Patient 10001234  
Gender: Female  
Age: 68  
Race: WHITE  

Admission 30245871  
    DRGs:  
    - APR: PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE (Severity 3.0)  
    - HCFA: PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE W CC  

    Medications:  
    - Apixaban (Eliquis)  
    - Heparin IV  
    - Furosemide  
    - Metoprolol Tartrate  
    - Sodium Chloride 0.9% Flush  
    - Oxygen Therapy  
    - Acetaminophen  
    - Albuterol Inhaler  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Apixaban (Eliquis): PO, Discontinued via patient discharge  
    - Heparin IV: Continuous infusion, Discontinued via patient discharge  
    - Furosemide: PO, Discontinued via patient discharge  
    - Metoprolol Tartrate: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Oxygen Therapy: NC 2L/min, Discontinued via patient discharge  
    - Acetaminophen: PO/NG, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - CT Pulmonary Angiography  
    - Lower Extremity Venous Doppler Ultrasound  

---

Admission 30984212  
    DRGs:  
    - APR: RECURRENT PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE (Severity 4.0)  
    - HCFA: PULMONARY EMBOLISM REQUIRING THROMBOLYSIS  

    Medications:  
    - Alteplase (tPA)  
    - Unfractionated Heparin  
    - Apixaban (Eliquis)  
    - Sodium Chloride 0.9% Flush  
    - Ondansetron  
    - Acetaminophen  
    - Metoprolol Tartrate  
    - Oxygen Therapy  

    Orders:  
    - Alteplase (tPA): IV bolus + infusion, Completed  
    - Unfractionated Heparin: IV infusion, Discontinued via patient discharge  
    - Apixaban: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO/NG, Discontinued via patient discharge  
    - Metoprolol Tartrate: PO, Discontinued via patient discharge  
    - Oxygen Therapy: NC 4L/min, Discontinued via patient discharge  
    
    Procedures:  
    - Systemic Thrombolysis with Alteplase  
    - Repeat CT Pulmonary Angiography  
    - Echocardiogram for right ventricular strain  

Patient 20001234  
Gender: Male  
Age: 74  
Race: BLACK/AFRICAN AMERICAN  

Admission 31274590  
    DRGs:  
    - APR: PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE (Severity 2.0)  
    - HCFA: PULMONARY EMBOLISM W/O ACUTE COR PULMONALE, NO MCC  
    Medications:  
    - Rivaroxaban (Xarelto)  
    - Enoxaparin (Lovenox)  
    - Aspirin 81mg  
    - Atorvastatin  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Ondansetron  
    - Oxygen Therapy (PRN)  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Rivaroxaban (Xarelto): PO, Discontinued via patient discharge  
    - Enoxaparin (Lovenox): SC, Discontinued after initiation of Rivaroxaban  
    - Aspirin 81mg: PO, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Oxygen Therapy: NC 2L/min, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - CT Pulmonary Angiography  
    - Bilateral Lower Extremity Venous Doppler Ultrasound  

---

Admission 31825644  
    DRGs:  
    - APR: PULMONARY EMBOLISM, READMISSION WITHOUT ACUTE COR PULMONALE (Severity 3.0)  
    - HCFA: RECURRENT PULMONARY EMBOLISM REQUIRING INTENSIVE ANTICOAGULATION  

    Medications:  
    - Dabigatran (Pradaxa)  
    - Heparin IV  
    - Sodium Chloride 0.9% Flush  
    - Metoprolol Succinate  
    - Acetaminophen  
    - Ondansetron  
    - Albuterol Inhaler  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Dabigatran (Pradaxa): PO, Discontinued via patient discharge  
    - Heparin IV: Continuous infusion, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Metoprolol Succinate: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Repeat CT Pulmonary Angiography  
    - Echocardiogram to assess right heart function  

Patient 30001234 
Gender: Female  
Age: 59  
Race: WHITE  

Admission 32145788  
    DRGs:  
    - APR: SEPTIC PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE (Severity 4.0)  
    - HCFA: PULMONARY EMBOLISM W SEPSIS, W CC  

    Medications:  
    - Piperacillin-Tazobactam (Zosyn)  
    - Vancomycin IV  
    - Heparin IV Drip  
    - Rivaroxaban (Xarelto)  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Ondansetron  
    - Norepinephrine IV (for hypotension)  
    - Albuterol Inhaler  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Piperacillin-Tazobactam: IV Q6H, Discontinued via patient discharge  
    - Vancomycin: IV Q12H, Discontinued via patient discharge  
    - Heparin Drip: IV infusion, Transitioned to Rivaroxaban  
    - Rivaroxaban: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Norepinephrine: IV infusion, Discontinued prior to discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - CT Pulmonary Angiography  
    - Transthoracic Echocardiogram (to rule out right heart strain and endocarditis)  
    - Blood Cultures x2  
    - Peripherally Inserted Central Catheter (PICC) line placement  

---

Admission 32987124  
    DRGs:  
    - APR: RECURRENT SEPTIC PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE (Severity 4.0)  
    - HCFA: PULMONARY EMBOLISM W SEPSIS REQUIRING PROLONGED IV ANTIBIOTICS  

    Medications:  
    - Meropenem  
    - Linezolid  
    - Heparin IV Drip  
    - Apixaban (Eliquis)  
    - Sodium Chloride 0.9% Flush  
    - Ondansetron  
    - Acetaminophen  
    - Albuterol Nebulizer  

    Orders:  
    - Meropenem: IV Q8H, Discontinued via patient discharge  
    - Linezolid: PO BID, Discontinued via patient discharge  
    - Heparin Drip: IV infusion, Transitioned to Apixaban  
    - Apixaban (Eliquis): PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO/NG, Discontinued via patient discharge  
    - Albuterol Nebulizer: IH, Discontinued via patient discharge  

    Procedures:  
    - Repeat CT Pulmonary Angiography  
    - Transesophageal Echocardiogram (TEE) to evaluate for endocarditis  
    - Central Venous Catheter Placement  
    - Bronchoscopy with BAL (bronchoalveolar lavage)  

Patient 40001234 
Gender: Female  
Age: 66  
Race: WHITE  

Admission 32741902  
    DRGs:  
    - APR: ACUTE VENOUS THROMBOEMBOLISM OF LOWER EXTREMITY (Severity 3.0)  
    - HCFA: ACUTE DVT OF LOWER EXTREMITY W CC  

    Medications:  
    - Enoxaparin (Lovenox)  
    - Warfarin  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Ondansetron  
    - Influenza Vaccine Quadrivalent  
    - Atorvastatin  
    - Omeprazole  
    - Bisacodyl  
    - Albuterol Inhaler  

    Orders:  
    - Enoxaparin (Lovenox): SC, Discontinued via patient discharge  
    - Warfarin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Omeprazole: PO, Discontinued via patient discharge  
    - Bisacodyl: PO, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, Discontinued via patient discharge  

    Procedures:  
    - Bilateral Lower Extremity Venous Doppler Ultrasound  
    - INR Monitoring for Warfarin Adjustment  

---

Admission 33452781  
    DRGs:  
    - APR: RECURRENT DEEP VEIN THROMBOSIS WITH EXTENSIVE CLOT BURDEN (Severity 4.0)  
    - HCFA: COMPLICATED VENOUS THROMBOEMBOLISM WITH MCC  

    Medications:  
    - Apixaban (Eliquis)  
    - Heparin IV  
    - Sodium Chloride 0.9% Flush  
    - Furosemide  
    - Acetaminophen  
    - Ondansetron  
    - Metoprolol Tartrate  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Apixaban (Eliquis): PO, Discontinued via patient discharge  
    - Heparin IV: Continuous infusion, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Furosemide: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Metoprolol Tartrate: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Catheter-Directed Thrombolysis  
    - Inferior Vena Cava (IVC) Filter Placement  
    - Repeat Lower Extremity Venous Doppler  


Patient 50001234  
Gender: Female  
Age: 67  
Race: WHITE  

Admission 31547812  
    DRGs:  
    - APR: CHRONIC VENOUS INSUFFICIENCY WITH LOWER LIMB EDEMA (Severity 2.0)  
    - HCFA: PERIPHERAL VASCULAR DISORDERS W/O MCC  

    Medications:  
    - Furosemide PO  
    - Compression Stockings  
    - Pentoxifylline PO  
    - Acetaminophen PO  
    - Aspirin EC PO  
    - Sodium Chloride 0.9% Flush IV  

    Orders:  
    - Furosemide: PO, Discontinued via patient discharge  
    - Compression Stockings: Applied daily, Discontinued via patient discharge  
    - Pentoxifylline: PO, Discontinued via patient discharge  
    - Aspirin EC: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Venous Doppler ultrasound of lower extremities  
    - Ankle-brachial index measurement  
    - Education on leg elevation and exercise  

Admission 31890543  
    DRGs:  
    - APR: CHRONIC VENOUS INSUFFICIENCY WITH VARICOSE VEIN COMPLICATIONS (Severity 3.0)  
    - HCFA: PERIPHERAL VASCULAR DISORDERS W CC  

    Medications:  
    - Furosemide PO  
    - Aspirin EC PO  
    - Rivaroxaban PO  
    - Compression Stockings  
    - Sodium Chloride 0.9% Flush IV  
    - Acetaminophen PO  

    Orders:  
    - Furosemide: PO, Discontinued via patient discharge  
    - Rivaroxaban: PO, Discontinued via patient discharge  
    - Compression Stockings: Daily use, Discontinued via patient discharge  
    - Aspirin EC: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Endovenous laser therapy (EVLT) for varicose veins  
    - Duplex ultrasound for venous reflux mapping  
    - Wound care for venous stasis ulcers  

Admission 32264128  
    DRGs:  
    - APR: SEVERE CHRONIC VENOUS INSUFFICIENCY WITH VENOUS ULCERATION (Severity 4.0)  
    - HCFA: MAJOR PERIPHERAL VASCULAR DISORDERS W MCC  

    Medications:  
    - Furosemide IV  
    - Rivaroxaban PO  
    - Aspirin EC PO  
    - Sodium Chloride 0.9% Flush IV  
    - Oxycodone PO  
    - Clindamycin PO  

    Orders:  
    - Furosemide: IV, Discontinued via patient discharge  
    - Rivaroxaban: PO, Discontinued via patient discharge  
    - Aspirin EC: PO, Discontinued via patient discharge  
    - Clindamycin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Oxycodone: PO, Discontinued via patient discharge  

    Procedures:  
    - Surgical debridement of venous ulcers  
    - Skin grafting for chronic ulceration  
    - Compression wrap therapy  
    - Vascular consult for advanced venous bypass evaluation
    

Patient 60001234  
Gender: Female  
Age: 42  
Race: WHITE  

Admission 51234678  
    DRGs:  
    - APR: MAJOR DEPRESSIVE DISORDERS (Severity 1.0)  
    - HCFA: DEPRESSIVE NEUROSES W/O MCC  

    Medications:  
    - Sertraline (Zoloft) 50mg PO daily  
    - Hydroxyzine 25mg PO PRN for anxiety  
    - Trazodone 50mg PO HS PRN for sleep  
    - Acetaminophen 500mg PO PRN for headache  
    - Sodium Chloride 0.9% Flush IV  
    - Influenza Vaccine Quadrivalent IM  

    Orders:  
    - Sertraline: PO, Scheduled, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Trazodone: PO, HS PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Initial psychiatric evaluation  
    - Safety assessment and suicide risk screening  
    - Cognitive Behavioral Therapy (CBT) session  

---

Admission 52347901  
    DRGs:  
    - APR: MILD DEPRESSION W OUTPATIENT FOLLOW-UP (Severity 1.0)  
    - HCFA: PSYCHIATRIC DISORDERS, MILD, W/O MCC  

    Medications:  
    - Escitalopram (Lexapro) 10mg PO daily  
    - Lorazepam 0.5mg PO PRN for acute anxiety  
    - Vitamin D3 1000 IU PO daily  
    - Ibuprofen 400mg PO PRN for mild pain  
    - Sodium Chloride 0.9% Flush IV  

    Orders:  
    - Escitalopram: PO, Scheduled, Discontinued via patient discharge  
    - Lorazepam: PO, PRN, Discontinued via patient discharge  
    - Vitamin D3: PO, Discontinued via patient discharge  
    - Ibuprofen: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Outpatient psychotherapy session  
    - Depression screening via PHQ-9  
    - Psychoeducation on lifestyle modifications  

---

Admission 53452190  
    DRGs:  
    - APR: PSYCHOTHERAPY-FOCUSED CARE (Severity 1.0)  
    - HCFA: PSYCHOTHERAPY FOR MILD MAJOR DEPRESSIVE EPISODE  

    Medications:  
    - Bupropion SR 150mg PO daily  
    - Melatonin 3mg PO HS PRN for sleep  
    - Multivitamin PO daily  
    - Acetaminophen 650mg PO PRN  
    - Influenza Vaccine Quadrivalent IM  

    Orders:  
    - Bupropion SR: PO, Scheduled, Discontinued via patient discharge  
    - Melatonin: PO, HS PRN, Discontinued via patient discharge  
    - Multivitamin: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Group Cognitive Behavioral Therapy  
    - Mindfulness-Based Stress Reduction training  
    - Discharge planning with outpatient follow-up  


Patient 10001278   
Gender: Male  
Age: 68  
Race: WHITE  

Admission 31598273  
    DRGs:  
    - APR: LUNG MALIGNANCY WITHOUT COMPLICATIONS (Severity 2.0)  
    - HCFA: PULMONARY NEOPLASMS W/O CC  

    Medications:  
    - Carboplatin  
    - Paclitaxel  
    - Ondansetron  
    - Dexamethasone  
    - Filgrastim  
    - Morphine Sulfate  
    - Oxygen Therapy  
    - Acetaminophen  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Carboplatin: IV, Administered per chemotherapy cycle  
    - Paclitaxel: IV, Administered per chemotherapy cycle  
    - Ondansetron: IV, Pre-chemotherapy antiemetic  
    - Dexamethasone: PO, Pre-chemotherapy antiemetic  
    - Filgrastim: SC, Daily x5 days post-chemotherapy  
    - Morphine Sulfate: PO, PRN for cancer-related pain  
    - Oxygen Therapy: NC, Continuous, discontinued via patient discharge  
    - Acetaminophen: PO, PRN, discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Bronchoscopy with biopsy  
    - CT-guided transthoracic lung biopsy  

---

Admission 32254890  
    DRGs:  
    - APR: RESPIRATORY SYSTEM NEOPLASM WITH COMPLICATIONS (Severity 3.0)  
    - HCFA: LUNG MALIGNANCY WITH CC  

    Medications:  
    - Pembrolizumab  
    - Albuterol Inhaler  
    - Tiotropium Bromide  
    - Hydrocodone-Acetaminophen  
    - Lorazepam  
    - Heparin  
    - Sodium Chloride 0.9% Flush  
    - Famotidine  
    - Ondansetron  
    - Filgrastim  

    Orders:  
    - Pembrolizumab: IV, q3 weeks, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, PRN, Discontinued via patient discharge  
    - Tiotropium Bromide: IH, Daily, Discontinued via patient discharge  
    - Hydrocodone-Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Lorazepam: PO, PRN for chemotherapy-related anxiety  
    - Heparin: SC, Daily, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Famotidine: PO, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Filgrastim: SC, Daily x5 days, Discontinued via patient discharge  

    Procedures:  
    - Mediport placement for chemotherapy access  
    - PET-CT scan for staging  

---

Admission 33462518  
    DRGs:  
    - APR: ACUTE RESPIRATORY FAILURE SECONDARY TO LUNG CANCER (Severity 4.0)  
    - HCFA: RESPIRATORY FAILURE WITH CC  

    Medications:  
    - Piperacillin-Tazobactam  
    - Vancomycin  
    - Methylprednisolone  
    - Albuterol 0.083% Neb Soln  
    - Tiotropium Bromide  
    - Morphine Sulfate IV  
    - Acetaminophen  
    - Oxygen Therapy  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Piperacillin-Tazobactam: IV, q8h, Discontinued via patient discharge  
    - Vancomycin: IV, q12h, Discontinued via patient discharge  
    - Methylprednisolone: IV, Daily, Discontinued via patient discharge  
    - Albuterol 0.083% Neb Soln: IH, PRN, Discontinued via patient discharge  
    - Tiotropium Bromide: IH, Daily, Discontinued via patient discharge  
    - Morphine Sulfate IV: Continuous infusion for respiratory distress  
    - Acetaminophen: PO/NG, Discontinued via patient discharge  
    - Oxygen Therapy: HFNC 50L, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Intubation and mechanical ventilation  
    - Thoracentesis for malignant pleural effusion  

Patient 20001278  
Gender: Female  
Age: 67  
Race: WHITE  

Admission 31589274  
    DRGs:  
    - APR: LUNG CANCER - PULMONARY MALIGNANCY (Severity 3.0)  
    - HCFA: RESPIRATORY NEOPLASMS W CC  

    Medications:  
    - Cisplatin  
    - Pemetrexed  
    - Dexamethasone  
    - Ondansetron  
    - Albuterol Inhaler  
    - Tiotropium Bromide  
    - Morphine Sulfate  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Cisplatin: IV, Scheduled, Discontinued via patient discharge  
    - Pemetrexed: IV, Scheduled, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Ondansetron: IV, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, Discontinued via patient discharge  
    - Tiotropium Bromide: IH, Discontinued via patient discharge  
    - Morphine Sulfate: IV, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Bronchoscopy with biopsy  
    - CT-guided transthoracic lung biopsy  
    - Port-a-cath insertion for chemotherapy  

---

Admission 32278115  
    DRGs:  
    - APR: ACUTE RESPIRATORY FAILURE SECONDARY TO LUNG CANCER (Severity 4.0)  
    - HCFA: RESPIRATORY FAILURE W MECHANICAL VENTILATION >96 HRS  

    Medications:  
    - Piperacillin-Tazobactam  
    - Vancomycin  
    - Furosemide  
    - Hydrocortisone IV  
    - Albuterol Nebulizer Solution  
    - Sodium Chloride 0.9% Flush  
    - Midazolam  
    - Propofol Infusion  
    - Heparin  
    - Omeprazole IV  

    Orders:  
    - Piperacillin-Tazobactam: IV, Scheduled, Discontinued via patient discharge  
    - Vancomycin: IV, Scheduled, Discontinued via patient discharge  
    - Furosemide: IV, PRN, Discontinued via patient discharge  
    - Hydrocortisone IV: Scheduled, Discontinued via patient discharge  
    - Albuterol Nebulizer Solution: IH, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Midazolam: IV Drip, Discontinued via patient discharge  
    - Propofol Infusion: IV Drip, Discontinued via patient discharge  
    - Heparin: SC, Discontinued via patient discharge  
    - Omeprazole IV: Scheduled, Discontinued via patient discharge  

    Procedures:  
    - Endotracheal intubation  
    - Mechanical ventilation management  
    - Thoracentesis for malignant pleural effusion  

---

Admission 33567492  
    DRGs:  
    - APR: LUNG CANCER WITH METASTASIS (Severity 4.0)  
    - HCFA: SECONDARY MALIGNANCY W CC  

    Medications:  
    - Nivolumab (Opdivo)  
    - Carboplatin  
    - Folic Acid  
    - Dexamethasone  
    - Ondansetron  
    - Oxycodone  
    - Senna  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  
    - Enoxaparin  

    Orders:  
    - Nivolumab (Opdivo): IV, Scheduled, Discontinued via patient discharge  
    - Carboplatin: IV, Scheduled, Discontinued via patient discharge  
    - Folic Acid: PO, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Ondansetron: IV, Discontinued via patient discharge  
    - Oxycodone: PO, PRN, Discontinued via patient discharge  
    - Senna: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  
    - Enoxaparin: SC, Discontinued via patient discharge  

    Procedures:  
    - PET-CT scan for metastatic disease assessment  
    - Thoracic lymph node biopsy  
    - Palliative radiation therapy

Patient 30001278  
Gender: Male  
Age: 69  
Race: WHITE  

Admission 41256320  
    DRGs:  
    - APR: LUNG CANCER - MALIGNANT NEOPLASM, UPPER LOBE (Severity 3.0)  
    - HCFA: PULMONARY NEOPLASMS W CC  

    Medications:  
    - Cisplatin  
    - Pemetrexed  
    - Dexamethasone  
    - Ondansetron  
    - Morphine Sulfate  
    - Tiotropium Bromide  
    - Albuterol Inhaler  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  
    - Pantoprazole  

    Orders:  
    - Cisplatin: IV, Scheduled, Discontinued via patient discharge  
    - Pemetrexed: IV, Scheduled, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Ondansetron: IV, Discontinued via patient discharge  
    - Morphine Sulfate: IV, PRN, Discontinued via patient discharge  
    - Tiotropium Bromide: IH, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  
    - Pantoprazole: PO, Discontinued via patient discharge  

    Procedures:  
    - Bronchoscopy with transbronchial biopsy  
    - CT-guided upper lobe mass biopsy  
    - Port-a-cath placement for chemotherapy  

---

Admission 42178905  
    DRGs:  
    - APR: RESPIRATORY FAILURE SECONDARY TO LUNG CANCER (Severity 4.0)  
    - HCFA: RESPIRATORY FAILURE W MECHANICAL VENTILATION >96 HRS  

    Medications:  
    - Piperacillin-Tazobactam  
    - Vancomycin  
    - Methylprednisolone IV  
    - Albuterol Nebulizer  
    - Midazolam IV Drip  
    - Propofol Infusion  
    - Sodium Chloride 0.9% Flush  
    - Omeprazole IV  
    - Heparin  
    - Furosemide  

    Orders:  
    - Piperacillin-Tazobactam: IV, Scheduled, Discontinued via patient discharge  
    - Vancomycin: IV, Scheduled, Discontinued via patient discharge  
    - Methylprednisolone IV: Scheduled, Discontinued via patient discharge  
    - Albuterol Nebulizer: IH, Discontinued via patient discharge  
    - Midazolam IV Drip: Continuous, Discontinued via patient discharge  
    - Propofol Infusion: Continuous, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Omeprazole IV: Scheduled, Discontinued via patient discharge  
    - Heparin: SC, Discontinued via patient discharge  
    - Furosemide: IV, PRN, Discontinued via patient discharge  

    Procedures:  
    - Endotracheal intubation  
    - Mechanical ventilation management  
    - Thoracentesis for malignant pleural effusion  

---

Admission 43789211  
    DRGs:  
    - APR: LUNG CANCER WITH METASTATIC PROGRESSION (Severity 4.0)  
    - HCFA: SECONDARY MALIGNANCY W CC  

    Medications:  
    - Nivolumab (Opdivo)  
    - Carboplatin  
    - Folic Acid  
    - Dexamethasone  
    - Ondansetron  
    - Oxycodone  
    - Senna  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  
    - Enoxaparin  

    Orders:  
    - Nivolumab (Opdivo): IV, Scheduled, Discontinued via patient discharge  
    - Carboplatin: IV, Scheduled, Discontinued via patient discharge  
    - Folic Acid: PO, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Ondansetron: IV, Discontinued via patient discharge  
    - Oxycodone: PO, PRN, Discontinued via patient discharge  
    - Senna: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  
    - Enoxaparin: SC, Discontinued via patient discharge  

    Procedures:  
    - PET-CT scan for metastatic assessment  
    - Supraclavicular lymph node excision  
    - Palliative radiation therapy to upper lobe mass


Patient 40001278  
Gender: Female  
Age: 62  
Race: WHITE  

Admission 51278345  
    DRGs:  
    - APR: SECONDARY MALIGNANCY OF BONE (Severity 3.0)  
    - HCFA: PATHOLOGICAL FRACTURES & BONE METASTASES W CC  

    Medications:  
    - Zoledronic Acid (Zometa)  
    - Denosumab (Xgeva)  
    - Dexamethasone  
    - Oxycodone  
    - Acetaminophen  
    - Ondansetron  
    - Calcium Carbonate  
    - Vitamin D3 Supplement  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Zoledronic Acid (Zometa): IV, Monthly, Discontinued via patient discharge  
    - Denosumab (Xgeva): SC, Monthly, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Oxycodone: PO, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO/NG, Discontinued via patient discharge  
    - Ondansetron: PO, Discontinued via patient discharge  
    - Calcium Carbonate: PO, Discontinued via patient discharge  
    - Vitamin D3 Supplement: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Whole-body PET-CT scan  
    - CT-guided biopsy of metastatic bone lesion  
    - Port-a-cath placement for systemic therapy  

---

Admission 52419781  
    DRGs:  
    - APR: PATHOLOGICAL FRACTURE DUE TO BONE METASTASIS (Severity 4.0)  
    - HCFA: ORTHOPEDIC SURGERY FOR FRACTURES W CC  

    Medications:  
    - Hydromorphone PCA  
    - Methadone  
    - Ketorolac IV  
    - Cefazolin IV  
    - Zoledronic Acid  
    - Ondansetron  
    - Enoxaparin  
    - Senna  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Hydromorphone PCA: IV Continuous, Discontinued via patient discharge  
    - Methadone: PO, Scheduled, Discontinued via patient discharge  
    - Ketorolac IV: Scheduled, Discontinued via patient discharge  
    - Cefazolin IV: Perioperative, Discontinued via patient discharge  
    - Zoledronic Acid: IV, Monthly, Discontinued via patient discharge  
    - Ondansetron: IV, Discontinued via patient discharge  
    - Enoxaparin: SC, Discontinued via patient discharge  
    - Senna: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Open reduction and internal fixation (ORIF) of femoral pathological fracture  
    - Intraoperative fluoroscopy  
    - Bone cement augmentation for stability  

---

Admission 53968210  
    DRGs:  
    - APR: CANCER PAIN MANAGEMENT - SECONDARY BONE NEOPLASM (Severity 4.0)  
    - HCFA: PALLIATIVE CARE W CC  

    Medications:  
    - Fentanyl Transdermal Patch  
    - Hydromorphone IV  
    - Gabapentin  
    - Dexamethasone  
    - Ondansetron  
    - Lorazepam  
    - Acetaminophen  
    - Bisacodyl  
    - Sodium Chloride 0.9% Flush  
    - Zoledronic Acid  

    Orders:  
    - Fentanyl Transdermal Patch: TD, Scheduled, Discontinued via patient discharge  
    - Hydromorphone IV: PRN, Discontinued via patient discharge  
    - Gabapentin: PO, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Ondansetron: PO, Discontinued via patient discharge  
    - Lorazepam: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Bisacodyl: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Zoledronic Acid: IV, Discontinued via patient discharge  

    Procedures:  
    - Palliative radiation therapy to spine metastasis  
    - MRI of thoracic and lumbar spine  
    - Ultrasound-guided celiac plexus block for cancer-related pain


Patient 50001278
Gender: Male
Age: 68
Race: WHITE

Admission 33845721
    DRGs:
    - APR: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) (Severity 3.0)
    - HCFA: CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC

    Medications:
    - Tiotropium Bromide (Spiriva)
    - Albuterol 0.083% Neb Soln
    - Ipratropium Bromide Neb
    - Fluticasone-Salmeterol (Advair Diskus)
    - Prednisone
    - Azithromycin
    - Montelukast
    - Sodium Chloride 0.9% Flush
    - Acetaminophen
    - Influenza Vaccine Quadrivalent
    - Heparin
    - Oxygen Therapy (2L NC)

    Orders:
    - Tiotropium Bromide (Spiriva): IH, Discontinued via patient discharge
    - Albuterol 0.083% Neb Soln: IH, Discontinued via patient discharge
    - Ipratropium Bromide Neb: IH, Discontinued via patient discharge
    - Fluticasone-Salmeterol (Advair Diskus): IH, Discontinued via patient discharge
    - Prednisone: PO, Discontinued via patient discharge
    - Azithromycin: PO, Discontinued via patient discharge
    - Montelukast: PO, Discontinued via patient discharge
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge
    - Acetaminophen: PO, Discontinued via patient discharge
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge
    - Heparin: SC, Discontinued via patient discharge
    - Oxygen Therapy: Continuous, Discontinued via patient discharge

    Procedures:
    - Chest X-Ray (portable)
    - Arterial Blood Gas (ABG) analysis
    - Pulse Oximetry monitoring
    - Non-invasive ventilation initiation (BiPAP)

Admission 34572890
    DRGs:
    - APR: ACUTE EXACERBATION OF COPD (Severity 4.0)
    - HCFA: ACUTE RESPIRATORY FAILURE W MCC

    Medications:
    - Methylprednisolone IV
    - Piperacillin-Tazobactam (Zosyn)
    - Albuterol Inhaler
    - Tiotropium Bromide
    - Budesonide Neb
    - Levofloxacin
    - Sodium Chloride 0.9% Flush
    - Lorazepam
    - Magnesium Sulfate IV
    - Heparin
    - Acetaminophen

    Orders:
    - Methylprednisolone IV: IV, Discontinued via patient discharge
    - Piperacillin-Tazobactam (Zosyn): IV, Discontinued via patient discharge
    - Albuterol Inhaler: IH, Discontinued via patient discharge
    - Tiotropium Bromide: IH, Discontinued via patient discharge
    - Budesonide Neb: IH, Discontinued via patient discharge
    - Levofloxacin: PO, Discontinued via patient discharge
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge
    - Lorazepam: PO, Discontinued via patient discharge
    - Magnesium Sulfate IV: IV, Discontinued via patient discharge
    - Heparin: SC, Discontinued via patient discharge
    - Acetaminophen: PO, Discontinued via patient discharge

    Procedures:
    - Endotracheal intubation with mechanical ventilation
    - Continuous cardiac telemetry monitoring
    - Bronchoscopy for airway clearance
    - CT Chest without contrast

Admission 35698710
    DRGs:
    - APR: RESPIRATORY INFECTION WITH COPD (Severity 2.0)
    - HCFA: SIMPLE PNEUMONIA & PLEURISY W CC

    Medications:
    - Amoxicillin-Clavulanate
    - Tiotropium Bromide
    - Albuterol Inhaler
    - Fluticasone Propionate Nasal Spray
    - Prednisone
    - Oseltamivir
    - Sodium Chloride 0.9% Flush
    - Guaifenesin
    - Influenza Vaccine Quadrivalent
    - Heparin

    Orders:
    - Amoxicillin-Clavulanate: PO, Discontinued via patient discharge
    - Tiotropium Bromide: IH, Discontinued via patient discharge
    - Albuterol Inhaler: IH, Discontinued via patient discharge
    - Fluticasone Propionate Nasal Spray: IH, Discontinued via patient discharge
    - Prednisone: PO, Discontinued via patient discharge
    - Oseltamivir: PO, Discontinued via patient discharge
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge
    - Guaifenesin: PO, Discontinued via patient discharge
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge
    - Heparin: SC, Discontinued via patient discharge

    Procedures:
    - Sputum culture and sensitivity
    - High-resolution CT scan (HRCT)
    - Spirometry



Patient 60001278  
Gender: Female  
Age: 42  
Race: WHITE  

Admission 51890324  
    DRGs:  
    - APR: FOREARM FRACTURE - CLOSED REDUCTION / CASTING (Severity 2.0)  
    - HCFA: UPPER EXTREMITY FRACTURE W/O MCC  

    Medications:  
    - Acetaminophen  
    - Ibuprofen  
    - Oxycodone  
    - Ondansetron  
    - Cefazolin  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Ibuprofen: PO, PRN, Discontinued via patient discharge  
    - Oxycodone: PO, PRN, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Cefazolin: IV, Single dose pre-op, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Closed reduction of right distal radius fracture  
    - Application of short-arm cast under conscious sedation  
    - X-ray imaging of right forearm (pre- and post-reduction)  

---

Admission 52678415  
    DRGs:  
    - APR: OPEN REDUCTION AND INTERNAL FIXATION OF RADIUS (Severity 3.0)  
    - HCFA: OPEN TREATMENT OF FOREARM FRACTURE W CC  

    Medications:  
    - Cefazolin  
    - Hydromorphone  
    - Acetaminophen  
    - Ibuprofen  
    - Enoxaparin  
    - Ondansetron  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Cefazolin: IV, Perioperative, Discontinued via patient discharge  
    - Hydromorphone: IV, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, Scheduled, Discontinued via patient discharge  
    - Ibuprofen: PO, PRN, Discontinued via patient discharge  
    - Enoxaparin: SC, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Open reduction and internal fixation (ORIF) of right distal radius  
    - Placement of volar locking plate and screws  
    - Intraoperative fluoroscopy for alignment confirmation  

---

Admission 53429587  
    DRGs:  
    - APR: POSTOPERATIVE COMPLICATIONS FOLLOWING ORIF (Severity 2.0)  
    - HCFA: POSTPROCEDURAL INFECTION W CC  

    Medications:  
    - Vancomycin  
    - Piperacillin-Tazobactam  
    - Acetaminophen  
    - Oxycodone  
    - Ondansetron  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Vancomycin: IV, Scheduled, Discontinued via patient discharge  
    - Piperacillin-Tazobactam: IV, Scheduled, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Oxycodone: PO, PRN, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Bedside irrigation and debridement of surgical wound  
    - Wound culture collection  
    - Follow-up X-ray for hardware position verification  


Patient 10001279  
Gender: Male  
Age: 55  
Race: HISPANIC  

Admission 41908751  
    DRGs:  
    - APR: TYPE 2 DIABETES MELLITUS W/O COMPLICATIONS (Severity 1.0)  
    - HCFA: DIABETES MELLITUS W/O COMPLICATIONS  

    Medications:  
    - Metformin 1000 mg BID  
    - Glimepiride 4 mg daily  
    - Lisinopril 10 mg daily  
    - Atorvastatin 20 mg nightly  
    - Aspirin 81 mg daily  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Metformin: PO, Discontinued via patient discharge  
    - Glimepiride: PO, Discontinued via patient discharge  
    - Lisinopril: PO, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Fasting plasma glucose test  
    - HbA1c measurement  
    - Lipid panel  

---

Admission 42569013  
    DRGs:  
    - APR: DIABETES WITH HYPERGLYCEMIA, NO COMPLICATIONS (Severity 2.0)  
    - HCFA: TYPE 2 DM W UNCONTROLLED BLOOD GLUCOSE  

    Medications:  
    - Metformin 1000 mg BID  
    - Insulin Glargine (Lantus) 15 units nightly  
    - Insulin Lispro sliding scale  
    - Atorvastatin 40 mg nightly  
    - Lisinopril 20 mg daily  
    - Aspirin 81 mg daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Metformin: PO, Discontinued via patient discharge  
    - Insulin Glargine: SC, Discontinued via patient discharge  
    - Insulin Lispro: SC, Sliding scale, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Lisinopril: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Continuous glucose monitoring initiation  
    - Comprehensive metabolic panel  
    - Nutrition counseling with certified diabetes educator  

---

Admission 43287145  
    DRGs:  
    - APR: ROUTINE DIABETES FOLLOW-UP VISIT (Severity 1.0)  
    - HCFA: DIABETES MANAGEMENT, OUTPATIENT  

    Medications:  
    - Metformin 1000 mg BID  
    - Insulin Glargine 18 units nightly  
    - Insulin Lispro sliding scale  
    - Atorvastatin 40 mg nightly  
    - Aspirin 81 mg daily  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Metformin: PO, Discontinued via patient discharge  
    - Insulin Glargine: SC, Discontinued via patient discharge  
    - Insulin Lispro: SC, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - HbA1c recheck  
    - Retinal fundus photography for diabetic retinopathy screening  
    - Urine microalbumin test  
    - Blood pressure monitoring  


Patient 20001279  
Gender: Female  
Age: 62  
Race: BLACK/AFRICAN AMERICAN  

Admission 51234781  
    DRGs:  
    - APR: TYPE 2 DIABETES MELLITUS, NEWLY DIAGNOSED (Severity 1.0)  
    - HCFA: DIABETES MELLITUS W/O COMPLICATIONS  

    Medications:  
    - Metformin 500 mg BID  
    - Sitagliptin 100 mg daily  
    - Atorvastatin 20 mg nightly  
    - Lisinopril 5 mg daily  
    - Aspirin 81 mg daily  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Metformin: PO, Discontinued via patient discharge  
    - Sitagliptin: PO, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Lisinopril: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Oral glucose tolerance test  
    - HbA1c measurement  
    - Lipid profile screening  

---

Admission 52650942  
    DRGs:  
    - APR: DIABETES WITH POOR GLYCEMIC CONTROL (Severity 2.0)  
    - HCFA: TYPE 2 DIABETES WITH HYPERGLYCEMIA W/O COMPLICATIONS  

    Medications:  
    - Metformin 1000 mg BID  
    - Empagliflozin 25 mg daily  
    - Atorvastatin 40 mg nightly  
    - Lisinopril 10 mg daily  
    - Aspirin 81 mg daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Metformin: PO, Discontinued via patient discharge  
    - Empagliflozin: PO, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Lisinopril: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - HbA1c follow-up test  
    - Comprehensive metabolic panel  
    - Diabetes education and lifestyle counseling session  

---

Admission 53891276  
    DRGs:  
    - APR: DIABETES ANNUAL OUTPATIENT REVIEW (Severity 1.0)  
    - HCFA: ROUTINE DIABETES MANAGEMENT, OUTPATIENT  

    Medications:  
    - Metformin 1000 mg BID  
    - Empagliflozin 25 mg daily  
    - Atorvastatin 40 mg nightly  
    - Aspirin 81 mg daily  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Metformin: PO, Discontinued via patient discharge  
    - Empagliflozin: PO, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - HbA1c recheck  
    - Retinal fundus photography  
    - Urine microalbumin screening  
    - Diabetic foot exam  
    - Blood pressure monitoring  


Patient 30001279  
Gender: Male  
Age: 59  
Race: WHITE  

Admission 54821903  
    DRGs:  
    - APR: TYPE 2 DIABETES WITH HYPERGLYCEMIA - INITIAL PRESENTATION (Severity 2.0)  
    - HCFA: DIABETES MELLITUS WITH HYPERGLYCEMIA W/O MCC  

    Medications:  
    - Metformin 1000 mg BID  
    - Glimepiride 4 mg daily  
    - Insulin Glargine 15 units nightly  
    - Insulin Lispro sliding scale before meals  
    - Atorvastatin 20 mg nightly  
    - Lisinopril 10 mg daily  
    - Aspirin 81 mg daily  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Metformin: PO, Discontinued via patient discharge  
    - Glimepiride: PO, Discontinued via patient discharge  
    - Insulin Glargine: SC, Discontinued via patient discharge  
    - Insulin Lispro: SC, Sliding scale, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Lisinopril: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - HbA1c measurement  
    - Basic metabolic panel  
    - Diabetes nutrition counseling session  

---

Admission 55376421  
    DRGs:  
    - APR: DIABETES WITH ACUTE HYPERGLYCEMIC EXACERBATION (Severity 3.0)  
    - HCFA: UNCONTROLLED TYPE 2 DIABETES W HYPERGLYCEMIA W CC  

    Medications:  
    - Insulin Glargine 25 units nightly  
    - Insulin Lispro sliding scale pre-meals  
    - Metformin 500 mg BID  
    - Empagliflozin 25 mg daily  
    - Atorvastatin 40 mg nightly  
    - Losartan 50 mg daily  
    - Aspirin 81 mg daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Insulin Glargine: SC, Discontinued via patient discharge  
    - Insulin Lispro: SC, Sliding scale, Discontinued via patient discharge  
    - Metformin: PO, Discontinued via patient discharge  
    - Empagliflozin: PO, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Losartan: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Continuous glucose monitoring initiation  
    - IV fluids for hyperglycemia management  
    - Endocrinology consultation for insulin titration  

---

Admission 56788134  
    DRGs:  
    - APR: FOLLOW-UP DIABETES MANAGEMENT - PERSISTENT HYPERGLYCEMIA (Severity 2.0)  
    - HCFA: OUTPATIENT GLUCOSE CONTROL & DIABETES EDUCATION  

    Medications:  
    - Insulin Glargine 28 units nightly  
    - Insulin Lispro sliding scale before meals  
    - Metformin 1000 mg BID  
    - Empagliflozin 25 mg daily  
    - Atorvastatin 40 mg nightly  
    - Aspirin 81 mg daily  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Insulin Glargine: SC, Discontinued via patient discharge  
    - Insulin Lispro: SC, Discontinued via patient discharge  
    - Metformin: PO, Discontinued via patient discharge  
    - Empagliflozin: PO, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - HbA1c recheck  
    - Retinal fundus exam for diabetic retinopathy screening  
    - Urine microalbumin test  
    - Diabetes self-management education  


Patient 40001279  
Gender: Female  
Age: 57  
Race: WHITE  

Admission 56278103  
    DRGs:  
    - APR: HYPERLIPIDEMIA, UNSPECIFIED - INITIAL MANAGEMENT (Severity 1.0)  
    - HCFA: LIPID METABOLISM DISORDERS W/O MCC  

    Medications:  
    - Atorvastatin 20 mg nightly  
    - Omega-3 Fish Oil 1g daily  
    - Aspirin 81 mg daily  
    - Vitamin D3 2000 IU daily  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Omega-3 Fish Oil: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Vitamin D3: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Fasting lipid panel  
    - HbA1c screening  
    - Nutrition counseling for cholesterol reduction  

---

Admission 57498322  
    DRGs:  
    - APR: HYPERLIPIDEMIA WITH ELEVATED CARDIOVASCULAR RISK (Severity 2.0)  
    - HCFA: MIXED DYSLIPIDEMIA MANAGEMENT W CC  

    Medications:  
    - Rosuvastatin 40 mg nightly  
    - Ezetimibe 10 mg daily  
    - Aspirin 81 mg daily  
    - Coenzyme Q10 100 mg daily  
    - Lisinopril 10 mg daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Rosuvastatin: PO, Discontinued via patient discharge  
    - Ezetimibe: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Coenzyme Q10: PO, Discontinued via patient discharge  
    - Lisinopril: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Coronary calcium scoring CT  
    - Advanced lipid particle testing  
    - Cardiovascular risk assessment and management planning  

---

Admission 58900274  
    DRGs:  
    - APR: REFRACTORY HYPERLIPIDEMIA REQUIRING SPECIALIZED THERAPY (Severity 3.0)  
    - HCFA: SEVERE DYSLIPIDEMIA W CC  

    Medications:  
    - Evolocumab (Repatha) 140 mg SC every 2 weeks  
    - Rosuvastatin 40 mg nightly  
    - Ezetimibe 10 mg daily  
    - Aspirin 81 mg daily  
    - Lisinopril 10 mg daily  
    - Omega-3 Fish Oil 2g daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Evolocumab (Repatha): SC, Discontinued via patient discharge  
    - Rosuvastatin: PO, Discontinued via patient discharge  
    - Ezetimibe: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Lisinopril: PO, Discontinued via patient discharge  
    - Omega-3 Fish Oil: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Referral to lipid specialist  
    - LDL apheresis planning  
    - Echocardiogram to evaluate cardiac function  


Patient 50001279
Gender: Male
Age: 64
Race: WHITE

Admission 41239581
    DRGs:
    - APR: HYPERTENSION WITHOUT COMPLICATIONS (Severity 1.0)
    - HCFA: HYPERTENSION W/O MCC

    Medications:
    - Lisinopril 10mg
    - Hydrochlorothiazide 25mg
    - Amlodipine 5mg
    - Sodium Chloride 0.9% Flush
    - Acetaminophen
    - Aspirin EC 81mg
    - Influenza Vaccine Quadrivalent

    Orders:
    - Lisinopril: PO, Discontinued via patient discharge
    - Hydrochlorothiazide: PO, Discontinued via patient discharge
    - Amlodipine: PO, Discontinued via patient discharge
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge
    - Acetaminophen: PO, Discontinued via patient discharge
    - Aspirin EC 81mg: PO, Discontinued via patient discharge
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge

    Procedures:
    - Basic Metabolic Panel (BMP)
    - Electrocardiogram (ECG)
    - Blood Pressure Monitoring

Admission 41876325
    DRGs:
    - APR: HYPERTENSIVE URGENCY / EMERGENCY (Severity 3.0)
    - HCFA: HYPERTENSIVE CRISIS W MCC

    Medications:
    - Labetalol IV
    - Nicardipine IV Drip
    - Hydralazine IV
    - Sodium Nitroprusside IV
    - Aspirin 81mg
    - Sodium Chloride 0.9% Flush
    - Acetaminophen
    - Atorvastatin 20mg
    - Lorazepam PO
    - Heparin SC

    Orders:
    - Labetalol IV: IV infusion, Discontinued via patient discharge
    - Nicardipine IV Drip: Continuous IV, Discontinued via patient discharge
    - Hydralazine IV: IV push, Discontinued via patient discharge
    - Sodium Nitroprusside IV: Continuous IV, Discontinued via patient discharge
    - Aspirin 81mg: PO, Discontinued via patient discharge
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge
    - Acetaminophen: PO, Discontinued via patient discharge
    - Atorvastatin 20mg: PO, Discontinued via patient discharge
    - Lorazepam: PO, Discontinued via patient discharge
    - Heparin SC: SC, Discontinued via patient discharge

    Procedures:
    - Continuous cardiac telemetry monitoring
    - CT Head without contrast (rule out hemorrhage)
    - Renal Function Panel
    - Chest X-Ray portable

Admission 42680412
    DRGs:
    - APR: HYPERTENSION WITH COMPLICATIONS (Severity 2.0)
    - HCFA: HYPERTENSION W CC

    Medications:
    - Metoprolol Succinate 50mg
    - Amlodipine 10mg
    - Losartan 50mg
    - Chlorthalidone 25mg
    - Aspirin EC 81mg
    - Sodium Chloride 0.9% Flush
    - Influenza Vaccine Quadrivalent
    - Atorvastatin 20mg
    - Acetaminophen

    Orders:
    - Metoprolol Succinate: PO, Discontinued via patient discharge
    - Amlodipine: PO, Discontinued via patient discharge
    - Losartan: PO, Discontinued via patient discharge
    - Chlorthalidone: PO, Discontinued via patient discharge
    - Aspirin EC 81mg: PO, Discontinued via patient discharge
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge
    - Atorvastatin 20mg: PO, Discontinued via patient discharge
    - Acetaminophen: PO, Discontinued via patient discharge

    Procedures:
    - Echocardiogram (TTE)
    - 24-hour ambulatory BP monitoring
    - Serum electrolytes
    - Lipid panel


Patient 60001279  
Gender: Male  
Age: 46  
Race: WHITE  

Admission 61247853  
    DRGs:  
    - APR: TRAUMATIC SUBDURAL HEMORRHAGE WITHOUT LOSS OF CONSCIOUSNESS (Severity 3.0)  
    - HCFA: INTRACRANIAL HEMORRHAGE W/O MCC  

    Medications:  
    - Levetiracetam 1000 mg BID  
    - Acetaminophen 650 mg Q6H PRN  
    - Mannitol IV 20%  
    - Ondansetron 4 mg IV PRN  
    - Sodium Chloride 0.9% Flush  
    - Pantoprazole 40 mg IV daily  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Levetiracetam: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Mannitol: IV, PRN for ICP, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Pantoprazole: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - CT scan of head without contrast  
    - Neurological monitoring every 2 hours  
    - Intravenous hyperosmolar therapy initiation  

---

Admission 62471329  
    DRGs:  
    - APR: POST-TRAUMATIC SUBDURAL HEMATOMA OBSERVATION (Severity 2.0)  
    - HCFA: CLOSED TRAUMATIC BRAIN INJURY OBSERVATION  

    Medications:  
    - Levetiracetam 500 mg BID  
    - Acetaminophen 500 mg PO PRN  
    - Dexamethasone 4 mg IV Q8H  
    - Ondansetron 4 mg IV PRN  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Levetiracetam: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Dexamethasone: IV, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - MRI brain with gradient susceptibility imaging  
    - Repeat CT scan for hematoma progression  
    - Neuro checks every 4 hours  

---

Admission 63980244  
    DRGs:  
    - APR: SURGICAL MANAGEMENT OF TRAUMATIC SUBDURAL HEMORRHAGE (Severity 4.0)  
    - HCFA: CRANIOTOMY FOR TRAUMATIC BRAIN INJURY W CC  

    Medications:  
    - Levetiracetam 1000 mg BID  
    - Mannitol 20% IV bolus  
    - Hypertonic Saline 3% IV infusion  
    - Cefazolin 2 g IV prophylaxis  
    - Fentanyl IV PRN  
    - Ondansetron IV PRN  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Levetiracetam: PO, Discontinued via patient discharge  
    - Mannitol: IV, Discontinued via patient discharge  
    - Hypertonic Saline: IV infusion, Discontinued via patient discharge  
    - Cefazolin: IV, Discontinued via patient discharge  
    - Fentanyl: IV, PRN, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Craniotomy for evacuation of subdural hematoma  
    - Placement of ICP monitoring catheter  
    - Postoperative ICU monitoring  
    - Physical therapy evaluation prior to discharge  


Patient 10001280  
Gender: Female  
Age: 35  
Race: HISPANIC  

Admission 61820347  
    DRGs:  
    - APR: ASTHMA EXACERBATION - UNSPECIFIED (Severity 2.0)  
    - HCFA: ACUTE ASTHMA ATTACK W/O MCC  

    Medications:  
    - Albuterol Inhaler 90 mcg, 2 puffs q4h PRN  
    - Ipratropium Bromide Neb 0.5 mg q6h  
    - Prednisone 40 mg PO daily  
    - Montelukast 10 mg nightly  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Albuterol Inhaler: IH, PRN, Discontinued via patient discharge  
    - Ipratropium Bromide Neb: IH, Discontinued via patient discharge  
    - Prednisone: PO, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Spirometry testing  
    - Peak expiratory flow measurement  
    - Chest X-ray to rule out pneumonia  

---

Admission 62789415  
    DRGs:  
    - APR: MODERATE PERSISTENT ASTHMA EXACERBATION (Severity 3.0)  
    - HCFA: ASTHMA W ACUTE RESPIRATORY DISTRESS W CC  

    Medications:  
    - Albuterol 2.5 mg Neb q4h  
    - Budesonide Neb 0.5 mg BID  
    - Methylprednisolone 60 mg IV q8h  
    - Montelukast 10 mg nightly  
    - Loratadine 10 mg daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Albuterol Nebulizer: IH, Discontinued via patient discharge  
    - Budesonide Neb: IH, Discontinued via patient discharge  
    - Methylprednisolone: IV, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Loratadine: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Arterial blood gas (ABG) analysis  
    - Continuous pulse oximetry monitoring  
    - Chest CT to evaluate airway inflammation  

---

Admission 63917528  
    DRGs:  
    - APR: OUTPATIENT ASTHMA MANAGEMENT AND FOLLOW-UP (Severity 1.0)  
    - HCFA: CHRONIC ASTHMA CONTROL - OUTPATIENT  

    Medications:  
    - Fluticasone-Salmeterol (Advair) 250/50 BID  
    - Albuterol Inhaler PRN  
    - Montelukast 10 mg nightly  
    - Cetirizine 10 mg daily  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Fluticasone-Salmeterol: IH, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, PRN, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Cetirizine: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Pulmonary function testing (PFTs)  
    - Asthma action plan counseling  
    - Allergen skin testing referral  


Patient 20001280  
Gender: Male  
Age: 42  
Race: BLACK/AFRICAN AMERICAN  

Admission 62134781  
    DRGs:  
    - APR: ASTHMA EXACERBATION - UNSPECIFIED (Severity 2.0)  
    - HCFA: ACUTE ASTHMA ATTACK W/O MCC  

    Medications:  
    - Albuterol Inhaler 90 mcg, 2 puffs q4h PRN  
    - Ipratropium Bromide Neb 0.5 mg q6h  
    - Prednisone 40 mg PO daily  
    - Loratadine 10 mg PO daily  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Albuterol Inhaler: IH, PRN, Discontinued via patient discharge  
    - Ipratropium Bromide Neb: IH, Discontinued via patient discharge  
    - Prednisone: PO, Discontinued via patient discharge  
    - Loratadine: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Peak expiratory flow measurement  
    - Chest X-ray to rule out pneumonia  
    - Spirometry testing  

---

Admission 63391852  
    DRGs:  
    - APR: MODERATE PERSISTENT ASTHMA WITH ACUTE EXACERBATION (Severity 3.0)  
    - HCFA: ACUTE RESPIRATORY DISTRESS DUE TO ASTHMA W CC  

    Medications:  
    - Albuterol 2.5 mg Neb q4h  
    - Budesonide Neb 0.5 mg BID  
    - Methylprednisolone 60 mg IV q8h  
    - Montelukast 10 mg PO nightly  
    - Cetirizine 10 mg PO daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Albuterol Nebulizer: IH, Discontinued via patient discharge  
    - Budesonide Neb: IH, Discontinued via patient discharge  
    - Methylprednisolone: IV, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Cetirizine: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Arterial blood gas (ABG) analysis  
    - Continuous pulse oximetry  
    - Chest CT scan for airway assessment  

---

Admission 64752019  
    DRGs:  
    - APR: OUTPATIENT ASTHMA FOLLOW-UP MANAGEMENT (Severity 1.0)  
    - HCFA: CHRONIC ASTHMA CONTROL - OUTPATIENT  

    Medications:  
    - Fluticasone-Salmeterol (Advair) 250/50 BID  
    - Albuterol Inhaler PRN  
    - Montelukast 10 mg nightly  
    - Cetirizine 10 mg daily  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Fluticasone-Salmeterol: IH, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, PRN, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Cetirizine: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Pulmonary function testing (PFTs)  
    - Allergy evaluation and skin testing referral  
    - Asthma action plan counseling  


Patient 30001280  
Gender: Female  
Age: 29  
Race: WHITE  

Admission 65321904  
    DRGs:  
    - APR: ACUTE ASTHMA EXACERBATION - UNSPECIFIED (Severity 3.0)  
    - HCFA: ASTHMA WITH ACUTE EXACERBATION W/O MCC  

    Medications:  
    - Albuterol Inhaler 90 mcg, 2 puffs q4h PRN  
    - Ipratropium Bromide Neb 0.5 mg q6h  
    - Prednisone 60 mg PO daily  
    - Montelukast 10 mg nightly  
    - Cetirizine 10 mg daily  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Albuterol Inhaler: IH, PRN, Discontinued via patient discharge  
    - Ipratropium Bromide Neb: IH, Discontinued via patient discharge  
    - Prednisone: PO, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Cetirizine: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Peak expiratory flow measurement  
    - Chest X-ray to rule out pneumonia  
    - Spirometry pre- and post-bronchodilator  

---

Admission 66738129  
    DRGs:  
    - APR: SEVERE ASTHMA EXACERBATION REQUIRING INPATIENT MANAGEMENT (Severity 4.0)  
    - HCFA: STATUS ASTHMATICUS W CC  

    Medications:  
    - Albuterol 2.5 mg Neb continuous infusion  
    - Budesonide Neb 0.5 mg BID  
    - Methylprednisolone 80 mg IV q8h  
    - Montelukast 10 mg nightly  
    - Loratadine 10 mg daily  
    - Magnesium Sulfate IV bolus  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Albuterol Continuous Neb: IH, Discontinued via patient discharge  
    - Budesonide Neb: IH, Discontinued via patient discharge  
    - Methylprednisolone: IV, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Loratadine: PO, Discontinued via patient discharge  
    - Magnesium Sulfate: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Arterial blood gas (ABG) monitoring  
    - Continuous pulse oximetry and cardiac monitoring  
    - High-resolution chest CT to evaluate airway inflammation  

---

Admission 67542912  
    DRGs:  
    - APR: OUTPATIENT ASTHMA MANAGEMENT AND FOLLOW-UP (Severity 1.0)  
    - HCFA: CHRONIC ASTHMA CONTROL - OUTPATIENT  

    Medications:  
    - Fluticasone-Salmeterol (Advair) 250/50 BID  
    - Albuterol Inhaler PRN  
    - Montelukast 10 mg nightly  
    - Cetirizine 10 mg daily  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Fluticasone-Salmeterol: IH, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, PRN, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Cetirizine: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Pulmonary function testing (PFTs)  
    - Personalized asthma action plan counseling  
    - Allergy testing and referral for immunotherapy evaluation  


Patient 40001280  
Gender: Female  
Age: 31  
Race: ASIAN  

Admission 66237102  
    DRGs:  
    - APR: ALLERGIC RHINITIS, UNSPECIFIED - INITIAL MANAGEMENT (Severity 1.0)  
    - HCFA: ALLERGIC RHINITIS W/O MCC  

    Medications:  
    - Loratadine 10 mg daily  
    - Fluticasone Nasal Spray 50 mcg per nostril daily  
    - Cetirizine 10 mg nightly  
    - Sodium Chloride Nasal Spray PRN  
    - Montelukast 10 mg nightly  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Loratadine: PO, Discontinued via patient discharge  
    - Fluticasone Nasal Spray: IN, Discontinued via patient discharge  
    - Cetirizine: PO, Discontinued via patient discharge  
    - Sodium Chloride Nasal Spray: IN, PRN, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Nasal endoscopy for evaluation of airway inflammation  
    - Peak nasal inspiratory flow measurement  
    - Allergen blood panel  

---

Admission 67849255  
    DRGs:  
    - APR: SEASONAL ALLERGIC RHINITIS WITH MODERATE SYMPTOMS (Severity 2.0)  
    - HCFA: ALLERGIC RHINITIS WITH PERSISTENT CONGESTION  

    Medications:  
    - Fexofenadine 180 mg daily  
    - Fluticasone Nasal Spray 2 sprays per nostril daily  
    - Montelukast 10 mg nightly  
    - Azelastine Nasal Spray BID  
    - Cetirizine 10 mg daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Fexofenadine: PO, Discontinued via patient discharge  
    - Fluticasone Nasal Spray: IN, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Azelastine Nasal Spray: IN, Discontinued via patient discharge  
    - Cetirizine: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Skin prick allergy testing  
    - Pulmonary function testing (PFTs) to rule out asthma overlap  
    - Patient education on allergen avoidance strategies  

---

Admission 69372891  
    DRGs:  
    - APR: CHRONIC ALLERGIC RHINITIS MANAGEMENT - FOLLOW-UP (Severity 1.0)  
    - HCFA: OUTPATIENT ALLERGIC RHINITIS CONTROL  

    Medications:  
    - Fluticasone Nasal Spray 1 spray per nostril daily  
    - Loratadine 10 mg daily  
    - Montelukast 10 mg nightly  
    - Cetirizine 10 mg daily  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Fluticasone Nasal Spray: IN, Discontinued via patient discharge  
    - Loratadine: PO, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Cetirizine: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Repeat allergy testing for environmental triggers  
    - Nasal cytology to evaluate eosinophilic inflammation  
    - ENT referral for chronic nasal obstruction evaluation  


Patient 50001280  
Gender: Female  
Age: 71  
Race: WHITE  

Admission 50381247  
    DRGs:  
    - APR: RESPIRATORY SYMPTOMS & OTHER SIGNS (Severity 2.0)  
    - HCFA: SHORTNESS OF BREATH / DYSPNEA W/O MCC  

    Medications:  
    - Albuterol 0.083% Neb Soln  
    - Ipratropium Bromide Neb  
    - Fluticasone-Salmeterol (Advair Diskus)  
    - Montelukast  
    - Prednisone  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Oxygen Therapy (2L NC)  
    - Influenza Vaccine Quadrivalent  
    - Lorazepam (for anxiety-related dyspnea)  

    Orders:  
    - Albuterol 0.083% Neb Soln: IH, Discontinued via patient discharge  
    - Ipratropium Bromide Neb: IH, Discontinued via patient discharge  
    - Fluticasone-Salmeterol (Advair Diskus): IH, Discontinued via patient discharge  
    - Montelukast: PO, Discontinued via patient discharge  
    - Prednisone: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Oxygen Therapy: Continuous, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  
    - Lorazepam: PO, Discontinued via patient discharge  

    Procedures:  
    - Pulse oximetry monitoring  
    - Chest X-Ray (portable)  
    - Basic Metabolic Panel (BMP)  
    - Arterial Blood Gas (ABG)  

Admission 51243709  
    DRGs:  
    - APR: ACUTE DYSPNEA WITH EXACERBATION (Severity 3.0)  
    - HCFA: RESPIRATORY DISTRESS W CC  

    Medications:  
    - Methylprednisolone IV  
    - Budesonide Neb  
    - Albuterol Inhaler  
    - Tiotropium Bromide  
    - Furosemide IV (for possible pulmonary edema)  
    - Levofloxacin  
    - Sodium Chloride 0.9% Flush  
    - Atorvastatin  
    - Heparin SC  
    - Acetaminophen  

    Orders:  
    - Methylprednisolone IV: IV, Discontinued via patient discharge  
    - Budesonide Neb: IH, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, Discontinued via patient discharge  
    - Tiotropium Bromide: IH, Discontinued via patient discharge  
    - Furosemide IV: IV, Discontinued via patient discharge  
    - Levofloxacin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - High-resolution CT Chest (HRCT)  
    - Bronchoscopy for airway evaluation  
    - Non-invasive ventilation initiation (BiPAP)  
    - Continuous cardiac telemetry monitoring  

Admission 52649803  
    DRGs:  
    - APR: RESPIRATORY SYMPTOMS SECONDARY TO CARDIAC DYSFUNCTION (Severity 4.0)  
    - HCFA: RESPIRATORY FAILURE W MCC  

    Medications:  
    - Furosemide IV  
    - Nitroglycerin Drip  
    - Morphine IV (dyspnea relief in CHF)  
    - Oxygen Therapy (high-flow)  
    - Piperacillin-Tazobactam (Zosyn)  
    - Metoprolol Tartrate  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Heparin SC  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Furosemide IV: IV bolus, Discontinued via patient discharge  
    - Nitroglycerin Drip: Continuous IV, Discontinued via patient discharge  
    - Morphine IV: IV, Discontinued via patient discharge  
    - Oxygen Therapy: High-flow nasal cannula, Discontinued via patient discharge  
    - Piperacillin-Tazobactam (Zosyn): IV, Discontinued via patient discharge  
    - Metoprolol Tartrate: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Echocardiogram (TTE)  
    - Pulmonary Function Testing (PFTs)  
    - Arterial Line Placement  
    - Endotracheal Intubation with Mechanical Ventilation


Patient 60001280  
Gender: Male  
Age: 24  
Race: HISPANIC  

Admission 70125894  
    DRGs:  
    - APR: UNSPECIFIED ACUTE APPENDICITIS - INITIAL PRESENTATION (Severity 3.0)  
    - HCFA: ACUTE APPENDICITIS W/O PERITONITIS W/O MCC  

    Medications:  
    - Piperacillin-Tazobactam 3.375 g IV q6h  
    - Ondansetron 4 mg IV q6h PRN  
    - Morphine 4 mg IV q4h PRN  
    - Acetaminophen 650 mg PO q6h PRN  
    - Sodium Chloride 0.9% Flush  
    - Ceftriaxone 2 g IV q24h  

    Orders:  
    - Piperacillin-Tazobactam: IV, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Morphine: IV, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Ceftriaxone: IV, Discontinued via patient discharge  

    Procedures:  
    - CT abdomen and pelvis with contrast  
    - IV fluid bolus for resuscitation  
    - Preoperative blood work and anesthesia clearance  

---

Admission 71490312  
    DRGs:  
    - APR: LAPAROSCOPIC APPENDECTOMY FOR ACUTE APPENDICITIS (Severity 4.0)  
    - HCFA: LAPAROSCOPIC APPENDECTOMY W CC  

    Medications:  
    - Piperacillin-Tazobactam 3.375 g IV q6h  
    - Ceftriaxone 2 g IV q24h  
    - Metronidazole 500 mg IV q8h  
    - Hydromorphone 0.5 mg IV q4h PRN  
    - Ondansetron 4 mg IV PRN  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Piperacillin-Tazobactam: IV, Discontinued via patient discharge  
    - Ceftriaxone: IV, Discontinued via patient discharge  
    - Metronidazole: IV, Discontinued via patient discharge  
    - Hydromorphone: IV, PRN, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Laparoscopic appendectomy  
    - Intraoperative irrigation of peritoneal cavity  
    - Placement of JP drain due to intraoperative findings  

---

Admission 72844576  
    DRGs:  
    - APR: POSTOPERATIVE FOLLOW-UP FOR ACUTE APPENDICITIS (Severity 1.0)  
    - HCFA: OUTPATIENT POST-SURGICAL CARE  

    Medications:  
    - Amoxicillin-Clavulanate 875/125 mg PO BID for 7 days  
    - Ibuprofen 600 mg PO q6h PRN  
    - Ondansetron 4 mg PO PRN  
    - Acetaminophen 650 mg PO PRN  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Amoxicillin-Clavulanate: PO, Discontinued via patient discharge  
    - Ibuprofen: PO, PRN, Discontinued via patient discharge  
    - Ondansetron: PO, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Wound check and dressing change  
    - Removal of surgical staples  
    - Postoperative ultrasound to rule out intra-abdominal abscess  


Patient 10001281  
Gender: Female  
Age: 54  
Race: WHITE  

Admission 74125689  
    DRGs:  
    - APR: MALIGNANT NEOPLASM OF BREAST - INITIAL PRESENTATION (Severity 3.0)  
    - HCFA: BREAST CANCER W/O MCC  

    Medications:  
    - Doxorubicin 60 mg/m² IV q21d (cycle-based)  
    - Cyclophosphamide 600 mg/m² IV q21d  
    - Ondansetron 8 mg IV q8h PRN for nausea  
    - Dexamethasone 8 mg PO daily (chemo pre-medication)  
    - Filgrastim 300 mcg SC daily x5 days post-chemo  
    - Acetaminophen 650 mg PO PRN  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Doxorubicin: IV, Discontinued via patient discharge  
    - Cyclophosphamide: IV, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Filgrastim: SC, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Ultrasound-guided core needle breast biopsy  
    - Staging MRI of breast and axilla  
    - Port-a-cath placement for chemotherapy administration  

---

Admission 75438214  
    DRGs:  
    - APR: PARTIAL MASTECTOMY W AXILLARY NODE SAMPLING (Severity 4.0)  
    - HCFA: BREAST SURGERY W CC  

    Medications:  
    - Cefazolin 2 g IV perioperatively  
    - Morphine 2 mg IV q4h PRN  
    - Ondansetron 4 mg IV PRN  
    - Ketorolac 30 mg IV q6h  
    - Acetaminophen 1 g PO q8h  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  

    Orders:  
    - Cefazolin: IV, Discontinued via patient discharge  
    - Morphine: IV, PRN, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Ketorolac: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Enoxaparin: SC, Discontinued via patient discharge  

    Procedures:  
    - Lumpectomy with sentinel lymph node biopsy  
    - Axillary lymph node dissection  
    - Intraoperative frozen section pathology  

---

Admission 76901527  
    DRGs:  
    - APR: ADJUVANT RADIATION THERAPY FOR BREAST CANCER (Severity 2.0)  
    - HCFA: RADIATION THERAPY - OUTPATIENT FOLLOW-UP  

    Medications:  
    - Tamoxifen 20 mg PO daily  
    - Ondansetron 4 mg PO PRN  
    - Lorazepam 1 mg PO PRN for treatment-related anxiety  
    - Ibuprofen 600 mg PO q6h PRN  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Tamoxifen: PO, Discontinued via patient discharge  
    - Ondansetron: PO, PRN, Discontinued via patient discharge  
    - Lorazepam: PO, PRN, Discontinued via patient discharge  
    - Ibuprofen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - External beam radiation therapy planning CT  
    - Adjuvant radiation delivery to breast and axilla  
    - Follow-up oncology evaluation for long-term treatment response  


Patient 20001281  
Gender: Female  
Age: 49  
Race: BLACK/AFRICAN AMERICAN  

Admission 78245109  
    DRGs:  
    - APR: MALIGNANT NEOPLASM OF BREAST - INITIAL DIAGNOSIS & WORKUP (Severity 3.0)  
    - HCFA: BREAST CANCER W/O MCC  

    Medications:  
    - Paclitaxel 175 mg/m² IV q21d  
    - Carboplatin AUC 5 IV q21d  
    - Dexamethasone 8 mg PO daily (pre-medication)  
    - Ondansetron 8 mg IV q8h PRN  
    - Filgrastim 300 mcg SC daily x5 days post-chemo  
    - Lorazepam 1 mg PO PRN  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Paclitaxel: IV, Discontinued via patient discharge  
    - Carboplatin: IV, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Filgrastim: SC, Discontinued via patient discharge  
    - Lorazepam: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Ultrasound-guided breast biopsy  
    - MRI of bilateral breasts for staging  
    - Port-a-cath placement for chemotherapy  

---

Admission 79624587  
    DRGs:  
    - APR: MODIFIED RADICAL MASTECTOMY WITH AXILLARY DISSECTION (Severity 4.0)  
    - HCFA: BREAST SURGERY W CC  

    Medications:  
    - Cefazolin 2 g IV perioperatively  
    - Hydromorphone 0.5 mg IV q4h PRN  
    - Acetaminophen 1 g PO q8h  
    - Ondansetron 4 mg IV PRN  
    - Ketorolac 30 mg IV q6h  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  

    Orders:  
    - Cefazolin: IV, Discontinued via patient discharge  
    - Hydromorphone: IV, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Ketorolac: IV, Discontinued via patient discharge  
    - Enoxaparin: SC, Discontinued via patient discharge  

    Procedures:  
    - Right-sided modified radical mastectomy  
    - Axillary lymph node dissection (level I & II nodes)  
    - Intraoperative frozen pathology for nodal staging  

---

Admission 81235967  
    DRGs:  
    - APR: POSTOPERATIVE FOLLOW-UP & ADJUVANT THERAPY INITIATION (Severity 2.0)  
    - HCFA: OUTPATIENT BREAST CANCER MANAGEMENT  

    Medications:  
    - Letrozole 2.5 mg PO daily  
    - Zoledronic acid 4 mg IV q6mo for bone protection  
    - Ondansetron 4 mg PO PRN  
    - Ibuprofen 600 mg PO q6h PRN  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Letrozole: PO, Discontinued via patient discharge  
    - Zoledronic acid: IV, Discontinued via patient discharge  
    - Ondansetron: PO, PRN, Discontinued via patient discharge  
    - Ibuprofen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Postoperative wound evaluation and dressing changes  
    - Initiation of adjuvant endocrine therapy  
    - Dual-energy X-ray absorptiometry (DEXA) scan for baseline bone density  


Patient 30001281  
Gender: Female  
Age: 57  
Race: WHITE  

Admission 86420319  
    DRGs:  
    - APR: MALIGNANT NEOPLASM OF RIGHT BREAST - INITIAL STAGING & CHEMOTHERAPY (Severity 3.0)  
    - HCFA: BREAST CANCER W/O MCC  

    Medications:  
    - Doxorubicin 60 mg/m² IV q21d  
    - Cyclophosphamide 600 mg/m² IV q21d  
    - Pegfilgrastim 6 mg SC once per cycle  
    - Ondansetron 8 mg IV q8h PRN nausea  
    - Dexamethasone 8 mg PO daily (chemo pre-med)  
    - Lorazepam 1 mg PO PRN anxiety  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Doxorubicin: IV, Discontinued via patient discharge  
    - Cyclophosphamide: IV, Discontinued via patient discharge  
    - Pegfilgrastim: SC, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Lorazepam: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Ultrasound-guided core biopsy of right breast  
    - PET-CT for staging and lymph node mapping  
    - Port-a-cath placement for systemic therapy  

---

Admission 87563427  
    DRGs:  
    - APR: RIGHT MODIFIED RADICAL MASTECTOMY WITH LYMPH NODE DISSECTION (Severity 4.0)  
    - HCFA: BREAST SURGERY W CC  

    Medications:  
    - Cefazolin 2 g IV perioperatively  
    - Morphine 2 mg IV q4h PRN  
    - Ondansetron 4 mg IV PRN  
    - Acetaminophen 1 g PO q8h  
    - Ketorolac 30 mg IV q6h  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  

    Orders:  
    - Cefazolin: IV, Discontinued via patient discharge  
    - Morphine: IV, PRN, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ketorolac: IV, Discontinued via patient discharge  
    - Enoxaparin: SC, Discontinued via patient discharge  

    Procedures:  
    - Right modified radical mastectomy  
    - Sentinel and axillary lymph node dissection  
    - Intraoperative frozen section nodal pathology  

---

Admission 89374251  
    DRGs:  
    - APR: ADJUVANT RADIATION THERAPY & HORMONAL TREATMENT INITIATION (Severity 2.0)  
    - HCFA: RADIATION THERAPY OUTPATIENT FOLLOW-UP  

    Medications:  
    - Letrozole 2.5 mg PO daily  
    - Zoledronic acid 4 mg IV q6mo  
    - Ondansetron 4 mg PO PRN  
    - Ibuprofen 600 mg PO q6h PRN  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Letrozole: PO, Discontinued via patient discharge  
    - Zoledronic acid: IV, Discontinued via patient discharge  
    - Ondansetron: PO, PRN, Discontinued via patient discharge  
    - Ibuprofen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Adjuvant external beam radiation therapy  
    - CT-based treatment planning and simulation  
    - Postoperative oncologic evaluation with breast MRI  


Patient 40001281  
Gender: Male  
Age: 66  
Race: WHITE  

Admission 74591302  
    DRGs:  
    - APR: MALIGNANT NEOPLASM OF LUNG - INITIAL DIAGNOSIS & STAGING (Severity 3.0)  
    - HCFA: LUNG CANCER W/O MCC  

    Medications:  
    - Cisplatin 75 mg/m² IV day 1 q21d  
    - Pemetrexed 500 mg/m² IV day 1 q21d  
    - Folic Acid 1 mg PO daily (pre-Pemetrexed)  
    - Vitamin B12 1,000 mcg IM q9wks  
    - Ondansetron 8 mg IV q8h PRN  
    - Dexamethasone 8 mg PO BID day before & after chemo  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Cisplatin: IV, Discontinued via patient discharge  
    - Pemetrexed: IV, Discontinued via patient discharge  
    - Folic Acid: PO, Discontinued via patient discharge  
    - Vitamin B12: IM, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Dexamethasone: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - CT-guided lung mass biopsy  
    - PET-CT for staging  
    - Mediastinoscopy for nodal sampling  

---

Admission 75942817  
    DRGs:  
    - APR: LOBECTOMY OF LUNG WITH MEDIASTINAL LYMPH NODE DISSECTION (Severity 4.0)  
    - HCFA: THORACIC SURGERY W CC  

    Medications:  
    - Cefazolin 2 g IV perioperatively  
    - Hydromorphone 0.5 mg IV q4h PRN  
    - Acetaminophen 1 g PO q8h  
    - Ketorolac 30 mg IV q6h  
    - Ondansetron 4 mg IV PRN  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  

    Orders:  
    - Cefazolin: IV, Discontinued via patient discharge  
    - Hydromorphone: IV, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ketorolac: IV, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Enoxaparin: SC, Discontinued via patient discharge  

    Procedures:  
    - Right upper lobectomy via VATS  
    - Mediastinal lymph node dissection  
    - Chest tube placement with postoperative drainage  

---

Admission 77461594  
    DRGs:  
    - APR: ADJUVANT IMMUNOTHERAPY FOLLOW-UP (Severity 2.0)  
    - HCFA: LUNG CANCER OUTPATIENT MANAGEMENT  

    Medications:  
    - Pembrolizumab 200 mg IV q3wks  
    - Albuterol Inhaler PRN  
    - Fluticasone-Salmeterol Inhaler BID  
    - Acetaminophen 650 mg PO q6h PRN  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Pembrolizumab: IV, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, PRN, Discontinued via patient discharge  
    - Fluticasone-Salmeterol: IH, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - CT chest follow-up for tumor response  
    - Pulmonary function testing  
    - Oncology-directed surveillance planning  


Patient 50001281  
Gender: Female  
Age: 46  
Race: WHITE  

Admission 61248390  
    DRGs:  
    - APR: BREAST DISORDERS EXCEPT MALIGNANCY (Severity 1.0)  
    - HCFA: BENIGN MAMMARY DYSPLASIA W/O CC/MCC  

    Medications:  
    - Acetaminophen  
    - Ibuprofen 600mg  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  
    - Cephalexin 500mg  
    - Lorazepam (for peri-procedural anxiety)  

    Orders:  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ibuprofen 600mg: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  
    - Cephalexin 500mg: PO, Discontinued via patient discharge  
    - Lorazepam: PO, Discontinued via patient discharge  

    Procedures:  
    - Bilateral breast ultrasound  
    - Mammography screening  
    - Core needle aspiration biopsy  

Admission 62459127  
    DRGs:  
    - APR: BREAST BIOPSY & EXCISION PROCEDURES (Severity 2.0)  
    - HCFA: BREAST BIOPSY W CC  

    Medications:  
    - Cefazolin IV (peri-operative prophylaxis)  
    - Ketorolac IV  
    - Acetaminophen  
    - Oxycodone 5mg  
    - Sodium Chloride 0.9% Flush  
    - Ondansetron IV  
    - Heparin SC (DVT prophylaxis)  

    Orders:  
    - Cefazolin IV: IV, Once, Discontinued via patient discharge  
    - Ketorolac IV: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Oxycodone 5mg: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  

    Procedures:  
    - Excisional biopsy of right breast lesion  
    - Sentinel lymph node sampling  
    - Pathology tissue analysis  

Admission 63710284  
    DRGs:  
    - APR: COMPLICATIONS OF BREAST PROCEDURES (Severity 2.0)  
    - HCFA: POST-OPERATIVE BREAST COMPLICATIONS W CC  

    Medications:  
    - Piperacillin-Tazobactam (Zosyn) IV  
    - Acetaminophen  
    - Morphine IV PRN  
    - Ondansetron IV  
    - Sodium Chloride 0.9% Flush  
    - Enoxaparin SC  
    - Probiotic Supplement (Lactobacillus)  

    Orders:  
    - Piperacillin-Tazobactam: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Morphine IV: IV PRN, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Enoxaparin SC: SC, Discontinued via patient discharge  
    - Probiotic Supplement: PO, Discontinued via patient discharge  

    Procedures:  
    - Breast wound debridement  
    - Ultrasound-guided seroma drainage  
    - Repeat breast MRI for evaluation of healing


Patient 60001281  
Gender: Female  
Age: 42  
Race: WHITE  

Admission 78542013  
    DRGs:  
    - APR: ACUTE UPPER RESPIRATORY INFECTION WITHOUT COMPLICATIONS (Severity 1.0)  
    - HCFA: ACUTE URI W/O MCC  

    Medications:  
    - Acetaminophen 650 mg PO q6h PRN fever  
    - Ibuprofen 400 mg PO q6h PRN  
    - Guaifenesin 600 mg PO BID  
    - Loratadine 10 mg PO daily  
    - Saline Nasal Spray PRN  
    - Dextromethorphan 30 mg PO q12h PRN cough  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Ibuprofen: PO, PRN, Discontinued via patient discharge  
    - Guaifenesin: PO, Discontinued via patient discharge  
    - Loratadine: PO, Discontinued via patient discharge  
    - Saline Nasal Spray: IH, Discontinued via patient discharge  
    - Dextromethorphan: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Rapid influenza A/B testing  
    - COVID-19 PCR screening  
    - Throat swab culture for bacterial pathogens  

---

Admission 79268450  
    DRGs:  
    - APR: ACUTE URI WITH DEHYDRATION REQUIRING IV HYDRATION (Severity 2.0)  
    - HCFA: ACUTE RESPIRATORY INFECTION W CC  

    Medications:  
    - Acetaminophen 650 mg PO q6h  
    - Ondansetron 4 mg IV PRN nausea  
    - IV Fluids: Sodium Chloride 0.9% 1L bolus  
    - Benzonatate 200 mg PO TID PRN cough  
    - Oxymetazoline Nasal Spray BID x 3 days  
    - Albuterol Inhaler PRN wheezing  

    Orders:  
    - Sodium Chloride IV Bolus: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Benzonatate: PO, PRN, Discontinued via patient discharge  
    - Oxymetazoline Nasal Spray: IH, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, PRN, Discontinued via patient discharge  

    Procedures:  
    - Chest X-ray to rule out pneumonia  
    - Pulse oximetry monitoring  
    - Basic metabolic panel for hydration status  

---

Admission 80413572  
    DRGs:  
    - APR: FOLLOW-UP VISIT FOR ACUTE URI RECOVERY (Severity 1.0)  
    - HCFA: OUTPATIENT RESPIRATORY EVALUATION  

    Medications:  
    - Fluticasone Nasal Spray 2 sprays each nostril daily  
    - Cetirizine 10 mg PO daily  
    - Vitamin C 500 mg PO daily  
    - Zinc Sulfate 50 mg PO daily  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Fluticasone Nasal Spray: IH, Discontinued via patient discharge  
    - Cetirizine: PO, Discontinued via patient discharge  
    - Vitamin C: PO, Discontinued via patient discharge  
    - Zinc Sulfate: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Outpatient pulmonary function testing  
    - Upper airway endoscopic evaluation  
    - Preventive counseling on respiratory infection avoidance  


Patient 10001282  
Gender: Female  
Age: 29  
Race: WHITE  

Admission 81245739  
    DRGs:  
    - APR: MAJOR DEPRESSIVE DISORDER - INITIAL EVALUATION & MANAGEMENT (Severity 1.0)  
    - HCFA: MILD MDD W/O PSYCHOSIS  

    Medications:  
    - Sertraline 25 mg PO daily  
    - Hydroxyzine 25 mg PO q6h PRN anxiety  
    - Trazodone 50 mg PO at bedtime PRN insomnia  
    - Acetaminophen 650 mg PO PRN mild headache  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Initiate Sertraline 25 mg PO daily, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Trazodone: PO, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Initial psychiatric evaluation  
    - PHQ-9 screening for depression severity  
    - Baseline labs (TSH, CMP, CBC) to rule out organic causes  

---

Admission 82354107  
    DRGs:  
    - APR: OUTPATIENT COGNITIVE-BEHAVIORAL THERAPY (CBT) FOLLOW-UP (Severity 1.0)  
    - HCFA: MILD MDD W/O MCC  

    Medications:  
    - Sertraline 50 mg PO daily (dose titrated)  
    - Hydroxyzine 10 mg PO q8h PRN  
    - Vitamin D3 2,000 IU PO daily  
    - Melatonin 3 mg PO at bedtime  

    Orders:  
    - Sertraline titration to 50 mg daily, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Vitamin D3: PO, Discontinued via patient discharge  
    - Melatonin: PO, Discontinued via patient discharge  

    Procedures:  
    - Weekly CBT therapy sessions  
    - Structured journaling and mood monitoring  
    - Lifestyle counseling: sleep hygiene, nutrition, exercise  

---

Admission 83672058  
    DRGs:  
    - APR: PSYCHIATRIC MAINTENANCE FOLLOW-UP (Severity 1.0)  
    - HCFA: DEPRESSION MEDICATION RESPONSE REVIEW  

    Medications:  
    - Sertraline 50 mg PO daily  
    - Bupropion SR 100 mg PO QAM (added for persistent low energy)  
    - Omega-3 Fatty Acids 1 g PO daily  
    - Lorazepam 0.5 mg PO PRN severe anxiety  

    Orders:  
    - Continue Sertraline 50 mg PO, Discontinued via patient discharge  
    - Start Bupropion SR 100 mg PO, Discontinued via patient discharge  
    - Omega-3 supplementation: PO, Discontinued via patient discharge  
    - Lorazepam: PO, PRN, Discontinued via patient discharge  

    Procedures:  
    - Hamilton Depression Rating Scale reassessment  
    - Medication adherence counseling  
    - Follow-up telehealth appointment scheduling  


Patient 20001282  
Gender: Female  
Age: 37  
Race: WHITE  

Admission 84521096  
    DRGs:  
    - APR: MILD MAJOR DEPRESSIVE DISORDER - INITIAL DIAGNOSIS (Severity 1.0)  
    - HCFA: SINGLE EPISODE MDD W/O PSYCHOSIS  

    Medications:  
    - Escitalopram 5 mg PO daily  
    - Hydroxyzine 10 mg PO TID PRN anxiety  
    - Acetaminophen 650 mg PO q6h PRN headaches  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Start Escitalopram 5 mg PO daily, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Comprehensive psychiatric evaluation  
    - PHQ-9 screening  
    - CBC, CMP, and TSH to rule out organic contributors  

---

Admission 85634781  
    DRGs:  
    - APR: FOLLOW-UP FOR ANTIDEPRESSANT TITRATION (Severity 1.0)  
    - HCFA: OUTPATIENT DEPRESSION MANAGEMENT W/O MCC  

    Medications:  
    - Escitalopram 10 mg PO daily (titrated dose)  
    - Hydroxyzine 25 mg PO q8h PRN anxiety  
    - Melatonin 3 mg PO nightly for sleep regulation  
    - Omega-3 Fatty Acids 1 g PO daily  

    Orders:  
    - Escitalopram increased to 10 mg PO, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Melatonin: PO, Discontinued via patient discharge  
    - Omega-3 Fatty Acids: PO, Discontinued via patient discharge  

    Procedures:  
    - Cognitive Behavioral Therapy (CBT) initiation  
    - Weekly mood tracking assignments  
    - Sleep hygiene counseling  

---

Admission 87269012  
    DRGs:  
    - APR: MAINTENANCE AND STABILITY FOLLOW-UP (Severity 1.0)  
    - HCFA: DEPRESSION MEDICATION RESPONSE REVIEW  

    Medications:  
    - Escitalopram 10 mg PO daily  
    - Bupropion XL 150 mg PO QAM (added for fatigue)  
    - Vitamin D3 2,000 IU PO daily  
    - Lorazepam 0.5 mg PO PRN severe anxiety  

    Orders:  
    - Continue Escitalopram 10 mg PO, Discontinued via patient discharge  
    - Start Bupropion XL 150 mg PO, Discontinued via patient discharge  
    - Vitamin D3: PO, Discontinued via patient discharge  
    - Lorazepam: PO, PRN, Discontinued via patient discharge  

    Procedures:  
    - Hamilton Depression Rating Scale reassessment  
    - CBT progress evaluation  
    - Telehealth follow-up scheduling  


Patient 30001282  
Gender: Female  
Age: 42  
Race: WHITE  

Admission 90231458  
    DRGs:  
    - APR: MODERATE MAJOR DEPRESSIVE DISORDER - INITIAL EVALUATION (Severity 2.0)  
    - HCFA: SINGLE EPISODE MDD W/O PSYCHOSIS  

    Medications:  
    - Fluoxetine 10 mg PO daily  
    - Hydroxyzine 25 mg PO q8h PRN anxiety  
    - Trazodone 50 mg PO at bedtime PRN insomnia  
    - Acetaminophen 650 mg PO PRN mild headache  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Start Fluoxetine 10 mg PO daily, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Trazodone: PO, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Psychiatric diagnostic evaluation  
    - PHQ-9 depression screening  
    - Baseline labs (CBC, CMP, TSH, Vitamin B12)  

---

Admission 91854726  
    DRGs:  
    - APR: FOLLOW-UP FOR ANTIDEPRESSANT TITRATION & THERAPY INTEGRATION (Severity 2.0)  
    - HCFA: OUTPATIENT MDD MANAGEMENT W/O MCC  

    Medications:  
    - Fluoxetine 20 mg PO daily (titrated dose)  
    - Hydroxyzine 10 mg PO PRN anxiety  
    - Vitamin D3 2000 IU PO daily  
    - Melatonin 5 mg PO at bedtime  
    - Omega-3 Fatty Acids 1 g PO daily  

    Orders:  
    - Increase Fluoxetine to 20 mg PO daily, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Vitamin D3: PO, Discontinued via patient discharge  
    - Melatonin: PO, Discontinued via patient discharge  
    - Omega-3 Fatty Acids: PO, Discontinued via patient discharge  

    Procedures:  
    - Cognitive Behavioral Therapy (CBT) initiation  
    - Weekly group therapy sessions  
    - Mood and sleep diary tracking  
    - Lifestyle counseling for stress management  

---

Admission 93462081  
    DRGs:  
    - APR: MAINTENANCE MANAGEMENT & AUGMENTATION THERAPY (Severity 2.0)  
    - HCFA: RESPONSE TO DEPRESSION TREATMENT REVIEW  

    Medications:  
    - Fluoxetine 20 mg PO daily  
    - Bupropion XL 150 mg PO every morning (augmentation for persistent low energy)  
    - Lorazepam 0.5 mg PO PRN severe anxiety  
    - Magnesium Glycinate 200 mg PO nightly for sleep  

    Orders:  
    - Continue Fluoxetine 20 mg PO daily, Discontinued via patient discharge  
    - Start Bupropion XL 150 mg PO daily, Discontinued via patient discharge  
    - Lorazepam: PO, PRN, Discontinued via patient discharge  
    - Magnesium Glycinate: PO, Discontinued via patient discharge  

    Procedures:  
    - Hamilton Depression Rating Scale reassessment  
    - Medication adherence counseling  
    - CBT progress evaluation  
    - Telepsychiatry follow-up appointment scheduling  


Patient 40001282  
Gender: Female  
Age: 35  
Race: WHITE  

Admission 77102546  
    DRGs:  
    - APR: GENERALIZED ANXIETY DISORDER - INITIAL EVALUATION (Severity 2.0)  
    - HCFA: GAD W/O PSYCHOSIS OR SEVERE IMPAIRMENT  

    Medications:  
    - Sertraline 25 mg PO daily  
    - Hydroxyzine 25 mg PO q8h PRN anxiety  
    - Acetaminophen 650 mg PO PRN mild headache  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Start Sertraline 25 mg PO daily, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - GAD-7 anxiety assessment  
    - Baseline labs (TSH, CBC, CMP, Vitamin D)  
    - Initial mental health intake evaluation  

---

Admission 78154092  
    DRGs:  
    - APR: FOLLOW-UP VISIT FOR MEDICATION TITRATION (Severity 2.0)  
    - HCFA: OUTPATIENT MANAGEMENT OF ANXIETY DISORDERS  

    Medications:  
    - Sertraline 50 mg PO daily (titrated dose)  
    - Buspirone 10 mg PO BID  
    - Hydroxyzine 10 mg PO PRN  
    - Vitamin D3 2000 IU PO daily  
    - Melatonin 5 mg PO nightly for sleep support  

    Orders:  
    - Increase Sertraline to 50 mg PO daily, Discontinued via patient discharge  
    - Start Buspirone 10 mg PO BID, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Vitamin D3: PO, Discontinued via patient discharge  
    - Melatonin: PO, Discontinued via patient discharge  

    Procedures:  
    - Cognitive Behavioral Therapy (CBT) initiation  
    - Breathing retraining and relaxation techniques  
    - Sleep hygiene counseling  
    - GAD-7 reassessment to evaluate treatment response  

---

Admission 79561234  
    DRGs:  
    - APR: AUGMENTATION AND MAINTENANCE MANAGEMENT (Severity 2.0)  
    - HCFA: LONG-TERM MANAGEMENT OF GAD WITH MEDICATION AND THERAPY  

    Medications:  
    - Sertraline 50 mg PO daily  
    - Buspirone 10 mg PO BID  
    - Propranolol 10 mg PO PRN for performance anxiety  
    - Omega-3 Fatty Acids 1 g PO daily  
    - Lorazepam 0.5 mg PO PRN severe anxiety (short-term use)  

    Orders:  
    - Continue Sertraline 50 mg PO daily, Discontinued via patient discharge  
    - Continue Buspirone 10 mg PO BID, Discontinued via patient discharge  
    - Start Propranolol 10 mg PO PRN, Discontinued via patient discharge  
    - Lorazepam: PO, PRN, Discontinued via patient discharge  
    - Omega-3 Fatty Acids: PO, Discontinued via patient discharge  

    Procedures:  
    - GAD-7 score monitoring  
    - CBT progress evaluation  
    - Mindfulness-based stress reduction (MBSR) therapy  
    - Telepsychiatry follow-up appointment scheduling  


Patient 50001282  
Gender: Female  
Age: 39  
Race: WHITE  

Admission 70124852  
    DRGs:  
    - APR: ANXIETY, STRESS & ADJUSTMENT DISORDERS (Severity 2.0)  
    - HCFA: POST-TRAUMATIC STRESS DISORDER W/O MCC  

    Medications:  
    - Sertraline 50mg  
    - Hydroxyzine 25mg  
    - Trazodone 50mg  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Sertraline: PO, Discontinued via patient discharge  
    - Hydroxyzine: PO, Discontinued via patient discharge  
    - Trazodone: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Psychiatric evaluation  
    - Screening for comorbid depression (PHQ-9)  
    - Sleep hygiene counseling  

Admission 71365907  
    DRGs:  
    - APR: ACUTE EXACERBATION OF PTSD SYMPTOMS (Severity 3.0)  
    - HCFA: POST-TRAUMATIC STRESS DISORDER W CC  

    Medications:  
    - Sertraline 100mg  
    - Prazosin 2mg (for nightmares)  
    - Lorazepam 1mg PRN  
    - Quetiapine 25mg  
    - Sodium Chloride 0.9% Flush  
    - Ondansetron IV  
    - Diphenhydramine 25mg  

    Orders:  
    - Sertraline: PO, Discontinued via patient discharge  
    - Prazosin: PO, Discontinued via patient discharge  
    - Lorazepam: PO PRN, Discontinued via patient discharge  
    - Quetiapine: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Diphenhydramine 25mg: PO, Discontinued via patient discharge  

    Procedures:  
    - Intensive psychiatric monitoring  
    - Trauma-focused cognitive behavioral therapy (TF-CBT)  
    - Sleep study for insomnia  

Admission 72638415  
    DRGs:  
    - APR: SEVERE PTSD WITH COMORBIDITIES (Severity 4.0)  
    - HCFA: POST-TRAUMATIC STRESS DISORDER W MCC  

    Medications:  
    - Venlafaxine XR 150mg  
    - Clonazepam 0.5mg BID  
    - Gabapentin 300mg  
    - Zolpidem 10mg (for insomnia)  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Propranolol 10mg (for autonomic symptoms)  

    Orders:  
    - Venlafaxine XR: PO, Discontinued via patient discharge  
    - Clonazepam: PO, Discontinued via patient discharge  
    - Gabapentin: PO, Discontinued via patient discharge  
    - Zolpidem: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Propranolol: PO, Discontinued via patient discharge  

    Procedures:  
    - Inpatient psychiatric stabilization  
    - Group trauma therapy sessions  
    - Biofeedback and relaxation training  
    - Continuous sleep monitoring


Patient 60001282  
Gender: Female  
Age: 28  
Race: WHITE  

Admission 65091824  
    DRGs:  
    - APR: UNSPECIFIED CONJUNCTIVITIS - INITIAL EVALUATION (Severity 1.0)  
    - HCFA: ACUTE CONJUNCTIVITIS W/O COMPLICATIONS  

    Medications:  
    - Erythromycin Ophthalmic Ointment 0.5%, Apply to affected eye QID x 7 days  
    - Artificial Tears Ophthalmic Solution, 1 drop OU QID PRN dryness  
    - Loratadine 10 mg PO daily for associated allergic symptoms  
    - Acetaminophen 500 mg PO PRN mild discomfort  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Start Erythromycin Ophthalmic Ointment: Topical, Discontinued via patient discharge  
    - Artificial Tears: Ophthalmic, PRN, Discontinued via patient discharge  
    - Loratadine: PO daily, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Slit-lamp examination of both eyes  
    - Fluorescein staining for corneal involvement  
    - Conjunctival swab for bacterial culture  

---

Admission 66143709  
    DRGs:  
    - APR: PERSISTENT CONJUNCTIVITIS FOLLOW-UP (Severity 1.0)  
    - HCFA: FOLLOW-UP CARE FOR UNSPECIFIED CONJUNCTIVITIS  

    Medications:  
    - Tobramycin Ophthalmic Drops 0.3%, 1 drop OD q4h x 7 days  
    - Cetirizine 10 mg PO daily for itching and watery eyes  
    - Warm Compress Therapy BID  
    - Ibuprofen 400 mg PO PRN eye pain  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Start Tobramycin Ophthalmic Drops: Topical, Discontinued via patient discharge  
    - Cetirizine: PO daily, Discontinued via patient discharge  
    - Warm Compresses: Apply BID, Discontinued via patient discharge  
    - Ibuprofen: PO, PRN, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Visual acuity testing  
    - Ocular pH testing (negative for chemical injury)  
    - Patient education on hygiene and avoiding eye touching  

---

Admission 67458230  
    DRGs:  
    - APR: RECURRENT CONJUNCTIVITIS WITH DIFFERENTIAL ASSESSMENT (Severity 2.0)  
    - HCFA: CONJUNCTIVITIS - RULE OUT VIRAL VS ALLERGIC  

    Medications:  
    - Olopatadine Ophthalmic Drops 0.2%, 1 drop OU daily for allergic relief  
    - Prednisolone Acetate Ophthalmic Suspension 1%, 1 drop OS BID x 5 days (short course)  
    - Diphenhydramine 25 mg PO at bedtime PRN itching  
    - Sodium Chloride 0.9% Flush  
    - Vitamin D3 1000 IU PO daily  

    Orders:  
    - Start Olopatadine Ophthalmic Drops: Ophthalmic, Discontinued via patient discharge  
    - Prednisolone Ophthalmic Suspension: Topical, Discontinued via patient discharge  
    - Diphenhydramine: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Vitamin D3: PO, Discontinued via patient discharge  

    Procedures:  
    - PCR testing for adenovirus and HSV  
    - Tear osmolarity testing  
    - Education on avoiding contact lenses until symptoms resolve  
    - Scheduled follow-up with ophthalmology in 1 week  


Patient 10001283  
Gender: Female  
Age: 63  
Race: BLACK/AFRICAN AMERICAN  

Admission 78124560  
    DRGs:  
    - APR: SEPSIS DUE TO OTHER GRAM-NEGATIVE ORGANISMS (Severity 4.0)  
    - HCFA: SEVERE SEPSIS W/ ACUTE ORGAN DYSFUNCTION  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV q6h  
    - Vancomycin IV per pharmacy dosing protocol  
    - Norepinephrine IV infusion (titrated for MAP > 65 mmHg)  
    - Acetaminophen 650 mg PO q6h PRN fever  
    - Sodium Chloride 0.9% IV continuous infusion  
    - Insulin Regular IV infusion per sliding scale  
    - Pantoprazole 40 mg IV daily  
    - Heparin 5000 units SC q8h for DVT prophylaxis  

    Orders:  
    - Start broad-spectrum antibiotics (Piperacillin-Tazobactam + Vancomycin), Discontinued via patient discharge  
    - Initiate norepinephrine infusion for hypotension, Discontinued via patient discharge  
    - Blood cultures x2 before antibiotic administration, Completed  
    - Insert central venous catheter for pressor support, Completed  
    - Sodium Chloride 0.9% IV: Continuous infusion, Discontinued via patient discharge  
    - Acetaminophen: PO, PRN, Discontinued via patient discharge  
    - Pantoprazole: IV, Discontinued via patient discharge  
    - Heparin prophylaxis: SC, Discontinued via patient discharge  

    Procedures:  
    - Central venous catheter placement  
    - Arterial blood gas analysis  
    - Continuous cardiac telemetry monitoring  
    - Initial sepsis resuscitation bundle initiation (30 mL/kg crystalloid bolus)  

---

Admission 79243681  
    DRGs:  
    - APR: SEPTIC SHOCK MANAGEMENT AND ORGAN SUPPORT (Severity 4.0)  
    - HCFA: GRAM-NEGATIVE BACTEREMIA WITH RENAL FAILURE  

    Medications:  
    - Meropenem 1 g IV q8h (switched from Piperacillin-Tazobactam based on cultures)  
    - Gentamicin 5 mg/kg IV q24h (synergy for multidrug-resistant E. coli)  
    - Hydrocortisone 50 mg IV q6h for refractory septic shock  
    - Norepinephrine IV infusion  
    - Midodrine 10 mg PO TID for weaning from pressors  
    - Furosemide 40 mg IV PRN for volume overload  
    - Calcium Gluconate IV PRN for electrolyte correction  

    Orders:  
    - Switch antibiotic coverage to Meropenem + Gentamicin based on culture sensitivity, Discontinued via patient discharge  
    - Start hydrocortisone IV for refractory shock, Discontinued via patient discharge  
    - Blood cultures: Repeat x2, Completed  
    - Initiate continuous renal replacement therapy (CRRT), Completed  
    - Insert arterial line for blood pressure monitoring, Completed  
    - Midodrine: PO, Discontinued via patient discharge  

    Procedures:  
    - Continuous renal replacement therapy initiation  
    - Arterial line placement  
    - Serial lactate monitoring q4h  
    - Echocardiography to rule out septic cardiomyopathy  

---

Admission 80529344  
    DRGs:  
    - APR: POST-SEPSIS REHABILITATION & LONG-TERM FOLLOW-UP (Severity 2.0)  
    - HCFA: POST-SEPTIC SYNDROME WITH PERSISTENT INFLAMMATION  

    Medications:  
    - Ciprofloxacin 500 mg PO BID x 7 days (step-down therapy)  
    - Probiotic supplement PO daily to restore gut microbiota  
    - Vitamin C 1000 mg PO daily  
    - Gabapentin 300 mg PO BID for neuropathy  
    - Acetaminophen 500 mg PO PRN mild pain  

    Orders:  
    - Start Ciprofloxacin PO for outpatient therapy, Discontinued via patient discharge  
    - Begin probiotic supplementation, Discontinued via patient discharge  
    - Physical therapy referral for post-ICU syndrome, Completed  
    - Dietitian consult for nutritional optimization, Completed  

    Procedures:  
    - Follow-up blood cultures to ensure clearance of bacteremia  
    - Pulmonary function testing due to prolonged mechanical ventilation  
    - Outpatient nephrology follow-up scheduling for renal recovery assessment  


Patient 20001283  
Gender: Male  
Age: 70  
Race: WHITE  

Admission 80321542  
    DRGs:  
    - APR: SEPSIS DUE TO OTHER GRAM-NEGATIVE ORGANISMS (Severity 4.0)  
    - HCFA: GRAM-NEGATIVE SEPTICEMIA WITH ACUTE ORGAN DYSFUNCTION  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV q6h  
    - Vancomycin IV dosed per pharmacy protocol  
    - Norepinephrine IV infusion titrated for MAP > 65 mmHg  
    - Acetaminophen 650 mg PO q6h PRN fever  
    - Sodium Chloride 0.9% IV continuous infusion  
    - Insulin Regular IV per sliding scale protocol  
    - Pantoprazole 40 mg IV daily  
    - Heparin 5000 units SC q8h for DVT prophylaxis  

    Orders:  
    - Start broad-spectrum antibiotics (Piperacillin-Tazobactam + Vancomycin), Discontinued via patient discharge  
    - Initiate norepinephrine infusion for refractory hypotension, Discontinued via patient discharge  
    - Obtain blood cultures x2 prior to antibiotic initiation, Completed  
    - Insert central venous catheter for vasopressor administration, Completed  
    - Start pantoprazole IV for GI prophylaxis, Discontinued via patient discharge  
    - Heparin prophylaxis: SC, Discontinued via patient discharge  

    Procedures:  
    - Central venous catheter placement  
    - Initial sepsis resuscitation bundle with 30 mL/kg fluid bolus  
    - Continuous cardiac telemetry  
    - Arterial blood gas (ABG) assessment  

---

Admission 81546327  
    DRGs:  
    - APR: SEPTIC SHOCK MANAGEMENT WITH MULTI-ORGAN FAILURE (Severity 4.0)  
    - HCFA: GRAM-NEGATIVE SEPSIS WITH ACUTE RENAL FAILURE  

    Medications:  
    - Meropenem 1 g IV q8h (de-escalation based on cultures)  
    - Tobramycin IV once daily for synergy against multidrug-resistant Klebsiella  
    - Hydrocortisone 50 mg IV q6h for refractory septic shock  
    - Norepinephrine IV infusion  
    - Midodrine 10 mg PO TID for vasopressor weaning  
    - Furosemide 40 mg IV PRN for pulmonary edema  
    - Calcium Gluconate IV PRN electrolyte correction  

    Orders:  
    - De-escalate antibiotics to Meropenem + Tobramycin based on susceptibility results, Discontinued via patient discharge  
    - Start hydrocortisone IV for persistent hypotension, Discontinued via patient discharge  
    - Obtain repeat blood cultures x2, Completed  
    - Initiate continuous renal replacement therapy (CRRT) for AKI, Completed  
    - Place arterial line for invasive blood pressure monitoring, Completed  
    - Midodrine: PO, Discontinued via patient discharge  

    Procedures:  
    - Continuous renal replacement therapy initiation  
    - Arterial line placement  
    - Serial lactate monitoring every 4 hours  
    - Transthoracic echocardiogram to assess septic cardiomyopathy  

---

Admission 82751604  
    DRGs:  
    - APR: POST-SEPSIS REHABILITATION AND FOLLOW-UP (Severity 2.0)  
    - HCFA: RECOVERY PHASE AFTER GRAM-NEGATIVE SEPSIS  

    Medications:  
    - Ciprofloxacin 500 mg PO BID x 10 days (oral step-down therapy)  
    - Probiotic supplement PO daily  
    - Vitamin D3 2000 IU PO daily  
    - Gabapentin 300 mg PO BID for neuropathic pain from critical illness polyneuropathy  
    - Acetaminophen 500 mg PO PRN mild pain  

    Orders:  
    - Start Ciprofloxacin PO for outpatient therapy, Discontinued via patient discharge  
    - Start probiotics for gut microbiome restoration, Discontinued via patient discharge  
    - Refer to physical therapy for post-ICU weakness, Completed  
    - Dietitian consult for high-protein nutritional recovery, Completed  

    Procedures:  
    - Follow-up blood cultures to confirm clearance of bacteremia  
    - Pulmonary function testing after mechanical ventilation  
    - Outpatient nephrology follow-up for renal recovery  
    - Functional assessment and mental health screening for post-sepsis syndrome  


Patient 30001283  
Gender: Female  
Age: 66  
Race: WHITE  

Admission 84201934  
    DRGs:  
    - APR: SEPSIS DUE TO ANAEROBIC ORGANISMS (Severity 4.0)  
    - HCFA: ANAEROBIC SEPTICEMIA WITH ACUTE ORGAN DYSFUNCTION  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV q6h  
    - Metronidazole 500 mg IV q8h  
    - Vancomycin IV dosed per pharmacy protocol  
    - Norepinephrine IV infusion titrated to maintain MAP > 65 mmHg  
    - Acetaminophen 650 mg PO/NG q6h PRN fever  
    - Sodium Bicarbonate infusion PRN for metabolic acidosis  
    - Heparin 5000 units SC q8h for DVT prophylaxis  
    - Pantoprazole 40 mg IV daily for GI protection  

    Orders:  
    - Initiate Piperacillin-Tazobactam + Metronidazole combination therapy, Discontinued via patient discharge  
    - Add Vancomycin empirically for MRSA coverage, Discontinued via patient discharge  
    - Insert central venous catheter for pressor and antibiotic administration, Completed  
    - Start norepinephrine infusion for persistent hypotension, Discontinued via patient discharge  
    - Obtain blood cultures x2 prior to antibiotic initiation, Completed  
    - Pantoprazole IV: Discontinued via patient discharge  
    - Heparin SC: Discontinued via patient discharge  

    Procedures:  
    - Central venous catheter placement  
    - Initial sepsis bundle activation (30 mL/kg IV fluids)  
    - Arterial blood gas (ABG) assessment  
    - Continuous cardiac monitoring  

---

Admission 85236719  
    DRGs:  
    - APR: ANAEROBIC SEPSIS WITH MULTI-ORGAN FAILURE (Severity 4.0)  
    - HCFA: SEVERE SEPSIS WITH ACUTE KIDNEY INJURY AND RESPIRATORY FAILURE  

    Medications:  
    - Meropenem 1 g IV q8h (escalated therapy)  
    - Clindamycin 900 mg IV q8h (to inhibit toxin production)  
    - Hydrocortisone 50 mg IV q6h for refractory shock  
    - Norepinephrine IV infusion  
    - Vasopressin 0.03 units/min IV infusion for septic shock  
    - Insulin infusion for hyperglycemia management  
    - Calcium Gluconate IV PRN electrolyte stabilization  
    - Albuterol-Ipratropium Neb q6h PRN for ventilated bronchospasm  

    Orders:  
    - Switch to Meropenem + Clindamycin for extended anaerobic coverage, Discontinued via patient discharge  
    - Start Hydrocortisone IV for refractory hypotension, Discontinued via patient discharge  
    - Initiate Vasopressin infusion for persistent hypotension, Discontinued via patient discharge  
    - Initiate mechanical ventilation due to acute hypoxemic respiratory failure, Completed  
    - Start CRRT for AKI, Completed  
    - Obtain repeat blood and urine cultures, Completed  

    Procedures:  
    - Endotracheal intubation and initiation of mechanical ventilation  
    - Arterial line placement for invasive blood pressure monitoring  
    - Continuous renal replacement therapy (CRRT)  
    - Serial lactate monitoring q4h  
    - Chest X-ray to confirm ETT and central line position  

---

Admission 86452033  
    DRGs:  
    - APR: POST-SEPSIS OUTPATIENT MANAGEMENT (Severity 2.0)  
    - HCFA: RECOVERY PHASE AFTER ANAEROBIC SEPSIS  

    Medications:  
    - Amoxicillin-Clavulanate 875/125 mg PO BID x10 days (oral step-down)  
    - Probiotics PO daily for microbiome support  
    - Vitamin C 1000 mg PO daily  
    - Gabapentin 300 mg PO BID for critical illness neuropathy  
    - Acetaminophen 500 mg PO PRN mild pain  

    Orders:  
    - Start Amoxicillin-Clavulanate for step-down therapy, Discontinued via patient discharge  
    - Start probiotics for gut health, Discontinued via patient discharge  
    - Referral to physical therapy for post-ICU weakness, Completed  
    - Nutrition consult for calorie and protein optimization, Completed  

    Procedures:  
    - Pulmonary function testing after ventilator weaning  
    - Follow-up echocardiogram to assess septic cardiomyopathy recovery  
    - Outpatient infectious disease follow-up  
    - Functional status evaluation for rehabilitation planning  


Patient 40001283  
Gender: Female  
Age: 54  
Race: HISPANIC  

Admission 74502814  
    DRGs:  
    - APR: INFECTIOUS GASTROENTERITIS WITH DEHYDRATION (Severity 2.0)  
    - HCFA: ACUTE INFECTIOUS ENTEROCOLITIS WITHOUT MCC  

    Medications:  
    - Ciprofloxacin 500 mg PO BID x5 days  
    - Ondansetron 4 mg IV q8h PRN nausea  
    - Loperamide 2 mg PO PRN diarrhea (used cautiously)  
    - Oral Rehydration Solution (ORS) 250 mL PO q2h  
    - Acetaminophen 650 mg PO q6h PRN fever  
    - Sodium Chloride 0.9% IV infusion at 125 mL/hr  

    Orders:  
    - Start Ciprofloxacin PO, Discontinued via patient discharge  
    - Initiate IV fluids for dehydration, Discontinued via patient discharge  
    - Ondansetron: IV, PRN, Discontinued via patient discharge  
    - Oral Rehydration Solution: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Stool culture and sensitivity, Completed  
    - Test for *Clostridioides difficile* toxin, Completed  

    Procedures:  
    - IV fluid bolus (2L NS)  
    - Stool PCR testing for bacterial pathogens  
    - Isolation precautions initiated  

---

Admission 76103955  
    DRGs:  
    - APR: INFECTIOUS GASTROENTERITIS WITH HYPOVOLEMIC SHOCK (Severity 3.0)  
    - HCFA: SEVERE ENTERIC INFECTION WITH ELECTROLYTE IMBALANCE  

    Medications:  
    - Azithromycin 500 mg PO daily x3 days  
    - Rifaximin 550 mg PO BID x7 days  
    - Lactobacillus probiotics PO daily  
    - IV Potassium Chloride 20 mEq in NS for hypokalemia  
    - Pantoprazole 40 mg IV daily for stress ulcer prophylaxis  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  

    Orders:  
    - Switch from Ciprofloxacin to Azithromycin due to resistance, Discontinued via patient discharge  
    - Add Rifaximin for suspected *E. coli*-associated gastroenteritis, Discontinued via patient discharge  
    - Start probiotics PO, Discontinued via patient discharge  
    - Potassium Chloride IV replacement, Completed  
    - Pantoprazole IV: Discontinued via patient discharge  
    - Enoxaparin SC: Discontinued via patient discharge  
    - Serial electrolyte panels q6h, Completed  

    Procedures:  
    - Nasogastric tube placement for severe vomiting  
    - Abdominal ultrasound to rule out colitis complications  
    - Central venous line insertion for hydration and antibiotics  

---

Admission 77461588  
    DRGs:  
    - APR: OUTPATIENT MANAGEMENT OF POST-INFECTIOUS IBS (Severity 1.0)  
    - HCFA: FOLLOW-UP FOR GASTROENTERITIS RECOVERY  

    Medications:  
    - Dicyclomine 20 mg PO TID for abdominal cramping  
    - Probiotics PO daily  
    - Vitamin D3 2000 IU PO daily  
    - Zinc Sulfate 220 mg PO daily  
    - Oral Rehydration Solution 250 mL PO PRN  

    Orders:  
    - Start Dicyclomine for IBS-like post-infectious abdominal pain, Discontinued via patient discharge  
    - Continue probiotics PO, Discontinued via patient discharge  
    - Nutrition consult for hydration recovery, Completed  
    - Referral to gastroenterology for follow-up, Completed  

    Procedures:  
    - Lactose tolerance testing  
    - Small bowel ultrasound for persistent bloating  
    - Dietary consultation for low-FODMAP transition plan  


Patient 50001283  
Gender: Male  
Age: 67  
Race: WHITE  

Admission 80127643  
    DRGs:  
    - APR: PNEUMONIA, UNSPECIFIED ORGANISM (Severity 2.0)  
    - HCFA: SIMPLE PNEUMONIA & PLEURISY W CC  

    Medications:  
    - Ceftriaxone IV  
    - Azithromycin PO  
    - Albuterol 0.083% Neb Soln  
    - Acetaminophen  
    - Sodium Chloride 0.9% Flush  
    - Guaifenesin  
    - Oxygen Therapy (2L NC)  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Ceftriaxone IV: IV, Discontinued via patient discharge  
    - Azithromycin PO: PO, Discontinued via patient discharge  
    - Albuterol 0.083% Neb Soln: IH, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Guaifenesin: PO, Discontinued via patient discharge  
    - Oxygen Therapy: Continuous, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Chest X-ray  
    - Sputum culture and sensitivity  
    - Pulse oximetry monitoring  
    - Blood cultures  

Admission 81459207  
    DRGs:  
    - APR: PNEUMONIA WITH RESPIRATORY DISTRESS (Severity 3.0)  
    - HCFA: PNEUMONIA W ACUTE RESPIRATORY FAILURE W CC  

    Medications:  
    - Piperacillin-Tazobactam (Zosyn) IV  
    - Levofloxacin IV  
    - Methylprednisolone IV  
    - Albuterol Inhaler  
    - Budesonide Neb  
    - Sodium Chloride 0.9% Flush  
    - Heparin SC (DVT prophylaxis)  
    - Ondansetron IV  
    - Acetaminophen  

    Orders:  
    - Piperacillin-Tazobactam IV: IV, Discontinued via patient discharge  
    - Levofloxacin IV: IV, Discontinued via patient discharge  
    - Methylprednisolone IV: IV, Discontinued via patient discharge  
    - Albuterol Inhaler: IH, Discontinued via patient discharge  
    - Budesonide Neb: IH, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Arterial blood gas (ABG)  
    - High-resolution CT Chest (HRCT)  
    - Continuous cardiac telemetry monitoring  
    - Bronchoscopy for airway clearance  

Admission 82937411  
    DRGs:  
    - APR: SEVERE PNEUMONIA WITH COMPLICATIONS (Severity 4.0)  
    - HCFA: PNEUMONIA W MCC  

    Medications:  
    - Meropenem IV  
    - Vancomycin IV  
    - Methylprednisolone IV  
    - Oxygen Therapy (high-flow nasal cannula)  
    - Morphine IV (for dyspnea relief)  
    - Sodium Chloride 0.9% Flush  
    - Enoxaparin SC  
    - Acetaminophen  
    - Oseltamivir PO (empiric for viral coverage)  

    Orders:  
    - Meropenem IV: IV, Discontinued via patient discharge  
    - Vancomycin IV: IV, Discontinued via patient discharge  
    - Methylprednisolone IV: IV, Discontinued via patient discharge  
    - Oxygen Therapy: High-flow, Discontinued via patient discharge  
    - Morphine IV: IV PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Enoxaparin SC: SC, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Oseltamivir PO: PO, Discontinued via patient discharge  

    Procedures:  
    - Endotracheal intubation with mechanical ventilation  
    - Chest ultrasound for pleural effusion  
    - Thoracentesis  
    - Repeat chest CT scan for evaluation of progression


Patient 60001283  
Gender: Female  
Age: 32  
Race: ASIAN  

Admission 81239041  
    DRGs:  
    - APR: ATOPIC DERMATITIS - INITIAL PRESENTATION (Severity 2.0)  
    - HCFA: ATOPIC DERMATITIS W/O MCC  

    Medications:  
    - Hydrocortisone 2.5% Cream, Apply to affected areas BID x 7 days  
    - Cetirizine 10 mg PO daily for itching  
    - Aquaphor Ointment, Apply liberally to dry skin PRN  
    - Diphenhydramine 25 mg PO at bedtime PRN pruritus  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Start Hydrocortisone 2.5% Cream: Topical, Discontinued via patient discharge  
    - Cetirizine: PO daily, Discontinued via patient discharge  
    - Aquaphor Ointment: Topical, Discontinued via patient discharge  
    - Diphenhydramine: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Skin patch allergy testing ordered, Completed  

    Procedures:  
    - Dermatology consult for initial management  
    - Skin barrier assessment  
    - Moisture level testing  

---

Admission 82458177  
    DRGs:  
    - APR: ATOPIC DERMATITIS WITH FLARE-UP (Severity 3.0)  
    - HCFA: SEVERE ATOPIC DERMATITIS WITH SECONDARY INFECTION  

    Medications:  
    - Prednisone 40 mg PO daily x5 days (short steroid taper)  
    - Tacrolimus 0.1% Ointment, Apply to affected areas BID  
    - Cephalexin 500 mg PO QID x7 days for suspected bacterial superinfection  
    - Loratadine 10 mg PO daily  
    - Hydroxyzine 25 mg PO at bedtime PRN itching  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Start Prednisone taper: PO, Discontinued via patient discharge  
    - Tacrolimus Ointment: Topical, Discontinued via patient discharge  
    - Cephalexin: PO, Discontinued via patient discharge  
    - Loratadine: PO daily, Discontinued via patient discharge  
    - Hydroxyzine: PO, PRN, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Skin culture and sensitivity: Completed  

    Procedures:  
    - Wound culture from eczematous lesion  
    - Dermatology follow-up for tacrolimus titration  
    - Education on infection prevention  

---

Admission 83945710  
    DRGs:  
    - APR: CHRONIC ATOPIC DERMATITIS MANAGEMENT (Severity 1.0)  
    - HCFA: LONG-TERM MANAGEMENT OF ATOPIC DERMATITIS  

    Medications:  
    - Dupilumab 300 mg SC every 2 weeks  
    - Fexofenadine 180 mg PO daily  
    - Hydrating Cream with Ceramides, Apply to entire body BID  
    - Vitamin D3 2000 IU PO daily  
    - Zinc Oxide Ointment for flare areas PRN  

    Orders:  
    - Start Dupilumab SC therapy, Ongoing  
    - Fexofenadine: PO daily, Discontinued via patient discharge  
    - Ceramide Hydrating Cream: Topical, Discontinued via patient discharge  
    - Vitamin D3: PO, Discontinued via patient discharge  
    - Zinc Oxide: Topical, Discontinued via patient discharge  
    - Referral to allergy/immunology for further workup, Completed  

    Procedures:  
    - Spirometry testing to assess associated atopic asthma  
    - Patch testing to identify triggers  
    - Education on allergen avoidance and skincare routines  
    - Scheduled follow-up every 3 months  


Patient 10001284  
Gender: Female  
Age: 67  
Race: WHITE  

Admission 78541230  
    DRGs:  
    - APR: OSTEOARTHRITIS - RIGHT KNEE (Severity 2.0)  
    - HCFA: UNILATERAL PRIMARY OSTEOARTHRITIS OF RIGHT KNEE W/O MCC  

    Medications:  
    - Acetaminophen 650 mg PO q6h PRN pain  
    - Ibuprofen 400 mg PO q8h PRN inflammation  
    - Diclofenac 1% Topical Gel, Apply to right knee QID  
    - Glucosamine-Chondroitin 500 mg PO daily  
    - Vitamin D3 2000 IU PO daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Start Diclofenac Gel: Topical, Discontinued via patient discharge  
    - Ibuprofen PO: PRN, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Referral to physical therapy for strengthening program, Completed  
    - Knee X-ray ordered, Completed  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Diagnostic knee X-ray  
    - Gait and stability assessment  
    - Physical therapy consultation  

---

Admission 79658022  
    DRGs:  
    - APR: OSTEOARTHRITIS FLARE WITH EFFUSION (Severity 3.0)  
    - HCFA: OSTEOARTHRITIS OF RIGHT KNEE WITH SYNOVITIS  

    Medications:  
    - Methylprednisolone 40 mg IA injection (intra-articular)  
    - Naproxen 500 mg PO BID x10 days  
    - Pantoprazole 40 mg PO daily (GI protection)  
    - Tramadol 50 mg PO q6h PRN moderate pain  
    - Ice therapy protocol, Applied BID  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Methylprednisolone IA injection: Completed  
    - Naproxen PO: BID, Discontinued via patient discharge  
    - Pantoprazole PO: Discontinued via patient discharge  
    - Tramadol: PO PRN, Discontinued via patient discharge  
    - Joint aspiration for analysis of synovial effusion, Completed  
    - Referral for MRI of right knee, Completed  

    Procedures:  
    - Intra-articular corticosteroid injection  
    - Synovial fluid aspiration  
    - MRI of right knee to assess cartilage integrity  

---

Admission 80234591  
    DRGs:  
    - APR: KNEE JOINT REPLACEMENT - RIGHT KNEE (Severity 4.0)  
    - HCFA: TOTAL KNEE ARTHROPLASTY W/O MCC  

    Medications:  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  
    - Cefazolin 2 g IV pre-op and q8h post-op x24h  
    - Oxycodone 5 mg PO q6h PRN severe pain  
    - Acetaminophen 1000 mg PO q6h scheduled  
    - Ondansetron 4 mg IV q8h PRN nausea  
    - Multivitamin with minerals PO daily  

    Orders:  
    - Start Enoxaparin SC post-op, Discontinued via patient discharge  
    - Oxycodone: PO, PRN, Discontinued via patient discharge  
    - Cefazolin IV prophylaxis: Completed  
    - Physical therapy: Start POD#1, Discontinued via patient discharge  
    - Continuous passive motion (CPM) device ordered, Completed  
    - Wound care instructions reviewed, Completed  

    Procedures:  
    - Right total knee arthroplasty performed under spinal anesthesia  
    - Post-op wound closure with staples  
    - Early mobilization with physical therapy team  
    - DVT prophylaxis initiated immediately post-op  

---

Admission 81426078  
    DRGs:  
    - APR: POST-ARTHROPLASTY REHABILITATION (Severity 1.0)  
    - HCFA: POST-OP KNEE FUNCTIONAL RECOVERY  

    Medications:  
    - Celecoxib 200 mg PO daily  
    - Acetaminophen 650 mg PO q6h PRN pain  
    - Calcium Carbonate + Vitamin D PO daily  
    - Diclofenac Patch, Apply to right knee PRN  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Continue Celecoxib PO, Discontinued via patient discharge  
    - Transition to home-based physical therapy, Completed  
    - Schedule follow-up orthopedic evaluation in 6 weeks, Completed  
    - CPM therapy discontinued, Completed  

    Procedures:  
    - Supervised functional training  
    - Gait training with assistive device  
    - Assessment of range of motion (ROM) milestones  
    - Counseling for long-term osteoarthritis management  


Patient 20001284  
Gender: Female  
Age: 70  
Race: WHITE  

Admission 87234510  
    DRGs:  
    - APR: OSTEOARTHRITIS OF RIGHT KNEE (Severity 2.0)  
    - HCFA: UNILATERAL PRIMARY OSTEOARTHRITIS RIGHT KNEE W/O MCC  

    Medications:  
    - Acetaminophen 650 mg PO q6h PRN mild pain  
    - Ibuprofen 400 mg PO q8h PRN inflammation  
    - Diclofenac 1% Gel, Apply to right knee BID  
    - Vitamin D3 2000 IU PO daily  
    - Calcium Carbonate 500 mg PO BID  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Initiate Diclofenac 1% Gel: Topical, Discontinued via patient discharge  
    - Start Ibuprofen PO: PRN, Discontinued via patient discharge  
    - Physical therapy referral for strengthening and ROM, Completed  
    - Knee X-ray ordered, Completed  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Right knee diagnostic X-ray  
    - Gait and mobility assessment  
    - Physical therapy initiation for knee stabilization  

---

Admission 88347926  
    DRGs:  
    - APR: OSTEOARTHRITIS FLARE WITH SWELLING (Severity 3.0)  
    - HCFA: UNILATERAL OSTEOARTHRITIS RIGHT KNEE W SYNOVITIS  

    Medications:  
    - Methylprednisolone 40 mg intra-articular injection  
    - Naproxen 500 mg PO BID x14 days  
    - Pantoprazole 40 mg PO daily (for GI protection)  
    - Tramadol 50 mg PO q6h PRN moderate pain  
    - Ice compression therapy BID  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Intra-articular steroid injection: Completed  
    - Naproxen PO: BID, Discontinued via patient discharge  
    - Pantoprazole PO: Discontinued via patient discharge  
    - Tramadol PO: PRN, Discontinued via patient discharge  
    - Joint aspiration to rule out infection, Completed  
    - MRI ordered for cartilage evaluation, Completed  

    Procedures:  
    - Intra-articular corticosteroid injection  
    - Synovial fluid aspiration and analysis  
    - MRI of right knee joint performed  

---

Admission 89562478  
    DRGs:  
    - APR: VISCOSUPPLEMENTATION THERAPY FOR OSTEOARTHRITIS (Severity 2.0)  
    - HCFA: HYALURONIC ACID INJECTION SERIES  

    Medications:  
    - Hyaluronan (Hyalgan) 20 mg IA weekly x3 doses  
    - Acetaminophen 500 mg PO q6h PRN post-injection soreness  
    - Ice therapy PRN  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Start Hyaluronan IA therapy: Completed (3 weekly injections)  
    - Continue home-based physical therapy, Completed  
    - Follow-up scheduled for post-injection assessment, Completed  

    Procedures:  
    - Hyaluronic acid intra-articular injections  
    - Post-injection ROM evaluation  
    - Counseling for weight management and strengthening exercises  

---

Admission 90837615  
    DRGs:  
    - APR: PRP THERAPY FOR KNEE OSTEOARTHRITIS (Severity 2.0)  
    - HCFA: PLATELET-RICH PLASMA JOINT INJECTION  

    Medications:  
    - Platelet-rich plasma (PRP) intra-articular injection performed  
    - Acetaminophen 650 mg PO q6h PRN  
    - Celecoxib 200 mg PO daily  
    - Vitamin D + Calcium supplement PO daily  

    Orders:  
    - PRP knee injection performed under ultrasound guidance, Completed  
    - Celecoxib PO: Daily, Discontinued via patient discharge  
    - Continue strengthening and low-impact mobility program, Completed  

    Procedures:  
    - PRP extraction and knee injection  
    - Ultrasound-guided intra-articular placement  
    - Functional outcome evaluation with orthopedic follow-up  


Patient 30001284  
Gender: Female  
Age: 68  
Race: WHITE  

Admission 81456231  
    DRGs:  
    - APR: BILATERAL PRIMARY KNEE OSTEOARTHRITIS — INITIAL MANAGEMENT (Severity 2.0)  
    - HCFA: OSTEOARTHRITIS OF BOTH KNEES WITHOUT MCC  

    Medications:  
    - Acetaminophen 650 mg PO q6h PRN pain  
    - Naproxen 500 mg PO BID x14 days  
    - Diclofenac 1% Gel, Apply to both knees BID  
    - Calcium + Vitamin D3 500 mg PO daily  
    - Glucosamine-Chondroitin 1500 mg PO daily  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Start Naproxen PO BID, Discontinued via patient discharge  
    - Apply Diclofenac Gel, Discontinued via patient discharge  
    - Referral to physical therapy for quadriceps strengthening, Completed  
    - Bilateral knee X-rays ordered, Completed  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Bilateral knee X-ray  
    - Physical therapy evaluation for gait optimization  
    - Weight-bearing analysis for joint alignment  

---

Admission 82790422  
    DRGs:  
    - APR: OSTEOARTHRITIS EXACERBATION WITH FUNCTIONAL LIMITATION (Severity 3.0)  
    - HCFA: BILATERAL OSTEOARTHRITIS OF KNEES WITH SWELLING  

    Medications:  
    - Methylprednisolone 40 mg IA injection (each knee)  
    - Ibuprofen 600 mg PO q8h x10 days  
    - Pantoprazole 40 mg PO daily for gastric protection  
    - Tramadol 50 mg PO q6h PRN moderate pain  
    - Compression wraps for bilateral knees  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Perform bilateral intra-articular corticosteroid injections, Completed  
    - Ibuprofen PO q8h, Discontinued via patient discharge  
    - Pantoprazole PO daily, Discontinued via patient discharge  
    - Tramadol PO PRN, Discontinued via patient discharge  
    - MRI of both knees ordered for cartilage damage assessment, Completed  

    Procedures:  
    - Bilateral steroid injections under ultrasound guidance  
    - Joint aspiration for inflammatory markers  
    - MRI of bilateral knees for OA staging  

---

Admission 83976512  
    DRGs:  
    - APR: VISCOSUPPLEMENTATION FOR SEVERE BILATERAL KNEE OA (Severity 3.0)  
    - HCFA: HYALURONAN INJECTION SERIES — BILATERAL  

    Medications:  
    - Hyaluronic Acid (Synvisc-One) 6 mL IA injection per knee, Single dose  
    - Acetaminophen 500 mg PO q6h PRN soreness  
    - Cold compress therapy BID  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Start Synvisc-One injections for bilateral knees, Completed  
    - Recommend home exercise program for ROM improvement, Completed  
    - Schedule follow-up in 4 weeks for reassessment, Completed  

    Procedures:  
    - Ultrasound-guided Synvisc-One injections  
    - Post-procedure flexion-extension ROM assessment  
    - Functional mobility testing  

---

Admission 85123477  
    DRGs:  
    - APR: ROBOT-ASSISTED TOTAL KNEE ARTHROPLASTY (Severity 4.0)  
    - HCFA: BILATERAL KNEE REPLACEMENT WITH MAJOR COMPLICATION RISK  

    Medications:  
    - Cefazolin 2 g IV pre-op for infection prophylaxis  
    - Oxycodone 5 mg PO q4h PRN post-op pain  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  
    - Celecoxib 200 mg PO daily for post-op inflammation  
    - Acetaminophen 650 mg PO q6h scheduled  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Preoperative antibiotics administered, Completed  
    - Bilateral robot-assisted total knee arthroplasty performed, Completed  
    - Start DVT prophylaxis with Enoxaparin, Discontinued via patient discharge  
    - Start inpatient rehabilitation protocol, Completed  
    - Outpatient physical therapy referral, Completed  

    Procedures:  
    - Bilateral robot-assisted total knee arthroplasty  
    - Continuous passive motion (CPM) therapy initiated  
    - Postoperative wound care and dressing change  
    - Inpatient rehabilitation for early ambulation  


Patient 40001284  
Gender: Male  
Age: 54  
Race: WHITE  

Admission 74120531  
    DRGs:  
    - APR: ACUTE RIGHT KNEE PAIN — INITIAL ASSESSMENT (Severity 1.0)  
    - HCFA: KNEE PAIN WITHOUT TRAUMATIC INJURY  

    Medications:  
    - Acetaminophen 650 mg PO q6h PRN mild pain  
    - Ibuprofen 600 mg PO q8h PRN swelling/pain  
    - Diclofenac 1% Gel, Apply to right knee BID  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Right knee X-ray ordered, Completed  
    - Apply cold compresses to right knee, Completed  
    - Start Diclofenac topical treatment, Discontinued via patient discharge  
    - Ibuprofen PO q8h PRN, Discontinued via patient discharge  
    - Physical therapy referral for ROM and gait training, Completed  

    Procedures:  
    - Right knee X-ray  
    - Physical therapy evaluation for strengthening and mobility  

---

Admission 75284629  
    DRGs:  
    - APR: CHRONIC KNEE PAIN EXACERBATION (Severity 2.0)  
    - HCFA: FUNCTIONAL LIMITATION DUE TO RIGHT KNEE PAIN  

    Medications:  
    - Naproxen 500 mg PO BID x14 days  
    - Tramadol 50 mg PO q6h PRN moderate pain  
    - Pantoprazole 40 mg PO daily for gastric protection  
    - Lidocaine 5% Patch, Apply to right knee q24h  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - MRI of right knee ordered, Completed  
    - Naproxen PO BID, Discontinued via patient discharge  
    - Tramadol PO PRN, Discontinued via patient discharge  
    - Pantoprazole PO daily, Discontinued via patient discharge  
    - Initiate home exercise plan for knee stability, Completed  

    Procedures:  
    - MRI of right knee for meniscal and ligament evaluation  
    - Joint aspiration to rule out inflammatory or septic causes  
    - Gait analysis and correction via physical therapy  

---

Admission 76895104  
    DRGs:  
    - APR: INTERVENTIONAL MANAGEMENT OF PERSISTENT KNEE PAIN (Severity 3.0)  
    - HCFA: INTRA-ARTICULAR INJECTION FOR PAIN CONTROL  

    Medications:  
    - Methylprednisolone 40 mg IA injection to right knee  
    - Celecoxib 200 mg PO daily  
    - Acetaminophen 650 mg PO q6h scheduled  
    - Cold compresses PRN swelling  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Perform corticosteroid injection to right knee under ultrasound guidance, Completed  
    - Start Celecoxib PO daily, Discontinued via patient discharge  
    - Continue physical therapy plan, Completed  
    - Follow-up in 4 weeks for reassessment, Completed  

    Procedures:  
    - Right knee ultrasound-guided steroid injection  
    - Post-injection ROM and functional assessment  
    - Physical therapy strengthening session  

---

Admission 78264012  
    DRGs:  
    - APR: SURGICAL INTERVENTION FOR CHRONIC KNEE PAIN (Severity 4.0)  
    - HCFA: RIGHT KNEE ARTHROSCOPY WITH MENISCAL DEBRIDEMENT  

    Medications:  
    - Cefazolin 2 g IV pre-op for infection prophylaxis  
    - Oxycodone 5 mg PO q4h PRN post-op pain  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  
    - Celecoxib 200 mg PO daily for inflammation  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Perform right knee arthroscopy, Completed  
    - Start DVT prophylaxis with Enoxaparin, Discontinued via patient discharge  
    - Initiate inpatient rehabilitation post-op, Completed  
    - Outpatient PT referral for recovery, Completed  

    Procedures:  
    - Arthroscopic right knee meniscal debridement  
    - Postoperative wound care and dressing changes  
    - Continuous passive motion (CPM) therapy  
    - Physical therapy for quadriceps and hamstring strengthening  


Patient 50001284  
Gender: Female  
Age: 73  
Race: WHITE  

Admission 90128463  
    DRGs:  
    - APR: GAIT & MOBILITY DISORDERS (Severity 2.0)  
    - HCFA: DIFFICULTY IN WALKING W/O MCC  

    Medications:  
    - Acetaminophen  
    - Ibuprofen 600mg  
    - Vitamin D3 Supplement  
    - Calcium Carbonate  
    - Sodium Chloride 0.9% Flush  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ibuprofen 600mg: PO, Discontinued via patient discharge  
    - Vitamin D3 Supplement: PO, Discontinued via patient discharge  
    - Calcium Carbonate: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Physical therapy evaluation  
    - Gait assessment and balance testing  
    - MRI of lumbar spine (rule out neurological cause)  

Admission 91348752  
    DRGs:  
    - APR: GAIT DISTURBANCES W MUSCULOSKELETAL DISORDERS (Severity 3.0)  
    - HCFA: DIFFICULTY IN WALKING W CC  

    Medications:  
    - Naproxen 500mg  
    - Cyclobenzaprine 5mg  
    - Acetaminophen  
    - Sodium Chloride 0.9% Flush  
    - Heparin SC (DVT prophylaxis)  
    - Calcium + Vitamin D Supplement  
    - Ondansetron IV  

    Orders:  
    - Naproxen 500mg: PO, Discontinued via patient discharge  
    - Cyclobenzaprine 5mg: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  
    - Calcium + Vitamin D Supplement: PO, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  

    Procedures:  
    - Nerve conduction studies (EMG/NCV)  
    - CT scan of hips and pelvis  
    - Assistive device fitting (walker)  

Admission 92751008  
    DRGs:  
    - APR: SEVERE GAIT IMPAIRMENT DUE TO NEUROLOGICAL DISORDERS (Severity 4.0)  
    - HCFA: DIFFICULTY IN WALKING W MCC  

    Medications:  
    - Methylprednisolone IV (suspected inflammatory cause)  
    - Gabapentin 300mg  
    - Baclofen 10mg  
    - Acetaminophen  
    - Sodium Chloride 0.9% Flush  
    - Enoxaparin SC  
    - Lorazepam 1mg (for anxiety related to gait training)  

    Orders:  
    - Methylprednisolone IV: IV, Discontinued via patient discharge  
    - Gabapentin 300mg: PO, Discontinued via patient discharge  
    - Baclofen 10mg: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Enoxaparin SC: SC, Discontinued via patient discharge  
    - Lorazepam 1mg: PO, Discontinued via patient discharge  

    Procedures:  
    - Brain MRI with contrast  
    - Comprehensive neurological evaluation  
    - Intensive inpatient rehabilitation therapy  
    - Fall risk assessment and mobility training


Patient 60001284  
Gender: Female  
Age: 48  
Race: WHITE  

Admission 78124563  
    DRGs:  
    - APR: BILATERAL HYPERMETROPIA WITH REFRACTIVE ERROR MANAGEMENT (Severity 1.0)  
    - HCFA: HYPERMETROPIA, BILATERAL — REFRACTION & CORRECTIVE LENS FITTING  

    Medications:  
    - Artificial Tears (Carboxymethylcellulose) 1 drop OU QID  
    - Ketotifen 0.025% Ophthalmic Drops 1 drop OU BID (for ocular itching)  
    - Sodium Chloride 0.9% Flush (eye irrigation PRN)  

    Orders:  
    - Comprehensive eye exam with dilated fundus evaluation, Completed  
    - Manifest and cycloplegic refraction testing, Completed  
    - Fitting of corrective prescription lenses (hyperopic correction), Completed  
    - Ketotifen eye drops initiated, Discontinued via patient discharge  
    - Patient education on eye strain reduction techniques, Completed  

    Procedures:  
    - Automated keratometry and refraction  
    - Optical coherence tomography (OCT) for baseline retinal assessment  

---

Admission 79265428  
    DRGs:  
    - APR: REFRACTIVE ERROR MANAGEMENT WITH PERSISTENT VISUAL STRAIN (Severity 1.0)  
    - HCFA: BILATERAL HYPERMETROPIA WITH ASTHENOPIA — FOLLOW-UP EXAM  

    Medications:  
    - Artificial Tears (Preservative-Free) 1 drop OU Q4H PRN dryness  
    - Low-dose Pilocarpine 1% Ophthalmic Drops (trial for accommodative support)  
    - Ketorolac 0.5% Ophthalmic Drops 1 drop OU BID PRN irritation  

    Orders:  
    - Binocular vision assessment, Completed  
    - Updated corrective lens prescription with progressive lenses, Completed  
    - Start artificial tears PRN dryness, Discontinued via patient discharge  
    - Trial of low-dose pilocarpine drops for near vision, Discontinued via patient discharge  
    - Patient counseling on reducing prolonged near-work strain, Completed  

    Procedures:  
    - Humphrey Visual Field testing  
    - Non-contact tonometry for intraocular pressure monitoring  

---

Admission 80395142  
    DRGs:  
    - APR: REFRACTIVE SURGERY EVALUATION FOR BILATERAL HYPERMETROPIA (Severity 2.0)  
    - HCFA: CANDIDACY ASSESSMENT FOR LASIK/PRK  

    Medications:  
    - Moxifloxacin 0.5% Ophthalmic Drops 1 drop OU QID (pre-op prophylaxis)  
    - Prednisolone Acetate 1% Ophthalmic Drops 1 drop OU QID (post-eval inflammation control)  
    - Preservative-Free Lubricating Drops QID  

    Orders:  
    - Corneal topography for LASIK/PRK candidacy, Completed  
    - Pachymetry to assess corneal thickness, Completed  
    - Moxifloxacin drops initiated, Discontinued via patient discharge  
    - Prednisolone acetate eye drops post-evaluation, Discontinued via patient discharge  
    - Follow-up scheduled for surgical planning, Completed  

    Procedures:  
    - Corneal pachymetry  
    - Anterior segment OCT for corneal mapping  
    - LASIK surgical candidacy consultation  

---

Admission 81402653  
    DRGs:  
    - APR: POST-CORRECTIVE LENS ADJUSTMENT & SYMPTOM MANAGEMENT (Severity 1.0)  
    - HCFA: BILATERAL HYPERMETROPIA WITH ADAPTATION ISSUES  

    Medications:  
    - Artificial Tears Gel QHS  
    - Cyclosporine Ophthalmic Emulsion 0.05% 1 drop OU BID  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Lens refit with updated prescription for intermediate and near vision, Completed  
    - Initiate Cyclosporine ophthalmic drops for chronic dryness, Discontinued via patient discharge  
    - Patient advised to follow visual ergonomics strategies, Completed  
    - Annual follow-up scheduled, Completed  

    Procedures:  
    - Trial fitting of multifocal contact lenses  
    - Near-point convergence testing  
    - Contrast sensitivity testing for low-light vision  


Patient 10001285  
Gender: Female  
Age: 42  
Race: WHITE  

Admission 77231845  
    DRGs:  
    - APR: ULCERATIVE COLITIS WITH RECTAL BLEEDING — ACUTE EXACERBATION (Severity 3.0)  
    - HCFA: ULCERATIVE COLITIS W RECTAL BLEEDING — MAJOR GASTROINTESTINAL DISORDERS  

    Medications:  
    - Mesalamine (Asacol) 1.6 g PO TID  
    - Methylprednisolone IV 40 mg q12h  
    - Pantoprazole 40 mg PO daily  
    - Sodium Chloride 0.9% Flush IV PRN  
    - Ondansetron 4 mg IV q6h PRN nausea  
    - Acetaminophen 650 mg PO q6h PRN  
    - Heparin 5000 units SC q12h for DVT prophylaxis  

    Orders:  
    - Admit to inpatient GI service  
    - Colonoscopy with biopsies, Completed  
    - Start Mesalamine, Discontinued via patient discharge  
    - IV Methylprednisolone initiated, Discontinued via patient discharge  
    - Ondansetron IV for nausea, Discontinued via patient discharge  
    - Start clear liquid diet advancing as tolerated, Completed  
    - GI consult requested, Completed  

    Procedures:  
    - Colonoscopy with biopsy of inflamed rectal mucosa  
    - Abdominal ultrasound to rule out megacolon  

---

Admission 78249302  
    DRGs:  
    - APR: ULCERATIVE COLITIS WITH RECTAL BLEEDING — STEROID-DEPENDENT FLARE (Severity 3.0)  
    - HCFA: GASTROINTESTINAL DISORDERS — REFRACTORY UC  

    Medications:  
    - Mesalamine 1.6 g PO TID  
    - Prednisone taper starting at 60 mg PO daily  
    - Infliximab (Remicade) IV 5 mg/kg at weeks 0, 2, and 6  
    - Calcium Carbonate + Vitamin D PO daily  
    - Pantoprazole 40 mg PO daily  
    - Hydrocortisone rectal suppository 25 mg BID  

    Orders:  
    - Initiate Infliximab infusion therapy, Completed  
    - Prednisone taper protocol, Discontinued via patient discharge  
    - Continue Mesalamine PO therapy, Discontinued via patient discharge  
    - CBC, CMP, CRP monitoring, Completed  
    - Nutritional consult for low-residue diet, Completed  

    Procedures:  
    - Flexible sigmoidoscopy to assess disease extent  
    - CT abdomen/pelvis for complications  

---

Admission 79516478  
    DRGs:  
    - APR: ULCERATIVE COLITIS WITH RECTAL BLEEDING — MAINTENANCE PHASE (Severity 2.0)  
    - HCFA: LONG-TERM UC MANAGEMENT ON BIOLOGIC THERAPY  

    Medications:  
    - Infliximab 5 mg/kg IV every 8 weeks  
    - Mesalamine 1.2 g PO daily  
    - Probiotic Supplement BID  
    - Ferrous Sulfate 325 mg PO daily  
    - Loperamide 2 mg PO PRN diarrhea  

    Orders:  
    - Continue scheduled Infliximab infusions, Discontinued via patient discharge  
    - Maintain Mesalamine oral therapy, Discontinued via patient discharge  
    - Annual colonoscopy surveillance recommended, Scheduled  
    - Dietician follow-up for anti-inflammatory diet, Completed  
    - Order fecal calprotectin for relapse monitoring, Completed  

    Procedures:  
    - Colonoscopy surveillance  
    - Infliximab infusion under observation  

---

Admission 80647911  
    DRGs:  
    - APR: ULCERATIVE COLITIS — ACUTE RECTAL BLEEDING REQUIRING SURGICAL CONSULT (Severity 4.0)  
    - HCFA: GASTROINTESTINAL BLEEDING MANAGEMENT  

    Medications:  
    - IV Hydrocortisone 100 mg q8h  
    - Infliximab 10 mg/kg IV (rescue dose)  
    - Piperacillin-Tazobactam 4.5 g IV q6h  
    - Tranexamic Acid IV 1 g once  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Admit to step-down ICU for hemodynamic monitoring  
    - Start high-dose IV steroids, Discontinued via patient discharge  
    - Escalate Infliximab dosing, Discontinued via patient discharge  
    - Start broad-spectrum antibiotics, Discontinued via patient discharge  
    - Surgical consult for possible colectomy, Completed  
    - Crossmatch blood for possible transfusion, Completed  

    Procedures:  
    - Flexible sigmoidoscopy to localize active bleeding  
    - Red blood cell transfusion x2 units  
    - Central line placement for rapid access  


Patient 20001285  
Gender: Male  
Age: 51  
Race: WHITE  

Admission 88316421  
    DRGs:  
    - APR: ULCERATIVE COLITIS WITH RECTAL BLEEDING — INITIAL SEVERE FLARE (Severity 3.0)  
    - HCFA: ULCERATIVE COLITIS — GASTROINTESTINAL BLEEDING MANAGEMENT  

    Medications:  
    - Mesalamine 2.4 g PO daily  
    - Methylprednisolone IV 60 mg daily  
    - Pantoprazole 40 mg PO daily  
    - Ondansetron 4 mg IV q8h PRN nausea  
    - Sodium Chloride 0.9% IV flush PRN  
    - Acetaminophen 650 mg PO q6h PRN pain  
    - Heparin 5000 units SC q12h for DVT prophylaxis  

    Orders:  
    - Start Mesalamine PO, Discontinued via patient discharge  
    - IV Methylprednisolone for acute flare, Discontinued via patient discharge  
    - Start clear liquid diet progressing to soft diet, Completed  
    - Ondansetron IV for nausea, Discontinued via patient discharge  
    - GI consult initiated, Completed  
    - Order CBC, CMP, ESR, and CRP labs, Completed  

    Procedures:  
    - Colonoscopy with biopsy confirming ulcerative colitis  
    - Abdominal X-ray to assess for toxic megacolon  

---

Admission 89647208  
    DRGs:  
    - APR: ULCERATIVE COLITIS WITH RECTAL BLEEDING — STEROID-REFRACTORY FLARE (Severity 3.0)  
    - HCFA: GASTROINTESTINAL INFLAMMATORY DISEASES — REFRACTORY UC  

    Medications:  
    - Mesalamine 2.4 g PO daily  
    - Prednisone taper starting at 60 mg PO daily  
    - Infliximab IV 5 mg/kg at weeks 0, 2, and 6  
    - Calcium Carbonate + Vitamin D PO daily  
    - Pantoprazole 40 mg PO daily  
    - Hydrocortisone rectal foam 10% BID  

    Orders:  
    - Initiate Infliximab infusion, Completed  
    - Prednisone taper protocol, Discontinued via patient discharge  
    - Continue Mesalamine, Discontinued via patient discharge  
    - Weekly CRP monitoring, Completed  
    - Dietician consult for low-residue diet, Completed  

    Procedures:  
    - Flexible sigmoidoscopy to assess disease severity  
    - CT abdomen/pelvis for complication screening  

---

Admission 90834297  
    DRGs:  
    - APR: ULCERATIVE COLITIS — MAINTENANCE PHASE (Severity 2.0)  
    - HCFA: LONG-TERM MANAGEMENT OF BIOLOGIC-RESPONSIVE UC  

    Medications:  
    - Infliximab 5 mg/kg IV every 8 weeks  
    - Mesalamine 1.6 g PO daily  
    - Probiotic supplement BID  
    - Ferrous Sulfate 325 mg PO daily for anemia  
    - Loperamide 2 mg PO PRN diarrhea  

    Orders:  
    - Continue scheduled Infliximab infusions, Discontinued via patient discharge  
    - Maintain Mesalamine therapy, Discontinued via patient discharge  
    - Fecal calprotectin ordered for monitoring inflammation, Completed  
    - Nutrition counseling for maintenance diet, Completed  
    - Annual colonoscopy surveillance recommended, Scheduled  

    Procedures:  
    - Infliximab infusion with monitoring  
    - Colonoscopy for long-term disease surveillance  

---

Admission 91953762  
    DRGs:  
    - APR: ULCERATIVE COLITIS — ACUTE MASSIVE RECTAL BLEEDING (Severity 4.0)  
    - HCFA: GI BLEEDING REQUIRING SURGICAL CONSULT  

    Medications:  
    - IV Hydrocortisone 100 mg q8h  
    - Infliximab 10 mg/kg IV rescue dose  
    - Piperacillin-Tazobactam 4.5 g IV q6h  
    - Tranexamic Acid 1 g IV once  
    - Pantoprazole 40 mg IV daily  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Admit to ICU for hemodynamic monitoring  
    - Start high-dose IV steroids, Discontinued via patient discharge  
    - Escalate Infliximab dosing, Discontinued via patient discharge  
    - Start broad-spectrum antibiotics, Discontinued via patient discharge  
    - Surgical consult requested for potential colectomy, Completed  
    - Blood transfusion consent obtained, Completed  

    Procedures:  
    - Flexible sigmoidoscopy to localize active bleeding  
    - RBC transfusion x3 units  
    - Central venous catheter placement for rapid infusion access  


Patient 30001285  
Gender: Female  
Age: 38  
Race: WHITE  

Admission 77198204  
    DRGs:  
    - APR: ULCERATIVE COLITIS WITHOUT COMPLICATIONS — INITIAL DIAGNOSIS (Severity 2.0)  
    - HCFA: ULCERATIVE COLITIS — NON-COMPLICATED MANAGEMENT  

    Medications:  
    - Mesalamine 2.4 g PO daily  
    - Budesonide 9 mg PO daily  
    - Pantoprazole 40 mg PO daily  
    - Ondansetron 4 mg PO q8h PRN nausea  
    - Sodium Chloride 0.9% IV flush PRN  
    - Acetaminophen 650 mg PO q6h PRN abdominal pain  

    Orders:  
    - Start Mesalamine PO, Discontinued via patient discharge  
    - Budesonide PO for anti-inflammatory effect, Discontinued via patient discharge  
    - Begin low-residue diet, Completed  
    - Ondansetron PO PRN nausea, Discontinued via patient discharge  
    - Labs ordered: CBC, CMP, CRP, ESR, Completed  
    - Stool studies ordered to rule out infectious causes, Completed  

    Procedures:  
    - Colonoscopy with biopsy showing mild ulcerative inflammation  
    - Abdominal ultrasound to rule out secondary pathology  

---

Admission 78513472  
    DRGs:  
    - APR: ULCERATIVE COLITIS WITHOUT COMPLICATIONS — SYMPTOM FLARE (Severity 2.0)  
    - HCFA: ULCERATIVE COLITIS — NON-SEVERE DISEASE MANAGEMENT  

    Medications:  
    - Mesalamine 3.6 g PO daily  
    - Prednisone taper starting at 40 mg PO daily  
    - Probiotic supplement 2 capsules PO daily  
    - Calcium Carbonate + Vitamin D daily  
    - Pantoprazole 40 mg PO daily  
    - Simethicone 80 mg PO PRN bloating  

    Orders:  
    - Adjust Mesalamine dose to 3.6 g PO daily, Discontinued via patient discharge  
    - Begin short-course prednisone taper, Discontinued via patient discharge  
    - Initiate probiotic supplementation, Discontinued via patient discharge  
    - Nutrition counseling for anti-inflammatory diet, Completed  
    - Schedule follow-up with GI clinic in 4 weeks, Completed  

    Procedures:  
    - Flexible sigmoidoscopy showing mild proctosigmoid involvement  
    - CRP re-evaluation for flare monitoring  

---

Admission 80236954  
    DRGs:  
    - APR: ULCERATIVE COLITIS — MAINTENANCE THERAPY (Severity 1.0)  
    - HCFA: LONG-TERM DISEASE MONITORING  

    Medications:  
    - Mesalamine 2.4 g PO daily  
    - Vitamin D3 2000 IU PO daily  
    - Omega-3 Fatty Acids 1 g PO daily  
    - Ferrous Sulfate 325 mg PO daily  
    - Loperamide 2 mg PO PRN diarrhea  

    Orders:  
    - Continue maintenance Mesalamine therapy, Discontinued via patient discharge  
    - Fecal calprotectin ordered to monitor mucosal healing, Completed  
    - Annual surveillance colonoscopy recommended, Scheduled  
    - Nutritional counseling for high-fiber diet during remission, Completed  
    - Refer to patient support group for chronic UC management, Completed  

    Procedures:  
    - Routine colonoscopy showing mild mucosal improvement  
    - Mesalamine adherence review by clinical pharmacist  

---

Admission 81925743  
    DRGs:  
    - APR: ULCERATIVE COLITIS — ASYMPTOMATIC FOLLOW-UP (Severity 1.0)  
    - HCFA: LOW-RISK MAINTENANCE MANAGEMENT  

    Medications:  
    - Mesalamine 2.4 g PO daily  
    - Probiotic supplement daily  
    - Multivitamin with minerals PO daily  

    Orders:  
    - Continue stable Mesalamine regimen, Discontinued via patient discharge  
    - Schedule annual GI follow-up, Completed  
    - Monitor CBC and CRP yearly, Completed  
    - Educate patient on early flare recognition, Completed  

    Procedures:  
    - Surveillance colonoscopy performed, no active disease detected  
    - Nutritional assessment performed during outpatient visit  


Patient 40001285  
Gender: Male  
Age: 62  
Race: WHITE  

Admission 78845312  
    DRGs:  
    - APR: LOWER GI BLEED — INITIAL EPISODE (Severity 3.0)  
    - HCFA: HEMORRHAGE OF ANUS AND RECTUM — NON-VARICEAL SOURCE  

    Medications:  
    - Pantoprazole 40 mg IV BID  
    - Octreotide infusion 50 mcg/hr  
    - Sodium Chloride 0.9% IV at 100 mL/hr  
    - Ceftriaxone 1 g IV daily (prophylaxis for infection risk)  
    - Acetaminophen 650 mg PO q6h PRN pain  
    - Ondansetron 4 mg IV q8h PRN nausea  

    Orders:  
    - Start Pantoprazole IV, Discontinued via patient discharge  
    - Start Octreotide IV drip for bleeding control, Discontinued via patient discharge  
    - Begin IV fluids for hypovolemia, Discontinued via patient discharge  
    - Ceftriaxone prophylaxis initiated, Discontinued via patient discharge  
    - Monitor hemoglobin and hematocrit q6h, Completed  
    - Type and crossmatch blood for potential transfusion, Completed  
    - Colonoscopy scheduled for evaluation, Completed  

    Procedures:  
    - Colonoscopy with epinephrine injection and thermal coagulation at bleeding site  
    - Rectal anoscopy to identify bleeding source  
    - IV fluid resuscitation  

---

Admission 79902461  
    DRGs:  
    - APR: LOWER GI BLEED — READMISSION FOR RECURRENT BLEEDING (Severity 2.0)  
    - HCFA: HEMORRHAGE OF ANUS AND RECTUM — NON-SURGICAL MANAGEMENT  

    Medications:  
    - Pantoprazole 40 mg PO daily  
    - Mesalamine suppository 1 g PR nightly (for associated rectal inflammation)  
    - Sucralfate 1 g PO TID  
    - Ferrous Sulfate 325 mg PO daily for anemia  
    - Polyethylene Glycol PO daily for stool softening  
    - Ondansetron 4 mg PO PRN nausea  

    Orders:  
    - Transition Pantoprazole IV to PO, Discontinued via patient discharge  
    - Mesalamine rectal suppository initiated, Discontinued via patient discharge  
    - Sucralfate started for mucosal healing, Discontinued via patient discharge  
    - Iron supplementation ordered for anemia recovery, Discontinued via patient discharge  
    - Polyethylene Glycol PRN for constipation prevention, Discontinued via patient discharge  
    - Schedule follow-up with GI clinic in 2 weeks, Completed  

    Procedures:  
    - Flexible sigmoidoscopy revealing small internal hemorrhoids with recent bleeding  
    - No active bleeding at time of evaluation  
    - Nutrition consult for high-fiber diet  

---

Admission 81173584  
    DRGs:  
    - APR: LOWER GI BLEED — ELECTIVE SURVEILLANCE (Severity 1.0)  
    - HCFA: CHRONIC ANORECTAL BLEEDING — LONG-TERM MANAGEMENT  

    Medications:  
    - Pantoprazole 40 mg PO daily  
    - Hydrocortisone rectal cream BID PRN irritation  
    - Vitamin C 500 mg PO daily  
    - Zinc Sulfate 220 mg PO daily  
    - Probiotic supplement PO daily  

    Orders:  
    - Continue oral Pantoprazole for prophylaxis, Discontinued via patient discharge  
    - Start hydrocortisone rectal cream PRN irritation, Discontinued via patient discharge  
    - Recommend high-fiber diet and hydration, Completed  
    - Surveillance colonoscopy scheduled yearly, Completed  

    Procedures:  
    - Annual surveillance colonoscopy — stable mucosa, no new bleeding  
    - Anorectal ultrasound confirming mucosal healing  

---

Admission 82519670  
    DRGs:  
    - APR: LOWER GI BLEED — OUTPATIENT FOLLOW-UP (Severity 1.0)  
    - HCFA: POST-BLEEDING RECOVERY MONITORING  

    Medications:  
    - Pantoprazole 40 mg PO daily  
    - Ferrous Sulfate 325 mg PO every other day  
    - Multivitamin with folate PO daily  

    Orders:  
    - Continue long-term Pantoprazole PO, Discontinued via patient discharge  
    - Monitor CBC q6 months, Completed  
    - Nutritional counseling for bleeding prevention, Completed  
    - Patient education provided on early warning signs of recurrent bleeding, Completed  

    Procedures:  
    - Surveillance sigmoidoscopy performed — no active bleeding  
    - Dietary and hydration counseling session  


Patient 50001285  
Gender: Female  
Age: 55  
Race: WHITE  

Admission 10023761  
    DRGs:  
    - APR: IRON DEFICIENCY ANEMIA W/O MCC (Severity 2.0)  
    - HCFA: ANEMIA & NUTRITIONAL DISORDERS W/O CC/MCC  

    Medications:  
    - Ferrous Sulfate 325mg PO  
    - Folic Acid 1mg PO  
    - Vitamin B12 (Cyanocobalamin) 1000mcg IM  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Ondansetron 4mg IV  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Ferrous Sulfate: PO, Discontinued via patient discharge  
    - Folic Acid: PO, Discontinued via patient discharge  
    - Vitamin B12: IM, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Complete blood count (CBC)  
    - Iron studies (serum iron, TIBC, ferritin)  
    - Peripheral smear review  

Admission 10194523  
    DRGs:  
    - APR: IRON DEFICIENCY ANEMIA W BLOOD LOSS (Severity 3.0)  
    - HCFA: ANEMIA W CC  

    Medications:  
    - IV Iron Sucrose (Venofer) 200mg  
    - Pantoprazole 40mg PO  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Lorazepam 1mg PO  
    - Ondansetron IV  
    - Heparin SC (DVT prophylaxis)  

    Orders:  
    - IV Iron Sucrose: IV, Discontinued via patient discharge  
    - Pantoprazole: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Lorazepam: PO, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  

    Procedures:  
    - Upper GI endoscopy (to rule out bleeding source)  
    - Colonoscopy screening  
    - Serum folate & vitamin B12 panel  
    - Abdominal ultrasound  

Admission 10385742  
    DRGs:  
    - APR: SEVERE IRON DEFICIENCY ANEMIA W TRANSFUSION (Severity 4.0)  
    - HCFA: ANEMIA W MCC  

    Medications:  
    - Packed Red Blood Cell (PRBC) transfusion  
    - IV Iron Dextran 1000mg  
    - Pantoprazole IV  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Diphenhydramine 25mg IV (pre-medication for transfusion)  
    - Ceftriaxone IV (empiric coverage)  
    - Multivitamin Supplement  

    Orders:  
    - PRBC Transfusion: IV, Completed  
    - IV Iron Dextran: IV, Discontinued via patient discharge  
    - Pantoprazole IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Diphenhydramine: IV, Discontinued via patient discharge  
    - Ceftriaxone IV: IV, Discontinued via patient discharge  
    - Multivitamin Supplement: PO, Discontinued via patient discharge  

    Procedures:  
    - Packed red blood cell transfusion (2 units)  
    - Bone marrow aspiration and biopsy  
    - Ferritin and transferrin saturation studies  
    - Continuous pulse oximetry monitoring


Patient 60001285  
Gender: Female  
Age: 45  
Race: WHITE  

Admission 78563214  
    DRGs:  
    - APR: PSORIASIS VULGARIS — INITIAL DIAGNOSIS AND MANAGEMENT (Severity 2.0)  
    - HCFA: PSORIASIS WITHOUT SYSTEMIC COMPLICATIONS  

    Medications:  
    - Clobetasol propionate 0.05% topical cream BID  
    - Calcipotriol (Vitamin D analog) 50 mcg/g topical BID  
    - Cetirizine 10 mg PO daily for pruritus  
    - Aquaphor ointment topical PRN for dryness  
    - Acetaminophen 650 mg PO PRN mild discomfort  

    Orders:  
    - Initiate clobetasol topical therapy, Discontinued via patient discharge  
    - Start calcipotriol BID for plaque control, Discontinued via patient discharge  
    - Recommend daily emollient use, Completed  
    - Patient education provided on trigger avoidance, Completed  
    - Schedule dermatology follow-up in 4 weeks, Completed  

    Procedures:  
    - Wood’s lamp exam to rule out fungal coinfections  
    - Initial PASI (Psoriasis Area and Severity Index) scoring for baseline disease severity  

---

Admission 79620485  
    DRGs:  
    - APR: PSORIASIS VULGARIS — SYSTEMIC TREATMENT INITIATION (Severity 3.0)  
    - HCFA: MODERATE TO SEVERE PSORIASIS WITH SYSTEMIC THERAPY  

    Medications:  
    - Methotrexate 15 mg PO weekly  
    - Folic acid 1 mg PO daily  
    - Clobetasol propionate 0.05% topical cream PRN  
    - Hydroxyzine 25 mg PO nightly for pruritus  
    - Ibuprofen 400 mg PO PRN mild pain  
    - Vitamin D3 2000 IU PO daily  

    Orders:  
    - Start methotrexate PO weekly, Discontinued via patient discharge  
    - Initiate folic acid supplementation, Discontinued via patient discharge  
    - CBC, LFTs, and renal function monitoring ordered, Completed  
    - Continue high-potency topical steroid PRN, Discontinued via patient discharge  
    - Counseling on alcohol avoidance and infection risk, Completed  

    Procedures:  
    - Liver function panel and kidney function testing pre-methotrexate  
    - Repeat PASI scoring to assess response after 8 weeks  
    - Phototherapy counseling performed  

---

Admission 81259732  
    DRGs:  
    - APR: PSORIASIS VULGARIS — BIOLOGIC THERAPY MANAGEMENT (Severity 3.0)  
    - HCFA: MODERATE TO SEVERE PLAQUE PSORIASIS WITH BIOLOGIC INITIATION  

    Medications:  
    - Adalimumab (Humira) 40 mg SC every other week  
    - Methotrexate 10 mg PO weekly  
    - Folic acid 1 mg PO daily  
    - Moisturizing ointments topical PRN dryness  
    - Cetirizine 10 mg PO daily  
    - Influenza Vaccine Quadrivalent IM once  

    Orders:  
    - Start adalimumab SC per dermatology, Discontinued via patient discharge  
    - Reduce methotrexate dose for dual therapy, Discontinued via patient discharge  
    - Tuberculosis and hepatitis B screening ordered before biologic initiation, Completed  
    - Annual influenza vaccine administered, Completed  
    - Patient counseling on biologic safety, Completed  

    Procedures:  
    - Subcutaneous injection training for adalimumab self-administration  
    - Regular follow-up visits scheduled every 12 weeks  
    - PASI and DLQI (Dermatology Life Quality Index) monitoring for treatment effectiveness  

---

Admission 82956340  
    DRGs:  
    - APR: PSORIASIS VULGARIS — LONG-TERM DISEASE MONITORING (Severity 1.0)  
    - HCFA: STABLE CHRONIC PSORIASIS ON MAINTENANCE THERAPY  

    Medications:  
    - Adalimumab (Humira) 40 mg SC every other week  
    - Folic acid 1 mg PO daily  
    - Calcipotriol topical PRN  
    - Multivitamin with zinc and omega-3s PO daily  

    Orders:  
    - Continue biologic therapy per dermatology protocol, Discontinued via patient discharge  
    - Annual labs for LFTs, CBC, and creatinine clearance, Completed  
    - Patient education provided on maintaining moisturization and trigger avoidance, Completed  
    - Recommend yearly dermatology check-up, Completed  

    Procedures:  
    - Full skin assessment and photographic documentation  
    - Updated PASI score showing >85% improvement from baseline  
    - Nutrition counseling for anti-inflammatory diet  


Patient 10001286  
Gender: Female  
Age: 29  
Race: WHITE  

Admission 77543210  
    DRGs:  
    - APR: ACUTE CYSTITIS WITH HEMATURIA — INITIAL EPISODE (Severity 2.0)  
    - HCFA: ACUTE LOWER URINARY TRACT INFECTION WITH BLOOD IN URINE  

    Medications:  
    - Nitrofurantoin 100 mg PO BID × 7 days  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Acetaminophen 650 mg PO PRN pain  
    - Lactobacillus probiotic PO daily  
    - Sodium Chloride 0.9% Flush IV PRN hydration  

    Orders:  
    - Start nitrofurantoin 100 mg PO BID × 7 days, Discontinued via patient discharge  
    - Start phenazopyridine 200 mg PO TID × 2 days for dysuria, Discontinued via patient discharge  
    - Urine culture and sensitivity ordered, Completed  
    - Encourage oral hydration (>2L daily), Completed  
    - Acetaminophen PRN for discomfort, Discontinued via patient discharge  

    Procedures:  
    - Urinalysis with microscopy  
    - Urine culture and antibiotic sensitivity testing  

---

Admission 78905421  
    DRGs:  
    - APR: ACUTE CYSTITIS WITH HEMATURIA — RECURRENT EPISODE (Severity 3.0)  
    - HCFA: RECURRENT LOWER URINARY TRACT INFECTION WITH GROSS HEMATURIA  

    Medications:  
    - Cefdinir 300 mg PO BID × 10 days  
    - Phenazopyridine 200 mg PO TID × 3 days  
    - Ibuprofen 400 mg PO PRN mild pelvic pain  
    - Lactobacillus probiotic PO daily  
    - Estradiol 10 mcg vaginal tablet twice weekly (for UTI prevention)  

    Orders:  
    - Start cefdinir 300 mg PO BID × 10 days, Discontinued via patient discharge  
    - Start phenazopyridine 200 mg PO TID × 3 days, Discontinued via patient discharge  
    - Urine microscopy and culture ordered, Completed  
    - Post-void residual ultrasound ordered, Completed  
    - Counsel patient on voiding after intercourse, Completed  

    Procedures:  
    - Bladder ultrasound  
    - Renal ultrasound to rule out upper urinary tract involvement  
    - Repeat urine culture 7 days post-antibiotics  

---

Admission 80123976  
    DRGs:  
    - APR: RECURRENT CYSTITIS WITH HEMATURIA — MULTIDRUG-RESISTANT ORGANISM (Severity 4.0)  
    - HCFA: COMPLEX URINARY TRACT INFECTION WITH GROSS BLOOD IN URINE  

    Medications:  
    - Piperacillin-tazobactam 4.5 g IV q8h × 7 days  
    - Fluconazole 150 mg PO weekly × 2 doses (antifungal prophylaxis)  
    - Acetaminophen 650 mg PO PRN fever  
    - Ondansetron 4 mg IV PRN nausea  
    - Probiotic supplementation PO daily  

    Orders:  
    - Start IV piperacillin-tazobactam based on urine culture resistance, Discontinued via patient discharge  
    - Fluconazole prophylaxis ordered, Discontinued via patient discharge  
    - Insert peripheral IV line, Completed  
    - Monitor CBC, CMP, and renal function daily, Completed  
    - Schedule follow-up with urology, Completed  

    Procedures:  
    - CT abdomen/pelvis with contrast to rule out obstructive uropathy  
    - Cystoscopy to evaluate hematuria origin  
    - Post-treatment urine analysis and sensitivity testing  


Patient 20001286  
Gender: Female  
Age: 37  
Race: ASIAN  

Admission 76543122  
    DRGs:  
    - APR: ACUTE CYSTITIS WITH HEMATURIA — INITIAL DIAGNOSIS (Severity 2.0)  
    - HCFA: ACUTE LOWER URINARY TRACT INFECTION WITH BLOOD IN URINE  

    Medications:  
    - Cephalexin 500 mg PO Q6H × 7 days  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Acetaminophen 650 mg PO PRN fever or pelvic pain  
    - Sodium Chloride 0.9% IV PRN hydration  
    - Cranberry extract supplement PO daily  

    Orders:  
    - Start cephalexin 500 mg PO Q6H × 7 days, Discontinued via patient discharge  
    - Phenazopyridine PO TID for dysuria, Discontinued via patient discharge  
    - Urinalysis and urine culture ordered, Completed  
    - Encourage oral hydration ≥2.5 L/day, Completed  
    - Schedule follow-up in 7 days, Completed  

    Procedures:  
    - Urinalysis with microscopy  
    - Urine culture and sensitivity testing  

---

Admission 78204915  
    DRGs:  
    - APR: ACUTE CYSTITIS WITH HEMATURIA — RECURRENT EPISODE (Severity 3.0)  
    - HCFA: RECURRENT LOWER UTI WITH BLOOD IN URINE  

    Medications:  
    - Ciprofloxacin 500 mg PO BID × 7 days  
    - Phenazopyridine 200 mg PO TID × 3 days  
    - Ibuprofen 400 mg PO PRN suprapubic pain  
    - Lactobacillus probiotic PO daily  
    - Vitamin C 500 mg PO daily  

    Orders:  
    - Start ciprofloxacin 500 mg PO BID × 7 days, Discontinued via patient discharge  
    - Phenazopyridine PO TID × 3 days, Discontinued via patient discharge  
    - Bladder scan for residual urine volume, Completed  
    - Renal ultrasound ordered, Completed  
    - Patient counseled on UTI prevention strategies, Completed  

    Procedures:  
    - Bladder ultrasound for incomplete emptying  
    - Renal ultrasound to rule out upper tract involvement  
    - Repeat urine culture 7 days post-antibiotic therapy  

---

Admission 80361740  
    DRGs:  
    - APR: COMPLICATED CYSTITIS WITH GROSS HEMATURIA — IV THERAPY REQUIRED (Severity 4.0)  
    - HCFA: ACUTE LOWER UTI WITH SIGNIFICANT BLOOD LOSS AND SYSTEMIC SYMPTOMS  

    Medications:  
    - Ceftriaxone 1 g IV q24h × 5 days  
    - Fluconazole 150 mg PO weekly × 2 doses  
    - Ondansetron 4 mg IV PRN nausea  
    - Acetaminophen 650 mg PO PRN fever  
    - Sodium Chloride 0.9% IV continuous for hydration  

    Orders:  
    - Start ceftriaxone IV therapy, Discontinued via patient discharge  
    - Initiate antifungal prophylaxis with fluconazole, Discontinued via patient discharge  
    - Monitor vital signs q4h for sepsis risk, Completed  
    - Insert peripheral IV line, Completed  
    - Urology consult ordered, Completed  

    Procedures:  
    - CT urography to assess for urinary tract obstruction  
    - Cystoscopy to evaluate source of bleeding  
    - Post-discharge urine culture to confirm clearance  


Patient 30001286  
Gender: Female  
Age: 45  
Race: WHITE  

Admission 76843211  
    DRGs:  
    - APR: INTERSTITIAL CYSTITIS / CHRONIC BLADDER PAIN SYNDROME — INITIAL DIAGNOSIS (Severity 2.0)  
    - HCFA: CHRONIC BLADDER INFLAMMATORY DISORDERS W/O OBSTRUCTION  

    Medications:  
    - Pentosan Polysulfate Sodium (Elmiron) 100 mg PO TID  
    - Amitriptyline 25 mg PO QHS  
    - Hydroxyzine 25 mg PO QHS  
    - Acetaminophen 650 mg PO PRN pelvic pain  
    - Sodium Chloride 0.9% Flush IV PRN hydration  

    Orders:  
    - Start Elmiron 100 mg PO TID, Continued  
    - Amitriptyline 25 mg PO nightly for neuropathic bladder pain, Continued  
    - Hydroxyzine 25 mg PO nightly for mast cell stabilization, Continued  
    - Bladder diary instructed for symptom monitoring, Completed  
    - Urinalysis and urine culture ordered to rule out infection, Completed  

    Procedures:  
    - Baseline cystoscopy to evaluate bladder wall integrity  
    - Post-void residual urine ultrasound  

---

Admission 78403129  
    DRGs:  
    - APR: INTERSTITIAL CYSTITIS WITH PERSISTENT PAIN — FLARE MANAGEMENT (Severity 3.0)  
    - HCFA: CHRONIC BLADDER PAIN SYNDROME WITH URGENCY AND FREQUENCY  

    Medications:  
    - Intravesical Heparin 40,000 units + Lidocaine 2% + Sodium Bicarbonate instillation weekly × 6  
    - Gabapentin 300 mg PO BID for pelvic nerve pain  
    - Phenazopyridine 200 mg PO TID × 2 days for flare-associated dysuria  
    - Ibuprofen 400 mg PO PRN pelvic cramping  
    - Lactobacillus probiotic PO daily  

    Orders:  
    - Weekly bladder instillation therapy × 6 sessions, Completed  
    - Initiate gabapentin 300 mg PO BID, Continued  
    - Urine cytology to rule out atypical cells, Completed  
    - Physical therapy referral for pelvic floor relaxation, Completed  
    - Patient counseled on anti-inflammatory diet, Completed  

    Procedures:  
    - Intravesical bladder instillation therapy  
    - Urodynamic testing to evaluate bladder compliance and capacity  

---

Admission 81294567  
    DRGs:  
    - APR: REFRACTORY INTERSTITIAL CYSTITIS WITH SEVERE PERSISTENT SYMPTOMS (Severity 4.0)  
    - HCFA: COMPLEX BLADDER PAIN SYNDROME REQUIRING ADVANCED INTERVENTION  

    Medications:  
    - Cyclosporine A 75 mg PO BID (immunomodulator for refractory disease)  
    - Diazepam 5 mg PO BID for pelvic floor muscle spasm  
    - Tramadol 50 mg PO PRN severe pain  
    - Sodium Bicarbonate 650 mg PO daily (urine alkalization)  
    - Hydrocodone-acetaminophen 5/325 mg PO PRN breakthrough pain  

    Orders:  
    - Start cyclosporine PO BID with CBC and renal monitoring, Continued  
    - Schedule hydrodistension under anesthesia, Completed  
    - Insert peripheral IV for peri-procedural hydration, Completed  
    - Referral to urology pain specialist, Completed  
    - Follow-up cystoscopy scheduled in 3 months, Pending  

    Procedures:  
    - Cystoscopy with bladder hydrodistension under anesthesia  
    - Bladder biopsy to evaluate for Hunner lesions  
    - Pelvic MRI to exclude secondary causes of chronic pain  


Patient 40001286  
Gender: Male  
Age: 49  
Race: WHITE  

Admission 77451203  
    DRGs:  
    - APR: KIDNEY STONES — INITIAL EPISODE WITH HYDRATION MANAGEMENT (Severity 2.0)  
    - HCFA: URINARY CALCULUS WITHOUT OBSTRUCTION  

    Medications:  
    - Tamsulosin 0.4 mg PO daily  
    - Ketorolac 15 mg IV q6h PRN flank pain  
    - Ondansetron 4 mg IV PRN nausea  
    - Acetaminophen 650 mg PO PRN mild pain  
    - Sodium Chloride 0.9% IV continuous for hydration  

    Orders:  
    - Start tamsulosin PO daily, Continued  
    - Initiate IV hydration with normal saline, Discontinued via patient discharge  
    - Non-contrast CT scan abdomen/pelvis to confirm stone location, Completed  
    - Strain urine for stone passage, Completed  
    - Encourage oral hydration ≥3 L/day, Completed  

    Procedures:  
    - Non-contrast abdominal CT scan  
    - Urinalysis and metabolic panel  

---

Admission 79283155  
    DRGs:  
    - APR: OBSTRUCTING KIDNEY STONE WITH ACUTE FLARE (Severity 3.0)  
    - HCFA: KIDNEY STONES WITH URINARY TRACT OBSTRUCTION  

    Medications:  
    - Morphine 2 mg IV q4h PRN severe renal colic  
    - Tamsulosin 0.4 mg PO daily  
    - Ceftriaxone 1 g IV q24h (prophylaxis against infection)  
    - Ondansetron 4 mg IV PRN nausea  
    - Ibuprofen 600 mg PO q8h for inflammation  

    Orders:  
    - Place peripheral IV for fluid resuscitation, Completed  
    - Start ceftriaxone IV prophylaxis, Discontinued via patient discharge  
    - Renal ultrasound to evaluate obstruction severity, Completed  
    - Urology consult for potential intervention, Completed  
    - Patient education on stone prevention, Completed  

    Procedures:  
    - Renal ultrasound  
    - Intravenous pyelogram (IVP) to evaluate obstruction  
    - Stone analysis ordered post-passage  

---

Admission 82193704  
    DRGs:  
    - APR: COMPLICATED KIDNEY STONES REQUIRING SURGICAL MANAGEMENT (Severity 4.0)  
    - HCFA: CALCULUS OF KIDNEY WITH PERSISTENT OBSTRUCTION  

    Medications:  
    - Ceftriaxone 1 g IV pre-op prophylaxis  
    - Ketorolac 15 mg IV PRN postoperative pain  
    - Acetaminophen 650 mg PO PRN pain  
    - Tamsulosin 0.4 mg PO daily for stone passage support  
    - Sodium Bicarbonate 650 mg PO daily (alkalinization of urine)  

    Orders:  
    - Schedule ureteroscopy with laser lithotripsy, Completed  
    - Insert ureteral stent post-procedure, Completed  
    - Continuous IV fluids for 24 hours post-op, Discontinued via patient discharge  
    - Repeat abdominal X-ray (KUB) to confirm stone clearance, Completed  
    - 24-hour urine collection ordered for metabolic stone workup, Pending  

    Procedures:  
    - Ureteroscopy with laser lithotripsy  
    - Ureteral stent placement  
    - 24-hour urine analysis for stone recurrence prevention  


Patient 50001286  
Gender: Male  
Age: 61  
Race: WHITE  

Admission 11023958  
    DRGs:  
    - APR: HEMATURIA W/O MAJOR COMPLICATIONS (Severity 2.0)  
    - HCFA: HEMATURIA, UNSPECIFIED W/O CC/MCC  

    Medications:  
    - Acetaminophen  
    - Sodium Chloride 0.9% Flush  
    - Ciprofloxacin 500mg PO (empiric coverage)  
    - Phenazopyridine 200mg PO  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Ciprofloxacin 500mg: PO, Discontinued via patient discharge  
    - Phenazopyridine 200mg: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Urinalysis with microscopy  
    - Urine culture and sensitivity  
    - Renal ultrasound  

Admission 11148723  
    DRGs:  
    - APR: HEMATURIA WITH UROLOGIC EVALUATION (Severity 3.0)  
    - HCFA: GROSS HEMATURIA W CC  

    Medications:  
    - Ceftriaxone IV  
    - Tamsulosin 0.4mg PO  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Ondansetron IV  
    - Heparin SC (DVT prophylaxis)  

    Orders:  
    - Ceftriaxone IV: IV, Discontinued via patient discharge  
    - Tamsulosin 0.4mg: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  

    Procedures:  
    - CT Urogram  
    - Flexible cystoscopy with bladder inspection  
    - Uroflowmetry and post-void residual measurement  

Admission 11287591  
    DRGs:  
    - APR: SEVERE HEMATURIA WITH OBSTRUCTION OR BLEEDING SOURCE (Severity 4.0)  
    - HCFA: HEMATURIA W MCC  

    Medications:  
    - Piperacillin-Tazobactam (Zosyn) IV  
    - Aminocaproic Acid IV (for bleeding control)  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Phenazopyridine 200mg PO  
    - Enoxaparin SC (DVT prophylaxis held peri-procedure)  
    - Hydromorphone IV (for pain control)  

    Orders:  
    - Piperacillin-Tazobactam: IV, Discontinued via patient discharge  
    - Aminocaproic Acid IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Phenazopyridine 200mg: PO, Discontinued via patient discharge  
    - Enoxaparin SC: SC, Discontinued via patient discharge  
    - Hydromorphone IV: IV, Discontinued via patient discharge  

    Procedures:  
    - Cystoscopy with clot evacuation  
    - Bilateral retrograde pyelogram  
    - Ureteroscopic evaluation  
    - Bladder fulguration for bleeding source control


Patient 60001286  
Gender: Female  
Age: 32  
Race: ASIAN  

Admission 77510392  
    DRGs:  
    - APR: UNSPECIFIED CONJUNCTIVITIS — INITIAL EVALUATION (Severity 1.0)  
    - HCFA: ACUTE EYE INFLAMMATION W/O COMPLICATIONS  

    Medications:  
    - Artificial Tears (Carboxymethylcellulose) 1 drop OU QID  
    - Olopatadine 0.1% Ophthalmic Drops, 1 drop OU BID  
    - Acetaminophen 500 mg PO PRN eye discomfort  
    - Sodium Chloride 0.9% Flush PRN eye irrigation  

    Orders:  
    - Start olopatadine drops BID, Continued  
    - Artificial tears QID for lubrication, Continued  
    - Visual acuity assessment, Completed  
    - Slit-lamp eye exam ordered, Completed  
    - Educate patient on avoiding eye rubbing and allergen exposure, Completed  

    Procedures:  
    - Slit-lamp examination to rule out corneal involvement  

---

Admission 78492316  
    DRGs:  
    - APR: UNSPECIFIED CONJUNCTIVITIS — RECURRENT FLARE (Severity 2.0)  
    - HCFA: CHRONIC CONJUNCTIVAL INFLAMMATION W/O VISION LOSS  

    Medications:  
    - Tobramycin Ophthalmic Drops 0.3% 1 drop OU Q6H × 7 days  
    - Prednisolone Acetate 1% Ophthalmic Drops, 1 drop OU BID (short course)  
    - Cetirizine 10 mg PO daily for allergic control  
    - Ibuprofen 400 mg PO PRN swelling or irritation  

    Orders:  
    - Bacterial culture from conjunctival swab ordered, Completed  
    - Start Tobramycin drops Q6H × 7 days, Discontinued via patient discharge  
    - Prednisolone drops BID for 5 days, Discontinued via patient discharge  
    - Patient educated on warm compresses twice daily, Completed  
    - Ophthalmology follow-up scheduled in 1 week, Completed  

    Procedures:  
    - Conjunctival swab and bacterial culture  
    - Fundoscopic exam to rule out posterior eye involvement  

---

Admission 80123741  
    DRGs:  
    - APR: RECURRENT BILATERAL CONJUNCTIVITIS — SEVERE INFLAMMATORY FLARE (Severity 3.0)  
    - HCFA: EYE INFLAMMATION WITH SEVERE SWELLING BUT NO VISION THREAT  

    Medications:  
    - Moxifloxacin Ophthalmic Drops 0.5% 1 drop OU Q8H × 10 days  
    - Cyclosporine Ophthalmic Drops 0.05% 1 drop OU BID  
    - Loratadine 10 mg PO daily for allergic triggers  
    - Hydrocortisone 0.5% Ophthalmic Ointment nightly OU × 5 days  
    - Sodium Chloride 0.9% Flush PRN eye irrigation  

    Orders:  
    - Initiate moxifloxacin ophthalmic therapy, Discontinued via patient discharge  
    - Start cyclosporine drops BID for recurrent inflammation, Continued  
    - Perform fluorescein staining to rule out corneal abrasions, Completed  
    - Provide patient education on hand hygiene and eye protection, Completed  
    - Referral to ophthalmology subspecialty clinic, Completed  

    Procedures:  
    - Fluorescein staining for corneal integrity  
    - Schirmer’s test to evaluate tear production  
    - High-resolution anterior segment OCT for inflammation monitoring  


Patient 10001287  
Gender: Female  
Age: 31  
Race: HISPANIC  

Admission 78145210  
    DRGs:  
    - APR: PREGNANCY-RELATED HYPERTENSION — THIRD TRIMESTER (Severity 3.0)  
    - HCFA: PREGNANCY-INDUCED HYPERTENSION W/O SEVERE FEATURES  

    Medications:  
    - Labetalol 100 mg PO BID  
    - Nifedipine ER 30 mg PO daily  
    - Prenatal Vitamins 1 tab PO daily  
    - Acetaminophen 650 mg PO PRN mild headache  
    - Sodium Chloride 0.9% Flush PRN IV access maintenance  

    Orders:  
    - Daily blood pressure monitoring, Continued  
    - Non-stress test (NST) for fetal heart rate monitoring, Completed  
    - Start labetalol PO BID, Continued  
    - Low-sodium diet counseling, Completed  
    - Educate patient on signs of worsening preeclampsia, Completed  

    Procedures:  
    - Non-stress test  
    - Urine protein-to-creatinine ratio testing  

---

Admission 79382467  
    DRGs:  
    - APR: PREGNANCY-RELATED HYPERTENSION WITH ELEVATED RISK (Severity 4.0)  
    - HCFA: GESTATIONAL HYPERTENSION REQUIRING CLOSE SURVEILLANCE  

    Medications:  
    - Labetalol 200 mg PO BID  
    - Nifedipine ER 60 mg PO daily  
    - Magnesium Sulfate 4 g IV loading dose, then 1 g/hr continuous infusion  
    - Ondansetron 4 mg IV PRN nausea  
    - Aspirin 81 mg PO daily (low-dose prophylaxis)  

    Orders:  
    - Start magnesium sulfate infusion for seizure prophylaxis, Discontinued via patient discharge  
    - Continuous fetal heart monitoring, Completed  
    - Weekly biophysical profile (BPP) ordered, Completed  
    - Serial lab monitoring: CBC, CMP, uric acid, Completed  
    - Consult maternal-fetal medicine specialist, Completed  

    Procedures:  
    - Biophysical profile ultrasound  
    - Serial fetal growth assessments  
    - Non-stress testing ×2 per week  

---

Admission 81693240  
    DRGs:  
    - APR: SEVERE PREECLAMPSIA — THIRD TRIMESTER (Severity 5.0)  
    - HCFA: PREGNANCY-RELATED HYPERTENSION WITH MULTIORGAN INVOLVEMENT  

    Medications:  
    - Magnesium Sulfate 4 g IV loading + 1 g/hr continuous  
    - Hydralazine 10 mg IV PRN severe hypertension  
    - Betamethasone 12 mg IM Q24H × 2 doses for fetal lung maturity  
    - Labetalol 300 mg PO BID  
    - Lactated Ringer’s IV fluids  

    Orders:  
    - Admit to Labor & Delivery for close maternal and fetal monitoring, Completed  
    - Initiate magnesium sulfate therapy, Discontinued via patient discharge  
    - Prepare for possible induction of labor, Completed  
    - Continuous electronic fetal monitoring, Completed  
    - Neonatal ICU team alerted for potential preterm delivery, Completed  

    Procedures:  
    - Induction of labor using oxytocin  
    - Epidural anesthesia administered  
    - Spontaneous vaginal delivery achieved at 36 weeks  
    - Placental pathology sent for evaluation  


Patient 20001287  
Gender: Female  
Age: 29  
Race: WHITE  

Admission 81156392  
    DRGs:  
    - APR: PREGNANCY-INDUCED HYPERTENSION — THIRD TRIMESTER (Severity 3.0)  
    - HCFA: GESTATIONAL HYPERTENSION WITHOUT SEVERE FEATURES  

    Medications:  
    - Labetalol 100 mg PO BID  
    - Nifedipine ER 30 mg PO daily  
    - Prenatal Vitamins 1 tab PO daily  
    - Low-dose Aspirin 81 mg PO daily  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Start labetalol PO BID, Continued  
    - Daily blood pressure monitoring, Continued  
    - Non-stress test (NST) for fetal heart rate, Completed  
    - Educate patient on diet and warning signs of preeclampsia, Completed  
    - Follow-up growth ultrasound ordered, Completed  

    Procedures:  
    - Non-stress test  
    - Basic metabolic panel to assess renal function  

---

Admission 82547913  
    DRGs:  
    - APR: PREGNANCY-RELATED HYPERTENSION WITH LAB ELEVATIONS (Severity 4.0)  
    - HCFA: GESTATIONAL HYPERTENSION REQUIRING CLOSE SURVEILLANCE  

    Medications:  
    - Labetalol 200 mg PO BID  
    - Nifedipine ER 60 mg PO daily  
    - Magnesium Sulfate 4 g IV loading, then 1 g/hr continuous  
    - Ondansetron 4 mg IV PRN nausea  
    - Betamethasone 12 mg IM Q24H × 2 doses for fetal lung maturity  

    Orders:  
    - Initiate magnesium sulfate infusion for seizure prophylaxis, Discontinued via patient discharge  
    - Continuous fetal monitoring, Completed  
    - Weekly biophysical profile (BPP) ordered, Completed  
    - Serial CBC, CMP, and urine protein-to-creatinine ratio, Completed  
    - Maternal-fetal medicine consult requested, Completed  

    Procedures:  
    - Biophysical profile ultrasound  
    - 24-hour urine protein collection  
    - Serial Doppler velocimetry for placental flow  

---

Admission 84231977  
    DRGs:  
    - APR: SEVERE PREECLAMPSIA WITH DELIVERY — THIRD TRIMESTER (Severity 5.0)  
    - HCFA: PREGNANCY-RELATED HYPERTENSION WITH COMPLICATIONS  

    Medications:  
    - Magnesium Sulfate 4 g IV bolus + 1 g/hr continuous infusion  
    - Hydralazine 10 mg IV Q6H PRN severe BP elevation  
    - Labetalol 300 mg PO BID  
    - Oxytocin infusion for induction of labor  
    - Acetaminophen 650 mg PO PRN postpartum discomfort  

    Orders:  
    - Admit to Labor & Delivery for induction, Completed  
    - Magnesium sulfate infusion initiated, Discontinued via patient discharge  
    - Continuous electronic fetal monitoring, Completed  
    - NICU team alerted for possible preterm delivery, Completed  
    - Postpartum follow-up for blood pressure monitoring scheduled, Completed  

    Procedures:  
    - Induction of labor using oxytocin  
    - Epidural anesthesia administered  
    - Vaginal delivery achieved at 35 weeks  
    - Placental pathology sent for evaluation  


Patient 30001287  
Gender: Female  
Age: 33  
Race: ASIAN  

Admission 76231480  
    DRGs:  
    - APR: GESTATIONAL HYPERTENSION WITHOUT PROTEINURIA — THIRD TRIMESTER (Severity 2.0)  
    - HCFA: HYPERTENSION COMPLICATING PREGNANCY — NO PROTEINURIA  

    Medications:  
    - Labetalol 100 mg PO BID  
    - Nifedipine ER 30 mg PO daily  
    - Prenatal Vitamins 1 tab PO daily  
    - Aspirin 81 mg PO daily  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Start labetalol PO BID, Continued  
    - Daily BP monitoring, Completed  
    - Non-stress test (NST) for fetal heart rate, Completed  
    - Dietary counseling for low-sodium intake, Completed  
    - Fetal growth ultrasound scheduled, Completed  

    Procedures:  
    - Non-stress test  
    - Basic labs: CBC, CMP, urine dipstick  

---

Admission 78520433  
    DRGs:  
    - APR: GESTATIONAL HYPERTENSION REQUIRING CLOSE MONITORING (Severity 3.0)  
    - HCFA: HIGH-RISK OBSTETRICAL OBSERVATION WITHOUT PROTEINURIA  

    Medications:  
    - Labetalol 200 mg PO BID  
    - Nifedipine ER 60 mg PO daily  
    - Betamethasone 12 mg IM Q24H × 2 doses for fetal lung maturity  
    - Ondansetron 4 mg IV PRN nausea  
    - Prenatal Vitamins PO daily  

    Orders:  
    - Serial BP monitoring Q4H, Completed  
    - Weekly biophysical profile (BPP) ordered, Completed  
    - Non-stress test twice weekly, Completed  
    - Labs: urine protein-to-creatinine ratio, CBC, CMP, Completed  
    - Maternal-fetal medicine (MFM) consult requested, Completed  

    Procedures:  
    - Biophysical profile ultrasound  
    - Doppler assessment for placental perfusion  
    - Fetal monitoring ×2 per week  

---

Admission 80296751  
    DRGs:  
    - APR: GESTATIONAL HYPERTENSION — INDUCTION OF LABOR (Severity 4.0)  
    - HCFA: DELIVERY-ASSOCIATED HYPERTENSION MANAGEMENT  

    Medications:  
    - Labetalol 300 mg PO BID  
    - Hydralazine 10 mg IV PRN SBP >160 mmHg  
    - Oxytocin infusion for induction of labor  
    - Magnesium Sulfate 4 g IV bolus + 1 g/hr continuous infusion  
    - Acetaminophen 650 mg PO PRN postpartum discomfort  

    Orders:  
    - Admit to Labor & Delivery, Completed  
    - Initiate induction protocol with oxytocin, Completed  
    - Continuous fetal monitoring, Completed  
    - NICU team alerted for potential late preterm delivery, Completed  
    - Postpartum BP monitoring and follow-up, Completed  

    Procedures:  
    - Induction of labor using oxytocin  
    - Epidural anesthesia administered  
    - Spontaneous vaginal delivery achieved at 37 weeks  
    - Placenta evaluated and sent to pathology  


Patient 40001287  
Gender: Female  
Age: 27  
Race: HISPANIC  

Admission 73126489  
    DRGs:  
    - APR: HYPEREMESIS GRAVIDARUM — UNSPECIFIED, FIRST TRIMESTER (Severity 2.0)  
    - HCFA: EXCESSIVE VOMITING IN PREGNANCY — INITIAL MANAGEMENT  

    Medications:  
    - Ondansetron 4 mg IV Q8H PRN nausea  
    - Doxylamine-Pyridoxine 10-10 mg PO BID  
    - Promethazine 12.5 mg IV Q6H PRN  
    - Sodium Chloride 0.9% IV bolus 1L, then continuous hydration  
    - Prenatal Vitamins 1 tab PO daily  
    - Thiamine 100 mg IV daily  

    Orders:  
    - Initiate IV fluids for dehydration, Completed  
    - Ondansetron IV PRN, Continued  
    - Diet consult for bland, high-calorie meal plan, Completed  
    - Monitor electrolytes and ketones daily, Completed  
    - Schedule follow-up with obstetrics clinic, Completed  

    Procedures:  
    - IV hydration therapy  
    - Basic labs: CMP, CBC, urine ketones  

---

Admission 74598311  
    DRGs:  
    - APR: HYPEREMESIS GRAVIDARUM WITH MODERATE COMPLICATIONS (Severity 3.0)  
    - HCFA: REFRACTORY PERSISTENT VOMITING IN PREGNANCY  

    Medications:  
    - Metoclopramide 10 mg IV Q6H  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Diphenhydramine 25 mg PO Q8H PRN  
    - Pantoprazole 40 mg IV daily  
    - Sodium Chloride 0.9% IV + Dextrose 5% infusion  
    - Thiamine 100 mg IV daily  
    - Folic Acid 1 mg PO daily  

    Orders:  
    - Admit for uncontrolled vomiting and dehydration, Completed  
    - Initiate IV multivitamin supplementation, Completed  
    - Daily weight monitoring, Completed  
    - Abdominal ultrasound ordered to evaluate fetal growth, Completed  
    - Consider home ondansetron pump, Pending  

    Procedures:  
    - IV hydration and electrolyte replacement  
    - Ultrasound for fetal viability and growth  
    - Nutritional assessment  

---

Admission 76834122  
    DRGs:  
    - APR: SEVERE HYPEREMESIS GRAVIDARUM WITH COMPLICATIONS (Severity 4.0)  
    - HCFA: ADVANCED MANAGEMENT OF INTRACTABLE PREGNANCY-RELATED VOMITING  

    Medications:  
    - Ondansetron continuous infusion at 8 mg/hr IV  
    - Metoclopramide 10 mg IV Q6H  
    - Methylprednisolone 16 mg IV Q12H for refractory nausea  
    - Potassium Chloride 40 mEq IV daily  
    - Thiamine 100 mg IV + Multivitamin infusion  
    - Parenteral Nutrition (TPN) initiated via PICC line  

    Orders:  
    - Place PICC line for TPN initiation, Completed  
    - Daily metabolic panel and electrolyte replacement, Completed  
    - Serial weight and hydration status monitoring, Completed  
    - Fetal non-stress test ordered, Completed  
    - Post-discharge plan for home health TPN support, Completed  

    Procedures:  
    - PICC line placement for long-term nutrition  
    - Initiation of total parenteral nutrition (TPN)  
    - Fetal monitoring with NST and BPP  

Patient 50001287  
Gender: Male  
Age: 59  
Race: WHITE  

Admission 12034125  
    DRGs:  
    - APR: HYPERTENSION WITHOUT COMPLICATIONS (Severity 1.0)  
    - HCFA: ESSENTIAL HYPERTENSION W/O MCC  

    Medications:  
    - Lisinopril 10mg PO  
    - Hydrochlorothiazide 25mg PO  
    - Amlodipine 5mg PO  
    - Sodium Chloride 0.9% Flush  
    - Aspirin EC 81mg PO  
    - Acetaminophen  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Lisinopril: PO, Discontinued via patient discharge  
    - Hydrochlorothiazide: PO, Discontinued via patient discharge  
    - Amlodipine: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Aspirin EC 81mg: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Electrocardiogram (ECG)  
    - Basic metabolic panel  
    - Blood pressure monitoring  

Admission 12149867  
    DRGs:  
    - APR: HYPERTENSIVE URGENCY / EMERGENCY (Severity 3.0)  
    - HCFA: MALIGNANT HYPERTENSION W CC  

    Medications:  
    - Labetalol IV  
    - Nicardipine IV Drip  
    - Hydralazine IV  
    - Sodium Nitroprusside IV  
    - Aspirin EC 81mg  
    - Atorvastatin 20mg  
    - Lorazepam 1mg PO  
    - Sodium Chloride 0.9% Flush  
    - Heparin SC  
    - Acetaminophen  

    Orders:  
    - Labetalol IV: IV, Discontinued via patient discharge  
    - Nicardipine IV Drip: IV, Discontinued via patient discharge  
    - Hydralazine IV: IV, Discontinued via patient discharge  
    - Sodium Nitroprusside IV: IV, Discontinued via patient discharge  
    - Aspirin EC 81mg: PO, Discontinued via patient discharge  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Lorazepam: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Continuous cardiac telemetry monitoring  
    - CT Head without contrast (rule out intracranial hemorrhage)  
    - Renal function panel  
    - Chest X-ray portable  

Admission 12287504  
    DRGs:  
    - APR: HYPERTENSION WITH ORGAN DAMAGE (Severity 4.0)  
    - HCFA: ESSENTIAL HYPERTENSION W MCC  

    Medications:  
    - Losartan 50mg PO  
    - Metoprolol Succinate 50mg PO  
    - Chlorthalidone 25mg PO  
    - Amlodipine 10mg PO  
    - Sodium Chloride 0.9% Flush  
    - Atorvastatin 20mg  
    - Aspirin EC 81mg  
    - Clonidine 0.1mg PO  
    - Acetaminophen  

    Orders:  
    - Losartan: PO, Discontinued via patient discharge  
    - Metoprolol Succinate: PO, Discontinued via patient discharge  
    - Chlorthalidone: PO, Discontinued via patient discharge  
    - Amlodipine: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Atorvastatin 20mg: PO, Discontinued via patient discharge  
    - Aspirin EC 81mg: PO, Discontinued via patient discharge  
    - Clonidine: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Echocardiogram (TTE)  
    - 24-hour ambulatory BP monitoring  
    - Serum electrolytes  
    - Microalbuminuria screening


Patient 60001287  
Gender: Female  
Age: 29  
Race: WHITE  

Admission 71234019  
    DRGs:  
    - APR: ASTHMA EXACERBATION WITHOUT STATUS ASTHMATICUS (Severity 2.0)  
    - HCFA: UNSPECIFIED ASTHMA WITHOUT COMPLICATIONS  

    Medications:  
    - Albuterol Inhaler 90 mcg: 2 puffs Q4H PRN  
    - Fluticasone Propionate 110 mcg: 1 puff BID  
    - Montelukast 10 mg PO QHS  
    - Cetirizine 10 mg PO daily  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Initiate albuterol inhaler PRN, Completed  
    - Spirometry testing for baseline control, Completed  
    - Patient education on asthma action plan, Completed  
    - Environmental allergen reduction counseling, Completed  
    - Follow-up scheduled with primary care and pulmonology, Completed  

    Procedures:  
    - Pulmonary function testing (PFT)  
    - Peak flow measurement  

---

Admission 73451288  
    DRGs:  
    - APR: ACUTE ASTHMA EXACERBATION — MODERATE SEVERITY (Severity 3.0)  
    - HCFA: ASTHMA WITH RESPIRATORY DISTRESS — NON-ICU  

    Medications:  
    - Albuterol 2.5 mg Nebulizer Q2H PRN  
    - Ipratropium Bromide 0.5 mg Nebulizer Q4H PRN  
    - Prednisone 40 mg PO daily × 5 days  
    - Fluticasone-Salmeterol 250/50 mcg Diskus: 1 puff BID  
    - Montelukast 10 mg PO daily  

    Orders:  
    - Admit for acute asthma exacerbation, Completed  
    - Initiate DuoNeb treatments Q4H, Completed  
    - Oxygen therapy initiated for SpO₂ < 94%, Completed  
    - Chest X-ray to rule out pneumonia, Completed  
    - Daily peak expiratory flow monitoring, Completed  

    Procedures:  
    - Nebulizer therapy  
    - Chest X-ray imaging  
    - Continuous oxygen saturation monitoring  

---

Admission 75268043  
    DRGs:  
    - APR: ASTHMA STABILIZATION FOLLOW-UP (Severity 1.0)  
    - HCFA: ASTHMA MAINTENANCE — NO COMPLICATIONS  

    Medications:  
    - Fluticasone-Salmeterol 250/50 mcg Diskus: 1 puff BID  
    - Montelukast 10 mg PO QHS  
    - Albuterol Inhaler 90 mcg: 2 puffs PRN  
    - Loratadine 10 mg PO daily  
    - Influenza Vaccine Quadrivalent: IM once  

    Orders:  
    - Continue asthma controller medications, Completed  
    - Asthma education and inhaler technique check, Completed  
    - Influenza vaccine administered, Completed  
    - Schedule 3-month follow-up for medication review, Completed  

    Procedures:  
    - Peak flow monitoring  
    - Allergy panel ordered for environmental triggers  


Patient 10001288  
Gender: Male  
Age: 56  
Race: WHITE  

Admission 61247890  
    DRGs:  
    - APR: SEPSIS DUE TO MRSA INFECTION (Severity 4.0)  
    - HCFA: MRSA-ASSOCIATED BLOODSTREAM INFECTION WITH ACUTE ORGAN DYSFUNCTION  

    Medications:  
    - Vancomycin IV 1.25g Q12H (dose-adjusted per trough levels)  
    - Piperacillin-Tazobactam 4.5g IV Q6H  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Sodium Chloride 0.9% IV continuous infusion  
    - Lactated Ringer’s IV bolus 500 mL PRN hypotension  
    - Heparin 5000 U SC Q8H for DVT prophylaxis  

    Orders:  
    - Blood cultures ×2 from separate sites before antibiotics, Completed  
    - Initiate Vancomycin per infectious disease protocol, Completed  
    - Daily renal function monitoring due to nephrotoxic risk, Completed  
    - MRSA nasal screening ordered, Completed  
    - ID consultation ordered, Completed  

    Procedures:  
    - Central venous catheter placement for IV therapy  
    - Ultrasound-guided fluid resuscitation  
    - Serial lactate monitoring  

---

Admission 64321754  
    DRGs:  
    - APR: COMPLICATED MRSA SOFT-TISSUE INFECTION (Severity 3.0)  
    - HCFA: CELLULITIS AND ABSCESS SECONDARY TO MRSA  

    Medications:  
    - Linezolid 600 mg PO Q12H  
    - Vancomycin IV 1g Q12H (discontinued after 48 hrs due to nephrotoxicity)  
    - Daptomycin 6 mg/kg IV Q24H started after renal function decline  
    - Ibuprofen 600 mg PO Q8H PRN pain  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Wound culture with MRSA sensitivity panel, Completed  
    - ID re-consultation for therapy adjustment, Completed  
    - Switch from vancomycin to daptomycin per nephrology recommendations, Completed  
    - Daily CBC and CMP monitoring, Completed  
    - Wound care nurse evaluation, Completed  

    Procedures:  
    - Surgical incision & drainage (I&D) of left thigh abscess  
    - Negative pressure wound therapy (VAC dressing)  
    - Bedside wound debridement performed twice  

---

Admission 67230987  
    DRGs:  
    - APR: RECURRENT MRSA INFECTION — CHRONIC MANAGEMENT (Severity 2.0)  
    - HCFA: MRSA-RELATED OSTEOARTICULAR INVOLVEMENT  

    Medications:  
    - Doxycycline 100 mg PO BID × 6 weeks (suppressive therapy)  
    - Rifampin 600 mg PO daily for biofilm coverage  
    - Probiotic supplementation PO daily to reduce antibiotic-associated GI effects  
    - Acetaminophen 500 mg PO Q6H PRN  
    - Influenza Vaccine Quadrivalent IM once  

    Orders:  
    - Outpatient infectious disease follow-up scheduled, Completed  
    - MRI ordered to evaluate for MRSA-associated osteomyelitis, Completed  
    - PICC line placed for prolonged IV antibiotic therapy, Completed  
    - Weekly labs for monitoring ESR, CRP, renal function, Completed  

    Procedures:  
    - PICC line placement for long-term IV antibiotics  
    - MRI of right ankle showing early MRSA-related osteomyelitis  
    - Outpatient wound care and physical therapy referral  


Patient 20001288  
Gender: Female  
Age: 62  
Race: BLACK/AFRICAN AMERICAN  

Admission 78124566  
    DRGs:  
    - APR: MRSA SEPTICEMIA WITH ACUTE ORGAN DYSFUNCTION (Severity 4.0)  
    - HCFA: SEVERE MRSA BLOODSTREAM INFECTION WITH MULTI-SYSTEM INVOLVEMENT  

    Medications:  
    - Vancomycin IV 1.25 g Q12H (dose-adjusted based on trough levels)  
    - Piperacillin-Tazobactam IV 4.5 g Q6H  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Norepinephrine IV infusion for septic shock, titrated per MAP  
    - Sodium Chloride 0.9% IV continuous  
    - Heparin 5000 U SC Q8H for DVT prophylaxis  

    Orders:  
    - Obtain blood cultures ×2 prior to starting antibiotics, Completed  
    - Infectious disease (ID) consult for MRSA bacteremia, Completed  
    - Vancomycin trough level monitoring ordered, Completed  
    - Strict I/O monitoring and fluid resuscitation plan, Completed  
    - Daily renal panel monitoring due to nephrotoxic risk, Completed  

    Procedures:  
    - Central venous line placement  
    - Serial lactate monitoring  
    - Continuous telemetry monitoring  

---

Admission 79431025  
    DRGs:  
    - APR: COMPLICATED MRSA SKIN AND SOFT-TISSUE INFECTION (Severity 3.0)  
    - HCFA: CELLULITIS AND DEEP ABSCESS SECONDARY TO MRSA  

    Medications:  
    - Linezolid 600 mg PO Q12H  
    - Clindamycin 600 mg IV Q8H for toxin suppression  
    - Ibuprofen 600 mg PO Q8H PRN pain  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Wound cultures for MRSA with sensitivity testing, Completed  
    - Consult wound care for dressing changes, Completed  
    - Switch from Vancomycin to Linezolid per ID recommendations, Completed  
    - Daily CBC, ESR, and CRP ordered to track inflammation, Completed  

    Procedures:  
    - Incision and drainage (I&D) of right lower extremity abscess  
    - Negative pressure wound therapy initiated  
    - Bedside wound debridement performed twice  

---

Admission 81249537  
    DRGs:  
    - APR: RECURRENT MRSA OSTEOMYELITIS — CHRONIC MANAGEMENT (Severity 2.0)  
    - HCFA: MRSA BONE AND JOINT INVOLVEMENT — NON-ACUTE  

    Medications:  
    - Daptomycin IV 6 mg/kg Q24H × 6 weeks via PICC  
    - Rifampin 600 mg PO daily for biofilm penetration  
    - Doxycycline 100 mg PO BID as suppressive therapy after IV course  
    - Probiotic PO daily to minimize antibiotic-associated diarrhea  
    - Influenza Vaccine Quadrivalent IM once  

    Orders:  
    - MRI of left tibia to evaluate for chronic MRSA osteomyelitis, Completed  
    - PICC line placement for extended IV therapy, Completed  
    - Weekly ESR, CRP, and renal function monitoring, Completed  
    - Outpatient ID follow-up scheduled, Completed  

    Procedures:  
    - PICC line insertion  
    - MRI confirming MRSA-related osteomyelitis  
    - Outpatient wound care follow-up  


Patient 30001288  
Gender: Male  
Age: 64  
Race: WHITE  

Admission 71528491  
    DRGs:  
    - APR: MSSA BACTEREMIA WITH ACUTE ORGAN DYSFUNCTION (Severity 4.0)  
    - HCFA: STAPHYLOCOCCUS AUREUS BLOODSTREAM INFECTION WITH SYSTEMIC COMPLICATIONS  

    Medications:  
    - Nafcillin IV 2 g Q4H (first-line MSSA treatment)  
    - Piperacillin-Tazobactam IV 4.5 g Q6H until susceptibilities finalized  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Norepinephrine IV infusion for hypotension, titrated per MAP  
    - Sodium Chloride 0.9% IV continuous for fluid resuscitation  
    - Heparin 5000 U SC Q8H for DVT prophylaxis  

    Orders:  
    - Obtain blood cultures ×2 from separate sites, Completed  
    - Initiate Nafcillin after MSSA confirmed, Completed  
    - ID consultation for treatment duration planning, Completed  
    - Daily renal and hepatic function monitoring, Completed  
    - Echocardiogram ordered to rule out endocarditis, Completed  

    Procedures:  
    - Central venous line insertion for IV antibiotics  
    - Serial lactate monitoring  
    - Echocardiography performed — negative for vegetations  

---

Admission 73862540  
    DRGs:  
    - APR: COMPLICATED MSSA SKIN AND SOFT-TISSUE INFECTION (Severity 3.0)  
    - HCFA: CELLULITIS AND ABSCESS SECONDARY TO MSSA  

    Medications:  
    - Cefazolin IV 2 g Q8H (narrowed after susceptibility testing)  
    - Clindamycin 600 mg IV Q8H for toxin suppression  
    - Ibuprofen 600 mg PO Q8H PRN pain  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Wound culture and Gram stain, Completed  
    - Surgical consult for abscess drainage, Completed  
    - Daily wound dressing changes ordered, Completed  
    - ID re-evaluation for narrowing therapy to Cefazolin, Completed  
    - CBC and CRP monitored daily, Completed  

    Procedures:  
    - Incision and drainage (I&D) of left forearm abscess  
    - Placement of negative pressure wound VAC therapy  
    - Bedside wound debridement performed once  

---

Admission 76423812  
    DRGs:  
    - APR: MSSA SEPTIC ARTHRITIS OF THE KNEE (Severity 3.0)  
    - HCFA: ACUTE SEPTIC JOINT SECONDARY TO MSSA  

    Medications:  
    - Cefazolin IV 2 g Q8H × 6 weeks via PICC line  
    - Rifampin 600 mg PO daily for biofilm penetration  
    - Naproxen 500 mg PO BID PRN joint pain  
    - Acetaminophen 500 mg PO Q6H PRN  
    - Influenza Vaccine Quadrivalent IM once  

    Orders:  
    - Joint aspiration for synovial fluid analysis and MSSA culture, Completed  
    - PICC line placed for prolonged IV antibiotics, Completed  
    - Daily ESR and CRP ordered to monitor resolution, Completed  
    - Physical therapy consult initiated, Completed  

    Procedures:  
    - Arthroscopic irrigation and debridement of the right knee  
    - PICC line placement for long-term IV therapy  
    - Synovial fluid drainage performed successfully  


Patient 40001288  
Gender: Female  
Age: 58  
Race: HISPANIC  

Admission 67124890  
    DRGs:  
    - APR: SEVERE E. COLI SEPTICEMIA WITH ACUTE ORGAN DYSFUNCTION (Severity 4.0)  
    - HCFA: E. COLI BLOODSTREAM INFECTION WITH MULTI-SYSTEM INVOLVEMENT  

    Medications:  
    - Ceftriaxone IV 2 g Q24H (empiric treatment, adjusted per culture)  
    - Piperacillin-Tazobactam IV 4.5 g Q6H until sensitivities returned  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Norepinephrine IV infusion titrated for hypotension  
    - Sodium Chloride 0.9% IV continuous for resuscitation  
    - Heparin 5000 U SC Q8H for DVT prophylaxis  

    Orders:  
    - Obtain blood and urine cultures ×2 before antibiotics, Completed  
    - Infectious disease (ID) consultation initiated, Completed  
    - Start broad-spectrum coverage, then narrow to Ceftriaxone once sensitivities available, Completed  
    - Daily renal panel monitoring due to risk of AKI, Completed  
    - Foley catheter inserted for strict urine output monitoring, Completed  

    Procedures:  
    - Central venous line placement  
    - Serial lactate monitoring  
    - Continuous telemetry monitoring  

---

Admission 68195743  
    DRGs:  
    - APR: COMPLICATED PYELONEPHRITIS WITH E. COLI BACTEREMIA (Severity 3.0)  
    - HCFA: E. COLI-ASSOCIATED ACUTE PYELONEPHRITIS WITH SYSTEMIC RESPONSE  

    Medications:  
    - Levofloxacin IV 750 mg Q24H (based on susceptibility results)  
    - Acetaminophen 650 mg PO Q6H PRN pain or fever  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Sodium Chloride 0.9% Flush IV PRN  
    - Probiotic PO daily to reduce antibiotic-associated diarrhea  

    Orders:  
    - CT abdomen/pelvis ordered to assess for obstruction or perinephric abscess, Completed  
    - Daily urinalysis and urine cultures, Completed  
    - Urology consult to evaluate for possible stent placement, Completed  
    - Transition from IV Levofloxacin to oral Ciprofloxacin after discharge, Completed  
    - Renal ultrasound scheduled to assess for hydronephrosis, Completed  

    Procedures:  
    - CT imaging confirmed left-sided pyelonephritis  
    - Foley catheter removed after 48 hours  
    - IV-to-PO switch therapy coordinated with ID  

---

Admission 69931428  
    DRGs:  
    - APR: E. COLI-RELATED INFECTIVE ENDOCARDITIS (Severity 4.0)  
    - HCFA: COMPLICATED E. COLI ENDOVASCULAR INFECTION  

    Medications:  
    - Meropenem IV 1 g Q8H (chosen due to ESBL-producing E. coli)  
    - Gentamicin IV 3 mg/kg daily for synergistic effect, dose adjusted per levels  
    - Aspirin 81 mg PO daily for endocarditis-related embolic risk  
    - Pantoprazole 40 mg PO daily for GI prophylaxis  
    - Influenza Vaccine Quadrivalent IM once  

    Orders:  
    - Transesophageal echocardiography (TEE) ordered to confirm vegetations, Completed  
    - PICC line placed for prolonged IV therapy, Completed  
    - Weekly ESR and CRP monitoring to track infection clearance, Completed  
    - Blood cultures repeated every 48 hours until negative, Completed  
    - Outpatient ID follow-up arranged for continuation of therapy, Completed  

    Procedures:  
    - TEE confirmed aortic valve vegetation  
    - PICC line successfully inserted for 6-week IV antibiotic course  
    - Regular outpatient bloodwork arranged to monitor drug levels and kidney function  


Patient 50001288  
Gender: Female  
Age: 62  
Race: WHITE  

Admission 13028754  
    DRGs:  
    - APR: INFECTION FOLLOWING SURGICAL PROCEDURE (Severity 3.0)  
    - HCFA: POSTOPERATIVE WOUND INFECTION W CC  

    Medications:  
    - Piperacillin-Tazobactam (Zosyn) IV  
    - Vancomycin IV  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Ondansetron IV  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Piperacillin-Tazobactam IV: IV, Discontinued via patient discharge  
    - Vancomycin IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Wound culture and sensitivity  
    - Bedside wound debridement  
    - Blood cultures  

Admission 13195428  
    DRGs:  
    - APR: SEVERE INFECTION FOLLOWING PROCEDURE WITH DRAINAGE (Severity 4.0)  
    - HCFA: POSTOPERATIVE SEPSIS W MCC  

    Medications:  
    - Meropenem IV  
    - Linezolid IV  
    - Sodium Chloride 0.9% Flush  
    - Enoxaparin SC  
    - Acetaminophen  
    - Fluconazole IV (fungal coverage)  
    - Ondansetron IV  

    Orders:  
    - Meropenem IV: IV, Discontinued via patient discharge  
    - Linezolid IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Enoxaparin SC: SC, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Fluconazole IV: IV, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  

    Procedures:  
    - Surgical incision and drainage  
    - Placement of negative pressure wound therapy (VAC)  
    - CT abdomen/pelvis to evaluate abscess  
    - Repeat wound cultures  

Admission 13367294  
    DRGs:  
    - APR: POSTOPERATIVE INFECTION WITH COMPLICATIONS (Severity 2.0)  
    - HCFA: INFECTION FOLLOWING PROCEDURE W/O CC/MCC  

    Medications:  
    - Cefepime IV  
    - Daptomycin IV  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Probiotic Supplement  
    - Ondansetron PO  

    Orders:  
    - Cefepime IV: IV, Discontinued via patient discharge  
    - Daptomycin IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Probiotic Supplement: PO, Discontinued via patient discharge  
    - Ondansetron PO: PO, Discontinued via patient discharge  

    Procedures:  
    - Ultrasound-guided aspiration of fluid collection  
    - Wound vacuum dressing change  
    - Follow-up MRI to evaluate healing status


Patient 60001288  
Gender: Female  
Age: 52  
Race: WHITE  

Admission 78124561  
    DRGs:  
    - APR: AGE-RELATED VISION DISORDERS — PRESBYOPIA (Severity 1.0)  
    - HCFA: PRESBYOPIA WITH MILD VISUAL FUNCTIONAL IMPAIRMENT  

    Medications:  
    - Artificial Tears (Polyethylene Glycol 0.4%) — 1 drop OU QID PRN dryness  
    - Carboxymethylcellulose Eye Drops — 1 drop OU BID  
    - Omega-3 Fatty Acid Supplements — PO daily  
    - Multivitamin with Lutein — PO daily  

    Orders:  
    - Comprehensive eye exam performed, Completed  
    - Refraction assessment for near vision correction, Completed  
    - Prescription bifocals provided, Completed  
    - Patient counseled on the use of progressive lenses vs. separate reading glasses, Completed  
    - Advised routine ophthalmology follow-up every 12 months  

    Procedures:  
    - Visual acuity testing  
    - Autorefraction assessment  
    - Tonometry screening to rule out elevated intraocular pressure  

---

Admission 79653482  
    DRGs:  
    - APR: PRESBYOPIA WITH COMORBID DRY EYE SYNDROME (Severity 2.0)  
    - HCFA: DRY EYE-ASSOCIATED AGE-RELATED NEAR-VISION LOSS  

    Medications:  
    - Restasis (Cyclosporine Ophthalmic 0.05%) — 1 drop OU BID  
    - Systane Ultra Lubricating Drops — 1 drop OU Q6H PRN  
    - Vitamin A Supplements — PO daily  
    - Acetaminophen 500 mg PO Q6H PRN headache  

    Orders:  
    - Schirmer’s test performed to evaluate tear production, Completed  
    - Prescription for progressive lenses adjusted, Completed  
    - Warm compresses advised BID for meibomian gland support, Completed  
    - Recommended humidifier usage at home to manage dryness, Completed  
    - Dry eye management plan discussed with patient, Completed  

    Procedures:  
    - Schirmer tear production testing  
    - Tear break-up time evaluation  
    - Optical coherence tomography (OCT) performed to exclude macular pathology  

---

Admission 80432659  
    DRGs:  
    - APR: ROUTINE OPHTHALMOLOGY FOLLOW-UP — PRESBYOPIA MANAGEMENT (Severity 1.0)  
    - HCFA: STABLE AGE-RELATED VISION CHANGES WITHOUT COMPLICATIONS  

    Medications:  
    - Refresh Tears (Hypromellose 0.5%) — 1 drop OU QID  
    - Omega-3 Fish Oil 1000 mg PO daily  
    - Preservative-Free Artificial Tears — 1 drop OU PRN  

    Orders:  
    - Annual follow-up for vision reassessment, Completed  
    - Updated reading glasses prescription, Completed  
    - Counseling on blue-light filtering lenses, Completed  
    - Recommended workplace ergonomics adjustments, Completed  

    Procedures:  
    - Visual acuity re-evaluation  
    - Digital eye strain assessment  
    - Intraocular pressure monitoring via non-contact tonometry  


Patient 10001289  
Gender: Male  
Age: 61  
Race: WHITE  

Admission 74523816  
    DRGs:  
    - APR: LOBAR PNEUMONIA WITH HYPOXEMIA (Severity 3.0)  
    - HCFA: COMMUNITY-ACQUIRED LOBAR PNEUMONIA, UNSPECIFIED ORGANISM  

    Medications:  
    - Ceftriaxone 2 g IV Q24H (empiric treatment)  
    - Azithromycin 500 mg PO day 1, then 250 mg PO daily × 4 days  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Albuterol Nebulizer 2.5 mg Q6H PRN wheezing  
    - Sodium Chloride 0.9% IV continuous at 100 mL/hr  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  

    Orders:  
    - Chest X-ray ordered and completed, confirmed right lower-lobe consolidation  
    - Sputum and blood cultures drawn, Completed  
    - Oxygen therapy initiated at 3 L/min nasal cannula, titrated based on SpO₂, Completed  
    - Pulmonary consult requested, Completed  
    - Daily BMP and CBC monitoring ordered, Ongoing  

    Procedures:  
    - Chest radiograph performed and reviewed  
    - Supplemental oxygen started  
    - Incentive spirometry instruction provided  

---

Admission 75218904  
    DRGs:  
    - APR: LOBAR PNEUMONIA WITH EXACERBATION OF COPD (Severity 4.0)  
    - HCFA: PNEUMONIA WITH ACUTE RESPIRATORY DISTRESS  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV Q6H (broadened coverage due to hypoxia)  
    - Levofloxacin 750 mg IV Q24H  
    - Methylprednisolone 40 mg IV Q12H × 3 days  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - DuoNeb (Albuterol/Ipratropium) inhalation Q6H  
    - Pantoprazole 40 mg PO daily  

    Orders:  
    - Chest CT without contrast ordered, Completed — multilobar pneumonia visualized  
    - Arterial blood gases ordered, Completed — pO₂ 62 mmHg on room air  
    - Respiratory therapy initiated for airway clearance, Completed  
    - High-flow nasal cannula started at 40 L/min, Completed  
    - Daily electrolyte monitoring and aggressive hydration, Ongoing  

    Procedures:  
    - Chest CT performed  
    - Bronchodilator treatments provided by respiratory therapy  
    - High-flow nasal cannula oxygen initiated  

---

Admission 76954122  
    DRGs:  
    - APR: PNEUMONIA WITH POST-INFECTIOUS PLEURAL EFFUSION (Severity 3.0)  
    - HCFA: LOBAR PNEUMONIA WITH PERSISTENT INFILTRATE  

    Medications:  
    - Vancomycin IV (dosed per trough levels)  
    - Cefepime 2 g IV Q8H  
    - Prednisone taper starting at 40 mg PO daily  
    - Guaifenesin 600 mg PO BID PRN cough  
    - Saline Nebulizer 3 mL Q8H  

    Orders:  
    - Ultrasound-guided thoracentesis ordered and completed  
    - Pleural fluid analysis sent for culture and cytology, Completed  
    - Repeat chest X-ray post-procedure showed partial lung re-expansion, Completed  
    - Infectious disease consultation requested, Completed  
    - Home oxygen qualification testing ordered, Completed  

    Procedures:  
    - Ultrasound-guided pleural drainage performed  
    - Thoracentesis yielded 450 mL serosanguinous fluid  
    - Post-procedure monitoring for pneumothorax — no complications observed  


Patient 20001289  
Gender: Male  
Age: 58  
Race: WHITE  

Admission 78542103  
    DRGs:  
    - APR: LOBAR PNEUMONIA WITH HYPOXEMIA (Severity 3.0)  
    - HCFA: COMMUNITY-ACQUIRED LOBAR PNEUMONIA, UNSPECIFIED ORGANISM  

    Medications:  
    - Ceftriaxone 2 g IV Q24H (empiric coverage)  
    - Azithromycin 500 mg PO day 1, then 250 mg PO daily × 4 days  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Albuterol Nebulizer 2.5 mg Q6H PRN shortness of breath  
    - Sodium Chloride 0.9% IV continuous at 125 mL/hr  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  

    Orders:  
    - Chest X-ray ordered and completed, showing right upper-lobe consolidation  
    - Blood and sputum cultures obtained, Pending  
    - Oxygen therapy initiated at 2 L/min via nasal cannula, Completed  
    - Incentive spirometry ordered, Ongoing  
    - Daily CBC and CMP ordered for monitoring, Ongoing  

    Procedures:  
    - Chest radiograph performed  
    - Oxygen therapy initiated  
    - Respiratory therapy provided patient education  

---

Admission 79261452  
    DRGs:  
    - APR: LOBAR PNEUMONIA WITH RESPIRATORY FAILURE (Severity 4.0)  
    - HCFA: PNEUMONIA WITH ACUTE HYPOXIC RESPIRATORY FAILURE  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV Q6H  
    - Levofloxacin 750 mg IV Q24H  
    - Methylprednisolone 40 mg IV Q12H × 3 days  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - DuoNeb (Albuterol/Ipratropium) inhalation Q6H  
    - Pantoprazole 40 mg PO daily  

    Orders:  
    - CT Chest without contrast ordered, Completed — left lower-lobe consolidation confirmed  
    - Arterial blood gas ordered, Completed — pO₂ 58 mmHg  
    - Respiratory therapy initiated, Completed  
    - High-flow nasal cannula oxygen started at 35 L/min, Completed  
    - Daily renal and liver function panels ordered, Ongoing  

    Procedures:  
    - CT Chest performed  
    - Arterial blood gases measured  
    - High-flow oxygen initiated  

---

Admission 80429877  
    DRGs:  
    - APR: LOBAR PNEUMONIA WITH PLEURAL EFFUSION (Severity 3.0)  
    - HCFA: PERSISTENT INFILTRATE AND COMPLICATED RECOVERY  

    Medications:  
    - Vancomycin IV (dosed per trough levels)  
    - Cefepime 2 g IV Q8H  
    - Prednisone taper starting at 40 mg PO daily  
    - Guaifenesin 600 mg PO BID PRN mucus clearance  
    - Saline Nebulizer 3 mL Q8H  

    Orders:  
    - Ultrasound-guided thoracentesis performed, Completed  
    - Pleural fluid cultures sent, Completed  
    - Post-procedure chest X-ray ordered, Completed  
    - Infectious disease consultation requested, Completed  
    - Recommended follow-up chest CT in 6 weeks, Pending  

    Procedures:  
    - Ultrasound-guided thoracentesis  
    - Pleural drainage yielded 550 mL serous fluid  
    - Post-procedure monitoring completed — no pneumothorax noted  


Patient 30001289  
Gender: Male  
Age: 66  
Race: WHITE  

Admission 81254901  
    DRGs:  
    - APR: PNEUMONIA, UNSPECIFIED ORGANISM WITHOUT COMPLICATIONS (Severity 2.0)  
    - HCFA: COMMUNITY-ACQUIRED PNEUMONIA, UNSPECIFIED ORGANISM  

    Medications:  
    - Ceftriaxone 1 g IV Q24H  
    - Azithromycin 500 mg PO day 1, then 250 mg PO daily × 4 days  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Guaifenesin 600 mg PO BID PRN cough  
    - Albuterol Inhaler 2 puffs Q6H PRN shortness of breath  
    - Sodium Chloride 0.9% IV 100 mL/hr  

    Orders:  
    - Chest X-ray ordered and completed — right middle lobe consolidation visualized  
    - Blood and sputum cultures ordered, Completed  
    - Oxygen therapy initiated at 2 L/min via nasal cannula, Completed  
    - Incentive spirometry instructed, Ongoing  
    - Daily CBC, CMP, and inflammatory markers ordered, Ongoing  

    Procedures:  
    - Chest radiograph performed  
    - Supplemental oxygen started  
    - Incentive spirometry education provided  

---

Admission 82463315  
    DRGs:  
    - APR: PNEUMONIA WITH ACUTE HYPOXEMIA (Severity 3.0)  
    - HCFA: HOSPITAL-ACQUIRED PNEUMONIA, UNSPECIFIED ORGANISM  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV Q6H  
    - Levofloxacin 750 mg IV Q24H  
    - Methylprednisolone 40 mg IV Q12H × 3 days  
    - DuoNeb (Albuterol/Ipratropium) inhalation Q6H  
    - Pantoprazole 40 mg PO daily  
    - Acetaminophen 650 mg PO Q6H PRN fever  

    Orders:  
    - CT Chest ordered, Completed — bilateral infiltrates visualized  
    - Arterial blood gases performed, Completed — pO₂ 64 mmHg  
    - Respiratory therapy initiated with bronchodilators and airway clearance, Completed  
    - High-flow nasal cannula started at 30 L/min, Completed  
    - Infectious disease consult requested, Completed  

    Procedures:  
    - CT Chest performed  
    - High-flow oxygen therapy initiated  
    - Respiratory therapy-assisted breathing treatments  

---

Admission 83641227  
    DRGs:  
    - APR: PNEUMONIA WITH PERSISTENT COUGH AND SLOW RECOVERY (Severity 2.0)  
    - HCFA: PNEUMONIA FOLLOW-UP ADMISSION  

    Medications:  
    - Amoxicillin-Clavulanate 875/125 mg PO BID × 7 days  
    - Prednisone taper starting at 40 mg PO daily × 5 days  
    - Guaifenesin 600 mg PO BID PRN cough  
    - Saline Nebulizer 3 mL Q8H  
    - Zinc 50 mg PO daily  
    - Vitamin D 2000 IU PO daily  

    Orders:  
    - Repeat chest X-ray ordered, Completed — resolving infiltrates noted  
    - Outpatient pulmonary function testing scheduled, Pending  
    - Smoking cessation counseling provided, Completed  
    - Home oxygen evaluation ordered, Completed  

    Procedures:  
    - Post-treatment chest radiograph  
    - Pulmonary education sessions completed  
    - Home oxygen assessment performed


Patient 40001289  
Gender: Female  
Age: 42  
Race: WHITE  

Admission 84521032  
    DRGs:  
    - APR: ACUTE BRONCHITIS WITHOUT COMPLICATIONS (Severity 1.0)  
    - HCFA: COMMUNITY-ACQUIRED BRONCHITIS, UNSPECIFIED ORGANISM  

    Medications:  
    - Albuterol Inhaler 2 puffs Q6H PRN shortness of breath  
    - Guaifenesin 600 mg PO BID PRN mucus clearance  
    - Acetaminophen 650 mg PO Q6H PRN fever or pain  
    - Dextromethorphan 10 mg PO Q6H PRN cough  
    - Sodium Chloride 0.9% IV at 75 mL/hr for hydration  
    - Benzonatate 100 mg PO TID PRN cough suppression  

    Orders:  
    - Chest X-ray ordered, Completed — no evidence of pneumonia  
    - COVID-19 and Influenza PCR panel performed, Negative  
    - Oxygen saturation monitoring ordered, Ongoing  
    - Encourage fluids and rest, Ongoing  
    - Outpatient follow-up with primary care physician recommended, Pending  

    Procedures:  
    - Chest radiograph performed  
    - Pulse oximetry monitored  
    - Patient education on hydration and recovery provided  

---

Admission 85674927  
    DRGs:  
    - APR: ACUTE BRONCHITIS WITH BRONCHOSPASM (Severity 2.0)  
    - HCFA: ACUTE BRONCHITIS WITH ACUTE HYPOXEMIA  

    Medications:  
    - Prednisone 40 mg PO daily × 5 days  
    - Albuterol/Ipratropium (DuoNeb) nebulizer Q6H  
    - Levofloxacin 500 mg PO daily × 7 days  
    - Guaifenesin-Codeine Syrup 5 mL PO Q6H PRN severe cough  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Pantoprazole 40 mg PO daily  

    Orders:  
    - Chest X-ray repeated, Completed — mild right lower lobe hyperinflation  
    - Peak expiratory flow monitoring initiated, Ongoing  
    - Oxygen therapy started at 2 L/min via nasal cannula, Discontinued after 24 hrs  
    - Pulmonary therapy initiated for bronchospasm management, Completed  
    - Daily vitals and respiratory assessments ordered, Ongoing  

    Procedures:  
    - Nebulizer treatments administered  
    - Bedside spirometry performed  
    - Supplemental oxygen initiated and discontinued  

---

Admission 86732514  
    DRGs:  
    - APR: ACUTE BRONCHITIS WITH SECONDARY BACTERIAL INFECTION (Severity 3.0)  
    - HCFA: ACUTE BRONCHITIS REQUIRING HOSPITALIZATION  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV Q8H  
    - Azithromycin 500 mg IV Q24H  
    - Methylprednisolone 40 mg IV Q12H  
    - Acetylcysteine Nebulizer 3 mL Q8H  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  

    Orders:  
    - High-resolution CT chest ordered, Completed — airway wall thickening noted  
    - Sputum culture and sensitivity ordered, Completed — E. coli isolated  
    - Infectious disease consultation requested, Completed  
    - High-flow nasal cannula oxygen at 35 L/min, Completed  
    - Discharge planning initiated with 7-day follow-up, Pending  

    Procedures:  
    - High-resolution CT chest performed  
    - Sputum sample collected for culture  
    - High-flow oxygen therapy initiated and discontinued after improvement  


Patient 50001289  
Gender: Male  
Age: 66  
Race: WHITE  

Admission 14039821  
    DRGs:  
    - APR: SEPSIS WITHOUT ACUTE ORGAN DYSFUNCTION (Severity 2.0)  
    - HCFA: SEPSIS W/O CC/MCC  

    Medications:  
    - Piperacillin-Tazobactam (Zosyn) IV  
    - Vancomycin IV  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Ondansetron IV  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Piperacillin-Tazobactam IV: IV, Discontinued via patient discharge  
    - Vancomycin IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Blood cultures x2 sets  
    - Chest X-ray  
    - Complete blood count with differential  
    - Serum lactate measurement  

Admission 14176244  
    DRGs:  
    - APR: SEPSIS WITH ACUTE ORGAN DYSFUNCTION (Severity 3.0)  
    - HCFA: SEPSIS W CC  

    Medications:  
    - Meropenem IV  
    - Linezolid IV  
    - Norepinephrine IV (vasopressor)  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Heparin SC (DVT prophylaxis)  
    - Ondansetron IV  

    Orders:  
    - Meropenem IV: IV, Discontinued via patient discharge  
    - Linezolid IV: IV, Discontinued via patient discharge  
    - Norepinephrine IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  

    Procedures:  
    - Central venous catheter insertion  
    - Arterial blood gas (ABG) analysis  
    - Abdominal ultrasound  
    - Continuous cardiac monitoring  

Admission 14309875  
    DRGs:  
    - APR: SEVERE SEPTIC SHOCK WITH MULTIPLE ORGAN FAILURE (Severity 4.0)  
    - HCFA: SEVERE SEPSIS W MCC  

    Medications:  
    - Cefepime IV  
    - Metronidazole IV  
    - Vancomycin IV  
    - Hydrocortisone IV (stress dose)  
    - Norepinephrine IV infusion  
    - Dobutamine IV infusion  
    - Sodium Bicarbonate IV  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  

    Orders:  
    - Cefepime IV: IV, Discontinued via patient discharge  
    - Metronidazole IV: IV, Discontinued via patient discharge  
    - Vancomycin IV: IV, Discontinued via patient discharge  
    - Hydrocortisone IV: IV, Discontinued via patient discharge  
    - Norepinephrine IV: IV, Discontinued via patient discharge  
    - Dobutamine IV: IV, Discontinued via patient discharge  
    - Sodium Bicarbonate IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Endotracheal intubation with mechanical ventilation  
    - Continuous renal replacement therapy (CRRT)  
    - Repeat blood cultures  
    - CT abdomen/pelvis for source identification  
    - Invasive hemodynamic monitoring via Swan-Ganz catheter


Patient 60001289  
Gender: Female  
Age: 28  
Race: ASIAN  

Admission 91234567  
    DRGs:  
    - APR: BILATERAL MYOPIA EVALUATION AND MANAGEMENT (Severity 1.0)  
    - HCFA: REFRACTIVE ERROR MANAGEMENT  

    Medications:  
    - Artificial Tears 1 drop OU (both eyes) PRN dryness  
    - Ketotifen 0.025% Ophthalmic Solution 1 drop OU BID PRN allergy-related irritation  
    - Oral Omega-3 Supplements 1000 mg PO daily  
    - Multivitamin PO daily  

    Orders:  
    - Comprehensive eye exam performed, Completed  
    - Cycloplegic refraction test ordered, Completed  
    - Retinal examination performed, Completed  
    - Patient educated on eye strain prevention and regular breaks, Completed  
    - Recommended blue-light filter lens usage, Ongoing  

    Procedures:  
    - Dilated fundus examination  
    - Corneal topography mapping  
    - Optical coherence tomography (OCT) scan performed  

---

Admission 92367842  
    DRGs:  
    - APR: MYOPIA WITH SYMPTOMATIC ASTHENOPIA (Severity 2.0)  
    - HCFA: REFRACTIVE ERROR REQUIRING PRESCRIPTION CHANGE  

    Medications:  
    - Artificial Tears 1 drop OU TID PRN dryness  
    - Olopatadine 0.1% Ophthalmic Solution 1 drop OU BID  
    - Lutein 20 mg PO daily  
    - Oral Vitamin D3 2000 IU PO daily  

    Orders:  
    - Updated manifest refraction performed, Completed  
    - New prescription glasses ordered, Completed  
    - Discussed potential eligibility for refractive surgery, Completed  
    - Recommended reducing near work and adjusting computer ergonomics, Ongoing  

    Procedures:  
    - Visual acuity reassessment performed  
    - Slit-lamp examination performed  
    - Binocular vision testing done  

---

Admission 93542011  
    DRGs:  
    - APR: HIGH MYOPIA, BILATERAL (Severity 3.0)  
    - HCFA: COMPLEX REFRACTIVE ERROR MANAGEMENT  

    Medications:  
    - Atropine 0.01% Ophthalmic Solution 1 drop OU QHS for progression control  
    - Lubricating Eye Gel at bedtime OU  
    - Vitamin A & E Supplementation PO daily  
    - Omega-3 Fish Oil 1200 mg PO daily  

    Orders:  
    - Retinal detachment risk counseling provided, Completed  
    - Ordered prophylactic lattice degeneration screening, Completed  
    - Scheduled 6-month follow-up for progression monitoring, Pending  
    - Patient advised on contact lens hygiene and reduced overnight usage, Ongoing  

    Procedures:  
    - Retinal wide-field imaging performed  
    - Axial length measurement performed  
    - High-resolution OCT imaging completed  


Patient 10001290  
Gender: Male  
Age: 49  
Race: WHITE  

Admission 77451201  
    DRGs:  
    - APR: VERTEBROGENIC LOW BACK PAIN — INITIAL MANAGEMENT (Severity 2.0)  
    - HCFA: LUMBAR SPINE DISORDERS WITHOUT NEUROLOGICAL DEFICITS  

    Medications:  
    - Acetaminophen 650 mg PO Q6H PRN mild pain  
    - Ibuprofen 600 mg PO Q8H PRN inflammation  
    - Cyclobenzaprine 5 mg PO TID PRN muscle spasms  
    - Lidocaine 5% Patch — Apply daily to lumbar region  
    - Vitamin D3 2000 IU PO daily  

    Orders:  
    - Lumbar spine MRI ordered, Completed — Modic Type 1 endplate changes  
    - Physical therapy evaluation initiated, Completed  
    - Heat therapy recommended for lower back, Ongoing  
    - Daily pain assessments ordered, Ongoing  
    - Lifestyle counseling on posture and ergonomic adjustments, Completed  

    Procedures:  
    - Lumbar spine MRI performed  
    - Baseline gait and strength assessment done  
    - Home exercise program demonstrated  

---

Admission 77451268  
    DRGs:  
    - APR: VERTEBROGENIC LOW BACK PAIN WITH FUNCTIONAL LIMITATION (Severity 3.0)  
    - HCFA: CHRONIC LOW BACK PAIN MANAGEMENT  

    Medications:  
    - Gabapentin 300 mg PO TID for neuropathic pain  
    - Diclofenac 75 mg PO BID with food  
    - Baclofen 10 mg PO TID PRN muscle spasms  
    - Duloxetine 30 mg PO daily for pain modulation  
    - Calcium + Vitamin D supplementation PO daily  

    Orders:  
    - Repeat lumbar MRI ordered, Completed — No nerve compression  
    - Referred to interventional pain specialist, Completed  
    - Transcutaneous Electrical Nerve Stimulation (TENS) therapy initiated, Completed  
    - Low-impact aquatic physiotherapy ordered, Ongoing  
    - Outpatient orthopedic follow-up in 4 weeks, Pending  

    Procedures:  
    - Trigger point injections with lidocaine performed  
    - TENS therapy administered in clinic  
    - Aquatic rehabilitation therapy initiated  

---

Admission 77451354  
    DRGs:  
    - APR: VERTEBROGENIC LOW BACK PAIN — ADVANCED INTERVENTION (Severity 4.0)  
    - HCFA: SPINAL STABILITY & PAIN MANAGEMENT  

    Medications:  
    - Pregabalin 75 mg PO BID  
    - Tramadol 50 mg PO Q8H PRN breakthrough pain  
    - Celecoxib 200 mg PO daily  
    - Methylprednisolone 4 mg PO daily × 7 days  
    - Omega-3 Supplements 1000 mg PO daily  

    Orders:  
    - Basivertebral nerve ablation ordered, Completed  
    - Inpatient rehab referral initiated, Completed  
    - Pain management consult ordered, Completed  
    - Pre-procedure labs ordered, Completed  
    - Follow-up MRI planned for 3 months, Pending  

    Procedures:  
    - Basivertebral nerve radiofrequency ablation performed under fluoroscopic guidance  
    - Sedation-assisted outpatient procedure conducted successfully  
    - Post-op monitoring for complications, Completed  


Patient 20001290  
Gender: Female  
Age: 52  
Race: WHITE  

Admission 88230115  
    DRGs:  
    - APR: VERTEBROGENIC LOW BACK PAIN — INITIAL EVALUATION (Severity 2.0)  
    - HCFA: LUMBAR SPINE PAIN WITHOUT RADICULOPATHY  

    Medications:  
    - Acetaminophen 650 mg PO Q6H PRN mild pain  
    - Ibuprofen 600 mg PO Q8H PRN inflammation  
    - Methocarbamol 750 mg PO TID PRN muscle spasm  
    - Lidocaine 5% Topical Patch — Apply to lower back Q24H  
    - Vitamin D3 1000 IU PO daily  

    Orders:  
    - Lumbar spine X-ray ordered, Completed  
    - Physical therapy consult initiated, Completed  
    - Daily stretching and strengthening program provided, Ongoing  
    - Heat/ice therapy recommended, Ongoing  
    - Posture and ergonomic counseling provided, Completed  

    Procedures:  
    - Lumbar spine X-ray performed  
    - Initial musculoskeletal exam completed  
    - Functional mobility assessment done  

---

Admission 88230188  
    DRGs:  
    - APR: CHRONIC VERTEBROGENIC LOW BACK PAIN WITH FUNCTIONAL LIMITATION (Severity 3.0)  
    - HCFA: SPINAL PAIN MANAGEMENT WITH MEDICATION OPTIMIZATION  

    Medications:  
    - Naproxen 500 mg PO BID with meals  
    - Gabapentin 300 mg PO TID for neuropathic pain  
    - Baclofen 10 mg PO TID PRN muscle spasms  
    - Duloxetine 30 mg PO daily for chronic pain  
    - Calcium + Vitamin D PO daily  

    Orders:  
    - Lumbar MRI ordered, Completed — Modic Type 1 changes at L4-L5  
    - Referred to pain management specialist, Completed  
    - Initiated core-strengthening physiotherapy program, Ongoing  
    - Occupational therapy consult requested, Completed  
    - Outpatient follow-up scheduled for 6 weeks, Pending  

    Procedures:  
    - Lumbar MRI performed and reviewed  
    - TENS (Transcutaneous Electrical Nerve Stimulation) therapy trial initiated  
    - Ultrasound-guided trigger point injections administered  

---

Admission 88230257  
    DRGs:  
    - APR: ADVANCED VERTEBROGENIC LOW BACK PAIN — INTERVENTIONAL MANAGEMENT (Severity 4.0)  
    - HCFA: COMPLEX SPINAL PAIN WITH PROCEDURAL INTERVENTION  

    Medications:  
    - Pregabalin 75 mg PO BID  
    - Tramadol 50 mg PO Q8H PRN breakthrough pain  
    - Celecoxib 200 mg PO daily  
    - Methylprednisolone Dose Pack PO × 6 days  
    - Omega-3 Fatty Acids 1200 mg PO daily  

    Orders:  
    - Basivertebral nerve ablation procedure scheduled, Completed  
    - Pre-procedure bloodwork ordered, Completed  
    - Pain management care plan updated, Ongoing  
    - Referral to inpatient rehab for mobility and core recovery, Completed  
    - Post-procedure MRI planned for 3 months, Pending  

    Procedures:  
    - Basivertebral nerve ablation performed under fluoroscopic guidance  
    - Conscious sedation administered, Uneventful recovery  
    - Discharged with home exercise and post-op pain control instructions  


Patient 30001290  
Gender: Male  
Age: 55  
Race: WHITE  

Admission 66121501  
    DRGs:  
    - APR: LUMBAR RADICULOPATHY — INITIAL PRESENTATION (Severity 2.0)  
    - HCFA: LUMBAR DISC DISEASE WITH NERVE ROOT INVOLVEMENT WITHOUT SURGERY  

    Medications:  
    - Ibuprofen 600 mg PO Q8H PRN pain  
    - Acetaminophen 650 mg PO Q6H PRN  
    - Methocarbamol 750 mg PO TID PRN muscle spasm  
    - Prednisone 40 mg PO daily × 5 days  
    - Lidocaine 5% Patch — Apply daily to lumbar region  

    Orders:  
    - Lumbar spine MRI ordered, Completed — L5-S1 disc protrusion compressing right L5 nerve root  
    - Physical therapy consult initiated, Completed  
    - Activity modification plan initiated, Ongoing  
    - Patient education on proper lifting techniques, Completed  
    - Outpatient follow-up scheduled in 4 weeks, Pending  

    Procedures:  
    - Lumbar spine MRI performed  
    - Straight leg raise test positive, Completed  
    - Physical therapy evaluation with home exercise program given  

---

Admission 66121588  
    DRGs:  
    - APR: LUMBAR RADICULOPATHY WITH FUNCTIONAL LIMITATION (Severity 3.0)  
    - HCFA: SPINAL PAIN MANAGEMENT — MEDICATION OPTIMIZATION  

    Medications:  
    - Naproxen 500 mg PO BID with meals  
    - Gabapentin 300 mg PO TID for neuropathic pain  
    - Baclofen 10 mg PO TID PRN muscle spasms  
    - Duloxetine 30 mg PO daily for chronic pain  
    - Calcium + Vitamin D supplementation PO daily  

    Orders:  
    - Epidural steroid injection ordered, Completed  
    - Referral to pain management specialist, Completed  
    - Initiated aquatic therapy program, Ongoing  
    - Nerve conduction study ordered, Completed  
    - Return visit in 6 weeks scheduled, Pending  

    Procedures:  
    - Lumbar transforaminal epidural steroid injection at L5-S1 performed  
    - Electromyography (EMG) testing completed  
    - Aquatic physiotherapy initiated  

---

Admission 66121642  
    DRGs:  
    - APR: LUMBAR RADICULOPATHY — SURGICAL MANAGEMENT (Severity 4.0)  
    - HCFA: SPINAL DECOMPRESSION PROCEDURE WITH OR WITHOUT FUSION  

    Medications:  
    - Pregabalin 75 mg PO BID  
    - Tramadol 50 mg PO Q6H PRN post-op pain  
    - Celecoxib 200 mg PO daily  
    - Methylprednisolone 4 mg PO × 7 days  
    - Multivitamin with minerals PO daily  

    Orders:  
    - Minimally invasive lumbar microdiscectomy scheduled, Completed  
    - Pre-op labs and EKG ordered, Completed  
    - Post-op physiotherapy ordered, Ongoing  
    - Pain management referral placed, Completed  
    - Follow-up MRI scheduled for 3 months, Pending  

    Procedures:  
    - Minimally invasive lumbar microdiscectomy performed at L5-S1  
    - Intraoperative fluoroscopic guidance used  
    - Post-op rehabilitation started 48 hours after surgery  


Patient 40001290  
Gender: Female  
Age: 60  
Race: WHITE  

Admission 77122401  
    DRGs:  
    - APR: LUMBAR SPONDYLOLISTHESIS — INITIAL PRESENTATION (Severity 2.0)  
    - HCFA: LUMBAR SPINE INSTABILITY WITHOUT SURGERY  

    Medications:  
    - Acetaminophen 650 mg PO Q6H PRN mild pain  
    - Naproxen 500 mg PO BID with meals  
    - Cyclobenzaprine 10 mg PO TID PRN muscle spasms  
    - Calcium + Vitamin D PO daily  
    - Topical Diclofenac 1% Gel — Apply to lumbar region BID  

    Orders:  
    - Lumbar spine X-ray ordered, Completed — Grade I anterolisthesis at L4-L5  
    - Physical therapy consult initiated, Completed  
    - Provided lumbar stabilization exercise plan, Ongoing  
    - Weight management counseling recommended, Completed  
    - Outpatient follow-up scheduled in 4 weeks, Pending  

    Procedures:  
    - Lumbar spine X-ray performed  
    - Physical therapy evaluation completed  
    - Home exercise program issued  

---

Admission 77122475  
    DRGs:  
    - APR: SYMPTOMATIC LUMBAR SPONDYLOLISTHESIS WITH RADICULOPATHY (Severity 3.0)  
    - HCFA: SPINAL PAIN MANAGEMENT — NON-SURGICAL INTERVENTION  

    Medications:  
    - Gabapentin 300 mg PO TID for radicular pain  
    - Ibuprofen 600 mg PO Q8H PRN inflammation  
    - Baclofen 10 mg PO TID PRN muscle spasms  
    - Duloxetine 30 mg PO daily for chronic back pain  
    - Vitamin B12 supplementation PO daily  

    Orders:  
    - Lumbar spine MRI ordered, Completed — Grade II L4-L5 anterolisthesis with bilateral foraminal narrowing  
    - Epidural steroid injection ordered, Completed  
    - Referral to pain management specialist, Completed  
    - Initiated aquatic therapy program, Ongoing  
    - Outpatient re-evaluation planned in 6 weeks, Pending  

    Procedures:  
    - Lumbar spine MRI performed  
    - Transforaminal epidural steroid injection at L4-L5 performed  
    - Gait assessment and postural re-training completed  

---

Admission 77122540  
    DRGs:  
    - APR: LUMBAR SPONDYLOLISTHESIS — SURGICAL MANAGEMENT (Severity 4.0)  
    - HCFA: COMPLEX SPINAL FUSION WITH INSTRUMENTATION  

    Medications:  
    - Pregabalin 75 mg PO BID  
    - Tramadol 50 mg PO Q6H PRN post-op pain  
    - Celecoxib 200 mg PO daily  
    - Methylprednisolone taper PO × 6 days  
    - Multivitamin with minerals PO daily  

    Orders:  
    - Posterior lumbar interbody fusion (PLIF) scheduled, Completed  
    - Pre-op labs, EKG, and anesthesia evaluation ordered, Completed  
    - Post-op rehabilitation and bracing ordered, Ongoing  
    - Pain management plan reviewed, Ongoing  
    - Follow-up imaging planned for 3 months, Pending  

    Procedures:  
    - L4-L5 posterior lumbar interbody fusion performed with pedicle screw instrumentation  
    - Intraoperative fluoroscopy guidance used  
    - Discharged with lumbar support brace and home exercise program instructions  


Patient 50001290  
Gender: Female  
Age: 57  
Race: WHITE  

Admission 15028763  
    DRGs:  
    - APR: LUMBOSACRAL PLEXUS DISORDERS WITHOUT COMPLICATIONS (Severity 2.0)  
    - HCFA: LUMBOSACRAL PLEXUS NEUROPATHY W/O CC/MCC  

    Medications:  
    - Gabapentin 300mg PO  
    - Acetaminophen  
    - Naproxen 500mg PO  
    - Sodium Chloride 0.9% Flush  
    - Cyclobenzaprine 10mg PO  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Gabapentin: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Naproxen: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Cyclobenzaprine: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - MRI lumbosacral spine without contrast  
    - Electromyography (EMG) and nerve conduction studies  
    - Physical therapy evaluation  

Admission 15198244  
    DRGs:  
    - APR: LUMBOSACRAL PLEXOPATHY WITH MOTOR DEFICIT (Severity 3.0)  
    - HCFA: LUMBOSACRAL PLEXUS DISORDERS W CC  

    Medications:  
    - Pregabalin 75mg PO  
    - Methylprednisolone IV  
    - Acetaminophen  
    - Ketorolac IV  
    - Sodium Chloride 0.9% Flush  
    - Heparin SC (DVT prophylaxis)  
    - Ondansetron IV  

    Orders:  
    - Pregabalin: PO, Discontinued via patient discharge  
    - Methylprednisolone: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ketorolac IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  

    Procedures:  
    - CT myelogram  
    - Epidural steroid injection  
    - Gait and balance testing  
    - Occupational therapy assessment  

Admission 15367108  
    DRGs:  
    - APR: SEVERE LUMBOSACRAL PLEXUS NEUROPATHY WITH FUNCTIONAL IMPAIRMENT (Severity 4.0)  
    - HCFA: LUMBOSACRAL PLEXUS DISORDERS W MCC  

    Medications:  
    - Duloxetine 60mg PO  
    - Intravenous Immunoglobulin (IVIG)  
    - Baclofen 10mg PO  
    - Morphine IV (for severe neuropathic pain)  
    - Sodium Chloride 0.9% Flush  
    - Enoxaparin SC  
    - Lorazepam 1mg PO  

    Orders:  
    - Duloxetine: PO, Discontinued via patient discharge  
    - IVIG: IV, Completed  
    - Baclofen: PO, Discontinued via patient discharge  
    - Morphine IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Enoxaparin SC: SC, Discontinued via patient discharge  
    - Lorazepam: PO, Discontinued via patient discharge  

    Procedures:  
    - Lumbosacral plexus decompression surgery  
    - Ultrasound-guided nerve block  
    - Intensive inpatient rehabilitation therapy  
    - Neuromuscular ultrasound monitoring


Patient 60001290  
Gender: Female  
Age: 48  
Race: ASIAN  

Admission 88131021  
    DRGs:  
    - APR: COMPLETE BILATERAL BLINDNESS — INITIAL DIAGNOSIS (Severity 3.0)  
    - HCFA: VISUAL IMPAIRMENT MANAGEMENT WITHOUT SURGERY  

    Medications:  
    - Acetazolamide 250 mg PO BID (if elevated intraocular pressure)  
    - Artificial Tears — Instill 1 drop both eyes QID  
    - Vitamin A 10,000 IU PO daily  
    - Lutein-Zeaxanthin supplement PO daily  
    - Ibuprofen 400 mg PO Q8H PRN mild headache  

    Orders:  
    - Formal ophthalmology consultation ordered, Completed  
    - Optical coherence tomography (OCT) performed, Completed  
    - Visual field testing attempted, Limited due to complete blindness  
    - Low-vision rehabilitation referral placed, Completed  
    - Outpatient follow-up scheduled in 6 weeks, Pending  

    Procedures:  
    - Comprehensive dilated fundus examination performed  
    - OCT revealed optic nerve atrophy  
    - Low-vision rehabilitation evaluation initiated  

---

Admission 88131102  
    DRGs:  
    - APR: BILATERAL BLINDNESS WITH FUNCTIONAL ADAPTATION (Severity 4.0)  
    - HCFA: ADVANCED VISUAL IMPAIRMENT SUPPORT MANAGEMENT  

    Medications:  
    - Prednisolone Acetate 1% Eye Drops — 1 drop OU QID (short taper trial)  
    - Brimonidine 0.2% Eye Drops — 1 drop OU BID  
    - Multivitamin with minerals PO daily  
    - Omega-3 fish oil 1 g PO daily  
    - Gabapentin 300 mg PO TID PRN for ocular neuropathic pain  

    Orders:  
    - Referral to occupational therapy for adaptive skills training, Completed  
    - Mobility and orientation training ordered, Completed  
    - Social work consult initiated for disability resources, Completed  
    - Prescription for voice-assisted screen reader technology issued, Completed  
    - Psychiatric evaluation for coping and adjustment scheduled, Completed  

    Procedures:  
    - Adaptive low-vision assessment performed  
    - White cane mobility training initiated  
    - Environmental modification consultation for home safety completed  

---

Admission 88131198  
    DRGs:  
    - APR: COMPLETE BLINDNESS — LONG-TERM MANAGEMENT & SUPPORT (Severity 4.0)  
    - HCFA: VISION LOSS REHABILITATION & HOME ADAPTATION  

    Medications:  
    - Duloxetine 30 mg PO daily for depression/anxiety  
    - Melatonin 3 mg PO QHS for sleep regulation  
    - Calcium + Vitamin D PO daily  
    - Artificial Tears — Instill 1 drop OU PRN dryness  
    - Cetirizine 10 mg PO daily for allergic eye irritation  

    Orders:  
    - Assistive technology integration program initiated, Ongoing  
    - Blind rehabilitation center referral placed, Completed  
    - Braille literacy training ordered, Ongoing  
    - Community support services linked, Completed  
    - 6-month follow-up with ophthalmology, Pending  

    Procedures:  
    - Advanced visual rehabilitation performed  
    - Hands-on Braille literacy training session completed  
    - Training on tactile navigation tools initiated  


Patient 10001291  
Gender: Female  
Age: 39  
Race: WHITE  

Admission 66120450  
    DRGs:  
    - APR: CROHN'S DISEASE WITH RECTAL BLEEDING — ACUTE FLARE (Severity 3.0)  
    - HCFA: CROHN'S DISEASE OF SMALL INTESTINE WITH HEMORRHAGE  

    Medications:  
    - Methylprednisolone IV 40 mg Q8H for acute inflammation  
    - Infliximab (Remicade) 5 mg/kg IV infusion — Induction dose  
    - Mesalamine 2.4 g PO daily  
    - Pantoprazole 40 mg PO daily for GI protection  
    - Acetaminophen 650 mg PO Q6H PRN pain/fever  
    - Ondansetron 4 mg IV Q8H PRN nausea  

    Orders:  
    - CT enterography ordered, Completed — Severe small bowel inflammation with mucosal thickening  
    - Colonoscopy scheduled, Completed — Active Crohn’s with terminal ileal ulcerations  
    - Stool cultures ordered, Completed — Negative for infection  
    - Nutritional assessment ordered, Completed  
    - IV hydration protocol initiated, Completed  

    Procedures:  
    - Colonoscopy with biopsies performed  
    - CT enterography completed  
    - Peripheral IV placed for biologic therapy  

---

Admission 66120512  
    DRGs:  
    - APR: CROHN'S DISEASE — REFRACTORY FLARE WITH BLEEDING (Severity 4.0)  
    - HCFA: IMMUNOMODULATOR MANAGEMENT FOR CROHN’S DISEASE  

    Medications:  
    - Vedolizumab (Entyvio) 300 mg IV infusion — Initiated after poor infliximab response  
    - Prednisone taper starting at 40 mg PO daily  
    - Azathioprine 150 mg PO daily  
    - Ferrous sulfate 325 mg PO BID for iron-deficiency anemia  
    - Loperamide 2 mg PO PRN for diarrhea  

    Orders:  
    - MR enterography ordered, Completed — Persistent transmural inflammation in distal ileum  
    - Small bowel capsule endoscopy scheduled, Completed  
    - Blood transfusion crossmatch ordered, Completed  
    - Dietitian consult for low-residue diet, Completed  
    - Vitamin B12 supplementation initiated, Ongoing  

    Procedures:  
    - MR enterography completed  
    - Capsule endoscopy performed  
    - Iron infusion administered via IV  

---

Admission 66120604  
    DRGs:  
    - APR: CROHN’S DISEASE — SURGICAL MANAGEMENT FOR STRICTURE & BLEEDING (Severity 4.0)  
    - HCFA: SMALL BOWEL RESECTION WITH PRIMARY ANASTOMOSIS  

    Medications:  
    - Adalimumab (Humira) 40 mg SC every 2 weeks for maintenance  
    - Ceftriaxone 2 g IV Q24H (peri-op prophylaxis)  
    - Metronidazole 500 mg IV Q8H (peri-op prophylaxis)  
    - Hydromorphone PCA pump for pain control  
    - Pantoprazole 40 mg PO daily  
    - Multivitamin with minerals PO daily  

    Orders:  
    - Laparoscopic ileocecal resection ordered, Completed  
    - Pre-op labs, anesthesia clearance, and bowel prep ordered, Completed  
    - Central line placed for peri-op fluid and biologic administration, Completed  
    - Post-op physical therapy initiated, Ongoing  
    - Outpatient follow-up planned for 2 weeks post-surgery, Pending  

    Procedures:  
    - Laparoscopic-assisted ileocecal resection performed  
    - Intraoperative endoscopy confirmed hemostasis  
    - Post-operative recovery supported with TPN for 5 days  


Patient 20001291  
Gender: Male  
Age: 46  
Race: WHITE  

Admission 77450121  
    DRGs:  
    - APR: CROHN'S DISEASE WITH ACTIVE BLEEDING — INITIAL PRESENTATION (Severity 3.0)  
    - HCFA: CROHN’S DISEASE OF SMALL INTESTINE WITH RECTAL BLEEDING  

    Medications:  
    - IV Methylprednisolone 60 mg daily for acute flare  
    - Mesalamine 4.8 g PO daily  
    - Infliximab (Remicade) 5 mg/kg IV infusion — Week 0  
    - Pantoprazole 40 mg PO daily  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Acetaminophen 650 mg PO Q6H PRN fever  

    Orders:  
    - Colonoscopy ordered, Completed — Multiple ulcerations and active bleeding in ileum  
    - Stool studies for C. difficile and ova/parasites, Completed — Negative  
    - CT enterography performed, Completed — Segmental ileal thickening  
    - CBC and iron panel ordered, Completed — Hemoglobin 9.2 g/dL  
    - IV hydration protocol initiated, Completed  

    Procedures:  
    - Colonoscopy with biopsy performed  
    - CT enterography performed  
    - Peripheral IV line inserted for infusion  

---

Admission 77450210  
    DRGs:  
    - APR: CROHN'S DISEASE — PERSISTENT BLEEDING DESPITE INITIAL THERAPY (Severity 4.0)  
    - HCFA: CROHN’S FLARE REQUIRING ESCALATED IMMUNOSUPPRESSION  

    Medications:  
    - Vedolizumab (Entyvio) 300 mg IV infusion — Switched due to Remicade failure  
    - Prednisone taper starting at 40 mg PO daily  
    - Azathioprine 150 mg PO daily  
    - Ferrous sulfate 325 mg PO daily  
    - Loperamide 2 mg PO PRN diarrhea  
    - Hydrocodone-Acetaminophen 5/325 mg PO Q6H PRN abdominal pain  

    Orders:  
    - MR enterography ordered, Completed — Ongoing inflammation in terminal ileum  
    - Capsule endoscopy performed, Completed — Multifocal ulcerations  
    - Nutrition consult for low-fiber diet, Completed  
    - Vitamin B12 and folate supplementation initiated, Ongoing  
    - Blood transfusion ordered, Completed — 1 unit PRBCs  

    Procedures:  
    - Capsule endoscopy performed  
    - MR enterography completed  
    - IV iron infusion administered  

---

Admission 77450342  
    DRGs:  
    - APR: CROHN'S DISEASE — SURGICAL MANAGEMENT FOR REFRACTORY BLEEDING (Severity 4.0)  
    - HCFA: SMALL BOWEL RESECTION FOR STRICTURING DISEASE  

    Medications:  
    - Adalimumab (Humira) 40 mg SC every 2 weeks for long-term maintenance  
    - Ceftriaxone 2 g IV Q24H peri-op prophylaxis  
    - Metronidazole 500 mg IV Q8H peri-op prophylaxis  
    - Morphine PCA for post-op pain control  
    - Multivitamin with minerals PO daily  
    - Calcium + Vitamin D supplementation daily  

    Orders:  
    - Laparoscopic-assisted small bowel resection ordered, Completed  
    - Post-op TPN initiated for 5 days, Completed  
    - Central line placed, Completed  
    - Physical therapy ordered for early ambulation, Ongoing  
    - Outpatient gastroenterology follow-up scheduled, Pending  

    Procedures:  
    - Laparoscopic-assisted ileocecal resection performed  
    - Intraoperative bleeding controlled  
    - Post-op endoscopy verified anastomosis integrity  


Patient 30001291  
Gender: Female  
Age: 41  
Race: WHITE  

Admission 88210155  
    DRGs:  
    - APR: CROHN’S DISEASE WITH STRICTURE & FISTULA FORMATION (Severity 3.0)  
    - HCFA: CROHN’S SMALL INTESTINE WITH COMPLICATIONS — INITIAL PRESENTATION  

    Medications:  
    - IV Methylprednisolone 40 mg Q12H for acute inflammation  
    - Infliximab (Remicade) 5 mg/kg IV induction dose  
    - Mesalamine 2.4 g PO daily  
    - Ciprofloxacin 400 mg IV Q12H for suspected fistula infection  
    - Metronidazole 500 mg IV Q8H for perianal fistula prophylaxis  
    - Acetaminophen 650 mg PO Q6H PRN abdominal pain  
    - Ondansetron 4 mg IV Q8H PRN nausea  

    Orders:  
    - MR enterography ordered, Completed — Multiple areas of segmental inflammation  
    - Colonoscopy ordered, Completed — Terminal ileum stricture identified  
    - Stool calprotectin ordered, Completed — Significantly elevated  
    - Small bowel ultrasound ordered, Completed — Complex entero-enteric fistula seen  
    - Nutrition consult for elemental diet, Completed  

    Procedures:  
    - MR enterography completed  
    - Colonoscopy with biopsy performed  
    - Peripheral IV line placed for infliximab infusion  

---

Admission 88210227  
    DRGs:  
    - APR: CROHN’S DISEASE — REFRACTORY FLARE WITH FISTULA & ABSCESS (Severity 4.0)  
    - HCFA: CROHN’S FLARE WITH COMPLICATED PERIANAL DISEASE  

    Medications:  
    - Vedolizumab (Entyvio) 300 mg IV infusion — Switched from infliximab after antibody formation  
    - Azathioprine 150 mg PO daily  
    - Prednisone taper starting at 40 mg PO daily  
    - Piperacillin-Tazobactam 4.5 g IV Q6H for pelvic abscess coverage  
    - Ferrous sulfate 325 mg PO BID for chronic blood loss anemia  
    - Loperamide 2 mg PO PRN diarrhea  

    Orders:  
    - Pelvic MRI ordered, Completed — 3 cm perianal abscess identified  
    - CT-guided abscess drainage ordered, Completed  
    - Wound care consult ordered, Completed  
    - Stool studies ordered, Completed — Negative for infection  
    - B12 supplementation initiated, Ongoing  

    Procedures:  
    - CT-guided perianal abscess drainage performed  
    - Pelvic drain placement completed  
    - IV antibiotics administered via central line  

---

Admission 88210392  
    DRGs:  
    - APR: CROHN’S DISEASE — SURGICAL MANAGEMENT FOR STRICTURE & FISTULA (Severity 4.0)  
    - HCFA: ILEOCECAL RESECTION WITH STRICTUROPLASTY  

    Medications:  
    - Adalimumab (Humira) 40 mg SC every 2 weeks for maintenance therapy  
    - Ceftriaxone 2 g IV Q24H peri-op prophylaxis  
    - Metronidazole 500 mg IV Q8H peri-op prophylaxis  
    - Morphine PCA for post-op pain control  
    - Multivitamin with minerals PO daily  
    - Vitamin D3 2000 IU PO daily  

    Orders:  
    - Ileocecal resection with stricturoplasty ordered, Completed  
    - Post-op TPN ordered, Completed — 7 days  
    - Central line placement ordered, Completed  
    - Physical therapy for early mobilization ordered, Ongoing  
    - Outpatient follow-up with GI and colorectal surgery scheduled, Pending  

    Procedures:  
    - Laparoscopic ileocecal resection performed  
    - Strictureplasty completed  
    - Post-op endoscopic evaluation confirmed anastomotic healing  


Patient 40001291  
Gender: Female  
Age: 63  
Race: WHITE  

Admission 66743210  
    DRGs:  
    - APR: DIVERTICULITIS OF LARGE INTESTINE WITHOUT PERFORATION — INITIAL PRESENTATION (Severity 2.0)  
    - HCFA: ACUTE DIVERTICULITIS WITHOUT ABSCESS OR COMPLICATIONS  

    Medications:  
    - Ciprofloxacin 500 mg PO BID x10 days  
    - Metronidazole 500 mg PO TID x10 days  
    - Acetaminophen 650 mg PO Q6H PRN abdominal pain  
    - Ondansetron 4 mg PO Q8H PRN nausea  
    - Polyethylene Glycol 17 g PO daily for bowel regulation  
    - Multivitamin PO daily  

    Orders:  
    - CT abdomen/pelvis ordered, Completed — Mild sigmoid diverticulitis, no perforation or abscess  
    - CBC and CRP ordered, Completed — Mild leukocytosis  
    - Diet: Clear liquid, advanced to low-fiber diet on day 3, Completed  
    - Outpatient colonoscopy ordered in 6 weeks, Pending  
    - GI consult ordered, Completed  

    Procedures:  
    - Peripheral IV placement  
    - CT imaging performed  

---

Admission 66743385  
    DRGs:  
    - APR: RECURRENT DIVERTICULITIS WITHOUT PERFORATION OR ABSCESS (Severity 2.0)  
    - HCFA: RECURRENT UNCOMPLICATED DIVERTICULITIS MANAGEMENT  

    Medications:  
    - Amoxicillin-Clavulanate 875/125 mg PO BID x10 days  
    - Acetaminophen 500 mg PO Q6H PRN pain  
    - Dicyclomine 20 mg PO Q6H PRN abdominal cramps  
    - Lactobacillus probiotic PO daily  
    - Ondansetron ODT 4 mg PO Q8H PRN nausea  
    - Fiber supplement (Psyllium) 5 g PO daily  

    Orders:  
    - Abdominal ultrasound ordered, Completed — No signs of abscess  
    - Colonoscopy performed, Completed — Moderate sigmoid diverticulosis, no active bleeding  
    - Low-residue diet ordered, Completed  
    - Stool occult blood test ordered, Completed — Negative  
    - Referral for outpatient nutrition counseling, Completed  

    Procedures:  
    - Colonoscopy performed  
    - IV hydration administered  

---

Admission 66743504  
    DRGs:  
    - APR: DIVERTICULITIS WITH SEVERE INFLAMMATION BUT NO PERFORATION OR ABSCESS (Severity 3.0)  
    - HCFA: INTENSIFIED MANAGEMENT OF ACUTE DIVERTICULITIS  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV Q8H x5 days  
    - Metronidazole 500 mg IV Q8H x5 days  
    - Pantoprazole 40 mg PO daily  
    - Morphine 2 mg IV Q4H PRN severe abdominal pain  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Multivitamin + Vitamin D supplementation PO daily  

    Orders:  
    - CT abdomen with IV contrast ordered, Completed — Significant sigmoid inflammation, no abscess  
    - IV antibiotics initiated, Completed  
    - Serial abdominal exams ordered, Ongoing  
    - Full-liquid diet ordered, Completed  
    - Outpatient follow-up colonoscopy scheduled in 8 weeks, Pending  

    Procedures:  
    - CT scan performed  
    - Peripheral IV access maintained  
    - IV antibiotics administered  


Patient 50001291  
Gender: Male  
Age: 68  
Race: WHITE  

Admission 16023845  
    DRGs:  
    - APR: DIVERTICULOSIS WITH BLEEDING (Severity 2.0)  
    - HCFA: DIVERTICULOSIS W BLEEDING W/O CC/MCC  

    Medications:  
    - Pantoprazole IV  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Ondansetron IV  
    - Ferrous Sulfate 325mg PO  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Pantoprazole IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Ferrous Sulfate 325mg: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Colonoscopy with diagnostic evaluation  
    - Complete blood count (CBC)  
    - Fecal occult blood test  

Admission 16174329  
    DRGs:  
    - APR: LOWER GI BLEEDING SECONDARY TO DIVERTICULOSIS (Severity 3.0)  
    - HCFA: DIVERTICULAR BLEEDING W CC  

    Medications:  
    - Pantoprazole IV infusion  
    - Ciprofloxacin IV  
    - Metronidazole IV  
    - Sodium Chloride 0.9% Flush  
    - Ondansetron IV  
    - Acetaminophen  
    - Heparin SC (DVT prophylaxis held during bleeding)  

    Orders:  
    - Pantoprazole IV infusion: IV, Discontinued via patient discharge  
    - Ciprofloxacin IV: IV, Discontinued via patient discharge  
    - Metronidazole IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Heparin SC: SC, Discontinued via patient discharge  

    Procedures:  
    - Therapeutic colonoscopy with epinephrine injection  
    - Endoscopic clipping of bleeding diverticulum  
    - CT angiography abdomen/pelvis to localize source  
    - Hemoglobin and hematocrit monitoring q6h  

Admission 16318277  
    DRGs:  
    - APR: SEVERE DIVERTICULAR BLEEDING WITH TRANSFUSION (Severity 4.0)  
    - HCFA: LOWER GI HEMORRHAGE W MCC  

    Medications:  
    - Pantoprazole continuous IV infusion  
    - Piperacillin-Tazobactam IV  
    - Tranexamic Acid IV  
    - Sodium Chloride 0.9% Flush  
    - Ondansetron IV  
    - Acetaminophen  
    - Packed red blood cells (PRBCs) transfusion  

    Orders:  
    - Pantoprazole continuous IV: IV, Discontinued via patient discharge  
    - Piperacillin-Tazobactam IV: IV, Discontinued via patient discharge  
    - Tranexamic Acid IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - PRBC transfusion: IV, Completed  

    Procedures:  
    - Colonoscopy with cauterization of active bleeding site  
    - Interventional radiology-guided mesenteric embolization  
    - Serial hemoglobin monitoring  
    - ICU observation for hypotension and volume resuscitation



Patient 60001291  
Gender: Male  
Age: 34  
Race: WHITE  

Admission 77420115  
    DRGs:  
    - APR: EPILEPSY AND SEIZURE DISORDERS — INITIAL PRESENTATION (Severity 2.0)  
    - HCFA: EPILEPSY, UNSPECIFIED — NON-INTRACTABLE, WITHOUT STATUS  

    Medications:  
    - Levetiracetam (Keppra) 500 mg PO BID  
    - Lorazepam 2 mg IV PRN seizure >5 minutes  
    - Acetaminophen 650 mg PO Q6H PRN headache  
    - Ondansetron 4 mg IV Q8H PRN nausea  
    - Multivitamin PO daily  

    Orders:  
    - Routine EEG ordered, Completed — Abnormal sharp waves, temporal predominance  
    - MRI brain with contrast ordered, Completed — No acute findings  
    - CMP + CBC ordered, Completed — Normal results  
    - Driving restriction counseling provided, Completed  
    - Outpatient neurology referral placed, Pending  

    Procedures:  
    - EEG performed  
    - MRI brain performed  

---

Admission 77420298  
    DRGs:  
    - APR: EPILEPSY — MEDICATION TITRATION AND FOLLOW-UP (Severity 2.0)  
    - HCFA: FOLLOW-UP MANAGEMENT OF NON-INTRACTABLE EPILEPSY  

    Medications:  
    - Levetiracetam (Keppra) increased to 750 mg PO BID  
    - Vitamin B6 50 mg PO daily (for mood stabilization on Keppra)  
    - Lorazepam 1 mg PO PRN aura or prolonged seizure  
    - Naproxen 250 mg PO BID PRN post-ictal headaches  

    Orders:  
    - 48-hour ambulatory EEG ordered, Completed — Decreased seizure frequency, one subclinical event  
    - Serum Keppra levels ordered, Completed — Within therapeutic range  
    - Sleep study ordered, Pending — Evaluate nocturnal seizure activity  
    - Outpatient follow-up with neurology scheduled in 2 weeks, Pending  

    Procedures:  
    - Ambulatory EEG monitoring performed  

---

Admission 77420442  
    DRGs:  
    - APR: BREAKTHROUGH SEIZURE EPISODE ON MAINTENANCE THERAPY (Severity 3.0)  
    - HCFA: ACUTE BREAKTHROUGH SEIZURE WITHOUT STATUS  

    Medications:  
    - Added Lamotrigine (Lamictal) 25 mg PO daily for dual therapy initiation  
    - Levetiracetam maintained at 750 mg PO BID  
    - Diazepam nasal spray 10 mg PRN rescue for prolonged seizure  
    - Pantoprazole 40 mg PO daily for GI protection  
    - Folic acid 1 mg PO daily  

    Orders:  
    - Continuous inpatient EEG monitoring ordered, Completed — One electrographic seizure noted  
    - CT head without contrast ordered, Completed — Negative for acute pathology  
    - Neuropsychology consult ordered, Completed — Counseling provided on medication adherence  
    - Seizure safety counseling ordered, Completed — Patient educated on lifestyle modifications  

    Procedures:  
    - Continuous video EEG monitoring performed  
    - Rescue therapy administered via nasal diazepam  


Patient 10001292  
Gender: Male  
Age: 45  
Race: WHITE  

Admission 78120432  
    DRGs:  
    - APR: ACUTE ALCOHOL-INDUCED PANCREATITIS WITHOUT NECROSIS (Severity 3.0)  
    - HCFA: ALCOHOL-RELATED ACUTE PANCREATITIS — INITIAL EPISODE  

    Medications:  
    - Lactated Ringer’s IV infusion 150 mL/hr  
    - Hydromorphone 0.5 mg IV Q4H PRN severe abdominal pain  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Pantoprazole 40 mg IV daily  
    - Thiamine 100 mg IV daily  
    - Folic acid 1 mg PO daily  
    - Multivitamin PO daily  

    Orders:  
    - CT abdomen with contrast ordered, Completed — No necrosis, peripancreatic inflammation only  
    - Serum lipase & amylase ordered, Completed — Lipase 785 U/L (elevated)  
    - NPO status ordered, Completed  
    - IV fluids initiated, Completed  
    - Alcohol cessation counseling ordered, Completed  
    - Outpatient GI referral placed, Pending  

    Procedures:  
    - Peripheral IV placement  
    - Abdominal CT performed  

---

Admission 78120614  
    DRGs:  
    - APR: RECURRENT ALCOHOL-INDUCED ACUTE PANCREATITIS WITHOUT NECROSIS (Severity 3.0)  
    - HCFA: MANAGEMENT OF RECURRENT ACUTE PANCREATITIS  

    Medications:  
    - Lactated Ringer’s IV infusion 125 mL/hr  
    - Morphine 2 mg IV Q4H PRN severe abdominal pain  
    - Ondansetron ODT 4 mg PO Q8H PRN nausea  
    - Pantoprazole 40 mg PO daily  
    - Naltrexone 50 mg PO daily for alcohol-use disorder  
    - Multivitamin PO daily  

    Orders:  
    - Abdominal ultrasound ordered, Completed — No gallstones or ductal obstruction  
    - Triglycerides level ordered, Completed — Normal  
    - Diet: NPO → clear liquids → low-fat diet, Completed  
    - GI consult ordered, Completed  
    - Alcohol rehabilitation referral placed, Pending  

    Procedures:  
    - Abdominal ultrasound performed  
    - IV hydration maintained  

---

Admission 78120872  
    DRGs:  
    - APR: SEVERE ALCOHOL-INDUCED ACUTE PANCREATITIS WITHOUT NECROSIS (Severity 4.0)  
    - HCFA: HIGH-ACUITY PANCREATITIS MANAGEMENT — NO NECROSIS  

    Medications:  
    - Lactated Ringer’s IV infusion 200 mL/hr  
    - Hydromorphone PCA pump initiated for pain control  
    - Ondansetron 4 mg IV Q6H PRN vomiting  
    - Pantoprazole 40 mg IV daily  
    - Chlordiazepoxide 25 mg PO Q6H for alcohol withdrawal prophylaxis  
    - Multivitamin + Thiamine + Folic acid IV daily  

    Orders:  
    - Repeat CT abdomen ordered, Completed — No necrosis, worsening peripancreatic edema  
    - Continuous monitoring for SIRS criteria ordered, Ongoing  
    - Alcohol withdrawal CIWA protocol ordered, Completed  
    - Nutrition consult ordered, Completed — Recommended low-fat, high-protein diet upon recovery  
    - Outpatient follow-up with hepatology & addiction medicine, Pending  

    Procedures:  
    - Repeat abdominal CT scan  
    - IV PCA management  
    - Continuous monitoring for alcohol withdrawal  


Patient 20001292  
Gender: Male  
Age: 48  
Race: WHITE  

Admission 78231011  
    DRGs:  
    - APR: ALCOHOL-INDUCED ACUTE PANCREATITIS WITHOUT NECROSIS — INITIAL PRESENTATION (Severity 3.0)  
    - HCFA: ACUTE PANCREATITIS — ALCOHOL-RELATED, NON-NECROTIZING  

    Medications:  
    - Lactated Ringer’s IV infusion 150 mL/hr  
    - Morphine 2 mg IV Q4H PRN abdominal pain  
    - Ondansetron 4 mg IV Q6H PRN nausea/vomiting  
    - Pantoprazole 40 mg IV daily  
    - Thiamine 100 mg IV daily  
    - Folic acid 1 mg PO daily  
    - Multivitamin PO daily  

    Orders:  
    - CT abdomen with contrast ordered, Completed — Diffuse pancreatic swelling, no necrosis  
    - Lipase/amylase panel ordered, Completed — Lipase 980 U/L, Amylase 400 U/L  
    - NPO status ordered, Completed  
    - IV hydration initiated, Completed  
    - CIWA protocol for alcohol withdrawal initiated, Completed  
    - Addiction counseling referral placed, Pending  

    Procedures:  
    - Peripheral IV placement  
    - Abdominal CT performed  

---

Admission 78231288  
    DRGs:  
    - APR: RECURRENT ALCOHOL-INDUCED ACUTE PANCREATITIS WITHOUT NECROSIS (Severity 3.0)  
    - HCFA: ACUTE PANCREATITIS READMISSION MANAGEMENT  

    Medications:  
    - Lactated Ringer’s IV infusion 125 mL/hr  
    - Hydromorphone 0.5 mg IV Q4H PRN pain  
    - Ondansetron ODT 4 mg PO Q8H PRN nausea  
    - Pantoprazole 40 mg PO daily  
    - Naltrexone 50 mg PO daily for alcohol dependence  
    - Multivitamin PO daily  

    Orders:  
    - Abdominal ultrasound ordered, Completed — No gallstones, normal bile ducts  
    - Triglyceride panel ordered, Completed — Normal  
    - Diet: NPO → clear liquids → low-fat diet, Completed  
    - GI consult ordered, Completed  
    - Alcohol recovery program referral placed, Pending  

    Procedures:  
    - Abdominal ultrasound performed  
    - IV fluid resuscitation maintained  

---

Admission 78231546  
    DRGs:  
    - APR: SEVERE ALCOHOL-INDUCED ACUTE PANCREATITIS WITHOUT NECROSIS (Severity 4.0)  
    - HCFA: COMPLICATED ACUTE PANCREATITIS — INTENSIVE MANAGEMENT  

    Medications:  
    - Lactated Ringer’s IV infusion 200 mL/hr  
    - Hydromorphone PCA pump initiated for breakthrough pain control  
    - Ondansetron 4 mg IV Q6H PRN vomiting  
    - Pantoprazole 40 mg IV daily  
    - Chlordiazepoxide 25 mg PO Q6H for alcohol withdrawal prophylaxis  
    - Thiamine 100 mg IV daily  
    - Folic acid 1 mg PO daily  

    Orders:  
    - Repeat CT abdomen ordered, Completed — Increased edema, still no necrosis  
    - Continuous monitoring for SIRS/sepsis ordered, Ongoing  
    - Nutrition consult ordered, Completed — Recommended early enteral feeding via low-fat diet once stable  
    - Counseling for alcohol cessation ordered, Completed  
    - Follow-up hepatology appointment scheduled, Pending  

    Procedures:  
    - Repeat CT abdomen performed  
    - IV PCA pump initiation  
    - Continuous monitoring for alcohol withdrawal  


Patient 30001292  
Gender: Male  
Age: 51  
Race: WHITE  

Admission 79342105  
    DRGs:  
    - APR: ALCOHOL-INDUCED ACUTE PANCREATITIS WITH UNINFECTED NECROSIS — INITIAL EPISODE (Severity 4.0)  
    - HCFA: NECROTIZING ALCOHOLIC PANCREATITIS MANAGEMENT WITHOUT INFECTION  

    Medications:  
    - Lactated Ringer’s IV infusion 250 mL/hr  
    - Hydromorphone PCA pump for severe abdominal pain  
    - Ondansetron 4 mg IV Q6H PRN nausea/vomiting  
    - Pantoprazole 40 mg IV daily  
    - Ceftriaxone 2 g IV daily (prophylaxis for secondary infection)  
    - Thiamine 100 mg IV daily  
    - Folic acid 1 mg PO daily  
    - Multivitamin PO daily  

    Orders:  
    - CT abdomen with contrast ordered, Completed — 35% pancreatic necrosis, no peripancreatic infection  
    - Lipase/amylase panel ordered, Completed — Lipase 1450 U/L, Amylase 530 U/L  
    - NPO status ordered, Completed  
    - NG tube insertion ordered, Completed for gastric decompression  
    - Addiction medicine consult ordered, Completed  
    - ICU transfer for close monitoring ordered, Completed  

    Procedures:  
    - Abdominal CT with contrast performed  
    - NG tube placement  
    - ICU admission  

---

Admission 79342378  
    DRGs:  
    - APR: RECURRENT ALCOHOL-INDUCED PANCREATITIS WITH UNINFECTED NECROSIS (Severity 4.0)  
    - HCFA: PANCREATIC NECROSIS MONITORING — SECONDARY ADMISSION  

    Medications:  
    - Lactated Ringer’s IV infusion 225 mL/hr  
    - Morphine 2 mg IV Q3H PRN abdominal pain  
    - Ondansetron ODT 4 mg PO Q8H PRN nausea  
    - Meropenem 1 g IV Q8H (given due to concern for potential secondary infection)  
    - Pantoprazole 40 mg PO daily  
    - Naltrexone 50 mg PO daily for alcohol-use disorder  
    - Multivitamin PO daily  

    Orders:  
    - Repeat contrast CT ordered, Completed — Stable 35% necrosis, no abscess formation  
    - Endoscopic ultrasound (EUS) ordered, Completed — Confirmed pancreatic necrosis without fluid collections  
    - Enteral feeding via NJ tube ordered, Completed  
    - Addiction counseling ordered, Completed  
    - Hepatology consult placed, Pending  

    Procedures:  
    - Repeat abdominal CT performed  
    - Endoscopic ultrasound performed  
    - NJ tube placement for enteral feeding  

---

Admission 79342792  
    DRGs:  
    - APR: SEVERE ALCOHOL-INDUCED PANCREATITIS WITH EXTENSIVE UNINFECTED NECROSIS (Severity 4.0)  
    - HCFA: HIGH-ACUITY MANAGEMENT OF NECROTIZING PANCREATITIS  

    Medications:  
    - Lactated Ringer’s IV infusion 300 mL/hr  
    - Hydromorphone PCA pump continued  
    - Ondansetron 4 mg IV Q6H PRN vomiting  
    - Piperacillin-tazobactam 4.5 g IV Q8H (prophylactic antibiotic coverage)  
    - Pantoprazole 40 mg IV daily  
    - Chlordiazepoxide 25 mg PO Q6H for alcohol withdrawal prophylaxis  
    - Thiamine 100 mg IV daily  
    - Multivitamin PO daily  

    Orders:  
    - Repeat abdominal CT ordered, Completed — Necrosis increased to 45%, still uninfected  
    - Continuous hemodynamic monitoring ordered, Completed  
    - Early surgical consult ordered, Completed — Conservative management recommended  
    - Nutrition consult ordered, Completed — Recommended high-protein, low-fat enteral feeding  
    - Addiction medicine referral ordered, Completed  

    Procedures:  
    - Repeat CT abdomen performed  
    - ICU monitoring maintained  
    - Initiation of continuous enteral nutrition  


Patient 40001292  
Gender: Male  
Age: 53  
Race: WHITE  

Admission 80453212  
    DRGs:  
    - APR: ALCOHOLIC HEPATITIS WITHOUT ASCITES — INITIAL PRESENTATION (Severity 3.0)  
    - HCFA: ACUTE ALCOHOLIC HEPATITIS MANAGEMENT WITHOUT FLUID ACCUMULATION  

    Medications:  
    - Prednisolone 40 mg PO daily  
    - Thiamine 100 mg IV daily  
    - Folic acid 1 mg PO daily  
    - Multivitamin PO daily  
    - Pantoprazole 40 mg PO daily  
    - Lactulose 20 g PO BID  
    - Ondansetron 4 mg IV Q8H PRN nausea/vomiting  

    Orders:  
    - Liver function panel ordered, Completed — AST 280 U/L, ALT 130 U/L, INR 1.6  
    - Abdominal ultrasound ordered, Completed — Hepatomegaly, no ascites  
    - Maddrey’s Discriminant Function calculated: 28 → Initiated corticosteroid therapy  
    - Hepatitis screening ordered, Completed — Negative  
    - Alcohol cessation counseling ordered, Completed  
    - Nutrition consult ordered, Completed  

    Procedures:  
    - Abdominal ultrasound performed  
    - IV access placement for fluid and vitamin administration  

---

Admission 80453607  
    DRGs:  
    - APR: RECURRENT ALCOHOLIC HEPATITIS WITHOUT ASCITES (Severity 3.0)  
    - HCFA: SECONDARY ADMISSION FOR HEPATIC FLARE MANAGEMENT  

    Medications:  
    - Prednisolone 30 mg PO daily  
    - Thiamine 100 mg IV daily  
    - Folic acid 1 mg PO daily  
    - Multivitamin PO daily  
    - Naltrexone 50 mg PO daily for alcohol-use disorder  
    - Pantoprazole 40 mg PO daily  
    - Ondansetron ODT 4 mg PO Q8H PRN nausea  
    - Rifaximin 550 mg PO BID  

    Orders:  
    - Liver ultrasound ordered, Completed — Fatty liver changes, no ascites  
    - Hepatic function panel ordered, Completed — Mildly worsened bilirubin 3.2 mg/dL  
    - PT/INR monitoring ordered, Completed  
    - Referral to outpatient alcohol recovery program, Pending  
    - Dietitian consult ordered, Completed — High-protein, low-fat, vitamin-rich diet  

    Procedures:  
    - Abdominal ultrasound performed  
    - Alcohol cessation counseling session completed  

---

Admission 80454029  
    DRGs:  
    - APR: SEVERE ALCOHOLIC HEPATITIS WITHOUT ASCITES (Severity 4.0)  
    - HCFA: HIGH-ACUITY MANAGEMENT OF ACUTE HEPATIC INFLAMMATION  

    Medications:  
    - Prednisolone 40 mg PO daily  
    - N-acetylcysteine (NAC) 100 mg/kg IV infusion  
    - Thiamine 100 mg IV daily  
    - Folic acid 1 mg PO daily  
    - Multivitamin PO daily  
    - Lactulose 30 g PO TID  
    - Rifaximin 550 mg PO BID  
    - Piperacillin-tazobactam 4.5 g IV Q8H (prophylaxis due to elevated WBC)  
    - Ondansetron 4 mg IV Q6H PRN nausea/vomiting  

    Orders:  
    - Repeat liver function panel ordered, Completed — AST 340 U/L, INR 2.1  
    - CT abdomen with contrast ordered, Completed — Diffuse hepatic inflammation, no ascites  
    - Continuous hemodynamic monitoring ordered, Completed  
    - Alcohol withdrawal prophylaxis via CIWA protocol initiated, Completed  
    - Hepatology referral ordered, Pending  
    - Plan for long-term transplant evaluation if hepatic function declines  

    Procedures:  
    - CT abdomen performed  
    - NAC infusion initiated  
    - CIWA monitoring implemented  


Patient 50001292  
Gender: Male  
Age: 45  
Race: WHITE  

Admission 17024561  
    DRGs:  
    - APR: ALCOHOL ABUSE WITHOUT COMPLICATIONS (Severity 1.0)  
    - HCFA: ALCOHOL USE DISORDER W/O CC/MCC  

    Medications:  
    - Thiamine 100mg PO  
    - Folic Acid 1mg PO  
    - Multivitamin PO  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Ondansetron PO  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Thiamine 100mg: PO, Discontinued via patient discharge  
    - Folic Acid 1mg: PO, Discontinued via patient discharge  
    - Multivitamin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Ondansetron PO: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Basic metabolic panel  
    - Liver function tests (LFTs)  
    - Counseling on alcohol cessation and referral to outpatient rehab  

Admission 17185934  
    DRGs:  
    - APR: ALCOHOL USE WITH EARLY WITHDRAWAL SYMPTOMS (Severity 2.0)  
    - HCFA: ALCOHOL DEPENDENCE W CC  

    Medications:  
    - Diazepam IV PRN (CIWA protocol)  
    - Thiamine 100mg PO  
    - Folic Acid 1mg PO  
    - Multivitamin PO  
    - Ondansetron IV  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  

    Orders:  
    - Diazepam: IV, Discontinued via patient discharge  
    - Thiamine: PO, Discontinued via patient discharge  
    - Folic Acid: PO, Discontinued via patient discharge  
    - Multivitamin: PO, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - CIWA-Ar scoring and monitoring  
    - Intravenous fluid resuscitation  
    - Addiction medicine consult  

Admission 17349712  
    DRGs:  
    - APR: SEVERE ALCOHOL USE WITH WITHDRAWAL AND COMPLICATIONS (Severity 3.0)  
    - HCFA: ALCOHOL DEPENDENCE W MCC  

    Medications:  
    - Lorazepam IV continuous infusion  
    - Phenobarbital IV PRN  
    - Thiamine 200mg IV  
    - Folic Acid IV  
    - Magnesium Sulfate IV  
    - Sodium Chloride 0.9% Flush  
    - Multivitamin IV  
    - Ondansetron IV  

    Orders:  
    - Lorazepam IV infusion: IV, Discontinued via patient discharge  
    - Phenobarbital IV: IV, Discontinued via patient discharge  
    - Thiamine IV: IV, Discontinued via patient discharge  
    - Folic Acid IV: IV, Discontinued via patient discharge  
    - Magnesium Sulfate IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Multivitamin IV: IV, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  

    Procedures:  
    - Continuous vital sign and telemetry monitoring  
    - Arterial blood gas analysis  
    - ICU admission for alcohol withdrawal management  
    - Psychiatric evaluation and inpatient rehab referral


Patient 60001292  
Gender: Male  
Age: 66  
Race: WHITE  

Admission 76542103  
    DRGs:  
    - APR: BENIGN PROSTATIC HYPERPLASIA WITHOUT LOWER URINARY TRACT SYMPTOMS — INITIAL EVALUATION (Severity 1.0)  
    - HCFA: ELECTIVE ASSESSMENT OF BENIGN PROSTATE ENLARGEMENT WITHOUT OBSTRUCTION  

    Medications:  
    - Tamsulosin 0.4 mg PO daily  
    - Finasteride 5 mg PO daily  
    - Multivitamin PO daily  
    - Influenza Vaccine Quadrivalent IM yearly  

    Orders:  
    - PSA test ordered, Completed — PSA: 2.6 ng/mL  
    - Urinalysis ordered, Completed — Normal findings  
    - Renal ultrasound ordered, Completed — Mild symmetric enlargement, no obstruction  
    - Urology consult ordered, Completed  
    - Lifestyle counseling ordered, Completed — Fluid timing adjustments, alcohol reduction  
    - Scheduled follow-up in 6 months  

    Procedures:  
    - Abdominal and pelvic ultrasound performed  
    - Digital rectal exam (DRE) performed — Smooth, symmetrically enlarged prostate  

---

Admission 76542612  
    DRGs:  
    - APR: BENIGN PROSTATIC HYPERPLASIA — MEDICATION RESPONSE FOLLOW-UP (Severity 1.0)  
    - HCFA: BPH MANAGEMENT VISIT WITHOUT VOIDING DYSFUNCTION  

    Medications:  
    - Tamsulosin 0.4 mg PO daily (continued)  
    - Finasteride 5 mg PO daily (continued)  
    - Vitamin D3 2000 IU PO daily  
    - Pravastatin 20 mg PO nightly  

    Orders:  
    - Repeat PSA test ordered, Completed — PSA: 2.4 ng/mL  
    - Renal function panel ordered, Completed — Creatinine: 1.0 mg/dL  
    - Abdominal ultrasound ordered, Completed — Stable prostate volume  
    - Uroflowmetry ordered, Completed — Peak flow: 18 mL/sec, within normal range  
    - Counseling for continued medical therapy ordered, Completed  
    - Follow-up scheduled in 1 year  

    Procedures:  
    - Uroflowmetry performed  
    - Bladder scan performed — No post-void residual detected  

---

Admission 76543145  
    DRGs:  
    - APR: BENIGN PROSTATIC HYPERPLASIA — ROUTINE SURVEILLANCE VISIT (Severity 1.0)  
    - HCFA: LONG-TERM MONITORING OF BPH WITHOUT LUTS  

    Medications:  
    - Tamsulosin 0.4 mg PO daily  
    - Finasteride 5 mg PO daily  
    - Multivitamin PO daily  
    - Influenza Vaccine Quadrivalent IM yearly  

    Orders:  
    - Annual PSA test ordered, Completed — PSA: 2.5 ng/mL  
    - Urology follow-up ordered, Completed — No urinary symptoms  
    - Counseling ordered, Completed — Maintain hydration, avoid bladder irritants  
    - Screening for urinary retention ordered, Completed — Negative findings  
    - Physical activity guidance ordered, Completed — Encouraged moderate exercise  

    Procedures:  
    - Digital rectal exam performed — Stable size, no nodules  
    - Post-void bladder ultrasound performed — 20 mL residual, clinically insignificant  


Patient 10001293  
Gender: Female  
Age: 41  
Race: WHITE  

Admission 71245980  
    DRGs:  
    - APR: ACUTE CYSTITIS WITH HEMATURIA — INITIAL PRESENTATION (Severity 2.0)  
    - HCFA: URINARY TRACT INFECTIONS WITH HEMATURIA, NONCOMPLICATED  

    Medications:  
    - Nitrofurantoin 100 mg PO BID × 7 days  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Ibuprofen 400 mg PO Q6H PRN pain  
    - Sodium Chloride 0.9% Flush IV PRN hydration  
    - Influenza Vaccine Quadrivalent IM  

    Orders:  
    - Urinalysis ordered, Completed — Positive nitrites, RBCs present  
    - Urine culture ordered, Completed — E. coli >100,000 CFU/mL  
    - Serum creatinine panel ordered, Completed — Normal renal function  
    - Counseling on hydration and bladder hygiene ordered, Completed  
    - Follow-up in 2 weeks to reassess hematuria  

    Procedures:  
    - Straight catheter urine specimen collected  
    - IV fluids administered for hydration  

---

Admission 71246321  
    DRGs:  
    - APR: RECURRENT CYSTITIS WITH HEMATURIA — FOLLOW-UP EPISODE (Severity 2.0)  
    - HCFA: NONCOMPLICATED LOWER URINARY TRACT INFECTION WITH BLEEDING  

    Medications:  
    - Cefuroxime 500 mg PO BID × 10 days  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Acetaminophen 650 mg PO Q6H PRN dysuria  
    - Probiotic supplement PO daily  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Urine culture ordered, Completed — Klebsiella pneumoniae, sensitive to cefuroxime  
    - Post-treatment urinalysis ordered, Completed — RBCs resolved  
    - Abdominal and pelvic ultrasound ordered, Completed — No hydronephrosis or obstruction  
    - Preventive urology referral ordered, Completed  
    - Education on UTI prevention strategies ordered, Completed  

    Procedures:  
    - Bladder ultrasound performed  
    - Urinary catheterization avoided due to intact voiding  

---

Admission 71247055  
    DRGs:  
    - APR: SEVERE CYSTITIS WITH HEMATURIA AND COMPLICATED INFECTION (Severity 3.0)  
    - HCFA: COMPLICATED LOWER UTI WITH BLOOD IN URINE  

    Medications:  
    - Piperacillin-Tazobactam 3.375 g IV Q8H × 5 days  
    - Ciprofloxacin 500 mg PO BID × 7 days after IV antibiotics  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Lactobacillus probiotic PO daily  
    - Sodium Chloride 0.9% IV continuous hydration  

    Orders:  
    - Blood cultures ordered, Completed — Negative growth  
    - Urine culture ordered, Completed — E. coli ESBL-positive  
    - CT abdomen/pelvis ordered, Completed — No renal stones, no obstruction  
    - Hematuria evaluation via cystoscopy ordered, Completed — Mild bladder mucosal inflammation  
    - Follow-up plan: Outpatient urology review scheduled in 3 weeks  

    Procedures:  
    - CT abdomen and pelvis performed  
    - Diagnostic cystoscopy performed  
    - IV antibiotics administered via peripheral line  


Patient 20001293  
Gender: Female  
Age: 54  
Race: BLACK/AFRICAN AMERICAN  

Admission 84532710  
    DRGs:  
    - APR: ACUTE CYSTITIS WITH HEMATURIA — INITIAL EPISODE (Severity 2.0)  
    - HCFA: URINARY TRACT INFECTION WITH HEMATURIA, NONCOMPLICATED  

    Medications:  
    - Nitrofurantoin 100 mg PO BID × 7 days  
    - Phenazopyridine 200 mg PO TID × 3 days  
    - Acetaminophen 650 mg PO Q6H PRN pain  
    - Sodium Chloride 0.9% Flush IV PRN hydration  
    - Influenza Vaccine Quadrivalent IM  

    Orders:  
    - Urinalysis ordered, Completed — RBCs 25/HPF, positive nitrites  
    - Urine culture ordered, Completed — E. coli sensitive to nitrofurantoin  
    - Serum creatinine and BUN ordered, Completed — Normal renal function  
    - Bladder hydration counseling ordered, Completed  
    - Scheduled follow-up urinalysis in 2 weeks  

    Procedures:  
    - IV fluids administered  
    - Straight catheter specimen collected for culture  

---

Admission 84533284  
    DRGs:  
    - APR: RECURRENT CYSTITIS WITH HEMATURIA (Severity 2.0)  
    - HCFA: LOWER UTI WITH BLEEDING, NONCOMPLICATED  

    Medications:  
    - Cefuroxime 500 mg PO BID × 10 days  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Ibuprofen 400 mg PO Q6H PRN pelvic discomfort  
    - Lactobacillus probiotic PO daily  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Repeat urine culture ordered, Completed — Klebsiella pneumoniae, cefuroxime-sensitive  
    - Pelvic ultrasound ordered, Completed — No obstruction, bladder wall thickening noted  
    - Urinalysis ordered, Completed — RBCs resolved post-treatment  
    - Urology referral ordered, Completed  
    - Preventive counseling ordered, Completed — Proper hygiene and timed voiding  

    Procedures:  
    - Bladder ultrasound performed  
    - No catheterization required  

---

Admission 84534072  
    DRGs:  
    - APR: SEVERE CYSTITIS WITH HEMATURIA AND COMPLICATED INFECTION (Severity 3.0)  
    - HCFA: COMPLICATED LOWER UTI WITH BLOOD IN URINE  

    Medications:  
    - Piperacillin-Tazobactam 3.375 g IV Q8H × 5 days  
    - Ciprofloxacin 500 mg PO BID × 7 days following IV therapy  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Multivitamin PO daily  
    - Sodium Chloride 0.9% IV continuous infusion  

    Orders:  
    - Blood cultures ordered, Completed — No growth  
    - Urine culture ordered, Completed — E. coli ESBL-positive, switched to IV therapy  
    - CT urogram ordered, Completed — No stones or obstruction, mild bladder edema  
    - Cystoscopy ordered, Completed — Small mucosal erythema and hyperemia  
    - Discharge follow-up with urology ordered, Completed — 3-week follow-up  

    Procedures:  
    - CT urogram performed  
    - Diagnostic cystoscopy performed  
    - IV antibiotics administered via peripheral line  


Patient 30001293  
Gender: Female  
Age: 39  
Race: WHITE  

Admission 93521840  
    DRGs:  
    - APR: ACUTE UNCOMPLICATED CYSTITIS — INITIAL PRESENTATION (Severity 1.0)  
    - HCFA: ACUTE LOWER URINARY TRACT INFECTION, NONCOMPLICATED  

    Medications:  
    - Nitrofurantoin 100 mg PO BID × 5 days  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Ibuprofen 400 mg PO Q6H PRN pain  
    - Sodium Chloride 0.9% Flush IV PRN hydration  
    - Influenza Vaccine Quadrivalent IM  

    Orders:  
    - Urinalysis ordered, Completed — Positive leukocyte esterase, negative RBCs  
    - Urine culture ordered, Completed — E. coli sensitive to nitrofurantoin  
    - Renal panel ordered, Completed — No renal impairment  
    - Hydration counseling ordered, Completed  
    - Follow-up urine dipstick in 10 days ordered, Pending  

    Procedures:  
    - Straight catheter urine sample collected for culture  
    - IV fluids administered for mild dehydration  

---

Admission 93522591  
    DRGs:  
    - APR: RECURRENT ACUTE CYSTITIS — SECOND EPISODE (Severity 1.0)  
    - HCFA: LOWER URINARY TRACT INFECTION WITHOUT BLEEDING  

    Medications:  
    - Trimethoprim-Sulfamethoxazole DS 1 tab PO BID × 7 days  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Probiotic supplement PO daily × 14 days  
    - Acetaminophen 650 mg PO Q6H PRN dysuria  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Urine culture ordered, Completed — Klebsiella pneumoniae sensitive to TMP-SMX  
    - Pelvic ultrasound ordered, Completed — No hydronephrosis, bladder wall normal  
    - Post-treatment urinalysis ordered, Completed — Leukocytes resolved  
    - Patient counseling on timed voiding and prevention strategies ordered, Completed  
    - Urology referral ordered, Completed  

    Procedures:  
    - Ultrasound of kidneys and bladder performed  
    - No catheterization performed due to intact spontaneous voiding  

---

Admission 93523164  
    DRGs:  
    - APR: ACUTE CYSTITIS WITH ANTIBIOTIC RESISTANCE — COMPLICATED CASE (Severity 2.0)  
    - HCFA: COMPLICATED LOWER UTI REQUIRING IV ANTIBIOTICS  

    Medications:  
    - Ceftriaxone 1 g IV Q24H × 5 days  
    - Levofloxacin 500 mg PO daily × 5 days post-IV therapy  
    - Phenazopyridine 200 mg PO TID × 2 days  
    - Sodium Bicarbonate PO BID for urine alkalinization  
    - Sodium Chloride 0.9% IV continuous infusion  

    Orders:  
    - Urine culture ordered, Completed — E. coli ESBL-positive  
    - Blood cultures ordered, Completed — Negative  
    - CT abdomen/pelvis ordered, Completed — No obstruction or calculi  
    - Foley catheter avoided due to intact voiding  
    - Urology follow-up appointment ordered, Scheduled for 4 weeks  

    Procedures:  
    - CT abdomen and pelvis performed  
    - IV antibiotics administered via peripheral line  
    - Urine pH monitoring performed during treatment  


Patient 40001293  
Gender: Male  
Age: 46  
Race: WHITE  

Admission 78120456  
    DRGs:  
    - APR: RENAL CALCULUS WITH OBSTRUCTION (Severity 2.0)  
    - HCFA: KIDNEY STONES WITHOUT MAJOR COMPLICATIONS  

    Medications:  
    - Ketorolac 15 mg IV Q6H PRN pain  
    - Tamsulosin 0.4 mg PO daily × 7 days  
    - Ondansetron 4 mg IV Q8H PRN nausea  
    - Acetaminophen 650 mg PO Q6H PRN mild pain  
    - Sodium Chloride 0.9% IV continuous infusion  

    Orders:  
    - Non-contrast CT scan ordered, Completed — 5 mm stone in right proximal ureter  
    - Urinalysis ordered, Completed — RBCs 10/HPF, negative nitrites  
    - Basic metabolic panel ordered, Completed — Creatinine 1.1 mg/dL  
    - Urine straining ordered, Ongoing — Patient instructed to collect passed stones  
    - Urology consult ordered, Completed — Outpatient follow-up planned  

    Procedures:  
    - Non-contrast CT abdomen and pelvis performed  
    - IV hydration administered  
    - Pain managed with IV ketorolac and oral acetaminophen  

---

Admission 78121572  
    DRGs:  
    - APR: SYMPTOMATIC KIDNEY STONE WITH HYDRONEPHROSIS (Severity 3.0)  
    - HCFA: URETERAL CALCULUS WITH OBSTRUCTION AND ACUTE PAIN  

    Medications:  
    - Morphine 2 mg IV Q4H PRN severe pain  
    - Tamsulosin 0.4 mg PO daily × 10 days  
    - Ceftriaxone 1 g IV Q24H × 3 days (prophylaxis)  
    - Ibuprofen 600 mg PO Q6H PRN  
    - Ondansetron 4 mg IV Q6H PRN nausea  

    Orders:  
    - KUB X-ray ordered, Completed — Confirmed persistence of 7 mm ureteral stone  
    - Renal ultrasound ordered, Completed — Moderate right hydronephrosis  
    - Serum creatinine ordered, Completed — 1.4 mg/dL, mild AKI noted  
    - Pre-op evaluation ordered, Completed — Cleared for procedure  
    - Urology procedure scheduled, Completed — Ureteroscopy planned  

    Procedures:  
    - Cystoscopy with ureteroscopy performed  
    - Stone retrieved via basket extraction  
    - Temporary ureteral stent placed  

---

Admission 78122944  
    DRGs:  
    - APR: COMPLEX KIDNEY STONE MANAGEMENT WITH STENT (Severity 3.0)  
    - HCFA: RECURRENT RENAL CALCULI WITH PROCEDURAL INTERVENTION  

    Medications:  
    - Ciprofloxacin 500 mg PO BID × 7 days (post-procedure prophylaxis)  
    - Tamsulosin 0.4 mg PO daily × 14 days  
    - Hydrocodone-Acetaminophen 5-325 mg PO Q6H PRN pain  
    - Sodium Chloride 0.9% Flush IV PRN hydration  
    - Multivitamin PO daily  

    Orders:  
    - Follow-up KUB X-ray ordered, Completed — Stone fragments absent  
    - Serum creatinine ordered, Completed — Normal at 1.0 mg/dL  
    - Stent removal scheduled, Completed — Outpatient procedure after 7 days  
    - 24-hour urine collection ordered, Completed — Elevated calcium levels detected  
    - Diet modification counseling ordered, Completed — Low-oxalate diet recommended  

    Procedures:  
    - Ureteral stent successfully removed  
    - Post-procedure ultrasound performed — No residual stones  
    - Outpatient dietary counseling session completed  


Patient 50001293  
Gender: Male  
Age: 52  
Race: WHITE  

Admission 18024317  
    DRGs:  
    - APR: ACUTE RENAL COLIC WITHOUT OBSTRUCTION (Severity 2.0)  
    - HCFA: RENAL CALCULI W/O CC/MCC  

    Medications:  
    - Ketorolac 30mg IV  
    - Morphine 2mg IV PRN  
    - Ondansetron IV  
    - Tamsulosin 0.4mg PO  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Influenza Vaccine Quadrivalent  

    Orders:  
    - Ketorolac IV: IV, Discontinued via patient discharge  
    - Morphine IV: IV, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Tamsulosin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Non-contrast CT abdomen/pelvis  
    - Urinalysis with microscopy  
    - Serum creatinine and electrolytes monitoring  

Admission 18201984  
    DRGs:  
    - APR: RENAL COLIC WITH URETERAL OBSTRUCTION (Severity 3.0)  
    - HCFA: URINARY OBSTRUCTION W CC  

    Medications:  
    - Ketorolac 30mg IV  
    - Hydromorphone 0.5mg IV PRN  
    - Ondansetron IV  
    - Tamsulosin 0.4mg PO  
    - Ceftriaxone 1g IV  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  

    Orders:  
    - Ketorolac IV: IV, Discontinued via patient discharge  
    - Hydromorphone IV: IV, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Tamsulosin PO: PO, Discontinued via patient discharge  
    - Ceftriaxone IV: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - CT urogram  
    - Cystoscopy with diagnostic evaluation  
    - IV hydration and pain management  
    - Serum creatinine monitoring  

Admission 18352749  
    DRGs:  
    - APR: COMPLICATED RENAL COLIC WITH SEVERE OBSTRUCTION (Severity 4.0)  
    - HCFA: URETERAL OBSTRUCTION W MCC  

    Medications:  
    - Hydromorphone 1mg IV  
    - Ketorolac 30mg IV  
    - Ondansetron IV  
    - Cefepime 2g IV  
    - Tamsulosin 0.4mg PO  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  
    - Phenazopyridine 200mg PO  

    Orders:  
    - Hydromorphone IV: IV, Discontinued via patient discharge  
    - Ketorolac IV: IV, Discontinued via patient discharge  
    - Ondansetron IV: IV, Discontinued via patient discharge  
    - Cefepime IV: IV, Discontinued via patient discharge  
    - Tamsulosin PO: PO, Discontinued via patient discharge  
    - Phenazopyridine PO: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Ureteroscopy with laser lithotripsy  
    - Double-J stent placement  
    - Ultrasound-guided hydration monitoring  
    - Follow-up renal ultrasound for resolution of obstruction


Patient 60001293  
Gender: Female  
Age: 29  
Race: ASIAN  

Admission 88321017  
    DRGs:  
    - APR: ATOPIC DERMATITIS FLARE REQUIRING SYSTEMIC THERAPY (Severity 2.0)  
    - HCFA: ATOPIC DERMATITIS — ACUTE EXACERBATION WITHOUT INFECTION  

    Medications:  
    - Hydrocortisone 2.5% topical cream BID × 7 days  
    - Cetirizine 10 mg PO daily PRN itching  
    - Aquaphor emollient topical BID  
    - Sodium Chloride 0.9% Flush IV PRN hydration  
    - Influenza Vaccine Quadrivalent IM  

    Orders:  
    - Skin hydration protocol ordered, Completed  
    - Allergy panel testing ordered, Completed — Positive for dust mites and grass pollen  
    - Topical steroid taper counseling ordered, Completed  
    - Dermatology follow-up ordered, Scheduled for 2 weeks  
    - Avoidance education ordered, Completed  

    Procedures:  
    - Patch testing performed — Negative for contact allergens  

---

Admission 88321845  
    DRGs:  
    - APR: ATOPIC DERMATITIS WITH SECONDARY INFECTION (Severity 3.0)  
    - HCFA: INFECTED ECZEMA REQUIRING ORAL ANTIBIOTICS  

    Medications:  
    - Triamcinolone 0.1% topical ointment BID × 10 days  
    - Cephalexin 500 mg PO Q6H × 7 days  
    - Diphenhydramine 25 mg PO QHS PRN itching  
    - Moisturizing barrier cream topical TID  
    - Ibuprofen 400 mg PO Q6H PRN inflammation  

    Orders:  
    - Wound culture ordered, Completed — Staphylococcus aureus, methicillin-sensitive  
    - CBC and CRP ordered, Completed — Elevated CRP, mild leukocytosis  
    - Dermatology referral ordered, Completed — Telemedicine review performed  
    - Education on bleach bath protocol ordered, Completed  
    - Antihistamine counseling ordered, Completed  

    Procedures:  
    - Wound swab culture obtained  
    - Wet-wrap therapy initiated for severe lesions  

---

Admission 88322592  
    DRGs:  
    - APR: CHRONIC MODERATE ATOPIC DERMATITIS — SYSTEMIC ESCALATION (Severity 3.0)  
    - HCFA: REFRACTORY ATOPIC DERMATITIS MANAGEMENT WITH BIOLOGICS  

    Medications:  
    - Dupilumab 300 mg SC Q2 weeks × 6 months  
    - Tacrolimus 0.1% topical ointment BID  
    - Hydroxyzine 25 mg PO QHS for pruritus  
    - Vitamin D3 supplement 2000 IU daily  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Baseline IgE levels ordered, Completed — Elevated at 520 IU/mL  
    - Chest X-ray ordered, Completed — Normal, cleared for biologic therapy  
    - Dupilumab initiation counseling ordered, Completed  
    - Patient enrolled in eczema biologic registry, Completed  
    - Follow-up dermatology evaluation ordered, Scheduled at 6 weeks  

    Procedures:  
    - Subcutaneous Dupilumab loading dose administered  
    - Biologic injection technique education session completed  


Patient 10001294  
Gender: Male  
Age: 67  
Race: WHITE  

Admission 88561432  
    DRGs:  
    - APR: ACUTE ON CHRONIC SYSTOLIC HEART FAILURE WITH RESPIRATORY DISTRESS (Severity 3.0)  
    - HCFA: HEART FAILURE & SHOCK W MCC  

    Medications:  
    - Furosemide 80 mg IV BID  
    - Carvedilol 12.5 mg PO BID  
    - Lisinopril 10 mg PO daily  
    - Spironolactone 25 mg PO daily  
    - Potassium Chloride 40 mEq PO daily  
    - Aspirin 81 mg PO daily  
    - Atorvastatin 40 mg PO QHS  

    Orders:  
    - Echocardiogram ordered, Completed — EF 25%, global hypokinesis  
    - BNP ordered, Completed — Elevated at 2120 pg/mL  
    - Continuous telemetry ordered, Ongoing  
    - Daily weights ordered, Ongoing  
    - Low-sodium diet ordered, Ongoing  
    - Cardiology consult ordered, Completed  

    Procedures:  
    - Chest X-ray performed — Pulmonary vascular congestion  
    - IV diuresis initiated  
    - Supplemental O₂ via nasal cannula started  

---

Admission 88562357  
    DRGs:  
    - APR: ACUTE DECOMPENSATED HEART FAILURE WITH WORSENING RENAL FUNCTION (Severity 4.0)  
    - HCFA: HEART FAILURE W CC + ACUTE KIDNEY INJURY  

    Medications:  
    - Furosemide infusion at 10 mg/hr IV  
    - Metoprolol Succinate 25 mg PO daily  
    - Sacubitril/Valsartan 24/26 mg PO BID  
    - Spironolactone 25 mg PO daily  
    - Dapagliflozin 10 mg PO daily  
    - Heparin 5000 units SC Q8H prophylaxis  
    - Acetaminophen 650 mg PO Q6H PRN  

    Orders:  
    - Renal panel ordered, Completed — BUN 42, Creatinine 1.8 mg/dL  
    - Strict intake/output monitoring ordered, Ongoing  
    - BNP ordered, Completed — Elevated at 3100 pg/mL  
    - Sleep apnea screening ordered, Completed  
    - Dietitian consult ordered, Completed — Heart failure diet reinforced  

    Procedures:  
    - Non-invasive positive pressure ventilation started for acute hypoxia  
    - Right heart catheterization performed — Elevated pulmonary wedge pressure  
    - Ultrasound-guided IV line placed  

---

Admission 88564021  
    DRGs:  
    - APR: CHRONIC SYSTOLIC HEART FAILURE EXACERBATION REQUIRING ADVANCED THERAPY (Severity 4.0)  
    - HCFA: REFRACTORY HEART FAILURE WITH PULMONARY HYPERTENSION  

    Medications:  
    - Dobutamine infusion at 5 mcg/kg/min IV  
    - Sacubitril/Valsartan 49/51 mg PO BID  
    - Spironolactone 25 mg PO daily  
    - Furosemide 80 mg IV BID  
    - Ivabradine 5 mg PO BID  
    - Empagliflozin 10 mg PO daily  
    - Magnesium Sulfate 2g IV once  

    Orders:  
    - Cardiac MRI ordered, Completed — Extensive LV remodeling  
    - Palliative care consult ordered, Completed — Discussed advanced heart failure management  
    - Evaluation for LVAD candidacy ordered, Completed  
    - 6-minute walk test ordered, Completed — Marked exercise limitation  
    - Advanced heart failure clinic follow-up ordered, Scheduled  

    Procedures:  
    - Dobutamine stress echocardiogram performed — EF remained at 22%  
    - Swan-Ganz catheter placed for hemodynamic monitoring  
    - Oxygen therapy escalated to high-flow nasal cannula  


Patient 20001294  
Gender: Male  
Age: 70  
Race: BLACK/AFRICAN AMERICAN  

Admission 89342115  
    DRGs:  
    - APR: ACUTE ON CHRONIC SYSTOLIC HEART FAILURE WITH RESPIRATORY DECOMPENSATION (Severity 3.0)  
    - HCFA: HEART FAILURE & SHOCK W MCC  

    Medications:  
    - Furosemide 80 mg IV BID  
    - Carvedilol 6.25 mg PO BID  
    - Lisinopril 5 mg PO daily  
    - Spironolactone 25 mg PO daily  
    - Potassium Chloride 40 mEq PO daily  
    - Atorvastatin 40 mg PO QHS  
    - Aspirin 81 mg PO daily  

    Orders:  
    - Echocardiogram ordered, Completed — EF 30%, global hypokinesis  
    - BNP ordered, Completed — 1950 pg/mL  
    - Cardiology consult ordered, Completed  
    - Continuous telemetry ordered, Ongoing  
    - Daily weights and strict intake/output monitoring ordered, Ongoing  
    - 2g sodium restriction and 1.5L fluid restriction ordered  

    Procedures:  
    - Chest X-ray performed — Cardiomegaly with pulmonary edema  
    - IV diuresis initiated  
    - Oxygen therapy started via nasal cannula  

---

Admission 89342877  
    DRGs:  
    - APR: ACUTE DECOMPENSATED HEART FAILURE WITH CONCURRENT RENAL DYSFUNCTION (Severity 4.0)  
    - HCFA: ACUTE ON CHRONIC HEART FAILURE W CC & KIDNEY IMPAIRMENT  

    Medications:  
    - Furosemide infusion at 10 mg/hr IV  
    - Sacubitril/Valsartan 24/26 mg PO BID  
    - Metoprolol Succinate 25 mg PO daily  
    - Spironolactone 25 mg PO daily  
    - Empagliflozin 10 mg PO daily  
    - Heparin 5000 units SC Q8H prophylaxis  
    - Acetaminophen 650 mg PO Q6H PRN  

    Orders:  
    - Renal function panel ordered, Completed — BUN 46, Creatinine 1.9 mg/dL  
    - BNP ordered, Completed — 2840 pg/mL  
    - Strict fluid balance and daily labs ordered, Ongoing  
    - Nephrology consult ordered, Completed  
    - Heart failure education session ordered, Completed  

    Procedures:  
    - Right heart catheterization performed — Elevated PCWP 28 mmHg  
    - Non-invasive positive pressure ventilation started  
    - IV access upgraded to midline catheter  

---

Admission 89343520  
    DRGs:  
    - APR: ADVANCED SYSTOLIC HEART FAILURE WITH REFRACTORY SYMPTOMS (Severity 4.0)  
    - HCFA: CHRONIC SYSTOLIC HEART FAILURE WORSENING — LVAD EVALUATION  

    Medications:  
    - Dobutamine infusion at 5 mcg/kg/min IV  
    - Sacubitril/Valsartan 49/51 mg PO BID  
    - Furosemide 80 mg IV TID  
    - Spironolactone 25 mg PO daily  
    - Ivabradine 5 mg PO BID  
    - Empagliflozin 10 mg PO daily  
    - Magnesium Sulfate 2g IV once  

    Orders:  
    - Cardiac MRI ordered, Completed — Marked LV dilation, EF 22%  
    - Evaluation for LVAD candidacy ordered, Completed  
    - Palliative care consult ordered, Completed  
    - Dietary sodium restriction reinforced, Ongoing  
    - 6-minute walk test ordered, Completed — Severe limitation  

    Procedures:  
    - Dobutamine stress echocardiogram performed — EF remained at 20%  
    - Swan-Ganz catheter inserted for hemodynamic monitoring  
    - Oxygen therapy escalated to high-flow nasal cannula  


Patient 30001294  
Gender: Male  
Age: 73  
Race: WHITE  

Admission 77451236  
    DRGs:  
    - APR: UNSPECIFIED HEART FAILURE EXACERBATION (Severity 2.0)  
    - HCFA: HEART FAILURE, UNSPECIFIED W CC  

    Medications:  
    - Furosemide 40 mg IV BID  
    - Lisinopril 10 mg PO daily  
    - Metoprolol Tartrate 25 mg PO BID  
    - Spironolactone 25 mg PO daily  
    - Aspirin 81 mg PO daily  
    - Atorvastatin 20 mg PO QHS  
    - Potassium Chloride 20 mEq PO daily  

    Orders:  
    - BNP ordered, Completed — 950 pg/mL  
    - Echocardiogram ordered, Completed — EF 45%  
    - Continuous telemetry monitoring ordered, Ongoing  
    - Daily weights and strict fluid balance monitoring ordered  
    - 2g sodium restriction and 1.5L fluid restriction ordered  
    - Cardiology consult ordered, Completed  

    Procedures:  
    - Chest X-ray performed — Mild pulmonary edema  
    - IV diuresis initiated  
    - Oxygen via nasal cannula started  

---

Admission 77452690  
    DRGs:  
    - APR: RECURRENT HEART FAILURE EXACERBATION WITH DYSPNEA (Severity 3.0)  
    - HCFA: UNSPECIFIED HEART FAILURE WORSENING  

    Medications:  
    - Furosemide infusion 8 mg/hr IV  
    - Sacubitril/Valsartan 24/26 mg PO BID  
    - Metoprolol Succinate 50 mg PO daily  
    - Spironolactone 25 mg PO daily  
    - Dapagliflozin 10 mg PO daily  
    - Heparin 5000 units SC Q8H prophylaxis  
    - Acetaminophen 650 mg PO Q6H PRN  

    Orders:  
    - BNP ordered, Completed — 1600 pg/mL  
    - Basic metabolic panel ordered, Completed — Mild hyponatremia at 131 mmol/L  
    - Cardiology follow-up ordered, Completed  
    - 24-hour urine output monitoring ordered, Ongoing  
    - Low-sodium diet reinforced, Ongoing  
    - Advanced care planning discussion scheduled, Pending  

    Procedures:  
    - Non-invasive positive pressure ventilation initiated for dyspnea  
    - Ultrasound-guided IV line placement performed  
    - Cardiac stress test ordered, Completed — Ischemia ruled out  

---

Admission 77453344  
    DRGs:  
    - APR: CHRONIC HEART FAILURE WITH MULTIFACTORIAL DECOMPENSATION (Severity 3.0)  
    - HCFA: UNSPECIFIED HEART FAILURE — PROGRESSIVE SYMPTOMS  

    Medications:  
    - Furosemide 80 mg IV BID  
    - Sacubitril/Valsartan 49/51 mg PO BID  
    - Ivabradine 5 mg PO BID  
    - Empagliflozin 10 mg PO daily  
    - Spironolactone 25 mg PO daily  
    - Magnesium Sulfate 2g IV once  
    - Aspirin 81 mg PO daily  

    Orders:  
    - Cardiac MRI ordered, Completed — EF 35%, moderate global hypokinesis  
    - Advanced heart failure clinic referral ordered, Completed  
    - Daily weights and input/output monitoring ordered  
    - Telemetry monitoring ordered, Ongoing  
    - Education on fluid and sodium management provided  

    Procedures:  
    - Swan-Ganz catheter inserted for hemodynamic monitoring  
    - Dobutamine stress echocardiogram performed — EF remained stable  
    - Oxygen therapy escalated to high-flow nasal cannula  


Patient 40001294  
Gender: Male  
Age: 68  
Race: WHITE  

Admission 67215432  
    DRGs:  
    - APR: ATHEROSCLEROTIC HEART DISEASE WITHOUT ANGINA — INITIAL MANAGEMENT (Severity 1.0)  
    - HCFA: CORONARY ATHEROSCLEROSIS W/O ACUTE CORONARY SYNDROME  

    Medications:  
    - Atorvastatin 40 mg PO QHS  
    - Aspirin 81 mg PO daily  
    - Metoprolol Succinate 25 mg PO daily  
    - Lisinopril 10 mg PO daily  
    - Nitroglycerin 0.4 mg SL PRN chest discomfort  
    - Omega-3 Acid Ethyl Esters 2g PO daily  

    Orders:  
    - Lipid panel ordered, Completed — LDL 152 mg/dL  
    - ECG ordered, Completed — Normal sinus rhythm  
    - Cardiology referral ordered, Completed  
    - Dietary consult ordered, Completed  
    - 6-month follow-up stress testing scheduled  

    Procedures:  
    - Transthoracic echocardiogram performed — EF 55%, no wall motion abnormality  
    - Carotid duplex ultrasound performed — No significant stenosis  

---

Admission 67216218  
    DRGs:  
    - APR: ATHEROSCLEROSIS WITH HIGH CARDIOVASCULAR RISK FACTORS (Severity 2.0)  
    - HCFA: CORONARY ATHEROSCLEROSIS W MULTIPLE CO-MORBIDITIES  

    Medications:  
    - Rosuvastatin 20 mg PO QHS  
    - Aspirin 81 mg PO daily  
    - Metoprolol Succinate 50 mg PO daily  
    - Ezetimibe 10 mg PO daily  
    - Lisinopril 20 mg PO daily  
    - Empagliflozin 10 mg PO daily  

    Orders:  
    - CT coronary calcium scoring ordered, Completed — Agatston score 230  
    - HbA1c ordered, Completed — 7.1%  
    - Nutrition counseling for heart-healthy diet provided, Completed  
    - Smoking cessation program referral ordered, Completed  
    - Annual cardiology surveillance visit scheduled  

    Procedures:  
    - Coronary CT angiography performed — Mild diffuse coronary plaque, no obstruction  
    - Carotid intima-media thickness (IMT) study performed for vascular risk profiling  

---

Admission 67217893  
    DRGs:  
    - APR: ADVANCED ATHEROSCLEROTIC HEART DISEASE MANAGEMENT (Severity 3.0)  
    - HCFA: CHRONIC CORONARY ARTERY DISEASE — MULTIPLE INTERVENTION PLANNING  

    Medications:  
    - Rosuvastatin 40 mg PO QHS  
    - Aspirin 81 mg PO daily  
    - Clopidogrel 75 mg PO daily  
    - Metoprolol Succinate 50 mg PO daily  
    - Lisinopril 20 mg PO daily  
    - Ezetimibe 10 mg PO daily  
    - Nitroglycerin 0.4 mg SL PRN  

    Orders:  
    - Stress echocardiogram ordered, Completed — Mild inferior hypokinesis, no ischemia  
    - High-sensitivity CRP ordered, Completed — 5.8 mg/L (elevated)  
    - Repeat coronary risk stratification ordered, Completed  
    - Education on medication adherence and lifestyle modification provided  
    - Cardiovascular rehab referral ordered, Completed  

    Procedures:  
    - Coronary calcium score re-evaluated — Increased to 290  
    - Non-invasive fractional flow reserve CT performed — No hemodynamically significant lesions  
    - Exercise treadmill test performed — Low-risk Duke treadmill score  


Patient 50001294  
Gender: Male  
Age: 58  
Race: WHITE  

Admission 19054231  
    DRGs:  
    - APR: HYPERLIPIDEMIA WITHOUT COMPLICATIONS (Severity 1.0)  
    - HCFA: LIPID METABOLISM DISORDERS W/O CC/MCC  

    Medications:  
    - Atorvastatin 20mg PO  
    - Aspirin 81mg PO  
    - Sodium Chloride 0.9% Flush  
    - Vitamin D3 Supplement  
    - Influenza Vaccine Quadrivalent  
    - Acetaminophen  

    Orders:  
    - Atorvastatin: PO, Discontinued via patient discharge  
    - Aspirin 81mg: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Vitamin D3 Supplement: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Fasting lipid panel  
    - HbA1c screening  
    - Dietitian counseling on low-fat diet  

Admission 19185762  
    DRGs:  
    - APR: MIXED HYPERLIPIDEMIA WITH CARDIOVASCULAR RISK (Severity 2.0)  
    - HCFA: LIPID METABOLISM DISORDERS W CC  

    Medications:  
    - Rosuvastatin 10mg PO  
    - Ezetimibe 10mg PO  
    - Aspirin 81mg PO  
    - Fish Oil 1g PO  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  

    Orders:  
    - Rosuvastatin: PO, Discontinued via patient discharge  
    - Ezetimibe: PO, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Fish Oil Supplement: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Echocardiogram for CV risk assessment  
    - Exercise stress test  
    - Dietary consultation with cholesterol reduction planning  

Admission 19309217  
    DRGs:  
    - APR: SEVERE HYPERLIPIDEMIA WITH ORGAN COMPLICATIONS (Severity 3.0)  
    - HCFA: LIPID METABOLISM DISORDERS W MCC  

    Medications:  
    - Rosuvastatin 20mg PO  
    - Evolocumab (Repatha) 140mg SC every 2 weeks  
    - Aspirin 81mg PO  
    - Omega-3 Fatty Acids 2g PO  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  

    Orders:  
    - Rosuvastatin: PO, Discontinued via patient discharge  
    - Evolocumab: SC, Discontinued via patient discharge  
    - Aspirin: PO, Discontinued via patient discharge  
    - Omega-3 Fatty Acids: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Coronary CT angiography  
    - Carotid Doppler ultrasound for plaque burden  
    - Advanced lipid fractionation testing  
    - Referral to lipid specialist for long-term management


Patient 60001294  
Gender: Male  
Age: 34  
Race: WHITE  

Admission 89342107  
    DRGs:  
    - APR: ACUTE APPENDICITIS WITHOUT PERFORATION OR PERITONITIS (Severity 2.0)  
    - HCFA: SIMPLE APPENDECTOMY W/O COMPLICATIONS  

    Medications:  
    - Ceftriaxone 2 g IV q24h  
    - Metronidazole 500 mg IV q8h  
    - Acetaminophen 650 mg PO q6h PRN  
    - Ondansetron 4 mg IV q8h PRN  
    - Sodium Chloride 0.9% IV fluids at 100 mL/hr  

    Orders:  
    - CT Abdomen/Pelvis with contrast ordered, Completed — Findings consistent with acute appendicitis  
    - NPO status ordered pre-operatively  
    - Surgical consult ordered, Completed  
    - Pre-operative labs ordered, Completed — WBC 14.8K  
    - Sequential compression devices for DVT prophylaxis ordered  
    - Post-operative pain control with IV acetaminophen and oxycodone ordered  

    Procedures:  
    - Laparoscopic appendectomy performed successfully  
    - Pathology confirmed inflamed appendix without perforation  
    - Post-op wound care provided  

---

Admission 89343215  
    DRGs:  
    - APR: POST-OPERATIVE SURVEILLANCE AND INFECTION PREVENTION (Severity 1.0)  
    - HCFA: ROUTINE FOLLOW-UP AFTER APPENDECTOMY  

    Medications:  
    - Amoxicillin-Clavulanate 875 mg PO BID for 5 days  
    - Acetaminophen 650 mg PO q6h PRN  
    - Ibuprofen 400 mg PO q8h PRN  
    - Ondansetron 4 mg PO q8h PRN  

    Orders:  
    - Follow-up wound inspection scheduled, Completed — No erythema or drainage  
    - Post-op diet advancement ordered, Completed  
    - Outpatient follow-up visit scheduled for suture removal in 10 days  
    - Return-to-work clearance provided after 2 weeks  
    - Activity restriction order — No lifting >10 lbs for 4 weeks  

    Procedures:  
    - Suture removal performed at follow-up  
    - Abdominal ultrasound at 2 weeks — No post-op abscess or fluid collection  

---

Admission 89344981  
    DRGs:  
    - APR: UNCOMPLICATED ABDOMINAL PAIN EVALUATION POST-SURGERY (Severity 1.0)  
    - HCFA: OBSERVATION FOR POSSIBLE POST-OPERATIVE COMPLICATION  

    Medications:  
    - IV Fluids: Lactated Ringer’s at 75 mL/hr  
    - Ondansetron 4 mg IV PRN  
    - Ketorolac 15 mg IV q6h PRN  

    Orders:  
    - CT Abdomen ordered, Completed — No intra-abdominal collection, normal post-op changes  
    - Basic metabolic panel ordered, Completed — Within normal limits  
    - Observed for 24 hours for possible post-op ileus  
    - Discharged with instructions to return if fever, worsening pain, or drainage  

    Procedures:  
    - Repeat abdominal exam performed — Soft, non-tender  
    - No intervention required  


Patient 10001295  
Gender: Female  
Age: 64  
Race: WHITE  

Admission 78124560  
    DRGs:  
    - APR: METABOLIC ENCEPHALOPATHY — ACUTE EPISODE MANAGEMENT (Severity 3.0)  
    - HCFA: METABOLIC DISORDERS W MCC  

    Medications:  
    - Lactulose 30 mL PO Q6H  
    - Rifaximin 550 mg PO BID  
    - Sodium Bicarbonate 50 mEq IV Q8H  
    - Thiamine 100 mg IV daily  
    - Potassium Chloride 20 mEq IV PRN hypokalemia  
    - Furosemide 20 mg IV daily  
    - Sodium Chloride 0.9% IV fluids at 75 mL/hr  
    - Insulin regular sliding scale for hyperglycemia  

    Orders:  
    - Comprehensive metabolic panel ordered, Completed — Ammonia 122 µmol/L, Na+ 128 mmol/L  
    - Arterial blood gas ordered, Completed — pH 7.28, HCO₃ 17  
    - Neurology consult ordered, Completed  
    - Non-contrast CT Head ordered, Completed — No acute intracranial process  
    - EEG ordered, Completed — Mild generalized slowing consistent with encephalopathy  
    - Initiate neuro checks q2h  
    - Strict I/O monitoring and daily weights  

    Procedures:  
    - Central venous catheter placement for IV medication access  
    - Non-invasive brain monitoring during acute episode  

---

Admission 78125912  
    DRGs:  
    - APR: METABOLIC ENCEPHALOPATHY WITH ELECTROLYTE DERANGEMENTS (Severity 2.0)  
    - HCFA: COMPLICATED METABOLIC DISORDERS W/O RENAL FAILURE  

    Medications:  
    - Lactulose 30 mL PO TID  
    - Rifaximin 550 mg PO BID  
    - Magnesium Sulfate 2g IV PRN  
    - Vitamin B12 1000 mcg IM weekly  
    - Sodium Chloride 0.9% IV bolus PRN dehydration  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Ondansetron 4 mg IV Q8H PRN nausea  

    Orders:  
    - Repeat ammonia levels ordered, Completed — Improved to 78 µmol/L  
    - MRI Brain ordered, Completed — No structural abnormalities  
    - Glucose monitoring Q6H ordered  
    - Dietitian consult ordered, Completed  
    - Liver function panel ordered, Completed — ALT 68, AST 72  

    Procedures:  
    - Continuous EEG monitoring for 24 hours  
    - Bedside swallow study performed — Safe for oral intake  

---

Admission 78127145  
    DRGs:  
    - APR: POST-ACUTE FOLLOW-UP OF METABOLIC ENCEPHALOPATHY (Severity 1.0)  
    - HCFA: OBSERVATION AND COGNITIVE RECOVERY MANAGEMENT  

    Medications:  
    - Lactulose 20 mL PO BID  
    - Rifaximin 550 mg PO daily  
    - Thiamine 100 mg PO daily  
    - Multivitamin PO daily  

    Orders:  
    - Neurocognitive testing ordered, Completed — Mild residual short-term memory impairment  
    - Discharge referral to outpatient neurology ordered, Completed  
    - Sleep hygiene counseling provided, Completed  
    - Diet modified to low-protein regimen per hepatology recommendations  

    Procedures:  
    - Outpatient EEG follow-up performed — Normalized background activity  
    - Repeat cognitive evaluation performed at 3 weeks  


Patient 20001295  
Gender: Male  
Age: 68  
Race: WHITE  

Admission 77483210  
    DRGs:  
    - APR: METABOLIC ENCEPHALOPATHY WITH ACUTE ORGAN DYSFUNCTION (Severity 4.0)  
    - HCFA: METABOLIC DISORDERS W MCC  

    Medications:  
    - Lactulose 30 mL PO Q6H  
    - Rifaximin 550 mg PO BID  
    - Sodium Bicarbonate 50 mEq IV Q8H  
    - Potassium Chloride 20 mEq IV PRN hypokalemia  
    - Thiamine 100 mg IV daily  
    - Furosemide 20 mg IV daily  
    - Sodium Chloride 0.9% IV fluids at 75 mL/hr  
    - Insulin regular sliding scale for hyperglycemia  
    - Ceftriaxone 1 g IV Q24H (empiric for possible infection)  

    Orders:  
    - Comprehensive metabolic panel ordered, Completed — Ammonia 135 µmol/L, Na+ 124 mmol/L, Creatinine 1.8 mg/dL  
    - Arterial blood gas ordered, Completed — pH 7.25, HCO₃ 15  
    - Non-contrast CT Head ordered, Completed — No acute intracranial process  
    - EEG ordered, Completed — Generalized slowing, consistent with encephalopathy  
    - Blood cultures ordered, Completed — Negative  
    - Initiate neuro checks q1h during acute phase  
    - Strict I/O monitoring, Foley catheter placed  
    - Cardiology consult ordered, Completed — Ruled out cardiogenic contribution  

    Procedures:  
    - Central venous catheter placed for IV access  
    - Non-invasive brain monitoring performed  
    - Nasogastric tube inserted for lactulose administration  

---

Admission 77484592  
    DRGs:  
    - APR: METABOLIC ENCEPHALOPATHY WITH ELECTROLYTE DERANGEMENTS (Severity 3.0)  
    - HCFA: METABOLIC DISORDERS W/O RESPIRATORY FAILURE  

    Medications:  
    - Lactulose 30 mL PO TID  
    - Rifaximin 550 mg PO BID  
    - Magnesium Sulfate 2g IV PRN  
    - Vitamin B12 1000 mcg IM weekly  
    - Sodium Chloride 0.9% IV bolus PRN dehydration  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Ondansetron 4 mg IV Q8H PRN nausea  
    - Metoprolol 25 mg PO BID for rate control  

    Orders:  
    - Repeat ammonia levels ordered, Completed — Improved to 88 µmol/L  
    - MRI Brain ordered, Completed — No acute ischemia  
    - Glucose monitoring Q6H ordered  
    - Dietitian consult ordered, Completed  
    - Liver function panel ordered, Completed — ALT 54, AST 62  
    - Sodium correction protocol initiated, Completed  

    Procedures:  
    - Continuous EEG monitoring for 36 hours  
    - Bedside swallow study performed — Cleared for soft solids  

---

Admission 77486104  
    DRGs:  
    - APR: POST-ACUTE FOLLOW-UP FOR METABOLIC ENCEPHALOPATHY (Severity 2.0)  
    - HCFA: COGNITIVE RECOVERY MANAGEMENT AND MONITORING  

    Medications:  
    - Lactulose 20 mL PO BID  
    - Rifaximin 550 mg PO daily  
    - Thiamine 100 mg PO daily  
    - Multivitamin PO daily  
    - Zinc Sulfate 220 mg PO daily  

    Orders:  
    - Neurocognitive testing ordered, Completed — Mild residual attention deficits  
    - Discharge referral to outpatient neurology ordered, Completed  
    - Sleep optimization and circadian hygiene counseling ordered, Completed  
    - Protein-restricted diet ordered per hepatology recommendations  
    - Physical therapy consult ordered for strength and balance evaluation  

    Procedures:  
    - Outpatient EEG follow-up performed — Normalized electrical activity  
    - Repeat ammonia level at 3-week follow-up — Stable at 42 µmol/L  
    - Cognitive rehabilitation therapy initiated  


Patient 30001295  
Gender: Male  
Age: 56  
Race: WHITE  

Admission 80431210  
    DRGs:  
    - APR: ANOXIC BRAIN DAMAGE — ACUTE CRITICAL CARE MANAGEMENT (Severity 4.0)  
    - HCFA: RESPIRATORY FAILURE W MCC  

    Medications:  
    - Mannitol 20% 100 mL IV Q6H (for cerebral edema)  
    - Levetiracetam 1 g IV Q12H (seizure prophylaxis)  
    - Midazolam infusion 2 mg/hr IV (sedation)  
    - Fentanyl infusion 50 mcg/hr IV (analgesia)  
    - Norepinephrine 0.05 mcg/kg/min IV (for blood pressure support)  
    - Sodium Chloride 3% IV continuous (hypertonic therapy for ICP control)  
    - Pantoprazole 40 mg IV daily (stress ulcer prophylaxis)  
    - Heparin 5000 U SC Q12H (DVT prophylaxis)  
    - Acetaminophen 650 mg PO/NG Q6H PRN fever  

    Orders:  
    - Non-contrast CT Head ordered, Completed — Diffuse hypoxic-ischemic injury noted  
    - Arterial blood gas ordered, Completed — pO₂ 42 mmHg pre-intubation  
    - EEG ordered, Completed — Burst-suppression pattern, consistent with severe injury  
    - Intubation performed, mechanical ventilation initiated  
    - Intracranial pressure monitoring ordered, Ongoing  
    - Neurology and critical care consultations ordered, Completed  
    - Serum lactate monitoring Q6H ordered  
    - Maintain strict normothermia: Cooling blanket initiated  

    Procedures:  
    - Endotracheal intubation performed emergently  
    - Placement of intracranial pressure (ICP) monitor  
    - Central venous catheter insertion for vasoactive medications  
    - Therapeutic hypothermia initiated for 24 hours post-cardiac arrest  

---

Admission 80432477  
    DRGs:  
    - APR: POST-ACUTE CARE — ANOXIC BRAIN DAMAGE WITH SEVERE FUNCTIONAL IMPAIRMENT (Severity 3.0)  
    - HCFA: NEUROLOGICAL DISORDERS W CC  

    Medications:  
    - Levetiracetam 750 mg PO BID  
    - Baclofen 10 mg PO TID (for spasticity)  
    - Gabapentin 300 mg PO BID (neuropathic pain control)  
    - Amantadine 100 mg PO BID (neurostimulant for recovery)  
    - Enoxaparin 40 mg SC daily (DVT prophylaxis)  
    - Polyethylene Glycol 17g PO daily (bowel regimen)  

    Orders:  
    - MRI Brain ordered, Completed — Diffuse cortical atrophy, chronic hypoxic changes  
    - Speech and swallow evaluation ordered, Completed — PEG tube recommended  
    - Nutrition consult ordered, Completed — Initiated tube feeding formula  
    - Physical therapy evaluation ordered, Completed — Minimal voluntary motor recovery  
    - Occupational therapy evaluation ordered, Completed  
    - Neurobehavioral testing ordered, Completed — Profound deficits with minimal responsiveness  

    Procedures:  
    - Percutaneous endoscopic gastrostomy (PEG) tube placement  
    - Tracheostomy performed for prolonged ventilatory support  
    - Bedside bronchoscopy for secretion clearance  

---

Admission 80433902  
    DRGs:  
    - APR: LONG-TERM NEUROLOGICAL REHABILITATION AFTER ANOXIC INJURY (Severity 2.0)  
    - HCFA: REHABILITATION AND COGNITIVE RECOVERY FOLLOW-UP  

    Medications:  
    - Levetiracetam 500 mg PO BID  
    - Baclofen 5 mg PO BID  
    - Amantadine 100 mg PO daily  
    - Multivitamin daily  
    - Omega-3 fatty acids 2 g PO daily  

    Orders:  
    - Neurocognitive rehabilitation program ordered, Ongoing  
    - Outpatient EEG ordered, Completed — Slow background activity persists  
    - Pulmonary rehabilitation consult ordered, Completed  
    - Social work and palliative care consultations ordered, Completed  
    - Caregiver training ordered for family  

    Procedures:  
    - Wheelchair mobility assessment performed  
    - Repeat brain MRI performed — Stable chronic injury  
    - Assistive communication device evaluation completed  


Patient 40001295  
Gender: Female  
Age: 42  
Race: WHITE  

Admission 68341210  
    DRGs:  
    - APR: SEIZURE DISORDERS — ACUTE MANAGEMENT (Severity 3.0)  
    - HCFA: EPILEPSY & CONVULSIONS W CC  

    Medications:  
    - Lorazepam 2 mg IV PRN seizure activity  
    - Levetiracetam 1 g IV loading dose, then 500 mg PO BID  
    - Phenytoin 100 mg IV Q8H (bridging until levetiracetam stabilized)  
    - Sodium Chloride 0.9% IV fluids at 75 mL/hr  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Heparin 5000 U SC Q12H (DVT prophylaxis)  

    Orders:  
    - EEG ordered, Completed — Abnormal with focal epileptiform discharges  
    - Non-contrast CT Head ordered, Completed — No acute hemorrhage  
    - Basic metabolic panel ordered, Completed — Na+ 138 mmol/L, Glucose 104 mg/dL  
    - Serum phenytoin levels ordered, Completed — 12 mcg/mL  
    - Initiate seizure precautions: padded bedrails, neuro checks Q1H  
    - Neurology consult ordered, Completed  
    - Continuous cardiac monitoring initiated  

    Procedures:  
    - Video EEG monitoring performed for 24 hours  
    - Peripheral IV line placed for anti-epileptic infusions  

---

Admission 68342879  
    DRGs:  
    - APR: ELECTIVE SEIZURE CONTROL OPTIMIZATION (Severity 2.0)  
    - HCFA: SEIZURE DISORDERS W/O MCC  

    Medications:  
    - Levetiracetam 750 mg PO BID  
    - Lamotrigine 25 mg PO daily, titrated to BID after week 2  
    - Folic Acid 1 mg PO daily  
    - Vitamin D 2000 IU PO daily  
    - Melatonin 3 mg PO HS (for sleep hygiene)  

    Orders:  
    - Ambulatory EEG ordered, Completed — Improved baseline, no generalized seizure activity  
    - MRI Brain with contrast ordered, Completed — No structural abnormalities  
    - Patient education session ordered, Completed — Medication adherence and seizure triggers  
    - Driving restriction counseling ordered, Completed  
    - Sleep study referral ordered, Completed — Evaluated for possible nocturnal seizures  

    Procedures:  
    - Neurocognitive evaluation performed to assess memory and processing  
    - Outpatient seizure diary tracking initiated  

---

Admission 68344520  
    DRGs:  
    - APR: LONG-TERM FOLLOW-UP FOR EPILEPSY MANAGEMENT (Severity 1.0)  
    - HCFA: CHRONIC NEUROLOGICAL CARE W/O MCC  

    Medications:  
    - Levetiracetam 500 mg PO BID  
    - Lamotrigine 50 mg PO BID  
    - Multivitamin PO daily  
    - Omega-3 fatty acids 1 g PO daily  

    Orders:  
    - Neurology follow-up ordered, Completed — Stable seizure control  
    - Routine EEG ordered, Completed — Occasional focal discharges, no seizure correlation  
    - Psychiatric consult ordered, Completed — No depression, cleared for continued therapy  
    - Transition plan to outpatient epilepsy clinic ordered, Completed  

    Procedures:  
    - Outpatient EEG performed — Stable background activity  
    - Cognitive behavioral therapy initiated for stress-related seizure triggers  


Patient 50001295  
Gender: Female  
Age: 34  
Race: WHITE  

Admission 20018745  
    DRGs:  
    - APR: ACUTE HYPERAMMONEMIA SECONDARY TO UREA CYCLE DISORDER (Severity 3.0)  
    - HCFA: INBORN ERRORS OF METABOLISM W CC  

    Medications:  
    - Sodium Benzoate IV  
    - Arginine HCl IV  
    - Lactulose PO  
    - Levocarnitine PO  
    - Rifaximin PO  
    - Sodium Phenylbutyrate PO  
    - Ondansetron IV  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  

    Orders:  
    - Sodium Benzoate: IV infusion, Discontinued via patient discharge  
    - Arginine HCl: IV infusion, Discontinued via patient discharge  
    - Lactulose: PO, Discontinued via patient discharge  
    - Levocarnitine: PO, Discontinued via patient discharge  
    - Rifaximin: PO, Discontinued via patient discharge  
    - Sodium Phenylbutyrate: PO, Discontinued via patient discharge  
    - Ondansetron: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Plasma ammonia level monitoring every 6 hours  
    - Venous blood gas analysis  
    - High-protein restriction with calorie supplementation via NG tube  

Admission 20094362  
    DRGs:  
    - APR: UREA CYCLE DEFICIENCY WITH MODERATE CRISIS (Severity 2.0)  
    - HCFA: GENETIC DISORDERS OF METABOLISM W/O MCC  

    Medications:  
    - Sodium Phenylbutyrate PO  
    - Glycerol Phenylbutyrate PO  
    - L-Citrulline PO  
    - Levocarnitine PO  
    - Ondansetron IV  
    - Lactulose PO  
    - Sodium Chloride 0.9% Flush  
    - Acetaminophen  

    Orders:  
    - Sodium Phenylbutyrate: PO, Discontinued via patient discharge  
    - Glycerol Phenylbutyrate: PO, Discontinued via patient discharge  
    - L-Citrulline: PO, Discontinued via patient discharge  
    - Levocarnitine: PO, Discontinued via patient discharge  
    - Ondansetron: IV, Discontinued via patient discharge  
    - Lactulose: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Serial plasma amino acid monitoring  
    - MRI brain for metabolic encephalopathy  
    - Dietary consult with low-protein plan  

Admission 20164781  
    DRGs:  
    - APR: SEVERE UREA CYCLE CRISIS WITH HYPERAMMONEMIC ENCEPHALOPATHY (Severity 4.0)  
    - HCFA: INBORN ERRORS OF METABOLISM W MCC  

    Medications:  
    - Sodium Phenylbutyrate IV  
    - Sodium Benzoate IV  
    - Arginine HCl IV  
    - Levocarnitine PO  
    - Lactulose PO  
    - Mannitol IV  
    - Ondansetron IV  
    - Sodium Chloride 0.9% Flush  

    Orders:  
    - Sodium Phenylbutyrate: IV, Discontinued via patient discharge  
    - Sodium Benzoate: IV, Discontinued via patient discharge  
    - Arginine HCl: IV, Discontinued via patient discharge  
    - Levocarnitine: PO, Discontinued via patient discharge  
    - Lactulose: PO, Discontinued via patient discharge  
    - Mannitol: IV, Discontinued via patient discharge  
    - Ondansetron: IV, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  

    Procedures:  
    - Continuous renal replacement therapy (CRRT) for ammonia clearance  
    - PICC line placement for long-term medication infusion  
    - Genetic panel confirmation of OTC gene mutation  
    - Neurocognitive evaluation for metabolic encephalopathy


Patient 60001295  
Gender: Female  
Age: 28  
Race: ASIAN  

Admission 74589231  
    DRGs:  
    - APR: FULL-TERM UNCOMPLICATED VAGINAL DELIVERY (Severity 1.0)  
    - HCFA: NORMAL LABOR & DELIVERY W/O COMPLICATIONS  

    Medications:  
    - Oxytocin 20 units in 1,000 mL NS IV infusion (for labor augmentation)  
    - Fentanyl 50 mcg IV PRN during early labor  
    - Lidocaine 1% 10 mL epidural (for anesthesia)  
    - Acetaminophen 650 mg PO Q6H PRN pain  
    - Ibuprofen 600 mg PO Q6H PRN postpartum cramping  
    - Sodium Chloride 0.9% Flush IV PRN line maintenance  
    - Prenatal vitamins PO daily  
    - Rh immune globulin 300 mcg IM (administered if Rh-negative)  

    Orders:  
    - Non-stress test (NST) ordered, Completed — Reactive  
    - CBC and type & screen ordered, Completed — WNL  
    - Continuous fetal monitoring ordered, Ongoing  
    - Group B strep screen ordered, Completed — Negative  
    - Initiate spontaneous vaginal delivery protocol, Completed  
    - Skin-to-skin initiation immediately after delivery  
    - Breastfeeding consultation ordered, Completed  

    Procedures:  
    - Vaginal delivery performed — Full-term, healthy infant  
    - Delayed cord clamping performed  
    - Perineal inspection performed — First-degree laceration repaired with 3-0 Vicryl  
    - Immediate postpartum fundal massage performed  

---

Admission 74590852  
    DRGs:  
    - APR: POSTPARTUM OBSERVATION FOLLOWING VAGINAL DELIVERY (Severity 1.0)  
    - HCFA: ROUTINE POST-DELIVERY CARE W/O COMPLICATIONS  

    Medications:  
    - Ibuprofen 600 mg PO Q6H PRN uterine cramping  
    - Docusate sodium 100 mg PO BID PRN constipation  
    - Acetaminophen 650 mg PO Q6H PRN discomfort  
    - Ferrous sulfate 325 mg PO daily (for mild postpartum anemia)  
    - Prenatal vitamins PO daily  
    - Influenza vaccine IM prior to discharge  

    Orders:  
    - Vital signs Q4H ordered, Ongoing  
    - Fundal assessment ordered, Ongoing — Firm, midline  
    - Lactation consultation ordered, Completed — Breastfeeding established  
    - Postpartum education ordered, Completed — Safe sleep, bleeding precautions, pelvic rest  
    - Discharge instructions provided, Completed  

    Procedures:  
    - Postpartum perineal care performed  
    - Screening for postpartum depression initiated  
    - Infant car seat fit evaluation completed  

---

Admission 74601327  
    DRGs:  
    - APR: OUTPATIENT FOLLOW-UP FOR POSTPARTUM CARE (Severity 1.0)  
    - HCFA: ROUTINE MATERNAL CHECK, 6-WEEK POSTPARTUM VISIT  

    Medications:  
    - Prenatal vitamins PO daily  
    - Ibuprofen 400 mg PO PRN mild discomfort  
    - Norethindrone 0.35 mg PO daily (progestin-only contraception started)  

    Orders:  
    - Postpartum depression screening ordered, Completed — Negative  
    - Breast examination ordered, Completed — No masses, breastfeeding continues  
    - Blood pressure monitoring ordered, Completed — Stable  
    - Family planning counseling ordered, Completed  
    - Clearance to resume normal activities, Completed  

    Procedures:  
    - Routine pelvic exam performed — Uterus involuted, healing complete  
    - Pap smear performed per screening guidelines  
    - Infant weight check performed — Healthy growth  


Patient 10001296  
Gender: Male  
Age: 57  
Race: WHITE  

Admission 61278345  
    DRGs:  
    - APR: OBSTRUCTIVE UROPATHY WITH HYDRONEPHROSIS (Severity 3.0)  
    - HCFA: KIDNEY & URINARY TRACT OBSTRUCTION W CC  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV Q8H (empiric coverage for urinary obstruction infection risk)  
    - Tamsulosin 0.4 mg PO daily (to improve urinary flow)  
    - Ketorolac 15 mg IV Q6H PRN flank pain  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Sodium Chloride 0.9% IV fluids 125 mL/hr  
    - Ondansetron 4 mg IV Q8H PRN nausea  
    - Enoxaparin 40 mg SC daily (DVT prophylaxis)  

    Orders:  
    - CT Abdomen/Pelvis without contrast ordered, Completed — Right-sided severe hydronephrosis with proximal obstruction  
    - Renal ultrasound ordered, Completed — Confirmed obstruction at ureteropelvic junction  
    - Serum creatinine ordered, Completed — Elevated at 2.1 mg/dL  
    - Insert Foley catheter ordered, Completed — Initial drainage of 600 mL  
    - Urology consult ordered, Completed — Recommended urgent decompression  
    - IV antibiotics initiated before intervention  
    - NPO status ordered pre-procedure, Completed  

    Procedures:  
    - Right percutaneous nephrostomy tube placed for decompression  
    - Cystoscopic evaluation performed — Identified obstruction at ureteropelvic junction  

---

Admission 61280192  
    DRGs:  
    - APR: ELECTIVE UROLOGICAL STENT PLACEMENT (Severity 2.0)  
    - HCFA: URETERAL STENT INSERTION W/O MCC  

    Medications:  
    - Ciprofloxacin 400 mg IV Q12H (perioperative prophylaxis)  
    - Tamsulosin 0.4 mg PO daily  
    - Acetaminophen 650 mg PO Q6H PRN  
    - Oxycodone 5 mg PO Q4H PRN post-procedure pain  
    - Docusate sodium 100 mg PO BID PRN constipation  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Ureteral stent insertion ordered, Completed — Successful placement of double-J stent  
    - Post-stent urine culture ordered, Completed — No growth  
    - Serum electrolytes ordered, Completed — Normalized after decompression  
    - Foley catheter discontinued after stent placement  
    - Outpatient urology follow-up ordered, Scheduled at 2 weeks  
    - Patient education ordered, Completed — Instructions on stent care and follow-up  

    Procedures:  
    - Ureteral stent placement under fluoroscopic guidance  
    - Intraoperative retrograde pyelogram performed  

---

Admission 61281745  
    DRGs:  
    - APR: FOLLOW-UP FOR OBSTRUCTIVE UROPATHY (Severity 1.0)  
    - HCFA: ROUTINE UROLOGY VISIT FOR STENT REMOVAL  

    Medications:  
    - Tamsulosin 0.4 mg PO daily  
    - Ibuprofen 400 mg PO Q8H PRN mild discomfort  
    - Multivitamin PO daily  

    Orders:  
    - Ureteral stent removal ordered, Completed — Procedure tolerated well  
    - Repeat renal ultrasound ordered, Completed — Resolution of hydronephrosis  
    - Serum creatinine ordered, Completed — Improved to 1.0 mg/dL  
    - Urinalysis ordered, Completed — No hematuria, no infection  
    - Patient counseling ordered, Completed — Hydration, stone prevention, and monitoring plan  

    Procedures:  
    - Outpatient ureteral stent removal performed  
    - Ultrasound-guided renal assessment confirmed resolution  


Patient 20001296  
Gender: Female  
Age: 63  
Race: HISPANIC  

Admission 78124567  
    DRGs:  
    - APR: SEVERE HYDRONEPHROSIS WITH OBSTRUCTIVE UROPATHY (Severity 3.0)  
    - HCFA: URINARY TRACT OBSTRUCTION W CC  

    Medications:  
    - Ceftriaxone 1 g IV Q24H (empiric antibiotic for UTI risk)  
    - Tamsulosin 0.4 mg PO daily (to facilitate drainage)  
    - Ketorolac 15 mg IV Q6H PRN flank pain  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Sodium Chloride 0.9% IV fluids 100 mL/hr  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Enoxaparin 40 mg SC daily (DVT prophylaxis)  

    Orders:  
    - Non-contrast CT abdomen/pelvis ordered, Completed — Left-sided moderate hydronephrosis with distal ureteral obstruction  
    - Renal ultrasound ordered, Completed — Confirms obstruction  
    - Urinalysis and urine culture ordered, Completed — Positive for E. coli  
    - Foley catheter insertion ordered, Completed — 450 mL drained  
    - Urology consult ordered, Completed — Recommended urgent stent placement  
    - IV antibiotics initiated pre-procedure  
    - NPO status ordered before intervention  

    Procedures:  
    - Left retrograde ureteral stent placed to relieve obstruction  
    - Bladder irrigation performed post-procedure  

---

Admission 78126210  
    DRGs:  
    - APR: UROLOGICAL STONE MANAGEMENT WITH OBSTRUCTION (Severity 2.0)  
    - HCFA: URETEROSCOPIC STONE EXTRACTION W/O MCC  

    Medications:  
    - Levofloxacin 500 mg PO daily x 5 days (post-op prophylaxis)  
    - Tamsulosin 0.4 mg PO daily  
    - Ibuprofen 600 mg PO Q8H PRN post-procedure pain  
    - Acetaminophen 650 mg PO Q6H PRN  
    - Docusate sodium 100 mg PO BID PRN constipation  
    - Sodium Chloride 0.9% Flush IV PRN line care  

    Orders:  
    - Ureteroscopic laser lithotripsy ordered, Completed — 8 mm distal stone successfully fragmented and removed  
    - Ureteral stent exchanged during procedure  
    - Serum creatinine ordered, Completed — Improved to 1.2 mg/dL  
    - Post-op urine culture ordered, Completed — Negative  
    - Urology follow-up ordered, Scheduled in 3 weeks  
    - Patient education ordered, Completed — Hydration and dietary modifications  

    Procedures:  
    - Ureteroscopic stone removal with laser fragmentation  
    - Ureteral stent exchanged intraoperatively  

---

Admission 78128395  
    DRGs:  
    - APR: POST-STENT REMOVAL FOLLOW-UP (Severity 1.0)  
    - HCFA: ROUTINE UROLOGY VISIT, NO COMPLICATIONS  

    Medications:  
    - Tamsulosin 0.4 mg PO daily (continued temporarily)  
    - Multivitamin PO daily  
    - Ibuprofen 400 mg PO Q8H PRN mild discomfort  

    Orders:  
    - Ureteral stent removal ordered, Completed — No complications  
    - Renal ultrasound ordered, Completed — Normalized renal pelvis diameter  
    - Serum electrolytes ordered, Completed — Stable  
    - Urinalysis ordered, Completed — Clear, no hematuria or infection  
    - Patient counseling ordered, Completed — Kidney stone prevention and regular follow-up plan  

    Procedures:  
    - Outpatient ureteral stent removal performed  
    - Post-procedure ultrasound confirmed full resolution of hydronephrosis  


Patient 30001296  
Gender: Male  
Age: 61  
Race: WHITE  

Admission 71546281  
    DRGs:  
    - APR: HYDRONEPHROSIS WITH RENAL & URETERAL CALCULOUS OBSTRUCTION (Severity 3.0)  
    - HCFA: KIDNEY & URETERAL STONES WITH OBSTRUCTION W CC  

    Medications:  
    - Piperacillin-Tazobactam 4.5 g IV Q8H (empiric therapy due to possible obstruction-related infection)  
    - Tamsulosin 0.4 mg PO daily (to relax ureteral smooth muscle)  
    - Ketorolac 15 mg IV Q6H PRN severe flank pain  
    - Acetaminophen 650 mg PO Q6H PRN fever  
    - Sodium Chloride 0.9% IV fluids 125 mL/hr  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Enoxaparin 40 mg SC daily (DVT prophylaxis)  

    Orders:  
    - CT Abdomen/Pelvis ordered, Completed — Right-sided hydronephrosis with 9 mm proximal ureteral stone  
    - Urinalysis ordered, Completed — Moderate hematuria, positive leukocyte esterase  
    - Urine culture ordered, Completed — No significant growth  
    - Foley catheter insertion ordered, Completed — Initial drainage 350 mL  
    - Urology consult ordered, Completed — Recommended urgent stent placement  
    - IV fluids ordered, Started  
    - NPO status ordered pre-procedure, Completed  

    Procedures:  
    - Right retrograde ureteral stent insertion under fluoroscopic guidance  
    - Intraoperative cystoscopic evaluation performed  

---

Admission 71547293  
    DRGs:  
    - APR: URETEROSCOPIC STONE EXTRACTION WITH LASER (Severity 2.0)  
    - HCFA: URETEROSCOPIC CALCULI REMOVAL W/O MCC  

    Medications:  
    - Cefazolin 1 g IV perioperative  
    - Tamsulosin 0.4 mg PO daily  
    - Ibuprofen 600 mg PO Q8H PRN post-op pain  
    - Acetaminophen 650 mg PO Q6H PRN  
    - Oxycodone 5 mg PO Q6H PRN severe pain  
    - Sodium Chloride 0.9% Flush IV PRN  

    Orders:  
    - Ureteroscopic laser lithotripsy ordered, Completed — 9 mm stone fragmented successfully  
    - Post-op urine culture ordered, Completed — No bacterial growth  
    - Serum creatinine ordered, Completed — Improved to 1.1 mg/dL  
    - Foley catheter removed post-procedure, Completed  
    - Outpatient urology follow-up ordered, Scheduled at 2 weeks  

    Procedures:  
    - Ureteroscopic laser lithotripsy  
    - Stone fragments retrieved and sent for compositional analysis  

---

Admission 71549024  
    DRGs:  
    - APR: POST-STENT REMOVAL & RECOVERY (Severity 1.0)  
    - HCFA: ROUTINE UROLOGY FOLLOW-UP  

    Medications:  
    - Tamsulosin 0.4 mg PO daily  
    - Multivitamin PO daily  
    - Ibuprofen 400 mg PO Q8H PRN mild flank discomfort  

    Orders:  
    - Ureteral stent removal ordered, Completed — No complications  
    - Renal ultrasound ordered, Completed — Resolution of hydronephrosis  
    - Serum electrolytes ordered, Completed — Within normal limits  
    - Urinalysis ordered, Completed — Clear urine, no hematuria  
    - Patient counseling ordered, Completed — Stone prevention, hydration, and low-oxalate dietary guidance  

    Procedures:  
    - Outpatient ureteral stent removal performed  
    - Ultrasound-guided renal assessment confirmed recovery  


Patient 40001296  
Gender: Female  
Age: 58  
Race: ASIAN  

Admission 67124821  
    DRGs:  
    - APR: CALCULUS OF KIDNEY WITH OBSTRUCTIVE UROPATHY (Severity 2.0)  
    - HCFA: KIDNEY STONE W/O COMPLICATIONS  

    Medications:  
    - Ketorolac 15 mg IV Q6H PRN renal colic  
    - Tamsulosin 0.4 mg PO daily (facilitates stone passage)  
    - Ceftriaxone 1 g IV Q24H (prophylactic, given mild hydronephrosis)  
    - Ondansetron 4 mg IV Q6H PRN nausea  
    - Acetaminophen 650 mg PO Q6H PRN mild pain  
    - Sodium Chloride 0.9% IV fluids 100 mL/hr  
    - Enoxaparin 40 mg SC daily for DVT prophylaxis  

    Orders:  
    - Non-contrast CT ordered, Completed — Left kidney 6 mm non-obstructing stone with mild hydronephrosis  
    - Renal ultrasound ordered, Completed — Confirms mild obstruction  
    - Urinalysis ordered, Completed — Trace blood, no infection  
    - Strain urine ordered, Completed — Stone fragments collected  
    - Urology consult ordered, Completed — Recommended conservative management  
    - IV hydration initiated, Completed  
    - Patient education ordered — Low-sodium, high-fluid diet to prevent recurrence  

    Procedures:  
    - None performed; stone expected to pass spontaneously  

---

Admission 67126504  
    DRGs:  
    - APR: URETEROSCOPIC REMOVAL OF PERSISTENT KIDNEY STONE (Severity 2.0)  
    - HCFA: STONE EXTRACTION W/O MCC  

    Medications:  
    - Levofloxacin 500 mg PO daily x 5 days post-op prophylaxis  
    - Tamsulosin 0.4 mg PO daily  
    - Ibuprofen 600 mg PO Q8H PRN post-op discomfort  
    - Acetaminophen 650 mg PO Q6H PRN mild fever  
    - Sodium Chloride 0.9% Flush IV PRN line care  
    - Docusate sodium 100 mg PO BID PRN constipation  

    Orders:  
    - Ureteroscopic laser lithotripsy ordered, Completed — 6 mm left renal stone fragmented successfully  
    - Ureteral stent inserted, Completed  
    - Serum creatinine ordered, Completed — Stable at 0.9 mg/dL  
    - Post-procedure urinalysis ordered, Completed — No hematuria  
    - Stone composition analysis ordered, Completed — Calcium oxalate monohydrate  
    - Outpatient follow-up ordered, Scheduled in 3 weeks  

    Procedures:  
    - Ureteroscopic laser lithotripsy with stent placement  
    - Stone fragments removed endoscopically  

---

Admission 67128977  
    DRGs:  
    - APR: STENT REMOVAL FOLLOW-UP (Severity 1.0)  
    - HCFA: ROUTINE UROLOGY FOLLOW-UP  

    Medications:  
    - Tamsulosin 0.4 mg PO daily (continued temporarily)  
    - Ibuprofen 400 mg PO Q8H PRN  
    - Multivitamin PO daily  

    Orders:  
    - Ureteral stent removal ordered, Completed  
    - Renal ultrasound ordered, Completed — No hydronephrosis  
    - Urinalysis ordered, Completed — Negative for blood and infection  
    - Dietary counseling ordered, Completed — Advised low-oxalate, high-fluid regimen  
    - Follow-up ordered, Completed — Annual monitoring for stone recurrence  

    Procedures:  
    - Outpatient ureteral stent removal  
    - Renal ultrasound performed, confirming full recovery  


Patient 50001296  
Gender: Male  
Age: 62  
Race: WHITE  

Admission 30124781  
    DRGs:  
    - APR: HEMATURIA WITHOUT MAJOR COMPLICATIONS (Severity 1.0)  
    - HCFA: DISORDERS OF URINARY TRACT W/O CC/MCC  

    Medications:  
    - Phenazopyridine PO  
    - Ciprofloxacin PO  
    - Sodium Chloride 0.9% Flush IV  
    - Acetaminophen PO  
    - Influenza Vaccine Quadrivalent  
    - Tamsulosin PO  

    Orders:  
    - Phenazopyridine: PO, Discontinued via patient discharge  
    - Ciprofloxacin: PO, Discontinued via patient discharge  
    - Tamsulosin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  
    - Influenza Vaccine Quadrivalent: IM, Discontinued via patient discharge  

    Procedures:  
    - Urinalysis with microscopy  
    - Urine culture and sensitivity  
    - Renal ultrasound  

Admission 30291453  
    DRGs:  
    - APR: HEMATURIA WITH ASSOCIATED UPPER URINARY TRACT INFECTION (Severity 2.0)  
    - HCFA: KIDNEY/URINARY TRACT INFECTIONS W CC  

    Medications:  
    - Ceftriaxone IV  
    - Phenazopyridine PO  
    - Tamsulosin PO  
    - Acetaminophen PO  
    - Sodium Chloride 0.9% Flush  
    - Probiotic Supplement PO  

    Orders:  
    - Ceftriaxone: IV, Discontinued via patient discharge  
    - Phenazopyridine: PO, Discontinued via patient discharge  
    - Tamsulosin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Probiotic Supplement: PO, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - Cystoscopy with bladder evaluation  
    - Non-contrast CT urogram  
    - Foley catheter placement for urine output monitoring  

Admission 30547862  
    DRGs:  
    - APR: SEVERE HEMATURIA WITH OBSTRUCTIVE UROPATHY (Severity 3.0)  
    - HCFA: MAJOR URINARY TRACT DISORDERS W MCC  

    Medications:  
    - Piperacillin-Tazobactam IV  
    - Phenazopyridine PO  
    - Tamsulosin PO  
    - Oxybutynin PO  
    - Sodium Chloride 0.9% Flush IV  
    - Acetaminophen PO  
    - Hydromorphone IV  

    Orders:  
    - Piperacillin-Tazobactam: IV, Discontinued via patient discharge  
    - Phenazopyridine: PO, Discontinued via patient discharge  
    - Tamsulosin: PO, Discontinued via patient discharge  
    - Oxybutynin: PO, Discontinued via patient discharge  
    - Sodium Chloride 0.9% Flush: IV, Discontinued via patient discharge  
    - Hydromorphone: IV, Discontinued via patient discharge  
    - Acetaminophen: PO, Discontinued via patient discharge  

    Procedures:  
    - CT abdomen and pelvis with contrast  
    - Retrograde pyelogram  
    - Ureteral stent placement  
    - Bladder irrigation via three-way catheter


Patient 60001296  
Gender: Female  
Age: 55  
Race: WHITE  

Admission 78456219  
    DRGs:  
    - APR: AGE-RELATED VISION CHANGES — PRESBYOPIA (Severity 1.0)  
    - HCFA: OPHTHALMIC DISORDERS W/O MCC  

    Medications:  
    - Carboxymethylcellulose 0.5% Eye Drops — 1 drop OU PRN dryness  
    - Artificial Tears — 1 drop OU QID PRN  
    - Multivitamin with Lutein — 1 tablet PO daily  
    - Omega-3 Fatty Acid Supplement — 1 g PO daily  

    Orders:  
    - Comprehensive eye exam ordered, Completed — Confirmed presbyopia  
    - Visual acuity test ordered, Completed — 20/40 near vision  
    - Refraction test ordered, Completed — Recommended +1.50 reading glasses  
    - Intraocular pressure check ordered, Completed — Normal (14 mmHg)  
    - Patient counseling ordered, Completed — Discussed age-related lens rigidity and need for corrective lenses  
    - Prescription for reading glasses issued, Completed  

    Procedures:  
    - None required; diagnosis managed conservatively  

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Admission 78457502  
    DRGs:  
    - APR: REFRACTIVE ERROR FOLLOW-UP (Severity 1.0)  
    - HCFA: ROUTINE OPHTHALMOLOGY EXAM  

    Medications:  
    - Carboxymethylcellulose 0.5% Eye Drops — 1 drop OU PRN dryness  
    - Preservative-free Artificial Tears — 1 drop OU QID PRN  

    Orders:  
    - Follow-up visual acuity testing ordered, Completed — Stable at 20/40 near vision  
    - Updated refraction test ordered, Completed — Glasses strength increased to +1.75  
    - Patient education ordered, Completed — Guidance on computer-related eye strain and blue-light filter recommendations  
    - Annual comprehensive ophthalmology follow-up ordered, Scheduled  

    Procedures:  
    - Dilated fundus examination performed — No signs of diabetic or hypertensive retinopathy  
    - Updated optical prescription issued  

---

Admission 78458834  
    DRGs:  
    - APR: ANNUAL OPHTHALMIC WELLNESS VISIT (Severity 1.0)  
    - HCFA: ROUTINE EYE EXAM W/O COMPLICATIONS  

    Medications:  
    - Same as prior regimen — Artificial tears and multivitamin continued  

    Orders:  
    - Comprehensive ophthalmologic examination ordered, Completed — No progression beyond expected presbyopia  
    - Optical coherence tomography (OCT) scan ordered, Completed — Normal macular and optic nerve findings  
    - Patient counseling ordered, Completed — Recommended bifocals for smoother distance/near transitions  
    - Follow-up ordered, Scheduled — Annual monitoring unless vision changes occur  

    Procedures:  
    - OCT imaging performed  
    - Visual field testing performed — Normal results  