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14500788-DS-5 | 23,864,285 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had high blood pressure and chest
pain.
What happened while I was in the hospital?
- Because you had chest pain, we did blood tests and an EKG to
look at your heart. Both of these tests looked normal which is
reassuring. You should follow up with your outpatient
cardiologist, Dr. ___ 3 weeks after leaving the
hospital. *** Please call ___ to schedule an
appointment. ***
- You were also found to have high blood pressure, so we started
you on your home blood pressure medication (carvedilol). We also
started another medication called Losartan. Your blood pressure
is now back to normal.
- You were also found to have low sodium in your blood. We gave
you fluid through your veins to correct this, and your sodium
level returned to normal. We also stopped your home medication
(Hyzaar) because this can cause low sodium in your blood. Please
stop taking this medication at home.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team | ====================
ASSESSMENT AND PLAN:
====================
Ms. ___ is a ___ with h/o GERD, a fib on rivaroxaban, HTN,
HLD who presents for atypical chest pain and found to have
hyponatremia.
============= | 232 | 28 |
18093133-DS-17 | 27,853,818 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
-Splint must be left on until follow up appointment unless
otherwise instructed
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity
Physical Therapy:
Weight bearing as tolerated in left lower extremity
Treatments Frequency:
Dressing changes as needed for comfort only. Dressings are not
needed as long as wound continues to be non draining. Staples
will be removed at follow up appointment. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left tib/fib fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction internal fixation of
left tib/fib fracture which the patient tolerated well (for full
details please see the separately dictated operative report).
The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 173 | 244 |
15396153-DS-16 | 25,626,552 | Craniotomy for Hemorrhage
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
You may shower.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this only after clearance from your
neurosurgeon.
You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101.5° F. | Ms. ___ was admitted to ___ under the care of Dr.
___ and On ___ she was taken emergently to the OR for a
craniotomy. She was trasnferred to the TSICU post-op erativeyl,
CT imaging showed expected post-op changes.
On ___: Repeat Head CT was done earlier due to concern for
increased confusion in TICU; There was slight improvement.
Sutures placed around JP drain site due to bleeding. She was
transferred to the SDU in stable condition on ___. MRI done on
___ was negative for acute or subacute stroke. On ___, her
HCO3 was low at 13, an ABG was ordered which then showed she was
metabolic acidotic. Renal was consulted for further management.
She remained aphasic, following commands, and noded her head
appropriately intermittently. EEG monitoring was started on ___
to further evaluate her aphasia as her MRI head was negative for
stroke. on ___ her NG tube was replaced and tubefeeds were
started. Medicine was consulted for further management of her
DKA. They recommended changing her insulin to regular and when
TF to goal can d/c IVF. Repeat head CT was performed for R
pronator drift which was stable. EEG showed no seizure activity.
NG tube was pulled out by patient overnight.
On ___, her exam improved, she was able to say her name and
hospital. She continued to follow commands. She was able to take
her pills craushed with ice cream, a formal speech and swallow
evaluation was ordered. Her HA1C was 7.8. EEG showed no seziure
activity for 48 hrs and was discontinued.
Patient's examination continued to improve on ___ with her
aphasia demonstrating signs of resolving by her ability to say
her name and current location.
On ___, her staples were removed. Her exam continues to
improve. She received a bed at ___. | 249 | 296 |
12465435-DS-10 | 25,234,523 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___. Please find detailed discharge instructions
below:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because you appeared to have elevated
potassium levels in your blood, and you had some premature heart
beats, noted at your outpatient urology appointment.
WHAT HAPPENED TO YOU IN THE HOSPITAL?
- Your blood potassium levels were rechecked and found to be
within the normal range. The first potassium level at your
outpatient appointment was falsely elevated because the blood
had deteriorated in the collection tube.
- You had occasional premature heart beats, as seen on the heart
monitor, but you did not have any symptoms from it. Occasional
premature heart beats are very common and not dangerous.
- Your urine was examined in the lab and sent for a culture.
Your urine looks like it may have an infection, but it is
difficult to tell because of your complicated kidney history
with the PCN tube (percutaneous nephrostomy tube) and ureter
stent. You also did not seem to have obvious symptoms of a urine
infection. However, because of your complicated medical history,
we felt it was best to be safe and treat you with antibiotics
for a possible urinary tract infection.
- You received IV antibiotics while you were in the hospital for
a urinary tract infection.
- You were transitioned to oral antibiotics to take as an
outpatient.
- CT scan of your chest and abdomen showed that you had a
prostate mass, with lesions in the bone that were concerning for
metastatic cancer.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please follow up with your urologist and oncologist outpatient
to discuss further cancer testing and options.
- Please follow up with your PCP.
- Please take all your medications as prescribed.
- In particular, please complete a total 7-day course of
antibiotics. You last day of antibiotics will be on ___.
We wish you the best!
- Your ___ treatment team | ======================
BRIEF SUMMARY
======================
___ man with history of bladder cancer, prostate cancer,
TCC, left nephroureterectomy with percutaneous nephrostomy,
right renal pelvic tumor who presented from clinic with initial
concern for hyperkalemia and PVCs on ECG.
Initial presenting hyperkalemia was determined to be falsely
elevated from a hemolyzed sample, and repeat potassium was
within normal range.
He was monitored overnight on telemetry, which revealed
occasional PVCs, from which he was asymptomatic. Urine analysis
was possibly suggestion of a UTI, though difficult to interpret
in the setting of his complicated history with percutaneous
nephrostomy tube. Though he was asymptomatic, he did have mild
leukocytosis, so he was treated for UTI with ceftriaxone, then
transitioned to amoxicillin (history of enterococcus UTI in the
past, urine culture is pending), to complete a 7-day course of
antibiotics for complicated UTI.
CT chest/A/P revealed findings concerning for a recurrence of
his prostate cancer (PSA markedly elevated and imaging showing
numerous bone mets and a large mass arising from the prostate).
==========================
PROBLEM-BASED SUMMARY
==========================
ACUTE PROBLEMS:
#Hyperkalemia:
He was found to have K 6.3 at his outpatient urology visit, but
from a hemolyzed specimen. EKG at outpatient visit showed PVCs,
so he was referred to the ED. This admission, he was found to
have potassium levels within the normal range (ranging from 4.4
to 5.2 on nonhemolyzed samples). EKG and telemetry revealed
moderate PVC burden from which was asymptomatic, no other
changes. No intervention was required for pseudohyperkalemia. At
the time of discharge he did have a mild true hyperkalemia which
we did not treat as this is likely chronic and well tolerated in
the setting of his known CKD.
#Premature ventricular contractions:
Occasional PVCs were noted on EKG and telemetry, moderate
burden. Given that his potassium level was within the normal
range, and he was asymptomatic, he did not require further work
up.
#UTI:
He had a UA significant for large leukocytes and large blood, in
the setting of leukocytosis 12.5 on admission. He was
asymptomatic, but in the setting of his complicated medical
history, s/p L nephrectomy and now with R percutaneous
nephrostomy tube and ureter stent, as well as his leukocytosis,
he was treated for possible UTI. He received ceftriaxone
(___), then was transitioned to amoxicillin (as he grew
enterococcus in the past) to complete a total 7-day course of
antibiotics (last day on ___. Urine culture was pending at
discharge. Please follow up urine culture to guide treatment.
#R Nephrostomy tube, ureter stent
#R Hydronephrosis:
He was evaluated by urology who thought his nephrostomy tube to
be draining well, no concern for obstruction despite mild
hydronephrosis noted on CT, without indication for intervention.
He does have hydronephrosis seen at OSH abdominal ultrasound
with right indwelling ureteral stent. He should follow up with
urology regarding scheduled ureteroscopy and laser ablation with
Dr. ___ on ___.
#CKD vs ___:
Creatinine was elevated at 2.4 from prior baseline of around
1.8. Elevated creatinine at this admission likely represents new
baseline creatinine due to progression of his renal disease.
Less likely obstructive ___ from prostate mass. Low concern for
obstruction from nephrostomy tube given urology evaluation with
good urine output.
#Malignancy
#Suspicion for recurrent prostate cancer w/ bone metastasis
He has a history of prostate cancer previously treated in
___, with likely prostatectomy or partial prostatectomy
followed by radiotherapy in ___. PSA had resolved to ___ in
___. Recently, a PSA surveillance at PCP was elevated at 241.
Repeat PSA performed day prior to admission was elevated at 388.
CT torso showed a prostate mass and bony lesions concerning for
metastatic prostate cancer. Patient and his family were made
aware of the imaging findings, and the high suspicion for
recurrence of prostate cancer with metastases. Patient generally
defers medical decision making to his family, but he did ask
questions about the work up his cancer and appears to understand
the situation. Patient and family were informed of the necessity
of oncology follow-up as an outpatient. He has an appointment
scheduled with Dr. ___. He does complain of bony
sacral pain, controlled with Tylenol, possibly related to
malignancy.
CHRONIC PROBLEMS:
#HTN: He was normotensive and was continued on home amlodipine
5mg.
#Constipation: He was continued on home colace PRN.
#Depression: He was continued on home duloxetine.
==========================
TRANSITIONAL ISSUES
==========================
- He will finish total 7-day course of antibiotics, last day of
amoxicillin is on ___.
- Please follow up results of urine culture to guide treatment.
- He has CT findings suspicions for recurrent prostate cancer
with bony metastases, in the setting of elevated PSA. Patient
and family are aware.
New medications: amoxicillin
Changed medications: none
Stopped medications: none
#CODE: Full (presumed)
___
Relationship: wife
Phone number: ___ | 338 | 771 |
11839448-DS-16 | 27,830,035 | Dear Ms. ___,
You were transferred to ___ for evaluation of your
abdominal pain. A CT scan of your abdomen done at ___
___ showed inflammation of your colon. The doctors at
___ were concerned that you may have had ischemic colitis,
which is a condition in which the colon does not get enough
blood supply and is damaged. This can occur because of very low
blood pressure or because of a clot in the vessels that supply
the colon. The doctors at ___ were concerned that you may
have needed surgery, so you were sent to ___. The
surgeons here did not believe that you needed surgery because
you were feeling better. We got another CT scan of your abdomen,
which showed that your colon had not suffered more damage; it
was unchanged from your CT scan in ___. It also did not show
any clots or blockages in the blood vessels that supply your
colon.
It is also possible that the inflammation in your colon is due
to infection (infectious colitis), so we gave you antibiotics
while you were in the hospital. We also tested your stool for
bacteria. The results of your stool tests have not yet returned.
We will contact you with these results when they are available.
You no longer need to take antibiotics.
When the inflammation in your colon has resolved, we recommend
that you get a colonoscopy. Please discuss the timing of this
procedure with your primary care doctor and with the surgeon at
your follow-up appointment.
While you were in the hospital, your blood pressure was lower
than it normally is, so we stopped your blood pressure
medication (lisinopril). You should not restart this medication
until talking with your primary care doctor. You should also
drink lots of fluids to help keep your blood pressure up.
We made the following changes to your medications:
1. lisinopril - we stopped this medication.
We have scheduled follow-up appointments for you with your
primary care physician and with acute care surgery. If you
cannot keep your appointments, please call to reschedule.
It was a pleasure taking part in your care. We wish you a quick
recovery and good health. | # Colitis - There was initial concern for ischemic colitis that
would require surgical intervention. Lactate was 1.0 on arrival,
increased to 2.0 several hours later, but repeat lactate was
1.3. Patient clinically improved quickly, and surgery was not
necessary. Presentation and CTA findings were consistent with
ischemic colitis in ___ distribution, but
infectious/inflammatory colitis could not be excluded as no
occlusion was seen in ___. Ciprofloxacin and flagyl were
continued throughout admission and stool studies were sent and
pending upon discharge. Patient was without abdominal pain and
was tolerating PO.
# Hypotension: Pt was borderline hypotensive with complains of
intermittent lightheadedness. Lisinopril was held and IVF @
125cc/hr given. When patient was able to take PO, fluid and salt
intake encouraged. BPs returned to normal when patient returned
to normal diet and she was no longer lightheadeded.
# Anemia: Patient reported bloody bowel movements, but they
ceased after admission. Hemoglobin decreased with hydration from
12.4 on admission to a low of 9.5. It rose to 10.0 on day of
admission. Transfusion was not required.
# Hypokalemia: Was likely due to GI losses. Resolved with
repletion.
# HTN: Lisinopril was held due to borderline hypotension. Pt
instructed not to restart his medication until she followed-up
with her PCP.
# Hyperlipidemia: Stable. Continued simvastatin, aspirin 81mg.
# GERD: Stable. Continued omeprazole. | 358 | 216 |
14044093-DS-12 | 22,564,092 | Dear Ms. ___,
It was a pleasure being involved in your care. You were admitted
to the hospital for worsening neck pain and nausea. Your neck
was evaluated by the neurosurgery service who felt that there
were no complications from your surgery. You developed lower
back pain likely from a muscle spasm while here. We started you
on medications to help with the pain and recommended continued
physical therapy.
Sincerely,
Your ___ Team | Ms. ___ is a23F s/p C6/C7 anterior discectomy/fusion on ___
for syrinx and C67 disc herniation, discharged on ___ who
initially presented with acute neck pain. While in the hospital
she developed thoraco/lumbar/sacral musculoskeletal pain with
radation down the right posterior thigh concerning for muscle
spasm and radiculopathy.
#Radiculopathy
While the patient was in the ED and turning to her side she
noted sudden onset lower back pain with radiation down her right
posterior thigh. Her symptoms were thought to be consistent with
a radiculopathy and muscle spasm as she had tenderness to
palpation over the paraspinal muscles and positive straight leg
raise. Neurologically the patient's exam remained normal with
the exception of strength in the right lower extremity initially
that was limited by pain though improved prior to discharge.
Imaging of the region was not felt to be warranted given lack of
true focal neuro deficits on exam, patient's age, and no
previous history of malignancy, fevers or IVDU. She was
initially given dilaudid with minimal relief of her symptoms and
profuse itching secondarily. Dilaudid was subsequently
discontinued. She was then started on muscle relaxant, IV
toradol, ultram, and gabapentin with improvement of her pain.
She was discharged with a 10 day course of gabapentin, tramadol,
ibuprofen, flexeril for pain managment and plan for physical
therapy. She was also provided with omeprazole to take in the
setting of her high dose NSAID use. Prior to discharge she was
ambulating the floors without significant pain.
# Cervical syrinx s/p C6/C7 anterior discectomy/fusion with
anterior neck pain.
Ms. ___ was admitted to the hospital for neck pain and nausea.
She was assessed by the neurosurgery team and had imaging of her
C-spine that did not show any complications or change in
alignment from her recent surgery. In addition Ms. ___
incision site was without evidence of skin or soft tissue
infection with well-healing scar in the post-surgical period. It
was thought that her worsening neck pain that brought her into
the hospital was secondary to overuse/strain in the setting of
recently walking 6 miles after being relatively inactive.
#Headache
#Nausea
She was also noted to have a headache, nausea/dry heaving, and
dizziness. It was thought very unlikely that her symptoms were
due to meningitis because she was without elevated white count
or fever throughout the course of her hospitalization, no
meningismus or other infectious signs. It was thought that her
symptoms were most likely due to a viral syndrome and improved
prior to discharge. Her nausea was treated with zofran and
compazine with QTc monitoring.
#Normocytic Anemia Hg/Hct 12.3/ 34.9 MCV 91
Patient with anemia noted on CBC to somewhat be expected in the
setting of her age and menstruation with some drop likely
diluational in nature in setting of IVF. Iron studies including
ferritin and serum iron were obtained and normal. | 70 | 484 |
14667135-DS-2 | 20,287,524 | Dear ___-
___ were admitted to the Acute Care Surgery Unit at ___ and
___ were treated for an acute episode of diverticulitis. Please
continue your antibiotics for a total of two weeks.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
___ have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
___.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications. | The patient presented to Emergency Department on ___. She
was diagnosed to have acute uncomplicated diverticulitis and was
admitted to Acute Care Surgery unit for appropriate management.
She was made NPO, put on antibiotics (IV ciproflagyl and PO
metronidazole) and IV fluids.
During the entire hospital course review of systems had as
follow:
Neuro: The patient was alert and oriented throughout
hospitalization and pain was well managed.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. She was
therefore, the diet was advanced sequentially to a Regular diet,
which was well tolerated. Patient's intake and output were
closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. Her white cell count
trended from 19.7 to 9.6 on discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 238 | 251 |
17313753-DS-7 | 23,431,961 | You were admitted to ___ with
worsened shorntess of breath and coughing up blood. While you
were here you were evaluated by Radiation Oncology and it was
not thought that you tumor could be treated by radiation. Due
to the risk of bleeding with blood thinners and your goals of
focusing more on quality of life and symptom management, you
were not started on a blood thinner. You did have an IVC filter
placed.
While you were in the hospital we treated your symptoms with
medications and after a conversation with your family and
palliative care, we decided that we could provide you with the
best care by adding hospice services to your team. | ___ yo male with metastatic NSCLC now here with dyspnea, found to
have DVT and PE. CT head showed multiple metastatic lesions,
and
a hemorrhagic component could not be entirely excluded. Thus,
pt
was not started on anticoagulation. He did have an IVC filter
placed on ___.
# Metastatic NSCLC: discussed with Dr. ___ contacted Dr
___. Radiation oncology determinted that XRT to tumor
would not be beneficial from a palliative perspective for his
hemoptysis. Patient and family met with palliative care on ___
and elected for ___. I discussed his plan with his
daughter ___ on ___ and they would prefer to avoid outpatient
appointments for now. They know that they can call us in the
clinic at any point for assistance. He will be continued on
oxygen and morphine for pain and dyspnea control.
# DVT/PEs: Due to brain mets and intermittent hemoptysis as well
as pt's preference, pt was not started on anticoagulation. IVC
filter was placed. No concern for pneumonia.
# COPD: Continued Albuterol, Tiotropium, Symbicort for
symptomatic
relief.
# DVT ppx: Pneumoboots
# Code status: DNR/DNI | 116 | 171 |
19863368-DS-11 | 22,816,576 | Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit or stand more than ~45 minutes without getting up and
walking around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have
some constipation after surgery. You have been given medication
to help with this issue.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so please plan ahead. You can either
have them mailed to your home or pick them up at the clinic
located on ___ 2. We are not allowed to call in or fax
narcotic prescriptions (oxycontin, oxycodone, percocet) to your
pharmacy. In addition, we are only allowed to write for pain
medications for 90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Gait training, lower extremity strengthening, balance
Treatments Frequency:
Wound assessments | Patient was admitted to the ___ Spine Surgery Service.
Intravenous antibiotics were not given. His inflammatory
markers were trended and improved through his hospital admission
as did his pain. Hospital course was otherwise unremarkable.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet. | 386 | 61 |
12170291-DS-10 | 25,905,147 | Dear ___,
___ were hospitalized due to symptoms of headache,
lightheadedness,
intermittent dysarthria, left lower face weakness, and
difficulty
using the left side resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- High Blood Pressure
- High Cholesterol
We are changing your medications as follows:
- We are STARTING ___ on ATORVASTATIN 80mg daily
- We are STARTING ___ on TYLENOL ___ every 6 hours as need for
pain or fever
- We are INCREASING your ASPIRIN to 325mg daily
- We are STARTING ___ on AMLODIPINE 10mg dailhy
- We are STARTING ___ on BISACODYL 10mg as needed for
constipation
- We are STARTING ___ on CLOPIDOGREL 75mg daily
- We are STARTING ___ on DOCUSATE 100mg two times daily
- We are STARTING ___ on FLUCONAZOLE 200mg daily
- We are STARTING ___ on METOPROLOL 50mg BID
- We are STARTING ___ on PIPERACILLIN-TAZOBACTAM 4.5g IV every
eight hours
- We are STARTING ___ on SENNA 8.6mg two times daily
- We are STARTING ___ on VANCOMYCIN 1000mg IV two times daily
- We are INCREASING your OMEPRAZOLE to 40mg once a day.
- We are STOPPING ATENOLOL 50mg daily
- We are STOPPING ALPRAZOLAM 0.25mg BID as needed
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing ___ with care during this
hospitalization. | ___ is an ___ year old woman who presented in the
evening of ___ complaning of progressive right temporal
pulsatile headache and acute onset left hemiparesis, facial
droop and vision loss. When she initially presented to the ED,
CT showed no clear infarct or hemorrhage but CTA reveled
high-grade stenosis of the right ICA. In the scanner in the ED
she became unresponse with right gaze deviation and less
movement in her left arm. SBP was in the 140s (down from 200s)
and the initial thought was that there may have been a brief
seizure or possible flow-related symptoms in the setting of BP
drop. Repeat CT showed developing right cerebral watershed
distribution infarcts. Neurosrugery was consulted urgently who
made a decision to take the patient to angio for R ICA stenting.
Post-angio scans showed improved flow and she was awake, alert,
with mild dysarthria, following commands antigravity in her LUE.
Per Nsurg ASA 325, plavix 75 was started. By 7:45 ___, however,
she was no longer following comands on the left, only
withdrawing to pain and triple flexing the left leg. Repeat CTA
showed restenosis of the R carotid, and M1 distribution
infarction on the R. Neurosurgery had a discussion with the
family about the risks and benefits integrelin and repeat angio
for aspiration of the clot, which they agreed to. She recieved
15mg integrelin and post-angio again had improved flow in the R
MCA territory. She has had improved spontaneous movement on the
left side and is following simple commands off sedation. MRI
showed patchy ischemia in the right MCA territory.
She was transferred to floor after extubation. She became
febrile and had a worsening leukocytosis. She underwent a fever
workup, which included blood cultures, urine cultures, and a
chest x-ray. Chest x-ray showed that she had a new right lower
lobe opacity concerning for pneumonia. She was given Vancomycin
and Zosyn for empiric treatment for pneumonia, for a planned 14
day course to finish on ___. A PICC line was placed
after antibiotics were started. Upon transferring to the floor
she was found to be in atrial fibrillation with rapid
ventricular response. She was given IV metoprolol and her oral
metoprolol dose was increased to 50mg BID. She spontaneously
converted to normal sinus rhythm and her rate has been while
controlled since. She was not started on warfarin because she
was already on Aspirin and Plavix for her carotid stent (which
she will continue for three months). Starting a third
anticoagulation agent would greatly increase her risk of
hemmorhage.
Her blood cultures grew out gram positive cocci in clusters
which speciated to staph epidermidis. Her urine culture grew out
yeast and she was started on fluconazole on ___, for a
planned 7 day course to be completed on ___.
Her physical exam improved and she had increased stregth in both
the left upper and left lower extermity. She became more
interactive and her mental status also improved. A repeat
bedside swallow evaluation found that she was still at increased
risk of aspiration. Her hematocrit continued to drop and a CT
abdomen/pelvis showed show a right groin hematoma that was
stable. An incidental finding of portal venous gas was noted as
well as a 1.8 cm pancreatic cystic lesion. Her lactate was
normal and the suspicion of bowel perforation was low.
Acute care surgery placed a PEG tube on ___, after her repeat
blood cultures were negative. Her blood pressure continued to be
difficult to controll and amlodipine 5mg was added. She resumed
tube feeds on ___ without incidence.
During the admission, her blood pressures have been mildly
difficult to control. She was put back on her home medications
and amlodipine was also started. If her blood pressures
continue to be above a systolic of 180, would uptitrate her oral
antihypertensives. | 299 | 642 |
14799773-DS-19 | 27,967,100 | Dear ___ was our pleasure caring for you at the ___.
You were admitted to the hospital for concerns of a possible
seizure you endured the night before admission which caused you
to have confusion and agitation thereafter. We did a CT and MRI
scan of your head and worked with the neurology team to
investigate the cause of your confusion. The images of your
brain showed old lesions which indicate past strokes. We could
not find any brain infection which could have also been the
cause of your seizure. We are treating you with an antibiotic
for a urinary tract infection which you are to complete at home
(total of 10 day course).
You expressed your wish to return home and have comfort-focused
care. You will have visiting nurses and physical therapy to care
for you at home. The palliative care team will also continue to
see you and further discuss your goals of care.
Since you are possibly at risk for future seizures, we also
recommend you follow-up with a neurologist (their office will
call you). | ___ female presenting with question of new seizure day
prior to admission, presenting with lower abdominal pain and
found to have complicated UTI.
#Possible seizure, AMS: According to pt's husband, episode day
prior to admission was most likely consistent with a seizure of
unknown etiology. As pt has had poor PO intake and malnutrition,
pt may have had hypoglycemia or electrolyte imbalance triggering
seizure. Acute stroke was considered especially with pt's
history of HTN and vasculopathy and husband endorsing pt having
aphasia, and imaging ruled out intracranial hemorrhage, acute
ischemic infarct and mass. Infectious process was considered and
LP was not consistent with bacterial meningitis or viral
encephalitis; HSV PCR of CSF negative. Pt was initially
empirically treated with IV acyclovir until PCR came back
negative on ___. CSF and blood cultures did not have
microbial growth. Neurology was consulted and recommended EEG.
Per neurology, L temporal sharps were seen on 24hr continuous
EEG which were indicative of being at risk for future seizures.
This L temporal activity would explain pt's seizure episode and
accompanying aphasia. Keppra seizure prophylaxis was held at
this time due to fact that this has sedating effects and pt was
already having waxing and waning delirium throughout hospital
course. Moreover, pt expressed wish to have her treatment
comfort-focused. It was recommended that the pt follow-up in
neurology clinic and if pt has future episodes of seizures,
Keppra will be re-considered. Pt was discharged alert and
oriented x2, and was given a prescription for Ativan 0.5-1mg PRN
agitation.
#UTI, complicated: Pt had leukocytosis initially which resolved
on hospital Day 2 and pt with lower abdominal pain after having
seizure day prior to admission, and this may have been related
to UTI. Urine culture grew out enterococcus and pt was treated
with ampicillin PO, and Foley catheter was discontinued. UCx
sensitivities returned on ___ which showed sensitivity to
ampicillin. Pt remained hemodynamically stable and did not
fulfill SIRS criteria. HD stable, no criteria for SIRS except
for fever. U/A rechecked as initial ua was not fully consistent
with infection- repeat clean but repeat UCx growing
enterococcus. Pt was discharged with Ampicillin 500mg q6H and
instructed to complete 10-day course for complicated UTI.
#Labile BP: Pt's BP initially 180s on ___. Pt was not on
antihypertensives as outpt but pt's chronic hypertension is most
likely reason for pt's past infarcts that were seen on imaging.
Pt was given a day of lisinopril 2.5 daily which brought
pressures were 140-150s but as pt had poor PO intake, she
triggered on ___ for SBP at 78. BP responded well to bolus
and was put on maintenance IVF to maintain BP for one night, and
lisinopril was discontinued. FeNa calculated to be 0.1% and thus
most likely hypovolemic ___ poor PO intake. Thereafter, BP
elevated to 170s and remained stable in 150-170s upon discharge.
As pt was asymptomatic with elevated BP, and pt wished to have
comfort-focused care, we deferred starting antihypertensive
although could be reconsidered if was symptomatic.
#Peripheral arterial disease: Pt was on coumadin and Plavix as
outpt. She had multiple vascular surgeries in past, most recent
surgeries in ___ on lower extremities. After intracranial
hemorrhage was ruled out with imaging, pt was cleared by
neurology to continue Plavix and coumadin throughout
hospitalization. INR remained therapeutic and no changes were
made to coumadin dose. Pt has a follow-up appt with vascular
surgery on ___.
#Chronic pain: Pt has chronic pain in lower extremities, mainly
in L leg. Per pt, there has been no acute worsening of chronic
pain and this was managed with
continued home medications: standing gabapentin, Dilaudid PRN,
Tylenol PRN.
#Palliative care: Upon admission, pt's husband (HCP) reversed
pt's DNR/DNI status to full code as he believed that pt agreed
to that code status without fully understanding the meaning of
DNR. As we have ruled out many acute processes which could have
caused pt's acute change in mental status besides UTI, and main
issues at time of discharge appeared to be chronic in nature
including pain control and poor PO intake/weight loss.
Palliative care was consulted and spoke to pt on goals of care-
pt expressed wish to have comfort focused care at home. A formal
meeting was done with ___ (pt's husband and proxy) on
___ and he was emotionally overwhelmed by pt's
hospitalization and was educated on pt's needs. He is amenable
to discussing goals of care at home with palliative care team
and is onboard in terms of being comfort-focused. Pt's husband
recommended that ___ work with pt in order to assist her out of
bed to wheelchair so that she can enjoy the outdoors. Social
work was also consulted and upon discharge, pt was set up with
___ services along with palliative care and social work
follow-up to visit home in order to further discuss goals of
care, code status and possible transition to hospice care. Pt is
to continue to have infusion therapy through midline three times
a week as before admission as pt continues to have poor PO
intake. | 175 | 834 |
11648387-DS-12 | 23,921,568 | Mr. ___,
You were admitted to ___
because of some falls you have been having at home. Your medical
work up for the cause of your falls was negative. You were also
seen by physical therapy and psychiatry. Please make sure you
follow up with your primary care physician, ___, Dr.
___ your neurologist at your earliest convenience.
It was a pleasure taking part in your care
Your ___ Team | Information for Outpatient Providers: Mr. ___ is a ___ with
a history significant for CF and anxiety disorder, as well as
depression, was referred in from PCP for further evaluation by
PCP after presenting today with falls and lower extremity
weakness.
ACTIVE ISSUES
# FALLS/WEAKNESS: patient reporting falls at home because felt
that "legs cannot support him." Not likely neurological in
nature. On neurological exam, patient exhibits ___ strength.
Gait WNL, but endorsed subjective weakness. He demonstrated heel
and toe walking, and was able to stand up from squatting
position without assistance. Further, MRA/V of head, noncon CT
were negative. Cardiogenic etiology not likely either as EKG
WNL, and no SOB/chest pain/ palpitations endorsed. ___ be due to
dehydration/possible malnutrition however patient states that
eating/drinking habits and bowel habits remain unchanged. Most
likely not related to chronic peripheral vertigo as dizziness
episodes did not always coincide with weakness. Physical therapy
cleared him as safe to go home, and psychiatry evaluated him and
was in agreement with primary team, that he does not currently
endorse any SI and is safe to discharge home.
# PASSIVE SUICIDAL IDEATION: patient with no prior history of
suicide attempts but active ideation in ___ and passive
suicidality currently. ED staff overheard what is to be though
of as active ideation. Psychiatry evaluated him and was in
agreement with primary team: that he does not currently endorse
any SI and is safe to discharge home. He will follow up with Dr.
___ as an ___.
# ACUTE KIDNEY INJURY: unclear precipitant but likely prerenal
in nature. After 1L NS and maintenance fluids, Cr normalized.
CHRONIC ISSUES
# MYCOBACTERIUM AVIUM INTRACELLULARE INFECTION: followed by ID.
Not currently in treatment, per last note, given stable symptoms
and difficulty with regimen.
# CYSTIC FIBROSIS: continued, levalbuterol,
fluticasone-salmeterol. Dornase was held ___ being non
formulary.
# GERD: Continued home pantoprazole, ranitidine.
# TEMPORAL LOBE EPILEPSY: continued home clonazepam. Not on
keppra.
# PRIMARY NOCTURNAL ENURESIS: home desmopressin.
# HYPERTENSION: home valsartan.
Transitional Issues
====================
[]Consider repeat UA for microscopic hematuria seen during this
admission
[]Patient hesitant to go to therapist in ___. ___ benefit
from referral to more local therapist. | 67 | 356 |
16140979-DS-20 | 26,684,381 | Mrs. ___,
___ were hospitalized with shortness of breath. ___ have a
severe COPD exacerbation that is likely related to the amount of
sedating medications ___ take at home. Per ___ family
request, ___ are being transferred to ___ for further care.
It was a pleasure taking care of ___!
Your ___ team | ___ with history of COPD, HTN, DM2, chronic opioid use,
schizoaffective disorder who presented ___ to ___
with dyspnea x 10 days. Had concerning respiratory status with
tachypnea so transferred to ___ ED for further care. At ___
patient required intubation ___ for hypercarbia and altered
mental status. Extubated ___, now transferred to ___ per
patient and family request. | 52 | 63 |
13267346-DS-12 | 27,194,703 | Dear Ms. ___
___ were admitted to ___
because ___ had severe and sudden chest pain. As such, we were
concerned about your heart. We did an EKG to look at your heart
and it was found to be unchanged. We checked enzymes, which
inform us if ___ have heart damage, and they were found to be
normal. Given that ___ were complaining of chest pain, ___
underwent a stress test, which did not reveal abnormalities in
your heart. ___ were started on atorvastatin to help control
your cholesterol.
___ were seen by your pulmonologist, who recommended changes to
your medication regimen. He discussed decreasing your ___ to
3 times a week, changing Omeprazole 40 mg twice a day, and
recommended Vitamin B6 for your muscle cramps. He recommended
continuing your current CellCept dosing. Your pulmonary
appointment was also moved to ___.
___ were scheduled for a cardiology appointment on ___. ___
are also scheduled to see your primary care physician on ___
___.
It was a pleasure to take care of ___. We wish ___ the best with
your health!
Your ___ Cardiac Care Team | Mrs. ___ is a ___ y/o F with a history of mixed connective
tissue disease complicated by ILD, esophageal dysmotility,
atypical chest pain and asthma who presented with atypical chest
pain.
#Chest Pain:
She has had a history of atypical chest pain but this time she
noted that it lasted for much longer than it usually does. The
differential is broad including angina, pericarditis, esophageal
dysmotility, and MSK (myositis). In the context of having mixed
connective tissue disorder, she was considered to be at higher
risk for cardiovascular disease (Ungprasert ___, I___).
A pharmacologic stress test showed no abnormalities
(communicated to her cardiologist). A1c at 5.5. LDL at 173. The
results were inconclusive, but this was thought to be either due
to esophageal spasm/dysmotility or GERD. She was treated with
Maalox and lidocaine and she was discharged on omeprazole twice
a day. She was also discharged on atorvastatin 40 mg.
#Cramping
Has had leg cramps for many years. Electrolytes normal, CK
normal. Thought due to CellCept and Prednisone combination, but
etiology unknown. At discharge, cramps at baseline. Discharged
on Vitamin B6.
#Mixed Connective Tissue Disorder c/b ILD
Being managed by Pulmonology at ___ and Rheumatology at ___.
Pulmonology consulted in patient. Continued on prednisone 10 mg
daily, myocphenolate mofetil 1000mg BID. Bactrim for PCP
prophylaxis decreased to 3x/week. | 185 | 214 |
10953471-DS-19 | 21,281,174 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for some transient vision
changes in your left eye. You had an MRI of your brain which
showed no evidence of a stroke. An MR venogram showed that the
veins draining the left side of your brain are smaller than the
right. This is likely something you were born with and is
unlikely to be related to your visual complaints. You should
have a repeat MRV in ___ months to re-evaluate this. You also
had an echocardiogram to rule out the possibility of a blood
clot in your heart, and this showed no blood clot on prelim
report.
You were evaluated by opthalmology who did not find any
abnormality inside your eye to explain your symptoms. You will
need to follow up in their clinic for a repeat evaluation as
well as formal visual field testing. You will also need to
follow up with your primary care doctor as well as Dr. ___
in neurology clinic (see details below).
We started you on a baby aspirin to reduce your risk of future
strokes. We did not make any changes in the rest of your
medications. It is important that you take all medications as
prescribed, and keep all follow up appointments. | # Transient visual loss: Pt initially presented with 2 episodes
of transient monocular vision loss, and had other instances of
visual abnormalities during daily examinations by the neurology
team in the ED and each morning. In the ED, pt reported seeing a
ring of black, while during subsequent exams, pt reported
blacking out of central vision and "cracked" appearance of her
visual field in the left eye. She was worked up for multiple
etiologies. No apparent neurologic pathology on CT, MRI, MRA/MRV
scans. Scans were normal, with the exception of a hypoplastic L
sigmoid sinus and partial thrombus of unclear chronicity and
likely unrelated to current presentation. Ocular etiologies were
investigated with ophthalmology slit lamp exam, which showed no
abnormalities. Of note, visual fields were not completed (to be
completed in Neuro-ophthalmology visit). CTA showed normal
vasculature/no significant atherosclerosis in the aortic arch
and TTE showed a PFO but no thrombus. Hematologic causes (i.e.,
hypercoagulable diseases) were not investigated due to low risk
factor profile; pt is a non-smoker, has never been on estrogen,
has no h/o prior clots, and has no significant FH. Thus, the
etiology of her symptoms is unclear. She was started on ASA 81mg
during this admission. She will be followed in ___
clinic with VF testing, and will also follow up with her regular
ophthalmologist. She was instructed to make an appt for MRI of
orbits prior to her neuro-ophtho appt.
# L sigmoid sinus partial thrombosis: seen on MRV. This was felt
to be an incidental finding unrelated to the patients
presentation. She was started on ASA 81. She will need a repeat
MRV and follow up with Stroke neurology. She was given the
number to schedule her outpt MRV.
#Chronic kidney disease: pt was noted to have an elevated Cr of
1.3-1.4 during admission. Her baseline is 1.3-1.5 for the past
several years due to prior ___ nephrotoxicity. Her Cr
levels remained stable during admission (based on baseline
levels.) Pt is being followed by PCP and nephrology for this
issue.
#Hypernatremia: pt was noted to have slightly elevated Na at 146
on day of admission. Etiology was unclear, and her level was
tracked during admission. Her baseline Na has previously been in
high 130s-140s, and she has had previous issues with
hypernatremia. Her Na level came WNL at 143 at the time of
discharge. Pt is being followed carefully by her PCP and
nephrologist. | 214 | 399 |
17138402-DS-11 | 26,018,195 | Discharge Instructions
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication until your follow up appointment with Dr. ___. It
is important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs. | The patient was transferred from ___ for small R
parietal SDH and admitted to the Neurosurgery Service on ___.
Her initial head CT showed expansion of right parietal SDH. She
was started on levitiracetam for seizure prophylaxis and
monitored with serial neurologic checks per routine.
On ___, the patient remained neurologically stable. Repeat
head CT on ___ showed stable right parietal SDH. She was
deemed ready for discharge home. A thorough discussion was had
regarding post-discharge instructions. She was provided with a
prescription for levitiracetam to continue until follow up and
she was instructed to follow up with Dr. ___ in ___ weeks
with repeat head CT at that time. | 307 | 115 |
17508733-DS-19 | 27,482,117 | You left the hospital against medical advice. We strongly
recommend that you continue to stay here and receive IV
antibiotics for at least the next day but you decided to leave.
YOU MUST RETURN TO THE EMERGENCY ROOM IF YOU HAVE A FEVER OR
ABDOMINAL PAIN THAT IS WORSE. These things could be a sign of an
under-treated infection. You could die if you have an infection
that is not properly treated.
General instructions:
* Take your medications as prescribed. Continue to take both
oral antibiotics and complete a ___o not consume
alcohol while on these antibiotics, as this will cause severe
nausea/discomfort.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* You may eat a regular diet
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | On ___, Ms. ___ was made NPO and admitted from the
emergency department for serial abdominal exams and IV
gentamicin and clindamycin for presumed pelvic inflammatory
disease in the setting of leukocytosis to 19.7 with left shift,
elevated ESR and CRP, and a final pelvic ultrasound consistent
with 5.2cm left pyosalpinx that was not amenable to ___ guided
drainage. General surgery was consulted as appendicitis could
not be ruled out and recommended the addition of IV flagyl.
Since she had significant RLQ tenderness and the initial CT scan
was not able to visualize the appendix, a repeat CT with IV and
oral contrast was ordered to rule-out appendicitis. She refused
to drink oral contrast throughout the day, saying that she would
have emesis with it although she continued to ask for coffee and
food. Her abdominal exam throughout hospital day 1 was unchanged
with significant RLQ tenderness and some voluntary guarding but
no rebound tenderness. She was afebrile and her vital signs were
stable.
On hospital day 2, Ms. ___ continued to refused to drink the
oral contrast through the day, ultimately throwing the oral
contrast on the floor. In the afternoon, she was unable to void
despite several attempts, and a foley was placed for urine
output monitoring. She had two brief episodes of anxiety marked
by crying, hyperventilation, tachycardia to 120 and elevated
blood pressure (140/70). The first was related to her aversion
to drinking oral contrast, and the second was related to placing
the foley catheter. She continued to report no change in her
abdominal pain, and her abdominal exams during both episodes was
unchanged with continued tenderness on the right side but no
rebound. Both episodes resolved with IV ativan. Social work was
consulted for support as the patient repeatedly threatened to go
home during these episodes. In the afternoon, she spiked her
first fever to 102.7 at 5pm. She initially refused to have labs
drawn but eventually consented to labs. Her WBC remained
elevated. As she had not received a full 24 hours of intravenous
antibiotics and her exam continued to have no evidence of
peritoneal signs, she was monitored with serial exams overnight.
Early in the morning on hospital day 3, Ms. ___ had increased
abdominal pain, continued fever to 101.5 at 3am and new
development of rebound tenderness on exam. She was again
counseled on the importance of a repeat CT scan with oral
contrast. She then agreed to drink some oral contrast in order
to proceed with a repeat CT scan, which revealed bilateral
pyosalpinx and normal appendix. Infectious disease was consulted
for persistent fever despite IV antibiotics, and they
recommended intravenous levofloxacin and flagyl for 24 hours
afebrile, which could then be transitioned to a 7 days oral
outpatient antibioitic course. At this point, she had been
afebrile since 7am, her WBC count was trending down, and her
abdominal pain was improved with less tenderness on exam and no
peritoneal signs. Throughout the day she continued to express
her desire to stop intravenous antibiotics, to eat, and to go
home. Multiple efforts were made to explain the importance of
continued inpatient hospitalization for intravenous antibiotics,
labs, and monitoring for her pelvic infection. Later in the
evening, Ms. ___ ultimately signed out against medical advice
with the knowledge that improper treatment of her infection
could result in her death. Her foley catheter and IVs were
removed prior to her departure. She was counseled on the
importance of continuing outpatient antibiotics and to return to
the emergency room if she had any change in symptoms including
continued fever, worsened abdominal pain, nausea/vomiting, or
any other concerns. | 165 | 601 |
14804548-DS-20 | 27,248,337 | Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You were admitted when you developed an acute
onset of shortness of breath. We were worried that this could
have been due to your heart not functioning as well or from a
problem with your lungs. We obtained a scan of your lungs that
showed that you had blood clots in your lungs. We kept you on a
blood thinner and started you on a medication called Rivaroxaban
that you should continue taking for at least six months. You
also reported poor appetite so we performed a endoscopy and
colonoscopy to make sure that there were no anatomical problems
with your gastrointestinal system. This showed mild irritation
for which you should take a medication called pantoprazole twice
a day. We also gave a you a medication for your sleep.
We have followup with Dr. ___ you next ___.
We wish you the best,
Your ___ team | ___ with a PMH of non-ischemic cardiomyopathy with last EF 35%
p/w several weeks of DOE with significant worsening over the
past day.
# Pulmonary embolism: Dyspnea, likely secondary to PE. His
presentation was initially concerning for a systolic CHF
exacerbation given the gradual onset and known cardiomyopathy.
However, he has not had prior CHF episodes in the past but he
only has mild bibasilar crackles, no ___ edema, no history of
PND/orthopnea. No evidence of acute ischemia with negative
biomarkers in ED. Alternatively, give his acute worsening on the
day PTA and presentation with tachycardia/hypoxia in the setting
of potential malignancy and recent plane flight a PE could be
considered. Wells score indicates moderate probability and
D-dimer was elevated. Cr too elevated for CTA so patient
recieved a VQ scan was ordered which shoed In terms of other
potential diagnoses, no evidence of pneumonia or infection.
Patient has sickle cell but does not appear to be in a crisis
and is without significant anemia.
- Was up to date on age appropriate cancer screening. However
early satiety prompted up to rule out a GI maligancy, discussed
below.
- Rivaroxaban 15mg BID for 21 days then 20mg daily for at least
6 months of anti-coagulation.
# EARLY SATIETY: Weight stable since ___ but reports subacute
onset of poor appetite and early satiety. No night sweats. Hct
is slightly down. Given recent possibly unprovoked PE, occult
malignancy should be excluded. CT Torso and ___ without
concerning findings for malignancy.
# ACUTE KIDNEY INJURY: Presented with Cr of 1.9. Patient with
diabetic nephropathy based on past labs but no evidence of CKD
and recent Cr measurement of 1.0 within 1 week. Suspect a
pre-renal etiology potentially related to decreased cardiac
output related to his above dyspnea. No evidence of poor PO or
increased volume losses. Could consider a post-renal etiology
given his suspected prostate cancer and recent urologic
procedure although he does not endorse any obstructive symptoms.
Urine lytes with FeUrea of 47%. Creatinine was 1.2 by time of
discharge.
# HEMATURIA: Likely ___ recent prostate biopsy procedure +
heparin gtt. However does have history of bladder cancer, but
most recent cystoscopy was normal. Unlikely from renal course
given presence of small clots.
# LACTIC ACIDOSIS: Most likely reflects a type B lactic acidosis
related to metformin use in the setting of renal failure. Could
consider a type A acidosis although his vitals and exam are not
c/w shock. LFTs within normal limits.
# DM2: Held home metformin given lactic acidosis above. Please
restart as an outpatient.
# HTN: Cont metoprolol, HCTZ, simvastatin
# Code: FULL (confirmed)
# Emergency Contact: ___ (daughter) ___ | 157 | 437 |
12024257-DS-19 | 25,403,251 | Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WERE YOU IN THE HOSPITAL?
- You were recently in the hospital because of heart failure and
atrial fibrillation. You came back to the hospital because of
fatigue and garbled speech.
- Because of these symptoms, you were concerned that you were
back in atrial fibrillation.
WHAT HAPPENED IN THE HOSPITAL?
- Because of the garbled speech, you had imaging of the brain.
This showed old strokes but nothing new.
- Your amiodarone dose was increased.
- You went for another cardioversion procedure. This was
successful and you went back in to a normal rhythm.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- You should take all of your medications as prescribed,
including the increased dose of amiodarone. You should take the
400 mg twice a day for 1 week, then 400 mg per day thereafter.
- You should take it easy at work.
- You should follow up with your cardiologist on ___.
- You should follow up with your primary care doctor on
___, ___.
We wish you the best,
Your ___ Care Team | PATIENT SUMMARY:
====================
___ with HFrEF, persistent AF despite multiple cardioversions,
recently admitted at ___ from ___ for CHF exacerbation
in the setting of AF with RVR s/p successful cardioversion, now
readmitted with profound fatigue and transient neurologic
symptoms, found to have recurrent atrial tachycardia and
subacute/chronic CVAs with no residual deficits. | 178 | 50 |
10119391-DS-35 | 26,812,710 | Dear ___,
You were admitted to ___
because you were confused.
While you were here, you had a cat scan of your head which
showed that you had a stroke.
We gave you medicines to help make you feel better.
Your family and your doctors decided that ___ be happiest
at home with home ___. These doctors and ___ help
manage any symptoms that you have.
It was a pleasure taking part in your care. We wish you all the
best.
Sincerely,
The team at ___ | PATIENT SUMMARY FOR ADMISSION:
================================
___ with h/o dementia, bipolar disorder, T2DM, hypothyroidism,
CVA, recurrent UTIs, and recent admission from ___
forconfusion and worsening tardive dyskinesia attributed to E
coli UTI, who represents to the ED with worsening mental status,
agitation, and tardive dyskinesia found to have
subacutecerebellar stroke.
Ultimately, due to a persistent decline in mental status and
failure to thrive, especially with regard to severe malnutrition
and cachexia, the medical team, psychiatry team, and geriatric
service met with the family and it was determined that the
patient would benefit most from home hospice. | 82 | 94 |
12953072-DS-21 | 25,994,701 | Dear Mr. ___,
It was a pleasure taking care of you. You were admitted to the
___ because you had severe
diarrhea with dehydration and weight loss from a bacteria in
your large intestine known as Clostridium difficile. In the
hospital, we continued your antibiotics and gave you intravenous
fluids to rehydrate you. Your diarrhea has decreased in
frequency, but you will need to continue your antibiotic for
another 10 days after you leave the hospital (total of 14 days -
last day ___.
You should follow-up with your primary care physician ___ ___
days of discharge and your GI specialist after you finish your
antibiotic course. In some cases, the infection may recur. If
your diarrhea increases in frequency or recurs after it has
completely resolved, please see your GI specialist.
We wish you a speedy recovery,
Your ___ Care Team | Mr. ___ is a ___ yo man w PMHx significant for DMII, HTN,
HLD, GERD
presents with 5 weeks of watery diarrhea (24x/day) associated
with abdominal cramps and 25lb weight loss. Prior to admission,
he was found to have a stool sample positive for C. difficile
and an abdominal CT that showed pancolitis.
# C.Difficile Colitis: Prior to admission, the patient was
started on PO vancomycin 24h per GI recommendation. Because the
patient he was reporting >24 BMs per day, he was instructed to
go to the ED, given concern for dehydration and electrolyte
abnormalities. On admission, the patient was HD stable, afebrile
with WBC 9.3. Exam notable for generalized weakness and dry
mucous membranes. Labs were notable for Na of 132, glucose of
302. KUB showed normal bowel gas pattern without evidence of
obstruction or free intraperitoneal air. He received a bolus of
2L NS and was continued on his vancomycin 125 mg PO Q6h. Over
the course of his hospital stay, the patient's symptoms improved
with decreased frequency of BMs to approximately 10/day,
improved appetite, and significant improvement in his abdominal
pain. He was discharged with instructions to complete a 14-day
regimen of vancomycin (First day: ___ - Last day: ___.
# Anemia/BRBPR: Patient's HgB dropped from 13.8 on admission to
11.9 on ___ but did not continue to downtrend. Likely
multifactorial including initial hemoconcentration with dilution
following IVF as well as GI losses as patient reported
occasional blood on the toilet paper that started in the setting
of his very frequent BMs. On discharge, his Hgb was 11.8.
Requires outpatient follow with GI after resolution of colitis
for colonoscopy.
# DM2: Patient with known DM2, recent HbA1C=10.1. On admission,
blood sugar >300. Despite standard HISS, an diabetic diet
in-hospital, blood sugar remained high. Requires follow-up and
adjustment of oral antidiabetics with possible addition of
insulin.
#Hyponatremia: Likely hypovolemic hyponatremia in the setting
above c. diff infection.
***TRANSITIONAL ISSUES***
# Continue Vancomycin 125 mg PO QID for a total of 14 days (Last
day: ___.
# To follow-up with PCP, ___ (___) within
___ days of discharge.
# To follow-up with GI specialist, Dr. ___
(___) as an out-patient within 2 weeks of discharge.
# Patient had reported a little bright red blood per rectum
without hematochezia, likely from hemorrhoids. Will require
follow-up.
# Patient is diabetic with last HbA1c of 10.1. Blood sugar in
the hospital >300. Patient may require increasing oral
antidiabetics or adding on insulin. Will require follow-up with
PCP for proper management of diabetes.
#CODE: Full
#Contact: Girlfriend (___) - ___ | 139 | 414 |
10174935-DS-12 | 23,150,740 | Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | ___ with history of HTN and high cholesterol who is presenting
as a transfer from ___ with NSTEMI on heparin and
nitro found to have inferior STEMI successfully
revascularization of RCA, remaining 90% LAD occlusion
complicated by reperfusion VT and cardiogenic shock requiring
mechanical support with Impella.
In CCU, ___ catheter placed. Attempted echo verification
of placement of impella, however this appeared somewhat shallow
so bedside advancement was attempted. This was complicated by
coiling of impella in LV. Attempted to withdraw the impella
unsuccessfully, and so CSurg was consulted. Patient was taken to
the the OR on ___ for impella removal and concomitant coronary
artery bypass graft x 1. Please see operative note for surgical
details. Following surgery she was transferred to the CVICU for
invasive monitoring. Arrived from OR intubated and sedated on on
Epi infusion for hramodynamic support. On POD#1 was noted to
have a cold right foot and loss of pedal pulses. Vascular
surgery was consulted and the patient was taken tot he operating
room for a Right femoral exploration and thrombectomy. She
underwent a thrombectomy on ___ and pedal pulses returned and
systemic anticoagulation with heparin was maintained for
profusion. The patient will not require anticoagulation and will
be discharged on Plavix and aspirin. She will follow up with the
vascular surgery team as an outpatient. She has groin staples in
place which should be removed 2 weeks after placement (___).
Her perfusion returned after surgery, however she has moderate
right foot sensation loss. She will be discharged with a
multi-podus boot and will need follow up with physical therapy.
CT's were removed and patient developed a right PTX-a pigtail as
placed with lung re-expansion. Water seal trial was successful
and Pigtail was removed without incident on ___. Her discharge
CXR shows no residual PTX. She was started on Lopressor prior to
discharge but was not started on a statin due to allergy. A
foley was replaced on ___ due to acute urinary retention. She
was started on Flomax and will be discharged with a foley
catheter in place. A UA was obtained and was negative. A voiding
trial should be attempted at rehab. The patient was evaluated by
physical therapy and was deemed appropriate for rehab. The
patient should have aggressive physical and occupational therapy
at rehab to help facilitate recovery of strength in her right
foot. She will be discharged to ___ at
___ on ___ on POD 5. | 137 | 406 |
11787818-DS-4 | 21,107,766 | Dear Mr. ___,
You were admitted to the hospital after falling at home. You
likely fell because your blood sugar was so low.
When you fell you broke a bone in your neck. This should heal
without surgery, but you will need to wear a collar for quite a
while. You will see the spine surgeons in clinic.
We decreased your insulin dose to prevent your blood sugar from
going so low.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team | HOSPITAL COURSE
===============
Mr. ___ is a ___ man with a history of A. fib on
apixaban, type 2 diabetes, MVR, mental disability with
developmental delay who presented after an unwitnessed fall,
found to be severely hypoglycemic likely in the setting of
medication errors and had C3 fracture with plan for non-surgical
management.
ACTIVE ISSUES
=============
# Hypoglcyemia
# DMII: Likely ___ to missed meal and incorrect medication
administration. Per most recent PCP ___ (in external reports),
on glimepiride 2mg daily and 34 u lantus. Per ___ is on 40 U
lantus, 4mg BID glimepiride, and metformin 500mg BID. Based on
his pill bottles from home, it appeared he was taking
glimepiride 4mg BID and lantus without any metformin. ___
consulted and decreased his Lantus significantly with good
results.
# A-fib: Failed cardioversion ___. Initial heart rates are
not well
controlled in the 120's, started metop tatrate 12.5mg q6h,
titrated to 25mg q6 for goal HR < 110. Continued apixiban 5mg
BID.
# Fall
# C3 spine fracture: C3 avulsion fracture: Non-operative per
orthopedics. Cervical collar in place at all times. Activity as
tolerated. Follow-up in spine clinic in 2 weeks.
# Home safety
# Medication errors: Multiple falls recently. Likely both
hypoglycemia and excess amlodipine dosing could be contributing.
___ recommended acute rehab, and on discharge will need higher
level of care to assist with medication and insulin
administration.
CHRONC ISSUES
=============
# Prostatomegaly
# Hematuria
# Flexible cystoscopy: Follows with urology. No current change
in
management, follow up in 6 months for possible procedure. Stable
inpatient.
# PE: Subsegmental, found in syncopal work up last admission. On
apixiban for afib. Unclear if significant or incidental finding.
Continued apixiban.
TRANSITIONAL ISSUES
===================
[] Medication changes
- Reduced dose of insulin Lantus to 18U QHS
- Increased Metoprolol Succinate XL from 50mg to 100 mg PO DAILY
- Stopped amLODIPine 10 mg PO BID (normal blood pressure)
- Stopped glimepiride 4 mg oral BID
[] Check morning blood sugars, if < 120 would decreased his
Lantus by at least 2 units
[] Follow up scheduled with ___ Diabetes and Spine Clinic
# CONTACT: ___
___: sister
Phone number: ___
Cell phone: ___
>30 minutes spent on complex discharge. | 89 | 364 |
16839550-DS-38 | 20,796,374 | It was a pleasure taking care of you during your recent
admission.
You were admitted because of worsening shortness of breath. You
were given lasix to help get excess fluid off of your lungs, and
you improved. You had no ongoing shortness of breath.
You had a cardiac catheterization and a stent was placed. You
had no ongoing chest pain for the remainder of admission.
You were very delerious throughout the admission, requiring lots
of medication to help you calm down. For help sleeping at
night, please take seroquel, and do not take trazodone or
alprazolam. If you are more confused or agitated after taking 1
dose of seroquel, you may take a second tab.
You also had difficulty urinating on your own, and need to have
a catheter placed in your bladder. You were started on a
medication to help you urinate, but for now should keep the
catheter in place until you see a urologist.
The following changes were made to your medication regimen:
- START plavix daily
- INCREASE aspirin to 325mg daily
- INCREASE metoprolol to 100mg twice a day
- STOP spironolactone
- STOP donepezil
- STOP alprazolam as this will cause confusion
- STOP trazodone as this will cause confusion
- START seroquel at night to help with sleep and decrease
confusion. For increasing agitation, may give an extra dose of
seroquel.
- START tamsulosin once daily at night for help with urinary
retention
Please continue the remainder of medications as prescribed prior
to admission | IMPRESSION: ___ M with a PMH significant for A.fib (on
Coumadin), carotid stenosis, presumed ILD, severe coronary
artery disease (s/p 4V CABG), ischemic cardiomyopathy with an
LVEF of 25% with recent admission for mechanical fall and
conservatively managed liver laceration, who presented with
refractory shortness of breath now with hospital course
complicated by delirium now status-post cardiac catheterization
(___) with right coronary artery stenting.
# ACUTE ON CHRONIC DYSPNEA - Patient presented with increasing
dyspnea since discharge and evidence of persistent mild
pulmonary edema on CXR. Thought to be acute on chronic CHF
exacberation (LVEF 28%) but not much improvement with diuresis.
No evidence of consolidation or obvious infection on admission.
His BNP was mildly elevated. Cardiac enzymes on admission were
negative and his EKGs were reassuring. Received Lasix 40 mg IV x
1 on ___. Pulmonary embolism seemed less likely given his
anticoagulation needs. Given these findings, a chronic etiology
was considered most likely (deconditioning, pulmonary disease or
natural evolution of CHF). Cardiology was consulted and decided
a cardiac catheterization was necessary given his long-term
ischemic cardiomyopathy and concern for a reversible lesion. He
underwent cardiac catheteriztion on ___ with stenting of the
right coronary artery. Following the procedure, he was
maintained on Aspirin and started on Plavix 75 mg PO daily. He
was diuresed following catheterization, and was euvolemic for
several days prior to discharge. He was discharged on home dose
of lasix 40mg po daily.
# ACUTE DELIRIUM - Concern for delirium following admission with
inattentiveness and combativeness. Sleep patterns had been
erratic. Has occurred with prior hospitalizations. No infectious
cause was identified. Cardiac etiologies were treated as above,
but did not appear to be acute in nature, so unlikely to
precipitate acute change in mental status. Hematocrit was
stable, as was CT abd/pelvis, so unlikely to be related to
recent fall and liver laceration. in addition, CT head was
unchanged. Patient has underlying dementia predisposing him to
delerium.
Geripsych was consulted and followed patient closely. Optimal
regimen for controlled agitation was seroquel 25mg qHS with prn
dose. Patient was still confused at the time of discharge, and
___, primary team and geripsych recommended ___
___ facility to family. Family refused rehab, and
insisted on taking patient home. Family was encouraged to avoid
alprazolam and trazodone, and to continue seroquel as dosed
in-house.
# ACUTE DIARRHEA - Overnight on ___ developed episodic, watery
diarrhea that remained non-bloody. No abdominal pain or
cramping. Afebrile and without leukocytosis. C.diff toxin was
negative. Patient had been receiving large amount of
medications to prevent constipation which likely precipitated
diarrhea. It resolved spontaneously and did not return.
Abdominal exam was reassuring. Patient had stable hematocrit.
# CORONARY ARTERY DISEASE - Patient presented with strong
history of CAD and known 4-vessel disease with two prior CABG
surgeries. EKG reassuring on admission and cardiac enzymes flat
despite subjective dyspnea complaints. BNP slightly elevated on
admission. No history of chronic stable angina symptoms
recently. P-MIBI in ___ showing fixed RCA and LAD lesions.
Despite these findings, cardiology opted for cardiac
catheterization on ___ and stented his right coronary artery.
He was continued on Aspirin 325 mg PO daily, Simvastatin 20 mg
PO QHS, Imdur 90 mg PO daily and his Ranolazine. Plavix 75 mg PO
daily was added given his stent placement.
# CHRONIC SYSTOLIC HEART FAILURE WITH PRESUMED ACUTE
EXACERBATION - Presented with chronic systolic failure and LVEF
of 25% (since ___. Secondary to chronic graft occlusions with
WMA and fixed deficits in RCA, LAD remaining (ischemic
cardiomyopathy). Admitted with concern for volume overload,
requiring IV Lasix. His supplemental oxygen was weaned. His ACEI
was held on admission given concern for renal insufficiency, but
was restarted prior to discharge given improving renal function.
Metoprolol was increased to 100mg po BID and home sasix dosing
was continued. His aldosterone antagonist was held throughout
admission and at discharge. His daily weight was monitored and
he was maintained on strict I/O monitoring with a goal fluid
balance of even to 0.5L negative daily.
# ATRIAL FIBRILLATION - CHADs-2 score of 5 (CHF, HTN, DMII, h/o
TIA). Increased metoprolol to 100mg BID for improved rate
control. Coumadin was held on the two days prior to discharge
and patient was instructed to have INR checked by ___ on ___
with results sent to cardiologist Dr. ___ further
instructions on dosing.
# OSA/RLD - Likely contributing to chronic dyspnea complaints.
Patient has underlying ILD per report, without CT imaging
suggestive of interstitial process. FEV1 is 60% of predicted
value. No prior smoking history. CT chest showing pleural
plaques only with possible prior asbestos exposure. Consider
repeat PFTs and possible thin-cut CT scan of chest to evaluate
chronic dyspnea.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY - Baseline CR 1.2-1.7,
elevated on admission. Attributed to systolic failure
exacerbation vs. worsening baseline renal insufficiency. This
improved with improvement in his cardiac function and decreased
diuresis.
# TRANSITIONAL ISSUES -
- INR to be checked on ___ and sent to Dr. ___,
___ warfarin on discharge until further instructions
- electrolytes to be checked on ___ and sent to Dr.
___
- spironolactone held on discharge
- for delerium, trazodone, alprazolam, and donepezil were
discontinued. Patient should be given 25mg seroquel qHS with
additional 25mg as needed for agitation. Follow-up scheduled
with cognitive neurologist Dr. ___. | 250 | 893 |
19065508-DS-7 | 26,972,260 | MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Keep your donor graft site open to air. The area will form a
scab and can be left dry.
- Daily dressing changes with xeroform and gauze over skin graft
site for 5 days.
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing left lower extremity in unlocked
___. ROM as tolerated.
Physical Therapy:
Touch down weight bearing in unlocked ___.
Treatments Frequency:
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Keep your donor graft site open to air. The area will form a
scab and can be left dry.
- Daily dressing changes with xeroform and gauze over skin graft
site for 5 days. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left calf compartment syndrome and tibial plateau
fracture and was taken emergently to the operating room on
___ for left calf fasciotomy and external fixation of tibial
plateau fracture. Postoperatively she was admitted to the
orthopedic surgery service. She subsequently underwent several
operations including repeat I&D and vac change on ___,
ex-fix removal, ORIF left tibial plateau fracture, and vac
placement on ___, and left lower extremity lateral wound
split thickness skin graft and medial primary closure with vav
placement over skin graft and incisional vac placement over
medial primary closure.
The patient tolerated the procedure well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. She was transfused
2 units of pRBCs for a HCT of 20.3 on POD2. The patients home
medications were continued throughout this hospitalization. She
was evaluated by psychiatry for medication management with mild
agitation while an inpatient. They recommended limiting
benzodiazepine use in addition to continuing her home
medications. Her platelet count increased to greater than ___ on
___ and hematology was consulted for further evaluation.
Given her lack of signs of an infection this was thought to be
reactive in nature and they recommended following her CBC and
monitoring her clinical status. Her platelets began to trend
down on ___ and she remained afebrile with stable vital
signs and no signs of an infectious process. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is touch down weight bearing in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 227 | 411 |
14566733-DS-6 | 24,142,460 | Dear Ms. ___,
It was a pleasure being involved in your care. You were admitted
to the hospital because you had bright red blood in your stool.
We were concerned that you were having bleeding from your
gastrointestinal tract. You had a sigmoidoscopy that looked at
the lower part of your gastrointestinal tract that showed showed
inflammation or colitis. This was thought to most likely be due
to constipation. We started you on a medication called colace
and miralax that you should take daily to help with
constipation. It is also important for you to drink fluids daily
to help prevent constipation. You also had a scope of your upper
gastrointestinal tract that showed your hiatal hernia. It was
recommended that you continue to take prilosec.
Sincerely,
Your ___ Team | Ms. ___ is an ___ year female with history significant for
hemorrhoids, diverticulitis, and polyps who presents with 2 day
history of colicky abdominal pain, constipation, followed by 2
loose stools with "mucousy" blood in the toilet noted to be
guiac positive in the ED with signs/symptoms concerning for
possible lower GI bleed.
# Bright red blood per rectum:
Ms. ___ was admitted to the hospital because she noted
bright red blood per rectum. She was noted to be guiac positive
in the Emergency room. She was admitted and evaluated with
sigmoidoscopy and endoscopy. She remained hemodynamically stable
throughout the course of her hospital stay. Her sigmoidoscopy
showed colitis that was thought to be most likely due to
constipation or ischemia though CTA was without evidence of
mesenteric ischemia. Endoscopy was also done that showed known
hiatal hernia but no active evidence of bleeding. A biopsy was
taken at time of sigmoidoscopy and the results will be mailed to
the patient. It was recommended that Ms. ___ continue
taking daily prilosec and also take daily colace and miralax for
constipation.
#Colicky abdominal pain
Ms. ___ endorsed symptoms of colicky abdominal pain prior
to admission in the setting of constipation. Given her history
of constipation, straining with stooling, and hard stools her
symptoms were thought to be most likely due to constipation.
Infection less likely given absence of fever and exam that was
non-focal, with no evidence of rebound or guarding. She was
discharged with stool regimen including colace and miralax.
# Hypertension
-continued atenolol 25 mg daily
# Hypercholesterolemia
-continued lovastatin
-Aspirin held intially in setting of possible GI bleed but
restarted prior to discharge
# GERD with large hiatal hernia also seen on EGD
It was recommended by gastroenterology that patient continue
prilosec daily.
#Hypothyroidism
-continued levothyroxine
#Depression/Anxiety
-continued mirtazapine
-continued AM and ___ lorazepam | 128 | 297 |
15102082-DS-5 | 24,263,341 | Dear Mr ___,
You were hospitalized due to symptoms of right hand weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Hypertension
High Cholesterol
We are changing your medications as follows:
Aspirin 81 daily
Atorvastatin 80 daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | ___ presenting with stroke causing sensorimotor deficits of RUE
s/p tPA at 7:06am ___ (___ and some subjective
improvement in signs and symptoms. Etiology likely large vessel
to vessel embolus. His HA1c=5.6, and LDL=78.
CTA Head/Neck no acute intracranial hemorrhage or mass effect
but did reveal extensive atherosclerotic disease with calcified
and noncalcified plaques in the aortic arch, arch vessels,
common carotid arteries and the bifurcations and cervical
internal carotid arteries. MRI Head w/o showed several foci of
acute-subacute infarction in primarily the left MCA territory as
well as chronic small vessel ischemic disease. ECHO (TTE) showed
LVEF>55% and a normal left atrium with no trombus/mass. Carotid
dopplers showed less than 40% stenosis of the bilateral internal
carotid arteries. The patient was started on aspirin 81 and
atorvastatin 80. He was also evaluated by occupational therapy
who recommended outpatient OT. He was provided a prescription
for these services. He was discharged in stable condition with
close neurology follow up.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 78) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? () Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A | 271 | 383 |
12276520-DS-14 | 27,641,056 | Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted with a left wrist fracture
after a fall. You were seen by hand surgery, who partially
externally fixed the fracture. You will need to follow up in
hand clinic on ___ for likely surgery later in the week.
It is important that you avoid driving or operating heavy
machinery while taking oxycodone for pain. Please take all
medications as prescribed, and keep all follow up appointments. | ___ with PMH significant for hypertension, atrial fibrillation
(not on anticoagulation), adjustment disorder, anxiety, prior
left breast cancer (invasive lobular adenocarcinoma, s/p XRT and
tamoxifen), osteopenia presenting to the ED with a comminuted
displaced left distal radius fx with ulnar styloid fx that
underwent closed reduction in the ED, admitted to medicine with
escalating pain requirements.
# COMMUNITED DISPLACED LEFT DISTAL RADIUS, ULNAR STYLOID
FRACTURE - Status post closed reduction by Hand surgery. Now in
a splint, the patinet continues to have severe pain. Is S/p a
large amount of pain medication in the ED for which she required
narcan. She was discharged on tylenol, naproxen, and oxycodone,
with some continued pain (she was counseled that she would
continue to have some pain until she had surgery). She will
follow up in hand clinic for surgery later this week. Pre-op
labs and EKG done.
# HYPERTENSION - BP well controlled in the 100-110 systolic
range. continued home ACEI and ___
# ATRIAL FIBRILLATION - CHADS-1. Currently in NSR on EKG with
adequate rate control on ___ and ___. cont beta blocker
and ___ 81
# OSTEOPENIA - started calcium and vitamin D supplementation.
# ANXIETY AND ADJUSTMENT DISORDERS - Stable mood. Continue
mirtazapine, paroxetine. Held alprazolam given concern for
sedation
# dizziness: cont meclizine
# CODE: FULL
# CONTACT: ___ (son) - ___
TRANSITIONAL ISSUES
- follow up outpatient with Hand Clinic for outpatient surgical
fixation | 80 | 233 |
10870829-DS-15 | 24,805,590 | Dear Mr. ___,
It was a pleasure to take part in your care during your stay at
the ___. As you know, you were
admitted to the hospital to receive a blood transfusion and
investigate the cause of your anemia (low blood counts). You
received a Esophagogastroduodenoscopy or EGD in which a camera
took pictures of your esophagus, stomach and the upper part of
your small intestine. There was no site of bleeding identified
during the EGD.
You also received a CT scan to look for changes in your
intestine that might be bleeding and could also result in a low
blood count. The results of this test were pending at the time
of discharge.
We have made you an appointment with your primary doctor who you
should ___ with so that he can help get you scheduled for
an outpatient colonoscopy. You may also need a capsule study
(which looks at your small intestine), but only if the other
tests are negative.
We wish you good health in the future. | Mr. ___ is a ___ y/o gentleman with approximately one
month of melenic stools, excessive aspirin use and labs
suggestive of ___ deficiency anemia suggestive for upper
gastrointestinal bleeding. | 175 | 29 |
17420474-DS-14 | 23,342,068 | Surgery:
You underwent a surgery called a craniectomy. A portion of
your skull was removed to allow your brain to swell. You then
underwent a cranioplasty and the skull was replaced.
You had a thin catheter in your brain that helped the
neurosurgeon monitor the pressure and oxygen level in your
brain. This was removed on ___.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity:
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
You make shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications:
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after traumatic
brain injury. Headaches can be long-lasting.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
More Information about Brain Injuries:
You were given information about headaches after TBI and the
impact that TBI can have on your family.
If you would like to read more about other topics such as:
sleeping, driving, cognitive problems, emotional problems,
fatigue, seizures, return to school, depression, balance, or/and
sexuality after TBI, please ask our staff for this information
or visit ___
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | ___ year old male status post fall off the back of a moving
pick-up truck with a severe traumatic brain injury. CT of the
head in the Emergency Department revealed extensive traumatic
right sided subdural, bilateral subarachnoid, left sided
epidural, and left parietotemporal intraparenchymal hematomas
with mass effect and 5mm of leftward midline shift.
#Traumatic Brain Injury
The patient was admitted to the Neurosurgery Service for close
neurologic monitoring. He was started on Keppra for seizure
prophylaxis. He was started on 3% hypertonic saline. A right
Neurovent was placed for ICP monitoring. The procedure was
uncomplicated. Please see ___ Record for further
intraprocedural details. Repeat CT of the head showed proper
Neurovent placement, but worsening of the patient's multifocal
traumatic intracranial hemorrhage. Additionally, the patient's
ICPs were spiking to and sustaining in the ___. He was given a
bolus of mannitol, which brought his ICPs down to the ___,
however his ICPs remained consistently high despite medical
management. Given this, the patient was taken to the OR for a
right decompressive hemicraniectomy with subdural hematoma
evacuation and removal of right Neurovent. The operation was
uncomplicated. Please see ___ Record for further
intraoperative details. The patient was maintained on Keppra and
3% hypertonic saline postoperatively. His neurologic exam
remained stable. 3% was discontinued for hypernatremia. Patient
sodium was titrated to goal of >140. Overnight ___, the
patient had roving eyes on exam. STAT CT was stable. Patient was
placed on EEG, which was concerning for seizures. Keppra dose
was increased to 2g BID. He continued to have intermittent
seizures on EEG overnight and early morning on ___ and
Epilepsy recommended starting Vimpat 200mg BID as a second
agent. EEG remained negative for seizure thereafter and the EEG
was discontinued on ___. Repeat NCHCT on ___ showed expected
evolution of TBI but was otherwise stable. The patient's
neurological exam remained stable throughout the subsequent
period in the ___. He was then transferred to the floor ___.
On ___, he underwent cranioplasty with Dr. ___. Please see
operative report for further detail. Postoperatively, he was
closely monitored in the TSICU. VP shunt placement was offered
due to concern for hydrocephalus. This was discussed at length
with the patient's guardian (his brother) who ultimately decided
against pursuing a VP shunt or EVD placement. On ___ the
patient was made floor status. CT head on ___ demonstrated a
0.9cm extraaxial fluid collection on the right side, correlating
with mild swelling observed on exam. Cranioplasty staples were
removed on ___. Keppra was weaned off with last dose scheduled
___. Patient underwent a repeat CTH due to concerns for ongoing
right facial droop on ___. CTH with evolving infarcts in the
right temporal lobe and left frontoparietal regions, with no
evidence of hemorrhagic transformation or new major acute
infarct and persistent enlargement of the lateral ventricles,
third ventricle, and fourth ventricle.
#Agitation/Restlessness
Patient remained neurologically stable but with persistent
restlessness and agitation in bed requiring the use of
restraints to prevent patient injury to himself and pulling at
tubes/lines. Psych was consulted for medication recommendations.
Remelteon was added ___. Neurology was consulted to assist in
transitioning AEDs to include mood stabilization, and Lamictal
was added ___. They plan to uptitrate as outpatient prior to
weaning keppra. He was unable to wean from mitts and enclosure
bed, and buspirone was started on ___ per psych
recommendations for continuing agitation, and Trazodone was
increased. He was weaned from mitts on ___ and agitation
continued to improve. Lamictal was increased to 50mg BID on
___ per neurology recommendations. Buspirone was increased to
15mg TID and Seroquel PRN was added per psych recommendations on
___. Mitts were placed back on briefly on ___ due to
concern for pulling at PEG. Lamictal dose was slowly titrated up
to goal of 150mg BID on ___. He was starting on standing
Seroquel to help with agitation. Enclosure bed was discontinued
on ___ and patient was placed in a low bed with a 1:1 sitter.
#Left Temporal Bone Fracture
Otolaryngology was consulted for a left temporal bone fracture.
A dedicated CT of the temporal bones was obtained.
Otolaryngology recommended an outpatient audiogram and
outpatient follow-up.
#Concern For CSF Leak
Otolaryngology was consulted for concern for a CSF leak when the
patient began draining fluid from his nose. He was placed on CSF
leak precautions. The drainage self resolved.
#Respiratory Failure
The patient was intubated and was unable to wean from the
ventilator. Acute Care Surgery was consulted for a tracheostomy,
which was placed on ___. ACS removed the trach sutures ___.
First trach downsize was done by respiratory therapy on ___.
He was first seen by speech and swallow on ___ to assess PMV
use, they saw him again on ___ and noted that he could begin
to use PMV with supervision. On ___, a cap trial was started,
but the cap had to be discontinued after 1 hour following a
desaturation to 89% in the setting of agitation. Cap trials were
re-initiated on ___ with QID capping for ___ minutes. Trach
was changed to 6 CFS on ___. 24 hour cap trial started ___
was successful; the patient did not desaturate. His trach was
decannulated by respiratory therapy on ___. Patient was
without respiratory concerns throughout remainder of
hospitalization.
#Aspiration Pneumonia
The patient developed an aspiration pneumonia. He was initially
started on broad spectrum antibiotics, which were narrowed once
the cultures resulted. Patient developed leukocytosis and a low
grade fever ___, Tmax of 100.8. CXR was concerning for PNA.
Antibiotics were changed to Keflex based on the sensitivities.
On ___, he was noted to be febrile to 103, chest xray with
concern for worsening pneumonia. He was started on Nafcillin x 1
days. Infectious Disease weighed in, as patient was continually
febrile. He was changed to Vancomycin and Cefepime on ___.
He was given Tylenol Q6hr and started on a cooling blanket to
help with temperature control. A CT chest revealed improvement
in bilateral lower lobe atelectasis. Sputum culture was obtained
on ___ and grew out commensal respiratory flora. The patient
continued to experience low grade temperates and ID recommending
continuing vancomycin and cefepime, with the possibility of a
central component to these episodes. Vancomycin and cefepime
were discontinued on ___. Patient remained afebrile.
#Leukocytosis
In addition to a chest xray demonstrating pneumonia. On ___, a
urine culture was obtained which was negative. Bilateral ___
were negative. Blood cultures continued to be negative. CDiff
was sent on ___ and was negative. A head CT was obtained to
rule out intracranial infection, it was negative. WBC down
trended and was within normal range at time of discharge.
#Hypertension
Patient was started on labetalol for tachycardia/hypertension,
and it was titrated as tolerated.
#Dysphagia
Speech and Language Pathology was consulted and recommended the
patient be NPO. A NGT was placed. Nutrition was consulted for
tube feeding recommendations and adjusted tube feedings as
needed. Acute Care Surgery was consulted for a PEG, which was
placed on ___. Feeds were adjusted by nutrition, changed to
bolus feeds on ___. PEG was pulled out by patient on ___,
foley catheter placed in tract. ACS replaced PEG on ___ and
placement confirmed. Patient remained on bolus tube feeds.
#Family Coping
Social Work was consulted and followed for family coping. There
was a family meeting that took place on ___ with social work
to discuss steps for rehab once medically stable and prognosis.
Guardianship paperwork was obtained by his brother.
#Disposition
Physical Therapy and Occupational Therapy were both consulted
and recommended rehabilitation. Case management was contacted
and informed the team on ___ that the brother has outside
legal councel completing the guardianship. ___ legal is also
aware of the plan. CM looked for rehab facilities speciailizing
in TBI care at the request of the brother. ___ was
obtained. ___ guardianship was obtained. Patient was
discharged to rehab on ___. | 595 | 1,295 |
11867852-DS-4 | 26,217,236 | You were admitted to the hospital for evaluation and treatment
of your biliary stricture. You underwent ERCP with stent
placement, as well as cholecystectomy and a biliary bypass. You
tolerated these well and are ready to continue your recovery at
home.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. You will complete a course of
oral antibiotics as prescribed. You should continue stool
softeners and a bowel regimen. Please take toradol for pain
control and try to slowly decrease the amount of oxycodone that
you are needing for pain control.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | Patient was admitted with biliary obstruction. She underwent
ERCP on ___ with replacement of her common duct stent with
good drainage of bile. Her liver function tests improved
greatly, and she was tolerating a regular diet and passing
flatus and stool. Due to chronic cholecystitis and chronic
severe biliary stricture, she underwent cholecystectomy,
choledochojejunostomy and intraoperative ultrasound of the
pancreas on ___. She tolerated the procedure well. The rest
of her postoperative course was uncomplicated as follows:
Neuro: The patient had an epidural placed for pain control.
However it did not provide good pain relief. On POD #2 the
epidural dislodged inadvertently and was subsequently removed.
She was started on a PCA and was transitioned to oxycodone. She
was also given IV toradol on POD #4 as an adjunct and discharged
home with 3 days of PO toradol, and oxycodone prn.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. She tolerated a
regular diet on POD #4 without nausea or vomiting. She also
received an aggressive bowel regimen which was successful in
producing multiple episodes of gas and a large stool.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. She received unasyn from
___ through the am of ___. She was switched to augmentin which
she tolerated. She will take augmentin through ___ for a total
of 14 days of antibiotics.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. She is passing gas and having bowel movements with
the help of a bowel regimen and is being encouraged to wean the
oxycodone and use toradol as a bridge for the next few days. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. | 242 | 417 |
11714071-DS-63 | 23,066,079 | Dear Ms. ___,
Thank you for choosing us for your care. You were admitted for
chest pain in conjunction with feelings of lightheadedness.
There are many reasons for chest pain. You previously had a
filter placed in one of your body's large veins to prevent
pulmonary embolism. This time, we have done testing to rule out
dangerous conditions such as heart attack and aortic dissection.
When you arrived in the ER, one of your blood tests showed that
your kidneys were not working optimally. We placed a catheter in
your bladder to help measure your urine output. When placed, it
drained a large amount of urine, suggesting that your bladder is
not emptying properly. We ruled out a physical obstruction by
kidney stone using ultrasound. Since we've been draining your
urine with a foley, your kidney function has returned to normal.
Please see your urologist to follow up this issue of urinary
retention on an outpatient basis.
When we looked at your urine, we found that it contained
bacteria. This can happen if urine is retained for a long time.
However, without a fever and without a rise in your immune
response, this was more likely to be a benign bacterial
colonization of your bladder than an invasive infection.
We have started the following medication:
Omeprazole 20mg by mouth daily - for treatment of your heartburn | HOSPITAL COURSE: ___ year old female with a PMH of CAD, DVT s/p
IVC filter, HTN, HLD, and presyncope who presents with worsening
presyncopal symptoms and chest pain. She had a cardiac workup
including CTA to rule out microdissection which was negative.
She was found to be retaining urine and failed a voiding trial
so a foley to gravity placed. | 223 | 61 |
18424033-DS-2 | 22,243,243 | Dear Mr. ___,
You were admitted to ___
(___) due to your nausea, jaundice, and pruritus. Your labs
showed that you had an acute hepatitis. We did an extensive
laboratory workup to understand the cause of your hepatitis.
Additionally, we performed a biopsy for which we will call your
doctor with the results.
While inpatient, we continued to monitor your progress and saw
that you had a low neutrophil count (immune cells that help to
fight infections). You had no signs of infection while in the
hospital, but please follow-up with your primary care doctor
about this issue.
Please follow up with your outpatient providers and all your
scheduled appointments. Thank you for allowing us to be involved
in your care.
Sincerely,
Your ___ Care Team | Mr. ___ is a ___ male without significant medical
history who presented with a 2-week history of nausea, anorexia,
10lb weight loss, tea-colored urine, and pruritus found to have
transaminitis with AST/ALT ___, Tbili 7.3, Dbili 5.2, IBil
2.1. Ultrasound revealed only hepatic steatosis. Laboratory
workup was unrevealing. He subsequently underwent liver biopsy
on ___. Tolerated the procedure well. Discharged home on ___
with follow-up with Dr. ___. | 123 | 68 |
12251785-DS-80 | 22,772,872 | Dear Ms. ___,
You were admitted to the hospital for symptoms of dizziness,
gait instability, and double vision that were concerning for
stroke. Your brain CT was normal. Your symptoms improved to
baseline after you received dialysis. The likely cause of your
problems was electrolyte abnormalities or drug clearance
problems due to your renal disease, not stroke. You were cleared
by ___ to go home. We made a follow-up appointment with Dr. ___
___ neurology) for you.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Continue taking your home medications.
Best,
Your ___ Neurology Team | Ms. ___ presented with dizziness, gait instability, and
double vision that were concerning for stroke. CTA was normal.
Her symptoms improved to baseline after dialysis. She was
cleared by ___. No changes were made. She has had similar
presentation and workup for it multiple times. She should
continue her outpatient regimen, including her warfarin
according to her treating physicians recommendations.
- CTA revealed mall apical bilateral pleural effusions with
adjacent
atelectasis and ground glass opacities. Recommended follow-up CT
in 3 months.
- Continue home medications. | 100 | 86 |
19094356-DS-20 | 29,600,831 | You were admitted to the hospital with abdominal pain related to
acute cholecystitis. You subsequently underwent a laparascopic
cholecystectomy and recovered in the hospital. You are now
preparing for discharge to home with the following instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery. | The patient was admitted to the Acute Care Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed a tensely distended
gallbladder with two stones, one of which may have impacted the
gallbladder neck, equivocal for cholecystitis. The patient was
subsequently placed on bowel rest, given intravenous fluids,
pain medication and Unasyn. The patient subsequently underwent
laparoscopic cholecystectomy, which went well without
complication; please see operative note for details. After a
brief, uneventful stay in the recovery room, the patient was
transferred to the general surgical ward for further
observation.
Post-operatively, pain was well controlled. Diet was
progressively advanced as tolerated to a regular diet and well
tolerated. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirrometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge on POD1, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. | 331 | 217 |
12777045-DS-24 | 28,605,259 | Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
-You were having nausea and vomiting.
WHAT HAPPENED WHILE YOU WERE HERE?
- You were diagnosed with a small bowel obstruction
- You had a tube placed into your stomach and you did not eat
for 24 hours to give your bowel rest.
- Your nausea improved and you were able to tolerate eating, and
your ostomy output improved.
- It is possible that some of your symptoms may be due to
opiates, which slow down the gut's movement.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please continue to take all of your medications as directed,
and follow up with all of your doctors.
Again, it was a pleasure taking care of you!
Sincerely,
Your ___ Team | ___ PMH of Metastatic colon cancer (s/p right colectomy, right
heparin lobectomy, chemoradiation, w/ recurrence, s/p LAR, loop
ileostomy, hysterectomy/BSO , on ___ until ___, Rectal
Wall dehiscence (c/b presacral abscess s/p ___ drain then
upsizing, on prolonged Abx), Right leg DVT (s/p IVC filter, on
lovenox), who presents with vomiting found to have SBO, reoslved
with 24 hours bowel rest.
#SBO
Patient with vomiting and lack of ostomy output at home with
imaging on admission consistent with small bowel obstruction,
surgery consulted, without acute complication requiring surgical
intervention. Made NPO, NG placed. Ostomoy output resumed fairly
quickly, NG tube removed, advanced diet slowly which was
tolerated well. Patient had some episodes of hypoglycemia which
resolved after resuming full diet.
#Anemia
Hb downtrended from 9.5 on admission to 7.1 on ___ AM. There was
some cncern about blood clots from NGT. However, Hgb stabilized,
and patient did not require transfusion.
#Chronic Malignant Pain
Symptoms at baseline. Transitioned to IV morphine given NPO
status, but then resumed home dose. Also started standing bowel
regimen. Slightly down-titrated oxycodone dose given SBO/?ileus
at discharge.
#Metastatic colon cancer (s/p right colectomy, right heparin
lobectomy, chemoradiation, w/ recurrence, s/p LAR, loop
ileostomy, hysterectomy/BSO , on ___ until ___ As per
Dr ___ recent note, was to have restaging after Abx
complete, as she is considering restarting FOLFOX at that time.
However, now CT with increased pulm mets, which will need to be
communicated to her oncologist
#Rectal Wall dehiscence
CT A/P on admission revealed persistent dehiscence of the
posterior rectal wall with slight interval decrease in
associated
presacral air and fluid collection. Having 50cc daily output
from
JP. Continued daptomycin, cipro, flagyl through ___. Daptomycin
dose was adjusted from 600mg daily to 300mg daily per OPAT.
#Right leg DVT (s/p IVC filter, on lovenox)
-Continued once daily lovenox
#Hypothyroidism
-Continued synthroid
Transitional Issues
[] increased size of pulmonary mets seen on CT AP
[] Please continue on standing bowel regimen to prevent SBO in
the
setting of chronic opioid use.
[] oxycodone dose reduced from ___ to 2.5mg-5mg while patient
was in the hospital with good pain control. Please assess
whether increased dose is needed
[] Daptomycin dose reduced from 600mg to 300mg daily per OPAT.
Patient to continue antibiotics through ___.
[] Consider removal of JP drain if persistent low output
#HCP/Contact: Mother ___ ___
#Code: Full confirmed | 132 | 369 |
17086127-DS-9 | 28,756,307 | Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted with chest pain due to a pulmonary embolus which
originated from a vein in your leg. You were started on a
heparin drip with the plan to transition to warfarin as an
outpatient. Because it will not be therapeutic for a few days,
you will need to take lovenox for a short period of time as a
bridge. During your admission, you did not have shortness of
breath, fever or evidence of heart damage. This is your second
pulmonary embolus occurring in the post-operative period, which
may indicate that you need a longer course of warfarin. Please
follow up with a hematologist to discuss further. | Ms. ___ is a ___ year old woman with a h/o PE in ___ (negative
thrombophilia w/u), presenting with gradual onset CP ___
partially occlusive PEs. | 121 | 26 |
11897489-DS-10 | 21,795,368 | Dear Mr. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
fevers at home. Your family also noticed that you seemed more
weak than usual, and you had a hard time getting up after you
fell at home.
WHAT HAPPENED WHILE I WAS HERE?
- You were started on antibiotics to treat for a possible
pneumonia. We did a CT scan of your chest which did not show any
signs of pneumonia so the antibiotics were stopped.
-You received IV fluids because we felt that you were
dehydrated.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please follow up with your PCP
- ___ take all of your medications as prescribed
We wish you the best!
Sincerely,
Your ___ Care Team | ___ man with past medical history of idiopathic
pulmonary fibrosis, hypertension, hyperlipidemia, depression,
and dysphagia who presents with about 4 days of fever to a high
of 102, increased nonproductive cough, mild epigastric abdominal
pain, decreased appetite, and general weakness, likely a viral
infection.
#Weakness, poor po intake
#SHortness of breath
#Viral Syndrome
Patient presents with 4 days of high fevers, non productive
cough, sore throat, mild epigastric pain, poor po intake,
increased home O2 use, and weakness. Patient has diffuse
crackles on exam but consistent with his known IPF. CXR reading
is confounded by his concomitant ILD, could not rule out
underlying infection. Started on CAP therapy with azithromyicn
and ceftriaxone. CT scan done which did not show any evidence of
a PNA or aspiration (h/o aspiration PNA with normal video
swallow study), so abx were stopped. WBC remained wnl. Urine Cx
negative, blood cxs NGTD. He was saturating well on RA at rest,
but did become more visibly dyspneic with minimal exertion (such
as holding conversation), so patient was placed 1L NC for
comfort (uses O2 most of the time at home). Patient afebrile for
>24 hours prior to discharge. He reports feeling weak but much
better than when he came in to the hospital. ___ evaluated and
recommended rehab.
#Fall:
Patient had a fall at home in the setting of weakness. CT head
and CT neck were normal. He is normally independent at home but
was more deconditioned than baseline. Will be discharged to
rehab per ___ recs.
# ___ (Baseline Cr ___:
Patient had elevation in creatinine to 1.5, likely due to
hypovolemia in the setting of illness. Received 2L IVF
throughout his admission and Cr at time of discharge was 1.5.
# Liver lesion:
RUQUS showed slight interval increase in size of right complex
right hepatic lobe cystic lesion with internal avascular
echogenic contents. He will need nonurgent, multiphasic liver MR
for further evaluation.
CHRONIC ISSUES
--------------
# BPH
# Bladder thickening:
Continued on finasteride and tamsulosin.
# HLD:
He was continued on rosuvastatin
# Primary prevention:
He was continued on aspirin and home Vitamin D
# Rhinitis:
He was continued on loratadine. He should resume ipratrop nasal
spray after discharge as this was not on formulary.
# Depression:
Continued citalopram
# HTN:
Continued on home chlorthalidone
TRANSITIONAL ISSUES
=================
[ ] Please check Chem 7 in ___ days to check kidney function, as
patient's discharge Cr 1.5, which was stable throughout
admission but above recent baseline of ___.
[ ] Please encourage good PO fluid intake given patient's ___
and viral illness
[ ] Patient should be scheduled for follow up with his
Pulmonologist for follow up of his IPF.
[ ] Patient will need a ___, multiphasic liver MR for
further evaluation of interval increase in size of complex right
hepatic lobe cystic lesion with interval avascular echogenic
contents, which was identified on ultrasound during this
admission.
[ ] Patient saturates well and appears comfortable on RA at
rest, but does become more visibly dyspnic after minimal
exertion such as holding a long conversation. Please provide NC
O2 for patient as needed for exertion and as needed for patient
comfort.
[] Patient has history of aspiration but normal video swallow
study, showed no evidence of aspiration during admission and was
eating and drinking well, but would continue to monitor closely
#CONTACT: Name of health care proxy: ___
Relationship: wife
Phone number: ___ | 130 | 555 |
16729700-DS-12 | 26,237,372 | If you have staples, keep your wound clean and dry until they
are removed.
No tub baths or pool swimming for two weeks from your date of
surgery.
Do not smoke.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. Pain medication should
be used as needed when you have pain. You do not need to take it
if you do not have pain.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. for two weeks.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Loss of control of bowel or bladder functioning
You have to wear you TLSO brace at all times when you are at
30 degrees or more in bed.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 101.5° F.
Loss of control of bowel or bladder functioning | ___ year old male with minimal PMH besides known MSSA
osteomyelitis, discitis, and epidural abcess at ___ s/p prior
laminectomy (___) and Nafcillin course who presented with
worsening back pain from continued infection and cough from CAP.
# MSSA T7-8 Osteomyelitis/Discitis: MRI spine ___ showed
interval anterior collapse of T7/T8 since ___, with
increased prevertebral soft tissue edema and new paravertebral
fluid collections, and new adjacent RLL consolidations,
concerning for discitis and osteomyelitis with prevertebral
spread. Patient was initially admitted to Neurosurgery service.
Underwent ___ guided deep bone biopsy of this area on ___,
with gram stain showing GPCs in pairs and clusters and cultures
growing MSSA. Antibiotics were held prior to the biopsy.
Following the biopsy, he was started on Vancomycin, and switched
to Nafcillin once MSSA confirmed. He was transferred to
Medicine service for further management of his infection, with
ID and Neurosurgery following. His pain was controlled with
oxycontin, gabapentin, with oxycodone and hydromorphone as
needed for breakthrough pain. The pain service was also
consulted for assistance with pain management. On medicine, he
remained afebrile and leukocytosis resolved. He was
neurologically intact, but given significant bony destruction
and instability in his spine, decision was made to operate. Due
to the prevertebral extension of his infection and fluid
collections in the thorax, he need a combined surgery with both
Thoracics and Neurosurgery, via an anterior approach. Went to
the OR on ___.
# RLL Pneumonia: His CXR on admission showed significant
consolidations concerning for pneumonia. He received
Levofloxacin 750 mg IV once in the ED on ___, but no other
antibiotics prior to his bone biopsy. His MRI showed increased
prevertebral soft tissue edema and new paravertebral fluid
collections with adjacent right lower lobe consolidations,
suggesting that his pneumonia may actually be prevertebral
spread from his spine infection rather than a typical CAP. He
was nevertheless treated for CAP with Levofloxacin 750 mg PO
daily for 5 days given evidence of possible aspiration and
___ opacities on CT torso. | 256 | 343 |
11172056-DS-19 | 24,088,353 | Dear ___,
___ were admitted to the hospital for severe difficulty with
breathing. We feel this was due to taking too much tramadol,
along with your COPD and congestive heart failure. We treated
with a drug to reverse the tramadol, and antibiotics and ___
improved. The physical therapists saw ___ and recommended ___ go
to an acute rehab facility to help with your care and improve
your strength. Please continue to take your medications as
directed. Also please weigh yourself every morning, and call MD
if weight goes up more than 3 lbs. Finally, please stop taking
your tramadol. We have replaced it with a medication called
duloxetine which will not have the same side effects. It was a
pleasure taking care of ___.
Best of luck,
Your ___ medical team | Summary
==========================
___ year old female with history of COPD not compliant with home
O2, HFpEF, spinal stenosis, severe OA, and neuropathy secondary
to chemotherapy who presented with respiratory failure requiring
BIPAP. She was found to have overdosed on tramadol along with
COPD and CHF exacerbations. She was treated with naloxone,
prednisone, antibiotics and lasix diuresis and improved. She was
transferred to acute rehab in good condition.
Acute Issues
==================
# Hypercapneic respiratory failure ___ opioid overdose, COPD and
CHF exacerbations
This was felt to be secondary to tramadol overdose with COPD and
CHF exacerbations. She was initially given naloxone and
improved. She was subsequently stabilized with 5 days of
levoquin and 5 days 40mg po prednisone for COPD exacerbation and
IV lasix diuresis for CHF exacerbation. She was subsequently
transitioned to home torsemide regimen. ___ evaluated patient
and recommended discharge to rehab. She was at her baseline
status with clear mentation and no daytime O2 requirement at
time of discharge.
#Toxic Encephalopathy. Patient with encephalopathy likely
secondary to some metabolic component of hypercarbia, as well as
supratherapeutic doses of tramadol. Improved with naloxine and
improved respiratory status. At baseline upon discharge.
# Acute Kidney Injury (baseline 1.1). Patient with ___ in
setting of likely hypovolemia and poor PO intake. Improved with
some IVF and improved PO intake.
# NSTEMI, type II. Patient with T wave inversions and mildly
elevated trops already downtrending suggestive of demand
ischemia in setting of COPD exarbation. Patient with known
history of demand NSTEMI in setting of COPD exacerbations.
Troponin peaked at 0.12. Aspirin continued. No chest pain
throughout admission.
# UTI
Urine culture grew >100,00 K. pneumonia with levoquin coverage
as above.
Chronic issues
============================
# Atrial fibrillation. Remained in normal sinus rhythm.
Continued metoprolol for rate control and aspirin.
# Neuropathic Pain
Patient trialed on Duloxetine 20mg and pain was well controlled
throughout admission.
Transitional Issues
==============================
- Patient was evaluated by ___ and requires acute rehab.
- She should follow up with her PCP following rehab stay.
- Tramadol was discontinued as it may have contributed to her
presentation of respiratory failure.
- She was started on duloxetine and tylenol with good pain
control.
- She was mildly hypernatremic during admission, Na 149 on
discharge. Please recheck Na on ___ and consider free water if
uptrending or not improved.
- Discharge weight: 83.7 kg
# CODE: Full (confirmed)
# CONTACT: ___ (___) ___ | 130 | 387 |
15818671-DS-11 | 22,624,052 | Dear Mr. ___,
You were hospitalized at ___ after a fall at home. We think
that fall was due to high blood sugars and a urine infection.
Unfortunately, because you were on the ground for such a long
time, you developed high sodium (blood salt levels) and a mild
injury to your kidney from dehydration. Your blood sugars, urine
infection, sodium level, and kidney injury are all getting
better.
If you fall again and cannot get up, please promptly call
Emergency Medical Services for assistance.
Please see appointments and medications below.
Sincerely,
Your ___ Internal Medicine Team | Mr. ___ is a ___ year old male with PMH of DM2, HTN, CKD
stage 3 who presents to the hospital after a fall. Because his
wife ___ certain that the fall was serious enough to call
EMS, he was on the ground for 13 hours. In the ED, found to have
hyperGlc (400s) and UA c/w UTI, thought to have been the cause
of the fall. Due to dehydration, pt had hypernatremia and mild
___. In the ED, he had a single episode of maroon-colored emesis
(guaiac+) for which NGT was placed; stools were guaiac negative
and rectal exam revealed brown stool. H/H were stable through
his admission, and NGT was discontinued. The derangements above
were treated as described below:
Problem List
# Falls
# UTI
# Hyperglycemia/DM2
# Hypernatremia
# ___
# Maroon-colored emesis/?GIB
# Disorientation
# Troponinemia
# HTN
# Falls: Pt with reported history of several falls at home. This
fall was most likely precipitated by UTI, hyperglycemia,
?delirium. Due to being on the ground for 13h, patient had
hypernatremia (see below), mild ___ (see below), and CK
elevation to 1800. No reported hx of seizure-like activity or
sxs of syncope; additionally, other causes better explain the
fall. Given murmur heard on exam, echo was obtained showing LVH,
LVEF 70%, moderate aortic valve stenosis (valve area = 1.1cm2).
Patient discharged to rehab for further evaluation and
treatment.
# UTI: Patient's UA c/w UTI and urine cx growing Enterococcus.
Sensitive to ampicillin, nitrofurantoin (contraindicated due to
___, and vancomycin. Given sensitive to ampicillin, patient
was started on amoxicillin-clavulanic acid ___ PO q12h for a 10d
course for complicated UTI. This should be continued at rehab to
completion.
# Hyperglycemia/DM2: Patient presented with hyperglycemia to
400s, most likely due to infection and missed insulin doses. He
is on a glargine (50u breakfast, 42u dinner) and humalog (15u
breakfast, 50 units lunch) at home. Follows with an
endocrinologist at ___. Needs to f/u with Endocrinology
on discharge from rehab.
# Hypernatremia: As high as Na 150. Most likely ___ dehydration
due to being on the ground without free water access for 13h.
Initially we corrected with D5W based on free water deficit; Na
remained normal once patient taking PO as usual.
# ___ / CKD: Has history of stage 3 CKD (Cr baseline 2.5); Cr
3.0 on arrival. ___ most likely multifactorial due to (1)
relative hypotension in setting of UTI and (2) dehydration from
osmotic diuresis/hyperglycemia + free water restriction while he
was stuck on the floor. Re: (1), the patient had relatively low
systolic pressures (120s) during ___ 48 hours of admission; with
appropriate antibiosis, systolic pressures rebounded to
170s-200s (see HTN below). Cr improving (3.0 -> 2.8 -> 2.6).
Almost at baseline on discharge. Follow up with ___
nephrology.
# Maroon-colored emesis/?GIB: Single episode guaiac pos emesis
with guaiac neg brown stools. Hgb stable in ___. NGT placed in
ED but removed due to malposition on KUB and clinical stability.
# Disorientation: Patient with 24h of waxing-waning mental
status in hospital in setting of hyperglycemia, hyperNa, UTI as
above. Resolved with tx of illnesses as described above and
appropriate delirium precautions.
# Troponinemia: Patient with very mild Tn-emia on presentation
(0.13->0.14) and ECG at baseline, no chest discomfort. Most
likely represents a minimal elevation in setting of relative
hypotension, multiple illnesses as above, and ___ preventing
clearance of Tn.
# HTN: Patient was normotensive off home BP meds on arrival to
the floor. Initially held BP meds due to ___. However, once UTI
was txed, SBPs 170s-200s. Losartan 100/day restarted the day of
discharge; HCTZ continues to be held. Can be restarted at
discretion of rehab physician or PCP.
# Social: Initially thought that wife ___ filed with ___ at the
Elder Abuse Hotline and faxed written report to Ethos given
patient was down for 13 hours before EMS was called. Discussed
further with wife who noted that she didn't realize a fall was
"serious enough" to call EMS but would do so in the future if
something similar happened.
TRANSITIONAL
-Home Eval for fall prevention measures
-UTI: needs Augmentin 10d course for complicated UTI
-Hyperglycemia/DM2: needs f/u with ___ endocrinology
-___: f/u with ___ nephrology
-HTN: restart HCTZ or add additional antihypertensives as
appropriate | 92 | 694 |
10376769-DS-13 | 26,153,797 | Ms. ___ you were admitted for further evaluation of your pain
and weakness. Your weakness improved dramatically with time,
nutrtional supplementation and B12. Your pain medications were
adjusted a bit as whenever these medications were increased to
your home regiment you became unarousable and your oxygen level
would drop down. This is an indication of over medication and is
dangerous. Therefore we will provide you prescriptions of the
medication doses that you were on here, as detailed in the
discharge medications.
Please contact your regular neurologist. | ___ yo RHW with h/o chronic LBP s/p L4-5 fusion, fibromyalgia,
anxiety, depression, who presents with progressive distal lower
extremity numbness and weakness for the past 3 months. Neuro
exam is signficant for weakness that is asymmetric L>R and
more prominent distally than proximally in the lower
extremities, though there is question of giveway/effort in
judging the true degree of the weakness. This also makes it
difficult to distinguish an upper vs lower motor neuron pattern.
There is
decreased pinprick mostly in L4 distribution up to the knee,
with hyperasthesia in L5. Vibration sense is also diminished L>R
great toe, and DTRs are diminished in lower extremities.
Etiology of this presentation is unclear despite extensive
outpatient workup including MRI brain and spine, EMG, LP, and
several lab studies.
The patient had vague, non-specific positive findings, including
elevated CRP which has trended down, and elevated CK at initial
presentation, as well as leukocytosis intermittently seen. The
patient was admitted and monitored. A CT of the abdomen was done
that showed a duodenal wall thickening. She received a EGD and
biopsy that revealed only a cyst and no signs of neoplasm. the
CT of chest showed multiple small pum nodules/calcifications
with mediatinal LAD, however these were thought for the most
part to be chronic (based on previous radiology reports from
___ and ___ faxed from PCP ___.
Over her week of hospitalization the patient gained weight and
her objective signs of weakness (left foot drop) improved. Prior
to hospitalization the patient was eating only one meal a day.
She was also treated with B12 for a low normal B12, that may
have also contributed to her improvement. The patient was very
uncomfortable and frustrated with a diagnosis of compression
neuropathy secondary to malnutrition.
The patient's chronic pain was treated while she was here on her
home regimen on ___ and gabapentin. Of note, when her
medications were at her home dosing the patient was very
somnolent, difficult to arouse and O2 sat to the low ___. This
may have contributed to the patient's decreased PO.
The patient received physical therapy during her time and was
much improved on discharge. She was able to ambulate with a cane
and was deamed ready for d/c home with ___ services. Her hospital
course was discussed with her primary neurologist who
coordinated a follow-up for her. She was discharged on the pain
regiment she was on inpatient as detailed below. | 86 | 404 |
12708338-DS-2 | 21,933,980 | Dear Mr. ___,
You were admitted to the hospital because you were having chest
pain and the CAT scan of your chest showed a mass.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were treated with antibiotics, because the mass in your
lung is most likely an infection/abscess.
- You were evaluated by the infectious disease team, who
recommended a long course of antibiotics.
- You were evaluated by the thoracic surgeons and interventional
pulmonologists (lung specialists). They did not recommend biopsy
or other procedures at this time because they felt the
antibiotics alone should treat the infection.
- You had an echo (an ultrasound of your heart) and an
ultrasound of the veins in your neck. There was no evidence that
the infection in your lungs had spread to those areas.
- You had a PICC line placed so that you could get IV
antibiotics at home.
- Your blood tests showed some kidney injury. This may be from
one of the antibiotics you got in the hospital. You will be
taking a different antibiotic at home. Your primary care doctor
___ continue to monitor this to ensure it improves.
WHAT SHOULD I DO WHEN I GO HOME?
- You will need to complete at least 4 weeks of IV antibiotics.
The infectious disease doctors ___ be in touch with you
regarding the exact duration.
- ***You will need to get blood tests each week while on
antibiotics, starting on ___. *** This is to monitor
for side effects.
- Please keep all your follow up appointments as listed below.
- You will see the infectious disease, interventional
pulmonology, and thoracic surgery doctors as ___ outpatient.
- You will get a repeat CAT scan of your chest in ___ as
listed below to make sure the mass in your lungs improved with
antibiotics. If the mass is still there, you will likely need
additional testing and treatment.
- It is very important not to drink alcohol or use any other
recreational drugs while you are on antibiotics.
WHEN SHOULD I COME BACK TO THE HOSPITAL?
- If you have fevers/chills, chest pain, difficulty breathing,
nausea/vomiting.
- If you have pain, redness, swelling around your PICC line.
It was a pleasure caring for you, and we wish you all the best.
Sincerely,
Your ___ team | ___ man with no chronic medical problems who presented with left
sided chest pain and cough, with outpatient imaging showing left
upper lobe mass felt to be an abscess. He was treated with
vancomycin/zosyn and transitioned to ertapenem at discharge.
# Lung Abscess with Pneumomediastinum:
Patient presented with lung mass on CT scan, felt most likely an
abscess possibly precipitated by aspiration event in the setting
of alcohol/drug use v. small nodular bacterial pneumonia that
coalesced into abscess given inadequate treatment with 4 days of
PO levoquin as outpatient. Differential diagnosis also included
atypical infection (e.g. fungal) v. inflammatory process v.
malignant process, all felt much less likely. CT imaging ___
with progression of mass and concern for pneumomediastinum.
Infectious disease was consulted who recommended treatment for
pyogenic lung abscess with vancomycin/zosyn. Thoracic surgery
and interventional pulmonology were consulted for consideration
of biopsy v. abscess drainage. Both teams recommended
conservative medical management with close follow up, given low
concern for pleural involvement and very low concern for
mediastinitis given patient very well appearing and stable
throughout admission. Pneumomediastinum may have occurred
secondary to intranasal cocaine use v. coughing. HIV was
negative. ___ and ANCA negative. Blood cultures were no growth
to date. TTE without evidence of pericardial seeding. Jugular
vein ultrasound without thrombosis. On discharge, he was
transitioned to ertapenem with plan for at least 4 weeks of
antibiotics [Day 1 ___, with repeat CT chest in 4 weeks and
close PCP, ___, interventional pulmonology, and
thoracic surgery follow up. He will need further workup if mass
persists on repeat imaging status post antibiotics.
# Reduced ejection fraction:
Patient's TTE was notable for reduced ejection fraction of 45%
and mild global left ventricular hypokinesis. Most likely
secondary to alcohol and cocaine use. TSH was elevated at 5.3,
but T3 and free T4 were normal. He will need repeat TTE in 3
months and further outpatient work-up if persistent depression
of ejection fraction.
# Acute kidney injury:
Patient developed ___ from 0.9 on admission to 1.3. This
remained stable the next day, without improvement with IV
fluids. ___ was felt secondary to zosyn he received in house.
Vancomycin level was 19, so vancomycin felt less likely to be
culprit. Urine sediment without concerning findings. Patient was
encouraged to continue good PO intake on discharge. He will need
a repeat creatinine in 1 week to ensure normalization. | 374 | 395 |
16459432-DS-24 | 28,393,857 | Dear Ms. ___,
You were admitted to the hospital because you had an episode of
unresponsiveness at your extended care facility. We did several
studies including an EEG, a CT of your head, and blood work and
did not see any concerning cause of this episode. We believe it
may have been caused by a medication recently started called
olanzapine (Zyprexa). We stopped this medication and you had no
more episodes. We did have one blood culture grow some bacteria,
and we started you on antibiotics. However, after further
review, it appears the baceteria was contamination from your
skin and you do not need to be on antiobiotics. Please note the
following changes to your medications:
INCREASE Coumadin (Warfarin) to 2.5 mg daily or as otherwise
directed
CONTINUE Heparin 5000 units SC until INR>2.0
STOP Olanzapine (Zyprexa)
STOP Artificial tears
No other changes were made to your medications. Please weigh
yourself every morning, and call your MD if weight goes up more
than 3 lbs. It has been a pleasure taking care of you. | ASSESSMENT & PLAN:
Ms ___ is a ___ year old with a history of ESRD, Afib on
coumadin, and history of CVA who presents from her ECF after
being found unresponsive this morning. She awoke spontaneously
in the ED during workup and is currently without significant
complaint.
# Unresponsive episode: Patient was last seen normal at 8am
morning of discharge. She was found unresponsive by staff at ECF
sometime between 9am and noon. She was brought to ED where she
was noted to be breathing comfortably with intact gag reflex.
She withdrew from pain in all four extremities. CT of head, CXR,
and initial lab work was unremarkable. During preparation for
intubation, patient apparently awoke spontaneously while staff
was out of the room. She was noted to be oriented and without
complaint. She was admitted to medicine for further workup and
observation. On arrival to the medicine floor she had no
significant complaint. Zyprexa was held. Troponins were negative
x2 and telemetry showed only occasional PVC's overnight. Given
concern for seizure, routine EEG was performed, which was
negative for epileptiform discharges per preliminary report.
Neurology was consulted who felt episode most likely due to
medication effect of zyprexa with poor baseline substrate given
recent hospitalziations and initation of HD. No further imaging
was felt to be indicated. Zyprexa should be discontinued on
discharge and any additional neuroleptic or sedating medications
should be used cautiously.
# Positive blood cultures: Patient noted to have GPC in clusters
growing from one culture set drawn in the ED. She was afebrile,
hemodynamically stable, and without complaint. She was
empirically started on daptomycin given recent VRE in urine
culture. Speciation of blood culture returned coagulase negative
staph, and antibiotics were discontinued as this was felt to be
contaminant
# VRE Bacteruria: Patient with VRE in urine culture on ___ prior
to previous discharge. She was not treated as she was
asymptomatic. Again had VRE in urine culture from ED on ___, and
again is asymptomatic. She did receive 1 dose of daptomycin
empirically for positive blood culture, as above. However,
antibiotics were discontinued with no current intention to treat
her VRE bacteruria.
# Afib: Continued rate controle with metoprolol tartrate 12.5mg
po bid. Discharged on home 25mg metoprolol succinate.
Additionally, patients CHADS-2 is at least 5 and she was
subtherapeutic on her INR on admission. However, given history
of GI bleed in past, she was not bridged with heparin drip.
Coumadin was increased to 2.5mg daily.
# ESRD. Due to PCKD. Initiated HD on ___. Continued HD on
TTS schedule. Continued home sevelemer.
# ?COPD: Patient recently treated for COPD exacerbation during
recent hospitalization. She was breathing comfortably now on
room air without signficant wheezes on exam. Continued home
albuterol and ipratroprium prn, which she did not require.
# Hx of CVA: Continued anticoagulation as above. Given embolic
nature of stroke, it was deemed reasonable for patient not to be
on statin.
# Hx of delerium/sundowning: Has occured with prior amissions.
Held zyprexa as above. Remained alert, oriented, and appropriate
during her stay.
# HTN: Continued metoprolol 12.5 bid as above. Discharged on
home 25mg metoprolol succinate. | 168 | 514 |
17639771-DS-17 | 22,324,616 | Dear Mr. ___,
You were hospitalized due to symptoms of trouble speaking, word
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Diabetes
Hypertension
Heart disease
You were also noted to have had a minor heart attack this
admission or NSTEMI. You were on a blood thinner for this and
were seen by the cardiologists and cardiothoracic surgeons. You
will see ___ as an outpatient and will follow-up with
We are changing your medications as follows:
- Starting Apixiban 5mg twice daily (this is a blood thinner,
please take it every day)
- Start Metoprolol
- Increased Valsartan (blood pressure medication)
- Stop atenolol
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team | SUMMARY
==========
___ is a ___ male w/ hx of DM, HTN, prostate CA
(currently opting for observation), colon CA s/p resection, CAD,
and prior traumatic SDH who presents as OSH transfer for R arm
weakness/sensory loss and aphasia, s/p TPA, course c/b NSTEMI.
TRANSITIONAL ISSUES
=====================
[ ] Follow-up w/ ___ expedited CABG, if patient were
to develop chest pain he would need to be urgently evaluated for
emergent PCI or CABG, please continue to monitor closely
[ ] Tentative plan to discharge on apixaban with Ziopatch, if
Ziopatch negative for occult arrhythmia will likely discontinue
apixaban and treat with Aspirin alone
[ ] Follow-up w/ interventional cardiology to discuss options
[ ] Continue optimization of diabetes given elevated A1c (8.3)
#Acute Ischemic Stroke
Pt presented w/ a mixed aphasia and RUE weakness concerning for
left MCA stroke. He received tPA on ___. CTA did not
demonstrate any large vessel occlusion or significant
atherosclerosis. MRI 24 hours s/p tPA demonstrated multifocal
acute infarcts in multiple vascular territories consistent w/ a
cardioembolic source, however TTE w/o an obvious source (EF
mildly reduced 50-55%). Per echocardiography fellow, windows
were appropriate and they didn't believe a TEE would offer
further advantage. Etiology of his stroke is believed to be
embolic stroke of undetermined source (ESUS), though given his
concurrent cardiac disease suspicion is highest for a transient
cardiac arrhythmia which led to cardiac thrombus formation. Pt
was transitioned to apixaban this admission (5mg BID), which we
will continue and consider stopping if his Ziopatch is negative.
Noted to have A1c of 8.2 and LDL of 109. Pt has an allergy to
statins and thus is on a PSCK9 inhibitor. He was seen by both
physical therapy, occupational therapy and speech therapy.
#NSTEMI
#CAD
Pt underwent recent LHC ___ (as an outpatient) and noted to
have 3V disease. Presented this admission w/ concern for chest
pain (was initially difficult to evaluate given aphasia) and
elevated troponin to 1.2. Cardiology was consulted and he was
started on a heparin gtt for an NSTEMI. Cardiac enzymes
downtrended. He was additionally evaluated by cardiothoracic
surgery who are pursuing an expedited workup for CABG. From a
stroke perspective he is okay for a heparin gtt as needed for
surgery. He additionally had a CXR, labs, and carotid dopplers
while inpatient. We also reached out to the structural heart
team for consideration of a complex PCI as an alternative to
surgery. Of note, the cardiology team did not believe there was
an acute indication for intervention during this
hospitalization. Pt was switched from atenolol to metoprolol
(consolidated at discharge to 50mg succinate). Also started on
ASA 81mg. He was discharged w/ a Ziopatch.
#DM
#HTN
Noted to have uncontrolled risk factors of DM and HTN. Increased
Valsartan this admission. Stopped atenolol and switched to
metoprolol as above.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =109) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ X] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (X) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[X ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (X)
Antiplatelet - (X) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (X) N/A -- high concern for atrial
fibrillation, so discharge on apixaban pending Ziopatch | 302 | 746 |
15118488-DS-32 | 20,679,444 | Dear Ms. ___,
You were admitted with renal injury that improved with IVF. We
have adjusted doses of several of your medications. Please keep
all of your followup appointments.
Eating a lactose free diet should help with your loose stool as
your GI tract recovers from the infection.
Please have labs checked on ___. These will be sent to the
___. Your INR should be checked at that time as
well.
Sincerely,
Your ___ Team | This is a ___ woman with a deceased donor renal
transplant in ___ c/b stage IV chronic kidney disease in the
transplant ___ chronic allograft nephropathy, baseline Cr 3.7,
as well as secondary hyperparathyroidism, recurrent PEs who
presented with N/V/D and ___. | 70 | 43 |
10303080-DS-18 | 29,055,641 | It was a pleasure to participate in your care at ___. You
were admitted to the hospital because of your left foot ulcer.
You were treated with antibiotics. A biopsy of your bone was
performed by the podiatry service and a portion of infected bone
was removed. Cultures were obtained from the deep tissues
during surgery. Your wound continued to improve and was closed
with sutures. A PICC line was placed so that you can receive IV
antibiotics outside of the hospital. You remained stable and
were discharged home.
You will be treated with the IV antibiotic nafcillin through
your PICC line for 6 weeks. A visiting nurse ___ show you how
to set up the infusion. You will follow up with the Infectious
Disease department as well as Podiatry for care of the ulcer. | ___ year old gentleman with h/o of type 2 diabetes complicated by
diabetic retinopathy, neuropathy, and persistent foot infections
presenting with acute worsening of an ulcer on his L foot, found
to have osteomyelitis of ___ metatarsal and ___ proximal
phalanx.
ACTIVE ISSUES
1. Osteomyelitis: The patient was started on empiric
antibiotics for cellulitis and suspected osteomyelitis upon
admission. He received 1 dose each of linezolid and cefepime,
and then was started on ampicillin-sulbactam on ___. The
foot ulcer was cultured and grew Group B streptococcus as well
as coagulase positive, methicillin-sensitive staphylcococcus
aureus. An MRI of the foot was performed which showed
osteomyelitis, and the patient was taken to the OR for
debridement and deep tissue culture by the Podiatry service on
___. Infectious diseases was consulted for antibiotic
management and agreed with coverage by ampicillin-sulbactam
pending final cultures. Deep tissue cultures revealed the same
organisms as above, and the patient was switched to nafcillin 2g
q4h per ID recommendations for a total course of 6 weeks. A
PICC line was placed, and the patient was discharged. He
remained afebrile and without signs of systemic infection
throughout the admission. Blood cultures remained negative.
Baseline ESR and CRP were drawn to be followed for improvement
as an outpatient. The patient will follow up with Podiatry in 1
week after admission and with ID in the ___ clinic in 2 weeks.
2. Type 2 Diabetes: The patient's diabetes is uncontrolled with
complications, including diabetic retinopathy and neuropathy.
He was initially started on his home regimen of Lantus 43 units
qhs and Humalog 8 units QAC, but due to uncontrolled blood
glucose levels (elevated to high 300s at times throughout
admission), his Lantus was titrated up to 50 units qhs and
Humalog was titrated to 20 units qac with SSI. The
hyperglycemia was likely caused, in part, by his acute
infection. He was discharged on this new insulin regimen and
will follow up with his primary physician for further
adjustments.
3. Rash: The patient was found to have multiple erthematous
papules covalesecing into plaques on the gluteal fold.
Differential diagnosis includes inverse psorias vs eczema. He
was empirically treated with topical Clobetasol Propionate 0.05%
Ointment. He was scheduled for a follow up appointment with
Dermatology as an outpatient.
CHRONIC ISSUES
1. Chronic Diastolic Congestive heart failure: the patient's
last echocardiogram ___ showed the left atrium was
moderately dilated, with mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). The patient was continued on his home carvedilol 25
mg BID and torsemide 20 mg BID. CHF was stable throughout the
admission.
2. Coronary artery disease: Stable during admission. Home
aspirin 81 mg and atorvastatin 80 mg were continued.
3. Hypertension: Stable during admission. Home torsemide 20 mg
BID was continued.
TRANSITIONAL ISSUES
1. The patient has a PICC line placed in his left arm and will
receive IV nafcillin q4h for 6 weeks. He received teaching from
___ prior to discharge. The PICC should be removed upon
completion of antibiotic course. He will follow up with ID in
the ___ clinic in 2 weeks for management. | 142 | 533 |
12069102-DS-7 | 26,925,637 | Dear Mr. ___ you were admitted to the hospital following
surgery to repair the leak in your aorta. You have done
amazingly well and are now ready for discharge. Please allow us
to give you some general instructions regarding your discharge
as well as a few specific to you.
1) we have started a new medication metoprolol to help control
your blood pressure. You should continue to take this and follow
up with your PCP ___ ___ weeks to have your blood pressure
checked.
2) Because your aorta had an aneursym it is possible that other
blood vessels in your body may be predisposed to aneursym.
Accordingly we have scheduled you to have an ultrasound of the
arteries in your knees next week.
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for ___
weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
Wear loose fitting pants/clothing (this will be less
irritating to incision)
Elevate your legs above the level of your heart with ___
pillows every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
Take all the medications you were taking before surgery,
unless otherwise directed
Take one aspirin daily. Continue to take your plavix.
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
You should get up every day, get dressed and walk, gradually
increasing your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (let the soapy water run over incision, rinse
and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR : ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 101.5F for 24 hours
Bleeding from incision
New or increased drainage from incision or white, yellow or
green drainage from incisions | The patient was transferred to ___ with a ruptured AAA on
___. He underwent emergent open repair. Despite the magnitude
of blood loss and surgery he tolearted the surgery well and his
post-operative course was uneventful. He was discharged home on
POD#6. His hospital course by system is summarized below.
Neuro: At the conclusion of the surgery an epidural was placed
for pain control. The patient suffered from some perioperative
delirium however this resolveed by POD#2. His epidural was
removed on POD#3 and he was transititoned to oral oxycodone and
tylenol which he required minimal amounts of up to the time of
discharge.
CV: The patient had a large amount of intra-op blood loss (7.2L)
requiring 9 units of PRBC as well as FFP and platelets
intraoperatively. He was hemodynamically post-operatively. On
POD#1 he was briefly on a nitroglycerin drip for pain control
which was weaned and he was started on home lisinopril as well
as metoprolol for blood pressure control. His blood pressure
remained in good control with the lisinopril and metoprolol
which he was discharged on.
Resp: The patient remained intubated following surgery. He was
weaned from the ventilator on POD#1. Due to the resuscitation
during the operation he was significantly fluid overloaded and
required lasix diuresis for seveal days. After diuresis his
oxygen was weaned and he was stable on room air by POD#3. There
were some incidental pulmonary nodules commented upon on his CT
scan that will require follow up scans in ___ months.
Renal: During the operation the aorta was clamped between above
the left renal artery. His creatinine peaked at 2.2 upon
admission and steadily improved post-operatively. He was
diuresed each day and his weight returned within 2 kgs of his
dry weight.
Endo: The patient initially was on an insulin sliding scale. His
blood sugar remained in good control and this was stopped. He
had no other endo issues.
Heme: Following the ___ transfusions the patient did
not require any further transfusions. His plavix and aspirin
were restarted following removal of the epidural. He was on subq
heparin for DVT prophylaxis.
ID: The patient was afebrile throughout the hospitalization. His
white count was initially elevated likely to a SIRS response to
the surgery but he never manifested any signs of infeciton and
was discharged without antibiotics.
Transitional issues:
1) Hypertension: The patient was started on metoprolol in
additon to his lisinopril for blood pressure control. He was
discharged on metoprolol and was instructed to follow up with
his PCP in the next week or two for a blood pressure check and
titration of his medication.
2) Pulmonary nodules that were incidentally found on his CTA
will need follow up in ___ months. | 509 | 451 |
12956096-DS-25 | 24,484,390 | Dear Ms. ___,
You came to ___ with a swollen
and painful right shoulder. While you were here, we noticed you
had low sodium and high potassium, and you were admitted to the
intensive care unit for monitoring. Your electrolytes improved.
Infection of the shoulder joint is the most likely explanation
of your shoulder pain, so please continue your antibiotic until
___, for a total of 2.5 weeks.
We also did a chest catscan to see why your right arm was
swollen. We saw evidence of a lung infection. However, you did
not have symptoms. The most likely lung infections are also
treated with the antibiotic (cefpodoxime) that you are taking.
We recommend your PCP get ___ imaging in ___ weeks to see
if the lung findings have improved.
Your legs started swelling, so we treated you with medicine to
help remove fluid from your body. We also restarted your
lisinopril, which should help.
You will follow up with your nephrologist as scheduled below.
Please get labs drawn in one week (___). Please also weigh
yourself every day. If your weights start to rise, or if you
notice worsening swelling in your legs, call the renal
transplant clinic at ___.
It was a pleasure taking care of you!
We wish you the ___.
- Your Care Team at ___ | ___ with a history of End Stage Renal Disease (secondary to
Focal segmental glomerulosclerosis, status post living-relative
renal transplant in ___, on Tacrolimus/Mycophenolic
acid/prednisone), now with chronic scarring and Chronic Kidney
Disease stage IV, coronary artery disease (status post
drug-eluting stent to left anterior descending artery), with
right shoulder presumed septic arthritis, right-upper extremity
swelling, found to have severe hyponatremia and hyperkalemia.
Patient was monitored in ICU, and course complicated by atrial
fibrillation with rapid ventricular response, which
spontaneously converted to normal sinus rhythm. She was given
antibiotics for presumed septic arthritis and found on CT to
have ground glass opacities consistent with pneumonia.
#PRESUMED SEPTIC ARTHRITIS: Sudden-onset pain, swelling, and
reduced range of motion, in setting of known shoulder/rotator
cuff injuries. Acute pain began on ___ and worsened over
subsequent days, not improved with pain medication. She
presented to the ED for evaluation but was admitted to the ICU
for hyponatremia and received a dose of ampicillin-sulbactam
prior to arthrocentesis by interventional radiology. In this
setting, white blood count on tap was well below threshold for
septic arthritis. MRI findings supported infectious process. She
had no leukocytosis or fever, but is chronically
immunosuppressed and thus unlikely to mount full response.
Notably, crystal stain negative for gout and lyme serology
negative. In terms of rheumatoid labs, none were conclusive.
C-reactive protein and erythrocyte sedimentation rate both
elevated at 198 and 38 respectively. Other labs included:
Rheumatoid Factor 15 (nml ___ C3-85 (nml 90-180); C4 31 (nml
___ anti-CCP negative. Consulted infectious disease, who
recommended ceftriaxone for lung as below while working up
shoulder. Progressed to cefpodoxime and had clinical improvement
on this regimen. Arthrocentesis culture data all negative though
acid fast culture is pending. Plan to continue cefpodoxime for a
total of 2.5 weeks.
#LOWER EXTREMITY EDEMA: Onset ___ afternoon. Recent
echocardiogram normal, no history of liver disease, bilateral
deep-vein thromboses unlikely on anticoagulation. Known historic
nephrotic syndrome though on admission urine protein was 1.1g,
elevated but not nephrotic range, increased to 2.2 on ___.
Concerning for worsening of underlying FSGS in setting of
reduced immunosuppression (discontinued mycophenylate,
prednisone switched to dexamethasone briefly for cortisol
stimulation test) vs. consequence of holding home lisinopril vs.
could be from fluid shifts in setting of repletion (though none
3 days prior to development). On 2-liter restriction. Given 60mg
IV furosemide on ___ with good urine output (1L),
-1650 on ___. Recommended to weigh self daily on discharge and
contact the renal transplant clinic if her weights are
increasing.
#GROUND GLASS OPACITIES, RADIOGRAPHICALLY CONSISTENT WITH
PNEUMONIA: CT chest was ordered to evaluate for etiology of RUE
edema (see below) but showed diffuse ground-glass opacities,
combined to small left pleural effusion, likely reflect
infection. Mild symptoms (intermittent nonproductive mild cough,
mild worsening of vitals though nothing severe). Treated with
cefpodoxime since ___, previously ceftriaxone/vancomycin
(started ___. Of note, ___ chest x-ray consistent with
worsening pulmonary edema, though patient remained without
dyspnea, tachypnea. Consider repeat imaging after antibiotic
therapy to ensure resolution and no underlying pulmonary
pathology.
RESOLVED HOSPITAL ISSUES
===========================
#HYPONATREMIA: Asymptomatic. Baseline 127-133. Admitted due to
hyponatremia to 117. This improved with normal saline in ICU and
3 amps bicarb in D5W on the floor. She required no repletion
after ___. Free T4 normal. Could have component of adrenal
insufficiency (see below) but difficult to assess given chronic
prednisone.
#CONCERN FOR ADRENAL INSUFFICIENCY (AI): Could fit clinical
picture on presentation (weight loss, hyponatremia,
hyperkalemia, acidosis, hypotension, anemia), though many of
these symptoms can be explained by chronic kidney disease, and
AI typically causes hypercalcemia. On cosyntropyn stimulation
test she technically met criteria for adrenal insufficiency
(prednisone replaced with dexamethasone for 2 days preceding).
However, patient chronically on prednisone ___ years) since
transplant. Patient is thus iatrogenically adrenally suppressed
for transplant, and we would expect insufficient physiologic
response to cosyntropin. Would consider stress dose steroids in
future times of acute illness, though she did not receive any
this hospitalization.
#RIGHT UPPER EXTREMITY EDEMA: Resolved over hospitalization.
Likely reactive from presumed septic arthritis, though this is
not well described in literature. Imaging was negative for
right-upper extremity DVT; normal arterial duplex. Chest CT
could not evaluate vasculature without contrast. Not consistent
with thoracic outlet syndrome or SVC syndrome. Normal capillary
refill; no associated neurologic symptoms.
#NEW ATRIAL FIBRILLATION: Noted to have new onset atrial
fibrillation with raid ventricular response while in the ICU.
Converted spontaneously to normal sinus rhythm. Unclear
precipitant; probably presumed septic arthritis. Thyroid
stimulating hormone and free T4 normal. Started on empiric
antibiotics (as above) for concern that an infection may have
been the precipitating factor. Discontinued telemetry ___ due
to normal rate/rhythm.
#HYPERKALEMIA: K was elevated on admission (K peaked to 6.3),
treated with insulin, dextrose and kayexelate with improvement.
Likely secondary to renal failure although adrenal insufficiency
possible. No EKG changes during admission.
#END-STAGE RENAL DISEASE (ESRD) s/p LIVING RELATIVE RENAL
TRANSPLANT: Surgery in ___. Creatinine around baseline. UPEP
negative. SPEP with hypogammaglobulinemia (Immunoglobulin M 22,
normal is 40-230). Discontinued Mycophenylate on ___ per
transplant renal recommendations. Held home lisinopril on
admission but restarted on ___ in setting of increasing
proteinuria. Discharged on 1mg tacrolimus in the morning and
1.5mg at night due to subtherapeutic troughs on 1mg BID.
Continued on prednisone 4mg (though this was replaced with
dexamethasone preceding cosyntropin stimulation test).
#METABOLIC ACIDOSIS: Pt with chronic non-anion gap metabolic
acidosis. Was not tolerating oral sodium bicarb at home due to
abdominal pain. At baseline during admission. Possibly secondary
to ESRD, although concern adrenal insufficiency may be
contributing. Received 3 amps sodium bicarb as above.
#ANEMIA: History of anemia in setting of ESRD, on Darbepoetin
alfa injections. Baseline hemoglobin ___. Hemoglobin slightly
below baseline with no evidence of active bleeding currently.
Received 1u packed RBC each on ___ and ___, with appropriate
rise in hemoglobin. B12 250, Iron (on ___ was 59.
CHRONIC ISSUES:
======================
#HYPERTENSION: On amlodipine, carvedilol, and lisinopril at
home. These were initially held due to hypotension in the MICU.
They were all restarted prior to discharge.
#CORONARY ARTERY DISEASE: Patient with drug-eluting stent in
___. Last Echo in ___ was largely normal. Continued
Aspirin and Ticagrelor while in house. Reached out to
cardiologist Dr. ___ about stopping Ticagrelor >12
months out from Drug-eluting stent, but did not hear back prior
to discharge. Scheduled patient for follow up with Dr. ___ to
discuss. Additionally continued atorvastatin.
#h/o WEIGHT LOSS: Pt with recent weight loss. Fairly up to date
with cancer screenings. Needs outpatient follow up for repeat
colonoscopy.
#CODE: full code
#CONTACT: ___, husband, ___
TRANSITIONAL ISSUES
===================
[] MYCOPHENOLATE MOFETIL: discontinued on admission per Dr.
___
[] TACROLIMUS: reduced to 1.5 QAM and 1 mg QPM from 1.5 BID.
(Trough was elevated on admission, but low while inpatient on
1mg BID.)
[] ANTIBIOTICS: Patient should continue Cefpodoxime PO 400 mg
once per day until ___ for a 2.5 week course.
[] GROUND GLASS OPACITIES ON CT: Asymptomatic, though read as
most consistent with infection. Recommend repeat imaging in ___
weeks to evaluate for resolution.
[] LEG SWELLING: This developed on ___, 3+ edema, in setting of
worsening proteinuria. Her lisinopril was restarted. The
swelling was somewhat responsive to 60mg IV furosemide x3. Per
transplant nephrology team, she should weigh herself daily and
call if she is gaining weight. Otherwise she will have follow up
with Dr. ___ in 2 weeks.
[] CXR WITH PULMONARY EDEMA: Worsened on ___ compared to ___.
Described as "substantial increase in asymmetric pulmonary
edema, more prominent on the right. Blunting of the costophrenic
angles is consistent with developing effusions and bibasilar
atelectasis." Patient was asymptomatic with reassuring vitals
saturating well w/o dyspnea on room air. Correlate clinically on
follow up appointment.
[] ADRENAL INSUFFICIENCY: Technically, cosyntropin stimulation
test confirmed adrenal insufficiency, however, this is difficult
to interpret in setting of iatrogenic suppression of adrenals
with prednisone. It was ordered due to metabolic abnormalities
on admission and concern that the patient was not mounting a
systemic response to presumed infection. ___ consider stress
dose steroids for severe illnesses in the future.
[] WEIGHT LOSS: Recent history of weight loss. She is only 80lb
currently. She is fairly up to date on cancer screening. Further
workup should be discussed and considered in outpatient setting.
[] TICAGRILOR: In setting of ecchymoses, purpura, and ___ year
since stenting, would consider discontinuing ticagrilor pending
conversation with cardiology (Dr. ___.
[] PENDING RESULTS: Joint aspirate acid fast stain pending from
___, no growth as of ___. Low suspicion given improvement
without treatment for mycobacterium. | 212 | 1,401 |
12455543-DS-8 | 22,983,860 | * You were admitted to ___ for treatment of a
pneumothorax. A chest tube was placed at ___
and you were transferred to ___ for further management.
There is a persistent air leak from your lung which will need
time to heal and seal over. Your chest xray shows full expansion
of the lung which is good.
You are ready to go home, but still need your chest tube. A
small device, called an Atrium Pneumostat, has been placed on
the end of your chest tube to help you get better. The ___ will
help you manage this device.
* Your oxygen has been reordered for you and you should wear it
at ___ LPM as you were doing at home.
* If you have any increased shortness of breath, fevers > 101 or
any new concerns call Dr. ___ at ___.
About The Atrium Pneumostat:
The Atrium Pneumostat is made to allow air and a little fluid to
escape from your chest until your lung heals. The device will
hold 30ml of fluid. Empty the device as often as needed (see
directions below) and keep track of how much you empty each day.
Items Needed for Home Use:
Atrium Pneumostat Chest Drain Valve (provided by hospital)
___ syringes to empty drainage, if needed (provided by
hospital or ___ Nurse)
Wound dressings (provided by hospital or ___ Nurse)
Securing the Pneumostat:
Utilize the pre-attached garment clip to secure the Pneumostat
to your clothes. It is small and light enough that you won't
even feel it hanging at your side. Make sure to keep the
Pneumostat in an upright position as much as possible. Before
lying down to sleep or rest, empty the Pneumostat so there will
be no fluid to potentially leak out.
Wound Dressing:
You have a dressing around your chest tube. This should be
changed at least every other day or as prescribed by your
doctor.
Showering/Bathing:
Showering with a chest tube is all right as long as you don't
submerge the tube or device in water. Place the pneumostat in a
zip lock bag for showering then remove. No baths, swimming, or
hot tubs.
Note:
This device is very important and the tubing must stay attached
to the end of your chest tube.
If it falls off, reconnect it immediately and tape it
securely.
If it falls off and you can't get it back together, go to the
closest hospital emergency room.
Warnings:
1. Do not obstruct the air leak well.
2. Do not clamp the patient tube during use.
3. Do not use or puncture the needleless ___ port with a
needle.
4. Do not leave a syringe attached to the needleless ___ port.
5. Do not connect any ___ connector to the needleless
___ port located on the bottom of the chest drain valve.
6. If at any time you have concerns or questions, contact your
nurse or physician.
Emptying the Pneumostat
Keep the Pneumostat in an upright position and make sure the
tubing stays firmly attached to the end of your chest tube. Make
sure the Pneumostat stays clean and dry. Do not allow the
Pneumostat to completely fill with fluid or it may start to leak
out. If fluid does leak out, clean off the Pneumostat and use a
Q-tip to dry out the valve.
If the Pneumostat becomes full with fluid, empty it using a
___ syringe. Firmly screw the ___ onto the port
located on the bottom of the Pneumostat.
Pull the plunger back on the syringe to empty the fluid. When
the syringe is full, unscrew the syringe and empty the fluid
into the nearest suitable receptacle. Repeat as necessary. If it
becomes difficult to empty the fluid using a syringe, squirt
water through the port to flush out the blockage or consult your
nurse or physician. The Pneumostat may need to be changed out. | Ms. ___ was evaluated by the Thoracic Surgery service in the
Emergency Room and admitted to the hospital for further
management of her chest tube. She was having some discomfort at
the tube insertion site which was relieved with Oxycodone. She
also had a one chamber air leak from her pleurovac.
Following admission to the Surgical floor her chest tube
remained on waterseal with the same air leak and her chest xray
showed almost full expansion of the right lung. Her oxygen
saturations were 99% on 2 LPM nasal cannula and attempts were
made to wean it off. She admits to being on oxygen at home but
states she uses it mainly with activity. She has been off of it
for 3 weeks during her stay in ___ as she couldn't fly with
an O2 tank.
After 48 hours on waterseal her air leak persisted and a
pneumostat was placed so that she could go home with her chest
tube while the lung healed and be followed in clinic. A
pneumostat was placed on ___ and 2 subsequent chest xrays
showed almost complete re expansion of the lung. Her oxygen
saturations were 95-99% on 2 LPM but attempts at weaning failed
with room air resting saturations of 85%. She had pleuritic
chest pain with deep breathing but was otherwise stable.
Arrangements were made for home oxygen therapy.
Of note, her Chest CT which was done at ___ on ___
showed a spiculated nodule in the left lower lobe and a PET CT
was recommended by Radiology after she is stable from this
pneumothorax. I explained the findings to the patient and her
husband and suggested that they stop at ___ Radiology
before they return to ___ so that they can get a hard
copy to give to her pulmonologist Dr. ___ ___
___. ___.
Ms. ___ was discharged to home on ___ with ___ services
for her pneumostat and home oxygen and will return to see Dr.
___ in the ___ Clinic on ___. | 624 | 340 |
19635323-DS-12 | 29,430,709 | You were admitted to the hospital with non adherent ostomy due
to leaking. As a result you developed a fungal skin rash that is
beingtreated with an anti-fungal powder. A new ostomy appliance
has been used - you will be given prescriptions for the new
supplies.
DO NOT use the old ostomy appliance that you have at home.
You may resume your home medications as prescribed.
Return to the Emergency room if your ostomy appliance leaks
again. | She was admitted to the Acute Care Surgery team for management
of her leaking ostomy appliance and treatment for fungal skin
infection. Due to the location of the stoma and patient's body
habitus the ostomy location was very close to her mid-line
incision. The wound itself was not infected. Wound ostomy
nursing was consulted and were able to make adjustments in her
appliances to new equipment which adhered over 24 hour period
without leakage. Miconazole powder was ordered for the fungal
irritation which showed signs of improvement during her stay.
She remained on her home medications during her stay and is
being discharged to home with services. She will follow up in
Acute Care Surgery clinic as instructed. | 76 | 117 |
10068304-DS-12 | 23,499,122 | Dear Ms. ___,
Thank you for choosing to get your care at ___!
You were admitted with anemia ("low blood counts") and dark
stools, which were concerning for GI bleeding. The GI
specialists were consulted and perfermed endoscopic studies
including an EGD and a colonoscopy. Your EGD was unrevealing,
and the colonoscopy showed some possible sources of bleeding but
no active bleeds. A capsule study was performed but was
incomplete because the capsule never left your stomach. This
test can be performed again outside the hospital. You have a
scheduled ___ appointment with the GI doctors to discuss
this further.
During your hospitalization, you were found to be having some
problems with the amount of water in your body because of your
Congestive Heart Failure (CHF). This had caused some problems
with your breathing as is typical for this condition. You were
treated with diuretics to remove the extra water. As we did
this, your breathing was better and your kidney function
improved. You will be discharged on a new dose of the diuretic
furosemide. You should follow up with your cardiologist as an
outpatient to make sure this is the right dose for you. In the
meantime, you should weigh yourself every morning and call your
doctor if weight goes up more than 3 lbs. Also let your doctor
know if you are having difficulty breathing, especially when you
are lying down or in the middle of the night.
You were not treated for your polycythemia ___ during this
hospitalization because your blood counts were low and Dr. ___
___ already been holding your hydroxyurea. You have a follow up
appointment with your hematologists scheduled, at which point
you can discuss this further.
We wish you the best of future health!
Sincerely,
Your ___ care team | ___ female with history of polycythemia ___, systolic CHF
complicated by mitral regurgitation and mitral valve prolapse
now s/p recent mitral valve replacement in ___, as well as
recent admission & ICU stay for GI bleed presented with weakness
and dyspnea x1 week with dark, guaiac positive stools. Found to
be profoundly anemic in ED and tranfused 2U PRBC, then
transfused a third unit on ___. After transfusions, patient's
anemia was improved and she had no active bleeding during
hospitalization. She was also treated for volume overload in the
setting of acute on chronic congestive heart failure.
============================ | 290 | 97 |
18257430-DS-18 | 20,794,717 | Dear Ms. ___,
It was a pleasure taking care of you during your recent hospital
stay at the ___. You were
admitted for back pain with low oxygen levels and a new
productive cough consistent with a lung infection called
pneumonia. You also had your urine tested and you also had
evidence of a urinary tract infection. You were treated with
intravenous antibiotics, and your symptoms improved. Because
you had some difficulty with breathing, you were also treated
with steroids to treat a COPD exacerbation in the setting of
your infections, and your breathing improved. While you were
here, you were also noticed to have some difficulty with
swallowing, so our speech and swallow specialists evaluated you,
and recommended you have someone with you to help feed you your
meals to prevent food going into your lungs, to help prevent
future lung infections.
Your medications and future medical appointments are listed
below for you.
We wish you the best with your health.
Sincerely,
Your ___ Care Team | ___ yo female with PMH significant for DM, COPD chronically on 2L
home O2, developmental delay and numerous psychiatric diagnoses
who presents with hypoxia at her group home, found to have MRSA
PNA, UTI, meeting SIRS criteria on admission, found to be
grossly aspirating on video swallow.
ACTIVE ISSUES
=============
# Sepsis, MRSA PNA:
Patient initially with complaints of back pain at her group
home, noted to have an oxygen saturation in the ___. EMS arrived
and noted O2 sats 97% on patient's home O2, transported to our
ED where she was hypoxic requiring nonrebreather briefly,
tachycardic, tachypneic, with leukocytosis up to 19 this
admission, meeting sepsis criteria, with dirty UA and concerning
CXR for pulmonary source. Sputum cultures grew MRSA, and patient
was treated with an 8 day course of vancomycin to complete HCAP
course (lives in group home). Grossly dirty UA on admission (+
nitrite, large leuks, WBC 37 and 0 Epis), though with mixed
flora on urine culture, treated with 5 day course of cefepime,
transitioned to ceftriaxone once cultures resulted.
# COPD exacerbation:
Given history of COPD, with worsening productive cough, SOB,
consistent with COPD flare in the setting of above infection,
treated with 5 days total of steroids, standing duonebs, prn
albuterol neb, as well as home medications (guaifenesin and
advair). Additionally, given relative immobility, tachypnea, and
tachycardia, PE on the differential, however Ddimer is 548,
which is negative based on age-adjusted upper limit for Ddimer
(in her case, 500 + 270), making this less likely.
# Aspiration:
Given concern for aspiration during observed meals, speech and
swallow team consulted who on bedside evaluation cleared for
ground solids, nectar thickened liquids, meds whole in puree.
However, given continued concern with worsening lung exam and
repeat CXR with new R lower lobe opacity, video swallow obtained
which showed gross aspiration. Given patient with end-stage
dementia, and poor outcomes of gastric tubes in demented
patients (pressure ulcers, infections, delirium, and lack of
evidence for decreased aspiration events), continued patient on
ground solids, nectar thickened liquids, essential meds whole in
puree. Recommend mechanical soft diet, 1:1 feeding with frequent
encouragement to clear airways, oral care TID, standard
aspiration precautions (feeding when patient fully alert, seated
upright during PO intake and 30 minutes after, small bites/sips
at slow rate).
# ?UTI:
Grossly dirty UA on admission (+ nitrite, large leuks, WBC 37
and 0 Epis), though with mixed flora on urine culture. Given
mixed flora on initial culture despite floridly positive UA,
repeat UA and culture were done, however patient had been on
antibiotic coverage for 48 hours, and repeat UA/cultures were
negative. Patient incontinent and demented, unable to provide
reliable history regarding symptoms, thus given low risk for
antibiotics and high potential benefit if patient with true UTI,
treated with 5 day course of cefepime, transitioned to
ceftriaxone once cultures resulted with mixed flora.
# Abdominal pain:
Patient complained one evening of right sided abdominal pain,
exam unremarkable with stable vital signs, however given poor
historian abdominal films were obtained, which were negative for
obstruction or intraabdominal free air. | 165 | 500 |
17967857-DS-19 | 25,156,170 | Ms. ___, you were admitted to the ___ after gaining
weight despite your water pills at home. You were given strong
medications through an IV to get water out of your body. It was
also noted that there was a leak around your mitral valve and
unfortunately, this valve needs to be replaced. The plan is for
you to go home for several days to take care of your mother and
then come back to the Hospital on ___ to have the special
catheter placed to measure the pressures in your heart prior to
going to surgery for a valve replacement.
In preparation for your procedure, your last dose of coumadin
(warfarin) should be on ___.
You will be contacted with a time to come back to the Hospital
on ___ with the plan to stay and have your
valve replaced.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ year old lady with history of Mitral valve prolapse ___
bioprosthetic MVR, atrial flutter (on Coumadin) morbid obesity,
sleep apnea who presented with 2 days of worsening dyspnea,
orthopnea, peripheral edema, weight gain consistent with acute
on chronic CHF exacerbation. | 155 | 41 |
14346747-DS-19 | 24,725,833 | Hi Mr. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because you had very low blood
counts (anemia) and had a lot of fluid on your body due to your
heart failure.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- You received multiple blood transfusions to help with your
anemia
- You had a colonoscopy and upper endoscopy to look for a cause
of your anemia and showed no source of bleeding
- You received diuretics to help remove the extra fluid from
your body.
WHAT SHOULD I DO WHEN I GET HOME?
You are leaving the hospital against medical advice. Please be
sure to follow up with your doctors as below.
1) Follow up with your Primary Care Doctor.
2) Follow up with a Hematologist, Cardiologist, and Primary Care
Physician
3) Take all your medications as prescribed by your doctors.
4) Return to the emergency room if you see black tarry or blood
in your stool or if you develop new shortness of breath or
dizziness.
Your ___ Care Team | This is a ___ year old male with past medical history of
diastolic CHF, atrial fibrillation on apixaban, CKD stage III
admitted ___ with severe symptomatic anemia requiring
transfusion, suspected to be related to chronic GI blood loss,
workup without clear etiology, subsequently leaving the
hospital against medical advice.
Severe Anemia of Chronic Blood Loss secondary to occult GI
bleed
Patient presented with dizziness, found to have Hgb 5.7. He was
transfused 4 units of PRBCs with improvement in Hgb > 7, and
resolution of symptoms. Labs consistent with severe iron
deficiency. No signs of bleeding on cross-sectional imaging
,but did show splenomegaly, felt to relate to CHF below (and
not cirrhosis, per discussion with GI). Patient was seen by GI
and underwent ___ on ___, which showed no clear signs of
upper GI bleed, and was incomplete due to colonic redundancy
preventing visualization to the cecum on colonoscopy. Of note,
colonoscopy did show diverticulosis. Patient was seen by
Hematology who agreed with diagnosis of iron deficiency anemia
and recommended outpatient IV iron infusions. Given severity
of his initial anemia, and unknown cause, patient was
recommended for inpatient CT colonography and pill endoscopy,
however patient left against medical advice as below
# Discharge against medical advice
Team discussed recommendation for above workup with patient and
also the risks of not pursuing, including bleeding/hemorrhage,
cancer or death; patient was able to verbalize his
understanding of these risks and our recommendations; he
requested discharge home with outpatient GI, PCP and hematology
___. Team arranged for outpatient ___, discharged
against medical advice.
#Acute on Chronic Diastolic CHF
Patient with diastolic CHF who was admitted with 22lb weight
gain since last admission ___. Exam notable for JVD, lower
extremity edema. TTE without new wall motion abnormality.
Patient was IV diuresed from 322lbs to 308lb, but was not at
his dry weight at time of discharge against medical advice. Of
note, TTE did show elevated R sided filling pressures--would
consider repeat TTE when patient is euvolemic, and if still
present could consider additional workup. Discharged on home
Bumex 3mg BID.
#Splenomegaly
As above, attributed to CHF exacerbation. Could consider
repeat imaging when euvolemic, and if still present consider
additional workup
# Paroxysmal Atrial fibrillation
Initially held apixaban. Continued on amiodarone. Per
discussion with ___ cardiology, stopped patient's metoprolol
given good rate control with amiodarone and patient feeling
like metoprolol was causing side effects. Given that patient
had never had acute bleed (felt to be chronic and slow as
above), risk benefit was felt to favor restarting patient's
apixaban. Discussed with patient who agreed.
# ___ on CKD stage 4 - Cr 1.9 on admission, improved to
baseline 1.6 with diuresis.
#GERD: continued omeprazole 20mg daily
#BPH: Continued Flomax
# Lower Back pain: Tylenol PRN | 177 | 471 |
19053763-DS-17 | 26,649,773 | Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You were admitted to
the hospital with abdominal pain, and underwent a workup
including a CT scan, and an ultrasound which did not show any
cause of this abdominal pain. Unfortunately we were unable to
find a specific cause for your pain, and after treating you
conservatively you started to improve.
Please follow up with your primary care physician this week, and
continue to take all of your medications as prescribed. Before
you left, you met with our social work team here to help provide
you transportation home.
Take Care,
Your ___ Team. | This is a ___ year old male with past medical history of type 2
diabetes, bipolar disorder, chronic abdominal pain of unclear
etiology admitted ___ with reports of abdominal pain,
workup notable for CT pelvis, scrotal ultrasound within
normal limits, lipase of 165, but clinical picture not
consistent with acute pancreatitis (symptomatically improved
with eating), with course notable for pain migrating throughout
abdomen depending on who asked him.
>> ACTIVE ISSUES:
# Abdominal Pain: Upon admission, patient was complaining of
abdominal pain with radiation to the groin. Patient underwent a
RUQ ultrasound which was negative for any abnormalities other
than mild hepatic steatosis, and patient also underwent a
scortal ultrasound for concerns for testicular pathology, which
was also negative. Patient then underwent a dedicated pelvic low
dose CT scan which did not reveal any appendicitis. Initial labs
were notable for a mild leukocytosis, thought to be stress
related and downtrended on HD#1. Other abnormalities including a
mildly elevated lipase, however not significant for
pancreatitis. Patient was treated conservatively with pain
regimen (oral no IV pain medications) and started to have
improvement in symptoms. Collateral information obtained from
family members reports that patient has had a history of
abdominal pain in the past with negative workup,
and per his mother, this may be a manifestation of personal
stress. He tolerated a normal diet, symptoms improved and he was
discharged home
# Concern for Steatosis - RUQ ultrasound showed possible
echogenic liver; this was communicated to patient's PCP; workup
deferred to outpatient
# Hypertension: Patient was restarted on home dose of atenolol
50 mg, however soon became hypotensive to the ___, asymptomatic.
It was considered that patient not compliant on this regimen,
and therefore was given low dose 12.5 mg daily. However because
of significant effect on blood pressure, this medication was
discontinued. This was relayed to patient's mother as well.
Patient to make appointment with PCP at which point can restart
this medication as an outpatient. No lightheadedness, dizziness,
syncopal episode or episodes of hypertension while inpatient.
.
# Diabetes Mellitus Type II: Patient on oral agents at home, and
was continued on insulin sliding scale while inpatient. Patient
did not have episodes of hyperglycemia or hypoglycemia while
inpatient.
.
# Hyperlipidemia: Patient was continued on home statin and
fenfibrate while inpatient.
.
# Bipolar Disease: Per patient, has not been on any psychiatric
type medication for several months. Patient previously was on
seroquel 600 mg PO QHS per his mother, and has an upcoming
intaking appointment at ___ (mental health ___ in ___
___. Patient appeared stable, and able to make informed
decisions, and therefore reinitiation of his therapy was not
indicated while inpatient. To be titrated by psychiatry as an
outpatient.
.
# Disposition: Patient was seen by social work prior to
discharge. Patient was given $15 for bus pass to return to ___
___, and was given a T-ticket for public transit. Patient
voiced understanding of plan to see a PCP upon discharge from
the ___ to ensure stability, and reinforced continuity of
care as paramount to patient's health. Communication with family
also through Mr. ___ mother.
.
>> TRANSITIONAL ISSUES:
# Steatosis: RUQ ultrasound showed possible echogenic liver, can
consider outpatient follow-up
# HTN: Patient's atenolol was held at discharge given normal
pressures without it and reported non-compliance at home
# Bipolar Disease: Patient to f/u with intake at ___ (___
Health Provider in ___, to consider re-initiation of
therapy. | 108 | 569 |
10550641-DS-10 | 22,663,532 | Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) other than what is being prescribed
for you at discharge.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason | #Altered mental status/Fever/aseptic meningitis/metabolic
encephalopathy/metastatic neuroendocrine tumor to the ___
On ___, Mr. ___ was admitted to the Neuro ICU with altered
mental status. LP in the ED had elevated protein, low glucose
and high opening pressure. Cultures were sent. He was noted to
have a mass on his neck on admission felt to be lymphadenopathy.
MRI was performed which did not show abscess. His wound was
noted to have purulent drainage and he was started on empiric
vancomycin, cefepime and ampicillin. Infectious disease was
consulted. Ampicillin was discontined on ___ per ID. He was
placed on EEG on ___ which was negative for seizure. He had
leukocytosis on admission which downtrended. He was transferred
to ___ on ___. Repeat MRI was stable and negative for clear
abscess but there was concern for ventriculitis ___ he had a
fever to 101.2 with WBC up trending, urine cultures and blood
cultures were sent and were all negative. Repeat CXR was done
and was negative. His family was consented for PICC line ___.
Placement of PICC was deferred in setting of elevated WBC with
unknown source. CSF culture was negative. Due to continued
fevers, worsening altered mental status, and continuing
elevation of WBC a family discussion was had regarding
additional surgical procedures verse CMO, after thorough
discussion, the patient was transitioned to CMO care with
Palliative care consult on ___. The patient's case was
re-discussed at ___ TUmor Conference on ___ and consensus
was that given the negative cultures, the profound
encephalopathy that the patient developed aseptic meningitis
with poor prognosis due to disease progression. All invasive
intervention were stopped per family's request as the patient
transitioned to CMO. Over ___ to ___ the patient
gradually improved, still confused, with expressive aphasia, non
lethargic anymore so the family asked for guidance in whether
the CMO status should be reversed or continue care. With the
involvement of Palliative Care, Hem/Onc, ID, nursing and
neurosurgery as discussed with Dr. ___ family
meeting took place on ___ where the family was presented
with the grim prognosis due to the pathology of the tumor
(neuroendocrine tumor, STAGE IV metastatic lesion possibly due
to lung). After hearing different opinions the family elected to
proceed with hospice care option and continue CMO status.
#Dysphagia
Due to altered mental status, the patient was made NPO on
admission. NGT was attempted to be placed on ___ for tube
feeding, but was unsuccessful as the patient non-compliant with
placement. SLP evaluated and recommended puree consistency with
thin liquids and 1:1 feeding. Family was consented ___ for PEG
placement for nutrition supplementation, however NGT was placed
over concern for patient self d/c'ing PEG. Tube feeds were
started ___. Given CMO status on ___ and repeat family meeting
on ___ to agree to hospice, the Dobhoff was removed and the
patient was allowed to eat to comfort.
#Bilateral lower extremity DVT's
On admission, the patient was found to have b/l DVT's and was
started on heparin drip with PTT goal of 50-70. Given CMO the
family elected to stop needle sticks with SQH and PTT checks,
and after discussion with Dr. ___ (patient's son)
elected to start Xarelto po for DVT and PE prophylaxis. ___
acknowledged the fact that there is a possibility for ___
hemorrhage while on anticoagulation. ___ discussed with his
mother ___ who also agreed on the patient being discharged
on Xarelto 20mg daily for patient compliance and minimal
medications since he is CMO status. It was also explained that
this medication provides prophylaxis protection but does not
guarantee that a PE or a DVT will not happen or expand.
Palliative care / hospice team to re-assess need for
anticoagulation. Per their request and after discussing with Dr
___ will discharge the patient on Xarelto and Hospice may
decide for continuation after discussion with the patient and
family and agree.
#Pain
Patient appeared to be in pain with movement on ___. MRI L
spine was ordered to evaluate for spinal metastasis. The patient
was moving to much in the scan so MRI was not obtained with
contrast, but non-enhanced scan was found to be negative for
metastasis. IV morphine and po oxycodone PRN were given
#Gout
On prior admission patient was found have gout flair in right
knee. Rheumatology had been consulted and colchicine started.
___ Rheumatology was consulted for updated recommendations for
persistent redness and swelling in right knee and new redness of
right ankle. Colchicine was titrated up per their
recommendation. | 355 | 739 |
10924116-DS-23 | 29,086,138 | Dear Ms. ___,
You were admitted to ___ for repeated falls and a change in
your mental status.
WHAT WAS DONE
==============
-You were found to have high calcium levels that made you
confused and damaged your kidneys. This was treated with fluids
and other medications
-You had a pacemaker placed for a slow heart rate that was
thought to be the cause of your falls
-You did not have a bleed in your brain, which was a concern at
an outside hospital
WHAT TO DO NEXT
===============
-Take your medications as prescribed
-Follow up with your doctors, including device clinic in ___
for your pacemaker. You should also follow up with an
endocrinologist
-Call your doctors ___ develop chest pain, fevers, chills, or
worsening confusion
Wishing you the best of health moving forward,
Your ___ team | ___ with hx of chronic A-Fib on coumadin, tachy-brady syndrome,
severe AS s/p bioprosthetic AVR/CABG in ___, CKD,
hypoparathyroidism, and hypothyroidism transferred for syncope,
bradycardia and suspected intracranial hemorrhage that was
revealed to be a calcification. She was admitted for
encephalopathy, ___, and PPM.
# Toxic Metabolic Encephalopathy: Patient with baseline dementia
but generally alert and confused. However, declining mental
status per HCP over past week; she presented agitated and
nonverbal. Patient noted to be obtunded and minimally arousable
on arrival to floor. Did follow commands and grossly appeared to
have cranial nerves intact. Suspicion was medication induced
given olanzapine IM 5mg x2 in ED with concurrent ___.
Additioanlly, patient with history of AMS with hypercalcemia.
She was found to be hypercalcemic to a corrected value >14. With
time and treatment of hypercalcemia, her mental status improved
to baseline.
#Hypercalcemia in setting of hypoparathyroidism: Pt with history
of hypercalcemia and AMS in past secondary to increased
exogenous calcium/vitD. Pt in ___ discharged on 0.25
calcitriol BID, appears to have been receiving 0.5mg BID at
nursing home. Her PTH was 5, suggesting again an exogenous
source of calcium. She was treated with IVFs, furosemide, and
48hrs of calcitonin. Her calcium supplementation was held as
calcium normalized. She was discharged on 0.25mg calcitriol once
daily and calcium carbonate 1250 mg BID.
Endocrinology follow up was scheduled. She will need to have her
calcium checked weekly. If corrected calcium falls below 8,
please increase calcitriol to 0.25 BID. Patient would benefit
from regular labs as below.
# Tachy-Brady syndrome and syncope: Patient with known
tachy-brady
syndrome. ECG with evidence of LBBB and LAFB in slow AF. Patient
was having symptomatic bradycardia with syncope. A
single-chamber PPM was placed ___ without complication.
Follow-up with ___ device clinic is scheduled.
# A-fib: patient with chronic A-fib on warfarin with goal INR
___. INR supratherapeutic on admission to 5.3. She was reversed
with Kcentra and Vitamin K given suspected ICH. No ICH on CT
Head re-read. Her CHADS-VASC2 is at least 6. She was restarted
on her home Coumadin.
___ on CKD: Patient presented with elevated Cr to 2.3, baseline
somewhere between 1.1 and 1.5. Urine lytes and hypercalcemia
consistent with intrinsic renal disease from hypercalcemia. Her
discharge creatinine was 1.7.
# HTN: Patient with known HTN presented with SBP to 200 treated
initially with hydralazine in ER. Patient apparently not on
antihypertensives although had prior discharge on amlodipine.
She was restarted on amlodipine 10mg daily.
# Hypothyroidism: Patient with known h/o hypothyroidism.
Continued on ___ synthroid per recent prescription refill.
# Microcytic hypochromic anemia: Consistent with baseline,
continue to monitor
# Chronic ischemic congestive heart failure (40-45%) with
history of aortic valve replacement and coronary artery bypass
graft ___: Patient with known h/o AVR and CABG (SVG to OM1)
both done at same
procedure in ___. She was maintained on aspirin and
atorvastatin. By discharge, she was restarted on home Lasix.
# Restless Leg Syndrome: Baclofen PRN | 126 | 489 |
19712479-DS-19 | 23,796,590 | Surgery
- You underwent a surgery called burr holes to have blood
removed from your brain.
- Please keep your staples along your incision dry until they
are removed.
- It is best to keep your incision open to air but it is ok to
cover it when outside.
- Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
- No driving while taking any narcotic or sedating medication.
- If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
- No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
- Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
- You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
- You may have difficulty paying attention, concentrating, and
remembering new information.
- Emotional and/or behavioral difficulties are common.
- Feeling more tired, restlessness, irritability, and mood
swings are also common.
- You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
- You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
- Headache is one of the most common symptoms after a brain
bleed.
- Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
- Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
- There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site.
- Fever greater than 101.5 degrees Fahrenheit
- Nausea and/or vomiting
- Extreme sleepiness and not being able to stay awake
- Severe headaches not relieved by pain relievers
- Seizures
- Any new problems with your vision or ability to speak
- Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
- Sudden numbness or weakness in the face, arm, or leg
- Sudden confusion or trouble speaking or understanding
- Sudden trouble walking, dizziness, or loss of balance or
coordination
- Sudden severe headaches with no known reason | Mr. ___ is an ___ year old male known to the
neurosurgery service s/p right burr hole evacuation on ___
for chronic bilateral subdural hematoma. Patient was readmitted
on ___ from OSH with worsening gait and confusion, found to
have worsening bilateral SDH Left > right.
#Chronic bilateral Subdural hematoma
Mr. ___ was admitted to neurosurgery service on ___
with worsening chronic bilateral SDH, Left>right. Consent was
obtained from health care proxy, and patient was taken to the OR
on ___ for Left burr holes for subdural hematoma evacuation
with placement of left subdural drain. The procedure went
accordingly with no intraoperative compilations. Please refer to
op note in OMR for further intraoperative details. Patient was
taken to Post operative area for further monitoring, where he
remained intact on exam, and was then transferred to the step
down unit for continued care. Post op head CT demonstrated a an
area of hyperdenisty at the drain terminus concerning for new
hemorrhage. The patient remained intact and a repeat CT on ___
remained stable. Subdural drain was pulled on ___. The patient
was evaluated by ___ and OT on ___ who recommended discharge
home with inhome ___ services. Patient remained stable and was
cleared to be discharged home on ___. | 589 | 209 |
16335991-DS-10 | 26,680,451 | It was a pleasure taking care of you at ___
___. You came in with difficulty moving your limbs
and falling. Your MRI and CT imaging did not show any
concerning pathology. This was likely due to medications you
were taking (oxycodone with gabapentin). We have changed your
medications and discontinued gabapentin.
You also complained of chest pain and there was no evidence of
damage to your heart. You had normal imaging of your heart.
You also had elevated liver tests. The pictures of your liver
were normal except for some fatty changes. The numbers
decreased and you will need to follow up with your primary care
doctor and avoid any medications toxic to the liver such as
tylenol.
You came in with back pain and had an MRI of you ___ done that
showed only mild degenerative changes seen with age. You also
complained of hip pain and an x-ray of your hip did not show any
breaks or fractures. | ___ history of Factor V Leiden, tobacco abuse, chronic low back
pain, known herniated discs at L4-L5 and L5-S1 who presents
after multiple falls at home. There was concern for cord
compression based on ER exam with resultant MRI showed no acute
cord compression. Hospital course was significant for fall and
transient loss of consciousness work-up that revealed no serious
etiologies. Etiology of falls and transient loss of
consciousness was attributed to oversedation from gabapentin and
narcotics. Secondary issue was transaminitis of unknown
etiology.
# Recurrent falls secondary to acute toxic-metabolic
encephalopathy: Patient reported inability to move upper and
lower limbs after multiple falls. She is vague about the
descriptions of each fall but does not give a clear history of
syncope. Differential diagnosis includes primary neurological,
toxic-metabolic, medication side effect, orthostasis among other
considerations. On physical exam the patient was noted to be
very sedated but arousable. She also had small non-reactive
pupils. Her neurological exam was limited by effort, but
initially revealed decreased strength in the lower extremity
greater than upper extremity. Neurology was consulted and felt
that the patient had a functional problem. Serial exam showed
normalization of function after withholding sedating
medications. She had an MRI of the ___ done which showed no
cord compression with mild disc buldge at L4-L5 and L5-S1, no
spinal stenosis, and mild degenerative changes. The patient was
place on telemetry, no malignant arrhythmias were seen. A head
CT was done to look for an acute bleed given history of falls
and elevated INR but no evidence of SDH. The head CT showed no
acute process with mild age-related atrophy and chronic small
vessel ischemic disease. A tylenol level was performed, given
transaminiitis and percocet use, but was normal. An ESR was
done to evaluate for inflammatory myopathy, but was normal.
It was felt that her falls, difficulty moving her limbs and
sedation represented acute toxic-metabolic encephalopathy
secondary to percocet use and gabapentin. After holding
percocet and decreasing her gabapentin dose, the patient
improved remarkably. Her strength improved to ___ in upper
and lower limbs. ___ reevaluated patient and she was able to
resume her normal activity level. Her mental status improved and
she was alert and oriented x3 and talkative. It was decided to
discontinue her gabapentin and percocet and restart her on a
lower dose of oxycodone as needed for pain. Patient much more
alert today and strength is restored to normal after
discontinuing sedating medications.
The etiology of her likely recurrent falls is secondary to
medication side effect - specifically excessive sedation from
gapabentin and narcotics.
She was discharged home with ___ and services.
# Transient loss of consciousness- The patient reported a
possible loss of consciousness. It was unclear if this
represented syncope vs. transient loss of consciousness from
sedating medications as above. The patient did not describe any
syncopal prodrome nor did she describe a seizure like episode.
There was no evidence of malignant arryhthmia on telemetry and
an ECHO performed showed preserved EF without valvular lesions.
Neurology did not recommend any further imaging. Patient was
initially very sedated and mental status cleared after
decreasing sedating medications. Possible transient loss of
conscious was likely due to combination of gabapentin and
oxycodone causing sedation. No evidence of primary cardiac or
neurological process was observed.
# Transaminitis -
Patient noted to have elevated LFTs ___ 07:00AM
ALT(SGPT)-267* AST(SGOT)-249* LD(LDH)-307* CK(CPK)-33 ALK
PHOS-132* TOT BILI-0.4). Patient has history of elevated LFTs
(Atrius records show ALT/AST in low 40-50, negative recent
Hepatitis panels for A,B). She drinks only rarely. The patient
also complained of some nausea and vomiting. A RUQ ultrasound
with doppler was performed and showed status post
cholecystectomy with no biliary dilatation with fatty liver and
mild splenomegaly or vascular issues given history of Factor V
Leiden. Liver function tests have improved significantly.
Tylenol level was within normal limits. The patient had been
tested for hepatitis in the past. A hepatitis C test was done
and negative. Hepatotoxic medications were discontinued and the
patient was instructed not to take anymore tylenol and follow up
as an outpatient.
Patient should have further outpatient work-up.
# Elevated INR: INR was >7 on admission and trended down to ~4
and then ~ 2. The patient reports carefully following
outpatient provider ___. There was no evidence of
bleeding and a head CT was done to rule out intracranial bleed
after fall. The patient was restarted on 5 mg of warfarin per
day and will follow up with ___ clinic.
# Headache: Patient reported new onset frontal headache that
she describes as typtical migraine. Given fall and elevated
INR, concern for hematoma. No evidence of increaesed ICP or
bleed on CT. Headache resolved on own.
# Chest Pressure: The patient incidentally reporting vague chest
pain on morning of admission. MI has been ruled out, ECG without
ischemic changes, telemetry benign. CXR revealed incidental
nodules and ___ on CXR. ECHO showed normal LVEF without
valvular pathology. Her home omeprazole was continued.
Symptoms subsided.
# Back Pain: She does not describe any bowel or bladder
involvement with her back pain and MRI is also reassuring that
there is no evidence of cord compresson. Patient recently
evaluated at ___ by neurology and neurosurgery. Likely
chronic back pain. No evidence of cord compression, spinal
stenosis, or acute compression fracture. No spinal stenosis
seen. No abnormal signal within the
spinal cord. Multilevel mild degenerative changes without
spinal stenosis. Pain medication changed to oxycodone and
gabapentin discontinued. Patient may follow up as outpatient
with PCP.
# Depression and Anxiety: Patient reports anxiety at baseline.
She denied SI/HI. Is followed as outpatient by psychiatrist.
Outpatient meds including ___, wellbutrin were
continued.
# Hypertension: Stable. Continued doxepin, lasix, inderal.
# Gout: No evidence of acute gout flare. Colchicine was
continued.
# Incidental findings:
A. ___ CXR
Radiodensity in that region could be due to large hilar lymph
node calcifications or additional nodules. In any case prior
chest CT should be consulted, and if
unavailable, should be supplemented by a chest CT performed
here.
B. Chest CT performed on ___:
1. Resolving pulmonary edema.
2. Two subcentimeter lung nodules should be followed with
repeat CT scanning
in six months.
C. Fatty liver and mild splenomegaly. The possibility of more
significant
underlying liver disease, including fibrosis and cirrhosis,
should be
considered, particularly in view of the flattened portal venous
waveforms.
# Transitional Issues
- continue titration of pain regimen as outpatient, avoid
oversedation
- home with ___, continued assessment of fall risk
- follow-up LFTs on outpatient basis, consider work-up if still
elevated
- continuing management of anti-coagulation
- follow-up incidental findings as above related to lung nodule
and fatty liver | 169 | 1,150 |
12013673-DS-9 | 24,266,078 | You were evaluated in the Emergency Room following a fall down a
flight of stairs. You were found to have a small bleed in your
brain, facial fractures (maxillary and zygomatic fractures),
Left hand fractures for which you were evaluated by
Neurosurgery, Plastic Surgery, and Hand Surgery.
FACIAL FRACTURES INFORMATION
You were diagnosed with a facial fracture. Some facial fractures
require an operation, others do not and heal on their own.
Until you can be further evaluated, you do need to take some
precautions:
- Sleep with the head of your bed elevated about 45 degrees
(prop yourself up with some pillows)
- Do not do anything to increase pressure in your face: Do not
use straws to drink, do not blow your nose, if you have to
sneeze do so with an open mouth, and do not strain with bowel
movements.
- Avoid contact sports or strenuous physical activity
- Take an over-the-counter stool softener, such as Colace, for
the next 2 weeks to prevent straining with bowel movements. This
is especially important if you have been prescribed narcotic
pain medications, because all narcotics are constipating.
- If an antibiotic was prescribed, please take it as directed.
Call your doctor or return to the emergency room for:
- Fevers or chills
- Worsening headaches
- Purulent or foul smelling drainage from one or both nostrils
- Worsening tenderness in your face
- Pain with ___ movement or difficulty moving eyes
- Blurry vision
- Nausea or vomiting
- Any other concerns
HAND/WRIST FRACTURES
Many hand and wrist injuries are simple sprains or strains that
will resolve over ___ weeks. Some types of ligament tears can
take longer or require surgery. Fractures will require
follow-up care for casting.
The severity of some injuries can be difficult to determine at
the time of an emergency visit. Certain types of injuries are
always treated with a plaster splint since some fractures can
take more than a week to show up on X-Rays.
If X-Rays were taken: they were reviewed by physicians in the
Emergency Department today, and will also be reviewed by a
radiologist within 24 hours. We will call you if there are any
questions, or if more x-rays are needed.
<B>Treatment:</B>
* Rest the affected area. If a splint was applied, be sure to
wear it and use a sling. As much as possible, you should keep
your arm elevated above the level of your heart.
* For the first 2 days, apply ice packs for 15 minutes at a
time. You can do this as frequently as possible, up to once
every hour if there is a lot of swelling. Be sure to always
place a towel between the ice pack and your skin.
* After 2 days you can switch to heat if it is more comfortable,
or continue using the ice.
* Unless told otherwise by your doctor, you can use over the
counter pain relievers such as acetaminophen (Tylenol) or
ibuprofen (Advil, Motrin). If you were given a prescription for
strong pain medications you should not drive, operate machinery
or drink alcohol while taking them.
* Be sure to follow up with your doctor or the specialist as
instructed.
<B>Warning Signs:</B>
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* Your pain or swelling gets much worse
* Your arm or hand is cold or numb
HEAD INJURY
You have been diagnosed as having sustained an injury to your
head. Most head injuries are not serious and get better over a
few days. However in rare cases, further problems develop, so it
is important that you, and a friend or relative monitor your
condition and seek immediate help if you notice any of the
warning signs below.
If X-Rays were taken: they were reviewed by physicians in the
Emergency Department today, and will also be reviewed by a
radiologist within 24 hours. We will call you if there are any
questions, or if more x-rays are needed.
<B>Treatment:</B>
* It is important that you stay with a friend or relative for at
least 24 hours so they can help you watch for the warning signs
below.
* You should rest, and avoid exertion or heavy lifting for ___
days or until you feel completely well again. Do not drive,
operate machinery or perform other tasks that require strict
concentration until you are well.
* Avoid alcohol, sedatives and any other substances that will
make you sleepy.
* Mild nausea is normal for a few hours after an injury. If you
have severe nausea or if you are vomiting, seek medical
attention.
* A mild to moderate headache is to be expected. For the first
24 hours take only Tylenol (acetaminophen) for headache.
<B>Warning Signs:</B>
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* Prolonged nausea
* Vomiting
* Confusion, drowsiness, change in normal behavior
* Trouble walking, or speaking (slurred speech)
* Numbness or weakness of an arm or leg.
* Severe headache
* Convulsions or seizures
Dizziness, changes in sleep, forgetfulness and difficulty
concentrating are not uncommon after a head injury. These
symptoms will usually clear over a few days, but if they persist
or become worrisome, you may benefit from following up with a
Neurologist specializing in head injuries. Please call
___ to schedule an appointment at the Concussion
Clinic. Indicate that you were recently seen in the ___
Emergency Room and you will generally be seen within 1 to 2
weeks. | The patient presented to pre-op/Emergency Department on ___.
Pt was evaluated by upon arrival to ED with X-ray (Chest, Wrist,
pelvis) and CAT scan (head, c-spine, Maxillofacial, CTA head &
neck) which were notable for Minimal amount of hemorrhage in the
lateral ventricles, Left zygomaticomaxillary complex fracture.
Left sphenoid sinus wall fracture, and comminuted distal radius
fracture with mild impaction and intra-articular extension.
Given findings, the patient was admitted to the Acute Care
Surgery/Trauma Surgery service for further evaluation and
management.
Neuro/Traumatic IVH: Given findings on CT, neurosurgery was
consulted upon arrival to the ED. Initial recommendations given
traumatic IVH were non surgical management with q1 neuro checks,
repeat head CT, seizure precautions with Keppra, blood pressure
control and CTA head and neck all of which were implemented.
Findings on repeat CT Head/CTA were reassuring and no further
neurosurgical management was indicated. Neurological status was
closed monitor and the patient was alert and oriented throughout
hospitalization
Facial Fractures: Given multiple facial fractures, plastic
surgery was consulted who recommended no acute surgical
intervention, a short course of augmenting, sinus precautions,
and soft diet, along with outpatient follow for consideration of
surgical intervention. All recommendations were implemented. An
ophthalmology consult given orbital fracture was also obtained.
Recommendations included conservative management with oral
antibiotics and sinus precautions as per Plastics and followup
as outpatient with ___ were implemented.
Radial Arm Fractures: Given with left distal radial fracture
Hand Surgery was consulted who attempted
bedside reduction and splint and recommended followup as an
outpatient in Hand Clinic.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially kept NPO for possible
operative intervention. The diet was advanced sequentially to a
soft diet, which was well tolerated. Patient's intake and output
were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. | 900 | 398 |
12975145-DS-18 | 21,540,365 | Dear Ms ___,
You presented to ___ hospital because of concern that
you had a seizure.
While in the hospital, you were monitored on EEG. You also
received antibiotics for a possible skin infection. You were
seen by our addiction psychiatry team.
After leaving the hospital, make sure you take your medications
as prescribed.
We wish you the best,
Your ___ team | ___ with PMHx of bipolar disorder, anxiety, IVDU, chronic HCV,
and seizure disorder presented with increasing seizure
frequency and witnessed GTC in the ED. She was monitored with
EEG off home keppra for spell capture and characterization who
course was complicated by symptoms of opioid withdrawal.
# Seizure Disorder
Patient reports epilepsy secondary to traumatic brain injury in
___, now with increasing frequency in setting of stopping her
keppra recently. She had witnessed GTC in the ED with high
lactate. Patient states she has not seen a neurologist in ___
years(last saw Dr. ___ @ ___) and is managed by PCP (Dr.
___ ___. Given her complex social history, she may have
both seizures and pseudoseizures, so home keppra was held for
EEG monitoring. Her EEG did not show any epileptiform discharges
or electrographic seizures even with sleep deprivation. She was
not comfortable with restarting keppra, because she thinks that
it doesn't work for her so she was discharged on zonisamide
400mg qhs. She will follow-up with epilepsy outpatient in one
month.
#Opioid withdrawal
The patient has a history of IVDA with last use of heroin 6 days
prior to admission. During this admission she experienced
withdrawal symptoms, which had improved significantly by the
time of discharge. She was given a prescription for a week of
dicyclomine and Simethicone.
#Right Hand Cellulitis
Gives history of significant swelling and pain, though currently
exam is not impressive. With history, and high risk nature of
site of injection, was treated with a 5 day course of
doxycycline
# ___ use including IV opiates
Last used IV heroin 6 days prior to admission. On chronic
methadone at ___ at ___
___ in ___, ___. Confirmed methadone dose 150mg daily, last
taken ___. During admission she was found to be using heroin.
She readily admitted to the incident and her needles were
confiscated. There were no other issues. She was seen by
addiction specialists and social work.
# Bipolar disorder
Reports mood is "okay" and denies SI/HI. Recent inpatient
psychiatric hospitalization in past ___. She was
continued on home Seroquel, sertraline, buspirone, prazosin,
mirtazapine, trazodone.
# Hx of endocarditis
History of endocarditis at ___ reportedly within past year.
No suspicion at this time for recurrent endocarditis, though is
at somewhat elevated risk due to active IVDU. Blood cultures
were negative.
# Chronic HCV
LFTs WNL. Plan to be treated at ___ (no need for GI
follow-up
at this time)
# IBS
Held home linaclotide since it was non-formulary, and patient
was exhibiting diarrhea from withdrawal.
# Fibromyalgia
Patient states she has a history of fibromyalgia and takes
Pregabalin and has been maintained on her home dose
TRANISTIONAL ISSUES
--------------------
AEDs on discharge:
Zonisamide 400mg qHS
[] follow up with neurologist
[] follow up chronic hepatitis C for treatment | 57 | 435 |
13355556-DS-19 | 22,838,362 | Dear ___,
___ were admitted to the hospital with a pulmonary embolism,
which is a large blood clot in your lungs.
=============================================
What happened while ___ were in the hospital?
=============================================
- ___ received heparin, a blood thinning medicine, through your
IV. The day before ___ were discharged, this was switched to a
tablet called apixaban.
- Because of the large blood clot in your lungs, the
interventional radiologists put a filter to prevent other clots
in your legs from traveling to your lungs.
- ___ had low blood pressures and signs of an infection. This
made ___ somewhat confused. We think the infection may have been
from your urinary catheter, but we cannot say for sure. ___ were
given antibiotics and fluids through the IV, which led to
improvement.
- ___ also had low blood counts and required a few blood
transfusions.
===============================================
What should ___ do when ___ leave the hospital?
===============================================
- Make sure to work hard at rehab to rebuild strength and follow
up with the gastroenterology team.
- ___ should continue taking the new blood thinner medicine,
apixaban (Eliquis), 5mg twice a day, for at least 3 months to
treat the blood clot.
It was a pleasure taking care of ___! Congratulations on your
90th birthday!
Sincerely,
Your ___ Team | ==========================
BRIEF SUMMARY
==========================
___ yo F with a history of bullous pemphigoid on steroids,
Alzheimer's dementia, who presented with syncope and found to
have extensive bilateral pulmonary emboli with right heart
strain. She received an IVC filter and was treated with a
heparin drip, transitioned to oral apixaban prior to discharge.
========================== | 200 | 50 |
17693573-DS-24 | 21,433,237 | Dear Mr. ___,
It was a privilege to care for you at the ___
___. You were admitted for alcohol detox. You were
also noted to have poorly controlled Bipolar Disorder with
depressive symptoms requiring inpatient psychiatric therapy.
While you were here, you were diagnosed with an infection called
C. Difficile which causes diarrhea. You were treated with
antibiotics for this with improvement in your symptoms.
You were also started on propranolol for your tremor.
Now that you have completed treatment for your infection, you
are ready for transfer to ___ at ___ for ongoing ECT
treatments and management of your depression.
We wish you the best in your recovery.
Sincerely,
Your ___ Team | Mr. ___ is a ___ male with bipolar disorder and
alcohol use disorder who presented to the ED with alcohol
intoxication and withdrawal with course complicated by severe
bipolar depression and Clostridium difficile infection.
# Alcohol use disorder
# Alcohol withdrawal, history of withdrawal seizures:
Patient has a long-standing history of heavy alcohol use
complicated by severe withdrawal with seizures. He received PO
phenobarbital (about 4mg/kg) in the ED after receiving a few
doses of PO and IV diazepam. The diazepam did not significantly
improve his withdrawal symptoms but the phenobarbital did help.
Upon arrival to the floor, his CIWA score was 12 so he was given
an additional ~4mg/kg dose of PO phenobarbital with improvement
in his symptoms. He had no further symptoms of withdrawal. He
was counseled on EtOH cessation.
# BPD
# Major depression:
No current signs of mania but rather severe depression. He did
not endorse any SI. He does have a complex psychiatric history
including multiple inpatient hospitalizations requiring ECT. Due
to concern for a manic episode prompting recent EtOH binge,
psychiatry was consulted and recommended inpatient psychiatric
admission for bipolar disorder with depressive symptoms. Due to
diagnosis of Cdiff as below, ECT was initiated while on the
medicine floor with treatments on ___ and ___ before completion
of cdiff treatment. He was transferred to an inpatient
psychiatry facility for ongoing management of bipolar disorder
on discharge.
# C. diff diarrhea:
Developed liquid stools, C.diff PCR positive, toxin positive
confirming active infection. Was started on PO vancomycin on
___. His mild diarrhea resolved rapidly, within 2 days of
starting PO vancomycin. Last dose on ___ for total course
of 10 days of PO vancomycin for a first episode of non-severe
CDI.
# Tremor:
In the setting of EtOH withdrawal. Persisted for a significant
time after all other withdrawal symptoms subsided. Based upon
subsequent history obtained from the patient, sounds chronic and
most likely essential tremor. He reports having been
treated with propranolol in the past with success (he was able
to tell me the typical doses or propranolol without any
prompting). He reported a good initial response to 20 mg
propranolol, but this eventually stopped being as effective, and
his treatment was apparently limited by lightheadedness
("wooziness") at a dose of 40 mg of propranolol. Given this
history and patient having some significant difficulty with
tremor during eating/drinking (e.g. trouble holding cup of water
to mouth), propranolol started at 20mg TID. Outpatient neurology
f/u scheduled for ongoing evaluation of tremor.
# Dyspepsia:
Suspect EtOH-induced gastritis. Improved w/ empiric PPI which he
should continue through ___.
# Thrombocytopenia: Suspect EtOH-related. Remained stable in
110s. Will need outpatient follow-up of thrombocytopenia after
discharge.
# Chronic back pain:
Treated conservatively with heat packs, tylenol, and lidocaine
ointment/patch.
# Housing instability
Currently living on the streets. SW consulted for resources. He
will benefit from ongoing SW involvement at the inpatient
psychiatric unit. | 114 | 479 |
15788134-DS-30 | 20,404,004 | Dear Ms. ___,
You were admitted to the hospital because you could not breath
and had chest pain.
These symptoms were due to an extremely high blood pressure,
which we have treated by increasing your blood pressure
medications.
When you leave the hospital, please follow up with any doctor
appointments listed below and make a note of any medication
changes below.
It was a pleasure caring for you!
Your ___ Team | ___ is an ___ year old woman w/ ___ CAD (70% mid LAD,
80% Diagonal, 100% occlusion of the LCx, mid RC 50-60%), PVD,
DM2, CKD who presented with dyspnea and chest pain, found to be
in a hypertensive emergency with demand ischemia and flash
pulmonary edema.
TRANSITIONAL ISSUE:
=========================
[ ] Follow up blood pressure and basic metabolic panel at
post-hospitalization visit
ACTIVE ISSUES:
=========================
#HYPERTENSIVE EMERGENCY:
#ACUTE HYPOXEMIC RESPIRATORY FAILURE ___ FLASH PULMONARY EDEMA:
#NSTEMI, TYPE II:
#CORONARY ARTERY DISEASE:
Felt to be secondary to recently held losartan/hctz given
concern for progressive CKD outpatient. First felt dyspneic on
___ ___, worse on ___, and then presented to the ___ ED. Did
well in the ED on a nitro gtt and was diuresed, weaned from O2
to room air. Overnight, minimal events, until the first day of
her admission when she triggered for acute hypoxemic respiratory
failure and severe hypertension to 220s/120s. It appeared that
she still needed further diuresis and titration of her blood
pressure medications while on a nitro gtt. Nitro gtt was
re-started, and blood pressure medications rapidly titrated up
along with diuresis. The patient's blood pressure quickly
dropped to a much safer level within the hour, and was soon back
on room air, and was stable over the next two days. Please see
below for her final antihypertensive regimen at discharge.
Additionally, she had chest pain that resolved with her blood
pressure and diuresis. Trops were trended and did increase, but
not trended further despite further increase because she was
completely asymptomatic. All of this was felt to be demand
ischemia from her hypertensive emergency. Additionally, she did
not require any further diuresis once her blood pressure was
under better control.
CHRONIC/STABLE ISSUES:
=========================
#PVD:
- Continued home antiplatelets
#CKD:
- Monitored closely in the hospital. Did not restart hctz but
did restart losartan due to uncontrolled blood pressure.
#NEUROPATHY:
- Continued home pain medications
#DM2:
- Continued home insulin. No changes made.
#DEPRESSION:
- Continued home bupropion | 70 | 326 |
13299787-DS-30 | 26,265,245 | You were admitted for an infection of your bloodstream
associated with your PICC line. This has been treated with
antibiotics, which will continue for 4 weeks total. The last day
of your IV antibiotics will be ___. You will also
complete 2 weeks of an antibiotic, Ciprofloxacin, by mouth. The
first dose will be tonight.
I have included prescription for lidocaine cream to apply to
your low back for pain, as needed.
It was also found while in the hospital that you had a new rash
reaction to your niacin. You may continue to use it at home as
previously directed, though if there is a repeat of this
reaction, you should stop and discuss future use with your
outpatient doctor. | TRANSITIONAL ISSUES:
PCP:
- please assess clinical resolution of bacteremia
- please discontinue PICC following full course of antibiotics
- Determine need for DEXA scan to evaluate for osteoporosis in
setting of T12 compression fracture in a male.
- CT chest ___ with bilateral pulmonary nodules, the majority
of which are stable however there is a slightly larger 4 mm
nodule which is seen along the course of prior biopsy tract.
Three to six-month follow-up chest CT is suggested.
- ___ year follow-up from ___ renal ultrasound to assess
interval change of the 3.6 cm right upper pole cyst
HOSPITAL COURSE:
#Staph bacteremia:
#Acenitobacter bacteremia:
#low back pain: MSSA bacteremia ___ bottles) + 1 Acenitobacter
___ bottles on initial set; of less clear clinical
significance), associated with PICC placed for daily hydration
at home. Working up any metastatic infection unrevealing. TTE
showing RA density, but nothing apparent on TEE. MRI not
suggesting osteo. Initially on Vanc/CTX. Cleared culture x72+
hours. Transitioned to Cefazolin 2g Q8 and Cipro 500 BID with
plans for 4 weeks (given the presence of a DVT) and 14 days,
respectively. In the meantime, while pt is to have his PICC in
place, continued the daily PRN saline boluses, though this plan
will be evaluated by PCP ___ 4 week treatment, given the
risk of complication long term.
#PEs:
#acute DVT: R First incident of clot per chart was ___.
Segmental and Subsegmental diagnosed in ___ and now confirmed
PICC-related DVT in right axillary vein as of pm of ___ pt
endorsing rivaroxaban adherence at home. Heme feeling that low
burden PE I/s/o PICC does not represent treatment failure and
may continue Rivaroxaban.
#niacin flushing reaction: Patient with an acute onset of upper
chest, bilateral UE flushing on day 6 of admission, with
pruritus, resolved in 2 hours without intervention. No evidence
of other drug rash. No recurrence. Most consistent with a niacin
reaction. Pt endorses generally not taking at home. He is on
Niacin per Dr. ___ oncologist, due to low niacin
levels, attributed to his ___
(which reportedly can cause pellagra). Unclear whether there was
some issue with his SR formulation releasing immediately; it was
restarted on a trial basis as of ___ with the plan to discontinue
if subsequent reaction occurred.
#RECURRENT ACUTE ON CHRONIC NAUSEA AND VOMITING, LACTIC ACIDOSIS
(RESOLVED): Multiple workups unrevealing. Patient reports
symptoms worsened following his chemotherapy, so GI thinks this
is possibly cisplatin-induced gastroparesis. He has previously
had an extensive work-up of his diarrhea during inpatient
hospitalizations, which has been notable for an elevated fecal
calprotectin, colonoscopy ___ without active mucosal
inflammation, normal MRE aside from known hepatic steatosis, and
stool cultures negative for c diff, campylobacter, salmonella or
shigella. Last hospitalization team attributed symptoms to
alcoholic hepatitis/gastritis in setting of AST>>ALT. This
dmission transaminases and lipase are normal, making alcoholic
hepatitis/gastritis less likely. During his stay, intermittently
with nausea Sx seemingly without specific prompt, but resolved
with PRN. Most effective agent appears to have been Compazine
IV. No nausea over the 2 days prior to ___. Returned on regular
home regimen.
#CHRONIC DIARRHEA: Has been worked up extensively both as
inpatient and outpatient in past and workup has been largely
negative. Per GI, they suspect diarrhea is related to past
radiation from anal cancer treatment as well as dysmotility from
his cisplatin treatment. Loperamide dose increased on last
discharge. Gets standing K supplementation. On the floor,
diarrhea is improved somewhat.
#CHRONIC ORTHOSTATIC HYPOTENSION: Likely ___ chronic diarrhea
and autonomic neuropathy, possibly from chronic alcohol, at home
on midodrine and fludrocortisone 0.2 and per pt gets 1L fluid
through PICC every day. BP generally stable this admission
though did have +orhtostatics responsive to NS bolusing
#ANEMIA: Stable, normocytic. No evidence of hemolysis on prior
admissions. Had normal B12, folate. Ferritin > 100, making iron
deficiency less likely, but with iron sat <20% need to consider
iron supplementation. Would repeat iron studies as outpatient.
# GERD, ___ ESOPHAGUS: Omeprazole increased to 40mg BID
last hospitalization. Will continue.
# THORACIC COMPRESSION FRACTURE: Severe T12 compression
deformity, new in ___. MRI was repeated given his staph
bacteremia without e/o diskitis but with disc retropulsion,
accounting for his pain. Partial response to Tylenol and lido;
but pt tolerating ambulation as of ___. | 119 | 696 |
12480374-DS-17 | 25,714,247 | Mr. ___,
It was a pleasure meeting and caring for you during your
hospitalization at ___. You
were admitted with chest pain and arm pain. We found that you
had a small heart attack. Your heart attack was probably not
from a blockage in the heart artery (coronary artery) but
because of very elevated blood pressures.
We performed a stress test on your heart which returned normal
which makes a blockage in a heart artery even less likely. We
changed your blood pressure medication regimen which is
expalined below.
Please continue to take your blood pressure pills as they are
prescribed at the same time each day. Also, please record your
blood pressures in a journal. Bring the journal and your blood
pressure cuff to your next primary care appointment.
We wish you a speedy recovery.
All the best,
Your ___ Care Team | BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ gentleman
with a history of difficult-to-manage HTN and IDDM who presented
with 1 day of L arm and chest pain and was found to have cardiac
enzyme elevation and EKG changes consistent with NSTEMI.
Initially, pt's NSTEMI managed for ACS with heparin gtt.
Following evaluation, pt's NSTEMI was thought to be type 2
demand ischemia in the setting of hypertensive emergency. As his
BP improved on a nitro gtt, pt's chest pain and arm pain
resolved. Exercise stress test was done and returned within
normal limits. He was started on a modified anti-hypertensive
regimen with success. BPs on day of discharge 130-150s/70-90s.
ACTIVE ISSUES
================
# NSTEMI: Pt. presented with left arm and chest pain. He was
found to have elevated cardiac enzymes and t-wave inversions in
inferior leads consistent with NSTEMI. Pt was found to be in
hypertensive emergency which was thought to be the likely cause
of his symptoms resulting in demand ischemia and a type II
NSTEMI. Pt. was initially medically managed with heparin gtt
which was later discontinued following improvement of his
symptoms with improvement of his blood pressures (arguing
against a coronary event). Pt. was maintained on heparin gtt
for 24 hours and d/c'ed when coronary event was thought to be
unlikely. Given significant risk factors of age, HTN, DM and
NSTEMI, pt. had a stress TTE which was without wall motion
abnormalities at rest and without ischemic changes with exercise
supporting more of a demand ischemia event. He was discharged
on ASA 81mg, atorvastatin 80mg, beta blockade, and ace
inhibitor.
# Hypertensive emergency: Per PCP, ___. has had difficult to
treat hypertension most likely ___ non-compliance. Pt. was
noted to be with SBP at home in 220s and on admission in 180s.
He was initially managed with nitro gtt and later transitioned
to a 4 drug oral regimen including amlodipine, chlorthalidone,
carvedilol, and lisinopril which he tolerated well. Pt. had a
significant headache, following admission in addition to blurry
vision in the setting of anti-plt therapy. For concern of an
intracranial bleed, pt. had a NCHCT which was negative for an
acute intracranial process. His neuro exam remained non-focal
and his vision returned to baseline shortly following improved
blood pressure control. We had extensive discussion with pt.
regarding the long-term effects of hypertension. It seems that
pt. has been non-compliant because he sometimes feels that his
BP meds make him lightheaded especially when he is at work (his
job is strenuous as he is a ___).
# ___: Pt. with ___ above his known baseline creatinine of
1.1-1.3 (in ___ records, verified by PCP). His creatinine
was elevated on admission consistent with ___. His urine lytes
return with evidence of intrinsic injury with FeNa 2.8%, FeUrea
55.8% consistent with ___ ___ hypertensive emergency. His
creatinine remained stable. He was instructed to have repeat
chemistry in approximately 7 days as an outpatient.
CHRONIC ISSUES
=================
# IDDM: Stable. Continued on home regimen of glargine 34 units
qAM and Humalog ISS
# Asthma: Continued Albuterol nebs prn
# Hyperlipidemia. Continued Atorvastatin 80mg daily
TRANSITIONAL ISSUES
===================
# Type 2 NSTEMI: Pt. continued on atorvastatin 80, asa 81,
carvedilol, and lisinopril at discharge.
# Hypertensive emergency: Pt. managed initially on nitro gtt
transitioned to PO regimen consisting of lisinopril,
chlorthalidone, carvedilol, and amlodipine.
# Outpatient Labs: Pt. should have repeat chemistries drawn one
week after discharge (sometime after ___.
# Code: Full Code
# Emergency Contact: Wife ___ | 145 | 593 |
10156269-DS-14 | 22,026,410 | Dear Ms. ___,
You were admitted to ___ for pneumonia. You were given
Levofloxacin and your symptoms improved, and your white count
went down. Please continue to take Levofloxacin for 5 more
days. Return to the hospital or clinic if you develop fevers,
worsening of your symptoms, trouble breathing, or diarrhea. | Ms. ___ is a ___ with Hx of Lymphoblastic blast crisis of
CML day ___ after a double cord transplant who presented to the
ED with productive cough, headache, sinus and ear congestion,
found to have possible multifocal PNA on CXR.
# PNA: Patient with multifocal pneumonia, leukocytosis, though
no documented fevers. She endorses a history of congestion and
cough prior to this episode as well as nausea/vomiting;
possible that she had a viral URI and now has a super-imposed
PNA. Although do not need to treat with Tamiflu (as has had
symptoms for more than 48 hours), a nasal swab was performed but
did not have adequate cells for evaluation. She was discharged
on levofloxacin to finish a ___nd a 5 day course of
tamiflu.
# CML: In remission. Continue follow-up with outpatient
providers.
# TACHYCARDIA: likely secondary to acute inflammatory response
to pneumonia. Resolved with fluid resuscitation.
# ACUTE ON CHRONIC KIDNEY INJURY: Basline 1.1-1.3, Unclear
etiology of CKD. Patient has been encouraged to see nephrology
in the past, but is does not appear as if she has gone. Her
medications were renally dosed and her ___ improved back to its
baseline with fluids.
# INURANCE: Patient lost her insurance prior to this visit and
was notified in ___ clinic. Case management and social work
consults performed, and she obtained her insurance again. | 53 | 241 |
19188450-DS-15 | 25,089,218 | You were admitted to ___ with an obstruction in your bile
ducts. You had an ultrasound that was concerning for a mass in
your pancreas. You had a stent placed to keep your bile ducts
open, and you had biopsies taken which were still pending at the
time of discharge. Finally, you also had a CT scan, which showed
a pancreatic malignancy, with concern for metastases to the
liver. The CT scan also showed a mass in your stomach.
You are being discharged to a rehab facility. You will need to
follow-up with an oncologist to further discuss your results and
treatment options. You will also need to discuss potential
additional evaluation of the mass in your stomach. You should
discuss this further with your primary care physician.
You will need a repeat ERCP in approximately 6 weeks to have
your stent replaced for a metal one. Our ERCP office will be in
contact to schedule this. You can contact them at ___
if you have any questions.
It was a pleasure taking part in your medical care. | This is an ___ gentleman with a PMHx significant for
HTN, TIA, and AAA repair who is admitted with jaundice, elevated
LFTs, and RUQ concerning for mass.
# BILIARY OBSTRUCTION, ELEVATED LFTS, JAUNDICE: RUQ performed
on admission revealing echogenic lesion in the region of the
pancreatic head. Given concern for mass obstructing CBD, the
patient underwent ERCP with stent placement. With this therapy,
bilirubin and LFT's trended down. Biopsies were taken during
ERCP and were pending at the time of discharge. After ERCP, the
patient underwent CTA abdomen, which confirmed a pancreatic
lesion concerning for malignancy with evidence of likely liver
metastases. Given these findings, oncology f/u was recommended.
After discussion with the patient's PCP's office, it was decided
to refer the patient to Dr. ___. Unfortunately,
appointment was not able to be scheduled prior to discharge
because pathology had not yet returned. Dr. ___ office will
be in contact to arrange a follow-up appointment with the
patient after pathology has returned. Pt will need repeat ERCP
in approximately 6 weeks. ERCP office will contact him to
arrange this appointment.
# Stomach Lesion: Seen on CTA abdomen, concerning for potential
GIST. Given slow growth of GIST tumors and relatively rapid
growth of patient's pancreatic malignancy, further evaluation of
this stomach lesion was deferred to patient's PCP and
oncologist.
# Delirium: Likely toxic-metabolic encephalopathy in the setting
of biliary obstruction. Patient's mental status improved to
baseline after biliary stent was placed.
# Hypokalemia: Pt noted to have low potassium on the day of
discharge (3.0). Was repleted with 60 meq. Potassium will be
closely monitored at his rehab.
# HTN, BENIGN: Continued atenolol and lisinopril
# DMII WITHOUT COMPLICATIONS: Continued lantus. Held metformin
during admission, restarted on discharge.
# HISTORY OF TIA: Aspirin and aggrenox held for 5 days after
ERCP with sphincterotomy, can be restarted on ___.
# B12 DEFICIENCY: Continued B12 supplementation | 175 | 311 |
16482392-DS-8 | 20,083,521 | Dear ___,
You were admitted to the hospital with left arm and leg weakness
and confusion. Initial concerns were for a stroke or a seizure.
We obtained imaging of your brain with MRI, as well as vessels
with CTA head and neck which did not show any evidence of stroke
or vessel spasm. We sent a Lyme blood test which is still
pending. We also monitored your cardiac enzymes as you had
symptoms of chest tightness and these were stable. You
complained of leg pain and swelling so we checked your veins for
clots and this was also negative. Your gait and strength slowly
improved back to baseline. At this point we recommend close
follow up with your PCP and one follow up appointment with us
here in Neurology. We think that this episode was likely a
physical manifestation of the severe stress you have been
undergoing as well as possible transient small vasospasm due to
cocaine use. We strongly urge you to NOT use cocaine in the
future. Please have an ultrasound of your heart done in the
outpatient setting. It was a pleasure caring for you and we are
glad that you are on your way to recovery.
It was a pleasure taking care of you,
Your ___ neurology team | ___ yo woman with no significant medical history presenting with
an episode of headache, confusion, LT sided weakness, and chest
tightness in the setting of severe anxiety after cocaine use.
Imaging with brain MRI and CTA head/neck unremarkable (without
vessel reformats to rule out small vasospasm read as normal by
both outside hospital radiologists and ___ radiologists). Lyme
serum sent and is pending. Orthostatics negative. Cardiac
enzymes normal. She was monitored on telemetry, given IVF
repletion, evaluated by ___. Symptoms improved spontaneously.
Gabapentin was trialed, however it made patient sleepy so this
medication was discontinued. Likely this could have represented
a transient vasospasm from cocaine that has resolved, as well as
a functional disorder given her significant anxiety.
Transitional Issues
- Follow serum Lyme
- Close PCP follow up
-___ with neurology x1 in ___ ___ at 3:30 ___
-outpatient echocardiogram to complete the stroke work up. | 212 | 145 |
11611840-DS-19 | 23,994,461 | Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were admitted for a rash and worsening kidney function.
WHAT HAPPENED IN THE HOSPITAL?
-Your rash and kidney function remained stable. You were
evaluated by the rheumatologists, nephrologists and
dermatologists who did not feel you needed immediate treatment.
-You received a transfusion for anemia, which has likely been
chronic. You were evaluated by hematology who did not find
abnormalities on your blood smear. Please have your PCP continue
to monitor your anemia.
WHAT SHOULD YOU DO AT HOME?
-You should take your medications as prescribed.
-You should follow-up with your physicians based on the
appointments listed below.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | SUMMARY STATEMENT:
Mr. ___ is a ___ y/o man with a history of rheumatoid
arthiritis (previously on anti-TNF; stopped ___,
prior alcohol abuse complicated by chronic portal vein
thrombosis in the setting of pancreatitis, portal hypertension
with varices s/p band ligation who presented with worsening rash
and ___.
ACUTE ISSUES
============
# Rash
# Leukocytoclastic Vasculitis:
Patient with several month history of rash, with biopsy in ___
consistent with LCV vs hypersensitivity (eosinophils). ___ be
secondary to Influenza/pneumonia in ___, although this does
not explain progression of rash recently. ___ be related to
antibiotic use. Felt unrelated to rheumatoid arthritis by
rheumatology despite patient being off Humira. Autoimmune panel
was sent with most studies negative except for positive RF and
HBcAb. Hepatitis B viral load not detected. Resent HBcAb for
possible false positive, but results still pending at discharge.
Patient also had elevated IgA, concerning for IgA
nephropathy/henoch-schonlein purpura, though patient denied
abdominal pain and arthralgias. Per dermatology, patient did not
need treatment for rash itself as it was asymptomatic. Patient
also evaluated by wound nurse for blisters on feet and heels.
# Acute kidney injury:
Baseline creatinine 1.0, elevated to 1.7 on admission. Concern
for possible glomerulonephritis in setting of
LCV as above. Renal US showed no hydronephrosis. Patient had low
protein/Cr ratio and sediment showed few RBC casts. His Cr
remained stable, discharge Cr 1.7. Per renal, given patient's
recent NSAID use, his ___ could be NSAID induced ATN. Discharged
with close follow-up with nephrology for outpatient renal biopsy
if Cr remains elevated.
# Acute on chronic anemia:
No evidence of bleeding. Iron studies suggest anemia of chronic
disease. Haptoglobin, t. bili, fibrinogen argue against
hemolysis. Patient has a history of esophageal varices, but he
did not have changes in his bowel movements. The patient
received one unit RBC, and hemoglobin remained stable. Patient
had been taking OTC iron supplement which was held for concern
that it was related to rash. Evaluated by hematology who
reviewed his smear and did not see evidence of MDS. ___
consider outpatient hematology work-up if anemia persistent.
# History of portal vein thrombosis:
RUQ US showed stable chronic portal vein thrombosis.
# Right humeral fracture:
Patient with traumatic right humeral fracture on ___ of this
year, awaiting arthroplasty in ___. Patient had ongoing shoulder
pain not well controlled on home oxycodone regimen, so frequency
was increased to oxycodone 5 mg q4h PRN.
CHRONIC ISSUES
==============
# Rheumatoid Arthritis:
Diagnosed about ___ years ago. Previously on methotrexate, and
then started on Humira about ___ years ago.
Humira has been on hold since ___ and he has not had any flares
since then.
# Portal hypertension
# Esophageal varices s/p banding:
Held nadolol in setting of renal failure
# BPH:
Continued home tamsulosin
# Hypothyroidism:
Continued home levothyroxine
# Anxiety:
Continued home lorazapam as needed
# Insomnia:
Held zolpidem during this admission
TI:
[ ] Patient needs close follow-up with nephrology for possible
renal biopsy
[ ] Patient should have his Cr drawn on ___ with results
sent to PCP
[ ] Held home nadolol in setting ___
[ ] Patient found to be HBcAb positive, hepatitis B viral load
negative. Repeat HBV serology pending, to be followed up by
hepatologist, Dr. ___
[ ] Patient's anemia should be monitored. Consider outpatient
hematology work-up if does not improve with
[ ] Started on folic acid and thiamine for history of alcohol
use
[ ] Oxycodone increased for severe shoulder pain to 5 mg q6h PRN
on discharge | 128 | 560 |
13035566-DS-12 | 20,855,439 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were short of
breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You had a lot of tests to determine the cause of your
shortness of breath.
- The pulmologists (lung doctors) saw you and think it was due
to COPD so we treated you with nebulizers and prednisone.
- You also developed shingles in the hospital and were given a
medicine to treat this.
- You had cellulitis (an infection of your skin) on your left
leg and you were given antibiotics for this. You had an MRI to
make sure the infection wasn't in the bone.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor (___)
at ___ if your weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 365 lbs. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team | SUMMARY
===================
___ is a ___ year old woman w/hx AS s/p TAVR
(___), afib, HFpEF (EF 60-65%), BiV ICD (___), TIA
presenting with subacute dyspnea on exertion and chest pain.
Patient underwent a battery of tests and it was thought her
symptoms were likely due to COPD and deconditioning and
therefore she was started on a prednisone taper. Her hospital
course was complicated by both shingles outbreak and cellulitis
for which she was treated.
TRANSITIONAL ISSUES
=======================
[] Patient provided with albuterol, Spiriva and advair at
discharge
[] Should have cardiology follow up for HFpEF.
[] Should have pulmonary follow up for COPD as well as sleep
medicine for OSA.
[] increased Lisinopril to 10 mg qd for BP control. consider
further uptitration
[] if suspicion for angina, consider amlodipine 5 mg qd vs Imdur
30 mg qd for microvascular angina
[] Patient developed cellulitis of the left lower extremity
while inpatient and was instructed to complete a 10 day course
of Keflex. Patient should be evaluated for resolution of
cellulitis after completing the antibiotic course.
[] Next INR should be checked on ___.
Discharge Weight: 365 lbs
Discharge Cr: 0.8
ACUTE ISSUES
===================
# Subacute Dyspnea on Exertion:
Ongoing dyspnea on exertion in pre and post TAVR with similar
symptoms noted at last Cardiology visit in ___. Given the
large differential, patient underwent a battery of tests. Her
PFTs showed mild to moderate obstructive pattern with normal
DLCO. Pulmonary was consulted and thought that her symptoms were
unlikely due to pHTN despite her prior TTE (___) showing
elevated pressures because it was thought these pressures were
reflective of her pre-TAVR stenotic valve. Unfortunately, her
body habitus precluded nuclear imaging and TTEs have suboptimal
quality which precluded dobutamine/pacemaker-mediated stress
testing. However she did have a CTA Coronary which showed a
total Ca score of 1476. Given the elevated calcium score her
atorvastatin was increased. After reviewing her cath from
___, it was thought her symptoms were unlikely cardiac. She
was treated for a COPD exacerbation for 5 days which improved
her dyspnea.
#Cellulitis of the L ankle
Patient noted to have significant erythema and warmth of the L
ankle on ___. Denies fevers or chills. Per patient, she has
frequent episodes of cellulitis. Significant pain of palpation
of the ankle. Xray showing concern for erosive changes and
unable to rule out osteomyelitis. MRI was ordered and showed no
evidence of osteomyelitis. ID was consulted and recommended
treating for cellulitis. Patient was discharged to complete a 10
day course of Keflex.
# Atypical angina:
Symptoms occurring at rest without correlation to activity.
Troponin negative x2, no ischemic EKG changes. Given duration of
symptoms, and relatively clear cath in ___, low suspicion for
active ACS. Patient was trialed on amlodipine 2.5mg for
antinginal effects without relief in symptoms so this was
discontinued.
#VZV
Patient evaluated by dermatology on ___ for new rash consistent
with shingles. Treated with Valcyclovir 1g TID x7 days (start
___, end ___.
# AS s/p TAVR
TTE from ___ showing peak gradient 14mmHg, mean gradient 7mmHg,
valve area 2.8cm, EKG without ischemic changes. TTE on ___
showed valve was well seated.
# Afib
# Coagulopathy
On warfarin as had TIA/amaurosis fugax while on xarelto INR
supratherapeutic on admission. Rate control with metop succinate
100mg daily.
# HFpEF (EF 60-65%)
No evidence of volume overload on exam. BNP low though ___ be
falsely low iso obesity. Continued ___,
atorvastatin, and increased lisinopril.
#Asymptomatic pyuria
No symptoms of UTI. UA with 10 epis and likely contamination. No
indication for treatment of asymptomatic UTI and as such will
not repeat UA.
# IDDM
- decreased home Insulin U-500 160mg qAM and 120mg qdinner while
in house given change in eating habits while inpatient (carb
consistent, low fat diet).
#Coping
Patient taking care of two sons at home as well as herself.
Recently lost husband ___ years ago). SW consulted for coping.
================
CHRONIC ISSUES:
================
#Back/knee pain
Significant back and knee pain with activity and only on Tylenol
at home
- Tylenol PRN
# CAD
- Continued ___ 81mg
- Continued Atorvastatin 80mg
- Continued metoprolol XL 50mg daily
# HTN
- Continued lisinopril 10mg daily and metoprolol as above
# Depression
- Continued home Venlafaxine XR 225mg DAILY
- Continued home ClonazePAM 2mg QHS:PRN sleep
# OSA
- Continued CPAP
# Vitamin D deficiency
- Continued home vitamin D
=====================================
# CODE STATUS: Full confirmed
# CONTACT: ___ ___
Greater than 30 minutes spent on discharge planning. | 226 | 714 |
18763864-DS-18 | 23,039,861 | Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for a fever. We did not think you had an
obvious infection but are sending you home on antibiotics to
cover for possible infection. We think that the fever is most
likely likely due to Neupogen and/or chemotherapy. Please talk
to your outpatient hem/onc doctor about how long to continue the
antibiotics.
Please keep the follow-up appointments made for you.
___ MDs | ___ year old man with stage IIB Hodgkin lymphoma s/p 2 cycles of
ABVD c/b pneumonitis with subsequent PET-CT ___ showing
progression of disease who is currently receiving ICE
chemotherapy, p/w fever. Likely non-infectious but continued on
flagyl/cipro at time of dc. Cultures pending at dc but ngtd.
# Fever: T 102 at home with main localizing sign being a mild
productive cough. CXR in the ED showed no evidence of an
infiltrate or PNA. No antibiotics were started in ED. Exam on
admission did not suggest PNA. As a result, fever was thought to
be 2/t Neupogen and/or recent chemo. Pt was monitored while on
the ___ floor while not on antibiotics and Tmax was 101 after
the first day of admission. Neupogen was held on admission and
given the following day, at a lower dose of 300mcg QD, after he
did not have evidence of a fever. Cultures showed no growth to
date at time of dc. Was low grade in ___ at time of dc so
cipro/flagyl was continued. patient had close followup with
outpatient hem onc attending.
# Stage IIB Hodgkins Lymphoma: S/p 3 cycles of ABVD c/b
decreased DLCO that resolved with prednisone. Currently on ICE
(ifosfamide, carboplatin, etoposide) salvage chemotherapy since
___ after PET scan on ___ showed disease progression.
Repeat PET-CT ___ after cycle 2 ICE showed decreased LN size
and decreased FDG avidity. Recieved cycle 3 without incident
(c3d1 ___. Continued ppx with Acyclovir/Bactrim.
Transfusion scales in place for hct <21, plts <10.
# Depression/Anxiety: Continued Citaloparm, Zolpidem. | 79 | 255 |
14717765-DS-19 | 20,261,056 | Mr. ___,
You were admitted to the hospital because you had gained a lot
of weight because you were refusing your diuretic medicine at
your rehab. This weight was all fluid. As well, we found that
you had a urinary tract infection that we treated with
antibiotics.
The wound on your leg was treated with dressings but we did not
think it was infected.
At home you should check your weight every day and if you gain
more than 3 pounds you should call your doctor right away.
You decided to leave AGAINST MEDICAL ADVICE on ___. We
strongly encourage you to seek care at a hospital after leaving
because you still have a lot of extra fluid causing strain on
your heart and you need ongoing treatment with IV medication to
remove fluid. However, you understand the risks of leaving the
hospital, including the risks of serious illness and death.
Be well,
your ___ team | ****LEFT AMA******
Mr. ___ was admitted ___ with acute systolic heart failure
exacerbation in setting of refusing diuresis at rehab. He was
treated with Lasix gtt at 20/hr with intermittent boluses of
80mg IV. He diuresed well but was refusing dietary restrictions.
He was maintained on a regular diet but was successfully losing
___ kgs per day. On the morning of ___, he became upset with
the ongoing diuresis and leg wounds in the middle of the night
and he left AMA. He was encouraged to stay but refused because
he didn't like the treatment which he felt was "experimental."
He understood the risks of leaving without adequate diuresis
including worsening heart failure and even sudden death. He
planned to seek care at a different hospital. He was also
treated for a UTI while admitted and finished his antibiotic
course while at ___.
#Acute on chronic systolic CHF exacerbation: EF 20% per ECHO
from ___. Patient presenting in setting of significant
systolic CHF but personality limits adherence to medications.
Currently refuses Lasix and torsemide as outpatient. Eventually
agreed to 60-80mg IV Lasix doses on condition of staying in the
hospital. Also continued on metoprolol. Did not obtain TTE as
exacerbation clearly related to non-compliance with medications.
He was attempted to be diuresed ultimately with a Lasix drip at
20mg/hr with some good effect (losing ___ per day) but this
was limited by his behavioral issues as mentioned above. He also
refused a fluid restriction.
#UTI: Found to have VRE UTI for which he was treated with
Fosfomycin.
#Leg ulcers: Do not look actively infected. Likely secondary to
venous stasis, seen by wound care and clean dressings were
maintained.
#Personality or mood disorder: very combative at baseline. On
Seroquel 50qAM and 100qPM Psychiatry consulted and recommended
behavioral interventions consistent with a prior social work
note. See recommendations:
For staff
Behavioral plan for ___ | 153 | 310 |
18260419-DS-9 | 23,420,350 | Dear Mr. ___,
You were admitted to ___ with concern for worsening confusion.
This is due to your liver disease. There was no evidence of
infection. We increased your lactulose and your mental status
improved.
Please follow up with your appointments and continue to take
your lactulose. Please increase your lactulose to every 2 hours
if you notice worsening confusion.
Best of luck, it was a pleasure taking care of you.
Your ___ medical team | ___ with hx cirrhosis (NASH + ETOH), IDDM, COPD, CVA (L
hemiplegia), and schizophrenia, now presenting with altered
mental status.
# HEPATIC ENCEPHALOPATHY:
History of encephalopathy on lactulose maintenance, now with
acute encephalopathy and asterixis. Infectious workup negative
including bland UA, urine culture NGTD, blood culture NGTD,
negative CXR. No ascites. No portal vein thrombosis on RUQUS.
Patients home lactulose increased to 30mL po/pr q2h until he
cleared, then discharged on 30mL four times daily. Please
titrate to 3BM-5BM daily. Rifaximin 550 BID was started given
decompensated encephalopathy. Lactulose also written PRN for
additional orders if he becomes encephalopathic. If this is used
as a PRN order, please notify the staff MD.
# NASH / ETOH Cirrhosis: MELD 11 on admission, stable from
prior. Decompensated by encephalopathy as above. Last EGD in
___. History of variceal banding, but did not tolerate beta
blockers. No ascites currently. He was continued on his home
medications: pantoprazole, spironolactone, and furosemide.
# COAGULOPATHY: No evidence of active bleeding
CHRONIC ISSUES:
# Type 2 Diabetes: Continued insulin.
# Hypertension: Continued Lisinopril 10 mg daily.
# Schizophrenia: Continued Topiramate 100 mg PO BID, risperidone
briefly held but then restarted.
# COPD: Continued Fluticasone-Salmeterol Diskus (250/50) BID.
# Chronic pain: Held HYDROcodone-Acetaminophen while acutely
encephalopathic.
# Eye drops: Continued Latanoprost 0.005% Ophth. Soln. QHS.
# Hypothyroidism: Continued Levothyroxine Sodium 200 mcg daily. | 76 | 250 |
14413277-DS-13 | 23,611,431 | Craniotomy for Hemorrhage
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
**Your wound was closed with staples. You may wash your hair
only after sutures and/or staples have been removed on ___
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
**You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to. | Ms. ___ was admitted to the Neurosurgery service. Pre-op
work up was initiated for plans for surgery on ___. Aspirin was
held and platelets were ordered on call to the OR. SBP was
controlled for a goal of less than 140. Consent was obtained for
the OR.
On ___ she was neurologically unchanged, (left drift, and LLE
weakness). She was taken to the OR in the afternoon, she
underwent a right frontal temporal craniotomy for ___
evacuation. A subdural drain was left in. She was extubated and
transferred to the ICU where she stayed over night.
On ___, the patients subdural drain was electively discontinued
and the insertion site was closed with staples. A physical
therapy consult was placed and the patient was mobilized out of
bed to the chair with assistance. The patient tolerated a
regular diet well. In the morning the patient went into atrial
fibrillation and had low urine output. The patient was given a
250cc bolus and the patient converted back into normal sinus
rhythm spontaneously. The urine output increased to over 30 cc
an hour. Given the patient low urine output and atrial
fibrillation the patient was kept in the intensive care unit for
one more day. In the evening the Foley catheter was
discontinued. On exam, the patient was alert and oriented to
person, place and time. Strength was full. There was no
pronator drift. The patient's incision was well approximated
and clean without drainage.
On ___ she was seen and evaluated and felt to be appropriate
for transfer to the floor with telemetry. She awaited a floor
bed, however none became available. On ___ she was stable and
underwent a head CT prior to discharge. There was no increase in
hemorrhage. She was on the floor on ___ and was stable. ___ was
following. Screening LENS were ordered and there was no blood
clot in either leg. She was transferred to rehab on ___ | 160 | 329 |
18560515-DS-16 | 29,015,841 | Dear Ms. ___,
You were admitted with a headache and back pain. We were
concerned that the two symptoms together may have indicated
meningitis so we performed a lumbar puncture, which returned as
normal. Therefore, we feel that your symptoms were related to a
migraine headache.
We made no following changes to your medications. Please
continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization. | A/P: ___ h/o migraines p/w severe headache with bland LP and
unremarkable NCHCT. Her headaches improved with toradol and
sleep and were ascribed to migraine.
.
ACTIVE ISSUES
# Headache: The patient had a normal non-contrast head CT and
lumbar puncture. Her symptoms were likely migraine- related. She
responded well to Zofran and Toradol; she was discharged the day
after admission with unchanged exam.
.
INACTIVE ISSUES
# ruptured ovarian cyst
# lactose intolerance
.
TRANSITIONAL ISSUES
# MIGRAINE: Follow for prophylaxis needs | 95 | 76 |
14020659-DS-17 | 25,653,831 | Mr ___,
You were admitted for control of your blood pressure, evaluation
of your shoulder pain, and follow up of your recurrent thymic
cancer. You were continued on your home medications and placed
on pain control with improvement in your symptoms.
You had a CT scan that showed likely recurrence of your thymic
cancer. We discussed a biopsy of the site but your declined an
inpatient and requested this be worked up as an outpatient
instead.
As we discussed arthritis pain is not well treated with narcotic
pain medication and you will have a short course but the
intention is to taper off of this over the upcoming week. Please
follow up as noted below. | This is a ___ with Hodgkin lymphoma s/p chemo and mantle-XRT
___, thymic carcinoma s/p resection ___ with recurrence ___,
stable until ___ when lost to followup in our center, CAD s/p
IPMI and PCI with "3 stents", HTN, HL, COPD, active smoking,
BPH, GERD, depression/anxiety, chronic left shoulder pain, who
presents with fairly nebulous complaints.
# Multiple longstanding complaints in setting of known diagnosis
of recurrent thymic carcinoma: He has multiple complaints that
sound very chronic in nature. It is not entirely clear the
extent of his workup, also not unclear how closely he has been
followed for his thymic carcinoma. He has not been seen since
___ when the plan was for yearly CT scan and follow up with
Thoracic Surgery and Oncology. At the time he was lost to f/u
here he had fairly stable imaging. It is not clear if he has had
imaging in the last ___ years. CT imaging done at ___ here shows
a new 2-3cm lesion in the anterior medistiumum that is
concerning for recurrence. The case was discussed with thoracic
surgery who recommended ___ guided biopsy (if possible). The
patient declined this biopsy and requested outpatient evaluation
including a PET CT prior to discussion with Dr. ___. He
declined the inpatient ___ guided biopsy. He will have na
outpatient PET-CT and PFTs prior to his appointment with Dr.
___. Onc follow up as an outpatient. PCP has ___ to
Dr ___ (___)
# Acute on chronic pain,
# Shoulder and arm pain: Given longstanding history, report of
MRI shoulder, this sounds most likely due to
arthritis/capsulitis/tendinitis. Could have neuropathic/cervical
radiculopathy component (cervical arthritis, less likely
metastatic disease). Brachial plexopathy in context of expanding
intrathoracic mass is possible but not seen on imaging. Pain
better controlled in the hospital. Discussed with Patient and
family that will need long term follow up as appears arthritis
and that narcotics have no role in long term therapy for
arthritis pain. He will follow up with his PCP.
# HTN: Report of labile and elevated BPs PTA, but currently BPs
are reasonable here in spite of pain SBP 100-130 on home
medication while pain was well controlled. Continued home
regimen with pain control.
# HL
# CAD s/p MI
# Chest "clicking": Unlikely to be cardiac/ischemic etiology of
his symptoms given his ability to walk on level ground upwards
of ___ mile and his report of stable dyspnea when taking stairs.
Chest clicking is not an anginal type of pain. He is clear that
he does not have any chest pain. Troponin x1 here on admission,
many many hours (days per patient) out from onset of his
arm/shoulder pain. BNP negative. Pain improved with therapy for
MSK pain. Follow up with PCP as an outpatient.
# COPD: Stable. He says he takes Advair, Spiriva, and albuterol
- Continued inhalers
# GERD: Stable
- Continued omeprazole
# Depression/anxiety: Stable
- Continued citalopram
# BPH: Stable
- Continued Flomax | 113 | 480 |
17915006-DS-12 | 20,248,684 | Dear Mr ___,
It was a pleasure talking care of you at ___
___. You were admitted to the vascular surgery
service with an infection iof your Rt bellow knee amputation
stump. You were admitted with febrile illness and a CT scan of
your lower extremities showed a collection at the distal part of
your stump. which later drained spont. You were treated
conservatively with intravenous antibiotics. You tolerated the
treatment well and got better. you were admitted with a Cr of
1.9 ( your lowest levels recently were 1.6) which during your
stay went up as high as 2.8 and now trending down. On your day
of discharge you are afebrile and feel well.
What to expect: You should get stronger every day and the fever
should nor return. Your stump should be getting better as well
with no erythema or pain.
If your fever returns and /or the stump starts to be painful
red, warm or develop ulcer and/or a discharge you should be
reffered to the ED or call your surgeon.
ACTIVITY:
- please do not use a prosthesis at least until your visit with
Dr ___ a new prosthesis was contumed for you by this
time please bring it with you to your visit.
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
MEDICATIONS:
- Take all the medicines you were on before the admission just
as you did before, unless you have been told differently.
- If you have any questions about what medicine to take or not
to take, please call your surgeon. | Mr ___ is a ___ year old male with poorly controlled DM2,
who had BKA c/b surgical site infection who necessitated
revision and cyst excision one month prior to his current
admission, . The patient presented with wound discharge and
chills concerning for another episodes of right stump infection.
The patient presented with fever to 102.3 shacking chills with
no apparent source of infection other the Hx of mild discharge
from a tiny wound in the stump which on physical examination was
not apparent. Blood and urine culture were taken and the
patient was put on vanco cypro flagyl IV. He underwent CT of his
lower extremities which revealed a small fluid collection at the
tip of the stump ant. and distal to the tibia. a conservative
treatment was decided upon.
The patient presented with high levels of blood glucose that
were first hard to manage but as his infection was controlled so
as his glucose levels.
3 days before discharge the tiny crack in the stump was open and
an offensive smell purulent material was discharged with an
immediate relief. The fever did nor reoccurred. He was put back
on his home meds and tolerated diet well. Of note that the
patient suffers from CRF with Cr in the range of 1.7-3.3. His Cr
level during admission was 1.9 which went up as high as 2.8 and
now trending down to 2.3 on the day of his discharge. He has an
appointment with his nephrologist on the ___ and will be
trend his Cr level for this encounter on the beginning of the
week.
Mr ___ wound culture grew mixed bacteria, blood culture
had no growth. He was switched to Bactrim and was discharged
home with dry dressing and Po Abx. He was instructed not to wear
his prosthesis until he will be followed by Dr ___ in his
office within 10 days. | 464 | 312 |
14594880-DS-16 | 29,865,899 | Dear ___
___ was a pleasure taking care of you at ___. You were admitted
to the Podiatric Surgery service for your right foot infection
which also required surgery. You were given IV antibiotics while
here. You are being discharged home with the following
instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your R foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness ___ or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4
weeks after surgery or until cleared by your physician.
Your dressing should be changed daily with betadine soaked gauze
and a gauze wrap.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods ___ your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE. | The patient was admitted to the podiatric surgery service from
the emergency room on ___ for a R foot infection. On
admission, he was
started on broad spectrum antibiotics. He was taking to the OR
for Right foot debridement. Pt was evaluated by anesthesia and
taken
to the operating room on ___ for bone debridement and
primary closure. There were no adverse events ___ the operating
room; specimens were sent for micro and patholgy. please see the
operative note for details. Afterwards, pt was taken to the PACU
___ stable condition, then transferred to the ward for
observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled oral pain medication on a
PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized. The
infectious disease team consulted post operatively for
antibiotic recommendation for possible osteomyelitis. Per ___
Infectious Disease, Patient was discharged with IV cefazolin, PO
flagyl and PO Cipro based on sensitivities for 6 weeks. His
intake and output were closely monitored and noted to be
adequtae. The patient received subcutaneous heparin throughout
admission; early and frequent ambulation were strongly
encouraged.
The patient was subsequently discharged to home on ___ with
antibiotics x 6 weeks and follow up with OSH infectious disease
___ ___. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with
the discharge plan. Patient is to be NON-WEIGHTBEARING to R
foot. | 424 | 247 |
19228066-DS-9 | 25,384,674 | Ms. ___, it was a pleasure to participate in your care
while you were at ___. You came to the hospital after you
feel and fractured your right leg. You were taken to the
operating room on ___ to repair your fracture. You had
some low blood counts after your surgery so you were given som
blood prodcuts. During your hospitalization you became
delirious, but this improved.
MEDICATION CHANGES:
- Medications ADDED:
----> Please start taking lovenox as prescribed for 1 month to
prevent blood clots
- Medications STOPPED:
----> Hydrochlorothiazide 25 mg daily: While you were in the
hospital you did not require this medication. You may not need
to be on this medication in the future. Please talk to your
primary care doctor about restarting this medication.
- Medications CHANGED: None. | PRIMARY REASON FOR HOSPITALIZATION:
___ F w dementia presents s/p fall presumed to be mechanical,
found to have R femur fracture. | 134 | 22 |
10885949-DS-2 | 25,353,598 | You came to the hospital with abdominal pain. Your abdominal
imaging showed acute appendicitis. You were brought to the
operating room and had your appendix removed. There were no
complications. Your pain is being controlled and you are
tolerating your diet. You are ready for discharge home.
Please continue your recovery at home by following the
instructions below:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon. | ___ year old male, admitted for RLQ abdominal pain,
abdomen/pelvis CT showed acute uncomplicated appendicitis. The
patient was made NPO and given intravenous fluids. Subsequently
went to the OR on ___ for a laparoscopic appendectomy. No
complications. He has been tolerating a regular diet and has no
issues voiding. His pain has been well controlled on
analgesics. He has been ambulatory. Follow up appointment was
made with Dr. ___. | 733 | 79 |
17083316-DS-9 | 20,596,397 | Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with an open leg wound.
You were seen by both orthopedic surgery and plastic surgery.
Plastic surgery performed bedside drainage of the wound which
was likely a hematoma (clotted blood). You were treated with
antibiotics and you will be discharged on oral antibiotics.
You should continue to change your dressing once per day. You
have been scheduled for follow up with your primary care
physician. Please discuss returning to work with your primary
care doctor.
We wish you the best,
Your ___ Care team | ___ woman with history of hypertension who presented to
the ED with left leg pain, swelling and redness for the past 3
weeks since two falls with an open pretibial wound.
# Cellulitis
# Left Leg hematoma
The patient presented with extensive edema of LLE with open
pre-tibial wound. She was seen by orthopedics given concern for
compartment syndrome which was felt to be unlikely. She had a
___ which ruled out DVT and an ultrasound which showed a fluid
collection. She was started on IV vancomycin and subsequently
underwent an MRI of her calf which confirmed a hematoma,
infection can not be ruled out. She was seen by plastic surgery
who performed a bedside I and D and hematoma evacuation. They
also made a second incision to drain the hematoma. The patient
remained afebrile without systemic signs of infection. She was
transitioned to oral Bactrim/Keflex to complete a 7 day course.
She will continue daily dressing changes with packing and kerlix
and follow up with plastic surgery next week. She was advised
to keep her leg elevated and to discuss returning to work at her
PCP follow up.
# Hypertension
Chronic, stable continued home medications: Lisinopril, HCTZ,
ASA
# HLD
- Continued statin
# Gout
Chronic, stable, no flares for "years" per patient
- Continued Allopurinol
# Glaucoma
Chronic, stable
- Continued Latanoprost eye drops | 99 | 222 |
13297394-DS-14 | 23,942,625 | Dear Mr. ___,
You were admitted to the ___ because you broke your bones in
the left leg after falling down. Your broken bones were fixed by
the orthopedic surgeons and you tolerated the procedure very
well.
The surgeons placed a splint to keep you leg stabilized and
allow it to heal. Your pain was treated with Tylenol.
When you were admitted, your sodium was high and you were
treated with fluids. Your sodium levels returned to normal at
the time of discharge.
Please follow your discharge instructions for the care of your
left leg splint. Please take your medications as instructed.
Please take Lovenox 40mg daily for 2 weeks after discharge for
prophylaxis against blood clots. You are nonweightbearing in
your left lower extremity until follow-up. Please followup with
orthopedics as directed.
It was a pleasure taking care of you.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Nonweightbearing left lower extremity | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left open distal tibial shaft fracture and
hyponatremia and was initially admitted to the medicine service.
He was found to have hypovolemic hyponatremia, and when this was
corrected by oral intake, the patient was transferred to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left distal tibia I&D and ORIF,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to either rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the left lower
extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. | 289 | 269 |
17504263-DS-23 | 27,954,022 | You were admitted with a blood clot associated with your port
and pacemaker wire. Your blood thinner was switched from
Apixaban to Enoxaparin (Lovenox), which you have used before.
Please follow with your hematologist-oncologist in about 1
months. You will have a repeat ultrasound of the heart around
the time of that visit.
Additionally, your thyroid tests were abnormal. It seems like
your thyroid is not producing enough hormone. After conversation
with your outpatient provider, we have decided to start you on a
thyroid hormone replacement and they will recheck values in
about 1 month.
We wish you all the best,
Your ___ care team | ___ with history of metastatic bladder cancer with no evidence
of disease after 9 cycles of pembrolizumab, pembro-induced COOP
and atrial thrombus on apixaban, who presents with increased
fatigue and new pulmonary embolism and port-associated right
atrial clot on CT Torso.
# Pulmonary embolism and port-associated RA thrombus. This may
be explained by apixaban failure as clot seemed to decrease
previously on enoxaparin. Workup included Trop/EKG/BNP that is
reassuring against heart strain. TTE suggests new atrial lead
thrombus, but poor quality. TEE was recommended for further
characterization, but this would not change management and was
not pursued as discussed with outpatient hematologist. Pacer
remains functional and treatment would be anticoagulation. Close
cardiology follow up would be valuable to monitor pacer
function. Interventional radiology was consulted for
consideration of port removal. Per ___, the removal of port would
only be performed after a minimum of ___ days of effective
anticoagulation with lovenox or coumadin (per protocol). Per ___,
the port only needs to be removed if malfunctioning. No need to
access port at this time. Patient was treated with heparin
infusion and transitioned to 1 mg/kg enoxaparin without
incident. RUE Doppler did not reveal RUE DVT.
# Fatigue. Hypothyroidism.
Fatigue is likely caused by hypothryroidism (related to steroid
use versus late pembrolizumab effects). Less likely due to clot
burden and inflammatory state.
Fatigue may also be due to steroid taper. TSH elevated and FT4
low. Initiating levothyroxine therapy as discussed with
outpatient provider who will monitor response.
# Constipation: Treated with bowel regimen.
# Metastatic bladder cancer, in remission. s/p radical
cystectomy and ileal conduit, ___. Solitary L parietal lobe
metastasis s/p resection ___ followed by CK to surgical bed
___. Received 9 cycles of Pembrolizumab (last ___ and
developed
COOP 6 months off pembrolizumab. Will update primary oncologist.
# Pembrolizumab associated COOP
Developed COOP 6 months off pembro. Treated with steroids; most
recently restarted on tmt dose steroid ___ for worsening
pneumonitis, but now tapered down to 5 mg daily. CT yesterday w/
stable 2mm nodules, no evidence of worsening pneumonitis.
Patient is continued on prednisone 5 mg daily.
# Normocytic anemia, stable. This is a combination of ACD and
iron deficiency. Continued on iron supplement.
#L3 Compression fracture: likely in setting of underlying
osteoporosis and prolonged steroid use. s/p denosumab on ___.
- Cont home Ca/vit D
Hospital course, assessments, and discharge plans discussed with
patient and family who express understanding and agree with
discharge. The above was discussed with outpatient oncologist
who also agreed with plan. | 104 | 411 |
10682915-DS-15 | 28,172,484 | Dear Ms. ___,
You were admitted to the hospital from ___ because you
had a syncopal episode in the ER, with low heart rate and blood
pressure. When you came here your vital signs were stable, and
the enzyme we check for people with heart attacks (troponin)
were negative. You had some changes in your EKG, but since we
didn't have a comparison, we didn't know if they were new.
While in the hospital we watched your heart rate on telemetry
and you didn't have any unusual rhythms or more syncopal
episodes. We felt the episode was likely due to a vasovagal
response, which can occur in times of emotional or physiologic
stress such as your recent diarrhea.
We feel it's important to diagnose what's causing your diarrhea,
and feel it's safe for you to be discharged home to complete the
colonoscopy on ___.
Please follow up with your primary care physician on your
appointment ___ they may recommend additional follow-up
with cardiology, but we didn't feel the need to run additional
cardiac tests during your admission. Please do not drive until
you feel well again.
Thank you for letting take part in your medical care.
Sincerely,
Your ___ Health Team | ___ is a ___ year-old woman with a month-long
history of copious diarrhea presenting to ___ with
right-sided numbness and paresthesia, and was transferred to
___ after an episode of syncope, bradycardia, and
hypotension for further evaluation. Notably, the patient
recently underwent extensive workup for possible stroke/TIA and
infectious causes of diarrhea at BID-P, with no etiology found.
At ___ the patient's ED course was notable for negative
tropsx2 and non-specific t-wave inversions on several EKGs (no
baseline comparison available), AM cortisol 10.4 (nl). She was
monitored on telemetry overnight with no arrhythmias identified,
and had no further parasthesias or syncopal episodes, though she
had one short episode of dizziness. Low concern for cardiac
etiology, presumed vasovagal exacerbated by stress of recent
diarrhea, patient discharged to follow up with planned
outpatient colonoscopy on ___ in ___.
ACTIVE PROBLEMS
===============
# Syncope: Syncope in the setting of bradycardia and
hypotension, EKG with T-wave inversions of varying depths.
Differential diagnosis initially bradyarrhythmia vs. vasovagal
vs. hypocortisolism as primary causes. Ischemia seemed unlikely
in setting of negative trops and minimal chest discomfort in a
woman with high exercise tolerance. Seemed very likely vasovagal
and less likely cardiac, AM cortisol within normal limits. Safe
for discharge with outpatient follow-up
# Chest heaviness: Patient with chest heaviness and dyspnea
after crossfit workout on ___, resolved with rest, though
patient had repeat, milder chest heaviness and slight dyspnea on
___ while walking. Patient also with T-wave changes, DDx
vasospasm vs. MSK vs. anxiety. Determined low risk and possible
___ anxiety in setting of diarrhea, can ___ with PCP outpatient
for cardiology referral if deemed necessary
# Diarrhea: Voluminous, loose, non-bloody diarrhea ___ times
daily since ___. DDx infectious vs. autoimmune vs. IBS. Has had
extensive infectious workup at BID-P, all negative. Patient w/
colonoscopy schedule ___, should complete for most diagnostic
utility.
# Transient weakness/numbness extremities: Patient with
extensive workup at BID-P, no cause seen for stroke/TIA (MRI,
CTA/MRA, TTE w/ bubble), also no sign of MS on MRI. PCP should
___ hypercoag labs and Lyme studies from BID-P.
CHRONIC PROBLEMS
================
# Borderline B12 deficiency: Continue B12 PO as outpatient.
TRANSITIONAL ISSUES
===================
Transitional issues
[] Follow up with Dr. ___, ___
[] Complete scheduled colonoscopy on ___ with prep the night
before
[] Talk to your PCP about their perspective on starting a statin
and on the need for further cardiac workup of the T-wave changes
on your EKGs | 194 | 389 |
15856039-DS-12 | 23,675,137 | Dear ___,
It was a pleasure taking care of you. You were admitted to the
hospital for low back pain. We treated you with medications to
control your pain and nausea. You will follow up with your
orthopedist for further management of this issue.
Please do not drive or operate machinery for the rest of the day
or in the future if you have used sedating medications (eg
oxycodone, valium)
Sincerely,
Your ___ Team | ___ yo F with long history of pelvic joint disease who is
admitted for pain control.
#Acute Pain: Patient has a long history of pelvic joint disease.
CT scan of the pelvis and lumbar spine showed no acute changes
in the applicable joints. She was seen in the ED by her
orthopedist Dr. ___ recommended an sacro-illiac joint
injection as an outpatient the following day. Physical Therapy
also saw the patient in the ED and cleared her to go home with
outpatient pain control and her walker at home. However, given
her reported pain in the ED in the setting of multiple drug
allergies she was admitted for pain control. She was given 10mg
oxycodone, 5mg valium, and standing Tylenol for pain relief. She
was also given Zofran for her nausea. The following morning, she
stated that she was ready for discharge and that her pain was
controlled for the time being and that she was planning on
attending her outpatient appointment for injection of the SI
joint. On day of discharge, she was able to walk to the bathroom
without difficulty, sit up unassisted, and shower unassisted.
#History of anaphylaxis: Multiple allergies (including
oxycodone) listed after anaphylactic reaction post surgery 2
weeks ago. Causative agent was not found. Oxycodone given in ED
without issue. An epipen was ordered for immediate use if she
began to have symptoms of
#HTN: continued enalapril and HCTZ
#Postmenopausal: continued estradiol
#Important Hospital Events:
1. Upon admission to medical floor, patient refused to transfer
to the hospital bed because she needed a harder mattress such as
the one on the stretcher. Fortunately, a compromise was found to
place the stretcher mattress on the hospital bed.
2. Her husband was seen taking pictures of Emergency room staff
citing litigous purposes and security was called to warn him
that he would be escorted off the premises if did so again.
3. Patient complained of a migrain headache the morning of
discharge and before the physician could respond to the
complaint and prescribe medication, the husband was seen by
patient sitter to provide the patient with outside pills after
very clear instructions that this was against hospital policy.
He refused inspection of the bottle
4. The patient insisted on ambulance transfer out of hospital,
and refused to pay for it out of pocket when informed that she
did not meet criteria for insurance coverage.
#Transitional Issues:
-Pt provided a Rx for home ___ | 70 | 405 |
10610387-DS-5 | 22,388,745 | You were admitted for evaluation of a seizure. For this, you
were started on a new medication called depakote to help prevent
further seizures. In addition, you had a head imaging (CT scan)
that showed concern for a possible small bleed and you were
evaluated by the neurosurgical service. In addition, you
underwent an MRI that showed which did not show anyhing further
though was limited by motion artifact. You were evaluated by the
physical therapists as well as occupational therapists who felt
that you wouild be ideally served in rehab. You declined to go
to rehab so services are being increased for you at home.
Please take acetaminophen and oxycodone for any residual
headache. Please follow up with your physicians. | Pt is a ___ y.o female with h.o metastatic RCC to the skull s/p
cyberknife on chemo, HTN, HL, s/p ostomy for incontinence,
depression, COPD who was admitted with suspicion of new seizure,
c/b possible encephalopathy.
.
#Seizure, convulsive: No clear suggestion of infection or
metabolic cause. Pt was on tramadol as an outpatient which can
decrease the seizure threshold. This was discontinued. Primary
concern remained for metastasis. OSH CT was without acute
findings. However, CT at ___ concern for small hemorrhage near
craniotomy site. Unclear if this could precipitate seizure. The
patient was loaded on keppra and started on this medication.
Given, no fever, leukocytosis, or signs of meningitis, there was
no current indication for LP. Given, pt's history of depression,
there was some consideration of changing keppra to an
alternative AED and it was decided on ___ to transition over to
depakote. Pt was given a final dose of keppra on ___ and a
depakote load of 1500mg. Depakote was started at 750mg BID on
___. Neurosurgical did not think there was anything to do
regarding the possible small intracranial hemorrhage. ___
recommended transitioning to depakote and checking a level on
___ AM, and the ___ will draw this and fax to Dr. ___
(___) and Dr. ___. She has follow up with oncology
at ___, ___ in 2 weeks. She is discharged home with a
walker.
.
#chronic headache/intracranial ___ has a h.o
headaches. She is s/p cyberknife therapy for frontal skull vs.
frontal lobe metastasis, details unclear. Headache and possible
small bleed were felt to be due to fall after seizure. As
above, initial OSH CT unrevealing for acute process. No fever or
leukocytosis or signs of meningitis. However, CT at ___
revealed small extraaxial hemorrhage which was very small and
possibly related to trauma from fall. The neurosurgical service
was consulted and did not have further recommendations. The
neurooncology service recommended transition to depakote for
seizure prophylaxis. Her tramadol was discontinued and she was
started on PO oxycodone and acetaminophen therapy.
-headache is semiacute, on chronic (was taking meds at home)
.
#Encephalopathy, NOS vs. mood ___ exhibited some frontal
disinhibition as well as mood lability during admission. Per her
home SW, and PCP she has exhibited lability in the past and has
had some cognitive impairments after her prior surgery. Seemed
as though disinhibition and emotional lability were increased
during this admission, though decreased prior to discharge. It
is theoretical that this could be atypical manifestation of
concussion, or from keppra (was discontinued), vs. acute
exacerbation of her depression/stress related to her current
medical and social condition (finances, divorce). Social work
was consulted as well as ___ and OT who recommended rehab, but
patient refused, so will go home with increased services. Pt was
given PO ativan with good effect. Pt has ___ TIWK, home health
aids who help her clean weekly and help with her finances, and
home Soc worker. She will get ___ services too.. She has a
friend who helps with her cat. Her husband according to SW,
appears agreeable by phone, but patient reports he's not that
helpful to the patient. Pt does have a therapist, but stated
that she has been unable to see her therapist due to financial
concerns (of note, it appears that her finances are helped by
social worker, but pt has some cognitive deficits and forgets
her PINs and then reports having difficulty with fiances. She
has insurance. She is discharged to home with increased
services and will follow up with neurooncology ___.
.
#metastatic ___ on pazopanib as outpt, held during admission.
OK to restart upon discharge. follow up with oncologist ___
.
#adrenal ___ hydrocortisone and
fludricortisone at home doses.
.
#HTN, ___ home meds
.
#depression- Continued outpt sertraline and remeron. Social work
was consulted. Pt expressed that she has a therapist in the
outpatient setting and that financial concerns have been a
barrier in the outpatient setting. She will benefit from
continued support by social work and therapist.
.
DVT PPx:hep SC TID
.
CODE: DNR/DNI
.
Transitional (external):
-continued SW and therapist support for ongoing depression and
social situation | 124 | 705 |
17276069-DS-13 | 28,343,752 | You came to the hospital because you noted fluid draining from
your an area in your abdomen. You were found to have a
colocutaneous fistula. It has been determined that it is not
safe to surgically fix the draining fistula at this time. You
have been seen by the ostomy nurse who has placed an appliance
to collect the drainage. You were also noted to have an area of
redness around the fistula, likely related to the drainage. A CT
scan was done to ensure that there is no drainable collection of
fluid under your skin. You are being treated with antibiotics
for the infection of you skin in that area. You will be on
antibiotics for 2 weeks.
Please follow up at the appointment listed below in the ___
clinic. If you have any questions/concerns prior to your follow
up appointment you can call the clinic at ___.
Your coumadin has been held for short time because of the
interaction it has with one of the antibiotics you were on
initially. You are no longer on this antibiotic and can resume
taking your coumadin on ___.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*If you have increase abdominal distention, abdominal pain or
nausea.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you. | Mr. ___ was admitted on ___ under the Acute Care Surgery
Service for management of his colocutaneous fistula. Given his
extensive past medical history, he was deemed not a surgical
candidate for repair of the fistula. The wound/ostomy nurse was
consulted who applied an appropriate pouching appliance to the
fistula. Errythema was noted near the site of the fistula, and
an ultrasound was obtained to rule out a drainable fluid
collection, which was negative. He was initially started on
empiric antibiotic treatment with
vancomycin/ciprofloxacin/flagyl on admission, however, after the
negative ultrasound, the errythema was attributed to cellulitis
and his antibiotics were changed to keflex for a total course of
2 weeks. His coumadin was held on admission given the initial
consideration of surgery as well as its possible interaction
with ciprofloxacin. The patient's INR remained therapeutic
during his hospitalization between 2.3 and 2.4. At discharge,
plan to restart coumadin at prior dose on ___.
.
His vital signs were monitored throughout his hospitalization
and he remained afebrile and hemodynamicaly stable. His home
cpap therapy was continued. He wasm encouraged to mobilize out
of bed as tolerated. He was initially kept NPO and given IV
fluids, but was restarted on a regular diet on ___, which he
tolerated without abdominal symptoms. His intake and output were
monitored. His blood glucose levels were monitored QID and
covered with an insulin sliding scale as needed. His home
medications were continued while in the hospital, with the
exception of the coumadin as noted above.
.
At discharge he is feeling well, afebrile and hemodynamically
stable, tolerating a regular diet and is at his baseline
functional status. His cellulitis is improving on exam and his
fistula is well contained in a colostomy pouch. | 316 | 284 |
19210913-DS-19 | 20,643,491 | Mr. ___,
You were admitted to the hosptial with severe upper back/neck
pain. We were concern that this could be a sign of a problem
with your thoracic artery stent. You were treated with muscle
relaxers and pain medications. The neurology team evaluated you
and did an MRI of the cervical spine. We did not see any
abnormalities. THe pain improved and we have arranged for you
to follow up with your PCP to discuss ___ or other therapies for
your discomfort.
Duing your hopitalization, your BP control was excellent on your
new medication regiment. 130-110/80s. Please continue all the
medications you were taking before you were admitted. You were
given a prescription for a muscle relaxer to take if needed. | Mr. ___ was admitted to the hospital with severe upper
back/neck pain. Given his recent TEVAR he was admitted to the
hospital for full evaluation. THe pain team was consulted who
felt the pain was musculoskeletal and recommended muscle
relaxers and pain medications. The neurology team also
evaluated and did a MRI of the cervical spine which was
basically unremarkable. The pain improved with time and
medication. We have arranged for follow up with the PCP ___ 2
days to discuss ___ or other therapies for the discomfort. A
prescription for a muscle relaxer to take if needed was also
given.
During the hopitalization, BP was in excellent control,
130-110/80s. All BP medications were continued in the hospital.
He will follow up with his PCP further titration. | 129 | 135 |
14209398-DS-8 | 23,849,196 | Dear Mr. ___,
You came to the hospital with chest pain. You were found to have
no signs of worsening cardiac disease. Your chest pain resolved
by the time you got to the hospital. If your pain is not
responsive to nitroglycerin you should go to the emergency room.
You are scheduled for your cardiac catheterization with
Rotoblader treatment on ___. Dr. ___ is aware
of your hospitalization.
It was a pleasure meeting you.
Sincerely,
Your ___ Team | ___ yo M with history of CAD s/p attempted PCI of CTO of RCA
___ with plan for re-canalization ___ who presented to the
ED with CP concerning for ACS.
# Coronary artery disease:
Patient presented with chest pain at rest and given underlying
CAD, the pain was concerning for unstable angina. He had known
total occlusion of RCA s/p failed PCI in ___ with planned
recanalization procedure on ___. Initial chest pain was
sub-sternal and resolved about 40 minutes after taking
sublingual nitroglycerin.
Throughout hospital stay EKG's were normal and troponin x3 were
negative. He did not have any chest pain throughout this
hospital course. Dr. ___ was informed of the patient's
condition and hospitalization. In discussion with him and
cardiology team, it was determined that the patient could return
for planned RCA recanalization procedure on ___. Patient
was continued on his home dose of 325 mg Aspirin, Plavix,
metoprolol, and Pravastatin throughout his hospital stay.
# Paroxysmal Atrial fibrillation (___: 3):
Patient was in normal sinus rhythm throughout hospitalization.
Patient has never been on anticoagulation. He was previously
taking Flecainide, but this was recently stopped given abnormal
stress test and he was started on Metoprolol. Further discussion
regarding anticoagulation of atrial fibrillation at time of
follow up should be considered. He was continued on home dose of
Metoprolol and aspirin.
# PVD s/p stenting:
Patient was continued on high dose aspirin and Plavix. Aspirin
325 mg continued as patient on this previously per
recommendation for PVD.
# HTN: Patient was continued on home losartan and amlodipine. He
remained normotensive throughout hospital stay.
# HLD: Patient was continued on pravastatin, fish oil.
# BPH: Patient was continued on home doxazosin
# Gout: Patient was continued on home dose of allopurinol | 77 | 297 |
11260983-DS-21 | 20,547,378 | Mr. ___,
You were admitted after a fall and had some
confusion/hallucinations. We think the confusion might have been
related to a viral illness, which resolved promptly without
intervention. Your INR was high which was likely from the
antibiotics you received outpatient. We held a few doses of
warfarin, but you may resume your normal dose after discharge.
Our physical therapist evaluated you and think you will benefit
from rehab.
Please follow up with your primary care doctor in 2 weeks. It
was a pleasure caring for you in ___! | Mr. ___ is a ___ year old man w/ PMH anemia, DVT/PE on Coumadin,
glaucoma, CKD, NSTEMI ___, depression, thrombocytopenia who
presented with delirium and left shoulder pain s/p fall.
#Toxic metabolic encephalopathy: Per family, several days of
hallucinations and weakness prior to admission consistent with
delirium. Felt to be most likely related to recent URI with poor
sleep due to cough, ultimately leading to delirium. Initially on
azithromycin for ? bronchitis which was stopped due to lack of
evidence of bacterial infection. Treated with cough suppressant
and bowel regimen as well as delirium precautions with
improvement in delirium.
#Fall/Weakness: Trauma eval in ED negative. Seen by ___ with plan
for rehab.
#Supratherapeutic INR
#H/o DVT/PE: On warfarin at home with INR elevated on admission,
possibly related to azithromycin. Warfarin was held until ___,
on which his home dose of 7.5mg is resumed given INR of 2.5 | 88 | 144 |
19163027-DS-23 | 29,448,773 | Ms. ___,
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with fevers and found to
have inflammation surrounding your colon. You were followed by
the surgical teams, and infectious diseases. A repeat CT scan
showed fluid collections which are not able to be drained. You
will need to continue antibiotics until you see the infectious
disease doctors at which time they will discuss with you further
work up and treatment. If you develop, fever, nausea/vomiting or
worsening abdominal pain or other symptoms which concern you,
please return to the hospital.
.
You were also noted to have fluid surrounding your lung. This
fluid was removed and did not show an infection.
.
For your pancreatitis, you were continued on tube feeds and
clear liquids. You will need to follow up with Dr. ___. | ___ w/Necrotizing gallstone pancreatitis requiring multiple
hospitalizations presents with fever, found to have transverse
colitis, managed conservatively with antibiotics.
#Transverse colitis, diverticulitis
The patient presented with fevers and was initially started on
cipro and flagyl, suspecting a GI source. She continued to
have fever and rising WBC. A CT neck to eval for mastoiditis or
neck abscess was obtained as the pt had a dobhoff and mild neck
pain which did not show signs of infection. Antibiotics were
broadened to include vanc and aztreonam. Repeat CT abd then
revealed transcolonic inflammation and colitis/diverticulitis
with possible mircoperforation that may have been due to
longstanding inflammation from pancreatitis. The patient was
followed by infectious diseases who recommended continuing
Cipro/flagyl/aztreonam. The patient improved clinically but
platelets continued to rise despite dropping WBC count. The
patient therefore underwent repeat abdominal CT scan on ___
which showed an area of fat necrosis and a sub diaphragmatic
abscess. Radiology felt there was no approach to safely drain
this abscess via ___ guided drainage. The case was also discussed
with surgery who have been following the patient who felt
operative intervention was not indicated. The decision was made
with infectious disease to discharge the patient on a prolonged
course of PO flagy and IV aztreonam. She will follow up in the
___ clinic at which point a decision will be made regarding
repeat imaging and duration of antibiotic therapy.
#Pleural Effusion:
The patient has had a recurrent left pleural effusion. She
underwent thoracentesis to evaluate for infection. Studies were
not consistent with infection but cytology did show atypical
cells - favor reactive mesothelial cells; inflammatory cells and
histiocytes. The patient will need repeat imaging to asses for
underlying malignancy once her acute illness and pleural
effusion have resolved.
#Pancreatitis with pseudocyst
The patient remained on tube feeds and was tolerating clear
liquids. She is followed by the ___ team/Dr. ___
follow up at the beginning of ___ as scheduled.
#Diabetes: ___ pancreatic insufficiency
The patient's lantus was decreased to 12 units with good glucose
control. | 139 | 338 |
15228038-DS-9 | 21,964,665 | Dear Ms. ___,
You were admitted to ___ because you were having fevers. You
were found to have an abscess in your liver and infection in
your bile, called cholangitis. The liver abscess was aspirated,
and you had two drains placed to drain your bile. You were also
given antibiotics to treat your infection. Please continue to
take the ceftriaxone and fluconazole until ___ and when you
are seen by the infectious disease doctors. ___ will tell you
when to stop taking these.
You were also experiencing some shortness of breath and had
fluid drained from your lung which helped this.
Physical therapy also worked with you to help you get stronger.
Thank you for choosing ___ for your health care.
Sincerely,
Your ___ Team | Ms. ___ is a ___ w/ Stage IV adenocarcinoma of the
appendix recently on cetuximab, s/p R hemicolectomy with
diverting ileostomy, complicated by chronic
partial SBO on TPN, b/l hydronephrosis s/p b/l ureteral stents
and PCNs, recent polymicrobial bacteremia and liver abscesses
s/p 6 weeks of IV antibiotics, who p/w chief complaint of fevers
and was found to have a hepatic abscess, cholangitis requiring 2
PTBDs, and progression of stage IV appendiceal cancer. The
hepatic abscess was aspirated by ___ and grew ___ and
klebsiella. She was also found to have cholangitis and had 2
PTBDs placed with ___. For the hepatic abscess and cholangitis
she was treated with ceftriaxone and fluconazole. Per ID recs
she will receive 4wks of antibiotics from PTBD placement (last
day ___ and will be followed by OPAT. PTBDs were capped prior
to discharge and further plan will be decided by ___ as an
outpatient.
She also had a CT placed for R pleural effusion which was
removed prior to discharge. Her pleural fluid analysis was
consistent with an exudate, but was negative for malignant cells
on cytology.
#Cholangitis.
She had an elevated bilirubin, fevers, and an elevated WBC
count, all consistent with cholangitis. The patient already has
4 biliary stents that were placed by ___. ERCP was attempted but
unable to be completed as there was external compression of the
pylorus, likely from progression of her malignancy, that made it
impossible to pass the scope. As a result she underwent
bilateral internal/external PTBD placement with ___ on ___ with
good drain output. There was a slight decrease in her bilirubin,
with marked improvement in her clinical status. With drain
placement and ceftriaxone her WBC went down, she was afebrile,
and her abdominal pain improved. Her bilirubin stabilized at
around 5.1 and is unlikely to drop much further given her
metastatic disease. Her PTBDs were capped, and her bilirubin
remained stable. ___ will see her as an outpatient to discuss
further management of the drains. Per ID she will continue
ceftriaxone for 4 weeks from drain placement (last day ___.
She will be followed by OPAT as an outpatient.
#Hepatic abscess
Cultures from hepatic abscess on most recent admission grew pan
sensitive Enterococcus and E.coli ___. She received Zosyn
for about 6 weeks and completed treatment ___ per chart. CT
abdomen from ___ showed a small hepatic abscess. Hepatic
abscess was aspirated ___ and grew ___ and klebsiella. She
was initially started on zosyn, but was transitioned to
ceftriaxone per ID recs with a plan to continue until ___ (per
above). She was also started on fluconazole to treat the
___. She will be followed by OPAT as an outpatient.
#R Pleural effusion.
The patient had reaccumulation of her R sided pleural effusion
so IP was consulted and placed a chest tube. The fluid analysis
was consistent with an exudate but cytology was negative for
malignancy. The chest tube was pulled a few days after
placement. She was monitored for signs of reaccumulation but did
not develop any.
#Goals of care.
There were many goals of care discussion had with the patient
and her family and friends. Before speaking with the family, the
inpatient team reached out to the patient's outpatient
oncologist, Dr. ___ her thoughts on the patients
prognosis. She informed the team that the patient had been
reluctant to have goals of care discussions in the past and
expressed that the patient may not benefit from further
therapies, may not even be able to receive them given her
current clinical condition, but that if she is able and wants
more treatment Dr. ___ will discuss options with her. She
also stated that if the patient wants hospice she feels that is
a good option today. Hospice was brought up with the patient and
her family. The family felt hospice would be a good option for
the patient, but the patient was still hesitant and was asking
about more treatment options. Ultimately the patient agreed to
go home on hospice, with the knowledge that if she does improve
clinically she has the option of coming off hospice and
receiving more treatment. Unfortunately the company that
provides her ___ services will not provide hospice services to
someone who is still receiving TPN and antibiotics. As a result
she went home resuming her prior ___ services with palliative
care with the option of readdressing hospice when she completes
her antibiotic course on ___.
#Erythema around colostomy site.
Patient states that she has had erythema and irritation around
the ostomy site for weeks. She says she was supposed to see
wound care as an outpatient but unfortunately it did not happen.
Wound care saw her here and gave her a new ostomy bag. She feels
the erythema and irritation is improving. A few days prior to
discharge she was noted to have some blood in her ostomy which
appeared to be coming from her stoma. She says this happens
intermittently at home. Her hgb was stable so there was low
concern for a GI bleed.
#Vomiting.
The patient had one day where she had dark brown emesis that was
gastroccult positive. There was a concern for a GI bleed so she
was started on a high dose pantoprazole IV BID and given a PRBC
transfusion. The next day she was still having some emesis
(which is baseline for her), but it was not dark and was
non-bloody. Her hgb was also stable, decreasing the concern for
a GI bleed. She continued to have intermittent nausea and so she
was continued on her home regimen of IV Zofran 8mg BID, with one
8mg PRN Zofran. Of note, she has a chronic malignant partial
SBO, but a CT abdomen on ___ was negative for obstruction. She
also had ostomy output throughout her admission.
#Pain.
On admission the patient was on a fentanyl patch 50mcg/hr with
oxycodone PRN. She was also given IV dilaudid while here for
breakthrough pain. Her fentanyl patch was also increased to 75
mcg/hr because of increased pain. Prior to discharge she needed
to be transitioned to PO medications so her pain medication
needs were calculated based on her PRNs. As a result her
fentanyl patch was increased to 100mcg/hr with oxycodone 15mg PO
Q4H:PRN with adequate pain control.
#Appendiceal cancer.
Followed by ___. Her chemo has been on hold given her
infection and overall clinical decline. The patient plans to see
her outpatient oncologist after discharge and wants to pursue
further treatment options.
#Severe Protein calorie malnutrition.
She was continued on her home TPN. Nutrition was consulted and
made adjustments as needed.
# Anemia
Likely secondary to antineoplastic therapy and inflammatory
blockade from
malignancy. She had a hgb drop at one point during the admission
when there was a concern for GI bleed. She was transfused at
that time, and her hgb remained stable but low after that.
#Hyperglycemia.
Had elevated glucoses during this admission. She was started on
a regular insulin sliding scale and had 10U insulin added to her
TPN. The hyperglycemia was most likely from her infection.
#Vaginal discharge.
Likely yeast infection. Patient has been on antibiotics, also
patient reports symptoms are similar to prior yeast infections.
She was being covered with the fluconazole she was getting for
the ___ that grew out of her hepatic abscess. | 120 | 1,191 |
15461339-DS-13 | 26,810,126 | Dear Dr. ___,
___ were hospitalized at ___ from ___.
WHY WERE ___ ADMITTED?
- ___ were admitted because your kidney function had declined.
WHAT HAPPENED WHILE ___ WERE ADMITTED?
- We stopped your diuretics, which was likely contributing to
your kidney injury.
- We gave ___ IV fluids and medicine that helped your kidney
function to improve.
- We did an endoscopy and banded three swollen blood vessels in
your throat to prevent them from bleeding in the future.
WHAT SHOULD ___ DO AFTER ___ LEAVE THE HOSPITAL?
- Follow up with your doctors as listed in this paperwork.
- Take all of your medications.
- Refrain from drinking any amount of alcohol as it will damage
your already unhealthy liver.
It was a pleasure caring for ___.
Sincerely,
Your ___ Care Team | ___ year-old gentleman with alcoholic cirrhosis decompensated by
refractory ascites and encephalopathy who referred from liver
clinic for sub-acute worsening renal function in setting of
intermittent hematuria. | 121 | 27 |
19778536-DS-20 | 27,605,620 | Dear Mr. ___,
You were admitted to the hospital with nausea/vomiting and found
to have a small bowel obstruction due to your pancreatic
neuroendocrine tumor. In addition to your primary medicine team,
the surgery, hepatology and gastroenterology teams also
evaluated you.
For the small bowel obstruction, your symptoms improved, and
surgery decided based on the imaging and your symptoms that it
is reasonable to wait to do a bypass. Please go to the follow up
appointment with them.
For your ascites, the hepatology team evaluated and felt that it
was unlikely due to underlying cirrhosis and more likely due to
portal hypertension as well as lymph node system obstruction. We
did a paracentesis and will notify you of the results.
In addition to your surgery follow up appointment, we also
scheduled a follow up appointment with your oncologist and
primary care doctor.
It was a pleasure taking care of you!
Sincerely,
Your ___ team | #Small bowel obstruction
#Pancreatic neuroendocrine tumor
The patient initially presented with nausea and was found to
have a small bowel obstruction secondary to his known pancreatic
neuroendocrine tumor. He was initially treated with an NG tube,
kept NPO, treated with fluids and Zofran for nausea. However, by
the second day of his admission, his symptoms were markedly
improved, his NGT was removed and his diet was advanced.
Endoscopy showed normal mucosa in esophagus, stomach and
duodenum. MRE showed evidence of unchanged distal small-bowel
obstruction secondary to the central mesenteric mass. Based on
these findings, the patient's clinical improvement, and his
ongoing ascites, surgery decided to hold off on a bypass at this
time and see him in follow up as an outpatient.
# Ascites
Per hepatology evaluation, ascites seems to be multifactorial
due to portal hypertension due to the obliteration of his portal
vein and encasement of his SMA/SMV by his tumor, as well as
obstruction of his lymph system contributing to chylous nature
of the ascites. The liver is unlikely cirrhotic given normal
LFTs,
synthetic function and non-cirrhotic appearance on OSH CT scan.
For the concern for chylous ascites (based on patient's
description) as well as overall malnutrition, he was seen by
nutrition, who recommended a low fat, sodium restricted diet
with ensure enlive supplements mixed with beneprotein and 15 mL
medium chain triglycerides oil. A triene/tetraene ratio was also
checked with results pending on discharge; if> 0.4 and s/sx of
deficiency consider parenteral fat emulsion. He had a
paracentesis on the day of discharge, both therapeutic on
schedule for his weekly tap and also diagnostic to evaluate for
chylous ascites. Also continued home Lasix 10 mg daily while
inpatient. | 147 | 276 |
15786637-DS-10 | 23,238,551 | Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY YOU WERE ADMITTED:
-You were having difficulty breathing and we were concerned you
had a urinary infection
WHAT HAPPENED IN THE HOSPITAL:
-You were treated with antibiotics for the infection in your
urine
-Imaging of your lungs showed the right side of your diaphragm
is higher than usual. There is nothing that needs to be done
about this
-An echocardiogram of your heart was normal
-Your breathing improved with treating your infection
WHAT YOU SHOULD DO AT HOME:
-It is very important to be cleaned well after any incontinence
to prevent future infections
-Follow-up with your doctors as ___ below.
We wish you all the best!
Your ___ Team | ___ woman with history of hypertension, diabetes,
rheumatoid arthritis on steroids, dementia presented with UTI,
abdominal pain, and dyspnea/hypoxia. Treated with 5 days
ceftriaxone, etiology of hypoxia unclear but resolved
spontaneously. | 110 | 31 |
11474065-DS-16 | 24,333,646 | Dear ___,
___ were admitted to ___ on ___ with worsening shortness of
breath, cough, weakness and urinary incontinence. ___ were seen
by our ENT, Neurology, and Pulmonary specialists and we had
further discussions with our Interventional Pulmonary team who
recommended that there was no acute intervention that could be
offered at this time.
___ were found to have a urinary tract infection and have been
prescribed antibiotics to continue taking for several days after
hospital discharge. ___ also had some mild electrolyte
abnormalities which were corrected with oral supplementation and
we have prescribed ongoing oral supplementation for ___ to take
at home on an ongoing basis.
Regarding your ongoing urinary incontinence, we are in the
process of setting up a follow up appointment for ___ with
neurology. ___ will be called regarding scheduling this
appointment. We also highly recommend that ___ follow up with
your outpatient urologist for further management of this issue.
Regarding your ongoing cough and shortness of breath, ___ have
been scheduled follow up with your pulmonologist.
It was a pleasure to take care of ___ during your hospital stay.
Sincerely,
Your ___ Team | ___ with h/o sarcoidosis, hypercalcemia and recent laryngeal
surgery for vocal cord paralysis admitted for progressive DOE
and coughing since her surgical procedure 1 month ago, as well
as expedited neurology consultation for new urinary incontinence
and gait instability.
# Dyspnea and cough without hypoxemia: Patient presented with
dyspnea and cough that had worsened since her ENT surgical
intervention 1 month ago. Appeared to be upper airway in nature.
No evidence of PNA on CXR, no elevated WBC count, EKG unchanged
from prior. Patient localized a sensation to her throat which is
worse with eating and results in coughing. Lungs were clear to
auscultation without wheezing but with occasional transmission
of upper airway sounds. ENT was consulted and declined to scope
the patient because she had been scoped the day prior to
admission without evidence of any pathology that could be
contributing to her presentation. They recommended video swallow
to rule out aspiration but otherwise no acute intervention.
Video swallow on ___ was w/o evidence of aspiration.
Differential includes paradoxical vocal cord dysfunction. Her
omeprazole was subsequently increased to 40mg BID. Despite the
patient's ongoing symptoms, there was no immediate need for
inpatient work up. She was therefore able to be discharged home
for ongoing workup as an outpatient. She will have close follow
up in pulmonary and neurology clinic. We have also recommended
referral to speech pathology for empiric treatment of
paradoxical vocal cord dysfunction.
# Hypercalcemia: Total serum calcium of 11.0 on admission which
resolved after receiving 2L IVF in the ED. Differential includes
sarcoidosis (1,25-OH-VitD pending), malignancy, and
calcium-alkali syndrome (serum bicarbonate elevated). Normal PTH
makes primary hyperparathyroidism highly unlikely. Low 25-Vit-D
(value of 21 this admission) could be consistent with
sarcoidosis or other granulomatous processes if the 1,25-Vit-D
comes back as high (currently pending). Patient's serum
phosphate was low on presentation but this is confounded by her
poor PO intake in the setting of her dysphagia. The patient is
scheduled to follow up with both pulmonology and neurology at
___, as well as her PCP, for ongoing evaluation of this issue.
1,25-OH-Vitamin D will be followed up by her pulmonologist.
# Back Pain, Urinary Incontinence, Lower Extremity Weakness /
Gait Instability: Per patient, her back pain has not changed in
years. However, her gait instability and urinary incontinence
are new/subacute in onset and raised concern for malignancy vs
neurosarcoidosis. Neurology was consulted on ___ for evaluation
of her lower extremity weakness, gait instability and urinary
incontinence. They felt that her presentation was not consistent
with neurosarcoidosis or normal pressure hydrocephalus and there
was no need for imaging studies. Their impression was that her
weakness was secondary to deconditioning and mild electrolyte
abnormalities (mild hypophosphatemia) and that they would
resolve with physical therapy and electrolyte repletion. At
discharge, the patient was prescribed potassium, phosphate and
magnesium supplements to aid in preventing electrolyte
imbalances.
# UTI: Urine culture from admission grew >100k E.coli resistant
to ampicillin, cefazolin, ceftriaxone, ciprofloxacin, tobramycin
and bactrim. It was sensitive to ampicillin/sulbactam,
ceftazidime, gentamicin, meropenam, nitrofurantoin, and zosyn.
Given the patient's allergy history and use of prednisone, she
was prescribed a 7 day course of Augmentin (___) to
complete as an outpatient.
# Diabetes: The patient's insulin sliding scale was increased at
discharge given hyperglycemia into 300s-400s during admission.
==== TRANSITIONAL ====
# 1,25-OH-Vit-D pending at discharge
- Patient has pulmonology follow up with her outpatient
provider. Please follow up the 1,25-OH-VitD sendout lab for
question of sarcoidosis as underlying cause of her hypercalcemia
# Urinary Incontinence
- 7 day Augmentin course for UTI
- Started oxybutynin 5mg PO TID
- Patient has an outpatient urologist with whom she will
schedule a follow up appointment
# Cough, SOB, possible paradoxical vocal cord dysfunction
- Pulmonary follow up appointment scheduled
- PCP follow up within 1 week: we highly recommend outpatient
speech pathology referral for empiric treatment of paradoxical
vocal cord dysfunction
# Back pain and lower extremity weakness / gait instability
- Patient will be called regarding scheduling follow up with
Neurology | 182 | 652 |
16302322-DS-10 | 26,687,876 | Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ broke your left hip and our orthopedic surgions successfully
repaired it. We observed ___ for several days and ___ have
remained stable after requiring a brief stay in the ICU
following your surgery. ___ will continue to work on regaining
your strength at rehab. | Ms. ___ is a ___ woman with h/o ESRD on HD ___, HTN,
and moderate AS who presents with a fall c/b L hip fracture and
s/p ORIF and transferred to MICU for continued intubation and
hypotension intra-operatively requiring phenylepherine.
# L Hip fracture: s/p successful ORIF by orthopedics.
Orthopedics continued to monitor patient's recovery daily during
her MICU and medicine floor stay and there were no
complications.
# Respiratory status: Pt intubated for general anesthesia
administration as patient did not tolerate spinal block. She
received 1 unit pRBC and 1.3L of fluid in the OR and remained
intubated in the event she developed flash pulmonary edema as
she does not make any urine and is on HD. Patient was
successfully extubated on ___. She had no further respitatory
distress during admission.
# Hypotension: Likely ___ multifactorial in setting of
intubation with positive pressure ventilation and likely volume
depletion given symptoms prior to fall (light-headedness ___
HD). Required phenylepherine in the OR and was then s/p 1 unit
pRBC and 1.3L as well. Patient did have a leukocytosis but no
fevers or chills and no report of any localizing source of
infection. She was weaned from phenylephrine and propofol and
pressures remained stable. Her blood pressure remained in the
85-100 Systolic range once transitioned to floor. She was
asymptomatic.
# Leukocytosis: Most likely reactive in nature, patient without
any localizing sources of infection and no fevers or chills on
presentation. Patient was given clindamycin perioperatively but
antibiotics were not continued. He leukocytosis is 12 and
downtrending at the time of discharge.
# ESRD: Anuric by report, has dialysis ___.
Patient missed HD on ___ and, on ___, patient was found to
have K 7.9 and decreased bicarb of 9. She had urgent bedside HD
and her lab abnormalities improved. Her last HD session was
___. She is scheduled for her next session on ___.
#Delirium: Pt had episodes of hypoactive delirium overnight
which improved with reorientation and during day light hours.
Attempt to minimize pain medications as possible.
# s/p fall
Per family, patient felt lightheaded as she usually does after
dialysis and unfortunately fell after standing. Family denies
patient was having any chest pain, shortness of breath. Denies
any recent cough as well. | 57 | 366 |
12505092-DS-15 | 24,248,204 | Dear Mr. ___,
You came to the hospital because of left hand weakness and
numbness. Your MRI showed a new mass in the thoracic spine. A
CT scan of your abdomen, pelvis and chest showed a mass on the
kidney with spread to an adrenal gland and the spleen. Your
underwent a biopsy of the spinal mass which showed that there
are malignant (cancerous) cells present. We suspect you likely
have a kidney cancer, but this needs to be finalized by the
pathologist over the next few days. You were seen by oncology
who is working on scheduling follow up for you (they will
contact you with the appointment and time). Please follow up
with your PCP and ___ liver doctor here at ___. | ___ year old man with history of C4-C5 cervical fusion ___ years
ago), L2-L5 stenosis, DM2 and HTN, who presented with left upper
extremity paresthesias and weakness. His PCP completed ___ spinal
MRI which showed a new T1-T3 mass without current cord
compression per our radiology second read. He was admitted for
expedited work up and biopsy. CT torso showed right renal mass
with likely metastases to adrenal gland and spleen. He received
a biopsy of the T1-T3 mass by interventional radiology on
___. Preliminary pathology on discharge showed likely
metastatic clear cell carcinoma, although final stains are
pending. He was seen by oncology who will continue to see the
patient upon discharge. He had significant left shoulder and
arm pain that improved with addition of oxycontin and oxycodone
for break through pain.
CT torso also showed cirrhosis suspected due to prior liver
injury from methotrexate treatment for his psoriasis. He will
be evaluated by hepatology as an outpatient prior to
chemotherapy initiation.
Work up for thrombocytopenia and anemia inclding normal iron
panel, normal B12, SPEP/UPEP negative, and reticulocyte count
low at 0.8. Poor production may be due to his malignancy or
other primary bone marrow process.
Patient's other health issues were managed during the hospital
stay per home regimens (hypertension, GERD, glaucoma).
Metformin was held during hospitalization and resumed on
discharge for diabetes mellitus.
Patient was FULL CODE throughout hospital stay. We conducted
several family meetings including the patient, his wife, and
their daughter, during his hospitalization to discuss the
medical plan and results as they were obtained. The patient was
aware of the malignant cells on his cytology, and the suspicion
for a renal origin as the primary, pending further pathologic
results. The patient also expressed understanding that further
diagnostic steps, discussion of the pathology results, and
eventually determination of a treatment plan and prognosis would
be forthcoming as he met with the oncology team as an
outpatient. | 129 | 329 |
Subsets and Splits