Admission Date:  [**2178-8-3**]              Discharge Date:   [**2178-8-26**]

Date of Birth:  [**2100-9-20**]             Sex:   M

Service: MEDICINE

Allergies:
Dilantin Kapseal / Sulfa (Sulfonamide Antibiotics) / Tegretol /
Fentanyl / Thiopental / Succinylcholine / Vecuronium Bromide

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Weight gain

Major Surgical or Invasive Procedure:
PICC line placement
Milrinone infusion
admission to the cardiac intensive care unit
right heart catheterization


History of Present Illness:
Mr. [**Known lastname 109642**] is 77M with h/o systolic and diastolic CHF, a-fib,
cardiac amyloidosis, and multiple myeloma transferred from
[**Hospital1 **] initially for volume overload and need for lasix
drip and chemotherapy.
The patient was recently discharged from [**Hospital1 18**] on [**2178-6-5**], at
which time RV biopsy demonstrated cardiac amyloidosis, as well
as a bone marrow biopsy with e/o multiple myeloma. ECHO showed
e/o new systolic heart failure on top of preexisting diastolic
heart failure and is s/p cardiac catheterization with e/o 50%
left main disease, 50% LAD stenosis.
Since discharge, the patient reports weight gain, as well as
DOE. He denies orthopnea, PND, palpitations, syncope or
presyncope. He waited until he was seen by Dr. [**Last Name (STitle) **] on [**2178-7-22**]
where he was noted to have elevated JVD and 3+ LE edema. Lasix
was switched to torsemide 40mg [**Hospital1 **] with continued spironolactone
50mg daily.
When he initially presented to [**Hospital1 **], the patient was
noted to have change in mental status that was attributed to
uremia, [**Last Name (un) **], and medication side effect from torsemide. He also
had a bandemia of 9% and was initially treated for a potential
UTI. His CXR showed recurrent right pleural effusion. He was
treated for acute on chronic systolic and diastolic heart
failure with IV lasix but of note this was limited by his BP's.
Weight prior to discharge from [**Location (un) 620**] 105kg.
While on the [**Hospital1 1516**] service, the patient was being diuresed on
Lasix drip 30 mg/hour, with diuresis limited by increasing
creatinine. After discussion with Dr. [**First Name (STitle) 437**], it was thought that
the patient could benefit from milronone drip in the setting of
having a Swan placed to measure his wedge and his CO. The
patient also has an element of systolic failure, which could
also be improved with milronone.
On transfer to the floor, the patient reports feeling well.

Past Medical History:
Afib on coumadin
Diastolic heart failure (EF 60-65%)
OSA
Gout
GERD with Barrett's esophagus
Hiatal hernia
Elevated PSA
Erectile dysfunction
s/p cholecystectomy ([**2172**])
s/p right hip replacement ([**2170**])
s/p tailers bunion, fascia release, prosthesis (left foot)
([**2169**])
s/p deviated septum repair ([**2168**])
s/p tailers bunion removal ([**2166**])
s/p multiple laminectomies ([**2164**], [**2151**], [**2148**])
s/p tendon repair right arm ([**2145**])
s/p hemorrhoidectomy ([**2126**])
s/p pilonidal cyst removal ([**2120**])
s/p appendectomy ([**2116**])
s/p bone removal left foot ([**2114**])
s/p tonsillectomy ([**2106**])


Social History:
The patient is married and worked in the import business and
worked for the navy in the shipyards. He never smoked.


Family History:
Positive for hay fever.

Physical Exam:
ADMISSION EXAM:
VS - 97.9 117/63 72 18 98% on RA 105.7kg
GENERAL - chronically ill appearing male in NAD, comfortable,
slightly short of breath while speaking
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, JVP at 12, no carotid bruits
LUNGS - bibasilar crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 3+ pitting LE edema to upper thighs, 2+
peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-13**] throughout

DISCHARGE EXAM:
24hr I/O: 1236/1620
87.6 ->88 ->89.1
General: Well NAD,pleasant, well appearing, elderly gentleman in
NAD, laying comfortably in bed
HEENT:  EOMI, PERRLA, no cerivcal lymphadenopathy, 12cm JVP
LUNGS: Fine Crackles at right base, no wheezing, rhonchi
HEART - PMI non-displaced, RRR, II/VI systolic murmur at apex,
nl S1-S2,
ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - 1+ pitting edema to calves, 2+ peripheral pulses
(radials, DPs), PICC Line in right arm w/o errythema or
tenderness.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-13**] throughout


Pertinent Results:
ADMISSION LABS:
[**2178-8-3**] 11:39PM BLOOD WBC-10.8 RBC-3.43* Hgb-11.1* Hct-35.0*
MCV-102* MCH-32.3* MCHC-31.6 RDW-15.7* Plt Ct-194
[**2178-8-3**] 11:39PM BLOOD Neuts-80.9* Lymphs-8.5* Monos-9.1 Eos-1.0
Baso-0.5
[**2178-8-3**] 11:39PM BLOOD PT-25.4* PTT-37.9* INR(PT)-2.4*
[**2178-8-3**] 11:39PM BLOOD Glucose-119* UreaN-50* Creat-1.6* Na-138
K-4.3 Cl-98 HCO3-30 AnGap-14
[**2178-8-5**] 04:20PM BLOOD CK(CPK)-31*
[**2178-8-5**] 04:20PM BLOOD CK-MB-4 cTropnT-0.14*
[**2178-8-3**] 11:39PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.4

TRANSFER LABS:
[**2178-8-7**] 03:45PM BLOOD PT-27.2* INR(PT)-2.6*
[**2178-8-7**] 03:10PM BLOOD Glucose-100 UreaN-81* Creat-2.3* Na-135
K-4.0 Cl-91* HCO3-31 AnGap-17
[**2178-8-7**] 03:10PM BLOOD Calcium-8.9 Phos-4.8* Mg-2.6
[**2178-8-6**] 11:19AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2178-8-6**] 11:19AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
[**2178-8-6**] 11:19AM URINE Hours-RANDOM Creat-37 Na-74 K-38 Cl-88

DISCHARGE LABS:
[**2178-8-26**] 04:26AM BLOOD WBC-15.9* RBC-3.02* Hgb-9.2* Hct-28.3*
MCV-94 MCH-30.4 MCHC-32.4 RDW-16.1* Plt Ct-233
[**2178-8-25**] 05:32AM BLOOD PT-22.4* PTT-36.2 INR(PT)-2.1*
[**2178-8-26**] 04:26AM BLOOD Glucose-118* UreaN-66* Creat-1.7* Na-131*
K-4.6 Cl-93* HCO3-29 AnGap-14
[**2178-8-15**] 06:40AM BLOOD ALT-22 AST-22 AlkPhos-93 TotBili-0.9
[**2178-8-26**] 04:26AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
Blood Culture, Routine (Final [**2178-8-26**]):    NO GROWTH.
URINE CULTURE (Final [**2178-8-21**]):    NO GROWTH.

KAPPA/LAMDA:
Test                          Result              Reference
Range/Units
FREE KAPPA, SERUM             20.0  H             3.3-19.4 mg/L
FREE LAMBDA, SERUM            2.7  L              5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO       7.41  H             0.26-1.65

Cardiac Cath Report [**8-19**]: Elevated right- and left-sided filling
pressures, moderate pulmonary arterial hypertension in the
setting of left-sided heart failure, large V waves suggestive of
moderate to severe mitral regurgitation.  Normal cardiac output
and index.

EKG [**2178-8-25**]
Atrial fibrillation. Right bundle-branch block. Left axis
deviation. Left
anterior fascicular block. Old inferior myocardial infarction.
Compared to
the previous tracing of [**2178-8-22**] no significant changes are
noted.

 	Intervals	Axes
Rate	PR	QRS	QT/QTc	P	QRS	T
70	0	148	440/457	0	-70	107
CXR [**2178-8-20**]: As compared to the previous radiograph, the patient
has received a Swan-Ganz catheter.  The catheter needs to be
pulled back given that the tip is projecting over distal parts
of the right pulmonary artery.  An opacity that pre-existed at
the bases of the right upper lobe is no longer visible. However,
the lung volumes have decreased and a small pleural effusion is
unchanged at the right lung base.  Unchanged moderate
cardiomegaly.  The right PICC line is constant in position.
RENAL ULTRASOUND:
1.  No hydronephrosis.  Simple bilateral renal cysts.
2.  Right pleural effusion and trace of ascites seen in the
right upper
quadrant.
3.  Arterial and venous flow is documented within each of the
kidneys,
however, further Doppler analysis cannot be performed as the
patient is unable to hold his breath.
Social Work:
Family has met w/ palliative team and wife expresses that the
conversation is "premature". Pt and wife have not signed DNR and
still solidifying long-term plans. Pt, wife and [**Name2 (NI) **] are aware of
life expectancy ([**7-21**] mos) and reiterated to SW and physician
that Pt is going to optimize highest level of care and the
priority is to be at home.

Pt and family met w/ infusion home care co. as an option for
next
steps. Physician communicated to pt/family that PT will be
consulted on recommendations for home vs rehab.

Family and Pt are continuing to explore all options and continue
to look into rehab's that can manage current medications however
family has reiterated that going home is their first preference.

Assessment: Family and Pt is experiencing difficult adjustment
to
illness and next steps on the best approach for Pt. SW provided
empathic listening, guidance on resources that are available,
and
encouraged Pt and family to continue to utilize clinicians to
help make an informed decision on where Pt should transition to
next.


Brief Hospital Course:
Mr. [**Known lastname 109642**] is 77M with history of atrial fibrillation on
coumadin, systolic and diastolic heart failure, cardiac
amylodosis, and multiple myeloma who initially presented from
OSH with weight gain and need aggressive IV diuresis, requiring
CCU admission for initiation of milrinone drip.
.
# Acute on chronic systolic and diastolic heart failure: Patient
with baseline restrictive disease secondary to his cardiac
amyloid. Also with systolic CHF first seen [**5-21**] with RV free
wall hypokinesis.  He presented with diffuse peripheral edema,
worsening abdominal distention and JVP elevated to 12 cm,
consistent with right sided failure.  He also presented with
right pleural effusion that represented transudate [**3-12**] CHF. He
was initially diuresed with lasix drip and metolazone with good
effect, but was stopped after increasing creatinine.  He was
then transferred to the ICU for diuresis with milrinone for
inotropic effect and pulomary vasodilation allowing right sided
unloading. His right heart pressures were monitored by swan-ganz
cath with PA pressure 50 to 40s and wedge pressures of 28 to 19
after administartion of milrinone.  He diuresed well in the CCU,
was transfered to the floor, but after weaning milrinone, he
required reinitiation of milrinone in the CCU due to drop off in
energy level, urine output an reaccumulation of fluid.   He
tolerated reinstitution of milrinone infusion well and was
transferred to the floor.  He was also continued spironolactone
and torsemide after period of autodiuresis from [**Last Name (un) **] ended.  Over
the course of the hospitalization he lost about 40lbs.  His
discharge weight was roughly equivalent to his dry weight at
89.1 kg (196 lbs).  He was counseled on the importance of daily
weights and CHF management.  He will follow up with Dr. [**Last Name (STitle) **]
in cardiology clinic.
.
[**Last Name (un) **]: Pt developed [**Last Name (un) **] in the setting of aggressive diuresis.
Nephrology was consulted and felt this was likely ATN vs
pre-renal due to hypoperfusion.  It was unlikely a sequelae of
MM or amyloid as no protein was found in the urine.  After
discontinuing Lasix gtt, he autodiuresed.  Upon discharge, his
Creatinine returned to his baseline of 1.7.
.
Community Acquired Pneumonia:  Pt developed cough and
leukocytosis with CXR findings of right upper lobe infiltrate.
He was treated with Ciprofloxacin and then Levofloxacin caused
him to have a supratherapeutic INR above 5.  For the remainder
of 10 day abx course, his coumadin was held.
.
# Cardiac amyloidosis with restrictive myopathy: The patient has
history of cardiac amyloidosis confirmed on RV biopsy, and has
resulting restrictive heart disease, with subsequent R sided
dilation and R sided heart failure as above.
.
# Multiple Myeloma: During his last admission, patient was found
to have a monoclonal kappa band and severe hypogammaglobulinemia
on SPEP/UPEP. He underwent bone marrow biopsy which showed 40%
plasma cells. Abdominal fat pad biopsy both performed [**5-28**],
revealed no amyloid but RV cardiac biopsy was positive for
amyloid.  He also continued dexamentasone/velcade treatment
while inpatient. Cycle4 Day8 Velcade administration on [**8-25**].
Will continue treatment with Dr. [**Last Name (STitle) 109643**].
.
# Coronaries: The patient has history of 3VD s/p NSTEMI during
his last admission. Cath from that admission with e/o 50% left
main disease, 50% LAD stenosis. It was decided that the patient
was too high risk for CABG, as well as PCI given his amyloidosis
and was discharge on medical management of his CAD.  He was
continued on atorvastatin 80 mg daily, ASA 162 mg daily,
metoprolol 12.5 mg [**Hospital1 **].
.
# Afib: Stable.  CHADS score of 2 (age and CHF). He was
continued on coumadin for goal INR of 2.0-2.5 given for
increased risk of bleeding with amyloid.  During the hospital
course, he reached a supratherapeutic INR ~5 after
fluoroquinolones were addded.  His coumadin was held for a few
days and restarted to maintain appropriate anticoagulation.  He
will continue INR checks and Coumadin management through Dr. [**Name (NI) 109644**] office.
.
# BPH: stable, continued doxazosin
.
# GERD/Barrett's/hiatal hernia: stable, continued omeprazole,
home tums
.
# DEPRESSION/sleep: stable, continued amitriptyline, zolpidem.
.
# GOUT: stable, continued allopurinol, colchine, tramadol prn
.
TRANSITIONAL ISSUES:
-Cycle4 Day8 Velcade administration on [**8-25**]. will f/u with Dr.
[**Last Name (STitle) 3759**]
[**Name (STitle) **] monitored by Dr. [**Last Name (STitle) 3759**]
[**Name (STitle) 30412**] not amenable to palliative care now
-patient is a full code
-?depression versus adjustment reaction with depression
-Discharge and dry weight 89.1 kg (196 lbs).

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR OSH records.
1. Atenolol 12.5 mg PO DAILY
2. Aspirin 162 mg PO DAILY
3. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral qAM
4. Multivitamins 1 TAB PO DAILY
5. Torsemide 40 mg PO BID
6. Omeprazole 20 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Amitriptyline 30 mg PO HS
9. Doxazosin 4 mg PO HS
10. Zolpidem Tartrate 5-10 mg PO HS
11. Allopurinol 100 mg PO QHS
12. Colchicine 0.6 mg PO HS
13. Guaifenesin Dose is Unknown  PO Frequency is Unknown
14. Warfarin 5 mg PO DAILY16
15. TraMADOL (Ultram) 50 mg PO QID pain
16. Nitroglycerin SL 0.3 mg SL PRN CP
17. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg Oral prn  indigestion


Discharge Medications:
1. Hospital Bed
2. Milrinone 0.26 mcg/kg/min IV INFUSION
RX *milrinone in D5W 20 mg/100 mL (200 mcg/mL) 0.26 mcg/kg/min
continuous infusion Disp #*1 Mutually Defined Refills:*12
3. Amitriptyline 30 mg PO HS
4. Aspirin 162 mg PO DAILY
5. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg Oral prn  indigestion
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*3
9. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
10. Warfarin 4 mg PO DAILY16
RX *warfarin 2 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
11. Zolpidem Tartrate 10 mg PO HS:PRN sleep
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
RX *Milk of Magnesia 400 mg/5 mL 30 mL(s) by mouth every 6 hours
Disp #*1 Bottle Refills:*3
13. Sarna Lotion 1 Appl TP DAILY:PRN itchy
RX *Sarna Anti-Itch 0.5 %-0.5 % apply to itchy skin daily Disp
#*1 Bottle Refills:*3
14. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet
Refills:*3
15. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone 80 mg 1-2 tablets by mouth four times a day Disp
#*120 Tablet Refills:*3
16. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral qAM
17. Nitroglycerin SL 0.3 mg SL PRN CP
18. Allopurinol 100 mg PO QHS
19. Outpatient Lab Work
INR check on [**8-28**] with results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 109645**] at
[**Telephone/Fax (1) 21962**].  ICD-9 427.31


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
PRIMARY
-acute on chronic systolic heart failure
-amyloidosis with restrictive myopathy
-multiple myeloma
-community acquired pneumonia
-Hyponatremia
-acute kidney injury
-atrial fibrillation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
It was a pleasure caring for you while you were at [**Hospital1 18**].  You
were admitted for treatment of your congestive heart failure.
Our testing suggested this was a result of the effects on your
heart from your multiple myeloma.  You were started on a
medication called milrinone that helped your heart pump better
and given medications to help you urinate off all the excess
fluid.  Your weight was decreased by about 40 pounds.  We tried
to stop the milrinone infusion, but your clinical picture
worsened without this medication and it was determined that you
will need it chronically infusing from now on.  Home services to
assist with this have been set up for you.  You also continued
to recieve therapy for your multiple myeloma while and inpatient
and will continue to see Dr. [**Last Name (STitle) 109645**] as an outpatient.

You were discharged on diuretics (torsemide) in order to keep
your weight down.  Your discharge weight was 89.1 kg (196 lbs),
you should call Dr.[**Name (NI) 10159**] office at [**Telephone/Fax (1) 9832**] if you
notice your daily weight goes up by more than 3 lbs in a day or
if you notice worsening swelling in your legs, shortness of
breath while walking or any other symptoms that concern you.

Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2178-9-1**] at 2:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/BMT
When: TUESDAY [**2178-9-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2178-9-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2178-8-30**]

Mr. [ * * Known lastname 109642 * * ] is 77 M with h / o systolic and diastolic CHF , a - fib , cardiac amyloidosis , and multiple myeloma transferred from [ * * Hospital1 * * ] initially for volume overload and need for lasix drip and chemotherapy .

The patient was recently discharged from [ * * Hospital1 18 * * ] on [ * * 2178 - 6 - 5 * * ] , at which time RV biopsy demonstrated cardiac amyloidosis , as well as a bone marrow biopsy with e / o multiple myeloma .

Pt developed cough and leukocytosis with CXR findings of right upper lobe infiltrate .

Discharge Diagnosis < > PRIMARY -acute on chronic systolic heart failure -amyloidosis with restrictive myopathy -multiple myeloma -community acquired pneumonia -Hyponatremia -acute kidney injury -atrial fibrillation

# Coronaries < > The patient has history of 3VD s / p NSTEMI during his last admission .

EKG [ * * 2178 - 8 - 25 * * ] Atrial fibrillation . Right bundle - branch block . Left axis deviation . Left anterior fascicular block . Old inferior myocardial infarction .

Cardiac Cath Report [ * * 8 - 19 * * ] < > Elevated right- and left - sided filling pressures , moderate pulmonary arterial hypertension in the setting of left - sided heart failure , large V waves suggestive of moderate to severe mitral regurgitation .

<think>
Okay, let's tackle this step by step. First, I need to thoroughly read the clinical note provided. The patient is a 77-year-old male with a complex medical history including systolic and diastolic CHF, atrial fibrillation, cardiac amyloidosis, multiple myeloma, and recent weight gain. He was admitted for volume overload requiring aggressive diuresis and chemotherapy.

Starting with the first pass, I'll go through each section. The Chief Complaint is weight gain. The History of Present Illness mentions multiple issues like volume overload, use of Lasix drip, cardiac amyloidosis confirmed by RV biopsy, multiple myeloma with bone marrow biopsy, ECHO findings of new systolic heart failure, and right heart catheterization results. Past Medical History includes Afib, diastolic heart failure, OSA, Gout, GERD, etc. Physical exams show JVD, LE edema, crackles in lungs, and other findings. Labs show abnormalities like elevated WBC, creatinine, and others. Procedures like PICC line placement, milrinone infusion, and right heart catheterization are noted. Discharge diagnoses include acute on chronic systolic heart failure, amyloidosis, multiple myeloma, community-acquired pneumonia, hyponatremia, AKI, and Afib.

Next, cross-referencing with ML conditions. The discharge diagnoses are primary, so I need to ensure all ML-identified conditions are covered. The note lists these clearly, so I'll confirm each is addressed.

In the second pass, listing all symptoms, findings, labs, etc. Symptoms include weight gain, DOE, denied orthopnea, PND, etc. Physical findings: JVD, LE edema, crackles. Labs: elevated WBC, creatinine, INR. Imaging: pleural effusion, cardiomegaly. Procedures: PICC, milrinone infusion, right heart cath. Diagnoses: as per discharge. Treatments: milrinone, diuretics, chemotherapy. Medications listed on admission and discharge. Follow-up with cardiology and hematology.

Third pass: categorize each entity. For example, weight gain is a symptom. Cardiac amyloidosis is a diagnosis. Milrinone infusion is a procedure. Elevated JVP is a finding. Each lab result is a lab finding. Medications need to be linked to conditions, like warfarin for Afib.

Fourth pass: attributes. Assertion status for each entity. For example, weight gain is present. Severity: moderate to severe edema. Temporality: acute on chronic for heart failure. Clinical impact: significant for heart failure, critical for amyloidosis. Monitoring: routine for INR, close for weight.

Fifth pass: relationships. Milrinone treats heart failure. Chemotherapy for multiple myeloma. Lasix for volume overload. AKI likely due to diuresis.

Quality control: Ensure all procedures and their findings are captured. Check all labs, meds, follow-ups. Make sure no combining of separate conditions.

Clinical significance: Heart failure and amyloidosis are critical, requiring ongoing treatment. Multiple myeloma needs chemotherapy follow-up. Pneumonia treated with antibiotics.

Now, structuring the XML sections. The clinical summary should encapsulate the primary reasons and key findings. Identified entities must be listed exactly as in the note, categorized correctly. Relationships show how treatments address conditions. Differential diagnoses might consider other causes of heart failure or weight gain. Ambiguities could include the exact cause of AKI (ATN vs. pre-renal). Clinical impact prioritizes heart failure, amyloidosis, myeloma. Care coordination involves cardiology, hematology, home services. Medications must be linked to conditions, noting exceptions if any.

Need to ensure no interpretation, only exact terms from the note. For example, "acute on chronic systolic heart failure" is a diagnosis, not just "heart failure." Medications like torsemide are for CHF, warfarin for Afib. Chemotherapy regimen for myeloma is a therapy regime.

Finally, check that all sections are covered, no extra info, only the required XML tags. Make sure each entity is unique and properly categorized with evidence from the note.
</think>

<clinical_summary>
77-year-old male with cardiac amyloidosis, multiple myeloma, and acute-on-chronic systolic/diastolic heart failure admitted for volume management. Key findings include restrictive cardiomyopathy from amyloidosis, 40lb weight gain with peripheral edema, community-acquired pneumonia, and acute kidney injury. Required milrinone infusion initiation and ongoing chemotherapy for myeloma. Discharged with home milrinone therapy and coordinated specialty follow-up.
</clinical_summary>

<identified_medical_entities>
1. Acute on chronic systolic heart failure - Worsening cardiac function with fluid overload  
2. Cardiac amyloidosis with restrictive myopathy - Confirmed by RV biopsy causing diastolic dysfunction  
3. Multiple myeloma - 40% plasma cells on bone marrow biopsy with kappa/lambda ratio 7.41  
4. Community acquired pneumonia - Treated with fluoroquinolones with CXR infiltrate  
5. Hyponatremia - Na 131 on discharge labs  
6. Acute kidney injury - Creatinine peak 2.3 during diuresis  
7. Atrial fibrillation - Chronic on coumadin with CHADS2 score 2  
8. Moderate mitral regurgitation - Large V waves on cardiac cath  
9. Pulmonary arterial hypertension - Elevated PA pressures on catheterization  
10. 3-vessel coronary disease - 50% left main/LAD stenosis per cath  
11. Right pleural effusion - Recurrent transudative effusion on CXR  
12. Lower extremity edema - 3+ pitting edema to thighs on admission  
13. Elevated JVP - 12 cm neck vein distension  
14. Weight gain - 40lbs from dry weight  
15. Milrinone infusion - Inotropic support initiated in CCU  
16. Velcade chemotherapy - Cycle 4 Day 8 administered for myeloma  
17. Supratherapeutic INR - Reached 5 during antibiotic therapy  
18. Barrett's esophagus - Chronic GERD complication  
19. OSA - Obstructive sleep apnea in PMH  
20. Gout - Chronic on allopurinol/colchicine  
</identified_medical_entities>

<relationships>
1. Cardiac amyloidosis → Restrictive cardiomyopathy → Systolic/diastolic HF  
2. Milrinone infusion ↔ Improvement in PA pressures/urine output  
3. Velcade chemotherapy ↔ Multiple myeloma treatment  
4. Fluoroquinolones ↔ Supratherapeutic INR via drug interaction  
5. Aggressive diuresis ↔ Acute kidney injury  
6. 3-vessel CAD ↔ NSTEMI history/contraindication for revascularization  
7. Atrial fibrillation ↔ CHADS2 score guiding anticoagulation  
8. Cardiac amyloidosis ↔ Contraindication for CABG/PCI  
9. Community pneumonia ↔ Leukocytosis/bandemia 9%  
10. Multiple myeloma ↔ Hypogammaglobulinemia risk for infections  
</relationships>

<differential_diagnosis>
1. Acute CHF exacerbation vs. volume overload from renal dysfunction  
2. Cardiac vs. non-cardiac pulmonary edema  
3. ATN vs. pre-renal AKI in setting of diuresis  
4. Myeloma renal involvement vs. diuretic-induced AKI  
5. Infectious vs. inflammatory cause of bandemia  
6. Uremic encephalopathy vs. medication-induced mental status changes  
</differential_diagnosis>

<ambiguities>
1. "Autodiuresis" mechanism unclear - attributed to medication adjustment but exact physiology not documented  
2. "Depression versus adjustment reaction" - insufficient behavioral health documentation to differentiate  
3. PICC line necessity vs. peripheral access feasibility not discussed  
4. "Element of systolic failure" unspecified etiology beyond amyloidosis  
5. Discrepancy between "dry weight" 89.1kg and admission weight 105kg - unclear baseline reference  
</ambiguities>

<clinical_impact>
1. Critical: Cardiac amyloidosis with restrictive physiology dictating HF management  
2. High: Milrinone dependence requiring home infusion coordination  
3. High: Multiple myeloma requiring ongoing chemotherapy monitoring  
4. Moderate: Recurrent pleural effusions needing serial imaging  
5. Moderate: Fall risk from 40lb weight loss/ambulatory assistance need  
6. Moderate: Anticoagulation balance in amyloidosis bleeding risk  
7. Low: Chronic gout/Barrett's managed with maintenance meds  
</clinical_impact>

<care_coordination>
1. Cardiology: Milrinone titration/wedding monitoring  
2. Hematology: Velcade chemotherapy cycle coordination  
3. Home health: IV infusion management/weight monitoring  
4. Anticoagulation clinic: INR management post-antibiotics  
5. Palliative care: Future goals of care discussions  
6. Physical therapy: Ambulation safety assessment  
7. Nephrology: Renal function monitoring post-AKI  
8. Primary care: Medication reconciliation/geriatric assessment  
</care_coordination>

<medication>
1. Milrinone 0.26mcg/kg/min IV - Active for systolic heart failure  
2. Torsemide 40mg DAILY - Active for volume overload  
3. Spironolactone 12.5mg DAILY - Active for diuresis  
4. Warfarin 4mg DAILY - Active for atrial fibrillation  
5. Velcade - Active chemotherapy for multiple myeloma  
6. Allopurinol 100mg QHS - Active for gout prophylaxis  
7. Omeprazole 20mg BID - Active for GERD/Barrett's  
8. Zolpidem 10mg HS PRN - Exception (sleep aid without documented insomnia Dx)  
9. Senna/BID PRN - Exception (constipation management without chronic Dx)  
10. Sarna Lotion DAILY - Exception (pruritus without specific dermatologic Dx)  
</medication>

The patient has documented three-vessel coronary artery disease (3VD) confirmed via cardiac catheterization showing 50% stenosis in left main and LAD arteries. The condition is managed medically due to high surgical risk from amyloidosis. No active angina is documented in the current encounter, supporting use of I25.10.

- **Chronicity**: 3VD is a chronic coronary artery disease requiring lifelong management.  
- **Documentation**: Tier 3 (PMH + Coronaries section).  
- **MEAT Strength**: Moderate in all components except Monitoring (Moderate).  
- **Bearing on Stay**: Direct bearing via treatment decisions and medical management.

The patient was diagnosed with community acquired pneumonia (CAP) confirmed by CXR showing a right upper lobe infiltrate and leukocytosis (WBC 10.8-15.9). A right pleural effusion was documented but attributed to congestive heart failure (CHF), not CAP. Antibiotic treatment (Ciprofloxacin/Levofloxacin) was administered.

MEAT criteria are met but with moderate strength in Monitoring and Evaluation due to incomplete CXR tracking and lack of microbiological confirmation. CAP is explicitly documented as a separate condition.

The patient has a documented history of cholecystectomy (2012) with no current symptoms, complications, or management related to the procedure during this hospitalization for heart failure and myeloma. The anatomical absence of the gallbladder qualifies for coding under Z90.49.

- The Milrinone infusion was actively performed during this encounter, adjusted based on clinical response, and deemed necessary for chronic use.  
- Documentation meets MEAT criteria for a current, ongoing inpatient procedure.

Documented acute exacerbation of chronic CHF with both systolic/diastolic components, requiring milrinone therapy

Chronic a-fib managed with Coumadin, CHADS2 score 2

Confirmed by RV biopsy, causing restrictive cardiomyopathy

40% plasma cells on bone marrow biopsy, ongoing Velcade/dexamethasone treatment

Treated with fluoroquinolones during hospitalization

50% left main/LAD disease per cath, managed medically

Documented on right heart catheterization

Chronic inotropic support for heart failure

Historical procedure with no current complications

Patient with baseline restrictive disease secondary to his cardiac amyloid. Also with systolic CHF first seen with RV free wall hypokinesis.

The patient has history of cardiac amyloidosis confirmed on RV biopsy, and has resulting restrictive heart disease, with subsequent R sided dilation and R sided heart failure.

During his last admission, patient was found to have a monoclonal kappa band and severe hypogammaglobulinemia on SPEP/UPEP.

Pt developed cough and leukocytosis with CXR findings of right upper lobe infiltrate.

<think>
Okay, let's tackle this step by step. First, I need to thoroughly read the clinical note provided. The patient is a 77-year-old male with a history of various cardiac and hematological conditions, admitted for acute on chronic systolic and diastolic heart failure, weight gain, and the need for aggressive diuresis. The note mentions multiple myeloma, cardiac amyloidosis, atrial fibrillation, and community-acquired pneumonia among other issues.

Starting with the clinical summary, I need to capture the primary reasons for admission, key findings, and outcomes. The patient was transferred for volume overload and required a milrinone infusion. He had significant weight gain, elevated JVD, and peripheral edema. The summary should highlight his complex medical history, treatments received, and discharge plans.

Next, identifying medical entities. I'll go through each section methodically. The Chief Complaint is weight gain. The History of Present Illness includes systolic and diastolic CHF, atrial fibrillation, cardiac amyloidosis, multiple myeloma, volume overload, lasix drip, chemotherapy, RV biopsy, bone marrow biopsy, ECHO findings, right heart catheterization, weight gain, DOE, elevated JVD, LE edema, change in mental status, uremia, bandemia, UTI, pleural effusion, IV lasix, increasing creatinine, milrinone drip, Swan-Ganz catheter placement, systolic failure, and transfer to the floor.

Past Medical History includes Afib on coumadin, diastolic heart failure, OSA, gout, GERD with Barrett's esophagus, hiatal hernia, elevated PSA, erectile dysfunction, and multiple past surgeries. Social history is non-smoker, family history of hay fever. Physical exam findings on admission and discharge, pertinent labs showing abnormalities like elevated WBC, creatinine, INR, etc. Imaging results like CXR showing pleural effusion, EKG findings of atrial fibrillation, cardiac cath report with elevated filling pressures, pulmonary hypertension, mitral regurgitation. Discharge diagnoses include acute on chronic systolic heart failure, amyloidosis, multiple myeloma, community-acquired pneumonia, hyponatremia, acute kidney injury, atrial fibrillation.

Procedures: PICC line placement, right heart catheterization, Swan-Ganz catheter placement, biopsies. Medications on admission and discharge, including diuretics, anticoagulants, chemotherapy agents. Follow-up plans with cardiology and hematology.

Now, categorizing each entity. For example, "weight gain" is a symptom. "Systolic and diastolic CHF" is a diagnosis. "Milrinone infusion" is a treatment regimen. Each entity must be listed as it appears, without interpretation. Lab findings like elevated creatinine are noted as lab findings. Procedures like PICC line are procedures. Medications are listed with their associated conditions, like warfarin for Afib.

Relationships: Milrinone treating heart failure, chemotherapy for multiple myeloma, diuretics for volume overload. The acute kidney injury related to diuresis and medication side effects. Community-acquired pneumonia treated with antibiotics affecting INR.

Differential diagnoses might consider other causes of heart failure exacerbation, but the note clearly attributes it to amyloidosis and myeloma. Ambiguities include whether the mental status change was solely due to uremia or medications, but the note attributes it to multiple factors.

Clinical impact prioritizes heart failure management, amyloidosis, myeloma treatment, and pneumonia. Care coordination involves cardiology, hematology, home health for milrinone, and monitoring by primary care.

Medications must be linked to conditions. For example, torsemide and spironolactone for CHF, warfarin for Afib, dexamethasone/velcade for myeloma. Exceptions would be medications without clear indications, but in this case, most are documented with conditions.

Throughout, ensuring that entities are exactly as documented, not interpreting lab results into conditions unless stated. For instance, elevated JVP is a finding, not equated to a diagnosis. Each step requires cross-referencing sections to ensure all entities are captured without omission or duplication.
</think>

<clinical_summary>
77-year-old male with complex cardiac/hematologic history (cardiac amyloidosis, multiple myeloma, atrial fibrillation) admitted for acute-on-chronic systolic/diastolic heart failure management. Key findings include volume overload (40lb weight gain), restrictive cardiomyopathy from amyloidosis, active multiple myeloma treatment, and community-acquired pneumonia. Required milrinone infusion and Swan-Ganz monitoring. Discharged on chronic milrinone therapy with coordinated home care.
</clinical_summary>

<identified_medical_entities>
1. Acute on chronic systolic heart failure - Primary cardiac diagnosis
2. Cardiac amyloidosis with restrictive myopathy - Confirmed by RV biopsy
3. Multiple myeloma - 40% plasma cells on bone marrow biopsy
4. Community-acquired pneumonia - Treated with fluoroquinolones
5. Atrial fibrillation on coumadin - CHADS2 score 2
6. Volume overload - 3+ LE edema, JVP 12cm
7. Right pleural effusion - Recurrent on CXR
8. Mitral regurgitation - Large V waves on cath
9. Pulmonary arterial hypertension - Cath findings
10. Acute kidney injury - Creatinine elevation to 2.3
11. Hyponatremia - Na 131 on discharge
12. Barrett's esophagus - PMH component
13. OSA - Documented comorbidity
14. Gout - Chronic management
15. Depression - On amitriptyline
16. Right heart catheterization - Procedure performed
17. Swan-Ganz catheter placement - For hemodynamic monitoring
18. Milrinone infusion - Continuous inotropic support
19. Velcade chemotherapy - Cycle 4 Day 8 administered
20. Elevated JVP - 12cm documented
</identified_medical_entities>

<relationships>
1. Cardiac amyloidosis → Restrictive cardiomyopathy → Systolic/diastolic HF
2. Milrinone infusion ↔ Improvement in PA pressures/urine output
3. Multiple myeloma → Chemotherapy (Velcade/dexamethasone)
4. Community-acquired pneumonia → Fluoroquinolone-induced INR elevation
5. Aggressive diuresis ↔ Acute kidney injury
6. Atrial fibrillation ↔ Coumadin therapy with INR fluctuations
7. Right heart catheterization ↔ Identification of pulmonary hypertension
8. Cardiac amyloidosis + Multiple myeloma → Combined organ involvement
9. PICC line ↔ Enables chronic milrinone administration
10. Weight gain ↔ Fluid overload in CHF exacerbation
</relationships>

<differential_diagnosis>
1. CHF exacerbation etiology: Amyloid vs ischemic vs hypertensive
2. AKI causes: ATN vs prerenal vs myeloma kidney
3. Mental status changes: Uremia vs medication effect vs metabolic
4. Pleural effusion: Transudative vs parapneumonic
5. Bandemia source: Infection vs stress leukocytosis
</differential_diagnosis>

<ambiguities>
1. Mental status changes attributed to multiple factors (uremia/medications) without clear primary cause
2. "Element of systolic failure" unclear if new onset or progression
3. Discrepancy between fat pad (-) and cardiac (+) amyloid biopsies
4. "50% left main disease" significance in non-revascularized patient
5. Depression vs adjustment reaction documentation conflict
</ambiguities>

<clinical_impact>
1. Critical: Cardiac amyloidosis with restrictive physiology
2. High: Chronic milrinone dependence
3. Urgent: Multiple myeloma treatment continuity
4. Significant: Anticoagulation management in amyloid
5. Moderate: Pneumonia resolution monitoring
6. Watch: Renal function trends post-AKI
</clinical_impact>

<care_coordination>
1. Cardiology: Milrinone management, CHF monitoring
2. Hematology: Velcade chemotherapy continuation
3. Home health: IV infusion supervision
4. Primary care: Daily weight/edema surveillance
5. Anticoagulation clinic: INR monitoring
6. Palliative care: Future goals discussion
7. Physical therapy: Mobility assessment
</care_coordination>

<medication>
1. Milrinone: Heart failure (Active infusion) - Inotropic therapy
2. Torsemide: Volume overload (Active) - Diuretic regimen
3. Spironolactone: CHF (Active) - Aldosterone antagonism
4. Warfarin: Atrial fibrillation (Active) - Anticoagulation therapy
5. Velcade: Multiple myeloma (Active) - Chemotherapy regimen
6. Amitriptyline: Depression (Active) - Psychotropic treatment
7. Allopurinol: Gout (Active) - Urate-lowering therapy
8. Zolpidem: Sleep (PRN) - Exception (no documented sleep disorder)
9. Simethicone: Bloating (PRN) - Exception (no formal GI diagnosis)
10. Sarna Lotion: Pruritus (PRN) - Exception (no dermatologic diagnosis)
</medication>

The patient has documented 50% stenosis in both the left main coronary artery and left anterior descending (LAD) artery confirmed via cardiac catheterization. These findings are part of chronic coronary artery disease (CAD) managed medically. A historical NSTEMI is noted in the clinical text, requiring I25.2 per ICD-10 guidelines.

The 50% left main and LAD stenosis is a confirmed chronic condition managed medically. No active workup or new interventions occurred during this admission. The stenosis is clinically significant but does not require an abnormal finding code (R90-R94) as it is explained by the definitive CAD diagnosis.

The patient developed acute kidney injury (creatinine peaked at 2.3) during aggressive diuresis with Lasix for heart failure. Nephrology consultation attributed this to acute tubular necrosis (ATN) or pre-renal azotemia due to hypoperfusion from diuretic-induced hypovolemia. The creatinine normalized after discontinuing Lasix, confirming resolution with management. The condition met MEAT criteria through nephrology evaluation and treatment changes.

All MEAT elements (Monitoring, Evaluation, Assessment, Treatment) were strongly documented. The condition was actively managed during the encounter, resolved at discharge, and explicitly coded in the discharge diagnosis.

The patient's acute-on-chronic combined systolic/diastolic heart failure is driven by cardiac amyloidosis secondary to multiple myeloma. Clinical evidence includes elevated JVP (12cm), 3+ edema, bibasilar crackles, and right pleural effusion. Cardiac catheterization confirmed elevated pressures, while ECHO showed new systolic failure on top of diastolic dysfunction. Treatments included milrinone infusion and spironolactone dose reduction. Co-morbidities include acute kidney injury, pneumonia, and chronic atrial fibrillation requiring anticoagulation.

- **MEAT Criteria Met**: All components (M, E, A, T) satisfied with explicit documentation and interventions.  
- **Integral Symptoms**: Edema, JVP elevation, and crackles are inherent to heart failure and not separately coded.  
- **Coding Eligibility**: Meets ICD-10-CM guidelines for acute-on-chronic heart failure (I50.43 for combined systolic/diastolic with acute-on-chronic specifiers).

The patient has chronic atrial fibrillation managed with warfarin (Coumadin), documented through INR monitoring and continued post-discharge. This necessitates coding both the underlying arrhythmia (I48.20) and the ongoing anticoagulant therapy (Z79.01).

- **MEAT Criteria Met**: Monitoring (INR tracking), Evaluation (dose adjustment for toxicity), Assessment (discharge continuation plan), and Treatment (active warfarin use).  
- **Key Findings**: Anticoagulation therapy was integral to the admission and discharge plans, with documented adjustments and monitoring.

The patient has documented permanent atrial fibrillation managed with coumadin, right bundle-branch block, left anterior fascicular block, old inferior myocardial infarction, and acute-on-chronic systolic/diastolic heart failure. Comorbidities include cardiac amyloidosis, multiple myeloma, pneumonia, GERD, gout, obstructive sleep apnea, and depression, all confirmed in discharge diagnoses.

The bone marrow biopsy confirmed active multiple myeloma (C90.00), which directly influences current chemotherapy and cardiac management. Z85.79 is added to reflect the historical diagnostic significance of the biopsy, per guideline recommendations for providing contextual information.

The patient has confirmed cardiac amyloidosis (light chain type) with restrictive myopathy, documented via biopsy. This condition caused acute on chronic combined systolic/diastolic heart failure (I50.43), moderate mitral regurgitation, and pulmonary hypertension secondary to left heart failure. The coding follows guidelines requiring both the underlying amyloidosis (E85.81) and cardiomyopathy (I43) to be coded, with additional codes for documented complications.

- **MEAT Strength**: All components show **Strong** evidence.  
- **Documentation Tier**: Tier 1 (discharge diagnosis and explicit care plan).  
- **Bearing on Stay**: Direct bearing via hemodynamic monitoring, chemotherapy adjustments, and discharge infusion setup.

The patient was diagnosed with community acquired pneumonia (CAP) confirmed by CXR showing right upper lobe infiltrate and leukocytosis (WBC 15.9). Treatment with antibiotics (Ciprofloxacin/Levofloxacin) was administered. No specific pathogen was identified, meeting criteria for J18.9 (unspecified organism).

All MEAT components (Monitoring, Evaluation, Assessment, Treatment) are met. CAP is explicitly documented as a primary diagnosis, supported by imaging, labs, and targeted treatment. No evidence suggests CAP symptoms are integral to another condition (e.g., CHF or amyloidosis).

The patient's discharge diagnosis explicitly lists "DEPRESSION/sleep" as stable, with ongoing treatment via amitriptyline (antidepressant) and zolpidem (sleep aid). Documentation confirms active management of both depressive symptoms and insomnia linked to the mental disorder.

The condition meets MEAT criteria for coding due to explicit documentation, stability assessment, and pharmacotherapy. No remission noted; ongoing management confirms active status.

The patient has explicit documentation of "GERD with Barrett's esophagus" in their past medical history and assessment/plan. Omeprazole is maintained throughout the admission, indicating ongoing management. No acute complications like esophagitis or dysplasia are mentioned in the clinical text.

- **Chronicity**: Meets criteria (ongoing treatment, no cure, lifelong management)  
- **Documentation**: Tier 2 (assessment/plan mentions stability and treatment)  
- **MEAT Strength**: Moderate assessment and treatment components  
- **Bearing**: Indirect via medication interactions (e.g., omeprazole's effect on warfarin metabolism) and dietary restrictions impacting heart failure management

Hyponatremia is explicitly documented as a primary discharge diagnosis with sodium levels decreasing from 138 to 131 mEq/L. No specific cause (e.g., renal failure, heart failure) is explicitly linked to the hyponatremia in the clinical text. The condition is managed with spironolactone and torsemide, but these are primarily for heart failure. No neurological symptoms directly attributed to hyponatremia are noted.

- Hyponatremia is explicitly documented as a primary diagnosis.  
- Labs confirm progressive sodium decline.  
- Daily weight tracking and diuretic adjustments demonstrate targeted monitoring and treatment.

OSA is documented in the patient's Past Medical History but no additional details (severity, treatment, or symptoms) are provided. The code G47.33 is selected as the most specific code for obstructive sleep apnea in adults. No complications or symptoms specific to OSA are noted in the clinical text.

OSA is documented only in the PMH with no evidence of monitoring, evaluation, treatment, or impact on current care. The MEAT components all show "None" strength.

The patient has a PICC line placed in the right arm for milrinone infusion during an inpatient stay. The line was documented as intact without erythema or tenderness at discharge. No complications (e.g., infection, displacement) were noted. The PICC line is actively used for ongoing therapy and included in discharge planning for home infusion services.

The patient had a temporary Swan-Ganz catheter placed during inpatient admission for hemodynamic monitoring. The catheter was used to measure pulmonary artery pressures and guide milrinone therapy, meeting coding criteria as an active vascular access device requiring adjustment/management during the encounter.

The Swan-Ganz catheter was actively used for hemodynamic monitoring and treatment decisions during the inpatient stay. It was a temporary device placed during the encounter, meeting coding criteria under inpatient rules for devices with documented MEAT components.

The patient's discharge diagnosis explicitly lists "depression versus adjustment reaction with depression," managed with amitriptyline and zolpidem. Documentation meets inpatient coding criteria for uncertain diagnoses, allowing coding as confirmed. Adjustment disorder with depressed mood (F43.21) aligns with the clinical description and guideline requirements. Z91.89 was rejected as ICD-10-CM does not mandate Z codes for adjustment disorder stressors.

The patient presented with bacteriuria (WBC-3 in urine, leukocyte esterase) but UTI was ruled out by negative culture. Antibiotics were initially administered but discontinued after exclusion. Follow-up care was documented post-resolution.

The potential UTI was evaluated via labs, treated with antibiotics, and resolved by discharge. While the provider dismissed it after negative culture, the initial management met MEAT criteria for clinical significance.

The patient has a history of bone removal from the left foot (2014), documented only in the past medical history. No current clinical impact, monitoring, evaluation, or treatment related to this condition is present in the clinical text.

The "s/p bone removal left foot" is a historical procedure with no clinical impact on the current hospitalization. No MEAT components are present, and the condition is isolated to the PMH section.

The patient has a documented history of cholecystectomy (2012) in the Past Medical History (PMH). No gallbladder-related symptoms, complications, monitoring, or treatment were noted during this admission for heart failure and myeloma management. The condition represents a permanent anatomical change but does not impact current care.

The patient has a documented history of multiple laminectomies but no current symptoms, complications, or clinical involvement related to these procedures during the admission for heart failure management. No active monitoring, evaluation, or treatment for spinal issues was performed.

The laminectomies are purely historical with no active role in the current hospitalization. No MEAT components are present, and the condition does not directly influence treatment decisions or resource use during this admission.

The patient has a documented history of right hip replacement (2170) with no current hip-related symptoms, complications, or interventions during this hospitalization. The encounter focuses on cardiac and oncologic conditions.

The s/p right hip replacement is documented only in PMH with no clinical activity during this admission. No MEAT components are present.

The patient has a documented history of tonsillectomy (performed in 2106) with no current complications or active management related to this procedure during the current hospitalization for heart failure and myeloma treatment.

The "2+ peripheral pulses" are documented but not clinically significant. They are part of routine extremity exams and not linked to a specific diagnosis, further evaluation, or treatment.

The cardiac catheterization was performed **during this admission** to monitor pressures and guide therapy. Historical catheterization findings are noted but do not impact current care.

The "chronically ill appearance" was noted once in the admission exam but was not monitored, evaluated, or treated separately. It is fully explained by the patient’s confirmed chronic conditions (cardiac amyloidosis, multiple myeloma, CHF). No clinical actions were taken specifically for this finding.

- **MEAT Components:** None of the MEAT criteria (monitoring, evaluation, assessment, treatment) are met.  
- **Qualifying Terms:** None (e.g., "borderline" or "suspected") are used, but the lack of clinical action indicates it is incidental.  
- **Setting:** Inpatient status does not override the absence of clinical significance.

The findings are fully explained by the patient’s confirmed diagnoses of cardiac amyloidosis and heart failure. MEAT criteria are met through monitoring (Swan-Ganz), evaluation (catheterization), explicit provider linkage in the assessment, and targeted treatment. No separate abnormal finding codes are needed.

The family history of hay fever was documented but did not trigger any monitoring, evaluation, assessment, or treatment changes during this inpatient stay. No clinical actions were tied to this history.

The RV biopsy is a historical procedure performed prior to this admission. Its results are critical to the current diagnosis and management but do not constitute a procedure performed during this encounter. No monitoring, evaluation, or treatment related to the biopsy itself is documented in this admission.

The right heart catheterization was performed **during this inpatient encounter** to diagnose and manage heart failure. It directly influenced treatment (milrinone), required active monitoring, and was documented as a current procedure. No historical catheterization impacts current care.

The Swan-Ganz catheter was placed **during this admission** for acute hemodynamic monitoring. It was actively used to measure pressures, guide milrinone therapy, and adjust care. The catheter was repositioned per CXR findings and removed prior to discharge, with no post-discharge use documented.

- **Swan-Ganz Catheter**: Critical for hemodynamic monitoring and guiding milrinone therapy.  
- **Pleural Effusion/Cardiomegaly**: Stable findings explained by CHF/amyloidosis, no separate workup needed.  
- **PICC Line**: Essential for ongoing milrinone administration post-discharge.

The systolic murmur is an incidental finding with no associated monitoring, evaluation, or treatment. It is likely a manifestation of the patient’s known cardiac conditions (amyloidosis, mitral regurgitation) and does not meet criteria for separate coding.

Weight gain was fully explained by acute decompensated heart failure and cardiac amyloidosis. All interventions (diuretics, inotropes, imaging) addressed the underlying conditions. No independent management or workup for weight gain beyond heart failure management was documented.

No evidence of coumadin non-adherence during antibiotic treatment exists in the documentation. The elevated INR was pharmacologically induced by levofloxacin, not patient behavior. No MEAT criteria met for noncompliance coding.

No MEAT criteria met for noncompliance coding. All care adjustments were medically driven, with no provider documentation linking care changes to patient noncompliance.

The "s/p appendectomy" is an isolated historical procedure with no clinical activity or impact on the current inpatient stay. No MEAT components are present, and the condition does not influence treatment, monitoring, or outcomes.

The "s/p deviated septum repair" is a historical procedure with no clinical impact on the current hospitalization. No MEAT components (monitoring, evaluation, assessment, or treatment) were documented for this condition during the stay.

The "s/p hemorrhoidectomy" is a historical procedure with no current clinical significance. No MEAT components (monitoring, evaluation, assessment, or treatment) were documented, and the condition did not influence the hospital stay.

The "s/p pilonidal cyst removal" is a historical procedure with no current clinical relevance. No MEAT components (monitoring, evaluation, assessment, or treatment) were documented for this condition during the hospital stay.

The "s/p tailers bunion removal" is a historical procedure with no active clinical impact during this admission. No MEAT components were engaged, and the condition was not addressed in care planning.

The condition "s/p tailers bunion, fascia release, prosthesis (left foot)" is documented solely in the PMH. No MEAT components (monitoring, evaluation, assessment, or treatment) are present during the current hospitalization. The procedure is unrelated to the patient’s acute presentation or care.

The patient has no current or historical tobacco use documented. The sole mention ("never smoked") negates any need for coding or clinical action related to tobacco.

Chief complaint and symptom of CHF exacerbation

Patient with baseline restrictive disease from cardiac amyloidosis, presenting with volume overload, edema, and elevated JVP

Stable on coumadin, with CHADS score of 2

Confirmed by RV biopsy, causing restrictive heart disease and CHF

Confirmed by bone marrow biopsy (40% plasma cells), on dexamethasone/velcade treatment

Part of past medical history, current status not addressed in admission

Part of past medical history, not actively managed during admission

Part of past medical history, not active issue during admission

Developed during admission with cough and leukocytosis, treated with antibiotics

Lab finding during admission (Na 131 at discharge)

Developed during aggressive diuresis, resolved to baseline creatinine

II/VI systolic murmur at apex, related to cardiac amyloidosis

Diagnostic procedure showing elevated filling pressures

Diagnostic procedure confirming cardiac amyloidosis

Diagnostic procedure confirming multiple myeloma

Showed 50% left main disease and 50% LAD stenosis

Coronary findings from catheterization, managed medically due to high risk

Cardiac cath findings related to amyloidosis and CHF

EKG findings of chronic conduction abnormalities

Temporary issue during fluoroquinolone treatment for pneumonia

Patient and family declined palliative care at this time

Nephrology consult opinion on acute kidney injury

Coumadin management for atrial fibrillation

Negative for amyloid (performed during previous admission)

Temporary monitoring device during admission

s/p cardiac catheterization with e/o 50% left main disease, 50% LAD stenosis

Nephrology was consulted and felt this was likely ATN vs pre-renal due to hypoperfusion.

Abdominal fat pad biopsy both performed [ * * 5 - 28 * * ] , revealed no amyloid

[ * * Last Name ( un ) * * ] < > Pt developed [ * * Last Name ( un ) * * ] in the setting of aggressive diuresis.

Patient with baseline restrictive disease secondary to his cardiac amyloid. Also with systolic CHF first seen [ * * 5 - 21 * * ] with RV free wall hypokinesis.

EKG [ * * 2178-8-25 * * ] Atrial fibrillation. Right bundle-branch block. Left axis deviation. Left anterior fascicular block. Old inferior myocardial infarction. Compared to the previous tracing of [ * * 2178-8-22 * * ] no significant changes are noted.

Simethicone 40 - 80 mg PO QID < > PRN bloating

bone marrow biopsy with e/o multiple myeloma

s/p bone removal left foot ( [ * * 2114 * * ] )

RV biopsy demonstrated cardiac amyloidosis

It was decided that the patient was too high risk for CABG, as well as PCI given his amyloidosis and was discharge on medical management of his CAD. He was continued on atorvastatin 80 mg daily, ASA 162 mg daily, metoprolol 12.5 mg [ * * Hospital1 * * ].

For the remainder of 10 day abx course, his coumadin was held.

# DEPRESSION / sleep < > stable , continued amitriptyline , zolpidem.

Since discharge , the patient reports weight gain , as well as DOE.

He waited until he was seen by Dr. [ * * Last Name ( STitle ) * * ] on [ * * 2178 - 7 - 22 * * ] where he was noted to have elevated JVD and 3 + LE edema.

DEPRESSION / sleep. stable, continued amitriptyline, zolpidem.

-?depression versus adjustment reaction with depression

s/p deviated septum repair ( [ * * 2168 * * ] )

He also continued dexamentasone / velcade treatment while inpatient. Cycle4 Day8 Velcade administration on [ * * 8 - 25 * * ]. Will continue treatment with Dr. [ * * Last Name ( STitle ) 109643 * * ].

Past Medical History < > Afib on coumadin Diastolic heart failure ( EF 60 - 65 % )

but after weaning milrinone , he required reinitiation of milrinone in the CCU due to drop off in energy level , urine output an reaccumulation of fluid.

Past Medical History < > Afib on coumadin Diastolic heart failure ( EF 60 - 65 % ) OSA Gout GERD with Barrett's esophagus Hiatal hernia Elevated PSA

Cardiac Cath Report [ * * 8-19 * * ] < > Elevated right- and left-sided filling pressures, moderate pulmonary arterial hypertension in the setting of left-sided heart failure, large V waves suggestive of moderate to severe mitral regurgitation. Normal cardiac output and index.

Past Medical History < > Afib on coumadin Diastolic heart failure ( EF 60 - 65 % ) OSA Gout GERD with Barrett's esophagus Hiatal hernia Elevated PSA Erectile dysfunction

GERD with Barrett's esophagus. stable, continued omeprazole, home tums.

Past Medical History < > Afib on coumadin Diastolic heart failure ( EF 60 - 65 % ) OSA Gout GERD with Barrett's esophagus

Past Medical History < > Afib on coumadin Diastolic heart failure ( EF 60 - 65 % ) OSA Gout

GOUT. stable, continued allopurinol, colchine, tramadol prn.

s/p hemorrhoidectomy ( [ * * 2126 * * ] )

Past Medical History < > Afib on coumadin Diastolic heart failure ( EF 60 - 65 % ) OSA Gout GERD with Barrett's esophagus Hiatal hernia

PRIMARY -acute on chronic systolic heart failure -amyloidosis with restrictive myopathy -multiple myeloma -community acquired pneumonia -Hyponatremia -acute kidney injury -atrial fibrillation

Gaviscon * NF * ( [ * * First Name5 ( NamePattern1 ) * * ] [ * * Last Name ( NamePattern1 ) * * ] -Mg tr - alg ac - sod bicarb;<br > aluminum hydrox - magnesium carb ) 80 - 14.2 mg Oral prn indigestion

Sarna Lotion 1 Appl TP DAILY < > PRN itchy

requiring CCU admission for initiation of milrinone drip

He was then transferred to the ICU for diuresis with milrinone for inotropic effect and pulomary vasodilation allowing right sided unloading. His right heart pressures were monitored by swan - ganz cath with PA pressure 50 to 40s and wedge pressures of 28 to 19 after administartion of milrinone. He diuresed well in the CCU, was transfered to the floor, but after weaning milrinone, he required reinitiation of milrinone in the CCU due to drop off in energy level, urine output an reaccumulation of fluid. He tolerated reinstitution of milrinone infusion well and was transferred to the floor.

It was determined that you will need it chronically infusing from now on. Home services to assist with this have been set up for you.

s/p multiple laminectomies ( [ * * 2164 * * ] , [ * * 2151 * * ] , [ * * 2148 * * ] )

ECHO showed e/o new systolic heart failure on top of preexisting diastolic heart failure

Past Medical History < > Afib on coumadin Diastolic heart failure ( EF 60 - 65 % ) OSA

He denies orthopnea , PND , palpitations , syncope or presyncope.

PICC Line in right arm w/o erythema or tenderness

Major Surgical or Invasive Procedure < > PICC line placement

Family has met w/ palliative team and wife expresses that the conversation is "premature". Pt and wife have not signed DNR and still solidifying long - term plans.

s/p pilonidal cyst removal ( [ * * 2120 * * ] )

He also had a bandemia of 9% and was initially treated for a potential UTI.

His CXR showed recurrent right pleural effusion

Major Surgical or Invasive Procedure < > right heart catheterization

s/p right hip replacement ( [ * * 2170 * * ] )

s/p tailers bunion removal ( [ * * 2166 * * ] )

s/p tailers bunion, fascia release, prosthesis ( left foot ) ( [ * * 2169 * * ] )

s/p tendon repair right arm ( [ * * 2145 * * ] )

RENAL ULTRASOUND < > 1. No hydronephrosis. Simple bilateral renal cysts. 2. Right pleural effusion and trace of ascites seen in the right upper quadrant. 3. Arterial and venous flow is documented within each of the kidneys, however, further Doppler analysis can not be performed as the patient is unable to hold his breath.

Zolpidem Tartrate 10 mg PO HS < > PRN sleep

the patient has received a Swan-Ganz catheter

CXR [ * * 2178 - 8 - 20 * * ] < > As compared to the previous radiograph, the patient has received a Swan-Ganz catheter.

CXR [ * * 2178-8-20 * * ] < > As compared to the previous radiograph, the patient has received a Swan-Ganz catheter. The catheter needs to be pulled back given that the tip is projecting over distal parts of the right pulmonary artery. An opacity that pre-existed at the bases of the right upper lobe is no longer visible. However, the lung volumes have decreased and a small pleural effusion is unchanged at the right lung base. Unchanged moderate cardiomegaly. The right PICC line is constant in position.

Cycle4 Day8 Velcade administration on [ * * 8 - 25 * * ]

<think>
Okay, let's tackle this step by step. First, I need to thoroughly read the clinical note provided. The patient is a 77-year-old male with a history of systolic and diastolic CHF, atrial fibrillation, cardiac amyloidosis, and multiple myeloma. He was admitted for weight gain and DOE, needing aggressive diuresis and chemotherapy.

Starting with the primary reason for the encounter: the chief complaint is weight gain and DOE, which points towards heart failure exacerbation. The clinical summary should mention his transfer for volume overload, use of Lasix, and subsequent need for milrinone. Key findings include cardiac amyloidosis confirmed by biopsy, multiple myeloma with bone marrow results, and community-acquired pneumonia during the stay.

Next, listing all medical entities. From the note, I need to extract each condition, symptom, procedure, etc., exactly as stated. For example, "systolic and diastolic CHF" is a diagnosis, "weight gain" is a symptom, "PICC line placement" is a procedure. I have to ensure I don't miss any entities mentioned in the HPI, PMH, assessments, etc.

Now, categorizing each entity. "Cardiac amyloidosis" is a diagnosis, "RV biopsy" is a procedure. For each, I need to note where in the text it's mentioned. Assertion statuses: most are present, some like past surgeries are historical. Severity and temporality: acute on chronic CHF, moderate pulmonary hypertension.

Relationships: Cardiac amyloidosis leads to restrictive cardiomyopathy, which contributes to CHF. Milrinone treats the heart failure. Multiple myeloma relates to the amyloidosis. I need to link these appropriately.

Differential diagnoses: The pneumonia could be bacterial given leukocytosis and treatment with fluoroquinolones. The AKI could be prerenal from diuresis vs ATN.

Ambiguities: The "change in mental status" was attributed to multiple factors; it's unclear which was primary. Also, the palliative care discussion being "premature" indicates unresolved goals of care.

Clinical impact: CHF and amyloidosis are critical, requiring milrinone and close monitoring. Multiple myeloma needs ongoing chemo. Pneumonia was treated but affected INR.

Care coordination needs cardiology, hematology, home health for milrinone, and monitoring weights and INR.

Medications: Torsemide and spironolactone for CHF, warfarin for afib, allopurinol for gout. Each medication must be linked to its condition. Exceptions would be any meds without a documented condition, but in this case, they all seem accounted for.

I need to ensure all entities are as written, no interpretations. For example, "50% LAD stenosis" is a finding from cath, not a diagnosis. Also, therapy regimens like chemotherapy with Velcade and dexamethasone are noted as treatment plans, not just med names.

Finally, cross-checking to make sure all sections of the note are covered, especially procedures, labs, and discharge diagnoses. Each entity should be listed once, with evidence from the text. Making sure not to combine or separate conditions unless explicitly stated.
</think>

<clinical_summary>
77-year-old male with cardiac amyloidosis, multiple myeloma, and chronic heart failure admitted for acute decompensation with weight gain and dyspnea. Key findings include acute-on-chronic systolic/diastolic heart failure requiring milrinone infusion, community-acquired pneumonia, and acute kidney injury. Hospital course involved aggressive diuresis, chemotherapy continuation, and management of anticoagulation complications. Discharged on chronic milrinone therapy with home health services.
</clinical_summary>

<identified_medical_entities>
1. Acute on chronic systolic heart failure - Worsening cardiac function requiring IV diuresis
2. Diastolic heart failure (EF 60-65%) - Baseline restrictive cardiomyopathy
3. Cardiac amyloidosis - Confirmed by RV biopsy
4. Multiple myeloma - 40% plasma cells on bone marrow biopsy
5. Community-acquired pneumonia - Treated with fluoroquinolones
6. Atrial fibrillation - Managed with warfarin
7. 50% left main disease - Coronary artery disease finding
8. 50% LAD stenosis - Coronary artery stenosis
9. Moderate pulmonary arterial hypertension - Cath findings
10. Moderate-severe mitral regurgitation - Large V waves on cath
11. Right bundle branch block - EKG finding
12. Left anterior fascicular block - Conduction abnormality
13. Barrett's esophagus - GERD complication
14. Obstructive sleep apnea - PMH documented
15. Acute kidney injury - Creatinine elevation to 2.3
16. Hyponatremia - Na 131 on discharge
17. PICC line placement - Vascular access procedure
18. Right heart catheterization - Swan-Ganz placement
19. Milrinone infusion - Inotropic therapy
20. Velcade/dexamethasone regimen - Multiple myeloma treatment
</identified_medical_entities>

<relationships>
1. Cardiac amyloidosis → Restrictive cardiomyopathy → Systolic/diastolic HF
2. Milrinone infusion ← Treatment for → Acute HF exacerbation
3. Multiple myeloma → Potential cause of → Cardiac amyloidosis
4. Aggressive diuresis → Contributed to → Acute kidney injury
5. Fluoroquinolone therapy → Caused → Supratherapeutic INR
6. Coronary artery disease → Contributes to → Chronic heart failure
7. Barrett's esophagus ← Chronic GERD management
8. Velcade regimen ← Directed at → Multiple myeloma
9. OSA ← Comorbid condition affecting → Cardiopulmonary status
10. PICC line ← Enables → Chronic milrinone administration
</relationships>

<differential_diagnosis>
1. Acute mental status changes: Uremia vs medication effect vs amyloid CNS involvement
2. AKI etiology: Pre-renal vs ATN vs myeloma kidney
3. Pleural effusion: CHF vs parapneumonic vs amyloid-related
4. Weight gain: Cardiac decompensation vs corticosteroid effect vs renal dysfunction
</differential_diagnosis>

<ambiguities>
1. "Change in mental status" attribution - Multiple documented causes without clear primary
2. Palliative care status - Family describes discussion as "premature"
3. Long-term milrinone safety - No documented discussion of alternatives
4. Amyloid typing - Fat pad biopsy negative but cardiac positive
</ambiguities>

<clinical_impact>
1. Critical: Cardiac amyloidosis with restrictive physiology (dictates prognosis)
2. High: Chronic milrinone dependence (requires home infusion team)
3. High: Multiple myeloma treatment (ongoing Velcade cycles)
4. Moderate: Anticoagulation management (INR instability risk)
5. Moderate: 40lb weight fluctuation (CHF monitoring imperative)
6. Moderate: CAD with left main disease (limits therapeutic options)
</clinical_impact>

<care_coordination>
1. Cardiology: Milrinone titration, Swan monitoring
2. Hematology: Velcade chemotherapy coordination
3. Home health: IV infusion management
4. Anticoagulation clinic: Warfarin monitoring
5. Palliative care: Future goals discussion
6. Physical therapy: Mobility assessment
7. Nephrology: Renal function monitoring
</care_coordination>

<medication>
1. Milrinone: Heart failure (Active, Chronic infusion)
2. Torsemide: CHF (Active, Dose adjusted)
3. Spironolactone: CHF (Active, Reduced dose)
4. Warfarin: Atrial fibrillation (Active, Dose adjusted)
5. Velcade: Multiple myeloma (Active, Cycle 4)
6. Dexamethasone: Multiple myeloma (Active, Chemo combo)
7. Allopurinol: Gout (Active, Maintenance)
8. Colchicine: Gout (Active, Prophylaxis)
9. Zolpidem: Sleep (Active, PRN)
10. Omeprazole: GERD (Active, BID dosing)
11. Exception: Multivitamins (No specific condition documented)
</medication>

The patient has atrial fibrillation (AFib) managed with long-term warfarin therapy. Documentation includes ongoing INR monitoring (Z51.81), supratherapeutic INR requiring dose adjustments (R79.1), and indefinite anticoagulation use (Z79.01). The underlying AFib (I48.91) is explicitly coded as the indication for therapy.

The patient’s anticoagulation therapy meets all MEAT criteria: ongoing monitoring (INR checks), evaluation of therapy adjustments, explicit acknowledgment of indefinite use, and active continuation of warfarin. No evidence of discontinuation or historical use is present.

The patient has benign prostatic hyperplasia (BPH) documented as stable with ongoing doxazosin therapy. No explicit lower urinary tract symptoms (e.g., retention, frequency) are noted in the clinical text, meeting criteria for N40.0 (BPH without symptoms).

The patient has confirmed cardiac amyloidosis via right ventricular biopsy, leading to restrictive myopathy and acute on chronic diastolic heart failure. The condition is actively managed with milrinone, diuretics, and myeloma therapy. Discharge diagnoses explicitly include "amyloidosis with restrictive myopathy" and "acute on chronic systolic and diastolic heart failure."

The condition meets all MEAT criteria with **strong evidence** across monitoring (CXR/BNP), evaluation (biopsy/echo), assessment (EF metrics), and treatment (milrinone/coumadin adjustments). It is explicitly documented in discharge diagnoses, drives therapeutic decisions, and requires ongoing management.

The patient has acute-on-chronic combined systolic and diastolic heart failure secondary to cardiac amyloidosis and multiple myeloma. Key features include pulmonary hypertension due to left heart failure, moderate-to-severe mitral regurgitation, and chronic milrinone infusion therapy. Documentation explicitly states indefinite milrinone use and home infusion setup, meeting criteria for long-term drug therapy coding.

All MEAT criteria met with strengthened evidence:  
- **Monitoring**: Quantified weight targets + specific follow-up dates  
- **Evaluation**: Antibiotic-coumadin interaction management + catheterization-guided dosing  
- **Assessment**: Explicit chronicity documentation + coronary anatomy impact  
- **Treatment**: Home infusion coordination + palliative care integration

The patient has chronic coronary artery disease (3VD with left main/LAD stenosis) managed medically with aspirin, atorvastatin, and metoprolol. No angina is documented. Long-term drug therapy is indefinite.

- **MEAT Criteria Met**: Assessment (strong) and Treatment (moderate) meet threshold.  
- **ICD-10 Relevance**: Z79.82 (aspirin) and Z79.8 (metoprolol) apply. Atorvastatin exclusion in discharge weakens Z79.8 coding for statins.  
- **Discrepancy**: Atorvastatin mentioned in narrative but absent in discharge meds requires reconciliation.

The patient has documented "DEPRESSION/SLEEP" managed with amitriptyline and zolpidem. The condition is labeled as stable with ongoing medication, meeting coding criteria for chronic depression and insomnia linked to mental disorder.

The condition meets MEAT criteria due to:  
- Weak monitoring via mental status exams.  
- Moderate assessment (stability documentation + medication continuity).  
- Strong treatment.  
Chronicity is supported by long-term medication use and no resolution noted.

The patient has GERD with confirmed Barrett's esophagus (without dysplasia), managed with indefinite omeprazole therapy. Documentation explicitly states stable status with continued PPI use, meeting criteria for chronic management coding. No acute complications or dysplasia are noted.

- **MEAT Criteria Met**: Assessment (strong) + Treatment (strong) = 2+ components.  
- **Indefinite Therapy**: No end date for omeprazole; provider confirms ongoing need.  
- **Coding Eligibility**: Z79.8 applies for indefinite PPI therapy despite minimal monitoring/evaluation.

The patient has documented GERD with Barrett's esophagus in the Past Medical History and assessment. The condition is managed with omeprazole and Tums, indicating ongoing treatment. No acute symptoms (e.g., dysplasia, esophagitis) are mentioned in the clinical text.

The patient has documented chronic gout managed with allopurinol and colchicine, confirmed as secondary to multiple myeloma (C90.00). No acute flares or tophi are noted during this admission.

- **Chronicity**: Gout meets chronic criteria (requires ongoing medication, no cure, and long-term management).  
- **Documentation Tier**: Tier 3 (PMH + reference in assessment/medications).  
- **MEAT Strength**: Treatment (Strong) and Assessment (Moderate) meet coding thresholds.  
- **Bearing on Stay**: Indirect (medications require monitoring for interactions/side effects, e.g., colchicine’s renal dosing adjustments given elevated creatinine).

The patient has a documented history of stable gout managed with allopurinol and colchicine. No acute flares or tophi are noted. The clinical text explicitly states continuation of gout medications, indicating ongoing chronic management. Multiple myeloma is present, suggesting a potential secondary cause of hyperuricemia.

- **MEAT Strength**: Assessment (A) and Treatment (T) are strongly documented.  
- **Key Evidence**: Stable status, unchanged medications, and explicit indefinite continuation.  
- **Missing Elements**: No uric acid monitoring or joint exam findings.

Hyponatremia is explicitly listed as a primary discharge diagnosis with documented sodium levels decreasing from 138 mEq/L (admission) to 131 mEq/L (discharge). Nephrology consultation and medication adjustments (torsemide, spironolactone) support active management of the condition.

Hyponatremia meets MEAT criteria:  
- **Monitoring**: Serial sodium measurements.  
- **Evaluation**: Labs and nephrology consult linked to sodium imbalance.  
- **Assessment**: Explicitly documented as a primary diagnosis.  
- **Treatment**: Diuretic adjustments with nephrology guidance.  
Not an integral symptom of chronic conditions (e.g., CHF, amyloidosis).

Milrinone infusion therapy was administered for acute-on-chronic systolic and diastolic heart failure secondary to cardiac amyloidosis and multiple myeloma. Documentation explicitly states chronic infusion requirements with hemodynamic monitoring and renal function tracking. Underlying conditions (amyloidosis, myeloma) are actively managed and impact therapy decisions.

Milrinone infusion meets all MEAT criteria with:  
- Quantitative hemodynamic monitoring  
- Adjustments based on objective response metrics  
- Explicit chronic continuation plan  
- Integral role in managing heart failure alongside diuretics

The patient has confirmed multiple myeloma with active treatment (Velcade/dexamethasone) and biopsy-confirmed cardiac amyloidosis secondary to myeloma. Discharge diagnosis explicitly lists multiple myeloma as primary, meeting criteria for C90.00. Amyloidosis (E85.81) is required as a secondary code per ICD-10-CM guidelines for neoplasm-associated amyloidosis.

Multiple myeloma is actively documented in discharge diagnoses, supported by definitive diagnostic testing (bone marrow biopsy), ongoing chemotherapy (Velcade Cycle4), and direct clinical management (INR monitoring for amyloidosis-related coagulopathy). All MEAT components demonstrate strong evidence of active disease impacting the hospitalization.

The patient is undergoing active treatment for multiple myeloma with Velcade and dexamethasone during inpatient admission. Documentation includes Cycle4 Day8 Velcade administration, continued outpatient oncology follow-up, and discharge orders for ongoing therapy. Cardiac amyloidosis confirmed by biopsy and associated cardiomyopathy are directly related to the myeloma. Chemotherapy administration during the encounter supports Z51.11 as a secondary code.

The patient received active chemotherapy (Velcade/dexamethasone) with documented administration, monitoring of hematologic/renal parameters, safety adjustments, and explicit continuation plans. The therapy is central to the encounter, satisfying MEAT criteria for coding.

The RV biopsy confirmed cardiac amyloidosis secondary to active multiple myeloma (C90.00), leading to restrictive cardiomyopathy (I43) and acute-on-chronic heart failure (I50.43). Velcade chemotherapy administration (Z51.11) was documented as part of myeloma treatment.

The RV biopsy definitively established cardiac amyloidosis, which was actively managed with chemotherapy, diuretics, and quantitative monitoring. All MEAT components (Monitoring, Evaluation, Assessment, Treatment) are strongly met.

The patient received inpatient Velcade (bortezomib) administration for multiple myeloma treatment. The encounter included active chemotherapy administration, monitoring of drug interactions (e.g., elevated INR managed by adjusting coumadin), and discharge plans for continued therapy. The adverse effect of drugs (T50.995D) and underlying malignancy (C90.2) are required per ICD-10-CM guidelines.

Velcade administration was an active component of the inpatient stay with robust monitoring of myeloma-specific parameters (light chains), renal function, and drug interactions. While efficacy assessment was indirect, the discharge plan confirms ongoing therapy. The encounter addressed both CHF exacerbation and chemotherapy administration, requiring dual coding.

The patient developed acute kidney injury (AKI) during hospitalization, evidenced by rising creatinine (peaking at 2.3 mg/dL) attributed to aggressive diuresis with Lasix and torsemide. Nephrology consultation confirmed the diagnosis, and the condition resolved with treatment adjustments. No specific etiology (e.g., tubular necrosis) was definitively documented.

- **MEAT Criteria Met**: All components (M, E, A, T) satisfied with strong evidence.  
- **Not Integral**: AKI explicitly attributed to diuretic overuse, not chronic conditions.  
- **Acute Resolution**: Creatinine returned to baseline post-intervention.