oriented x3. Good attention MOYB ___ registration ___ spontaneous recall ___ recall with multiple choice. Can follow 2 step commands. Speech and language comprehension intact. Can name both low and high frequency objects. Mildly tangential in thought process. Mildly paranoid thought content. Moderate insight. DISCHARGE PHYSICAL EXAM ___ VS HR 65 81 RR ___ O2 99 100 RA fingersticks daytime 66 106 nighttime 246 488 Gen Well appearing NAD walking around floor HEENT Sclera anicteric dry mucous membranes oropharynx clear Neck supple JVP not elevated no LAD normal thyroid exam Lungs Clear to auscultation bilaterally no wheezes rales rhonchi CV RRR S1 S2 no m r g Abdomen soft ND NT no rebound guarding bowel sounds present Back no CVAT b l Ext Warm well perfused 2 pulses no clubbing cyanosis or edema Skin improving non tender non pruritic papules on erythematous base on cheeks and upper chest Neuro PERRL EOMI Psych Oriented x3 Good attention MOYB ___ registration and recall at 3 minutes moderate intermediate memory names last 3 presidents good comprehension speech follows 1 step commands but struggles w 2 step commands mildly tangential thought process. Pertinent Results ADMISSION LABS ___ 11 45PM URINE bnzodzpn NEG barbitrt NEG opiates NEG cocaine NEG amphetmn NEG oxycodn NEG mthdone NEG ___ 11 45PM URINE BLOOD NEG NITRITE NEG PROTEIN TR GLUCOSE 1000 KETONE 80 BILIRUBIN NEG UROBILNGN NEG PH 6.5 LEUK LG ___ 02 34PM GLUCOSE 412 UREA N 16 CREAT 0.8 SODIUM 130 POTASSIUM 5.1 CHLORIDE 92 TOTAL CO2 28 ANION GAP 15 ___ 02 34PM CK MB 3 cTropnT 0.01 ___ 02 34PM TSH 2.0 ___ 02 34PM WBC 9.3 RBC 4.51 HGB 14.0 HCT 40.9 MCV 91 MCH 31.0 MCHC 34.2 RDW 12.1 RDWSD 40.2 INTERIM LABS ___ 05 03PM BLOOD CK MB 3 cTropnT 0.01 ___ 05 30AM BLOOD CK MB 3 cTropnT 0.01 ___ 10 37AM BLOOD HbA1c 8.6 eAG 200 DISCHARGE LABS ___ 09 10AM BLOOD WBC 6.4 RBC 3.88 Hgb 12.1 Hct 36.1 MCV 93 MCH 31.2 MCHC 33.5 RDW 12.4 RDWSD 42.5 Plt ___ ___ 09 10AM BLOOD ___ PTT 26.4 ___ ___ 09 10AM BLOOD Glucose 191 UreaN 15 Creat 0.9 Na 135 K 4.8 Cl 100 HCO3 25 AnGap 15 ___ 05 30AM BLOOD ALT 16 AST 21 LD LDH 177 AlkPhos 61 TotBili 0.4 ___ 02 27AM BLOOD CK MB 2 cTropnT 0.01 ___ 09 10AM BLOOD Calcium 9.6 Phos 3.8 Mg 1.8 STUDIES ECG ___ Sinus rhythm. Non specific ST T wave changes. No previous tracing available for comparison. ECG ___ Sinus rhythm. ST T wave changes concerning for ischemia or infarction. Compared to the previous tracing of the same day ST T wave changes are more significant. Clinical correlation is suggested. ECG ___ Sinus rhythm. Baseline artifact. Compared to the previous tracing of ___ the ST segment depression in the inferolateral leads has improved while the rate has slowed. Consider active inferolateral ischemic process. Followup and clinical correlation are suggested. Transthoracic ECHO ___ The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 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 inferior wall appears borderline hypokinetic in some views. There is no ventricular septal defect. 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. IMAGING CT HEAD W O CONTRAST ___ IMPRESSION No acute intracranial process specifically no hemorrhage. CHEST PORTABLE AP ___ IMPRESSION Lungs are fully expanded and clear. Cardiomediastinal and hilar silhouettes and pleural surfaces are normal. In ___ the patient had severe disseminated predominantly micronodular infiltrative pulmonary abnormality and abundant central adenopathy. Although that appears to have cleared. Investigation of that diagnosis may be pertinent to her medical management. Brief Hospital Course ___ yo woman w PMHx schizophrenia and IDDM presenting in a delirious state in the setting of insomnia x3 days and admitted for further evaluation and monitoring of hyperglycemia UTI and a question of NSTEMI. Myocardial Ischemia In the ED patient was found on ECG to have diffuse ST depressions but 2mm depressions in V4 V5 . On floor patient was given 325mg of ASA. Of note patient received stress test in ___ which showed borderline myocardia ischemia. Patient denied symptoms of chest pain substernal pressure SOB cough or N V. Upon further probing however she did report having had SOB with exercise and recent heart palpitations which she attributes her insomnia. On the inpatient floor patient was put on tele and her troponins and CK MB were trended returned all negative ruling out NSTEMI. ECGs were trended and remained stable. Cardiology was consulted and medical management was initiated with daily 81mg aspirin metoprolol 12.5mg TID atorvastatin and lisinopril. Of note Plavix was contraindicated due to concern for potential cath . Given stability of ECGs negative trops catheterization was deferred. Hospital stay was complicated by a hypotensive episode overnight on ___ to 84 50 in the setting of new medications and NPO which improved with ambulation and IV fluids. Her lisinopril was discontinued given low BPs and normal BUN Cr. She received a TTE which revealed normal EF 50 55 and inferior wall appears borderline hypokinesis in some views she was discharged on metoprolol asa atorvastatin. She will follow up with Cardiology in x2 weeks as an outpatient for further evaluation. Hyperglycemia Patient who has a hx of type I DM since age ___ was found to have 412 serum glucose in the ED on day of presentation ___ and 209 the day after. Patient says she had been compliant with her insulin regimen but may have been less strict about her doses due to recent insomnia for 3 days. She also reports missing her insulin the morning of her presentation to ED. Labs in the ED were reassuring w corrected sodium 135 and normal anion gap ruling out DKA. On admission patient was continued on home insulin regimen ___ Novolog w meals 14 Humulin N qAM 10 Humulin N QHS and monitored by fingersticks. Fingersticks which showed normal glucose during the day 60s 100s but increased glucose during the night 246 488 possibly due to binging on night snacks after being NPO during the day. No changes were made to her insulin regimen. By day of discharge serum glucose decreased to 191 ___ . Her HbA1c was found to be 8.6 which is reassuring for relative compliance. Our recommended goal for Ms. ___ is an HbA1c below 8.0 . UTI In the ED patient was found concerning for UTI due to WBC 182 on microscopy. Both urine microscopy and culture however showed contamination. Patient denied any fever dysuria hematuria or changes in urinary habits. Patient received x1 dose of Bactrim in the ED and was admitted for continued monitoring. Repeat UA on admission showed increased WBC 56 and minimal epithelial cells so Bactrim DS BID was restarted on ___. Antibiotics was stopped the following day however when repeat urine culture returned skin flora in the absence of symptoms. Psych Patient has history of undifferentiated psychosis with differential including paranoid schizophrenia. On day of presentation patient presented with complaints of insomnia x3 days and hysteria. Patient is unsure of specific triggers however patient reports she is a light sleeper and that everything can interrupt her sleep including sounds of car alarms and people talking coming from the parking lot during the night. Patient also does mention she has been recently distressed by many people including boyfriend telling her what to do which has contributed to her coming to the ED. Of note patient has not seen her outpatient psych therapist for couple months due reasons that are unclear even to the patient and even her stepfather. Tried calling outpt therapist but staff says provider does not direct calls. In the ED patient received psych consult and found to have inconsistent orientation attentiveness organization and short term memory on mental status exam. Patient denied any SI HI or any hallucinations. Patient was suspected however to be delirious ___ hyperglycemia UTI and or sleep wake cycle disruptions superimposed on long standing schizophrenia. On admission patient presented with some paranoia delusions including thoughts that someone poisoned my water and that her chest was shrinking. Patient was started on home trifluoperazine 10mg daily and Benztropine 0.5mg daily. While patient did not sleep the first night of admission she reported she slept 7.5 hrs the following night. Serial mental status exams were negative except for moderately tangential thought processes and mildly paranoid delusional thought content. Close PCP ___ for psych med management is recommended until patient can reconnect or find new outpt psychiatrist. Transitional Issues pt reported no contact w her psychiatrist since ___ please try to have pt reestablish care HbA1C 8.6 on current regimen close ___ with cardiology. started on asa 81mg atorvastatin 80mg metoprolol XL 12.5mg given high concern for CAD stable angina Code status Full Contact ___ ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. NPH 14 Units Breakfast NPH 10 Units Bedtime Novolog 2 Units Breakfast Novolog 2 Units Lunch Novolog 2 Units Dinner 2. Trifluoperazine HCl 10 mg PO DAILY 3. Benztropine Mesylate 0.5 mg PO DAILY 4. Senna 8.6 mg PO BID PRN constipation Discharge Medications 1. Benztropine Mesylate 0.25 mg PO DAILY 2. Senna 8.6 mg PO BID PRN constipation 3. Trifluoperazine HCl 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY RX aspirin Adult Low Dose Aspirin 81 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 5. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet s by mouth at bedtime Disp 30 Tablet Refills 0 6. Metoprolol Succinate XL 12.5 mg PO DAILY RX metoprolol succinate 25 mg 0.5 One half tablet s by mouth daily Disp 30 Tablet Refills 0 7. NPH 14 Units Breakfast NPH 10 Units Bedtime Novolog 2 Units Breakfast Novolog 2 Units Lunch Novolog 2 Units Dinner RX insulin NPH human recomb Humulin N 100 unit mL AS DIR 14 Units before BKFT 10 Units before BED Disp 10 Vial Refills 0 RX insulin aspart Novolog 100 unit mL AS DIR 2 Units before BKFT 2 Units before LNCH 2 Units before DINR Disp 10 Vial Refills 0 Discharge Disposition Home Discharge Diagnosis PRIMARY DIAGNOSES Coronary artery disease Angina Hyperglycemia UTI SECONDARY DIAGNOSES Schizophrenia Type 1 DM 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 your blood sugars were high and you had a urinary tract infection. We restarted you on your home insulin regimen and your blood sugars returned to normal. You were treated for your urinary tract infection with an antibiotic. While you were in the hospital we noticed that your heart showed signs of coronary artery disease which means you have narrowing of the vessels in your heart. You were evaluated by the Cardiologists and had an ultrasound of your heart performed. You should continue taking aspirin 81mg daily along with atorvastatin 80mg daily. You should also take metoprolol XL 12.5mg daily. You will need to ___ with your new cardiologist Dr. ___ on ___ at 140PM. Thank you for letting us be a part of your care Your ___ Team Followup Instructions ___ The icd codes present in this text will be I25119, G92, E10319, I959, F200, Z794, G4700, I259, E861. The descriptions of icd codes I25119, G92, E10319, I959, F200, Z794, G4700, I259, E861 are I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris; G92: Toxic encephalopathy; E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema; I959: Hypotension, unspecified; F200: Paranoid schizophrenia; Z794: Long term (current) use of insulin; G4700: Insomnia, unspecified; I259: Chronic ischemic heart disease, unspecified; E861: Hypovolemia. The common codes which frequently come are Z794, G4700. The uncommon codes mentioned in this dataset are I25119, G92, E10319, I959, F200, I259, E861.
The icd codes present in this text will be D282, Q613, I471, D271, D270, R55, K449, K269, H409, I160, B9681, K2960, E8352, E876, K5730. The descriptions of icd codes D282, Q613, I471, D271, D270, R55, K449, K269, H409, I160, B9681, K2960, E8352, E876, K5730 are D282: Benign neoplasm of uterine tubes and ligaments; Q613: Polycystic kidney, unspecified; I471: Supraventricular tachycardia; D271: Benign neoplasm of left ovary; D270: Benign neoplasm of right ovary; R55: Syncope and collapse; K449: Diaphragmatic hernia without obstruction or gangrene; K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation; H409: Unspecified glaucoma; I160: Hypertensive urgency; B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere; K2960: Other gastritis without bleeding; E8352: Hypercalcemia; E876: Hypokalemia; K5730: Diverticulosis of large intestine without perforation or abscess without bleeding. The uncommon codes mentioned in this dataset are D282, Q613, I471, D271, D270, R55, K449, K269, H409, I160, B9681, K2960, E8352, E876, K5730. Allergies latex Chief Complaint large pelvic pass rectal bleeding Major Surgical or Invasive Procedure TOTAL ABDOMINAL HYSTERECTOMY BILATERAL SALPINGO OOPHORECTOMY History of Present Illness Ms. ___ is a ___ y o G1P1 transferred from ___ with a large pelvic mass which was found on CT scan after she presented to the ED with worsening abdominal pain nausea and vomiting on ___. On arrival to the floor today she had repeated severe range BPs of 210s 100. Denied SOB chest pain palpitations change in baseline dizziness and HA. Denies h o HTN but notes does not follow with PCP. On arrival to the ED 2 weeks ago her BP was 170s 90 but states she has never started HTN medications. In regards to her rectal bleeding. She notes noticing intermittent black stools for the past month. She denies overt rectal bleeding but states she has noticed a small amount of blood covering the stools intermittently. Also endorses recent weakness because of change in ability to tolerate solids. Has continued to ambulate. Has never had colonoscopy. Past Medical History Glaucoma Social History ___ Family History Denies family history of breast cancer Gyn cancer or colon cancer Family history of prostate cancer in dad and brother both deceased Physical Exam Physical Exam on Discharge Gen elderly female lying in bed CV RRR S1S2 Pulm CTAB Abd soft nontender vertical low abdominal incision c d I with staples in place Neuro A O x 2 oriented to self type of building identified month as ___ or ___ but did not know year grossly wnl Pertinent Results Labs on Admission ___ 07 50PM WBC 10.6 RBC 3.70 HGB 10.9 HCT 33.2 MCV 90 MCH 29.5 MCHC 32.8 RDW 12.4 RDWSD 40.6 ___ 07 50PM PLT COUNT 425 ___ 07 50PM ___ PTT 28.3 ___ ___ 07 50PM ___ 07 50PM GLUCOSE 163 UREA N 10 CREAT 0.5 SODIUM 141 POTASSIUM 3.9 CHLORIDE 100 TOTAL CO2 29 ANION GAP bdomen bilateral renal cysts Labs on Discharge ___ 07 31AM BLOOD WBC 12.2 RBC 3.52 Hgb 10.6 Hct 31.4 MCV 89 MCH 30.1 MCHC 33.8 RDW 12.9 RDWSD 41.9 Plt ___ ___ 07 31AM BLOOD Plt ___ ___ 07 31AM BLOOD Glucose 87 UreaN 10 Creat 0.4 Na 144 K 2.9 Cl 104 HCO3 28 AnGap 12 ___ 07 31AM BLOOD Calcium 8.4 Phos 2.6 Mg 1.9 Brief Hospital Course Ms. ___ was admitted to the gynecologic oncology service for a large pelvic mass and rectal bleeding. Upon arrival to the hospital her BP was 216 100. Patient was asymptomatic at the time. EKG showed normal sinus rhythm. She was given 25mg hydralazine and placed on telemetry. The medicine service was consulted regarding her hypertensive urgency. They recommended 5mg Amlodipine QD and 25mg Q6 PRN hydralazine for SBP 160. Given continued elevated BP medicine consult team decided to change regimen to Diltiazem 60mg Q6H with PRN hydralazine for SBP 180. They also recommended no further testing needed to optimize patient prior to surgery. Patient is to follow up with her PCP outpatient for HTN. The GI service was consulted regarding her rectal bleeding. They performed an EGD and colonoscopy on HD 2 and found an esophageal hiatal hernia duodenal bulb ulcer mild diverticulosis. Biopsy of ulcer was positive for H. pylori. Patient was then started on 14 day course of prevpac. Of note on the night of HD 1 patient was had a code blue for loss of conscious while on the toilet after drinking the bowel prep for her GI procedure. Patient returned to conscious after 10 seconds. Stat labs EKG telemetry and CXR were ordered and were assuring. Patient was given two 500mL bolus of LR and symptoms improved. After careful evaluation event was attributed to a likely vagal response while using the restroom. Patient then underwent exlap TAH BSO pelvic mass resection for serous cyst adenofibroma. Her post operative course is detailed as follows. Immediately postoperatively her pain was controlled with IV dilaudd. Her diet was advanced without difficulty and she was transitioned to PO tramadol and acetaminophen. On post operative day 1 her urine output was adequate so her Foley catheter was removed and she voided spontaneously. By post operative day 3 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 Timolol eye drops Discharge Medications 1. Acetaminophen 500 mg PO Q6H PRN Pain Mild Do not exceed 4000mg in 24 hours RX acetaminophen 500 mg ___ tablet s by mouth every 6 hours Disp 50 Tablet Refills 1 2. Amoxicillin 1000 mg PO Q12H Take until ___ RX amoxicillin 500 mg 2 tablet s by mouth twice a day Disp 48 Tablet Refills 0 3. Clarithromycin 500 mg PO Q12H Take until ___ RX clarithromycin 500 mg 1 tablet s by mouth twice a day Disp 24 Tablet Refills 0 4. Diltiazem 60 mg PO Q6H RX diltiazem HCl 360 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 3 5. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 1 6. Lansoprazole Oral Disintegrating Tab 30 mg PO Q12H RX lansoprazole 30 mg 1 tablet s by mouth twice a day Disp 24 Tablet Refills 0 7. Lisinopril 10 mg PO DAILY RX lisinopril 10 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 3 8. TraMADol 25 mg PO Q6H PRN pain Do not drink or drive while taking this medication. RX tramadol 50 mg 0.5 One half tablet s by mouth every 4 hours Disp 50 Tablet Refills 0 9. Timolol Maleate 0.5 1 DROP BOTH EYES DAILY Discharge Disposition Home Discharge Diagnosis Serous cystadenofibroma 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 being seen in clinic for a large pelvic mass in the setting of recent weight loss and rectal bleeding. We consulted the gastrointestinal physicians and they scoped both your upper and lower gastrointestinal tract. During the procedure they found a hiatal hernia and an ulcer. They took a biopsy of the ulcer and it showed a bacterial infection. We started you on treatment for this infection while you were in the hospital. You will continue to take these medications to complete a 14 day course. The gynecology oncology service then performed the procedures listed below. You have recovered well after your operation and the team feels that you are safe to be discharged home. While you were here your blood pressures were elevated. We consulted the internal medicine physicians to evaluate you. They recommended we start you on a new blood pressure medication called Diltiazem and Lisinopril. You will continue to take this medication as an outpatient. Please follow up with your primary care physicians for ongoing treatment. You had an episode of loss of consciousness while on the toilet during your bowel preparation for the scoping procedure. We did an EKG imaging of your chest and blood work that was all reassuring. You were given more fluids and your symptoms resolved. Please follow these instructions Abdominal instructions Take your medications as prescribed. We recommend you take non narcotics i.e. Tylenol 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. Take a stool softener to prevent constipation. You were prescribed Colace. If you continue to feel constipated and have not had a bowel movement within 48hrs of leaving the hospital you can take a gentle laxative such as milk of magnesium. 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. Constipation Drink ___ liters of water every day. Incorporate 20 to 35 grams of fiber into your daily diet to maintain normal bowel function. Examples of high fiber foods include Whole grain breads Bran cereal Prune juice Fresh fruits and vegetables Dried fruits such as dried apricots and prunes Legumes Nuts seeds. Take Colace stool softener ___ times daily. Use Dulcolax suppository daily as needed. Take Miralax laxative powder daily as needed. Stop constipation medications if you are having loose stools or diarrhea. Followup Instructions ___ The icd codes present in this text will be D282, Q613, I471, D271, D270, R55, K449, K269, H409, I160, B9681, K2960, E8352, E876, K5730. The descriptions of icd codes D282, Q613, I471, D271, D270, R55, K449, K269, H409, I160, B9681, K2960, E8352, E876, K5730 are D282: Benign neoplasm of uterine tubes and ligaments; Q613: Polycystic kidney, unspecified; I471: Supraventricular tachycardia; D271: Benign neoplasm of left ovary; D270: Benign neoplasm of right ovary; R55: Syncope and collapse; K449: Diaphragmatic hernia without obstruction or gangrene; K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation; H409: Unspecified glaucoma; I160: Hypertensive urgency; B9681: Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere; K2960: Other gastritis without bleeding; E8352: Hypercalcemia; E876: Hypokalemia; K5730: Diverticulosis of large intestine without perforation or abscess without bleeding. The uncommon codes mentioned in this dataset are D282, Q613, I471, D271, D270, R55, K449, K269, H409, I160, B9681, K2960, E8352, E876, K5730.
The icd codes present in this text will be E1110, N179, I10, E8770, E669, D72829, E785, Z7984, Z9114, J3489, D649, Z794, Z6835. The descriptions of icd codes E1110, N179, I10, E8770, E669, D72829, E785, Z7984, Z9114, J3489, D649, Z794, Z6835 are E1110: Type 2 diabetes mellitus with ketoacidosis without coma; N179: Acute kidney failure, unspecified; I10: Essential (primary) hypertension; E8770: Fluid overload, unspecified; E669: Obesity, unspecified; D72829: Elevated white blood cell count, unspecified; E785: Hyperlipidemia, unspecified; Z7984: Long term (current) use of oral hypoglycemic drugs; Z9114: Patient's other noncompliance with medication regimen; J3489: Other specified disorders of nose and nasal sinuses; D649: Anemia, unspecified; Z794: Long term (current) use of insulin; Z6835: Body mass index [BMI] 35.0-35.9, adult. The common codes which frequently come are N179, I10, E669, E785, D649, Z794. The uncommon codes mentioned in this dataset are E1110, E8770, D72829, Z7984, Z9114, J3489, Z6835. Allergies Trulicity Chief Complaint DKA Major Surgical or Invasive Procedure None History of Present Illness Mr. ___ is a ___ year old man with a pmh of DMII HTN HLD and acute pancreatitis who presents with DKA. He was previously on insulin 70U Tresiba 30U short acting w meals . Per the patient he was having consistent BG in 300s despite compliance with insulin regimen. 3 months ago his endocrinologist held his insulin and started metformin and glipizide and his BGs were 200s. On ___ he was started on ketogenic diet Kind Bar in am ___ drink for lunch normal dinner meal and he was started on oral Jardiance and phentermine ___. He subsequently lost 25 lbs in 18 days and was feeling well. 5 days prior to presentation he started feeling fatigued and lightheaded when walking around. He was concerned this was related to his new diabetic medications and self discontinued them 3 days ago. His symptoms continued to progress and worsen and he developed lightheadedness at rest new DOE with stairs headache nausea and vomiting 1x on day of presentation after eating a donut . During this time he continued his ketogenic diet and had a normal appetite. His BG levels remained 200 throughout checking twice daily which has been his baseline since starting Jardiance. However on the day of presentation he had some coke and his BG were subsequently 400s prompting presentation to the ED. He recently had a mild sore throat and rhinorrhea for several days but improved prior to presentation. He denies fevers chills night sweats cough chest pain abdominal pain back pain diarrhea ___ swelling dysuria hematuria polyuria melena BRBPR. He has not had a BM for the past 5 days. Past Medical History HTN HLD DMII Pancreatitis ___ Social History ___ Family History Father deceased lung cancer and diabetes. Mother alive CAD Sister deceased uterine cancer 3 aunts had colon cancer. Physical Exam ADMISSION PHYSICAL EXAM VS HR 88 BP 150 66 RR 16 SaO2 97 on RA GENERAL well appearing alert and interactive in no acute distress lying in bed CARDIAC RRR nl s1 s2 no m g r LUNGS CTAB no wheezing crackles or other adventitious breath sounds BACK No CVA tenderness ABDOMEN NABS obese soft nondistended nontender EXTREMITIES No clubbing cyanosis or edema. Pulses DP Radial 2 bilaterally. SKIN Warm. Cap refill 2s. No rash. NEUROLOGIC CN2 12 intact. ___ strength throughout. Normal sensation. Gait is normal. AOx3. DISCHARGE EXAM VS 98.0 149 80 67 18 99 RA GEN Alert and in no apparent distress EYES Anicteric non injected ENT MMM grossly nl OP CV RRR nl S1 S2 no g r m CHEST CTAB no w r r EWOB ABD soft NT ND NABS no r g EXT WWP no edema. 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 Pertinent Results ADMISSION LABS ___ 02 17PM BLOOD WBC 12.4 RBC 5.19 Hgb 15.3 Hct 47.4 MCV 91 MCH 29.5 MCHC 32.3 RDW 13.1 RDWSD 43.8 ___ 02 17PM BLOOD Neuts 83.6 Lymphs 10.3 Monos 5.2 Eos 0.2 Baso 0.2 Im ___ AbsNeut 10.38 AbsLymp 1.28 AbsMono 0.64 AbsEos 0.02 AbsBaso 0.03 ___ 09 39PM BLOOD ___ PTT 25.0 ___ ___ 02 17PM BLOOD Glucose 472 UreaN 30 Creat 1.6 Na 136 K 5.5 Cl 100 HCO3 6 AnGap 29 ___ 07 25PM BLOOD TotBili 0.4 ___ 03 17AM BLOOD ALT 13 AST 12 LD LDH 156 AlkPhos 89 TotBili 0.5 ___ 02 17PM BLOOD Calcium 9.8 Phos 4.5 Mg 2.6 ___ 03 17AM BLOOD HbA1c 10.2 eAG 246 ___ 07 25PM BLOOD Beta OH 6.0 ___ 03 50PM BLOOD ___ pO2 48 pCO2 22 pH 7.18 calTCO2 9 Base XS 18 ___ 07 32PM BLOOD Lactate 1.3 ___ 07 32PM BLOOD O2 Sat 79 ___ 09 53PM BLOOD freeCa 1.23 MIBROBIOLOGY ___ 3 20 pm URINE FINAL REPORT ___ URINE CULTURE Final ___ NO GROWTH. IMAGING STUDIES ___ CXR Cardiac size is normal. The lungs are clear. There is no pneumothorax or pleural effusion. Brief Hospital Course Mr. ___ is a ___ year old man with a pmh of DMII HTN and HLD admitted for euglycemic DKA from SGLT 2 use recently switched from insulin and ketogenic diet. Euglycemic DKA Presented with blood glucose of 440 pH 7.18 bicarbonate of 8 anion gap 29. Admitted to ICU for insulin drip. ___ consult felt mixed picture from Jiardance use and starvation ketosis from pre admission extremely low carb diet . His ICU course was slightly prolonged due to rising anion gap but euglycemic after transition from an insulin ggt to SubQ. However once Jiardance washout time completed AG closed and HCO3 subsequently rose to normal. He was transferred to the floor where ___ service continued to make insulin adjustments. It was decided to transition back to lantus Humalog as patient had been on previously. On day of discharge patient was feeling well with controlled FSBS closed AG near normal HCO3. ___ service felt that glycemic control was stable enough for discharge and he was discharged with intent for close ___ outpatient follow up. CHRONIC ISSUES HTN Continued home antihypertensives. HLD Medication list with atorvastatin but pt not taking TRANSITIONAL ISSUES Jiardance discontinued pt returned to ___. Has all supplies at home in sufficient quantity. Temporary phosphate and potassium repletion provided for limited prescription after discharge. Time spent coordinating discharge 30 minutes Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Losartan Potassium 100 mg PO DAILY 2. phentermine 37.5 mg oral DAILY 3. empagliflozin 25 mg oral DAILY Discharge Medications 1. Glargine 24 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 2. Phosphorus 500 mg PO BID Duration 2 Days RX sod phos di mono K phos mono Phosphorous 250 mg 2 tablet s by mouth twice a day Disp 8 Tablet Refills 0 3. Potassium Chloride 20 mEq PO DAILY Duration 5 Days RX potassium chloride 10 mEq 2 capsule s by mouth once a day Disp 10 Capsule Refills 0 4. Losartan Potassium 100 mg PO DAILY Discharge Disposition Home Discharge Diagnosis Euglycemic Diabetic Ketoacidosis Starvation Ketosis Type II Diabetes 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 with diabetic ketoacidosis a severe complication of diabetes due to your jiardance and extremely low carb diet. You were treated in the ICU with an insulin drip and your condition improved. After you had recovered it was decided to change your medications back to insulin. You were seen by the ___ diabetes service while hospitalized and will need to follow up with your endocrinologist after you leave the hospital. Medication changes Jiardance and phentermine were stopped Phosphprus supplements for the next two days ___ and ___ then stop Potassium supplements for the next 5 days Insulin lantus and Humalog were restarted Please take all medications as prescribed and keep all scheduled doctor s appointments. Seek medical attention if you develop a worsening or recurrence of the same symptoms that originally brought you to the hospital experience any of the warning signs listed below or have any other symptoms that concern you. It was a pleasure taking care of you Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be E1110, N179, I10, E8770, E669, D72829, E785, Z7984, Z9114, J3489, D649, Z794, Z6835. The descriptions of icd codes E1110, N179, I10, E8770, E669, D72829, E785, Z7984, Z9114, J3489, D649, Z794, Z6835 are E1110: Type 2 diabetes mellitus with ketoacidosis without coma; N179: Acute kidney failure, unspecified; I10: Essential (primary) hypertension; E8770: Fluid overload, unspecified; E669: Obesity, unspecified; D72829: Elevated white blood cell count, unspecified; E785: Hyperlipidemia, unspecified; Z7984: Long term (current) use of oral hypoglycemic drugs; Z9114: Patient's other noncompliance with medication regimen; J3489: Other specified disorders of nose and nasal sinuses; D649: Anemia, unspecified; Z794: Long term (current) use of insulin; Z6835: Body mass index [BMI] 35.0-35.9, adult. The common codes which frequently come are N179, I10, E669, E785, D649, Z794. The uncommon codes mentioned in this dataset are E1110, E8770, D72829, Z7984, Z9114, J3489, Z6835.
The icd codes present in this text will be I214, J90, J9811, I25119, R0902, F17200, Z8249. The descriptions of icd codes I214, J90, J9811, I25119, R0902, F17200, Z8249 are I214: Non-ST elevation (NSTEMI) myocardial infarction; J90: Pleural effusion, not elsewhere classified; J9811: Atelectasis; I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris; R0902: Hypoxemia; F17200: Nicotine dependence, unspecified, uncomplicated; Z8249: Family history of ischemic heart disease and other diseases of the circulatory system. The uncommon codes mentioned in this dataset are I214, J90, J9811, I25119, R0902, F17200, Z8249. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest pain Major Surgical or Invasive Procedure ___ Coronary artery bypass grafting x 4 left internal mammary artery to left anterior descending artery saphenous vein graft to ramus intermedius saphenous vein graft to obtuse marginal branch saphenous vein graft to posterior descending artery. History of Present Illness Mr. ___ is a ___ year old man with a strong family history of early coronary artery disease. He developed substernal chest pain radiating to his left shoulder. He denied associated nausea vomiting diaphoresis cough shortness of breath or syncope. He had stuttering symptoms over the course of the day and presented to the ED and was placed on a nitgroglycerin drip. An EKG revealed Q waves inferiorly. A cardiac catheterization the following day revealed multivessel coronary artery disease. He was transferred to ___ for surgical revascularization. Past Medical History None Social History ___ Family History unremarkable Physical Exam BPL 139 83 RR 18 O2 sat 96 Height 69 Weight 255 lbs General 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 Extremities Warm X well perfused X Edema ___ Varicosities None Neuro Grossly intact Pulses Femoral Right 2 Left 2 DP Right 2 Left 2 Radial Right 2 Left 2 Pertinent Results Transthoracic Echocardiogram ___ The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal dyskinesis of the inferior wall and severe hypokinesis to akinesis of the remainder of the inferior wall. There is an inferobasal left ventricular aneurysm. Overall ejection fraction is mildly depressed EF 50 55 . 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 no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION Suboptimal image quality. Mild symmetric left ventricular hypertrophy with regional left ventricular systolic dysfunction c w CAD. Normal right ventricular cavity size and systolic function. Transesophageal Echocardiogram ___ PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium left atrial appendage or the body of the right atrium right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal inferior wall. The right ventricle displays normal free wall contractility. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets 3 are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild 1 mitral regurgitation is seen. There is no pericardial effusion. Dr. ___ was notified in person of the results in the operating room at the time of the study. CXR ___ Median sternotomy wires are intact. Postoperative widening of the cardiomediastinal silhouette is stable. No pulmonary edema. Stable moderate left pleural effusion with an air fluid level seen medially and posteriorly suggesting a small pneumothorax. No right pleural effusion. Stable low lung volumes bilaterally. Stable substantial left lower lobe atelectasis. IMPRESSION 1. Stable moderate left pleural effusion with a small posteromedial pneumothorax. 2. Stable substantial left lower lobe atelectasis. Admission Labs ___ WBC 9.8 RBC 4.48 Hgb 13.5 Hct 40.1 MCV 90 MCH 30.1 MCHC 33.7 RDW 12.5 RDWSD 40.9 Plt ___ ___ ___ PTT 33.6 ___ ___ Glucose 101 UreaN 8 Creat 0.9 Na 134 K 3.9 Cl 101 HCO3 24 ___ ALT 52 AST 42 LD LDH 289 AlkPhos 116 TotBili 0.6 ___ Calcium 8.4 Phos 2.8 Mg 2.0 ___ HbA1c 6.6 eAG 143 Discharge Labs ___ 06 10AM BLOOD WBC 9.3 RBC 3.96 Hgb 11.9 Hct 35.8 MCV 90 MCH 30.1 MCHC 33.2 RDW 12.7 RDWSD 42.0 Plt ___ ___ 02 05AM BLOOD ___ PTT 30.4 ___ ___ 06 10AM BLOOD Glucose 150 UreaN 26 Creat 1.0 Na 135 K 4.1 Cl 96 HCO3 27 AnGap 16 Brief Hospital Course He was admitted on ___ and underwent routine preoperative testing and evaluation. Prior to his cardiac catheterization he was given a Plavix load of 600mg. This was allowed to wash out and he was taken to the operating room on ___. He underwent coronary artery bypass grafting x 4. 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 weaned from sedation awoke neurologically intact and was extubated on POD 1. He was weaned from inotropic and vasopressor support. Beta blocker was initiated and he was diuresed toward his preoperative weight. He remained hemodynamically stable and was transferred to the telemetry floor for further recovery. Diltiazem and Lopressor was continued for sinus tachycardia. He was hypoxic from left lower lobe atelectasis and pleural effusion. Aggressive pulmonary toilet nebs and ambulation he improved. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 he was ambulating freely the wound was healing and pain was controlled with oral analgesics. He was discharged to home in good condition with appropriate follow up instructions. Medications on Admission None Discharge Medications 1. Acetaminophen ___ mg PO Q6H PRN pain RX acetaminophen 500 mg 2 tablet s by mouth four times a day Disp 160 Tablet Refills 0 2. Aspirin EC 81 mg PO DAILY RX aspirin 81 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 3. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 4. Fluticasone Propionate 110mcg 2 PUFF IH BID RX fluticasone Flovent HFA 110 mcg actuation 2 puffs twice a day Disp 1 Inhaler Refills 0 5. Guaifenesin ER 1200 mg PO Q12H RX guaiFENesin 1 tablets by mouth twice a day Disp 30 Tablet Refills 0 6. HYDROmorphone Dilaudid ___ mg PO Q3H PRN pain RX hydromorphone 2 mg ___ tablet s by mouth every six 6 hours Disp 60 Tablet Refills 0 7. Ipratropium Bromide MDI 2 PUFF IH QID RX ipratropium bromide 0.2 mg mL 0.02 2 puffs four times a day Disp 1 Inhaler Refills 0 8. Potassium Chloride 40 mEq PO BID RX potassium chloride 20 mEq 2 tablet s by mouth twice a day Disp 56 Tablet Refills 0 9. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 0 10. Metoprolol Tartrate 50 mg PO Q8H RX metoprolol tartrate 50 mg 1 tablet s by mouth three times a day Disp 90 Tablet Refills 0 11. Albuterol Inhaler 2 PUFF IH Q4H PRN wheezing RX albuterol sulfate ProAir HFA 90 mcg 2 puffs every four 4 hours Disp 1 Inhaler Refills 0 12. Furosemide 40 mg PO BID Duration 14 Days RX furosemide 40 mg 1 tablet s by mouth twice a day Disp 28 Tablet Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Coronary Artery Disease s p CABG x 4 ___ Discharge Condition Alert and oriented x3 nonfocal Ambulating gait steady Sternal pain managed with oral analgesics Sternal Incision healing well no erythema or drainage Discharge Instructions Please shower daily including washing incisions gently with mild soap no baths or swimming and look at your incisions 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 Please call with any questions or concerns ___ 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 I214, J90, J9811, I25119, R0902, F17200, Z8249. The descriptions of icd codes I214, J90, J9811, I25119, R0902, F17200, Z8249 are I214: Non-ST elevation (NSTEMI) myocardial infarction; J90: Pleural effusion, not elsewhere classified; J9811: Atelectasis; I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris; R0902: Hypoxemia; F17200: Nicotine dependence, unspecified, uncomplicated; Z8249: Family history of ischemic heart disease and other diseases of the circulatory system. The uncommon codes mentioned in this dataset are I214, J90, J9811, I25119, R0902, F17200, Z8249.
The icd codes present in this text will be I70221, B1920, I252, G500, Z8541, Z9221, Z923, I2510, F17210. The descriptions of icd codes I70221, B1920, I252, G500, Z8541, Z9221, Z923, I2510, F17210 are I70221: Atherosclerosis of native arteries of extremities with rest pain, right leg; B1920: Unspecified viral hepatitis C without hepatic coma; I252: Old myocardial infarction; G500: Trigeminal neuralgia; Z8541: Personal history of malignant neoplasm of cervix uteri; Z9221: Personal history of antineoplastic chemotherapy; Z923: Personal history of irradiation; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; F17210: Nicotine dependence, cigarettes, uncomplicated. The common codes which frequently come are I252, I2510, F17210. The uncommon codes mentioned in this dataset are I70221, B1920, G500, Z8541, Z9221, Z923. Allergies atenolol Paxil iv contrast gabapentin o2 nose cannula Chief Complaint right leg rest pain Major Surgical or Invasive Procedure ___ 1. Femoral to femoral bypass with ringed PTFE. 2. Catheter placement into abdominal aorta. 3. Abdominal aortogram. History of Present Illness Ms. ___ is a ___ woman with previous pelvic radiation and urostomy bag with iliac stenting on the right. She presented to clinic with continued rest pain on the right. After reviewing her CT scan from ___ as well as her ultrasound in ___ Dr. ___ for a left to right fem fem bypass and possible left external iliac stent and possible common iliac artery stent. Past Medical History 1. peripheral arterial disease s p right external iliac artery stent in ___ unsuccessful. 2. Cervical cancer status post chemo and radiation. diagnosis in ___. 3. Hydronephrosis. 4. Hepatitis C past infection. 5. Polysubstance abuse. 6. Trigeminal neuralgia. 7. Hypertension. 8. Active smoker. 9. Myocardial infarction ___ 10. Hypertension. 12. DVT. 13. anxiety and depression. PSH R iliac stent urostomy secondary to ureter obstruction from radiation. Social History ___ Family History heart disease heart failure COPD Physical Exam Discharge Physical Exam Gen Alert and oriented x 3 NAD HEENT Neck supple full ROM Carotids 2 no bruits or JVD Resp nl effort CTABL no wheezes rales rhonchi CV RRR S1 S2 no S3 S4 no mrumurs rubs gallops Abd Soft non tender non distended Ext Pulses Left Femoral palp DP doppler ___ palp Right Femoral palp DP palp ___ doppler Feet warm well perfused. No open areas Left and Right groin puncture site Dressing clean dry and intact. Soft no hematoma or ecchymosis Pertinent Results Labs ___ 06 00AM BLOOD WBC 6.4 RBC 3.83 Hgb 12.3 Hct 38.3 MCV 100 MCH 32.1 MCHC 32.1 RDW 13.2 RDWSD 48.5 Plt ___ ___ 06 00AM BLOOD Glucose 83 UreaN 15 Creat 0.8 Na 137 K 4.2 Cl 103 HCO3 23 AnGap 15 ___ 06 00AM BLOOD Calcium 8.6 Phos 4.0 Mg 1.8 ___ 06 00AM BLOOD VitB12 279 Folate 17.6 ___ 06 00AM BLOOD TSH 0.69 ___ 06 00AM BLOOD T4 6.8 Operative Report ___ Surgeon ___ M.D. ___ ASSISTANT ___ PREOPERATIVE DIAGNOSIS Right leg rest pain. POSTOPERATIVE DIAGNOSIS Right leg rest pain. PROCEDURES PERFORMED 1. Femoral to femoral bypass with ringed PTFE. 2. Catheter placement into abdominal aorta. 3. Abdominal aortogram. CONTRAST USED Used 7.5 mL Omnipaque. FLUORO DOSE 39 mGy. FLUORO TIME 1.4 minutes. INDICATIONS ___ woman with history of right iliac occlusion presents for femoral femoral bypass and possible left iliac stenting. DESCRIPTION OF PROCEDURE The patient was brought to the operating room and placed in the supine position. Both groins and the abdomen were prepped and draped in standard fashion and a time out was performed. Two horizontal incisions were made overlying the femoral arteries in both groins. The soft tissue was divided using electrocautery. Once the femoral sheaths were identified these were incised and the arteries were identified. The SFA and profunda were isolated with vessel loops bilaterally. The common femoral artery was then dissected out proximally and isolated with a vessel loop. Once all of these major vessels and their branches had been controlled the patient was given full dose therapeutic heparin and the left common femoral artery was accessed with the access needle. There was an excellent pulse and good return of blood. A 0.035 wire was passed into the abdominal aorta under direct visualization. A ___ sheath was placed. We then placed a flush catheter into the aortic bifurcation and performed an aortogram. This revealed patent left common iliac external iliac and hypogastric with good flow into the common. There was a small area of stenosis of the proximal common as well as areas of the external iliac that looked irregular on the left. Therefore we advanced a pressure catheter and checked pressure measurements across all of the areas of the iliac system on the left. We found that there was no pressure gradient across the left common iliac stenosis and there was no pressure gradient across the length of the external iliac. Therefore the decision was made not to treat these areas. The right iliac system was occluded on angiography as was suspected. Therefore we removed the needle and clamped the inflow and outflow vessels. We then extended the arteriotomy using Potts scissors. Prior to heparinization we had created a tunnel in the subcutaneous tissue of the anterior abdominal wall using blunt dissection. We then passed a ringed 7 mm PTFE bypass graft through this area. Now with the left arteriotomy prepared we beveled the bypass graft and performed a circumferential anastomosis using a Gore Tex suture. We reinforced this with BioGlue. We then restored flow through the bypass graft and had good hemostasis. We packed the wound and re clamped the graft after flushing it. We then turned our attention to the right groin. We clamped the inflow and the outflow of the right groin and made an arteriotomy at the very distal common femoral onto the SFA itself. We then beveled the graft and performed a circumferential anastomosis using a Gore Tex suture. Prior to completing this we backflushed from the SFA and then we flushed the graft making sure there was no debris or air in the system. We then completed the anastomosis and placed glue on the anastomosis to reinforce it. We then restored flow. There was good hemostasis. We spent some time assuring this using electric cautery in both groins. We then closed the femoral sheath with interrupted 3 O Vicryl suture and closed the fat over the bypass graft with ___ suture. We then closed the soft tissue bilaterally with ___ Vicryl suture and the skin with a ___ Monocryl. The skin was then covered with Dermabond. At the completion of this the patient s drapes were taken down. She was noted to have bilateral palpable pedal pulses. She was extubated and transferred to the PACU for recovery. Brief Hospital Course Ms. ___ is a ___ old woman with right leg rest pain who presented to ___ on ___ for planned left to right femoral femoral bypass which she underwent at this time. For full details of this procedure please refer to the operative report. She tolerated this procedure well and was taken to the PACU then the vascular surgery step down unit for further monitoring and recovery from surgery. She remained hemodynamically stable. She was started on low dose aspirin and atorvastatin post operatively. Because she was on narcotics pre operatively including long acting morphine and she has a history of drug abuse anesthesia suggested we start a dilaudid PCA for pain control. Her pain was controlled with a dilaudid PCA and her home meds except MS ___. On POD 1 she continued to have pain and it was difficult to examine her due to pain. She maintained palpable pedal pulses on the right. Chronic pain service was consulted and suggested her to be put back on all home medications including MS ___ with increase from BID to TID increase dosage of oxycodone and add pregabalin. These changes had good effect and her pain was adequately controlled for the rest of her hospitalization. Over the next several days she progressed in terms of eating as well as ambulation. She continued to have adequate urine output through her urostomy. On POD 4 she worked with physical therapy who recommended home with home ___. At this time her pain was well controlled she was tolerating regular diet making adequate urine and ambulating with assistance. She was given instructions to wean her MS contin back to her home dose of BID next week. In addition she was also instructed to wean off the oxycodone to her home dose or less as she should no longer have rest pain. She was discharged to home with services and ___ on POD 4 with follow up in vascular surgery clinic in about 1 month with a duplex. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q8H PRN nausea 2. Acetaminophen 1000 mg PO Q8H PRN Pain Mild 3. QUEtiapine Fumarate 50 mg PO QHS 4. ClonazePAM 1 mg PO Q8H PRN anxiety 5. OxyCODONE Immediate Release 5 mg PO BID severe pain 6. Vitamin D 1000 UNIT PO BID 7. Morphine SR MS ___ 30 mg PO Q12H Discharge Medications 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 2. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet s by mouth at bedtime Disp 30 Tablet Refills 0 3. Docusate Sodium 100 mg PO DAILY PRN constipation Hold for loose stool diarrhea. 4. Nicotine Patch 14 mg TD DAILY Follow up with your PCP to further discuss smoking cessation. RX nicotine 14 mg 24 hour apply 1 patch to skin daily Disp 14 Patch Refills 0 5. Omeprazole 40 mg PO DAILY 6. Pregabalin 75 mg PO BID RX pregabalin Lyrica 75 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 0 7. Senna 8.6 mg PO BID PRN constipation Hold for loose stool diarrhea. 8. Morphine SR MS ___ 30 mg PO Q8H Decrease to your home dose of 30mg every 12 hours for pain on ___. RX morphine 30 mg 1 tablet s by mouth three times a day Disp 20 Tablet Refills 0 9. OxyCODONE Immediate Release ___ mg PO Q4H PRN severe pain As your pain improves wean off of this medication to your home dose of ___ twice a day or less RX oxycodone 10 mg 0.5 1.5 tablet s by mouth q4hrs Disp 30 Tablet Refills 0 10. Acetaminophen 1000 mg PO Q8H PRN Pain Mild 11. ClonazePAM 1 mg PO Q8H PRN anxiety 12. QUEtiapine Fumarate 50 mg PO QHS 13. Vitamin D 1000 UNIT PO BID Discharge Disposition Home With Service Facility ___ ___ Diagnosis right leg rest 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 Dear Ms. ___ It was a pleasure taking care of you at ___ ___. You were admitted to the hospital after surgery on your leg. This surgery was done to improve blood flow to your leg. 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. Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions WHAT TO EXPECT 1. 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 Unless you were told not to bear any weight on operative foot 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 2. It is normal to have swelling of the leg you were operated on Elevate your leg above the level of your heart use ___ pillows or a recliner every ___ hours throughout the day and at night Avoid prolonged periods of standing or sitting without your legs elevated 3. 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 aspirin as instructed Follow your discharge medication instructions ACTIVITIES No driving until post op visit and you are no longer taking pain medications Unless you were told not to bear any weight on operative foot You should get up every day get dressed and walk You should gradually increase your activity You may up and down stairs go outside and or ride in a car Increase your activities as you can tolerate do not do too much right away No heavy lifting pushing or pulling greater than 5 pounds until your post op visit You may shower unless you have stitches or foot incisions 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 that is draining as needed CALL THE OFFICE FOR ___ Redness that extends away from your incision A sudden increase in pain that is not controlled with pain medication A sudden change in the ability to move or use your leg or the ability to feel your leg Temperature greater than 100.5F 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 I70221, B1920, I252, G500, Z8541, Z9221, Z923, I2510, F17210. The descriptions of icd codes I70221, B1920, I252, G500, Z8541, Z9221, Z923, I2510, F17210 are I70221: Atherosclerosis of native arteries of extremities with rest pain, right leg; B1920: Unspecified viral hepatitis C without hepatic coma; I252: Old myocardial infarction; G500: Trigeminal neuralgia; Z8541: Personal history of malignant neoplasm of cervix uteri; Z9221: Personal history of antineoplastic chemotherapy; Z923: Personal history of irradiation; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; F17210: Nicotine dependence, cigarettes, uncomplicated. The common codes which frequently come are I252, I2510, F17210. The uncommon codes mentioned in this dataset are I70221, B1920, G500, Z8541, Z9221, Z923.
The icd codes present in this text will be T82868A, F17210, I10, F419, F329, I252, K589, G893, Z86718, Z8541, Z23. The descriptions of icd codes T82868A, F17210, I10, F419, F329, I252, K589, G893, Z86718, Z8541, Z23 are T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter; F17210: Nicotine dependence, cigarettes, uncomplicated; I10: Essential (primary) hypertension; F419: Anxiety disorder, unspecified; F329: Major depressive disorder, single episode, unspecified; I252: Old myocardial infarction; K589: Irritable bowel syndrome without diarrhea; G893: Neoplasm related pain (acute) (chronic); Z86718: Personal history of other venous thrombosis and embolism; Z8541: Personal history of malignant neoplasm of cervix uteri; Z23: Encounter for immunization. The common codes which frequently come are F17210, I10, F419, F329, I252, Z86718. The uncommon codes mentioned in this dataset are T82868A, K589, G893, Z8541, Z23. Allergies atenolol Paxil iv contrast o2 nose cannula Chief Complaint R foot pain Major Surgical or Invasive Procedure S p fem fem bypass revision with thrombectomy ___ ___ History of Present Illness ___ is a ___ w hx of PVD w occluded R iliac stent s p fem fem L R bypass w PTFE ___ Dr. ___ who is presenting here to the ED w a 1 wk hx of worsening R leg pain. She says she has been having R foot numbness and pain since her fem fem bypass and was o w in her usual state of health when 1 wk ago she had sudden onset L leg pain throughout her entire leg which has worsened over time and prompted her to present to an OSH and she was txfr ed here for further management for which we were consulted. Of note she was last seen by us in clinic on ___ but has not f u d since she notes that her PCP has been managing all of her care. Past Medical History PMHx PVD w occluded R iliac stent s p fem fem L R bypass w PTFE ___ cervical cancer s p chemo XRT HCV HTN smoking MI HTN DVT anxiety d o depressive d o polysubstance use d o hydronephrosis PSHx fem fem L R bypass w PTFE ___ prior R iliac stent urostomy ___ ureteral obstruction related to XRT Social History ___ Family History heart disease heart failure COPD Physical Exam Admission Physical Exam VS 98.1 79 143 77 24 96 RA Gen appears in pain CV RRR Pulm non labored breathing no resp distress MSK extremities skin L p p p R leg L foot and lower leg cool slight skin discoloration ttp d venous limited ROM of L foot decreased sensation decreased strength Discharge Physical Exam Vitals 24 HR Data last updated ___ 745 Temp 97.4 Tm 98.5 BP 136 70 88 136 55 73 HR 64 58 87 RR 16 ___ O2 sat 94 92 98 O2 delivery RA Wt 160.93 lb 73.0 kg GENERAL x NAD CV x RRR PULM x no respiratory distress ABD x soft x Nontender EXTREMITIES Warm no peripheral edema PULSES L p p p R d d Pertinent Results Lab Results ___ 04 32AM BLOOD WBC 7.6 RBC 3.12 Hgb 9.7 Hct 29.9 MCV 96 MCH 31.1 MCHC 32.4 RDW 13.5 RDWSD 47.7 Plt ___ ___ 04 13AM BLOOD WBC 7.8 RBC 3.23 Hgb 10.0 Hct 31.1 MCV 96 MCH 31.0 MCHC 32.2 RDW 13.4 RDWSD 47.0 Plt ___ ___ 05 30PM BLOOD WBC 9.0 RBC 3.41 Hgb 10.7 Hct 32.9 MCV 97 MCH 31.4 MCHC 32.5 RDW 13.2 RDWSD 46.5 Plt ___ ___ 04 15AM BLOOD WBC 8.2 RBC 4.59 Hgb 14.3 Hct 43.7 MCV 95 MCH 31.2 MCHC 32.7 RDW 13.2 RDWSD 46.4 Plt ___ ___ 05 27AM BLOOD WBC 6.7 RBC 4.51 Hgb 13.9 Hct 43.3 MCV 96 MCH 30.8 MCHC 32.1 RDW 13.2 RDWSD 47.3 Plt ___ ___ 03 09PM BLOOD WBC 7.2 RBC 4.54 Hgb 14.3 Hct 42.8 MCV 94 MCH 31.5 MCHC 33.4 RDW 13.5 RDWSD 46.9 Plt ___ ___ 03 09PM BLOOD Neuts 56.4 ___ Monos 6.7 Eos 1.8 Baso 0.4 Im ___ AbsNeut 4.07 AbsLymp 2.45 AbsMono 0.48 AbsEos 0.13 AbsBaso 0.03 ___ 04 32AM BLOOD Glucose 103 UreaN 9 Creat 0.8 Na 141 K 4.0 Cl 107 HCO3 24 AnGap 10 ___ 04 13AM BLOOD Glucose 87 UreaN 9 Creat 0.8 Na 141 K 4.4 Cl 107 ___ 05 30PM BLOOD Glucose 117 UreaN 10 Creat 0.7 Na 141 K 3.9 Cl 108 HCO3 23 AnGap 10 ___ 04 15AM BLOOD Glucose 124 UreaN 13 Creat 0.9 Na 139 K 4.4 Cl 101 HCO3 25 AnGap 13 ___ 05 27AM BLOOD Glucose 98 UreaN 13 Creat 1.0 Na 139 K 4.4 Cl 99 HCO3 26 AnGap 14 ___ 03 09PM BLOOD Glucose 78 UreaN 15 Creat 0.9 Na 139 K 6.1 Cl 101 HCO3 26 AnGap 12 ___ 04 13AM BLOOD CK MB 1 cTropnT 0.01 ___ 06 29PM BLOOD CK MB 1 cTropnT 0.01 ___ 04 32AM BLOOD Calcium 8.3 Phos 2.5 Mg 1.9 ___ 05 30PM BLOOD Phos 3.3 ___ 04 15AM BLOOD Calcium 9.4 Phos 3.9 Mg 1.8 ___ 05 27AM BLOOD Calcium 9.2 Phos 4.1 Mg 1.9 Brief Hospital Course Neuro Pain was initially controlled with a dilaudid PCA which was transitioned to po oxycodone. Chronic pain services were consulted within admission and recommended increasing patient s gabapentin dosage to 300mg TID which was well tolerated. 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 has a urostomy bag at baseline. ID The patient s vital signs were monitored for signs of infection and fever. Heme The patient had blood levels checked post operatively during the hospital course to monitor for signs of bleeding. Patient was initially kept on a heparin gtt and pre authorization was obtained to discharge patient on Xarelto. The patient had vital signs including heart rate and blood pressure monitored throughout the hospital stay. Discharge Medications 1. Acetaminophen 1000 mg PO Q6H PRN Pain Mild Fever 2. Docusate Sodium 100 mg PO BID constipation 3. Rivaroxaban 20 mg PO DAILY 4. Gabapentin 300 mg PO TID 5. amLODIPine 2.5 mg PO DAILY 6. ClonazePAM 1 mg PO TID 7. Morphine SR MS ___ 30 mg PO Q12H 8. QUEtiapine Fumarate 50 mg PO QHS 9. Topiramate Topamax 100 mg PO QPM Discharge Disposition Home With Service Facility ___ ___ Diagnosis Occlusion of fem fem bypass Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Discharge Instructions Dear Ms. ___ You were admitted to ___ and underwent revision of your fem fem bypass graft thrombectomy and right lower extremity patch angioplasty. You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery WHAT TO EXPECT 1. 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 Unless you were told not to bear any weight on operative foot 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 2. It is normal to have swelling of the leg you were operated on Elevate your leg above the level of your heart use ___ pillows or a recliner every ___ hours throughout the day and at night Avoid prolonged periods of standing or sitting without your legs elevated 3. 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 your Xarelto as instructed for anticoagulation Follow your discharge medication instructions ACTIVITIES No driving until post op visit and you are no longer taking pain medications Unless you were told not to bear any weight on operative foot You should get up every day get dressed and walk You should gradually increase your activity You may up and down stairs go outside and or ride in a car Increase your activities as you can tolerate do not do too much right away No heavy lifting pushing or pulling greater than 5 pounds until your post op visit You may shower unless you have stitches or foot incisions 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 that is draining as needed CALL THE OFFICE FOR ___ Redness that extends away from your incision A sudden increase in pain that is not controlled with pain medication A sudden change in the ability to move or use your leg or the ability to feel your leg Temperature greater than 100.5F for 24 hours Bleeding new or increased drainage from incision or white yellow or green drainage from incisions ___ MD ___ Completed by ___ The icd codes present in this text will be T82868A, F17210, I10, F419, F329, I252, K589, G893, Z86718, Z8541, Z23. The descriptions of icd codes T82868A, F17210, I10, F419, F329, I252, K589, G893, Z86718, Z8541, Z23 are T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter; F17210: Nicotine dependence, cigarettes, uncomplicated; I10: Essential (primary) hypertension; F419: Anxiety disorder, unspecified; F329: Major depressive disorder, single episode, unspecified; I252: Old myocardial infarction; K589: Irritable bowel syndrome without diarrhea; G893: Neoplasm related pain (acute) (chronic); Z86718: Personal history of other venous thrombosis and embolism; Z8541: Personal history of malignant neoplasm of cervix uteri; Z23: Encounter for immunization. The common codes which frequently come are F17210, I10, F419, F329, I252, Z86718. The uncommon codes mentioned in this dataset are T82868A, K589, G893, Z8541, Z23.
The icd codes present in this text will be K922, N179, D684, I4891, I5022, D696, G629, K7460, I129, D869, C61, D500, K31819, K5790, N189, Z7901, E785, M109, D573, M1990, J45909, Z96651, Z923. The descriptions of icd codes K922, N179, D684, I4891, I5022, D696, G629, K7460, I129, D869, C61, D500, K31819, K5790, N189, Z7901, E785, M109, D573, M1990, J45909, Z96651, Z923 are K922: Gastrointestinal hemorrhage, unspecified; N179: Acute kidney failure, unspecified; D684: Acquired coagulation factor deficiency; I4891: Unspecified atrial fibrillation; I5022: Chronic systolic (congestive) heart failure; D696: Thrombocytopenia, unspecified; G629: Polyneuropathy, unspecified; K7460: Unspecified cirrhosis of liver; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; D869: Sarcoidosis, unspecified; C61: Malignant neoplasm of prostate; D500: Iron deficiency anemia secondary to blood loss (chronic); K31819: Angiodysplasia of stomach and duodenum without bleeding; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; N189: Chronic kidney disease, unspecified; Z7901: Long term (current) use of anticoagulants; E785: Hyperlipidemia, unspecified; M109: Gout, unspecified; D573: Sickle-cell trait; M1990: Unspecified osteoarthritis, unspecified site; J45909: Unspecified asthma, uncomplicated; Z96651: Presence of right artificial knee joint; Z923: Personal history of irradiation. The common codes which frequently come are N179, I4891, D696, I129, N189, Z7901, E785, M109, J45909. The uncommon codes mentioned in this dataset are K922, D684, I5022, G629, K7460, D869, C61, D500, K31819, K5790, D573, M1990, Z96651, Z923. Allergies lisinopril niacin Chief Complaint Weakness Major Surgical or Invasive Procedure ___ EGD and Colonoscopy History of Present Illness Mr. ___ is a ___ gentleman with PMH significant for atrial fibrillation on warfarin prostate cancer s p radiation HFrEF EF 40 45 and history of lower GI bleed in ___ due to rectal angioectasia in the setting of radiation proctitis who presents with weakness found to have BRBPR and Hgb 4.4. Per patient he was at work earlier today when he developed feelings of weakness lightheadedness and dizziness while standing. He reports he sat down to take a break and on attempting to stand back up became extremely dizzy again. He reports a co worker told him he looked really pale and ill and so called EMS. On EMS arrival patient was noted to have 1 mm STE in I and aVL. He received aspirin x4 and was transferred to ___. Of note patient reports x3 days of BRBPR he reports seeing bright red blood in the toilet bowl and mixed with his stool. He also notes some maroon colored stools he denies tarry or black stools diarrhea increased frequency of BM. He denies N V abd pain f c CP palp SOB dysuria MSK joint pain. In the ED initial vitals HR 71 BP 90 64 RR 18 SAT 98 on RA. Exam notable for gross blood in the rectum. Labs were notable for H H 4.4 16.1 PLT 52 INR 3.1 Cr 2.2 Trop T 0.02. CXR showed Cardiomegaly without evidence of pulmonary edema. No evidence of pneumonia. Patient was given 1L NS 1 unit of uncrossmatched blood pantoprazole 40 mg IV x1 Kcentra 2490 units vitamin K 10 mg IV 1u crossmatched blood. GI was consulted in the ED. On arrival to the MICU patient reports feeling much better than this AM. He denies current dizziness lightheadedness. Past Medical History Atrial fibrillation Systolic heart failure LVEF of 40 45 in ___ Hypertension Hyperlipidemia Gout Prostate cancer status post radiation therapy Sarcoidosis Sickle cell trait Right total knee replacement in ___ Solitary pulmonary nodule followed since ___ Osteoarthritis Peripheral neuropathy Asthma Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory. Physical Exam ADMISSION PHYSICAL EXAM Vitals afebrile 70 126 71 15 97 RA GENERAL Alert oriented no acute distress HEENT Sclera anicteric pale conjunctiva MMM oropharynx clear NECK supple JVP not elevated no LAD 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 Warm well perfused 2 pulses no clubbing cyanosis or edema SKIN clear without ecchymoses rash NEURO AAOx3 moves all extremities spontaneously ACCESS PIVs DISCHARGE PHYSICAL EXAM VS 97.8 74 110 72 18 100 RA GENERAL NAD pleasant HEENT PERRL EOMI poor dentition NECK no JVD CARDIAC Irregularly irregular S1 S2 no MRG LUNG LCTA bl no w r r ABDOMEN Soft NTND no HSM EXTREMITIES FROM no c e e PULSES 2 DP pulses bilaterally NEURO CN II XII intact strength and sensation symmetric and intact bl Pertinent Results ADMISSION LABS ___ 09 30AM BLOOD WBC 4.7 RBC 2.50 Hgb 4.4 Hct 16.1 MCV 64 MCH 17.6 MCHC 27.3 RDW 23.7 RDWSD 53.5 Plt Ct 52 ___ 09 30AM BLOOD Neuts 70.5 Lymphs 13.8 Monos 11.0 Eos 3.9 Baso 0.2 NRBC 1.1 Im ___ AbsNeut 3.28 AbsLymp 0.64 AbsMono 0.51 AbsEos 0.18 AbsBaso 0.01 ___ 09 30AM BLOOD ___ PTT 59.0 ___ ___ 09 30AM BLOOD Glucose 137 UreaN 58 Creat 2.2 Na 138 K 4.9 Cl 104 HCO3 22 AnGap 17 ___ 09 30AM BLOOD ALT 12 AST 21 AlkPhos 82 TotBili 0.4 ___ 02 03PM BLOOD Ret Man 4.1 Abs Ret 0.12 ___ 09 30AM BLOOD proBNP 1654 ___ 09 30AM BLOOD cTropnT 0.02 ___ 09 30AM BLOOD Albumin 4.1 Calcium 9.3 Phos 3.6 Mg 2.2 Iron 46 ___ 09 30AM BLOOD calTIBC 455 ___ Ferritn 5.8 TRF 350 ___ 09 36AM BLOOD Glucose 131 Lactate 1.9 Na 138 K 4.9 Cl 105 calHCO3 23 ___ 09 36AM BLOOD Hgb 4.9 calcHCT 15 MICRO DATA ___ MRSA Screen Negative IMAGING STUDIES CXR ___ IMPRESSION Cardiomegaly without evidence of pulmonary edema. No evidence of pneumonia EKG ___ Sinus rhythm. Left axis deviation with left anterior fascicular block. Right bundle branch block. Occasional premature ventricular contraction. Compared to the previous tracing of ___ atrial flutter has now converted to sinus rhythm. Abd US ___ FINDINGS LIVER The hepatic parenchyma appears coarsened. The contour of the liver is nodular. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS There is no intrahepatic biliary dilation. The CBD measures 7 mm. GALLBLADDER There is no evidence of stones or gallbladder wall thickening. PANCREAS Imaged portion of the pancreas appears within normal limits without masses or pancreatic ductal dilation with portions of the pancreatic tail obscured by overlying bowel gas. SPLEEN Normal echogenicity measuring 12.1 cm. KIDNEYS The right kidney measures 11.3 cm. The left kidney measures 10.9 cm. 2 parapelvic cysts are noted in the upper pole of the right kidney. Several cysts are that are identified in the left kidney. The largest measures 3.6 cm. A 2.0 cm cyst is seen in the interpolar region on the left. A 4 cm cyst is seen in the lower pole a 2.8 cm cyst is seen in the upper pole. Normal cortical echogenicity and corticomedullary differentiation is seen bilaterally. There is no evidence of masses stones or hydronephrosis in the kidneys. RETROPERITONEUM Visualized portions of aorta and IVC are within normal limits. IMPRESSION 1. Coarsened liver echotexture and nodular contour of the liver are concerning for cirrhosis. 2. Multiple bilateral renal cysts 3. Normal size of spleen EGD ___ Findings Esophagus Normal esophagus. Stomach Mucosa Diffuse angioectasias of the antrum consistent with GAVE. There were also more scattered angioectasias spreading up into the body. Some of those in the body displayed mild ooze and were treated with APC. Small areas in the antrum were also treated with APC. An Argon Plasma Coagulator was applied for hemostasis and tissue destruction successfully. Duodenum Normal duodenum. Impression Diffuse angioectasias of the antrum with scattered in the stomach thermal therapy Otherwise normal EGD to third part of the duodenum Recommendations GAVE likely a source of chronic blood loss but likely does not explain acute bleeding BID PPI Sucralfate QID for a week Consider repeat EGD in 8 weeks Proceed to colonoscopy Colonoscopy ___ Findings Contents Dark red and clotted blood was seen only in the rectum and the recto sigmoid junction. Despite extensive washing no source of underlying mucosal abnormality was identified. Careful exam in retroflexion also did not reveal any abnormalities. Excavated LesionsMultiple non bleeding diverticula were seen. Diverticulosis appeared to be of mild severity. Impression Diverticulosis of the colon Blood in the colon Otherwise normal colonoscopy to cecum Recommendations Return to hospital ward Source of bleeding likely from rectum or rectosigmoid given the distribution of blood however no specific source identified. A rectal Dieulafoy is possible. DISCHARGE LABS ___ 06 55AM BLOOD WBC 7.4 RBC 3.29 Hgb 7.3 Hct 24.0 MCV 73 MCH 22.2 MCHC 30.4 RDW 28.2 RDWSD 72.5 Plt Ct 36 ___ 06 55AM BLOOD ___ PTT 31.9 ___ ___ 06 55AM BLOOD Glucose 89 UreaN 30 Creat 2.0 Na 138 K 4.1 Cl 108 HCO3 24 AnGap 10 ___ 06 55AM BLOOD ALT 10 AST 18 AlkPhos 73 TotBili 0.5 ___ 06 55AM BLOOD ALT 10 AST 18 AlkPhos 73 TotBili 0.5 ___ 06 55AM BLOOD Calcium 8.7 Phos 3.1 Mg 1.8 Other Relevant Labs ___ 07 43PM BLOOD Hypochr 2 Anisocy 3 Poiklo 3 Macrocy NORMAL Microcy 2 Polychr OCCASIONAL Spheroc OCCASIONAL Ovalocy OCCASIONAL Schisto OCCASIONAL Pencil OCCASIONAL Tear ___ ___ 02 03PM BLOOD Ret Man 4.1 Abs Ret 0.12 ___ 09 30AM BLOOD proBNP 1654 ___ 09 30AM BLOOD cTropnT 0.02 ___ 07 43PM BLOOD cTropnT 0.01 ___ 07 43PM BLOOD TotProt 6.7 ___ 09 30AM BLOOD D Dimer 167 ___ 09 30AM BLOOD calTIBC 455 ___ Ferritn 5.8 TRF 350 ___ 07 43PM BLOOD PEP TRACE ABNO IgG 1031 IgA 398 IgM 147 IFE TRACE MONO ___ 09 36AM BLOOD Glucose 131 Lactate 1.9 Na 138 K 4.9 Cl 105 calHCO3 23 ___ 09 36AM BLOOD Hgb 4.9 calcHCT 15 ___ 07 42PM URINE Hours RANDOM TotProt 7 ___ 07 42PM URINE U PEP NO PROTEIN Brief Hospital Course BRIEF SUMMARY STATEMENT Mr. ___ is a ___ man with atrial fibrillation on warfarin prostate cancer s p radiation HFrEF EF 40 45 and history of lower GI bleed in ___ due to rectal angioectasia likely secondary to radiation proctitis who presented with weakness found to have new profound anemia with gross rectal bleeding concerning for lower GI bleed. Pt was admitted to the ICU but transferred to general medicine floor on ___. LOWER GI BLEED On admission Hgb 4.4 with GI bleed was thought to be lower given gross blood. He had a history of angioectasia in the rectum secondary to radiation proctitis and had APC in ___. He also had a coagulopathy with thrombocytopenia and received reversal with Kcentra vitamin K and platelets. On admission he was not tachycardic or hypotensive but he was taking a beta blocker at home. He received 4 units of pRBCs on ___ with improvement in H H. He also received 1U platelts. GI was consulted and patient received EGD colonoscopy on ___ which showed GAVE and mild diverticulosis. Colonoscopy showed likely rectal bleeding but no clear lesion. Bleeding was thought to be ___ diverticulosis vs. rectal dieulafoy lesion. On discovery of pt s cirrhosis rectal varices vs. other ectopic varices were in ddx but given pt s creatinine further eval was limited. During Colonoscopy these were not noted. Pt GIB resolved during hospitalization and HCT remained stable. Per GI pt was felt to be safe for discharge. ___ on CKD Baseline Cr 1.5 1.7 c w grade 3 CKD based on previous labs here in ___ and at ___ in ___. Here on admission 2.2 likely pre renal in the setting of poor renal perfusion from blood loss. At time of discharge creatinine was 2 which was considered close to baseline. ___ was held at time of discharge. THROMBOCYTOPENIA Baseline low PLT 100s. S p 1u platelets in ED with inappropriate response. LFTs were normal haptoglobin and fibrinogen were normal SPEP showed non specific abnormality and UPEP wnl. Abd US showed cirrhosis. CHRONIC COMPENSATED SYSTOLIC HEART FAILURE last TTE ___ showed LVEF 45 . Euvolemic on exam. CV meds were held on initial presentation given concern for instability. As he stabilized his Nifedipine was re started. Metoprolol was re started at below home dose Metoprolol 50mg day as compared to 100mg per day in outpatient setting . ___ was held prior to discharge given Cr 2 and normotension. Lasix was also held in setting of euvolemia. Atrial Fibrillation CHADS2 VASc score of 3 for C H A . Given active bleeding patient received kaycentra and vitamin K in ED. In anticipation of GI intervention patient s anticoagulation was held. given cirrhosis thrombocytopenia and recent GIB and per conversation with pt s Cardiologist decision was made to hold anticoagulation pending outpatient re assessment. Notably pt was in sinus rhythm during admission. Anemia concern for acute on chronic etiology given low MCV patient reported weeks of fatigue. Has known Sickle Cell trait. Iron studies were notable for low ferritin. Cirrhosis Given thrombocytopenia pt underwent abd US which showed evidence of cirrhosis. Dx discussed with pt and he endorsed drinking a considerable amount of etoh use several beers shots of liquor per day . He denied prior hx of withdrawal sx. Folate and thiamine were prescribed after discharge and sent to pt s pharmacy. DDx for cirrhosis included sarcoid. Per GI pt was felt to be safe for discharge with outpatient Hepatology follow up. TRANSITIONAL ISSUES Please start on iron supplementation given low ferritin Consider hematology CS Please ensure Sucralfate is continued for 1 week Per GI f u for repeat EGD in 8 weeks Please ensure follow up with Hepatology for evaluation of new dx of cirrhosis Please ensure follow up with Cardiology for decision re risk benefit of resuming anticoagulation Please note Lasix and Valsartan held metoprolol re started at below home dose consider switching to Carvedilol given lower selectivity and possible advantage from Hepatology perspective if pt were to develop varices. Please repeat CBC at follow up Please note evidence of MGUS on SPEP please consider repeat SPEP Medications on Admission The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 50 mg PO BID 2. Atorvastatin 40 mg PO QPM 3. NIFEdipine CR 60 mg PO DAILY 4. Tamsulosin 0.4 mg PO BID 5. Allopurinol ___ mg PO DAILY 6. Furosemide 40 80 mg PO ASDIR 7. Warfarin 2.5 5 mg PO DAILY16 8. Valsartan 160 mg PO DAILY 9. Aspirin EC 81 mg PO 3X WEEK ___ 10. Vitamin D 1000 UNIT PO DAILY 11. Osteo Bi Flex Triple Strength ___ 750 mg 644 mg 30 mg 1 mg oral DAILY 12. Multivitamins 1 TAB PO DAILY Discharge Medications 1. Aspirin EC 81 mg PO 3X WEEK ___ 2. NIFEdipine CR 60 mg PO DAILY 3. Metoprolol Succinate XL 50 mg PO DAILY RX metoprolol succinate 50 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 4. Allopurinol ___ mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Tamsulosin 0.4 mg PO BID 7. Multivitamins 1 TAB PO DAILY 8. Osteo Bi Flex Triple Strength ___ 750 mg 644 mg 30 mg 1 mg oral DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 11. Sucralfate 1 gm PO QID RX sucralfate 1 gram 1 tablet s by mouth four times a day Disp 28 Tablet Refills 0 Discharge Disposition Home Discharge Diagnosis Lower GI bleeding Cirrhosis GAVE 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 to participate in your care at ___. You were admitted for gastric bleeding. You underwent blood transfusion platelet transfusion EGD and Colonoscopy and your symptoms resolved. You were found to have scarring of the liver. Your blood thinning medications were held because of your recent bleeding though there is a slight increase in stroke risk as a result. Please follow up with your Cardiologist to discuss if it is safe to re start Coumadin. Please follow up with a liver specialist to discuss treatment plan for cirrhosis. Please note that a repeat endoscopy was recommended in approximately 8 weeks. If you experience any recurrence in bleeding please seek medical attention. Best Regards You ___ Medicine Team Followup Instructions ___ The icd codes present in this text will be K922, N179, D684, I4891, I5022, D696, G629, K7460, I129, D869, C61, D500, K31819, K5790, N189, Z7901, E785, M109, D573, M1990, J45909, Z96651, Z923. The descriptions of icd codes K922, N179, D684, I4891, I5022, D696, G629, K7460, I129, D869, C61, D500, K31819, K5790, N189, Z7901, E785, M109, D573, M1990, J45909, Z96651, Z923 are K922: Gastrointestinal hemorrhage, unspecified; N179: Acute kidney failure, unspecified; D684: Acquired coagulation factor deficiency; I4891: Unspecified atrial fibrillation; I5022: Chronic systolic (congestive) heart failure; D696: Thrombocytopenia, unspecified; G629: Polyneuropathy, unspecified; K7460: Unspecified cirrhosis of liver; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; D869: Sarcoidosis, unspecified; C61: Malignant neoplasm of prostate; D500: Iron deficiency anemia secondary to blood loss (chronic); K31819: Angiodysplasia of stomach and duodenum without bleeding; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; N189: Chronic kidney disease, unspecified; Z7901: Long term (current) use of anticoagulants; E785: Hyperlipidemia, unspecified; M109: Gout, unspecified; D573: Sickle-cell trait; M1990: Unspecified osteoarthritis, unspecified site; J45909: Unspecified asthma, uncomplicated; Z96651: Presence of right artificial knee joint; Z923: Personal history of irradiation. The common codes which frequently come are N179, I4891, D696, I129, N189, Z7901, E785, M109, J45909. The uncommon codes mentioned in this dataset are K922, D684, I5022, G629, K7460, D869, C61, D500, K31819, K5790, D573, M1990, Z96651, Z923.
The icd codes present in this text will be I130, I5023, N184, N179, E870, I441, N138, K7031, I428, N401, D649, F1020. The descriptions of icd codes I130, I5023, N184, N179, E870, I441, N138, K7031, I428, N401, D649, F1020 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; N184: Chronic kidney disease, stage 4 (severe); N179: Acute kidney failure, unspecified; E870: Hyperosmolality and hypernatremia; I441: Atrioventricular block, second degree; N138: Other obstructive and reflux uropathy; K7031: Alcoholic cirrhosis of liver with ascites; I428: Other cardiomyopathies; N401: Benign prostatic hyperplasia with lower urinary tract symptoms; D649: Anemia, unspecified; F1020: Alcohol dependence, uncomplicated. The common codes which frequently come are I130, N179, D649. The uncommon codes mentioned in this dataset are I5023, N184, E870, I441, N138, K7031, I428, N401, F1020. Allergies lisinopril niacin Chief Complaint 3 weeks of worsening lower extremity edema abdominal distension and 30 pound weight gain. Major Surgical or Invasive Procedure None History of Present Illness ___ with NICM EF 45 CKD Stage III IV baseline Cr 3 eGFR 22 alcoholic cirrhosis presenting with 3 weeks of worsening lower extremity edema abdominal distension and 30 pound weight gain. He has noticed decreased urine output over the same time period. He has had increasing difficulty walking due to leg swelling but he denies any dyspnea on exertion. No orthopnea PND or cough. No chest pain diaphoresis nausea or palpitations. He follows a low salt diet and restricts himself to 1 quart of water a day. He is adherent to all medications. His Lasix was increased from 40 to 80 mg several days ago. He continues to drink up to 1 cocktail per day had 5 last week none this week . No tobacco cocaine or drug use. No fevers chills or localizing infectious symptoms. No abdominal pain nausea melena hematochezia or jaundice. In the ED initial vitals were 97.4 73 160 93 18 93 RA Past Medical History Atrial fibrillation Systolic heart failure LVEF of 40 45 in ___ Hypertension Hyperlipidemia Gout Prostate cancer status post radiation therapy Sarcoidosis Sickle cell trait Right total knee replacement in ___ Solitary pulmonary nodule followed since ___ Osteoarthritis Peripheral neuropathy Asthma Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory. Physical Exam ADMISSION PHYSICAL EXAM VS 97.7 PO 166 108 L Lying 83 20 97 ra GENERAL Appears well lying comfortably flat in bed. HEENT No icterus or injection. MMM. No xanthelasma. CV JVP 16cm. RRR soft heart sounds no audible murmurs or gallops. LUNGS Normal work of breathing. Decreased breath sounds at bilateral bases. No dullness to percussion or egophony. ABDOMEN Soft distended shifting dullness. EXTREMITIES Warm. 4 pitting edema to thighs. No erythema. SKIN No spider angiomata rashes or other lesions. NEURO Alert oriented intact attention and memory. No deficits. DISCHARGE PHYSICAL EXAM VITALS T 98.2 BP 115 70 HR 76 RR 18 95 RA GENERAL Appears well sitting in bedside chair HEENT No icterus or injection. MMM. No xanthelasma. CV JVP not visible. Irregularly irregular soft heart sounds no audible murmurs or gallops. LUNGS Normal work of breathing. Decreased breath sounds at bilateral bases. No dullness to percussion or egophony. ABDOMEN Soft distended non tender to palpation in all 4 quadrants EXTREMITIES Warm. 2 pitting edema up to knees. SKIN No spider angiomata rashes or other lesions. NEURO Alert oriented intact attention and memory. No deficits. Pertinent Results ADMISSION LABS ___ ___ 02 00PM BLOOD WBC 3.6 RBC 3.43 Hgb 10.4 Hct 31.8 MCV 93 MCH 30.3 MCHC 32.7 RDW 16.2 RDWSD 54.4 Plt ___ ___ 02 00PM BLOOD Neuts 70.9 Lymphs 18.0 Monos 9.4 Eos 1.4 Baso 0.0 NRBC 0.6 Im ___ AbsNeut 2.57 AbsLymp 0.65 AbsMono 0.34 AbsEos 0.05 AbsBaso 0.00 ___ 02 00PM BLOOD ___ PTT 30.9 ___ ___ 02 00PM BLOOD Glucose 73 UreaN 82 Creat 4.4 Na 149 K 3.9 Cl 111 HCO3 20 AnGap 18 ___ 02 00PM BLOOD Albumin 3.7 ___ 11 31PM BLOOD Lactate 1.0 PERTINENT INTERVAL LABS ___ 02 00PM BLOOD CK MB 3 proBNP 70000 ___ 02 00PM BLOOD cTropnT 0.12 ___ 10 30PM BLOOD cTropnT 0.10 ___ 06 05AM BLOOD calTIBC 199 Ferritn 161 TRF 153 ___ 06 05AM BLOOD TSH 1.2 ___ 02 00PM BLOOD ALT 15 AST 28 LD LDH 262 CK CPK 44 AlkPhos 214 TotBili 0.7 ___ 06 05AM BLOOD ALT 10 AST 14 LD LDH 197 AlkPhos 177 TotBili 0.6 DISCHARGE LABS ___ 06 30AM BLOOD WBC 2.8 RBC 3.18 Hgb 9.7 Hct 28.5 MCV 90 MCH 30.5 MCHC 34.0 RDW 15.4 RDWSD 50.6 Plt ___ ___ 06 30AM BLOOD Glucose 75 UreaN 97 Creat 4.4 Na 140 K 3.9 Cl 95 HCO3 32 AnGap 13 ___ 06 30AM BLOOD Calcium 8.5 Phos 4.0 Mg 2.0 IMAGING STUDIES CXR ___ Marked cardiomegaly small right effusion and hilar congestion no frank edema or pneumonia. TTE ___ The left atrial volume index is severely increased. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with akinesis of the basal to mid inferior and inferolateral walls as well as the basal inferior septum. There is hypokinesis of the remaining segments LVEF 25 . There is considerable beat to beat variability of the left ventricular ejection fraction due to an irregular rhythm premature beats. The estimated cardiac index is depressed 2.0L min m2 . The right ventricular cavity is markedly dilated with moderate to severe global free wall hypokinesis. There is abnormal septal motion position in part due to volume overload and also IVCD. The aortic root is mildly dilated at the sinus level. The ascending aorta is mild to moderately dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets 3 appear structurally normal with good leaflet excursion and no aortic stenosis. Mild 1 aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild 1 mitral regurgitation is seen. Moderate to severe 3 tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION Moderate left ventricular hypertrophy with moderate chamber dilation moderate regional and severe global systolic dysfunction. Severely dilated right ventricle with moderate to severe global hypokinesis. Moderate to severe tricuspid regurgitation. At least moderate pulmonary hypertension. Small circumferential pericardial effusion without chamber collapse. Compared with the prior study images reviewed of ___ the pericardial effusion is slightly larger. There are frequent VPBs. Global left ventricular systolic function is reduced in that context. There is less mitral regurgitation. The left ventricle is more dilated. Abdominal U S ___ IMPRESSION 1. Small amount of non specific perihepatic ascites. 2. Sludge is seen layering in a distended gallbladder. However there is no pericholecystic fluid or gallbladder wall thickening to suggest acute cholecystitis. 3. The IVC and hepatic veins are enlarged likely due to known congestive heart failure. 4. Incidental note is made of a right pleural effusion. Brief Hospital Course ASSESSMENT AND PLAN ___ with NICM 25 ___ CKD stage ___ cirrhosis with ongoing alcohol use presenting with marked volume overload including dyspnea on exertion lower extremity edema 30lb weight gain and oliguric ___. Pump LVEF 25 ___ Coronaries MIBI ___ with no ischemia scarce CAD in circumflex OM Rhythm sinus with frequent PVCs RBBB ACUTE ACTIVE ISSUES Acute on chronic HFrEF exacerbation Non ischemic cardiomyopathy EF 25 ___ Patient admitted with evidence of significant volume overload peripheral edema ascites dyspnea on exertion weight gain 30lb over last few weeks with proBNP 70k and cardiomegaly on CXR concerning for decompensated heart failure. Repeat TTE on admission showing reduced LVEF 25 from 55 ___ with moderate LVH and severely dilated right ventricle with moderate to severe global hypokinesis. Differential also includes worsening renal failure as below . In terms of triggers for heart failure exacerbation most likely ___ poorly controlled HTN. Low suspicion for ischemia trops 0.12 0.10 in setting of renal failure and CK MB 3 without ischemic EKG changes or chest pain. Low suspicion for infection without fevers chills or localizing infectious symptoms. During this admission he was successfully diuresed with IV Lasix gtt and metolazone from 89.5kg 197lbs to 82.8kg 182lbs . His reported dry weight is 180lbs. He was transitioned to PO torsemide 30mg daily at discharge which is an increase from his home Lasix 40mg daily. Afterload reducing medications were also up titrated during admission for systolic BP 140s 180s including hydralazine 20mg to 75 mg TID and Imdur 30mg to 120mg daily. Metoprolol succinate 50mg also switched to Carvdedilol 50 mg BID. Continue home ASA 81mg and atorvastatin 40mg daily. Will need EP follow up at discharge for evaluation for ICD placement with newly reduced EF 25 . Elevated troponin Trop 0.12 0.10 CK MB 3. No ischemic symptoms or EKG changes to suggest ischemia. Suspect decreased clearance from renal failure and CHF rather than active ischemia. Asymptomatic ___ Patient noted to have intermittent second degree heart block on telemetry during this admission. Asymptomatic and normotensive. ___ be precipitated by up titration of Coreg. Consider down titration of Coreg if symptomatic as an outpatient. ___ on CKD Stage III IV Cr elevated to ___ during admission from last baseline of 3.0 on ___ eGFR 22 . Unclear whether this preceded or resulted from patient s worsening heart failure however Cr has not improved with significant diuresis as above. Likely related to progression of underlying CKD which may be exacerbated by poorly controlled HTN. Held patient s home ___ valsartan 160mg daily and allopurinol during this admission. Discharge Cr 4.4 with plan to re establish follow up with renal as an outpatient. Poorly controlled HTN SBP 140 180s on admission. Also recorded as 182 100 in clinic recently ___ likely ___ volume overload and worsening renal function. Home hypertensive medications were uptitrated during admission Hydralazine 20mg to 75 mg TID Imdur 30mg to 120mg daily and Metoprolol succinate 50mg to Carvdedilol 50 mg BID. Discharge BP Cirrhosis with ascites Likely due to cardiogenic congestion with possible contribution from alcohol use. Fibroscan in ___ with stage 2 fibrosis. MELD 22 on admission. LFTs down trended with diuresis. EGD ___ with 2 cords of possible small esophageal varices without high risk features. Plan for follow up with ___ as an outpatient. Of note he is due for screening EGD this year. CHRONIC STABLE ISSUES BPH Post void residual 0cc during this admission. Continue home tamsulosin GERD Continue home pantoprazole TRANSITIONAL ISSUES ADMISSION WEIGHT 89.5 kg DISCHARGE WEIGHT 82.8 kg DISCHARGE CR 4.4 Continue titration of BP medications as an outpatient Goal BP 130 80 Consider restarting home valsartan as an outpatient as he would likely benefit from ___ in the setting of CKD Continue Torsemide 30mg daily with daily weights at home plan for follow up with ___ clinic as well as outpatient cardiologist Dr. ___ Found to have intermittent second degree heart block on telemetry during this admission. Asymptomatic and normotensive. ___ be precipitated by up titration of Coreg. Consider down titration of Coreg if he becomes symptomatic as an outpatient. Will also need EP follow up at discharge for evaluation for ICD placement with newly reduced EF 25 Follow up with liver clinic he is due for screening EGD this year Please care connect with renal for progression of CKD appears that he has seen a nephrologist in the past but this was years ago and he cannot recall the physician s name ___ changes ___ 40mg daily to torsemide 30mg daily Hydralazine 20mg to 75 mg TID Imdur 30mg to 120mg daily Metoprolol succinate 50mg to Carvdedilol 50 mg BID Medications continued ASA 81mg Atorvastatin 40mg daily Pantoprazole Tamsulosin Vit D Medications held Allopurinol Valsartan HCP Proxy Relationship son Phone ___ Full code presumed Medications on Admission The Preadmission Medication list is accurate and complete. 1. HydrALAZINE 25 mg PO TID 2. Valsartan 160 mg PO DAILY 3. Tamsulosin 0.4 mg PO BID 4. Pantoprazole 40 mg PO Q24H 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Isosorbide Mononitrate Extended Release 30 mg PO DAILY 7. Furosemide 80 mg PO DAILY 8. Aspirin 81 mg PO 3X WEEK ___ 9. Vitamin D 1000 UNIT PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Allopurinol ___ mg PO DAILY 12. Ferrous Sulfate 325 mg PO DAILY 13. Osteo Bi Flex Triple Strength ___ 750 mg 644 mg 30 mg 1 mg oral DAILY 14. Atorvastatin 40 mg PO QPM Discharge Medications 1. Carvedilol 50 mg PO BID RX carvedilol 25 mg 2 tablet s by mouth twice a day Disp 60 Tablet Refills 0 2. Torsemide 30 mg PO DAILY RX torsemide 10 mg 3 tablet s by mouth once a day Disp 90 Tablet Refills 0 3. HydrALAZINE 75 mg PO TID RX hydralazine 50 mg 1.5 tablet s by mouth three times a day Disp 135 Tablet Refills 0 4. Isosorbide Mononitrate Extended Release 120 mg PO DAILY RX isosorbide mononitrate 120 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 5. Aspirin 81 mg PO 3X WEEK ___ 6. Atorvastatin 40 mg PO QPM 7. Ferrous Sulfate 325 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Osteo Bi Flex Triple Strength ___ 750 mg 644 mg 30 mg 1 mg oral DAILY 10. Pantoprazole 40 mg PO Q24H 11. Tamsulosin 0.4 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. HELD Allopurinol ___ mg PO DAILY This medication was held. Do not restart Allopurinol until speaking with your kidney doctors 14. HELD Valsartan 160 mg PO DAILY This medication was held. Do not restart Valsartan until speaking with your kidney doctors ___ Home With Service Facility ___ Discharge Diagnosis Primary Congestive Heart Failure CKD Stage III IV Secondary Hypertension Cirrhosis with ascites 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 admitted to the hospital You were admitted because you had worsening leg swelling abdominal swelling and 30 pound weight gain. What happened while I was in the hospital While you were here we did a chest x ray blood tests and an ultrasound of your heart and abdomen. All of these tests showed that you had increased fluid in your body likely because of your heart failure. We gave you medicines through your veins to help you urinate out this extra fluid and you lost over 15lbs of fluid while in the hospital. We changed your home Lasix to a stronger medication called torsemide while you were in the hospital. You will need to continue to take torsemide 30mg daily at home to prevent this extra fluid from re accumulating. You were also found to have high blood pressures in the hospital which can increase the stress on your heart. We increased your blood pressure medications while you were in the hospital. Please continue to take these medications at higher doses Isosorbide Mononitrate 120 mg daily Carvedilol 50 mg twice daily and hydralazine 75 mg three times daily What should I do after leaving the hospital Please weigh yourself when you get home and every morning call MD if weight goes up more than 3 lbs. Please take your medications as listed in discharge summary and follow up at the listed appointments. Thank you for allowing us to be involved in your care we wish you all the best Sincerely Your ___ Healthcare Team Followup Instructions ___ The icd codes present in this text will be I130, I5023, N184, N179, E870, I441, N138, K7031, I428, N401, D649, F1020. The descriptions of icd codes I130, I5023, N184, N179, E870, I441, N138, K7031, I428, N401, D649, F1020 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; N184: Chronic kidney disease, stage 4 (severe); N179: Acute kidney failure, unspecified; E870: Hyperosmolality and hypernatremia; I441: Atrioventricular block, second degree; N138: Other obstructive and reflux uropathy; K7031: Alcoholic cirrhosis of liver with ascites; I428: Other cardiomyopathies; N401: Benign prostatic hyperplasia with lower urinary tract symptoms; D649: Anemia, unspecified; F1020: Alcohol dependence, uncomplicated. The common codes which frequently come are I130, N179, D649. The uncommon codes mentioned in this dataset are I5023, N184, E870, I441, N138, K7031, I428, N401, F1020.
The icd codes present in this text will be K652, J9691, I5023, I130, N184, A0472, I429, F05, Z992, D869, I4891, K7031, G629, D573, E785, M109, Z96651, Z8546, Z923, Z930, D649, E162. The descriptions of icd codes K652, J9691, I5023, I130, N184, A0472, I429, F05, Z992, D869, I4891, K7031, G629, D573, E785, M109, Z96651, Z8546, Z923, Z930, D649, E162 are K652: Spontaneous bacterial peritonitis; J9691: Respiratory failure, unspecified with hypoxia; I5023: Acute on chronic systolic (congestive) heart failure; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N184: Chronic kidney disease, stage 4 (severe); A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent; I429: Cardiomyopathy, unspecified; F05: Delirium due to known physiological condition; Z992: Dependence on renal dialysis; D869: Sarcoidosis, unspecified; I4891: Unspecified atrial fibrillation; K7031: Alcoholic cirrhosis of liver with ascites; G629: Polyneuropathy, unspecified; D573: Sickle-cell trait; E785: Hyperlipidemia, unspecified; M109: Gout, unspecified; Z96651: Presence of right artificial knee joint; Z8546: Personal history of malignant neoplasm of prostate; Z923: Personal history of irradiation; Z930: Tracheostomy status; D649: Anemia, unspecified; E162: Hypoglycemia, unspecified. The common codes which frequently come are I130, I4891, E785, M109, D649. The uncommon codes mentioned in this dataset are K652, J9691, I5023, N184, A0472, I429, F05, Z992, D869, K7031, G629, D573, Z96651, Z8546, Z923, Z930, E162. Allergies lisinopril niacin Chief Complaint Leukocytosis fever Major Surgical or Invasive Procedure Diagnostic Paracentesis ___ History of Present Illness ___ with history of NICM EF 25 ___ CKD Stage IV baseline Cr 4.4 from ___ presumed due to cardiorenal origin alcoholic cirrhosis who was discharge from ___ ___ to rehab who re presents to the ED from rehab after being found to have WBC of 17 and temp of 100.9 at rehab. Per report he was also extremely agitated and tried to remove his dialysis line and is now restrained. He was also found to have a hematocrit of 22 which is in the range of his norm and the ED transfused 1 unit of pRBC. The patients labs reflect CHF exacerbation as he has a BNP of 70000. No immediate source of infection was found on initial ED workup. Of note the patient received a ketamine bolus and was started on a ketamine drip prior to surgical consult so no history or reliable physical exam can be obtained. Past Medical History Atrial fibrillation Systolic heart failure LVEF of 40 45 in ___ Hypertension Hyperlipidemia Gout Prostate cancer status post radiation therapy Sarcoidosis Sickle cell trait Right total knee replacement in ___ Solitary pulmonary nodule followed since ___ Osteoarthritis Peripheral neuropathy Asthma Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory. Physical Exam Admission Vitals 98.5 82 109 74 17 94 on 40 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 mildly distended nontender on ketamine no rebound or guarding no palpable masses Ext No ___ edema ___ warm and well perfused Brief Hospital Course Mr. ___ was admitted to the Trauma ICU where he was known given his recent hospital admission. He was off pressors and off ketamine drip. His mental status improved. His WBC was 17.3. He continued to produce copious amounts of respiratory secretions and receive chest physical therapy as before. He was on trach mask with intermittent vent requirement for agitation. CT abd pelvis showed ascites post surgical changes in the splenic fossa and no drainable collections. He had no abdominal pain. He was started on CTX. Diagnostic paracentesis suggested spontaneous bacterial peritonitis. A 10 day Ceftriaxone course was planned followed by prophylactic Ciprofloxacin per Hepatology recommendation. He received HD as scheduled. The patient remained stable with normal vital signs. He was discharged to ___ to continue his recovery. Medications on Admission 1. Acetaminophen Liquid 650 mg PO Q8H PRN Pain Moderate RX acetaminophen 325 mg 10.15 mL 20 cc by mouth Every 8 hours Disp 2 Bottle Refills 0 2. Albuterol Inhaler ___ PUFF IH Q6H RX albuterol sulfate ProAir HFA 90 mcg 2 puff Trach Every 6 hours Disp 2 Inhaler Refills 0 3. Carvedilol 25 mg PO BID RX carvedilol 25 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 4. Chlorhexidine Gluconate 0.12 Oral Rinse 15 mL ORAL BID RX chlorhexidine gluconate 0.12 Mouth rinse with 15 cc three times a day Refills 0 5. Docusate Sodium Liquid 100 mg PO BID RX docusate sodium Diocto 50 mg 5 mL 100 mg by mouth twice a day Disp ___ Milliliter Refills 0 6. Heparin 5000 UNIT SC TID RX heparin porcine 5 000 unit mL 1 mL 5000 units Subcutaneous three times a day Disp 90 Cartridge Refills 0 7. Ipratropium Bromide MDI 2 PUFF IH Q6H RX ipratropium bromide Atrovent HFA 17 mcg actuation 2 PUFF Trach every six 6 hours Disp 2 Inhaler Refills 0 8. Metoprolol Tartrate 12.5 mg PO BID RX metoprolol tartrate 25 mg Half tablet s by mouth twice a day Disp 30 Tablet Refills 0 9. OLANZapine 2.5 5 mg PO QHS RX olanzapine 5 mg 1 tablet s by mouth at bedtime Disp 30 Tablet Refills 0 10. OxycoDONE Liquid 2.5 5 mg PO Q8H PRN Pain Severe RX oxycodone 5 mg 5 mL 5 mg NG tube three times a day Refills 0 11. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram dose 17 grams by mouth Daily Refills 0 12. Ramelteon 8 mg PO QHS PRN insomnia RX ramelteon Rozerem 8 mg 1 tablet s by mouth QHR Disp 30 Tablet Refills 0 13. Senna 8.6 mg PO BID RX sennosides senna 8.8 mg 5 mL 8.8 mg by mouth twice a day Disp ___ Milliliter Refills 0 14. Sodium Chloride 3 Inhalation Soln 15 mL NEB Q6H PRN resp secretions RX sodium chloride 3 15 cc Trach Q6H PRN Disp 100 Vial Refills 0 15. Vancomycin Oral Liquid ___ mg PO NG Q6H RX vancomycin Firvanq 50 mg mL 125 mg by mouth every six 6 hours Refills 0 Discharge Medications 1. Acetaminophen Liquid 650 mg PO Q6H PRN Pain Mild RX acetaminophen 160 mg 5 mL 650 mg by mouth Every 6 hours Disp 2 Bottle Refills 0 2. Carvedilol 25 mg PO BID RX carvedilol 25 mg 1 tablet s by mouth every 12 hours Disp 60 Tablet Refills 0 3. CefTRIAXone 2 gm IV Q24H RX ceftriaxone in dextrose iso os 2 gram 50 mL 2 grams IV Daily Disp 7 Intravenous Bag Refills 0 4. Chlorhexidine Gluconate 0.12 Oral Rinse 15 mL ORAL BID RX chlorhexidine gluconate 0.12 15 ml for mouth rinse twice a day Refills 0 5. Heparin 5000 UNIT SC TID RX heparin porcine 5 000 unit mL 1 mL 5000 units Subcutaneous twice a day Disp 30 Cartridge Refills 0 6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID RX lansoprazole 30 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 7. OLANZapine 2.5 5 mg PO QHS RX olanzapine 5 mg ___ tablet s by mouth Every night Disp 30 Tablet Refills 0 8. Ramelteon 8 mg PO QHS RX ramelteon Rozerem 8 mg 1 tablet s by mouth Every night Disp 30 Tablet Refills 0 9. Vancomycin Oral Liquid ___ mg PO Q6H RX vancomycin Firvanq 25 mg mL 125 mg by mouth Every 6 hours Refills 0 Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Spontaneous Bacterial Peritonitis 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 Mr. ___ You were re admitted to ___ for fevers and a high white blood cell count suggestive of infection. You were found to have Spontaneous Bacterial Peritonitis which was treated with antibiotics. You are ready for discharge. Follow these instructions You should continue to take your oral Vancomycin 125 mg Q6H until ___. You should continue your antibiotic Ceftriaxone 2gr day until ___. On ___ you should start taking Ciprofloxacin 500 mg day to prevent recurrent infections. Keep taking this medication until you see your Hepatologist in clinic. Followup Instructions ___ The icd codes present in this text will be K652, J9691, I5023, I130, N184, A0472, I429, F05, Z992, D869, I4891, K7031, G629, D573, E785, M109, Z96651, Z8546, Z923, Z930, D649, E162. The descriptions of icd codes K652, J9691, I5023, I130, N184, A0472, I429, F05, Z992, D869, I4891, K7031, G629, D573, E785, M109, Z96651, Z8546, Z923, Z930, D649, E162 are K652: Spontaneous bacterial peritonitis; J9691: Respiratory failure, unspecified with hypoxia; I5023: Acute on chronic systolic (congestive) heart failure; I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; N184: Chronic kidney disease, stage 4 (severe); A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent; I429: Cardiomyopathy, unspecified; F05: Delirium due to known physiological condition; Z992: Dependence on renal dialysis; D869: Sarcoidosis, unspecified; I4891: Unspecified atrial fibrillation; K7031: Alcoholic cirrhosis of liver with ascites; G629: Polyneuropathy, unspecified; D573: Sickle-cell trait; E785: Hyperlipidemia, unspecified; M109: Gout, unspecified; Z96651: Presence of right artificial knee joint; Z8546: Personal history of malignant neoplasm of prostate; Z923: Personal history of irradiation; Z930: Tracheostomy status; D649: Anemia, unspecified; E162: Hypoglycemia, unspecified. The common codes which frequently come are I130, I4891, E785, M109, D649. The uncommon codes mentioned in this dataset are K652, J9691, I5023, N184, A0472, I429, F05, Z992, D869, K7031, G629, D573, Z96651, Z8546, Z923, Z930, E162.
The icd codes present in this text will be S36039A, N170, T794XXA, N186, J95822, I313, I4892, I428, N390, A0472, I132, I5022, T17490A, I248, W19XXXA, Y92009, I493, I4891, Z23, S0101XA, N400, M109, K7031, E785, D573, J45909, G629, Z96651, Z8546, Z923, B952, I351, Z992, I4510, X58XXXA, Y92230, E162. The descriptions of icd codes S36039A, N170, T794XXA, N186, J95822, I313, I4892, I428, N390, A0472, I132, I5022, T17490A, I248, W19XXXA, Y92009, I493, I4891, Z23, S0101XA, N400, M109, K7031, E785, D573, J45909, G629, Z96651, Z8546, Z923, B952, I351, Z992, I4510, X58XXXA, Y92230, E162 are S36039A: Unspecified laceration of spleen, initial encounter; N170: Acute kidney failure with tubular necrosis; T794XXA: Traumatic shock, initial encounter; N186: End stage renal disease; J95822: Acute and chronic postprocedural respiratory failure; I313: Pericardial effusion (noninflammatory); I4892: Unspecified atrial flutter; I428: Other cardiomyopathies; N390: Urinary tract infection, site not specified; A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent; I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease; I5022: Chronic systolic (congestive) heart failure; T17490A: Other foreign object in trachea causing asphyxiation, initial encounter; I248: Other forms of acute ischemic heart disease; W19XXXA: Unspecified fall, initial encounter; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; I493: Ventricular premature depolarization; I4891: Unspecified atrial fibrillation; Z23: Encounter for immunization; S0101XA: Laceration without foreign body of scalp, initial encounter; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; M109: Gout, unspecified; K7031: Alcoholic cirrhosis of liver with ascites; E785: Hyperlipidemia, unspecified; D573: Sickle-cell trait; J45909: Unspecified asthma, uncomplicated; G629: Polyneuropathy, unspecified; Z96651: Presence of right artificial knee joint; Z8546: Personal history of malignant neoplasm of prostate; Z923: Personal history of irradiation; B952: Enterococcus as the cause of diseases classified elsewhere; I351: Nonrheumatic aortic (valve) insufficiency; Z992: Dependence on renal dialysis; I4510: Unspecified right bundle-branch block; X58XXXA: Exposure to other specified factors, initial encounter; Y92230: Patient room in hospital as the place of occurrence of the external cause; E162: Hypoglycemia, unspecified. The common codes which frequently come are N390, I4891, N400, M109, E785, J45909, Y92230. The uncommon codes mentioned in this dataset are S36039A, N170, T794XXA, N186, J95822, I313, I4892, I428, A0472, I132, I5022, T17490A, I248, W19XXXA, Y92009, I493, Z23, S0101XA, K7031, D573, G629, Z96651, Z8546, Z923, B952, I351, Z992, I4510, X58XXXA, E162. Allergies lisinopril niacin Chief Complaint Fall unwitnessed Major Surgical or Invasive Procedure Exploratory laparotomy with splenectomy History of Present Illness ___ with NICM EF 25 ___ CKD Stage IV baseline Cr 4.4 from ___ presumed due to cardiorenal origin alcoholic cirrhosis who was found down at home with a pool of blood around his head. Upon arrival to ED he was found to be hypotensive to SBP ___ and bradycardic. A large scalp lac was documented and FAST was positive. He received 2 units od RBC without improvement in his SBP. Past Medical History Atrial fibrillation Systolic heart failure LVEF of 40 45 in ___ Hypertension Hyperlipidemia Gout Prostate cancer status post radiation therapy Sarcoidosis Sickle cell trait Right total knee replacement in ___ Solitary pulmonary nodule followed since ___ Osteoarthritis Peripheral neuropathy Asthma Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory. Brief Hospital Course Mr. ___ was transported to the OR in the setting of hypotension non responsive to blood products Hct 17.5 and positive FAST exam splenic window . He underwent exploratory laparotomy and splenectomy for details on the procedure refer to the operative report . His scalp lac was washed and stapled. He received a total of 2uPRBC in ED and 5uPRBC and 1 unit of platelets in OR. He was transported to the Trauma ICU intubated and on pressors. He underwent CT head and C spine which showed no evidence of traumatic injury. His C collar was cleared. CT chest showed no acute rib fractures. He presented with a CKD requiring CRRT for volume overload. Echocardiogram showed LVEF ___ with biventricular hypokinesis focal in left global in right . The patient remained intubated with poor mental status and requiring pressors for the following 10 days. There was no concern for bleeding given stable H H and no concern for cardiogenic shock given CI ___. There was no concern for infection given lack of leukocytosis fevers stable CXR and normal UA. While his pressors and ventilator support were being slowly weaned he was started on tube feeds with adequate tolerance. CRRT continued attempting to remove volume as tolerated. On ___ he underwent bedside bronchoscopy that showed left lung secretions. He was started on CTX azithro for 7 days and post procedure CXR showed lung reinflation. BAL did not grew anything in cultures. On ___ the patient was extubated to a face mask but eventually required reintubation due to poor cough and hypercapnia. On ___ he had a low grade temperature 100.1 and a work up was sent. UC was growing pseudomonas and he was started on Cefepime. His OGT had been pulled and coiled repeatedly at 35 cm when attempting to replace. EGD was performed showing hardened caked matter in the mid esophagus. An NJ tube was placed and tube feeds were restarted. On ___ the patient had low grade temperatures. UA UC showed 100 000 CFU of pseudomonas resistant to Cefepime and he was treated with a 10 day course of Cipro. EGD was performed showing hardened caked matter in the mid esophagus TF and an OG tube was placed. Tube feeds were advanced to goal. On ___ the patient underwent bedside uncomplicated tracheostomy. Over the next ___ days he was slowly weaned from the vent to a trach mask. He would develop tachycardia tachypnea and ectopy requiring placement on the vent. There was concern for tamponade physiology given his persistent pericardial effusion on echocardiogram. Cardiology and Thoracic surgery were consulted but deferred pericardiocentesis and pericardial window. He was started on Seroquel for agitation. On ___ he was started on PO Vancomycin for C. diff Course ___. On ___ Hepatology was consulted. GGT was 188. Ammonia level 12. Liver ultrasound showed cirrhosis with mild ascites patent PV. Paracentesis was deferred. On ___ single lumen R PICC and RIJ tunneled pheresis line placed. RIJ temporary catheter removed. His scalp staples were removed. Medications on Admission MEDS AT HOME 1. Carvedilol 50 mg PO BID RX carvedilol 25 mg 2 tablet s by mouth twice a day Disp 60 Tablet Refills 0 2. Torsemide 30 mg PO DAILY RX torsemide 10 mg 3 tablet s by mouth once a day Disp 90 Tablet Refills 0 3. HydrALAZINE 75 mg PO TID RX hydralazine 50 mg 1.5 tablet s by mouth three times a day Disp 135 Tablet Refills 0 4. Isosorbide Mononitrate Extended Release 120 mg PO DAILY RX isosorbide mononitrate 120 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 5. Aspirin 81 mg PO 3X WEEK ___ 6. Atorvastatin 40 mg PO QPM 7. Ferrous Sulfate 325 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Osteo Bi Flex Triple Strength ___ 750 mg 644 mg 30 mg 1 mg oral DAILY 10. Pantoprazole 40 mg PO Q24H 11. Tamsulosin 0.4 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. HELD Allopurinol ___ mg PO DAILY This medication was held. Do not restart Allopurinol until speaking with your kidney doctors 14. HELD Valsartan 160 mg PO DAILY This medication was held. Do not restart Valsartan until speaking with your kidney doctors Medication changes done on recent admission ___ Lasix 40mg daily to torsemide 30mg daily Hydralazine 20mg to 75 mg TID Imdur 30mg to 120mg daily Metoprolol succinate 50mg to Carvdedilol 50 mg BID Medications continued ASA 81mg Atorvastatin 40mg daily Pantoprazole Tamsulosin Vit D Medications held Allopurinol Valsartan Discharge Medications 1. Acetaminophen Liquid 650 mg PO Q8H PRN Pain Moderate RX acetaminophen 325 mg 10.15 mL 20 cc by mouth Every 8 hours Disp 2 Bottle Refills 0 2. Albuterol Inhaler ___ PUFF IH Q6H RX albuterol sulfate ProAir HFA 90 mcg 2 puff Trach Every 6 hours Disp 2 Inhaler Refills 0 3. Carvedilol 25 mg PO BID RX carvedilol 25 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 4. Chlorhexidine Gluconate 0.12 Oral Rinse 15 mL ORAL BID RX chlorhexidine gluconate 0.12 Mouth rinse with 15 cc three times a day Refills 0 5. Docusate Sodium Liquid 100 mg PO BID RX docusate sodium Diocto 50 mg 5 mL 100 mg by mouth twice a day Disp ___ Milliliter Refills 0 6. Heparin 5000 UNIT SC TID RX heparin porcine 5 000 unit mL 1 mL 5000 units Subcutaneous three times a day Disp 90 Cartridge Refills 0 7. Ipratropium Bromide MDI 2 PUFF IH Q6H RX ipratropium bromide Atrovent HFA 17 mcg actuation 2 PUFF Trach every six 6 hours Disp 2 Inhaler Refills 0 8. Metoprolol Tartrate 12.5 mg PO BID RX metoprolol tartrate 25 mg Half tablet s by mouth twice a day Disp 30 Tablet Refills 0 9. OLANZapine 2.5 5 mg PO QHS RX olanzapine 5 mg 1 tablet s by mouth at bedtime Disp 30 Tablet Refills 0 10. OxycoDONE Liquid 2.5 5 mg PO Q8H PRN Pain Severe RX oxycodone 5 mg 5 mL 5 mg NG tube three times a day Refills 0 11. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram dose 17 grams by mouth Daily Refills 0 12. Ramelteon 8 mg PO QHS PRN insomnia RX ramelteon Rozerem 8 mg 1 tablet s by mouth QHR Disp 30 Tablet Refills 0 13. Senna 8.6 mg PO BID RX sennosides senna 8.8 mg 5 mL 8.8 mg by mouth twice a day Disp ___ Milliliter Refills 0 14. Sodium Chloride 3 Inhalation Soln 15 mL NEB Q6H PRN resp secretions RX sodium chloride 3 15 cc Trach Q6H PRN Disp 100 Vial Refills 0 15. Vancomycin Oral Liquid ___ mg PO NG Q6H RX vancomycin Firvanq 50 mg mL 125 mg by mouth every six 6 hours Refills 0 Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Splenic laceration Postoperative respiratory failure UTI C diff colitis Discharge Condition Mental Status Confused sometimes. Level of Consciousness Lethargic but arousable. Activity Status Bedbound. Discharge Instructions Dear Mr. ___ You were admitted to ___ after a fall. You had a scalp laceration and bleeding from your spleen. You were taken to the operating room as an emergency and your spleen was removed. You remained intubated requiring support from the ventilator. On ___ you underwent tracheostomy. This allowed to remove the tube in your mouth that helped you breath while allowing to help you breath with the ventilator. You also had a urinary tract infection and an infection of your colon that were treated with antibiotics. You are now ready to be discharged to a facility to continue your recovery. Followup Instructions ___ The icd codes present in this text will be S36039A, N170, T794XXA, N186, J95822, I313, I4892, I428, N390, A0472, I132, I5022, T17490A, I248, W19XXXA, Y92009, I493, I4891, Z23, S0101XA, N400, M109, K7031, E785, D573, J45909, G629, Z96651, Z8546, Z923, B952, I351, Z992, I4510, X58XXXA, Y92230, E162. The descriptions of icd codes S36039A, N170, T794XXA, N186, J95822, I313, I4892, I428, N390, A0472, I132, I5022, T17490A, I248, W19XXXA, Y92009, I493, I4891, Z23, S0101XA, N400, M109, K7031, E785, D573, J45909, G629, Z96651, Z8546, Z923, B952, I351, Z992, I4510, X58XXXA, Y92230, E162 are S36039A: Unspecified laceration of spleen, initial encounter; N170: Acute kidney failure with tubular necrosis; T794XXA: Traumatic shock, initial encounter; N186: End stage renal disease; J95822: Acute and chronic postprocedural respiratory failure; I313: Pericardial effusion (noninflammatory); I4892: Unspecified atrial flutter; I428: Other cardiomyopathies; N390: Urinary tract infection, site not specified; A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent; I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease; I5022: Chronic systolic (congestive) heart failure; T17490A: Other foreign object in trachea causing asphyxiation, initial encounter; I248: Other forms of acute ischemic heart disease; W19XXXA: Unspecified fall, initial encounter; Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause; I493: Ventricular premature depolarization; I4891: Unspecified atrial fibrillation; Z23: Encounter for immunization; S0101XA: Laceration without foreign body of scalp, initial encounter; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; M109: Gout, unspecified; K7031: Alcoholic cirrhosis of liver with ascites; E785: Hyperlipidemia, unspecified; D573: Sickle-cell trait; J45909: Unspecified asthma, uncomplicated; G629: Polyneuropathy, unspecified; Z96651: Presence of right artificial knee joint; Z8546: Personal history of malignant neoplasm of prostate; Z923: Personal history of irradiation; B952: Enterococcus as the cause of diseases classified elsewhere; I351: Nonrheumatic aortic (valve) insufficiency; Z992: Dependence on renal dialysis; I4510: Unspecified right bundle-branch block; X58XXXA: Exposure to other specified factors, initial encounter; Y92230: Patient room in hospital as the place of occurrence of the external cause; E162: Hypoglycemia, unspecified. The common codes which frequently come are N390, I4891, N400, M109, E785, J45909, Y92230. The uncommon codes mentioned in this dataset are S36039A, N170, T794XXA, N186, J95822, I313, I4892, I428, A0472, I132, I5022, T17490A, I248, W19XXXA, Y92009, I493, Z23, S0101XA, K7031, D573, G629, Z96651, Z8546, Z923, B952, I351, Z992, I4510, X58XXXA, E162.
The icd codes present in this text will be I213, I2542, I25110, T859XXA, Y840, Y92239, I10, E785, F988, F329. The descriptions of icd codes I213, I2542, I25110, T859XXA, Y840, Y92239, I10, E785, F988, F329 are I213: ST elevation (STEMI) myocardial infarction of unspecified site; I2542: Coronary artery dissection; I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; T859XXA: Unspecified complication of internal prosthetic device, implant and graft, initial encounter; Y840: Cardiac catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F988: Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence; F329: Major depressive disorder, single episode, unspecified. The common codes which frequently come are I10, E785, F329. The uncommon codes mentioned in this dataset are I213, I2542, I25110, T859XXA, Y840, Y92239, F988. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Chest Pain Major Surgical or Invasive Procedure coronary angiography History of Present Illness Mr. ___ is a ___ year old man with a history of CAD with a stent to the RCA in ___ who presents with chest pain and shortness of breath over the past two days. He had been in his normal state of health until 10 days ago when he deveoped severe chest pain associated with nausea vomiting and presyncope. He presented to an ED in ___ and was discharged with follow up with his primary cardiologist. He had a stress test on ___ that showed newly depressed LVEF with inferosetpal hypokinesis. His cardiologist wanted to treat him medically and he was started on metoprolol which he has only taken for three days. However since that time he has experienced chest pain with shortness of breath including paroxysmal nocturnal dyspnea. He describes the CP as a tightness pressure in the ___ his chest nonradiating assoc w SOB and lightheadedness. It subsides w in 1 min. He has not taken anything to relieve the pain. Pt takes 81mg ASA every day he took it this AM. Prior to the past 10 days he has been able to ski boat fish all without any chest pain. He has never taken his sublingual nitroglycerin. He denies weight gain orthopnea PND palpitations syncope aside from 10 days ago lower extremity edema fevers chills nausea vomiting diarrhea dysuria. Had cough several days ago that resolved. EMERGENCY DEPARTMENT COURSE In the ED initial vitals were T 96.8 HR 68 BP 147 85 RR 18 O2 99 RA Exam notable for Heart RRR no murmur Lungs CTAB No JVD No ___ edema EKG Normal sinus rhythm no ST changes unchanged from EKG in ___ Labs studies notable for Trop 0.01 normal electrolytes and CBC Imaging studies notable for CXR No acute intrathoracic process Patient was given Aspirin 243 Heparin bolus and infusion Vitals on transfer T98.1 HR 58 BP 115 75 RR 18 O2 98 RA Upon Arrival to the Floor He initially reported no chest pain and then subsequently develop central chest pain rated ___ while at rest. REVIEW OF SYSTEMS A 10 point review of systems was positive per the history of present illness and otherwise negativ Past Medical History PAST MEDICAL HISTORY 1. CARDIAC RISK FACTORS Known CAD 2. CARDIAC HISTORY CAD PCI to distal RCA ___ 3.25x18mm Xience at ___ 3. OTHER PAST MEDICAL HISTORY Thrombophlepitis of lower extremity Hypertension Colonic polyp Hyperlipidemia Social History ___ Family History FAMILY HISTORY Brother ___ cancer hypertension Father CAD PVD early Maternal Aunt Cancer ___ Grandfather Severe HTN with sympathectomy Maternal Grandmother ___ Physical ___ PHYSICAL EXAMINATION VS T 98.0 BP 122 76 HR 50 RR 18 O2 97 on RA GENERAL Comfortable appearing man sitting up and bed and speaking to me in no distress HEENT Pupils equal and reactive no scleral icterus or injection moist mucous membranes NECK JVP approximately 10 with positive hepatojuglar reflex CARDIAC S1 S2 bradycardic regular no murmurs rubs or S3 s4 LUNGS Clear bilaterally ABDOMEN Soft non tender non distended EXTREMITIES Warm. No lower extremity edema. SKIN No abnormal skin findings PULSES Strong pedal pulses DISCHARGE EXAM GENERAL sitting up and bed and speaking in short sentences HEENT Pupils equal and reactive no scleral icterus or injection moist mucous membranes NECK JVP approximately 10 CARDIAC S1 S2 bradycardic regular no murmurs rubs or S3 s4 LUNGS Clear bilaterally ABDOMEN Soft non tender non distended EXTREMITIES Warm. No lower extremity edema. SKIN No abnormal skin findings PULSES Strong pedal pulses Pertinent Results ___ 07 45AM BLOOD Hct 42.7 Plt ___ ___ 03 44PM BLOOD WBC 8.1 RBC 4.60 Hgb 14.2 Hct 41.1 MCV 89 MCH 30.9 MCHC 34.5 RDW 12.4 RDWSD 40.4 Plt ___ ___ 03 44PM BLOOD Neuts 69.3 Lymphs 17.7 Monos 9.8 Eos 2.1 Baso 0.5 Im ___ AbsNeut 5.61 AbsLymp 1.43 AbsMono 0.79 AbsEos 0.17 AbsBaso 0.04 ___ 07 45AM BLOOD Plt ___ ___ 03 44PM BLOOD Plt ___ ___ 07 45AM BLOOD UreaN 17 Creat 0.9 K 4.6 ___ 03 44PM BLOOD Glucose 91 UreaN 25 Creat 1.0 Na 142 K 5.1 Cl 105 HCO3 25 AnGap 12 ___ 07 18AM BLOOD ALT 19 AST 22 LD LDH 197 AlkPhos 62 TotBili 0.6 ___ 07 45AM BLOOD cTropnT 0.01 ___ 03 44PM BLOOD cTropnT 0.01 ___ 07 18AM BLOOD Calcium 9.2 Phos 3.1 Mg 2.0 Iron 102 ___ 10 15PM BLOOD Calcium 9.2 Phos 2.7 Mg 2.1 ___ 07 18AM BLOOD calTIBC 330 Ferritn 123 TRF 254 ___ 07 18AM BLOOD TSH 2.2 ___ 03 44PM BLOOD HoldBLu HOLD ___ 03 44PM BLOOD GreenHd HOLD ___ TTE IMPRESSION Suboptimal image quality. Normal biventricular cavity sizes and low normal global systolic function. Mild mitral regurgitation. Normal estimated pulmonary artery systolic pressure. ___ CATH REPORT Impressions Ulcearted 50 60 stenosis in the distal RCA by ___ that was succesfully treated with 2 DES. Brief Hospital Course Summary Mr. ___ is a ___ year old gentleman with hisotry of CAD with a stent to the RCA in ___ who presents with chest pain and shortness of breath over the past two days with negative troponins concerning for unstable angina developed STEMI ___ am went for cath s p ___ 2 to RCA ulcerated RCA lesion . ACTIVE ISSUES STEMI Known history of CAD with stent to RCA in ___. He had a stress test a month after his PCI in ___ that was negative for ischemia and a stress test a year later showed ischemia in a small inferoapical segment. On stress test two days prior to admission he had newly depressed EF and moderately increased ischemia concerning for worsening ischemia. On admission ECG showed anterior and inferior sub mm elevations and continues to have some vague ___ pain but he has had three negative troponins and no progression on his ECG all consistent with unstable angina. On the mornign of ___ with new chest pain and ecg changes with ST elevations in II III aVF indicative of inferior RCA STEMI. Patient was loaded with ASA ticag heparin bolus taken to cath lab and received 2 DES to RCA. He remained CP free for the remainder of his hospital admission. He was discharged on ASA81 Ticagrelor 90BID atorva 80 lisinopril 5 metoprolol xl 12.5. Heart failure with reduced ejection fraction ___ stress test shows newly depression LVEF of 40 related to inferior hypokinesis only after exercise. Etiology is likely ischemic given evidence of increased ischemia on stress test from prior. He is not currently decompensated. Does endorse dyspnea with exertion but CXR does not show pulmonary edema and he has been able to exercise to his full capacity. He denies orthopnea PND weight gain or leg swelling. Post PCI TTE demonstrated Normal biventricular cavity sizes and low normal global systolic function Mild mitral regurgitation Normal estimated pulmonary artery systolic pressure and an EF of 55 . CHRONIC ISSUES Attention Deficit Disorder Held amphetamine in setting of ongoing ischemia Resumed methylphenidate 20mg ER daily after angiography Depression Continued citalopram TRANSITIONAL ISSUES DAPT for 12 months recommended Should be set up for cardiac rehab as an outpatient Medication Changes Atorvastatin 40 80mg daily Metoprolol XL 25 daily Metoprolol Succinate XL 12.5 mg PO DAILY Medication Additions TiCAGRELOR 90 mg PO NG BID Medications Discontinued none Code Status full Contact wife ___ cp ___ Cr 0.9 EF 55 on ___ Weight 103.1kg Medications on Admission The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 25 mg PO DAILY 2. Methylphenidate SR 20 mg PO QAM 3. Citalopram 20 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Atorvastatin 40 mg PO QPM 6. Aspirin 81 mg PO DAILY Discharge Medications 1. TiCAGRELOR 90 mg PO BID to prevent stent thrombosis RX ticagrelor Brilinta 90 mg 1 tablet s by mouth twice a day Disp 180 Tablet Refills 0 2. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet s by mouth daily Disp 90 Tablet Refills 0 3. Metoprolol Succinate XL 12.5 mg PO DAILY RX metoprolol succinate 25 mg 0.5 One half tablet s by mouth daily Disp 90 Tablet Refills 0 4. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet s by mouth daily Disp 90 Tablet Refills 0 5. Citalopram 20 mg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Methylphenidate SR 20 mg PO QAM Discharge Disposition Home Discharge Diagnosis Primary Diagnosis STEMI Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You came to ___ because you were having chest pain. You were found to have a blockage in an artery that supplies blood to your heart. WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL You were found to have a blockage in an artery that supplies blood to your heart. You underwent an intervention to place a stent to re open the blocked artery You improved considerably and were ready to leave the hospital WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL Please follow up with your primary care doctor and other health care providers see below Please take all of your medications as prescribed see below . It is very important that you do NOT miss ___ dose of your aspirin or ticagrelor as these medications are to keep the stent open. Missing a dose could cause a heart attack. Seek medical attention if you have shortness of breath chest pain abdominal pain weight gain leg swelling or other symptoms of concern. Weight yourself daily and call your PCP if your weight is greater than 3lb from discharge weight of 227 pounds. Sincerely Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I213, I2542, I25110, T859XXA, Y840, Y92239, I10, E785, F988, F329. The descriptions of icd codes I213, I2542, I25110, T859XXA, Y840, Y92239, I10, E785, F988, F329 are I213: ST elevation (STEMI) myocardial infarction of unspecified site; I2542: Coronary artery dissection; I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; T859XXA: Unspecified complication of internal prosthetic device, implant and graft, initial encounter; Y840: Cardiac catheterization as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; F988: Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence; F329: Major depressive disorder, single episode, unspecified. The common codes which frequently come are I10, E785, F329. The uncommon codes mentioned in this dataset are I213, I2542, I25110, T859XXA, Y840, Y92239, F988.
The icd codes present in this text will be R569, F329, Z8669, G4730, E785, K219, Z86711. The descriptions of icd codes R569, F329, Z8669, G4730, E785, K219, Z86711 are R569: Unspecified convulsions; F329: Major depressive disorder, single episode, unspecified; Z8669: Personal history of other diseases of the nervous system and sense organs; G4730: Sleep apnea, unspecified; E785: Hyperlipidemia, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; Z86711: Personal history of pulmonary embolism. The common codes which frequently come are F329, E785, K219. The uncommon codes mentioned in this dataset are R569, Z8669, G4730, Z86711. Allergies Dilantin Kapseal Depakote Tegretol Codeine Phenobarbital Penicillins Chief Complaint transfer Major Surgical or Invasive Procedure N A History of Present Illness ___ is a ___ year old man followed at ___ Epilepsy clinic Dr. ___ diagnosis of intractable complex partial epilepsy status post VNS affecting right arm leg and PNES who is transferred from an OSH in ___ for seizure management. His typical events occur ___ times per month. ___ weeks ago they began to happen daily without a clear precipitant. Describes events as 15 min of room spinning vertigo and rt arm leg numbness sometimes with right face followed by ___ hours of right arm leg shaking. Afterwards he is often confused but frequently receives Ativan . Does not lose consciousness can hear throughout may or may not follow commands eyes closed urinary incontinence. Denies eye deviation eyes rolling up head version tongue biting frothing drooling at mouth stool incontinence. Had 2 GTCs in 1990s not since. Patient presented to the OSH on ___ after he had about 6 hrs of continuous jerking of his rt arm and leg. Per report he was able to walk to the car with his wife. Upon arrival to the ED he received 4 mg of IV Ativan 5 mg of valium and 4 mg of Versed before his seizure was aborted. He was set to be discharged on the morning of ___ then had recurrence of the intermittent jerking movements. In the early AM hours of ___ he once again had jerking movements of the right arm leg which took 11 mg Ativan to abate. The ED attending called Dr. ___ recommended transfer. In the past when seizure like events have been refractory to Ativan they have been psychogenic in nature. En route to ___ he had an 8 minute long event characterized by shaking and unresponsiveness limbs and side involved unclear. He received 1mg of Ativan at 6 18pm and another at 6 23pm. He subsequently was unable to recall the date and was more subdued. Today patient denies recent illnesses or missing AED doses. No recent stressors. Is non compliant with ketogenic diet. Past Medical History PNES and seizures Depression No suicidal ideation. Follows with Dr. ___ 2x year Sleep apnea on CPAP Prior myocarditis details unclear since on Toprol Hypercholesterolemia Gastroesophageal reflux Chronic headaches and prior sinusitis Low back surgery L4 5 disc herniation s p left L4 5 hemilaminectomy median facetectomy and L4 5 diskectomy ___ ___ Tonsillectomy Vasectomy Benign hematuria kidney stones thought to be ___ topamax Pulmonary Embolus in ___ 6 months of Coumadin Social History ___ Family History Mother passed last year ___ with a history of MI and uterine cancer. Father died at age ___ of a stroke and MI. Physical Exam Physical Exam General Awake cooperative NAD. HEENT NC AT no scleral icterus noted MMM Neck Supple Pulmonary Regular respirations Cardiac RRR Abdomen soft Skin maculopap rash on chest Neurologic Mental Status Alert oriented x 3. Able to relate history without difficulty. Able to name months of year backwards. 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. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. Cranial Nerves I Olfaction not tested. II PERRL 3 to 2mm and brisk. VFF to confrontation. III IV VI EOMI full. V Facial sensation intact to light touch. VII No facial droop facial musculature 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 tone throughout. No pronator drift bilaterally. No adventitious movements such as tremor noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ 5 5 R ___ 5 5 Sensory No deficits to light touch pinprick cold sensation proprioception throughout. Decreased vibration at toes present at ankles. Unable to test Romberg due to inability to stand with feet together eyes open. DTRs Bi Tri ___ Pat Ach L ___ 2 1 R ___ 2 1 Plantar response was flexor bilaterally. Coordination No intention tremor no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Gait Good initiation. Narrow based normal stride and arm swing. Able to walk in tandem without difficulty. Pertinent Results LABS ON ADMISSION ___ 06 39AM BLOOD WBC 9.0 RBC 4.32 Hgb 13.3 Hct 40.5 MCV 94 MCH 30.8 MCHC 32.8 RDW 13.8 RDWSD 46.4 Plt ___ ___ 06 39AM BLOOD ___ PTT 36.4 ___ ___ 06 39AM BLOOD Glucose 90 UreaN 16 Creat 0.8 Na 142 K 4.0 Cl 102 HCO3 27 AnGap 17 ___ 06 39AM BLOOD ALT 27 AST 32 AlkPhos 116 TotBili 0.2 ___ 09 06AM BLOOD Calcium 9.2 Phos 3.6 Mg 1.7 EEGs ___ IMPRESSION This is an abnormal video EEG monitoring session because of an asymmetry between the two hemispheres. Amplitudes over the left hemisphere particularly in the temporal region are of high amplitude more disorganized and with sharp features. This finding is consistent with known breach artifact. There are no patient events captured during this recording. There are no definite epileptiform discharges or electrographic seizures. ___ IMPRESSION This is an abnormal video EEG monitoring session because of intermittent focal slowing over the left hemisphere indicative of focal subcortical dysfunction in this region. Higher amplitude sharper more chaotic activity over the left hemisphere is consistent with known breach artifact. There are 3 pushbutton activations for a prolonged half hour episode of non rhythmic waxing and waning right arm and leg movements associated with unresponsiveness and deep breathing with no associated epileptiform activity on EEG. This event is consistent with a non epileptic seizure. There are no definite epileptiform discharges or electrographic seizures. ___ IMPRESSION This is an abnormal video EEG monitoring session because of 1 rare left mid temporal sharp waves and 2 intermittent focal slowing over the left hemisphere indicative of focal subcortical dysfunction in this region. Higher amplitude and sharper activity over the left hemisphere is consistent with known breach artifact. There are 4 pushbutton activations for two episodes of non rhythmic asynchronous right arm and leg movements associated with unresponsiveness and deep breathing which have no associated epileptiform activity on EEG. These two events are both consistent with non epileptic seizures. There are no definitely epileptiform discharges or electrographic seizures in this recording. ___ IMPRESSION This is an abnormal video EEG monitoring session because of 1 rare left mid temporal sharp waves and 2 intermittent focal slowing over the left hemisphere indicative of focal subcortical dysfunction in this region. Higher amplitude sharper more chaotic activity over the left hemisphere is consistent with known breach artifact. There is a pushbutton activation at 04 22 for an 8 minute long episode of non rhythmic right arm and leg movements associated with unresponsiveness with a normal posterior dominant rhythm throughout. This episode is similar in semiology to previous events captured during hospitalization and is consistent with a non epileptic seizure. There are no definite epileptiform discharges or electrographic seizures in this recording. ___ IMPRESSION This is an abnormal video EEG monitoring session because of intermittent focal slowing over the left hemisphere indicative of focal subcortical dysfunction in this region. Higher amplitude sharper more chaotic activity over the left hemisphere is consistent with known breach artifact. There are no definite epileptiform discharges or electrographic seizures in this recording. Brief Hospital Course Patient was transferred from ___ for evaluation of prolonged events concerning for seizures including right face and arm twitching nonrhythmically which lasted up to a few hours and required large benzodiazepine doses before aborting. At ___ he was started on continuous video EEG. He had numerous events ranging from 8 to 45 minutes which were captured and had NO electrographic correlate on EEG. These were also clinically variable with right upper extremity lower extremity nonrhythmic and variable frequency shaking with preserved consciousness and ability to cooperate fully with commands. Therefore these were all felt to be non epileptic events. He was discharged with close follow up with his Epilepsy provider. Of note there was some confusion with his anti epileptic medications based on an incongruent list from the outside ___ and these were clarified that he was taking the appropriate regimen as prescribed by Dr. ___. Please refer to the discharge medication regimen for an accurate list. He was seen by the Psychiatry liaison consultant for the Epilepsy team who recommended increasing his Effexor from 150mg to 187.5mg daily and ultimately to 225mg. He also recommended an outpatient referral to Psychiatry or cognitive behavioral therapist for assistance in reducing the frequency of his non epileptic events. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Venlafaxine XR 150 mg PO DAILY 2. Metoprolol Succinate XL 50 mg PO DAILY 3. Atorvastatin 40 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. LevETIRAcetam 1000 mg PO TID 6. LACOSamide 200 mg PO TID 7. felbamate 1800 mg oral QAM 8. Ezetimibe 10 mg PO DAILY 9. Ranitidine 300 mg PO DAILY 10. LamoTRIgine 200 mg PO BID 11. Clobazam 10 mg PO QAM 12. Clobazam 20 mg PO QHS 13. felbamate 1200 mg oral QPM 14. LamoTRIgine 300 mg PO QPM 15. Aspirin 81 mg PO DAILY Discharge Medications 1. Atorvastatin 40 mg PO DAILY 2. Clobazam 10 mg PO QAM 3. Clobazam 20 mg PO QHS 4. Ezetimibe 10 mg PO DAILY 5. felbamate 1800 mg oral QAM 6. felbamate 1200 mg ORAL QPM 7. LACOSamide 200 mg PO TID 8. LamoTRIgine 200 mg PO BID 9. LamoTRIgine 300 mg PO QPM 10. LevETIRAcetam 1000 mg PO TID 11. Metoprolol Succinate XL 50 mg PO DAILY 12. Omeprazole 20 mg PO DAILY 13. Ranitidine 300 mg PO DAILY 14. Venlafaxine XR 225 mg PO DAILY RX venlafaxine 225 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 1 15. Aspirin 81 mg PO DAILY Discharge Disposition Home Discharge Diagnosis Non epileptic events of nonrhythmic arm shaking and altered awareness with NO EEG correlate Prior history of epilepsy Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You were transferred from your local hospital in ___ for prolonged episodes of arm shaking which were concerning for epileptic events. We started continuous EEG monitoring which showed that the events you were having were NOT epileptic seizures. While you were in the hospital you were evaluated by our psychiatrist who recommended increasing your Effexor to 225mg daily. You should follow up with your PCP who can refer you to a psychiatrist or cognitive behavioral therapist who can help you decrease the frequency of these events. Please ensure that you take your medications exactly as listed on your medication list. Please call your Epilepsy provider as listed below if you have any questions or concerns. You should follow up with ___ and Dr. ___ as below. It was a pleasure taking care of you. We wish you the best. Sincerely Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be R569, F329, Z8669, G4730, E785, K219, Z86711. The descriptions of icd codes R569, F329, Z8669, G4730, E785, K219, Z86711 are R569: Unspecified convulsions; F329: Major depressive disorder, single episode, unspecified; Z8669: Personal history of other diseases of the nervous system and sense organs; G4730: Sleep apnea, unspecified; E785: Hyperlipidemia, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; Z86711: Personal history of pulmonary embolism. The common codes which frequently come are F329, E785, K219. The uncommon codes mentioned in this dataset are R569, Z8669, G4730, Z86711.
The icd codes present in this text will be T85111A, G40219, Z6842, T85113A, F458, Z8661, F329, G4733, E669, E785, K219, R51, Z86711, Z87891, F4320, I10. The descriptions of icd codes T85111A, G40219, Z6842, T85113A, F458, Z8661, F329, G4733, E669, E785, K219, R51, Z86711, Z87891, F4320, I10 are T85111A: Breakdown (mechanical) of implanted electronic neurostimulator of peripheral nerve electrode (lead), initial encounter; G40219: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus; Z6842: Body mass index [BMI] 45.0-49.9, adult; T85113A: Breakdown (mechanical) of implanted electronic neurostimulator, generator, initial encounter; F458: Other somatoform disorders; Z8661: Personal history of infections of the central nervous system; F329: Major depressive disorder, single episode, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); E669: Obesity, unspecified; E785: Hyperlipidemia, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; R51: Headache; Z86711: Personal history of pulmonary embolism; Z87891: Personal history of nicotine dependence; F4320: Adjustment disorder, unspecified; I10: Essential (primary) hypertension. The common codes which frequently come are F329, G4733, E669, E785, K219, Z87891, I10. The uncommon codes mentioned in this dataset are T85111A, G40219, Z6842, T85113A, F458, Z8661, R51, Z86711, F4320. Allergies Dilantin Kapseal Depakote Tegretol Codeine Penicillins Chief Complaint Epilepsy Major Surgical or Invasive Procedure ___ REPLACEMENT OF VNS LEAD AND BATTERY History of Present Illness ___ is a ___ year old man who presented for elective admit for VNS battery w lead replacement. The patient experienced reported seizure in OR after extubation eyes rolled back into head right arm and mouth twitching given 1 mg of midazolam in OR. Epilepsy service consulted and patient transferred to Neuro ICU for monitoring of seizures respiratory status. Respiratory status improved back to baseline overnight. Patient continued on all home medications. Past Medical History Viral meningitis at ___ PNES and seizures as above Depression No suicidal ideation. Follows with Dr. ___ 2x year Sleep apnea on CPAP Prior myocarditis details unclear since on Toprol Hypercholesterolemia Gastroesophageal reflux Chronic headaches and prior sinusitis Low back surgery L4 5 disc herniation s p left L4 5 hemilaminectomy median facetectomy and L4 5 diskectomy ___ ___ Tonsillectomy Vasectomy Benign hematuria kidney stones thought to be ___ topamax Pulmonary Embolus in ___ 6 months of Coumadin Social History ___ Family History Mother passed at ___ with a history of MI and uterine cancer. Father died at age ___ of a stroke and MI. Physical Exam On admission General drowsy with non rebreather on face HEENT NCAT gauze tegaderm intact on left neck and upper chest with serosang on neck bandage ___ RRR no murmur Pulmonary CTAB upper transmitted airway sounds snoring Abdomen Soft NT ND Extremities Warm no edema Neurologic Examination MS Drowsy but opens eyes to voice. Regards examiner. Follows command to give thumbs up and raise hands. Cranial Nerves PERRL 3 2 brisk. Face symmetric. EOM crosses midline. Motor Normal bulk and tone. Raises arms on command anti gravity wiggles toes b l. Sensory No deficits to light touch bilaterally. DTRs Bic ___ Quad L 1 2 tr R 1 2 tr Plantar response flexor bilaterally. Coordination deferred. Gait deferred. On discharge General cooperative attentive conversive HEENT non traumatic incision clean and dry Neck NO JVD CV RRR Lungs clear bilaterally Abdomen abdomen obese bowel sounds present GU foley in place Ext warm and well perfused Skin neck and chest incision intact Neuro MS GCS 15 oriented to person place time CN PERRL 3 2 brisk. Face symmetric. EOMI. Sensory Motor right delt biceps triceps grip 4 5 otherwise LUE BLE full no pronator drift. Pertinent Results Labs ___ TYPE ART PO2 83 PCO2 47 PH 7.37 TOTAL CO2 28 BASE XS 0 141 104 17 AGap 18 113 4.6 24 0.9 Comments K Hemolysis Falsely Elevates This Test Glucose If Fasting 70 100 Normal 125 Provisional Diabetes Ca 8.3 Mg 1.8 P 3.6 12.1 12.2 249 37.8 ___ 11.7 PTT 30.9 INR 1.1 Brief Hospital Course ___ is a ___ year old man who presented for elective admit for VNS battery w lead replacement. The patient experienced reported seizure in OR after extubation eyes rolled back into head right arm and mouth twitching given 1 mg of midazolam in OR. Epilepsy service consulted and patient transferred to Neuro ICU for monitoring of seizures respiratory status. Respiratory status improved back to baseline overnight. Patient continued on all home medications. Video EEG recorded one nonepileptic psychogenic event. No electrographic seizures. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO QPM 2. Clobazam 20 mg PO BID 3. Clobazam 10 mg PO NOON 4. Ezetimibe 10 mg PO DAILY 5. Felbatol felbamate 600 mg oral NOON 6. Felbatol felbamate 400 mg oral QPM 7. LACOSamide 200 mg PO TID 8. LevETIRAcetam 1000 mg PO TID 9. LamoTRIgine 200 mg PO BID 10. LamoTRIgine 300 mg PO QPM 11. Omeprazole 20 mg PO DAILY 12. Ranitidine 300 mg PO QHS 13. Venlafaxine XR 75 mg PO QPM 14. Venlafaxine XR 150 mg PO QAM 15. Aspirin 81 mg PO DAILY Discharge Medications 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Clobazam 20 mg PO QPM 4. Clobazam 10 mg PO QAM 5. Ezetimibe 10 mg PO DAILY 6. felbamate 1800 mg oral DAILY 1200 7. felbamate 1200 mg oral QPM qpm 8. LACOSamide 200 mg PO TID 9. LamoTRIgine 200 mg PO BID 10. LamoTRIgine 300 mg PO QPM At 6pm 11. LevETIRAcetam 1000 mg PO TID 12. Omeprazole 20 mg PO DAILY 13. Ranitidine 300 mg PO QHS 14. Venlafaxine XR 150 mg PO QAM 15. Venlafaxine XR 75 mg PO QPM Discharge Disposition Home Discharge Diagnosis Intractable focal epilepsy with complex partial seizures. Intractable nonepileptic psychogenic events. Obstructive sleep apnea. Respiratory compromise. Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions SURGERY You underwent a VNS replacement including battery and lead. Your dressing may come off on the second day after surgery. Your incision is closed with dissolvable sutures underneath the skin. You do not need suture removal. Please keep your incision dry for 72 hours after surgery. Please avoid swimming for two weeks. Call your surgeon if there are any signs of infection like redness fever or drainage. Medications 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. Your Aspirin can be re started 3 days after your surgery. 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 T85111A, G40219, Z6842, T85113A, F458, Z8661, F329, G4733, E669, E785, K219, R51, Z86711, Z87891, F4320, I10. The descriptions of icd codes T85111A, G40219, Z6842, T85113A, F458, Z8661, F329, G4733, E669, E785, K219, R51, Z86711, Z87891, F4320, I10 are T85111A: Breakdown (mechanical) of implanted electronic neurostimulator of peripheral nerve electrode (lead), initial encounter; G40219: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus; Z6842: Body mass index [BMI] 45.0-49.9, adult; T85113A: Breakdown (mechanical) of implanted electronic neurostimulator, generator, initial encounter; F458: Other somatoform disorders; Z8661: Personal history of infections of the central nervous system; F329: Major depressive disorder, single episode, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); E669: Obesity, unspecified; E785: Hyperlipidemia, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; R51: Headache; Z86711: Personal history of pulmonary embolism; Z87891: Personal history of nicotine dependence; F4320: Adjustment disorder, unspecified; I10: Essential (primary) hypertension. The common codes which frequently come are F329, G4733, E669, E785, K219, Z87891, I10. The uncommon codes mentioned in this dataset are T85111A, G40219, Z6842, T85113A, F458, Z8661, R51, Z86711, F4320.
The icd codes present in this text will be I340, I511, D62, I10, Z8551, K589, I341, E039, Z87891, Y831, Y92239. The descriptions of icd codes I340, I511, D62, I10, Z8551, K589, I341, E039, Z87891, Y831, Y92239 are I340: Nonrheumatic mitral (valve) insufficiency; I511: Rupture of chordae tendineae, not elsewhere classified; D62: Acute posthemorrhagic anemia; I10: Essential (primary) hypertension; Z8551: Personal history of malignant neoplasm of bladder; K589: Irritable bowel syndrome without diarrhea; I341: Nonrheumatic mitral (valve) prolapse; E039: Hypothyroidism, unspecified; Z87891: Personal history of nicotine dependence; 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. The common codes which frequently come are D62, I10, E039, Z87891. The uncommon codes mentioned in this dataset are I340, I511, Z8551, K589, I341, Y831, Y92239. Allergies Sulfa Sulfonamide Antibiotics NSAIDS Non Steroidal Anti Inflammatory Drug shrimp shellfish derived Chief Complaint Dyspnea on exertion Major Surgical or Invasive Procedure ___ Mitral valve repair with a resection of the middle scallop of the posterior leaflet P2 and a mitral valve annuloplasty with a 32 ___ annuloplasty band History of Present Illness ___ year old female who was found to have a murmur in ___ and an echocardiogram at that time demonstrated MVP with moderate MR. ___ had remained fairly asymptomatic and requested to defer any type of surgical intervention at that time. Over the past year she has been experiencing progressive shortness of breath with walking up inclines or stairs. A stress echocardiogram in ___ demonstrated severe MVP and MR. ___ was referred for a cardiac catheterization to further evaluate. She was found to have insignificant coronary artery disease and is now being referred to cardiac surgery for a mitral valve repair vs replacement. A TEE performed today showed 4 mitral regurgitation with bileaflet prolapse. Past Medical History Mitral regurgitation and prolapse Hypertension Hypothyroidism ___ s thyroiditis Bladder CA ___ s p excision Strep UTI ___ Irritable bowel syndrome Bladder Excision d t CA Hysterectomy Tonsillectomy Social History ___ Family History Father died at ___ of CVA Physical Exam BP 128 85. Heart Rate 68. Resp. Rate 12. O2 Saturation 100. Height 5 6 Weight 134lb General WDWN in NAD. Somewhat somnolent from anesthetic at this mornings TEE Skin Dry X intact X Warm X HEENT PERRLA X EOMI X Sclera anicteric OP benign. Teeth in good repair. Neck Supple X Full ROM X No JVD Chest Lungs clear bilaterally X Heart RRR IV VI systolic murmur heard best at mid sternal border and apex Abdomen Soft X non distended X non tender X bowel sounds X Extremities Warm X well perfused X No Edema Varicosities None X Neuro Grossly intact X Pulses Femoral Right 2 Left 2 DP Right 2 Left 2 ___ Right 2 Left 2 Radial Right 2 Left 2 Carotid Bruit Right None Left None Pertinent Results Echo ___ The left ventricular cavity size is normal. Overall left ventricular systolic function is normal LVEF 55 . Right ventricular chamber size and free wall motion are normal. The ascending transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic disease.. The aortic valve leaflets 3 appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. There is moderate severe mitral regurgitaion.the P2 leaflet is flail.There are ___ predictors.The posterior mitral leaflet length is 1.0cm . Severe 4 There is mild tricuspid regurgitation.. There is no pericardial effusion. Post bypass There is mild mitral regurgitation .No mitral stenosis.The ___ ring is intact.The LVEF is 55 the rest of the exam is unchnged. The thoracic aorta os intact. Brief Hospital Course Mrs. ___ was a same day admit and on ___ she was brought to the operating room where she underwent a mitral valve repair. Please see operative note for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. on POD 0 she was weaned from sedation awoke neurologically intact and extubated. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up ___ and home ___. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Amoxicillin ___ mg PO ONCE dental 3. Calcitriol 0.25 mcg PO DAILY 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Acetaminophen 650 mg PO Q6H PRN pain Discharge Medications 1. Acetaminophen 325 650 mg PO Q4H PRN pain 2. Amitriptyline 10 mg PO QHS 3. Calcitriol 0.25 mcg PO DAILY 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Aspirin EC 81 mg PO DAILY RX aspirin Adult Low Dose Aspirin 81 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 6. Docusate Sodium 100 mg PO BID 7. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet s by mouth daily Disp 5 Tablet Refills 0 8. Potassium Chloride 20 mEq PO DAILY RX potassium chloride 20 mEq 1 tablet s by mouth daily Disp 5 Tablet Refills 0 9. Metoprolol Tartrate 6.25 mg PO BID RX metoprolol tartrate 25 mg ___ tablet s by mouth twice a day Disp 60 Tablet Refills 0 10. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 11. Milk of Magnesia 30 mL PO DAILY 12. HYDROmorphone Dilaudid ___ mg PO Q3H PRN pain RX hydromorphone Dilaudid 2 mg ___ tablet s by mouth every 3 hours Disp 65 Tablet Refills 0 13. Amoxicillin ___ mg PO ONCE dental 14. Outpatient Physical Therapy Rolling walker diagnosis s p mitral valve repair prognosis good expected length of use 13 months Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Mitral regurgitation and prolapse s p Mitral valve repair Past medical history Hypertension Hypothyroidism ___ s thyroiditis Bladder CA ___ s p excision Strep UTI ___ Irritable bowel syndrome Bladder Excision d t CA Hysterectomy Tonsillectomy 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 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 Please call with any questions or concerns ___ 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 I340, I511, D62, I10, Z8551, K589, I341, E039, Z87891, Y831, Y92239. The descriptions of icd codes I340, I511, D62, I10, Z8551, K589, I341, E039, Z87891, Y831, Y92239 are I340: Nonrheumatic mitral (valve) insufficiency; I511: Rupture of chordae tendineae, not elsewhere classified; D62: Acute posthemorrhagic anemia; I10: Essential (primary) hypertension; Z8551: Personal history of malignant neoplasm of bladder; K589: Irritable bowel syndrome without diarrhea; I341: Nonrheumatic mitral (valve) prolapse; E039: Hypothyroidism, unspecified; Z87891: Personal history of nicotine dependence; 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. The common codes which frequently come are D62, I10, E039, Z87891. The uncommon codes mentioned in this dataset are I340, I511, Z8551, K589, I341, Y831, Y92239.
The icd codes present in this text will be I25110, I429, I480, E039, I10, E785, Z7982, Z7901, Z95810, Z9861. The descriptions of icd codes I25110, I429, I480, E039, I10, E785, Z7982, Z7901, Z95810, Z9861 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; I429: Cardiomyopathy, unspecified; I480: Paroxysmal atrial fibrillation; E039: Hypothyroidism, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z7982: Long term (current) use of aspirin; Z7901: Long term (current) use of anticoagulants; Z95810: Presence of automatic (implantable) cardiac defibrillator; Z9861: Coronary angioplasty status. The common codes which frequently come are I480, E039, I10, E785, Z7901. The uncommon codes mentioned in this dataset are I25110, I429, Z7982, Z95810, Z9861. Allergies Imdur nitroglycerin Bactrim Chief Complaint Chest Pain Major Surgical or Invasive Procedure ___ Cardiac catherization History of Present Illness Mr. ___ is a ___ gentleman with atypical chest pain and CAD s p PCI and stent to LAD cardiomyopathy hypertension hypercholesterolemia paroxysmal atrial fibrillation s p multiple ablations and defibrillator who presents with chest pain. He had a stress test during his recent admission to ___ ___ which was indeterminate for inducible ischemia secondary to maximum heart rate and since chest pain was producible he is now referred for coronary angiogram. He has been treated with a Lovenox bridge since discharge on ___. On interview today Mr ___ reports no chest discomfort since his stress test two days ago. Reports decreased appetite and mild nausea. Denies shortness of breath or diaphoresis. Has been belching a lot with gas. Denies palpitations lightheadedness presyncope syncope and falls. Denies pedal edema and claudication. Denies orthopnea and PND. Sleeps with one pillow In the ED initial vitals were 97.9 88 121 73 18 95 RA. EKG Atrial paced rhythm Rate 70 PR 193 QTc 469 Labs studies notable for trops 2X 0.01 electrolytes w K 4.4 and Cr 0.8 ALT 55 AST 34 Alkphos 83 with LDH 302 tbili 1.0 Alb 4.3. WBC slightly elevated at 10.1 with normal hgb 14.6 plt 132. Patient was given ASA 325 mg Ondansetron 4 mg SLN 0.3 morphine 2 mg IV. Vitals on transfer 98.4F HR 70 bpm BP 125 75 RR 16 96 RA. On the floor patient complaining of pains in his shoulder blades present since his dobutamine stress echo on ___. He states early this AM he had chest pressure worse with deep inspiration but sharp stabbing pains that he experienced after dobutamine stress echo had resolved. He states the morphine in ED somewhat relieved his shoulder blade pain. ROS Denies hx GI bleed CVA DVT. Denies recent fevers chills or rigors. Denies exertional buttock or calf pain. Cardiac review of systems is notable for absence dyspnea on exertion paroxysmal nocturnal dyspnea orthopnea ankle edema palpitations syncope or presyncope. Past Medical History PAST MEDICAL HISTORY 1. CARDIAC RISK FACTORS hypertension dyslipidemia diabetes 2. CARDIAC HISTORY CABG None PERCUTANEOUS CORONARY INTERVENTIONS None PACING ICD ICD 3. PAST MEDICAL HISTORY Atypical chest pain CAD stenting of LAD and multiple attempts to intervene on ___ diagonal Ventricular tachycardia fibrillation w cardiac arrest during stress test s p defibrillator and demand pacemaker Defibrillator Paroxysmal atrial fibrillation w Lovenox bridge s p multiple ablations 1st degree AV block Hx of pericarditis at age ___ Cellulitis Hypothyroidism Borderline diabetes Social History ___ Family History Father with CAD and MI at age ___. Physical Exam ON ADMISSION PHYSICAL EXAM VS T 98.1 BP Left 142 93 Right 155 90 ___ RR 20 O2 sat 97 RA GENERAL Oriented x3. Mood affect appropriate. HEENT Sclera anicteric. PERRL Conjunctiva were pink no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK Supple with JVP of 5 cm. CARDIAC RR normal S1 S2. No murmurs rubs gallops. No thrills lifts. LUNGS No chest wall deformities scoliosis or kyphosis. Resp were unlabored no accessory muscle use. No crackles wheezes or rhonchi. ABDOMEN Soft NTND. No HSM or tenderness. EXTREMITIES No c c e. No femoral bruits. SKIN No stasis dermatitis ulcers scars or xanthomas. PULSES Distal pulses palpable and symmetric ON DISCHARGE PHYSICAL EXAM VS T 98.3 BP 108 64 121 81 HR 70 ___ O2 sat 99 RA I O 120 950 Weight 114.7 kg GENERAL Oriented x3. Mood affect appropriate. HEENT Sclera anicteric. PERRL Conjunctiva were pink no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK Supple with JVP of 5 cm. CARDIAC RR normal S1 S2. No murmurs rubs gallops. No thrills lifts. LUNGS No chest wall deformities scoliosis or kyphosis. Resp were unlabored no accessory muscle use. No crackles wheezes or rhonchi. ABDOMEN Soft NTND. No HSM or tenderness. EXTREMITIES No c c e. No femoral bruits. SKIN No stasis dermatitis ulcers scars or xanthomas. PULSES Distal pulses palpable and symmetric Pertinent Results LABS ON ADMISSION ___ 03 00PM cTropnT 0.01 ___ 10 50AM GLUCOSE 109 UREA N 15 CREAT 0.8 SODIUM 136 POTASSIUM 4.4 CHLORIDE 99 TOTAL CO2 25 ANION GAP 16 ___ 10 50AM ALT SGPT 55 AST SGOT 34 LD LDH 302 ALK PHOS 83 TOT BILI 1.0 ___ 10 50AM LIPASE 37 ___ 10 50AM cTropnT 0.01 ___ 10 50AM ALBUMIN 4.3 ___ 10 50AM WBC 10.1 RBC 5.10 HGB 14.6 HCT 44.3 MCV 87 MCH 28.6 MCHC 33.0 RDW 12.9 RDWSD 40.7 ___ 10 50AM NEUTS 62.9 ___ MONOS 11.6 EOS 3.3 BASOS 0.8 IM ___ AbsNeut 6.37 AbsLymp 2.13 AbsMono 1.17 AbsEos 0.33 AbsBaso 0.08 ___ 10 50AM PLT COUNT 132 ___ 10 50AM ___ PTT 36.6 ___ LABS ON DISCHARGE ___ 05 35AM BLOOD WBC 7.5 RBC 5.12 Hgb 14.6 Hct 43.9 MCV 86 MCH 28.5 MCHC 33.3 RDW 12.6 RDWSD 39.2 Plt ___ ___ 05 35AM BLOOD Plt ___ ___ 05 35AM BLOOD Glucose 94 UreaN 17 Creat 0.9 Na 135 K 4.4 Cl 95 HCO3 30 AnGap 14 ___ 07 35AM BLOOD ALT 50 AST 30 AlkPhos 84 TotBili 1.1 ___ 07 35AM BLOOD Lipase 27 ___ 03 00PM BLOOD cTropnT 0.01 ___ 10 50AM BLOOD cTropnT 0.01 ___ 05 35AM BLOOD Calcium 9.4 Phos 3.8 Mg 2.0 IMAGES STUDIES PROCEDURES ___ Cardiac Cath Systolic 128 Diastolic 89 MAP 89 HR 69 LMCA short vessel without disease LAD ___ stent patent without restenosis D1 ostial 75 stenosis jailed vessel thin vessel. Circumflex without disease. Large dominant vessel. RCA ostial 30 stenosis suspicious for spasm Impression CAD with patent LAD stent and partially jailed thin D1 vessel with ostial 75 stenosis. HTN. HLD. ___ CXR A left sided pacemaker and dual leads are seen in expected position. The cardiomediastinal and hilar contours are within normal limits. The lungs are clear without focal consolidation pleural effusion pulmonary edema or pneumothorax. IMPRESSION No acute cardiopulmonary process. ___ Atrial pacing with ventricular sensing. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT QTc ___ P QRS T 70 193 98 ___ ___ year old gentleman with atypical chest pain and CAD status post PCI and stent to LAD cardiomyopathy hypertension hypercholesterolemia paroxysmal atrial fibrillation status post multiple ablations and defibrillator presented to ED on ___ with ongoing chest pain and back pain after dobutamine stress ECHO on ___. CORONARIES CAD stenting of LAD and multiple attempts to intervene on ___ diagonal PUMP LEVF 65 no segmental wall motion abnormalities. RHYTHM Atrial paced sinus rhythm Coronary Artery Disease In the ED patient was normotensive and ECG showed an atrial paced rhythm Rate 70 PR 193 QTc 469 but was otherwise unremarkable. Trops 2X 0.01. Patient presented on enoxaparin 120 mg BID as a bridge from warfarin for his scheduled cardiac catherization on ___. On arrival to the floor patient was chest pain free. He was continued on home dose 81 mg ASA atorovstatin 80 mg metoprolol 100 mg lisinopril 10 mg and sotalol 120 mg. He remained chest pain free during admission. He underwent cardiac catherization on ___ that showed clean coronaries and no intervention was done. Lisinopril was held day of cardiac cath and restarted on discharge. Back Pain He experienced ___ pain in paraspinal muscle bilaterally radiating to his shoulder blades that was somewhat responsive to baclofen and PO diludad. No pulsatile mass in abdomen bilateral BP were 150 s 90 s and equal. ALT was mildly elevated to 55 but LFTs were otherwise unremarkable with normal lipase. Prior to cardiac catherization patient s back pain resolved. Paroxysmal afib Patient remained in a paced sinus rhythm at a rate of 70 s during admission. Patient has a history of paroxysmal atrial fibrillation s p pacemaker. Patient stopped warfarin on ___ and bridged with 120 mg BID enoxaparin in preparation for cardiac cath. On admission he was continued on 120 mg BID enoxaparin while inpatient with last dose evening of ___ prior to cardiac catherization. Enoxaparin should be restarted morning of ___ and warfarin restarted evening ___. His INR should be checked on ___. Patient states he checks his INR at home and calls into his physician. He verified he would check on ___ and call his physician. h o ventricular tachycardia s p backup pacemaker. He was continued on home dose sotolol. Hypothyroidism Continued home dose levothyroxine Transitional Issues Patient was chest and back pain free on day of discharge. Warfarin was restarted on discharge with bridge with enoxaparin 120 mg BID. ___ should be checked on ___ Cardiac Cath on ___ showed clean coronaries no intervention was done. Full code Contact Wife ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Warfarin 5 mg PO DAILY16 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Levothyroxine Sodium 88 mcg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 8. Sotalol 120 mg PO BID 9. Enoxaparin Sodium 120 mg SC BID Discharge Medications 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Levothyroxine Sodium 88 mcg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 6. Sotalol 120 mg PO BID 7. Lisinopril 10 mg PO DAILY 8. Warfarin 5 mg PO DAILY16 Start taking this medicine tomorrow evening ___ 9. Enoxaparin Sodium 120 mg SC BID Start taking tomorrow morning ___ 10. Outpatient Lab Work ICD 10 I48 Atrial Fibrillation Please check ___ Fax result ATTN ___. MD ___ Discharge Disposition Home Discharge Diagnosis PRIMARY Coronary Artery Disease Afib paroxysmal on warfarin anticoagulation h o ventricular tachycardia w s p backup pacemaker CHRONIC Hypothyroidism HTN HLD 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 ___ for chest and back pain after your stress test. While you here to underwent a procedure called a cardiac catheterization to look at the coronary arteries that supple blood to the muscles in your heart. The arteries that supply your heart are clear and healthy you did not have a heart attack. You should start taking your lovenox enoxaparin 120mg BID starting morning of ___ and warfarin 5 mg on the evening of ___. Please check your ___ on ___ and call your results in. Please keep your appointments as scheduled below. Please call your primary care doctor if your chest or back pain returns. Thank you for allowing us to participate in your care. ___ care team Followup Instructions ___ The icd codes present in this text will be I25110, I429, I480, E039, I10, E785, Z7982, Z7901, Z95810, Z9861. The descriptions of icd codes I25110, I429, I480, E039, I10, E785, Z7982, Z7901, Z95810, Z9861 are I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris; I429: Cardiomyopathy, unspecified; I480: Paroxysmal atrial fibrillation; E039: Hypothyroidism, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; Z7982: Long term (current) use of aspirin; Z7901: Long term (current) use of anticoagulants; Z95810: Presence of automatic (implantable) cardiac defibrillator; Z9861: Coronary angioplasty status. The common codes which frequently come are I480, E039, I10, E785, Z7901. The uncommon codes mentioned in this dataset are I25110, I429, Z7982, Z95810, Z9861.
The icd codes present in this text will be R0789, E1122, I129, N183, K219, Z21, I2510, Z955, E785, G4733, D472, E669, Z6832, J45909, E11319. The descriptions of icd codes R0789, E1122, I129, N183, K219, Z21, I2510, Z955, E785, G4733, D472, E669, Z6832, J45909, E11319 are R0789: Other chest pain; 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; N183: Chronic kidney disease, stage 3 (moderate); K219: Gastro-esophageal reflux disease without esophagitis; Z21: Asymptomatic human immunodeficiency virus [HIV] infection status; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z955: Presence of coronary angioplasty implant and graft; E785: Hyperlipidemia, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); D472: Monoclonal gammopathy; E669: Obesity, unspecified; Z6832: Body mass index [BMI] 32.0-32.9, adult; J45909: Unspecified asthma, uncomplicated; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema. The common codes which frequently come are E1122, I129, K219, I2510, Z955, E785, G4733, E669, J45909. The uncommon codes mentioned in this dataset are R0789, N183, Z21, D472, Z6832, E11319. Allergies Lisinopril amlodipine iodine Chief Complaint Chest pain Major Surgical or Invasive Procedure None History of Present Illness HISTORY OF THE PRESENTING ILLNESS ___ man with past medical history of coronary artery disease s p 4 stents most recent in ___ difficult to control diabetes GERD HIV with recent CD4 of 1700 and obesity who presents today with 24 hours of atypical chest pain while flying from ___. He states yesterday evening while resting in bed in ___ he felt pressure over his xiphoid process epigastrum associated with nausea that prevented him from sleeping and lasted about 8 hours. With this episode he had no associated vomiting diaphoresis arm pain jaw pain or left chest pain or dyspnea. In the morning on his flight back to the ___ he had 2 separate events lasting 5 minutes each of stabbing chest pain over the left pectoral No radiation to his arms and was not associated with dyspnea diaphoresis nausea vomiting or jaw pain. Both these episodes abated on their own. He was able to ambulate once he returned to the ___ but was concerned as this was similar to prior presentation of ACS when traveling from ___. He denies any recent surgery immobilization leg swelling calf pain or history of cancer. He denies any infectious symptoms or traumatic events. In the ED initial vitals were T 98.5 73 137 72 17 98 RA Exam notable for A Ox3 RRR with nl S1S2 no MRG CTAB no calf swelling erythema or bilateral lower extremity swelling Labs notable for negative trops x2 D dimer 378 Mg 1.5 Cr 1.5 Hgb 12.4 Imaging was notable for ___ CXR PA LAT No acute cardiopulmonary process. Patient was given 1 L NS IVF heparin gtt Upon arrival to the floor patient is doing well and has no symptoms. ROS Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History 1. CARDIAC RISK FACTORS Diabetes Dyslipidemia Hypertension 2. CARDIAC HISTORY CABG None PERCUTANEOUS CORONARY INTERVENTIONS S P prior D1 Cypher stenting on ___ at ___ and an Endeavor stent to the LAD in ___. Had a50 D1 lesion at last cath. Had ___ cath at ___ with finding of 80 instent resten of the LAD treated with angioplasty. A 3 4 mm pseudoaneurysm was seen at the distal tip of the patent stent in the diag. Dr. ___ a 6 mos CT scan of the chest for that. That was done in ___ and no FA was noted. PACING ICD None 3. OTHER PAST MEDICAL HISTORY HIV recently put on therapy PUD w h o GIB CAD DM with DIABETIC RETINOPATHY am sugar 100 135 SLEEP APNEA HTN HLD GERD ED BPH RHINITIS CLBP OBESITY DEPRESSION ASTHMA Social History ___ Family History No family history of early MI arrhythmia cardiomyopathies or sudden cardiac death otherwise non contributory. Physical Exam ADMISSION PHYSICAL EXAM PHYSICAL EXAM VS ___ 1042 Temp 98.3 PO BP 144 82 L Lying HR 52 RR 18 O2 sat 97 O2 delivery Ra FSBG 125 GENERAL AA gentleman in NAD HEENT AT NC anicteric sclera MMM NECK supple no LAD CV RRR S1 S2 no murmurs gallops or rubs PULM CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles GI abdomen soft obese nondistended nontender in all quadrants EXTREMITIES no cyanosis clubbing or edema PULSES 2 radial pulses bilaterally NEURO Alert moving all 4 extremities with purpose face symmetric DISCHARGE PHYSICAL EXAM 24 HR VS afebrile HR 48 67 BP 105 138 64 81 RR ___ O2 sat 96 98 on room air GENERAL NAD alert and interactive HEENT AT NC anicteric sclera CV RRR S1 S2 no murmurs gallops or rubs PULM CTAB no wheezes rales rhonchi breathing comfortably without use of accessory muscles GI abdomen soft obese nondistended nontender in all quadrants EXTREMITIES no edema NEURO Alert moving all 4 extremities with purpose face symmetric Pertinent Results ADMISSION LABS ___ 09 30PM BLOOD WBC 4.0 RBC 4.52 Hgb 12.4 Hct 38.9 MCV 86 MCH 27.4 MCHC 31.9 RDW 14.6 RDWSD 45.8 Plt ___ ___ 09 30PM BLOOD Neuts 50.8 ___ Monos 11.0 Eos 3.8 Baso 0.3 Im ___ AbsNeut 2.04 AbsLymp 1.35 AbsMono 0.44 AbsEos 0.15 AbsBaso 0.01 ___ 09 30PM BLOOD Glucose 181 UreaN 21 Creat 1.5 Na 139 K 3.5 Cl 101 HCO3 28 AnGap 10 ___ 09 30PM BLOOD cTropnT 0.01 ___ 03 44AM BLOOD cTropnT 0.01 ___ 02 45PM BLOOD CK MB 5 cTropnT 0.01 ___ 09 30PM BLOOD Calcium 8.9 Phos 2.1 Mg 1.5 ___ 09 30PM BLOOD D Dimer 378 PERTINENT STUDIES ___ Cardiac perfusion imaging FINDINGS Left ventricular cavity size is mildly enlarged. Resting 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 54 . IMPRESSION Mildly enlarged left ventricular cavity. Normal systolic ventricular function. No focal perfusion defects. ___ Stress Test exercise EKG INTERPRETATION This ___ year old IDDM man with a h o CAD HTN and HLD s p MI in ___ and stenting x4 in ___ was referred to the lab for evaluation of chest discomfort. The patient exercised for 9.25 minutes of ___ protocol and stopped for fatigue. The estimated peak MET capacity is 10.4 representing a good functional capacity for his age. There were no chest neck arm or back discomforts reported during exercse however at 1.5 minutes of recovery the patient reported a ___ focal upper left sided chest discomfort different from the discomfort he was referred for which was reportedly absent by 4.25 minutes of recovery. At peak exercise there was 2.0 2.5 mm horizontal ST segment depression in the inferior leads 1.5 2.0 mm horizontal ST segment depression in leads I V4 6 and 1.0 1.5 mm ST segment elevation in lead aVR. These changes slowly improved with rest during recovery and returned to baseline by 10 minutes of recovery. The rhythm was sinus with one isolated APB and one isolated VPB early post exercise. Appropriate blood pressure response to exercise and recovery with a blunted heart rate response to exercise in the setting of beta blockade. IMPRESSION Ischemic EKG changes in the absence of anginal type symptoms during exercise. Atypical anginal type symptoms early post exercise. Good functional capacity. Nuclear report sent separately. CHEST PA LAT Study Date of ___ 12 30 AM No acute cardiopulmonary process. ECGStudy Date of ___ 9 41 58 ___ Sporadically abnormal T wave inversions mild ST depressions in leads I and aVL as noted in ___ EKG less prominent bleeding noted on post angioplasty EKG but ___ EKG with same T wave inversions arguably even mildly more prominent ST depression in I and aVL chronic Q wave in lead III with mild ST elevation 0.5 1 mm which was also in today s study not dramatically different from most previous EKGs. MICROBIOLOGY None DISCHARGE LABS ___ 06 20AM BLOOD WBC 5.3 RBC 4.75 Hgb 13.5 Hct 41.9 MCV 88 MCH 28.4 MCHC 32.2 RDW 14.7 RDWSD 47.3 Plt Ct ERROR ___ 06 20AM BLOOD ___ PTT 28.8 ___ ___ 06 20AM BLOOD Glucose 206 UreaN 15 Creat 1.2 Na 139 K 4.2 Cl 101 HCO3 25 AnGap 13 ___ 06 20AM BLOOD Calcium 8.9 Phos 2.8 Mg 1.8 Brief Hospital Course Mr. ___ is a ___ AA gentleman with CAD s p stentsx4 difficult to control T2DM obesity GERD HIV with recent CD4 of 1700 and CKD stage 3 presenting with atypical chest pain. ACS workup negative. First episode of xiphoid epigastric pressure that lasted for 8hr while lying in bed at night favored to be GERD. Second episode of sharp stabbing pain on plane the next day more worrisome given hx of similar symptoms that resulted in previous positive ACS workup. ACTIVE PROBLEMS Atypical chest pain iso CAD s p stentsx4 most recent ___ Presented with atypical chest pain. ACS work up negative and d dimer within normal limits. Patient was placed on heparin gtt for 24 hours and remained chest pain free. Heparin gtt was discontinued and patient had no recurrent of chest pain. He had exercise stress test on ___ which showed ischemic EKG changes in the absence of anginal type symptoms during exercise. He had good functional capacity as well. Patient discharged with Cardiology follow up. HTN On amlodipine metop losartan terazosin and chlorthalidone at home. Held losartan and chlorthalidone for renal protection and patient will continue to hold Chlorthalidone and losartan until he has outpatient cardiology follow up on ___. TRANSITIONAL ISSUES Discharge weight 105 kg Check BP at follow up Cardiology appointment. Would recommend restarting Chlorthalidone and losartan at outpatient follow up appointment ___. Recheck BMP at follow up appointment. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Terazosin 10 mg PO DAILY 2. Losartan Potassium 50 mg PO BID 3. Gabapentin 300 mg PO TID 4. Metoprolol Succinate XL 50 mg PO BID 5. MetFORMIN Glucophage 500 mg PO BID 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. amLODIPine 5 mg PO DAILY 8. Dolutegravir 50 mg PO DAILY 9. LaMIVudine 300 mg PO DAILY 10. Atorvastatin 80 mg PO QPM 11. Aspirin 81 mg PO DAILY 12. Nitroglycerin SL 0.4 mg SL Q5MIN PRN chest pain 13. Pantoprazole 40 mg PO QAM 14. TraZODone 200 mg PO QHS 15. Vitamin D ___ UNIT PO DAILY 16. liraglutide 0.6 mg 0.1 mL 18 mg 3 mL subcutaneous DAILY 17. Oxybutynin 10 mg PO DAILY 18. ammonium lactate 12 topical BID 19. Chlorthalidone 25 mg PO DAILY 20. HumaLOG KwikPen Insulin insulin lispro 100 unit mL subcutaneous TID W MEALS 21. Lantus Solostar U 100 Insulin insulin glargine 100 unit mL 3 mL subcutaneous QAM Discharge Medications 1. amLODIPine 10 mg PO DAILY RX amlodipine 10 mg 1 tablet s by mouth Daily Disp 30 Tablet Refills 0 2. ammonium lactate 12 topical BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Dolutegravir 50 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. Gabapentin 300 mg PO TID 8. HumaLOG KwikPen Insulin insulin lispro 100 unit mL subcutaneous TID W MEALS 9. LaMIVudine 300 mg PO DAILY 10. Lantus Solostar U 100 Insulin insulin glargine 100 unit mL 3 mL subcutaneous QAM 11. liraglutide 0.6 mg 0.1 mL 18 mg 3 mL subcutaneous DAILY 12. MetFORMIN Glucophage 500 mg PO BID 13. Metoprolol Succinate XL 50 mg PO BID 14. Nitroglycerin SL 0.4 mg SL Q5MIN PRN chest pain 15. Oxybutynin 10 mg PO DAILY 16. Pantoprazole 40 mg PO QAM 17. Terazosin 10 mg PO DAILY 18. TraZODone 200 mg PO QHS 19. Vitamin D ___ UNIT PO DAILY 20. HELD Chlorthalidone 25 mg PO DAILY This medication was held. Do not restart Chlorthalidone until you follow up with your cardiologist on ___. 21. HELD Losartan Potassium 50 mg PO BID This medication was held. Do not restart Losartan Potassium until you follow up with your cardiologist on ___. Discharge Disposition Home Discharge Diagnosis Atypical chest pain 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 having chest pain and came to the hospital. WHAT HAPPENED TO ME IN THE HOSPITAL Your cardiac enzymes were checked and were negative. You were put on heparin to thin your blood while your chest pain was evaluated. You had a stress test which did not show any new concerning findings. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL You should take all of your medications as prescribed. You should attend all of your follow up appointments. You should not take Chlorthalidone or losartan until you follow up with your Cardiologist on ___. We wish you the best Sincerely Your ___ Team Followup Instructions ___ The icd codes present in this text will be R0789, E1122, I129, N183, K219, Z21, I2510, Z955, E785, G4733, D472, E669, Z6832, J45909, E11319. The descriptions of icd codes R0789, E1122, I129, N183, K219, Z21, I2510, Z955, E785, G4733, D472, E669, Z6832, J45909, E11319 are R0789: Other chest pain; 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; N183: Chronic kidney disease, stage 3 (moderate); K219: Gastro-esophageal reflux disease without esophagitis; Z21: Asymptomatic human immunodeficiency virus [HIV] infection status; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z955: Presence of coronary angioplasty implant and graft; E785: Hyperlipidemia, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); D472: Monoclonal gammopathy; E669: Obesity, unspecified; Z6832: Body mass index [BMI] 32.0-32.9, adult; J45909: Unspecified asthma, uncomplicated; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema. The common codes which frequently come are E1122, I129, K219, I2510, Z955, E785, G4733, E669, J45909. The uncommon codes mentioned in this dataset are R0789, N183, Z21, D472, Z6832, E11319.
The icd codes present in this text will be K4090, R634, Z6824, I10, N400, I82411, Z86711, Z7902, Z87891. The descriptions of icd codes K4090, R634, Z6824, I10, N400, I82411, Z86711, Z7902, Z87891 are K4090: Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent; R634: Abnormal weight loss; Z6824: Body mass index [BMI] 24.0-24.9, adult; I10: Essential (primary) hypertension; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; I82411: Acute embolism and thrombosis of right femoral vein; Z86711: Personal history of pulmonary embolism; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I10, N400, Z7902, Z87891. The uncommon codes mentioned in this dataset are K4090, R634, Z6824, I82411, Z86711. Allergies Hayfever Keflex filbert nuts Penicillins Chief Complaint weight loss L groin pain Major Surgical or Invasive Procedure none History of Present Illness ___ yo M with history of recent hospitalization ___ for PE diagnosis then started on rivaroxaban who returns to clinic for continued weight loss. Patient has several year history of weight loss from 200 lbs in ___ to 155 lbs now. He saw his PCP ___ in clinic today for hospitalization follow up and complained of new onset groin pain on L in addition to 10 lbs weight loss since discharge. PCP noticed hernia and was also concerned about extension of known DVT in RLE to abdomen despite being on rivaroxaban. With addition of weight loss PCP concerned for underlying malignancy as cause of VTE so was sent to ED for evaluation. In the ED initial vitals were 98.0 68 135 68 16 99 RA Labs notable for Normal CBC Ca ___ INR 1.6 Imaging notable for CT Abd Pelvis W W O Contrast ___ 1. No acute process within the abdomen or pelvis. 2. Left inguinal hernia containing fat and nonobstructed portion of descending colon. 3. Thrombus within the right common femoral vein. No evidence of intraabdominal extension of deep vein thrombus. 4. Enlarged prostate. Patient was given nothing Vitals prior to transfer 74 159 112 18 98 RA On the floor patient endorses some L groin pain but otherwise is comfortable. He states that he has had 3 inguinal hernias in his life and then this most recent time pain started about 3 weeks ago. He was pretty sure it was a hernia again. He continues to have bowel movements flatus. Pain is ___ and mostly when he sits bent at the waist. Regarding weight loss he says over the past years he has lost weight unintentionally. He denies diarrhea polyuria or dysphagia. He does note that some days he does not have an appetite so will eat little more than some fruit and a muffin. No nausea or vomiting associated with this simply states that he s not hungry. Denies night sweats. No red or black stools. No difficulty with urination. Of note he has had recent issues with memory loss and has been seen by our cognitive neurology team. Initially started on donepezil he stopped this 5 days ago in case this was contributing to weight loss. ROS Complete ROS obtained and is otherwise negative Past Medical History HL HTN BPH a w elevated PSA to 18. Sees Urology regularly bx in ___ was negative for malignancy. Last PSA 15.5 ___ Nasal plyps Elevated PSA Spinal stenosis Varicose veins History of remote spine surgery History of hernia repair Social History ___ Family History History of provoked DVT in daughter in her ___ w neg coag w u. Physical Exam PHYSICAL EXAM ON ADMISSION Vital Signs 97.7 104 40 68 18 100RA ___ 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 bulge TTP in L groin region did not attempt to reduce no overlying erythema Ext Warm well perfused 2 pulses no clubbing cyanosis or edema Neuro CNII XII intact ___ strength upper lower extremities Rectal hemoccult negative no gross blood PHYSICAL EXAM ON DISCHARGE AM of discharge States he is feeling well this AM. States good understanding of why PCP was concerned describes Dr. ___ that blood clot could be linked to underlying cancer but reviewed recent scan results with no obvious cancer source at this time and UTD on screenings . Concerned about recent weight loss in setting of loss of appetite per patient no problems at home no stressors not feeling depressed. Denies CP SOB states otherwise he is feeling well. L inguinal hernia per patient is a small problem he has some mild pain with palpation and with movement but laying bed very little pain. Denies pain in legs. Vital Signs 1725 ___ ___ ___ Alert oriented no acute distress. Pleasant and cooperative white male sleeping laying comfortably in bed in NAD. HEENT Sclera anicteric MMM oropharynx clear EOMI PERRL neck supple 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 mild bulge mildly TTP in L groin region did not attempt to reduce no overlying erythema Ext Warm well perfused 2 pulses no clubbing cyanosis or edema. Has superficial varicose veins noted bilaterally and large superficial mass likely clot in L inner thigh. No palpable cord no calf tenderness. Neuro CNII XII intact ___ strength upper lower extremities Pertinent Results PERTINENT LAB RESULTS ___ 05 27PM BLOOD WBC 9.0 RBC 4.96 Hgb 14.0 Hct 44.9 MCV 91 MCH 28.2 MCHC 31.2 RDW 12.3 RDWSD 40.2 Plt ___ ___ 10 40AM BLOOD WBC 8.3 RBC 5.15 Hgb 14.5 Hct 45.2 MCV 88 MCH 28.2 MCHC 32.1 RDW 12.3 RDWSD 39.1 Plt ___ ___ 05 27PM BLOOD ___ PTT 40.5 ___ ___ 05 27PM BLOOD Glucose 155 UreaN 26 Creat 1.0 Na 140 K 4.4 Cl 100 HCO3 30 AnGap 14 ___ 10 40AM BLOOD Glucose 97 UreaN 24 Creat 0.9 Na 139 K 3.6 Cl 97 HCO3 30 AnGap 16 ___ 05 27PM BLOOD Albumin 3.9 Calcium 10.5 Phos 3.6 Mg 2.1 ___ 10 40AM BLOOD Calcium 10.0 Phos 3.5 Mg 2.1 MICROBIOLOGY none IMAGING AND PERTINENT PREVIOUS RESULTS CT Abd Pelvis W W O Contrast ___ 1. No acute process within the abdomen or pelvis. 2. Left inguinal hernia containing fat and nonobstructed portion of descending colon. 3. Thrombus within the right common femoral vein. No evidence of intraabdominal extension of deep vein thrombus. 4. Enlarged prostate. CTA ___ 1. Subsegmental pulmonary emboli involving the left lower lobe with probable left lower lobe infarct. 2. Filling defects within subsegmental pulmonary veins in the right and left lower lobes. 3. Intermediate density small left pleural effusion. R ___ ___ There is thrombosis of the majority of the greater saphenous vein from its origin to the level of the distal calf with extension into the common femoral vein at the greater saphenous vein origin compatible with superficial and deep venous thrombosis. Colonoscopy ___ Retroflex view of right colon was undertaken. Diverticulosis of the sigmoid colon Sessile polyp in the mid rectum path hyperplastic polyp Otherwise normal colonoscopy to cecum CTA CHEST ___ There is no supraclavicular axillary mediastinal or hilar lymphadenopathy. The thyroid gland appears unremarkable. There is no evidence of pericardial effusion. There is a small intermediate density left pleural effusion. The major airways are patent. There is mild compressive atelectasis adjacent to the left lung base pleural effusion. Mild dependent atelectasis is noted along the posterior aspect of the right lung. There is no evidence of pneumonia. Limited images of the upper abdomen demonstrate hypodensities within the liver the largest measuring 1.3 cm unchanged from a prior CT from ___ likely cysts and or biliary hamartomas. No lytic or blastic osseous lesion suspicious for malignancy is identified. IMPRESSION 1. Subsegmental pulmonary emboli involving the left lower lobe with probable left lower lobe infarct. 2. Filling defects within subsegmental pulmonary veins in the right and left lower lobes. 3. Intermediate density small left pleural effusion. Brief Hospital Course ___ yo M with history of PE now on rivaroxaban who presents for chronic ongoing weight loss and newly diagnosed L inguinal hernia. CT ABdomen Pelvis on admission with no acute process in abdomen pelvis L inguinal hernia with nonobstructed descending colon no evidence of intraabdominal extension of DVT and enlarged prostate. Recent weight loss thought to be multifactorial given negative colonoscopy ___ and no occult blood on rectal exam normal TSH and previous screenings of prostate and skin as outpatient. Perhaps recent contribution of stress death of close family member recent hospitalization for DVT diagnosis of mild cognitive impairment GI upset from recent medications Donepezil Ibuprofen . Hernia pain improving patient counseled about need for close follow up of weight loss and symptoms with outpatient provider. Patient was up to date on recommended screening tests. During his inpatient stay Lisinopril was held ___ low blood pressures 100s 110s systolic . Weight loss weight trend 155.4 lbs in clinic ___ 165 ___ ___ ___. Possible malignant sources include GI had colonoscopy ___ that removed 1 hyperplastic polyp or GU has history of enlarged prostate with elevated PSA bx negative last PSA downtrending ___ . Rectal exam on admission negative for blood and hemoccult negative. A1c pending but unlikely source of weight loss. TSH 1.5 on admission thyroid disorder unlikely. Unclear source of weight loss but potentially multifactorial GI upset related to donepezil recent inpatient admission for DVT PE stress of death of close cousin recent ___ use in setting ___ pain. At this time patient would most likely benefit from close outpatient follow up and workup for underlying malignancy. L inguinal hernia new diagnosis does not appear incarcerated at this time. No leukocytosis afebrile. Patient has significant history of hernias s p repair potentially worsened in the setting of recent constipation. Care Connections to set up Gen Surg appointment as outpatient. Warning signs for return to ED were discussed with the patient. Pain improved on morning of discharge. Recent PE on rivaroxaban since ___. PCP concerned for GI malignancy so overnight team started on heparin gtt held Rivaroxaban on admission in case planning for procedure. Heparin gtt d ced and Rivaroxaban restarted. Will continue homegoing Rivaroxaban with plans to follow up with outpatient PCP for follow up of dosing after ontinued. HTN holding lisinopril as inpatient ___ soft BPs. Will determine plan to restart or hold on discharge recommend further follow up as outpatient. Memory loss patient is recently off donepezil. per patient and wife significant GI issues after taking medication. Will recommend further follow up with medication regimen as outpatient with cognitive neurology. BPH not taking meds at this time no symptoms. Recommend ___ and consider Urology follow up as outpatient. TRANSITIONAL ISSUES patient weight loss thought to be multifactorial GI irritation from Donepezil stress surrounding hospitalization and stress of cousin s recent death possible irritation from Ibuprofen in setting of DVT pain started on symptomatic treatement with tums Maalox. Consider initiation of PPI if continued upper GI symptoms as outpatient. held patient s Lisinopril in the setting of low BPs to 100 110s as inpatient. Please reassess BPs as outpatient and restart as needed appointment made with ___ Surgery team for consideration of elective hernia repair recommend continued follow up with other specialists Urology Neurology as needed continued on Rivaroxaban for DVT please follow up repeat PSA sent while inpatient HbA1c pending. Please follow up Medications on Admission The Preadmission Medication list is accurate and complete. 1. Rivaroxaban 15 mg PO BID 2. Lisinopril 40 mg PO DAILY Discharge Medications 1. Rivaroxaban 15 mg PO BID 2. HELD Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until you discuss it with your primary care doctor Discharge Disposition Home Discharge Diagnosis Primary Left inguinal hernia Weight loss NOS Secondary Unprovoked RLE DVT PE Hypertension BPH Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ You came into the hospital because your Primary Care doctor was concerned that you were having worsening weight loss and groin pain. In the hospital you got a CT scan that showed that you had a hernia. The CT scan showed that your blood clot was stable and was not worsening. For your burping and reflux we will recommend you try over the counter medications like Tums or Maalox. Please discuss these symptoms with Dr. ___. For your hernia please call your primary care doctor or return to the hospital if the bulge becomes larger if it won t pop back in on it s own if you have severe abdominal pain or if the area over the hernia becomes very red or discolored. If you are having trouble with constipation you may try over the counter medications like Colace Senna or Miralax to help your bowel movements stay regular. Followup Instructions ___ The icd codes present in this text will be K4090, R634, Z6824, I10, N400, I82411, Z86711, Z7902, Z87891. The descriptions of icd codes K4090, R634, Z6824, I10, N400, I82411, Z86711, Z7902, Z87891 are K4090: Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent; R634: Abnormal weight loss; Z6824: Body mass index [BMI] 24.0-24.9, adult; I10: Essential (primary) hypertension; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; I82411: Acute embolism and thrombosis of right femoral vein; Z86711: Personal history of pulmonary embolism; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I10, N400, Z7902, Z87891. The uncommon codes mentioned in this dataset are K4090, R634, Z6824, I82411, Z86711.
The icd codes present in this text will be I2699, I82411, I8390, Z7902, I10, G3184, Z87891. The descriptions of icd codes I2699, I82411, I8390, Z7902, I10, G3184, Z87891 are I2699: Other pulmonary embolism without acute cor pulmonale; I82411: Acute embolism and thrombosis of right femoral vein; I8390: Asymptomatic varicose veins of unspecified lower extremity; Z7902: Long term (current) use of antithrombotics/antiplatelets; I10: Essential (primary) hypertension; G3184: Mild cognitive impairment, so stated; Z87891: Personal history of nicotine dependence. The common codes which frequently come are Z7902, I10, Z87891. The uncommon codes mentioned in this dataset are I2699, I82411, I8390, G3184. Allergies Hayfever Keflex filbert nuts Chief Complaint pleuritic chest pain Major Surgical or Invasive Procedure None History of Present Illness Mr. ___ is a ___ year old man with a history of varicose veins who presented to his PCP earlier today with ___ weeks of R leg pain. The pain developed while he was on vacation in ___ but he did not mention the pain to his family until 3 days ago at which time he was brought to ___ in ___ and extensive superficial venous thrombosis was noted and it was recommended that he undergo f u ultrasound in ___ days which he underwent this morning and was found to have worsening SVT and also DVT. When he presented to his PCP this AM he denied dyspnea but did endorse some pleuritic L sided chest pain and worsening ___ edema. He was referred from PCP to ___ for PE scan which L subsegmental pulmonary emboli involving the LLL with possible early infarct. Of note the patient reports 50 lbs weight loss over approximately ___ years. He reports mostly this has been gradual although potentially more rapid recently. He reports that to some degree he feels he is less hungry but his wife also reports that sometimes he forgets to eat. He also notes that he is in the process of evaluation for memory loss. He is still able to do complex legal work he is a retired ___ and manage finances but has been somewhat slower at these jobs and repeats things more often than he used to. He is awaiting brain MRI. He has been taken off Lipitor for this reason. He has also been taken off some of his antihypertensives recently atenolol and amlodipine . He reports that he is up to date on colonoscopy screening. He also reports that he has an elevated PSA that has been attributed to BPH and that he is followed closely by urology who does not feel he has prostate cancer. No recent prolonged immobility. Patient s daughter believes he had superficial vein thrombosis remotely. His daughter also had a DVT in her ___ with negative work up for hypercoagulability. She was on OCP and had been on long plane flight. ___ Course Afebrile HRs ___ BPs 120s 150s 50s 80s 99 100 on RA Received 500 cc NS and 70 mg lovenox Review of systems Const no fevers chills dizziness weight change as above HEENT no HA changes in vision or hearing CV pleuritic chest pain Pulm no dyspnea cough or wheezing GI no abd pain n v c d increased eructation today GU no changes in urine or dysuria MSK no new myalgias arthralgias Neuro no new focal weakness or numbness Derm no new rashes Hem no new bleeding bruising Endo no hot cold intolerance Psych no recent mood changes per patient although his wife feels he has been down at times Past Medical History HL HTN BPH Nasal plyps Elevated PSA Spinal stenosis Varicose veins History of remote spine surgery History of hernia repair Social History ___ Family History History of provoked DVT in daughter in her ___ w neg coag w u. Physical Exam Admission Physical Exam Vital signs 97.9 188 78 87 16 100 on RA gen pt in NAD HEENT nc at sclera anicteric conjunctiva noninjected PER EOMI MMMs CV RRR no m r g Pulm CTAB No c r w notes L sided lateral chest wall pain w deep inspiration Abd GI S NT ND BS no masses HSM palpated Extr wwp distal pulses intact bilateral legs w varicose veins R medial thigh with hardened cords and tenderness mild edema R L GU no CVA tenderness no Foley Neuro alert and interactive strength intact sensation to light touch slightly reduced over distal RLE Skin no rashes on limited skin exam Psych MS normal range of affect DISCHARGE VS 97.8 124 64 62 16 100 RA Gen sitting up in bed comfortable Eyes EOMI ENT OP clear MMM Heart RRR no mrg Lungs CTA bilaterally Abd soft nontender normoactive bowel sounds Ext no edema Skin chronic venous stasis changes bilaterally Vasc venous varicosities over R leg 2 ___ pulses bilaterally Neuro AOx3 moving all extremities Psych appropriate Pertinent Results ADMISSION ___ 02 40PM BLOOD WBC 7.6 RBC 4.38 Hgb 12.5 Hct 39.0 MCV 89 MCH 28.5 MCHC 32.1 RDW 12.9 RDWSD 42.2 Plt ___ ___ 02 40PM BLOOD ___ PTT 29.2 ___ ___ 02 40PM BLOOD Glucose 125 UreaN 27 Creat 0.9 Na 142 K 3.8 Cl 107 HCO3 27 AnGap 12 DISCHARGE ___ 08 00AM BLOOD WBC 6.3 RBC 4.45 Hgb 12.6 Hct 38.9 MCV 87 MCH 28.3 MCHC 32.4 RDW 12.5 RDWSD 40.2 Plt ___ ___ 08 00AM BLOOD ___ PTT 38.1 ___ ___ 08 00AM BLOOD Glucose 99 UreaN 19 Creat 0.7 Na 141 K 3.8 Cl 107 HCO3 27 AnGap 11 RLE Doppler There is thrombosis of the majority of the greater saphenous vein from its origin to the level of the distal calf with extension into the common femoral vein at the greater saphenous vein origin compatible with superficial and deep venous thrombosis. CTA Chest 1. Subsegmental pulmonary emboli involving the left lower lobe with probable left lower lobe infarct. 2. Filling defects within subsegmental pulmonary veins in the right and left lower lobes. 3. Intermediate density small left pleural effusion. Brief Hospital Course This is a ___ year old male with past medical history of hypertension BPH varicose veins who was referred for admission from PCP s office after diagnosis of new DVT in the setting of pleuritic chest pain subsequently found to have acute pulmonary embolism with reassuring telemetry and EKG started on rivaroxaban and able to be discharged home Acute pulmonary embolism Acute right Common Femoral DVT Patient with several days worsening leg swelling in setting of recent diagnosis of superficial thromboembolism found to have acute R common femoral DVT given ongoing pleuritic chest pain he was referred to ___ ___ where he was found to have acute DVT. He was started on lovenox and admitted to medicine. Per PESI score he was intermediate risk based on age and gender no additional risk factors . EKG without signs of right heart strain and patient was without any vital sign abnormalities or symptoms other than mild pleuritic L chest pain . Telemetry was unremarkable. After discussion with patient and his PCP ___. ___ was prescribed rivaroxaban delivered to bedside and instructed to begin taking 12 hours after last dose of lovenox. At time of discharge patient was ambulating comfortably. He and wife were educated on warning signs that should prompt additional care and verbalized their understanding. Hypertension continued lisinopril Mild Cognitive Impairment continued donezpezil TRANSITIONAL Discharged home with 21 day supply of rivaroxaban twice daily at follow up visit he will need prescription for maintenance daily dosing of rivaroxaban Defer to outpatient providers regarding utility of additional workup for unprovoked venous thromboembolism 30 minutes spent on this discharge Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. Donepezil 5 mg PO QHS 3. Ibuprofen 600 mg PO Q8H PRN Pain Mild Discharge Medications 1. Rivaroxaban 15 mg PO BID with food continue for 21 days RX rivaroxaban ___ 15 mg 1 tablet s by mouth twice a day Disp 42 Tablet Refills 0 2. Donepezil 5 mg PO QHS 3. Lisinopril 40 mg PO DAILY Discharge Disposition Home Discharge Diagnosis Acute pulmonary embolism Acute right Common Femoral DVT Hypertension Mild Cognitive Impairment Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Mr. ___ It was a pleasure caring for you at ___. You were admitted with a new diagnosis of a deep vein thrombosis blood clot in your leg and a pulmonary embolism blood clot in your lung. You were treated with a blood thinning medication. You underwent cardiac testing that was reassuring. We discussed the situation with your primary care doctor who recommended the medication Xarelto rivaroxaban . Please take it twice a day for 21 days. After this you will be able to take it once a day please see your primary doctor who will provide you with this once a day prescription. Followup Instructions ___ The icd codes present in this text will be I2699, I82411, I8390, Z7902, I10, G3184, Z87891. The descriptions of icd codes I2699, I82411, I8390, Z7902, I10, G3184, Z87891 are I2699: Other pulmonary embolism without acute cor pulmonale; I82411: Acute embolism and thrombosis of right femoral vein; I8390: Asymptomatic varicose veins of unspecified lower extremity; Z7902: Long term (current) use of antithrombotics/antiplatelets; I10: Essential (primary) hypertension; G3184: Mild cognitive impairment, so stated; Z87891: Personal history of nicotine dependence. The common codes which frequently come are Z7902, I10, Z87891. The uncommon codes mentioned in this dataset are I2699, I82411, I8390, G3184.
The icd codes present in this text will be M8088XA, I5030, I110, K5900, R339, J449, E039, Z66, R0902, Z85038. The descriptions of icd codes M8088XA, I5030, I110, K5900, R339, J449, E039, Z66, R0902, Z85038 are M8088XA: Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture; I5030: Unspecified diastolic (congestive) heart failure; I110: Hypertensive heart disease with heart failure; K5900: Constipation, unspecified; R339: Retention of urine, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; E039: Hypothyroidism, unspecified; Z66: Do not resuscitate; R0902: Hypoxemia; Z85038: Personal history of other malignant neoplasm of large intestine. The common codes which frequently come are I110, K5900, J449, E039, Z66. The uncommon codes mentioned in this dataset are M8088XA, I5030, R339, R0902, Z85038. Allergies Sulfa Sulfonamide Antibiotics Chief Complaint back pain Major Surgical or Invasive Procedure none History of Present Illness ___ with history of COPD CHF hypertension TIA osteoarthritis and remote colon cancer who presented with atraumatic back pain that started when she was getting out of bed and found to have a T spine fracture. She developed atraumatic back pain 3 days prior to admission while walking to the bathroom. She states the pain was ___ in severity and non radiating. She states it is worse with movement and pain medication helps with the pain. She also reported some subjective left leg weakness. She presented to the eye ___ where she was found to have urinary retention and a Foley was placed. She states that she has been having urinary retention for about a year but never sought medical attention. She also states that she has not had a bowel movement in 3 days and has good appetite. She denied any fever night sweats chest pain shortness of breath lightheadedness abdominal pain nausea vomiting. In the ED initial vitals were T 97.7 HR 94 BP 138 51 RR 16 O2 96 RA Exam was notable for Midline low T spine and ___ tenderness. Strength and sensation intact in distal extremities although the right lower extremity flexion is limited by pain. Normal rectal tone. Labs were notable for CBC unremarkable BMP unremarkable LFTs unremarkable UA unremarkable INR 1.0 Studies were notable for MR ___ spine with and without contrast Cord or cauda equina compression No. Please note that imaging can make the anatomic diagnosis of cauda equina COMPRESSION but that cauda equina SYNDROME is a clinical diagnosis based on the patient examination. Imaging can never make a diagnosis of cauda equina SYNDROME. Cord signal abnormality no Epidural collection no Other Increased fluid signal within the T12 and L1 vertebral bodies at the site of known compression fractures. Multilevel disc bulges most prominent at L2 L3 causing moderate spinal canal stenosis and bilateral neural foraminal stenosis. The patient was given IV morphine sulfate 2 mg x3 Spine were consulted and recommended TLSO ___ at edge of bed no ___ restrictions follow up with Dr. ___ in 1 month with lumbar spine AP lateral x ray pain management. On arrival to the floor She states her pain is ___ and her pain is adequately controlled. She also complains of constipation. Past Medical History HTN COPD TIA Osteoarthritis Hypothyroidism CHF EF 60 in ___ Colon cancer Sigmoid diverticulitis Hysterectomy Colectomy in ___ COPD Squamous cell carcinoma Social History ___ Family History Not relevant to current presentation Physical Exam ADMISSION PHYSICAL EXAM VITALS 24 HR Data last updated ___ 742 Temp 98.4 Tm 98.4 BP 172 70 HR 86 RR 20 O2 sat 97 O2 delivery 2L Fluid Balance last updated ___ 756 Last 8 hours Total cumulative 360ml IN Total 360ml PO Amt 360ml OUT Total 0ml Last 24 hours Total cumulative 360ml IN Total 360ml PO Amt 360ml OUT Total 0ml GENERAL Alert and interactive. In no acute distress. NECK No cervical lymphadenopathy. No JVD. CARDIAC Regular rhythm normal rate. Audible S1 and S2. crescendo decrescendo murmur RUSB LUNGS Clear to auscultation bilaterally. No wheezes rhonchi or rales. No increased work of breathing. BACK No CVA tenderness. Non tender to palpation. Deferred Sciatic exam given fracture. 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. multiple healed scars. NEUROLOGIC AOx3. CN2 12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM PHYSICAL EXAM VS ___ 1115 Temp 98.0 PO BP 123 61 HR 70 RR 18 O2 sat 94 O2 delivery Ra Fluid Balance last updated ___ 1200 Last 8 hours Total cumulative 185mL IN Total 360 ml PO OUT Total 175ml Urine Amt 175ml inctx1 Last 24 hours Total cumulative 700ml IN Total 940ml PO Amt 940ml OUT Total 285ml inctx3 GENERAL Alert and interactive. In no acute distress. Not wearing TLSO brace while in bed. NECK No cervical lymphadenopathy. No JVD. CARDIAC Regular rhythm normal rate. Audible S1 and S2. ___ crescendo decrescendo murmur appreciated throughout precordium LUNGS Decrease breath sound in all lung fields anteriorly BACK Deferred Sciatic exam given fracture. ABDOMEN Normal bowels sounds non distended non tender to deep palpation in all four quadrants. EXTREMITIES 1 pitting edema in bilateral lower extremities. Pulses DP Radial 2 bilaterally. SKIN Warm. Cap refill 2s. multiple healed scars. NEUROLOGIC AOx3. CN2 12 intact. Moving all 4 limbs. Pertinent Results ADMISSION LABS ___ 01 10PM WBC 9.4 RBC 3.79 HGB 11.7 HCT 35.6 MCV 94 MCH 30.9 MCHC 32.9 RDW 14.5 RDWSD 49.6 ___ 01 10PM NEUTS 78.7 LYMPHS 11.1 MONOS 7.2 EOS 2.1 BASOS 0.4 IM ___ AbsNeut 7.39 AbsLymp 1.04 AbsMono 0.68 AbsEos 0.20 AbsBaso 0.04 ___ 01 10PM PLT COUNT 242 ___ 01 10PM GLUCOSE 63 UREA N 25 CREAT 0.7 SODIUM 138 POTASSIUM 3.9 CHLORIDE 96 TOTAL CO2 24 ANION GAP 18 ___ 01 10PM estGFR Using this IMAGING MR ___ W O CONTRAST ___. No evidence of cauda equina compression. 2. Compression fractures of L1 vertebral body severe and with mild retropulsion and L3 vertebral body moderate . Superior endplate fracture of T12 vertebral body. The L1 and T12 fractures appear recent. 3. Moderate lumbar spondylosis most marked at L2 L3 with moderate spinal canal narrowing secondary to diffuse disc bulge and ligamentum flavum thickening. There is moderate bilateral neural foraminal narrowing at L3 L4. Chest radiograph ___. Mild pulmonary vascular congestion without frank pulmonary edema. 2. Consolidation in the left lower lung field consistent with moderate left pleural effusion alongside associated atelectasis. Remaining left lung is clear. Right lung is free of consolidation 3. Density projecting above the aortic arch is of unknown etiology. Recommend clinical correlation. DISCHARGE LABS ___ 07 59AM BLOOD WBC 7.1 RBC 3.56 Hgb 11.1 Hct 34.6 MCV 97 MCH 31.2 MCHC 32.1 RDW 14.6 RDWSD 52.4 Plt ___ ___ 07 59AM BLOOD Glucose 88 UreaN 27 Creat 0.8 Na 138 K 5.1 Cl 99 HCO3 31 AnGap 8 ___ 07 59AM BLOOD Calcium 9.2 Phos 3.6 Mg 2.8 Brief Hospital Course ___ with history of COPD DMII hypertension and remote colon cancer who presented with atraumatic back pain and found to have T spine fracture urinary retention for about a year and hypoxia which has improved. Currently has a TSLO brace for support and HD and vitally stable. Discharged to rehab. ACUTE ACTIVE ISSUES Atraumatic T spine fracture Concerning for underlying osteoporosis. No cord compression by imaging and urinary symptoms of unclear duration potentially. No surgical intervention per spine surgery. Being treated with TLSO brace when ambulating and pain medications. She also has an appointment with Dr. ___ in 2 weeks. She should continue to wear TLSO for duration when out of bed until f u appointment. She should continue to take calcium and vitamin D and f u with pcp for osteoporosis management. Pain control with Tylenol and PRN oxycodone pt at times not taking oxycodone. Encourage pt to consider small dose in AM to help with mobilization getting out of bed to chair. Constipation resolved Patient complained of 5 days with no BM and recent indigestion. She was started on multiple bowel regiments and had 2 bowel movements on ___ and multiple BM on ___. Outpatient bowel regimen can be PRN. Urinary retention resolved Concerning for cord compression but no evidence on imaging and rectal tone is normal which is reassuring. Patient states that she has been having an issue with urinary retention for about a year. Perhaps secondary to severe pain. Foley in place and removed on ___. She has been voiding without complaint. New Left pleural effusion Resolved Hypoxemia She was noted to be hypoxic to the low ___ on RA after receiving multiple doses of IV morphine. CXR revealed left sided pleural effusion which was resolved after continuation of home lasix. Subsequent CXR shows resolved effusion. CHRONIC STABLE ISSUES Hypertension Continue home amlodipine and losartan Hypothyroidism Continue home levothyroxine TRANSITIONAL ISSUES f u appointment with Dr. ___ in 2 weeks ___ at 10 45 am at ___. She should continue to wear TLSO brace when out of bed until this appointment. She will repeat Xray on same day as appt with Dr. ___ ___ no HCP on file Emergency ___ ___ ___ DAUGHTER ___ ___ New medications oxycodone vitamin d Changed medications none Stopped medications none CORE MEASURES CODE DNR DNI Medications on Admission The Preadmission Medication list is accurate and complete. 1. Furosemide 20 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. ProAir HFA albuterol sulfate 90 mcg actuation inhalation Q4H PRN wheezing Discharge Medications 1. Acetaminophen 1000 mg PO Q8H 2. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Severe RX oxycodone 5 mg 1 tablet s by mouth every four 4 hours Disp 14 Tablet Refills 0 3. Vitamin D 1000 UNIT PO DAILY 4. amLODIPine 10 mg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Levothyroxine Sodium 50 mcg PO DAILY 7. Losartan Potassium 100 mg PO DAILY 8. ProAir HFA albuterol sulfate 90 mcg actuation inhalation Q4H PRN wheezing Discharge Disposition Extended Care Facility ___ ___ Diagnosis Atraumatic T spine fracture Constipation Urinary retention pleural effusion Resolved Hypoxemia 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 DISCHARGE INSTRUCTIONS Dear Ms. ___ It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL You were in the hospital because severe back pain. WHAT HAPPENED TO ME IN THE HOSPITAL At the hospital we did imaging of your back that showed a fracture in your lower back. We got a brace for you to stabilize your back. We also noted that you were having a hard time with passing stool which we gave you some medication to help you have a bowel movement. You were also having a hard time voiding so we place a foley that we removed on ___. You were voiding with no issues afterward. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL Please continue to take all of your medications and follow up with your appointments as listed below. You should wear your brace when out of bed until your follow up appointment with Dr. ___. We wish you the best Sincerely Your ___ Team Followup Instructions ___ The icd codes present in this text will be M8088XA, I5030, I110, K5900, R339, J449, E039, Z66, R0902, Z85038. The descriptions of icd codes M8088XA, I5030, I110, K5900, R339, J449, E039, Z66, R0902, Z85038 are M8088XA: Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture; I5030: Unspecified diastolic (congestive) heart failure; I110: Hypertensive heart disease with heart failure; K5900: Constipation, unspecified; R339: Retention of urine, unspecified; J449: Chronic obstructive pulmonary disease, unspecified; E039: Hypothyroidism, unspecified; Z66: Do not resuscitate; R0902: Hypoxemia; Z85038: Personal history of other malignant neoplasm of large intestine. The common codes which frequently come are I110, K5900, J449, E039, Z66. The uncommon codes mentioned in this dataset are M8088XA, I5030, R339, R0902, Z85038.
The icd codes present in this text will be S62515A, S56322A, W312XXA, Y929. The descriptions of icd codes S62515A, S56322A, W312XXA, Y929 are S62515A: Nondisplaced fracture of proximal phalanx of left thumb, initial encounter for closed fracture; S56322A: Laceration of extensor or abductor muscles, fascia and tendons of left thumb at forearm level, initial encounter; W312XXA: Contact with powered woodworking and forming machines, initial encounter; Y929: Unspecified place or not applicable. The common codes which frequently come are Y929. The uncommon codes mentioned in this dataset are S62515A, S56322A, W312XXA. Allergies cefaclor Chief Complaint CRPP and EPL repair Major Surgical or Invasive Procedure CRPP and EPL repair of left thumb History of Present Illness ___ yo Healthy LHD Male who sustained table saw injury to L thumb today at 1pm. Was working with his grandfather when table saw kicked back on him and lacerated the dorsum of thumb. bleeding no amputated parts. No other injuries. Went to ___ where he received a nerve block and ancef. tetanus UTD. Transferred here for further care Past Medical History PMH denies PSH appendectomy bilateral ___ fasciotomies for compartment syndrome of unknown origin septoplasty Social History ___ Family History non contributory Brief Hospital Course The patient was admitted to the plastic surgery service on ___ and had a CRPP and EPL repair of the left thumb. The patient tolerated the procedure well. Neuro Post operatively the patient received oral pain medications with good effect. 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. His diet was advanced when appropriate which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. ID Post operatively the patient was started on IV cefazolin then switched to PO cefadroxil for discharge home. The patient s temperature was closely watched for signs of infection. Prophylaxis The patient was encouraged to get up and ambulate as early as possible. At the time of discharge the patient was doing well afebrile with stable vital signs tolerating a regular diet ambulating voiding without assistance and pain was well controlled. He was discharged in a splint with follow up with Dr. ___ in 2 weeks. Discharge Medications 1. Acetaminophen 1000 mg PO Q8H PRN pain 2. cefaDROXil 500 mg oral BID Duration 5 Days RX cefadroxil 500 mg 1 capsule s by mouth twice a day Disp 10 Capsule Refills 0 3. Docusate Sodium 100 mg PO BID 4. OxycoDONE Immediate Release ___ mg PO Q4H PRN pain RX oxycodone 5 mg ___ tablet s by mouth Q4H PRN Disp 50 Tablet Refills 0 Discharge Disposition Home Discharge Diagnosis table saw injury to Left thumb w EPL laceration and P1 frx Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Follow up Instructions ___ The icd codes present in this text will be S62515A, S56322A, W312XXA, Y929. The descriptions of icd codes S62515A, S56322A, W312XXA, Y929 are S62515A: Nondisplaced fracture of proximal phalanx of left thumb, initial encounter for closed fracture; S56322A: Laceration of extensor or abductor muscles, fascia and tendons of left thumb at forearm level, initial encounter; W312XXA: Contact with powered woodworking and forming machines, initial encounter; Y929: Unspecified place or not applicable. The common codes which frequently come are Y929. The uncommon codes mentioned in this dataset are S62515A, S56322A, W312XXA.
The icd codes present in this text will be M47816, J80, J690, A4181, R6521, I82492, K567, E872, N179, J90, D62, G931, M5136, M419, I10, K219, R578, H3530, Z66, Z515, I469, T2101XA, T24012A, T24011A, Y658, Y92230, H168, R740. The descriptions of icd codes M47816, J80, J690, A4181, R6521, I82492, K567, E872, N179, J90, D62, G931, M5136, M419, I10, K219, R578, H3530, Z66, Z515, I469, T2101XA, T24012A, T24011A, Y658, Y92230, H168, R740 are M47816: Spondylosis without myelopathy or radiculopathy, lumbar region; J80: Acute respiratory distress syndrome; J690: Pneumonitis due to inhalation of food and vomit; A4181: Sepsis due to Enterococcus; R6521: Severe sepsis with septic shock; I82492: Acute embolism and thrombosis of other specified deep vein of left lower extremity; K567: Ileus, unspecified; E872: Acidosis; N179: Acute kidney failure, unspecified; J90: Pleural effusion, not elsewhere classified; D62: Acute posthemorrhagic anemia; G931: Anoxic brain damage, not elsewhere classified; M5136: Other intervertebral disc degeneration, lumbar region; M419: Scoliosis, unspecified; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; R578: Other shock; H3530: Unspecified macular degeneration; Z66: Do not resuscitate; Z515: Encounter for palliative care; I469: Cardiac arrest, cause unspecified; T2101XA: Burn of unspecified degree of chest wall, initial encounter; T24012A: Burn of unspecified degree of left thigh, initial encounter; T24011A: Burn of unspecified degree of right thigh, initial encounter; Y658: Other specified misadventures during surgical and medical care; Y92230: Patient room in hospital as the place of occurrence of the external cause; H168: Other keratitis; R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]. The common codes which frequently come are E872, N179, D62, I10, K219, Z66, Z515, Y92230. The uncommon codes mentioned in this dataset are M47816, J80, J690, A4181, R6521, I82492, K567, J90, G931, M5136, M419, R578, H3530, I469, T2101XA, T24012A, T24011A, Y658, H168, R740. Allergies Sulfa Sulfonamide Antibiotics Chief Complaint Lumbar stenosis Major Surgical or Invasive Procedure Anterior Lumbar Decompression and Fusion L3 S1 Lateral Decompression and fusion L1 L3 Posterior Decompression and Fusion L1 S1 Intubation Central line placement Arterial line placement History of Present Illness Pt is a ___ who was on the spine service s p anterior lateral and posterior spine fusion c b post operative ileus. The team had also been concerned about rising O2 requirement and tachycardia. Upon arrival she was on her side with copious bilious vomit coming from he mouth. She was unresponsive and pulseless and CPR was initiated. Pads were placed and her rhythm was consistent with PEA. Epinephrine was given first at 3 55 and 3 additional times prior to ROSC. She was intubated at 4 02 AM. There were several prior attempts that were difficult due to copious vomitus. At 4 03 AM ROSC was achieved. She was noted to have agonal breathing and had a blood pressure of 183 95. She was transported to the ICU for further care. Past Medical History HTN Macular Degeneration Depression GERD Spine Fusion TAH Cysto Giant cell tumor excision Social History ___ Family History NC Physical Exam MICU ADMISSION PHYSICAL EXAM VS reviewed in metavision GEN Intubated and sedated bilious output from NGT HEENT Triple lumen right IJ. PERRLA CV Tachycardic regular rhythm no m r g RESP Course breath sound bilateral with rhonchi throughout GI Nontender abdomen SKIN No bruising or petechia . . ICU DISCHARGE EXAM 24 HR Data last updated ___ 1418 Temp 100.1 Tm 101.9 RR 28 ___ GENERAL lying in bed elevated RR but otherwise appears comfortable nonresponsive to verbal stimuli HEENT eyes open NC AT LUNGS RR elevated currently SKIN No rash NEUROLOGIC nonresponsive to verbal stimuli . . DISCHARGE EXAM Deceased. Pertinent Results Admission Labs ___ 06 29AM BLOOD WBC 10.7 RBC 3.87 Hgb 11.5 Hct 36.6 MCV 95 MCH 29.7 MCHC 31.4 RDW 12.8 RDWSD 44.3 Plt ___ ___ 06 29AM BLOOD Plt ___ ___ 06 29AM BLOOD Glucose 80 UreaN 8 Creat 0.6 Na 139 K 3.9 Cl 103 HCO3 24 AnGap 12 ___ 06 29AM BLOOD Calcium 8.7 Phos 2.5 Mg 1.7 ___ 05 02AM BLOOD Lactate 5.3 No Discharge Labs Brief Hospital Course ___ ANTERIOR LUMBAR FUSION L3 S1 no intraop comps ___ LATERAL LUMBAR INTERBODY FUSION XLIF RIGHT L1 L3 no inraop comps ebl 20. ___ LUMBAR LAMINECTOMY FUSION L1 S1 EBL 750 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. ___ were used for postoperative DVT prophylaxis. 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. She developed a post op ileus and was made NPO. Foley was removed on POD 2. Physical therapy and Occupational therapy were consulted for mobilization OOB to ambulate and ADL s. Hospital course was complicated by ileus and on ___ she developed increasing tachycardia SOB RT attempted NT suctioning pt began vomiting copious amounts of bilious vomit aspirated PEA arrested cpr immediately initiated pt was intubated brought to MICU labile BP on 3 pressors evaluated for ecmo. Patient developed ARDS. Patient was proned and paralyzed with eventual improvement in ARDS. Targeted temperature management was instituted. Eventually had an MRI showing evidence of anoxic brain injury. No improvement in neurological status after several days off sedation. Patient was made CMO after discussion with family. DEATH NOTE Note Date ___ Time 0430 Note Type Event Note Title Death Note Electronically signed by ___ MD on ___ at 4 36 am Affiliation ___ Electronically cosigned by ___ MD on ___ at 5 47 pm Called to bedside by RN. No spontaneous movements were present. There was no response to verbal or tactile stimuli. Pupils were mid dilated and fixed. No breath sounds were appreciated over either lung field. No carotid pulses were palpable. No heart sounds were auscultated over entire precordium. Patient pronounced dead at 23 15 on ___ and primary care physician ___. ___ were notified. Family wanted autopsy and both Medical Examiner Office and Pathology were contacted. Medications on Admission The Preadmission Medication list may be inaccurate and requires further investigation. 1. Omeprazole 40 mg PO DAILY Discharge Medications N A Discharge Disposition Expired Discharge Diagnosis Lumbar Stenosis PEA arrest ARDS Sepsis Discharge Condition N A deceased Discharge Instructions N A Followup Instructions ___ The icd codes present in this text will be M47816, J80, J690, A4181, R6521, I82492, K567, E872, N179, J90, D62, G931, M5136, M419, I10, K219, R578, H3530, Z66, Z515, I469, T2101XA, T24012A, T24011A, Y658, Y92230, H168, R740. The descriptions of icd codes M47816, J80, J690, A4181, R6521, I82492, K567, E872, N179, J90, D62, G931, M5136, M419, I10, K219, R578, H3530, Z66, Z515, I469, T2101XA, T24012A, T24011A, Y658, Y92230, H168, R740 are M47816: Spondylosis without myelopathy or radiculopathy, lumbar region; J80: Acute respiratory distress syndrome; J690: Pneumonitis due to inhalation of food and vomit; A4181: Sepsis due to Enterococcus; R6521: Severe sepsis with septic shock; I82492: Acute embolism and thrombosis of other specified deep vein of left lower extremity; K567: Ileus, unspecified; E872: Acidosis; N179: Acute kidney failure, unspecified; J90: Pleural effusion, not elsewhere classified; D62: Acute posthemorrhagic anemia; G931: Anoxic brain damage, not elsewhere classified; M5136: Other intervertebral disc degeneration, lumbar region; M419: Scoliosis, unspecified; I10: Essential (primary) hypertension; K219: Gastro-esophageal reflux disease without esophagitis; R578: Other shock; H3530: Unspecified macular degeneration; Z66: Do not resuscitate; Z515: Encounter for palliative care; I469: Cardiac arrest, cause unspecified; T2101XA: Burn of unspecified degree of chest wall, initial encounter; T24012A: Burn of unspecified degree of left thigh, initial encounter; T24011A: Burn of unspecified degree of right thigh, initial encounter; Y658: Other specified misadventures during surgical and medical care; Y92230: Patient room in hospital as the place of occurrence of the external cause; H168: Other keratitis; R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]. The common codes which frequently come are E872, N179, D62, I10, K219, Z66, Z515, Y92230. The uncommon codes mentioned in this dataset are M47816, J80, J690, A4181, R6521, I82492, K567, J90, G931, M5136, M419, R578, H3530, I469, T2101XA, T24012A, T24011A, Y658, H168, R740.
The icd codes present in this text will be K8042, K8590, K651, K631, B3789, K9189, Y838, L270, T360X5A, Y92239, R197. The descriptions of icd codes K8042, K8590, K651, K631, B3789, K9189, Y838, L270, T360X5A, Y92239, R197 are K8042: Calculus of bile duct with acute cholecystitis without obstruction; K8590: Acute pancreatitis without necrosis or infection, unspecified; K651: Peritoneal abscess; K631: Perforation of intestine (nontraumatic); B3789: Other sites of candidiasis; K9189: Other postprocedural complications and disorders of digestive system; 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; L270: Generalized skin eruption due to drugs and medicaments taken internally; T360X5A: Adverse effect of penicillins, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; R197: Diarrhea, unspecified. The uncommon codes mentioned in this dataset are K8042, K8590, K651, K631, B3789, K9189, Y838, L270, T360X5A, Y92239, R197. Allergies ciprofloxacin Unasyn Chief Complaint Abdominal pain Major Surgical or Invasive Procedure ___ ERCP . ___ CT guided drainage of a retroperitoneal and pelvic collections. . ___ ___ . ___ CT guided drainage of right perinephric collection. History of Present Illness Mrs. ___ is a ___ w h o chest epigastric pain who presents with 3 days of symptoms and U S concerning for acute cholecystitis. Patient reports that she has had a few of these attacks over the past ___ years occurring about every 6 months and described mostly as twisting chest pain but usually spontaneously resolves. For her current episode she had symptoms again mostly described as chest pain and was worsened with food intake. Her pain had not improved over the past few days thus she went to her PCP. There she was noted to have RUQ tenderness and an U S was obtained which was concerning for acute cholecystitis. Patient underwent ERCP with sphincterotomy on ___. Post ERCP patient developed abdominal pain distention lipase was 1886 concerning for post ERCP pancreatitis. Patient was admitted to the ___ surgery service for evaluation management of pancreatitis and possible cholecystectomy. Past Medical History None Social History ___ Family History Diabetes h o CAD Physical Exam Prior to Discharge VS 98.3 61 118 78 18 97 RA GEN Somewhat anxious without acute distress HEENT NC AT EIOM PERRL neck supple no scleral icterus SKIN Trunk and thighs with multiple dark circular spots CV RRR no m r g PULM CTAB ABD Soft non tender non distended. Right flank with ___ drain to bulb suction with minimal cloudy yellow output. Site with drain sponge over and c d I. EXTR Warm no c c e Pertinent Results RECENT LABS ___ 11 40AM BLOOD WBC 11.1 RBC 2.81 Hgb 7.8 Hct 24.1 MCV 86 MCH 27.8 MCHC 32.4 RDW 13.8 RDWSD 43.8 Plt ___ ___ 11 40AM BLOOD Glucose 124 UreaN 10 Creat 0.6 Na 132 K 4.0 Cl 98 HCO3 24 AnGap 14 ___ 06 01AM BLOOD ALT 156 AST 90 AlkPhos 289 TotBili 0.9 ___ 11 40AM BLOOD Lipase 62 ___ 11 40AM BLOOD Calcium 7.7 Phos 3.5 Mg 2.3 MICROBIOLOGY ___ 12 30 pm PERITONEAL FLUID PERITONEAL FLUID FROM RETROPERITONEAL ABSCESS DRAIN . FINAL REPORT ___ GRAM STAIN Final ___ 1 1 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE Final ___ ___ ALBICANS PRESUMPTIVE IDENTIFICATION. Isolated from broth media only INDICATING VERY LOW NUMBERS OF ORGANISMS. ANAEROBIC CULTURE Final ___ NO ANAEROBES ISOLATED. ___ 4 40 pm FLUID OTHER PERIPHERAL COLLECTION. GRAM STAIN Final ___ NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE Final ___ ___ ALBICANS. SPARSE GROWTH. Yeast Susceptibility . Fluconazole MIC 0.5 MCG ML SUSCEPTIBLE. Results were read after 24 hours of incubation. Sensitivity testing performed by Sensititre. ANAEROBIC CULTURE Preliminary NO ANAEROBES ISOLATED. RADIOLOGY ___ LIVER US IMPRESSION 1. Mobile gallstones and sludge within a moderately distended gallbladder. No gallbladder wall edema or pericholecystic fluid is seen at the present time although findings may represent early acute cholecystitis. In addition there is note of choledocholithiasis with at least 1 shadowing stone seen in the common bile duct. 2. Echogenic liver consistent with steatosis. Other forms of liver disease and more advanced liver disease including steatohepatitis or significant hepatic fibrosis cirrhosis cannot be excluded on this study. Relative areas of hypo echogenicity within the liver parenchyma are consistent with geographic sparing from steatosis. 3. Trace right pleural effusion. ___ ERCP The scout film was normal. Normal major papilla. 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 common bile duct common hepatic duct right and left hepatic ducts biliary radicles and cystic duct were filled with contrast and well visualized. The course and caliber of the structures are normal with no evidence of extrinsic compression no ductal abnormalities one small stone was noted at the distal CBD 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. Balloon sweeps reveled small amount of sludge and one small stone. Occlusion cholangiogram showed no evidence of filling defects. Post balloon sweeps good drainage of contrast and bile was noted both endoscopically and fluoroscopically Otherwise normal ercp to third part of the duodenum ___ KUB IMPRESSION No evidence of free intraperitoneal air. ___ CT ABD IMPRESSION 1. Extraluminal retroperitoneal air is identified posterior to the second portion of duodenum. There is fluid extending from the duodenum and to right perinephric space. Duodenal wall is thickened. Findings are suspicious for duodenal perforation although no oral contrast extravasation or discrete duodenal wall defect is identified. 2. Cholelithiasis with gallbladder wall thickening. Hyperenhancement of gallbladder mucosa and extrahepatic bile ducts may be inflammatory. 3. Peritoneal enhancement is consistent with peritonitis. Omental nodularity may reflect edema. 4. Right colonic wall thickening may reflect secondary inflammation. 5. Small to moderate ascites. 6. Bilateral pleural effusions are small. ___ CT ABD IMPRESSION 1. Unchanged extraluminal retroperitoneal air and fluid posterior to the second portion of the duodenum and extending throughout the right perirenal space remaining suggestive of duodenum perforation. 2. Moderate free fluid throughout the abdomen pelvis is slightly increased from prior with new rim enhancement suggestive of organizing fluid collections early abscess formation. New peritoneal enhancement particularly in the pelvis suggestive of peritonitis. 3. Mildly prominent small bowel loops with air fluid levels are suggestive of reactive ileus. 4. Probable reactive colonic mucosal thickening. 5. No definite CT evidence of acute cholecystitis. ___ ___ PROCEDURE 1. Repositioning of wire placed under CT guidance from the retroperitoneal abscess into the retro duodenum region 2. Placement of 8 ___ biliary drain over wire with pigtail formed in the retro duodenum region 3. Upper GI series through NG tube to evaluate for persistent duodenum perforation ___ CT ABD IMPRESSION 1. Interval placement of a pigtail catheter with resulting decrease in size of the retroperitoneal fluid collection along its course. 2. However remainder of the small multiloculated perirenal fluid collections on the right are unchanged in size. 3. Within the pelvis a new 3.7 x 1.9 cm organized collection in the region of the left adnexa could represent walled off ascites. Fluid collection along the posterior uterine wall has decreased. 4. Fatty infiltration of the liver. 5. Trace pericardial effusion grossly unchanged. ___ ___ PROCEDURE IMPRESSION Successful CT guided placement of an ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. Brief Hospital Course The patient is a ___ female with acute cholecystitis s p ERCP. She was admitted to the HPB Surgical Service for possible cholecystectomy. Overnight patient developed abdominal pain and her lipase was 1886 with WBC 12. Surgery was postponed and patient was started treatment for acute pancreatitis. She was started on Unasyn aggressive fluid resuscitation and made NPO pain was controlled with Dilaudid PCA. On HD 3 patient was patient was noticed to have SOB she was required supplemental O2. Fluid rate was turned down she was diuresed with Lasix x 2 and her respiratory status improved. On HD 6 patient s diet was advanced to clear liquids. After taking clears patient s abdominal pain increased and she developed fever she was made NPO. On HD 7 ___ patient s WBC increased to 14K and CT scan was obtained. Abdominal CT demonstrated extraluminal retroperitoneal air thickened duodenal wall no active contrast extravasation peritoneal enhancement concerning for peritonitis ascites and acute cholecystitis. Patient s antibiotics were changed to Cipro Flagyl in the setting of possible perforation. On HD 8 ___ patient s diet was advanced to clears per GI recommendations. Patient spiked fever to 103 vomited and WBC increased to 16K she was pan cultured and ID was consulted. Cipro Flagy was changed to meropenem per ID recommendations. On HD 9 ___ patient remained febrile her blood urine and stool cultures were negative. Patient developed itchy rash which start on her abdomen and spread. Dermatology was consulted. Patient s WBC continued to climb and was 18K. Patient was started on Allegra for itching and Diprolene cream per Dermatology. On HD 10 ___ patient s WBC continued to increase to 18.8 patient was afraid to have CT scan secondary to her resent allergic reaction. On HD 11 ___ WBC up to 19.6 and CT scan was obtained. CT demonstrated unchanged extraluminal retroperitoneal air and fluid posterior to the second portion of the duodenum and extending throughout the right perirenal space remaining suggestive of duodenum perforation moderate free fluid throughout the abdomen pelvis is slightly increased from prior with new rim enhancement suggestive of organizing fluid collections early abscess formation new peritoneal enhancement particularly in the pelvis suggestive of peritonitis please see Radiology report for details . ___ was consulted for possible CT guided drainage of the fluid collections. On HD 12 ___ patient underwent placement of two drains one in retroperitoneal and second into pelvic fluid collections. Sample was sent for microbiology and cell count. On HD 13 ___ patient underwent PICC line placement and TPN was started for nutritional support. Abdominal fluid cultures were positive for yeast and Mucafungin was added per ID recommendations. On HD 14 ___ patient s diet was advanced to clears and was well tolerated. On HD 15 ___ micofungin was changed to Fluconazole as cultures growing ___. Patient s pelvic drain was discontinued. On HD 16 ___ patient s diet advanced to fulls. Patient s spiked a fever to 101.7 WBC started to downward. Patient remained febrile next four days with Tmax 102.1 WBC continued to downtrend. On HD 19 ___ patient underwent CT scan which revealed decreased retroperitoneal fluid collection small multiloculated perirenal fluid collections and small walled off ascites please see Radiology report for details . On HD 20 ___ patient underwent CT guided drainage of right perinephric collection. After drainage diet was advanced to regular. HD 21 ___ pain was well controlled both retroperitoneal and perinephric drain with minimal output WBC down tranding and patient remained afebrile. HD 22 ___ TPN was discontinued. On HD 23 ___ perinephric drain fluid positive for Candina retroperitoneal drain was discontinued as output was scant. HD 23 ___ patient discharged home in stable condition with one drain remained in place and on Fluconazole for 7 days total. Prior to discharge patient remained afebrile pain was well controlled PICC line was removed patient tolerated regular diet and ambulate without assistance. Patient was discharged home with ___ services to continue drain care. Follow up appointment with abdominal CT was scheduled prior to discharge patient instructed to call back if fever or increased output from ___ drain. Medications on Admission None Discharge Medications 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild do not exceed more then 3000 mg day 2. Betamethasone Dipro 0.05 Cream 1 Appl TP BID RX betamethasone augmented 0.05 aplly twice a day on affected areas twice a day Refills 0 3. Docusate Sodium 100 mg PO BID 4. Fexofenadine 180 mg PO DAILY 5. Fluconazole 400 mg PO Q24H RX fluconazole 200 mg 2 tablet s by mouth once a day Disp 7 Tablet Refills 0 6. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth every four 4 hours Disp 20 Tablet Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis 1. Acute cholecystitis 2. Post ERCP pancreatitis and small bowel perforation 3. Severe allergic reaction to antibiotics Unasyn Ciprofloxacin with skin rash 4. ___ peritonitis with intra abdominal abscesses Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You were admitted to the surgery service at ___ for management acute pancreatitis and small bowel perforation after ERCP which was performed for acute cholecystitis. Your recovery was complicated by severe allergic reaction to antibiotics and ___ peritonitis with intraabdominal abscesses which required ___ drainage. You required bowel rest and were placed on TPN for nutritional support. Your diet is now advanced and TPN was discontinued. You are now safe to return home to complete your recovery with the following instructions . Please call Dr. ___ office at ___ or ___ ___ RN at ___. During off hours Call pager operator at ___ and ask to page ___ ___ ___ team. . Please call back right away if you have fever 100.5 or increased abdominal pain. Call the numbers above if you drain output significantly increase. Please resume all regular home medications unless specifically advised not to take a particular medication. Also please take any new medications as prescribed. Please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow up with your surgeon who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow up with your surgeon and Primary Care Provider PCP as advised. . ___ drain care Keep to bulb suction. Please look at the site every day for signs of infection increased redness or pain swelling odor yellow or bloody discharge warm to touch fever . Please note color consistency and amount of fluid in the drain. Call the doctor ___ or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output if instructed to do so. Wash the area gently with warm soapy water or ___ strength hydrogen peroxide followed by saline rinse pat dry and place a drain sponge. Change daily and as needed. Keep the insertion site clean and dry otherwise. Avoid swimming baths hot tubs do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions ___ The icd codes present in this text will be K8042, K8590, K651, K631, B3789, K9189, Y838, L270, T360X5A, Y92239, R197. The descriptions of icd codes K8042, K8590, K651, K631, B3789, K9189, Y838, L270, T360X5A, Y92239, R197 are K8042: Calculus of bile duct with acute cholecystitis without obstruction; K8590: Acute pancreatitis without necrosis or infection, unspecified; K651: Peritoneal abscess; K631: Perforation of intestine (nontraumatic); B3789: Other sites of candidiasis; K9189: Other postprocedural complications and disorders of digestive system; 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; L270: Generalized skin eruption due to drugs and medicaments taken internally; T360X5A: Adverse effect of penicillins, initial encounter; Y92239: Unspecified place in hospital as the place of occurrence of the external cause; R197: Diarrhea, unspecified. The uncommon codes mentioned in this dataset are K8042, K8590, K651, K631, B3789, K9189, Y838, L270, T360X5A, Y92239, R197.
The icd codes present in this text will be R1013, G8929, K830, Z9049. The descriptions of icd codes R1013, G8929, K830, Z9049 are R1013: Epigastric pain; G8929: Other chronic pain; K830: Cholangitis; Z9049: Acquired absence of other specified parts of digestive tract. The common codes which frequently come are G8929. The uncommon codes mentioned in this dataset are R1013, K830, Z9049. Allergies ciprofloxacin Unasyn Chief Complaint abdominal pain Major Surgical or Invasive Procedure none History of Present Illness Patient is a ___ year old woman with history of choledocholithiasis cholecystitis in ___ s p ERCP decompression complicated by post ERCP pancreatitis duodenal microperforation with RP and pelvic abscesses s p ___ drain placement briefly requiring TPN s p cholecystectomy ___ now with episodic epigastric pain who presents with worsening of her known abdominal pain. Patient has had episodic epigastric pain for the past ___ year. Prior to her cholecystitis episode in ___ she used to experience the epigastric pain during ___ episodes per day characterized by sudden onset burning throbbing pain that feels like spasms. The pain lasted 30 seconds to 1 minute and then would go away. She was admitted for abdominal pain and was diagnosed to have cholecystitis. She underwent ERCP with stone extraction. However subsequently had a complicated course with worsening sxs fever leukocytosis and eventually diagnosed with duodenal perforation with RP pelvic abscesses. SHe was treated with a prolonged course of antibiotics unasyn cipro flagyl meropenem and ___ drainage of the fluid collections. Abdominal fluid cultures were positive for yeast and Mucafungin was also added per ID recommendations. SHe also briefly required TPN. Her LFTs WBC were trending down on day of discharge. Her drains were removed at outpatient follow up and she completed her course of abx. Her fluid collections improved on post dc CT scans. SHe was then admitted in ___ for n v presumed to viral gastroenteritis improved with symptomatic therapy. SHe then underwent CCY on ___. For the past week she has been having ___ episodes of the epigastric pain per day and also has a baseline ___ aching in epigastrium for most of the day. Severe cramping non radiating worse when she does not eat for a long time worst in the morning. Also associated with several episodes of bilious emesis over the past 2 days. Denies fevers chills recent weight loss In ED VSS On exam tender in epigastrium to light palpation voluntary guarding in epigastrium. Labs unremarkable KUB did not show any free air under diaphragm or any other abnormality Declined any pain medications On arrival to floor ROS negative except for as noted above. During interview noted to have one of the episodes of pain lasted 30 seconds patient curled up clutching stomch visibly in significant distress associated with retching. Past Medical History Choledocholithiasis and cholecystitis ___ s p ERCP decompression complicated by post ERCP pancreatitis duodenal microperforation with RP and pelvic abscesses s p ___ drain placement briefly requiring TPN S p cholecystectomy ___ Chronic abdominal pain Social History ___ Family History No liver gallbladder FH Dyslipidemia HTN diabetes CAD Physical Exam Gen NAD lying in bed Eyes EOMI sclerae anicteric ENT MMM OP clear GI soft epigastric tenderness guarding ND MSK No significant kyphosis. No palpable synovitis. Skin No visible rash. No jaundice. Neuro AAOx3. No facial droop. Psych Full range of affect Pertinent Results ___ 01 14PM ___ PTT 31.0 ___ ___ 12 37PM ___ COMMENTS GREEN TOP ___ 12 37PM LACTATE 0.9 ___ 12 34PM GLUCOSE 95 UREA N 15 CREAT 0.7 SODIUM 137 POTASSIUM 4.4 CHLORIDE 103 TOTAL CO2 22 ANION GAP 16 ___ 12 34PM estGFR Using this ___ 12 34PM ALT SGPT 20 AST SGOT 21 ALK PHOS 63 TOT BILI 0.2 ___ 12 34PM LIPASE 57 ___ 12 34PM ALBUMIN 4.5 CALCIUM 9.2 PHOSPHATE 3.8 MAGNESIUM 2.0 ___ 12 34PM WBC 9.9 RBC 4.87 HGB 13.2 HCT 40.0 MCV 82 MCH 27.1 MCHC 33.0 RDW 14.7 RDWSD 44.4 ___ 12 34PM NEUTS 58.5 ___ MONOS 4.4 EOS 1.9 BASOS 0.6 IM ___ AbsNeut 5.78 AbsLymp 3.40 AbsMono 0.44 AbsEos 0.19 AbsBaso 0.06 ___ 12 34PM PLT COUNT 292 ___ 11 45AM URINE HOURS RANDOM ___ 11 45AM URINE UCG NEGATIVE ___ 11 45AM URINE COLOR Straw APPEAR Clear SP ___ ___ 11 45AM URINE BLOOD TR NITRITE NEG PROTEIN NEG GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 6.0 LEUK SM ___ 11 45AM URINE RBC 1 WBC 1 BACTERIA NONE YEAST NONE EPI 2 ___ 11 45AM URINE MUCOUS RARE KUB There is a nonobstructive bowel gas pattern. No large air fluid levels are seen. There is no evidence of free air. Right upper quadrant surgical clips are from presumed cholecystectomy. The lung bases are grossly clear. MRCP official read pending at time of discharge Brief Hospital Course ___ year old woman with history of choledocholithiasis cholecystitis in ___ s p ERCP decompression complicated by post ERCP pancreatitis duodenal microperforation with RP and pelvic abscesses s p ___ drain placement briefly requiring TPN s p cholecystectomy ___ now with episodic epigastric pain who presented with worsening of her chronic abdominal pain. The cause of the acute increase of her chronic abdominal pain remained unclear. She had no signs of perforation or obstruction on KUB. MRCP was performed. GI team contacted radiology who stated the wet read had no concerning findings. Labs including lipase are unremarkable. She remained hemodynamically stable with no systemic signs of toxicity. GI and ERCP teams recommended discharge to home on PPI BID and hyoscyamine prn abdominal cramping. They plan on performing an outpatient EGD in the next ___ days. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Docusate Sodium 100 mg PO BID 2. Polyethylene Glycol 17 g PO DAILY 3. Ranitidine 150 mg PO BID 4. Senna 8.6 mg PO BID 5. Multivitamins 1 TAB PO DAILY 6. OxyCODONE Immediate Release 5 mg PO BID PRN Pain Moderate Discharge Medications 1. Hyoscyamine 0.125 mg SL Q4H PRN abdominal cramping RX hyoscyamine sulfate 0.125 mg 1 tablet s sublingually every four 4 hours Disp 30 Tablet Refills 0 2. Omeprazole 40 mg PO BID RX omeprazole 20 mg 2 capsule s by mouth twice a day Disp 120 Capsule Refills 0 3. Docusate Sodium 100 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. OxyCODONE Immediate Release 5 mg PO BID PRN Pain Moderate 6. Polyethylene Glycol 17 g PO DAILY 7. Senna 8.6 mg PO BID Discharge Disposition Home Discharge Diagnosis abdominal pain Discharge Condition condition good mental status intact at baseline ambulatory status independent Discharge Instructions You were admitted to the hospital for abdominal pain and expedited work up. You had an MRCP that was unrevealing. You were seen by GI who recommend an outpatient EGD be done early this week. They will contact you with the specific date and time. They have also recommended you start 2 new medications. Omeprazole is to decrease gastric acid production and Levsin hyoscyamine to treat abdominal cramping muscle spasms. Followup Instructions ___ The icd codes present in this text will be R1013, G8929, K830, Z9049. The descriptions of icd codes R1013, G8929, K830, Z9049 are R1013: Epigastric pain; G8929: Other chronic pain; K830: Cholangitis; Z9049: Acquired absence of other specified parts of digestive tract. The common codes which frequently come are G8929. The uncommon codes mentioned in this dataset are R1013, K830, Z9049.
The icd codes present in this text will be A084, E43, E878, K8020, K219, K5900, D649, Z6822. The descriptions of icd codes A084, E43, E878, K8020, K219, K5900, D649, Z6822 are A084: Viral intestinal infection, unspecified; E43: Unspecified severe protein-calorie malnutrition; E878: Other disorders of electrolyte and fluid balance, not elsewhere classified; K8020: Calculus of gallbladder without cholecystitis without obstruction; K219: Gastro-esophageal reflux disease without esophagitis; K5900: Constipation, unspecified; D649: Anemia, unspecified; Z6822: Body mass index [BMI] 22.0-22.9, adult. The common codes which frequently come are K219, K5900, D649. The uncommon codes mentioned in this dataset are A084, E43, E878, K8020, Z6822. Allergies ciprofloxacin Unasyn Chief Complaint Abdominal pain Major Surgical or Invasive Procedure None History of Present Illness Ms ___ is a ___ with no PMHx and recent ERCP ___ complicated by post ERCP pancreatitis microperforation with RP and pelvic abscesses s p ___ drain placement briefly requiring TPN who presents with sudden onset epigastric RUQ pain nausea and vomiting. She states that the pain began the evening prior to arrival she last had a small meal of ___ fries and tomato soup that evening. Shortly thereafter she started having ___ stabbing burning throbbing aching epigastric abdominal pain that radiates up into the sternum. She also had nausea and vomiting several times throughout the night she was unable to tolerate anything by mouth overnight. She tried taking two oxycodone tablets overnight which did not improve the pain. Pt has had pain similar to this in the epigastrium and RUQ with her prior flare of cholecystitis. She states she has had these episodes of pain every ___ weeks over the past ___ years also associated with nausea generally however the pain has improved with several bouts of nausea and vomiting. The current pain persisted despite her vomiting. For this reason she presented to the ED for further evaluation. Of note Pt has two children at home with a similar vomiting illness. Her husband also just started having diarrhea today. In the ED initial vitals were T 97.7 BP 130 96 HR 68 RR 22 O2 100 on RA Labs notable for Lactate 1.6 WBC 12.9 baseline ___ platelets 574 lipase 42 AST ALT ALP within normal limits Imaging notable for CT ABDOMEN AND PELVIS WITH CONTRAST ___ 1. Retroperitoneal fat stranding and scattered small fluid collections extending inferiorly and posteriorly from the pancreatic head are unchanged compared to 2 weeks prior. 2. Cholelithiasis. 3. A small amount of pneumobilia is not unexpected status post ERCP with sphincterotomy. LIVER OR GALLBLADDER ULTRASOUND ___ 1. Cholelithiasis without cholecystitis. 2. Pneumobilia is not unexpected given history of ERCP with sphincterotomy. 3. Somewhat heterogeneous appearing visualized pancreas may be the sequela of recent pancreatitis documented in the electronic medical record. Consults called SURGERY No radiographic laboratory or physical exam findings suggestive of acute cholecystitis. Pain is predominantly sub xiphoid midline. Both children at home w recent vomiting illness from possible gastroenteritis which could be a component of her current presentation. Recommend medicine admission for hydration pain control further workup. Would consider GI consult as the patient is well known to their service. GASTROENTEROLOGY Pending Treatments given A total of 14mg IV morphine ondansetron 4mg IV x3 and 750cc NS. On the floor Pt endorses the above history. She states that she has been very thirsty and drinking a lot of water down in the ED without issue. She is willing to try a diet of clear liquids and toast and advance from there. Her pain is currently improved down to a ___ as is her nausea. She notes some associated lightheadedness constipation last bowel movement was some time last week which she attributes to taking oxycodone intermittently and a 15 pound weight loss since her last admission. She denies CP SOB fevers chills diarrhea vaginal bleeding discharge and dysuria hematuria. Past Medical History Cholelithiasis cholecystitis Social History ___ Family History No liver gallbladder FH Dyslipidemia HTN diabetes CAD Physical Exam ADMISSION EXAM Vital Signs T 98.4 BP 110 68 HR 105 RR 20 O2 99 on RA General Alert oriented female laying in bed occasionally joking with friend. In no acute distress. HEENT Sclerae anicteric MMM. CV Borderline tachycardic with regular rhythm normal S1 S2 II VI systolic ejection murmur best heard at ___ and ___. Lungs Clear to auscultation bilaterally no wheezes rales rhonchi Abdomen Very hypoactive bowel sounds. Abdomen is distended per Pt report diffusely tender to light palpation worst in the epigastrium and RUQ . Pt with positive ___ sign. No splenomegaly appreciated. GU No foley Ext Warm well perfused wearing stockings this evening. 2 dorsalis pedis pulses no pitting edema Neuro Moves all four extremities spontaneously DISCHARGE EXAM Vitals T 98.3 98.5 BP 97 104 47 70 HR ___ RR ___ O2 97 99 on RA General Oriented female laying in bed in no acute distress fatigued appearing. HEENT Sclera anicteric Lungs Clear to auscultation bilaterally no wheezes rales rhonchi CV Regular rate and rhythm normal S1 S2 no murmurs rubs gallops Abdomen Hypoactive bowel sounds. Abdomen is soft exquisitely tender in epigastrium no rebound or guarding. Ext Warm well perfused 2 pulses in the dorsalis pedis bilaterally no peripheral edema Neuro A O x3 moves all extremities purposefully. Pertinent Results ADMISSION LABS ___ 04 26AM ___ COMMENTS GREEN TOP ___ 04 26AM LACTATE 1.6 ___ 04 05AM GLUCOSE 147 UREA N 9 CREAT 0.7 SODIUM 134 POTASSIUM 3.7 CHLORIDE 95 TOTAL CO2 23 ANION GAP 20 ___ 04 05AM estGFR Using this ___ 04 05AM LIPASE 42 ___ 04 05AM ALBUMIN 3.9 ___ 04 05AM HCG 5 ___ 04 05AM WBC 12.9 RBC 3.91 HGB 9.7 HCT 31.6 MCV 81 MCH 24.8 MCHC 30.7 RDW 13.5 RDWSD 39.4 ___ 04 05AM NEUTS 75.1 ___ MONOS 4.2 EOS 0.7 BASOS 0.4 IM ___ AbsNeut 9.69 AbsLymp 2.46 AbsMono 0.54 AbsEos 0.09 AbsBaso 0.05 ___ 04 05AM PLT COUNT 574 PERTINENT IMAGING RUQ ULTRASOUND ___ 1. Cholelithiasis without cholecystitis. 2. Pneumobilia is not unexpected given history of ERCP with sphincterotomy. 3. Somewhat heterogeneous appearing visualized pancreas may be the sequela of recent pancreatitis documented in the electronic medical record. CT ABDOMEN AND PELVIS W CONTRAST ___ 1. Retroperitoneal fat stranding and scattered small fluid collections extending inferiorly and posteriorly from the pancreatic head are unchanged compared to 2 weeks prior. 2. Cholelithiasis. 3. A small amount of pneumobilia is not unexpected status post ERCP with sphincterotomy. PERTINENT MICRO Blood Culture Routine Final ___ NO GROWTH. DISCHARGE LABS ___ 07 40AM BLOOD WBC 13.0 RBC 3.45 Hgb 8.5 Hct 27.7 MCV 80 MCH 24.6 MCHC 30.7 RDW 13.5 RDWSD 39.5 Plt ___ ___ 07 40AM BLOOD Glucose 108 UreaN 7 Creat 0.6 Na 137 K 3.8 Cl 101 HCO3 23 AnGap 17 ___ 07 40AM BLOOD Calcium 8.6 Phos 3.8 Mg 2.1 Iron 13 ___ 07 40AM BLOOD calTIBC 177 Ferritn 448 TRF 136 ___ 04 26AM BLOOD Lactate 1.___ with PMH cholecystitis complicated by post ERCP pancreatitis microperforation retroperitoneal and intra abdominal abscesses s p ___ drainage from ___ planned for outpatient CCY in ___ who presented with sudden onset RUQ and epigastric abdominal pain accompanied by N V and inability to tolerate PO. Pt with a husband and two children at home who seem to have come down with a similar stomach bug all with vomiting husband with some diarrhea within the past few days. Pt presented to the ED due to her abdominal pain she has had some bouts of similar abdominal pain over the past ___ years that generally improve with vomiting but the current episode did not. She denied concomitant fevers diarrhea dysuria hematuria. Pt s exam notable for significant diffuse abdominal tenderness without peritoneal signs. Lab workup notable for leukocytosis to 18.2 presumed due to viral etiology a CT scan of the abdomen did not show any acute cholecystitis. She was given IV fluids pain medication ranitidine and ondansetron to improvement of her Sx. The morning after she arrived she was tolerating PO and her pain much improved. She was discharged with plan to follow up as outpatient with the surgery team to plan her outpatient cholecystectomy. TRANSITIONAL ISSUES CODE STATUS Presumed full CONTACT Hiren husband ___ ___ ___ as backup MEDICATION CHANGES Added ranitidine 150mg BID for possible gastritis Added stool softeners though Pt may use her OTC softeners as she wishes. Held oxycodone as it can worsen constipation and contribute to abdominal pain as well as feelings of nausea and vomiting. FOLLOW UP APPOINTMENTS Please follow up with Dr. ___ as scheduled. FOLLOW UP LABS Iron studies drawn ___ for anemia. ACTIVE PROBLEMS RUQ EPIGASTRIC CHEST PAIN Imaging negative for acute cholecystitis Pt with negative lipase on admission. Most likely some element of gastritis as well as her baseline cholelithiasis and cholecystitis superimposed on retching with viral gastroenteritis see below . Resolved on arrival to the floor. Acetominophen PRN Ranitidine 150mg BID provided for possible gastritis NAUSEA VOMITING In the setting of ill children and husband at home with vomiting diarrheal illness. Most likely some combination of viral gastroenteritis combined with Pt s baseline chronic cholelithiasis cholelithiasis as well as gastritis. Associated with abdominal pain that did not relent with vomiting as well as several days of preceding constipation while taking percocet . Initially received IV fluids for hydration and IV ondansetron. On arrival to floor was able to tolerate clear liquid diet. Advanced as tolerated to regular diet. Oxycodone held given propensity to cause constipation and exacerbate N V Ranitidine 150mg BID provided for possible gastritis Malnutrition Seen by nutrition and patient is with severe malnutrition. Encouraged patient to supplement diet with ensure. She will need to discuss her nutrition with her primary care doctor. HYPOCHLORMEIA Likely due to ongoing vomiting. Improved with IVF and PO intake. LEUKOCYTOSIS Patient with chronic leukocytosis in teens. Likely due to viral infection reactive in setting of N V as above. Improved prior to discharge. Blood cultures negative. CONSTIPATION Patient reported no BM in the last 2 days. Given bowel regimen with senna docusate and polyethylene glycol. CHRONIC STABLE ISSUES CHOLELITHIASIS Patient has ___ year history of abdominal pain and N V. Had imaging consistent with cholelithiasis during this stay. Patient is scheduled to have gallbladder removed electively at ___. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 2. OxyCODONE Immediate Release 5 mg PO BID PRN Pain Moderate Discharge Medications 1. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 2. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram 1 powder s by mouth Daily Disp 30 Packet Refills 0 3. Ranitidine 150 mg PO BID RX ranitidine HCl Acid Control ranitidine 150 mg 1 tablet s by mouth twice a day Disp 56 Tablet Refills 0 4. Senna 8.6 mg PO BID RX sennosides senna 8.6 mg 1 tablet by mouth twice a day Disp 60 Tablet Refills 0 5. Multivitamins 1 TAB PO DAILY 6. HELD OxyCODONE Immediate Release 5 mg PO BID PRN Pain Moderate This medication was held. Do not restart OxyCODONE Immediate Release until you speak with Dr. ___ Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY Viral gastroenteritis Constipation SECONDARY History of cholelithiasis and cholecystitis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Dr. ___ ___ was a pleasure to care for you at the ___ ___. You were seen at our hospital because you were having a lot of abdominal pain with nausea and vomiting that did not improve for several hours. We gave you fluids through the IV as well as medicine to reduce your nausea and pain. There may be several things that contributed to your symptoms your husband and children at home with a stomach bug your constipation and your history of gallstones with cholecystitis could all have played a part. Fortunately you were feeling better the morning after you arrived. Your pain and nausea had improved and you were able to eat and drink without vomiting. For these reasons we were able to discharge you home today. Please follow up with Dr. ___ office as below for further discussion as to when you should have your gallbladder out. We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be A084, E43, E878, K8020, K219, K5900, D649, Z6822. The descriptions of icd codes A084, E43, E878, K8020, K219, K5900, D649, Z6822 are A084: Viral intestinal infection, unspecified; E43: Unspecified severe protein-calorie malnutrition; E878: Other disorders of electrolyte and fluid balance, not elsewhere classified; K8020: Calculus of gallbladder without cholecystitis without obstruction; K219: Gastro-esophageal reflux disease without esophagitis; K5900: Constipation, unspecified; D649: Anemia, unspecified; Z6822: Body mass index [BMI] 22.0-22.9, adult. The common codes which frequently come are K219, K5900, D649. The uncommon codes mentioned in this dataset are A084, E43, E878, K8020, Z6822.
The icd codes present in this text will be J189, E119, D649, J45909, I10, M069. The descriptions of icd codes J189, E119, D649, J45909, I10, M069 are J189: Pneumonia, unspecified organism; E119: Type 2 diabetes mellitus without complications; D649: Anemia, unspecified; J45909: Unspecified asthma, uncomplicated; I10: Essential (primary) hypertension; M069: Rheumatoid arthritis, unspecified. The common codes which frequently come are E119, D649, J45909, I10. The uncommon codes mentioned in this dataset are J189, M069. Allergies Augmentin Bactrim Chief Complaint cough confusion Major Surgical or Invasive Procedure None. History of Present Illness ___ y.o male with h.o positive PPD per OMR rheumatoid arthritis DM asthma HL who presented with cough. Pt reports that he developed new cough x 1 day last night and felt dehydrated. He reports that he felt well up until that point. He reports that the hardwood floors in his home were redone an he attributes the cough to this process. He reports feeling drowsy and confused x 1 day with chills and fever but denies SOB CP palpitations headache ST abdominal pain nausea vomiting diarrhea constipation dysuria myualgias arthralgias. . In the ED he was given IVF Tylenol ibuprofen levofloxacin. He presented with fever and tachycardia. Flu negative. Last vitals T 97.9 BP 119 86 HR 98 RR 24 sat 97 on RA . 10Pt ROS reviewed and otherwise negative. Past Medical History Rheumatoid arthritis on methotrexate Asthma DM type II HTN Chronic sinusitis Hx of positive PPD Social History ___ Family History Dad MI mom colon cancer Physical Exam ADMISSION EXAM . GEN well appearing NAD vitals T 97.4 BP 120 59 HR 95 RR 18 sat 96 on RA HEENT ncat eomi anicteric MMM neck supple chest b l ae rhonchi L.mid and lower lung heart s1s2 rr no m r g abd bs soft NT ND no guarding or rebound ext no cce 2 pulses neuro face symmetric speech fluent psych calm cooperative . DISCHARGE EXAM . GEN well appearing NAD VS Tc 97.2 Tm 97.4 BP 116 71 HR 98 RR 16 sat 100 on RA Ambulatory sats 97 on RA with max HR 109 no dyspnea palpitations CP HEENT ncat eomi anicteric MMM neck supple chest mild crackles in bilateral lower lung fields more prominent at bases trace rhonchi L.mid and lower lung good air movement no increased WOB or accessory muscle use at rest or with ambulation heart s1s2 rr no m r g abd bs soft NT ND no guarding or rebound ext WWP no cyanosis or edema 2 pulses neuro face symmetric speech fluent AOx3 stable gait psych calm cooperative Pertinent Results ___ 09 58PM URINE HOURS RANDOM ___ 09 58PM URINE UHOLD HOLD ___ 09 58PM URINE COLOR Yellow APPEAR Clear SP ___ ___ 09 58PM URINE BLOOD NEG NITRITE NEG PROTEIN 30 GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 6.5 LEUK LG ___ 09 58PM URINE RBC 2 WBC 41 BACTERIA NONE YEAST NONE EPI 0 TRANS EPI 1 ___ 09 58PM URINE HYALINE 1 ___ 09 58PM URINE CA OXAL RARE ___ 09 58PM URINE MUCOUS RARE ___ 09 25PM OTHER BODY FLUID FluAPCR NEGATIVE FluBPCR NEGATIVE ___ 09 01PM LACTATE 1.6 ___ 08 55PM GLUCOSE 136 UREA N 20 CREAT 1.0 SODIUM 137 POTASSIUM 4.6 CHLORIDE 102 TOTAL CO2 24 ANION GAP 16 ___ 08 55PM estGFR Using this ___ 08 55PM WBC 9.0 RBC 4.04 HGB 11.9 HCT 36.3 MCV 90 MCH 29.5 MCHC 32.8 RDW 14.8 RDWSD 47.9 ___ 08 55PM NEUTS 82.6 LYMPHS 5.7 MONOS 10.8 EOS 0.2 BASOS 0.3 IM ___ AbsNeut 7.39 AbsLymp 0.51 AbsMono 0.97 AbsEos 0.02 AbsBaso 0.03 ___ 08 55PM PLT COUNT 202 . CXR IMPRESSION Findings compatible with right middle lobe pneumonia. . . DISCHARGE LABS ___ 05 53AM BLOOD WBC 9.2 RBC 3.33 Hgb 9.8 Hct 29.9 MCV 90 MCH 29.4 MCHC 32.8 RDW 14.9 RDWSD 47.5 Plt ___ ___ 05 53AM BLOOD Glucose 105 UreaN 19 Creat 0.9 Na 140 K 4.1 Cl 111 HCO3 22 AnGap 11 ___ 05 53AM BLOOD Phos 2.7 Mg 2.0 . . MICROBIO ___ URINE URINE CULTURE PENDING INPATIENT ___ BLOOD CULTURE Blood Culture Routine PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture Routine PENDING EMERGENCY WARD Brief Hospital Course ___ y.o male with PMH of positive PPD who presented with cough and reports of confusion found to have PNA. . Community acquired bacterial pneumonia with sepsis fever tachycardia tachypnea IN ED . CXR with infiltrate. Flu negative. Notably was treated with cipro for chronic sinusitis approximately 1 month ago so there was concern that he might have a resistant organism. However he responded well to levofloxacin chosen initially in ED because of reported Augmentin allergy however patient notes that this is NOT an allergy he did not have rash just had mild moderate diarrhea . Also given IVF with improvement in his tachycardia. Continued levofloxacin on discharge given his good clinical response. On day of discharge he had mild tachycardia HR ___ at rest but ambulatory sats were wnl ambulatory HR was only 100s and he was feeling well without any cardiopulmonary symptoms. Advised him to seek immediate medical attention of recurrent fevers chills worsening cough SOB DOE or other concerning symptoms due to risk of antibiotic resistance. Advised follow up with PCP ___ 1 week. . Confusion resolved quickly with treatment of CAP as above. . Anemia Asymptomatic. Patient denies any recent evidence of bleeding no hemoptysis epistaxis hematemesis melena BRBPR or hematuria . Reports he has chronic anemia due to his RA. Hgb 9.8 on discharge. Outpatient follow up. . Positive UA in ED large leuk esterase 41 WBCs but no urinary symptoms to suggest UTI. UCx pending at the time of discharge if UCx grows fluoroquinolone resistant organisms would advocate for changing abx given his initial presentation was consistent with sepsis by old criteria . . Day of discharge was feeling well VSS afebrile ambulatory sats wnl and no symptoms with ambulation. Tolerating PO meds. Patient comfortable with discharge wanted to go and verbalized understanding of need for seeking medical attention immediately if recurrent fevers chills worsening cough SOB DOE or other concerning symptoms. Time in care 35 minutes in patient care and discharge related activities. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Fluticasone Salmeterol Diskus 100 50 1 INH IH BID 2. Tamsulosin 0.4 mg PO QHS 3. MetFORMIN Glucophage 500 mg PO BID 4. Os Cal 500 D3 calcium carbonate vitamin D3 500 mg 1 250mg 200 unit oral DAILY 5. Tiotropium Bromide 1 CAP IH DAILY 6. Vitamin D 1000 UNIT PO DAILY 7. Cetirizine 10 mg PO DAILY 8. Naproxen 500 mg PO Q8H PRN pain 9. Fish Oil Omega 3 1000 mg PO BID 10. Benicar olmesartan 20 mg oral DAILY 11. Methotrexate Dose is Unknown PO Frequency is Unknown Discharge Medications 1. Cetirizine 10 mg PO DAILY 2. Fluticasone Salmeterol Diskus 100 50 1 INH IH BID 3. Tamsulosin 0.4 mg PO QHS 4. Tiotropium Bromide 1 CAP IH DAILY 5. Acetaminophen 325 650 mg PO Q6H PRN pain Do not take more than ___ mg of acetaminophen in any 24 hour period. 6. Guaifenesin Dextromethorphan 5 mL PO Q6H PRN cough 7. Levofloxacin 500 mg PO DAILY Duration 5 Days RX levofloxacin 500 mg 1 tablet s by mouth daily Disp 5 Tablet Refills 0 8. Benicar olmesartan 20 mg oral DAILY 9. Fish Oil Omega 3 1000 mg PO BID 10. MetFORMIN Glucophage 500 mg PO BID 11. Methotrexate 8 tabs PO QWED Patient does not know strength of tabs. Thinks are 1 mg each for total dose of 8 mg. 12. Naproxen 500 mg PO Q8H PRN pain 13. Os Cal 500 D3 calcium carbonate vitamin D3 500 mg 1 250mg 200 unit oral DAILY 14. Vitamin D 1000 UNIT PO DAILY 15. Tessalon Perles benzonatate 100 mg oral TID PRN cough Duration 3 Days RX benzonatate 100 mg 1 capsule s by mouth TID PRN Disp 9 Capsule Refills 0 Discharge Disposition Home Discharge Diagnosis RML Pneumonia Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Mr. ___ You were admitted to the hospital due to cough and CXR findings concerning for pneumonia. You were started on oral antibiotics levofloxacin and given IV fluids with improvement. You were feeling well on the day of discharge and your vital signs were stable. You are being discharged on the same antibiotic levofloxacin and will need to take this for 5 more days. Please arrange to see your primary care physician ___ 1 week to ensure that your symptoms have resolved upon completion of antibiotics. Please seek immediate medical attention if you develop fevers shaking chills worsening productive cough shortness of breath shortness of breath with exertion or worsening fatigue. As we discussed because of your underlying medical conditions rheumatoid arthritis and diabetes as well as the medication you take for RA methotrexate you are at higher risk for serious infection. As a result if you start feeling unwell despite the antibiotics do not hesitate to seek medical attention. It was a pleasure caring for you while you were in the hospital and we wish you a speedy recovery Sincerely The ___ Medicine Team Followup Instructions ___ The icd codes present in this text will be J189, E119, D649, J45909, I10, M069. The descriptions of icd codes J189, E119, D649, J45909, I10, M069 are J189: Pneumonia, unspecified organism; E119: Type 2 diabetes mellitus without complications; D649: Anemia, unspecified; J45909: Unspecified asthma, uncomplicated; I10: Essential (primary) hypertension; M069: Rheumatoid arthritis, unspecified. The common codes which frequently come are E119, D649, J45909, I10. The uncommon codes mentioned in this dataset are J189, M069.
The icd codes present in this text will be R079, G3184, F22, I2510, Z951, Z955, Z8673, I10, E785, E7800, E119, E669, Z6832, Z87891. The descriptions of icd codes R079, G3184, F22, I2510, Z951, Z955, Z8673, I10, E785, E7800, E119, E669, Z6832, Z87891 are R079: Chest pain, unspecified; G3184: Mild cognitive impairment, so stated; F22: Delusional disorders; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E7800: Pure hypercholesterolemia, unspecified; E119: Type 2 diabetes mellitus without complications; E669: Obesity, unspecified; Z6832: Body mass index [BMI] 32.0-32.9, adult; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I2510, Z951, Z955, Z8673, I10, E785, E119, E669, Z87891. The uncommon codes mentioned in this dataset are R079, G3184, F22, E7800, Z6832. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint chest pain Major Surgical or Invasive Procedure none History of Present Illness Mr. ___ by ___ is a ___ year old man with PMH CVA HTN HLD DM2 diet controlled remote CABG w subsequent occluded grafts s p stents to OM and LAD ___ and dementia who presents with one week intermittent chest pain w rad to left arm. Per history taken in the ED his chest pain is worsened by walking relieved by rest and nitroglycerin. History limited by patient dementia. Patient denies concomitant SOB DOE N V changes in bowel bladder. Of note patient reports tumultuous living condition due to conflict with his landlord. Intermittently endorsing wanting to harm someone but no clear plan. Per review of Atrius records this has been chronic and is being actively worked on by PCP who is involving social work and legal. Per last PCP ___ ___ services has gone into his home which has revealed unusual behavior such as keeping refrigerator locked claiming someone stealing his food claiming strangers come in to use his telephone and he has no phone. Multiple unpaid bills. He is at risk of being evicted because of the disruption his paranoia thoughts are causing to the management of the complex. It appears he may not be safe to be living alone. In the ED initial vitals were 97.8 77 149 84 18 99 RA Exam notable for sating well on RA RRR CTABL no ___ edema AO to person ___ Year ___ Month ___ Date ___ word finding difficulties perseverates on conflict w landlord fixed paranoia NOT aggressive or violent redirectable Labs showed leukopenia to 3.9 Hgb 12.9 plts 201. Chem 7 WNL. Trop negative x1 with another pending on transfer. Imaging showed CXR with Low lung volumes. Subtle left base opacity could be due to atelectasis although infection or aspiration are also in the differential. Received 324 of aspirin Transfer VS were 97.9 75 135 85 19 99 RA ___ cardiology was consulted and agreed with ED plan for nuclear stress test. Psych were consulted for fixed delusions and intent to harm landlord. They recommended Patient does not currently meet ___ criteria Please continue 1 1 sitter to monitor acute agitation and fall prevention For acute agitation that does not respond to verbal redirection can offer PRN Seroquel 25mg BID Patient may benefit from outpatient formal neurocognitive testing for dementia evaluation Decision was made to admit to medicine for further management and for nuclear stress testing. On arrival to the floor patient denies having chest pain. Last chest pain was 3 weeks ago. Was also nauseous 3 weeks ago. He denies SOB. No palpitations. Tangential on history. Stating I don t want to hurt no one. Past Medical History Hypertension essential Cerebrovasc disease Elevated PSA Blood in stool Hypercholesterolemia DM diabetes mellitus type 2 with ophthalmic complications Screening for colon cancer History of coronary artery bypass surgery Obesity MCI mild cognitive impairment Social History ___ Family History Mother died of a heart attack. Otherwise does not know family history. Physical Exam Admission Physical Exam Vital Signs 97.9 155 81 70 18 95 RA General Alert oriented to person place and time. Not oriented to situation no acute distress. HEENT Sclerae 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 or cyanosis. 1 ___ edema bilaterally Neuro CNII XII intact ___ strength upper lower extremities grossly normal sensation gait deferred. No asterixis. Patient mirroring suggestive of frontal release. Psych Tangential speech Discharge Physical Exam Vital Signs 97.5 155 88 66 18 96 RA General Alert oriented to person place and time. Not oriented to situation no acute distress. HEENT Sclerae 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 GU No foley Ext Warm well perfused ___ b l lower extremity edema Neuro CNII XII grossly intact Psych Tangential speech Pertinent Results Admission Labs ___ 07 51PM BLOOD WBC 3.9 RBC 4.38 Hgb 12.9 Hct 39.4 MCV 90 MCH 29.5 MCHC 32.7 RDW 15.6 RDWSD 51.0 Plt ___ ___ 07 51PM BLOOD Neuts 47.5 ___ Monos 13.3 Eos 1.0 Baso 0.5 Im ___ AbsNeut 1.85 AbsLymp 1.46 AbsMono 0.52 AbsEos 0.04 AbsBaso 0.02 ___ 07 51PM BLOOD Glucose 106 UreaN 9 Creat 0.9 Na 142 K 4.2 Cl 105 HCO3 26 AnGap 15 ___ 07 51PM BLOOD cTropnT 0.01 ___ 02 10AM BLOOD cTropnT 0.01 Pertinent Labs ___ 06 15AM BLOOD VitB12 ___ ___ 06 15AM BLOOD TSH 2.5 Imaging ___ CXR Low lung volumes. Subtle left base opacity could be due to atelectasis although infection or aspiration are also in the differential. Posterior to a lower thoracic vertebral body is a radiopaque structure measuring 1.6 x 0.9 cm of unclear etiology but could represent shrapnel. ___ P MIBI The image quality is adequate but limited due to soft tissue attenuation. Resting perfusion images reveal uniform tracer uptake throughout the myocardium. Discharge Labs ___ 06 15AM BLOOD WBC 4.9 RBC 4.11 Hgb 11.9 Hct 36.8 MCV 90 MCH 29.0 MCHC 32.3 RDW 15.5 RDWSD 50.3 Plt ___ ___ 06 15AM BLOOD Glucose 152 UreaN 9 Creat 0.9 Na 142 K 3.9 Cl 106 HCO3 26 AnGap ___ year old man with ___ CVA HTN HLD DM2 diet controlled remote CABG w subsequent occluded grafts s p stents to OM and LAD ___ and cognitive impairment who presents with one week intermittent chest pain and chronic paranoid delusions. CAD Chest pain significant PMH for CAD s p CABG and PCIs. Per history obtained by EMS and ED patient was having active chest pain which prompted his presentation but he denied chest pain on arrival to the floor and could not recall any recent chest pain. Troponin was negative x 2. P MIBI was attempted but after obtaining resting images patient refused further testing and attempted to leave. Continued home aspirin. metoprolol atorvastatin diltiazem Paranoid delusions ongoing issue that is referred to in recent Atrius notes. He was evaluated by psychiatry who did not feel that inpatient psychiatric hospitalization was indicated. They recommended Risperdal with close monitoring of QTc but patient refused. Spoke to patient s PCP ___. Currently he lives alone with meal and homemaking services per elder services and per Dr. ___ has been managing but has come close to eviction in the past. He and others within the ___ system have been working on arranging a more supervised living arrangement. He will follow up with Dr. ___ will continue to process of transitioning to more supervised living situation HTN continued home lisinopril furosemide metoprolol and diltiazem Transitional Issues needs follow up for housing issues TSH RPR B12 pending at discharge consider Risperdal 0.5mg BID per psychiatry recommendations will need monitoring of QTc 30 minutes spent coordinating discharge home Medications on Admission The Preadmission Medication list is accurate and complete. 1. Potassium Chloride 20 mEq PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Metoprolol Succinate XL 200 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Diltiazem Extended Release 180 mg PO DAILY 6. Furosemide 40 mg PO DAILY 7. Nitroglycerin SL 0.4 mg SL Q5MIN PRN chest pain 8. Multivitamins 1 TAB PO DAILY 9. Aspirin EC 325 mg PO DAILY Discharge Medications 1. Aspirin EC 325 mg PO DAILY 2. Atorvastatin 80 mg PO QPM 3. Diltiazem Extended Release 180 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Lisinopril 5 mg PO DAILY 6. Metoprolol Succinate XL 200 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Nitroglycerin SL 0.4 mg SL Q5MIN PRN chest pain 9. Potassium Chloride 20 mEq PO DAILY Hold for K Discharge Disposition Home Discharge Diagnosis Primary Chest pain Secondary Cognitive impairment Psychosis Coronary artery disease chronic Discharge Condition Mental Status Confused always. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Mr. ___ WHY YOU CAME TO THE HOSPITAL You came to the hospital because you were having chest pain WHAT WE DID FOR YOU HERE You had blood tests that showed that you were not having a heart attack WHAT YOU SHOULD DO AFTER LEAVING THE HOSPITAL 1. Please follow up for Dr. ___ see below for your appointment Followup Instructions ___ The icd codes present in this text will be R079, G3184, F22, I2510, Z951, Z955, Z8673, I10, E785, E7800, E119, E669, Z6832, Z87891. The descriptions of icd codes R079, G3184, F22, I2510, Z951, Z955, Z8673, I10, E785, E7800, E119, E669, Z6832, Z87891 are R079: Chest pain, unspecified; G3184: Mild cognitive impairment, so stated; F22: Delusional disorders; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z951: Presence of aortocoronary bypass graft; Z955: Presence of coronary angioplasty implant and graft; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E7800: Pure hypercholesterolemia, unspecified; E119: Type 2 diabetes mellitus without complications; E669: Obesity, unspecified; Z6832: Body mass index [BMI] 32.0-32.9, adult; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I2510, Z951, Z955, Z8673, I10, E785, E119, E669, Z87891. The uncommon codes mentioned in this dataset are R079, G3184, F22, E7800, Z6832.
The icd codes present in this text will be M1612, R55, T8859XA, T4145XA, Y92234, Z7982. The descriptions of icd codes M1612, R55, T8859XA, T4145XA, Y92234, Z7982 are M1612: Unilateral primary osteoarthritis, left hip; R55: Syncope and collapse; T8859XA: Other complications of anesthesia, initial encounter; T4145XA: Adverse effect of unspecified anesthetic, initial encounter; Y92234: Operating room of hospital as the place of occurrence of the external cause; Z7982: Long term (current) use of aspirin. The uncommon codes mentioned in this dataset are M1612, R55, T8859XA, T4145XA, Y92234, Z7982. Allergies Epinephrine Chief Complaint left hip pain Major Surgical or Invasive Procedure ___ left total hip arthroplasty History of Present Illness ___ year old male with history of left hip osteoarthritis present for definitive treatment. Past Medical History OA s p hernia repair remote hx of vasovagal with blood draws Social History ___ Family History Non contributory 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 Incision healing well with staples Scant serosanguinous drainage Thigh full but soft No calf tenderness ___ strength SILT NVI distally Toes warm Pertinent Results ___ 06 15AM BLOOD WBC 7.6 RBC 3.10 Hgb 9.3 Hct 28.8 MCV 93 MCH 30.0 MCHC 32.3 RDW 13.7 RDWSD 46.8 Plt ___ ___ 05 10AM BLOOD WBC 7.6 RBC 3.11 Hgb 9.3 Hct 28.9 MCV 93 MCH 29.9 MCHC 32.2 RDW 13.8 RDWSD 46.9 Plt ___ ___ 05 15AM BLOOD WBC 8.5 RBC 3.55 Hgb 10.7 Hct 32.7 MCV 92 MCH 30.1 MCHC 32.7 RDW 13.8 RDWSD 47.3 Plt ___ ___ 01 29PM BLOOD WBC 5.4 RBC 4.01 Hgb 11.8 Hct 37.0 MCV 92 MCH 29.4 MCHC 31.9 RDW 13.4 RDWSD 45.8 Plt ___ ___ 06 15AM BLOOD Plt ___ ___ 05 10AM BLOOD Plt ___ ___ 05 15AM BLOOD Plt ___ ___ 01 29PM BLOOD Plt ___ ___ 06 15AM BLOOD Glucose 104 UreaN 11 Creat 0.6 Na 138 K 3.6 Cl 101 HCO3 31 AnGap 10 ___ 05 10AM BLOOD Glucose 106 UreaN 13 Creat 0.7 Na 136 K 3.7 Cl 100 HCO3 33 AnGap 7 ___ 05 15AM BLOOD Glucose 127 UreaN 16 Creat 0.7 Na 136 K 3.7 Cl 100 HCO3 28 AnGap 12 ___ 01 29PM BLOOD Glucose 126 UreaN 15 Creat 0.7 Na 137 K 3.9 Cl 104 HCO3 28 AnGap 9 ___ 06 15AM BLOOD Calcium 8.8 Phos 2.8 Mg 2.0 ___ 05 10AM BLOOD Calcium 8.3 Phos 2.6 Mg 1.9 ___ 05 15AM BLOOD Calcium 8.5 Phos 3.7 Mg 1.9 ___ 01 29PM BLOOD Calcium 8.6 Phos 3.4 Mg 2.0 Brief Hospital Course The patient was admitted to the orthopedic 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. Following the placement of the spinal by anesthesia patient had a suspected vaso vagal episode with lightheadedness bradycardia and hypotension. During this time he complained of mid chest pressure no pain . Responded to ephedrine and glycopyrrolate with improvement in hemodynamics and resolution of symptoms. Rest of case was uneventful. He was monitored on continuous O2 monitoring telemetry. The patient s urine looked cloudy. His urine tests came back negative for an infection. Otherwise pain was controlled with a combination of IV and oral pain medications. The patient received lovenox for DVT prophylaxis starting on the morning of POD 1. The foley was removed and the patient was voiding independently thereafter. The overlying dressing was removed on POD 2 and the Silverlon dressing was found to be clean and dry. 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 wound was benign. The patient s weight bearing status is weight bearing as tolerated on the operative extremity with posterior precautions. Walker or two crutches at all times for 6 weeks. Mr. ___ is discharged to home with services in stable condition. Medications on Admission 1. Acetaminophen ___ mg PO Q8H PRN pain 2. Aspirin 81 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Naproxen 220 mg PO PRN pain 5. Fish Oil Omega 3 Dose is Unknown PO Frequency is Unknown Discharge Medications 1. Aspirin 81 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Senna 8.6 mg PO BID 4. Enoxaparin Sodium 40 mg SC DAILY Duration 28 Days Start ___ First Dose First Routine Administration Time 5. Docusate Sodium 100 mg PO BID 6. Acetaminophen 1000 mg PO Q8H 7. OxycoDONE Immediate Release ___ mg PO Q4H PRN Pain 8. Fish Oil Omega 3 1000 mg PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis left hip 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 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. Please DO NOT take any non steroidal anti inflammatory medications NSAIDs such as Celebrex ibuprofen Advil Aleve Motrin naproxen etc . 8. ANTICOAGULATION Please continue your Lovenox for four 4 weeks to help prevent deep vein thrombosis blood clots . If you were taking aspirin prior to your surgery it is OK to continue at your previous dose while taking anticoagulation medication. ___ STOCKINGS x 6 WEEKS. 9. WOUND CARE It is okay to shower five days after surgery but no tub baths swimming or submerging your incision until after your four 4 week checkup. You may place a dry sterile dressing on the wound otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two 2 weeks. 10. ___ once at home Home ___ dressing changes as instructed wound checks and staple removal at two weeks after surgery. 11. ACTIVITY Weight bearing as tolerated with walker or 2 crutches at all times for six weeks. Posterior precautions. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy Weight bearing as tolerated with walker or 2 crutches at all times for six weeks. Posterior precautions. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Treatments Frequency daily dressing changes as needed for drainage wound checks daily ice TEDs staple removal and replace with steri strips on POD 14 at ___ Followup Instructions ___ The icd codes present in this text will be M1612, R55, T8859XA, T4145XA, Y92234, Z7982. The descriptions of icd codes M1612, R55, T8859XA, T4145XA, Y92234, Z7982 are M1612: Unilateral primary osteoarthritis, left hip; R55: Syncope and collapse; T8859XA: Other complications of anesthesia, initial encounter; T4145XA: Adverse effect of unspecified anesthetic, initial encounter; Y92234: Operating room of hospital as the place of occurrence of the external cause; Z7982: Long term (current) use of aspirin. The uncommon codes mentioned in this dataset are M1612, R55, T8859XA, T4145XA, Y92234, Z7982.
The icd codes present in this text will be R0600, M314, M4854XA, Z6842, D869, I272, M4800, Z23, E039, R591, G629, K219, N393, H9319, F329, E6601, G4733, Z950. The descriptions of icd codes R0600, M314, M4854XA, Z6842, D869, I272, M4800, Z23, E039, R591, G629, K219, N393, H9319, F329, E6601, G4733, Z950 are R0600: Dyspnea, unspecified; M314: Aortic arch syndrome [Takayasu]; M4854XA: Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture; Z6842: Body mass index [BMI] 45.0-49.9, adult; D869: Sarcoidosis, unspecified; I272: Other secondary pulmonary hypertension; M4800: Spinal stenosis, site unspecified; Z23: Encounter for immunization; E039: Hypothyroidism, unspecified; R591: Generalized enlarged lymph nodes; G629: Polyneuropathy, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; N393: Stress incontinence (female) (male); H9319: Tinnitus, unspecified ear; F329: Major depressive disorder, single episode, unspecified; E6601: Morbid (severe) obesity due to excess calories; G4733: Obstructive sleep apnea (adult) (pediatric); Z950: Presence of cardiac pacemaker. The common codes which frequently come are E039, K219, F329, G4733. The uncommon codes mentioned in this dataset are R0600, M314, M4854XA, Z6842, D869, I272, M4800, Z23, R591, G629, N393, H9319, E6601, Z950. Allergies codeine Chief Complaint dyspnea Major Surgical or Invasive Procedure none History of Present Illness ___ y o female with a past medical history significant for sarcoidosis c b neuropathy wide complex tachycardia and paroxysmal AV block s p PPM in ___ spinal stenosis obesity and hypothyroidism presenting with dyspnea. She notes ___ weeks of increased dyspnea on exertion. She is short of breath with small amounts of walking. She is not short of breath at rest. She is able to lie flat but notes that she is undergoing testing for sleep apnea in the near future given concern of her husband that she has heavy breathing at night. At the direction of her outpatient Neurologist she underwent outpatient chest CT on ___. This showed stable mediastinal adenopathy but abnormal wall thickening of the right brachiocephalic artery and ascending aorta which can be seen with ___ s arteritis. Her Neurologist directed the patient to ___ ED for admission for further evaluation. She recommended ECHO and possible CTA to rule out pulmonary embolism. Regarding the patient s sarcodiosis history she was hospitalized in ___ for workup of extensive paraspinal cervical parasplenic and mediastinal lymphadenopathy found on CT while being worked up by her neurologist for limb paresthesias numbness and gait disturbance. More specifically multiple CTs revealed cervical and mediastinal lymphadenopathy and a PET scan on ___ was concerning for lymphoma with possible cord involvment compression. MRI ___ revealed significant brain and cord involvement with concern for cord compression at C3 and T8 despite absence of clinical findings. She underwent mediastinoscopy for biopsy and tissue and the pathology was c w sarcoidosis. She was given IV pulse methylprednisolone x3 days and discharged on 50mg PO. LP for CSF evaluation was unable to be performed ___ risk of herniation. She also had gait problems during that hospitalization thought to be related to spinal stenosis. In the ED initial vitals were 97.1 88 143 61 18 100 RA Labs notable 9.7 13.2 40 8 174 MCV 103 88.5 neuts ___ 9.8 PTT 26.7 INR 0.9 Bicarb 21 BUN Cr ___ Bland U A Lactate 2.6 ProBNP 82 Upon arrival to the floor she is without complaints. She also notes that she has had several days of a cough that is mildly productive of white sputum. She has had no fevers. Her daughter and several co workers have had upper respiratory infections. Past Medical History Wide complex tachycardia pacemaker in ___ Hypothyroidism Lymphadenopathy GERD gastroesophageal reflux disease on pantoprazole SUI stress urinary incontinence female Tinnitus Depression Adenomatous colon polyp due ___ Genital herpes Obesity morbid THYROID DISEASE polycysitc ovaries Social History ___ Family History Brother DM Father Died of lung cancer MGF Heart disease MGM Lung cancer PGM Aneurysm PGF Stomach cancer Physical Exam ADMISSION PHYSICAL EXAM Vital Signs 98.9 160 76 93 20 95 on room air Resting HR 80 90ss O2 sat 95 96 on room air Ambulation HR 90 100s O2 sat 94 95 on room air General Alert oriented no acute distress. Prominent cushinoid appearance. HEENT Sclera anicteric MMM oropharynx clear EOMI PERRL NECK supple JVP not elevated no LAD CV Regular rate and rhythm no murmurs Lungs Distant breath sounds but few wheezes appreciated Abdomen Soft non tender non distended bowel sounds present no organomegaly no rebound or guarding GU No foley Ext Warm well perfused no edema Neuro CNII XII intact ___ strength upper lower extremities no focal deficits DISCHARGE PHYSICAL EXAM Vitals Tm 98.7 Tc 98.7 ___ 20 97 RA General Alert oriented no acute distress. Prominent cushinoid appearance. HEENT Sclera anicteric conjunctivae noninjected MMM oropharynx clear alopecia NECK supple JVP difficult to appreciate secondary to body habitus no LAD CV Regular rate and rhythm no murmurs Lungs CTAB no wheezes rales rhonchi appreciated Abdomen Soft non tender non distended bowel sounds present GU No foley Ext Warm well perfused ___ pitting edema to knee Neuro MAE no focal deficits Pertinent Results ADMISSION LABS ___ 04 00PM URINE BLOOD NEG NITRITE NEG PROTEIN NEG GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 7.0 LEUK NEG ___ 04 00PM URINE COLOR Straw APPEAR Clear SP ___ ___ 05 40PM ___ PTT 26.7 ___ ___ 05 40PM PLT COUNT 174 ___ 05 40PM NEUTS 88.5 LYMPHS 6.0 MONOS 4.1 EOS 0.1 BASOS 0.1 IM ___ AbsNeut 8.60 AbsLymp 0.58 AbsMono 0.40 AbsEos 0.01 AbsBaso 0.01 ___ 05 40PM WBC 9.7 RBC 3.97 HGB 13.2 HCT 40.8 MCV 103 MCH 33.2 MCHC 32.4 RDW 13.5 RDWSD 50.4 ___ 05 40PM proBNP 82 ___ 05 40PM GLUCOSE 142 UREA N 15 CREAT 0.7 SODIUM 139 POTASSIUM 4.2 CHLORIDE 104 TOTAL CO2 21 ANION GAP 18 ___ 05 54PM LACTATE 2.6 STUDIES ___ Chest X ray Moderate cardiomegaly is stable. Pacer leads are in standard position. The lungs are clear. There is no pneumothorax or pleural effusion. ___ TTE Very poor image quality unable to perform bubble study due to poor echo windows . The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function LVEF 55 . There is no ventricular septal defect. 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. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study images reviewed of ___ no clear change. ___ MRA chest 1. Subacute compression fracture of the T8 vertebral body with greater than 50 loss of height new since ___. 2. Mild thickening along the proximal right subclavian artery has imaging features most consistent with fibrosis and healing likely from prior vasculitis rather than active inflammation. There is no luminal narrowing. 3. Resolution of ascending thoracic aortic wall thickening with normal appearance of the wall and no luminal narrowing consistent with resolution of previously seen extensive inflammatory changes on the prior FDG PET CT. MICROBIOLOGY ___ BLOOD CULTURE negative DISCHARGE LABS ___ 06 14AM BLOOD WBC 8.1 RBC 4.06 Hgb 13.4 Hct 43.3 MCV 107 MCH 33.0 MCHC 30.9 RDW 13.9 RDWSD 54.4 Plt ___ ___ 06 14AM BLOOD Glucose 72 UreaN 12 Creat 0.8 Na 143 K 4.0 Cl 103 HCO3 30 AnGap 14 ___ 06 14AM BLOOD Calcium 9.9 Phos 4.0 Mg 2.___ is a ___ year old woman with a past medical history significant for sarcoidosis c b wide complex tachycardia and paroxysmal AV block s p PPM in ___ obesity and hypothyroidism who presented with dyspnea. Investigations Interventions 1. Dyspnea Patient presenting with 2 weeks of worsened dyspnea on exertion. She had an outpatient CT chest which showed stable adenopathy but new abnormal wall thickening of the right brachiocephalic artery and ascending aorta which was concern for ___ s arteritis. She had an MRA which was more consistent with sarcoidosis than ___ s however and changes were noted to be more fibrotic and chronic than acute. ACE level was 20 down from 30 in ___. A TTE was done to evaluate for pulmonary hypertension but unfortunately due to poor windows was unable to do so. She did have normal EF and no significant valvular disease. Her dyspnea may represent worsening sarcoidosis. Her outpatient rheumatologist had been considering initiating infliximab she is currently on prednisone and MMF . She was seen by rheumatology as an inpatient but decisions about further treatment of her sarcoidosis were deferred to her outpatient provider Dr. ___. She may also benefit from PFTs and sleep study as an outpatient as she was noted to desaturate at night but never during the day. Pt had slight expiratory wheeze on exam so was discharged with albuterol inhaler with plan for outpatient PFTs 2. Compression Fracture No notable abnormalities on neuro exam but pt did have mild pain in the corresponding area. Likely ___ chronic prednisone use and therefore downtitration should be considered as well as treatment of osteoporosis with bisphosphonate and Ca Vitamin D. Transitional issues Patient found to have a mid thoracic compression fracture on MRA from ___ seen on outside CT but not present on MRI from ___. Thus needs outpatient osteoporosis workup and treatment bisphosphonate calcium vitamin D Patient had normal oxygen saturations during the day both at rest and with ambulation however she desaturated transiently to the high ___ while sleeping. She is encouraged to follow up as scheduled for an outpatient sleep study. Pt would benefit from outpatient PFTs as had slight expiratory wheeze on exam CODE Full code CONTACT ___ husband ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Timolol Maleate 0.25 2 DROP BOTH EYES BID 2. Pantoprazole 20 mg PO Q24H 3. Sulfameth Trimethoprim SS 1 TAB PO DAILY 4. PredniSONE 40 mg PO DAILY 5. Mycophenolate Mofetil 1000 mg PO BID 6. Gabapentin 600 mg PO QAM 7. Gabapentin 900 mg PO QHS 8. Levothyroxine Sodium 150 mcg PO DAILY 9. urea 40 topical BID 10. Docusate Sodium 100 mg PO BID 11. Senna 8.6 mg PO BID 12. Acyclovir 400 mg PO Q12H 13. Metoprolol Succinate XL 100 mg PO QHS 14. Vitamin D 1000 UNIT PO DAILY 15. Multivitamins 1 TAB PO DAILY Discharge Medications 1. Acyclovir 400 mg PO Q12H 2. PredniSONE 40 mg PO DAILY 3. Gabapentin 600 mg PO QAM 4. Gabapentin 900 mg PO QHS 5. Levothyroxine Sodium 150 mcg PO DAILY 6. Metoprolol Succinate XL 100 mg PO QHS 7. Multivitamins 1 TAB PO DAILY 8. Mycophenolate Mofetil 1000 mg PO BID 9. Pantoprazole 20 mg PO Q24H 10. Senna 8.6 mg PO BID 11. Sulfameth Trimethoprim SS 1 TAB PO DAILY 12. Timolol Maleate 0.25 2 DROP BOTH EYES BID 13. Vitamin D 1000 UNIT PO DAILY 14. Docusate Sodium 100 mg PO BID 15. urea 40 topical BID 16. Albuterol Inhaler ___ PUFF IH Q6H PRN SOB RX albuterol sulfate ProAir HFA 90 mcg 2 puff INH q6h prn Disp 1 Inhaler Refills 0 17. Lidocaine 5 Patch 1 PTCH TD QAM 18. Lidocaine 5 Ointment 1 Appl TP DAILY RX lidocaine 5 Apply to painful area of back Daily Refills 0 RX lidocaine 5 Apply to painful area of back for 12 hours Daily Disp 30 Patch Refills 0 Discharge Disposition Home Discharge Diagnosis Primary diagnoses Dyspnea Sarcoidosis Vertebral Compression Fracture Secondary diagnoses Hypothyroidism Gastroesophageal reflux disease Depression Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were hospitalized because you were having trouble breathing. Unfortunately we are not sure what was causing your symptoms. Before coming into the hospital you had imaging of your lungs and chest a CT scan which showed some changes in your aorta the major blood vessel leaving your heart which were concerning for an inflammatory condition called arteritis. You had an MRI that did not show any evidence of arteritis but it did show possible chronic changes due to your sarcoid. Your shortness of breath may be due to your sarcoidosis asthma or sleep apnea. You should follow up with your rheumatologist after you leave the hospital and you may need additional testing of your lung function and sleep study. You will also need to follow up with your rheumatologist regarding your compression fracture in your spine as it is likely caused by your chronic prednisone use. 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 R0600, M314, M4854XA, Z6842, D869, I272, M4800, Z23, E039, R591, G629, K219, N393, H9319, F329, E6601, G4733, Z950. The descriptions of icd codes R0600, M314, M4854XA, Z6842, D869, I272, M4800, Z23, E039, R591, G629, K219, N393, H9319, F329, E6601, G4733, Z950 are R0600: Dyspnea, unspecified; M314: Aortic arch syndrome [Takayasu]; M4854XA: Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture; Z6842: Body mass index [BMI] 45.0-49.9, adult; D869: Sarcoidosis, unspecified; I272: Other secondary pulmonary hypertension; M4800: Spinal stenosis, site unspecified; Z23: Encounter for immunization; E039: Hypothyroidism, unspecified; R591: Generalized enlarged lymph nodes; G629: Polyneuropathy, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; N393: Stress incontinence (female) (male); H9319: Tinnitus, unspecified ear; F329: Major depressive disorder, single episode, unspecified; E6601: Morbid (severe) obesity due to excess calories; G4733: Obstructive sleep apnea (adult) (pediatric); Z950: Presence of cardiac pacemaker. The common codes which frequently come are E039, K219, F329, G4733. The uncommon codes mentioned in this dataset are R0600, M314, M4854XA, Z6842, D869, I272, M4800, Z23, R591, G629, N393, H9319, E6601, Z950.
The icd codes present in this text will be R591, R5383, R634, R079, Z23. The descriptions of icd codes R591, R5383, R634, R079, Z23 are R591: Generalized enlarged lymph nodes; R5383: Other fatigue; R634: Abnormal weight loss; R079: Chest pain, unspecified; Z23: Encounter for immunization. The uncommon codes mentioned in this dataset are R591, R5383, R634, R079, Z23. Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Fatigue weight loss and chest pain Major Surgical or Invasive Procedure None History of Present Illness Mr. ___ is a ___ man with no past medical history who presents with two months of B symptoms found to have significant chest and mesenteric LAD c w lymphoma. He was in his normal state of health until about two months ago when he began to develop fevers chills and a significant amount of weight loss almost 40 lbs. In the past several weeks he has developed increasing chest pain and right arm pain. He had an MRI today which showed lymphadenopathy and was referred to the ED. In our emergency room labs were normal. He had a CT of his chest which showed 1. Extensive mediastinal bilateral hilar and paraesophageal lymphadenopathy. Differential considerations include lymphoma or metastatic disease. Right paratracheal station nodal conglomerate measures up to 3.5 cm and causes mild narrowing of the mid SVC without occlusion. 2. Bilateral pulmonary nodules measuring up to 8 mm. 3. Mildly enlarged mesenteric lymph node in the left mid abdomen. No other evidence of malignancy in the abdomen or pelvis. Patient therefore admitted to medicine. ROS Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative. Past Medical History None Social History ___ Family History No family history of malignancy. Physical Exam ADMISSION EXAM VITALS 98.6 PO 107 71 56 18 94 RA GENERAL Alert and in no apparent distress 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 LYMPH no cervical supraclavicular and pelvis lymphadenopathy GU No suprapubic fullness or 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 Pertinent Results ADMISSION LABS ___ 11 50AM WBC 5.2 RBC 5.03 HGB 15.3 HCT 46.1 MCV 92 MCH 30.4 MCHC 33.2 RDW 12.6 RDWSD 41.9 ___ 11 50AM NEUTS 56.4 ___ MONOS 15.0 EOS 1.0 BASOS 0.8 IM ___ AbsNeut 2.91 AbsLymp 1.37 AbsMono 0.77 AbsEos 0.05 AbsBaso 0.04 ___ 11 50AM PLT COUNT 202 ___ 11 50AM ___ PTT 28.3 ___ ___ 11 50AM RET AUT 1.6 ABS RET 0.08 ___ 11 50AM GLUCOSE 94 UREA N 14 CREAT 1.1 SODIUM 141 POTASSIUM 4.5 CHLORIDE 103 TOTAL CO2 27 ANION GAP 11 ___ 11 50AM CALCIUM 9.5 PHOSPHATE 3.2 MAGNESIUM 2.0 URIC ACID 7.4 ___ 11 50AM LD LDH 168 ___ 11 57AM CREAT 1.0 K 4.0 ___ 03 10PM URINE COLOR Straw APPEAR Clear SP ___ ___ 03 10PM URINE BLOOD NEG NITRITE NEG PROTEIN TR GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 7.0 LEUK NEG ___ 03 10PM URINE RBC 1 WBC 1 BACTERIA NONE YEAST NONE EPI 0 IMAGING EXAMINATION CT CHEST ABDOMEN PELVIS INDICATION History ___ with 1 month of night sweats and weight loss incidentally found to have mediastinal adenopathy on cervical spine MRI. Further evaluate mediastinal adenopathy seen on earlier MRI of the cervical spine at ___ ___. Evaluate for evidence of other adenopathy SVC syndrome. TECHNIQUE MDCT axial images were acquired through the chest abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was not administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE Total DLP Body 1 018 mGy cm. COMPARISON None. FINDINGS CHEST HEART AND VASCULATURE The thoracic aorta is normal in caliber. The heart pericardium and great vessels are within normal limits. No pericardial effusion is seen. There is mild narrowing of the midportion of the SVC by mediastinal lymphadenopathy without occlusion. There is also mild narrowing of the right upper lobar artery by hilar lymphadenopathy. AXILLA HILA AND MEDIASTINUM No axillary lymphadenopathy is present. Extensive supraclavicular mediastinal and bilateral hilar adenopathy is demonstrated with index lesions as follows 1.6 cm left supraclavicular lymph node 2 7 . 3.5 x 2.8 cm right paratracheal nodal mass 02 21 . 2.1 cm left hilar lymph node 02 30 . 1.9 cm right hilar lymph node 02 34 . 4.3 x 2.5 cm subcarinal nodal mass 02 30 . PLEURAL SPACES No pleural effusion or pneumothorax. LUNGS AIRWAYS Multiple pulmonary nodules are visualized bilaterally. For example a right upper lobe nodule measures 8 mm 02 32 a right lower lobe nodule measures 6 mm 02 44 a left upper lobe nodule measures 7 mm 02 19 and a subpleural posterior left lower lobe nodule measures 4 mm 02 38 . Additional scattered and smaller pulmonary nodules are visualized bilaterally. No focal consolidations are identified. The airways are patent to the level of the segmental bronchi bilaterally. BASE OF NECK The thyroid is unremarkable. ABDOMEN HEPATOBILIARY The liver demonstrates homogenous attenuation throughout. There is no evidence of focal lesion. There is no evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder is within normal limits. PANCREAS The pancreas has normal attenuation throughout without evidence of focal lesions or pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN The spleen shows normal size and attenuation throughout without evidence of focal lesion. ADRENALS The right and left adrenal glands are normal in size and shape. URINARY The kidneys are of normal and symmetric size with normal nephrogram. There is no evidence of focal renal lesions or hydronephrosis. There is no perinephric abnormality. GASTROINTESTINAL The stomach is unremarkable. Small bowel loops demonstrate normal caliber wall thickness and enhancement throughout. The colon and rectum are within normal limits. The appendix is not visualized. PELVIS The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS The prostate and seminal vesicles are unremarkable. LYMPH NODES There is a distal paraesophageal nodal conglomerate measuring 3.3 x 2.1 cm and a 8 mm in short axis lymph node near the gastroesophageal junction 02 53 . There is a mildly enlarged 8 mm lymph node in the left mid abdomen 2 73 . Other small mesenteric and retroperitoneal lymph nodes are not enlarged by CT size criteria. There is no pelvic or inguinal lymphadenopathy. VASCULAR The abdominal aorta and IVC are normal in course and caliber. BONES There is no acute fracture. No focal suspicious osseous abnormality. SOFT TISSUES The abdominal and pelvic wall is within normal limits. IMPRESSION 1. Extensive mediastinal bilateral hilar and paraesophageal lymphadenopathy. Differential considerations include lymphoma or metastatic disease. Right paratracheal station nodal conglomerate measures up to 3.5 cm and causes mild narrowing of the mid SVC without occlusion. 2. Bilateral pulmonary nodules measuring up to 8 mm. 3. Mildly enlarged mesenteric lymph node in the left mid abdomen. No other evidence of malignancy in the abdomen or pelvis. Brief Hospital Course Assessment ___ man with no significant PMHx who was referred to ED after an outpatient MRI of the spine ordered for pinched nerve showed extensive thoracic lymphadenopathy. Upon further questioning patient also notes few months of increased chills denies fevers weight loss of 20 lbs and mild dyspnea with strenuous activity. Clinical picture and imaging concerning for lymphoma. Brief Hospital Course Lymphadenopathy concerning for lymphoma The patient was admitted to medicine for further work up. Chest CT as above showed extensive supraclavicular mediastinal and bilateral hilar adenopathy an enlarged mesenteric lymph node in the left mid abdomen. It also showed right paratracheal nodal conglomerate measures up to 3.5 cm which was causing mild narrowing of the mid SVC without occlusion. Acute Care Surgery and Interventional Pulmonology were consulted for lymph node biopsy. Surgery felt excisional biopsy of the cervical lymph nodes may be difficult to perform and recommended endobronchial biopsy. IP evaluated the patient and scheduled him for flexible bronchoscopy EBUS TBNA with lymphoma protocol for diagnosis on ___. The patient was adamant about leaving the hospital to be home for ___ and did not want to stay for the biopsy while hospitalized. He had no symptoms of TLS or SVC syndrome. He was counseled on warning signs that would indicate he needed to return to the hospital sooner. He will follow up with his PCP ___ ___ and with IP for procedure on ___ as above. Hematology Oncology was not formally consulted but the case was discussed with them over the phone. TRANSITIONAL ISSUES Needs lymph node biopsy schedule for core biopsy with IP on ___ Medications on Admission None Discharge Medications None Discharge Disposition Home Discharge Diagnosis Mediastinal lymphadenopathy Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You came to the hospital with abnormal findings on an outpatient MRI. You had a CT scan of the chest abdomen and pelvis which showed swelling in the lymph nodes. You were seen by our surgery team and our interventional pulmonology team. You will need a biopsy of one of these lymph nodes. The Interventional Pulmonology team will call you with the time of the biopsy. It is tentatively scheduled for ___. Please follow up with your PCP as below. Please call your doctor or return to the hospital if you develop shortness of breath chest pain cough headache lightheadedness face or arm swelling abnormal bleeding vision change. Followup Instructions ___ The icd codes present in this text will be R591, R5383, R634, R079, Z23. The descriptions of icd codes R591, R5383, R634, R079, Z23 are R591: Generalized enlarged lymph nodes; R5383: Other fatigue; R634: Abnormal weight loss; R079: Chest pain, unspecified; Z23: Encounter for immunization. The uncommon codes mentioned in this dataset are R591, R5383, R634, R079, Z23.
The icd codes present in this text will be I481, T8111XA, J9601, I97710, Z7901, Y840, Y92238, Z5309, J439, Z9981, E1122, I129, N189, Z9181, E785, G8929, M549, F329, Z8701, G540, H5461, M3219, G4733, I341, M797, Z981, Z87891, R911, Z006. The descriptions of icd codes I481, T8111XA, J9601, I97710, Z7901, Y840, Y92238, Z5309, J439, Z9981, E1122, I129, N189, Z9181, E785, G8929, M549, F329, Z8701, G540, H5461, M3219, G4733, I341, M797, Z981, Z87891, R911, Z006 are I481: Persistent atrial fibrillation; T8111XA: Postprocedural cardiogenic shock, initial encounter; J9601: Acute respiratory failure with hypoxia; I97710: Intraoperative cardiac arrest during cardiac surgery; Z7901: Long term (current) use of anticoagulants; 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; Y92238: Other place in hospital as the place of occurrence of the external cause; Z5309: Procedure and treatment not carried out because of other contraindication; J439: Emphysema, unspecified; Z9981: Dependence on supplemental oxygen; 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; Z9181: History of falling; E785: Hyperlipidemia, unspecified; G8929: Other chronic pain; M549: Dorsalgia, unspecified; F329: Major depressive disorder, single episode, unspecified; Z8701: Personal history of pneumonia (recurrent); G540: Brachial plexus disorders; H5461: Unqualified visual loss, right eye, normal vision left eye; M3219: Other organ or system involvement in systemic lupus erythematosus; G4733: Obstructive sleep apnea (adult) (pediatric); I341: Nonrheumatic mitral (valve) prolapse; M797: Fibromyalgia; Z981: Arthrodesis status; Z87891: Personal history of nicotine dependence; R911: Solitary pulmonary nodule; Z006: Encounter for examination for normal comparison and control in clinical research program. The common codes which frequently come are J9601, Z7901, E1122, I129, N189, E785, G8929, F329, G4733, Z87891. The uncommon codes mentioned in this dataset are I481, T8111XA, I97710, Y840, Y92238, Z5309, J439, Z9981, Z9181, M549, Z8701, G540, H5461, M3219, I341, M797, Z981, R911, Z006. Allergies tofu moxifloxacin Chief Complaint DOE Major Surgical or Invasive Procedure Aborted ___ occlusion device implant ___ CPR ___ Intubation ___ History of Present Illness ___ woman with atrial fib flutters s p AVNRT ablation ___ COPD on home 3L and diabetes now s p failed ___ device procedure c b episode of pulseless who is transferred to the CCU as remain intubated for airway protection. Given a history of falls she was anticoagulated with coumadin and plan for ___ device placement. This decision was made after recent admission to ___ for dyspnea found to have acute on chronic COPD exacerbation and atrial fibrillation with rapid ventricular response. Prior to this her metoprolol dose had been decreased to 25 mg twice a day. On discharge she was started on diltiazem 120 mg p.o. daily. In the past diltiazem had thought to cause lightheadedness falling and questionable syncopal episodes. As such she never started diltiazem. Per report she refused thromboembolic prophylaxis with anticoagulation as such her aspirin dose was increased from 81 mg to 325 daily. Since the time of discharge she was sent to rehab and was there until 10 days prior ___ . During attempted ___ on ___ underwent general anesthesia with 14 sheath and left arterial line. Once transeptal attempted device placement x2 which failed she then became hypotensive bradycardic ST elevation in inferior leads with suspected air embolism to RCA. While in atrial fibrillation with profound bradycardia there was concern for loss of pulse epinephrine was given then CPR performed for 3min after repeat epi regained pulse. She received 1L NS. A third trial of ___ device placement was attempted but failed. ___ femoral sheath in right was closed. Left aline remained in place L antecubital PIV in place. She arrived on propofol 20 mcg kg min and phenylephrine 0.3 mcg kg min. On arrival to the CCU she is intubated but responsive mouthing words to simple commands including taking deep breath sticking out tongue squeezing fingers. Past Medical History 1. HTN 2. Hypercholesterolemia 3. chronic back pain 4. COPD emphysema 5. C spine disc disease 6. Depression 7. pneumonia ___. Right brachial plexus neuropathy 9. Right eye with decreased vision macular degeneration 10. SLE severe ophthalmopathy diffuse arthropathy 11. OSA cpap 12. MVP 13. Fibromyalgia PSH 1. S P B L cataracts 2. S P C4 5 fusion 3. S P multiple skin Ca exc both squamous and basal cell Social History ___ Family History Significant for an uncle with diabetes. Physical Exam ADMISSION PHYSICAL GENERAL Intubated no distress RASS ___ HEENT Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. NECK Supple. JVP flat. CARDIAC Irregular no murmurs nor rubs appreciated LUNGS equal breath sounds with no crackles nor rhonchi appreacited 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 97.9 Tm 98.7 BP 160 93 129 160 72 97 HR 73 72 87 RR 16 ___ O2 sat 94 94 100 O2 delivery 3L GENERAL sitting up in bed HEENT Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. NECK Supple. JVP flat. CARDIAC Irregular no murmurs nor rubs appreciated LUNGS equal breath sounds with no crackles nor rhonchi appreacited 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 ___ 09 33PM GLUCOSE 173 UREA N 11 CREAT 0.8 SODIUM 142 POTASSIUM 3.7 CHLORIDE 103 TOTAL CO2 24 ANION GAP 15 ___ 09 33PM estGFR Using this ___ 09 33PM CK MB 7 cTropnT 0.14 ___ 09 33PM CALCIUM 8.4 PHOSPHATE 3.7 MAGNESIUM 1.9 ___ 09 33PM WBC 8.2 RBC 3.41 HGB 10.2 HCT 31.8 MCV 93 MCH 29.9 MCHC 32.1 RDW 14.3 RDWSD 48.9 ___ 09 33PM PLT COUNT 266 ___ 03 09PM TYPE ART PO2 119 PCO2 57 PH 7.32 TOTAL CO2 31 BASE XS 1 ___ 02 16PM TYPE ART PO2 83 PCO2 64 PH 7.29 TOTAL CO2 32 BASE XS 1 ___ 02 16PM LACTATE 1.2 ___ 02 16PM freeCa 1.14 ___ 02 00PM GLUCOSE 123 UREA N 12 CREAT 0.7 SODIUM 141 POTASSIUM 4.0 CHLORIDE 102 TOTAL CO2 27 ANION GAP 12 ___ 02 00PM CK CPK 69 ___ 02 00PM CK MB 6 cTropnT 0.13 ___ 02 00PM CALCIUM 8.0 PHOSPHATE 4.8 MAGNESIUM 1.9 ___ 02 00PM WBC 9.7 RBC 3.40 HGB 9.9 HCT 31.9 MCV 94 MCH 29.1 MCHC 31.0 RDW 14.0 RDWSD 47.6 ___ 02 00PM PLT COUNT 312 ___ 10 12AM TYPE ART PO2 434 PCO2 55 PH 7.27 TOTAL CO2 26 BASE XS 2 INTUBATED INTUBATED ___ 10 12AM GLUCOSE 239 NA 138 K 2.9 CL 104 ___ 10 12AM HGB 10.1 calcHCT 30 ___ 06 45AM ___ PERTINENT LABS ___ 02 00PM BLOOD CK MB 6 cTropnT 0.13 ___ 09 33PM BLOOD CK MB 7 cTropnT 0.14 ___ 02 00PM BLOOD CK CPK 69 MICRO None STUDIES TEE ___ TEE for Procedural Guidance during ___ Procedure 1. Mild spontaneous echo contrast is seen in the body of the left atrium. No mass thrombus is seen in the left atrium or left atrial appendage. Left atrial appendage flow velocity 0.27 m s 2. ___ neck and length measured at 0 degrees 45 90 and 135 and discussed with ___ device representatives Dr. ___ ___ Dr. ___. Maximum orifice diameter 1.9 cm depth 2.5 cm. Appenadge has at least two lobes. 3D view of demonstrates elliptical shaped orifice. 3. Overall left ventricular systolic function is low normal LVEF 50 55 . 4. There is mild global RV free wall hypokinesis. 5. There are focal calcifications in the aortic arch as well as simple atheroma in the arch and descending aorta. 6. There are three aortic valve leaflets. 7. There is a very small pericardial effusion. CXR ___ ET tube tip is 5.5 cm above the carina. Heart size and mediastinum are unchanged in appearance. Right mediastinal shift is stable. Hyperinflation in the upper lungs is demonstrated as well as evidence of previous right upper lobectomy. No new consolidations demonstrated. No definitive evidence of new rib fractures demonstrated on this non dedicated radiograph. TTE ___ The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy 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 55 60 . There is no resting left ventricular outflow tract gradient. 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. The aortic valve leaflets appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild 1 tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION Adequate image quality. Mild symmetric left ventricular hypertrophy with normal cavity size and regional global systolic function. MIld global RV systolic dysfunction. Moderate pulmonary artery systolic hypertension. DISCHARGE LABS ___ 06 30AM BLOOD WBC 7.2 RBC 3.48 Hgb 10.2 Hct 33.3 MCV 96 MCH 29.3 MCHC 30.6 RDW 14.3 RDWSD 50.3 Plt ___ ___ 06 30AM BLOOD ___ PTT 31.4 ___ ___ 06 30AM BLOOD Glucose 130 UreaN 9 Creat 0.7 Na 143 K 4.1 Cl 101 HCO3 28 AnGap 14 ___ 06 30AM BLOOD Calcium 8.8 Phos 3.6 Mg 2.___ woman with persistent atrial fib flutter AVNRT s p ablation ___ COPD on home 3L admitted for ___ device placement. Procedure was c b PEA arrest and was not completed. Patient was quickly resuscitated and briefly admitted to the CCU. She was discharged at baseline functional status on her prior rate rhythm control agents and warfarin. ACUTE ISSUES PEA Arrest Shock Pt experienced PEA arrest in dueing attempted implantion of ___ device and underwent 3 min of chest compressions and treatment with epinephrine after which ROSC was achieved. Cause of arrest may have been severe vasovagal vs air embolism in coronary artery. After ROSC she was hypotensive requiring phenylephrine. Pressor requirement post procedurally was in setting of propofol. Successfully weaned of vasopressors after extubation. Her neuro exam was intact. TTE was unchanged from prior. Atrial fibrillation s p PVI S p aborted ___ device implant Permanent afib CHA2DS2VASC HTN age female 3 HASBLED ___ s p AVNRT in ___ on warfarin but deemed not to be long term a c candidate. After extubation she was continued on home metoprolol and digoxin. After discussion with EP she was continued on warfarin and will continue on warfarin until follow up appointment next week. Hypoxemic respiratory failure Resolved Initially intubated in setting of procedure successfully extubated and on home NC. Fall Risk Pt undergoing ___ procedure due to frequent falls with headstrike at home. Falls appear to be from a combination of poor vision occasional lightheadedness and dizziness general weakness and mechanical falls. She is also on a number of sedating medications as home including gabapentin clonazepam diazepam and hydrocodone. ___ consult recommended home with ___. Would recommend continued down titration of these medications as an outpatient. CHRONIC ISSUES COPD FEV FVC 23 severely depressed DLCO. follows with Dr. ___ supposed to be on Spiriva 2.5 two puffs daily pro air HFA inhalers 2 puffs up to ___ times a day prednisone 5mg daily home O2 3L 6L pulse when walking with goal So2 90 . She was continued on home Spiriva and had standing albuterol nebs. Diabetes She was maintained on HISS in house. TRANSITIONAL ISSUES Discharge INR 1.6 Discharge warfarin dose 2.5 mg daily Pt will need INR checked on ___ Pt will need follow up with electrophysiology to ongoing discussion about anticoagulation Please continue to titrate down sedating medications in this patient with history of multiple falls. NEW MEDICATIONS none CHANGED MEDICATIONS Clonazepam decreased to 1 mg QHS PRN STOPPED MEDICATIONS HYDROcodone acetaminophen 7.5 325 mg oral Q6H PRN CODE Full CONTACT HCP ___ home ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. PredniSONE 5 mg PO DAILY 2. azelastine 137 mcg 0.1 nasal QPM 3. Gabapentin 800 mg PO QHS 4. Nicotine Polacrilex 4 mg PO Q1H PRN urge to smoke 5. ClonazePAM ___ mg PO QHS PRN insomnia 6. Diazepam 5 mg PO Q12H PRN muscle spasm as needed caution re sedation and fall risk 7. Metoprolol Tartrate 25 mg PO BID 8. MetFORMIN XR Glucophage XR 500 mg PO DAILY 9. Digoxin 0.125 mg PO DAILY 10. HYDROcodone acetaminophen 7.5 325 mg oral Q6H PRN 11. flaxseed oil 1 000 mg oral DAILY 12. Sucralfate 1 gm PO QID 13. Cetirizine 10 mg PO DAILY allergy symptoms 14. DULoxetine 120 mg PO DAILY 15. Albuterol Inhaler ___ PUFF IH Q6H 16. Warfarin 2.5 mg PO 3X WEEK ___ 17. Warfarin 2.5 mg PO 4X WEEK ___ Discharge Medications 1. ClonazePAM 1 mg PO QHS PRN insomnia 2. Albuterol Inhaler ___ PUFF IH Q6H 3. azelastine 137 mcg 0.1 nasal QPM 4. Cetirizine 10 mg PO DAILY allergy symptoms 5. Diazepam 5 mg PO Q12H PRN muscle spasm as needed caution re sedation and fall risk 6. Digoxin 0.125 mg PO DAILY 7. DULoxetine 120 mg PO DAILY 8. flaxseed oil 1 000 mg oral DAILY 9. Gabapentin 800 mg PO QHS 10. MetFORMIN XR Glucophage XR 500 mg PO DAILY 11. Metoprolol Tartrate 25 mg PO BID 12. Nicotine Polacrilex 4 mg PO Q1H PRN urge to smoke 13. PredniSONE 5 mg PO DAILY 14. Sucralfate 1 gm PO QID 15. Warfarin 2.5 mg PO 4X WEEK ___ 16. Warfarin 2.5 mg PO 3X WEEK ___ 17.Outpatient Lab Work I48.91 ___ ___ please fax results to ___ Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSES PEA Arrest Cardiogenic shock Acute hypoxemic respiratory failure Atrial fibrillation SECONDARY DIAGNOSES COPD Type II Diabetes HTN HLD 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 in the hospital WHY WAS I ADMITTED TO THE HOSPITAL You were admitted to the hospital because you had a procedure for your heart to stop blood clots from forming. Unfortunately this procedure was unable to be completed. WHAT HAPPENED WHILE I WAS IN THE HOSPITAL Your blood pressure became very low and your heart rate was very slow. You needed CPR and a breathing tube to save your life. You came to the cardiac intensive care unit. You got the breathing tube out and are able to go home. WHAT SHOULD I DO WHEN I GO HOME Continue to take all of your medications. See below for an updated list. Go to the follow up appointments listed. Talk to your primary care doctor about the medications you take which are sedating. Weigh yourself every morning. Call your doctor if your weight goes up more than 3 lbs. We wish you all the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be I481, T8111XA, J9601, I97710, Z7901, Y840, Y92238, Z5309, J439, Z9981, E1122, I129, N189, Z9181, E785, G8929, M549, F329, Z8701, G540, H5461, M3219, G4733, I341, M797, Z981, Z87891, R911, Z006. The descriptions of icd codes I481, T8111XA, J9601, I97710, Z7901, Y840, Y92238, Z5309, J439, Z9981, E1122, I129, N189, Z9181, E785, G8929, M549, F329, Z8701, G540, H5461, M3219, G4733, I341, M797, Z981, Z87891, R911, Z006 are I481: Persistent atrial fibrillation; T8111XA: Postprocedural cardiogenic shock, initial encounter; J9601: Acute respiratory failure with hypoxia; I97710: Intraoperative cardiac arrest during cardiac surgery; Z7901: Long term (current) use of anticoagulants; 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; Y92238: Other place in hospital as the place of occurrence of the external cause; Z5309: Procedure and treatment not carried out because of other contraindication; J439: Emphysema, unspecified; Z9981: Dependence on supplemental oxygen; 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; Z9181: History of falling; E785: Hyperlipidemia, unspecified; G8929: Other chronic pain; M549: Dorsalgia, unspecified; F329: Major depressive disorder, single episode, unspecified; Z8701: Personal history of pneumonia (recurrent); G540: Brachial plexus disorders; H5461: Unqualified visual loss, right eye, normal vision left eye; M3219: Other organ or system involvement in systemic lupus erythematosus; G4733: Obstructive sleep apnea (adult) (pediatric); I341: Nonrheumatic mitral (valve) prolapse; M797: Fibromyalgia; Z981: Arthrodesis status; Z87891: Personal history of nicotine dependence; R911: Solitary pulmonary nodule; Z006: Encounter for examination for normal comparison and control in clinical research program. The common codes which frequently come are J9601, Z7901, E1122, I129, N189, E785, G8929, F329, G4733, Z87891. The uncommon codes mentioned in this dataset are I481, T8111XA, I97710, Y840, Y92238, Z5309, J439, Z9981, Z9181, M549, Z8701, G540, H5461, M3219, I341, M797, Z981, R911, Z006.
The icd codes present in this text will be I481, J439, Z9981, E119, E7800, F329, Z781, M797, I10, G8929, M488X2, G4733, M3219, Z87891, Z7901, Z8674, Z9181, Z85828, Z902. The descriptions of icd codes I481, J439, Z9981, E119, E7800, F329, Z781, M797, I10, G8929, M488X2, G4733, M3219, Z87891, Z7901, Z8674, Z9181, Z85828, Z902 are I481: Persistent atrial fibrillation; J439: Emphysema, unspecified; Z9981: Dependence on supplemental oxygen; E119: Type 2 diabetes mellitus without complications; E7800: Pure hypercholesterolemia, unspecified; F329: Major depressive disorder, single episode, unspecified; Z781: Physical restraint status; M797: Fibromyalgia; I10: Essential (primary) hypertension; G8929: Other chronic pain; M488X2: Other specified spondylopathies, cervical region; G4733: Obstructive sleep apnea (adult) (pediatric); M3219: Other organ or system involvement in systemic lupus erythematosus; Z87891: Personal history of nicotine dependence; Z7901: Long term (current) use of anticoagulants; Z8674: Personal history of sudden cardiac arrest; Z9181: History of falling; Z85828: Personal history of other malignant neoplasm of skin; Z902: Acquired absence of lung [part of]. The common codes which frequently come are E119, F329, I10, G8929, G4733, Z87891, Z7901. The uncommon codes mentioned in this dataset are I481, J439, Z9981, E7800, Z781, M797, M488X2, M3219, Z8674, Z9181, Z85828, Z902. Allergies tofu moxifloxacin Chief Complaint persistent atrial fibrillation Major Surgical or Invasive Procedure ___ Left mini thoracotomy Left atrial appendage exclusion with Atriclip History of Present Illness Ms. ___ is a very nice ___ year old woman with a history of atrial fibrillation severe chronic obstructive pulmonary disease on oxygen and frequent falls. She was deemed to be high risk for chronic anti coagulation therapy due to recurrent fall history. She was admitted to ___ in ___ for ___ occlusion device whoever the procedure was aborted due to recurrent device dislodgements. During the procedure she had an episode of severe hypotension and bradycardia requiring two minutes of CPR until her condition stabilized. This was thought to be secondary to an air embolism. Dr. ___ was consulted for left atrial appendage ligation. She presented for preadmission testing and evaluation. She stated that she feels overall improved due following her hospitalization. She continues to have shortness of breath and dyspnea on exertion. She also noted episodes of dizziness lightheadedness. She denied chest pain palpitations orthopnea paroxysmal nocturnal dyspnea or lower extremity edema. Past Medical History 1. HTN 2. Hypercholesterolemia 3. chronic back pain 4. COPD emphysema 5. C spine disc disease 6. Depression 7. pneumonia ___. Right brachial plexus neuropathy 9. Right eye with decreased vision macular degeneration 10. SLE severe ophthalmopathy diffuse arthropathy 11. OSA cpap 12. MVP 13. Fibromyalgia PSH 1. S P B L cataracts 2. S P C4 5 fusion 3. S P multiple skin Ca exc both squamous and basal cell Social History ___ Family History No family history of premature coronary artery disease cardiomyopathy congestive heart failure or sudden death. Physical Exam Admission Exam Height 71 inches Weight 85.28 kg General Pleasant woman WDWN NAD Skin Warm dry intact HEENT NCAT PERRLA EOMI OP benign Neck Supple limited ROM Chest Lungs clear bilaterally but breath sounds faint Heart Distant heart sounds irregularly irregular rhythm no murmur Abdomen Normal BS soft non tender non distended Extremities Warm well perfused no edema Neuro Grossly intact Pulses DP Right 2 Left 2 ___ Right 2 Left 2 Radial Right 2 Left 2 Carotid Bruit none appreciated . Discharge Exam 98.6 140 86 67 18 98 Ra General Neuro NAD x A O x3 non focal x Cardiac RRR Irregular x Nl S1 S2 Lungs CTA x No resp distress x Abd NBS x Soft x ND x NT x Extremities no CCE Pulses doppler palpable Wounds left min thoracotomy CDI x no erythema or drainage x Pertinent Results ___ 05 56AM BLOOD WBC 6.4 RBC 3.75 Hgb 10.9 Hct 35.3 MCV 94 MCH 29.1 MCHC 30.9 RDW 14.3 RDWSD 49.0 Plt ___ ___ 04 47AM BLOOD WBC 11.2 RBC 3.36 Hgb 9.6 Hct 31.6 MCV 94 MCH 28.6 MCHC 30.4 RDW 14.4 RDWSD 49.0 Plt ___ ___ 05 56AM BLOOD ___ ___ 05 18AM BLOOD ___ ___ 05 13AM BLOOD ___ ___ 08 59AM BLOOD ___ ___ 02 00AM BLOOD ___ PTT 25.6 ___ ___ 05 56AM BLOOD Glucose 122 UreaN 16 Creat 0.8 Na 144 K 4.3 Cl 99 HCO3 34 AnGap 11 ___ 05 18AM BLOOD Glucose 121 UreaN 16 Creat 0.7 Na 144 K 4.4 Cl 101 HCO3 34 AnGap 9 . ___ Echo Conclusions Echo performed for intraoperative guidance of left atrial appendage ligation via left minithoracotomy. ___ The left atrium is mildly dilated. No mass thrombus is seen in the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed 0.2m s . No thrombus is seen in the left atrial appendage. In its longest dimension 3.09cm was measured before the exclusion of the left atrial appendage. After exclusion 2.12cm remained. RA IAS No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. LV Overall left ventricular systolic function is normal LVEF 55 . Post exclusion of the left atrial appendage all walls lateral wall included remained with normal systolic function unchanged . RV Right ventricular chamber size and free wall motion are normal. Aorta There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex 4mm atheroma in the descending thoracic aorta. AV There are three aortic valve leaflets. The aortic valve leaflets 3 are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. MV The mitral valve leaflets are moderately thickened. Mild 1 mitral regurgitation is seen. TV Normal leaflets mild TR. There is mild pulmonary artery systolic hypertension. Pericardium There is no pericardial effusion. No pericardial effusion post procedure. I certify that I was present for this procedure in compliance with ___ regulations. Interpretation assigned to ___ MD Interpreting ___ . Brief Hospital Course The patient was brought to the Operating Room on ___ where the patient underwent Exclusion of left atrial appendage via left mini thoracotomy with Dr. ___. Overall the patient tolerated the procedure well and post operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Coumadin resumed for AFib. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN sob 2. Albuterol Inhaler 2 PUFF IH Q4H PRN sob 3. azelastine 137 mcg 0.1 nasal QPM 4. Cetirizine 10 mg PO DAILY 5. ClonazePAM ___ mg PO QHS PRN agitation 6. DULoxetine 120 mg PO DAILY 7. Diazepam 5 mg PO Q12H PRN m spasm 8. Digoxin 0.125 mg PO DAILY 9. flaxseed oil ___ units oral DAILY 10. Gabapentin 2400 mg PO QHS 11. VICOdin ES HYDROcodone acetaminophen 7.5 300 mg oral Q6H PRN 12. melatonin 10 mg oral QHS PRN 13. MetFORMIN XR Glucophage XR 500 mg PO DAILY 14. Metoprolol Tartrate 25 mg PO BID 15. nicotine polacrilex 4 mg buccal DAILY PRN 16. Omeprazole 40 mg PO DAILY 17. PredniSONE 5 mg PO DAILY 18. Sucralfate 1 gm PO QID 19. Warfarin 5 mg PO DAILY16 Discharge Medications 1. Aspirin EC 81 mg PO DAILY RX aspirin 81 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 1 2. Docusate Sodium 100 mg PO BID hold for loose stool RX docusate sodium 100 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 3. Furosemide 20 mg PO DAILY Duration 7 Days RX furosemide 20 mg 1 tablet s by mouth daily Disp 7 Tablet Refills 0 4. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain moderate severe RX oxycodone 5 mg ___ tablet s by mouth every four 4 hours Disp 60 Tablet Refills 0 5. Metoprolol Tartrate 25 mg PO TID RX metoprolol tartrate 25 mg 1 tablet s by mouth three times a day Disp 90 Tablet Refills 1 6. Warfarin ___ mg PO DAILY16 dose to change daily per ___ clinic 7. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN sob 8. Albuterol Inhaler 2 PUFF IH Q4H PRN sob 9. azelastine 137 mcg 0.1 nasal QPM 10. Cetirizine 10 mg PO DAILY 11. ClonazePAM ___ mg PO QHS PRN agitation 12. Diazepam 5 mg PO Q12H PRN m spasm 13. Digoxin 0.125 mg PO DAILY 14. DULoxetine 120 mg PO DAILY 15. flaxseed oil ___ units oral DAILY 16. Gabapentin 2400 mg PO QHS 17. melatonin 10 mg oral QHS PRN 18. MetFORMIN XR Glucophage XR 500 mg PO DAILY 19. nicotine polacrilex 4 mg buccal DAILY PRN 20. Omeprazole 40 mg PO DAILY 21. PredniSONE 5 mg PO DAILY 22. Sucralfate 1 gm PO QID Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Atrial Fibrillation Flutter Basal Cell Carcinoma Cervical Spine Disease Chronic Obstructive Pulmonary Disease ___ O2 requirement Chronic Pain Depression Diabetes Mellitus Type II Fibromyalgia Gastroesophageal Reflux Disease Hypertension Insomnia Lung Nodule left Skin Cancer Sleep apnea Systemic Lupus Erythematous Uveitis wears glasses Past Surgical History Right thoracotomy and upper lobectomy C5 6 fusion L3 S1 decompression laminectomy hardware rotator cuff repair Discharge Condition Alert and oriented x3 non focal Ambulating gait steady pain managed with oral analgesics Thoracotomy Incision healing well no erythema or drainage Edema trace Discharge Instructions Please shower daily wash incisions gently with mild soap no baths or swimming look at your incisions daily Please NO lotion cream powder or ointment 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 Clearance to drive will be discussed at follow up appointment with surgeon No lifting more than 10 pounds for 10 weeks Encourage full shoulder range of motion unless otherwise specified 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 I481, J439, Z9981, E119, E7800, F329, Z781, M797, I10, G8929, M488X2, G4733, M3219, Z87891, Z7901, Z8674, Z9181, Z85828, Z902. The descriptions of icd codes I481, J439, Z9981, E119, E7800, F329, Z781, M797, I10, G8929, M488X2, G4733, M3219, Z87891, Z7901, Z8674, Z9181, Z85828, Z902 are I481: Persistent atrial fibrillation; J439: Emphysema, unspecified; Z9981: Dependence on supplemental oxygen; E119: Type 2 diabetes mellitus without complications; E7800: Pure hypercholesterolemia, unspecified; F329: Major depressive disorder, single episode, unspecified; Z781: Physical restraint status; M797: Fibromyalgia; I10: Essential (primary) hypertension; G8929: Other chronic pain; M488X2: Other specified spondylopathies, cervical region; G4733: Obstructive sleep apnea (adult) (pediatric); M3219: Other organ or system involvement in systemic lupus erythematosus; Z87891: Personal history of nicotine dependence; Z7901: Long term (current) use of anticoagulants; Z8674: Personal history of sudden cardiac arrest; Z9181: History of falling; Z85828: Personal history of other malignant neoplasm of skin; Z902: Acquired absence of lung [part of]. The common codes which frequently come are E119, F329, I10, G8929, G4733, Z87891, Z7901. The uncommon codes mentioned in this dataset are I481, J439, Z9981, E7800, Z781, M797, M488X2, M3219, Z8674, Z9181, Z85828, Z902.
The icd codes present in this text will be I2699, J189, J810, J9621, J440, Z66, J441, N179, I824Z3, I482, Y95, G8929, M549, G4733, M797, E7800, F329, F419, K219, G4700, F17210, E119, T380X5A, I10, I341, M329, G540, Z981, Z8701, Z95818, Z9181, Z9981, Z85828, Z87891. The descriptions of icd codes I2699, J189, J810, J9621, J440, Z66, J441, N179, I824Z3, I482, Y95, G8929, M549, G4733, M797, E7800, F329, F419, K219, G4700, F17210, E119, T380X5A, I10, I341, M329, G540, Z981, Z8701, Z95818, Z9181, Z9981, Z85828, Z87891 are I2699: Other pulmonary embolism without acute cor pulmonale; J189: Pneumonia, unspecified organism; J810: Acute pulmonary edema; J9621: Acute and chronic respiratory failure with hypoxia; J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection; Z66: Do not resuscitate; J441: Chronic obstructive pulmonary disease with (acute) exacerbation; N179: Acute kidney failure, unspecified; I824Z3: Acute embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral; I482: Chronic atrial fibrillation; Y95: Nosocomial condition; G8929: Other chronic pain; M549: Dorsalgia, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); M797: Fibromyalgia; E7800: Pure hypercholesterolemia, unspecified; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; G4700: Insomnia, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; E119: Type 2 diabetes mellitus without complications; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; I10: Essential (primary) hypertension; I341: Nonrheumatic mitral (valve) prolapse; M329: Systemic lupus erythematosus, unspecified; G540: Brachial plexus disorders; Z981: Arthrodesis status; Z8701: Personal history of pneumonia (recurrent); Z95818: Presence of other cardiac implants and grafts; Z9181: History of falling; Z9981: Dependence on supplemental oxygen; Z85828: Personal history of other malignant neoplasm of skin; Z87891: Personal history of nicotine dependence. The common codes which frequently come are Z66, N179, G8929, G4733, F329, F419, K219, G4700, F17210, E119, I10, Z87891. The uncommon codes mentioned in this dataset are I2699, J189, J810, J9621, J440, J441, I824Z3, I482, Y95, M549, M797, E7800, T380X5A, I341, M329, G540, Z981, Z8701, Z95818, Z9181, Z9981, Z85828. Allergies tofu moxifloxacin Chief Complaint Dyspnea Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ yo F with medical history notable for atrial fibrillation not on Coumadin due to recurrent fall history s p watchman ___ COPD on O2 5L at rest and frequent falls who presented with shortness of breath and dizziness. Per PCP notes patient was discharged from ___ ___ after being admitted 1 week previously with a severe flare of her advanced COPD. Unfortunately no records available on BID community link in OMR. She was recommended to go to rehab but apparently did not want to do this. Per note PCP started her on ___ mg Lasix PO on ___ due to cocern for volume overload. In the last few days since discharge from the hospital she has had significant worsening of her baseline shortness of breath. Normally when she gets up from lying down to sitting her saturations will drop to mid ___ and then recover to low ___. This week she has been dropping to the ___ with significant shortness of breath. Today she became extremely dyspneic when going to the bathroom got dizzy and fell down. Denies striking her head. She crawled to her bedroom and was able to call for an ambulance. In the ED Initial vitals 98.6 90 115 82 26 92 5L NC Labs notable for WBC 15.8 Hb 9.7 Cr 1.3 pBNP 3155 trop 0.1 INR 1.0 pH 7.51 Imaging notable for CTA with extensive segmental and subsegmental PE right ventricular prominence and pHTN noted Pt given ___ 02 37 IH Albuterol 0.083 Neb Soln 1 NEB ___ 02 37 IH Ipratropium Bromide Neb 1 NEB ___ 02 51 IH Albuterol 0.083 Neb Soln 1 NEB ___ 02 51 IH Ipratropium Bromide Neb 1 Neb ___ 03 40 IH Albuterol 0.083 Neb Soln 1 Neb ___ 03 40 IH Ipratropium Bromide Neb 1 Neb ___ 06 52 IV Azithromycin ___ 06 52 IV CefTRIAXone ___ 06 52 IV Heparin 7000 UNIT ___ 06 52 IV Heparin ___ 07 03 IV CefTRIAXone 1 gm ___ 07 37 IV Azithromycin 500 mg Vitals prior to transfer HR 90 BP 105 65 RR 20 SPO2 87 5L NC Of note patient was also admitted to ___ in ___ for Watchman occlusion device however the procedure was aborted due to recurrent device dislodgements. During the procedure she had an episode of severe hypotension and bradycardia requiring two minutes of CPR until her condition stabilized. After This was thought to be secondary to an air embolism. Dr. ___ was consulted for left atrial appendage ligation went to operating Room on ___ where she underwent exclusion of left atrial appendage via left mini thoracotomy with Dr. ___. She was on warfarin but due to multiple falls and appendage surgery this was stopped at some point in ___. Upon arrival to the floor the patient denies chest pain or dizziness. She reports mild shortness of breath. Past Medical History 1. HTN 2. Hypercholesterolemia 3. chronic back pain 4. COPD emphysema 5. C spine disc disease 6. Depression 7. pneumonia ___. Right brachial plexus neuropathy 9. Right eye with decreased vision macular degeneration 10. SLE severe ophthalmopathy diffuse arthropathy 11. OSA cpap 12. MVP 13. Fibromyalgia PSH 1. S P B L cataracts 2. S P C4 5 fusion 3. S P multiple skin Ca exc both squamous and basal cell Social History ___ Family History No family history of premature coronary artery disease cardiomyopathy congestive heart failure or sudden death. Physical Exam ADMISSION PHYSICAL EXAM ___ 1506 Temp 97.8 PO BP 117 67 R Lying HR 87 RR 20 O2 sat 90 O2 delivery 5 L General Lying in bed on 5L NC HEENT Sclerae anicteric MMM oropharynx clear EOMI Right pupil fixed 6mm Left pupil 5 4mm CV Irregular no murmurs rubs gallops Lungs Globally decreased breath sounds no wheezes rales rhonchi Abdomen Soft non tender non distended bowel sounds present no organomegaly no rebound or guarding Ext Warm well perfused 2 pulses 1 edema to the ankles b l Skin Warm dry no rashes or notable lesions. Neuro CNII XII intact pupil exam as above ___ strength upper lower extremities grossly normal sensation DISCHARGE PHYSICAL EXAM VITALS Afebrile HR ___ BP 127 79 RR ___ satting 96 on hi flow NC 40L with 50 FiO2 GENERAL Resting in bed overall appears comfortable HEENT Sclera anicteric CARDIAC Tachycardic distant heart sounds no murmurs PULMONARY Significant diffuse wheezing w reduced breath sounds ABDOMEN Soft nt nd EXTREMITIES Warm with lower extremity ecchymoses no ___ edema SKIN Warm and dry NEURO A O x3 Pertinent Results ___ 11 09PM BLOOD WBC 15.8 RBC 3.64 Hgb 9.7 Hct 32.4 MCV 89 MCH 26.6 MCHC 29.9 RDW 14.7 RDWSD 48.0 Plt ___ ___ 07 09AM BLOOD WBC 16.3 RBC 3.08 Hgb 8.3 Hct 28.3 MCV 92 MCH 26.9 MCHC 29.3 RDW 15.7 RDWSD 51.7 Plt ___ ___ 05 03AM BLOOD WBC 15.3 RBC 2.82 Hgb 7.7 Hct 25.9 MCV 92 MCH 27.3 MCHC 29.7 RDW 15.6 RDWSD 51.1 Plt ___ ___ 04 40AM BLOOD WBC 11.5 RBC 2.58 Hgb 7.0 Hct 23.3 MCV 90 MCH 27.1 MCHC 30.0 RDW 15.4 RDWSD 49.4 Plt ___ ___ 11 09PM BLOOD Glucose 277 UreaN 17 Creat 1.3 Na 143 K 4.4 Cl 95 HCO3 29 AnGap 19 ___ 05 10PM BLOOD Glucose 285 UreaN 18 Creat 1.0 Na 136 K 4.2 Cl 96 HCO3 25 AnGap 15 ___ 04 40AM BLOOD Glucose 253 UreaN 30 Creat 1.0 Na 139 K 3.7 Cl 102 HCO3 27 AnGap 10 ___ 07 09AM BLOOD cTropnT 0.01 proBNP 2778 ___ 06 30PM BLOOD Digoxin 0.9 ___ 06 09PM BLOOD ___ pO2 22 pCO2 43 pH 7.43 calTCO2 29 Base XS 2 CTA CHESTStudy Date of ___ 5 15 AM 1. Extensive filling defects in the pulmonary vascular tree compatible with pulmonary emboli. These are seen as proximal as the right intralobar artery. Emboli are seen at both the segmental and subsegmental level involving nearly every lobe but predominantly in the lower lobes. 2. There is mild prominence of the right ventricle. Clinical correlation for right heart strain is recommended. 3. Dilation of the main pulmonary and right and left pulmonary arteries compatible with pulmonary hypertension. 4. Severe emphysematous changes. Ground glass opacification is seen bilaterally which suggests interstitial pneumonitis. However in the superior left upper lobe there is a more consolidative appearance favored to represent infection with atelectasis and infarction also considerations. 5. Trace left pleural effusion. Transthoracic Echocardiogram Report The left atrium is mildly elongated. The estimated right atrial pressure is ___ mmHg. The left ventricle has a normal cavity size. Overall left ventricular systolic function is normal. Mildly dilated right ventricular cavity with moderate global free wall hypokinesis. Intrinsic right ventricular systolic function is likely lower due to the severity of tricuspid regurgitation. The mitral valve leaflets appear structurally normal. There is trivial mitral regurgitation. There is moderate to severe 3 tricuspid regurgitation. There is SEVERE pulmonary artery systolic hypertension. In the setting of at least moderate to severe tricuspid regurgitation the pulmonary artery systolic pressure may be UNDERestimated. IMPRESSION Right ventricular cavity dilation with free wall hypokinesis. Severe pulmonary artery systolic hypertension. Moderate to severe tricuspid regurgitation. Brief Hospital Course ___ is a ___ year old woman a history of atrial fibrillation s p Watchman procedure in ___ with prior Watchman issues with device dislodgments and a cardiac arrest ___ possible air embolism in ___ not on home anticoagulation due to frequent falls COPD 5L O2 at home who was admitted to ___ on ___ for a submassive pulmonary embolism. She was treated in the medical ICU until ___ for this along with pneumonia copd exacerbation and pulmonary edema before being discharged directly to ___ ___. ACUTE ISSUES ACUTE RESPIRATORY FAILURE SUBMASSIVE PULMONARY EMBOLISM PULMONARY EDEMA COPD WITH EXACERBATION HOSPITAL ACQUIRED PNEUMONIA Admitted to medicine initially treated on the floor initially with a heparin gtt stable O2 transitioned to apixaban. She was transferred to the MICU when she developed worsening hypoxemia as well as tachcyardia and hemoptysis. She maintained that she was DNR DNI and was managed with non invasive oxygenation methods. Failure of anticoagulation was considered unlikely but she was transitioned to enoxaparin BID. Her acute respiratory failure was felt to be from pulmonary edema copd exacerbation and possible pneumonia. She improved with treatment of all three and was weaned to 10 L hr oxymizer sats ok on NRB mask for transfer to rehab. Discharged with azithromycin as well as a slow prednisone taper finishing vancomycin and cefepime D7 last day ___ Restarted home furosemide at discharge GOALS OF CARE Spoke at length with the team and palliative care. She very clearly wants to be in the hospital as little as possible. Remains DNR DNI. She was OK with a short stay at rehab to maximize her chances of doing well at home very important for her to return there to be with her cats. Her mother does not know that wants to be DNR DNI and is even considering hospice care but her friend sister in law HCP ___ ___ is in the loop. STEROID INDUCED ANXIETY Prednisone taper significantly affecting the patient s anxiety well known issue for the patient. She was given large doses of clonazepam here without respiratory drive depression and it is OK and actually preferable to continue controlling her anxiety at rehab with this medication. Please call PCP if any concerns. CHRONIC ISSUES ATRIAL FIBRILLATION Now on anticoagulation but for PEs. Continued metoprolol and digoxin. DIABETES MELLITUS Continued insulin DEPRESSION ANXIETY Continued home antidepressants and anxiety medications GERD Continued home PPI sucralfate CHRONIC PAIN Continued home gabapentin oxycodone TRANSITIONAL ISSUES Last day of vanc cefepime is ___. OK to continue vancomycin at 750 mg BID without checking levels. Last day of azithromycin is ___ OK for patient to get significant doses of clonazepam especially while on prednisone taper. Please call PCP if any concerns. Please consult palliative care and social work if available Prednisone taper written out in discharge orders OK to use IV pain medication if needed please avoid sending patient back to hospital for pain management if possible CODE STATUS DNR DNI HCP ___ ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN sob 2. Albuterol Inhaler 2 PUFF IH Q4H PRN sob 3. Cetirizine 10 mg PO DAILY 4. ClonazePAM 1.5 mg PO QHS PRN insomnia and agitation 5. Digoxin 0.125 mg PO DAILY 6. DULoxetine 120 mg PO DAILY 7. Gabapentin 2400 mg PO QHS 8. Omeprazole 40 mg PO DAILY 9. PredniSONE 10 mg PO DAILY Tapered dose DOWN 10. Sucralfate 1 gm PO QID PRN GI upset 11. Diazepam 5 mg PO Q12H PRN m spasm 12. melatonin 10 mg oral QHS PRN 13. MetFORMIN XR Glucophage XR 500 mg PO DAILY 14. nicotine polacrilex 4 mg buccal DAILY PRN 15. Aspirin EC 81 mg PO DAILY 16. Furosemide 20 mg PO DAILY 17. ClonazePAM 0.5 mg PO DAILY PRN anxiety 18. Ipratropium Bromide Neb 1 NEB IH Q6H PRN shortness of breath wheezing 19. Metoprolol Succinate XL 100 mg PO DAILY 20. GlipiZIDE XL 5 mg PO DAILY 21. HYDROcodone Acetaminophen 5mg 325mg 1 TAB PO Q6H PRN Pain Moderate 22. ipratropium bromide 0.03 nasal DAILY Discharge Medications 1. Atorvastatin 40 mg PO QPM 2. Azithromycin 250 mg PO DAILY Duration 4 Doses Last day ___. Bisacodyl 10 mg PO PR DAILY PRN Constipation Second Line 4. CefePIME 2 g IV Q8H Last day ___. Enoxaparin Sodium 80 mg SC Q12H 6. Glargine 8 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Ipratropium Albuterol Neb 1 NEB NEB Q6H 8. Metoprolol Tartrate 25 mg PO Q6H 9. OxyCODONE Immediate Release ___ mg PO Q6H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth every six 6 hours Disp 12 Tablet Refills 0 10. PredniSONE 10 mg PO DAILY Duration 3 Days Start after the patient finishes 3 days of pred 20 mg Qd and then stop prednisone completely. Tapered dose DOWN 11. Ramelteon 8 mg PO QHS PRN insomnia Should be given 30 minutes before bedtime 12. Senna 8.6 mg PO BID PRN Constipation First Line 13. Vancomycin 750 mg IV Q 12H Last day ___. ClonazePAM 0.5 mg PO BID PRN anxiety RX clonazepam 0.5 mg 1 tablet s by mouth twice a day Disp 6 Tablet Refills 0 15. PredniSONE 60 mg PO DAILY Duration 2 Days 16. PredniSONE 50 mg PO DAILY Duration 3 Doses This is dose 1 of 5 tapered doses 17. PredniSONE 40 mg PO DAILY Duration 3 Doses This is dose 2 of 5 tapered doses 18. PredniSONE 30 mg PO DAILY Duration 3 Doses This is dose 3 of 5 tapered doses Tapered dose DOWN 19. PredniSONE 20 mg PO DAILY Duration 3 Doses This is dose 4 of 5 tapered doses Tapered dose DOWN 20. Albuterol 0.083 Neb Soln 1 NEB IH Q6H PRN sob 21. Aspirin EC 81 mg PO DAILY 22. ClonazePAM 1.5 mg PO QHS PRN insomnia and agitation RX clonazepam 1 mg 1.5 tablet s by mouth at bedtime Disp 5 Tablet Refills 0 23. Digoxin 0.125 mg PO DAILY 24. DULoxetine 120 mg PO DAILY 25. Furosemide 20 mg PO DAILY 26. Gabapentin 2400 mg PO QHS 27. nicotine polacrilex 4 mg buccal DAILY PRN 28. Omeprazole 40 mg PO DAILY 29. Sucralfate 1 gm PO QID PRN GI upset 30. HELD Albuterol Inhaler 2 PUFF IH Q4H PRN sob This medication was held. Do not restart Albuterol Inhaler until you go home 31. HELD Cetirizine 10 mg PO DAILY This medication was held. Do not restart Cetirizine until you need it 32. HELD Diazepam 5 mg PO Q12H PRN m spasm This medication was held. Do not restart Diazepam until you need it 33. HELD GlipiZIDE XL 5 mg PO DAILY This medication was held. Do not restart GlipiZIDE XL until you go home 34. HELD HYDROcodone Acetaminophen 5mg 325mg 1 TAB PO Q6H PRN Pain Moderate This medication was held. Do not restart HYDROcodone Acetaminophen 5mg 325mg until you go home 35. HELD Ipratropium Bromide Neb 1 NEB IH Q6H PRN shortness of breath wheezing This medication was held. Do not restart Ipratropium Bromide Neb until you go home 36. HELD ipratropium bromide 0.03 nasal DAILY This medication was held. Do not restart ipratropium bromide until you go home 37. HELD melatonin 10 mg oral QHS PRN This medication was held. Do not restart melatonin until you go home 38. HELD MetFORMIN XR Glucophage XR 500 mg PO DAILY This medication was held. Do not restart MetFORMIN XR Glucophage XR until you go home. 39. HELD Metoprolol Succinate XL 100 mg PO DAILY This medication was held. Do not restart Metoprolol Succinate XL until you go home. Right now you are getting a short acting version of this while in the hospital rehab. Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Submassive pulmonary embolism COPD exacerbation Pneumonia Pulmonary edema 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 ___ because you were having trouble breathing. You were diagnosed with a blood clot in your lungs and given blood thinners to treat this while being closely monitored in the intensive care unit. You were also treated for pneumonia a COPD exacerbation and diuresed to get extra fluid out of your lungs. Now that you are breathing with much less oxygen support we are able to discharge you to a rehabilitation center so that you can get stronger before going home. It was a pleasure caring for you Your ___ team Followup Instructions ___ The icd codes present in this text will be I2699, J189, J810, J9621, J440, Z66, J441, N179, I824Z3, I482, Y95, G8929, M549, G4733, M797, E7800, F329, F419, K219, G4700, F17210, E119, T380X5A, I10, I341, M329, G540, Z981, Z8701, Z95818, Z9181, Z9981, Z85828, Z87891. The descriptions of icd codes I2699, J189, J810, J9621, J440, Z66, J441, N179, I824Z3, I482, Y95, G8929, M549, G4733, M797, E7800, F329, F419, K219, G4700, F17210, E119, T380X5A, I10, I341, M329, G540, Z981, Z8701, Z95818, Z9181, Z9981, Z85828, Z87891 are I2699: Other pulmonary embolism without acute cor pulmonale; J189: Pneumonia, unspecified organism; J810: Acute pulmonary edema; J9621: Acute and chronic respiratory failure with hypoxia; J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection; Z66: Do not resuscitate; J441: Chronic obstructive pulmonary disease with (acute) exacerbation; N179: Acute kidney failure, unspecified; I824Z3: Acute embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral; I482: Chronic atrial fibrillation; Y95: Nosocomial condition; G8929: Other chronic pain; M549: Dorsalgia, unspecified; G4733: Obstructive sleep apnea (adult) (pediatric); M797: Fibromyalgia; E7800: Pure hypercholesterolemia, unspecified; F329: Major depressive disorder, single episode, unspecified; F419: Anxiety disorder, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; G4700: Insomnia, unspecified; F17210: Nicotine dependence, cigarettes, uncomplicated; E119: Type 2 diabetes mellitus without complications; T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter; I10: Essential (primary) hypertension; I341: Nonrheumatic mitral (valve) prolapse; M329: Systemic lupus erythematosus, unspecified; G540: Brachial plexus disorders; Z981: Arthrodesis status; Z8701: Personal history of pneumonia (recurrent); Z95818: Presence of other cardiac implants and grafts; Z9181: History of falling; Z9981: Dependence on supplemental oxygen; Z85828: Personal history of other malignant neoplasm of skin; Z87891: Personal history of nicotine dependence. The common codes which frequently come are Z66, N179, G8929, G4733, F329, F419, K219, G4700, F17210, E119, I10, Z87891. The uncommon codes mentioned in this dataset are I2699, J189, J810, J9621, J440, J441, I824Z3, I482, Y95, M549, M797, E7800, T380X5A, I341, M329, G540, Z981, Z8701, Z95818, Z9181, Z9981, Z85828.
The icd codes present in this text will be M1711, I110, I5032, I2510, E785, K219, M109, Z955. The descriptions of icd codes M1711, I110, I5032, I2510, E785, K219, M109, Z955 are M1711: Unilateral primary osteoarthritis, right knee; I110: Hypertensive heart disease with heart failure; I5032: Chronic diastolic (congestive) heart failure; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; M109: Gout, unspecified; Z955: Presence of coronary angioplasty implant and graft. The common codes which frequently come are I110, I5032, I2510, E785, K219, M109, Z955. The uncommon codes mentioned in this dataset are M1711. Allergies pollen extracts Chief Complaint right knee pain Major Surgical or Invasive Procedure ___ right total knee replacement History of Present Illness ___ year old female with right knee osteoarthritis which has failed conservative management and has elected to proceed with a right total knee replacement on ___ Past Medical History ___ CAD s p cardiac stenting hyperlipidemia HTN prostate cx rectal bleeding dermatitis diastolic CHF on lasix GERD gout PSHx Radical prostatectomy in ___ cardiac stents ___ herniorrhaphy bilateral cardiac cath Social History ___ Family History non contributory 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 Incision healing well with staples Scant serosanguinous drainage Thigh full but soft No calf tenderness ___ strength SILT NVI distally Toes warm Brief Hospital Course The patient was admitted to the orthopedic 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 Otherwise pain was controlled with a combination of IV and oral pain medications.. The patient received Lovenox for DVT prophylaxis starting on the morning of POD 1. The foley was removed and the patient was voiding independently thereafter. The surgical dressing was changed on POD 2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. 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 wound was benign. The patient s weight bearing status is weight bearing as tolerated on the operative extremity. Mr. ___ is discharged to home with services in stable condition Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Xtandi enzalutamide 40 mg oral take 4 capsules by mouth daily 4. Furosemide 20 mg PO 3X WEEK ___ 5. Nitroglycerin SL 0.4 mg SL 1 TABLET SL Q1 H PRN CHEST PAIN chest pain 6. Leuprolide Acetate 22.5 mg IM EVERY 3 MONTHS 7. Aspirin 81 mg PO DAILY 8. Cyanocobalamin ___ mcg PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis right knee 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 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 . 8. ANTICOAGULATION Please continue your Lovenox for four 4 weeks to help prevent deep vein thrombosis blood clots . If you were taking aspirin prior to your surgery it is OK to continue at your previous dose while taking this medication. 9. WOUND CARE Please keep your incision clean and dry. It is okay to shower five days after surgery 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 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. Staples will be removed at your follow up appointment in two weeks. 10. ___ once at home Home ___ dressing changes as instructed wound checks. 11. ACTIVITY Weight bearing as tolerated on the operative extremity. Mobilize. ROM as tolerated. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy WBAT RLE ROMAT Mobilize frequently wean from assistive devices when appropriate Treatment Frequency daily dressing changes as needed for drainage inspect incision daily for erythema drainage ice and elevation of operative limb remove staples and replace with steri strips at follow up visit in clinic. Followup Instructions ___ The icd codes present in this text will be M1711, I110, I5032, I2510, E785, K219, M109, Z955. The descriptions of icd codes M1711, I110, I5032, I2510, E785, K219, M109, Z955 are M1711: Unilateral primary osteoarthritis, right knee; I110: Hypertensive heart disease with heart failure; I5032: Chronic diastolic (congestive) heart failure; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; K219: Gastro-esophageal reflux disease without esophagitis; M109: Gout, unspecified; Z955: Presence of coronary angioplasty implant and graft. The common codes which frequently come are I110, I5032, I2510, E785, K219, M109, Z955. The uncommon codes mentioned in this dataset are M1711.
The icd codes present in this text will be K830, C259, E871, I4891, E8342, I10, N400, E806, E119, Z794, Z7901, Z23. The descriptions of icd codes K830, C259, E871, I4891, E8342, I10, N400, E806, E119, Z794, Z7901, Z23 are K830: Cholangitis; C259: Malignant neoplasm of pancreas, unspecified; E871: Hypo-osmolality and hyponatremia; I4891: Unspecified atrial fibrillation; E8342: Hypomagnesemia; I10: Essential (primary) hypertension; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; E806: Other disorders of bilirubin metabolism; E119: Type 2 diabetes mellitus without complications; Z794: Long term (current) use of insulin; Z7901: Long term (current) use of anticoagulants; Z23: Encounter for immunization. The common codes which frequently come are E871, I4891, I10, N400, E119, Z794, Z7901. The uncommon codes mentioned in this dataset are K830, C259, E8342, E806, Z23. Allergies adhesive tape seasonal allergies Chief Complaint vomiting fever Major Surgical or Invasive Procedure ERCP History of Present Illness ___ year old male with new dx pancreatic CA unresectable s p biliary stent placed ___ at ___ with Atrial fibrillation on Coumadin presented to initiate FOLFIRINOX today but referred in for leukocytosis elevated LFTs bilious vomiting and some increased confusion. Note that he had port placed ___ XR today ___ at ___ showed mild bibasilar opacity R L may be ___ microaspiration but appeared improved compared to CXR one day prior reportedly. RUQ u s at ___ today also read as 1. Hypoechoic mass the head of the pancreas with pancreatic duct dilatation upstream consistent with the patient s known pancreatic carcinoma 2. Cyst with a thin internal septation in the liver. On my interview he states he has been feeling well other than mild cough disclosed only specifically on prompting since his EUS on ___ at time of biopsy which is productive of mucous has no pain at all but today vomiting some greenish slimy material nonbloody once. Has had 1 episode roughly of looser stool daily for past several days but no watery diarrhea and no blood or melena. Did not have fever or chills until noted today in the ED as below. Has been feeling reasonably well and very disappointed and frustrated he didn t get chemotherapy. He remembers that he was a bit confused earlier today but he feels this was due to frustration over the plan not going as expected. NO dysuria rash chest pain dyspnea back pain all other 10 point ROS neg. ED COURSE T 101 7 HR 83 108 BP 116 75 RR 22 18 99 RA Labs with ALT 147 AST 237 Tbili 1.9 AP 279 Mg 1.4 P 2.6 chem reassuring. WBC 16 Hct 30 plts 294 pmns 90 lactate 1.5. UA reassuring. Na down to 130 on second draw. CT a p without evidence of fluid collection or acute abd process. Pt received 1L nS 2g cefepime 650 mg APAP. Past Medical History PAST ONCOLOGIC HISTORY He first presented to Oncology in ___ for evaluation of anemia. He had routine blood work done on ___ which demonstrated hemoglobin of 13.2 g dL with a normal white count normal platelet count and normal MCV. The differential of this white count was normal and his baseline hemoglobin had been in the 14 and 15 range with an MCV of 89 to 90. Repeat CBC on ___ showed hemoglobin of 11.9 again with the rest of his cell counts being normal. However his creatinine had risen at that point to 1.9 on ___ thought to be medication induced. It had returned to 1.2 by ___. Iron studies and CRP were normal although I do not have copies of those numbers with myself. He also describes significant fatigue and increased dyspnea on exertion. Labs on the day of the consult on ___ showed a white count of 5.9 hemoglobin at 12.3 platelets of 308 000 MCV of 85 and a reticulocyte count of 2.6. He also had labs from ___ and on those labs there were 2 circulating metamyelocytes described. So Dr. ___ recommended a bone marrow biopsy and this was performed on ___ to evaluate for MDS. ___ bone marrow biopsy was ___ cellular with an M E ratio of 2.5 1. There is no significant dysplasia. Flow cytometry was unremarkable. Cytogenetics and MDS ___ FISH were still pending at the time of his followup with Hematology but it was overall felt that the bone marrow was unremarkable. He was advised to simply follow his creatinine for any evidence of persistent renal insufficiency as the possible cause for his symptoms. He was then referred to the emergency room on ___ so approximately six weeks later because he had blood work done that showed an INR of 7.4 he was also noted at that time to be jaundiced. Labs at that time showed a bilirubin of 6.7 and AST of 196 ALT of 562 and an alkaline phosphatase of 466 creatinine was 2.1. He was described as being very fatigued and reporting a 65 pound weight loss over the course of the year. He had a decreased appetite and generally felt weak and tired. He denied any fevers or abdominal pain. He denied any nausea vomiting or diarrhea. He was admitted to ___. He had a urinalysis performed which showed a little bit of protein and red blood cells in his urine but was otherwise unremarkable. He was given vitamin K to reverse his INR. He was given IV fluids to try to bring his creatinine down. The patient reported that the jaundice has been present for approximately two to three weeks and then in addition he developed pruritus. His stool had also become light and his urine had become dark. Upon admission additional labs were sent. He had a white count of 5.73 hemoglobin of 15 hematocrit of 43.0 MCV of 84 platelet count of 317 000 with normal differential 74 polys 19 lymphocytes 6 monocytes 1 eosinophil and 1 basophil. Lipase was normal at 45 CA ___ returned elevated at 355 direct bilirubin was 4.3. He underwent an ultrasound on the ___ which showed fatty changes in the liver. He had a subcapsular cyst with septation in the posterior inferior right hepatic lobe measuring 13 x 13 x 10 mm. There is no ascites. The hepatic artery was patent with normal arterial waveforms and the main left and right portal veins were all patent with normal hepatopetal flow. The middle right and left hepatic veins are patent with normal direction of flow towards the IVC. There was intrahepatic biliary dilatation present. Common duct was 9 mm. The spleen was 12 cm in size with normal echotexture. The kidneys were fairly symmetric in size. There was no hydronephrosis. He had a simple cyst in the lower pole of the left kidney. There is also pancreatic ductal dilatation seen measuring up to 8 mm with hypoattenuated region and the head to the pancreas measuring 3.4 cm suspicious for a mass. He then underwent a CT of the chest and abdomen with contrast and that showed that he had scattered pulmonary micronodules as well as ill defined hypodense mass involving the pancreatic head that was 3.9 x 3.8 cm concerning for a primary pancreatic neoplasm. The pancreatic duct was markedly dilated with pancreatic parenchymal atrophy where calcifications within the pancreatic parenchyma suggested a prior inflammation of pancreatitis. At the level of the pancreatic neck the pancreatic duct measured up to 1.3 cm. It contacted the SMA circumferentially and resulted in significant narrowing but without complete occlusion. He contacted 180 degrees of the SMV without significant narrowing or occlusion. The portal vein and splenic vein were not felt to be involved nor was the celiac trunk or splenic artery. The common hepatic artery and GDA contacted peripancreatic adenopathy but not the mass. There is also loss of a fat plane between the second portion of the duodenum and the pancreatic mass. In the liver there was moderate intra and extrahepatic biliary ductal dilatation. There were no suspicious liver lesions. There was a 1.5 cm hypodensity in segment VI which was thought to represent a cyst. He then underwent an ERCP on ___. ___ this was performed on ___. He underwent an endoscopic ultrasound and ERCP on ___ by GI at ___ and they were able to biopsy the pancreatic head mass and that was positive for malignant cells consistent with an adenocarcinoma. There was abundant necrosis noted in the background. We do not have the report of the ERCP unfortunately but by the patient s report they did place a stent and after doing that his bilirubin was able to trend down. While in the hospital he saw Dr. ___ of the ___ oncology team who recommended a surgical consultation but thought that based on the encasement of the SMA that this was an unresectable pancreatic cancer and recommended chemotherapy. Surgery by report also felt that this was not a resectable pancreatic cancer and thus the recommendation was for definitive chemotherapy and radiation. Dr. ___ met with the patient upon discharge and stated that he would like to proceed with FOLFIRINOX with a reassessment of the disease after two months. He thought that the likelihood that he would be converted into a surgical candidate would be slim but that could be reassessed after two months. If it seems that he is still not a surgical candidate then at that time they could make plans for stereotactic radiation. Due to the distance that he would have to travel to get to ___ the patient opted to switch his care to ___ PAST MEDICAL HISTORY Fairly unremarkable. He has diabetes which he states he has had for many years probably approximately ___ years hypertension atrial fibrillation. PAST SURGICAL HISTORY He had surgery on his shoulder in ___ arthroscopy with rotator cuff repair he has had an appendectomy arthroscopy on his knee and a cholecystectomy. Social History ___ Family History His father died of colon cancer as did his brother. His mother had breast cancer diagnosed late in life. She also had kidney cancer by the ___ reports. Physical Exam ADMISSION PHYSICAL EXAM VITAL SIGNS 99.0 122 77 85 18 98 RA General NAD HEENT MMM no OP lesions no cervical supraclavicular or axillary adenopathy no thyromegaly CV irregularly irregular NL S1S2 no S3S4 MRG PULM CTAB GI BS soft NTND no masses or hepatosplenomegaly LIMBS No edema clubbing tremors or asterixis no inguinal adenopathy SKIN No rashes or skin breakdown NEURO Oriented x3. Cranial nerves II XII are within normal limits excluding visual acuity which was not assessed no nystagmus strength is ___ of the proximal and distal upper and lower extremities reflexes are 2 of the biceps triceps patellar and Achilles tendons toes are down bilaterally gait is normal coordination is intact. Discharge Physical Exam VS AF 100s 130s 70s 90s ___ 18 95 99 on RA HEENT NC AT sclera anicteric conjunctiva noninjected PER EOMI MMMs CV RRR no m r g Pulm CTAB no c r w Abd S NT ND BS no HSM or masses Extr wwp no edema distal pulses intact Neuro alert and interactive strength sensation and CNs grossly intact symmetric Skin no lesions noted on limited exam Psych normal range of affect Pertinent Results Admission data LABORATORY ANALYSIS WBC a 17.3 b 16.0 . RBC a 3.51 b 3.76 . HGB a 10.1 b 10.9 . HCT a 28.6 b 30.0 . MCV a 82 b 80 . RDW a 13.3 b 12.9. Plt Count a 294 b 310. Neuts 90.7 . Lymphs 4.6 . MONOS 3.6 . Eos 0.0 . BASOS 0.2. ___ 13.9 . INR 1.3 . Na a 130 b 136. K a 3.7 b 3.5. Cl a 92 b 99. CO2 a 22 b 24. BUN a 15 b 18. Creat a 0.9 b 1.0. Ca 9.9. Mg 1.4 . PO4 2.6 . AST 237 . ALT 147 . Alk Phos 279 . Total Bili 1.9 . Subsequent data CT ___. Approximately 2.8 cm ill defined hypodense mass within the head of the pancreas is consistent with known pancreatic cancer. The mass completely encases and attenuates the SMA and abuts 180 degrees of the posterior aspect of the SMV. Loss of fat plane between the mass and the second and third portions of the duodenum is also demonstrated along with multiple enlarged peripancreatic lymph nodes. There is associated upstream pancreatic ductal dilatation and atrophy of the pancreatic parenchyma. 2. Peripancreatic stranding and fluid about the head and uncinate process may reflect acute pancreatitis. Recommend correlation with lipase levels. 3. Multiple ill defined nodules at the lung bases concerning for metastatic disease. 4. Ill defined subcentimeter hypodensity in segment 8 of the liver is concerning for metastatic disease. Additional focal hypodense area with subtle capsular retraction in segment 4B could possibly be due to an underlying metastatic lesion as well. 5. Biliary stent appears to be patent with expected pneumobilia. No intrahepatic biliary dilatation. 6. Mild periportal edema mild pulmonary edema and small amount of pelvic free fluid. 7. Prostatomegaly. 8. Colonic diverticulosis. ERCP ___ Impression Limited exam of the esophagus was normal Limited exam of the stomach was normal Limited exam of the duodenum was normal The scout film revealed a metal stent in the RUQ. A metal stent was emerging from the major ampulla. The stent was successfully cannulated with an extraction balloon catheter. A 0.025in guidewire was advanced into the biliary tree. The stent was swept several times with sucessful removal of small amounts of sludge material. Careful contrast injection revealed excellent flow throught the stent. There was excellent spontaneous flow of bile and contrast at the end of the procedure. The PD was not injected or cannulated. Recommendations Return to ward under ongoing care. Clear fluids when awake then advance diet as tolerated. Continue with antibiotics to complete course for cholangitis. Repeat ERCP as needed for suspected stent occlusion. Follow for response and complications. If any abdominal pain fever jaundice gastrointestinal bleeding please call ERCP fellow on call ___ Post port placement CXR Successful placement of a single lumen chest power Port a cath via the right internal jugular venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. Successful removal of existing right subclavian approach chest port. Day of discharge labs ___ 05 19AM BLOOD WBC 5.6 RBC 3.02 Hgb 8.5 Hct 24.7 MCV 82 MCH 28.1 MCHC 34.4 RDW 13.2 RDWSD 38.9 Plt ___ ___ 05 19AM BLOOD Glucose 133 UreaN 15 Creat 1.0 Na 136 K 3.5 Cl 101 HCO3 20 AnGap 19 ___ 05 19AM BLOOD ALT 54 AST 21 AlkPhos 175 TotBili 1.0 ___ 05 19AM BLOOD Mg 1.___ year old male with new dx pancreatic CA unresectable s p biliary stent placed ___ at ___ with Atrial fibrillation on Coumadin presented to care to initiate FOLFIRINOX but was referred to ED for leukocytosis fever elevated LFTs bilious vomiting and some increased confusion. Presentation c f cholangitis although quickly improved with unrevealing ERCP so remains somewhat unclear. Suspected cholangitis aspiration vs PNA Patient presented with the above symptoms c f cholangitis in the setting of biliary stent. He was treated with fluids and cefepime flagyl. However his symptoms labs findings and vitals rapidly improved and the ERCP did not reveal significant obstruction or pus. It is also possible that he had these symptoms from pneumonia or an aspiration event given the imaging findings suggestive of such and his recent cough although the XR on day of admission actually appeared improved and his cough had nearly completely resolved by the day of admission so this seems somewhat unlikely. He will complete 8 more days of augmentin for a total 10 day cholangitis course. He was counseled to ___ w recurrent symptoms. The day after ERCP he was continued NPO for port replacement. Subsequently his diet was advanced for successfully and he was discharged home. Pancreatic cancer Patient will follow up with onc provider to reschedule chemotherapy. Port placement Port was replaced during admission due to proximal location of catheter. R IJ catheter and prior R subclavian was removed. Hyponatremia Mild hyponatremia on presentation that improved with fluids. Diabetes Held home meds and started sliding scale. Discharged back on home meds with instructions to start with a low lantus dose and gradually increase based on glucose levels given his reduced PO intake. HypoMg Kept on home repletion and received additional IV repletion Afib Stopped Coumadin ___ ___ procedure and was told to hold until ___. Continued to hold will defer to outpatient providers for restarting. may need reduced dose if starting while still on abx. Continued home dilt. 30 minutes spent in face to face time and coordination of discharge Transitional issues 1 f u final blood cultures 2 determine starting time for chemo 3 consider restarting time of Coumadin 4 continue monitoring magnesium levels 5 completing 8 more days of augmentin for cholangitis course Medications on Admission The Preadmission Medication list is accurate and complete. 1. Benzonatate 100 mg PO TID PRN cough 2. Diltiazem Extended Release 180 mg PO DAILY 3. Glargine 28 Units Bedtime 4. Zenpep lipase protease amylase 20 000 68 000 109 000 unit oral TID 5. MetFORMIN Glucophage 1000 mg PO BID 6. LORazepam 0.5 mg PO QHS PRN insomnia 7. Ondansetron 8 mg PO Q8H PRN nausea 8. Tamsulosin 0.4 mg PO QHS 9. Warfarin 5 mg PO DAILY16 10. Magnesium Oxide 400 mg PO DAILY Discharge Medications 1. Amoxicillin Clavulanic Acid ___ mg PO BID Duration 8 Days RX amoxicillin pot clavulanate Augmentin 875 mg 125 mg 1 tablet by mouth twice daily Disp 16 Tablet Refills 0 2. Glargine 28 Units Bedtime 3. Benzonatate 100 mg PO TID PRN cough 4. Diltiazem Extended Release 180 mg PO DAILY 5. LORazepam 0.5 mg PO QHS PRN insomnia 6. Magnesium Oxide 400 mg PO DAILY 7. MetFORMIN Glucophage 1000 mg PO BID 8. Ondansetron 8 mg PO Q8H PRN nausea 9. Tamsulosin 0.4 mg PO QHS 10. Zenpep lipase protease amylase 20 000 68 000 109 000 unit oral TID 11. HELD Warfarin 5 mg PO DAILY16 This medication was held. Do not restart Warfarin until instructed by your outpatient doctors ___ Home Discharge Diagnosis Cholangitis Pancreatic cancer Port replacement Atrial fibrillation Diabetes Mellitus Hypomagnesemia Discharge Condition Patient hemodynamically stable and afebrile with baseline cognitive and functional status. Discharge Instructions You were admitted to the hospital because of a fever and concern for an infection related to your bile duct stent. Fortunately your condition improved quickly and the ERCP procedure did not show any significant problems. We still recommend taking antibiotics for the next 8 days because of the concern for infection. You should contact your oncologist to determine when you will restart chemo. You also had your port replaced to fix the positioning of it. We also recommend touching base with your outpatient providers about when to restart your Coumadin. If you restart the Coumadin while you are still taking the antibiotics then you may need a lower dose. Regarding your insulin as we discussed you should start at a lower dose than normal and gradually increase back to normal based on how much you are eating and what your glucose levels are at home. Followup Instructions ___ The icd codes present in this text will be K830, C259, E871, I4891, E8342, I10, N400, E806, E119, Z794, Z7901, Z23. The descriptions of icd codes K830, C259, E871, I4891, E8342, I10, N400, E806, E119, Z794, Z7901, Z23 are K830: Cholangitis; C259: Malignant neoplasm of pancreas, unspecified; E871: Hypo-osmolality and hyponatremia; I4891: Unspecified atrial fibrillation; E8342: Hypomagnesemia; I10: Essential (primary) hypertension; N400: Benign prostatic hyperplasia without lower urinary tract symptoms; E806: Other disorders of bilirubin metabolism; E119: Type 2 diabetes mellitus without complications; Z794: Long term (current) use of insulin; Z7901: Long term (current) use of anticoagulants; Z23: Encounter for immunization. The common codes which frequently come are E871, I4891, I10, N400, E119, Z794, Z7901. The uncommon codes mentioned in this dataset are K830, C259, E8342, E806, Z23.
The icd codes present in this text will be E6601, E559, I10, Z6843, E780, L709, K660, D509, L309, F419, R000, R110. The descriptions of icd codes E6601, E559, I10, Z6843, E780, L709, K660, D509, L309, F419, R000, R110 are E6601: Morbid (severe) obesity due to excess calories; E559: Vitamin D deficiency, unspecified; I10: Essential (primary) hypertension; Z6843: Body mass index [BMI] 50.0-59.9, adult; E780: Pure hypercholesterolemia; L709: Acne, unspecified; K660: Peritoneal adhesions (postprocedural) (postinfection); D509: Iron deficiency anemia, unspecified; L309: Dermatitis, unspecified; F419: Anxiety disorder, unspecified; R000: Tachycardia, unspecified; R110: Nausea. The common codes which frequently come are I10, D509, F419. The uncommon codes mentioned in this dataset are E6601, E559, Z6843, E780, L709, K660, L309, R000, R110. Allergies Tetracycline Analogues amoxicillin iodopropynl glutaraldehyde Chief Complaint Morbid obesity Major Surgical or Invasive Procedure ___ laparoscopic sleeve gastrectomy History of Present Illness Per Dr. ___ has class III morbid obesity with weight of 286.9 pounds as of ___ with her initial screen weight of 285.1 pounds on ___ height of 63.25 inches and BMI of 50.4. Her previous weight loss efforts have included Weight Watchers multiple times calorie counting low carbohydrate diet ___ ___ diet prescription weight loss medications over the counter dietary ___ visits as well as counseling with obesity specialist Dr. ___ ___ at ___. She stated that her lowest weight was in the 180s in her teenage years and her highest weight was 297 pounds. She stated that she has been struggling with weight since puberty and cites as factors contributing to her excess weight convenience eating lack portions emotional eating ___ times a month genetics eating too many carbohydrates and lack of exercise although she does walk for 60 minutes ___ times per week and does track her progress via a pedometer. She denied history of eating disorders no anorexia bulimia diuretic or laxative abuse and she denied binge eating. She does not have a diagnosis of depression but does have anxiety with history of panic attacks. She has not been followed by a therapist and she has not been hospitalized for mental health issues and she is not on any psychotropic medications. Past Medical History Her medical history includes 1 hyperlipidemia with elevated triglycerides 2 hypertension not a medication 3 vitamin D deficiency 4 iron deficiency with saturation of 16 5 acne 6 eczema 7 ___ fracture of the right foot inversion plantar flexion after tripping down stairs at ___ at a ___ She has no surgical history. Social History Works as ___ at ___. Physical Exam VS T 98.3 P 76 BP 135 81 RR 18 02 100 RA Constitutional NAD Neuro Alert and oriented x 3 Cardiac Regular rate and rhythm no murmurs appreciated Resp Clear to auscultation bilaterally Abdomen Soft non tender non distended no rebound tenderness guarding Wounds Abd lap sites CDI no periwound erythema or drainage Ext no lower extremity edema Pertinent Results LABS ___ 05 50AM BLOOD Hct 39.8 ___ 10 32AM BLOOD Hct 40.4 IMAGING BAS UGI W KUB No evidence of leak or obstruction. Brief Hospital Course The patient presented to pre op on ___. Pt was evaluated by anaesthesia and taken to the operating room for laparoscopic sleeve gastrectomy. There were no adverse events in the operating room please see the operative note for details. Pt was extubated taken to the PACU until stable then transferred to the ward for observation. Neuro The patient was alert and oriented throughout hospitalization pain was initially managed with a PCA and then transitioned to oral oxycodone once tolerating a stage 2 diet. 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 The patient was initially kept NPO with a ___ tube in place for decompression. On POD1 the NGT was removed and an upper GI study was negative for a leak therefore the diet was advanced sequentially to a Bariatric Stage 3 diet which was well tolerated. Patient s intake and output were closely monitored. ID The patient s fever curves were closely watched for signs of infection of which there were none. HEME The patient s blood counts were closely watched for signs of bleeding of which there were none. Prophylaxis The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge the patient was doing well afebrile with stable vital signs. The patient was tolerating a stage 3 diet ambulating voiding without assistance and pain was well controlled. The patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. levonorgestrel 20 mcg 24 hr ___ years intrauterine DAILY 2. Spironolactone 50 mg PO QHS 3. Multivitamins W minerals 1 TAB PO DAILY 4. Imipramine 50 mg PO AS DIRECTED Discharge Medications 1. Docusate Sodium 100 mg PO BID PRN constipation RX docusate sodium 50 mg 5 mL 10 ml by mouth twice a day Refills 0 2. OxycoDONE Liquid 5 mg PO Q6H PRN Pain Moderate RX oxycodone 5 mg 5 mL 5 ml by mouth q 6 hours Refills 0 3. Ranitidine Liquid 150 mg PO BID RX ranitidine HCl 15 mg mL 10 ml by mouth twice a day Refills 0 4. Imipramine 50 mg PO AS DIRECTED 5. levonorgestrel 20 mcg 24 hr ___ years intrauterine DAILY 6. Multivitamins W minerals 1 TAB PO DAILY 7. HELD Spironolactone 50 mg PO QHS This medication was held. Do not restart Spironolactone until you discuss with Dr. ___. Discharge Disposition Home Discharge Diagnosis Obesity Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Discharge Instructions Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5 chest pain shortness of breath severe abdominal pain pain unrelieved by your pain medication severe nausea or vomiting severe abdominal bloating inability to eat or drink foul smelling or colorful drainage from your incisions redness or swelling around your incisions or any other symptoms which are concerning to you. Diet Stay on Stage III diet until your follow up appointment. Do not self advance diet do not drink out of a straw or chew gum. Medication Instructions Resume your home medications CRUSH ALL PILLS. You will be starting some new medications 1. You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. 2. You should begin taking a chewable complete multivitamin with minerals. No gummy vitamins. 3. You will be taking Zantac liquid ___ mg twice daily for one month. This medicine prevents gastric reflux. 4. You should take a stool softener Colace twice daily for constipation as needed or until you resume a normal bowel pattern. 5. You must not use NSAIDS non steroidal anti inflammatory drugs Examples are Ibuprofen Motrin Aleve Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. Activity No heavy lifting of items ___ pounds for 6 weeks. You may resume moderate exercise at your discretion no abdominal exercises. Wound Care You may shower no tub baths or swimming. If there is clear drainage from your incisions cover with clean dry gauze. Your steri strips will fall off on their own. Please remove any remaining strips ___ days after surgery. Please call the doctor if you have increased pain swelling redness or drainage from the incision sites. Followup Instructions ___ The icd codes present in this text will be E6601, E559, I10, Z6843, E780, L709, K660, D509, L309, F419, R000, R110. The descriptions of icd codes E6601, E559, I10, Z6843, E780, L709, K660, D509, L309, F419, R000, R110 are E6601: Morbid (severe) obesity due to excess calories; E559: Vitamin D deficiency, unspecified; I10: Essential (primary) hypertension; Z6843: Body mass index [BMI] 50.0-59.9, adult; E780: Pure hypercholesterolemia; L709: Acne, unspecified; K660: Peritoneal adhesions (postprocedural) (postinfection); D509: Iron deficiency anemia, unspecified; L309: Dermatitis, unspecified; F419: Anxiety disorder, unspecified; R000: Tachycardia, unspecified; R110: Nausea. The common codes which frequently come are I10, D509, F419. The uncommon codes mentioned in this dataset are E6601, E559, Z6843, E780, L709, K660, L309, R000, R110.
The icd codes present in this text will be O1415, O99215, E669, R0789, O9989. The descriptions of icd codes O1415, O99215, E669, R0789, O9989 are O1415: Severe pre-eclampsia, complicating the puerperium; O99215: Obesity complicating the puerperium; E669: Obesity, unspecified; R0789: Other chest pain; O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium. The common codes which frequently come are E669. The uncommon codes mentioned in this dataset are O1415, O99215, R0789, O9989. Allergies lidocaine Chief Complaint elevated BP Major Surgical or Invasive Procedure none History of Present Illness ___ G3P3 POD4 from primary LTCS for arrrest of dilation and fetal intolerance to augmentation of labor c b gestational hypertension now with severe BP at home. Reports assymetric calf swelling R L starting this morning. Has intermittent shortness of breath but none now. Endorse chest pressure which started on arrival to the ED also comes and goes. Denies substernal chest pain arm pain jaw pain heart pain. Breast nt feeding and pumping well. incisional pain will controlled at home on tylenol oxy ibuprofen with normal lochia. Infant is at home with grandma. Denies headache vision changes RUQ pain subcostal cheat discomfort as above . Remainder of ROS as per HPI. Past Medical History OBHx G1 SVD term 5 15 pre eclampsia at 40 weeks G2 SVD term 9 10oz gHTN G3 pLTCS as above GynHx No h o abnormal Pap fibroids Gyn surgery STIs PMH none PSH wisdom teeth cesarean delivery Meds PNV All lidocaine difficulty breathing Social History SHx denies T E D Physical Exam General NAD CV RRR Lungs Nonlabored breathing CTAB Abd soft fundus firm at umbilicus appropriate fundal tenderness Incision clean dry intact no erythema induration Lochia minimal Extremities no calf tenderness 1 edema Pertinent Results ___ 01 15PM cTropnT 0.01 ___ 11 04AM ___ PTT 33.7 ___ ___ 10 10AM GLUCOSE 91 UREA N 9 CREAT 0.7 SODIUM 143 POTASSIUM 4.1 CHLORIDE 105 TOTAL CO2 26 ANION GAP 12 ___ 10 10AM ALT SGPT 45 AST SGOT 45 ALK PHOS 97 TOT BILI 0.3 ___ 10 10AM cTropnT 0.01 ___ 10 10AM proBNP 257 ___ 10 10AM ALBUMIN 3.5 CALCIUM 9.1 PHOSPHATE 3.6 MAGNESIUM 1.8 ___ 10 10AM URINE HOURS RANDOM ___ 10 10AM URINE UCG POSITIVE ___ 10 10AM URINE UHOLD HOLD ___ 10 10AM WBC 11.0 RBC 3.67 HGB 10.0 HCT 31.3 MCV 85 MCH 27.2 MCHC 31.9 RDW 16.7 RDWSD 50.5 ___ 10 10AM NEUTS 83.1 LYMPHS 11.7 MONOS 3.6 EOS 0.1 BASOS 0.3 IM ___ AbsNeut 9.14 AbsLymp 1.29 AbsMono 0.40 AbsEos 0.01 AbsBaso 0.03 ___ 10 10AM PLT COUNT 245 ___ 10 10AM URINE COLOR Yellow APPEAR Hazy SP ___ ___ 10 10AM URINE BLOOD MOD NITRITE NEG PROTEIN 100 GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 7.5 LEUK LG ___ 10 10AM URINE RBC 5 WBC 107 BACTERIA MOD YEAST NONE EPI 4 TRANS EPI 2 Brief Hospital Course Ms. ___ was readmitted on ___ with elevated blood pressures found to have pre eclampsia severe by blood pressures. She presented to the ED on post operative day 4 from primary low transverse cesarean section. She received 20mg IV labetalol was started on 24 hours of magnesium. Her home nifedipine was continued and labetalol was added for better control of her blood pressures. In the ED she also complained of chest pressure w bilateral leg sweeling bedside echocardiogram was within normal limit and EKG demonstrated NSR. CTA demonstrated no evidence of pulmonary embolism or aortic abnormalities however ground glass opacities in dependent areas were noted that may have represented fluid overload. During her hospital course she continued to have persistent HA ___ . MRI MRA obtained showed no evidence of ischemia hemorrhage or edema. She received acetaminophen ibuprofen fioricet and Compazine. She had elevated liver enzymes which downtrended prior to her discharge. Her anti hypertensive medications were uptitrated to labetalol 600 q8h and nifedipine 30 mg daily. By hospital day 5 she was stable for discharge. Discussed return precautions included severe range blood pressures and persistent headache. She was discharged home with outpatient follow up. Medications on Admission prenatal vitamins Discharge Medications 1. Labetalol 600 mg PO Q8H RX labetalol 300 mg 2 tablet s by mouth three times a day Disp 120 Tablet Refills 1 2. NIFEdipine Extended Release 30 mg PO DAILY hypertension hold if bp below 110 70 RX nifedipine 30 mg 1 tablet s by mouth q day Disp 20 Tablet Refills 1 Discharge Disposition Home Discharge Diagnosis post partum pre ecclampsia with headache symptoms pulmonary edema Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions rest. take meds. no heavy lifting exercise for 4 weeks Followup Instructions ___ The icd codes present in this text will be O1415, O99215, E669, R0789, O9989. The descriptions of icd codes O1415, O99215, E669, R0789, O9989 are O1415: Severe pre-eclampsia, complicating the puerperium; O99215: Obesity complicating the puerperium; E669: Obesity, unspecified; R0789: Other chest pain; O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium. The common codes which frequently come are E669. The uncommon codes mentioned in this dataset are O1415, O99215, R0789, O9989.
The icd codes present in this text will be K430, C8580, Z9484, Z85038, Z9049, I10, Z87891, E860. The descriptions of icd codes K430, C8580, Z9484, Z85038, Z9049, I10, Z87891, E860 are K430: Incisional hernia with obstruction, without gangrene; C8580: Other specified types of non-Hodgkin lymphoma, unspecified site; Z9484: Stem cells transplant status; Z85038: Personal history of other malignant neoplasm of large intestine; Z9049: Acquired absence of other specified parts of digestive tract; I10: Essential (primary) hypertension; Z87891: Personal history of nicotine dependence; E860: Dehydration. The common codes which frequently come are I10, Z87891. The uncommon codes mentioned in this dataset are K430, C8580, Z9484, Z85038, Z9049, E860. Allergies Penicillins Zofran Chief Complaint Nausea and vomiting Major Surgical or Invasive Procedure none History of Present Illness ___ w hx remote colon cancer ___ s p sigmoid resection c b leak requiring reoperation diverting colostomy s p takedown with long standing incisional hernia who presents to the ED with 4 days of nausea and bilious emesis found on CT to have recurrent SBO. Patient reports 4 days ago she noticed cramping abdominal pain associated with nausea had several episodes of bilious emesis. Did not have any bowel movements for 3 days flatus x 2 days however initially tried managing by increasing her stool softeners and starting lactulose 2 days ago. However her nausea vomiting did not resolve prompting her to present today. A CT scan was done results detailed below demonstrating an incarcerated ___ hernia for which we are consulted. Only prior hospitalization for this issue was in ___ at which time she was admitted to ___ service w obstructive symptoms ACS was consulted several days into her hospital stay but at that point her symptoms had already improved and CT demonstrated partial SBO at most. Given her recurrent lymphoma and plans to perform repeat aSCT she deferred definitive surgical repair her symptoms resolved with non operative management did not follow up with surgery as outpatient. Successfully underwent repeat aSCT and has been in remission for ___ years with last scans ___ showing no evidence of disease recurrence. No recurrent SBO s in the subsequent ___ years until her presentation today. Last colonoscopy ___ which noted several adenomatous polyps plans for repeat in ___. ROS per HPI Past Medical History PAST ONCOLOGIC HISTORY 1. Recurrent marginal zone lymphoma stage IIIA. Initially treated with R CVP completed in ___ Relapsed in ___ with extensive adenopathy treated with total 6 cycles of Rituxan Bendamustine completed in ___ Increasing left breast lesion and skin nodule. Biopsy on ___ showed diffuse large B cell lymphoma and transformation in the background of a marginal zone lymphoma 4 cycles of DA EPOCH followed by high dose Cytoxan and autologous stem cell transplantation D 0 ___. 2. Colon cancer status post surgery in ___. She does not remember the stage of her disease but she did not receive any adjuvant treatment. Colonoscopy needs to be repeated. PAST MEDICAL HISTORY Osteoarthritis. Adnexal cyst. Hypertension Chemotherapy induced pneumonitis on steroids with taper. Social History ___ Family History Adopted. Family history unknown. Physical Exam Admission physical exam Vitals T98 HR110 BP 130 80 RR 18 ___ 92RA GEN A O NAD non toxic appearing HEENT No scleral icterus mucus membranes dry CV mild tachycardia reg rhythm PULM unlabored respirations ABD Soft morbidly obsese nondistended large palpable incisional hernia just to the left of umbilicus with gas filled small bowel. Tender to palpation over hernia but no diffuse abdominal tenderness no rebound or guarding. Ext No ___ edema ___ warm and well perfused Discharge physical exam VS 98.2 135 75 87 20 95 RA Gen A O x3. Ambulatory. In NAD. CV HRR Pulm LS CTAB Abd soft obese large hernia. nontender to palp. Ext WWP trace edema Pertinent Results Admission labs ___ 10 00AM BLOOD WBC 10.5 RBC 5.57 Hgb 16.5 Hct 50.0 MCV 90 MCH 29.6 MCHC 33.0 RDW 13.5 RDWSD 44.5 Plt ___ ___ 10 00AM BLOOD Neuts 74.5 Lymphs 14.2 Monos 9.5 Eos 0.7 Baso 0.5 Im ___ AbsNeut 7.81 AbsLymp 1.49 AbsMono 0.99 AbsEos 0.07 AbsBaso 0.05 ___ 10 00AM BLOOD ___ PTT 27.8 ___ ___ 10 00AM BLOOD Plt ___ ___ 10 00AM BLOOD Glucose 252 UreaN 17 Creat 0.9 Na 141 K 3.8 Cl 97 HCO3 26 AnGap 18 ___ 10 00AM BLOOD Calcium 9.7 Phos 2.7 Mg 1.9 ___ 11 03AM BLOOD Lactate 3.2 ___ 01 48AM BLOOD Lactate 1.2 ___ 06 13AM BLOOD Lactate 1.5 Discharge labs ___ 05 30AM BLOOD WBC 8.9 RBC 4.13 Hgb 12.4 Hct 40.0 MCV 97 MCH 30.0 MCHC 31.0 RDW 14.3 RDWSD 50.4 Plt ___ ___ 04 50AM BLOOD WBC 10.4 RBC 4.48 Hgb 13.3 Hct 42.9 MCV 96 MCH 29.7 MCHC 31.0 RDW 14.5 RDWSD 50.2 Plt ___ ___ 04 09AM BLOOD WBC 18.9 RBC 4.89 Hgb 14.7 Hct 46.4 MCV 95 MCH 30.1 MCHC 31.7 RDW 14.1 RDWSD 48.9 Plt ___ ___ 05 30AM BLOOD Glucose 124 UreaN 10 Creat 0.6 Na 143 K 3.7 Cl 105 HCO3 31 AnGap 7 ___ 04 50AM BLOOD Glucose 167 UreaN 12 Creat 0.6 Na 143 K 3.9 Cl 103 HCO3 30 AnGap 10 Imaging CXR ___ PA and lateral views of the chest provided. Port A Cath resides over the right chest wall with catheter tip in the mid SVC region. The lungs are clear bilaterally. There is no focal consolidation large effusion pneumothorax or signs of edema. Cardiomediastinal silhouette appears stable. Bony structures are intact. No free air below the right hemidiaphragm. CT A P ___ 1. Small bowel obstruction due to a left periumbilical small bowel containing hernia. Please correlate for reducibility. No free fluid free air or bowel wall thickening. 2. Multiple additional fat containing abdominal wall hernias. 3. Right adnexal cystic lesion previously characterized as hydrosalpinx. 4. Thickened endometrium measuring up to 2.8 cm consider nonemergent pelvic ultrasound to further assess. ___ KUB Multiple air filled mildly dilated loops of small and large bowel compatible with ileus. ___ KUB Interval decrease in mildly dilated loops of small and large bowel compatible with improving ileus. ___ CHEST ABD PELVIS CT 1. Left periumbilical incisional hernia with a 4. ontaining loops of small bowel with interval slight improvement of upstream small bowel dilatation. The oral contrast material has passed through the trapped loops of small bowel in the incisional hernia however given the continued upstream dilation there appears to be an element of persisting partial obstruction. 2. Thickened endometrium measures 0.9 cm as noted on pelvic ultrasound dated ___. Please correlate with prior endometrial biopsy. 3. Unchanged right hydrosalpinx. 4. Please refer to separate report of CT chest performed on the same day for description of the thoracic findings. Brief Hospital Course ___ y o F hx marginal zone lymphoma s p alloSCT x 2 remote colon cancer s p resection with incisional hernia admitted to the General Surgical Service on ___ for evaluation and treatment of abdominal pain nausea and vomiting. Admission abdominal pelvic CT revealed a small bowel obstruction due to a left periumbilical small bowel containing hernia. The patient was hemodynamically stable. She was treated non operatively with bowel rest IV fluids nasogastric tube for decompression and close monitoring or lab work and abdominal exam. Serial abdominal x rays showed gradual improvement. The patient eventually began passing consistent flatus. On ___ a repeat CT scan showed no bowel obstruction. NGT was removed and diet was progressively advanced as tolerated to a regular diet with good tolerability. During this hospitalization the patient ambulated early and frequently was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge the patient was doing well afebrile with stable vital signs. The patient was tolerating a regular diet ambulating voiding without assistance and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow up instructions with understanding verbalized and agreement with the discharge plan. She would follow up as an outpatient to discuss an elective hernia repair. Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acyclovir 400 mg PO Q8H 2. Hydrochlorothiazide 25 mg PO DAILY 3. Vitamin D ___ UNIT PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID 6. Omeprazole 20 mg PO DAILY Discharge Medications 1. Polyethylene Glycol 17 g PO DAILY 2. Acyclovir 400 mg PO Q8H 3. Docusate Sodium 100 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. Omeprazole 20 mg PO DAILY RX omeprazole 20 mg 1 capsule s by mouth once a day Disp 30 Capsule Refills 0 6. Senna 8.6 mg PO BID 7. Vitamin D ___ UNIT PO DAILY Discharge Disposition Home Discharge Diagnosis Distal small bowel obstruction due to a left periumbilical hernia containing multiple small bowel loops 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 recurrent small bowel obstruction and irreducible small bowel containing incisional hernia. You were managed non operatively with bowel rest IV fluids and nasogastric tube for stomach decompression. A repeat CT scan was done which showed resolution of the obstruction and you also had begun to have reliable return of bowel function. You have been tolerating a regular diet now passing flatus and having bowel movements. You are ready to be discharged home to continue your recovery. You can follow up in clinic to discuss elective hernia repair. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following You experience new chest pain pressure squeezing or tightness. New or worsening cough shortness of breath or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting diarrhea or other reasons. Signs of dehydration include dry mouth rapid heartbeat or feeling dizzy or faint when standing. You see blood or dark black material when you vomit or have a bowel movement. You experience burning when you urinate have blood in your urine or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms or any new symptoms that concern you. Please resume all regular home medications unless specifically advised not to take a particular medication. Also please take any new medications as prescribed. Please get plenty of rest continue to ambulate several times per day and drink adequate amounts of fluids Followup Instructions ___ The icd codes present in this text will be K430, C8580, Z9484, Z85038, Z9049, I10, Z87891, E860. The descriptions of icd codes K430, C8580, Z9484, Z85038, Z9049, I10, Z87891, E860 are K430: Incisional hernia with obstruction, without gangrene; C8580: Other specified types of non-Hodgkin lymphoma, unspecified site; Z9484: Stem cells transplant status; Z85038: Personal history of other malignant neoplasm of large intestine; Z9049: Acquired absence of other specified parts of digestive tract; I10: Essential (primary) hypertension; Z87891: Personal history of nicotine dependence; E860: Dehydration. The common codes which frequently come are I10, Z87891. The uncommon codes mentioned in this dataset are K430, C8580, Z9484, Z85038, Z9049, E860.
The icd codes present in this text will be R5383, Z944, D61818, N179, I252, I2510, Z634, K589, M810, Z87310, F909, F319, F1021, Z86718, E7849, R911, J449, Z981, Z87891, I509, R9431, D509. The descriptions of icd codes R5383, Z944, D61818, N179, I252, I2510, Z634, K589, M810, Z87310, F909, F319, F1021, Z86718, E7849, R911, J449, Z981, Z87891, I509, R9431, D509 are R5383: Other fatigue; Z944: Liver transplant status; D61818: Other pancytopenia; N179: Acute kidney failure, unspecified; I252: Old myocardial infarction; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z634: Disappearance and death of family member; K589: Irritable bowel syndrome without diarrhea; M810: Age-related osteoporosis without current pathological fracture; Z87310: Personal history of (healed) osteoporosis fracture; F909: Attention-deficit hyperactivity disorder, unspecified type; F319: Bipolar disorder, unspecified; F1021: Alcohol dependence, in remission; Z86718: Personal history of other venous thrombosis and embolism; E7849: Other hyperlipidemia; R911: Solitary pulmonary nodule; J449: Chronic obstructive pulmonary disease, unspecified; Z981: Arthrodesis status; Z87891: Personal history of nicotine dependence; I509: Heart failure, unspecified; R9431: Abnormal electrocardiogram [ECG] [EKG]; D509: Iron deficiency anemia, unspecified. The common codes which frequently come are N179, I252, I2510, Z86718, J449, Z87891, D509. The uncommon codes mentioned in this dataset are R5383, Z944, D61818, Z634, K589, M810, Z87310, F909, F319, F1021, E7849, R911, Z981, I509, R9431. Allergies Penicillins rifampin Lamictal lorazepam risperidone mushrooms propofol Chief Complaint Generalized Weakness Major Surgical or Invasive Procedure None History of Present Illness ___ male with a past medical history significant for liver transplant in ___ for PBC hemorrhagic pericarditis in ___ s p pericardial window MI x2 in ___ IBS vs Crohn s disease osteoporosis with multiple pathological fractures who presents for generalized weakness. Notably the pt was admitted recently to ___ ___ at which time his presenting symptoms was also weakness. Work up was significant for ___ adrenal insufficiency and CMV viremia. He underwent a colonoscopy and EGD that were unrevealing. The pt was treated w steroids and valganciclovir and his Cr improved to baseline by time of discharge. The pt now complains of about 2 days of generalizes weakness and fatigue. Prior to that he was in his usual state of health. Also endorses low appetite nausea and some abdominal discomfort without vomiting or change in bowel movements. The pt was initially seen at ___ where labs flu swab UA and CXR were reportedly unremarkable with the exception of elevated Cr to 1.8. He was given 100 mg of Hydrocort for concerns of adrenal insufficiency. The pt was then transferred to ___ for continued care. In the ED initial VS were T 96.7 HR 64 BP 140 70 RR 16 O2 98 on RA. Exam was notable for diffuse abdominal tenderness. Labs were significant for Pancytopenia with WBC 2.7 Hbg 9.0 Plts 89 Otherwise normal chemistry panel Cr 1.2 LFTs coags lactate and U A negative Studies included CT A P with no acute intra abdominal process RUQ US w doppler with high resistance waveform in the main hepatic artery with diminished antegrade diastolic flow as well as interval decrease in peak systolic velocity 31.3 cm s nonvisualization of the right or left hepatic arteries patent portal veins and splenomegaly The pt was continued on his home medications. He was transferred to the Heparorenal service for further management. On arrival to the floor the pt endorsed the above history. Aside from the weakness nausea and abdominal pain the pt denied having and fevers chills vomiting cough or urinary frequency. He also denied any new medications recent travel or sick contacts. REVIEW OF SYSTEMS Per HPI otherwise 10 point review of systems was within normal limits. Past Medical History Attention deficit hyperactivity disorder Bipolar disorder Hemorrhoids History of alcohol abuse History of deep vein thrombosis in ___ History of hemorrhagic pericarditis complicated by cardiac tamponade status post pericardial window in ___ recurrent pericarditis in ___ History of neutropenia complicated by neutropenic fever History of positive tuberculin skin test status post INH Hyperlipidemia Osteoporosis Primary biliary cirrhosis status post orthotopic liver transplant Pulmonary nodule COPD Alternating constipation diarrhea IBS vs Crohn s Disease CAD s p MI x 2 in ___ T1 compression fx T6 burst fracture T4 8 FUSION ___ LIVER TRANSPLANT ___ Social History ___ Family History Noncontributory to the patients current admission Father passed away from head and neck cancer Physical Exam ADMISSION PHYSICAL EXAM VITALS T 97.9 BP 137 90 HR 75 RR 18 O2 98 on RA GENERAL Alert and interactive NAD CARDIAC RRR no m r g LUNGS CTAB no wheezes or crackles ABDOMEN Soft tenderness to palpation diffusely worse in midline nor rebound or guarding BS EXTREMITIES Trace edema in ___ SKIN Warm no rashes NEUROLOGIC AOx3 CNII XII intact moving extremities gait deferred DISCHARGE PHYSICAL EXAM 24 HR Data last updated ___ 812 Temp 97.5 Tm 98.6 BP 138 97 114 139 83 97 HR 67 61 74 RR 18 ___ O2 sat 98 97 98 O2 delivery Ra HEENT NC AT EOMI sclera nonicteric MMM no oropharyngeal erythema Neck No thyromegaly no thyroid nodules CV RRR S1 S2 normal RESP CTAB ABD TTP periumbilical. soft nondistended. BACK Diffuse tenderness to palpation at flanks paraspinal spinous processes inferior to rib borders EXT No C C E Pertinent Results ADMISSION LABS ___ 05 40AM tacroFK 3.2 ___ 03 04AM LACTATE 1.1 ___ 03 00AM CK CPK 38 ___ 03 00AM cTropnT 0.01 ___ 03 00AM TSH 3.2 ___ 03 00AM T4 3.9 T3 68 ___ 01 30AM ___ PTT 26.8 ___ ___ 12 05AM URINE HOURS RANDOM ___ 12 05AM URINE UHOLD HOLD ___ 12 05AM URINE COLOR Straw APPEAR Clear SP ___ ___ 12 05AM URINE BLOOD NEG NITRITE NEG PROTEIN NEG GLUCOSE NEG KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 6.5 LEUK NEG ___ 10 30PM GLUCOSE 95 UREA N 15 CREAT 1.2 SODIUM 143 POTASSIUM 3.9 CHLORIDE 107 TOTAL CO2 26 ANION GAP 10 ___ 10 30PM estGFR Using this ___ 10 30PM ALT SGPT 17 AST SGOT 17 ALK PHOS 106 TOT BILI 0.3 ___ 10 30PM LIPASE 18 ___ 10 30PM cTropnT 0.01 ___ 10 30PM ALBUMIN 3.8 CALCIUM 8.9 PHOSPHATE 3.0 MAGNESIUM 1.9 ___ 10 30PM WBC 2.7 RBC 4.11 HGB 9.0 HCT 31.4 MCV 76 MCH 21.9 MCHC 28.7 RDW 16.6 RDWSD 45.4 ___ 10 30PM NEUTS 48.9 ___ MONOS 12.5 EOS 1.1 BASOS 1.1 IM ___ AbsNeut 1.33 AbsLymp 0.98 AbsMono 0.34 AbsEos 0.03 AbsBaso 0.03 ___ 10 30PM PLT COUNT 89 PERTINENT STUDIES ___ DOPP ABD PEL 1. High resistance waveform in the main hepatic artery with diminished antegrade diastolic flow as well as interval decrease in peak systolic velocity 31.3 cm s represents a change from ultrasound of ___ and is concerning for possible occlusion. Recommend clinical correlation with LFTs and CT angiogram. 2. Patent portal veins. 3. Splenomegaly. ___ ABD PELVIS WITH CO 1. No acute intra abdominal process. 2. Unremarkable appearance of the liver transplant. The transplant main hepatic artery appears patent to level of the liver hilum. Suboptimal evaluation of the hepatic arterial vasculature on this non dedicated study. 3. Splenomegaly. ___ ABD PELVIS 1. Main left and right hepatic arteries are patent and appear similar to CTA from ___ with no evidence of focal stenosis. 2. Stable pancreatic cystic lesion is likely a side branch IPMN and can be re evaluated at next follow up. Brief Hospital Course ___ is a ___ year old male w hx of PBC s p liver transplant ___ hemorrhagic pericarditis s p window CAD c b MI x 2 ___ IBS vs Crohn s disease OA and pancytopenia who presented with generalized weakness malaise and dyspnea on exertion. Of note this is his second hospitalization for similar presentation in the last several months. Workup here as detailed below was largely unremarkable with greatest suspicion for endocrine or psychosomatic etiology of his weakness. TRANSITIONAL ISSUES Consider broader endocrine workup for fatigue including testosterone testing FSH LH If workup for other organic causes is negative consider psychiatric etiology given recent life stressors and possible referral to psychiatry We were unable to provide an appointment with cardiology while inpatient please ensure patient follows up with cardiology for his history of pericarditis and reported MI history Recommend ___ week follow up of thyroid function tests For sick day dosing recommend prednisone increase from 5 to 10mg dosing for ___ days after which he can be tapered back to 5mg. ACUTE ISSUES Fatigue Patient presented with several weeks of worsening fatigue without frank weakness associated with vague diffuse aching and tenderness across his torso. This is his second admission in several months for similar complaints. During his prior admission there were concerns for adrenal insufficiency given low AM cortisol and ACTH levels although these were checked at suboptimal timings around the time of steroid administration. For this hospitalization he presented to ___ where due to concern of adrenal insufficiency he was given 100mg hydrocortisone and transferred to ___ for further management and continuity of care. Workup here notable for low repeat AM cortisol although now in setting of hydrocortisone administration normal TSH with low T3 T4 negative CMV viral load and culture data. He additionally had CTA abdomen to evaluate hepatic vasculature admission RUQ US with decreased velocities which was unremarkable. Other endocrine etiologies were currently left unexplored. He has had prior cardiac coronary cath in ___ which was unremarkable. Of note patient s father recently passed away 3 months ago which has been a significant life stressor and associated with subjectively depressed mood anhedonia sleep disturbance and decreased energy levels. Started on prednisone 10mg on date of admission for sick day dosing. He was told to taper back to 5mg over two days at discharge. Acute Kidney Injury Patient with baseline serum creatinine of 1.0 increased to 1.6 which resolved with IV albumin administration and subsequently again to 1.3 with IVF administration. Likely in setting of poor PO intake and unrelated to ongoing above pathology. Not on diuretics. Primary Biliary Cirrhosis s p Deceased Donor Liver Tx ___ Maintained on tacrolimus 1mg BID. Prednisone dosing as above. CHRONIC ISSUES H o pericarditis Pt found to have hemorrhagic pericarditis c b tamponade s p pericardial window in ___ with recurrent pericarditis in ___ and moderate pericardial effusion seen on TTE in ___. Resolved on recent TTE ___. Continue home colchicine 0.6mg BID Continue home ASA full dose Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. BuPROPion Sustained Release 300 mg PO QAM 3. Colchicine 0.6 mg PO BID 4. OxyCODONE Immediate Release 5 mg PO Q6H PRN Pain Moderate 5. Pantoprazole 40 mg PO Q24H 6. Ranitidine 150 mg PO DAILY 7. Tacrolimus 1 mg PO QAM 8. Tacrolimus 1 mg PO QPM 9. Senna 8.6 mg PO BID 10. DICYCLOMine 20 mg PO BID diarrhea 11. Gabapentin 800 mg PO BID 12. Naloxone Nasal Spray 4 mg IH ONCE MR1 13. Aspirin 325 mg PO DAILY 14. PredniSONE 5 mg PO DAILY 15. Ondansetron ODT 4 mg PO Q8H PRN Nausea Vomiting First Line 16. Polyethylene Glycol 17 g PO DAILY PRN Constipation Third Line 17. DICYCLOMine 10 mg PO DAILY PRN Abd pain cramping Discharge Medications 1. Ursodiol 500 mg PO BID 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. BuPROPion Sustained Release 300 mg PO QAM 5. Colchicine 0.6 mg PO BID 6. DICYCLOMine 20 mg PO BID diarrhea 7. DICYCLOMine 10 mg PO DAILY PRN Abd pain cramping 8. Gabapentin 800 mg PO BID 9. Naloxone Nasal Spray 4 mg IH ONCE MR1 10. Ondansetron ODT 4 mg PO Q8H PRN Nausea Vomiting First Line 11. OxyCODONE Immediate Release 5 mg PO Q6H PRN Pain Moderate 12. Pantoprazole 40 mg PO Q24H 13. Polyethylene Glycol 17 g PO DAILY PRN Constipation Third Line 14. PredniSONE 5 mg PO DAILY Please start this on ___. Ranitidine 150 mg PO DAILY 16. Tacrolimus 1 mg PO QAM 17. Tacrolimus 1 mg PO QPM Discharge Disposition Home Discharge Diagnosis Fatigue Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Thank you for coming to ___ for your care. Please read the following instructions carefully Why was I admitted to the hospital You were admitted to the hospital because you have been having shortness of breath with activities general feelings of weakness and pain throughout her back and abdomen. What was done for me while I was here We performed several blood tests and a CAT scan to ensure that there are no serious or life threatening causes of your symptoms We believe that the issues you are currently having will be better addressed with the doctors in ___ What do I need to do when I leave the hospital Please take your medications as listed below Tomorrow please take 7.5mg of prednisone and you can resume your normal dose of 5mg daily on ___ Please keep your appointments as listed below It is very important that you continue to follow with the cardiologist due to your history of pericarditis. The information to contact their office is below We wish you the best with your care Your ___ care team Followup Instructions ___ The icd codes present in this text will be R5383, Z944, D61818, N179, I252, I2510, Z634, K589, M810, Z87310, F909, F319, F1021, Z86718, E7849, R911, J449, Z981, Z87891, I509, R9431, D509. The descriptions of icd codes R5383, Z944, D61818, N179, I252, I2510, Z634, K589, M810, Z87310, F909, F319, F1021, Z86718, E7849, R911, J449, Z981, Z87891, I509, R9431, D509 are R5383: Other fatigue; Z944: Liver transplant status; D61818: Other pancytopenia; N179: Acute kidney failure, unspecified; I252: Old myocardial infarction; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z634: Disappearance and death of family member; K589: Irritable bowel syndrome without diarrhea; M810: Age-related osteoporosis without current pathological fracture; Z87310: Personal history of (healed) osteoporosis fracture; F909: Attention-deficit hyperactivity disorder, unspecified type; F319: Bipolar disorder, unspecified; F1021: Alcohol dependence, in remission; Z86718: Personal history of other venous thrombosis and embolism; E7849: Other hyperlipidemia; R911: Solitary pulmonary nodule; J449: Chronic obstructive pulmonary disease, unspecified; Z981: Arthrodesis status; Z87891: Personal history of nicotine dependence; I509: Heart failure, unspecified; R9431: Abnormal electrocardiogram [ECG] [EKG]; D509: Iron deficiency anemia, unspecified. The common codes which frequently come are N179, I252, I2510, Z86718, J449, Z87891, D509. The uncommon codes mentioned in this dataset are R5383, Z944, D61818, Z634, K589, M810, Z87310, F909, F319, F1021, E7849, R911, Z981, I509, R9431.
The icd codes present in this text will be K208, N179, D696, E440, Z944, I319, B0089, E7800, F319, K3184, Z6823, K2970, F1011, F909, M810, J449, I509, Z86718, Z9181, Z87891. The descriptions of icd codes K208, N179, D696, E440, Z944, I319, B0089, E7800, F319, K3184, Z6823, K2970, F1011, F909, M810, J449, I509, Z86718, Z9181, Z87891 are K208: Other esophagitis; N179: Acute kidney failure, unspecified; D696: Thrombocytopenia, unspecified; E440: Moderate protein-calorie malnutrition; Z944: Liver transplant status; I319: Disease of pericardium, unspecified; B0089: Other herpesviral infection; E7800: Pure hypercholesterolemia, unspecified; F319: Bipolar disorder, unspecified; K3184: Gastroparesis; Z6823: Body mass index [BMI] 23.0-23.9, adult; K2970: Gastritis, unspecified, without bleeding; F1011: Alcohol abuse, in remission; F909: Attention-deficit hyperactivity disorder, unspecified type; M810: Age-related osteoporosis without current pathological fracture; J449: Chronic obstructive pulmonary disease, unspecified; I509: Heart failure, unspecified; Z86718: Personal history of other venous thrombosis and embolism; Z9181: History of falling; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, D696, J449, Z86718, Z87891. The uncommon codes mentioned in this dataset are K208, E440, Z944, I319, B0089, E7800, F319, K3184, Z6823, K2970, F1011, F909, M810, I509, Z9181. Allergies Penicillins rifampin Lamictal lorazepam risperidone mushrooms Chief Complaint chest pain difficulty swallowing Major Surgical or Invasive Procedure EGD with esophageal and gastric biopsies ___ History of Present Illness ___ yo M primary biliary cirrhosis s p orthotopic liver transplant prior hemorrhagic pericarditis with tamponade requiring pericardial window ___ gastritis prior DVT HLD and bipolar disorder who presents with pain with swallowing for the past 4 days. Four days prior to presentation the patient was eating a cheesesteak when he noticed a stabbing pain in his mid chest with swallowing both liquids and solids. He describes the pain as a stabbing sensation worse with hot things that spreads throughout his chest bilaterally and radiates to his right arm. Maalox Benadryl lidocaine makes the pain somewhat better. The pain is not worse with lying down. He reports that he has woken up with chest pain in the middle of the night before but not within the last 4 days. He says that this pain is distinctly different than his pain with his pericarditis and his MIs and does not remember ever having experienced anything like this previously. He takes a PPI daily. He has been able to tolerate PO with difficulty. He denies foreign body sensation. He contacted his transplant hepatologist who recommended he present to the ED. Of note he does report increase in SOB. Normally he is able to walk up several flights without difficulty however recently he becomes winded with 1 flight. Patient reports he has a history of COPD but does not take any medications for it because he does not like them. He reports a history of CHF but has not had any exacerbations since his liver transplant. Patient reports compliance with his immunosuppressives and denies oral thrush. Also of note about 2 weeks prior to presentation he had a fall when he slipped on the floor. He does not remember having a headstrike. Per patient his PCP increased his prednisone to 60 mg day after this incident with a taper of 5 days of 60 5 days of 40 5 days of 20. His last dose of 20 mg was the day prior to presentation and he is now taking 5 mg daily. Per chart review he picked up 20 mg of Prednisone from his pharmacy on ___. He denies fever chills cough and N V though he had an elevated temp of 99.9 on the evening prior to presentation. He has chronic non bloody diarrhea that he reports as pudding to watery and has ___ bowel movements day normally. No recent changes in bowel movements. Cardiology clinic outpatient notes significant for a hospitalization in ___ for sharp tight chest pain that radiated to L shoulder not associated with exertion with endoscopy showing diffuse gastritis. At that time his ASA was stopped and he was discharged on PPI and sucralfate with an increase in his colchicine. In the ED Initial vital signs were notable for Pain ___ T 97.4 HR 100 BP 147 84 RR 20 100 RA Exam notable for Dry mucous membranes Nontender neck on palpation Labs were notable for Crea of 1.5 baseline 1.2 1.5 BUN 15 Alt 20 Ast 19 AP 203 Tbili 1.3 Alb 3.7 WBC 6.5 N79.0 L11.0 H H ___ platelets 60 ___ 11.4 PTT 23.9 INR 1.1 Studies performed include ___ CXR FINDINGS Streaky left basilar opacities are most likely due to atelectasis and or scarring. The lungs are otherwise clear without consolidation effusion or pneumothorax. There is biapical scarring again noted. Cardiomediastinal silhouette is stable noting prominent fat along the mediastinum superiorly. There is no pneumomediastinum. No free intraperitoneal air. No acute osseous abnormalities. IMPRESSION No acute cardiopulmonary process. Patient was given 1L NS bolus and 1L LR Started on full liquid diet Consults Hepatology Recommended Labs please obtain barium study Esophagus to evaluate for strictures CXR If above work up is negative will likely need EGD tomorrow Will need daily tacro levels Please admit to ET under Dr. ___ ___ on transfer T97.8 BP 117 80 HR 74 RR16 99 RA Upon arrival to the floor the patient was eating dinner comfortably NAD. He reports increased pain with hot liquids. Past Medical History Primary biliary cirrhosis s p orthotopic liver transplant Neutropenia c b neutropenic fever DVT ___ Prior Alcohol abuse Hemorrhagic pericarditis c b tamponade s p pericardial window ___ recurrent pericarditis ___. Positive PPD s p INH Hyperlipidemia Osteoporosis Bipolar disorder ADHD Hemorrhoids Social History ___ Family History Mother thyroid disease Father head and neck cancer deceased Physical Exam Admission Physical VITALS 97.8 PO 117 80 HR 74 RR16 99 RA GENERAL Alert and interactive. In no acute distress. HEENT Normocephalic atraumatic. Pupils equal round and reactive bilaterally extraocular muscles intact. Sclera anicteric and without injection. Moist mucous membranes edentulous. Oropharynx is clear. NECK No cervical lymphadenopathy. CARDIAC Regular rhythm normal rate. Audible S1 and S2. No murmurs rubs gallops. Tenderness to palpation at the xyphoid process and the right lower ribs. LUNGS Clear to auscultation bilaterally in apices crackles in the bases bilaterally that clear with deep breaths. No wheezes rhonchi or rales. No increased work of breathing. BACK No CVA tenderness. ABDOMEN Normal bowels sounds non distended tenderness to palpation in the epigastrium. EXTREMITIES No clubbing cyanosis or edema. Pulses DP Radial 2 bilaterally. SKIN Warm. No rash. NEUROLOGIC CN2 12 intact. ___ strength throughout. Normal sensation. Discharge Physical VITALS ___ 0740 Temp 98.0 PO BP 111 78 HR 91 RR 18 O2 sat 96 O2 delivery Ra GENERAL Laying in bed NAD pleasant HEENT sclerae anicteric MMM poor dentition CARDIAC RRR nl s1 s2 no m r g t LUNGS Clear to auscultation bilaterally. No wheezes rhonchi or rales. No increased work of breathing. ABDOMEN Normal bowel sounds non distended non tender. EXTREMITIES warm well perfused no clubbing cyanosis or lower extremity edema. NEUROLOGIC AOx3 no facial asymmetry moving all extremities Pertinent Results ADMISSION LABS ___ 09 00AM BLOOD WBC 6.5 RBC 5.38 Hgb 15.2 Hct 45.2 MCV 84 MCH 28.3 MCHC 33.6 RDW 15.1 RDWSD 45.4 Plt Ct 60 ___ 09 00AM BLOOD Neuts 79.0 Lymphs 11.0 Monos 8.2 Eos 0.6 Baso 0.3 Im ___ AbsNeut 5.10 AbsLymp 0.71 AbsMono 0.53 AbsEos 0.04 AbsBaso 0.02 ___ 09 00AM BLOOD ___ PTT 23.9 ___ ___ 09 00AM BLOOD Glucose 101 UreaN 15 Creat 1.5 Na 136 K 4.0 Cl 98 HCO3 24 AnGap 14 ___ 09 00AM BLOOD ALT 20 AST 19 AlkPhos 203 TotBili 1.3 ___ 09 00AM BLOOD Albumin 3.7 ___ 11 55PM BLOOD Calcium 8.0 Phos 2.1 Mg 2.5 PERTINENT INTERVAL LABS ___ 05 17AM BLOOD ALT 15 AST 12 LD LDH 250 AlkPhos 167 TotBili 0.7 ___ 05 17AM BLOOD CK MB 1 cTropnT 0.01 ___ 02 41PM URINE bnzodzp NEG opiates NEG cocaine NEG amphetm NEG oxycodn NEG mthdone NEG DISCHARGE LABS ___ 05 30AM BLOOD WBC 2.9 RBC 4.47 Hgb 12.7 Hct 37.0 MCV 83 MCH 28.4 MCHC 34.3 RDW 15.5 RDWSD 45.8 Plt Ct 78 ___ 05 30AM BLOOD Neuts 46.3 ___ Monos 9.0 Eos 2.8 Baso 1.0 Im ___ AbsNeut 1.34 AbsLymp 1.12 AbsMono 0.26 AbsEos 0.08 AbsBaso 0.03 ___ 05 30AM BLOOD Glucose 81 UreaN 12 Creat 1.2 Na 139 K 3.6 Cl 104 HCO3 24 AnGap 11 ___ 05 30AM BLOOD Calcium 7.7 Phos 2.8 Mg 2.0 ___ 05 30AM BLOOD 25VitD 20 ___ 05 30AM BLOOD tacroFK 5.1 MICROBIOLOGY Blood Culture ___ No Growth Final IMAGING AND STUDIES ___ CXR Streaky left basilar opacities are most likely due to atelectasis and or scarring. The lungs are otherwise clear without consolidation effusion or pneumothorax. There is biapical scarring again noted. Cardiomediastinal silhouette is stable noting prominent fat along the mediastinum superiorly. There is no pneumomediastinum. No free intraperitoneal air. No acute osseous abnormalities. ___ EGD Gastritis biopsied Ulcers in distal esophagus biopsied ___ CXR PA and LAT Comparison to ___. New subtle parenchymal opacities at the left and the right lung basis could reflect recent or developing pneumonia. Stable normal size of the heart. Moderate widening and relatively dense mediastinum is likely caused by a mild degree of mediastinal lipomatosis as documented on a previous CT examination from ___. No pleural effusions. No pneumothorax. Brief Hospital Course PATIENT SUMMARY ___ yo M primary biliary cirrhosis s p orthotopic liver transplant prior hemorrhagic pericarditis with tamponade requiring pericardial window ___ gastritis prior DVT HLD and bipolar disorder who presented with pain with swallowing found to have HSV esophagitis. ACUTE ISSUES HSV Esophagitis Presented with several days of pain with swallowing with prior episode of central chest pain that was thought to be a costochondritis flare but my have been esophagitis. Per EGD esophageal mucosa demonstrated evidence of friable with punched out lesions. Given recent prednisone burst two weeks prior to admission patient was likely even more immunocompromised than baseline. Preliminary pathology was consistent with HSV esophagitis so the patient was started on acyclovir with plan to complete a course for 3 weeks with outpatient transplant ID followup. Of note gastric mucosa also showed non specific inflammation and was biopsied. Final pathology results are pending. Acute Kidney Injury Moderate Malnutrition Likely difficulty swallowing over past few weeks has caused decreased PO intake and contributed to moderately malnourished state as well as ___. Patient s ___ was prerenal and improved with fluid administration. Thrombocytopenia Chronic and stable during hospitalization. s p Liver Transplant Patient with PBC status post liver transplant in ___ complicated by recurrent pericarditis requiring pericardial window. Alk phos elevated consistent with outpatient levels and elevated anti mitochondrial Ab. Patient currently stable on tacrolimus and prednisone. CHRONIC ISSUES Gastroparesis Patient with history of gastroparesis per chart. He initially denied nausea and vomiting but was thought to contribute to the patients esophageal pain as above. Bipolar Disorder Continued on home wellbutrin. History of Pericarditis No rub on exam. No positional change in chest pain. Holding home ASA in setting of esophagitis gastritis. Home colchicine initially decreased to daily instead of BID given ___. Hypercholesterolemia Continued home atorvastatin. TRANSITIONAL ISSUES HSV Esophagitis patient to take acyclovir 800mg TID for 3 weeks ending on ___ New Meds See Med sheet. Consider outpatient evaluation for esophageal dysmotility if continuing to have symptoms of nausea and vomiting Patient to have twice weekly CBC to monitor leukopenia coordinated through liver clinic CODE Full presumed CONTACT ___ Sister ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Aspirin 650 mg PO DAILY 2. Colchicine 0.6 mg PO BID hx of pericarditis 3. Tacrolimus 1 mg PO Q12H 4. PredniSONE 5 mg PO DAILY 5. Gabapentin 600 mg PO BID 6. Atorvastatin 10 mg PO QPM 7. Vitamin D ___ UNIT PO 1X WEEK FR 8. DICYCLOMine 20 mg PO QID 9. Ranitidine 150 mg PO BID 10. Maalox Diphenhydramine Lidocaine ___ mL PO TID PRN odynophagia 11. Ondansetron 4 mg PO Q8H PRN nausea secondary to gastroparesis 12. BuPROPion XL Once Daily 150 mg PO DAILY Discharge Medications 1. Acetaminophen 650 mg PO Q6H 2. Acyclovir 800 mg PO Q8H RX acyclovir 800 mg 1 tablet s by mouth three times a day Disp 55 Tablet Refills 0 3. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 4. Sucralfate 1 gm PO QID RX sucralfate 1 gram 1 tablet s by mouth four times a day Disp 120 Tablet Refills 0 5. TraMADol 25 mg PO BID PRN Pain Moderate Reason for PRN duplicate override Alternating agents for similar severity RX tramadol 50 mg 0.5 One half tablet s by mouth twice a day Disp 3 Tablet Refills 0 6. Ursodiol 300 mg PO TID RX ursodiol 300 mg 1 capsule s by mouth three times a day Disp 90 Capsule Refills 0 7. Atorvastatin 10 mg PO QPM 8. BuPROPion XL Once Daily 150 mg PO DAILY 9. Colchicine 0.6 mg PO BID hx of pericarditis 10. DICYCLOMine 20 mg PO QID 11. Gabapentin 600 mg PO BID 12. Maalox Diphenhydramine Lidocaine ___ mL PO TID PRN odynophagia 13. Ondansetron 4 mg PO Q8H PRN nausea secondary to gastroparesis 14. PredniSONE 5 mg PO DAILY RX prednisone 5 mg 1 tablet s by mouth once a day Disp 30 Tablet Refills 0 15. Ranitidine 150 mg PO BID 16. Tacrolimus 1 mg PO Q12H RX tacrolimus Astagraf XL 1 mg 1 capsule s by mouth every twelve 12 hours Disp 60 Capsule Refills 0 17. Vitamin D ___ UNIT PO 1X WEEK FR 18. HELD Aspirin 650 mg PO DAILY This medication was held. Do not restart Aspirin until you you discuss further with your PCP ___ Home Discharge Diagnosis Primary Diagnoses HSV esophagitis ___ s p Liver transplant Secondary Diagnoses Bipolar Disorder Pericarditis Hypercholesterolemia 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 WHY DID YOU COME TO THE HOSPITAL You were having pain with swallowing WHAT HAPPENED TO YOU DURING YOUR HOSPITAL STAY We checked your esophagus the tube that brings food from your mouth to your stomach and found that it was infected We gave you medication to help control the pain from the infection as well as to treat the virus and to assist in healing WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL Take all of your medications as prescribed Keep all of your appointments as schedule We wish you the best Your ___ Care Team Followup Instructions ___ The icd codes present in this text will be K208, N179, D696, E440, Z944, I319, B0089, E7800, F319, K3184, Z6823, K2970, F1011, F909, M810, J449, I509, Z86718, Z9181, Z87891. The descriptions of icd codes K208, N179, D696, E440, Z944, I319, B0089, E7800, F319, K3184, Z6823, K2970, F1011, F909, M810, J449, I509, Z86718, Z9181, Z87891 are K208: Other esophagitis; N179: Acute kidney failure, unspecified; D696: Thrombocytopenia, unspecified; E440: Moderate protein-calorie malnutrition; Z944: Liver transplant status; I319: Disease of pericardium, unspecified; B0089: Other herpesviral infection; E7800: Pure hypercholesterolemia, unspecified; F319: Bipolar disorder, unspecified; K3184: Gastroparesis; Z6823: Body mass index [BMI] 23.0-23.9, adult; K2970: Gastritis, unspecified, without bleeding; F1011: Alcohol abuse, in remission; F909: Attention-deficit hyperactivity disorder, unspecified type; M810: Age-related osteoporosis without current pathological fracture; J449: Chronic obstructive pulmonary disease, unspecified; I509: Heart failure, unspecified; Z86718: Personal history of other venous thrombosis and embolism; Z9181: History of falling; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, D696, J449, Z86718, Z87891. The uncommon codes mentioned in this dataset are K208, E440, Z944, I319, B0089, E7800, F319, K3184, Z6823, K2970, F1011, F909, M810, I509, Z9181.

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