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The icd codes present in this text will be G3183, F0280, R441, R296, E785, Z8546. The descriptions of icd codes G3183, F0280, R441, R296, E785, Z8546 are G3183: Dementia with Lewy bodies; F0280: Dementia in other diseases classified elsewhere without behavioral disturbance; R441: Visual hallucinations; R296: Repeated falls; E785: Hyperlipidemia, unspecified; Z8546: Personal history of malignant neoplasm of prostate. The common codes which frequently come are E785. The uncommon codes mentioned in this dataset are G3183, F0280, R441, R296, Z8546.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Visual hallucinations Major Surgical or Invasive Procedure N A History of Present Illness ___ male with ___ disease dyslipidemia and a history of prostate cancer s p prostatectomy who was referred to the ED by his neurologist for worsening gait falls and visual hallucinations. The following history is taken from chart review The patient was seen by his neurologist on ___ at which time he was noted to have visual hallucinations and worsening gait freezing. For his gait freezing his mirapex was increased by 0.125 mg every week to a goal dose of 0.75 mg t.i.d. He successfully up titrated the medicine to 0.75 0.625 0.625 but began to have visual hallucinations and confusion so on ___ his neurologist recommended decreasing the dose to 0.625 TID. Despite the changes to his Mirapex the patient s daughter has noted progressive gait stiffness and increased difficulty standing. This has resulted in difficulty with simply getting to the bathroom leading to episodes of incontinence. A UA performed on ___ was reassuring. On the day of presentation to the hospital the patient began to experience visual hallucinations of a motor cross race in his backyard. He subsequently had a fall while transferring from the couch to a chair. His wife was unable to get him off the floor. The fall was witnessed and there was no head strike. Per the patient s wife his gait has acutely worsened over the past 24 hours to the point where he has been unable to ambulate on his own. The patient s daughter called his neurologist who recommended presentation to the ED. In the ED the patient was afebrile HRs ___ normotensive and SpO2 100 RA. On exam he was noted to have cogwheeling of upper extremities and decrease ___ strength. Labs were remarkable for a negative urine and serum tox Na 132 K 5.8 hemolyzed and no EKG changes negative troponin normal LFTs unremarkable CBC. Chest Xray showed no acute process and CTH was reassuring. He was evaluated by neurology who recommended admission to medicine for failure to thrive to continue the patient s home medications and complete a toxo metabolic workup. The patient was given his home pramipexole and pravastatin before he was admitted. On arrival to the floor the patient is comfortable in bed. He is not accompanied by family on my interview. He knows that he is in the hospital and that it is ___. He is not sure why he is here and begins to tell me about a party in his house with a motor cross race in his backyard. When I asked him about his fall he mentions that he has not had a fall for ___ years. He denies any fevers chills cough chest pain abdominal pain nausea diarrhea or dysuria. REVIEW OF SYSTEMS Per HPI otherwise 10 point review of systems was within normal limits. Past Medical History ___ disease ___ Body Dementia dyslipidemia prostate cancer s p prostatectomy Social History ___ Family History His mother died at age ___ of old age. His father died of prostate cancer at ___. He has an older sister age ___ and a younger sister age ___. He has a younger brother age ___. As noted he has 2 daughters. There is no family history of neurologic illness or dementia. There is no family history of neurodevelopmental mental disorders such as learning disability or ADHD. There is no family history of psychiatric problems. Physical Exam ADMISSION PHYSICAL EXAM VITALS reviewed in OMR GENERAL Alert and interactive. In no acute distress. HEENT PERRL EOMI. Sclera anicteric and without injection. MMM. NECK No cervical lymphadenopathy. No JVD. CARDIAC Regular rhythm normal rate. Audible S1 and S2. No murmurs rubs gallops. LUNGS Clear to auscultation bilaterally. No wheezes rhonchi or rales. No increased work of breathing. BACK No CVA tenderness. ABDOMEN Normal bowels sounds non distended non tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES No clubbing cyanosis or edema. Pulses DP Radial 2 bilaterally. SKIN Warm. Cap refill 2s. No rashes. NEUROLOGIC AOx3. CN2 12 intact. cogwheel UE b l. Increased tone in LEs ___ strength b l ___. Normal sensation. DISCHARGE PHYSICAL EXAM 24 HR Data last updated ___ 2340 Temp 97.7 Tm 98.4 BP 130 80 130 153 80 90 HR 80 80 104 RR 18 ___ O2 sat 100 95 100 O2 delivery Ra GENERAL In no acute distress. Talking very quietly. CARDIAC Regular rhythm normal rate. Audible S1 and S2. No murmurs rubs gallops. LUNGS Clear to auscultation bilaterally. No wheezes rhonchi or rales. No increased work of breathing. ABDOMEN Normal bowels sounds non distended non tender to deep palpation in all four quadrants. EXTREMITIES No clubbing cyanosis or edema. Pulses DP Radial 2 bilaterally. SKIN Warm. NEUROLOGIC AOx3. CN2 12 intact. cogwheel UE b l. Increased tone in LEs ___ strength b l ___. Normal sensation. Pertinent Results ADMISSION LABS ___ 10 30PM BLOOD WBC 8.6 RBC 4.03 Hgb 12.8 Hct 38.2 MCV 95 MCH 31.8 MCHC 33.5 RDW 13.0 RDWSD 45.2 Plt ___ ___ 10 30PM BLOOD Neuts 48.1 ___ Monos 15.9 Eos 2.0 Baso 0.6 Im ___ AbsNeut 4.13 AbsLymp 2.86 AbsMono 1.36 AbsEos 0.17 AbsBaso 0.05 ___ 10 30PM BLOOD ___ PTT 23.4 ___ ___ 10 30PM BLOOD Glucose 100 UreaN 17 Creat 0.8 Na 132 K 5.8 Cl 98 HCO3 19 AnGap 15 ___ 10 30PM BLOOD ALT 18 AST 38 AlkPhos 39 TotBili 0.4 ___ 10 30PM BLOOD Lipase 47 ___ 10 30PM BLOOD cTropnT 0.01 ___ 10 30PM BLOOD Albumin 4.0 Calcium 9.9 Phos 3.7 Mg 2.0 ___ 10 30PM BLOOD VitB12 570 ___ 10 30PM BLOOD TSH 1.4 ___ 07 00AM BLOOD Trep Ab NEG ___ 10 30PM BLOOD ASA NEG Ethanol NEG Acetmnp NEG Tricycl NEG IMAGING ___ Imaging CT HEAD W O CONTRAST FINDINGS There is no evidence of infarction hemorrhage edema or mass. There is prominence of the ventricles and sulci suggestive of involutional changes. There is no evidence of fracture. The visualized portion of the remaining paranasal sinuses and middle ear cavities are clear. The visualized portion of the orbits are unremarkable apart from bilateral lens replacements. IMPRESSION 1. No acute intracranial abnormality. No hydrocephalus. ___ Imaging CHEST PA LAT IMPRESSION Mild atelectasis in the lung bases without focal consolidation. Age indeterminate moderate to severe compression deformity of a low thoracic vertebral body. DISCHARGE LABS ___ 06 21AM BLOOD WBC 7.0 RBC 4.02 Hgb 12.9 Hct 38.1 MCV 95 MCH 32.1 MCHC 33.9 RDW 12.8 RDWSD 44.4 Plt ___ ___ 06 21AM BLOOD Glucose 88 UreaN 10 Creat 0.7 Na 140 K 4.0 Cl 104 HCO3 24 AnGap 12 ___ 06 21AM BLOOD Calcium 9.5 Phos 3.2 Mg 1.___ male with ___ disease dyslipidemia and a history of prostate cancer s p prostatectomy who was referred to the ED by his neurologist for worsening gait falls and visual hallucinations concerning for progression of his neurologic disorder. ACUTE ACTIVE ISSUES ___ disease ___ Body Dementia Visual Hallucinations The patient appears to have acute on chronic progression of his ___ disease. Unclear if this is disease progression or underlying medical cause. Continued mirapex rasagiline and rivastigmine. Neurology recommended started Seroquel for his hallucinations. He was evaluated by physical therapy who recommended rehab. This recommendation was discussed with the family who opted for discharge to home with home physical therapy as this was in line with the patient s goals of care. TRANSITIONAL ISSUES f u visual hallucination symptoms on Seroquel f u physical therapy at home Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Rasagiline 1 mg PO DAILY 2. Pramipexole 0.625 mg PO TID 3. rivastigmine 9.5 mg 24 hr transdermal DAILY 4. Pravastatin 40 mg PO QPM 5. Cyanocobalamin Dose is Unknown PO DAILY 6. Loratadine 10 mg PO DAILY Discharge Medications 1. QUEtiapine Fumarate 25 mg PO QHS RX quetiapine 25 mg 1 tablet s by mouth AT NIGHT Disp 30 Tablet Refills 0 2. Loratadine 10 mg PO DAILY 3. Pramipexole 0.625 mg PO TID 4. Pravastatin 40 mg PO QPM 5. Rasagiline 1 mg PO DAILY 6. rivastigmine 9.5 mg 24 hr transdermal DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis ___ Dementia Discharge Condition Mental Status Confused sometimes. Level of Consciousness Alert and interactive. Discharge Instructions Dear Mr. ___ It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL You were sent to the emergency room by your neurologist who was concerned that you were having visual hallucinations. WHAT HAPPENED TO ME IN THE HOSPITAL You were started on a new medication to help treat your symptoms. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL Continue to take all your medicines and keep your appointments. We wish you the best Sincerely Your ___ Team Followup Instructions ___
The icd codes present in this text will be G3183, F0280, R441, R296, E785, Z8546. The descriptions of icd codes G3183, F0280, R441, R296, E785, Z8546 are G3183: Dementia with Lewy bodies; F0280: Dementia in other diseases classified elsewhere without behavioral disturbance; R441: Visual hallucinations; R296: Repeated falls; E785: Hyperlipidemia, unspecified; Z8546: Personal history of malignant neoplasm of prostate. The common codes which frequently come are E785. The uncommon codes mentioned in this dataset are G3183, F0280, R441, R296, Z8546. |
The icd codes present in this text will be R1310, R0989, K31819, K219, K449, F419, I341, M810, Z87891. The descriptions of icd codes R1310, R0989, K31819, K219, K449, F419, I341, M810, Z87891 are R1310: Dysphagia, unspecified; R0989: Other specified symptoms and signs involving the circulatory and respiratory systems; K31819: Angiodysplasia of stomach and duodenum without bleeding; K219: Gastro-esophageal reflux disease without esophagitis; K449: Diaphragmatic hernia without obstruction or gangrene; F419: Anxiety disorder, unspecified; I341: Nonrheumatic mitral (valve) prolapse; M810: Age-related osteoporosis without current pathological fracture; Z87891: Personal history of nicotine dependence. The common codes which frequently come are K219, F419, Z87891. The uncommon codes mentioned in this dataset are R1310, R0989, K31819, K449, I341, M810.
Allergies omeprazole Chief Complaint dysphagia Major Surgical or Invasive Procedure Upper endoscopy ___ History of Present Illness ___ w anxiety and several years of dysphagia who p w worsened foreign body sensation. She describes feeling as though food gets stuck in her neck when she eats. She put herself on a pureed diet to address this over the last 10 days. When she has food stuck in the throat she almost feels as though she cannot breath but she denies trouble breathing at any other time. She does not have any history of food allergies or skin rashes. In the ED initial vitals 97.6 81 148 83 16 100 RA Imaging showed CXR showed a prominent esophagus Consults GI was consulted. Pt underwent EGD which showed a normal appearing esophagus. Biopsies were taken. Currently she endorses anxiety about eating. She would like to try eating here prior to leaving the hospital. Past Medical History GERD Hypercholesterolemia Kidney stones Mitral valve prolapse Uterine fibroids Osteoporosis Migraine headaches Social History ___ Family History HTN father Dementia father Physical Exam ADMISSION DISCHARGE EXAM VS 97.9 PO 109 71 70 16 97 ra GEN Thin anxious woman lying in bed no acute distress HEENT Moist MM anicteric sclerae NCAT PERRL EOMI NECK Supple without LAD no JVD PULM CTABL no w c r COR RRR S1 S2 no m r g ABD Soft non tender non distended BS no HSM EXTREM Warm well perfused no ___ edema NEURO CN II XII grossly intact motor function grossly normal sensation grossly intact Pertinent Results ADMISSION LABS ___ 08 27AM BLOOD WBC 5.0 RBC 4.82 Hgb 14.9 Hct 44.4 MCV 92 MCH 30.9 MCHC 33.6 RDW 12.1 RDWSD 41.3 Plt ___ ___ 08 27AM BLOOD ___ PTT 28.6 ___ ___ 08 27AM BLOOD Glucose 85 UreaN 8 Creat 0.9 Na 142 K 3.6 Cl 104 HCO3 22 AnGap 20 ___ 08 27AM BLOOD ALT 11 AST 16 LD LDH 154 AlkPhos 63 TotBili 1.0 ___ 08 27AM BLOOD Albumin 4.8 IMAGING CXR ___ IMPRESSION Prominent esophagus on lateral view without air fluid level. Given the patient s history and radiographic appearance barium swallow is indicated either now or electively. NECK X ray ___ IMPRESSION Within the limitation of plain radiography no evidence of prevertebral soft tissue swelling or soft tissue mass in the neck. EGD ___ Impression Hiatal hernia Angioectasia in the stomach Angioectasia in the duodenum biopsy biopsy Otherwise normal EGD to third part of the duodenum Recommendations no obvious anatomic cause for the patient s symptoms follow up biopsy results to rule out eosinophilic esophagitis follow up with Dr. ___ if biopsies show eosinophilic esophagitis Brief Hospital Course Ms. ___ is a ___ with history of GERD who presents with subacute worsening of dysphagia and foreign body sensation. This had worsened to the point where she placed herself on a pureed diet for the last 10 days. She underwent CXR which showed a prominent esophagus but was otherwise normal. She was evaluated by Gastroenterology and underwent an upper endoscopy on ___. This showed a normal appearing esophagus. Biopsies were taken. TRANSITIONAL ISSUES f u biopsies from EGD if results show eosinophilic esophagitis follow up with Dr. ___. ___ for management pt should undergo barium swallow as an outpatient for further workup of her dysphagia f u with ENT as planned Code Full presumed Medications on Admission The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO BID Discharge Medications 1. Omeprazole 20 mg PO BID Discharge Disposition Home Discharge Diagnosis PRIMARY DIAGNOSIS dysphagia and foreign body sensation SECONDARY DIAGNOSIS GERD Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ You were hospitalized at ___. You came in due to difficulty swallowing. You had an endoscopy to look for any abnormalities in the esophagus. Thankfully this was normal. They took biopsies and you will be called with the results. You should have a test called a barium swallow as an outpatient. We wish you all the best Your ___ Team Followup Instructions ___
The icd codes present in this text will be R1310, R0989, K31819, K219, K449, F419, I341, M810, Z87891. The descriptions of icd codes R1310, R0989, K31819, K219, K449, F419, I341, M810, Z87891 are R1310: Dysphagia, unspecified; R0989: Other specified symptoms and signs involving the circulatory and respiratory systems; K31819: Angiodysplasia of stomach and duodenum without bleeding; K219: Gastro-esophageal reflux disease without esophagitis; K449: Diaphragmatic hernia without obstruction or gangrene; F419: Anxiety disorder, unspecified; I341: Nonrheumatic mitral (valve) prolapse; M810: Age-related osteoporosis without current pathological fracture; Z87891: Personal history of nicotine dependence. The common codes which frequently come are K219, F419, Z87891. The uncommon codes mentioned in this dataset are R1310, R0989, K31819, K449, I341, M810. |
The icd codes present in this text will be S72012A, W010XXA, Y93K1, Y92480, K219, E7800, I341, G43909, Z87891, Z87442, F419, M810, Z7901. The descriptions of icd codes S72012A, W010XXA, Y93K1, Y92480, K219, E7800, I341, G43909, Z87891, Z87442, F419, M810, Z7901 are S72012A: Unspecified intracapsular fracture of left femur, initial encounter for closed fracture; W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter; Y93K1: Activity, walking an animal; Y92480: Sidewalk as the place of occurrence of the external cause; K219: Gastro-esophageal reflux disease without esophagitis; E7800: Pure hypercholesterolemia, unspecified; I341: Nonrheumatic mitral (valve) prolapse; G43909: Migraine, unspecified, not intractable, without status migrainosus; Z87891: Personal history of nicotine dependence; Z87442: Personal history of urinary calculi; F419: Anxiety disorder, unspecified; M810: Age-related osteoporosis without current pathological fracture; Z7901: Long term (current) use of anticoagulants. The common codes which frequently come are K219, Z87891, F419, Z7901. The uncommon codes mentioned in this dataset are S72012A, W010XXA, Y93K1, Y92480, E7800, I341, G43909, Z87442, M810.
Allergies omeprazole Iodine and Iodide Containing Products hallucinogens Chief Complaint Left hip pain Major Surgical or Invasive Procedure Status post left CRPP ___ ___ History of Present Illness REASON FOR CONSULT Femur fracture HPI ___ female presents with the above fracture s p mechanical fall. This morning pt was walking ___ when dog pulled on leash. Pt fell on L hip. Immediate pain. ___ ___ with movement. Denies Head strike LOC or blood thinners. Denies numbness or weakness in the extremities. Past Medical History GERD Hypercholesterolemia Kidney stones Mitral valve prolapse Uterine fibroids Osteoporosis Migraine headaches Social History ___ Family History HTN father Dementia father Physical Exam General Well appearing female in no acute distress. Left Lower extremity Skin intact No deformity edema ecchymosis erythema induration Soft non tender thigh and leg Full painless ROM knee and ankle Fires ___ SILT S S SP DP T distributions 1 ___ pulses WWP Brief Hospital Course The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left valgus impacted femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for left closed reduction and percutaneous pinning of hip which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications and progressed to a regular diet and oral medications by POD 1. The patient was given ___ antibiotics and anticoagulation per routine. The patient s home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient s pain was well controlled with oral medications incisions were clean dry intact and the patient was voiding moving bowels spontaneously. The patient is weightbearing as tolerated in the left lower extremity and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post discharge course including reasons to call the office or return to the hospital and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow up care. The patient expressed readiness for discharge. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Lactaid lactase 3 000 unit oral DAILY PRN 2. Calcium Citrate D calcium citrate vitamin D3 315 200 mg unit oral DAILY Discharge Medications 1. Acetaminophen 1000 mg PO Q6H PRN Pain Mild Fever 2. Bisacodyl 10 mg PO PR DAILY PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS RX enoxaparin 40 mg 0.4 mL 40 mg Subcutaneously Nightly Disp 30 Syringe Refills 0 5. OxyCODONE Immediate Release ___ mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth q4 PRN Disp 25 Tablet Refills 0 6. Senna 8.6 mg PO BID 7. Calcium Citrate D calcium citrate vitamin D3 315 200 mg unit oral DAILY 8. Lactaid lactase 3 000 unit oral DAILY PRN 9. Multivitamins 1 TAB PO DAILY 10. Vitamin D 400 UNIT PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Left valgus impacted femoral neck fracture Discharge Condition AVSS NAD A Ox3 LLE Incision well approximated. Dressing clean and dry. Fires FHL ___ TA GCS. SILT ___ n distributions. 1 DP pulse wwp distally. Discharge Instructions INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY You were in the hospital for orthopedic surgery. It is normal to feel tired or washed out after surgery and this feeling should improve over the first few days to week. Resume your regular activities as tolerated but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING Weightbearing as tolerated left lower extremity MEDICATIONS 1 Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2 Add oxycodone as needed for increased pain. Aim to wean off this medication in 1 week or sooner. This is an example on how to wean down Take 1 tablet every 3 hours as needed x 1 day then 1 tablet every 4 hours as needed x 1 day then 1 tablet every 6 hours as needed x 1 day then 1 tablet every 8 hours as needed x 2 days then 1 tablet every 12 hours as needed x 1 day then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3 Do not stop the Tylenol until you are off of the narcotic medication. 4 Per state regulations we are limited in the amount of narcotics we can prescribe. If you require more you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5 Narcotic pain relievers can cause constipation so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds senna colace miralax are over the counter and may be obtained at any pharmacy. 6 Do not drink alcohol drive a motor vehicle or operate machinery while taking narcotic pain relievers. 7 Please take all medications as prescribed by your physicians at discharge. 8 Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION Please take Lovenox daily for 4 weeks Followup Instructions ___
The icd codes present in this text will be S72012A, W010XXA, Y93K1, Y92480, K219, E7800, I341, G43909, Z87891, Z87442, F419, M810, Z7901. The descriptions of icd codes S72012A, W010XXA, Y93K1, Y92480, K219, E7800, I341, G43909, Z87891, Z87442, F419, M810, Z7901 are S72012A: Unspecified intracapsular fracture of left femur, initial encounter for closed fracture; W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter; Y93K1: Activity, walking an animal; Y92480: Sidewalk as the place of occurrence of the external cause; K219: Gastro-esophageal reflux disease without esophagitis; E7800: Pure hypercholesterolemia, unspecified; I341: Nonrheumatic mitral (valve) prolapse; G43909: Migraine, unspecified, not intractable, without status migrainosus; Z87891: Personal history of nicotine dependence; Z87442: Personal history of urinary calculi; F419: Anxiety disorder, unspecified; M810: Age-related osteoporosis without current pathological fracture; Z7901: Long term (current) use of anticoagulants. The common codes which frequently come are K219, Z87891, F419, Z7901. The uncommon codes mentioned in this dataset are S72012A, W010XXA, Y93K1, Y92480, E7800, I341, G43909, Z87442, M810. |
The icd codes present in this text will be I130, I5033, E872, N184, E1122, N2581, I2510, E11319, D6489, E785, Z955, Z86718, I252, Z2239, G4700, M1A9XX0, R0902, E1151, Z794, E669, Z6831. The descriptions of icd codes I130, I5033, E872, N184, E1122, N2581, I2510, E11319, D6489, E785, Z955, Z86718, I252, Z2239, G4700, M1A9XX0, R0902, E1151, Z794, E669, Z6831 are I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; I5033: Acute on chronic diastolic (congestive) heart failure; E872: Acidosis; N184: Chronic kidney disease, stage 4 (severe); E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; N2581: Secondary hyperparathyroidism of renal origin; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema; D6489: Other specified anemias; E785: Hyperlipidemia, unspecified; Z955: Presence of coronary angioplasty implant and graft; Z86718: Personal history of other venous thrombosis and embolism; I252: Old myocardial infarction; Z2239: Carrier of other specified bacterial diseases; G4700: Insomnia, unspecified; M1A9XX0: Chronic gout, unspecified, without tophus (tophi); R0902: Hypoxemia; E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene; Z794: Long term (current) use of insulin; E669: Obesity, unspecified; Z6831: Body mass index [BMI] 31.0-31.9, adult. The common codes which frequently come are I130, E872, E1122, I2510, E785, Z955, Z86718, I252, G4700, Z794, E669. The uncommon codes mentioned in this dataset are I5033, N184, N2581, E11319, D6489, Z2239, M1A9XX0, R0902, E1151, Z6831.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint shortness of breath Major Surgical or Invasive Procedure None History of Present Illness Patient is a ___ with history of coronary artery disease c b ischemic MR ___ DES to LCX ___ TTE ___ with mild regional LV systolic dysfunction heart failure with preserved ejection fraction LVEF 50 ___ peripheral vascular disease chronic kidney disease stage IV prior unprovoked DVT c b severe UGIB while on AC HTN dyslipidemia and T2DM who presents with several days of shortness of breath. Patients says that she first noticed rather acute onset dyspnea starting ___ when trying to walk up the stairs in her home. She had to sit down and catch her breath whereas just days prior she was able to mount ___ of stairs without difficulty. Patient denies any associated chest pain or palpitations. No dizziness or lightheadedness. Patient further denies any cough fevers chills or pleuritic chest discomfort. She has not experienced any symptoms consistent with orthopnea or PND. No increased ___ swelling patient notes that she has experienced this in the past. Patient takes her weight nearly every day 7lbs reported weight gain over the past week 154lbs 161lbs which she attributes to eating more over the ___. She is currently taking torsemide 40mg qd no missed doses. No issues with abdominal bloating or constipation. No recent travel. Patient s husband just recovered from a viral URI. In the ED initial VS were 97.2 90 186 87 22 100 RA Exam notable for Obvious bilateral wheezing. No overt volume overload. EKG NSR 92bpm normal axis normal PR QRS intervals QTc 479 q waves III aVF TWIs III aVF V3 V6 submm lateral STDs no STEs. Labs showed CBC 6.0 9.0 27.8 176 PMNs 75.2 MCV 97 BMP 142 4.8 105 ___ 2.4 189 Trop .01 proBNP 4512 VBG 7.33 40 UA 1.010 SG pH 6.0 urobilinogen NEG bilirubin NEG leuk NEG blood NEG nitrite NEG protein 100 glucose NEG ketones NEG RBC 1 WBC 1 few bacteria Imaging showed CXR ___ FINDINGS Lungs are moderately well expanded. There is an asymmetric right lower lung opacity new from ___. The heart appears mildly enlarged and there is mild pulmonary vascular congestion. No pleural effusion or pneumothorax. IMPRESSION Right lower lobe opacity could represent pneumonia in the right clinical setting although atelectasis or asymmetric pulmonary edema could account for this finding. Dedicated PA and lateral views could be helpful for further assessment. Consults NONE Patient received ___ 21 45 IH Albuterol 0.083 Neb Soln 1 NEB ___ 22 08 IH Albuterol 0.083 Neb Soln 1 NEB ___ 22 08 IH Ipratropium Bromide Neb 1 NEB ___ 22 47 IH Albuterol 0.083 Neb Soln 1 NEB ___ 22 47 IH Ipratropium Bromide Neb 1 NEB ___ 22 51 IV Azithromycin ___ 22 51 IV CefTRIAXone ___ 22 51 PO PredniSONE 60 mg ___ 22 51 IV Furosemide 80 mg ___ 23 01 IV CefTRIAXone 1 gm ___ 00 13 IV Azithromycin 500 mg ___ 00 23 PO NG Atorvastatin 80 mg ___ 00 23 PO NG Carvedilol 25 mg ___ 00 23 PO NIFEdipine Extended Release 60 mg ___ 00 23 IH Albuterol 0.083 Neb Soln 1 NEB ___ 00 23 IH Ipratropium Bromide Neb 1 NEB ___ 00 26 PO NG Gabapentin 100 mg ___ 00 44 SC Insulin 4 Units Transfer VS were 98.2 77 141 76 18 100 2L NC On arrival to the floor patient recounts the history as above. She says that she feels improved after treatment in the ED no ongoing SOB. 10 point ROS is otherwise NEGATIVE. Past Medical History Coronary artery disease Peripheral vascular disease Type II Diabetes Mellitus c b diabetic retinopathy Obesity Esophageal ring Hypertension Dyslipidemia Bilateral unprovoked posterior tibial DVTs ___ off AC given severe UGIB CKD Stage IV iso DM HTN secondary hyperparathyroidism Anemia Gout Social History ___ Family History Niece had some sort of cancer. Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam ADMISSION PHYSICAL EXAM VS 97.5 162 93 78 16 100RA GENERAL Pleasant female appearing younger than her stated age taking deep breaths while speaking HEENT EOMI PERRL anicteric sclera pink conjunctiva MMM. NECK JVD 10 CM. HEART RRR S1 S2 no murmurs gallops or rubs. LUNGS CTAB no wheezes. ABDOMEN Obese abdomen normoactive BS throughout nondistended nontender in all quadrants no rebound guarding no hepatosplenomegaly. EXTREMITIES No cyanosis clubbing or edema. PULSES 2 radial pulses bilaterally. NEURO A Ox3 moving all 4 extremities with purpose. SKIN Warm and well perfused no excoriations or lesions no rashes. DISCHARGE PHYSICAL EXAM VS Afeb 144 78 HR 57 97 RA RR 12 GEN Well appearing in NAD Neck No JVD appreciated CV RRR no m r g no carotid bruits appreciated PULM CTAB no wheezes rales or crackles. Symmetric expansion EXT warm well perfused no pitting edema Pertinent Results ADMISSION LABS ___ 09 37PM BLOOD WBC 6.0 RBC 2.88 Hgb 9.0 Hct 27.8 MCV 97 MCH 31.3 MCHC 32.4 RDW 15.1 RDWSD 52.0 Plt ___ ___ 09 37PM BLOOD Neuts 75.2 Lymphs 17.6 Monos 4.4 Eos 1.8 Baso 0.3 Im ___ AbsNeut 4.49 AbsLymp 1.05 AbsMono 0.26 AbsEos 0.11 AbsBaso 0.02 ___ 06 40AM BLOOD ___ PTT 25.9 ___ ___ 09 37PM BLOOD Glucose 189 UreaN 38 Creat 2.4 Na 142 K 4.8 Cl 105 HCO3 20 AnGap 17 ___ 09 37PM BLOOD proBNP 4512 ___ 09 37PM BLOOD cTropnT 0.01 ___ 06 40AM BLOOD CK MB 6 cTropnT 0.05 ___ 02 01PM BLOOD CK MB 5 cTropnT 0.04 ___ 09 37PM BLOOD Calcium 9.4 Phos 4.1 Mg 2.3 ___ 09 41PM BLOOD ___ pO2 30 pCO2 40 pH 7.33 calTCO2 22 Base XS 5 IMAGING TTE ___ The left atrial volume index is mildly increased. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal inferoseptal inferior inferolateral as well as mid inferior inferoseptal wall motion abnormalities. Doppler parameters are most consistent with Grade II moderate left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus ascending and arch levels are normal. The aortic valve leaflets 3 are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild 1 mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION 1 Mild regional LV systolic dysfunction c w prior myocardial infarction in the RCA territory. 2 Grade II LV diastolic dysfunction. Compared with the prior study images reviewed of ___ LV sytolic function appears mildly less vigorous. Regional wall motion abnormalities encompassess slightly greater territory. CXR PA LAT ___ No focal consolidation or pulmonary edema. BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND ___ 1. Nonocclusive thrombosis of one of the paired posterior tibial veins in the bilateral lower extremities which appears grossly unchanged compared to bilateral lower extremity ultrasound ___. No new deep venous thrombosis in either extremity. 2. Right ___ cyst measuring up to 1.8 cm across maximal diameter is unchanged in size compared to ___. MICROBIOLOGY URINE CULTURE ___ ENTEROCOCCUS SP.. 100 000 CFU mL. BLOOD CULTURE ___ Blood Culture PENDING BLOOD CULTURE ___ Blood Culture PENDING DISCHARGE LABS ___ 05 45AM BLOOD WBC 5.1 RBC 2.57 Hgb 7.9 Hct 24.5 MCV 95 MCH 30.7 MCHC 32.2 RDW 15.0 RDWSD 51.8 Plt ___ ___ 05 45AM BLOOD Glucose 144 UreaN 49 Creat 2.6 Na 147 K 4.0 Cl 105 HCO3 24 AnGap ___ yo F PMH CAD c b ischemic MR ___ DES to ___ ___ TTE ___ with mild regional LV systolic dysfunction HFpEF LVEF 50 ___ PAD CKD stage IV prior DVT c b severe UGIV on AC T2DM presents with subacute SOB weight gain c f acute heart failure exacerbation. She underwent diuresis with IV Lasix 80 mg 120mg IV x2 with rapid improvement in subjective dyspnea. ___ showed no acute DVT CXR without sign of consolidation. Given her improvement in dyspnea no supplemental O2 requirement the patient was discharged w o medication changes. Shortness of breath Hypoxia acute exacerbation of chronic diastolic heart failure with preserved LVEF 50 Dry weight per pt 154 lbs. Admission weight above baseline BNP elevated. Regarding trigger suspect dietary vs uncontrolled BP. No EKG changes for ACS trop negative repeat TTE showed mild regional LV systolic dysfunction c w prior myocardial infarction in the RCA territory as well as Grade II LV diastolic dysfunction and similar to prior ___ TTE. Doubt PNA given CXR and lack of cough fever doubt PE given low Wells score 1.5 and stable repeat ___. Underwent diuresis with IV Lasix 80 mg 120mg IV x2 with rapid improvement in subjective dyspnea. Resumed home torsemide 40mg nifedipine 60mg BID and carvedilol 25mg BID. Was stable on RA prior to discharge. Hypertension Patient missed her antiHTN medications earlier day of admission. Continued home carvedilol 25mg BID and nifedipine 60mg BID with holding parameters. Appears that a trial of ___ or spironolactone would be limited by hyperkalemia so this was deferred. Urinary frequency urge incontinence occurred in setting of diuresis however UCx ordered in ED did grow enterococci likely colonization. If symptoms persists would revaluate treat. CHRONIC STABLE ISSUES Normocytic anemia recent baseline Hb 9.4 ___ Hb was at baseline no signs of active bleeding. Likely multifactorial anemia of chronic disease as well as decreased erythropoiten production iso CKD. Non anion gap metabolic acidosis Patient has intermittently had a NAGMA in the past. No recent diarrhea. ___ suspect Type IV RTA given advanced age and history of T2DM both of which can cause hyporeninemia . Stage IV Chronic Kidney Disease baseline Cr 2.3 2.8 CKD iso HTN and T2DM Cr is currently at baseline. Low K Phos Na diet. Continued home calcitriol avoided nephrotoxins and renally dosed all medications. Coronary artery disease ___ DES to LCX ___ troponins were trended from 0.01 to 0.05 to 0.04 then stopped. CK MB was flat. Patient deneied any chest pain. A TTE showed mild regional LV systolic dysfunction c w prior myocardial infarction in the RCA territory and similar to prior ___ TTE. Continued home aspirin 81mg qd home carvedilol 25mg BID with holding parameters home atorvastatin 80mg qHS. Type II Diabetes Mellitus last HbA1C 6.4 ___ Under excellent control most recently in the pre diabetic range. Continue home 70 30 sliding scale t dinner if blood sugar over 130 10 units 90 130 none if blood sugar under 90 Dyslipidemia continued home atorvastatin Insomnia continued home gabapentin Gout continued home allopurinol TRANSITIONAL ISSUES Discharge weight 69.2kg Discharge creatinine 2.6 Discharge oral diuretic torsemide 40mg daily Transitional issue consider outpatient epo with renal Transitional issue BP goal of 140 90 per accord or even 130 80 per ACC AHA ___ guidelines however anticipate difficulty in adding additional agents iso CKD limits use of clonidine and baseline potassium would likely limit ___ or spironolactone TTE showed prior LV hypokinesis could consider MIBI or outpatient pharmacological stress test had some urinary retention incontinence while undergoing IV diuresis would assess for recurrent symptoms at routine outpatient visits CODE Full confirmed CONTACT ___ husband ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Atorvastatin 80 mg PO QPM 3. Calcitriol 0.5 mcg PO DAILY 4. Carvedilol 25 mg PO BID 5. Gabapentin 100 mg PO QHS 6. NIFEdipine Extended Release 60 mg PO BID 7. Torsemide 40 mg PO DAILY 8. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 9. Acetaminophen 325 650 mg PO Q6H PRN Pain Mild 10. Aspirin 81 mg PO DAILY 11. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70 30 Insulin Discharge Medications 1. Acetaminophen 325 650 mg PO Q6H PRN Pain Mild 2. Allopurinol ___ mg PO EVERY OTHER DAY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Calcitriol 0.5 mcg PO DAILY 6. Carvedilol 25 mg PO BID 7. Gabapentin 100 mg PO QHS 8. Insulin SC Sliding Scale Insulin SC Sliding Scale using 70 30 Insulin 9. NIFEdipine Extended Release 60 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 11. Torsemide 40 mg PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS Acute on chronic diastolic congestive heart failure SECONDARY DIAGNOSES Hypertension History of prior DVT Anemia NOS Chronic Kidney Disease stage IV Coronary Artery Disease ___ drug eluting stent Diabetes Mellitus Type 2 controlled Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear ___ You were admitted to the hospital with shortness of breath and weight gain. This was likely caused by an exacerbation of your heart failure possibly from salty foods over the holiday. While you were in the hospital we gave you IV diuretics to help remove extra fluid we checked for pneumonia with a chest x ray there was no sign of a pneumonia we checked for signs on new clots in your legs there was no new clot Now that you are going home continue to take all of your medications as prescribed monitor your salt intake this should be no more than 2 grams every day ask your doctors for help with this if you do not know how to keep track of your salt continue to weigh yourself every morning call your doctor if weight goes up more than 3 lbs. follow up with your primary care doctor regarding your blood pressure and blood sugar control It was a pleasure taking care of you Your ___ Inpatient Care Team Followup Instructions ___
The icd codes present in this text will be I130, I5033, E872, N184, E1122, N2581, I2510, E11319, D6489, E785, Z955, Z86718, I252, Z2239, G4700, M1A9XX0, R0902, E1151, Z794, E669, Z6831. The descriptions of icd codes I130, I5033, E872, N184, E1122, N2581, I2510, E11319, D6489, E785, Z955, Z86718, I252, Z2239, G4700, M1A9XX0, R0902, E1151, Z794, E669, Z6831 are I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; I5033: Acute on chronic diastolic (congestive) heart failure; E872: Acidosis; N184: Chronic kidney disease, stage 4 (severe); E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease; N2581: Secondary hyperparathyroidism of renal origin; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema; D6489: Other specified anemias; E785: Hyperlipidemia, unspecified; Z955: Presence of coronary angioplasty implant and graft; Z86718: Personal history of other venous thrombosis and embolism; I252: Old myocardial infarction; Z2239: Carrier of other specified bacterial diseases; G4700: Insomnia, unspecified; M1A9XX0: Chronic gout, unspecified, without tophus (tophi); R0902: Hypoxemia; E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene; Z794: Long term (current) use of insulin; E669: Obesity, unspecified; Z6831: Body mass index [BMI] 31.0-31.9, adult. The common codes which frequently come are I130, E872, E1122, I2510, E785, Z955, Z86718, I252, G4700, Z794, E669. The uncommon codes mentioned in this dataset are I5033, N184, N2581, E11319, D6489, Z2239, M1A9XX0, R0902, E1151, Z6831. |
The icd codes present in this text will be D500, I5023, N184, E118, K2970, Z23, K259, K5730, I2510, Z87891, I252, Z955, I129, Z794, Z8673, R0789, Z86718, R791, T45515A, I70218, K222, K219. The descriptions of icd codes D500, I5023, N184, E118, K2970, Z23, K259, K5730, I2510, Z87891, I252, Z955, I129, Z794, Z8673, R0789, Z86718, R791, T45515A, I70218, K222, K219 are D500: Iron deficiency anemia secondary to blood loss (chronic); I5023: Acute on chronic systolic (congestive) heart failure; N184: Chronic kidney disease, stage 4 (severe); E118: Type 2 diabetes mellitus with unspecified complications; K2970: Gastritis, unspecified, without bleeding; Z23: Encounter for immunization; K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation; K5730: Diverticulosis of large intestine without perforation or abscess without bleeding; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z87891: Personal history of nicotine dependence; I252: Old myocardial infarction; Z955: Presence of coronary angioplasty implant and graft; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z794: Long term (current) use of insulin; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; R0789: Other chest pain; Z86718: Personal history of other venous thrombosis and embolism; R791: Abnormal coagulation profile; T45515A: Adverse effect of anticoagulants, initial encounter; I70218: Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity; K222: Esophageal obstruction; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are I2510, Z87891, I252, Z955, I129, Z794, Z8673, Z86718, K219. The uncommon codes mentioned in this dataset are D500, I5023, N184, E118, K2970, Z23, K259, K5730, R0789, R791, T45515A, I70218, K222.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint fatigue anemia Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ year old woman with a past medical history of type 2 DM hypertension stage IV CKD CAD s p distant MI and bare metal stent stroke recent unprovoked DVTs on Coumadin and recent upper GI bleeding who was sent to ___ by her physician for anemia Hgb 6.5 . The patient was admitted to ___ in ___ with unprovoked bilateral lower extremity DVTs. She was started on heparin as an inpatient but anticoagulation was complicated by severely elevated PTT 150 and upper GI bleed. Endoscopy was notable for significant erythema superficial ulceration and gastritis without active bleeding. She was placed on BID PPI prophylaxis. She was eventually bridged to Coumadin for a planned 6 month course. Her INR is managed by her rehab facility and she is followed by Dr. ___ in ___ clinic. For the last two weeks she has noted increasing fatigue along with shortness of breath exertional sub sternal chest pain relieved with rest and symmetrical lower extremity swelling. During this period she reports that her appetite remained good and he bowel function was normal. She denies bloody stools or dark stool. On ___ she presented to her PCP office from rehab reporting increasing shortness of breath and fatigue. She was found to have a Hgb of 6.5 with an unconcerning CXR. She was sent to the ___ ED. In the ED her initial vitals were T 97.5 P 60 BP 156 76 RR 16 SPO2 100 RA. Exam was notable for guiac negative stool. Imaging was notable for 1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex ___ cyst. The patient was transfused with 2 units of pRBCs with appropriate increase in Hgb to 9.0. Following transfusion a repeat CXR was notable for pulmonary edema with bilateral pleural effusions. She was given 20mg PO Lasix and 40mg IV Lasix in the ED. The decision was made to admit the patient for anemia and flash pulmonary edema. On the floor vitals notable for T 97.9 BP 154 75 P 65 R 20 O2 99RA FSBG 76. She reports no acute complaints and that her shortness of breath has resolved. She denies chest pain dizziness lightheadedness. Past Medical History hypertension diabetes hx CVA cerebellar medullary stroke in ___ CAD hx of MI in ___ BMS to circumflex and POBA ___ peripheral arterial disease claudication followed by vascular managed conservatively stage IV CKD baseline 2.1 2.6 GERD esophageal rings Social History ___ Family History Niece had some sort of cancer. Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam ADMISSION PHYSICAL EXAM Vitals T 97.9 BP 154 75 P 65 R 20 O2 99RA FSBG ___ General Overweight woman alert oriented no acute distress HEENT Sclera anicteric MMM oropharynx clear Neck supple JVP not elevated Lungs Crackles to the mid lungs bilaterally CV Regular rate and rhythm normal S1 S2 no murmurs or gallops Abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly Ext Warm well perfused 2 pulses no clubbing or cyanosis. 2 pitting edema in dependent areas to the buttocks Skin no rashes noted Neuro ___ strength in deltoids biceps triceps wrist extensors finger extensors hip flexors hamstrings quadriceps gastrocs tibialis anterior bilaterally. Sensation intact bilaterally. PSYCH Alert and fully oriented normal mood and affect. sometimes slow to respond and responding with repetitive answers but otherwise appropriate DISCHARGE PHYSICAL EXAM VS T 97.6 BP 150s 160s 70s 80s P 60s 70s RR 18 SPO2 100RA General Overweight woman alert oriented no acute distress HEENT Sclera anicteric MMM oropharynx clear Neck supple JVP not elevated Lungs Clear to auscultation bilaterally CV Regular rate and rhythm normal S1 S2 no murmurs or gallops Abdomen soft non tender non distended bowel sounds present no rebound tenderness or guarding no organomegaly Ext Warm well perfused 2 pulses no clubbing or cyanosis. 1 pitting edema in shins bilaterally Skin no rashes noted Pertinent Results LABORATORY STUDIES ON ADMISSION ___ 12 30PM WBC 4.4 RBC 2.03 HGB 6.5 HCT 20.6 MCV 102 MCH 32.0 MCHC 31.6 RDW 16.3 RDWSD 59.6 ___ 12 30PM ___ ___ 12 30PM ALBUMIN 4.1 CALCIUM 9.2 PHOSPHATE 4.7 IRON 61 ___ 12 30PM calTIBC 303 FERRITIN 155 TRF 233 ___ 12 30PM UREA N 42 CREAT 2.3 SODIUM 142 POTASSIUM 4.7 CHLORIDE 109 TOTAL CO2 23 ANION GAP 15 ___ 04 50PM LD ___ 247 TOT BILI 0.2 ___ 04 50PM HAPTOGLOB 188 IMAGING LENIs ___ 1. Nonocclusive deep vein thrombosis of one of the paired posterior tibial veins bilaterally. The extent of thrombus bilaterally has decreased. No new deep venous thrombosis in either lower extremity. 2. Right complex ___ cyst. CXR ___ 1. New mild pulmonary edema with persistent small bilateral pleural effusions. 2. Severe cardiomegaly is likely accentuated due to low lung volumes and patient positioning. CXR ___ As compared to ___ the lung volumes have slightly decreased. Signs of mild overinflation and moderate pleural effusions persist. Moderate cardiomegaly. Elongation of the descending aorta. No pneumonia. LABORAROTY STUDIES ON DISCHARGE ___ 05 45AM BLOOD WBC 3.4 RBC 2.93 Hgb 8.9 Hct 28.0 MCV 96 MCH 30.4 MCHC 31.8 RDW 17.5 RDWSD 59.7 Plt ___ ___ 05 45AM BLOOD ___ PTT 30.6 ___ ___ 05 45AM BLOOD Glucose 116 UreaN 41 Creat 2.1 Na 144 K 4.0 Cl 108 HCO3 25 AnGap 15 ___ 04 50PM BLOOD LD LDH 247 TotBili 0.2 ___ 05 45AM BLOOD Calcium 9.4 Phos 4.7 Mg 1.7 Brief Hospital Course Ms. ___ is a ___ year old woman with a past medical history of type 2 DM hypertension stage IV CKD CAD s p distant MI and bare metal stent stroke recent unprovoked DVTs on Coumadin and recent upper GI bleed who was sent to ___ by her physician for anemia. Anemia Patient presented with Hgb of 6.5 down from her recent baseline of 7.5 since her ___ hospitalization. Upon presentation she had a new macrocytic anemia. Hemolysis labs were negative. She received two units of packed red cells with an appropriate rise in her Hgb to 9.0. Stool was guiac negative with no reports of dark stool or blood in stool. Her hemoglobin remained stable at this level there was no overt bleeding and her stool was guiac negative. After transfusion the patient reported significant improvement in her shortness of breath and fatigue. Given her history of gastritis and diverticulosis a GI bleed was believed responsible for her anemia. Patient should receive an EGD colonoscopy as an outpatient. Acute exacerbation of heart failure with preserved ejection fraction The patient was also found to be slightly volume overloaded and was treated with 2x40mg IV Lasix with good urine output and symptomatic improvement. Her pulmonary edema and peripheral edema resolved with diuresis. CHRONIC ISSUES Gastic ulceration Continued on home pantoprazole BID Hypertension Continued on home nifedipine carvadilol lisinopril. Stage IV Chronic Kidney Disease Creatinine remained at baseline b l Cr 2.1 2.6 during admission. TRANSITIONAL ISSUES Patient s Anemia is thought to be due to slow GI bleed given history of gastritis and diverticulosis. Please schedule EGD colonoscopy within the next month Patient continued on Coumadin for bilateral DVTs please continue to weigh the risks and benefits of anticoagulation given history of bleed. Discharge weight 167.7 CONTACT ___ ___ CODE full confirmed Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Lisinopril 40 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. NIFEdipine CR 30 mg PO BID 8. Vitamin D ___ UNIT PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Gabapentin 100 mg PO QHS neuropathic pain 11. Pantoprazole 40 mg PO Q12H 12. Senna 8.6 mg PO BID constipation 13. Warfarin 4 mg PO 3X WEEK ___ 14. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 15. Furosemide 20 mg PO DAILY 16. Polyethylene Glycol 17 g PO DAILY 17. Acetaminophen 325 650 mg PO Q6H PRN pain or fever 18. Warfarin 3 mg PO 4X WEEK ___ 19. 70 30 30 Units Dinner Discharge Medications 1. Acetaminophen 325 650 mg PO Q6H PRN pain or fever RX acetaminophen 325 mg ___ tablet s by mouth Q6H PRN Disp 120 Tablet Refills 0 2. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 3. Atorvastatin 80 mg PO QPM RX atorvastatin 80 mg 1 tablet s by mouth QPM Disp 30 Tablet Refills 0 4. Carvedilol 12.5 mg PO BID RX carvedilol 12.5 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 5. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule s by mouth twice a day Disp 60 Capsule Refills 0 6. Gabapentin 100 mg PO QHS neuropathic pain RX gabapentin 100 mg 1 capsule s by mouth at bedtime Disp 30 Capsule Refills 0 7. Lisinopril 40 mg PO DAILY RX lisinopril 40 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 8. Multivitamins 1 TAB PO DAILY RX multivitamin 1 capsule s by mouth daily Disp 30 Capsule Refills 0 9. NIFEdipine CR 30 mg PO BID RX nifedipine 30 mg 1 tablet s by mouth twice a day Disp 60 Tablet Refills 0 10. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain RX nitroglycerin Nitrostat 0.3 mg 1 tablet s sublingually Q5MIN PRN Disp 10 Tablet Refills 0 11. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet s by mouth every twelve 12 hours Disp 60 Tablet Refills 0 12. Polyethylene Glycol 17 g PO DAILY RX polyethylene glycol 3350 17 gram dose 1 powder s by mouth daily Refills 0 13. Senna 8.6 mg PO BID constipation RX sennosides senna 8.6 mg 1 capsule by mouth twice a day Disp 60 Capsule Refills 0 14. Vitamin D ___ UNIT PO DAILY RX ergocalciferol vitamin D2 2 000 unit 1 tablet s by mouth daily Disp 30 Tablet Refills 0 15. Warfarin 4 mg PO 3X WEEK ___ RX warfarin 4 mg 1 tablet s by mouth 3X WEEK Disp 30 Tablet Refills 0 16. Warfarin 3 mg PO 4X WEEK ___ RX warfarin 3 mg 1 tablet s by mouth 4X WEEK Disp 30 Tablet Refills 0 17. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet s by mouth daily Disp 30 Tablet Refills 0 18. Allopurinol ___ mg PO EVERY OTHER DAY RX allopurinol ___ mg 1 tablet s by mouth EVERY OTHER DAY Disp 30 Tablet Refills 0 19. 70 30 30 Units Dinner RX insulin NPH and regular human Humulin 70 30 KwikPen 100 unit mL 70 30 30 units SC Take 30 Units before DINER Disp 2 Package Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary diagnosis Anemia Congestive heart failure exacerbation Secondary diagnosis Hypertension DMII on insulin Coronary artery disease Stage IV chronic kidney disease Deep vein thrombosis Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear ___ It was a pleasure caring for you. You were admitted to the hospital with fatigue chest pain and shortness of breath. You were found to have too few red blood cells anemia . We gave you blood and your symptoms improved. Additionally you were found to have too much fluid in your legs and lungs. We treated you with a diuretic which helped eliminate the fluid. Weigh yourself every morning call MD if weight goes up more than 3 lbs. Sincerely Your ___ Team Followup Instructions ___
The icd codes present in this text will be D500, I5023, N184, E118, K2970, Z23, K259, K5730, I2510, Z87891, I252, Z955, I129, Z794, Z8673, R0789, Z86718, R791, T45515A, I70218, K222, K219. The descriptions of icd codes D500, I5023, N184, E118, K2970, Z23, K259, K5730, I2510, Z87891, I252, Z955, I129, Z794, Z8673, R0789, Z86718, R791, T45515A, I70218, K222, K219 are D500: Iron deficiency anemia secondary to blood loss (chronic); I5023: Acute on chronic systolic (congestive) heart failure; N184: Chronic kidney disease, stage 4 (severe); E118: Type 2 diabetes mellitus with unspecified complications; K2970: Gastritis, unspecified, without bleeding; Z23: Encounter for immunization; K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation; K5730: Diverticulosis of large intestine without perforation or abscess without bleeding; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z87891: Personal history of nicotine dependence; I252: Old myocardial infarction; Z955: Presence of coronary angioplasty implant and graft; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z794: Long term (current) use of insulin; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; R0789: Other chest pain; Z86718: Personal history of other venous thrombosis and embolism; R791: Abnormal coagulation profile; T45515A: Adverse effect of anticoagulants, initial encounter; I70218: Atherosclerosis of native arteries of extremities with intermittent claudication, other extremity; K222: Esophageal obstruction; K219: Gastro-esophageal reflux disease without esophagitis. The common codes which frequently come are I2510, Z87891, I252, Z955, I129, Z794, Z8673, Z86718, K219. The uncommon codes mentioned in this dataset are D500, I5023, N184, E118, K2970, Z23, K259, K5730, R0789, R791, T45515A, I70218, K222. |
The icd codes present in this text will be I5023, N184, D631, E1121, Z86718, I129, Z955, I2510, Z7901, Z794, I340, I252, Z8673, Z87891, Z91128, E785. The descriptions of icd codes I5023, N184, D631, E1121, Z86718, I129, Z955, I2510, Z7901, Z794, I340, I252, Z8673, Z87891, Z91128, E785 are I5023: Acute on chronic systolic (congestive) heart failure; N184: Chronic kidney disease, stage 4 (severe); D631: Anemia in chronic kidney disease; E1121: Type 2 diabetes mellitus with diabetic nephropathy; Z86718: Personal history of other venous thrombosis and embolism; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z955: Presence of coronary angioplasty implant and graft; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z7901: Long term (current) use of anticoagulants; Z794: Long term (current) use of insulin; I340: Nonrheumatic mitral (valve) insufficiency; I252: Old myocardial infarction; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Z87891: Personal history of nicotine dependence; Z91128: Patient's intentional underdosing of medication regimen for other reason; E785: Hyperlipidemia, unspecified. The common codes which frequently come are Z86718, I129, Z955, I2510, Z7901, Z794, I252, Z8673, Z87891, E785. The uncommon codes mentioned in this dataset are I5023, N184, D631, E1121, I340, Z91128.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint dyspnea on exertion Major Surgical or Invasive Procedure None History of Present Illness ___ with a history of of HTN CAD s p DES with ischemic MR and systolic dysfunction ___ on torsemide hx of DVT who presents with 4 days of dyspnea on exertion leg swelling and 10 weight gain. Of note patient was seen in the Heart Failure Clinic with Dr. ___ on ___ where she noted that she has had persistent dyspnea on exertion and PND after a lengthy prior hospitalization for DVT GIB. At that time she was started on 40mg po torsemide which initially improved her symptoms. Over the holiday she indulged in a high salt diet and developed slow onset dyspnea on exertion. Denies any medication noncompliance chest pain palpitations palpitations. Describes PND worsening exercise tolerance unable to walk 50 feet and orthopnea. In the ED patient was found to have 1 bilateral lower extremity edema and have bibasilar crackles on exam. Patient underwent CXR BNP and was given one dose of IV 40mg Lasix. In the ED initial vitals were 97.8 73 199 100 18 95 RA. Prior to transfer vitals were 74 188 95 18 100 RA. Patient s labs were remarkable for sodium 146 Chloride 115 K 5.4 Bicarb 19 BUN 39 Creatinine 2.3. Patient had CK 229 with MB 6 Trop 0.01. Patient had BNP of 10 180. Patient also had Hgb 8.1 Hct 26.8 Platelet 168 WBC 5.4. Urinalysis still pending upon discharge. EKG notable for SR 76 with LAD TWI in the inferior leads which appears unchanged from prior on ___ On the floor she is symptomatically improved since coming to the ED. Past Medical History hypertension diabetes hx CVA cerebellar medullary stroke in ___ CAD hx of MI in ___ BMS to circumflex and POBA ___ peripheral arterial disease claudication followed by vascular managed conservatively stage IV CKD baseline 2.1 2.6 GERD esophageal rings Social History ___ Family History Father died in his ___ due to lung disease. Mother died in her ___ due to an unknown cause. No early CAD or sudden cardiac death. No other known history of cancer. Physical Exam ADMISSION PHYSICAL EXAMINATION VS T 98.0 BP 168 96 HR 67 RR 16 O2 sat 100 on 2L NC Admission weight 178lbs GENERAL WDWN obese sitting upright in bed in NAD. AOx3. Mood affect appropriate. HEENT NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva were pink no pallor or cyanosis of the oral mucosa. NECK Supple with JVP of 8cm. CARDIAC PMI located in ___ intercostal space midclavicular line. RR normal S1 S2 S3. No murmurs rubs gallops. No thrills lifts. LUNGS Resp were unlabored no accessory muscle use dyspneic at the end of a long sentence. Bibasilar crackles ___ up thorax diffuse wheezing. ABDOMEN Soft NTND. No HSM or tenderness. EXTREMITIES 2 edema to shins. No femoral bruits. PULSES Distal pulses palpable and symmetric DISCHARGE PHYSICAL EXAMINATION VS T 98.0 BP 135 72 HR 67 RR 16 O2 sat 100 on RA weight 74kg GENERAL WDWN obese sitting upright in bed in NAD. AOx3. Mood affect appropriate. HEENT NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva were pink no pallor or cyanosis of the oral mucosa. NECK Supple with JVP of 7cm. CARDIAC PMI located in ___ intercostal space midclavicular line. RR normal S1 S2 S3. No murmurs rubs gallops. No thrills lifts. LUNGS Resp were unlabored no accessory muscle use. Bibasilar crackles trace diffuse wheezing. ABDOMEN Soft NTND. No HSM or tenderness. EXTREMITIES dry. No femoral bruits. PULSES Distal pulses palpable and symmetric Pertinent Results ADMISSION LABS ___ 11 55AM BLOOD WBC 5.4 RBC 2.63 Hgb 8.1 Hct 26.8 MCV 102 MCH 30.8 MCHC 30.2 RDW 17.2 RDWSD 64.7 Plt ___ ___ 11 55AM BLOOD Neuts 80.6 Lymphs 11.2 Monos 5.0 Eos 2.4 Baso 0.2 Im ___ AbsNeut 4.38 AbsLymp 0.61 AbsMono 0.27 AbsEos 0.13 AbsBaso 0.01 ___ 12 45PM BLOOD ___ PTT 32.9 ___ ___ 07 30AM BLOOD Ret Aut 2.4 Abs Ret 0.06 ___ 11 55AM BLOOD Glucose 153 UreaN 39 Creat 2.3 Na 146 K 5.4 Cl 115 HCO3 19 AnGap 17 ___ 11 55AM BLOOD CK MB 6 cTropnT 0.01 ___ ___ 07 38PM BLOOD CK MB 6 cTropnT 0.01 ___ 11 55AM BLOOD Calcium 9.0 Phos 3.9 Mg 1.8 DISCHARGE LABS ___ 07 10AM BLOOD WBC 3.9 RBC 2.81 Hgb 8.6 Hct 26.7 MCV 95 MCH 30.6 MCHC 32.2 RDW 16.0 RDWSD 56.4 Plt ___ ___ 07 10AM BLOOD ___ ___ 07 10AM BLOOD Glucose 100 UreaN 37 Creat 1.9 Na 144 K 3.9 Cl 105 HCO3 29 AnGap 14 ___ 07 10AM BLOOD Calcium 9.5 Phos 4.4 Mg 1.8 IMAGING ___ CXR FINDINGS There is mild pulmonary edema with superimposed region of more confluent consolidation in the left upper lung. There are possible small bilateral pleural effusions. Moderate cardiomegaly is again seen as well as tortuosity of the descending thoracic aorta. No acute osseous abnormalities. IMPRESSION Mild pulmonary edema with superimposed left upper lung consolidation potentially more confluent edema versus superimposed infection. Brief Hospital Course ___ year old female with history of hypertension CAD s p DES with ischemic MR and systolic dysfunction ___ hx of DVT who admitted for CHF exacerbation. Acute on chronic decompensated heart failure presented in the setting of high salt diet with dyspnea on exertion decreased exercise tolerance ___ edema crackles on exam elevated BNP to 10K 8lbs above dry weight and pulmonary congestion on CXR. Later discovered on pharmacy review that patient had not filled torsemide after last outpatient Cardiology appointment where she was instructed to start taking it. Troponins cycled and negative. On admission she was placed on a salt and fluid restricted diet. She was diuresed with IV Lasix 80mg for 2 days and then transitioned to po torsemide 40mg with steady weight decline and net negative fluid balance of goal ___ and stable renal function. Electrolytes repleted for goal Mg 2 and K 4. She was continued on home carvedilol 12.5mg BID atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP 140. Discharged with close PCP and ___ to monitor weights and blood pressure control. Hypertension She was continued on home carvedilol 12.5mg BID atorvastatin 80mg daily and lisinopril 40mg daily for blood pressure control and increased home nifedipine CR from 30 to 60mg BID to achieve goal SBP 140. Positive U A patient asymptomatic but with 32WBCs ___ bacteria although 3 epis . Asymptomatic with no fevers dysuria malaise. Urine culture negative. Left upper lung consolidation infiltrate per Radiology read on admission CXR. No cough fevers leukocytosis. Rereviewed with on call radiologist who favored pulmonary edema with no need for repeat imaging or PNA treatment unless clinically indicated. Monitored without any significant clinical findings. DVT anticoagulated on Coumadin goal 2.0 3.0 no signs of thrombus on exam. Daily INR trended and continued on home Coumadin 5mg daily. Anemia no signs of external loss specifically denying any melena. Chronically anemic with baseline ___ presented with Hgb 8. Likely ___ renal disease and ACD however elevated MCV indicates possible reticulocytosis. Altogether low suspicion for GIB so Coumadin was continued. Reticulocytes 2.4 which is inappropriate arguing against acute loss. Trended daily CBC with noted uprising by discharge. Chronic kidney disease stage IV baseline ___ likely ___ HTN and DM. Renally dosed medications and trended Cr with no significant change. HLD continued home atorvastatin DM held home 25U 70 30. Patient maintained on aspart ISS and glargine qHS with good glycemic control. TRANSITIONAL ISSUES CHF diuresed with IV lasix transitioned to po diuretics discharged home on 40mg po torsemide to take in the AM and take a banana. Pt complained of unilateral R sided incomplete hearing loss on day of discharge was not felt to be related to diuretics but would ___. HTN increased nifedipine CR to 60mg BID given elevated SBPs. Please f u at next appointments. Anemia multiple prior workups showing ACD. Hgb 8s during admission Prior DVT PE continued on warfarin will need continued monitoring DM stopped home 70 30 while in house and put on aspart glargine discharged on home regimen Discharge weight 74kg Discharge Cr 1.9 Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 650 mg PO Q6H PRN pain or fever 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 12.5 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Gabapentin 100 mg PO QHS neuropathic pain 7. Lisinopril 40 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. NIFEdipine CR 30 mg PO BID 10. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 11. Pantoprazole 40 mg PO Q12H 12. Polyethylene Glycol 17 g PO DAILY 13. Senna 8.6 mg PO BID constipation 14. Vitamin D ___ UNIT PO DAILY 15. Warfarin 5 mg PO DAILY16 16. Allopurinol ___ mg PO EVERY OTHER DAY 17. Torsemide 40 mg PO DAILY 18. HumuLIN 70 30 insulin NPH and regular human 100 unit mL 70 30 subcutaneous 25 units with dinner Discharge Medications 1. HumuLIN 70 30 insulin NPH and regular human 100 unit mL 70 30 subcutaneous 25 units with dinner 2. Warfarin 5 mg PO DAILY16 3. Vitamin D ___ UNIT PO DAILY 4. Acetaminophen 325 650 mg PO Q6H PRN pain or fever 5. Allopurinol ___ mg PO EVERY OTHER DAY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Docusate Sodium 100 mg PO BID 9. Gabapentin 100 mg PO QHS neuropathic pain 10. Lisinopril 40 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Nitroglycerin SL 0.3 mg SL Q5MIN PRN chest pain 13. Polyethylene Glycol 17 g PO DAILY 14. Senna 8.6 mg PO BID constipation 15. Torsemide 40 mg PO DAILY RX torsemide 20 mg 2 tablet s by mouth once daily Disp 60 Tablet Refills 0 16. Pantoprazole 20 mg PO Q12H 17. Carvedilol 25 mg PO BID 18. NIFEdipine CR 60 mg PO BID RX nifedipine 20 mg 3 capsule s by mouth twice daily Disp 180 Capsule Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis Primary Diagnoses Acute on chronic decompensated congestive Heart Failure Hypertension Secondary Diagnoses Anemia Diabetes mellitus Prior deep vein thrombosis Chronic Kidney Disease Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Mrs. ___ ___ were admitted to ___ for treatment of your congestive heart failure and hypertension. ___ were given IV diuretics with improvement in your symptoms labs and exam. We increased one of your blood pressure medications and continued your other home medicines. It was a pleasure taking care of ___ during your stay we wish ___ all the best Your ___ Team Followup Instructions ___
The icd codes present in this text will be I5023, N184, D631, E1121, Z86718, I129, Z955, I2510, Z7901, Z794, I340, I252, Z8673, Z87891, Z91128, E785. The descriptions of icd codes I5023, N184, D631, E1121, Z86718, I129, Z955, I2510, Z7901, Z794, I340, I252, Z8673, Z87891, Z91128, E785 are I5023: Acute on chronic systolic (congestive) heart failure; N184: Chronic kidney disease, stage 4 (severe); D631: Anemia in chronic kidney disease; E1121: Type 2 diabetes mellitus with diabetic nephropathy; Z86718: Personal history of other venous thrombosis and embolism; I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease; Z955: Presence of coronary angioplasty implant and graft; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; Z7901: Long term (current) use of anticoagulants; Z794: Long term (current) use of insulin; I340: Nonrheumatic mitral (valve) insufficiency; I252: Old myocardial infarction; Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Z87891: Personal history of nicotine dependence; Z91128: Patient's intentional underdosing of medication regimen for other reason; E785: Hyperlipidemia, unspecified. The common codes which frequently come are Z86718, I129, Z955, I2510, Z7901, Z794, I252, Z8673, Z87891, E785. The uncommon codes mentioned in this dataset are I5023, N184, D631, E1121, I340, Z91128. |
The icd codes present in this text will be C675, I10, D259, Z87891, E785, E890. The descriptions of icd codes C675, I10, D259, Z87891, E785, E890 are C675: Malignant neoplasm of bladder neck; I10: Essential (primary) hypertension; D259: Leiomyoma of uterus, unspecified; Z87891: Personal history of nicotine dependence; E785: Hyperlipidemia, unspecified; E890: Postprocedural hypothyroidism. The common codes which frequently come are I10, Z87891, E785. The uncommon codes mentioned in this dataset are C675, D259, E890.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Bladder cancer Major Surgical or Invasive Procedure robotic anterior exenteration and open ileal conduit History of Present Illness ___ with invasive bladder cancer pelvic MRI concerning for invasion into anterior vaginal wall now s p robotic anterior exent Dr ___ and open ileal conduit Dr ___. Past Medical History Hypertension laparoscopic cholecystectomy six months ago left knee replacement six to ___ years ago laminectomy of L5 S1 at age ___ two vaginal deliveries. Social History ___ Family History Negative for bladder CA. Physical Exam A Ox3 Breathing comfortably on RA WWP Abd S ND appropriate postsurgical tenderness to palpation Urostomy pink viable Pertinent Results ___ 06 50AM BLOOD WBC 7.6 RBC 3.41 Hgb 10.6 Hct 32.5 MCV 95 MCH 31.1 MCHC 32.6 RDW 14.4 RDWSD 50.2 Plt ___ ___ 06 50AM BLOOD Plt ___ ___ 06 45AM BLOOD Glucose 117 UreaN 23 Creat 0.6 Na 136 K 4.4 Cl 104 HCO3 23 AnGap 13 ___ 06 45AM BLOOD Calcium 7.9 Phos 3.4 Mg 2.0 Brief Hospital Course Ms. ___ was admitted to the Urology service after undergoing robotic anterior exenteration with ileal conduit . No concerning intrao perative events occurred please see dictated operative note for details. Patient received ___ intravenous antibiotic prophylaxis and deep vein thrombosis prophylaxis with subcutaneous heparin. The post operative course was notable for several episodes of emesis prompting NGT placement on ___. Pt self removed the NGT on ___ but nausea emesis resolved thereafter and pt was gradually advanced to a regular diet with passage of flatus without issue. With advacement of diet patient was transitioned from IV pain medication to oral pain medications. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema swelling or purulent drainage. Her drain was removed. The ostomy was perfused and patent and one ureteral stent had fallen out spontaneously. ___ was consulted and recommended disposition to rehab. Post operative follow up appointments were arranged discussed and the patient was discharged to rehab for further recovery. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Heparin 5000 UNIT SC ONCE Start in O.R. Holding Area 2. Losartan Potassium 50 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Levothyroxine Sodium 175 mcg PO DAILY Discharge Medications 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID take while taking narcotic pain meds RX docusate sodium Colace 100 mg 1 capsule s by mouth twice a day Disp 50 Capsule Refills 0 3. Enoxaparin Sodium 40 mg SC DAILY Start ___ First Dose Next Routine Administration Time RX enoxaparin 40 mg 0.4 mL 40 mg sc daily Disp 28 Syringe Refills 0 4. Nitrofurantoin Monohyd MacroBID 100 mg PO DAILY take while ureteral stents are in place RX nitrofurantoin monohyd m cryst Macrobid 100 mg 1 capsule s by mouth daily Disp 14 Capsule Refills 0 5. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth q4h prn Disp 30 Tablet Refills 0 6. Atorvastatin 10 mg PO QPM 7. Levothyroxine Sodium 175 mcg PO DAILY 8. Losartan Potassium 50 mg PO DAILY Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Bladder cancer Discharge Condition WdWn NAD AVSS Abdomen soft appropriately tender along incision Incision is c d I steris Stoma is well perfused Urine color is yellow Ureteral stent noted via stoma JP drain has been removed Bilateral lower extremities are warm dry well perfused. There is no reported calf pain to deep palpation. No edema or pitting Discharge Instructions Please also refer to the handout of instructions provided to you by your Urologist Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy You will be sent home with Visiting Nurse ___ services to facilitate your transition to home care of your urostomy Resume your pre admission home medications except as noted. Always call to inform review and discuss any medication changes and your post operative course with your primary care doctor ___ you have been prescribed IBUPROFEN please note that you may take this in addition to the prescribed NARCOTIC pain medications and or tylenol. FIRST alternate Tylenol acetaminophen and Ibuprofen for pain control. REPLACE the Tylenol with the prescribed narcotic if the narcotic is combined with Tylenol examples include brand names ___ Tylenol 3 w codeine and their generic equivalents . ALWAYS discuss your medications especially when using narcotics or new medications use with the pharmacist when you first retrieve your prescription if you have any questions. Use the narcotic pain medication for break through pain that is 4 on the pain scale. The MAXIMUM dose of Tylenol ACETAMINOPHEN is 4 grams from ALL sources PER DAY and remember that the prescribed narcotic pain medication may also contain Tylenol acetaminophen so this needs to be considered when monitoring your daily dose and maximum. If you are taking Ibuprofen Brand names include ___ this should always be taken with food. If you develop stomach pain or note black stool stop the Ibuprofen. Please do NOT drive operate dangerous machinery or consume alcohol while taking narcotic pain medications. Do NOT drive and until you are cleared to resume such activities by your PCP or urologist. You may be a passenger Colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener NOT a laxative. You may shower 2 days after surgery but do not tub bathe swim soak or scrub incision for 2 weeks If you had a drain or skin clips staples removed from your abdomen bandage strips called steristrips have been applied to close the wound OR the site was covered with a gauze dressing. Allow any steristrips bandage strips to fall off on their own ___ days . PLEASE REMOVE any gauze dressings within two days of discharge. Steristrips may get wet. No heavy lifting for 4 weeks no more than 10 pounds . Do not be sedentary. Walk frequently. Light household chores cooking folding laundry washing dishes are generally ok but AGAIN avoid straining pulling twisting do NOT vacuum . Followup Instructions ___
The icd codes present in this text will be C675, I10, D259, Z87891, E785, E890. The descriptions of icd codes C675, I10, D259, Z87891, E785, E890 are C675: Malignant neoplasm of bladder neck; I10: Essential (primary) hypertension; D259: Leiomyoma of uterus, unspecified; Z87891: Personal history of nicotine dependence; E785: Hyperlipidemia, unspecified; E890: Postprocedural hypothyroidism. The common codes which frequently come are I10, Z87891, E785. The uncommon codes mentioned in this dataset are C675, D259, E890. |
The icd codes present in this text will be I2699, I82412, N390, I471, I10, I872, R918, B952, E039, E785, E876, E8342, G4700, K5900, Z66, N63, D509, D638, Z7901, Z8551, Z906, Z87891, Z96652. The descriptions of icd codes I2699, I82412, N390, I471, I10, I872, R918, B952, E039, E785, E876, E8342, G4700, K5900, Z66, N63, D509, D638, Z7901, Z8551, Z906, Z87891, Z96652 are I2699: Other pulmonary embolism without acute cor pulmonale; I82412: Acute embolism and thrombosis of left femoral vein; N390: Urinary tract infection, site not specified; I471: Supraventricular tachycardia; I10: Essential (primary) hypertension; I872: Venous insufficiency (chronic) (peripheral); R918: Other nonspecific abnormal finding of lung field; B952: Enterococcus as the cause of diseases classified elsewhere; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; E876: Hypokalemia; E8342: Hypomagnesemia; G4700: Insomnia, unspecified; K5900: Constipation, unspecified; Z66: Do not resuscitate; N63: Unspecified lump in breast; D509: Iron deficiency anemia, unspecified; D638: Anemia in other chronic diseases classified elsewhere; Z7901: Long term (current) use of anticoagulants; Z8551: Personal history of malignant neoplasm of bladder; Z906: Acquired absence of other parts of urinary tract; Z87891: Personal history of nicotine dependence; Z96652: Presence of left artificial knee joint. The common codes which frequently come are N390, I10, E039, E785, G4700, K5900, Z66, D509, Z7901, Z87891. The uncommon codes mentioned in this dataset are I2699, I82412, I471, I872, R918, B952, E876, E8342, N63, D638, Z8551, Z906, Z96652.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint dyspnea on exertion Major Surgical or Invasive Procedure None History of Present Illness Patient is a ___ year old woman s p robotic radical cystectomy ___ with ileal conduit creation with postop course complicated by bacteremia and abscess LLE DVT on prophylactic dosing lovenox who presents with dyspnea on exertion for past 3 days. Briefly patient was initially admitted to the Urology service from ___ for robotic anterior exenteration with ileal conduit. She was discharged to rehab on prophylactic dosing lovenox for 1 month. She was then readmitted from ___ for ileus requiring NGT decompression TPN. BCx grew Citrobacter for which CTX was started. CT showed intra abdominal interloop simple fluid collection and LLQ drain was placed by ___. Patient improved passing BMs and tolerating PO and was discharged on cipro flagyl. She was also discharged on PO Bactrim for presumed UTI though unclear if she actually took this. During this admission she was noted to have new bilateral ___ edema. LENIs at the time showed aute deep vein thrombosis of the duplicated mid and distal left femoral veins. She was discharged on Enoxaparin Sodium 40 mg SC daily. She reports that her PCP started PO ___ 20mg daily and since then there has been improvement of the swelling. Per her report a repeat ___ at the rehab facility ___ was negative for DVT. Patient reports that she recovered well post operatively and was doing well at her assisted living facility up until a week ago when she began experiencing dyspnea on exertion. She states that she typically is able to ambulate a block before stopping to catch her breath however in the past week she has been unable to take more than a few steps. She states that it has become increasingly more difficult to ambulate from her bedroom to the bathroom. When visited by the NP her ambulatory saturation was noted to be in the ___ with associated tachycardia to 110 pallor and diaphoresis. She endorses associated leg swelling left worse than right and she states that her thighs feel heavy . She denies any associated chest pain fever chills pain with deep inspiration abdominal pain rashes dizziness lightheadedness. In the ED initial VS were 97.7 72 136 93 20 100 Nasal Cannula ED physical exam was recorded as patient resting comfortably with NC pursed lip breathing unable to speak in full sentences before becoming short of breath urostomy pouch in RLQ stoma pink 2 edema to bilateral lower extremities L R. ED labs were notable for Hb 9 Hct 29 plt 479 UA large ___ 182 WBC many bact 0 epi. Trop neg x1 proBNP normal CTA chest showed 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper middle and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted as noted previously with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe suspicious for malignancy on the previous PET CT. 4. Re demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. EKG showed NSR with frequent PAC Patient was given ___ 20 26 PO NG Ciprofloxacin HCl 500 mg ___ 20 26 IV Heparin 6600 UNIT ___ 20 26 IV Heparin Transfer VS were 98.1 77 145 63 20 99 Nasal Cannula When seen on the floor she reports significant dyspnea with minimal exertion. Denies chest pain palpitations lightheadedness. A ten point ROS was conducted and was negative except as above in the HPI. Past Medical History Hypertension laparoscopic cholecystectomy left knee replacement six to ___ years ago laminectomy of L5 S1 at age ___ two vaginal deliveries. s p ___ 1. Robot assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot assisted hysterectomy and bilateral oophorectomy for large uterus greater than 300 grams with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History ___ Family History Negative for bladder CA. Physical Exam ADMISSION EXAM Gen NAD speaking in 3 word sentences pursed lip breathing no accessory muscle use lying in bed Eyes EOMI sclerae anicteric ENT MMM OP clear Cardiovasc RRR no MRG full pulses 1 edema bilaterally with compression stockings in place no JVD Resp normal effort no accessory muscle use lungs CTA ___ to anterior auscultation. GI soft NT ND BS . Urostomy site does not appear infected MSK No significant kyphosis. No palpable synovitis. Skin No visible rash. No jaundice. Neuro AAOx3. No facial droop. Psych Full range of affect DISCHARGE EXAM vitals 98.3 140 42 90 24 96 1L Gen Lying in bed in no apparent distress HEENT Anicteric MMM Cardiovascular RRR normal S1 S2 no right sided heave ___ systolic murmur Pulmonary Lung fields clear to auscultation throughout. No crackles or wheezing. GI Soft distended nontender bowel sounds present urostomy in place. Extremities no edema though left leg appears larger than right leg warm well perfused with motor function intact. Her left lower leg is wrapped. Pertinent Results LABS Admission labs ___ 02 40PM GLUCOSE 101 UREA N 22 CREAT 0.7 SODIUM 136 POTASSIUM 4.1 CHLORIDE 98 TOTAL CO2 22 ANION GAP 20 ___ 02 40PM cTropnT 0.01 ___ 02 40PM proBNP 567 ___ 02 40PM WBC 7.7 RBC 3.07 HGB 9.0 HCT 29.1 MCV 95 MCH 29.3 MCHC 30.9 RDW 14.9 RDWSD 52.1 ___ 02 40PM PLT COUNT 479 ___ 02 40PM ___ PTT 33.4 ___ Discharge labs ___ 06 55AM BLOOD WBC 11.0 RBC 2.60 Hgb 7.5 Hct 24.5 MCV 94 MCH 28.8 MCHC 30.6 RDW 14.8 RDWSD 51.4 Plt ___ ___ 06 55AM BLOOD Glucose 99 UreaN 10 Creat 0.5 Na 141 K 4.3 Cl 105 HCO3 26 AnGap 14 ___ 06 55AM BLOOD Calcium 8.2 Phos 3.8 Mg 2.0 ___ 07 15AM BLOOD calTIBC 134 Ferritn 507 TRF 103 ___ 07 15AM BLOOD Iron 18 MICROBIOLOGY ___ 4 30 pm URINE FINAL REPORT ___ URINE CULTURE Final ___ MIXED BACTERIAL FLORA 3 COLONY TYPES CONSISTENT WITH SKIN AND OR GENITAL CONTAMINATION. ENTEROCOCCUS SP.. 100 000 CFU mL. PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION. SENSITIVITIES MIC expressed in MCG ML ___ ENTEROCOCCUS SP. AMPICILLIN 2 S NITROFURANTOIN 16 S TETRACYCLINE 1 S VANCOMYCIN 1 S IMAGING ___ CXR IMPRESSION Hilar congestion without frank edema. No convincing signs of pneumonia. ___ CTA chest showed 1. Extensive pulmonary embolism with thrombus seen extending from the right main pulmonary artery into the segmental and subsegmental right upper middle and lower lobe pulmonary arteries. No right heart strain identified. 2. Additionally there are smaller pulmonary emboli seen in the segmental and subsegmental branches of the left upper and lower lobes. 3. Several pulmonary nodules are noted as noted previously with the largest appearing spiculated and measuring up to 1 cm in the right middle lobe suspicious for malignancy on the previous PET CT. 4. Re demonstration of 2 left breast nodules for which correlation with mammography and ultrasound is suggested. ___ ___ IMPRESSION 1. Interval progression of deep vein thrombosis in the left lower extremity with occlusive thrombus involving the entire femoral vein previously only involving the mid and distal femoral vein. There is additional nonocclusive thrombus in the deep femoral vein. The left common femoral and popliteal veins are patent. 2. The bilateral calf veins were not visualized due to an overlying dressing. Otherwise no evidence of deep venous thrombosis in the right lower extremity. ___ TTE Conclusions The left atrium is normal in size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness cavity size and global systolic function are normal LVEF 55 . Doppler parameters are most consistent with Grade I mild left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened . There is no aortic valve stenosis. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. ___ CXR IMPRESSION Compared to chest radiographs ___ through ___. Heart size top normal. Lungs grossly clear. No pleural abnormality or evidence of central lymph node enlargement. Brief Hospital Course Ms. ___ is a ___ woman s p robotic radical cystectomy omplicated by bacteremia and abscess LLE DVT currently on daily lovenox who presents with dyspnea on exertion and dyspnea on exertion and found to have large PE and progression of DVT. PE DVT Likely due to undertreatment of known LLE DVT with prophylactic dosing of lovenox. Given underdosing of lovenox this was not thought to be treatment failure and IVC filter was deferred. She had no signs of right heart strain on imaging EKG exam. TTE showed no evidence of right heart strain. She was treated with a heparin gtt then transitioned to treatment dose lovenox given malignancy associated thrombosis as noted in CLOT trial. She is quite symptomatic and requires oxygen supplementation though improved during hospitalization. Please wean oxygen as tolerated. Pulmonary nodules Known spiculated masses that were noted on CT in ___ concerning for primary lung malignancy vs mets. Current CT showed stable nodules still concerning for malignancy. She was evaluated by the thoracic team who recommended CT biopsy vs. surveillance. Given her current PE DVT the family and the patient decided for surveillance at this time. They will follow up with her primary care provider. Enterococcal UTI She was noted to have rising WBC in the setting of UCX from urostomy growing Enterococcus. Given her rising leukocytosis we proceeded with treatment. She was started on IV Ampicillin and transitioned to macrobid based on sensitivies. Leukocytosis improved on antibiotics. She should complete a 7 day course day 1 ___ day 7 ___. Normocytic Anemia No signs of bleeding or hemolysis. Hb dropped to nadir of 7.3 stable at discharge at 7.5. Iron studies consistent with likely combination iron deficiency anemia and anemia of chronic disease with low iron but elevated ferritin and low TIBC. Would recommend checking again as outpatient and work up as needed. ___ swelling Likley multifactorial including venous insufficiency as well as known LLE DVT. She responded quite well with compression stockings. Hx of bladder cancer s p ___ TURBT high grade TCC T1 no muscle identified . Then in ___ pelvic MRI showed bladder mass invasion perivesical soft tissue anterior vaginal wall on right C W T4 lesion . In ___ underwent robotic TAH BSO lap radical cystectomy and anterior vaginectomy with pathology showing pT2b node and margins negative. No plan for any further therapy at this time per Dr ___. The patient is safe to discharge today and 30min were spent on discharge day management services. Transitional issues She will need follow up chest CT for pulmonary nodules in 3 months ___ To complete 7 day course for UTI with macrobid day 7 ___ Continue oxygen therapy and wean as tolerated to maintain O2 sat 92 Please check CBC on ___ to ensure stability of h h and demonstrate resolution of leukocytosis HCP son Dr. ___ ___ Medications on Admission The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY Start ___ First Dose Next Routine Administration Time 4. Levothyroxine Sodium 175 mcg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Losartan Potassium 50 mg PO DAILY 7. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate 8. LORazepam 0.25 mg PO BID PRN anxiety 9. Senna 8.6 mg PO BID Discharge Medications 1. Nitrofurantoin Monohyd MacroBID 100 mg PO Q12H Last day ___. Enoxaparin Sodium 90 mg SC Q12H Start Today ___ First Dose Next Routine Administration Time 3. LORazepam 0.25 mg PO QHS PRN insomnia RX lorazepam 0.5 mg 0.5 One half tab by mouth QHS prn Disp 3 Tablet Refills 0 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Levothyroxine Sodium 175 mcg PO DAILY 8. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate RX oxycodone 5 mg 1 tablet s by mouth Q8H prn Disp 3 Tablet Refills 0 9. Senna 8.6 mg PO BID Discharge Disposition Extended Care Facility ___ Discharge Diagnosis PE Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Out of Bed with assistance to chair or wheelchair. Discharge Instructions Ms. ___ it was a pleasure taking care you during your admission to ___. You were admitted for a clot in your lungs and leg. You were treated with a blood thinner. You will need to continue the blood thinner. You were also treated for a urinary tract infection. For your pulmonary nodules you should follow up with your primary care doctor. Followup Instructions ___
The icd codes present in this text will be I2699, I82412, N390, I471, I10, I872, R918, B952, E039, E785, E876, E8342, G4700, K5900, Z66, N63, D509, D638, Z7901, Z8551, Z906, Z87891, Z96652. The descriptions of icd codes I2699, I82412, N390, I471, I10, I872, R918, B952, E039, E785, E876, E8342, G4700, K5900, Z66, N63, D509, D638, Z7901, Z8551, Z906, Z87891, Z96652 are I2699: Other pulmonary embolism without acute cor pulmonale; I82412: Acute embolism and thrombosis of left femoral vein; N390: Urinary tract infection, site not specified; I471: Supraventricular tachycardia; I10: Essential (primary) hypertension; I872: Venous insufficiency (chronic) (peripheral); R918: Other nonspecific abnormal finding of lung field; B952: Enterococcus as the cause of diseases classified elsewhere; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; E876: Hypokalemia; E8342: Hypomagnesemia; G4700: Insomnia, unspecified; K5900: Constipation, unspecified; Z66: Do not resuscitate; N63: Unspecified lump in breast; D509: Iron deficiency anemia, unspecified; D638: Anemia in other chronic diseases classified elsewhere; Z7901: Long term (current) use of anticoagulants; Z8551: Personal history of malignant neoplasm of bladder; Z906: Acquired absence of other parts of urinary tract; Z87891: Personal history of nicotine dependence; Z96652: Presence of left artificial knee joint. The common codes which frequently come are N390, I10, E039, E785, G4700, K5900, Z66, D509, Z7901, Z87891. The uncommon codes mentioned in this dataset are I2699, I82412, I471, I872, R918, B952, E876, E8342, N63, D638, Z8551, Z906, Z96652. |
The icd codes present in this text will be T814XXA, K651, N179, I82412, C679, I10, B966, R7881, Y838, Y9289, F17210, Z436, Z90710, D72829, Z96652. The descriptions of icd codes T814XXA, K651, N179, I82412, C679, I10, B966, R7881, Y838, Y9289, F17210, Z436, Z90710, D72829, Z96652 are T814XXA: Infection following a procedure; K651: Peritoneal abscess; N179: Acute kidney failure, unspecified; I82412: Acute embolism and thrombosis of left femoral vein; C679: Malignant neoplasm of bladder, unspecified; I10: Essential (primary) hypertension; B966: Bacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhere; R7881: Bacteremia; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y9289: Other specified places as the place of occurrence of the external cause; F17210: Nicotine dependence, cigarettes, uncomplicated; Z436: Encounter for attention to other artificial openings of urinary tract; Z90710: Acquired absence of both cervix and uterus; D72829: Elevated white blood cell count, unspecified; Z96652: Presence of left artificial knee joint. The common codes which frequently come are N179, I10, F17210. The uncommon codes mentioned in this dataset are T814XXA, K651, I82412, C679, B966, R7881, Y838, Y9289, Z436, Z90710, D72829, Z96652.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Abdominal pain distention nausea Major Surgical or Invasive Procedure Interventional radiology placement of abdominal abscess drain History of Present Illness ___ F with h o muscle invasive bladder cancer returning to the ED POD 15 with abdominal pain nausea and distension. She has been obstipated for nearly three days. KUB and CT scan notable for dilated loops air fluids and tapering small bowel without an obvious transition point. Labwork notable for ___ and leukocytosis. Concerned for small bowel obstruction or an ileus in presence ___ and leukocytosis she was re admitted for IVF bowel rest NGT decompression. Past Medical History Hypertension laparoscopic cholecystectomy left knee replacement six to ___ years ago laminectomy of L5 S1 at age ___ two vaginal deliveries. s p ___ 1. Robot assisted laparoscopic bilateral pelvic lymph node dissection. 2. Robot assisted hysterectomy and bilateral oophorectomy for large uterus greater than 300 grams with large fibroid. 3. Laparoscopic radical cystectomy and anterior vaginectomy with vaginal reconstruction. Social History ___ Family History Negative for bladder CA. Physical Exam WdWn NAD AVSS Abdomen soft appropriately tender along incision Incision is c d I Stoma is well perfused Urine color is yellow Bilateral lower extremities are warm dry well perfused. There is no reported calf pain to deep palpation. Bilateral lower extremities have 2 pitting edema but no erythema callor pain. Pigtail drain has been removed dressing c d i Pertinent Results ___ 05 58AM BLOOD WBC 9.9 RBC 2.76 Hgb 8.2 Hct 26.2 MCV 95 MCH 29.7 MCHC 31.3 RDW 13.9 RDWSD 47.3 Plt ___ ___ 06 45AM BLOOD WBC 10.3 RBC 2.87 Hgb 8.7 Hct 27.7 MCV 97 MCH 30.3 MCHC 31.4 RDW 14.0 RDWSD 49.4 Plt ___ ___ 05 13AM BLOOD WBC 11.6 RBC 3.27 Hgb 9.8 Hct 31.0 MCV 95 MCH 30.0 MCHC 31.6 RDW 13.6 RDWSD 47.5 Plt ___ ___ 07 06PM BLOOD WBC 22.5 RBC 3.58 Hgb 10.9 Hct 34.0 MCV 95 MCH 30.4 MCHC 32.1 RDW 13.9 RDWSD 47.9 Plt ___ ___ 07 06PM BLOOD Neuts 89 Bands 1 Lymphs 5 Monos 3 Eos 0 Baso 0 ___ Metas 1 Myelos 0 Hyperse 1 AbsNeut 20.48 AbsLymp 1.13 AbsMono 0.68 AbsEos 0.00 AbsBaso 0.00 ___ 01 04PM BLOOD ___ PTT 30.9 ___ ___ 05 58AM BLOOD Glucose 106 UreaN 26 Creat 0.4 Na 136 K 4.6 Cl 107 HCO3 26 AnGap 8 ___ 06 45AM BLOOD Glucose 114 UreaN 32 Creat 0.4 Na 137 K 4.1 Cl 106 HCO3 25 AnGap 10 ___ 06 00AM BLOOD Glucose 121 UreaN 39 Creat 0.4 Na 140 K 3.6 Cl 107 HCO3 26 AnGap 11 ___ 07 06PM BLOOD Glucose 117 UreaN 60 Creat 1.7 Na 133 K 5.0 Cl 96 HCO3 21 AnGap 21 ___ 08 30AM BLOOD ALT 20 AST 19 AlkPhos 77 ___ 05 58AM BLOOD Calcium 7.6 Phos 2.8 Mg 2.2 ___ 06 45AM BLOOD Calcium 7.7 Phos 2.4 Mg 2.1 ___ 08 30AM BLOOD Albumin 1.8 Calcium 7.7 Phos 3.5 Mg 2.1 Iron 23 ___ 07 06PM BLOOD Calcium 8.0 Phos 5.5 Mg 2.2 ___ 08 30AM BLOOD calTIBC 116 Ferritn 789 TRF 89 ___ 05 09AM BLOOD Triglyc 106 ___ 08 30AM BLOOD Triglyc 89 ___ 07 06PM BLOOD Lactate 1.5 ___ 03 00PM ASCITES Creat 0.4 Amylase 18 Triglyc 29 Lipase 8 ___ 03 00PM OTHER BODY FLUID Creat 0.5 ___ 7 12 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture Routine Final ___ CITROBACTER KOSERI. FINAL SENSITIVITIES. SENSITIVITIES MIC expressed in MCG ML ___ CITROBACTER KOSERI CEFEPIME 1 S CEFTAZIDIME 1 S CEFTRIAXONE 1 S CIPROFLOXACIN 0.25 S GENTAMICIN 1 S MEROPENEM 0.25 S PIPERACILLIN TAZO 4 S TOBRAMYCIN 1 S TRIMETHOPRIM SULFA 1 S Aerobic Bottle Gram Stain Final ___ GRAM NEGATIVE ROD S . Reported to and read back by ___ ___ 14 35 ON ___. ___ 3 00 pm ABSCESS . PELVIC ASPIRATION. FINAL REPORT ___ GRAM STAIN Final ___ 4 10 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. 1 1 per 1000X FIELD GRAM NEGATIVE ROD S . WOUND CULTURE Final ___ NO GROWTH. ANAEROBIC CULTURE Final ___ BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. ___ 10 52 am STOOL CONSISTENCY NOT APPLICABLE Source Stool. FINAL REPORT ___ C. difficile DNA amplification assay Final ___ Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. Reference Range Negative . Brief Hospital Course Ms. ___ was admitted to Dr. ___ service for management of ileus. Upon admission a nasogastric tube was placed for decompression. On ___ PICC was placed and TPN started. Blood cultures grew gram negative rods and ceftriaxone was started. On ___ pt started to pass small amount of flatus. ___ CT scan demonstrated improving ileus but concern for possible urine leak and increased free fluid. On ___ a LLQ drain was placed by interventional radiology. on ___ pt passed clamp trial and NGT was removed. Pt continued to pass flatus and also started to have bowel movements. On ___ pt was advanced to a clear liquid diet. Repeat blood cultures were negative and positive blood culture from admission grew citrobacter. Diet was gradually advanced and ensure added. IV medications were gradually converted to PO and she was re evaluated by physical therapy for rehabilitative services. She was ambulating with walker assistance and prepared for discharge to her ___ facility ___ . TPN was continued up until day before discharge. At time of discharge she was tolerating regular diet passing flatus regularly and having bowel movements. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H 5. Docusate Sodium 100 mg PO BID 6. Enoxaparin Sodium 40 mg SC DAILY 7. Nitrofurantoin Monohyd MacroBID 100 mg PO DAILY 8. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate Discharge Medications 1. Ciprofloxacin HCl 500 mg PO Q12H Duration 7 Days Last dose ___ 2. MetroNIDAZOLE 500 mg PO Q6H Duration 7 Days Last dose ___ 3. Senna 8.6 mg PO BID 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Docusate Sodium 100 mg PO BID 7. Enoxaparin Sodium 40 mg SC DAILY Start ___ First Dose Next Routine Administration Time 8. Levothyroxine Sodium 175 mcg PO DAILY 9. LORazepam 0.25 mg PO BID PRN anxiety 10. Losartan Potassium 50 mg PO DAILY 11. Nitrofurantoin Monohyd MacroBID 100 mg PO DAILY 12. OxyCODONE Immediate Release 5 mg PO Q4H PRN Pain Moderate Discharge Disposition Extended Care Facility ___ Discharge Diagnosis bladder cancer post operative ileus bacteremia CITROBACTER KOSERI and abdominal pelvic abscess BACTEROIDES FRAGILIS GROUP requiring ___ drainage Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Please also refer to the instructions provided to you by the Ostomy nurse specialist that details the required care and management of your Urostomy Resume your pre admission home medications except as noted. Always call to inform review and discuss any medication changes and your post operative course with your primary care doctor ___ acetaminophen and Ibuprofen for pain control. Ciprofloxacin and Metronidazole are new ANTIBIOTIC medications to treat your infection. Continue for 7 days through ___. The MAXIMUM dose of Tylenol ACETAMINOPHEN is 3 grams from ALL sources PER DAY If you are taking Ibuprofen Brand names include ___ this should always be taken with food. If you develop stomach pain or note black stool stop the Ibuprofen. Please do NOT drive operate dangerous machinery or consume alcohol while taking narcotic pain medications. Do NOT drive and until you are cleared to resume such activities by your PCP or urologist. You may be a passenger Colace may have been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener NOT a laxative. No heavy lifting for 4 weeks no more than 10 pounds . Do not be sedentary. Walk frequently. Light household chores cooking folding laundry washing dishes are generally ok but AGAIN avoid straining pulling twisting do NOT vacuum . Followup Instructions ___
The icd codes present in this text will be T814XXA, K651, N179, I82412, C679, I10, B966, R7881, Y838, Y9289, F17210, Z436, Z90710, D72829, Z96652. The descriptions of icd codes T814XXA, K651, N179, I82412, C679, I10, B966, R7881, Y838, Y9289, F17210, Z436, Z90710, D72829, Z96652 are T814XXA: Infection following a procedure; K651: Peritoneal abscess; N179: Acute kidney failure, unspecified; I82412: Acute embolism and thrombosis of left femoral vein; C679: Malignant neoplasm of bladder, unspecified; I10: Essential (primary) hypertension; B966: Bacteroides fragilis [B. fragilis] as the cause of diseases classified elsewhere; R7881: Bacteremia; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y9289: Other specified places as the place of occurrence of the external cause; F17210: Nicotine dependence, cigarettes, uncomplicated; Z436: Encounter for attention to other artificial openings of urinary tract; Z90710: Acquired absence of both cervix and uterus; D72829: Elevated white blood cell count, unspecified; Z96652: Presence of left artificial knee joint. The common codes which frequently come are N179, I10, F17210. The uncommon codes mentioned in this dataset are T814XXA, K651, I82412, C679, B966, R7881, Y838, Y9289, Z436, Z90710, D72829, Z96652. |
The icd codes present in this text will be T8140XA, A4181, R6520, N179, N1330, N12, T8144XA, Z936, I10, E785, E039, Z87891, Z8551, Z86718, Y848, Y92239. The descriptions of icd codes T8140XA, A4181, R6520, N179, N1330, N12, T8144XA, Z936, I10, E785, E039, Z87891, Z8551, Z86718, Y848, Y92239 are T8140XA: Infection following a procedure, unspecified, initial encounter; A4181: Sepsis due to Enterococcus; R6520: Severe sepsis without septic shock; N179: Acute kidney failure, unspecified; N1330: Unspecified hydronephrosis; N12: Tubulo-interstitial nephritis, not specified as acute or chronic; T8144XA: Sepsis following a procedure, initial encounter; Z936: Other artificial openings of urinary tract status; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E039: Hypothyroidism, unspecified; Z87891: Personal history of nicotine dependence; Z8551: Personal history of malignant neoplasm of bladder; Z86718: Personal history of other venous thrombosis and embolism; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause. The common codes which frequently come are N179, I10, E785, E039, Z87891, Z86718. The uncommon codes mentioned in this dataset are T8140XA, A4181, R6520, N1330, N12, T8144XA, Z936, Z8551, Y848, Y92239.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Fevers and chills Major Surgical or Invasive Procedure ___ stent exchange History of Present Illness Ms. ___ is a ___ female with the past medical history notable for history of bladder cancer status post robotic TAH BSO lap radical cystectomy with ileal loop diversion and anterior vaginectomy in ___ complicated by abdominal fluid requiring placement of drainage catheters further complicated by a severe bilateral hydronephrosis requiring bilateral urostomy tube placement and then ultimately ureteral stent placements with improvement who presented to the hospital for routine stent exchange and cystoscopy. The patient underwent an uncomplicated procedure but then postoperatively in the PACU she developed a fever to 102.4 and was tachycardic 105 and as such was felt to need admission for treatment of sepsis. At that time she was given ampicillin and gentamicin given her history of drug resistant organisms. She reported at that time she was feeling feverish and chills with nausea and vomiting x1. She received IV fluids and her IV antibiotics and her symptoms improved. She was admitted to the medical service for further evaluation and management On the floor the patient reports that she continues to have persistent chills. She feels slightly nauseous. She denies any abdominal pain. She otherwise reports that she is feeling better than she did immediately postprocedural but is still significantly off of her baseline. She reports that she has a history of urinary tract infections and was most recently on ciprofloxacin and ___. She reports that she was on this medication for 7 day course. No ___ acute complaints. Past Medical History Hypertension s p lap chole s p left knee replacement s p laminectomy of L5 S1 at age ___ Bladder Cancer high grade TCC T1 diagnosed in ___ then ___ pelvic MRI w invasion into bladder wall perivesical soft tissue and anterior vaginal wall c w T4 staging s p hysterectomy and bilateral oophorectomy for large uterus w fibroid s p laparascopic b l pelvic lymph node resection s p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation ___ course complicated by bacteremia and development of intra abdominal fluid collection no s p drain placement by ___ ___ h o LLE DVT and PE no longer on anticoagulation. Social History ___ Family History Negative for bladder CA. Physical Exam ADMISSION EXAM VITALS ___ 2227 Temp 99.3 PO BP 119 54 HR 80 RR 16 O2 sat 98 O2 delivery RA Dyspnea 0 RASS 0 Pain Score ___ GENERAL Alert and in no apparent distress facial twitches EYES Anicteric pupils equally round ENT Ears and nose without visible erythema masses or trauma. Oropharynx without visible lesion erythema or exudate CV Heart regular no murmur no S3 no S4. No JVD. RESP Lungs clear to auscultation with good air movement bilaterally. Breathing is non labored GI Abdomen soft non distended non tender to palpation. Bowel sounds present. No HSM GU No suprapubic fullness or tenderness to palpation foley catheter in place MSK Neck supple moves all extremities strength grossly full and symmetric bilaterally in all limbs SKIN No rashes or ulcerations noted NEURO Alert oriented face symmetric gaze conjugate with EOMI speech fluent moves all limbs sensation to light touch grossly intact throughout PSYCH pleasant appropriate affect DISCHARGE EXAM AVSS ambulating comfortably at baseline. Urostomy bag in place with no surround erythema or pain. Pertinent Results LABORATORY RESULTS ___ 05 30AM BLOOD WBC 16.5 RBC 3.23 Hgb 9.8 Hct 31.8 MCV 99 MCH 30.3 MCHC 30.8 RDW 14.5 RDWSD 52.3 Plt ___ ___ 06 09AM BLOOD WBC 14.1 RBC 3.39 Hgb 10.2 Hct 33.2 MCV 98 MCH 30.1 MCHC 30.7 RDW 14.6 RDWSD 52.7 Plt ___ ___ 06 10AM BLOOD WBC 10.0 RBC 3.55 Hgb 10.5 Hct 33.6 MCV 95 MCH 29.6 MCHC 31.3 RDW 14.1 RDWSD 49.9 Plt ___ ___ 05 30AM BLOOD Glucose 115 UreaN 34 Creat 1.6 Na 142 K 4.2 Cl 106 HCO3 22 AnGap 14 ___ 06 10AM BLOOD Glucose 99 UreaN 29 Creat 1.3 Na 141 K 3.8 Cl 104 HCO3 23 AnGap 14 ___ 05 30AM BLOOD Calcium 8.1 Phos 3.4 Mg 1.8 MICROBIOLOGY ___ 3 00 pm URINE Site CYSTOSCOPY RIGHT KIDNEY WASH. FINAL REPORT ___ URINE CULTURE Final ___ ENTEROCOCCUS FAECIUM. 10 000 CFU ML. ___ ___ REQUESTS SUSCEPTIBILITY TESTING ___. STAPHYLOCOCCUS COAGULASE NEGATIVE. 1 000 10 000 CFU ML. CORYNEBACTERIUM SPECIES DIPHTHEROIDS . 1 000 10 000 CFU ML. SENSITIVITIES MIC expressed in MCG ML ___ ENTEROCOCCUS FAECIUM AMPICILLIN 8 S NITROFURANTOIN 16 S TETRACYCLINE 16 R VANCOMYCIN 2 S Blood cultures NGTD Brief Hospital Course Ms. ___ was admitted with sepsis from a urinary tract infection after her stent exchange. She was placed empirically on vancomycin and cefepime narrowed to vanc ceftriaxone on HD 1 because of her history of resistant organisms. She rapidly improved. Her urine grew E. faecium sensitive to ampicillin. Therefore a PICC line was placed and she will complete two weeks total of ampicillin for a complicated urinary tract infection additional day days . She will follow up with Dr. ___ as an outpatient. She will stop her prophylactic TMP while on ampicillin but then resume after finishing her course. ampicillin 500 mg TID x 9 additional days restart TMP 100 mg daily for ppx after antibiotic course follow up with Dr. ___ ___ problems addressed this hospitalization 1. ___. Ms. ___ initially had an ___ likely prerenal from her sepsis. She received IV fluids and antibiotics as above and her creatinine down trended. Losartan was initially held but restarted on discharge. 2. Hyperlipidemia continued atorvastatin 10 mg daily 3. Hypothyroidism continue levothyroxine 175 mcg daily 30 minutes spent on discharge activities. Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 2. Atorvastatin 10 mg PO QPM 3. Cyanocobalamin 1000 mcg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Levothyroxine Sodium 175 mcg PO DAILY 6. LORazepam 0.5 mg PO Q12H PRN anxiety 7. Losartan Potassium 50 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 10. Trimethoprim 100 mg PO Q24H Discharge Medications 1. Ampicillin 500 mg IV Q8H RX ampicillin sodium 500 mg 500 mg IV Every eight hours Disp 15 Vial Refills 0 RX ampicillin sodium 500 mg 500 mg IV Every eight hours Disp 27 Vial Refills 0 2. Acetaminophen 650 mg PO Q6H PRN Pain Mild Fever 3. Atorvastatin 10 mg PO QPM 4. Cyanocobalamin 1000 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Levothyroxine Sodium 175 mcg PO DAILY 7. LORazepam 0.5 mg PO Q12H PRN anxiety 8. Losartan Potassium 50 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY PRN Constipation First Line 11. HELD Trimethoprim 100 mg PO Q24H This medication was held. Do not restart Trimethoprim until after you finish your ampicillin. Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Complicated E. faecium UTI Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions You were admitted to the hospital after you developed fevers and chills after you developed fevers and chills from your stent exchange. Your urine grew the enterococcus species the source of your infection. Because it was enterococcus a PICC line was placed and you will finish a total 14 day course of IV ampicillin. You also had kidney injury likely from infection that resolved with antibiotics and fluids. It was a pleasure taking care of you Followup Instructions ___
The icd codes present in this text will be T8140XA, A4181, R6520, N179, N1330, N12, T8144XA, Z936, I10, E785, E039, Z87891, Z8551, Z86718, Y848, Y92239. The descriptions of icd codes T8140XA, A4181, R6520, N179, N1330, N12, T8144XA, Z936, I10, E785, E039, Z87891, Z8551, Z86718, Y848, Y92239 are T8140XA: Infection following a procedure, unspecified, initial encounter; A4181: Sepsis due to Enterococcus; R6520: Severe sepsis without septic shock; N179: Acute kidney failure, unspecified; N1330: Unspecified hydronephrosis; N12: Tubulo-interstitial nephritis, not specified as acute or chronic; T8144XA: Sepsis following a procedure, initial encounter; Z936: Other artificial openings of urinary tract status; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E039: Hypothyroidism, unspecified; Z87891: Personal history of nicotine dependence; Z8551: Personal history of malignant neoplasm of bladder; Z86718: Personal history of other venous thrombosis and embolism; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y92239: Unspecified place in hospital as the place of occurrence of the external cause. The common codes which frequently come are N179, I10, E785, E039, Z87891, Z86718. The uncommon codes mentioned in this dataset are T8140XA, A4181, R6520, N1330, N12, T8144XA, Z936, Z8551, Y848, Y92239. |
The icd codes present in this text will be T814XXA, A419, K651, N179, N1330, D62, I2782, N138, C679, I10, E785, E039, K439, K435, E876, Y838, Y929, Z96652, Z86718, N63, Z7901, Z87891. The descriptions of icd codes T814XXA, A419, K651, N179, N1330, D62, I2782, N138, C679, I10, E785, E039, K439, K435, E876, Y838, Y929, Z96652, Z86718, N63, Z7901, Z87891 are T814XXA: Infection following a procedure; A419: Sepsis, unspecified organism; K651: Peritoneal abscess; N179: Acute kidney failure, unspecified; N1330: Unspecified hydronephrosis; D62: Acute posthemorrhagic anemia; I2782: Chronic pulmonary embolism; N138: Other obstructive and reflux uropathy; C679: Malignant neoplasm of bladder, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E039: Hypothyroidism, unspecified; K439: Ventral hernia without obstruction or gangrene; K435: Parastomal hernia without obstruction or gangrene; E876: Hypokalemia; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable; Z96652: Presence of left artificial knee joint; Z86718: Personal history of other venous thrombosis and embolism; N63: Unspecified lump in breast; Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, D62, I10, E785, E039, Y929, Z86718, Z7901, Z87891. The uncommon codes mentioned in this dataset are T814XXA, A419, K651, N1330, I2782, N138, C679, K439, K435, E876, Y838, Z96652, N63.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint subjective fevers lethargy and bloody drain output Major Surgical or Invasive Procedure ___ For the large pelvic fluid collections CT guided repositioning of existing drain and placement of an additional drain. ___ Removal of more recently placed drain History of Present Illness Ms. ___ is an ___ with PMH of hypertension and bladder cancer high grade invasive urothelial carcinoma pT2b s p TAH BSO radical cystectomy w ileal conduit c b intra abdominal infection and pelvic fluid collection s p ___ guided drain placement ___ who presents with 2 days of generalized malaise and 1 day of fevers. Patient underwent ___ guided JP drain placement for intra abdominal fluid collection and infection thought to be complicated of recent TAH BSO radical cystectomy and pelvic lymph node biopsy. This procedure was done on ___. Over the past 2 days she had noticed generalized malaise and 1 day of fever w rigors to Tmax 101.5 at home. She notes that the drainage from her intra abdominal drain is darker but her urostomy output has been unchanged. She notes some associated mild LLQ pain. She denies diarrhea BRBPR rash cough headache neck stiffness. She presented initially to OSH where she was evaluated with BCx and drain culture and was started on zosyn and vancomycin and given 650mg acetaminophen. She was transferred to ___ for further management. Past Medical History Hypertension s p lap chole s p left knee replacement s p laminectomy of L5 S1 at age ___ Bladder Cancer high grade TCC T1 diagnosed in ___ then ___ pelvic MRI w invasion into bladder wall perivesical soft tissue and anterior vaginal wall c w T4 staging s p hysterectomy and bilateral oophorectomy for large uterus w fibroid s p laparascopic b l pelvic lymph node resection s p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation ___ course complicated by bacteremia and development of intra abdominal fluid collection no s p drain placement by ___ ___ h o LLE DVT and PE on lovenox Social History ___ Family History Negative for bladder CA. Physical Exam ADMISSION EXAM Vital Signs 100.9 PO 130 54 L Lying 80 24 95 RA General Alert oriented no acute distress HEENT Sclerae anicteric MMM oropharynx clear CV RRR normal S1 S2 systolic murmur RUBS no rubs gallops Lungs Clear to auscultation bilaterally no wheezes rales rhonchi Abdomen Soft non tender non distended bowel sounds present ileal conduit drain in RLQ with pigtail drain in LLQ draining dark sang fluid GU No foley Ext Warm well perfused 1 nonpitting edema LLE Neuro CN2 12 grossly intact moving all extremities spontaneously DISCHARGE EXAM Vital signs 98.3 134 64 71 20 96 RA General AxO x3 HEENT Sclera anicteric Neck supple Lungs Clear to auscultation bilaterally no wheezes rales rhonchi on anterior auscultation CV Regular rate and rhythm normal S1 S2 III VI SEM Abdomen BS ileal conduit draining clear yellow urine. Has one LLQ drain in place draining serosanguinous fluid. Ext Warm well perfused 2 pulses no clubbing cyanosis or edema Pertinent Results ADMISSION LABS ___ 07 10PM BLOOD WBC 19.4 RBC 2.53 Hgb 6.9 Hct 22.9 MCV 91 MCH 27.3 MCHC 30.1 RDW 15.1 RDWSD 49.5 Plt ___ ___ 07 10PM BLOOD Neuts 81.4 Lymphs 9.4 Monos 7.4 Eos 0.0 Baso 0.1 Im ___ AbsNeut 15.77 AbsLymp 1.81 AbsMono 1.43 AbsEos 0.00 AbsBaso 0.02 ___ 07 10PM BLOOD ___ PTT 33.4 ___ ___ 07 10PM BLOOD Ret Aut 2.9 Abs Ret 0.07 ___ 07 10PM BLOOD Glucose 118 UreaN 25 Creat 1.1 Na 133 K 5.0 Cl 97 HCO3 23 AnGap 18 ___ 07 10PM BLOOD ALT 9 AST 9 AlkPhos 56 TotBili 0.3 ___ 07 10PM BLOOD Lipase 9 ___ 07 10PM BLOOD Albumin 2.5 Iron 6 ___ 07 10PM BLOOD calTIBC 170 Hapto 518 Ferritn 489 TRF 131 ___ 07 13PM BLOOD Lactate 1.0 DISCHARGE LABS ___ 06 00AM BLOOD WBC 6.9 RBC 2.92 Hgb 8.3 Hct 26.8 MCV 92 MCH 28.4 MCHC 31.0 RDW 15.4 RDWSD 52.4 Plt ___ ___ 06 00AM BLOOD ___ PTT 31.2 ___ ___ 06 00AM BLOOD Plt ___ ___ 06 00AM BLOOD Glucose 86 UreaN 8 Creat 0.8 Na 143 K 3.6 Cl 106 HCO3 25 AnGap 16 ___ 06 00AM BLOOD Calcium 7.5 Phos 3.7 Mg 2.3 MICROBIOLOGY Blood cultures x3 pending ___ 4 35 pm pelvic aspiration GRAM STAIN Final ___ 1 1 per 1000X FIELD POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE Final ___ NO GROWTH. ANAEROBIC CULTURE Preliminary NO GROWTH. PERTINENT IMAGING CT ABD PEL W CONTRAST ___ 1. Interval decrease in size of the right hemipelvis fluid collection 7.0 x 6.5 x 11.3 cm previously 10.0 x 12.7 x 14.8 cm with the anterior approach pigtail catheter unchanged in position. The pigtail is again located partly within the collection and partly outside its wall. 2. Interval increase in size of the left pelvic fluid collection now measuring 14.7 x 16.2 x 23.3 cm previously 13.6 x 13.9 x 23.0 cm . Increased peripheral enhancement may suggest superimposed infection. 3. No new fluid collection identified. CTA ABD PELVIS ___ 1. Decrease in size of right lower quadrant fluid collection that has percutaneous drain within it with areas of high attenuation on noncontrast exam consistent with blood products and associated hyperemia which is likely inflammatory but without evidence of contrast extravasation. 2. There is large stable fluid collection in the low left abdomen pelvis with mild linear peripheral enhancement infection cannot be excluded. 3. There is severe left and moderate to severe right hydroureteronephrosis with delayed left nephrogram stable from today. Mass effect about anastomosis between distal ureters and neobladder has resolved all since ___ and while hydronephrosis may be from residual edema if this does not resolve alternative etiologies including stenosis tumor infiltration should be excluded. 4. Tiny hepatic lesion segment ___ attention to this area on subsequent followups recommended. CT INTERVENTIONAL PROCEDURE ___ 1. Complete collapse the patient has recently drained left lower quadrant collection. The catheter from this collection was removed. 2. Near complete collapse of the patient is originally drained collection in the mid pelvis with pigtail catheter in place. 3. Left lower quadrant and deep pelvic collections as above. These findings were discussed with the team. Given the patient s improving clinical status the decision was made to pursue no further collection drainage at this time. 4. Severe bilateral hydronephrosis as on prior examinations. RECOMMENDATION Given persistence of severe hydronephrosis percutaneous nephrostomy tubes should be considered. Brief Hospital Course BRIEF SUMMARY ___ year old women with a history of bladder cancer s p cystectomy hysterectomy and BSO now with ileal conduit whose post operative course has been complicated by DVT PE ileus and pelvic fluid collections w one LLQ drain presented with subjective fevers lethargy and bloody drain output. She was found to have worsening anemia and was given 2 units of pRBC with appropriate increase in hemoglobin noted. She was also found on CT imaging to have an interval increase in size of a left abdominal fluid collection. Decision was made to place a drain per ID. Fluid was sent and revealed negative cultures negative malignant cells no evidence of lymphatic or urinary fluid. This new drain was subsequently removed per ___ as fluid collection was completely drained. The prior drain was still draining serosanguinous fluid and was kept in but repositioned. ID was consulted for the fevers leukocytosis and fluid collections and was deemed to need antibiotics and tranisitioned from broad spectrum to IV ertapenem at discharge. Will require multiple follow ups and imaging as specified in the transitional issues. ACUTE ISSUES Pelvic fluid collections patient arrived with one anterior drain putting out serosanguinous fluid. CT abdomen pelvis revealed enlarging left fluid collection and decision was made to place a drain per ___. The fluid was negative for malignant cells. The fluid had Cr 1 and triglycerides 9 suggesting that fluid collection is neither urine nor lymphatic fluid. Fluid culture was negative for bacteria. On interval imaging the new enlarging fluid collection had completely collapsed and the drain was removed. As for the other fluid collection that already had a drain putting out serosanguinous fluid it continued to drain serosanguinous fluid but at a lower rate than prior to admission. The drain was left in place as the fluid collection on imaging had not completely collapsed. BID N cultures for the aforementioned fluid collection came back positive for MSSA but per ID does not reflect rue intra abdominal infection. Given that patient had a fever at OSH and a leukocytosis she was placed on broad spectrum antibiotics with vanc ceftaz and flagyl. This was tapered per ID team to IV zosyn. On discharge ID recommended ertapenem for approximately 4 weeks with final length of treatment to be determined by fluid collection changes on repeat imaging on outpatient basis. Mrs. ___ remained afebrile and leukocytosis resolved. Pulmonary embolism Likely developed in the setting of being diagnosed with a post op DVT. She was placed on lovenox. She was transitioned to heparin ggt as she needed ___ procedures and was transitioned back to lovenox but at a lower dose per weight dosing to 70mg q12H upon discharge. Acute renal injury SCr has been steadily rising from a baseline of around 0.04 0.06 in ___ to 1.1 likely ___ obstructed uropathy ___ large pelbic fluid collections. ___ resolved over the course of her hospital stay with final Cr 0.8. Hydronephrosis bilateral and worsening on interval imaging from prior studies. Given patient s age adequate urinary output adequate creatinine clearance and no significant electrolyte abnormalities patient likely would not significantly benefit from intervention at this time. Per urology consult deemed stable for discharge and recommended outpatient urology followup. Anemia likely a combination of anemia of chronic inflammation and acute blood loss ___ to anterior abdominal drain showing serosanguinous fluid. Labs not consistent with hemolysis. Received 2 units of pRBC with appropriate response. Patient was discharged with Hgb of 8.3 per hem onc recommendation for threshold Hgb 8 as patient feels and functionally performs better with higher blood counts. Hypokalemia was hypokalemic and was repleted with oral KCl PRN. CHRONIC ISSUES Invasive high grade urothelial carcinoma involving the deep muscularis propria S p cystectomy hysterectomy and BSO now with ileal conduit whose post operative course has been complicated by DVT PE ileus and pelvic fluid collections. Patient stating that there is no plan for chemo and radiation her PET scan does show concerning foci of metastatic disease in the lung and peritoneum. Per patient s son Mrs. ___ has seen a doctor to work up the lung mass. Will need ongoing discussion with outpatient hem onc regarding how to best manage concerning lesions. Breast mass ___ mammogram showing BI RADS 5 Solid mass in the 3 o clock left breast with features of a highly suspicious for malignancy. Per patient s son she has seen a doctor for evaluating the new breast mass. Would recommend ongoing discussion with aforementioned doctor and outpatient hem onc about plan to manage. HLD continued atorvastatin without changes. Consider evaluation regarding stopping atorvastatin on outpatient basis Hypothyroidism continued levothyroxine without changes. HCP Dr. ___ son ___ physician ___ Code status full code confirmed with patient on ___ TRANSITIONAL ISSUES Will need infectious disease follow up. If ID has not contacted Mrs ___ by ___ she should call ___ to set up an appointment. The ID appointment needs to be AFTER her CT abdomen pelvis has already been done Assure that Mrs ___ has her CT abdomen pelvis with contrast in the week of ___ She should get weekly lab draws of the following CBC with differential BUN Cr AST ALT TB ALK PHOS. ALL LAB REQUESTS SHOULD BE ANNOTATED WITH ATTN ___ CLINIC FAX ___ If possible please give ertapenem at night time so it does not interfere with her daily activities. Tentatively she will be receiving ertapenem for ___ weeks but with final treatment length determined by the infectious disease team. Will need ongoing discussion with outpatient PCP and hem onc regarding how to manage new breast lesion and lung peritoneum lesions. Reevaluate need for atorvastatin Will need outpatient follow up with urology Dr. ___ his team regarding worsening hydronephrosis Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H 2. Atorvastatin 10 mg PO QPM 3. Enoxaparin Sodium 90 mg SC Q12H Start ___ First Dose Next Routine Administration Time 4. Levothyroxine Sodium 175 mcg PO DAILY 5. LORazepam 0.25 0.5 mg PO DAILY PRN anxiety Discharge Medications 1. Ertapenem Sodium 1 g IV 1X Duration 1 Dose please give ertapenem daily preferably at nighttime to not interfere with her daily activities 2. Milk of Magnesia 30 mL PO Q6H PRN constipation 3. Enoxaparin Sodium 70 mg SC Q12H Start Today ___ First Dose Next Routine Administration Time 4. Acetaminophen 650 mg PO Q6H 5. Atorvastatin 10 mg PO QPM 6. Levothyroxine Sodium 175 mcg PO DAILY 7. LORazepam 0.25 0.5 mg PO DAILY PRN anxiety Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Primary diagnosis Pelvic fluid collection infection ___ acute blood loss anemia Secondary diagnosis acute renal failure acute on chronic anemia recent pulmonary embolism invasive high grade urothelial carcinoma left breast mass BIRADS 5 hypothyroidism Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear ___ ___ did you come to the hospital You were feeling tired and your drain output was bloody. What happened at the hospital A CT scan showed very large fluid collections in your pelvis The radiologists placed another drain and removed it once it appeared that the large fluid collection was gone You were given a blood transfusion We placed a PICC a long IV so that you can receive antibiotics after you get discharged from the hospital What needs to happen when you leave the hospital Please continue seeing the doctors that are ___ your lung and breast lesions and follow their recommendations. Continue taking Lovenox every day to treat the blood clot in your lung. If the infectious disease doctor has not contacted you by ___ please call the following number to set up an appointment ___. Please make sure you have a repeat CT scan done BEFORE your appointment with the infectious disease doctor You will be getting IV antibiotics for several weeks. The infectious disease doctor ___ determine how long you will need to be on it. It was a pleasure taking care of you. Your ___ team Followup Instructions ___
The icd codes present in this text will be T814XXA, A419, K651, N179, N1330, D62, I2782, N138, C679, I10, E785, E039, K439, K435, E876, Y838, Y929, Z96652, Z86718, N63, Z7901, Z87891. The descriptions of icd codes T814XXA, A419, K651, N179, N1330, D62, I2782, N138, C679, I10, E785, E039, K439, K435, E876, Y838, Y929, Z96652, Z86718, N63, Z7901, Z87891 are T814XXA: Infection following a procedure; A419: Sepsis, unspecified organism; K651: Peritoneal abscess; N179: Acute kidney failure, unspecified; N1330: Unspecified hydronephrosis; D62: Acute posthemorrhagic anemia; I2782: Chronic pulmonary embolism; N138: Other obstructive and reflux uropathy; C679: Malignant neoplasm of bladder, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; E039: Hypothyroidism, unspecified; K439: Ventral hernia without obstruction or gangrene; K435: Parastomal hernia without obstruction or gangrene; E876: Hypokalemia; Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable; Z96652: Presence of left artificial knee joint; Z86718: Personal history of other venous thrombosis and embolism; N63: Unspecified lump in breast; Z7901: Long term (current) use of anticoagulants; Z87891: Personal history of nicotine dependence. The common codes which frequently come are N179, D62, I10, E785, E039, Y929, Z86718, Z7901, Z87891. The uncommon codes mentioned in this dataset are T814XXA, A419, K651, N1330, I2782, N138, C679, K439, K435, E876, Y838, Z96652, N63. |
The icd codes present in this text will be N99820, E43, R310, N131, D62, R8271, E039, E785, N9989, I10, Z86718, Z936, Z7902, Z86711, Z87891, Z6822, Z8551, Z96652, Y848, Y833, Y929. The descriptions of icd codes N99820, E43, R310, N131, D62, R8271, E039, E785, N9989, I10, Z86718, Z936, Z7902, Z86711, Z87891, Z6822, Z8551, Z96652, Y848, Y833, Y929 are N99820: Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure; E43: Unspecified severe protein-calorie malnutrition; R310: Gross hematuria; N131: Hydronephrosis with ureteral stricture, not elsewhere classified; D62: Acute posthemorrhagic anemia; R8271: Bacteriuria; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; N9989: Other postprocedural complications and disorders of genitourinary system; I10: Essential (primary) hypertension; Z86718: Personal history of other venous thrombosis and embolism; Z936: Other artificial openings of urinary tract status; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z86711: Personal history of pulmonary embolism; Z87891: Personal history of nicotine dependence; Z6822: Body mass index [BMI] 22.0-22.9, adult; Z8551: Personal history of malignant neoplasm of bladder; Z96652: Presence of left artificial knee joint; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y833: Surgical operation with formation of external stoma as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable. The common codes which frequently come are D62, E039, E785, I10, Z86718, Z7902, Z87891, Y929. The uncommon codes mentioned in this dataset are N99820, E43, R310, N131, R8271, N9989, Z936, Z86711, Z6822, Z8551, Z96652, Y848, Y833.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint Hematuria weakness Major Surgical or Invasive Procedure None History of Present Illness ___ y o female with h o PE on lovenox bladder cancer s p Robotic TAH BSO lap radical cystectomy with ileal loop diversion and anterior vaginectomy in ___ c b abdominal fluid requiring placement of drainage catheters. Recent abdominal imaging noted worsening of her bilateral severe hydronephrosis and her Cr was noted to have risen from 0.8 to 1.3 outside lab value . Patient recently underwent bilateral nephrostomy tube placement by ___ on ___. She first started feeling weak during ___ yesterday doing the exercises. Had palpitations with ambulation. Has tightness in chest with ambulating since yesterday. Felt light headed with ambulation. SNF noticed increased hematuria with R bag darker than L bag since yesterday. Her Urostomy placed in ___ also positive for hematuria. She was transferred to ___ ED for further management. In the ED initial vitals were Temp. 98.1 HR 72 BP 139 56 RR 16 99 RA Labs notable for WBC 5.9 Hg 8.1 platelets 374. Na 140 K 4.3 Cl 103 biacrb 22 BUN 29 Cr 1.0 UA from bilateral nephrostomy tubes with 100 WBC moderate leukocytes and large blood. Imaging was notable for CT abd pelvis w o contrast Interval placement of bilateral percutaneous nephroureterostomy tubes with resolved hydroureteronephrosis. No RP hematoma. Patient was given LR Upon arrival to the floor patient reports that she noticed shortness of breath today with walking in conjunction with bloody output from her ostomy tubes. She notes that the output from her nephrostomy tubes was pink tinged when she left the hospital 2 days ago. She also endorses associated chest tightness but no pain or pressure. She denies cough fever chills abdominal pain or diarrhea. She notes that she has an ostomy and nephroureterostomy without sensation of dysuria. Patient notes feeling dizzy and lightheaded previously though is currently asymptomatic. Past Medical History Hypertension s p lap chole s p left knee replacement s p laminectomy of L5 S1 at age ___ Bladder Cancer high grade TCC T1 diagnosed in ___ then ___ pelvic MRI w invasion into bladder wall perivesical soft tissue and anterior vaginal wall c w T4 staging s p hysterectomy and bilateral oophorectomy for large uterus w fibroid s p laparascopic b l pelvic lymph node resection s p radical cystectomy and anterior vaginectomy with vaginal reconstruction with ileal conduit creation ___ course complicated by bacteremia and development of intra abdominal fluid collection no s p drain placement by ___ ___ h o LLE DVT and PE on lovenox Social History ___ Family History Negative for bladder CA. Physical Exam ADMISSION PHYSICAL EXAM VITAL SIGNS Temp. 98.1 PO BP 158 66 HR 72 RR 18 Spo2 95 RA GENERAL well appearing elderly woman in no acute distress CARDIAC RRR no murmurs LUNGS clear to auscultation bilaterally ABDOMEN soft non tender to palpation normal bowel sounds. Ostomy draining brown stool. Nephroureterostomy draining dark red bloody urine. Bilateral nephrostomy tubes draining blood urine. EXTREMITIES No edema warm and well perfused. DISCHARGE PHYSICAL EXAM VS 98.3 PO 139 67 71 18 94 RA GENERAL well appearing elderly woman in no acute distress CARDIAC RRR no murmurs LUNGS clear to auscultation bilaterally ABDOMEN soft non tender to palpation normal bowel sounds. Nephroureterostomy draining dark red bloody urine. Bilateral nephrostomy tubes capped. EXTREMITIES No edema warm and well perfused Pertinent Results ADMISSION LABS ___ 05 20PM BLOOD WBC 5.9 RBC 2.90 Hgb 8.1 Hct 26.6 MCV 92 MCH 27.9 MCHC 30.5 RDW 15.4 RDWSD 51.2 Plt ___ ___ 05 48AM BLOOD WBC 4.6 RBC 2.46 Hgb 7.0 Hct 22.6 MCV 92 MCH 28.5 MCHC 31.0 RDW 15.3 RDWSD 51.7 Plt ___ ___ 05 20PM BLOOD Neuts 56.3 ___ Monos 12.6 Eos 1.5 Baso 0.3 Im ___ AbsNeut 3.29 AbsLymp 1.69 AbsMono 0.74 AbsEos 0.09 AbsBaso 0.02 ___ 05 20PM BLOOD Glucose 101 UreaN 29 Creat 1.0 Na 140 K 4.3 Cl 103 HCO3 22 AnGap 19 IMAGING STUDIES ___ CT Abd Pel w o Contrast IMPRESSION 1. Interval placement of bilateral percutaneous nephroureterostomy tubes with resolved hydroureteronephrosis. No RP hematoma. 2. Partially imaged nodular opacity in the right middle lobe which can be further assessed on a nonemergent dedicated CT chest. ___ CXR AP portable upright view of the chest. Right upper extremity access PICC line is seen with its tip in the upper SVC. Overlying EKG leads are present. Lungs are clear. Cardiomediastinal silhouette is stable. Bony structures are intact. MICROBIOLOGY ___ 6 35 pm URINE LEFT NEPHROSTOMY TUBE. FINAL REPORT ___ URINE CULTURE Final ___ NO GROWTH. DISCHARGE LABS ___ 05 08AM BLOOD WBC 5.4 RBC 2.86 Hgb 8.2 Hct 26.5 MCV 93 MCH 28.7 MCHC 30.9 RDW 15.3 RDWSD 51.8 Plt ___ ___ 05 08AM BLOOD Glucose 94 UreaN 29 Creat 0.9 Na 143 K 4.0 Cl 106 HCO3 26 AnGap 15 ___ 05 08AM BLOOD Calcium 8.8 Phos 5.2 Mg 2.1 Brief Hospital Course Ms. ___ is an ___ year old woman with history of provoked DVT PE on lovenox bladder cancer s p Robotic TAH BSO lap radical cystectomy with ileal loop diversion and anterior vaginectomy in ___ c b abdominal fluid requiring placement of drainage catheters and recent hydronephrosis requiring placement of bilateral PCN tubes on ___ presenting from rehab with hematuria and weakness. On arrival pt had evidence of frank hematuria in her urostomy bag and PCN tubes. Her hemoglobin was initially 8.1 which subsequently dropped to 7.0 Her lovenox was held and she was transfused with 1 U PRBC with an appropriate hemoglobin bump to 8.2. Hematuria was likely caused by recent instrumentation in the setting of anticoagulation. Her hematuria improved as did her dizziness weakness. ___ was consulted and recommending capping her PCN tubes. After discussion with the patient s hematologist it was decided to stop her lovenox treatment given that her DVT PE were provoked in the setting of her recovery from surgery and that she had received almost 6 months of treatment. Secondary Issues Asymptomatic bacteruria Patient with asymptomatic bacteruria in setting of recent procedural manipulation. She was afebrile and without leukocytosis so treatment with antibiotics was deferred. Hyperlipidemia continued atorvastatin 10 mg daily Hypothyroidism continue levothyroxine 175 mcg daily TRANSITIONAL ISSUES Medication Changes Lovenox stopped CT Abdomen Pelvis showed partially imaged nodular opacity in the right middle lobe which can be further assessed on a nonemergent dedicated CT chest. Pt s PCN tubes were capped per ___ recommendation during her hospitalization she was discharged with scheduled followup to decide on long term management If pt develops hematuria and or lightheadedness or other symptoms of anemia a CBC should be rechecked to assess for bleeding Hemoglobin Hematocrit on discharge 8.2 26.5 CODE presumed full CONTACT ___ MD ___ cell ___ home Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO QPM 2. Enoxaparin Sodium 70 mg SC Q12H Start ___ First Dose Next Routine Administration Time 3. Levothyroxine Sodium 175 mcg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Probiotic Digestive Enzymes L. acidophilus dig ___ 5 ___ mg oral daily Discharge Medications 1. Atorvastatin 10 mg PO QPM 2. Levothyroxine Sodium 175 mcg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Probiotic Digestive Enzymes L. acidophilus dig ___ 5 ___ mg oral daily Discharge Disposition Extended Care Facility ___ Discharge Diagnosis Primary Diagnoses Hematuria anemia Secondary Diagnoses Bladder cancer hydronephrosis hypothyroidism DVT PE Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear Ms. ___ It was a pleasure taking care of you at ___. WHY DID YOU COME TO THE HOSPITAL You noticed blood in your urine and you were feeling weak lightheaded. WHAT HAPPENED WHILE YOU WERE HERE We did not give you your blood thinner medication Lovenox and we gave you a unit of blood. The blood in your urine cleared up. WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL Along with your oncologist Dr. ___ have decided that you no longer need to take any Lovenox. You should continue to follow up with your doctors and take all of your medications as prescribed. Your followup appointments are listed below. Again it was a pleasure taking care of you Sincerely Your ___ Team Followup Instructions ___
The icd codes present in this text will be N99820, E43, R310, N131, D62, R8271, E039, E785, N9989, I10, Z86718, Z936, Z7902, Z86711, Z87891, Z6822, Z8551, Z96652, Y848, Y833, Y929. The descriptions of icd codes N99820, E43, R310, N131, D62, R8271, E039, E785, N9989, I10, Z86718, Z936, Z7902, Z86711, Z87891, Z6822, Z8551, Z96652, Y848, Y833, Y929 are N99820: Postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure; E43: Unspecified severe protein-calorie malnutrition; R310: Gross hematuria; N131: Hydronephrosis with ureteral stricture, not elsewhere classified; D62: Acute posthemorrhagic anemia; R8271: Bacteriuria; E039: Hypothyroidism, unspecified; E785: Hyperlipidemia, unspecified; N9989: Other postprocedural complications and disorders of genitourinary system; I10: Essential (primary) hypertension; Z86718: Personal history of other venous thrombosis and embolism; Z936: Other artificial openings of urinary tract status; Z7902: Long term (current) use of antithrombotics/antiplatelets; Z86711: Personal history of pulmonary embolism; Z87891: Personal history of nicotine dependence; Z6822: Body mass index [BMI] 22.0-22.9, adult; Z8551: Personal history of malignant neoplasm of bladder; Z96652: Presence of left artificial knee joint; Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y833: Surgical operation with formation of external stoma as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure; Y929: Unspecified place or not applicable. The common codes which frequently come are D62, E039, E785, I10, Z86718, Z7902, Z87891, Y929. The uncommon codes mentioned in this dataset are N99820, E43, R310, N131, R8271, N9989, Z936, Z86711, Z6822, Z8551, Z96652, Y848, Y833. |
The icd codes present in this text will be R471, I5030, E538, Z66, I4891, Z7902, I110, E7849, K5790, Z87891, R946, I455, R413. The descriptions of icd codes R471, I5030, E538, Z66, I4891, Z7902, I110, E7849, K5790, Z87891, R946, I455, R413 are R471: Dysarthria and anarthria; I5030: Unspecified diastolic (congestive) heart failure; E538: Deficiency of other specified B group vitamins; Z66: Do not resuscitate; I4891: Unspecified atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; I110: Hypertensive heart disease with heart failure; E7849: Other hyperlipidemia; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; Z87891: Personal history of nicotine dependence; R946: Abnormal results of thyroid function studies; I455: Other specified heart block; R413: Other amnesia. The common codes which frequently come are Z66, I4891, Z7902, I110, Z87891. The uncommon codes mentioned in this dataset are R471, I5030, E538, E7849, K5790, R946, I455, R413.
Allergies No Known Allergies Adverse Drug Reactions Chief Complaint slurred speech Major Surgical or Invasive Procedure None History of Present Illness ___ year old right handed woman with hx of Atrial fibrillation on Eliquis only once daily hypertension hyperlipidemia CHF presents as transfer from OSH after she had acute onset dysarthria and CTA showed possible partial thrombus or stenosis in superior division of L MCA. Transferred here for closer monitoring and possible thrombectomy if her exam acutely worsens. History obtained from patient and daughter at bedside. Patient is an excellent historian. On ___ she had dinner with friends and then returned to her apartment and was fooling around on her computer. Last known well was around 8 00 ___. Then she had an odd sensation and started throwing her arms around. She went to living room to sit down and tried to read but could not see the words very clearly. Then two family members were knocking at the door and she had a tough time standing up to open door. She was able to eventually stand up with great difficulty and walked with her walker. She usually walks with a walker because of knee replacement. Finally got up out of chair with walker and walked to the door to unlock. She noticed problems talking to family members. She had difficulty forming words and pronouncing words. Denies word finding difficulty. She could tell it was slurred like a person who had too much to drink. EMTs asked if she was intoxicated but she was not. She was very aware of her dysarthria and told her daughters that she thinks she s having a stroke. Then she said she had trouble sitting down but has no idea why she thought that. When she was standing she was able to walk with walker but she felt unsteady and almost fell. No visual changes. No numbness or tingling. Denies focal weakness she just had trouble standing up. She was able to unlock her door without issue but she felt shaky. She was brought by EMS to ___ where NIHSS was 1 for slurred speech. There she felt the same but her symptoms started to improve when she started to be transferred. Paramedics said her speech was improving rapidly en route. Last month started needing naps. Her hearing is poor at baseline and she normally uses hearing aids. For the past ___ months she has had ___ nocturia nightly. No dysuria. She has noticed more frequent headaches lately in the past ___ months. Last headache was yesterday. She takes tramadol and acetaminophen up to a couple times a night. She reports headaches at night which wake her up. She denies that the headache is positional it is the same sitting up or lying down. She has had some gradual weight loss over the past 12 months ___ year ago she was almost 140 lbs and now she is ___ lbs. Her appetite is still good and she enjoys eating but she is less hungry that she used to be. Daughter says that she has had marked decline in memory in past ___ weeks. Over past few years she has been forgetting plans times for pickpup and dinner plans which has become normal. Over the past ___ weeks family has noticed dramatic worsening. She doesn t remember which grandkids were coming to visit when she bought the plane tickets herself. She endorses 2 pillow orthopnea. Past Medical History Divertoculosis Atrial fibrillation on Eliquis CHF Hypercholesterolemia Hypertension Social History ___ Family History Father severe alcoholic schizophrenia Mother CHF Brother stroke carotid stenosis Physical Exam ADMISSION EXAM Vitals T 97.9 HR 79 BP 164 121 RR 19 SaO2 94 on RA General Awake cooperative elderly woman NAD. HEENT NC AT no scleral icterus noted MMM no lesions noted in oropharynx. Neck Supple. No nuchal rigidity. Pulmonary Normal work of breathing. Cardiac RRR warm well perfused. Abdomen Soft non distended. Extremities No ___ edema. Skin ecchymoses in L shin more extensive on R shin. Neurologic Mental Status Alert oriented ___. Able to relate history without difficulty. Attentive able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. Cranial Nerves II III IV VI PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V Facial sensation intact to light touch and pinprick. VII No facial droop facial musculature symmetric. VIII Hearing intact to finger snapping b l. Did not bring her hearing aids. IX X Palate elevates symmetrically. XI ___ strength in trapezii bilaterally. XII Tongue protrudes in midline with good excursions. Strength full with tongue in cheek testing. Motor Normal bulk and tone throughout. No pronator drift. No adventitious movements such as tremor or asterixis noted. ___ L 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 Sensory No deficits to light touch pinprick temperature throughout. Decreased vibratory sense in b l feet up to ankles. Joint position sense intact in b l great toes. No extinction to DSS. Romberg absent. Reflexes Bic Tri ___ Pat Ach L 2 2 2 2 0 R 2 2 2 2 0 Plantar response was flexor bilaterally. Coordination No intention tremor. No dysmetria on FNF bilaterally. HKS with L heel without dysmetria. Unable to bend R knee due to knee surgery. Gait unable to assess as patient needs a walker at baseline DISCHARGE EXAM 24 HR Data last updated ___ 419 Temp 97.4 Tm 98.6 BP 146 76 116 155 65 94 HR 53 53 86 RR 17 ___ O2 sat 96 92 97 O2 delivery Ra General Awake cooperative elderly woman NAD. HEENT NC AT no scleral icterus noted MMM no lesions noted in oropharynx. Neck Supple. No nuchal rigidity. Pulmonary Normal work of breathing. Cardiac NR RR warm well perfused. Abdomen Soft non distended. Extremities No ___ edema. Skin ecchymoses in L shin more extensive on R shin. Neurologic Mental Status Alert oriented to person and situation. Able to relate history without difficulty. Attentive to examiner. Language is fluent with intact comprehension. Normal prosody. There were no paraphasic errors. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. Cranial Nerves II III IV VI PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. V Facial sensation intact to light touch. VII No facial droop facial musculature symmetric. VIII Hearing intact to conversation. IX X Palate elevates symmetrically. XI ___ strength in trapezii bilaterally. XII Tongue protrudes in midline with good excursions. Motor Normal bulk and tone throughout. No pronator drift. No adventitious movements such as tremor or asterixis noted. Delt Bic Tri ECR FEx IO IP Quad Ham TA Gas L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 Knee cannot bend after prior surgery Sensory No deficits to light touch throughout. Coordination No intention tremor. No dysmetria on FNF bilaterally. Gait needs a walker at baseline Pertinent Results ___ 01 50AM BLOOD WBC 7.2 RBC 4.75 Hgb 14.6 Hct 45.5 MCV 96 MCH 30.7 MCHC 32.1 RDW 13.2 RDWSD 46.5 Plt ___ ___ 01 50AM BLOOD Neuts 53.1 ___ Monos 8.2 Eos 1.5 Baso 0.3 Im ___ AbsNeut 3.81 AbsLymp 2.63 AbsMono 0.59 AbsEos 0.11 AbsBaso 0.02 ___ 01 50AM BLOOD ___ PTT 29.7 ___ ___ 01 50AM BLOOD Glucose 97 UreaN 18 Creat 0.7 Na 139 K 4.3 Cl 102 HCO3 26 AnGap 11 ___ 07 35AM BLOOD CK MB 4 cTropnT 0.01 ___ 07 35AM BLOOD Calcium 9.3 Phos 3.6 Mg 1.8 Cholest 207 ___ 07 35AM BLOOD Triglyc 62 HDL 69 CHOL HD 3.0 LDLcalc 126 ___ 10 57AM BLOOD HbA1c 5.5 eAG 111 ___ 05 22AM BLOOD VitB12 249 ___ 05 22AM BLOOD TSH 5.8 ___ 05 22AM BLOOD Trep Ab NEG ___ 03 12AM URINE Color Straw Appear Clear Sp ___ ___ 03 12AM URINE Blood NEG Nitrite NEG Protein NEG Glucose NEG Ketone NEG Bilirub NEG Urobiln NEG pH 6.5 Leuks NEG ___ OSH CTA head neck ___ opinion ___ IMPRESSION 1. Segmental left vertebral artery occlusion of indeterminate chronicity. No evidence of ischemia. 2. Somewhat small caliber attenuated left M2 inferior branch without evidence of focal occlusion. 3. No acute intracranial abnormality on noncontrast CT head. ___ MRI head w o contrast IMPRESSION 1. No acute intracranial abnormality. Specifically no large territory infarction or hemorrhage. 2. Scattered foci of T2 high signal intensity in the subcortical and periventricular white matter are nonspecific and may reflect changes due to chronic small vessel disease. ___ TTE IMPRESSION No structural source of thromboembolism identified underlying rhythm predisposes to thrombus formation . Preserved left ventricular systolic function in the setting of beat to beat variability due to arrhythmia. Mild to moderate mitral and tricuspid regurgitation. Normal pulmonary pressure. Very small pericardial effusion Brief Hospital Course Ms. ___ is a ___ year old female with AFib on Eliquis CHF HLD HTN who presented w sudden onset dysarthria abnormal arm movements and poor balance walker at baseline . NIHSS 1 for slurred speech at OSH. There a CTA head and neck was completed and there was concern for left M2 branch attenuation concerning for stenosis or occlusion and she was subsequently transferred for consideration of thrombectomy but NIHSS 0 on arrival so she was not deemed a candidate. She was admitted to the Neurology stroke service for further evaluation of possible TIA vs stroke. No further symptoms noted during admission. MRI head w o contrast were without evidence of stroke. Reports recent echocardiogram per outpatient PCP cardiologist reported as no acute findings and so this was not repeated. She mentioned concern about worsening memory but able to perform ADLs w meals cleaning provided by ALF moved 10 months ago it appears there has been no acute change. She was taking apixiban 2.5mg once daily unclear why as this is a BID medication and so her dose was increased to 2.5mg BID she was not a candidate for 5mg BID due to her age and weight . She was started on atorvastatin for her hyperlipidemia LDL 126 . EP cardiology was consulted for frequent sinus pauses noted on telemetry that persisted despite holding home atenolol recommending discontinuing home digoxin and close cardiology ___. Discharged to home w ___ ___ and close PCP ___. Transient slurred speech and instability c f TIA ___ consult cleared for home with home services Started on atorvastatin for HLD and increased home apixaban to therapeutic level ___ with stroke neurology after discharge Her stroke risk factors include the following 1 DM A1c 5.5 2 Likely chronic segmental left vertebral artery occlusion and somewhat small caliber attenuated left M2 inferior branch 3 Hyperlipidemia LDL 126 4 Obesity 5 No concern noted for sleep apnea she does not carry the diagnosis An echocardiogram did not show a PFO on bubble study. AHA ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake X Yes confirmed done Not confirmed No 2. DVT Prophylaxis administered X Yes No 3. Antithrombotic therapy administered by end of hospital day 2 X Yes No 4. LDL documented X Yes LDL 126 No 5. Intensive statin therapy administered simvastatin 80mg simvastatin 80mg ezetemibe 10mg atorvastatin 40mg or 80 mg rosuvastatin 20mg or 40mg for LDL 100 X Yes No if LDL if LDL 70 reason not given Statin medication allergy Other reasons documented by physician advanced practice nurse physician ___ physician APN PA or pharmacist LDL c less than 70 mg dL 6. Smoking cessation counseling given Yes X No reason X non smoker unable to participate 7. Stroke education personal modifiable risk factors how to activate EMS for stroke stroke warning signs and symptoms prescribed medications need for followup given verbally or written X Yes No 8. Assessment for rehabilitation or rehab services considered X Yes No 9. Discharged on statin therapy X Yes No if LDL 70 reason not given Statin medication allergy Other reasons documented by physician advanced practice nurse physician ___ physician APN PA or pharmacist LDL c less than 70 mg dL 10. Discharged on antithrombotic therapy X Yes Type Antiplatelet X Anticoagulation No 11. Discharged on oral anticoagulation for patients with atrial fibrillation flutter X Yes No N A Cognitive complaints B12 249 one time IM supplementation then start oral B12 supplementation Treponemal antibodies negative consider cognitive neurology referral as outpatient for memory difficulties not appreciated on our examination Afib frequent sinus pauses stopped digoxin will ___ closely w otpt cardiologist also PCP increased to appropriate therapeutic dosing at Eliquis 2.5 mg BID reduced dose given age and weight 60 kg HLD started atorvastatin HTN continue home antihypertensives elevated troponin RESOLVED Troponin elevated at OSH negative on admission elevated TSH should recheck as otpt w PCP ___ Medications on Admission The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. Apixaban 2.5 mg PO DAILY 3. Losartan Potassium 50 mg PO DAILY 4. Digoxin 0.125 mg PO DAILY 5. LevoFLOXacin 500 mg PO Q24H Discharge Medications 1. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet s by mouth once daily at bedtime Disp 30 Tablet Refills 5 2. Cyanocobalamin 500 mcg PO DAILY RX cyanocobalamin vitamin B 12 500 mcg 1 tablet s by mouth once daily Disp 30 Tablet Refills 5 3. Apixaban 2.5 mg PO BID 4. Atenolol 50 mg PO DAILY 5. LevoFLOXacin 500 mg PO Q24H 6. Losartan Potassium 50 mg PO DAILY Discharge Disposition Home With Service Facility ___ Discharge Diagnosis transient dysarthria not secondary to TIA or stroke Mild Vitamin B12 deficiency Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Ms. ___ You were hospitalized due to symptoms of slurred speech due to concern for an ACUTE ISCHEMIC STROKE a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. However the MRI of your brain did not show evidence of stroke or TIA. Your symptoms could have been related to blood pressure dehydration alcohol use or a combination of these factors. We are changing your medications as follows Increase apixaban to 2.5mg twice daily Start Vitamin B12 daily supplement Please take your other medications as prescribed. Please follow up with your primary care physician as listed below. You should also follow up with your cardiologist as you were noted to have occasional pauses on cardiac monitoring. If you experience any of the symptoms below please seek emergency medical attention by calling Emergency Medical Services dialing 911 . In particular please pay attention to the sudden onset and persistence of these symptoms Sudden partial or complete loss of vision Sudden loss of the ability to speak words from your mouth Sudden loss of the ability to understand others speaking to you Sudden weakness of one side of the body Sudden drooping of one side of the face Sudden loss of sensation of one side of the body Sincerely Your ___ Neurology Team Followup Instructions ___
The icd codes present in this text will be R471, I5030, E538, Z66, I4891, Z7902, I110, E7849, K5790, Z87891, R946, I455, R413. The descriptions of icd codes R471, I5030, E538, Z66, I4891, Z7902, I110, E7849, K5790, Z87891, R946, I455, R413 are R471: Dysarthria and anarthria; I5030: Unspecified diastolic (congestive) heart failure; E538: Deficiency of other specified B group vitamins; Z66: Do not resuscitate; I4891: Unspecified atrial fibrillation; Z7902: Long term (current) use of antithrombotics/antiplatelets; I110: Hypertensive heart disease with heart failure; E7849: Other hyperlipidemia; K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding; Z87891: Personal history of nicotine dependence; R946: Abnormal results of thyroid function studies; I455: Other specified heart block; R413: Other amnesia. The common codes which frequently come are Z66, I4891, Z7902, I110, Z87891. The uncommon codes mentioned in this dataset are R471, I5030, E538, E7849, K5790, R946, I455, R413. |
The icd codes present in this text will be J441, N179, Z9981, I4891, D649, I10, E785, G5622, I2510, M1990, Z96649, Z87891, J45909, F419, G4700, R040, I739. The descriptions of icd codes J441, N179, Z9981, I4891, D649, I10, E785, G5622, I2510, M1990, Z96649, Z87891, J45909, F419, G4700, R040, I739 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; N179: Acute kidney failure, unspecified; Z9981: Dependence on supplemental oxygen; I4891: Unspecified atrial fibrillation; D649: Anemia, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; G5622: Lesion of ulnar nerve, left upper limb; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; M1990: Unspecified osteoarthritis, unspecified site; Z96649: Presence of unspecified artificial hip joint; Z87891: Personal history of nicotine dependence; J45909: Unspecified asthma, uncomplicated; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; R040: Epistaxis; I739: Peripheral vascular disease, unspecified. The common codes which frequently come are N179, I4891, D649, I10, E785, I2510, Z87891, J45909, F419, G4700. The uncommon codes mentioned in this dataset are J441, Z9981, G5622, M1990, Z96649, R040, I739.
Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint Shortness of breath Major Surgical or Invasive Procedure None History of Present Illness Ms. ___ is a ___ with hx COPD on home O2 atrial fibrillation on apixaban hypertension CAD and hyperlipidemia with recurrent hospitalizations for COPD exacerbations who presented with dyspnea. She has had multiple prior admissions for dyspnea. She was recently discharged on ___ after 3 day inpatient admission for COPD exacerbation. She was discharged on extended prednisone taper with plan for 5d 40mg Prednisone to finish ___ followed by 10mg taper every 5 days 35mg from ___ 30mg ___ etc... . On the evening prior to presentation patient experienced worsening shortness of breath nonproductive cough and wheezing c w prior COPD exacerbations. She reported taking inhalers as directed without relief. The patient reported that this is almost identical to her last presentation. She also felt that she was taking too many medications and does not wish to continue to take prednisone. The patient was also noted to have increased O2 requirement and she was referred to the ___ ED for further management. Of note please see prior admission note for details regarding prior admission. In the ED initial vital signs were 88 143 105 26 94 RA. Labs were notable for normal BNP and a creatinine of 1.2. Patient was given azithromycin and duoneb. Patient was scheduled to have methylpred but did not have it administered until arrival to the floor. Upon arrival to the floor she complained of wheezing and SOB. She otherwise felt well. She agreed to take the methyprednisone but does not wish to take prednisone any more. REVIEW OF SYSTEMS Per HPI. Denies headache visual changes pharyngitis fevers chills sweats weight loss chest pain abdominal pain nausea vomiting diarrhea constipation hematochezia dysuria rash paresthesias and weakness. Past Medical History COPD Asthma on home 2L O2 Atypical Chest Pain Hypertension Hyperlipidemia Osteroarthritis Atrial Fibrillation on Apixaban Anxiety Cervical Radiculitis Cervical Spondylosis Coronary Artery Disease Headache Herpes Zoster GI Bleeding Peripheral Vascular Disease s p bilateral iliac stents s p hip replacement Social History ___ Family History Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam PHYSICAL EXAMINATION ON ADMISSION VITALS 97.3 159 91 75 16 94 on 2L GENERAL Pleasant well appearing in no apparent distress. HEENT Normocephalic atraumatic no conjunctival pallor or scleral icterus PERRLA EOMI OP clear. NECK Supple no LAD no thyromegaly JVP flat. CARDIAC Normal S1 S2 no murmurs rubs or gallops. PULMONARY Mild expiratory wheezes in all lung fields ABDOMEN Normal bowel sounds soft non tender non distended no organomegaly. EXTREMITIES Warm well perfused no cyanosis clubbing or edema. SKIN Without rash. NEUROLOGIC A Ox3 CN II XII grossly normal normal sensation with strength ___ throughout. PHYSICAL EXAMINATION ON DISCHARGE VITALS 98.6 127 150 50 60 70 90 S 16 98 on 3L GENERAL Pleasant well appearing in no apparent distress. HEENT Normocephalic atraumatic no conjunctival pallor or scleral icterus PERRLA EOMI OP clear. NECK Supple no LAD no thyromegaly JVP flat. CARDIAC Normal S1 S2 no murmurs rubs or gallops. PULMONARY Minimally decreased bilateral air entry no wheezes in all lung fields ABDOMEN Normal bowel sounds soft non tender non distended no organomegaly. EXTREMITIES Warm well perfused no cyanosis clubbing or edema. SKIN Without rash. NEUROLOGIC A Ox3 CN II XII grossly normal normal sensation with strength ___ throughout. Pertinent Results LABS ON ADMISSION ___ 06 15PM BLOOD WBC 7.7 RBC 4.92 Hgb 13.5 Hct 42.4 MCV 86 MCH 27.4 MCHC 31.8 RDW 19.6 RDWSD 61.2 Plt ___ ___ 06 15PM BLOOD Neuts 87.4 Lymphs 5.7 Monos 6.1 Eos 0.0 Baso 0.1 Im ___ AbsNeut 6.72 AbsLymp 0.44 AbsMono 0.47 AbsEos 0.00 AbsBaso 0.01 ___ 06 15PM BLOOD ___ PTT 29.6 ___ ___ 06 15PM BLOOD Plt ___ ___ 06 15PM BLOOD Glucose 122 UreaN 21 Creat 1.2 Na 136 K 3.4 Cl 92 HCO3 31 AnGap 16 ___ 06 15PM BLOOD ALT 52 AST 34 AlkPhos 69 TotBili 0.3 ___ 06 15PM BLOOD Lipase 28 ___ 06 15PM BLOOD cTropnT 0.01 proBNP 325 ___ 06 15PM BLOOD Albumin 4.2 LABS ON DISHCHARGE ___ 06 40AM BLOOD WBC 10.3 RBC 4.20 Hgb 11.8 Hct 37.0 MCV 88 MCH 28.1 MCHC 31.9 RDW 19.9 RDWSD 65.1 Plt ___ ___ 06 40AM BLOOD Plt ___ ___ 06 40AM BLOOD Glucose 112 UreaN 18 Creat 0.9 Na 137 K 3.6 Cl 96 HCO3 28 AnGap 17 ___ 06 40AM BLOOD Calcium 9.5 Phos 2.6 Mg 2.1 IMAGING ___ CXR No acute cardiopulmonary process. Brief Hospital Course ___ yo F with history of COPD on home O2 atrial fibrillation on apixaban hypertension CAD hyperlipidemia and recurrent hospitalization for COPD exacerbation over the last 4 months who presented with dyspnea and increased wheezing secondary to severe COPD. Recurrent COPD exacerbation Patient presented with increased dyspnea and diffuse wheezing likely secondary to COPD exacerbation. She has a history of multiple recurrent COPD hospitalizations. According to Pulmonary patient has severe COPD based on her obstructive deficits on PFTs as well as her severe symptoms even at rest as well as her more frequent exacerbations and is likely approaching end stage disease. We continued Advair 500 50 BID Spiriva standing nebulizers and theophylline. Pulmonary recommended additional budesonide inhalers to allow reduction of PO prednisone dose. Prednisone dose was increased back to 40mg where patient was better with a plan for slow wean by 5mg every 2 weeks. Also patient was started on chronic azithromycin for chronic anti inflammation after discussion with Dr. ___ was agreed to stop azithromycin on discharge due to inability to monitor QT the week after discharge with plan to restart azithromycin once Dr. ___ is able to see the patient. Patient did not want to go to pulmonary rehab. She was seen by Palliative Care who recommended initiation of morphine liquid suspension as needed for shortness of breath. Acute kidney injury Creatinine was slightly elevated to 1.2 from a baseline of 1.0. She likely had poor PO intake. Creatinine on discharge was 0.9. CHRONIC ISSUES Anxiety Insomnia We continued home lorazepam. Atrial fibrillation We continued diltiazem for rate control and apixaban for anticoagulation. Hypertension We continued home imdur hydrochlorothiazide and diltiazem. CAD Cardiac catheterization in ___ showed no evidence of significant stenosis of coronaries. ECHO on ___ showed EF 55 and no regional or global wall motion abnormalities. We continued home aspirin and atorvastatin. Anemia We continued home iron supplements. TRANSITIONAL ISSUES Continue Advair 500 50 BID Spiriva and theophylline Make sure patient receives standing nebulizers Added additional budesonide inhalers to allow reduction of PO prednisone dose Start chronic azithromycin for chronic anti inflammation. Patient was started on azithromycin in the hospital and QTc on ___ was 472 ms. ___ discussion with Dr. ___ was agreed to stop azithromycin on discharge due to inability to monitor QT the week after discharge with the plan to restart azithromycin once Dr. ___ is able to see the patient. Would recommend audiology testing at some point while patient is on chronic azithromycin Continue supplemental oxygen for comfort Follow up with Dr. ___ discharge Continue Bactrim PPX 1 tab SS daily given extended courses of steroids Patient was discharged on prednisone 40 mg with plan for taper by 5mg every 2 weeks Prednisone 40 mg for two weeks Day 1 ___ end ___ Prednisone 35 mg for two weeks Day 1 ___ end ___ Prednisone 30 mg for two weeks Day 1 ___ end ___ etc... CONTACT ___ husband HCP ___ CODE STATUS Full confirmed Medications on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. albuterol sulfate 90 mcg actuation inhalation Q4H 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended Release 240 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 11. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 12. Guaifenesin ___ mL PO Q4H PRN cough 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 15. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 16. Lorazepam 0.5 mg PO Q8H PRN Insomnia anxiety vertigo 17. Multivitamins 1 TAB PO DAILY 18. PredniSONE 30 mg PO DAILY Tapered dose DOWN 19. Ranitidine 300 mg PO DAILY 20. Theophylline SR 300 mg PO BID 21. Tiotropium Bromide 1 CAP IH DAILY 22. Levofloxacin 750 mg PO DAILY 23. Sulfameth Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use 24. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 25. cod liver oil 1 capsule oral BID 26. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing Discharge Medications 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 3. Tiotropium Bromide 1 CAP IH DAILY 4. Theophylline SR 300 mg PO BID 5. Sulfameth Trimethoprim SS 1 TAB PO DAILY prophylaxis for long term steroid use 6. Ranitidine 300 mg PO DAILY 7. PredniSONE 40 mg PO DAILY 8. Lorazepam 0.5 mg PO Q8H PRN Insomnia anxiety vertigo 9. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 10. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 11. Ipratropium Bromide Neb 1 NEB IH Q6H Wheezing 12. Hydrochlorothiazide 50 mg PO DAILY 13. Guaifenesin ___ mL PO Q4H PRN cough 14. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 15. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 16. Ferrous Sulfate 325 mg PO DAILY 17. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 18. albuterol sulfate 90 mcg actuation inhalation Q4H 19. Apixaban 5 mg PO BID 20. Aspirin 81 mg PO DAILY 21. Atorvastatin 10 mg PO QPM 22. Diltiazem Extended Release 240 mg PO BID 23. Docusate Sodium 100 mg PO BID 24. Sodium Chloride Nasal ___ SPRY NU QID PRN nasal discomfort RX sodium chloride 0.65 ___ spray QID nasal congestion Disp 1 Spray Refills 0 25. Morphine Sulfate Oral Solution 2 mg mL 5 mg PO Q4H PRN shortness of breath RX morphine 10 mg 5 mL 2.5 mL by mouth every four 4 hours Disp ___ Milliliter Milliliter Refills 0 26. Budesonide Nasal Inhaler 180 mcg Other DAILY RX budesonide Pulmicort Flexhaler 180 mcg actuation 160 mcg delivered 1 puff INH DAILY Disp 1 Inhaler Refills 0 Discharge Disposition Home With Service Facility ___ Discharge Diagnosis PRIMARY DIAGNOSIS Severe COPD SECONDARY DIAGNOSES CAD Hypertension Atrial fibrillation Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory Independent. Discharge Instructions Dear ___ ___ was a great pleasure taking care of you at ___ ___. You came to the hospital because you were experiencing worsening shortness of breath. Pulmonary team saw you and reviewed your condition and your symptoms are thought to be related to severe COPD. We did some changes in your medications and increased the dose of prednisone. The Palliative Care team was consulted and started you on morphine liquid suspension to help with your breathing symptoms. Please take all your medications on time and follow up with your doctors as ___. Best regards Your ___ team Followup Instructions ___
The icd codes present in this text will be J441, N179, Z9981, I4891, D649, I10, E785, G5622, I2510, M1990, Z96649, Z87891, J45909, F419, G4700, R040, I739. The descriptions of icd codes J441, N179, Z9981, I4891, D649, I10, E785, G5622, I2510, M1990, Z96649, Z87891, J45909, F419, G4700, R040, I739 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; N179: Acute kidney failure, unspecified; Z9981: Dependence on supplemental oxygen; I4891: Unspecified atrial fibrillation; D649: Anemia, unspecified; I10: Essential (primary) hypertension; E785: Hyperlipidemia, unspecified; G5622: Lesion of ulnar nerve, left upper limb; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; M1990: Unspecified osteoarthritis, unspecified site; Z96649: Presence of unspecified artificial hip joint; Z87891: Personal history of nicotine dependence; J45909: Unspecified asthma, uncomplicated; F419: Anxiety disorder, unspecified; G4700: Insomnia, unspecified; R040: Epistaxis; I739: Peripheral vascular disease, unspecified. The common codes which frequently come are N179, I4891, D649, I10, E785, I2510, Z87891, J45909, F419, G4700. The uncommon codes mentioned in this dataset are J441, Z9981, G5622, M1990, Z96649, R040, I739. |
The icd codes present in this text will be J441, Z9981, I4891, J45909, Z7901, I10, I2510, E785, M1990, F419, I739, G4700, D649, Z96649, Z87891. The descriptions of icd codes J441, Z9981, I4891, J45909, Z7901, I10, I2510, E785, M1990, F419, I739, G4700, D649, Z96649, Z87891 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; Z9981: Dependence on supplemental oxygen; I4891: Unspecified atrial fibrillation; J45909: Unspecified asthma, uncomplicated; Z7901: Long term (current) use of anticoagulants; I10: Essential (primary) hypertension; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; M1990: Unspecified osteoarthritis, unspecified site; F419: Anxiety disorder, unspecified; I739: Peripheral vascular disease, unspecified; G4700: Insomnia, unspecified; D649: Anemia, unspecified; Z96649: Presence of unspecified artificial hip joint; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I4891, J45909, Z7901, I10, I2510, E785, F419, G4700, D649, Z87891. The uncommon codes mentioned in this dataset are J441, Z9981, M1990, I739, Z96649.
Allergies IV Dye Iodine Containing Contrast Media Oxycodone cilostazol Varenicline Chief Complaint Shortness of Breath Major Surgical or Invasive Procedure N A History of Present Illness Ms. ___ is a ___ female with history of COPD on home O2 atrial fibrillation on apixaban hypertension CAD and hyperlipidemia who presents with shortness of breath cough and wheezing for one day. The patient reports shortness of breath increased cough productive of ___ red flected sputum and wheezing since yesterday evening. She has been using albuterol IH more frequently ___ with ipratropium nebs every 4 hours with minimal relief. She had to increase her O2 flow up to 4L without significant improvement. She was currently taking 10mg of prednisone. She has also been taking tiotropium IH theophylline advair IH at home as prescribed. She denies sick contacts. She quit smoking approximately 1 month ago. She reports an episode of chest pain in waiting room while sitting down non exertional resolved after 2 minutes. She denies fever chills abdominal pain nausea vomiting palpitations and diaphoresis. She was recently admitted from ___ to ___ for dyspnea that was thought to be secondary to steroid taper for recent COPD exacerbation with a component of anxiety not an acute COPD exacerbation and was treated with steroids and duonebs but no antibiotics. She had a CT that showed emphysema but no evidence of infection such as ___. Pulmonary was consulted and recommended increasing her Advair dose to 500 50 which was done and switching from theophylline to roflumilast and initiation of long term azithromycin therapy which was deferred for outpatient follow up She was initiated on a steroid taper on ___ of prednisone 30 mg for 3 days then 20 mg for 3 days then 10 mg until outpatient follow up. In the ED initial vital signs were 97.6 67 132 82 22 97 4L. Exam was notable for limited air movement with wheezing bilaterally. Labs were notable for WBC 7.1 H H 12.8 41.1 Plt 233 Na 133 K 3.6 BUN Cr ___ trop 0.01 BNP 181 lactate 1.5 VBG 7.43 ___. Imaging with CXR showed mild basilar atelectasis without definite focal consolidation. The patient was given Duonebs and solumedrol 125mg IV. Vitals prior to transfer were Upon arrival to the floor she reports her breathing is improved. REVIEW OF SYSTEMS Per HPI. Denies headache visual changes pharyngitis rhinorrhea nasal congestion fevers chills sweats weight loss abdominal pain nausea vomiting diarrhea constipation hematochezia dysuria rash paresthesias and weakness. Past Medical History COPD Asthma on home 2L O2 Atypical Chest Pain Hypertension Hyperlipidemia Osteroarthritis Atrial Fibrillation on Apixaban Anxiety Cervical Radiculitis Cervical Spondylosis Coronary Artery Disease Headache Herpes Zoster GI Bleeding Peripheral Vascular Disease s p bilateral iliac stents s p hip replacement Social History ___ Family History Mother with asthma and hypertension. Father with colon cancer. Brother with leukemia. Physical Exam ADMISSION PHYSICAL EXAM VITALS Temp 97.3 HR 76 O2 sat 160 80 RR 20 O2 sat 94 4L GENERAL AOx3 speaking in full sentences NAD resting in bed comfortably. HEENT NCAT. PERRL. EOMI. Sclera anicteric and not injected. MMM. Oropharynx is clear. NECK Supple. No LAD. JVP not appreciated at 45 degrees. CARDIAC Irregularly irregular normal rate. ___ systolic murmur at the RUSB. No rubs or gallops. LUNGS Expiratory wheezes throughout with poor air movement. ABDOMEN BS soft nontender and nondistended. EXTREMITIES Warm and well perfused. No edema. 2 DP pulses bilaterally. NEUROLOGIC A Ox3 CNII XII intact strength and sensation grossly intact bilaterally. DISCHARGE PHYSICAL EXAM VITALS Tm 99.1 146 69 143 159 69 77 94 22 94 95 2L GENERAL speaking in full sentences NAD resting in bed comfortably. CARDIAC rrr normal rate. ___ systolic murmur at the RUSB LUNGS mild wheezes throughout ABDOMEN BS soft nontender and nondistended. EXTREMITIES Warm and well perfused. 1 b l ___ edema. NEUROLOGIC grossly nonfocal aaox3 Pertinent Results ADMISSION LABS ___ 05 54PM BLOOD WBC 7.1 RBC 4.74 Hgb 12.8 Hct 41.1 MCV 87 MCH 27.0 MCHC 31.1 RDW 22.6 RDWSD 69.0 Plt ___ ___ 05 54PM BLOOD Neuts 81.8 Lymphs 9.6 Monos 7.6 Eos 0.3 Baso 0.1 Im ___ AbsNeut 5.82 AbsLymp 0.68 AbsMono 0.54 AbsEos 0.02 AbsBaso 0.01 ___ 06 35AM BLOOD Calcium 9.9 Phos 4.1 Mg 2.0 ___ 05 54PM BLOOD ___ pO2 52 pCO2 49 pH 7.43 calTCO2 34 Base XS 6 ___ 05 54PM BLOOD Lactate 1.5 ___ 05 54PM BLOOD proBNP 181 ___ 05 54PM BLOOD cTropnT 0.01 STUDIES CXR ___ Mild basilar atelectasis without definite focal consolidation. EKG Sinus rhythm at 69 left bundle branch block no acute ST or T wave changes. DISCHARGE LABS ___ 06 38AM BLOOD WBC 14.4 RBC 4.34 Hgb 11.8 Hct 37.6 MCV 87 MCH 27.2 MCHC 31.4 RDW 22.5 RDWSD 69.4 Plt ___ ___ 06 38AM BLOOD Glucose 113 UreaN 18 Creat 0.8 Na 137 K 3.1 repleted Cl 94 HCO3 31 AnGap 15 Brief Hospital Course Ms. ___ is a ___ female with history of COPD on home O2 atrial fibrillation on apixaban hypertension CAD and hyperlipidemia who presents with shortness of breath cough and wheezing for one day. Pt recently DC d from hospital for dyspnea treated only w nebs and steroids as not thought ___ true COPD exacerbation c f anxiety component. Pt re admitted w similar Sx thought ___ COPD exacerbation received nebs steroids azithromycin. Pt s wheezing cough SOB improved shortly after admission O2 titrated down satting well on 2L in mid 90s which is baseline. Evaluated by ___ recommended DC to pulmonary rehab pt was agreeable. ACTIVE ISSUES Shortness of Breath Patient with history of COPD and recent admission for dyspnea in the setting of steroid taper. Her symptoms on presentation were consistent with severe COPD given diffuse wheezing and poor air movement. She likely had an exacerbation in the setting of a decrease in her steroids. There may also be a component of anxiety. She underwent CT last admission that was negative for infections such as ___. She was continued on home spiriva theophylline advair. She was started on standing duonebs q6h and albuterol q2h prn and prednisone was started at 40mg daily with slow taper. She was also given azithromycin to complete 5 day course. She had improvement in her wheezing and returned to baseline O2 requirement after 48 hours. She was seen by ___ who felt that she would benefit from discharge to inpatient pulmonary rehabilitation program. On DC to ___ rehab recommended continued Prendisone 40mg daily for 1x week with slow taper by 5mg every 5 days. ___ also consider starting bactrim ppx with extended duration of steroids if unable to wean less than 20mg qd. Will also f u as outpatient with pulm. CHRONIC ISSUES Anxiety Insomnia Continued home lorazepam. Consider starting SRRI as an outpatient. Atrial Fibrillation Continued dilt for rate control and apixaban for anticoagulation. Hypertension Continued home imdur hydrochlorothiazide and diltiazem. CAD Cardiac catheterization in ___ without evidence of significant stenosis of coronaries. ECHO on ___ with EF 55 and no regional or global wall motion abnormalities. Continued home aspirin and atorvastatin. Anemia Continued home iron supplements. TRANSITIONAL ISSUES For pt s continued COPD exacerbations recommend finishing 5d course of Azithromycin 250mg qd until ___ Recommend extended prednisone taper for pt 5d 40mg Prednisone to finish ___ followed by 10mg taper every 5 days 35mg from ___ 30mg ___ etc... . Would consider PCP prophylaxis with ___ if unable to wean prednisone to less than 20mg daily. Pt s SOB may have an anxiety component may benefit from starting SSRI in addition to home benzos already prescribed CONTACT Full Code CODE STATUS ___ husband HCP ___ ___ on Admission The Preadmission Medication list is accurate and complete. 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 10 mg PO QPM 5. Diltiazem Extended Release 240 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 8. Ferrous Sulfate 325 mg PO DAILY 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 10. Hydrochlorothiazide 50 mg PO DAILY 11. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 12. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 13. Multivitamins 1 TAB PO DAILY 14. PredniSONE 10 mg PO DAILY 15. Ranitidine 300 mg PO DAILY 16. Theophylline SR 300 mg PO BID 17. Tiotropium Bromide 1 CAP IH DAILY 18. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing 19. cod liver oil 1 capsule oral BID 20. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 21. albuterol sulfate 90 mcg actuation inhalation Q4H 22. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 23. Lorazepam 0.5 mg PO Q8H PRN Anxiety 24. Guaifenesin ___ mL PO Q4H PRN cough Discharge Medications 1. Acetaminophen 325 mg PO Q4H PRN Pain 2. albuterol sulfate 90 mcg actuation inhalation Q4H 3. Apixaban 5 mg PO BID 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 10 mg PO QPM 6. Diltiazem Extended Release 240 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Dorzolamide 2 Ophth. Soln. 1 DROP BOTH EYES BID 9. Ferrous Sulfate 325 mg PO DAILY 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN allergies 11. Fluticasone Salmeterol Diskus 500 50 1 INH IH BID 12. Guaifenesin ___ mL PO Q4H PRN cough 13. Hydrochlorothiazide 50 mg PO DAILY 14. Isosorbide Mononitrate Extended Release 240 mg PO DAILY 15. Latanoprost 0.005 Ophth. Soln. 1 DROP BOTH EYES QHS 16. Lorazepam 0.5 mg PO Q8H PRN Anxiety 17. Multivitamins 1 TAB PO DAILY 18. Ranitidine 300 mg PO DAILY 19. Theophylline SR 300 mg PO BID 20. Tiotropium Bromide 1 CAP IH DAILY 21. Calcitrate Vitamin D calcium citrate vitamin D3 315 mg 200 units oral DAILY 22. cod liver oil 1 capsule oral BID 23. Ipratropium Bromide Neb 1 NEB IH Q6H PRN Wheezing 24. Nicotine Patch 7 mg TD DAILY 25. Azithromycin 250 mg PO Q24H Duration 4 Doses please take until ___. PredniSONE 40 mg PO DAILY Duration 5 Days 40mg until ___ Tapered dose DOWN Discharge Disposition Extended Care Facility ___ ___ Diagnosis PRIMARY COPD Exacerbation SECONDARY Afib Anxiety HTN CAD Discharge Condition Mental Status Clear and coherent. Level of Consciousness Alert and interactive. Activity Status Ambulatory requires assistance or aid walker or cane . Discharge Instructions Dear Ms. ___ You were admitted to ___ after you developed shortness of breath and wheezing at home shortly after your last discharge. You were treated for a COPD exacerbation and your breathing quickly got better. Our physical therapists evaluated you and recommended that you have a short stay at Pulmonary ___ before going home to improve your breathing. We wish you all the best at rehab and send our condolences to your family on your recent loss. It was truly a pleasure taking care of you. Your ___ Team Followup Instructions ___
The icd codes present in this text will be J441, Z9981, I4891, J45909, Z7901, I10, I2510, E785, M1990, F419, I739, G4700, D649, Z96649, Z87891. The descriptions of icd codes J441, Z9981, I4891, J45909, Z7901, I10, I2510, E785, M1990, F419, I739, G4700, D649, Z96649, Z87891 are J441: Chronic obstructive pulmonary disease with (acute) exacerbation; Z9981: Dependence on supplemental oxygen; I4891: Unspecified atrial fibrillation; J45909: Unspecified asthma, uncomplicated; Z7901: Long term (current) use of anticoagulants; I10: Essential (primary) hypertension; I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris; E785: Hyperlipidemia, unspecified; M1990: Unspecified osteoarthritis, unspecified site; F419: Anxiety disorder, unspecified; I739: Peripheral vascular disease, unspecified; G4700: Insomnia, unspecified; D649: Anemia, unspecified; Z96649: Presence of unspecified artificial hip joint; Z87891: Personal history of nicotine dependence. The common codes which frequently come are I4891, J45909, Z7901, I10, I2510, E785, F419, G4700, D649, Z87891. The uncommon codes mentioned in this dataset are J441, Z9981, M1990, I739, Z96649. |
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