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Generate a treatment plan with clinical reasoning for this case: | {'patient_profile': {'age': 52, 'gender': 'F', 'symptoms': 'Abdominal pain', 'medical_history': ['ONCOLOGY HISTORY:\n___ Presented with 3 month history of abdominal pain.\n___ Endovaginal ultrasound: Uterus was slightly enlarged\nat 7.6 x 4.2 x 3.5 cm. She appeared to have a right fundal\nsubserosal fibroid. The endometrial thickness was 4 mm, the\nupper limit for this menopausal lady, and the uterus was \nsomewhat\ndistended by fluid with a 1 cm echogenic nodule. The left ovary\nwas of normal size and appearance and the right ovary was not\nseen. The patient was referred to Dr. ___.\n___ Hysteroscopy: The endometrial cavity appeared\nunremarkable, although there were 4 small "pellets." Endometrial\nbiopsy did not reveal any pathology. Only scant inactive\nendometrium was seen and the biopsy itself did not reveal \ntissue.\nThat biopsy may represent the small "pellets." There was no\nevident mass or polyp.\n___ Returned to Dr. ___ of\nmore pelvic pain and dysuria. Urinalysis was unremarkable and\nshe was referred to Dr. ___ urogynecology. He did not find\nlocal pathology and planned a cystoscopy. He did not feel that\nthe more general abdominal pain was related to her dysuria.', '- HTN', '- DL', '- T2DM', '- DVT L leg (dx ___', '- OSA'], 'family_history': '- ___: uterine - vs - ovarian ca in her mother', 'present_illness': 'Ms. ___ is a ___ w/ HTN, DL, DM, mucinous peritoneal\ncarcinomatosis, presumed ovarian origin, who p/w fever to ___\nand increasing abdominal pain.\nShe states she developed the abdominal pain as usual with chemo\non C1D1 Abraxane 120 mg/m2 d1, Gemcitabine 800 mg/m2 on ___. \nSHe\nstates she normally gets abdominal discomfort with chemo.\nYesterday, she developed a sweaty forehead transiently. Then\ntoday she developed increasing abdominal pain that is persistent\nin the lower quadrants and sometimes radiates to the epigastric\nand ant abd. No real nausea; decreased appetite however. Has\nongoing constipation (BM qday at baseline and most recent stool\nwas yesterday and described as normal). Today she felt feverish\nand measured it at home to 101 and called her doctor who \nreferred\nher here. She passed gas once today and has not passed stool\nsince yesterday.\nIn the ED, she was found to have Temp: 101.2 HR: 100 BP: 110/40\nResp: 20 O(2)Sat: 99 Case was discussed with Dr. ___. \nCT abd/pelv w/ con scan revealed no acute abdominal process. She\nreceived several rounds of 2mg IV morphine and was consequently\nadmitted to OMED under Dr. ___ presumptive SBP.\nREVIEW OF SYSTEMS:\n10 point ROS reviewed in detail and negative except for what is\nmentioned above in HPI', 'medications': [{'medication': 'Bisacodyl', 'proc_type': 'Unit Dose', 'status': 'Discontinued', 'route': 'PR', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Bisacodyl', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'PO', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Senna', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'PO', 'frequency': 'BID:PRN', 'doses_per_24_hrs': None}, {'medication': 'Calcium Carbonate', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'BID', 'doses_per_24_hrs': 2.0}, {'medication': 'Bisacodyl', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PR', 'frequency': 'DAILY:PRN', 'doses_per_24_hrs': None}, {'medication': 'Raltegravir', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'BID', 'doses_per_24_hrs': 2.0}, {'medication': 'Fluticasone Propionate 110mcg', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IH', 'frequency': 'BID', 'doses_per_24_hrs': 2.0}, {'medication': 'Docusate Sodium (Liquid)', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'PO', 'frequency': 'BID', 'doses_per_24_hrs': 2.0}, {'medication': 'Albuterol 0.083% Neb Soln', 'proc_type': 'Unit Dose', 'status': 'Discontinued', 'route': 'IH', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Influenza Vaccine Quadrivalent', 'proc_type': 'Unit Dose', 'status': 'Discontinued', 'route': 'IM', 'frequency': 'NOW X1', 'doses_per_24_hrs': 0.0}, {'medication': 'Sodium Chloride 0.9% Flush', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'Q8H', 'doses_per_24_hrs': 3.0}, {'medication': 'Lactulose', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'TID', 'doses_per_24_hrs': 3.0}, {'medication': 'Albuterol Inhaler', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IH', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Docusate Sodium (Liquid)', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'BID:PRN', 'doses_per_24_hrs': None}, {'medication': 'Rifaximin', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'BID', 'doses_per_24_hrs': 2.0}, {'medication': 'Albumin 25% (12.5g / 50mL)', 'proc_type': 'Unit Dose', 'status': 'Discontinued', 'route': 'IV', 'frequency': 'ONCE', 'doses_per_24_hrs': 1.0}, {'medication': 'TraMADOL (Ultram)', 'proc_type': 'Unit Dose', 'status': 'Discontinued', 'route': 'PO', 'frequency': 'ONCE', 'doses_per_24_hrs': 1.0}, {'medication': 'Heparin', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'SC', 'frequency': 'BID', 'doses_per_24_hrs': 2.0}, {'medication': 'TraMADOL (Ultram)', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Emtricitabine-Tenofovir (Truvada)', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Bisacodyl', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'DAILY:PRN', 'doses_per_24_hrs': None}, {'medication': 'Tiotropium Bromide', 'proc_type': 'Unit Dose', 'status': 'Discontinued', 'route': 'IH', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Albumin 25% (12.5g / 50mL)', 'proc_type': 'Unit Dose', 'status': 'Expired', 'route': 'IV', 'frequency': 'ONCE', 'doses_per_24_hrs': 1.0}, {'medication': 'Senna', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'BID:PRN', 'doses_per_24_hrs': None}]}, 'clinical_findings': {'labs': [{'value': '14', 'valuenum': 14.0, 'valueuom': 'mEq/L', 'ref_range_lower': 8.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '21', 'valuenum': 21.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '9.3', 'valuenum': 9.3, 'valueuom': 'mg/dL', 'ref_range_lower': 8.4, 'ref_range_upper': 10.3, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '102', 'valuenum': 102.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '0.5', 'valuenum': 0.5, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '___', 'valuenum': 115.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 100.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': 'IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES.'}, {'value': '2.3', 'valuenum': 2.3, 'valueuom': 'mg/dL', 'ref_range_lower': 1.6, 'ref_range_upper': 2.6, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.4', 'valuenum': 2.4, 'valueuom': 'mg/dL', 'ref_range_lower': 2.7, 'ref_range_upper': 4.5, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '4.7', 'valuenum': 4.7, 'valueuom': 'mEq/L', 'ref_range_lower': 3.3, 'ref_range_upper': 5.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '132', 'valuenum': 132.0, 'valueuom': 'mEq/L', 'ref_range_lower': 133.0, 'ref_range_upper': 145.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '33', 'valuenum': 33.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '114', 'valuenum': 114.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '3.8', 'valuenum': 3.8, 'valueuom': 'g/dL', 'ref_range_lower': 3.5, 'ref_range_upper': 5.2, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '86', 'valuenum': 86.0, 'valueuom': 'IU/L', 'ref_range_lower': 35.0, 'ref_range_upper': 105.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '9', 'valuenum': 9.0, 'valueuom': 'mEq/L', 'ref_range_lower': 8.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '187', 'valuenum': 187.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '24', 'valuenum': 24.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.7', 'valuenum': 2.7, 'valueuom': 'mg/dL', 'ref_range_lower': 0.0, 'ref_range_upper': 1.5, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '9.2', 'valuenum': 9.2, 'valueuom': 'mg/dL', 'ref_range_lower': 8.4, 'ref_range_upper': 10.3, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '102', 'valuenum': 102.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '0.4', 'valuenum': 0.4, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '___', 'valuenum': 107.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 100.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': 'IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES.'}, {'value': '173', 'valuenum': 173.0, 'valueuom': 'IU/L', 'ref_range_lower': 94.0, 'ref_range_upper': 250.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.0', 'valuenum': 2.0, 'valueuom': 'mg/dL', 'ref_range_lower': 1.6, 'ref_range_upper': 2.6, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.2', 'valuenum': 2.2, 'valueuom': 'mg/dL', 'ref_range_lower': 2.7, 'ref_range_upper': 4.5, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '5.0', 'valuenum': 5.0, 'valueuom': 'mEq/L', 'ref_range_lower': 3.3, 'ref_range_upper': 5.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '130', 'valuenum': 130.0, 'valueuom': 'mEq/L', 'ref_range_lower': 133.0, 'ref_range_upper': 145.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '28', 'valuenum': 28.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '34.8', 'valuenum': 34.8, 'valueuom': '%', 'ref_range_lower': 36.0, 'ref_range_upper': 48.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '11.9', 'valuenum': 11.9, 'valueuom': 'g/dL', 'ref_range_lower': 12.0, 'ref_range_upper': 16.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '34.9', 'valuenum': 34.9, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '34.1', 'valuenum': 34.1, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '102', 'valuenum': 102.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '___', 'valuenum': 94.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': 'VERIFIED BY SMEAR.'}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'LOW.'}, {'value': '15.8', 'valuenum': 15.8, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '3.40', 'valuenum': 3.4, 'valueuom': 'm/uL', 'ref_range_lower': 4.2, 'ref_range_upper': 5.4, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '4.1', 'valuenum': 4.1, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '1.8', 'valuenum': 1.8, 'valueuom': None, 'ref_range_lower': 0.9, 'ref_range_upper': 1.1, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '19.5', 'valuenum': 19.5, 'valueuom': 'sec', 'ref_range_lower': 9.4, 'ref_range_upper': 12.5, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '34.2', 'valuenum': 34.2, 'valueuom': 'sec', 'ref_range_lower': 25.0, 'ref_range_upper': 36.5, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.0', 'valuenum': 2.0, 'valueuom': None, 'ref_range_lower': 0.9, 'ref_range_upper': 1.1, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '21.6', 'valuenum': 21.6, 'valueuom': 'sec', 'ref_range_lower': 9.4, 'ref_range_upper': 12.5, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '37.6', 'valuenum': 37.6, 'valueuom': 'sec', 'ref_range_lower': 25.0, 'ref_range_upper': 36.5, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '96', 'valuenum': 96.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '69', 'valuenum': 69.0, 'valueuom': 'IU/L', 'ref_range_lower': 35.0, 'ref_range_upper': 105.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '11', 'valuenum': 11.0, 'valueuom': 'mEq/L', 'ref_range_lower': 8.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '168', 'valuenum': 168.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '27', 'valuenum': 27.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '1.7', 'valuenum': 1.7, 'valueuom': 'mg/dL', 'ref_range_lower': 0.0, 'ref_range_upper': 1.5, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '8.6', 'valuenum': 8.6, 'valueuom': 'mg/dL', 'ref_range_lower': 8.4, 'ref_range_upper': 10.3, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '97', 'valuenum': 97.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '0.4', 'valuenum': 0.4, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '___', 'valuenum': 121.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 100.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': 'IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES.'}, {'value': '2.1', 'valuenum': 2.1, 'valueuom': 'mg/dL', 'ref_range_lower': 1.6, 'ref_range_upper': 2.6, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '2.4', 'valuenum': 2.4, 'valueuom': 'mg/dL', 'ref_range_lower': 2.7, 'ref_range_upper': 4.5, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '5.2', 'valuenum': 5.2, 'valueuom': 'mEq/L', 'ref_range_lower': 3.3, 'ref_range_upper': 5.1, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '130', 'valuenum': 130.0, 'valueuom': 'mEq/L', 'ref_range_lower': 133.0, 'ref_range_upper': 145.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '35', 'valuenum': 35.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '32.1', 'valuenum': 32.1, 'valueuom': '%', 'ref_range_lower': 36.0, 'ref_range_upper': 48.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '11.2', 'valuenum': 11.2, 'valueuom': 'g/dL', 'ref_range_lower': 12.0, 'ref_range_upper': 16.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '35.4', 'valuenum': 35.4, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '34.8', 'valuenum': 34.8, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '102', 'valuenum': 102.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '95', 'valuenum': 95.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '15.8', 'valuenum': 15.8, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '3.15', 'valuenum': 3.15, 'valueuom': 'm/uL', 'ref_range_lower': 4.2, 'ref_range_upper': 5.4, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '4.8', 'valuenum': 4.8, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}], 'exams': 'Physical exam on admission:\n=====================\nGeneral: NAD\nVITAL SIGNS: ___ 118/64 71 20 96% RA\nHEENT: MMM, no OP lesions, mild cervical but no supraclavicular\nadenopathy\nCV: RR, NL S1S2 no S3S4 No MRG\nPULM: CTAB, No C/W/R\nABD: BS+, soft, diffusely tender and mild distention, could not\nelicit fluid wave due to pain\nLIMBS: WWP, no ___, no tremors\nSKIN: No rashes on the extremities\nNEURO: Grossly normal\n\nPhysical exam on discharge:\n=====================\nGeneral: NAD, appears comfortable\nVITAL SIGNS: 98.8 65 116/56 18 99% RA\nHEENT: MMM\nCV: RR, NL S1S2 no S3S4 No MRG\nPULM: CTAB, No C/W/R\nABD: BS+, soft, some tenderness diffusely\nLIMBS: WWP, no ___, no tremors, some pain when sitting up\nSKIN: No rashes on the extremities\nNEURO: Grossly normal', 'diagnoses': [{'icd_code': '45829', 'desc': 'Other iatrogenic hypotension'}, {'icd_code': '07044', 'desc': 'Chronic hepatitis C with hepatic coma'}, {'icd_code': '7994', 'desc': 'Cachexia'}, {'icd_code': '2761', 'desc': 'Hyposmolality and/or hyponatremia'}, {'icd_code': '78959', 'desc': 'Other ascites'}, {'icd_code': '2767', 'desc': 'Hyperpotassemia'}, {'icd_code': '3051', 'desc': 'Tobacco use disorder'}, {'icd_code': 'V08', 'desc': 'Asymptomatic human immunodeficiency virus [HIV] infection status'}, {'icd_code': 'V4986', 'desc': 'Do not resuscitate status'}, {'icd_code': 'V462'}, {'icd_code': '496', 'desc': 'Chronic airway obstruction, not elsewhere classified'}, {'icd_code': '29680', 'desc': 'Bipolar disorder, unspecified'}, {'icd_code': '5715', 'desc': 'Cirrhosis of liver without mention of alcohol'}], 'summary': "Labs on admission:\n================\n\n___ 07:30PM BLOOD WBC-6.6 RBC-3.92* Hgb-11.6* Hct-32.9* \nMCV-84 MCH-29.7 MCHC-35.4* RDW-17.6* Plt ___\n___ 07:30PM BLOOD Neuts-82.4* Lymphs-14.5* Monos-2.5 \nEos-0.4 Baso-0.2\n___ 07:30PM BLOOD Plt ___\n___ 07:30PM BLOOD ___ PTT-33.1 ___\n___ 07:30PM BLOOD Glucose-117* UreaN-7 Creat-0.6 Na-132* \nK-3.7 Cl-93* HCO3-28 AnGap-15\n___ 07:30PM BLOOD ALT-33 AST-69* AlkPhos-129* TotBili-0.4\n___ 07:18AM BLOOD Albumin-3.1* Calcium-8.9 Phos-2.8 Mg-1.3*\n___ 07:30PM BLOOD Albumin-3.6\n___ 08:10PM BLOOD Lactate-2.0\n\n================\nReports:\n================\n\n___ Peritoneal fluid:\nPERITONEAL FLUID:\nNEGATIVE FOR MALIGNANT CELLS.\n\n___ CT abd and pelvis with contrast:\nIMPRESSION: \n1. No evidence of acute intra-abdominal process.\n2. Moderate to large volume ascites, increased from ___. \nPeritonitis cannot be excluded.\n3. Similar extent of diffuse peritoneal disease with omental \ncaking and\ntethering of small bowel loops, consistent with the patient's \nhistory of\nmetastatic mucinous peritoneal carcinoma.\n4. Fluid filled endometrium and uterine fibroids, unchanged.\n\n___ Paracentesis diag/thera:\nIMPRESSION: \nUneventful diagnostic and therapeutic paracentesis yielding 2.1 \nL of yellow\nascitic fluid.\n\n================\nMicrobiology:\n================\n___ - BCx x 2 - no growth\n___ - UCx - mixed flora, consistent with contamination\n___ - Peritoneal fluid:\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count..\n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n\n ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.\n\nPeritoneal fluid analysis:\n___ 09:47AM ASCITES WBC-710* RBC-110* Polys-68* Lymphs-18* \nMonos-2* Macroph-12*\n___ 09:47AM ASCITES TotPro-4.4 Glucose-111 LD(LDH)-148 \nAlbumin-2.5\n\n================\nLabs on discharge:\n================\n\n___ 06:14AM BLOOD WBC-5.9 RBC-3.33* Hgb-9.9* Hct-27.9* \nMCV-84 MCH-29.6 MCHC-35.3* RDW-17.2* Plt ___\n___ 06:14AM BLOOD Plt ___\n___ 06:14AM BLOOD ___ PTT-33.2 ___\n___ 06:14AM BLOOD Glucose-99 UreaN-5* Creat-0.6 Na-132* \nK-3.9 Cl-98 HCO3-28 AnGap-10\n___ 06:14AM BLOOD Calcium-9.4 Phos-3.6 Mg-1.___\nyo F with history of HTN, DL, DM, mucinous peritoneal \ncarcinomatosis on paclitaxel/gemcitabine, presumed ovarian \norigin, p/w fever to ___ and increasing abdominal pain. She was \nfound to have ascites, and paracentesis was consistent with SBP. \n\n# SBP - Patient received ceftriaxone IV which was changed to PO \nciprofloxacin for a ___nding ___. Symptoms \nimproved and patient was afebrile after starting antibiotics. \n\n# Pain control - patient with severe pain on admission. pain \nwas controlled with oxycontin 120mg TID, with oxycodone for \nbreakthrough pain. Patient was tolerating this regimen per \npalliative care recoomendations with minimal pain and without \nsedation. \n\nTRANSITIONAL ISSUES:\n- abdominal pain - please assess pain and consider adjusting \npain medications depending on symptoms\n- DVT - patient with known DVTs, currently on lovenox bridging \nas INR was 1.5 at time of discharge in setting of antibiotics\n- ciprofloxacin - last day ___\n- code during hospitalization: DNR/DNI\n- HCP: Daughter ___, cell: ___"}} | {'final_diagnoses': ['spontaneous bacterial peritonitis', 'abdominal pain', 'mucinous peritoneal carcinomatosis (likely ovarian primary)'], 'procedures': ['guided paracentesis'], 'visit_summary': 'yo F with history of HTN, DL, DM, mucinous peritoneal \ncarcinomatosis on paclitaxel/gemcitabine, presumed ovarian \norigin, p/w fever to ___ and increasing abdominal pain. She was \nfound to have ascites, and paracentesis was consistent with SBP. \n\n# SBP - Patient received ceftriaxone IV which was changed to PO \nciprofloxacin for a ___nding ___. Symptoms \nimproved and patient was afebrile after starting antibiotics. \n\n# Pain control - patient with severe pain on admission. pain \nwas controlled with oxycontin 120mg TID, with oxycodone for \nbreakthrough pain. Patient was tolerating this regimen per \npalliative care recoomendations with minimal pain and without \nsedation. \n\nTRANSITIONAL ISSUES:\n- abdominal pain - please assess pain and consider adjusting \npain medications depending on symptoms\n- DVT - patient with known DVTs, currently on lovenox bridging \nas INR was 1.5 at time of discharge in setting of antibiotics\n- ciprofloxacin - last day ___\n- code during hospitalization: DNR/DNI\n- HCP: Daughter ___, cell: ___', 'medications_prescribed': ['1. OxyCODONE SR (OxyconTIN) 120 mg PO Q8H', '2. Enoxaparin Sodium 70 mg SC Q12H', '3. Atorvastatin 40 mg PO QPM', '4. Lorazepam 0.5 mg PO Q8H:PRN pain, nausea, anxiety', '5. OxycoDONE (Immediate Release) 20 mg PO Q4H:PRN pain', '6. Vitamin B Complex 1 CAP PO DAILY', '7. Warfarin 1.5 mg PO ONCE Duration: 1 Dose', '8. Amlodipine 10 mg PO DAILY', '9. irbesartan 150 mg oral DAILY', '10. MetFORMIN (Glucophage) 1000 mg PO BID', '11. Metoprolol Tartrate 50 mg PO BID', '12. Senna 8.6 mg PO BID', '13. Polyethylene Glycol 17 g PO BID', '14. Docusate Sodium 200 mg PO BID', '15. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Doses']} |
Generate a treatment plan with clinical reasoning for this case: | {'patient_profile': {'age': 48, 'gender': 'F', 'symptoms': 'abdominal pain', 'medical_history': ['___:', 'HLD', 'Mesenteric ischemia', 's/p celiac artery stent placement in ___ c/b re-stenosis', 's/p SMA stent placement', 's/p ___: Balloon angioplasty of in-stent superior mesenteric artery stenosis c/b left brachial pseudoaneurysm s/p repair and evacuation of hematoma', 'COPD', 'HTN', 'DJD, chronic back pain on narcotics', 'GERD/PUD', 'ETOH abuse with h/o ___ syndromoe', 's/p MVA with multiple rib fractures, right ribs ___ and left ribs ___ Right femur fracture and L3-L4 transverse process fractures in ___, CBD stricture s/p CBD stent placement ___, Chronic pancreatitis', 'PSHx:', 's/p Open reduction internal fixation right intra-articular distal femur fracture with internal fixation ___', 's/p SMA angioplasty ___', 's/p celiac artery stent', 's/p repair of L brachial pseudoaneurysm ___'], 'family_history': 'Mother died of lung cancer and emphysema. His father died of a stroke.', 'present_illness': 'Mr. ___ is a ___ who is cachectic with a history of ETOH abuse, chronic pancreatitis, PUD, CBD stricture with a CBD stent (left in since ___ as he was lost to follow up), mesenteric ischemia with a celiac stent who presents with acute onset abdominal pain at OSH. The pain was severe, radiates to the back, and made worse after eating a hamburger. He had several episodes of bilious emesis though he denies diarrhea. CT there demonstrated ascites and free air around the duodenum concerning for a perforated duodenal ulcer. He was transferred to ___ for further surgical evaluation.', 'medications': [{'medication': 'CeFAZolin', 'proc_type': 'IV Piggyback', 'status': 'Discontinued', 'route': 'IV', 'frequency': 'Q8H', 'doses_per_24_hrs': 3.0}, {'medication': 'Vitamin D', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Acetaminophen IV', 'proc_type': 'Unit Dose', 'status': 'Discontinued', 'route': 'IV', 'frequency': 'ONCE', 'doses_per_24_hrs': 1.0}, {'medication': 'Multivitamins', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Bisacodyl', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PR', 'frequency': 'DAILY:PRN', 'doses_per_24_hrs': None}, {'medication': 'Acetaminophen', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'PO/NG', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Multivitamins', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'PO', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': None, 'proc_type': 'IV Large Volume', 'status': 'Discontinued', 'route': 'IV', 'frequency': 'ASDIR', 'doses_per_24_hrs': None}, {'medication': 'Cepacol (Sore Throat Lozenge)', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'Q2H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Bisacodyl', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'DAILY:PRN', 'doses_per_24_hrs': None}, {'medication': 'OxyCODONE (Immediate Release)', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'PO/NG', 'frequency': 'Q4H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Docusate Sodium', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'BID', 'doses_per_24_hrs': 2.0}, {'medication': None, 'proc_type': 'IV Large Volume', 'status': 'Discontinued', 'route': 'IV', 'frequency': 'ASDIR', 'doses_per_24_hrs': None}, {'medication': 'Ondansetron', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'Q8H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Senna', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'BID', 'doses_per_24_hrs': 2.0}, {'medication': 'Acetaminophen', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'PO/NG', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': None, 'proc_type': 'IV Large Volume', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'ASDIR', 'doses_per_24_hrs': None}, {'medication': 'Sodium Chloride 0.9% Flush', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'Q8H', 'doses_per_24_hrs': 3.0}, {'medication': 'Morphine Sulfate', 'proc_type': 'Unit Dose', 'status': 'Expired', 'route': 'IV', 'frequency': 'Q4H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Acetaminophen', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Enoxaparin Sodium', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'SC', 'frequency': 'QHS', 'doses_per_24_hrs': 1.0}, {'medication': 'OxyCODONE (Immediate Release)', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'Q4H:PRN', 'doses_per_24_hrs': None}, {'medication': 'OxyCODONE (Immediate Release)', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'PO/NG', 'frequency': 'Q4H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Influenza Vaccine Quadrivalent', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IM', 'frequency': 'NOW X1', 'doses_per_24_hrs': 0.0}]}, 'clinical_findings': {'labs': [{'value': '1.1', 'valuenum': 1.1, 'valueuom': None, 'ref_range_lower': 0.9, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '12.2', 'valuenum': 12.2, 'valueuom': 'sec', 'ref_range_lower': 9.4, 'ref_range_upper': 12.5, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '28.9', 'valuenum': 28.9, 'valueuom': 'sec', 'ref_range_lower': 25.0, 'ref_range_upper': 36.5, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '45.1', 'valuenum': 45.1, 'valueuom': '%', 'ref_range_lower': 34.0, 'ref_range_upper': 45.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '14.8', 'valuenum': 14.8, 'valueuom': 'g/dL', 'ref_range_lower': 11.2, 'ref_range_upper': 15.7, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '31.0', 'valuenum': 31.0, 'valueuom': 'pg', 'ref_range_lower': 26.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '32.8', 'valuenum': 32.8, 'valueuom': 'g/dL', 'ref_range_lower': 32.0, 'ref_range_upper': 37.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '95', 'valuenum': 95.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '218', 'valuenum': 218.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 400.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '12.6', 'valuenum': 12.6, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '4.77', 'valuenum': 4.77, 'valueuom': 'm/uL', 'ref_range_lower': 3.9, 'ref_range_upper': 5.2, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '9.0', 'valuenum': 9.0, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 10.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '44.0', 'valuenum': 44.0, 'valueuom': 'fL', 'ref_range_lower': 35.1, 'ref_range_upper': 46.3, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '___', 'valuenum': 21.0, 'valueuom': 'mEq/L', 'ref_range_lower': 10.0, 'ref_range_upper': 18.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': 'New reference range as of ___.'}, {'value': '22', 'valuenum': 22.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '103', 'valuenum': 103.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '0.9', 'valuenum': 0.9, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '___', 'valuenum': 100.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 100.0, 'flag': None, 'priority': 'ROUTINE', 'comments': 'If fasting, 70-100 normal, >125 provisional diabetes.'}, {'value': '5', 'valuenum': 5.0, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '3', 'valuenum': 3.0, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '___', 'valuenum': 4.2, 'valueuom': 'mEq/L', 'ref_range_lower': 3.5, 'ref_range_upper': 5.4, 'flag': None, 'priority': 'ROUTINE', 'comments': 'New reference range as of ___.'}, {'value': '___', 'valuenum': 146.0, 'valueuom': 'mEq/L', 'ref_range_lower': 135.0, 'ref_range_upper': 147.0, 'flag': None, 'priority': 'ROUTINE', 'comments': 'New reference range as of ___.'}, {'value': '10', 'valuenum': 10.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '7', 'valuenum': 7.0, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '___', 'valuenum': 12.0, 'valueuom': 'mEq/L', 'ref_range_lower': 10.0, 'ref_range_upper': 18.0, 'flag': None, 'priority': 'ROUTINE', 'comments': 'New reference range as of ___.'}, {'value': '24', 'valuenum': 24.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '107', 'valuenum': 107.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '0.8', 'valuenum': 0.8, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '___', 'valuenum': 106.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 100.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': 'If fasting, 70-100 normal, >125 provisional diabetes.'}, {'value': '4', 'valuenum': 4.0, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '2', 'valuenum': 2.0, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '___', 'valuenum': 4.3, 'valueuom': 'mEq/L', 'ref_range_lower': 3.5, 'ref_range_upper': 5.4, 'flag': None, 'priority': 'ROUTINE', 'comments': 'New reference range as of ___.'}, {'value': '___', 'valuenum': 143.0, 'valueuom': 'mEq/L', 'ref_range_lower': 135.0, 'ref_range_upper': 147.0, 'flag': None, 'priority': 'ROUTINE', 'comments': 'New reference range as of ___.'}, {'value': '9', 'valuenum': 9.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '5', 'valuenum': 5.0, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '39.3', 'valuenum': 39.3, 'valueuom': '%', 'ref_range_lower': 34.0, 'ref_range_upper': 45.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '13.2', 'valuenum': 13.2, 'valueuom': 'g/dL', 'ref_range_lower': 11.2, 'ref_range_upper': 15.7, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '31.7', 'valuenum': 31.7, 'valueuom': 'pg', 'ref_range_lower': 26.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '33.6', 'valuenum': 33.6, 'valueuom': 'g/dL', 'ref_range_lower': 32.0, 'ref_range_upper': 37.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '94', 'valuenum': 94.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '180', 'valuenum': 180.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 400.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '12.6', 'valuenum': 12.6, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '4.17', 'valuenum': 4.17, 'valueuom': 'm/uL', 'ref_range_lower': 3.9, 'ref_range_upper': 5.2, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '8.8', 'valuenum': 8.8, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 10.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '43.5', 'valuenum': 43.5, 'valueuom': 'fL', 'ref_range_lower': 35.1, 'ref_range_upper': 46.3, 'flag': None, 'priority': 'ROUTINE', 'comments': None}], 'exams': 'Admission Physical Exam:\nVitals:\n97.4 120 ___ 92% RA \nGEN: A&O x 2, sleepy but arousable, cachectic appearing male\nHEENT: No scleral icterus, mucus membranes dry\nCV: tachycardia \nPULM: Clear to auscultation \nABD: Rigid abdomen, peritoneal. No masses. Non-distended. \nExt: No ___ edema\n\nDischarge Physical Exam: \nVS: T: 98.1, BP: 148/66, HR: 95, RR: 18, O2: 95% TM \nGENERAL: A+Ox2-3 with periods of confusion \nCV: RRR\nRR: rhonchi b/l, diffuse. tracheostomy in place with passy-muir \nvalve. \nABD: midline abdominal incision with fibrinous wound edges at \n3:00 and 6:00 positions, red wound base. Packed wet-to-dry. RLQ \nJP in place with drain gauze dressing. \nExtremities: warm, well-perfused, no edema.', 'diagnoses': [{'icd_code': 'S72012A', 'desc': 'Unspecified intracapsular fracture of left femur, initial encounter for closed fracture'}, {'icd_code': 'W010XXA', 'desc': 'Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter'}, {'icd_code': 'Y93K1', 'desc': 'Activity, walking an animal'}, {'icd_code': 'Y92480', 'desc': 'Sidewalk as the place of occurrence of the external cause'}, {'icd_code': 'K219', 'desc': 'Gastro-esophageal reflux disease without esophagitis'}, {'icd_code': 'E7800', 'desc': 'Pure hypercholesterolemia, unspecified'}, {'icd_code': 'I341', 'desc': 'Nonrheumatic mitral (valve) prolapse'}, {'icd_code': 'G43909', 'desc': 'Migraine, unspecified, not intractable, without status migrainosus'}, {'icd_code': 'Z87891', 'desc': 'Personal history of nicotine dependence'}, {'icd_code': 'Z87442', 'desc': 'Personal history of urinary calculi'}, {'icd_code': 'F419', 'desc': 'Anxiety disorder, unspecified'}, {'icd_code': 'M810', 'desc': 'Age-related osteoporosis without current pathological fracture'}, {'icd_code': 'Z7901', 'desc': 'Long term (current) use of anticoagulants'}], 'summary': "___ 08:56PM TYPE-ART PO2-106* PCO2-25* PH-7.31* TOTAL \nCO2-13* BASE XS--11\n___ 08:56PM LACTATE-3.6*\n___ 08:56PM freeCa-1.16\n___ 06:36PM TYPE-ART PO2-239* PCO2-23* PH-7.31* TOTAL \nCO2-12* BASE XS--12\n___ 06:36PM LACTATE-4.5*\n___ 06:36PM freeCa-1.11*\n___ 06:25PM GLUCOSE-139* UREA N-14 CREAT-0.6 SODIUM-136 \nPOTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-12* ANION GAP-22*\n___ 06:25PM CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-1.5*\n___ 06:25PM WBC-5.6 RBC-4.04* HGB-12.1* HCT-36.7* MCV-91 \nMCH-30.0 MCHC-33.0 RDW-18.2* RDWSD-59.0*\n___ 06:25PM PLT COUNT-270\n___ 06:25PM ___ PTT-41.7* ___\n___ 06:25PM ___ 03:24PM GLUCOSE-147* UREA N-15 CREAT-0.6 SODIUM-141 \nPOTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-18* ANION GAP-19\n___ 03:24PM CK(CPK)-46*\n___ 03:24PM CK-MB-1 cTropnT-<0.01\n___ 03:24PM CALCIUM-8.1* PHOSPHATE-3.9 MAGNESIUM-1.6\n___ 03:24PM WBC-3.9* RBC-3.44* HGB-10.3* HCT-31.4* MCV-91 \nMCH-29.9 MCHC-32.8 RDW-17.5* RDWSD-57.7*\n___ 03:24PM PLT COUNT-225#\n___ 03:24PM ___ PTT-44.1* ___\n___ 03:24PM ___\n___ 03:17PM TYPE-ART PO2-131* PCO2-38 PH-7.36 TOTAL \nCO2-22 BASE XS--3\n___ 03:17PM LACTATE-5.0* NA+-139 K+-3.6 CL--108\n___ 03:17PM HGB-11.6* calcHCT-35\n___ 03:17PM freeCa-1.17\n___ 02:16PM TYPE-ART PO2-124* PCO2-41 PH-7.18* TOTAL \nCO2-16* BASE XS--12\n___ 02:16PM GLUCOSE-161* LACTATE-3.4* NA+-133 K+-4.0 \nCL--112*\n___ 02:16PM HGB-13.0* calcHCT-39\n___ 02:16PM freeCa-1.30\n___ 01:03PM TYPE-ART PO2-304* PCO2-45 PH-7.16* TOTAL \nCO2-17* BASE XS--12\n___ 01:03PM GLUCOSE-138* LACTATE-3.1* NA+-135 K+-3.2* \nCL--111*\n___ 01:03PM HGB-8.2* calcHCT-25 O2 SAT-99 CARBOXYHB-1\n___ 02:16PM freeCa-1.30\n___ 01:03PM TYPE-ART PO2-304* PCO2-45 PH-7.16* TOTAL \nCO2-17* BASE XS--12\n___ 01:03PM GLUCOSE-138* LACTATE-3.1* NA+-135 K+-3.2* \nCL--111*\n___ 01:03PM HGB-8.2* calcHCT-25 O2 SAT-99 CARBOXYHB-1\n___ 01:03PM freeCa-1.05*\n___ 10:32AM ___ PO2-133* PCO2-18* PH-7.43 TOTAL \nCO2-12* BASE XS--9 COMMENTS-GREEN TOP\n___ 10:32AM LACTATE-3.8*\n___ 10:15AM GLUCOSE-153* UREA N-22* CREAT-1.0 SODIUM-137 \nPOTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-13* ANION GAP-25*\n___ 10:15AM ALT(SGPT)-7 AST(SGOT)-20 ALK PHOS-63 TOT \nBILI-0.8\n___ 10:15AM LIPASE-20\n___ 10:15AM ALBUMIN-2.3*\n___ 10:15AM WBC-2.8*# RBC-3.20* HGB-10.5*# HCT-31.0* \nMCV-97# MCH-32.8* MCHC-33.9# RDW-16.8* RDWSD-59.5*\n___ 10:15AM NEUTS-64 BANDS-14* LYMPHS-11* MONOS-10 EOS-0 \nBASOS-0 ___ MYELOS-1* AbsNeut-2.18 AbsLymp-0.31* \nAbsMono-0.28 AbsEos-0.00* AbsBaso-0.00*\n___ 10:15AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ \nMACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-OCCASIONAL \nTARGET-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL \nPAPPENHEI-1+\n___ 10:15AM PLT SMR-HIGH PLT COUNT-475*\n___ 10:15AM ___ PTT-22.4* ___\n\nImaging:\n\n___: ECHO: \nSuboptimal image quality.Normal left ventricular cavity sizes \nwith low normal global systolic function. \n\n___: CXR: \nAs compared to prior radiograph from earlier today, following \nrecent \nreintubation, an endotracheal tube is in standard position. \nOverall \nappearance of the chest is not appreciably changed since recent \nstudy of \napproximately 3 hr earlier. \n\n___: CT ABD/PEL:\n1. Diffuse anasarca, moderate bilateral pleural effusions, \npulmonary edema, compatible with third-spacing. \n2. No definite drainable intra-abdominal collection is \nidentified. \n3. Interval development of an ill-defined 1.1 x 1.5 cm right \nlobe hepatic \nhypodensity in segment ___ as detailed above, which given its \nrapid interval appearance may represent a focal infarct or early \nphlegmon. No drainable collection is seen at this time. This \ncould also represent focal retractor injury. Continued clinical \nunder radiologic surveillance of this finding is recommended. \n4. Severe atherosclerotic change noted at the origin of the \nsuperior \nmesenteric artery and celiac artery, with poor opacification of \nthe proximal segments of both these vessels. The SMA does \nrecannulized distally. \n\n___: 1. Ill-defined fluid density just beneath the surgical \nstaples within the anterior abdominal wall. Correlation with \ndedicated ultrasound is recommended to assess for any drainable \nfluid collections in this region as evaluation by streak \nartifact limits assessment on CT. \n2. No evidence of perforation or enteric leak. \n3. Tiny organized fluid collection is seen measuring 1.0 x 1.9 \ncm insinuating between the pancreas and the gastric antrum. At \nthis stage, it is too small for percutaneous drainage. \n4. Ascending and transverse colonic dilation detailed above, \nfindings which raise the possibility of colonic ___ \nsyndrome. For close clinical and radiographic follow-up. \n5. Anasarca. \n6. Left lower lobe consolidation and pneumothorax, for further \ndetail please refer to the separate CT chest report. \n\n___: CT Chest:\nNear complete drainage of bilateral effusions with tiny right \nhydropneumothorax and small left hydropneumothorax. Left chest \ntube is \nperifissural. \n \nComplete left lower lobe collapse with substantial airway \nsecretions. \n \nInterval improvement of pulmonary edema of the upper lobes and \nlikely \nre-expansion edema in the right lower and lingula. \n\n___: CHEST PORT LINE/TUBE PLCT 1:\nDobhoff tube tip isin the stomach. NG tube tip appears to be in \nthe distal esophagus. Moderate left pneumothorax has increased. \nNo other interval change from prior study. \n \n___: CT ABD/PEL:\n \n1. No retroperitoneal hematoma. \n2. Mild mesenteric edema/free fluid. Interval resolution of \npreviously \ndescribed fluid collection deep to the anterior abdominal wall \nstaples. \n3. Mild left-sided intrahepatic biliary dilatation in the region \nof prior \npneumobilia. \n4. Right greater than left non-hemorrhagic pleural effusions \nhave increased from ___. Left lower lobe atelectasis is \ndecreased. \n5. Partially imaged left pneumothorax. \n6. Diffuse anasarca. \n7. Partial occlusion of both common femoral arteries as before. \n\n___: DC Chest Portable PICC:\nComparison to ___, 04:52. The patient has received a \nright PICC line. The course of the line appears unremarkable, \nthe tip of the line can not be identified, as it parallels the \nsimultaneously placed right internal jugular vein catheter. No \nright pneumothorax. The small left pneumothorax is stable. \n \nThe other monitoring and support devices are in constant correct \nposition. \n\n___: CXR: \nIn comparison with the earlier study of this date, there is \nlittle change and no evidence of pneumothorax several hr after \nremoval of the chest tube. \n\n___: CT ABD/PEL:\n1. Partially thrombosed celiac artery stent with only threadlike \ncontrast \ntraversing distally, progressed compared to priors. No evidence \nof bowel \nischemia. \n2. Hypodensity in a vessel in the right lower lobe of lung \n(03:01), only \npartially visualized and unable to determine if this is a \npulmonary artery or vein. Cannot exclude pulmonary embolus. \n3. Moderate left greater than right pleural effusions with \ncompressive \natelectasis. \n4. Chronic pancreatitis.\nMr. ___ is a ___ gentleman with a history of alcohol abuse, chronic\npancreatitis, peptic ulcer disease, a chronic, non-malignant CBD stricture with a\nchronic CBD stent left in since ___, and significant mesenteric ischemia with\nceliac stent. The patient presented to the hospital this admission with an acute onset of abdominal pain. On physical exam, he had peritonitis with a\nrigid abdomen, was tachycardic to the 120s and had a CT scan which showed evidence of free air and concern for perforated viscus. The patient was urgently brought to the operating room and underwent exploratory laparotomy, duodenal primary repair\nwith ___ patch, placement of a post pyloric and post duodenal repair with Dobbhoff tube. The patient tolerated this procedure well. Once medically stable, the patient was transferred to the Trauma ICU for further medical care.\n\nPlease refer to the dates below for ICU events: \n\nOn POD1, the patient received 500cc of 5% albumin given due to decreasing UOP. Vasopressin was weaned and he remained on levophed. The patient had >1L of output from his abdominal JP overnight. A nutrition consult was placed in anticipation of forthcoming tube feeds. The patient passed spontaneous breathing trial in AM, RSBI of 29, on pressure support ventilation 5/5/50%. The patient was extubated. He was then noted to have low urine output and he received 3 doses of albumin. He was given D50 AMP for hypoglycemia. TTE was completed which was within normal limits.\n \nOn POD2, the patient had persistent hypoglycemia to ___ requiring D50 Amp. Fluids were temporarily switched to D5LR at maintenance. Vitamin K was given for elevated INR. Tube feedings were held given levophed requirement. 12.5g 25% albumin was given to try to wean levophed. Hct was 26.1 (from 34.8), which was likely dilutional, Hct was rechecked later in the evening which was stable. The patient received Vit K PO 5mg and 250cc albumin. Fluid were administered to replace JP drain output. The patient became progressively lethargic throughout the day and he was found to have metabolic acidosis. The patient was intubated and fluid resuscitated. NiCOM indicated lack of SV variation. His fluids were discontinued and repletions were stopped. H.Pylori was sent off and FeNa showed: 0.1% pre-renal \n\n\nOn POD3, AM bloods showed improvement in Hct (Hb 9.5 and Hct 29.0), however, WBC increased from 13 to 23. Ciprofloxacin was discontinued and Ceftazedime was started for better gram negative coverage (per AST recommendation). The patient had a CXR which showed large bilateral pleural effusions. Precedex was started in an effort to wean from propofol. UA/UCx and blood cx were sent due to leukocytosis, c. diff was ordered and D10@10 was started due to persistent hypoglycemia. Vancomycin dosing was changed from Q24 to Q12 per AST recommendation. Later in the evening, the patient self-extubated (from PSV 5/5/50%). Initially the patient was stable on aerosol mask, but then he was started on BIPAP due to pO2 down to 56. H. pylori came back negative. \n\nOn POD4, the patient was intubated in AM. ABG 7.32 --> ___ s/p intubation. The patient was switched from propofol to midazolam given concern for propofol associated acidosis. Phenobarbital protocol was discontinued. CT Torso was performed. pH 7.35 at recheck. CT Abd/Pelvis showed anasaraca, pleural effusions, with questionable focal hypodensity of liver that may have been a phlegmon vs infarct. \n\nOn POD5, Versed was weaned down. He was on levophed 0.12. ABG 7.46 and RR decreased thereafter. ___ pigtails were placed. Left CT had >1L output. His increased pressor requirement was likely from fluid shift, given concentrated albumin. Fe Urea 51.2% was suggestive of intrinsic renal. Post procedure CXR shows good expansion of lungs. Vanco 1000mg qd started on the night of ___. Vanco trough was 35.5. His pressor requirement decreased with albumin. Overnight Cr uptrended to 1.0. \n\nOn POD6, midazolam was weaned. The PICC was unable to be placed and TPN started through TPL port, tube feeds were trickled. B/l pigtails were placed to waterseal. A therapeutic mattress was ordered, and the patient was -1.4L negative in fluid balance. \n\nOn POD7, WBC increased from 11->15. INR was 3.1 and he received 2.5mg of vitamin K. BCx and UCx were repeated. He passed his spontaneous breathing trial with RSBI of 4. He was placed back on CMV because the ABG demonstrated was unable to compensate for metabolic acidosis. TPN was added. Albumin was discontinued as he had adequate urine output and pulmonary edema on the CXR. In the evening, the patient was tachycardic to the 120s which did not respond to pain control. CXR demonstrated a stable pneumothorax. He received albumin for hypotension and mild tachycardia. \n\nOn POD8, WBC 15->19.4 and lactate increased to 2.3. Tube feeds were stopped. CT chest showed complete LLL collapse with substantial airway secretions. CT abdomen was stable. INR was 2.5 and he received 5mg of Vitamin K. Lactate normalized to 1.2. \n \n\nOn POD9: the patient was bronched with BAL and he was extubated. Tube feeds were restarted at 10cc/hr. Lactate was 1.2. Dobhoff was self discontinued overnight. The right chest tube was removed. CXR showed persistent LLL pnemothorax. The wound vac was changed.\n \nOn POD10, tube feeds at goal. Speech and swallow left recommendations. The patient was to be NPO and tube feeds were to be continued through the NGT. The right pigtail was discontinued. \n \nOn POD11, the patient had rapid-sequence re-intubation for acute respiratory decompensation with sats in high ___ and no left-sided breath sounds in the setting of a large mucus plug found in the left mainstem and had bronchoscopy with BAL. The wound was inspected and staples removed with purulence expressed. He received 500ml albumin for hypotension and oliguria. He was started on Precedex for agitation and sedation. \n \n\nOn POD12, Hct was 18.9 and he received 2u pRBC in the early AM, and SQH was held due to concern for potential bleeding. He received 5mg of Vitamin K and 1u FFP. CT abdomen/pelvis w/ contrast was without evidence of abdominal collection suggestive of bleeding. The patient's sister (HCP) was at the bedside and consent completed for tracheostomy. Staples were removed from ___ midline incision and the wound was packed with wet to dry. \n\nOn POD13, Hct was stable and he was restarted on ___ BID. He had an uncomplicated tracheostomy at the bedside. Tube feeds were started. On POD14, the patient had increased abdominal pain in AM. Lactates were downtrending 1.5->0.9; TF@30 were trialed in the ___ and he was unable to tolerate them due to pain, and TF were held again. The wound demonstrated increased tracking without defects. He had a KUB w/o free air; WBC and HCT were within normal limits and were stable. He was on a trach-mask for 10hrs during the day/ He required CPAP then CMV due to tachypnea and increased work of breathing. Methylnaltrexone was given. On POD15, the dressing changed twice. TPN was started and maintenance fluids were stopped. He was on a trach mask for 8 hours, cmv 2 hours alternating. He had a bowel movement. On POD16,the right IJ IV was removed and a PICC was placed. He was started on elemental tube feeds at a low rate (10cc/hr). The pigtail was removed. He had a bowel movement. On POD17, the patient was on trach mask for 24hrs and was held in the TICU due to increased suctioning requirement. Tube feeds were continuing (20cc/hr) and were then held for abdominal discomfort. He was unable to re-start @10 cc/hr. He continued on TPN. \n\nOn POD18, the patient was transferred to the surgical floor. The patient had a CTA abdomen/pelvis which showed the celiac artery stent was mostly thrombosed and vascular was later consulted for celiac stenosis. He will follow-up with Vascular Surgery as an outpatient. As the patient was having several loose bowel movements, a c.dificile stool specimen was sent which was negative. On ___, the patient was evaluated by speech and swallow and had an episode of emesis after swallowing a small amount of clear fluid. Tube feedings were not administered and the patient continued on TPN. \n\nAt the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan."}} | {'final_diagnoses': ['Perforated duodenal ulcer', 'early cirrhosis'], 'procedures': ['___ - Exploratory laparotomy, duodenal primary repair with ___ patch, placement of a post pyloric and post duodenal repair Dobbhoff tube.'], 'visit_summary': "Mr. ___ is a ___ gentleman with a history of alcohol abuse, chronic\npancreatitis, peptic ulcer disease, a chronic, non-malignant CBD stricture with a\nchronic CBD stent left in since ___, and significant mesenteric ischemia with\nceliac stent. The patient presented to the hospital this admission with an acute onset of abdominal pain. On physical exam, he had peritonitis with a\nrigid abdomen, was tachycardic to the 120s and had a CT scan which showed evidence of free air and concern for perforated viscus. The patient was urgently brought to the operating room and underwent exploratory laparotomy, duodenal primary repair\nwith ___ patch, placement of a post pyloric and post duodenal repair with Dobbhoff tube. The patient tolerated this procedure well. Once medically stable, the patient was transferred to the Trauma ICU for further medical care.\n\nPlease refer to the dates below for ICU events: \n\nOn POD1, the patient received 500cc of 5% albumin given due to decreasing UOP. Vasopressin was weaned and he remained on levophed. The patient had >1L of output from his abdominal JP overnight. A nutrition consult was placed in anticipation of forthcoming tube feeds. The patient passed spontaneous breathing trial in AM, RSBI of 29, on pressure support ventilation 5/5/50%. The patient was extubated. He was then noted to have low urine output and he received 3 doses of albumin. He was given D50 AMP for hypoglycemia. TTE was completed which was within normal limits.\n \nOn POD2, the patient had persistent hypoglycemia to ___ requiring D50 Amp. Fluids were temporarily switched to D5LR at maintenance. Vitamin K was given for elevated INR. Tube feedings were held given levophed requirement. 12.5g 25% albumin was given to try to wean levophed. Hct was 26.1 (from 34.8), which was likely dilutional, Hct was rechecked later in the evening which was stable. The patient received Vit K PO 5mg and 250cc albumin. Fluid were administered to replace JP drain output. The patient became progressively lethargic throughout the day and he was found to have metabolic acidosis. The patient was intubated and fluid resuscitated. NiCOM indicated lack of SV variation. His fluids were discontinued and repletions were stopped. H.Pylori was sent off and FeNa showed: 0.1% pre-renal \n\n\nOn POD3, AM bloods showed improvement in Hct (Hb 9.5 and Hct 29.0), however, WBC increased from 13 to 23. Ciprofloxacin was discontinued and Ceftazedime was started for better gram negative coverage (per AST recommendation). The patient had a CXR which showed large bilateral pleural effusions. Precedex was started in an effort to wean from propofol. UA/UCx and blood cx were sent due to leukocytosis, c. diff was ordered and D10@10 was started due to persistent hypoglycemia. Vancomycin dosing was changed from Q24 to Q12 per AST recommendation. Later in the evening, the patient self-extubated (from PSV 5/5/50%). Initially the patient was stable on aerosol mask, but then he was started on BIPAP due to pO2 down to 56. H. pylori came back negative. \n\nOn POD4, the patient was intubated in AM. ABG 7.32 --> ___ s/p intubation. The patient was switched from propofol to midazolam given concern for propofol associated acidosis. Phenobarbital protocol was discontinued. CT Torso was performed. pH 7.35 at recheck. CT Abd/Pelvis showed anasaraca, pleural effusions, with questionable focal hypodensity of liver that may have been a phlegmon vs infarct. \n\nOn POD5, Versed was weaned down. He was on levophed 0.12. ABG 7.46 and RR decreased thereafter. ___ pigtails were placed. Left CT had >1L output. His increased pressor requirement was likely from fluid shift, given concentrated albumin. Fe Urea 51.2% was suggestive of intrinsic renal. Post procedure CXR shows good expansion of lungs. Vanco 1000mg qd started on the night of ___. Vanco trough was 35.5. His pressor requirement decreased with albumin. Overnight Cr uptrended to 1.0. \n\nOn POD6, midazolam was weaned. The PICC was unable to be placed and TPN started through TPL port, tube feeds were trickled. B/l pigtails were placed to waterseal. A therapeutic mattress was ordered, and the patient was -1.4L negative in fluid balance. \n\nOn POD7, WBC increased from 11->15. INR was 3.1 and he received 2.5mg of vitamin K. BCx and UCx were repeated. He passed his spontaneous breathing trial with RSBI of 4. He was placed back on CMV because the ABG demonstrated was unable to compensate for metabolic acidosis. TPN was added. Albumin was discontinued as he had adequate urine output and pulmonary edema on the CXR. In the evening, the patient was tachycardic to the 120s which did not respond to pain control. CXR demonstrated a stable pneumothorax. He received albumin for hypotension and mild tachycardia. \n\nOn POD8, WBC 15->19.4 and lactate increased to 2.3. Tube feeds were stopped. CT chest showed complete LLL collapse with substantial airway secretions. CT abdomen was stable. INR was 2.5 and he received 5mg of Vitamin K. Lactate normalized to 1.2. \n \n\nOn POD9: the patient was bronched with BAL and he was extubated. Tube feeds were restarted at 10cc/hr. Lactate was 1.2. Dobhoff was self discontinued overnight. The right chest tube was removed. CXR showed persistent LLL pnemothorax. The wound vac was changed.\n \nOn POD10, tube feeds at goal. Speech and swallow left recommendations. The patient was to be NPO and tube feeds were to be continued through the NGT. The right pigtail was discontinued. \n \nOn POD11, the patient had rapid-sequence re-intubation for acute respiratory decompensation with sats in high ___ and no left-sided breath sounds in the setting of a large mucus plug found in the left mainstem and had bronchoscopy with BAL. The wound was inspected and staples removed with purulence expressed. He received 500ml albumin for hypotension and oliguria. He was started on Precedex for agitation and sedation. \n \n\nOn POD12, Hct was 18.9 and he received 2u pRBC in the early AM, and SQH was held due to concern for potential bleeding. He received 5mg of Vitamin K and 1u FFP. CT abdomen/pelvis w/ contrast was without evidence of abdominal collection suggestive of bleeding. The patient's sister (HCP) was at the bedside and consent completed for tracheostomy. Staples were removed from ___ midline incision and the wound was packed with wet to dry. \n\nOn POD13, Hct was stable and he was restarted on ___ BID. He had an uncomplicated tracheostomy at the bedside. Tube feeds were started. On POD14, the patient had increased abdominal pain in AM. Lactates were downtrending 1.5->0.9; TF@30 were trialed in the ___ and he was unable to tolerate them due to pain, and TF were held again. The wound demonstrated increased tracking without defects. He had a KUB w/o free air; WBC and HCT were within normal limits and were stable. He was on a trach-mask for 10hrs during the day/ He required CPAP then CMV due to tachypnea and increased work of breathing. Methylnaltrexone was given. On POD15, the dressing changed twice. TPN was started and maintenance fluids were stopped. He was on a trach mask for 8 hours, cmv 2 hours alternating. He had a bowel movement. On POD16,the right IJ IV was removed and a PICC was placed. He was started on elemental tube feeds at a low rate (10cc/hr). The pigtail was removed. He had a bowel movement. On POD17, the patient was on trach mask for 24hrs and was held in the TICU due to increased suctioning requirement. Tube feeds were continuing (20cc/hr) and were then held for abdominal discomfort. He was unable to re-start @10 cc/hr. He continued on TPN. \n\nOn POD18, the patient was transferred to the surgical floor. The patient had a CTA abdomen/pelvis which showed the celiac artery stent was mostly thrombosed and vascular was later consulted for celiac stenosis. He will follow-up with Vascular Surgery as an outpatient. As the patient was having several loose bowel movements, a c.dificile stool specimen was sent which was negative. On ___, the patient was evaluated by speech and swallow and had an episode of emesis after swallowing a small amount of clear fluid. Tube feedings were not administered and the patient continued on TPN. \n\nAt the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan.", 'medications_prescribed': ['1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain', '2. Artificial Tears ___ DROP BOTH EYES PRN dryness', '3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID', '4. Clopidogrel 75 mg PO DAILY', '5. Cyanocobalamin 100 mcg PO DAILY', '6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol', '7. Docusate Sodium (Liquid) 100 mg PO BID please hold for loose stools', '8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol', '9. Glucose Gel 15 g PO PRN hypoglycemia protocol', '10. Heparin 2500 UNIT SC BID', '11. Insulin SC Sliding Scale\n\nFingerstick Q6H\nInsulin SC Sliding Scale using REG Insulin', '12. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY', '13. Mineral Oil ___ mL PO DAILY:PRN constipation', '14. Ondansetron 4 mg IV Q8H:PRN nausea', '15. OxyCODONE (Immediate Release) 15 mg PO Q3H pain please hold for somnolence, RR<14, patient may refuse', '16. Polyethylene Glycol 17 g PO DAILY:PRN constipation', '17. TraZODone ___ mg PO QHS:PRN insomnia']} |
Generate a treatment plan with clinical reasoning for this case: | {'patient_profile': {'age': 34, 'gender': 'M', 'symptoms': 'Dyspnea', 'medical_history': ['-HFpEF', '-Diabetes mellitus II', '-Hypertension', '-Anxiety', '-Autonomic dysfunction (orthostatic hypotension)', '-Hyperlipidemia', '-Right distal fibular fracture ___', '-L1 and L4 compression fractures', '-Peripheral neuropathy', '-PAD with stent to the right leg', '-s/p Hysterectomy', '-s/p Cholecystectomy', '-chronic mesenteric ischemia s/p cecitis'], 'family_history': 'Sister who died of breast cancer.', 'present_illness': '___ female w/ PMH HTN, DMT2, MR, HRpEF, PAD s/p stent on \nPlavix and ASA, ESRD on HD, chronic mesenteric ischemia, and \nbronchiectasis presents from her dialysis center. The patient \nhas been reporting feeling unwell all day, and developed \nshortness of breath once she got into the ambulance. Patient has \nan existing Pleur-evac lungs are the right for known pleural \neffusion. She was able to complete her dialysis session before \nbeing transferred. Per report, the patient had a relatively \nquick onset of dyspnea in the ambulance and was placed on CPAP. \nShe reports a severe cough, ongoing for the past 2 days. Denied \nchest pain, abdominal pain, NVD, dysuria. \n\nOf note, patient recently admitted in ___ for hypoxemic \nrespiratory failure, thought to be related to pulmonary edema \nand recurrent pleural effusion. Patient has a history of \nexudative, hemorrhagic effusion with negative cytology x1 and \nwas found on prior imaging to have a 7 mm right lower lobe \nnodule (on ___, \nthought to represent most likely malignancy. She has discussed \nthese findings with heme/onc, pulmonary and with palliative care \nand has chosen to defer further work-up of this nodule. She has \nelected to continue with HD for now. \n\nIn the ED, initial vitals: 98.3 110 28 100% Non-Rebreather \n- Labs: trop 0.57, VBG 7.14/108 (last PCO2 a month prior was 56) \nwith lactate 1.1, HCO3 33, BUN/Cr ___, BNP 22259 (elevated), \nWBC 6.9 with lymphocytosis, H/H 9.7/34.8, blood culture x 2 \n- Imaging: \nCXR: Right basilar opacity likely in part due to right-sided \npleural effusion which appears partially loculated and slightly \nlarger compared to prior. Likely some component of at adjacent \natelectasis. Infection cannot be excluded. \n- Pt treated with 15 mg IV dilt, 30 mg PO for HR reportedly to \n130, she was placed on BiPAP with improvement in her respiratory \nstatus\nwas dosed cefepime and vancomycin for presumed HCAP \n\nOn transfer, vitals were: 97.5 98 153/44 29 100% Nasal Cannula', 'medications': [{'medication': 'OxycoDONE (Immediate Release) ', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'Q4H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Acetaminophen', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'Q8H', 'doses_per_24_hrs': 3.0}, {'medication': 'Sodium Chloride 0.9% Flush', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'Q8H', 'doses_per_24_hrs': 3.0}, {'medication': 'Influenza Vaccine Quadrivalent', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IM', 'frequency': 'NOW X1', 'doses_per_24_hrs': 0.0}]}, 'clinical_findings': {'labs': [{'value': '___', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'HOLD.'}, {'value': '103', 'valuenum': 103.0, 'valueuom': '%', 'ref_range_lower': 50.0, 'ref_range_upper': 200.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '1.0', 'valuenum': 1.0, 'valueuom': None, 'ref_range_lower': 0.9, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '10.8', 'valuenum': 10.8, 'valueuom': 'sec', 'ref_range_lower': 9.4, 'ref_range_upper': 12.5, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '35.2', 'valuenum': 35.2, 'valueuom': 'sec', 'ref_range_lower': 25.0, 'ref_range_upper': 36.5, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'HOLD. DISCARD GREATER THAN 4 HOURS OLD.', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': '___'}, {'value': '0.2', 'valuenum': 0.2, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 2.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.4', 'valuenum': 2.4, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 4.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '29.8', 'valuenum': 29.8, 'valueuom': '%', 'ref_range_lower': 40.0, 'ref_range_upper': 52.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '10.6', 'valuenum': 10.6, 'valueuom': 'g/dL', 'ref_range_lower': 14.0, 'ref_range_upper': 18.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '20.4', 'valuenum': 20.4, 'valueuom': '%', 'ref_range_lower': 18.0, 'ref_range_upper': 42.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '29.6', 'valuenum': 29.6, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '35.6', 'valuenum': 35.6, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '83', 'valuenum': 83.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '7.2', 'valuenum': 7.2, 'valueuom': '%', 'ref_range_lower': 2.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '69.7', 'valuenum': 69.7, 'valueuom': '%', 'ref_range_lower': 50.0, 'ref_range_upper': 70.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '286', 'valuenum': 286.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '14.7', 'valuenum': 14.7, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '3.58', 'valuenum': 3.58, 'valueuom': 'm/uL', 'ref_range_lower': 4.6, 'ref_range_upper': 6.2, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '6.6', 'valuenum': 6.6, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '14', 'valuenum': 14.0, 'valueuom': 'mEq/L', 'ref_range_lower': 8.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '28', 'valuenum': 28.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '101', 'valuenum': 101.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '0.8', 'valuenum': 0.8, 'valueuom': 'mg/dL', 'ref_range_lower': 0.5, 'ref_range_upper': 1.2, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': "Using this patient's age, gender, and serum creatinine value of 0.8,. Estimated GFR = >75 if non African-American (mL/min/1.73 m2). Estimated GFR = >75 if African-American (mL/min/1.73 m2). For comparison, mean GFR for age group 30-39 is 107 (mL/min/1.73 m2). GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure."}, {'value': '___', 'valuenum': 93.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 100.0, 'flag': None, 'priority': 'STAT', 'comments': 'IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES.'}, {'value': '4.1', 'valuenum': 4.1, 'valueuom': 'mEq/L', 'ref_range_lower': 3.3, 'ref_range_upper': 5.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '139', 'valuenum': 139.0, 'valueuom': 'mEq/L', 'ref_range_lower': 133.0, 'ref_range_upper': 145.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '15', 'valuenum': 15.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'RANDOM.'}, {'value': 'HOLD.', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': '___'}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'FEW.'}, {'value': None, 'valuenum': None, 'valueuom': 'mg/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'NEG.'}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'NEG.'}, {'value': '0', 'valuenum': 0.0, 'valueuom': '#/hpf', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '6.0', 'valuenum': 6.0, 'valueuom': 'units', 'ref_range_lower': 5.0, 'ref_range_upper': 8.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '30', 'valuenum': 30.0, 'valueuom': 'mg/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': None, 'valuenum': None, 'valueuom': '#/hpf', 'ref_range_lower': 0.0, 'ref_range_upper': 2.0, 'flag': None, 'priority': 'STAT', 'comments': '<1.'}, {'value': '1.022', 'valuenum': 1.022, 'valueuom': ' ', 'ref_range_lower': 1.001, 'ref_range_upper': 1.035, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'Clear.'}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'Yellow.'}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'RARE.'}, {'value': None, 'valuenum': None, 'valueuom': 'mg/dL', 'ref_range_lower': 0.2, 'ref_range_upper': 1.0, 'flag': None, 'priority': 'STAT', 'comments': 'NEG.'}, {'value': '1', 'valuenum': 1.0, 'valueuom': '#/hpf', 'ref_range_lower': 0.0, 'ref_range_upper': 5.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'NONE', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '0.2', 'valuenum': 0.2, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 2.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '1.6', 'valuenum': 1.6, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 4.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '27.0', 'valuenum': 27.0, 'valueuom': '%', 'ref_range_lower': 40.0, 'ref_range_upper': 52.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '9.7', 'valuenum': 9.7, 'valueuom': 'g/dL', 'ref_range_lower': 14.0, 'ref_range_upper': 18.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '17.6', 'valuenum': 17.6, 'valueuom': '%', 'ref_range_lower': 18.0, 'ref_range_upper': 42.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '29.4', 'valuenum': 29.4, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '36.0', 'valuenum': 36.0, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '82', 'valuenum': 82.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '8.4', 'valuenum': 8.4, 'valueuom': '%', 'ref_range_lower': 2.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '72.3', 'valuenum': 72.3, 'valueuom': '%', 'ref_range_lower': 50.0, 'ref_range_upper': 70.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '238', 'valuenum': 238.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '14.7', 'valuenum': 14.7, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '3.30', 'valuenum': 3.3, 'valueuom': 'm/uL', 'ref_range_lower': 4.6, 'ref_range_upper': 6.2, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '6.6', 'valuenum': 6.6, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '26.2', 'valuenum': 26.2, 'valueuom': '%', 'ref_range_lower': 40.0, 'ref_range_upper': 52.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '9.3', 'valuenum': 9.3, 'valueuom': 'g/dL', 'ref_range_lower': 14.0, 'ref_range_upper': 18.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '29.7', 'valuenum': 29.7, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '35.7', 'valuenum': 35.7, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '83', 'valuenum': 83.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '241', 'valuenum': 241.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '14.6', 'valuenum': 14.6, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '3.14', 'valuenum': 3.14, 'valueuom': 'm/uL', 'ref_range_lower': 4.6, 'ref_range_upper': 6.2, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '5.2', 'valuenum': 5.2, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '27.1', 'valuenum': 27.1, 'valueuom': '%', 'ref_range_lower': 40.0, 'ref_range_upper': 52.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '9.9', 'valuenum': 9.9, 'valueuom': 'g/dL', 'ref_range_lower': 14.0, 'ref_range_upper': 18.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '30.3', 'valuenum': 30.3, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '36.5', 'valuenum': 36.5, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '83', 'valuenum': 83.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '242', 'valuenum': 242.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '14.7', 'valuenum': 14.7, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '3.27', 'valuenum': 3.27, 'valueuom': 'm/uL', 'ref_range_lower': 4.6, 'ref_range_upper': 6.2, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '6.3', 'valuenum': 6.3, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}], 'exams': 'ADMISSION PHYSICAL EXAM:\nVitals: T: NR BP: NR P: 90 R: 27 O2:95% on ___\nGENERAL: no acute distress\nHEENT: Sclera anicteric, MMM\nNECK: supple, JVD not visualized\nLUNGS: decreased breath sounds in b/l bases, expiratory wheeze \nin upper lobes b/l\nCV: RRR, nl S1 S2, systolic murmur RUSB and LUSB, no gallops\nABD: soft, NT, ND, NABS, no organomegaly\nEXT: WWP, 2+ pulses, trace edema\nSKIN: ecchymosis/abrasion on b/l anterior calves\nNEURO: CN ___ grossly intact, moving all extremities \nspontaneously \n\nDISCHARGE PHYSICAL EXAM:\n98.7 97.8 114-131/49-55 64-115 18 100 2LNC\n Tele: PVBs\n GENERAL: cachectic, elderly, speaking in full sentences, NAD\n HEENT: Sclera anicteric, MMM\n NECK: supple, +JVD\n LUNGS: diminished breath sounds at bases, L>R, bibasilar rales, \ncrackles heard throughout L lung fields anterior and posterior, \nno crackles R anterior or upper fields.\n CV: Regular rhythm. mildly tachycardic. ___ murmur at LUSB\n ABD: soft, NT, ND, NABS, no organomegaly\n EXT: LUE AVG. biphasic pulse present as before in LUE forearm. \nNo dop pulse in radial wrist. ___ fingers cool to touch, palms \nwarm ___. equal ___.\n NEURO: CN ___ grossly intact, moving all extremities \nspontaneously.\n L hand with poor resistance compared to right hand. Full ROM, \nbut ___ strength L compared to ___ R hand. ___ strength ___ upper \narms, shoulders.', 'diagnoses': [{'icd_code': '9222', 'desc': 'Contusion of abdominal wall'}, {'icd_code': '920', 'desc': 'Contusion of face, scalp, and neck except eye(s)'}, {'icd_code': 'E8854', 'desc': 'Fall from snowboard'}, {'icd_code': 'E8495', 'desc': 'Street and highway accidents'}, {'icd_code': '2860', 'desc': 'Congenital factor VIII disorder'}, {'icd_code': '2859', 'desc': 'Anemia, unspecified'}], 'summary': 'ADMISSION LABS:\n___ 04:55PM BLOOD WBC-6.9 RBC-3.45* Hgb-9.7* Hct-34.8 \nMCV-101* MCH-28.1 MCHC-27.9* RDW-19.6* RDWSD-72.1* Plt ___\n___ 04:55PM BLOOD Neuts-63.9 Lymphs-15.0* Monos-12.5 \nEos-7.6* Baso-0.6 NRBC-0.3* Im ___ AbsNeut-4.43# \nAbsLymp-1.04* AbsMono-0.87* AbsEos-0.53 AbsBaso-0.04\n___ 04:55PM BLOOD Glucose-132* UreaN-8 Creat-1.6*# Na-137 \nK-3.6 Cl-98 HCO3-33* AnGap-10\n___ 04:55PM BLOOD CK-MB-2 ___\n___ 04:55PM BLOOD cTropnT-0.57*\n___ 04:55PM BLOOD CK(CPK)-18*\n___ 02:56AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7\n___ 05:01PM BLOOD pO2-31* pCO2-108* pH-7.14* calTCO2-39* \nBase XS-2\n\nDISCHARGE LABS\n___ 06:21AM BLOOD WBC-12.4* RBC-2.96* Hgb-8.3* Hct-29.5* \nMCV-100* MCH-28.0 MCHC-28.1* RDW-18.9* RDWSD-69.0* Plt ___\n___ 06:21AM BLOOD Plt ___\n___ 06:15AM BLOOD Plt ___\n___ 06:21AM BLOOD Glucose-101* UreaN-15 Creat-2.5* Na-137 \nK-4.2 Cl-99 HCO3-33* AnGap-9\n___ 06:21AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.9\n___ 07:10AM BLOOD ___ pO2-56* pCO2-50* pH-7.39 \ncalTCO2-31* Base XS-3\n\nPERTINENT INTERVAL LABS:\n___ 03:35AM BLOOD ___ pO2-33* pCO2-73* pH-7.26* \ncalTCO2-34* Base XS-1\n___ 09:18PM BLOOD pO2-216* pCO2-35 pH-7.45 calTCO2-25 Base \nXS-1 Comment-GREEN TOP\n\nIMAGING/STUDIES: \n\nCXR ___\nRight basilar opacity is in part due to pleural effusion which \nmay be \npartially loculated and appears larger when compared to prior. \nPleural-based catheter is in unchanged position compared to \nprior. There may also be a small left pleural effusion given \nblunting of left costophrenic angle. Left upper lung opacity has \nnot significantly changed since priors. Cardiomediastinal \nsilhouette is within normal limits. Dense atherosclerotic \ncalcifications are noted. Left upper extremity vascular stent \nis visualized. \nIMPRESSION: \nRight basilar opacity likely in part due to right-sided pleural \neffusion which appears partially loculated and slightly larger \ncompared to prior. Likely some component of at adjacent \natelectasis. Infection cannot be excluded. \n\n___ CT Chest \nAs compared to the previous examination, the right pleural \neffusion persists in almost unchanged manner, causing a \nrelatively large right atelectasis. Increasing left pleural \neffusion with subsequent atelectasis. 3 cm left upper lobe \nspiculated mass, suspicious in morphology. \n\n___ CXR \nComparison to ___. No relevant change. The small right \nbasal \npneumothorax and the position of the right chest tube is stable. \n Moderate \ncardiomegaly persists. The bilateral parenchymal opacities at \nthe lung bases are stable. The presence of a small left pleural \neffusion is likely. On the right, the effusion might have \nminimally decreased. \n\nCHEST (PORTABLE AP) Study Date of ___ 12:56 AM \nTiny right pneumothorax has minimally decreased. Right chest \ntube is in place. Cardiomediastinal contours are unchanged and \nmidline. Small left effusion is a stable. Spiculated lesion in \nthe left upper lobe and emphysema are better seen in prior CT. \nThe trachea is deviated to the left due to a thyroid nodule, \nalso better seen on prior CT \n\nMICROBIOLOGY: \n___ Blood Cultures x 2 pending \n___ 2:56 am PLEURAL FLUID\n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count..\n\n FLUID CULTURE (Preliminary): NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n___ CT CHEST\nIMPRESSION: \nAs compared to the previous examination, the right pleural \neffusion persists in almost unchanged manner, causing a \nrelatively large right atelectasis. Increasing left pleural \neffusion with subsequent atelectasis. 3 cm left upper lobe \nspiculated mass, suspicious in morphology. \n\nART DUP EXT UP UNI OR LMTD LEFT Study Date of ___ \nPatent left ulnar artery. Left radial artery occlusion\n___ yo F with PMH HTN, DMT2, MR, HRpEF, PAD s/p stent, ESRD on \nHD, chronic, mesenteric ischemia, bronchiectasis, COPD and \nrecurrent pleural effusions treated with TPC concerning for \nmalignancy who presents with hypercarbic respiratory failure \nrequiring BiPAP as well as afib with RVR.\n\nPatient was in the Medical ICU from ___ and again ___ \nfor BiPAP treatment. \n\n# Acute on Chronic Hypercarbic, Hypoxemic Respiratory Failure: \nPatient presented with dyspnea, found on VBG to have pCO 108, \nfrom recent baseline 56 with pO2 31. This was likely \nmultifactorial in origin, related to worsening pleural effusion \n(noted on CXR on presentation), pulmonary edema, baseline COPD, \nand significant anxiety. The patient was treated with vancomycin \nand cefepime for a presumed pneumonia, but low suspicion for \nthis given the patient had no leukocytosis and reported no \nhistory of fever. 60cc of serous fluid was darined from pleurex \nand sent for cx. We continued ipratropium nebs q6hrs, ad held \nhome albuterol given history of tachycardia. Repeated ABG the \nday after admission improved, so patient was called out to the \nfloor. After call out to the floor, the patient was noted to be \nhypoxemic to the ___. She was transferred back to the MICU on \n___. Upon arrival, the patient initially refused all \ntreatment, including morphine for symptomatic management, but in \nconversation with her son, consented to wear BiPAP mask. \nRecurrent respiratory failure was thought to be secondary to \nvolume overload. The patient was treated with HD, with \nimprovement in respiratory status. When stabilized, she was \ncalled back out to the floor. CT chest showed recurrent pleural \neffusions which were not draining due to malpositioned PleurX \ncatheter. Patient was seen by IP, who removed the Pleurx and \nreplaced it with a new one in good location for effusion \ndrainage, 300cc serous fluid output after placement. Good output \nthe first 3 drainage sessions. No drainage by the ___ drainage. \nPatient\'s breathing improved back to baseline. \n - continued management of pleural effusion, heart failure and \nESRD \n - Ipratropium Bromide Neb, home albuterol was held due to \ntachycardia \n - blood cultures and pleural effusion cultures were negative \nfor evidence of infection h \n - f/u with IP in 2 weeks. drain pleurx daily per IP recs.\n\n# Afib with RVR: Patient with reported AF with RVR treated with \ndiltiazem 15mg IV and 30mg PO. Patient remained HD stable. \nUnclear if h/o AF, possibly triggered by respiratory distress. \nThe patient was monitored on telemetry and noted to have \nintermittent, self-limited episodes of tachycardia to the 120s. \nThe patient refused further intervention. She continues to have \noccasional episodes of NSVT and fast HR but remains \nhemodynamically stable and asymptomatic.\n\n# Troponinemia: patient presented with trop elevated to 0.57, \nlower than more recent baseline. Likely due to ESRD given flat \nMB. No evidence of cardiac etiology. Nothing to do. \n\n# Acute on Chronic Diastolic Heart Failure: patient with some \nevidence of pulmonary edema on CXR, clinically with some \nevidence of increased ___ edema, but denies history of \northopnea/PND. Continued volume management with HD, with \noccasional ultrafiltration for fluid removal. \n\n# Depression: continued home venlafaxine \n\n# ESRD on HD: ___, substituted nephrocaps for renal caps \ngiven NF. \n\n# Orthostatic Hypotension: continued midodrine with HD \n\n# After a fistulogram done ___ for a clotted AV fistula, she \nexperienced some L hand numbness and weakness and was found to \nhave an arterial clot on ultrasound. After discussions with \nTransplant Surgery and Interventional Radiology it was felt that \nno further intervention or testing was necessary given her \noverall goals of care, adequacy of collaterals, and resolution \nof symptoms of numbness. Can re-evaluate L hand and consider \nfurther evaluation or testing if there is a significant change \nin her symptoms or exam. The idea of anticoagulation for this \nlesion was discussed with her health care proxy, ___, \nbut ___ and Transplant surgery did not recommend intervention or \nanticoagulation at this time. ___ consider starting \nanticoagulation if worsening of L hand numbness or weakness in \nthe future. \n\n# GOC: patient with history of recurrent pleural effusions, \nfound to have spiculated lung nodule for which she declined \nfurther evaluation. Has been evaluated by heme/onc and pulmonary \nin the past. Continued home acetaminophen, morphine and \nlorazepam. Held home atropine drops and biotene mouth rinse. The \npatient was noted to intermittently refuse care while in the \nMICU, including refusal of BiPAP or NC despite hypoxemia to the \n___. Goals of care discussions were continued with the \npalliative care team. \n - acetaminophen for pain \n - discontinue morphine SL for pain (as can accumulated in ESRD) \n \n - holding Ativan for anxiety \n - holding home atropine drops \n - holding biotene mouth rinse as NF \n - renewed MOLST form with patient and with son ___\n\nDetails from palliative care consultation:\n"IMPRESSION/RECOMMENDATIONS: Ms. ___ at times seems \nconflicted about her wishes for her care. However, presently, \nshe is clear that she wants to continue to receive care that \nwill help her live longer so that she can engage with and \nsupport her son and grand-daughter. If she were to get so sick \nthat she were unable to be awake and engage w/ the them, she \nwould not want to have her life prolonged (and she has also \nclearly conveyed not wanting to be resuscitated or intubated \neven in her current condition). Her son, ___, is aware of these \nwishes and wants to support his mom in fulfilling them.\n- For now, continue current level of care\n- Further discussion of goals/ wishes as course evolves\n- DNR/DNI"\n\n# PAD s/p stents: patient previously on ASA, plavis and atorva \nbut held on prior discharge given GOC and risk/benefit. \n\n# Communication: \nName of health care proxy: ___ \n___: son \nPhone number: ___ \nCell phone: ___ \n# Code: DNR/DNI (confirmed) \n\nTRANSITIONAL ISSUES\n# continue Hemodialysis \n# During the hospitalization, AVG was found to be clotted. \nUnderwent ___ removal of clot with tPA. Experienced L hand \nnumbness and weakness after clot formation; please continue to \nevaluate L hand and consider vascular surgery vs anticoagulation \nif there are any serious changes in examination. \n# discussed anticoagulation with HCP, ___, but ___ and \ntransplant do not recommend intervention or anticoagulation at \nthis time. ___ consider starting anticoagulation if worsening of \nL hand numbness or weakness in the future. \n# respiratory distress during initial presentation improved with \nBiPAP. Patient is DNR/DNI but okay for hospitalization, ICU \ntransfer and BiPAP \n#lung nodules concerning for primary lung cancer - likely \netiology of chronic pleural effusions. No intervention at this \ntime. Pleural effusion drainage for improved comfort of \nbreathing\n#Goals of care: patient is currently DNR/DNI. She required ICU \nadmission for BiPAP >1 times during this admission; continue to \ndiscuss goals of care and to delineate patient\'s wishes for \nlevel of invasiveness of interventions\n# New PleurX tube was placed bu interventional pulmonology in a \nbetter position to drain the chronic pleural effusion\n## PleurX management recommendations:\n___ PLeurex instructions- right (side)\n1. Please drain Pleurx every day.\n2. Do not drain more than 1000 ml per drainage.\n3. Stop draining for pain, chest tightness, or cough.\n4. Do not manipulate catheter in any way.\n5. Keep a daily log of drainage amount and color, have the\npatient bring it with her to her appointment.\n6. You may shower with an occlusive dressing\n7. If the drainage is less than 50cc for three consecutive\ndrainages please call the office for further instructions.\n8. Please call office with any questions or concerns at\n___. \n\nPleurex catheter sutures to be removed when seen in clinic ___ \ndays post PleurX placement.\n\n Name of health care proxy: ___ \n ___ \n Phone number: ___ \n Cell phone: ___ \n # Code: DNR/DNI (confirmed). Can transfer to ICU for BIPAP'}} | {'final_diagnoses': ['chronic pleural effusions, likely malignant', 'CHF exacerbation', 'hypercarbic respiratory distress'], 'procedures': ['- fistulogram with tPA administration and ballooning for AV \nfistula clot', '- removal and replacement of Pleurx catheter for malpositioned \ncatheter'], 'visit_summary': '___ yo F with PMH HTN, DMT2, MR, HRpEF, PAD s/p stent, ESRD on \nHD, chronic, mesenteric ischemia, bronchiectasis, COPD and \nrecurrent pleural effusions treated with TPC concerning for \nmalignancy who presents with hypercarbic respiratory failure \nrequiring BiPAP as well as afib with RVR.\n\nPatient was in the Medical ICU from ___ and again ___ \nfor BiPAP treatment. \n\n# Acute on Chronic Hypercarbic, Hypoxemic Respiratory Failure: \nPatient presented with dyspnea, found on VBG to have pCO 108, \nfrom recent baseline 56 with pO2 31. This was likely \nmultifactorial in origin, related to worsening pleural effusion \n(noted on CXR on presentation), pulmonary edema, baseline COPD, \nand significant anxiety. The patient was treated with vancomycin \nand cefepime for a presumed pneumonia, but low suspicion for \nthis given the patient had no leukocytosis and reported no \nhistory of fever. 60cc of serous fluid was darined from pleurex \nand sent for cx. We continued ipratropium nebs q6hrs, ad held \nhome albuterol given history of tachycardia. Repeated ABG the \nday after admission improved, so patient was called out to the \nfloor. After call out to the floor, the patient was noted to be \nhypoxemic to the ___. She was transferred back to the MICU on \n___. Upon arrival, the patient initially refused all \ntreatment, including morphine for symptomatic management, but in \nconversation with her son, consented to wear BiPAP mask. \nRecurrent respiratory failure was thought to be secondary to \nvolume overload. The patient was treated with HD, with \nimprovement in respiratory status. When stabilized, she was \ncalled back out to the floor. CT chest showed recurrent pleural \neffusions which were not draining due to malpositioned PleurX \ncatheter. Patient was seen by IP, who removed the Pleurx and \nreplaced it with a new one in good location for effusion \ndrainage, 300cc serous fluid output after placement. Good output \nthe first 3 drainage sessions. No drainage by the ___ drainage. \nPatient\'s breathing improved back to baseline. \n - continued management of pleural effusion, heart failure and \nESRD \n - Ipratropium Bromide Neb, home albuterol was held due to \ntachycardia \n - blood cultures and pleural effusion cultures were negative \nfor evidence of infection h \n - f/u with IP in 2 weeks. drain pleurx daily per IP recs.\n\n# Afib with RVR: Patient with reported AF with RVR treated with \ndiltiazem 15mg IV and 30mg PO. Patient remained HD stable. \nUnclear if h/o AF, possibly triggered by respiratory distress. \nThe patient was monitored on telemetry and noted to have \nintermittent, self-limited episodes of tachycardia to the 120s. \nThe patient refused further intervention. She continues to have \noccasional episodes of NSVT and fast HR but remains \nhemodynamically stable and asymptomatic.\n\n# Troponinemia: patient presented with trop elevated to 0.57, \nlower than more recent baseline. Likely due to ESRD given flat \nMB. No evidence of cardiac etiology. Nothing to do. \n\n# Acute on Chronic Diastolic Heart Failure: patient with some \nevidence of pulmonary edema on CXR, clinically with some \nevidence of increased ___ edema, but denies history of \northopnea/PND. Continued volume management with HD, with \noccasional ultrafiltration for fluid removal. \n\n# Depression: continued home venlafaxine \n\n# ESRD on HD: ___, substituted nephrocaps for renal caps \ngiven NF. \n\n# Orthostatic Hypotension: continued midodrine with HD \n\n# After a fistulogram done ___ for a clotted AV fistula, she \nexperienced some L hand numbness and weakness and was found to \nhave an arterial clot on ultrasound. After discussions with \nTransplant Surgery and Interventional Radiology it was felt that \nno further intervention or testing was necessary given her \noverall goals of care, adequacy of collaterals, and resolution \nof symptoms of numbness. Can re-evaluate L hand and consider \nfurther evaluation or testing if there is a significant change \nin her symptoms or exam. The idea of anticoagulation for this \nlesion was discussed with her health care proxy, ___, \nbut ___ and Transplant surgery did not recommend intervention or \nanticoagulation at this time. ___ consider starting \nanticoagulation if worsening of L hand numbness or weakness in \nthe future. \n\n# GOC: patient with history of recurrent pleural effusions, \nfound to have spiculated lung nodule for which she declined \nfurther evaluation. Has been evaluated by heme/onc and pulmonary \nin the past. Continued home acetaminophen, morphine and \nlorazepam. Held home atropine drops and biotene mouth rinse. The \npatient was noted to intermittently refuse care while in the \nMICU, including refusal of BiPAP or NC despite hypoxemia to the \n___. Goals of care discussions were continued with the \npalliative care team. \n - acetaminophen for pain \n - discontinue morphine SL for pain (as can accumulated in ESRD) \n \n - holding Ativan for anxiety \n - holding home atropine drops \n - holding biotene mouth rinse as NF \n - renewed MOLST form with patient and with son ___\n\nDetails from palliative care consultation:\n"IMPRESSION/RECOMMENDATIONS: Ms. ___ at times seems \nconflicted about her wishes for her care. However, presently, \nshe is clear that she wants to continue to receive care that \nwill help her live longer so that she can engage with and \nsupport her son and grand-daughter. If she were to get so sick \nthat she were unable to be awake and engage w/ the them, she \nwould not want to have her life prolonged (and she has also \nclearly conveyed not wanting to be resuscitated or intubated \neven in her current condition). Her son, ___, is aware of these \nwishes and wants to support his mom in fulfilling them.\n- For now, continue current level of care\n- Further discussion of goals/ wishes as course evolves\n- DNR/DNI"\n\n# PAD s/p stents: patient previously on ASA, plavis and atorva \nbut held on prior discharge given GOC and risk/benefit. \n\n# Communication: \nName of health care proxy: ___ \n___: son \nPhone number: ___ \nCell phone: ___ \n# Code: DNR/DNI (confirmed) \n\nTRANSITIONAL ISSUES\n# continue Hemodialysis \n# During the hospitalization, AVG was found to be clotted. \nUnderwent ___ removal of clot with tPA. Experienced L hand \nnumbness and weakness after clot formation; please continue to \nevaluate L hand and consider vascular surgery vs anticoagulation \nif there are any serious changes in examination. \n# discussed anticoagulation with HCP, ___, but ___ and \ntransplant do not recommend intervention or anticoagulation at \nthis time. ___ consider starting anticoagulation if worsening of \nL hand numbness or weakness in the future. \n# respiratory distress during initial presentation improved with \nBiPAP. Patient is DNR/DNI but okay for hospitalization, ICU \ntransfer and BiPAP \n#lung nodules concerning for primary lung cancer - likely \netiology of chronic pleural effusions. No intervention at this \ntime. Pleural effusion drainage for improved comfort of \nbreathing\n#Goals of care: patient is currently DNR/DNI. She required ICU \nadmission for BiPAP >1 times during this admission; continue to \ndiscuss goals of care and to delineate patient\'s wishes for \nlevel of invasiveness of interventions\n# New PleurX tube was placed bu interventional pulmonology in a \nbetter position to drain the chronic pleural effusion\n## PleurX management recommendations:\n___ PLeurex instructions- right (side)\n1. Please drain Pleurx every day.\n2. Do not drain more than 1000 ml per drainage.\n3. Stop draining for pain, chest tightness, or cough.\n4. Do not manipulate catheter in any way.\n5. Keep a daily log of drainage amount and color, have the\npatient bring it with her to her appointment.\n6. You may shower with an occlusive dressing\n7. If the drainage is less than 50cc for three consecutive\ndrainages please call the office for further instructions.\n8. Please call office with any questions or concerns at\n___. \n\nPleurex catheter sutures to be removed when seen in clinic ___ \ndays post PleurX placement.\n\n Name of health care proxy: ___ \n ___ \n Phone number: ___ \n Cell phone: ___ \n # Code: DNR/DNI (confirmed). Can transfer to ICU for BIPAP', 'medications_prescribed': ['1. Acetaminophen 650 mg PR Q6H:PRN T>100 or if unable to take PO', '2. Bisacodyl 10 mg PR QHS:PRN constipation', '3. Docusate Sodium 100 mg PO BID', '4. Midodrine 10 mg PO 3X/WEEK (___)', '5. Polyethylene Glycol 17 g PO DAILY', '6. Senna 8.6 mg PO BID', '7. Venlafaxine XR 75 mg PO DAILY', '8. Acidophilus (Lactobacillus acidophilus) 1 CAPSULE oral QHS', '9. Ativan (LORazepam) 0.5 mg SL Q4H:PRN anxiety', '10. Atropine Sulfate 1% 2 DROP SL Q6H:PRN secretions', '11. Biotene Dry Mouth Oral Rinse (saliva substitute combo no.9) \n1 tbsp mucous membrane TID', '12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H', '13. morphine 0.25 mg SL Q4H:PRN pain, dyspnea', '14. Pioglitazone 30 mg PO DAILY', '15. Renal Caps (B complex with C#20-folic acid) 1 mg oral DAILY']} |
Generate a treatment plan with clinical reasoning for this case: | {'patient_profile': {'age': 53, 'gender': 'F', 'symptoms': 'Encephalopathy', 'medical_history': ['___ disease', 'Bipolar disorder', 'Anemia, suspected myelodysplastic syndrome (followed by \nHeme/Onc)', 'Diet-controlled diabetes mellitus', 'Hypertension', 'Primary hyperparathyroidism', 'Anxiety', 'Mild intellectual disability', 'Vertigo', 'History of thyroid nodule', 'History of proteinuria', 'Prostate cancer'], 'family_history': 'Unable to obtain, as altered', 'present_illness': 'This is a ___ year old man with a PMH of ___ disease, \nMDS, numerous recent admissions for altered mental status and \nhematuria who presented with fever & encephalopathy.\n\nThe patient is unable to provide full history, given his \nencephalopathy. Per RN notes, he was transferred from his SNF \nwith encephalopathy and fevers (to 99.7) for 2 days. \n\nOf note, he had 2 recent admissions for altered mental status. \n\nThe first ___ was for subacute changes in cognition, \nmemory, and behavior. Per that discharge summary, "Initially the \npatient\'s presentation was felt to be d/t a metabolic \nencephalopathy from UTI, and so he was started on ceftriaxone. \nHowever culture was negative and so this was discontinued. He \nwas also found to have urinary retention, with bladder scan of \n800cc, so this was another potential insult to explain the \nchanges. However they did not improve s/p Foley placement. MRI \nbrain was obtained and was unrevealing." EEG (obtained for \nreported but unwitnessed "staring spells" showed nonspecific \nfindings and recommended repeat during sleep if clinically \nindicated to "increase the yield for epileptiform activity." Per \nGeriatrics and neurology, "it was felt that his changes likely \nrepresented a primary psychiatric or medication induced process. \nHis seroquel was reduced by half with some mild improvement in \nsymptoms. He was discharged on that dose with close follow-up \nwith his outpatient providers. On discharge, he was "alert and \ninteractive; oriented to exact date and location; dysarthric; \nmild resting tremor; able to say days of week backwards at \nnormal pace." \n\nAdmission also notable for hypercalcemia in setting of primary \nhyperparathyroidism, urinary retention with foley from prior \n(___) admission requiring q4h bladder scans, hematuria from \ntraumatic removal, and new finding of R kidney mass concerning \nfor RCC. \n\nSecond admission ___ was for hematuria and AMS. Per this \nd/c summary, he was at his baseline on presentation "(AAOx2, \nslow to respond), however after prolonged time in ED he was \nfound to be minimally responsive." Work-up notable for ___ \nwithout acute change, infectious work-up w/elevated lipase in \nabsence of abdominal pain/problems with eating, electrolytes \nnotable for elevated calcium (stable from prior admission), \nammonia level normal. Concern for contribution from urinary \nretention given recent traumatic foley displacement, although \nwas able to urinate during hospitalization and did not require \nreplacement of foley. Also concern for contribution from \npsychiatric medications and his seroquel and clonazepam were \nheld." Neurology attributed his presentation to delirium in \nsetting of subacute functional decline. \n\nIn the ED, initial vitals: unable to assess pain, T 101.6, P \n90-95, HR 115/76, R 18, SpO2 97%/? O2 NC, FSG 126\n\n- Upon arrival to the ED, the patient is non-verbal, without \nevidence of respiratory distress or dyspnea. \n- Exam notable for: tremor, wet & warm skin, brisk capillary \nrefill\n- Labs were notable for: WBC 29, Hb 11.4, lipase 198, Na 164, Cr \n1.6, INR 1.2, TBili 2.1, grossly positive UA \n- CXR, by my read, slight right lower lobe haziness \n- Patient was given: vancomycin, cefepime, 2L NS\n\nOn arrival to the MICU, he was unresponsive to voice and sternal \nrub. He tightly closed eyes and mouth during attempted exam but \npupils were apparently equal and reactive to light. A stat ABG \nwas drawn which was grossly normal. He became more responsive \nand was able to endorse that his voice was more slurred than \nusual, no pain.\n\nREVIEW OF SYSTEMS: As above, difficult to assess secondary to \nalteration and slurred speech.', 'medications': [{'medication': 'Acetaminophen', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'Q4H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Lorazepam', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Metoclopramide', 'proc_type': 'Unit Dose', 'status': 'Expired', 'route': 'IV', 'frequency': 'ONCE', 'doses_per_24_hrs': 1.0}, {'medication': 'Ondansetron', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'Q4H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Promethazine', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'HYDROmorphone (Dilaudid)', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'IVPCA', 'frequency': 'ASDIR', 'doses_per_24_hrs': None}, {'medication': None, 'proc_type': 'IV Large Volume', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'ASDIR', 'doses_per_24_hrs': None}, {'medication': 'Ketorolac', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': None, 'proc_type': 'IV Large Volume', 'status': 'Inactive (Due to a change order)', 'route': 'IV', 'frequency': 'ASDIR', 'doses_per_24_hrs': None}, {'medication': 'Docusate Sodium', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'BID', 'doses_per_24_hrs': 2.0}, {'medication': 'Aluminum-Magnesium Hydrox.-Simethicone', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'QID:PRN', 'doses_per_24_hrs': None}, {'medication': 'Scopolamine Patch', 'proc_type': 'Unit Dose', 'status': 'Expired', 'route': 'TP', 'frequency': 'ONCE', 'doses_per_24_hrs': 1.0}, {'medication': None, 'proc_type': 'IV Large Volume', 'status': 'Discontinued', 'route': 'IV', 'frequency': 'ASDIR', 'doses_per_24_hrs': None}, {'medication': 'DiphenhydrAMINE', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Sodium Chloride 0.9% Flush', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'Q8H:PRN', 'doses_per_24_hrs': None}, {'medication': 'HYDROmorphone (Dilaudid)', 'proc_type': 'Unit Dose', 'status': 'Discontinued', 'route': 'IVPCA', 'frequency': 'ASDIR', 'doses_per_24_hrs': None}, {'medication': 'Hydrocodone-Acetaminophen', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Lorazepam', 'proc_type': 'Unit Dose', 'status': 'Inactive (Due to a change order)', 'route': 'PO', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}]}, 'clinical_findings': {'labs': [{'value': '33.8', 'valuenum': 33.8, 'valueuom': '%', 'ref_range_lower': 36.0, 'ref_range_upper': 48.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '11.9', 'valuenum': 11.9, 'valueuom': 'g/dL', 'ref_range_lower': 12.0, 'ref_range_upper': 16.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '31.2', 'valuenum': 31.2, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '35.2', 'valuenum': 35.2, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '89', 'valuenum': 89.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '161', 'valuenum': 161.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '12.8', 'valuenum': 12.8, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '3.82', 'valuenum': 3.82, 'valueuom': 'm/uL', 'ref_range_lower': 4.2, 'ref_range_upper': 5.4, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '7.6', 'valuenum': 7.6, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '11', 'valuenum': 11.0, 'valueuom': 'mEq/L', 'ref_range_lower': 8.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '27', 'valuenum': 27.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '104', 'valuenum': 104.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '0.9', 'valuenum': 0.9, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': "Using this patient's age, gender, and serum creatinine value of 0.9,. Estimated GFR = 66 if non African-American (mL/min/1.73 m2). Estimated GFR = >75 if African-American (mL/min/1.73 m2). For comparison, mean GFR for age group 50-59 is 93 (mL/min/1.73 m2). GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure."}, {'value': '150', 'valuenum': 150.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 105.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '3.8', 'valuenum': 3.8, 'valueuom': 'mEq/L', 'ref_range_lower': 3.3, 'ref_range_upper': 5.1, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '138', 'valuenum': 138.0, 'valueuom': 'mEq/L', 'ref_range_lower': 133.0, 'ref_range_upper': 145.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '10', 'valuenum': 10.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}], 'exams': 'ADMISSION EXAM:\n===============\nVITALS: T 99.3 BP 110/65 HR 80 RR 18 O2 98 \nGENERAL: Somnolent, initially not rousable to voice or sternal \nrub, then rousable to voice and soft touch. NAD. \nHEENT: Dry mucous membranes with thick secretions in oropharynx. \nThick secretions in eyes. Pupils equal and reactive to light. \nCARDIAC: RRR, no m/r/g appreciated\nLUNG: Normal respiratory effort. \nABDOMEN: Soft, nontender, nondistended. ?Possible hepatomegaly. \nEXTREMITIES: WWP, no edema. \nNEURO: Dysarthric, difficult to understand. Follows some \ncommands. Baseline coarse tremor. Rigidity. DOWB only \n___ then gets confused. ___, could not understand \nhis answer to the date. \n\nDISCHARGE EXAM:\n===============\nEXAM: \nVital Signs: 98.4 121/62 71 18 98RA\nmumbling, not oriented, speech limited. \narms, extremities shaking at times, fine tremor distally, not\nwaving arms', 'diagnoses': [{'icd_code': '1890', 'desc': 'Malignant neoplasm of kidney, except pelvis'}, {'icd_code': 'V1582', 'desc': 'Personal history of tobacco use'}, {'icd_code': 'V1201', 'desc': 'Personal history of tuberculosis'}], 'summary': "ADMISSION LABS:\n===============\n___ 12:55PM BLOOD WBC-29.0*# RBC-3.16*# Hgb-11.4*# \nHct-35.9*# MCV-114*# MCH-36.1* MCHC-31.8* RDW-14.4 RDWSD-60.3* \nPlt ___\n___ 12:55PM BLOOD Neuts-88.7* Lymphs-4.2* Monos-5.9 \nEos-0.1* Baso-0.1 Im ___ AbsNeut-25.72*# AbsLymp-1.23 \nAbsMono-1.70* AbsEos-0.02* AbsBaso-0.04\n___ 12:55PM BLOOD ___ PTT-24.8* ___\n___ 12:05AM BLOOD Ret Aut-2.0 Abs Ret-0.05\n___ 12:55PM BLOOD Glucose-127* UreaN-55* Creat-1.6* Na-164* \nK-4.4 Cl-123* HCO3-27 AnGap-17\n___ 12:55PM BLOOD ALT-7 AST-10 AlkPhos-128 TotBili-2.1* \nDirBili-0.6* IndBili-1.5\n___ 12:55PM BLOOD Lipase-198*\n___ 12:55PM BLOOD cTropnT-<0.01\n___ 12:55PM BLOOD Albumin-3.9 Calcium-12.6* Phos-4.3 \nMg-2.9*\n___ 12:05AM BLOOD Hapto-140\n___ 12:55PM BLOOD Osmolal-357*\n___ 05:55PM BLOOD ___ Temp-36.9 Rates-/16 O2 Flow-2 \npO2-73* pCO2-47* pH-7.36 calTCO2-28 Base XS-0 Intubat-NOT INTUBA \nComment-NASAL ___\n___ 01:07PM BLOOD Lactate-1.8\n___ 05:55PM BLOOD Lactate-1.4 Na-158*\n___ 05:55PM BLOOD freeCa-1.55*\n\n___ 06:50AM BLOOD ALT-<5 AST-10 AlkPhos-131* TotBili-1.0\n___ 09:20AM BLOOD calTIBC-176* VitB12-850 Folate-6 \n___ Ferritn-347 TRF-135*\n___ 09:20AM BLOOD TotProt-4.8* Calcium-10.3 Phos-2.2* \nMg-2.1 Iron-72\n___ 07:00AM BLOOD Ammonia-28\n___ 09:20AM BLOOD TSH-2.4\n___ 06:40AM BLOOD PTH-117*\n___ 06:50AM BLOOD 25VitD-37\n___ 09:20AM BLOOD PEP-NO SPECIFI\n___ 07:40AM BLOOD Valproa-11*\n___ 09:38AM BLOOD Lactate-1.4\n\nTotal Protein, Urine\n35 mg/dL\nOTHER URINE CHEMISTRY\nProt. Electrophoresis, Urine\xa0\nALBUMIN IS THE ONLY PROTEIN DETECTED\nNEGATIVE FOR ___ PROTEIN\nFOR ACCURATE QUANTITATION, ORDER RANDOM URINE ALBUMIN/CREATININE \nRATIO\n\nMICROBIOLOGY:\n=============\n___ Blood culture pending x2\n___ Urine culture \n___ CULTURE (Final ___: \n ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ <=2 S\nNITROFURANTOIN-------- <=16 S\nTETRACYCLINE---------- =>16 R\nVANCOMYCIN------------ 1 S\n\n___ MRSA swab: Negative\n\nPERTINENT STUDIES:\n==================\n___ CXR: Hazy lower lung opacities likely atelectasis, \ndifficult to exclude pneumonia.\n\n___ CXR: Comparison to ___. The patient has \nreceived a nasogastric tube. The tip is not visualized on the \nimage but the course of the tube is unremarkable. Lung volumes \nhave decreased. There are new areas of platelike atelectasis at \nboth the left and the right lung basis. No pleural effusions. \nNo pulmonary edema. Stable borderline size of the cardiac \nsilhouette. No pneumothorax. \n\n___:\nLiver or Gallbladder Ultrasound\n\nFINDINGS:\xa0\n\xa0\nL\nI\nV\nE\nR\n:\n\xa0\nT\nh\ne\n\xa0\nhepatic\xa0parenchyma\xa0appears\xa0within\xa0normal\xa0limits.\xa0\xa0The\xa0contour\xa0of\nt\nh\ne\n\xa0\nl\ni\nv\ne\nr\n\xa0\ni\ns\n\xa0smooth.\xa0\xa0There\xa0is\xa0no\xa0focal\xa0liver\xa0mass.\xa0\xa0The\xa0main\xa0portal\xa0vein\xa0is\npatent\xa0with\xa0hepatopetal\xa0flow.\xa0\xa0There\xa0is\xa0no\xa0ascites.\n\xa0\nB\nI\nL\nE\n\xa0\nD\nU\nC\nT\nS\n:\n\xa0\nT\nhere\xa0is\xa0no\xa0intrahepatic\xa0biliary\xa0dilation.\xa0\xa0The\xa0CHD\xa0measures\xa04\xa0mm.\n\xa0\nG\nA\nL\nL\nB\nL\nA\nD\nD\nE\nR\n:\n\xa0\nCholelithiasis\xa0without\xa0gallbladder\xa0wall\xa0thickening.\xa0\xa0Gallbladder\ncontains\xa0sludge.\n\xa0\nP\nA\nN\nC\nR\nE\nA\nS\n:\n\xa0\nThe\xa0imaged\xa0portion\xa0of\xa0the\xa0pancreas\xa0appears\xa0within\xa0normal\xa0limits,\nw\ni\nt\nh\no\nu\nt\n\xa0\nm\na\ns\ns\nes\xa0or\xa0pancreatic\xa0ductal\xa0dilation,\xa0with\xa0portions\xa0of\xa0the\xa0pancreatic\ntail\xa0obscured\xa0by\xa0overlying\xa0bowel\xa0gas.\n\xa0\nSPLEEN:\xa0Normal\xa0echogenicity,\xa0measuring\xa013.9\xa0cm.\n\xa0\nK\nI\nD\nN\nE\nY\nS\n:\n\xa0\nT\nh\ne\n\xa0\nright\xa0kidney\xa0measures\xa012.2\xa0cm.\xa0\xa0A\xa03.5\xa0cm\xa0simple\xa0cyst\xa0is\xa0noted\xa0at \nt\nh\ne\n\xa0\nu\np\np\ne\nr\n\xa0\npole\xa0the\xa0right\xa0kidney.\xa0\xa0There\xa0is\xa0a\xa01.8\xa0x\xa01.6\xa0cm\xa0echogenic\xa0lesion\na\nr\ni\ns\ni\nn\ng\n\xa0\nf\nr\nom\xa0the\xa0interpolar\xa0region\xa0of\xa0the\xa0right\xa0kidney.\xa0\xa0Assessment\xa0of\xa0the\nleft\xa0kidney\xa0was\xa0limited\xa0due\xa0to\xa0patient\xa0cooperation.\n\xa0\nR\nE\nT\nR\nO\nP\nE\nR\nI\nT\nO\nN\nEUM:\xa0\xa0The\xa0visualized\xa0portions\xa0of\xa0aorta\xa0and\xa0IVC\xa0are\xa0within\xa0normal\nlimits.\n\xa0\nIMPRESSION:\xa0\n\xa0\n1\n.\n\xa0\n\xa0\nN\no\n\xa0\nfindings\xa0to\xa0explain\xa0the\xa0patient's\xa0elevated\xa0alkaline-phosphatase.\n2\n.\n\xa0\n\xa0\nRe-demonstrated\xa0solid\xa0lesion\xa0in\xa0the\xa0right\xa0kidney,\xa0concerning\xa0for\nmalignancy.\n\xa0\n\n___:\nEXAMINATION:\xa0\xa0CHEST\xa0(PORTABLE\xa0AP)\n\xa0\nCompared\xa0to\xa0chest\xa0radiographs\xa0___.\n\xa0\nP\nulmonary\xa0vascular\xa0congestion\xa0and\xa0early\xa0pulmonary\xa0edema\xa0are\xa0new.\xa0\nLeft\xa0lower \nl\no\nb\ne\xa0aeration\xa0has\xa0decreased,\xa0either\xa0atelectasis\xa0or\xa0early\xa0pneumonia,\nc\no\nn\nc\ne\ni\nv\na\nb\nl\ny\xa0aspiration.\xa0\xa0Second\xa0region\xa0of\xa0persistent\xa0consolidation\xa0in\xa0the\nr\ni\ng\nh\nt\xa0lower\xa0lung\xa0is\xa0atelectasis\xa0or\xa0pneumonia\xa0in\xa0the\xa0middle\xa0lobe.\xa0\xa0Heart\xa0\nsize \nt\no\np-\nn\no\nrmal.\xa0\xa0Small\xa0left\xa0pleural\xa0effusion\xa0is\xa0likely.\xa0\xa0No\xa0pneumothorax.\n\xa0\nPortable Abdomen X-ray\n___:\n\nFINDINGS:\xa0\n\xa0\nT\nh\ne\nr\ne\n\xa0\na\nr\ne\n\xa0\nno\xa0abnormally\xa0dilated\xa0loops\xa0of\xa0large\xa0or\xa0small\xa0bowel.\xa0\xa0There\xa0is\xa0a\nm\no\nd\ne\nr\na\nt\ne\n\xa0\nto\xa0large\xa0amount\xa0of\xa0stool\xa0throughout\xa0the\xa0colon,\xa0predominantly\xa0in\xa0\nthe transverse\xa0colon\xa0and\xa0rectum.\nS\nu\npine\xa0assessment\xa0limits\xa0detection\xa0for\xa0free\xa0air;\xa0there\xa0is\xa0no\xa0gross\npneumoperitoneum.\nOsseous\xa0structures\xa0are\xa0unremarkable.\nT\nh\ne\nr\ne\n\xa0\na\nr\ne\n\xa0\nno\xa0unexplained\xa0soft\xa0tissue\xa0calcifications\xa0or\xa0radiopaque\xa0foreign\nbodies.\n\xa0\nIMPRESSION:\xa0\n\xa0\nModerate\xa0stool\xa0burden\xa0throughout\xa0the\xa0colon.\nASSESSMENT & PLAN: ___ h/o Bipolar d/o, ___ disease, \nmultiple recent admissions for AMS thought to be \nmedication/psych induced admitted with hypernatremia, worsening \nencephalopathy, enterococcus UTI. Course c/b aspiration PNA, \nhypercalcemia, catatonia. \n. \n\nACTIVE ISSUES\n=============\n#Toxic metabolic encephalopathy\n#Catatonia\nMr. ___ initial course during this hospitalization was \ncharacterized by a non-verbal, non-responsive state. This was \nattributed to del___ compounded by catatonia (underlying \n___ and underlying psychiatric illness and exacerbated \nby urosepsis, aspiration PNA, hypernatremia (Na 164), \nhypercalcemia (Ca ___, alb 3.9). \n His electrolyte abnormalities were corrected with IV fluids \nand his UTI/pneumonia were treated with antibiotics. His course \nimproved somewhat with treatment of these issues, however, he \ncontinued to have ongoing somnolence and inattention - which was \nsignificantly worse than baseline (reportedly ambulatory, \ninteractive, alert/oriented, but speaks with slurred speech). \nPsychiatry and neurology were consulted - and the thought was \nthat he had signs of catatonia vs. hypoactive delirium. EEG was \ndone - and revealed no signs of seizure. A recent brain MRI last \nmonth was without focal abnl (mod brain atrophy) and CVA or \nmeningitis was considered unlikely based on exam and clinical \ncourse.\n Ultimately, the cause of his encephalopathy was unclear, but \nwas attributed to a multitude of factors: possibly meds \n(Depakote), underlying dementia ___ Body) w/exacerbation from \npast Seroquel use, primary hyperparathyroidism (hypercalcemia), \nor residual emotional stressors from mother's death (___). He \nwas treated with lorazepam (for catatonia) with improvement - \nand should be continued on day of discharge until outpt \nneuro/psych follow-up. Valproic acid was weaned off, and he was \ngiven TF via NG tube temporarily for nutrition - with gradual \nimprovement. By the time of discharge, he was oriented to \nperson/place, and interactive. \n\n# BIPOLAR DISORDER/PSYCH: held divalproex, fluoxetine, \nclonazepam, and quetiapine on arrival to FICU in setting of AMS. \nDivalproex and fluoxetine restarted on transfer to the floor. \nFluoxetine was then discontinued after it was titrated down from \n40 mg to 20 mg. As above, he was started on Lorazepam .5 mg q6 \nfor catatonia. ECT was considered but ultimately not performed \ndue to his steady improvement. \n\n# HYPERNATREMIA: Suspect that AMS led to decreased PO intake in \naddition to insensible losses secondary to fevers. Free water \ndeficit estimated to be 8L and received NS in the ED and \ntransitioned to D5W in the FICU to replenish free water deficit. \nOn arrival to the ED, Na was 164, and during her FICU stay, Na \ndowntrended toward within normal limits with noticeable \nimprovement in his mental status. He was continued on \nintermittent D5W at 75 cc/hr with resolution of hypernatremia on \nthe floor. \n\n# Sepsis\n# Enterococcal UTI: Given his high risk of aspiration pneumonia, \nAMS, leukocytosis of 29, and fever, he was started on broad \nspectrum antibiotics with vancomycin and ceftaz. However, CXR \nwas unremarkable for infiltrate. U/A did have few bacteria in \naddition to 11 WBC and preliminary urine culture was positive \nfor enterococcus. Given higher concern for UTI and low suspicion \nfor pneumonia, ceftaz was discontinued and vancomycin was \ncontinued for enterococcus coverage. He was transitioned to \nampicillin on the floor based on urine culture sensitivities \nwith a course from ___. \n\n#Heme:\nMacrocytic anemia: He has a known history of MDS with \n___ H/H likely in setting of hemoconcentration on \nadmission. Work-up notable for low retic count with normal iron \nand no e/o hemolysis. Low retic suggests possible contribution \nfrom MDS. \n___ guardian and obtained consent for transfusion. Given 1 \nunit PRBC on ___. SPEP/UPEP was negative. UPEP with albumin \nnoted, can order further albumin/creatinine ratio as outpatient. \nWill need f/u with hematology/oncology as outpatient. \n\n#RENAL CELL CARCINOMA SUSPECTED BASED ON IMAGING \n[]F/U WITH UROLOGY FOR SUSPECTED RENAL CELL CARCINOMA SEEN ON CT \nABDOMEN ___\n 2.2 cm hypoenhancing mass in the inferior pole of the right \nkidney, concerning \nfor RCC. There is no evidence of vascular involvement or \ndefinite metastatic \ndisease within the abdomen and pelvis.\nI communicated these results to the guardian who is aware of \nthese results. \n \n\n# ACUTE KIDNEY INJURY: Cr elevated to 1.6 on admission; baseline \nCr 0.8-1.0. Suspect related to sepsis and free water deficit. Cr \nimproved to baseline with fluids. \n\n# HYPERCALCEMIA: Hypercalcemia ___ PTH, dehydration. ON \nadmission, his labs were notable for Ca ___, alb 3.9, ionized \n1.55. Other workup labs included the following: PTH 117, VitD \n37, 24hr urine CA 225. This was consistent with primary \nhyperparathyroidism (which was documented on past studies with \nevidence of PTH adenoma in the R inf lobe of the thyroid). To \nrule out other etiologies: SPEP, rPTH (given likely presence of \nRCC) were sent and were unremarkable. Ultimately to address the \nhypercalcemia, he received Pamidronate 30 mg IV x1 on ___. \nHe was continued on daily Vit D for PTH suppression. Short term \nCalcinet may be considered if no acute normalization of Ca.\n Ultimately, he will likely require surgery for \nhyperparathyroidism. The endocrinologist was updated the \nresults (above) and the guardian was also notified of the need \nfor eventual surgery in the future. \n\nURINARY RETENTION: ON TAMSULOSIN AS OUTPATIENT, required \nstraight cath for urinary retention started ___\n[]straight cath q6h\n\n#Elevated alk phos: GGT elevated. Alk phos trending down, \npatient with history of hyperparathyroidism as well which may be \ncontributing. RUQ ultrasound with no acute abnormalities. \nContinue to trend, on discharge alk phos was 131. RCC noted on \nRUQ ultrasound on ___, redemonstrated solid lesion in the \nright kidney, concerning for malignancy. Spoke to urology \nregarding outpatient follow-up in this case, no further imaging \nwas needed during current hospitalization. He should follow up \nwith urology as an outpt. \n\n#Concern for Aspiration Pneumonia: Started on Unasyn on ___ \ngiven concern for leukocytosis and aspiration on CXR. Completed \na 7 day course. \n\n#FEN: consulted speech/swallow given concern for aspiration \nrisk, Full liquids only given mental status waxing/waning, \nEnsure shakes. With improved mental status, re-evaluation was \nperformed by Speech path on ___. It revealed no bedside \nspiration, but delayed swallow onset with poor oral bolus \nformation and manipulation & impaired mastication. As a result, \nhis diet was advanced to Pureed diet with nectar thick liquids. \nHe was encouraged to increase PO intake, Ensure supplementation. \n He will likely benefit from video swallow in near future (but \nonce more alert). Given his steady improvement, difficulty with \nmaintain NG tube (and requirement of simultaneous restraints), \nplacement of NG tube was held off in the latter portion of his \nhospitalization. \n\nCHRONIC ISSUES:\n===============\n# ___ DISEASE: continued home carbidopa-levodopa, \ninitially through NGT due to altered mental status, unclear if \npatient's ___ symptoms were result of prior history of \nantipsychotics or if he truly had Parkinsons. \n\n# HYPERTENSION: held lisinopril in setting of likely sepsis. \n\n# VERTIGO: held home regimen of meclizine in setting of AMS\n\n# BENIGN PROSTATIC HYPERTROPHY: held tamsulosin in setting of \nlikely sepsis. \n\n#CORE MEASURES: \n# FEN: ___ NS with speech/swallow and full liquids\n# Prophylaxis: HSQ\n# Access: PIV\n# ___ (legal guardian) ___, \nhome phone/cell phone ___\n# Code: Full \n\nTRANSITIONAL ISSUES:\n[]F/U WITH UROLOGY FOR SUSPECTED RENAL CELL CARCINOMA SEEN ON CT \nABDOMEN ___\n \n2.2 cm hypoenhancing mass in the inferior pole of the right \nkidney, concerning \nfor RCC. There is no evidence of vascular involvement or \ndefinite metastatic \ndisease within the abdomen and pelvis. \n \n0.8 cm well-circumscribed cyst in the pancreatic tail, MRI/MRCP \nin ___ year \nrecommended in further evaluation. \n\n[]F/U WITH REPEAT MRCP IN ___ YEARS TIME FOR PANCREATIC CYST"}} | {'final_diagnoses': ['Enterococcal Urinary Tract Infection', 'Aspiration pneumonia', 'Hypernatremia', 'Hypercalcemia', 'Catatonia', 'Anemia', '___ disease'], 'procedures': ['None'], 'visit_summary': "ASSESSMENT & PLAN: ___ h/o Bipolar d/o, ___ disease, \nmultiple recent admissions for AMS thought to be \nmedication/psych induced admitted with hypernatremia, worsening \nencephalopathy, enterococcus UTI. Course c/b aspiration PNA, \nhypercalcemia, catatonia. \n. \n\nACTIVE ISSUES\n=============\n#Toxic metabolic encephalopathy\n#Catatonia\nMr. ___ initial course during this hospitalization was \ncharacterized by a non-verbal, non-responsive state. This was \nattributed to del___ compounded by catatonia (underlying \n___ and underlying psychiatric illness and exacerbated \nby urosepsis, aspiration PNA, hypernatremia (Na 164), \nhypercalcemia (Ca ___, alb 3.9). \n His electrolyte abnormalities were corrected with IV fluids \nand his UTI/pneumonia were treated with antibiotics. His course \nimproved somewhat with treatment of these issues, however, he \ncontinued to have ongoing somnolence and inattention - which was \nsignificantly worse than baseline (reportedly ambulatory, \ninteractive, alert/oriented, but speaks with slurred speech). \nPsychiatry and neurology were consulted - and the thought was \nthat he had signs of catatonia vs. hypoactive delirium. EEG was \ndone - and revealed no signs of seizure. A recent brain MRI last \nmonth was without focal abnl (mod brain atrophy) and CVA or \nmeningitis was considered unlikely based on exam and clinical \ncourse.\n Ultimately, the cause of his encephalopathy was unclear, but \nwas attributed to a multitude of factors: possibly meds \n(Depakote), underlying dementia ___ Body) w/exacerbation from \npast Seroquel use, primary hyperparathyroidism (hypercalcemia), \nor residual emotional stressors from mother's death (___). He \nwas treated with lorazepam (for catatonia) with improvement - \nand should be continued on day of discharge until outpt \nneuro/psych follow-up. Valproic acid was weaned off, and he was \ngiven TF via NG tube temporarily for nutrition - with gradual \nimprovement. By the time of discharge, he was oriented to \nperson/place, and interactive. \n\n# BIPOLAR DISORDER/PSYCH: held divalproex, fluoxetine, \nclonazepam, and quetiapine on arrival to FICU in setting of AMS. \nDivalproex and fluoxetine restarted on transfer to the floor. \nFluoxetine was then discontinued after it was titrated down from \n40 mg to 20 mg. As above, he was started on Lorazepam .5 mg q6 \nfor catatonia. ECT was considered but ultimately not performed \ndue to his steady improvement. \n\n# HYPERNATREMIA: Suspect that AMS led to decreased PO intake in \naddition to insensible losses secondary to fevers. Free water \ndeficit estimated to be 8L and received NS in the ED and \ntransitioned to D5W in the FICU to replenish free water deficit. \nOn arrival to the ED, Na was 164, and during her FICU stay, Na \ndowntrended toward within normal limits with noticeable \nimprovement in his mental status. He was continued on \nintermittent D5W at 75 cc/hr with resolution of hypernatremia on \nthe floor. \n\n# Sepsis\n# Enterococcal UTI: Given his high risk of aspiration pneumonia, \nAMS, leukocytosis of 29, and fever, he was started on broad \nspectrum antibiotics with vancomycin and ceftaz. However, CXR \nwas unremarkable for infiltrate. U/A did have few bacteria in \naddition to 11 WBC and preliminary urine culture was positive \nfor enterococcus. Given higher concern for UTI and low suspicion \nfor pneumonia, ceftaz was discontinued and vancomycin was \ncontinued for enterococcus coverage. He was transitioned to \nampicillin on the floor based on urine culture sensitivities \nwith a course from ___. \n\n#Heme:\nMacrocytic anemia: He has a known history of MDS with \n___ H/H likely in setting of hemoconcentration on \nadmission. Work-up notable for low retic count with normal iron \nand no e/o hemolysis. Low retic suggests possible contribution \nfrom MDS. \n___ guardian and obtained consent for transfusion. Given 1 \nunit PRBC on ___. SPEP/UPEP was negative. UPEP with albumin \nnoted, can order further albumin/creatinine ratio as outpatient. \nWill need f/u with hematology/oncology as outpatient. \n\n#RENAL CELL CARCINOMA SUSPECTED BASED ON IMAGING \n[]F/U WITH UROLOGY FOR SUSPECTED RENAL CELL CARCINOMA SEEN ON CT \nABDOMEN ___\n 2.2 cm hypoenhancing mass in the inferior pole of the right \nkidney, concerning \nfor RCC. There is no evidence of vascular involvement or \ndefinite metastatic \ndisease within the abdomen and pelvis.\nI communicated these results to the guardian who is aware of \nthese results. \n \n\n# ACUTE KIDNEY INJURY: Cr elevated to 1.6 on admission; baseline \nCr 0.8-1.0. Suspect related to sepsis and free water deficit. Cr \nimproved to baseline with fluids. \n\n# HYPERCALCEMIA: Hypercalcemia ___ PTH, dehydration. ON \nadmission, his labs were notable for Ca ___, alb 3.9, ionized \n1.55. Other workup labs included the following: PTH 117, VitD \n37, 24hr urine CA 225. This was consistent with primary \nhyperparathyroidism (which was documented on past studies with \nevidence of PTH adenoma in the R inf lobe of the thyroid). To \nrule out other etiologies: SPEP, rPTH (given likely presence of \nRCC) were sent and were unremarkable. Ultimately to address the \nhypercalcemia, he received Pamidronate 30 mg IV x1 on ___. \nHe was continued on daily Vit D for PTH suppression. Short term \nCalcinet may be considered if no acute normalization of Ca.\n Ultimately, he will likely require surgery for \nhyperparathyroidism. The endocrinologist was updated the \nresults (above) and the guardian was also notified of the need \nfor eventual surgery in the future. \n\nURINARY RETENTION: ON TAMSULOSIN AS OUTPATIENT, required \nstraight cath for urinary retention started ___\n[]straight cath q6h\n\n#Elevated alk phos: GGT elevated. Alk phos trending down, \npatient with history of hyperparathyroidism as well which may be \ncontributing. RUQ ultrasound with no acute abnormalities. \nContinue to trend, on discharge alk phos was 131. RCC noted on \nRUQ ultrasound on ___, redemonstrated solid lesion in the \nright kidney, concerning for malignancy. Spoke to urology \nregarding outpatient follow-up in this case, no further imaging \nwas needed during current hospitalization. He should follow up \nwith urology as an outpt. \n\n#Concern for Aspiration Pneumonia: Started on Unasyn on ___ \ngiven concern for leukocytosis and aspiration on CXR. Completed \na 7 day course. \n\n#FEN: consulted speech/swallow given concern for aspiration \nrisk, Full liquids only given mental status waxing/waning, \nEnsure shakes. With improved mental status, re-evaluation was \nperformed by Speech path on ___. It revealed no bedside \nspiration, but delayed swallow onset with poor oral bolus \nformation and manipulation & impaired mastication. As a result, \nhis diet was advanced to Pureed diet with nectar thick liquids. \nHe was encouraged to increase PO intake, Ensure supplementation. \n He will likely benefit from video swallow in near future (but \nonce more alert). Given his steady improvement, difficulty with \nmaintain NG tube (and requirement of simultaneous restraints), \nplacement of NG tube was held off in the latter portion of his \nhospitalization. \n\nCHRONIC ISSUES:\n===============\n# ___ DISEASE: continued home carbidopa-levodopa, \ninitially through NGT due to altered mental status, unclear if \npatient's ___ symptoms were result of prior history of \nantipsychotics or if he truly had Parkinsons. \n\n# HYPERTENSION: held lisinopril in setting of likely sepsis. \n\n# VERTIGO: held home regimen of meclizine in setting of AMS\n\n# BENIGN PROSTATIC HYPERTROPHY: held tamsulosin in setting of \nlikely sepsis. \n\n#CORE MEASURES: \n# FEN: ___ NS with speech/swallow and full liquids\n# Prophylaxis: HSQ\n# Access: PIV\n# ___ (legal guardian) ___, \nhome phone/cell phone ___\n# Code: Full \n\nTRANSITIONAL ISSUES:\n[]F/U WITH UROLOGY FOR SUSPECTED RENAL CELL CARCINOMA SEEN ON CT \nABDOMEN ___\n \n2.2 cm hypoenhancing mass in the inferior pole of the right \nkidney, concerning \nfor RCC. There is no evidence of vascular involvement or \ndefinite metastatic \ndisease within the abdomen and pelvis. \n \n0.8 cm well-circumscribed cyst in the pancreatic tail, MRI/MRCP \nin ___ year \nrecommended in further evaluation. \n\n[]F/U WITH REPEAT MRCP IN ___ YEARS TIME FOR PANCREATIC CYST", 'medications_prescribed': ['1. Aspirin 81 mg PO DAILY', '2. Carbidopa-Levodopa (___) 1.5 TAB PO QAM', '3. Carbidopa-Levodopa (___) 1.5 TAB PO NOON', '4. Carbidopa-Levodopa (___) 1 TAB PO QPM', '5. Divalproex (DELayed Release) 250 mg PO QHS', '6. Docusate Sodium 100 mg PO BID:PRN constipation', '7. FLUoxetine 40 mg PO DAILY', '8. Lisinopril 10 mg PO DAILY', '9. Meclizine 12.5 mg PO Q12H:PRN vertigo', '10. Tamsulosin 0.4 mg PO QHS', '11. Vitamin D ___ UNIT PO 1X/WEEK (___)', '12. Lidocaine Jelly 2% (Urojet) 1 Appl TP DAILY:PRN straight \ncath']} |
Generate a treatment plan with clinical reasoning for this case: | {'patient_profile': {'age': 32, 'gender': 'F', 'symptoms': 'behavioral problems', 'medical_history': ['1. Schizophprenia vs schizoaffective disorder-manic type: Last \nhospitalization was a few weeks ago at ___ for \naggressive behavior at ___. Psychiatrist: \nDr ___ at ___ ___ per OMR.', '2. Diabetes mellitus type II', '3. Hypertension', '4. Dyslipidemia', '5. Chronic systolic dysfunction: EF 35-40%', '6. Mental retardation s/p injury from boxing', '7. Chronic right shoulder pain', '8. T-spine fracture'], 'family_history': 'Non-contributory', 'present_illness': 'Mr. ___ is a ___ year-old ___ speaking man with a history \nof schizophrenia and recent T10 fracture who presents with back \nand chest pain. \n. \nRecently admitted (___) for dizziness. This was felt to \nbe from volume depletion with a possible contribution from his \npneumonia. During this admission, his hydrochlorothiazide / \ntriamterene was discontinued. A pneumonia was treated with 5 \ndays of Levaquin. \n. \nRepresented to the ___ ED on ___ with threatening behaviour \ntowards a client in his group home. He was discharged on ___ \nfrom the ED. \n. \nPatient then admitted to ___ after a fall in the shower \nwhile at ___. Per the discharge summary, a CT \nscan showed an apparently old right shoulder fracture and a new \nT10 fracture. Neurosurgery recommended conservative management \nwith a TLSO brace. His pain was treated with morphine initially, \nchanged to Tramadol and Toradol on discharge. For work-up of the \nfall, an echo was done and show showed an EF of 60% and he was \nruled-out by enzymes. ___ for rehab on ___. \n. \nPer psychiatry note, on the day of admission, patient was sent \nto ___ from ___ for combative behavior. Psychiatry \ncontacted ___ and per their note: "the nursing staff \non the ___ floor reported that the patient had been \'combative \nwith care\' and a \'fall risk\'. When prompted to stay in bed so as \nto not fall the patient would ignore the staff and walk anyway. \nThe staff report that the patient was a danger to himself while \nat the ___ because he would require a 1:1 and they \ncannot provide that because \'this is not a psychiatric unit\'. \nThe patient was also not cooperating with his need to wear a \nbrace for his thoracic spine fracture." \n. \nIn speaking with the patient via interpreter phone, he complains \nof back pain, chest pain and heart pain. The pain in his back \nhas been since his fall and the chest pain has been going on for \nsome time. He is vague with timing and generally perseverates on \nthe pain and is unable to provide much in the way of history. It \nis his understanding that he was admitted for a physical exam of \nthe whole body. \n. \nIn the ED, T 99.9, BP 142/64, HR 88, RR 20, 95% on room air. He \nwas given aspirin 325mg and 6 units of regular insulin.', 'medications': [{'medication': 'Sodium Chloride 0.9% Flush', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'IV', 'frequency': 'Q8H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Albumin 25% (12.5g / 50mL)', 'proc_type': 'Unit Dose', 'status': 'Expired', 'route': 'IV', 'frequency': 'ONCE', 'doses_per_24_hrs': 1.0}, {'medication': 'FoLIC Acid', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Lorazepam', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'Q8H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Thiamine', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Nicotine Patch', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'TD', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Multivitamins', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}, {'medication': 'Amitriptyline', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'HS', 'doses_per_24_hrs': 1.0}, {'medication': 'OxycoDONE (Immediate Release) ', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'Q6H:PRN', 'doses_per_24_hrs': None}, {'medication': 'Lactulose', 'proc_type': 'Unit Dose', 'status': 'Discontinued via patient discharge', 'route': 'PO/NG', 'frequency': 'DAILY', 'doses_per_24_hrs': 1.0}]}, 'clinical_findings': {'labs': [{'value': '0.3', 'valuenum': 0.3, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 2.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '1.2', 'valuenum': 1.2, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 4.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '34.1', 'valuenum': 34.1, 'valueuom': '%', 'ref_range_lower': 36.0, 'ref_range_upper': 48.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '11.0', 'valuenum': 11.0, 'valueuom': 'g/dL', 'ref_range_lower': 12.0, 'ref_range_upper': 16.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '14.8', 'valuenum': 14.8, 'valueuom': '%', 'ref_range_lower': 18.0, 'ref_range_upper': 42.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '33.9', 'valuenum': 33.9, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '32.3', 'valuenum': 32.3, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '105', 'valuenum': 105.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '6.1', 'valuenum': 6.1, 'valueuom': '%', 'ref_range_lower': 2.0, 'ref_range_upper': 11.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '77.5', 'valuenum': 77.5, 'valueuom': '%', 'ref_range_lower': 50.0, 'ref_range_upper': 70.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '198', 'valuenum': 198.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '14.0', 'valuenum': 14.0, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '3.25', 'valuenum': 3.25, 'valueuom': 'm/uL', 'ref_range_lower': 4.2, 'ref_range_upper': 5.4, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '17.9', 'valuenum': 17.9, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '1.9', 'valuenum': 1.9, 'valueuom': None, 'ref_range_lower': 0.9, 'ref_range_upper': 1.1, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '20.9', 'valuenum': 20.9, 'valueuom': 'sec', 'ref_range_lower': 10.4, 'ref_range_upper': 13.4, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '39.3', 'valuenum': 39.3, 'valueuom': 'sec', 'ref_range_lower': 22.0, 'ref_range_upper': 35.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '33', 'valuenum': 33.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.7', 'valuenum': 2.7, 'valueuom': 'g/dL', 'ref_range_lower': 3.5, 'ref_range_upper': 5.2, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '186', 'valuenum': 186.0, 'valueuom': 'IU/L', 'ref_range_lower': 35.0, 'ref_range_upper': 105.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '13', 'valuenum': 13.0, 'valueuom': 'mEq/L', 'ref_range_lower': 8.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '124', 'valuenum': 124.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '27', 'valuenum': 27.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.4', 'valuenum': 2.4, 'valueuom': 'mg/dL', 'ref_range_lower': 0.0, 'ref_range_upper': 1.5, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '93', 'valuenum': 93.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '0.5', 'valuenum': 0.5, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': "Using this patient's age, gender, and serum creatinine value of 0.5,. Estimated GFR = >75 if non African-American (mL/min/1.73 m2). Estimated GFR = >75 if African-American (mL/min/1.73 m2). For comparison, mean GFR for age group 30-39 is 107 (mL/min/1.73 m2). GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure."}, {'value': '___', 'valuenum': 133.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 100.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': 'IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES.'}, {'value': '51', 'valuenum': 51.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 60.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '3.8', 'valuenum': 3.8, 'valueuom': 'mEq/L', 'ref_range_lower': 3.3, 'ref_range_upper': 5.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '129', 'valuenum': 129.0, 'valueuom': 'mEq/L', 'ref_range_lower': 133.0, 'ref_range_upper': 145.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '6', 'valuenum': 6.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '___', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'HOLD.'}, {'value': 'HOLD. DISCARD GREATER THAN 4 HOURS OLD.', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': '___'}, {'value': None, 'valuenum': None, 'valueuom': 'g/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': '<1.0.'}, {'value': '42', 'valuenum': 42.0, 'valueuom': 'IU/L', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '1.1', 'valuenum': 1.1, 'valueuom': 'g/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '1', 'valuenum': 1.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '20', 'valuenum': 20.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '50', 'valuenum': 50.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '16', 'valuenum': 16.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '0', 'valuenum': 0.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '13', 'valuenum': 13.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '98', 'valuenum': 98.0, 'valueuom': '#/uL', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '52', 'valuenum': 52.0, 'valueuom': '#/uL', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '30', 'valuenum': 30.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '2.3', 'valuenum': 2.3, 'valueuom': 'g/dL', 'ref_range_lower': 3.5, 'ref_range_upper': 5.2, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '152', 'valuenum': 152.0, 'valueuom': 'IU/L', 'ref_range_lower': 35.0, 'ref_range_upper': 105.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '10', 'valuenum': 10.0, 'valueuom': 'mEq/L', 'ref_range_lower': 8.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '149', 'valuenum': 149.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '28', 'valuenum': 28.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '2.7', 'valuenum': 2.7, 'valueuom': 'mg/dL', 'ref_range_lower': 0.0, 'ref_range_upper': 1.5, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '7.4', 'valuenum': 7.4, 'valueuom': 'mg/dL', 'ref_range_lower': 8.4, 'ref_range_upper': 10.3, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '96', 'valuenum': 96.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '0.4', 'valuenum': 0.4, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '___', 'valuenum': 104.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 100.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': 'IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES.'}, {'value': '___', 'valuenum': 271.0, 'valueuom': 'IU/L', 'ref_range_lower': 94.0, 'ref_range_upper': 250.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': 'SPECIMEN SLIGHTLY HEMOLYZED. HEMOLYSIS FALSELY ELEVATES LDH..'}, {'value': '2.0', 'valuenum': 2.0, 'valueuom': 'mg/dL', 'ref_range_lower': 1.6, 'ref_range_upper': 2.6, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '3.8', 'valuenum': 3.8, 'valueuom': 'mg/dL', 'ref_range_lower': 2.7, 'ref_range_upper': 4.5, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '4.3', 'valuenum': 4.3, 'valueuom': 'mEq/L', 'ref_range_lower': 3.3, 'ref_range_upper': 5.1, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '130', 'valuenum': 130.0, 'valueuom': 'mEq/L', 'ref_range_lower': 133.0, 'ref_range_upper': 145.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '8', 'valuenum': 8.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '2.1', 'valuenum': 2.1, 'valueuom': None, 'ref_range_lower': 0.9, 'ref_range_upper': 1.1, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '22.0', 'valuenum': 22.0, 'valueuom': 'sec', 'ref_range_lower': 10.4, 'ref_range_upper': 13.4, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '42.2', 'valuenum': 42.2, 'valueuom': 'sec', 'ref_range_lower': 22.0, 'ref_range_upper': 35.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '29.9', 'valuenum': 29.9, 'valueuom': '%', 'ref_range_lower': 36.0, 'ref_range_upper': 48.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '9.7', 'valuenum': 9.7, 'valueuom': 'g/dL', 'ref_range_lower': 12.0, 'ref_range_upper': 16.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '33.3', 'valuenum': 33.3, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '32.3', 'valuenum': 32.3, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '103', 'valuenum': 103.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '196', 'valuenum': 196.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '14.1', 'valuenum': 14.1, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '2.90', 'valuenum': 2.9, 'valueuom': 'm/uL', 'ref_range_lower': 4.2, 'ref_range_upper': 5.4, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '15.5', 'valuenum': 15.5, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': 'FEW', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'SM', 'valuenum': None, 'valueuom': 'mg/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'NEG', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '11-20', 'valuenum': None, 'valueuom': '#/hpf', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'NEG', 'valuenum': None, 'valueuom': 'mg/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '0-2', 'valuenum': None, 'valueuom': '#/lpf', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'TR', 'valuenum': None, 'valueuom': 'mg/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'TR', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '6.5', 'valuenum': 6.5, 'valueuom': 'units', 'ref_range_lower': 5.0, 'ref_range_upper': 8.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '25', 'valuenum': 25.0, 'valueuom': 'mg/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '0-2', 'valuenum': None, 'valueuom': '#/hpf', 'ref_range_lower': 0.0, 'ref_range_upper': 2.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '1.024', 'valuenum': 1.024, 'valueuom': ' ', 'ref_range_lower': 1.001, 'ref_range_upper': 1.035, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'Clear', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'Amber', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'ABN COLOR MAY AFFECT DIPSTICK.'}, {'value': '0CC', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '1', 'valuenum': 1.0, 'valueuom': 'mg/dL', 'ref_range_lower': 0.2, 'ref_range_upper': 1.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '6-10', 'valuenum': None, 'valueuom': '#/hpf', 'ref_range_lower': 0.0, 'ref_range_upper': 5.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': 'NONE', 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': None, 'valuenum': None, 'valueuom': 'mEq/L', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'LESS THAN 10.'}, {'value': '190', 'valuenum': 190.0, 'valueuom': 'mg/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': 'NEG', 'valuenum': None, 'valueuom': '+/-', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'FOR QUANTITATION OF POSITIVES, SEND SERUM FOR HCG.'}, {'value': None, 'valuenum': None, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': 'RANDOM.'}, {'value': '582', 'valuenum': 582.0, 'valueuom': 'mOsm/kg', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '87', 'valuenum': 87.0, 'valueuom': 'mEq/L', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '855', 'valuenum': 855.0, 'valueuom': 'mg/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '32.1', 'valuenum': 32.1, 'valueuom': '%', 'ref_range_lower': 36.0, 'ref_range_upper': 48.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '30.2', 'valuenum': 30.2, 'valueuom': '%', 'ref_range_lower': 36.0, 'ref_range_upper': 48.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '9.9', 'valuenum': 9.9, 'valueuom': 'g/dL', 'ref_range_lower': 12.0, 'ref_range_upper': 16.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '34.1', 'valuenum': 34.1, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '32.7', 'valuenum': 32.7, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '104', 'valuenum': 104.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '146', 'valuenum': 146.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '14.0', 'valuenum': 14.0, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.90', 'valuenum': 2.9, 'valueuom': 'm/uL', 'ref_range_lower': 4.2, 'ref_range_upper': 5.4, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '13.0', 'valuenum': 13.0, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '27', 'valuenum': 27.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '2.4', 'valuenum': 2.4, 'valueuom': 'g/dL', 'ref_range_lower': 3.5, 'ref_range_upper': 5.2, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '157', 'valuenum': 157.0, 'valueuom': 'IU/L', 'ref_range_lower': 35.0, 'ref_range_upper': 105.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '13', 'valuenum': 13.0, 'valueuom': 'mEq/L', 'ref_range_lower': 8.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '115', 'valuenum': 115.0, 'valueuom': 'IU/L', 'ref_range_lower': 0.0, 'ref_range_upper': 40.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '26', 'valuenum': 26.0, 'valueuom': 'mEq/L', 'ref_range_lower': 22.0, 'ref_range_upper': 32.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '1.8', 'valuenum': 1.8, 'valueuom': 'mg/dL', 'ref_range_lower': 0.0, 'ref_range_upper': 1.5, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '95', 'valuenum': 95.0, 'valueuom': 'mEq/L', 'ref_range_lower': 96.0, 'ref_range_upper': 108.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '0.4', 'valuenum': 0.4, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '___', 'valuenum': 113.0, 'valueuom': 'mg/dL', 'ref_range_lower': 70.0, 'ref_range_upper': 100.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': 'IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES.'}, {'value': '204', 'valuenum': 204.0, 'valueuom': 'IU/L', 'ref_range_lower': 94.0, 'ref_range_upper': 250.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '4.0', 'valuenum': 4.0, 'valueuom': 'mEq/L', 'ref_range_lower': 3.3, 'ref_range_upper': 5.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '130', 'valuenum': 130.0, 'valueuom': 'mEq/L', 'ref_range_lower': 133.0, 'ref_range_upper': 145.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '7', 'valuenum': 7.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '1.9', 'valuenum': 1.9, 'valueuom': None, 'ref_range_lower': 0.9, 'ref_range_upper': 1.1, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '20.8', 'valuenum': 20.8, 'valueuom': 'sec', 'ref_range_lower': 10.4, 'ref_range_upper': 13.4, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '17', 'valuenum': 17.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '45', 'valuenum': 45.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '21', 'valuenum': 21.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '3', 'valuenum': 3.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '14', 'valuenum': 14.0, 'valueuom': '%', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '290', 'valuenum': 290.0, 'valueuom': '#/uL', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '104', 'valuenum': 104.0, 'valueuom': '#/uL', 'ref_range_lower': 0.0, 'ref_range_upper': 0.0, 'flag': 'abnormal', 'priority': 'ROUTINE', 'comments': None}, {'value': '___', 'valuenum': 596.0, 'valueuom': 'mg/24hr', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': 'REFERENCE RANGE -- ROUGHLY 1000 MG/DAY [MEN 20 MG/KG, WOMEN 15 MG/KG].'}, {'value': '149', 'valuenum': 149.0, 'valueuom': 'mg/dL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '24', 'valuenum': 24.0, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '6', 'valuenum': 6.0, 'valueuom': None, 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '400', 'valuenum': 400.0, 'valueuom': 'mL', 'ref_range_lower': None, 'ref_range_upper': None, 'flag': None, 'priority': 'ROUTINE', 'comments': None}, {'value': '30.7', 'valuenum': 30.7, 'valueuom': '%', 'ref_range_lower': 36.0, 'ref_range_upper': 48.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '10.0', 'valuenum': 10.0, 'valueuom': 'g/dL', 'ref_range_lower': 12.0, 'ref_range_upper': 16.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '33.3', 'valuenum': 33.3, 'valueuom': 'pg', 'ref_range_lower': 27.0, 'ref_range_upper': 32.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '32.5', 'valuenum': 32.5, 'valueuom': '%', 'ref_range_lower': 31.0, 'ref_range_upper': 35.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '102', 'valuenum': 102.0, 'valueuom': 'fL', 'ref_range_lower': 82.0, 'ref_range_upper': 98.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '161', 'valuenum': 161.0, 'valueuom': 'K/uL', 'ref_range_lower': 150.0, 'ref_range_upper': 440.0, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '14.0', 'valuenum': 14.0, 'valueuom': '%', 'ref_range_lower': 10.5, 'ref_range_upper': 15.5, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '3.00', 'valuenum': 3.0, 'valueuom': 'm/uL', 'ref_range_lower': 4.2, 'ref_range_upper': 5.4, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '11.1', 'valuenum': 11.1, 'valueuom': 'K/uL', 'ref_range_lower': 4.0, 'ref_range_upper': 11.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}, {'value': '0.4', 'valuenum': 0.4, 'valueuom': 'mg/dL', 'ref_range_lower': 0.4, 'ref_range_upper': 1.1, 'flag': None, 'priority': 'STAT', 'comments': None}, {'value': '5', 'valuenum': 5.0, 'valueuom': 'mg/dL', 'ref_range_lower': 6.0, 'ref_range_upper': 20.0, 'flag': 'abnormal', 'priority': 'STAT', 'comments': None}], 'exams': 'VITALS - BP 164/94 \nGEN - Lying in bed at 30 degrees. Hands behind head. Moaning. \nHEENT - Pupils equal and reactive 4mm --> 2mm. \nCV - Regular. No murmurs. \nPULM - Clear. Limited exam. \nABD - Soft. Active bowel sounds. \nEXT - Warm. No edema.', 'diagnoses': [{'icd_code': '5723', 'desc': 'Portal hypertension'}, {'icd_code': '78959', 'desc': 'Other ascites'}, {'icd_code': '2761', 'desc': 'Hyposmolality and/or hyponatremia'}, {'icd_code': '5712', 'desc': 'Alcoholic cirrhosis of liver'}, {'icd_code': '2875', 'desc': 'Thrombocytopenia, unspecified'}, {'icd_code': '5711', 'desc': 'Acute alcoholic hepatitis'}, {'icd_code': '7242', 'desc': 'Lumbago'}, {'icd_code': '33829', 'desc': 'Other chronic pain'}], 'summary': '___ 06:30PM GLUCOSE-305* UREA N-20 CREAT-0.7 SODIUM-133 \nPOTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-25 ANION GAP-16\n___ 06:30PM estGFR-Using this\n___ 06:30PM CK(CPK)-175*\n___ 06:30PM CK-MB-4 cTropnT-<0.01\n___ 06:30PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-1.9\n___ 06:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 06:30PM WBC-5.8 RBC-3.38* HGB-11.1* HCT-31.1* MCV-92 \nMCH-32.8* MCHC-35.7* RDW-13.3\n___ 06:30PM PLT COUNT-\n___ with a history of schizophrenia, hypertension, diabetes and \nrecent T10 fracture, presenting from rehab with behavioral \nproblems. \n. \nBehavioral problems: The patient was noted to have combative \nbehavior at his ___ rehabilitation facility. On \nadmission to ___ his medications were adjusted per psychiatry. \nLiberal use of the interpreter services was made and assisted \ngreatly in de-escalating the patient. At the time of discharge \nhe had been off a 1:1 sitter for greater than 48 hours.\n. \nChest pain: The patient has chronic chest pain, atypical for \nACS. He was ruled out for myocardial infarction by cardiac \nenzymes. He was continued on his home cardiac medications.\n. \nT10 fracture: The patient was encouraged to wear his brace but \nrefused. He was given oral pain medications.\n. \nSchizophprenia vs schizoaffective disorder-manic type: The \npatient was on the attached regimen of Depakote, Cogentin, \nKlonopin, Risperdal, Trazodone, Tegretol, and Haldol as directed \nby the ___ psychiatry service.\n. \nDiabetes mellitus type II: The patient was placed on an adjusted \nregimen of NPH and regular insulin. \n. \nHypertension: The patient was continuedon his home regimen of \ndiovan, carvedilol. \n.\nChronic systolic dysfunction: The patient was continued on his \nhome regimen of diovan, carvedilol. \n. \nFEN: The patient was placed on a cardiac, diabetic diet.\n.\nPPx: The patient was placed on SC heparin.'}} | {'final_diagnoses': ['Agitation', 'Schizophrenia vs shcizoaffective disorder', 'T10 fracture'], 'procedures': ['none'], 'visit_summary': '___ with a history of schizophrenia, hypertension, diabetes and \nrecent T10 fracture, presenting from rehab with behavioral \nproblems. \n. \nBehavioral problems: The patient was noted to have combative \nbehavior at his ___ rehabilitation facility. On \nadmission to ___ his medications were adjusted per psychiatry. \nLiberal use of the interpreter services was made and assisted \ngreatly in de-escalating the patient. At the time of discharge \nhe had been off a 1:1 sitter for greater than 48 hours.\n. \nChest pain: The patient has chronic chest pain, atypical for \nACS. He was ruled out for myocardial infarction by cardiac \nenzymes. He was continued on his home cardiac medications.\n. \nT10 fracture: The patient was encouraged to wear his brace but \nrefused. He was given oral pain medications.\n. \nSchizophprenia vs schizoaffective disorder-manic type: The \npatient was on the attached regimen of Depakote, Cogentin, \nKlonopin, Risperdal, Trazodone, Tegretol, and Haldol as directed \nby the ___ psychiatry service.\n. \nDiabetes mellitus type II: The patient was placed on an adjusted \nregimen of NPH and regular insulin. \n. \nHypertension: The patient was continuedon his home regimen of \ndiovan, carvedilol. \n.\nChronic systolic dysfunction: The patient was continued on his \nhome regimen of diovan, carvedilol. \n. \nFEN: The patient was placed on a cardiac, diabetic diet.\n.\nPPx: The patient was placed on SC heparin.', 'medications_prescribed': ['1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 \nhours) as needed.', '2. Benztropine 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).', '3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).', '4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times \na day).', '5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) \nTablet, Delayed Release (E.C.) PO DAILY (Daily).', '6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) \nCapsule, Delayed Release(E.C.) PO once a day.', '7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a \nday).', '8. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2 \ntimes a day).', '9. Divalproex ___ mg Tablet Sustained Release 24 hr Sig: Eight \n(8) Tablet Sustained Release 24 hr PO QHS (once a day (at \nbedtime)).', '10. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at \nbedtime).', '11. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a \nday).', '12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice \na day.', '13. Senna 8.6 mg Capsule Sig: ___ Capsules PO twice a day as \nneeded for constipation.', '14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Fifteen \n(15) units Subcutaneous three times a day: At breakfast, lunch, \nand dinner.', '15. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: \n___ (35) units Subcutaneous at bedtime.']} |
Generate a treatment plan with clinical reasoning for this case: | "{'patient_profile': {'age': 73, 'gender': 'F', 'symptoms': 's/p fall', 'medical_history': ['HTN', '(...TRUNCATED) | "{'final_diagnoses': ['s/p fall', 'Left proximal humerus fracture', 'Left tibial shaft fracture', 'R(...TRUNCATED) |
Generate a treatment plan with clinical reasoning for this case: | "{'patient_profile': {'age': 64, 'gender': 'F', 'symptoms': 'difficulty reading', 'medical_history':(...TRUNCATED) | "{'final_diagnoses': ['1. Transient Ischemic Attack (TIA)', '1. Hypertension'], 'procedures': ['none(...TRUNCATED) |
Generate a treatment plan with clinical reasoning for this case: | "{'patient_profile': {'age': 46, 'gender': 'F', 'symptoms': 'Syncope', 'medical_history': ['lung can(...TRUNCATED) | "{'final_diagnoses': ['Syncope', 'Cough'], 'procedures': ['None'], 'visit_summary': '___ yo man with(...TRUNCATED) |
Generate a treatment plan with clinical reasoning for this case: | "{'patient_profile': {'age': 55, 'gender': 'F', 'symptoms': 'Right leg pain', 'medical_history': ['h(...TRUNCATED) | "{'final_diagnoses': ['Right tibial plateau fracture'], 'procedures': ['___: ORIF Right tibial plate(...TRUNCATED) |
Generate a treatment plan with clinical reasoning for this case: | "{'patient_profile': {'age': 55, 'gender': 'F', 'symptoms': 'Fall', 'medical_history': ['1. Diabetes(...TRUNCATED) | "{'final_diagnoses': ['Dementia', 'Urinary Tract Infection', 'Hypertension', 'Bradycardia', 'Chronic(...TRUNCATED) |
End of preview. Expand
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Dataset Card for med1-instruct
Curated dataset of patient ER visits from MIMIC-IV.
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Dataset contains 119,293 visits with complete data on patient demographics, labs, pharmacy, diagnosis, procedures and discharge.
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