Coding Hint: This chart has 1 principal diagnosis, 13 secondary diagnosis codes, and 5 Z codes. In this case, the Z codes include two status heart procedure codes and three long-term drug use codes.
Discharge Diagnosis: (all present on admission)
ARF on stage 3 CKD
C. Difficile colitis
Patient Active Problem List
This patient was transferred from an outside facility where he was initially treated for acute hypoxic respiratory failure 2/2 medications and subsequently developed AKI with a creatinine of 4.6 from his baseline of 2.4-2.8. At the time of admission he was on room air and creatinine was 2.7. Echo was repeated showing EF 25-30 (which is about baseline), cyclosporine 72 and mycophenolate 0.9.
Cardiology was consulted on admission and agreed advised to restart home doses of immune suppression once levels resulted. On 6/7 his creatinine began to rise to a high of 5.6 on 6/8 and WBC increased to a high of 31. Infectious disease recommended linezolid and cefepime which was stopped 6/10. He was changed to ceftriaxone then to cipro PO for a klebsiella UTI. He denied diarrhea; however c diff resulted positive, therefore he was started on flagyl, initially IV, then switched to PO after which his WBC improved. He was given a small amount of fluids and his creatinine returned to baseline of 2.8 at discharge. Rheumatology was consulted as he has tophaceous gout (due to renal impairment) with a uric acid of 11.4. They recommended increasing prednisone to 7.5mg daily with increasing to 20mg in case of flares and adding allopurinol 100mg daily. Prior to discharge he was restarted on carvedilol which he had not been taking for quite some time.
General: alert, no distress
HEENT: Normocepahlic and atraumatic
Neck: Supple, no palpable lymphadenopathy
Pulmonary: Clear to auscultation bilaterally without any wheezing, rales, or ronchi
Cardiac: S1 S2, RRR, no rubs, murmurs, gallops
GI/Abdomen: obese, normal bowel sounds, soft, non-tender, no palpable masses. No guarding or rebound
Extremities: no edema, redness or tenderness in the calves or thighs, tophi over elbows, L wrist incision CDI
Skin: Skin color, texture, turgor normal. No rashes or lesions
Musculoskeletal: Full ROM in the bilateral upper and lower extremities. 5/5 muscle strength at the bilateral shoulder, elbow, wrist, hip, knee, and ankle joints
Neuro: CN II-XII grossly intact bilaterally w/o focal deficits
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Discharge Medication List