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15159987-DS-26 | 20,088,596 | Dear Ms. ___,
It was a pleasure taking care of you while you were a patient at
___. You came to us with fever
and abdominal pain. Your fever most likely represents a viral
illness. Your abdominal pain is most likely mild gastritis. Your
symptoms resolved overnight. On the recommendations of Dr.
___ are sending you home with 6 days of oral clindamycin
to cover for a bacterial infection. We wish you all the best. | ___ yo F with PMH of severe atopic dermatitis complicated by MSSA
bacteremia, eosinophilia, elevated IgE, osteopenia, and
depression/anxiety who presents with likely viral illness.
ACTIVE ISSUES
# Fevers: Most likely continuation of viral illness. Attributed
last week to a brief viral gastroenteritis. Resolved rapidly
with IV fluids after which patient was discharged. On follow-up
with ID on ___ patient was feeling better with the exception of
fatigue. Labs drawn at that time remarkable for leukocytosis to
14.8. The patient subsequently developed fever to 101.4, sore
throat, and burning epigastric pain. On the recommendation of
ID, she presented to the ED. CXR with interval improvement in
RML opacity. UA negative. Rapid respiratory viral screen sent
but specimen was inadequate. Patient was treated with 1 day of
aztreonam and clindamycin IV for possible pneumonia. She was
never febrile in the hospital and reported that her symptoms
improved overnight. Given resolution of the opacity on CXR and
resolution in symptoms with the exception of sore throat and
nasal congestion, antibiotics discontinued on HD#2. Per ID,
patient was discharged on 6 days of clindamycin 300 mg PO Q6H to
cover for possible bacterial infection. Follow-up with Dr. ___
was scheduled.
# Sore throat: Likely viral syndrome. Treated as above.
# GERD: Epigastric pain on admission most likely due to GERD vs.
mild gastritis. Symptoms resolved spontaneously.
CHRONIC ISSUES
# Severe atopic dermatitis: Extensive confluent maculopapular
rash. Continued home skin regimen.
# Osteopenia: Continued home calcium and vitamin D.
# Multiple allergies: Continued home hydroxyzine.
TRANSITIONAL ISSUES
- Discharged on clindamycin 300 mg PO Q8H for 6 days
- Consider PPI if patient has further issues with abdominal pain
- Follow-up with ID scheduled
- Follow-up with PCP scheduled | 74 | 272 |
10886912-DS-13 | 25,788,827 | Dear Mr. ___,
You were hospitalized for a partial obstruction of your small
bowel and have undergone testing to determine the cause of your
obstruction. Thus far, testing has been inconclusive.
You obstruction has since resolved and you are now tolerating a
low residue diet. You are now preparing for discharge to home,
but will need to follow-up with your gastroenterologist for
ongoing evaluation.
Please note 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 presented to the Emergency Department on ___.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with either intravenous
morphine or hydromorphone. The patient's pain resolved entirely
prior to discharge.
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 and ambulation were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially placed on bowel rest with a
___ tube in place for decompression. On HD 3, given
evidence of resolving obstruction, the NGT was removed. On HD
4, he underwent MR ___ to evaluate for evidence of
crohn's disease. The MR was suggestive of resolving partial
bowel obstruction without definitive evidence of active
inflammation, but did not possible delayed gastric emptying.
Additionally, per the radiology fellow, there was no evidence of
stricture suggesting chronic inflammation. Following the MR,
the patient's diet was resumed and advanced to low residue per
gastroenterology, which he tolerated without pain, nausea or
vomiting. Given po tolerance, he was discharged to home and
will follow-up with his gastroenterologist and surgeon as an
output for further work-up of possible crohn's disease.
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.
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. | 363 | 313 |
19510620-DS-21 | 21,708,508 | Brain Hemorrhage with Surgery
Surgery
You underwent a surgery called a craniotomy to have blood
removed from your brain.
Please keep your sutures or 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 | # L ___
Mr. ___ is a ___ male on ASA 81mg with history of fall,
no headstrike, with presented to OSH with 5 weeks of headache
and feeling off. OSH CT head showed large L acute on chronic
SDH. He was transferred to ___ for neurosurgical evaluation.
He was admitted to the neuro step down unit and consented for
surgery. He went to the OR on ___ for left craniotomy for ___
evacuation. A subdural drain was placed. patient tolerated the
procedure well. He was extubated in the OR and transferred to
the PACU for recovery. He was alert and joking with family on
post-op check with improvement in right sided weakness. He was
straight cathed x1 for urinary retention. He remained
neurologically and hemodynamically stable and transferred to
___ for further monitoring. Post-op ___ showed
pneumocephalus, but with improvement in midline shift. He was
started on a nonrebreather mask for 24hrs. Subdural drain was
removed on POD#2. He remained neurologically and hemodynamically
stable. He was evaluated by physical therapy who recommended
discharge home. He was discharged home in stable condition on
POD#4. | 595 | 184 |
13870141-DS-23 | 24,258,173 | Dear Mr. ___:
It was our pleasure caring for you at ___
___. You were admitted because you fell and there was
concern that you may have been confused. You were evaluated by
the physical therapists who determined that you were safe to
return home. Please use your walker or wheelchair at all times
to avoid future falls. Please also consider a bed alarm at night
to avoid falls at night. Please also start taking the new dose
of your Levothyroxine which has been decreased.
When you arrived on the general medicine floor, there was no
evidence that you were confused.
Thank you for choosing ___. We wish you the best.
Sincerely,
Your ___ Team | Mr. ___ is a ___ w/ ___ dz, hypothyroidism,
multiple recent admissions for PNA/empyema s/p decortication and
acute renal failure (AIN) likely from DRESS syndrome ___ zosyn,
who presents from home with possible confusion and falls.
ACUTE ISSUES
#History of Fall/Pre-syncope:
From the patient's history, his fall was secondary to not using
his walker at home which he uses at baseline due to ___
disease and bradykinesia. He reports no trauma, and his CT head,
and CT C spine were negative. He was evaluated by physical
therapy, and discharged home with recommendations for discharge
home with 24 hour assistance.
#Encephalopathy:
On arrival to the general medicine floor, the patient had no
signs of reduced attention; there was concern for infection in
the ED due to a possible LLL infiltrate on CXR, however the pt
did not meet SIRS criteria, and had a normal CBC and
differential and normal lung exam. All of his electrolytes were
normal, in addition to renal and liver functions testing. Thus
antibiotics were held on admission.
A TSH on admission was low at 0.095. After speaking to his
nurse, his medications were reconciled, and he has been taking
Levothyroxine 100mcg QD. Given his reduced TSH, his
Levothyroxine dose was decreased to 88 mcg QD, which was
verbally communicated to his nurse, and he should have repeat
TSH testing with his PCP.
#Lung nodule:
Incidentally found on imaging. Discussed with patient. 6 month
follow up recommended
CHRONIC ISSUES
#Parkinsons dz:
The patient was continued on his home medications including
Carbidopa-Levodopa and Pramiprexole.
#Hypothyroidism:
The patient's home Levothyroxine dose was decreased to 88 mcg as
described above.
#Orthostatic Hypotension:
The patient was discharged to continue his home Fludrocortisone.
TRANSITIONAL ISSUES
-please check repeat TSH as levothyroxine dose was decreased to
88 mcg given low TSH of 0.095 on admission. Prior dose was
100mcg
-pls consider bed alarm at night to avoid future falls.
-pls institute fall precautions and monitor pt at all times
during the day to avoid falls. Pls ensure pt uses walker or
wheel chair at all times
-Pt was found to have a Left 5-mm apical lung nodule, overall
unchanged compared to the prior exam. A CT in six months is
recommended for further evaluation. | 110 | 358 |
15876287-DS-7 | 20,266,317 | Surgery
Your incision is closed with sutures. You will need suture
removal. Please keep your incision dry until suture removal.
Do not apply any lotions or creams to the site.
Please avoid swimming for two weeks after suture removal.
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. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs. | Mr. ___ is a pleasant ___ year old gentleman who was
transferred to ___ from ___ on ___ for
evaluation of cervical spinal cord compression after a fall
sustained on ___.
#Cervical Spine Compression: He was admitted to the Neurosurgery
service for preoperative assessment. His cervical spine was
immobilized in an Aspen collar. He underwent a posterior
bilateral laminectomy C3-C4, C5-C6, and superior C7 with
proximal foraminotomies left C3-4, right C5-6, and left C6-7 on
___. Please see separately dictated operative report by Dr.
___ for full detail. Hemovac drain was left in place
following surgery. The patient was instructed to continue Aspen
cervical collar at all times when out of bed for 10 days
following surgery. His neurologic examination was stable
postoperatively and remained notable for four-extremity
paresthesias as well as decreased grip strength. The patient was
evaluated by physical and occupational therapy who recommended
acute rehabilitation following discharge.
#Urinary Tract Infection: Preoperative urinalysis was consistent
with urinary tract infection. The patient was initiated on 7-day
course of ciprofloxacin, which he will plan to complete
following discharge.
#Urinary Retention
The patient was admitted with foley catheter in place given
urinary retention. He underwent repeat voiding trial on
___ and was unable to void. The foley was replaced with
plans for follow-up with Urology in one week. An MRI of the
thoracis and Lumbar spine was performed to rule out neurologic
cause for urinary retention. It showed diffuse disc bulge at
L2-L3 flattens the anterior thecal sac with crowding of the
nerve roots. No severe spinal canal narrowing at any level. No
abnormal signal abnormalities in the thoracic spinal cord. MRI
reviewed with Neurosurgeon on-call, consistent with epidermal
lipomatosis.
At the time of discharge, the patient's vital signs were within
normal limits and neurologic examination remained stable. He
stated that his pain was adequately controlled. He was able to
tolerate oral intake without nausea and vomiting. The patient
was ambulating with supervision. Foley catheter was in place.
Patient feels when his foley catheter is tugged, and also felt
the insertion of catheter. He is able to feel normally when he
wipes his anus. He is able to feel the urge to urinate, just
unable to initiate stream. He will plan to follow up with Dr.
___ Urology following discharge. | 197 | 380 |
11316115-DS-4 | 25,671,427 | Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you fell and were thought to have pneumonia.
Fortunately, you did not have symptoms of pneumonia. You have
been started on new breathing treatments which will better
management your shortness of breath and cough.
Physical therapy evaluated you given your fall, and felt that
you needed rehab to help improve your strength and mobility. You
would prefer to go home. After discussing with you and your
family decision was made to send you home.
You will need to call and set up an appointment with your PCP.
You a have an appointment with the ___ regarding your
fracture, see below.
You were seen by the speech and swallow team and they were
concerned that you have some difficulty with swallowing thin
liquids. They recommended thickened liquids. You will need to
have this followed up.
We wish you the best,
Your ___ Care Team | ___ yoF with h/o ischemic CVA not on anticoagulation, COPD, lung
cancer s/p lobectomy, and ___ transferred from
___ for evaluation of T4 compression fracture s/p
mechanical fall, admitted for presumed pneumonia based on chest
x-ray findings and reported cough and shortness of breath.
Patient's fall was thought to be secondary to progressive
weakness of her right lower extremity, which she has had since
CVA in ___. She appears to have had multiple falls over the
past month due to buckling sensation of her right leg upon
walking. Other etiologies to fall, including orthostatic
hypotension, cardiac event, and infection, were ruled out.
Neurosurgery evaluated her in the ED and recommended outpatient
follow-up in 2 weeks. Physical therapy evaluated her and
recommended discharge to rehab to increase strength and
mobility. However the patient declined and would prefer home ___.
Patient was also evaluated by speech and swallow and found to be
aspirating on thin liquids. The patient was given information on
thickening liquids.
Patient was admitted for pneumonia given report of cough and
shortness of breath, as well as CXR and CT torso showing signs
suggestive of pneumonia. However, she clinically did not appear
to have pneumonia given lack of fever, hypoxia, leukocytosis, or
new shortness of breath or cough. She stated that her current
cough and dyspnea were chronic from her COPD. Of note, she was
admitted at OSH from ___ for pneumonia and treated with
levofloxacin. It was therefore thought that radiographic
findings were residual from her recent pneumonia and not
indicative of an active infection.
Given her COPD patient was started on tiotropium and advair. She
should follow up further titration. | 156 | 271 |
16672042-DS-16 | 20,274,970 | You have been managed for a spinal cord injury called central
cord syndrome. Please see below for management of this when you
are discharged from the hospital
Activity: You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit in a
car or chair for 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.
Cervical Collar / Neck Brace: You ___ this brace if it
makes you feel more comfortable - you do not need to wear it
You should resume taking your normal home medications.
Follow up:
___ Please Call the office and make an appointment for 2
weeks after the day of your injury if this has not been done
already. | Patient was admitted to the ___ Spine Surgery Service for
observation to ensure that he recovered from his injury.
pnemoboots were used for DVT prophylaxis. Pain was controlled
with IV and PO pain medications. Diet was advanced as
tolerated. The patient was transitioned to oral pain medication
when tolerating PO diet. Physical therapy was consulted for
mobilization OOB to ambulate. 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. | 186 | 97 |
18148892-DS-14 | 26,749,741 | Dear Ms ___,
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.
Though your ileostomy is not new, please keep in mind the below
instructions. The most common complication from an ileostomy is
dehydration. You must measure your ileostomy output for the next
few weeks- please bring your I&O sheet to your post-op
appointment. The output should be no less than 500cc or greater
than 1200cc per day. If you find that your output has become too
much or too little, please call the office. Please monitor for
signs and symptoms of dehydration. If you notice these symptoms,
please call the office or go to the emergency room. You will
need to keep yourself well hydrated, if you notice your
ileostomy output increasing, drink liquids with electrolytes
such as Gatorade.
Please monitor the appearance of your stoma and care for it as
instructed by the ostomy nurses. ___ you notice that the stoma is
turning darker blue or purple please call the office or go to
the emergency room. The stoma may ooze small amounts of blood at
times when touched which will improve over time. Monitor the
skin around the stoma for any bulging or signs of infection.
Please avoid prolonged direct pressure to the area of the
incision where your rectum once was for at least 2 weeks after
surgery. For example, if you ride in a car, sit in the back seat
with your feet up or if sitting in the front seat, sit with the
back of the seat down. While sitting on the couch, swing your
feet onto the couch and place pillows behind your back. When you
are in bed, turn side to side frequently with a pillow behind
your back. It is okay to lie on your back for a limited amount
of time with your head down. For meals it is okay to sit for
___ minutes as long as you move from side to side. There is no
limit to walking and you should walk as much as you can
tolerate. At your follow-up appointment your surgeon will lift
precautions as the incision is healing.
You will be going home with your JP (surgical) drain, which will
be removed at your post-op visit. Please look at the site every
day for signs of infection (increased redness or pain, swelling,
odor, yellow or bloody discharge, warm to touch, fever).
Maintain suction of the bulb. Note color, consistency, and
amount of fluid in the drain. Call if the amount increases
significantly or changes in character. Be sure to empty the
drain as needed and record output. You may shower; wash the area
gently with warm, soapy water. Keep the insertion site clean and
dry otherwise. Avoid swimming, baths, hot tubs; do not submerge
yourself in water. Make sure to keep the drain attached securely
to your body to prevent pulling or dislocation. | Ms. ___ presented to ___ ED on ___ for pain and
swelling along her incision s/p lap proctectomy. She was
admitted for further workup.
Neuro: Pain was well controlled on Tylenol and tramadol for
breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. He/She had good
pulmonary toileting, as early ambulation and incentive
spirometry were encouraged throughout hospitalization.
GI: The patient was initially kept NPO. Patient's intake and
output were closely monitored.
GU: At time of discharge, the patient was voiding without
difficulty. Urine output was monitored as indicated.
ID: The patient was closely monitored for signs and symptoms of
infection and fever. CT imaging did not reveal a drainable fluid
collection. Examination of the incision site did not indicate
active infection. She was initially started on Cipro and flagyl
empirically which was discontinued. She had concern for a yeast
infection predating the admission and exacerbated by the
antibiotic infusion.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. She was encouraged to get up and
ambulate as early as possible. The patient is being discharged
on prophylactic Lovenox.
On ___, the patient was discharged to home. At discharge,
She will follow-up in the clinic. This information was
communicated to the patient directly prior to discharge. | 729 | 226 |
15001834-DS-12 | 25,096,299 | *********PATIENT ELECTED TO LEAVE AGAINST MEDICAL
ADVISE**********
You were hospitalized because of chest pain and abnormal, fast
heart rhythm. Your fast heart rate improved with IV fluids. Your
liver enzymes were also found to be elevated, likely because of
your recent alcohol consumption, but they were noted to be
trending down on the morning that you decided to leave.
You were able to verbalize that you understood that you were
leaving against medical advice and would assume the risk of
leaving against medical advice in light of incomplete work-up.
****DO NOT DRINK ALCOHOL OR USE OTHER ILLEGAL SUBSTANCES****
We have *NOT* made any medication changes. Continue taking
medications as prescribed by your health care providers.
Please follow-up with your primary care physician at ___
___. | Patient left against medical adivce. He was able to voice that
he was leaving against medical advice and understood the risks
of leaving against medical advice. He was advised that if his
symptoms worsened, then he should return to the ED to be
re-evaluated.
#Atrial fibrillation/atrial multifocal tacyhcardia: Patient has
a history of paroxysmal atrial fibrillation and has presented to
ED in RVR previously. Converted to sinus after 2L NS. The
patient reports that drinking can exacerbate his heart rhythm.
It was planned for him to received metoprolol 12.5mg QID, but
the patient left AMA. Of note, cardiac enzymes were negative.
#History of alcohol abuse: Patient was placed on CIWA scale upon
admission. He was given a banana bag as well. The patient also
had LFTs that were elevated likely due to his recent alcohol
ingestion. The patient's LFTs were noted to be downtrending. | 123 | 144 |
15131736-DS-16 | 24,444,558 | Dear ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for swelling of your legs which the medicine
team believes is due to chronic venous stasis (poor circulation)
with a possible overlying cellulitis. You should continue taking
the prescribed antibiotics for 5 days total. Also, please use
compression stockings regularly to help with the poor
circulation.
Your increased urination was attributed to use of your diuretic
pill after periods of non-use. If you develop worsening burning,
tingling, or urinary frequency, especially without taking the
diuretic, please notify your primary care provider.
A discussion was had concerning your need for anti-coagulation
in the setting of atrial fibrillation. Because you don't like
needles, you chose not to take warfarin. The alternative of
___ was presented, which does not require monitoring, and
you agreed to try it. Because you are on aspirin, this will be
deferred until your cardiologist approves it.
Overall your vital signs were stable, you were breathing at
baseline, and you were without fever, so you were deemed safe
for discharge back to your nursing home.
Wishing you well,
Your ___ Medicine Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ AAF with diabetes, CHF, COPD, recurrent multi-drug resistant
UTI and multiple comorbidities presents with lower exrem
swelling, L>R, as well as dysuria with pyuria on U/A. ___
grossly negative for PE but not conclusive. CXR shows
potentially mild increase in pulmonary vascular congestion but
exam less concerning for fluid overload as cause and patient
satting well on baseline oxygen. Exam showed chronic venous
stasis changes with developing ulcer on left medial leg and some
erythema concerning for possible overlying cellulitis. Pt
overall afebrile, satting ___ home oxygen, vital signs
stable, deemed safe for discharge home on antibiotics for
cellulitis and to follow-up management of chronic venous
insufficiency. | 199 | 108 |
11495019-DS-21 | 25,955,596 | INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand surgery. It is normal to
feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated Right upper extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTIBIOTICS:
- Please take oral cefadroxil twice daily for 7 days.
WOUND CARE:
- You may shower. 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.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns | The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have a Right forearm cellulitis and potential septic olecranon
bursitis and was admitted to the hand surgery service. The
patient was started on IV ancef, which resulted in improvement
in symptoms. The patient was given anticoagulation per routine,
and the patient's home medications were continued throughout
this hospitalization. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
Right upper extremity. He will take oral cefadroxil for 7 days
for antibiotic therapy. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. | 497 | 180 |
19509694-DS-23 | 28,576,521 | It was a pleasure taking care of you at ___.
You were admitted with heart failure and was given diuretics to
remove the extra fluid. Your weight this morning is 187 pounds
and this should be considered your ideal weight. Weigh yourself
every morning, call ___ if weight goes up more than 3
lbs in 1 day or 5 pounds in 3 days.
It is extremely important that you follow a low sodium diet. You
were given written information about this and should feel free
to call the heart failure clinic if you have any questions.
Your kidneys worsened because your heart was not pumping enough
blood but have now improved as the congestion has improved. | Mr. ___ is a ___ year-old gentleman with a PMH of non-ischemic
dilated cardiomyopathy (EF 20%), COPD, previous PNAs, admitted
with dypsnea and chest pain.
ACTIVE ISSUES
# Dyspnea: Dyspnea was thought to be multifactorial from acute
on chronic systolic HF, cocaine induced pulmonary fibrosis, and
COPD flare. He has a baseline LVEF of ___ from his previous
echo. On physical exam, he demonstrates all the classic signs of
heart failure (elevated JVP, crackles in the lungs, and lower
extremity edema). Patient is not on a beta-blocker due to
ongoing cocaine use, and not on spiranolactone due to
non-compliance. He was diuresed with IV lasix and continued on
home losartan, digoxin, atorva and aspirin. He required 3L
nasal cannula, which was weaned off with diuresis. For his
subjective SOB he was given nebs, which improved his symptoms.
At discharge, his weight was 85.3 kg.
# Chest Pain: His chest pain was unlikely to be ischemic in
nature given that his troponin is around his baseline level of
0.04 to 0.10 and an ECG showing no signs of ischemia. It was
described as chronic and intermittent. He was monitored on
telemtry without any events.
CHRONIC ISSUES
# CKD: His baseline creatinine level is around 1.3 to 1.5 with
elevations to 2 occasionally. Usually, he presents with an
elevated creatinine from baseline on presentation and trend down
during the course of hospitalization. He presented with Cr 1.7
which trended down to his baseline and was thought that in the
setting of decompensated heart failure, he had poor forward flow
to the kidneys.
# COPD: Stable. Continued albuterol nebs at needed.
# Diabetes: Stable. His last HbA1c was 7.9 on ___. Continued
reduced regimen of insulin glargine 40 units at breakfast and
bedtime and titrated up to home regimen with insulin sliding
scale AC and HS
# GERD: Stable. Continued home omeprazole.
# Anxiety: Continued home lorazepam as needed.
TRANSITIONAL ISSUES:
- At discharge, patient was referred to ___
___/ ___ Counseling as part of discharge plan.
- At the time of discharge, blood cultures x2 from ___ had
not finalized. As of ___, there was still no growth to date.
- CODE: confirmed FULL
- EMERGENCY CONTACT: ___ (sister), ___,
alternatively, ___ (sister), ___,
___ | 115 | 374 |
19570901-DS-37 | 28,708,519 | Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
You were admitted to the hospital because you had a fever and
were disoriented in the setting of a skin infection in your
right lower extremity.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- While you were in the hospital, you were closely monitored for
signs of infection. You did not have a fever and your white
blood cell count (cells that fight infections) returned to
normal.
- You received imaging (chest x-ray, CT of your right leg,
ultrasound of your right leg) to determine the source and
severity of the infection. The imaging and exam showed that you
have a skin infection of the right lower leg.
- You were treated for the skin infection in your right lower
leg with IV antibiotics (vancomycin and ceftriaxone).
- You did NOT receive your scheduled IVIG treatment for your
___ lymphoma. Please be sure to reschedule this
appointment after your discharge from the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please take your antibiotics Bactrim and Keflex for 5 more
days (last dose on ___.
- Please go to your follow up appointment with your primary care
physician.
- Please follow up with your oncologist, Dr. ___
rescheduling your IVIG treatment.
We wish you all the best!
Sincerely,
Your ___ Care Team | TRANSITIONAL ISSUES
===================
[] Patient was not able to attend IVIG appointment for NHL.
Please ensure this is rescheduled (per oncologist, defer until
infection has resolved).
[] CXR demonstrated stable pleural effusions since CT chest from
___. Please f/u for symptoms and repeat CXR to assess for
resolution.
[] Patient and husband reported desire to re-establish care with
a psychiatrist/therapist and may need assistance to accomplish
this.
[] Patient should re-establish care with cognitive neurology.
[] Patient should be referred to ___ wound clinic
# CODE: FULL
# CONTACT/HCP: Husband (___) ___
(cell) | 229 | 86 |
17047736-DS-10 | 23,887,363 | MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and 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
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin 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 or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room. | Mr. ___ is a ___ M w/ hx of PAD and right lower extremity
limb ischemia who was admitted to the ___
___ on ___. The patient was taken to the
endovascular suite and underwent R angiojet thrombolysis &
popliteal stent placement. For details of the procedure, please
see the surgeon's operative note. The patient tolerated the
procedure well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the vascular surgery floor
where he remained through the rest of the hospitalization.
Post-operatively, he did well without any groin swelling. he was
able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. He was deemed ready for discharge,
and was given the appropriate discharge and follow-up
instructions. | 339 | 144 |
14821269-DS-16 | 26,364,199 | Dear ___,
It was a pleasure taking part in your care at ___
___. As you know, you were admitted for
confusion due to low blood sugar in the setting of your known
diabetes, as well as low temperature. It is likely that you were
receiving more insulin than necessary at home, and it is very
important that you and your caretakers follow your new insulin
regimen. It is also very important that you eat 3 meals every
day. Please follow up with your primary care doctor on ___ regular
basis so that she can adjust your insulin regimen as needed. If
you feel ill or nauseated, experience vomiting or diarrhea, of
are not eating as much as usual, please let you caretakers know
since your insulin regimen may need to be adjusted. Also, if you
experience confusion, lightheadedness, nausea, or sense of
shakiness, please let your caretaker know since these may be
signs of low blood sugar. After you were warmed with a warming
device and warmed intravenous fluids, your temperature remained
normal throughout admission.
Please weigh yourself every morning, and call your doctor if
your weight goes up more than 3 pounds.
The following changes were made to your medications:
- Please STOP insulin NPH entirely. Please DECREASE insulin
glargine to 5 units at breakfast. Please STOP Humalog insulin
sliding scale. It is extremely important that you follow this
new insulin regimen in order to avoid low blood sugar in the
future. Your primary care doctor may adjust this regimen as
needed.
- Please STOP metoprolol, clonidine, and nifedipine since these
blood pressure medications are no longer needed and in
combination may cause your blood pressure to become too low.
- Please STOP spironolactone for now. This medication may be
restarted by your primary care doctor if needed.
- Please DECREASE calcium carbonate to 1000mg daily.
- Please INCREASE vitamin D to 1000 units daily. | Ms. ___ is a ___ with history of insulin-dependent
diabetes mellitus, cerebrovascular accident, dementia, diastolic
heart failure, and recent admission for complete heart block
with permanent pacemaker placement and possible seizure who was
transported from her assisted living facility after she was
noted to be confused and hypogylcemic to ___ despite oral
glucose. | 309 | 54 |
12452610-DS-22 | 21,203,625 | Mr. ___,
You were admitted to the neurology stroke service after being
transferred from another ___'s Emergency Department where
they were concerned you were having a stroke because of your
left face, arm, and leg weakness. You received a mediation
called tPA to help dissolve a possible clot.
Fortunately, your brain MRI did not show evidence of a stroke --
making it possible that the tPA worked and prevented permanent
brain damage; alternatively, it is possible that your symptoms
were caused by a TIA (transient ischemic attack or
"mini-stroke") or that they were due to your known spinal
disease.
You have several factors that put you at risk for having strokes
in the future, including:
- Atrial fibrillation
- Hypertension (high blood pressure)
- Hyperlipidemia (high cholesterol), although this has been well
controlled with your Atorvastatin
Because atrial fibrillation is your biggest risk for a stroke,
we discontinued your aspirin and started apixaban (Eliquis),
which is an anticoagulant or "blood thinner."
You had an echocardiogram (ultrasound of your heart) which
showed that the systolic (squeezing) function of your heart is
severely low at 23% (normal is >55%). We strongly recommend you
follow up with your primary cardiologist for ongoing management
of your systolic heart dysfunction.
You developed severe left neck and shoulder pain while in the
hospital which is musculoskeletal in nature. You were treated
with your home pain medications as well as lidocaine patches,
Flexiril (muscle relaxant).
Your heart rhythm was in atrial fibrillation during your
admission, occasionally beating too fast in what we call "rapid
ventricular response." Because of this, we increased your
metoprolol dose and then changed it to a once daily medication
called metoprolol succinate. Please note that this medication
may need to be increased in the future if you continue to go
into rapid ventricular response. | ___ is a ___ year old man with hypertension,
hyperlipidemia, atrial fibrillation L (on ASA), and chronic
spine disease with resultant baseline left-sided weakness. He
presented to an OSH on ___ with acute worsening of his
baseline left arm and leg weakness. There, he was found to also
have left-sided facial weakness and his initial ___ stroke scale
was 5. He was given tPA and then transferred to the ___
neurology stroke service.
His MRI brain did not show evidence of an acute stroke. His left
facial weakness resolved but his left arm and leg weakness
persisted. Altogether, we were suspicious of a TIA as the cause
of his worsening symptoms, but an acute worsening of his chronic
left limb weakness secondary to pain was also considered.
He has several factors that puts him at risk for having strokes
in the future, including:
- Atrial fibrillation
- Hypertension
- Hyperlipidemia, although this has been well controlled with
Atorvastatin (LDL 66)
Because of his atrial fibrillation, we discontinued his home
aspirin and started apixaban (5 mg BID).
He was in atrial fibrillation throughout his admission,
occasionally in RVR. His PO metoprolol was increased and then
converted to Toprol XL. He required one dose of IV diltiazem for
RVR.
He had an echocardiogram as a part of his stroke work-up which
showed a severely decreased LVEF of 23%.
He developed severe left neck and shoulder pain while in the
hospital which seemed to be musculoskeletal in nature, as he had
spasms of his cervical paraspinal and trapezius muscles. He was
continued on his home pain medications as well as lidocaine
patches and Flexiril. | 296 | 268 |
10933609-DS-41 | 21,868,479 | You were admitted to the hospital after a motor vehicle crash
where you sustained a broken nasal bone, fractures of your right
middle finger fracture and left arm. Your injuries required
several operations to repair the fractures. It is important
that you do not put any full weight on your left arm and right
hand and be sure to keep your left arm elevated as high as
possible to minimize the swelling.
You are being recommneded for rehab after discharge from the
hospital to help with rebuilding your strength and endurance
from all of your injuries. | He was admitted to the Acute Care Surgery team. Orthopedics
consulted for the fractures in his left forearm and he was taken
to the operating room for repair of these injures.
Postoperatively he was noted to have significant swelling and
was monitored closely for compartment syndrome. His compartments
on exam did remain soft and the swelling decreased significantly
with elevation using a stockinette attached to IV pole.
His right middle finger fracture was evaluated by Hand Surgery.
His finger remained splinted while discussions for operative
repair were underway. Occupational therapy was consulted for
splinting of his extremities.
He was taken to the operating room again on ___ for repair
of his finger fractures and nasal fracture (of note, was an
exacerbation of an old nasal fracture and elective repair had
been scheduled prior to this injury). Following the procedure,
he desaturated in the PACU requiring re-intubation. This is
believed to be from residual anesthetic. He was admitted to the
SICU. Over the next ___ hours, he was weaned from the ventilator
and extubated without incident. He was bronched prior to
extubation and purulent secretions were found. His chest x-ray
at that time showed bilateral atelectasis with mild hilar
congestion. He was started on Cipro which will continue through
___.
He was transferred to the floor the following day
hemodynamically stable. He did require intermittent nasal oxygen
once transferred form the ICU and was continued on nebulizer
treatments.
He was noted with pain control issues postoperatively and was
initially started on MS ___ with oral ___ for
breakthrough pain. Because of some mental status changes felt
likely from the narcotics these were stopped and he was started
on around the clock Tylenol and standing Ultram.
He was also seen by Physical therapy given his history of
frequent falls. It is being recommneded that he go to rehab
after his acute hospital stay. | 96 | 309 |
12452636-DS-17 | 29,940,748 | You were admitted to the hospital after you were involved in a
motor vehicle accident. You sustained a small bleed to your
head, a fracture around your left eye, and a fracture to your
lower back. You did not require any surgery. You were seen by
physical therapy in preparation for discharge home with the
following instructions:
Because of your head injury, please report:
*change in severity of headache
*visual changes
*drooping face
*difficulty speaking
*weakness in upper or lower ext.
You also had a fracture to the bones around your left eye:
please report:
*change in vision
*inability to move eye
*double vision
*spots, flashes light left eye
Sacral fracture:
*lower back pain
*weakness in lower ext.
*difficulty urinating
*inability to hold urine
*inability to control your bowel movements
*numbness in lower ext. | The patient was admitted from an outside hospital after being
involved in a motor vehicle accident. He reportedly sustained a
loss of consciousness. On imaging studies, he was reported to
have sustained a left orbital floor blowout fracture, a sacral
fracture, a bi-frontal subdural hematoma and a subarachnoid
hematoma. He also sustained a laceration to his eye lid and lip.
Because of the head injuries, he was evaluated by the
Neurosurgery service. The patient was placed on neuro checks
and was started on a course of keppra for seizure prophalaxis.
During his hospital course, the patient remained neurologically
intact. He was evaluated by occupational therapy and no
out-patient cognitive evaluation was warrented.
Additional injuries to the face included a left orbital floor
blowout fracture. The patient was evaluated by the Plastic
surgery service who determined that there was no facial
instability and no need for surgical intervention at this time.
The patient was placed on sinus precautions and the laceration
to his upper eyelid and lip were sutured.
Upon admission, the patient reported low back pain. Cat scan
imaging was done and showed an oblique fracture of the left
sacrum. For this, the patient was evaluated by the Orthopedic
service. Serial hematocrits remained stable. To further
evaluate this, the patient underwent pelvic films which showed a
pelvic fracture with a sacral component but no anterior ring
injury. This was treated in a closed manner without
manipulation. The patient was instructed in TDWB by the
physical therapist and was cleared for discharge home. Prior to
discharge, the patient met with the social worker who offered
referrals for substance abuse resources.
On HD #4, the patient was discharged home in stable condition.
His vital signs were stable and he was afebrile. He was
tolerating a regular diet and his pain was controlled with oral
analgesia. He was instructed to follow-up with his primary care
provider if he continued to have left knee swelling.
Appointments for follow-up were made with the Orthopedic,
Neurosurgery, and Plastic Surgery service. | 121 | 354 |
14260082-DS-15 | 28,477,447 | 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
ANTIBIOTICS:
- Please take Keflex for 10 days after discharge as instructed
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:
- Heel weightbearing as tolerated in right lower extremity
- Please remain in short aircast boot
Physical Therapy:
Heel weightbearing as tolerated.
Please remain in short aircast boot until follow-up.
Treatments Frequency:
Daily dressing changes, leave open to air when dry.
Any sutures/staples will be removed on follow-up appointment. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R tibial shaft fracture and multiple R foot fractures
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for IM nail of the R
tibia and closed reduction and washouts of the R foot fractures,
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 home with services 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 heel weightbearing as tolerated in
the right lower extremity in a short aircast boot, and will be
discharged on Lovenox for DVT prophylaxis. He will be
discharged on a 10 day course of Keflex for his open fracture.
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. | 200 | 280 |
13185931-DS-13 | 28,876,225 | 1. Change dressing with Xeroform and DSD daily
2. You can shower. Pat the incision dry afterwards. Do not
immerse the incision in water, e.g. swimming or hot tub.
3. Take your antibiotics as directed until completed.
4. Continue your OT exercises
Physical Therapy:
Activity: Ambulate
Treatments Frequency:
Wound care:
Site: left index finger
Type: Surgical
Cleansing agent: Saline
Dressing: Xeroform with DSD daily
Splint: Dorsal blocking orthoplast splint | Ms. ___ was admitted to the Orthopaedic Hand Surgery service
following I&D of her left ___ digit with repair of FDP tendon
and radial digital nerve on ___. She tolerated the procedure
well and was taken to the PACU in stable condition.
Intra-operative cultures were taken, which ultimately grew H.
influenza and Coag + S. aureus. While in-house, she was given IV
Unasyn for empiric antimicrobial coverage. She was given an
orthoplast radial gutter splint POD #2. She remained afebrile
during her stay. At time of discharge, she was tolerating a
regular diet, her pain was well-controlled with oral medications
and her clinical exam continued to show improvement. She was
discharged home on POD #1 with plan to continue on PO Augmentin
for another 12 days. | 68 | 127 |
16052230-DS-23 | 29,383,858 | Dear Mr. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital for confusion, and were found to have
hepatic encephalopathy. ___ were given 60mL lactulose every 2
hours, with resolution of your symptoms. ___ were also given
some albumin for dehydration, and blood for anemia. Your blood
levels stabilized and ___ were safe for discharge with close
follow up.
While ___ were in the hospital, ___ had back pain. An XRAY
showed compression deformity of one of your vertebra. ___ should
take tylenol ___ every 8 hours as needed for pain, use hot
packs, and start physical therapy. If your pain worsens, ___ can
talk to your doctor about getting an MRI. ___ should also talk
to Dr. ___ protecting your bones in the future.
Your lactulose regimen has been changed to 30mL four times a
day, with a goal of ___ bowel movements a day. If ___ find
yourself having less than 4 bowel movements or feeling confused
in any way, take an extra dose of lactulose and call ___ at the
___ to let her know. She can inform ___ how to increase
your dose hopefully keep ___ out of the hospital. Taking your
lactulose as directed is an important part of the transplant
process.
We wish ___ the best of health,
Your medical team at ___ | Mr. ___ is a ___ with PMH significant for cryptogenic
cirrhosis c/b variceal bleeding s/p TIPS (___), ascites,
hepatic encephalopathy requiring high doses of lactulose, and
recurrent right hepatic hydrothorax (used to have to get weekly
thoracentesis) on diuretic presenting with confusion and back
pain.
# HEPATIC ENCEPHALOPATHY: On arrival to ED, pt AOx0. No signs of
infections (bl cx NGTD, Urine cx NGTD, no ascites), no portal
vein thrombosis seen on US. Started on 60mL lactulose Q2H, with
resolution of encephalopathy in 24 hours. Transitioned to 30mL
Lactulose QID with ___ daily and no signs of encephalopathy.
Some concern that patient was not taking lactulose at home as
directed. Wife and pt adamant about compliance with medications.
Discharged on lactulose 30mL QID with close updates to the liver
center. Dr. ___ was contacted and suggested possibly reducing
size of TIPS in the future if hepatic encephalopathy continued
to be a problem.
# ANEMIA: Pt noted to have worsening anemia of Hgb 6.8 from
baseline ~8. Given 2U rbc with appropriate bump. No melena,
BRBPR. Vit B12, folate, iron, ferritin wnl. Needs outpatient
followup. Endoscopy in ___ with grade 2 varices and portal
gastropathy, no evidence of bleeding. Colonoscopy in ___
without polyps or evidence of bleeding.
# T12 COMPRESSION DEFORMITY: Pt had ongoing back pain from
previous hospitalization when he fell off the toilet. XRAY
showed T12 anterior compression. No neurologic symptoms. Likely
___ osteoperosis from chronic steroids used to treat adrenal
insufficiency. Instructed to take acetaminophen 650mg TID prn,
hot packs, ___. Can consider MRI in the future. Pt already set up
with outpaitent ___.
# Variceal bleed s/p TIPS: Last EGD in ___ with GEJ
varices which did not require intervention.
# Ascites: h/o TIPS in ___. Recent diagnostic
paracentesis on ___ was without evidence of SBP or
malignancy. No history of SBP. Lasix and spironolcatone
discontinued on recent admission due to hyponatremia. RUQ US
without significant ascites in ED.
# Cirrhosis: Cryptogenic. MELD 11 on admission, trended up to
16. Patient is on transplant list.
# COAGULOPATHY: INR up to 1.9 on ___. Likely from decreased PO
intake and frequent bowel movements. Given Vitamin K 5mg once on
___. Received heparin SC as platelets were over 50.
# Adrenal insufficiency: Continued home hydrocortisone 15mg TID.
No stress dose steroids were given since no signs of infection
or hemodynamic instability. Spoke to outpatient endocrinologist,
Dr. ___ suggested close followup to reassess steroids.
# GERD: Continued home pantoprazole q12h and calcium carbonate.
======================== | 226 | 420 |
12135369-DS-25 | 23,296,891 | Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You came in because you
were acutely short of breath. We treated you for an exacerbation
of your COPD and your symptoms improved. You should continue on
your home oxygen. Our physical therapists evaluated you and
recommended rehabilitation. You also had a red rash around your
eyes that seemed to improve without treatment. Your home
captopril (blood pressure medication) was changed to a once
daily pill called lisinopril.
It is now safe for you to be discharged. Please be sure to take
all of your medications as prescribed and keep your follow-up
appointments. We wish you the very best !
Sincerely,
Your ___ Team | ___ with medical history of COPD, on home Oxygen 4L, presenting
with acute on chronic shortness of breath.
Active Issues:
--------------
# EMPHYSEMA/COPD: GOLD STAGE 4. COPD exacerbation given
increased SOB, increased cough and sputum production over the
last several days. Trigger for exacerbation unclear, though she
does endorse subjective fevers and chills recently, which may be
suggestive of a URI; of note, her CXR is without evidence of
consolidation. Her D-dimer was negative so imaging for PE was
not pursued. Will plan to treat for other causes of chronic
cough, including GERD and allergic rhinitis. Continued her home
O2 requirement of 4L; she was started on a levofloxacin course
for 7 days, end date ___ in the setting of a COPD
exacerbation. Levofloxacin was chosen because she had
chronically been on azithromycin. She should restart
azithromycin 250mg daily as chronic prophylaxis on ___.
Continued home long-acting inhalers: Dulera and aclidinium and
started standing albuterol and ipratropium nebs. She was also
started on prednisone 40mg x7 days, followed by prolonged taper
30mg x1 week, 20mg x1 week, 10mg x1 week- pulmonologist Dr.
___ was made aware. She was also given a proton pump inhibitor
to treat for GERD and loratidine and fluticasone proprionate
for allergic rhinitis. ___ consult recommended acute ___
rehab vs LTAC.
# Periorbital dermatitis: Improved and resolving. History of
eczema. Most likely in the setting of seasonal allergies vs.
other allergic exposure such as contact. Dermatomyositis felt
unlikely given no proximal muscle weakness or evidence of
myopathy on exam. Improved with supportive management. Recommend
hydrocortisone cream x1 wk if patient is willing
Chronic Issues:
----------------
# HTN: held home meds for now, with plan to restart at time of
discharge
# Anxiety: continued home medications
***TRANSITIONAL ISSUES***
- will need prolonged steroid taper: Prednisone 40mg x1 week,
30mg x1 week, 20mg x1 week, 10mg x1week, and possibly indefinite
steroids.
- treated with Levoquin in setting of COPD exacerbation, end
date ___
- restart azithromycin 250mg daily on ___
- goal O2 sats on 4L NC should be 90-95%
- consider outpatient palliative care given her end stage lung
disease to discuss future goals of care with regards to
hospitalization, potential for repeat tracheostomy, etc. | 117 | 370 |
17462472-DS-3 | 24,311,827 | Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital because you
were found to be bleeding from an area in your GI tract near
your stomach. You were given medicine and the GI doctors put ___
___ into your stomach to help treat some of the ulcers. Your
bleeding stopped and you did well so you were able to go home
with medicine.
It is important that you take the new medicine every day. The
medicine is in a class called "proton pump inhibitors". We gave
you a prescription for omeprazole, but if your co-pay is too
high we can write you a prescription for any other medicine in
the same class. Please call us if you will need another
prescription.
It is very important that you NEVER take NSAIDs for pain. These
include ibuprofen, Advil, naproxen, Aleve, and Motrin. These
medicines can worsen your ulcers and make you bleed again. If
you have pain, please take Tylenol or acetaminophen.
You will also need to make an appointment with the GI doctors
for ___ in 8 - 10 weeks.
It was a pleasure caring for you!
Sincerely,
Your ___ Team | Key Information for Outpatient ___ year old gentleman
with history of aortic stenosis currently undergoing TAVR
workup, CAD s/p DES to the left main, left circumflex, LAD, type
II DM, who was admitted to ___ with a low H/H and melena.
# Acute blood loss secondary to GI bleed: On admission the
patient was hemodynamically stable. His Hgb was 6.8 from a
baseline of 9. He was given 2 units of PRBCs and responded
appropriately. He was started on Pantoprazole 40mg IV BID, given
fluids. His aspirin and Plavix were continued in the setting of
his recent DES placed in ___. GI evaluated the patient
and performed an EGD on ___. They found multiple duodenal
ulcers and cauterized a visible vessel within one of the ulcers.
He was observed overnight and did not have signs of a rebleed.
His diet was advanced to a regular diet and the patient did
well. His Hgb remained stable at > 8.0. Patient was discharged
home on a PO PPI and with instructions not to take NSAIDs. He
should be on high dose PPI for at least 8 weeks followed by
daily after that. He will need repeat outpatient endoscopy.
# CAD: Patient is s/p catheterizaiton in ___ with DES to
left main, left circumflex, LAD.
- continued aspirin and clopidogrel as above.
- continued atorvastatin 80 mg PO QPM.
- Metoprolol was initially held in the setting of GI bleed.
After he remained stable he was restarted on metoprolol prior to
discharge.
# Left Lower Extremity Swelling: Patient had 2+ pitting edema in
his LLE. ___ was performed and showed no evidence of deep
venous thrombosis.
# Hypertension:
- Initially held valsartan given GI bleed, and re-started upon
stabilization.
- Initially held metoprolol succinate and re-started prior to
d/c.
# Type II DM:
- Held glipizide while in house.
- Started Humalog insulin sliding scale.
# BPH:
- Held tamsulosin initially give GI bleed. Re-started prior to
discharge.
*****TRANSITIONAL ISSUES*****
#CODE: DNR/DNI
#HCP/CONTACT
Next of Kin: ___
Relationship: DAUGHTER
Phone: ___
- NEW MEDICATION: Omeprazole 40mg PO Twice a day for the next 8
weeks followed by daily there after
- FOLLOW-UP: Patient needs a repeat EGD in 8 - 10 weeks.
- INR elevated to 1.4. Not on warfarin. Likely secondary to poor
nutrition status over past month. Please re-draw INR at next
visit and consider vitamin K supplementation.
- continued work up for TAVR
- follow up panorex taken on ___ for TAVR | 199 | 406 |
19482457-DS-28 | 29,117,868 | Dear Mr. ___,
You were admitted with a prolonged seizure, and you were
confused afterward. Your infectious work-up did not reveal a
urinary infection or a pneumonia. However, it's possible that a
cold may have increased your risk of seizures. We started you on
a new medication in consultation with Dr. ___. Also, we
changed your omeprazole to famotidine to minimize interactions
with clobazam.
It was a pleasure meeting you!
Your ___ Neurology Team | ___ is a ___ man with PMH significant for intractable
epilepsy ___ childhood meningitis on ZON/PHT who presented after
a prolonged
GTC treated at an OSH with LZP. His mental status was initially
concerning for a a prolonged post-ictal state. His Dilantin
level was in the middle of his baseline range. The precipitant
for prolonged seizure was unknown, but infection (none
identified on UA or CXR) and non-compliance were initially
considered. Initial EEG showed L hemispheric slowing with
occasional sharp and slow-wave discharges, and he had one
subclinical L temporal seizure on morning the morning of ___
on EEG. His work-up, which included LFTs, CXR, lactate, CBC,
chem 10, UA, and urine culture were unremarkable. He was
monitored on telemetry without any events noted.
He was started on clobazam 5mg BID in consultation with his
outpatient epileptologist Dr. ___. His mental status improved
to baseline. Also, we switched his omeprazole to famotidine to
minimize interactions with clobazam. Subsequent EEG over last 24
hours improved significantly as well with only occasional L
temporal
discharges.
Overall, it is possible that a URI may have lowered his seizure
threshold, but there were no other clear triggers. He was
discharged home with resumption of prior home ___ services. He
will follow-up with Dr. ___ | 73 | 205 |
12766659-DS-14 | 25,785,795 | Dear Ms. ___,
It was a pleasure taking care of your at ___
___.
WHY WERE YOU ADMITTED?
You came to the hospital because you were confused.
WHAT HAPPENED IN THE HOSPITAL?
While in the hospital you were found to have an infection of
your urine. This was treated with antibiotics and your confusion
improved.
We did a scan of your brain to make sure nothing else was going
on and found a lesion in your right frontal lobe. Neurology saw
you and recommend you follow up with a vascular neurologist as
an outpatient.
WHAT SHOULD YOU DO AT HOME?
You should follow up with you PCP and schedule an appointment
with your primary neurologist within 2 weeks.
You should also schedule an appointment with your outpatient
neurologist Dr. ___ in Vascular ___ within 2 weeks of
leaving the hospital. We have made you an appointment, but
please call to see if you can change it to be seen within ___
weeks of discharge. The phone number is ___.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team | Patient Summary
Ms. ___ is a ___ year-old woman with history of
___ Disease, cognitive impairment, schizoaffective
disorder who presented from nursing home with tachycardia,
diaphoresis and confusion and was found to have UTI (ucx grew
GAS)treated with 5 day course of ceftriaxone last day ___ and
new frontal lobe lesion on CT Head.
================ | 180 | 52 |
14370333-DS-19 | 20,669,752 | You came in with pancreatitis related to having a type of high
cholesterol called triglycerides. We treated you with insulin
which helps bring this level of cholesterol down. You will
continue to take insulin after you leave as well metformin for
your diabetes and a new omega-three fatty acid called Lovaza (in
addition to gemfibrozil).
Please also discuss with your PCP about an ___
referral as these issues are relatively complex and may require
follow-up with a subspecialist. | Mr. ___ is a ___ yo M h/o hypertriglyceridemia, HTN, DM, who
presents with acute pancreatitis in the setting of
hypertriglyceridemia, admitted to the ICU for persistent
tachycardia and initiation on insulin gtt for treatment of
hypertriglyceridemia in setting of pancreatitis.
#Acute pancreatitis ___ hypertriglyceridemia: No complicating
features on CT scan with lipase elevated to 588 on admission.
Pain was controlled successfully with morphine and tylenol. A
RUQ ultrasound was performed that showed steatosis and no
gallstones. GI was consulted and recommended initiation of
insulin gtt with D5 containing IV fluids. The patient was kept
NPO, insulin gtt and IVF fluids were initiated. His ___ level
dropped from 3013 on admission ___ to 580s with insulin gtt.
Triglycerides were trended twice daily along with LFT to monitor
for complication of pancreatitis which remained within normal
limits. Gemfibrozil was continued. His diet was started after
triglycerides stabilized in the high 500 range. Insulin lantus
10U given and insulin gtt stopped two hours later. He tolerated
diet and was transferred to the floor. On the floor he
continued to do well with pain resolved on regular diet on day
of discharge. Discharge ___ was stable in the 500's.
#Diabetes mellitus: The patient presented with recently
diagnosed diabetes mellitus, started on metformin and glyburide
less than one week prior to presentation. HbA1C measured at 12%.
He was started on insulin gtt for treatment of
hypertrigylceridemia as above. ___ diabetes consult was
placed. He was given Lantus 10U to overlap with completion of
gtt and placed on humalog sliding scale. He will be discharged
with 10U Lantus, 1:25 ISS for BG>170 and metformin for diabetes
control. He will discuss with his PCP ___ referral to local
endocrinologist.
#Hypertriglyceridemia: As discussed above. Additionally, patient
continued on gemfibrozil and endocrinology recommended starting
Lovaza 4g. He will be discharged with prescription for this
medication.
#OSA: The patient was trialed on CPAP at night.
#Constipation: He was given bowel regimen including senna,
colace, bisacodyl, and miralax.
#Sinus tachycardia: likely in the setting of ongoing
inflammatory response to acute pancreatitis, along with volume
depletion in the setting of pancreatitis as well. He was volume
resuscitated. | 79 | 356 |
13994812-DS-24 | 23,020,534 | Dear, Ms. ___
___ was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for stomach pain, body aches, and fever
recorded at home
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We treated your pain symptomatically with improvement
- You saw our palliative care doctors who helped recommend a
treatment to better control your pain. They asked that you stop
taking the Dilaudid and only take the Oxycodone instead. This
will make it easier to adjust your pain medications in the
future.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- We started a new medication you can take for your abdominal
pain
- If you experience any of the danger signs listed below, please
contact your oncologist or go to an emergency room immediately
We wish you the best!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
=================
[] Please follow up with palliative care regarding initiation of
duloxetine and further management of pain symptoms
[] Please follow up with oncology, especially in regards to
having missed chemotherapy originally planned for ___
[] Please follow up with oncology regarding stable normocytic
anemia as well as blood cultures drawn on ___ (currently
NGTD)
BRIEF HOSPITAL SUMMARY
=====================
___ PMH Roux-En-Y gastric bypass and metastatic gastric cancer
diagnosed ___ on FOLFOX (___) with multiple recent
admissions in the last month for self-resolving gastric outlet
obstruction, hematochezia ___ presumed anal fissure, as well as
abdominal pain, N/V, body aches believed to be due to neulasta
reaction who presented for this hospitalization with fever at
home up to 102, N/V, and crampy abdominal pain. She was treated
symptomatically with oxycodone, ibuprofen, and dicyclomine for
pain as well as Compazine for nausea with improvement in her
symptoms.
ACUTE ISSUES
===========
#Fever/Chills
Patient presented with 2 day history of chills and reported
temperature measured at home up to 102. Of note, she had a
similar presentation the week prior that was believed to be due
to a reaction to Neulasta that improved with Tylenol,
diphenhydramine, and cetirizine; however, she has not had
Neulasta again between that last admission and this current one.
Patient was afebrile upon admission and remained as such
throughout admission. Her WBC count was 11.4 and trended down to
8.4 during her stay. CXR, CT A/P, and UA were not concerning for
any source of infection. Blood cultures on day 2 showed NGTD. As
she was not neutropenic on admission, she did not receive
antibiotics. She was treated with Tylenol and ibuprofen PRN with
resolution of her chills.
#Abdominal Pain
#Body Aches
Patient presented with R crampy abdominal pain that was
intermittent in nature and not associated with radiation in
symptoms or changes with eating or stooling. She stated she had
been having regular bowel movements prior to admission without
any bright red blood per rectum or black stools. She stated the
pain was partially relieved with dilaudid in the ED. In addition
she also endorsed diffuse body aches that started the same time
as fevers and chills on ___. She denied any recent sick
contacts. LFTs and CK were within normal limits. CT A/P did not
suggest obstruction or other identifiable causes of her
abdominal pain aside from noting stable gastric changes
associated with her known malignancy. She was treated
symptomatically with dicyclomine (a new medication for her),
Tylenol, ibuprofen. Palliative care was consulted and
recommended switching dilaudid to oxycodone, which also helped
her pain. We recommend she follows up with palliative care in
the outpatient setting to consider starting duloxetine to help
both with mood and body aches.
#HA
#Nausea/Vomiting
Patient reported feeling nauseous and experiencing 1 episode of
non-bloody, nonbilious emesis on ___. On admission she denied
further emesis and was able to tolerate PO without issue. Also
reported persistent HA that was worse in morning and associated
with blurry vision and sensitivity to light and sound. Of note,
she endorsed a similar HA on prior admission for which a brain
MRI was done and revealed no metastatic disease or intracranial
pathology. Her nausea was treated with Compazine and her
headaches were treated with the pain medications discussed
above.
#Metastatic Gastric Cancer
On FOLFOX (last ___ with chemotherapy originally planned
for ___. This dose of FOLFOX was missed given her
hospitalization and symptoms described above. Dr. ___
primary oncologist, was the attending on service and aware of
this. Plan to continue chemotherapy when outpatient. Appointment
scheduled for day after discharge.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. | 151 | 639 |
17767593-DS-3 | 27,537,212 | You were admitted to the hospital with DKA due to not taking
insulin. There was no evidence of infection on imaging or blood
work. Your blood sugar improved with restarting humalog ___
and a humalog sliding scale.
You were also started on lisinopril (to help protect your
kidneys) and Lipitor (to help improve your cholesterol).
Please see below for your follow up appointments. | BRIEF SUMMARY STATEMENT: ___ with Type I DM with 1 prior
episode of DKA presenting with weakness and hyperventilation
found to have DKA thought to be secondary to medication
noncompliance and likely dietary indiscretion.
ACTIVE ISSUES
=============
#Diabetic Ketoacidosis: Pt. found to have an anion gap
metabolic acidosis, ketonuria, and hyperglycemia, consistent
with DKA in the setting of insulin noncompliance and high sugar
intake at work. Desite an elevated WBC, pt. without any clear
infectious source on admission. His serum and urine tox
returned negative. Pt. was admitted to the ICU, volume
resuscitated with IVF, and placed on an insulin gtt. His anion
gap gradually closed over the first 24 hours. He began
tolerating POs and was placed on a subcutaneous regimen of
insulin (36 units of Humalog ___ + ISS) per ___ Diabetes
Consult recommendations. Given difficult vascular access, a
PICC line was placed on ___. Pt. remained stable and was
transferred to the floor. ___ was increased to 40 units BID,
and humalog sliding scale increased. A1c 14.2, indicating long
term poor control. Blood sugars improved to 200s for 24 hours
prior to discharge. Patient was offered ___ follow up, but
declined, easier for him to follow with his PCP for the time
being. He has follow up the day after discharge to ensure
adherence and establish close follow up with diabetic nurses for
the next days to weeks. He was started on lisinopril for
proteinuria. He was counseled on and reported good knowledge of
a diabetic diet.
#Hypertriglyceridemia- likely due to diabetes and insulin
deficiency. Improved significantly, started on Lipitor
(previously prescribed by PCP, patient was not taking prior to
admission).
His family visited during this admission and were supportive of
the patient. He agreed to improve adherence and work closely
with his outpatient providers to improve diabetic control.
Full code. | 63 | 319 |
18902344-DS-84 | 27,644,883 | Dear Mr ___,
You were admitted for low blood sugar and low oxygen levels. You
received IV diuresis and your breathing improved. While in the
hospital your blood sugars have improved with adjustments to
your insulin regimen. We continued care for the heel and
abdominal wounds and treating with antibiotics.
It was a pleasure taking care of you!
Your ___ Care Team | ___ is a ___ year old man with a history of morbid
obesity c/b obesity hypoventilation syndrome, OSA, HFpEF, hernia
repairs c/b chronic abdominal wounds, IDDM, HTN, EtOH use
disorder, anxiety/depression, chronic pain (methadone), chronic
foley, and recent calcanel osteomyelitis (on
levofloxacin/flagyl) who was admitted from rehab with
hypoglycemia and initially required ICU stay for hypercarbic and
hypoxemic respiratory failure and significant diuresis for
volume overload.
# Acute on chronic hypercapneic hypoxic resp failure:
# Acute on chronic diastolic CHF
# Obesity hypoventilation syndrome (OVHS)
# Obstructive sleep apnea (OSA):
Patient arrived at THE hospital lethargic and requiring 6L NC to
15L NRB a rebreather to maintain normal saturations, requiring
admission to the medical ICU. However being more alert, he was
quickly weaned to 2L NC with sats in ___, and safe for transfer
to medicine. Soon he was weaned to RA. However he continued to
desaturate to ___ when sleeping. Assessed by sleep medicine
but adamantly refused BiPAP, CPAP, or a sleep study. Also
refused tracheostomy with ventilator use. Daytime O2 sats
improved modestly with IV diuresis although continued to drop
his O2 when asleep. He used to be on 4L O2 at night but has not
since at least ___ due to insurance issues. Patient likely
has OHVS and OSA. Long smoking history so likely has COPD and
pHTN as well. His (mild) response to diuresis suggests
hypervolemia may play a role although no clear evidence of
pulmonary edema on exam or imaging (both limited due to his
habitus); no evidence of PNA or PE on imaging either. He was
continually diuresed with Lasix 160 IV ___ until ___. He
was then transitioned to oral torsemide. He will be discharged
on 120 mg QAM and 80 mg QPM and will need ongoing monitoring of
labs and volume status. (Unfortunately weights and intake/output
data were inaccurate and/or challenging to interpret).
# IDDM:
Presented with hypoglycemia. The diabetes consult service
followed during this admission and was noted to have extremely
erratic sugars associated with erratic eating habits. Home
metformin held and restarted at a reduced dose on discharge. He
will be discharged on lantus 64 U BID, and a Humalog regimen
incorporating meal-associated insulin and sliding scale together
(see sliding scale for details).
# Enterococcal bactiuria
# Chronic Foley
Ucx ___ sensitive only to linezolid. Likely colonizer given
chronic foley. No fevers, WBC, urinary symptoms, and so not
treated.
# Chronic foot wounds c/b calcaneal osteomyelitis:
Continued metronidazole and levofloxacin (per ID plan for at
least 10 weeks of antibiotics). Continued wound care per
podiatry's instructions. Follow-up in ___ clinic. (See wound care
recommendations below)
# Depression:
Patient endorsed depressed mood and dissatisfaction with poor
quality of life as well as hopelessness. SW consulted this
admission. Patient denied any thoughts of hurting himself.
Continued on buspirone, hydroxyzine PRN, trazodone, and
ramelteon.
# Chronic Abdominal Wound:
# Abdominal pain
Patient with chronic abdominal wound, which remained stable and
did not appear infected during the admission. He experienced
abdominal pain that was stable during the admission, without
evidence of a new acute process. Continued dressing changes. He
has outpatient plastics follow-up next week for pre-op for
surgical intervention in ___.
CHRONIC ISSUES
# HTN: Continued amlodipine and lisinopril
# HLD: Continued Atorvastatin
# Chronic pain: Continued gabapentin, methadone, oxycodone
# Smoker: Continued nicotine patch
# Vitamin D deficiency: Continued cholecalciferol
# GERD: restarted omeprazole at discharge
==================================================
==================================================
POST-DISCHARGE PLANS/RECOMMENDATIONS AND TRANSITIONAL ISSUES | 59 | 552 |
14653003-DS-18 | 27,723,795 | You were admitted for recurrent cellulitis. You were started on
IV daptomycin and ID was consulted. Wound care nurses helped
with your wounds. You had CT scan which did not show a bone
infection or an area that needs to be drained. You improved with
IV antibiotics and will be transitioned to Oral antibiotics to
complete an additional 7 days. You will need to follow up with
Dr. ___ infectious disease. You were also seen by
orthopedics who would consider removing your ankle hardware,
although at this time, it does not seem to be infected. | ___ w schizoaffective d/o, chronic cellulitis and previous
hardware infections in LEs presents with recurrent cellulitis
# BLE cellulitis:
The patient has a history of complicated lower extremity
infections with history of MRSA. Elevated CRP 35. Wound culture
from ___ grew pan-sensitive enterobacte which is likely a
contaminant. The patient had CT of her ___ which was consistent
with cellulitis. There was no drainable fluid collection and no
evidence of osteomyelitis. The patient was seen in consultation
by ID who recommended starting IV daptomycin. The patient's exam
improved and she will be discharged on oral clindamycin to
complete an additional 7 days. She will need to follow up with
ID after discharge. She was seen by orthopedics who felt that
her hardware isn't currently causing a problem, but could be
removed on patient request. The patient should follow up with
Dr. ___ as an outpatient to discuss further. The patient
was also seen by wound care nurses.
# Chronic pain:
The patient is on high doses of narcotics in additon to other
sedaiting medications as an outpatient. She was contiued on her
home regimen of MS contin, oxycodone, tizanidine, baclofen and
gabapentin. She was also continued on bowel regimen. I discussed
the risk of high dose narcotics with the patient and encouraged
her to discuss tapering these medications with her PCP. She
currently follows with PCP at the ___, Dr. ___ will
continue care here at ___ following her discharge from her
___.
#Schizoaffective disorder
The patient was appropriate throughtou her hospitalization and
was continued on seroquel.
# COPD: no acute exacerbation
Continued home inhalers (advair, spiriva)
#?Rheumatoid arthritis
COntinued on Plaquenil | 96 | 263 |
16392858-DS-25 | 25,429,058 | Dear Mr. ___,
It was a pleasure taking care of you while you were admitted
to the ___. You were admitted because you were having
shortness of breath and difficulty doing your normal activities.
Your weight was up slightly and you were having palpitations.
You were found to have high heart rates given your atrial
fibrillation. We gave you some IV diuresis that initially helped
get some fluid off, but then we saw a decrease in your kidney
function. We held diuresis for a day and in the meantime
increased your diltiazem in order to control your ventricular
response to your Afib. We think that this will improve your
shortness of breath because your heart will not have to work as
hard, thus you will have less congestion in your lungs. We
increased your home lasix as well. Please continue to take all
of your medications and keep your follow-up appointments.
Best,
The ___ Cardiology Team
TRANSITIONAL ISSUES:
#Please have your INR checked ___ since we have increased your
coumadin to 7.5 daily from your home dosing
#Weigh yourself every morning, call Dr. ___ your weight
goes up by more than 3 lbs.
#please make sure you that your diet is low in sodium (NO fast
food) since salty food can lead to another exacerbation and
hospital admission | ___ with PMHx HTN, diastolic HF (EF 55%), tachy-brady syndrome
s/p pacemaker, atrial fibrillation CHADS2 of 2 on warfarin,
obesity, and chronic pain recently tapered off of narcotics
presenting with chest pain, DOE and weight gain consistent with
heart failure exacerbation.
# Acute on chronic dCHF exacerbation: Has history of HFPEF, last
echo in ___ with LVEF > 55% and mild symmetric LVH with
normal biventricular cavity size and global systolic function.
He was last hospitalized with exacerbation in ___ and was
discharged with 20mg PO lasix daily. Last seen in ___ clinic on
___ and appeared relatively euvolemic, so no changes to
medications or management were made. He reported complaince with
medications but BP was elevated on admission. He also reported
not "being perfect" with his diet. He had no evidence of
ischemic etiologies for worsening heart failure with negative
trops and normal EKG. The most likely cause for worsening heart
failure could be related to his recent exacerbation of his Afib
with rapid ventricular response despite successful cardioversion
in ___. He briefly had an IV Lasix gtt that was changed to
bolus dosing with moderate repsonse. He appeared euvolemic and
he was continued on Lasix 40mg PO daily. His heart rate was
controlled by increasing his diltiazem to 240 BID with good
response and ventricular rate in the 60-80s. His lisinopril was
held initially given Cr bump, but was restarted prior to
discharge with stable kidney function.
# Hypertension: Patient reported compliance with all mediations,
but BP elevated on admission to floor of 140/103. Goal SBP <
130. His diltiazem was uptitrated and he was continued on
hydralazine, labetalol and lisinopril while also being diuresed.
Patient's blood pressure were more controlled on discharge with
SBP 120-130s.
# AoCRF: Serum creatinine levels have been elevated since ___,
which coincided with his treatment for CHF with diuretics.
Patient with baseline Cr of 1.8. Elevated on admission to 2.2,
likely ___ poor forward flow and renal vasculature congestion
with aggressive diuresis. He was discharged with stable renal
function on lasix 40mg daily and lisinopril 40.
# Atrial Fibrillation: First noted in ___. CHADS2 = 2 for CHF
and age. S/p ablation in ___ that was successful for approx
1 month per patient. Since that time he has noted more frequent
palpitations and worsening heart failure symptoms. He was
continued on warfarin for goal INR ___, which was increased to
coumadin to 7.5 for persistent low INR. His diltiazem was
increased to 240 BID, and continued on labetalol with
ventricular rate <90.
# Tachy/Brady Syndrome: S/P biventricular pacemaker. Not pacing
on recent ECG or tele during admission.
# Chronic Pain: Tapered off of his narcotics as of ___.
Avoided NSAIDs in setting of CKD and hypertension. Tylenol PRN
for pain.
#Depression/Anxiety: Chronic. Stable. Continue home fluoxetine
and lorazepam | 213 | 470 |
10030753-DS-29 | 26,285,510 | Dear Ms. ___,
You were admitted to ___ on
___ for nausea, vomiting, and weakness.
You were found to have a very high blood sugar and acidic blood
due to a condition called 'diabetic ketoacidosis'. Your kidney
function was also temporarily decreased, most likely due to
dehydration. Your blood sugars and your kidney function improved
with continuous insulin and intravenous fluids. This episode of
'diabetic ketoacidosis' was likely triggered by a urinary tract
infection, for which you were treated with the antibiotic
medicine Vancomycin, and were switched to the oral medicine
nitrofurantoin (Macrobid) before discharge, which you will take
every 12 hours until the evening of ___. Finally, your INR
was found to be higher than normal, so several doses of your
home warfarin were held until the INR came back down to a normal
level, at which time your warfarin was restarted. Please note
that your INR subsequently decreased to 1.1 which is below the
desired level, so please continue checking your INR at home and
call your ___ clinic with the results so that they
can adjust your dose.
You should also have your tacrolimus level checked at the
outpatient laboratory in one week, on ___.
You should continue to administer your long-acting insulin every
morning and every evening. You should also administer
short-acting insulin before each meal based on your blood sugar
levels and carbohydrate counting, as you have been in the past.
When it is necessary to catheterize yourself for urination, you
should make sure to use good sterile technique.
Please not the following change in your medication:
-ADDITION of nitrofurantion (to treat urinary tract infection) | This is a ___ F with complex past medical history, most notable
for poorly controlled Type I DM c/b ESRD s/p renal transplant
___, CAD s/p MI ___, antiphospholipid Ab syndrome with remote
h/o PE on coumadin, and scleroderma, who presented with DKA,
___, and enterococcal UTI.
Active issues:
#DIABETIC KETOACIDOSIS: The patient initially presented to ___
___ with glucose >600, Anion gap 30. This rapidly improved
with administration of IV fluids and insulin gtt. On transfer to
___ ED, her glucose was 297, and anion gap had almost closed
at 14. She was transition to subcutaneous insulin with one hour
overlap with gtt and maintained on IV fluids until ___, at
which point her creatinine returned to baseline and she was
taking adequate PO fluids. Her nausea and vomiting had resolved
prior to admission to the floor. She was restarted on her home
insulin regimen and her FSBGs remained mostly stable in the
___. The trigger for this episode of DKA was most likely
the patient's UTI, treatment for this was begun immediately upon
admission as below.
#ENTEROCOCCAL URINARY TRACT INFECTION: UA on admission showed
trace leukocytes, 5WBC, few bacteria. The patient has a history
of frequent UTI (likely ___ self-catheterization), although the
patient denied dysuria. She was begun immediately on antibiotic
treatment with vancomycin and ciprofloxacin. Urine culture grew
out >100,000 Enterococcus sensitive to vancomycin, after which
the ciprofloxacin was discontinued and the patient was
maintained on vancomycin until blood cultures from ___ showed
no growth by ___. Prior to discharge, the patient was
transitioned from vancomycin to PO nitrofurantoin, on which she
is discharged and will finish the remainder of a 10-day course
at home. The patient remained afebrile and asymptomatic
throughout her admission.
#ACUTE RENAL INSUFFICIENCY: The patient presented with Crt 2.0
(baseline 1.0), most likely secondary to dehydration, with
possible contribution from post-renal obstruction (patient had
no urine output the day prior to admission). Acute rejection in
the setting of missing 3 doses of immunosuppressants is
possible, but unlikely in this case with rapid response to
intravenous fluid repletion. The patient was maintained on
intravenous fluids until her creatinine returned to near
baseline (1.2) and remained stable, and she was taking adequate
PO fluids. Her creatinine remained at baseline throughout the
remainder of her admission.
#ESRD S/P RENAL TRANSPLANT: The patient missed 3 doses of her
home tacrolimus and Cellcept due to nausea and vomiting. She was
restarted on her immunosuppresant medications upon admission to
the hospital and her tacrolimus levels were trended and followed
by the renal transplant team. Her renal function quickly
returned to baseline with IV fluid repletion. Acute rejection in
the setting of missed immunosuppressants was thought unlikely. A
renal transplant ultrasound on ___ showed no evidence of
obstruction in the graft kidney. The patient's home vitamin D
and calcitriol were continued throughout her admission. She
will need to have her tacrolimus level checked one week after
discharge (___).
#SUPRATHERAPEUTIC INR: On coumadin for antiphospholipid
syndrome. She had an elevated INR of 6.5 (goal 2.5-3.5) on
admission likely due to drug-drug interaction between warfarin
and ciprofloxacin. Her warfarin was held and INR was trended
until it returned to her goal range. It was restarted at 3mg
daily on ___ following an INR of 3.5 the previous day. Her INR
was 1.1 on discharge, and she was instructed to measure her INR
at home daily for the next several days and to communicate the
results to her ___ clinic for further titration of
coumadin. Lovenox bridge was considered, but the patient
reports having been subtherapeutic in the past without any need
for bridge.
#TYPE I DIABETES MELLITUS: The patient was maintained on her
home dose of insulin Glargine (40U QAM and 30U QHS) as well as
her home Humalog sliding scale, with stable daytime FSBGs.
Chronic issues:
#ANTIPHOSPHOLIPID AB SYNDROME with H/O PE: The patient's
warfarin was held due to a supratherapeutic INR as above and
restarted on ___. She will check her INR at home and
communicate results with her ___ clinic as she has
been doing.
#CAD s/p MI: Due to an episode of chest pain during vomiting
before admission, she was ruled out for MI, with EKG only
significant for right axis deviation that was resolving on
follow-up EKG. Her troponin was mildly elevated, peaking at 0.07
in the setting of demand ischemia due to tachycardia on
admission. She remained asymptomatic and was continued on her
home regimen of atorvastatin, metoprolol, and aspirin.
#SCLERODERMA: The patient was maintained on her home dose of
7.5mg prednisone daily with good symptom control.
#HYPERTENSION: The patient remained normotensive to slightly
hypertensive during admission, with systolic blood pressures
ranging 120s - 160, with a one-time asymptomatic SBP of 188,.
She was continued on her home regimen of amlodidpine and
metoprolol. Her home valsartan was held until her Creatinine
returned near baseline and was restarted on ___.
# GOUT: The patient was continued on her home allopurinol.
# PAD: The patient was continued on her home cilostazol 100 mg
every other day.
# DEPRESSION/ANXIETY: The patient was continued on her home
duloxetine and despiramine for depression and Ativan for
anxiety. She was continued on her home trazodone and zolpidem
QHS for sleep.
# HYPOTHYROIDISM: The patient was continued on her home
levothyroxine dose.
# GERD: The patient was continued on her home ranitidine and
Nexium.
Transitional issues:
# FOLLOW-UP:
-Primary care: the patient will be contacted by Dr. ___
office to schedule a follow-up appointment
-Nephrology: the patient will be contacted by Dr. ___
office to schedule a follow-up renal appointment within the next
two weeks
-Endocrinology/diabetes: the patient will follow up with Dr.
___ at the ___ on ___ at 3:30pm
-___: the patient was scheduled to have an appointment
with Dr. ___ the ___ on ___ to plan for a breast biopsy. The patient's admission was
communicated to Dr. ___ the ___ will contact
the patient within a few days of discharge to schedule a new
appointment.
-Blood cultures from admission were pending on discharge | 271 | 1,007 |
19267836-DS-16 | 23,756,220 | Dear Mr. ___,
It was a pleasure to care for you at ___
___.
WHY WERE YOU ADMITTED?
- You were confused and had abdominal pain.
WHAT HAPPENED IN THE HOSPITAL?
- You were treated with lactulose and your confusion improved.
- There was initial concern that you might have a urinary tract
infection, but ultimately we did not find any evidence of
infection, which can cause confusion.
- You were discharged back to your rehab with a new prescription
for lactulose.
WHAT SHOULD YOU DO AT HOME?
- Take your medications as written.
- Go to your follow up appointments as scheduled.
We wish you the best,
Your ___ team | ___ with h/o B cell lymphoma s/p EPOCH and CHOP in remission,
cirrhosis of unknown etiology c/b ascites s/p peritoneal drain,
SBP, esophageal varices, hepatic hydrothorax, non occlusive
portal vein thrombus, HTN, T2DM, CKD not on HD, seizure d/o, who
presented as transfer from OSH with abdominal pain and AMS. | 111 | 51 |
14979074-DS-3 | 21,581,027 | Dear Mr. ___,
You were hospitalized due to symptoms of <> 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:
Possible heart arrhythmia
We are changing your medications as follows:
1. Stop taking Aspirin 81 mg
2. Start taking Eliquis 5 mg Twice a day
Please take your other medications as prescribed.
Please followup 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 | Mr. ___ is a ___ man with a PMH of HLD, thyroid
cancer s/p resection, Tourette syndrome and macular
degeneration, who initially presented to an outside hospital
with the acute onset of RUE weakness and facial droop. On
initial assessment at OSH, exam notable for SBP 200s-220s, NIHSS
4 with right facial and upper extremity weakness. Was given tPA
approximately 1:45 hrs from onset with improvement in proximal
right upper extremity strength by the time of transfer to ___
for post-tPA care.
Pt has risk factors given hyperlipidemia and prior history of
malignancy. No known hx of HTN, although presented with SBP>200.
No hx of atrial#Fo fibrillation in the past. The patient was
admitted to the Neurology Stroke Service for post-TPA management
and further care.
The following issues were managed:
#Neuro: Multiple punctate foci of ischemia
-Given the abrupt onset and multiple areas of ischemia in the
left cortex, the patient was started on eliquis.
-Telemetry monitoring did not show atrial fibrillation, however
likely the patient could have paroxysmal afib and will require
further long-term monitoring.
-Other stroke risk factors were also assessed, LDL was within
normal limits . HbA1C was also 5.4. No significant
atherosclerosis was noted, however patient was found to have a
left fetal PCA on imaging.
-Patient recovered well s/p TPA and was cleared by ___ to return
home with outpatient ___ services.
#Neuro: Focal Motor Status Epilepticus
-During the patient's hospitalization, the patient was noted to
have developed sudden onset right facial and arm twitching that
lasted 12 minutes consistent with focal motor status epilepticus
likely due to cortical irritation in the area where patient had
ischemic injury.
-The patient was loaded with IV keppra and put on a maintenance
dose of this medication of PO 750mg BID. Since this episode, the
patient did not have any further events.
-The patient also had a routine EEG obtained to have for
baseline purposes s/p his ischemic injury.
#Pulmonary:
-Patient noted to at times desaturated overnight during deep
sleep with spontaneous recovery. The patient could also have an
underlying sleep apnea or sleep disorder which can be evaluated
in the outpatient with a sleep study.
#ID: Urinary Tract Infection:
-On Urinalysis testing, patient noted to have leukocyturia and
hematuria. He was placed on IV Ceftriaxone with a goal of
treatment for UTI with antibiotics for 7 days total (until
___.
-The patient remained aefebrile during the hospitalization.
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?
() Yes - () No
4. LDL documented? (X) Yes (LDL = 73) - () 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 - (X)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 (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? () Yes - (X) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X Yes [Type: ()
Antiplatelet - (X Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X Yes - () No - () N/A
Transitions of Care Issues:
1. Stroke follow-up appointment is scheduled for this patient.
2. In addition, patient will be sent home with ___
monitor to look for evidence of afib.
3. Patient was started on eliquis
4. Patient's TSH was measured to be high and the T3 was noted to
be low. Patient should have repeat testing to elucidate the
interpretation of thyroid function tests. | 268 | 672 |
11160857-DS-5 | 21,968,947 | Dear Ms ___,
You were admitted with episodes of difficulty walking as well as
an abnormal finding on head imaging. We did a test on you called
the ___ Hall Pike Maneuver which was positive and recreated your
symptoms. Because of this, we feel that you have a condition
called BPPV or Benign paroxysmal positional vertigo. We asked
our physical therapists to evaluate you and show you some
exercises to help reduced these sensations.
Prior to your arrival at ___, you had a head CT which showed a
mass that was consistent with a benign brain tumor called a
meningioma. Because of your history of breast cancer, we sent
you to the MRI to characterize this mass more and confirmed that
it is consistent with a meningioma. This mass is not responsible
for any of your symptoms.
If you have any additional episodes of room spinning, please
perform the maneuvers provided by the physical therapist. We
have also ordered home ___ for you as well.
You do not need to follow up with neurology for this condition.
Please call your PCP to schedule ___ follow up appointment in ___
weeks. | ___ right handed female with h/o breast cancer s/p right
mastectomy (___), hypothyroidism, with incidental mass on CT
who presents with intermittent unsteadiness x5d. CT mass
suspicious for meningioma given that it is well circumscribed
and there is no visible edema on CT. MRI was ordered which
confirm this as well as no evidence of infarct. After admission
to the neurology service, ___ Hall Pike Maneuver was performed
and was positive to the right consistent with a diagnosis of
benign paroxysmal positional vertigo. Physical therapy was
consulted and performed vestibular physical therapy with relief
some of her symptoms. They recommended discharge home with home
physical therapy services. She was instructed to call her PCP to
schedule ___ follow up appointment in ___ weeks. | 191 | 124 |
10751641-DS-27 | 22,347,408 | Dear Ms. ___,
It was a pleasure of taking care of you at ___!
You were here because you were having left chest pain and arm
pain.
While you were here, you were given medications in your IV to
help get extra fluid off. This was changed to a pill prior to
leaving the hospital. You also had your blood pressure
medication increased because your blood pressure was elevated.
When you leave, make sure to take your medications as
prescribed. Also you should attend all of your follow-up
appointments as listed below. Weigh yourself every morning, call
MD if weight goes up more than 3 lbs in 1 day or 5 lbs in 3
days. Your weight on discharge is 174 lbs.
If you have anymore chest pain, shortness of breath, or
palpitations, please seek medical care immediately.
We wish you the best!
Your ___ Care Team | Ms. ___ is a ___ year old female with history of CAD s/p
multiple stents, HFpEF, PVD, CKD, DMII, HTN, and HLD who
presents with substernal chest pressure found to have mild
troponin elevation without EKG changes iso CKD concerning for
unstable angina vs. NSTEMI. Patient remained chest pain free
while in house. She was diuresed due to volume overload and had
uptitration of coreg and losartan due to hypertension. She was
discharged on a diuretic regimen of furosemide 40mg daily.
ACUTE ISSUES:
==============
# ?Unstable Angina
# Known Coronary Artery Disease
# Chest pain
Patient presents with substernal chest pressure radiating to her
left arm and back that occurred while ambulating to her house.
Pain resolved after 3 doses of NG with symptoms concerning for
angina. Troponin on admission mildly elevated to 0.02 in the
setting of CKD, but EKG reassuringly without STE or depressions
and patient was without chest pain on arrival to ER. She has a
known history of significant coronary artery disease with
multiple stents.
Recent dobutamine stress in ___ without evidence of
inducible ischemia. Suspect pain was secondary to volume
overload and hypertension. Per patient, she would not like to
undergo cath due to risk of kidney injury in the setting of
contrast. She was monitored on telemetry and continued on home
Aspirin 81mg daily and pravastatin 80mg daily. Her carvedilol
was increased to 25mg BID for antianginal effects and blood
pressure control. Her home losartan was increased to 50mg BID
for blood pressure control. She also continued on her home
ranexa.
#HFpEF:
#LVOT obstruction
LVEF >55% on last TTE. Appeareded volume overloaded with
elevated JVP and 2+ pedal edema to knees on admission. Not on
daily diurectics at home due to worsening renal function. Due to
an inducible LVOT gradient on her ___ stress test, careful
diuresis was done to avoid detrimental preload reduction. She
was diuresed with lasix 20mg IV daily or BID. When euvolemic,
she was switched to 40mg daily. She was continued on home
losartan. Her coreg was increased as above. Her losartan was
also increased.
#HTN:
Patient continued to have elevated SBPs while in house with SBP
values of 150-180s. Her coreg was increased and her home
losartan was increased. Her home amlodipine 10mg was continued.
#Normocytic Anemia: Likely anemia of chronic disease. No current
signs or symptoms of bleeding. Will require further follow-up
with out-patient provider | 141 | 387 |
13752571-DS-14 | 27,634,980 | Mr. ___,
You were admitted for your abnormal heart rhythm. This was
improved with intravenous and oral medicine. We imaged your
heart which did not show any abnormalities. We also started you
back on a lower dose of your ___ medicine. Please
follow up in Health Care Associates Episodic in the next week
for a blood pressure check. You can make an appointment at
___.
You were also noted to have weight loss and a hoarse voice. We
deemed that this should be worked up on an outpatient basis with
your primary care doctor. Please make an appointment with your
primary care doctor within the next ___ weeks. Dr ___ be
reached at ___. | Mr. ___ is a ___ with hypertension, diabetes mellitus,
rheumatoid arthritis, remote H/O documented atrial fibrillation
in ___, presented with palpitations and was found to be in
atrial fibrillation with a rapid ventricular rate that converted
after initial attempts at rate control with diltiazem.
# Atrial fibrillation: Per ED report, ventricular rate to 170s
on presentation. He received diltiazem 10 mg IV x3 and diltiazem
30 mg po x 2 and 3 L IVF in ED. Upon transfer to floor, he was
in NSR at ___ with stable BP and no longer feeling palpitations.
TSH normal. Possible triggers included hypovolemia and
electrolyte shifts from diarrhea, decreased appetite and PO
intake (discussed below). ___ seemed unlikely (afebrile,
no leukocytosis). CHADS2 = 2. CHADS2VASC = 3. Patient has
history of GI bleed as well as H/O syncope/falls and
subarachnoid hemorrhage. ___ = 3. Given this,
anticoagulation was deferred. He was started on metoprolol 25 mg
q6 hours and transitioned to metoprolol succinate. Lisinopril
was decreased (after initial discontinuation) to allow for BP
toleration of metoprolol. TTE revealed normal EF.
# Diarrhea: Possibly causing hypovolemia and electrolyte shifts,
triggering his episode of atrial fibrillation. Stool O+P and
stool culture were negative.
# Weight loss and decreased appetite: Given smoking history, his
recent voice change, 8 lb weight loss in the past few months,
decreased appetite and PO intake were concerning for malignancy.
CXR without any nodules. Patient has declined colonoscopy
several times due to not having a ride. This could be
contributing to hypovolemia and AF discussed above.
# Hypertension: Hypotensive in setting of metoprolol and
lisinopril. Discontinued home lisinopril initially and resumed
at lower dose as above.
# Type 2 Diabetes mellitus: Last HbA1c in ___ was 5.8%. Not
currently on any agents per patient. He did not require insulin
during this admission.
# RA: Continued Leflunomide 20 mg and acetaminophen prn.
# BPH: Continued home Doxazosin 4 mg QHS
TRANSITIONAL ISSUES:
[ ] New medication: Metoprolol 50 mg extended release daily.
[ ] Continue to encourage colonoscopy.
[ ] Consider further workup as outpatient, e.g., lung CT.
[ ] Consider ENT referral as outpatient.
[ ] Patient reports that he would like to be DNR/DNI, however
has not discussed this in the past with any providers.
Exploration of patient's values/goals should be continued with
___ provider as outpatient, especially if malignancy
workup is pursued.
[ ] Monitor for diarrheal symptoms.
[ ] Will require BP check and assessment of renal function and
electrolytes at ___ Episodic Visit given that lisinopril was
started at half of home dose (5 mg instead of 10 mg). Will also
require PCP follow up for similar issues in ___ weeks.
# CODE: Do not resuscitate (DNR/DNI). Patient says he would not
want measures to "bring him back." This includes intubation and
resuscitation, even if felt to be temporary.
# CONTACT/HCP: ___ | 112 | 461 |
12161387-DS-13 | 26,988,375 | Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you had a fever, a
low white blood cell count, and diarrhea.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had a test that showed you had a C difficile infection.
- You received IV and oral antibiotics to treat your C difficile
colitis.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Please take all of your medications as prescribed and go to
your follow up appointments with your doctors ___ below)
- Please get laboratory work on ___.
- Seek medical attention if you have new or concerning symptoms
or you develop.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team | PATIENT SUMMARY
==============
Ms. ___ is a ___ woman with hx acute liver failure ___
acetaminophen overdose s/p DDLT (___) c/b delayed abdominal
closure, sigmoid ulceration, renal failure requiring RRT,
recently admitted for GI bleed, who presented with fever,
headache, diarrhea, neutropenia, and metabolic acidosis and was
found to have C diff colitis. She is s/p 10 days of inpatient
treatment, with improvement of symptoms. Immunosuppressive meds
were also adjusted during her stay.
ACUTE ISSUES:
=============
# Neutropenic fever
# Diarrhea
# C. difficile colitis
C. diff PCR and toxin assay positive on admission. CT showed
pancolitis. Absolute neutrophil count ~1000. Course also
complicated by BRBPR which likely reflected irritation of known
sigmoid ulcer in setting of c. diff colitis and known
hemorrhoids. CRP elevated 167, which downtrended to 30 after
treatment with IV Flagyl and PO/PR Vancomycin. Blood and urine
cultures, UA without growth.
#RUQ vs. Right chest wall pain
Patient with ongoing pain ill-described of R chest wall/ RUQ.
Elevated alk phos but otherwise LFTs wnl. Hx of PE and on
apixiban. Sometimes described reproducible pain with palpation
of chest wall. CXR without evidence fracture. RUQUS without PVT.
Initially concerning for hepatic artery stenosis, but CTA
abdomen was not concerning. Increased hepatic artery velocities
likely ___ R hepatic pseudoaneurysm vs aberrant L hepatic
anatomy, but thought to be clinically insignificant per
radiology. Suspect diaphragmatic irritation secondary to
colitis, improved with treatment of c diff.
#Non-anion gap metabolic acidosis
Most likely secondary to bicarbonate losses in the setting of
severe diarrhea from C. difficile colitis. Improved with
treatment of c. diff.
___ on CKD
Post transplant course c/b ___, renal failure with brief HD
requirement. Cr 2.5 on admission, up from 1.9 on recent
discharge now down to 1.8. Most likely pre-renal in setting of
diarrhea/decreased PO intake and now improving.
#R foot pain
Currently being worked up as outpatient, had EMG ___.
Decreased gabapentin dosing for renal function.
CHRONIC ISSUES:
===============
#H/o fulminant liver failure ___ APAP OD s/p DDLT ___
CMV negative donor/recipient. Course c/b sigmoid ulceration and
renal failure. Azathioprine was recently discontinued during
last
admission due to leukopenia. Decreased tacrolimus to 4 mg Q12H,
then to 3.5 mg Q12H on discharge. Continue Bactrim SS daily,
valganciclovir 450 q48h.
#Hx of PE: Continued apixaban 5mg BID.
#HTN: Stopped home carvedilol while infected, then restarted at
a lower dose.
#GERD: Continued home pantoprazole.
#MDD/Anxiety
s/p multiple suicide attempts, most recently ___. Continued
home mirtazapine, hydroxyzine, venlafaxine. Decreased gabapentin
per renal dosing.
TRANSITIONAL ISSUES:
====================
#Immunosuppresion
#S/p DDLT ___
[] Monitor tacro level (decreased to 3.5 at discharge)
[] Monitor neutropenia with weekly CBC.
[] Increased valgancyclovir to 450mg daily per creatinine
clearance.
#C difficile colitis
[] Consider probiotics to prevent recurrence
#Known sigmoid ulcer
[] Plan for repeat colonoscopy after stable resolution of c.
diff colitis
#Stable right pleural effusion:
[] Noted on imaging since ___. TTE with normal cardiac
function. Did not pursue thoracentesis this admission as
effusion stable, patient was asymptomatic and would require
stopping anticoagulation with apixaban.
#HTN:
[] Restarted carvedilol at a lower dose s/p resolution of
infection. Uptitrate prn.
# CODE: FULL confirmed
# CONTACT: ___ son ___ ___ | 149 | 509 |
11629754-DS-23 | 27,500,455 | Dear Ms. ___,
You came to us with a temperature and with feelings of maliase
and fatigue most likely from a viral illness. Your symptoms
improved with supportive care. We did a paracentesis which did
not show any signs of infection. Your symptoms improved during
the course of this hospital stay. Unfortuantely on the day of
your discharge your dobhoff tube became clogged. We spoke to
Dr. ___ reocmmended taking out your feeding tube and
monitoring you on oral feeding. Please follow up with your PCP
and Dr. ___ further care. | ASSESSMENT AND PLAN
___ yo F w/PMH significant for alcoholic cirrhosis and previous
Roux-en-Y gastric bypass presents with fever.
# Fever: Most likely infectious source is upper respiratory
tract infection vs. SBP secondary to paracentesis. Received
vanc/cef in ED, narrowed to ceftriaxone overnight on night of
admission.
Viral panel was negative. We started ceftriaxone at 2g daily. ___
guided diagnostic para on ___ showed 525 WBC, 9 Polys, at which
point we decided to treat for SBP for 5 days with oral
Ciprofloxacin.
Her dobbhoff became clogged. We were unsuccessful at unclogging.
Pt needs placed under MAC. Pt made follow up for replacement. | 94 | 107 |
13621284-DS-15 | 23,637,525 | You were hospitalized with a GI bleed resulting from gastric
ulcers and inflammation of your duodenum. You should avoid all
NSAID medications and also avoid alcohol use. You will now be
treated for H. Pylori infection. You are recommended to have a
repeat endoscopy to evaluate these ulcers and look for healing.
You are also being treated for possible pneumonia vs. aspiration
pneumonitis. The antibiotics that treat h. pylori infection are
also effective at treating pneumonia. Please take these
medications as instructed and take with food to avoid nausea.
You are also on an antacid.
Take the prevpac that has the 2 antibiotics and the antacid for
2 weeks to treat the h.pylori. Then you should take the
protonix twice a day as instructed following the completion of
the prevpac.
You should also talk with your PCP about evaluation for fatty
liver disease. | ___ y/o M history of HTN, HLD presents with hypotension and
shortness of breath, with initial concern for PE given recent
travel. However d-dimer and CTA were negative. Patient
ultimately found to have anemia and UGI bleed and transferred to
___.
.
# GIB: Pt presented with tachycardia, lethargy, found to have
melena on rectal exam and coffee grounds on NG lavage (not
clearing with 400cc). Denies n/v/epigastric pain. Denies
significant NSAID use or hx of ulcers, gastritis. Endorses some
EtOH use s/p trip to ___ but no h/o ETOH abuse. HCT 35 on
admission, down from ___ HCT of 49.5. Repeat HCT was 22.2. got
5uprbc. No known cirrhosis or varices. Imaging here documented
fatty liver but no cirrhosis. [patient was electively intubated
for egd due to episodes of apnea. intubated ___, extubated ___
w/o events] Patient undewent EGD on endoscopy showed dried blood
mixed with food in stomach, couldn't visualize well. on ___
underwent repeat EGD which showed stomach ulcer with "cherry red
spot" that was clipped x2, likely source of bleeding, also had
some smaller erosions. Patient will need f/u with GI as well as
repeat EGD in ___ weeks.
Patient HCT were trended and remained stable. On day of transfer
out of ICU HCT was 31. Patient's diet was advanced to clears on
___ and tolerated well. His H pylori serology was POSITIVE.
Since is currently on levofloxacin for possible pneumonia, he
can start a course of triple therapy for H. Pylori once he is
done with a course of levofloxacin. He remained on a protonix
drip for 72h to end on ___ and then transition to high dose
oral BID PPI. It will be important to document a treatment cure
for h. pylori during his future endoscopy because of the
presence of significant PUD.
He will be discharged on a prevpac
(lansoprazole/clarithromycin/amoxicillin) to take for 14d and
then take a BID PPI after completion.
# FEVER/Respiratory Distress requiring intubation and mechanical
ventillation after first EGD
Patient with fever to 102.9 on day of admission with
non-specific respiratory symptoms. His initial CXR not
suggestive of PNA. Patient at the time was hypotensive with
concern for sepsis so he was started on vanc/levoflox/flagyl.
Antibiotics were then narrowed to levofloxacin for ?CAP.
Following procedure patient developed productive cough and nasal
congestion with cxr note of bibasilar opacities suggesive of
?aspiration event given recent intubation. Upon arriving to the
medical floor he had a lower grade fever to 100.2, but no signs
of ongoing sepsis. The GI team reported copious purulent nasal
secretions at the time of his second endoscopy raising the
possibility of sinusitis. His fever curve continued to decline.
He will be discharged on clarithromycin/amoxicillin to treat
his H.Pylori and these antibiotics also have good coverage for
community acquired pneumonia organisms.
# Hyperglycemia: Patient was hyperglycemic on presentation,
possibly due to stress response. A1C of 6.2
# Seizure/Loss of Consciousness - on arrival to FICU pt
experienced a short episode of seizure activity, followed by
confusion. Denies history of seizure disorder. Received 1mg
ativan. No further episodes since. ___ have been related to
metabolic disturbances. Unlikely withdrawal seizure, as patient
has not been scoring on CIWA. No further seizure activity.
# ?Alcohol Abuse: Pt endorses ___ glasses of wine a night,
though this value changes with different encounters with various
medical providers. Recent trip to ___ but denies drinking
to excess at that time. Pt with documented hx of alcohol use on
Atrius records but no clear documentation of abuse.
# ___: Cr 1.1 at presentation (baseline 0.8). Improved to
baseline with fluid resuscitation.
.
# Fatty liver - seen on CT. c/f diabetes or could be ___ alcohol
use vs metabolic syndrome given A1c 6.2. Does not appear to have
progressed to cirrhosis. ALT mildly elevated, AST wnl. Alk phos
mildly elevated. No RUQ symptoms, no vomiting or pain. No
abdominal pain or tenderness. Recommend outpatient followup.
Plan At discharge
--clarithromycin/amoxicillin for possible pneumonia
--nasal saline rinse
--clarithromycin/amoxicillin/omeprazole x2 weeks for h. pylori
--arrange outpatient GI followup for repeat endoscopy | 147 | 678 |
10063856-DS-12 | 22,345,354 | You were admitted with low blood pressure and low heart rates.
You were found to have recurrent c. diff and are being treated
with Vancomycin by mouth. Your blood pressure improved and you
had no further episodes of dizziness. | ___ yo female with a history of metastatic lung cancer s/p cycle
4 premetrexed/carboplatin who is admitted with bradycardia and
hypotension.
Concern for UTI: U/A at ___ concerning for UTI with
___ WBC, ___ RBC, 0 Epis, 2 + bacteria, moderate ___, -
nitrites but culture growing mixed bacteria consistent with
contamination. U/a and culture here negative. She was initially
put on ceftriaxone which was discontinued.
C. Diff: C. diff positive with some increased watery ostomy
output. Started on PO vancomycin for 14 day course.
Hypotension: possibly due to infection, adrenal insufficiency or
dehydration. Her baseline systolic blood pressures in clinic
appears to be 100-120. She did not appear significantly
hypovolemic on examination and infection overall did not appear
severe enough to be causing this degree of hypotension. She was
placed on stress dose steroids with hydrocortisone with
improvement in her blood pressure. She was transitioned back to
her home dose of decadron prior to discharge. BP's on day of
discharge 120's systolic.
Bradycardia: she has chronic sinus bradycardia for years, no
changes on ECG, no evidence of conduction disease on telemetry
or ECG. She does report increased falls and ? syncopal episode
at home. Her bradycardia may be contributing but she is not
interested in an intervention such as a pacemaker. TSH normal.
Chest pressure: Atypical chest pressure since she fell, likely
musculoskeletal (reproducible on exam), no ischemic ECG changes,
troponin negative and resolved. Could also be due to lung mets.
Thrush
Continued home clotrimazole.
Metastatic Lung Cancer
S/p cycle 4 premetrexed/carboplatin ___. She is finished
with carboplatin, per oncology plan to continue with maintenance
premetrexed. Continued home atovaquone, dronabinol, folic acid,
keppra, ativan, omeprazole, pampazine, and trazadone.
FEN:
Regular diet
PAIN: Continued home oxycontin at night and PRN ultram. | 41 | 290 |
18367977-DS-9 | 26,415,206 | Dear ___,
You were admitted to the hospital because you had trouble
breathing due to your heart failure. This may have occurred
because you had a urinary tract infection. You were given
antibiotics for the infection and intravenous medicines to help
remove the fluid. Medications were adjusted. You were able to
come off the oxygen. Once your volume appeared to be normal, you
underwent right heart catheterization with showed slightly high
pressures on both left and right sides of your heart.
Please limit your salt intake and avoid eating salty foods.
Continue to weight yourself every morning. Your weight at
discharge is 73.7 kg (162 lbs). It is very important to call
your doctor if your weight goes up by more than 3 lbs in one day
or five pounds in one week to avoid needing to be admitted to
the hospital again.
It was a pleasure taking care of you during your stay in the
hospital.
- Your ___ Team | ___ y/o F w/hx CAD s/p MI and s/p CABG ___ ago, HTN, HLD, DM,
and CHF with preserved EF presenting with CHF exacerbation in
setting of hypertension and diet indiscretion.
# Acute on Chronic Diastolic Heart Failure: Previous TTE in
___ with EF > 75%. proBNP elevated to 1610 on admission.
Potential triggers include patient's reported dietary
indiscretion, hypertension to 180s on arrival, and UTI (see
below). No known history of CAD and CMs negative. She was
diuresed with Lasix drip and boluses. When euvolemic she
underwent R heart cath which showed moderate pulmonary
hypertension and mildly elevated right/left sided filling
pressures with preserved cardiac output. She was continued on
imdur and amlodipine as below. Carvedilol was decreased to 12.5
mg bid.
# Hypertension: Continued home imdur and amlodipine. Carvedilol
was decreased to 12.5 mg bid from 25 mg bid given heart failure.
As patient remained hypertensive in house hydralazine was added
and dose uptitrated.
# Complicated urinary tract infection: Urine culture on
admission grew E. coli and Klebsiella. She denied symptoms.
Given DM2 she was treated for complicated UTI with ceftriaxone
and transitioned to ciprofloxacin to complete ___AD s/p MI and CABG: Patient had ___ persantine stress which
showed no large WMAs. Patient has had no recent chest pain and
troponins negative. She was continued on home ASA, imdur, and
carvedilol. Simvastatin was changed to atorvastatin given that
simvastatin is contraindicated with amlodipine.
# CKD: Cr 1.8 on admission (baseline Cr 1.7-2.0). No further
action was required.
# Diabetes Type II: Contineud on glargine and Humalog sliding
scale. Doses adjusted as needed.
# Hyperlipidemia: Home simvastatin was changed to atorvastatin
given concern for contraindication of simvastatin with
amlodipine.
# Gout: Continued home allopurinol
#GERD: Continued home omeprazole 40mg
# Glaucoma: Continued home eye drops
# CODE: Full Code
# CONTACT: ___ (brother) ___ (home),
___ (cell) | 157 | 297 |
15918560-DS-4 | 25,742,795 | Dear Ms. ___,
It was a pleasure caring for you here at ___.
What happened while you were admitted?
- You were admitted to ___ because you were having weight loss
and difficulty eating. You were found to have decompensation in
your liver cirrhosis likely due to infection and recent alcohol
use.
- You were very sick in the ICU. You were on multiple
antibiotics and at one point required resuscitation and
mechanical ventilation.
- You had difficulty breathing and were found to have fluid
accumulating in your right lower lung fields near you liver. You
were seen by the interventional pulmonary team who placed a
chest tube to drain the fluid. You had improvement, although the
fluid started to accumulate again and you had difficulty
breathing. We also increased your diuretic medications to help
eliminate this fluid. You required more oxygen and were
transfused to the ICU for further care.
- Despite antibiotics, another catheter placed for your fluid,
you got very sick. After transferring out of the ICU, you
improved significantly.
- You were treated for pneumonia.
- On discharge, you were sent to ___ for continued care
What to do after discharge?
- Follow up with your hepatologist and primary care doctor.
- You will be discharged to rehab to get stronger.
- Please refrain from consuming any alcohol. Your liver is still
very sick and even a little bit can be life threatening.
We are happy to see you feeling better. We are wishing you all
the best.
Sincerely,
Your ___ team | ___ woman with decompensated EtOH cirrhosis who
initially presented to ___ on ___ with fatigue, and was found
to have new ascites/hydrothorax and a UTI. Patient has had a
long complicated hospital course, has been transferred twice to
the ICU for hypoxemic respiratory failure, most recently on
___ when she then developed hypotension in the setting of
bleeding esophageal varices. She underwent TIPS w/banding on
___, without further episodes of GI bleeding. During this MICU
stay, she also developed an enterococcus UTI which was treated
with linezolid. She continued to be febrile and hypotensive even
after a full treatment course, and in this setting received
further broad spectrum antibiotics and antifungals. A family
meeting was held, and the decision was made to focus on comfort
measures only. Antibiotics were therefore stopped, and when this
happened her fevers also stopped and her mental status improved.
Infectious work-up, including pleural fluid and ascitic fluid,
remains negative. She continued to have ongoing large hepatic
hydrothorax, requiring frequent thoracentesis and at one point a
chest tube was placed. However given the large volume output and
subsequent fluid/hemodynamic shifts as well as the rapid
reaccumulation of fluid, the chest tube was removed and she was
aggressively diuresed with Lasix gtt, spironolactone,
torsemide/metolazone with improvement. Given ongoing hypoxemia,
repeat chest xray was done which showed improvement of
hydrothorax but also revealed a consolidation consistent with
HAP. Patient was treated with HAP coverage with resolution of
oxygen requirement. After a palliative consult, patient made it
clear she wanted everything to be done so she could go home
healthy and see her family/new grandson. Patient was discharged
to an LTAC.
#CAP: presented with CAP on CXR, treated with CTX, azithro until
___.
#Fever: Patient had temperature of 100.8 on ___. Urine thought
to be most likely source given weakly positive UA and patient
was empirically covered with linezolid given h/o VRE; when urine
culture returns her LTAC will be contacted to narrow her
antibiotics.
#HAP
#Respiratory Distress/Tachypnea/R Pleural Effusion/Pneumonia
Patient initially transferred to the MICU for tachypnea and
hypoxemia. Found to have an acute increase in R sided pleural
effusion concerning for recurrent hepatic hydrothorax with
evidence of acute pulmonary edema. She had negative CTA, and TTE
was without intrapulmonary shunting. She was diuresed
aggressively with and started on duonebs and albuterol along
with levofloxacin with improvement in her oxygenation. On ___
- TIPS upsize was performed by ___ with further diuresis w/ Lasix
and metolazone with further improvement in her respiratory
status. She was subsequently transferred out of the ICU to the
floor, where she continued to be hypoxemic. CXR showed worsening
right hydrothorax so patient had several thoracentesis done to
help alleviate this. Once improved, patient continued to be
hypexoemic. Repeat CXR showed forming consolication consistent
with HAP. Patient was treated with vanc and ceftax for 8 days.
Oxygen requirement resolved.
# E. Coli UTI: UCx grew E. Coli sensitive to CTX. She was
treated with CTX from ___ to ___.
#Alcoholic cirrhosis/hepatitis w/ grade 2 varices and
encephalopathy:
Continued home FoLIC Acid, rifaxamin, lactulose, spironolactone;
held nadolol briefly while in the ICU.
# Hyponatremia: Patient had an acute decrease in sodium with a
nadir of 126. This was thought to be a combination of diuretic
effect and SIADH in the setting of her lung disease. She was
placed on a fluid restriction with some improvement in her
sodium. She was discharged on a 1.2L fluid restriction with a
sodium of 130.
#Weight loss/poor nutrition/Refeeding: Started on tubefeeds with
nutrition following.
#Anemia Hb slightly down from baseline on admission, drop in H/H
with hematemesis on ___ with multiple transfusions of PRBC, on
endoscopy bleeding esophageal varices s/p TIPS and banding on
___. No further bleeding. Discharge H/H: 7.6/22.9
___: Renal consulted, attributed to over diuresis. Patient was
kept even and ___ resolved. On discharge, Cr: 0.7
CHRONIC:
# History of alcohol abuse: Although patient denying alcohol
use, family is concerned about her alcohol use. Her current
presentation was consistent with alcohol use. She was counseled
extensively about the importance of stopping alcohol use and
enrolling in relapse prevention as outpatient.
#Electrolyte abnormalities
#Refeeding sydnrome: Hyponatremia, hypomagnesaemia,
hypocalcemia, hypophosphatemia, and hypokalemia likely
nutritional given poor PO intake. Consistent with starvation
ketosis on admission, which is now improved although developed
refeeding syndrome after starting tube feeds which required
aggressive electrolyte repletion.
#Anxiety/depression. The patient is followed by Dr. ___
___. She was continued on home remeron and clonazepam. She also
received lorazepam PRN.
#History of asthma, chronic bronchitis: She received duoneb and
albuterol treatments. She was also placed on advair for
controller medication. | 245 | 764 |
18256203-DS-2 | 24,369,954 | Mr ___,
It was a pleasure taking care of you at ___. As you know, you
were admitted after a significant care accident for observation
to ensure that you were ok. Fortunately you did not seem to
suffer any significant injury and had only bruises. You will
need to follow up with your primary care doctor on discharge.
For the area of bruising/swelling inside your mouth, we would
like you to call the ear, nose, and throat doctors to ___ a
follow up appointment. | ___ PMH of Afib (s/p PPM placed in ___, on coumadin), HTN, who
presented s/p motor vehicle accident of unclear circumstances,
had a negative trauma workup, but was admitted for observation
and evaluation of chest pain, which was thought to be mostly
musculoskeletal who was discharged with appropriate follow up
#Motor Vehicle Accident
Circumstances are unclear as patient is unable to provide
clarity as to what led his car to flip over causing airbags to
deploy. Denies mechanical dysfunction of car or hitting an
object. Patient denied LOC and noted that he recalls entire
incident. Patient was seen by trauma surgery in ED, and had CT
C-Spine, Head, Torso which was negative for acute injury.
However, had chest pain and was admitted to medicine service.
Patient ambulated with nurse the night after the incident, and
strength/balance was found to be normal. Pain on right chest
wall was felt to be musculoskeletal.
#Chest Pain
Presented with two sources of mild chest pain: substernal and on
lateral aspect of R ribcage. ACS workup negative as troponin
were negative x3. EKG was difficult to interpret as was paced,
and interrogation of pacer showed no abnormalities. TTE
performed which showed mild AS/AR, moderate LVH, normal LV
regional/global systolic function, mild RV dilation, mild global
RV systolic hypokinesis, trivial pericardial effusion, no clear
evidence of cardiac trauma. Fortunately, sub-sternal chest pain
resolved with time, however, patient warrants consideration of
outpatient stress test or repeat TTE to trend findings, as he
noted that he had similar pain 2 months ago. As for right sided
chest pain, it was reproducible with palpation, felt to be ___
airbag trauma, and was given a lidocaine patch for it.
#HTN
During hospitalization patient was noted to have HTN to 190 most
likely ___ withholding medications in setting of trauma.
Patient's BP improved with restarting home regimen.
#AFib
Coumadin was continued at home dose of 5mg daily during
hospitalization. INR 1.9 on discharge, and patient needs repeat
INR checked on ___ by ___
#Oral lesion
Patient was found to have ~1.5 cm raised purple lesion on hard
palate which he noticed after the accident. Was felt to be
possibly ___ trauma from dentures being forced backward by
airbag. Speech and swallow performed bedside exam and patient
was able to swallow normally. He was rec'd to follow up with ENT
in 2 weeks to ensure that it has resolved, or for further
evaluation if it persists. | 83 | 394 |
13793264-DS-19 | 24,492,751 | Dear Mr. ___,
What brought you into the hospital?
-You came into the hospital with weakness
What happened while you were here?
-We took pictures of your back and it showed a mass in your
spine
-This mass was removed by our orthopedic spine doctors
-___ weakness improved
___ should you do when you leave the hospital?
-You should continue to try and get strong at rehab
-We made some changes to your medicines that you can see below
It was a pleasure taking care of your Mr. ___!
Best,
Your ___ Team | SUMMARY STATEMENT
=================
___ male history of intellectual disability, diabetes
mellitus, papillary urothelial renal cancer status post partial
nephrectomy, transitional cell carcinoma s/p resection of
bladder tumor, ESRD on ___ who presented with days ___ weeks
of worsening back pain and difficulty w/ambulation found to have
osseous lesion in the posterior aspect of the T7 vertebral body
with associated epidural mass from mid T6 through mid T8 levels,
with spinal cord compression
at T7 and associated spinal cord edema from T6 through T8.
Underwent ___ guided biopsy on ___ which was non-revealing.
He underwent embolization of the mass followed by T6-T8
laminectomy w/ tumor resection on ___.
Pathology of the mass returned shortly before discharge as
papillary hemangioma. The final report is still pending.
ACUTE ISSUES
============
#T7 vertebral body mass
#Spinal cord compression
Patient presented with symptoms of cord compression with nearly
1 month of lower extremity weakness (R>L) and urinary retention
with evidence T7 bony lesion and new extra medullary extradural
mass extending from T6-T8 on MRI w/ evidence of cord
compression. Given the patient's history of malignancy, we were
concerned that this mass may represent metastatic transitional
cell carcinoma. Ortho spine and radiation oncology were
consulted. Before treatment, it was decided that pt have biopsy
to determine etiology. He underwent ___ biopsy on ___ w/o
evidence of tumor on path (nondiagnostic). Patient underwent
embolization of the mass prior to resection with neurosurgery.
He then underwent T6-T8 laminectomy w/ tumor resection on ___
(ortho spine). Tumor was noted to be very vascular. Imaging
studies conducted included (1) CT chest/abd/pelvis w/o evidence
of metastatic disease, (2) MRI brain w/ 7mm dural based L
occipital mass, c/f meningioma but cannot r/o metastatic
disease. After surgical resection of the mass, pt had improved
___ weakness on exam ___ bilaterally on exam). He
received dexamethasone while waiting surgical resection and
several days days post-op (___). No evidence of urinary
retention after surgery. ___ post op plain films were without
acute change. Neuro oncology/neurology was also consulted given
MRI findings and have recommended follow up as an outpatient
with repeat imaging. Radiation oncology is planning for
potential radiation therapy ___ weeks after surgery. Weakness
significantly improved at discharge.
Pathology of the mass returned shortly before discharge as
papillary hemangioma. The final report is still pending.
#Post op pain
Pt had back pain in the setting of known vertebral lesion and
and T6-T8 laminectomy ___. Pain is worse when dependent on
incision site. Incision site looks c/d/i, though he is quite
tender under dressing on exam. He has been receiving Tylenol 1g
TID with good effect. Post-op he has been receiving OxyCODONE
5mg PO PRN (asking for ___ doses per day). He also has a
lidocaine 5% Patch.
#Sacral wound
Was being followed outpatient in group home. Has two stage 3
pressure ulcers. Wound care team has been following patient
with recommendations of:
-Commercial wound cleanser or normal saline to cleanse
wounds.
-Pat the tissue dry with dry gauze.
-Apply protective barrier wipe to periwound tissue and air
dry.
-Apply Duoderm gel to yellow wound bed
-Apply Sacral Mepilex to cover both sites
-Change dressing q 3 days
CHRONIC ISSUES
=================
#ESRD
HD MWF. HD MWF. Patient initially underwent extra sessions of
dialysis given need for MRI with contrast. Access: RUE AVF. His
sevelamer was increased from 800 mg TID to ___ mg TID w/meals
given persistently elevated phos. Due to hypercalcemia, his
vitamin D and calcitriol were held. He was continued on
cinacalcet and nephrocaps. Diet was renal. EPO was held as we
were concerned for malignancy.
#Hypercalcemia
Elevated PTH, calcium and phos consistent with tertiary
hyperparathyroidism given ESRD. VItamin D supplementation and
calcitriol were stopped during this hospitalization.
#Anemia: Likely secondary to ESRD. Hgb very slowly
down-trending. We held EPO given concern for malignancy. ___ be
able to resume EPO pending final path. Received mircera 150 mcg
on ___.
#Urothelial cell (transitional cell) carcinoma of the bladder
s/p TURBT
#Urothelial cell (transitional cell) carcinoma s/p R
nephroureterectomy:
Followed by urology as outpatient with recent hospitalization in
___ for urinary retention and failed voiding trials.
Continued on tamsulosin.
#Developmental delay
#Intermittent explosive disorder
Continued risperidone 3 mg QPM and 1mg daily
Lorazepamd 0.5 mg PO BID:PRN anxiety
#Seizure disorder
Continued CarBAMazepine 300 mg PO TID
#HTN:
Continued amlodipine 5 mg daily
#HLD
Continued rosuvastatin 40 mg qpm
Continued ezetimibe 10 mg daily
Continued aspirin 81 mg daily
#DM
Held home linaGLIPtin 5 mg oral DAILY in house and pt was on
ISS. He required very little insulin.
#BPH:
Continued home tamsulosin
#GERD:
Continued famotidine 20 daily
#Rhinitis
Continued fluticasone propionate nasal 2 spray daily
**TRANSITIONAL ISSUES** | 81 | 757 |
15332104-DS-12 | 21,753,134 | It was a pleasure looking after you, Mr. ___. As you may
know, you were admitted to the hospital for confusion, fever,
and nausea. You were found to have infection of the bile duct
with possible involvement of the gallbladder. You also had a
pneumonia. You were treated with antibiotics with significant
improvement.
Please complete a 2-week course of antibiotic (last day
___. Your other medications remain unchanged. | ASSESSMENT & PLAN: ___ h/o HTN/HLD, CKD Stage II, s/p L hip fx
___ admitted for elevated LFTs.
# GI: Mr. ___ was admitted from ___ with elevated LFTs
and RUQ U/S, abd CT w/ signs of acute cholecystitis which
included GB distention, perichole fluid, wall thickening, and GB
stones. There was however no CBD dilation. He also presented
with elevated LFT which were concerning for cholangitis. He,
however, did not have any leukocytosis or ___ sign on
presentation or throughout the hospitalization. He was initially
placed on unasyn IV and then later levo/flagyl which was
transitioned to oral form on HD3.
He was evaluated by ERCP who recommended MRCP. The MRCP did
not reveal any new findings (cholecystitis, no CBD) and was
largely limited by motion artifact (as he was delirious during
the study). Ultimately, his LFTs downtrended and the OSH blood
cxs returned positive for Citrobacter (pansens). These were
consistent with cholangitis/transitioned bacteremia with passage
of a stone.
Mr. ___ was able to tolerate a regular diet and had no N/V,
abd pain on the day of discharge. He will complete a 2 week
course of abx for presumed cholecystitis and cholangitis. He
still has GB stones, but is not a likely candidate for elective
cholecystectomy given his age.
# RLL PNA: Mr. ___ also was noted to be hypoxic requiring
initially 4L NC O2. CXR showed RLL infiltrate and was likely
___ aspiration in setting of N/V. It is likely that the
cholangitis/cholecystitis led to N/V and then to the aspiration
PNA. He was able to wean off the oxygen and the levoflox was
continued to help cover the aspiration pneumonia too.
# Delirium: Mr. ___ had episodes of sundowning. He was
initially delirious, but became increasingly cognitively intact
as the cholangitis/cholecystitis and pneumonia was treated. He
is exceptionally hard of hearing and had a hearing aid in place.
We aimed to optimize his nutrition, hydration, sleep. His
daughter ___ also came daily to help provide frequent
reorientation.
# AAA - Mr ___ was found to have an incidental infrarenal 7 cm
AAA on U/S and Abd CT. There was some evidence of intramural
thrombus. This was treated conservatively given his age. His
daughter (HCP) was made aware of this diagnosis and agreed with
conservative approach.
# HTN/HLD: on zebeta, norvasc. On statin, ASA.
# Glaucoma: on latanoprost and alphagan gtt
# OTHER ISSUES AS OUTLINED.
#FEN: [X] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: [X]heparin sc []SCDs
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [X] Foley
#PRECAUTIONS: [X] Fall [] Aspiration []
MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic
#COMMUNICATION: daughter ___ (HCP) at ___
#CONSULTS: ERCP, ___
#CODE STATUS: DNR/DNI. Confirmed w/ daughter ___ (HCP) after
extensive discussions. | 75 | 492 |
17857670-DS-19 | 23,961,295 | Dear Mr. ___,
You were admitted to ___ for
thigh pain. We evaluated you with an ultrasound and did not
find any blood clots in your leg. You also did not have any
problems with your breathing other than your baseline COPD and
sleep apnea, so a pulmonary embolism is not likely. Your
symptoms sounded more consistent with lumbar radiculopathy and
you should continue to take your pain medications and work with
your physical therapists at your rehab facility.
In regards to your anticoagulation, we decided to start
enoxaparin therapy which you are able to get at your rehab
facility until your INR is therapeutic on the warfarin. Please
take your medications as prescribed and follow up with your
doctors as detailed below. | ___ s/p spine surgery on ___ who presents from Rehab d/t
Right anterior thigh pain
#Lumbar radiculopathy
Leg pain was initially though to be DVT with possible PE as
patient was thought to be dyspneic with low SpO2 and therapy
initiated for presumed PE. However, on further discussion with
patient, his respiratory symptoms are chronic without any acute
change. He has long standing COPD/hypoventilation from habitus
and home SaO2 range high ___ to low ___ not on O2 at home. (Per
patient, wears night time O2 monitor). Right thigh pain not
consistent with DVT and has no exam or U/S findings to suggest
DVT. Pain was transient and patient reports having similar
episodes in the past. Seems more likely radiculopathic (L3) or
perhaps superfical femoral nerve impingement. Patient's post
surgical back pain is more symptomatic at this time.
-- pain control with home oxycodone
-- continue ___ at rehab facility
# History of Pulmonary Embolus - Patient did have moderate
probability on Wells ___ = 3 (Surgery < 4 wks, previous DVT),
Simp ___ = 4 (Age, Surgery < 1mo, Unilateral limb pain,
HR > 75). His h/o provoked PE is about ___ years ago, in the
setting of cellulitis and surgery, and on warfarin since with no
subsequent events. Of note patient's INR subtherapeutic since
___ in setting of reversal with Vitamin K d/t surgery.
-- Bridge with lovenox at discharge
-- Continue Warfarin and trend INR at rehab facility
CHRONIC ISSUES:
===============
# CKD: Cr 1.7 on arrival. Recent baseline 1.5-1.7.
-- Avoided nephrotoxic medications during admission
# COPD - not on O2 at home, per patient O2 at home 86- low ___.
Longtime former smoker.
-- continued home Tiotropium
-- titrated O2 to 88-93%
# OSA on CPAP:
-- Continued home CPAP settings
# Hypertension
-- Continued nifedipine
# Iron deficiency anemia - pt reporting recent normal endoscopy
at the ___. He does not take his iron pills because they cause
him constipation. Consider further work-up on follow up with PCP | 128 | 342 |
18510156-DS-5 | 23,020,055 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You had a fall and there was concern that you would have more
difficulty at home with everyday tasks
What was done while I was in the hospital?
- You were seen by our physical and occupational therapists, who
recommended going to acute rehab; you prefer to stay at home
with additional services
- You were started on a medication to help control your heart
rate because it was going quite fast
What should I do when I get home from the hospital?
- Be sure to take all of your medications as prescribed,
especially your diltiazem, which is supposed to help lower your
heart rate
- Please go to all of your follow up appointments listed below
- If you have fevers, chills, dizziness, fall, have increased
pain, or generally feel unwell, please call your doctor or go to
the emergency room
Sincerely,
Your ___ Treatment Team | SUMMARY STATEMENT
Ms. ___ is a ___ year-old woman with a history of
recently diagnosed (___) invasive carcinoma of the R breast
with ductal/lobular features on letrozole (ER+/PR+/HER2- Gr2 R,
no surgical intervention planned), EtOH use disorder (prior),
known gait imbalance (evaluated by neurology in ___, possible
myelopathic process in the setting of cervical spondylosis),
HTN, and dyslipidemia, who presented after a fall, and was found
to have arrhythmias on telemetry.
ACUTE ISSUES
#Fall
#Fractured humerus: The patient initially presented in the
setting of a mechanical fall, though she may have had prodromal
symptoms of dizziness. XR of the R arm ultimately showed a
proximal humeral fracture. Orthopedics determined that there was
no indication for operative management and recommended pain
control with physical therapy. She was made non-weight bearing
with the RUE. The patient was seen by physical and occupational
therapy and felt that the patient should undergo a period of
acute rehab. However, the patient preferred to go home with
additional services given poor experiences at rehab in the past.
#Supraventricular tachycardia: In-house, the patient was noted
to have intermittent increases in her heart rate to the 140s
that were intermittently symptomatic with lightheadedness and
palpitations. Electrophysiology was consulted and recommended
Linq recorder placement and addition of diltiazem for rate
control. The patient ultimately achieved excellent rate control
and her Linq recorder placed on ___ without incident.
CHRONIC ISSUES
# R breast with ductal/lobular features on letrozole
(ER+/PR+/HER2- Gr2 R, no surgical intervention planned): Patient
follows with Dr. ___ (hematology/oncology) and Dr. ___
___ (breast surgery). Letrozole was continued
in-house.
# HTN: Home ACE-i was held given normotension.
# Dyslipidemia: Continued home pravastatin.
# Insomnia: Continued home amitriptyline, though patient did
note dry mouth. (NB patient does complain of dry
mouth, should make this a transitional issue for her PCP)
# GERD: Continued home omeprazole
# Anxiety: Continued home lorazepam
# Urinary issues: Given immediate release oxybutynin while
inpatient.
TRANSITIONAL ISSUES
[]consider alternate sleep medication to amitryptiline given
patient reports dry mouth
[]consider home safety evaluation as an outpatient given
history of falls
[]patient is non-weight bearing on the R upper extremity
# CODE: Full with Limited trial of life-sustaining treatments
# CONTACT: ___, ___ (friend) | 157 | 409 |
11755436-DS-6 | 21,627,992 | Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
when you were found down after using heroinn and you had a
seizure. You were intubated and monitored in the intensive care
unit.
Please follow-up in the ___ clinic. Please return to the
emergency room if you experience fevers, chills, chest pain,
shortness of breath or any other new or concerning symptoms.
We wish you the best,
Your ___ team | This is a ___ yo M with PMH of substance abuse who presents with
altered mental status in the setting of opioid and cocaine
abuse, intubated for airway protection and admitted to the ICU.
# Altered mental status: A thorough workup performed prior to
the patients arrival in the ICU included a tox screen that was
positive for cocaine and opioids, a negative non-contrast head
CT, a negative CTA head and neck, and an LP that had normal WBC
and RBCs that cleared. This information all points towards acute
drug intoxication as the most likely cause of his initial
presentation (described as stupor, miosis, bradypnea which
improved with narcan). Patient admitted to snorting a bag of
heroin and taking cocaine 2 days prior to presentation once
extubated. He was initially evaluated by toxicology. Evaluation
by neurology given possible seziures and patient received EEG
and started on phenytoin 100mg BID. EEG returned negative and
phenytoin was stopped on ___. Spoke to PCP who corroborated no
history of seizure disorder (except in the presence of drug
intoxication). No history of EtOH withdrawal. Asterixis thought
to be due to phenytoin, no evidence of liver disease. Patient
was successfully extubated and mental status cleared after
extubation.
#Narcotic withdrawal: Patient began experiencing heroin
withdrawal morning of ___ and was scoring on ___. He was
placed on clonidine, dicyclomine, hydroxyzine, kaopectate,
triaminic, and methocarbamol per ___ ___ protocol. Spoke to
staff at ___ (below) who put us in contact with his
___ (had not yet actually seen MD) Dr. ___ ___ (cell), who felt it was okay and even preferable to
initiate methadone while hospitalized since this would mean
being in a monitored setting. He was started on methadone 20 mg
daily on ___. Dr. ___ that Mr. ___ come to the clinic
following discharge to continue his methadone titration - no
appointment necessary. Patient received 25 mg methadone on ___
and 25 mg methadone on ___ prior to discharge. He was not
scoring on ___ prior to discharge and his symptoms of anxiety
and HTN were likely related to craving. Dr. ___ was contacted
on ___ (the AM of patient's discharge) and he advised that
patient should follow up in the ___ clinic tomorrow
morning (___) between 6am and 11am (address as written below).
This was communicated to the patient and he understood and
expressed that he would likely have a ride to the ___
clinic tomorrow around 9am. Dicyclomine, hydroxyzine,
kaopectate, triaminic, and methocarbamol were discontinued prior
to discharge as patient was not requiring these medications and
his symptoms were likely related to craving rather than
withdrawal. | 73 | 440 |
14079811-DS-9 | 20,211,198 | Dear Ms. ___,
You were admitted to ___ for
progressive fatigue, headaches, and poor appetite. A CAT scan of
your abdomen revealed a liver abscess, or an infection ___ your
liver. A catheter was placed to help drain the abscess and you
were started on antibiotics, and your condition improved.
Additionally, an ERCP procedure was performed to replace your
old biliary stent, which was clogged. Once your symptoms
improved and you showed good response to the antibiotics and
drainage, you were discharged to a rehab facility for continued
antibiotics administration and to improve you physical strength
before returning home.
It was a pleasure take care of you at ___ and we wish you all
the best during your ongoing recovery. If you have any
questions about your care, please do not hesitate to ask.
Sincerely,
Your ___ Care Team | Ms. ___ is an ___ female with hx of pancreatic cancer (dx
___ s/p tx), T2DM, and recent history of GI bleed admitted with
fever, fatigue, headache, and anorexia; found to have a large
hepatic abscesses and biliary stent obstruction.
ACTIVE ISSUES
==============
# Hepatic Abscess:
Patient was admitted from urgent care with increased fatigue,
fevers, headaches, and poor PO tolerance. CT abdomen/pelvis with
contrast revealed a new "large septated hypodense lesion within
the left lobe of the liver" and "innumerable hypodense lesions"
scattered ___ the liver. labs were also notable for an isolated
alk phos elevation and normal T. Bili, concerning for early
obstruction. The patient remained hemodynamically stable, but
was started on Ampicillin/Sulbactam for coverage gram negative
and anaerobic bacteria. After spiking fever she was
transitioned to zosyn and a biliary percutaneous catheter was
placed, draining 50cc from the largest abscess. Initial gram
stain revealed gram negative and gram positive bacteria, so
Vancomycin was added. An ERCP investigation of a previous
biliary stent revealed migration and obstruction. It was
removed and successfully replaced with a full metal stent.
Cultures from the catheter placement revealed moderately
resistant E. Coli and gram positive cocci. The patient was
transitioned to meropenem and vancomycin with plan for ertopenem
antibioisis ___ the outpatient setting. The patient remained
afebrile and hemodynamically stable on following start of
meropenem. She was discharged with plans for close follow up
with infectious disease.
# Headache:
Patient presented with persistent bilateral headaches over the
past month, bilateral ___ front and back. she also reported
occasional vision blurriness, right temporal tenderness. She
denied lightheadedness/dizziness, significant change ___ vision,
and any tongue/jaw claudication with chewing. Given previous
history of temporal arteritis, rheumatology and ophthalmology
was consulted, but not found to have ocular involvement, and
symptoms of headaache and temporal tenderness self resolved.
Given low pretest probability, temporal biospy was deferred.
# Hyponatremia:
Na+ 126 on admission, with frank glycosuria on UA and
Fingerstick glucose ___ 400s. With tighter glucose control and
IVF hyponatremia self corrected without incident. Na+ on
discharge: 140
CHRONIC ISSUES
===============
# Type II Diabetes:
At home NPH 45 units breakfast and dinner. Her home regimen was
too aggressive, with some episodes of hyperglycemia, so she was
de-escalated to 35 units of NPH at breakfast and dinner, and a
less aggressive sliding scale.
# Anemia:
Patient was anemic on admission likely secondary to known
bleeding from hemorrhoids. Admitted ___ and underwent Flex sig
and colonoscopy which showed external hemorrhoids and
diverticulosis, but no active bleeding. Hemoglobin/HCT were
trended on this admission and remained stable.
# GERD:
Stable during this hospital stay. Continued home omeprazole.
# Hypertension:
Patient was hemodynamically stable ___ setting of infection. She
had multiple episodes of hypertension, requiring 1x dosing of
home labetolol. However, BP medications were generally ___
setting of infection, with normotensive vital signs. Will plan
to restartlosartan 25mg PO Qday, labetalol 200mg po BID,
amlodipine 10mg PO Qday on discharge
# DVT:
Patient had history of previous DVT, and was maintained on
weight dosed enoxparin 120mg daily (increased from home dose of
90 mg SubQ per pharmacy).
# OSA: Patient has history of OSA, and used nightly CPAP without
event.
# Anxiety: This issue was stable during this hospital stay.
Patient continued continued home medication lorazepam.
# Depression: This issue was stable during this hospital stay.
Patient continued will continue home medication of citalopram.
#DNR/DNI
HCP: ___ (daughter) ___ | 139 | 576 |
10601663-DS-3 | 25,227,083 | Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
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.
DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
***You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine, you will not require blood work
monitoring. Please take this for a total of 7 days since your
admission.
Do not drive until your follow up appointment.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy 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.
New onset of the loss of function, or decrease of function on
one whole side of your body. | Mrs. ___ was directly transferred from ___ for
traumatic subarachnoid hemorrhage and subdural hematoma. She was
admitted to the Neurosurgery service with Keppra 1000mg initial
load and Keppra 500mg BID. She was placed on a ___ protocol
given her history of EtOH abuse. Her neurovascular exam was
intact on admission.
___: She tolerated a regular diet. She was making adequate
urine output. Pain was well-controlled on PO pain meds. Her
neural exam remained to be intact. She was safe to be discharged
to home. | 173 | 83 |
17259897-DS-17 | 29,645,762 | Ms. ___:
It was a pleasure caring for you at ___. You were admitted
with jaundice (yellowing of the skin). We discussed with your
guardian who agreed that you would want to focus on comfort and
that you would not want any invasive testing.
You are now ready for discharge back to your nursing home, with
a plan to establish with hospice services. | This is a ___ year old female nursing home resident with past
medical history of dementia, cerebral palsy,
hyperparathyroidism, hypertension, CAD, seizures, recent onset
of painless jaundice, referred for admission and found to have
evidence of pancreatic head mass and ovarian mass concerning for
metastatic abdominal malignancy, subsequently discussed with
patient's guardian who supported previous documentation that
patient was DNR/DNI/do-not-hospitalize, discharged back to
nursing home with plan to establish with hospice care
# Goals of Care
# Biliary obstruction secondary to pancreatic Head Mass
# Ovarian Mass
Patient referred for admission with painless jaundice, with
imaging at ___ concerning for ovarian mass, and imaging at
___ concerning for pancreatic mass. Reviewed patient's chart,
which included a MOLST form indicating do not attempt
resuscitation, do not intubate, do not transfer to hospitalize.
Situation was discussed with patient's guardian ___,
___ who agreed that initial MOLST form should be
upheld, and patient's wishes respected. Discussed with guardian
that imaging was concerning for metastatic abdominal malignancy,
but that diagnosis would require biopsy--per guardian, patient's
goals were palliative and comfort-oriented, and invasive biopsy
and other diagnostic procedures would not be consistent with
those goals. Reviewed patient's medications and modified her
regimen to reflect her comfort-oriented goals. Started prn
Zofran and oxycodone for symptoms.
# Abnormal EKG
Noted to have abnormal EKG with poor baseline, felt to represent
likely sinus with PACs; initial plan had been to repeat EKG, but
in setting of above described goals, further workup was not
indicated
# Hydroureter
On OSH CT scan, hydroureter was seen, felt to be secondary to
adjacent ovarian mass. In setting of above described goals,
further workup was not indicated
# Hyponatremia
# Hypomagnesemia
On labs noted to have electrolyte deficiencies. In setting of
above described goals, further workup and treatment was not
indicated
# Abnormal CXR
Noted to have elevation of left hemidiaphragm of unclear
etiology. In setting of above described goals, further workup
and treatment was not indicated
# Coagulopathy
Found to have INR 2 on admission. Unclear if nutritional versus
synthetic. In setting of above described goals, further workup
and treatment was not indicated
Transitional Issues
- Discharged to nursing home with plan to establish with hospice
services
- Per discussion with guardian, patient would only want to focus
on treatments that provided her with comfort; patient's
medication list was adjusted accordingly to only include
medications that might bring symptomatic benefit to patient;
added prn anti-emetic and pain medications (although patient did
not require any during her hospital stay here)
- Guardian is ___, ___
- Prior to discharge, provided warm hand-off to ___
provider NP ___ (___)
> 30 minutes spent on this discharge | 66 | 436 |
11690403-DS-16 | 26,009,101 | Dear Ms. ___,
You were admitted to the neurology service at ___ after
diagnosis of a hemorrhagic stroke (intraparenchymal hemorrhage).
After discussion with your family members, it was decided to go
forward with measures to make you as comfortable as possible,
rather to pursue invasive tests and procedures. We have arranged
for you to have continued palliative care with inpatient
hospice. | After discussion with the patient's family at the time of
presentation, the decision was made to pursue comfort measures
only and planning for discharge to hospice with palliative care
was initiated. On the morning following admission, the patient
was noted to be more awake than at the time of presentation,
likely due to clearing of lorazepam that was given at the OSH.
Symptomatic treatment of pain, nausea, distress, etc. were
continued and extraneous medications were stopped. Ms. ___
was discharged to inpatient hospice.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? () Yes - (x) No -
Not consistent with GOC
2. DVT Prophylaxis administered? () Yes - (x) No - Not
consistent with GOC
3. Smoking cessation counseling given? () Yes - () No [reason ()
non-smoker - (x) unable to participate]
4. 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
5. Assessment for rehabilitation and/or rehab services
considered? () Yes - (x) Not consistent with ___ | 60 | 188 |
17790538-DS-19 | 22,632,757 | * You were admitted to the hospital with a right pneumothorax,
requiring placement of a chest drain to help remove the excess
air and reinflate the lung. You have improved with the tube in
but will need more time for the lung to heal and the air leak to
resolve. You are being discharged to home with the tube in
place, connected to a pneumostat, which is a one way valve that
allows the excess air to escape. You will see Dr. ___
week to see if the leak has resolved and potentially have the
tube removed. The ___ will also come by to check you and assure
that the pneumostat is functioning properly.
* You may shower with the pneumostat in place. Place the device
in a zip lock bag to keep it as dry as possible.
* If you have any increased shortness of breath, fevers > 101 or
any trouble with the chest drain, call Dr. ___ at
___.
Caring for your Chest Tube with Pneumostat
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.
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 every other day.
Showering/Bathing:
Showering with a chest tube is all right as long as you don't
submerge the tube or device in water. No baths, swimming, or hot
tubs.
The pneumostat can be placed in a zip lock bag for showers.
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 admitted to the hospital for further
management of her right pneumothorax. Her chest tube was on
suction and an air leak was present. Her chest xray showed an
apical , partially lateral pneumothorax but subjectively she
felt better and was able to walk without getting dyspneic. Her
chest xray remained the same on a waterseal trial and she
subsequently had a chest CT done to evaluate bullous disease
along with the extent of the pneumothorax.
He chest CT on ___ showed a smaller "chronic" right
pneumothorax compared to her CT scan in ___. Following 24
hours on waterseal her air leak was less but present therefore a
pneumostat was placed so that she could be more ambulatory and
return home while the leak resolved. Her chest xray with the
pneumostat in place showed the same stable right apical/lateral
pneumothorax. Her room air saturations were 97%. She was
instructed how to drain the device and ___ was set up for home
services. She was discharged home on ___ and will follow up
with Dr. ___ in one week to assess the leak/tube and hopefully
remove the pneumostat. | 696 | 191 |
15570344-DS-24 | 29,139,289 | Dear Ms. ___,
Thank you for receiving your care at ___! You were admitted
for after sustaining a fall at your assisted living facility.
You underwent a CT scan of your head and spine and Xrays of your
pelvis and your right femur. No signficant injuries were noted
though the CT of your spine showed some mild widening at the
"atlantodens interval" in your neck. Because of this widening
we would like you to wear a soft neck collar for 1 week at which
point we would like you to see one of our orthopedists, Dr.
___. As well, during your workup you were found to have a
urinalysis and an elevated white blood cell count that was
concerning for a urinary tract infection. You were treated with
antibiotics during your admission but we would like you to
continue taking another antibiotic called cefpodoxime for the
next ___ days. Please take your medications as directed and
follow up in clinic as directed. | In brief, this patient is an ___ year old woman with a history of
CHF, stroke, dementia, diabetes mellitus type 2, multiple UTIs,
and a history of frequent falls who presents with a ground level
multifactorial fall and minor trauma.
#Ground level fall:
Presented to the ED after sustaining a fall at her assisted
living facility. Fall reportedly occurred after she attempted
to use the washroom at night, without assistance, in the dark,
and without her walker. She sustained head trauma and she
denied preceding symptoms and is unsure if she lost
consciousness. In the Emergency Department she was worked up to
assess for injury after the fall. CT head, pelvis film, and
right femur film did not show any significant findings.
However, a CT of the spine showed new apparent borderline
widening of atlantodens interval to 3 mm since ___.
Gerontology evaluated her on HD#1 and, after discussion, it was
felt that the etiology of her fall was multifactorial though
likely involved a mechanical component as she tried to walk
without her walker or shoes in the setting of long-standing
residual right sided weakness after her previous stroke. The
fall was considered unlikely to be due to syncopal episode (she
is on a number of antihypertensives though her blood pressure
has been 130s-170s systolic while she has been on the floor) and
given her lack of urinary symptoms (aside from increased
frequency over weeks to months in the setting of furosemide)it
was also considered unlikely to be related to complicated
cystitis. She is being discharged with a soft neck collar which
she is to wear for 1 week until she follows up with her
orthopedist Dr. ___ she ___ also get follow up
flexion-extension films).
#Complicated cystitis:
In addition, a urinalysis was performed in the ED which showed
signs of urinary tract infection. It was thought that urinary
tract infection may be a possible cause of fall and therefore
she was admitted for further work-up. While in the ED she
received one dose of nitrofurantoin and upon admission to the
floor she was given 1g IV ceftriaxone. Labs were drawn again on
the morning of ___ and she was found to have a new
leukocytosis (to 14.7) with left shift. Initially, there was
reservation to treat her for an infection given unreliable
symptoms, however, the leukocytosis made the case more
compelling so she was given a 10 day course of cefpodoxime. Her
allergy history is questionable and she tolerated this last
admission. Please monitor for signs of allergic reaction. | 168 | 434 |
17173041-DS-28 | 25,669,347 | Dear Ms. ___,
It was a pleasure taking care of you during your stay. You were
admitted for dizziness and shortness of breath. Your dizziness
may be due to your heart arrhythmia. You will go home with a
heart monitor to further monitor your heart rhythm and to see if
it is contributing to the dizziness. Please follow up with Dr.
___ electrophysiologist, after dicharge. In
addition, you will follow up with neurology. PLEASE call Dr.
___ office to schedule an appointment with him within 2
weeks of discharge.
Your shortness of breath may be due to increased pressures in
your heart, causing fluid buildup in your lungs. You were given
diuretics with improvement of your breathing. You will go home
with lasix (a new medicaton) to be taken three times per week.
Please follow up with your PCP and Dr. ___ discharge.
We wish you the best!
Your ___ care team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ year old female with PMH of afib on coumadin, CAD s/p PCI
with LAD stent ___, presents with severeal months of dizziness
and dyspnea, likely due to CHF exacerbation and atrial
arrhythmia. | 161 | 33 |
11965254-DS-33 | 29,513,680 | Dear ___ were admitted because ___ had worsening abdominal pain,
nausea, vomitting, and increased stool output. This was causing
___ to be unable to eat or drink enough and ___ were starting to
feel weak. ___ also were unable to take your Xaljenz
(Tofacitinib) because ___ had left your pills here on your last
visit. Before discharge, your pain was under better control and
___ were able to eat and drink without problems.
We also started Hyoscyamine which was recommended by the GI
team. This should also help with your pain
___ are now ready to be discharged. Please follow up with Dr.
___ your PCP within one week.
It was a pleasure taking care of ___,
Your ___ Care Team | PATIENT:
Mrs ___ is a ___ year old female with ileocolonic
Crohn's disease with many recent admissions for concern of
partial SBO who presents to the ___ ED with abdominal pain,
nausea, vomitting, intermittent liquidy ostomy output, decreased
PO, and lightheadedness.
ACUTE ISSUES
# Abdominal pain/N/V: Mrs ___ was admitted for
recurrent abdominal pain, nausea, vomitting, increased liquidy
stool output, and decreased PO intake. She had sharp pain at her
old ostomy site about ___ min after meals. KUB did not show
concern for obstruction, and abdominal U/S did not show any
abnormalities. She was given dilaudid for the pain. She was also
started on Hyoscyamine for abdominal pain and local lidocaine
patches for pain at her old ostomy site. Abdominal ultrasound
performed to evaluate for fistulous disease but was unable to
identify any developing pathology. She remained afebrile with
stable vital signs throughout and infectious work-ups were
negative. As she was able to eat and tolerate an oral pain
regimen she was discharged home with intent for outpatient
follow-up.
# Myalgias: Patient reported aches in her hips and legs at night
and is also tender to palpation in neck, sternocleidomastoid,
and right posterior hip. Treated symptomatically with her above
pain regimen.
# Pyuria: Patient's urinalysis had 100+ WBCs and bacturia on
admission although patient did not endorse urinary symptoms. She
was thought to have sterile pyuria and the medical team elected
not to treat with antibiotics. Her urine culture eventually grew
mixed flora consistent with contamination. | 120 | 244 |
16788366-DS-13 | 22,277,461 | Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
-You came to the hospital because you were feeling short of
breath and you were having more swelling in your body.
What was done for you while you were here?
-You were evaluated and it was found that your kidney is
failing.
-You had a tube placed in your kidney called a PCN that was then
converted to an inside tube call the PCNU.
-You had a tunneled line placed in your right neck for
hemodialysis.
-You restarted on hemodialysis.
-Your tunneled line developed a clot and you underwent an
angioplasty to clear the clot.
-You was started on a blood thinner called warfarin so that you
do not develop another clot.
What should you do when you go home?
-You must have your INR checked at hemodialysis every week to
make sure that your blood is not too thick or thin.
-You will follow-up with your primary care physician on ___,
___.
-You will have hemodialysis on ___ and ___.
We wish you the best.
Sincerely,
Your ___ Medicine Team | Mr. ___ is a ___ man s/p 2 renal transplants c/b acute graft
rejection and recurrent IgA nephropathy, on chronic
immunosuppression, initially presenting with volume overload and
hypertensive emergency, found to have hydronephrosis, consistent
with acute on chronic renal failure, now s/p PCN placement ___,
converted to PCNU on ___, and initiated on HD on ___. Course
complicated by SVC syndrome s/p angioplasty as well as tunneled
HD line associated clot. | 181 | 71 |
16724859-DS-8 | 24,964,563 | Dear Mr. ___,
It was a pleasure taking care of you during your admission to
the ___. You were admitted
because you had elevated liver enzymes, ___ were feeling weak and
fatigued and you were intoxicated with alcohol. You were
concerned about your heart and we did an EKG and cardiac enzymes
that ruled out heart attack. You also had a chest x-ray that did
not show any signs of pneumonia or other infection. You had an
ultrasound of your liver that showed liver damage called
cirrhosis that can be consistent with alcohol use. You were
given some IVF and your nausea was controlled with some
medications. We strongly encourage you to stop drinking and
avoid further damage to your liver. You have some labs about
your liver that we did not get back yet, so it is very important
that you follow-up with your primary care doctor in order to
obtain the results. Please continue to take all of your
medications at home and keep all of your follow-up appointments.
All the Best,
The ___ Team | ___ w/ hx of HIV, EtOH dependence and mild COPD, presents to ED
with 1 month hx of abdominal discomfort, nausea and recent hx of
DOE and cough w/o increased sputum production. Pt found to have
transaminitis. Pt has multiple complaints with no clear
unifying diagnosis.
# Transaminitis - Directly hepatocellular pattern w/ only
cholestatic evidence being mildly elevated alk phos. AST: ALT
elevated in 2:1 ratio c/w etoh toxicity. In OMR, has not had
this degree of transaminitis in past however. The RUQ US showed
cirrhotic liver without any acute finding. Pt's abdominal pain,
malaise and myalgias could be indicative of infectious
hepatitis, hepatitis panel and EBV/CMV was pending at discharge.
Tylenol level was negative. In conjunction with recent increase
in alcohol abuse, drug effect hepatotoxicity could be
compounded. LFTs currently downtrending. GGT was elevated to
703.
# Cough/DOE - No evidence of pneumonia/pulm edema on CXR, EKG
was unremarkable and first set of trops neg. In an
immunocompromised pt could consider atypical infection like PCP
but no radiological evidence and pt would likely be in more
acute respiratory distress. COPD exacerbation is possible given
increased cough, some mild expiratory wheezing and SOB, however
no increase in sputum. Shortly after admission did not complain
of shortness of breath. Did not require supplemental O2. Spiriva
and albuterol was continued.
# Thrombocytopenia - Has not had this degree of abnormality in
our OMR in the past. Could be evidence of ongoing alcoholism and
worsening cirrhosis over the years. Could also be from acute
infectious viral etiology. EBV/CMV and hepatitis serologies
pending.
# EtOH intoxication. Patient denies having history of
withdrawals. He also denies any regular drinking since he
started his antiretroviral therapy regimen. He was placed on a
CIWA scale, however did not exhibit any signs or symptoms of
withdrawal. He was started on folate, thiamine and a MVI.
# Hypokalemia- Likely nutritional as patient has had poor po
intake for at least a week or two. Was repleted this AM.
# Cirrhosis - Patient with evidence of cirrhosis on RUQ US.
Bili/cr/inr not elevated. Patient was encouragted to stop
dirnking alcohol, especially while he is on antiretroviral
therapies. He will follow-up hepatitis serologies as an
outpatient.
# HIV - Last CD4 140, pt reports that he is due for viral load
and CD4 check which are currently pending. Continued on home
medication regimen and dapsone.
# COPD - continud with home medications
# back pain - continued with oxycodone and gabapentin | 175 | 419 |
15398519-DS-27 | 21,614,171 | You came to the hospital with a cough and shortness of breath.
X-ray showed no signs of pneumonia. You have been treated for a
COPD exacerbation and are improving. Please continue to take the
medications as directed below.
We are adding a new inhaled medication called Spiriva to help
with your breathing on a daily basis.
Please follow-up at the appointments listed below.
It was a pleasure taking care of you, Mr ___. | Mr. ___ is a ___ w/hx of HIV on HAART, asthma, COPD (not on
home O2) with recent hospitalization for Influenza c/b
intubation for hypercarbic respiratory failure who presents with
shortness of breath due to COPD exacerbation.
.
# COPD exacerbation: Patient presented with history of shortness
of breath, cough with sputum production, and an increased oxygen
requirement. CXR ruled out pneumonia as there was no sign of
infiltrate. Patient showed rapid improvement with management of
COPD exacerbation. He will complete a 5-day course of
azithromycin (day ___ and prednisone 60mg PO X 5 days (day
___. The patient received education regarding COPD
management. Spiriva was added to his home regimen of Symbicort
daily and albuterol PRN. On discharge his ambulatory O2 sat was
89-90% on RA and 91-92% on room air at rest.
.
# HIV on HAART therapy: Last CD4 count 780, viral load
undetectable in ___.
We continued the patient's home regimen of
Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY, Etravirine 200
mg PO BID, and Raltegravir 400 mg PO BID.
.
# HTN: Home regimen of labetalol 300 mg PO BID and lisinopril 5
mg PO DAILY was continued. The patient remained hypertensive
throughout this admission with BPs as high as 170s/110s. The
patient remained hemodynamically stable and asymptomatic.
. | 70 | 206 |
11057828-DS-21 | 24,942,093 | Discharge Instructions:
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.
ACTIVITY AND WEIGHT BEARING:
- Touch down weight bearing, unlocked ___ ROM as tolerated
Physical Therapy:
TDWB
Unlocked ___ and ROM knee as tolerated
Treatments Frequency:
Unlocked ___ and ROM knee as tolerated | ___ s/p fall with R distal femur fracture. Her imaging showed
x-rays show comminuted Right distal femur fracture with likely
intra-articular extension
CT shows comminuted Right distal femur fracture with
intra-articular fracture
She underwent an open reduction and internal fixation on ___.
The procedure was uncomplicated, her diet was advanced as
tolerated and she was transitioned to PO pain medications. She
will be touch down weight bearing, she has follow up in ___
days. | 141 | 72 |
13637928-DS-14 | 28,570,346 | Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
because you were having severe back pain. You had an MRI that
showed you had a new compression fracture in your lumbar
vertebrae (L1 ___. You were seen by the ___ doctors who
recommended that you wear a brace and follow-up with them in 3
weeks. You were also seen by physical therapy who recommended
that you participate in outpatient physical therapy.
All the best,
Your ___ Team | ___ y/o female with a past medical history of MS, CKD stage II,
PE, osteoporosis, T12 compression fracture who presents to the
ED with severe low back pain.
# L1 Compression Fracture
Patient reports continued lower spinal pain with negative plain
film imaging at OSH. Repeat lumbar plain films negative for
acute fracture however patient with poorly controlled pain. No
concerning symptoms or exam findings for spinal compression.
Patient had an MRI ___ which showed a new acute L1
compression fracture. She was seen by Orthopedics who
recommended that she wear a TLSO brace. Her pain was controlled
with Tylenol and Oxycodone. She was evaluated by ___ and
discharged home in stable condition. She was continued on
calcium and Vitamin D.
# Hypertension
She was continued on HCTZ and Metoprolol. Her blood pressure was
well-controlled.
# Hypothyroidism
She was continued on home levothyroxine.
# Chronic Diastolic Heart Failure
She was continued on metoprolol and torsemide.
# GERD
She was continued on home omeprazole. | 90 | 159 |
12613687-DS-33 | 28,990,456 | Mr. ___, you were seen in the ___ emergency
room for facial swelling and tooth pain. You also had chest pain
and thoughts of suicide there. You did not have a lung infection
(pneumonia) or heart attack to explain your chest pain. A CT
scan of your head showed stable findings from your old stroke
and some areas of inflammation around the teeth in the right
upper jaw. Psychiatry evaluated you and thought that you needed
to be admitted to psychiatric hospital. We recommend that you
see a dentist within a few weeks to discuss removing any teeth
that are infected. | =====================================================
___ case manager: ___ ___
___ Nurse coordinator: ___ ___
___ including ___ ___
=====================================================
ASSESSMENT AND PLAN: ___ year old Ethipian male with past history
of left MCA stroke in ___ with lasting expressive aphasia as
well as severe major depression with psychotic features
requiring ___ guardianship who presents from his group home
with complaints of facial swelling & dental pain. In the ER he
complained of suicidalilty so ___ initiated. Because of
carboxyhemoglobinemia and mild leukocytosis was admitted to
medicine for workup.
#Leukocytosis: White blood cell count was 12 in the ER. He
received cefazolin and azithromycin. There was concern for acute
bacterial rhinosinusitus or pneumonia. He was afebrile with
normal vital signs. He did not have bacterial sinusitis or
pneumonia clinically or radiographically. He did not have a
clear skin or soft-tissue infection of the face or neck to
warrant antibiotics. He most likely has an odontogenic infection
that lead to his leukocytosis, however, he had no pain or
purulence on exam and interval exam showed improvement of mild
facial asymmetry. Therefore, antibiotics were not continued and
when his WBC count was then normal the day after admission he
was felt to be medically cleared for discharge. A panorex dental
series was done for dental consultants to evaluate for any teeth
that would require extraction if he goes to an inpatient
psychiatric facility.
The dental consultant said that he would place a note in OMR
based on the Panorex dental imaging and could do inpatient
extractions, but not more complicated treatment planning such as
fillings. However, the patient refused to get dental X-rays.
Dental consult can see patient while on ___ 4 if necessary
for dental pain. They would be more insightful as to how
necessary the Panorex images are in the short term, rather than
deferring any tooth extraction to the outpatient setting.
Encourage oral hygiene with chlorhexidine oral rinse if
tolerated.
#Major depressive disorder with psychotic features, recurrent:
He has a history of complex psychiatric disease with psychotic
features associated with his depression. He has a ___
guardianship with ___ (___). He has been
hospitalized multiple times in the past and has had ECT in
addition to multiple antidepressants and antipsychotics. He saw
his psychiatrist (Dr. ___ last on ___ at which time
haloperidol PO was stopped in favor of higher dose ziprasidone.
Since then he may have had changing behavior and worsening
auditory hallucinations.
He was seen by psychiatry in the ER and ___ was
initiated prior to admission. Upon obtaining collateral from
community based flexible support (___) team and outpatient
psychiatrist, the psychiatry consult service concluded that Mr.
___ was off of his baseline because of recent refusal of care
and behavior changes. It was therefore recommended that he have
inpatient psychiatric admission for stabilization of his
psychiatric disease for fear of further decompensation if he
were to return home.
He otherwise appeared cognitively at baseline in terms of
answering questions with ___ word answers compared to his ___
neurology discharge exam in our documentation. He had no
findings of serotonin syndrome, neuroleptic malignant syndrome,
nor tardive dyskinesia.
He was continued on his home medications of venalafaxine XR
150 mg po qam, benztropine 1 mg po qhs, ziprasidone 80 mg po
BID, trazodone 50 mg po qhs.
#History of left ___ territory ischemic stroke: He had an
ischemic stroke in ___ with subsequent expressive aphasia,
encephalomalacia, gait instability, and right hand weakness. He
is able to speak in short answers, but responds appropriately to
questions. His speech is laconic, but without dysarthria or
paraphasic errors. He was continued on aspirin 81 mg daily.
#Carboxyhemoglobinemia: Presented with COHb ___. He is a
smoker and the most likely contributor is tobacco smoke
inhalation. He was treated with oxygen in the ER, which was
discontinued when he was admitted because the carbon monoxide
source had been removed.
#Tobacco abuse: Long-standing tobacco use. He was given a
nicotine patch 14 mg daily
#Hyperlipidemia: On simvastatin 20mg daily at home. This was
continued.
#GERD: On a proton-pump inhibitor at home. This was continued.
#CODE STATUS: FULL
TRANSITIONAL ISSUES
-------------------
-please contact the patient's guardian with any medication
changes as these must conform to a treatment plan
-if he does not have inpatient tooth extraction by BID dental
consultants, he requires close follow up with a dentist after
discharge from inpatient psychiatry for tooth extraction | 101 | 726 |
18470665-DS-17 | 28,703,799 | Ms. ___,
- ___ were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down weightbearing Left lower extremity
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 ___ should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take 5000 units subcutaneous heparin for 2 weeks
WOUND CARE:
- ___ may shower. 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.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if ___ experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___
___ will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
touchdown weight bearing for left lower extremity
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Site: L hip
Description: dsg c/d/Ichanged by MD ___
Care: keep dressing clean, dry intact. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a L acetabulum fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a L acetabulum orif, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory 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 ___
antibiotics and anticoagulation per routine. The patient began
experiencing continued bleeding from the incisional site during
POD#1 for which her lovenox was put on hold from POD1-3. The
bleeding stopped and the patient was restarted on
anticoagulation. The patient's 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's 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 extremity, and will be
discharged on 5000 units subcutaneous heparin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. | 343 | 291 |
11287998-DS-18 | 28,449,328 | Dear Ms. ___,
You presented with fatigue, weakness and shortness of breath.
This was believed to be from progression of your cancer. You
decided that you wanted to go to hospice so we discharged you to
a hospice house.
We wish you the best.
Sincerely,
Your ___ Team | Ms. ___ is a ___ y/o female with a history of COPD, PE on
lovenox, and metastatic SCLC with prior hospitalization for
pericardial effusion who now presents for weakness, dyspnea, and
poor appetite.
# Failure to thrive
# Weakness
# Malnutrition
Pt presents with subacute failure to thrive characterized by
weakness, exhaustion, poor appetite, and dyspnea. She had few
lab abnormalities on admission except for hypokalemia and
hypoalbuminemia. She met with her outpatient oncology team while
inpatient who felt that these symptoms were due mostly to
progression of her cancer, and recommended hospice. The patient
agreed, and decision was made to go to a hospice house.
# Hypoxia
# Dyspnea
Her worsening dyspnea and hypoxia are likely secondary to
progression of her SCLC. PET/CT in ___ demonstrated new
subpleural mass along anterolateral chest wall, new nodules in
lingual, and worsening mediastinal and left hilar
lymphadenopathy. No wheezing or evidence to suggest active COPD
exacerbation. No CXR evidence of infection. She was given
supplemental O2 to maintain oxygen saturation > 92% which will
continue at hospice and her home inhalers were continued. There
is no indication to start antibiotics.
# Extensive stage SCLC: Pt with diagnosis of SCLC in ___,
now s/p 4 cycles of carboplatin/etoposide. Pt excluded from
SRS/CK due to enlarging brain metastases and patient declined
WBRT. PET/CT scan in ___ showed overall disease
progression. Pt was initiated on nivolumab in ___ and
received her ___ cycle on ___ and second cycle on ___. No
further treatments are planned and the patient is transitioned
to hospice hospice.
For nausea, she was given Zofran prn and prochlorperazine prn
For pain, she was given Acetaminophen prn
# Oral candidiasis: stopped nystatin since going to hospice
# Atrial fibrillation: holding rate control with metoprolol
given hospice. Continuing lovenox but if patient decides she
doesn't want to take it she can refuse.
# History of pulmonary embolism: continuing lovenox.
# COPD: Continue home albuterol and tiotropium
More than 30 minutes were spent preparing this discharge | 45 | 323 |
13777829-DS-16 | 28,169,808 | Dear Ms. ___,
You were hospitalized due to symptoms of difficulty speaking and
difficulty walking. We believe that these occurred because of a
TRANSIENT ISCHEMIC ATTACK. This is a condition where a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot which then clears. 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:
- atrial fibrillation
- hypertension
You had a collection of fluid around your right lung. We drained
this collection of fluid. There are still tests which are
pending to find out exactly what caused this collection to
appear. You will follow up in the pulmonary clinic in ___ weeks
to discuss the lab results and any further tests.
We are changing your medications as follows:
- starting apixaban (a blood thinning medication)
- stopping furosemide (lasix)
- stopping aspirin
- increased carvedilol
We are starting you on apixaban (Eliquis) to thin your blood.
This is instead of the coumadin. Just like the coumadin, this
medication increases the risk of bleeding.
We saw that you have weakness in your arms and legs. We believe
this is due to arthritis in your neck. We have given you a
cervical collar to wear at nighttime in order to help support
your neck which can relieve some of these symptoms.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
Sincerely,
Your ___ Neurology Team | ___ is an ___ right-handed woman with atrial
fibrillation off coumadin due to recent traumatic SDH and SAH,
who presented to an OSH with a transient episode of word-finding
difficulties and difficulty ambulating. She was transferred to
___ for further workup. On examination she had no aphasia or
dysarthria as well as a symmetric pattern of lower extremity
weakness most consistent with myelopathy. Her history is most
concerning for TIA secondary to atrial fibrillation. MRI
demonstrated no acute infarct, MRA showed patent vasculature.
Neurosurgery cleared her to resume anticoagulation. She was
started on apixaban 2.5 mg BID (given age and weight) and her
aspirin was stopped.
She was found to have a right pleural effusion in the context of
multiple rib fractures as well as several borderline lymph
nodes. A chest tube was placed with uncomplicated removal of 2.5
liters of exudative effusion. CT chest after drainage showed
trapped lung with residual pneumothorax but no effusion. She
will follow up in pulmonology clinic. Her lasix which was
started for the effusion was discontinued.
She was hypertensive to the 150-170s and her carvedilol dose was
increased.
============================================
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 = 73) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) 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? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A | 311 | 407 |
13746600-DS-13 | 26,828,663 | Dear Ms. ___:
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office with
any questions or concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* Since you have steri-strips, leave them on. They will fall off
on their own or be removed during your followup visit.
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
* Stop constipation medications if you are having loose stools
or diarrhea.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___. | Ms. ___ was admitted to the general surgery service for
further workup of her pelvic fluid collection seen on CT and its
associated abdominal pain. She was initially kept NPO on IV
fluids in case of potential drainage or surgical procedure. She
remained hemodynamically stable with stable hematocrits. Her
pain was controlled with IV medications given her NPO status and
she underwent serial abdominal exams, which revealed stable
lower abdominal discomfort, but no peritoneal signs. Imaging was
discussed with interventional radiology and it was felt that the
mass appeared to be primarily clot and therefore would not be
amenable or advisable for percutaneous drainage.
Ms. ___ then underwent further imaging of the collection
with pelvic sonogram and pelvic MRI (full radiology impressions
are elsewhere in this document). On ___ her pelvic MRI was read
and discussed with radiology. At this time it was felt that the
mass likely originated from the patient's right ovary and was
possibly a hemorrhagic ruptured cyst vs. endometrioma vs. torsed
ovary vs. less likely ovarian mass. Given these imaging findings
it was felt that she would be ___ served on the gynecology
service and transfer was arranged.
MRI revealed a right adnexal mass concerning for ovarian torsion
versus ruptured endometrioma. She was transferred to the
gynecology service and on ___, she underwent a laparoscopic
bilateral oophorectomy, right ureteral lysis, anterior lysis,
placement of right double-J stent, rigid proctoscopy and
sigmoidoscopy, and cystoscopy. Please see operative report for
full details.
Immediately postoperatively, her pain was controlled with IV
morphine. She was subsequently transitioned to oral oxycodone,
Tylenol, and ibuprofen. The right ureteral stent placed
intraoperatively remained in place for a planned 14 days. Her
Foley catheter was removed on postoperative day 1 and she voided
without difficulty. She was ambulating and tolerating a regular
diet. For her hypertension, she was maintained on carvedilol
and lisinopril. For her type 2 diabetes, she was maintained on
an insulin sliding scale, metformin, and glipizide when she
resumed her regular diet. On postoperative day 1, she was
discharged home with close follow-up. | 237 | 350 |
11946585-DS-6 | 24,220,847 | Dear Mr. ___,
You were admitted for flashing and your vision and difficulty
seeing on the right. You had imaging of your brain (CT and MRI)
which showed a stroke in your brain. You had an ultrasound of
your heart which showed slightly abnormal function but no large
clot in your heart. Your aspirin was stopped and you were
started on Plavix (clopidogrel) instead. You had an EEG (brain
wave test) which did not show any seizure during the study, but
you did not have any flashing in your vision during the study.
You were started on a medication called levetiracetam (Keppra)
to prevent seizures. By law, you may not drive until you have
had no seizures for six months. You should continue to take the
levetiracetam (Keppra) to prevent seizures unless told to stop
by your neurologist. Some of your blood pressure medications
were held or reduced in the hospital just after your stroke. You
should re-start these at your usual doses at the time of
hospital discharge. You will have follow up with your primary
care doctor who will arrange followup with a Neurologist,
Ophthalmologist, and Cardiologist. You should also have
occupational therapy for vision services. You will have a heart
monitor; please follow the instructions given to you in the
hospital.
Dear Mr. ___,
You were hospitalized due to symptoms of vision problems and
flashing 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, high blood pressure,
heart disease, high cholesterol
We are changing your medications as follows:
Stopping aspirin. Starting clopidogrel and levetiracetam.
Please take your other medications as prescribed.
Please followup 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
Thank you.
Sincerely,
Your ___ Neurology Stroke Team | Mr. ___ is a ___ year old gentleman with DMII, history of
CAD s/p stents in ___, HTN, dyslipidemia who presented from
___ Ophthalmology with complaint of three days of flashing
lights in his right visual field and vision problems and was
found to have a dense right homonymous hemianopsia. Upon
admission, he had a CT/CTA of his head and neck which showed
evidence of acute infarction of the medial left occipital lobe
with a P2 cutoff of the left posterior cerebral artery felt
secondary to a thrombus. Patient then had an MRI which showed
the corresponding area FLAIR hypertensity within the medial L
occipital lobe with associated restricted diffusion consistent
with subacute left occipital infarct. This also showed right
frontal gliosis presumably from a prior infarct as well as a
chronic infarct in the right centrum semiovale. Possible
etiologies of the stroke included cardioembolic (though no
evidence of thrombus on echo)vs artery to artery/atheroembolic.
Patient is not known to have atrial fibrillation and was
monitored on telemetry throughout his stay. He will have ___
___ Hearts monitor as an outpatient (arranged on day of
discharge) to monitor for atrial fibrillation. Patient had a
transthoracic echo which showed mild symmetric left ventricular
hypertrophy with regional left ventricular systolic dysfunction
c/w CAD, LVEF 45-50%, no evidence of intracardiac embolism or
septal defect. On admission labs were notable for HbA1c 6.2, LDL
103 TSH 2.0, CRP 0.8. Patient was on aspirin 81 mg daily and
atorvastatin 80mg daily at the time of admission. His aspirin
was stopped, and he was started on clopidogrel, instead. He was
continued on his atorvastatin. He should continue atorvastatin
as an outpatient.
Patient's blood pressure medications were reduced or held during
hospitalization to allow him to autoregulate his blood pressures
post-stroke. He was resumed on his home antihypertensives at
their prior doses upon discharge.
Patient was given acetaminophen given that he had a headache and
with the thought that the strobing may represent stroke-induced
migraine. Despite acetaminophen, the strobing/flashing
continued. He had an EEG to evaluate whether the flashing might
be due to seizure. EEG showed focal slowing over the area of
infarct, did not show seizure but patient did not have
flashing/"strobing" of his vision during the EEG. Patient was
started on Keppra (levetiracetam) 750 mg BID for empiric
treatment of possible seizure. After starting levetiracetam,
patient had much less prominent flashing.
Mr. ___ should have outpatient clinic followup with a
Neurologist. Mr. ___ should continue his levetiracetam for
several months, at least until he is seen in Neurology clinic.
He should continue this until he is told to discontinue by a
Neurologist.
Mr. ___ should have outpatient followup in cardiology
given his Echo findings as well as his history of intracardiac
stents.
Mr. ___ was evaluated by occupational therapy who felt he
should have outpatient occupational therapy for vision services.
He should also have follow up with an ophthalmologist as an
outpatient. | 489 | 489 |
16573705-DS-40 | 22,112,253 | Dear Mr. ___,
It was a pleasure caring for you while you were admitted to the
hospital. You were admitted with fever and initially started on
IV antibiotics. You had a number of tests to look for the source
of infection and all of them were negative. We think that your
fever was likely due to a viral infection.
Also your sodium level was low. You should hold your
Triamterene-Hydrochlorothiazide for now and make an appointment
to see your doctor next week to have your blood pressure and
electrolytes checked (blood test). At that time you can decide
if your should restart this medication or change to a different
blood pressure medication.
Please continue to take all the rest of your medications as
prescribed and follow up with your doctors as ___. | ___ yo M with incomplete quadriplegia, frequent urinary tract
infections with urosepsis, and recurrent nephrolithiasis who
presents with fever and chills. | 133 | 22 |
14695209-DS-20 | 22,346,919 | An area of your brain has had an ischemic insult. Please be
careful to avoid falling (use a cane or walker if you feel
unstable, remove any loose carpets in your home, sit or lie down
if you feel unstable). Be sure to follow up with your outpatient
appointments to try to find a source for the problem that
brought you in, to treat it and avoid it happening again.
Dear ___,
___ was a pleasure taking care of you at ___. You were admitted
to the hospital because of seizures and had to be intubated and
stabilized in the medical ICU. An MRI scan showed evidence of
multiple small strokes, likely due to blood clots. We did an
extensive work-up but were unable to determine the exact cause
of these potential clots. We did not find evidence of any heart
structural or rhythm abnormalities, and laboratory results
suggest against any predisposing condition for clot formation.
We started you on aspirin to try to prevent further strokes, and
you will follow up in a stroke clinic ___ months after
discharge. You have a heart monitor to take home for 90 days for
further monitoring of your heart rhythm.
We were also investigating an infectious cause of your seizures,
but the laboratory sample could not be used. Because the risk
for an HSV infection is low, you have been taken off antiviral
medications.
During this hospitalization, your kidney function also declined.
This was thought to be due to low blood volume going to your
kidneys or from the antiviral medication, acyclovir, that has
now been stopped. Your kidney function improved greatly prior to
discharge, but you will need to have this re-checked on
___, and follow up with the kidney doctors.
___ you were in the hospital, you did not take your
antidepressant medications, which you stated you preferred. It
is recommended that you follow up with your psychiatrist, Dr.
___ further management.
It is very important to remember:
Follow up with Dr. ___. Follow up with your
kidney doctor. See your new primary care doctor as well. Also as
we discussed, absolutely NO driving for the next 6 months in
___ given your recent seizure.
Thank you for letting us participate in your care.
-Your ___ team | ___ is a ___ y/o F with history of IVDU in remission
who presents following a seizure with severe lactic acidosis and
acute hypoxic respiratory failure. No history of prior
seizures, no FH epilepsy or hypercholesterolemia or early
stroke/MI. CT and MRI and LP collectively form picture of acute,
bilateral, posterior infarcts (septic emboli vs. cardioembolic
vs. cocaine) without prior neurologic disease. EEG showed no
seizure activity throughout MICU stay and was discontinued. She
was maintained on Keppra, empirically treated with antibiotics
and acyclovir. Negative TTE and TEE for valvular vegetation,
with bubble studies showing no PFO. Daily blood cultures were
sent, and antibiotics were discontinued with plan to send
additional blood cultures if she became febrile. CTA/MRA
head/neck were negative for bilateral vertebral dissection or
vasospasm. She had repeated episodes of agitation on multiple
sedation drips but was weaned and extubated without incident. On
the medicine floor, she was stable with no seizure episodes, and
telemetry did not reveal any arrhythmias. She developed ___
which may be attributed to acyclovir toxicity, hypovolemia,
rhabdomyolysis, or CIN. Her ___ was resolving after
discontinuing acyclovir and increasing fluid intake, with
decreasing CK throughout her stay. She will have a repeat lab
check after discharge and see nephrology in ___. For continued
concern for cardiac source of embolic stroke, she was sent home
with ___ of Hearts event monitor to detect any cardiac
arrhythmias. The acyclovir was never restarted given pt had
received 7 days at the time of discharge and given low suspicion
for HSV infection.
========================
Active issues
========================
#Seizure: She had multiple seizures initially with no reported
past history of seizures, etiology unclear. She was noted to
have hyperreflexia and clonus on exam which raised the question
of serotonergic excess, especially as a SSRI was recently added
to her meds. LP excluded bacterial meningitis. HSV PCR sample
was inadequate, but clinical suspicion was low. MRI showed
bilateral nonenhancing posterior lesions, TEE showed no PFO
(repeat TTE showed same result) or endocarditis, MRA/CTA showed
no vertebral artery disease. ___ be related to the possibility
of paroxysmal atrial fibrillation or other abnormal heart
rhythm, although no arrhythmias have been noted on tele.
Hypercoagulable state less likely given negative b2-glycoprotein
and anti-cardiolipin. She was started on keppra and scheduled
to follow up with the stroke service at the time of discharge.
___: Cr up to 2.2 on ___ from baseline 0.7. Possibly
drug-induced from acyclovir vs CIN. Initial UA showed blood with
minimal RBCs consistent with rhabdo. Repeat UA on ___ showed no
blood. Renal US showed no hydronephrosis. An embolic etiology of
the renal failure was considered as well, however, the rapid
improvement in function made this less likely. Ultimately
nephrology assisted with management, recommending IVF which led
to improvement in patient's renal function. Pt is scheduled for
repeat labs as an outpt and renal ___.
#Elevated CK: elevated to 2439 and 270 on dc, indicating
resolving rhabdomyolysis likely due to seizure.
#Abnormal LFTs: ALT/AST peak at 136/164 on ___, downtrended
during the hospitalization. ___ have been drug-induced, although
Keppra and acyclovir are not common hepatotoxic agents vs
ischemic vs rhabdo. Hepatitis panel was negative and RUQ US was
WNL.
#History of Opioid Abuse - Stable, ___ clinic confirmed
dosage of 1.25 tabs. Pt was on 1 tab during the hospitalization
and did well with this, could consider decreasing dose as an
outpt.
#Depression - Stable, has not been receiving home medications
due to initial concern for serotonin syndrome in the ICU.
Patient was feeling well without medications and so these were
held at discharge. She should see her psychiatrist after
discharge.
# Shock, likely septic: She was febrile, tachycardic, with
leukocytosis in ED. She was initially hemodynamically stable,
then became hypotensive refractory to fluids after intubation,
requiring levophed. This was subsequently discontinued as BPs
improved. Most likely etiology of shock is sepsis given the
fevers and leukocytosis. Possible sources include pulmonary in
the setting of aspiration. UA was unremarkable and LP did not
demonstrate meningitis. Medication effect is also possible given
the temporal relationship with sedation and intubation. She was
weaned from pressors and sedation and extubated. She was treated
broadly on vancomycin/zosyn.
#Acute hypercarbic/hypoxic respiratory failure / Mild ARDS: She
was intubated due to inability to protect airway in setting of
seizures. Chest x-ray showed rapidly worsening bilateral
effusions and edema, which was concerning for ARDS vs.
aggressive fluid resuscitation. P/F ratio was 264. She was
maintained on low tidal volume ventilation, covered on
antibiotics as above. She had improving chest x-rays and was
extubated.
#Anion gap metabolic acidosis due to lactic acidosis: Initial
gas post intubation was 6.75/58. Gap rapidly closed and pH
normalized as lactate cleared. Lactate was likely elevated due
to seizure given the rapid clearance. She was initially treated
with fomepizole for concern for ethylene glycol poisoning, but
assay was negative. This resolved as she improved.
# Leukocytosis: WBC was 16 on admission, without neutrophilic
predominance. ___ be reactive in the setting of seizures or due
to infection. She was covered on antibiotics as above.
#Subdural hemorrhage: Initial CT imaging showed a 4mm hyperdense
thickening of posterior falx concerning for subdural hemorrhage
and neurosurgery was consulted. MRI showed no evidence of bleed
and subsequent course did not suggest
#Anemia: 14->9->9->10.4->12. Possibly dilutional i/s/o initially
resuscitation. Trending upward prior to discharge (see lab
section).
======================== | 368 | 888 |
18024959-DS-34 | 29,083,978 | You were admitted to the hospital because you were having nausea
and vomiting in the setting of very high blood sugars. This was
likely due to replenishing your insulin pump with a bad batch of
insulin. You improved with receiving good insulin. You were seen
by the ___ diabetes doctors who confirmed that your pump was
working properly.
In the future, if you have problem with the pump or the insulin
in the pump, please yourself lantus injection 10 units daily for
basal coverage until the pump insulin problem can be corrected. | BRIEF HOSPITAL COURSE
___ year old man with a history of Type 1 DM leading to L BKA,
ESRD s/p LRD ___, CAD, PAD and osteoporosis who presents with 2
days of poor PO intake, vomiting, and difficult to control
hyperglycemia.
Nausea/vomiting: Patient presented with 2 day hx of nausea,
vomiting which was none bloody, non bilious, non projectile in
setting of replacing pump insulin with ? expired batch of
insulin. He was seen by ___ who evaluated the pump and
confirmed its proper function and agreed that the most likely
etiology of his nausea and vomiting was indeed refilling with a
bad bunch of insulin, leading to HONK state with subsequenty
osmotic diuresis and dehydration. He recieved IVF inhouse, was
quickly able to tolerate a regular diet without nausea/vomiting,
with the initial complaint that his stomach felt "raw" with p.o
however this sensation resolved. He restarted his insulin pump
with the correction factor changed to 1.55. He was discharged
with a prescription for lantus 10Units to use in the event of
pump failure for basal coverage.
.
ESRD s/p transplant: pt with hx of ESRD s/p transplant with
chronic rejection. Cr elevated from recent baseline 1.3-1.4 to
2.0 on initial admission. Elevated Cr likely prerenal in
setting of dehydration, and improved with initial IVF and oral
hydration, 1.5 on discharge. Rejection was not suspected given
that he only missed 2 doses of cellcept/tacrolimus when he was
having nausea/vomiting. His tacrolimus level was 5.3 on
discharge and he continued his home tacro 2mg q12 and cellcept
500mg BID.
.
Leukocytosis: pt with leukocytosis of unclear etiology. Exam non
focal. DDx includes infection, gastroperesis flare. Infectious
workup was negative and leukocytosis resolved. Blood cultures
were pending at the time of discharge. | 92 | 290 |
18066032-DS-4 | 26,659,592 | Dear Mr. ___,
WHY YOU CAME TO THE HOSPITAL
You were admitted to ___ following an episode of collapse,
during which you fell to the ground.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL
- You had a number of scans which ruled out any evidence of
injury
- Your pacemaker was reviewed and was found to be working well
- You had a scan of your heart, which did not show any cause for
your collapse
- You had a further episode of collapse while walking with the
physical therapist
- Your blood pressure readings showed a drop when moving from a
lying/sitting to standing position, with subsequent collapse,
which may be responsible for these episodes.
WHAT YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL
- You need to follow-up with a PCP to ensure you are receiving
adequate care
- We would recommend follow-up with a neurologist
It was a pleasure taking care of you.
Your ___ Healthcare Team
MEDICATION CHANGES:
[] started midodrine 10mg three times a day
[] started docusate 100mg two times a day
[] started senna 8.6mg two times a day as required | ___ with advanced dementia, stage III CKD, sick sinus syndrome
with PPM placement in ___, and a background history of colon
cancer and DVT status post IVC filter placement, who was BIBA
following an episode of syncope.
==================== | 173 | 37 |
13035993-DS-30 | 20,875,664 | Dear Ms. ___,
You came to our hospital for back pain and lightheadedness.
Both problems have been going on for a long time. Your symptoms
are likely a result of medication and possibly a mild viral
illness. In the ED, you also complained of chest pain, and has
been ruled out for heart attack. Your condition is stable, and
can go home now. Based on the description of your symptoms of
excessive daytime sleepiness, snoring at night, and poor
nighttime sleep, you may have a condition called sleep apnea. We
strongly recommend going to your sleep study (and perhaps moving
it up), and physical therapy for further improvement of your
symptoms.
.
Please note that the following medication has been changed:
- Please STOP taking meclizine
- Please STOP taking cyclobenzaprine (Flexeril)
- Please decrease carvedilol dose to 25 mg twice a day
- Please decrease your Imdur dose to 30 mg daily, and please
take it in the morning
- Please take your metformin in the morning rather than before
bed
- There are no further changes to your medication.
.
It has been a pleasure taking care of you here at ___. We
wish you a speedy recovery.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. | ___ yo F w/ h/o CAD s/p RES in RCA, DM2, COPD/Asthma, pulmonary
HTN, fibromyalgia, who presented for back pain and
lightheadedness.
.
# Lightheadedness: Pt's light headedness is subacute, likely
multifactorial. Temporally, it is associated with the initiation
of Lyrica in the past two weeks. Other iatrogenic causes
included meclizine. Hypotension from qhs use of imdur with
higher dose carvedilol as well as hypoglycemia from qhs use of
metformin can both cause morning lightheadedness. Other
medications include meclizine, flexeril, Ultram, oxycodone,
lasix. There is no evidence of orthostatic hypotension on the
physical exam. URI and overall deconditioning could also be
contributing factors. We continued her pain medication,
including oxycodone and ultram, held her flexeril, meclizine,
and decreased imdur from 60 mg qhs to 30 mg qAM, and decreased
her carvedilol to 25 mg bid. We would recommend taking the
medication in the morning rather than at night.
.
# Back pain: Pt has chronic lower back pain managed with
epidural injection every three months and chronic pain
medication. There were no red flag signs concerning for cord
compression on the exam. She has known anterolisthesis of L4/L5,
and prior diagnosis of spinal stenosis. Her chronic pancreatitis
could potentially contribute to her pain. Depression is a
potential cause/contributor to her symptoms. The resolution of
her back pain is unlikely during his hospitalization. We
continued her pain medication, and had social worker to help
patient deal with the social stresses.
.
# Fever: She self reported fever at home to 102. She also had a
documented rectal temperature of 100.6 in the ED. She had
cervical tender lymphadenopathy, likely suggesting an URI. There
were no evidence of pneumonia on CXR. There was a qusetion of
pyuria, but urine culture showed skin flora . Pt remained
afebrile with no leukocytosis during this admission.
.
# Coronary artery disease: Pt has DES in RCA. She had some chest
pain in the ED with no EKG changes and her cardiac enzymes were
negative. This has been consistent with her prior presentations,
most likely secondary to fibromyalgia. We continued her home
medication, with the exception of decreasing isosorbide
mononitrate to 30 mg qd and carvedilol to 25 mg bid.
.
CHRONIC ISSUES
# Diabetes mellitus: Pt has diagnosis of type II diabetes,
currently only on metformin 1g per day. She was switched on
sliding scale insulin during this hospitalization.
.
# Chronic diastolic CHF: likely secondary to hyertension. We
held her furosemide for one day during this admission.
.
# COPD and asthma: Pt is obstructive airway disease likely ___
smoking. She uses 3L O2 at baseline. Her O2 sat drops to 91%
on RA. We continued the equivalence of her inhalers.
.
# Chronic pancreatitis: Pt carries diagnosis of chronic
pancreatitis. We continued her Creon with meal.
.
# GERD: Pt carries diagnosis of GERD and is on pantoprazole,
ranitidine and sucralfate. We continued all three medication,
however, given the dizziness, will consider discontinuing
ranitidine.
.
TRANSITIONAL ISSUES
# CODE STATUS: FULL
# CONTACT: ___ (___) and ___
(___)
# PENDING STUDIES AT DISCHARGE: none
# MEDICATION CHANGES
- STOPPED meclizine
- STOPPED cyclobenzaprine
- DECREASED Imdur dose to 30 mg in the AM from 60 mg qHS
- DECREASED Carvediolol to 25 mg bid from 25 qAM & 50 qHS
# FOLLOWUP PLAN
- Pt will arrange followup with Dr. ___
- She has appointment on ___ at HCA with NP ___
- will recommend consolidate GERD medication, especially
ranitidine
- Sleep studies pending | 210 | 611 |
19612461-DS-26 | 22,868,607 | Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
-You came to the hospital because you were having severe
abdominal pain.
What was done for you while you were here?
-You had a CT scan of your abdomen which did not show an
obstruction.
-We started you on a laxative called senna which she will take
twice daily to keep your bowels moving.
-We continued your lactulose and gave you an extra dose.
What should you do when you go home?
-You should continue taking all of her medications as directed
on this paperwork.
-If you do not have a bowel movement one day, you should call
your primary liver doctor. Your abdominal pain will worsen if
you become constipated and stool builds up in your abdomen.
We wish you the best.
Sincerely,
Your ___ Medicine Team | Ms. ___ is a ___ y/o woman with a PMH of alcoholic
cirrhosis (c/b SBP, ascites, HE), non-variceal UGIB, s/p RNYGB,
current G-tube for enteral feedings, recent admissions for
abdominal wall abscess with EC fistula and recurrent ileus/SBO
c/b ATN, encephalopathy, and recurrent clogging of G-tube, who
now presents with diffuse abdominal pain and nausea.
#Acute on chronic abdominal pain
#Opioid induced constipation
#Concern for ileus
Recently admitted with abdominal pain, nausea, and emesis
thought secondary to recurrent ileus or intermittent small bowel
obstruction and now presents with similar symptoms; main
presenting symptom right now is abdominal pain. CT abdomen and
pelvis negative for acute obstruction but did demonstrate
extensive fecalization and findings consistent with slow
transit. Her symptoms are likely worsened by chronic opioid use,
and on her prior admission, she was placed on simethicone and
advised to limit her opioid use. Has not taken tramadol in 1
week due to her pharmacy not having it. Unlikely SBP, on ppx.
Unlikely to represent complication of prior abdominal wall
abscess given the reassuring CT findings. Med rx refill history
shows that she was started on methylnaltrexone and Linzess,
however patient is unsure if she has been getting these. These
meds were not on her pre-admission or discharge medication lists
on her last admission. After speaking with patient's boyfriend
who manages her medications, it was determined that she does
have a Linzess as well as methylnaltrexone at home, however was
not being given these medications because he was following the
last discharge paperwork medication list. Spoke with transplant
surgery regarding her JP drain, they will not see her on this
admission as her drain is functioning well and there is no
purulent drainage or complications currently. | 138 | 281 |
14738747-DS-19 | 20,522,519 | Dear Mr. ___,
You were hospitalized due to symptoms of neck pain and eye
blurriness. We saw that you your right eyelid was drooping, but
this looks like it is old. We did an MRI of your brain, which
shows no sign of a stroke. Your blood vessels did not show a
sign of a tear.
We believe that your neck pain is caused by muscle strain. We
recommend treatment with heat, stretching and ibuprofen. In
order to avoid taking too much ibuprofen we recommend
alternating with Tylenol.
We are not making any changes to your medications. We do
recommend that you do not take more than 3200mg of ibuprofen (16
200-mg tablets) a day because there is a risk of injuring your
kidneys. Also, if you take pain medications every day you can
get medication rebound headaches. Therefore, once your shoulder
is feeling better we recommend that you cut back on the amount
of ibuprofen you are taking.
Please followup with Neurology and your primary care physician.
Sincerely,
Your ___ Neurology Team | ___ presented with neck pain and intermittent blurry
vision in the setting of recent weight lifting. On examination
he had a right ptosis which was present prior to the weight
lifting as well as tenderness over the right temple and neck.
Given the concern for a potential carotid dissection, he was
admitted to the Neurology service for vessel imaging. MRI showed
not acute stroke. MRA was incomplete due difficulty completing
the study and the origins of the vessels were not visualized.
However, there was good flow within all of the cerebral
vasculature which was imaged and there was no evidence of
dissection. Given his reassuring examination, his MRA was not
repeated and he was discharged home with supportive care. As
there was no evidence of stroke, secondary stroke prevention was
not necessary. | 179 | 133 |
19464239-DS-16 | 26,364,552 | INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weight bearing as tolerated
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40mg SC daily for 4 weeks
WOUND CARE:
- You may shower. 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.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
weight bearing as tolerated in the left lower extremity
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively. | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left oblique tibial shaft fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibial IMN, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
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 ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's 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 with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. | 561 | 257 |
12727147-DS-10 | 27,084,628 | ======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- Heart failure
- Fluid overload
- Pneumonia
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received an x-ray and labs
- You took antibiotics for pneumonia
- You took diuretic medications to take fluid off of your lungs
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Weigh yourself daily, keep a weight journal, and call your
primary doctor if you gain >3 pounds in 24 hours.
- Attend your primary care doctor at 3:30PM on ___ with
Dr. ___
- ___ your cardiology appointment at 4PM on ___
with Dr. ___
- ___ to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | ==========PATIENT SUMMARY==========
Mr. ___ is a ___ year-old male with a history of coronary
artery disease, recent MI s/p PCI w stent failure and repeat
PCI, ischemic cardiomyopathy with reported prior EF 35%
following MI, recent course of treatment for pyelonephritis,
DM2, HTN, tobacco use who presented with shortness of breath and
hypoxia and found to have CAP and acute heart failure, treated
with a course of antibiotics and diuretics, now with improved
shortness of breath and hypoxia.
==========ACUTE ISSUES ADDRESSED==========
#Acute on chronic systolic heart failure (EF 25%): Presentation
consistent with flash pulmonary edema in the setting of
hypertension at rehab given ischemic cardiomyopathy. Initially
required O2, but quickly weened to room air. Though overall
improved, continues to have shortness of breath with ambulation,
though sats consistently >90 during ambulation on room air. EF
on TTE this admission at 25% severe regional left ventricular
systolic dysfunction. Previous TTE ___ ___ with EF
35-40% with hypokinesis of anteroseptal and inferoseptal WMA.
Given possible worsening, outpatient cardiologist spoken with;
overall, reassured by clinical status and felt this change on
echo EF prediction was likely just difference in estimation, and
new area of reversible infarct was exceedingly unlikely,
recommending swift outpatient follow up with Dr. ___
against possible recathetritization/viability studies
(scheduled, see follow-up). Patient treated with IV Lasix to
good effect, losartan, PO toresamide, and spironolactone started
for heart failure management. Continued on metoprolol succ 50mg.
Discharge weight 150 lbs.
#CAP
Dense consolidation in RLL w leukocytosis. Though patient denies
cough, fevers upon admission or during hosptial stay, he did
have episode of diaphoresis with shortness of breath; he was
treated with CTX/azitho x5d (___), and upon discharge was
without cough, sputum or fever.
#CAD
#NSTEMI ___ demand
No chest pain at presentation, or during stay. No concerning ECG
changes. Trop peaked at 0.11. Likely ___ increased demand in the
setting of HF exacerbation and infection. The patient was
continued on ASA, ticagrelor, metop. and lisinopril.
===============CHRONIC ISSUES=====================
#DM2
Discharged on NPH 5 twice daily.
#Tobacco Use
Offered smoking cessation assistance, declined
===============TRANSITIONAL ISSUES================
1. Appointment with Dr. ___ care) on ___.
2. Please obtain electrolytes and renal function at follow up
appointment.
3. Please monitor diuretic dosages and weights (patient plans to
keep daily weight journal; dry weight of 150lbs).
4. Appointment with Dr. ___ on ___ for
cardiac follow-up, changed from lisinopril to losartan per Dr.
___. Can consider initiation of Entresto
given heart failure with reduced EF.
5. Please consider additional work up given EF reduction from
40% to 25% with outpatient cardiologist. | 132 | 408 |
10581673-DS-2 | 20,082,443 | Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were having back pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We found that your spinal canal was narrow and was pressing on
your spinal cord.
- You had urgent surgery to fix this.
- After the surgery, your blood pressures were low. You were
given fluids and blood transfusions, and your blood pressures
became normal.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
Surgery
Your incision is closed with staples or sutures. You will need
suture/staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your
sutures/staples.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
*** You must wear your brace at all times when out of bed. You
may apply your brace sitting at the edge of the bed. You do not
need to sleep with it on.
*** You must wear your brace while showering.
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. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
***Please do NOT take any blood thinning medication
(Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
It is OK to take a baby aspirin.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ y/o woman with history of dilated
cardiomyopathy (LVEF ___, HTN, HLD, nonrheumatic MR, history
of kyphoplasty at L1 4 weeks prior to presentation who presented
with lower extremity numbness and weakness, found to have L1
compression fracture and severe lumbar spinal stenosis with
compression of the thecal sac on MRI s/p urgent decompression
with laminectomy, reduction, and fusion T11-L4 on ___, with
post-operative course complicated by acute on chronic anemia,
hypotension, ___, and toxic-metabolic encephalopathy.
============================
ACUTE ISSUES
============================
# L1 compression fracture:
# Severe lumbar stenosis:
# Cauda equina syndrome: On ___, Ms. ___ presented with
back pain and lower extremity weakness after an outpatient
epidural steroid injection. MRI at an outside hospital showed
severe stenosis; Foley catheter was placed for urinary retention
and the patient was transferred to ___ for further care. She
was initially admitted to the neurosurgical service, and whe was
taken urgently to the OR on ___ with Dr. ___ L1
laminectomy and T11-L4 fusion. Her operative course was
uncomplicated; drain was placed in the OR. Postoperatively, she
was extubated and monitored in PACU before transfer back to the
floor. Post-op x-ray was performed on POD#1. Hemovac remained in
place POD#1 due to high output and she was fit with a TLSO
brace. On POD#3, ___, the Hemovac drain was removed. She
mobilized with ___. The patient's Foley was removed and she was
able to void spontaneously. The patient's pain was treated with
scheduled Tylenol and Tramadol as needed. She should continue to
wear TLSO brace when out of bed. She will need her staples
removed and wound check in ___ days post-operatively, as well
as spine follow up with AP/lateral spinal plain films in 4
weeks.
# Toxic-metabolic encephalopathy: ___ hospital course was
complicated by waxing and waning mental status consistent with
delirium in setting of surgery and acute illness. NCHCT was
obtained without acute intracranial abnormality. The patient's
pain was treated as above. Her gabapentin dose was decreased.
The patient was given Ramelteon to help promote a normal
sleep-wake cycle.
# Acute on chronic anemia: Patient with history of iron
deficiency anemia, found to have worsened anemia on ___ and
transfused 2 units PRBCs with appropriate increase in
hemoglobin. Likely related to procedural blood losses.
Hemoglobin subsequently remained stable and the patient did not
require further transfusions. Hb 10 on day of discharge. Patient
continued on home iron supplement.
# Bacteriuria: Urinalysis from ___ notable for 4 WBC, small
amount of bacteria, trace leukocytes, urine culture negative,
without clear symptoms of urinary tract infection. She was
initially started on ciprofloxacin, but this was stopped on ___
as culture was negative and patient was asymptomatic. The
patient complained of urinary frequency after Foley was removed;
multiple repeat urinalysis and cultures were negative for
infection.
# ___: Cr 1.1 initially from baseline of 0.6. Resolved with
fluids. Cr 0.5 on day of discharge.
# HTN: The patient had an episode of symptomatic orthostatic
hypotension on post-operative day 1, likely secondary to
hypovolemia and anemia. The patient's antihypertensives were
initially held, and she was given intravenous fluids and blood
transfusions as above with resolution of her hypotension. Her
antihypertensives were slowly re-introduced, with stable blood
pressures. Her home carvedilol was resumed, and half her home
dose of valsartan. Please continue to monitor blood pressures
and titrate medications as appropriate.
# Chronic sCHF: LVEF ___. TTE from ___ unchanged from prior.
Cardiology was consulted for assistance with management. Patient
was initially hypovolemic and was given intravenous fluids to
good effect. She was subsequently euvolemic throughout the rest
of her course and did not require further fluids or diuresis.
Her carvedilol and valsartan were resumed as above. Unable to
obtain true discharge weight as patient unable to stand without
TLSO brace.
=============================
CHRONIC/STABLE ISSUES
=============================
# HLD: Continued atorvastatin. Resumed aspirin (81 mg daily
decreased from home 325 mg daily) in discussion with
neurosurgery.
# Depression: Patient no longer taking escitalopram
>30 minutes spent on care/coordination on day of discharge.
=============================
TRANSITIONAL ISSUES
=============================
- Discharge weight: unable to obtain as patient in TLSO brace
- Monitor volume status and consider diuresis if needed (LVEF
25%)
- Patient should wear TLSO brace when out of bed
- Patient will need an appointment for suture/staple removal and
wound check in ___ days postoperatively (surgery on ___.
Please call ___ to make this appointment.
- Patient to follow up with Dr. ___ in 4 weeks, and
will need AP/Lateral X-rays at the time of this appointment.
Please call ___ to make this appointment.
- Discharged on scheduled Tylenol and low-dose tramadol as
needed for pain control. Please continue to assess pain and
adjust regimen as appropriate. Patient has required very little
tramadol while hospitalized.
- Please check blood pressure and adjust antihypertensive
regimen as appropriate. Discharged on half of home valsartan
dose, uptitrate to home dose as appropriate.
- Gabapentin dose decreased from 300 TID to ___ TID due to
confusion; please continue to assess mental status and adjust
dose as appropriate.
- Started on Ramelteon at night for sleep; continue to assess
need for this medication.
- Continued home vitamin D and started on calcium
supplementation for bone health.
- Patient on ASA 325 as an outpatient; restarted on ASA 81 mg
daily given no clear indication for full-dose aspirin
- Communication: ___, daughter, ___
- Code: Full (confirmed) | 341 | 866 |
18705722-DS-34 | 27,014,186 | Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital due to difficulties breathing, and
concerns for an asthma exacerbation.
What did you receive in the hospital?
- While in the hospital, we gave you multiple medications to
help resolve your exacerbation. This included inhalers,
steroids, and magnesium. You continued to remain symptomatic in
the emergency room, and thus we admitted you to the hospital
overnight. Thankfully, in the morning your symptoms had
improved, and we felt you were safe for discharge home.
What should you do once you leave the hospital?
- Please continue to take your medications as prescribed
- We would recommend you try and avoid sick friends and family
so as to not exacerbate your asthma.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Continue taking 3mg warfarin until you have a chance to have
your INR drawn on ___.
We wish you the best!
Your ___ Care Team | ___ with extensive cardiac history, presenting for asthma
exacerbation. His symptoms markedly improved with nebulizer
treatments and steroids.
ACUTE ISSUES
============
#Acute Asthma Exacerbation
Patient's history and symptoms were concerning for asthma
exacerbation. In the ED, patient was started on ipratriopium and
albuterol, and given a dose of methylprednisolone. He was
brought to ED obs for further monitoring, but had marked
improvement after initial therapy. However, while boarding he
was still symptomatic, and tachypnic while talking. There was
initial concern for a possible PNA, and thus patient was started
on Ceftriaxone and azithromycin, but this was discontinued given
final read of his CXR. Though his sats continued to remain
stable on RA, he continued to report subjective dyspnea, and had
tachycardia to the 100s with ambulation. He was brought up to
the floor were inhalers and steroids were continued, along with
his home montelukast and advair. By the morning, the patient's
symptoms had markedly improved, with ambulatory O2 sats ~94.
There was low concern this was a HF exacerbation, as his CXR,
BNP, and exam were not consistent with this.
[] Patient should have close monitoring of his asthma, and
discussion whether this is an appropriate regiment for him.
CHRONIC ISSUES
==============
#. Atrial Fibrillation
INR goal 2.5-3.5 in setting of mechanical valve. INR 4.1 on
morning of discharged. Was given 3mg, and instructed to
follow-up closely for further monitoring of his INR. He was
continued on metoprolol and digoxin.
[] Patient will need close follow-up for monitoring of his INR,
preferably ___
#. HFrEF
Continued home Torsemide, Entresto, Spironolactone, and Digoxin.
#. CAD/HLD
Continued home atorvastatin
#. Normocytic Normochormic Anemia
Hemoglobin at baseline
#. H/o Prostate CA
Continued home tamsulosin 0.4mg PO QHS
#RESTLESS LEG SYNDROME
Continued ropinirole
TRANSITIONAL ISSUES
===================
[] Patient should have close monitoring of his asthma, and
discussion whether this is an appropriate regimen for him.
[] Patient had supratherapeutic INR at discharge in setting of
receiving antibiotics for possible pneumonia. Consulted with
pharmacy and decided to decrease warfarin from home 6.5mg to 3mg
daily. He will need repeat INR drawn on ___, and
adjustment to his warfarin dosing based on the result.
#CODE: FULL
#Health care proxy/emergency contact: ___ (wife):
___ | 188 | 350 |
10917306-DS-11 | 25,779,103 | Dear Ms. ___,
You were admitted to the hospital with difficulty breathing. We
found that you had the flu, and we gave you treatment for that.
We also felt that you had some extra fluid in your lungs due to
an exacerbation of your heart failure that was triggered by the
flu, so we gave you additional medication to help you to urinate
more to decrease that fluid. We also gave you oxygen to help
with your breathing.
You are improving but still symptomatic with the flu. To prevent
spreading it to others, please try to limit close contact with
others (especially children) and stay at home while you are
still recovering.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team | ___ with PMH of CAD s/p CABG (___), CHF (EF 40%), DM2, HTN,
CLL (stable), strokex3 and CKD (baseline Cr 2.0) with residual
hemiparesis who presented with productive cough and wheezing
over the past 5 days and found to have the flu and CHF
exacerbation.
# Cough and wheezing: Positive for the flu. Given tamaflu and
continued levofloxacin for possible superimposed bacterial
infection. Treated symptomatically with oxygen, DuoNebs,
Benzonatate, Guaifenesin, lozenges.
# CHF exacerbation: BNP on admission 5434. Slightly volume up on
exam and diuresed to dry weight on discharge.
#Tropinemia: Likely in setting of demand from mild CHF
exacerbation in setting of CKD. No chest pain or acute ST
changes concerning for ACS. Held heparin drip. Continued home
ASA. Not on ACE because of CKD.
# Pancytopenia: Patient has history of CLL which can lead to
pancytopenia since Autoimmune hemolytic anemia (AIHA), immune
thrombocytopenia (ITP), and pure red cell aplasia (PRCA) are
well-described complications associated with chronic lymphocytic
leukemia (CLL). Her hematocrit was around her baseline on this
admission, and her admission leukopenia (___ 1798) and
thrombocytopenia were likely exacerbated by infection; improved
on discharge.
CHRONIC MEDICAL ISSUES:
# Type 2 diabetes: poorly controlled. Daughter states pt has
very labile blood sugars at home. Continued home insulin regimen
and ISS, held standing humalog with meals given episodes of
hypoglycemia on recent hospital stay.
# Chronic kidney disease: Patient's creatinine 1.9-2.1
throughout admission which is at her baseline.
# Hypertension: Continued Metoprolol Tartrate 25 mg PO BID,
changed to metoprolol succ 50 mg daily on discharge.
# HL: Continued home statin. | 120 | 255 |
19388963-DS-9 | 26,498,440 | You presented to the hospital with a recurrent urinary tract
infection. You were treated with strong intravenous antibiotics
and a urine culture was sent, which returned without a clear
answer. As the urine culture done at ___ also did not give us a
clear answer, you were seen by Infectious Disease who
recommended a particular oral antibiotic based on your prior
infections.
You will need to continue these antibiotics THROUGH ___ (last dose that evening).
As we discussed, it is strongly recommended you see a Urologist
given your recurrent infections. Your PCP can help refer you to
one at the ___ based on your preference to be seen here. | ___ year old male w/ a history of paraplegia (s/p work accident
in his teens), recurrent UTIs, migraines, who presents with
several days of lethargy and diaphoresis in the setting of
recently treated UTI, now w/ likely inadequately treated UTI
leading to sepsis due to pyelonephritis.
# Sepsis secondary to
# Pyelonephritis:
CTU shows R perinephric stranding c/w pyelo. Multiple stones,
but non-obstructing. Urine cx shows GPC and GPR, likely not
treated by ___ as prescribed last week. Started on Vanc/CTX
here with marked improvement in symptoms, fever curve, and WBC
(24->7). Urine cx at ___ from ___ with 3 different GPC
isolate and one GPR isolate Urine culture here at ___
contaminated. Based on unrevealing culture data, ID was
consulted to help provide guidance re: optimal oral abx
treatment upon discharge. Based on prior culture data,
Augmentin was recommended to complete 14-day total course of
antibiotics Patient is strongly recommended to see Urology
given h/o stones and prior urologic procedures with now frequent
UTIs; he may also benefit from suppressive antibiotics in the
future.
# ___ - mild on the right hand after exposure prior to
admission. Treated with triamcinolone cream x 7 days. | 109 | 198 |
19438782-DS-21 | 25,892,850 | Mr. ___,
You were admitted to the hospital for operative treatment of
perforated small intestine, colonic volvulus and an incarcerated
ventral hernia. This took place on ___, and the operation
performed was a subtotal colectomy with an end-ileostomy. Here
are some instructions for your post-operative period:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 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.)
You may start some light exercise when you feel comfortable.
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.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
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 may have a sore throat because of a tube that was in your
throat during surgery.
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 INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
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).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
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.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
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 folloiwng, 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.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
OSTOMY CARE:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours. | Mr. ___ was admitted to the General Surgery - Acute Care
Service (ACS) at ___ on ___ for surgical management of
colonic volvulus, an incarcerated ventral hernia and small bowel
perforation in the setting of past Roux-en-Y gastric bypass. The
patient was first evaluated at an outside hospital, but
transferred to ___ emergently upon discovery of the small
intestinal perforation. In the emergency department, the patient
was noted to become hemodynamically unstable and required
vasopressor support. He was taken urgently to the operating room
at which point he underwent a subtotal colectomy with
end-ileostomy. Two JP drains were placed, in the hernia sac and
paracolic gutter, respectively. Please see the operative note
for further details regarding this procedure. Post-operatively
he remained intubated due to the complexity of the procedure and
the patient's body habitus; he was transferred to the SICU for
further care.
While in the SICU, the patient's course was notable for a
continued early vasopressor requirement including phenylephrine
and norepinephrine. His lactate trended down appropriately. The
patient remained intubated on HD#2 - HD#3 due to agitation with
multiple attempts at weaning his sedation. He was extubated on
HD#4 without difficulty. The hernia sac JP was removed and his
NG tube was clamped with no residual. He was transferred to
floor care on HD#6 once tolerating a full diet and off pressor
requirement. The second JP drain was removed on HD#8. The
patient remained on a regular diet which he tolerated well. He
had adequate urine output via indwelling Foley catheter.
Electrolytes were monitored due to high ostomy output; this
trended down with addition of psyllium wafers to the patient's
diet. He was evaluated by Physical Therapy and underwent
multiple conditioning sessions with our ___ team. On day of
discharge the patient was able to be transferred from bed to
chair with assist and stand unsupported. He was discharged to a
___ rehabilitation facility in improved condition. | 719 | 317 |
17196400-DS-15 | 23,082,450 | Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment 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
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours** | SUMMARY:
==========
___ is a ___ y/o M w/ PMH of mitral valve endocarditis,
alcohol use disorder with history of alcohol withdrawal seizures
and IDDM2 that was found unresponsive in bed at his home on
___ and brought to ___ for hypoglycemia (BS 45) and
hypoxemia (SpO2 ___, had seizures, required ___
transferred to ___ and admitted to the ___ where he was
treated for septic shock and ARDS. He was extubated and
transferred to medical floor on ___. *** | 104 | 78 |
15178179-DS-18 | 25,693,051 | 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. | ___ s/p open cholecystectmoy at ___ on ___ w/ subsequent
obstruction s/p ERCP with stent placed on ___, admitted here
with persistent biliary leak. Patient was admitted and had a
HIDA scan, which was consistent with a small biliary stump leak.
He was started on cipro/flagyl to complete 5 days of
antibiotics. Fluid collection in gall bladder fossa was stable
and did not require drainage. Patient's pain improved and diet
was advanced as tolerated. Patient as ambulating prior to
discharge. He will follow up with us in surgery clinic given his
desire to transfer care away from ___ and should follow up with
GI at ___ for stent removal. | 263 | 109 |
10892316-DS-16 | 25,469,485 | Dear Mr. ___,
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
experiencing shortness of breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were given a water pill to help you get rid of the extra
fluid buildup.
- You had a catheterization to look at your heart vessels. You
did not receive any stents.
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: 71.7 kg. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team | ___ y/o male with CAD s/p DES x2 to RCA in ___ (___), thoracic
aneurysm s/p grafting TEVAR, s/p infrarenal aorta repair with
aorto right iliac graft, HTN, bilateral RAS, DVT s/p IVC filter,
PVD, CKD, who presented with shortness of breath, transferred to
Cardiology for management of unstable angina and HFpEF
exacerbation.
CORONARIES: 100% in-stent restenosis of RCA, R-L collaterals,
20%
stenosis of pLM, dLM, 40% pLAD, 40% mLAD, 70% pDiag
PUMP: EF 36% (___)
RHYTHM: Sinus tachycardia.
==================== | 199 | 77 |
19885726-DS-21 | 29,902,732 | Dear Ms. ___,
======================================
Why did you come to the hospital?
======================================
-You were having abdominal pain.
======================================
What was done for you at the hospital?
======================================
-An imaging study of your belly showed many large fluid
collections known as "cysts". They were located in various
organs including your liver, spleen, kidney, and pancreas. Some
of these cysts were pressing on your stomach, and our team
believes this is the source of your pain and lack of appetite.
-We drained one of these large liver cysts and your symptoms
improved, though did not completely resolve.
=================================================
What needs to happen when you leave the hospital?
=================================================
-Follow up with your primary care doctor
-___ up with our liver team
-Have your INR checked on ___ | ***TRANSITIONAL ISSUES***
#Patient has a chronic, polycystic process affecting her liver,
spleen, pancreas, and spleen of unclear etiology. ___ need
further workup and drainage procedures depending on her pain
level, goals of care.
#Please assist for follow up with Dr. ___, her GI
doctor in ___. Patient's nephew aware and will reach out
for a follow up appointment.
#CT A/P showing extensive bilateral fibrosis with honeycombing
of the lung bases. Diagnosis may need clarification.
#Patient noted to desat to 88% with ambulation, quickly
recovered with rest, may need to wear oxygen more than just at
night
#Patient is troubled by her psoriasis, consider starting
treatment
#Warfarin follow by Dr. ___ ___, currently 2mg
daily
#Digoxin level 1.5, monitor closely as outpatient may need dose
reduction
#Discharge weight: 44.32kg (euvolemic exam)
#CODE STATUS: DNR/DNI (confirmed ___ with patient)
#CONTACT: ___, nephew ___, ___
___ year old female with history of a chronic, polycystic process
affecting her liver, spleen, pancreas, and spleen of unclear
etiology, afib/SSS s/p PPM on warfarin, fibrosis/honeycombing of
the lung bases on O2 at night who presents as transfer from
___ with chronic, worsening LUQ and epigastric abdominal
pain. Abdominal imaging showed mass effect from these cysts, and
our team believed this explained her chronic abdominal pain.
On ___ she had an uncomplicated ultrasound-guided
aspiration of a 9.4 cm left hepatic cyst with collapse of the
cavity on post aspiration imaging. 350 cc of dark non purulent
fluid. Cytologic evaluation was negative for malignant cells
and no microorganisms were seen on gram stain or culture.
After the procedure her pain had improved, though not
completely. Our team believed this was most likely due to the
multiple cysts that were not drained. We spoke extensively with
the patient regarding the utility of further aspiration
procedures. We noted that is very difficult to determine which
cysts are generating her pain and that the cysts can
re-accumulate fluid. Also explained the risk of infection and
bleeding with each additional procedure. Given that her pain
was "tolerable", she elected to defer any additional procedures
at this time. We told her this can be readdressed as an
outpatient if her pain level changes.
Additionally, patient had diarrhea for ___ days after her
procedure. This was likely related to an overly aggressive
bowel regimen which was started given her presenting complaint
of constipation. She was sent home with a bowel regimen to use
as needed. | 118 | 404 |
18921677-DS-2 | 21,092,319 | Dear Mr. ___,
You were admitted to ___ for back pain related to a recent
back injury. You were found to have a pinched sciatic nerve due
to slipped disk in back that was seen on MRI. The surgery team
saw you and decided the following: ******. We treated your pain
with oral Morphine and Ibuprofen. Physical therapy saw you twice
and recommended *****. You will also receive home physical
therapy for your back. We wish you all the best.
From,
Your care team at ___ | ___ s/p L5-S1 hemilaminectomy, microdiscectomy in ___
presenting with acute back pain with positive straight leg raise
with sciatica.
#L5-S1 radiculopathy:
Patient presented with lumbar back pain, radiating down the leg,
MRI findings of herniated nucleus pulposus causing foraminal
narrowing L>R, suggesting that his pain is most likely due to
radiculopathy without evidence of cord compression. Also had
paraspinal muscle tenderness which suggests presence of
concommitant muscle spasm as well. Patient evaluated by spinal
surgery team without recommendation for surgical intervention.
Pain was controlled with IV/PO medication and transitioned
primarily to PO ibuprofen with oxycodone for breakthrough pain.
Valium also used for muscle spasm. Patient evaluated by ___ who
recommended outpatient ___ and rolling walker that were provided.
Patient was discharged with plan for close follow up with PCP
and ___ to evaluate renal function in setting of hypertension
and ibuprofen use. | 84 | 142 |
14598293-DS-11 | 21,999,725 | Dear Ms. ___,
You were admitted to ___ due to generalized weakness and
fatigue. To look into your symptoms, we did an MRI of your
entire spine as well as an MRI of your brain. These studies did
not reveal any significant abnormalities or changes compared to
prior imaging. We also checked for infections or electrolyte
changes, and found that you had a urinary tract infection. By
the morning, you had some improvement in your lower extremity
strength. You were evaluated by Physical and Occupational
Therapy and determined to be safe for discharge. Moving forward,
it will be important for you to go to a number of follow up
visits. We have arranged for you to follow up in the Cognitive
Neurology clinic for an evaluation of your gait, and to check in
with Dr. ___ to see how things are going. You should
also follow up with Dr. ___ as scheduled in ___. Finally,
we ask that you see the social worker in our cognitive neurology
clinic to make sure your stressors are controlled.
It was a pleasure taking care of you.
Sincerely,
Your ___ care team | Patient presented with somewhat unclear, vague complaints of
generalized, symmetric weakness, with the legs more prominent
than the arms. For further evaluation, she had a metabolic and
infectious workup that revealed grossly positive UA, in the
context of dysuria and recent treatment courses for UTI with
CIprofloxacin. She was started on Ceftriaxone and discharged to
complete 5 day course with Cefpodoxime, given the recent Cipro
course with persistent symptoms. Repeat urine culture was
pending at the time of discharge. Given ___ increasing
disability and exacerbation of symptoms, it is possible that
this could represent a mild flare of MS. ___ pan-spine and
brain MRI did not reveal any new lesions. ___ examination
slightly improved on the morning following admission. She was
able to stand and walk without assistance. On day of discharge,
she also had ___ evaluation who determined patient was safe for
discharge home, with plans to resume ___ baseline ___ services.
She was also given a prescription for walker per ___
recommendations. | 187 | 172 |
13349882-DS-5 | 25,849,161 | Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You were recently admitted because of a fall at your rehab
facility in the setting of fever. Because you had recent surgery
on your neck, the neurosurgeon evaluated the wound in the
emergency room and did not notice any signs of infection. You
were found to be retaining urine as well, which can result from
some of your medications. However, the urine was not infected.
The most likely cause of your fever after an operative procedure
result from not breathing in deeply enough because of pain.
During your hospitalization, we optimized your pain medication
and you had no more fevers. You will have to wear your hard
c-collar until your follow-up with Dr. ___
___ receive physical therapy at rehab.
Sincerely,
Your ___ care team | ___ year old woman with PMHx notable for anxiety, depression,
chronic neck pain s/p C4-C5 laminectomy and C2-C6 fusion on
___ who presented from rehab s/p falling and hitting her
head at ___ today and was admitted for work up of
post-op fevers.
ACUTE ISSUES
============
# Post Op Fevers: The patient is s/p C4-C5 laminectomy and C2-C6
fusion on ___ with fevers that were present post op
according to the patient. Pt was placed on PO cipro prior to
discharge despite having a negative U/A and urine culture with
no growth. She presented to Rehab where she continued to be
febrile with the highest documented fever of 100.6. In the ED,
she had a mild temperature of 99.8. She had no signs of
infection on exam and no WBC count. On the floor, the patient
reported feeling well other than pain in her neck. She denied
any shortness of breath, pain with breathing, dysuria or
increased urinary frequency, pain or swelling in her legs. The
ciprofloxicin was stopped, and Tylenol was discontinued to
monitor the fever curve. No fevers occurred. A UA and urine
culture was negative. Neurosurgery inspected the wound and
reported that the wound was not infected. As no source of
infection could be identified and the patient had no shortness
of breath/chest pain, the most likely cause of the
post-operative fever is atelectasis. The patient was given
incentive spirometry and had no recurrence of fevers since
admission. She will be discharged to ___, where she
will continue to receive physical therapy and pain management.
# Urinary retention: Likely related to opiate and other
medications including cyclobenzaprine and amitriptyline. She was
bladder scanned for >1000cc on two different occasions and was
emptied with a straight catheter. Given the failure of the
urinary retention to resolve, a Foley catheter was placed, which
should remain in place for ___ days.
# C4-C5 laminectomy and C2-C6 fusion: She achieved adequate pain
relief from morphine ___ q6h prn. Neurosurgery recommended
that the patient stay in a hard c-collar for 6 weeks or until
cleared at her appointment with Dr. ___.
# Post-op ileus: The patient was discharged with post-op ileus,
and she has been taking a large number of bowel meds at rehab
(8x daily miralax). She has been passing gas, having bowel
movements, and is eating. As she returns to rehab, the goal
should be to decrease pain medications as tolerated and to
continue the aggressive bowel regimen.
#s/p fall: per patient report, her "legs gave out" while
walking. The cause of her fall is likely multifactorial, but
medication effect may play a significant role. Would benefit
from medication reduction in the future.
CHRONIC ISSUES
==============
# Depression: continued home antidepressants
# Anxiety: Continued home medications
TRANSITIONAL ISSUES
===================
# Neurosurgery noted that the patient should remain in a hard
c-collar for 6 weeks after the procedure or until her Dr.
___ her.
# A Foley catheter was placed ___ due to urinary retention >1L.
The Foley should stay in for 3 days and then a voiding trial
should be conducted.
# Please consider decreasing pain medications as tolerated in
the setting of postoperative ileus. Presently, the patient
requires a very aggressive bowel regmen to have bowel movements.
# The patient and her PCP should review her medication list in
detail. In particular, she remains on two benzodiazepines, and
she is also on cyclobenzaprine and amitriptyline, which can
cause urinary retention. She may benefit from a reduction in the
number of medications she is taking.
# Code: confrimed full
# Emergency Contact: ___ (son), phone number:
___. | 138 | 585 |
17012058-DS-16 | 27,832,186 | Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for abdominal pain, nausea, and inability
to eat or drink
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, we started you on IV
antibiotics
- We did an MRI of your liver and gallbladder which did not
show any evidence of abscess. Your symptoms improved
significantly with IV antibiotics.
- You were seen by our infectious disease specialists who
recommended you get a 2 week course of IV antibiotics and follow
up with your outpatient specialist after this is done.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team | Ms. ___ is a ___ year old woman with secondary sclerosing
cholangitis due to biliary strictures, recurrent pancreatitis,
whipple surgery, surgical revision, redo Roux-En-Y
hepaticojejunostomy in ___ and suppressive antibiotics who
presented with worsening abdominal pain, inability to tolerate
PO consistent with acute on chronic cholangitis. Patient was
started on IV antibiotics (D1: ___- planned end ___
TRANSITIONAL ISSUES
===================
[] Should complete 2 weeks of IV antibiotics (D14: ___-
subsequent supporession choice/course will be determined by
patient's outpatient ID doctor (___).
ACUTE ISSUES
============
#Acute on chronic cholangitis
Patient has a history of chronic cholangitis and recurrent
pancreatitis managed on suppressive augmentin. She has recently
experienced worsening symptoms of abdominal pain, nausea, and
inability to tolerate PO. She was initially managed outpatient
with increased doses of her chronic augmentin but her symptoms
did not resolve. She was referred to the ED where she underwent
RUQ U/S without abscess. She was started on Zosyn and then
transitioned to CTX/flagyl (D1: ___. She underwent MRCP ___
which showed stable mild acute on chronic cholangitis without
evidence of abscess. Plan for 2 weeks of ceftriaxone 2 gm q24H +
metronidazole 500 mg q8H ending ___ she will have ID follow up
at that time to determine further course.
==============
CHRONIC ISSUES
==============
#Roux-En-Y Bypass
Continued home Lansoprazole 30mg ___ ___ 150mg BID,
Calcium citrate-Vit D (250-200) BID, Cholecalciferol 1000u
daily, Lactobacillus, and Multivitamin-minerals-lutein
CORE MEASURES
=============
#CODE: Full, confirmed
#CONTACT: ___, husband, ___ | 156 | 234 |
18664411-DS-8 | 26,181,656 | Dear Ms. ___,
You were admitted with sore throat and difficulty eating and
breathing. This is likely due to mono. You were given steroids
and pain medications in the hospital which controlled your
symptoms. Please follow up with your primary care doctor. | ___ with tonsilar swelling and exudates with tender cervical
lymphadenopathy and positive monospot test with mild hepatitis
overall consistent with a mono-like illness with decreased PO
intake and reported dyspnea at night prior to admission.
# Mono-like illness: Patient has a mono-like illness with some
atypical features. However, her overall clinic presentation
with abnormal LFTs, atypical lymphocytosis, tender cervical
adenopathy, and tonsilar exudates and swelling with positive
heterophile antibody are very suggestive of infectious
mononucleosis. Acute HIV was ruled out with undetectable viral
load. The differential would include autoimmune or malignant
(lymphomatous) processes but these appear to be less likely
based on history, exam, and LDH. They can be considered for
further workup if symptoms persist unexpectedly.
# Concern for airway obstruction: patient brought in with
concern for night time obstructive symptoms related to her
lymphadenopathy and tonsilar enlargement. Currently not at risk
for pending airway obstruction. She was monitored overnight on
telemetry with continuous O2 sat monitoring. She did not
desaturate overnight on room air. She was given Prednisone 40mg
daily for a planned 5 day course.
# Odynophagia with decreased PO intake: Likely related to her
mono-like illness with inflamed tonsils. She has been able to
drink >1L of a liquid diet prior to discharge. Pain was
initially controlled with roxicet elixir and ketoralac IV. Once
her pain was under control and she could take pills without
difficulty her regimen was changed to standing tylenol and
ibuprofen pills with oxycodone ___ Q4H PRN.
# Abnormal LFTs: Likely ___ suspected mono as above, was they
were previously normal in ___. Potential related to weight and
NASH vs. tylenol use but these were felt to be less likely. Her
LFTs should be rechecked as an outpatient when she is
recovering. | 45 | 310 |
19898805-DS-14 | 28,419,294 | Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You fainted.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had blood tests which were all normal.
- You had imaging of your chest and head which was normal.
- You were seen by Cardiology and were kept on a heart monitor
which was normal.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
-Please follow the instructions below to make sure you schedule
a heart ultrasound/Echo, get an event heart monitor, and make
Cardiology and PCP appointments as below.
Please take care!
Sincerely,
Your ___ Team | TRANSITIONAL ISSUES
===================
[ ] Patient to get outpatient TTE in the next week. The order
has been placed in OMR for this to be performed at ___.
[ ] Patient to get outpatient event ___ of Hearts) monitor for
2 weeks. The order has been placed in OMR for this to be
scheduled by ___.
[ ] Patient to follow-up with Dr. ___ at ___
Cardiology in ___ weeks to follow up on the results of the above
studies. Patient to call office at ___ to make the
appointment. | 129 | 87 |
13280844-DS-11 | 27,138,420 | Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. Briefly, you were hospitalized with pain in your right
hip. The prosthesis was found to be dislocated from the hip
socket. This was thought to be caused by chronic infections in
the tissue surrounding the hip joint for which you were treated
with antibiotics. You underwent several surgeries with
orthopedics and plastic surgery ad you prosthesis was remove due
to surgery and infection was controlled and your wound was
closed. You were in the hospital for surgery and It is normal to
feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non Weigh Bearing in Right Lower Extremity
MEDICATIONS:
- You were restarted on intravenous antibiotics, Vancomcyin and
Ceftriaxone to treat hip joint infection
- 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.
- You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
ANTICOAGULATION:
- Please take lovenox with coumadin until INR >2, then just take
coumadin. If you were taking aspirin prior to your surgery, it
is OK to continue at your previous dose while taking this
medication.
WOUND CARE:
- Please keep your incision clean and dry.Please place a dry
sterile dressing on the wound each day if there is drainage,
otherwise leave it open to air. No dressing is needed if wound
continues to be non-draining.
- It is okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup.
- Check wound regularly for signs of infection such as redness
or thick yellow drainage. Staples will be removed by the
visiting nurse or rehab facility in two (2) weeks.
Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns. | ___ with h/o afib on coumadin, prostate cancer s/p
prostatectomy, breast cancer s/p chemo/XRT/mastectomy, total
right hip replacement, revision in ___, chronic right hip
ulceration, p/w right thigh pain
ACTIVE ISSUES
# Right Hip Prosthesis Dislocation: ___ and Hip X ray on
admission showed interval dislocation of acetabular prosthesis.
Joint aspiration was negative on ___ and fluid culture. He was
continued on PO Amoxicillin and Ciprofloxacin which he was
taking after completing a 6 week course of IV Ceftriaxone and
Daptomycin for prior enterococcous/Enterococcus/Klebsiella
septic R hip. He was evaluated by orthopedics and plastic
surgery and underwent flap preservation and I/D with synovectomy
of chronically infected right revision total knee replacement,
removal of acetabulum cup insert and femoral head and insertion
of endoprosthetic unipolar head on ___. | 526 | 126 |
11966699-DS-35 | 20,097,937 | Mr. ___, it was a pleasure to participate in your care while
you were at ___. You came to the hospital after an episode of
nose bleeding that did not stop at home. While you were in the
emergency department you had a procedure to stop the bleeding
from your nose. You experienced some chest pain and were
admitted to the cardiology service. While you were here we
ruled out a heart attack as the cause of your chest pain. You
have chronic angina which is likely what caused your pain.
Given your recent stress test that did not show any areas of
heart that needed any intervention, we did not feel that you
needed any futher evaluation while you were here. You chest
pain did not recur in the hospital.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
MEDICATION INSTRUCTIONS:
- Medications ADDED: None.
- Medications CHANGED: None.
- Medications STOPPED: None. | REASON FOR HOSPITALIZATION:
___ with M h/o of CAD, s/p CABG ___ and PCI to RCA ___,
stable angina, CHF (EF = 30%), LV thrombus on coumadine, pacer +
ICD, HTN, HLD who is admitted for epistaxis and chest pain. | 163 | 41 |
13880080-DS-24 | 23,643,867 | You were admitted for evaluation of confusion and agitation. For
this, you were evaluated by the geriatrics, psychiatry and
neurology teams. A work up was performed including lab testing,
CT of the head, and looking for infection and was unremarkable.
You symptoms were felt to be a medication effect from keppra.
Therefore, you are being tapered off this medication. Please see
below for instructions. You will need to follow up with the
neurology team after discharge.
. | Assessment/Plan:
___ is an ___ y.o female with h.o AFib, CVA, s/p fall with hip fx
and SDH, ?seizures, depression who was admitted for evaluation
of encephalopathy and agitation.
.
#metabolic encephalopathy with agitation/aggression-EKG, EEG,
head CT and laboratory testing were unrevealing. Considered
possibility of CVA and behavioral changes related to SDH and TBI
as well as possible seizure. However, her symptoms were felt to
be likely due to medication effect from keppra. The geriatrics,
neurology, and psychiatry teams were all consulted and
recommended a keppra taper (750mg BID x3 days-complete, 500mg
BID x3 days (Started ___, then 250mg BID x3 days, then 250mg
QHS x3 days then off. These teams also recommended considering
an ativan taper to off as well. However, she is currently on 1mg
TID and doing very well with this regimen. Trazodone was also
discontinued her her gabapentin dosing was changed to be renally
dosed at 300mg BID. As the keppra taper was started, pt's
symptoms markedly improved. She was calm, cooperative, and did
not exhibit confusion from ___. There was
never any evidence of seizure or CVA noted during admission.
B12, rpr were unrevealing and dilantin level appeared to be
apppropriate. The patient will need to follow up with the
Traumatic Brain Injury clinic with Dr. ___ (___)
as well as Drs. ___ in the General Neurology clinic
(___) as planned during her prior admission. She should
followup with Dr. ___ in the ___ clinic
(___) at the beginning of ___ as previously planned
planned.
++ Of note, after discussion with neurology, it was decided that
pt should be therapeutic with an INR of 2.0 on her coumadin. Her
coumadin dosing was increased to 3mg on ___. This should be
continually uptitrated to reach an INR goal of about 2.
++Of note, her Free t4 was mildly decreased. Her levothyroxine
can be further titrated in the outpatient setting.
.
#afib-continued coumadin. Increased dosing to 3mg daily as she
was subtherapeutic. She should continue her coumadin with
increasing uptitration to a goal INR of about 2.0 given her
prior CVAs. She was not bridged with heparin or lovenox given
her prior history of intracranial bleeding. Neurology agreed
with this plan.
-follow daily INR and continue to uptitrate coumadin carefully
to INR of 2
.
#h.o sub dural hematoma/h.o seizures?-Neurology was consulted.
Pt's dilantin was continued a current dosing for seizure
propylaxis. Dilantin levels were appropriate. Keppra titration
to off was started. See above given pt's delerium and mood
swings. Please see above for keppra instructions. Pt will need
to follow up with neurology, TBI, and ___ clinic.
.
#HTN benign-continued metoprolol
.
#s/p CVA-continued coumadin (see dosing changes above under
afib), statin
.
#Hyperlipidemia- continued statin
.
#neuropathy-gabapentin decreased to appropriate renal dosing at
300mg BID
.
#hypothyroidism-continued levothyroxine at current dosing.
However, given slighly low free t4 (see results section above),
may want to uptitrate.
.
FEN: regular
.
DVT PPx: hep SC TID while INR suptherapeutic while admitted.
.
CODE: DNR/DNI
.
Transitional care
1.continue keppra taper as outlined above
2.consider downtitration of ativan
3.pt will need f/u with neurology, ___ clinic, an
neurosurgery
4.INR monitoring and uptitration of coumadin to INR goal of 2
. | 77 | 541 |
15273056-DS-5 | 28,248,575 | You were admitted to the hospital with weight gain, lower
extremity edema, shortness of breath, and anemia. You received
2 units of PRBC's during this admission. You received an IV
diuretic with good urine output, leading to resolution of your
edema and shortness of breath. You had ultrasounds done of your
heart and legs. The ultrasound of your leg showed no evidence
of blood clots. The echocardiogram of your heart did NOT show
significant left sided heart failure. It did show moderate
pulmonary hypertension. The cause of your symptoms was likely
multi-factorial, including your history of pulmonary
hypertension, recent Prednisone course and possible side effects
from your chemotherapy (Vidaza).
.
Your CXR showed a mild abnormality and will require repeat CXR
in ___ weeks. Please ask your PCP or ___ MD to repeat a
CXR. | ___ yo M with history of gout, recently diagnosed hyperthyroidism
(treated with metoprolol with improvement in symptoms, no
antithyroid medications given), and MDS ___ by hematology
for ___ years) for which she was recently started on treatment
with azacitidine (finished first course 3 days prior to
admission); who presented with ___ edema, SOB, weight gain, and
anemia.
Her symptoms may be attributable to azacitadine (based on
reading, ___ swelling may be seen in up to 19% of patients and
SOB in up to 29%) however more concerning is that this may be
new
diastolic heart failure stemming from iron overload given her
long history of multiple transfusions (ferritin recently
>1,000). She may be a candidate for chelation therapy and/or
consideration
for bone marrow transplant. Will trial Lasix and check echo/BNP
to confirm dx.
Low grade temperature and ? infrahilar opacity raise the
possibility of pneumonia however given clinical stability, lack
of other respiratory symptoms of infection despite multiple
recent courses of antibiotics, will observe and hold antibiotics
for now and see for improvement with trial of diuresis as below.
___ edema/?New onset CHF: given history of iron overload,
SOB, ___ edema, 8lb weight gain, with vascular congestion on CXR.
Possible contributing factors of hyperthyroidism and recent
steroid taper. Side effect of recent Vidaza may be
contributing. PE is less likely given evidence of volume
overload, negative ___ and positive CXR findings. Troponin
was negative in the ED. Flu swab negative. Clinically and
radiographically responded well to diuresis. TTE with normal
LVEF, but does have mild elevated LV filling pressure. Has
known moderate pulm HTN, which is confirmed on TTE. Responded
well to 2 doses of IV Lasix (20mg x 1, 40mg x 1), with
improvement in ___ edema, decrease in weight of 7 pounds and
improvement on CXR. Per d/w ___ team, current ferritin level
unlikely to be causing iron deposition related cardiomyopathy.
Ultimately, her symptoms felt to represent volume overload due
to multiple factors - prednisone course, hyperthyroidism,
pulmonary HTN due to OSA and possible side effect of
azacitadine.
#Hyperthyroidism: At her PCPs office in ___, she was noticed
to be anxious, tremulous, and with a rapid heart rate even at
rest. Evaluation by her PCP found she was hyperthyroid (TSH 0.25
on ___ and 0.024 on ___, Free T4 elevated). She was
referred to a local endocrinologist who placed her on metoprolol
to control her symptoms, but held off on any treatment. She
states she had a thyroid u/s at ___ which was
reportedly normal but she has not had a RAI uptake scan per the
patient. Palpitations had reportedly improved as well as her
tremulousness. She was continued on metoprolol. TFT's were
checked, with persistent low TSH but T4 only minimally elevated.
She should follow-up with Endocrinology as previously scheduled.
#MDS:
-per outpatient notes, she learned recently that her sister is a
match for allogeneic bone marrow transplant. "Ms. ___ is not
ready to embark down that path." Hematologist is Dr. ___
___ NP.
#Anemia: sideroblastic anemia unresponsive to Epo per outpt
notes. Consistent with known MDS +/- anemia of chronic disease
(recent iron studies from ___ showed Fe 182 and ferritin >1000).
Also note that EGD was performed on ___ which noted a small
hiatal hernia but was otherwise normal in appearance. No
evidence of bleeding was noted. Biopsies of the antrum and body
were
normal with negative stains for H. pylori. Duodenal biopsy was
within normal limits. s/p 2 units PRBC during this admission.
#CXR Abnormality: Ms. ___ was diagnosed with a multifocal
pneumonia diagnosed in ___. She subsequently had a
follow up CXR done locally by her PCP in late ___ to
document
resolution of a previous pneumonia which did show resolution of
the opacity but revealed a new nodule for which she subsequently
had a chest CT which according to her local pulmonologist, Dr.
___ in ___, which did not show a nodule, but
reported "infiltrations" at the bases of her lungs. She was
placed on a course of clindamycin and 5 day course of prednisone
30 mg daily, which she completed at the end of ___. She
will need follow up imaging for abnormality seen on CXR this
admission but would defer to her outpatient pulmonologist or
PCP. This was discussed with patient and letter also sent to
PCP.
#Gout: continue allopurinol, will need to renally dose if Cr
worsens. Currently asymptomatic.
#HTN: continue home amlodipine/metoprolol
#OSA: pt has her own variable pressure CPAP which she has
brought
#Transitional:
-CXR abnormality: Note region over left lung requires short term
follow up. Can be monitored by PCP or outpatient pulmonary MD
-___ f/u to discuss chelation therapy and BMT
-She has follow up with Endocrinology scheduled in early ___. | 141 | 784 |
14611177-DS-27 | 29,240,941 | Mr. ___,
You were admitted to ___ due to
a bowel obstuction from your pancreatic cancer. You had a
gastric tube place to help relieve the discomfort from this
obstruction.
Medication Changes:
You have oral morphine for pain control. You may discontinue
other medications if you do not want to take them. You may take
Creon with meals if you would like. | ___ yo M with hx of advanced unresectable pancreatic ca (s/p
palliative choledochojejunostomy & gastroenterostomy) with hx of
SBO s/p duodenal stent with multiple recurrent partial SBOs who
presented 1 day after discharge with recurrent abdominal pain
and symptoms of bowel obstruction.
# Partial SBO - The patient presented with his ___ partial SBO
despite stent placement in ___. He was initially made NPO and
his abdominal pain was relieved with NGT placement (and put to
suction). A repeat CT was again concerning for a pSBO and
ultimately the patient was taken to ___ for G-J tube placement.
A J tube was unable to be placed due to the duodenal stent, but
a G-tube was successfully placed. The patient was started on
tube feeds, but will limited success due to developing bowel
discomfort. Ultimately we attempted to perform tube feeds at
night and venting during the the day via the G-tube, but he
remained unable to tolerate this. Pain and nausea were
controlled as needed with medication. He was transitioned to
hospice and goals of care were shifted to comfort measures only.
# Pancreatic cancer - The patient underwent cycle 2 of
FOLFIRINOX starting on ___, and completed treatment on ___
without complication other than low counts. No obvious clinical
improvement and pt unwilling to continue with chemotherapy in
the absence of evidence of clinical benefit. A pallative care
consult was obtained and he switched to comfort measures only.
His CODE status was made DNR/DNI.
# History of Nonsustained VT and bradycardia: He evaluated by
cardiology during a prior hospitalization. Cardiology
previously documented that there is "no indication for
pacemaker or ICD, given lack of symptoms and patient's poor
prognosis and short life expectance; No need to obtain
echocardiogram, as this would not change management." They
recommended avoiding BB, CCB and reccommended caffeine intake.
Electrolytes were repleted in the usual fashion
# Atrial flutter: CHADS2 score 0, had been on ASA in the past,
currently not anticoagulated due to thrombocytopenia.
# Achalasia and GERD: Continued outpatient PPI BID. | 60 | 347 |
13986499-DS-14 | 24,361,961 | Dear Mr. ___,
.
It was a pleasure taking care of you at ___. You were admitted
initally due to having lightheadedness, difficulty speaking, and
an acute onset of left-sided weakness. We performed inital
imaging of your head and found out that you had a clot in
several of the arteries (Right Internal Carotid and Middle
Cerebral Arteries) that supply the right side of the brain.
There was a resultant stroke in the region of the brain supplied
by thses vessels, which accounts for the symptoms you have. You
were given an IV medication to break up the clot, and then taken
for an intervention to help remove the clot, although this was
unsuccessful.
.
To treat you, we started a blood thinning medication (heparin)
and are giving you another medication to keep your blood thin
(coumadin). Your blood levels were checked routinely, and one of
the markers in your blood of how thin it is, is known as an INR.
Your goal INR range is ___. This will be followed at your
rehabilitation facility, and when you are discharged from rehab.
.
Your stroke risk factors were assessed, and it was found that
you had an elevated cholesterol. For this reason we recommended
starting a cholesterol medication (Atorvastatin). Plesae take
this as prescribed. Please note that this medication can cause
muscle pain, and notify your primary care physician if you start
to have any symptoms concerning for this. Your liver function
tests should be checked in the next few weeks to confirm the
medication is not having adverse side effects.
.
You have appoinmtents scheduled for follow-up with a primary
care provider, as well as Dr. ___ Neurology. Please see
below.
We made the following changes to your medications:
START Atorvastatin 80mg take one tablet by mouth daily
START Warfarin 5mg tablet (take one tablet by mouth daily at
4pm, your blood will be checked to see how thin it is with a
blood test known as INR with a goal INR of ___
START Lisinopril 20mg tablet take one tablet by mouth daily
START Docusate 100mg take one tablet by mouth two times a day
STOP Aspirin 325
START Acetaminophen 650mg take one tablet by mouth every 6
hours as needed for pain | Mr. ___ is a ___ RHM with no significant medical history (he
reports having not seen a physician in ___ years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 AM (___)
after taking a shower. He presented to the ___ ___ and was
admitted to the Stroke Service for further evaluation and care.
He was discharged on ___ to rehabilitation.
.
#Right Basal Ganglia Infract from Right Internal Carotid Artery
Occlusion (and Right Middle Cerebral Artery Occlusion - since
recanalized): Initially on admission a code stroke called given
his significant acute deficits. At ___ ED, the patient was
hypertensive to 190s and initial NIHSS was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. There was evidence of a right MCA and ICA occlusion
on CTA concerning for dissection. CTP showed a large area of
right MCA hypoperfusion. He was administered IV tPA at 9:12 AM.
After this, his symptoms initially significantly improved with
good antigravity on the left with NIHSS then 3. However, as his
blood pressure dipped to SBP 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. Accordingly, the Neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits. Unfortunately, the ICA could not be opened. (The
difficulty passing the catheter through the ICA was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
The patient was started on heparin gtt. A subsequent MRI showed
patent R MCA later that night. His goal PTT was 50-70, and was
checked every 6 hours. Dosing adjustments were made accordingly.
In the acute setting the patient required a nicardipine gtt with
goal SBP 140-190's, he eventually did not require this anymore.
After his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg QD with a goal SBP of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent R ICA occlusion). He was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
His stroke risk factors were assessed: FLP 175, ___ 76, HDL 47,
LDL 113, A1C 5.4. As his LDL was not at goal <70 the patient was
started on high dose Atorvastatin 80mg QD. A TTE was obtained
(see full report above) which did not show an ASD/PFO/thrombus,
and the patient had a preserved EF. A Speech and Swallow
evaluation was obtained, and the patient was cleared for a
regular diet. The patient was evaluated by Physical Therapy and
Occupational Therapy, and has been recommended for ___
rehab. Also, the patient will have a follow-up CTA in 3 months,
to be reviewed at his follow-up appointment with Dr. ___ in
Neurology (scheduled prior to discharge).
.
#Hypertension: Patient has had goal SBP 140's-180's, he
previously was not on any anti-HTN medications. We started the
patient on lisinopril and uptitrated to 20mg QD. We have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. In about 2 days post discharge (___) his
SBP range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#Left Rib Pain, Left Ankle Pain s/p fall: Patient had a CXR and
a Left Ankle Xray without evidence of fracture. He was treated
with acetaminophen for pain and tolerated this well.
.
#Antiocoagulation: Patient will need anticoagulation for his
occlusion for at least 3 months. His goal INR is ___. His INR
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
. | 363 | 606 |
15386737-DS-18 | 22,099,239 | You were admitted with abdominal pain and found to have
pancreatitis, or an inflammation of the pancreas. You had an
ERCP procedure, the results of which have been discussed and
printed for you to review. Biopsies were obtained from the
choledochal cyst, which needs to be followed up and a referral
made to a local gastroenterologist who regularly performs
endoscopy.
Dr. ___, gastroenterology (performed your procedure)
___ of Gastroenterology/GI /West
___
Phone: ___
Fax: ___
Please make sure to contact Dr. ___ if you do not
hear back from them in 2 weeks' time in order to get the results
of the biopsies. Please also give this information to your
primary care physician in order for a proper referral to be
made. | ___ y/o M with no significant PMHx, who presented to ___ with
epigastric pain x 3 days, found to have acute pancreatitis.
# Acute Pancreatitis: The cause of the pancreatitis was found to
be due to a choledochocele. An MRCP from ___ revealed an
8 mm choledochocele with mild mass effect against the adjacent
pancreatic duct and mild upstream pancreatic duct dilation to 5
mm. The CBD measures up to 6 mm. Mild prominence of the
intrahepatic bile ducts. The patient had an ERCP on ___,
with sphincterotomy performed and biospy of the choledocal cyst
done afterwards. The patient was also noted to have the presence
of an abnormal pancreatobiliary junction. He was able to
tolerate a normal diet the following day and made a bowel
movement prior to discharge. The biopsy results will need to be
followed up on and he will need a referral to a
gastroenterologist specializing in endoscopy. His LFTs also
downtrended post-procedure and are expected to normalize. A
repeat check of LFTs in ___ weeks will be at the discretion of
the patient's PCP. | 119 | 181 |
10599949-DS-27 | 22,735,926 | Dear Ms. ___,
You were admitted because you had a fainting spell. You
underwent an extensive workup. We believe your symptoms are due
to orthostasis. At this time we feel that you are safe for
discharge back to your skilled nursing facility.
It was a pleasure to be a part of your care,
Your ___ treatment team | Ms. ___ is an ___ year old woman with a history of pulmonary
hypertension and multiple myeloma who presents with syncope
after getting into her daughters car.
# Syncope: Highest on the differential is orthostasis vs cardiac
etiology. Orthostatic signs are positive with precipitation of
her symptoms. Concern for worsening RV function in the setting
of pulmonary hypertension. No evidence of PE on CTA. EKG at
baseline, troponins elevated on admission, though downtrended.
CK-MB flat. Telemetry without evidence of arrhythmias. Low
suspicion for seizure activity or vasovagal. ECHO revealed no
changes from prior.
# Orthostatic hypotension: Patient presented with symptomatic
Orthostasis. Differential included worsening RV function as
above vs autonomic dysfunction, vs adrenal insufficiency, aging,
and the effect of medications. ECHO revealed no changes from
prior. AM cortisol was wnl. B12 level was WNL. Home
antihypertensives were initially held. She wore TEDS during her
admission and HOB was kept elevated 30 degrees. Side effect of
donepezil was also considered, but this was continued as her
orthostatic hypotension resolved with fluids and improved PO
intake.
# Multiple myeloma: S/P induction velcade with clinical and
laboratory response. Now off of treatment, though with evidence
of multiple compression fractures throughout on CT.
# Left sided chest pain: CTA with evidence of numerous
fractures, including left sided 2nd rib fracture, which is
consistent with where the patient is experiencing pain. Pain
control with standing Tylenol, lidocaine patch, and tramadol
PRN.
# Memory impairment: Continued donepezil
# Insomnia: Continued remeron
***TRANSITIONAL ISSUES***
- Pancreatic lesion: CTA at admission incidentally noted diffuse
pancreatic ductal prominence with an area of focal dilation
measuring up to 8mm, increased from ___. No interval
imaging available for comparison. Consider MRCP for further
evaluation as outpatient. Patient's lipase and LFTs overall
unremarkable and patient was asymptomatic. | 55 | 294 |
Subsets and Splits